1
NURSING EDUCATORS AND NURSING LEADERS VIEWS ON PRACTICE
Introduction
Transition to practice can be a difficult time for both new graduate nurses and for
the hospital nurse leaders who hire these novice nurses and expect a certain level of
competency. Novice nurses lack confidence in their new role regarding skill performance,
which results in increased dependency until they are able to perform the skills
proficiently (Dwyer & Hunter Revell, 2016). Hospital nurse leaders have a set level of
expectations for newly hired nurses to be proficient at the onset of practice (Dwyer &
Hunter Revell, 2016). Hospital nurse leaders are currently providing extensive
orientations for new graduate nurses to ensure they are ready to meet the practice
requirements necessary to provide safe and efficient care for patients in the hospital
setting (Thomas, Bertram, & Allen, 2012). Nursing educators play a role in developing
the formative knowledge and skills of these novice nurses. However, many novice nurses
will learn to navigate their current practice and perfect their level of competency without
the support of an intensive orientation or residency program (Mellor & Gregoric, 2016).
Transition to practice changed in 1994 with the introduction of computer adaptive
testing (CAT) (Dyess & Sherman, 2009). Prior to 1994, nurses were considered graduate
nurses and worked with a provisional license while they practiced with seasoned nurses
for several months until their NCLEX board results were reported (Dyess & Sherman,
2009). The use of CAT allows successful NCLEX candidates to obtain their licensure
within days of testing (Dyess & Sherman, 2009), which allows new graduates to enter
practice earlier as a fully registered licensed nurse. Many novice nurses are not provided a
2
structured period of time that allows them to learn under the supervision of a seasoned
nurse (Dyess & Sherman, 2009).
Nursing educators believe that new graduate nurses are prepared for the transition
into practice, but they may only be prepared for successful completion of the NCLEX
exam (Numminen et al., 2014). Numminen et al. (2014) found that novice nurse
competence was assessed considerably higher by nursing educators than managers in all
areas evaluated (p < 0.001). A systematic review by AL-Dossary, Kitsantas, and Maddox
(2014) revealed that according to nursing hospital leaders, nurse managers, hospital
nursing educators, and preceptors, the current preparation for transition to practice is
inadequate. Kavanagh and Szweda (2017) studied entry-level competency and practice
readiness in newly graduated nurses; they found that only 23% of these nurses were able
to demonstrate entry-level competencies (Kavanagh & Szweda, 2017).
Kramer (1974) first reported the incongruence in understanding between job
performance expectations and the reality of current job performance for novice nurses.
Hospital nurse leaders expect new graduate nurses to be proficient at using cutting-edge
technology when caring for patients with advanced acuity levels (Dwyer & Hunter
Revell, 2016; Baldwin, Bentley, Langtree, & Mills, 2014). These expectations for new
graduate nurses may not align with the views of nursing educators (Numminen et al.,
2014). Consistent expectations for new graduate nurses for both nursing educators and
hospital nurse leaders will assist in bridging the gap that currently exists between these
two stakeholders. This study will add to the knowledge of whether differences in
viewpoints exist regarding readiness to practice for new graduate nurses between nursing
3
educator and hospital nurse leaders. The results of this study have the potential for
positive social change by providing data that will help nurse educators evaluate the need
for curriculum changes. In addition, hospital nurse leaders can review the orientation and
mentoring programs developed for new graduates to ensure that the areas not addressed
in their nursing curriculum are provided to ensure safe practice. I cover the following
topics in Chapter 1: background, problem statement, purpose of the study, research
questions and hypothesis, theoretical framework, nature of the study, definitions,
assumptions, scope and delimitations, limitations, significance, and a description of how
this study will address the identified gap that exists between the major stakeholders.
Background
The theory-practice gap was first documented by Armstrong (1974), who stated
there are factors that complicate the theory-practice gap including different levels of
education and exposure to different clinical experiences. Novice nurses may have the
theoretical knowledge but not a vast amount of clinical experience (Armstrong, 1974).
The American Association of Colleges of Nursing (AACN) developed the AACN
essentials, a framework for developing nursing curriculum for baccalaureate through
doctoral level nursing education (AACN, 2018). These essentials are used to assist
nursing programs with designing and delineating the content and expected competencies
for students enrolled in nursing education (AACN, 2018). The essentials outline nine
areas of expected practice for graduates: (a) liberal education for baccalaureate generalist
nursing practice; (b) basic organizational and systems leadership for quality care and
patient safety; (c) scholarship for evidence-based practice; (d) information management
4
and application of patient care technology; (e) healthcare policy, finance, and regulatory
environments; (f) interprofessional communication and collaboration for improving
patient health outcomes; (g) clinical prevention and population health; (h)
professionalism and professional values; and (i) baccalaureate generalist nursing practice
(Price, Buch, & Hagerty, 2015; AACN, 2018).
Core competencies developed by the Quality and Safety Education for Nurses
(QSEN) institute are also included in nursing education curriculums. QSEN is a project,
funded by the Robert Wood Johnson Foundation, with the inherit purpose of preparing
future nurses for practice so they have the necessary skill to address the knowledge,
skills, and attitudes needed to provide safe quality care to the public (QSEN, 2018a).
There are six core competencies identified by QSEN based on the Institute of Medicine’s
competencies: (a) patient centered care, (b) teamwork and collaboration, (c)
evidencebased practice, (d) quality improvement, (e) safety, and (f) informatics (QSEN,
2018b). These competencies have been further divided to address prelicensure and
graduate-level competencies (QSEN, 2018b). The prelicensure competencies assist
nursing programs in developing and revising their curriculum according to these
standards to ensure nurses are adequately prepared (QSEN, 2018b).
Nursing educators are faced with the challenge of developing a nursing
curriculum that integrates the core competencies necessary to support new graduate
nurses during their transition into active practice (Brown, Crookes, & Iverson, 2015).
Educators design the nursing curriculum with clinical time to allow nursing students
practice to develop core competencies to the expected level of performance for new
5
graduates (Baldwin et al., 2014; Brown et al., 2015; Institute of Medicine [IOM], 2003).
The development of competent nurses who have achieved a level of competence and are
work-ready is challenging for nursing educators (Brown et al., 2015). According to
Benner (1982), nurses develop skills over time and with experience.
Current barriers that exist and impact the development of the essential skills in
nursing students include the shortage of clinical sites, limited exposure to clinical
skillbuilding opportunities, and lack of collaboration between nursing educators and
hospital nurse leaders to provide the best experience for the development of essential
skills
(Papagiorgis et al., 2016; Radford, 2018; AL-Dossary et al., 2014; Berkow, Virkstis,
Stewart, & Conway, 2009). Practice is an essential element needed for nursing students to
develop skill competency (Benner, 1982; Brown et al., 2015; Papagiorgis et al., 2016).
The clinical exposure that each student experiences is unique, but opportunities to
perform and perfect skills may not be available to every student (Bennett, 2017). For
example, some students may experience different areas in the hospital that are not offered
to every student (Bennett, 2017). In addition, students experience delays in their
development of organization and higher-level problem-solving skills until they are
actively practicing (Bennett, 2017). The ability to organize care cannot be achieved if
students are only expected to care for a few patients at a time or have a light workload
compared to seasoned staff nurses who are providing care for a heavy workload of
patients during their shift (Bennett, 2017). The shortage of clinical sites restricts nursing
educators’ ability to provide time in the facilities to experience and develop the skills that
6
are expected once these novice nurses enter the workforce (Papagiorgis et al., 2016;
Radford, 2018). Finally, improved collaboration and communication between nursing
educators and hospital nurse leaders regarding best practices for clinical rotations is
needed and will lead to an overall improved clinical experience for students, resulting in
enhanced clinical competence at the initial stage of the transition period (AL-Dossary et
al., 2014; Berkow et al., 2009).
Hospital nurse leaders expect novice nurses to demonstrate proficiency of skills
during the transition period (Berkow et al., 2009). However, hospital nurse leaders are
reporting that new graduate nurses are not able to perform the required skills
independently and therefore do not meet their expected level of competency performance
(Brown & Crookes, 2016). Brown and Crookes (2016) identified the level of competency
expected in new graduate nurses in a modified Delphi study. The study was conducted to
improve clarity regarding the expected level of competency of new registered nurse (RN)
graduates in Australia. The study surveyed experienced nurses and assessed if new
graduates could practice independently when performing 30 skill areas. The researchers
found that the expectations for competency in newly graduated RNs were not clear and
that there is a need for well-defined guidelines. Brown and Crookes (2007) identified 30
skill areas necessary for new graduates to be considered work ready. Each skill was
ranked utilizing Bondy’s criteria on five levels: (a) independent, (b) supervised, (c)
assisted, (d) marginal, and (e) the lowest level dependent. These researchers identified
only four skill areas that the majority of respondents believed the new graduates were
7
competent and could complete independently (Brown & Crookes, 2016). In the clinical
monitoring and management skill area, which included use of assessment tools, only
52.58% of the respondents believed the new graduates would be able to perform
independently (Brown & Crookes, 2016). Hospital nurse leaders can help by identifying
and prioritizing the essential skills that need improvement to determine the greatest gaps
in knowledge and abilities not being addressed in the nursing curriculum (Berkow et al.,
2009). An identified expectation for level of competence for new graduate nurses among
all stakeholders will assist in the development of a plan to combat the dissidence in
current understanding of expectations for new graduate nurses. A clear understanding of
expectations for new graduate nurses consistent between nursing educators and hospital
nurse leaders will assist in bridging the gap that currently exists between these two
stakeholders.
Problem Statement
A discrepancy exists between nursing educators’ and hospital nurse leaders’ views
of readiness to practice for new graduate nurses (AL-Dossary et al., 2014). According to
Berkow et al. (2009), 90% of nursing educators state that new graduate nurses are
prepared to enter the workforce. In contrast, hospital nurse leaders express that only 10%
of novice nurses are adequately prepared (Berkow et al., 2009). There is a paucity of
research on a common understanding between nursing educators and hospital nurse
leaders on student preparation and the required expectations for novice nurses. It is well-
established in the literature that these new graduate nurses experience difficulties during
the transition period that begins after graduation and continues as they learn their new
8
role as a nurse. These difficulties include anxiety, lack of confidence, and reality shock
(AL-Dossary et al., 2014; Berkow et al.,2009; Dwyer & Hunter Revell, 2016).
Difficulty during the transition process may influence novice nurses to change jobs within
the first year of practice (Dwyer & Hunter Revell, 2016). According to Snavely (2016),
the exit rate for unsupported new graduate nurses is 30–50%.
The AACN’s essentials of clinical resources includes clinical guidelines that
outline essential competencies, including (a) critical thinking, (b) communication, (d)
assessment, and (e) development of professional roles as the provider of care, which need
to be developed in an environment with preceptors and professional mentors to facilitate
the learning process (AACN, 2018; Martin, Godfrey, & Walker, 2015). Despite the use of
these guidelines, novice nurses entering the workforce do not understand their
responsibilities and expected performance in the clinical setting, resulting in a lack of
proficiency and a compromise of patient safety (AL-Dossary et al., 2014, Bennett, 2017).
Nurse residency programs have been used with some success to promote the development
of competencies, but the absence of standardized residency programs may be one of the
causes for the high turnover rate for novice nurses in the first year of practice (AlDossary
et al., 2014; Spector & Echternacht, 2010). The current gap between nurse educators’ and
nurse executives’ expectations relative to preparation for practice can be addressed with
an examination of their views (AL-Dossary et al., 2014).
The dichotomy that exists between the stakeholders on theory-practice gap
adversely impacts novice nurses’ transition into practice. Further investigation may assist
in bridging the divide in understanding between student preparation and the required
9
expectations for novice nurses to make the transition more effective. Improvement in this
transition period can begin by examining the viewpoints of the two major stakeholders—
nurse educators and hospital nurse leaders—in relation to the desired competencies (AL-
Dossary et al., 2014).
Purpose of the Study
The purpose of this descriptive quantitative study was to determine whether a
difference exists between the beliefs of hospital nurse leaders and nursing educators about
the frequency and competency levels in (a) leadership for novice nurses transitioning into
practice, (b) critical care nursing performance, (c) teaching and collaboration, (d) ability
to plan and evaluate (e) interpersonal relations and communications, and (f) professional
development for novice nurses transitioning into practice. I used descriptive and
inferential statistics to determine whether differences existed between these two major
stakeholders. I used surveys to develop an understanding of these stakeholders’ current
views on the desired level of performance for novice nurses. The results of this study will
have a positive social impact by encouraging nursing educators to evaluate the current
curriculum to determine needs for revision and as a reference for hospital nurse leaders to
determine how to best structure content in hospital orientation programs for novice
nurses.
The independent variables in the first five RQs were two groups: nursing
educators and hospital nurse leaders. The dependent variables were the frequency and
level of competency based on the performance measures in Schwirian’s (1978)
10
sixdimension scale of nursing performance (6-DSNP). The independent variable in RQ6
were the two groups: nursing educator and hospital nurse leaders, and the dependent
variable for RQ6 was the level of performance of professional development (Schwirian,
1979).
