Program Evaluation in Graduate Nursing Education: Hardiness as a Predictor of Success Among Nursing Administration Students

SHARON JUDKINS, PHD, RN, CNAA, BC,* LATONIA ARRIS, RN, MSN, BC,y AND ELIZABETH KEENER, RN, MSN, BCy

In an effort to develop meaningful program evaluation data, this exploratory study examined hardiness and stress among a select group of graduate nursing administration students at The University of Texas at Arlington in Arlington, TX. Students completed a questionnaire, which included the Hardiness Scale and Perceived Stress Scale, at both beginning and end of their program. Six to 12 months after graduation, each participant completed a telephone survey with items related to hardiness and American Association of Colleges of Nursing and American Organization of Nurse Executives core competencies. Mean scores for both hardiness and stress did improve from beginning to end of program; however, alpha coefficient reliabilities were disappointing, so no further quantitative analyses were completed. Most enlightening were the telephone interviews, which revealed that graduates were engaged in behaviors indicative of high hardiness. Use of hardiness as a guiding construct may prove useful to nursing administration program faculty in developing and refining a quality program; use of both quantitative and qualitative methods are recommended for obtaining meaningful program evaluation data. (Index words: Evaluation; Hardiness; Stress; Graduate students; Nursing administration) J Prof Nurs 21:314 321, 2005. A 2005 Elsevier Inc. All rights reserved.

formative and summative program evaluations. Although evaluation of programs has been an essential component of nursing education for decades, nurse educators have more recently been encouraged to expand their scope of program evaluation activities to assure information gained is comprehensive, meaningful, and useful. Accreditation agencies such as the National League for Nursing Accrediting Commission (NLNAC) and Commission on Collegiate Nursing Education continue to challenge nursing education to enhance its evaluation efforts. Outcomes are becoming the norm in evaluation efforts as faculty seek to integrate student learning with teaching and ongoing departmental/institutional activities (Keith, 1991). Often, undergraduate education is the primary focus in discussions of program evaluation, excluding needs of graduate nursing education, particularly programs in nursing administration.
Evaluation

S NURSING CONTINUES to meet an increasing demand for accountability in the delivery of patient care, nursing education also strives to keep pace in the accountability race through both

*Director, Nursing Administration Program, and Assistant Professor, School of Nursing, University of Texas at Arlington, Arlington, TX. yCentral Texas Veterans Health Care System, Temple, TX. Address correspondence and reprint requests to Dr. Judkins: Director, Nursing Administration Program and Assistant Professor, School of Nursing, University of Texas at Arlington, Box 19407, Arlington, Texas 76019-0407. E-mail: judkins@uta.edu 8755-7223/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2005.07.003 314

Evaluation is about the verification of reality, an attempt to determine what reality is in relation to or in comparison with criteria the evaluator thinks reality should be (Bevis, 1989). Thus, program evaluation must be closely tied to both curricular issues and student learning. For program evaluation to serve decision making, development, and planning, it must possess several characteristics, including practicality, utility, propriety, and technical adequacy. In deciding what to evaluate, an evaluation plan should be able to provide information that clearly documents effectiveness of the program and be helpful to faculty in developing and improving the curriculum (Bevil, 1991). In deciding when to evaluate, collection of data at different levels of aggregation are important (Ramsden, 1991), and changes over time are more significant than comparisons at one particular time (Cowman, 1996).

Journal of Professional Nursing, Vol 21, No 5 (SeptemberOctober), 2005: pp 314-321

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Nursing Administration

Difficulties in evaluating graduate students in nursing administration stem from challenges in students intellect, ability, interest, and from complexities associated with students career goals and their diversity of administrative backgrounds, ranging from staff nurse to top administrative officer. Accounting for these diversities, nursing education curricula must also reflect rapidly changing technologies and the expansion of knowledge and practice and include theory, science, professional standards, and consumer/service input (Young, Urden, Wellman, & Stoten, 2004). To that extent, the University of Texas at Arlington (UTA) School of Nursing used the Essentials of Graduate Education for Professional Nursing Practice core competencies established by the American Association of Colleges of Nursing (AACN) and the American Organization of Nurse Executives (AONE) (1997) to guide its content in all courses. As evaluation methods were developed, both subjective and objective evaluations were viewed as necessary conditions for successful program evaluation (Milne & Whyke, 1988). However, difficulties arose when looking for both methods to measure or address AACN and AONE core competencies. In addition to various papers, projects, and endof-program evaluation tools, faculty desired to find ways to measure success of graduates as they entered practice regardless of career goal diversities. The construct hardiness was found to encompass many of the AACN competencies and emerged as a possible factor. The subject of this report is a comparison of beginning (pre) and ending (post) findings in relation to hardiness among graduate nursing students in a nursing administration program.
Literature Review

