Can a Synthesis of Nursing Practice course be used to enhance senior nursing students' self-concept and perception of role competence? Assertions of the new graduate nurses' low self-concept and lack of self-confidence in their perceived roles continue to occupy considerable space in the nursing literature. New graduate nurses frequently come to their first work experience with marked discrepancies between what they feel capable of doing and what is expected of them, which in turn provokes criticism from the nursing staff and administrators (Blanchard, 1983; Ellis, 1980; Field, Gallman, Nicholson & Dreher, 1984; McGrath & Princeton, 1987). Such criticisms can be devastating for the new nurse's self concept and selfconfidence.
It is believed that a low self-concept may be fostered during the educational process, and some research has found that self-concept and self-confidence may even be destroyed by certain teaching methods (Ellis, 1980; Windsor, 1987; Woolf, 1984). It is suggested that nursing education focus on ways to build and enhance the students' self-concept and self-confidence.
The literature is replete with claims of the new graduate nurse's inadequate practice skills, which are thought to be due, at least partly, to a low self-concept and lack of self-confidence. Much of the nursing education research in recent years has focused on strategies to build the nursing student's self-concept and self-confidence.
Using Pitts' (1965) Tennessee Self Concept Scale to measure self-concept, Ellis (1980) investigated levels of self-concept in nursing students at the four academic levels: freshman, sophomore, junior, and senior. The study was based on the assumption that if self concept levels are increased during the educational process in a baccalaureate nursing program, then differences should be found between each academic level. The results of the study indicated that the self-concept level was highest at the begiiming of the sophomore level and lowest at the beginning of the senior level; however, the differences found between groups were not statistically significant (Ellis, 1980).
Burgess (1980) used the Tennessee Self-Concept Scale (Fitts, 1965) to study the self-concept of nursing students in relation to clinical performance, attrition, and selected other variables. The findings of the study indicated no significant relationship between the Tennessee SelfConcept Scale subscores and a) clinical performance, b) grade point average, and c) attrition from the program (Burgess, 1980).
A work-study program that combined academic and work experiences and enabled the nursing students to engage in real employee roles proved to be valuable in bridging the gap between school and the real work world (Huckstadt, 1981). Upon completion of the program, data analysis revealed several significant findings: "a more positive self-concept, increased self-confidence, increased ability to praise others . . . and an increase in assertiveness" (Huckstadt, 1981, p. 727).
Success in promoting a more positive self-concept and self confidence has been achieved with selected clinical teaching strategies. Woolf (1984) found that the use of students' self-evaluation in the clinical setting and self clinical assignments resulted in increased feelings of self-worth and self-confidence in the student, and fostered a greater sense of responsibility for their own learning.
Olson, Gresley, and Heater (1984) found no significant differences in baccalaureate nursing students' self concept and professional role mastery after participation in an undergraduate clinical internship program. One of several possible explanations given for the finding of no differences related to the small sample size, with resulting low statistical power (Olson et al., 1984). More recently, Dobbs (1988) found that the use of a senior preceptorship program during the last clinical course resulted in a significant decrease in the students' perceived role deprivation, "and a significant increase in the work-centered role models, indicating changes in the students' self-image and role expectations" (p. 167). The findings support the effectiveness of the preceptorship program as a strategy that enables students to increase their competencies and learn to cope with the differing demands of the work environment. This program also promotes anticipatory socialization in the professional nurse's work role prior to graduation (Dobbs, 1988).
In a study that focused on senior nursing students' perceptions of their clinical experiences, Windsor (1987) found three major areas of learning perceived to be the result of their clinical experiences: a) nursing skills, including assessment, therapeutic communication, and other psychomotor skills; b) time management, and c) professional socialization into the nurse's role. The findings revealed that students perceived their clinical experiences to be very valuable, particularly when they felt they were part of the health team and contributed to the team's work. Additionally, the findings indicated that the students regarded teacher feedback (both positive and negative) to be extremely valuable, with most appreciation being for feedback provided in privacy; and that which was not provided in privacy, particularly negative feedback, generally resulted in embarrassment, anger, and loss of self-confidence (Windsor, 1987).
The clinical objectives and evaluation criteria of 64 National League for Nursing accredited baccalaureate nursing schools were examined for the purpose of determining the level of preparation of the baccalaureate graduate (Field et al., 1984). The objectives were classified according to the cognitive, affective, and psychomotor domains, and level of domain based on Bloom's (1956) and Kraftwohl's (1964) taxonomies and definitions (Field et al.).
