CHAPTER 1

INTRODUCTION

The context of the research investigation was in the field of decision

making of nursing students, with the focus of the study being on the clinical

performance in every area of duty.

Background of the Study

In recent years, nursing education focused on theoretical education and

deep gap between theoretical and clinical education created. Many nursing

researchers reported that nursing students, in spite of good knowledge base,

weren’t skillful in clinical settings. In result, with entrance of these unskillful

students to the nursing care system, the quality of this system falls day to day.

Today, many of medical science trainers search for suitable educational

methods to educate high level of clinical skills for their students. The best way for

reaching this goal is using an educational method that activates learners and

gives them suitable feedback about their learning. An educational method that

can help trainers in reaching this goal is mastery learning.

Mastery learning was originated in viewpoints of John Carroll. Carroll

(1963) believed that an important factor to distinguish between learners is the

time they need for learning educational goals; he believed that if enough time

gave to learners, all of them can learn educational goals in a good level. Based

on this viewpoint, Benjamin Bloom innovate mastery learning method. Bloom

(1973) believed that this method engage learners in a process that mastery level

established in them via frequent assessments (formative and summative),

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feedback and reparation education. The aim of formative assessments is to

provide feedback for learners and determine the educational goals that need

reparation education and the aim of summative assessment is to determine the

final mastery level in learners.

It should be considered that this educational method, like any other

methods, has some faults. This method is time consuming and further help to

weak students; in this method instructor focuses on these students. Another fault

is that this method makes anxiety in learners because of frequent assessments.

In spite of these faults mastery learning method has an important benefit;

learners educated with this method, in the time of graduation, are skillful and

have necessary skills to perform their professional responsibilities.

The case for universal measurement of clinical performance now seems

unanswerable. However, as a recent OECD conference has highlighted, the

obstacles to implement an efficient and effective system of performance

measurement are formidable. To get the most out of performance measurement,

certain design issues need to be addressed. In this paper we consider two

aspects of design: what should a clinical performance measurement system seek

to measure? And how should we measure it? In the second and concluding part,

we shall look at the pitfalls and how to avoid them.

Despite 40 years of nursing research history into the development of a

valid and reliable method of assessing the clinical performance of nurses, there

are no universally accepted tools. This remains a matter of concern for the

profession (Dolan, 2003; Robb et al., 2002; Watson et al., 2002). Therefore the

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development of analytical, validated tools for clinical assessment is justified

(Chambers, 1998; Dumas et al., 2000; Dunn et al., 2000; Failla et al., 1999;

Garland, 1996; Keonig et al., 2003; Nahas and Yam, 2001; Pelletier et al., 2000;

Watson et al., 2002).

In the Philippines, nursing students need an extensive knowledge of

biological and physical science concepts for safe, competent clinical practice

(Casey, 2004). However, nursing students frequently have difficulties with

content in science courses (Clancy, Defensor, 2007). The difficulties have been

attributed to several factors in nursing education.

In Davao City, nursing curriculum changes in the past few decades has

led to a decline in emphasis in science. Science course content generates a

great deal of anxiety for nursing students (Nicoll & Butler, 2008). Nurses

traditionally have not perceived a need for an in-depth scientific knowledge base.

These problems with science courses decrease motivation and the ability to

effectively use learning strategies in science courses (Andrew & Puno, 2007).

Statement of the Problem

This study was conducted to determine the relationship of decision making

skills and clinical performance of nursing students in Davao City. Specifically, it

sought to answer the following questions.

1. What is the level of decision making of nursing students in terms of:

1.1 Providing health care treatment to the patient?

1.2 Prescribing appropriate drugs to the patient?

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 2. What is the level of clinical performance of nursing student in terms of?

2.1 Prescribing appropriate drugs

2.2 Health care

2.3 Medical

2.4 Surgical

2.5 Desirable process of care

3. Is there a significant relationship between decision making skills and

clinical performance of the nursing students?

Hypothesis

Based on the study gathered the null hypothesis stated that there is no

significant relationship in the level of decision making skills and clinical

performance of the nursing students.

Review of the related Literature

The assessment of candidates in clinical practice presents a multitude of

problems and is an issue that will not be easily resolved, with educationalists

experiencing difficulties in developing a tool that includes objectivity, validity and

reliability for the assessment of clinical competencies in nursing (Chambers,

1998; Wigens and Westwood, 2000; Wiles and Bishop, 2001). Ensuring any

instrument developed to measure the construct of interest, in this case the

operating room nurse competency, is reliable and valid is vital (Watson et al.,

2002). While there is consensus that all instruments must be valid and reliable

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(Gillis and Bateman, 1999; Watson et al., 2002) these technical terms are applied

to the instrument without sufficient evidence to support their development (Gillis

and Bateman, 1999; Watson et al., 2002).

