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Smith, Mary Colette, Ed. _

implications of Research for Nursing Practice,Education, and PoIicymaking. Proceedings of theAnnual SCCEN Research Conference (2nd, Birmingham,Alabama, December 3-4, 1982)- _

Alabama Univ., Birmingham. School of Nursing.;Southern Council on Collegiate Education for Nursing,Atlanta, GA.83114p.Southern Regional Education Board, 1340 SpringStreet, NW, Atlanta, GA 30309 ($5.00).Collected Works Conference Proceedings (021) --Viewpoints (120) Reports Research/Technical(143)

MF01/PC05 Plus Postage.Higher Education; Nurses; *Nursing; *NursingEducation; *Policy Formation; *Research; *Research

NeedS

ABSTRACTProceedings are presented from a research conference

to promote nursing research as a basis for policymaking in nursing

practice, education, and health care services. The keynote address,by Patricia Jones, describes issues in health care financing in the

1980t and urges researchers to provide the kind of data andguidelines needed to support professional nursing services. Thesecond paper, by Ora L. Strickland, names establishment of anAcceptable and stable economic bate for the provision of nursingServices as the most important public policy issue facing nursing and

gives pointers on collaborative research as one'approach tocontributing to the knowledge base. The 'third presentation, byJeanette Lancaster, eichorts nurse researchers to affect policy byidentifying critical study areas and initiating research. Abstracts

follow of 32 studies, with almost equal numbers focusing on clinical

practice, education, and the delivery -of health care areas ; the

majority have implications in all three areas. They generallyunderscore the interrelatedness of research, education, and tbrvice.

Specific topics_ include nurse-patient negotiationt, predictivefactors of supply and salaries of nurse practitioners, cultural

determinantt of health and seIf-care, job satiSfCtion, skills of

nurse administrators,'continuing education, nursing gestalt, nurses'

decision making, and factors related to student success in cpmpIeting

a baccalaureate nursing education. (YLB)

y'IV**********************************************************************Reproductions supplied by EDRS 're the best that can be made

from the original document.************":***************N******************************************

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LLAMPLICATIONS OF RESEARCH FORNURSING PRACTICE EDUCATION,AND POLICYMAKING

Proceedings of theSecond Annual SCCEN Research Conference

December 3-4, 1982Birmingham, Alabama

Edited by Mary Colette Smith. DEPARTMENT OE EDUCATION

NATIONAL INSTITUTE OF EDUCATIONEDI/CA I IONAI 131 SCEURCES INFORMATION

CENTER IERICIThis dilEurnerii hits been reproduced as

eived horn ILIP .person or ordEniwition(Mgr! ratogMinor Endow., Eidve tesdi mode to improvereurorliii riot. riodlils

Points id view or ripindire. stated in ilss docrs01,11 14, nII nor essdrily represent officio! NIEpi ...di. di or poid_y

"FERM[SSION'TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY

(.6:--1/U

TO THE EDUCATIONALRESGURCESINFORMATION CENTER (ERIC)."

Southern Council on Collegiate Education for Nursingand

The University of Alabama in BirminghamSchool of Nursing

1340 Spring Street, N.W.Atlanta, Georgia 30309

1983$5.00

2

TABLE OF CONTENTS

Page

FOREWORD ix

IMPLICATIONS OF RESEARCH FOR 1

NURSING PRACTICE; EDUCATION,ANDPOLICYMAKING- Patricia Jones

DEVELOPING AND APPLYING POLICY-ORIENTED RESEARCH FOR NURSINGPRACTICE AND EDUCATIONOra L. Strickland

THE PROCESS, PERILS; AND JOYSOF COLLABORATIVE RESEARCHJeanette Lancaster

Abstracts of Studies

A DESCRIPTION OF NEGOTIATIONBEHAVIORS IN NURSE-PATIENTVERBAL ENCOUNTERS IN HOSPITALS-Jan Biasini

CHILDHOOD SOCIALIZATION FORVIGOROUS EXERCISE HABITS=Kathleen C. Brown

AN ECONOMETRIC MODEL -- PREDICTIVEFACTORS OF SUPPLY AND SALARIESOF NURSE PRACTITIONERS- Joan Farrell Brownie

MILK YIELD ASSESSMENT IN ASSISTING:MOTHERS DURING THE INITIATIONOF LACTATION=Ellen B. Buckner

iii

17

21

23

25

28

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CULTURAL DETERMINANTS OFHEALTH AND SELF-CARE IN URBANAMERICA- Jacqueline Clinton

34

A COMPARISON OF ATTITUDES, WORKING 36CONDITIONS, AND NURSING PRACTICEOF FOREIGN NURSE GRADUATES ANDU.S. NURSE GRADUATES IN FLORIDA- Marie E. Cowart

COMPARISON OF JOB SATISFACTIONBETWEEN NURSES PRACTICINGIN PRIMARY AND TEAM NURSINGSETTINGS-Jimmie G. Davis

BACCALAUREATE GRADUATES'SUCCESS ON STATE BOARDS:A PREDICTION STUDY-Mary,E. Duffy, Mary A. Lubno,Grace A. Willard

INVESTING IN NURSING: DEVELOP=N1ENT OF AN INTENSITY -OF -NEEDRESOURCE ALLOCATION TECHNIQUE-Denise E. Edwards-Weiss, SteVe A. Freed-man;Patricia M. Pierce

rHE OCCURRENCE AND TREA TMENTDF AUDITORY HALLUCINATION-William E. Field, Jr.

CHE DRUCILLA MANTLE STUDYDF THE CURRICULUM IMPLInATIONSOF INTENDED WORK=RELATED BEHAVIORSAMONG- NURSE ADMINISTRATORSIN SOUTHEASTERN UNITED STATESHOSPITALS-Beverly M. Henry

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iv

39

41.

46

48

50

AQUANTITATIVE DETERMINATION OF /53PROGRAM IMPACT ON REGISTEREDN_URSE SiUDENTS- Sarnuel,T. Hughes, Dorothy J.Turpin;

John C. Reed

COLLABORATION: A BASIS FORPOLICYMAKING- Kathleen Mikan and Kathryn Barchard

PROFESSIONAL DEVELOPMENTAND CONTINUED LEARNING- Virginia Layng Millonig

DEPRESSION AS AN EXPLANATIONFOR DECREASED SUBJECTIVETIME IN THE ELDERLY- Margaret A. Newman and

Judith K Gaudiano

HEALTH STATUS OF CHILDRENIN RURAL AREAS OF THE DOMINICANREPUBLIC: POLICY IMPLICATIONSFOR NURSING PRACTICE ANDNURSING EDUCATION INTHIRD WORLD COUNTRIES-Francine E. Nichols

DOES CONTINUING EDUCATIONIMPROVE NURSES' CLINICAL BEHAVIOR?- Sandra K. Oliver

ACADEMIC CREDENTIALS ACCEPTEDFOR TEACHING IN BACCALAUREATESCHOOLS OF NURSING, MPH and MSNWilliam Larry: O'Neal,Cheryl M. Porter, Edna G. Treuting

THE EFFECT OF_ A CITIZENS' NURSINGTASK FORCE GROUP ON NURSINGPRACTICE_AND COMMUNITY PLANNINGFOR HEALTH CARE-JoAnn H. Patray

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58

61

65

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71

76

.

THE UTILIZATION OF DERLVIATOGLYPHICSIN THE ASSESSMENT OF LEARNINGDISABILITIES AND HYPERACTIVITYPatricia A. Payne

DISCOVERY OF_NURSIN_G_GESTALT INCRITICAL CARE NURSING: THEIMPORTANCE OF THE GRAYGORILLA SYNDROME=Sue: HolIand-Pylet

EFFECTS OF INTERMITTENT MANDA-TORY STIMULATION ON APNEA ANDTcPO. IN PREMATURE INFANTS-Patricia Boudolf Rausch, Jeffg,ey

M. Majewski, Gene Cranston Anderson

A VALIDATION STUDY OF COREITEMS' FOR A GRADUATE MATERNAL-INFANT NURSING CURRICULUM-Rene Reeb

SECONDARY ANALYSIS OF DATAON NURSES' ETHICAL JUDGMENTSMEASURED BY TYPE OF BASICEDUCATION AND CLINICAL UNIT

"-Barbara J. Reid and Burge

79

81

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85

THE RELATIONSHIP BETWEEN SELECTED 88ENVIRONMENTAL VARIABLES AND THEGROWTH OR DECLINE OF BACCA-LAUREATE, ASSOCIATE DEGREE,DIPLOMA,MASTER'S AND DOCTORAL PROGRAMS INNURSING BETWEEN 1960 and 1978-Mary Ann RoSe

RELATIONSHIP OF LIFE STRESSTO DYSFUNCTIONAL UTERINEBLEEDING IN WOMEN OFCHILDBEARING AGE-Anti M. Rosenow and James Geyer

VI

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91

THE ROLE OF FACULTY PRACTICEIN NURSING ACADEMIA- Deidra Henley Sanders, KathleenBellinger, Jacqueline Reid

THE RELATIONSHIP BETWEEN SELF=CONCEPT AND SOCIAL ACTIVITYOF LEUKEMIC AND HEALTHY SCHOOL=AGE CHILDREN- Joanne B. Scungio

BACCALAUREATE NURSING PROGRAMEVALUATION BY ALUMNI AND-ALUMNI-EVALUATION BY THEIR EMPLOYERS.UTILIZING SURVEY QUESTIONNAIRES:POLICY IMPLICATIONS_Virginia R. Stcozier, Lois M. Knowles,Jennet M. Wil6on, Tanya L. Bobo,Diane Es-_), Greene

DIABETIC COMPLIANCE BEHAVIORSAND THEIR RELATIONSHIP TO SELECTEDVARIABLES- Ann E. Smith

THE IDENTIFICATION OF SELECTED_ _STUDENT FACTORS; PRIOR TO ADMISSIONINTO THE.,NURSING SEQUENCE; INSUCCESSFUL COMPLETION OF ABACCALAUREATE NURSING PROGRAM- Patricia E. Thompson

PERCEIVED COMPETENCY BEHAVIORSFOR THE CLINICAL NURSE SPECIALISTROLE- Mary Ellen Wyers, Susan K. Grove,Nancy L. Ackley

VII

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FOREWORD

The second annual research conference of the South-ern Council Oti Collegiate Education for Nursing(SCCEN) aimed to promote nursing research as a basisfor policymaking in nursing practice; education; andhealth care services. Keynoter Patricia Jones describedissues in health -care financing in the 80s and urgedresearchers to provide the kind of data and _guidelinesneeded . to support professional nursing services. OtherspeakerS included_ Ora I-. Strickland; who exhorted nurseresedetheit to affect policy by identifying critical areasthat need Study and initiating.research studies dealingwith cilietiotis--- surrounding_ these critical issues.Jeanette Lancaster noted that the most important publicpolicy issue facing the profession of nursing is theestablishment of an acceptable and stable economic baSefar th6 provision of nursing services; and gaVe pointersor collaborative 'research as one'.approach to contrib-:uting to the knowledge base;

Researchers reported on 32 studies; with alnioStequal numbers focusing on clinical practice, ethcation;and the delivery of health care services; the majorityhave implications in all three areas.; As a whole; theyunderscored the interrelatedness of research; -edUcatibri;and service.

The conference; co-sponsored by the SCh.361 Of Nurs-:

ing, University of. Alabama in Birmingham; WAS _heldDecember 3-4; 1982, in Birmingham. MemberS of theResearch Committee; SCCEN, Who plan the catiferehceSare: William E. Field; 5r;; University of Teica at Austin;Mary Colette Smith; University of Alabamajn Birming7ham; Margaret T; Beard; Texas woman's thiiVertity; andOra L. Strickland; University of Maryland; Baltimore;

Audrey F. SpectorExecutiveDirectorSouthern council on Collegiate

Education for Nursing

ix

IMPLICATIONS OF RESEARCH FOR NURSINGPRACTICE; EDUCATION; AND POLICYMAKING

Patricia Jones; RN, MSNDirector of the Washington Offide

Deputy Wcutive DirectorDivision of Legislative & GOvernMent Affairs

American Nurses' Association,

I have deliberately chosen to continue the intro-ductory theme of this conte--ence: "Health Care Financ-ing in the 1980s."

The most important public polity issue confrontingthe profession of nursing is the etablishment of an_ac-ceptable and stable economic base for the proxisionofnursing services. Quality of care, issues of nursing ed-7

ucation, entry leVel; standards of practice; and nursingresearch can. got and Will not be addressed until the pro-fession has firmly .established with the public that pro-fessional nursing services are needed, valuable; arid; thus;have a specific monetary value.

Similarly thed issues are all economically based:

Quality of cate=at what cost to the patient andiortaxpayer?

*What are the cost- effective contributions or impli-cations of nursing research?

How do we educate economically?

If nursing services are not valued, then the need forstandards of practice issuperfluous;.

CoSt containment legislation .failed during the pre=viouS. Administration; and the "voluntary effort" by hoSzpitalt was put in place only to fail also in terms of hold=ing doWri inflation in htalth care costs. At the root ofexcessive costs is the provider-reimbursement system.

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. It is widely recognized that the current retrospectivemethod of reimbursing health care proViderS is a primecontributor to rapidly escalating health care costs. The

cost pass-through provisions of the retrospective_ re-imbursement system do nor, in the -opinion of many ex-perts; provide any incentive for health care providers toOffer their services at the lowest possible cost: conse-quently, provider costs--and prices, of services--continueto increase despite an overall lesSening of inflationarypressures in the general economy.

As a result of rising health care tbSt8, considerablesupport has evolved for changing the reimbursementsystem frorn a retrospective to a prospective method asa means of forcing health care providers to_ become morecost conscious: There have been prbpOSed, and in somecanes adopted at the state leVel, many different vari-ations of rate control systems-;- virviallk all of themutilize the prospective method of reimbursement as theircenterpiece: The concept is Simple: the rate (price)ofreimbursement for health __care _services is pradeterzmined; and providers are obligated to offer their servicesat the given rate. Cost consciousness is developedbecause those providesS whO cannot keep their operatingcosts (including "profit") below the reimbursement rateare punished economically. Furthermore; prospectivereimbursement inserts a leVel of predictability in thecosting out of health care services, which is beneficial-topayers as well as providers.

In an effort to control federal Medicare spending,Congress added several reimbursement-related provi-sions to the recently enacted Tax Equity and FiscalResponsibility Act (TEFRA). Although those provisionspertain to Medicare reimbursements; because of themagnitude of federal ekpend,itures in this area, they arebound to have a ripple 'effect which can ,significantly 4

alter thee manner in which health care services are de-livered and providers are reimbursed;

While TEFRA contains many reimbursement-relatedprovisions, four provisions are particularly significant.

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Two rprovisions establish reimblirsement limits for athree-year period of time for hospitals and skilled nurs-ing facilities. Another provision mandates the establish-ment of a prospective reimbursement system- willapply to hospitals, skilled nursing 'facilities; and othernon-institutional providers. A fourth, provision providesintentives for state legislatures to enact comprehen4ive,state-administered,;xate control systems;

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Section.g23 E&imbursement Limits-The current Section 223 Medicre limitations have-

been expanded by TEFRA to include Sncillary:COSts,applied on a cost per -case basis (as opposed to the cur-rent routine per=diern basis), and adjusted, for case mix;This provision will be implemented in the following,man-ner: hospitals will be grouped according to similar olaar-acteristict and, based upon -hikoricai cost datbL, thegroup's ay.eragt cost- per -case- will be computed for abase year The case year cost-per-case will then beadjusted for inflation and area wage differentials in amanner similar to those that are currently being util4ed.

"Ohce the adjusted cost- per -case is determined for thehospitals in the group, a reimbursement `cap of ,120 per-cent of the group average will be established for eachhospital's fiscal year commencing on or after October 1,1982. The group reimbursement cap mill then be reducedto 115 percent and 110 percent in each of the followingyears. Although this, and other, reimbursement pro-visions apply to hospitals over 50 beds, there are ,somecircumstances_ in which "appropriate exemptions, ex-cel5tions, and adjustments" may,..4ae made.

Target Rate of Increase in Reimbursement Rate

Although all hospitals are caered by he Section 223reimbursement limitS, TEFRA also establishes-a "target"rate of increase in the reimbursement rate for individual-hospitals. The target serves as an incentive for hospitalsto hold their per-case-costs in line with acceptable in-creases in the reimbursement rate. For example, an

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individual hospital's cost-per-case will be computed andadjusted by the percentage increase in the Health CareFinancing Administration's ,(HCFA) "hospital marketbasket," which is estimated to be 7;9 percent. This willthen be increased by one percent; A hospital's "target"fiscal year 1982 thus will be 108;9 percent of its currentcost-per-casej Furthermore) if a hospital can keep itsper-case-costs below this target, the hospital will re-ceive 50 percent of the savings (and HCFA will save theother 0 percent). If a. hospital's costs exceed the targetin the next two fiscal years, it will be reimbursed cifly25 percent of its costs above the target. In the third'yearthe hospital would have to absorb all of the cost overages:

, State Rate Control kicentive

TEFRA contairit a provision .which would exempt allof the hospitals in the state from Medicare reimburse-ment requirements if the state would enact a compre-hensive rate control system; To receive the Medicarereimbursement waiver, the state rate control system,must, apply to at least 75 percent of all the state's hos-pital inpatient-revenues and it must apply to "substan-tially" all non-federal hospitals; Additionally, the statesystem must both provide equitable treatment for pay-ers, hospital employees and patients, and the state mustdemonstrate that the reimbursement system would resultin a net MediCare saving over a three-year period oftime.

If the hospital's actual cost is lower ,than its targetamount) its reimbursement for inpatient operating costswill be whichever of_the following is least: the inpatientoperating cost-per"=-Ase plus 50 percent of the differencebetween that amount and the applicable target amount;the inpatient operating cost-per-case' plus 5 percent ofthe target amount; or, t hospital's allowable cost-vr-case under the case mix adjusted limits (yet to be deter-mined); Federal Register Vol. 47, NO:190, September 30,1982..

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Prospective Medicare Reimbursement

The Act mandates that the Secretary of Health andHuman Services, specifically, the Health Care .FinancingAdministration (HCFA), in conjunction with Congres-sional committees, prepare for introducing a prospectivereimbursement system for Medicare reimbursements toboth hospitals and skilled nursing facilities and othernon-institutional providers.

