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Are the Nurses able to Reflect their Undergraduate Education upon the Clinic? The Effect Factors
Available online at www.sciencedirect.com
ScienceDirect Procedia - Social and Behavioral Sciences 186 (2015) 143 – 150
5th World Conference on Learning, Teaching and Educational Leadership, WCLTA 2014
Are The Nurses able to Reflect Their Undergraduate Education upon The Clinic? The Effect Factors Kıymet Yesilcicek Calıka*, Songul Aktasa, Hacer Kobya Buluta, Elif Ozdas Anaharb, Hacer Erdola a
Instructor at Nursing School, Faculty of Health Sciences, Karadeniz Technical University, Trabzon, 61080, Turkey b Nurse at Education Unit of Directorate of Trabzon Public Hospital Union, Trabzon, 61100, Turkey
Abstract One of the main problems in the provision of nursing services in Turkey is that nurses are not able to transfer their theoretical knowledge and skills to practice sufficiently. This study aims to uncover the causes of this situation. This descriptive research was carried out with 176 nurses working in five public hospitals in a metropolis in the northeast of Turkey. Numerical and percentage values were used in the evaluation of data. As a result, nurses' clinical working environment (72.7%), the clinic's physical structure and hardware (75.0%), health care team members (80.1%), management's attitude (65.9%) and institutional / health policies (67.6%) were found to be significantly influential in transferring their training to clinics. © 2015 2015The TheAuthors. Authors.Published Published Elsevier © byby Elsevier Ltd.Ltd. This is an open access article under the CC BY-NC-ND license Peer-review under responsibility of Academic World Education and Research Center. (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of Academic World Education and Research Center Keywords: Factors influencing nursing care, nursing undergraduate education, clinic, Turkey;
1. Introduction With the development of technology, care requirements vary, and day by day people increasingly demand for quality nursing care. This situation enhances the expectations and the need for highly motivated and innovative nurses with advanced professional qualifications in the health care system (Sabacıoğulları & Doğan, 2014). Despite the increasing demand for quality nurses, the professional qualities of nurses such as autonomy, problem solving,
* Kıymet Yesilcicek Calık. Tel.: +90-4623778865. E-mail address: [email protected]
1877-0428 © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of Academic World Education and Research Center doi:10.1016/j.sbspro.2015.04.073
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responsibility and care competence were found to have problems in the studies carried out in our country (Sabancıoğulları & Doğan, 2014; Kelleci, Gölbaşı, Yılmaz & Doğan, 2008). This is because uncertainty of nurses' duty, adverse physical environment, working involuntarily in other units and long working hours (Nehir, 2003; Stordeur, D’Hoore & Vandenberghe, 2001), the number of patients receiving care (Ergüney, Tan, Sivrikaya & Erdem, 2001; McVicar, 2003), excessive work load (İleri & Kocaman, 2007; Healy & McKey, 2000; Callaghan, Tak-Ying & Wyatt 2000), lack of high quality material/ equipment, patient, patients’ relatives, team communication problems, lack of motivation ( Gjerberg, Førde, Pedersen & Bollig, G. 2010; Uğurlu, Yılmaz & Karacak 2010; Öztürk, Yılmaz, & Demir, 2009) different levels of education have led nurses to have non-purpose roles (Çınar & Demir, 2009). Certainly, this situation may reduce professional qualifications of nurses and lead nurses to give insufficient care and be desensitized. At the same time, insufficient nursing practices cause nurses to be perceived as technicians that give only treatment, and nursing profession is perceived negatively by the community and other health professionals (Deppoliti, 2008; Sabancıoğulları & Doğan, 2014; Yıldırım, Sezgin & Timuçin, 2007; http://www.turkhemsirelerdernegi.org.tr 2013). As can be understood, the problem is related to working order, manpower planning and management. Clarifying the nurses’ roles within the health care team and reducing the miscommunication in the team will increase job satisfaction, and consequently service effectiveness, efficiency, patient and staff satisfaction will increase (O’Connel & Twigg, 1999; Karadağ & Taşçı, 2005). Nurses’ being able to provide optimal care to individuals can be achieved with arrangements in these factors. Nurses’ being able to implement their theoretical knowledge and skills that they received in their fields, improving nursing practice, solving existing and possible future professional issues will be guiding for the strategies to be made and established for the image of the profession and professional development. This study was conducted to determine the problems faced by graduate nurses working at the hospital in transferring their undergraduate education to clinic and the influential factors on them. 2. Method 2.1. Type of Research: This study is cross-sectional and descriptive. 2.2. Population and Sample The research population consisted of 517 nurses with undergraduate degrees and working in five public hospitals in a metropolis located in a province in northeastern Turkey (Trabzon). 176 nurses with at least 6 month-working experience and who agreed to participate the study were included in the study sampling after selected by using 5% selected reliability proportional stratified sampling technique. Nurses working in polyclinics, laboratory and managerial positions were excluded from the study. 2.3. Data Collection Tool In the collection of data, a questionnaire prepared by the researchers as a result of an extensive literature study was used. In the data collection tool; there are nurses' personal and professional status variables (age, education, the institutions they work, professional and institutional experience) and 17 questions about the influential factors in transferring under graduate education to clinical practice. The factors that are influential in transferring under graduate education to clinical practice were assessed by seven dimensions developed by the researchers. These dimensions consist of the impact of undergraduate education adequacy, clinical work environment, the clinic's physical competence, health care team members and the management and institutional health policies. 2.4. Data Collection
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Data were collected between January-June 2014 after consultation with the directors of nursing services and institutions (hospitals and related Trabzon Provincial Health Directorate) and after receiving formal written permission. After the completion of the permitting process, the managers of nursing services were interviewed again, the hospitals were visited on designated days, and the data collection tool was administered with voluntary nurses using face to face interview technique. The interviews were held at nurses’ room, and each interview took about 30 minutes. 2.5. Data analysis The data were analyzed using the SPSS 17.0 program. In the analysis of the data, descriptive analyses (percentage, average) were used. In this study, all findings were tested at p <.05 significance level. 2.6. Limitations of the Study That the results are representative for only the institutions in a province of Turkey where the study was conducted was accepted as the limitation of the study. 3. Findings The analysis of research data showed that 94.3% of nurses were female, 67.6% were married, 31.43 ± 6.38 years old on average and the majority of them (51.1%) were in 20-29 age group, 47.1% had 1-5 year working experience and 62.5% 1-4 year of working experience in the institution, 62.5% were ward nurses, 79.5% worked 40 hours per week, 51.7's% had shift work schedules, 63.6% were responsible for 11 patients and over, and 72.7% did not participate in scientific studies related to nursing. 75.0% of the participants stated that theoretical education they had received in their undergraduate courses was adequate but practical training was inadequate (66.5%). Table 1. The effect of working environment and physical hardware of clinics in transferring undergraduate education to clinics (n=176) Is working environment influential? Yes No How does the work environment influence?* Staff shortage Long and exhausting working hours Nurses shortage Fatigue and lack of motivation Uncertainty of duties, powers and responsibilities Failure in the appropriate employment of the nurses Excessive workload Excessive number of patients High age average of nurses Operating at off-duty work I have no idea Is physical hardware of the clinic influential? Yes No How does physical hardware of the clinic influence?* Lack of sufficient and high quality material/equipment Supplying drugs late Poor quality products causes time loss and process repetition Delaying application to patients or unavailable at all Quality of nursing care falls I have no idea * More than one answer was given and percentages were calculated based on n.