Research Questions and Hypotheses
The research questions addressed in this study were the following:
RQ1: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing performance
needed by novice nurses transitioning into practice?
H01: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
Ha1: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
RQ2: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing performance
needed by novice nurses transitioning into practice?
H02: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
11
Ha2: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
RQ3: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice?
H03: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
Ha3: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
RQ4: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate needed by
novice nurses transitioning into practice?
H04: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
Ha4: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
12
RQ5: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice?
H05: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice.
Ha5: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice.
RQ6: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance needed by
novice nurses transitioning into practice?
H06: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
Ha6: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
Theoretical Framework for the Study
Benner’s (1982) from novice to expert theory was used as a framework for this
study. In this theory, Benner (1982) described five stages that beginners transition through
to develop skills from beginner to expert practitioners; the theory was developed from the
13
Dreyfus model of skill acquisition, which can be used to help determine the differences
between an experienced and novice nurse (Benner, 1982). Novice nurses are considered
beginners without experience who can be relied on to apply discretionary judgement
(Benner, 1984). At the advanced beginner stage, nurses have some prior experience that
can be applied to current patient situations, but they still rely on supportive cues (Benner,
1984). In the next stage of Benner’s (1984) theory, nurses are considered proficient;
proficient nurses can prioritize and evaluates patient situations in a holistic manner. The
final stage is expert, where nurses’ recognition and assessment skills are at the highest
level and linked with intuition (Benner, 2004). Benner (1982) explained the attributes of
each level of proficiency and the desired performance to attain each level. The
epistemology assumption was that an exploration of the differences in these viewpoints,
on both sides of this issue, would provide new knowledge regarding novice nurses
entering the workplace. Benner’s theory is described in greater depth in Chapter 2.
Nature of the Study
This study was a nonexperimental quantitative descriptive study with a
crosssectional design. Data were collected by a survey using Schwirian’s (1978) 6-DSNP
to evaluate the desired competencies for novice nurses. For the study, I used a
convenience sample of nursing educators and nurses working in the hospital in one the
following roles: nurse manager, nurse preceptor, or hospital nurse educator. I collected
demographic information as part of the survey, including academic preparation, years of
practice as an RN, and level of experience in their current role as a hospital nurse leader
or nursing educator. I used descriptive statistics to determine the characteristics of the
14
sample population. To examine if differences exist between hospital nurse leaders and
nursing educators regarding beliefs for novice nurses’ readiness for practice, applying the
first five dimensions in Schwirian’s assessment tool, I used a multivariate analysis of
variance (MANOVA). I performed an independent t test to examine if differences exist
between hospital nurse leaders’ and nursing educators’ beliefs about professional
development performance in novice nurses’ readiness for practice, the sixth dimension in
Schwirian’s assessment tool.
The independent variables were the type of stakeholder (nursing educator or
hospital nurse leader). The dependent variables were the frequency and level of
performance of leadership, critical care, teaching/collaboration, planning/evaluating, and
interpersonal relations/communication. I used an independent t test to evaluate the
independent variable type of leader and the dependent variable professional development.
Definitions
Competence: “Having the capacity to perform or potential ability to function”
(Johnson, Opfer, VanCura, & Williams, 2000, para. 5).
Competency: An outcome of performance of a skill that can be measured based on
the desired level of performance (Becker et al., 2018).
Hospital nurse leaders: An RN who works in one of the following capacities in
the hospital setting: a preceptor, a nurse manager, or a nursing educator.
Novice nurse: A newly licensed RN with less than 1 year of job experience
(Phillips, Kenny, Esterman, & Smith, 2012).
15
Nursing educators: An instructor who prepares novice nurses for clinical practice.
As per the National League for Nursing (2013), nurse educators should be able to (a)
facilitate learning, (b) enable the development of socialization, (c) employ assessment
and evaluation strategies, (d) play an active role in curriculum design and evaluation of
program outcomes and quality improvement in the nurse educator role, (e) engage in
scholarship, and (f) work effectively in the education environment. In addition, nurse
educators are required to have effective communication skills and be proficient at
teaching and facilitating student learning (Poindexter, 2013).
Preceptorship: One-on-one process where learners obtain experience under the
guidance of an experienced nurse (Henderson & Eaton, 2013). Novice nurses are able to
identify and assimilate their new role from a colleague who acts a role model (Henderson
& Eaton, 2013). The preceptee’s abilities and progress are assessed by the preceptor
(Henderson & Eaton, 2013).
Readiness to practice: The ability of new graduate nurses to have a general
foundation and some job specific abilities to provide safe patient care, including (a) the
ability to adapt to the future needs of the client; the ability to simultaneously balance
doing, knowing, and thinking; and the ability to continually stay up-to-date with current
nursing practice (Woods et al., 2015).
Theory-practice gap: A noted difference between theoretical knowledge and
reality (El Haddad, Moxham, & Broadbent, 2017). The difference between what should
happen, and actual outcomes encountered in practice (El Haddad et al., 2017).
16
Transition to practice: A 1-year period of time after a nurse completes all nursing
courses and successfully completes the NCLEX exam (Phillips et al., 2012).
Assumptions
The following assumptions were accepted as true for this study. It was assumed
that the respondents to the survey met the screening requirements outlined in the
informed consent. An assumption of the study was that nurse educators desire to prepare
nurses to practice and meet the competency expectations of hospital nurse leaders. The
final assumption was that respondents would answer the questions honestly and
completely.
Scope and Delimitations
Using the data from this study, I examined if differences exist in views of nursing
educators and hospital nurse leaders regarding new graduate nurses’ level of
preparedness. I used the six-dimension scale of nursing performance to measure the
frequency and quality of expected performance of nursing skills using close-ended Likert
scale responses rather than open-ended responses. Each survey was an assessment of a
participant’s views on the frequency and quality of expected performance of desired
nursing behaviors in new graduate nurses. I considered the Casey-Fink nurse experience
survey for this study, but the verbiage in the tool could not be modified to fit the
population in this study; the authors did not allow revisions or modifications (UC Health,
2018). I considered Lewin’s change theory for this study because it would address the
change experienced by novice nurses during the transition period. However, this theory
would not help to explain how novice nurses develop competency.
17
I analyzed my data using a MANOVA and an independent t test. A MANOVA can
be used to determine significant difference between two groups or more and when there
are more than two dependent variables with concurrent evaluation (Polit & Beck,
2018). The use of a MANOVA would be more accurate than running multiple ANOVAS
(Field, 2013). I used the MANOVA to test the hypothesis for the first five research
questions that had two groups and two dependent variables considered at the same time
(Polit & Beck, 2018). An independent t test was used to test the null hypothesis of RQ6,
which compared the independent variable type of leader and the dependent variable
professional development.
My target sample was nursing educators and hospital nurse leaders. I chose to
evaluate nursing educators and hospital nurse leaders because only a few studies in the
literature use these two stakeholders. Nonetheless, each of them plays an important role
in the formation of fostered development of novice nurses. I considered including novice
nurses, but this population was not included in my study because the data were not
represented in my research questions and this population has been heavily researched
previously. I considered a qualitative study for this research but did not choose this
methodology because it would not answer the research questions regarding the
differences between stakeholder expectations. I used a convenience sample in this study
and generalizability depended on attainment of a true sample of the population.
Limitations
I identified limitations for this study that could potentially impact the outcomes.
First, the participants were a convenience sample of survey respondents and may not be a
18
true reflection of the examined populations. The results of this study depended on
participation of qualified respondents. The study also depended on accurate human
responses to questions about their beliefs. The study depended on an adequate number of
respondents and each comparison group needed to have an equal number. The results of
the t test were assumed correct, but the results cannot be assumed 100% correct (Mertler
& Vannatta, 2013). For the MANOVA, there must be a correlation between the two
dependent variables for the test to detect an effect (Field, 2013).
Several time and resource constraints may have influenced the data collection.
The survey was initially scheduled to be available for a 30-day period. The results of the
survey could have been limited by both the length of the survey and participants who had
access to answer the survey questions. The survey contained 52 items that were scored
twice and took up to 30 minutes to complete. Participants may not have completed the
entire survey if it took too much time, resulting in incomplete survey data. Because of the
recruitment strategies used in this study, I did not have an opportunity to remind
participants to complete the survey.
Potential limitations included the design of this study. The evidence obtained in a
nonexperimental study will not be as strong as the evidence that could be obtained with
an experimental study (Polit & Beck, 2018). Interventions were not utilized in this
nonexperimental study. The study was a cross-sectional design, which would not allow
me to compare the results to a second sample of data from the same population. The use
of a convenience sample may not be a true representation of the population studied and
therefore the results cannot be generalized to the larger population (Polit & Beck, 2018).
19
The modification of the Schwirian (1978) tool could affect the validity and reliability of
the study results. Therefore, the tool had validity re-established. The Cronbach’s alpha
ranged from 0.84–0.90 for Schwirian’s original tool, demonstrating high reliability.
Content validity of the revised tool was established by a peer review panel to reassure
that the changes made to Question 18 in the survey reflected the intended constructs
(Zamanzadeh et al., 2015). Peer review panel members were asked to rate the changes in
terms of clarity and relevancy (Zamanzadeh et al., 2015). Validity was reconfirmed post
hoc using confirmatory analysis to ensure the constructs were accurately measured in the
modified Schwirian tool (Zamanzadeh et al., 2015). I verified the validity of the scores
obtained using confirmatory factor analysis.
I ensured the survey was free from errors that could have resulted in the
participants’ misunderstanding questions. The items in this survey were reviewed for
readability, clarity, and comprehensiveness to reduce participant error. Participant bias
could have affected the reliability and was controlled by presenting the facts of the
research proposal and not my opinion of the possible outcomes. Researcher error was
limited by gathering data in multiple ways and multiple sites to vary the participants who
took the survey. I used quantitative data to reduce the risk of researcher bias.
Significance
Employers expect new graduate nurses to function in the clinical environment at
the onset of their practice as RNs (Falk, Falk, & Jakobsson Ung, 2016). In 2000, the IOM
published a report that addressed the need for improvements to the education of health
professionals (Stafford, 2000; Sherwood & Zomorodi, 2014). The IOM suggested in this
20
report that incorporating six core competencies in the curriculum would enhance the
ability of new graduates to function and deliver patient-centered care: (a) patient centered
care, (b) teamwork and collaboration, (c) evidence-based care (d) continuous quality
improvement, (e) a mindset on safety, and (f) knowledge of informatics (Sherwood &
Zomorodi, 2014). The expectations during the transition period for new graduates are not fully
understood by novice nurses (AL-Dossary et al., 2014). According to Benner (1982), beginners
are expected to perform tasks in situations where they do not have experience. Novice nurses
progress from a level of beginner to competent development of skills with experience during the
transition period (Benner, 1982, Martin & Wilson, 2011). The ability to understand and address
the differences in competency expectations of the major stakeholders has the potential for positive
social change for three groups: (a) nurse educators, (b) nurse leaders, and (c) nursing students.
Nurse educators could use the study results to review and revise curriculum to ensure that
students are able to perform at the expected level of competency upon graduation. Nurse leaders
may use the study results to develop orientation and residency programs to build on novice
nurses’ current skills and abilities. Based on clearer expectations from both stakeholders, novice
nurses would be able to identify areas of practice they need to strengthen to be better prepared to
transition into their new role. Nurses who feel competent during their transition to active practice
will more positively impact the care outcomes for patients and will have decreased desire to leave
the workforce.
Summary
In summary, I reviewed the difficulties experienced by novice nurses at the onset
of their new career as the background for this study. In the problem statement, I reviewed
21
the dichotomy that exists between nursing educators and hospital nurse leaders regarding
expectations for novice nurses; this dissidence may impact novice nurses’ transition into
practice. The purpose of this quantitative cross-sectional study was to examine if there is
a relationship between nurse educators’ and nurse leaders’ views on the frequency and
competency level in novice nurses and to address the gap that exists between the views of
these two stakeholders utilizing Benner’s theory as a framework. An expanded
understanding of the views of the major stakeholders may assist in bridging the divide
that currently exists regarding successful transition to practice for novice nurses. I
examined for differences in beliefs regarding novice nurses’ ability to transfer into
practice between hospital nurse leaders and nursing educators using Schwirian’s six
dimensions. This study has significance by providing clearer expectations for novice
nurses regarding what is expected at the onset of practice. This will have a positive
impact on patient outcomes and novice nurses’ desire to continually improve and remain
in the workforce. In Chapter 2, I provide a review of the literature regarding transition to
practice for novice nurses and the current gap that exists between nursing educators and
hospital nurse leaders.
Chapter 2: Literature Review
Introduction
A discrepancy exists between nursing educators’ and hospital nurse leaders’ views
of new graduate nurses’ readiness to practice (AL-Dossary et al., 2014). According to
Berkow et al. (2009) 90% of nursing educators state that new graduate nurses are
22
prepared to enter the workforce. In contrast, hospital nurse leaders express that only 10%
of these novice nurses are adequately prepared (Berkow et al., 2009). The purpose of this
descriptive study was to determine whether a significant difference exists between
hospital nurse leaders’ and nursing educators’ beliefs about the frequency and
competency levels in the following areas for novice nurses transitioning into practice: (a)
leadership for novice nurses transitioning into practice, (b) critical care nursing
performance, (c) teaching and collaboration, (d) ability to plan and evaluate (e)
interpersonal relations and communications, and (f) professional development.