Political Aspects

The concept of retrospective payment has been polit-ically popular with both Republicans and Democrats andhas been included in all major competition-based legis=lation. In the early days of Medicare; prospective pay-

t was rejected in order to gain support of the hos-pit 1 industry and the American Medical Association;The American Nurses' Association was the only groupthat supported Medicare in its early legislative days;When Medicare finally _passed; nursing was left waitingat the altar while the 'groom walked off with the AMAand American Hospital Association; Both groups, AMA*d AHA; are still ambivalent in their approach to pros-pective payment; with physicians arguing it will inter-fere with the physician's right to admit patients and thehospitals arguing (correctly so) that the system of pros-pective payment passed under: 'TEFRA only focuses onthe one cost componentthe tx4ital. 4%

The Reagan Administration views prospective pay-ment as one of many ways, long-range in nature, ofwhittling down the size of Medicare. Therefore, it-doesnot assign any great significance to prospective paymentas such, and prefers to push for immediate cost savingsby increasing copayments and deductiblesi instituting avoucher system; or establishing a means test - -all ofwhich increase the burden to the elderly and disabled.

HCFA is preparing the specifications for prospectivepayment and has adopted, in part, the system utilized by

-the NeW Jersey State Rate Setting Commissiorr.particular._ the rnethOd for classifying_ costs-per-caseknown as Diagnostic Related Groupings (DRGs).

HCFA at this_time appears inflexible in what it Willbe proposing to Congress. Congress, on the other hand,is concerned that the prospective system proposed byHCFA may contribute to a decrease in quality patientcare. Once again) this concern is biparti5an on the Houseside and that probably will be echoed on the Senate side;

Where does this leave nursing? Last spring the HouseEnergy and Commerce Subcommittee on Health heldhearings on the voluntary effort, i.e., cost containment.The voluntary effort had not worked, and hospital costshad continued to_soar. During the hearings, AHA and theFederation of American Hospitals _both alluded to amajor source of high costs: nursing services and otherlabor7related costs.

Historically, the American Nurses' Association hasconsistently supported efforts by the federal governmentand other third-party payers to curb the rapid escalationof costs that have plagued the economy in general andthe health care 'industry specifically. In the past; ANAhas supported those cost containment measures that pro -tect the consumer's access to quality health care andservices in a timely fashion, and that protect the,publichealth care facilitieswhich provide the majority ofcare to the most vulnerable populations, the aged andthe poor--from undue financial hardship. Additionally;ANA has supported those cost containment measuresthat include a rational plan to maintain sufficient full-time-equivalent_professional,employees with appropriatecompensation; so that quality of care and services can beassured;

More than 60 percent of employed registered nurseswork in the nation's hospitals. Except where waivered;services of a registered nurse are available to patientsand families 24 hours a day, 7 days a week, 52 weeks ayear; The availability of nursing services in a hospital is

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the major reason why patients are admitted; If the pa-tient did not need support and assistance with activitiesof daily living, if the patient and family did not requireinstruction and counseling with respect to self-caremanagement, if the patient did not need frequent mon-itoring of vital signs and life processes; if the patient didnot need professional intervention to alleviate pain; tocope with loss or disfigurement, to adjust to the impactof emotional or physical g.rises, then the patient wouldnot need to be admitted to the hospital. Treatment ofthe patient's medical problem could occur in the phy-sician's office, in a health maintenance facility; in thepatient's home, or in one of a variety of other com-munity-based facilities. Therefore,-any future system ofMedicare reimbursement to hospitals for care and serv-ices must include recognition of the need for and thecost of the services of professional nurses. Most of youare aware, I am sure, that the . present Medicare re-imbursement system included nursing services along withbed, board, and maintenance costs under the generalrubric of routine operating costs. This accounting sys-tem places nursing services in a highly vulnerable posi-tion and makes them a prime target for the budget-cutting ax.

As new measures to contain costs are planned; ANAremains concerned about the complement of and com-pensation for professional nurses in the nation's hos-pitals. In the past, the wages and benefits paid to healthcare workers have bee^ the target of efforts to controlhealth care costs. With the implementation of the Medi-care caps and certain state 'rate-setting programs, weare beginning to see this happening again and, indeed,have received reports of nurse lay-offs and overnightdisappearance of nurse shortages.- Therefore, we feelstrongly that any payment mechanism must provide safe-guards against this ill-advised method of cost contain-ment. Not only does it place a misguided and unfairburden on health care employees; but it has severeadverse consequences for the quality of care. Any pay-ment mechanism to control health care costs must

encompass standards to ensure that there is no disincentivefor health care employers to provide decent wages andbenefits to employees..

We are certain that without such safeguards, healthcare cost reductions will becorne"the burden of healthcare employees; We have all heard representatives ofthe health care industry _citing the increases in the earn-ings of health care workers as a major contribUting_fac-tbr to rising health care costs. The figures; _which havebeen receiving a disproportionate amount of attention,tell only [Dalt of the story. Health care workers_ areamong the lowest paid workers in any industry. Eventhough their wages-have been increasing at a faster ratethan has been the case in some industries; they only earn88 percent of the average of all wage and salaryworkers. Blamingspirafing health care costs on workerswhose wages average $6.49 an hour this year and $5;84per. hour last year is absurd.

Concurrently; during cost-containment attempts; hos-pitals have decreased the number of nurse administrativepositions; eliminated staff development and on-the-jobtraining programs; and have done away with supportservices; such as transportation and messenger services,and ward clerks. These support services have beenessential in decreasing the non-cosi-effective; non-nursing tasks performed by professional nurses;

In a milieu of limited support, professional nurses arethen required to 'perform a wide variety of tasks nor-mally performed by unlicensed workers. Some hospitals

-- have attempted the reverse, that is, the numbers of pro-fessional staff are reduced and the numbers of support orunlicensed workers are increased. These unlicensed, andsometimes undereaucated, indiVidUals are then requiredto assume responsibilities normally performed by licensed

4._.professionals: In either. case, the hospital requirespatients to sustain a position of extreme jeopardy withrespect to receiving quality, necessary; and timely careand services.

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The elimination or diminution of on-the-job-trainingor staff development programs places the patient in fur-ther jeopardy; as underedutated individuals are calledupon to provide care and services for which they do nothave sufficient baCkground or experience; Furthermore;as new technologies or procedures are added to the pa-7tient'S treatment schedule; the patient is placed in theposition of receiving substandard and potentially hazard-ous care.

Protection from the potentially adverse impact ofcost containment measures on the quality of care andServices provided to patients in hospitals and on the em-ployment and compensation of all professional providers,including nurses, is essential; If the patterns of costcontainment measures that were implemented in the early70s with wage, and price controls were reinstituted; anurse exodus from the nation's hospitals can be pre-dicted, as the hospital will become a particularly un-attractive place for employment of nurses; If nursesleave the hospital this time; they may not return in thefuture.

Some of you may say "Good; What have hospitalsever done for nursing except co-opt the profession?" ButI submit that this is not a decision the profession canmake; Nor is it one that the hospitals can make. It istruly a public decision to determine whether professionalnursing services are needed in hospitals.

Prospective payment for care and services to be pro-vided through a hospital has many appealing features.Basic to this payment mechanism; however, is the pre-determination of how much money each facility -will re-ceive; The Diagnostic Related Groupings (DRGs) havebeen proposed as the main feature for determining, pay-ment to_hospitals under the currently proposed cwt con-tainment measures; Diagnostic Related Groupings arenot a panacea, and are highly problernatit *heti this isthe sole categorization for determination of payment.

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First, when the total number of DRGs is small, thepatients will be unlikely to know the true costs of healthcare services received, since the patients will not knowwhere, within the grouping, their actual diagnosis falls.Cost containment measures that do not provide suf-ficient information about costs to the consumer will notpromote more effective and efficient delivery of careand services. Furthermore, a DRG, that includes a widerange of diagnoses, with varying lengths of stay, maypromote extended stays for some patients or too early adischarge for others.

Second, the DRG mechanism does not adequately re,flect the intensity and variety of necessary support andassistance required by a particular patient and family orby the grouping; The need for support and assistancefrom nursing personnel is an individual determinationthat is influenced by a variety of fattOis, including thepatient's level of knowledge about the diagnosis and theimpact on his or her lifestyle and future capabilities, the ca- \pacity of the patient and family to participate in the \

care- giving process, the presence of disabling conditionsassociated with the aging process, prior incidences ofdisease debilitation or trauma, and the cultural back-ground of the patient/family. Even in some states wheremeasurements of the relative intensity of services havebeen attempted, the result has been a retrospective de:-termination of the costs of services provided but notof the care and services needed by the patient or thegrouping.

Third, use of. the DRG inappropriately assumes thatmedicine and nursing have established proven methods oftreatment for all medical diagnoses and combinations ofdiagnoSeS. The DRG mechanism is insensitive to theamount of time that may be needed to determine theproper treatment approach for an individual when physi-ological imbalance is complex, severe, and unstable; Torelegate theSe indiVidUalS to the "outlier" group is to beblinded to the true costs of care. As length of stay inthe hospital decreases and as more medical and surgical

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treatments are performed outside the hospital, the num-bers of patients who can be described as having complex,severe, and unstable conditions in the hospital will in-crease. The "outlier" group may become more the normthan the exception in future years, and a prospectivepayment mechanism must be able to accommodate thischange.

Fourth; the DRG schema assumes that emergencytreatment and elective treatment require equal amountsof resources; with respect to the use of nursing services,the patient and family need for support and assistancevaries widely with this variable. Additionally, the DRGapproach assumes that individuals within any groupingwith the same diagnosis present themselves for treat-ment under the same conditions. Whether the treatmentthat is required is elective will influence the condition ofthe patient. But, other factors, such as the patient'snutritional status and hydration level, are important de-terminers of response to treatment as well as the use ofresources.

Fifth, because of the use of the number of proceduresin calculating payments, the DRG mechanism favors sur-gical treatment over nonsurgical treatment of a con-dition. Such a bias in payment will do nothing to curtailthe number of surgical procedures performed, and will do,less to encourage research and continued clinical explor-ation for nonsurgical solutions to health probk.ns. I donot wish to suggest, that all surgery is unnecessary, butrather wish to stress that surgical intervention is but oneof a variety of modes of treatment for many conditiOns.To encourage surgical interventions through a paymentmechanism is unwise.

Finally; the DRG mechanism; in and of itself, doesnot provide the essential requirements to prevent skim-ming, dumping, and manipulation of admissions or services. It is assumed that a particular hospital may beable to provide the needed care and services for a par-

, ticular diagnostic°arouping

more cost ,effectively; how-ever, to make the determination that the hospital is not

dumping patients who consume a greater amount of re-sources will be difficult under thiS system and logic;Transfer of such *patients to other facilities will place anunfair burden on the receiving hoSpital; which is morelikely to be a public facility or a community nonprofithospital;

In summary; the DRG thechanitril dOes little to rec-ognize the reality of care and services provided by professional nurses to hospitalized patientS-; or to recognizethe varying needs and conditions of the patients. _Al-though the DRG mechanism may appear as _a manage-able; logical approaCh for payment, the problems citedearlier will diminish any savings or cost control. I be-lieve other classifidation Schema must be developed for'determining the payment to hciSpitals for care and ser-vices rendered; which inClUde the patient's .and family'sneed for support and assistance, as well as the overallcondition of the patient; such classifications already exist.

For example; the DRG system being utilized in NewJersey has recently added a relative intensity of nursing,,measure; which may alleviate some of the problems as-sociated with the reliability and validity of the DRG as ameasure of cost per case.

In addition; we are watching with great interest thedevelopment of the severity of illness index; cUrrentlyunder study at Johns HcipkinS University; as a more ac-curate predictor of costs per case; The patient severityindex used is a matrix_ of seven patient characteristicsmatched with four 'levels of intensity.

Reliance on the proposed DRG mechanism for deter-mining prospective payrheht will divert attention away,from other alternativeS that have real potential_for con-taining the escalation of health care casts Such athditional measures, which are consistent with the generalgoal of prospective payment; include increased corp.,petition among vendors to hospitals; so that the rate ofincrease for supplies and .new or replacement tech-nologies i§/curtailed, or the total vendor costs to thehospital are decreased.

120

At a time when Containing costs has never beenmore important, the American Nurses' Association isdistressed to read the headlines in the July edition ofValue Line about the health care - hospital supplies indus-try which stated, "Re Cord a982 and 1983 profits are instore for most of the companies." The industry's netprofits are expected to be 15.5 percent higher in 1982than in 1981.

Of the proprietary drug industry, the article says,"Few industries can match the proprietary drug group forrecession-resistance." Their net profits will be 27 per-cent higher this year than last. Of the medical servicesindustry, Value Line says "What recession? The hospital-servicesindustry is going full throttle." _Their net profitswill be 52 :percent higher this year. Of the ethical drugindustry, the comment. is, "For the most part, prescrip-tion drug manufacturers remain recession-resistant."Their profits will be 11.2 percent higher this year. Willsuch vendors also be labeled cost containment-resistant?

Another measure that could help contain costs is theelimination of payment of costs borne through paymentmechanisms for the education of medical, nursing, andother students. For decades, the American Nurses' As-sociation has stated that the patient should not be ex-

pected to bear the costs of educating health care pro-videi.S. It is unconscionable to expect that the poor theelderly, and the disabled of this nation should be made tobear the brunt of increased copayments and deductibles anddecreased services so that this subsidy may be continued;

During periods of cost containment, professional stan-dard review and other peer review activities aimed atmeasuring the appropriateness of care and servicesshould receive increased emphasis; It is of paramount

importance that care and services are "Provided at theappropriate time,-in the appropriate setting, by the ap-propriate provider, and with the appropriate intensityand diversity. Peer review mechanisms are an essentialway to accomplish these determinations.

13 ° 21'

When cost containment requirements are placed onthe health care industry, the need for quality assurance,peer review, -appropriate usei and - distribution of re-,sources increases; It is of great concern to ANA thatthose mechanisms provided by professional standardsreview organizations and health planning systems havebeen significantly weakened by recent legislation; Al-though the PSROs and USAs were far frern perfect, bothprograms contributed to the maintenance of peer reviewsystems and the prevention of over-proliferation of tech-nologies, over-bedding, and over-bUilding.

Without strong federal deterrents, cost can be ex-pected to continue :o spiral with subsequent diminutionof patient access to quality serVices.

The length of stay of a patient in the hospital is asignificant contribution to the costs of that care; Earlierdischarge of patientS is proposed for the prospectivepayment mechanism, bLit this will be a viable option onlyif sufficient outpatient clinics and community and/orhome care service capacitieS exist. Patients may bedi.stharged because they no longer need the intensity orvariety of services proVid&I in a hospital, but that doesnot mean they do not need any continuing services andcare; If such services are not available in sufficientquantity, the re-admiSSion rate of discharged_ patientswill likely rise, thUS defeating the purposes of thesystem;

The length Of stay of a particular patient is oftenrelated to the availability of non-acute facilities towhich the patient may be transferred; or the availabilityof home and family members who are able and willing toprovide the needed support and assistance; Althoughearlier discharge may be a goal, the patient and familyrequire some mechanism for continued care and services.cost, containment that applies to hospitals only is likelyto lead to increased and uncontrolled costs in other areasof the health care delivery system,

Finally; _a measure which can enhance the cast -effectiveness of .the health care indUstry it the reductionof the statutory control of the Medical profession overthe consumer's acres: tO'special professional nursing ser7vices in the hospital; and; in the community, consumer'saccess to Visiting nurse service and other home healthcare services; As stated earlier, access to nursing serrVer.es is the reason why _most_ patients_ are admitted to ahospital, for they could otherwise be treated, in thehome; or office; or in an alternative_community servicefacility; In efforts to promote earlier discharge fromthe hospital and to preiltrit the rampant escalation-of re-admission to the hoSpitel; the consumer shout i havedirect access to_ nursing services provided outside thehospital. As with PSRO't and health planning; Congresscontinues -to make legislatiVe detitionS which conflictwith the notion of cost containment.

We were deeply disteett-ed Over the vote by the US;House of Representative to exempt state licensed pro-fessionals from anti-trust scrutiny by the Federal TradeCommissiom ANA, di6eis with may other health andconsumer organizations, has strongly opposed curtailingFTC jurisdiction.

In the face of .increasing health care costs; the Househas voted to.. remove a major deterrent to anti-competitive practice- by physicians. This will serve onlyto, increase the consumer burden of pkyment for healthcare costs.

Recent Medicare cuts by Congress and proposals ofthe Reagan Administration have increased the athount ofout-of-pocket medical expenses to be carried by the el-derly and disabled.

The FTC has focused on the costs of health care andmonopolistic husiness practices which keep health carecosts unrealistically high by shutting out cost- effective

-alternative health service delivery by nonphysician providers.

-.15

We are at a highly critical point in our history. It isclear that if we are :ci continue to grow and develop as aprofessioni we must gain control of the economics under-girding our professional services;

The development of guidelines for classification of_ intensity of nursing Services- t. ucial to gaining control

and; interestingly enough, we find hospital adminis-trations more than willing to utilize this iniormation.

Nursing researcher!, and nurse adi-ninistrators mustcome together now and provide the kind of data andguidelines that are needed to support professional nurs-ing services. This is also the charge-1 present to you.

16

DEVELOPING AND APPLYING_POLICY.,ORIENTEDRESEARCH FOR NURSING PRACTICE AND EDUCATION

Ora L; Strickland; RN0 PhD;. F.A:A.NDoctoral- ..Program Evaluator and

Associate Professor, School of NursingUniversity of Maryland at Baltimore

Policy to define the boundaries of action of profes-sionals as well as consumers of services is necessary in

all arenas which have an impact on the- public. Policiesregulate the behavior of individuals, agencies, and or-ganizations by setting forth a plan intended to propagatethe general good; Decision making and adtiion based .onpolicy occur at local, state, national, and internationallevels; The behavior of nurses in clinical and educationalinstitutions is controlled by policies established by theiremploying agency as well as by governmental policy.Once established, policy is difficult to change.. .

Policy often reflects _the social environment andaddresses societal need. The nurse's role and the typesof rewards received as well as contributions that he Orshe will be aUowed to make to patient care, health caredelivery, and nursing education are set by policy, whetherthrough legislation or the rules and regulations of aparticular institution. Nurse researchers_ must be cogni=zant of the fact that research, i.e., their research, canserve as a forceful contributor to change through theinitiation, modification, or eliminationcof policy. Nurseresearchers can affect policy I) by identifying criticalareas which need the development of new approaches oralternative strategies for the improvement ,.of patientcare, health care delivery, or nursing education, and2) by initiating research studies which will deal withquestions surrounding the critical issues; Areas which

17

6

need the deliberate direct attention of Clinical nurseresearchers include:,

Health PranotionIncluding stress control, exercise and fitness, reduc7ing,drug abuse, cessation of smoking, improved --nutrition, and control of violent behavior

2. Preventive Health ServicesIncluding high blood pressure control,.family plan-ning, pregnancy and infant care, immunizations, andsexually transmissible diseases

3. Health ProtectioriIncluding toxic agent control, occupational safetyand health, accidental injury control, and infec-tious agent control

(U.S. Dept. HHS,PHS, 1979;1 980);

Areas 'which need study by educational nurse researchersare:

1. Educational approaches and strategies including,studies of existing programs and of innovativeprograms, various teaching-strategies, particularlyfor clinical nursing education, and program out-comes

2. Faculty roles and faculty practice3. Educational resources and environments4. Continuing education

Other .areas which need to be focused upon forinvestigation by nurse researchers it order to providedata for policymaking include:

I. Nursing roles and interrelationships between nursesand other health care provideri

2. Cost containment in health care delivery

4

3. Factors in nurse satisfaction and manpower supply4; Organizational modes for nursing care delivery5; Reimbursement for nursing services6; Credentialing in nursing

Nurses and collective bargaining

Nursing research findings also can be used to influence resource allocation for clinical practice, nursingeducation; and in health care deliverY at large, The nurseresearcher can influence resources allocation as dictatedvia policy through he development and _or study of newcare delivery approaches and demonstration programs todetermine their benefits to clieritS and their costs tosociety (Aiken; 1981).

