JOGN. Nursing. A Nursing Internship in. Gynecology and Obstetrics. Why? How? and How Good?

Transcription

1 Volume 7, Number I, January/February 1978 JOGN Nursing Journal of The Nurses Association of The American College of Obstetricians and Gynecologists A Nursing Internship in Gynecology and Obstetrics Why? How? and How Good? VIRGINIA H. ASPY, RN, EdD As a result of the many changes in nursing service and nursing education, young (neophyte) nurses are finding it extremely difficult to adjust to the real world of nursing. This situation creates a great deal of frustration and dissatisfaction on the part of employers, co-workers, and the new nurses themselves. To solve this problem, a nurse internship. of. six months duration is proposed for departments of gynecology and obstetrics. Historically, nurse internships have been based in schools of nursing. However, the more appropriate place for the nurse internship is within the service agency. If well planned, it could be both an introduction to the employee role and an extension of the educational experience. For nurses beginning employment in gynecology and obstetrics especially, such a program would have many benefits. Outcomes of a gynecology and obstetrics nurse internship could include: 1) an increase in the length of time that new nurses remain within the institution, 2) a decrease in the amount of money expended where turnover rates are extremely high, 3) help for the neophyte nurse in becoming socialized into the real world of the acute care agency, 4) an increase in the basic gynecologic and obstetric skills of neophyte and/or inexperienced nurses, and 5) as a result of the above, upgrading of the nursing care delivered to the patients in gynecology and obstetrics. January/February 1978 JOCN Nursing WHY? The idea that a nursing internship should be added to the basic education of nurses is certainly not new. According to Tobin, it has been quite a long time since new graduate nurses could function effectively on the job with only a brief orientation. Sporadically, for the past 10 years at least, schools of nursing, in conjunction with medical centers, have developed internship programs as an option for new graduates. In this way, the internship has come to be a frill open to only a small percentage of nursing graduates. This author would like to suggest a different approach to the nurse internship, based on an analysis of recent changes in nursing education and the nursing profession. In the late 1960s, nurse training gave way to nurse education. With the first position paper of the ANA,2 a number of hospital schools (training) were closed and professional programs were born. 7

2 This movement brought with it the advent of concept teaching in nursing rather than task and disease identification. It became abundantly clear that consumers of health care were demanding not only to know what the two yellow pills would do, but also what they were and why they needed to take them. The consumer was saying, I am a total person who is capable of being involved at a very important level with my health care. The nurse who must function at this level of nursing care certainly needs facts to give, but she also needs to be cognizant of the total concept of health care. Nursing faculties have come to the realization that health care is indeed health care. For far too long nursing was involved in only ill care. In response to this new orientation toward the purpose of nursing care, nursing curricula are including more and more of the health promoting skills along with the health restoring skills. Nurses are called on to do very extensive health teaching which includes cradle-to-grave concerns. Modern nursing education has given up using nursing students to staff hospitals. No longer is the student expected to work a great number of evenings, nights, and weekends. In most cases, it was realized that such coverage did not greatly enhance skill learning, but it did, in many instances, greatly jeopardize the student s ability to study as well as the patients well-being. The above changes in nursing and nursing education are only a few of the recent, very important, and long overdue advances. If nursing is to become truly a profession, these and many other professional stances must be taken. However, curriculum additions and changes in an already full program do take time away from other activities-something must give. In the case of nursing, the aspect that changed was clinical practice. Clinical practice in most nurse education programs has been greatly curtailed in the past 10 or 15 years. Both the number of hours per week and the number of patients assigned to each student have been reduced. As pointed out by Arm~trong,~ one result of these changes is that even though new graduates come to the work situation possessing more knowledge, they are not focused on the world of service, but rather on education. Such a situation is frustrating for the employers and the colleagues of these new nurses and for the new nurses themselves. Ironically, the very things that have strengthened the nursing profession have also created unrest and insecurity among young nursing graduates. They have also created a situation where more young nurses are becoming involved in special care units (cardiac care, intensive care, oncology) where the nurse : patient ratio is usually no greater than 1 : 3 or less; or they go immediately into agencies or services that do not deal with the acutely ill patient; or again, they go immediately into graduate school and then into teaching, research, etc., never