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Staff development for Florida nurses

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Staff development for Florida nurses an analysis of curriculum, administration, and resources, by hospital size and profit system
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Rue, Nancy Roberts
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English
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vii, 147 leaves : ill. ; 28 cm.

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Continuing education ( jstor )
Educational resources ( jstor )
Health care industry ( jstor )
Hospital administration ( jstor )
Hospitals ( jstor )
Nurses ( jstor )
Nursing ( jstor )
Nursing education ( jstor )
Questionnaires ( jstor )
Support personnel ( jstor )
Curriculum planning -- Florida ( lcsh )
Dissertations, Academic -- Educational Leadership -- UF
Educational Leadership thesis Ph. D
Hospitals -- Staff -- Florida ( lcsh )
Nursing -- Study and teaching -- Florida ( lcsh )
City of St. Petersburg ( local )
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bibliography ( marcgt )
non-fiction ( marcgt )

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

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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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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




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


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.
11


Finally, for my husband, Ellis, who gave more than anyone
should ever have to give--thank you now and forever.
in


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 2 4
The Staff Development Director 29
Internal Resources for Staff Development... 32
External Resources Available to Staff
Development 3 6
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 6 7
IV


Ill METHODOLOGY 6 8
Population 68
Instrument Development 70
Collection of Data 74
Analysis of Data 74
Summary of Methodology 7 6
IV SURVEY RESULTS 7 7
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 10 9
V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS.. Ill
Summary Ill
Conclusions 115
Recommendations 122
APPENDICES
A INSTRUCTIONS TO PANEL OF CONSULTANTS 12 6
B STAFF DEVELOPMENT FOR NURSES IN FLORIDA
HOSPITALS QUESTIONNAIRE 12 9
C LETTER 13 5
REFERENCES 13 6
BIOGRAPHICAL SKETCH 14 6
v


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
vi


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.
Vll


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
1


2
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


3
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).


4
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


5
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


6
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).


7
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).


9
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.
0
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 person(s)
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


13
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


15
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.


16
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 nursesnow 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
18


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


21
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).


22
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. Earner, 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).


23
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 resourcesare 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


24
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


25
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


26
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


27
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


28
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.


29
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


30
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).


31
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


32
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).


33
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


34
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


35
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).


36
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 trainingis 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


37
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 knowlege,
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 ageement 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


39
institutions can be served from many sectors (Truelove &
Linton, 1980).
Shared-services consortiums 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 confining 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.


40
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 (Toiler,
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.


41
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 milion 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 orientee.
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


43
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 exerimental program was
$1,600. The use of the transitional modules reduced cost by
as much as $200 per orientee (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


44
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; accommodationthe period in which the
individual sees what the organization is really like and
attempts to become a member; and role managementwhen
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


45
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,


46
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


47
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


48
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.


49
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


51
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


52
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


54
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


56
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


58
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),
V
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


59
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


60
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.


61
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:


62
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).


63
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


64
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 hositals 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 11th annual meeting of the American Society for
Health Manpower Education and Training, emphasized the
necessity of coordinating overall quality assurance efforts


65
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


66
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


67
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
68


69
(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.


70
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.


71
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


72
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


73
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


74
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


76
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).
77


78
Four categories for size were
Size
Beds
Small
Medium
Large
Extra large
200-299
300-399
400-499
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.


79
!
20
15
Figure 1. Distribution of hospitals categorized by size
and profit system showing response pattern.


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


82
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 same5.5
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,


84
(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


85
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


86
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 7
Large
5 46
3 27
3
27 x (4,n=46)=1.365
2=
.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
2=
.37
Perceived Need for
Emphasis
on
Continuing Education
Small
13 65
3 15
4
20
Medium
3 20
5 33
7
47 2
Large
2 18
2 18
7
64 x (4,n=46)=11.242
2=
.02
Perceived Need for
Emphasis
on
Management and
Organizational Skills
Small
16 80
0 0
4
20
Medium
12 80
2 13
1
7 2
Large
10 91
0 0
1
9 (4,n=46)=5.595
2=
.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


87
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
(£=.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 (£=.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


89
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
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.


91
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


Full Text

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UNIVERSITY OF FLORIDA
3 1262 07332 063 1


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

©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.
11

Finally, for my husband, Ellis, who gave more than anyone
should ever have to give--thank you now and forever.
in

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 2 4
The Staff Development Director 29
Internal Resources for Staff Development... 32
External Resources Available to Staff
Development 3 6
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 6 7
IV

Ill METHODOLOGY 6 8
Population 68
Instrument Development 70
Collection of Data 74
Analysis of Data 74
Summary of Methodology 7 6
IV SURVEY RESULTS 7 7
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 10 9
V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS.. Ill
Summary Ill
Conclusions 115
Recommendations 122
APPENDICES
A INSTRUCTIONS TO PANEL OF CONSULTANTS 12 6
B STAFF DEVELOPMENT FOR NURSES IN FLORIDA
HOSPITALS QUESTIONNAIRE 12 9
C LETTER 13 5
REFERENCES 13 6
BIOGRAPHICAL SKETCH 14 6
v

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
vi

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.
Vll

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
1

2
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

3
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).

4
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

5
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

6
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).

7
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).

9
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 person(s)
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

13
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

15
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.

16
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
18

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

21
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).

22
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. Earner, 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).

23
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

24
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

25
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

26
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

27
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

28
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.

29
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

30
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).

31
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 & More,
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

32
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).

33
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

34
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

35
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).

36
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

37
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 knowlege,
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 ageement 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

39
institutions can be served from many sectors (Truelove &
Linton, 1980).
Shared-services consortiums 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 confining 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.

40
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 (Toiler,
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.

41
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 milion 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 orientee.
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

43
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 exerimental program was
$1,600. The use of the transitional modules reduced cost by
as much as $200 per orientee (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

44
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

45
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,

46
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

47
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

48
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.