Nursing research is only as useful as it is in address-ing the issues;- problems; and needS of the larger society;Findings from nursing research studies must be system-atically compiled and communicated in a manner so thatthe policyrriakers will have their full benefit in theirdecision-making and structuring of policy;

References

Aiken, Linda H. (Ed.). Health- policyand-nursing_praCtice;New York: MCGraW Hill Bobk Compny; 1981;

Healthy people: The SUrgeon-generaPs-report on healthpromotion and diseaselevention; U.S. Departmentof Health, Edticaticiri,and Welfare; Public HealthService, 1979.

Preventing diSeaSeuprOmtiting-heal-th:_Objectives for thenation. U.S: Department of Health and Human ServiCeS;Public Health Service; 1980;

19

THE PROCESS, PERILS, AND 30YSOF

COLLABORATIVE RESEARCH

Jeanette Lancaster, RN, PhDProfessor and Chairman

Master's ProgramSchool of Nursing

University of Alabama in Birmingham

Collaborative research presents many challenges forcontemporary nursing. Thr-OUgh pooling of intellectual,financial, and energy resources, a team of research-oriented people can make subStantial contributions tohealth knowledge; However, it must be rememberedthat group process often poses hurdles to productivityjust as it contributes to creativity. There is no doubtthat research efforts in nursing should be accelerated,and collaboration is one way of doing

At least four traits characterize individuals whocontribute substantially to research: intellectual Curi-osity; conceptual ability, competence, and creativitytempered with caution. IridiVidUal researchers need theseskills; however, in any One person certain of the fourrequisite skills may preddininate. Through collaborativeresearch efforts, a team can be formulated comprised ofmembers possessing-these skillS.

There are at least six crucial "C's" inherent in suc-cessful collaboration contribution, communication,commitment, consensus, CoMpatability, and credit; Eachof the "c's" offers the potential to be an advantage or adisadvantage to collaboration To elaborate; each,Iparti-cipant brings a Unique contribution to the project due topast experience, ethication, goals; and so on Effectivecommunication IS ettontiaL for collaborative research tobe successful. In each geoup there must be a "good fit"among participants whereby their personality styles andcommunication patterns complement rather than con-flict with one another.

21

Members of each group will vary in level of corn-II-lament to the project. However, projects run moreeffectively if the level of variance is not great; Some-times the motivation level of highly committed memberswill stimulate those who are less committed to completeassignments and meet deadlines. Teams also fare betterif members are compatible or, at least, can recognize;respect; and capitalize upon their differences; Somemembers will be more skilled in .generating ideas; while-others can refine the ideas and draft the report; To

some extent; the degree to which compatability existswill affect if and when consensus will be reached.Consensus involves a never-ending process_of communi-cation charatterized by negotiation and compromise.

The final "c" of collaborative research; credit; is

crucial. If arguments and hurt feelings occur around whowill get credit for the project, these feelings s-will cloudthe overall perspective of the entire project. If mem-bers are facing major decisions regarding promotion andtenure, or otherwise have a vested interest in the al-location of credit, they may not be able to clearly deter-mine a positive course of action.

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29

A DESCR1PTION_OF NEGOTIATLON_BEHAVIORS INNURSE-PATIENT VERBAL ENCOUNTERS

IN HOSPITALS

Jan Biasini) RN, MSNAdministrative ResidentHospital AdMinistration

University of Alabama Hospitals) Birmingham

Negotiation has been defined as the exchangeideas in order to change relationships (Nirenberg, 1968).Orem (1980) suggested that negotiation was essentialbetween nurses and patients so_ that nurses might assistpatients to determine their self-care requirements. Thepurpose of this study was to determine whether or nothospital staff nurses negotiated with hospitalized pa-tients; If nurses and patients negotiated) what issues didthey negotiate and what specific negotiation behaviorsdid they employ? In addition, the contextual variablesaffecting the negotiation were dekribed and the out-comes of the negotiation determined.

The study was based on Orem's (1980) theory ofnursing and the Strauss (1978) paradigm of negotiation.Strauss emphasized the interrelationship between the con-text and process of negotiation.

The first encounter- of the day 1:etween 10 staffnurses and 30 patients was recorded) using a pocket taperecorder and lapel microphone attached to the nurse;Written consent was obtained from each participant.The staff nurses were graduates of baccalaureate nursing

-programs with at least two months of nursing experi-ence. All worked on noncritical care medical nursingunits. The patients were selected because they were beingcared for by the nurses previously selected and werein stable condition with no communication impairments.

Once the -30 encounters_ were recorded they weretranscribed by the investigator and given to a panel ofthree udges. Negotiation was determined to occur in agiven encounter When two of the three judges) based onan operational definition of the term, agreed negotiationhad oc urred.

23 30

The nurses and patients were found to negotiate ineight Of the 30' encounters. In seven of the eightnegotiated encounters, the patient initiated the negoti-ation. The issues that were negotiated mainly concernedthe patient's daily activities, for example, oral intake,movement in and out of bed;.and bathing schedule.

The most frequently used_negotiation behaviors weremaking promises and making concessions; The nursesand patients seldom made counter offers or initiatedtrade-offs; Threats were never employed.

The most important contextual variables to the tie=gotiated nurse-patient encounter were the length Of theencounter the differences between the mean ages of thenurses and the patients; and the degree of previoUSlydeveloped trusting relationship between the nurses andthe patients. In all eight negotiated encounters thenurses and_patients reached a mutually acceptable agree=ment which was beneficial to both parties.

.

Orem (1980) indicated that negotiation was a desit=able nurse-patient interaction behavior; however, nursesand patients negotiated in only eight of 30 encounters.Thereforej_ it could be suggested that some instructionin negotiation behaviors would be an important additionto the nursing curriculum. In the practice Setting nursesneed to be trained and encouraged to negotiate withtheir patients.

References

Nirenberg, G. The art of negotiating; New York:Cornerstone Library, 1968.

Orem, D. Nursing: Concepts of practice.,New York: McGraw Hill, 1980.

Strauss, A. Negotiation: Variables,--coritextsi_pro-cessesi and social order. Sari Francisco: Jossey-BassPublishers, 1978.

31 24

CHILDHOOD SOCIALIZATIONFOR

VIGOROUS EXERCISE HABITS

-Kathleen C; Brown; RN; PhDAssociate Professor; School of NursingUniversity of Alabama in Birmingham

Many professionals assume that peopleperform healthbehaviors primarily owing to a concern for health;Some authors; however; speculate that people engage inhealth behaviors because of a desire for social approval'or because of socially determined habits; Little is knownabout how individuals are socialized into health habitsand why they continue or discontinue these patterns;The purpose of this research was to investigate socialfactors related to the performance of one health be-havior--exercise; Social learning theory with emphasison modeling and reinforcement served as a theoreticalperspective for explaining the process of becoming in-volved in exercise;

Currently the public is preoccupied with physicalfitness and health-promoting activities; Although theefficacy of exercise is still a matter of debate; healthprofessionals and the public generally accept the impor-tance of exercise for promoting health and preventingdisease; Industries are developing programs to promoteemployees' leisure time physical activity; improve workperformance; and decrease absenteeism; Evidence ex-ists; however; that some .persons 'seldom engage in vig-orous activity during their lifetimes; Even in workwhich is considered traditionally Laborious; high levels= ofenergy expenditure are rare. Research is needed tounderstand factors which predispose individuaLs to pursuevigorous lifestyles.

The sample was 117 manufacturing employees; 41males and 76_females, who volunteered to participate inthe study. The majority of the respondents were bluecollar workers. A questionnaire measuring behavioral;

2532

cognitive; situational, and sociodemographie variableswas developed and evaluated by validity and reliabilityprocedures. Frequencies, t tests, bivariate, and multi-variate techniques were used to analyze the data.

Socialilation questions revealed -that less than one-fifth of the subjects reported that their friends, room-mates; or spouses exercised frequently. In terms ofchildhood influences, one-half of the subjects indicatedneither of their parents had encouraged them to ex-ercise, and only one -tenth of the subjects reported theirfamily had frequently played a sport together._ Subjectswho were vigorous as adults were found to have highrates of particiPaiF in childhood sports activities in-eluding Little League and high school teams, while

-sedentary respondents were low in childhood sports par-ticipation. perhaps during well=thild health visits, chil-dren could be encouraged to participate in sports andparent could be encouraged to support their children inphysical activities.

An important finding to emerge from this study wasthat vigorous subjects had been active sports partici-pants during childhood. This finding supports the notionthat exercise perhaps learned ,for reasons unrelated tohealth, is a ger era! lifestyle habit of some individuals.The view that behaviors may be learned in social situa-tions or from experiences of other persons was supportedby the positive association of performance of voluntaryexercise with ehildhbOd sports participation; but failedto be supported by the weak correlation with familyparticipation. Thus the findings provide mixed supportfor the social learning theory's tenet that behavior islearned social situations.

The question of how people are socialized into exer-cise habits requires further research; The study could bereplicated to determine if similar results are found incomparing other sedentary and vigorous groups; Studies

26

may be done to determine the specific high school teamsports which are related to adult performance of -_xer--cise and whether the number of years of participation insports during childhood influences exercise behavior.Emphasis on socialization for exercise is consistent withthe Department of Health and Human Service's attemptto shift health policy from a disease orientation to oneof health consciousness and health promotion.. There-fore, it is further recommended that researchers con-tinue to explore the _role of 'childhood socialization fordeveloping vigorous lifelong exercise habits.

AN ECONOMETRIC TvLODEL==PREDICTIVE FACTORS OFSUPPLY AND SALARIES OF NURSE PRACTITIONERS

Joan Farrell Browniei RNi PhDDean2 SChool efMursing

Medical College of VirginiaVirginia Commonwealth Universityi Richmond

In the laSt decade, the. development of the new healthprofessional (NHP), alto known as Nrse practitioner (NP)and physician assistant (PA), maybe one of the mostsignificant changes in the professional organization ofmedicine and nursing. Formal NP and PA programs havereceived direct federal support since 1971 under theauthority of the Nurse Training Act and Health Profes-sional Educatidn Assistance Act. Growth in governmentsupport for health manpower has led to stUdies of healthmanpower frOrn a pblicy viewpoint, including its impactupon the economic systemi political organization, andthe ptiblic/conSumer interest and the role of professionalinterest groups.

Although a growing body of research/ literature re-garding health manpower policy has emerged, studieshave been primarily addressed toward defining cate-=gorieS of health workers and forecasting need for ter=vices. Little attention has been given to the moredifficult questions concerned with geographical diStri;button and productivity; This study is concerned withthe development of two econometric models: one toexplain the ,difference instate by state supply of nursepractitioners; the other to explain salary differentials asa measure of their_ perceived value to society. ItSpecifically investigates how supply and prodiittiVity ofnurse practitioners vary with a variety of demographicieducational; and health service variables.

The" problem demanded n du l leVel of analysis: oneim whiCh aggregate data for 50 states was used in ananalysis of the relationship of supply to selected con-te,kvial variablesi the other in which individual subject

35

data for 1,012 NPs was employed in analysis of salarydifferentials; After evaluating the distributional char-acteristics of the data, multiple regression (forwardinclusion and stepwise solution) was employed to testthe following hypothesis:

I. The state supply of nurse practitioners in theU.S.A. varies with demographic factors, with statefactors concerning distribution of hospital and medicalservices, and with the type of statutory laws regulatingnursing and medical practice.

2. The 'annual salaries of nurse practitiOners, as ameasure of their perceived value to society (produc-tivity), vary with demographic factors, with statefactors concerning distribution of hospital and medicalservices, and with. the type of statutory state lawsregulating nursing and medical practice.

The results of this study record evidence that, of thefive factors tested, the nature of the medical practiceacts and the ratio of generalists to specialists con-sistently account for large percentages of difference inthe nOrse practitioner to population ratio. When type ofmedical practice acts was controlled, the percent ofstate population residing in rural areas and the nature ofthe medical practice acts and-the ratio of generalists tospecialists consistently account for large percentages ofdifference in the nurse practitioner to population ratio.When type of medical practice acts was controlled, thepercent of state population residing in rural areas andthe nature of the nurse practice acts became the mostpowerful predictors of difference in state-by-state sup-ply- of nurse practitioners.

It was also determined that the salaries of NPs varyconsistently with a number of selected indices. Earningsprior to NP training, average hours worked per week, andhighest earned nursing\ degree were the variables thatheld the most predictive poWer of differences in NP

29 \\36

salarieS. Their consistent ability to account for signifi-cant proportions of variance under all circumstancestested, suggest that they play the most important role indevelopment of an econometric model to ekplain NPsalaries. There is eVidence suggesting that the NPcredentials and the number of years worked prior toadvanced training also contribute .significantly to theexplanation; Salaries were inversely proportional to thehours worked, indicating that NPs who work aitietee hOurstended to earn higher salaries than those WhO workedlonger hours.

When the _equations were controlled fOr type ofnursing and medical practice lawsi results concerningsalary differential were not remarkably different. Nota-ble, however; were the results regarding incomes ofNPs working in states with the most restrictive :nursepractice laws. The salary model under these circum-stances explained the most variance (39.6%) of any ofthe conditions studied; Although previous earnings ex-plained the largest amount of variance,_ average hoursworked was not significant. The credentials of the NP,the ratio of generalist to specialiSt MDS; and the ruralityfactor were among the significant predictors. Thesefindings indicate that in states with restraining nursepractice acts the predictor of salary differentials aresomewhat different tharisfor most other conditions tested.

Since the two econometric modelS tested proved_ toexplain significant amounts_ of variance in the supply andthe salaries of nurse practitioners under numerous con-ditions; its seems reasonable that the models could beused to study similar lactOrS aff-ecting other groups ofnurses; From a policy point of view, -the issues ofgeographic distribution of nursing services and thesalaries nurses earn are among the most importantproblems facing health care in our nation today;

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37

MILK YIELD ASSESSMENT IN ASSISTINGMOTHERS DURING THE INITIATION OF LACTATION

Ellen B. Buckneri RN; MSAssistant Professor; School of NursingUniversity of Alabama in Birmingham

The problem of perceived or actual inadequate milksupply is one of the most common reasons given for earlydiscontinuance of breastfeeding. This research wasundertaken to identify factors which may influence milkproduction through alterations in physiological mech-anisms. The purpose of the project was to determineways nurses mayAmprove their practice in the assess-ment and management of women with poor lactation.Other investigators have studied the influence of pro-lactin and the prcilactin response to suckling on milkproduction. Nurses and physicians have attempted man-agement protocols for breastfed infants which presentwith failure to thrive. The focus of the study was todelineate physiological processes which could be usefulin planning the nurse's assessments and r!::cisions regard-ing interventions.

Thirty-two breastfeeding mothers were seen by the.nurse-investigator between two and four weeks post-partum. Each Mother planned to nurse her infant at thevisit. Milk yield at the feeding was calculated as thechange in the infant's weight from 'before to afternursing phis the - amount of milk remainin* in the breastWhich could be expressed using an electric breastpump.Maternal serum samples were obtainEA bfore and alterthe nursing. Baseline prolactini peak prolactin, theirdifference (the prolactin response to suckling), and es-tradiol were determined from the samples by radio-immunoassay. Other data were obtained by subject self-report in a structured interview during the visit. Length

31

of solely breaStfeeding and reasons for 5uppldnieDtation.were obtained from phone interviews at three rno ths;Statistical analysis was done using Pearson prod ct-moment correlation and One-way analysis of variance;

. The breastfeeding experience showed Wide individualvariation between mothers in the initiation phase; Milkyield at a single feeding ranged from 0;75 ounces to 8;0

ounces; infant weight gain or loss was similarly wide,ranging from a loSs of seven percent of birthweight perweek to a gain of eight percent of birthweight per week;There was wide variation in the number of infant stoolsand voids, number of letdown reflexes noted, and allhormone:leVelS. Mean maternal caloric intake was beiowrecommended daily allowances for lactating women;The variation obServed documents the profound individ-ual differenteS which exist in the breagtfeeding experi-ence and the importance of a comprehensive nursingassessment when problems arise;

The milk yield measured at the single feeding wassignificantly correlated with infant weight change sincebirth .60, p<.001) and hence had criterion-based valid-ity as a measure of intake during 'the initiation oflactation. There was a significant relationship betweenmilk yield and length of breastfeeding Those motherswho Supplemented for reasons of inadequate or perceivedinadequate supply had significantly lower milk yields andshorter,: lerigthS of breastfeeding than thosewho -sup-plemented for other reasons and were still breastfeeding.

Hormonal findings confirmed suspected effects ofsome factOrS on ttie process of lactation. The prolactinresponse to Suckling was significantly correlated withmilk yield (r = .36; p <;02). Women who had experienced apostpartum infection or,a previous breastfeeding failurehad loWer prolactin responses; The baseline prolactinlevel which had not been previously correlated in studiesin the firSt days postpartum was negatively relatedtdmilk yield at two to four weeks (r = -.37, p_<_ .01). This may

32

represent a compensatory system or- an inhibipory in-fluence; Estradiol (a milk in'tibitor) was ele6ated inwomen who reported their infants sucked poOriy. Thisdocuments resumption of ovarian function when suckingstimulus is inadequate.

A nursing practice protocol is presented which de-scribes the screening, assessment, and intervention strat-egies for nurses assisting clients with breastfeedingproblems related to low milk supply. Streening consistsof an infant weight check at two weeks with .time formother to express concerns. Criteria_ can be definedeither broadly or narrowly to identify mothers whoshould be assessed,further. Comprehensive assessmentincludes milk yield measures, interview, and possiblyhormonal analyses. Decision points are delineated fordetermining women at risk for poor lactation who shouldbe entered into intervention protocols: . Interventionsoften require use of multiple modalities, including phar.macological management, manipulation of physiologicalstimuli, therapeutic communication, values clarificatibh,and decision making.