Transition to practice continues to be a complex and difficult period for novice
nurses during their first year of practice. New graduate nurses have been prepared to pass
the NCLEX exam and perform at the most basic level as a nurse generalist (Falk et al.,
2016). Although the stakeholders share a common understanding about the problems
involved in the transition period, the theory-practice gap continues to be addressed
inadequately. The dissidence in beliefs between nursing educators and hospital nurse
leaders exists in multiple areas, including roles, responsibilities, and performance
expectations (AL-Dossary et al., 2014; Mauro, Escallier, & Rosario-Sim, 2016). Few
studies have been conducted that compare the ideals from the perspectives of the major
stakeholders. A review of the literature indicates that common expectations for novice
nurses remain unclear at the onset of practice (El Haddad et al., 2017). Therefore, in this
study, I will investigate and provide a comparison of beliefs regarding expectations for
novice nurses in six areas of practice to contribute to the body of knowledge related to
improving transition to practice for novice nurses, which will lead to positive social
23
change. In Chapter 2, I discuss how I obtained the studies for this literature review,
provide a review of the theoretical foundation and how this theory guided current studies,
and review the literature related to key variables and concepts.
Literature Search Strategy
I used the following databases to search the existing literature: CINAHL,
MEDLINE, and ProQuest Nursing and Allied Health Source. Literature that included
issues related to transition to practice were included in the sample. I used a thematic
approach to organize and discuss the issues surrounding transition to practice and the
theory-practice gap that exists. Key terms I used included transition to practice, novice
nurses, Benner, readiness to practice, newly licensed nurses, nursing educators and new
graduates, transition to practice, and hospital nurse leaders. The literature review was
mainly limited to peer-reviewed articles written between 2010 and 2018. An exception
was made to include seminal literature that demonstrated the history of the topic, theory
related articles that provided a framework for the study, and articles that discussed
Schwirian’s (1978) 6-DSNP.
Theoretical Foundation
Benner first published her novice to expert model in 1984 and applied the Dreyfus
model of skill acquisition to nursing (Benner, 1982, 2004). According to Benner (1984,
2004), nurses progress through five stages—novice, advanced beginner, competent,
proficient, and expert—as they gain knowledge and experience through practice (see
Figure 1). This evolution of practice is described in distinct levels with common
meanings that can be used to set expectations and evaluate nurses based on their level of
24
practice (Benner, 1984, 2004). Benner’s (1984) model identifies seven domains of
nursing practice that outline nurses’ responsibilities and expected competencies.
Figure 1. Benner’s novice to expert theory (on the basis of Benner, 1982).
Levels of Competency
Stakeholders need to comprehend how novice nurses gain understanding. Novice
nurses need to have a strong foundation of knowledge at the onset of their career, which
can be developed throughout the remainder of their profession (Benner, 1982; Bridges,
Herrin, Swart, & McConnell, 2014). Novice nurses who previously functioned under a
clinical instructor now have legal and professional responsibility for their patients
(Benner, 2004). These novice nurses need coaching to decrease their anxiety and to build
confidence in themselves as they experience clinical situations unfamiliar to them
(Benner, 2004). Application of Benner’s theory will help to explain how novice nurses
gain experience throughout their first year of practice. Educators and hospital nurse
leaders need to have an understanding that novice nurses will progress through the five
stages—novice, advanced beginner, competent, proficient, and expert—as they gain
25
knowledge and experience through practice. Novice nurses are responsible for tasks
outlined in each of the following roles identified by Benner (1984):
•Helping role: should give comfort and provide pain relief to patients,
include patients in the plan of care, and provide informational support.
•Teaching role: should teach patients how to care for their current condition
and provide rationales for interventions, should explore patients’
understanding of their illness, and should assist patients to implement a
plan of recovery.
•Diagnostic and monitoring: should identify changes in patients’
conditions, including the ability to recognize early warning signs and
symptoms; the nurse should anticipate patients’ needs and possible
problems.
•Effective management of change: should have skillful performance in
emergent situations and respond appropriately, including utilization of
emergency resources.
•Administration and monitoring of interventions: should administer
medications accurately and implement therapies to prevent complications.
•Monitoring of quality practice: should provide safe care, assess
appropriateness of orders, and work with physicians to ensure care is
appropriate and timely.
26
•Evaluation of organization and role competencies: should be able to care
for multiple patients, prioritize care, work well with other team members,
display a caring attitude, and act as a resource to other nurses.
The six areas of assessment included in Schwirian’s (1978) 6-DSNP can be
identified in the roles outlined by Benner (1984). The leadership role assessed by
Schwirian is included in the evaluation and role competencies described by Benner. The
critical care nursing performance assessed by Schwirian is described in the effective
management of change role described by Benner. Schwirian assesses for teaching and
collaboration in her six dimensions, and Benner described this as nursing responsibilities
in the teaching role. Schwirian assesses for nurses’ ability to plan and evaluate, which is
described in three of Benner’s roles: effective management of change, monitoring of
quality practice, and evaluation of organization and role competencies. Interpersonal
relations and communications that Schwirian has included in her assessment are included
in Benner’s teaching and helping roles. Finally, Schwirian included an evaluation for
professional development in her assessment tool that is evident in Benner’s evaluation of
organization and role competencies.
Application of Benner’s theory will be useful to help determine the current stage
of learning for novice nurses and will help hospital nurse leaders establish a learning plan
that will help novice nurse develop nursing knowledge that must be developed during the
transition period. I used this theory to aid in developing an improved understanding about
the beliefs of these two stakeholders, where they agree or disagree on the level of
competencies for novice nurses in transition. Novice nurses must adapt to their new
27
environment and depend on adequate preparation by nursing educators to pass the
NCLEX exam as well as retain the tools needed to have a successful transition into
practice. Novice nurses also depend on the support and guidance of hospital nurse leaders
who have set expectations and access to support that will ease the process during the
transition period. Stakeholders need to understand how novice nurses will learn and adapt
to their new environment. Benner’s (1982) theory posits that novice nurses will gain
proficiency in stages with time and experience. The use of deductive research on
transition to practice in the literature has supported Benner’s theory for the development
of skills in novice practitioners. Benner’s theory can be used as a guide for nurse
educators and nurse hospital leaders to build a mutual understanding of what stage a
novice nurse is in when entering professional nursing practice (Carlson, Crawford, &
Contrades,1989; Schoessler & Waldo, 2006).
Notably, application of Benner’s theory has been widely accepted and has
influenced how the matriculation of knowledge is gained in the science of nursing. The
following studies demonstrate confirmation that the novice to expert theory continues to
apply. Chappell, Richards, and Barnett (2014) used Benner’s theory as a framework to
establish the development of leadership skills in new graduate nurses by applying the
novice to expert theory on experience over time. Chappell et al. (2014) used hierarchical
regression modeling to assess predictors of the development of leadership skills in
relation to the use of transition programs in this population. They found that nurses who
participated in new graduate nurse transition programs, with a duration of at least 24
28
weeks, were 21 times more likely to remain employed compared to new graduate nurses
who participated in programs that were 12 weeks or less.
Substantial examples exist that show Benner’s theory in use. Dale et al. (2013)
applied Benner’s proficiency levels to develop an evaluation tool that would ensure
advanced practice professionals were consistently meeting their job expectations.
Benner’s theory has also been applied to education. Carlson, Crawford, and Contrades
(1989) used Benner’s novice to expert model to help nursing educators and students see
their ability to acquire clinical skills as a development process. Schoessler and Waldo
(2006) used three theories, including Benner’s novice to expert theory, to provide an
understanding of the developmental experience of novice nurses. Their framework used
reflection of the lived experiences of novice nurses in the first 18 months of practice
(Schoessler & Waldo, 2006). The resulting process model can help new graduate nurses
understand novice to expert skill acquisition, adult learning, and more about the transition
process. The process model Schoessler and Waldo developed also allowed organizations
to develop appropriate strategies to support this novice nurse population.
Articulation of knowledge in the first year of practice and the ability to function in
a safe and effective manner when providing care are essential elements for novice nurses.
Ongoing debates between health and education providers continue regarding baseline
requirements and the factors that determine practice readiness (El Haddad et al., 2017).
Student nurses depend on clinical educators to provide practice education by exposing
them to situations where they will gain clinical experience (Benner, 2004). I chose
Benner’s model because it provides a framework for the stages experienced by novice
29
nurses as they develop proficiency, and it can be used to evaluate their current level of
functioning (Benner, 1984, 2004).
Benner’s theory establishes a set of standards for nursing educators and hospital
nurse leaders in determining the level of preparedness for entry-level practice.
Schwirian’s 6-DSNP uses a survey to compare areas that are essential to practice for a
novice nurse and will allow stakeholders to establish expectations in each area. The
survey examines five expectations on frequency and quality of performance of essential
nursing behaviors: (a) leadership, (b) critical care, (c) teaching and collaboration, (d)
planning and evaluation, and (e) interpersonal relations and communication. The sixth
area include in the survey examines the expectation for professional development
performance (Schwirian, 1978). Expectations for novice nurses should be influenced by
Benner’s (1984) novice to expert theory to help mitigate the required standard level of
performance.
Literature Review Related to Key Variables and Concepts
In this literature review, I will examine current studies related to readiness to
practice and dissidence in beliefs between nursing educators and hospital nurse leaders. I
will include articles that are related to transition to practice including the theory practice
gap, competence, and transition programs. The following key terms are essential elements
that pertain to the theory-practice gap problem.
30
Theory-Practice Gap
The theory-practice gap is an ongoing phenomenon that has been highly
recognized in the literature and attempts to explain the difficulties that novice nurses
experience in the beginning of their career (Armstrong, 1974: AL- Dossary et al., 2014;
El Haddad et al., 2017; Innes & Calleja, 2018; Patterson, Boyd, & Mnatzaganian, 2017).
The theory practice gap can be further explained as the disparity that is observed in
novice nurses between the knowledge gained in the classroom and the performance in the
clinical setting (Akram, Mohamad, & Akram, 2018; Berkow, 2009). The knowledge
gained in the classroom should be used to maximize the novice nurse’s performance in
the clinical setting (Factor, Matienzo, & de Guzman, 2017). Akram et al. (2018)
performed a descriptive quantitative cross-sectional study to identify nursing student’s
perception of the knowledge practice gap. In this study, the researchers identified that the
clinical instructor plays a pivotal role in the student’s connection of theory material
presented in the classroom and the application of this knowledge in the clinical setting
(mean 3.6, t = 14.6) (Akram et al., 2018). Akram et al. (2018) found that nursing
instructors need to remain updated on current clinical practice and create a positive
learning environment that fosters the development of clinical connections. Additional
problems that are experienced during the theory-practice gap include problems with
competence, confidence, building peer relationships, and job satisfaction (Innes & Calleja
2018; Spence Laschinger, Zhu, & Read, 2016). The identified problems are the result of a
lack of experience that builds the nurses ability to apply role-related knowledge, skills,
and critically thinking when delivering patient care (Innes & Calleja, 2018). Novice
31
nurses may be described as ineffective; however, this viewpoint may be based on unreal
and unreasonable expectations (Brown et al., 2015).
Readiness for Practice
Nursing educators strive to prepare students that are work ready (Baldwin et al.,
2014, El Haddad et al., 2017). El Haddad et al. (2017) states that fitness to practice or
work readiness is unformulated and these researchers’ question who the appropriate
stakeholder is to define this construct. Nursing educators prepare novice nurses to
successfully perform in the real-world setting (Missen et al., 2018). Nursing educators
attempt to accomplish this by employing several teaching strategies to improve clinical
judgement and performance in the clinical setting including reflective journaling,
simulation, and shadowing nurses in the clinical setting that model the desired
professional behaviors (Bennett, 2017, Bussard, 2015, 2018). Bennett (2017) found that
nursing students practice in the clinical setting with a limited number of patients and are
not exposed to opportunities that will help them learn to prioritize care. This absence of
exposure to real life situations that require dealing with multiple patient care issues at the
same time is an area that could be reviewed and addressed by nursing educators (Bennett,
2017). Radford (2018) conducted a study to determine if high fidelity simulation could be
used as an alternative in a rural area where colleges of nursing were challenged by the
decreased number of clinical opportunities in their area. This researcher found that
simulation can assist students to improve their clinical judgement skills and confidence
with simulated patient scenarios (Liljedahl et al., 2016). Currently, the state board of
nursing allows simulation to replace 50 % of traditional clinical hours (Radford, 2018).
32
New graduate nurses are expected to perform skills at the onset of practice in a complex
care environment, including the ability to interpret the patient’s response, prioritize care,
and proficiently communicate to the healthcare team (Bridges et al., 2014, Brown et al.,
2015). It is important for novice nurses to be aware of their current level of competency,
areas in their practice where they need to improve, and the importance of continuing
education to maintain their current practice (Theisen & Sandau, 2013).
