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Beginning nursing students' perceptions of the effective characteristics and caring behaviors of their clinical instructor

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Noreen Nelson
Abstract:
Demonstration of caring behaviors and the importance of effective characteristics are identified as important influences in a nursing student-clinical instructor relationship. The purpose of this study was to examine associate and baccalaureate degree traditional and nontraditional nursing students' perceptions of clinical instructors to provide insights into the dynamics of the student-instructor relationship with regard to caring behaviors and effective characteristics in a beginning level clinical setting. Data was collected from a sample of 503 male and female nursing students at the end of 2009 from four accreditated nursing programs located in an urban setting. Findings of this study support the overall reliability of Whitehead's Characteristics of Effective Clinical Instructor Rating Scale (WCECIRS) and the Nursing Student Perception of Instructor Caring (NSPIC) tool as instruments to measure, respectively, effective characteristics and caring behaviors of clinical instructors. Data presented from this study indicates age and gender may influence nursing students' perceptions. Study results of traditional and nontraditional student nurses revealed common and unique perspectives on the importance of a clinical instructor demonstrating effective characteristics. In addition, caring behaviors demonstrated by clinical instructors were identified. Data revealed nursing students, except for baccalaureate nursing students age 33 and over, perceived their clinical instructors demonstrated the highest number of caring behaviors from the subscale of instills confidence through caring. Conversely, associate and baccalaureate degree nursing students perceived some clinical instructors less frequently demonstrated caring behaviors within the subscales of supportive learning climate and appreciation of life's meanings. Some effective characteristics were also perceived as caring behaviors. Nursing students' perceptions of the importance of these effective characteristics and their demonstration as caring behaviors by clinical instructors were presented. Implications for both types of programs are that clinical instructors need to demonstrate caring behaviors to reduce beginning level student nurses anxiety. Clinical instructors in baccalaureate programs need to demonstrate caring behaviors in regards to evaluation procedures. Furthermore, clinical instructors in associate programs need to demonstrate caring behaviors in regards to the flexibility needed for adult learners. An implication for nursing programs is to consider the incorporation of the science of caring into their curriculum.

Table of Contents Acknowledgments iv List of Tables ix CHAPTER 1. INTRODUCTION 1 Introduction to the Problem 1 Background of the Study 3 Statement of the Problem 10 Purpose of the Study 11 Rationale, Relevance and Significance of the Study 11 Research Questions 13 Study Variables 14 Nature of the Study 14 Definition of Terms 17 Assumptions 20 Limitations 20 Theoretical Framework 20 Organization of the Remainder of the Study 22 CHAPTER 2. LITERATURE REVIEW 24 Introduction 24 Historical Context of the Concept of Caring in Nursing 24 Theoretical Framework 26 Review of Clinical Learning Dimensions 33 Effective and Ineffective Clinical Teaching 41

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Qualitative Research on Effective Characteristics 41 Quantitative Research on Effective Characteristics 44 Historical Context of Caring Behaviors 55 Qualitative Research on Caring Behaviors 56 Quantitative and Mixed Method Research on Caring Behaviors 57 Associate and Baccalaureate Nursing Programs 62 Traditional and Non-traditional Nursing Students 65 Evaluation of Viable Research Designs 71 Summary 75 CHAPTER 3. METHODOLOGY 79 Introduction 79 Research Questions 80 Philosophical Alignment of Methodology 81 Research Design Model 85 Research Design Strategy 86 Limitations of Research Design Strategy 88 Sampling Design 90 Measures and Rationale 91 Instrumentation 92 Data Collection Procedure 94 Data Analysis Procedure 96 Ethical Issues 99 Summary 100

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CHAPTER 4. DATA COLLECTION AND ANALYSIS 102 Introduction 102 Research Questions 102 Description of the Population 104 Instrumentation 104 Data Analysis Overview 105 Results 106 Demographic Findings 107 Primary Research Question 109 Additional Research Questions 117 Effective Characteristics and Caring Behaviors 159 Summary 160 CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS 162 Introduction 162 Summary of the Study 163 Summary of Research Questions 164 Effective Characteristics and Caring Behaviors 170 Discussion of Results 170 Discussion of Reliability 174 Relationship to Theory 176 Limitations of this Study 177 Implications for Teaching in the Clinical Setting 178 Implications for Associate and Baccalaureate Program Curriculum 183