This research was supported by aNisltirsing ResearchEmphasis Grant/Doctoral Programs, 54-R21.7:Ni_1=00835.02.

33

CULTURAL DETERMINANTS OF HEALTHAND SELF-CARE IN URBAN AMERICA

Jacgueline'Clinton, PhD, F.A.A.NASsociate professor and ReSearch ScientistCenter for Nursing Research and Evaluation

University of Wisconsin-MilWaukee

This study concerned the development of an inte-grative ultivariate, computerlassisted approach to themeasurement of ethnic identity, and evaluation of itsusefulness in cross.-cultural nursing_ research onEuropean-Americans. Examined were the influenee ofethnicity on beliefs about health and ifInessi self-saliency in health, reliance on both indigenous and pro-fessional health resources, patterns of self-care, and thefit between self-perceived and professionally-cliagnbsedhealth status.

The design of the study was a descriptive surveyconducted at the Institufe for Social Research at theUniversity of Michigauga A multi-stage probabilitysampliiig_procedure washigned for the Detroit Metro-politan Area using 55 minor civil divisions, 22 censustracts, and 270 blocks, based on 1978 population estimatesfor the Standard ,iyietropolitan Statistical Area ofaetroit. The sampletonsistea of .645 randomly selecti4,non=institutionalized_ adults (18 or older) residing13troit and claiming to be of European origin. DaWwere collected using a pre-tested, standardized inter=

-View which was administered in each respondent's hameAll empirical constructs usca in the study were firstSubmitted to reliability and validity testing. Health' datawere analyzed lisinvANOVA, MANOVA, canonical cor-relation, discriminant functions and linear rcg:Effects of other derirgraphic factors were Oa finelyremoved by statistical partialllng prior to evaluation of

34

;

the ethnic component. The dependent construct, ethnicidentity, was developed using a computer program de-signed to test predictive relationships using onlynominal-level data.

It was discovered that white Americans are not ahomogenous group in terms of their ethnic identity andpatterns of healthy For those who persist in identifyingwith European country of origin, strength of affectiveties to a primary group and religion are not only themost salient factors in self-ascribed ethnic identity, theyalso play a significant role in shaping health ,beliefs,perceptions, and self-care behaviors.

The integrated, multivariate, computer-assisted ap-proach to the measurement of ethnic identity was foundto be a useful heuristic for partitioning the sample forthe analysis of health data, for it allowed the investi-gator to discover differences in health that were notdetectable when the traditional univariate approach tocapturing the ethnic dimension was used. The integratedapproach warrants further investigation for its potentialusefulness in future cross-cultural nursing research andpractice as well as cross-cultural studies in other applieddisciplines; Beyond applied research; the construct usedto represent ethnic identity was also found to be a usefultool for testing current theory in the area of ethnicity andadvancing its development.

35 42

Val

COMPARISON OF ATTITUDES, WORKING CONDITIONS,AND NURSING PRACTICE OF

FOREIGN NURSE GRADUATES ANDU.S. NURSE GRADUATES IN FLORIDA

Marie H. Cowart, RN, DrPHAssociate ProfetSorSchool of NurSibg

Florida State UniverSity, Tallahassee

This study eicarninedcertain characteristics of licensednurses by geographic background of their basic_ ntirs-ing education; The purpose was to determine whetherdifferenceS in attitudes, practice patterns; and workingconditionS exist between foreign nurse graduates andU.S. nurse graduates.

Independent systematic samples of U.S. nurse gradu-ates and fOreign nurse graduates4(FNGs) were selectedfrom individuals applying for nurse licebsure -in Floridafrom 'July 1, 1978 to June 30, 1980: IfidiVidualS whobecarhe licensed and who subsequently renewed,, theirlicense and responded to a questionnaire accompanyingthe renewal form comprised the sample yields. It wasnoted that there was a greater loss of FNGS during thesampling process than of U.S. nurses, probably due tovarious causes including a high failure rate on the nurselicensure examination and a lower response rate to thequestionnaire. Tests for internal consistency of the self7reported_ data revealed some inconsistency for selectvariables;

Three phases of analysis were conducted- using thechiquare test to examine for differences__ in the pro-portions of the variables for two samples. First, the twosamples of nurses were examined byeach variable. Allvariables were significant at the 0.05 level of probabil-ity, but many of the differences were small. Furtheranalysis was done for variables with a 10 percent orgreater difference by examining regional subgroupsamong the, FNGs. FOur world regions had enough sub-jects to be studied using the chi-square test: the

43 36--

Philippines, the British Isles, Canada, and Jamaica/Bahamas. - Significant differences in the distributionswere demonstrated for these variabks: age, typebasic nursing education, opportunity_ to use-skills;for a bili

worked,in the nursing position,

--thiftI.Vorked, and annual salary. Nurses from the, BritishIsles and Jamaica/Bahamas were °observed to functionmost like U.S. nurses, while those from the Philippineswere most dissimilar.

Further analysis was conducted by examining allvariables, in combinations of three variables simultane-ously, .using the chi-square test for three variables.Differences were demonstrated for three variable inter-actions for the personal/social background variables(age, type of basic nursing education), for the attitudevariables (opportunity to use skills, desire for change inresponsibility), and for the practice pattern variable(shift worked), and one work status variable (annualsalary). Contributing to differences in the distributionsin the two samples were the personal/social character-istics and the geographic origin of the nurse.

The FNG who is licensed in Florida reports manysimilarities to the U.S.-prepared nurse who is licensedduring a like time period: Reports of choice of worksetting, primary nursing speciality; attitudes about thebenefit of continuing education, number of hours workedweekly, and the title of the nursing position; whilestatistically significant in their differences; actually aresmall enough to have little social significance.

Since the socially significant differences in the twogroups of nurses are attributed to personal/social char-acteristics as well as to geographic origin, one mayconclude the following: I) Nurses choices in attitudesand practice patterns will vary,by age and by their basicnursing educational preparation. 2) Nurses with culturalorigins that are most distinctive from the U.S. willcontribute more difference in practice than nurses whosecultural origins share many similarities with the U.S.

37

The -study concludes that FNGs who are licenSed inFlorida do participate in the nursing practice to thesame extent as U.S. nurses who are licensed during asimilar time period.

38

CC MPARISON OF 305 SATISFACTION BETWEENNURSES PRACTICING IN A PRIMARY NURSING

MODALITY AND NURSES PRACTICING INA TEAM NURSING MODALITY

Jimmie G. Davis, RN, MSNPrimary Nursing Coordinator

University HospitalBirmingham, Alabama

Since the turn of the century, nursing administratorshave sought a practice modality that would increasenurse job satisfaction; prevent fragmentation of patientcare; and provide individual nurse accountability fornursing actions and outcomes. Thereforei job satisfac-tion of nurses practicing in the various modalities (i.e.,casei functional; team; primary) needs to be examined.

It was the investigator's intent through this researchto answer the following research question; tri adesignated hospitali was there a statistically significantdifference in job satisfaction between nurses who prac-ticed in a primary nursing modality and those nurses whopracticed in a team nursing modality?

A descriptive-comparative research design wasdeveloped in which questionnaires were administered toregistered and licensed practical nurses (N=105) on eightmedical-surgical units. The questionnaire was anadapted version of: the__ Work Satisfaction Inventoryde veloped_rby__Stamps,_ Haase(1978) which measured nurse job satisfaction by a Liken-type attittidinal scale. Mscriptive statistics were celcu-lated for the total nurse job satisfaction scores and thesix silbscores) and the means for the primary and teamnursing modalities were compared using a two factorhierarchical analysis =of variance. The two factors in theanalysis were modality and '.sing unit;

There was no statistically significant difference inmean scores of total nurse

39

job satisfaction betweenq 6

nurses practicing in a primary nursing modality and thciSepracticing in a team nursing modality. Furthermore, nostatistically significant difference was found betweenthe mean scores of the two modalities for each of the sixsubscores of nurse job satisfaction. However, there wasa Statistically significant difference among the unitmean scores for the total nurse job satisfaction and foreach of the six subscores. Further research is needed todetermine the factors that contribute to nurse job satis-faction.

Reference

Stamps, P., Piedmont, E.; Slavitt, 13;i Haase, A.Measurement of work satisfac_tion among health pro-fessionals; Medical Care. 1978, 16 (4). 337=-352;

40

o

BACCALAUREATE GRADUATES' SUCCESS ONSTATE BOARDS: A PREDICTION STUDY

Mary B. Duffy, RN, PhDAssistant Dean and Assistant Professor

Mary A. Lubno, RN, RSADoctoral Student

Grace A. WillardL RN, MSDoctoral StudentSchool of Nursing

University of Texas at Austin

The offering of formal review courses to new gradu-ates prior to taking the State Board Test Pool Exami-nation (SBTPE) is a development of recent years. Accord,ing to Lufkin and Jones (1981), increased numbers ofState Board failures, coupled with the increased aware-ness of .emPlciyers regarding the- shortage of RNs, havecontributed to the proliferation of these courses. Manyagencies now have these courses as an integral part" pftheir recruitment packageSi since new graduates placehigh Value on the availability of this formal review(Lufkin and Jones; 1981; p; 14);

Although a large number of studies-have been donewhich document that performance on NLN achievementtests predicts performance on State_Board EXanit_,_(Wolfeand Bryant, 1978; Shelley et al, 1976; Deardorff et al,1976; Bell and Martindill, 1976; Taylor et al, 1965,1966), no study has been undertaken to demonstrateWhether participation in a formal review courseinfluences performance on the State Board Test PoolExamination (SBTPE). Because a great deal of time,energy and resources are invested in the planning andconduct of such courses by agencies-and new graduates,a study of this type js needed to provide data upon whichto base policy decisions. The cost containment iiiiplica;tions Of the content review process alone warrants sucha study (Lufkin and Jones, 1981; p. 15).

41 4 6

Previous research analyzed data by examining thebivariate relationship between the sets of predictorS andthe criterion; However; this type of strategy.r dbeS notaccount for the effect of other variables on Ahat_te:lationship. Since successful completion of the SBTPE israrely decided by examining one variable at a tirrie, thepresent investigators adapted the strategy used by TrippAnd Duffey (1981) in their recently pUbliShed study.Instead of looking solely at participation-nonparticipation in a 'State Board Review course, othereducational predictors which might contribute to successOr failure were included in the analysis. The currentstudy sought to answer the following questions:

1. Could a discriminant fUnction be derived fromreadily available student data which,Would allow forclassification of baccalaureate graduates into one oftwo criterion categories: those_ who successfullypassed_ the State Board Test Pool Examination(SBTPE) and those who failed the SBTPE?

2; Would State Board Review_ course participation-nonparticipation be a significant contributor toderiving the one discriminant function?

3; How efficient is the,derived discriminant functionin classifying individuals into the two criterion cate-gories?

The sample consisted of 183 graduates of the Univet-sity of Texas at Austin School of Nursing who finishedschool in 1981. Permission was obtained from the entiresample to secure information on the following variables:age; 17 t?, xt _race, SAT Scores, BPA, NLN achievementscores, SBTPE_scores, and participatibn-nonparticipationin a formal State Board Review course; Data werecollected during the 1981-82 academic year. The Samplewas comprised of 91 percent females and 9 percentMales with a mean age of 21.5 years; a standard deVi=ation of 9.7 years; and a range of 21 to 55 years.Caucasians made up _77;5 _percent of the sample;Mexican- Americans, 5.5 percent; Blacks; 1.6 percent;

4942

Orl_ntals, 1.1 percent and Other; 143 percent; Of the183 graduates in the sample; 77 percent participated' in aformal State Board Review course; 23 percent did notEighty-seven percent successfully passed all sections ofthe SBTPE; 13 percent failed one or more sections ofthe exam;

The data were analyzed by stepwise discriminantanalysis; a multivariate technique which allowed theinvestigators to avoid the data-analysis problems in-herent in previous research (Tripp and Duffey; 1981). Acollection of discriminating variables on which the twocriterion groups (SBTPF. SuccessfulN. = 160; SBTPE.Not SuccessfulN. = 13) were expected to differs wereselected from available hudent records; sex; age; race;verbal and quantitative SAT scores, lower, division andupper division GPA, 9 NLN achievement test_scores; andparticipation-nonparticipation in a formal State BoardReview course.

The One discriminant function had a canonical cot-,relation of .37; x2 = 25.68 dif. = 3, .000p, andaccounted for 100 percent of the variance of the discri,minant space. Utilizing the. 3 variables which comprisedthe one discriminant function; (Race; Upper DivisionGPA, Verbal SAT), approximately 76 percent of thegrouped cases were classified correctly.; Tau; a propor-tional reduction in en-or statistic, was next computed asa- direct measure-of- predictive accuracy and was .52.Thus, classification based on the discriminating variablesMade 52 percent fewer errors than would be expected byrandom assignments; -i.e., 1 actual error versus 52expected by chappce. Participation-nonparticipatioh in aformal review Cburse had very low correlations with allof the other predictors. Thus; it was not surprising tonote that it was excltided in the discriminant function.

The investigators concluded that, although the analy-sis indicated a high degree of efficiency in classification,the findings should be interpreted very cautiously. The

43

;percent of correct prediction and tau tended to over-estimate the power Of the classification procedure dueto the validation being based on the' same cases used toderive the classification functions. The equations mayhave utilized idiosyncratic sampling error to createclassification functions which were more accurate forthis particular sample than they would be for the entirepopulation. Future research should be carried out withlarger samples utilizing a cross-validation procedure inorder to validate whether the predictors of success inthis sample can be reproduced.

References

Bell, J.A. & Martindill, C.F. "Crott4alidatioristudy forpredictors of scores on state board examinations."Nursing Research 25: 54=57, January- February, 1976.

Deardorff, M., Denver, R. & Miller, S. "Selected NationalLeague for Nursing achievemint test scores as pre-dictors of state_ board examination scores." Nursing-Research 25: 35-38, January=February, 1976.

Guilford, J.P. & Fruchter, B. Fundamental statistics inpsychology_ and education. New York: McGraw-HillBook Co., 1973.

_Klecka, W.R. Discriminant analysis. Beverly Hills: SagePublication, 1980:

Lufkin, S.R. & jones, M.K. "Study Shows review coursesdo not improve new nurses' performance on state boardexaminations." Southern-Hospitals, 14, September-October, 1981.

Shelley, B. et al. "Correlation of NLN achievement testscores with state board test poOl examination scores:"Nursing Outlook. 24: 52=55. January, 1976:

Taylor, C. W. et al. RePoriofmeasurement__and pre-e, Part I. Salt Lake City:. III -

UniversitY \of 'Utah Press, ;1965.

5.1

. Selection and recruitment afnurses andnursing students._ (2nd ed.). Salt Lake City: University

-of Utah PreSS, 1966

Tripp, A. & Duffy, M. "Discriminant analysis to predictgraduationinon-graduation in a master's degree pro-

.gram in nursing." Resear1981, 4 -(4),-pp.-34-5-353.

Wolfe, L.M. & Bryant, L.W. "A causal model of nursingeducation and state board examination scores."Nursing Research, 27: 311-315) ptember-October,1978.

INVESTING IN NURSING:DEVELOPMENT OF AN INTENSITY;OF;NEED

RESOURCE ALLOCATION TECHNIQUE

Denise E. Edwards-Weiss; MAAssistant Project Dire&tor

Steve A. Freedman, MAProject Director.

Patricia M. Pierce, RN4 PhDAssociate Director fqr

Nursing education and ServicesR.E.A.C.H. Project

College of Nursing, University of Florida

The purpose of this study is to examine a techniquefor reporting and analyzing time and effort data; Re-suits of this technique will be used to establish a staffingpolicy for specialized public health case managementnurses.

The technique, which is based on intensity-of-. service-need' rather than traditional general population

and demographic data, uses a specially developed timeand effort reporting form. The technique was designedto permit development of recommendations to theFlorida Department of Health and Rehabilitative $er-vices under a grant from the Roberti Wood JohnsonFoundation in support of a project entitld Rural Effortsto Assist Children at Home (R.E.A.C.H.);

R.E.A.C.H. is a four-year c[emopstration project inwhich 16 experienced registered nurses are providingspecialized decentralized health care and supportiveservices to Medicaid eligible, chronically-ill children whoreside in a rural 16=county area in north central Florida."Under an agreement with the University of FloridaCollege of Nprsing, the nurses are concurrently enrolled

53 46

in an educational program which prepares them tosdesigncomplex case management plans for implementation inthe home etiVircinment. The nurses live in the ruralcommunities Where they provide instruction; consulta-tion; and coordination of services;

The nurses are requird to complete a daily time andeffort reporting form -which-perrnits-he-compilatiinformation, including diagnosis-related encounters oftypes; length of each encounter; service site and fecii:CL.cents, and chrondgraphic information; Nine basic dataelements are Collected which can be -aa-i5rzei-d in total orby subsets. These basic data-elements are also being'used in relatibn to existing clinical and Cost daia; Thefocus of the methodology is to estimate allocatiOnfactors in the sioal5lishment of full-time-equivalent:nursing positions,_ to predict coct efficiencies for budjustifications; and to monitor field services.

Analyset of the daily reporting forms is ongoing. Anessential implication of the study is a description of, thetime/cost relationship in nursing services. ResultS ofthis study will be submitted to the state agency tosupport developrnent of new state personnel classifi-cations and staffing patterns for nurses providing similarServices to agency clients;

/'47

54

THE OCCURRENCE AND TREATMENTOF

AUDITORY HALLUCINATIONS

William E. Field, Jr., PhD, F.A.A.NProfessor and Assistant Dean

School of Nursi.dgThe University of Texas at Austin

Following years of clinical data-gathering, this fieldstudy was designed to determine the occurrence, quan-tity, and quality of the hallucinatory process in 318hospitalized schizophrenic patients. These hypotheseswere tested:

1. Significantly more hospitalized psychiatric patientswill experience the hallucinatory process thanthose who do not;

2. SignIficantly more hallucinatory experiences willbe in the auditory realm than in other modalities.

3; There will be ;:o significant differences in thenumber of patients expressing relief _from the halluci-natory process and those not expressing relief fromthe hallucinatory process when prescriptions of dis-missal are instigated.

4; There will be no significant differences in thenumber of patients expressing relief from the hal-lucinatory process between three modes of nursinginterventions: (a) acknowledg:nent; (b) rationale-emotive; (c) dismissal.

The first two hypotheses were accepted in the direc-tion proposed and were significant at the .001 level usingchi square. -The third, a null hypothesis related -totreatment, was rejected. at the .05 level using chi squArp.This hypothesis confirmed that hallucinations are vul-nerable to prescriptions of dismissal, initiated through

55 484

nursing intervention; The fourth hypothesis was rejectedat the .05 level using chi vivare; Significantly morepatients do express relief from the hallucinatory processwith the dismissal method;

In summary, the results indicate that nursing inter-vention makes a significant contribution to the reliefpatients experience from the hallucinatory process, whichenable them to improve in the three primary modesthinking, feeling, and acting.