49
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

51
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

52
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

54
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

56
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

58
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),
t
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

59
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

60
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.

61
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:

62
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).

63
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

64
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 hositals 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 11th annual meeting of the American Society for
Health Manpower Education and Training, emphasized the
necessity of coordinating overall quality assurance efforts

65
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

66
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

67
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
68

69
(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.

70
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.

71
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

72
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

73
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

74
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

76
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).
77

78
Four categories for size were
Size
Beds
Small
Medium
Large
Extra large
200-299
300-399
400-499
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.

79
20
15
Figure 1. Distribution of hospitals categorized by size
and profit system showing response pattern.

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

82
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,

84
(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

85
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

86
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 7
Large
5 46
3 27
3
27 x (4,n=46)=1.365
2=
.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
2=
.37
Perceived Need for
Emphasis
on
Continuing Education
Small
13 65
3 15
4
20
Medium
3 20
5 33
7
47 2
Large
2 18
2 18
7
64 x (4,n=46)=11.242
2=
.02
Perceived Need for
Emphasis
on
Management and
Organizational Skills
Small
16 80
0 0
4
20
Medium
12 80
2 13
1
7 2
Large
10 91
0 0
1
9 (4,n=46)=5.595
2=
.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

87
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
(£=.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 (£=.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

89
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
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.

91
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

92
Table 4
Directors' Rankings of Those Who Influence Curriculum Choices
Rank*
Agency Size
Small
Medium Large
Extra Large
For-Profit
1.
Nurse manager
Nurse manager
Nursing
adm.
2.
Staff dev.
Nursing
Staff dev.
instructor
admin.
director
3.
Staff nurse
Staff dev.
director
Staff dev.
instructor
4.
Staff dev.
director
Staff nurse
Nurse manager
5.
Nursing admin.
Staff dev.
instructor
Nursing
supervisor
6.
Nursing
supervisor
Hospital
admin.
Staff nurse
7.
Hospital
Nursing
Hospital
admin.
supervisor
admin.
8.
Other
Other
Other
Not-for-Profit
1.
Staff, dev.
Nurse manager
Nursing
Nurse manager
dir.
admin.
2.
Staff nurse
Nursing
Staff dev.
Staff nurse
admin.
director
3.
Staff dev.
Staff nurse
Staff dev.
Nursing
instructor
instructor
admin.
4.
Nursing
Nursing
Nurse manager
Staff dev.
admin.
supervisor
director
5.
Nurse manager
Staff dev.
Nursing
Staff dev.
director
supervisor
instructor
6.
Nursing
Staff dev.
Staff nurse
Nursing
supervisor
instructor
supervisor
7.
Hospital
Hospital
Hospital
Hospital
admin.
admin.
admin.
admin.
8.
Other
Other
Other
Other
*l-high; 8-low

93
agencies. Nurse managers and staff nurses, the groups that
receive direct service from staff development activities,
were ranked in the upper half for influence in all but the
large for-profit hospitals.
For most institutions, staff development directors
ranked hospital administrators and nursing supervisors in
the lower third for influence on the curriculum. Staff
development directors or instructors ranked in the upper
half in for-profit agencies.
Through use of a normal transformation process
recommended by Li (1964), the ordinal data in responses to
this question were converted to continuous data and, using
ANOVA, converted, and then analyzed for differences between
means of the normalized ranks. Using this method, the ANOVA
for staff nurse influence by hospital size yielded an F
ratio of 3.89, statistically significant at the .02 level.
No other significant F values occurred when hospitals were
categorized by either size or profit system. Of the 16
null hypotheses tested for perceived influence variables,
only one was rejected. Based on the binomial model,
more than that number could have occurred by chance
(Guilford & Fructer, 1978). Therefore, research hypothesis
2 was not supported.

94
Subsample B
The calculated medians for directors' rankings for
extra large not-for-profit hospitals are shown in Table 4.
The similarity of ranked data between the small and extra
large agencies is greater than between large and extra large
institutions.
Analysis of Data Related to Administration
Research hypotheses 3 and 4 involved administration of
staff development.
Research hypothesis 3. The organizational designation
for the director of staff development varies with hospital
size and profit system.
Two null hypotheses were tested, each derived from the
general format:
Ho 3. The distinction between line and staff designation of
staff development directors will not differ by agency size;
profit system.
The dependent variable for hypothesis 3 was derived
from responses to questionnaire item 13; separate
statistical hypotheses were tested for each independent
variable.
Questionnaire item 13: Is the position of staff development
director at this hospital designated (a) line, (b) staff?

95
Subsample A
Comparison by hospital size; Among small, medium, and
large hospitals, line and staff designations (as reported by
staff development directors) are shown in Table 5. The chi
square value (£=.73) for this comparison did not reach the
level required to reject the null hypothesis. Sixty percent
of the directors from small, 47% from medium, and 55% from
large hospitals reported line designation.
Table 5
Staff Development Position Assignment Categorized by
Hospital Size
Size
n
Line
%
n
Staff
%
Small
12
60
6
55
Medium
7
47
8
53
Large
6
55
5
45
X2 (2,n=46)=.614 £=.735
Comparison by profit system: More directors of for-
profit agencies reported line positions (65%). Conversely,
more directors of not-for-profit agencies reported staff
positions (67%). However, the chi square value did not
reach the level required to reject the null hypothesis.
Neither of the hypotheses related to the organizational

96
level of the staff development director was rejected.
Therefore, research hypothesis 3 was not supported.
Subsample B
Fifty percent of the directors of extra large hospitals
reported assignment to line positions.
Research hypothesis 4. The department that administers
staff development for nurses varies with hospital size and
profit system.
Two null hypotheses were tested, each derived from the
general format:
Ho 4. The department from which staff development is
administered will not differ by agency size; profit system.
The dependent variable for the fourth hypothesis was
derived from questionnaire item 18; separate statistical
hypotheses were tested for each of the independent
variables. That item elicited information related to the
department that administered staff development--hospital
administration, nursing administration, or other.
Questionnaire item 18: From what department is staff
development for nurses administered in this hospital?
(a) hospital administration, (b) nursing administration,
(c) other.