Educators develop program outcomes as a framework to ensure that novice nurses
develop competencies that align with the expectations expected by the board of nursing,
employers, and the community (Baldwin et al., 2014). Baldwin et al. (2014) suggested
that more graduate attributes need to be added that more closely resemble the set of
competencies required for novice nurses to enter the workplace prepared. Numminen et
al. (2014) evaluated nursing program educational outcomes to determine if these
outcomes met the requirements of nursing practice. The aim of the study was to find areas
where competency differences existed utilizing the Nurse Competency Scale (Numminen
et al., 2014). Numminen (2014) identified that educators and managers have different set
benchmarks for the desired novice nurse competency (Numminen et al., 2014). The
viewpoint of these two stakeholders was determined to be different with educators
viewing competence from the standpoint of achieving a basic nursing education and
managers viewing competence from the desired needs for the novice nurse to succeed in
clinical practice (Numminen et al., 2014).
Hospital nurse leaders desire to have nurses that can seamlessly transition into the
workforce (El Haddad et al., 2017). According to stakeholders, from the hospital nurse
33
leaders’ perspective, novice nurses need to be able to successfully perform the anticipated
competencies with the desired outcomes in the real-world setting (Missen et al., 2018).
Performance also requires that novice nurses are equipped with the necessary knowledge
and critical thinking necessary to provide quality care to their patients (Bussard, 2018,
Missen et al., 2016). When novice nurses start the transition process hospital nurse
leaders and novice nurses assess and identify deficits in their competencies and
knowledge and recognize that additional training is needed to meet their job performance
requirements (Bridges et al., 2014, Numminen et al., 2014, Theisen & Sandau, 2013).
Hospital nurse leaders attempt to improve the transition period by providing nurse
residency programs, simulation, debriefing, nursing preceptors, and evaluation tools to
accurately measure nursing performance (Theisen & Sandau, 2013). Meaningful
collaboration by both nursing educators and hospital nurse leaders would improve the
focus held by each stakeholder and hopefully result in collaboration to improve the
dissidence that currently exists (El Haddad et al., 2017).
Novice nurse’s readiness to practice has been examined employing tools that
measure self-competency (Patterson et al., 2017, Roud, Giddings, & Koziol-McLain,
2005, Woods et al., 2015). Woods et al. (2015) used Casey-Fink’s readiness tool in a
descriptive quantitative study to compare the perceptions of third-year nursing students in
their final semester. Woods et al. (2015) found that 88.8% of the students reported feeling
prepared for practice. The students in this study stated that smaller clinical groups and
expanded clinical placement were beneficial measures for enhancing student confidence.
Roud, Giddings, and Koziol-McLain (2005) used a modified version of Schwirian’s
34
(1978) 6-DSNP to quantify self-reported changes in the six domains of nursing skills that
are essential to practice over time. Several studies have previously used Schwirian’s tool
to compare the performance of new graduates (Rafferty & Lindell, 2011, Roud et al.,
2005). The outcome for Roud et al. (2005) was consistent with the previous research that
used Schwirian’s tool. The Cronbach’s alpha or alpha coefficient was calculated to
determine internal consistency (Roud et al., 2005). The Cronbach’s alpha reported in this
study was 0.60 – 0.74 (Roud et al., 2005). This study was limited by the use of one single
cohort of new graduates (Roud et al., 2005).
Active involvement in the clinical setting is needed to practice skills and develop
proficiency (Patterson et al., 2017). However, several studies examined the shortage of
clinical sites that resulted in unmet clinical learning objectives (Radford, 2018, Parsh,
2010). Multiple nursing schools compete for clinical placement for their students due to
limited availability (Radford, 2018). Alternatively, simulation can be used to replicate
clinical situations that may not be encountered in the actual clinical setting (Radford,
2018). The use of simulation in several studies was determined to increase the student’s
confidence and could be used to offer common scenarios that would be encountered in
the clinical setting (Radford, 2018, Woods et al., 2015).
Competence in Nursing Practice
Competence in nursing is an expectation of practice. It can take a novice nurse
several years to gain the necessary situational experience needed to be considered a
competent practitioner (Benner, 1984). Novice nurses enter practice as advanced
beginners and do not display the speed or flexibility of nurses at the proficient or expert
35
levels (Benner, 1984). A competency assessment during the orientation period identifies
the novice nurse’s strengths and weaknesses (Numminen et al., 2014). Only one
quantitative cross-sectional study was identified in the literature that used nursing
educators and nursing managers to determine if educational outcomes met the needs of
nursing practice and used the Nurse Competence Scale that was based on Benner’s model
(Numminen et al., 2014). Numminen et al. (2014) found that nursing educators rated the
level of competency for novice nurses as higher than the nursing managers.
The expectations of a baccalaureate novice nurse have been outlined in an
organizational framework called the Baccalaureate Big 5 (Martin et al., 2015). The
Baccalaureate Big 5 incorporated the following essential elements: (a) nursing across the
lifespan, (b) professional identity and communication, (c) leadership, (d) population
health, and (e) use of evidence-based practice and quality improvement (Martin et al.,
2015). The Big 5 is a framework can be used to guide for curriculum and as a framework
for expectations of practice (Martin et al., 2015). Sortedahl, Persinger, Sobtzak, Farrell,
and Jaeger (2017) surveyed hospital nurse leaders were surveyed to assess the following
skills: change, communication, conflict, leadership, and self-awareness. Sortedahl et al.
(2017) used a one-way ANOVA to determine statistical significance between the variables
and found that the participants reported communication was ranked as the most important
skill. The remaining skills ranked in the following descending order: selfawareness,
change, leadership, and finally conflict (Sortedahl et al., 2017).
Collaboration between the stakeholders, nursing educators and hospital nurse
leaders, is needed to ensure that novice nurses are adequately prepared and have the
36
support during the transition into practice process to be successful (Berkow et al., 2009).
The Nurse Executive Center [NEC] (2007) used the new graduate nurse performance
survey to assist these two major stakeholders in the identification of specific nursing
competencies that address the theory-practice gap. The researcher had stakeholders rate
proficiency on 36 competencies and found that 25% of nurse leaders are satisfied with
new graduate nurse performance. The new graduates experienced the greatest difficulty
with management of responsibilities. The outcome of this study identified weaknesses in
practice that can be addressed by both academia and health systems to develop ways to
strengthen these areas of practice (NEC, 2007).
Missen, McKenna, Beauchamp, and Larkins (2016) assessed the perceptions of
qualified nurses evaluating the abilities of new nurses for a variety of skills. This
descriptive quantitative study used a survey to determine new nursing graduate abilities
rated on a 5-point Likert scale (Missen et al., 2016). Results from this study demonstrated
that the seasoned nurses determined that 35.5% of skills were rated as good or very good
and 33.3% of skills were rated as adequate. However, 31.4% of skills were rated as
poorly or very poorly performed (Missen et al., 2016). The identified areas of concern
included critical thinking, problem solving, working independently, and assessment
procedures (Missen et al., 2016). Missen et al. (2016) identified areas that nursing
educators can examine and enhance in the nursing curricula to ensure adequate
preparation is provided.
A qualitative study by Brown, Crookes, and Iverson (2015) used an analysis of the
curriculum to document and identified 30 skill areas that included: communication,
37
teamwork, leadership, and supervision. The researchers determined that inadequate time
to demonstrate and practice these skills was a factor that limited skill development
(Brown et al., 2015). These studies have added valuable information regarding
deficiencies that need to be addressed in both nursing curriculum and improvement to the
supportive methods used during the onboarding process. However, the current studies in
the literature are deficient in examining the comparative views of both nursing educators
and hospital nurse leaders in relation to skill expectations. The development of a common
understanding for both stakeholders would help to clarify expectations for nursing
educators, hospital nurse leaders, and for novice nurses that are entering practice.
Transition Programs
Transition programs have been developed to assist new graduate nurses during
this period to make transition to practice successful (Innes & Calleja, 2018; Theisen &
Sandau, 2013). Identified competencies that needed to be reinforced included:
communication, leadership, organization, critical thinking, and stress management
(Theisen & Sandau, 2013). Strategies that have been used to address these areas include
nursing orientation, residency programs, simulation, debriefing, and the use of preceptors
to facilitate the transition period (Theisen & Sandau, 2013). A study by Silvestre, Ulrich,
Johnson, Spector, and Blegen (2017) reviewed the onboarding process and discovered
that 26 of the 44 sites did not have a structured curriculum. Orientation programs cost
facilities money to run and maintain but the research from this study indicated that the
cost savings for retention of each new hire is a worthwhile investment (Silvestre et al.,
2017). One recommendation from this study is for hospitals to create partnerships with
38
other facilities to decrease overall onboarding and orientation costs (Silvestre et al.,
2017). Formal training programs to provide education for preceptors and mentors has
been used to enhance and standardize the support that novice nurses will receive (Theisen
& Sandau, 2013).
Innovative measures that have been implemented to improve the success of novice
nurses include specialized classes, programs to ensure professional socialization, and
pathways to assist novice nurses with their career goals and path for professional growth
(Bridges et al., 2014, Mauro et al., 2016). A study by Laschinger et al. (2016) used a
survey to determine factors that would help predict career satisfaction and decrease job
turn-over rate for new nurses. Laschinger et al. (2016) determined from the qualitative
portion of this study that job satisfaction is highly linked to working conditions. The
researchers concluded that support for new graduates can influence jobrelated retention
(Laschinger et al., 2016).
Other types of support that are documented in the literature include programs that
provide preceptors and mentors during the transition period (AL-Dossary et al., 2014,
Gueorguieva et al., 2016, Mauro et al., 2016, Nielsen et al., 2016). Nielsen, Lasater, and
Stock (2016) conducted a qualitative study that used the Lasater clinical judgement rubric
as a framework for evaluation during the orientation process. The use of this rubric
allowed novice nurses to visualize and track their progress (Nielsen et al., 2016). The
researchers also suggested the use of this tool for assessment of pre-licensure students to
improve the student’s ability to build their clinical judgement and clinical reasoning skills
(Lasater et al., 2016). Many novice nurses will begin their practice in a specialty area that
39
will require additional support. A literature review by Innes and Callaja (2018) explored
the support that is offered to these novice nurses. These researchers found successful
transition to specialty areas should be supported by transition programs that will help the
novice nurse build confidence and competence (Innes & Callaja, 2018). Several factors
are also crucial to the success of these novice nurses including a dedicated resource
person, an environment of overall support, a positive work culture, socialization into the
workplace, and use of simulation and repetition of skills (Innes & Callaja, 2018). These
measures provide the resources, mentoring, and support for novice nurses to improve and
succeed in their new positions. However, despite these interventions, the theory-practice
gap continues to effect novice nurses at the start of their careers.
Summary and Conclusions
In Chapter 2, I provided a review of the theoretical foundation including
application to current studies and a literature review related to key variables and concepts.
The literature reviewed supports the fact that there is a dissidence in beliefs between
nursing educators and hospital nurse leaders for readiness to practice for the novice nurse.
However, the congruence between nursing educators and hospital nurse leaders’ views on
level expectations on skills readiness for practice that would promote success for novice
nurse during their transition into practice is not known.
Research has focused on the novice nurse’s view or a unilateral view of nursing
managers. Communication between the nursing educators and hospital nurse leaders is
deficient and must be improved so that both stakeholders are able to make appropriate
changes that will support novice nurses’ ability to be successful (AL-Dossary et al.,2014;
40
Berkow et al., 2009). My study could fill a gap in the literature by providing comparative
views of nursing educators and hospital nurse leaders on the desired competencies for
novice nurses entering practice to address the gap in the literature. The following
dependent variables: leadership, critical care, teaching/collaboration, planning/evaluation,
interpersonal relations/communication, and professional development will be evaluated in
conjunction with the independent variable, nursing educators’ beliefs and hospital nurse
leaders’ beliefs about novice nurse performance. The outcome of this study may be used
to develop policy changes for transition programs in the clinical setting and curriculum
changes in the academic setting. Chapter 3 provides a review of the research methods
including the design, population, sampling, recruitment, data collection, instrumentation,
data analysis plan, and threats to validity.
Chapter 3: Research Method
Introduction
The purpose of this quantitative descriptive study was to determine whether a
significant difference exists between hospital nurse leaders’ and nursing educators’ beliefs
about the frequency and competency levels of novice nurses transitioning into practice in
the following areas: (a) leadership, (b) critical care nursing performance, (c) teaching and
collaboration, (d) ability to plan and evaluate (e) interpersonal relations and
communications, and (f) professional development. In Chapter 3, I present a review of the
research design and a formal description of the components that comprise the
methodology, including threats to validity.
41
Research Design and Rationale
Using a descriptive, nonexperimental design, I gathered survey data to compare
the beliefs of nursing educators and hospital nurse leaders. The survey I used was a
modified Schwirian’s 6-DSNP, which allowed me to gather data about the beliefs of these
two major stakeholders. I used a MANOVA to test for differences in the means of hospital
nurse leaders’ beliefs and nursing educators’ beliefs on the two dependent variables that
were the frequency and level of performance needed by novice nurses transitioning into
practice as outlined in the first five dimensions in Schwirian’s assessment tool (Polit &
Beck, 2018; Schwirian, 1978). Schwirian’s sixth dimension only assesses the level of
performance needed for professional development; therefore, I conducted an independent
t test on this last dimension to test for significance (Polit &
Beck, 2018).