having worked in the acute care agencies; or, even more distressing, these young nurses become disillusioned with nursing and elect to leave the profession entirely. Marlene Kramer s book, Reality Shock,4 provides some clues to the causes of neophyte nurse dissatisfaction. Among these is the fact that the young nurse is taught by teachers who are themselves unfamiliar with the real world of hospitals. Therefore, the nurse is taught skills for which there is no market, and she/he frequently lacks those skills vital to function in a modern health care system. Iiramer also describes reality shock as being the reaction that new workers experience when they realize they do not have the skills necessary for doing the job for which they have been preparing for several years. What then is the future of nursing in the acute and long-term agencies? From where do the much needed supervisory and administrative staffs for hospitals of the future come? If nursing education is to be both relevant and practical, what will be the source of the experienced (as well as educated) teachers? Given a more medically aware consumer, where is the supply of professional nurses able to function as staff nurses in acute and long-term facilities? Almost daily, new and sophisticated medicines, equipment, treatments, and tests are being instituted in hospitals. Where are the equally sophisticated, educated, and skilled nurses who can help physicians deliver and consumers understand the care they are receiving? The situation would seem to be critical. We must make the kinds of adjustments that will not only attract bright, young students of nursing, but will also keep them in the profession after they have become nurses. One solution to this growing need is the nursing internship. The nursing internship would serve as a transitional phase from student to employee and orient the nurse to the roles and responsibilities of real world nursing. As defined by Tobin, an orientation is an attempt to socialize new employees into the workaday world. It teaches the specifics that will enable one to function effectively in a given agency. Such a program would provide assistance in turning theory into practice. Brocks feels that the associate and baccalaureate nursing graduates have been taught lots of theory; however, they must be provided the opportunity and assistance to put this theory into practice. An alternative way to provide clinical experience 8 January/February 1978 JOGN Nursing

3 might be to increase the time spent in school from 4 to 5 years; from 2 to 3 years; or from 3 to 4 yearsdepending on the type of program pursued. This does not really seem to be a viable solution, however, in light of the realities of today s world. There is a greater urgency for young people to get on with their life s work. Early marriages and less help from the extended family require early maturing and independent functioning. On the other hand, a great number of young people are contemplating going to graduate school and are therefore eager to get on with their program. Coupled with these facts is the very real concern of the additional cost for another year of college. Escalating costs of college have sent the expense of 1 year of baccalaureate nursing education to an average of more than $ The above considerations, among others, militate against adding another year to any of the three basic nursing educational programs. Thus, the responsibility for ameliorating the theory-practice schism in nursing education has devolved on the nursing director, the inservice education instructor, or the hospital administrator of the employing agency. It has become a problem of management rather than of the educator. Nurse internships as a solution adopted by management (rather than as merely an extension of the educational institution) could also be a very important cost effective strategy. The cost to recruit only one new nurse is approximately $600. Given a turn- over rate among new graduates of 50%, this represents a significant, annually recurring, financial outlay. In 1970, the national turnover rate was 70%.7 For one large medical center, the registered nurse turnover rate in 1976 was 24%. In a recent study reported by Knoff, it was noted that 1 year after graduation, 48.5 % of the associate degree graduates had changed jobs, giving job related reasons for moving. During the same period, 42.9% of the diploma graduates made a job change, and 38% of the baccalaureate graduates made a change. This is an average overall attrition rate of 43% within the first year of employment. In McCloskey s st~dy,~ 18- to 25-year-old nurses left their jobs on an average of 1.4 years sooner than nurses aged 26 to 35, and new graduates of 1 year or less tended to leave their jobs within the first 6 months. In effect, then, many of the new gynecology and obstetric nurses do not stay on the job even as long as their pregnant patients are under care. This is a particularly important observation, since continuity of care may play a part in the future well-being of mothers and their children. If an institution were to effectively lower turnover rates by even 50%, the savings accrued to that institution per year would amount to a sizeable figure. This is indeed worth attending to! The potentiality of the nursing internship for effecting lower turnover rates while providing substantial benefits to both the nursing profession and the health care consumer has much to recommend it to nursing and hospital administrations. But this potentiality should be tested on the firing line and evaluated against real life criteria. HOW? An effective nurse internship program for a department of gynecology and obstetrics in a teaching hospital could be developed along the following lines : 1. All gynecology-obstetrics neophytes (new graduate nurses, nurses without gynecologyobstetrics experience, and those who have been out of active nursing for more than 5 years) should be included in the program. 