Staff development for Florida nurses

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Title:
Staff development for Florida nurses an analysis of curriculum, administration, and resources, by hospital size and profit system
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vii, 147 leaves : ill. ; 28 cm.
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English
Creator:
Rue, Nancy Roberts
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Subjects / Keywords:
Nursing -- Study and teaching -- Florida   ( lcsh )
Hospitals -- Staff -- Florida   ( lcsh )
Curriculum planning -- Florida   ( lcsh )
Educational Leadership thesis Ph. D
Dissertations, Academic -- Educational Leadership -- UF
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bibliography   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1985.
Bibliography:
Bibliography: leaves 136-145.
Statement of Responsibility:
by Nancy Roberts Rue.
General Note:
Typescript.
General Note:
Vita.

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University of Florida
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All applicable rights reserved by the source institution and holding location.
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Full Text










STAFF DEVELOPMENT FOR FLORIDA NURSES:
AN ANALYSIS OF CURRICULUM, ADMINISTRATION, AND
RESOURCES, BY HOSPITAL SIZE AND PROFIT SYSTEM











By


NANCY ROBERTS RUE


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA


1985





















































@1986


NANCY ROBERTS RUE


All Rights Reserved















ACKNOWLEDGEMENTS


I wish to thank Dr. Margaret K. Morgan, chairperson of

my committee, for her assistance and guidance during this

experience. Without her encouragement and help I would

never have completed this task. The suggestions and support

of all of my committee members have been invaluable in

this endeavor, and I wish to thank Dr. Amanda S. Baker,

Dr. Nita W. Davidson, Dr. James W. Hensel, and Dr. Forrest

W. Parkay.

Without the cooperation of the staff directors of

Florida hospitals the study would have been impossible. I

was repeatedly impressed by their knowledge, enthusiasm,

commitment, and professionalism.

The reinforcement of my colleagues, Dr. Joan Gregory,

Anastasia M. Hartley, and Dr. Joea E. Bierchen, made the days

less difficult. Dr. Rose Mary Ammons deserves particular

thanks not only for her encouragement but also for that

most precious commodity, her time.

My special gratitude goes to my family: to Brian,

Melissa, and Anthony who understood why their mother went

back to school; to my mother, who always knew I could do it;

and to my brother, who listened when I needed to talk.









Finally, for my husband, Ellis, who gave more than anyone

should ever have to give--thank you now and forever.


iii















TABLE OF CONTENTS

Page


ACKNOWLEDGEMENTS....... ........................ ii

ABSTRACT........................................ vi

CHAPTERS

I INTRODUCTION............................... 1

Background of the Study.................... 2
Problem Statement.......................... 9
Purpose of the Study....................... 9
Significance of the Study.................. 10
Definition of Terms........................ 10
Limitations............................... 14
Research Question.......................... 15
Research Hypotheses........................ 16
Summary of Introduction.................... 17

II REVIEW OF THE LITERATURE................... 18

American Health Care System ................ 18
Staff Development.......................... 24
The Staff Development Director............. 29
Internal Resources for Staff Development... 32
External Resources Available to Staff
Development... .......................... 36
Orientation............................... 40
Inservice Education........................ 45
Continuing Education...................... 47
Management and Organizational Training..... 52
Planning for Staff Development Education... 55
Evaluation.. .............................. 61
Changing Patterns Within Staff Development. 63
Summary of Literature Review................. 67










III METHODOLOGY... ............................ 68

Population................................. 68
Instrument Development..................... 70
Collection of Data......................... 74
Analysis of Data........................... 74
Summary of Methodology..................... 76

IV SURVEY RESULTS............................ 77

Description of Sample..................... 77
Description of Analysis ................... 82
Analysis of Data Related to Curriculum..... 83
Analysis of Data Related to Administration. 94
Analysis of Data Related to Internal
Resources................................ 98
Ratio of Staff Developers to Nurses........ 102
Categories of Hospital Personnel........... 103
Analysis of Data Related to External
Resources................................. 105
Summary of Findings........................ 109

V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS.. 111

Summary.................................... ill
Conclusions................................. 115
Recommendations........................... 122

APPENDICES

A INSTRUCTIONS TO PANEL OF CONSULTANTS....... 126

B STAFF DEVELOPMENT FOR NURSES IN FLORIDA
HOSPITALS QUESTIONNAIRE.................. 129

C LETTER...................................... 135

REFERENCES........................................ 136

BIOGRAPHICAL SKETCH ............... ............ 146















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

STAFF DEVELOPMENT FOR FLORIDA NURSES:
AN ANALYSIS OF CURRICULUM, ADMINISTRATION, AND
RESOURCES, BY HOSPITAL SIZE AND PROFIT SYSTEM

By

Nancy Roberts Rue

December, 1985

Chairperson: Margaret K. Morgan, Ph.D.
Major Department: Educational Leadership


Staff development for nurses is changing as a result of

diminishing resources within the health care system. New

funding formulas (the prospective payment system and

diagnosis related grouping) have resulted in revised

government and private reimbursement to hospitals and caused

administrators to reevaluate all aspects of management and

hospital services. In this climate decision makers must

implement rapid changes, but they often have difficulty

obtaining the information they need to validate those

decisions.

This study was designed to analyze information related

to curriculum, administration, and resources available for

staff development for nurses in Florida hospitals. Analysis

by agency size and profit system provided differentiated









data relative to the three designated categories. Through

responses to mailed questionnaires staff development

directors in 50 for-profit and nongovernmental not-for-

profit medical-surgical short-stay hospitals provided

demographic data and reported their perceived needs and

opinions.

Findings revealed more similarities than dissimilarities

among hospitals both by size and profit system. They showed

significant differences in perceived needs for continuing

education in an influence ranking of who chose the cur-

riculum and in the ratio of staff development personnel to

staff nurses.

Recommendations included developing a similar study to

be implemented another time, to expand the data base, and

developing another study to compare the effectiveness of the

lower ratio of staff developer-to-staff nurse in for-profit

hospitals with that of not-for-profit agencies. Other

recommendations: new strategies to accommodate shifts in

content emphasis and to coordinate unit priorities with

staff development curriculum; an examination of the assign-

ment of the staff development director to a line or staff

position to determine the more productive role; and an

exploration by all hospitals of the use of external educa-

tional resources to replace those lost through reorganization

or cost-cutting measures.


vii















CHAPTER I
INTRODUCTION


The department of staff development is the hospital

unit responsible for planning and coordinating all training

and education by employees to improve the occupational skills

and personal attitudes of employees (Follett, 1982). In

recent years the management and operating policies of

hospitals in the United States have changed as new funding

formulas from federal, state, and private industry have

modified reimbursements to institutions (Friedman, 1983).

Staff development departments are affected by these changes

and are a part of the reorganization that is occurring in

agencies today (Franz, 1984). Decision makers who will

guide the future of staff development for nurses in Florida

hospitals need information from which to implement change.

This study was designed to provide an analysis of data

obtained from staff development directors' reports on

curriculum, administration, and resources in selected Florida

hospitals. The information generated in the study provided

a data base of what existed for staff development of nurses

at the time the study took place. Analysis by hospital size

and profit system differentiated the information for use in









decision making and formed a benchmark of data for future

use by leaders in the health care system.


Background of the Study


In the face of reduced resources and increased demands

for sophisticated services, the traditional ownership pattern

in American hospitals is changing. Multi-hospital systems

and a variety of other organizations are rapidly becoming

the major health care providers in the country. In 1983

centrally managed hospital chains expanded their operations

by 9.5%; at the same time, contract management business in

these same chains increased 10.5% (Johnson, 1984). As the

balance of ownership and management systems shifts from the

pattern of traditional, not-for-profit, independently owned

institution, changes occur within the agency that affect

every department and function within the hospital (Brown &

McCool, 1983).

New owners or managers will not likely, at the expense

of their own profits and survival, freely offer services

that cannot be supported directly. Traditionally, staff

development expenses are reimbursed indirectly from total

revenues and therefore are considered at risk during periods

of reevaluation for cost effectiveness (Grubb, 1981).

Hospital owners and managers lack current information

concerning the comparison of practices within for-profit and

not-for-profit agencies on which to base such decisions as









to whether departments of staff development will change,

remain the same, or disappear (J. Randall, personal communi-

cation, Hospital Research and Educational Trust, June 5,

1984).

Program planning for staff development is a process by

which the nature and sequence of future educational events

are determined and organized; it is a flexible means through

which a group of people can share in planning in an organized

way (DiVincenti, 1977). Staff development efforts should be

planned in a 1-, 2-, or 3-year program rather than in a

series of intermittent or unrelated events. In the absence

of long-range planning, staff development deteriorates into

an unbalanced program, wasting money and time (Follett,

1982). This is especially true in a period of economic

stress when hospital administrators examine all programs for

value or productivity, and rapid changes are implemented as

cost-saving measures (Franz, 1984).

The nursing staff must be clinically competent and

achieve nursing practice skills to meet criteria specified

by the Joint Commission for Accreditation of Hospitals

(JCAH). The Joint Commission requires that a department or

individual "knowledgeable in education methods and current

nursing practice" provide orientation, inservice education,

continuing education, and instruction on safety, infection

control, and cardiopulmonary resuscitation (CPR) for all

nursing employees" (Joint Commission, 1983, p. 115).









However, JCAH guidelines relative to staff development are

minimal and vague. Consequently, hospital administrators

interpret the rules in different ways that reflect individual

agency needs. Also, institutional philosophy influences

policies relative to staff development, and resources may

vary due to the type of ownership, profit system, and size

of the hospital (Mistarz, 1984).

For many years the most significant educational activi-

ties in hospital settings were those that hospital-based

schools of nursing conducted. These educational activities

had important benefits for nurses employed by the hospitals

and, ultimately, for patients (Haggard, 1984). Through

constant contact with nursing faculty and students, staff

nurses encountered new concepts and techniques. However,

since World War II most hospital-based schools of nursing

have closed, and colleges and universities have assumed

responsibility for education of student nurses (Aiken, 1983).

Hospital administrators responded to the closing of

diploma schools of nursing by instituting departments of

inservice education to provide education for staff nurses

and other personnel. Those in charge did not clearly define

the tasks and functions of inservice education and developed

programs only as needs arose. In a 1970 survey for RN,

investigators found that no matter what the goals of

inservice departments, most hospital administrators claimed









that the institution derived benefits from instruction that

the educational staff provided (Munk & Lovett, 1977).

Staff development has evolved from a simple buddy

or apprenticeship system into a complex program designed

to provide induction training (orientation), inservice

instruction (skills training), continuing education, manage-

ment training, and organizational development. The range of

staff development resources in hospitals varies from a

single staff person with limited teaching aids to large

departments using complex teaching strategies and equipment

(Rowlands & Rowlands, 1980). Because of rapidly changing

technology, particularly in medically related fields, those

involved in hospital management developed methods of educat-

ing staff nurses to maintain proficiency (Haggard, 1984).

Those who administer hospital policies do not routinely

require educational experience or credentials beyond basic

nursing preparation for staff development positions.

Curriculum planning and program offerings, especially in

smaller hospitals, are the responsibility of staff who may

have little or no preparation in education (Wise, 1983).

Only since the 1970s have institutions begun to employ

individuals prepared as educators to coordinate educational

activities. Sovie (1983) stated that "a systematic approach

to professional career development in hospital nursing is

absolutely essential" (p. 6). According to Del Bueno (1980),

those trained in both education and nursing can accomplish










this best. However, a critical shortage exists of nurses

prepared beyond basic education (Aiken, 1983). For example,

only 4.3% of Florida nurses have master's degrees (Florida

Hospital Assn., 1983).

Hospital-based education flourished in the 1970s when

the expansion of health care institutions peaked (Kalisch &

Kalisch, 1982). The number and frequency of orientation,

inservice instruction, continuing education, and management

classes were increased to accommodate the needs of staff in

a changing environment. During the 1970s and early 1980s,

trained personnel turnover rates were high, technological

advances escalated, newly graduated nurses required different

types of orientation, and registered nurses returning to

practice needed refresher courses (Haggard, 1984).

These factors caused institutions to increase the

number of full-time staff educators and to create new methods

of organizing staff development. All health care personnel

needed education; therefore, hospitalwide or centralized

staff development departments became a means of providing

assistance from one unit (Lawrence & Peoples, 1982).