The independent variables were nursing educators and hospital nurse leaders. The
dependent variables were the frequency and level of competency based on the
performance measures in Schwirian’s 6-DSNP survey. The frequency of the nursing
behavior was scored using a four-point Likert scale with the following values: 1 = never,
not expected in this job; 2 = seldom; 3 = occasional; and 4 = frequently. The expected
level of performance was measured on a Likert scale with the following values: 1 = not
very well, 2 = satisfactory, 3 = well, and 4 = very well.
Table 1
Dependent, Continuous Variables on the Schwirian’s Six-Dimension Tool
Variable name # of questions
Leadership 5
42
Critical care 7
Teaching, collaboration 11
Planning, evaluating 7
Intrapersonal relations, communication 12
Professional development 10
A survey is the best research method to gather data on stakeholders’ beliefs that
cannot be observed (Schwirian, 1978). Using a survey allowed me to collect data from a
large group of participants who met the qualifications for this study. Surveys are a
costeffective method of gathering convenience data from the intended population and
allowed me to generalize my findings from this sample to the larger population with the
expectation of adding information to the science of nursing to help address a gap in the
literature.
Methodology
Population
The population of interest for this study was nursing educators and hospital nurse
leaders. Hospital nurse leaders were further defined as nursing educators working in the
hospital setting, nursing managers, and preceptors for novice nurses. The sample was
drawn from participants that responded to my survey flyer that was sent to them my email
or in response to the flyer that was posted on a social media site. In addition, respondents
to the study were asked to refer and share the link to the study with qualified
RNs.
Sampling and Sampling Procedures
I used a nonprobability sampling approach for this study. I gained access to this
population through two methods: convenience and snowball sampling. First, I obtained a
43
convenience sample by recruiting qualified participants by email and through a social
media site. The second method involved peer-to-peer recruitment using a snowball
sampling technique.
The calculated sample size was 49 nursing educators and 49 hospital nurse leaders
based on G*Power analysis to determine sufficient sample size. I used Faul, Erdfelder,
Lang, and Buchner’s (2007) G*Power 3.1.9.2. to determine the sample size using a
medium 0.15 effect, the significance level of alpha 0.05, the power 0.80, which yielded a
sample size of 98 participants (Cohen, 1988).
Inclusion criteria were the following: nurses working in an academic setting as
nurse educators or nurses working in the hospital as nurse managers, nurse hospital
educators, or nurse preceptors who work with novice nurses entering the beginning stage
of practice. All participants were RNs with at least 1 year of experience in their current
job role. Retired RNs were excluded from the study. Eligibility to participate in the study
was verified through screening questions and an electronic informed consent at the
beginning of the electronic survey (Appendix D).
Procedures
Recruitment. I emailed my flyer to licensed registered nurses that were obtained
from the Ohio and Florida board of nursing. The list of licensed nurses is available to the
public upon request from both states. The flyer for my study was also posted on a social
media site to recruit participants. All participants were asked to share the flyer with the
link to the study with their peers who would also meet the study requirements. I collected
demographic information from each potential participant, including (a) type of
44
participant, i.e., either nursing educator or hospital nurse leader, (b) gender, (c) age, (d)
ethnicity, (e) education, (f) years of practice as an RN, and (g) length of time in current
nursing position (Appendix E).
Participation. All participants were provided an electronic informed consent prior
to beginning the online survey. Completion of the survey was voluntary, and informed
consent was implied when the participant completed the survey. The informed consent
stated the participant could withdraw from the study at any time prior to completing the
study. The consent included a description of the study as a part of the fulfillment of a
dissertation for Walden University, identified me as the researcher, and explained the
benefits and risks of participation. Participants’ anonymity was guaranteed, and names
were not collected. The next part of the survey included eligibility screening questions
and a demographics questionnaire (Appendixes D and E). If the participant did not meet
the eligibility screening questions, the survey ended. If the participant did meet the
inclusion criteria reviewed in the eligibility screening, then the questionnaire advanced
the demographic questions including (a) type of participant, i.e., either nursing educator
or hospital nurse leader, (b) gender, (c) age, (d) ethnicity, (e) education, (f) years of
practice as an RN, and (g) length of time in current nursing position (Appendix E). The
last part of the questionnaire advanced to a modified version of the Schwirian’s 6-DSNP
(Appendix C).When all questions were answered, a final screen thanked the participant
for their input and included my name, phone number, and email address if they had
questions about their participation in the study (Appendix F).
45
Data Collection. I recruited participants by posting my research flier with
information about my study and the link to the survey on a social media site and I sent my
flyer by email to registered nurses in Ohio and Florida. In addition, I asked all
participants to share the link with other possible participants who would qualify for this
study. I collected data from the survey using a secure internet-based survey company. The
data were collected anonymously. Participants were able to opt out of the survey by
ending their participation any time prior to selecting a final submission button at the end
of the survey. Participants could access the survey at any time or place of their choosing
within the time period when the survey was open and available. The data obtained from
this survey are stored in a password-protected account. Once data collection was
completed, the data were transferred to SPSS and stored on a password-protected
computer that will be maintained for 5 years from the date of my doctoral degree
completion. When this period has expired, the data will be deleted. Follow up is not
warranted for this study design.
Instrumentation and Operationalization of Constructs
I modified Schwirian’s 6-DSNP for my survey. The 6-DSNP has established
reliability and validity. The Cronbach’s alpha ranged from 0.84–0.90. Schwirian
developed this pioneering tool to quantify observable nursing performance. The 6-DSNP
is a 52-item inventory rated on a 4-point Likert scale. The first 42 items are scored twice:
once for the frequency of the behavior being evaluated and the second evaluation
representing the quality desired for each behavior. This nursing performance tool was
developed by Schwirian in 1978 to be used for self-performance appraisals or evaluation
46
by employers. The tool has been found to be highly reliable in evaluation of all six
dimensions that were intended and is suitable for evaluation and research (Schwirian,
1978). I obtained written permission from Schwirian to use and modify her scale as
needed for my study. A copy of Schwirian’s original tool is included in Appendix A. A
copy of the modified tool I used in this study is in Appendix B.
The language in some items of the tool was modified to appropriately reflect the
population being assessed. For example, the question in Column A was revised from How
often does this nurse perform these activities in his/her current job? to How often does
the novice nurse perform these activities in his/her current job? The question in Column
B was revised from How well does the nurse perform these activities in his/her current
job? to How well should the novice nurse perform these activities in his/her current job?
Terminology in the tool was updated. For example, the terms in Question 18, Gomco,
respirator, and cardiac monitor were deleted, and IV pump and PCA pump were added to
Question 18. This tool, with these minor modifications, allowed me to examine if
differences existed between two major stakeholders, and the use of quantitative methods
allowed me to identify the degree to which these stakeholders’ beliefs are in alignment on
a Likert scale. Construct validity was re-established through expert review by five peers,
and validity was reconfirmed post hoc using confirmatory analysis. The Cronbach’s alpha
for the original 6-DSNP ranged from 0.84 to 0.90 when used in Schwirian’s (1978) initial
research when the tool was used for employer appraisals.
Historically, various modifications have been made to the Schwirian instrument
without affecting the validity and reliability of this tool. The term Gomco was deleted
47
from Question 18 and replaced with the term suction machines in a study by Mrayyan
and Al-Faouri (2008). The term infusion devices was added to the tool previously in a
study by Rafferty and Lindell (2011), with a reported Cronbach’s alpha ranging from 0.91
to 0.92 (Rafferty & Lindell, 2011). In a study by Roud et al. (2005), modifications were
made to the verbiage to ensure applicability, readability, and appropriateness, and they
used a four-step procedure for content validation. Five experts in this study were
responsible for the changes (Roud et al., 2005). The reported reliability coefficient
measuring internal consistency, Cronbach’s alpha, ranged from 0.62 to 0.74 (Roud et al.,
2005).
Schwirian’s (1978) initial research developed an appraisal tool to evaluate the
frequency and quality of nursing performance that was used in her study of graduate
nurses as a self-evaluation and by their employers to provide a quantitative comparison.
Other studies also used this tool in the same manner, investigating nursing behaviors
examined by both graduates and their employers (Bellinger & McCloskey, 1992; Failla,
Maher, & Duffy, 1999). Roud et al. (2005) used Schwirian’s tool to evaluate and quantify
self-reported changes over time in a cohort of newly graduated nurses.
Schwirian’s 6-DSNP tool has established reliability and validity. Cronbach’s alpha
was used to establish reliability estimates and ranged from 0.84 to 0.90 (Schwirian,
1978). Construct validity was verified by expert review and validity was established
when use of Schwirian’s tool (1978) identified low and high nursing performers in
subsequent field testing. The 6-DSNP is a useful tool for measuring performance in
48
periods of transition for both nurses self-reporting and performance evaluation by
employers (Battersby & Hemmings, 1991, Dyess & Parker, 2012, Rafferty & Lindell,
2011, Schwirian, 1978;).
Data Analysis Plan
The data analysis was completed using IBM SPSS Statistics software, version 25
(IBM Corp., 2017). The data were entered into SPSS, version 25, where the variable will
be named, typed as numeric, width and decimal places set, labeled, responses set, missing
values coded as –999, column size set and type of variable set (scale, ordinal, nominal).
Once the data were entered, frequency tables were run to check for missing values and
incorrect or impossible values (Osborne, 2013). Then, box plots were produced to check
for significant outliers.
The demographic data were analyzed using descriptive statistics (Sheskin, 2011).
The demographic data included data on status of nursing educator or hospital nurse leader
(nominal); gender (nominal); age (ratio); ethnicity (nominal); education as ASN, BSN,
master’s degree, DNP, or PhD (nominal); years of practice as an RN (ratio); and length in
current position (ratio). Nominal data are presented in tables with frequency and percent
(Sheskin, 2011). Ratio data are presented in tables with means and standard deviations
(Sheskin, 2011).
The survey was a modification of Schwirian’s 6-DSNP tool that allowed me to
gather data about the beliefs of these two major stakeholders. The use of a MANOVA
allowed me to determine whether significant differences exist between nursing educators’
beliefs and hospital nurse leaders’ beliefs and level of performance of leadership, critical
49
care, teaching and collaboration, planning and evaluating, and interpersonal relations and
communication (Schwirian, 1978: Sheskin, 2011). The use of MANOVA was used to test
the null and alternative hypothesis for the first five questions in this research study. The
following assumptions were met normal distribution, linearity, homogeneity of variances,
and homoscedasticity. This quantitative analysis was aligned with the following five
research questions and hypothesis;
RQ1: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing performance
needed by novice nurses transitioning into practice?
H01: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
Ha1: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
RQ2: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing performance
needed by novice nurses transitioning into practice?
H02: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
50
Ha2: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
RQ3: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice?
H03: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
Ha3: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
RQ4: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate needed by
novice nurses transitioning into practice?
H04: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
Ha4: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
51
RQ5: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice?
H05: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice.
Ha5: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice.
RQ6: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance needed by
novice nurses transitioning into practice?
H06: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
Ha6: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
Threats to Validity
It is essential that the researcher ensures the accuracy and consistency of the
research instrument that is being used in a study. Validity is the accurate measurement of
a concept that is under investigation (Heale & Twycross, 2015). Reliability measures
52
accuracy and the ability to have consistent results with repeated measures (Heale, &
Twycross, 2015). Schwirian’s 6-DSNP tool aligned with the research questions in this
study and has a history of established validity and reliability (Schwirian, 1978).
Schwirian’s tool demonstrated highly reliability with a Cronbach’s alpha coefficient from
0.84 to 0.90 for nursing performance on the subscale as evaluated by employer appraisals
(Schwirian, 1978). These results demonstrate the usefulness of the tool to assess nursing
performance. The following is a review of threats to validity in my study.
External Validity
Replication of a study is one way to assess for external validity (Lehmann &
Bengart, 2016). The use of Schwirian’s 6-DSNP tool have been used successfully in
several studies (Rafferty & Lindell, 2011, Roud et al., 2005). Two factors posed a threat
to the external validity: the number of participants in the study and the need to receive an
adequate number of responses from each group identified in the study and the sampling
method. A sample size that does not meet power analysis calculations or an uneven
amount of responses between the two groups would alter the external validity and my
ability to generalize the results to the larger populations that are represented in the study.
An adequate number of participants were needed in each group to adequately represent
each group and to ensure effect and equal representation of each type of group in the
study. Post hoc analysis could help to improve the external validity by isolating the
differences between group means if the number of responses from each group is not
equal. The second concern was the use of a convenience sampling technique in this study
may not be a true representation of the generalized population. Random selection would
53
minimize this threat. However, this method was not chosen to ensure an adequate sample
was achieved to ensure demonstration of significance.
