- Email: [email protected]
The Development of a Malaysian Model Internship Programme (MyMIP): A Preceptor Model for Nurses in their Early Stage of Profession
Available online at www.sciencedirect.com
Procedia - Social and Behavioral Sciences 64 (2012) 492 – 500
International Educational Technology Conference 2012
The Development of a Malaysian Model Internship Programme (MyMIP): A Preceptor Model for Nurses in their Early Stage of Profession Hamidah, H.a, Maziah, M.a, Ayesha, B.b, Subahan, T.b, Siti Rahayah, A.b a
Department of Nursing, Faculty of Medicine, UKM Medical Centre, 56000 Cheras Kuala Lumpur, Malaysia b Faculty of Education, Universiti Kebangsaan Malaysia, UKM Bangi, Malaysia
Abstract
This study reports on the development of a model called MyMIP (Malaysian Model Internship Programme) for the fresh graduate nurses. Six themes and sixty three items were obtained for the development of the programme. Reliability and validity were tested by the Rasch Model. Result had shown high reliability index of 0.8 to 1.00 PTMEA (Point – Measure Correlation Index) and in-fit of MNSQ at 0.6 to 1.4 and thep value was at 0.001. MyMIP was recommendeda model for the fresh graduates nurses to gain self-confidence particularly in the transition period of students status toa qualified nurse. © 2012 2012 Published Publishedby byElsevier ElsevierLtd. Ltd.Selection Selectionand/or and/orpeer-review peer-reviewunder under responsibility The Association Science Education and © responsibility of of The Association Science Technology Education and Technology Keywords:New graduates; internship; supervision model; workplace; nurse
1. Introduction In this study, Nurses in their Early Stage of Profession (NESP) mean fresh graduating nurses completing training. They will usually be placed in wards that require manpower in caring for the patients. In this transition period, they are often perceived to be under immense pressure and are often blamed for unintentional mistakes. Kramer (1974), Charnley (1999), Chang (2003) and Charleston & Happell (2005) and Beecroft et al (2008) say that this plunge into reality comes as a reality shock for the nurses. They believe that there should be a balance between patient safety and service when recruiting new nurses. Charnley (1999) believes that the difficulties experienced by fresh graduating nurses such as stress, fatigue, ambiguous roles and heavy workload, result in errors especially in administrating medication. In a study conducted by Hamidah et al (2009) on medication errors among nurses at a Corresponding author : Hamidah, H. E mail : [email protected]
1877-0428 © 2012 Published by Elsevier Ltd. Selection and/or peer-review under responsibility of The Association Science Education and Technology doi:10.1016/j.sbspro.2012.11.058
Hamidah H. et al. / Procedia - Social and Behavioral Sciences 64 (2012) 492 – 500
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hospital in East Malaysia, found that 81.25% of medication error among nurses are made by nurses with less than 5 years of work experience. Parker, Ashley& Hegney (2003), state that there is constant criticism of nurses in their early stage of profesion (NESP) due to their failure in applying theory to practice. Duchscher (2001), Delaney (2003), Ellerton & Gregor (2003) and Dracup et al. (2004) believe that fresh graduating nurses lack the confidence and ability to combine the knowledge of caring for the patients with the work carried out. Problems experienced by fresh graduating nurses occur during the transition stage from student nurse to trained nurse. Halfer & Graf (2006), Ellerton (2004), Blanzola (2004) and Chang (2003) suggest that during the transition period, NESP will be under immense pressure due to heavy work load, complex roles and vague instructions received. According to Dearmun (2000), each nurse in their early stage of profesion will undergo three stages in the first year of transition, of which the first stage is adaptation, the second stage is mastery and the third stage of acceptance. Agnew (2000) believes that there are some problems in the recruitment and retention of NESP. These factors result in a shortage of experienced nurses in clinical areas. Baillie (2003) found that in his study of recruitment of NESP in public hospitals, nurses in their early stage of profession experience difficulties during the transition period and in the process of adapting to the roles of a trained nurse. According to Baillie (2003), if they are given the experience to build upon or provide a specific clinical approach, the transition process won’t be too difficult to undergo by each NESP. According to Baillie (2003), Lavoie et al (2002) and Fry et al (1998), internship is needed for NESP to provide them with additional learning, individual development and socialisation. Establishing a good orientation program is the initial step in evaluating the efficiency of NESP before they are able to officially step out into the working field (Charlton 2004). In developed countries like the United States, Canada and Great Britain, internship is mandatory for all new nurses (American Association of Colleges of Nursing, 2001). It is estimated that 7000 fresh graduate nurses register with the Malaysian Nursing Board every year. In the last two years, the number of fresh graduate nurses to register has doubled (LJM Registration Books, 2008). However, there still aren’t any nursing institutions that carry out a structured internship programme. What is worrying is that if serious measures are not taken to overcome this problem, it will threaten the health system of the country. The shortage of nurses currently occurring is due to these critical factors. According to Cruez (2006), a total of 174,000 nurses are needed by year 2020. This figure must be achieved in order to obtain a ratio of one nurse to 200 patients, of which the existing ratio is 1: 650. This data shows that the heavy workload of nurses is far from the standards set by the World Health Organization of which one nurse is to monitor 200 patients / clients. The shortage of nurses is discussed in the New Straits Times, dated 10th. March 2006, entitled Shortage of Staff Nurses Still Severe. Four aspects identified as problems faced by NESP include: stress at work, unsure about the roles of a trained nurse, mistakes made while attending to the patient, and the shortage of nurses by year 2020. Various studies have been carried out to prove that NESP experience most problems in the early stages of their profession. Difficulties experienced by NESP in their transition stage need to be addressed positively in order to retain nurses to work safely and efficiently. Constant criticism of NESP will only demotivate them and deter their interest in the profession. Weakness experienced by NESP in their transition stage should be handled constructively without pressure so as to avoid a negative impact on the service of the profession. The shortage of nurses in the country will be more pressing if every weakness is scrutinised, when the resolution to the problem has not been thought of. A strategy needs to be implemented in order to produce nurses who are able to function safely and effectively. This strategy hopes to overcome the difficulties mentioned and need to begin at the recruitment of NESP during their transition stage. This study aims to develop a model internship program for nurses in their early stages of profession and measure the implementation of the model. 2. Methodology
