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Reliability Precision and Accuracy Reliability and validity
Summary of important terms to validate a measurement method
Reliability Precision and Accuracy Reliability and validity
Validity Trueness Accuracy of the mean
Accuracy Reliability and validity
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difference between the study groups is too small, or the scatter of the measurements is too great. Sterne demands that the quality of studies should be increased by increasing their size and increasing the precision of measurement (25). On the other hand, if the study is too large, unnecessarily many test persons (or ani- mals) are exposed to stress and resources (such as per- sonnel or financial resources) are wasted. It is therefore necessary to evaluate the feasibility of a study during the planning phase by calculating the sample size. It may be necessary to take suitable measures to ensure that the power is adequate. The excuse that there is not enough time or money is misplaced. The power may be increased by reducing the heterogeneity, improving measurement precision, or by cooperation in multicenter studies. Much more new knowledge is won from a single accurately performed, well designed study of adequate size than from several inadequate studies.
Only adequately planned studies give results which can be published in high quality journals. Planning errors and inadequacies can no longer be corrected once the study has been completed. It is therefore advisable to consult an experienced biometrician during the planning phase of the study (1, 16, 17, 18).
Conflict of interest statement The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
Manuscript received on 30 November 2007, revised version accepted on 8 February 2008.
Translated from the original German by Rodney A. Yeates, M.A., Ph.D.
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Altman DG, Machin D, Bryant TN, Gardner MJ: Statistics with con- fidence. 2nd edition Bristol: BMJ Books 2000; 173.
DocCheck- Flexikon: Thema: Studiendesign. http://flexikon.doccheck.com/Studiendesign.
Schumacher M, Schulgen G: Methodik klinischer Studien, Metho- dische Grundlagen der Planung, Durchführung und Auswertung. 2. Aufl., Berlin, Heidelberg, New York: Springer 2007; 1–28
Moher D, Schulz KF, Altman D, for the CONSORT Group: The CONSORT Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomized Trials. Ann Intern Med 2001; 134 : 657–62.
Beaglehole R, Bonita R, Kjellström T: Einführung in die Epidemio- logie. Bern: Verlag Hans Huber 1997; 53–84.
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Fleiss JL: The design and analysis of clinical experiments. New York: John Wiley & Sons 1986: 1–32.
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Machin D, Campbell MJ, Fayers PM, Pinol APY: Sample Size Tables for Clinical Studies. 2. Aufl., Oxford, London, Berlin: Blackwell Science Ltd. 1987: 296–9.
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Checklist to evaluate study design
Question � Is the question clearly defined? to be answered
Study population � Information on – recruitment (type, area, time) – sociodemographic information on test persons
(for example, age, sex, illness) – inclusion and exclusion criteria – period of follow-up observation
Type of study � Research on secondary data � Research on primary data (actual trials)
Experimental studies – Clinical studies – Epidemiological studies
Unit of observation � Technical model (for example, a prosthesis, material in dentistry, a blood sample)
� Hereditary information � Cell � Cell system � Organ (for example, heart or lung) � Organ system (for example, cardiovascular system) � Single test subject (animal or man) � Selected patient group (for example, hospital group,
risk group) � Population (for example, from a region)
Measuring technique � Use of measuring instruments (=validation) – Reliability – Validity
� Measurement plan – Time points – Number of investigators – Standardization of measurement conditions – Type of scale
Calculation of � Was the sample size calculated? sample size � If yes,what were the conditions?
Type of test – Level of significance – Power – Clinically relevant difference – Scatter/variance
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Altman DG: Statistics and ethics in medical research, misuse of statistics is unethical. BMJ 1980; 281: 1182–4.
Sackett DL: Bias in analytic research. J Chronic Dis 1979; 32: 51–63.
May WW: The composition and function of ethical committees. J Med Ethics 1975; 1: 23–9.
Palmer CR: Ethics and statistical methodology in clinical trials. JME 1993; 19: 219–22.
