Original Article
Ann Nurs Res Pract. 2024; 9(1): 1063.
A Model for Bridging the Gap in the Perception of Self-efficacy Between Graduated Nursing School to the Receiving Hospitals
Yossi Weiss; May Shik*
Department of Health Systems Management, Ariel University, Israel.
*Corresponding author: May Shik Department of Health Systems Management, Ariel University, Israel. Email: mayshik1997@gmail.com
Received: February 02, 2024 Accepted: February 14, 2024 Published: February 21, 2024
Abstract
Objective: The study deals with the question of the gap in self-efficacy for the role of nurse, as it is perceived among new nurses and among the administrative staff in Israel.
Background: New nurses are required to meet the accepted standard from the beginning of their employment. Variables such as complex, changing realities and experience directly affect their perception of self-efficacy.
Methods: Two questioners distributed among 200 hospitals’ nurses and 102 management staff. Semi- structured interviews were conducted among nursing schools.
Results: The perception of the hospitals’ managing staff about the self-efficacy of the new nurses was significantly greater in all metrics, compared to the perception of the nurses as they reported themselves.
Conclusions: The curriculum will always be behind the changing reality, and thus the gap will always be existing. This gap is what should be bridged to strengthen the new nurse’s sense of self-efficacy and to overcome turnover intentions.
Keywords: Self-efficacy; Curriculum; Instrument development; Program outcomes assessment.
Introduction
In Israel, the duration to certificate a nurse takes four years. Of these, only about a quarter are intended for practical experience. Graduates of nursing schools are accepted into the ranks of nursing practitioners without prior experience, directly into the requirements of the provision and management of care in clinics in the HMOs and hospitals.
The need for research on the subject arose from sharing the personal feelings of the graduates at the beginning of their employment, in the face of interest in the satisfaction of the directors of the care institutions they employ.
The study deals with the question of the gap in self-efficacy for the role of nurse as it is perceived among new Registered Nurses (RN) and among the administrative staff in Israel. I will present the level of readiness of the graduates when entering the practice which will be determined by self-esteem, the level of confidence to manage and follow instructions and the ability to meet the required standards, in comparison to employers, i.e., hospitals. It should be noted that these criteria were not examined in the current study among HMO nurses. This work gives a deeper perspective according to which the gap is relevant not only to nurses but also to the rest of the medical professions. In other words, the prism of the research in terms of its structure, the results and the conclusions touch on the common aspects to all health system.
The research method is based on two validated research questionnaires. First, which examining the nurse's experience, "Casey-Fink Graduated Nurse Experience Survey" was distributed among nurses with up to 5 years of their certification in various departments in different hospitals [1]. Second, which examines the concept of professional level, "BELIMAGE", was distributed among the nursing and medical management staff in the same departments and hospitals [2].
The conclusions of the study are also based on previous studies with similar findings according to which there is a consensus that the new nurse isn't sufficiently prepared for her role. She possesses a great deal of knowledge but not the tools to channel it into the necessary nursing work. To get the best out of the new nurse, additional training is needed during the initial period of post-certification whose purpose is to teach her how to translate knowledge into practice and be accompanied by a nurse with experience who will serve as a role model.
Review of the Literature
Students during their studies are closely supervised and controlled for their activities, but at the moment they're employment as RN, they stand responsible for their actions and are accompanied by a receiving nurse- a RN to whom they delegated training positions of nursing staff in the care ward [3]. The Ministry of Health of Israel defined the term "self-efficacy" as self-assessment of the nurse that she can perform the professional role [4].
Unpreparedness, as a result of lack of practice, is related to the inability to cope alone in the clinical field. This is the gap between theory, practice and the nature of the work environment both in eyes of the graduates and the senior staff in hospitals [5]. Moreover, workload, past experiences, lack of orientation, the need for holistic assessment of a patient, help availability and inexperience are factors that directly affect the efficacy of the new nurse to do what is required from her [6].
In part of the departments designated for experiences, there is a shortage of nursing staff required for guidance and accompaniment. In such cases the student receives a partial orientation and inconsistent guidance resulting in a decreased sense of security and competence [7]. The advanced clinical experience is the last means of preparing the student to work in the nursing field. The purpose of the prolonged experience is to enable the student to integrate what is being studied on his own, and to express it in practice. If there is a lack of the factors mentioned before or if they are not sufficiently embedded in the curriculum - the student will refrain from functioning as a nurse or even turnover their profession [8]. The term "reality shock" came to explain anxiety, doubts and confusion in the transition between those roles, and causes the abandonment of the profession during the first year of employment among 30% of them [9]. However, it was found that internship programs for RN yielded positive results regarding their coping with the role transition [10]. It was found that the accompaniment of a receiving nurse assisted in integrating the material studied into the clinical field. Only 10% of all the graduates were sufficiently willing to provide proper nursing care, and only 25% of the nurses in charge were satisfied with the clinical skills of the RN. The term "theory-practice gap" refers to the gap between theory and practice, and in the nursing profession to the transition between roles. Gaps in efficacy were found in various areas such as critical thinking, communication, time management, physical examination and teamwork [11]. Previous studies showed that learning also through simulations would contribute to a more in-depth preparation because it will integrate the studied material into practice ahead of time [12].