97
Subsample A
Comparison by hospital size: Hospitals, categorized by
size, did not differ significantly in the chi square
analysis, but, according to findings, nursing administers an
overall 65% of staff development. Directors of large
hospitals reported the highest percentage of departments
administered by hospital administration (36%).
Comparison by hospital profit system: Nursing
administration administered a higher percentage of
for-profit staff development (70%) while hospital adminis¬
tration controlled 10% and other departments (human
resources or personnel) administered 20%. Directors of
not-for-profit agencies reported that nursing administra¬
tion administered 62%; hospital administration, 19%; and
other groups, 19%. Chi square values in this analysis were
not significant. Because null hypotheses related to this
dependent variable were not rejected, research hypothesis 4
was not supported.
Subsample B
Directors of extra large hospitals reported that
hospital administration administered 25% of staff develop¬
ment departments, nursing administration, 67%, and others,
9%.

98
Analysis of Data Related to Internal Resources
Research hypothesis 5. Internal resources available for
staff development for nurses vary according to hospital
size and profit system.
The three null hypotheses related to this research
hypothesis were generated from more than one format. The
first format involved the number of categories of educa¬
tional resources available to staff development departments
from within the agency.
Number of Available Educational Resources
Ho 5. The number of educational resources available for
staff development departments vary according to agency size;
profit system.
The dependent variable was derived from questionnaire
item 7. Separate statistical hyptheses were tested for each
independent variable.
Questionnaire item 7: What educational resources are avail¬
able for staff development in this hospital (Appendix B)?
(check all that apply) [Directors received a list of
resources and were asked to place a check beside the item(s)
available in their institution (Appendix B)].

99
Subsample A
Comparison by hospital size; Few differences among
hospitals emerged on standard items such as classrooms,
clerical assistance, audiovisual equipment, slides/films,
videocassettes, cardiopulmonary resuscitation simulation
models, and libraries (Table 6). Television cameras were
available in 75% of the small, 44% of the medium, and 43% of
the large hospitals. Computers were reported in large
agencies, but the percentage of agencies having software was
less than that of those having computers. Seventy-five
percent of directors of small, medium, and large agencies
reported their hospitals had a liaison with an educational
institution. In the analysis of the number of educational
resources by hospital size, the value of chi square was not
significant.
Comparison by hospital profit system; Few descriptive
differences emerged in this area (Table 7). Using the chi
square statistic there were no significant values in the
number of educational resources when compared by hospital
profit system.
Subsample B
Resources available in extra large agencies are
reported in Table 6. Respondents from these agencies
indicated high percentages (above 75%) of available

100
Table 6
Availability of Internal
Resources
for Staff
D0vglopmGnt¡ by
Hospital Size
Resource
Small
Medium
Large
Extra Large
%
%
%
%
Classrooms
90
87
100
100
Clerical
assistance
90
78
75
91
Slide projector
100
100
100
100
Slide/tape
90
95
100
100
Movie projector
100
100
100
100
16 mm movies
81
90
71
100
Library
90
87
100
100
Learning lab
9
9
28
25
Simulation models
100
100
100
100
TV cassette
player
90
100
100
100
TV recorder
81
95
71
100
TV camera
75
86
42
91
Closed circuit TV
62
44
28
75
Audiovisual
technician
37
44
42
91
Computers
50
9
42
41
Computer software
50
9
14
33
Automated CPR
0
0
0
8
Liaison with
educational
institution
75
73
45
75

101
Table 7
Availability of Internal
Resources for
Staff Development,
by Profit System
Resource
For-profit
%
Not-for-profit
%
Classrooms
88
97
Clerical assistance
80
93
Slide projector
100
100
Slides/audio tapes
96
97
Movie projector
96
100
16 mm movies
93
81
Library
88
96
Learning laboratory
3
39
Simulation models
96
100
TV cassette player
90
100
TV recorder
93
93
TV camera
68
73
Closed circuit TV
34
59
Audio technician
16
66
Computer
8
43
Computer software
0
31
Automated CPR
0
2
Liaison with corporate
headquarters
97
0
Liaison with educa¬
tional institution
65
71

102
educational resources in 13 categories with only four
selections below 25%.
Ratio of Staff Developers to Nurses
A second hypothesis format involved the ratio of staff
development personnel to nursing FTEs (full-time-
equivalency ) .
Ho 5b. The percentage ratio of staff development personnel
to nurse FTEs (full-time-equivalency) does not differ by
hospital size; profit system.
The dependent variables were derived from responses to
items 8 and 9. Data from the two items were combined to
quantify staff development personnel of each hospital as
percentage of the nursing FTE.
Questionnaire item 8: Approximately how many full-time-
equivalency (FTE) nurses are employed by this hospital?
Questionnaire item 7: How many full-time-equivalency staff
members are assigned to education.
Comparison by size and profit system: The percent
ratio was the dependent variable in one-way ANOVA, with size
and profit system as independent variables. Separate one¬
way ANOVAs were done using the percentage ratio of staff
developer FTEs to nursing FTEs differentiated by size and
profit system. The F ratio with size as the independent
variable was not statistically significant; however, the
ANOVA by profit system yielded an F ratio of 9.2670,