2. The first 6 months of the intern s employment should be spent in didactic/experiential training under close preceptorship, with the program being continually adapted to the individual s needs and progress. 3. Salary paid during this period should be at the beginning registered nurse rate. 4. The trainees in such a program should not be assigned to any specific cost center within the department, but rather would fall within a separate training cost center. 5. Scheduling of trainees should be accomplished by those responsible for the program. 6. Each major division of the department should be included in the program. 7. All three shifts for major divisions within the department should be experienced by the nurse-interns. 8. The preceptor:intern ratio should be no greater than 1 : 6 in order to optimally meet the individualized learning needs of the trainees. Content of Training The training should include such specifics as interpersonal skills training, priority setting, work organization in dealing with the health needs of a group of clients, how to assign and work with auxilliary personnel, interviewing skills, client assessment skills, and technical skills. Each of these skills should be carefully assessed at the beginning of the program and individual assignments made appropriate to each trainee. In this way, each trainee would have her/his needs met without spending time on skills already mastered at the student level. Further, if a given trainee needed additional time in a guided learning experience, that need would be January/February 1978 JOGN Nursing 9

4 met by increasing the length of the specific experience or by organizing additional related instruction. The typical clinical (experiential) schedule would include the following: 1. Outpatient clinics 3 weeks (gynecology and obstetrics) 2. Labor and delivery 3 weeks 3. Postpartum 3 weeks 4. Nursery 3 weeks 5. Gynecology (inpatient) 3 weeks 6. Other specialty areas 5 weeks (abortion unit, oncology, operating room, etc.) The ratio of didactic : experiential hours should be approximately 1 :3. This would then result in 30 hours per week on the wards and 10 hours per week in classroom work, on the average. Midway in each clinical experience, the Nursing Instructor/Supervisor, the Unit Head Nurse and Supervisor, and the intern would confer on progress and adjust training as needed. At the conclusion of the rotating clinical schedule (as above) during the first 5 months of the internship, each intern would meet with a preceptor for an individual evaluation conference. In this conference, the preceptor and the intern would mutally explore and assess the trainee s strengths and weaknessness as they relate to specific areas of care within the department. Based on this exploration process, a permanent work assignment would be agreed on between the intern and preceptor. The intern would then be assigned to the unit head nurse for a month s induction into that unit. This sixth month of the internship would be the final step in helping the neophyte learn to function in the real world of obstetric and gynecologic nursing. By spending that month in the specific area of future employment, fulfilling the functions expected of a nurse in that area, but remaining within the learning framework under the aegis of an identified preceptor, the transition from student to employee should occur gradually and almost unnoticeably. Preparation of Leadership Personnel Since the success of such a program would depend on personnel with the skills necessary to induct the trainees into the world of the professional nurse, training of leadership personnel should precede the first group of interns. Specifically, the head nurses and supervisors of all units in the department should receive training in teaching skills, interpersonal communication, individualized program development, and assessment skills. This training could be conducted by the nursing administrator/ supervisor or instructor/supervisor who would be in charge of the internship program. HOW GOOD? In the past, nursing innovations have frequently been implemented without tight, well-designed, and controlled evaluation which would both document effects of the changes and eliminate the possibility of results being explained by rival hypotheses. Preplanning for implementing evaluation as part of a new program could avoid this pitfall. Analyzing the two previous sections of this paper indicates that specific outcomes can be anticipated from the implementation of the program. By restating these outcomes as objectives, it is possible to plan for the measurement of important variables and for subsequent evaluation of the program. Some specific objectives of a nurse internship program for a department of gynecology and obstetrics follow. Given implementation of the program, the nursing interns will be able to perform the following tasks: 1. Demonstrate more adequate socialization to nursing in acute care gynecology and obstetrics by an increased ability to a. care for groups of patients rather than for an individual patient, b. set priorities for functioning in situations involving conflicting demands for nursing care responses, c. develop and implement plans of care for groups of patients rather than for an individual patient, d. supervise the work of ancillary nursing personnel, e. assign patient care appropriately to ancillary personnel, f. evaluate the work of ancillary personnel, g. develop time sheets for the work of other professionals and ancillary personnel assigned to a particular unit, as measured by pre- and post-test scores on nursing situation tests and by periodic supervisor ratings. 