A Study of the Lived Experiences of Newly Licensed Nurses by Lynn M

A Study of the Lived Experiences of Newly Licensed Nurses

Lynn M. Derickson

A dissertation submitted to the faculty of

Wilmington University in partial fulfillment

of the requirements for the degree of

Doctor of Education

Innovation and Leadership in Higher Education

Wilmington University

November 2011

A Study of the Lived Experiences of Newly Licensed Nurses

Lynn Derickson

I certify that I have read this dissertation and that in my opinion it meets the academic and professional standards required by Wilmington University as a dissertation for the degree of Doctor of Education in Innovation and Leadership.

Pamela M. Curtiss, Ph.D., Chairperson of Dissertation Committee

Susan Luparell, Ph.D., Member of Dissertation Committee

Michael S. Czarkowski, Ed.D., Member of Dissertation Committee

John C. Gray, Ed.D, Professor and Dean College of Education

iii

Dedication

This work is dedicated to my husband, my best friend and my greatest supporter. You have been with me through all of my frustrations, encouraging me, loving me unconditionally. Now is our time. To my girls, Heather and Andrea, who do not remember a time in their lives when I wasn’t involved in some educational endeavor, I love you both. Please remember that learning changes your life. And to my grandsons, my ‘boys’, I love you--all five of you!

It is also dedicated to all the nurses out there who have ever been victims of incivility. My hope is that this will help us to no longer ‘eat our young’.

Acknowledgements

I wish to acknowledge my committee, Dr. Pam Curtiss, Dr. Susan Luparell, and Dr. Michael Czarkowski. Please accept my deepest appreciation for all of your guidance, support and encouragement. Thank you, Pam, for encouraging me to “think more deeply” and for all your encouragement. To Susan, thank you for giving me the courage to follow my passion. To Dr. Czarkowski (“Dr. Mike”), thank you for your support throughout this program.

I wish to thank my participants, who were kind enough to share their stories and without whose help this would not have been possible, “Thank You” from the bottom of my heart.

I wish to thank the members of Cohort 18, who have made this journey unique and interesting. Thank you for accepting me and for your encouraging words when I needed them.

Thanks to my colleagues at work for keeping me on track, when I would have taken a break.

To my family for all your love and unwavering support, and for making me feel like I can do anything, and to God for giving me such blessings and a profession that I love and enjoy.

And lastly (but most importantly) to my parents, Bill and Shirley McKenzie, you taught me to pursue my dreams. Now on to the next…! v

Abstract

A qualitative study of newly licensed nurses within their first five years of practice, this study looked at twelve participants’ receptions into the nursing workforce, and their intent to stay or leave their first nursing positions were examined. Factors influencing their perceived satisfaction in their first nursing jobs were found to be reception by other nurses and doctors, perceived support from management, and their perceptions of preceptors/mentors. From this study a grounded theory emerged.

From that theory, A Model for Promoting Newly Licensed Nurse Success was developed that includes: zero-tolerance in the organization for incivility, a formal preceptor/mentoring program that incorporates Benner’s skill acquisition model

(2001), and formal leadership training for all levels that also incorporates Benner’s model (2001).

Table of Contents

Dedication ...... iv Acknowledgements...... v Abstract ...... vi Table of Contents ...... vii List of Tables ...... xi List of Figures ...... xii Chapter I ...... 1 Introduction ...... 1 Background of the Study ...... 1 The Purpose of the Study ...... 10 Need for the Study ...... 10 Research Questions ...... 12 Definition of Terms ...... 12 Incivility...... 12 License...... 12 New nursing graduate...... 13 Nursing code of ethics...... 13 Nursing education...... 13 Nursing Practice...... 13 Nursing shortage...... 13 Practice registered nursing...... 13 Registered Nurse (RN)...... 14 Overview ...... 14 Chapter II ...... 15 Literature Review ...... 15 Inclusion Criteria ...... 16 Nursing ...... 17

vii

Changes over the past 50 years...... 21 Nursing Education ...... 23 Nursing Shortage ...... 26 Theoretical Framework ...... 28 Oppression Theory ...... 28 Incivility in Nursing ...... 32 Administrative Support ...... 34 Preceptors and Mentors ...... 37 Professionalism ...... 39 Facilities of Excellence and Magnetism ...... 42 Conclusion ...... 43 Chapter III ...... 44 Methodology ...... 44 Introduction ...... 44 Choosing a Research Design ...... 45 Risk Benefit Analysis ...... 49 Sampling and Participants ...... 49 Data Collection Procedures/Sources ...... 51 Grounded Theory ...... 52 Data Sources ...... 53 Data Analysis ...... 58 Coding...... 58 Memo-writing...... 60 Trustworthiness ...... 61 Researcher as instrument...... 61 Triangulation...... 61 Ethical Concerns ...... 62 Data Management ...... 63 Chapter IV ...... 64 viii

Findings ...... 64 Introduction ...... 64 Participants ...... 65 The Interviews ...... 67 Focus Group Sessions...... 69 The Participants ...... 69 Amanda...... 69 Bethany ...... 70 Betty...... 71 Jack...... 72 Jill...... 74 Katie...... 75 Mant...... 76 Robert...... 77 Rosie...... 78 Ruby...... 79 Stella...... 79 Victoria...... 80 Themes and Trends ...... 81 Theme One: Treatment by Others: Nurses ...... 83 Emotional trauma...... 95 Theme Two: Treatment by Others: Doctors ...... 101 Theme Three: Perceptions of Administrative Involvement and Support ...... 105 Theme Four: Preceptor/Mentor Consistency and Guidance: ...... 120 Chapter V ...... 128 Summary, Conclusions and Recommendations ...... 128 Summary ...... 128 Research Question One: ...... 129 Research Question Two: ...... 147 ix

Conclusions ...... 153 Recommendations ...... 157 Implications ...... 158 Recommendations for Future Research ...... 162 Delimitations ...... 163 Limitations ...... 163 Appendix B ...... 194 Appendix C ...... 197 Appendix D ...... 199 Appendix E ...... 201

List of Tables

1. Participants Demographic Characteristics

List of Figures

1. Figure 1. A Model for Promoting New Nurse Success

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Chapter I

Introduction

Background of the Study

“I am not happy in nursing; I wish I had never become a nurse.” (Personal communication, anonymous student, 2005).

I was dismayed when I met one of my former students at a social function, asked her how she was doing, and received this response. It was not what I had expected from her. She had loved nursing as a student. That was when I began to wonder why nurses would choose to leave the profession? I had been a nurse for almost 40 years and, while there had been times that were rough, I had never considered leaving the profession. It was then that I began this journey to learn about nurses’ experiences working their first years in the profession.

My journey in nursing began soon after graduating from nursing school. I was hired in a small hospital in a rural area on the Eastern Shore of Maryland. There were few nurses from different schools of nursing who were employed there, and I was the nurse from ‘outside’. While I enjoyed the work, I did not enjoy the experience, or the relationships I had with coworkers, and I left the hospital for another nursing job after four years. It was nine years into my nursing career that I found a place where I not only enjoyed the work I did, but I was also comfortable with the respect and relationships I shared with my colleagues.

I found that nursing is a many-faceted profession; there are multiple areas in which a nurse can choose to practice, ranging from intensive care to nursing homes to community settings. No matter where the nurse decides to practice, the demands are many. Nurses are required to meet patients’, families’ and coworkers’ needs in timely fashions. Many encounters they have are with distraught and stressed individuals, who expect to have their needs met immediately. Nurses are expected to put others’ needs first (Echternacht, 1999), and to accept that certain conditions are a

“part of the job” (Rippon, 2000, p. 4).

Those of us who have been in nursing for many years have had to adjust to the changes in nursing and healthcare. There have been many changes for nursing through the past half century (Sitzman & Eichelberger, 2004; University of San

Diego, 2010), patient acuity is greater, hospital stays are shorter (Stanton, 2004), and the demands on the individual nurse have undergone phenomenal changes (Rheaume,

Clement, & LeBel, 2011; Sindul-Rothschild, Berry, & Long-Middleton, 1998;

Stanton, 2004). Nurses are required to maintain competencies and are encouraged to pursue further education; they are working twelve-hour shifts and are being asked to do overtime to cover for shortages. Nurses perform complete head to toe assessments on every patient to whom they are assigned, on every shift, establish a nursing care plan with all patients and constantly evaluate the accomplishment of established goals, revising the plan as needed (Berman & Snyder, 2012; Stanton, 2004). They handle all emergencies, complete doctor’s orders, teach patients and families, and

communicate with all healthcare professionals delivering services to patients. Nurses ensure that all equipment and supplies are available and in good repair and that all personnel know how to use them. Additionally, they serve on various committees to formulate policies and procedures that will improve care and to meet licensure and certification requirements, and serve on professional boards and in professional organizations. In addition to all of these demands, they must monitor themselves for burnout and bear the consequences of its effect on the nursing staff with whom they work.

With the changes that confront nurses come stressors (Rheaume, Clement, &

LeBel, 2011; Stanton, 2004). Whether it is the nursing shortage, increased patient acuity, or the pressures to decrease hospital stays, some unique problems exist for retaining nurses in the profession.

Cowles (2007) quoted Kathleen Bartholomew, RN, MN (2006):

Our virtues are killing us. The facts that we adapt incredibly, work so hard and never complain are no longer compatible with the healthcare system. The values have changed. Healthcare is now a business. We’re the only country in the world that uses the word ‘industry’ in conjunction with taking care of people. The implications of that are profit, loss, productivity, business and technology; all things that at their core, have nothing to do with nursing. (p. 2)

The act of caring is a hallmark of the profession of nursing. Benner (2001) observes “becoming a member participant in nursing practice assumes a helping intent and a commitment to developing caring practices” (p. vi). The Code of Ethics 3

for Nurses (American Nurses Association [ANA], 2001) identifies values that every nurse is bound to hold in esteem and to portray behaviorally. Provision 1 of the Code of Ethics for Nurses (ANA, 2001) states: “The nurse, in all professional relationships, will practice with compassion, and respect for the inherent dignity, worth, and uniqueness of every individual…” (p. 7).

The American Association of Colleges of Nursing (April, 2011) published a

Nursing Shortage Fact Sheet, which included the following:

• The shortage is expected to increase as Baby Boomers age and the need for healthcare grows. • Only 50% of nurses are prepared at the baccalaureate level. • Health care reform is creating an even greater need for RNs. • There will be an increased need for RNs by an estimated 22% by 2018. • The shortage of 260,000 RNs by 2025 will be twice as large as any shortage since the 1960’s. • The average age of RNs is rising, currently 47 years of age, with 50% of nurses surveyed intending to retire between 2011 and 2020. • 75% of nurses believe the shortage is affecting the quality of their work life, their patient care and safety, and is causing nurses to leave the profession. • 98% believe that it is a catalyst of stress for nurses, for decreasing the quality of patient care and for nurses leaving the profession. • Failure to retain nurses contributes to avoidable patient deaths. (p. 1)

Reading these statistics should sound an alarm that there is something wrong in nursing. When a balloon has a pinhole in it, the air escapes and the balloon is no 4

longer able to provide the pleasure or service for which it was intended. So is the case with the nursing profession. When nurses leave the profession for reasons of dissatisfaction, burnout, or whatever reason, the profession loses its ability to provide care in the manner that it intends, or that is needed by the patients it serves. It is estimated by various researchers that up to 50% of new graduates leave their first nursing job after 2 years (Ferrell, James, & Holland, 2011); another survey found that

4.9% of nurses were definitely planning on leaving while another 45.5% in the survey were undecided about whether to stay or leave (Rheaume, Clement, & LeBel, 2011).

Kovner, Brewer, Fairchild, Poornima, Kim, and Djukic (2007) reported that 13% of new RNs left their principle jobs after one year and 37% felt ready to leave. This is a slow leak that is tapping the reserves of the profession.

The U.S Bureau of Labor Statistics reported (April 1, 2011) that the healthcare sector of the economy is continuing to grow. In their article, Buerhaus, et al. (July,

2009) identified conditions that have stabilized the nursing workforce, including many retired nurses returning to the workforce, nurses postponing retirement, and nurses who were working part-time taking full-time positions. In the November 26,

2008 Journal of the American Medical Association , Dr. Buerhaus, an authority on nurse employment and the nursing shortage, cautioned that the relief was only temporary, and that the industry needed to continue to plan for long term solutions.

Most of the recent employment increase seen was in nurses over the age of 50

(Buerhaus, et al., 2009). In September 2010, the average age of RN’s was 47.0 years 5

(Health Resources and Services Administration: Department of Health and Human

Services, 2010). The United States Bureau of Labor Statistics (American Association of Colleges of Nursing, 2011) reported an increased number of 581,500 new RN positions, increasing the demand for the nursing workforce by 22% through 2018, plus thousands of vacant positions to replace experienced nurses who will leave the profession by 2016 (NLN, 2009). The most recent projections in 2009 were that there will be a shortfall of RN’s developing around 2018 that will plateau at approximately

260,000 by 2025 (Buerhaus, et al., 2009). What that number means, is that on average there will be a shortage of 5,200 nurses per state by 2025. “The Center for

Workforce Development University of Maryland Baltimore projects that there will be a supply shortage of nearly 13,000 nurses by 2010 in Maryland, and a shortage of one million nurses nationally by the year 2015” (University of Maryland School of

Nursing, Nov. 8, 2005, p.1).

When newly licensed nursing graduates enter their first nursing jobs, they are optimistic, enthusiastic and eager to join the ranks of the nursing world. These new nurses have need for further developing their knowledge base and increasing their skill levels, and for learning the policies and procedures of their workplace

(Bartholomew, 2006; Griffin, 2004,). The transition is often extremely stressful and disenchanting for the new graduate (Boychuk Duchscher, 2008; Newton & McKenna,

2006; Oermann & Garvin, 2002). They are met with values and nursing philosophies that may conflict with those they learned in their education programs, fear of making

mistakes and lack of support in the nursing work place (Boychuk Duchscher, 2001;

Casey, Fink, Krugman, & Propst, 2004; Gerrish, 2000; Oermann & Moffitt-Wolfe,

1997; Rheaume, Clement, & LeBel, 2011). The patients they care for are increasingly more acutely ill; staffing patterns are increasingly more challenging, leaving no time for collaboration or downtime (Griffin, 2004; McKenna, Smith, Poole

& Coverdale, 2003). Success in their new position is usually dependent upon the guidance and assistance of a “clinical peer in a higher power position” (Griffin,

2004). Opportunities for mentoring, or orientation, may vary from setting to setting.

Marcum and West (2004) found that the significance of transition programs was reflected in turnover and retention studies, and that when mentoring or orientation programs were tailored to the needs of the new nurses, retention rates increased (Salt,

Cummings, & Profetto-McGrath, 2008).

In spite of efforts to recruit and retain nurses, there are nurses leaving the profession in their first years of practice. New nursing graduates encounter different experiences and values in the workplace than they did in school (Boychuk Duchscher,

2001). One of the major reasons identified for nurses leaving the workforce is incivility, or bullying, in the nursing workplace; identified as “repetitive inappropriate behavior, direct or indirect, whether verbal, physical, or otherwise, carried out by one or more persons against another or others, at the workplace and/or in the course of employment, which undermines the individual’s right to dignity at work” (Center for

American Nurses, 2008; Stagg, Sheridan, Jones, & Speroni, 2011, p. 3). A U.S.

survey of staff nurses reported that 70% of those surveyed had been bullied at work

(Vessey, Demarco, Gaffney & Budin, 2009). Stagg, et al (2011) reported that their survey found that 80% of those RN’s surveyed had experienced incivility in the workplace.

Incivility occurs often enough that it has been a phenomenon of study around the world in all types of nursing communities (Center for American Nurses, 2008;

Hutton & Gates, 2008; Rocker, 2008). Childers (2004) reported that incivility caused up to 70% of victims to leave their jobs. In 2011, Rheaume, et al. conducted a study which revealed that almost half of the new graduates in the study were dissatisfied and were contemplating leaving their employment, and related their discontent to working conditions, including treatment by peers.

Incivility has occurred in all practice settings. It has been reported in nephrology nursing journals (Gilmore, 2006), orthopedic nursing (Sofield &

Salmond, 2003), occupational health nursing (Hutton & Gates, 2008), nurse anesthetists’ journals (Anonymous, 2007), psychiatric nursing (Stanley, Martin,

Michel, Welton & Nemeth, 2007) and operating room nursing (Dunn, 2003). The descriptions are much the same in each practice setting (Anonymous, 2007; Dunn,

2003; Gilmore, 2006; Hutton & Gates, 2008; Sofield & Salmond, 2003; Stanley,

Martin, Michel, Welton & Nemeth, 2007). The effects are debilitating for the individual, ranging from leaving the profession, physical symptoms, Post Traumatic

Stress Disorder (PTSD) to suicide (Bartholomew, 2006; Delez, 2003; Hastie, 1995) 8

and for the agency in costs for productivity, absence, insurance, compensation and replacement (Hutton & Gates, 2008; Letvak & Buck, 2008).

When observing interactions between nurses and staff in any practice setting, behaviors associated with incivility or workplace bullying can be observed.

Behaviors that are demeaning, eye rolling, face-making, verbal affronts, snide comments, ignoring requests or suggestions made by the nurse who is the subject of incivility, or undermining the nurse, or withholding information (Bartholomew, 2006;

Griffin, 2004). Many nurses may not be familiar with the terms used to identify it, but most have seen it demonstrated or experienced it during their careers (Childers,

2004; Christmas, 2007; Dellasega, 2009; Felblinger, 2008; Hamlin, 2000; Stagg, et al., 2011). This phenomenon has been labeled “incivility in nursing”, or “nurses eating their young”, “lateral violence” or “horizontal violence” or “workplace bullying” (Anderson, 2001; Bartholomew, 2006; Delez, 2003; Griffin, 2004;

Luparell, 2003; Rippon, 2000; Stagg, et al., 2011). Hippeli (2009) reports that “since the mid-1960’s, the term ‘Nurses eat their young’ has been a well known but dark secret within the nursing profession” (p. 186). My personal experience was that it was much easier to seek another nursing position and leave than to confront my abusers.

The worst nursing shortage that has ever existed is projected to continue as the first baby boomers are increasing the need for health care (Buerhaus, et al., 2009;

Palmer, 2003). To compound this problem, incivility is causing nurses to leave the 9

profession (Buerhaus, Potter, Staiger, French, & Auerbach, 2009,

PriceWaterhouseCoopers’ Health Research Institute, 2007).

The Purpose of the Study

The purpose of this study is to examine registered nurses’ (RNs’) (who are in the first one to five years of practice after graduation from an initial nursing education program) perceived experiences with respect to their transition into the nursing workplace and the relationships encountered there. The first five years of practice are ones in which RNs are able to find their comfort level in the employment setting and to transition from the role of novice to the role of expert nurse (Benner, 2001).

Need for the Study

Many nurses are choosing to leave the profession (Buerhaus, Donelan, Ulrich,

Norman & Dittus, 2005). Reports of a continuing and cyclical nursing shortage

(Buerhaus, et al., 2009; Buerhaus, Potter, et al., 2009; Health Resources and Services

Administration [HRSA], 2006, 2010; United States Bureau of Labor Statistics, 2007,

2011) make it ever more important to examine the reasons RNs leave either the profession or their position. Reasons frequently cited in the nursing literature are the topics of nurse burnout, job stress and incivility, lateral or horizontal violence (Center for American Nurses, 2008; Childers, 2004; Hutton & Gates, 2008; Rocker, 2008).

There is a dearth of research information on new graduates and their early work experiences. Some of the few studies found that focused on new graduates were conducted by Duchscher and Myrick (2008) and Rheaume, et al. (2011) in Canada. 10

The telling of the nurses’ stories, examining and clarifying their perceptions, and identifying any coping skills they have utilized may provide information for further developing nursing education and orientation programs, thus enabling a more productive and safer workplace. By exploring the lived experiences of RN’s, identifying areas that may be a source of problems in the nursing workplace, solutions can be investigated. Improved workplace conditions may further improve RN retention, and create a degree of satisfaction so that they will influence others to be recruited into the profession.

Most research studies on the nursing shortage and problems of incivility in the workplace have been conducted in the United Kingdom and Australia (Baillien,

Neyens, De Witte, & De Cuyper, 2008; Bray, 2001; Duchscher & Myrick, 2008;

Farrell, 1997; Healy & McKay, 2000; Hutchinson, Wilkes, Vickers & Jackson, 2008;

MacIntosh, 2005; Roche, Diers, Duffield & Catling-Paull, 2010; Seigne, Randall &

Parker; 2007; Smorti, Bisaccia & Pagnucci, 1999). Those studies concerning the nursing shortage in the United States have focused on ways of increasing numbers of people entering the profession, attracting more qualified nurse educators, filling vacant positions, expanding nursing programs, and providing more clinical experiences using simulation and technology. Others have examined job satisfaction among nurses and verbal abuse in the specialty settings as well as incivility in nursing education (Bartholomew, 2006; Delez, 2003; Dunn, 2003; Luparell, 2003; Simons,

2008; Smailes, 2003).

This study will examine a group of RNs shortly after entry into practice post graduation. Research into what the experiences of these graduates have been and skills used to cope with the pressures of the nursing workplace may yield material that can be used to improve the nursing workplace. It may also provide future nurses with skills to cope with stressors in the profession.

Research Questions

This qualitative study will examine the lived professional experiences of new nursing graduates. Research questions are:

1. What are the perceptions of newly licensed nurses concerning their

reception when entering the nursing workplace?

2. What are the perceptions of newly licensed nurses regarding support

from administration and preceptors/mentors?

Definition of Terms

Incivility. Overt or covertly inappropriate social behavior toward another in the workplace, to include demeaning, insulting, overly critical, shunning, intimidating, threatening, gossiping, ignoring, or name-calling; also referred to as lateral violence or horizontal violence, or ‘nurses eating their young’ (Bray, 2001;

Delez, 2003; Hockley, 2000).

License. A license issued by the State Board of Nursing to practice registered nursing.

New nursing graduate. A licensed registered nurse within five years of graduation from a State Board of Nursing accredited education program (Simons,

2008).

Nursing code of ethics. The primary goals, values, and obligations of the profession of nursing as set forth and interpreted by the American Nurses Association

(2001).

Nursing education. A State Board of Nursing approved program of education that upon successful completion awards a degree in nursing (either

Associate Degree or Bachelors Degree) that will allow them to sit for the National

Council Licensure Exam (NCLEX).

Nursing Practice. Fulfilling the responsibilities of a registered nurse in delivering care to patients, or in conducting the duties of a registered nurse position in an employment setting (Maryland Board of Nursing, 2011).

Nursing shortage. The supply of registered nurses not meeting the demand for a period of time, either for the current, or for a predicted time in the future

(Maryland Hospital Association, 2007).

Practice registered nursing. The performance of acts requiring substantial specialized knowledge, judgment, and skill based on the biological, physiological, behavioral, or sociological sciences as the basis for assessment, nursing diagnosis, planning, implementation, and evaluation of the practice of nursing in order to: 13

i. Maintain health; ii. Prevent illness; or iii. Care for or rehabilitate the ill, injured, or infirm.

2. For these purposes, “practice registered nursing” includes:

i. Administration; ii. Teaching; iii. Counseling; iv. Supervision, delegation and evaluation of nursing practice; v. Execution of therapeutic regimen, including the administration of medication and treatment; vi. Independent nursing functions and delegated medical functions; and vii. Performance of additional acts authorized by the Board under § 8-205 of this title [Annotated Code of Maryland] (Maryland Board of Nursing, 2011).

Registered Nurse (RN). “Registered nurse” “means, unless the context requires otherwise, an individual who is licensed by the [State Board of Nursing]

Board to practice registered nursing.” (Maryland Board of Nursing, 2011)

Overview

An overview of the nursing profession and problems presented in the nursing workplace has been provided that will provide a context for understanding factors that influence RNs in the workplace. Also identified is a review of the problem of the nursing shortage, documented rationales for new RNs leaving the profession, and a list and definition of terminologies relevant to this study. 14

Chapter II

Literature Review

Curiosity about the object of knowledge and the willingness and openness to engage

theoretical readings and discussion is fundamental (Freire & Macedo, 1995).

In Chapter I, the challenges facing the nursing profession, the current nursing shortage, the need to address the shortage, in particular the issue of newly licensed registered nurses choosing to leave the profession, and how those issues were affected by conditions in the nursing workforce were introduced. This second chapter begins with a review of the history of nursing, enabling the understanding of how nursing interfaces with other healthcare professions, why nurses choose to enter nursing, and the challenges nurses face in the course of their work. It then explores the process of nursing education, the various ways of entry into the profession, licensure and certification, and how those routes impact the nurse’s role. The theories of oppression and feminism will be explored as will Benner’s (2001) landmark work

From Novice to Expert. These are all important as they describe reactions to interpersonal and professional experience. Issues in the workplace will be explored, as well as current efforts to address those issues as they pertain to the profession of nursing. The chapter will include a summary of current research on the topic of incivility in nursing.