Internal Validity
Examination of internal validity helps to ensure accuracy and strength of the
evidence (Bolarinwa, 2015). The data obtained were reviewed for accuracy and
completeness. The use of a MANOVA helped me determine the strength of the evidence
by determining the significance between two groups. Confounding variables can
influence the outcome of a study and can make difficult to make a clear causal link
(Skelly, Dettori, & Brodt, 2012). Confounding variable were not assessed but could have
affected the study outcome. Additional identified threats of internal validity included
changes in the environment where the participant completes the survey, physical or
mental changes in the participants, instrumentation or survey construction, absence of
randomization, and absence of consistency within groups. The survey was available for
the participants to take at their convenience but, were limited by the time frame of
availability for the study.
Construct Validity
Construct validity is defined as how meaningful a research tool is in practical use
and measures the intended construct so that the researcher can make conclusions based on
the study results (Bolarinwa, 2015; Heale, & Twycross, 2015). Construct validity related
to my ability to accurately obtain the beliefs about competency levels for novice nurse
from the major stakeholders that participate in this study. Construct validity was
previously established for the Schwirian’s 6-DSNP tool (Schwirian, 1978). Modifications
54
to the tool could have threatened the established construct validity. However, construct
validity was re-established by expert review and validity was re-confirmed post hoc using
confirmatory analysis. The original 6-DSNP tool, (Appendix A), and the modified
6DSNP tool can be found in Appendix B. Rafferty et al. (2011) used a modified version
of
Schwirian’s instrument with a reported Cronbach’s alpha ranging from 0.91 to 0.92.
Rafferty (2011) also modified Question 18 in the survey to update the terminology.
Ethical Procedures
Potential ethical concerns for my study were identified. The study was submitted
for approval to the Walden University Institutional Review Board (IRB). The approval
process ensured the protection of human participants. No data were collected until IRB
approval was obtained. I completed human research protection training. No vulnerable
populations were used in this study. This study had minimal to no potential risk to the
participants that volunteer for this study. There were no potential conflicts of interest
identified or ethical concern regarding data collection methods described in this study.
An informed consent was used to obtain each participant’s consent to partake in
this study. The informed consent explained the purpose of the research study, the benefits
of participation, level of risk for each participant, measure taken for the participant’s
confidentiality, the participant’s ability to withdraw from the study at any time prior to
survey submission, and finally how to contact me if any questions or issues arose after
participation in the study. I ensured the anonymity of the participants would be
maintained.
55
Summary
In this chapter, the use of Schwarian’s 6-DSNP tool to appraise novice nursing
performance was reviewed. A one-way MANOVA with global effects and an independent
t test were the statistical methods that were used to determine if there was a difference in
beliefs in the two major stakeholders in this research study. The use of these statistical
method aligned with the purpose of this research and helped me answer the null and
alternative hypothesis in this study. The threats to validity were reviewed for
transparency. Finally, measures to ensure the ethical procedures were followed during this
study were reviewed. Chapter 4 provides a review of the data collection, results, and a
summary of the answers to the research questions.
56
Chapter 4: Results
Introduction
The purpose of this descriptive quantitative study was to determine whether a
difference exists between hospital nurse leaders’ and nursing educators’ beliefs about the
frequency and competency levels of novice nurses transitioning into practice, in the
following areas: (a) leadership, (b) critical care nursing performance, (c) teaching and
collaboration, (d) ability to plan and evaluate (e) interpersonal relations and
communications, and (f) professional development. The following are the research
questions and hypotheses for this study:
RQ1: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing performance
needed by novice nurses transitioning into practice?
H01: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
Ha1: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
RQ2: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing performance
needed by novice nurses transitioning into practice?
57
H02: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
Ha2: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
RQ3: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice?
H03: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
Ha3: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
RQ4: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate needed by
novice nurses transitioning into practice?
H04: There is no difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
58
Ha4: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
RQ5: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice? H05:
There is no difference between hospital nurse leaders’ beliefs and nursing educators’
beliefs about the frequency and level of interpersonal relations and communications
performance needed by novice nurses transitioning into practice. Ha5: There is a
difference between hospital nurse beliefs and nursing educators’ beliefs about the
frequency and level of interpersonal relations and communications performance needed
by novice nurses transitioning into practice.
RQ6: What is the difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance needed by
novice nurses transitioning into practice?
H06: There is no difference between hospital nurse leaders’ beliefs nursing
educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
Ha6: There is a difference between hospital nurse leaders’ beliefs and nursing
educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
59
In Chapter 4, I present a review of data collection, changes in the data collection
methods, descriptive and demographic characteristics of the sample, statistical
assumptions, a review of the research questions and hypothesis testing, and the analyses
of the research questions and hypotheses testing. I also review the data analysis and a
summary of the study findings.
Data Collection
Data collection via an online survey website began on February 1, 2019 and
concluded on March 19, 2019. Because the survey was anonymous, participants did not
receive a follow-up email. Based on 142 potential participants who responded to the
survey, only 104 participants returned the completed survey and met the study
qualifications, resulting in a 75% response rate. The study flier was emailed to 4,021
possible participants; 36 emails were undeliverable due to an inaccurate email address,
yielding a 4% response rate. Thirty-eight of the responses were not included as they did
not meet the criteria for inclusion because participants were retired from nursing, had less
than 1 year in their current position, or they did not complete the entire survey.
Initially, the survey was scheduled to be posted for only 30 days. However, the
survey was extended by an additional 19 days to ensure that the required number of
participants was reached. I had planned to recruit participants at two nursing conferences,
but I was not able to recruit at either of these conferences because IRB approval was not
obtained in time. I submitted a change in procedures to the IRB and received approval to
recruit participants by email. I requested the list of names and email addresses of all the
RNs from the Florida Board of Nursing and the Ohio Board of Nursing; such lists were
60
available and free to the public upon request. These potential participants were invited to
complete the survey after receiving the study flier by email. In addition, I applied for and
received IRB approval to post my flier on a social media site with a link to the survey.
Verification of Validity and Reliability
Construct Validity
Because changes were made to the Schwirian tool, construct validity was
reestablished by a panel of experts. Six experts responded to a survey in December 2018,
with a 100% response rate (Appendix M). These experts reviewed the changes made to
the tool to ensure the instrument retained construct validity. It is recommended that at
least five experts be consulted when re-establishing construct validity (Zamanzadeh et al.,
2015). The experts’ quantitative and qualitative viewpoints were analyzed for the
relevancy, clarity, and comprehensiveness of the changes made to the items to ensure
construct validity of the revised instrument.
The expert panel members were asked to rate the revised instrument items in
terms of relevancy and clarity to the underlying study construct. The item content validity
indexes (I-CVIs) were computed to determine the proportion of agreement on the
relevance of each item on a scale from zero to one. The I-CVI results indicated that all
revisions were relevant and clear (Table 2). The scale level content validity index (SCVI)
for these changes demonstrated universal agreement among the experts and therefore all
changes were considered appropriate (Zamanzadeh et al., 2015).
Table 2
61
Calculation of Item and Scale Level Content Validity Index Results
Item # relevant ratings # not relevant ratings
2 6 0
3 6 0
5 6 0
6 6 0
8 6 0
9 6 0
Note. Relevant ratings were those rated 3 or 4; not relevant ratings were those rated 1 or
2. Number of content experts = 6.
Content Validity
Content validity was re-established by a panel of experts that included participants
similar to the potential study subjects. These content experts had previous research
experience, work in nursing education, and followed the recommendations Zamanzadeh
et al. (2015) outlined to ensure adequate representation of the intended population. The
qualitative responses were used to correct grammar and wording. The quantitative
responses were used to calculate the content validity ratio (CVR) that confirmed that the
changes made to the instrument were necessary for operating a construct in survey items.
The expert panel scored the verbiage of the mechanical devices and the addition of the
word novice. The formula used was CVR = (Ne – N/2)/(N/2) (Zamanzadeh et al., 2015).
The number of panelists that stated this change was essential was represented as Ne in this
calculation and N was the total number of panelists. All panelists were in perfect
agreement on these verbiage changes as demonstrated by the
CVR results that indicated the verbiage changes should remain (Table 3).
Table 3
62
Content Validity Ratio Results for Verbiage Changes
Items N e CVR Interpretation
1 6 1 Remained
4 6 1 Remained
7 6 1 Remained
Note. CVR = (Ne – N/2)/(N/2) (N = 6). Items with CVR bigger than 0.49 remained in the
instrument.
The data were downloaded from the survey website and entered into SPSS for
analysis on my personal computer, which is password protected. I created subscales for
each of the frequency and competency levels evaluated for each of the research questions.
I created a frequency subscale for the question that addressed the level of professional
development. The frequency tables were examined and there were no missing, incorrect,
or impossible values. Box plots were run to check for significant outliers (Appendix N).
Outliers were identified, but all data collected were restricted to the limits of the Likert
scales. Therefore, I used the original data without alteration.
Reliability
Since the tool was revised, it is important to re-establish reliability or indicate if
the revised tool is free from random error and that the revised tool items in the tool
measure the underling attribute, internal consistency (Pallant, 2016). Nunnally (1978)
established that a Cronbach’s alpha of .70 is the minimum level that should be achieved
to ensure a tool is reliable, unless the sample size is small. The reliability with each
sample can change and reinforce the need to re-establish reliability of the tool (Pallant,
2016). The revised tool had a high level of internal consistency, as determined by a
63
Cronbach’s alpha of .886.
Justification for Use of Parametric Test with Likert Scale
Results obtained with parametric tests are more powerful than nonparametric
measures (Sullivan & Artino, 2013). Likert scales are helpful in identifying attitudes that
cannot be observed (Willits, Theodori, & Luloff, 2016). A 4-point Likert scale was used
in this study. According to Willits et al., (2016) four items are minimally needed for
internal consistency but, there is no set rule regarding the maximum number of choices
that need to be included in the scale. According to Norman (2010) researchers need to
address three concerns to provide justification for using a parametric measure with
ordinal data obtained from a Likert scale including adequate sample size, normal
distribution, and normality concerns with ordinal data. There is no evidence to support
that non-parametric measures are better than parametric measures with smaller sample
sizes (Norman, 2010). There were 104 participants that responded to this study (N=104),
meeting the required assumption for justification and the MANOVA assumption
requirement for adequate sample size (Norman, 2010, Sullivan & Artino, 2013). I
determined that the data were approximately normally distributed by observing scatter
plots (Appendix F). The assumption of normality must be met for parametric tests but,
even when normal distribution is violated, parametric tests generate the right answer
(Norman, 2010, Sullivan & Artino, 2013). The final justification addresses normality
concerns with ordinal data (Norman, 2010). Norman (2010) addresses the concern that
normality cannot be assumed with ordinal data. Normally, data obtained from a Likert
scale would be considered ordinal data. However, the Likert scale used to evaluate each
64
research question consists of a sum of many values across several questions in the tool
and are therefore considered to be interval data and not ordinal (Norman, 2010).
Justification for use of parametric measures is therefore satisfied in this study.
Results
Descriptive Statistics
The data collected yielded 104 participants that were actively working as RNs and
were in their current position for at least 1 year. The sample included 52-nursing
educators working in academia (50%) and 52-hospital nurse leaders that were working as
nurse manager (11.54%), nurse educator in the hospital (13.46%), or novice nurse
preceptor (25%). The sample included 96 female participants (92.3%) and 8 male
participants (7.7%). There was a significant statistical association between gender and the
two RN groups as assessed by Fisher’s Exact Test (p=.135). The following races were
represented in the sample: White (84.6%), Hispanic/Latino (2.9%), Black (7.7%), and
Other (4.8%). There was no significant statistical association by ethnicity and the two RN
groups as assessed by Chi-square test (𝑥2 = 3.044, df = 3, p = .385). The following
educational levels were represented in the sample: diploma (3.8%), associate in science
(9.6%), bachelor’s in science (19.2), master’s (46.1%), Doctorate of Nursing Practice
(DNP) (14.4%), and PhD (6.7%). There was a significant statistical association between
educational level and the two RN groups as assessed by Chi-square test (𝑥2 = 47.704, df
= 5, p = .000). The participants ranged in age from 23 to 70 years with a mean age of 52
(SD 11.250). There was a statistically significant difference in means between the age of
65
the participants and the two RN groups as assessed with independent t-test (t102) =2.464,
p =.015. The participant’s demographic information is summarized in Table 4. The mean
and standard deviation for each type of participant is displayed in Table 5.
