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Stakeholder perceptions of basic nursing education Frissell, Sharon Elaine 1989

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STAKEHOLDER PERCEPTIONS OF BASIC NURSING EDUCATION By SHARON ELAINE FRISSELL B.Sc, The University of Alberta, 1974 M.A., Simon Fraser University, 1980 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION in THE FACULTY OF GRADUATE STUDIES CENTER FOR THE STUDY OF CURRICULUM AND INSTRUCTION We accept this dissertation as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA January 1989 @ Sharon Elaine Frissell, 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of C u r rt c<J u - - r "XfrS^ruch-Cr^ €<J u-c &&-V)r^ The University of British Columbia Vancouver, Canada Date DE-6 (2/88) Abstract "Stakeholder Perceptions of Basic Nursing Education" This study addresses three aspects of basic nursing education. First, the study docu-ments the extent to which those people whose views shape nursing education (stakeholders) disagree. Second, the study considers the sorts of reasons offered by nurse educators for curricular choices and, third, it focusses on recommendations for basic nursing education. In the first part of the study, which addresses the first four questions, the sample (n=740) consisted of five groups: nurse service administrators, representatives from the ministries of health and education, representatives from the Registered Nurses Association of British Columbia, nurse educators and physicians. Each person was asked to complete a questionnaire. In the second part of the study, which addresses the fifth research question, the random sample (n = 33) consisted of nurse educators. Each was interviewed by the researcher. Completion of the questionnaire by the five groups revealed that stakeholders differed significantly in their rating of objectives, course content and clinical areas, and in their views of the appropriate type and the length of educational preparation. Much of the disagreement occurred between physicians and other groups. While some agreement was found on objectives, course content and clinical areas among the groups, there was also disagreement among all groups studied. Types of reasons given by nurse educators for particular curricular choices were (in order of frequency): educational, institutional, client, traditional, professional and 'other'. How-ever the emphasis given to these categories varied — depending on the type of educational institution at which the educator was employed. In the third portion of the study the author — considering, among other things, the expressed wishes of the stakeholders surveyed — offers a proposal on the general form basic nursing education in British Columbia might take. It is her opinion that a suitable basic nursing education program should be at least four years in length, be one which allows students a choice of electives and one which offers a choice of clinical specialties. ii TABLE OF CONTENTS Page Abstract n Table of Contents iii Appendices ix List of Tables x Acknowledgements xii CHAPTER ONE Introduction 1 The Problem 1 Rationale for the Study 4 Research Questions 6 Delimitations of the Study 7 Definition of Terms 7 Organization of the Thesis 8 CHAPTER TWO Background to the Problem 9 Stake and Stakeholder 9 Historical Roles of Stakeholders in Nursing Education 11 Summary 23 CHAPTER THREE Methodology 25 The Questionnaire 25 Subjects 25 Nurse Educators 25 Nurse Service Administrators 26 Physicians 26 Ministry 26 Registered Nurses Association of British Columbia 26 Development of the Questionnaire 26 Data Collection 29 Data Analysis 29 iii Page The Interview Schedule 30 Subjects 30 Development of the Interview Schedule 30 Data Collection 31 Procedure 31 Data Analysis 32 Summary 33 C H A P T E R FOUR Presentation of Findings From the Questionnaire 34 Demographic Characteristics of the Respondent Groups 34 Nurse Educators 34 Nurse Service Administrators ' 35 Physicians 35 Representatives from the R.N.A.B.C 35 Ministry Officials 36 Objectives for Nursing Education 36 Comparison of the Categories of Objectives 36 Objectives for Category One "Exercises Professional Prerogatives Based on Clinical Judgment " 39 Objectives for Category Two "Promotes Patient's Ability to Cope with Immediate, Long Range, or Potential Health Related Changes" 39 Objectives for Category Three "Helps Maintain Patient Comfort and Normal Body Functions" . . 43 Objectives for Category Four "Takes Precautionary and Preventative Measures in Giving Patient Care " 44 Objectives for Category Five "Checks, Compares, Verifies, Monitors and Follows Up Medications and Treatment Processes" 46 Objectives for Category Six "Interprets Symptom Complex and Intervenes Appropriately " . . . 48 iv Page Objectives for Category Seven "Responds to Emergencies" 48 Objectives for Category Eight "Obtains, Records and Exchanges Information on Behalf of the Patient" 51 Objectives for Category Nine "Collaborates with Staff Within the Organizational Structure" . . . 52 Objectives for Category Ten "Utilizes Patient Care Planning" 54 Objectives for Category Eleven "Teaches and Supervises Other Staff for Whom Responsible" . . . 55 Objectives for Category Twelve "Demonstrates Personal Characteristics Suitable for Nursing" . . . . 57 Objectives for Category Thirteen "Uses Nursing Models in Assessing and Giving Patient Care" . . . . 58 Objectives for Category Fourteen "Carries out Research in the Practise of Nursing" 58 Objectives for Category Fifteen "Participates in Professional Activities Related to Nursing" . . . . 60 Bipolarization of Response Ratings of Objectives 61 Summary of Objective Ratings 62 Course Content for Nursing Education 62 Comparison of the Categories of Course Content Areas 62 Course Content for Category One "Support Course Content" 63 Course Content for Category Two "Nursing Course Content" 66 Bipolarization of Response Ratings of Course Content Areas 69 Summary of Course Content Ratings 69 Clinical Areas for Nursing Education 70 Comparision of the Categories of Clinical Areas 70 V Page Clinical Areas for Category One "Critical Care Areas" 71 Clinical Areas for Category Two "Community Health Areas" 73 Clinical Areas for Category Three "General Areas" 75 Bipolarization of Response Ratings 78 Summary of Clinical Area Ratings 79 Length and Type of Educational Preparation for Nursing Education 79 Comparison of Length and Type of Basic Nursing Education 79 Summary 80 Objectives, Course Content and Clinical Areas 80 Educational Preparation Ratings 83 C H A P T E R FIVE Presentation of Findings From the Interviews 86 Educational Reasons 88 Conception of Nursing 88 Pedagogical Reasons 89 Institutional Reasons 90 Demands of the Workplace 91 Expectations of the Accrediting Body 92 Availability of Resources 93 Client Reasons 93 Quality Care of Clients 94 Client Teaching 94 Client Demographics 95 Traditional Reasons 95 Past Work Experience 96 Educational Background 96 Lack of Experience or Education 97 vi Page Professional Reasons 98 Status of Profession 98 Professional Self-image 99 Communication with Public . . . . 101 Other Reasons 101 Basic Preparation for an R.N. Baccalaureate or Diploma 102 Support for Diploma Nursing Program 103 Support for Baccalaureate Nursing Program 104 Difficulty in Deciding 105 Length of Program 106 Discussion of the Findings 107 Summary 109 CHAPTER SIX Interpretation of the Findings and Recommendations 110 Limitations of the Study 110 The Stakes of Stakeholder 110 Stakes of Administrators I l l Stakes of Educators 112 Stakes of the R.N.A.B.C 116 Stakes of Physicians 117 Stakes of the Ministry 118 Purposes of Schooling 119 Physicians' Perception on Uses of Basic Nursing Education 121 Minstrys' Perception on Uses of Basic Nursing Education 121 Educators' Perception on Uses of Basic Nursing Education 122 R.N.A.B.C.s' Perception on Uses of Basic Nursing Education 123 Administrators' Perception on Uses of Basic Nursing Education 123 Recommendations for Basic Nursing Education 124 Summary 130 vii Page CHAPTER SEVEN Summary and Conclusions 132 Summary 132 Purpose of the Research 132 Research Questions and Methodology 132 Findings . 133 Interpretation of the Findings 136 Conclusions 137 Program Recommendations 137 Alternate Recommendations 139 Policy Implications 140 Suggestions for Further Research 141 BIBLIOGRAPHY 142 viii APPENDICES Appendix Page A. Questionnaire and Letters to Subjects 151 B. Demographic Characteristics of the Respondent Groups 191 C. Cross Tabulation by Profession 213 D. Letters of Permission 269 E. Summary of Rank Ordering of Category 273 F. Interview Schedule 281 ix List of Tables Table Page 4-1 Responses to questionnaires 35 4-2 Comparison of categories by respondent group 37 4-3 Summary of objectives by respondent group "Exercises professional prerogatives based on clinical judgment" 40 4-4 Summary of objectives by respondent group "Promotes patient's ability to cope with immediate, long range, or potential health related changes" 41 4-5 Summary of objectives by respondent group "Helps maintain patient comfort and normal body functions" 43 4-6 Summary of objectives by respondent group "Takes precautionary and preventative measures in giving patient care" . . . . 45 4-7 Summary of objectives by respondent group "Checks, compares, verifies, monitors and follows up medication and treatment process" 47 4-8 Summary of objectives by respondent group "Interprets symptom complex and intervenes appropriately" 49 4-9 Summary of objectives by respondent group "Responds to emergencies" 50 4-10 Summary of objectives by respondent group "Obtains, records and exchanges information on behalf of the patient" . . . . 51 4-11 Summary of objectives by respondent group "Collaborate with staff within the organizational structure" 53 4-12 Summary of objectives by respondent group "Utilizes patient care planning" 55 4-13 Summary of objectives by respondent group "Teaches and supervises other staff for whom responsible" 56 4-14 Summary of objectives by respondent group "Demonstrates personal characteristics suitable for nursing" 57 4-15 Summary of objectives by respondent group "Uses models in assessing and giving care to patients" 59 4-16 Summary of objectives by respondent group "Carries out research in the practise of nursing" 59 X Page 4-17 Summary of objectives by respondent group "Participates in professional activities related to nursing" 60 4-18 Comparison of course content categories by respondent group 62 4-19 Summary of support course content by respondent group 64 4-20 Summary of nursing course content by respondent group 67 4-21 Comparison of clinical categories by respondent group 71 4-22 Summary of critical care areas by respondent group 72 4-23 Summary of community health areas by respondent group 74 4-24 Summary of general areas by respondent group . 76 4-25 Comparison of length of program by respondent groups 80 4-26 Number of disgreements among respondent groups 82 4- 27 Number of agreements among respondent groups 83 5- 1 Frequency of reasons by type of educational institution 87 5-2 Reasons averaged by type of educational institution 87 5-3 Support for type of program 103 5- 4 Support for length of program 103 6- 1 Clinical areas compared by type of educator 114 6-2 Objectives compared by type of educator 115 6-3 Course content compared by type of educator 115 xi ACKNOWLEDGEMENTS The author is indebted to the many people who contributed to the completion of this study. Sincere appreciation is extended to: Dr. LeRoi Daniels for his supervision of the work, from conception to completion, and for providing guidance, faith, encouragement and leadership throughout the writing of the work. Drs. Walter Werner, Jennifer Craig and Frank Echols for their patience in reading, editing and critiquing multiple drafts of this work. The administrators, educators, ministry officials, physicians and R.N.A.B.C. represen-tatives who thoughtfully completed the questionnaire. The educators who were willing to be informants in the interviews. Sharon Lazeroff, whose cooperation and willingness to type the questionnaire, enter all the computer data and check it for errors all on short notice enabled me to meet established deadlines. Joan Weir who gave editorial assistance in the writing of this thesis. My husband for his endurance, his support, and love. xii 1 C H A P T E R O N E Introduction This study addresses three aspects of basic nursing education. First, the study doc-uments the extent to which people (stakeholders)* whose views shape nursing education disagree. Second, the study considers the sorts of reasons offered by nurse educators for curricular choices, and third, it focusses on recommendations for basic nursing education which are consistent with the views of stakeholders. This chapter discusses and justifies the importance of the problem, spells out the research questions and their delimitations, defines terminology appropriate to the research and offers an overview of the remaining chapters. The Problem According to some authors nursing education is in a state of chaos (Stanton 1982, p. 11; Scoloveno 1981, p. 1; Johnson 1986, p. 1; Velsor-Friedrich 1986, p. 4). This chaos may have occurred because groups of stakeholders appear to hold conflicting views about the components needed for a basic nursing education program. Some of the stakeholders are: nurse educators, nurse service administrators, physicians, government ministry officials and the professional nurse registering body. Not only do these groups disagree about what nursing education should consist of, but each group of stakeholders has their own reasons for their particular view. In this study, these stakeholders have been chosen for a variety of reasons. Nurse educators are important stakeholders as they are responsible for daily curriculum decisions, curriculum development and curriculum evaluation. For this reason educators play a major role in supplying good programs for basic nursing education. Hospital administrators are stakeholders because they hire and orient new graduates. They are responsible for supervising new graduates and are centrally involved in providing quality nursing care to clients (Shantz 1985, p. 169). Physicians are also interested in quality care for their clients, in both the acute and rehabilitative stages of illness. They are identified as stakeholders because they have been * Sometimes the term "stakeholder" is used in the plural form. This form refers to individ-uals within a group. At other times, the term "stakeholder" is used in the singular form. In this form, the term refers to the actual group. 2 involved in the past in teaching nurses, and because through their medical association lobbies they potentially have the power to prevent or assist change in nursing education (Shantz 1985). In addition, physicians govern some tasks (dependent nursing functions) carried out by nurses. People selected as representatives of the government ministries of health and education are stakeholders because through the legislative assembly they are the legitimate policy makers and they control decisions concerning funding for education and health care. Their role is crucial to the realization of change in nursing education (Shantz 1985). The professional nursing association (Registered Nurses Association of British Columbia or R.N.A.B.C.) is a stakeholder. As a part of its mandate, the association is responsible for approving schools of nursing, for licensing eligible graduate nurses and for maintaining educational standards. Conflicting views have arisen over basic nursing education programs. For example, for almost a century, nursing has faced a dilemma over the level of educational preparation needed for the practice of nursing (Scoloveno 1981, p. 1). This has led to different patterns of nursing education. At present in British Columbia, registered nurses can be prepared by three different routes: 1. two year education at a college leading to a college Registered Nurse (R.N.) diploma, 2. three year education at a hospital-affiliated school, leading to a hospital R.N. diploma, 3. four year education at a university, leading to a bachelor of science degree in nursing (B.S.N.). However, in spite of the differing levels of skill and preparation, nurses graduating from the three types of programs are hired for the same positions. For example, all three types of graduates function as staff nurses, team leaders and head nurses throughout all clinical areas of a hospital (Soules 1978, p. 199 and Iwasiw 1985, p. 38). Regardless of the type of program, all graduates write the same Canadian National Association Testing Service Examination and are required to pass this examination with a grade of 350 or higher in order to commence employment as a registered nurse. Velsor-Friedrich (1986, p. 4) states in her thesis that the availability of different educational routes leaves many confused not only as to who is a registered nurse but also as to what the capabilities of a registered nurse should be. Some literature supports having three types of nursing education programs (Johnson 3 1986, Scoloveno 1981). This literature holds that existence of three types of nursing education programs is necessary because graduates produced are serving different purposes in society. College and hospital programs are said to produce a type of generalist - one who works primarily in a hospital or home care setting. University programs, on the other hand, prepare nurses to work not only in hospitals, but in community health settings. In the past some literature has been unsupportive of the coexistence of three types of programs and argues for two types instead: the college program preparing a technical nurse, and the baccalaureate program preparing a professional nurse (Montag 1959, Mussallem 1964). By eliminating hospital based training programs, it was thought that students would no longer have to give a lengthy period of service in return for training. In other words, it was believed that the college and baccalaureate programs would serve the best interests of the student because the student would spend just enough time in a program learning how to function adequately as a technical or professional nurse. Others hold that the best education for nurses is traditionally referred to as "training" with a career ladder, by which the nurse can gradually improve his/her educational status. Under this plan a student could enter or leave a nursing program at his or her convenience. For example, a student could complete one year of educational preparation then commence work as a practical nurse. At some later time this student could re-enter an educational setting and on the completion of two more years of study would be qualified to work as a registered nurse. Further educational upgrading could be undertaken in administrative and teaching skills (Montag 1959, p. 344). More recently, there has been a move to advocate one level of practitioner. The Canadian Nurses Association (C.N.A.) and the R.N.A.B.C. have argued that by the year 2000 all nurses should be prepared at the baccalaureate level (C.N.A. 1982, R.N.A.B.C. 1985). The C.N.A. board of directors concluded that "educational changes are necessary if we are to be accountable to the public as a professional dicipline...Nursing must prepare scientifically based practitioners whose skills in practice arise from a research orientation" (C.N.A. 1982, p. 29). This C.N.A. proposal has caused concern among some stakeholders. Some, for example, think that a four year nursing program is too long. They believe such lengthy preparation could increase the nurse's frustration at not being able to do more after graduation and as a result could decrease the nurse's desire to remain at the client's bedside. 4 Many stakeholders hold competing views regarding what constitutes a basic nursing education. These views may have resulted in the development of the existing different types of education program which graduate students with differing levels of skill and preparation. This variation constitutes a problem because as Stanton says, graduates from all three types of programs are assigned to the same positions and given the same job description in order to satisfy the staffing pattern of the clinical setting (1982, p. 16). In assigning staff with differing levels of skills to the same position a further problem is posed for administrators. This problem is related to individualizing staff orientation and inservice programs Orientation programs for the nursing graudates will not be effective unless they are geared specifically to the needs of the nursing grad-uate...which may not be cost effective to the hospital (Shoemaker 1985, p. 133). Further, these differences pose a problem for other health care workers who may be confused about the capabilities of a registered nurse and for nursing students who may wish to transfer from one program to another. Rationale for the Study There has been little attempt to document differing views of stakeholders regarding the curricular components needed for basic nursing education, or for the type and length of such a program. In addition, there has been little attempt to understand educators' reasons for curricular choices. If registered nurses are prepared in different ways, yet all are employed in similar positions upon graduation, might not certain types of programs be more suitable than others? Although nurses have been writing about nursing education curricula for many years (Weir 1932, Stewart 1962, Brown 1948, Russell 1956, Montag 1972, Mussallem 1960, Rogers 1961, Bullough and Bullough 1978, Innes 1970, Shantz 1985), there has been little work done to identify the perceptions of these five stakeholders concerning the composition and justification of a satisfactory basic nursing education program in Canada. Several American studies have researched the level of education necessary for nurses. Curran (1982) compared perceptions of two stakeholders: nurse service administrators and nurse education administrators and found that their opinions differed about the relative de-gree of importance of nursing courses and clinical areas. Killgore (1984) found that educa-tors from three types of nursing programs differed in their expectations of beginning nurses. Wilds (1982) discovered incongruencies in the perceptions of four stakeholders (nurse edu-5 cators, associate degree nurses*, physicians, and nurse administrators) regarding the role of associate degree nurses. Her findings indicate a difference of opinion between administrators and educators; the administrators thought the educational preparation of associate degree nurses was inadequate, whereas the educators believed it was adequate. Schuyler's (1983) results indicate general agreement among three stakeholders (nurse educators, supervisors and recent graduates) on the perceived importance of ten critical program areas. However, when comparing educators from the three types of nursing education programs, there was less agreement on rank ordering of these critical areas. Johnson (1981) found a consensus between educator and administrator groups concerning the competencies perceived neces-sary for professional nursing practice. Shoemaker (1985) found no significant differences in perceptions of head nurses and deans about ideal competencies for nursing graduates. More recently, Hasek (1987) found that there were significant differences in perceptions among physicians, nurses, and health care administrators regarding future nursing roles in direct care and management. One study (Mengel 1987) attempted to resolve the conflict regarding nursing education by using a delphi technique with three iterations. The first iteration asked 448 American Academy of Nursing members to respond to the question, "what should be taught to the student in a baccalaureate nursing program?" Successive iterations concluded that 103 out of 112 items were considered to be desirable, very de-sirable or essential program components. She went on to conclude that a baccalaureate curriculum should provide a broad liberal education and should address technical, political, scientific, aesthetic and ethical questions (Mengel 1987). Performance of graduates from the different types of nursing programs has also been studied. Johnson (1986) found few differences in performance in a clinical setting when comparing associate degree graduates and university graduates. Wende (1984), too, when comparing nursing skills of baccalaureate and associate degree senior nursing students con-cluded that all students were equally competent. Further she described groups as being deficient in exactly the same nursing skills and stated that she found a lack of congruency between the nursing skills taught and those expected in the workplace. Fochtman (1987) also discovered differences in perception among graduates, educators and administrators *Associate degree nurses - graduates from a nursing educational program in the United States sponsored by a community college varying in length from 18 months to two years, with the graduate receiving an associate of arts or science degree with a major in nursing (Killgore 1984, p. 22). 