571600
research-article2015
NSQXXX10.1177/0894318415571600Nursing Science QuarterlyAshton
Article
The Orientation Period: Essential for New Registered Nurses’ Adaptation
Nursing Science Quarterly 2015, Vol. 28(2) 142–150 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415571600 nsq.sagepub.com
Kathleen S. Ashton, RN; PhD1
Abstract The purpose of this research study was to explore adaptation in new registered nurses using the Roy adaptation model as the guiding conceptual framework. This quantitative study employed a random sampling of new nurses in the state of North Carolina. Personal attributes of the new registered nurses and characteristics of their work setting were modeled with four measures considered suitable proxies for adaptation. Being in a formal orientation period significantly supported the new nurses’ overall adaptation. This may represent the benefit of social support, including education, which seems to facilitate adaptation. Keywords adaptation, new registered nurses, orientation, Roy adaptation model The nursing profession’s interest in the transition experiences of new registered nurses (RNs) came about very slowly until the 1990s and past decade when activity to support new RNs surged. Despite this increased attention from within the nursing profession, new RNs continue to report work-related stress, multiple challenges, and negative emotional responses through and beyond their first year in practice (Fink, Krugman, Casey, & Goode, 2008; Kramer, Brewer, & Maguire, 2011; Schoessler & Waldo, 2006). Most of the prior research has focused on strategies to improve new RNs’ critical thinking or clinical performance. Other topics of consideration in the nursing literature focus on the financial cost and benefits of providing support to new nurses during their transition from nursing student to that of a self-reliant registered nurse. These are important topics but up to this point, this transition has not been viewed from the perspective of adaptation.
Related Literature The topic of new nurses’ challenges and needs is an international concern. New RNs do not feel prepared to meet the expectations for their performance in the clinical area (Fink, et al., 2008). Despite successfully completing a nursing education program and a licensing exam, new nurses feel tested in the work environment (Craig, Moscato, & Moyce, 2012; Schoessler & Waldo, 2006). They struggle for months to organize their workload (Schoessler & Waldo, 2006). Once off orientation, new RNs’ assignments are similar to those of more experienced nurses (Kovner et al., 2007). Caring for patients with complex medical problems, deteriorating clinical status, and end of life needs tax new RNs’
skill level (Fink, et al., 2008; Olson, 2009). New RNs fear that they may cause harm to a patient (Duchscher, 2009). Duchscher (2009) commented that new nurses fear “being ‘exposed’ as clinically incompetent” (p. 5). In addition to clinical challenges, they also experience workplace incivility (Pellico, Brewer, & Kovner, 2009). Beyond the workplace, new RNs have personal stressors. They manage debt, relationships, and other life events at the same time they are developing in their professional role (Fink, et al., 2008). New RNs’ experience a grief reaction as friends disburse and routines are disrupted (Schoessler & Waldo, 2006). While these personal sources of stress are not unique to new nurses, the potential cumulative effect of personal and professional stress may interfere with new nurses’adaptation. Several authors have documented new RNs negative emotional responses to the work-related challenges they experience. These negative emotions include anxiety (Fink et al., 2008), frustration, and anger (Schoessler & Waldo, 2006), and they are not confined to time spent at work. New RNs report work-related thoughts intrude and disrupt sleep (Duchscher, 2009; Schoessler and Waldo, 2006) or prevent them from falling asleep (Pellico et al., 2009). Thoughts about work infiltrate their waking hours as well (Duchscher, 2009). New RNs are preoccupied with thoughts of work. Nothing in the nursing literature points to this phenomenon as a positive or satisfying experience. This level of negative emotional response is concerning because it represents ineffective response adaptation. 1
Assistant Professor, Duke University School of Nursing, Durham, NC
143
Ashton
Occupational Fatigue Acute occupational fatigue occurs when work drains an individual’s “available energy” and limits their capacity to participate in other, non – work related activities (Winwood, Winefield, Dawson, & Lushington, 2005, pp. Materials, para. 1) Unless resolved with adequate rest, acute occupational fatigue may result in chronic occupational fatigue, leading to a withdrawal of interest, engagement, and commitment (Winwood, Lushington, & Winefield, 2006). It seems reasonable that occupational fatigue may represent an ineffective response.
Significance Little is known about new RNs’ adaptation to the role of the registered nurse. Adaptation, specifically as it is described in the Roy adaptation model (RAM), is a relevant conceptual framework with which to study new nurses’ experiences. Roy (2009) viewed adaptation both as a process and an outcome of human and environmental integration. This is congruent with the idea that new nurses need time and experience to grow into the role of registered nurse and it allows for inquiry into the process of adaptation. Roy maintained that human beings are in constant interaction with their environment and in turn, both people and their environment influence each other. In this constant interface with the environment that optimally leads to adaptation, human beings are capable of a range of responses that are complex and diverse, including those that facilitate or interfere with adaptation (Roy, 2009). Effective responses support the human and environmental integration that is adaptation while ineffective responses “threaten” adaptation (Roy, 2009, p. 40). These responses are behaviors that represent the individual’s capacity to maintain wholeness in four different domains (Roy, 2009). At the individual level, the four adaptive modes are: physiological, self-concept, role function, and interdependence (Roy, 2009). Stimuli in one adaptive mode have the potential to elicit a response in another adaptive mode (Roy, 2009). As individuals respond to environmental stimuli, their behaviors provide insight about overall adaptation (Roy, 2009). Viewed from the perspective of the RAM, adaptation is essential if human beings are togrow, survive, “master” and “transform” their environment (Roy, 2009, p. 39). For the new RN, successful role acquisition depends on successful adaptation. At the professional level, the current call for nurses to ensure safety and quality in healthcare delivery, to shape healthcare policy, and to generate and translate new knowledge depends on an engaged, well-adapted nurse workforce.