103
significant at .004, with the for profit category showing a
percent ratio of .825, compared to a percent ratio of 1.65
for not-for-profit agencies.
Subsample B
The mean percent ratio of staff developers to staff
nurses in extra large hospitals was 1.79%.
Categories of Hospital Personnel
The third hypothesis format involved the number of
categories of hospital personnel who were presenters of
staff development education for staff development of nurses.
Ho 5c. The number of categories of hospital personnel who
are presenters of staff development education varies accord¬
ing to agency size; profit system.
Questionnaire item 10; Who, on the staff of this hospital,
presents continuing education and inservice instruction?
(check all that apply) [A list of hospital personnel was
provided with a blank for added choices].
Comparison by hospital size: Staff developers,
registered nurses, and physicians were major presenters of
staff development in all hospitals. Medical technologists,
physical therapists, respiratory therapists, and social
workers were frequent presenters of programs. This list
(Table 8) represents the variety of disciplines and
knowledge available for education within the hospital

104
Table 8
Who From Within the
Hospital
Presents
Instruction, by
Hospital Size
Source
Small
%
Medium
%
Large
%
Extra Large
%
Staff developers
100
100
100
100
Registered nurses
95
87
66
91
Physicians
95
100
87
100
Registered
dietitian
85
87
66
91
Medical
technologist
47
33
29
58
Physical therapist
77
54
16
83
Respiratory
therapist
6
16
20
16
Occupational
therapist
6
0
20
0
Medical social
worker
64
62
62
66
Clergy
12
16
25
66
Pharmacist
16
16
0
8
Psychologist
0
4
8
0
Administrator/
manager
4
4
0
16
Safety engineer
12
4
0
8
Biomedical
engineer
6
0
0
0
Speech therapist
0
0
8
0

105
setting. Compared by hospital size, number of categories of
presenter did vary. The chi square statistic for internal
presenters was not significant.
Comparison by profit system: Hospital staff from 11
categories of for-profit agencies and 16 categories of not-
for-profit agencies were reported as presenters (Table 9).
The chi square statistic for this comparison was not
significant.
Subsample B
Twelve categories of presenters were reported by
directors in extra large hospitals.
In summary for hypothesis 5c, one null hypothesis was
rejected (Ho 5); however, that was insufficient to provide
support for research hypothesis 5.
Analysis of Data Related to External Resources
Research hypothesis 6. The use of external resources for
staff development for nurses varies according to hospital
size and profit system.
Ho 6. The number of external resources for staff develop¬
ment for nurses will not differ by agency size; profit
system.
The dependent variable for the sixth hypothesis was
derived from questionnaire item 11. Separate statistical

106
Table 9
System
Presenters
For-profit
Not-for-profit
%
%
Staff developers
100
100
Registered nurses
72
93
Physicians
88
100
Registered dietitian
69
90
Medical technologist
36
42
Physical therapist
38
65
Respiratory therapist
16
13
Occupational therapist
8
7
Medical social worker
42
76
Clergy
0
43
Pharmacist
19
4
Psychologist
0
6
Administrator/manager
2
6
Safety engineer
0
10
Biomedical engineer
0
3
Speech therapist
0
4

107
hypotheses were listed for each of the independent
variables.
Questionnaire item 11; Are classes for continuing educa¬
tion, inservice, or credits leading to a degree from another
institution offered at this institution? (yes or no) If
yes, where do they come from? [A list of resources was
given, and respondents placed a check beside the item(s)
their institutions used. A space was provided for listing
resources not on the list.]
Separate statistical hypotheses were tested for each of
the independent variables.
Comparison by hospital size; Three-fourths of the
directors of small and medium hospitals reported another
institution presented continuing education, inservice, or
degree classes in their agencies (Table 10). Large
institutions showed the lowest (54%) use of external
resources from this category. Community colleges and
universities have presented the highest number of classes in
the hospital setting for all agencies in the group. All but
the large hospitals used vocational schools as presenters.
Independent consultants and proprietary representatives
provide between 13% and 30% of programs. The required level
of significance for chi square was not achieved in this
comparison.

108
Table 10
Availability of Outside Resources, by Hospital Size
Source
Small
%
Medium
%
Large
%
Extra large
%
Vocational school
7
21
0
12
Technical institute
0
2
0
3
Community college
40
36
35
19
University
43
21
45
16
Proprietary
representative
16
27
12
12
Independent
consultant
24
19
32
16
Consortium
5
6
0
5
Associations
7
13
12
17
Public officials
5
0
0
0
Comparison by profit system: Two thirds of for-profit
agencies and almost three fourth of the not-for-profit
institutions have a liaison with an outside institution
(Table 11). Chi square was not significant at the .05
level.

109
Table 11
Availability of
Outside Resources, by Hospital Profit System
Source
For-profit Not-for-profit
% %
Vocational school
6
20
Technical institute
0
10
Community college
40
42
University
33
35
Proprietary representative
20
1
Independent consultant
20
27
Consortium
0
1
Associations
3
25
Public officials
0
2
Summary of Findings
1. Staff development directors identified the areas of
inservice and management/organizational training as high
priorities for emphasis. The chi square for emphasis on
continuing education yielded a significant value (.02) in
the comparison by institution size: More directors in small
agencies perceived a need for emphasis on continuing
education.
2. Comments from staff development directors that
related to curriculum emphasis reflected concern for
inservice and management/organizational content and methods

110
to cope with changes related to DRGs and diminishing
resources.
3. Staff development directors ranked staff nurses and
nurse managers highest overall in influence on content
choices. Analysis using Li's transformation and ANOVA of
staff nurses' influence by hospital size was significant
(p=.04).
4. Comparisons for line and staff position designation
for staff development director yielded no statistically
significant differences for hospital size or profit system.
A higher percentage of directors in for-profit agencies were
designated line than in not-for-profit hospitals.
5. Sixty-five percent of the staff development
directors reported nursing administration controlled staff
development departments.
6. The ratio of staff developers to staff nurses did
not differ when hospitals were compared by size but did
differ significantly when compared by profit system. Pro¬
portionately, directors of not-for-profit hospitals reported
a ratio that was double that of for-profit agencies.
7. All staff development directors reported the
availability of internal resources in similar proportions
regardless of hospital size or profit system.
8. All directors reported use of external resources,
most citing cooperation with community colleges and univers¬
ities.

