The views expressed are those of the author and do not necessarily represent the views of the Veterans A dmin tstration.
A substantial amount of learning is going on in today's hospitals. Many disciplines, specially nursing and medicine, rely upon the hospital setting to support the education of its future practitioners. Traditionally this institution has served as the practice setting, the student's laboratory. Nurses, however, unlike physicians, often abandon the great opportunity to continue learning in a dynamic way as they provide care to patients and support for their families - as weli as to their peers - as they practice in graduate professional nurse roles.
It is imperative that we continue to learn all of our lives. It is likewise imperative that nurse administrators and educators in hospital settings make every effort to capture and maintain that excitement in daily practice for the entire staff that matches that of the student. Such excitement should be transposed into the program goals for nursing service and administration. As nurses effect this excitement in meaningful programs, however, it is imperative to recognize and appreciate hospital employees as adult learners in the majority of instances. Their needs - as well as their potential - must be fully recognized as being an influence upon the learning climate. Highly individualistic approaches must often be incorporated in program plans. These approaches may differ substantially in degree and kind to those provided for younger learners or the full-time student.
What can nurses do to capitalize on the hospital as one of the many influences to enhance personnel performance and gain personal fulfillment? First, look to leadership. In a hospital, one should look to the Director of Nurses - look to him as he creates a climate conducive to learning; look to his associates in education, too, for expertise in developing program goals and implementing plans.
Ours is an age of rapid change marked by turbulence, conflict and often chaos. There is a disturbing public outcry, often a frustrated and angry one, as the consumer demands a- voice with which to participate in decisions affecting him. The new participative mood has its disturbing components. It must not be ignored. Instead, it should be capitalized upon and channeled into useful avenues as we plan with the learner to meet his needs and the institution's goals. Our society, and hence the hospital environment, is experiencing - perhaps for the first time - a reverse transmission of culture. In today's world the young probably have more new information and exciting ideas than their elders. Culture, wisdom and empirical knowledge are generally ascribed to the elder members of a society. Historically, they have been passed down to the young. Today, however, our life styles are influenced by a reversal of the process whereby culture, new information and new forms are being transmitted by the young. We must recognize that the learning climate in all institutions is changing in response to the influence of the life style of the young.
The speed of technological innovation is accelerating. Its scale and cost are increasing phenomenally, challenging nurses as health professionals to become intricately involved in the change process.
If the learning climate is an infectious and challenging one, the nurse leader must be one who is highly motivated to catch up, keep up, and move ahead! He must keep up with trends, first of all in society at large, and become aware of the implications of societal forces on his patient and his family, the nursing staff, and other agency associates as educational programs are developed.
Advances in the health sciences, bold innovations in technology along with the explosion of new knowledge create an exciting environment for learning in today's hospital. The problems amidst the many advances that are inherent in the delivery of health care to all citizens in rural or urban America, in affluent or not-so-affluent communities provide the challenges: the challenge to question, to plan together, to offer ideas, define, redefine, refine, change. We do not learn, we are not motivated, we cannot grow unless we are stimulated. A good leader is the medium who gives those he leads not only the vision but the willingness to see. As a leader the nurse administrator should infect his staff with enthusiasm and the concept that learning is continuous and is a lifetime pursuit.
Today's administrator is becoming less crisis oriented and more a planner; less a conservator, resistor, preserver of the culture and more an innovator; a creater - even a quiet constructive revolutionary. If the excitement and the many challenges of this era are to be captured in meaningful staff development programs, constant reassessment of the rapidly moving forces which influence the continually changing role of the nurse in our· society is mandatory.
The nurse administrator must look beyond nursing service in the hospital. Today's total management team must become aware, commit itself, and fulfill that commitment through relevant programs. The management team should have the ability to charge the atmosphere with its enthusiasm, support, and sound convictions. The resulting action should result in soundly planned programs designed to evaluate its effectiveness.
Coordination with all hospital disciplines as well as other community agencies improves the learning climate. When the nurse administrator considers it an obligation to interpret nursing to other disciplines and transmits in words and action the philosophy of nursing service and education, the return from this investment of time and energy is noteworthy. Better programs, shared programs and new information covering available services often result. In addition, when a mutually helpful climate prevails, program goals, problem areas, strengths and weaknesses have yet another platform for airing, refining and redefining.
The adult learner and his unique needs require special emphasis in developing nursing service objectives in a hospital setting. Nurse administrators and educators must take hold of the individual as he is and assist him in developing his individuality in order for him to contribute his own talents and creativity to better patient care. One word and a predictable response do not develop toward this creative goal. Recognition of this fact must be built into the learner's environment; they must be reflected in our philosophy of care and in the objectives developed for achieving them - as well as in our policy guidelines of administration for nursing.