6 concerning the ideal and real performance expectations of baccalaureate graduates. These studies indicate conflicting views about expectations and actual performance of graduates from three types of nursing education programs in the United States, but though American literature documents these views, none of these studies have been conducted in British Columbia or in Canada. Furthermore, there has been very little attempt to identify the type(s) of nursing education program best suited to stakeholder demands or to justify stakeholder selections. By determining stakeholder perceptions about basic nursing education, including agreement and disagreement concerning particular objectives, course content and clinical areas, a curriculum might be planned which is consistent with the views of stakeholders. In order to plan such a curriculum it is important to understand the reasons educators give for selections of course content, clinical areas, and objectives, and their preference regarding the type and length of preparation. The importance of understanding such dif-ferences in points of view is stressed by Werner and Aoki (1980): Despite agreement about the components there may be consid-erable disagreement about the shape of these components if the individuals do not share similar assumptions, values and priorities (Werner and Aoki 1980, p. 3). The importance of giving reasons or justifying a particular choice is described in the literature (Taylor 1961, Daniels 1971, Gleadow 1978) which argues that in order to justify the choice or ranking of goals, the selection of courses, or the determination of needs for education, one must also be prepared to give reasons for or against that choice, ranking, selection or determination. Only by giving adequate reasons, can one argue that a position is justifiable. This study will contribute to nursing education by identifying educators' justification of particular curricular choices. By documenting the differences in stakeholders' selection of course content, clinical areas, objectives, length and type of educational preparation needed for basic nursing education, this thesis will assist in the recommendations of a curriculum for basic nursing education. Research Questions In addressing the problem, the following research questions were posed: 1. What differences exist in stakeholder perceptions regarding the need for particular ob-jectives in a basic nursing education curriculum? 7 2. What differences exist in stakeholder perceptions regarding the need for particular course content areas in a basic nursing education curriculum? 3. What differences exist in stakeholder perceptions regarding the need for particular clin-ical areas in a basic nursing education curriculum? 4. What differences exist in stakeholder perceptions regarding the educational preparation and the length of preparation for a basic nursing education program? 5. What are the reasons offered by nurse educators regarding the selection of particular objectives, course content and clinical areas, and the type and length of educational preparation for a basic nursing education program? Delimitations of the Study This study is delimited in the following ways: 1. The findings of the study are limited to British Columbia. 2. The nursing population under study is confined to registered nurses who are classified as full time nursing service administrators at the director level or higher, and nurse educators who are teaching full time in accredited hospital diploma, college diploma and baccalaureate nursing programs. 3. The medical population under study is confined to a sample taken from all physicians practising in the province of British Columbia. 4. The employment setting for nurse educators is restricted to those full-time approved nursing programs located in British Columbia. 5. The employment setting for nurse service administrators is restricted to those hospitals in British Columbia which are listed in the Canadian Hospitals Directory. 6. The scope of this study is confined to the subjects' perceptions of need of the specifically stated objectives, course content and clinical areas, and of the type and length of educational preparation needed by beginning practitioners. Definition of Terms 1. Basic Nursing Education. Either a diploma or baccalaureate program which prepares candidates to become licensed as registered nurses. 2. Objective. The behaviour or competency expected of a nursing student at the end of the final semester of a basic nursing education program. 3. Beginning nurse. One who has just completed a nursing education program in a school 8 of nursing and is employed in a hospital setting prior to receiving the results of the licensing exams. 4. Course/course content. The academic part of a basic nursing education program. 5. Clinical area. A location where client services are obtained. 6. Perception. The views expressed by groups of people regarding the need for specific components of a basic nursing education program. Organization of the Thesis This thesis comprises seven chapters. Chapter One gives an introduction to the study by describing the problem, explaining the rationale for the study, stating the research questions, clarifying the delimitations of the study and defining the terminology. Chapter Two provides a review of the stakeholder literature and an historical background to the stakeholders' roles in nursing education. Chapter Three presents the research design and methodology: this chapter includes an overview of the research design, a discussion of the subjects, the development of the questionnaire and interview schedule, data collection procedures and data analysis procedures. Chapter Four contains the results of statistical analysis from the quantitative data. Chapter Five contains the results of the qualititative data from the interviews of nurse educators and a discussion of these finding. Chapter Six contains an outline of the limitations of the study, interpretation of the findings from the quantitative and qualitative data in light of Broudy's notion of "the uses of schooling" as well as recommendations about what ought to be included in a nursing education program. Chapter Seven comprises a summary of the research, conclusions, and policy implications, and offers suggestions for further research. 9 C H A P T E R T W O Background to the Problem Chapter Two defines the terms 'stake' and 'stakeholder', determines stakeholders in nursing education and traces their role in the historical development of nursing education programs in British Columbia to the present. Stake and Stakeholder Originally the term 'stake' was used to describe that which could be won or lost in a game, race or contest. Literally, the term referred to cash values assigned to chips in a game, such as poker. Thus to have a stake meant that there was both a personal interest in gaining and a risk of losing. Use of the word 'stake' expanded to include meanings related to the assertion of a right or title by placing a stake in the ground to satisfy legal requirements for claiming land. In other words, stake became identified with 'territory' in that one would 'stake out' a territory as a way of identifying boundaries to prevent loss. In educational literature, a stake has come to mean an interest with a view to achieving gain. For the purposes of this research, a stake will be defined as a professional interest or investment in nursing education. As the term 'stake' was associated with gambling so was the word 'stakeholder.' Stake-holder was used to refer to activities of wagers, where one held stakes — a position of trusteeship and responsibility. In education, stakeholder generally refers to those who have an interest in some aspect of schooling. Worthen and Sanders define a stakeholder as "one who is affected by or can be affected by the program or the evaluation in some way" (1988, p. 9). McNeil identifies stakeholders as "different pressure groups [who] propose competing values about what to teach" (1985, p. 230). Mitroff calls stakeholders all those "interest groups, parties, actors, claimants and institutions — both internal and external to a corpo-ration — that exert a hold on it" (1983, p. 6). Virginia Conley identifies these individuals as those who directly or indirectly exert some influence in determining the nature and activ-ities of the curriculum (1973, p. 33). Shantz (1985, pp. 165, 218) identifies stakeholders as those groups who will be affected by change or will influence its direction, as well as external groups who have vested interests in the process. Based on these definitions, there are several groups of stakeholders who can influence nursing education. Nurse educators are a category of stakeholders who can directly influence curriculum decisions, and who are directly influenced by them: 10 Teachers have a direct influence in their classes and clinical ac-tivities on students, subject matter, methods and materials of in-struction, and physical and social environments... They are active participants in the more formalized study of curriculum components and are directly responsible for recommending that certain changes take place in the nature and sequence of curriculum events (Conley 1973, p. 34). A second stakeholder is the professional association to which all practicing registered nurses must belong. For example, in British Columbia the Registered Nurses Association (R.N.A.B.C. ) controls a nurse's entry into practice, his or her exit from it and approves his or her eligibility for registration. This association also exercises power of approval over schools of nursing in British Columbia. As such, one of their chief tasks is to ensure that standards of nursing education are maintained. The association has power to grant or deny permission to operate a school of nursing. Another stakeholder is the hospital administrator who is ultimately affected by the performance of graduate nurses. The administrator is concerned about quality care of clients and is interested in having a qualified staff (Shantz 1985). Other groups, too, hold stakes in nursing education. Physicians, individually and through their medical association lobbies, have power to prevent or assist change in nursing education (Shantz 1985). Physicians work directly with nurses in hospitals and control some nursing activities (dependent nursing functions). Both health and education ministries directly influence nursing education by approving or not approving funding and by establishing policies (Shantz 1985). This group is interested in limiting educational and health care costs. Testing agencies also influence curriculum decisions (McNeil 1985, p. 245). For exam-ple, the Canadian Nurses Association Testing Service is responsible for setting the regis-tered nursing examinations which all nursing students must pass before registration can be granted. Thus, schools of nursing must design their curricula according to testing standards. Nursing students, too, are stakeholders in nursing education. "Students become de-terminants of curriculum content in relation to characteristics, such as abilities, interests, background and goals," says Conley who cites student course evaluations and protests as contributing to curriculum change (1973, p. 34). Shantz (1985, p. 165) asked deans of nursing education institutions and the professional licensing body to rank in order the stakeholders in nursing education. She found the stakeholders to be in order of importance: the provincial government, medical doctors, 11 employers, nurses in general, diploma nurse educators, the public, potential students, degree nurse educators, allied health groups, the university system, and nursing administrators. In another study, Styles (1982 p. 216) identified the following claimants as having a stake in nursing: nurses, patients, the nursing profession, other professions, institutions and the public. She suggests that one claimant's right is another's responsibility and illustrates this assertion in the following quote: The patient's right to competent nursing care is the direct respon-sibility of the nurse and the indirect responsibility of the profession, the institution and the public (Styles 1982, p. 216). Because of the different ways stakeholders may influence nursing education, determining which stakeholders should be involved in this research was a difficult task. Five stakeholders were chosen because all have the following characteristics: 1. They have been historically involved in the development of one or more programs in nursing education. 2. They have responsibility for one or more nursing programs. 3. They seek to influence nursing education programs by exerting pressure. 4. They may be affected by curricular changes. Thus, 'stakeholders' in this thesis is used to refer to the following identifiable groups of people judged to have relevant expertise and to have or have had significant influence in nursing education: nurse educators, nurse administrators, physicians, representatives from the R.N.A.B.C. , and representatives from the ministries of health and education. In Chapter Six, the terms 'stake' and 'stakeholder' will be used to analyze the results of the questionnaire and interviews. Even though some of the recommendations most strongly supported by various groups can be well understood by considering the stake of the group, others do not neatly fit such an account. Indeed, sometimes the groups are best characterized by revealing their interests. Historical Role of Stakeholders in Nursing Education Having identified stakeholders in nursing education, it is appropriate to trace their his-torical role in the development of nursing education programs. Over the past century, nursing education programs have been, in the main, financially and administratively con-trolled by hospitals. As a result, hospital administrators regarded the school of nursing as another hospital department under their governance (Letourneau 1974, p. 2). Under this type of governance, the first Canadian school of nursing, known as the Mack school, opened in St. Catherines, Ontario in 1874 at the General and Marine hospital 12 (Gibbon 1947, p. 155). Nursing students were committed to serve for a three year period, in return for a training program. Up until the opening of schools of nursing "much of the responsibility for care of the sick had been assumed by religious institutions" (Shantz 1985, p. 19). The Provincial Jubilee Hospital (Royal Jubilee) in British Columbia opened May 21, 1890. Three months later, the hospital admitted its first two students into a training program for nurses (Pearson 1985, p. 1). In 1899, the Vancouver City Hospital, (now known as the Vancouver General Hospital), opened its school of nursing (Cavers 1949, p. 14). Programs such as these developed rapidly so that by 1909 there were seventy schools of nursing in Canada (Mussallem 1962, p. 6). These schools were popular because the training program supplied staff for hospitals. A nurses' training school provided a ready, dependable and cheap supply of staff for the wards, so much so, that most large hospitals opened training schools (Shantz 1985, p. 23). Most of the instruction afforded to nurses was freely given by the medical staff who were often professors in the medical school. The relationship of physician to nurse was paternalistic (Street 1973, p. 22). Nursing students learned from their medical preceptors, not only in lecture periods but also in the wards, particularly when the oppor-tunity arose to assist at medical rounds. Although nursing books were few and elementary, the students if motivated to learn, could gain access to medical texts (Street 1973, p. 22). Before long, however, conflict arose between educators and administrators because of what some regarded as the exploitation of nursing students. Hospital administrators placed increasing job demands on nursing students, whereas educators wanted a better education for students. Usually the job demands left minimal time for education and as such, educational aims were often sacrificed (Letourneau 1974, p. 3). Writes Ethel John: An assignment to night duty was never less than two months...During this time, there was no relief from 12 hour duty, except for the pur-poses of attending doctor's lectures which were always given late in the evening... The lecturers were all busy men, often arrived late and seldom kept within their allotted time. The night nurse did not get back to her ward until nearly 10 o'clock and her exhausted relief staff staggered off duty, more dead than alive (Street 1973, p. 24). Problems regarding time scheduling and lecture content soon led to nurse instructors replacing physicians in the classroom. Because, of surgical operations, physicians were 13 often forced to cancel classes, and it was difficult to reschedule them. When physicians did lecture, the content was mostly medical information, with the result that less and less emphasis was being placed on the how and why of nursing (Cashman 1966, p. 186). Support for improved nursing education standards was given by leaders in medicine. In his graduation speech for the class of 1902, Dr. Gray, registrar of the College of Physicians and Surgeons in Manitoba, included ideas about a curriculum for nurses. Among his ideas was the need for a nursing curriculum to include history, sociology and literature. He also stated that more consideration should be given to the nurses' welfare, including recreation, sleep and rest (Street 1973, p. 29). Even though some educators and physicians were critical of nurses' training, hospital administrators seemed happy with the training programs. As a result of this conflict, felt both in the United States and in Canada, a conference of nurse educators was held at the Chicago World's Fair in 1903. Present were nurse educator leaders from the U.S. and Canada, and the American Society of Superintendents of Training Schools for Nurses was formed (Dock and Stewart 1931, p. 163). Some members of this newly formed society were also members of the Canadian Nurses Association (C.N.A.) , previously formed in 1895 (Colquohuon 1905, p. 16). The American Society of Superintendents of Training Schools for Nurses pressured for educational standards and an end to further expansion of programs. Among their resolu-tions were: shorter work hours, better teaching, improved living conditions for students and minimum entrance requirements. The society continued in existence until legal incorpora-tion for national societies made it imperative for Canadian and American nurses to organize separately. In 1904 the Canadian Society of Superintendents of Training Schools for Nurses was formed (Dock and Stewart 1931, p. 166), which later became part of the Canadian Nurses Association. The first subsidiary of the Canadian Nurses Association was the Graduate Nurses As-sociation of Ontario established in 1905 (McMurchy 1905, p. 33). This was followed in 1907 by the formation of the Vancouver Graduate Nurses Association (C.N.A. 1907, p. 157). Even as early as then, a need was felt for the registration of the "trained nurse." An organizational meeting held in Vancouver, September 10, 1912 united all British Columbia subsidiaries into one body called the Graduate Nurses Association of British Columbia (The Graduate Nurses Association of B.C. 1912, p. 612). This association, which later be-14 came known as the Registered Nurses Association of British Columbia (News Notes 1935, p. 221), controlled labor negotiations* for registered nurses, qualifications for graduates, curriculum requirements and standards of testing. For example, in 1916, a committee was appointed to investigate educational standards of the training schools in British Columbia (Kerr 1944, p. 2). This resulted in annual inspections for all training schools (Kerr 1944, p. 5). Meanwhile, in the rest of Canada, continued pressure from national nurse leaders for better educational standards caused the formation in 1915 of a Special Committee on Nurse Education. This committee recommended transfer of nursing education to the provincial ministries of education (Letourneau 1974, p. 4). Five years later (in 1919) the first university school of nursing in Canada opened at the University of British Columbia. Street (1973, p. 115) reports that the department of nursing would not have been established as early as 1919 without the initiatives of Dr. Malcolm MacEachern, the medical superintendent of Vancouver General Hospital and Dr. McKechnie, Chancellor of the University of British Columbia. Dr. MacEachern's intent was that this new program would give increased recognition to nursing and would stimulate the initiation of more efficient training schools. Street pointed out that although this new university school had opened in British Columbia, there was no evidence that the Graduate Nurses Association of British Columbia was consulted about the move to a post secondary degree granting institution (1973, p. 118). Even though the new nursing school was based in a university, demands for practical training were taken into account. The first two years were spent at the university under the control of the university. The next two and a half years were at the Vancou-ver General Hospital, under the control of the Vancouver General Hospital (Mussallem 1964, p. 75). After the initiation of the University of British Columbia's degree program, similar programs developed elsewhere. In 1920 and 1924 respectively, Dalhousie University and the University of Alberta began baccalaureate nursing programs. By 1964, there were sixteen university schools of nursing: McGill, Manitoba, Toronto, McMaster, Ottawa, New Brunswick, British * In 1980, the labor relations division legally separated from the R.N.A.B.C. British Columbia Nurses Union was chosen as the name to replace the R.N.A.B.C. Labour Relations Division (R .N .A .B .C . News 1980, p. 19). 15 Columbia, Nnstitut Marguerite d'Youville, Nova Scotia, Alberta, Mount St Vincent, As-sumption, Queens, Western Ontario, Saskatchewan and St. Francis Xavier (Letourneau, 1974, pp. 18-19). The most common type of university program was a "two-plus-two-plus-one pattern or a one-plus-three-plus-one design" (Shantz 1985, p. 30). These patterns comprised study in non-nursing university courses followed by a period of basic preparation, usually under the control of an affiliated hospital school of nursing. The final year was at the university, with advanced nursing courses in public health, administration and teaching (Shantz 1985, p. 30). None of these programs, however, had full control of a student's time, and educators in the university settings began to realize that control was essential for optimal student learning. As university programs developed in Canada, the baccalaureate pro-gram came under scrutiny and universities began to recognize the need for complete control of the student's educational experience. Nursing schools developed five year then four year programmes in which theory and practice were integrated (Mussallem 1964, p. 75). The first institution to secure complete control of student time was the University of Toronto in 1942 (Shantz 1985, p. 31). Other universities in Canada made slower progress not only because of a dearth of educators with advanced preparation, but also because of their inability to convince nurses and the government of the need for such control (Shantz 1985, p. 31). Even though there were new programs developing, hospital schools of nursing continued to proliferate so that by 1930 there were 218 in Canada, 17 of which were in British Columbia (Weir 1932, p. 278). Nurse educators continued to be dissatisfied with traditional hospital programs as manifested by reports on nursing education. The most significant study at the time was the Weir report jointly launched by two stakeholders in 1932, the Canadian Nurses Association and the Canadian Medical Association. This report recommended that education of nurses be transferred from hospitals to the provincial educational system (Weir 1932). In spite of these recommendations little progress was made. Educators knew what they wanted — the opportunity to provide a general education as well as a professional education (Shantz 1985, p. 27). However, they were unable to surmount the powerful lobby of major stakeholders such as the hospital associations, physicians and the government (Shantz 1985, 16 p. 27). Nursing had made repeated representations to the government re-questing the funding needed to provide nursing education in the general education system, but without success (Shantz 1985, p. 27). The hospital programs continued to be a concern, and following the Weir report, the Canadian Nurses Association organized a National Curriculum Committee to develop a curriculum guide for nursing education (C.N.A. 1936, p. 6). This guide, written in the belief that nursing education would continue for some time to be under the administration and control of hospitals, was presented at the 1936 C.N.A. biennial meeting (C.N.A. 1936, p. 7). It stated that establishment of a financially independent nursing school could not be secured by revolutionary measures, but would come about gradually (C.N.A. 1936, p. 6). Ten years later, in 1946, the Canadian Nurses Association took action to demonstrate that a financially independent school, free of hospital control, could adequately prepare a nurse in less than three years. This new two-year program, funded substantially by the Red Cross (Stewart 1962, p. 250), was set up two years later in Windsor, Ontario as part of a four-year study (1948 - 1952). The purpose was to demonstrate that a clinical nurse could be prepared in a shorter time in a post secondary institution (Lord 1952, pp. 7, 53). The objectives were: 1. To establish nursing schools as educational institutions, separate entities in their own right. 2. To demonstrate that a skilled clinical nurse can be prepared in a period shorter than three years, once the school is given control of the student's time (Lord 1952, pp. 7-8). Results of this study revealed the possibility of preparing a clinical nurse in a two year period who would be "at least as well prepared as the average previously trained hospital nurse" (Lord 1952, p. 53). However, this two-year program was unable to continue, owing to a lack of financial support from the government. Studies with similar recommendations followed. One of the major ones was Rus-sell's, "The Report of A Study of Nursing Education In New Brunswick" (1956 p. 60). She indicated that goals identified by George Weir had still not been realized. Consequently, her recommendations were similar to Weir's: 1. Each school shall have full control over the use of student time when in hospital. 2. Each school shall have its own administrative board prepared to accept responsibility and quite apart from the governing board of the hospital. 3. Each school shall have its own financial structure (Russell 1956 p. 60). 