Nurse Educator
Nurse Educator Vol. 39, No. 2, pp. 85-90 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Enhancing Resilience, Empowerment, and Conflict Management Among Baccalaureate Students Outcomes of a Pilot Study Eula W. Pines, PhD, DNP, RN, PMHCNS, BC & Maureen L. Rauschhuber, PhD, RN, RNC Jennifer D. Cook, PhD, CNS, BC & Gary H. Norgan, PhD, RN & Leticia Canchola, MSN, RN Cynthia Richardson, MSN, RN & Mary Elaine Jones, PhD, RN To manage interpersonal conflict, nursing students need evidence-based interventions to strengthen stress resiliency, psychological empowerment, and conflict management skills. A pilot 1-group, pre-post–design, 2-semester intervention used simulated experiences to enhance these skills with 60 undergraduate nursing students. Findings suggest that integration of conflict resolution skills throughout the curriculum, with repeated opportunities to practice using a variety of styles of conflict management in relation to situational factors, may be beneficial to prepare students for the challenges of today’s healthcare environment.
T
he complexity of the healthcare environment requires effective communication, collaboration, decision making, authentic leadership, and competencies to address conflict.1,2 Interpersonal conflict is inevitable in the workplace and has many costs including moral distress,3 burnout, absenteeism, and turnover.4 Traditionally, nurses have responded with avoidance and accommodating behaviors when confronted with difficult individuals or situations.5 Like experienced nurses, nursing students experience aggression and bullying in clinical settings from staff nurses, nursing managers, and patients and their families.6 New nurses7 and nursing students8 are particularly unprepared to deal with conflict and frequently choose to avoid conflict situations. Dealing effectively with conflict is an essential skill for team membership and the provision of collaborative care. Multiple national initiatives, including the Institute of Medicine,9 the American Association of Colleges of Nursing (AACN),10 and the Interprofessional Education Collaborative (IPEC),11 require nurse educators to prepare nursing students for the challenges of effectively engaging in interpersonal conflict. A small body of evidence documents the conflict manageAuthor Affiliations: Associate Professors (Drs Pines, Rauschubber, and Cook), Professors (Drs Norgan and Jones), and Instructors (Mss Canchola and Richardson), Ila Faye Miller School of Nursing, University of the Incarnate Word, San Antonio, Texas. Funding support was received from the Brig Gen Lillian Dunlap Endowed Chair of the University of the Incarnate Word and Graduate Research Assistant Fund. The authors declare no conflicts of interest. Correspondence: Dr Pines, Ila Faye Miller School of Nursing, University of the Incarnate Word, 4301 Broadway, San Antonio, TX 78209 ([email protected]). DOI: 10.1097/NNE.0000000000000023
Nurse Educator
ment styles of nursing students and other health-related professional students.12,13 Theoretically, conflict can be viewed as an external stressor that requires internal resiliency and a sense of empowerment to manage it effectively. Few studies document outcomes of educational interventions to assist nursing students to strengthen perceptions of resilience and psychological empowerment. The purpose of the pilot intervention project was to determine whether nursing students who participate in simulated training exercises that manage intimidating and disruptive behaviors of others have increased perceptions of resiliency, psychological empowerment, and conflict management styles after training.
Review of Literature The AACN10 delineated Interprofessional Communication and Collaboration for Improving Patient Health Outcomes as 1 of 9 essentials to guide the baccalaureate-nursing curriculum. Within the framework, the AACN outlined learning opportunities that should ensure graduates attain adequate knowledge and skills to enter into professional nursing practice. In addition, clinical experiences must assist the graduate to ‘‘apply professional communication strategies to client and interprofessional interactions.’’10(p33) IPEC11 recommended inclusion of communication competencies in current interprofessional education. Under the IPEC individual competency statements, health professionals must ‘‘work with individuals of other professions to maintain a climate of mutual respect and shared values.’’11(p19) Nurses working in today’s dynamic healthcare delivery system need personal resilience and psychological empowerment skills to be prepared to respond to workplace adversity. Volume 39 & Number 2 & March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
85
Resilience is the ability of an individual to adjust to adversity, maintain equilibrium, retain some control over the environment, and move in a positive direction.14 The authors believe that nurses can strengthen resilience through development of strategies to reduce vulnerability to the impact of adversity in the workplace. Self-development strategies include building positive nurturing professional relationships and networks, maintaining positivity, developing emotional insight, achieving life balance and spirituality, and becoming more reflective. In a study by Randle,15 nursing students who reported experiencing bullying from nursing staff eventually bullied patients under their care. By contrast, in a qualitative study of the clinical experiences of Australian baccalaureate-nursing (BSN) students, Jackson et al6 reported that students who experienced incivility or other forms of aggression intentionally supported each other and collaboratively developed action plans to address repression. Bullying behaviors affect psychological empowerment, which is the individual’s perceived sense of meaning and purpose, competence, self-determination, and impact on the work role. Rao16 asserts that psychological empowerment is necessary for nurses to fulfill professional practice responsibilities. Nurse empowerment is the emergent product of interactions of the individual with organizational and sociocultural factors. Rao16 further asserted that the level of perceived empowerment varies with contextual antecedents that shape the capacity for empowerment. The extent to which undergraduate nursing students perceive psychological empowerment is under studied. Folger et al17 define conflict as ‘‘the interaction of interdependent people who perceive incompatibility and the possibility of interference from others as a result of this incompatibility.’’17(p4) Conflict can manifest in a number of ways including intimidating and disruptive behaviors between individuals. These behaviors can be covert or overt and include nonverbal and verbal behaviors such as withholding information, innuendo, and negative verbal responses.17,18 Such behaviors decrease communication between individuals and impede the development of positive working relationships, necessary for effective collaboration.17,18 It is generally accepted that conflict management style depends on the situation and the parties involved and involves a choice of methods to manage a situation. Thomas and Kilmann19 identify 5 conflict management styles: accommodating, avoiding, collaborating, competing, and compromising. Accommodating is unassertive and cooperative and allows the other person to dominate. Avoiding is both uncooperative and unassertive and is characterized by the individual’s avoidance of taking any action. Collaborating is assertive and cooperative and represents an attempt to find a solution to the conflict. Competing is assertive and uncooperative. Finally, compromising is intermediate in both assertiveness and cooperativeness and partially satisfies the needs of each party. With competing, 1 assertively pursues personal concerns at the expense of the concerns of another. In compromising, the object is to find a mutually agreeable solution that partially satisfies both parties. Resiliency and empowerment reflect application of the appropriate strategy/style in response to the situation. The conflict management styles of nurses have been well studied, but only a limited number of studies describe 86
Volume 39 & Number 2 & March/April 2014
styles among nursing students; few to no intervention studies of nursing students were found. Sportsman and Hamilton’s12 study of nursing and allied health professions students reported that compromise was the conflict management style used most by the nursing students, whereas the allied health students mostly chose avoidance. The nursing students chose competition as the least-preferred management style. Pines et al13 reported that undergraduate nursing students preferred avoiding and accommodating behaviors and were less likely to use competing or collaborating strategies to manage conflict. A sample of Jordanian nursing students preferred collaboration and accommodation as conflict management techniques and were less likely to use avoidance and compromise.20 Kantek and Gezer21 examined conflict management styles used by nursing students in conflict with their faculty members. Students were found to use integrating (an individual shows more interest in the concerns of the self and others and includes cooperation between groups) and obliging (the individual shows less concern for the self and a high level of concern for others) the most. The students were least inclined to use the dominating (competing) style. Considering the inconsistency in findings of preferred conflict management styles among nursing students, further research is needed.