Diminishing resources are now creating pressures that

directly affect the number of full-time staff assigned to

education, and administrators are seeking other methods to

dispense the same product in a cost-effective manner (Franz,

1984).









Continuing education has developed as a major respon-

sibility in staff development departments. Florida is among

several states that mandate continuing education as a

requirement for licensure for nurses (Cooper, 1983). Since

1979, Florida has required 24 contact hours (50-minute

instructional units) of State Board of Nursing-approved

courses each biennium for the renewal of a license by the

registered nurse (Nursing, 1977). In Florida, hospitals are

major providers of continuing education and usually offer

free contact hours as an employee benefit (Austin, 1983).

Continuing education requirements for Florida nurses will

undergo "sunset review" on October 1, 1986. Whether the

state will continue to mandate contact hours for continued

licensure remains to be seen. Scientific and technological

advances make the need for continuing education self-evident,

but the controversy over whether mandatory contact hours are

effective continues (Cooper, 1983; Keltner, 1983; Puetz,

1983). If continuing education is not mandatory, hospital

administrators may reevaluate it as a function of staff

development.

For the first time since World War II, the shortage of

registered nurses appears to have ended except in isolated

areas of the country and on critical care units requiring

high technological skills (Aiken, 1983). The national

hospital census declined by 3.4% in 1984 due to decreased

admissions of patients by physicians (Cupito, 1984). This







8

decrease is believed to be a direct result of new government

funding formulas (prospective payment system [PPS] with

diagnosis related grouping [DRG] for Medicare patients)

(Toth, 1984).

The impact of PPS is upon the short-term, general

medical-surgical hospital. As the hospital census declines,

administrators close units and reassign or lay off nurses.

As a result of the change in hiring patterns, staff develop-

ment departments face the problem of reorienting existing

staff to different units and orienting part-time nurses to

work in a variety of areas (Franz, 1984). Staff development

is also responsible for implementing career ladders, merit

pay systems, critical care courses, and management training

programs. These are a few of the offerings administrators

currently use to provide career stimulation and growth

opportunities for nurses within hospitals (Sovie, 1983).

Nursing practice is changing and staff development

remains the department within the hospital that is respon-

sible for continued development of the nursing staff. Since

the 1920s nurse educators in hospitals have contributed to

quality patient care through organized staff development

activities. One of the challenges to health care delivery

systems in the 1980s is to assist nurses to adapt to the

realities of change while they continue to meet the potential

for professional growth and development (Kelly, 1984).










Problem Statement


Development and maintenance of a data base for decision

making in this period of rapid change is a problem facing

leaders in the health care system today. One kind of data

that is lacking is an analysis of whether differences exist

between staff development practices in institutions of

various sizes and hospitals operating under diverse profit

systems. The professional literature treats staff develop-

ment as one entity with a few references to the size or

profit system of the agency. Published research usually

originates from teaching institutions in large medical

centers, and these hospitals are of the nongovernmental not-

for-profit category. Events in smaller institutions are

seldom reported in the literature.

Decision makers, regardless of agency size or profit

system, search for methods to improve and maintain services

when resources are diminished. These leaders need informa-

tion concerning differences as benchmark data for staff

development of nurses.


Purpose of the Study


The purpose of this study was to provide an analysis of

data related to curriculum, administration, and resources to

determine what existed for staff development of nurses at

the time the data were obtained. Information based on

reports from staff development directors of Florida







10
for-profit and nongovernmental not-for-profit general medical

surgical hospitals was analyzed by hospital size and profit

system to establish a benchmark of practices related to

staff development for nurses.


Significance of the Study


With the trend toward an increase in the number of for-

profit hospitals, determining if differences exist between

staff development departments in the now predominately not-

for-profit hospitals and those in the for-profit category is

important. Findings from this study provided data on which

decision makers can assess the current status of their staff

development programs and plan for change. The analysis of

data categorized by institutional size and profit system

establishes a base against which future measurements can be

made.


Definition of Terms


The following terms are defined as they are used in

this study:

Contact hours are the 50-minute instructional units

of continuing education content approved by the Florida

State Board of Nursing to satisfy license renewal require-

ments.

Continuing education is the planned learning activities,

beyond the basic nursing education program, that are designed








11
to provide knowledge, skills, and attitudes for the enhance-

ment of nursing practice (Cooper, 1983).

Decentralization is the placement of decision making,

planning, and control of resources at the unit level in the

charge of a middle manager; a flat nursing service structure

that has fewer levels of authority distribution (Schweiger,

1980).

Diagnosis related grouping (DRG) is a set of 467

diagnoses categorized to provide a basis for reimbursement

for Medicare patients (Davis, 1983).

Education coordinator, staff development educator,

and instructor are interchangeable terms for the persons)

assigned to produce, manage, and monitor educational activi-

ties in the hospital (Truelove & Linton, 1980).

For-profit hospitals are agencies operated to pay

dividends to those owning shares in the company (Florida

Hospital Assn., 1983).

Hospital size in this study is categorized into four

levels according to the number of patient beds listed for

each institution listed in Florida Hospitals: The Facts

(Florida Hospital Assn., 1983):

Small 200-299 beds

Medium 300-399 beds

Large 400-499 beds

Extra large 500+ beds







12
Hospitalwide educational activities are those that are

available to all disciplines and ancillary personnel. They

encompass the concepts of human resource development and

the broader concept of organizational development (Lawrence

& Peoples, 1982).

Induction training is a brief, standardized indoctrina-

tion to the philosophy, purpose, programs, policies, and

regulations of the hospital, given each worker during the

first few days of employment (DiVincenti, 1977).

Inservice education is on-the-job instruction the

hospital offers to enhance the worker's performance in the

present job (Haggard, 1984).

Internships are programs for beginning nurses designed

to extend theoretical learning into clinical application

in a systematic manner (Haggard, 1984).

Line position connotes the tasks, functions, or

organizational components for fulfilling the service and

economic objectives of the organization. It explicitly

refers to producing values in the form of goods and services

for which the customer or client will pay (Arndt & Huckabay,

1975).

Nongovernmental hospitals refers to those hospitals not

owned by the county, state, or federal government (Florida

Hospital Assn., 1983).

Nongovernmental not-for-profit hospitals are agencies

owned by individuals, organizations, or foundations and









operated to consume all revenue with no taxable dividends

remaining (Florida Hospital Assn., 1983).

Nursing-centered refers to a department or service

that is primarily responsible for nursing activities and

education (Haggard, 1984).

Nursing unit is a group of patient rooms operated by a

head nurse or nurse manager and associated staff for a

defined population of patients (Arndt & Huckabay, 1975).

Orientation is a program used to acquaint the newly

employed nurse to job responsibilities, workplace, clients,

and coworkers (Lawrence & Peoples, 1982).

A preceptor is the registered nurse employee designated

and trained in teaching methodology who acts as a unit

resource for specific clinical activities (Plasse & Lederer,

1981).

Preservice education is preparation in basic nursing

at the diploma, associate degree, or baccalaureate level,

acquired prior to licensure as a registered nurse (Aiken,

1983).

Prospective payment system (PPS) is a method of reim-

bursement based on a previously established fee schedule

established by Public Law 98-21, the Social Security Amend-

ments of 1983 (Davis, 1983).

A registered nurse is a graduate of an approved program

of nursing, who successfully passes the State Board of

Nursing examination, and is licensed by the state to practice







14
nursing under the rules and regulations of the state (Aiken,

1983).

Staff position refers to the tasks, functions, and

organizational components that are required to supply infor-

mation and services to the line (administration) components.

Staff provides services to help the line administrator

achieve the best results (Arndt & Huckabay, 1975).

Staff development is all training and education provided

by an employer to help employees improve occupational and

personal knowledge, skills, and attitudes (Follett, 1982).

Staff nurse is a role which has developed with the

growing demands of nurses for professional autonomy, and

refers to the nurse who participates in the assessment,

planning, implementation, and evaluation of patient care.

Sunset review is a process resulting from legislation

that mandates review of a state agency and may culminate in

altering or abolishing the authorizing statute--the sun is

allowed to set on the agency (Cooper, 1983).


Limitations


The following limitations applied to this research:

1. The conclusions to research questions were based on

self-report data obtained from staff development directors

through a written questionnaire.

2. This study was confined to Florida short-stay

general medical-surgical for-profit and nongovernmental









not-for-profit hospitals. Responses represented the

perceptions of the 58 staff development directors who

responded to the mailed questionnaire.


Research Question


As related to staff development for nurses in the

identified hospital population, do for-profit and nongovern-

mental not-for-profit general medical-surgical short-stay

hospitals differ on the following variables?

1. The areas of staff development that directors

perceive as needing emphasis in their employing institutions;

2. The individual or group who influences content

selection of staff development for nurses;

3. Organizational designation of staff development

directors;

4. The organizational design used for staff development

for nurses for hospitals;

5. The department that controls staff development for

nurses;

6. Internal resources provided for staff development

for nurses;

7. External resources staff educators use to provide

staff development for nurses.









Research Hypotheses


The research hypotheses were generated from the primary

research question using guidelines from Munk and Lovett

(1977) and Rowland and Rowlands (1980). The independent

variables were hospital size (small [200-299 beds], medium

[300-399 beds], large [400-499 beds], and extra large [500+

beds]) and type of profit system (for-profit or nongovern-

mental not-for-profit). The hospital size categories were

based on the classifications used in the Florida Hospitals:

The Facts (Florida Hospital Assn., 1983).

The three staff development categories were curriculum,

administration, and resources. The research hypotheses

included dependent variables that related to each of these

major categories:

Curriculum

1. The areas of staff development that staff develop-

ment directors perceive as needing emphasis vary according

to hospital size and profit system.

2. The individual or group who influences content

selection for staff development for nurses varies according

to size and profit system.

Administration

3. The organizational designation of staff development

directors varies according to hospital size and profit

system.







17
4. The department that controls the administration of

staff development for nurses varies according to hospital

size and profit system.

Resources

7. Internal resources available for staff development

for nurses vary according to hospital size and profit system.

6. External resources available for staff development

for nurses vary according to hospital size and profit system.


Summary of Introduction


Education in health care settings expanded rapidly in

the sixties and seventies in response to the increase in

facilities, numbers of patients, and technological advances.

In the mid-eighties these resources diminished and the

health care industry began to adjust. The purpose of this

study was to provide a differential data base for decision

making in Florida hospital staff development departments.















CHAPTER II
REVIEW OF THE LITERATURE


Hospitals and health care changed more between 1981 and

1984 than at any time since the implementation of Medicare

in 1965. The changes occurring within the institutions

affect nursing and staff development in many ways, primarily

in lost resources and increased demands. Adaptation to a

totally different system based on cost containment and

increased productivity is a reality that is shaping the

health care industry of tomorrow. Staff development plays

an important role in providing the educational support

nurses need to weather this difficult time (McConnel,

1984). The literature of nursing contains recommendations

on staff development for nurses--now and in the future.


The American Health Care System


Professional nurses comprise the largest group of

patient care providers in the country and are among the

most valuable resources of the health care industry (Sovie,

1982). Sixty-six percent of all U.S. nurses work in

hospitals. In recent years nurses have increased in

numbers, assumed expanded roles in patient care, and become

more directly involved in the management of institutions







19

(Aiken, 1983). Hospitals accredited by the Joint Commission

for Accreditation of Hospitals (JCAH) are required to

provide staff development for nurses (Joint Commission,

1983); therefore, some type of educational activity is found

in all accredited institutions.

In earlier periods of relative stability in health

care, professionals have been confident and comfortable in

their grasp of technical aspects of the practice, but the

accelerated pace of today contributes to fears of

obsolescence and isolation. The situation is not likely to

improve in the future as society places new demands on

organizations and professionals engaged in the planning and

delivery of health care services (Brown, 1983).

In the past generation changes have occurred in

American demographic characteristics (decreased birthrate,

increased proportion of aged), growth of public awareness

about health, greater sophistication in medical treatment,

concern for financial responsibility, increases in the

complexity of technology, a larger variety of preparation

for health care personnel, and escalating federal and state

legislative control over health care institutions (Mistarz,

1984). The days of quality care regardless of cost are

gone; therefore, staff development delivered by the most

efficient, cost-effective method is the major objective

of hospital decision makers across the nation (McConnel,

1984).