During the transition period of the new nurse, she is oriented in the department and establishes contacts with caregivers whom role is important in dealing with clinical conditions and challenges. Therefore, implementing strategies to promote social support can have a far-reaching impact on the perception of efficacy [13]. Also, the clinical orientation itself has been found to be a factor with most noticeable influence on narrowing or deepening the gap [14].
Cognitive failure is defined as the inability to successfully complete tasks that can usually be performed daily. Failure in simple tasks can be exhausting to the extent that the individual perceives the event as threatening and uncontrollable. Hence, a student who had a negative experience will tend to suffer a cognitive failure that will affect his self-efficacy as a RN. The various circumstances reviewed put the new nurse under pressure to confront challenges regardless her cognitive abilities and skills, which has a negative impact on the development of efficacy [15].
Materials and Method
Study Design
The study involved 102 administrative hospitals staff members and 200 nurses with up to five years of experience, randomly selected in a convenience sample from twenty different hospitals in the country- privates, mental, government hospitals and HMOs to provide a diverse sample. The questionnaires were distributed twice. The response rate was high (70%). In addition, semi-structured interviews were conducted with academics and the Ministry of Health for extra depth to complete the results of the questionnaires.
Instruments
Casey-Fink Graduate Nurse Experience Survey [1]. Questionnaire for new RN. The first part of the questionnaire included 24 questions. Likert scale answers range between 1-4 when 1 strongly disagrees and 4 strongly agrees and included the following sub-indices: communication (a=0.40), performance of skills (a=0.50), order and organization (a=0.50), accompaniment and receiving (a=0.82), professionalism (a=0.46) and satisfaction (a=0.56).
BELIMAGE (BELgian professional self-IMAGE instrument for hospital) instrument. (2) Questionnaire for management staff. The second part of the questionnaire examined the perception of the ability of specific nursing skills in relation to the new RN. Likert scale answers range between 1-5 where 1 incompetent and 5 very capable. The metrics were made up of the average of the answers so the higher the score, the higher the perception of ability. The questionnaire included the following sub-indices: technical skills (a=0.86), intellectual cognitive skills (a=0.87), order and organization skills (a=0.89), communication skills (a=0.90) and professional approach (a=0.83).
Semi-structured interview. Interview with the directors of three nursing schools, director of the Accreditation Department at the Ministry of Health and acting department of Research and Innovation at the Nursing Administration. The interview included two questions: whether the nursing program is currently adapted to the needs of the Israeli health system? And according to which criteria is evaluated and determined the ability of the students during their studies to succeed as RN in the future?.
Results
The Sample of new RN
The average age of the respondents was 29.54 years, the average number of years from graduation was 2.56 years and the average number of receiving nurses per RN was 2.52. Furthermore, 76% were females, 36% of the respondents work in internal departments and 64% had previous experience in the health system during their studies. The duration of admission to the ward of more than half of the nurses was two months and less.
The Sample of Managerial Staff. The study involved 102 members, among them identified 19 head nurses, 33 clinical coordinators or instructor nurses and two department managers.
Statistical Analysis
An averages tests show that communication skills have the highest perception of ability comparing the two study populations (x=3.57 and x=3.75, respectively). Subsequently, technical skills were perceived as the least capable performing skills (x=2.77 and x=3.72, respectively). The transition period was also examined, and it was found that more than half of the answers (52%) indicated workload difficulty as most common. Workload included difficulties in order and organization and setting priorities. Participants were asked about the actions required to facilitate the transition period. Most respondents (46%) believed that improving their orientation would have been beneficial for their transition to the role of RN. The orientation aspect included the support and consistency of the receiving nurse, comprehensive orientation (i.e., familiarity with the department) and practice actions unique to the department.
Statistical Hypothesis Testing
To compare the gap in the perception of efficacy between the management staff and the new nurses, a t-test was conducted for the independent samples. It should be noted that for the purposes of statistical analysis, the scale of answers of the two questionnaires was adjusted. As can be seen in (Table 1), significant differences were found in the way in which the efficacy of the RN in the various nursing skills in all the measures examined is perceived: Technical capability (t(300)=7.08, p<.01), cognitive ability (t(300)=3.49, p<.01), organizing capability (t(300)=4.76, p<.01), communicative abilities (t(300)=2.15, p<.05) and professional abilities (t(300)=7.78, p<.01). The data show that the staff assesses the abilities of the new nurses higher in each of the different skills, than the nurses assess their own.