As a faculty of nursing, we frequently enter into discussions about problems facing the nursing profession, how nurses treat each other, how they respond to stress, and how we can teach our students. One of my fellow faculty members has a couple of expressions that she regularly uses to encourage teamwork among students: “play nice in the sandbox” and “nursing is a team sport”. These expressions are meant to remind them that they will always work in collaboration with someone else and that we must consciously strive to work well with others. Nursing is a profession that is extremely rewarding, but is riddled with stress producing experiences. It is very easy to lose sight of the need to treat our coworkers with respect and consideration.

I think of how far nursing has come, since the early 1900’s, practicing with elementary skills and providing care in patients’ homes, to the present day, serving as

Chief Executive Officers of hospitals, health care corporations, professional organizations, and at the bedside operating highly technical equipment, keeping watch for patient’s vital signs, electrolyte status, acid-base balances, offering support to families, and many other complicated services. I am amazed that our profession has grown so quickly, become so vast and encompasses so much information.

Inclusion Criteria

An extensive literature search was conducted to investigate the body of knowledge pertaining to incivility in nursing, theories relating to the interfacing of nursing with other health care professions, attitudes toward nursing as a profession, entry into nursing, and strategies to address the nursing shortage. A search of 16

CINAHL Plus with Full Text, ERIC, ProQuest Nursing and Allied Health Source databases was conducted using the search terms “incivility”, “incivility in nursing”,

“lateral violence”, “ horizontal violence”, “bullying”, “nurses eating their young”,

“nursing work environment”, “cultural narration”, “oppression”, “nursing shortage”,

“feminist theory”, “men in nursing”, “experiences in nursing careers”, “stress in nursing”, “conflict”, “workplace violence in healthcare”, “mentoring in nursing”,

“preceptors in nursing”, “on-boarding” and “incivility toward nursing students”.

Recognizing that changes in healthcare are rapid, the search was initially limited to that material which was no more than five years old. As it became apparent that this topic has only recently been recognized as a topic of interest for research, the search was expanded to articles no more than seven years and longer for those including theories of oppression and feminism.

In the review that follows, the information will be divided into the following categories: nursing, nursing education and entry into practice, nursing shortage, theories, bullying and incivility, a review of current research on incivility and efforts to address incivility., administrative support, preceptor/mentors, professionalism, and facilities of Excellence and Magnetism®.

Nursing

While there have been those who have cared for the sick throughout history, the Knights of Lazarus, the Teutonic Knights, the Knights of St. John, and varied religious orders, such as the deaconesses of Kaiserwerth (DeLaune & Ladner, 2006), 17

it is only since the mid 1800’s that nursing has come into its own as a respected and

organized profession with a formal means of education and acquisition of knowledge

(Potter & Perry, 2009). Florence Nightingale, also known as the founder of modern

nursing, wrote the first philosophy of nursing, describing what it was and was not,

and set the course for nursing to become the profession that it is today (Nightingale,

1992; NurseGroups.com., 2010).

In the early 1900’s, nursing focused on menial tasks, and required minimal

critical thinking skills, knowledge of disease processes, or of the sciences. Schools of

nursing were maintained in hospitals; student nurses staffed the hospitals (Morgan,

1998; Tone, 1999). Nurses were basically housekeepers, responsible for dusting,

cleaning, cooking meals, doing dishes, sterilization of needles, bandages and cleaning

operating rooms (Travel Nurses Now, 2010). At the turn of the century, nurses were

paid five dollars a week, and were expected to defer to physicians and supervisors.

By 1920 the nurse earned fifty cents per hour (Morgan, 1998). As graduate nurses,

they could give baths, care for wounds, give medications and enemas, and even apply

leeches, poultices, stupes, and plasters (1998).

As the century progressed, there was increasing evidence that nursing needed

to be organized and regulated (Kendall, 2010) in order to ensure that quality and

consistency was guaranteed in both education and in practice. First organized as the

Nurses’ Associated Alumni of the United States and Canada (NAAUSC) in 1890, the

NAAUSC became the American Nurses Association (ANA) in 1911 (Potter & Perry, 18

2009). Nurses wanted autonomy in practice in order to practice critical thinking and

to promote innovation in practice (2009). The ANA was to become a voice for

nursing in establishing autonomy and collaborative practice, setting standards for

practice and spurring the evolution of a scientific, evidence-based body of nursing

knowledge.

Nursing education began to move from the hospital based schools of nursing,

where they were found to be too costly and cumbersome for the institutions to

manage (Tone, 1999), to the university and college setting. The first university

affiliated nursing program was established in 1901 (Potter & Perry, 2009). Several

events occurred which facilitated the development of nursing education. Nursing

curriculum became standardized, and a movement began for the testing and

registration of nurses to practice (Kendall, 2010).

A major study, supported by the Rockefeller Foundation, was conducted in

1918 by the Committee for the study of Nursing Education. The committee consisted

of nurse leaders of the time: Annie Aldrich, Adelaide Nutting, and Lillian Wald.

They were known as “The Great Triumverate” (Fondiller, 2000). The study resulted

in a 500 page paper, published in 1923, Nursing and Nursing Education in the United

States, also known as the Goldmark Report, that called for nursing education to take

place in a collegiate setting (Nation’s Health, The, 1922; Tone, 1999). It also set the course for the debate over whether nurses should be seen as professionals or technicians (1999). 19

The 1946 Hill-Burton Act funded expansion of hospital services for the public, creating a demand for more nurses (Tone, 1999). In 1952, the first associate degree nursing program was established, which coincided with the evolution of the community college system, supported by federal funding (1999). In the 1960’s, the

Kennedy administration and the Consultative Group on Nursing recognized the need for more nurses to be prepared at the bachelor’s and graduate levels, and $300 million was made available for nursing education (1999).

Those events and the development of different ways to enter into professional practice set the stage for the debate over technical or professional nursing. Those supporting bachelor education programs felt that those nurses were better prepared to fill the role of professional nurse, and that those educated at the associate degree or diploma level should be in the role of technical nurse. Those who supported associate degree or diploma education felt equally qualified to fill the role of professional nurse since they sat for the same licensure exam as those prepared at the bachelor’s level.

This was supported, and continues to be supported by the ANA, but has never come to fruition (American Nurses’ Association, 2000). More recently, the Institute of

Medicine (IOM) (2010) has called for barriers to nurses transitioning along the education continuum to be identified and removed. In 2008, a resolution was approved by 85% of the ANA House of Delegates to pursue recommendations and the ANA is working to develop a strategic plan that will be available to states wishing

to pursue legislation along this path (Trossman, 2008). This will not affect those

RN’s already in practice.

Changes over the past 50 years. The latter half of the twentieth century saw

the development of nursing as a profession, with a well defined body of knowledge,

and a strong service component. Also included are the development of nursing

theories by people such as Hildegard Peplau, Dorothea Orem, Madeleine Leininger,

Virginia Henderson, Myra Levine, Ida Jean Orlando, Sister Callista Roy, and Martha

Rogers, among others, all leaders in the profession and all able to define a theoretical

perspective to patient care (Sitzman & Eichelberger, 2004; University of San Diego,

2010). These theories have served as guides for nursing educations programs in their

curriculum development and in nursing practice settings.

Many national and international nursing organizations were formed in the 20 th century. The major ones that govern all of nursing and nursing education are the

ANA, the National League for Nursing (NLN), and the National Council of State

Boards of Nursing (NCSBN). The ANA is the organization that serves all of nursing as an advocate in government, for health care reform establishing standards of practice for nursing, codes of conduct and ethical standards and forming a social policy statement for nursing (ANA, 2001; ANA, 2010). Comprised of constituent organizations from the fifty states, each state has individual memberships and the state organization is represented by delegates to the ANA. It continues to advocate for a scientific and research base for nursing practice and for workplace advocacy 21

(ANA, 2010). The NLN is the voice for nursing education in the nursing community, setting the standards for nursing education programs, and preparation of nursing faculty. It was the first nursing organization in the United States, formed in 1893 as the American Society of Superintendents of Training Schools for Nurses, and continues to champion for excellence in nursing education through program certification and approval (NLN, 2010). Formed in 1978, the NCSBN is the organization that serves to protect the safety of the public. It was originally a branch of the ANA, but it was felt that it needed to be a separate entity from the nurses’ organization (NCSBN, 2010) The organization is comprised of state boards of nursing; in collaboration they are responsible for testing and monitoring nurses for licensure. The NCSBN continues to conduct pertinent research, further nursing initiatives and develop regulatory mechanisms (2011).

Nursing has become a profession highly dependent on knowledge and technical ability. Nursing procedures and nursing care planning are guided by best practice models and evidence based practice. “In the beginning, nursing was a non- professional practice but the development of theories has greatly influenced its advancement as a science” (Kendall, 2010, p. 2). In the new century, we see nursing stratification with advanced practice nurses, nurse practitioners, registered nurses, and ancillary personnel working side by side with all levels of training and experience

(2010).

Today, there are more than 3.1 million registered nurses in the United States

(Health Resources and Services Administration [HRSA], 2010), practicing in over

200 specialty areas. Their practices are built upon evidence based research, and scientific and nursing theories (Berman & Snyder, 2012; DeLaune & Ladner, 2006).

Nurses function autonomously and work independently and in collaboration with other health care specialists and physicians (Berman & Snyder, 2012; DeLaune &

Ladner, 2006; Harkreader, Hogan & Thobaden, 2007).

Nursing Education

Nurses are prepared for entry into practice by one of several ways. All must meet the requirements of the National Council of State Boards of Nursing (NCSBN)

(2011) for curricula, and the individual school’s requirements for diploma, degree or certificate conferral. One may be prepared by a two or three year diploma school of nursing, a two year associate degree college program of nursing, a four year bachelor degree program at a college or university, or as a second degree through a college or university program bachelor’s of science in nursing program. Graduates from any of these programs are eligible to sit for the National Council Licensure Exam for

Registered Nurses (NCLEX-RN). The varying levels of education licensed and employed at the same status gives rise to tensions in some workplaces. Quite naturally, one prepared at the bachelor’s level feels that they are better prepared than one at the diploma or associate degree level, while those at the associate’s or diploma level feel that they are better clinically prepared than those at the bachelor’s level.

Licensure preparation and entry into practice, whether there should be one entry into practice requirement for registered nurses and the others called by another title, has been debated since the 1960’s (ANA, 2010). The ANA takes the position that more education is required to give nurses an equal seat at the health care table with those who are members of medical and governing boards, or from the business, investor, and insurance communities (2010).

Initially, the only way to enter the profession was through completion of a program at a hospital based diploma school of nursing. These programs still exist.

Some have as a prerequisite for entry, in addition to a high school diploma or the equivalent, a certification as a nursing assistant and completion of some collegiate level general education courses, such as Chemistry, English, Anatomy and

Physiology I and II, and Psychology (Beebe School of Nursing, 2010, WorWic

Community College, 2011).

With the issuance of the Goldmark report (Nation’s Health, The, 1922; Tone,

1999) and the call for nursing education to take place at the collegiate level, university programs began to be developed. They issue a baccalaureate degree as a means to enter into nursing practice.

The first associate degree nursing programs for the education of nurses were begun in the 1950’s, when the Hill-Burton Act called for more hospital beds, and there was a demand for more nurses (Tone, 1999). As the need for nurses has

increased, many universities have paved the way for those who possess degrees in

other areas to have easier access to a practice in nursing. Many pursue second

degrees or even proceed from RN to master’s degree in the collegiate programs that

have been developed (Salisbury University, 2011, Wilmington University, 2011).

As the century (turned), nursing has moved from some 400 hospital-based programs in 1900 to an educational base that includes 80 doctoral programs, 340 master’s programs, 650 baccalaureate programs, 880 associate degree programs, and 80 hospital-based diploma programs (Tone, 1999).

All of the programs have been successful in preparing qualified nurses to care

for the public. All are required to be approved by their State Board of Nursing, and

meet the criteria set forth by the legislature (Maryland Board of Nursing, 2011). All

graduates of approved nursing programs are qualified to sit for the National Council

Licensure Exam for Registered Nurses (NCLEX-RN) (National Council of State

Boards of Nursing, 2011).

The various routes for entry into practice in nursing have created friction among its members. The ANA has repeatedly called for the baccalaureate degree to be the education required for entry into professional nursing practice, first in 1965 and more recently in 2002 (Donley & Flaherty, 2008). The ANA, however, does not have the power to legislate, it can only recommend. The PEW Health Professions

Commission (1995) also recommended that there be a differentiation between educational levels of nursing. There has been no move to change any of the structure

of positions, or qualifications to test for NCLEX-RN included in those

recommendations. A major challenge for the nursing profession as it has grown has

been and remains to be “the task of describing and differentiating the competencies

and the scope of practice of nurses with multiple entry-level programs” (DeLaune &

Ladner, 2006). The NCLEX-RN, the licensing exam given to all new nursing

graduates, remains the same for all registered nursing graduates (NCSBN, 2011).

Nurses in the 21 st century now have the choice to decide whether to advance through clinical practice or to choose to pursue administrative ladders. While there are many specialties areas, and certification is available in them, many of them require a master’s degree in the related specialty area of nursing in order to be certified as a clinical specialist, and a baccalaureate to certify as a generalist

(American Nurses Credentialing Center [ANCC], 2011).

Nursing Shortage

Throughout the twentieth century, healthcare has been plagued by shortages of nurses. According to the Kaiser Family Foundation, the United States has been dealing with a nursing shortage for decades (Kullen, Ranji, & Salganicoff, 2010).

Ever since World War II, there has been discussion of nursing shortages, and since the 1960’s there have been shortages that health care has been able to deal with.

However, since 1998 a shortage has existed that is only predicted to worsen, so that by the year 2025, the shortage of registered nurses will reach 500,000 (Buerhaus,

Potter, et al., 2009). The United States Bureau of Labor Statistics (2007) cites a 26

shortage figure of 587,000, plus thousands more, in addition to that figure, to replace

experienced nurses who will leave the profession by 2016 (NLN, 2009). In 2007, the

American Hospital Association reported that hospitals need 116,000 registered nurses to fill vacant positions.

Early nursing shortages have been influenced by events such as population shifts (Goodin, 2003), international conflicts, and legislation like the Hill Burton Act of 1949 (Tone, 1999), calling for the expansion of hospital services for the public and increasing the demand for nurses. Throughout the past century, legislation has created demands on the health care system and nursing. The shortages of the 1970’s and 1980’s were related to nurses’ dissatisfaction and lack of autonomy in their practice settings (Alspach, G., 2000).

The current crisis is different in that it is not simply that positions are not filled; there is a definite risk to the quality of care and the safety and welfare of those in need of nursing care. One landmark study (Aiken, Clarke, Sloane, Sochalski &

Silber, 2002) found that “each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue” (p. 1987). That same study looked at nurse burnout and satisfaction, finding that “each additional patient per nurse was associated with a 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction”

(p. 1987). Nurses are challenged by increased levels of patient acuity, low nurse to

patient ratios, lack of adequate compensation, and the demand for more specialization and experience (Sigma Theta Tau, 2001).

Theoretical Framework

Nursing has been and is still a predominantly female profession. It has progressed as a profession since the days of Florence Nightingale, her vision providing a light for generations of nurses to follow (Dossey, 2000; Fitzpatrick,

1992). Nursing has not, however, assumed a status of equality among the hierarchy of health care (Bartholomew, 2006; David, 2000; Roberts, 1983; Torres, 1981).

Oppression Theory

Oppression theory has come from the study of groups, such as incarcerated

Jews, colonized Africans, and other groups of people who are controlled by others

(Freire, 2010). Roberts (1983, 1996, 1997, 2000) associated nurses with the oppressed because they work in hierarchical systems, and have not achieved equality in the health care process. Nursing can be related to Freire’s model (2010) in which the oppressed group feels that they are inferior to their superiors, or to the dominant group and assume that role.

While we can read about oppressed people throughout history and throughout the world today, the first formal work about oppression was written concerning those in Third World countries. Paulo Freire (2010) first wrote about the oppressed in his doctoral dissertation in 1959. He was jailed for his writing because it was felt to be a

threat to the old order of Brazil. He went to Chile and was subsequently associated with UNESCO and the World Council of Churches in Geneva, eventually working at

Harvard. He later he wrote his theory Pedagogy of the Oppressed.

Freire’s pedagogy (2010) looks at both the oppressed and the oppressor. They both have a struggle for humanization. Freire it seems theorizes on the basic assumption that man has a calling to be one who transforms their world to develop a richer, fuller and more meaningful life existence. His world is a real one with problems that must be mediated and solved. He also declares that “people educate each other through mediation of the world” (p. 32). As the individual makes new meaning of his world they give name to it, see it and themselves with new dignity and derive hope from this new meaning.

All people want to be treated in a humane manner. It is a central concern in human existence. When one is concerned about humanization, automatically one is concerned about dehumanization (Freire, 2010). As pedagogy considers the calling of the individual, it recognizes that humanization is the goal. It is in humanization that the individual realizes a richer and fulfilling existence and makes new meaning of his world. However, humanization and dehumanization often conflict, presenting continual struggle for humanization that is blocked by oppression, struggle and bitterness.

The oppressor also is involved in a struggle for humanization. Freire’s pedagogy (2010) describes the oppressor’s existence as a distortion of humanization;

in an effort to achieve humanization, they inflict dehumanization. The oppressors become violent toward the oppressed and the result is an unjust order that dehumanizes the oppressed. The human goal of humanization is then thwarted, so that neither realizes humanization.

It is only in the struggle for liberation that the oppressed will achieve power and free their oppressors that humanization occurs. What initially happens is that the oppressed, in gaining power, often become oppressors themselves. Their efforts to achieve freedom pose a threat not only to the oppressor, but to themselves as they are fearful of still greater repression. When the oppressed have a picture of what the oppressor is, they fear freedom. Freire (2010) also identifies the concept of prescription, the imposing of one’s desires or wishes upon another. In securing freedom, the oppressed impose the prescription of their wishes on the oppressor, as the oppressor had done.

It is only through reflection that the oppressed can begin to have freedom. It is a struggle, an awakening, a new birth that results in a new person, a new freedom, a new view of the world where the individual functions neither as the oppressor or the oppressed, but human (Freire, 2010).

Roberts (1983) addressed oppressed group behavior as it applies to nursing.

Both she and Duffy (1995) observed that nurses are not equal players at the table in healthcare. This causes them to be in a position of powerlessness, and causes them to engage in lateral violence to release their frustration. When they perceive that they

are in a dominated position, have no control over their practice, and are subject to

direction from physicians and “marginal nursing leaders” (Roberts, 1983), then nurses engage in acts of lateral violence, incivility, to their peers in nursing. Marginal nursing leaders are described as nurse leaders, who are on the outskirts of the nursing group and have taken on some of the characteristics of the dominant group.

Thus, nurses are members of an oppressed group. By its history, it has a reputation and society continues to view them as handmaidens to physicians. They are not seen by others as professionals who assess, make nursing diagnoses, set goals and outcomes for care, implement interventions to meet those outcomes and evaluate the effectiveness of the interventions (Berman & Snyder, 2012).

As nurses struggle to gain freedom, and to assert themselves, they fear the freedom to make decisions and to have autonomy. Thus, in gaining freedom, they are afraid of repression, and begin to prescribe, or force their beliefs and decisions on other nurses, who may think or believe differently than them.

Although the profession has made significant strides in the past several decades, it must continue to develop itself as a profession, achieving educational and experiential status. These are goals that will enable them to sit at the policy table and be seen as equally deserving of a voice in making health care decisions.

Incivility in Nursing

Throughout the nursing literature, there is concern for the nursing shortage, for nurses leaving the profession, and for the discontent expressed by nurses in the profession (Aiken, et al., 2002; Vessey, Demarco, Gaffney & Budin, 2009). The literature is rife with the discussion and documentation of incidents of incivility, also known as lateral violence, bullying and other terminology mentioned under inclusion criteria for the search of literature. Stagg, et al. (2011) report that, in a study conducted in a similar area as this study, 80% of nurses had been victims of workplace bullying in the previous year.

Examples of this type of treatment by fellow nurses, and other colleagues has been identified as physical, emotional, or verbal violence, being rude, critical, being ignored or shunned by others, or not being given essential information with which to do a job, to mention only a few (Center for American Nurses, 2007). It may be readily identified, or it may be discreet and not readily discernible. It not only affects new nurses, it may be directed at nurses at all levels, including nursing students

(Randle, 2003).

On July 9, 2008, the Joint Commission issued a sentinel event alert concerning rude and disruptive behavior in healthcare settings, stating that:

…intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators, and managers to

seek new positions in more professional environments. Safety and quality of patient care is dependent on more professional environments. Safety and quality of patient care requires teamwork, communication, and a collaborative work environment. To ensure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team (p. 1).

In 2008, the American Psychiatric Nurses Association issued a position statement recognizing violence in the workplace as a pressing occupational concern, and took the stand that managers must create and maintain supportive work environments. Nurse educators must include workplace violence and conflict management in the curriculum.

In an editorial piece for the Association of periOperative Nurses Journal

(October 2011), Patricia Seifert, MSN, RN, CNOR, CRNFA, FAAN discussed the costs of bullying in nursing. She states that we know what we must do, but asks, are we doing it? Things like: How do we mandate accountable behaviors? Is the zero tolerance policy consistently enforced, and by whom? How do we educate staff about accountable behaviors? Who does the training and what is that trainer’s own track record? How do we document abusive behavior, and what has been the result of the past documentations? What has happened to the whistleblowers? (p. 326). She also talks of the financial costs such as increased absences, staff turnover with replacement costs between $60,000 to $100,000; increased stays for patients; lack of payment for regulatory compliance with standards; reduced patient satisfaction and

the facility’s reputation; increase in errors and ‘never events’ and fines for mistakes

(p. 327). Seifert makes the point that until we make the case for appropriately civil behavior, and put it in terms, dollars and cents, terms that can be understood by administrators, only then will we strengthen the case for change and have influence in the nursing workplace.

Carolyn Buppert, N.P., J.D. wrote a column in Medscape Nursing (September

14, 2010). In it, she stated that nurses cannot sue if they are bullied at work. The reason is that there is no legal definition of bullying. Should the behaviors become harassment or assault, there may be legal recourse, as there is a legal definition for those terms.

It is suggested that when addressing bullying or horizontal violence, the focus be on the impact on financial and economic costs associated with the problem, rather than on the individual impact. Our definition may be too narrow and not one that is understood by the administration, or seen as important to the institution or its mission

(Seifert, 2011).

Administrative Support

Stagg, et al. (2011) identify that it is important for manager and administrators to participate in trainings for workplace violence that include incivility, or bullying, as well as to enforce the policy at all levels of management. It is also their responsibility to see that employees are made aware of the policy.

Important to nurses feeling comfortable, being committed to their facility, and to feeling included in the workplace is the communication they receive from coworkers, but especially from their managers and administration. Porter-O’Grady

(2010) identifies the leader as essential in making change in the health care environment, but cautions that the behaviors in systems are unpredictable and the manager must understand relationships and interactions. People in a system are constantly relating and interacting and giving feedback to one another. Knowing and understanding human communication and responses will serve the manager and the system well. It is up to the manager to create a balance in the system. In order to do that, the manager must be visible and accessible, becoming aware of the changes and variances in the responses of the components of the system (the individuals).

Support from managers is very important to the individual nurse on the unit.

Kovner, Brewer, Fairchild, Poornima, and Djukic (2007) conducted a study of newly licensed nurses and found that they “believed they had only mild support from supervisors” (p. 341). Of those interviewed, 41% would have left their nursing position if they were free to do so; work related injuries were as high as 46%; 62% had experienced verbal abuse; and 13 % had left their prior nursing positions.

Several studies revealed that work environments, especially ones in which interactions were civil, were predictors of satisfaction and of organizational commitment in nurses (Laschinger, Leiter, Day, & Gilin, 2009; Nedd, 2006; Stone,

Mooney-Kane, Larson, Pastoe, Zwaniger, & Dick 2007).

Mullenbach (2010) asked senior nursing students to design a plan to recruit and retain nurses on a medical-surgical unit for five years. The timeframe was selected based upon Patricia Benner’s (2001) theory on the development of nurses from novice to expert (proficient). Her theory finds that nurses, who remain in the same setting, and with increased knowledge and experience in that practice area, achieve competency within three years and expertise within five years.

The model Kereen F. Mullenbach, PhD, RN (2010) had developed by nursing students, who were seniors, included staff that were accepting, preceptors who were supportive and managers who were supportive. Also important were loan repayment programs, educational opportunities, empowerment and autonomy, and leadership education, and co-workers who were positive.

In 2010, Chullen, Benjamin, Angermeier, Boss, Alan, and Kirby conducted a study that investigated the effects of supportive leadership and job design. They found that the likelihood of deviant behaviors (harassment, bullying, and aggression) was positively correlated to their relationships with their leaders or supervisor/manager. If they felt that their relationship with their manager was high quality, the chance of deviant behaviors was lessened, providing “empirical evidence that supportive management practices and enriched work design can build a committed, productive workforce and reduce the occurrence of deviant behavior” (p.