Tremendous changes have occurred within the nursing profession since the mid-19th century. The domain of nursing knowledge has exploded, the scope of practice has increased dramatically, and nursing roles exist that were unimaginable 50 years ago. As a reaction to changes in the health-care industry in the last 20 years, roles of the nurse administrator have evolved significantly, and characteristics for success are based on competencies that require sophisticated business knowledge and skills. The health-care marketplace requires midlevel managers and directors to have executive-level expertise in budgeting, trend and variance analysis, strategic planning, marketing,

and an understanding of information technology (Kleinman, 2003). Furthermore, nurses in managerial positions must manage day-to-day operations, empower staff, build productive work teams, maintain quality, and satisfy customers. Currently, the average nurse is 45 years old, a fact that is predicted to produce serious nursing shortage as retirements of large cohorts occur (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000). Nurse managers and executives are part of this retiring cohort; thus, it is imperative to prepare nurses educationally for these ever-increasing vacancies. Educational programs are trying to respond. The Hallmarks of Excellence of Nursing Education are standards created by the Nursing Education Advisory Council for the NLNAC that identify several categories essential in education programs to achieve excellence (National League of Nursing, 2004). Standards related to students include commitment to lifelong learning, innovation, continuous quality improvement, and a career in nursing. Hardiness appears to be inherent throughout both NLNAC and AACN standards, yet hardiness research, although abundant, has yet to focus on nursing administration graduate students. While obtaining a nursing administration graduate degree, students are often managing stressors relative to the educational experience. Todays graduate student enters the academic arena with anticipation, visions of self-fulfillment, and hopes of increased professional and personal credibility, only to be confronted with the reality of negotiating multiple roles (Kaminski, 2000). Kaminski shares that students with multiple roles experience more role-related stress and poorer psychological adjustment than do individuals who have fewer roles. Most would agree that nursing graduate students have multiple roles to juggle, with a diverse array of work, personal, social, environmental, and academic factors presenting difficult challenges as they steer through graduate school. Since the construct hardiness has been found to act as a mediator of stress, promoting hardiness throughout a nursing administration program of study may assist graduate nursing students to reduce or cope with these multiple roles.
HARDINESS

Kobasa (1979) introduced hardiness as a group of personality characteristics that function as a resistance resource in the encounter with stressful life events. Hardiness is generally viewed as the composite of three elements: commitment of oneself and work,

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feelings of personal control over events and outcomes, and an inner belief that change is a challenge and an opportunity for growth rather than a threat (Turnipseed, 1999). Hardy individuals do not see themselves as victims of change, but rather an active determinant of the consequences brought about by change (Kobasa, 1979).
Commitment

Commitment is a tendency to involve oneself in, rather than experience alienation from whatever one is doing or encounters (Maddi, Hoover, & Kobasa, 1981). Committed individuals have the type of cognitive appraisal that provides a general sense of purpose, which allows them to identify with events, things, and persons in their relevant environment and find meaning in them (Kobasa, Maddi, & Kahn, 1982). Committed individuals do not easily buckle under pressure due to investments made to self and the environment. Nursing graduate students generally project a certain level of commitment as they reengage in the academic process, again placing themselves into the vulnerable position of student learner.
Control

levels after employees/managers participated in stress-coping and hardiness-promoting activities. Additionally, Maddi and Rowe reported sustained increases in hardiness scores over an extended period (624 months) when attendees were exposed to periodic training and that effects of stress tend to be mediated among high hardy individuals. Consequently, the faculty in the UTA Nursing Administration Program determined to incorporate elements of hardiness throughout the program of study. Topics that are believed to meet AACN core competencies and promote hardiness include (but are not limited to) communication, conflict resolution, stress management, group dynamics/team building, change agent, evidenced-based decision making, and influence of the political environment. Inclusion of these topics were intended not only to increase hardiness, but to lay a foundation for future ability of each student to effectively cope with the ever-changing health-care environment and perhaps contribute toward a healthy work force.
The Study