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Recommendations for Future Research 184 Summary and Conclusions 186 REFERENCES 188 APPENDIX A. WCECIRS 203 APPENDIX B. NSPIC 205

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List of Tables Table 1. Most Important Effective Characteristics: Associate & Baccalaureate 110 Table 2. Perceptions of Effective Characteristics by Categories 111 Table 3. Perceptions of Caring Behaviors by Subscale 116 Table 4. Most Important Effective Characteristics: Male Associate 118 Table 5. Most Important Effective Characteristics: Female Associate 119 Table 6. Associate: Male and Female Perceptions 121 Table 7. Most Important Effective Characteristics: Male Baccalaureate 123 Table 8. Most Important Effective Characteristics: Female Baccalaureate 124 Table 9. Baccalaureate: Male and Female Perceptions 125 Table 10. Male and Female Results by Caring Subscales 132 Table 11. Effective Characteristics by Age Groups: Associate 136 Table 12. Effective Characteristics by Age Groups: Baccalaureate 141 Table 13. Caring Behaviors by Age Groups: Associate 149 Table 14. Caring Behaviors by Age Groups: Baccalaureate 157 Table 15. Effective Characteristics and Caring Behaviors 171

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CHAPTER 1. INTRODUCTION

Introduction to the Problem Nursing students are prepared in both the classroom and clinical setting to become registered nurses through successful completion of a diploma, associate, baccalaureate or, in more recent years, a masters‟ program and the successful passage of the national nursing licensing exam. Nursing students spend the majority of their nursing education in the clinical setting with a clinical instructor. Beginning level nursing students are placed in the clinical setting with patients in their first semester of a nursing program. In baccalaureate programs, these students would be considered juniors. In associate programs, beginning level students are considered first year nursing students. Each semester of didactic course work has one or more concurrent clinical components with the average student-instructor ratio of six to eight students per instructor in the clinical setting with patients. Research studies and standards for nurse educators supported the importance of the relationship between clinical instructors and students (Barham, 1965; Beck, 1991; Brown, 1981; Gignac-Caille & Oermann, 2001; Jacobson, 1966; Kiker, 1973; Knox & Morgan, 1985; National Council of State Boards of Nursing, 2005; National League for Nurses, 2002; Wade, 2003; Whitehead, 1997). Nursing students learn from the behaviors, knowledge, experience and skills of their clinical instructors. Successful development of nursing students into a professional role as caring nurses is increasingly believed to be dependent on the quality of the clinical learning environment (Amendola, 1998; Bruderle, 2003; Charasika, 1998; Duffy, 1993; Hofler, 2008; Jenkins, 2006; Laitinen-Vaananen,

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Talvitie & Luukka, 2007; McBrien, 2006; Wang Letzkus, 2005; Waterman, 2007; Whitehead, 1997; Wilkes, 2006). Conversely, perceptions of unfair treatment by nursing faculty leads to student nurses voicing their concerns, leaving a program or conforming to the situation to avoid being failed (Clark, 2008). According to Thomas (2003), some nurses still harbor negative feelings of unfair faculty treatment even after 10-20 years. Two major areas of research on student-instructor relationships have emerged as important to the clinical education of nursing students. One area is related to nursing student and faculty perceptions of clinical instructor characteristics considered effective or ineffective (Benor & Leviyof, 1997; Brown, 1981; Jacobson, 1966; Knox & Morgan, 1985; Kotzabassaki, Panou, Dimou, Karabagli and Ikonomou, 1997; Kube, 2010; Li, 1997; O‟Shea & Parsons, 1979; Tang, Chou & Chiang, 2005; Wiles, 1995; Woo-Sook, Cholowski & Williams, 2002). The second and more recent area is related to caring behaviors of clinical instructors (Beck, 1991; Clawson Roe, 2009; Duffy, 1993; Kube, 2010; Langford, 2007; Lin, 2001; Wade, 2003; Wang Letzkus, 2005). Subsequent studies on the caring dimensions influencing nursing student- instructor relationships tended to indicate differences based on mediating variables such as ethnicity, gender, or level of student in the program (Eberhard, 1998; Gardner, 2005; Grady, Stewardson & Hall, 2008; Langford, 2007; McManemy, 2002; Sutherland, Hamilton & Goodman, 2007; Wade, 2003). Findings from the Pew-Fetzer task force report indicated that within a learning environment “the caring relationship between practitioner and patient is modeled by the nurturing environment that students, faculty, and practitioners themselves create through the quality of their relationships” (Tresolini & the Pew-Fetzer task force, 1994, p. 42).