17 Even though reports such as Russell's were presented in the late 1950's, there was little sign of movement to dissolve the hospital training schools (Letourneau 1974 p. 10). The Canadian Nurses Association believed that a national accreditation program might serve as a valid instrument to upgrade existing hospital diploma nursing programs (Mussallem I960, p. 1). To this end, Helen K. Mussallem was commissioned by the Canadian Nurses Association to investigate nursing education in Canada. Her report, which did not name any particular schools, recommended further studies of nursing education, and further school improvement programs aimed toward better standards for schools of nursing. Her report showed that, of the twenty-five schools evaluated, only four would have met her criteria for accreditation (Mussallem 1960, p. 81). Mussallem's doctorate (1962) and her next reports (1964, 1965) supported Weir's and Russell's reports. All these reports recommended transfer of diploma schools of nursing from hospital control to that of post secondary institutions in university and college settings. Mussallem's (1964, p. 73) report also recommended two levels of practitioners to accommodate the needs of the hospital. These nurse practitioners were to be differentiated on the basis of function: the professional, prepared at the university, and the technical, prepared at the college. The one report which did not recommend the transfer of nursing education to post sec-ondary institutions was the Scarlett report in Alberta (1963). This report, which considered educational and employment needs, advised that the present hospital schools of nursing be enlarged and strengthened. While the debate about the location and type of nursing education programs continued, the length of program was also an issue about which reports were written. MacLaggan's 1966 report promoted two-year programs. She supported Mussallem's earlier study which recommended two levels of nurses (R.N. and the B.Sc.N.) and the transfer of nursing education into post secondary institutions (MacLaggan 1966, p. 3). The Registered Nurses Association of British Columbia wanted to act on MacLaggan's recommendation which was to develop different patterns of nursing education. However, the R.N.A.B.C. Act prevented the approval of diploma nursing programs if they were less than three years in length. The R.N.A.B.C. thus set up a task force to formulate a compre-hensive plan for the future orderly development of nursing education in British Columbia 18 (R .N .A .B .C . 1967). This resulted in the R.N.A.B.C. 's Act being changed and the estab-lishment of the first two-year diploma nursing program in an educational institution — the British Columbia Institute of Technology — in September 1967 (R .N .A .B .C . 1967, pp. 16-17). In developing this new two-year program, the roles of the two major stakeholders were apparent, the R.N.A.B.C. and the Department of Education. The R.N.A.B.C. was willing to allow for experimentation and change and the Department of Education was willing to finance a college diploma nursing program (Letourneau 1974, p. 155). The two-year program met with some favor, and by September 1971, in spite of eco-nomic difficulties, there were three college diploma nursing programs located in post sec-ondary institutes: British Columbia Institute of Technology, Vancouver City College, and Selkirk College ( R . N . A . B . C News 1972, p. 17). Other programs developed over the next fifteen years. In 1973, the Cariboo College nursing program started, followed by Douglas College in 1975, Okanagan College in 1976, College of New Caledonia in 1977, Malaspina College in 1986 and Kwantlen College in 1987 (Kermacks 1988). At the same time as the new two-year programs developed, many hospital programs were phased out. In 1971, St Paul's Hospital and the Royal Inland Hospital accepted their last class of students. The next hospital programs to be phased out were the Royal Columbian in 1975, St. Joseph's in 1978 and the Royal Jubilee in 1980 (Kermacks 1988). After the inception of the two-year program, several studies were conducted comparing the abilities of two-year college graduates with three-year trained hospital graduates. The Canadian Hospital Report, for example, reported that: Initial performances were lower for two-year graduates, particularly in the area of technical performance. Two-year graduates were less preferred for job placement, on specific services, and in general, as members of the nursing staff (Canadian Hospital Association 1972, pp. 3-4). Studies such as this focussed the debate over two and three-year programs. As a consequence, two-year college diploma programs were lengthened to a maximum of twenty-four months over two and a half calendar years. The battle of two vs three year programs clouded most views of quality and content of the program. Positions [were] drawn primar-ily on the basis of emotion, loyalities and traditional values rather than on empirical evidence (Shantz 1985, p. 34). Bill 81, the Medical Center Qf British Columbia Act (enacted in 1973), further af-19 fected nursing education (Letourneau 1974, pp. 160-161). Following passage of Bill 81, R .N.A.B.C. pressured for committee representation to establish policies, direct educational programs and make recommendations to the minister of education for expanding or closing training facilities in the health field (Riedel 1974, p. 11). In its report, the committee identified the confusion over role differentiation of various categories of nursing personnel. It is not clearly defined as to what the L.P.N, [licensed practical nurse] does for the patient, what the R.N. with a diploma does and what the R.N. with a baccalaureate does. In practice all three tend to do many of the same things for patients. Basic nursing education is in a quandry as to what its objectives of education are for these three categories of nurses (R .N.A.B.C. 1974, p. 2). To decrease problems such as these, the committee recommended increased career mobility in nursing and common standards of nursing practice (R .N.A.B.C. 1974, pp. 2-3). The enactment of Bill 81 resulted in the presentation of many briefs. In 1976, the R.N.A. B.C. sent a brief to Dean Goard, Minister of Education. Among its recommendations for changes in nursing education programs was the need for a core curriculum and for standardization of admission requirements in order to facilitate the transfer and re-entry of students (R .N.A.B.C. 1976, p. 10). Currently there are eighteen schools of nursing offering basic nursing education in British Columbia. One is a hospital program, one is a generic degree program, one is a post-basic baccalaureate program for registered nurses and five are remote access diploma programs (Kermacks 1988). Of the remaining ten, all are diploma programs located in colleges or institutes. Nine programs are full time, whereas one is part time (R .N.A.B.C. September 1987). While the R.N.A.B.C. continues to approve schools of nursing, their criteria for pro-gram approval are broad. "The criteria are intentionally broad to allow for variation among schools. Such details as hours of instruction, and hours of clinical experience are inten-tionally omitted" (R .N .A .B .C . 1977). Such deliberately broad criteria have resulted in considerable variation in program length, clinical hours, clinical experiences, and in the choice, sequence and distribution of courses within general education, support sciences and nursing. For example, no two colleges or universities use the same nursing model. The length of full time programs varies: twenty-two months over two calendar years (B.C. l .T . 1982), twenty-four months over three academic years (Cariboo 1987), thirty-two months over three years (V .G.H. 1984) or thirty-two months over four years (U.B.C. 1985). 20 Some programs have electives (Douglas 1983, U.B.C. 1985), whereas others do not (Cariboo 1987, V . G . H . 1984). The total hours per week of nursing content and experience vary within programs: twenty hours in the first semester to thirty-six in the final semester (Cariboo 1987), twenty-one hours in the first semester to thirty-seven and a half in the last (B .C. l .T . 1982), and sixteen hours in the first semester to forty hours in the last (Camosun 1982). All programs offer a course and clinical experience in core major areas (medicine, surgery, pediatrics, psychiatry, and obstetrics) as stipulated by the R.N.A.B.C. minimum require-ments. The extent of the clinical experience in the core areas varies from less than two to ten or more weeks. A comparison of the degree program with the diploma programs shows a a similar variation; however, all registered nurses anywhere in British Columbia, whether diploma or university graduates and regardless of the variation in their educational preparation, must write the same Canadian National Association Testing Service Examination and achieve the minimal score of 350 before being allowed to start practice. The ministry of education has commissioned studies to determine future goals for nurs-ing education. One report outlined a classification of types of nurses needed for the province. Among Kermacks' recommendations were the establishment of a provincial competency based curriculum for general nursing, post basic clinical courses and the dissolution of the existing hospital program (1979 pp. x-xii). A second study attempted to distinguish the differences in nursing education in the province of British Columbia. This study by Zabawski, funded and initiated by the ministry of education, found that there were differences in philosophies, admission criteria, terminal objectives, selection of support courses, length of program, supervision, and in the number of hours of instruction and clinical practice. It was further found there were differences in the degree of self-directed learning, scheduled class workload, content and learning experiences, textbook selection, methods for designing examinations and types of clinical evaluation tools in the five programs studied (Zabawski 1983, pp. 1, 7). These differences were recognized as serious issues by those administrators who have to individualize orientation programs for graduates; by the R.N.A.B.C. who is responsible for approving different schools; by other health care workers who may not understand the capabilities of the graduates; and by students who seek transfer from one school to another. 21 For example, students who transfer are usually required to enter at a lower level because they must learn a new nursing model and make up for required courses. Attempts at standardization have occurred. For example, the Canadian Nurses Associ-ation took the stance that the minimal educational preparation by the year 2000 should be a baccalaureate in nursing (C.N.A. 1982). In November 1983, this statement was endorsed by the Registered Nurses Association of British Columbia (R .N.A.B.C. 1985), as well as by associations in Alberta, Saskatchewan, Ontario, Quebec, Newfoundland, Manitoba, New Brunswick, and Prince Edward Island (Shantz 1985, p. 145). Having decided to move towards baccalaureate education, the Canadian Nurses Asso-ciation delineated objectives for the nurse in the year 2000. They are listed as follows: 1. A solid basis in: the physical, biological and social sciences; nursing as a discipline, including nursing research and ethics. 2. Emphasis on "caring to know — and knowing to care" (Diers 1982). 3. Emphasis on all aspects of health promotion: generation, development, protection, maintenance, and restoration; and on palliation (Simmons 1981). 4. Emphasis on critical thinking skills in relation to effective problem solving; ethical decision making; clinical practice evaluation; and application of nursing research to practice. 5. Emphasis not only on the nursing of individuals and families but also groups and communities, multicultural populations, and within a variety of contexts: institutions, workplace, school, home, recreational settings. 6. Emphasis on promoting "self care"; and working with other professional and lay groups. 7. Emphasis on flexibility and competence in "learning how to learn" spe-cialized knowledge and skills. 8. Knowledge of health care policy dynamics and of the basics of resource allocation. 9. Emphasis on the professional imperatives of integrity, knowledge, ser-vice to society, continuous learning, and accountability for one's actions (C.N.A. 1982, p. 30). Among the major reasons for baccalaureate preparation is that fact that "hospital nursing directors report that 43.2% of hospital nursing jobs require nurses to have skills not taught in the basic nursing programs" (R .N.A.B.C. 1981, p. 2). The type of curriculum outlined by the C.N.A. cannot be taught within the existing R.N. program. Imai considers it a priority for nursing to deal with the questions of "what kind of practitioners are to be developed, why and to meet what kind of service needs" (1980, p. 189). Currently we face a critical decision point:.. Changes in health care delivery...the explosive growth in high technology treatment meth-ods, and the development of primary care and community based 22 service...and the evolution of the nursing discipline...necessitates a review of the initial and ongoing educational needs of nurses (R .N .A .B .C . 1985, p. 2). In 1980, the British Columbia Nurses Union (B.C.N.U.) legally separated from the Registered Nurses Association of British Columbia. The R.N.A.B.C. News reported that this separation would "allow the two groups to cooperate even more closely than at present" (1980, pp. 3, 19). However, early in 1988, the B.C.N.U. became vocal about the necessary preparation of registered nurses. In a recent B.C.N.U. article, the council rejected the C.N.A. and R.N.A.B.C. proposal for a baccalaureate degree as the minimal educational requirement for a nurse in the year 2000. In rejecting this proposal, B .C.N.U. believes nurses should be able to choose their own type of nursing education and pursue their preference in specialties. The council expressed its position this way: B.C.N.U. recognizes that the practice of nursing is undergoing change and, further, that nursing education needs to change in or-der to meet the future health care needs of B.C. citizens... B .C.N.U. supports the development of specialized nursing education and the involvement of nurses... B .C.N.U. cannot support a baccalaure-ate in nursing as the minimum requirement... as the concept is currently structured... In some work areas specialized educational training may be required to perform the job... nurses currently in the work force should have the choice of what type of nursing ed-ucation to pursue for their chosen specialty (B .C .N .U . May 1988, P- I)-Thus, there is continued conflict over the preparation needed for basic nursing education. While some stakeholders have pushed for an upgrading and standardization of nursing education programs, this has not yet occurred. Summary This chapter began with brief discussions of the terms 'stake' and 'stakeholder' followed by an identification of stakeholders in nursing education. Stakeholders, by definition, usually have reasons for their interest in something: it may be that they are potentially affected by curricular changes, that they want to influence nursing education programs, that they have had responsibilities for one or more programs, or that they may have been historically involved in the development. For this thesis, those stakeholders chosen as subjects in this research are: the provincial professional nursing association, nurse educators, nurse administrators, physicians and the ministries of health and education. Tracing the role of stakeholders in the development of nursing education programs began with the initiation of hospital based programs. Physicians were involved in both de-23 veloping and teaching in these programs which flourished for many years. Some stakeholders (educators) felt that students were being exploited in hospital programs; however, others (administrators) were content with the hospital program. Such conflict resulted in studies of nursing education which recommended the transfer of nursing education to educational institutions. The first program in an educational institution in Canada was developed as a baccalaureate degree program at the University of British Columbia. The initiation of this program was largely due to the efforts of a physician and a university chancellor. Other degree programs developed. Thus, hospital programs and degree programs co-existed. Nearly fifty years later, following additional studies of nursing education, the first British Columbia two-year college program was started at the British Columbia Institute of Tech-nology. The development of this program was due to the influence of the Canadian Nurses Association, the Registered Nurses Association and the Department of Education. Two-year college programs developed around the province. At the same time most hospital programs were dissolved, with the exception of the Vancouver General Hospital program. Accordingly, all three types of programs still exist in the province. The three programs were (and still are) quite varied. They differ in length, in course content, in choice of electives, and in type of clinical experiences. In recent years this has come to the attention of the ministry who have funded studies to investigate the type of nurse practitioner needed for the future and to investigate differences among the nursing education programs. In an attempt to standardize programs, the Registered Nurses Association of British Columbia in conjunction with the Canadian Nurses Association have recommended that preparation for basic nursing education should be one level of practitioner. These asso-ciations aim for the minimum educational level to be at the baccalaureate level by the year 2000. Recently (May 1988) this proposal was rejected by the British Columbia Nurses Union (B.C.N.U.) because it was felt that that nurses should be given choices of educational preparation. The union's preference is one which allows for the development of specialties in nursing. Such conflict over stakeholder preferences for basic nursing education is the problem this thesis addresses. This conflict results in differing expectations for what is needed for basic nursing education. The approach taken to address the problem in this thesis is, first, to document stake-24 holders' perceptions of basic nursing education; second, to understand the reasons that educators have for their curricular choices and third, to make recommendations for basic nursing education which are consistent with the views of stakeholders. In the following chapter (Chapter Three) the method of answering the problem of this study will be described. 25 C H A P T E R T H R E E Methodology The dearth of studies related to stakeholder perceptions about basic nursing education in Canada suggests that a survey followed by an interview of selected subjects would provide useful data. The research design incorporated two means of collecting data: a mail-out questionnaire and a semi-structured interview. While the questionnaire was a means of obtaining the opinions from a larger number of people, the interviews gave more compre-hensive responses from a smaller group of subjects. Discussions of the questionnaire and interview schedule are subdivided into the following headings: (1) Subjects, (2) Develop-ment of the Instrument, (3) Data Collection, and (4) Data Analysis. Limitations and a summary conclude the chapter. The Questionnaire Subjects The target population for the questionnaire survey was: 1. all nurse educators in the province of British Columbia; 2. all nurse service administrators employed at the director level or higher in all hospitals in British Columbia; 3. all physicians (general practitioners and specialists) from the province of British Columbia; 4. key officials in the ministries of health and education in British Columbia; 5. all board members of the Registered Nurses Association of British Columbia. Nurse Educators (educators). A list of nurse educators was obtained from current calendars of the colleges, hospitals and universities and verified by telephone calls to departments of nursing in each school. It was found that there were 260 nurse educators employed full time at the time of this study. Of those, 40 were on leave and were omitted from the study. Questionnaires were sent to the remaining 220. 26 Nurse service administrators (administrators). The Canadian Hospital Directory (1986) listed hospitals in all provinces in Canada- acute care, psychiatric, or in-bed rehabilitation hospitals for children and adults. Questionnaires were sent to the 168 directors (nurse service administrators) at each of the 143 hospitals in British Columbia. Eighteen hospitals had more than one director. Physicians. The names of the physicians were obtained from the 1986 British Columbia Medical Associate Directory. This directory listed 6,890 physicians licensed to practise medicine in the province of British Columbia. Questionnaires were sent to a representative sample of 300 physicians. Because previous research indicated that the response rate of physicians has been low (Wilds 1982, p. 90), physicians were oversampled. Ministry. The list of government ministry officials was formulated using recommendations of min-istry officials and the provincial nursing association. It included those people on whom the ministries relied for advice when making decisions. These representatives include both the ministries of health and education. This list totaled 27. Registered Nurses Association of British Columbia. (R.N.A.B.C) . Names of the 25 representatives from the Registered Nurses Association of British Columbia (R.N.A.B.C. ) were obtained from the executive office of the provincial nurses association. This group consisted of people who were board members of the the R.N.A.B.C. The selected sample was 740. Development of the Questionnaire The survey questionnaire used in this study consisted of five parts (Appendix A). Part one was adapted from an existing instrument designed by Angeline Jacobs (1978) and her associates in a project undertaken in 1974 at the request of the Council of State Boards of Nursing in the U.S.A. Permission to use her instrument was obtained from the American Nurses Association (Appendix D). 27 Jacob's instrument was adapted for use in British Columbia by compiling a list of 630 terminal behavioural objectives (objectives) obtained from documents found in each school's report to the R.N.A.B.C. approval committee. The 630 objectives were compared with items in the Jacob's instrument and overlapping items were deleted from the list of 630 objectives. Thirty-four objectives not found in Jacob's forty-nine item instrument were added to the questionnaire making a total of eighty-three objectives. Jacob's original forty-nine item instrument had ten categories: 1. Exercises prerogatives based on clinical judgment. 2. Promotes patient's ability to cope with immediate, long range or potential health related change. 3. Helps maintain patient comfort and normal body functions. 4. Takes precautionary and preventative measures in giving patient care. 5. Checks, compares, verifies, monitors and follows up medication and treatment pro-cesses. 6. Interprets symptom complex and intervenes appropriately. 7. Responds to emergencies. 8. Obtains, records, and exchanges information on behalf of the patient. 9. Collaborates with staff within the organizational structure. 10. Utilizes patient care planning (Jacobs 1978). Five new categories were added to accommodate the thirty-four additional objectives. 11. Teaches and supervises other staff for whom responsible. 12. Demonstrates personal characteristics suitable for nursing. 13. Uses models in assessing and giving care to patients. 14. Carries out research in the practise of nursing. 15. Participates in professional activities related to nursing. Thus, all eighty-three objectives were classified into one of fifteen categories. These categories were used only for the purposes of grouping objectives to report findings. They were not included in the questionnaire. Part two of the questionnaire was adapted from another questionnaire developed by Curran (1984), which considered courses and clinical areas for a basic R.N. curriculum. She identified thirty-two items as possible course content and thirty items as possible clinical areas for nursing education. After permission from the author was sought, Curran's instrument was adapted for use in this study. A list was compiled of one hundred course/course content areas from all schools of nursing in British Columbia. The designation course/course content was used because organization of material was not uniform in all schools of nursing. For example, one school of nursing had a semester course devoted to one particular course content area, whereas another school had included similar content in several courses. After the course content 28 was extracted from the documents, the one hundred course content areas were compared to the Curran instrument and areas of overlap were deleted. Thirteen course content areas not included in the Curran instrument were added (abnormal psychology, care of ill adults, care of ill children, communication, epidemiology, family nursing, gerontology, human needs, immunology, nursing skills, physical assessment, physical education, professional issues) making a grand total of forty-five course content areas. These forty-five course content areas were then categorized, where appropriate, under one of two categories: support course content areas and nursing course content areas. For example, course content categorized as "support" were those areas which did not directly include nursing content (such as sociology, psychology, and English), whereas nursing course content was that which directly included nursing (e.g., care of the ill adult). These categories were used to group course content for the purpose of reporting the findings. These categories were not included in the questionnaire. Part three of the present instrument was created in a similar fashion. A list was compiled of 141 clinical areas from curricula of all schools of nursing in British Columbia. The 141 clinical areas were compared with the Curran instrument and areas of overlap were deleted from the list. Eight clinical areas not found in the Curran instrument were added (burn unit, cardiovascular-thoracic, dermatology, home care, nursery school, physician's offices, plastic surgery, and radiology), making a total of thirty-eight clinical areas. These thirty-eight clinical areas were categorized, where appropriate, under three categories: general, critical care, and community health. General areas were those which could be found on a medical-surgical ward such as general medicine, general surgery, and orthopedics. Critical care areas were those found in critical areas of the hospital (e.g., medical intensive care, surgical intensive care and pediatric intensive care). Community health were those which focussed on preventative care or home care (e.g., public health and home care). These categories were used to group clinical areas for the purpose of reporting the findings. These categories were not included in the questionnaire. Part four consisted of two closed-choice questions which asked respondents to indicate their preference regarding the type of basic nursing education and the length of program. Part five of the questionnaire, the demographic section, consisted of closed-choice ques-tions requesting respondents to indicate their educational background, work experience, age, gender, profession, and involvement with nursing education programs. 