Moher D, Dulberg CS, Wells GA: Statistical power, sample size, and their reporting in randomized controlled trials. JAMA 1994; 272: 122–4.
Faller, H: Signifikanz, Effektstärke und Konfidenzintervall. Reha- bilitation 2004; 43: 174–8.
Sterne JAC, Smith GD: Sifting the evidence—what’s wrong with significance tests? BMJ 2001; 322: 226–31.
Why Are Nurses Leaving? Findings from an Initial Qualitative Study on
In the United States, nursing workforce projections indicate the registerednurse (RN) shortage may exceed 500,000 RNs by 2025 (American Association of Colleges of Nursing [AACN], 2010; Cipriano, 2006; U.S. Department of Health and Human Services, 2002). In 2008, the national RN vacancy rate in the United States was greater than 8% (AACN, 2010). Evidence suggests experiences as a newly licensed RN directly impact indi- vidual perceptions related to the profession (Cowin & Hengstberger-Sims, 2006). An estimated 30%-50% of all new RNs elect either to change positions or leave nursing completely within the first 3 years of clinical practice (AACN, 2003; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Cipriano, 2006; Cowin & Hengstberger-Sims, 2006). While an abundance of data exist regard- ing the RN who stays at the bedside, few studies have explored the percep- tions of the RN who decides to leave clinical nursing. Understanding factors associated with RNs’ practice decisions is the first step necessary in devel- oping effective nursing-retention strategies.
Purpose The purpose of this study was to identify the factors influencing the
decision of RNs to leave clinical nursing practice. Nurses who had elected to leave clinical nursing were interviewed at the setting of their choice. Previous clinical nursing experience included a variety of clinical practice settings. For this study, the term clinical nursing is defined as providing direct patient care in the hospital setting.
Background Limited data exist about individuals no longer employed in nursing; no
literature was found about the perceptions or decision-making processes of RNs no longer in clinical practice. A review of the literature was conducted searching nursing, medical, labor, and psychological/sociological databas- es. Years of search ended with 2007, the year of the interviews. A broad search began with GoogleScholar® and was narrowed to include CINAHL, MEDline, PsycINFO, and LexisNexis. Several issues concerning practice decisions are associated with the current nursing shortage, including job dissatisfaction (Aiken et al., 2002; Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005), an aging workforce coupled with increased demands (Auerbach, Buerhaus, & Staiger, 2007), and problematic relationships among members of the health care team (Aiken et al., 2002). While these fac- tors may lead to increased nursing attrition, they have not been explored from the perspective of the former RN. A thorough examination of RNs’ per- ceptions regarding the decision to leave is necessary. Thus, the purpose of
The nursing shortage remains problematic, yet research with nurses no longer in clinical practice is scarce. The purpose of this study was to understand the factors influencing the deci- sion of registered nurses (RNs) to leave clinical nurs- ing. A phenomenological research design was chosen to reveal the complex phe- nomena influencing the RNs’ decisions to leave clinical nursing practice. Interviews were conducted with RNs who were no longer practic- ing clinically.
336 MEDSURG Nursing—November/December 2010—Vol. 19/No. 6
this study was to identify factors influencing the decision of regis- tered nurses to leave clinical prac- tice.
In a descriptive correlational study of new RNs (n=187), investi- gators found up to half had consid- ered leaving nursing within the first year. By the third year, almost one- third of the new RNs had left nurs- ing or decreased work hours to part-time (Cowin & Hengstberger- Sims, 2006). Lafer (2005) hypothe- sized the substantial loss of nurses from patient care is correlated directly to suboptimal working con- ditions, stressors placed on RNs, and low economic benefits com- pared to other industries.
For a complete understanding of why RNs leave clinical nursing, a thorough review of RN perceptions regarding the decision to leave clin- ical practice is needed. Achieving this understanding requires aware- ness of reasons RNs have elected to leave clinical nursing. The review of literature found limited research about nurses who no longer prac- tice clinically. Takase, Maude, and Manias (2005) noted research is needed concerning reasons RNs elect to leave clinical practice; this topic has been overlooked repeat- edly in development of nursing pol- icy.