Number 128
Percentage 72.7
48
27.3
43 48 58 45 55 39 44 56 7 44 2
24.4 27.3 33.0 25.6 31.2 22.2 25.0 31.8 4.0 25.0 1.1
132 44
75.0 25.0
72 39 60 31 46 5
40.9 22.2 34.1 17.6 26.1 2.8
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72.7% of the nurses indicated that their working environment is influential in transferring their professional knowledge and skills that they had received during their undergraduate education to clinics. 33.0%, 31.8%, 31.2% of the nurses were experiencing nurse shortage, excessive number of patients and their unclear duties, powers and responsibilities as the problems resulting from the work environment respectively. 75.0 % of the nurses stated that physical hardware of the clinic is influential in transferring the professional knowledge and skills they had received in their undergraduate education to clinics. Lack of sufficient and high quality material/equipment, poor quality products that led time loss and process repetition and reduction in the quality of nursing care were regarded as problems by 40.9%, 34.1% and 26.1% of nurses respectively (Table 1). Table 2. The effect of the health care team members and management in transferring undergraduate education to clinics (n = 176) Are health care team members influential?Yes No How do the health care team members influence? * Nurses without undergraduate degree and inexperienced nurses Nurses and doctors are not innovative Lack of harmony and communication among team members Unsupportive team members Team members do not know their responsibilities Doctors impose sanctions on nurses for their own duties I have no idea Is management influential ? Yes No How does management influence?* Lack of management support, fairness and respect Mobbing application Not being supportive for nurses to participate in scientific studies Failure in acting selectively in determining the supervisor nurses Inability to generate solutions to problems Not controlling and caring about the quality of care and supervision Not being innovative in education and being open to change Not using rewarding system appropriately Not protecting nurses’ rights and remedies Forcing nurses to do off-duty works I have no idea * More than one answer was given and percentages were calculated based on n.
Number 141 35
Percentage 80.1 19.9
59 26 74 39 30 62 5
33.5 14.8 42.0 22.2 17.0 35.2 2.8
116 60
65.9 34.1
90 40 27 14 50 8 5 41 53 68 5
51.1 22.7 15.3 8.0 28.4 10.2 2.8 23.3 30.1 38.6 2.8
80.1% of the participants indicated that the members of health care team were influential in transferring their professional knowledge and skills that they had received during their undergraduate education to clinics. 42.0%, 35.2%, %33.5% were experiencing lack of harmony and communication among team members, doctors’ imposing sanctions on nurses for their own duties and nurses without undergraduate degree and inexperienced nurses as problems respectively. 65.9 % expressed management’ attitude as an important factor in transferring their professional knowledge and skills during undergraduate education to clinics. Lack of management support, fairness and respect, being forced to do off-duty works and not protecting nurses’ rights and remedies are perceived as problems by %51.1, %38.6 and %30.1 of the participants respectively (Table 2). Table 3. The effect of institutional/health policies in transferring undergraduate education to clinics (n=176) Are institutional and health policies influential? Yes No How do institutional and health policies influence?* Health policies that do not support nurses Considering nurses as assistant health care staff Not taking employees’ opinions into consideration while establishing Health Policies Differences between institutional mechanism and the things taught during undergraduate education Abuse of patients’ rights by patients and their relatives
Number 119 57
Percentage 67.6 32.4
80 37 31 39
45.5 21.0 17.6 22.2
32
18.2
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Inhibition of innovation in the health sector by politicians Failure in enforcing standards of nursing care I have no idea * More than one answer was given and percentages were calculated based on n.