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This research is a case study using the Mixed Method approach which involves several methods of qualitative and quantitative data collection. Triangulation of interviews with specialist nurses, NESP focus group discussions, document analyses, and item construction in the form of Likert scale items were used in the development of a model internship program called MyMIP (Malaysian Model of Internship Program). For the preliminary study, the researcher used two methods of qualitative data collection. The first method consists of in-depth interviews with several specialists nurses from various fields of expertise. The interview protocol was adhered to retrieve the required information (Wiersma, 2002). The interview began with and introduction followed by transitional questions, key questions, and finally closing question. The following data collection was through the focus group discussions (Yin, 2000; Miles & Huberman, 2003). Discussions were conducted with 32 nurses in their early stage of profession. Three open-ended questions were prepared in order to discuss experiences and problems of NESP in their clinical area. Data was collected in the form of written notes, while respondents were requested to write their opinions and views on paper provided. The session was repeated until every question in the protocol reached the saturation point (Debus & Novelli 1986; Khan 1991; Krueger 1988; Morgan 1993; Helitzer et al 1994; Powell 1998). 3. Data analysis The information obtained was systematically rewritten. Categories and coding was applied using NviVO analysis version 2. Themes were formed using the content obtained. For example, the statement "they need to be guided and a comprehensive orientation need to be carried out" is categorized under‘Implementation of Orientation Programme’. From the results of the data analysis, six specific themes were drawn i) Implementation of orientation program, ii) Preceptor as a role model, iii) Teaching in clinical areas, iv) Communication and support, v) Management and Leadership, and vi) Evaluation in clinical areas. Once the themes were agreed upon by experts in the field of nursing, the themes were used as the main constructs of the study. Data obtained from the focus group discussions were then analysed. Each answer was typed systematically until it reached saturation point (Debus& Novelli 1986; Khan 1991; Krueger 1988; Morgan 1993; Helitzer et al 1994; Powell 1998. Data was then analysed using NVivo version 2. A total of 63 items obtained include the six main constructs. 63 five-point likert scale items were constructed in the form of a questionnaire named MyMIP. Figure 1 shows the framework of the model internship program gathered from interviews, focus group discussions, and analyses of previous studies. Document analyses and previous studies for the development of preceptor package
Interview protocol with experts in the field of nursing
Focus group discussion with nurses in the early stage of profession 6 Themes, 63 Items ( MyMIP )
Implementation of Orientation Program
10 items
Preceptor as a Role Model
13 items
Teaching in Clinical Areas
18 items
Hamidah H. et al. / Procedia - Social and Behavioral Sciences 64 (2012) 492 – 500
Communication and Support
8 items
Management and Leadership
8 items
Evaluation in Clinical Areas
6 items
495
MALAYSIAN MODEL INTERNSHIP PROGRAM (MyMIP)
Figure 1. Internship Model Profram for Nurses in their Early Stages of Profession (NESP) The following triangulation technique used was the analyses of previous studies on the implementation of internship programs. Almost all the analyses conducted found that the execution of an internship program will be successful with the presence of a preceptor (Hands 2008; Burns 2006; RNAO 2003; Myrick 2002; Furgeusson 1996). Preceptor in this study is a registered nurse with extensive experience who is assigned to provide support and guidance to all new nurses and student nurses in the clinical areas. Their main task is to support NESP in their transition stage. Work satisfaction of NESP is related to the orientation session given by preceptors, teaching styles, and learning needs of new nurses. High levels of work satisfaction amongst new nurses are an asset, especially in the long-term (RNAO, 2003 and Anderson 1998). 4. Implementation Process of Internship Program This study was conducted in 2007, at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). A total of 386 nurses in their early stage after graduating with a Diploma in Nursing were the main respondents of the study, of which convenience sampling was used (Wiersma 2002, Kerlinger 2000). Fourteen staff nurses fulfilling the necessary requirements and undergone the Preceptorship training program conducted by the researchers were selected.Respondents were placed in fourteen wards in UKMMC supervised by the 14 specialist preceptors placed in wards with their fields of expertise. Each preceptor had a total of about 14 respondents for the morning and afternoon shifts. A round of supervision took duration of two weeks, after which respondents moved to other wards to gain comprehensive experience in the diverse fields required in nursing. Overall implementation of the program covered 9 cycles or 18 weeks. Teaching and learning occur simultaneously, where preceptors supervise respondents according to the guidelines given during the Preceptorship training. Respondents will also evaluate the experience and supervision received using MyMIP that consists of 63 items and 6 constructs in the form of a Likert scale. Over the duration of 18 weeks, data is entered into SPSS version 12 every 2 weeks, while the researchers conduct other test analyses using Winstep Software version 3.64.2. The Rasch Model was used to ensure the validity and
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reliability of the items and constructs developed as well as determining the item difficulty index and item discrimination index. 5. Findings Interview results and analyses of the six themes formed the six constructs in MyMIP. MyMIP comprises of 63 items, of which 10 items represent the construct Implementation of Orientation Program, 13 items represent the construct Preceptor as a Role Model, 18 items represent the construct Teaching in Clinical Areas, 8 items represent the construct Communication and Support, 8 items represent Management and Leadership, and 6 items represent the construct Evaluation in Clinical Areas. Cronbach's Alpha was used to determine overall consistency and reliability of MyMIP. Table 1 shows that MyMIP has a high reliability index of 0.973. A high reliability index indicates that the items are measuring the concept of the study (Trochim 2006; Santos R.J. 1999; Bland & Altman 1997). Alpha Cronbach 0.982 0.972 0.976 0.960 0.987 0.957 0.973
Table 1 Overall Reliability of MyMIP Construct
Items
1. Implementation of Orientation Program 2. Preceptor as a Role Model 3. Teaching in Clinical Areas 4. Communication and Support 5. Management and Leadership 6. Evaluation in Clinical Areas Overall
10 13 18 8 8 6 63
Overall Validity and Reliability MyMIP (Person) Overall validity and reliability of MyMIP was determined using the Rasch Model, Winsteps version 3.62.4. Table 2 shows the reliability of the model program discretely. Overall analysis shows that person reliability index is high at 0.97, where a value of 0.8 and above is acceptable with high reliability (Linacre 2006). Person separation index is at 5.03, which shows the ability of respondents in answering the items. According to Linacre (2006), a good separation index is 2.0 and above. Hence, MyMIP has a good separation index that is able to separate the abilities of the nurses. Results of this study demonstrate that the ability of the respondents in this study is very agreeable towards the internship program.