29 T h u s , the survey quest ionnaire consisted of f ive parts; Part I inc luded the objectives; Part II inc luded the course content areas; Part III included the c l in ica l areas; Part IV conta ined the length of program and type of preparat ion for a basic nursing educat ion program; and Part V conta ined demograph ic da ta . Parts I, II and III used seven-point rat ing scales ranging f r o m 'not needed' to 'needed' whereas parts IV and V each consisted of two c losed-choice quest ions ( A p p e n d i x A ) . Four pi lot tests were conducted to determine clar ity in word ing and content for both the rat ing scales and quest ionnaire i tems. These tests were conducted w i t h graduate students and medica l s tudents in Br i t ish C o l u m b i a and w i th out -o f -p rov ince educators , administ rators , physic ians and representatives f rom the professional nurs ing assoc iat ion . These pilot tests resulted in minor word ing changes to the inst rument and changes to the seven-po int rat ing scale. D a t a Co l lect ion In Ap r i l 1987, 740 quest ionnaires were mai led to part ic ipants w i th an in t roductory letter and consent fo rm ( A p p e n d i x A ) . Because of the length of the quest ionnaire , three versions were used to reduce the possible effects of fat igue, w i th subsect ions occur r ing in different orders in each version. T h e three versions were randomly d ist r ibuted to the part ic ipants . In M a y 1987, a second mai l ing of the quest ionnaire to the 500 non - respondents was comp le ted . A post card reminder was sent dur ing the latter part of M a y 1987 to the remain ing 326 non- respondents . There were 500 questionaires returned. D a t a Ana lys is D a t a were coded , entered and checked for accuracy before they were analysed. T h e data were analysed using A N O V A and A N O V A one-way a posterior i contrasts of Tukey analysis of honestly s ign i f icant ly differences (Nie , 1986) . T h e a lpha was set at 0.05. Each i tem was classif ied into categories. T h e r e were f i fteen categories for the objectives, two categories for course content , two categories for c l in ica l areas and two categories for type and length of educat iona l preparat ion. Fo l lowing c lass i f icat ion into a category, mean scores for each i tem in the categories were ca lcu la ted . Based on the mean scores, each i tem was assigned a rank order for compar isons a m o n g groups. In add i t ion , the means of mean scores were also ca lcu lated for addi t ional compar isons . 30 T h e demograph ic in format ion obta ined was tabu lated and presented in the form of f requency d ist r ibut ions , measures of central tendency and measures of variabi l i ty. T h e first research quest ion considered the objectives for basic nurs ing educat ion , the second quest ion was related to course content for basic nursing educat ion , and the th i rd research quest ion ident i f ied c l in ica l areas needed for basic nurs ing educat ion . T h e type and the length of educat iona l preparat ion was the basis for the fourth research quest ion . T h e Interview Schedule Sub jects Nurse educators are the ones who make decisions about the object ives, course content and c l in ica l areas for nurs ing programs. For th is reason, educators were chosen for the second part of the study. A random strat i f ied representative sample of those educators who had responded to the quest ionnaire was interviewed. O f the th i r ty - four educators employed in a hospita l nurs ing program, twenty - four responded to the quest ionnaire . O f the forty -three employed in a university nursing program, twenty -n ine responded to the quest ionnaire. O f the one hundred and forty - three educators employed in a col lege nurs ing program, one hundred and six responded. S ince a twenty percent samp l ing is the recommended size for a smal l target popu la t ion , a strat i f ied sample of twenty percent was drawn randomly f rom those w h o responded: f ive educators f rom a hospi ta l , six f rom a university, and twenty - two f rom a col lege, for a to ta l of th i r ty - three . Deve lopment of the Interview Schedule T h e interview schedule was designed to discover the reasons educators have for choos ing part icular course content , objectives and c l in ica l areas as well as the type and length of educat iona l preparat ion. Dur ing the latter part of M a y 1987, two pi lot tests were conducted w i t h the interview schedule using alternat ive formats . In the f irst pi lot test, i tems selected for the interview schedule were those items f rom the quest ionnaire where stakeholder disagreement was displayed. S ince 142 (out of 166) items revealed stakeholder disagreement, the interview schedule conta ined 11 questions w i t h 142 i tems. Pa r t ic ipants in th is pi lot test were asked to choose five object ives, to specify five course content areas, and to select f ive c l in ica l areas f rom a provided list. Fo l lowing the se lect ion , in formants were asked t o rank their choices and t o supply reasons for their choices. 31 In add i t i on , in formants were asked to choose a type and length of program suitable for basic nurs ing educat ion and present, once again , reasons for these selections. Unfortunately , owing t o the length of the schedule, part ic ipants spent more t ime in select ing i tems than presenting reasons. In the second pi lot test, the interview schedule was reduced to those i tems f rom the survey quest ionnaire where at least ten percent of educators ' responses clustered at the two extremes of the seven point rat ing scale or had an overal l stakeholder mean located between 3.5 and 5.5. For example , in the sect ion under course content , phi losophy was selected as a t o p i c for the interview because frequency counts revealed disagreement. S o m e educa -tors ( 1 5 % ) rated phi losophy 7.0 (needed) whi le other educators (10 .7%) rated it 1.0 (not needed). Add i t iona l ly , the overall mean for phi losophy was 3.97 (Tab le 156, A p p e n d i x C ) . A s imi lar procedure was fo l lowed for all i tems selected for the interview schedule (Append ix F) . There were 48 i tems that had polar ity in f requency counts or whose overal l mean was located between 3.5 and 5.5. In t o t a l , the interview schedule had 11 quest ions w i th 48 i tems. A s was the case in the f irst pi lot test, the interview schedule in the second one also asked in formants to choose five objectives, f ive course content areas and f ive c l in ica l areas f rom a provided list, to rank their selections and to supply reasons for their choices. It also asked in formants to choose a type and length of program suitable for basic nurs ing educat ion and to present reasons for their selections. However, because this interview schedule was shorter, in formants were able to spend more t ime presenting reasons than select ing i tems, and as a result th is schedule was used for interv iewing. D a t a Co l lec t ion In M a y and J u n e (1987) , th i r ty - three subjects were contacted by telephone and permis -sion to interview was sought . A l l subjects agreed. Procedure . Sub jects were given four sets of color coded cards. T h e f irst set of cards (n = 20) represented c l in ica l areas, the second (n = 18) represented course content areas, the th i rd (n = 10) represented objectives and the fourth (n = 2) asked subjects to identify and give reasons for the type and length of educat iona l preparat ion offered for basic nursing educat ion . 32 Fo l lowing the select ion f rom the first set of cards, each subject was asked to rank her selections f rom one t o f ive, one being the most needed and five be ing the least needed. T h e subject was then asked t o give reasons for each select ion. T h e interview fo l lowed the same fo rmat for the second and th i rd sets of cards. For the four th set of cards, each subject was asked t o offer a type and length of educat iona l preparat ion and explain the choice w i th reasons ( A p p e n d i x F) . T h e m o d a l length of the interview was 45 minutes . T h e interviews were tape recorded for later t ranscr ip t ion and analysis. D a t a Ana lys is T h e data were coded and reduced to categories. Fo l lowing data reduct ion , frequencies for each category of reasons were tabu la ted . T h i s procedure identi f ied the categories of reasons most c o m m o n l y and least c o m m o n l y c i ted . S ix categories were ident i f ied: educa -t i ona l , i ns t i tu t iona l , c l ient , t rad i t iona l , professional , and other. A fu l l descr ipt ion of these categories fo l lows in Chapter Five. Researcher rater rel iabi l i ty was establ ished by g iv ing two graduate students unmarked t ranscr ipt ions w i t h the establ ished categories and def in it ions. E a c h graduate student was asked to independent ly identify the researcher's categories f rom the t ranscr ipt ions and def in i -t ions given. T h e r e was an overal l 9 0 % agreement between researcher and graduate students . T h e 1 0 % disagreement resulted f rom previously unnot iced overlap in categories and led to the col lapse of two categories into a single category. T h e category ' f undamenta l ' was c o l -lapsed into the category 'other ' . S u m m a r y Cons t ruc t i on of a survey quest ionnaire designed to el icit stakeholder responses about the components of a basic nursing educat ion program has been descr ibed. T h e quest ionnaire surveyed five s takeho lde rs -a sample of seven hundred and forty p a r t i c i p a n t s - a n d consisted of f ive parts: course content , c l in ica l areas, objectives, the type and length of educat iona l preparat ion and demograph ic in format ion . Each part ic ipant was asked to rate the first three parts accord ing to a scale of need. T h e four th and f inal part consisted of c losed-choice quest ions w h i c h asked part ic ipants to select a type and length of educat iona l preparation for basic nurs ing educat ion , and t o supply demograph ic in format ion . A fo l l ow -up interview wh ich questions m a t c h i n g the survey inst rument was employed. 33 In th is taped interview, educators were required to select and rank course content , c l in ica l areas and objectives and supply reasons for their choices. Each of the th i r ty - three inter -v iewed subjects was also asked to state their preference concern ing the type and length of educat iona l preparat ion for a basic nursing educat ion program. Chapters Four and Five describe the results of the surveys. 34 C H A P T E R F O U R Presentat ion of F indings F rom T h e Quest ionnai re Chapte r Th ree described the const ruct ion of the five part quest ionnaire designed to el icit responses about components for a basic nursing educat ion program: objectives, course content areas, c l in ica l areas, and the type and length of the educat iona l p rogram. M e a n scores al lowed the responses to each quest ion by the stakeholder groups to be assigned a rank order so that compar isons could be made. In add i t ion , categories of questions were given mean scores and ranked. T h e f irst sect ion in th is chapter out l ines the response rates and provides some demo-graph ic in format ion on the five stakeholder groups. T h e second and th i rd sect ions report the percept ions of the stakeholders relevant to the first and second research quest ions. Sec -t ion four presents data relative to the th i rd quest ion , and sect ion f ive presents data relative to the four th research quest ion concern ing the type of educat iona l preparat ion necessary for beg inn ing nurses, and the length of such a program. A summary of the f ind ings concludes the chapter . Demograph ic Character is t ics of the Respondent G r o u p s * T h e to ta l response rate was nearly s ixty -e ight percent (67 .6%) for the five groups (Tab le 4 -1 ) . T h e highest rate was admin ist rators (82 .1%) , compared w i t h the lowest reponse rate of physic ians (54 .0%) . Not every quest ion was responded to by every par t ic ipant , m a k i n g the tota ls different on some questions. Nurse Educators (educators) T h e typ ica l educator respondent was female, aged forty - three years, and was presently teach ing in a college d ip loma program that graduated e ighty - f ive students each year. M o s t educators had graduated f rom a hospita l school of nurs ing. Teach ing experience ranged f rom one year to more than twenty -one years, w i th the average be ing eight years. M o s t educators (62 .3%) had at ta ined a m i n i m u m of a B . S . N . , twenty -s ix percent (25 .8%) a M . S . N . , and eighteen percent (18 .2%) had at ta ined a master 's degree in an area or d iscip l ine other than nursing. C l in ica l experience for educators was * A complete descr ipt ion on the demograph ic profiles of the respondent groups may be found in A p p e n d i x B. 35 TABLE 4-1 Responses to Questionnaires RESPONDENTS Number Mailed Number Returned Percent Returned Usable Questionnaires Educators 220 159 72.3 159 Administrators 168 138 82.1 134 Physicians 300 162 54.0 156 R.N.A.B.C. 25 20 80.0 20 Ministry 27 21 77.8 21 TOTAL 740 500 67.6 490 predominant ly medica l and surgical (Tables 2 through 14, A p p e n d i x B ) . Nurse Service Admin is t ra to rs (admin ist rators ) T h e typ ica l admin is t ra tor was female, aged forty - f ive years, educated in a hospita l nurs ing program, had extensive c l in ica l experience and had worked in their present posi t ion for f ive and one -ha l f years. M o s t had not taught in nursing educat ion programs and the R . N . was the highest level of educat ion achieved. T h e size of the hospita l where admin ist rators worked ranged f rom 2 beds to 1800 beds, w i th 224 as the average (Tables 15 through 26, A p p e n d i x B ) . Phys ic ians T h e typ ica l physic ian was forty - four years o ld , male, had been in pract ice for ten years, was equal ly l ikely t o be categor ized as either a general pract i t ioner or as a special ist , and had a 5 0 % chance of hav ing been involved in teach ing in a nursing program. T h e hospita l where he pract iced had an average of 308 beds. Nearly seventy-n ine percent (78 .8%) of physic ians had not been provided w i t h in format ion concern ing nurs ing educat ion programs, and 5 2 . 5 % were 'not aware' or only ' somewhat aware' of the differences in the three types of nurs ing educat ion programs (Tables 27 -38 , A p p e n d i x B ) . Representat ives f rom the Registered Nurses Assoc ia t ion of Br i t ish C o l u m b i a ( R . N . A . B . C . ) T h e typ ica l R . N . A . B . C . representative was female, aged forty - three and had been e m -ployed in her present pos i t ion for f ive and a one-ha l f years. E ighty - f i ve percent were nurses. O f these th i r ty - f i ve percent had at ta ined a baccalaureate degree in nursing, and forty per-36 cent were work ing in admin is t rat ive posit ions. C l in ica l preparat ion of the representatives was extensive, most ly in medic ine and surgery (Tables 39 th rough 49, A p p e n d i x B ) . M i n i s t r y Off ic ia ls ( M i n i s t r y ) M in i s t r y off icials were equal ly l ikely to be male or female. T h e average age was forty -five years. T h e y had been employed in their present pos i t ion for four years. Ten ministry off icials were nurses and of those, seven had received their basic nurs ing educat ion in a hosp i ta l . M o s t had not taught in a nursing program (66 .7%) ; however, 6 1 . 9 % had worked in a hospi ta l set t ing . 7 1 . 5 % of ministry off icials were found to be 'aware' or 'very aware' of the differences in the three types of nursing educat ion programs (Tables 50 th rough 60, A p p e n d i x B ) . Object ives for Bas ic Nurs ing Educat ion (Research Quest ion # 1 )  Compar i son of the Categor ies of Object ives Tables 39 -121 in A p p e n d i x C conta in frequencies, means, overal l means, and standard deviat ions for each of the e ighty - three objectives. A compar ison of the rat ings reveals that al l stakeholders perceived all f i fteen categories as being needed w i t h the except ion of category fourteen wh ich was "carries out research in the pract ice of nurs ing" (Tab le 4 -2 ) . W h i l e physicians and the ministry rated category fourteen lower than other groups, al l groups rated it as being least needed. Four groups identi f ied category five, "checks , compares , verifies, moni tors and fol lows up medicat ion and t reatment processes" as most needed. However, the R . N . A . B . C . rated category eight, "obta ins , records and exchanges in format ion on behal f of the pat ient" as the most needed (Tab le 4 -2 ) . N ine categories were ranked equal ly by three or more groups (Tab le 4 -2 ) : 1. "Exerc ises prerogatives based on c l in ica l j udgment " (educators , R . N . A . B . C , and m i n -istry) . 2. "Takes precaut ionary and preventative measures in g iv ing pat ient care" (administ rators , physic ians and R . N . A . B . C ) . 3. " C h e c k s , compares , verifies, moni tors and fol lows up med icat ion and t reatment pro-cesses" (educators , admin ist rators , physicians, and min ist ry ) . 4. "Responds to emergencies" (educators, admin ist rators , and R . N . A . B . C ) . 5. "Ut i l i zes pat ient care p lann ing" (administ rators , R . N . A . B . C . and min ist ry ) . 6. "Teaches and supervises other staff" (educators, admin ist rators , and min ist ry ) . 7. "Uses nurs ing models in assessing and g iv ing patient care" (educators, admin ist rators , and phys ic ians) . 37 TABLE 4-2 Comparison of Categories By Respondent Group Group 1 Educator n=156 Group 2 Adminis-trator n=130 Group 3 Physician n=135 Group 4 R.N.A.B.C. n=18 Group 5 Ministry n=20 BROAD CATEGORY X rank X rank JJ rank x rank X rank 1. Exercises prerogatives based on clinical judgement. 2. Promotes patient's ability to cope with immediate, long range or potential health related changes. 3. Helps maintain patient comfort and normal body functions. 6.63 7 6.42 9 5.75 10 6.43 7 6;11 7 6.63 7 6.49 8 5.79 9 6.31 9 6.05 8 6.74 4 6.85 2 6.38 2 6.68 4 6.64 3 4. Takes precaution-ary and preventative measures in giving patient care. 5. Checks, compares verifies, monitors and follows up medication and treatment processes. 6. Interprets symptom complex and intervenes appropriately. 6.86 2 6.83 3 6.26 3 6.77 3 6.69 2 6.91 1 6.90 1 6.55 1 6.79 2 6.85 1 6.69 5 6.61 6 6.02 7 6.53 5 6.42 4 7. Responds to emergencies. 8. Obtains, records and exchanges information on behalf of the patient. 5.87 11 6.23 11 6.23 4 6.10 11 6.03 9 6.76 3 6.76 4 6.08 5 6.81 1 6.33 5 38 TABLE 4-2 Cont'd Group 1 Group 2 Group 3 Group 4 Group 5 Educator Adminis- Physician R.N.A.B.C. Ministry trator n=156 n=130 n=135 n=18 n=20 BROAD CATEGORY X rank X rank X rank X rank X rank 9. Collaborates 6.36 10 6.60 7 6.05 6 6.34 8 6.22 6 with staff within the organizational structure. 10. Utilizes 6.37 9 6.26 10 5.32 12 6.16 10 6.01 10 patient care planning. 11. Teaches and 5.80 12 6.00 12 5.57 11 5.55 14 5.28 12 supervises other staff for whom responsible. 12. Demonstrates 6.65 6 6.66 5 5.95 8 6.49 6 5.85 11 personal character-istics suitable for nursing. 13. Uses models 5.12 14 5.85 14 5.18 14 5.75 12 5.15 13 in assessing and giving care to patients. 14. Uses 4.29 15 4.62 15 3.90 15 4.86 15 3.73 15 research in the practise of nursing. 15. Participates 5.59 13 5.86 13 5.26 13 5.75 12 4.80 14 in professional activities related to nursing. Mean Total 93.27 94.94 86.29 93.32 88.16 Mean and Rank 6.22 3 6.33 1 5.75 5 6.22 2 5.88 4 8. "Uses research in the pract ice of nurs ing" (educators, admin ist rators , physicians, R . N . A . B . C , and min ist ry ) . 9. "Pa r t i c ipa tes in professional act iv i t ies related to nurs ing" (educators, admin ist rators , and phys ic ians) . These nine categories showed ranking agreement by three or more groups but two showed rank ing differences. Phys ic ians ranked "responds to emergencies" four th , whi le the min ist ry ranked it n in th , and educators , admin ist rators and the R . N . A . B . C . ranked it eleventh. Category twelve, "demonstrates personal character ist ics suitable for nurs ing" was 39 ranked f i f th by admin ist rators , s ixth by educators and the R . N . A . B . C , e ighth by physicians and eleventh by the ministry. Object ives for Category One. "Exerc ises professional prerogatives based on c l in ica l j udgment " In order to assess the stakeholders ' op in ions concern ing the need for th is category, eight objectives were del ineated. O n the whole , there was agreement a m o n g all the groups regarding the need for objectives one, two, f ive, six and seven because the mean rat ings were all over 6.0 (Tables 39 -46 , A p p e n d i x C ) . There was also agreement on the rank order ing. There were three to four groups w h o agreed on the rank order ing of objectives one, three, four, f ive, six seven and eight. However, as is revealed in Tab le 4 -3 , stakeholders differed in their percept ions over the degree of need on al l eight of these objectives because more than one th i rd of the objectives had as many as four or f ive combinat ions of s igni f icant differences. Educators and physicians revealed differences in eight areas w i t h educators provid ing a higher rat ing in every case. T h e next greatest number of differences, seven, was between admin is t rators and physicians; here admin ist rators had s igni f icant ly higher ratings. T h e next greatest difference, three, was between educators and the ministry. T w o differences were found between the R . N . A . B . C and physicians and between admin ist rators and the ministry whereas the least number of differences, one, was found between educators and admin ist rators . T h e remain ing compar isons showed no differences. Educators consistent ly provided the highest ratings, w i t h seven rat ings ranging between 6.44 and 6.98. O n l y for object ive eight (Tab le 4 -3 ) did rat ings drop below six. In contrast , physic ians consistent ly provided the lowest ratings. In add i t ion to ident i fy ing s igni f icant differences in mean ratings, the study also compared rank order ing. For purposes of report ing, s igni f icant differences were defined as those fa l l ing in extreme th i rds of the d is t r ibut ion . T h i s meant a difference of three wou ld be required since there were eight objectives. There were no ranking differences of this magni tude . Object ives for Category T w o . " P r o m o t e s pat ient 's abi l i ty to cope w i th immediate , long range or potent ia l health related changes" T o assess stakeholders ' op in ions regarding this category, ten objectives were presented. 40 TABLE 4-3 Summary of Objectives by Respondent Group "Exercises prerogatives based on clinical judgment." Group 1 Group 2 Group 3 Group 4 Group 5 Fvalue Groups Educator Adminis- Physician R.N.A.B.C. Ministry Significantly trator Different n=156 n=130 n=135 n=18 n=20 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v OBJECTIVES X rank x rank X rank X rank X rank 2 3 4 5 3 4 5 4 5 5 1. Adapts care to 6.93 3 6.87 3 6.52 3 6.94 1 6.60 2 10.31* x x individual patient needs. 2. Fulfills respons- 6.95 2 6.89 2 6.71 1 6.87 3 6.50 3 6.29* x x x x ibility to patient and others. 3. Questions orders 6.66 5 6.37 6 4.72 7 6.25 6 5.50 6 45.46* x x x x x and decisions made by medical and other professional staff. 4. Acts as patient 6.44 7 5.88 7 4.65 8 6.05 7 5.21 8 28.44* x x x x x advocate in obtain-ing appropriate medical, psychiatric, or other help. 5. Recognizes, 6.98 1 6.90 1 6.59 2 6.88 2 6.90 1 8.62* x x corrects and reports own errors. 6. Analyzes and 6.65 6 6.52 5 6.13 4 6.41 5 6.35 5 5.17* x x changes own be-haviour in order to maintain therapeutic relationship with patient. 7. Evaluates 6.83 4 6.67 4 5.89 5 6.47 4 6.45 4 16.80* x x whether patient's requirements for nursing care were met. 8. Uses community 5.65 8 5.26 8 4.86 6 5.58 8 5.40 7 4.14* x resources to help patient resolve problems. Mean Total 53.09 51.36 46.07 51.45 48.91 Mean and Rank 6.63 1 6.42 3 5.75 5 6.43 2 6.11 4 * significant beyond the 0.05 level of significance. 41 TABLE 4-4 Summary of Objectives by Respondent Group "Promotes Patient's Ability to Cope with Immediate, Long Range or Potential Health Related Changes" OBJECTIVES Group 1 Educator n=156 rank Group 2 Adminis-trator n=130 rank Group 3 Physician n=135 rank Group 4 R.N.A.B.C. n=18 rank Group 5 Ministry n=20 rank Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Assesses patient learn-ing needs in relation to disability. 6.62 5 6.20 8 4.98 10 6.29 4 5.95 6 29.49* 2. Provides health care instruction or information to patients, family or significant other. 6.71 6.39 6 5.13 9 6.17 7 6.05 5 30.56* 3. Ensures that instruction is understood. 6.76 6.55 5 5.85 5 6.43 3 6.35 3 13.41* 4. Encourages patient or family to make informed decisions about accepting care or adhering to treatment regime. 6.51 8 6.19 9 5.24 8 6.11 8 5.60 8 16.76* 5. Helps patient 6.41 9 6.01 10 5.44 6. 6.05 9 5.40 9 11.04* x x x recognize and deal with psych-ological stress. 