21 30 6
11.9 17.0 3.4
67.6% of the nurses noted that institutional and health policies were influential in transferring their professional knowledge and skills to clinics. 45.5%, 22.2% and 21.0% of the participants were experiencing health policies that do not support nurses, the differences between institutional mechanism and the things taught during undergraduate education and being regarded as assistant health care staff as problems (Table 3). 4. Discussion In this section, in line with the findings from the study, the sufficiency of the professional knowledge and skills of the nurses during undergraduate education and the factors that are influential in transferring these knowledge, and skills into nursing care and clinics are discussed. Although theory and practice skills in nursing education are given sufficiently, this accumulation can not be transferred into applications at desired level (Karaöz, 2003; Sabancıoğulları & Doğan, 2014). In our study, 75.0% of the nurses expressed that they had adequate theoretical knowledge but inadequate practical training during their undergraduate education (66.5%). In the previous studies, it has been stated that new graduate nurses are insufficient to fulfill the basic nursing skills, and they need to develop them (Hiton & Polland, 2004; Solyers, 2007; Yiğit, Esenay & Derebent, 2007). In a study carried out with nurses, Buldukoğlu, Kantek, and Öncel, (2004) found out that 35.6% of the participants indicated the university training they had received was adequate in the workplace, while 44.7% and 17.1% considered it as partially adequate and insufficient respectively. The results of previous studies support our research results. The provision of quality health services depends on working environment supporting health workers' capacity, performance and health. In our study, 72.7% of the nurses stated that working environment and clinic's physical hardware is influential in transferring their professional knowledge and skills to clinics. The top three opinions of nurses related with work are nurses’ shortage (33.0%), excessive number of patients (31.8%) and lack of certainty about duties, powers and responsibilities (31.2%) (Table 1). Nurses’ excessive work load due to the high patientnurse ratio lead to nurses’ fatigue both physically and spiritually, and as a result of this overload nurses confront physical and mental diseases (http://www.turkhemsirelerdernegi.org.t of 2013; ICN, 2006). Previous studies show that stress factors that affect the nurses most in the working place are role uncertainty, involuntarily work in other units, (Nehir, 2003; Stordeur, D’Hoore & Vandenberghe 2001), the number of patient receiving care (Ergüney, Tan, Sivrikaya &Erdem, 2001; McVicar, 2003), excessive work load (İleri & Kocaman, 2007; Healy & McKay, 2000). Nursing is the only discipline where there are non-specific working and application area borders and nurses roles are tried to be identified other than themselves in the health workforce. In the health work environment, instead of functioning directly for patient care for professional purposes, nurses are forced to perform as imposed by the system away from caring itself. Health institutions in Turkey inherently (insufficient staff, inadequate tools and equipment, physical space deficiencies) have many problems in terms of employees. In our study, 75.0% of nurses stated that the physical hardware of the clinics is influential in transferring their professional knowledge and skills they received during their undergraduate education to clinics. The top three views of nurses regarding clinic’s physical sufficiency are lack of sufficient and high quality material/equipment (40.9%), poor quality products cause time loss and process repetition (34.1%), and this situation lowers quality of nursing care (26.1%) (Table 1). In the service sector, especially at hospitals despite the excessive number of patients and over workload, incomplete and inappropriate materials/devices have been identified as the most stressful situations (Argon, Özgür & Vatan, 2001). The previous studies also show that among health care personnel, nurses are the ones who have problems in giving care due to staff and material shortage and physical environment the most ( Gjerberg, Førde, Pedersen & Bollig, 2010; Uğurlu, Yılmaz & Karacak, 2010; Mollaoğlu, Kars & Özkan, 2009; Öztürk, Yılmaz & Demir, 2009). Lack of sufficient material inevitably causes time loss and the process repetition and thus deterioration in the quality of nursing care. In our study, 80.1% of the nurses indicated that health care members are influential in transferring professional
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knowledge and skills received during undergraduate education to clinics. The first three views regarding the impact of health care members are lack of harmony and communication among team members (42.0%), doctors’ imposing sanctions on nurses for their own duties (35.2%) and nurses without undergraduate degree and inexperienced nurses (33.5%) (Table 2). Effective communication and teamwork among health care workers is very important. The team is a group acting in accordance with a common purpose. The harmony and success of the team depends on identifying the roles and functions of each member clearly, being in effective communicative and cooperative atmosphere (Nadzam, 2009; Kumcağız, Yılmaz, Balcı, Çelik &Aydın, 2013; McVicar, 2003) and each member’s fulfilling their roles and functions at the highest level (Erdemir, 1998). According to the previous studies, 31.3% of the nurses regarded communication problems in the health care team as a factor influencing the care they gave (Karadağ &Taşçının, 2005), had insufficient duty identification, had to do a lot of off duty things (Uygur, Kaya, Kaya & Karaman, 2009; Stewart, 2009; Önerbay & Sayan, 2009), did a lot of work other than their own duties which was the most important factor leading to role ambiguity (Ocak, Gider, Top, Şahin & Tarcan, 2004) and doctors’ imposing behaviors and attitudes towards nurses caused conflicts (Copnell et al., (2004). Similar to our study, in their studies Çimensel and Argon (2000), Brinket (2010), Hendel, Fish, and Galon, (2005). also emphasize that nurses have troubles with doctors because of "the doctor authority and repression". Communication problems lead to problems in patients’ treatment and care, eliminate inter professional support and increase work stress (Nadzam, 2009; Arıkan & Karabulut, 2004). It is obvious that problems in communication not only causes work stress but also may affect services and service areas as well. International Labour Organization (ILO) defines the major stressors in the work environment as conflicts with managers, role conflicts and ambiguity (ILO, 2001; Mollaoğlu, Kars & Özkan, 2009). In our study, 65.9% of the nurses indicated that the attitude of the management is influential in transferring their professional knowledge and skills to clinics. This top three views of nurses on the impact of management are lack of management support, fairness and respect (%51.1), making nurses operate at off-duty work (%38.6) and not protecting nurses’ rights and remedies (%30.1) (Table 2). Political and bureaucratic pressures, managerial problems, non supportive management style, lack of rewarding, lack of management respect, lack of constructive feedback and inability to perform nursing practices appropriately due to the bureaucratic reasons has resulted in difficulties and restrictions in nurses’ nursing applications (Argon, Özgür & Vatan, 2000; Stewart, 2009; Deveci, 2008; Mersinlioğlu, Balık, Kurt, Sayan, Öztürk &Demirbağ 2014). Similarly, Özkan (2008), Hendel, Fish and Galon (2005), Akça and Ergüç (2006) and Brinket (2010) pointed out in their studies that management style provide the least satisfaction for nurses. They experience conflicts with managers, cannot get enough support from them, and they request respect, love, democratic approach and solutions to problems respectively from their managers. In our study, 67.6% of the nurses stated that institutional and health policies are influential in transferring professional knowledge and skills during undergraduate education to clinics. Among the views of nurses regarding institutional and health policies, the first three are health policies that do not support nurses (45.5%), differences between institutional mechanism and the things taught during undergraduate education (22.2%) and nurses’ being regarded as assistant health care personnel (21.0%) (Table 3). Politics is one of the most important factors influencing their practices. In our country, when the laws and regulations organizing the nurses 'working conditions, duties, powers and responsibilities and the delivery of nursing services are examined, it is clearly seen that nurses working under the Law No. both 657 and 4857 experience serious gaps and human rights violations related to working hours and their duration, wage distribution and especially in shift working system. Besides, there are not sufficient regulations protecting human rights violations or effective control (http://www.turkhemsirelerdernegi.org.tr 2013). In the previous studies, existing laws and regulations related to nurses have been found out to be far from responding to the needs (Mersinlioğlu, Balık, Kurt, Sayan, Öztürk & Demirbağ 2014; Öztürk, Yılmaz & Demir, 2009; http://www.turkhemsirelerdernegi.org.t 2013). Besides physical, mental and social difficulties experienced by the nurses because of the unsupportive laws about nursing services, the most crucial problem here is that the security of nursing care which requires extreme attention and energy cannot be ensured and consequently public health is jeopardized.
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5.