Mean S.D. MAX. MIN.
INPUT: 386 Raw Score 283.8 36.1 324.0 144.0
Table 2 Overall Person Reliability persons 63 items MEASURED: 386 persons Model Infit Count Measure Error MNSQ 65.0 2.30 0.26 1.07 0.0 1.45 0.13 0.60 65.0 6.22 1.01 3.79 65.0 -0.97 0.12 0.19
REAL RMSE 0.31 ADJ.SD 1.41 SEPARATION 5.03 MODEL RMSE 0.29 ADJ.SD 1.42 SEPARATION 4.89 S.E. OF person MEAN = 0.11 SUMMARY OF 162 MEASURED (NON-EXTREME) persons MAXIMUM EXTREME SCORE: 2 PERSONS
63 items 5 CATS Outfit ZSTD MNSQ 0.0 1.01 2.6 0.54 8.7 3.07 -5.7 0.20
ZSTD -0.2 2.4 7.0 -5.8
person RELIABILITY 0.97 person RELIABILITY 0.96
Overall Validity and Reliability MyMIP (Item)
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Table 3.0 shows that item reliability is very high at 0.95, while item separation index is at 4.52. This determines that the difficulty of items in this study were satisfactory to be used in the implementation of the internship program. Table 3 Overall Item Reliability SUMMARY OF 63 MEASURED (NON-EXTREME) items RAW MODEL INFIT OUTFIT SCORE COUNT MEASURE ERROR MNSQ ZSTD MNSQ MEAN 707.3 162.0 0.0 0.13 1.02 0.1 1.01 S.D 35.6 0.0 0.61 0.02 0.23 1.5 0.29 MAX. 771.0 162.0 1.36 0.19 1.62 3.8 1.77 MIN. 603.0 162.0 -1.41 0.10 0.64 -2.7 0.55 REAL RMSE 0.14 ADJ.SD 0.59 SEPARATION 4.52 item RELIABILITY MODEL RMSE 0.13 ADJ.SD 0.59 SEPARATION 4.39 item RELIABILITY S.E. OF item MEAN = 0.08 UMEAN = 0.000 USCALE = 1.000 Item RAW SCORE-TO-MEASURE CORRELATION = - 0.99 10530 DATA POINTS. APPROXIMATE LOG-LIKELIHOOD CHI-SQUARE: 16034
ZSTD 0.2 1.6 4.2 -2.6 0.95 0.95
Reliability MyMIP According to Construct Table 4, is intended to determine the reliability of respondents according to the six themes of Implementation of Orientation Program, Preceptor as a Role Model, Teaching in Clinical Areas, Communication and Support, Management and Leadership, and Evaluation in Clinical Areas. All six constructs have an acceptable index of 0.8 and above according to Linacre (2006), while all six constructs have a good separation index of above 2.0. This means that all items in the six constructs are valid and reliable.
Reliability of MyMIP
Table 4 Reliability of MyMIP according to Construct Separation Person Separation
ITEM
SEPARATION 2.46
RELIABILITY 0.86
SEPARATION 2.79
RELIABILITY 0.89
RELIABILITY 0.88 RELIABILITY 0.80
SEPARATION 2.96 SEPARATION 3.85
RELIABILITY 0.90 RELIABILITY 0.94
Preceptor as a Role Model
SEPARATION 2.6 SEPARATION 2.0
RELIABILITY 0.82 RELIABILITY 0.87
SEPARATION 4.07 SEPARATION 3.11
RELIABILITY 0.94
Teaching in Clinical Areas
SEPARATION 2.15 SEPARATION 2.63 SEPARATION 2.81
RELIABILITY 0.89
SEPARATION 3.21
RELIABILITY 0.91
Implementation of Orientation Program
RELIABILITY 0.91
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Communication and Support
Management and Leadership
Evaluation in Clinical Areas
SEPARATION 2.45
RELIABILITY 0.86
SEPARATION 2.12
RELIABILITY 0.85
SEPARATION 2.70 SEPARATION 2.0
RELIABILITY 0.88 RELIABILITY 0.80
SEPARATION 2.0 SEPARATION 3.40
RELIABILITY 0.82 RELIABILITY 0.92
SEPARATION 2.16 SEPARATION 2.50
RELIABILITY 0 .82 RELIABILITY 0.88
SEPARATION 3.65 SEPARATION 2.23
RELIABILITY 0.93 RELIABILITY 0.85
SEPARATION 2.85
RELIABILITY 0.82
SEPARATION 2.0
RELIABILITY 0.88
6. Discussion In this study, internship program is defined as the space to provide opportunities and work experience while learning in order to enhance interaction with senior staff (University Wincosin-EauClaire 2009; Oregon Health & Science University 2002; California State University Northridge 2004; Hofmeister 2004; Erdogan 2009). Work experience while undergoing structured learning is a temporary process which hopes to shape individuals to achieve high levels. In this study, the individuals groomed are nurses in their early stages of professions. Results of this study were able to contribute to the Malaysian Ministry of Higher Education Malaysia, specifically in the development of nursing programs. Among these, significant contributions of this study include; i) ii)
iii) iv) iv)
Firstly, the theme and the items found in MyMIP are appropriate to the needs of the Malaysian Qualifications Agency (2008) which is a framework that unifies all qualifications recognised by the Malaysian Ministry of Higher Education. All six themes present in MyMIP; Implementation of orientation program, Preceptor as a Role Model, Teaching in clinical areas, Communication and Support, Management and Leadership, and Evaluation clinical areas, fulfil the requirement of the 8 domains of learning outcomes that form the pillar of the Malaysian Qualification Agency (2008) The findings of this study have also contributed significantly to the teaching, learning and supervision of nursing in the country. The six themes obtained in this study, also meet the requirements of the Integrated Student Generic Competency Evaluation System of Universiti Kebangsaan Malaysia (UKM). MyMIP has also contributed to the implementation of the Nursing curriculum at the Medical Faculty at UKM. MyMIP has a robust reliability that can be used in the arena of nursing in the country. The items of MyMIP focus on individual characteristics of a good role model for teachers, mentors, leaders, managers, and communication. Subsequently, MyMIP is able to help a good individual / professional.