Manager Team N=102
New RN N=200
T
P
M
SD
M
SD
Technical Skills
3.23
0.61
2.77
0.48
7.08**
0.00
Cognitive Skills
3.34
0.66
3.08
0.58
3.49**
0.00
Order and Organization
3.01
0.75
2.63
0.62
4.76**
0.00
Communication Skills
3.57
0.45
3.44
0.50
2.15*
0.03
Professional Skills
3.53
0.50
2.89
0.74
7.78**
0.00
p<.05*, p<.01**
Table 1: The Average Perception of Efficacy in Comparison between the Two Study Populations.
As can be seen in Table 2, the research hypothesis according to which an association would be found between the number of receiving nurses of a new nurse and her ability to function found significant negative associations between the number of receiving nurses and the perception of job efficacy in measures of performance of skills (r= -0.15, p<.05), accompaniment and receiving (r= -0.18, p<.05), professionalism (r= -0.15, p<.05), satisfaction (r= -0.14, p<.05) and communication skills (r= -0.21, p<.01).
Performance of Skills
Order and Organization
Accompaniment
and receivingProfessionalism
Satisfaction
Communication
Delegation
Number of Receiving
Nurses-.15*
-.03
-.18*
-.15*
-.14*
-.21**
.01
p<.05*, p<.01**
Table 2: Pearson Correlations between the Number of Receiving Nurses and the Perception of Efficacy for the Role (N=192).
Evaluating the hypothesis that previous experience in the health system during studies has an impact on perception of efficacy among new RN for the position is shown in (Table 3). The findings of job efficacy in the metrics of performance of skills (t(198)=2.08, p<.05), order and organization (t(198)=2.37, p<.05), accompaniment and receiving (t(198)=2.94, p<.01) and professionalism (t(198)=3.96, p<.01) show that the perception in these measures is significantly higher among nurses who had previous experience in the health system during studies compared to those who did not have.
With Previous
Experience N=127No Previous
Experience N=73T
P
M
SD
M
SD
Performance of Skills
2.82
0.47
2.68
0.48
2.08*
0.03
Order and Organization
2.70
0.58
2.49
0.66
2.37*
0.02
Accompaniment and Absorption
3.17
0.53
2.92
0.63
2.94**
0.00
Professionalism
3.05
0.64
2.63
0.82
3.96**
0.00
Satisfaction
3.29
0.51
3.16
0.53
1.65
0.09
Communication
3.48
0.50
3.36
0.49
1.60
0.11
Delegation
2.91
0.79
2.80
0.84
0.87
0.38
p<.05*, p<.01**
Table 3: The Differences in the Perception of Role Efficacy According to Previous Experience in the Health System.
Regarding the interview conducted with the interviewees, in their opinion, the curriculum today is adapted to the needs of the health system except for one respondent that the curriculum is too fast, the graduate student arrives unprepared to the field and doesn't know how to speak the language of the health system in terms of goals and objectives. Moreover, all the interviewees responded that there is no specific and reliable tool that can predict students' success as future RN. They also raised their position regarding the hospitals that provide the clinical areas for experiences that there is a discrepancy between the school's study requirements and the learning provided in the department in practice.
Discussion
In the current study, it was found that the skills of order and organization are perceived as those with the lowest level of ability. Managing nurses evaluated the longest period it will take for new nurses to complete these skills as required [16]. It was also found two major weaknesses among new nurses- technical skills and critical thinking [17]. In the interview, about half of the respondents noted that the curriculum according to the Ministry of Health currently doesn't emphasis enough Evidence-Based Practice (EBP) as a tool.
More than half of the students worked during their studies [19], and in this study, 64% of the participants worked during their studies. The findings of the study indicate that nurses who had employment experience in the health system during their studies had higher perception of competence compared to those who didn't, significantly. These nurses had more exposure time in the department, and familiarity with the departmental work method. Also was found that additional employment experience during studies shortened the time it took to be admitted to the ward [20]. Additional time, beyond the hours of the study department, gave them a greater sense of security that allowed them to get through the transition period well. Seems that the curriculum doesn't emphasize practice enough with the expectation that practice is an acquired function after certification.
The role of the receiving nurse is important to get through the transition period [22]. She assists in conducting proper integration between the material studied and the clinic in the field, or in other words- EBP [11]. The image of a receptive character strengthens the perception of competence among the new RN and therefore improves her performance [23]. The receiving nurse should know how to identify distress or call for help when needed, and at the same time consideration should be given to the degree of progress of the new nurse. It is her responsibility to direct and focus the new nurse to independent and make prudent decisions on her own.