CHAPTER V
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
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 for nurses at
the time the data were collected. Using hospital size and
profit system as independent variables, comparisons were
made based on the reports of staff development directors in
Florida hospitals. Institutions included in the study were
for-profit and nongovernmental not-for-profit general
medical-surgical short-stay agencies. Staff development
directors in 58 of 70 Florida hospitals of more than 200
beds responded to the questionnaire.
Summary
Responses from staff development directors to a ques¬
tionnaire provided the information for a data base of staff
development practices in Florida hospitals. The comparison
between for-profit and nongovernmental not-for-profit
agencies was made to differentiate practices by hospital
size and profit system. Responses to questions reflected
facts as well as opinions of staff development directors.
Ill

112
Description of Respondents
Staff development directors reported their highest
level of education: The range was from the associate degree
to the doctorate. Only 20% reported less than a bachelor's
degree, and the majority (48%) held master's degrees in
education or nursing. Five directors were not registered
nurses; four of those held doctorates. Directors reported
an average of 6 years' experience as staff development
educators in the small, medium, and large hospitals.
Directors in extra large agencies reported the most
experience in their positions (10 years); all of the
directors who held doctorates were in not-for-profit insti¬
tutions, and directors who held diplomas were only in small-
and medium-sized hospitals.
Summary of Data Analysis
Addressing the three major areas of the research ques¬
tion, curriculum, administration, and resources, included
using quantitative measures to compare the variables and
analyze questionnaire responses.
The items that related to curriculum elicited informa¬
tion on directors' perceptions of the need for emphasis in
the four major content areas of staff development (orienta¬
tion, inservice instruction, continuing education, and
management/organizational skills).

113
Only directors from small hospitals indicated a need
for more emphasis for orientation. Directors of medium and
large agencies most frequently reported less or no change.
Directors for small hospitals indicated a higher need for
continuing education than did those of larger agencies,
disclosing differences that were statistically significant
using chi square analysis. From 80% to 90% of respondents
perceived a need for more emphasis on inservice instruction
and management/organizational skills. Responses for extra
large hospitals (although analyzed separately), were similar
to those for small, medium, and large institutions. Added
comments included concerns over lower funding and reductions
in staff development personnel, a need for more education to
help staff nurses cope with changes attributable to the
introduction of a prospective payment system (PPS), and the
need for help in meeting the challenges of agencies in a
period of rapid change.
In rankings of the individual or group who influenced
curriculum, respondents usually placed staff nurses, nurse
managers, and nursing administrators in the first four
positions. Reports from directors of large agencies for
both size and profit system were identical and did not
follow the choices of other hospitals. The influence ranking
of staff nurses was statistically significant when tested by
ANOVA using Li's (1964) normal transformation process.

114
Staff nurses in small hospitals had more influence on
curriculum choice than did nurses in other sized agencies.
Extra large hospitals were not analyzed statistically
since no for-profit agencies of that size existed; however,
directors of medium sized agencies reported rankings similar
to those of the extra large.
Differences in reported use of internal resources were
minimal and chi square did not reach the required level of
significance. All directors reported use of human resources
from within the agency in varying percentages but, again,
the chi square for differences between categories was not
significant. Directors reported the availability of such
outside resources as community colleges, universities,
independent consultants, vocational schools, proprietary
representatives, associations, and consortiums, in that
order, whether agencies were categorized by hospital size or
profit system. Directors of for-profit agencies cited
access to corporate educational materials as a major source
of support.
The ratio of staff developers to staff nurses showed
few variations between for-profit and not-for-profit
agencies, but in for-profit hospitals developers worked with
a significantly higher number of staff nurses per developer.
The research hypotheses were not supported in any
aspects of this study. More similarities than

115
dissimilarities emerged when hospitals were categorized by
both size and profit system.
Conclusions
This study was designed to provide an analysis of data
related to staff development of nurses in Florida hospitals.
The information obtained from directors of staff development
provided demographic data, a profile of staff development
directors' credentials and experience, and a report on
current practices, curriculum, administration, and
resources. The analysis of data by hospital size and profit
system differentiates the information for use in decision
making by administrators in a variety of institutions.
The responses of directors indicated no significant
differences in chi square values when respondents were
asked concerning perceived need for orientation to choose
increased, decreased, or no change. A conclusion from this
finding is that orientation needs did not differ signifi¬
cantly; however, the majority of directors agreed that
orientation needs had decreased or remained the same. Only
directors in small hospitals reported increased need for
orientation.
Most directors indicated a need for more emphasis on or
no change in emphasis on inservice instruction. A conclusion
from this finding is that most directors perceived the need

116
for increased emphasis on inservice instruction. The chi
square for this comparison was not statistically significant.
Most directors did not perceive continuing education as
a major area of emphasis. This survey was conducted near
the end of the biennium, and many nurses had accrued the 24
contact hours required for licensure. When contact hours
for continued licensure were mandated in Florida, continuing
education content received much attention. Austin (1983)
found departments of staff development had increased the
number of instructors to meet anticipated needs. A conclu¬
sion of the present study is that as hospitals eliminate
nonessential services, continuing education will undergo
intense scrutiny. Education directors in all but two large
not-for-profit hospitals reported it as a benefit. The cost
of contact hours as determined by Austin from 1982 data and
from data obtained in this study was nearly the same;
therefore, no increase was noted over this 2-year period.
Nevertheless, hospital administrators will look at all
hospital functions, and this study will provide a measure of
what existed at the time of the investigations.
Staff development directors gave the highest endorsement
for any area of need to acquiring management and organiza¬
tional skills. The conclusion from perceptions of need in
this study is that content on management and organization
is recognized as necessary for nurses in the hospitals
included in the study.