Theoretical Framework The Neuman Systems Model22 guided this study. Neuman and Fawcett22 view the client as a central core of basic survival factors surrounded by lines of defense and resistance designed to protect the client core and to maintain stability and balance. Five interacting variables (physiological, psychological, sociocultural, developmental, and spiritual) within the client system interrelate and interact, thus determining the ability of the client to resist the stressors. In this study, interpersonal conflict is an internal and external environmental stressor.22 Stress resiliency,23 psychological empowerment,24 and TeamSTEPPS25 interventions potentially will strengthen nursing students’ flexible lines of defense and mitigate the stressor of interpersonal conflict, empowering students to apply the appropriate conflict management style in difficult situations. Research Questions 1. What are the pre and post differences in perceptions of resiliency, psychological empowerment, and conflict management style among a sample of undergraduate nursing students who participated in simulated training exercises to manage intimidating and disruptive behaviors of others? 2. What is the relationship of selected attribute characteristics of undergraduate nursing students and perceptions of resiliency, psychological empowerment, and conflict management style?
Methods Research Design/Setting This study used a quasi-experimental pre-post design. The setting was a small, private, faith-based university in the southwest United States. Participants were students in 2 upper Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
division courses, Psychiatric-Mental Health Nursing (PMHN) and Leadership/Management in Nursing (LMN), in the undergraduate baccalaureate-nursing curriculum.
Sample A convenience sample of volunteers was recruited from 2 cohorts of students enrolled in the undergraduate PMHN course. The 1st cohort was enrolled in PMHN in the 2010 fall semester and completed the LMN course in spring 2011. The 2nd cohort was enrolled in PMHN in the spring 2011 semester and completed LMN in fall 2011. Of the 62 students, 61 volunteered and consented to participate (98%); 1 student did not complete baseline tools and was eliminated from the analysis, for a total of 60 students in the sample. Intervention The pilot project provided didactic and simulated training using a variety of scenarios for learning resiliency skills, enhancing perceptions of empowerment and increasing knowledge of personal styles of conflict management. The Reaching Out and Reaching In26 curriculum based on the PENN Resiliency Program and TeamSTEPPS25 provided the basis of the resiliency intervention. The program also has been used successfully in early childhood human development programs with adolescents and college students. The course content consisted of 4 modules implemented over 2 consecutive semesters of course work. Faculty presented the 1st 3 modules in the PMHN class in 2 weekly, 3-hour class periods. Scenarios in each session provided an opportunity for students to role play the use of problem-solving and coping skills. Module 1 focused on the principles of resiliency and behaviors of resilient nurses. Module 2 content engaged students in professional empowerment and disempowerment strategies in the workplace. Students brainstormed words they have come to associate with resilience and that reflected the characteristics of a resilient and empowered nurse who had overcome adversity and persevered with courage and strength. Module 3 focused on analyzing the advantages and disadvantages of the 5 conflict management styles.27 Five simulated scenarios provided students the opportunity to apply knowledge and skills to manage conflict with colleagues and patients. Each simulated activity lasted 45 minutes, with 30 minutes for simulation and a 10-minute debriefing. The 4th module used content from TeamSTEPPS,28 an evidencebased teamwork training system. The program included a series of interactive didactic and discussion group sessions, role playing, and videotaped scenarios. TeamSTEPPS was implemented during a 3-hour class period in the LMN course, with a focus on the role of manager. Students viewed the Agency for Health Care Research and Quality, TeamSTEPPS, DESC script video.28 This video provides a step-by-step format for managing difficult situations. The steps include describe the situation, express your concerns about the action, suggest other alternatives, and consequences should be stated. Students then applied these principles to video scenarios from TeamSTEPPS.28 For example, 1 situation involved 2 nurses attending a unit meeting, 1 of whom was talking about unrelated material, whereas another nurse grows increasingly impatient to get on with the meeting (describe the situation). The charge nurse recognizes that the meeting must go on Nurse Educator
but does not want to alienate either party and suggests that they delay discussion of the unrelated material until later (express your concerns about the action). The charge nurse deflected defensiveness by keeping a positive tone in her voice and suggested that the unrelated material was not relevant but needed to be delayed to another time (suggest alternatives). The meeting proceeded as scheduled, and the involved parties did not feel slighted (consequences). During the debriefing, students completed the DESC selfassessment tool to reflect on the effect of the DESC script on conflict management.28
Instrumentation Four instruments were used to collect data at the beginning of the PMHN class and at end of semester for the LMN course. Demographic characteristics were collected on a researcherdesigned form and included a question relating to previous experience with conflict in the workplace. For this question, ‘‘workplace’’ included any previous or current work-related setting including healthcare. The Thomas-Kilmann Conflict Mode Instrument (TKI)19 is a 30-item forced choice tool, which assesses personal behavior along 2 dimensions: assertiveness, defined as the extent to which the individual attempts to satisfy personal concerns; and cooperativeness, defined as the extent to which the individual attempts to satisfy concerns of others. Possible scores range from 0 (none) to 12 (very high) frequency of use. The instrument has been used widely in studies on conflict management in healthcare with satisfactory testretest and internal consistency reliabilities ranging from .61 to .68.27 Traditional " reliability was not obtainable as the TKI is ipsative. Walker created a Likert-type scale of the TKI; the coefficient "’s (as cited in Sportsman and Hamilton12(p161)) for subscales included competing, .87; accommodating, .73; avoiding, .69; collaborating, .84; and compromising, .76. The Stress Resiliency Profile (SRP),23 an 18-item Likerttype survey, focuses on the development of effective mental habits for coping with stressors. Three interpretive habits for perceptions of stress are measured: deficiency focusing, the habit of focusing on the negatives rather than the positives in a situation; necessitating, the habit of focusing on commitment rather than choice in a situation, leading to the conclusion of no choice; and low-skill recognition, the habit of underestimating personal competence, suggesting success is due to external forces. Thomas and Tymon23 report an internal consistency of .81 among MBA students. Internal consistency analysis for this study yielded a Cronbach’s " of .77 for the preintervention measurement and .78 for the postintervention measurement. The Psychological Empowerment Instrument (PEI)24 is a 12-item, 7-point Likert scale tool that assesses motivational constructs of meaning, competence, self-determination, and impact. Meaning is the perception of the individual’s value of the work role; competence is the ability to perform effectively; self-determination is the perception of choice in a situation; and impact is the perception of individual ability to influence outcomes in a work environment.24 Validation of the instrument indicated Cronbach’s "’s of .81, .76, .85, and .83, respectively.29 For this study, internal consistency analysis revealed a Cronbach’s " of .94 for the preintervention measurement and .96 for the postintervention measurement. Volume 39 & Number 2 & March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
87
Procedures for Data Collection With approval from the university’s institutional review board for the protection of human subjects, the purpose of the project was described to students in PMHN classes in the beginning of the fall 2010 and spring 2011 semesters by a research team member who was not faculty in the undergraduate program. Survey instruments were administered to student volunteers after consents were signed. Postintervention survey instruments were administered following the LMN course. Data Analysis Descriptive and inferential statistics were used, including paired t test to determine pre-post differences in the outcome variables, and Pearson correlation to examine relationships of selected demographic characteristics and outcome variables.