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Results and Recommendations
In our study, nurses with undergraduate degree were determined to experience various difficulties in transferring their knowledge and skills that they had received during their undergraduate education into practice. These issues are experienced in working order, human resource planning, and management and health policies. These are reflected in nursing practice as inability to use the professional knowledge and skills effectively and fulfill nursing independent functions; care giving and helping adequately. As a result, society can not receive quality nursing care and nursing potential in achieving health goals can not be assessed. Therefore, the causes of nurses’ problems should be determined institutionally, and managerial, departmental, and individual measures should be taken for employees. Acknowledgements The authors especially thank all of the participating nurses. References Akça, C., & Erigüç, G.(2006). A study on reasons of conflict the hospital employees experience with their managers and colleagues. Hacettepe Journal of Health Administration, 9(2): 126-153. Argon, G., Özgür, G., & Vatan, F. (2000). Nurses' perceptions of their working lives in hospitals. 1st International & VIII. National Nursing Congress. Antalya, Turkey. 81-85. Arıkan, D., & Karabulut, N. (2004). Work-related strain in nurses and determination of the factors affecting this. Journal of Atatürk University School of Nursing, 7(1):10-18. Brinket, R. (2010). A literature review of conflict communication causes, costs, benefits and interventions in nursing. Journal of Nursing Management, 18: 145-156. Buldukoğlu, K., Kantek, F., & Öncel, S. (2004). Educational evaluation and improvement of study: First three semesters of college graduates in Antalya the views of health. Nursing Forum, 7 (2): 8-16. Callaghan, P., Tak-Ying, S. A., & Wyatt, P. A. (2000). Factors related to stres and coping among chinese nurses in Hong Kong. Journal of Advanced Nursing, 31 (6), 1518-1527. Çimensel, İ., & Argon, G. (2000). An investigation on the views of nurses regarding the causes of organizational conflict. 1st International & VIII. National Nursing Congress, Antalya, Turkey. 174-178. Çınar, Ş., & Demir, Y.(2009). Nursing image in community: A scale development study. Journal of Atatürk University School of Nursing, 12: 2, 24-33. Copnell, B., Johnston, L., Harrison, D., Wilson, A., Robson, A., Mulcahy, C., Ramudu, L., McDonnell, G., & Best, C. (2004). Doctor’s and nurses perception of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practioner model of practice. Journal of Clinical Nursing, 13(1): 105–113. Deppoliti, D. (2008). Exploration how new registered nurses construct professional identity in hospital settings. The Journal of Continuing Education in Nursing, 39(6):255-62. Deveci, F. (2008). Stress and job satisfaction, midwives and nurses working in hospitals in the province of Sinop attitude and behavior after stress. Health and Hospital Administration Congress Proceedings Book. Ankara: Health Administrators Association. 400-409. Erdemir, F. (1998). The roles and functions of nurses and the philosophy of nursing education. Journal of Cumhuriyet University School of Nursing, 2(1), 59-63. Ergüney, S., Tan, M., Sivrikaya, E., & Erdem, N. (2001). Occupational risks that nurses face. Journal of Atatürk University School of Nursing, 4 (1), 63-73. Gjerberg, E., Førde, R., Pedersen, R., & Bollig, G. (2010). Ethical challenges in the provision of end-of-life care in Norwegian nursing homes. Social Science & Medicine, 71: 677-684. Healy, M., & McKey, M. F. (2000). Nursing stress: The effects of coping strategies and job saticfaction in a sample of Australasian nurses. Journal of Advanced Nursing, 31 (3), 681-688. Hendel, T., Fish, M., & Galon, V. (2005). Leadership style and choice of strategy in conflict management among Israeli nurse managers in general hospitals. Journal of Nursing Management, 13: 137-146. Hiton, P., & Polland, C.(2004). Supporting clinical skills develop. Nurs Stand ,18(25):31-6. http://www.turkhemsirelerdernegi.org.tr/menu/hemsirelik-yayinlari/yayinlar/turkiyede-hemsirelerin-calisma-kosullari.aspx.Updated September 14, 2014. Accessed April 20, 2013. İleri, S., & Kocaman, G. (2007). An investigation on new graduate nurses' perceptions about transition to professional roles and the influential factors. 4th International 11th National Congress of Nursing, Ankara, Turkey. 89. ILO, 2001 http://www.ilo.org/safework_bookshelf/english? content&nd= 857170174 (28.01. 2012) Definition of occupational health adopted by the Joint ILO/WHO Committee on Occupational Health (1950). International Council of Nurses (ICN), (2006). Healthy lives employment, information and action guide international nurses day.
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Kıymet Yesilcicek Calık et al. / Procedia - Social and Behavioral Sciences 186 (2015) 143 – 150 Karadağ, S., & Taşçı, S. (2005). The factors affecting the nursing care given by the nurses working in Kayseri State Hospital. Journal of Health Sciences, 14(Additional Issue: Nursing Special Issue)13-21. Karaöz, S. (2003). General view of clinical education in nursing and recommendations for effective clinical education. Journal of Nursing Research and Development,1;15-21. Kelleci, M., Gölbaşı, Z., Yılmaz, M., & Doğan, S. (2008). The views o f nurses, about carrying out research and utilization of research results in nursing care in a university hospital. Journal of Nursing Research and Development, 10(2):1-16. Kumcağız, H., Yılmaz, M., Balcı, Çelik, S., & Aydın, A. (2013). Communication skills of nurses: Samsun sample. Dicle Medical Journal, 38 (1): 49-56. McVicar, A. (2003). Workplace stress in nursing: a literature review. Journal of Advanced Nursing, 44 (6), 633-642. Mersinlioğlu, G., Balık, T., Kurt, Ş.,Sayan, B., Öztürk, H., & Demirbağ B.C. (2014). The issues of newly-hired nurses at hospitals. 13th National Congress of Nursing Students, Trabzon. Turkey. 82. Mollaoğlu, M., Kars, F.T., & Özkan, T. F. (2009). An evaluation on the perceptions of newly-hired nurses at hospitals concerning their working environment. 12th National Nursing Congress (International Participation). Sivas, Turkey. 107. Nadzam, D.M.(2009). Nurses’ Role in communication and patient safety. J Nurs Care Quality, 24: 184–188. Nehir, S. (2003). Determining the working environment stressors of the nurses working at intensive care units in Ankara and their coping strategies. Unpublished Master's Thesis. Abant Izzet Baysal University Health Sciences Institute. Bolu, Turkey. O’Connel, B., & Twigg, D. (1999). Patient satisfation with nursing care: a measurement conundrum. Int Journal Pract, 5(2):72-77. Ocak, S., Gider, Ö., Top, M., Şahin, B., & Tarcan, M. (2004). A study on the role ambiguity of the nurses working at Muğla State Hospital. Nursing forum, Eylül-Ekim; 28-38. Önerbay, S., & Sayan, İ. (2009). Nurses' assessment of their work duties outside. 12th National Nursing Congress (International Participation). Sivas, Turkey. 