394). This is interpreted that if the manager is supportive, engaged, knowledgeable,

trusting and provide feedback regularly, the staff will be supportive, engaging, friendly, and welcoming to new nurses.

Preceptors and Mentors

The roles of preceptors and mentors are often seen as being the same. By definition, a preceptor is “an experienced and competent staff nurse who has received formal training to function in this capacity and who serves as a role model and a resource person to new staff nurses” (Alspach, J. G., 2000, p. 2). A mentor is someone who picks up when the perception, or orientation period, ends. While preceptors are assigned, mentors are either chosen or assigned. (Modic & Schoessler,

2007). Mentors may continue their role for several months or years, and the mentee may choose to replace the mentor as the mentee’s role and professional goals change.

Preceptorship is a process that accompanies orientation; it is on-boarding, into an organization’s systems and routines. On-boarding, which follows orientation, and involves precepting, and mentoring, brings a person into an organization and plans for performance management, developing skills, planning for their career, and allows for succession planning in the organization. It is also a process of helping the employee form good relationships and helping them move through important phases of their development (Velsoft, 2011). This process usually takes several months and, if done properly and with the needs of the individual and organization in mind, will save the organization financially. The cost to replace a nurse is estimated to be at least three

time their yearly salary. It is important for these programs to be systematic,

comprehensive, consistent, strategic, and integrated (2011).

Preceptors have different strengths, talents and levels of expertise (Modic &

Shoessler, 2007). These things should be taken into consideration when pairing a

preceptor with a new nurse. Often the assignment is done by convenience, or the new nurse may be assigned a different preceptor often during the perception period. This approach is not found to be beneficial in meeting the roles of the precepting as defined by J. G. Alspach (2000): “role modeling, socializer and educator, with a fourth role of designer of the environment “(p. 2). He does address the role of primary preceptor, with others also serving as additional preceptors, but with the experience being guided by the primary preceptor, and involving communication between those preceptors involved in the experience. Coordination and communication are the key ingredients in a multiple preceptor experience.

A mentor program one that begins when the initial orientation or preception period ends. The mentor continues the facilitation of the new nurse’s introduction and learning of the organization’s culture, understanding and becoming a member of the team, utilizing of time management and preparing for advancement and professional development (Ellisen, 2011). Mentors are selected on their ability to have positive influences, are team players and upon their ability to deal with difficult situations, and provide quality nursing practice. There are two types of mentors, the assigned mentor and the chosen mentor. The first is usually assigned at the end of the

initial orientation, and the second is chosen by the individual to further their professional goals and career development (Modic & Schoessler, 2007).

Young and Wright (2001) make the statement that “Anyone who pursues a profession wants to be successful.” (p.1, para. 1). Nurses do not enter the employment of an organization with the intent to leave, yet up to 69% of new nurses leave (Persaud, 2008). What needs to happen for those new nurses to stay?

Rather than short-term planning for an organization, planning for the long- term is more beneficial for an organization. The program needs to be planned and organized; and the participants need to be selected for their attributes and trained. It is costly to replace employees, especially in health care. Retention is the key to cost containment and quality. Planning for a program that will not only orient new nurses, but also plan for their development and retention is a key to the financial viability of the hospital and to positive patient outcomes.

Professionalism

Throughout the literature, there is documentation of incivility and poor treatment of nurses by others. Professionalism is most emphasized in the literature of the medical profession (Cherry, 2011). It is defined as “an explicit set of behaviors and values that require ongoing learning and development” (2011) that are required by a profession such as nursing. These are behaviors that are included in the curriculum and in objectives for all programs of nursing education. Since the time of

Florence Nightingale, nurses have valued and espoused their importance. 39

The literature is rife with incidents of unprofessional behaviors that influence nurses to leave the profession or to leave their first positions. While the nurse learns and incorporates professional behaviors during their nursing education program, it is up to the individual employer and to the profession to police the actions of the individual nurse once in the employment setting. If the behaviors are not addressed by individual nurses, employers, or boards of nursing, they will continue, and the problem of incivility or being unprofessional may become cyclical, and nurses may continue to leave their places of employment or their nursing practice altogether.

“Nursing education is very strong in the pedagogies….that are effective in helping students develop a deep sense of professional identify, commitment to the values of the profession, and to act with ethical comportment” (Benner, Sutphen,

Leonard & Day, 2010, p. 11). When nurses enter the workplace, they are treated by some other nurses with sarcasm, disdain and less than professional courtesy. If we are to assume that all nurses enter the profession with a desire and instruction to “act with ethical comportment” (2010, p. 11) what happens to nurses to have them lose sight of that teaching?

Benner (2001) presents us with the stages the nurse progresses through as he/she develops as a nurse. It has to do with acquiring knowledge and clinical experience, but may be pertinent to the way nurses are regarded by other nurses.

Benner utilizes the Dreyfuss (1980) model as it applies to nursing. As the nurse gains knowledge and experience, they move through five levels of proficiency, from novice 40

to expert. The changes experienced are related to three categories of skill performance. They are: “a movement from reliance on abstract principles to the use of past concrete experience as paradigms” (Benner, 2001, p. 13); “a change in the learner’s perception of the demand situation, in which the situation is seen less and less as a compilation of equally relevant bits, and more and more as a complete whole in which only certain parts are relevant” (p. 13), and “a passage from detached observer to involved participant” (p.13).

Novice and advanced beginner nurses are able to take in only a portion of the situation they are involved in. For a nurse to become a competent practitioner takes two or three years in the same situations, and thinking of their actions in terms of the long range results, being able to analyze and contemplate problems abstractly

(Benner, 2001).

Nurses, who have been at their jobs for several years, are at the proficient to expert level. When novice, or advanced beginners, come to the units, they are not at a level comparable to that of the nurse who may have been there a long time.

Professional behaviors would be identified as helping, supporting, respecting and encouraging other nurses, in order to develop them to the competent or expert level.

Combined with the frustration and stress of the profession, they are seen as being unable to perform up to other nurses’ expectations if they are in the same level position, assigned the same responsibilities as the more experienced nurses, and have

many questions. This breeds incivility and unprofessional behavior, when combined with job stress and heavy workloads.

Facilities of Excellence and Magnetism

Identified in the nursing literature are ‘centers of excellence’ and facilities that have entered into a journey for Magnet® recognition by the American Nurses

Credentialing Center (ANCC) (2011). While the number of Magnet® facilities is constantly changing, as of October 31, 2011 there were 391 facilities worldwide with

Magnet® status (2011). Very rigorous to attain and to maintain, this status helps hospitals:

• Promote a setting that supports nurses • Find the best ways to deliver nursing care to patients • Develop and deliver successful nursing practices (ANCC p.1) The benefits to recognition are nursing quality care, improved patient results, patient safety, the work environment, nurse satisfaction, nurse recruitment, and nurse retention (ANCC, p. 1) the exemplars that are studied during a certification journey are:

• Transformational leadership • Structural empowerment • Exemplary professional practice • New knowledge, innovations & improvements (ANCC, p.1).

The area that is to be studied in this research includes one Magnet® hospital that has seen a positive impact on recruitment and retention, as well as in patient

outcomes since beginning the journey to recognition (personal communication,

Bilconish, 2005).

Conclusion

This chapter has given a summary of the more recent history of nursing, as it has developed as a profession, nursing education, and nursing’s professional foundations. The theory of oppression has been discussed as it pertains to nursing.

The issues of incivility, professionalism, the professional maturation of the nurse, the methods of incorporating the nurse into the profession, and the supports needed for the success of the new nurse have been addressed.

Chapter III

Methodology

“Were there none who were discontented with what they have, the world would never

reach anything better.” Florence Nightingale (n.d.)

Introduction

There is a nursing shortage projected to have enormous impact on health care in the United States and worldwide. Many government and nursing organizations have endeavored to find causes and possible solutions to the shortage of both nurses and nurse educators. The shortage is still projected to worsen. To compound the problem of the nursing shortage, newly licensed RN’s are reported to be leaving their positions in the first years of practice (Ferrell, James, & Holland, 2011; Kovner, et al.,

2007; Rheaume, et al., 2011).

I began my inquiry into the problem of nurses leaving the profession to explore what it is that motivates them to leave either their first nursing positions or the profession. I had questions. I was aware of the statistics, and had seen that new graduates were leaving; some of whom I instructed to be nurses. I thought I had helped to instill in them the pride and love of the profession. I felt as though I had failed them--as if nursing had failed them. I wanted to know ‘why’? What were their experiences? What were their perceptions of their nursing work environment?

There were few studies that examined the experiences of nurses who were in the first years of practice. Some studies identified reasons for burnout or for dissatisfaction in nursing (Oermann & Garvin, 2002; Perry, 2006). There was a dearth of research that looked at the actual experiences of nurses in their first years of practice and their perceptions of those experiences.

This chapter addresses the reasons for selecting a qualitative research design and steps to gather data. It discusses methods to collect data, and to ensure its trustworthiness and credibility. The steps in the process to have the research project approved and the development of questions, record keeping and confidentiality agreements are outlined. There is discussion of each phase of the process along with references for doing such. The basis of this research study centers on two questions examining the perceptions of events experienced by newly registered nurses. The first question is: What are the perceptions of newly licensed nurses concerning their reception when entering the nursing workplace? The second research question is:

What are the perceptions of new nurses regarding support from administration and preceptors/mentors?

Choosing a Research Design

A qualitative methodology was selected to explore the participants’ experiences, as it is the human experiences that are desired to be captured and not pieces of measurable material sources. I wanted to listen to the stories of these RNs, explore their thoughts and how they made meaning of their experiences (Lincoln & 45

Guba, 1985; Maxwell, 2005; Merriam & Associates, 2002). I wanted to begin to understand how those experiences affected their decisions about their professional careers.

Qualitative research studies look at the process by which one event will influence another (Weiss, 1994). These are effective methods of inquiry for the social sciences because they look at naturalistic phenomena, experiences in the natural world (Denzin & Lincoln, 2003). These methods use multiple interactive and humanistic methods to focus on context, look at the data as they emerge, and are interpretive (Marshall & Rossman, 2006). Qualitative research was appropriate to study the experience of these participants as it examined their stories with depth and in detail. It allowed the researcher to go beyond what was seen and to enter the other’s perspective and gain insight into their feelings and emotions attached to their stories (Patton, 2002). These are the reactions that individuals have to what they have experienced, interpreted in their mind and about which they have formed conclusions.

Meanings can change over time. It is only the meanings at this particular point in time that were studied.

Individuals interact with their world, their workplace, home, social setting and make meanings of their experiences (Merriam & Associates, 2002). These experiences then influence their behaviors and shape realities for the individuals

(Guba & Lincoln, 1981; Merriam & Associates; 2002). The researcher interprets the

data in relation to the meanings that the studied individuals give to them (Denzin &

Lincoln, 2003; Maxwell, 2005).

There is a goal of exploring the issue more deeply, to be done with attention to detail, consideration of the context of the experience and with attention to the unspoken, the nonverbal innuendos or cues that give further meaning to the spoken data. It explores and delves more deeply into the experience than do the survey methods used in quantitative research (Lincoln & Guba, 1985; Maxwell, 2005;

Merriam & Associates, 2002, Patton, 2002).

In qualitative research the data collected cannot be measured by amount or frequency or numbers of occurrences (Denzin & Lincoln, 2003). The instrument for qualitative research is the researcher. Merriam (1998) spoke to this: “the researcher is the primary instrument for data collection and analysis. Data are mediated through this human instrument” (p. 7). He/she must rely on his/her own skills and talents of investigation, insights, and trustworthiness (Ely, Anzul, Friedman, Garner &

McCormack-Steinmentz, 1991) to interpret and report findings. The researcher observes, analyzes the data, and becomes a part of the naturalistic inquiry -- investigation in the natural environment. The interviewer is constantly looking for data that are out of the ordinary, different and unique (Guba & Lincoln, 1981). As the data are collected, inspected, interpreted and validated, the researcher develops a distinct visual image of what they have learned from the participant and the data

(Guba & Lincoln, 1981; Merriam & Associates, 2002). 47

Guba and Lincoln (1981) discuss the interviewer’s use of holism in qualitative investigation. He/she inspects the world being studied from a perspective that uses the visual, auditory and olfactory senses as they become immersed in the stories of those being studied. This process is described as examining the world of the participant as a seamless cloth and examining only one section at a time, but in a continuous context within which the participants exist, live and experience life.

Additionally, it is necessary to collect data on several participants simultaneously, coding and interpreting them as they are collected (Maxwell, 2005).

Manning (1960, as cited in Maxwell, 2005) gives the metaphor of the mountain climber who begins lunch immediately after breakfast, stopping lunch only briefly to eat dinner. So it is with the handling of qualitative data that begins immediately after the first interview and continues for the length of the research period.

Since I am also a RN with a history in the nursing community, it was important to recognize that fact and consider it when collecting and examining data from the interviews, and to remember that I had a frame of reference from my own nursing and workplace experiences. Holtzner (1969) is cited in Hagell (1989) as describing knowledge as the “mapping of experienced reality by some observer” (p.

227) that serves as a point of reference for the researcher and the data analysis. These frames of reference are important in understanding. They develop from the individual’s interaction in their world and situations, especially in work or occupational communities. As a researcher, I was aware of my own point of 48

reference and recognized that it could influence my observations and the interpretation of data.

Risk Benefit Analysis

There was minimal risk involved for the participants in this study. Any risk was that they could have been discussing situations that may have bothersome to them and to which they did not know how to respond. These situations were addressed with information that was made available to the participants at the end of the interviews should they have been needed.

Benefits gained from participation were minimal. They included the ability to flesh out more appropriate responses simply by discussing their experiences and the knowledge that they may have assisted to help in the creation of more acceptable workplaces for some of their colleagues.

The study was first be approved by the Wilmington University Human

Subjects Research Committee to ensure that there would be no harm to human participants involved in the study. It was with the committee’s approval that the study moved forward (Appendix A).

Sampling and Participants

Sampling in qualitative research is made with the depth of the inquiry into the issues in mind. Qualitative methods produce rich data from smaller number of subjects or cases than in quantitative research (Patton, 2002).

The most important consideration in qualitative research design is selecting individuals who can provide the information needed to answer the research questions

(Weiss, 1994). This is criterion-based selection, purposeful selection of a particular case or subject because they meet the purpose or criterion selected for the research

(Patton, 2002). In this case, participants were registered nurses who were in their first years of practice. It was this group who provided the richness of data and experiences that was studied.

The participants represented a segment of the nursing workforce that was reported to be at risk for leaving the profession due to issues of workplace dissatisfaction (Ferrell, et al., 2011; Rheaume, et al., 2011). For the purposes of this study, the geographic area of sampling was the lower Eastern Shore of Maryland.

Twelve RNs were asked to voluntarily participate in the study and were subsequently interviewed both individually and in focus groups. Participants involved in the study were employed in hospitals, nursing and rehabilitation centers and home health agencies on the Lower Eastern Shore of Maryland, so that a variety of settings were represented. Participants were from both associate degree and baccalaureate nursing programs to provide a blend of nursing education backgrounds. This process of selection also provided homogenous sampling, individuals who had common experiences (Creswell, 1998).

Inclusion criteria for participation in the study were: participants that were licensed as RNs in the State of Maryland or a compact state; they were within five 50

years of beginning their first nursing position; they were at least 18 years of age; and they were employed in a health care facility on the lower Eastern Shore of Maryland

(for geographic limitations and convenience).

Exclusion criteria for participation in the current study included: anyone who was not licensed in the State of Maryland or a compact state; any RN greater than five years from entering their first nursing position; anyone not 18 years of age or older; and any RN employed in a health care facility not on the lower Eastern Shore of

Maryland.

Data Collection Procedures/Sources

After approval of my dissertation proposal committee, a Human Subjects

Research Committee (HSRC) packet was forwarded for approval by the Wilmington

University HSRC.

Upon receipt of approval from the HSRC (Appendix A), participant recruitment was both purposeful and convenience sampling, from those who stated interest upon hearing that the study was being conducted and referrals from colleagues who know a newly licensed RN in Maryland. Letters of invitation were sent to those individuals who expressed interest in participating (Appendix B). As they replied, I scheduled appointments to meet with them, explained the study and their involvement, and had them sign informed consent forms (Appendix C).

Participants completed a demographic data sheet (Appendix D) containing a pseudo-

name for the purposes of the study. We then set up a mutually convenient date and time for a first interview.

Grounded Theory

Glaser and Strauss (1967) identify the concept of grounded theory. While they state it is applicable to both quantitative and qualitative research, it will be discussed here as applicable to qualitative research. It is a systematic method of analyzing data and identifying conceptual categories that lead to theory. Otis

Simmons (2011) of the Grounded Theory Institute ( www.groundedtheory.com ) outlines this process, and steps that are performed, often simultaneously, as the data are produced. These steps are: preparation, data collection, analysis: constant comparative analysis, memoing, sorting and theoretical outline (Glaser & Strauss,

1967; Guba & Lincoln, 1981; Merriam & Associates, 2002; Patton; 2002; Simmons,

2011). “…grounded theory emphasizes systematic rigor and thoroughness from initial design, through data collection and analysis, culminating in theory generation”

(Patton, 2002, p. 489). It is not assumed that this study will produce grounded theory, but following the precepts of its design will more likely ensure trustworthiness and credibility.

In order to prepare for this journey, I put my own preconceived ideas and knowledge of the nursing experience aside so that I could control any researcher bias.

Maxwell (2005) discusses researcher bias as something that is widely recognized in qualitative research (Denzin & Lincoln, 2003; Glaser & Strauss, 1967; Guba & 52

Lincoln, 1981; Lincoln & Guba, 1985; Merriam & Associates, 2002; Patton, 2002).

Doing minimal research prior to the study and partially completing Chapter 2 limited this, therefore, only the historical portion was completed. Throughout the research period, this was limited by member checks (having participants review transcriptions and summaries regularly) (Marshall & Rossman, 2006; Merriam & Associates, 2002;

Patton, 2002; Seidman, 2006) and by triangulating the data, discussed further on in this chapter.

Data Sources

Three sources of data are important in qualitative research studies (Maxwell,

2005; Merriam & Associates, 2002; Denzin & Lincoln, 2005). Those used in this study were audio-taped personal interviews, audio-taped focus group sessions, transcriptions of individual sessions and focus group sessions, field notes taken during and after individual and focus group sessions, memos, and demographic data.

Audio taped Interviews. The RNs’ interviews were the primary source of information, as it was those experiences that yielded the richest data to answer the research questions (Merriam & Associates, 2002). These were informal, yet semi- structured, conversational interviews that allowed the participants freedom in the telling of their stories, yet allowed the interviewer to collect some specific information from all participants (2002). Patton (2002) cautions the researcher that time is a precious commodity in interviewing. It is important to maintain control over the interview and control long-winded responses and digressions by being 53

knowledgeable about what is to be found out, using focused questions, attentive

listening, and use of appropriate verbal and nonverbal skills. Patton (2002) advocates

the use of open-ended questioning to allow people to give their own spontaneous

answers and to reduce the influence of the question on the response. I was the

interviewer in this study, and am an experienced and credentialed psychiatric clinical

nurse specialist, trained in the use of interviewing and therapeutic communication

skills (Appendix E).

Interviews were conducted in mutually agreed upon settings that provided

privacy and were free of distractions, such as cell phones and extraneous noises. The interviews were informal, yet semi- structured, conversational, ethnographic interviews (Patton 2002).

Questions that were asked in this study included, but were not limited to the following:

• Describe the experience of your first few years of employment as a registered nurse. • How do you feel other nurses have received you? • What experiences stand out in your memory? • What have your experiences with other professionals been like? • How has this affected your career or your decisions about your career? • How did it affect you personally? • How well do you feel your nursing education program prepared you for your role?

• Have you ever thought of leaving nursing or your present job because of your experiences? • What do you think would improve the experience for new nurses?

Other questions were appropriate as they emerged from the conversational interview, and were used for clarification, or to maintain the flow of conversation.

This was the case for both the individual and the focus group sessions.

Focus group sessions were conducted with participants once the individual interviews are completed. Focus groups are important in qualitative research. They enable the interviewer to access data quickly, and can yield a wider variety of information (Marshall & Rossman, 2006). These groups generally require participation for one to two hours and involve 6 to 10 participants (Patton, 2002). In the group, participants get to hear others’ responses and may provide further data beyond their initial interview(s) (2002). Guba and Lincoln (1981) recommend that group size be kept to three to four people because there are disadvantages to a larger group which include: difficulty controlling more than one person talking at a time, one member may be overpowered by another or feel uncomfortable voicing, and with larger groups there is less opportunity for interaction with the interviewer (p. 161).

The groups in this study involved three participants and lasted approximately one hour.

All interviews, both individual and group were audio taped and transcribed as soon as the interview was completed. Every effort was made to transcribe them as they were given, with notation to inflection, expression and any nonverbal

expressions or innuendos. These gave different meanings to pieces of data.

Transcriptions were shared with the participants and verified for their correctness and meaning, a method known as ‘member checks’ to ensure the trustworthiness of the data. (Guba & Lincoln, 1981). Participants made comments on them, and they were then modified. Transcriptions from group interviews were shared with all members in the group for validation.

Transcriptions were done using pseudo-names that the participants selected for themselves. Each participant’s interview was given a different colored paper for transcription, to readily differentiate data. Coding is discussed further in this chapter; the process will be completed as each interview is transcribed.

Field notes. Field notes were kept simultaneously with the interviews and transcriptions and became part of the data. The keeping of field notes, and journaling allowed me to reflect on my own thoughts and objectivity. They also allowed me to remember body positions, facial expressions, outward displays of emotion, and other observations that gave the verbal data different meanings. Field notes are important to qualitative analysis because they are what the researcher observes in the interview and will be important in interpreting the data obtained in the interview (Patton, 2002).

For instance, if I interview a registered nurse, and he/she comments that he/she are treated well by their peers, but at the same time tears begin to well in their eyes and they look away, those observations will not show in the audio tape. They must be noted in the field notes or the data, and when transcribed, may take on a different

meaning. These are the description of the circumstances of the setting, the participant, the nonverbal responses and the researcher’s feelings and observations.

The researcher should consider everything they feel is worth noting during data collection. Patton (2002) emphasized:

If it’s important as a part of your consciousness as an observer, if it’s information that has helped you understand the context, the setting, and what went on, then as soon as possible that information should be captured in the field notes. (p. 302-303)

Nothing should be left to recall later; one may forget, or view it differently at various points in time. The use of field notes assumes that all behavior has meaning and purpose and is indicative of deeper values and beliefs (Marshall & Rossman, 2006).

Field notes were recorded accurately and thoroughly, with specific, concrete examples of what was observed. They were recorded as such, with examples and with notations, and then summarized, as soon after the session as was possible (Guba

& Lincoln, 1981). These were my observational records of what transpired during the sessions (Marshall & Rossman, 2006).

Qualitative research also is a process of self-discovery, finding out things about oneself that was not known or recognized (Richardson 1994, 1997, in Denzin &

Lincoln, 2003, p. 283-284). This self-discovery is facilitated by the use of field notes.

Data Analysis

Data came from the individual interviews, the focus groups, member checks,

and field notes of the researcher. Interviews were audio taped and then transcribed.

The researcher transcribed all of the audio taped individual interviews and focus

groups. This enabled the researcher to further review the interviews and reflect upon

them as they were being transcribed. This also ensured the accuracy of the

transcriptions.

Coding. The data collected in the form of transcriptions of interviews and focus groups were then coded. Miles and Huberman (1994) describe codes:

Codes are tags or labels for assigning units of meaning to the descriptive or inferential information compiled during a study. Codes usually are attached to “chunks” of varying size – words, phrases, sentences or whole paragraphs, connected or unconnected to a specific setting. (p. 56)

“Coding is two simultaneous activities: mechanical data reduction and

analytic categorization of data into themes” (Neuman, 2000, p. 421). Coding helps to

organize the data in a way that is helpful and meaningful to the researcher (Charmaz,

2005). The data must be sifted through and sorted into pieces that are manageable

and organized as to themes that occur in the data. For instance, when reviewing

transcriptions of interviews of retiring nurses, a recurring theme might be concern for

identity (being threatened by giving up that part of self that is a nurse). All parts of

interviews that indicate this theme would be relegated to comparable data.

Strauss (1987) identified and defined three types of data coding for qualitative data, which he describes as a three-step process. They are: open coding, axial coding, and selective coding. Open coding was the first attempt to sort data. Initial labels were assigned after reading over field notes, transcriptions and other data, identifying possible themes, terms, or events. These themes may come from a theory or from the research questions (Neuman, 2000). A list of open themes is made after open-coding in order to help the researcher see the themes easily; it allows the researcher to find themes in future coding; and it enables the researcher to use it to build a portrait of all the themes in the study, reorganizing, sorting, combining, discarding or extending them (2000, p. 423).