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One way for nursing programs to support standards of quality within their programs is to obtain accreditation. All nursing programs are required to be certified by their state board of nursing prior to seeking national accreditation by an outside agency. The National League for Nurses Accreditation Commission (NLNAC) and the Commissions of Collegiate Nurse Educators (CCNE) are the two national accreditation agencies developed and utilized in the United States by nursing programs to achieve accreditation.

Background of the Study

Barham (1965) was the first researcher to study nursing student-instructor relationships in regards to the effectiveness of nursing instruction in the learning environment. Nursing students, in subsequent research studies conducted nationally and globally, identified characteristics of an effective and ineffective clinical instructor (Allison-Jones & Hirt, 2004; Benor & Leviyof, 1997; Holmes, 2006; Kotabassaki et al., 1997; McBrien, 2006; Morgan & Knox, 1987; Nehring, 1990; Tang et al., 2005; Woo- Sook et al., 2002). Whitehead (1997) developed an instrument to measure effective characteristics of clinical instructors which included concepts suggestive of caring. According to Kube (2010), student learning in the clinical setting was facilitated by a higher demonstration of effective teaching behaviors. Caring as the core of nursing was one of the beliefs identified in Watson‟s (1979) theory of human caring. Beginning in the 1990s, research, mostly qualitative, identified the caring of faculty as important in creating a positive learning environment, student development of professionalism, retention in nursing programs or the successful

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transition of a nursing student to a novice nurse (Amendola, 1998; Blackstock, 2003; Clark, 2006, 2008; Griffiths & Tagliareni, 2001; Langford, 2007; McManemy, 2002; Waterman, 2007). Wade (2003) developed the only instrument to date on the measurement of nursing student perceptions of the caring behaviors of an instructor in the clinical setting. Clinical Learning Environment Multiple studies established the learning environment in the clinical setting as a critical dimension for nursing student integration of theory into practice, program satisfaction or successful program completion (Blackstock, 2003; Clark, 2006; Eberhard, 1998; Griffiths & Tagliareni, 2001; Jenkins, 2006; McGregor, 2007; McManemy, 2002; Sutherland et al., 2007; Waterman, 2007). Research also revealed a poor learning environment, or learning in the presence of student anxiety, hindered effective learning in the clinical setting (Audit, 1995; Clawson Roe, 2009; Cook, 2005; Dearnley & Matthew, 2007; Thomas, 2003; Wang Letzkus, 2005). Several research studies explored student nurses perceptions in regards to anxiety and stressors within the clinical learning environment (Lengacher, 1996; Pagana, 1988). According to Pagana (1988), nursing student descriptors of stressors included five dimensions. These dimensions were as follows: (a) feeling personal inadequacy, (b) harming a patient by making an error, (c) feeling threatened by their clinical instructor, (d) fear of the unknown, and (e) fear of failing (Pagana, 1988). Baccalaureate nursing students in a study conducted by Lengacher (1996) reported the highest levels of stress were associated with the first clinical experience and nursing students perceived level of

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self-esteem. According to Lengacher (1996), associate degree nursing students were reported to have a higher level of role strain than baccalaureate degree nursing students. Accreditated Nursing Programs Accredited nursing programs are expected to measure student outcomes. Expected student outcomes include data on graduation rates and passage of the nursing licensing exam on the first attempt. The National Council of State Boards of Nursing (2005) recommended that improvements were needed within nursing education and nursing student-clinical instructor relationships. Research supported the presence of an effective caring clinical instructor may influence student nurses outcomes (Clark, 2006; Eberhard, 1998; Griffiths & Tagliareni, 2001; Jenkins, 2006; Kube, 2010; McGregor, 2007; McManemy, 2002; Sutherland et al., 2007). Clinical Instructors and Effective Characteristics Beginning in the 1960s, through qualitative inquiry, nursing students identified characteristics of an effective or ineffective clinical instructor (Barham, 1965; Humphrey, 1987; Jacobson, 1966; O‟Shea & Parsons, 1979; Wong, 1978). A plethora of quantitative research was subsequently conducted on the differences in the perceptions of either associate or baccalaureate degree nursing students and faculty in regards to the effective characteristics of a clinical instructor (Gignac-Caille & Oermann, 2001; Kotzabassaki et al., 1997; Morgan & Knox, 1987; Nehring, 1990; Woo-Sook et al., 2002). Findings from studies on student and faculty perceptions of effective characteristics tend to indicate the following: (a) a variance in nursing students and faculty perception of the important characteristics of an effective clinical instructor that continued to persist over time, (b) presence to an unknown extent of the existence of an effective learning environment, (c)