Table 2. PEI Pre-Post Score (n = 60) PEI Subscale Competence—pre Competence—post Meaning—pre Meaning—post Self-determination—pre Self-determination—post Impact—pre Impact—post Total—pre Total—post
The average age of the 60 students in the sample was 25 (SD, 5.68) years (range, 21-47 years); the majority were single (67%), female (88%), and Hispanic (73%), and 58% reported experience with conflict in the workplace. Research Question 1: What are the pre-post differences in perceptions of resiliency, psychological empowerment, and conflict management style among a sample of undergraduate nursing students who participated in simulated training exercises to manage intimidating and disruptive behaviors of others? Table 1 describes the pre-post mean scores and percentages on the SRP. Percentages at or greater than 75% indicate a predisposition to stress. Percentiles of 25% or less indicate stress resiliency. For this group of students, scores on the interpretive habit of necessitating were statistically significant after the program (t59 = 2.527, P e .01). Mean scores of the 5 subscales for the PEI are described in Table 2. There were no significant differences in pre-post scores on the PEI total or subscale scores. Table 3 presents mean pre-post scores for each of the 5 styles of conflict management as assessed by the TKI. Scores on the compromising subscale of the TKI were significantly higher (t59 = -2.388, P e .02) and significantly lower on the accommodating subscale (t59 = 2.835, P e .006) at the end of the intervention. Research Question 2: What is the relationship of selected attribute characteristics of undergraduate nursing students Table 1. Stress Resiliency Profile Pre-post Scores (N = 60)
Deficiency focusing—pre Deficiency focusing—post Necessitating—pre Necessitating—posta Skill recognition—pre Skill recognition—post a
Mean Score SD Range Percentile Rank 24.93 23.50 31.10 29.77 33.95 33.23
8 8 5 5 5 5
6-40 9-41 22-41 18-39 19-42 23-42
t59 = 2.527, P = .014.
88
SD
P
17.10 16.50 17.85 18.10 16.25 16.34 14.20 14.53 65.41 65.46
3.20 3.08 3.62 4.16 3.50 3.28 3.58 3.26 11.36 12.32
.235 .691 .878 .580 .980
and their perceptions of resiliency, psychological empowerment, and conflict management style?
Findings
Interpretive Habit
Mean Score
Volume 39 & Number 2 & March/April 2014
70% 65% 80% 68% 50% 58%
There were no significant relationships between age and gender, whether participants had experienced conflict in the workplace, and perceptions of resiliency, psychological empowerment, and conflict management style.
Discussion The findings from this pilot intervention study reflect the difficult task of educating students to use a range of styles to manage conflict in a work setting and increase resiliency to stress, which include strategies to improve perceptions of empowerment. The major goal of the intervention was primary prevention—to strengthen the individual’s flexible line of defense, a construct of the Neuman systems model, the theoretical model for this study. Primary prevention strategies to manage conflict were to increase the resiliency of nursing students by empowering them to cope with stressors in the workplace such as interpersonal conflict.13 Table 3. Conflict Management Inventory Pre-post Scores (N = 60) TKI Style
Mean Raw Score 0
Collaborating
Mean (SD)
Pre Post Accommodatinga Pre Post Competing Pre Post Compromisingb Pre Post Avoiding Pre Post
5.33 (2.3) 5.23 (1.8)
25
50
75
100
9 9
6.72 (2.3) 6.00 (2.3) 3.75 (2.8) 4.00 (2.7) 7.33 (2.1) 8.07 (2.1)
9 9 9 9 9 9
6.85 (2.1) 6.53 (2.1)
9 9
a
t59 = 2.835, P e .006. t59 = -2.388, P e .02.
b
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Little to no significant changes in empowerment and stress resiliency were demonstrated after training. As a group, student scores in conflict management were in what authors of the tool designate as the middle or 50th percentile. Preferences for managing conflict indicated a relatively high level of accommodating style (unassertive and highly cooperative, neglectful of personal concerns) at the beginning of the PMHN course and an increase in compromising styles (both assertive and cooperative, a partial satisfaction of personal concerns) at the end of the LMN course. Preference for use of the avoiding style to manage conflict (a withdrawal from the situation that can be a positive or negative strategy) was at a high level at baseline, at the 60th percentile, and remained at that level after training. The lowest style was collaborating the situation where all needs of both parties are met. Although student accommodating scores decreased, and compromising scores increased significantly in the postmeasurement period, there were no significant changes in collaboration or avoiding styles despite a fairly robust intervention over a 2-semester time period. To prepare students for practice in today’s complex healthcare environment requires a supportive learning environment in which they can practice realistic situations to manage intimidating and disruptive behaviors of others. Faculty can foster students’ development of understanding of the way healthcare providers respond to conflict and the ability to work collaboratively with each other and communicate positively. A number of issues may influence how educators can demonstrate changes in the constructs of stress resiliency, empowerment, and conflict management style. These issues include research design and methodology factors, timing and intensity or length of the intervention, and student role factors. To measure small clinical changes requires a large sample. The sample of 60 participants in the current study was relatively small, which may have reduced the power to identify clinically relevant changes. At another level, although the intervention included a ‘‘repeated dose’’ of simulated application to clinical settings in the 2nd semester, the intervention may not have been robust enough or contained sufficient repeated doses to change ways of thinking. It may be that interventions begun in the last 2 semesters of a program do not allow sufficient opportunities for students to practice these skills in realworld settings. The inherent stress of the final year of study in nursing may also be a barrier to changing long-standing ways of thinking and behaving. Of particular importance is the fact that senior-level nursing students are beginners with no experience in the situations in which they are expected to perform.30(p20) Novices are taught about situations in terms of measurable objective attributes in context-free rules to guide nursing action, but they have little understanding of the contextual meaning of the recently learned information.