The second examination of the data was to perform axial coding. I looked at the themes and initial coding to see if any themes could be added, or if any could be broken down more specifically. I further organized the codes, identifying axial or key concepts in the data. Of particular interest were any causes, consequences, or categories that clustered together. Axial coding will raise questions as well as stimulate and guide further thinking about the data. Support for some themes will gain strength and some will be weakened, but some core themes will emerge. A web of connectedness will begin to build, giving the research reliability as empirical evidence is identified (Neuman, 2000). The researcher, when coding data looks for patterns, ideas or events that occur with regularity (Patton, 2002). Some data will

dovetail into particular category, while other data will differ greatly and fit into

another category.

The third examination of the data involved selective coding. At this point the

major themes were already identified and the concepts were well developed. The

researcher scanned the data looking for cases that illustrate the core ideas that have

were extricated from the data (Neuman, 2000). More than one major theme will be

elaborated upon when the specific themes are reorganized.

Guba (1978) identified some criteria to test for completeness of the coding.

The set should have integratability, the categories should appear to be internally and

externally consistent, and the set should give a whole picture of the issue. The set of

codes should be inclusive of most of the data and should cover the varied views of the

issue. The set of themes and categories should be able to be reproduced by another

competent researcher or auditor. The set of categories should have credibility when

viewed by the participants who provided the information.

Memo-writing. When coding was accomplished, I wrote code notes. These were notes and questions that were written as the themes appear. It opened up the data by raising questions about the properties of the themes (Merriam & Associates,

2002). Each memo that was written was about a certain thought or theme and contained a discussion of the theme. These served an analytical purpose, providing a

bridge between the concreteness of the data and more abstract analytical or theoretical

thinking (Neuman, 2000).

Trustworthiness

Researcher as instrument. In qualitative research, the researcher serves as

the research instrument, becoming involved with the subjects and, as such, may hold

a bias. This can happen anytime the researcher is also the interviewer. Those biases

can affect the generalizability of the study, the ability to apply the inferences about

the group being studied to another group (Lincoln & Guba, 1985; Merriam &

Associates, 2002). To minimize this bias, I protected from this by the vigilant use of

member checks, participants checking the summaries and transcriptions at points in

the process (Merriam & Associates, 2002) and use of the constant comparative

method.

Lincoln and Guba (1985) discuss Glaser and Strauss’s (1967) concept of the

constant comparative method, in which the researcher uses a four-stage approach to

analyzing data. “The process of constant comparison stimulates thought that leads to

both descriptive and explanatory categories” (Lincoln & Guba, 1985, p. 341).

Triangulation. Triangulation is a means of validation, maintaining trustworthiness and reducing the risk of bias by using multiple methods to collect data

(Denzin & Lincoln, 2005). Triangulation strengthens a study and ensures trustworthiness by using multiple data collection methods and constantly comparing

them (Patton, 2002). This involved the regular and constant comparison of data from interviews, focus groups, field notes, and memos, as well as member checks, validation of transcriptions by the participants. This multiple method approach allowed me to investigate the data through the use of several tools and comparing the results and allowed me to come to a broader and more substantial understanding of the issues.

Ethical Concerns

The purpose of this study was to learn about the participants’ experiences.

Since I may also have needed to assume a role of advocacy and action, this had to be taken into account when analyzing and interpreting the collected data (Marshall &

Rossman, 2006).

Confidentiality was guaranteed to the participants through the researcher and

Wilmington University’s Human Subjects Review Committee. Each participant was given a confidentiality agreement, and signed consent to participate forms (Appendix

C). Having meetings conducted in private locations, such as on the campus of Wor-

Wic Community College, Salisbury, MD, further protected confidentiality. They were assured that participating in the study was strictly voluntary and no repercussions would ensue for refusing to participate or dropping out of the study.

Participants selected pseudo-names to ensure anonymity. The participants’ real names were not recorded on any forms or parts of written or transcribed documents.

Data Management

In order to maintain anonymity and confidentiality of the participants and the data, all material was and will be kept safely. All hard copies, such as demographic data sheets, confidentiality agreements, participation agreement, transcriptions, field notes, and audio-tapes of the interviews and focus groups, as well as files on the researcher’s flash drive are kept in a locked file cabinet in the researcher’s office.

Records on the researcher’s computer are password protected, and I remain the sole keeper of the password. Records will be kept for three years, or as long as required by Wilmington University’s HSRC committee. After that period, all records will be discarded in an acceptable manner.

Chapter IV

Findings

“Sometimes you have to be able to see the invisible in order to see the truth.”

Anonymous . (n.d.)

Introduction

In a rural, tri-state area in the mid-Atlantic region of the United States, there are three schools of nursing within a 40-mile radius. They prepare students for entry- level competence, to qualify to take the National Council Licensure Exam for registered nurses (NCLEX-RN), and to enter into the practice of nursing. These students are eager to care for patients and to begin their careers as registered nurses.

They are excited and full of anticipation to fit into the world of their new colleagues.

This research study contains the stories of twelve of these registered nurses and their experiences during their first one to five years in practice.

The intent of the researcher in conducting this study was to explore, and attempt to understand and interpret the experiences of new nurses in their first five years of practice upon graduating from their primary nursing education program. I hoped to identify issues that might lead to position or employment changes, and to seek to understand interrelated areas that might influence those experiences. The participants are registered nurses who had attended any of three types of nursing education programs, diploma, associate degree, or bachelor degree.

Denzin and Lincoln (2003) identify the importance of the researcher making a descriptive account of what has been learned that relates the true essence of the participants’ nursing experiences. To do that, the data were collected through individual interview sessions, focus group sessions, demographic information provided by the participants, and field notes collected during individual and focus group sessions.

The participants completed the demographic information tool created by this researcher, at the time of the first meeting and after they had signed the informed consent document. The tool was developed to collect data about educational settings, practice areas, gender and ethnicity, intent for further education and certification, and contact information.

The information gleaned is described in different parts of this chapter. The participants are introduced and demographic information provided. Their shared stories, particularly significant events in their nursing experiences, are told. Finally, common themes extracted from the coded data are discussed.

Participants

The participants in this study were selected as a purposive sampling, because they were conveniently available and the researcher wanted to examine a particular group in depth: registered nurses in their first one to five years of practice, in depth.

(Neuman, 2000; Patton, 2002). These 12 nurses were selected because they met the

timeframe of practice, they were in the practice area, on the Eastern Shore of

Maryland, and they were willing to participate. The participants were all asked to select a pseudo-name, which would protect their anonymity. These are used in this chapter.

Of the twelve participants, two are male, 10 are female. One is of African-

American descent, 11 are Caucasian. Three are older than 40 years of age, with the youngest being 22 years of age. Three of the nurses practice in more than one nursing setting, two participants practice in home health settings, while three practice in long-term care, and the remaining nine practice in acute care settings.

Demographic Characteristics : Table 1

Characteristics Total F (N=12) # % Race African-American 1 9 Caucasian 11 91

Gender Male 2 17 Female 10 83

Age 20-25 5 41.6 26-30 1 8.3 31-35 2 16.7 35-40 1 8.3 41-50 2 16.7 51-60 1 8.3

Practice Area Home Health 2 14.3 Acute Care 3 21.4 Long-term Care 9 64.3 *2 practice in more than one setting

Plans to continue/already 7 59 participating in further nursing education

Seeking advanced 5 42 certification

The Interviews

Interviews were conducted individually with each participant. The length of the interviews averaged 63 minutes in length. Eight interviews were conducted in a 67

classroom of the Allied Health Building on the campus of the local community

college. The classroom was not in a heavily traveled area and was secured. Four of

the interviews were conducted in alternate locations for the convenience of the

participants. Two interviews were conducted at the interviewer’s home, which was

free of other people and the phone and television were not in use. Another interview

location was a Sunday school classroom at a church in the participant’s hometown;

and one other was conducted at the participant’s place of employment in a room that housed an outpatient program, but was unused at the time. These locations were secure and free from interruptions. The lighting in the rooms was adequate and the ambient temperature was 73 to 76 degrees Fahrenheit.

Interview questions were open-ended in order to elicit the most information from the subjects in their own thoughts and words. Questions were: “Tell me about your practice in nursing.” And “What is (are) the most rewarding (or the most troublesome) events in your nursing career?”, “What suggestions would you make to improve the profession for other new nurses coming into the profession?”

The interviews were audio taped with a digital voice recorder. The interviews were transcribed using a Microsoft Word® and an Express Scribe® transcription system. The interviews were saved to a portable flash drive and to compact discs.

They will be kept secure in a locked location, along with field notes and demographic information, accessed only by the researcher for a period dictated by the Wilmington

University Human Subjects Review Committee. 68

Minimal field notes were taken during the interviews. After the interviews, I

made notations as to the affect of the participants, their body posture, their verbal and

nonverbal communications, and the manner of speech during the interviews, as well

as the attire of the participants, and the environment. These field notes enabled me to

have a better feel and recall of the entire situation as I transcribed the interviews.

Focus Group Sessions

After the interviews were reviewed and coded, two focus group sessions were

scheduled at varying times so as to accommodate the work hours of the participants.

There were no participants who were able to attend the first session. Three

participants attended the second session.

The Participants

Amanda. I first met Amanda when she was in a psychiatric nursing class I taught. She is a 22 year old, single Caucasian female, who has been a registered nurse for two years, having graduated from an associate degree nursing program.

Amanda works in acute care on a neurologic/orthopedic joint replacement floor in a

local hospital. While she enjoys her position on her present unit, she wishes she

could work in an area such as pediatrics or mother-baby. She expressed frustration

that her present experience has not been taken into consideration in applying for a

position on those areas. She is very small in stature and appears younger than her

stated age. Since the interviews were conducted, Amanda has accepted a position in

the operating room at the same facility. 69

She is pursuing a master’s in nursing through a local university. Not having

worked in a career prior to entering nursing, she has little to pull from in dealing with

coworkers or problem solving on the job. She expressed frustration about nursing

assistants, and about workload, and nurse to patient ratio.

During the interview, she was animated, dressed casually and was eager to

answer questions. Her telling of frustrating situations is cautious and she made every

attempt to be accurate. Amanda is actively involved in committees at the hospital and

she expresses ideas for change that are carefully thought out. These ideas may come

from her involvement on various committees. She was dressed casually in shorts and

a top, and seemed quite comfortable in the surroundings. The interview proceeded in

a relaxed and mutually comfortable manner.

Bethany. Bethany is a 24-year-old single Caucasian female. She is registered nurse in a Magnet© recognition hospital, practicing in the emergency room and has been a nurse for two years. She graduated from an associate degree nursing program.

I have known Bethany for six years, having been her nursing instructor for fundamentals of nursing, psychiatric nursing and nursing management. This is a first career for Bethany. She has no prior experience to pull from in dealing with coworkers or problem solving on the job. She would like to eventually work at a major trauma center. She enjoys her employment setting-- traveling a sixty mile round trip to work each shift.

During the interview, she was vivacious, engaged, and spoke freely about the

experiences she has had in practice. She was relaxed, casually dressed, and spoke

with conviction about the orientation experiences she had, and the sense of protection

of the emergency room staff toward the sense of ‘family’ they have, and being

cautious of welcoming someone into that group.

Bethany is also pursuing an RN to master’s program through a university in

another state. She has also recently taken an emergency nurse pediatric course, and

earned that certification.

She appeared self assured and described being involved in interests outside of

nursing. These interests help her in managing job related stress.

Betty. I first met Betty, as a new graduate nurse on the psychiatric unit, four years ago, when I had a group of students there for a clinical experience. The hospital where she is employed full time is a Magnet® recognition facility. A graduate of a bachelor’s program, Betty has been a nurse for four years. She is a pleasant, mature, easygoing, person who relates well to staff and patients.

Betty works more than one job. She is a 42-year-old African-American female, single, and mother of a daughter in college. Nursing is a second career choice for Betty; she had worked as a quality inspector for a military subcontractor, and brings those assessment and problem solving skills into the nursing arena. She serves

on the research council and on other committees within the local facility where she is employed.

Betty has ongoing concerns for relations with nursing assistants, who do not take direction well from the registered nurses, and tells of a tragedy that bonded the staff together, after the sudden death of a staff member

Certified as a generalist in adult psychiatric/mental health nursing through the

American Nurses Credentialing Center (ANCC), Betty is pursuing a master’s degree in nursing, specifically psychiatric/mental health nursing. She is enrolled at a local university and began classes in the fall of 2011.

Betty was interviewed at her place of employment, in an unoccupied room used for the intensive outpatient program. The interview was scheduled there for her convenience at the end of her shift. Originally scheduled for 7:30 pm, Betty had a late admission that delayed the interview until 8:10 pm. She was dressed in scrubs-- her uniform. Initially, she was still in work mode, not able to settle down to the interview, but, given a few minutes and conversation that was low key, she seemed to calm down and was comfortable participating in the interview. Her manner of speech was gentle, relating concerns and incidents in a manner that was matter of fact and still able to state her feeling.

Jack. Jack is a graduate of the nursing program in where I am an instructor.

We have been acquainted for four years. He has been a registered nurse for two

years, graduating from an associate degree nursing program. He is a 36-year-old divorced father of two, who is the primary caretaker of his children. Currently pursuing a bachelor’s degree in nursing, he was employed in a medical-surgical area-- a telemetry unit, but recently transferred to be a float nurse in the intensive care units.

He stated that he felt he had learned all he could about the unit he had worked on, and his goal was to work in critical care.

Jack had worked as a medic in the military and related how the two compared.

He discussed his frustration with the way nurses treat each other, and with how nursing assistants are not willing to take direction from registered nurses. He related incidents in which his preceptors did not give timely or adequate feedback during his preceptorship.

During the interview, he was soft-spoken, tired looking, and expressed frustration with living in this area, with nursing and with life in general. His plans are to earn critical care certification and be a travel nurse, preferably accepting an assignment in the western states. He is also in pursuit of a bachelor’s degree.

It should be noted that he frequently works overtime, both to his benefit and because he feels that it will earn him the respect of his colleagues. He describes it as making him more of a team player. It is important to him to be accepted, and frequently does things, like bringing in meals, that he feels will endear him to his

colleagues. Jack does not involve himself with any facility or unit committees to promote change or to look at the system in planning for improvements.

Jill. Jill is a 32-year-old registered nurse, a Caucasian female, married, mother of two; the only one of the participants who graduated from a diploma school.

Her plans are to further her education at a university in a nearby state. Her mother is a nurse, and Jill knew early on that she wanted to be a nurse, attending a health occupations program in high school and working as a nursing assistant in both long- term care and acute-care. Then, having earned her EMT-B certification [emergency medical technician], Jill found a position in the local emergency room as a tech.

While attending nursing school, she worked there part time as a tech. She continued to work there as a registered nurse upon graduation. She has been a registered nurse for five years.

Related in the telling of her story are two significant events. Her preceptor told her that she had been selected as Jill’s preceptor because no one else wanted to do it, and that the staff did not expect for Jill to successfully complete her orientation.

Later, Jill was faced with the fact that her preceptor was diverting drugs, and had been made to leave. Her subsequent suicide left Jill with self-doubt and emotional scars. While she successfully completed her orientation, worked in the emergency room for a period of time, and made many friends there, she left the position and now works for a home health agency. She refers to the emergency room of the trauma center as a ‘snake pit’, but also refers to the staff as ‘family’. 74

Jill was interviewed in the interviewer’s home. She was open, honest, and told her story with power and emotion. Tearfulness accompanied the telling of her preceptor’s suicide and her treatment by staff that she considered to be her friends.

She asked that the recorder be turned off several times while she regained her composure. We sat at the dining room table. She was casually dressed and comfortable relating her nursing experiences. She was self assured and comfortable in her role as a home health nurse. Jill is a vivacious and easy-going person who does not dwell on troubles or difficulties in her life. Her faith is a stronghold and she relies upon it in times of need.

Katie. Katie is a 47-year-old Caucasian female, a mother of several adopted children, and a graduate of an associate degree nursing program. She has been a registered nurse for two years, and works in both long-term care and on a medical- surgical telemetry unit. She is currently enrolled in an RN to master’s program and will finish in May of 2012. Her concentration is in administration.

Katie brings to the table a history of being a foster mother to over 70 children over the course of many years. She also has a business as a hairdresser, a venture that she calls her outlet. Organizational skills are her forte, and she is a no-nonsense kind of person. She does not like controversy, and expects people to work together and get the job done. She relies on her faith to help her through problems in her life.

Her interview was conducted at a local church, for the convenience of both

Katie and the interviewer. The Sunday school room was secluded and quiet, and

there were no interruptions. Katie was relaxed, dressed in casual clothing and was

not hurried.

Mant. Mant is a 22-year-old single Caucasian female, who has been a

registered nurse for one year. We have no prior history; a colleague of mine who is

her cousin referred Mant for this study. She is a graduate of a bachelor’s program in

nursing, and works on a general medical-surgical floor. Actively planning for a

wedding in October 2011, she is not planning any further nursing education at this

time.

Having no prior work history, Mant had no experience to pull from when

problem solving and relies on her orientation to meet her needs in this area. She

related concerns about feeling like she is bothersome when asking questions, and

about being in charge over her peers who were hired at the same time. I clinically

supervise students on the area where Mant works. I have observed her interactions

with her peers which are appropriate, and she appears comfortable when functioning as a registered nurse, although she seems timid when giving assignments or delegating.

During the interview, she was initially tense, but relaxed and was able to freely offer during the interview. She was dressed casually and seemed comfortable

with the content and with the interviewer. She is a very soft-spoken individual. In

the focus group session, Mant expressed frustration with how change, concerning a

vitally important issue, is being handled on her nursing unit. She is on the committee

to plan implementation of a new nursing model of care on the unit and has concerns

about the manner in which this new process is implemented.

Robert. Robert is a 29-year-old Caucasian married father of young children.

He is a graduate of an associate degree nursing program. A registered nurse for one

year, he works in long term care, accepting the position because it was offered, and he

needed the job. His ultimate goal is to work in critical care, and he is looking to

transfer to an acute care setting. He expresses concern for the workload in long-term

care and not being able to assess and perform interventions as needed.

Robert was formerly a truck driver, who entered nursing because he did not

want to be on the road and away from his children. He enjoys interacting with

people, has an easy going style and a dry sense of humor. He works much overtime

and realizes that it does add stress to his life. He believes the time management skills

learned from trucking have been transferred over to his nursing life.

During the interview, Robert was relaxed, not entirely comfortable with being

asked to identify areas in his nursing experience that were negative or positive. He

was quick to identify the workload as a negative, and expressed dissatisfaction about

not addressing every issue that came up for those patients in long-term care--that

some were chronic issues that were not addressed promptly. While he makes suggestions for change, he is not involved in any formal position to make change.

He posited that long-term care was not his desire and that maybe he was not cut out for long-term care nursing. Robert is married to a licensed practical nurse.

Since both work at the same facility, it is hard for them to leave the job at the facility.

Rosie. Rosie is a 23-year-old single Caucasian female who is a graduate of a bachelor’s nursing program. She is employed in a long-term care rehabilitation center, her second position, having transferred from a facility for the developmentally handicapped. She has been a registered nurse for one year. Not having been employed in any full time position prior to nursing, she has little experience to pull from to enhance her nursing practice. She is still seeking a comfort level in her nursing practice, and is not currently involved in any facility wide committees for process improvement.

During the interview, she was casually dressed, relaxed and bubbly. Not long into the interview, she seemed to unload the fact that she had been suspended early in her time at her first employment. This episode was very wounding to this new graduate. She is one of three persons interviewed who was left scarred by things that happened to them early in their nursing careers. She was finding support and confidence in her second nursing position where she feels more supported.

Ruby. Ruby is a 25-year-old Caucasian female, married, the mother of one and expecting a second. She has been a registered nurse for three years and is a graduate of an associate degree nursing program. Ruby is employed in two agencies-

-home care and the acute care hospital setting. She describes herself as needing to stay busy and having excellent time management skills.

During the interview, she was energetic, eager to contribute, and related well to the interviewer. She discussed both the positives and the negatives she has encountered in her practice. She identified time management and precepting as major needs for new graduates and elaborated on those. She was involved in several full time employment opportunities prior to nursing and has been able to pull from them to enhance her nursing practice.

She is enrolled in an RN to master’s program to earn a nurse practitioner certificate and wants to continue with home health to enhance the services they offer.

Ruby evaluates decisions she makes to see if they meet her goals. She is involved as a preceptor for other new nurses.

Stella. Stella is a 59-year-old Caucasian female, married and a mother. She has been a registered nurse for two years, having graduated from an associate degree nursing program. She works in a long-term care setting.

Having worked in other settings and having worked as a supervisor, Stella brings many skills to the table. She is able to handle conflicts, to teach and to coach

and precept effectively. Her demeanor is gentle, and nonjudgmental. She spoke to

the ways that nurses treat each other in the workplace and how it could improve. She

enjoys nursing and the long term-care setting. She has no desire to continue with

further education. She is involved as a preceptor for other new nurses.

During the interview, she was relaxed, dressed in scrubs, having come from

her shift at work. She was eager to interview and while she spoke softly, there was

conviction in her voice that nursing could be a better profession in which to practice.

She started the interview by addressing bullying that she had witnessed in nursing and

some of the inequities that existed in the workplace.

Victoria. Victoria is a 31-year-old Caucasian female, married with no children. She has been a registered nurse for four years, having graduated from an

associate degree nursing program. Victoria works at a Magnet® certified, rural

health system in peri-anesthesia care. She was employed there during the Magnet®

journey.

The interview was conducted at the home of the interviewer in order to

accommodate the on-call schedule of the participant, who could not be more than a

certain distance from her work setting. During the interview, the participant was

engaged, open and forthright in her sharing of her experiences in nursing. She was

dressed casually and appeared comfortable. The interview took place at the dining

room table. There was no one else present, and the television and telephone were turned off.

This young nurse was the third participant who was scarred from an incident that occurred in the workplace when a physician verbally attacked her. She did not perceive that the incident was handled properly, nor did she feel that she was supported by administration. She became tearful when describing the episode. As a result of the perceived lack of support from her manager, she is looking elsewhere for a position.

She is currently pursuing a bachelor’s in nursing and is preparing for certification in peri-anesthesia nursing. She was scheduled to attend a certification course the following weekend. Victoria is also involved in several committees involved in maintaining Magnet® certification at the hospital where she works, and will represent the unit at the national Magnet® conference in October 2011.

Themes and Trends

The interviews were conducted over a six-week period. Participants’ individual sessions and focus group session were transcribed as soon feasible after they were conducted. Minimal field notes were made during the interviews, with more extensive notes being made after the interviews individually ended. They included the participants’ attire, their posture, and comfort level with the interview, notes about the room, facial and nonverbal expressions of the participants, and

anything else that might have been considered noteworthy. The field notes enabled me to recall a picture of the session, enabled a clearer evaluation of the interview and to connect the circumstances with the verbiage that was recorded for congruency or unspoken innuendos.

As interviews were transcribed, open coding was used to examine the data, break it apart and have themes began to emerge. Axial coding was used to begin to group the individuals’ data by making connections and developing several main categories of data. Constant comparative analysis was used to compare sets of incidents and categories for similarities. Selective coding was then used to begin to establish relationships between sets of categories, and to attempt to identify one core category that the other categories could be related to as conditions that led to the core category’s occurrence (Merriam & Associates, 2002). To identify one central theme was difficult and challenging, as predicted by Glaser and Straus (1967).

Upon analysis of the data, common themes that emerged as the data from individual and focus group sessions were transcribed and coded. The themes were named, a) treatment by others: nurses, with a sub theme of emotional trauma, b) treatment by others: doctors, with a sub theme of emotional trauma, c) perceptions of administrative involvement and support, and d) preceptor/mentor consistency and guidance, with a sub theme of preceptor/mentor training.

While many things can influence a new nurse’s career path, the way that they are socialized into the role and into the nursing workplace can have a profound impact upon their decision to continue with the profession or with their first place of employment. These twelve new nurses tell us their stories, all having been influenced by their initial socializations into the profession.

Theme One: Treatment by Others: Nurses

Each of the participants has been previously described. Each of them described treatment by other nurses, or observations of the way other nurses treated new nurses. As previously noted some came into nursing with experiences that prepared them to deal with interpersonal issues that they would encounter in the workplace, while others were new to the workforce and did not have resources to pull from. Each was eager to relate how other nurses had treated them. Each was asked the question “How have you been received by the nurses you work with?’

Amanda related that she felt like an “outcast” at first and that the workplace was really “cliquish”, but that she was fortunate to work with a lot of other young nurses, who were new as well. When asked how she was treated by the older nurses, she responded, “Umm, most of them are fine, umm, some of them kind of have a negative attitude like you’re coming into their territory…” Amanda is a very vivacious and outgoing person, who is friendly to all and has a love for nursing.

Expressing disappointment in not being able to be hired in her choice of nursing department, she stated that although she would leave the position she is in, she would 83

not leave nursing because “… nursing has so many different aspects to it. Umm, yeah, I definitely don’t think this is the area I want to stay in. I enjoy it though, I don’t go home hating it every night.”

