Turnover of newly licensed registered nurses (NLRNs) results in billions of dollars in lost revenue for health care organizations nationwide (Kovner, Brewer, Fatehi & Jun, 2014). Nursing turnover, defined as nurses leaving or transferring positions for voluntary and involuntary reasons, has increased in NLRNs. Turnover in the first two years of practice is 17% to 33% (Kovner, Brewer, Fatehi & Jun, 2014). Evidence supports several factors contributing to turnover including stress (Casey, Fink, Krugman & Propst, 2004) and the phenomenon of transition shock. Transition shock occurs when NLRNs experience feelings of “anxiety, insecurity, inadequacy and instability” during the first year of practice (Duchscher, 2009). Furthermore, a lack of support (Suzuki, Kanoya, Katsuki & Sato, 2006, Beecroft, Santner, Lacy, Kunzman, Dorey 2008, Bowles & Candela, 2005), belonging (Hayes, O'Brien-Pallas, Duffield, Shamian, Buchanan, Hughes, Laschinger, North & Stone, 2006) and difficulties with communication (Flicek, 2012) impact NLRN during the first year of practice. Having a better understanding of interpersonal communication competence (ICC) levels and how nurses deal with stress through their attachment styles may have implications for nursing turnover. The purpose of this study is to describe interpersonal communication competence levels and attachment styles in pre-licensure nurses before entering the profession of nursing.
Methods
This descriptive study consisted of a convenience sample of baccalaureate nursing students from a university in the Midwestern United States. Students enrolled in a final semester nursing course were identified and the inclusion criteria included: 1) a baccalaureate nursing student 2) in a final semester nursing course 3) Graduating in December 2018. Study approval was obtained through the institutional review board (IRB)and the school of nursing research approval committee.
A demographic survey was used to collect the following descriptive information about the participants: age range, race, gender, educational progression track (traditional or accelerated), prior healthcare experience, and how many years' experience.
Interpersonal communication competence levels were measured using the Interpersonal Communication Competence Scale (ICCS) in pre-licensure nurses. The ICCS is a unidimensional measure with ten subscales consisting of self-disclosure, empathy, social relaxation, assertiveness, altercentrism, interaction management, expressiveness, supportiveness, immediacy, and environmental control. The survey is a 30-item self or other report scale with an overall Cronbach Alpha for internal consistency of .86 (Rubin & Martin, 1994).
The Experiences in Close Relationships-Short Form Scale (ECR-S) was used to measure attachment styles in participants. The ECR-S is a 12 item Likert Scale identifying Anxiety or Avoidance behaviors in relationships. The ECR-S is a shortened version of Experiences in Close Relationships (ECR) scale developed by Brennan et al. in 1998 and based on the length and applicability in all social settings is the preferred scale. The scale has test/retest reliability, internal consistency and constructs validity compared to original ECR scale with the Anxiety scale coefficient alpha of .77-.86 and the Avoidance subscale .78-.88 (Wei, Russell, Mallinckrodt, Vogel, 1994).
Data Analysis
The data was analyzed using SPSS statistical software package 25. Descriptive statistics were obtained for all demographic data and the ICCS. The ECR-S scale was recoded into an Anxiety and Avoidance subscales. Summation scores were obtained for the subscales to determine secure versus insecure attachment styles. Cronbach's alpha was obtained for the ICCS and ECR-S subscales. Finally, Spearman Correlation was run on ICCS and each ECR-S subscale.
Surveys were distributed to 91 final semester pre-licensure, baccalaureate nursing students with a response rate of 14% (n=13). One of the participants only completed demographic data and was only included in this portion of the analysis.
Results
The participants were predominately female (n=11,85%), white (n=12, 92%) with (n=4, 31%) ranging in age from 18-22 and (n=9, 69%) from 23-30. The majority (n=10, 77%) were in a traditional educational track (4 years) versus an accelerated track. Of the 13 participants (n=5, 39%) had prior health care experience and of those with experience, (n=3, 60%) had less than two years and the others had between 2-4 years’ experience.