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improvement needed in the skills and knowledge of clinical instructors to increase effectiveness in their role, (d) the need for additional research of the nursing student- clinical instructor relationship, and (e) characteristics of the clinical instructor identified as most important to students involved actions that tended to indicate caring behaviors (Gignac-Caille & Oermann, 2001; Holmes, 2006; Kotzabassaki et al., 1997; Morgan & Knox, 1987; Nehring, 1990; Wiles, 1995; Woo-Sook et al., 2002). Studies conducted on the similarities or differences of student nurses perceptions of effective teaching characteristics focused on either associate or baccalaureate programs in the clinical setting with the exception of one prior study. Poole (1982) conducted a study with a sample of associate and baccalaureate degree nursing students on their perceptions of teaching behaviors and teacher characteristics in the clinical setting. Three dimensions of teaching behavior were revealed as important in the clinical learning environment. These dimensions were related to the following: (a) professional nursing competence of clinical instructors, (b) interpersonal relationship skills, and (c) evaluation procedures (Poole, 1982, p. 232). Whitehead (1997) combined elements of caring dimensions with effective characteristics in a researcher developed instrument, the Whitehead‟s Characteristics of Effective Clinical Instructors Rating Scale (WCECIRS). Associate degree student nurses perceptions revealed that all of the effective characteristics were considered important for an instructor to demonstrate. According to Whitehead, “the essential dimensions of nursing instruction (were) interpersonal skills, professional nursing competence, adult instruction and evaluation skills, communications, and human caring” (p. 5).

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Kube (2010) conducted the first study which correlated the demonstration of effective characteristics of clinical instructors with baccalaureate degree student nurses perceptions of their learning in the clinical setting. Nursing students perceived a higher level of learning in the presence of a higher demonstration of effective characteristics by clinical instructors. According to Kube, nursing students perceived caring teaching behaviors positively influenced their learning in the clinical setting. Clinical Instructors and Caring Behaviors Swanson (1999) identified only one nursing student-clinical instructor study in a meta-analysis of caring research from 1980 to 1996. This qualitative study by Beck (1991) focused on student perceptions of faculty caring. Concepts of caring and their importance in nursing education continue to evolve (Beck, 2001; Clawson Roe, 2009; Leininger, 1991, 1993; Leininger & Watson, 1990; Watson, 1985, 2008; Wade, 2003). Research revealed the presence of caring behaviors facilitated nursing student learning or patient outcomes (Bevis & Watson, 1989; Clawson Roe, 2009; Duffy & Hoskins, 2003; Kube, 2010; Schumacher, 2005; Wade, 2001; Wang Letzkus, 2005; Waterman, 2007). One important variable to the success of nursing students or new nurses in practice was identified as the caring behaviors of nursing instructors in the learning environment (Amendola, 1998; Clark, 2006; Clawson Roe, 2009; Schumacher, 2005; Wade, 2001; Wang Letzkus, 2005; Waterman, 2007). Caring behaviors of nursing faculty toward students have emerged as a possible influencing factor to the retention of nursing students (Clark, 2008; Gardner, 2005; McManemy, 2002; Sutherland et al., 2007). Wade (2003) conducted a study with a sample of baccalaureate nursing students to develop a caring scale to measure caring behaviors of nursing instructors in the clinical