105. Özkan, Ş. (2008). The impact of role ambiguity and role conflicts on doctors and nurses’ fatigue level. Unpublished Master's Thesis. Hacettepe University Institute of Health Sciences, Ankara, 90-92. Öztürk, H., Yılmaz, F., & Demir, N. (2009). The matters of nurses managers working in hospital. Journal of Anatolia Nursing and Health Sciences, 12(2), 57-65. Sabancıoğulları, S., & Doğan, S. (2014). The professional self development levels and affecting factors of nurses working in a university hospital. Journal of Anatolia Nursing and Health Sciences, 17:1, 15-22. Solyers V.L.(2007). Teaching psycohomotor skills to beginning nursing students using a web-enhanced approch: A quasi-experimental study. Int J Nurs Sch, 4(1):1-9. Stewart, K.L.(2009). Nurse managers knowledge of staff nurse burnout. The thesis of master os science in nursing, Western Carolina University, Cullowhee/Noarth Carolina/USA. Stordeur, S., D’Hoore, W., & Vandenberghe C. (2001). Leadership, organizational stress, and emotional exhaustion among hospital nursing staff. Journal of Advanced Nursing, 35 (4),533-542. Uğurlu, N., Yılmaz, B., & Karacak, F. (2010). Determination of the professional risk factors of the nurses working in two different hospitals. Journal of İstanbul University Florence Nightingale School of Nursing, 18(1):19-25. Uygur, E., Kaya, N., Kaya, H., & Karaman, N. (2009). Insights of the nurses working at a hospital regarding with health team services. 4th International 11th National Congress of Nursing, Ankara, Turkey. 276. Yiğit, R., Esenay, İ.F., & Derebent, E. (2007). The profile of senior nursing students inTurkey. Journal of Cumhuriyet University School of Nursing, 11 (3): 1-12. Yıldırım, A., Sezgin, B., & Timuçin, A.(2007). Are the views of community on nursing changing? 4th International 11th National Congress of Nursing, Ankara, Turkey.159.
ScienceDirect Procedia - Social and Behavioral Sciences 186 (2015) 143 – 150
5th World Conference on Learning, Teaching and Educational Leadership, WCLTA 2014
Are The Nurses able to Reflect Their Undergraduate Education upon The Clinic? The Effect Factors Kıymet Yesilcicek Calıka*, Songul Aktasa, Hacer Kobya Buluta, Elif Ozdas Anaharb, Hacer Erdola a
Instructor at Nursing School, Faculty of Health Sciences, Karadeniz Technical University, Trabzon, 61080, Turkey b Nurse at Education Unit of Directorate of Trabzon Public Hospital Union, Trabzon, 61100, Turkey
Abstract One of the main problems in the provision of nursing services in Turkey is that nurses are not able to transfer their theoretical knowledge and skills to practice sufficiently. This study aims to uncover the causes of this situation. This descriptive research was carried out with 176 nurses working in five public hospitals in a metropolis in the northeast of Turkey. Numerical and percentage values were used in the evaluation of data. As a result, nurses' clinical working environment (72.7%), the clinic's physical structure and hardware (75.0%), health care team members (80.1%), management's attitude (65.9%) and institutional / health policies (67.6%) were found to be significantly influential in transferring their training to clinics. © 2015 2015The TheAuthors. Authors.Published Published Elsevier © byby Elsevier Ltd.Ltd. This is an open access article under the CC BY-NC-ND license Peer-review under responsibility of Academic World Education and Research Center. (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of Academic World Education and Research Center Keywords: Factors influencing nursing care, nursing undergraduate education, clinic, Turkey;
1. Introduction With the development of technology, care requirements vary, and day by day people increasingly demand for quality nursing care. This situation enhances the expectations and the need for highly motivated and innovative nurses with advanced professional qualifications in the health care system (Sabacıoğulları & Doğan, 2014). Despite the increasing demand for quality nurses, the professional qualities of nurses such as autonomy, problem solving,
* Kıymet Yesilcicek Calık. Tel.: +90-4623778865. E-mail address: [email protected]
1877-0428 © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of Academic World Education and Research Center doi:10.1016/j.sbspro.2015.04.073
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responsibility and care competence were found to have problems in the studies carried out in our country (Sabancıoğulları & Doğan, 2014; Kelleci, Gölbaşı, Yılmaz & Doğan, 2008). This is because uncertainty of nurses' duty, adverse physical environment, working involuntarily in other units and long working hours (Nehir, 2003; Stordeur, D’Hoore & Vandenberghe, 2001), the number of patients receiving care (Ergüney, Tan, Sivrikaya & Erdem, 2001; McVicar, 2003), excessive work load (İleri & Kocaman, 2007; Healy & McKey, 2000; Callaghan, Tak-Ying & Wyatt 2000), lack of high quality material/ equipment, patient, patients’ relatives, team communication problems, lack of motivation ( Gjerberg, Førde, Pedersen & Bollig, G. 2010; Uğurlu, Yılmaz & Karacak 2010; Öztürk, Yılmaz, & Demir, 2009) different levels of education have led nurses to have non-purpose roles (Çınar & Demir, 2009). Certainly, this situation may reduce professional qualifications of nurses and lead nurses to give insufficient care and be desensitized. At the same time, insufficient nursing practices cause nurses to be perceived as technicians that give only treatment, and nursing profession is perceived negatively by the community and other health professionals (Deppoliti, 2008; Sabancıoğulları & Doğan, 2014; Yıldırım, Sezgin & Timuçin, 2007; http://www.turkhemsirelerdernegi.org.tr 2013). As can be understood, the problem is related to working order, manpower planning and management. Clarifying the nurses’ roles within the health care team and reducing the miscommunication in the team will increase job satisfaction, and consequently service effectiveness, efficiency, patient and staff satisfaction will increase (O’Connel & Twigg, 1999; Karadağ & Taşçı, 2005). Nurses’ being able to provide optimal care to individuals can be achieved with arrangements in these factors. Nurses’ being able to implement their theoretical knowledge and skills that they received in their fields, improving nursing practice, solving existing and possible future professional issues will be guiding for the strategies to be made and established for the image of the profession and professional development. This study was conducted to determine the problems faced by graduate nurses working at the hospital in transferring their undergraduate education to clinic and the influential factors on them. 2. Method 2.1. Type of Research: This study is cross-sectional and descriptive. 2.2. Population and Sample The research population consisted of 517 nurses with undergraduate degrees and working in five public hospitals in a metropolis located in a province in northeastern Turkey (Trabzon). 176 nurses with at least 6 month-working experience and who agreed to participate the study were included in the study sampling after selected by using 5% selected reliability proportional stratified sampling technique. Nurses working in polyclinics, laboratory and managerial positions were excluded from the study. 2.3. Data Collection Tool In the collection of data, a questionnaire prepared by the researchers as a result of an extensive literature study was used. In the data collection tool; there are nurses' personal and professional status variables (age, education, the institutions they work, professional and institutional experience) and 17 questions about the influential factors in transferring under graduate education to clinical practice. The factors that are influential in transferring under graduate education to clinical practice were assessed by seven dimensions developed by the researchers. These dimensions consist of the impact of undergraduate education adequacy, clinical work environment, the clinic's physical competence, health care team members and the management and institutional health policies. 2.4. Data Collection