Hence, a model internship program to guide nurses in their early stages of profession was successfully developed and named the Malaysian Model of Internship Program (MyMIP). This model comprised of 6 themes and 63 items, each of which went through a structured process of review and evaluation of validity and reliability. The number of items present in each construct was as follows: Implementation of Orientation Program (10 items), Preceptor as a Role Model (13 items), teaching in clinical areas (18 items), Communication and Support (8 items), Management and Leadership (8 items), and Evaluation in clinical area (6 items). Overall, the instrument displayed high consistency and correlation of coefficient alpha = 0.973 and a separation index at 4.57 which showed a high level of ability.
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7. Conclusion This study has successfully met the research objectives which include: i) developing a model programs to guide nurses in their early stages of profession; ii) the assurance of resources needed to build the model; iii) formation of important constructs for the model iv) the construction of items that complement the model; v) identifying method of model implementation; vi) method of evaluating the model. In conclusion, this study has acquired two findings, namely, a model internship program (MyMIP) that has been certified to provide guidance to fresh graduating nurses before embarking into the working field, and the notion of a preceptor who can lead and guide. 8. References Agnew, C. (2000). Preceptorship: making it happen.Nurs Times.42(33), 17 – 23. American College of Nursing(2001). Preceptorship programme. Nurs Times, 26, 94 – 120. Baillie, L. 2003. The recruitment of newly qualified nurses to their local hospital: can improvement be made? Journal of Nursing Management, 11(1), 35. Beecroft, P.C., Dorey, F., & Wente, M. (2008). Turnover intention in new graduate nurses: a multivariate analysis. Journal of Advanced Nursing, 62 (1), 41 – 52. Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park: Addison – Wesley. Pp 13 –34 Blanzola, C. (2004). Nurse internship pathway to clinical comfort, confidence and competency. Journal for Nurses in Staff Development (JUSD), 20 (1), 27 – 37. Buku Panduan Lembaga Jururawat Malaysia.(2008). Jururawat berijazah. Kuala Lumpur: Dewan Bahasa dan Pustaka. Burns, C. (2006). Matering the preceptor role: challenges of clinical teaching. Journal of Paediatrics Health Care, 20(3), 172 – 183. California State University Northridge. (2004). Internship. Retrieved 5th March. 2009 from [email protected] Chang, E. (2003). Role stress and role ambiguity in new nursing graduates in Australia. Nursing and Health Science, 5 (2), 155. Charleton, R.,&Happell, B. (2005). Coping with uncertainty within the preceptorship experience: the perceptions of nursing students. International Journal of Psychiatrics and Mental Health Nursing, 12 (3), 303 – 309. Charlton, R. (2004). Evaluating the impact of a preceptorship course on mental health nursing practice. International Journal of Mental Health Nursing, 13, 191. Charnley,E. (1999). Occupational stress in newly qualified staff nurse. Nursing comparison of perception of qualified nurses and students. Journal of Advanced Nursing(JOAN),53 (6),721 – 728. Cruez, F. A. (2006). New Sunday Times. 5th November. ‘When Florence Nightingales come a knocking Delaney, C. (2003). Walking a fine line: graduate nurses’ transition experience during orientation. Journal of Nursing Education, 42 (10), 437. Dearmun,S. (2000). Supporting newly qualified staff nurse: the lecturer practitioner contribution. Journal of Nursing Management, 8 (3), 159. Debus M., &Porter, N. (1986).Handbook for excellence in focus group research.Washington: Academy for Educational Development Health. Dracup, K. et al. (2004). From novice to expert to mentor: shaping the future. American Journal of Critical Care, 13, 448 – 458. Duchscher, J.E.B. (2001). Out in the real world. Journal of Nursing Administration, 31(9), 426 – 439. Ellerton, M.L.,& Gregor, F. (2003). A study of transition: the new nurse graduate at 3 month.Journal of Continuing Education in Nursing, 34 (3), 103. Erdogan,F.M. (2009). Manager of UCSB international program. The international education site. Retrieved 10th Feb. 2009 fromhttp://www.instudy.com/student.htm
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Ferguson, L. M. (1996). Preceptors' needs for faculty support. Journal of Nursing Staff Development, 12(2), 73 – 80. Fry. B., Bottoms, G.,& Oneill, K. (1998). The principle internship. How can we get it right? Atlanta: Southern Regional Education Board (SREB). Halfer, D.,& Graf, E.( 2006). Graduate nurse perceptions of the work experience. Nursing Economic, 12 (3), 90 Hamidah, H.,S. Das, Ho, S.E., K. Damica, S. Letchimi, S., Mat,R., Packiavathy, S., Zulkifli, S.Z. (2009). A study of nurses perception on the medication error at one of the hospital in East Malaysia. La Clinical Terapeutica, 206 (10), 1 – 5. Hands, E.E. (2008). The preceptor connection 2002. Recruitment and retention. La Clinical Terapeutica, 200 (11), 34. Helitzer, A., Makhambera, M., &Wangel, A.M. (1994). Obtaining sensitive information: the need for more than focus groups. Reproductive Health Matters,3, 75 – 82. Hofmeister,B.S. (2004). Employer internship program information. University of Wincosin-Eau Claire. 