20

Hospital administrators can no longer plan according to

growth trends of the past. The environment has changed and

1983 aggregate data suggest that, instead of continuing in

the strong growth pattern of the past, community hospitals

of today face a drop in admissions, shorter patient stays, a

decrease in growth of expenses, and a decline in hospital

full-time-equivalent growth. The Florida Hospital Council

found the average length of stay for a patient in a hospital

dropped about half a day, from 7.4 to 6.9 days, between

the second quarter of 1983 and the second quarter of 1984.

Admissions were down about 3% in the first half of 1984

compared with the first 6 months of 1983 (Cupito, 1984).

Factors contributing to the decline in demand for hospital

services include federal and state health program revisions,

changes in the benefit programs offered by employers, and

unemployment, resulting in a loss of job-related benefits.

The prospective payment system (PPS) of Medicare and reduc-

tions in benefits provided by private insurance programs

have also created new economic incentives for hospitals

(Mistarz, 1984).

Hospital costs increased 12.6% in 1982, when the

general inflation rate was 3.9%. In 1982 Medicare payments

totaled $49.2 billion, with two thirds of this amount going

for acute care hospital services. A complex set of

variables is associated with this phenomenon: The combina-

tion of an aging population, the effects of supply and









demand, new technology, overall inflation, and third-party

payment programs has led to wider coverage, greater access,

and quality care. However, these factors have insulated

consumers from an awareness of health care costs (Davis,

1983).

Public Law 98-21, the Social Security Amendments of

1983, is the most important health care legislation since

Medicare came into being in 1965. The Congress and the

Administration have done more than alter the system--they

have legislated change (Davis, 1983).

The prospective payment system mandated by this law

changes reimbursement from retrospective fee-for-service

to a preset amount related to diagnosis. Investigators

at the Center for Health Studies at Yale University

researched and categorized 467 illnesses to create a basis

for diagnosis related grouping (DRG), the schedule for reim-

bursement in PPS. The regulations exclude long-term care,

psychiatric, pediatric, rehabilitataive, and certain special

hospitals (Davis, 1983).

The system rewards those who provide care at the lowest

cost. The law allows no additional billing of benefici-

aries; therefore, if costs exceed the allotted amount, the

hospital must absorb the loss.' This is causing intense

scrutiny of hospital departments in the use of human and

material resources (Mistarz, 1984).









One phenomenon of the latter half of the twentieth

century is the rapid increase of multihospital systems.

This growth is, in part, credited to new financial reim-

bursement policies and is expected to continue for the next

5 years. Currently 721 multi-unit health care facilities

provide services directly to consumers according to a 1984

survey for Modern Health Care of multi-unit providers

(Johnson, 1984). Alliances and health care chains pose

significant threats to independent hospitals. Organizations

determined to dominate the markets and entrepreneurs seeking

their fortunes are organizing and expanding through acquisi-

tion of existing institutions. The number of independent

and small multi-unit health care providers will shrink as

the larger agencies take over the small chains and small

ones merge, according to R. Eamer, chief executive officer

of National Medical Enterprises, Incorporated. Centrally

managed hospital chains expanded their operations by 9.5% in

1983 and at the same time the contract management business

of these chains increased 10.5% (Johnson, 1984).

Change in the management, ownership, and reimbursement

systems of United States hospitals affects every aspect of

agency policy and operation. The effect of these events

will impact on nursing service and all related departments

as administrators seek operational methods compatible with

fiscal realities (Kelly, 1984).









The effect of the prospective payment system upon

nursing is immediately apparent. As doctors admit only

the more acutely ill patients and cost containment mandates

shorter stays, the overall census declines, and hospitals

employ fewer nurses full time. As fewer nurses are

employed, nursing staff have reduced opportunities for

mobility from hospital to hospital. Hospitals use part-time

nurses and nurses from agency pools to cover patient care

when admissions increase (American Hospital Assn., 1984).

Recruitment and orientation of nurses--activities that have

consumed hospital resources--are now secondary functions for

staff developers. As a result, staff development personnel

experience a greater demand for curriculum designed to

increase clinical, managerial, and organizational skills

(Lang & Slayton, 1984).

Combined effects of the recession of 1978-83, and

restrictions in the rate of increase for financing health

services have reduced the effective demand for nursing

personnel. A shortage of highly skilled nurses for special

care units remains, but the general shortage of registered

nurses has eased (McKibben, 1983).

Authors of the Institute of Medicine study (Aiken,

1983), commissioned by Congress, concluded that the supply

and demand for nurses is now in reasonable balance and is

expected to remain so for the rest of the decade. The

report also included a number of recommendations to employer









institutions. The authors concluded that, contrary to

popular opinion, nurses are not leaving the profession

in large numbers; however, turnover of nursing staff is a

major problem in some hospitals and nursing homes. A

recommendation resulting from information gathered in the

Institute of Medicine study was that employers provide

greater opportunities for career advancement in the clinical

area as well as in administration; reward merit and experi-

ence in direct patient care with salary increases; and

encourage greater involvement of nurses in decisions about

patient care, management, and governance of the

institution. The investigators proposed the use of federal

demonstration monies to implement and evaluate innovative

approaches to improving the conditions of practice for

professional nurses (Aiken, 1983).

Nurses with the advanced education needed to administer

nursing services, teach, conduct research, and provide

highly specialized care are in short supply. The investi-

gators in the Institute of Medicine study recommended fed-

eral support to graduate education since those with advanced

preparation comprise a needed national resource (Aiken,

1983).


Staff Development


Education is a legitimate sphere of activity for reach-

ing organizational objectivities. Educational activities









can (a) develop the creative talents and abilities of

individuals; (b) develop skill in fact finding, problem

solving, planning, and implementation; and (c) increase

skill in discovering and using resources, promote teamwork,

and increase acceptance of responsibility--all crucial

to institutions in accomplishing objectives (DiVincenti,

1977). Education, training, and development are continuous

processes, designed to help individuals grow to their full-

est, to keep them up to date with new knowledge and tech-

nology, to enable them to do their present jobs better,

and to help them prepare for future opportunities with

the hospital if these should arise (Cooper, 1983).

A good relationship between the person and the organi-

zation is important for fostering hospital nursing careers

as much as effectively meeting institutional objectives.

Levinson (1968) named this process reciprocation, the ful-

fillment of mutual needs in the relationship between an

employee and the work organization. Another important

process Levinson described was identification--the process

of learning how to behave and what to become. This is

not simple imitation but the adoption of spontaneously

selected aspects of the model which fit the person who is

identifying and which will further that person's maturation.

Professional nurses experience reciprocation and

identification in several ways--in their experiences in

the total nursing practice organization, in interaction









and experiences in their particular units, and finally,

in cumulative experiences in the hospital. As Sovie (1983)

commented, "Nurses should feel a climate that communicates

how valuable they are for quality patient care and for

achieving institutional goals and objectives" (p. 7).

At the same time, nurses should be able to learn how the

organization can help them achieve their personal and pro-

fessional objectives through rewarding careers in hospital

nursing. Staff development educators share with nursing

and hospital leaders the responsibility to create and main-

tain an organizational climate and environment that encour-

age nursing career development (Sovie, 1983).

Levinson's work implies that a person has the potential

for development and expansion. The traditional role of

nursing is today challenged by career-oriented professionals

who are expanding beyond the stereotype of "handmaiden"

(O'Donovan & Bridenstine, 1983). The most effective method

of advancing within the profession is through attainment

of knowledge and skills past those of entry level. Profes-

sional maturation fostered by staff development for career

advancement enhances nursing practice in hospitals. The

necessity of keeping up with technical advances applies

constant pressure on working nurses. By adding opportuni-

ties for fuller professional growth and advancement, hospi-

tals increase the incentive for commitment to the organiza-

tion (Gothler, 1983). Staff developers have the challenge









of designing programs that meet the needs of both the

organization and the individual.

Staff development is often used to counter job-related

stress. The expanded role of nursing, lack of role clarifi-

cation, increasing demands for accountability, knowledge

explosion, and demand for new skills may all negatively

affect job performance. After the identification of stress

points, institutions often use inservice programs to empha-

size mastery of a specific knowledge or skill (Lang &

Slayton, 1984).

Persons charged with staff development have the respon-

sibility of presenting information designed to address

the identified problem. The methods of presenting such

programs have a direct effect on how the nurse applies

this information to the work setting. Too often instructors

present content without helping the individual nurse to

apply it (Haggard, 1984).

Lang and Slayton (1984) applied Stufflebeam's decision-

making model as the theoretical framework for a nursing

management course as a means of establishing relevance

and sequence. By following the guide of context, input,

process, and product, the educators tailored the course to

the needs of the agency. They decided to teach the course

using the resource model based on the assumption that

students bring knowledge and experience to the classroom.

In evaluating the course, they asked the following









questions: Was the course relevant and applicable to the

participants' work setting (context)? Were the relevant

issues in the work setting addressed in a useful way (con-

text and input)? Were the objectives and teaching strate-

gies congruent with the learning needs of the participant

and the institution (input)? How did the learning process

of the program contribute to the participants' ability

to handle the work setting productively (process)? How

are the knowledge, skills, and attitudes taught in the

course being used in the work setting (product)? The

Stufflebeam model can work effectively in the hospital

setting only when the goals and philosophies of nursing

and education are congruent (Lang & Slayton, 1984).

Staff development is the totality of educational and

personal experiences that helps an individual to be more

competent and better satisfied in an assigned professional

role. The purpose of staff development in hospitals is

two-fold--to assist the nurse in professional growth and

skills and to ensure quality of care for patients by provid-

ing competent staff (Rowlands & Rowlands, 1980).

Human resource development consultants imply that

appropriate training and education measures must communicate

that

1. Staff developers understand the work of the organi-

zation, the nature of the workforce, and special character-

istics of the work unit.









2. Staff developers provide consultation to line

managers in addition to providing programs in order to

share accountability and responsibility with management.

3. The right training is delivered to the right people

at the right place and time (Littledale, 1975).

The productivity model of the Ohio State University

Hospital Education and Training Department (Stein & Hull,

1981) shifts the emphasis from documenting education and

training efficiency to recording the manner in which the

department assists management to establish predictive action

plans. By understanding the work and environment, providing

consultation, and delivering the right service from a sound

data base, the department was able to enhance productivity.

This approach is in contrast with the usual mission of

institutional education and training: corrective coordina-

tion to rectify an error or dysfunction after the fact.


The Staff Development Director


An important function of the staff development director

is to provide leadership for staff development programs.

Interpretation of the philosophy and objectives of staff

education programs to the hospital administrator, department

directors, medical staff, and nursing personnel is a primary

function of this position. The degree of understanding

exhibited by the staff development director affects

attitudes toward the staff education program, acceptance









by nursing personnel, and the support received (DiVincenti,

1977). The director is responsible for program planning

of all nursing staff development activities. When the

staff development director is aware of the philosophy of

the administration and the willingness of administration

to commit resources and support to education and training,

the possibility of success increases (Wood, McQuarrie, &

Thompson, 1983). If the program is to be dynamic and

ongoing, someone must be accountable. After deciding what

is wanted and needed by consulting with line managers and

staff nurses, the director works with and through persons of

diverse backgrounds, training, and experience within the

organization. Strategic planning and a coordination system

can enable managers to forecast, plan, and deploy resources

which result in increased productivity (Stein & Hull, 1981).

Line managers usually initiate requests to an education

and training department to alleviate a current crisis or

have an action response to an urgent operational problem.

Failure of the line manager to have a clear understanding

of the educational process and failure on the part of the

staff developers to have the necessary management skills,

technical awareness, and knowledge of the work area to plan

and meet needs lead to resource development by crisis.

Crisis management and response invalidate the mission of

staff development, which is forecasting and anticipating

human resource development needs (Stein & Hull, 1981).









Staff developers submit to administration detailed

reports on learner contact hours, curriculum development,

course preparation time, instructor hours, and numbers of

participants as proof of productivity. While these measures

are useful tools for explaining the existence of staff

development education, the real issue of productivity is

circumvented. Staff development departments often fail

because they do not clearly describe or make visible to

management the benefits of training and education. The

staff development director is challenged to devise methods

to measure the impact of training and development on a

hospital, on a department, or on individual employee

productivity (Stein & Hull, 1981).