Amanda also related that when nurses who are in the float pool [a group of nurses who are sent wherever they may be needed] are assigned to her unit, a neuro- orthopedic joint replacement unit, which has some equipment and routines that are not familiar to the float pool nurses, these nurses are kind of let to “drown”. “They are on the floor all by themselves and then when they have to give report and say the person hasn’t been on the CPM [continuous passive motion] machine, they have to say ‘because I couldn’t figure it out’. Then the other nurses become upset with them.” She thought that this negatively affects patient care and satisfaction for both the nurse and patients

As a new nurse, Bethany also had issues with another nurse. She related how:

“…there is this one nurse, she doesn’t actually work there anymore, because of her attitude, but, you know, I just kind of, I’ve always been the kind of person, if someone is like that, I just stay away and when you want to talk to me, that’s fine.

But sometimes, she would get kind of snippy, and you know, people that are like that, that are snippy like that or say little comments, or are hard people to get along with, I just don’t mind them, and I just kind of, I just do my own thing, so… I use to hate working with her for a while. I think she also did it… some people know if they are going to be able to do that to you, or they’re not going to be able to do that to you, 84

and I just like ‘whatever’, you know… and I think she just realized that I’m not going away and it’s not really nice to talk to me that way, so she got better and we actually became good friends before she went away. But she was still snippy to other people.”

While some new nurses might be influenced to leave because of such treatment, Bethany was able to summon the strength to weather the storm and succeeded in making a colleague of her tormentor.

Betty, a well-spoken, second career nurse, related how she was treated as a new graduate. She describes the first couple of years as trying, and tells of a relationship with what she calls a “mean nurse”. “That is one of those things that I was surprised by, because you would think in a caring profession there wouldn’t be any mean nurses, but right now it’s like bullying is the big thing, and it’s really real, and until you have experienced it you don’t know that it is out there and it’s one of those things that makes it difficult to go in to work. Depending on when you look at that schedule and you are scheduled to work with that mean nurse, you know, you think, ‘ahhhh do I want to go in, or do I want to call out’, you know, and avoiding that mean nurse, it definitely effects your performance, especially if you are in an area where you have to work together. You don’t have separate patient load, where you share patient loads--like in psych--it makes it a long day. I had them to deal with when I first started, but after a while, when I started ignoring them [the mean nurse], and not letting them get to me, that mean nurse moved on to somebody else. But, I felt like because she knew I was a new nurse, she would give me like pop quizzes. 85

And I felt like I was back in nursing school. Some days, you know she would start asking me questions, and like some days I did okay and some days I didn’t. I got frustrated after a while and like ‘who is she to test me or question me about my knowledge base?’ So the avoidance started and after a while, I think it was people around us, when we worked together could tell that there was some tension there, because I was definitely different when I worked with her.”

Betty queried when she would no longer be referred to as the “novice nurse”, and stated that her “mean nurse” left the unit when a new manager took over. She has been able to utilize her problem solving and life skills to her advantage when dealing with problems and with the stress of the position and challenges it poses.

Jack noted that a message for new graduates would be that: “I think the hardest part for new grads to understand, and we had all talked about it in school, but until you go through you never realize it. Nurses really, they do eat their young. I think the way they eat their young is the way they talk about people, you know, as being a guy, I don’t think it’s any different. Like some people say that it is [different for males] because I don’t think that it’s that, I think that it’s just the culture in general. And I’m not saying it’s the new nurses, it’s the nurses who have been there for a while. You see somebody, a new person trying to get into our family; you see them get kind of protective I guess…”

Jack understands the nursing profession as a family and believes that nurses should become protective of their family. He does not see any difference in the way male or females are treated in the nursing workplace. Jack commented that his goals are to earn his CCRN [critical care registered nurse] certification and leave his position to become a traveling nurse in the western United States, indicating intent to leave his nursing position.

Jack talked about how he felt so watched over and was so afraid someone would find that he had done something wrong or forgotten to chart something that he began to think about it all the time. “I just had to think about where I could be better at work all the time. Where did I mess up tonight at work? Can I be better, and a lot of times I would just sit there and say ‘Oh my gosh, please, please don't let anybody get mad at me because I forgot this.’ you know, or this thing that wasn’t kept up, realizing that it is a 24 hour shift in the hospital, and that we do, ideally, help each other, but if somebody helps you, they tend to hang it over your head a little bit. At least that's my impression.” While this may be considered by some as insecurity,

Jack felt it was brought on by the attitudes and treatment of other nurses.

In order to please others and to create harmony, he would often bring dinner in to his coworkers. This was referred to as “making them feel appreciated”. He referred to nursing as a “talking industry”, in that the nurses talk about each other.

Jack told of being tempted to quit, when a fellow nurse was “driven out” of the ICU. “Talking behind your back drove a really good nurse out of the hospital and out of the ICU. I was really upset about that. He was a nurse who could be drowning within his patient care….he was helping somebody else with patient care, transferring a patient wasn’t a priority to him; his patient is stable and ready to go. So he left his transfer of his patient, because that wasn’t critical and came in to help me and they said, ‘No you have to go transfer that patient now.’ Rather than say ‘Good job, trying to help, you know. You did a fantastic job, but this one we need to do now, I’ll help him.’ There were incidents like that and the way they talked and it got back to him, and he knew all the talk, I mean they were awful and it drove him out of there. I could understand that, I could, I was about to quit, I really was, in ICU, I was ready about to quit.”

Though Jack, Jill and Bethany viewed their work group as a sort of “family”, they often felt like outsiders, as in a family with dysfunction.

Jill related discord in the emergency room, and how nurses were vengeful toward others. “This one nurse who had come in, she had been a charge nurse for ten years and she had been a nurse for more than 15 years, and the director came in one morning and there was a backup of more than two hours. She looked at the new charge nurse and said ‘What the hell have you been doing all night? Do you do anything? It’s like this every time I come in; I have to pick up after you.’ And she would put this nurse in tears every day, every shift. Now that nurse [the one who was 88

spoken to harshly] is the director and she had the other one fired. There was never any attempt at resolution. As a new nurse I felt that the nurse who was causing the backup was being picked on, and it could have been handled better.”

Jill also told of working as a tech in the emergency room, and not being liked by the nurses. When she was hired as a new nursing graduate, she related being told that they did not expect her to successfully complete her orientation. She proudly stated that she was successful in her completion of orientation.

Katie is a more mature new nurse, having had a prior profession, and having raised a family of foster children before coming into nursing. She spoke to the stress, and the first year being difficult and being scared all the time that you will make a mistake. A no nonsense kind of person, she wants problems resolved and put aside so the work can go on. She told of an episode as a new nurse with an older nurse.

“When I first started there the nighttime charge nurse was very in your face like, she was like a male dog marking her territory. Very much so, had no business being any kind of authority position and I hadn’t been there but a couple of weeks. You know one of the worst problems for me transitioning into nursing was doing report. You are so intimidated in giving the next person the report because you don’t even know if you did everything you needed to do and now you’ve got to report off to them and what if they ask a question and you don’t know the answer. You know what I mean?

It was like, it was just nail biting moments and one of the things we used to be able to do, which we can’t do now, was tape our reports. This one day I couldn’t give her, I 89

couldn’t tape the report so I had to give report to ‘the beast’. And if I were any other person, I would have quit that day. Because she just like hollered in my face ‘don’t you ever give me a verbal report. I want taped, I want a taped report.’ And I was like

‘there’s nowhere where it says that I have to tape my report.’ And there wasn’t. And she was like ‘I don’t care.’ And she was like in my face and she was ugly and she was marching around the unit and being you know grumbling and complaining about me specifically. She’s not there anymore by the way. Wasn’t too much longer then after that that she was removed from her position in the hospital but it was very, very intimidating to me and I was very, very upset. I had maybe been on that unit two weeks at the most. I was two weeks into orientation and had a very, very, very good preceptor and she was right there by my side. I just said ‘you know I’m not required to do that. Am I [preceptor]?’ And she was like ‘no’. So, that was a very uncomfortable and intimidating episode, and if I had been younger, my personality, I would’ve walked out. I would have refused to work with someone like her. But in your 40’s you have a little more tolerance because you have children and they act just like that”

Mant, a very quiet and soft-spoken nurse, felt that some nurses are “negative”.

She expressed that “I think that they’re [nurses] just sometimes they feel that they’re overworked and not appreciated. I know a lot of them have said that they haven’t gotten a raise in a long time, bonus, like holiday pay hasn’t been increased. There’s been one nurse who has been there; she just had her 30 years. She’s been on my floor

for 30 whole years and she has a very, she’s very humorous, and has a funny attitude, but she’s one of the main ones that complain all the time and she always says that in

15 or 20 years she hasn’t had a raise. And so, I think it’s they just don’t feel like they’re getting…good feedback or praised for what they’re doing”

Mant is currently content in her first nursing position. She has no plans to leave or to seek another position in the facility. She seems to be listening and processing what the older nurses are saying and doing, and may be able to separate out the good from dysfunctional coping strategies.

Long-term care is not Robert’s choice of practice for the long term; he plans to move to the acute care setting in the near future. Several times during the interview, he commented that he was better suited for acute care. When asked how he has been received in the workplace, he commented that nurse and doctors are often unkind to new nurses. “Some of them [nurses], yep, some of them are not kind. You have to put your foot down and it, you know, they ease up a little bit. Doctors are like that a lot. If you’re new they don’t want to hear anything you’ve got to say…”

Robert suggested that the new nurse feels isolated: “…it’s difficult because there is a lot to learn out there if you don’t have somebody to help you. A lot of times, they’re not, all the nurses don’t want to answer your questions.”

Rosie was eager to share that she “loves” her second nursing position. As she spoke to her excitement upon entering the profession, I asked her to think back to that

first time on the job that she was by herself, on her own, and to describe what that was like for her. “God, it felt great! I felt like I was so slow compared to the other nurses, but it felt so good, like giving meds on my own, I had my cart myself, and I was like ‘Oh man, I’m doing this!’ I don’t know, it was just, nothing will compare to that, and it’s just like you’re on top of the world. Of course, then something always happens…”

She spoke of one nurse, who was also her preceptor. “I don’t really favor the nurse that they used in the [unit], that is just a personal thing…she is lazy and I don’t like it. (Her voice rises.) I mean it [the relationship] was fine, I mean I didn’t treat her like crap or anything, but she really did get on my nerves. ‘[Rosie] go do this,

[Rosie] go do that.’ Not going to help me in any way. Especially after I came back from my suspension, they made me work with her again. She would make me do everything and she would just sit at the desk. I always thought that was kind of stupid, like we should be doing [things] together so we could get it done and we could learn more stuff together, but that’s not how it went. And every little thing she was like ‘Oh [Rosie] can do it; [Rosie] can do it.’ She just let me do it and like anything that had to be done, she would say ‘We’ll do it.’, like it was all of us in there. It was never her; it was always me and the other nurse. She never wanted to participate.

They said she used to not be like that and she is very smart. I don’t know, she is very favoritized and she gets away with stuff with the doctor and I don’t think that’s fair, but…”

Ruby readily acknowledged that nurses did not treat each other with respect.

She said that this was especially evident in the high stress atmospheres of codes, and emergency resuscitations. “The moments that stick out biggest in my head, are all the codes that I was ever in, and I think it is because of the atmosphere. It’s a high stress atmosphere and for myself and for nurses in general, I’ve seen a lot, people let words fly (laughs) in the codes, and there is a lot of nastiness. I can remember one code we had where I wanted to crawl under a rock because I wanted to help, to be there, because I wanted the experience, but I wanted to shrink into a corner because, you never knew what was going to be said to you, and God forbid, you didn’t know the answer…I always felt that those were not the times that anybody was tolerant, so I think that as a new nurse and for it to be your patient, it’s very hard…”

Ruby also described a situation where a new nurse, a second career nurse, had a disability, multiple sclerosis, and had difficulty starting intravenous lines. Other nurses became intolerant of this. Ruby suggested that the nurse offer to exchange one of the other nurse’s duties for the nurse starting an intravenous line for her, in an effort to promote teamwork and tolerance.

Stella has been able to deal with other nurses very effectively, but she has been observant of other nurses treating new nurses in uncivil ways. She uses the term

‘bullying’ readily, and this was the first thing she chose to discuss during the interview. When asked how she felt her colleagues had received her, she replied

“Good, for the most part.” The interviewer parroted that back “for the most part…” 93

“Yeah, there are always bullies. What comes to mind is another nurse I’ve worked with that’s been a nurse for about eight years now as an LPN [licensed practical nurse] and she‘s a bully. She bullies everybody that first starts there. It’s very hard on them until you stick to your guns with her. I’m currently a mentor on the unit for new nurses and some of the people that I’m mentoring, she’s bullied. I’m a mentor for a nurse that’s come from another facility who has been a nurse for 24 years, and she is a very good nurse with a lot of knowledge--a lot of good assets to the company.

However, the nurse that’s the bully has a point to prove. So she’s one of my obstacles. You have to constantly stick to your guns.”

Stella is in her second nursing position, having worked at another facility, also a long-term care facility. She had encounters there with what she referred to as “a bully nurse”. “This person started there as a GNA [geriatric nursing assistant] and became an RN, a very, very smart lady, excellent nurse, and you would think that she’d had a lot more years of experience as an RN than what she does because she is so smart. However, anybody that comes into that facility, she looks at as a threat, and she’s gotten people that have been there for a while--actually gotten them fired. So they have a very big turn over there. And the administrator is very fond of this person and it’s left unaddressed. Patient care suffers because of the high turn around and the orientation of new nurses.”

Stella also commented on the mix of personalities in nursing, and that nurses needed to remember that they are there for the sole purpose of caring for the patients. 94

While she felt that her nursing education program prepared her well for the workplace, she commented that “Nursing students get into the mindset that ‘I haven’t come this far to be a failure. I’m going to succeed and I’m going to do what it takes.’

One of the RN females that everybody just loves, she picked on this new RN, a guy, quite a bit and by the end of the shift, he had just quite enough. He wasn’t rude with her but he got his point across like ‘I’m not gonna take it anymore, I don’t have to.

You know I’m here to do a job.’ I don’t know if it got through to her, but that was how he handled it.”

Emotional trauma. Three of the nurses interviewed described situations that were as fresh to them in the telling as they had been when they were experienced.

They re-experienced the embarrassment, tearfulness or shame that they experienced during the actual events.

Jill told of her precepting experience and of going to work in the emergency room as a new nurse. This story evoked tears and she asked to have the recorder turned off several times in order to regain her composure. She had been a tech in the emergency room before being hired on as a staff nurse as a new graduate and explained her reception there. “[Name] was actually hand selected to be my preceptor, because I was expected to fail when I came into the ER. Not many people wanted me hired because I was a tech. Not many viewed me as a very good tech. So when I was hired on the night shift, they wanted to put me with someone who didn't know me. And she was fairly new to the ER. And they knew that she would have a 95

nonjudgmental attitude about precepting me. So one day we were talking she goes ‘I just want you to know that when they asked me to precept you, I did tell them 'no' because I don't like to precept, I am very good at it, and I can do it, but I don't like to’, she said, ‘but a lot of people have negative attitudes about you coming to work, and I want you to have a fair shot.’ I was thankful to her for giving me a chance. I was used to that because there was a lot of negativity in the ER over the years. So I knew

I was a good nurse, I might not have been a great tech, but I knew I wanted to be a nurse and I knew that I was a very good nurse....”

Isolation by the group, not being accepted, being scorned, and feeling

‘thankful’ to her preceptor helped to set the stage for Jill’s experience in the traumatic situation that led to her preceptor’s dismissal and subsequent suicide. “She had been a nurse for 15 or more years, she was a paramedic before she was a nurse. Later I found out she was addicted to [controlled drug], and she had been stealing from the

[computerized medication dispensing system]. I felt betrayed.” Tearfully, she said “I felt like she was asking me to keep a secret. That's it. Not long after, she got a job at

[hospital in another state]. On her last day in the ER, she was asked to leave because there was the second episode of missing [controlled drug] under her name in the

[computerized medication dispensing system] and she was asked to leave when she declined a drug test. And she went to [hospital in another state], and she was there about a month and then she committed suicide.”

When asked if that had any repercussions in the emergency room, Jill replied

“Yes and no, once we found out that she had killed herself, we had a debriefing, but she had already left and was gone for about a month. So.... some people weren’t affected at all and some were. When they had realized that the drugs were missing for the second time, she was pulled down to Employee Health, and the Employee

Health nurse asked her to submit to a drug test. She declined when they asked her and they had security escort her up to the ER, to collect her belongings and leave the premises of the hospital. It's my understanding, that if you're addicted to drugs, that if they ask you to submit to a test and you tell them you are going to test positive, they have to offer you counseling. But …she declined and told them that she was going to leave and that's when they had security escort her upstairs and then off the premises.”

When asked how she handled that, Jill answered “She was my preceptor, and she sent me a letter in the mail the day before that she committed suicide. I was sad; I shared the letter in the debriefing so that other people knew. She was a personal friend too, she had come to my wedding; she had shared personal things with me that she didn't share with anybody else.”

Discussing the drug use and how it might have been dealt with differently, Jill expressed that she was not aware of methods to report and of being afraid of being looked on as a person who could not be trusted on the team. “I probably would have reported her the first time that I saw her using [controlled drug]. I should have reported it then.” 97

When asked if her nursing education program had prepared her for dealing with anything like that, she replied “They touched on it, that you should report any and all drug use, but at the same time as a new grad, you don't want to feel like a tattle tale, you want your coworkers to know that they can trust you especially in life or death situations dealing with patients. You want them to know that they can trust you if they tell you something personal, you don't want to be a snitch or run and tell.

Now I know that you can do that anonymously, I did not know that before. I found that out through a friend who was a nurse.”

Rosie was a graduate of three months when she entered her first nursing position. Her experience has left her with questions about her abilities. During the interview, she blurted out that she got suspended and proceeded to tell the details.

“We had a patient come back to [state facility 1] who was basically dead, and um…I didn’t even know he was coming back. The supervisor knew, but she didn’t let me know he was coming back, and he came in my door, and he looked like crap, I didn’t even touch him, I called her and said ‘Hey this guy needs to go back to the hospital.’… and then we started trying to get vital signs and everything, and couldn’t find them. They said ‘Call 911!’ I hung up and called 911, getting ready to start pumping on him and the EMTs came in. They took him back and he was pronounced dead at 5:16. He got to me at 4:36 and he was back to them at 5:16 and they said that

I didn’t call 911 fast enough, I mean that was the first code I’ve ever had, but I really feel that I was, well I wasn’t very supported in that either, because I had a nurse who

was an agency nurse and he didn’t even have any clue what was going on, so I was all by myself and… it was just a really bad experience. I did what I knew, I did my best of my ability because…I mean, I did what I thought I could do. We were trying to get the vitals, because when someone comes back, you have to do an assessment and paperwork, but in order to send them out, you have to do an assessment too, so either way, I had to do an assessment, so we were trying to do that and then we started not being able to find anything, that is when we started freaking, you know that is when we did something, but they said my window gap was too big, so they suspended me for fifteen days with no pay. I was beside myself. Oh I felt terrible! I mean because

I kind, really I couldn’t have thought of anything else I could have done in my situation, but it is easy for someone to sit behind a desk and say ‘You should have done this.’ Or ‘There was too big of a gap.’ I mean I didn’t really have a whole lot of help, like I said that was the very first one on my own that I’ve ever had to do, I’ve never dealt with a whole lot of them anyway. I just did what I thought I was supposed to do, I mean, you kind of get yelled if you call 911 too fast and, it just seemed weird that [hospital] would send a guy home that was basically dead. Turns out the CNA (certified nursing assistant) that brought him home said that she said something to somebody at [hospital] and they said ‘Well he’s discharged. So if you think he needs to go back, take him to the ER because he is no longer under our care.’

Which I still thought you’re still under their care, till you leave the premises, or what, so I don’t know whether she called or what, but she still brought him back, but…

Even though they thought he shouldn’t come back. Very hard experience, but they paid me back for ten days of it. Half of it was they said was my documentation, but nobody ever sat down and helped me piece together what it was I was supposed to document. I just documented everything I had written down and could think of that needed to be in it, but apparently it was wrong, so I learned a lot from that.”

Rosie seemed to feel relieved at having told about the episode. She is now working in her second nursing position at another state facility, and reported that she enjoys the support and the organization of the facility.

Victoria is in her first nursing position, and reported experiences with both nurses in administrative positions on her unit, and with physicians that left her with what she called “scars”. She expressed pride in her work and reported that she serves on unit and system wide committees to facilitate change. While she did not identify problems dealing with other staff nurses, she noted problems with her nurse manager, who she described as “hot and cold” and not being very approachable.

Victoria reported experiencing an episode of incivility from her manager in response to a problem that she presented to her manager. “I went to my manager, and

I was crying, and she basically looked at me and it was like ‘it’s your problem’. I got no support, no help…and I had to leave for the rest of the day. .. I was so hurt and embarrassed, utterly embarrassed, in front of everybody. And she [manager], she’s just like ‘Well, suck it up, sorry about your luck, deal with it. If you have a problem

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with it, if you’re not going to stand up for yourself, then you will have to deal with whatever emotional issues that you’ve got.’ At that time, I was just like ‘Wow’ because I was out of school a year, you know, so I was really expecting a little something else. Something like ‘Well let’s bring her in and we’ll all three talk about it and we’ll bring in a mediator, the director, or the clinical coordinator or another nurse who witnessed it and we’ll all talk about it and do some conflict resolution.’ I told her that the anesthesiologist yelling at me was unprofessional behavior.”

In the retelling of this incident, Victoria was upright in her seat. Her expression was intense and her respirations were quickened. She had tears in her eyes. She appeared to be re-experiencing the emotions of the event.

Theme Two: Treatment by Others: Doctors

Several of the participants commented on their experiences with doctors.

Having moved to the intensive care setting from a med/surg floor, Jack expressed that he felt more respected by the physicians as an ICU nurse than he had as a floor nurse

“….and that's what I see, and that is where I really feel good about myself as a nurse too, is that the doctors treat us so much better in critical care. And it's not that the nurses on the [medical-surgical] floor don't know what they are doing, because they do. We have a lot of really great nurses, but they [doctors] just treat you different, and they trust you, a little bit more, and it's surgeons that are calling me, but they are saying ‘Call me by my first name.’ and I'm ‘No’. I was military and observe protocol.

A lot of times, it’s ‘Do what you want, do what you think needs to be done and call 101

me back and tell me what happens.’ That’s what we get, and I think a lot of that though is because they trust us, and that is good because they can’t be in the hospital

24/7.”

While that was Jack’s perception, other nurses found that, as new nurses, their reception by physicians was a problem, that they had to earn the respect or even, at times, the right to be heard by the physician. Robert was one of those who found it frustrating to be ignored by the physician when reporting patient assessments or concerns. “You can’t ask the doctor 'cause they don’t want to hear from you. The doctor, unless it's something that they are going to treat, they really don't want to hear it, so we're expected to know what it is they want to know. You know, you don't come with any minor issues to them, or they'll, like, say someone had a blood pressure of 180/95, if you call the doctor and tell them that, they're going to be mad at you because that's like a routine thing, they don't want to hear about it unless it’s had three or four readings like that or something like that. And you see there are not really a whole lot of people to go to if you don't know stuff, you kind of learn the hard way.”

Jill described situations in the emergency room that led to tension between staff members. “…with the [new computer system], the doctors didn't want to use it and the nurses had attitudes, the doctors had attitudes, nobody wanted to work well together. There was conflict about charting in a computer system, which was very…negative. I remember there was an eight hour back up in the waiting room, 102

because doctors wouldn’t use the system and weren't working, nurses couldn't do their jobs, and patient care was suffering.”

Victoria experienced the wrath of an anesthesiologist when she intervened as a patient advocate. "We had an anesthesiologist for permanent staffing. We had a patient, orthopedic patient, he had his hip broken, they fixed it once, and he had come back in, had to fix it again the second time. I get this guy and he’s got vital signs that are just off the wall weird, okay, so I’m trying to piece it all together, and I’m thinking ‘OK, this guy’s got to be septic, you know, he just has to be septic.’ That was the only thing that would just tie in the vital signs, what he’s like, what he looks like in front of me, and you know, he had a urinary tract infection, and now we had gone in and fixed it [the hip] the second time, and in my research, a lot of times, you can break off infection when you go in and fix something for the second time. It might have been isolated, and then when you go in again, you probably break a lot of the infection away when you have to go into those bone areas and things like that, so

I’m thinking to myself, ‘OK, so he’s got, he’s had a urinary tract infection for a while, more than likely, he’s septic. With the urinary tract infection, then if he had something going on infection wise, it’s because we had to drain it and he had some infection there.’ I’m on the phone with this surgeon, saying, ‘Can we do this, can we do this, and can we do this? Get this thing ordered, get this thing ordered. Can I get a lactic acid?’ and he’s saying, ‘Why do you want a lactic acid, and what’s a lactic acid?’ He asked me what one was at first. And I asked if I could start the sepsis

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protocol, and he asked ‘What’s a sepsis protocol?’ and I thought ‘OH my gosh!!’ So

I go to the anesthesiologist, and the anesthesiologist comes to the bedside and she says, ‘It’s just this minor little thing. He probably just needs a bolus of 500 mL of fluid, he’ll be fine. Let me just give him this one blood pressure medication.’ And that dropped his blood pressure down to like 80/30, and I’m like ‘Oh my god!! OK nobody is totally listening to me; nobody is hearing me with the red flags here!’ Ok, so I went to my manager at the time, and it was the [old] manager, and she came to the bedside, and she’s like ‘Ok, let’s call the physician that’s following the patient.’