Methodology The decision to leave clinical
nursing often is conceptualized as one influenced by multiple factors that compound over time. A phe- nomenological research design was used to provide an in-depth under- standing of nurses’ decisions to leave clinical practice. Because the focus of the research related to the perceptions of the RNs, and because no definitive research exists about this phenomenon, an interpretive, qualitative study was deemed appropriate. Interpretive hermeneutic phenomenology, with its intent to give meaning to the experience, was the ideal choice to guide this study (Benner, 1984; Heidegger, 1962; Lincoln & Guba, 1985; Patton, 2002).
The research question for this study was, “What is the experience of RNs who leave clinical nursing?” Investigators conducted semi- structured interviews with nurses
who left clinical practice. The ques- tions used to guide the interviews are presented in Table 1.
Methods Sample selection and recruit-
ment. Purposive sampling was used for recruitment (Patton, 2002). Inclusion criteria consisted of licensed RNs with a minimum of 1 year of clinical practice and no clin- ical practice in the last 6 months. RNs with more than 1 year of expe- rience were chosen as they could provide information about the fac- tors leading to their decision to leave clinical nursing; investigators’ assumption was that the decision to leave clinical practice was not related specifically to the initial shock of becoming a RN (Benner, 1984). RNs in supervisory or educa- tion roles were excluded, as were licensed practical nurses or other health care workers who self- described as nurse. RNs who allowed their professional licensure to lapse were excluded, based on the belief they may no longer iden- tify themselves as nurses and thus may differ from nurses who main- tain licensure yet do not practice clinically. RNs who were asked to surrender licensure by their state boards of nursing also were exclud- ed.
Data collection and analysis pro- cedures. After institutional review board approval was received from Georgia State University, study par- ticipants were recruited. Recruit – ment was done through the snow- balling technique (Patton, 2002).
Currently practicing RNs at various hospitals in the southeastern United States were contacted by the primary investigator and asked if they knew nurses no longer in clinical practice. The email described the study, and asked for these nurses’ help in recruiting potential participants. Telephone contact was made with each poten- tial participant prior to the inter- view process to ensure study crite- ria were met. All recruitment was done over the telephone. An effort was made to not limit recruitment to one hospital, but to contact all known non-practicing RNs who might be willing to participate in the study. After providing a brief description of the proposed study, the investigator determined a mutually convenient time and loca- tion for the interview. Written informed consent assured nurses’ participation in the study was vol- untary, anonymity would be provid- ed (to the fullest extent available), termination of the interviews was allowed at any time, and consent was obtained prior to the first inter- view. To maintain confidentiality, participants used a pseudonym during the interview.
Ten semi-structured interviews were conducted in 2007. All inter- views were audiotaped and field notes were made during the inter- view process. Interviews were tran- scribed verbatim, and the record- ings were compared with the tran- scription to ensure accuracy. Participants also received copies of their transcripts to review for accu-
Table 1. Interview Questions
What does the term bedside nursing mean to you?
How do you define the role of the bedside or clinical nurse?
Can you explain the relationship that existed between you as the RN and your patients?
Can you talk about the reasons or a situation that may have brought you to the decision to leave bedside nursing?
Can you think of a situation that exemplifies the relationships that you had with your co-workers while providing direct patient care?
Have you found career fulfillment in your current position?
Can you describe what you would require to return to the practice of clinical nursing?
Why did you decide to participate in this research?
Is there anything else you would like to share with me?