Knowledge of basic principles of education can assist

the director by providing a framework for the planning

needed to devise a curriculum with effective, sequential

learning experiences. Relevance to the task at hand is

a necessity for adult learners (Knowles, 1980); therefore,

plans made to fit specific clinical application will

encourage staff acceptance of programs. Planning programs

relevant to current and prospective needs is the responsi-

bility of the staff development director (Margolis & Amore,

1982). The success of staff development efforts depends

in part on proper organization of resources. Larger health

agencies customarily have a centralized education and

training department, responsible for all education in the









hospital, with the director a member of upper management.

The department can be organized into sections devoted to

educational planning and resources, induction and orien-

tation training, inservice instruction, and continuing

education. In this way, a manager whose primary responsi-

bilities are for staff development rather than patient

services can administer educational supplies, equipment,

instruction, and financial support (Linton, 1980).

Regardless of the structure of the organization, the

person in charge of education is responsible for providing

a program that will enrich and enhance the work experience.

For the nurse, lifelong learning is equated with successful

personal and work-related growth and fulfillment (Sullivan,

1980).


Internal Resources for Staff Development


At one time the staff of a hospital-based education

program could, by displaying an array of projection equip-

ment, software, and instructional materials, impress a

fairly sophisticated visitor. The mere possession of

resources, however, guarantees nothing. In some effective

programs the only training media are the instructor and

the chalkboard. Instructional materials can make learning

easier or more interesting but are not a substitute for

sound planning and good teaching (Patterson, 1980).









Many hospitals possess projectors, slides and films,

video cassette records and players, and TV cameras. Closed

circuit television is not uncommon and often patient

educators use it to provide instruction direct to hospital

rooms (Lewis, 1984). Computers are becoming commonplace

as hospitals take advantage of the capabilities of elec-

tronic record keeping. Computer-assisted instruction has

been available for about 35 years; however, health education

has made little use of this tool (Yucha & Reigluth, 1983).

Educators are in the process of incorporating basic computer

literacy into programs to demystify communication with a

computer. As they develop more programs and the cost of

software becomes more reasonable, teaching and learning with

computers will expand into the workplace (Smith & Sage,

1983).

Application of audiovisual media to instruction is

a promising area that requires a fair amount of educational

awareness. However, educators should not use audiovisuals

as a crutch for poor teaching or as a substitute for provid-

ing information an instructor could present better. Effec-

tive teaching requires careful timing. The media should

fit into the total schedule for instruction in a manner

that will enhance learning (Patterson, 1980).

Setting up an audiovisual library is costly and time

consuming. Finding well-prepared, effective materials

is often difficult and, in a field that changes as rapidly









as medicine and nursing, sometimes impossible. Hospitals

often resort to producing their own materials which may

or may not be the most efficient method. Patterson (1980)

estimated a minimum of 75 man-hours are required to prepare

a reasonably sound 45-minute educational video tape. To

produce 1 hour of computerized instruction requires

approximately 100 hours of work (Smith & Sage, 1983).

Thus purchasing a commercially prepared program, if one

is available, may be more cost effective (Patterson, 1980).

The hospital-based educator usually has the task of

maintaining audiovisual equipment. Unless an audiovisual

technician is on the staff, education department instructors

are also responsible for keeping equipment in running order

and for trouble-shooting problems (Rowlands & Rowlands,

1980).

Classrooms are necessary and an auditorium is desirable

to accommodate classes and groups attending hospital-based

programs. The department of education usually controls

the scheduling of such facilities and can build a calendar

of events around available space (Linton, 1980).

Since JCAH requires that all nursing personnel be

certified in CPR, almost every hospital owns mannequins

used for cardiopulmonary resuscitation practice (Joint

Commission, 1983). A new development in computerized educa-

tion is a system for teaching CPR. The interactive Cardio-

pulmonary Resuscitation Learning System being marketed by









Actronics, Inc., Pittsburgh, Pennsylvania, is a pioneer

system in the new field. A microcomputer interfaces with a

videodisc player, an interactive audio cassette player, and

a CPR mannequin wired with a series of electronic sensors.

The premise, based on learning theory, is that student

performance is improved by immediate feedback and that the

focus can be on identifying trainee mistakes as they occur

(Lewis, 1984).

The hospital offers a variety of human experience

and other resources within the walls of the institution.

Administrators, physicians, nurses, pharmacists, dietitians,

medical technologists, social workers, physical therapists,

respiratory therapists, and other trained personnel have

knowledge and skills that can enrich the educational pro-

gram. Guidelines for JCAH specifically state that reg-

istered nurses who provide direct patient care should

contribute to staff development (Joint Commission, 1983).

After assessing a need, the educator determines how best to

satisfy the objectives of the desired program and then

contacts experts to set up a schedule (Bedwell, 1982).

Knowledge of internal resources facilitates the process of

determining how to present information in a cost-effective

manner (Blazek & Royce, 1982).









External Resources Available to Staff Development


Emphasis on cost containment has forced many hospitals

to reexamine education as they are presenting it. The

outcome has been realignment of resources and personnel

as institutions struggle to survive the decrease in revenue

caused by the implementation of the prospective payment

system (PPS) and other measures aimed at reducing health

care costs (Mistarz, 1984).

At times decision makers in a hospital will find that

to develop and provide certain educational activities--

especially in continuing education and management/organiza-

tional training--is impractical and inappropriate. When the

need for learning persists, some form of cooperative or

contractual arrangement may be most practical (Bedwell,

1982).

The literature contains several references to

collaborative models between education and nursing service.

Colleges and universities have clinical affiliations to

provide experience for nursing students in preservice educa-

tion. Now hospitals are turning to institutions of higher

learning for continuing education, including management and

organizational courses (Gilbert, Gorman, Magill, Racine, &

Sweeney, 1982).

When Kentucky mandated continuing education for reli-

censure in 1978, the University of Louisville School of

Continuing Education Programs took a contractual approach









that was cost effective to both school and health care

agencies (Freeman & Adams, 1984). Management developed

a contract incorporating the number of contact hours nurses

needed for license renewal, conducted a cost analysis for

both the clinical and educational institutions, and formu-

lated policies that defined the services and implementation

of the program. To market the contract, the dean of the

School of Nursing and the assistant dean of the School of

Continuing Education Programs met with the hospital and

nursing administrators and director of education of each

agency. Communication at the administrative level ensured a

greater degree of commitment to the agreed upon program

(Freeman & Adams, 1984).

Those involved in designing the program developed

a portfolio to fit the needs of the hospital, including

topics to be taught, costs, and benefits for the institu-

tion. In evaluating the system at the end of 100 hours

of instruction, hospital administrators and staff cited

lower costs, greater accessibility, more agency staff

receiving the same information, increased exposure to

faculty skilled in teaching adults, improved long-range

planning, and equal opportunity with other agencies to

use the university as a resource. Representatives of the

university found advantages such as the opportunity for

faculty to share research results and demonstrate knowledge,

guaranteed income to the school, and incentives for the







38

buyer to remain with the university as the provider (Freeman

& Adams, 1984).

Montefiore Hospital and Medical Center works with

the Continuing Education Department, Teachers College,

Columbia University, in a similar manner. Those in nursing

administration were concerned about helping supervisors

apply leadership concepts to clinical settings. In a

three-phase program, as they worked with the university they

drew a positive response from participants on assessment,

implementation, and evaluation of the course (Gilbert et

al., 1982).

According to Bedwell (1982), a cooperative institu-

tional agreement is one in which each party provides some

part of the total learning program. The hospital may agree

to provide students, facilities, and technical equipment

while the school furnishes the teachers, classrooms, sup-

plies, guidance counseling, and credit. Contractual

agreements may be simple, but one thing is certain: The

written document forces both parties to think about their

association and requires organizational planning (Bedwell,

1982).

Community colleges, technical institutes, vocational

schools, and independent consultants work with hospitals

to provide the services needed to help staff keep skills

and knowledge bases current. The diverse needs of









institutions can be served from many sectors (Truelove &

Linton, 1980).

Shared-services consortium are another method of

providing education using both internal and external

resources. Several institutions form a network from which

to combine and share resources, thus decreasing costs and

enlarging the pool of materials and instructors available.

One example of this type of plan is the Staff Education

Consortium model developed by five Harvard-affiliated

teaching hospitals in Boston. Organization of such

activities requires long-range planning and commitment by

administrators to follow through on agreements. Designers

of this program developed a list of classes and a method of

exchange of services that all concerned agreed was

equitable. Two interesting outcomes of this endeavor were

the joint development of a continuing education program for

staff development educators and an informal network of

sharing and support that developed among the nurse adminis-

trators (Stetler, McGrath, Everson, Foster, & Halloran,

1983).

As these authors suggested, when two or more agencies

are involved in providing education, a potential exists

for problems. However, careful planning and perseverance

reduces friction and enhances the product.









Orientation


Employing agencies do not expect employees to appear

with all of the necessary preparation for the job

(DiVincenti, 1977). For example, the new graduate needs

a complete orientation to the hospital before assuming

full job responsibility (Haggard, 1984). Until the 1930s,

the hospital worker who did almost everything, from patient

care to preparing the food and cleaning, was the nurse.

Therefore, it is not surprising that the first hospital

orientation programs were for nurses (Haggard, 1984).

Before World War II, orientation programs consisted of

one person showing another what to do.

After World War II, nurses no longer remained until

retirement or death in the institution where they had

trained (Deloughery, 1977). Career mobility for skilled

workers and professionals became a way of life (Tofler,

1970). Before the 1940s, nurses could leave hospital work

and come back 20 years later to pick up where they had

left off with little adjustment for change. At present,

a nurse's skills and knowledge may become outdated in only

2 years; soon that period may be even shorter. Haggard

(1984) described orientation programs as a way of providing

the knowledge of new breakthroughs and of updating the

preparation of nurses who have been away from the profes-

sion.









Since the 1960s, basic nursing education has shifted

from hospital-based programs to preparation gained in the

academic setting, in colleges and universities. Citing

this change, Haggard (1984) stated that hospital educators

are affected in that these changes have produced a markedly

different product. "The new graduate has a wealth of infor-

mation on a variety of topics, but may not have had an

opportunity to apply this information in a real-world

setting" (p. 154).

While orientation is a requirement for the newly

employed nurse, realignment of resources caused by the

introduction of DRGs now necessitates the reorientation

of staff members moving from one unit to another within

the same institution. Medical treatment is so technical

that each area requires nurses to be educated in special

procedures and skills. Because of current emphasis on

cost containment, convalescing patients are discharged

as soon as possible and only the most seriously ill patients

remain. The number of acutely ill patients per unit

increases as administration, to improve cost effectiveness,

closes and consolidates units. Nurses transferred from

units that cared for convalescing patients must be oriented

to technical equipment and procedures in critical care areas

before assuming responsibility for patient care (American

Hospital Assn., 1984). Thus, staff developers are chal-

lenged to provide social and technical orientation to the







42

newly employed nurse and to reorient nurses moving from one

area to another (Haggard, 1984).

The number of nurses currently employed for full-time

work has decreased, however, due to a decline in patient

census. This is a result of the cost-containment measures

hospitals implemented during fiscal 1983-84 (American

Hospital Assn., 1984).

Orientation consumes major portions of staff develop-

ment and resources. Kase and Swenson (1976) found the total

estimated cost of in-hospital education to be $226 million of

which $135 million or 60% was spent on orientation. Average

costs per sample hospital were computed, and for small

(under 100 bed) hospitals, the combined costs for

in-hospital education averaged $11,034 per year and $1.05

per patient-day; hospitals of more than 500 beds spent

$210,412 and $.95 per patient-day. The U.S. Department

of Health, Education, and Welfare, Division of Nursing,

Health Resources Administration, sponsored this study,

and it contains comprehensive data on the costs of

orientation and inservice education gathered from 5,865

hospitals for 1973-74. A nurse in orientation in this

study sample received between 84 and 154 hours of orienta-

tion at a cost of $770 to $984 per oriented.

As part of the Southern Regional Education Board Nurs-

ing Curriculum Project, faculty on the Clearwater Campus,

St. Petersburg Junior College, received a grant to develop









a joint faculty-service plan to demonstrate that, given

a structured method of orientation to the hospital, new

graduates could perform at an optimal level. Two college

instructors and one nursing service director or education

coordinator from each of eight agencies formed a task force

to design the curriculum and develop instructional modules

for a program that would be covered in orientation.