So we called that physician and the physician comes up and starts the sepsis protocol, and she gets the lactic acid, and she is ‘Ok, I agree with you. Why did she give this blood pressure medicine? You could have given something else to bring the heart rate down that wouldn’t drop his blood pressure.’ So even though we don’t often do that in the recovery room, she started everything right then. And because I had gone behind the anesthesiologist, who has ordering authority in recovery, any medication that is given, anything that is done to the patient, is usually ordered by the anesthesiologist in that area. She blatantly called me out in the middle of the recovery room, in the middle of the patients, in front of the family, in front of the physicians, in front of the other nursing staff, and told me that I had no idea what I was talking about, I was just some stupid nurse who thought the patient was having sepsis, she knew better than I did, I was the one that made the mistake, and that if I ever double-crossed her again, she’d have my job. (She paused, and became

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emotional.) I had to be excused for the rest of the day, because I had broken down, and was just, I was floored; I was hurt and floored. I could not understand why she was saying that. I had been, basically, humiliated in front of the rest of the staff, and she treated me for the rest of that week like I was a complete idiot. So every patient that I received from her from the OR, she made sure to remind me that I was just some stupid nurse who didn’t know what she was doing.” Victoria was deeply affected by this altercation, and struggles to overcome the self-doubt and anger that stems from it.

Relations and communications with other disciplines are ones that the nurse makes frequently. To be shunned or ridiculed hampers the ability of the nurse to initiate further communications or relationships with providers and can affect the quality of patient care.

Theme Three: Perceptions of Administrative Involvement and Support

The participants were very conscious of administration and commented on their perceptions of the involvement of administrators at different levels and their support.

Amanda addressed the staffing situation on her unit and how the administration is working to implement a new “variance table” in which they will work as teams comprised of one nurse and one nursing assistant. Staffing was an issue that Amanda mentioned again in the telling of an episode that she termed “the

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worst thing” that had happened to her as a new nurse. “I was off orientation for about a week and a half, and I was on one end of the station by myself and my aide had been on the other end doing vitals for a patient she had on that end. There was another nurse on the other station, on the other end. The stations are about a good football field away from each other. I had a patient in my first room having an MI

[myocardial infarction] and unresponsive; I had no one to bring me the crash cart, and

I was screaming for help and finally the nurse on the other end came down to see what was going on, and heard me holler as she got closer. It was pretty scary, just being off orientation. It happened fast.”

Amanda reported feeling that she was put in a position that was unsafe. While the staffing patterns are being evaluated, and there is a proposal for change, she feels that this situation was unsafe.

She spoke about nursing assistants not accepting delegation from the nurses.

She addressed this matter with her manager. “Delegating is very difficult, a few of the individuals I work with are the same age as me or older than me, so they don't take me asking them to do things very well. The CNA's, the ones that are helping me for the day... it’s difficult. I am getting better at this. Even though I am swamped, I will just do it myself, it's better than sometimes getting in a confrontation. I have talked to my manager, I tried to stop doing as much by myself and being stressed out about it. I have tried to ask more, and I still get attitudes. One girl was yelling at me one day about it. I went to my manager and talked to her about it, and she said that 106

she had had similar complaints so, we haven't had it yet, but she was going to have a meeting.”

Amanda felt that the manager’s lack of intervention did not provide guidance or resolution with the problem.

When asked about the best thing that has happened, Amanda also refers to administration, recalling a time when she was praised by the supervisor. “The best thing is probably getting complimented from the nursing supervisor. A lot of them are kind of in and out of each floor kind of quickly, so they don’t really get a chance to know your name, they show their faces every shift. One day, she stopped me and said ‘You know you are never sitting down, when I see you, you are always running around busy and doing something.’ And it was good to know that they noticed.”

While new graduates, like Amanda, may regard always ‘running around’ as being efficient, the nursing supervisor did not recognize that perhaps time management or delegation skills were something that needed to be evaluated in this instance.

Bethany, who is training to be a charge nurse, related one of her first experiences, in which she was required to confront another employee. “I got put in a really bad spot because I was actually thrown into being charge last week, without being oriented yet. So I was really nervous about that. The supervisor was there, and she is very known to do this, there was a traveler [traveling nurse] there and she had

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on a tank top that was V-cut and a sweatshirt and we were really busy. As charge nurse, if we’re really busy, I’m not gonna stop you because you have a tank top on. I don’t care, as long as you are working, and you’re getting those patients moving, that’s not what I’m focused on anyway. As a charge, I’m focused on: ‘We’ve got to move these patients.’ So the supervisor came down and she was not happy about what the traveler was wearing and she wanted a scrub top put on. She wanted me to say something to her, but, really, the supervisor should have said something to her.

She is the one who noticed it; she’s the one who should have addressed it, not me. So

I was just like ‘Great!’ and I wasn’t going to say ‘No’ because with some people it’s better to just go along with it, cause you wouldn’t want to get on their bad side, you know the supervisor. So I just took her in the back and I just said, ‘Hey, I was informed of this and this is what needs to happen.’ She was fine with it, she was just,

‘I want to talk with the supervisor. She’s the one who has a problem with it.’ So then they talked anyway. That’s what should have happened in the first place. So I don’t know how that is going to work out, with being put into those situations.”

Bethany felt that she had been put in a position that she had not been trained for and in which her comfort level was not high. When the supervisor asks someone to do something that they are not trained to do, they are asking for the nurse to enter into unsafe practice, or to not follow procedure involving appropriate interventions.

To have required this new nurse to assume a charge nurse role without the appropriate orientation was not one in which Bethany felt safe. She was not given the

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opportunity to learn the role before assuming it. When asked if she felt that the supervisor would have done that to a more experienced nurse, Bethany replied: “She even made a comment, ‘Oh, it’s her first night in charge; I was just letting her do her job as charge.’ So she made a comment like she was doing it on purpose. Which I was like ‘That’s very nice, I haven’t been oriented, or trained for charge, so this is my first night and you’re going to add that on?’ Sounds really good,” she said sarcastically.

When asked about the administration being visible or supportive, Bethany stated “For night shift, not really. They pop their head in, and say ‘Hi!’” When asked if the manager was visible, she replied ‘Not really, I mean, the only time I really see her, because of the night shift is not even in the morning, I’ve seen her once in six months at a staff meeting. If they have a staff meeting at seven [in the morning], then she will usually be there, but other than that, she doesn’t come in until 8:00 [in the morning]. So we don’t really usually see her, the only way, I mean, I can call her, but

I usually shoot her an email, that’s like the best way for me.… she is very hard to read, and very hard to talk to. That is intimidating to me. I mean I’m not afraid to come to her with a problem or anything, but I would rather send her an email. She is a good manager, she is just awkward, and that’s a good way to put it.”

What Bethany explained is that there is no working relationship with her manager. She writes emails when there are problems, but there is no comfort level in

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communicating with the manager. Transparency and a working relationship do not exist.

Mant also expressed disappointment that her manager is not visible and involved to a greater extent. “It seems like in the morning that from like 7:00 to 8:00, that’s when I’m usually clocked in, they [nursing assistants] are just drinking coffee.

But at that time, I think it’s the busiest time because people are coming up to get them for tests, breakfast is coming, insulin needs to be given out, blood sugars… and they’re just like sitting there and all the nurses are getting report at that time, call bells are ringing it’s just kind of chaotic. But one of the charge nurses on day shift, who used to be the manager, she always complains and says that she just wishes that our manager would come early so she could see it but she never comes. Occasionally she will come at 7:00 am to check on things. I’d say I’d probably see her like once every two weeks or something. But even then, she just laughs things off and goes about her day. Doesn’t address what’s going on.’

Mant expressed understanding of the manager’s response as she sees the attitudes of the staff nurses that she described “They just complain saying that they’re tired, that nothing has changed, improved, that they’ve been working like this for a long time. That’s why when they say that they’re changing the way we do the nursing process for patient satisfaction, a lot of them, they say ‘not gonna believe it

‘til I see it, they’ve been saying that for years.’ So, sometimes it can get kind of a little bit annoying or discouraging cause, like where I’m new, I still have hope that 110

things will work out and things will change but it’s kind of hard talking to them when they kind of have, like, a little bit of a bad attitude all the time about if things will change or not.”

When asked if she felt the nurses were negative, she explained. “Yeah, I think that they’re just sometimes they feel that they’re overworked not appreciated. I know a lot of them have said that they haven’t gotten a raise in a long time; bonus like holiday pay hasn’t been increased. There’s been one nurse who has been there for 30 whole years and she’s very humorous and has a funny attitude, but she’s one of the main ones that complain all the time and she always says that in like 10, 15, 20 years she hasn’t had a raise. So I think it’s they just don’t feel like they’re getting good feedback or being praised for what they’re doing.”

Betty experienced a change in leadership on her unit and described that the different styles of leadership have been noticeable, and have made a difference for her. When asked if the administration was supportive, she replied “I do now. I mean, for a while, our last manager, I felt like he tried to maintain peace. He was more of a laissez-faire type leadership and I felt like I wasn’t always heard or, you know, I was expected to always, you know, ignore negative behaviors instead of dealing with the negative behavior which were snow balling with the staff and I looked to my leadership for guidance. I didn’t feel like I was getting good guidance, because they weren’t really dealing with the issues. So I don’t know. I couldn’t learn from them how to deal with it if they weren’t dealing with it and I think, had they done that, I 111

would’ve liked to think I would’ve been better able to deal with some of these staffing issues that I encountered.” [Referring to issues with other nurses and nursing assistants]

Betty expressed feeling that the present manager is one who is proactive and deals with issues before they become a problem. As a result, some of the older nurses have left.

Teamwork was the aspect of the emergency room that Jill liked the most.

When they actually got over the initial reaction to changes and worked together to make the changes and deliver higher quality care more efficiently, teamwork was at its best. “Working as a team, learning every day because you never knew what was going to walk through the door. Meeting new doctors, watching things change.

Change can be positive or negative, so when we went from… I actually worked in 3

ER's: it was the old and then changed to a different pattern, and then when we started initiating protocols, planning care for patients totally changed, because we were trying to have patients seen in a faster time. Then things changed, we initiated [name of computer program], the new computer system in the ER, and that was negative, and then changed into a positive. Because nobody wanted to use the [name of computer program] the hospital wanted to use, you had to learn a whole new way of charting, there was nothing the waiting room for eight hours or more, but once everybody go on track with it, we had wait times of less than 45 minutes. That took probably six or eight months to get straight.” 112

Jill moved from her emergency room position, out of the facility, to a position with a home health agency. While she doesn’t find many problems with administration in her agency, she comments on the follow up with addressing problems when they occur. “One thing I have found, is because it is such an easy job, there are always hard parts about a job, but home health is so much easier than ER nursing because of everything related to ER, the stress, the burnout, and in home health, what you find is you run into a lot of lazy nursing. They don't want see patients, they don't want to pick up patients, and they won't transmit their work in a timely fashion, which holds everyone else up. You’re supposed to transmit [patient records] every 24 hours and for some reason, some people won't transmit only every two weeks. This is unacceptable. It's not really dealt with at all, because they say,

‘We're going to write you up if you don't transmit.’ and then the ones that don't transmit, they don't get written up. I am one who transmits every day I work, it's so easy to transmit, just push a button. Just transmit it; it's not hard! It doesn’t create tension, not really, they don't care.”

“Change can be positive or negative”, as expressed by Jill, is something that administrators may not plan for. Managers need to plan for negative views of changes, because they may be seen as threatening, and need to put forth change transparently as expressed by Mant. “We are planning to put this new program in place, the [name], where the nurse will have six patients and one nursing assistant, and people are asking questions. Our manager is not giving information or answering

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questions, she is just saying, ‘I am not at liberty to discuss that right now.’ And I’m on the committee and I know about it and I’m just ‘I don’t know.’ I think if people knew about it, it would be accepted better.” There is a fear of the unknown.

When Mant was serving on a committee to look at improving patient satisfaction scores by changing the way nursing care was delivered, she relates that there was a director from performance improvement in attendance. “When I did this thing about changing the nursing process, we had the nursing executive director there, and then we had, I’m not sure what kind of engineer he was, but he worked for the performance improvement department. He had no nursing experience whatsoever, and he had this plan to change how to go about and get patient satisfaction scores up.

And one of the nurses that had been there for a while said, ‘Did you ever stop and wonder that maybe, just maybe, that our patient satisfaction scores aren’t where they should be because your nurses aren’t satisfied?’ And he didn’t want to hear it. He just skipped over that part. So, sometimes, I think the hospital kind of just does things because it looks good and they’re going to better the hospital and they don’t seem to ask the core people, that in my opinion, are running the hospital, which would be the nurses and the other nursing staff. I know that the executive people, they run the hospital but they’re not there every day like we are, dealing with what we deal with, and they just kind of think, ‘Oh well, this is a good idea. We’re going to go with it.’ And they don’t run it by anybody who’s in nursing. So, then, that’s why there’s so much trouble trying to get people to cooperate with new things is because

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they just don’t feel, like, we’re just not asked our opinions or valued. So you just kind of do whatever they say.”

This was discussed again in the focus group session, with Mant, Betty and Jill having input. Mant related how her manager was implementing change for the new nursing process delivery system that was planned. “They have hired them as techs, and now the techs can only be in ER or ICU now, so it will only be ancillary. You know, like the management has put it together, and, but don’t you think the…like I know what is going on, but like my manager said, you can’t go out and tell them stuff, so here I am like just sitting here and they’re talking and I’m just like sitting here and I’m like ‘but, but, but…..and I’m like I’ll just hold back’, and they’re like,

“Well what’s going on?” And I’m like “Oh I don’t know, [manager] will tell you someday. Betty added to that, “And that makes everybody anxious and it creates negative impressions of the program if they don’t know about it.”

Mant added, “We had a staff meeting and someone said, “Well I heard this was happening.” and she [manager] was ‘Well, well, umm I can’t comment on that right now.’ And I’m like thinking, ‘You could have come up with something better than that.’ Like ‘That’s not been decided at this time, let me get back to you.’ Instead of acting like we’re hiding something.” Betty then stated, “The more they know the more at ease they are with the change, and more willing to accept things. When change is sprung on us, all that uncertainty makes people not want to do it, they just

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want to make sure, and think they’re going to make us do it whether we want to or

not. Training is key in preparing people for those changes.”

This interchange gives light to how management’s implementation of change

is instrumental to the acceptance of change.

Katie identifies that she perceives things are not dealt with, and have

perpetuated with a new manager. “My manager is visible. We have a new manager in the past few months, but she is young. I mean, she’s been, I think she’s been a nurse for about ten years and I think she does a good job. I think that it’s the same as it was with the previous manager, that problems aren’t dealt with, they are kind of swept under the rug. Like problems with the nursing assistants.”

Katie identifies a change she would make as a manager that she has seen or experienced firsthand several times. It concerns the learning that comes from the critical stress debriefing after a code. “I really felt helpless in that situation. I mean, you know, I mean the reality is and I mean, I know that we don’t control life or death.

What I can learn from this. You know everybody sit down and let you talk about this.

That’s not how it works at the hospital, unless there’s a law suit or something, but, you know, I wanted everybody to sit down and say, ‘What could we have done differently in this situation; what would have made a difference? What was done well and what was not?’”

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She summarized the feelings of Amanda, Rosie, Victoria, Mant, Bethany, and

Ruby, who all described codes as their worst experiences and still had questions about them concerning what they knew, what was done, or the learning they took away from the situation. None had the opportunity to debrief afterwards, however Mant commented, “When we actually sent her down to nuclear med to get a scan done, they called the RR [rapid response] down there. So since I was her on-coming nurse,

I had to run down there and the charge nurse went with me, and there was a bunch of people down there all huddled around the patient, and she said that I did well handling and answering questions when they were asked like that.”

While this was not a code, she was able to take away positively reinforced learning from the situation. The experience of Rosie, was quite the opposite, leaving her with questions and self-doubt. “Nobody ever sat down with me and helped me piece together what it was I was supposed to document. I wish the supervisor had set down and kind of let me know, kind of afterwards, and like helped me with my documentation, knowing that it was going to be a big thing in the investigation. I guess that’s what ultimately tore me apart, I don’t know, they never really said anything about my documentation when they suspended me; they said it was because

I didn’t call fast enough.” She was never given the opportunity to understand or learn from the incident, and it has left many unanswered questions for her.

While Rosie had a rough experience with her first nursing position, she is able to compare the two as positive and negative experiences and to learn from them. 117

“The director of nursing at [first position], you do see her, but it’s not usually for a good thing, usually when you see her, she’s trying to find something wrong, or to tell you that you did something wrong. The acting director of nursing at [second position] has meetings on the floor with all the nurses. Like she will go to each shift, she’ll try to come in early for a night shift meeting, she does a day shift meeting, just to find out how people are feeling and how they like the new schedule or anything like that, like I was shocked when I saw that, but I think it’s a great idea. Because it doesn’t make you feel like ‘Here she is again, I wonder who is in trouble today.’ I feel that the acting director of nursing is very involved with all the nurses and I think that is a great way to be. It is nice when they are involved, it makes me feel like they want me there, and where they get their information is from staff.” Rosie is content with her new position and is doing well there. She will carry her experiences with her, but has already begun to turn them into tools with which to measure quality and positive management.

The experience of Victoria was extreme, but very important to hear. It gives ideas for improvement of retention and respect for nurses. In addition to the experience of incivility from the anesthesiologist, she tells of other experiences with the manager. “The way she delivers some of the information can be very harsh so that a lot of the time I don’t feel like I have a support system with my management staff… I don’t feel that input in that area would be received well. The manager that is there now is loved by everybody but the people that are under her, the other nurses

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that are there, she’s had other complaints by other nurses… She’ll come in and say things like ‘Your productivity is only at 50 percent, I don’t know what you all are doing wrong but you need to fix it and fix it now.’ So instead of going at it from a positive outlook and trying to encourage them, she will come at its from a negative and make you feel like you’re worthless and you’ve done something wrong and even though we’re back there kicking our butts trying to make sure all of the patient are recovering. So it’s very difficult to feel like she’s behind you or like she’s supporting you, like you’re doing a good job.”

Victoria further comments on the handling of the incident with the anesthesiologist by her manager. “I said that to my manager, I said, ‘This is not professional behavior.’ She basically told me to address that to the anesthesiologist, that she was not going to handle the conflict and that I needed to handle the conflict on my own. Eventually what had happened was that anesthesiologist took another job, within a couple of weeks of that happening.” She never had resolution or closure of the conflict and may have it rise with other conflicts for years to come. “That is the most horrifying experience that I’ve had, and it’s left a scar, because in the back of my mind, I don’t know everything, and it falters the trust I had with trusting my gut, you know what I mean? Even though I was eventually right, it makes me question now, still, ‘Is it right, or not right?’”

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Theme Four: Preceptor/Mentor Consistency and Guidance:

As a tool to provide retention and recruitment and job satisfaction, preceptor and mentor assignment is recognized a means to provide on-boarding. There were differences in the perceptions of preceptors and in the understandings of the trainings that the preceptor/mentor had received. Most of the participants commented on their experiences, and related that that, although they completed their orientation satisfactorily, there were problems with the experiences.

Amanda was able to speak to the difference between a preceptor and a mentor, but was unsure of the training involved for either. Her preceptor experience involved different preceptors, not one who followed her the entire nine weeks. She had asked for an extra week of orientation. She stated that her facility did not put much emphasis on orientation and “I kind of just got thrown in there, so my learning experience was kind of just learning on my own, and coming across things as I learned, so it’s been stressful.” Amanda now serves on a committee to develop a mentoring program for the facility. As opposed to preceptors who orient the new nurse, the mentor program will provide someone who will “help you with stress, being overwhelmed, they help you with knowing the hospital, they help you with knowing the facility, knowing educational opportunities, you know, getting scholarships to advance your education, things that aren't necessarily to your floor, they help you with hospital wide getting involved with the hospital.”

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Working and being oriented to an intensive care setting; Jack described two preceptor situations that were opposites. His first ICU preceptor was non directive, did not give clear instructions and guidance, and rather than give immediate feedback, would wait and report to the clinical specialist, who would then approach him about things as much as two weeks later. He states he was termed ‘lackadaisical’, but did not know the questions to ask because communication with his preceptors was so lacking. He also had different preceptors assigned to him. Having admitted to dealing with issues with self confidence, Jack shoulders the burden for not having asked for immediate feedback, and not knowing the questions to ask.

His second experience was much the opposite, providing him with guidance, encouragement and immediate feedback. When asked about preceptor training, (in the same facility as Amanda), he knew that “they teach you how to do the training in the correct way, how to read personalities and how to deal with if you have a personality conflict.” He had been through the preceptor training on his former unit when he was a new nurse of a year, so he spoke from having been through the training experience.

Differentiating between a mentor and a preceptor is something that he feels is a problem. Describing the difference, he states that a mentor is someone who is a support, a confidante and who helps you look at your experience holistically. A preceptor, on the other hand, is a teacher, one who teaches routine, skills and rationales for why things are done. 121

What is not happening during preceptorships, according to Jack, is the setting of goals at the beginning of the shift. Then, at the end of the shift, there should be a review of what went well and what didn’t, and what needs to be worked on. He says that people are exhausted at the end of their shifts and just want to leave, so this doesn’t get done.

Ruby supported Jack’s observations about the preceptor training. She feels that everyone who may be in a preceptor role should have the training. At the present time, not all preceptors go through the training, and she observes that a person may have multiple preceptors during an orientation period. One of the things she feels are essential to a perception experience is a “sit down with the manger at least periodically” and that does not always happen. As a new nurse, she had multiple preceptors and is able to identify advantages of that type of experience. She states that she was able to learn different things from each, such as time management and organizational skills. Ruby gives a tip for utilizing the best of each; she made notes of how each preceptor did things or told her to do them. Toward the end of her orientation, she sat down and made notes on what worked for her.

Six weeks was the preceptor period for Mant, but she felt that it should have been eight weeks. The unit had hired a lot of new graduate nurses at the same time, so they “were just trying to get through as fast as possible”, which may indicate a focus on quantity not quality. She did have the same preceptor each time, so she felt she was better than some of the others in that respect. She did not ask for more time 122

for orientation. Mant is a reserved, quiet person, who may have a problem with self-

assertion. Only out of school for 18 months, she is going to train as a preceptor in the

fall.

Jill’s experience with her preceptor has implications for some of the themes,

such as support from administration, treatment by nurses, and preceptor/mentor

consistency and guidance, that are entwined with one another. There appeared to be a lack of administrative oversight, a new preceptor was not assigned when it was suspected that drug diversion was taking place. It is the responsibility of administration to provide the most suitable and professional preceptor/mentor possible for a new nurse. Jill was not debriefed, nor was she provided with education or support after the incident and subsequent suicide. Her mentor shared with her that those she would be working with did not expect her to be successful. A preceptor/mentor’s role is to provide experiences, develop skills and work with the preceptee toward successful completion of the preceptorship; this would appear to be an effort to sabotage the preceptorship of the new nurse. It was not information that should have been shared with the preceptee.

Jill particularly appreciated the fact that her preceptor gave her guidance and helped her to correct mistakes. She did not disclose to the other nurses when Jill made a mistake, but showed her how to correct it in the future. While she sees her preceptor as supportive and a good preceptor, there are questions that are unanswered as to why the preceptor was selected, why she was not removed and why Jill was not 123

counseled or debriefed. While we are not privileged to the details of the final incident

of removal, one wonders whether the administration utilized all resources available to

them, through employee assistance or referral to the board of nursing, or whether the

preceptor was simply let go.

Several years ago, one of the systems where three of the participants are

employed, moved to develop a lengthy and educational orientation system in an effort to address recruitment and retention issues. As a result their retention increased from the high 70’s to above the 90 percent area (Personal discussion, B. Bilconish, 2003).

Three of the participants have participated in this program, Bethany, Betty and

Victoria. Bethany has been at the facility for over two years and Victoria has been there for four years.

Bethany describes her preceptor as being “just right” letting her ask questions, giving her guidance, not letting her “drown completely” but getting a feel for that experience. Her orientation experience was lengthy and involved several areas of the system. After the initial orientation, three novice nurses were assigned to one preceptor, and remained with that preceptor. One thing, she stated was to have the orientation build your confidence, and that it took her a year and a half to build that confidence. Admittedly, there are still some situations that she doesn’t know, but she says she knows where to go when she needs help.

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When asked about preceptor training, Bethany replied, “I really don’t think they train them, I think they just take an experienced nurse and then they have like checklists that they follow. They had meetings; I don’t think they had trainings prior to that.” The preparation of preceptors and planning of the experience was not something that was related to those who were being oriented.