Control is a tendency to feel and act as if one can exert influence rather than passivity when faced with the varied contingencies of life (Kobasa et al., 1982). Attending graduate school associates with several identifiable stressors such as time, energy, and learning or enhancing new knowledge and skills. The hardiness component of control enhances stress resistance, making the unforeseen stressors less overwhelming. With lifes unexpected events, hardy graduate students should be able to exert influence over outcomes rather than remaining passive.
Challenge

This exploratory pilot study examined the hardiness attributes of a select group of nursing administration students from the UTA School of Nursing at both beginning and end of the nursing administration program. In addition to achieving its core competencies, the AACN and AONE (1997) has recommended that continuous efforts be made to survey nurses to identify content and skills needed for programs in nursing administration and to assure continuation of advanced preparation of those involved in indirect care roles such as administration. Thus, follow-up evaluation was incorporated into the study.
DESIGN AND METHODOLOGY

Challenge involves the expectation that life will change and that changes will be stimuli to personal development (Kobasa, Maddi, Puccetti, & Zola, 1985). Challenge defines stressful events as stimulating rather than threatening (Kobasa et al., 1982). With a constantly changing and evolving health-care system, high hardy nursing graduate students will find challenge essential as they actively participate in or consider being an agent of change. Of note are findings from the literature that hardiness can be learned. Judkins and Ingram (2002), Maddi (1987), Rowe (1999), and Teirney and Lavelle (1997) all report an increase in hardiness

Data were collected from a convenience sample of eight nursing administration graduate students. These students entered as a cohort, matriculating through nursing administration courses together. Although the UTA School of Nursing has been graduating nursing administration students since 1984, this was the first evaluation method of this type. Data sought included demographic information and response to hardiness and stress inventions. Using a preposttest format, the questionnaire was administered during the first semester of entry into the Nursing Administration Program. The same questionnaire was then administered as students finished their last class,

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Figure 1. Telephone questionnaire.

approximately 2 years later. In addition, a telephone questionnaire was administered at 612 months after graduation to compare hardiness levels and postgraduation career accomplishments. Participation in all surveys was voluntary.
INSTRUMENTATION

The telephone questionnaire, administered by two graduate students, contained 10 open-ended questions (Figure 1) reflective of the hardiness literature and AACN and AONE (1997) core competencies. To promote accuracy of understanding, participants were asked to describe themselves relative to hardiness subscales of commitment, control, and challenge.
Results

The questionnaire included the 30-item version of the Hardiness Scale (Bartone, Ursano, Wright, & Ingraham, 1989). The Hardiness Scale is a 45-item questionnaire designed to measure dispositional resilience and consists of three subscales: commitment, control, and challenge. Based on a 4-point Likert scale, high numerical values are associated with higher levels of hardiness, and low values are associated with lower levels. The 45-item Hardiness Scale is reported to have an alpha coefficient of .85, and .83 for the 30-item version; subscales range from .56 to .82. Scores are sensitive to measuring change due to the level of stressful events (Bartone et al., 1989). The Perceived Stress Scale consisted of 14 items, measuring the degree to which situations in ones life are appraised as stressful. Perceived Stress Scale items were designed to tap the degree to which respondents find their lives unpredictable, uncontrollable, and overloaded (Cohen, Kamarck, & Mermelstein, 1983). Response is to a 5-point Likert scale, with higher scores indicating higher levels of stress. The average coefficient alpha reliability was .85.

The majority of participants (75%) were older than 42 years. All participants were White women

TABLE 1. Hardiness and Stress Means, Standard Deviations, and Ranges of Scores
Mean Hardiness Scale Pre Composite Commitment Control Challenge Post Composite Commitment Control Challenge SD Range Possible Range

65.8 24.9 23.0 16.6 67.3 25.5 22.8 19.8

4.5 1.1 1.1 2.5 3.2 1.6 2.4 1.8

61 73 23 26 21 25 15 22 61 72 22 27 19 27 17 22

0 90 0 30 0 30 0 30 0 90 0 30 0 30 0 30

Perceived Stress Scale Pre 28.5 Post 32.1

2.8 3.6

24 31 27 39

0 56 0 56

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holding a baccalaureate in nursing. The majority (75%) were married. All except one of the participants were employed full time, with a mean of 13.5 years of nursing experience. Seventy-five percent of the participants had less than 7 years of experience in nursing management. Means, standard deviation, and ranges are used to present levels of hardiness (Table 1). Alpha coefficient

reliabilities were disappointing for both Hardiness Scale and Perceived Stress Scale, so no further quantitative analyses were completed. Hardiness and stress scores ranged in the moderately high category from beginning to end of program. Mean scores for hardiness composite and subscales commitment and challenge improved with essentially no change in control. Mean stress scores increased from pre- to postevaluation.