Conclusion To prepare students to respond to conflict in the workplace, educators are encouraged to integrate conflict resolution skills throughout the curriculum, with repeated opportunities to practice using a variety of styles of conflict management. More studies with larger samples are needed to determine how best to strengthen resiliency and empower students to apply Nurse Educator
an appropriate conflict management style when confronted with real-world interpersonal conflict.
References 1. Scott DE. Addressing 2009 Joint Commission leadership standards. Nurses First. 2009;2(1):1-2. Available at http://.can.affiniscape .com/association/9102/files/ConflictJointCommission%(2).pdf. Accessed March 13, 2012. 2. Scott DE. Conflict resolution series: the cost of avoiding conflict. Nurses First. 2008;1:16-17. Available at http://.can.affiniscape.com/ association/9102/files/ConflictofAvoiding.pdf. Accessed April 12, 2012. 3. Browning AM. Moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am J Crit Care. 2013;22(2):143-152. 4. Brinkert R. A literature review of conflict communication causes, costs, benefits and interventions in nursing. J Nurs Manag. 2010; 18:145-156. 5. Sofield L., Salmond SW. A focus on verbal abuse and intent to leave the organization. Orthop Nurs. 2003;22(4):274-283. 6. Jackson D, Hutchinson M, Everett B, et al. Struggling for legitimacy: nursing student’s stories of organizational aggression, resilience, and resistance. Nurs Inq. 2011;18(2):102-110. 7. Dyess SM, Sherman RO. The first year of practice: new graduate nurses’ transition and learning needs. J Contin Educ Nurs. 2009; 40(9):403-410. 8. Thomas SP, Burk R. Junior nursing students’ experiences of vertical violence during clinical rotations. Nurs Outlook. 2009; 57(4):226-231. 9. Institutes of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 2003. 10. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. 2008. Available at http://www.aacn.nche.edu/educationresources/BaccEssentials08.pdf. Accessed April 1, 2012. 11. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. 12. Sportsman S, Hamilton P. Conflict management styles in the health professions. J Prof Nurs. 2007;23(3):157-166. 13. Pines EW, Rauschhuber ML, Norgan GH, et al. Stress resiliency, psychological empowerment and conflict management styles among baccalaureate nursing students. J Adv Nurs. 2012;68(7): 1482-1493. 14. Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs. 2007;60:1-9. 15. Randle J. Bullying in nursing. J Adv Nurs. 2003;43(4):395-401. 16. Rao A. The contemporary construction of nurse psychological empowerment. J Nurs Scholarsh. 2012;44(4):396-402. 17. Folger JP, Polle MS, Stutman RK. Working Through Conflict: Strategies for Relationships, Groups, and Organizations. 7th ed. Upper Saddle River, NJ: Pearson Education; 2013. 18. Fikelman A. Leadership and Management: Core Competencies for Quality Care. 2nd ed. Upper Saddle River, NJ: Pearson Education; 2012. 19. Thomas KW, Kilmann RH. Thomas-Kilmann Conflict Mode Instrument. Mountain View, CA: CPP, Inc; 2007. 20. Mrayyan MT, Modallal R, Awamreh K, et al. Readiness of organizations for change, motivation and conflict-handling intentions: senior nursing students’ perceptions. Nurse Educ Pract. 2008;8:120-128. 21. Kantek F, Gezer N. Conflict in schools: student nurses’ conflict management styles. Nurse Educ Today. 2009;29:100-107. Volume 39 & Number 2 & March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
89
22. Neuman B, Fawcett J. The Neuman System Model. 5th ed. Upper Saddle River, NJ: Pearson Education; 2011. 23. Thomas KW, Tymon WG. Stress Resiliency Profile. Tuxedo, NY: Xicom; 1992. 24. Spreitzer G. Psychological empowerment in the workplace: dimensions, measurement, and validation. Acad Manage J. 1995;38:1442-1465. 25. Agency for Healthcare Research and Quality. TeamSTEPPS Instructor Guide, Team Strategies & Tools to Enhance Performance & Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; 2006. 26. Winder C. Reaching In and Reaching Out: Resiliency College Curriculum. Toronto, Ontario, Canada: George Brown College; 2006.
27. Kilmann RH, Thomas KW. Developing a force-choice measure of conflict management behavior: the MODE instrument. Educ Psychol Meas. 1977;37:309-323. 28. Agency for Healthcare Research and Quality. TeamSTEPPS Fundamental Course Module 5. Mutual Support Classroom Slides, 2006. Available at http://ahrq.gov./professionals/education/ curriculum-tools/teamstepps/instructor/fundamental;2001ls/ module5/slmutualsupp.html. Accessed October 10, 2011. 29. Johnson BH. Psychological empowerment of nurse educators through organizational culture. Nurs Educ Perspect. 2009; 30:8-13. 30. Benner P. From Novice to Expert Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice Hall Health; 2001.
Free Curriculum Downloads Most scholars are familiar with the published works of the National Academies Press (NAP). The mission behind the scholarly publications has been in existence since 1863 as a private, nonprofit society of scholars and was created under the leadership of President Abraham Lincoln. In 2013, NAP publications continue to provide a wealth of FREE information for both academicians and students. NAP has published several new references to improve understanding of local to global health issues. These downloads are available at http://www.nap.edu/. Three publications have provided additional curriculum for community/public health, health policy, and global health courses. 1. Evaluating Obesity Prevention Efforts: A Plan for Measuring Progress addresses obesity as the largest current public health challenge. Content includes information on consequences for health, economic, and social concerns. This book outlines detailed plans that have demonstrated positive outcomes in reducing this healthcare crisis (http://www.nap.edu/catalog.php?record_id=18334). 2. US Health in International Perspective: Shorter Lives, Poorer Health reports a data-driven picture of the United States in relation to other comparable countries. The US health disadvantage is nondiscriminatory for rich and poor, majority and minority. Strategies for cause and intervention range from personal behaviors to government and organizational influences to improve the health of the nation (http://www.nap.edu/catalog.php?record_id=13497). 3. Best Care and Lower Cost: The Path to Continuously Learning Health Care in America discusses the complexity and costs of healthcare including quality and economic barriers as well as healthcare spending waste. It is a call to action for everyone from consumers of care to providers and payer sources (http://www.nap.edu/catalog.php?record_id=13444). Submitted by: Alma Jackson, PhD, RN, COHN-S, News Editor at [email protected]. DOI: 10.1097/NNE.0000000000000026
90
Volume 39 & Number 2 & March/April 2014
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse Educator Vol. 39, No. 2, pp. 85-90 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Enhancing Resilience, Empowerment, and Conflict Management Among Baccalaureate Students Outcomes of a Pilot Study Eula W. Pines, PhD, DNP, RN, PMHCNS, BC & Maureen L. Rauschhuber, PhD, RN, RNC Jennifer D. Cook, PhD, CNS, BC & Gary H. Norgan, PhD, RN & Leticia Canchola, MSN, RN Cynthia Richardson, MSN, RN & Mary Elaine Jones, PhD, RN To manage interpersonal conflict, nursing students need evidence-based interventions to strengthen stress resiliency, psychological empowerment, and conflict management skills. A pilot 1-group, pre-post–design, 2-semester intervention used simulated experiences to enhance these skills with 60 undergraduate nursing students. Findings suggest that integration of conflict resolution skills throughout the curriculum, with repeated opportunities to practice using a variety of styles of conflict management in relation to situational factors, may be beneficial to prepare students for the challenges of today’s healthcare environment.