Several external factors have amplified the difficulties for nursing students

in science course content. Lack of science background in nursing instructors has

contributed to the perception that science content is not important in their

practice (Courtenay, 1991). Conversely, lack of nursing background from science

instructors has

been attributed to student perceptions that content was more in-depth than

needed for their clinical performance (Clarke, 1995; Nicoll & Butler, 1996).

Performance in science courses at the graduate level is further complicated by

nursing students having time management difficulties when entering graduate

school due to responsibilities with balancing work, family (often including children

living at home) and school demands (Spratley, Johnson, Sochalski, Fritz, &

Spencer, 2000).

A normative referenced evaluation compares the student’s clinical

performance against other students within the group (Oermann & Gaberson,

1998). Portfolios are an evaluation tool that demonstrates the student’s best

work across the clinical term. It is a self-collected sample of projects to show

student learning and growth. Journals provide insight into a student’s values and

beliefs which may impact ability to learn. For example, a student who finds

wound drainage distasteful may do poorly in a surgical rotation. Student self

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evaluation of clinical performance and ability to meet objectives is also worthy of

consideration as a method of student evaluation. Reflection on strengths and

weaknesses, what growth has occurred, what attitudes have changed, helps the

student to be a reflective learner as well as provide information to the instructor

(Oermann & Gaberson, 1998).

One very common method of evaluation is anecdotal notes, a narrative

describing observations of the learner’s conduct. The note is brief and factual of

student behavior; it does not include faculty judgment. An anecdotal note is

correctly written as “The student left the room three times to obtain supplies”

instead of “The student was unprepared to do the procedure.” Anecdotals can

and should contain positive notes as well as negative observations. Reviewing

all anecdotal notes for a particular student is helpful in identifying trends and

patterns. Anecdotals do need to be kept confidential and secured for the length

of time specified by the institution, or at least the length of time the student is in

the program (Liberto, Roncher, &Shellenberger, 1999; Smith, McKoy, &

Richardson, 2001).

The evaluation tools described above are used to provide formative and

summative evaluative feedback to the student. Formative evaluation is frequent,

ongoing, comments to the student about progress in meeting objectives and

competencies. It is intended to identify learning needs; it is not meant for

grading. Formative feedback should be immediately related to the observed

action, citing both adherence to and deviation from practice standards.

Recommendations for improvement and a time frame for improvement to be

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evident, if applicable, are included. The instructor should keep documentation of

formal and informal conferences, as well as student progress in meeting

expected practice.

Summative evaluation communicates the student’s success at meeting

the stated objectives and competencies. As such, it occurs at the end of

instruction. In addition to the described evaluation tools, summative evaluation

may take into consideration the perspective of the unit staff the student worked

with, patient comments, professional behavior and appearance, participation in

pre- and post-conference, and written assignments (Smith et al, 2001). In

addition to clinical competency, do not forget to observe for any display of

academic dishonesty. This may include lying about a procedure not done,

copying another student’s work, or falsely presenting as a nurse instead of a

student. The clinical grade is the end result of the summative evaluation.

Clinical evaluation of the student assessed as not meeting standard is one

of the most difficult responsibilities of the clinical instructor. Although teachers

feel confident in the accuracy of their assessment, they feel less confident in

acting on it (Hrobsky & Kersberger, 2002). The teacher may feel it is a personal

failure instead of a student shortcoming. As a caring professional, the instructor

may be concerned about the impact of a failure on the student’s well-being. This

concern, although valid, needs to take a back seat to the higher concern of

patient safety and professionalism. Nurse educators are required to safeguard

standards of professional practice by graduating qualified, safe students.

Although some may view the act of failing students as being uncaring about the

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 student, it is more uncaring to allow this person to continue (Hrobsky &

Kersberger, 2004; Scanlon, Care, & Gessler, 2005).

Theoretical Framework of the study

Bennett and Franco (1999:4) proposed a conceptual framework of factors

that influence work motivation. Figure 1.2 depicts a complex web of links and

interaction between work motivation, performance, and organizational factors

within the health sector environment:

 Workers’ individual needs factors such as goals, self-concepts,

expectation, worker capability and worker experience of outcomes are

some of the individual’s determinants of motivation.

 The organizational factors and systems in which the worker is operating

with inputs such as drugs, supplies, support and feedback will affect the

outcomes of performance.

 The broader social and cultural factors which is outside the organizational

environment which include issues such as the interaction between health

worker and the client, the expectations from the community on how health

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 care services should be delivered may affect motivation for performance.