TABLE 2. Comparison: Selected Core Competencies, Hardiness, and Student Responses

Selected AACN Core Competencies Use advanced analytic, problem solving, and communication skills Hardiness Challenge and control Student Responses I like being in charge, making decisions. Having the MSN placed me above others with equal experience when obtaining a promotion. I am more comfortable and confident. . .at the administrative level. . .can speak the administrative language now and use what Ive learned to research what is needed. . .. (MSN) gave me the tools for evaluating and analyzing aspects of health care. In this world with fast communications, technology, and ever-changing economy, education is ones only weapon at times. Previously avoided change, now I embrace it. I look forward to change which usually means improvement I look forward to change and being challenged If. . .not challenged I feel stagnate. . .as though not giving of my talents as I should. I am now embrace new ideas and changes. Extremely committed to nursing. Highly committed to anything and everything I take part in. Electives in other disciplines. . .knowledge crucial in developing multidisciplinary patient care teams. . . crucial in quality patient care. Need to be in control in order to make a difference but dont feel a need to be controlling. (MSN) showed me how to understand administrative roles. . . to effectively support nursing and commitment to quality patient care. Learning is fun, enriches your life, and keeps you up-to-date. . .. (Learning) is needed to stay on top of things. Presently pursuing additional major in MBA or health care administration. I involve myself in new things to keep interested. I feel I make a difference daily by influencing others. More of a leader now. . .. Able to articulate what I want accomplished. Able to direct and have influence in all I participates in. Better able to control things and lead others. (MSN) helped me gain confidence. Place influence on all decisions (in the nursing dept) and desire autonomy. Committed to profession and staff. Leadership skills and ability to lead and direct others is stronger. Strongly committed to things I feel are worthwhile and will improve the world. . .. (MSN) offered me the peripheral vision that was missing in order. . . to create my own vision for nursing, to understand change. Gained an understanding of the organization and everyday operation of health care. . .. Gained abilities in business aspects. . .New knowledge in budgeting and financial aspects. (Graduate degree) gave me the financial insight to sit. . .at the administrative team table. . .to understand clinical and financial site of health care. Important thing. . .able to obtain additional resources and utilize them.

Embrace change and manage it effectively

Challenge

Facilitate collaborative relationships Assume risk-taking behavior that promotes quality patient care

Commitment Commitment and control

Use of team building strategies that create partnerships

Control

Develop and articulate a vision for nursing practice

Commitment and control

Make sound decisions that value parsimony. . .in use of resources

Control

Demonstrate creative problem solving

Challenge and control

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In this sample, the telephone survey seemed a more suitable or trustworthy method of capturing hardiness data. All participants reported a masters degree as being required or preferred for their current position; all were in a more advanced position exiting the program than upon entering. Autonomy, leadership, confidence, challenge, and change were consistent concepts provided throughout the answers of the participants. These concepts are closely related to concepts with hardiness and AACN and AONE (1997) core competencies. Comparisons of responses are presented in Table 2. When asked to describe themselves in terms of commitment, participants responded with, bI involve myself in decision making process rather than just being the recipientQ and bI feel highly committed to anything and everything I take part in.Q Related to control, respondents stated, bI am more of a leader now rather than just assisting the teamQ and bI feel the need to be in control in order to make a difference but do not feel the need to be controlling.Q Challenge was expressed as participants stated a desire for autonomy and to be a change agent through bI enjoy being challengedQ and bI previously avoided change, now I embrace it.Q When asked about lifelong learning, participants felt it was essential for growth and development and in managing todays health-care system. They believed that lifelong learning is bessential in keeping up with the changing environment in all aspectsQ and bto stay on top of things.Q When asked what specific information was gained throughout the program that benefited them the most, answers included organizational structure, financial and budgeting aspects, resource utilization, leadership skills, and policymaking. One expressed a newfound ability to create a vision for nursing and perform at an optimal level in an administrative nursing role.
Discussion