T
he complexity of the healthcare environment requires effective communication, collaboration, decision making, authentic leadership, and competencies to address conflict.1,2 Interpersonal conflict is inevitable in the workplace and has many costs including moral distress,3 burnout, absenteeism, and turnover.4 Traditionally, nurses have responded with avoidance and accommodating behaviors when confronted with difficult individuals or situations.5 Like experienced nurses, nursing students experience aggression and bullying in clinical settings from staff nurses, nursing managers, and patients and their families.6 New nurses7 and nursing students8 are particularly unprepared to deal with conflict and frequently choose to avoid conflict situations. Dealing effectively with conflict is an essential skill for team membership and the provision of collaborative care. Multiple national initiatives, including the Institute of Medicine,9 the American Association of Colleges of Nursing (AACN),10 and the Interprofessional Education Collaborative (IPEC),11 require nurse educators to prepare nursing students for the challenges of effectively engaging in interpersonal conflict. A small body of evidence documents the conflict manageAuthor Affiliations: Associate Professors (Drs Pines, Rauschubber, and Cook), Professors (Drs Norgan and Jones), and Instructors (Mss Canchola and Richardson), Ila Faye Miller School of Nursing, University of the Incarnate Word, San Antonio, Texas. Funding support was received from the Brig Gen Lillian Dunlap Endowed Chair of the University of the Incarnate Word and Graduate Research Assistant Fund. The authors declare no conflicts of interest. Correspondence: Dr Pines, Ila Faye Miller School of Nursing, University of the Incarnate Word, 4301 Broadway, San Antonio, TX 78209 ([email protected]). DOI: 10.1097/NNE.0000000000000023
Nurse Educator
ment styles of nursing students and other health-related professional students.12,13 Theoretically, conflict can be viewed as an external stressor that requires internal resiliency and a sense of empowerment to manage it effectively. Few studies document outcomes of educational interventions to assist nursing students to strengthen perceptions of resilience and psychological empowerment. The purpose of the pilot intervention project was to determine whether nursing students who participate in simulated training exercises that manage intimidating and disruptive behaviors of others have increased perceptions of resiliency, psychological empowerment, and conflict management styles after training.
Review of Literature The AACN10 delineated Interprofessional Communication and Collaboration for Improving Patient Health Outcomes as 1 of 9 essentials to guide the baccalaureate-nursing curriculum. Within the framework, the AACN outlined learning opportunities that should ensure graduates attain adequate knowledge and skills to enter into professional nursing practice. In addition, clinical experiences must assist the graduate to ‘‘apply professional communication strategies to client and interprofessional interactions.’’10(p33) IPEC11 recommended inclusion of communication competencies in current interprofessional education. Under the IPEC individual competency statements, health professionals must ‘‘work with individuals of other professions to maintain a climate of mutual respect and shared values.’’11(p19) Nurses working in today’s dynamic healthcare delivery system need personal resilience and psychological empowerment skills to be prepared to respond to workplace adversity. Volume 39 & Number 2 & March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
85
Resilience is the ability of an individual to adjust to adversity, maintain equilibrium, retain some control over the environment, and move in a positive direction.14 The authors believe that nurses can strengthen resilience through development of strategies to reduce vulnerability to the impact of adversity in the workplace. Self-development strategies include building positive nurturing professional relationships and networks, maintaining positivity, developing emotional insight, achieving life balance and spirituality, and becoming more reflective. In a study by Randle,15 nursing students who reported experiencing bullying from nursing staff eventually bullied patients under their care. By contrast, in a qualitative study of the clinical experiences of Australian baccalaureate-nursing (BSN) students, Jackson et al6 reported that students who experienced incivility or other forms of aggression intentionally supported each other and collaboratively developed action plans to address repression. Bullying behaviors affect psychological empowerment, which is the individual’s perceived sense of meaning and purpose, competence, self-determination, and impact on the work role. Rao16 asserts that psychological empowerment is necessary for nurses to fulfill professional practice responsibilities. Nurse empowerment is the emergent product of interactions of the individual with organizational and sociocultural factors. Rao16 further asserted that the level of perceived empowerment varies with contextual antecedents that shape the capacity for empowerment. The extent to which undergraduate nursing students perceive psychological empowerment is under studied. Folger et al17 define conflict as ‘‘the interaction of interdependent people who perceive incompatibility and the possibility of interference from others as a result of this incompatibility.’’17(p4) Conflict can manifest in a number of ways including intimidating and disruptive behaviors between individuals. These behaviors can be covert or overt and include nonverbal and verbal behaviors such as withholding information, innuendo, and negative verbal responses.17,18 Such behaviors decrease communication between individuals and impede the development of positive working relationships, necessary for effective collaboration.17,18 It is generally accepted that conflict management style depends on the situation and the parties involved and involves a choice of methods to manage a situation. Thomas and Kilmann19 identify 5 conflict management styles: accommodating, avoiding, collaborating, competing, and compromising. Accommodating is unassertive and cooperative and allows the other person to dominate. Avoiding is both uncooperative and unassertive and is characterized by the individual’s avoidance of taking any action. Collaborating is assertive and cooperative and represents an attempt to find a solution to the conflict. Competing is assertive and uncooperative. Finally, compromising is intermediate in both assertiveness and cooperativeness and partially satisfies the needs of each party. With competing, 1 assertively pursues personal concerns at the expense of the concerns of another. In compromising, the object is to find a mutually agreeable solution that partially satisfies both parties. Resiliency and empowerment reflect application of the appropriate strategy/style in response to the situation. The conflict management styles of nurses have been well studied, but only a limited number of studies describe 86
Volume 39 & Number 2 & March/April 2014
styles among nursing students; few to no intervention studies of nursing students were found. Sportsman and Hamilton’s12 study of nursing and allied health professions students reported that compromise was the conflict management style used most by the nursing students, whereas the allied health students mostly chose avoidance. The nursing students chose competition as the least-preferred management style. Pines et al13 reported that undergraduate nursing students preferred avoiding and accommodating behaviors and were less likely to use competing or collaborating strategies to manage conflict. A sample of Jordanian nursing students preferred collaboration and accommodation as conflict management techniques and were less likely to use avoidance and compromise.20 Kantek and Gezer21 examined conflict management styles used by nursing students in conflict with their faculty members. Students were found to use integrating (an individual shows more interest in the concerns of the self and others and includes cooperation between groups) and obliging (the individual shows less concern for the self and a high level of concern for others) the most. The students were least inclined to use the dominating (competing) style. Considering the inconsistency in findings of preferred conflict management styles among nursing students, further research is needed.