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setting. Wang Letzkus (2005) replicated Wade‟s study and found similar results. In the studies by Wade and Wang Letzkus, junior nursing students identified a greater importance of caring behaviors than seniors in a baccalaureate program sample. Wade and Wang Letzkus recommended research with associate degree programs. Clawson Roe (2009) reported data on research with baccalaureate junior and senior nursing students and clinical faculty as it related to stress and caring in the clinical setting. According to Clawson Roe, baccalaureate student nurses perceived stressors as a challenge in the presence of a caring instructor. Conversely, when clinical instructors‟ demonstrated caring behaviors less frequently, nursing students perceived stressors as a threat or as harm (Clawson Roe, 2009). In the studies conducted by Wade (2003), Wang Letzkus (2005), and Clawson Roe (2009), age and gender were not included as variables. Traditional and Non-traditional Beginning Nursing Students Historically, traditional nursing students in baccalaureate and associate degree programs were categorized as female, single, white, non-Hispanic, between the ages of 18-25 and considered first degree students (Langford, 2007; Persaud, 2002). Non- traditional nursing students were categorized as non-white females and males of any ethnicity or age, all students age 26 and older, and enrolled for a second degree (Bell- Scriber, 2008; Health Resources and Services Administration (HRSA), 2004; Langford, 2007; Walker, Martin, Haynie, Norwood, White & Grant, 2007). In 2000, males represented only 5.4% of the United States nursing workforce (HRSA, 2004). National organizations recommended nursing programs increase the enrollment of non-traditional students in their programs to expand the number of nurses in the health care workforce (Institute of Medicine, 2003; National League for Nursing,

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2008a; Sullivan Commission, 2004). According to the American Association of Colleges of Nursing (2009), male attendance in baccalaureate programs was 10.4%. Male graduation rates in associate degree programs were 13% according to a 2005-2006 data review (National League for Nursing, 2008a). Little is known about the non-traditional nursing student-clinical instructor relationship. In a study measuring role strain of male and female students, Sherrod (1991) identified a significant difference between genders. It was not known and to what extent beginning associate and baccalaureate nursing students perceived the importance of effective characteristics and demonstration of caring behaviors of their clinical instructor and to what degree the mediating variables of age and gender may have on their perception. Nursing Student-Clinical Instructor Relationships Clinical education continues to be a crucial element in the development of nursing students into novice nurses. Recommendations for transformation in nursing education were based on the evolving practice of nursing and technology (National League for Nursing, 2005b, 2008b). Core competencies for nurse educators were developed nationally and regionally (Council on Collegiate Education for Nursing, 2002; National League for Nursing, 2005a). Two of the core competencies recommended by the NLN for nurse educators related to the facilitation of student learning in the clinical setting and the importance of continuous quality improvement in the nurse educator role (Kalb, 2008; National League for Nursing, 2005a). According to the National Council of State Boards of Nursing (2005) more research on clinical education was needed.

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In light of the changing landscape of nursing education, data gathered from this study added to the body of knowledge in regards to nursing student-clinical instructor relationships not examined in this way. Inclusion of the variables of age and gender provided data which narrowed an identified gap in the literature. This gap related to a paucity of research on non-traditional associate and baccalaureate nursing student-clinical instructor relationships in regards to effective characteristics and caring behaviors.

Statement of the Problem

Since the mid 1960s, the relationship between nursing students and clinical instructors in the clinical setting was studied. These previous studies identified effective and ineffective characteristics of clinical instructors as perceived by students or faculty or both (Allison-Jones & Hirt, 2004; Benor & Leviyof, 1997; Holmes, 2006; Kotabassaki et al., 1997; Morgan & Knox, 1987; Nehring, 1990; Tang et al., 2005; Woo-Sook et al., 2002). Research indicated that caring behaviors may play an important part in the dynamics between nursing students and clinical instructors (Clawson Roe, 2009; Wang Letzkus, 2005). However, studies have not investigated traditional and nontraditional associate and baccalaureate nursing students‟ perceptions of the effective characteristics and caring behaviors of clinical instructors in a beginning clinical setting. Therefore, it was not known whether age and gender influenced beginning nursing students‟ perceptions of the effective characteristics and caring behaviors of clinical instructors from two types of programs.

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Purpose of the Study The purpose of this study was to examine associate and baccalaureate traditional and nontraditional student nurses perceptions of clinical nursing instructors to provide insights into the dynamics of the student-instructor relationship with regard to caring behaviors and effective teaching characteristics in a beginning level clinical setting.