6. Avoids creating 6.56 6 6.71 3 6.36 3 6.29 4 6.10 4 3.08* x or increasing anxiety or stress. 7. Conveys accep- 6.96 2 6.87 2 6.57 2 6.88 1 6.70 2 10.62* x x tance, respect and trust to patient. 8. Facilitates 6.31 10 6.38 7 5.36 7 5.76 10 5.40 9 12.50* x xx x relationship of family, self or significant other with patient. 42 TABLE 4-4 Cont'd Group 1 Group 2 Group 3 Group 4 Group 5 Fvalue Groups Educator Adminis- Physician R.N.A.B.C. Ministry Significantly trator Different n=156 n=130 n=135 n=18 n=20 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v OBJECTIVES X rank X rank X rank X rank X rank 2 3 4 5 3 4 5 4 5 5 9. Maintains 6.98 1 7.00 1 6.88 1 6.88 1 7.00 1 4:64* X X confidentiality of patient information. 10. Stimulates, 6.54 7 6.62 4 6.16 4 6.27 6 5.95 6 6.65* X X X X motivates patient or enables him/her to achieve self care and independence. Mean Total 66.36 64.92 57.97 63.13 60.50 Mean and Rank 6.63 1 6.49 2 5.79 5 6.31 3 6.05 4 * significant beyond the 0.05 level of significance. O n c e again , educators assigned the highest rat ings w i th in this category w i t h the overal l highest rat ing on objectives one, two, three, four, f ive, and seven. A n d once again , phys i -cians assigned the lowest rat ings to this category w i th the lowest rat ings on objectives one, two, three, four, seven, eight and nine. Extensive disagreement was found in the c o l u m n 'groups s ign i f icant ly different' (Table 4 -4) because the stakeholders differed s igni f icant ly on all ten , and a to ta l of six objectives had three or more comb ina t ions of s igni f icant group differences. In compar ing admin ist rators and physicians, admin ist rators had higher rat ings in all ten instances. T h e next greatest difference, nine, was between educators and physicians where again , educators responded w i th higher rat ings than physic ians. There were four areas of differences found between educators and the ministry. T w o areas of difference were found between physicians and R . N . A . B . C , between physicians and the ministry and between admin is t rators and the ministry. There were no differences between the remain ing four groups. A l l f ive groups agreed that object ive nine was the most needed. Th ree or more groups agreed on the rank ing of objectives three, four, f ive, seven and nine. A difference of three in rank order ing was found on six objectives: 1. Educators and the ministry ranked "assesses patient learning needs in relat ion to dis -abi l i ty" higher than physicians (5 vs. 10 and 6 vs. 10 respectively) . R . N . A . B . C . ranked th is object ive higher than admin ist rators (4 vs. 8) and physicians (4 vs. 10) . Educators also ranked th is object ive higher than admin ist rators (5 vs. 8). 43 2. Admin is t ra to rs , educators and the ministry ranked "provides health care inst ruct ion or in format ion to pat ient 's , fami ly or s igni f icant others" higher than physicians (6 vs. 9, 4 vs. 9 and 5 vs. 9 respectively) . 3. Phys ic ians ranked "helps patient recognize and deal w i th psycholog ica l stress" higher t h a n any of the other four groups (6 vs. 10 for admin ist rators and 6 vs. 9 for educators, R . N . A . B . C . and the min ist ry ) . 4. Admin i s t ra to rs and physicians ranked " fac i l i tates relat ionship of family , self or s igni f i -cant other w i th pat ient" higher than R . N . A . B . C . (7 vs. 10), educators (7 vs. 10). 5. Admin i s t ra to rs and physicians ranked "st imulates , mot ivates pat ient or enables h i m / h e r to achieve self care and independence" (4 vs. 7). 6. Admin i s t ra to rs and physicians ranked "avoids creat ing or increasing anxiety or stress" (3 vs. 6) higher than educators. Object ives for Category Three . "He lps ma in ta in pat ient comfort and normal body funct ions" In th is category (Tab le 4 -5 ) there was a tendency towards agreement in rat ings because not one object ive was rated less than 6.07 by the stakeholders. Agreement also occurred in rank ing because all groups ranked the objectives in the same sequence. OBJECTIVES 1. Keeps patient clean and comfortable. TABLE 4-5 Summary of Objectives by Respondent Group "Helps Maintain Patient Comfort and Normal Body Functions" Group 1 Educator n=156 Group 2 Adminis-trator n=130 X rank 6.91 1 rank 6.90 Group 3 Physician n=135 Si rank 6.70 1 Group 4 R.N.A.B.C. n=18 X rank 6.88 1 Group 5 Ministry n=20 X rank 6.85 1 Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 4.10* 2. Helps patient maintain or regain normal body functions. 3. Efficiently provides care for a group of 4 to 6 patients. Mean Total Mean and Rank 6.84 6.48 20.23 6.74 6.87 6.78 20.55 6.85 6.38 6.07 19.15 6.38 6.67 6.50 20.05 6.68 6.70 6;37 19.92 6.64 10.17* 6.48* * significant beyond the 0.05 level of significance. However, there were s igni f icant differences in the degree of need. These differences occur red between educators and physicians, and between admin ist rators and physicians on 44 all object ives. There were no differences between the remain ing eight groups. In compar ing the lowest and highest ratings, physicians once again had the overal l lowest rat ings but instead of educators , admin ist rators had the highest rat ings overal l . Object ives for Category Four. "Takes precaut ionary and preventative measures in g iv ing pat ient care" A s was the case in the previous category, there was overal l agreement concern ing the need for object ives in this category as object ive seven was the only one w i t h a group mean below 6.08. In add i t ion , there was agreement in the rank ing of objectives. A l l groups ranked object ive seven as the least needed, and four groups ranked object ive one as the most needed. However, as seen in the 'groups s igni f icant ly different' c o l u m n in Tab le 4 -6 , there were differences in the degree of need. Stakeholders differed s igni f icant ly in their percept ions on all objectives, and four objectives had three to four combinat ions of s igni f icant group differences. Seven differences were found between educators and physicians and between admin is -t rators and physicians. Three differences were found between the R . N . A . B . C . and phys i -c ians and two differences were found between physicians and the ministry. There were no differences between the remain ing six groups. O n c e aga in , physicians rated all objectives lower than any other group, and once again educators provided the highest rat ings for objectives two, three, four, f ive and six, w i th rat ings 6.9 or higher. In fact , educators rated no object ive lower than 6.4. Even though the min ist ry was second lowest on al l objectives, they assigned the highest rat ing (7.00) to object ive one. A difference of two in rank order ing occurred on five objectives: 1. Admin i s t ra to rs ranked "protects pat ient 's skin and mucous membrane f rom injurious mater ia l " higher than physicians (1 vs. 3 ), R . N . A . B . C . (1 vs. 3) and the ministry (1 vs. 4) . Educators also this object ive higher than the ministry (2 vs. 4) . 2. Phys ic ians and the ministry ranked "avoids using injurious techn ique in admin ister ing and m a n a g i n g intrusive or other potent ia l ly t r a u m a t i c t reatments" higher than educa -tors and admin ist rators (2 vs. 5). R . N . A . B . C . also ranked th is object ive higher (3 vs. 5) than educators and admin ist rators . 45 TABLE 4-6 OBJECTIVES n=156 X rank Summary of Objectives by Respondent Group "Takes Precautionary and Preventative Measures in Giving Patient Care" Group 1 Group 2 Educator Adminis-trator n=130 X rank Group 3 Group 4 Group 5 Fvalue Physician R.N.A.B.C. Ministry n=13S n=18 n=20 X rank X rank X rank Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Applies 6.93 2 6.90 1 6.60 1 6.94 1 7.00 1 9.25* x x x principles of infection control. 2. Protects 6.93 2 6.90 1 6.48 3 6.83 3 6.73 4 11.48* x x patient's skin and mucous membranes from injurious material. 3. Uses posit- 6.89 6 6.82 6 6.28 5 6.83 3 6.70 5 14.36* x x x ining or exercises to prevent injury or the compli-cations of im-mobility. 4. Avoids using 6.90 5 6.84 5 6.58 2 6.83 3 6.90 2 4.12* injurious technique in administering and managing intrusive or other potentially traumatic treatments. 5. Protects patient 6.97 1 6.86 4 6.39 4 6.78 6 6.80 3 13.40* from falls or other contact injuries. 6. Ensures safe 6.92 4 6.87 3 6.08 6 6.89 2 6.50 6 22.00* enviroment for patient. 7. Supervises 6.45 7 6.62 7 5.40 7 6.28 7 6.21 7 20.46* patient's activities. Mean Total 47.99 47.81 43.81 47.38 46.84 Mean and Rank 6.86 1 6.83 2 6.26 5 6.77 3 6.69 4 significant beyond the 0.05 level of significance. 46 3. R . N . A . B . C . ranked "ensures safe env i ronment" higher than educators (2 vs. 4) , phys i -cians (2 vs. 6) and the ministry (2 vs. 6). Admin is t ra to rs also ranked this objective higher than physicians and the ministry (3 vs. 6) . 4. R . N . A . B . C . ranked "uses pos i t ion ing or exercises to prevent injury or the compl icat ions of immob i l i t y " higher than did physicians (3 vs. 5), the min ist ry (3 vs. 5), educators (3 vs. 6) and admin ist rators (3 vs. 6). 5. Educators ranked "protects pat ient f rom falls or other contact injuries" higher than the ministry ( 1 vs. 3) , admin ist rators ( 1 vs. 4) , physicians (1 vs. 4) and R . N . A . B . C . (1 vs. 6). T h e min ist ry also ranked this object ive higher than the R . N . A . B . C . (3 vs. 6). Admin i s t ra to rs and physicians ranked th is object ive higher than R . N . A . B . C . (4 vs. 6). Object ives for Category Five. " C h e c k s , compares, verifies, moni tors and fo l lows up med icat ion and t reatment processes" T o assess stakeholders ' op in ions concern ing th is category, eight objectives were del in -eated. There was overal l agreement about the need for this category of objectives, as no object ive received a rat ing of less than 6.08. In fact , objectives one, two and four were given overal l mean rat ings of 7.00 by two or more groups. In add i t ion , there was ranking agreement on al l eight objectives w i th three or more groups. Even though there was overall agreement, there was disagreement about the degree of need for th is category. A s seen f rom the 'groups s igni f icant ly different' c o l u m n in Tab le 4 -7 , stakeholders differed s igni f icant ly in their percept ions on all eight objectives. Each object ive had two combinat ions of s igni f icant group differences; object ive eight had three. T h e greatest number of differences, eight, was between educators and physicians and between admin ist rators and physicians. O n e difference was found between physicians and the R . N . A . B . C . T h e r e were no disagreements a m o n g the remain ing seven groups. Overa l l , educators had the highest and physicians had the lowest rat ings. Educators had higher or equal rat ings w i th other groups on objectives one, two, four, six and seven, and physic ians rated objectives five and eight lowest, 6.27 and 6.08 respectively. Admin i s t ra to rs had the highest rat ings on objectives three and f ive, whi le R . N . A . B . C . assigned the highest rat ings to object ive eight. T w o or more groups rated objectives one, two, four and six equally. A difference of three in rank order ing was found on two objectives: 1. R . N . A . B . C . ranked "checks for and interprets effects of med icat ion , t reatment or care and takes correct ive act ion if needed" higher than admin ist rators (2 vs. 8), ministry (2 vs. 8), physicians (2 vs. 8), and educators (2 vs. 7). 2. R . N . A . B . C . ranked "checks pat ient readiness for med ica t ion , t reatment or other care" higher than educators (5 vs. 8). 47 TABLE 4-7 OBJECTIVES Group 1 Educator n=156 rank Summary of Objectives by Respondent Group "Checks, Compares, Verifies, Monitors and Follows Up Medications and Treatment Processes" Group 2 Adminis-trator n=130 rank Group 3 Physician n=135 rank Group 4 R.N.A.B.C. n=18 rank Group 5 Ministry n=20 rank Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Checks correct- 7.00 1 6.98 3 6.70 3 7.00 1 6.95 3 8.15* x x ness, condition and safety of medication being prepared. 2. Ensures that 7.00 1 7.00 1 6.84 2 6.83 3 7.00 1 6.42 * x x correct medication or care is given to the right patient and that patient takes or receives it. 3. Adheres to 6.82 6 6.89 5 6.53 5 6.67 6 6.86 5 6.19* x x schedule in giving medication, treat-ment or test. 4. Administers 7.00 1 7.00 1 6.88 1 6.83 3 7.00 1 6.43* x x medication by correct route, rate or mode. 5. Check patient's 6.75 8 6.80 7 6.27 7 6.72 5 6.70 7 8.42* x x readiness for medication, treat-ment or other care. 6. Checks to ensure 6.92 5 6.92 4 6.61 4 6.67 6 6.90 4 6.43* x x that those tests or measurements that the nurse is responsible for are done correctly. 7. Monitors patient 6.95 4 6.84 6 6.45 6 6.67 6 6.75 6 8.62* x x infusions and inhalations. 8. Checks for and 6.80 7 6.78 8 6.08 8 6.89 2 6.60 8 15.95* x x x interprets effects of medication, treatment or care and takes correct-ive action if needed. Mean Total 55.24 55.21 52.36 54.28 54.76 Mean and Rank 6.91 1 6.90 2 6.55 5 6.79 4 6.85 3 significant beyond the 0.05 level of significance. 48 Object ives for Category S ix . "Interprets s y m p t o m complex and intervenes appropr iately" T o assess stakeholders ' op in ions regarding th is category, eight objectives were presented. A s was the case in the previous category, there was a tendency towards agreement on the need for this category because most objectives were rated higher than 5.90 (only objective eight had a rat ing less than 5.90 by any of the groups) . In add i t ion , three or more groups gave equal rank ing to objectives one, four, six, seven and eight. However, as is revealed in Table 4 -8 , stakeholders differed in their percept ions about the degree of need on all eight objectives for this category because three objectives had three or more combinat ions of group differences and object ive eight had f ive combinat ions of group differences. In add i t ion , physicians and educators differed on seven objectives in this category. Admin i s t ra to rs and physicians differed on six. Phys ic ians and the R . N . A . B . C . differed on two. T h r e e groups: educators and admin ist rators ; educators and ministry ; and physicians and the min ist ry showed only one area of difference. T h e remain ing four groups had no s igni f icant difference. Overa l l , educators had the highest rat ings here, w i th highest mean rat ings on objectives two, four, f ive, six, seven and eight, whi le physicians had lowest rat ings on all objectives and the lowest overal l rat ing . Educators rated object ive seven most needed, whi le four groups label led object ive one most needed. A difference of three in rank order ing was found on two objectives: 1. Admin i s t ra to rs ranked "observes and correct ly assesses physical signs, s y m p t o m s or f indings and intervenes appropr iately" higher than physicians (2 vs. 6) and educators (2 vs. 5). 2. Phys ic ians ranked "uses a larm signals on a u t o m a t i c equ ipment as an adjunct to per-sonal assessment" higher than educators (3 vs. 8), admin ist rators (3 vs. 6) and the R . N . A . B . C . (3 vs. 7). T h e ministry ranked this object ive higher than educators (5 vs. 8)-Object ives for Category Seven. "Responds to emergencies" T o assess stakeholders ' op in ions regarding this category, four objectives were presented. T h i s category differed f rom all the others in that physicians had the highest rat ings for object ives two, three and four and equal led the rat ings of admin ist rators for the highest 49 TABLE 4-8 OBJECTIVES Summary of Objectives by Respondent Group "Interprets symptom complex and Intervenes Appropriately" Group 1 Educator n=156 rank Group 2 Adminis-trator n=130 rank Group 3 Group 4 Group 5 Physician R.N.A.B.C. Ministry n=13S n=18 n=20 Fvalue rank rank rank Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 V V V ' V V V V V V V 2 3 4 5 3 4 5 4 5 5 1. Detects changes in a patient's condition or status. 6.85 6.80 6.63 6.83 6.90 3.35* 2. Investigates or 6.83 3 verifies patient's complaints or problems. 3. Uses alarms and 6.26 8 signals on auto-matic equipment as an adjunct to personal assessment. 4. Observes and 6.61 7 correctly assesses signs of anxiety or behavioral stress. 6.65 4 6.05 4 6.67 2 6.70 2 14.19* x x 6.60 6 6.19 3 6.38 7 6.37 5 2.13 6.51 7 5.90 7 6.39 5 6.15 7 12.31* x x 5. Observes and correctly assesses physical signs, symptoms or findings and intervenes appropriately. 6. Correctly assesses severity or priority of patient's condition and gives or obtains necessary care. 6.70 5 6.71 6.69 2 5.91 6 6.61 4 6.40 4 14.35* x x 6.65 4 6.05 4 6.39 5 6.35 6 9.83* x x 7. Is able to 6.86 1 6.69 2 6.22 2 6.67 2 6.50 3 explain the reason for nursing judgments. 8. Uses under- 6.69 6 6.29 8 5.20 8 6.33 8 5.95 8 standing of develop-mental stages to aid in interpret-ting of patient's symptoms. Mean Total 53.51 52.88 48.15 52.27 51.32 Mean and Rank 6.69 1 6.61 2 6.02 5 6.53 3 6.42 t 13.12* 30.52* xx xx * significant beyond the 0.05 level of significance. 50 TABLE 4-9 Summary of Objectives by Respondent Group "Responds to Emergencies" Group 1 Educator n=156 Group 2 Adminis-trator n=130 OBJECTIVES X rank 1. Anticipates the 6.20 1 need for crisis care. 2. Takes instant 6.13 2 correct action in an emergency situation. 3. Maintains calm 6.05 3 efficient approach under pressure. 4. Assumes 5.11 4 leadership role in crisis situation when needed. Mean Total 23.49 Mean and Rank 5.87 5 X rank 6.53 1 6.45 2 6.43 3 5.50 4 24.91 6.23 Group 3 Physician n=135 Group 4 Group 5 R.N.A.B.C. Ministry X rank 5.87 4 6.55 1 6.50 2 5.99 24.91 6.23 n=18 X rank 6.24 3 6.39 1 6.28 2 5.50 4 24.41 6.10 n=20 X rank 5.95 3 6.40 1 6.30 2 5.45 24.10 6.03 Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 6.04* x 3.39* 3.88* x x 5.82* * significant beyond the 0.05 level of significance. overal l rat ings. In contrast , educators had the lowest overal l rat ings w i t h the lowest rat ings on object ives two, three and four. There was s igni f icant group disagreement (Tab le 4 -9 ) . Educators disagreed w i th phys i -cians on three object ives, and wi th admin ist rators on one object ive. Admin is t ra to rs dis -agreed w i t h physicians on one objective. In add i t ion , there was at least one comb ina t ion of group differences on all objectives and object ive three had two comb ina t ions of group differences. A difference of two in rank order ing was found on one object ive: Educators and admin ist rators both ranked "ant ic ipates the need for crisis care" higher than physicians (1 vs. 4), R . N . A . B . C . (1 vs. 3) and the ministry (1 vs. 3). In spite of these differences, there was a perceived degree of need for this category, as every object ive was rated higher than 5.10 by all groups, showing at least some degree of need for th is category of objectives. Th ree or more groups ranked objectives two, three and four equally. 51 Object ives for Category Eight . " O b t a i n s , records and exchanges in format ion on behalf of the pat ient" In this category (Tab le 4 -10) the R . N . A . B . C . had the highest overal l rat ings, rat ing object ives four and five higher than any other group, and physicians had the lowest ratings on objectives one, two and three. Because al l objectives were rated above 5.69, there is a pat tern of agreement a m o n g the stakeholders regarding the need for th is category of object ives. Even though there is agreement, there are s igni f icant differences over the degree of need. T h e 'groups s igni f icant ly different' c o l u m n displays disagreement on four objectives. TABLE 4-10 Summary of Objectives by Respondent Group "Obtains, Records and Exchanges Information on Behalf of the Patient" Group 1 Educator n=156 OBJECTIVES x rank 1. Checks data 6.85 1 sources for orders and other information about patient. 2. Obtains inform- 6.79 2 ation from patient and family. 3. Transcribes or 6.74 4 records information on charts, Kardex or other information systems. 4. Exchanges 6.77 3 information with nursing staff and other departments. 5. Exchanges 6.65 5 information with medical staff. Mean Total 33.80 Mean and Rank 6.76 3 Group 2 Adminis-trator n=130 X rank 6.71 4 6.72 6.93 6.82 6.63 33.81 6.76 Group 3 Physician n=135 X rank 5.95 4 5.69 5.96 3 6.24 6.57 30.41 6.08 Group 4 Group 5 R.N.A.B.C. Ministry n=18 X rank 6.83 2 6.67 6.83 6.89 6.83 34.05 6.81 n=20 X rank 6.50 2 6.15 6.55 6.30 6.15 31.65 6.33 Fvalue 20 .44* 28.34* 21.29* 12.16* 2.12 Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 34 5 3 4 5 4 5 5 * significant beyond the 0.05 level of significance. 52 O n l y object ive f ive, however, had no s igni f icant differences, whereas object ive two had four comb ina t ions of groups dif fering. T h e differences were on objectives one, two, three and four between educators and physicians; admin ist rators and physicians; and the R . N . A . B . C . and physic ians. In add i t ion , there were no objectives where three or more groups agreed on the rank ing . However, differences of two in rank order ing were found on five objectives: 1. Educators ranked "checks data sources for orders and other in format ion about pat ient" higher than physicians and admin ist rators (1 vs. 4) . R . N . A . B . C . and the ministry ranked this object ive higher than physicians and admin ist rators (2 vs. 4) . 2. Educators ranked "obta ins in format ion f rom patient and fami ly " higher than the m i n -istry (2 vs. 4) , physicians (2 vs. 5) and R . N . A . B . C . (2 vs. 5). Admin i s t ra to rs ranked th is object ive higher than physicians (3 vs. 5), and R . N . A . B . C . (3 vs. 5). 3. T h e min ist ry and admin ist rators ranked "t ranscr ibes or records in format ion on charts, Kardex or other in format ion sys tem" higher than physicians (1 vs. 3) , and educators (1 vs. 4) . T h e R . N . A . B . C . ranked this object ive higher than educators (2 vs. 4) . 4. R . N . A . B . C . ranked "exchanges in format ion w i th nursing staff and other nurs ing depart -ments" higher than the ministry or educators (1 vs. 3). 5. Phys ic ians ranked "exchanges in format ion w i th medica l staff" higher than the ministry (1 vs. 4) , admin ist rators (1 vs. 5), and educators ( 1 vs. 5). T h e R . N . A . B . C . ranked th is object ive higher than the ministry (2 vs. 4) , admin ist rators (2 vs. 5), and educators ( 2 vs. 5). Object ives for Category Nine. "Co l laborates w i t h staff w i th in the organizat iona l s t ructure" T o assess stakeholders ' op in ions regarding this category, seven objectives were pre-sented. F r o m Tab le 4 -11 , admin ist rators had the highest rat ings, fo l lowed by educators, the R . N . A . B . C , the ministry and physicians. Phys ic ians had the lowest mean rat ings on ob -ject ives one, two, three and four, whereas the ministry had the lowest rat ings on objectives f ive and seven. A l l seven objectives had one or more comb ina t ion of group disagreement. T h e most consistent number of d isagreements, six, was found between admin ist rators and physicians and between educators and physicians. Educators and admin ist rators differed on objectives two and six, whereas the R . N . A . B . C . and physicians and physicians and the ministry each differed on one object ive. T h e remain ing groups revealed no differences. In th is category, a difference of two in rank order ing occurred on three objectives: 1. T h e min ist ry ranked "cooperates w i th ward routines and hospita l regulat ions" higher than educators (2 vs. 4) and physicians (2 vs. 5). Admin is t ra to rs and the R . N . A . B . C . ranked th is object ive higher than physicians (3 vs. 5). 53 TABLE 4-11 OBJECTIVES Summary of Objectives by Respondent Group "Collaborates With Staff Within the Organizational Structure" Group 1 Group 2 rank Group 3 Group 4 Group 5 Fvalue Educator Adminis- Physician R.N.A.B.C. Ministry trator n=156 n=130 n=135 n=18 n=20 rank rank rank rank Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Cooperates 6.73 4 6.88 3 6.19 5 6.78 3 6.75 2 14.25* x x x x with ward routine and hospital regulations. 2. Knows the 5.24 7 5.85 7 4.53 7 5.65 7 4.80 7 11.84* x x x administrative organization and functioning of the institution at various levels. 3. Knows the 6.08 5 6.10 6 5.63 6 5.72 6 6.00 6 3.06* x x functions and responsibilities of each member of the health care team. 4. Adheres to a 6.92 1 6.96 1 6.60 1 6.83 2 6.80 1 10.31* x x nursing code of ethics. 5. Works together 6.82 2 6.91 2 6.59 2 6.89 1 6.55 3 6.40* x x with other nursing staff. 6. Helps other 5.95 6 6.63 5 6.28 4 5.76 5 6.20 5 6.00* x staff members with work during staff shortage. 7. Obtains 6.81 3 6.88 3 6.56 3 6.78 3 6.45 4 4.81* x x assistance when situation requires additional help, more skilled personnel or greater resources. Mean Total 44.55 46.21 42.38 44.41 43.55 Mean and Rank 6.36 2 6.60 1 6.05 5 6.34 3 6.22 4 * significant beyond the 0.05 level of significance. 54 2. R . N . A . B . C . ranked "works together w i th other nursing staff" higher than the ministry (1 vs. 3). 3. Phys ic ians ranked "helps other staff members w i t h work dur ing staff shortage" higher than educators (4 vs. 6). In spite of these differences, some agreement a m o n g the groups was found . For example, only object ive two was given a rat ing of less than 5.00 (rated 4.53 by physicians and 4.8 by the min is t ry ) . These higher rat ings show a tendency towards agreement. In add i t ion , there was some agreement in the rank order ing. A l l groups agreed that object ive two was least needed. Four groups agreed that object ive three was the next least needed, object ive four was most needed and object ive seven was th i rd most needed. Object ives f ive and six had three groups who agreed on rank order ing. Object ives for Category Ten . "Ut i l i zes pat ient care p lann ing" Tab le 4 -12 reveals that in category ten , all s igni f icant differences were between phys i -cians and another group. Phys ic ians disagreed w i th three or more groups on objectives one, three and f ive, and their rat ings were lower than any other group on all f ive objectives. In contrast , educators had the overal l highest rat ings w i th highest rat ings on objectives three and four. T h e greatest number of differences, four, existed between educators and physicians and admin ist rators and physicians. Th ree differences were found between physicians and the R . N . A . B . C , whereas two differences were shown between physicians and the ministry. There were no differences a m o n g the remain ing six groups. O n l y object ive two had no s igni f icant group differences. A difference in rank order ing of two was found on three objectives: 1. Phys ic ians ranked " includes doctor other staff or agencies in p lann ing care" higher than the ministry, (1 vs. 3), R . N . A . B . C , admin ist rators and educators (1 vs. 4) . 