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Data were collected between January-June 2014 after consultation with the directors of nursing services and institutions (hospitals and related Trabzon Provincial Health Directorate) and after receiving formal written permission. After the completion of the permitting process, the managers of nursing services were interviewed again, the hospitals were visited on designated days, and the data collection tool was administered with voluntary nurses using face to face interview technique. The interviews were held at nurses’ room, and each interview took about 30 minutes. 2.5. Data analysis The data were analyzed using the SPSS 17.0 program. In the analysis of the data, descriptive analyses (percentage, average) were used. In this study, all findings were tested at p <.05 significance level. 2.6. Limitations of the Study That the results are representative for only the institutions in a province of Turkey where the study was conducted was accepted as the limitation of the study. 3. Findings The analysis of research data showed that 94.3% of nurses were female, 67.6% were married, 31.43 ± 6.38 years old on average and the majority of them (51.1%) were in 20-29 age group, 47.1% had 1-5 year working experience and 62.5% 1-4 year of working experience in the institution, 62.5% were ward nurses, 79.5% worked 40 hours per week, 51.7's% had shift work schedules, 63.6% were responsible for 11 patients and over, and 72.7% did not participate in scientific studies related to nursing. 75.0% of the participants stated that theoretical education they had received in their undergraduate courses was adequate but practical training was inadequate (66.5%). Table 1. The effect of working environment and physical hardware of clinics in transferring undergraduate education to clinics (n=176) Is working environment influential? Yes No How does the work environment influence?* Staff shortage Long and exhausting working hours Nurses shortage Fatigue and lack of motivation Uncertainty of duties, powers and responsibilities Failure in the appropriate employment of the nurses Excessive workload Excessive number of patients High age average of nurses Operating at off-duty work I have no idea Is physical hardware of the clinic influential? Yes No How does physical hardware of the clinic influence?* Lack of sufficient and high quality material/equipment Supplying drugs late Poor quality products causes time loss and process repetition Delaying application to patients or unavailable at all Quality of nursing care falls I have no idea * More than one answer was given and percentages were calculated based on n.
Number 128
Percentage 72.7
48
27.3
43 48 58 45 55 39 44 56 7 44 2
24.4 27.3 33.0 25.6 31.2 22.2 25.0 31.8 4.0 25.0 1.1
132 44
75.0 25.0
72 39 60 31 46 5
40.9 22.2 34.1 17.6 26.1 2.8
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72.7% of the nurses indicated that their working environment is influential in transferring their professional knowledge and skills that they had received during their undergraduate education to clinics. 33.0%, 31.8%, 31.2% of the nurses were experiencing nurse shortage, excessive number of patients and their unclear duties, powers and responsibilities as the problems resulting from the work environment respectively. 75.0 % of the nurses stated that physical hardware of the clinic is influential in transferring the professional knowledge and skills they had received in their undergraduate education to clinics. Lack of sufficient and high quality material/equipment, poor quality products that led time loss and process repetition and reduction in the quality of nursing care were regarded as problems by 40.9%, 34.1% and 26.1% of nurses respectively (Table 1). Table 2. The effect of the health care team members and management in transferring undergraduate education to clinics (n = 176) Are health care team members influential?Yes No How do the health care team members influence? * Nurses without undergraduate degree and inexperienced nurses Nurses and doctors are not innovative Lack of harmony and communication among team members Unsupportive team members Team members do not know their responsibilities Doctors impose sanctions on nurses for their own duties I have no idea Is management influential ? Yes No How does management influence?* Lack of management support, fairness and respect Mobbing application Not being supportive for nurses to participate in scientific studies Failure in acting selectively in determining the supervisor nurses Inability to generate solutions to problems Not controlling and caring about the quality of care and supervision Not being innovative in education and being open to change Not using rewarding system appropriately Not protecting nurses’ rights and remedies Forcing nurses to do off-duty works I have no idea * More than one answer was given and percentages were calculated based on n.
Number 141 35
Percentage 80.1 19.9
59 26 74 39 30 62 5
33.5 14.8 42.0 22.2 17.0 35.2 2.8
116 60
65.9 34.1
90 40 27 14 50 8 5 41 53 68 5
51.1 22.7 15.3 8.0 28.4 10.2 2.8 23.3 30.1 38.6 2.8
80.1% of the participants indicated that the members of health care team were influential in transferring their professional knowledge and skills that they had received during their undergraduate education to clinics. 42.0%, 35.2%, %33.5% were experiencing lack of harmony and communication among team members, doctors’ imposing sanctions on nurses for their own duties and nurses without undergraduate degree and inexperienced nurses as problems respectively. 65.9 % expressed management’ attitude as an important factor in transferring their professional knowledge and skills during undergraduate education to clinics. Lack of management support, fairness and respect, being forced to do off-duty works and not protecting nurses’ rights and remedies are perceived as problems by %51.1, %38.6 and %30.1 of the participants respectively (Table 2). Table 3. The effect of institutional/health policies in transferring undergraduate education to clinics (n=176) Are institutional and health policies influential? Yes No How do institutional and health policies influence?* Health policies that do not support nurses Considering nurses as assistant health care staff Not taking employees’ opinions into consideration while establishing Health Policies Differences between institutional mechanism and the things taught during undergraduate education Abuse of patients’ rights by patients and their relatives
Number 119 57
Percentage 67.6 32.4
80 37 31 39
45.5 21.0 17.6 22.2
32
18.2
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Inhibition of innovation in the health sector by politicians Failure in enforcing standards of nursing care I have no idea * More than one answer was given and percentages were calculated based on n.