117
Other questions on curriculum content and control
included those concerning who, from within the hospital,
influenced curriculum choices, and who controlled staff
development for nurses. Respondents most frequently ranked
nurse managers, nursing administrators, and staff nurses in
the upper half among those who influenced curriculum
choices. Directors of the for-profit and not-for-profit
large hospitals were the only ones who ranked staff nurses
in the bottom third. When rankings were normalized, the
influence of nurses was significant when hospitals were
categorized by size. Post hoc comparisons revealed that
staff nurses in small hospitals had the most influence on
curriculum. There could be more small hospitals in the
future if the trend toward for-profit ownership continues.
These corporations tend to limit the size of agencies owned
and include a higher percentage of small agencies in the
sample used for this study; therefore, the influence of
staff nurses on future staff development in these small
agencies could represent a greater number of individuals.
According to the literature on teaching and learning,
the person served by education (especially the adult seeking
to improve work performance) should have input into what is
studied. Learning what is relevant and what is applied is
more efficient; this is a basic principle of adult learning
theory. Therefore, the finding of this study that most
content influence comes from the nursing department is a

118
positive one. Staff developers who rated themselves as high
in influence may perceive their role as managers of learning
without input from those receiving the education, or may be
working in a system that does not foster staff involvement.
Nursing departments control staff development in two
thirds of the sample. This reflects the traditional
involvement of nursing with hospital-based education, and, as
decentralization becomes more widespread, this information
provides a benchmark against which to measure change.
Tuition reimbursement and free continuing education
hours were employee benefits in most agencies in the sample.
Assignment of the staff development director to a line
position gives that person access to information and direct
entry to implementation of programs that is not open to
staff-level personnel. Sixty-four percent of the directors
of for-profit agencies, as opposed to 47% in the not-for-
profit group, reported they occupied line positions.
Inasmuch as profit-making companies usually study the role,
impact, and productivity of a position to achieve maximum
efficiency, a staff assignment could be a direct result of
planned approach. A conclusion of this study is that the
staff director of the for-profit agency is more likely to be
perceived as an administrator than is the director in a
not-for-profit institution.
The largest portion of hospital employees are assigned
to nursing; therefore, it was not surprising to find that

119
all but five of the directors were nurses (of those five,
four had doctorates). A conclusion of this study is that
hospital administrators or nursing administrators may
perceive that knowledge of the field is an asset to the
person in charge of planning, implementing, and evaluating
the education of nurses.
Basic resources are available in most agencies.
Directors from not-for-profit agencies reported the greatest
variety of resources. The larger the institution, the
greater the probability of having a variety of teaching aids
and a larger number of instructors. Directors of staff
development in for-profit agencies reported the use of fewer
internal resources but did list corporate organizations as a
source of learning materials. A conclusion of this study
is that a variety of educational resources were available in
the sample agencies at the time of this study.
Directors of medium-sized hospitals, more than any
others, reported the use of external resources. Small
agencies used community colleges and universities more than
large agencies did. Large and extra large hospitals used
this resource the least. Comparison by profit system
disclosed no significant differences. One conclusion from
these data is that few agencies are using external resources
to the full potential. These outside agencies are equipped
to provide educational services. If health care agencies
focused on providing health care and used external resources

120
to facilitate the teaching, hospital and educational agencies
would both benefit--each institution practicing an assigned
skill at the maximum level of efficiency.
The key to management of resources is the knowledge and
experience of the staff development director. The
coordinator of needs and interventions requires ability
above that of entry-level skills in nursing or education.
Knowing what is available and where to get it is a primary
function for the hospital-based educator. The report of the
level of staff development directors' academic preparation
revealed nearly half of the sample held masters' degrees or
higher; however, more educationally prepared nurses are
needed to meet the needs of an increasingly complex health
care industry.
Thus conclusions drawn from this study were as follows:
Curriculum
1. The perceived need for orientation programs was
reported as low by all but small hospitals.
2. Inservice instruction was cited as an area needing
increased emphasis.
3. Continuing education needs were reported as low by
directors in all but small hospitals which did achieve a
statistically significant chi square value.
4. Management/organizational skills were reported by
most of the sample as an area needing increased emphasis.

121
5. Nurse managers, nursing administrators, and staff
nurses were most frequently ranked high in choice of
curriculum influence. Staff nurse ranking using a trans¬
formation process and ANOVA produced a highly significant
difference for nurses in small hospitals who do have
influence on choice, according to director reports.
Administration
6. Nursing administers two thirds of the staff devel¬
opment departments in the study. Respondents from extra
large hospitals reported the most hospitalwide departments.
7. In the report of line or staff positions, for-profit
agencies were more likely to have directors in line
positions.
8. The quantity of internal resources did not vary
significantly between agencies by hospital size or profit
system.
9. For-profit agency directors reported a signifi¬
cantly lower number of nurse FTE (full-time equivalency) to
staff developer FTE.
Employee Education Benefits
7. Respondents from small hospitals reported the
fewest opportunities for classes to assist the nurse in
horizontal or vertical mobility, and those from extra large

122
hospitals reported the highest likelihood of opportunities
for mobility.
8. Tuition reimbursement and free continuing education
were offered in all but three large hospitals.
Recommendations
Findings from this study form a beginning data base in
a time of transition in the health care industry.
Curriculum is the entire spectrum of educational
experiences made available to learners through a given
institution. The questionnaire and analysis conducted in
this study was the first step in curriculum practice: to
(a) identify resources, (b) determine the administrational
practices, (c) assess the content needed, and (d) determine
the concerns and trends as perceived by working staff
development directors. Until what is can be adequately
identified, no curriculum plan of what could be can succeed.
This study was a first step in identifying current trends
and practices in staff development in selected Florida
hospitals.
The pattern for use of available resources in the
hospital is changing, and as fewer options are available
within the agency, due to decreases in staff and increases
in demands, the use of contract education and community
resources, and reassessment of current practices, are a
necessity. Hospitals are in the business of health care;