In this cohort of nursing administration graduate students, participants perceived themselves as possessing moderately high levels of hardiness, whereas mean scores did reflect some level of increased hardiness from beginning to end of program. Although reliability scores were below acceptable levels, positive changes in hardiness mean scores were verified by qualitative findings, which revealed important changes in skills or behavior related to all three elements of hardiness. Embracing and finding change stimulating demonstrated challenge; the emphasis placed on

leadership and lifelong learning was revealed in commitment; desires for autonomy and influence reflected control. These behaviors are sought among those hiring todays health-care leaders and deemed essential to creating positive work place cultures for staff retention (Kerfoot, 2000; Kleinman, 2004; Manion, 2004). The tendency of these nursing administration majors toward hardiness allows for the integration and effective appraisal of highly incongruent events by fostering openness and flexibility (Kobasa et al., 1982). Hardiness could become a key disposition in health care. It was also evident through the interviews that participants felt they left the nursing administration program equipped with tools to guide and direct health-care units or organizations and that high hardiness may be a contributor toward success in the workplace. Without doubt, these are desirable traits for individuals who are or will be administrating in rapidly changing health-care environments. Bevis (1989), who relates that the value of learning is personal, private, and often secret both from the learner and the teacher, stated, bIt often does not emerge as valuable until something triggers it, and then it pops into awarenessQ (p. 301). By their own admission, these graduates believe a masters program in nursing administration program prepares nurses to meet the constantly changing and evolving challenges of the health-care system. An increase in stress scores among this group of students is inconsistent with previous findings among nurses (Judkins, 2004; Judkins & Ingram, 2002; Patton & Goldberg, 1999; Rowe, 1999). These authors found significant inverse relationships between hardiness and stress (i.e., the higher the hardiness, the lower the stress). Further, when coupled with the low reliability findings, one must question appropriateness of the Perceived Stress Scale to accurately capture levels of stress among graduate nursing students particularly when facing small sample sizes. In the future, other stress measures for use among nurses and students should be explored.
Implications for Practice

Increasing hardiness among future nurse manager/ administrators may reap multifaceted rewards to the health-care industry. In 2001, Judkins found that high hardy nurse managers reported higher problem-focused coping skills and lower levels of stress and than those low hardy. With links of nurse manager hardiness to employee job satisfaction,

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productivity, and organization commitment (Larrabee et al., 2003; McNeese-Smith, 1995), promoting hardiness among future nurse managers/administrators may decrease burnout among staff (Rowe, 1998), improve job satisfaction (McGoldrick, Menshner, & Pollock, 2001), improve retention (Kerfoot, 2000), and improve patient outcomes (Shullanberger, 2000). Each of these elements is directly related to healthcare costs and improving bottomline orientation for any agency. Understanding relationships between hardiness and stress could prove beneficial to nursing faculty who prepare graduates for managerial roles. Patton and Goldenberg (1999) found levels of stress to be less among high hardy registered nurse students. Therefore, incorporating hardiness development into graduate and undergraduate nursing programs and even business or health-care administration programs may positively impact levels of hardiness among students. Further, using a concept such as hardiness in evaluating program outcomes may be useful in the ongoing quest for both formative and summative evaluation processes in education.
Recommendations for Future

of the Hardiness Scale or other hardiness measures may improve reliability issues among small sample sizes. Lastly, as this study has demonstrated, quantitative measures are one method of capturing information, but when coupled with a postgraduation interview, a more complete picture of program evaluation may be obtained. It is our belief that interview outcomes should continue to be an essential part of the evaluation process with results used not only for accreditation purposes, but also for program development and enrichment.
Conclusion

Recommendations for further research include replication of the study among similar groups, but utilizing other stress measures better suited to nurse populations. In addition, a longer version (45 items)

Systematic program evaluation is a vital component of contemporary educational systems, not only expected but demanded by all stakeholders in the educational process (Bevil, 1991). The requirement for evaluation presents nurse educators with a challenge greater than implementation of new programs. The enormity of the challenge is to define essential components of nurse education in a context of quality (Cowman, 1996). Use of hardiness as a guiding construct may prove useful to nursing administration faculty in developing and refining a quality program. Further, hardiness promotion during programs of study may assist students and graduates to achieve higher levels of problem-focused coping (Judkins, 2001) while helping them navigate successfully through stressful situations in health care.

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