Table 4
Participant Demographics
N %
Gender
Male
8
7.7
Female 96 92.3
Ethnicity White
88
84.6
Hispanic/Latino 3 2.9
Black 8 7.7
Other 5 4.8
Age 23–30
21
2
31–40 21 20.2
41–50 25 7.7
51–60 31 4.8
61–70 25 2
Education level
Diploma
4
3.8
Associate’s degree 10 9.6
Bachelor’s degree 20 19.2
Master’s degree 48 46.2
DNP 15 14.4
PhD 7 6.7
Table 5
Descriptive Statistics
Position Mean SD n
Leadership
How well Nurse educator 13.79 3.460 52
Hospital nursing leader 13.37 3.871 52
Total 13.58 3.660 104
66
How often Nurse educator 16.71 2.476 52
Hospital nursing leader 16.38 2.369 52
Total 16.76 2.417 104
Critical care
How well Nurse educator 18.67 5.268 52
Hospital nursing leader 18.25 5.455 52
Total 18.46 5.341 104
How often Nurse educator 23.54 4.099 52
Hospital nursing leader 22.37 4.078 52
Total 23.50 4.111 104
Teach, collaboration
How well Nurse educator 29.00 7.713 52
Hospital nursing leader 26.94 8.837 52
Total 27.97 8.318 104
How often Nurse educator 36.17 6.109 52
Hospital nursing leader 34.40 6.325 52
Total 36.26 6.251 104
Plan, evaluate
How well Nurse educator 19.98 5.389 52
Hospital nursing leader 18.33 5.487 52
Total 19.15 5.475 104
How often Nurse educator 25.10 40695 52
Hospital nursing leader 24.23 3.978 52
Total 24.66 4.028 104
Interpersonal relations, communications
How well Nurse educator 36.73 7.766 52
Hospital nursing leader 35.48 8.647 52
Total 36.11 8.202 104
How often Nurse educator 43.62 5.892 52
Hospital nursing leader 42.87 5.141 52
Total 43.24 5.515 104
Professional development
How well Nurse educator 30.38 6.814 5
2
67
Hospital nursing leader 29.83 7.496 5
2
Total 30.10 7.155 10
4
Comparison of Sample to Population
Because the nurses examined in this study hold various positions, I was unable to
determine the total number of nurses in each stakeholder position for this population. The
sample size obtained in this study met the required sample population to demonstrate
significance, according to the G Power calculated. According to the Bureau of Labor
Statistics, there are 2,955,200 RN positions in the United States (2019). From this
population of Registered Nurses, 61% work in the hospital setting and 3% of these RNs
work in the educational setting (Bureau of Labor Statistics, 2019). The sample
represented in this study was small in comparison to the total population of nursing
educators in academia and hospital nurse leaders, nursing managers, hospital nurse
educators, and nursing preceptors.
Statistical assumptions for MANOVA
The data obtained for this study were tested to ensure the figures conformed to the
ten assumptions for this statistical test. The first three assumptions that were met relate to
the design of the study: (a) there must be two or more dependent continuous variables, (b)
the independent variable is categorical and have two or more independent groups, and (c)
there must be independence of observations (Laerd Statistics, 2015). In this study, there
were two dependent variables measured on a continuous scale for each research question
assessed using a MANOVA. The independent variable, type of stakeholder, was
68
categorical and had two independent groups (nursing educators in academia and hospital
nurse leaders). Each participant responses in this research study were counted once,
therefore meeting the requirement for independence of observations.
The remaining assumptions include: (a) absence of outliers, (b) univariate and
multivariate normality, (c) no multicollinearity, (d) linearity of the dependent variables,
(e) adequate sample size, (f) multivariate homogeneity of variance -covariance matrices
and, (g) homogeneity of variances (Laerd Statistics, 2015). All of the following
assumptions were met.
Outliers. Outliers were identified by inspection of box plots (Appendix N). These
outliers were determined to be genuinely unusual values that were not due to data entry
errors. I was not able to determine if these errors were due to inaccurate entry by the
participant. The presence of outliers in the data introduces bias in the mean values of the
data that could over or underrepresent the identified research values (Kawak & Kim,
2017). Outliers in the data can be left in place, modified, or replaced however, any
corrections should be addressed prior to data analysis (Kawak & Kim, 2017). The
participants were restricted to provide answered based on a Likert scale therefore, no true
outliers were possible, therefore all data points were retained for this study.
Univariate normality. The dependent variable for each group of the independent
variable should be approximately normally distributed (Laerd Statistics, 2015). Normal
Q-Q plots were visually assessed and were found to be approximately normally
distributed (Appendix O). In each of the Q-Q plots the distribution of scores were in a
reasonably straight line, suggesting an approximately normal distribution (Pallant, 2016).
69
Multivariate normality. The data sets were assessed for multivariate normality
using Mahalanobis distances, a calculation used to determine the distance from the mean
(Field, 2013). The total sample size evaluated was N=104 with 52 evenly divided into
each group, meeting the minimum requirement for robustness according to Tabachnick
and Fidell (2013) which stated a sample size of at least 20 is needed in each group to
demonstrate robustness. The results of the Mahalanobis distances demonstrate the two of
the groups did not exceed the critical limit, two groups exceeded the limit by only one
violation, and one group exceeded the limit with two violations (Table 6). Because the
cases that violated the Mahalanobis critical limit were minimal, these scores were not
initially removed. According to Barnett and Lewis (1978) in a sample that is greater than
N=100, Mahalanobis values greater than 15 are problematic. A Cook’s distance was
calculated on both variables that demonstrated a Mahalanobis critical limit that was
greater than fifteen. The Cook’s distance for Planning/Evaluation was 0.162. The Cook’s
distance for IPR communication was 0.105. None of the Cook’s distances were
significant, because all the calculated Cook’s distances were less than one (Field, 2013).
Table 6
Mahalanobis Distances for Dependent Variables
Items Distance Violated cases Cook’s Distance Multivariate
Normality
Leadership 13.796 0 Met
Critical care 13.980 1 Acceptable
Teaching and
collaboration
13.643 0 Met
Planning and
evaluation
18.214 1 0.162 Acceptable
Interpersonal 17.601 2 0.105 Acceptable
70
relations and
communications.
Note. The number of dependent variables = 2. Critical Value for 2 dependent variables for
Mahalanobis distance = 13.82. (Tabachnick & Fidell, 2013).
Multicollinearity. Correlations that are too high or too low can alter the results of
a MANOVA, therefore screening to detect multicollinearity was essential (Laerd
Statistics, 2015). Moderate correlation with no multicollinearity was detected between
each group of dependent variables, as assessed by Pearson correlation (Table 7).
Table 7
Pearson Correlations to Rule Out Multicollinearity
Pearson
correlation
Sig (2-tailed)
Leadership .204 .038
Critical care .257 .009
Teaching and collaboration .397 .000
Plan and evaluation .293 .003
Interpersonal relations and
communications
.234 .017
Note. Correlation is significant at the 0.05 level (2-tailed)
Linearity of dependent variables. Scatterplot were examined for each pair of
dependent variables (Appendix F). A positive relationship, a positive direction, was
identified in each scatterplot. In addition, there was a linear relationship identified
between each dependent variable group, as assessed by scatterplot. The ability to detect
differences when using a MANOVA would be decreased if the variables are not linearly
related (Laerd Statistics, 2015).
Sample Size. According to Polit and Beck (2018) statistical power is necessary
for the researcher to detect true relationships between the study variables. The sample
71
size obtained in this study was N= 104, equally divided into two groups of 52 hospital
nurse leaders and 52 nursing educators in academia. Priori G Power calculation for this
study demonstrated that 98 participants were needed to demonstrate significance for this
study. This initial G*Power calculation was determined with an alpha of 0.05, a power of
0.80, and (f=0.15) for a medium effect size. The sample size attained in this study, N=
104 was greater than the total sample size recommended by the initial G Power
calculation. A retrospective power analysis was performed using G* Power 3.1.9.2. A
medium effect size was achieved at 0.153.
Multivariate homogeneity of variance-covariance. Box’s test of equality of
covariance was performed for each group of dependent variables (Table 8). There was
homogeneity of variance-covariances matrices for all groups of dependent variables
(p>.001).
Table 8
Box’s Test of Equality of Covariance Matrices
Boxes M
Sig.
Leadership 2.986 .404
Critical Care .307 .960
Teach and collaboration 5.390 .153
Planning and evaluation. 1.292 .738
Interpersonal relations and
communications
3.676 .308
Note. Tests the null hypothesis that the observed covariance matrices of the dependent
variables are equal across groups. a. Design: Intercept + RN2groups
Homogeneity of Variances. There should be equal variances between the groups
of independent variables, for each dependent variable (Laerd Statistics, 2015). The
72
Levene’s test of equality for equal variances was performed to check each group for this
assumption. There was homogeneity of variances between each group (p>.05), as
assessed by Levene’s test of homogeneity of variance (Table 9).
Table 9
Levene’s Test of Equality for Equal Variances
Levine Statistic
d/1 d/2 Sig.
Leadership
How often
.044 1 102 .834
Leadership
How well
1.627 1 102 .205
Critical care
How often
1.625 1 102 .205
Critical care
How well
0.011 1 102 .917
Teach and collaborate
How often
0.086 1 102 .770
Teach and collaborate
How well
1.692 1 102 .196
Planning and evaluation
How often
0.198 1 102 .657
Planning and evaluation
How well
0.008 1 102 .928
Interpersonal relations and
communications How often
0.252 1 102 .617
Interpersonal relations and
communications How well
0.046 1 102 .831
Note. Tests the null hypothesis that the error variance of the dependent variable is equal
across groups. a. Design: Intercept + RN2groups
Statistical Analysis Findings by Research Question
One-way multivariate analysis of variance. A one-way between groups
MANOVA was performed to determine whether there were differences between hospital
73
nurse leaders’ beliefs and nursing educators’ beliefs about the frequency and competency
levels including: (a) leadership for novice nurses transitioning into practice, (b) critical
care nursing performance, (c) teaching/collaboration, (d) ability to plan/evaluate (e) and
interpersonal relations/communications and addressed the first five questions in the study.
Research Question 1
What is the difference between hospital nurse leaders’ beliefs compared to nursing
educators’ beliefs about the frequency and level of leadership nursing performance
needed by novice nurses transitioning into practice?
H01: There is no difference between hospital nurse leaders’ beliefs compared to
nursing educators’ beliefs about the frequency and level of leadership nursing
performance needed by novice nurses transitioning into practice.
A one-way MANOVA was run to determine whether there were differences
between hospital nurse leaders’ beliefs and nursing educators’ beliefs about the frequency
and competency levels of leadership for novice nurses transitioning into practice. The
differences between hospital nurse leaders and nursing educators on the combined
dependent variables on leadership were not statistically significant, using an α level
of .05, F (2,101) =.338, p=.714;Wilks’s Λ = .993, partial Ƞ2 = .007. Therefore, the null
hypothesis was retained.
Research Question 2
What is the difference between hospital nurse leaders’ beliefs compared to nursing
educators’ beliefs about the frequency and level of critical care nursing performance
needed by novice nurses transitioning into practice?
74
H02: There is no difference between hospital nurse leaders’ beliefs compared to
nursing educators’ beliefs about the frequency and level of critical care nursing
performance needed by novice nurses transitioning into practice.
A one-way MANOVA was run to determine whether there were differences
between hospital nurse leaders’ beliefs and nursing educators’ beliefs about the frequency
and competency levels of critical care nursing performance needed by novice nurses
transitioning into practice. The differences between hospital nurse leaders and nursing
educators on the combined dependent variables on critical care were not statistically
significant, using an α level of .05, F (2,101) =1.060 , p=.350,Wilks’s Λ = .979, partial Ƞ2
= .021. Therefore, the null hypothesis was retained.
Research Question 3
What is the difference between hospital nurse leaders’ beliefs compared to nursing
educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice?
H03: There is no difference between hospital nurse leaders’ beliefs compared to
nursing educators’ beliefs about the frequency and level of teaching and collaboration
performance needed by novice nurses transitioning into practice.
A one-way MANOVA was run to determine whether there were differences
between hospital nurse leaders’ beliefs and nursing educators’ beliefs about the frequency
and level of teaching and collaboration performance by novice nurses transitioning into
practice. The differences between hospital nurse leaders and nursing educator on the
75
combined dependent variables on teaching and collaboration were not statistically
significant, using an α level of .05, F (2,101) =1.331, p=.269,Wilks’s Λ = .974, partial
Ƞ2= .026. Therefore, the null hypothesis was retained.
Research Question 4
What is the difference between hospital nurse leaders’ beliefs compared to nursing
educators’ beliefs about the frequency and level of ability to plan and evaluate needed by
novice nurses transitioning into practice?
H04: There is no difference between hospital nurse leaders’ beliefs compared to
nursing educators’ beliefs about the frequency and level of ability to plan and evaluate
needed by novice nurses transitioning into practice.
A one-way MANOVA was run to determine whether there were differences
between hospital nurse leaders’ beliefs and nursing educators’ beliefs about the frequency
and level of ability to plan and evaluate needed by novice nurses transitioning into
practice. The differences between hospital nurse leaders and nursing educators on the
combined dependent variables plan and evaluate were not statistically significant, using
an α level of .05, F (2,101) =1.424, p=.245,Wilks’s Λ = .973, partial Ƞ2 = .027.
Therefore, the null hypothesis was retained.
Research Question 5
What is the difference between hospital nurse leaders’ beliefs compared to nursing
educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice?
76
H05: There is no difference between hospital nurse leaders’ beliefs compared to
nursing educators’ beliefs about the frequency and level of interpersonal relations and
communications performance needed by novice nurses transitioning into practice.