2. R . N . A . B . C . ranked "develops and modif ies patient care p lan" higher than admin ist rators (1 vs. 3) and physicians (1 vs. 4) . Educators and the min ist ry ranked this objective higher t h a n physicians (2 vs. 4) . 3. A d m i n i s t r a t o r s ranked "contr ibutes construct ive ly to pat ient care conferences" higher than the min ist ry (2 vs. 4) . W h i l e there were differences revealed, there was rank ing agreement on objectives two, three, four and five where as few as three and as many as five groups agreed on ranking. A l l groups ranked object ive four as being the least needed. 55 TABLE 4-12 Summary of Objectives by Respondent Group "Utilizes Patient Care Planning" Group 1 Educator n=156 OBJECTIVES 1. Develops and modifies patient care plan. X rank 6.72 2 2. Includes doctor, 6.17 other staff or agencies in planning care. 3. Implements patient care plan. 4. Conducts patient care conferences. 5. Contributes constructively to patient care conferences. Mean Total Mean and Rank 6.90 5.52 5 6.56 31.87 6.37 Group 2 Adminis-trator n=130 5! rank 6.44 3 6.18 4 6.73 1 5.31 5 6.63 2 31.29 6.26 Group 3 Physician n=135 X rank 5.01 4 5.93 1 5.82 2 4.33 5 5.51 3 26.60 5.32 Group 4 R.N.A.B.C. n=18 X rank 6.78 1 5.94 4 6.78 1 4.88 5 6.44 3 30.82 6.16 Group 5 Ministry n=20 X rank 6.25 2 6.15 3 6.65 1 4.95 5 6.05 4 30.05 6.01 Fvalue 44.35* 0.89 25.31* 9.73* 22.89* Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 X X X X * significant beyond the 0.05 level of significance. Object ives for Category Eleven. "Teaches and supervises other staff for w h o m responsible" F rom Tab le 4 -13 it is evident that there was less disagreement a m o n g stakeholders concern ing category eleven than any of the others. T w o objectives, for example , had no signi f icant d isagreement and one had one group difference. T h e disagreement wh ich occurred was pr imari ly between admin ist rators and physicians, w i t h differences on four mean ratings, and between educators and physicians on two mean rat ings. Educators and admin ist rators differed on one object ive. T h e remain ing seven groups showed no signi f icant differences. Add i t iona l ly , there was disagreement in the rank order ing. A difference of two occurred on four objectives: 1. Phys ic ians ranked "supervises and checks the work of staff for w h o m she is responsible" higher than R . N . A . B . C . , educators and admin ist rators (1 vs. 3). 56 2. Educators ranked " identi f ies own behaviour that interferes w i t h leadership" higher than admin is t rators (2 vs. 4) , R . N . A . B . C . (2 vs. 4) and the ministry (2 vs. 5). Phys ic ians also ranked th is object ive higher than the ministry (3 vs. 5). 3. R . N . A . B . C . ranked "delegates care, w i th in legal l imits to the staff accord ing to their abi l i t ies" higher than physicians (2 vs. 4 ) , ministry (2 vs. 4) , educators (2 vs. 4) and admin is t rators (2 vs. 5). 4. Admin i s t ra to rs ranked "assists in in i t ia t ing planned change" higher than R . N . A . B . C . , physic ians and educators (2 vs. 5). T h e ministry also ranked th is object ive higher than R . N . A . B . C , physicians and educators (3 vs. 5). TABLE 4-13 Summary of Objectives by Respondent Group "Teaches and Supervises Other Staff For Whom Responsible" OBJECTIVES Group 1 Educator n=156 rank Group 2 Adminis-trator n=130 rank Group 3 Physician n=135 rank Group 4 R.N.A.B.C. n=18 rank Group 5 Ministry n=20 rank Fvalue Groups Significantly Different 1 1 1 2 2 2 3 3 4 v v v v v v v v v 3 4 5 3 4 5 4 5 5 1. Teaches correct 5.01 6 5.21 6 5.10 6 4.17 6 4.60 6 1.49 principles, procedures and techniques of patient care to staff. 2. Supervises and 5.81 3 6.12 3 6.01 1 5.82 3 5.90 2 0.86 checks the work of staff for whom she is responsible. 3. Performs tasks, 6.78 1 6.66 1 6.01 1 6.38 1 6.50 1 11.08* x x within legal limits, that cannot be delegated to other staff. 4. Identifies own 5.94 2 5.94 4 5.52 3 5.72 4 4.70 5 4.75* x x behavior that interferes with leadership. 5. Delegates care, 5.80 4 5.92 5 5.45 4 5.89 2 4.80 4 2.94* x within legal limits to staff according to their abilities. 6. Assists in 5.48 5 6.14 2 5.31 5 5.33 5 5.16 3 5.85* x x initiating planned change. Mean Total 34.82 35.99 33.40 33.31 31.66 Mean and Rank 5.80 2 6.00 1 5.57 3 5.55 4 5.28 5 significant beyond the 0.05 level of significance. 57 Even though there were some differences in rank order ing, there was also agreement. For example , al l groups ranked object ive three most needed and object ive one as least needed. Th ree or more groups agreed on the rank order ing of objectives one, two, three, f ive and six. W h i l e the mean score was considerably lower than for other categories, no objective had a rat ing under 4.00. T w o objectives ( two and three) had rat ings above 5.5. Admin i s t ra to rs had the highest ratings overal l , assigning the highest rat ings to objectives one, two, f ive and six. Phys ic ians had the lowest overal l rat ings. Object ives for Category Twelve . "Demonst ra tes personal character ist ics suitable for nurs ing" In this category, all three objectives were rated 5.5 or higher, thus reveal ing a tendency towards agreement (Tab le 4 -14) . In add i t ion , all groups rank ordered the three objectives in the same sequence. TABLE 4-14 Summary of Objectives by Respondent Group "Demonstrates Personal Characteristics Suitable for Nursing" OBJECTIVES Group 1 Educator n=156 rank Group 2 Adminis-trator n=130 rank Group 3 Physician n=135 rank Group 4 R.N.A.B.C. n=18 rank Group 5 Ministry n=20 rank Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Is punctual for work. 6.90 6.95 6.37 6.78 6.15 14.24* 2. Is self directed: 6.40 3 6.32 3 5.52 3 6.12 3 5.50 3 12.31* x xx x takes initiative and goes ahead on own. 3. Recognizes own 6.65 2 6.70 2 5.95 2 6.56 2 5.90 2 12.82* inability to deal with patient or situation and obtains substitute. Mean Total 19.95 19.97 17.84 19.46 17.55 Mean and Rank 6.65 2 6.66 1 5.95 4 6.49 3 5.85 5 * significant beyond the 0.05 level of significance. However whi le there was agreement, there were differences revealed on the degree of need for the object ives in this category. A l l objectives had four comb ina t ions of group 58 differences. Phys ic ians differed w i t h educators and admin ist rators ; and the ministry dif-fered w i t h admin is t rators and educators. There were no differences between educators and admin is t rators and no differences between the R . N . A . B . C . and any other group. Admin i s t ra to rs had the highest ratings, assigning highest rat ings for objectives one and three. However, th is t ime the ministry had the lowest ratings, assigning the lowest ratings t o all object ives. Object ives for Category Th i r teen "Uses nurs ing models in assessing and g iv ing patient care" A s was the case in the previous category, admin ist rators once again had the highest overal l rat ing for th is category, w i t h objectives two and three rated higher than any other group (Tab le 4 -15 ) . O n the other hand, educators gave the overal l lowest rat ings. Th ree groups differed on object ive one, whereas objectives two and three had two groups w i t h s igni f icant differences. B o t h educators and admin ist rators differed w i t h physicians on two object ives, and , in add i t ion , admin ist rators differed w i th educators on two objectives. Phys ic ians differed w i t h the R . N . A . B . C . on one object ive. There were no differences a m o n g the remain ing six groups. A compar ison of rank orders revealed that all groups ranked the objectives in the same sequence. One extreme rat ing occur red : object ive two ranged in value f rom 3.32 to 5.15. Object ives for Category Fourteen. "Uses research in the practise of nurs ing" In th is category, none of the rat ings exceeded 5.0. In fact , the highest rat ing was 4.89 m a k i n g this one of the most neutral ly rated categories (Tab le 4 -16) . T h e R . N . A . B . C . had the highest overal l rat ings and the ministry had the lowest overal l rat ings. In th is category, physicians differed s igni f icant ly w i th educators and admin ist rators on object ive two, whi le object ive one had no s igni f icant d isagreement. A compar ison of rank orders revealed that all groups ranked the objectives in the same sequence. 59 TABLE 4-15 OBJECTIVES Summary of Objectives by Respondent Group "Uses Nursing Models in Assessing and Giving Care to Patients" Group 1 Group 2 Group 3 Group 4 Group 5 Educator Adminis- Physician R.N.A.B.C. Ministry trator n=156 n=130 n=135 n=18 n=20 X rank rank X rank X rank X rank Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Demonstrates 6.43 1 6.24 1 5.31 1 6.53 1 5.70 1 14.51* knowledge of a nursing model when assessing patients and providing nursing care. 2. Understands 3.32 3 5.15 3 5.06 3 4.59 3 4.35 3 20.46* and uses a variety of nursing models in providing nursing care. 3. Adapts nursing 5.62 model learned in nursing program to fit with the hospital model. Mean Total Mean and Rank 15.37 5.12 6.17 2 17.56 5.85 5.16 2 15.53 5.18 6.12 2 17.24 5.75 5.40 2 15.45 5.15 6.85* * significant beyond the 0.05 level of significance. TABLE 4-16 OBJECTIVES Group 1 Educator n=156 rank Summary of Objectives by Respondent Group "Uses Research in the Practice of Nursing" Group 2 Adminis-trator n=130 rank Group 3 Physician n=135 rank Group 4 R.N.A.B.C. n=18 rank Group 5 Ministry n=20 rank Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Applies research 4.63 1 4.87 1 findings to improve nursing care. 2. Participates in 3.95 2 4.36 2 nursing research. 4.36 1 4.89 1 4.00 1 1.74 3.43 2 4.83 2 3.45 2 4.69* x x Mean Total 8.58 Mean and Rank 4.29 3 9.23 4.62 2 7.79 9.72 7.45 3.90 4 4.86 1 3.73 5 * significant beyond the 0.05 level of significance. 60 Object ives for Category Fi f teen. "Pa r t i c ipa tes in professional act iv i t ies related to nurs ing" There is s igni f icant disagreement on three of the four objectives for this category (Table 4 -17 ) . F rom the 'groups s igni f icant ly different c o l u m n ' , three objectives had four c o m b i -nat ions of group differences. Admin is t ra to rs differed w i t h physic ians and the ministry on three mean rat ings, whereas educators differed w i th physicians and the ministry on two mean rat ings. T h e ministry and R . N . A . B . C . and admin ist rators and educators each differed on one mean rat ing . T h e r e were no differences a m o n g the remain ing four groups. TABLE 4-17 Summary of Objectives by Respondent Group "Participates in Professional Activities Related to Nursing" OBJECTIVES Group 1 Group 2 Group 3 Group 4 Group 5 Educator Adminis- Physician R.N.A.B.C. Ministry trator n=156 n=130 n=135 n=18 n=20 X rank 5! rank X rank X rank X rank Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Accepts responsibility for developing and promoting the profession within a changing society. 2. Accepts responsibility for self directed, personal and professional growth. 3. Evaluates the present and emerging trends of the professional nurse in relation to trends in health care. 4.76 6.47 2 4.57 5.04 3 6.73 2 4.79 4.35 4 5.86 2 4.60 5.39 3 6.50 2 4.56 3.40 4 5.34* 5.60 2 13.31* 4.00 0.87 4. Updates nursing knowledge by attending inservices and workshops. 6.55 6 . 8 8 6.21 6.53 6.20 9 . 3 8 * x x Mean Total 22.35 Mean and Rank 5.59 23.44 5.86 21.02 5.26 22.98 5.75 19.20 4.80 * significant beyond the 0.05 level of significance. 61 Admin is t ra to rs provided the highest rat ings on objectives two, three and four, whi le the R . N . A . B . C . rated object ive one highest. O n the other hand, the min ist ry had the lowest rat ings by assigning the lowest rat ing to all four objectives. W h i l e there were differences in rat ing , there was consensus a m o n g the f ive groups w i th respect to object ive four being the most needed and object ive two be ing the second most needed. Educators , admin ist rators and the R . N . A . B . C . agreed on the rank ing of the other two object ives. B ipo la r i za t ion of Response Rat ings of Object ives Inspection of the data revealed considerable var iat ion w i th in the groups. In pat icular , th is var iat ion showed that 1 0 % or more of the responses were rated at both ends of the c o n t i n u u m (b ipo lar i zat ion ) . T h e f igure 1 0 % was chosen instead of, for example , 2 0 % t o ensure that potent ia l d isagreements wou ld not be over looked. Fifteen objectives had b ipolar ized responses ( A p p e n d i x C, Tables 38 -121) . A r ranged in order of var iabi l i ty w i th their associated groups in parenthesis, they are: 1. Teaches correct pr inciples, procedures and techniques of pat ient care to other staff (all f ive groups) . 2. App l ies research f indings to improve nursing care (all f ive groups) . 3. Evaluates the present and emerg ing trends of the professional nurse in relat ion to trends in health care (al l f ive groups) . 4. Par t ic ipates in nurs ing research (educators, admin ist rators , physicians, min ist ry ) . 5. A c c e p t s responsibi l i ty for developing and p romot ing the profession wi th in a chang ing society (educators , admin ist rators , physic ians) . 6. Understands and uses a variety of nursing models in provid ing nursing care (educators, admin ist rators , min ist ry ) . 7. A c t s as pat ient advocate in ob ta in ing appropr iate medica l , psychiat r ic or other help (physicians, min ist ry ) . 8. K n o w s the admin is t rat ive organ izat ion and funct ion ing of the inst i tut ion at various levels (physic ians, min ist ry ) . 9. Delegates care w i th in legal l imits to the staff accord ing to their abi l i t ies (physicians, min ist ry ) . 10. Quest ions orders and decisions by medica l and other professional staff (physic ians) . 11 . Uses c o m m u n i t y resources to help patient resolve problems (physic ians) . 12. Assesses pat ient learning needs in relat ion to disabi l i ty (physic ians) . 13. Prov ides health care inst ruct ion or other in format ion to pat ients, family, or s igni f icant others (physic ians) . 14. Develops and modi f ies pat ient care plan (physic ians) . 15. C o n d u c t s pat ient care conferences (physic ians) . 62 S u m m a r y of Object ive Rat ings There was at least one signi f icant difference a m o n g the stakeholder groups on seventy-six o f the e ighty - three objectives. Disagreement was most pronounced between physicians and educators and between physicians and admin ist rators a l though disagreements were found between educators and admin ist rators , between the ministry and educators , between physic ians and R . N . A . B . C , and between admin ist rators and the ministry. In add i t ion , there were f i f teen objectives where b ipo lar izat ion in frequencies occur red . Phys ic ians had b ipo -larized responses on all 15 objectives, compared to the ministry w i t h b ipolar ized responses in eight, admin ist rators on six, and the R . N . A . B . C . on three object ives. R a n k i n g differences were found on th i r ty -one objectives, whereas ranking agreement w i th three or more groups occur red on sixty object ives. O n the one hand, admin ist rators and educators each had the highest rat ings on th i r ty -one objectives, fo l lowed by the R . N . A . B . C . on nine, physicians on three and the ministry on two objectives. O n the other hand, physicians gave the lowest rat ings to f i f ty - f ive objectives, fo l lowed by the ministry on eighteen objectives, educators on five, the R . N . A . B . C . on four and admin ist rators w i t h no objectives rated lowest (Tab le 21 , A p p e n d i x E ) . In answer to the first research quest ion, there are s igni f icant differences in percept ions of the f ive groups in relat ion to the need for objectives for nursing educat ion . TABLE 4-18 Comparison of Course Content Categories by Respondent Group Group 1 Group 2 Group 3 Group 4 Group 5 Educator Adminis- Physician R.N.A.B.C. Ministry trator n=156 n=130 n=135 n=18 n=20 COURSE CONTENT x rank x rank x rank x rank X rank 1. Support 5.06 2 5.31 2 4.29 2 5.23 2 4.65 2 Course Content 2. Nursing 6.55 1 6.52 1 5.69 1 6.48 1 6.10 1 Course Content Mean Total 11.61 11.83 9.98 11.71 10.75 Mean and Rank 5.81 3 5.92 1 4.99 5 5.86 2 5.38 4 Course Conten t For Nurs ing Educat ion (Research Quest ion # 2)  C o m p a r i s o n of the Categor ies of Course Content Areas Tables 122 -166 in A p p e n d i x C conta in frequencies, means and standard deviat ions for 63 each of forty - f ive course content areas. T h e forty - f ive course content areas were categor ized as support course content or nursing course content . A compar ison of the rat ings reveals that all stakeholders rated al l the nursing content areas and most of the support course content as being needed (Tab le 4 -18) . A l l groups also rated nurs ing content as being more needed than support content . However, there was variety a m o n g the stakeholders in their rat ings. Suppor t content and nurs ing content were rated lowest by physicians compared w i t h admin ist rators w h o rated support content highest, w i th the highest ratings overal l . T h e R . N . A . B . C . was second, fo l lowed by educators. Educators had the highest rat ings for nursing course content . T h e ministry was fourth in rat ings. Course Conten t For Category One . "Suppor t course content" T h e data in Tab le 4 -19 indicate that stakeholders differed s igni f icant ly on twenty -six support course content areas: algebra, anatomy, anthropology, b iochemistry , biology, c o m m u n i c a t i o n , Eng l ish , epidemiology, general m a t h , human g rowth and development , i m -munology, i n t roduct ion to computers , inorganic chemistry, microbio logy, nut r i t ion , organic chemistry, pathology, pharmacology, phi losophy, physics, physiology, po l i t ica l science, psy-chology, publ ic speak ing , research methods and sociology. Twenty - f i ve s igni f icant differences were found between admin ist rators and physicians. In every case, admin ist rators provided a higher rat ing. T w e n t y differences were found be-tween educators and physicians. In two cases physicians provided a higher rat ing than educators : abnormal psychology and inorganic chemistry. Twe lve differences were found between physic ians and the R . N . A . B . C . In all but three content areas (fine arts, i n t roduc -t ion to computers and physical educat ion ) , R . N . A . B . C . respondents gave higher rat ings than physic ians. Admin i s t ra to rs and educators differed on six mean ratings: biochemistry, epidemiology, inorganic chemistry, physics, phi losophy and organic chemistry whereas the R . N . A . B . C . and educators differed on three: i n t roduct ion to computers , inorganic c h e m -istry and po l i t ica l science. Th ree groups had two differences: educators and the ministry ( i n t roduct ion to computers and Engl ish) ; admin ist rators and R . N . A . B . C . ( inorganic c h e m -istry and po l i t ica l science) ; and R . N . A . B . C . and ministry ( inorganic chemistry and pol i t ica l science) . 64 There were twenty -s ix content areas where one or more comb ina t ions of group differ-ences appeared; nineteen of these had three or more different group combinat ions ; and of those nineteen combinat ions , there were ten content areas where four or more combinat ions of group differences occur red . O f those, two had as many as six different group c o m b i -nat ions. Four content areas had no signi f icant differences (physical educat ion , abnormal psychology, f ine arts and genetics) . TABLE 4-19 Summary of Support Course Content By Respondent Group Fvalue Group 1 Educator Group 2 Adminis-trator Group 3 Physician Group 4 R.N.A.B.C. Group 5 Ministry CATEGORY n =156 n= =130 n= =135 n: =18 n= :20 Support Course Content X rank X rank X rank X rank X rank 1. Abnormal Psychology 5.19 16 5.66 14 5.28 10 5.41 15 4.90 13 1.73 2. Algebra 3.63 26 3.84 26 2.78 25 3.31 28 3.37 22 4.60* 3. Anatomy 6.82 5 6.94 1 6.26 1 6.89 2 6.80 2 13.92* 4. Anthropology 3.95 22 3.69 28 2.46 28 4.00 25 3.10 26 13.63* 5. Biochemistry 4.38 18 5.64 15 4.36 16 5.07 17 4.90 13 10.34* 6. Biology 6.04 11 6.48 8 5.57 7 5.89 11 5.20 12 7.00* 7. Communication 6.99 1 6.89 2 6.26 1 6.72 4 6.85 1 19.62* 8. English 6.23 9 6.43 9 5.78 5 5.78 14 4.80 15 7.59* 9. Epidemiology 5.11 17 5.94 12 4.78 13 5.88 12 5.25 10 10.16* 10. Fine Arts 2.56 30 2.59 29 2.23 29 2.00 30 1.70 30 2.34 11. General Math 5.42 14 5.61 16 4.63 14 4.83 20 4.20 19 5.54* 12. Genetics 4.32 19 4.65 21 4.08 18 4.89 19 4.40 17 2.35 13. Human Growth 6.91 2 6.84 3 5.40 8 6.56 6 6.50 5 56.51* Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 x X X X x x x X X X X x X X X and Development 14. Immunology 5.68 12 5.84 13 4.55 15. Introduction 5.60 13 5.23 19 4.32 to Computers 15 17 16. Inorganic 2.96 28 3.81 27 3.05 24 Chemistry 5.41 4.19 6.06 15 22 5.90 4.00 8 21 16.20* 12.92* x x X X X X 3.37 22 13.73* 17. Microbiology 6.32 8 6.28 10 5.23 11 6.72 4 5.80 9 19.27* x X X 18. Nutrition 6.52 6 6.53 6 5.67 6 6.28 8 6.30 6 15.32* x X 19. Organic 3.95 22 5.45 17 3.51 19 4.82 21 4.63 16 18.18* x X Chemistry 20. Pathology 6.18 10 6.02 11 5.09 12 6.00 10 5.22 11 12.66* X X 21. Pharmacology 6.84 3 6.83 4 5.91 3 6.94 1 6.55 4 31.22* X X X X 22. Philosophy 4.00 21 4.87 20 3.06 23 3.71 27 4.05 20 15.12* X X X 23. Physical Education 3.92 24 4.04 22 3.48 20 3.22 29 3.21 25 2.29 24. Physics 3.00 27 4.02 23 2.68 27 4.13 23 2.68 28 11.26* X X X X 65 CATEGORY Support Course Content 25. Physiology 26. Political Science TABLE 4-19 Cont'd Summary of Support Course Content By Respondent Group Group 1 Educator n=156 Group 2 Adminis-trator n=130 X rank 6.83 4 2.78 29 27. Psychology 6.40 7 28. Public Speaking 4.07 20 3.88 25 29. Research Methods 30. Sociology Mean Total Mean and Rank 5.39 15 151.87 5.06 3 X rank 6.80 5 2.57 30 6.53 6 3.86 25 3.94 24 5.44 18 159.26 5.31 1 Group 3 Group 4 Group 5 Physician R.N.A.B.C. Ministry n=135 X rank 5.89 4 1.55 30 5.29 9 3.25 22 2.75 26 3.47 21 128.62 4.29 5 n=18 X rank 6.89 2 4.00 25 6.33 7 4.11 24 4.94 18 5.83 13 156.81 5.23 2 n=20 X rank 6.75 3 2.35 29 6.10 7 2.95 27 3.35 24 4.40 17 139.58 4.65 4 Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 30.27* 15.92* 22.83* 4.44* 10.63* 30.47* x X X X X X X X X X X X X * significant beyond the 0.05 level of significance. T w e l v e content areas were given an overal l mean rat ing of less than 4 .50: algebra, anthropology, f ine arts, genetics, inorganic chemistry, organic chemistry, phi losophy, phys-ical educat ion , physics, po l i t ica l science, publ ic speaking , and research methods (Tables 122 -166 , A p p e n d i x C ) , imp ly ing that these were not considered to be as needed. W h i l e not all content was rated higher than 5.5 by each stakeholder , there were eleven content areas w i t h overal l means higher than 5.5: anatomy, biology, c o m m u n i c a t i o n , E n -gl ish, h u m a n growth and development , nut r i t ion , microbio logy, pathology, pharmacology, physiology, and psychology (Tables 122-166, A p p e n d i x C ) . These wou ld be regarded as being needed. Admin i s t ra to rs provided higher rat ings than d id any other group on fourteen content areas (abnormal psychology, algebra, anatomy, biochemistry, biology, Engl ish , ep idemi -ology, f ine arts, general m a t h , nut r i t ion , organic chemistry, phi losophy, physical educa -t ion and psychology) , whereas physicians provided lower rat ings than did any other group on twenty (algebra, anatomy, anthropology, b iochemistry, c o m m u n i c a t i o n , epidemiology, genet ics, human growth and development , immunology , microbio logy, nut r i t ion , organic chemistry , pathology, pharmacology, phi losophy, physiology, po l i t ica l science, psychology, research methods , and socio logy) . T h e r e were four content areas ( c o m m u n i c a t i o n , f ine arts, nut r i t ion , and psychology) 66 where three or more groups agreed on rank ing . A difference of ten in rank order ing was found on two content areas: 1. Phys ic ians ranked Engl ish higher than the ministry (5 vs. 15). 2. R . N . A . B . C . ranked inorganic chemistry higher than the min ist ry (9 vs. 22), physicians (9 vs. 24) , admin ist rators (9 vs. 27) and educators (9 vs. 28) . Course Content For Category T w o " N u r s i n g course content " Five groups differed s igni f icant ly in their views on fourteen content areas in this category (Tab le 4 -20) : care of ill adults , fami ly nurs ing, gerontology, history of nurs ing, human needs, legal aspects of nurs ing, medica l terminology, nursing ethics, nursing leadership, nursing ski l ls , nurs ing theory, nursing trends, physical assessment, and professional issues. Wh i l e there was s igni f icant disagreement on nursing content , only two were rated below 5.00 by one group. Phys ic ians rated history of nursing and professional issues 4.08 and 4.07 respectively. In fact , physicians had lower overal l rat ings than any other group. Five content areas received a rat ing above 6.00 by all groups: care of ill adul ts , care of ill ch i ldren , medica l terminology, nursing ethics, and nursing ski l ls . T h e overal l mean was 5.5 or greater on : care of ill adults , care of il l ch i ldren, fami ly nurs ing, gerontology, human needs, legal aspects of nursing, medica l terminology, nursing ethics, nurs ing leadership, nurs ing ski l ls , nurs ing theory, nursing trends, physical assessment and professional issues (Tables 122 -167 , A p p e n d i x C ) . Overa l l , educators had higher rat ings than did any other group, w i th the highest rat ings assigned to legal aspects of nursing, physical assessment and professional issues. A d m i n -istrators rated four nursing course content areas highest: care of ill adults , medica l t e r m i -nology, nurs ing ethics and nursing ski l ls . T h e R . N . A . B . C . ranked th i rd overal l , rat ing six content areas higher than any other group: fami ly nursing, gerontology, history of nursing, nurs ing leadership, nursing theory, and nursing trends. O n the other hand , physicians had lower rat ings than d id any other group on eleven content areas (care of ill adults , fami ly nurs ing, gerontology, history of nursing, human needs, legal aspects of nurs ing, nursing eth ics , nurs ing theory, nursing trends, physical assessment, and professional issues). N o other groups were as consistent ly high as educators and admin ist rators , whi le phys i -cians and the ministry were consistent ly lower. For example , physicians rat ings varied f rom 4.07 to 6.80; the min ist ry 's rat ing was simi lar w i t h var iat ions between 4.45 and 6.95. 