Katie had a preceptor for eight weeks when first starting as a new nurse, but does not have a mentor. She thought there might be a mentor program available. She was comfortable as a new registered nurse with a six-week orientation, but qualifies that is because she was a licensed practical nurse prior to that. Commenting on her preceptor, she said, “I had an excellent preceptor. She is very patient, she was very kind.” She has precepted new nurses, but says that, while she is good at it, she doesn’t have the patience for it.

Stella and Robert work in long term care, and comment on the orientation/preceptor experiences in that setting. Stella feels that the orientee or the preceptor should have the option to extend the precept time if necessary. She states that that was available with the previous director of nursing, but not with the present one; perhaps that is because of a lack of understanding of the orientation/preceptor experience and the on-boarding process. She sees herself as an advocate for the nurse to whom she is a preceptor, and will stand up for them if they are making progress, but are not up to speed, by the end of their orientation.

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Robert had a preceptor for the first six weeks of his employment. He was also assigned a mentor, but did not know who that was for the first three weeks he was there. He did not know whether they were trained as preceptors or mentors. He is frustrated with the system in which he practices. “My first year was very, very difficult. I think there is, I don’t think they treat me bad, but there is not a lot of mentoring that goes on. You have a so-called mentor. I don’t think I called or asked my mentor one question one time. I don’t think I even knew who she was until the third week of my orientation had started. So they just kind of throw you out there and expect you to do and so that’s part of the reception at the workplace.”

Robert is now a preceptor for new nurses, and regards them as an extra set of hands to get the job done. “They can get those things done and when things come up, you try to show them how to do those. So I think it’s pretty optimal for the most part, maybe if they had some training in how to precept, it would be better.” This would indicate that there is no preceptor training at the facility, and a consciousness that it is needed.

Victoria, who has had difficulties in the workplace with others, also had a lengthy, planned orientation. She floated through different units that were connected in some way to her assigned area. She felt that this prepared her for her role in the anesthesia recovery area. It also connected her to other areas of the facility, and led to her involvement in facility wide committees. Her orientation enabled her to see

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more than just her area, but to see the system holistically, and to realize that the areas were dependent and interrelated.

Rosie, in her second nursing position, did not relate well to her preceptor at the first facility where she worked. She relates that the preceptor would sit at the desk and tell her to go do things. She said she felt “that was kind of stupid”, that they should be doing things together so that they could get them done and she could learn.

Comparing her second preceptor to her first, she tells that she is open to explaining every step of what she is doing, and apologizes for repeating. Rosie says that she learns better that way, so that is good for her. She is gradually taking on more responsibility and the preceptor gives her good feedback. Enthused about her experience, Rosie says “she is very smart, she is so talented and she is just so open to help, she’s bubbly about it. It’s amazing, I couldn’t have asked for a better preceptor.” Connection and communication are essential ingredients for a good relationship with a preceptee.

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Chapter V

Summary, Conclusions and Recommendations

“For those of us who nurse, our nursing is a thing which, unless in it we are making progress every year, every month, every week, take my word for it we are going back. The more experience we gain the more progress we make.” (Nightingale, 1890’s) Summary

There is a nursing shortage in the United States and around the world that is projected to worsen in the next decade, so that by the year 2025, the shortage of registered nurses in the United States will reach 500,000 (Buerhaus, Potter, et al.,

2009). The United States Bureau of Labor Statistics (2007) cites a number of

587,000, plus thousands more to replace experienced nurses who will leave the profession by 2016 (NLN, 2009). In 2007, the American Hospital Association reported that hospitals need 116,000 registered nurses to fill vacant positions.

It is estimated by various researchers that up to 69% of new graduates leave their first nursing job after two years (Ferrell, et al., 2011; Hayes & Scott, 2007); another survey found that 4.9% of nurses were planning on leaving while another

45.5% in the survey were undecided about whether to stay or leave (Rheaum, et al.,

2011). Kovner, et al., (2007) reported that 13% of new RNs left their principle jobs after one year and 37% felt ready to leave. This is a slow leak that is tapping the reserves of the profession and has implications for safe patient outcomes.

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The purpose of this qualitative study was to look at the experiences of new registered nurses in their first one to five years of practice. This was an attempt to gain an understanding of their experiences and how those experiences formed their opinions and perceptions of nursing. It was also the hope of this researcher that the results will give some insight as to what might need to change in order to improve the initial experience of nursing for other newly registered nurses.

This research centered around two major research questions. These questions focused on the first one to five years of practice of the newly licensed registered nurse. There were four major themes that emerged from the information collected.

Each of the questions was addressed by the themes as they applied to the questions.

Research Question One:

What is the perception of newly licensed nurses of their reception upon entering the nursing workplace?

These twelve nurses entered the world of nursing eager and excited to pursue a career with others who shared the desire to help others. What they found were nurses who were disenchanted and who treated the participants and each other with a lack of civility. They referred to their work team as family, but reports that they gave describe dysfunction. Of the twelve, more than half have either left or plan to leave their first nursing position. From the interviews of these twelve nurses, incivility is alive and well in their nursing world. What was found in the interviews is that nurses

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face a problem of communication and understanding each other’s abilities. When new nurses enter the workforce, their colleagues expect them to function at the same level as nurses who are at the competent to expert stage of Benner’s model (Benner,

2001). The new nurse is expected to function at a higher level than that which they are capable. At times, they were not aware of what was expected of them because that was not communicated to them. Baltimore (2006) observes that this may be one effort to control the new nurse by more tenured staff.

There were also incidents of incivility perpetrated by physicians. These incidents are proof of the continued hierarchical relationship of nurses and doctors.

Nurses practice independently of physicians, collaborating with them concerning patient care. They are both members of the same team. What was found was a lack of support for this relationship from administration. When physicians behave in manners that are destructive to the collaborative team relationships, it results in the possibility of poor patient outcomes (IOM, 2010; Joint Commission, 2008.). This is a safety issue, and a patient satisfaction issue, as well as a recruitment and retention issue. Both affect the financial viability of the organization. This must become an issue for administrations to address regularly.

What was found, and what is felt to be needed, is a policy in the workplace of inclusion and of zero tolerance for ‘bullying’, incivility, horizontal violence’ that is made a part of the organizational culture from top to bottom. Organizational leaders must set the standard; espouse these values and ‘practice what they preach’, making 130

overt, conscious efforts to know their employees, and treating everyone with respect and dignity, thereby creating a culture of inclusion and recognition. Those behaviors are to be expected from more tenured nurses as well. I once had an adjutant general in the National Guard who made a point to know all of his soldiers’ names, and sent personal notes to them whenever they had an accomplishment, a promotion or a significant event. That was a culture of inclusion and recognition. It cost nothing, and directly affected recruitment and retention.

The participants were posed questions about how they were received in the nursing workplace. Most of the discussions centered around feeling a part of a team, or “family”, nurses being rude, disrespectful and “eating their young” (being uncivil to one another).

Incivility has been a topic in the nursing research for years (Center for

American Nurses, 2007, 2008). It is addressed in the American Nurses Association’s

Ethical Code for Nurses with Interpretive Statements (2001). In spite of this, all of the participants in this study report having experienced or witnessed some form of incivility, nurse on nurse hostility. Either during a code, when requesting help, when performing patient care, or in the course of the day’s work, all of the nurses interviewed have some form of incivility to report. Cohen and Bartholomew (2008) tell us that we, as nurses, have an obligation to “help bring new nurses into healthy work environments” (p. 27).

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The incivility seen by the participants in this study were those of refusing to help, telling the nurse she was on her own, to “suck it up”, being told they were not expected to be successful, being punished with no expectation for remediation or explanation, being called names, and other more common means of being demeaning.

Susan Luparell (May 3, 2011) referred to this phenomena as “joy stealing”. It rips from the new nurse the enthusiasm for their profession, for learning and for experiencing and developing as a nurse. Many of the participants expressed disappointment in how situations were handled, as in the cases of Rosie and Victoria.

Jill termed the emergency room the “snake pit”, and left her first place of employment. While she did not identify incivility specifically as being directly responsible for her leaving, she pointed to it during the interview.

Many researchers have studied the phenomenon, and those works have resulted in the Joint Commission (2008) developing leadership standards and suggesting that health care organizations have a policy in place to address intimidating and/or disruptive behaviors in the workplace. It addresses intimidating and disruptive behaviors, both overt and covert. These actions can contribute to medical errors, poor satisfaction levels, adverse events, increase cost of care, and cause professionals to leave their positions. Contributing factors to workplace disruption are increased demands for productivity, increased lengths of shifts, increased flux in human resources, and a culture of tolerance.

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The participants identified all of the types of intimidation and disruption identified in the Joint Commission’s (2008) Sentinel Event Alert. Forming “cliques”, allowing nurses from other floors to “drown”, being “mean” to other nurses and

“drilling” them, telling a new nurse she is expected to “not be successful”, withholding evaluation of performance during orientation for weeks, and making a person afraid to give a verbal report are all forms of incivility. Some of these have already led to costly loss of nurses in these settings. Others were taken to managers and administration with no active response. These behaviors are frequently a cause of job dissatisfaction and emotional distress for nurses

Barton et al. (2011) address the issue of “cliques”, stating that they are a form of childhood and adolescent behaviors that adults regress to in times of stress.

Managers must be cautious to address cliques on the units as they can erode the functioning of the team, impede the quality of patient care and lead to poor patient outcomes. They have a significant impact on recruitment and retention as well. It is important to have all members of the team feel included and valued.

It is often difficult to identify uncivil behaviors, because they are covert.

Even in the proofing of this research there was possible misinterpretation of Jack’s interpretation of his preceptor’s treatment as being Jack’s own insecurity. Nurses are conscious that the patient’s pain is “…whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1979, in Potter & Perry, 2009, p.

1052). It is an individual experience and can be interpreted differently by different 133

patients. From the literature and form these participants, like with pain, one could say that different nurses can interpret these behaviors differently; it is an individual experience, and is whatever the nurse interprets it to be. Some nurses, like Katie and

Stella, are able to pull from their life experiences and confront incivility, or not be bothered by it, and others, like Jack, Rosie, Jill and Victoria, are deeply affected by it.

It may be posited that, depending upon the person’s previous experiences, incivility may be experienced differently.

Many of the participants had looked forward to interdisciplinary collaboration, only to be disillusioned by the way physicians treated them. Jack was flattered by being asked to call doctors by their first names when he went to work in the intensive care unit, but it went against his values, gained in the military. Robert found it frustrating to be ignored by the doctor because he was a new nurse and hadn’t earned his respect yet. This caused delays in obtaining treatment interventions for some of his patients.

Those situations seem mild compared to the frustration caused to the staff in the emergency room when the doctors refused to use the new computer system and created an eight-hour backup. Victoria’s episode with the anesthesiologist was an extreme form of incivility, and left deep scars for her, as well as possibly threatening her professional reputation with those who witnessed the episode.

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The means to address the treatment of nurses by physicians lie with administration, if the nurse is not able to resolve conflict with them personally. Lack of collaboration between physicians and nurses, as well as a perceived lack of support by managers and other nurses, is frequently a cause of job dissatisfaction and emotional distress for nurses (MacKusick & Minick, 2010). Leaders in health care have known for years that these behaviors are alive and well in the healthcare setting, and that they lead to breakdowns in teamwork, lack of collaboration, poor or nonexistent communication, and poor patient outcomes (Blake & Rosenstein, 2008).

It behooves administrations to educate the medical staff about incivility, and to confront it when it occurs.

Physicians and nurses have a collaborative and synergistic role in the health care setting. Physicians are not able to have a presence 24/7; they depend on the nurse to be their eyes and ears, and to bring any significant events or changes in patient conditions to their attention. When there is a lack of respectful regard, that communication may be hampered, to the detriment of patient care. As with

Victoria’s treatment by the anesthesiologist, the result of that exchange was that

Victoria was hesitant to approach the physician to report future events. She was afraid of continued violent outbursts from the physician, and that could have resulted in poor patient outcomes. The collaborative relationship and the synergism in the relationship were destroyed, not to be renewed without resolution of the conflict, an issue not to be resolved because the physician left. Results of this interruption in

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collaborative practice can lead to poor patient outcomes and can be costly to the facility.

In the case of Jill’s emergency room incident, when the physicians chose not to use the new computer system, because they didn’t like it, patient wait-time in the emergency room was slowed down to eight hours. This caused tension with the nursing staff, and disrupted patient care, not just for the emergency room, but for the entire hospital. Units in the hospital are the recipients of emergency room admissions. They experienced a delay in receiving and treating patients. Delays in treatment for emergency patients could have resulted in poorer patient outcomes. The emergency room nurses were delayed in calling report to the floors; there was the possibility of a resultant degree of horizontal violence in the form of curtness, short tempers, and verbal mistreatment. All of this was a snowball effect, a result of the physician slowdown.

All members of the hospital staff, including privately practicing physicians must be held accountable for their actions. The Joint Commission (2008) identified these behaviors, saying that they often were “often manifested by persons in positions of power” (p. 1). The Commission further addressed the failure to address the incivility as a means of indirectly promoting it.

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It is important that nurses feel connected to administration. .Involvement in change process is important to their learning about the organization and feeling that they have a part in making change happen.

Mant’s telling of the actions of the unit manager gave the picture of a barrier between management and staff. While Mant was involved in planning a major change that was to take place on the unit, the manager was reluctant to be transparent with the details of the change, and would not discuss it with them. When they looked to Mant for information, she was placed in a middle position that was not comfortable and a rift was created between her and those with whom she worked.

The change was one that would have an effect on every one of the staff and how they were able to perform patient care. We do not know if the manager had instructions from higher authorities to not divulge details of the change until a certain point; we have the impression that she was not available or transparent in the making of the change. Communicating a sense of urgency, according to Kotter (1996) is essential to making change. Communicating a vision, and helping to overcome the status quo, and energizing the staff. Managers need to be trained in leadership skills, and in motivating people.

It is important for leaders, managers, to be on solid ground with those they supervise. “Trust is the foundation of leadership. It is the glue that holds the organization together.” (Maxwell, 2007, p. 61). If staff does not trust their leader to

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bring them information, to advocate for them, then there is no trust and the

relationship between them falters and corrodes. Kotter also addressed the process for

change in Leading Change (1996). He identified an eight stage process for change that includes the creation of a sense of urgency, guiding a coalition, communication of the vision, and empowering the employees for action (1996). Kouzes and Posner

(2007) discuss trust and the sharing of goals; they state that “one of the most significant ingredients to cooperation and collaboration is a sense of interdependence, a condition in which everyone knows that they cannot succeed unless everyone succeeds, or at least that they can’t succeed unless they coordinate their efforts” (p.

233). This is the essence of teamwork in nursing. As a leader, one cannot expect others to follow if there is not trust, and there cannot be success to a mission without collaboration and cooperation. Without honesty and transparency, being open and honest, and sharing information, trust cannot be built.

One wonders how the preparation for the changes regarding the computer program in Jill’s emergency room was handled. If staff, including physicians, were not involved in the change, if they did not have ‘buy-in’, it is no surprise that they did not involve themselves in cooperation and collaboration in the change process.

Maxwell (2007) speaks to the “Law of Buy-In” (p. 169) and tells us that it is not the cause the people follow, it is the leader. They must trust the leader first, and then they will be able to follow or buy-in to the change or the cause. When change is dictated from leadership, with no established relationship, or a relationship that is

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shaky, it is not likely that people will be receptive to change. They may give verbal message that they will, but then sabotage the change, as did the physicians in the emergency room. It is not known if there was any relationship established or if they did give verbal buy-in that preceded the incident.

Amanda told of the incident, in which she had a patient who coded on her. No one could hear her to respond because of the variance table; two nurses were a

“football field” apart and the nursing assistant was on the “other end” tending to a patient. This was a situation that was likely to result in poor patient outcomes.

Amanda did not feel that she was supported by administration; the nurse to patient ratio was felt to be inadequate, in her opinion. While all nurses are responsible for safe patient care, when administration is made aware, and make no change, there is the likelihood of sentinel events occurring, and of the nurse experiencing events that will cause them to be disillusioned with nursing.

Amanda did not feel supported; she was dependent upon administration and supervisors to make change for safe practice. “A good manager does things right. A leader does the right things.” (Kouzes & Posner, 2007, p. 7). Managers follow others, they get the truth from those they follow, while leaders assess and make the decisions about what reality is, analyzing the facts, forming a vision, and a plan to make change

(2007).

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Many of the participants spoke of delegating tasks to the nursing assistants, only to have them refuse to do what they were asked to do. Amanda addressed that and said that her manager acknowledged the problem, and that she had heard that before, but did not address the issue. The Nurse Practice Act (Maryland Board of

Nursing, 2011) gives nurses the right, under law, to delegate. It is a nursing function, taught in every nursing program, and presented in nursing fundamentals textbooks

(Berman & Snyder, 2012). Delegation is a tool to improve patient care, freeing the nurse to tend to more immediate and acute issues. Delegation is a high level cognitive skill that requires support and encouragement for critical thinking and use of interpersonal and intrapersonal skills. Those skills work in synergy (Derickson &

Caputi, 2010). For a manager not to facilitate that process is to impede the quality of patient care, to affect patient outcomes and to inhibit the development of those skills in the nurse. In Amanda’s situation, it frustrated her and created anxiety, since she had learned about delegation, and expected to be able to utilize it to her advantage in delivering patient care. We can only assume, that this is the reason Amanda has left the unit to work in the operating room. I was unable to explore the reasons, since the transfer occurred after the analysis of the interviews.

Allowing a nurse to handle a code by him/herself, as a new nurse just off of orientation, without guidance or some type of debriefing afterwards was a lost opportunity for support and development. More experienced nurses, nurse educators and supervisors have an obligation to seize those moments and use them to improve

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the process of patient care. Rosie was a novice nurse, according to Benner (2001) and had little experience to pull from; she had never handled a code prior to that incident. Administration and managers chose to suspend her, rather than have her learn and be supported from the experience, later paying her for two thirds of her suspension time. As a result, within five months of the incident, Rosie found another position at a facility where there was support, guidance and a sound education program. That one incident cost the facility over $60,000 (Seifert, 2011) to replace and train a new nurse, who had been there only seven months. Time and financial investment in a quality mentoring program will “increase recruitment, retention and job satisfaction” (Ellisen, 2011, p. 12). Some of the problems faced by new nurses are communication, recognizing signs that emergency intervention is needed, learning the culture of the organization, skills and becoming a member of the team (2011).

Guidance is expected and needed from more experienced nurses and administrators.

Benner (2001) postulates that it takes two to three years to reach the level of competent nurse, moving through the stages of novice and advanced beginner to reach the competent stage. During that time they have learned procedures, assessment, and have gained the ability to see the big picture, more than that which is in front of them. They can plan. Despite this time frame, we see new nurses being place in the role of charge nurse within their first two years, placing them in a role that they may not be adequately prepared for.

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Bethany, an emergency room nurse of two years, and Mant, a medical- surgical nurse of only a year, have both been place in charge nurse roles. Mant was a little tentative about asserting her role, and is responsible for two units at night. She often has nurses who are more experienced than she working with her. Bethany expressed concern that she was assigned to charge duties while not having been oriented to the role. She expressed her concern regarding the supervisor directing her to counsel a person, when she had no guidance, experience or training in how to do so. To place a nurse in a new role, returns them to the stage of beginner, or at best, advanced beginner and requires the support and guidance and support of a nurse who is at the level of competent or expert (Benner, 2001).

Many of the participants expressed their views of managers, of leadership styles, and the way that change was initiated. Betty, Bethany, Jill, Mant, Jack, Rosie,

Katie, Stella, Amanda, Victoria, and Ruby all made reference to their managers and/or how critical situations or planned changes were handled. All gave descriptions of barriers between staff and management. While some commented that management was visible, there was difficulty with communication or information shared with staff.

One hospital (Dunn, Shattuck, Baird, Mau, & Bakker, 2011), in preparation for Magnet® designation, defined the core beliefs of the hospital nursing department.

One of those beliefs was “We believe a supportive, collaborative environment is essential to optimal nursing performance.” (p. 24). This is the essence of teamwork.

Teamwork does not stop with the nurse on the unit; it involves all levels, from 142

housekeeping to the chief executive officer of the facility. All levels need to be

visible, approachable, honest and accessible. Managers need to be available to the

new nurse, providing information, guidance and support.

Participants expressed that managers were “on the unit, but in their office”,

leading one to believe that they didn’t want to be disturbed. Another stated that their

present manager was “proactive” and that their former manager had been a “laissez

faire leadership type”. Rosie observed that the director at her first place of

employment had only come around when something was wrong, or when she was

looking for something wrong; the director at her second placement was very visible,

positive and involved. Most did not have a solid relationship with their manager,

portraying them as distant and inaccessible. This is frequently a cause of frustration

for nurses who work nights and rarely see their managers.

The role of the preceptor is to facilitate the incorporation of the new nurse into the team and to the facility. The current buzzword for orientation is on-boarding

(Bauer, 2010; Velsoft, 2011), which involves a longer process than the traditional orientation period. All of the participants went through an orientation period for their facilities. What happened after that was much more significant to their careers. Their precepting experience involved multiple preceptors, inconsistencies, lack of knowledge or confusion about the process or of the preparation of their preceptors/mentors, and being used as “an extra pair of hands”.

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Modic and Schoessler (2007) suggested that preceptors are differentiated from mentors. Preceptors must have training to be preceptors, their individual strengths and talents should be matched with the needs of their preceptees. They serve as a socializer, educator and role model to the new nurse (Alspach, J. G. Mentors are those who may be assigned or chosen by the mentee, the new nurse, after the preceptorship is over. They continue the process of support, development and becoming part of the unit and the organization.

In this study, the participants described experiences in which their orientation or preceptor period was over and they were expected to function independently.

Benner (2001) describes these nurses as still novices.

There were those who had lengthy orientation periods. Victoria, Bethany, and

Betty were involved in programs that were designed to orient, educate and train nurses to function in their roles and provided them with a full-time preceptor during that period. The health system they are in developed this program prior to its pursuit and awarding of Magnet® recognition. Its development was in response to a perceived need to improve the retention rates of nurses (Bilconish, personal conversation, 2005).

Many of the participants found difficulties with their preceptor/mentor experience. Robert was not aware of who his mentor was for the first three weeks he was at the facility, saying, “I don't think I talked or asked my mentor one question

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one time. I don't think I even knew who she was until the third week of my orientation had started. So they just kind of throw you out there and expect you to do, and so that's part of the reception at the workplace. And it's difficult because there is a lot to learn out there if you don't have somebody to help you, a lot of times, they're not, all the nurses don't want to answer your questions.”

Rosie’s first employment situation paired her with a preceptor as she described, (voice raises) “I mean it was fine, I mean I didn’t treat her like crap or anything, but she really got on my nerves…’[Rosie] go do this, [Rose] to do that’ .

Not going to help me in any way. Especially after I came back from my suspension, they made me work with her again. She would make me do everything and she would just sit at the desk. I always thought that was kind of stupid, like we should be doing that together so we could get it done and we could learn more stuff together, but that’s not how it went. And every little thing she was like ‘Oh, [Rosie] can do it;

[Rosie] can do it.’ Just let me do it and like anything that had to be done, she would say ‘We’ll do it’ like it was all of us in there and it was never her it was always me and the other nurse. She never wanted to participate.” Her preceptor at her second placement is described as quite the opposite. “The nurse that I’ve been with so far, she is very smart, she is just so talented and she is just so open to [being helpful] help, she’s bubbly about it. It’s amazing like, I couldn’t have asked for a better preceptor.”

Jill’s preceptor provided her with information that could have been detrimental to her personal professional identity; she was not expected to be 145

successful in her orientation in the emergency room. She was assigned a preceptor and mentor who was neutral, did not know her, but that had issues with controlled drugs. This caused Jill to be drug-tested twice during her orientation period, because her preceptor diverted drugs signed out for a patient. Mentors and preceptors should be selected for their talents, strengths and clinical sophistication (Modic &

Schoessler, 2007). They should represent the ‘gold standard’ of the organization.

The program should be coordinated, preceptors and mentors should be trained, and the objectives of the training and the program should match the mission of the organization (Alspach, J. G., 2000; Modic & Schoessler, 2007; Ellisen, 2011).

Managers have a responsibility to become involved in the close supervision of the preception process.

Many of the participants are now serving as preceptors. Having been nurses for only two years, Bethany, Robert, Ruby, Jack, and Stella all have served, or are serving as preceptors. There has been no formal training for the role of preceptor.

Robert sees being a preceptor as an advantage to him because, “There are two people to get the work done”. Robert, Stella, and Ruby say that there is no formal training program for preceptors, and there may be several preceptors during the preceptorship.

John Maxwell (2008) describes the effect of this type of leadership and planning on retention, stating that “People quit people, not companies.” (p. 143). It is important for the preceptor or mentor, who are leaders for the preceptee, to be credible,

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competent and have a passion for personal growth, as well as valuing the new nurse, being trustworthy and credible (2008).

Research Question Two:

What is the perception of newly licensed nurses regarding support from administration and preceptors/mentors?