Purpose The purpose of this research study was to explore the adaptation of new RNs using the RAM as the guiding conceptual
framework. Personal attributes of new RNs and characteristics of their work setting were modeled with four measures considered suitable proxies for adaptation: acute and chronic occupational fatigue, job-related affective well-being, and turnover intent.
Research Questions The research questions were: What are the levels of acute and chronic occupational fatigue in new registered nurses; what variables predict acute and chronic occupational fatigue in new registered nurses; and what is the relationship between new RNs’ personal attributes and characteristics of their workplace on: acute and chronic occupational fatigue, negative affect, and intent to stay in the current position for two years?
Method This non-experimental, correlational study was implemented using a cross-sectional design and received approval from a university affiliated Institutional Review Board.
Sample Participants were new RNs who were working in the role of the registered nurse in North Carolina (NC) for 52 weeks or less. They were randomly selected from a list of all new RNs provided by the NC Board of Nursing (BON). Inclusion criteria were an initial nursing license issued by the NCBON and a professional tenure of 52 weeks or less. A total of 250 new RNs was surveyed. A power analysis demonstrated that a sample size of 85 participants would yield 80% power to detect what corresponded to a medium effect size, given a two sided alpha = 0.05.
Measures Independent variables. The independent variables in this study were chosen to represent the focal, contextual, or residual stimuli in the RAM. In keeping with Roy’s (2009) conceptualization, stimuli are dynamic and shift between being the most obvious in the situation (focal) to those with unclear effects on the individual’s behaviors (residual). Demographic data were collected, including age, gender, level of nursing education, professional tenure, and a self-report of perceived adjustment to the role of the registered nurse. These demographic data were described as the personal characteristics of the new RNs and represented the, focal, contextual, and residual stimuli, or the environment of the new RN. Adaptation level. The concept of adaptation level in the RAM has been somewhat neglected by researchers (DeSanto Madeya & Fawcett, 2009). Adaptation levels may be
144 described as integrated, compensatory, or compromised, and “affect the individual’s ability to respond positively in a situation” (Roy, 2009, p. 33). While it may be tempting to consider adaptation level as a measure of overall adaptation, Roy (2009) insisted that it is an internal stimulus. Consequently, it was employed an independent variable in this study and was operationalized as perceived adjustment. A single-item, visual analog scale was used to measure perceived adjustment in this study where 0 indicated “not adjusting well” and 10 represented “adjusting very well”. This variable was developed based on the Adjustment Scale, described by DeSanto-Madeya and Fawcett (2009). Researchers used a single- item measure to inquire about people adjusting to life after a spinal cord injury and women adjusting to motherhood (DeSanto Madeya & Fawcett, 2009). The correlation scores from the single-item measure of adjustment and an adaptation tool ranged from .19 - .48, and included a test – re-test measure in one of the studies (DeSanto Madeya & Fawcett, 2009). The lower correlation scores indicated that conceptually, adjustment and adaptation are not interchangeable (DeSanto Madeya & Fawcett, 2009). However adaptation and adjustment are related concepts (DeSanto Madeya & Fawcett, 2009). The use of a single-item measure to inquire about adjustment is congruent with the RAM and an appropriate tool for nurse researchers’ to use (DeSanto Madeya & Fawcett, 2009). Single–item measures have been used to gather demographic data and to inquire about concepts such as job satisfaction (Patrician, 2004). They allow participants to report their perceptions of a phenomenon and may be easier to use than multiple-response items, which may enhance validity (Patrician, 2004). Visual analog scales or Likert – scale responses are two frequently used methods of formatting single – item measures (Patrician, 2004). Barrone, Roy, and Frederickson (2008) support the use of visual analog scales in conjunction with the RAM. Characteristics of the workplace. Participants were also asked to describe the characteristics of their work setting. These included: usual shift length, whether shift rotation was required or not, whether the new RN was currently in their formal orientation period, the employer’s Magnet status, attendance at any form of a transition support program, and patient acuity. These characteristics of the new RNs’ work environment were included to assess for any relationship on the new RNs’ adaptation. For the purposes of this study, patient acuity was a created variable that represented the complexity of nursing care required by patients. It was felt that patient acuity was more descriptive of the complex work environment that new RNs may find themselves in than just naming their patient population (pediatrics or medical-surgical). Patients requiring critical care or a step-down level of care or even remote telemetry may need more nursing care and thus, may be more