67 Th i r teen s igni f icant differences were found between admin ist rators and physicians whi le educators and physicians differed on twelve. Seven differences were found between phys i -cians and R . N . A . B . C , whereas educators and the ministry differed on four: legal aspects, CATEGORY Nursing Course Content TABLE 4-20 Summary of Nursing Course Content by Respondent Group Group 1 Group 2 Group 3 Group 4 Group 5 Fvalue Educator Adminis- Physician R.N.A.B.C. Ministry trator n=156 n=130 n=135 n=18 n=20 X rank X rank X rank X rank X rank Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 1. Care of III Adults 6.93 2 6.98 1 6.79 2 6.94 2 6.95 1 3.66* 2. Care of III Children 6.64 8 6.78 8 6.80 1 6.56 7 6.95 1 1.40 3. Family Nursing 5.91 14 6.33 11 5.52 10 6.38 11 6.35 6 4. Gerontology 6.57 9 6.39 10 5.64 8 6.89 3 6.00 11 5.45 15 5.40 15 4.08 14 5.56 15 4.45 15 5. History of Nursing 6. Human Needs 6.86 4 6.86 4 5.35 11 5.88 14 7. Legal Aspects 6.83 6 6.73 9 5.57 9 6.22 12 of Nursing 8. Medical 6.54 10 6.86 4 6.57 4 6.50 9 Terminology 9. Nursing Ethics 6.80 7 6.89 3 6.24 5 6.56 7 10. Nursing 6.27 13 6.02 13 5.12 13 6.39 10 Leadership 11. Nursing Skills 6.96 1 6.98 1 6.74 3 6.61 6 12. Nursing 6.90 3 6.79 7 5.89 6 7.00 1 Theory 6.30 7 6.10 9 6.50 5 6.30 7 5.10 14 6.64* 13.87* 15.07* 43.46* 34.91* 2.61* 13.79* 14.72* 13. Nursing Trends 6.28 12 6.14 12 5.14 12 6.67 5 6.90 3 7.64* 6.05 10 26.74* 5.60 12 15.50* X X X X X X X X X X X X X X X X 14. Physical Assessment 6.86 4 6.83 6 5.79 7 6.83 4 6.65 4 33.12* 15. Professional 6.43 11 5.89 14 4.07 15 6.22 12 5.25 13 49.47* x x x x Issues Mean Total 98.23 Mean and Rank 6.55 97.87 6.52 2 85.31 97.21 5.69 5 6.48 91.45 3 6.10 4 significant beyond the 0.05 level of significance. 68 nurs ing theory, nursing leadership and professional issues. Four groups had two differences: educators and R . N . A . B . C . ( h u m a n needs and nursing ski l ls ) ; educators and admin ist rators (med ica l te rmino logy and professional issues); admin ist rators and R . N . A . B . C . (nursing skil ls and h u m a n needs); and R . N . A . B . C . and ministry (nurs ing leadership and nursing theory) . Care of ill chi ldren was the only area w i th no s igni f icant d isagreement. O n the other hand, there were eleven content areas where three or more combinat ions of group differences appeared; six had four or more combinat ions of group differences. A s many as six comb ina t ions of group differences were found on three content areas: nursing theory, professional issues and nursing leadership. Seven nursing course content areas (care of il l adults , history of nurs ing, legal aspects of nursing, nurs ing ethics, nursing leadership, nursing trends and physical assessment) were ranked the same by three or more groups. A difference of f ive in rank order ing occurred on nine areas: 1. T h e ministry ranked care of il l chi ldren higher than R . N . A . B . C . (1 vs. 7), educators (1 vs. 8) and admin ist rators (1 vs. 8). Phys ic ians also ranked this area higher than R . N . A . B . C . (1 vs. 7) , educators (1 vs. 8) and admin ist rators (1 vs. 8) . 2. T h e ministry ranked fami ly nursing higher than R . N . A . B . C . (6 vs. 11), admin ist rators (6 vs. 11) and educators (6 vs. 14). 3. R . N . A . B . C . ranked gerontology higher than physicians (3 vs. 8) , educators (3 vs. 9), admin ist rators (3 vs. 10) and the ministry (3 vs. 11). 4. Educators ranked human needs higher than physicians (4 vs. 11) and the R . N . A . B . C . (4 vs. 14). Admin i s t ra to rs also ranked this higher than physicians (4 vs. 11) and the R . N . A . B . C . (4 vs. 14). T h e ministry ranked this higher than the R . N . A . B . C . (7 vs. 14). 5. Educators ranked legal aspects of nursing higher than the R . N . A . B . C . (6 vs. 12). 6. Admin i s t ra to rs ranked medica l te rmino logy higher than R . N . A . B . C . (4 vs. 9) and e d -ucators (4 vs. 10). Phys ic ians ranked medica l te rmino logy higher than R . N . A . B . C . (4 vs. 9) and educators (4 vs. 10). T h e ministry ranked medica l te rmino logy higher than educators (5 vs. 10). 7. Educators ranked nursing skil ls higher than R . N . A . B . C . (1 vs. 6) . Admin i s t ra to rs ranked nurs ing ski l ls higher than R . N . A . B . C . (1 vs. 6). 8. R . N . A . B . C . ranked nursing theory higher than admin ist rators (1 vs. 7), physicians (1 vs. 6) and the min ist ry (1 vs. 10). Educators ranked nurs ing theory higher than the min ist ry (3 vs. 10). 9. R . N . A . B . C . ranked nursing trends higher than educators, admin ist rators , physicians and the min ist ry (5 vs. 12). 69 Bipo la r i za t ion of Response Rat ings of Course Content Areas Inspection of the data revealed considerable var iat ion w i th in the groups. In part icular , th is var iat ion showed that 1 0 % or more of the responses were rated at both ends of the c o n t i n u u m . T w e n t y - t h r e e course content areas had b ipolar ized responses (Append ix C, Tab les 122 -166) . A r ranged in order of variabi l i ty, w i t h their associated groups in parenthesis, they are: 1. General m a t h (all 5 groups) . 2. Ph i losophy (al l 5 groups) . 3. Int roduct ion to computers (physicians, R . N . A . B . C , min ist ry ) . 4. Genet ics (educators , admin ist rators , physicians, min ist ry ) . 5. P u b l i c speaking (educators, admin ist rators , R . N . A . B . C , physic ians) . 6. Research methods (educators, admin ist rators , min ist ry ) . 7. Phys ica l educat ion (admin ist rators , educators , physicians, R . N . A . B . C ) . 8. O rgan ic chemistry (educators, physicians, R . N . A . B . C , min ist ry ) . 9. B iochemis t ry (educators , physicians, R . N . A . B . C , min ist ry ) . 10. A lgebra (educators , admin ist rators , physic ians) . 11. A n t h r o p o l o g y (educators, admin ist rators ) . 12. Inorganic chemistry (administ rators , physic ians) . 13. Professional issues (physicians, min ist ry ) . 14. History of Nurs ing (ministry, physicians) . 15. Soc io logy (physic ians, min ist ry ) . 16. B io logy (min ist ry ) . 17. Engl ish (min ist ry ) . 18. A b n o r m a l Psycho logy (min is t ry ) . 19. Ep idemio logy (physic ians) . 20. Immunology (physic ians) . 21 . Pa tho logy (min is t ry ) . 22. Phys ics (admin is t rators ) . 23 . Po l i t i ca l science ( R . N . A . B . C ) . S u m m a r y of Course Content Area Rat ings T h e r e was at least one s igni f icant difference a m o n g the stakeholders on forty of the for ty - f ive course content areas. Disagreement was most pronounced between physicians and educators and between physicians and admin ist rators , a l though disagreements were 70 also found between educators and admin ist rators , between the ministry and educators, and between admin ist rators and the ministry. There were twenty - three content areas where b ipo lar i zat ion in frequencies occur red . T h e ministry had b ipolar ized responses on f i fteen content areas. Phys ic ians had bipolar ized responses on twelve content areas, educators had eleven, admin ist rators had ten and the R . N . A . B . C . had eight. Rank ing differences were found on eleven course content areas and ranking agreement w i t h three or more groups also occur red on eleven course content areas. Admin is t ra to rs had the highest ratings on eighteen course content areas, fo l lowed by the R . N . A . B . C . on seventeen, educators on seven, the min ist ry on two and physicians w i th none of the highest rat ings. Phys ic ians had the lowest rat ings on th i r ty -one course content areas, the ministry had nine, fo l lowed by the R . N . A . B . C . on two, educators on one, and admin ist rators w i th none of the lowest ratings (Tab le 23, A p p e n d i x E) . In answer to the second research quest ion , there are s igni f icant differences in percept ions of the stakeholders in relat ion to the need for certain course content areas for basic nursing educat ion . C l i n ica l Areas For Nurs ing Educat ion ( Research Quest ion # 3) Compar i son of the Categor ies of C l in ica l Areas Tables 1 to 38 in A p p e n d i x C conta in frequencies, means, overal l means and s t a n -dard deviat ions for each of th i r ty -e ight c l in ica l areas. T h e th i r ty -e ight c l in ica l areas were categor ized as cr i t ica l care, c o m m u n i t y health or general areas. A compar ison of rat ings (Tab le 4 -21) reveals that the five groups perceived all th i r ty -eight c l in ica l areas as being needed. However, cr i t ica l care and c o m m u n i t y health areas were given more neutral rat ings than general areas. Averaged means ranged f rom 2.91 to 4.73 for c r i t ica l care c l in ica l areas, whereas c o m m u n i t y health areas ranged f rom 3.68 to 4 .01. In contrast , general areas had higher means, ranging f rom 4.70 to 5.25. Admin i s t ra to rs had the highest rat ings overal l , fo l lowed by physicians. Educators had the lowest. T h e ministry and admin is t rators had equal rank ing of c l in ica l areas, and the R . N . A . B . C . and educators were equal in their rank ing . 71 TABLE 4-21 Comparison of Clinical Categories by Respondent Group Group 1 Group 2 Group 3 Group 4 Group 5 Educator Adminis- Physician R.N.A.B.C. Ministry n=156 trator n=130 =135 n =18 n: =20 CLINICAL AREA 5! rank X rank X rank X rank X rani 1. Critical Care 2.91 3 4.73 2 4.57 1 3.16 3 4.04 2 2. Community Health 3.68 2 3.69 3 3.93 3 3.80 2 4.01 3 3. General 4.70 1 5.25 1 4.56 2 4.89 1 4.84 1 Mean Total Mean and Rank 11.29 3.76 5 13.67 4.56 1 13.06 4.35 2 11.85 3.95 4 12.89 4.30 3 Cl in ica l areas for Category One. " C r i t i c a l Care A reas" Stakeholders varied in their percept ions on all cr i t ica l care areas (Tab le 4 -22) . Those receiv ing highest rat ings were: emergency and surgical recovery room. Rat ings for emer-gency ranged f rom 3.32 (educators) to 6.21 (physic ians) ; for surgical recovery f rom 4.44 ( R . N . A . B . C . ) to 5.91 (admin ist rators ) ; and medica l intensive care f rom 3.07 (educators) t o 5.01 (physic ians) . W h i l e the ministry d id not provide high ratings, their rat ings were higher than R . N . A . B . C . and educators . T h u s , physicians, admin ist rators and the ministry v iewed emergency, medica l intensive care and surgical recovery room as more needed than d id R . N . A . B . C . and educators . Educators rated pediatr ic intensive care and newborn intensive care lower than any other group, whereas admin ist rators ' rat ings here were the highest of all groups. Other areas w i t h low ratings were coronary intensive care (2 .25 by educators to 4 .63 by physic ians) , and surgical intensive care (2.83 by R . N . A . B . C . to 4 .54 by admin ist rators ) . F r o m the overal l means, there is a tendency towards the 'not needed' part of the seven po int ra t ing scale (Tab le 1-38, A p p e n d i x C ) , ind icat ing that cr i t ica l care was not needed. However, in reviewing the data a different pattern emerges. For example , coronary intensive care had means ranging f rom 2.25 to 4 .63, w i t h high standard deviat ions (Tab le 4, A p p e n d i x C ) . T h e f requency d is t r ibut ion reveals that approx imate ly 2 4 % of the admin ist rators rated coronary intensive care 'not needed' ( rat ing of one to two) , another 4 0 % rated 'needed' (six t o seven). Phys ic ians and the ministry were s imi lar in their rat ings (Tab le 4, A p p e n d i x C ) . 72 CATEGORY Clinical Areas Critical Care 1. Coronary Intensive Care 2. Emergency 3. Medical Intensive Care 4. Newborn Intensive Care 5. Surgical Intensive Care 6. Surgical Recovery Room 7. Pediatric Intensive Care Group 1 Educator n=156 TABLE 4-22 Summary of Critical Care Areas by Respondent Group Fvalue X rank 2.25 5 3.32 3.07 2.19 2.92 4.54 2.09 Mean Total 20.38 Mean and Rank 2.91 Group 2 Adminis-trator n=130 X rank 4.43 5 5.75 4.89 3.74 4.54 5.91 3.87 33.13 4.73 Group 3 Physician n=135 X rank 4.63 4 6.21 5.01 3.59 4.18 4.70 3.64 31.96 4.57 Group 4 R.N.A.B.C. n=18 X rank 2.44 6 4.17 3.17 2.78 2.83 4.44 2.28 22.11 3.16 Group 5 Ministry n=20 X rank 3.85 4 5.45 3.90 3.10 3.75 5.25 3.00 28.30 4.04 54.13* 23.86* 13.88* 13.69* 10.65* 19.97* Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 35.52* x x X X X X * significant beyond the 0.05 level of significance. Simi la r s i tuat ions exist for emergency, surgical intensive care, medica l intensive care, newborn intensive care, surgical recovery room, and pediatr ic intensive care. A l l had neu-t ra l means, high standard deviat ions, polar ity in frequency counts and two or more group comb ina t ions of s igni f icant disagreement. Seven differences were found between educators and admin ist rators . S ix differences were found between educators and physicians, and between admin ist rators and R . N . A . B . C . Four differences were found between physicians and R . N . A . B . C . (coronary intensive care, emergency, medica l intensive care, and pediatr ic intensive care), fo l lowed by a difference in two mean rat ings between educators and the ministry (coronary intensive care and emer-gency) . T h e r e was only one difference between admin ist rators and physicians (surgical recovery room) . There were no differences between the remain ing four groups. There were four areas w i th four or more combinat ions of group differences: coronary intensive care, medica l intensive care, pediatr ic intensive care and emergency. Overa l l , ad -min ist rators had the highest, rat ing newborn intensive care, surgical intensive care, surgical recovery room and pediatr ic intensive care highest. Phys ic ians were second, w i th three rat ings (coronary intensive care, emergency, and medica l intensive care) highest. Educators 73 had the lowest rat ings on five (coronary intensive care, emergency, medica l intensive care, newborn intensive care and pediatr ic intensive care). In this category, the means were more neutra l , as a result of b ipolar ized views. There were no areas w i t h overal l means above 5.5, however two areas had means below 3.5 (ped iat r ic intensive care and newborn intensive care) (Tables 29 and 19, A p p e n d i x C ) . S o m e respondents strongly supported the need for cr i t ica l care areas in a basic nursing educat ion program, but there were also respondents who did not. Five areas (emergency, medica l intensive care, surgical intensive care, surgical recovery r o o m , and pediatr ic intensive care) had three or more groups w i th rank ing agreement. O f those five, four were ranked by educators, admin ist rators and the R . N . A . B . C . Rank orders were also compared . A difference of two in rank order ing was found on three areas: 1. Phys ic ians and the ministry ranked coronary intensive care higher than R . N . A . B . C . (4 vs. 6) . 2. R . N . A . B . C . ranked newborn intensive care higher than admin ist rators and physicians (5 vs. 7). 3. Educators , admin ist rators and R . N . A . B . C . ranked surgical recovery room higher than physicians (1 vs. 3). C l in ica l Areas for Category T w o . " C o m m u n i t y Heal th Areas" Tab le 4 -23 revealed that stakeholders did not differ s igni f icant ly on eight of nine c o m m u -nity health areas. T h e only difference was between physicians and educators on physic ian 's offices. T h o s e w i t h highest mean rat ings were outpat ients w i t h rat ings ranging f rom 4.52 (educators) to 5.18 ( R . N . A . B . C ) , and home care w i th rat ings ranging f rom 4.34 (phys i -c ians) to 4 .85 (min ist ry ) . Industrial nursing was rated lowest w i th rat ings between 2.13 (educators) and 2.85 (min ist ry ) . Phys ic ian 's offices and nursery school were next w i t h respective rat ings be-tween 2.17 (educators) and 3.00 (min ist ry ) , and between 2.34 (admin is t rators ) and 2.75 (min is t ry ) . O w i n g to these low ratings, none of these three c o m m u n i t y areas were needed. Other areas w i t h low ratings were: publ ic health 3.94 (educators) to 4 .75 (min ist ry ) ; menta l health 4 .06 ( R . N . A . B . C . ) to 4.70 (physic ians) ; day care pediatr ics 3.94 ( R . N . A . B . C . ) to 4.47 (phys ic ians) ; and adult day care 4.15 (min ist ry ) to 4.76 ( R . N . A . B . C ) . A g a i n , the overal l means were more neutral ; however, in reviewing the data a different pattern emerges. For example , adult day care has a wide range of mean rat ings and high standard deviat ions 74 (Tab le 5, A p p e n d i x C ) . A g a i n the f requency d is t r ibut ion reveals that approx imate ly 2 5 % of admin is t rators rated adult day care 'not needed' (one to two) , yet 3 4 % of admin ist rators rated it 'needed' (six to seven). T h i s is also true of educators and physicians respectively where 2 0 % rated 'not needed' (one to two) , 3 2 % rated 'needed' (six to seven) compared w i t h 1 9 % of physicians who rated 'not needed' and 3 0 % rated 'needed. ' R . N . A . B . C . and min ist ry rat ings were simi lar . Perhaps this is why no signi f icant differences were found . S imi la r s i tuat ions exist for pediatr ic day care, home care, menta l health , outpat ients , and pub l ic heal th : al l had means wh ich were neutral , high standard deviat ions, and bipolar ized f requency counts . CATEGORY Group 1 Educator n=156 TABLE 4-23 Summary of Community Health Areas by Respondent Group Fvalue Group 2 Adminis-trator n=130 Clinical Areas Community Health X rank X rank 1. Day Care 4.45 2 4.29 5 Centers (Adult) 2. Day Care Center 4.35 5 4.04 6 (Pediatrics) 3. Home Care 4.40 4 4.36 3 4. Industrial 2.13 9 2.37 8 Nursing 5. Mental Health 4.43 3 4.30 4 (Outpatient) 6. Nursery School 2.72 7 7. Outpatient 4.52 1 (Community Clinic) 8. Physician's 2.17 8 Offices 9. Public Health 3.94 6 Mean Total 33.11 Mean and Rank 3.68 5 2.34 4.69 2.40 7 4.40 2 33.19 3.69 • Group 3 Physician n=135 X rank 4.45 4 4.47 3 Group 4 Group 5 R.N.A.B.C. Ministry 4.34 6 2.63 9 4.70 1 2.70 8 4.65 2 2.99 7 4.41 35.34 3.93 n=18 X rank 4.76 2 3.94 6 4.61 3 2.20 9 4.06 5 2.38 8 5.18 1 2.50 7 4.59 4 34.22 3.80 3 n=20 X rank 4.15 6 4.25 5 4.85 2 2.85 8 4.60 4 2.75 9 4.90, 1 3.00 7 4.75 3 36.10 4.01 1 0.35 0.87 0.33 2.32 0.92 0.91 0.55 4.21* 1.61 Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 * significant beyond the 0.05 level of significance. Overa l l , the min ist ry provided higher ratings than any other group on six areas. P h y s i -cians were second in rat ing overal l w i th two highest rat ings (day care pediatr ics and menta l 75 health) . R . N . A . B . C . had two highest rat ings (outpat ient and day care adu l t ) , whereas ed -ucators had the lowest rat ings on industr ia l nursing, outpat ients , phys ic ian 's offices and pub l ic heal th . Overa l l , a tendency towards neutral i ty on mean rat ings occurred because of b ipo lar ized views. N o areas had overal l mean rat ings above 5.5. However, three areas had overal l mean rat ings below 3.5 (nursery schoo l , industr ia l nurs ing, and physic ian 's off ices). (Tab les 1-38, A p p e n d i x C ) . There were respondents who strongly supported the need for c o m m u n i t y health c l in ica l areas to be inc luded in basic nursing educat ion but there were respondents w h o d id not. R a n k i n g agreement w i t h three or more groups occurred on three areas ( industr ia l nurs-ing, outpat ients , and physic ian 's off ices). A difference of three in rank order ing was found on f ive areas: 1. Educators and the R . N . A . B . C . ranked day care center (adu l t ) higher than the ministry (2 vs. 6) or admin ist rators (2 vs. 5). 2. Phys ic ians ranked day care pediatr ics higher than admin is t rators or R . N . A . B . C . (3 vs. 6) . 3. Phys ic ians ranked menta l health (outpat ient ) higher than admin ist rators (1 vs. 4) , the min ist ry (1 vs. 4) and the R . N . A . B . C . ( 1 vs. 5). 4. T h e ministry ranked publ ic health higher than educators (3 vs. 6) . Admin i s t ra to rs ranked it higher than physicians (2 vs. 5) and educators (2 vs. 6) . 5. T h e ministry, admin ist rators and R . N . A . B . C . ranked home care higher than physicians (2 vs. 6), (3 vs. 6) and (3 vs. 6) respectively. C l i n i ca l Areas For Category Three . "Genera l A reas" Here stakeholders differed s igni f icant ly on eighteen of twenty - two general areas (Tab le 4 -24) : burn unit , dermatology, extended care, gynecology, labor and delivery, general m e d -ica l , neurology, neurosurgery, or thopedics , general surgery, operat ing room, ophthamology , pos tpa r tum, psychiatry, radiology, rehabi l i tat ion , urology and well baby nursery. T h e highest rat ing for radiology was 3.05 (min ist ry ) ; burn unit 3.02 (admin ist rators ) ; card iovascu lar - thorac ic 3.22 (educators) ; p last ic surgery 3.38 (admin is t rators ) ; and cl in ical research 2.35 (min is t ry ) . M e a n rat ings did not exceed 3.06 ind icat ing that these areas were not needed (Tables 1-38, A p p e n d i x C ) . Overa l l mean rat ings higher than 5.50 were: general medic ine, general surgery, gynecology, or thopedics , labor and delivery, psychiatry, extended care, pediatr ics , pos tpa r tum, and well baby nursery (Tables 1-38, A p p e n d i x C ) . 76 Th i r teen differences occurred between admin ist rators and physicians. Twe lve differ-ences were found between educators and physicians, fo l lowed by nine differences between admin is t rators and educators . Th ree s igni f icant differences were found between physicians TABLE 4-24 Summary of General Areas by Respondent Group Group 1 Educator Group 2 Adminis-trator Group 3 Physician Group 4 Group 5 R.N.A.B.C. Ministry Fvalue Groups Significantly Different CATEGORY n= =156 n= 130 n=: 135 n= 18 n=20 Clinical Areas General X rank X rank X rank X rank X rank 1 1 1 1 2 2 2 3 3 v v v v v v v v v 2 3 4 5 3 4 5 4 5 1. Burn Unit 1.88 22 3.02 20 3.00 19 2.65 20 2.80 20 9.57* X X 2. Cardiovascular Thoracic 3.22 17 3.19 19 2.77 20 2.82 18 2.79 21 1.12 3. Clinical Research Unit 2.03 20 2.22 22 1.98 22 2.06 22 2.35 22 0.57 4. Dermatology 2.85 18 4.05 17 3.70 15 3.39 17 4.33 15 8.23* X X X 5. Extended Care 6.25 6 6.26 10 5.42 8 6.28 6 5.85 7 8.46* X X 6. Gynecology 5.52 10 6.40 5 5.80 5 6.56 3 5.79 8 8.29* X X X 7. Labor and Delivery 5.61 9 6.30 8 5.97 4 5.17 13 6.05 6 4.37* X X 8. Medical (General) 6.99 1 6.97 1 6.70 1 7.00 1 6.90 1 9.01* X X 9. Neurology 4.55 13 5.37 14 4.19 14 5.44 11 4.45 14 8.27* X X X 10. Neurosurgery 3.96 14 4.56 16 3.49 17 3.72 15 3.50 17 5.28* X 11. Orthopedics 5.72 8 6.40 5 5.27 9 6.00 9 5.25 10 12.29* X X X X 12. Surgery (General) 6.96 2 6.93 2 6.51 2 7.00 1 6.80 2 13.03* X X X 13. Operating Room 3.63 16 5.62 12 5.15 11 4.61 14 4.60 13 20.37* X X 14. Ophthamology 3.75 15 5.00 15 3.54 16 3.67 16 4.32 16 11.53* X X X 15. Pediatrics 6.36 4 6.52 4 6.22 3 6.22 7 6.50 3 1.17 16. Plastic Surgery 2.75 19 3.38 18 3.13 18 2.76 19 3.16 18 1.92 17. Postpartum 6.53 3 6.63 3 - 5.54 6 6.44 4 6.30 4 19.78* X X X 18. Psychiatry 6.11 7 6.40 5 5.44 7 6.06 8 5.55 9 7.81* X X 19. Radiology 2.02 21 2.67 21 2.44 21 2.29 21 3.05 19 3.57* X 77 TABLE 4-24 Cont'd CATEGORY Group 1 Educator n=156 Clinical Areas General X rank 20. Rehabilitation 5.44 11 21. Urology 5.00 12 22. Well Baby 6.27 5 Nursery Mean Total 103.40 Mean &. Rank 4.70 Group 2 Adminis-trator n=130 X rank 5.50 13 5.72 11 6.29 9 115.40 5.25 Group 3 Physician n=135 X rank 4.56 12 4.32 13 5.27 9 Group 4 Group 5 R.N.A.B.C. Ministry 4 1 * significant beyond the 0.05 level of significance. 100.41 4.56 5 n=18 X rank 5.76 10 5.39 12 6.35 5 107.64 4.89 n=20 X rank 5.25 10 4.75 12 6.21 5 106.55 4.84 Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 6.50* x x 9.93* xx x 10.06* x x and the R . N . A . B . C , whereas two differences were found between the R . N . A . B . C . and admin ist rators , and between admin ist rators and the ministry. O n e difference was found between educators and the R . N . A . B . C , and between educators and the ministry. There were no differences between physicians and the ministry, and between R . N . A . B . C . and the ministry. Four general areas had no signi f icant differences: c l in ica l research, card iovascular -thorac ic , pediatr ics and plast ic surgery. Admin i s t ra to rs had higher ratings than did any other grOup on eleven i tems (burn unit , labor and delivery, neurosurgery, or thopedics , operat ing room, ophthamology , pediatr ics, p last ic surgery, pos tpa r tum, psychiatry, urology) . By compar ison , the R . N . A . B . C . rated seven higher than any other group (extended care, gynecology, general med ica l , neurology, general surgery, rehabi l i tat ion , and well baby nursery), the ministry rated three higher than any other group (c l in ica l research unit , dermatology, and radio logy) , and educators rated only one higher — card iovascular - thorac ic . Phys ic ians had lower rat ings than any other group on fourteen (card iovascular - thorac ic , c l in ica l research unit , extended care, general med ica l , neurology, neurosurgery, general surgery, ophthamology , pediatr ics , postpar tum, psychiatry, rehabi l i tat ion , urology, well baby nursery), whereas educators had lower ratings t h a n any other group on six areas (burn unit , dermatology, gynecology, operat ing room, p last ic surgery, and radio logy) . Agreement in rank order ing occurred w i th three or more groups on ten areas: burn unit , c l in ica l research unit , general med ica l , neurology, general surgery, ophthamology , p last ic 78 surgery, radiology, urology, well baby nursery). A different of seven in rank order ing was found in two areas: 1. R . N . A . B . C . ranked gynecology higher then educators (3 vs. 10). 