Participants constructed modules so that each agency could

use its own policies, procedures, and chart forms. Each

agency chose the period for implementation with a minimum of

4 and maximum of 12 weeks during 1979 orientation at

participating agencies. The results of the study indicated

that the structured orientation was more successful in both

quality of graduate performance and cost to the institu-

tion. The cost of orienting a single graduate in the bench-

mark sample taken before the experimental program was

$1,600. The use of the transitional modules reduced cost by

as much as $200 per oriented (Haase, 1981).

In another study, in examining a single hospital,

the investigator reported 240 hours of general orientation,

including classroom and clinical hours. Not including

fringe benefits, indirect costs, or instructor time, the

direct cost per nurse was $1,512 (Haggard, 1984).

The current problem of rising costs and falling reven-

ues causes administrators to examine expense columns in

the budget. Education is often one of the first items









slashed during an economy drive, and orientation is one

of the most expensive items in the staff development budget

(Haggard, 1984).

The benefits of orientation include socialization;

familiarization with organizational structure, goals, and

philosophy; and an opportunity for assessment of skill

while the nurse adjusts to a new environment (Hollefreund,

Mooney, Moore, & Jerson, 1981). Organizational socializa-

tion occurs in three stages: anticipatory socialization--

all learning that occurs before the person enters the

organization; accommodation--the period in which the

individual sees what the organization is really like and

attempts to become a member; and role management--when

the person mediates conflicts between work life and home

life. A successful orientation period increases the nurse's

commitment to work and to the institution (Kramer, 1974).

Of the variety of ways in which orientation is con-

ducted, most fall into one of two categories: centralized

or decentralized (Follet, 1982). The trend in hospitals

is to decentralize nursing units allowing nurse managers

autonomy in fiscal and personnel matters. Education, how-

ever, has tended to go toward centralized, hospitalwide

department structure where the needs of a single source

can service an entire institution (Rostowsky, 1980). Grubb

(1981) cited several studies on orientation and concluded

that agencies have different needs that require alternate









approaches. Whether a central department or the employing

units conduct orientation, this activity remains an

educational experience requiring guidance and instruction

from staff development (Haggard, 1984).


Inservice Education


As Cooper (1983) explained,

In-service education is usually defined as a
planned instructional or training program provided
by an employing agency in the employment setting
and designed to increase competence in a specific
area of practice. Inservice education is one
aspect of continuing education, but the terms are
not interchangeable. (p. 6)

Staff development educators are usually responsible for

coordinating inservice instruction and keeping records on

attendance. The context of inservice programs is most often

directly associated with patient care and is presented to

satisfy an immediate need. Inservice classes may or may not

qualify for contact hour credit from the Florida State Board

of Nursing, depending on content (Nursing, 1977).

The JCAH requires that nursing inservice programs

be planned and scheduled on a continuing basis and that

employee attendance be documented. Today, in most

institutions, inservice programs concentrate on bringing

employees up to date with new or changed patient care pro-

cedures, new diagnostic or treatment techniques, proper

care and operation of equipment, optimal use of supplies,









and abilities and functions of new types of health care

workers (Follett, 1982).

Authorities disagree about the best way to organize

and deliver inservice programs. On the one hand, establish-

ing a centralized department to handle inservice instruction

seems more economical. The disadvantage of such a plan

is that nursing has become so specialized and complex that

most content considered to be "core" material has been

taught at undergraduate or orientation level. No one

inservice instructor has the background to teach the content

to the right persons at the right level (Haggard, 1984).

Regardless of whether the program is presented in

a centralized or decentralized manner, the goal is to

deliver information directly related to patient care.

Since the justification is to improve quality of care,

instructors should design classes to upgrade employee per-

formance. The identification of a problem does not

automatically call for an inservice class. According to

Haggard (1984), designers of inservice should include con-

cern for cost containment in the assessment they make prior

to planning and implementation of instruction. Inservice

is usually a required attendance class, and employees are

reimbursed for time spent away from the unit (Haggard,

1984).

Inservice is an important component in hospital-based

education as technology continues to advance at a rapid









rate. Between the need for new knowledge to operate

equipment or perform procedures and efforts to maximize

employee productivity, the demand for inservice is increas-

ing (Follett, 1982). According to Gothler (1983), the

emphasis for the next few years is going to be on retaining

staff, stimulating staff, and assisting staff with the

monumental task of keeping up with the explosion of new

information and technology.

As Linton (1980) stated,

To deliver safe, efficient, and effective health
care services, hospital personnel must function
at minimum competency levels. An education-
ally sound hospital-based program, if thought-
fully planned, carefully executed, and accurately
evaluated, can provide a hospital with a well-
trained staff capable of delivering quality
care. (p. 70)


Continuing Education


The American Nurses' Association (1975) defined

continuing education as "planned, organized learning

experiences designed to augment the knowledge, skills,

and attitudes of registered nurses for the enhancement

of nursing practice, education, administration, and

research, thus improving the health care to the public"

(p. 10).

The need for continuing education in nursing is related

to rapid technological advances and changes in the methods

of health care delivery that have occurred in the last

20 years (Haggard, 1984). Increased government involvement









at both state and federal levels has also created the need

for continued education of nurses. Nursing audits, peer

review, quality assurance programs, and cost containment

measures all stem from legislative concern for health care

and necessitate learning new techniques and procedures

(Cooper, 1983).

Changes within the practice of nursing requiring addi-

tional knowledge have occurred throughout the history of the

profession. According to Cooper (1983), public health

nursing was the first expanded role for nurses and probably

led to demands for continuing education. Advent of the

clinical specialist and nurse practitioner in the 1970s

increased the need for ongoing education to accommodate

expanded nursing responsibilities.

In 1971 California became the first state to legislate

continuing education for nurse relicensure, requiring 30

hours of approved nurse-related education within a 2-year

period. A study by Keltner (1983) indicated that California

nurses perceived mandatory continuing education as affecting

nursing practice in acute care facilities in a positive

manner. Keltner further found that nurses from critical

care units perceived clinically oriented classes as more

beneficial than decisionmaking and nonclinical courses.

Another conclusion from this study was that nurses appear to

be motivated by more than legislative mandate when they

attend continuing education classes.









In 1902, in an address concerning nursing as a profes-

sion, A. Worcester stated that one criterion for a

profession is acknowledging the need for continuous study

(Pfefferkorn, 1928). Schor (1981) concluded that many

nurses feel the need for continued learning because of

challenging advances in technology and the desire for upward

mobility. According to Schor, "inservice education," "staff

education," or "staff development" has been in evidence

since the 1930s. The responsibility for obtaining this type

of education usually rests with the professional; however,

rules enforced by legislation calculated to improve practice

have been enacted by several states (Cooper, 1983). While

debate continues regarding the relationship between

attendance at continuing education programs and changed

performance, efforts to measure results have not been very

successful. Deets and Froebe (1984) attempted to use direct

observation techniques to determine the effect of programs,

were forced to abandon the effort, and resorted to a ques-

tionnaire that also failed to obtain the desired informa-

tion. Keltner's review of literature concerning the effect

of continuing education indicated that "most research does

not support the California legislature's opinion that

nursing continuing education effectively improves nursing

practice" (1983, p. 23).

Puetz (1983) studied continuing education attendance

patterns of registered nurses in 1975 and 1978. The







50

findings of this investigator suggested that better educated

nurses attend continuing education activities, and nurses

employed full time attend at a higher rate than any other

group. Employment status, highest level of education com-

pleted, position, and field/place of employment were sig-

nificantly related to attendance. As Puetz stated,

"Apparently the more nurses work and the more the work is

related to nursing, the more they attend continuing educa-

tion activities" (1983, p. 11).

The Florida State Board of Nursing is authorized to

make rules "not inconsistent with law as may be neces-

sary to protect the health, safety, and welfare of the

public" (Nursing, 1977). Rules and regulations in Florida

cover qualification for licensure and continuing education.

The Florida State Board of Nursing approves continuing

education providers who meet the criteria set forth by the

Board. The Board may revoke a provider number if the

quality of courses is consistently below standard.

Austin (1983) found two effects on manpower as a result

of mandatory continuing education in Florida: More people

were hired by hospitals to meet the requirements of being

a continuing education provider, and a number of nurses

were temporarily off duty either because they were attending

classes or because they failed to meet the 24-contact-hour

requirement for relicensure. Also hospital departments of









education have added personnel to present more continuing

education to both staff and community nurses.

Austin (1983) found that 66% of all continuing educa-

tion was available at $4 per contact hour or less, resulting

in a maximum cost of $96 for the 24 contact hours "if the

nurse shopped for the best value" (p. 18). Hospitals were

the largest group of providers in Florida, with independent

providers second. As Austin also found, "Most providers

were supported by institutional budgets, so charges were

nominal since programs were not expected to be self-

supporting" (p. 20). Those with self-supporting continuing

education departments have to charge enough to meet direct

expenses of running the department (Rowlands & Rowlands,

1980). Nursing continuing education is costly to the nurse,

the employing health care facility, and the patient (Levine,

1978).

Some nurses' association administrators said that

hospitals were demanding more continuing education but

giving less time for staff to attend. Also nurses seeking

support for liberal continuing education reimbursement

policies may not get it from some state nurses' associa-

tions. As Regina M. Villa, executive director of the

Massachusetts Nurses' Association, stated, "Continuing

education is the nurse's responsibility, intellectually

and financially" (Rowlands & Rowlands, 1980, p. 178).

The Rowlands added, "most large hospitals offer extensive









inservice and staff development programs, and some form

of tuition reimbursement" (p. 178). Frequently in recruit-

ment literature agencies promise continuing education as

a benefit, but in an RN survey of a national cross section

of readers, 37% of the nurses received no pay for time

spent in continuing education courses. Of 32 nurses who

responded, only 22% said the hospital paid tuition,

expenses, and full salary (Donovan, 1978).

More hospitals are tightening policies than are liber-

alizing them. The cutback is most pronounced among larger

hospitals which provide the bulk of benefits (Rowlands

& Rowlands, 1980).

The impact of DRGs on hospitals has been immediate.

Increasing nurses' productivity while maintaining

high-quality care has become more of a challenge for nursing

directors with the advent of the new prospective payment

system of Medicare. At Cedars-Sinai Hospital in Los

Angeles, Spitzer eliminated central education in favor of

unit-based education and cited a $700,000 annual saving. As

institutions reevaluate education within the hospital,

emphasis may change and other providers may offer continuing

education (Franz, 1984).


Management and Organizational Training


Institutions are experiencing culture shock as they

move from the limited-controlled and noncompetitive









environment of the 1970s to the tightly controlled environ-

ment of the 1980s. Management of resources, human and

material, is a high priority in running an efficient,

cost-effective, competitive institution (Yokl, 1984).

Leadership and management training is that phase of

the staff development program directed toward equipping a

selected group of employees for growing responsibilities

and new positions in nursing. Identifying and encouraging

potential leaders is a task assigned to nursing administra-

tion, nurse managers, and education coordinators

(DiVincenti, 1977). The role of staff development is to

identify programs that can effectively meet organizational

needs, arrange presentations, and evaluate the outcomes

based on feedback from participants and their supervisors

(Sovie, 1982).

Few leadership appointees from the ranks of nursing

have had formal training in administration or management

(McKibben, 1983). To compound the problem, the positions

to which people are appointed are usually located on busy

patient care units where expert leadership and direction

are required to meet staff and patient needs. The result

is that individuals are given vacant management jobs with

some harried orientation and direction, then expected to

perform to standards they are not prepared to meet.

Designing programs to meet the needs of nursing managers

as they enter new positions and assuring, through program









planning and evaluation, that those already in such posi-

tions have continuing opportunities to master their job

functions is within the scope of staff development education

(Sovie, 1982).

Staff development educators work in the role of

internal consultant to the organization when they assist

supervisors and managers to differentiate between

performance problems that are caused by lack of training,

environmental factors, motivational factors, and internal

organization constraints. Through the use of management

principles, concepts from behavioral science, organizational

dynamics, and knowledge of the rules and regulations within

the hospital organization, the developer consults with

managers on such issues as resolving conflicts, building

organizational teamwork, identifying standards of perform-

ance, and defining employment development objectives. The

staff development educator can then design programs using

the best available and affordable resources (Finkelmeier,

1980).

Leadership development and management training programs

are fertile ground for reciprocation between nursing service

and nursing education personnel (Sovie, 1982). The hospital

education department, through affiliation with local col-

leges and universities, can offer management development

programs that are appropriate for the needs of each level

of nursing leadership. The staff development educator







55

forms the link between internal needs and external resources

(Follett, 1982).