A one-way MANOVA was run to determine whether there were differences
between hospital nurse leaders’ beliefs and nursing educators’ beliefs about the frequency
and level of interpersonal relations and communication performance by novice nurses
transitioning into practice. The differences between hospital nurse leaders and nursing
educators on the combined dependent variables interpersonal relations and
communications performance were not statistically significant, using an α level of .05, F
(2,101) =.436, p=.648,Wilks’s Λ= .991, partial Ƞ2 = .009. Therefore, the null hypothesis
was retained.
Research Question 6
Independent-sample t test. An independent sample t-test was performed to
determine whether there was difference between hospital nurse leaders’ beliefs and
nursing educators’ beliefs about the competency level of professional development for
novice nurses transitioning into practice. This test addressed the sixth research question in
the study. All assumptions for the Independent sample t-test were met. The participants
were restricted to provide answers based on a Likert scale consequently, no true outliers
were possible, therefore all data were retained for this study. The scores for professional
development were normally distributed for both hospital nurse leaders and nurse
educators, as assessed by Shapiro-Wilk’s test (p<.05). There was homogeneity of
variances, as assessed by Levene’s test for equality of variances (p=.770).
77
What is the difference between hospital nurse leaders’ beliefs compared to nursing
educators’ beliefs about the level of professional development performance needed by
novice nurses transitioning into practice?
H06: There is no difference between hospital nurse leaders’ beliefs compared to
nursing educators’ beliefs about the level of professional development performance
needed by novice nurses transitioning into practice.
An independent sample t test was conducted to determine whether there were
differences between hospital nurse leaders’ beliefs and nursing educators’ beliefs about
the level of professional development for novice nurses transitioning into practice. There
were no statistically significant differences in means between hospital nurse leaders’
beliefs and nursing educators’ beliefs on the dependent variable professional development
(t102) =.397, p =.692 therefore, the null hypothesis was retained.
Summary
From the data collected in this study, I found that there was no significant
difference in the beliefs of hospital nurse leaders’ and nursing educators’ beliefs about the
frequency and competency levels of: (a) leadership for novice nurses transitioning into
practice, (b) critical care nursing performance, (c) teaching and collaboration, (d) ability
to plan and evaluate (e) interpersonal relations and communications, and (f) the
competency level of professional development for novice nurses transitioning into
practice. Therefore, the null hypothesis, which stated that there would be no difference
between hospital nurse leaders’ beliefs compared to nursing educators’ beliefs about the
frequency and level of performance needed by novice nurses transitioning into practice,
78
was retained. In Chapter 5, I provided an interpretation of the findings including a review
the limitations of the study, recommendations, implications, and final conclusions.
79
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
The purpose of this descriptive quantitative study was to determine whether a
difference exists between hospital nurse leaders’ and nurse educators’ beliefs about the
frequency and competency levels of novice nurses transitioning into practice, in the
following areas: (a) leadership, (b) critical care nursing performance, (c) teaching and
collaboration, (d) ability to plan and evaluate (e) interpersonal relations and
communication, and (f) professional development. Previous literature reported a
dissidence between these two groups of stakeholders regarding expectations for novice
nurses (AL Dossary et al., 2014). The results in this study revealed no differences
between hospital nurse leaders’ and nurse educators’ beliefs on the frequency and
competency level for leadership, critical care, teaching and collaboration, planning and
evaluation, interpersonal relations and communication, and competency level of
professional development for novice nurses transitioning into practice.
Interpretation of the Findings
Comparison of Findings to Existing Literature
It has been widely published that the transition to practice period can be difficult
for novice nurses entering the nursing profession (AL-Dossary et al., 2014, Armstrong,
1974, El Haddad et al., 2017, Innes & Calleja, 2018). One factor documented in the
literature that complicates the transition to practice period is the dissidence in the beliefs
held by hospital nurse leaders’ and nurse educators’ regarding expectations for readiness
to practice among novice nurses (AL-Dossary et al., 2014; Berkow et al., 2009). Another
80
factor is the lack of collaboration between nursing educators and hospital nurse leaders to
provide the best experience for the development of essential nursing skills (AL-Dossary
et al., 2014, Berkow et al., 2009, Papagiorgis et al., 2016, Radford, 2018). Brown et al.
(2015) stated that expectations for common skills must be clearly defined between the
stakeholders to adequately develop and provide support for novice nurses (Brown et al.,
2015).
It is a priority for nurse educators to prepare students who are work ready
(Baldwin et al., 2014, El Haddad et al., 2017, Missen et al., 2018). Educators develop
program outcomes as a framework to ensure that novice nurses reach competencies that
align with the expectations of the board of nursing, employers, and the community
(Baldwin et al., 2014). Bennett (2017) identified that students need to have broadened
opportunities to help them learn to prioritize care. Novice nurses are expected to perform
skills proficiently and effectively communicate to the healthcare team (Bridges et al.,
2014; Brown et al., 2015). Graduate skill proficiency should closely align with employer
competencies (Baldwin et al., 2014). Numminen et al. (2014) conducted a study to find
areas where competency differences existed using the Nurse Competency Scale. They
found that educators and managers have different set benchmarks for novice nurse
competency. Educators assessed novice nurse competency slightly higher than managers
in all areas examined (Numminen et al., 2014). In my study, I found no difference
between hospital nurse leaders (a population that included nursing managers) and nurse
educators in all competency areas examined.
81
Two studies in the literature review were identified as studies that also used the
Schwirian tool. Roud et al. (2005) performed a longitudinal study of self-reported
changes in new graduate nurses. Rafferty and Lindell (2011) surveyed nurse managers
and compared accelerated baccalaureate students to traditional baccalaureate nursing
students using the Schwirian tool, with results supporting the accelerated programs. The
populations and methods used in these two studies were not comparable to my study. In
another study, Sortedahl et al. (2017) surveyed hospital leaders to examine five essential
classroom topics for nursing students including communication and leadership. Using a
one-way ANOVA, the researchers identified communication as the most important skill
(Sortedahl et al., 2017). The skill competencies in my study were not ranked and
therefore could not be compared to this study. However, this study used parametric
measures with survey data, as demonstrated in my study.
The purpose of my study was to determine whether a difference exists between
hospital nurse leaders’ and nurse educators’ beliefs about the frequency and competency
levels of novice nurses transitioning into practice, in the following areas: (a) leadership,
(b) critical care nursing performance, (c) teaching and collaboration, (d) ability to plan
and evaluate (e) interpersonal relations and communication, and (f) professional
development. My results showed there was no significant difference between hospital
nurse leaders’ beliefs and nurse educators’ beliefs about the frequency and competency
levels examined in this study, so there was no dissidence as identified previously in the
literature on novice nurse expectations (AL Dossary et al., 2014, Berkow et al., 2009).
82
This study addressed the gap in the literature by providing comparative views of nurse
educators and hospital nurse leaders on the desired competencies for novice nurses
entering practice. These findings extend the knowledge of the discipline of nursing by
providing evidence that these two stakeholders’ beliefs about the frequency and
competency levels for novice nurses transitioning into practice align.
Collaboration between hospital nurse leaders and nurse educators is needed to
address all factors that contribute to the practice gap and difficulties experienced by
novice nurses during the transition to practice period. Nurse educators need to perform
periodic curriculum reviews and seek feedback from hospital nurse leaders regarding
essential content for practice. Hospital nurse leaders need to review hospital transition
programs to make sure they support the needs of novice nurses. Collaboration and
continued communication will strengthen both stakeholders’ ability to understand how
they can best meet the needs of novice nurses transitioning into practice.
Theoretical Findings
I used Benner’s (1982) novice to expert theory to guide this study. Benner posits
that nurses progress through five stages of skill acquisition—(a) novice, (b) advanced
beginner, (c) competent, (d) proficient, and (e) expert—with time and experience.
Benner’s theory was applicable as it establishes that novice nurses entering practice
should be assessed at the novice level and allowed to progress and improve their practice
with time and experience. Novice nurses may need additional time to develop skill
competence if they had little or no exposure to these skills in nursing school. Benner’s
theory provides a consistent guide for stakeholders to set realistic expectations for novice
83
nurses entering practice. This theory provides a benchmark for achievement that novice
nurses can use to assess their progress in developing competency in practice. Schwirian’s
(1978) 6-DSNP tool was developed to predict successful nursing performance. The
results of my study support Benner’s theory by providing new evidence applicable to the
evaluation of novice nurses.
Limitations of the Study
The results of this study are limited in generalizability since the study participants
for this study were recruited using a convenience sample of nursing educators and
hospital nurse leaders that anonymously responded to my survey (Polit & Beck, 2018).
The results of this study were dependent on participation of qualified respondents and
accurate human responses to questions about their beliefs. The data were screened for
missing, incorrect, or impossible values. However, the study is limited by the fact that I,
as a researcher, am not able to identify partially random or inattentive responses (Meade
& Craig, 2012). Although to strengthen the results, the data were also screened for
repeating patterns and consecutive item responses that were identical, these were not
identified. According to Meade and Craig (2012) data quality is decreased when there is
lack of environmental control and the study can be limited by inattentive or careless
responses. Because I found statistically significant differences between my two groups in
age and educational level therefore, there is a limitation because of the differences
between the two groups which could have influenced by my study findings. The
modification of the Schwirian tool could have affected the validity and reliability of the
84
study results. However, I followed the process to reestablish construct and content
validity as recommendations by Zamanzadeh et al. (2015).
Recommendations
Future researches could compare nurse educators’ expectations from different
types of hospitals, community vs. magnet status. It would be interesting to note if
expectations for novice nurses change based on the level of the facility. Another study,
that could lead to improved novice nurse preparation, is to determine if hospital nurse
leaders’ and nurse educators’ expectations are different based on the level of education,
associate’s degree versus bachelor’s degree. This study could be duplicated with a larger
sample size to provide more information that may demonstrate improved generalizability.
Other additional research should include studies that will clearly identify benchmarks
determined by employers as skills that that must be completed independently by novice
nurses at the beginning of practice. Brown and Crookes (2016) identified 30 skill areas
graduates need to achieve and perform independently at the onset of practice. Delineation
of these skills in nursing programs would provide clearer end of program expectations
that are grounded on real world expectations that are projected by their future employers
as suggested by Baldwin et al. (2014) and Missen et al. (2018). These benchmarks should
be consistent in nursing school and at the onset of practice for the novice nurse
(Numminen et al., 2014). Future studies that address the barriers to development of
competent practice in nursing school would identify clinical concerns that nursing
educators need to address to improve a novice nurse’s independent skill proficiency. As
85
Bennett (2017) previously recommended, real-world situations are necessary for students
to build critical thinking skills.
The performance of full-time instructors verses adjunct instructors could be
examined for differences in consistency of educational/clinical experience provided and
actionable feedback given to students. This study would be beneficial in identifying
inconsistencies in these two types of educators and their ability to prepare the students to
meet the student learning outcomes. A final study that could contribute to improvement of
transition to practice for novice nurses would focus on the effectiveness of current
evaluation tools used to define and document the nursing student’s present competency
level in the clinical setting. Assessment tools should provide students with actionable
feedback that will guide their ability to understand their weaknesses and guide their path
to improvement. This type of study would ensure that all students understand what they
need to do to be successful and prepared to handle real world situations and graduate with
the necessary skills and preparation to be fit to practice (El Haddad et al., 2017,
Missen et al, 2018).
Implications
Positive Social Change
The findings of this study have the potential for positive social change by
providing new evidence that these two major stakeholders beliefs are in alignment on the
frequency and competency level for the skills identified for: (a) leadership for novice
nurses transitioning into practice, (b) critical care nursing performance, (c) teaching
86
/collaboration, (d) ability to plan/evaluate (e) interpersonal relations/communication, and
(f) the competency level of professional development for novice nurses transitioning into
practice. This study may also provide feedback, to these major stakeholders, that efforts
to improve alignment of expectations have been successful and may result of positive
social change by decreased job turn-over rate and decrease in novice nurses prematurely
leaving nursing practice (Snavely, 2016).
Hospital nurse leaders can use this evidence to confirm that their expectations for
novice nurses are in alignment with nursing educators on the six areas evaluated in this
study (AL-Dossary et al., 201, El Haddad et al., 2017, Mauro et al., 2016, Schwirian,
1978). This new information will help hospital nurse leaders focus their attention on other
factors that impact the success of novice nurse during the transition period including
orientation, internships, and programs to strengthen preceptor’s skills (Baldwin et al.,
2014, Bennett, 2017, Theisen & Sandau, 2013). Hospital nurse leaders should continue to
facilitate conversations with colleges of nursing to discuss how novice nurses can be
better prepared to enter practice and meet the grown needs to their patient population.
Nursing educators can identify that measures implemented to improve alignment
with hospital nurse leaders’ beliefs have been successful. Nurse educators must also
facilitate the communication process to continue open conversations that will continue to
support alignment between these two stakeholders (Bridges et al., 2014, Brown et al.,
2015). The curriculum must also be reviewed to ensure the graduates will be able to pass
the NCLEX exam that demonstrates the ability to provide safe care to the community
(Baldwin et al., 2014, Falk et al., 2016, Numminen et al., 2014). In addition, nurse
87
educators must continually evaluate their curriculum to ensure it meets the standards
required for the community stakeholders that they serve.