226/230. Schofield Hall Kerlinger, F.,& Lee, H. (2000). Foundations of behavioural research (4thed.). Hartcourt College: Fort Worth Khan, M. E., Anker, M., Patel, B. C., Barge, S., Sadhwani, H., &Kohle, R. (1991). The use of focus groups in social and behavioural research: some methodological issues. World Health Statistical Quarterly, 4 (4), 145-149 Knowles, M. (1975). Self directed learning. A guide for learners and teachers. New York: New York Association Press Kolb, D.A. (1984). Experiential learning. Englewood Cliffs, NJ: Prentice-Hall. Kramer, M. (1974). Reality shock. Why nurses leave nursing. St Louis: Mosby. Krueger, R. A. (1988).Focus groups. A practical guide for applied research. Newbury Park: Sage Publications. (In particular pp. 51-71 and 91-105.) Lavoie, T., & Melanie, K. (2002). How to facilitate the orientation of new nurses into workplace. Journal for Nurses in Staff Development,18 (2), pp 80 – 85. Malaysian Qualification Agency (MQA). (2008). Code of practice for programme accreditation. Retrieved 10th Feb. 2009 from www.mqa.gov.my Miles, M. B., & Huberman, A. M. (2003). Qualitative data analysis. Thousand Oaks, CA: Sage Morgan, D.L. (1993).Successful focus groups: advancing the state of the art. California: Sage Publications Inc Myrick, F. (2002).Preceptorship and clinical thinking in nursing education. Journal of Nursing Education, 4 (14), Pp 154 – 165. Oregon Health & Science University (updated April 19th. 2004). (2004). Nursing internship program. Portland: Third Avenue Suite. Parker,V., Ashley, P.,& Hegney, D. (2003). Adequacy of support for new graduates during their transition into workplace: Queensland Australia Study. International Journal of Nursing Practice, 9 (5), 1046 – 1440. Powell, R. A., & Simple, H. M. (1996). Methodology matters V: focus groups. International Journal for Quality in Health Care,8 (5):499 – 504. Registered Nurses Association of Ontario RNAO. (2003). Preceptorship: key to success. Newbury Park: Sage Publications. Roy, C. (1976). The roy adaptation model. Comment. Nursing Outlook, 24 (11), Pp 690 – 696. Speck, M. (1996). Best practice in professional development for sustained educational changes. Thousand Oaks, CA: Sage. University Wincosin- EauClaire (2009). Career Services. Retrieved 10th Feb. 2009 from [email protected] Wiersma, M. (2002). Making conscious choices in doing research on workplace spirituality.Utilizing the holistic development model to articulate values, assumptions and dogmas of the knower. Journal of Organizational Change Management, 16(4), 406 – 425. Yin, R.K. (2002). Case study research: design and methods. (3rd ed.). California: Sage Publications, Inc.
Procedia - Social and Behavioral Sciences 64 (2012) 492 – 500
International Educational Technology Conference 2012
The Development of a Malaysian Model Internship Programme (MyMIP): A Preceptor Model for Nurses in their Early Stage of Profession Hamidah, H.a, Maziah, M.a, Ayesha, B.b, Subahan, T.b, Siti Rahayah, A.b a
Department of Nursing, Faculty of Medicine, UKM Medical Centre, 56000 Cheras Kuala Lumpur, Malaysia b Faculty of Education, Universiti Kebangsaan Malaysia, UKM Bangi, Malaysia
Abstract
This study reports on the development of a model called MyMIP (Malaysian Model Internship Programme) for the fresh graduate nurses. Six themes and sixty three items were obtained for the development of the programme. Reliability and validity were tested by the Rasch Model. Result had shown high reliability index of 0.8 to 1.00 PTMEA (Point – Measure Correlation Index) and in-fit of MNSQ at 0.6 to 1.4 and thep value was at 0.001. MyMIP was recommendeda model for the fresh graduates nurses to gain self-confidence particularly in the transition period of students status toa qualified nurse. © 2012 2012 Published Publishedby byElsevier ElsevierLtd. Ltd.Selection Selectionand/or and/orpeer-review peer-reviewunder under responsibility The Association Science Education and © responsibility of of The Association Science Technology Education and Technology Keywords:New graduates; internship; supervision model; workplace; nurse
1. Introduction In this study, Nurses in their Early Stage of Profession (NESP) mean fresh graduating nurses completing training. They will usually be placed in wards that require manpower in caring for the patients. In this transition period, they are often perceived to be under immense pressure and are often blamed for unintentional mistakes. Kramer (1974), Charnley (1999), Chang (2003) and Charleston & Happell (2005) and Beecroft et al (2008) say that this plunge into reality comes as a reality shock for the nurses. They believe that there should be a balance between patient safety and service when recruiting new nurses. Charnley (1999) believes that the difficulties experienced by fresh graduating nurses such as stress, fatigue, ambiguous roles and heavy workload, result in errors especially in administrating medication. In a study conducted by Hamidah et al (2009) on medication errors among nurses at a Corresponding author : Hamidah, H. E mail : [email protected]
1877-0428 © 2012 Published by Elsevier Ltd. Selection and/or peer-review under responsibility of The Association Science Education and Technology doi:10.1016/j.sbspro.2012.11.058
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hospital in East Malaysia, found that 81.25% of medication error among nurses are made by nurses with less than 5 years of work experience. Parker, Ashley& Hegney (2003), state that there is constant criticism of nurses in their early stage of profesion (NESP) due to their failure in applying theory to practice. Duchscher (2001), Delaney (2003), Ellerton & Gregor (2003) and Dracup et al. (2004) believe that fresh graduating nurses lack the confidence and ability to combine the knowledge of caring for the patients with the work carried out. Problems experienced by fresh graduating nurses occur during the transition stage from student nurse to trained nurse. Halfer & Graf (2006), Ellerton (2004), Blanzola (2004) and Chang (2003) suggest that during the transition period, NESP will be under immense pressure due to heavy work load, complex roles and vague instructions received. According to Dearmun (2000), each nurse in their early stage of profesion will undergo three stages in the first year of transition, of which the first stage is adaptation, the second stage is mastery and the third stage of acceptance. Agnew (2000) believes that there are some problems in the recruitment and retention of NESP. These factors result in a shortage of experienced nurses in clinical areas. Baillie (2003) found that in his study of recruitment of NESP in public hospitals, nurses in their early stage of profession experience difficulties during the transition period and in the process of adapting to the roles of a trained nurse. According to Baillie (2003), if they are given the experience to build upon or provide a specific clinical approach, the transition process won’t be too difficult to undergo by each NESP. According to Baillie (2003), Lavoie et al (2002) and Fry et al (1998), internship is needed for NESP to provide them with additional learning, individual development and socialisation. Establishing