49

THE DRUCILLA MANTLE_STUDY:OF_THE CURRICULUM IMPLICATIONS OF

INTENDED WORK-RELATED BEHAVIORS AMONGNURSE ADMINISTRATORS IN SOUTHEASTERN

U.S. HOSPITALS

Be.-erly Henry, RN, PhDAssociate ProfessorSchool of Nursing

University of Alabama in Birmingham

Nurse administrators play a significant part in thequality of care patients_ receive, in nursing_morale, and

in-the-contro-rorla-rge budgets. Lett than 25percent of nursing administrators, however, hold grad-uate degrees in nursing or administration. The majority

__are _managing _large_hospital- departments- with minimalacademic preparation.

To rectify this situation, an increasing number ofuniversity schools of nursing are developing graduate andcontinuing education programs in nursing administration;

But what forms are these programs taking?Available information suggests that nursing serviceadministration curriculums are based on faculty per-ceptions of how nursing service administrators should

_ _function, and not on data about needed knowledges andskills derived from empirical investigations of admin-istrators themselves.

A major purpose of the study, therefore, was tosurvey directors of nursing service, and hospital adminis-trators, to determine which knowledges and skills they

*The data for this study was collecte by DrucillaMantle prior to her death in January 1981. _Utilizing thedatal--the- study .vds pursued by me through "he dataanalysis and reporting stages. The study was fu ded inpart by the W.K. Kellogg Foundatiom The data ar theproperty of the University of Alabama School of Nursi g.

N-

50

believed nurse administratorS needed and which should oeincluded in fernal academic and cOntiming educationprograms for nursing service aditinistration;

The major objectives of the study, undertaken be----tween-1979-and- 1980;-Were:__1)_To identify_and_compare_

nursing_ directors' and hospital administrators' percep-tionsof the knowledges and skills most necessary for therole of nursing service aditinittrator. 2) To identify andcompare nursing and hospital administrators' perceptionsof extent to which nursing administrators should partici-pate in managerial decisiont. -3) To identify and-comparenursing and hospital adminiSteatots' opinions about whichacademic and continuing edUtational experiences shouldbe emphasized for nursing administrators.

To accomplish these objectives; 1;000 hospitals in the14 Southeastern states were randomly selected to parti-cipate in the study. The thief executive officers ofthese hospitals were mailed 15 -page Questionnaires fordistribUtion to their executive level nursing and hOspitaladministrators. The number of nursing administrator andthe number Of hospital administrator respondents were206 and 208, respectively.

Frequencies; means, medians and modes, and stan-dard deviations were determined for all items on Section1 of the questionnairethe section dealing with therespondents and their hospitals' structural features; TvalueS and two-tail probabilities were calculated for theitems in Section 2 for the differences between the twosample population perceptions of the extent to whichnursing administrators should haVe knowledge and parti-cipate in administrative decisions; and the opinions ofboth groups about which educational experiences shouldbe emphasized for nursing administratort.

Texas; Alabama; and Florida were the- statesmost_heavily reptenthd- byltheparticipants, 70 1:Etetit ofwhom worked in governmental or non-profit medium7Si±ed hospitals. The mean Pges of the nursing and

51 _58

hospital administrators was not significantly different,nor Were the numbers of years of employmentand years in present positions;

A majority of both groups of respondents agreed thatnurse managers should have master's degrees with em-phaSiS in administration and that nurse managers shouldbe knOWledgeable about and participate in decisions onmanager training, patient management, operations, andinterdepartmental management; Nursing administratorsagreed more strongly that nurses shoule beknoWledgeable about and participate in physician man-agement; financial and policy rhanagemeA, and therewarding and disciplining of managerial employees.

Fifty-five percent of the hospital administrators saidnurses' administrative residencies should be seven totwelve months; whereas the majority of the nurses sarri=,pled said residencies should be six months or less.

The hospital and nurse administrators agreed to ap-proximately the same extent on 17 of the 21 itemsdealing with continuing education experiences whichwere most needed. High agreement was reached withinand between the groups for nursing law, nursing adminis7tration, labor relations, and nursing practice; The twogroups disagreed significantly about financial manage-ment, research, and economics.

The findings suggest that academic nursing adminis-tration curriculums be designed to prepare nurse man-agers who can develop and implement managementtraining programs for their Staff; that the curriculumsinclude elements of patient management, nursing prac-tice; finance, policy issues, processes and behaviors; and-that-research- be-integra ted-With-ntirsing-and-managem en t _processes- AnalySiS-617-theAata7also- suggests-thatcontinuing education curriculums be designed to empha-size nursing adminstra.tion, nursing law, labor relations,personnel management, financial management, and nursing practice.

52

A QUANTITATIVE DETERMINATION OFPROGRAM IMPACT ON

REGISTERED NURSE STUDENTS

Samuel T. Hughes, Jr., RN, EdDAssociate Professor and AssistantDean, Graduate Studies in Nursing

Dorothy J. Turpin, RN, ESNCoordinator, ?PR Alternative

John C. .Z=ed, EdDAssociate Professpr in Nursing

School of NursingUniversity of Texas at Arlington

The purpose of this study vas to determine theeffectiveness of the course of study in effecting changein the participant's skills, knowledge,. and behaviors atthe conclusion of the prpgram. A pre-test and post =testresearch design was used to determine the effectivenessOf the Individualized Plan for Evaluation (IPE)' in effect=.ing change in registered nurse students; The IPE is acomponent of the generic baccalaureate degree nursingprogram that provides an alternative educational op-portunity for registered nurses (RNs) who have com-pleted either the Associate Degree or Diploma nursingcurriculums. Eight questions were addressed in thisstudy to subjects enrolled in the' IPE alternative, anda control group; The experimental group (IPEN = 32)was further classified into four groups according to basicpreparation (associate degreeldiplomalancLyearsoinumingexperience; The control group consisted of twosubgroups: associate degree and diploma graduate RNswho have not enrolled in the baccalaureate degreenursing program and generic nursing students enrolled inthe upper-division baccalaureate degree nursing programBNC-=N = 35). The measurements used in this study for

53

60

the purpose of collecting pre- and post-test data were:The Health Care Professional Attitude Inventory Oh TheWatson-Glaser Critical Thinking Appraisal (2),-and theNilson-Denny Reading Test (3); Three additional post=test measurements were used in this study; NI-N=Community Health Nursing Achievement Test (4) NLN=Medical- Surgical Nursing AChievement Test (5), andVirginia Gover's Nursing Performance Simulation Itittrti=ment (NPSI) (6); Data were Collected from November1979 to May I981; Due to the high mortality rate of thesubjects; the experimental sub-groups and the RNC con=trol group were not considered in the analysis of thedata;, The t test was used to analyze the data -at the ;05level of significance. There were no signifitant dif=ferences noted on the Medical - Surgical Nursing Achieve=ment Test (NLN), Virginia Gover's NPSI; The

--Nelson-Denny Reading Testi and The Watson=-GlaserCritical Thinking Appraisal. Significant differenceswere noted in the COMMUnity Health Nursing Achie-.-ve-meat Test-(1PE mean score = 80.24; BNC mean score =57;41; t = 6;42) and-_ in the Health Care ProfessionalAttitude Directory. The areas of significant differenceon the attitude inventory pre-test were: "indifference tocredentialiSre = 2.36); and _"compassion" (t = 2;57);The areas of significant difference on the attitudeinventory post-test were: "consumer control" (t = 3;15);"superordinate_pUrpote" = 2;59); "attitudes of criti-cism" h = 2.32); and "impatience with rate of change"(t = 3.23). There was a significant difference on the BNCpre- and post -test on the attitude Inventory in theNiollow-ing area "SUperordinate purpose" (t = 2;15); There wereno significant differehtet on the IPEpre- and post-test onthe attitude inventory;

The resUltS of this study indicate that the course ofstudy was effectiVe in changing the participant's skillsiknowl&dgei and behaviors at the conclusion of the pro-gram. The significant findings of this study were thatthe NLN=IPE group mean score was higher - than theBNC group on the NLN-Community Health NursingAchieve-Merit Test, and the attitude inventory indicatedthat. the IPE group expressed a more positive attitude on

54

61

the post-test in the six areas of the measurement toolxhan did the BNC group. This study will be replicated inpar t_in_the-spring-1983-semester-to-evaluate-the effects-of the reorganization of the undergraduate curriculumwith the IPE alternative.

References

Stone, H. L. Health-care-Lvrofessional attitude inventory.Madison: University of Wisconsii Office of EdUtatiOnResourceS, Center for Health Sciences;

Watson, G., & Glaser E.M. Watson-Glaser critical thinkingappraisal, Buros Seventh Mental Measurement Book,

; Highland Park, N;3;: The Gryphon Press, 1972,pp; 1212-1215;

Nelson, M.3., Denny, E.C.,, & Brown, J.I. The Nelson=Denny-reading test (vocabulary, comprehension, rate).Boston: Houghton Mifflin Company, 1973.

_ .

National League for Nursing, Inc. Com Unity healthnursing- achievement test. New YOrk: Na ional Ldagu-dfor Nursing, Inc., 1980;

National League for Nursing, Inc. Medical SurgicalAchievement Test; New York: National League forNursing, Inc:, 1982.

Gover, Virginia F; Nursing Performance SimulationInstrument (NPSI); The UniVerSitY of North Carolina atChapel Hill, School of Nursing.

55

COLLABORATION :A- BASIS_FOR POLICYMAKING

Kathleen Mikan, 2N, PhDDirector of Learning Resources

Kathryn Barchard, PhDDirector of Research-and Development

School of NursingUniversity of Alabama in.Birmingham

Collaboration between nursing service and nursingeducation has long been a deSirable; but often difficult;goal to achieve. While educational institutions ZiSC't it*to the concept of collaboration and often report theycollaborate with their affiliated health care agencies,little research has been cOndUcted on the extent of thiscollaborative relationShip. The purpose of this study wasto measure the extent to which there was collaborationbetween nursing education and nursing service within oneuniversity setting.

While collaboration_ 1:tween nursing service andnursing education ofteii fOcuses on collaboration in re-gard to sereetioni Supervision; and evaluation of student:earning experiences, thit study measured the extent ofcollaboration in dot one, but three areas of nursing -prac-tice-- nursing, education, nursing service,' and nursing re-search.

Data _were collected through a questionnaire sentto all nursing Staff; faculty; and students who wereinvolved in undergraduate clinical learning experiencesin the university hospital setting at the time the studywas conducted.

The population surveyed included 163 nursing staff,31 faculty; and 137 students; The results were based onthe responses of 81 nursing staff; 24 faculty; and 121students.

5663

---Data were analyzed according to the perceived

collaboration of each of the three role groups andaccording to the combined groups' perception of tht,extent of colliiboration in regard to each of the educa-tion, nursing ca-e, and research activities listed on thequestionnaire. - Similarities and differences in percep-tions of collaboration regarding nursing education, ser-vice, and research were found pirnong and between thethree role groups. Also differences in perceptions werefourid in the extent to which there was collaboration inthe areas of education, service, and research;

The implications of this study for practice; educa-tion, and policy making are:

1. that nursing service and nursing educationidentify:

a. their philosophy of collaboration;

b. how collaboration relates to nursing education,nursing care, and nursing research; and

c. how much collaboration there should begiven the different job responsibilities of thefaculty and nursing service in a particularsetting.

2. that nursing education and service continue tocollaborate on nursing educational and nurs-ing service activities-and improve their collab-oration in the area of nursing research.

3. that nursing education and nursing serviceidentify ways within the setting to fosterfurther collaboration.

PROFESSLONAL tiEVELOPMENTAND CONTINUED LEARNING

Virginia Layng Millonig, PhD, CPNPAssociate Professor

Coordinator, Nursing Continuing EducationDepartment NursingGeorge Mason University

The purpose of this study was to investigate therelationship between motivational orientations towardlearning and participation, of registered nurses in con-tinuing edLitatiOn activities; Motivational orientationswere thoSe underlying reasons for participation in con-tinuing education activities; specifically the factors ex-tracted from an analysis of the responses to the Educa-tional Participation Scale (EPS); Answers were sought tosome related questions of secondary interest whichinClUdtd educational background; level of position held;job satisfaction levels; and participatory behaVicit. Theatriple included 350 registered nurses who had been

engaged in full=time practice for the past year. Theinstrument consisted of a 4elf-administered question-naire divided into three sections. The first _section wasdesigned to collect pertinent demographic information;the seelnd section was an adaptation of the EducationalParticipation_ Scale; and the fin s I part consisted of., anadaptation of the Minnesota Satisi;.-4,,ri Questionnaire.

Factor wrialygis of the EPS with subsequent analysisof the relationship between these factors and partici-.pation in continuing education indicated a significant;relationship between the motivational Orientations ofprofessional advancement and external expectations andparticipation in continuing education. Analysis of vari-ance to determine the relationship betWeen educationalbackground and participation in ,continuing education

58

65

resulted in a significant relationship. Subjects withmaster's degrees were the most frequent participantswith hospital diploma, baccalaureate; and associate ofarts degree graduates following respectively.

Cross tabulations generated for questions of second-ary interest revealed a significant relationship betweenlevel of position held and participatory behavior; The'most frequent participants were those at the adminis-trative level; subjects at the staff nurse level were leastfrequent- participants. A significant relationship wasfound between level of position and participation whencontrolled for prior education. Subjects with master'sdegrees at the mid-mlnagementlevelwerethe mostfrequen+ participants and subjects with associate of artsdegree.; at the staff level were the least frequentparticipants. A significant relationship was found be-tween job satisfaction and participation when controlledfor education and position level. Baccalaureate grad-uates at the mid-management level were high in both jobsatisfaction and participation. Associate/of arts degreegraduates at the staff level were low in/job satisfactionand participation.

Results of this study indicate that both education andpractice should be involved in policy-making decisionsregarding continuing education and job satisfaction. Re=sources need to be developed that will allow thediploma-prepared nurse to enter into the educationalsystem. Diploma-prepared nurses. demonstrated. .highparticipatory behavior in this study. However, the areafrom which the sample was selected is rich in resourcesand the practice arena is supportive of the educationalprocess. Satellite educational centers and flexible cur-ricula need to be developed to enable the diploma nurseto pursue further education. /If the profession proposesthe baccalauzeate degree as the professional degree,both education and practice must provide the resources.Nursing education also needs to be aware of the external \,forces that are motivating nurses to participate in

59

continued learning; Professional development throughcontinued learning must be an integrated. component ofthe nursing process. The practice arena needs to becomeaware of the participatory behavior of administrative)Mid=rnanagement) and staff nurse leVels. Reward sys-tems should be developed to increase participatory be-havior; A comprehensive reward system may thenContribute to higher job satisfaction level-. Finally)practice and education must together examine the rela-tionship between job satisfaction and participation incontinuing education: Does participatory behavior leadto increased job satisfaction or does _job satisfaction

influence-partiCipatory-behaVior?

References

Boshieri R.W. Education participation scale. Vancouver:Learning Preis, 1982.

Weisi D., Bawls, R., England) G., ?lc Lofquist, L.Manual for the Minnesota satisfaction Questionnaire.University of MiririeScita) 1967. ,

6067

DEPRESSION AS AN EXPLANATIONFOR DECREASED SUBJECTIVE TIME

IN THE ELDERLY

Principal Investigator: Margaret Newman, PhD, F.A.A.NProfessor of Nursing

PennsylVania State University

Co=InveStigator: Judith X: Gaudianb, MSInstructor, Department of Nursing

Bloomsburg State CollegeBloomsburg, Pennsylvania

While some previous studies regarding ten-it:iota.' ex-perience in the elderly- have demonstrated marked in-creases in subjective time in older subjects when com-pared to younger-groups, others show little or no differ-ence (Bull, 1973; Newman, 1976, 1979; Ent.e; 1980;Time perception is clearlY an individual phenomenonrelative to many known factors; by temperature;metabolism, drug intoxication, body _movement, culture,and mode of inforrnation-processing (Hoagland; 1933;Phaff, 1968; Goldstone, 1967; Hall, 19592 Newman,1976). Time perception relative to age has been con-ceptualized as a deVelopmental index of the humanbeing's increasing complexity across the life span(Newman, in press). Still, there are sufficient numbersof subjects within selected samples who do not demon-strate the projected pattern of increaced subjective timewith age, and at leaSt two questions must ;7e answbred inthis respect: Is age an adequate_ 'nolt-::tri? of develop-mental level? IS there a state factor operating whichwould alter the &lode: of information-processing andthereby explain the deviation from what appears to be atrend toward temporal expansion with age?

To address the latter question, the variable of de-pression was examined in relation to subjective time.

61

Depression is recognized_ as a common and serious prob-lem among the elderly (Goldfarb; 1960; Epstein; 1976).It is not the purpose of this study to explore reasons forthis occurrence, blit rather to determine whether or notthe occurrence of depreStion might provide an explana-tion for the experience of decreased subjective timeTherefore, it vas_ hypothesized that depression would benegatively related to subjective time.

Subjects for the study were volunteers from a con-gregate meal program in central Pennsylvania. Thesample (N = 68) was restricted to women over 65 yearsof age (mean=age,==70.44); All subjects were ambulatoryand lived at home.

Depression was defined as an affective state charac:teri2ed by a negative Self- concept associated with Self-reproach and self - blame; and was measured by the BeckIlpression. Inventory (BDI) (Beck; Beathesderfer, 1974).The BDI has been validated by correlation With clini-cians' ratings of depression (0.65 --and is _sensitive tochanges in clinical ratings. AliKcjiigh the BDI wasdeveloped and tested initially on young and iddle=agedadult psychiatric patients; GalLgher (1980) haS ShOWn itto be a consistent indicator of depression in the elderly.

The BDI was administered to the sample in twogroups of 30 to 35 subjects at the_ congregate mealtenter. Following completion of the BDI and a personaldata questionnaire, subjects were individually tested inregard to subjective time.

Subjective time was defined as an individual's esti7mate of. the duration of a short interval as determined byhaying the subject prodtke an interval Of 40 seconds.The interval produced by the subject was Wiled by theexperimenter using a fin-ely=calibrated Portspring stop-watch;

A Pearson product moment correlation statistic wasapplied to the depression scores in relation to the

62

6f)

subjective time estimates and resulted in a coefficientof 0.3474 (p < ;002); Therefore, the hypothesis wassupported; Higher levels of depression were related tolonger production estimates, which indicate underesti-mation of the interval, or decreased subjective. time.