Theoretical Framework The Neuman Systems Model22 guided this study. Neuman and Fawcett22 view the client as a central core of basic survival factors surrounded by lines of defense and resistance designed to protect the client core and to maintain stability and balance. Five interacting variables (physiological, psychological, sociocultural, developmental, and spiritual) within the client system interrelate and interact, thus determining the ability of the client to resist the stressors. In this study, interpersonal conflict is an internal and external environmental stressor.22 Stress resiliency,23 psychological empowerment,24 and TeamSTEPPS25 interventions potentially will strengthen nursing students’ flexible lines of defense and mitigate the stressor of interpersonal conflict, empowering students to apply the appropriate conflict management style in difficult situations. Research Questions 1. What are the pre and post differences in perceptions of resiliency, psychological empowerment, and conflict management style among a sample of undergraduate nursing students who participated in simulated training exercises to manage intimidating and disruptive behaviors of others? 2. What is the relationship of selected attribute characteristics of undergraduate nursing students and perceptions of resiliency, psychological empowerment, and conflict management style?
Methods Research Design/Setting This study used a quasi-experimental pre-post design. The setting was a small, private, faith-based university in the southwest United States. Participants were students in 2 upper Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
division courses, Psychiatric-Mental Health Nursing (PMHN) and Leadership/Management in Nursing (LMN), in the undergraduate baccalaureate-nursing curriculum.
Sample A convenience sample of volunteers was recruited from 2 cohorts of students enrolled in the undergraduate PMHN course. The 1st cohort was enrolled in PMHN in the 2010 fall semester and completed the LMN course in spring 2011. The 2nd cohort was enrolled in PMHN in the spring 2011 semester and completed LMN in fall 2011. Of the 62 students, 61 volunteered and consented to participate (98%); 1 student did not complete baseline tools and was eliminated from the analysis, for a total of 60 students in the sample. Intervention The pilot project provided didactic and simulated training using a variety of scenarios for learning resiliency skills, enhancing perceptions of empowerment and increasing knowledge of personal styles of conflict management. The Reaching Out and Reaching In26 curriculum based on the PENN Resiliency Program and TeamSTEPPS25 provided the basis of the resiliency intervention. The program also has been used successfully in early childhood human development programs with adolescents and college students. The course content consisted of 4 modules implemented over 2 consecutive semesters of course work. Faculty presented the 1st 3 modules in the PMHN class in 2 weekly, 3-hour class periods. Scenarios in each session provided an opportunity for students to role play the use of problem-solving and coping skills. Module 1 focused on the principles of resiliency and behaviors of resilient nurses. Module 2 content engaged students in professional empowerment and disempowerment strategies in the workplace. Students brainstormed words they have come to associate with resilience and that reflected the characteristics of a resilient and empowered nurse who had overcome adversity and persevered with courage and strength. Module 3 focused on analyzing the advantages and disadvantages of the 5 conflict management styles.27 Five simulated scenarios provided students the opportunity to apply knowledge and skills to manage conflict with colleagues and patients. Each simulated activity lasted 45 minutes, with 30 minutes for simulation and a 10-minute debriefing. The 4th module used content from TeamSTEPPS,28 an evidencebased teamwork training system. The program included a series of interactive didactic and discussion group sessions, role playing, and videotaped scenarios. TeamSTEPPS was implemented during a 3-hour class period in the LMN course, with a focus on the role of manager. Students viewed the Agency for Health Care Research and Quality, TeamSTEPPS, DESC script video.28 This video provides a step-by-step format for managing difficult situations. The steps include describe the situation, express your concerns about the action, suggest other alternatives, and consequences should be stated. Students then applied these principles to video scenarios from TeamSTEPPS.28 For example, 1 situation involved 2 nurses attending a unit meeting, 1 of whom was talking about unrelated material, whereas another nurse grows increasingly impatient to get on with the meeting (describe the situation). The charge nurse recognizes that the meeting must go on Nurse Educator
but does not want to alienate either party and suggests that they delay discussion of the unrelated material until later (express your concerns about the action). The charge nurse deflected defensiveness by keeping a positive tone in her voice and suggested that the unrelated material was not relevant but needed to be delayed to another time (suggest alternatives). The meeting proceeded as scheduled, and the involved parties did not feel slighted (consequences). During the debriefing, students completed the DESC selfassessment tool to reflect on the effect of the DESC script on conflict management.28
Instrumentation Four instruments were used to collect data at the beginning of the PMHN class and at end of semester for the LMN course. Demographic characteristics were collected on a researcherdesigned form and included a question relating to previous experience with conflict in the workplace. For this question, ‘‘workplace’’ included any previous or current work-related setting including healthcare. The Thomas-Kilmann Conflict Mode Instrument (TKI)19 is a 30-item forced choice tool, which assesses personal behavior along 2 dimensions: assertiveness, defined as the extent to which the individual attempts to satisfy personal concerns; and cooperativeness, defined as the extent to which the individual attempts to satisfy concerns of others. Possible scores range from 0 (none) to 12 (very high) frequency of use. The instrument has been used widely in studies on conflict management in healthcare with satisfactory testretest and internal consistency reliabilities ranging from .61 to .68.27 Traditional " reliability was not obtainable as the TKI is ipsative. Walker created a Likert-type scale of the TKI; the coefficient "’s (as cited in Sportsman and Hamilton12(p161)) for subscales included competing, .87; accommodating, .73; avoiding, .69; collaborating, .84; and compromising, .76. The Stress Resiliency Profile (SRP),23 an 18-item Likerttype survey, focuses on the development of effective mental habits for coping with stressors. Three interpretive habits for perceptions of stress are measured: deficiency focusing, the habit of focusing on the negatives rather than the positives in a situation; necessitating, the habit of focusing on commitment rather than choice in a situation, leading to the conclusion of no choice; and low-skill recognition, the habit of underestimating personal competence, suggesting success is due to external forces. Thomas and Tymon23 report an internal consistency of .81 among MBA students. Internal consistency analysis for this study yielded a Cronbach’s " of .77 for the preintervention measurement and .78 for the postintervention measurement. The Psychological Empowerment Instrument (PEI)24 is a 12-item, 7-point Likert scale tool that assesses motivational constructs of meaning, competence, self-determination, and impact. Meaning is the perception of the individual’s value of the work role; competence is the ability to perform effectively; self-determination is the perception of choice in a situation; and impact is the perception of individual ability to influence outcomes in a work environment.24 Validation of the instrument indicated Cronbach’s "’s of .81, .76, .85, and .83, respectively.29 For this study, internal consistency analysis revealed a Cronbach’s " of .94 for the preintervention measurement and .96 for the postintervention measurement. Volume 39 & Number 2 & March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
87
Procedures for Data Collection With approval from the university’s institutional review board for the protection of human subjects, the purpose of the project was described to students in PMHN classes in the beginning of the fall 2010 and spring 2011 semesters by a research team member who was not faculty in the undergraduate program. Survey instruments were administered to student volunteers after consents were signed. Postintervention survey instruments were administered following the LMN course. Data Analysis Descriptive and inferential statistics were used, including paired t test to determine pre-post differences in the outcome variables, and Pearson correlation to examine relationships of selected demographic characteristics and outcome variables.