Planning for Staff Development Education


Staff development activities are designed to encompass

all professional growth activities which meet the needs

of individuals within an educational context (Goodstein,

1978). Stoner (1978) added that staff development is

designed to educate personnel beyond the requirements of

their present condition. The purpose of inservice, on the

other hand, is to improve job performance (Goodstein, 1978).

Likert (1967) identified six processes with the organi-

zational structure that are potentially responsive to

change. These are communications, goal setting, decision

making, interaction/influence processes, motivation and

control, and performance appraisals. The cross relation-

ships between and among these processes are such that change

in one area will produce change in other areas (Schambier,

1983). Staff development, therefore, seems to be a logical

place to identify, address, and improve the competencies

of nurses in terms of the requirements of their employment

(Caldwell, 1979).

According to Schambier (1983), "without a philosophical

screen to sift various individual, group, and institutional

needs, staff development programs become little more than

piecemeal prescriptions" (p. 6). Self-directed personnel









may patch together a number of experiences; however, these

people generally become disenchanted when they encounter

goals not chosen or not understood. Mann (1978) labeled

this reaction a defensive characteristic of nonvolunteer

audiences.

To avoid the dilemma of a nonspecific program that

lacks relevance for the intended audience, staff development

efforts should have clear, straightforward goals. Moreover,

those whose lives will be affected by intended outcomes

should be the ones to determine, at least in part, what

those goals should be.

Monette (1977) identified four questions staff develop-

ment planners should consider:

1. Who can best perceive professional and agency

needs?

2. To what extent do selected needs pertain to

(a) individuals and (b) the system?

3. How can staff development planners prepare them-

selves to deal with shifting needs?

4. What critical relationship exists between needs

and the operational philosophy of the institution?

5. Based on answers to these questions, which atti-

tudes will prevail toward organizational growth and

development? (p. 117).

The organizational structure of the institution

directly affects planning for staff development activities.







57

Imel and Knowdell (1982) listed the following tasks that are

necessary for planning organizational career development

programs. These tasks were to

1. Determine organizational readiness and commitment.

2. Build a team to assist in planning.

3. Staff the program with qualified personnel in

carefully defined positions.

4. Assess internal and external resources.

5. Assess the needs of both the organization and

the staff.

6. Define program goals based on needs assessment.

7. Define the program from successful models and

derived strategies.

8. Implement the program by way of listing resources,

personnel, and deadlines for each program goal.

9. Evaluate the program.

According to Lancaster and Berne (1981), career pro-

grams have evolved for reasons that are both societally

and organizationally based. People now see career as

important in terms of overall quality of life--individuals

want to derive personal satisfaction from their work but,

at the same time, want to balance career interests with

personal considerations such as marriage, family, and

leisure activities. This change in individual career per-

spective has been accompanied by a decrease in job mobil-

ity. In the current economic climate, changing jobs in









order to achieve career goals is not easy. Individuals,

therefore, are seeking career satisfaction within their

current organizations (Imel, 1982).

Wandeldt (1980) surveyed 3,000 nurses and found that

employed nurses identified eight factors as reasons for not

working. Economic benefits were fourth and educational

benefits fifth in this authors' scale. Deets and Froebe

(1984) reviewed several studies and found dissatisfaction

with educational opportunities higher among employees hold-

ing longer tenure. Recognition (which includes salary),

educational programing, and organizational structure were

the major variables Deets and Froebe identified as

incentives for nurse employment. Recognition of these

factors by administration and staff development planners

forms a cornerstone for the amount and type of education the

institution offers (Sovie, 1983).

Whether organization of staff development is central-

ized or decentralized influences the priorities given to

program construction. In centralized or hospitalwide

programs staff developers work with all disciplines and the

director of education portions the department energies to

meet a variety of needs. Hospitalwide education is

controlled by a central department in charge of employee

orientations, on-the-job-training, inservice instruction,

continuing education for all disciplines, supervisory and

management training, and coordination of career mobility









programs (Grubb, 1981). Planning for the educational

calendar of the institution is simplified, and all resources

are under one director who can cross departmental lines to

coordinate programs (Lawrence & Peoples, 1982). Grubb

(1981) predicted that the trend toward management of

education and training from a central office would

accelerate; but the dilemma concerning what constitutes the

hospital education function, and how it is placed and

managed, will have to be resolved by hospital administra-

tion. Grubb also noted that the proliferation of program

activities, except for health and wellness promotion, would

level off under scrutiny of cost-benefit and cost-

containment measures.

Nursing administrators responsible for the educational

needs of nursing staff (who constitute 50-60% of hospital

personnel) are under pressure to contain cost while increas-

ing productivity and are seeking solutions that will satisfy

all concerned. A combination of centralized and decentral-

ized, or any other method that would demonstrate quality and

cost effectiveness, is acceptable in the transition caused

by the introduction of the prospective payment system

(Franz, 1984).

Haggard (1984) contrasted traditional education depart-

ment responsibilities to a decentralized model and found

that, as clinicians on the units assumed more responsibility

for staff education, the major problems were associated









with communication over purchase and use of resources or

changes in charting formats. The advantages of caretaker/

educators on the units justified the change in added

relevance of learning and demonstrated expertise in pro-

cedures. In this system, the educator is responsible for

teaching the clinician to teach and acting as a resource

person when needed.

Instructors in the department of education must "cope

with feelings of isolation from nursing service," according

to Haggard (1984), but the efficiency of this system justi-

fies the problems of transition. Flattening out the organi-

zational structure channels authority and accountability

for patient care to the unit level. Each practitioner

can have influence and an impact on where the organization

is going. Haggard further stated that as nursing practice

becomes more sophisticated, all areas need staff development

daily with three clinicians assigned to each unit--one

for each shift.

The planning of staff development education requires

input from all levels, including the staff nurse. Rowlands

and Rowlands (1980) noted that the more personnel are

involved, the easier it will be to get good attendance

at the activities and to give staff the feeling that they

have a responsibility in the success of the program.

Methods of identifying content include staff judgment,

focused observations, and needs surveys.








Evaluation


Evaluation is the process of delineating, obtaining,

and providing useful information for judging decision alter-

natives (Stufflebeam, 1977). Mehrens and Lehmann (1975)

noted that the determination of the congruence between

performance and objectives is another popular concept of

evaluation.

When evaluating staff development programs, the goal

is to establish some correlation between instruction given

and performance changes in the work area (Gosnell, 1984).

The process used most frequently in adult education is

based on the Tyler (1950) method of curriculum development.

Those responsible for teaching preset learning objectives,

present content, and judge outcomes according to attainment

of these objectives. This type of evaluation is designed to

provide feedback to the learner, to guide the teaching-

learning interaction, and to evaluate the instruction.

Organizations spend large sums of money conducting

educational programs, and evaluation of the product is

necessary to justify the expense. Four steps are involved

in the evaluation of hospital-based education: assessment

of (a) staff reaction, (b) cognitive learning, (c) improved

psychomotor performance, and (d) behavioral changes related

to the objective criteria (DiVincenti, 1977).

Gardner (1977) presented the following overview of

five general evaluation frameworks:









1. Evaluation as a professional judgment.

2. Evaluation as a measurement.

3. Evaluation as the assessment of congruence between

performance and objectives.

4. Decision-oriented evaluation.

5. Goal-free evaluation.

Nursing uses measurement as a professional judgment

for accreditation and licensure. Evaluation as a measure-

ment is often used in standardized tests, but the cost

is high and flexibility of these tests is limited (Cooper,

1983).

Evaluation using objectives is the most frequent method

of measurement in staff development education. The diffi-

culty is that the focus may become too limited, and some

major benefits of the program may be overlooked (Gardner,

1977).

Decision-oriented evaluation uses a systems approach

based on input, a set of laws, and an output (Stufflebeam,

1977). The advantage is that it encourages analysis of

all important factors; the disadvantage is that, if the

process is not employed properly, it lacks flexibility.

Goal-free evaluation allows assessment of all factors

with emphasis on the learners as individuals. The problem

with this is that if the focus is lost, the investigator

uses irrelevant data (Gardner, 1977).









When dealing with the many facets of hospital-based

education, an eclectic approach to evaluation, incorporating

those elements of the process best suited to the task is

necessary. Knowledge of evaluation procedures is essential

for those involved in staff development (Linton, 1980).


Changing Patterns Within Staff Development


Recognition of the need for change is the first step

to reorganization. Education and training are necessary

if hospital personnel are to deliver safe, efficient, and

effective health care services (Truelove & Linton, 1980).

During the 1970s, hospital-based education (in response to

growth stimulated by government funding) increased the

services offered and the numbers of staff assigned to pro-

vide instruction to agency personnel. Now, as a result of

Public Law 98-21, the process is being reversed.

Morath (1983) stated that "nursing directors are

expected to control costs and deliver quality service at

the same time" (p. 50). Problems facing directors as a

result of this mandate include the demands for highly

skilled specialized nursing care, requirements for patient

education, the needs of staff development, and the need

to organize an environment which stimulates professional

growth and results in reasonable job satisfaction. The

question evolves to, how can a health care setting provide

an environment which supports and encourages the fullest









use and practice of nursing when society demands that the

profession produce more for less?

According to Haggard (1984), "the newest trend in

nursing department systems development is decentralization--

the process of flattening out the hierarchy so that one

layer of management (supervisor) is removed" (p. 90).

In decentralized education, a nurse in each area is desig-

nated as the facilitator responsible for the needs of the

unit related to inservice, orientation, continuing educa-

tion, and management/organizational assessment (Linton,

1980). When a hospital nursing service flattens its struc-

ture, the benefits are immediate. If management has laid

adequate groundwork, authority and accountability for

patient care go to the unit level. Each individual

practitioner can have a dramatic impact on outcome and can

influence where the organization is going (Haggard, 1984).

Hospitalwide departments of education existed in 54%

of the nation's hospitals surveyed in 1979 by the American

Hospital Association in 1979 (Lawrence & Peoples, 1982).

The move toward hospitalwide education departments began in

the 1970s when facilities, patient census, and technology

were increasing at an astronomical rate.

John Affeldt, president of JCAH, in his keynote address

at the llth annual meeting of the American Society for

Health Manpower Education and Training, emphasized the

necessity of coordinating overall quality assurance efforts









in the hospital and reducing duplication. Managers and

educators who have attempted to plan for hospitalwide

education have been hampered by the absence of uniform

definitions and lack of practical models that facilitate

the definition, identification, and assessment of current

or desired educational programs (Lawrence & Peoples, 1982).

These statements, while true in theory and administration

of resources, do not take into consideration human factors

such as the culture of the workplace (Yokl, 1984).

"People are an organization's greatest asset" is a

common phrase in management circles but, as Drucker (1973)

stated, "while management proclaims that people are their

major resource, the traditional approaches to the management

of people do not focus on people as resources, but as prob-

lems, procedures, and costs" (p. 108). From an administra-

tive point of view, the advantages of centralized hospital

education are consistency in organizational style, direct

administrative control over education and training, faster

implementation, control and allotment of resources, and

ease of obtaining congruence with organizational goals

and objectives (Munk & Lovett, 1977). Problems that stem

from centralization may include the fact that unit managers

do not feel responsibility for education and training;

unit managers feel threatened by the authority or

credentials from within the education and training depart-

ment; staff development needs must filter through several









layers of the organization before the problem receives

attention; and relevance of the educational product to the

problem is diluted by time and interventions conceived away

from the area of need (Munk & Lovett, 1977).

The benefits of decentralized education are that the

potential exists for greater department head involvement

in education and training activities; the training function

responds directly to department need; the unit manager

feels more responsibility for staff development of direct

employees; and staff become involved in their own ability

to use education as a tool for change. The problems are

less direct control by administration of education and

training activities; possible lack of congruence with

organizational goals and objectives; and coordination of

the use of instructional resources and facilities (Munk &

Lovett, 1977).

As Ehrat (1983) stated, "Efforts toward effective and

successful planning and decision making are facilitated by a

working knowledge of past struggles and outcomes" (p. 31).

When the economy is constrained and budget cuts are made,

the cutting off of resources or personnel forces institu-

tional efficiency and increased productivity.

Decisions made by managers in periods of stress may

reflect an attempt to protect vested interests if informa-

tion is not available to facilitate rational choices.