Rationale, Relevance, and Significance of the Study Barham (1965) initiated qualitative research on nursing student-clinical instructor relationships which was followed by over 40 years of additional studies. Qualitative studies identified effective characteristics or caring behaviors of clinical instructors as perceived by nursing students and faculty. Quantitative instruments were subsequently developed. Reliability and validity of quantitative instruments measuring the importance of effective characteristics and caring behaviors of clinical instructors were reported. Prior studies on nursing student-clinical instructor relationships were conducted with samples of nursing students and faculty either from an associate or baccalaureate degree program. There were no studies which collected concurrent data from these two types of programs and included age and gender as variables. Earlier studies reported only demographic data on age or gender with the exception of two studies. Persaud (2002) reported perceptions of different age groups of graduate student nurses of their nursing faculty caring behaviors. Furthermore, Langford (2007) and Persaud (2002) reported nursing student perceptions of nursing faculty and included data by gender. However, these studies combined data on classroom and clinical instruction. In both studies, the

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instruments used to collect the data from the nursing student sample were non-specific to clinical instruction. Recommendations for research on age and gender were made from findings of previous studies (Langford, 2007; Okrainec, 1994; Persaud, 2002; Smith, 2006). Recommendations were also made by nursing organizations to increase the number of accelerated nursing programs to attract a larger diversity of second degree nursing students to reduce the critical shortage of nurses (American Association of Colleges of Nursing, 2008, 2009). According to the American Association of Colleges of Nursing (2010), in 1990 there were 31 programs for second degree students and in 2008 there were 230. Age and Gender as Variables Data gathered from this study narrowed the gap on the body of knowledge of nursing student-clinical instructor relationships in regards to age and gender. There was a paucity of research on whether age plays a role in student perception (Langford, 2007; Whitehead, 1997). Age as a variable was included in light of the increasing entry of older age students into second degree nursing programs. Gender was included based on the growing number of males entering nursing programs and gender differences cited in the literature (Anthony, 2006; Smith, 2006). Gender may influence student nurses perceptions within a traditionally female profession and may require a new approach in student-instructor relationships. The significance of this study was to add to the body of knowledge of nursing student-clinical instructor relationships in the beginning clinical setting. In addition, the identification of student nurses perceptions from different ages and male nursing students

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may provide data to nursing programs useful for program planning. A gap identified in the literature suggested a need to study student nurses perceptions of the effective characteristics and caring behaviors of their clinical instructor in the beginning level clinical setting to better understand the dynamics of this relationship.

Research Questions Given the aforementioned review of the literature, the following primary research question and subsequent additional sub-questions were developed. Primary Research Question What are the beginning level associate and baccalaureate degree nursing students‟ perceptions of the effective characteristics and caring behaviors of their clinical instructor? Additional Questions 1. What are beginning level associate degree nursing students‟ perceptions of the most and least important effective characteristics of their clinical instructor based on the nursing student being male or female? 2. What are beginning level baccalaureate degree nursing students‟ perceptions of the most and least effective characteristics of their clinical instructor based on the nursing student being male or female? 3. What are beginning level associate and baccalaureate degree nursing students‟ perceptions of their clinical instructor‟s caring behaviors based on the nursing student being male or female?

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4. What are beginning level associate degree nursing students‟ perceptions of the most and least important effective characteristics of their clinical instructor based on age? 5. What are beginning level baccalaureate degree nursing students‟ perceptions of the most important and least important effective characteristics of their clinical instructor based on age? 6. What are beginning level associate degree nursing students‟ perceptions of their clinical instructor‟s caring behaviors based on age? 7. What are beginning level baccalaureate degree nursing students‟ perceptions of their clinical instructor‟s caring behaviors based on age?

Study Variables The independent variables for this research study were associate and baccalaureate degree programs. The dependent variables for this research study were the student nurses perceptions of the effective characteristics and caring behaviors of their clinical instructors. Mediating variables for this research study were age and gender. This research study examined and explored associate and baccalaureate degree student nurses perceptions of their clinical instructors‟ effective characteristics and caring behaviors in a beginning level clinical setting.

Nature of the Study

Overall Research Approach This study was conducted using a quantitative descriptive research design. A survey method with two instruments was used to collect the data from beginning nursing students in accreditated associate or baccalaureate degree nursing programs.

