TITLE: FACTORS AFFECTING WORKING RELATIONSHIP BETWEEN CLINICAL INSTRUCTOR, STUDENT NURSE AND STAFF NURSES

CHAPTER 1 INTRODUCTION

BACKGROUND OF THE STUDY The instructor-student relationship is an important element in the mobility training process. The instructor does not teach apart from what he feels toward a particular student. Nor does the student learn as though he were receiving his information from a teaching machine. Each has feelings toward the other. If the feelings are positive they will facilitate the learning process. If they are negative they will interfere. The instructor who likes a particular student will be more interested in his progress. On the other hand, the student who likes his instructor will be more eager to please by doing well on his lessons. Conversely, the instructor who dislikes a student may still teach competently, but finds it costs him a greater effort; while the student who has such feelings may resist the efforts of the instructor to help him. The relationship is further complicated by the degree to which either or both are aware of the other's feelings. The instructor may not be experiencing negative feelings toward his student, but if he perceives such feelings in his client, he may find it difficult to maintain any degree of warmth toward him. On the other hand, if the student is aware that his instructor is cool toward him, he may find it difficult to trust the judgment of the instructor. When the instructor perceives positive feelings in his student, he looks forward to these lessons and works harder for the benefit of the student. If the student knows the instructor likes him, he finds it easier to accept constructive criticism. Both find it easier to communicate their ideas and wishes in such a situation. Transference and Counter Transference Often the feelings of one person toward another in a helping relationship have nothing to do with the people involved. The student may have positive or negative feelings toward his instructor because in this situation he reminds him of someone else. He transfers these feelings to

the new and immediate person. In a clinical setting this is called transference. The feelings may be positive or negative, but they stem from sources other than the immediate situation. Of course, in a clinical setting the process is more complicated; but even a teaching interaction has some of these elements. For example, the student may have had an unpleasant relationship with an authority figure whom he resented. If the mobility instructor reminds him of this person, he transfers this resentment to the instructor; or if the relationship with the previous authority figure was positive, he transfers these positive feelings to the mobility instructor and works well in the relationship. Similar feelings of the instructor toward his student may be called counter transference. These feelings may also be positive or negative; and as in the case of the student, they stem from some previous relationship rather than from the immediate situation. Several aspects of the mobility training process promote transference and counter transference. Lessons occur frequently and the time spent together on each lesson is relatively long. The instructor is, in a sense, an authority figure because he is knowledgeable, while the student is learning. The authority figure is only one basis for the stimulation of transference and counter transference. Further, the feelings of the student and instructor are very much involved in the training process because of the stress stimulated by the training process. The student cannot be expected to know about his reasons for liking or disliking a particular instructor. However, the instructor, as expert, should be aware that feelings present in the relationship may stem from sources unrelated to the immediate persons in the relationship. Often, being aware that the perceived negative feelings in the student may be the result of the transference process can help him deal more objectively with them. Knowing why he feels in a certain way can help the instructor control his reactions to the student. He can then teach him as competently as he does all his students. He can also decrease the effects of these mechanisms by seeing the student less frequently or by reducing the length of each lesson. Professional Distance This term can be defined as a certain reserve maintained by the instructor in order to control the interaction between him and his student. Control is essential if the instructor wishes

to insure his success in training each student to travel. The instructor must control not only the technical aspects of imparting knowledge, but he must control every element of teaching that can facilitate or interfere with the process. The relationship or the personal interaction between instructor and student is one such element. One case that came to my attention was that of a young woman who became infatuated with her instructor. Whenever he talked to her about his fiancee, she became jealous and angry. She stated that she often paid little attention to what she was doing on lessons, sometimes canceled lessons for no good reason, and frequently acted perversely when he gave her instructions. Her impression was that he never knew the real reason for her behavior. Another case is that of a student who functioned in a rather lack adaisical manner on his lessons because he thought of his instructor simply as a good friend. Either the expectations of the instructor were not as high because of the relationship, or the student did not think the instructor would insist on a normal standard of performance because they were friends. He felt he could goof off whenever he wanted to. There is a difference between being friendly with each student and developing such a close friendship that it interferes with the teaching process. If the relationship is too close, the instructor might not insist on performance standards he would expect from other students. He might not want to hurt the feelings of the student by telling him he is not doing well on a lesson. In addition, the student might be lax in carrying out instructions because a good friend would overlook mistakes. Certainly no instructor would deliberately or consciously lower his standards for any one student. But a certain casualness is an unavoidable part of any close relationship. And in such a relationship, people will assume things and behave in ways in which they would not if the situation were more controlled. This does not mean the instructor should become totally formal in his interaction with the student, or that he should become authoritarian. It simply means that he remains aware of what is happening in the relationship and controls the interaction so it does not become free and casual to such a degree that it interferes with his ability to instruct the student.