The findings revealed that "a disproportionately large number of clinical objectives were written in the cognitive domain and a disproportionately small number were written in the psychomotor domain . . . and there did not appear to be a pyramid effect building from multiple lower level objectives to a few at the higher levels" (p. 290), which is believed to be crucial (Field et al., 1984). Based on the findings of this study, these investigators concluded that the curriculum may be the major source of the problem for the new baccalaureate graduate - the fact that so few objectives used for clinical evaluation are written in the psychomotor domain (Field et al., 1984).
In summary, the literature review indicates that there are marked discrepancies between what nursing students get in their educational programs and what is expected of them in the workplace. Consequently, the inability to perform as expected in the workplace provokes criticism from the nursing personnel, which in turn promotes lower self-concept and self-confidence. Some teaching methods employed during the educational process are believed to foster and even destroy students' self-concept and selfconfidence. Some carefully planned methodologies such as work-study programs, preceptorship programs, and selected nontraditional teaching strategies have been found to promote a more positive self-concept and enhance self confidence. Further research is needed in these areas to help substantiate these findings; and other areas that may be useful in bunding self concept and self confidence should be explored.
This study investigated the effects of a 15-week Synthesis of Nursing Practice course on senior nursing students' self-concept and perception of role competencies. The Synthesis of Nursing Practice course is a 6-semester hour, 16-hours per week clinical course, placed in the second semester of the senior year. The overall goal of the course is to facilitate the transition from nursing school to the real work world. A major focus is to enhance the student's ability to synthesize, apply, and evaluate the knowledge and skills learned in the nursing program. It also enables them to strengthen their technical patient care skills. Organization, management, and leadership principles are applied in patient care. As the course progresses, the students' patient care assignments become increasingly similar to those of the staff nurses. The students are assigned in a variety of clinical settings, generally based on their respective preferences.
Perception is the mental image of self derived through the senses; and a person's behavior is the direct result of "how he sees himself, how he sees the situation in which he is involved, and the interaction of these two" (Combs, Blume, Newman, & Wass, 1974, p. 14). These authors view behavior as merely a surface manifestation of what goes on within the individual (Combs et al., 1974). According to Fitts (1965), a person's concept of self has been found to be not only highly influential of his behavior, but also "directly related to his general personality and state of mental health. Therefore, a knowledge of how an individual perceives himself is useful in attempting to help that individual, and in making evaluations of him" (p. 1).
The self-concept is believed to be the "most important single influence affecting an individual's behavior" (Combs et al., 1974, p. 17); therefore, nursing educators, particularly clinical teachers, must be concerned with the inner world of the student. According to Combs et al. (1974), the education of a professional person "requires changes in the student's perceptions - his feelings, attitudes and beliefs, and his understandings of himself and his world" (p. 16). Therefore, nursing educators must include experiences that will promote these changes in their students.
This study is based on the assumption that the Synthesis of Nursing Practice course provides an opportunity for senior nursing students to synthesize and utilize the knowledge which they have learned in providing patient care, strengthen their technical skills, manage patient care assignments similar to the staff nurses, and build their self-confidence, which in turn enhances the self-concept and perception of role competencies.
1. There will be a significant increase in self concept upon completion of the Synthesis of Nursing Practice course, as measured by Fitts" (1965) Tennessee SelfConcept Scale.
2. There will be a significant increase in the perception of role competencies upon completion of the Synthesis of Nursing Practice course, as measured by the Slater Nursing Competencies Rating Scale (Wandelt & Stewart, 1975).
This study used a one-group, pretest-posttest research design. It was conducted at a medium sized state supported university in a southwestern state. Seventy senior level nursing students enrolled in the Synthesis course comprised the sample for the study. The majority of the students (66, 94.28%) were generic baccalaureate students. Two of the students (2.85%) were diploma graduates and two (2.85%) were associate degree graduates who had been phased into the baccalaureate program at the junior level.
Clearance by the Human Subject Research Committee of the University was obtained and statements of consent were signed by the student participants. Data were collected at the beginning of the semester immediately following their first scheduled class, and following a scheduled class after completion of the clinical component of the course.