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Demographic data was collected on age, gender, race or ethnicity, previous degree and time of attendance in the nursing programs. Population Sample Data was collected from a convenience sample of beginning level nursing students. These nursing students attended accreditated associate or baccalaureate degree programs. Participating nursing programs were accreditated through the National League for Nurses Accreditation Commission (NLNAC) or the Commissions of Collegiate Nurse Educators (CCNE). Instrumentation Data was collected using a survey method. Two instruments were included. The first instrument was based on caring theory and developed by Wade (2003) and the second instrument, developed by Whitehead (1997), was based on adult learning theories. The Nursing Students‟ Perceptions of Instructor Caring (NSPIC) instrument consisted of 31 short declarative statements and used a 6-point Likert scale with ratings from strongly agree to strongly disagree (Wade, 2006). Established by psychometric testing, the NSPIC had an internal consistency or Cronbach‟s alpha of 0.97 and acceptable internal consistency of the five subscales. Psychometric results indicated that this instrument is a “valid and reliable measure of nursing students‟ perceptions of instructor caring” (Wade, 2006, p. 162). The NSPIC instrument was developed “to reflect the 10 carative factors embedded in Watson‟s Theory of Transpersonal Caring” (Wade, 2006, p. 165).

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The Whitehead Characteristics of Effective Clinical Instructors Rating Scale (WCECIRS) consisted of 39 short declarative statements and used a 5-point Likert scale with ratings from not important to most important (Whitehead, 1997). Cronbach‟s alpha reported for this tool ranged from α = 0.93 to 0.92. The Pearson correlation coefficient ranged from 0.83 to 0.80. Whitehead based the development of this instrument on adult learning theories, prior research on effective characteristics and included caring dimensions. Data Collection Procedures In order to ensure the anonymity of the participants, the names of the students and identifying information were not required on the survey instruments or demographic data form. The informed consent was read and provided to students in hard copy form. Return of a completed survey by the nursing student indicated their agreement to participate in the study. For this study, the identification of the nursing program will not be published or shared with other schools who participated. An organizational code number was assigned to the survey instruments for each individual school to permit grouping the data by type of program for statistical purposes only. All returned forms will be kept in a locked file cabinet for seven years. All nursing students from the participating associate and baccalaureate nursing programs were invited by the researcher to participate during the time of a scheduled class. Participation was voluntary and the nursing students were informed of this and their right to withdraw their participation at any time. Participants were asked to complete a pen and paper scannable-able demographic data form and the survey instrument which contained: The Nursing Students‟ Perceptions of Instructor Caring

Full document contains 218 pages
Abstract: Demonstration of caring behaviors and the importance of effective characteristics are identified as important influences in a nursing student-clinical instructor relationship. The purpose of this study was to examine associate and baccalaureate degree traditional and nontraditional nursing students' perceptions of clinical instructors to provide insights into the dynamics of the student-instructor relationship with regard to caring behaviors and effective characteristics in a beginning level clinical setting. Data was collected from a sample of 503 male and female nursing students at the end of 2009 from four accreditated nursing programs located in an urban setting. Findings of this study support the overall reliability of Whitehead's Characteristics of Effective Clinical Instructor Rating Scale (WCECIRS) and the Nursing Student Perception of Instructor Caring (NSPIC) tool as instruments to measure, respectively, effective characteristics and caring behaviors of clinical instructors. Data presented from this study indicates age and gender may influence nursing students' perceptions. Study results of traditional and nontraditional student nurses revealed common and unique perspectives on the importance of a clinical instructor demonstrating effective characteristics. In addition, caring behaviors demonstrated by clinical instructors were identified. Data revealed nursing students, except for baccalaureate nursing students age 33 and over, perceived their clinical instructors demonstrated the highest number of caring behaviors from the subscale of instills confidence through caring. Conversely, associate and baccalaureate degree nursing students perceived some clinical instructors less frequently demonstrated caring behaviors within the subscales of supportive learning climate and appreciation of life's meanings. Some effective characteristics were also perceived as caring behaviors. Nursing students' perceptions of the importance of these effective characteristics and their demonstration as caring behaviors by clinical instructors were presented. Implications for both types of programs are that clinical instructors need to demonstrate caring behaviors to reduce beginning level student nurses anxiety. Clinical instructors in baccalaureate programs need to demonstrate caring behaviors in regards to evaluation procedures. Furthermore, clinical instructors in associate programs need to demonstrate caring behaviors in regards to the flexibility needed for adult learners. An implication for nursing programs is to consider the incorporation of the science of caring into their curriculum.