From a physiological standpoint, aging is viewed asslowing down, or deterioration, accompanied by thedifficulties, emotional- and logistical, of adjusting tothese losses. At the. same time, the activity or utilitytheories of aging indicate that an individual can maintainor increase his or her functional capacities with aging aslong as he/she stays active and fulfills a useful purposein society; Consequently, policy decisions and healthpractices related to the elderly have emphasized rr.=..-n-taining high activity levels. Activity is vi.twco aspositive and inactivity as negative.

The results of this study, in conjunction with previousstudies of time perception across the adult life span,point toward subjective time as an indicator of quality oflife. The predominant trend toward increased subjeCtivetime with aging is evidence that as one grows older,one's time is expanded. Moreover, increasing recognitionof the therapeutic value of reminiscence suggests thatthis expanded time Lmay _represent ; contemplativeactivity, which is a meaningful developmental task ofaging. Such a view cast doubt on interventive measuresbased solely on increased interactivity and suggests theneed to explore measures designed to support and facili-tate intra-activity.

References

Beck, A., & Beamesderfe-,\A. assessment of depression:the depression inventorY, Psychological-Measurement

151-169., .

Bull; .Effects of aging on temora1 experience. Unpub-lished doctoral dissertation, Purdue Universityi 1-973.

63 \

70

\ Engle, V. A study of t 9 e i6 tion, personal tempo, and

time perception-in-elderly-women. Unpublisheddoctoral dissertation; WAyne State University, 1981:

Epstein, L. aepression in the elderly. Journal ofGerontolomb 1976, 3-1- (3), 278-282;

Gallaher, D., Thompson, L., & Levy, S. Clinicalpsychological assessment of older adults. In L. Poon(editor) Aging-in_the_1980s: Selected ContemporaryIssues in the Psychology of Aging. Washington, D.C.:American Psychology Association, 1980.

Goldfarb, A. Psychiatric disorders of the aged: Symp-tomatology, diagnosis and treatment.. Journal ofthe-American Geriatrics Society, 1960, 8, 698-706.

Goldstone, S. The human clock: A framework for thestudy of health and deViant time perception. AtiRalsNew York Academy of Science, 1967, 138 767-783!

Hall, E. The silent language. Greenwich, Connecticut:Fawcett Publications, Inc., 1959.

Hoagland, H. The psychological control of judgment ofduration: Evidence for a chemical clack. -Journal ofGeneral Psychology, 1533, 2, 267-287.

Newman, M. Movement tempo_and the experience oftime. Nursing; R-searcil, 1976, 25;

Newman,_M. Theory development in ni.,sing. Philadelphia:F.A. Davis Company, 1979.

Newman, M. Time_ as an index of expanding conscious-ness with age. Nursing Research, 1982, 31, (5),290-293.

Pfaff, D. Effects of temperature and time of_day entime judgments; Journal of Experimental Psychology,1968; 76- 419-422;

71 64

HEALTH STATUS OF CHILDREN INRURAL AREAS OF THE_DOMINICAN REPUBLIC:

POLICY IMPLICATIONS FORNURSING PRACTICE AND NURSING EDUCATION IN

THIRD WORLD COUNTRIES

Francine E. Nichols, RNC, MSNAssistant Professor

St. Mary of the Plains CollegeWichita, Kansas (on educational leave);

Doctoral (.7:didate .

The Universit,, or= Texas at AustinSchc.c1 Nursing

Few statistics are available on the health status ofchildren in rural areas of the Dominican Republic. Themajor purposes of this study were to determine: 1) thehealth problems of childreh in rural areas of theDominican Republic; 2) differences in types of childhealth problems in specific villages; anc; s1 o.:jor areasnurses should emphasize in rural 127-ograms fo:-children.

This study was conducted during a two-week medicalmissions project in a primitive region of the DominicanRepublic. Clinics were held in churches or schools invillages where health care was virtually nonexistent:The field research methodology was used;

The sample consisted of 666 children, 5 years of ageand younger, who were seen in ditties held in eight ruralvillages. A form, which included the child's history-weight, height, vital signs, hemoglobin, chief complaint,and findings of the examiner, was used for data f ollec-tion. An interpreter obtained the child's historp fromthe parent; the child was weighed using regular house-hold scales; height was measqted using oa tape measurefastened to a door frame. The McLare and Reednomogram was used to evaluate the child's nutritional

This study was funded by the Southcentral KansasChapter Marth of Dimes Birth Defects Foundation.

65 - 72

status. A blood sample for a hemoglobin test wasobtained by finger or toe stick and evaluated using aBMS hemoglobinometer. Each child received a physicalexamination by a registered nurse skilled in pediatricphysical assessment._ seriously ill children and unusualcases were referred to a physician;

Frequency distributions and chi-square were used fordata analysis. Significance was set at p> ;01; The majorhealth problems were protein-calorie malnutrition (66percent), upper respiratory infections (5S percent), andotitis media (25 percent); Other health problems en-countered were anemia (16 percent), impetigo (1 -1 per-cent), diarrhea (10 percent)i parasite infestation (9 per-cent), and scabies (3 percent). There was a significantdifference in the types of child health problems found inspecific villages;

All villages were at risk for epidemics of childhooddiseases because of low immunization levels of thechildren. Many children were not protected againsttetanus; There was a significant difference in theimmunization levels-Aiptheriai pertussis, tetanus, andmumps; measles, rubella --of children in different villages.

Ninety-three percent of the children were i3:--eastfed(N = 466); The mean length of breastfeeding was 8fimantis (N = 32?). There was a significant difference inthe length of breastfeedinE between villages. Childrenin isolated villages tended to;be breastfed '.onger.

The findings clearly indicated that many children inthis study had severe health problems which could beresolved or improved by a preventive health care pro-gram provided by nurses.

several policy recommendations for nursing practiceand nursing education in Third World countries areMicated by this research: 1) Provision of preventivehealth care programs for children in rural villages.These programs should be developed by nurses, basedupon the unique needs of each village, and implemented

73 66

in cooperation with lay health workers in the villages.2) Reduction of malnutrition through education programsthat focus on the nutritional needs of the child, theimportance of breastfeeding, and farming methods thatincrease the productivity of the land. 3) Developmentof nursing education programs which focus on communityhealth, primary health care, and maternal and childhealth care.

Reference

McLaren, D., and Reed, W. Classification of nutrition inearly childhood. Lancet 1972, 3, 146-148.

67

_DOES CONTINUING_EDUCATION IMPROVENURSES' CLINICAL BEHAVIOR?

Sandra K. Oliver, RN, PhDAssociate ProfessorCollege of Nursing

University of South Carolina, 'Columbia'

This investigation was undertaken to evaluate theeffectiveness of short-term continuing education work-shops on the clinical behavior of nurses. The objectivesof the investigation were: 1) to design and develdpinstruments to measure physical %assessment skills ofprofessional nurses, 2) to evaluate the physical assess-ment skill level of nurses in the clinical setting inrelation to attendance at a short-term continuing educa-tion workshop on 'adult health assessment; and 3) toexamine the effects of specific background variablesupon the physical assesgThent skill level of nurses.

The research design for this investigation was a non-equivalent control group design; The control groupconsisted of 66 nurses who had not attended an AdultHealth Screening Workshop (AHSW). The experimentalgroup consisted of 87 nurses who had attended AHSWs;25 nurses in the experimental group also had attended anAdvanced Adult Health' Screening Workshop (AAHSW).Participants in the study worked in 23_ community healthnursing agencies in east central Iowa.

The research instruments included an attitudinalquestionnaire of variables influencing the use of physicalassessment by nurses; a coding form for physical assess-ment, and a record analysis form of physical-assessment.1:rriographic data alw. were collected. Groups werepretested with_prerecord analyses; The two groups werepost :sted with postrecord analyses coded on site homevisits, written test of physical assessment, and writtenattitudinal questionnaire,

68

The nurses did not demonstrate that their clinicalbehavior was changed significantly by attending an AdultHealth Screening Workshop; Generally, the nurses per7formed very few physical assessments before AHSWattendance, and this did not change after attending aworkshop; The specific assessments made and the qual-ity of those assessments were not affected by workshopattendance; However, the nurses who had attended theAdvanced Adult Health Screening Workshop did performstatistically better than the other nur,se groups on theheart and lung test sections. The AAHSW focused onphysical assessment of diseases of the cardiac and pul-monary systems.

From the nurses' viewpoint, their limited use ofphysical assessment was not caused by the lack ofexposure to physical assessment, of knowledge of theanatomical and physiological bases of physical assess-ment, of technical expertise in_ the use of physicalassessments, or of the support. from supervisors, col-leagues and clients. Although the nurses indicated thatthe workshops were appropriate and necessary for .theirjobs, they stressed that too much material was given intoo short a period of time for them to retain theinformation, and that follow-up supervised instruction inPhysical assessment was necessary in ,the local com-muniry health nursing agencies.

Short-term continuing education workshops _designedto ekpand the clinical skills of nursing are ineffectiveunless nurses frequently receive reinforcement for theregular use of the skills in the local nursing agencies. Tointegrate assessment skills into clinical behavitir, nursesneed reassurance, at the time they are doing the skills,of the appropriateness of their performance and of thcorrectness_ of their clinical perceptions; Without re-irforcerhent and immediate feedbacici the skills may rotbe masteteiand may be forgotten.

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76

If nurses are to expand their professsional responsi-bility to include primary nursing care, there must be aconcerted effort by nurse adminiStrators to stress theintegration of physical assessment with the nurses' assess-ment of clients' nursing care and health maintenanceneeds. When evaluation of nurses' health assessmentsdoes not include physical assessment, it is possible thatthese skills will be unused and eventually forgotten.

Short-term continuing education workshops whichteach assessment skills should limit the amount of datapresented in a single session; Students should be givenan opportunity to become relatively familiar with physi-cal assessment skills under instructor feedback. Pre-sentation of a large amount of data and brief practice ofmany skills does not lead to proficient performance ofphysical assessment; Formal review and reinforcementprovided by the follow-up workshops proved to be ofsome success in helping sudents to integrate assessmentskills into their clinical practice.

77 70

ACADEMIC CREDENI1ALS_ACCEPTED FORTEACHING IN

BACCALAUREATE SCHOOLS OF° NURSING, MPH AND MSN

William Larry O'Neal, RN, MPHDirector of Nursing and Associate Hospital Director

Providence-St. Margaret Health Center

Cheryl N. Porter, RN, MPHPool Nurse (temporary)

New Orleans, LA.

Edna G. Treating, RV, DrPHDirector, Nursing Section

School of Public Health and Tropical MedicineTulane University

The purpose of the study was to determine if theMaster of Public Health (MPH) degree with Com-munity Health Nursing (CHN) has credibility for teachingcommunity health nursing in baccalaureate schools ofnursing (BSN) and if the graduates with a Master ofPublic Health degree from Tulane University School ofPublic Health and Tropical Medicine had been successfulin obtaining teaching positions in baccalaureate schoolsof nursing.

This is a descriptive exploratory study. The popula-tion surveyed included'50 State Boards of Nursing and 84Tulane University School of Public Health graduatesresiding in the United States. These graduates from1962 through 1978 earned the Master of Public. Healthdegree with a specialty in Community Health-Nursing;

Data for the study were obtained from 49 StateBoards of ,Nursing and 48 community health nursinggrhduates from Tulane through mail-out questionnaires.Two tables were utilized to demonstrate the extent ofState Board acceptance of the MPH degree in Com-munity Health Nursing for teaching; community health

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' nursing, and provisions for faculty members with othergraduate degrees who are currently teaching. An addi-tional series of four tab#s were used to demonstratecharacteristics of respealents for year of graduation,teaching status, type(s) of nursing program(s), state ofemployment and extent of opposition or difficulty en-countered ,with the MPH degree with a CHN specialty byfaculty any State Boards of Nursing; Additionally, datawere summari2ed in sentence form; No statisticaltesting was indicated it-. the presentation of data;

Of the 50 State Boards of Nursing survevea, only one(Utah) did riet respond, Two of the responding StateBoar& (NeW York and Mississippi) do not accredit bacca-laureate scheelt of nursing. The MSN is tic:: required forteaching in BSN programs by 29_ of the 49 respondingState Beards, however two of these (Marie and RhodeIsland) de not accept the MPH degrees Maine pre-approves faculty credentials and responded that thequestion of the degree was not applicable; Rhode IslandWas in the process of changing (1931) to a MSN require-Merit. AddltiOnallyi Pennsylvania and Illinois skated thatthey do not accept the MPH/CHN; Pennsylvania statesthat fatuity mit. did not possess the MSN on employmentPrior to J980 are required to do so within five years andcannot c lead teachers completion. Illinois has Agrandfather clause for faculty employed prior to '4980 asion; as they remain at the same institution. ReSpon=dents indicated 45 or 91;83 percent, of the State BOArdsaccepted the MPH with CHN specialty for teaching inBSN programs; regulation. was pending fot. the MSNrequirement in nine_ states between 1931=1990, witheight having provisions for faculty with graduate degreesother than nursing;

A total of 48 (57.14 percend of CHN graduates fromTulane responded, with 30 (35.71 percent) indicatingcurrent or previous teaching in baccalaureate or higherdegree nursing programs. Only two of these respondents

d 72

kr.vledged_some difficulty (Louisiana and Alabama)....:ciduate responses to la MSN requirement for teachingin respective states differed from State Board responsesin Louisiana; Georgia; Michigan; Alabama, Indiana,Missouri, and Texas.

Relatively little opposition from State Boards ofNursing and faculty in baccalaureate schools Of nursingexists with regard to acceptance of the Master of PublicHealth with a specialty in. Community Health Nursing forteaching this specialty in baccalaureate schools of riurs-

--itigT Of those states requiring the_MSN_; the _majority_have provisions for accepting the MPH. State Boards ofNursing should consider these findings and current trendsbefore changing regulations.

Public/Community Health Nursing was the first Nurs-ing specialty. Further study is recommended on a largersample of community health nursing graduates and theirunique contributions to teaching in their areas of spe-cialization in a BSN pi.ogram.

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80

THE _EFFECT OF A CITIZENS' NURSINGTASKFORCE GROUP ON NURSING PRACTICE ANDCOMMUNITY PLANNING FOR HEALTH CARE

JoAnn H. Patray; RN; PhDAssistant Dean for Continuing' Education

College,of_NtIrsin_University Of Florida a Jacksonville

A Citizens' TaSk F6rte on Nursing was organized toexplore the issues related to nurse recruitment andretention in the northeast Florida area.

Volunteers and community leaders were asked toactivate a citizens' study group to examine data from awide-scale survey of nursesi hoe. t-ttimony about nurs-ing practice from health care experts,_ and formulaterecommendations baSed on ahalysis of these data; Addi-tional resource rnaterials in the study process includedother national and state surveys, journal articlesi localand national media coverage. Task Force deliberationsincluded analysis of often conflicting data and discussionof many-sided complex issues and their resolution. Prob-lem areas were identified and recommendations Wereformulated. F6116W-Up studies based on the recommen-.dations are now in process.

Problem areas identified by the Task Force wereeducational CoriternS-, rapidly changing nursing roles andresponsibilitieSj inadequate compensationi difficult hier,.!archical professional relationships; and a high rate ofturnover and diSSatisfaction in nurse positions. TaskForce deliberatiOnS culminated with the drafting ofrecommendationg related to the following areas:

recognition of the essential need for continuingedutation and trainins\for new nursing roles

a study - to identify the grOwing judgment andskill levels require:i in nursing

74

determination of cost-specifications and revenuegeneration of nursing

establishment of pay - graded ugh careerladdering

management training for nurses at all levels

appointment of a joint steering committee-offaculty and nursing educators for planningstudent clinical experience

nurses' involvement in nurse practice committeesand peer review

top management appointments of nurseadministrators

career planning for all nurse employees

a concerted effort of the health professionsto provide public information on the changingrole of the nurse in today's health systems.

Both nurses and consumers of health care have avested interest :in resolving issues related to nurse re-cruitment and retention. An informed pUblic can providethe external power structure essential for char_iges 'innursing practice and health care institutions for theenhancement of quality health care. Citizens' taskforces on nursing can provide an accurate, objectivebroad data base for analyzing nurse problem areas andrecommendations for changes in long-range planning andformulation of policies related to nursing practice;

7582

THE UTILIZATION OF DERMATOGLYPHICSIN THE ASSESSMENT OF LEARNINGDISABILITIES AND HYPERACTIVITY

Patricia A. Payne, RN, PhDInstructor, School of NursingUniversity of Texas at Austin

Dermatoglyphics_, the scientific study of epidermalridges and their. pat ..rns, has been demonstrated to bean important too! in such diverse areas of study asforensic science, anthropology, human genetics, andmedicine (Wertelecki and Plato, 1979). It serves as aquick, inexpensive, and non-invasive diagnostic tool for avariety of genetic, 'chromosomal, and perinatal disorders'(Schaumann and Alter; 1976). The ove ing'_parpose ofthe present investigation was to deteriiiine theness of this method_ in the clinical practice of nursing;more specifically, the usefulness of dermatoglyphics inpredicting differences. in the diagnoses of .learning dis-abilities, hyperactivity, and. learning disibilities7 plushyperactivity.

The concepts of learning disability and hyperactivityare similar to many_ other cone..epts in nursing in thatthey lack clarity. The confusion stems from the con-cepts being poorly defined, both theoretically and open,atonally, and from the lack of_ _a clearly identifiedetiology for each of the conditions (Pine; 1977; Ross andRoss, 1976); Nurse practitioners, confronting the reality °

of human beings experiencing learning and behavioralproblems, might structure more accurate and appropri-ate interventions if they had a better understanding ofthe causation of such problems and a. quick, inexpensivemeans of screening for possible etiological influences.Theoretically, dermatoglyphics should provide a meansfor screening_ for learning disabilities and/or_ hyper-acti-Crity resulting from genetic or perinatal influences.

76

The forniation of the dermal ridges; their patterns,and place and frequency of occurrence is to a largeextent genetically determined (Holt; 1968); if the phe-nomena of learning and/or behavioral problems have agenetic etiology; the dermatoglyphics of persons withthe same problems should be similar. Dermatoglyphicformation is also affected by the uterine environment(Holt; 1968); If the learning and/or behavioral problemsare the result of perinatal insults which have commoneffects on the uterine environment; the derfilatoglyphicsof the persons with the same problem should be similar.11 the problems result from other factors or if they arethe same phenomena; dermatoglyphic data would notserve to distinguish among the groups.

,nis study attempted to determine if dermatoglyphicdata could contribute to correctly predicting the diag-noses of learning disabilities) hyperactivity) arid 'learningdisabilities plus -hyperactivity. It was hypothesized thatthe three diagnostic categories represent three distinctconcepts and that persons included in one category couldbe distinguished from persons in the other categories. Itwas also hypothesized that each of the three diagnostic

2gories was composed of etioi-aically distinct sub-:ro

le sample consisted of a if 255 cases ofcruldren diagnosed as learning dis,__Jility .136), hyper-activity (N 41), and learning disability f hyper-activity (N 78). Demographic and dermatoglyphicdata were obtained from an established data bank in,central Texas. The data obtained were analyzed usingdiscriminate analysis; a technique designed to identifydifierences among groups on several variablessimultaneously.