The Challenge of Change
In an era of rapid change, blind acceptance of things as they are, or conclusions reached and programs developed which have been based on earlier needs or the planner's needs will not suffice. We practice in an environment far different from the one in which we started. Today's student and tomorrow's graduate will be practicing in a world markedly different from the one which we know at present. With the massive expansion of knowledge, nursing students in basic curricula which prepare them to function as beginning level practitioners discover that a significant amount of information gained is obsolete on being graduated. As employers of the beginning practitioners, nursing service administrators and educators are discovering that significantly more is required than orientation to the hospital, nursing service and its policies.
Similarly, the inadequacy of yesterday's knowledge, skills and competencies is equally apparent to the nurse who remains in practice and to the one who has returned to practice recently. In-depth clinical concepts to improve nursing practice are aften indicated, along with as the need for acquiring and improving skills. Due consideration must be given to these findings as we develop our educational programs.
Identifying the Learner's Needs
The learner's needs must be met. How are those needs determined? I like to think of them as "felt needs" and "observed needs." As administrators we have usually determined and programmed what we have observed as needs, and we have successfully accomplished results in meeting these needs as they have been perceived. Al I too often, however, these decisions have been reached without any solicited input from the consumer, whether he is the patient, his family, or nursing personnel and sther work associates. This is not enough.
In a climate marked by learner input and participation in decisions affecting him, the learner expresses his needs and may well suggest ways of meeting them. Questionnaires are often utilized as one means of identifying areas of interest, of weakness and of strength. Discussion groups and individual conferences are other ways of gaining useful insights into the learners "felt needs". Above all, interest in the learner as an individual and the aid which can be provided in counseling and planning with him to attain his goals is paramount. Helping him to gain job satisfaction and greater personal fulfillment as he honors his commitment to the institution is a goal to be achieved. For it is through mutually developed objectives derived from a sound philosophy of nursing care that fulfilled employees' practice creditably.
One study conducted by the author in two hospital settings demonstrated the nursing staffs' "felt needs" for gaining increased knowledge to enhance clinical competence. One study hospital is predominately acute in a metropolitan setting with active university affiliation, while the other is basically devoted to long term psychiatric care in an isolated community, relatively far removed from a moderately large population center.
A twenty-item questionnaire was used to determine preferences among registered professional nurses for administrativesupervisory or clinical practice assignments. One hundred and forty-two questionnaires were analyzed. Findings revealed that, regardless of the respondent's age, level of educational attainment, type of program in which professional preparation was received, years of nursing experience or current assignment, a clinical practice role was preferred by most nurses. Even among nurses who preferred an administrative-supervisory assignment, the need for a broader base of clinical knowledge and competence in clinical nursing practice were considered necessary prerequisites to effectiveness in such an assignment.
Nurses were asked if they were interested in attending any work-related workshops, institutes or intensive courses. In both settings, an overwhelming majority (eighty-nine percent of all nurses in the large metropolitan hospital and ninety-two percent of those in the chronic hospital setting,} expressed interest in attending. The interest expressed by the majority of respondents in continued learning is not only vital to the practice of the nursing and personal fulfillment, but an integral characteristic of a truly professional person. The climate in our institutions should reflect our commitment to meet these "felt needs" as we maintain true professional stature.
The primary and secondary reasons for study were also asked of respondents, with the same six options offered and one choice indicated. The options were: job advancement, salary increase, greater clinical knowledge, greater administrative and supervisory knowledge, personal enjoyment, or pursuit of different occupational goal. Findings . in the chronic setting revealed that the largest number of nurses, thirty-nine percent, cited "greater clinical knowledge," as their primary reason for study, followed closely by "greater administrative and supervisory knowledge," (thirty-three percent); seventeen percent indicated "personal enjoyment," while eleven percent cited job advancement. No respondents chose "salary increase" or "pursuit of different occupational goal." This may indicate that the respondents did not feel free to respond to this question honestly, even though names were not elicited on the questionnaire. The lack of response may also reflect the favorable salary structure which these nurses enjoy, as well as the desire to remain in the community where they presently reside.
A "contentment level" of 71.5 percent, a composite figure for the two hospitals, was determined. Nurse leaders must use the discontentment level constructively - as a motivating force for the learner. Resourceful leaders may do well to reflect on raising the level or quality of the discontent in order to achieve an objective. For, if a leader who is properly directed and attuned to the building momentum at a time of crisis energizes and channels the prevailing mood appropriately, an improved climate for learning will result.
Among the secondary reasons for study, a choice different from the first one for each respondent, twenty-nine percent cited greater clinical knowledge, a comparable number listed personal enjoyment, while twenty-four percent chose greater administrative and supervisory knowledge. An increase in salary was chosen by eighteen percent of the respondents. None chose advancement in job or pursuit of a different occupational goal.
The majority of nurses in the larger setting indicated personal enjoyment as their primary reason for study (thirty-five percent); followed by a desire for greater clinical knowledge (twenty-five percent). Pursuit of a different occupational goal was chosen by thirteen percent, while twelve percent stated advancement in job. Greater administrative and supervisory knowledge was selected by ten percent; five percent chose increase in salary.