Nursing Science Quarterly 28(2) challenging for new RNs. These patients are not always located in a single nursing unit and are found in acute care and outpatient settings, and even in home care. New RNs were asked if they worked in critical care units, cared for patients requiring a step-down or intermediate level care, or care with remote telemetry. If they answered yes to any of these questions, the variable, patient acuity was coded to reflect this level of care. Dependent variables. In this study, four dependent variables where chosen to represent adaptation: acute occupational fatigue, chronic occupational fatigue, negative affect, and intent to stay in the current position for two years. A discussion of the specific measures for each of these variables follows. Acute and chronic occupational fatigue. The Occupational Fatigue Exhaustion Recovery (OFER) Scale was developed by researchers in Australia to measure: acute fatigue, chronic fatigue, and intershift recovery (Winwood, et al., 2005). The original 30 item instrument was revised to a 15 item scale containing both positively and negatively worded items using Likert scale response choices ranging from 0 (strongly disagree) to 6 (strongly agree) (Winwood & Lushington, 2006). In publications, with nurses as participants, the Cronbach’s alpha for the OFER ranged from 0 .83 (Winwood & Lushington, 2006) to 0.91 (Barker & Nussbaum, 2011). In the current study, the Cronbach alpha was .841 and .867 for the acute and the chronic occupational fatigue subscales of the OFER respectively. The trait version of the OFER is the most commonly used version (P. Winwood, personal communication, October 31, 2011) and was used in this study. For the purposes of this study, the terms acute occupational fatigue and chronic occupational fatigue were used consistently to reiterate that the source of fatigue was work-related. Negative affect. In this study, negative affect was measured with the negative emotion subscale of the Job-related Affective Well-being Scale (JAWS) (Van Katwyk, Fox, Spector, & Kelloway, 2000). The JAWS measures both positive and negative emotional responses to work and corresponding arousal states (Van Katwyk, et al., 2000). The 20-item short version of the JAWS subscale was used in this study and scores were calculated only for the negative emotion subscale. Participants chose from a 5- point, Likert scale format, ranging from 1 (never) to 5 (extremely often). The coefficient alpha for internal consistency of the negative emotion subscale of the 20-item version of the JAWS is .88 (Spector, 2006). In this study, the Cronbach alpha for the negative emotions subscale was .868. Intent to stay in the current position for two years. New RNs were asked about their intent to stay in their current nursing position using a single item, Likert scale response with “1”
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Ashton
Independent Variables New RNs’ personal attributes: Professional tenure Age Gender Nursing education Perceived adjustment Characteristics of new RNs’ workplace: Usual shift Shift rotation Patient acuity Orientation status Employer’s Magnet status Attendance at transition support program
Intent to stay in the current position for two years Negative emotion scale of the JobRelated Affective Well being Scale
Acute occupational fatigue/Chronic occupational fatigue
Dependent variables Behavioral responses in adaptive modes:
Figure 1. Diagram of independent and dependent variables.
representing “very unlikely” to “5” for “very likely”. Intent to stay or leave the current employer or position has been measured similarly by other nurse researchers, including Kovner,and colleagues (2007) and Brewer, Kovner, Greene, Tukov-Shuser, and Djukic (2011). The independent and dependent variables are described in Figure 1.
Procedures The paper survey was mailed to the new RNs in late May 2012. A waiver of written consent was approved by the IRB and participants were advised that returning the paper survey to the researcher conveyed informed consent. Ninety-six surveys were returned to the researcher. Of these, 8 surveys were excluded for failure to meet inclusion criteria. Ten surveys were returned to the researcher as undeliverable. Data from 88 new RNs were included in the final data analysis for a response rate of 37%.
Data Analysis Data were analyzed using SPSS for Windows version 19.0 (SPSS Inc., Chicago, Illinois). Descriptive statistics were calculated on all the variables. The independent variables were entered into the multiple regression model simultaneously. Polit (1996) recommended this standard approach “when all the independent variables are of equal importance to the research problem” (p. 270).
Results Demographics The mean age of new nurses in this study was 30.90 years. These new RNs had a mean length of time working in the professional nursing role of 7.63 months and 70 (80%) participants were no longer on orientation. The mean orientation length for this group of new RNs was 12.12 weeks. The RNs rated their adjustment to the professional role as 7.35 on a
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Nursing Science Quarterly 28(2)
Table 1. Demographic statistics of sample (N = 88). Variable Age Gender Male Female Nursing education Diploma/Associate’s Degree Baccalaureate or Master’s Degree Length of time working as an RN (months) Orientation length (weeks) Perceived adjustment
Minimum
Maximum
N (%) or Mean ± SD*
21 –
57 –
–
–
.25 0 3
12 26 10
30.90 ± 8.37 11 (12.5) 77 (87.5) 48 ( 55) 40 (45) 7.63 ± 3.68 12.12 ± 6.17 7.35 ± 1.58
Table 2. Descriptive statistics for subscales and intent to stay in current position for two years. Variable OFER – A* OFER – C** Negative affect (JAWS)*** Intent to stay in current position for two years****
Number of items 5 5 10 1
Possible score range 0-100 0-100 10-50 1-5
Minimum-Maximum 20-100 0-90 14-43 1-5
Mean ± SD 64.88 ± 19.69 41.86 ± 23.13 24.42 ± 6.25 3.38 ± 1.39
Note. *N = 85 OFER – Acute Occupational Fatigue. **N = 86 OFER –Chronic Occupational Fatigue. ***N = 78 Negative Affect JAWS. **** N = 78
scale of 0-10. Table 1 provides more details of the new RNs personal attributes. The majority of RNs in this study worked with patients requiring either a critical care or “step-down” level of care (n = 64, 73%) and worked 12 hour shifts (n= 74, 84%). They worked with diverse patient populations in acute care, long term care, and outpatient settings. More than half the participants (n = 52, 58%) had some form of transition support program available to them and of that group, all attended at least one or two sessions, while 39 (44 %) of these new RNs reported attending all the sessions. Few RN participants worked in facilities recognized as Magnet hospitals (n = 39, 44%). In this study, 70 (80%) of the new RNs were employed in their first nursing position. However, 18 (20%) of the new RNs in this study had already left either their original unit of hire or the institution where they began their nursing career.