Almost half of the participants in a study conducted the BELIMAGE questionnaire that was distributed among the graduates noted that there is minimal support from the management and the level of communication with them is lacking [7]. Whereas when the management staff was questioned in the current study, it was found that positive labor relations of a new nurse with the management aren't necessary to conduct a good nursing work. The very fact that the managerial staff doesn't see importance in various nursing skills suggests that they don't emphasis them at arrival of a student for experience or at the time of receiving a new nurse into ward. This deepens the gap between the existing and the required efficacy.
The managing nurses expect new nurses to fulfill their responsibilities immediately [21], and related results emerged in the current study when it was found that nurses at the managerial level rated high the perception of ability of new nurses to take responsibility for the care provided by them. Managing nurses have identified a relatively high degree of preparedness among skills of new nurses. Some of them went as far as to note that in their perception, the new nurse must be prepared for practice.
Wherever it may be, regardless the time of her seniority. They are expected to integrate into the ward on the go and demonstrate the quality of skills equivalent to senior nurses [24]. Further to the findings of the interviews whether the clinical area, the hospital, doesn't provide opportunities for exposure and involvement- the new RN's future to succeed starts from a lower starting position.
Nurses in management positions noted that the abilities of new nurses are high in communication skills with patients, their families and with caregivers [17,18]. In the nursing profession, communication has two functions- one is guiding the patient and the other is clarifying and searching for answers.
Poor orientation and lack of coordination of expectations were explanatory factors for the decline in the assessment of the new nurses towards their skills [17]. The administrative staff expects the new RN to integrate into the unit without close accompaniment even though they recognize that in practice they won't be able to do so [21]. As mentioned above, workload was the main difficulty that new nurses who participated in the study noted that they came across with. The need for a good orientation in the department is a basic condition during the transition period to improve the control over the things in the new nurse's ability to control.
Systematic experiences and structured exercises are required for effective training [25], and in the current study it was found that this was the main part that needed improvement in the eyes of the new nurses according to which the training was short or unorganized. In addition, it was found that new nurses don't receive enough feedback and mentoring as they would ask for. These two points of difference indicate that there is no utilization of the potential of the new nurse as it should have been. This claim is reinforced considering the study's findings according the higher the changeover of receiving nurses, the smaller the perception of the efficacy of the new nurses. As a result, buds of intentions to replace the workplace or profession can be seen in the current study. Dissatisfaction with the profession and the employing institution contributed to the increase in departure rates [26].
A three-factor relationship exists between new graduate nurses-the hospitals-the nursing schools. This relationship has three sides that influence and are influenced by each other. The proposed model, as can be seen in chart 1, aims to present the future curriculum because the way it works now, the impression is that every factor in the relationship works for itself and doesn't match the other factors.
Chart 1: A Model for Bridging the Gap.
This source of the gap is necessary to understand why there are significant differences between the two groups of the study. The interactions in reality prioritize low the needs of the third factor in each pair of connections. Action must be taken to abridge it by constructing a recurring feedback mechanism in each of the factors that maintain ties in the health systems worldwide. As stated, adjusting the certification "on the go" will enable closer ties between the various entities in the health system to achieve the overarching goal which is the highest perception of efficacy for the role.
Conclusion
There are several pillars in the training of a new nurse from the beginning of her studies and throughout the period of her receiving. Receiving nurse responsible for integration, information retention and familiarity with the departmental environment- this factor was found to affect almost 100% of the nurses who continued to practice in the same ward a year later [11]. It was found that their success included a positive clinical experience because there was a dedicated receiving nurse. [27].
A derivative of the practice is the field of the EBP, that if it is assimilated and used for continuous learning, the RN will reach a higher level of professionalism. In other words, will be more efficacy. The use of simulations enables learning in a high realistic image that raises the perception of efficacy, also serves as a component for performing EBP to bring the theory into practice before reaching the clinical field [28]. The emphasis should be placed on orientation from the stage of study and throughout the duration of receiving into the department because it forms the basis for receiving into the ward of a new nurse. Furthermore, it is necessary to increase the quota of the number of clinical hours that exist in the curriculum.
As for the main research question, having frequent and ongoing working relationships between the management staff and new nurses is a mandatory component to build a sense of efficacy among new nurses during the transition period and in general. Having frequent employment relationships will flood management staff with existing gaps at an earlier stage in their employment and will enable provision of an appropriate timely response to the needs that arise.
Future research should include an extension of this research to include the relationships of these three ties. In addition, it is advisable that a follow-up study investigate the percentage of new nurses leaving the profession because currently in the Israeli health system there is no monitoring of employment in the profession.
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