Assumptions are made on the whole based on certain simple









indicators. Those key, but arbitrary, boundaries provide

decision makers with a fundamental mechanism for making

judgments about the organization. Any significant change in

those data should cue the manager to take a proactive rather

than reactive course of planning and action (Ehrat, 1983).


Summary of Literature Review


Hospital-based education exists in all health care

settings; the scope varies with the size, identified need,

and philosophy of the institution. The four basic com-

ponents of staff development education are orientation,

inservice instruction, continuing education, and management/

organizational training.

One conclusion that can be drawn from the review of

literature is that change due to new funding formulas and

agency operational patterns is causing reorganization within

hospitals. Decentralization of nursing hierarchies to unit

control is a trend; and, in conjunction with this move,

staff development activities are shifting from hospitalwide

departments to the unit level. New methods of delivering

services are sought to use available resources as the

problems of diminishing supply force decision makers to

reevaluate current practices.















CHAPTER III
METHODOLOGY


This study was designed to form a differential data

base for staff development for nurses and to compare

specific aspects of staff development in relation to size

and profit system. Responses to a questionnaire mailed to

staff development directors provided data on curriculum,

available resources, and administration. This chapter

contains a description of the population, procedures used to

develop the questionnaire, an explanation of the validity

and reliability, and an identification of techniques used to

analyze data.


Population


The population for this study was composed of depart-

ments of staff development of hospitals listed in Florida

Hosptals: The Facts (Florida Hospital Assn., 1983), when

those hospitals met five criteria: (a) were nongovern-

mental, (b) were classified as general medical-surgical,

(c) provided short-stay care, (d) had a minimum of 200

patient-beds, and (e) were current members of the Florida

Hospital Association. Staff development departments of

long-term care, psychiatric, specialty, and government










(county, state, or federal) owned hospitals were not

included in the study. Staff development departments from

hospitals with fewer than 200 beds were excluded because a

preliminary survey of 10 randomly chosen hospitals in this

category disclosed that they did not have departments of

education.

The departments of staff development that made up

the population represented 70 hospitals or 37.4% of the 187

institutions listed in Florida Hospitals: The Facts and

included 52.8% of the total hospital beds in the state.

Table 1 shows the distribution of hospitals by size and

profit system. Because the for-profit category contained

no extra large hospitals, data on departments of education

of the nongovernmental not-for-profit hospitals of that

size were treated separately. Therefore, the hospitals

were divided into two subgroups for analysis. Subgroup A

was all small, medium, and large hospitals including both

for-profit and nongovernmenal not-for-profit agencies.

Subgroup B included only the extra large not-for-profit

hospitals.










Table 1

Distribution of Hospitals by Size and Profit System


For-profit Not-for-profit Total
Size n % n % n %


Subgroup A

Small
(200-299) 15 64 10 32 25 46

Medium
300-399) 4 18 14 45 19 35

Large
(400-499) 4 18 7 23 10 19

Subtotal 23 100 31 100 54 100

Subgroup B

Extra Large
(500+) 16 100 70 100


Instrument Development


I constructed a survey questionnaire to collect data

for the study using information from Munk and Lovett (1977)

and Rowlands and Rowlands (1980). I discussed the lists of

elements and critical criteria identified by these authors

as essential for staff development programs with selected

health care leaders (a hospital administrator, nursing

administrator, director of education, and education

coordinator) before constructing the questionnaire. Eleven

items related to the hypotheses and 19 items described the

sample.









The questionnaire was designed to elicit information

readily available to staff development directors, to

facilitate early completion and return of mailed instruments

(Babbie, 1973).

The questionnaire response format included open-ended

items, completion items, ranking items, and items requiring

a check mark. Validity, as content validity, was a function

of the construction of the instrument. Reliability evolved

from a test-retest model using results from a pilot study

and from the return of the final questionnaire.


Validity


After constructing the questionnaire I submitted the

items and the primary research question to a panel of

consultants to establish content validity. According to

Nunnally (1978) content validity is not determined by

statistical manipulation but rather is predetermined by the

plan and procedures used in instrument construction.

The panel, composed of two hospital administrators, two

directors of nursing, two directors of staff development, an

educational researcher, an educational psychologist, and a

nurse educator, received a copy of the research question,

the variables, and the questionnaire (Appendix B). Members

of the panel indicated whether, in the opinion of each, the

items were appropriate for eliciting data for the variable

for which it had been written. I discarded items that two









members of the panel rejected, thus eliminating two

categories of items that related to budget. The final form

of the instrument (Appendix B) contained 11 items to provide

data for the research question and 19 items designed to

describe the sample.


Pilot Study


I conducted a pilot study to develop an estimate of

reliability, ease of use, and clarity of the instrument. I

divided Florida hospitals that met the criteria for

inclusion into seven categories according to size and profit

system (the for-profit category included no extra large

hospitals). I blindly selected one agency and one alternate

from each cell to form a stratified random sample of

agencies for use in a pilot administration of the question-

naire. The sample was widely dispersed geographically and

represented the major areas of Florida.

I telephoned the staff development director in each

subject agency, explained the purpose of the study, and

arranged for a face-to-face interview. I made visits during

July, 1984. The staff development director of one of the

selected hospitals was not available so I conducted a

telephone interview with the staff development director of

the alternate agency. To see that all directors interpreted

the items in the same way, during each interview I read the

questionnaire items with the staff development director. At









the end of the respective interviews I gave a typed

questionnaire with a stamped, addressed envelope to the

participant and asked each to answer the questions after I

left and mail it within a week.

Following the pilot administration of the instrument, I

reworded three items to increase precision in communication

and returned the revised instrument to members of the panel

of consultants with the request that each again review the

items. I asked them to consider both content and clarity.

The panel made no changes.


Reliability


During the interview I read the questionnaire items

with each director from the seven staff development depart-

ments in the stratified random sample and recorded their

responses. At the end of the interview I left with each

director a copy of the questionnaire (to be returned within

a week) and later mailed each a copy of the final instru-

ment. These directors returned all of the instruments.

Comparison of responses revealed no individual differences

between the responses in the two administrations of the

instrument.

Investigators use this procedure to estimate

reliability when they plan to use the instrument to elicit

stable information. Since this questionnaire was designed

to generate information that is usually (but not










necessarily) stable during the fiscal year (resources and

administration), and to reflect staff development directors'

perceptions, I restricted time for readministration to 5

weeks.


Collection of Data


The items were printed for mailing to the directors of

staff development departments. I contacted each director by

telephone to verify name, title, and address. I mailed the

instruments on August 15, 1984, sending each questionnaire

(Appendix B), together with a letter (Appendix C), in a

small box containing a ceramic coffee mug with the following

postscript, "The enclosed cup is my gift to you to express

my appreciation for your participation in this survey, so

why not fill your new cup and take a break right now?" The

rationale behind this approach was that recipients are more

likely to respond to a questionnaire that is delivered in an

unusual manner and contains a reward for answering the

questions and returning the instrument.


Analysis of the Data


Responses to open-ended items were grouped according to

categories of staff development resources, administration,

and curriculum. The categories and frequencies of responses

in each were reported in tabular form.







75

Before the other responses were keypunched, the nominal

data were categorized and coded, and some of the quantita-

tive responses were grouped and coded as interval data.

Statistical hypotheses were derived from the research

hypothesis; each statistical hypothesis referred to one

dependent variable (with data generated from questionnaire

responses) and one independent variable (hospital size or

profit system). To consolidate the information obtained

from tests of the several statistical hypotheses related to

each research hypothesis, a binomial test was performed

using rejected hypotheses as successes and nonrejected

hypotheses as failures (Guilford & Fruchter, 1978).

Data were tabulated and analyzed using the Statistical

Package for the Social Sciences (Nie, Hull, Jenkins,

Steinbrenner, & Bent, 1970) as adapted for small computer

systems by Columbia University.

Frequencies and percentages of occurrence were reported

for nominal and interval data. The chi square test for

independence was used to test for those differences required

to answer the statistical hypotheses when nominal data were

involved. One ranking item provided ordinal data. I

reported the frequency of occurrence of each rank, then

tested for differences after converting the data using a

normal transformation process recommended by Li (1964).

After the transformation to continuous data, I tested for

differences using the ANOVA subprogram of the Statistical









Package for Social Sciences (Nie, Hull, Jenkins,

Steinbrenner, & Bent, 1970).


Summary of Methodology


This study was designed to survey departments of staff

development for nurses in those Florida hospitals that met

the criteria for inclusion. A questionnaire sent to the

staff development directors was based on one research

question that generated six research hypotheses. They

related to resources, administration, and curriculum for

staff development of nurses. A panel of consultants

reviewed the research question, variables, and questionnaire

items. I administered the questionnaire as an interview to

seven staff development directors as a stratified random

sample from the 70 Florida hospitals that met the criteria

for inclusion. The instrument was mailed to the staff

development director in each hospital. Analyses included

the use of frequencies, percentages, chi square, a normal

transformation process followed by an ANOVA, and statements

as to staff development directors' perceptions.















CHAPTER IV
SURVEY RESULTS


Responses to a questionnaire that staff development

directors completed provided data for this study. The

questionnaire contained 19 demographic items and 11 items

designed to answer a research question. Demographic items

were included to describe certain characteristics of the

sample. Responses to items related to the research

hypotheses were analyzed according to the appropriate

technique--frequencies, percentages, binomial tests, chi

square, and a normal transformation process followed by

ANOVA. Comments by respondents were included with the

questionnaire items to which they related.


Description of Sample


Of the 70 directors of staff development to whom ques-

tionnaires were addressed, 58 (83%) returned theirs within

10 days. Respondents represented 87% of the for-profit and

81% of the nongovernmental not-for-profit hospitals that

qualified for inclusion in the study.

Hospitals were categorized according to the number of

reported patient beds (questionnaire item 1) and type of

profit system (item 2).









Four categories for size were

Size Beds

Small 200-299
Medium 300-399
Large 400-499
Extra large 500 +


Two profit system categories were included: for-profit (FP)

and nongovernmental not-for-profit (NFP). Figure 1 shows

the distribution of hospitals by size and profit system,

further differentiated as to whether directors of staff

development did or did not respond to the survey.

Because no for-profit hospitals were in the extra large

category, the departments of staff development from that

category, referred to as subsample B, were studied separ-

ately. Subsample A included departments in small, medium,

and large agencies that had corresponding departments in

for-profit and not-for-profit hospitals. Subsample B

included departments from extra large not-for-profit

hospitals.

Fifty-two percent of hospitals whose staff development

directors responded had used diagnosis related grouping

(DRG) for 6 months or more--55% of the for-profit and 50% of

the not-for-profit institutions. Staff development direc-

tors of 40% of the small and medium, 46% of the large, and

58% of the extra large agencies reported hiring freezes

during that period.















20


15


10


5


0


(200-299)


H


NFP
Extra Large
(500 + )


Respondents


FP: For-profit; NFP: Not-for-profit


Figure 1. Distribution of hospitals categorized by size
and profit system showing response pattern.


H


Medium
(300-399)


Large
(400-499)







80

Directors at one medium and one large agency (3% of the

sample) reported the number of nurses who required orienta-

tion had increased. Fifty-nine percent of the directors

reported decreases and 39% perceived no change.

All directors reported that their agencies had Florida

State Board of Nursing-approved continuing education

provider numbers (questionnaire item 25) and offered con-

tinuing education classes to both staff and community nurses

(items 26 & 27). Costs for these classes averaged $3.70 per

contact hour in small agencies, $5.00 per hour in medium

hospitals, $4.20 per hour in large institutions, and $4.40

per hour in extra large hospitals. Of the not-for-profit

large hospitals, 27% did not offer free continuing education

contact hours as a benefit for staff. The remainder of the

sample did provide free continuing education. In the

opinion of sample staff development directors, if the

Florida State Board of Nursing should rescind the require-

ment for 24 contact hours of continuing education, 60 to 75%

of the hospitals would not offer as many classes. Examina-

tion of directors' responses to this question by hospital

profit system revealed no difference; 50% of both the

for-profit and not-for-profit agencies would decrease con-

tinuing education offerings.

When staff development departments were compared by

hospital size, 85-90% provided career counseling, which is a

requirement of JCAH (Joint Commission for Accreditatin of







81

Hospitals). Three fourths of the for-profit and 84% of the

not-for-profit hospitals offered career counseling.