Acute and Chronic Occupational Fatigue The first research question sought to describe new RNs’ levels of acute and chronic occupational fatigue. New RNs reported an acute occupational fatigue score of 64.88 and a chronic occupational fatigue score of 41.86. Descriptive statistics for the levels of acute and chronic occupational fatigue, negative affect, and intent to stay in the current position for two years are provided in Table 2. With regard to the second research question, neither the personal attributes of the new RNs, the characteristics of their workplace, nor the combination of these two sets of
variables predicted new RNs’ acute occupational fatigue. For the third research question, chronic occupational fatigue was modeled with the personal attributes of the new RNs, then with the characteristics of their work-setting, and finally with these groups of variables combined. In all three models, the grouped variables were statistically significant predictors of chronic occupational fatigue; however, the relationships were weak (see Table 3). The last four research questions explored the relationship between the personal attributes of the new RNs and the characteristics of their workplace on each of the four outcome measures: acute and chronic occupational fatigue, negative affect, and intent to stay in the current nursing position for two years. Data analysis in the last four research questions focused on the regression coefficient. With regard to acute occupational fatigue, none of the independent variables demonstrated a statistically significant association to acute occupational fatigue. Of the 11 independent variables in this multiple regression, only two were statistically significant in their association with chronic occupational fatigue. The predicted mean chronic occupational fatigue score was 30.42 points less for new RNs who are currently on orientation compared to new RNs who are no longer on orientation, adjusting for the other predictors in the model (p ≤ .001). In addition, for every one point increase in perceived adjustment, new RNs’ predicted mean chronic occupational fatigue scores decreased by 5.178 points accounting for the other predictor variables in the model (p = 0.005).
147
Ashton Table 3. Adjusted R² and overall regression tests for any significant predictors of chronic occupational fatigue. Model Attributes of the new RN Age Gender Nursing education Professional tenure Perceived adjustment Workplace Variables Usual shift length Shift rotation Orientation status Employer’s Magnet status Patient acuity Attendance at transition support programs Combined attributes of new RNs and workplace variables
Negative Affect The results of this statistical analysis for negative affect were similar to the findings for chronic occupational fatigue. For every one point increase in perceived adjustment, the predicted mean negative emotional score decreased by 1.81, adjusting for other variables in the model (p < .001). Similarly, the predicted mean score on the negative affect subscale of the JAWS decreased by 5.74 for new RNs during their formal orientation period compared to new RNs no longer on orientation, after accounting for other model predictors (p = .010).
Intent to Stay in the Current Position for Two Years With regard to new RNs’ intent to stay in the current position for two years, two variables were statistically significant. The predicted mean score on the intent to stay in their current nursing position decreased by 0.81 for new RNs with baccalaureate level or higher educational level educations, compared to new RNs with a diploma or associate’s degree, adjusting for other predictor variables in the model (p = .024). The predicted mean score on intent to stay in the current nursing position increased by 1.55 for new RNs who were on orientation, compared to new RNs no longer on orientation, adjusting for the other model covariates (p = .002). The descriptive statistics for the statistically significant relationships of the independent variables on the four dependent variables are summarized in Table 4.
Discussion Acute and Chronic Occupational Fatigue The level of acute occupational fatigue reported by the participants in this study is similar to other researchers’ findings.
Adjusted R²
df
p-value
0.080
5
0.104
6
0.207
11
0.041 0.032 0.006
The youngest nurses in Australia ages 18-24 years had a mean acute occupational fatigue score on the OFER of 61.9 (SD = 19.2) (Winwood, Winefield, & Lushington, 2006). Barker and Nussbaum (2011) reported a mean acute occupational fatigue score of 65.55 (SD = 22.06) for the nurse participants in their study but those findings were not correlated with professional tenure. The mean score for chronic occupational fatigue in this study was lower at 41.86. Australian nurses aged 18-24 years had a mean chronic occupational fatigue score of 57.3 (Winwood, Winefield, et al., 2006). Participants in Barker and Nussbaum’s (2011) study had a mean chronic occupational fatigue score of 50.07, which the authors described as “moderate” (p. 1378) In the current study, participants had higher acute occupational fatigue scores than chronic occupational fatigue, a finding that was similar to studies by Winwood, Winefield and Lushington (2006) and Barker and Nussbaum (2011). While the participants’ scores for chronic occupational fatigue in this study are lower than the scores for acute occupational fatigue, they are not low. As such, they may serve as an “early warning system” (P. Winwood, personal communication, October 31, 2011). The levels of acute and chronic occupational fatigue in this study are concerning in that they may represent an ineffective response to the professional nursing role
Significant Variables: Perceived Adjustment, Education Level, and Orientation Status Perceived adjustment Perceived adjustment was a statistically significant variable in three research questions that explored the relationships of the independent variables on the dependent variables of
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Nursing Science Quarterly 28(2)
Table 4. Summary of multiple regression analyses: statistically significant variables and outcome measures of adaptation. Outcome measure Chronic occupational fatigue Negative affect Intent to stay in the current position for two years
Variable Orientation status Currently on orientation vs. completed orientation (RC) Perceived adjustment Orientation status Currently on orientation vs. completed orientation (RC) Perceived adjustment Orientation status Currently on orientation vs. completed orientation (RC) Nursing education Baccalaureate or higher vs. Associate’s Degree/Diploma (RC)
b
95% CI for b
β
p-value
–30.42
(–46.156, –4.686)
–.514
research-article2015
NSQXXX10.1177/0894318415571600Nursing Science QuarterlyAshton
Article