21 30 6
11.9 17.0 3.4
67.6% of the nurses noted that institutional and health policies were influential in transferring their professional knowledge and skills to clinics. 45.5%, 22.2% and 21.0% of the participants were experiencing health policies that do not support nurses, the differences between institutional mechanism and the things taught during undergraduate education and being regarded as assistant health care staff as problems (Table 3). 4. Discussion In this section, in line with the findings from the study, the sufficiency of the professional knowledge and skills of the nurses during undergraduate education and the factors that are influential in transferring these knowledge, and skills into nursing care and clinics are discussed. Although theory and practice skills in nursing education are given sufficiently, this accumulation can not be transferred into applications at desired level (Karaöz, 2003; Sabancıoğulları & Doğan, 2014). In our study, 75.0% of the nurses expressed that they had adequate theoretical knowledge but inadequate practical training during their undergraduate education (66.5%). In the previous studies, it has been stated that new graduate nurses are insufficient to fulfill the basic nursing skills, and they need to develop them (Hiton & Polland, 2004; Solyers, 2007; Yiğit, Esenay & Derebent, 2007). In a study carried out with nurses, Buldukoğlu, Kantek, and Öncel, (2004) found out that 35.6% of the participants indicated the university training they had received was adequate in the workplace, while 44.7% and 17.1% considered it as partially adequate and insufficient respectively. The results of previous studies support our research results. The provision of quality health services depends on working environment supporting health workers' capacity, performance and health. In our study, 72.7% of the nurses stated that working environment and clinic's physical hardware is influential in transferring their professional knowledge and skills to clinics. The top three opinions of nurses related with work are nurses’ shortage (33.0%), excessive number of patients (31.8%) and lack of certainty about duties, powers and responsibilities (31.2%) (Table 1). Nurses’ excessive work load due to the high patientnurse ratio lead to nurses’ fatigue both physically and spiritually, and as a result of this overload nurses confront physical and mental diseases (http://www.turkhemsirelerdernegi.org.t of 2013; ICN, 2006). Previous studies show that stress factors that affect the nurses most in the working place are role uncertainty, involuntarily work in other units, (Nehir, 2003; Stordeur, D’Hoore & Vandenberghe 2001), the number of patient receiving care (Ergüney, Tan, Sivrikaya &Erdem, 2001; McVicar, 2003), excessive work load (İleri & Kocaman, 2007; Healy & McKay, 2000). Nursing is the only discipline where there are non-specific working and application area borders and nurses roles are tried to be identified other than themselves in the health workforce. In the health work environment, instead of functioning directly for patient care for professional purposes, nurses are forced to perform as imposed by the system away from caring itself. Health institutions in Turkey inherently (insufficient staff, inadequate tools and equipment, physical space deficiencies) have many problems in terms of employees. In our study, 75.0% of nurses stated that the physical hardware of the clinics is influential in transferring their professional knowledge and skills they received during their undergraduate education to clinics. The top three views of nurses regarding clinic’s physical sufficiency are lack of sufficient and high quality material/equipment (40.9%), poor quality products cause time loss and process repetition (34.1%), and this situation lowers quality of nursing care (26.1%) (Table 1). In the service sector, especially at hospitals despite the excessive number of patients and over workload, incomplete and inappropriate materials/devices have been identified as the most stressful situations (Argon, Özgür & Vatan, 2001). The previous studies also show that among health care personnel, nurses are the ones who have problems in giving care due to staff and material shortage and physical environment the most ( Gjerberg, Førde, Pedersen & Bollig, 2010; Uğurlu, Yılmaz & Karacak, 2010; Mollaoğlu, Kars & Özkan, 2009; Öztürk, Yılmaz & Demir, 2009). Lack of sufficient material inevitably causes time loss and the process repetition and thus deterioration in the quality of nursing care. In our study, 80.1% of the nurses indicated that health care members are influential in transferring professional
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knowledge and skills received during undergraduate education to clinics. The first three views regarding the impact of health care members are lack of harmony and communication among team members (42.0%), doctors’ imposing sanctions on nurses for their own duties (35.2%) and nurses without undergraduate degree and inexperienced nurses (33.5%) (Table 2). Effective communication and teamwork among health care workers is very important. The team is a group acting in accordance with a common purpose. The harmony and success of the team depends on identifying the roles and functions of each member clearly, being in effective communicative and cooperative atmosphere (Nadzam, 2009; Kumcağız, Yılmaz, Balcı, Çelik &Aydın, 2013; McVicar, 2003) and each member’s fulfilling their roles and functions at the highest level (Erdemir, 1998). According to the previous studies, 31.3% of the nurses regarded communication problems in the health care team as a factor influencing the care they gave (Karadağ &Taşçının, 2005), had insufficient duty identification, had to do a lot of off duty things (Uygur, Kaya, Kaya & Karaman, 2009; Stewart, 2009; Önerbay & Sayan, 2009), did a lot of work other than their own duties which was the most important factor leading to role ambiguity (Ocak, Gider, Top, Şahin & Tarcan, 2004) and doctors’ imposing behaviors and attitudes towards nurses caused conflicts (Copnell et al., (2004). Similar to our study, in their studies Çimensel and Argon (2000), Brinket (2010), Hendel, Fish, and Galon, (2005). also emphasize that nurses have troubles with doctors because of "the doctor authority and repression". Communication problems lead to problems in patients’ treatment and care, eliminate inter professional support and increase work stress (Nadzam, 2009; Arıkan & Karabulut, 2004). It is obvious that problems in communication not only causes work stress but also may affect services and service areas as well. International Labour Organization (ILO) defines the major stressors in the work environment as conflicts with managers, role conflicts and ambiguity (ILO, 2001; Mollaoğlu, Kars & Özkan, 2009). In our study, 65.9% of the nurses indicated that the attitude of the management is influential in transferring their professional knowledge and skills to clinics. This top three views of nurses on the impact of management are lack of management support, fairness and respect (%51.1), making nurses operate at off-duty work (%38.6) and not protecting nurses’ rights and remedies (%30.1) (Table 2). Political and bureaucratic pressures, managerial problems, non supportive management style, lack of rewarding, lack of management respect, lack of constructive feedback and inability to perform nursing practices appropriately due to the bureaucratic reasons has resulted in difficulties and restrictions in nurses’ nursing applications (Argon, Özgür & Vatan, 2000; Stewart, 2009; Deveci, 2008; Mersinlioğlu, Balık, Kurt, Sayan, Öztürk &Demirbağ 2014). Similarly, Özkan (2008), Hendel, Fish and Galon (2005), Akça and Ergüç (2006) and Brinket (2010) pointed out in their studies that management style provide the least satisfaction for nurses. They experience conflicts with managers, cannot get enough support from them, and they request respect, love, democratic approach and solutions to problems respectively from their managers. In our study, 67.6% of the nurses stated that institutional and health policies are influential in transferring professional knowledge and skills during undergraduate education to clinics. Among the views of nurses regarding institutional and health policies, the first three are health policies that do not support nurses (45.5%), differences between institutional mechanism and the things taught during undergraduate education (22.2%) and nurses’ being regarded as assistant health care personnel (21.0%) (Table 3). Politics is one of the most important factors influencing their practices. In our country, when the laws and regulations organizing the nurses 'working conditions, duties, powers and responsibilities and the delivery of nursing services are examined, it is clearly seen that nurses working under the Law No. both 657 and 4857 experience serious gaps and human rights violations related to working hours and their duration, wage distribution and especially in shift working system. Besides, there are not sufficient regulations protecting human rights violations or effective control (http://www.turkhemsirelerdernegi.org.tr 2013). In the previous studies, existing laws and regulations related to nurses have been found out to be far from responding to the needs (Mersinlioğlu, Balık, Kurt, Sayan, Öztürk & Demirbağ 2014; Öztürk, Yılmaz & Demir, 2009; http://www.turkhemsirelerdernegi.org.t 2013). Besides physical, mental and social difficulties experienced by the nurses because of the unsupportive laws about nursing services, the most crucial problem here is that the security of nursing care which requires extreme attention and energy cannot be ensured and consequently public health is jeopardized.