The discriminate analysis of the dermatoglyph:c andsex data of children with ti -.se diagnoses yielded asignificant discriminate function (x 2 = 65;27; df = 40;

ThT classification results for predicted group

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membership were also significant (ic2 = 49.12, df = 4,p< .001). The discriminate analisis of the dermatoglyphicand sex datl of children in the three diagn6Stic groupswho had a positive family history of learning andiorbehavioral problems = also yielded a significant diScriin7inate function (x2 = 65.01_ = 4, p ,= .0075) andclassification results (x2 = 48;69, df r7-- 4, p<.001). Thediscriminate analysis of the same variableS fo.- Childrenwith the three diagnoses but with a negative familyhistory failed to yield a significant discriminatefunction; The findings lend support to the nc. 'ic.i thatthe three diagnostic categories represent :distinct andseparate phenomena and that within the categories existetiologically distinct subgroups.

Further research is definitely needed in this area Ifthe findings of this study can be supported and `refined,dermatoglyphic data could bectime a very_impsrtant toolin the nurse's assessment of perSonS with learning and/orbehavioral problems. aerrriatoglyphi may also providedefinitive data for persons responSible for formulatingpolicies and legislation regarding genetic counseling i:s.n&early detection and intervention fOt persons with learning disabilities and/or hyperattivity;

Peferences

Fine, M ; 3 ; (Ed.) Principles and tot hri itiues of interventionwith hyperactive. childr--Charies C. ThomaS, Publisher, 1977;

1-Iolt, S.B. ThegeneticS of dermal-ridkze.s; Springfield, III.:Charles C. Thomas, Publither,1768;

Ross, D.M. and Ross, S.A. Hyperac:iviw! Researchtheory, and action. New York: :Tohn Wiley andSons, 1976.

Schaff -. Bann, B. and Alter, M; Dermatoglyohics in medical.;..1rders. New York: Springer-Verlag, 1976.

Wer-alecki,, W. and Plato, C.C. (Eds.) Dermatoglyphics_-fifty tears later; New York: Alan R;-Liss, Inc., 1979.

8578

DUCOVERY OF NURSING GESTALT INCRIT:CAL CARE NURSING: THE IMPORTANCE OF

THE GRAY GORILLA SYNDROME

Sue lioYland Pyles, RN, 43NAssistant ProfessorDivision of Nursing

College of Life SciencesLouis:ana Tech University

This research -addresses the question: What variables .inth:ence the development and use of assessment anddecision-rm..,%ing skills of critical' care nurses? Whilethese skills are inherent to critical care nursing, littleattention :las focused an what the underlying-cognitiveprocess involves or hcw it is developed and used; Whenthese processes are no. completely developed, nurses andpatients are often placed -in vulnerable situations; Meseproblems are of p rticular interest to nursing service andeducation-, in that nursing shortages and high turnover,rates have resulted in the increased use of new graduatesand less expe -.aced nurses in critical care units.

The research approach was that of grounded theory, afot m of quaiitativ:' methodology; Data were collected.\`rom interactions and in-depth irlterviews with 28regis-'tered nurses who work in medical intensive care units of

predorninantly)argei metropoliter. hospitals.

Findings from this study led to i r. generation andvalidation of NursirE _Gestalt as the cognitive processused by veteran crNca-f- nare' nurses in making assess-merits and judgments; Nursing Gestalt is. a matrix'operation .whereby nurses relate basic knowledge, pastexperiences, identify :;g cues, and sensory clues, includ7ing_what nurses call "gut feelings," to arrive by means ofcliff zrentiation at diagnoses upon which they bas^ theircare; Experience and mentor-neophyte relationships,termed. the Gray Gorilla L..:ndrorne, were found to bethe most impOrtant factor:, it the development and useof Nursing Gestalt.

79 tip-

The Gray Gorilla Syndrome involves the teaching-learning process and support system the critical careneophyte rierivr.s from mentor--the Gray _Gorilla. Theterm is descritive and refers to the silverback primatewho serves as a leader - teacher - protector -role model forhis group. The nature, benefits, causes and effects of itsabsence; and the development of the Gray Gorilla werediscussed. It was postulated that whether neophytenurses in critical care units will actually achieve success

depend a great deal on their socialization into thatworid; tha-r. develops rent of Nursing Gestalt; when itdoes occur, is an unintended_ result of the naturallyoccurring mentor-protege relationships; that developmentof Nursing Gestalt, without. the presence of a mentor,can occur, but it requires much experience, which isha1lrr eked by trial and error.

These findings provide direction to those invoi,ed innursing practice, nursing service, and nursing education.By identifying Gray Gorillas, encouraging their use anddeyelopMent, providing pcsitive feedback for their" ef-forts, and recognizing their contributions to nurses andnursing, great strides could be achieved in reducing theproblems of patient care; burnout, and nursing turnover

critical care units.

Other reco_mmendat.ons those which couldenhance the de.vel...-;ment and use of assessment anddezision-making sk..:Is of critical care nurses through theimplementation _of: (a) the assessment criteria identi-fied in this study; (b) standardi7..ed scales to documentsubjective findings; _(c) flow sheets designed for thespecific needs of medical intensive care units to aid inthe detection of ;rends; (d) guided ex,7eriencz,s withGray,, Gorillas in the development of critical care nee-phytes;, (e) Nursing Gestalt as the basis- for the decision-making process;_ (f) iri-service and continuing. educationalprograms specific to the needs of critical,care nurses.

80

EFFECTS OF INTERMITTENT MANDATORY_ STIMULATIONON APNEA AND TcP02 IN PREMATURE TNFA NTS

Patricia Boudolf Rausc.h.,, RN, NSW_Staff Nurse

Jeffrey K. Ma 4 'mit-SkiRespiratory TechnicianShandi Teaching Hospital

Gene Cranston Anderacm, P.A.Jj.N

Professor -and-Research CoordinatorCollege of Nursing

University of-Florida

The purpose of thit study was to determine the effectof intermittent mandatOry stimulation (IMS) upon apneaand transcutarieciUS arterial oxygen tension (TcP02) inthe infant with respiratory diStress syndrome. Thesample consisted of 10 prematUre infants who were notintubated or receiving theophyIliriej and who were diag-nosed _as having apnea followed by bradycardiaInformed parental consent WAS obtained.

The IM!7. treatment consisted of rhythmic and moder-ate inflation and defla.tion of an anesthesia bag 16 to 20times per rilinute. ThiS Ei far; -1 with time-cycledintermittent posi.ive t:Ss0:-* ,ors. The intentionwas to provide rn,:,%%,i similar to that which thepremature infant, fet-3 in utero, would haveexperienced from MaseeIal respirations; Each infantwas placed on the IMS bag for two consecutive 1,3,urs,divided into eight l5-MinUte r bag wasturned off during PeribdS 1, 3, 5; and and turned onduring PeriodS 1.. 6 and S. Heart rate, respirations,and Tr: PO2 were recorded once each minute. Apnea wasmeasured with an apnea monitor set at 20 seconds.

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During the periods that the IMS bag was turned onthe mean heart rate was 163; as opposed to a mean _heartrate of 154 while the IMS bag was turned off (p <.9001)-.Similarly, mean TcP02 'N.VaS 70 during the "on" periodsand 56 during the "off' periods (p <.005), There was onlyc ie apneic episode during "on" periods, as opposed to 22episodes for "Off" periods (p < .0001). Mean respiratoryrate was 42 fo both "on" and "off" periods;

The IMS treatment appears to have potential forincreasing TcP02 and reducing apnea ioninvasively; non-medically, and rei,.:.vely simply. Ce st _effectiveness ispossible through use of out - monied 1_,..1t functional venti-lators stored in many hospitals.

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VALIDATION STUDY OF CORE ri.:01FOR A GRADUATE

MATERNAL-INFANT NURSINi.'i CUP ULUM

Rene Mi Reebi CNMi PhDAssociate -rofessori School of Nuroin

University of Mississippi

Two major problems were identified in the literattir'?::oncerning delineation of clinical course content for;raduate nursing curricula. The first was the lack ofesearch related to the design and fovis for graduate!ducation in nursing; the second related In the lack of adearly defined body Of knowledge that constituted theliscipline of nursing. This_was not peculiar to the Uniteditates, as the structe of nursing programs was one of:he international concerns among leaders in nursing.ducation atteriding the International Council orSlursing's 16th quadrennial congress in Tokyo, June 1977.

The primary purpose of this study was to determine if;raduate nurse educators preprr.-A at the mastct's de-;ree level in three functional rt. areas would validate;elect knowledge ana skill items as a clinical core. This:ore could be used for the development of course con-.ent for maternal-infant graduate nursing students whowere enrolled in one of the three, functional role

secondary purpose was to measure any significantiifferences in the frequency oi responses among the;raduate nurse educator groups.

A descriptive survey design using mail-out ciJes-ionnaire to a national &ample of graduate nurse edu-:ators was used for the study. A pilot study was:onducted. Internal consistency and content validity of:he instrument were cl:.:.ermined. The instrument con-dsted of 60 items: A 75 percent agreement responseimong the three groups a!: graduate nurse educators waq'equired for an item to 15:: ransidered core;

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Data from 107 survey instruments (77 percent) wereincluded for the Study arla*::;es. Internal consistency wasescablished at r = .93 rising a Kuder-Richardson formula(KR =,20). Fdr-ty=ti.Vo of the 60 items met the criteriafor core. For two of the items (one core; one not core)there was a Significant difference in how the graduatenurse educators respr,lidedi as measured by the -chi;square test at p = ;05.

The identification of a core clinical content area formaternal=infant graduate nursing students enrolled inmultiple functional role areas could be beriefitial forprogram structure development; Development of amulti-track curriculum design with didactic care clinicalcontent areas would accommodate larger groups of stu-dents and provide for increased efficiency in facultyutilization. The increased interaction across functionalrole are could facilitate research efforts amongmaternal=inf ant clinical nursing leading to formulationof theoretical_ constructs and model development for thematernal-infant clinical nursing area.

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SECONDARY ANALYSIS OF DATA ONNURSES' ETHICAL JUDGMENTS MEASURED BY

TYPE OF BASIC EDUCATION AND CLINICAL UNIT

Barbara J. Reid RN, HdDASsociate professor

Janet M. Burge, RR, PhDProfessor and Chairman

Graduate ProgramUniversity of Alabama in Huntsville

Studie3 dealing with cogrative thee, moral de-velopmer.t have been widely dczumer `corks byPiaget (1965), Kolberg (1969), and F: 174) haveserved ,:as simile.: basic to the area ox develop-merit. These studie3 were based almost entirely onsubjects' responses to hypothetical. dilemmas. '.:udies byJacobs (1979), Damon (1977), and Haan (1978) show somedocumentation th:t morTc reasoning in hypot!tetical situ-ations is ccrsparable with moral reasoning made ;r1 real-life situations;

In n,.:rsingi which uses the problem-solving proceSs forbasic decision meting, There is tittle documentationwhich deals with thz personal value structure of nursesand the Impact of relationship of these values on de-cision making. Crharn OM found a low but signi-ficant correlation betwec-n nurses' znoral judgment abotnhypothetical dilemnias and moral judgment about real=life dilemmas; She had expecte(' to find ;, significantlyhigher correlation 'between the two.

It is felt that as medical care_ Lecornes morehigh'ytechnical and specialized, moral. decision Making by

nurses will become _more_ complex. The purport of thisstudy was to txp,--ond and build_on the research being_ donein all phases of decision making by nurses in clinicalsettings. Since the educational preparation has herdocumented as the most powerful correlate of moraljudgment development, it was selected as one of the

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variables for this study: second,irideperident ':able was the type of unit on which the nurse worked;These were divided into four majon categories: Surgical;Medital, Maternity; and Intensive cdee.

Three null hypotheses were formulated to test theresearch question at the ;05 level of significance. Whateffect does basic nursing educationa.k preparation and thetype of unit worked_on have on moral decision _making?

hypotheses were 0 There will be no difference inweighted rank scores between 3 levels of nurses'

bas:t educational preparation; regardleSS of unit whereen,DlOyed; 2) will be no differente in meinWeighted tank scores of nurses working tin four differentunits, regardless of basic educat:L.7i zpreparation; 3)

There will be no interaction between basic educationalpreparation and type of unit 1,/orked on as measured byMean weighted rank scores on the Nursing DilemmaTest.

A convenience sample of 92 nurses from severalnorth Alabama hospitals V./S An SPSS two-wayfixed effects analysis of vz.riance was performed; As aresult, there was a failu.-e to reject all three nullhypotheses (Unit p > .007;. Educational Lvel p> 835;Unit by E0Jcational Level p >.628);

In the sample of _registered nurses tested; basiceducational level or unit on which the subjects workeddid not make a difference in trieir ethical 'decisionmaking; Is nursing education making any impact onteae;ting ethical decision making? Probably not at thispoint in time. However; would m_wr obtain the saeresults five years from now --particularly when theteaching of ethics is just coming_to the forefront ofnursing education? There is also a :3;fference- between'.real life dilemmas versus hypothetical situations. Aninteresting topic fc:r further research is to have asampleof practicin nurses discuss the scenarios of Vie NDT and

then do the i Istrument. Would there then be a signifi-cant differie, due to basic educational experience, unitworked , and age`).,

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References

Crisham, P. Moral judgments in hypothetical and nursing /dilemmas. DOctoral dissertation, University ofMinnesota, 1979. Dissertation Abstracts- International,1979, 40, 4112=13.

nam)n; W. The social world of the child. San Francisco:Jossey-Bass, 1977;

Hann, N. Two moralities in action contexts: Relation-ships to thought, ego regulation and development.Journal of Personc.,I and Social Psychology, 1978, 36,286-3-05.

Jacobs, M.K. Women's moral reasoning and behaviior in acontractual form of prisoners' dilemma; Doctoraldissertation, University of Toledo, 1976;

Kolberg, L. Stage and sequence: The cognitive-developmen-..alapproach to socialization. In Handbo-ok-ofocial-ization theory and-research; ed; by D.A. Goslin; Chica:;f::Rand McNally; 1969; pp; 347-480;

Piaget, 3. The moral judgment of_the-child, translated b5M. Gabin. New York: Free Press; 1965;

Rest, R. Manual-for defining,istruert test: An ab'activeent. Minneapolis: University of

Minnesota, 1974. mimeographed)

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THE RELATIC 7"113 BETWEENSELECTED ENVIRONMk I AL VARIABLES AND

THE GROWTH OR DECLINE OF BACCALAUREATE;ASSOCIATE DEGREE, DIPLOMA; MASTER'S, AND

DOCTORAL PROGRAMS IN NURSINGBETWEEN 1960 AND 1978

Mary Ann Rose; RN; MSNi EdDActing Director of Graduate Studies

School of NursingEast Carolina University

Since the early Sixties; the number of nursirii;; c6;!L-a-tion programs of various types has C.L.;!'ec! rri :'rizPdly;Hospital-based programs have deer- whhz. thosebased in community colleges have dramati-

c.ally; Baccalaureate programs have inc:-eased slowly;but the number of master's and doctoral -programs hasrisen ;sharply; The objective of this study was todetermine whether there was a relationship betweenthese organizational changes and selected environmentalvariables; Environmental variables included wages - ofnurses after graduation; federal funds awarded to nursingeducation_ programs, therequirements for entry into nursing; accreditation re-quirements for director rind :acuity in nursing educationprograms; and career options open to.women.

[sing population ecology (Aldrichi_1979) and resourcedependence (Pfeffer and Salancik; 1978) perspectives forviewing organization-environment - relationships _agg,',7:sate tdata for the years 1960 through 1978 wei.z collectedto measure changes in each variable. Anaiysi:, revealeda strong positive relationship,etween wages of graduatenurses and the number of associate degree and bacca-laureate programs. An equally strong inverse relation-ship as demonstrated between wages of\nurses and t henumlier of diploma programs.

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There was a relationship between federal fundsawarded to baccalaureate and associate degree programsand the number of these programs. No such relationshipemerged betweer fund: awarded to diploma programsand the number of these programs. There was norelationship between the controversy over the entrylevel requirements and the number of any type ofprogram.

.Accreditation requirements were related strongly to

changes in the number of baccalaureate programs andifiVersely related to the number of diploma programs;They were less strongly._ related to the number of asso-ciate degree prograMs. A particularly strong relationship;however, was demonstr4ted between accreditation re-quiremerit§ for faculty and director of baccalaureateprogram§ and the nuitiber of doctoral programs. Finally;there was a strong inverse relationship between career

toptions for women and the number of diploma- programsland a strong positive relationship between these options

)and the other types of programs;

These findings have important policy implications.FirSt, the findings clearly indicate that the larger un-fOlding events in our society have a significant effect onthe survival and growth of schools of nursing; Inessence, it piaces the role of the administrator in ouredLCaL1unc I uigaIii4ations - n erspec Ive ,be-cause the administrator may net be totally responsiblefor the fate of he- own organization; the organiz.7,.tionmay be a ,ittim" of forces in the larger system itself.The recent closure of several baccalaureate programsmay be a good example of_ this phenomenoni Admin-istrators of schools of all types should be taking an activerole in trying to influence these environmental factors.

Second, it is apparent t'llt some forces or "trends" innursing today may have effects on the profeSSiOn whichare not intended by those who originate or favor thechange in question; For example, nursing has applaudedtne growth of the women's movement for the increased

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autonomy which it promises for the profession. How-ever, it may be that this societal force may also impacton the distribution of our schools of nursing in wayswhich were not intended by nursing itself; In evaluatingthe long-term impact of both present and propdsedpolicy, therefore, we must focus not only on the impactof such. policy on the practitioners of nursing individuallybut also on the policy impact on the nature and distri-bution of nursing education organizations themselves.

Ref e-re_nces

Aldrich, H. motions and environments;_EnglewoodCliffs; New ersey--iIYFentiee Hall, Inc., 1979.

Pfeffer; J; and Salanciki E. The external control _of_organizations; New York: Harper and Row, 1978.

RELATIONSHIP OF LIFE_STRESS TO DYSFUNCTIONALUTERINE BLEEDING IN

WOMEN OF CHILDBEARING AGE

Ann M; Rosenow, RN, PhDAssociate. Professor

University of North Carolina at Greensboro

James Geyer, PhDDirector of immunology

Roche-Biomedical LaboratoriesBurlington, Mirth Carolina

The relationship between life stress and dysfunctionaluterine bleeding (DUB) in women between the ages of 20and 45 was examined in a correlational survey incorpo-rating both psychosocial and physiologic measurements.Subjects were 25 women with abnormal uterine bleedingfor which no organic cause could be found through theusual diagnostic techniques, and a control group of 25women with normal menses. Data were collectedthrough gynecologic histories and physical examinations,administration of the Life Experiences Survey (Sarason,1979); and collection of blood and saliva samples.