The Orientation Period: Essential for New Registered Nurses’ Adaptation
Nursing Science Quarterly 2015, Vol. 28(2) 142–150 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415571600 nsq.sagepub.com
Kathleen S. Ashton, RN; PhD1
Abstract The purpose of this research study was to explore adaptation in new registered nurses using the Roy adaptation model as the guiding conceptual framework. This quantitative study employed a random sampling of new nurses in the state of North Carolina. Personal attributes of the new registered nurses and characteristics of their work setting were modeled with four measures considered suitable proxies for adaptation. Being in a formal orientation period significantly supported the new nurses’ overall adaptation. This may represent the benefit of social support, including education, which seems to facilitate adaptation. Keywords adaptation, new registered nurses, orientation, Roy adaptation model The nursing profession’s interest in the transition experiences of new registered nurses (RNs) came about very slowly until the 1990s and past decade when activity to support new RNs surged. Despite this increased attention from within the nursing profession, new RNs continue to report work-related stress, multiple challenges, and negative emotional responses through and beyond their first year in practice (Fink, Krugman, Casey, & Goode, 2008; Kramer, Brewer, & Maguire, 2011; Schoessler & Waldo, 2006). Most of the prior research has focused on strategies to improve new RNs’ critical thinking or clinical performance. Other topics of consideration in the nursing literature focus on the financial cost and benefits of providing support to new nurses during their transition from nursing student to that of a self-reliant registered nurse. These are important topics but up to this point, this transition has not been viewed from the perspective of adaptation.
Related Literature The topic of new nurses’ challenges and needs is an international concern. New RNs do not feel prepared to meet the expectations for their performance in the clinical area (Fink, et al., 2008). Despite successfully completing a nursing education program and a licensing exam, new nurses feel tested in the work environment (Craig, Moscato, & Moyce, 2012; Schoessler & Waldo, 2006). They struggle for months to organize their workload (Schoessler & Waldo, 2006). Once off orientation, new RNs’ assignments are similar to those of more experienced nurses (Kovner et al., 2007). Caring for patients with complex medical problems, deteriorating clinical status, and end of life needs tax new RNs’
skill level (Fink, et al., 2008; Olson, 2009). New RNs fear that they may cause harm to a patient (Duchscher, 2009). Duchscher (2009) commented that new nurses fear “being ‘exposed’ as clinically incompetent” (p. 5). In addition to clinical challenges, they also experience workplace incivility (Pellico, Brewer, & Kovner, 2009). Beyond the workplace, new RNs have personal stressors. They manage debt, relationships, and other life events at the same time they are developing in their professional role (Fink, et al., 2008). New RNs’ experience a grief reaction as friends disburse and routines are disrupted (Schoessler & Waldo, 2006). While these personal sources of stress are not unique to new nurses, the potential cumulative effect of personal and professional stress may interfere with new nurses’adaptation. Several authors have documented new RNs negative emotional responses to the work-related challenges they experience. These negative emotions include anxiety (Fink et al., 2008), frustration, and anger (Schoessler & Waldo, 2006), and they are not confined to time spent at work. New RNs report work-related thoughts intrude and disrupt sleep (Duchscher, 2009; Schoessler and Waldo, 2006) or prevent them from falling asleep (Pellico et al., 2009). Thoughts about work infiltrate their waking hours as well (Duchscher, 2009). New RNs are preoccupied with thoughts of work. Nothing in the nursing literature points to this phenomenon as a positive or satisfying experience. This level of negative emotional response is concerning because it represents ineffective response adaptation. 1
Assistant Professor, Duke University School of Nursing, Durham, NC
143
Ashton
Occupational Fatigue Acute occupational fatigue occurs when work drains an individual’s “available energy” and limits their capacity to participate in other, non – work related activities (Winwood, Winefield, Dawson, & Lushington, 2005, pp. Materials, para. 1) Unless resolved with adequate rest, acute occupational fatigue may result in chronic occupational fatigue, leading to a withdrawal of interest, engagement, and commitment (Winwood, Lushington, & Winefield, 2006). It seems reasonable that occupational fatigue may represent an ineffective response.
Significance Little is known about new RNs’ adaptation to the role of the registered nurse. Adaptation, specifically as it is described in the Roy adaptation model (RAM), is a relevant conceptual framework with which to study new nurses’ experiences. Roy (2009) viewed adaptation both as a process and an outcome of human and environmental integration. This is congruent with the idea that new nurses need time and experience to grow into the role of registered nurse and it allows for inquiry into the process of adaptation. Roy maintained that human beings are in constant interaction with their environment and in turn, both people and their environment influence each other. In this constant interface with the environment that optimally leads to adaptation, human beings are capable of a range of responses that are complex and diverse, including those that facilitate or interfere with adaptation (Roy, 2009). Effective responses support the human and environmental integration that is adaptation while ineffective responses “threaten” adaptation (Roy, 2009, p. 40). These responses are behaviors that represent the individual’s capacity to maintain wholeness in four different domains (Roy, 2009). At the individual level, the four adaptive modes are: physiological, self-concept, role function, and interdependence (Roy, 2009). Stimuli in one adaptive mode have the potential to elicit a response in another adaptive mode (Roy, 2009). As individuals respond to environmental stimuli, their behaviors provide insight about overall adaptation (Roy, 2009). Viewed from the perspective of the RAM, adaptation is essential if human beings are togrow, survive, “master” and “transform” their environment (Roy, 2009, p. 39). For the new RN, successful role acquisition depends on successful adaptation. At the professional level, the current call for nurses to ensure safety and quality in healthcare delivery, to shape healthcare policy, and to generate and translate new knowledge depends on an engaged, well-adapted nurse workforce.