The ICCS data was analyzed using frequency distributions for (n=12) participants. Total ICCS scores were analyzed. The ICCS ranges from 95 with low perceived ICC levels to 125 with high perceived ICC. Of the (n=12) participants the mean was 110.58, SD 6.48 with a range between 100-121. Cronbach alpha for the ICCS was .643. It is noted by Rubin and Martin (1994) that the internal consistency estimates on the ICCS may be lower than other communication scales due to the measure having less items than other scales resulting in lower alphas and more than one construct dimension.
The ECR-S was recoded into two scales based on insecure attachment style traits of anxiety and avoidance. Scores in each scale were summed for each participant to determine secure versus insecure attachment styles in (n=12) participants. The minimum score for each scale is 7 and maximum is 42. Participants who score high on either scale are assumed to have an insecure adult attachment orientation and in contrast those with low levels are viewed as having secure adult attachment orientation. See Table 1. Cronbach Alpha for Anxiety subscale was .818 and for the Avoidance subscale was .766.
Table 1 Secure vs Insecure in Anxiety and Avoidance Scale
|
Score |
Anxiety |
Avoidance |
|
Secure <19 |
n=2 17% |
n=6 50% |
|
Neutral 19-29 |
n=6 50% |
n=5 42% |
|
Insecure >30 |
n=4 33% |
n=1 8% |
As seen in Table 1 for anxiety attachment orientation (n=2,17%) of the participants were secure and (n=4, 33%) were insecure. The other (n=6, 50%) fell into a neutral orientation. For the avoidance attachment orientation (n=6, 50%) of the participants were secure and (n=1, 8%) were insecure. The other (n=5, 42%) fell into a neutral orientation. Spearman correlations were analyzed to determine if there was a correlation between ICC and adult attachment styles in pre-licensure nurses. For the ECR-S anxiety subscale there was a positive correlation between ICC and anxious attachment styles p=.752, alpha .005. There was no correlation between ICC and avoidance attachment styles.
Discussion
Prior research in the field of attachment styles supports that 50% of individuals have secure attachment styles, 30% anxious-ambivalent and 19% avoidant (Hazen & Shaver, 1990). Only 17% of the participants in the anxiety orientation were highly secure which does not support the literature. However, 50% of the participants were neutral in their responses. This could indicate that these participants were unable to determine their beliefs related to anxiety in relationships to others in social settings. The data did support the evidence that 33% of the participants were of insecure anxiety orientation. Individuals with insecure attachment anxiety are defined by Wei et. al. (2007) as those with “fear of interpersonal rejection or abandonment, an excessive need for approval from others and distress when one’s partner is unavailable or unresponsive.” Therefore, it is worth noting that in this sample of pre-licensure nurses the outcomes related to insecure attachment styles were congruent with the evidence and the sample size did not preclude these results.
Interpersonal communication competence is defined by Rubin & Martin (1994) as “an impression or judgment formed about a person’s ability to manage interpersonal relationships in communication settings.” Overall, the ICC in pre-licensure nurses was normally distributed with the majority of the sample having an average ICC level. This supports that both the time spent in an interpersonal setting like clinical experiences or prior healthcare work experience has provided pre-licensure nurses with a foundation of ICC. A longitudinal study would be necessary to fully understand the change in ICC over time.
Anders & Tucker (2000) reported a link between insecure attachment styles and ICC. This study supports this in the correlations drawn between insecure anxious attachment styles and ICC. Anders & Tucker (2000) have found that individuals with an insecure attachment orientation are unable to develop a “broad and satisfying social support networks.” Having an insecure attachment orientation could impact the support needed for NLRNs in the first year of practice . A longitudinal study looking at new nurses during the first year of practice is necessary to draw such conclusions.
Conclusion
For the purpose of this study, the ICC and adult attachment styles of pre-licensure nurses were described, and correlations were drawn among some of the constructs. However, limitations of the study did exist which supports the need for additional research with a larger sample. In addition, a more heterogeneous sample is necessary to generalize the results of the study.
Based on the results of this descriptive pilot study, follow up research is necessary for a better understanding of the attachment styles of new nurses entering the profession of nursing. This knowledge would further support if interpersonal characteristics in nurses such as communication competence and attachment styles are impacting NLRN turnover in the first two years of practice.
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