a good orientation program is the initial step in evaluating the efficiency of NESP before they are able to officially step out into the working field (Charlton 2004). In developed countries like the United States, Canada and Great Britain, internship is mandatory for all new nurses (American Association of Colleges of Nursing, 2001). It is estimated that 7000 fresh graduate nurses register with the Malaysian Nursing Board every year. In the last two years, the number of fresh graduate nurses to register has doubled (LJM Registration Books, 2008). However, there still aren’t any nursing institutions that carry out a structured internship programme. What is worrying is that if serious measures are not taken to overcome this problem, it will threaten the health system of the country. The shortage of nurses currently occurring is due to these critical factors. According to Cruez (2006), a total of 174,000 nurses are needed by year 2020. This figure must be achieved in order to obtain a ratio of one nurse to 200 patients, of which the existing ratio is 1: 650. This data shows that the heavy workload of nurses is far from the standards set by the World Health Organization of which one nurse is to monitor 200 patients / clients. The shortage of nurses is discussed in the New Straits Times, dated 10th. March 2006, entitled Shortage of Staff Nurses Still Severe. Four aspects identified as problems faced by NESP include: stress at work, unsure about the roles of a trained nurse, mistakes made while attending to the patient, and the shortage of nurses by year 2020. Various studies have been carried out to prove that NESP experience most problems in the early stages of their profession. Difficulties experienced by NESP in their transition stage need to be addressed positively in order to retain nurses to work safely and efficiently. Constant criticism of NESP will only demotivate them and deter their interest in the profession. Weakness experienced by NESP in their transition stage should be handled constructively without pressure so as to avoid a negative impact on the service of the profession. The shortage of nurses in the country will be more pressing if every weakness is scrutinised, when the resolution to the problem has not been thought of. A strategy needs to be implemented in order to produce nurses who are able to function safely and effectively. This strategy hopes to overcome the difficulties mentioned and need to begin at the recruitment of NESP during their transition stage. This study aims to develop a model internship program for nurses in their early stages of profession and measure the implementation of the model. 2. Methodology
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This research is a case study using the Mixed Method approach which involves several methods of qualitative and quantitative data collection. Triangulation of interviews with specialist nurses, NESP focus group discussions, document analyses, and item construction in the form of Likert scale items were used in the development of a model internship program called MyMIP (Malaysian Model of Internship Program). For the preliminary study, the researcher used two methods of qualitative data collection. The first method consists of in-depth interviews with several specialists nurses from various fields of expertise. The interview protocol was adhered to retrieve the required information (Wiersma, 2002). The interview began with and introduction followed by transitional questions, key questions, and finally closing question. The following data collection was through the focus group discussions (Yin, 2000; Miles & Huberman, 2003). Discussions were conducted with 32 nurses in their early stage of profession. Three open-ended questions were prepared in order to discuss experiences and problems of NESP in their clinical area. Data was collected in the form of written notes, while respondents were requested to write their opinions and views on paper provided. The session was repeated until every question in the protocol reached the saturation point (Debus & Novelli 1986; Khan 1991; Krueger 1988; Morgan 1993; Helitzer et al 1994; Powell 1998). 3. Data analysis The information obtained was systematically rewritten. Categories and coding was applied using NviVO analysis version 2. Themes were formed using the content obtained. For example, the statement "they need to be guided and a comprehensive orientation need to be carried out" is categorized under‘Implementation of Orientation Programme’. From the results of the data analysis, six specific themes were drawn i) Implementation of orientation program, ii) Preceptor as a role model, iii) Teaching in clinical areas, iv) Communication and support, v) Management and Leadership, and vi) Evaluation in clinical areas. Once the themes were agreed upon by experts in the field of nursing, the themes were used as the main constructs of the study. Data obtained from the focus group discussions were then analysed. Each answer was typed systematically until it reached saturation point (Debus& Novelli 1986; Khan 1991; Krueger 1988; Morgan 1993; Helitzer et al 1994; Powell 1998. Data was then analysed using NVivo version 2. A total of 63 items obtained include the six main constructs. 63 five-point likert scale items were constructed in the form of a questionnaire named MyMIP. Figure 1 shows the framework of the model internship program gathered from interviews, focus group discussions, and analyses of previous studies. Document analyses and previous studies for the development of preceptor package
Interview protocol with experts in the field of nursing
Focus group discussion with nurses in the early stage of profession 6 Themes, 63 Items ( MyMIP )
Implementation of Orientation Program
10 items
Preceptor as a Role Model
13 items
Teaching in Clinical Areas
18 items
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Communication and Support
8 items
Management and Leadership
8 items
Evaluation in Clinical Areas
6 items
495
MALAYSIAN MODEL INTERNSHIP PROGRAM (MyMIP)