Purpose The purpose of this research study was to explore the adaptation of new RNs using the RAM as the guiding conceptual
framework. Personal attributes of new RNs and characteristics of their work setting were modeled with four measures considered suitable proxies for adaptation: acute and chronic occupational fatigue, job-related affective well-being, and turnover intent.
Research Questions The research questions were: What are the levels of acute and chronic occupational fatigue in new registered nurses; what variables predict acute and chronic occupational fatigue in new registered nurses; and what is the relationship between new RNs’ personal attributes and characteristics of their workplace on: acute and chronic occupational fatigue, negative affect, and intent to stay in the current position for two years?
Method This non-experimental, correlational study was implemented using a cross-sectional design and received approval from a university affiliated Institutional Review Board.
Sample Participants were new RNs who were working in the role of the registered nurse in North Carolina (NC) for 52 weeks or less. They were randomly selected from a list of all new RNs provided by the NC Board of Nursing (BON). Inclusion criteria were an initial nursing license issued by the NCBON and a professional tenure of 52 weeks or less. A total of 250 new RNs was surveyed. A power analysis demonstrated that a sample size of 85 participants would yield 80% power to detect what corresponded to a medium effect size, given a two sided alpha = 0.05.
Measures Independent variables. The independent variables in this study were chosen to represent the focal, contextual, or residual stimuli in the RAM. In keeping with Roy’s (2009) conceptualization, stimuli are dynamic and shift between being the most obvious in the situation (focal) to those with unclear effects on the individual’s behaviors (residual). Demographic data were collected, including age, gender, level of nursing education, professional tenure, and a self-report of perceived adjustment to the role of the registered nurse. These demographic data were described as the personal characteristics of the new RNs and represented the, focal, contextual, and residual stimuli, or the environment of the new RN. Adaptation level. The concept of adaptation level in the RAM has been somewhat neglected by researchers (DeSanto Madeya & Fawcett, 2009). Adaptation levels may be
144 described as integrated, compensatory, or compromised, and “affect the individual’s ability to respond positively in a situation” (Roy, 2009, p. 33). While it may be tempting to consider adaptation level as a measure of overall adaptation, Roy (2009) insisted that it is an internal stimulus. Consequently, it was employed an independent variable in this study and was operationalized as perceived adjustment. A single-item, visual analog scale was used to measure perceived adjustment in this study where 0 indicated “not adjusting well” and 10 represented “adjusting very well”. This variable was developed based on the Adjustment Scale, described by DeSanto-Madeya and Fawcett (2009). Researchers used a single- item measure to inquire about people adjusting to life after a spinal cord injury and women adjusting to motherhood (DeSanto Madeya & Fawcett, 2009). The correlation scores from the single-item measure of adjustment and an adaptation tool ranged from .19 - .48, and included a test – re-test measure in one of the studies (DeSanto Madeya & Fawcett, 2009). The lower correlation scores indicated that conceptually, adjustment and adaptation are not interchangeable (DeSanto Madeya & Fawcett, 2009). However adaptation and adjustment are related concepts (DeSanto Madeya & Fawcett, 2009). The use of a single-item measure to inquire about adjustment is congruent with the RAM and an appropriate tool for nurse researchers’ to use (DeSanto Madeya & Fawcett, 2009). Single–item measures have been used to gather demographic data and to inquire about concepts such as job satisfaction (Patrician, 2004). They allow participants to report their perceptions of a phenomenon and may be easier to use than multiple-response items, which may enhance validity (Patrician, 2004). Visual analog scales or Likert – scale responses are two frequently used methods of formatting single – item measures (Patrician, 2004). Barrone, Roy, and Frederickson (2008) support the use of visual analog scales in conjunction with the RAM. Characteristics of the workplace. Participants were also asked to describe the characteristics of their work setting. These included: usual shift length, whether shift rotation was required or not, whether the new RN was currently in their formal orientation period, the employer’s Magnet status, attendance at any form of a transition support program, and patient acuity. These characteristics of the new RNs’ work environment were included to assess for any relationship on the new RNs’ adaptation. For the purposes of this study, patient acuity was a created variable that represented the complexity of nursing care required by patients. It was felt that patient acuity was more descriptive of the complex work environment that new RNs may find themselves in than just naming their patient population (pediatrics or medical-surgical). Patients requiring critical care or a step-down level of care or even remote telemetry may need more nursing care and thus, may be more