Similarly, when secondary reasons for study were selected, personal enjoyment and greater clinical knowledge ranked highest (twenty-eight percent and twenty-five percent respectively). Of equal rank, fourteen percent were advancement in job and greater administrative and supervisory knowledge; eleven percent cited pursuit of a different occupational goal, while ten percent responded to increase in salary.
The questions are clear. Implications for program planning with consideration given to the learner's "felt needs" are indicated. The survey or poll appears to be a useful administrative tool. As we plan let us ask whether we are planning inservice programs or workshops based on false premises or our own needs? Are we getting input from the practitioner and utilizing it in developing programs? Have we identified what is relevant or high on the interest scale of the respondent with whom we plan?
Our nursing service and educational organization in the hospital should enable us to attain our program goals. Are additional expert cl inicians needed? Do we need more administrative supervisors, fewer - or none at all? Are we continually defining and redefining nursing's role and its rapidly changing aspects? Are we utilizing all levels of the presently existing categories of nursing personnel maximally for the improvement of nursing care to patients? Should we eliminate some, substitute others? Should the head nurse role be strengthened or deemphasized? Nurse leaders must address themselves to these important issues.
It is imperative that the clinical practice component be emphasized and supported with streamlined and efficient administrative practices. It is clear that administrative, supervisory and educational functions and activities require reassessment now - and continued review. It is also clear that nonnursing tasks should be reassigned to the departments responsible for their accomplishment. More attention to deficiencies in these areas is indicated presently to match or exceed that which is focused on creating new categories of health assistants.
Under- utilized as well as nonutilized citizens are among the untapped and poorly nurtured manpower resources. I am speaking of minorities who, whether black, Indian, SpanishAmerican, men and women, young school dropouts, or those who have retired to limited existences, are making minimal or no contributions to the community or the agency's mission to its public. The climate that we create should be one of comfort and concern followed by deliberate action-directed programs. Are we aware of this problem? Are we diligent in our search for these individuals and groups in "tuning in" on them as we help them realize their dreams and aspirations? Have we explored with them reasons for their frustrations and, in this special way, enhanced our institution's climate for learning? As we introduce these citizens to our hospital work force, have we recognized their influence on the institution's learning climate, and provided an adequate orientation for them and the present staff?
A Climate for Research
It must come through to the practitioner that he must dare to question, dare to ask the "why," the "why not," the "how." He must dare to try new approaches. Yes, even dare to fail! In the right climate, the nursing staff is inspired to augment and transform their knowledge, competencies and skills into viable forms as they practice. Viable forms provide for creative, innovative and daring approaches. When the climate is comfortable personnel are able to critically examine the status quo and recommend changes.
Through research efforts we work toward change. Research activity must complement action as we deliver care. Educating our practitioners for research is an integral part of the challenge of change. It is through research and the systematic approaches inherent in its pursuit that we are enabled to correct our course repeatedly. Nurse administrators must dispel the notion that research is something engaged in by people who devote their careers to this pursuit exclusivejy, or who are more sophisticated, better trained, or more highly motivated. We must help today's practitioner recognize that this training can be attained if we see the need, and can develop the satisfactions derived from the pursuit of research. As nurses, we must recognize that our world - even our small hospital world - is changing as a result of scientific findings and their application. The penalty is ours if we fail to understand and prepare to function in ihis scientific world. We must participate fully in its methods as professional persons, or the present and the future will elude us. Leaders must set the climate for open discussion, for new ideas and for examining old practices. We must assist the practitioner to accept change, and as leaders we must not feel threatened as the new ideas spring forth.
- Bennis, W1, Benne, K. and Chin, R. The Planning of Change (New York: Holt, Rinehart and Winston, 1962.)
- Parson, Richard E. "How Could Anything So Bad Be So Good?", Saturday Review of Literature (September 6, 1969) pp. 20-21, 48.
- Ferguson, Vernice, "Who Are You?, Guest Editorial, Charl. 67:8 (October 1970), p. 227.
- Hall, Bernard. "Creating a Climate for Learning," Nursing Outlook 1 (July 1959), pp. 421-422.
- Harvey, Lillian. "Educational Problems of Minority Group Nurses," Nursing Outlook 18:9 (September 1970), pp. 48-50.
- Merton, Robert. "The Social Nature of Leadership," American Journal of Nursing 69:12 (December 1969), pp. 2614-2618.
- Reiter, Frances. "Nurse-Clinician," American Journal of Nursing 66:2 (February 1966), pp. 274-280.
- Unpublished Document
- Ferguson, Vernice. "Preferences Among Registered Professional Nurses for Administrative- Supervisory or Clinical Practice Assignments and an Approach to utilization, Veterans Administration Hospital, Denver, Colorado." Special Project, July 1967.