Table 2. PEI Pre-Post Score (n = 60) PEI Subscale Competence—pre Competence—post Meaning—pre Meaning—post Self-determination—pre Self-determination—post Impact—pre Impact—post Total—pre Total—post
The average age of the 60 students in the sample was 25 (SD, 5.68) years (range, 21-47 years); the majority were single (67%), female (88%), and Hispanic (73%), and 58% reported experience with conflict in the workplace. Research Question 1: What are the pre-post differences in perceptions of resiliency, psychological empowerment, and conflict management style among a sample of undergraduate nursing students who participated in simulated training exercises to manage intimidating and disruptive behaviors of others? Table 1 describes the pre-post mean scores and percentages on the SRP. Percentages at or greater than 75% indicate a predisposition to stress. Percentiles of 25% or less indicate stress resiliency. For this group of students, scores on the interpretive habit of necessitating were statistically significant after the program (t59 = 2.527, P e .01). Mean scores of the 5 subscales for the PEI are described in Table 2. There were no significant differences in pre-post scores on the PEI total or subscale scores. Table 3 presents mean pre-post scores for each of the 5 styles of conflict management as assessed by the TKI. Scores on the compromising subscale of the TKI were significantly higher (t59 = -2.388, P e .02) and significantly lower on the accommodating subscale (t59 = 2.835, P e .006) at the end of the intervention. Research Question 2: What is the relationship of selected attribute characteristics of undergraduate nursing students Table 1. Stress Resiliency Profile Pre-post Scores (N = 60)
Deficiency focusing—pre Deficiency focusing—post Necessitating—pre Necessitating—posta Skill recognition—pre Skill recognition—post a
Mean Score SD Range Percentile Rank 24.93 23.50 31.10 29.77 33.95 33.23
8 8 5 5 5 5
6-40 9-41 22-41 18-39 19-42 23-42
t59 = 2.527, P = .014.
88
SD
P
17.10 16.50 17.85 18.10 16.25 16.34 14.20 14.53 65.41 65.46
3.20 3.08 3.62 4.16 3.50 3.28 3.58 3.26 11.36 12.32
.235 .691 .878 .580 .980
and their perceptions of resiliency, psychological empowerment, and conflict management style?
Findings
Interpretive Habit
Mean Score
Volume 39 & Number 2 & March/April 2014
70% 65% 80% 68% 50% 58%
There were no significant relationships between age and gender, whether participants had experienced conflict in the workplace, and perceptions of resiliency, psychological empowerment, and conflict management style.
Discussion The findings from this pilot intervention study reflect the difficult task of educating students to use a range of styles to manage conflict in a work setting and increase resiliency to stress, which include strategies to improve perceptions of empowerment. The major goal of the intervention was primary prevention—to strengthen the individual’s flexible line of defense, a construct of the Neuman systems model, the theoretical model for this study. Primary prevention strategies to manage conflict were to increase the resiliency of nursing students by empowering them to cope with stressors in the workplace such as interpersonal conflict.13 Table 3. Conflict Management Inventory Pre-post Scores (N = 60) TKI Style
Mean Raw Score 0
Collaborating
Mean (SD)
Pre Post Accommodatinga Pre Post Competing Pre Post Compromisingb Pre Post Avoiding Pre Post
5.33 (2.3) 5.23 (1.8)
25
50
75
100
9 9
6.72 (2.3) 6.00 (2.3) 3.75 (2.8) 4.00 (2.7) 7.33 (2.1) 8.07 (2.1)
9 9 9 9 9 9
6.85 (2.1) 6.53 (2.1)
9 9
a
t59 = 2.835, P e .006. t59 = -2.388, P e .02.
b
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Little to no significant changes in empowerment and stress resiliency were demonstrated after training. As a group, student scores in conflict management were in what authors of the tool designate as the middle or 50th percentile. Preferences for managing conflict indicated a relatively high level of accommodating style (unassertive and highly cooperative, neglectful of personal concerns) at the beginning of the PMHN course and an increase in compromising styles (both assertive and cooperative, a partial satisfaction of personal concerns) at the end of the LMN course. Preference for use of the avoiding style to manage conflict (a withdrawal from the situation that can be a positive or negative strategy) was at a high level at baseline, at the 60th percentile, and remained at that level after training. The lowest style was collaborating the situation where all needs of both parties are met. Although student accommodating scores decreased, and compromising scores increased significantly in the postmeasurement period, there were no significant changes in collaboration or avoiding styles despite a fairly robust intervention over a 2-semester time period. To prepare students for practice in today’s complex healthcare environment requires a supportive learning environment in which they can practice realistic situations to manage intimidating and disruptive behaviors of others. Faculty can foster students’ development of understanding of the way healthcare providers respond to conflict and the ability to work collaboratively with each other and communicate positively. A number of issues may influence how educators can demonstrate changes in the constructs of stress resiliency, empowerment, and conflict management style. These issues include research design and methodology factors, timing and intensity or length of the intervention, and student role factors. To measure small clinical changes requires a large sample. The sample of 60 participants in the current study was relatively small, which may have reduced the power to identify clinically relevant changes. At another level, although the intervention included a ‘‘repeated dose’’ of simulated application to clinical settings in the 2nd semester, the intervention may not have been robust enough or contained sufficient repeated doses to change ways of thinking. It may be that interventions begun in the last 2 semesters of a program do not allow sufficient opportunities for students to practice these skills in realworld settings. The inherent stress of the final year of study in nursing may also be a barrier to changing long-standing ways of thinking and behaving. Of particular importance is the fact that senior-level nursing students are beginners with no experience in the situations in which they are expected to perform.30(p20) Novices are taught about situations in terms of measurable objective attributes in context-free rules to guide nursing action, but they have little understanding of the contextual meaning of the recently learned information.