Results were that women with DUB reported signifi-cantly greater negative impact from recent life eventsthan did women in the control group (t = =225, dfp = ;029). Although women with DUB reportedgreater stress in their daily lives during history takingthan did women in the control group, the difference wasnot statistically significant (t 1.85, df = 49, p =.07).There was a significant correlation between negativeimpact from recent life events and report of stress indaily life (r = .72, p .000). There was no statistically'significant difference in blOod and saliva control levelsbetween women with DUB and women in the controlgroup, or any significant correlation_ between life stressand blood and saliva cortisol levels. The correlationbetween blood and saliva scortisol levels was significant(r = .36, p = .007). Findings suggest that an association

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exists between recent stressful life eventand DUB;Physiologic correlates of this stress were not detectedin this study.

References

Saranson; I.G. "Stress and Anxiety." Vol. 6;Washington; I/C. : Hemisphere PublishingCorporation; 1979.

;--

Special appreciation is given to Roche-BiomedicalLaboratories for the laboratory work in this research; toJeanne Sears, MSN student at University of -NorthCarolina at Greensboro Schobl of Nursing; for assistancein data collection; and to Charlie Carrico and ChipsChapman, Radimmmunoassay Supervisors at Roche:-Bio=medical Laboratories for conducting the laboratorytests.

This research was supported by a Faculty Excellence,Summer Research Fellowship from the University ofNorth Carolina at Greensboro.

92

THE ROLE OF FACULTY PRACTICEIN NURSING ACADEMIA

Deidra Henley Sanders; RN; MSNInstructor

Associate Degree Program

Kathleen Bellinger, RN MS; EdDActing Associate Dean

Graduate Program

Jacquelyn Reid; RNC EdDAssociate ProfessorGraduate ProgramSchool of Nursing

University of Louisville

Nurses in academia have continually wrestled withthe dilemma of theoretical teaching in a disciplineevidenced by clinical practice.

A survey of 287 NEN-accredited baccalaureate nurs-ing progranis was conducted to ascertain the policiesregulating faculty clinical and/or consultative practice.The 124 participants were located -in private- and-publicinstitutions of higher education and represented 42 statesand the District of Columbia. Sixty-seven percent(83 programs) of the respondents reported that there wasno policy developed, although twenty-seven percent (24programs) indicated that at least some or all of thefaculty were engaged in practice outsidf. their a,.:adem-ic respons'bilities. Twenty-eight -percent (35 programs)reported a policy at the institution. Sixteen percent' (20programs) used the ins titutionaLpolicy as a guideline forregulating faculty activities. Eighty-seven, percent (10programs) reported having a policy specific to the de-partment or school of nursing. Tvio programs indicatedthat faculty, were not permitted to engage in clinical orconsultative practice during the contract period.

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Numerous implications; having profound effect onschools of nursing, health sciences centers, and overalluniversity faculty practice, arise from the above data.Because the federal and state monies are becomingscarce, joint faculty practice may emerge as a means ofcompensation for reduced, funds: The lines of authority,atcountability; and responsibility are issues that must beaddressed. The benefit to education would be evidenCedin more skilled practitioners if there was incr=easedaccess to research settings and facilities where newkrwwledge may be tested; Nurse educators 'must becommitted to further development of both theory andpractice of nursing..

A model arrangipg joint practice options within aHealth Sciences Center milieu is presently being pro-posed for implementation in the fall of 1982.

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THE RELATIONSHIP BETWEEN SELF-CONCEPT ANDSOCIAL ACTIVITY OF LEUKEMIC AND

HEALTHY SCHOOL-AGE CHILDREN

Joanne B. Scungio, RN; PhDAssociate ProfessorSchool of Nursing

University of Alabama in Birmingh&m

This descriptive study sought to determine the rela-tionship between selfconcept and social activity ofleukemic and healthy children; Three subproblems wereinvestigated: (a) Is there a difference between self--concepts of leukemic and healthy children? (b) Are thesocial-activities different between leukemic and-healthy.children? (c) Is sex a contributing' factor in -the differ7ences betWe,en self- concept and/or social activity ofleukemic and healthy children? A phenomenologicalapproach to self-concept theory Was used as the theoret=-icaf framework.

The study population was comprised of 40 randomlyselected school-age children (8-12 years of age)-20Children with acute lymphocytic leukemia from a pedi-atric oncology clinic and 2.0 healthy children .from aneighborhood in southern New England.

Tools utilized to obtain data on children's self-concepts included: (a) the Piers - Harris Children's Self-7Concept Scale, (b) human and self- figure drawings, (c)the ,'Wish Expression Test, and (d) se. rni-structured inter-views. To determine social activity of children, theChildren's Social Activity Scale was utilized. Analysis ofvariance, chi - square analysis, and Pearson productmoment col-relation were utilized in the data analysis..The data were analyzed for the total sample and for

- group and sex differences.

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The findings of the study indicated that: (a) leukemicchildren had significantly lower self-concepts than didhealthy children; (b) leukemic children included signifi7cantly.more emotional indicators on their human and selffigure- drawings than did healthy children, (c) leukemicchildren's positive and negative wish responses on theWish Expression Test reflected illness-related itemssignificantly more frequently than did healthy children,(d) leukemic children participated in significantly fewersocial activities and more non-social activities than didhealthy children; (e) no major sex differences' were foundbetween the two groups, (f) a strong positive relationshipwas found between children's self - concepts and socialactivity, (g) leukemic children who knew. their diagnosisreported higher self-coh,cepts and social activities thanthose children who did not know their diagnosis; and(h) many parents of leukemic children demonstratedover protection En their children's social activities andwere dishonest in telling tie children _about theirdiagnosis and treatment.

Results of the study suggest that the ramifications ofa chronic illness such as leukemia produce numerouspsychosocial stressors in the =school -age child:- Many ofthe stressors may be ameliorated if pedi4tric oncologynurses implement education programs to assist familiesarid teachers in understanding and identifying the ramifi-cations which. frequently occur;

References..

Piers, E.G. and Harris, D.B. Manual for the Piers-Harrischildren's self-concept scale. NaShVille: CounselorRecordings and Tests; 196%;

Koppitz, E. Psychological evaluation of children'shumari:-figuredrawings; New York: Green andStratton; 1968;

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sr

David, H.P. The projective question: Further explora-tory studies; Journal of Projee_tive-Techniques;1957; 20; 292-300;

Scungio; J.B. 9- -- - -onceptand soc'al ac 0 ,... ...... hYschool-age children: Unpublished doctoral.dissertation; University of Pittsburgh; 1981.

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`BACCALAUREATE NURSING PROGRAMEVALUATION BY ALUMNI AND

ALUMNI EVALUATION BYTHEIR EMPLOYERS, UTILIZING

SURVEY QUESTIONNAIRES: POLICY IMPLICATIONS

; aVirginia R. Sttb22-eri RN; MA

Associate Professor

Lois N. Knowlest RN, PhD, FAA.Professor

Jennet M. Wilson; RN, MAAssociate ProfessOr

Tanya L. Bobo, RN; MNAssistant Professor

Diane B; Greene; RN, MSNAssistant Professor

University of Florida; College of Nursing

Faculty members need to have program evaluationinformation from their graduates and their employers forpossible 'modification of their programs, to meet accred-itation requirements, and to identify psychological andsocial forces affecting the evaluation tof the program; Itis impbrtant to find instruments that will priiduce suchinformation as accurately and as economically aspossible;

The' prima6r purpose of this research was to enablefaculty members to know the evaluation of the programby alumni and the evaluation of the performance ofalumni by their ernployers

The researchers developed instru.aents to gain infor-mation which would establish the relationship betweenthe depender.t variables of alumni evaluation of theobjectives of the nursing grogram and the aluMni profes-sional performance; and the independent variables of

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curriculum. change; employer _ratings of graduates ofother prograims; and educational; level of employers.

The population was defined as all alumni of theUniversity of Florida nursing program who graduatedfrom spring 1960 through fall 1979 and their employers.

The population was divided into three groups: GroupI consisted of alumni (N = 795), response rate (N = 404);who were _graduated spring 1960 through spring 1977; andtheir employers (N = 795), response rate (N =. 201); GroupII were alumni (N 299) who were graduated summer1977 through fall 1979; response rate (N 161); and theiremployers (N a 299); response rate (N = 97). Group III;comprised of the sum of Group I and Group II; consistedof 1,094 alumni, response rate (N = 565) and 1;094employers; response rate (N =i 298);

This non-experimental project was a static groupcomparison evaluative study; the survey approa wasused;

Findings show: 1) 79 percent of the respondingalumni rated the program as excellent or above average;2) 99- percent of responding employers' held an overallopinion of the alumni as outstanding or satisfactory; 3)the proportion of alumni who graduated from a blockcurriculum rated outstanding by their employers did notdiffer signif icantly from the proportion ratedoutstanding who graduated from an integratedcurriculum; 4) the alumni's rating of the program is notsignificantly correlated with the employerV rating of thealumni; 5) the alumni's rating of the program is notsignificantlycorrelated with the employer's comparisonof the graduate with other:.nurses having a baccalaureatedegree; 6) the educational background -of the evaluatoris significantly correlated with the evaluator's overallopinion of the graduate:

The questionnaires were tested for reliability andevaluated as to their internal and external validity.Statistical analysis revealed significant reliability (a=.82).

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Qualitativc analysis of the questionnaires showed severalsources of external and internal invalidity might exist.The researchers believe that the alumni question-naire may be used by factilty from other programs bysubstituting their own objectives. If used by a largenumber of nursing_ programs, a data bank of information

°couldbe obtained that would be potentially useful_t rmaking decisions on a national basis.

The positive evtluation by the alumni and employersreassured the faculty and administration that the cur-riculum was meeting their needs; supplementary dataindicated that the program was meeting the needs ofsociety; This is partiWarly important for continuedfunding and support by Airministrative and political offi-cials; Facultiesneed to weigh -curriculum .changescarefully to justify the time, energy, and expense in=Volved in such changes._ Corristency in content ofnursing programs ana adherence to criteria designated bythe National League for Nursing may have contributed tothe fact that employers were not able to distinguishaltimni in the study group from others with similarpreparation; The tendency for employers with similar orhigher_ educational background to evaluate alumni higherthan those with different preparation is important fornew graduates to know.

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DIABETIC COMPLIANCE BEHAVIORS AND THEIRRELATIONSHIP TO SELECTED VARIABLES

Ann E. Smith RNC PhDAssociate ProfeSsorSchool of Nursing

University of Alabama in Birmingham

The purpose of this study was to identify a relatio6-ship between knowledge of diabetes; health perceptions;-interpersonal Values; and the level of compliance of theadult diabetic patient as reported by the patient; andbetween the leVel of c_ompliance as reported by thepatients and the patients' level of compliance as report-ed by the nurse practitioner. A descriptive surv.ey designwas utilized to determine Whether a significant relation-ship existed among the variables.

The subjects of the_ study were 76 adult members of a. Health Maintenance Organization. rive nurse practi-tioners were the professionals who participated in thestudy.

Four instruments_were mailed to the subjects: Com-,pliance Report and General Information about Diabetes;which were developed by the researchers; Health Perceptions Questionnaire (Ware; _1973); and Survey of Inter-personal Values (Cordon; 1976). Each nurse.practitionercompleted the Professional -Report _of Compliance; aresearcher-developed questionnaire; for the subjects forwhom the nurse was primarily responsible.

The data were analyzed. On the Texas Woman'sUniversity compUter system using_ the SPSS (StatisticalPackage for Social Sciencerfor Icsysternr20. Evalu-ation of the data utilized Pearson Product-Moment Correlation ant; .the -,FactOr Analysis techniques: The .05level was set as the level of acceptable statisticalsignificance.

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h was proposed that if leVels 'of compliance arerelates to patents' health perceptions and interpersonalvahies, then the nurse practitioner through identificationof these perceptions can design theory-bastd nursingintervention., and can apply principles of management to'implementation, for the purpose of providing effective,cost-efficient health care.

AndlySiS. of data indicated statistically signifibantrelationships among variableS of the study;

ReferencesYis

Gordon, L.V. Survey of interpersonal.values. Chicago:Science Research Associates, Inc., 1976;

ware, J. Conceptualization and measurement of healthin adults; Vol. V, Genera.1 Health-Pet-ceptions.California: Rand Co., 1978.

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THE IDENTIFICATION OF SELECTED STUDENTFACTORS, PRLOR TO ADMISSION INTO

THE NURSING SEQUENCE,_ INSUCCESSFUL COMPLETION OF

A BACCALAUREATE NURSING EDUCATION

Patricia E. Thompson, ESN, EdDAssociate ProfessorCollege of Nursing

Northwestern State University

The problem with which this study was concerned wasthe identification of selected factors, prior to a student'sadmission into the nursing sequence, that may be relatedto the gtudent's success in completing a baccalaureatenursing education. The purposes of the study were 1) todetermine if there is a relationship between the readingability of baccalaureate nursing students and theirgrades in their initial nursing course, 2) to determine ifthere are statistically significant differences in readingabilities among ,traditional groups and identified non-traditional nursing student subgroups (men, older stu-dents, blacks, Hispanicsi and others) of the population,and 3) to determine if prior educational experience,(junior college, senior college, or a previous bacca-laureate degree) is related to students' grades in theinitial clinical course.

The population of the study was limited to twoclasses of nursing students (N=145) who were in theirinitial clinical course at a state-supported institutionlocated in a large metropolitan area This populationwas composed of 135 fetnales and 10 males; of these,123 were white, 10 were black, 3 were Hispanic, and 9were cf other ethnic backgrounds; Information obtainedon each student includes (I) total percentile score on theNelson-Denny Reading Test (Form C), (2) grade in thefirst clinical nursing course, (3) sex, (4) age, (5) ethnicbackground, and (6) prior educational experience.

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The Spearnan Rank Correlatibh was used todetermine if there were statistically significant relation-ships between.readingabilitieS and grades of students inthe initial clinical nursing course. The Kruskal7Wallisone-way analysis of variance was used to determine ifthere were statistically significant differences in readingabilities between white female-students below the age of30 (traditional group) and men,43latk, HiSpanics, those of)ther ethnic backgrounds, or stddentS over the age of 30the nontraditional subgroups of the population);Kruskal-Wallis was also utilized to determine any statis-tically sign ficant difference betWeen students' grades inThe initial clinical nursing course_ arid" the type_ of thestudents' prior educational experience .(junior college,senior college or university, or a baccalaureate degree);

For the limited populatibn of thiS study, data findings.ndicate that there is an inverse relationship between the,tudents' reading ability and grades in their initial:finical course; that there are significant differences inthe reading ability of the subgroups of black students,students from other ethnic backgrounds; and older stu-dents; and that there is no relationship between prioreducational experience and students' grades in The initialclinical course. It is concluded, therefore; that readingability cannot be identified as a factor that is related tosuccess in the initial clinical nursing course, and thatneither the ability _Of men students nor the ability ofjunior college tranSfer students to complete the programshould be of concerti to nursing school admissionsofficers and faculty;

Reference

Brown, J.I. Examiners manual for the Nelson -DennyReading Test. Boston: Houghton Mifflin Company,1976.

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PERCEIVED COMPETENCY BEHAVIORS FORTHE CLINICAL NURSE SPECIALIST ROLE

Mary Ellen Wyers, RN; EdDAssociate Dean and Associate Professor

Susan K. Grove, RN; PhDAssociate ProfessorSchool of Nursing

The VniverSity of Texas at Arlington

Nancy L. Ackley; RS; MSDirector of Clinical Evaluation and Development

Methodist Hospitals of Dallas

During the past 10 years; perceptions of competencybehaviors, for the role of the clinical nurse specialisthave differed arrionz nurse administrators; graduatenurse educators; and clinical nurse specialists. Thisresearch study emerged from the discrepancies in roleperceptions that potentially may have contributed torole ambiguity and conflict;

This descriptive study involved the exploration of theclinical nurse specialist role within professional nursingpractice.

The following research questions were investigated:1) ehat are the competency behaviors for the role ofthe clinical nurse specialist as perceived by the nurseadministrators; graduate nurse educators; and clinicalnurse specialists'? 2) What are the areas of agreementand disagreement among the nurse administrators; grad-uate nurse educators; and clinical nurse specialists re-garding competency, behaviors for the clinical nursespecialist- role? 3)/_What sub-roles comprise the clinicalnurse specialist role?

The design involved the development of an instru-ment to determine the essential competency behaviorsfor the clinical nurse specialist role. In order to identify

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these behaviors,- a_pilot study was conducted resulting inan instrument of 40 essential behaviors.

Following_the pilot, this study was conducted involvinga national sample: 160 nurse administrators, 233 grad-uate nurse educators, and 110 clinical nurse specialists.The subjects of this sample completed the 40-iteminstrument by ranking the competency behaviors on asix-point scale from most essential to fleast essential;pertinent demographic data also were collected.

A frequency distribution identified the mean rangefor the behaVibrS to be 4.49 to 5.78. The behavior withthe lowest mean dealt with the discharge process; thebehavior With the highest mean dealt with role model-ing; The greatest variance between behavioral meansinvolved the graduate nurse educators and nurse admin-istrators. The least variance between the behavioralMeans involved the nurse administrators and clinicalnurse specialists. The mode for the 40 behaviors for eachgroup was predominantly six, indicating a positive re-sponse to the behaviors by the nurse administrators,graduate nurse educators, and clinical nurse specialists.The means for the groups were: nurse administrators,5.15; graduate nurse educators; 5.26; and clinical nursespecialistS, 5.18. There was no significant differencebetween the_ group means. The factor analysis reducedthe data to four factors within each of the three groups.In the factor analysis of the total sample (503 subjects).FactOr 1, explained 63.9 percent of the variance; Factor2, 15.7 percent variance; Factor 3, 10.9 percent vari-ance; and Factor 4; y.5 percent variance._ In analyzingthe behaviors that were clustered by the factor analysisthe follbwing sub-roles were predominant:_ practitioner,teacher, researcher, consultant; The degree of thefact& variance explained by the sub-roles varied be-tWeeti the three groups;

The instrument reliability for the total sample was.910. Thus, the implications the study has for nursingare multiple: 1) the list of behaviors will assist the nurseadminiStrators with effectively utilizing and evaluating

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the clinical ;iurse specialist; 2) the graduate nurseeducators will be able to use the behaviors and roledelineations for curriculum development for the clinicalnurse specialist role; 3) the clinical nurse specialists willbe able to clarify their role and be able to develop a jobdescription for their role.

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