(Gessle, 2005) stated that the rhetoric of clinical performance

management is that the focus should always be on the outcomes rather than the

processes of healthcare. Certainly, outcomes represent the ultimate product of

healthcare: they embody the additional quality and quantity of life added by

clinical intervention. In practice, finding an operational way of capturing outcomes

is a daunting task. In the past, mortality rates have often served as a substitute

for outcome. Their manifest shortcomings have led to the development of broader

generic quality-of-life measurement instruments such as EQ-5D and SF36 and a

plethora of condition-specific measures.

However, if the focus is on identifying and remedying apparent variations

in performance, it is often preferable to measure not only outcomes but also the

desirable processes of care. These can be viewed as professional actions

recommended as good practice on the basis of expert opinion or evidence. From

a performance management perspective, the key issue is that a desirable

process should be unambiguously associated with improved patient health

outcomes. Monitoring the process can then be a substitute for measuring

outcome. (Casey, 2004).

Significance of the Study

This study is very important for it will provide relevant data and

information. The result of this study will also give a benefit to the following

persons.

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 Fort and Voltero (2004:6) identify measurement and evaluation of

performance as keys to improving performance. They further identify key aspects

of performance:

 Standardization of care by describing what is the expected or desired

performance (standard of care)

 Determining if interventions are reducing the gap (measurement) so as to

contribute to the achievement of the goal (performance outcome).

The Respondents

The result of this study will enable them to know on how to give right

decision on giving treatment and this will improve the decision skills and give

them a broader view on clinical performance from data gathered, they can able to

make an adjustment, so they can cope up with the situations which enhancing

clinical performance.

Practicum Nurses

This will serve as their guide in making a right decision and improving

skills and on the clinical performance.

Nursing Students

This study may help to contribute for the students’ decision making skills

and the clinical performance on their respective duties. These will help them to

create a self adjustment on the behavior regarding ones duties.

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Definition of Terms

For better learning we have included the following terms and definition.

Clinical Behavior – the manner to aggregate of the responses or reactions or

movements made by individual in any situation or in clinical environment.

Treatment - Care provided to improve a situation (especially medical procedures

or applications that are intended to relieve illness or injury).

Performance - Process or manner of functioning or operating; "the power of its

engine determines its operation.

Nurse - try to cure by special care of treatment, of an illness or injury.

- Care for sick or handicapped people.

Anecdotal Note - short account of an interesting or humorous incident.

Summative Evaluation - refers to the assessment of the learning and

summarizes the development of learners at a particular time.

Rhetoric - using language effectively to please or persuade.

Daunt - cause to lose courage; "dashed by the refusal”

EQ-5D - is a standardized instrument for use as a measure of health outcome.

SF36 - is a survey of patient health.

Plethora - overplus: extreme excess; "an embarrassment of riches"

NDC – National Drug Code

OECD - Organization for Economic Co-operation and Development

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 Chapter 2

Methodology

Presented in this chapter are the discussions on research design,

participants, data gathering procedure and data analysis of the study.

Research Design

The researchers of this study used a descriptive co-relational method.

According to Gay (2003), this method involves in collecting data in order to

determine whether and to what degree, a relationship exist between two or more

variables In this study, we have to determine the level of relationship of decision

making skills and clinical performance of nursing students..

Research Local

There were almost 150 respondents involved in the study. These sample

were all practicumer and intern nurses in Davao Medical Hospital whose

appointments are being approved and attested by the NDC, at Davao Medical

Hospital in Davao City. The respondents represents fifty four (54%) of the 25

percent interns for the calendar 2009. The respondents as raters were group by

gender. The researcher made used of purposive sampling method in selecting

the participants of the study.

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Respondents of the Study

This study was conducted in Davao Medical Hospital, Davao City where

all the respondents are the Nursing Practicumers and Interns during their duty

and shift. The study focused on the level of their decision making skills and their

clinical performances during their time of duties. Previous and current

performances of the respondents were determined which were their final grades

and ratings. The respondents were the four general sections of the Hospital: The

ward section; OB Section; Emergency Section: and the Operating Section. Office

Section interns were also taken as respondents in the study.

Table 1

Distribution of Respondents

Gender Respondents Total Population Percentage

Male 121 60 32%

Female 150 80 22%

Total 271 140 54%

Research Instrument

The researcher used two set of questionnaires as means of gathering data

to the study. The first set contains about the level of decision making skills,

classified by two indicators such as: Providing Health Care Treatment to the

Patient; Prescribing Appropriate Drugs to the Patient. The second set of

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questionnaire is about the level of clinical performance of nursing students:

classified into five indicators: Prescribing Appropriate Drugs; Health Care;

Medical; Surgical; and Desirable Process of Care in Davao Medical Hospital. It

contains five questions.