Conclusion To prepare students to respond to conflict in the workplace, educators are encouraged to integrate conflict resolution skills throughout the curriculum, with repeated opportunities to practice using a variety of styles of conflict management. More studies with larger samples are needed to determine how best to strengthen resiliency and empower students to apply Nurse Educator
an appropriate conflict management style when confronted with real-world interpersonal conflict.
References 1. Scott DE. Addressing 2009 Joint Commission leadership standards. Nurses First. 2009;2(1):1-2. Available at http://.can.affiniscape .com/association/9102/files/ConflictJointCommission%(2).pdf. Accessed March 13, 2012. 2. Scott DE. Conflict resolution series: the cost of avoiding conflict. Nurses First. 2008;1:16-17. Available at http://.can.affiniscape.com/ association/9102/files/ConflictofAvoiding.pdf. Accessed April 12, 2012. 3. Browning AM. Moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am J Crit Care. 2013;22(2):143-152. 4. Brinkert R. A literature review of conflict communication causes, costs, benefits and interventions in nursing. J Nurs Manag. 2010; 18:145-156. 5. Sofield L., Salmond SW. A focus on verbal abuse and intent to leave the organization. Orthop Nurs. 2003;22(4):274-283. 6. Jackson D, Hutchinson M, Everett B, et al. Struggling for legitimacy: nursing student’s stories of organizational aggression, resilience, and resistance. Nurs Inq. 2011;18(2):102-110. 7. Dyess SM, Sherman RO. The first year of practice: new graduate nurses’ transition and learning needs. J Contin Educ Nurs. 2009; 40(9):403-410. 8. Thomas SP, Burk R. Junior nursing students’ experiences of vertical violence during clinical rotations. Nurs Outlook. 2009; 57(4):226-231. 9. Institutes of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 2003. 10. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. 2008. Available at http://www.aacn.nche.edu/educationresources/BaccEssentials08.pdf. Accessed April 1, 2012. 11. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. 12. Sportsman S, Hamilton P. Conflict management styles in the health professions. J Prof Nurs. 2007;23(3):157-166. 13. Pines EW, Rauschhuber ML, Norgan GH, et al. Stress resiliency, psychological empowerment and conflict management styles among baccalaureate nursing students. J Adv Nurs. 2012;68(7): 1482-1493. 14. Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs. 2007;60:1-9. 15. Randle J. Bullying in nursing. J Adv Nurs. 2003;43(4):395-401. 16. Rao A. The contemporary construction of nurse psychological empowerment. J Nurs Scholarsh. 2012;44(4):396-402. 17. Folger JP, Polle MS, Stutman RK. Working Through Conflict: Strategies for Relationships, Groups, and Organizations. 7th ed. Upper Saddle River, NJ: Pearson Education; 2013. 18. Fikelman A. Leadership and Management: Core Competencies for Quality Care. 2nd ed. Upper Saddle River, NJ: Pearson Education; 2012. 19. Thomas KW, Kilmann RH. Thomas-Kilmann Conflict Mode Instrument. Mountain View, CA: CPP, Inc; 2007. 20. Mrayyan MT, Modallal R, Awamreh K, et al. Readiness of organizations for change, motivation and conflict-handling intentions: senior nursing students’ perceptions. Nurse Educ Pract. 2008;8:120-128. 21. Kantek F, Gezer N. Conflict in schools: student nurses’ conflict management styles. Nurse Educ Today. 2009;29:100-107. Volume 39 & Number 2 & March/April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
89
22. Neuman B, Fawcett J. The Neuman System Model. 5th ed. Upper Saddle River, NJ: Pearson Education; 2011. 23. Thomas KW, Tymon WG. Stress Resiliency Profile. Tuxedo, NY: Xicom; 1992. 24. Spreitzer G. Psychological empowerment in the workplace: dimensions, measurement, and validation. Acad Manage J. 1995;38:1442-1465. 25. Agency for Healthcare Research and Quality. TeamSTEPPS Instructor Guide, Team Strategies & Tools to Enhance Performance & Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; 2006. 26. Winder C. Reaching In and Reaching Out: Resiliency College Curriculum. Toronto, Ontario, Canada: George Brown College; 2006.
27. Kilmann RH, Thomas KW. Developing a force-choice measure of conflict management behavior: the MODE instrument. Educ Psychol Meas. 1977;37:309-323. 28. Agency for Healthcare Research and Quality. TeamSTEPPS Fundamental Course Module 5. Mutual Support Classroom Slides, 2006. Available at http://ahrq.gov./professionals/education/ curriculum-tools/teamstepps/instructor/fundamental;2001ls/ module5/slmutualsupp.html. Accessed October 10, 2011. 29. Johnson BH. Psychological empowerment of nurse educators through organizational culture. Nurs Educ Perspect. 2009; 30:8-13. 30. Benner P. From Novice to Expert Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice Hall Health; 2001.
Free Curriculum Downloads Most scholars are familiar with the published works of the National Academies Press (NAP). The mission behind the scholarly publications has been in existence since 1863 as a private, nonprofit society of scholars and was created under the leadership of President Abraham Lincoln. In 2013, NAP publications continue to provide a wealth of FREE information for both academicians and students. NAP has published several new references to improve understanding of local to global health issues. These downloads are available at http://www.nap.edu/. Three publications have provided additional curriculum for community/public health, health policy, and global health courses. 1. Evaluating Obesity Prevention Efforts: A Plan for Measuring Progress addresses obesity as the largest current public health challenge. Content includes information on consequences for health, economic, and social concerns. This book outlines detailed plans that have demonstrated positive outcomes in reducing this healthcare crisis (http://www.nap.edu/catalog.php?record_id=18334). 2. US Health in International Perspective: Shorter Lives, Poorer Health reports a data-driven picture of the United States in relation to other comparable countries. The US health disadvantage is nondiscriminatory for rich and poor, majority and minority. Strategies for cause and intervention range from personal behaviors to government and organizational influences to improve the health of the nation (http://www.nap.edu/catalog.php?record_id=13497). 3. Best Care and Lower Cost: The Path to Continuously Learning Health Care in America discusses the complexity and costs of healthcare including quality and economic barriers as well as healthcare spending waste. It is a call to action for everyone from consumers of care to providers and payer sources (http://www.nap.edu/catalog.php?record_id=13444). Submitted by: Alma Jackson, PhD, RN, COHN-S, News Editor at [email protected]. DOI: 10.1097/NNE.0000000000000026
90
Volume 39 & Number 2 & March/April 2014
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