MEDSURG Nursing—November/December 2010—Vol. 19/No. 6 337
racy. Upon review of the tran- scripts, participants were given the opportunity to meet again with the researcher to clarify any issues they deemed important. Interpre – tation was ongoing during this time, with the underlying purpose to identify why RNs decided to leave clinical nursing. Transcriptions first were reviewed as a whole with a basic interpretation derived. From there, the use of hermeneutics allowed the researcher to probe fur- ther into the contextual meanings present in the interviews (Geanellos, 2000). Interpretive analysis was shared with research colleagues to ensure appropriate interpretations were being made. As analysis continued, ideas and major themes were identified. These themes were paired with like themes and recorded appropriate- ly, and supporting documentation coded. Themes emerged from the transcripts as analysis continued. When a new theme would appear, previous transcripts were reread to determine if that theme was identi- fied in previous interviews. During analysis, the research team searched for all possible meanings related to the decision to leave nursing to ensure a complete analy- sis of the data.
Results Sample. The majority of the par-
ticipants were female (n=8, 80%), Caucasian (n=7, 70%), and ages 40-49 (n=7, 70%). RNs practiced in a vari- ety of clinical settings, with 50% working on medical-surgical nursing units. Years of clinical practice ranged from 1 to 18 (M=6.5, SD=5.1), and number of RN positions ranged from 1 to 6 (M=2.4, SD=1.4). The majority of the participants had practiced in the southeastern United States (n=7, 70%). Demographics are summarized in Table 2.
Data analysis. Nurses reported many positive aspects to practicing clinically. They identified interac- tions with patients and families as being emotionally satisfying, and the loss of this interaction as their biggest regret since leaving prac- tice. Many RNs stated they “felt guilty” about no longer practicing clinically, and many nurses cried during the interviews.
In discussions of the decision
to leave clinical nursing, three themes emerged: (a) unfriendly workplace, (b) emotional distress related to patient care, and (c) fatigue and exhaustion. Unfriendly workplace was evidenced by nurses reporting issues of sexual harass- ment; verbal or physical abuse from co-workers, managers, or physicians in the workplace; and/or consistent lack of support from other RNs. The second theme, emo- tional distress related to the patient care, was recognized when RNs spoke of the conflict they felt regarding patient care decisions.
Often this was marked by a percep- tion that others ignored patient or family wishes. The third theme of fatigue and exhaustion was charac- terized by the frequent comments regarding overwhelming emotional and physical exhaustion.
Unfriendly Workplace Unfriendly workplace was re –
ported by all RNs in the study. Participants described being left alone or ignored as new RNs or being told to “toughen up” under the auspices of making them “bet- ter nurses.” They also relayed inci- dents of belittling confrontations, sexual harassment, or gender abuse with co-workers. RNs de – scribed perceived lack of support when they were new to the profes- sion, and indicated this influenced their clinical nursing practice and their decisions to leave clinical practice.
Tony worked in a surgical inten- sive care unit and left after 2 years of clinical nursing. He described his experience as a nurse as “simply disappointing.” Tony noted, “Nurses feed on their own. When I would ask for help, I was ignored…It was like I was an inconvenience.” Tony felt alone and isolated as a new RN.
Tina worked on a medical-surgi- cal unit after her initial orientation as a new RN. She had been working for approximately 2 months on the night shift when a patient care situ- ation became chaotic and she went to find help. Two RNs were in the break room, and the others “could- n’t be found.” She said:
I was totally alone…one patient in what I thought was SVT, one pulling out all of his lines because he was disoriented, and one who really seemed to have a hard time breath- ing. The RNs in the break room said they would be there “in a minute.” I called the supervisor [for help], and she told me to find my mentor. I was…all alone, all the time. Yet I was responsible.
Tina left clinical nursing after 1 year. Both Tony and Tina indicated they consistently felt they were alone in their transition as RNs in an unfriendly workplace.
The theme of unfriendly work- place also was characterized by stories of gender abuse and sexual harassment. All participants shared
Table 2. Demographic Characteristics
African American: 2
Highest Level of Nursing Education
Highest Level of Other Education
BS/BA other field: 3
Clinical Experience Setting
Medical-surgical nursing: 5
Critical care nursing: 3
Psychiatric nursing: 1
Labor and delivery: 1
Was Nursing Your First Career?
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