2. Deliver more sensitive and humane nursing care as measured by increased scores on interpersonal process scale ratings of periodic video recordings of nurse/patient interactions. 3. Function more effectively in the skills of primary importance to gynecologic and obstetric nursing as measured by the following: a. periodic supervisor s ratings on a structured skills checklist, b. micro-nursing situation tests, and c. patient reactionnaire. 10 January/February 1978 JOGN Nursing

5 4. Express increased work satisfaction as measured by pre- and post-test scores on the Semantic Differential. 5. Show a reduction in turnover and absentee rates for nursing interns and thus demonstrate the cost-effectiveness of the internship model when compared to a) prior turnover and absentee rates for new graduate nurses in the implementing institution, b) current turnover and absentee rates for comparable gynecoiogy and obstetric departments in other hospitals of comparable size and function, and c) current turnover and absentee rates for other departments in the implementing hospital. When objectives are specified as in the above examples, the requirement that outcomes be both observable and measurable encourages the implementor to delineate both the evaluation instruments and the schedule for their administration. Furthermore, such objectives focus evaluation on real life outcomes such as skills and behaviors rather than stepped-back or internal outcomes such as facts or ideas. Thus the evaluation is more closely related to the ultimate goal of patient benefit. SUMMARY The Why, How, and How Good of a nursing internship for a department of gynecology and obstetrics have been explored. The whys of such a program include: 1) a more enlightened consumer who demands a better qualified nurse to deliver health care; 2) changes in nursing education requiring less actual laying on of hands by nursing students; 3) nurses opting out of working in acute care agencies because they are frustrated with the gaps between their skills and expectations from employing agencies; and 4) turnover rates among registered nurses reaching nearly 50%. Pointing out a problem is only a very small part of dealing with the problem. Therefore, some hows were considered in the development of a nursing internship for gynecology and obstetric nurses. Specifics which were considered include the following: a. trainee membership, b. preceptors h ip, c. salary, d. administrative accounting, e. scheduling, f. student :teacher ratio, g. training content and experiences, h. leadership preparations, and i. individualization of the program to trainee s needs. The program should include interpersonal skills, management skills, and gynecology and obstetric nursing skills. Each major division of the department should be included for training purposes, making the program at least 6 months in length. Any program is only as good as its evaluation; therefore, each specific objective of the program should be measurable. That is, objectives should be established prior to implementation along with a way to measure each objective. Wide-scale adoption of any new program should only be instituted subsequent to such a rigorous evaluation process. References 1. Tobin, H. M.: Staff Development: A Vital Component of Continuing Education. j Contin Ed Nurs 1:33-39, American Nurses Association, Committee on Nurse Education: First Position Paper on Nurse Education. Am j Nurs 65:106111, December, Armstrong, M. L.: Bridging the Gap Between Graduation and Employment. J Nurs Admin 4:42-48, Kramer, M: Reality Shock. St. Louis, C. V. Mosby Company, Brock, M. A.: Bridging the Gap Between Service and Education. Sup Nurs 7:26-34, Davis, C. K.: Some Methodological Problems in the IOM Study of the Costs of Nursing Education. In The Cost of Nursing Education, National League for Nursing, New York, National Commission for the Study of Nursing and Nursing Education. An Abstract for Action. Lysaught, J. P., Project director. New York, McGraw-Hill Book Company, Knoff, L. : RN s One and Five Years After Graduation. National League for Nursing, New York, McCloskey, J. C.: What Rewards Will Keep Nurses on the Job? Am J Nurs 4: , 1975 Address reprint requests to Virginia Aspy, RN, EdD, Chairman, Dept. of Baccalaureate Nursing, Eastern Kentucky University, Richmond, KY Virginia Aspy is a graduate of St. Anthony Hospital in Louisville, Kentucky. She holds a BS from Spalding College, Louisville; an M N from the University of Florida in Gainesuille; and her EdD (Higher Educatton and Administration) is from East Texas State University, Commerce. Dr. Aspy was formerly Director of Nursing for the Woman s Clinic at the Johns Hopkins Hospital in Baltimore, Maryland, and Assistant Professor at johns Hopkins University. She is currently Chairman of the Department of Baccalaureate Nursing, Eastern Kentucky University, Richmond. Special interests include interpersonal relations in nursing, teaching, parentlchild relations, and clinical practice. She is a member of NAACOC, ANA, and NLN. January/February 1978 JOGN Nursing 11