One factor that affects the closeness of a relationship is the contact that the instructor has with his student apart from lessons. As part of a lesson he may meet with a student for lunch or a cup of coffee. However, he may receive an invitation to dinner or for a drink; or he may be asked to a party, or be asked to provide transportation for the student to some function. The possibilities of non-lesson contacts are endless. But whatever they are, they will add to the complexity of the relationship and the consequent ability to control the interaction; and without some control the instruction process may suffer. The instructor, of course, or his supervisor must be the ultimate judge of what is essential in the training process, and what may be detrimental. But the instructor should be aware that what often seems to be an insignificant or casual act has its effect on the relationship. And anything that affects the relationship between instructor and student will effect the outcome of mobility training. Because of the importance of the relationship between instructor and student, it is essential that the instructor should do what he can to control it. Addressing the negative attitudes of nurses is important because the problem of resolving the nursing shortage is compounded by the negative effects these negative attitudes have on nursing education. Wells (2003) stated that inability to retain students in nursing programs negatively impacts the supply of registered nurses to meet the demands of the nursing shortage. Research of nursing students revealed that negative attitudes and behaviors of nurses impede learning (Lofmark & Wikblad, 2001) and threaten student progression and retention within nursing programs (Chan, 2002). Furthermore, if student nurses do not identify with the nursing profession, they will eventually leave (Li, 1997). Nurses need to stop eating their young and help prepare a strong, competent workforce for the future. After all, a component of professionalism is to mentor those seeking to enter the profession. The student nurses socialization into the profession is dependent upon acceptance and approval by staff nurses, who have the greatest influence on the development of the student nurses professional role (Hardy & Conway, 1988). The purpose of this study was to gain a personal understanding of what kinds of attitudes nurses have toward student nurses, and how nurses develop negative attitudes toward student nurses.

STATEMENT OF THE PROBLEM Working relationships among Clinical Instructor, student nurses, staff nurses affect their performance in way that they can either work collaboratively or not with regards to their activities requiring cooperation and teamwork. Factors affecting work relationship are identified to reveal the reason having difficulties in working effectively.

OBJECTIVES OF THE STUDY GENERAL OBJECTIVES: This study aims to identify the different factors affecting working relationship.

SPECIFIC OBJECTIVES: Ways to improve working relationship between the student nurses, staff nurses and the clinical instructors. Working harmoniously Factors contributing hindrance, ways to eradicate To determine the perceptions of the student nurses towards the staff nurses and clinical instructor with regards to an effective and non-effective collaboration.

HYPOTHESES Null Hypotheses 1. There is no relationship between the attitude of the student nurse and the clinical instructor in their working relationship. 2. There are no ways to improve working relationship between the student nurses, staff nurses and the clinical instructor. 3. Perception of the student nurses towards the staff nurses is not a hindrance in their working relationship. 4.Seniority of the staff nurses does not affect the working relationship with the student nurse.

Alternative hypotheses 1. There is a significant relationship between the attitude of the student nurse and the clinical instructor in their working relationship. 2. There are ways to improve working relationship between the student nurses, staff nurses and the clinical instructor. 3. Perception of the student nurses towards the staff nurses is a hindrance in their working relationship. 4. Seniority of the staff nurses affect the working relationship with the student nurse.,

SCOPE AND LIMITATION The study aimed to describe or define the learning experiences of student nurses during their clinical rotations as they interact with staff nurses and clinical instructors. THEORETICAL FRAMEWORK The study adopted Sullivan and Peplaus Interpersonal Theory. Sullivan evolved a theory of personality that emphasized the importance of interpersonal relations. He insisted that personality is shaped almost entirely by the relationships we have with other people. (2002 McGraw-Hill Higher Education) Peplau's theory of interpersonal relations provides a useful framework for investigating clinical phenomena and guiding nurses' actions. While the case data are encouraging, it is suggested that there is a need to test the clinical effectiveness of Peplau's concepts by utilizing experimental research designs. Hildegard Peplau interpersonal theory incorporates communication and relationship concepts from Harry Stack Sullivanss Interpersonal Theory. (Joyce, 2005) This relationship also provides the context for the nurse to develop, apply, and evaluate theory-based knowledge for nursing care. Nurse interpersonal competencies, investigative skill, and the theoretical knowledge as well as patient characteristics and needs are well important dimensions in the process and outcomes of the relationship.