Because of the nature of precepting or mentoring relationships and the fact that they occur at the beginning of an employment relationship, many of the threads of the themes are intertwined with research question one.

What this study found was that preceptor programs were perceived as loose and poorly structured, with the exception of the lengthy preceptor program in the

Magnet® certified health system. There was little communication between the preceptor and management. Participants were not familiar with requirements for preceptor/mentors and lengths of perception periods varied; some in order to accommodate staffing needs. There was no definition between the roles of preceptor and mentor. It is felt that investment in a solid preceptor training program would benefit the organization in both financial and human resources areas. The selection of preceptors/mentors should represent the ‘gold standard’ of the organization, providing socialization into the organization, role modeling, knowledge, and excellence in clinical practice. This is born out in the successful retention rates of the Magnet® facilities represented in this study (Bilconish, personal conversation, 2005).

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Preceptors or mentors are placed with new nurses to introduce them into the role of nurse and to educate them as to how they will fit into the team. This is a crucial period for new nurses, many make the decision to stay or leave during this period. Investment in a well designed preceptor and mentor program is found to provide financial savings and to promote more positive client outcomes (Halfer,

2007; Persaud, 2008; Pine & Tart, 2007).

Thirty-five percent to 61% of new nurse leave their first employment during the first year of employment (North, Johnson, Knotts, & Whelan, 2006; Pine & Tart,

2007). Twenty five percent of the nurses in this study left their first nursing jobs within the first year, one left after four years, and four others are contemplating leaving. Three others work other nursing jobs, in addition to their primary nursing positions. The participants spoke about their preceptor experiences.

Many were confused or uncertain about the training that was provided to the preceptors. There was also confusion about the difference between a preceptor and a mentor. Only those employed in the Magnet® facility were aware of the efforts put into the mentoring program.

Working in the same facility, Ruby, Jack, Amanda, Jill, Katie and Mant all had different preceptor experiences. Mant would have liked her preceptor period to have been longer, but there were several new nurses on the unit and they “were just trying to get through as fast as possible”. Mant does relate that she was able to have

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the same person as a preceptor. She will train as a preceptor this fall, having been a

nurse for only 18 months. Benner (2001) tells us that this is when the nurse is likely

to be moving into the advanced beginner stage. It is suggested that preceptors be a

more “experienced and competent staff nurse who has received formal training to

function in this capacity and serves as a role model, socializer and educator.”(Modic

& Schoessler, 2007, p. 195)

Jack, who recently transferred from a medical, cardiac telemetry floor, to the

intensive care floor, has been a nurse for two years. He served as a preceptor on his

old unit, and stated that he had received training to perform as a preceptor.

Commenting on his experiences with preceptors in the intensive care setting, he

stated that they were critical, and did not give feedback to him for up to two weeks at a time, until he moved to a different area of intensive care. His preceptor was frequently out on emergency absences, some because of decreased staffing needs.

Performance evaluation should be well timed and given as close to the event as possible (University of Maryland, 2011). Jack was not provided with timely feedback to correct his performance nor to discuss it. The consistency of working with his preceptor was interrupted.

Jill was assigned a preceptor with whom she developed a close relationship, as is hoped in precepting/mentoring relationships. However, there was a perceived lack of screening or corrective action when her preceptor ran into problems of her own.

Preceptors should be trained in methods of coaching, in teaching techniques (Halfer, 149

2007) and serve as a clinical role model (Aaron, 2011), being selected for their

expertise, ability to role model the profession, and to assist the new nurse to become a

competent and stable staff member (Aaron, 2011; Modic & Schoessler, 2007).

Sharing with Jill that she was not expected to be successful served to put a

barrier, or to reinforce a barrier, between Jill and the rest of the staff. One of the

duties of the preceptor/mentor is to assimilate the new nurse into the membership of

the staff.

Ruby related that she had different preceptors during her orientation period.

Feeling that she was taught something from each, and being adaptable, she was able

to put all of her learning together and decide what worked the best for her. She now

uses that in precepting other new nurses. She has been out of school for three years,

and is clearly in the advanced beginner to competent stage according to Benner

(2001).

Both Robert and Stella work in long-term care; they have both been precepted

and have precepted others. They have both observed nurses who have targeted new

nurses and see problems with mentoring in that they are not identified, and that nurses are not formally trained in the role.

All from a Magnet® facility, Victoria, Betty and Bethany were all aware of the involvement of preceptors in the extensive orientation program. Victoria addressed the differences in her preceptors, but was able to relate that, in

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combination, they all contributed to her success. Bethany was able to identify that some of her preceptors were different from others, and recalled one that was very hard and made it difficult, like a ‘very difficult instructor in school’.

The Magnet® facility’s extensive and elaborately planned orientation program was in place well before the pursuit of excellence for Magnet® certification began. It came about in response to a recognized problem with recruitment and retention, but served them well in the process for recognition.

Each of the preceptor/mentoring programs was designed differently. It is not clear if they were designed from another program or specific plan.

Those in the long-term care setting, Robert, Stella and Rosie, described programs that had little or no structure. The preceptors were not chosen for their ability to lead or to utilize their personal strengths and abilities to incorporate the new nurse into their new surroundings. They relate that there is no training for precepting/mentoring in the long-term care system in which they work. They identify areas where training could help with orienting new employees, and possibly make their employment a more satisfying one.

Rosie related that no guidance was given to or from her preceptor in her first nursing position. Aaron (2011) addresses the impact of preceptors in the long-term care setting, citing a 50% turnover rate in long term care settings. A program that is successful will increase recruitment and retention and provide resident, family, and

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staff satisfaction as well as financial savings for the institution utilizing it. It is projected that it costs more than $60,000 to hire and train a new nurse (Seifert, 2011).

The primary roles of preceptors/mentors are guidance, socialization, nurturing, educating, coaching and role modeling, providing an optimal work setting for the new nurse, and increasing their confidence level (Halfer, 2007; Pine & Tart,

2007; Young & Wright, 2001). This was not the picture that Rosie painted of her preceptor in her first position, rather one of detachment, a nurse who sat at the desk giving orders and who gave no feedback to stimulate improvement. Rather than having taken the opportunity to seize on the teachable moment, as in the case of the code, the preceptor did not, and the result was that Rosie still has serious questions.

Rosie perceives that she was punished with no attempt at remediation.

Removing a preceptor at the first suspicion of drug diversion would have been in line with a well planned preceptor program. Clearly that did not happen; there was no guidance for Jill in dealing with the problem, nor was there any debriefing offered for the suicide. In an article about partnerships between mentors and new nurses,

Hayes (2007) refers to Beecroft, Kunzman, and Krocek (2001) in recognizing that

…institutions must help new graduates acquire the values, attitudes, and goals characteristic of a member of the profession and gain a sense of identity within their chosen occupation. Formalized mentoring programs, with one- on-one contact, facilitate the transition of new graduates to professional practice, prepare beginners who are able to provide competent and sage care,

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and strengthen the commitment and increase the retention of newly hired practitioners. (Hayes & Scott, 2007, p. 28)

As previously stated, there was a responsibility to re-evaluate the preceptor/mentor placement if an ethical issue arose.

Ruby, Katie, Jack, Mant and Amanda were all from a facility where the preceptor program was not clearly organized. While that may not have been a problem at the administrative level, there was no communication or continuity of that type of organization present at the unit level. Most of these nurses saw that the precepting was not coordinated. There was no evidence of involvement from unit managers. A successful program at The Methodist Hospital of Houston, Texas (Pine

& Tart, 2007) obtained “buy-in from all levels of nursing” (p. 17) including senior executives and all nursing staff, and the program was consistently on the agenda at all leadership meetings.

Conclusions

In this section I apply the findings from the study to the research questions:

1. What is the perception of newly licensed nurses of their reception upon

entering the nursing work place?

2. What is the perception of newly licensed nurses regarding support from

administration and preceptor/mentors?

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The experiences of these new nurses, as related in their personal interviews, tell their stories of difficulties adjusting to the nursing world. Their transitions from student to newly licensed nurse have not been easy ones, having been affected by events and people. In line with the national averages (Hayes & Scott, 2007; North,

Johnson, Knotts, & Whelan, 2006; Pine & Tart, 2007), 33% of the participant group had left their first nursing positions.

The responses to the question and the perceptions of the individuals are as different as they are as people. There is a difference in the perceptions and responses of the elder three, Betty, Katie and Stella; who seemed to have been able to take the experiences at face value, finding the good and not so pleasant aspects of their first years. They were able to look at a problematic situation and address it immediately, fleshing out the problem area and dealing with it. They seemed to be more able to critically think about their situation than the younger nurses. Zeller, Doutrich, Guido, and Hoeksel (2011), in a qualitative study of new nurses, identified that “emotional and mental maturity was more important than actual age” (p. 411). This would appear to be the case with these nurses.

With the younger nurses, there seemed to be more of an ownership, a responsibility for problems, for not knowing, or for doing something incorrectly.

They were reluctant to address problems head on, rather harboring their feelings and increase their stress.

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There was a difference in the perceptions of positive reception in the long-

term care and acute care settings. In the long-term care setting, there was no

perception of organization or sense of cohesiveness and belonging to the staff, or

about the preceptor/mentoring program. Aaron (2011) found that a structured and

organized effort to orient and train new nurses had a positive impact on recruitment

and retention.

In the acute care areas, nurses were involved in efforts and committees to

improve client outcomes, and in pursuing further education. I assessed most of the

acute care participants to be confused about the preceptor/mentor program in their

facilities, with the exception of those who were employed in the Magnet® setting.

There seemed to be no consistency with the preceptors themselves, switching

frequently, and having no organized structure to the precepting itself. Many did not

know whether there was a training program to be a preceptor. If one does not know

about a program, one cannot be supportive of it. Programs need to be supported by

leadership and celebrated in the facility; staff needs to make a concerted effort to

make the new nurse welcome in the work setting (Bally, 2007; Fawcett, 2002; Halfer,

2007; Modic & Schoessler, 2007; Pine & Tart, 2007).

This study found incidents of incivility throughout the interviews. These were incidents surrounding high stress problems, such as codes, high tension over a septic patient in a recovery room, and in emergency settings. These were all incidents that could have been managed with more finesse. Education of managers to deal with

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high stress and with critical incidents is essential to maintaining the optimum environment for patient care. Dion (2006) found that perceptions of supervisory support were positively linked to workplace satisfaction and intent to leave. One

Magnet® pediatric facility instituted a code debriefing team to help nurses deal with the reactions, either physical or emotional, that may exist after a critical incident

(Halfer, 2007).

The participants and other new nurse may not be prepared to know what questions to ask their preceptors/mentors. As Jack put it, “I didn't ask questions, because I didn't know which questions to ask. I ask more questions now that I'm off orientation, and I told them that, than I did on orientation, because now I know what questions to ask.” This needs to be anticipated by the preceptor, and information needs to be given. Establishing a trusting relationship with the preceptee will encourage effective communication.

I found that all nurses in this study want to be good nurses, and have positive patient outcomes, to help people. What seemed to be happening is that managers and more experienced nurses were not aware of the level, according to the Dreyfuss and

Dreyfuss model (1980) and Benner’s model (2001), at which the new nurse was functioning, and that they needed to progress, and gain experience before they were able to move to a higher stage. The nurse who has been there for five or for fifteen years may be expecting the new nurse to function at their level.

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When nurses are promoted to the levels of managers, there need to be a mentoring into that role as well, a learning period and training as to what the role involves. Glickman, Gordon, & Ross-Gordon (2010) address successful supervision in schools that can be applied to health care and state that the more difficult tasks of supervision are not the technical tasks, but the cultural tasks, facilitating change, addressing diversity, and building community. These tasks are difficult for the nursing manager as well, and they need support and training to assume those roles.

Kolouritis (2004) addressed change in her book Relationship-based Care: A

Model for Transforming Practice. Identifying twelve basic value assumptions, she posits that “Healthy relationships among members of the health care team lead to the delivery of quality care and result in high patient, physician, and staff satisfaction (p. viii)” and that “transformational change happens one relationship at a time” (p. viii).

Addressing a problem as a huge issue may be overwhelming on a unit, but dealt with one relationship, or person, at a time may be doable, like “eating an elephant” (one bite at a time).

Recommendations

The recommendations of this study that may lead to successful integration and development of newly licensed nurses are three fold: implementation and enculturalization of a zero-tolerance program for workplace incivility at all levels; implementation of a formal, structured and coordinated precepting program, and a leadership training program for tenured nurses and managers (both the leadership and 157

precepting program to include the tenets of Benner’s (2001) theory of skill

development). (Figure 1- Model for Success) It is with these structures in place that

the newly licensed nurse will be supported in integration into the workplace

Figure 1. A Model for Promoting Newly Licensed Nurse Success

Formal Preceptor Program (including Benner’s Model)

Success of the New Nurse

Leadership Training Zero tolerance (including for Incivility Benner’s Model)

Implications

I was a nurse who thought that incivility was a problem to be solved on an individual basis, between the victim and the perpetrator. As I have been involved in this research project, and have thought more deeply about the topic, what I have found is that the problem lies much deeper. It lies within the institution, and leadership at all levels. When nurses are not aware of the levels of professional development and competence of their colleague, they expect higher levels of 158

expertise than the colleague is able to provide. Benner (2001) gives us the best

measure for competence, referenced by multiple experts in the field. This should be

taught in all nursing educations programs, be a guide for staff nurses and managers at

all levels, and reinforced in the workplace. This tool to measure nurses’ skill

acquisition should be as second nature to us, in assessing nurses, as the Wong-Baker

FACES Scale (Hockenberry & Wilson, 2009) or the Braden Scale for predicting

pressure sores (Braden & Bergstrom, 1988) is to us when assessing our patients.

This study showed that, as well meaning as orientation programs are, they are only as good as their publicity and reinforcement. If staff nurses are not aware of what is involved for their preceptors/mentors in preparing to help them, and if the program is not reinforced throughout the organization, it will not have the intended results. Formal and well-developed preceptor/mentor programs need to be invested in; grant monies can be applied for to initiate their implementation. The literature has identified that the organization will get a return on its investment (Halfer, 2007; Pine

& Tart, 2007) in decreased human resource costs and in positive patient outcomes.

All levels of the organization need to be on board with the program; as Callahan and

Ruchlin (2003) observed, “The broader the ‘buy-in’ the greater the chances for success. Successful alignment requires effective communication encompassing ongoing rather than one-time efforts” (p. 296).

Mentors need to be screened, and then recognized, either by celebration for what they do, or by monetary remuneration. Once up and running, there needs to be 159

evaluation, recognition and celebration, involving all levels of management and nursing to develop a sense of belonging and ownership. This is born out in the literature (Bally, 2007; Persaud, 2008; Pine & Tart, 2007).

It would be beneficial for facilities to invest in a formal on-boarding program, training personnel in its use, and involving staff at all levels. The benefits in human resources will represent a cost savings as will the savings in positive patient outcomes. There needs to be buy-in for the program at all levels of the organization.

Organizations must have a program and a process to deal with incivility.

Putting in place a formal policy is only as good as the enforcement of the policy. All staff members need to be trained. There need to be planned interventions for dealing with incivility when it occurs. The realization that incivility is whatever the victim says it is, is a fact that must be reinforced in facilities. To not acknowledge this is to ignore the problem, and that will be costly to the organization.

Incivility is a holistic problem that permeates the experience for the new nurse and for other nurses as well as the organization. Not only is it important to deal with incivility, it goes much deeper. It is a three-fold problem: training of preceptors/mentors, support from administration/management, and support from other nurses. From the moment of hiring, there needs to be a formal program of precepting/mentoring that involves all levels of the organization. Preceptors/mentors need to be selected for their interpersonal abilities, their expertise in nursing and in

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teaching, and for their ethical standards; they need to be the ‘gold standard’ of what the organization considers to be excellence. Administration needs to be supportive and visible. If managers are not trained in management skills, that training needs to be provided for them. Managers need to be able to help with conflict resolution and with facilitating change. With support and encouragement from administration and management, and involvement by preceptors/mentors, staff nurses will be brought on board to support the new nurse. Involved in this process is a no-tolerance approach to incivility, which will involve that any incidents will be addressed as they occur.

Using this approach, will enable new nurses to become a member of the team, and have the support to deal with incivility.

With a nursing shortage predicted to worsen (Buerhaus, Potter, Staiger,

French, & Auerbach, 2009; NLN, 2009; United States Bureau of Labor Statistics,

2007) and with many nurses approaching retirement age, it is paramount to the safety of patients and to the viability of health care organizations that new nurses are welcomed and transitioned into the nursing workplace.

While there is little to be done about patient acuity and shift work for nurses, there is headway that can be made in the workplace. I find that it is essential to put programs in place that will remove the likelihood of nurses leaving their positions during the first years of practice. It is up to leaders in healthcare organizations to make this a priority. Organizations have found that their return on investments in this area is well worth the money the programs cost. For one medical center, the savings 161

yielded $707,608 annually, and nursing satisfaction increased and exceeds the national norms (Halfer, 2007, p. 6). Programs structured for increasing recruitment and retention must involve nursing at all levels and be supported by leadership at all levels.

All managers must utilize solid preceptor programs and conflict resolution skills. I found that the participants in this study had experiences that may have been resolved had the managers or preceptors been knowledgeable in conflict resolution or mentoring skills.

It is important to facilitate the assimilation of new nurses into the workforce, to provide them with support and guidance as they develop and mature as nurses.

On-boarding programs need to be put in place to enable that process. These programs need to constantly be updated to meet the ongoing needs of new nurses.

Recommendations for Future Research

Studies of this nature may continue to yield information. There are no studies found that look at culturally diverse populations as they are entering the nursing world. One might expect to find that there may be specific needs of that population.

This is a rather small segment of the nursing population, in a very small rural area. There is not a multitude of acute care agencies to which a nurse who is dissatisfied can move. Replication of this study in a more populated area with more acute care settings may yield more diverse and different findings.

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Stress levels of nurses are a possible factor in leaving nursing positions. A multi-method study that would interview new nurses and measure their stress levels as related to the nursing workplace would provide more measurable data. Repetition of a study that utilizes a stress index to investigate the effect of stress on intent to leave a nursing position may be useful in addressing the loss of nurses.

A study of preceptor programs may provide information on developing a program to increase the skills of preceptors/mentors, and to reduce attrition rates of new nurses. Also helpful would be an investigation of zero-tolerance policies for disruptive behaviors in the nursing workplace. Nursing education programs might look at developing a curriculum that includes management strategies to deal with conflict and incivility.

Delimitations

The only delimiting factor that existed for this study was that all of the participants were from a relatively small geographic area in a very rural setting. The acute care settings were geographically removed from one another, making leaving one acute care setting for another difficult. This may have been a delimiting factor in nurses staying at a place of employment.

Limitations

The sample size of this study was small. Although it was satisfactory for this study, it may not be appropriate for replication of this study in a larger urban area

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with more acute and long-term care facilities. While the population studied was representative the national nursing population, it did not include different cultural groups. Only one African-American participant was included.

While different facilities and nursing programs were represented, I, the principal investigator, taught many of the participants. I also supervised clinical groups at the facilities involved, and I had known some of the participants for a long period of time. These facts may have been inhibiting to some of the answers given.

It is also possible that a Hawthorne effect existed, that the participants might have given the information they thought I wanted to hear. I made every attempt to use open-ended questions and I explained that the purpose of the study was to look at their perceived experiences as new nurses.

It is hoped that through this study, the workplace will, in some way be improved for newly licensed nurses. They are the future of nursing and of health care.

No system can endure that does not march. Are we walking to the future or to the past? Are we progressing or are we stereotyping? We remember that we have scarcely crossed the threshold of uncivilized civilization in nursing; there is much to do. Don’t let us stereotype mediocrity. We are still on the threshold of nursing.

(Florence Nightingale, 1890’s)

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Appendix A

Permission to Study from Wilmington University’s

Human Subjects Resource Committee

192

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Appendix B

Disclosure Statement/Letter of Invitation to Participate in Study

194

Lynn M. Derickson, MS, RN, CNE 26280 Ibis Court Hebron, MD 21830 Current Date Candidate’s Name Candidate’s Address Dear ______, This letter is an invitation for you to participate in a qualitative research study that I am conducting as partial fulfillment of the requirements for obtaining a Doctor of Education degree from Wilmington University. I would like to provide you with further information about this project and what your involvement would require. As you are aware, the United States is in the midst of a nursing shortage in which it is predicted that there will be a need for 1.5 million new registered nurses to meet the demand of new positions and vacancies created by retiring nurses. It is also found through various studies that 1 in 5 newly registered nurses leave their first position within the first year of employment. It is my desire to study the experiences of newly registered nurses, such as you, who are within their first five years of practice. No study has been found that addresses just this population. Participation in this study is voluntary. It will involve at least one personal audio- taped interview that will last approximately 60 minutes. The interview will take place in a mutually agreed upon confidential setting. Should you feel that more time is needed, we can extend the time. Following the completion of all individual interviews, there will be focus group sessions where several participants in the study, to include you and I, will meet to discuss your experiences as a new registered nurse. There may be a total of two to three focus group sessions. As a participant, you may decline to answer any of the interview questions, should you so desire. You may also decide to withdraw from this study at any time without any negative consequences by advising the researcher. The individual interviews and focus group sessions will be audio-taped to facilitate collection of information, and later transcribed for analysis. After each session, I will send you a copy of the transcribed conversations to give you the opportunity to confirm the accuracy of our conversation and to add or clarify any 195

points that you wish. All of this information is considered strictly confidential, and your name will not appear anywhere in my dissertation or in any written reports from the study. However, with your permission and under a pseudonym, anonymous quotations from the interview and focus groups sessions may be used in the written dissertation or reports. Following the completion of the study, you may have the results sent to you upon request. All data collected during this study will be retained for a period of three years in a locked file in my office where one but me has access to it. There are no known or anticipated risks to you as a participant in this study. I would like to assure you that this study has been reviewed, and it has received approval from the Human Subjects Resource Committee at Wilmington University. I would like the opportunity to talk to you regarding your participation in this study. Please contact me at H-410-749-0186, O-410-572-8708, or C-443-880-7886 or by email to [email protected] within the next week so that we may plan a time when we can meet to further discuss the study. I very much look forward to speaking with you. Thank you in advance for your assistance in this study.

Yours Sincerely,

Lynn M. Derickson Doctoral Student Wilmington University

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Appendix C

Participant’s Informed Consent Form

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Participant’s Informed Consent for Participation in Research Study:

Incivility in Nursing: The Lived Experience of Registered Nurses in Their First Years of Practice

By my signature on this form I acknowledge the following:

1. My participation is voluntary, and I understand that I may choose to respond to any, all or none of the questions asked in the individual interview session(s) or focus group sessions.

2. I was informed that I may withdraw my consent to participate in the study at any time without penalty by advising the researcher.

3. I have been assured that my responses will remain strictly confidential with regard to my identity

4. I am also aware that excerpts from t he interview may be included in the thesis and/or publications to come from this research, with the understanding that the quotations will be anonymous.

5. I understand the research requirement that the individual interview session(s) and focus group sessions are audio-taped and that no identifying information will be associated with individuals in the study.

6. I understand that I will not receive any direct personal rewards from participating in this study, and my participation will not affect my occupational or student standing.

7. I understand that I will be given opportunity to review the transcribed audio-taped individual interview and focus group sessions of my comments and input before the transcripts are finalized for analysis.

8. I will have the opportunity of seeing the results of this study if I so request.\

______Participant ______Date

__Lynn M. Derickson ______Principal Investigator Phone # of IP _410-572-8708_

• I request a copy of the research results be sent to me at the following address: • ______

Any questions about this research may be directed to the Principal Investigator or Dr. Michael Czarkowski, Director of the Wilmington University Doctor of Education Program at Wilson Graduate Center, 31 Reads Way, New Castle, DE 19720; Phone # (302) 295- 1124. ANY QUESTIONS REGARDING YOUR RIGHTS AS A RESEARCH SUBJECT MY BE ADDRESSED TO THE WILMINGTON UNIVERSITY COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS (302-328-9401) ALL RESEARCH PROJECTS THAT ARE CARRIED OUT BY INVESTIGATORS AT WILMINGTON UNIVERSITY ARE GOVERNED BY REQURIEMENTS OF THE COLLEGE AND STATE AND THE FEDERAL GOVERNMENT.

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Appendix D

Participant’s Demographic Information Form

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Demographic Questionnaire: Incivility in Nursing: The Lived Experience of

Registered Nurses in Their First Years of Practice

Instructions: Please provide the following information by filling in the blanks or circling your response.

Please select a pseudo-name for the purposes of this study:

______

1. Age ______

2. Ethnicity ______

3. Male Female

4. How long have you been working as a Registered Nurse? ______

5. In which type of facility do you work? Long term care Acute Care Community

6. Are you currently pursuing a higher degree in nursing? Yes No

7. What type of degree are you pursuing? BS MS

8. Do you possess any certification in a nursing specialty area? Yes No

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Appendix E

Researcher’s Psychiatric/Mental Health Nursing Certificate

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