123
institutions of learning are in the business of education;
systematic cooperation between the two can only strengthen
and enhance both. The staff development director who under¬
stands this and has the ability to coordinate and consolidate
resources will be valuable to both institutions and to
clients within the health care setting.
Thus recommendations drawn from this study were as
follows:
1. A similar study should be done at another time to
add to the data base.
2. A qualitative study to determine attitudinal and
less measurable factors is recommended.
3. Further studies are needed to determine how staff
development is provided with a lower staff nurse-to-staff
developer ratio; what methods are used; and how effective
the product is. If the for-profit agencies are working
effectively with fewer staff developers, the economic
ramifications are important.
4. Staff developers need new supportive strategies to
facilitate the type of education and training currently
expected in hospitals.
5. The choice of curriculum for staff development
should be a joint effort among nurse educators, nurse
managers, nurse clinicians, and nursing administrators.
This type of cooperation was indicated in the item on ranking
of influence. Identification of who is served, what needs

124
exist, and how to build an effective staff development
curriculum should be an ongoing program with a definite plan.
6. Studies to determine the most effective department
and organizational design for staff development need to be
done.
7. Internal resources do exist in varying degrees in
all institutions, but the best method of implementation may
be different than in the past when financial constraint was
not as important. Methods of using these resources without
putting stress on the system need to be delineated.
8. Developers of staff development should explore
external resources to determine the most efficient and cost-
effective methods of delivering staff development education.
Many aspects of technical education (especially inservice
instruction) are best served from within the institution;
however, the use of every available external resource should
be explored and programs initiated to facilitate cooperation
between hospitals and educational institutions.
This study provided baseline data and was the first
step in determining the nature of staff development at the
time the survey was conducted. The next steps are to plan,
devise appropriate strategies, and implement a model that
can be tested within the hospital setting. The needs have
been identified; interventions will depend upon the ability
of staff development educators to react to changing forces
in the health care industry.

APPENDIX A
INSTRUCTIONS TO PANEL OF CONSULTANTS

Directions to the Panel of Consultants
Your expert opinion is needed to prepare a question¬
naire that will be sent to staff development directors of
Florida hospitals that meet the following criteria: (a) are
nongovernmental, b) are general medical-surgical, (c) pro¬
vide short-stay care, (d) have a minimum of 200 patient
beds, and (e) are current members of the Florida Hospital
Association. The purpose of this study is to gather
information about staff development for nurses related to
curriculum, administration, and resources in Florida
hospitals, informatin that will be used to prepare a disser¬
tation to be submitted to the University of Florida College
of Education.
The following research questions are keyed to the items
on the questionnaire, and the numbers in the left column
beside the items are indicative of the category each
question is intended to answer. Questions intended to
elicit demographic or descriptive information are identified
by the letter D. Please read the questionnaire and examine
each question for the following points:
1. Clarity of content.
2. Ease for respondent to answer (information readily
available).
3. Time required to complete the questionnaire.
4. Relativity of the question to obtaining information
126

127
about curriculum, administration, and resources of staff
development for nurses in Florida hospitals.
The health care industry is changing faster today than
at any time since the advent of Medicare. Information is
needed by those involved in hospital adminisration and
nursing service as changes are made to adapt to diminishing
or realigned resources. Enclosed in this packet is a
stamped, addressed envelope for return of the questionnaire
and for your comments. If you have questions, please call
me (home and office numbers are on the enclosed card). Your
assistance is appreciated and you will receive a copy of the
summary as soon as the study is completed.
Nancy R. Rue, R.N., M.S.N.
Doctoral Candidate
University of Florida

APPENDIX B
STAFF DEVELOPMENT FOR NURSES IN FLORIDA
HOSPITALS QUESTIONNAIRE

STAFF DEVELOPMENT FOR NURSES IN FLORIDA HOSPITALS
QUESTIONNAIRE
PLACE A CHECK MARK () IN THE APPROPRIATE SPACE:
1.What is the total number of patient beds in this hospital?
2.Who owns this hospital?
3. When did this hospital begin using Diagnosis Related Grouping?
month
year
4. Has this hospital had a "hiring freeze" for nurses since DRGs
went into effect?
yes
no
5. Has the number of nurses requiring orientation changed since
DRGs were implemented in this hospital
increased?
decreased?
stayed the same?
8. In the following categories of staff development, check the
area according to your perception of current needs.
orientation
more emphasis
less emphasis
no change
inservice
instruction
more emphasis
less emphasis
no change
continuing
education
more emphasis
less emphasis
no change
management/
organizational
skills
more emphasis
less emphasis
no change
Comments:

7.What educational resources are available for staff development
In this hospital? (check all that apply)
classroom space
clerical assistance
slide projector
slldes/audlo tapes
movie projector
movies
library
learning lab
simulation models
(rescusi-Ann)
other (specify)
television cassette player
television cassette recorder
television camera
closed circuit TV
audiovisual technicians
computers
computer software
liason with vocational school,
community college, or university
to share materials.
liaison with consortium or
corporate headquarters to obtain
materials
8.Approximately how many full-time equivalency (FTE) nurses are
employed by this hospital?
9.How many full-time equivalency staff members are assigned to
education?
10.Who, on the staff of this hospital, presents continuing
education and Inservlce instruction? (check all that apply)
staff developers medical technologist
nurses on staff physical therapist
physicians social worker
dieticians clergy
other (specify) other (specify)
11.Are classes for continuing education, inservice, or credits
leading to a degree from another Institution offered at this
hospital?
yes
no
If yes, where do they come from?
vocational school propietary salesman
technical institute independent consultant
community college other (specify)
university/college
12.Are there any other community resources (People, space, or
equipment) that this department uses for staff development of nurses?
Please explain.