The Tennessee Self Concept Scale developed by Fitts (1965) was used to measure self-concept, and the Slater Nursing Competencies Rating Scale (Wandelt & Stewart, 1975) was used to measure perception of role competencies. The Tennessee Self-Concept Scale (Fitts, 1965) consists of 100 self descriptive, Likert-type statements that the respondent uses to portray a picture (concept) of himself, yielding a total positive (P) score. "Persons with high scores tend to like themselves, feel that they are persons of value and worth, have confidence in themselves, and act accordingly; whereas, persons with low scores are doubtful about their worth, see themselves as undesirable, often feel anxious, depressed, unhappy, and have little faith or confidence in themselves" (Fitts, 1965, p. 2). The reliability coefficient for the total positive score is reported to be .88 and content validity is reported to be well established (Fitts, 1965).
The Slater Nursing Competencies Rating Scale consists of 84 items that identify actions performed by nursing personnel in providing patient care, and "the standard of measurement is the quality of performance of care expected of a first level staff nurse, and ... is held constant for all measurements made with the scale" (Wandelt & Stewart, 1975, p. xiii). The rating scale is a Likert-type scale with scores identified according to levels of competencies; excellent = 5, above average = 4, average = 3, below average = 2, and poor = 1. The possible scores range from 84 to 420; the higher the score, the higher the subject's perceived role competencies (Wandelt & Stewart, 1975). The odd-even split-half reliability of the Slater Nursing Competencies Rating Scale is reported to be .98, and content validity is reported to be well established, as items on the scale have been extensively and repeatedly examined by nurse educators and nurse practitioners with expertise in all clinical areas (Wandelt & Stewart, 1975).
Findings and Discussion
It was hypothesized that the students would exhibit a significant increase in their self-concept upon completion of the Synthesis of Nursing Practice course. The hypothesis was supported by the findings. A two- tailed t-test was used to determine the difference between group mean scores. The self-concept pretest group mean score was 350.48, with a standard deviation of 32.56; and posttest group mean score was 354.31, with a standard deviation of 33.92. The mean difference was - 3.83, with a t-value of - 1.86. The t-value was significant at .10 level.
It was also hypothesized that the students would demonstrate a significant increase in their perceptions of role competencies upon completion of the Synthesis of Nursing Practice course. This hypothesis was supported by the findings. The role competency pretest group mean score was 317.35, with a standard deviation of 42.23; and posttest group mean score was 346.07, with a standard deviation of 43.91. The mean difference was -28.71, with a t-value of -7.79. The ¿-value was significant at .001 level. The self-concept and role competency mean pre- and posttest scores are reflected in the Figure.
Figure: Mean pretest-posttest scores for self-concept and perception of role competency.
These findings supported the assumption that the Synthesis of Nursing Practice course enabled the students to strengthen their technical skills, manage patient care assignments similar to the staff nurses' duties, and build their self-confidence, which in turn enhanced their self concept and perceptions of role competencies. The nursing students' Tennessee Self Concept Scale pretest group mean total positive (self-esteem) score of 350.48 exceeded the Tennessee Self-Concept Scale mean norm score of 345.57 reported by Fitts (1965). This finding indicates that the overall level of self-esteem displayed by the study sample as reflected by pretest group mean score was higher than the group mean norms used in standardizing the scale.
The findings of this study were consistent with the findings of some related studies. Huckstadt (1981) found that nursing students' participation in a work-study program resulted in an increase in their self-confidence and a more positive self-concept. Dobbs (1988) found that the use of a senior preceptorship program resulted in changes in self-image and role expectations, and it enabled the students to increase their competencies and learn to cope with demands of the work environment. Woolf (1984) found that the use of selected nontraditional teaching methods resulted in increased feelings of self worth and self confidence in the students.
The self-concept is viewed as the most important single influence of behavior (Combs et al., 1974). The selfconcepts of nursing students and new graduate nurses are extremely vulnerable in relation to the devastating negative impact of some experiences and approaches employed in both the educational and work environments. The findings of this study support the fact that learning opportunities and experiences can be designed to build and promote a greater self-confidence and a more positive self-concept. Nurse educators must be constantly aware of their own behavior and interactions with students, and employ teaching methods and strategies that foster a more positive self-concept in students. Further research is needed in both clinical teaching methods and selected clinical learning experiences to identify optimum learning opportunities that yield the desired outcomes.
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