Banduras Social Learning Theory The social perspective of learning theorizes that human function occurs in a reciprocal relationship with the environment in which there is interplay between ones personal factors, the environment, and their behavior (Bandura, 1977). Learning is an internal process that does not necessarily result in an immediate change in behavior. Learners experience the environment and interpret it according to unique, internal, personal factors then display behavior in response (Bandura, 1977). The resulting behavior then has an effect on the environment and the cycle repeats. Therefore, it is important for teachers to ascertain what learners perceive about the environment and how they interpret it (Braungart & Braungart, 2008). The aspects of social learning theory that are particularly germane to this study are reciprocal determination,

modeling, and self-efficacy. Clinical experiences involve interaction between students and the learning environment. The learning environment consists of social interactions with instructors, patients and their families, other students, and a host of health care workers. As students interact with the environment, including clinical instructors, they experience how instructors interpret their behavior. The consequences they receive because of these interactions provide cues for future behavior.

CONCEPTUAL FRAMEWORK

Interaction between the clinical instructor, staff nurse and student nurse

Factors affecting working relationship

1. Affectation between the nurse and student nurse. 2. Affectation between the clinical instructor and student nurse.

Figure 1.Conceptual Framework of the Working Relationship between the Clinical Instructor, Staff Nurse and Student Nurse. This framework is based on Hildegard Peplaus theory, Interpersonal theory and Social theory by Albert Bandura. Harry Stack Sullivan was the first American theorist to construct a comprehensive personality theory in which he believed that development of the personality occurred within the context of the social group.Knowledge of the individual can only occur within the context of interpersonal relations.Healthy individuals experience both intimacy (+) and lust (-) toward the same person. The social perspective of learning theorizes that human function occurs in a reciprocal relationship with the environment in which there is interplay between ones personal factors, the environment, and their behavior (Bandura, 1977).

CHAPTER 2 REVIEW OF RELATED LITERATURE

Working relationship between staff nurse and student nurse Studies of nursing students perceptions of the clinical environment concluded that there is a need for nurses to welcome the nursing students into the profession (Atack, Comacu, Kenny, LaBelle, & Miller, 2000; Chan, 2002; Cope, Cuthbertson, &Stoddart, 2000; Drennan, 2002; Li, 1997; Lo, 2002; Lofmark&Wikblad, 2001; Seigel&Lucey, 1998; Suen& Chow, 2001).Nurses are the first role models for students in clinical settings. They can have a significant role on students motivation (2012 HanifiNasrin et al).As a staff nurse, you may have opportunities to work with nursing students and influence the next generation of nurses. You'll be viewed as an expert and a role model. Nursing has had the unfortunate reputation for "eating our young"; in other words, being unkind or destructive to new nurses or nursing students. This "unkindness" can take many forms, including belittling, unwarranted criticizing, and blaming. Some behaviors interpreted by students as unkind or disrespectful are eye rolling, heavy sighing, and using a dismissive or impatient tone of voice.(Crotty, Judy MSN, RN,March 2010 - Volume 40 - Issue 3 - p 5152).In the practice profession of nursing, the clinical setting is where students are allowed to provide selected aspects of care for patients. The interactive experiences nursing students have with nurses give the students the opportunity to internalize the role of the nurse as a caregiver. Some practicing nurses said they feel insecure about their skills or knowledge and are intimidated by having a student follow them. They're concerned that the student might possess more current knowledge and their own knowledge or skills might be outdated. This uncomfortable feeling caused some staff nurses to limit interactions with nursing students (Crotty, Judy MSN, RN, March 2010 - Volume 40 - Issue 3 - p 5152).Grindel, Patsdaughter, Medici, and Babington (2003) conducted a survey to investigate nurses perceptions of students contributions to clinical agencies. They reported that nurses had an increased sense of responsibility and accountability

for care provided by students to patients, therefore, producing more job-related stress for the nurses. Findings revealed that the more experienced nurses perceived nursing students as taking up too much time. The less experienced nurses perceived that nursing students did not take up time and freed them for other responsibilities. Both groups of nurses agreed that student participation in clinical, actual practice experiences with patients in clinical agencies, is a source for recruiting nursing staff. Both groups also agreed that nursing students enhance the clinical setting by stimulating staff intellectually, thus establishing collegial relationships. The recommendations of the study were to encourage staff nurses to display positive attitudes to support the learning experience of student nurses and use multi-method approaches using questionnaires, interviews, and observations to confirm the findings (Donna Hathorn, Volume 14 Number 2 June 2009 227-244).