Nursing Science Quarterly 28(2) challenging for new RNs. These patients are not always located in a single nursing unit and are found in acute care and outpatient settings, and even in home care. New RNs were asked if they worked in critical care units, cared for patients requiring a step-down or intermediate level care, or care with remote telemetry. If they answered yes to any of these questions, the variable, patient acuity was coded to reflect this level of care. Dependent variables. In this study, four dependent variables where chosen to represent adaptation: acute occupational fatigue, chronic occupational fatigue, negative affect, and intent to stay in the current position for two years. A discussion of the specific measures for each of these variables follows. Acute and chronic occupational fatigue. The Occupational Fatigue Exhaustion Recovery (OFER) Scale was developed by researchers in Australia to measure: acute fatigue, chronic fatigue, and intershift recovery (Winwood, et al., 2005). The original 30 item instrument was revised to a 15 item scale containing both positively and negatively worded items using Likert scale response choices ranging from 0 (strongly disagree) to 6 (strongly agree) (Winwood & Lushington, 2006). In publications, with nurses as participants, the Cronbach’s alpha for the OFER ranged from 0 .83 (Winwood & Lushington, 2006) to 0.91 (Barker & Nussbaum, 2011). In the current study, the Cronbach alpha was .841 and .867 for the acute and the chronic occupational fatigue subscales of the OFER respectively. The trait version of the OFER is the most commonly used version (P. Winwood, personal communication, October 31, 2011) and was used in this study. For the purposes of this study, the terms acute occupational fatigue and chronic occupational fatigue were used consistently to reiterate that the source of fatigue was work-related. Negative affect. In this study, negative affect was measured with the negative emotion subscale of the Job-related Affective Well-being Scale (JAWS) (Van Katwyk, Fox, Spector, & Kelloway, 2000). The JAWS measures both positive and negative emotional responses to work and corresponding arousal states (Van Katwyk, et al., 2000). The 20-item short version of the JAWS subscale was used in this study and scores were calculated only for the negative emotion subscale. Participants chose from a 5- point, Likert scale format, ranging from 1 (never) to 5 (extremely often). The coefficient alpha for internal consistency of the negative emotion subscale of the 20-item version of the JAWS is .88 (Spector, 2006). In this study, the Cronbach alpha for the negative emotions subscale was .868. Intent to stay in the current position for two years. New RNs were asked about their intent to stay in their current nursing position using a single item, Likert scale response with “1”
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Independent Variables New RNs’ personal attributes: Professional tenure Age Gender Nursing education Perceived adjustment Characteristics of new RNs’ workplace: Usual shift Shift rotation Patient acuity Orientation status Employer’s Magnet status Attendance at transition support program
Intent to stay in the current position for two years Negative emotion scale of the JobRelated Affective Well being Scale
Acute occupational fatigue/Chronic occupational fatigue
Dependent variables Behavioral responses in adaptive modes:
Figure 1. Diagram of independent and dependent variables.
representing “very unlikely” to “5” for “very likely”. Intent to stay or leave the current employer or position has been measured similarly by other nurse researchers, including Kovner,and colleagues (2007) and Brewer, Kovner, Greene, Tukov-Shuser, and Djukic (2011). The independent and dependent variables are described in Figure 1.
Procedures The paper survey was mailed to the new RNs in late May 2012. A waiver of written consent was approved by the IRB and participants were advised that returning the paper survey to the researcher conveyed informed consent. Ninety-six surveys were returned to the researcher. Of these, 8 surveys were excluded for failure to meet inclusion criteria. Ten surveys were returned to the researcher as undeliverable. Data from 88 new RNs were included in the final data analysis for a response rate of 37%.
Data Analysis Data were analyzed using SPSS for Windows version 19.0 (SPSS Inc., Chicago, Illinois). Descriptive statistics were calculated on all the variables. The independent variables were entered into the multiple regression model simultaneously. Polit (1996) recommended this standard approach “when all the independent variables are of equal importance to the research problem” (p. 270).
Results Demographics The mean age of new nurses in this study was 30.90 years. These new RNs had a mean length of time working in the professional nursing role of 7.63 months and 70 (80%) participants were no longer on orientation. The mean orientation length for this group of new RNs was 12.12 weeks. The RNs rated their adjustment to the professional role as 7.35 on a
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Table 1. Demographic statistics of sample (N = 88). Variable Age Gender Male Female Nursing education Diploma/Associate’s Degree Baccalaureate or Master’s Degree Length of time working as an RN (months) Orientation length (weeks) Perceived adjustment
Minimum
Maximum
N (%) or Mean ± SD*
21 –
57 –
–
–
.25 0 3
12 26 10
30.90 ± 8.37 11 (12.5) 77 (87.5) 48 ( 55) 40 (45) 7.63 ± 3.68 12.12 ± 6.17 7.35 ± 1.58
Table 2. Descriptive statistics for subscales and intent to stay in current position for two years. Variable OFER – A* OFER – C** Negative affect (JAWS)*** Intent to stay in current position for two years****
Number of items 5 5 10 1
Possible score range 0-100 0-100 10-50 1-5
Minimum-Maximum 20-100 0-90 14-43 1-5
Mean ± SD 64.88 ± 19.69 41.86 ± 23.13 24.42 ± 6.25 3.38 ± 1.39
Note. *N = 85 OFER – Acute Occupational Fatigue. **N = 86 OFER –Chronic Occupational Fatigue. ***N = 78 Negative Affect JAWS. **** N = 78
scale of 0-10. Table 1 provides more details of the new RNs personal attributes. The majority of RNs in this study worked with patients requiring either a critical care or “step-down” level of care (n = 64, 73%) and worked 12 hour shifts (n= 74, 84%). They worked with diverse patient populations in acute care, long term care, and outpatient settings. More than half the participants (n = 52, 58%) had some form of transition support program available to them and of that group, all attended at least one or two sessions, while 39 (44 %) of these new RNs reported attending all the sessions. Few RN participants worked in facilities recognized as Magnet hospitals (n = 39, 44%). In this study, 70 (80%) of the new RNs were employed in their first nursing position. However, 18 (20%) of the new RNs in this study had already left either their original unit of hire or the institution where they began their nursing career.