Figure 1. Internship Model Profram for Nurses in their Early Stages of Profession (NESP) The following triangulation technique used was the analyses of previous studies on the implementation of internship programs. Almost all the analyses conducted found that the execution of an internship program will be successful with the presence of a preceptor (Hands 2008; Burns 2006; RNAO 2003; Myrick 2002; Furgeusson 1996). Preceptor in this study is a registered nurse with extensive experience who is assigned to provide support and guidance to all new nurses and student nurses in the clinical areas. Their main task is to support NESP in their transition stage. Work satisfaction of NESP is related to the orientation session given by preceptors, teaching styles, and learning needs of new nurses. High levels of work satisfaction amongst new nurses are an asset, especially in the long-term (RNAO, 2003 and Anderson 1998). 4. Implementation Process of Internship Program This study was conducted in 2007, at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). A total of 386 nurses in their early stage after graduating with a Diploma in Nursing were the main respondents of the study, of which convenience sampling was used (Wiersma 2002, Kerlinger 2000). Fourteen staff nurses fulfilling the necessary requirements and undergone the Preceptorship training program conducted by the researchers were selected.Respondents were placed in fourteen wards in UKMMC supervised by the 14 specialist preceptors placed in wards with their fields of expertise. Each preceptor had a total of about 14 respondents for the morning and afternoon shifts. A round of supervision took duration of two weeks, after which respondents moved to other wards to gain comprehensive experience in the diverse fields required in nursing. Overall implementation of the program covered 9 cycles or 18 weeks. Teaching and learning occur simultaneously, where preceptors supervise respondents according to the guidelines given during the Preceptorship training. Respondents will also evaluate the experience and supervision received using MyMIP that consists of 63 items and 6 constructs in the form of a Likert scale. Over the duration of 18 weeks, data is entered into SPSS version 12 every 2 weeks, while the researchers conduct other test analyses using Winstep Software version 3.64.2. The Rasch Model was used to ensure the validity and
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reliability of the items and constructs developed as well as determining the item difficulty index and item discrimination index. 5. Findings Interview results and analyses of the six themes formed the six constructs in MyMIP. MyMIP comprises of 63 items, of which 10 items represent the construct Implementation of Orientation Program, 13 items represent the construct Preceptor as a Role Model, 18 items represent the construct Teaching in Clinical Areas, 8 items represent the construct Communication and Support, 8 items represent Management and Leadership, and 6 items represent the construct Evaluation in Clinical Areas. Cronbach's Alpha was used to determine overall consistency and reliability of MyMIP. Table 1 shows that MyMIP has a high reliability index of 0.973. A high reliability index indicates that the items are measuring the concept of the study (Trochim 2006; Santos R.J. 1999; Bland & Altman 1997). Alpha Cronbach 0.982 0.972 0.976 0.960 0.987 0.957 0.973
Table 1 Overall Reliability of MyMIP Construct
Items
1. Implementation of Orientation Program 2. Preceptor as a Role Model 3. Teaching in Clinical Areas 4. Communication and Support 5. Management and Leadership 6. Evaluation in Clinical Areas Overall
10 13 18 8 8 6 63
Overall Validity and Reliability MyMIP (Person) Overall validity and reliability of MyMIP was determined using the Rasch Model, Winsteps version 3.62.4. Table 2 shows the reliability of the model program discretely. Overall analysis shows that person reliability index is high at 0.97, where a value of 0.8 and above is acceptable with high reliability (Linacre 2006). Person separation index is at 5.03, which shows the ability of respondents in answering the items. According to Linacre (2006), a good separation index is 2.0 and above. Hence, MyMIP has a good separation index that is able to separate the abilities of the nurses. Results of this study demonstrate that the ability of the respondents in this study is very agreeable towards the internship program.
Mean S.D. MAX. MIN.
INPUT: 386 Raw Score 283.8 36.1 324.0 144.0
Table 2 Overall Person Reliability persons 63 items MEASURED: 386 persons Model Infit Count Measure Error MNSQ 65.0 2.30 0.26 1.07 0.0 1.45 0.13 0.60 65.0 6.22 1.01 3.79 65.0 -0.97 0.12 0.19
REAL RMSE 0.31 ADJ.SD 1.41 SEPARATION 5.03 MODEL RMSE 0.29 ADJ.SD 1.42 SEPARATION 4.89 S.E. OF person MEAN = 0.11 SUMMARY OF 162 MEASURED (NON-EXTREME) persons MAXIMUM EXTREME SCORE: 2 PERSONS
63 items 5 CATS Outfit ZSTD MNSQ 0.0 1.01 2.6 0.54 8.7 3.07 -5.7 0.20
ZSTD -0.2 2.4 7.0 -5.8
person RELIABILITY 0.97 person RELIABILITY 0.96
Overall Validity and Reliability MyMIP (Item)
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Table 3.0 shows that item reliability is very high at 0.95, while item separation index is at 4.52. This determines that the difficulty of items in this study were satisfactory to be used in the implementation of the internship program. Table 3 Overall Item Reliability SUMMARY OF 63 MEASURED (NON-EXTREME) items RAW MODEL INFIT OUTFIT SCORE COUNT MEASURE ERROR MNSQ ZSTD MNSQ MEAN 707.3 162.0 0.0 0.13 1.02 0.1 1.01 S.D 35.6 0.0 0.61 0.02 0.23 1.5 0.29 MAX. 771.0 162.0 1.36 0.19 1.62 3.8 1.77 MIN. 603.0 162.0 -1.41 0.10 0.64 -2.7 0.55 REAL RMSE 0.14 ADJ.SD 0.59 SEPARATION 4.52 item RELIABILITY MODEL RMSE 0.13 ADJ.SD 0.59 SEPARATION 4.39 item RELIABILITY S.E. OF item MEAN = 0.08 UMEAN = 0.000 USCALE = 1.000 Item RAW SCORE-TO-MEASURE CORRELATION = - 0.99 10530 DATA POINTS. APPROXIMATE LOG-LIKELIHOOD CHI-SQUARE: 16034
ZSTD 0.2 1.6 4.2 -2.6 0.95 0.95
Reliability MyMIP According to Construct Table 4, is intended to determine the reliability of respondents according to the six themes of Implementation of Orientation Program, Preceptor as a Role Model, Teaching in Clinical Areas, Communication and Support, Management and Leadership, and Evaluation in Clinical Areas. All six constructs have an acceptable index of 0.8 and above according to Linacre (2006), while all six constructs have a good separation index of above 2.0. This means that all items in the six constructs are valid and reliable.