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5.
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Results and Recommendations
In our study, nurses with undergraduate degree were determined to experience various difficulties in transferring their knowledge and skills that they had received during their undergraduate education into practice. These issues are experienced in working order, human resource planning, and management and health policies. These are reflected in nursing practice as inability to use the professional knowledge and skills effectively and fulfill nursing independent functions; care giving and helping adequately. As a result, society can not receive quality nursing care and nursing potential in achieving health goals can not be assessed. Therefore, the causes of nurses’ problems should be determined institutionally, and managerial, departmental, and individual measures should be taken for employees. Acknowledgements The authors especially thank all of the participating nurses. References Akça, C., & Erigüç, G.(2006). A study on reasons of conflict the hospital employees experience with their managers and colleagues. Hacettepe Journal of Health Administration, 9(2): 126-153. Argon, G., Özgür, G., & Vatan, F. (2000). Nurses' perceptions of their working lives in hospitals. 1st International & VIII. National Nursing Congress. Antalya, Turkey. 81-85. Arıkan, D., & Karabulut, N. (2004). Work-related strain in nurses and determination of the factors affecting this. Journal of Atatürk University School of Nursing, 7(1):10-18. Brinket, R. (2010). A literature review of conflict communication causes, costs, benefits and interventions in nursing. Journal of Nursing Management, 18: 145-156. Buldukoğlu, K., Kantek, F., & Öncel, S. (2004). Educational evaluation and improvement of study: First three semesters of college graduates in Antalya the views of health. Nursing Forum, 7 (2): 8-16. Callaghan, P., Tak-Ying, S. A., & Wyatt, P. A. (2000). Factors related to stres and coping among chinese nurses in Hong Kong. Journal of Advanced Nursing, 31 (6), 1518-1527. Çimensel, İ., & Argon, G. (2000). An investigation on the views of nurses regarding the causes of organizational conflict. 1st International & VIII. National Nursing Congress, Antalya, Turkey. 174-178. Çınar, Ş., & Demir, Y.(2009). Nursing image in community: A scale development study. Journal of Atatürk University School of Nursing, 12: 2, 24-33. Copnell, B., Johnston, L., Harrison, D., Wilson, A., Robson, A., Mulcahy, C., Ramudu, L., McDonnell, G., & Best, C. (2004). Doctor’s and nurses perception of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practioner model of practice. Journal of Clinical Nursing, 13(1): 105–113. Deppoliti, D. (2008). Exploration how new registered nurses construct professional identity in hospital settings. The Journal of Continuing Education in Nursing, 39(6):255-62. Deveci, F. (2008). Stress and job satisfaction, midwives and nurses working in hospitals in the province of Sinop attitude and behavior after stress. Health and Hospital Administration Congress Proceedings Book. Ankara: Health Administrators Association. 400-409. Erdemir, F. (1998). The roles and functions of nurses and the philosophy of nursing education. Journal of Cumhuriyet University School of Nursing, 2(1), 59-63. Ergüney, S., Tan, M., Sivrikaya, E., & Erdem, N. (2001). Occupational risks that nurses face. Journal of Atatürk University School of Nursing, 4 (1), 63-73. Gjerberg, E., Førde, R., Pedersen, R., & Bollig, G. (2010). Ethical challenges in the provision of end-of-life care in Norwegian nursing homes. Social Science & Medicine, 71: 677-684. Healy, M., & McKey, M. F. (2000). Nursing stress: The effects of coping strategies and job saticfaction in a sample of Australasian nurses. Journal of Advanced Nursing, 31 (3), 681-688. Hendel, T., Fish, M., & Galon, V. (2005). Leadership style and choice of strategy in conflict management among Israeli nurse managers in general hospitals. Journal of Nursing Management, 13: 137-146. Hiton, P., & Polland, C.(2004). Supporting clinical skills develop. Nurs Stand ,18(25):31-6. http://www.turkhemsirelerdernegi.org.tr/menu/hemsirelik-yayinlari/yayinlar/turkiyede-hemsirelerin-calisma-kosullari.aspx.Updated September 14, 2014. Accessed April 20, 2013. İleri, S., & Kocaman, G. (2007). An investigation on new graduate nurses' perceptions about transition to professional roles and the influential factors. 4th International 11th National Congress of Nursing, Ankara, Turkey. 89. ILO, 2001 http://www.ilo.org/safework_bookshelf/english? content&nd= 857170174 (28.01. 2012) Definition of occupational health adopted by the Joint ILO/WHO Committee on Occupational Health (1950). International Council of Nurses (ICN), (2006). Healthy lives employment, information and action guide international nurses day.
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