13. Is the position of staff development director at this
hospital designated as line or staff?
131
line
staff
14. How long have you been a staff development educator?
months
years
15 Are you a registered nurse?
yes
no
If yes, how many years?
18. What Is your highest level of preparation?
associate degree
diploma
baccalaureate degree (not nursing)
baccalaureate degree in nursing
master's degree (not nursing)
master's degree in nursing
doctorate in
other (specify)
17. Rank order how each of the following influences the classes
that staff development offers for nurses (1 strongest, 8 weakests).
hospital administrator
nursing administrator
nursing supervisor
staff development director
staff development Instructors
unit managers/head nurses
staff nurses
others
18. From what department Is staff development for nurses
administered in this hospital?
hospital administration
nursing administration
other (specify)
19. Does this hospital have any structured method for staff nurse
advancement such as a career ladder.
yes
no

20.Does staff development provide any structured classes to
prepare nurses for another position in the hospital?
132
yes
no
if yes, please explain:
21. Does this hospital offer tuition reimbursement as an
employee benefit?
yes
no
22. Do you, or members of your staff, provide career counseling
for nurses in this hospital?
yes
no
23. Does this department evaluate staff development classes using
a standard type of format?
yes
no
*
24. In your opinion, the method of course evaluation used in
this hospital is
m
adequate
inadequate
other (specify)
Comments:
25.Does this hospital have an approved Florida State Board of
Nursing provider number?
yes
no
28. Are "ho fee” continuing education contact hours included in
the benefit package for nurses in this hospital?
yes
no
27. Does this hospital offer continuing education classes for
nurses In the community?
yes
no
If yes, what Is the charge per hour?

133
28. In your opinion, would this hospital offer as many continuing
education classes if the Florida law for relicensure was changed
to exclude mandatory contact hours for nurses?
yes
no
29. Cite two major concerns related to staff development as you
perceive them.
1.
2.
30.Is this hospital offering something in staff development that
you consider innovative, especially effective, or particularly
timely? If so, describe or Include a brochure with this
questionnaire.
THANK YOU FOR YOUR COOPERATION IN COMPLETING THIS QUESTIONNAIRE
YOU WILL RECEIVE A COPY OF THE SUMMARY AS SOON AS I COMPLETE IT.

APPENDIX C
LETTER

1821 Cross Creek Way
Dunedin, FL 33528
August 15, 1984
Dear
Preparing for the future in health care education means
being aware of trends, issues, and problems. As a staff
development educator, you are aware of the pressures within
the hospital to conserve resources and reduce expenditures
in every area. Knowing what is happening now provides
facts for future use. If you will take a few minutes today
to fill out this questionnaire, I can provide information
on Florida trends for you by September. This survey is
part of a doctoral dissertation I will submit to the
University of Florida. The information you give is confi¬
dential and will be reported anonymously. The facts col¬
lected through this survey can be of value to you. Being
able to cite statewide statistics may be useful in demon¬
strating your effectiveness to administration. I will
send a summary at the end of the study.
Thank you.
Nancy R. Rue, R.N.,M.S.N.
P.S. The enclosed cup is my gift to you to express my
appreciation for your participation in this survey. It
takes just ten minutes to answer the questions, so why
not fill your new cup and take a break right now?
135

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BIOGRAPHICAL SKETCH
Nancy Roberts Rue, a native of Spencer, Indiana, was
graduated from Bloomington (Indiana) High School and Indiana
University School of Nursing, Indianapolis. She gained
her nursing and teaching experience at Marion County General
Hospital, Indianapolis; Colorado Springs (Colorado) Memorial
Hospital; Beth El School of Nursing, Colorado Springs;
and Bloomington Hospital. She was graduated from Indiana
University School of Nursing in 1973 with a master's degree
in nursing and a major in pediatrics. She taught pediatric
nursing in the associate degree program at Indiana University
and achieved the rank of assistant professor.
In August, 1973, she moved with her family to Dunedin,
Florida, where she participated in the design and implemen¬
tation of an innovative curriculum for associate degree
nursing on Clearwater Campus of St. Petersburg Junior
College. From 1977 to 1979 she was director of a W. K.
Kellogg Foundation project to design an orientation for
newly graduated nurses entering their first hospital emloy-
ment. This program was a part of the Curriculum Project
of the Southern Regional Education Board.
While on leave of absence from St. Petersburg Junior
College in 1980-82, Mrs. Rue began her doctoral studies at
146

147
the University of Florida. During the next 2 years she
worked as a graduate assistant to Dr. Margaret K. Morgan,
director of the Center for Allied Health Instructional
Personnel in the then Department of Instructional Leadership
and Support, College of Education. As part of that assign¬
ment she assisted in designing certification tests for
ward clerks and nursing assistants for the Florida Department
of Education.
She returned to St. Petersburg Junior College to teach
pediatrics before being granted leave to work in the Staff
Development Department and to assist in the implementation
of a career ladder for professional nurses at Morton F. Plant
Hospital, Clearwater. In August, 1984, she returned to
St. Petersburg Junior College as an instructor in pediatraic
nursing.

I certify that I have read this study and that in
my opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
rr)rt‘¡Xcr(b^í Jr ^
Margare/t K. Morgan, Chairperson
Professor of Educational
Leadership
I certify that I have read this study and that in
my opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Amanda S. Baker
Associate Professor of Nursing
I certify that I have read this study and that in
my opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Nita W. Davidson
Associate Professor of Nursing

I certify that I have read this study and that in
my opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
-L-<1
ímds W. Hensel
Professor of Educational
Leadership
I certify that I have read this study and that in
my opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Forrest W. Parkay C/
Associate Professor of
Educational Leadership
This dissertation was submitted to the Graduate Faculty
of the College of Education and to the Graduate School
and was accepted as partial fulfillment of the requirements
for the degree of Doctor of Philosophy.
December, 1985
(ffi)
Dean, College of Education
Dean, Graduate School

UNIVERSITY OF FLORIDA
3 1262 07332 063 1