Reliability of MyMIP
Table 4 Reliability of MyMIP according to Construct Separation Person Separation
ITEM
SEPARATION 2.46
RELIABILITY 0.86
SEPARATION 2.79
RELIABILITY 0.89
RELIABILITY 0.88 RELIABILITY 0.80
SEPARATION 2.96 SEPARATION 3.85
RELIABILITY 0.90 RELIABILITY 0.94
Preceptor as a Role Model
SEPARATION 2.6 SEPARATION 2.0
RELIABILITY 0.82 RELIABILITY 0.87
SEPARATION 4.07 SEPARATION 3.11
RELIABILITY 0.94
Teaching in Clinical Areas
SEPARATION 2.15 SEPARATION 2.63 SEPARATION 2.81
RELIABILITY 0.89
SEPARATION 3.21
RELIABILITY 0.91
Implementation of Orientation Program
RELIABILITY 0.91
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Communication and Support
Management and Leadership
Evaluation in Clinical Areas
SEPARATION 2.45
RELIABILITY 0.86
SEPARATION 2.12
RELIABILITY 0.85
SEPARATION 2.70 SEPARATION 2.0
RELIABILITY 0.88 RELIABILITY 0.80
SEPARATION 2.0 SEPARATION 3.40
RELIABILITY 0.82 RELIABILITY 0.92
SEPARATION 2.16 SEPARATION 2.50
RELIABILITY 0 .82 RELIABILITY 0.88
SEPARATION 3.65 SEPARATION 2.23
RELIABILITY 0.93 RELIABILITY 0.85
SEPARATION 2.85
RELIABILITY 0.82
SEPARATION 2.0
RELIABILITY 0.88
6. Discussion In this study, internship program is defined as the space to provide opportunities and work experience while learning in order to enhance interaction with senior staff (University Wincosin-EauClaire 2009; Oregon Health & Science University 2002; California State University Northridge 2004; Hofmeister 2004; Erdogan 2009). Work experience while undergoing structured learning is a temporary process which hopes to shape individuals to achieve high levels. In this study, the individuals groomed are nurses in their early stages of professions. Results of this study were able to contribute to the Malaysian Ministry of Higher Education Malaysia, specifically in the development of nursing programs. Among these, significant contributions of this study include; i) ii)
iii) iv) iv)
Firstly, the theme and the items found in MyMIP are appropriate to the needs of the Malaysian Qualifications Agency (2008) which is a framework that unifies all qualifications recognised by the Malaysian Ministry of Higher Education. All six themes present in MyMIP; Implementation of orientation program, Preceptor as a Role Model, Teaching in clinical areas, Communication and Support, Management and Leadership, and Evaluation clinical areas, fulfil the requirement of the 8 domains of learning outcomes that form the pillar of the Malaysian Qualification Agency (2008) The findings of this study have also contributed significantly to the teaching, learning and supervision of nursing in the country. The six themes obtained in this study, also meet the requirements of the Integrated Student Generic Competency Evaluation System of Universiti Kebangsaan Malaysia (UKM). MyMIP has also contributed to the implementation of the Nursing curriculum at the Medical Faculty at UKM. MyMIP has a robust reliability that can be used in the arena of nursing in the country. The items of MyMIP focus on individual characteristics of a good role model for teachers, mentors, leaders, managers, and communication. Subsequently, MyMIP is able to help a good individual / professional.
Hence, a model internship program to guide nurses in their early stages of profession was successfully developed and named the Malaysian Model of Internship Program (MyMIP). This model comprised of 6 themes and 63 items, each of which went through a structured process of review and evaluation of validity and reliability. The number of items present in each construct was as follows: Implementation of Orientation Program (10 items), Preceptor as a Role Model (13 items), teaching in clinical areas (18 items), Communication and Support (8 items), Management and Leadership (8 items), and Evaluation in clinical area (6 items). Overall, the instrument displayed high consistency and correlation of coefficient alpha = 0.973 and a separation index at 4.57 which showed a high level of ability.
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7. Conclusion This study has successfully met the research objectives which include: i) developing a model programs to guide nurses in their early stages of profession; ii) the assurance of resources needed to build the model; iii) formation of important constructs for the model iv) the construction of items that complement the model; v) identifying method of model implementation; vi) method of evaluating the model. In conclusion, this study has acquired two findings, namely, a model internship program (MyMIP) that has been certified to provide guidance to fresh graduating nurses before embarking into the working field, and the notion of a preceptor who can lead and guide. 8. References Agnew, C. (2000). Preceptorship: making it happen.Nurs Times.42(33), 17 – 23. American College of Nursing(2001). Preceptorship programme. Nurs Times, 26, 94 – 120. Baillie, L. 2003. The recruitment of newly qualified nurses to their local hospital: can improvement be made? Journal of Nursing Management, 11(1), 35. Beecroft, P.C., Dorey, F., & Wente, M. (2008). Turnover intention in new graduate nurses: a multivariate analysis. Journal of Advanced Nursing, 62 (1), 41 – 52. Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park: Addison – Wesley. Pp 13 –34 Blanzola, C. (2004). Nurse internship pathway to clinical comfort, confidence and competency. Journal for Nurses in Staff Development (JUSD), 20 (1), 27 – 37. Buku Panduan Lembaga Jururawat Malaysia.(2008). Jururawat berijazah. Kuala Lumpur: Dewan Bahasa dan Pustaka. Burns, C. (2006). Matering the preceptor role: challenges of clinical teaching. Journal of Paediatrics Health Care, 20(3), 172 – 183. California State University Northridge. (2004). Internship. Retrieved 5th March. 2009 from [email protected] Chang, E. (2003). Role stress and role ambiguity in new nursing graduates in Australia. Nursing and Health Science, 5 (2), 155. Charleton, R.,&Happell, B. (2005). Coping with uncertainty within the preceptorship experience: the perceptions of nursing students. International Journal of Psychiatrics and Mental Health Nursing, 12 (3), 303 – 309. Charlton, R. (2004). Evaluating the impact of a preceptorship course on mental health nursing practice. International Journal of Mental Health Nursing, 13, 191. Charnley,E. (1999). Occupational stress in newly qualified staff nurse. Nursing comparison of perception of qualified nurses and students. Journal of Advanced Nursing(JOAN),53 (6),721 – 728. Cruez, F. A. (2006). New Sunday Times. 5th November. ‘When Florence Nightingales come a knocking Delaney, C. (2003). Walking a fine line: graduate nurses’ transition experience during orientation. Journal of Nursing Education, 42 (10), 437. Dearmun,S. (2000). Supporting newly qualified staff nurse: the lecturer practitioner contribution. Journal of Nursing Management, 8 (3), 159. Debus M., &Porter, N. (1986).Handbook for excellence in focus group research.Washington: Academy for Educational Development Health. Dracup, K. et al. (2004). From novice to expert to mentor: shaping the future. American Journal of Critical Care, 13, 448 – 458. Duchscher, J.E.B. (2001). Out in the real world. Journal of Nursing Administration, 31(9), 426 – 439. Ellerton, M.L.,& Gregor, F. (2003). A study of transition: the new nurse graduate at 3 month.Journal of Continuing Education in Nursing, 34 (3), 103. Erdogan,F.M. (2009). Manager of UCSB international program. The international education site. Retrieved 10th Feb. 2009 fromhttp://www.instudy.com/student.htm
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