Acute and Chronic Occupational Fatigue The first research question sought to describe new RNs’ levels of acute and chronic occupational fatigue. New RNs reported an acute occupational fatigue score of 64.88 and a chronic occupational fatigue score of 41.86. Descriptive statistics for the levels of acute and chronic occupational fatigue, negative affect, and intent to stay in the current position for two years are provided in Table 2. With regard to the second research question, neither the personal attributes of the new RNs, the characteristics of their workplace, nor the combination of these two sets of
variables predicted new RNs’ acute occupational fatigue. For the third research question, chronic occupational fatigue was modeled with the personal attributes of the new RNs, then with the characteristics of their work-setting, and finally with these groups of variables combined. In all three models, the grouped variables were statistically significant predictors of chronic occupational fatigue; however, the relationships were weak (see Table 3). The last four research questions explored the relationship between the personal attributes of the new RNs and the characteristics of their workplace on each of the four outcome measures: acute and chronic occupational fatigue, negative affect, and intent to stay in the current nursing position for two years. Data analysis in the last four research questions focused on the regression coefficient. With regard to acute occupational fatigue, none of the independent variables demonstrated a statistically significant association to acute occupational fatigue. Of the 11 independent variables in this multiple regression, only two were statistically significant in their association with chronic occupational fatigue. The predicted mean chronic occupational fatigue score was 30.42 points less for new RNs who are currently on orientation compared to new RNs who are no longer on orientation, adjusting for the other predictors in the model (p ≤ .001). In addition, for every one point increase in perceived adjustment, new RNs’ predicted mean chronic occupational fatigue scores decreased by 5.178 points accounting for the other predictor variables in the model (p = 0.005).
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Ashton Table 3. Adjusted R² and overall regression tests for any significant predictors of chronic occupational fatigue. Model Attributes of the new RN Age Gender Nursing education Professional tenure Perceived adjustment Workplace Variables Usual shift length Shift rotation Orientation status Employer’s Magnet status Patient acuity Attendance at transition support programs Combined attributes of new RNs and workplace variables
Negative Affect The results of this statistical analysis for negative affect were similar to the findings for chronic occupational fatigue. For every one point increase in perceived adjustment, the predicted mean negative emotional score decreased by 1.81, adjusting for other variables in the model (p < .001). Similarly, the predicted mean score on the negative affect subscale of the JAWS decreased by 5.74 for new RNs during their formal orientation period compared to new RNs no longer on orientation, after accounting for other model predictors (p = .010).
Intent to Stay in the Current Position for Two Years With regard to new RNs’ intent to stay in the current position for two years, two variables were statistically significant. The predicted mean score on the intent to stay in their current nursing position decreased by 0.81 for new RNs with baccalaureate level or higher educational level educations, compared to new RNs with a diploma or associate’s degree, adjusting for other predictor variables in the model (p = .024). The predicted mean score on intent to stay in the current nursing position increased by 1.55 for new RNs who were on orientation, compared to new RNs no longer on orientation, adjusting for the other model covariates (p = .002). The descriptive statistics for the statistically significant relationships of the independent variables on the four dependent variables are summarized in Table 4.
Discussion Acute and Chronic Occupational Fatigue The level of acute occupational fatigue reported by the participants in this study is similar to other researchers’ findings.
Adjusted R²
df
p-value
0.080
5
0.104
6
0.207
11
0.041 0.032 0.006
The youngest nurses in Australia ages 18-24 years had a mean acute occupational fatigue score on the OFER of 61.9 (SD = 19.2) (Winwood, Winefield, & Lushington, 2006). Barker and Nussbaum (2011) reported a mean acute occupational fatigue score of 65.55 (SD = 22.06) for the nurse participants in their study but those findings were not correlated with professional tenure. The mean score for chronic occupational fatigue in this study was lower at 41.86. Australian nurses aged 18-24 years had a mean chronic occupational fatigue score of 57.3 (Winwood, Winefield, et al., 2006). Participants in Barker and Nussbaum’s (2011) study had a mean chronic occupational fatigue score of 50.07, which the authors described as “moderate” (p. 1378) In the current study, participants had higher acute occupational fatigue scores than chronic occupational fatigue, a finding that was similar to studies by Winwood, Winefield and Lushington (2006) and Barker and Nussbaum (2011). While the participants’ scores for chronic occupational fatigue in this study are lower than the scores for acute occupational fatigue, they are not low. As such, they may serve as an “early warning system” (P. Winwood, personal communication, October 31, 2011). The levels of acute and chronic occupational fatigue in this study are concerning in that they may represent an ineffective response to the professional nursing role
Significant Variables: Perceived Adjustment, Education Level, and Orientation Status Perceived adjustment Perceived adjustment was a statistically significant variable in three research questions that explored the relationships of the independent variables on the dependent variables of
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Table 4. Summary of multiple regression analyses: statistically significant variables and outcome measures of adaptation. Outcome measure Chronic occupational fatigue Negative affect Intent to stay in the current position for two years
Variable Orientation status Currently on orientation vs. completed orientation (RC) Perceived adjustment Orientation status Currently on orientation vs. completed orientation (RC) Perceived adjustment Orientation status Currently on orientation vs. completed orientation (RC) Nursing education Baccalaureate or higher vs. Associate’s Degree/Diploma (RC)
b
95% CI for b
β
p-value
–30.42
(–46.156, –4.686)
–.514