Working relationship between clinical instructor and student nurse Clinical nursing teachers are paramount in the process of clinical learning. Teachers plan the learning experiences, specify students scope of practice, and determine parameters of expected learning outcomes. Students are given assignments to care for patients in conjunction withregistered nurses who maintain final accountability for patient care. Students prepare for the assignment, then provide care as designated for the experience. The teachers facilitate learning by working with students to demonstrate, correct, and encourage appropriate nursing care. Students are expected to incorporate knowledge from each clinical experience into subsequent ones in which progression of nursing abilities isexpected to be demonstrated. Through a series of these clinical experiences, students learn to become nurses (Gaberson&Oermann, 2007; OConnor, 2006; Oermann, 1998; Tanner, 2002). To promote a positive psychosocial learning environment, nurses should offer support, be nurturing, and treat nursing students with dignity and respect. Demonstration of caring behaviors and the importance of effective characteristics are identified as important influences in a nursing student-clinical instructor relationship (Noreen Nelson, 2011).Most students who are beginning clinical instruction are anxious. They are afraid they won't perform procedures on their patients adequately and that they will make mistakes that might cause patient suffering. An effective instructor will develop a relationship with the student that is reassuring, nurturing and confidence-building. He will praise good work and create an

atmosphere in which the student is allowed to make mistakes, learn from them and develop initiative (Nina Kramer,1999-2013).

CHAPTER 3 METHODOLOGY

This chapter presents the research method employed in conducting this study. Also, it will stipulate the subjects of the study, the instrument/s used in gathering data, the procedure used in collecting and processing data, and the statistical tools utilized in analyzing, interpreting and presenting the findings. Research Design Qualitative type of research will be used in the study. Questionnaire will be utilized to identify and gather data about factors affecting working relationships between the clinical instructors, student nurses and staff nurses. Research Locale and Subject of the Study The subjects of the study includes 10 clinical instructor and 10 staff nurse working in Eastern Visayas Region Medical Center and 10 student nurse enrolled in Remedios Trinidad Romualdez Medical Foundation College of Nursing. Research Instrument Self-structured questionare guide based was used in data collection and in seeking relevant information needed in the study such as the clinical instructors and the student. The questionare consists of open ended questions.

Data Collection Procedure The researchers sought for recommendation of the Dean of College in Nursing, then, a letter seeking approval and request to gain permission to conduct a survey among the student and clinical instructors in RTRMF medical shool.

Data Processing and Statistical Tools The data that will be obtained will be analyzed with Microsoft Excel. Descriptive statistics such as means, standard deviations, frequency counts, and percentages will be used to

present the result in tables, graphs or charts. Other possible statistical tools will be utilized as needed and warrant by the data collected.

BIBILIOGRAPHY ELECTRONIC REFERENCES The Relationship of Nursing Faculty Clinical Teaching Behaviors to Student Learning
http://www.csm.edu/wfdata/files/Academics/Library/InstitutionalRepository/12.pdf

INTERPERSONAL THOERY IN NURSING PRACTICE http://www.facebook.com/l.php?u=http%3A%2F%2Fmrgadget.hubpages.com%2Fhub%2FHILDEGARD-PEPLAUES-INTERPERSONAL-THOERYIN-NURSING-PRACTICE&h=UAQG5ChRo Psychodynamic Theories Sullivan: Interpersonal Theory http://www.facebook.com/l.php?u=http%3A%2F%2Fhighered.mcgrawhill.com%2Fsites%2F0072316799%2Fstudent_view0%2Fpart2%2Fchapter8%2Fchapter_outline .html&h=UAQG5ChRo Nursing Challenges in Motivating Nursing Students through Clinical Education: A Grounded Theory Study http://www.hindawi.com/journals/nrp/2012/161359/ Staff nurses & nursing students: Learning from each other http://journals.lww.com/nursing/Fulltext/2010/03000/Staff nurses nursing students Learning_from.18.aspx The Relationship of Nursing Faculty Clinical Teaching Behaviors to Student Learning http://www.csm.edu/wfdata/files/Academics/Library/InstitutionalRepository/12.pdf The Lived Experience of Nurses Working with Student Nurses in the Clinical Environment http://www.nova.edu/ssss/QR/QR14-2/hathorn.pdf Iranian staff nurses' attitudes toward nursing students. http://www.ncbi.nlm.nih.gov/pubmed/20926166