With the assistance of their adviser, the researchers constructed the two

questionnaires. The construction of these questionnaires was taken from relevant

professional books, periodicals, journals, and other source materials. The draft of

questionnaires were presented and evaluated by some experts using a standard

validation tool. Comments, suggestions and recommendations were taken and

noted by the researchers in the revision of the final sets of questionnaires. Base

on the remarks made by evaluators, the questionnaires are valid and reliable.

The set of questionnaires were patterned from Likert scaling techniques using

fine point scale identifying “1” as the lowest and “5” as the highest.

Table 1: The level of decision making skills of nursing student.

Scale Description

5 Strongly Agree Very high level of decision making

skills of nursing student in Davao

Medical Hospital, approximately 81-

100%

4 Agree High level of decision making skills of

nursing student in Davao Medical

Hospital, approximately 61-81%.

3 Neither agree nor Disagree Moderate level of decision making

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 skills of nursing student Regional

Hospital, approximately 41-60%

2 Strong Disagree Low level of decision making skills of

nursing student in Davao Medical

Hospital, approximately 21-40%

1 Disagree Very low level of decision making skills

of nursing student in Davao Medical

Hospital, approximately 1-20%

Mean Weight Description Descriptive Level

4.50-5.00 Always Very High

3.50-4.49 Often High

2.50-3.49 Sometimes Moderate

1.50-2.49 Seldom low

1.00-1.49 Never Very Low

Table 2: The level of clinical performance of nursing student.

Scale Description

5 Strongly Agree Very high level of Clinical Performance

of nursing student in Davao Medical

Hospital, approximately 81-100%

4 Agree High level of Clinical Performance of

nursing student in Davao Medical

Hospital, approximately 61-81%.

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3 Neither agree nor Disagree Moderate level of Clinical Performance

of nursing student in Regional Hospital,

approximately 41-60%

2 Strong Disagree Low level of Clinical Performance of

nursing student in Davao Medical

Hospital, approximately 21-40%

1 Disagree Very low level of Clinical Performance

of nursing student in Davao Medical

Hospital, approximately 1-20%

Mean Weight Description Descriptive Level

4.50-5.00 Always Very High

3.50-4.49 Often High

2.50-3.49 Sometimes Moderate

1.50-2.49 Seldom low

1.00-1.49 Never Very Low

Data Gathering Procedure

The researcher observed the following steps:

1. Permission to conduct study. A letter of permission was asked from the

office of the Davao Medical Hospital, Davao City requesting to allow

the researcher to conduct a survey among the present practicumer and

intern nurses in Davao Medical Hospital.

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 2. Administration of the research instrument. The questionnaire was

distributed personally by the researcher to the respondents.

3. Retrieval of data. The questionnaire was retrieved by the researcher

after it was answered by the respondents.

4. Collection of Data. The data gathered were tallied and tabulated for

statistical analysis.

Statistical Treatment of Data

To answer the various problems of the study, the following statistical tools

were used.

Mean. This statistical tool was used to measure the decision making skills

of nursing student intern and practicumer in Davao Medical Hospital, Davao City.

Descriptive co-relational method – this was used to determine the level

of clinical performance of nursing students practicumer and interns in Davao

Medical Hospital.

For the decision rule is set to 0.05 level of decision making skills and

clinical performance.

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References

Batturs, B. (n.d.) Dealing with the difficult learning situation. Retrieved

December 6, 2005, from the Maryland Association of Community Colleges Web

site:http://webct.aacc.edu:8900/SCRIPT/DEVHEALTHCAREPRODEV3/scripts/

serve_home Diekelmann, N., and McGregor, A.(2002). Students who fail clinical

courses: Keeping open a future of new possibilities. Journal of Nursing

Education, 42(10), 433-440.

Gaberson, K.B., and Oermann, M.H. (1999). Clinical teaching strategies in

nursing. New York: Springer Publishing.

Hrobsky, P.E., and Kersberger, A.L. (2002). Preceptors” perceptions of clnical

performance failure. Journal of Nursing Education, 41(12). 550-553.

Liberto, T., Roncher, M., and Shellenberger, T. (1999). Anecdotal notes:

Effective Clinical evaluation and record keeping. Nurse Educator, 24 (6), 15-18.

Oermann, M.H., and Gaberson, K.B. (1998). Evaluation and testing in nursing

Education. New York: Springer Publishing.

Scanlon, J.M., Care, W.D., and Gessler, S. (2001). Dealing with the unsafe

student in clinical practice. Nurse Educator, 26 (1), 23-27.

Smith, M.H., McKoy, Y.D., and Richardson, J. (2001). Legal issues related to

dismissing students for clinical deficiencies. Nurse Educator, 26 (1), 33-38.

http://www.google.com: definition & search

http://wikipedia.com: definition & historical issues

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