Structured methods of career advancement were reported

in 25% of the small, 40% of the medium, 64% of the large,

and 85% of the extra large hospitals. Directors of an equal

proportion (40%) of for-profit and not-for-profit hospitals

reported such methods.

Directors of 25% of the small, 40% of the medium, 63%

of the large, and 83% of the extra large institutions

reported structured classes such as critical care or manage-

ment and organizational training. Directors reported 45% of

both for-profit and not-for-profit agencies had structured

classes for horizontal or vertical career mobility.

Two thirds or more of the directors in small and medium

hospitals felt the course evaluation procedures were

adequate. Slightly more than half of the directors of extra

large hospitals perceived evaluation as adequate. Directors

from 9% of the large hospitals did not use a standard

evaluation form, but the remainder of the sample reported

use of a standard format.

Staff development directors reported their highest

level of academic preparation. The distribution of the

academic preparation peaked at the master's level. The one

respondent whose highest credential was the associate degree

was an acting director, scheduled to be replaced within the

year. Forty-eight percent reported master's degrees in









education or nursing. The report of doctorates by 15% and

an education specialist degree by one (3%) of the directors

completed the report of highest level of academic

preparation.

In reporting the number of years they had been staff

educators, staff development directors of small hospitals

averaged 6 years and medium agencies, 4 years. In large

institutions the average was 5 years and in the extra large,

10 years. The average time as staff educator, when

hospitals were compared by profit system, was the same--5.5

years.

Two open-ended items were included to provide

respondents with an opportunity to present individual

concerns not within the scope of the questionnaire (items 29

and 30), and they were not included in this report.

Questionnaire item 12 did not elicit adequate responses and

was omitted.

The preceding responses to questionnaire items provided

a data base involving time, staff development practices, and

a profile of staff development directors' credentials for

the three areas of curriculum, administration, and

resources.


Description of Analysis


Statistical hypotheses were generated from the research

hypotheses to test each comparison. Because no for-profit







83

institutions were found in the extra large size, comparisons

were made only between staff development departments in

small, medium, and large hospitals, designated as subsample

A. Responses from directors of extra large hospitals

(designated subsample B) were reported separately.

Findings from data related to each research hypothesis

are presented, subdivided by items that related to that

hypothesis. The null hypotheses followed a general format,

and each was based on research hypotheses. The independent

variables were hospital size and hospital profit system.

All dependent variables were derived from responses for the

questionnaire item. Descriptive data are presented

separately for subsamples A and B. Statistical hypotheses

applied only to subsample A.


Analysis of Data Related to Curriculum


The first two research hypotheses related to curriculum

in staff development.

Research hypothesis 1. The areas of staff development

that directors perceive as needing emphasis vary according

to hospital size and profit system.

Eight null hypotheses were tested, each written from

the general format:

Ho 1. Staff development directors' level of perceived need

for emphasis in (a) orientation, (b) inservice instruction,









(c) continuing education, (d) management and organization

is independent of agency size; profit system.

Dependent variables were identified from the data

generated from item 6; separate statistical hypotheses were

tested for each of those variables. That item elicited

information concerning the respondents' perception of need

for emphasis in four content areas of staff development

(orientation, inservice instruction, continuing education,

management and organization).

Questionnaire item 6. In the following categories of the

staff development, check the area according to your percep-

tion of current needs. (Choices included more emphasis,

less emphasis, or no change [Appendix B]).


Subsample A


Perceived emphasis on orientation


Comparison by hospital size: When departments were

compared by hospital size, the level of significance

required to reject the null hypothesis for perceived need

for emphasis in orientation was not reached in chi square

analysis (p=.85). Directors from small, medium, and large

agencies were in close agreement (27%, 27%, and 30%) (Table

2) in reporting a perceived need for less orientation.

Comparison by hospital profit system: The level of

significance required to reject the null hypothesis was not

reached (p=.79) in the chi square analysis for perceived









need for emphasis on orientation when responses were

compared by hospital profit system. Directors of 50% of the

for-profit and 73% of the not-for-profit hospitals perceived

a need for more emphasis. Respondents for only 10% of the

for-profit and 4% of the not-for-profit hospitals perceived

a need for less emphasis.


Perceived need for emphasis on inservice instruction


Comparison by hospital size: Directors of small

hospitals reported the highest percentage (75%) of perceived

need for more emphasis on inservice instruction. No

respondents from large agencies saw a need for less

emphasis. The value for chi square did not reach the level

of significance for this comparison (Table 2).

Comparison by hospital profit system: Directors of 50%

of the for-profit and 73% of the not-for-profit institutions

perceived a need for more emphasis on inservice instruc-

tion. The level of significance required to reject the null

hypothesis was not reached in the chi square analysis

(p=.37) when the comparison was by hospital profit system.


Perceived need for emphasis on continuing education


Comparison by hospital size: Chi square analysis

yielded a statistically significant value (p=.02) in an

examination of perceived need for emphasis on continuing









Table 2

Staff Development Directors' Perceptions of Needs for
Emphasis on Orientation, Inservice Instruction, Continuing
Education, and Management and Organizational Skills, by
Hospital Size



Perceived Need for Emphasis in Orientation


Size More Less No Change
n % n % n %


Small 7 35 6 30 7 35
Medium 4 27 4 27 7 46
Large 5 46 3 27 3 27 X (4,n=46)=1.365 p=.85


Perceived Need for Emphasis on Inservice


Small 15 75 1 5 4 20
Medium 8 54 2 13 5 33
Large 6 55 0 0 5 35 X (4,n=46)=4.231 P=.37


Perceived Need for Emphasis on Continuing Education


Small 13 65 3 15 4 20
Medium 3 20 5 33 7 47
Large 2 18 2 18 7 64 x (4,n=46)=11.242 p=.02


Perceived Need for Emphasis on Management and
Organizational Skills


Small 16 80 0 0 4 20
Medium 12 80 2 13 1 7
Large 10 91 0 0 1 9 x (4,n=46)=5.595 p=.23



education when the comparison was by hospital size, the null

hypothesis of independence of size was rejected. Table 2

shows the percentages of directors who perceived a need for









emphasis on continuing education. Sixty-five percent of

directors in small hospitals perceived a need for more

emphasis on continuing education while directors of 20% of

medium and 18% of large agencies saw a need for more

emphasis.

Comparison by hospital profit system: The value of chi

square was not statistically significant in the analysis by

profit system for perceived need for emphasis on continuing

education. Directors from 40% of the for-profit and 39% of

the not-for-profit agencies indicated a need for more

emphasis on continuing education. The same distribution

perceived no need for change.


Perceived need for emphasis on management and organizational
skills


Comparison by hospital size: The value of chi square

(p=.23) was not statistically significant in analysis by

hospital size for perceived need for emphasis on management

skills (Table 2). Eighty percent of directors of small and

medium hospitals saw a need for more emphasis and 91% of

directors of large agencies made the same choice.

Comparison by hospital profit system: The value of chi

square (p=.91) was not significant for perceived need for

management and organizational skills by hospital profit

system. Directors from 80% of for-profit and 85% of

not-for-profit agencies perceived a need for more emphasis

on management and organizational skills.







88

Of eight null hypotheses tested in relation to research

hypothesis 1, only one was rejected. According to the

binomial model, more than that number of rejections could

have occurred simply by chance (Guilford & Fruchter, 1978).

The research hypothesis was not supported.

Comments added to responses to item 6 included the

following:

Small for-profit hospital--"A one-man department with less

than a year in the position, with responsibility for all

areas and patient education, is a hard task."

Small not-for-profit hospitals--"All facets are constantly

assessed to improve the delivery affected by the financial

aspects of hospital administration." "Today's nurses are

deficient in managerial leadership skill as well as many

business-related aspects of health care." "I feel that

education is needed for hospitals more than at any time in

their existence. Educators will have to change staff's

overall thinking and practice to provide high quality care

with less staff and at a reduced cost. Educators will have

to teach the staff to work smarter, not harder." "Education

is directed toward efficiency." "The need to assess

individual's skills and learning needs at an early stage is

even more crucial now than in the past. Our length of

orientation has shortened and we are faced with new GN's

[graduate nurses] coming in to a float pool situation. We

are striving toward development of competency-based









orientation and education. I see staff development as a

critical element in making the transition in health care

today." "It is the opinion of the education department that

an increase in management and organizational skills is a

must; however, hospital administration and nursing

administration do not agree."

Medium for-profit hospital--"More emphasis on quick-fix

orientation and mandatory classes is needed. Fewer

people in staff development are available to do the

work."

Medium not-for-profit hospitals--"Inservice, discharge

planning, and family teaching need the most emphasis."

"Program content for orientation and inservice instruction

is strongly influenced by DRG requirement." "We did not

hire as many graduate nurses--rather plan to hire

experienced nurses in order to emphasize orientation

less."

Large for-profit hospital--"More comprehensive orientation

due to need to have staff ready to roll."

Large not-for-profit hospital--"Needs have not changed;

providing quality programs in a cost-effective manner in

less time is our goal."


Subsample B


Directors of extra large not-for-profit agencies

reported their perceptions for questionnaire item 6







90

(Table 3). The highest percentage of directors perceived a

need for more emphasis on inservice instruction and on

management and organizational skills. Respondents perceived

the least need for emphasis on orientation and perceptions

of needed emphasis on continuing education were evenly

divided between more emphasis and no change. Directors

added no comments in this area. These are reported as

percentages of subsample B with no statistical calculation.



Table 3

Staff Development Directors' Perceptions of Needs for
Emphasis on Specific Areas as Reported from 16 Extra Large
Not-for-profit Hospitals



Content More Less No Change
% % %


Orientation 16 42 42
Inservice 75 0 25
Continuing Education 42 16 42
Management &
Organization 84 8 8


Research hypothesis 2. The individual or group who

influences content selection for staff development of nurses

varies according to hospital size and profit system.

Ho 2. There is no difference between the means of normal-

ized influence rankings of seven specific positions and one

category of "other" in hospitals categorized according to

size; profit system.









Dependent variables related to this hypothesis were

derived from questionnaire item 17. To determine if

significant differences in these variables existed between

the sample hospital categories, 16 null hypotheses (one

testing size and one testing profit system for each of the

positions), using the general format stated above, were

tested with ANOVA. Before running ANOVA, the ranks were

transformed to normalized values.

Questionnaire item 17: Rank order how each of the following

influences the classes that staff development offers for

nurses (1 strongest, 8 weakest). [The list included

hospital and nursing administrators, nursing supervisors,

nurse managers, staff nurses, and others.]


Subsample A


Comparison by hospital size and profit system:

Influence data were arranged according to medians (Table

4). Except in large hospitals, directors reported that

nurse managers had the highest overall influence on

curriculum choice. In large hospitals (for-profit and

not-for-profit), this group dropped to fourth place.

Respondents (except in large institutions) consistently

identified staff nurses and nurse managers as having the

most influence. Staff development directors and instructors

were in the top four places as to influence on the

curriculum in all except the medium not-for-profit










Table 4

Directors' Rankings of Those Who Influence Curriculum Choices


Rank* Agency Size


Small Medium Large Extra Large


For-Profit


1. Nurse manager

2. Staff dev.
instructor
3. Staff nurse

4. Staff dev.
director
5. Nursing admin.

6. Nursing
supervisor
7. Hospital
admin.
8. Other


Nurse manager

Nursing
admin.
Staff dev.
director
Staff nurse

Staff dev.
instructor
Hospital
admin.
Nursing
supervisor
Other


Nursing
adm.
Staff dev.
director
Staff dev.
instructor
Nurse manager

Nursing
supervisor
Staff nurse

Hospital
admin.
Other


Not-for-Profit


1. Staff. dev.
dir.
2. Staff nurse

3. Staff dev.
instructor
4. Nursing
admin.
5. Nurse manager

6. Nursing
supervisor
7. Hospital
admin.
8. Other


Nurse manager

Nursing
admin.
Staff nurse

Nursing
supervisor
Staff dev.
director
Staff dev.
instructor
Hospital
admin.
Other


Nursing
admin.
Staff dev.
director
Staff dev.
instructor
Nurse manager

Nursing
supervisor
Staff nurse

Hospital
admin.
Other


Nurse manager

Staff nurse

Nursing
admin.
Staff dev.
director
Staff dev.
instructor
Nursing
supervisor
Hospital
admin.
Other


*l-high; 8-low