2. Phys ic ians ranked labor and delivery higher than R . N . A . B . C . (4 vs. 13). T h e ministry ranked labor and delivery higher than R . N . A . B . C . (6 vs. 13). B ipo la r i za t ion of Response Rat ings of C l in ica l Areas Inspection of the data revealed considerable var iat ion w i th in the group. T w e n t y - n i n e c l in ica l areas had b ipolar ized responses (Append ix C, Tables 1-38). A r ranged in order of variabi l i ty, w i th their associated groups in parenthesis, they are: 1. Day Care A d u l t s (al l 5 groups) . 2. Day Care Ped iat r ics (al l 5 groups) . 3. Surg ica l Intensive Care (all 5 groups) . 4. H o m e Care (al l 5 groups) . 5. M e d i c a l Intensive Care (all 5 groups) . 6. O p h t h a m o l o g y (al l 5 groups) . 7. Ou tpa t i en ts (al l 5 groups) . 8. P u b l i c Hea l th (al l 5 groups) . 9. Dermato logy (admin ist rators , physicians, R . N . A . B . C , min ist ry ) . 10. M e n t a l Hea l th (educators , admin ist rators , physicians and R . N . A . B . C ) . 11 . Neuro logy (educators , admin ist rators , physicians, min ist ry ) . 12. Neurosurgery (educators, admin ist rators , physicians, R . N . A . B . C ) . 13. Coronary Intensive Care (administ rators , physicians, R . N . A . B . C and min ist ry ) . 14. P las t ic surgery (admin ist rators , educators , R . N . A . B . C , min ist ry ) . 15. O p e r a t i n g room (educators, physicians, R . N . A . B . C , min ist ry ) . 16. Surg ica l Recovery R o o m (educators, physicians, R . N . A . B . C , min ist ry ) . 17. Newborn Intensive Care (administ rators , physicians, R . N . A . B . C , and min ist ry ) . 18. Card iovascu la r - thorac ic (educators, admin ist rators and R . N . A . B . C ) . 19. Nursery S c h o o l (admin ist rators , educators, R . N . A . B . C ) . 20. Ped iat r ic Intensive Care (admin ist rators , physicians, and min is t ry ) . 21 . Phys ic ian ' s offices (physicians, R . N . A . B . C , and min ist ry ) . 22. Uro logy (educators , physicians, min ist ry ) . 23. Labor and delivery (educators, R . N . A . B . C , min ist ry ) . 24. Emergency (educators, R . N . A . B . C , min ist ry ) . 25. B u r n Uni t (admin ist rators and min ist ry ) . 79 26. Radio logy (admin ist rators , min ist ry ) . 27. Rehab i l i ta t ion (physic ians, min ist ry ) . 28. Industrial nurs ing (min ist ry ) . 29. C l i n ica l Research ( R . N . A . B . C ) . S u m m a r y of C l in ica l A rea Rat ings There was at least one s igni f icant difference on twenty -s ix of the th i r ty -e ight c l in ical areas. D isagreement was most pronounced between physicians and educators and between educators and admin ist rators , however, there was also disagreements between admin is t ra -tors and the R . N . A . B . C , between admin ist rators and physicians, and between physicians and the R . N . A . B . C . Add i t iona l ly , there were twenty -n ine c l in ica l areas w i t h b ipo lar izat ion in frequencies. T h e min ist ry had b ipolar ized reponses on twenty - four c l in ica l areas. These responses were compared to the R . N . A . B . C . who had b ipolar ized responses on twenty -two c l in ica l areas, physicians and admin ist rators w i t h twenty and educators w i th nineteen. R a n k i n g differences were found on ten c l in ica l areas, and ranking agreement w i t h three or more groups was found on eighteen c l in ica l areas. Rat ings were highest for admin ist rators on f i fteen c l in ica l areas, fo l lowed by the R . N . A . B . C . on nine, the min ist ry on eight, phys i -cians on five and educators on one c l in ica l area. Educators ' rat ings were lowest on f i fteen c l in ica l areas, fo l lowed by physicians on fourteen, the R . N . A . B . C . on five, the ministry on two and admin ist rators on one c l in ica l area (Tab le 22, A p p e n d i x E) . In answer to the th i rd quest ion , there are s igni f icant differences in percept ions of stakeholders concern ing the need for part icular c l in ica l areas in basic nursing educat ion . Length and Type of Educat iona l Preparat ion for  Nurs ing Educat ion (Research Quest ion # 4 ) Compar i son of the Length and Type of Bas ic Educat ion P r o g r a m M o s t R . N . A . B . C . representatives (88 .9%) viewed a baccalaureate as needed for basic nurs ing educat ion , whereas only eleven percent supported the college d ip loma . M o s t ed -ucators ( 6 5 % ) also supported a baccalaureate degree in nurs ing. However, 2 7 % of the educators were support ive of a college program and 5 % supported a hospita l program. M o s t admin is t rators (59%) supported the baccalaureate; however, 2 1 % were support ive of the hospita l d ip loma program and 1 1 . 5 % supported the college d ip loma program (Tables 167 -168 , A p p e n d i x C ) . Less than a th i rd (30%) of the min ist ry chose a baccalaureate, 4 0 % preferred a col lege d ip loma , and 2 0 % selected a hospita l d ip loma program. Phys ic ians 80 gave the highest support for hospita l d ip loma programs, (36 .7%) ; 4 3 % selected the college d i p l o m a program and only 1 8 % preferred the university degree as the basic preparat ion for beg inn ing nurses (Tab le 168, A p p e n d i x C ) . T h e r e was s igni f icant disagreement over a suitable length of the program (Table 167, A p p e n d i x C ) . R . N . A . B . C . had the highest rat ings w i th 6 6 . 6 % choos ing four academic years and the remain ing th i rd (33 .4%) choos ing two to three academic years. M o s t admin ist rators ( 59 .8%) favored four or more academic years and nearly forty percent (39 .1%) advocated two to three academic years. Nearly f i f ty -s ix percent (55 .5%) of educators recommended four or more years whi le 44.5 percent were in favor of two to three academic years. Mos t physic ians (78 .8%) and ministry representatives (70%) were in support o f a three year academic program or less. R . N . A . B . C . had the highest and physic ians the lowest overall expectat ions . F r o m Tab le 4 -25 , physicians showed signi f icant disagreement w i th educators , admin is -t rators and the R . N . A . B . C ; however, admin ist rators also disagreed w i t h the min ist ry regard-ing the length of preparat ion. Overa l l , physicians had the lowest rat ings and R . N . A . B . C . had the highest rat ings for the length of the program. In summary, stakeholders differed in their percept ions on both the length and the type of nurs ing educat ion program. In answer to the four th research quest ion , there are s igni f icant differences in percept ion of stakeholders concern ing the length and type of educat iona l preparat ion for basic nurs ing educat ion . TABLE 4-25 Comparison of Length of Program By Respondent Group Group 1 Group 2 Educator Adminis-trator n=156 n=130 Group 3 Group 4 Group 5 Physician R.N.A.B.C. Ministry n=135 n=18 n=20 Fvalue Groups Significantly Different 1 1 1 1 2 2 2 3 3 4 v v v v v v v v v v 2 3 4 5 3 4 5 4 5 5 Length of preparation (academic years) 3.45 years 3.60 years 3.15 years 3.61 years 3.25 years 9.09* significant beyond the 0.05 level of significance. 81 S u m m a r y T h i s summary is organized under headings that relate to the research questions in the study; stakeholder percept ions regarding the need for stated objectives, course content and c l in ica l areas in a basic nursing educat ion program, and stakeholder percept ions regarding the length and type of a basic nursing educat ion program. Object ives . Course Content and C l in ica l Areas Subjects were asked to respond by g iv ing their rat ing on the need for 83 objectives, 45 course content choices, and 38 c l in ica l areas as well as on the length and type of educat iona l preparat ion. Examina t i on of the data revealed s igni f icant overal l d isagreement on 76 object ives, 40 course content areas and 26 c l in ica l areas. M o s t of the disagreemnt occur red between physicians and educators and between physicians and admin ist rators . However, there was disagreement between all groups stud ied . T h i s d isagreement is displayed in Table 4 -26 . O u t of a possible to ta l of 1660 disagree-ments , there were 403 to ta l d isagreements (as many as 10 combinat ions of g roup differences cou ld have occur red on each of 166 i tems) . F rom Tab le 4 -26 , physic ians disagreed w i th other stakeholders more than any other group — a to ta l of 301 t imes ( 4 5 % disagreement) out of a possible 664 opportun i t ies (each group cou ld disagree w i t h a m a x i m u m of 4 groups on each of 166 i tems) . T h i s is compared to admin ist rators w i th 186 disagreements (28%) , educators w i t h 180 ( 27%) , the ministry w i th 69 (10%) , and R . N . A . B . C . w i th 70 (11%) disagreements. T h e overal l d isagreement averaged to 2 4 % . Disagreement in rank order ing occur red on 31 object ives, 11 course content areas, and 10 c l in ica l areas. Perhaps disagreement is less obvious on the part of the ministry and R . N . A . B . C . because fewer of t h e m were pol led. Where 159 educators replied to the survey, 134 admin ist rators , and 156 physicians, only 21 ministry personnel and 20 R . N . A . B . C . personnel responded. A s a result, a larger difference in means would need to occur in the min ist ry and R . N . A . B . C . groups than in the former three in order to reveal s igni f icant differences. In reviewing f requency counts , there is also disagreement w i th in groups on 29 c l in i -cal areas, 15 object ives, and 23 course content areas. T h u s , b ipo lar i zat ion of responses occur red a to ta l of 67 t imes. Phys ic ians , responses exhib i ted b ipo lar i zat ion on 50 items, the min ist ry fo l lowed w i th 46, educators and admin ist rators w i t h 35 and R . N . A . B . C . w i th 33. D isagreement over rank ing occurred on 31 objectives, 11 course content areas, and 10 c l in ica l areas, whereas ranking agreement of three or more groups occured on 60 objectives, 82 11 course content areas and 18 cl in ica l areas. TABLE 4-26 Number of Disagreements Among Respondent Groups Educators Administrators Physicians Ministry R.N.A.B.C. Educators xxxx 34 116 24 6 Administrators 34 xxxx 119 24 12 Physicians 116 119 xxxx 19 47 Ministry 24 21 19 xxxx 5 R.N.A.B.C. 6 12 47 5 xxxx Total Number of Disagreements 180 186 301 69 70 Percent Disagreement 27% 28% 45% 10% 11% Total Disagreements 403 Overall Average Disagreement (%) 24% It is also instruct ive to review the agreement* over the selection of course content , object ives and cl in ica l areas (Table 4 -27) . O u t of a possible to ta l of 1660 agreements, there were 1257 (as many as 10 combinat ions of group agreements cou ld have occurred on each of 166 i tems) . T h e R . N . A . B . C . and the ministry were more often in agreement w i t h stakeholders than were the others. For example , the ministry was in agreement 595 t imes (90%) , and the R . N . A . B . C . 594 t imes (89%) out of a possible 664 opportun i t ies (each group could agree w i th a m a x i m u m of four groups on each of 166 i tems) . T h i s is compared to admin ist rators w i th 478 agreements (72%) , educators w i th 484 (73%) , and physicians w i t h 363 (55%) agreements. T h e overal l agreement averaged to 7 6 % . Agreement in rank order ing a m o n g the five groups occur red on 60 objectives 11 course content areas and 18 c l in ica l areas. T h e overal l mean was greater than 5.5 for the fo l lowing c l in ica l areas: extended care, gynecology, labor and delivery, or thopedics , general surgery, general medic ine, pediatr ics, pos tpa r tum, psychiatry, well baby nursery. * B y agreement, it is meant that there was no signi f icant d isagreements found . It does not mean t o t a l agreement. 83 TABLE 4-27 Number of Agreements Among Respondent Groups Educators Administrators Physicians Ministry R.N.A.B.C. Educators xxxx 132 50 142 160 Administrators 132 xxxx 47 145 154 Physicians 50 47 xxxx 147 119 Ministry 142 145 147 xxxx 161 R.N.A.B.C. 160 154 119 161 xxxx Total Number of Agreements 484 478 363 595 594 Percent Agreement 73% 72% 55% 90% 89% Total Agreements 1257 Overall Average Agreement (%) 76% T h e overal l mean was greater than 5.5 for the fo l lowing course content areas: anatomy, biology, care of ill adults , care of ill ch i ldren, c o m m u n i c a t i o n , Eng l ish , fami ly nursing, geron -tology, human growth and development , human needs, legal aspects, medica l t e r m i n o l -ogy, microbio logy, nursing ethics, nursing leadership, nursing ski l ls , nursing theory, nursing trends, nut r i t ion , pathology, pharmacology, physical assessment, physiology, professional issues, and psychology. There were only nine objectives that d id not have a rat ing of 5.5 or greater. These objectives were (overal l means are in parenthesis) : 1. Uses c o m m u n i t y resources to help patient resolve problems (5.3) . 2. K n o w s admin is t rat ive organ izat ion and funct ion ing of the inst i tu t ion at various levels (5.2) . 3. C o n d u c t s pat ient care conferences (5.0) . 4. Teaches correct principles and techniques of pat ient care to other staff (5.0) . 5. Understands and uses a variety of nursing models in prov id ing nurs ing care (4.4). 6. App l ies research f indings to improve nursing care (4.6). 7. Par t ic ipates in nurs ing research (4.4). 8. A c c e p t s responsibi l i ty for developing and p romot ing the profession w i th in a chang ing society (4.7) . 9. Eva luates the present and emerg ing trends of the profession in relat ion to trends in health care (4.7) . 84 From Tables 1-24, A p p e n d i x E, it is evident that admin ist rators most often had the highest rat ings ( a to ta l of 31 objectives, 18 course content areas and 15 c l in ica l areas), compared to : educators w i th 31 objectives, 7 course content areas and 1 c l in ical area; the R . N . A . B . C . w i th 9 objectives, 17 course content areas and 9 c l in ica l areas; to the min ist ry w i t h 2 objectives, 2 course content areas and 8 c l in ica l areas; and to physicians w i t h 3 object ives, 0 course content areas and 5 c l in ica l areas. M o s t f requently (100 t imes) , physic ians gave the lowest ratings. However, the lowest rat ings were also chosen by the min ist ry on 29 i tems, educators on 21 , the R . N . A . B . C . on 11, and admin ist rators on 1 i tem. Educat iona l Preparat ion Rat ings T h e r e is s igni f icant disagreement over the length and type of educat iona l program best suited to basic nurs ing educat ion . M u c h of the disagreements occur red between physicians and another group. Suppor t for the B . S c . N . and four years of preparat ion was given by 8 9 % of the R . N . A . B . C . representatives, compared w i th 6 5 % of the educators , 5 9 % of the admin ist rators , 3 0 % of the ministry and 1 8 % of the physicians. W h i l e the major i ty of R . N . A . B . C . representatives wou ld select the B . S c . N . and nearly four years of preparat ion for basic nursing educat ion , the majorit ies in favor of the B . S c . N . a m o n g educators and admin ist rators are m u c h smaller . Phys ic ians and the ministry are not in favor of the B . S c . N . and four years of academic preparat ion for basic nursing educat ion . In summary, in answer to the first four research quest ions, there was s igni f icant dis -agreement a m o n g the f ive stakeholders groups over the rat ing of objectives, c l in ica l areas and course content , and over the type and length of preparat ion for basic nursing educa -t ion a m o n g the five stakeholder groups. T h e greatest number of d isagreements occurred between physic ians and educators and between physicians and admin ist rators ; however, there was also s igni f icant disagreement between educators and admin ist rators . O n several occas ions , d isagreement was found a m o n g admin ist rators , R . N . A . B . C . and the ministry. Concern ing course content areas, c l in ica l areas and objectives, al l f ive groups agreed that certa in areas should be included in basic nursing educat ion programs and certain ones should not. Phys ic ians disagreed more often both a m o n g themselves and w i t h other stakeholders than did any of the others. However, there is considerable disagreement not only across but w i th in the stakeholder groups stud ied . T h e histor ical issue of length and type of educat iona l preparat ion remains unresolved a m o n g the groups s tud ied . Chapte r Five wi l l address the f i f th research quest ion . 85 C H A P T E R F I V E Presentat ion of F ind ings F rom the Interviews Chapte r Four reported five stakeholders ' percept ions on the need for course content , c l in ica l areas and objectives, and a type and length of preparat ion for basic nursing edu -ca t ion . T h e first sect ion in th is chapter presents educators ' jus t i f icat ions for their choices of course content , c l in ica l areas and objectives in six categories: educat iona l , ins t i tu t iona l , c l ient , t rad i t iona l , professional , and 'other. ' T h e second sect ion deals w i t h the educa -tors ' reasons for choos ing a type and length of preparat ion for basic nurs ing educat ion . A d iscussion on the f indings concludes the chapter . W h e n establ ish ing a just i f iable program, the a im is to ascertain not only what the stakeholders support but why. One wants to know what reasons they offer for the program prescr ipt ions they favor and how they just i fy their choices. If person A makes a value j udgment ( X is good ) or a prescr ipt ion , (you should do X ) and person B asks, " W h y should I do X ? " then person A is under an ob l igat ion to come up w i th an argument t o support his value j udgment or prescr ipt ion. T o do this he must produce a special k ind of reasoning cal led "normat ive reasoning" (Dan ie ls 1971, p. 3). In the research reported herein, the researcher a t tempted to discover not only the op in ions of the var ious stakeholders concern ing the course content for a basic program, but the reasons given by educators for their choices. In effect, the interviews asked educators f r o m the three types of nursing programs ( n = 3 3 ) to rank part icular objectives, course content areas and just i fy their selections. A s G leadow says, " i f educators are not to lose their role in educat ion and yet st i l l make rat ional cu r r icu lum decisions in a society whose members are d e m a n d i n g a role in the sett ing of goals, they must try to f ind out why certain goals are considered t o be worthwhi le or more worthwhi le than others" (G leadow 1978, p. !)• T h e select ion and rank ing of c l in ical areas, course content and objectives were perceived to be a di f f icult task. M o s t in formants had t rouble select ing only five out of as many as twelve, eighteen or twenty i tems, and they also had t rouble rank ing their choices. Examples of their remarks regarding the di f f iculty of comp le t ing the task are found below: Interviewer D id you rank them? Informant # 1 1 Y o u want me to rank t h e m ? Interviewer Yes. Informant # 1 1 It's a bit like sp l i t t ing hairs in terms of wh ich is f i rst . 86 Informant # 3 How many of these can I choose? Interviewer Five. Informant # 3 On ly 5? C a n I have 6? Informant # 2 O K . How many do I get? Interviewer Five. Informant # 2 T h i s is go ing to be di f f icult . T h i s is a basic program we're ta lk ing . Interviewer A n d I want you to decide what the basic f ramework is. Informant # 2 If I go for a four -year program do I get 8? O the r in formants , for example , had t rouble decid ing on the select ing or rank ing of i tems. Interviewer T h e next area is course content . Informant # 8 How do you know what people wi l l need in the future? There should be some k ind of purpose in al l of the th ings that we require people to have, and how do we know that it wou ldn ' t be good for them to have algebra and general m a t h . Interviewer So are you select ing it . Informant # 1 0 No. Interviewer You ' re just ta lk ing about it? Informant # 1 0 I'm saying I can ' t deal w i th it. A few in formants changed their minds in the middle of presenting a reason. For example : Informant # 2 5 Ep idemio logy is just . . .as impor tant as i m m u n o l o g y and ge-netics. Interviewer W h a t do you see as being needed in ep idemio logy? Informant # 2 5 Actua l ly , I've changed my m ind . Somet imes in formants wou ld ta lk around the i tems but never qui te come to a decision. O ther t imes in formants were unsure of what was conta ined in course content . T h i s u n -certa inty usually resulted in rejection of the i tem. T h e researcher, however, found that when in formants did give reasons, these reasons cou ld be categor ized into six themes: ed -ucat iona l , i ns t i tu t iona l , c l ient , t rad i t iona l , professional and 'other ' . Def in i t ions of these categories wi l l be descr ibed later in th is chapter . Table 5-1 reveals the f requency of reasons offered by in formants f rom each type of educat iona l ins t i tu t ion . Because there was a differ-ent number of in formants f rom each inst i tu t ion , the reasons were averaged per in formant . T h e most f requent ly cited reason was educat iona l ( 3 9 . 4 6 % of the t ime) , fo l lowed by i n -s t i tu t iona l ( 20 .18%) , cl ient (11 .43%) , t rad i t iona l (8 .00%) , professional (6 .78%) and other ( 14 .15%) . A n average of one hundred and th i r teen reasons were given by each informant t o a m a x i m u m of for ty -e ight questions m a k i n g a to ta l of 3,746 reasons that were cited by the th i r ty - th ree in formants . 87 Informants in one type of nursing educat ion program adhered to some categories more than to others. For example , university in formants c i ted professional reasons more fre-quent ly than d id educators f rom any other type of inst i tu t ion . Hosp i ta l in formants gave educat iona l , t rad i t iona l and 'other ' reasons more frequently, whi le col lege in formants gave cl ient and inst i tu t iona l reasons (Tab le 5-2) . S ince in formants usually gave more than one reason for each select ion made, the to ta l number of reasons given by 22 college in formants made a to ta l o f 2,446 reasons; 5 hospita l in formants gave 649 reasons; and 6 university in formants gave 651 reasons. Categor ies of reasons are arranged in order of f requency of occur rence , and appear as subheadings th roughout th is chapter . TABLE 5-1 Frequency of Reasons by Type of Educational Institution College/ College/ College/ College/ Hosp- Univer- Number Percentage CATEGORY Institute Institute Institute Institute ital sity of Times of Total OF Cited Number of REASON n=5 n=7 n=5 n=5 n=5 n=6 Reasons Educational 251 298 203 205 273 243 1476 39.46 Institutional 150 142 122 110 112 120 756 20.18 Client 74 83 77 77 40 77 428 11.43 Traditional 63 45 37 34 77 44 300 8.00 Professional 34 38 15 27 55 85 254 6.78 Other 53 97 43 76 92 77 530 14.15 TOTAL 625 703 497 529 649 651 3746 100.00 TABLE 5-2 Reasons Averaged By Type of Educational Institution CATEGORY OF REASON College/ Institute Number of Reasons Average Number/ Informant** Hospital Number of Reasons Average Number/ Informant** University Number of Reasons Average Number/ Informant** Educational 957 43.50 273 54.6* 248 41.3 Institutional 524 23.80* 112 22.4 120 20.0 Client 311 14.10* 40 8.0 77 12.8 Traditional 179 8.10 77 15.4* 44 7.3 Professional 114 5.20 55 11.0 85 14.2* Other 361 16.41 92 18.4* 77 12.8 TOTAL 2466 100.00 649 100.0 651 100.0 * denotes the greatest number of reasons averaged by type of educat iona l inst i tut ion ** Informants gave more than one reason per i tem 88 Educat iona l Reasons Educat iona l reasons were used to just i fy course content , c l in ica l areas and objectives bo th in terms of a concept ion of nursing ( in forming one about what a student needs to know and t o be able to do as a nurse) and in terms of a concern for appropr iate pedagogy (how best to teach a nurs ing student ) . Educat iona l reasons typ ica l ly presented were, "the student needs to appreciate what goes o n . . . " , " th is wi l l give the student a broad awareness of . . ." , " to learn how to moni tor IV's, give inject ions " the conceptua l f ramework of the nurs ing program decides how I choose . . . " , " to improve the s tudent 's con f idence . . . " , "get the student m o t i v a t e d . . . " , " i f she goes there she wi l l know if she wants to work there as a g raduate . . . " , and " i t ' s t o o m u c h to expect a student for this leve l . . . " Educat iona l reasons (n = 1476) represented nearly forty (39 .46%) percent of the to ta l number of responses. Concept ion of Nurs ing A variety of reasons related to one's concept ion of nursing was presented. Reasons were given in terms of enhanc ing student understanding , such as their being aware of how the body funct ions and their ga in ing academic knowledge or observ ing for understanding . For example , Interviewer W h y do you th ink socio logy is impor tan t? Informant # 1 4 W e l l because it gives the student a lot of different perspec-t ives on how to look at m a n k i n d and h u m a n interact ion . Reasons were also given wh ich related t o the impor tance of learning certain ski l ls. For example , it was thought that students needed experience in a c l in ica l area because this wou ld teach t h e m ski l ls , such as how to give medicat ions , moni tor I.V.'s, and perform bedbaths. Interviewer So now you need to tel l me why you chose neurosurgery. Informant # 6 I th ink on a neurosurgery f loor, they 'd have a variety of c l in ica l funct ions to perform such as surgical procedures. T h e y ' d be able to provide good basic nurs ing care on a f loor like this and the same wi th urology. Interviewer W h e n you say good basic care, could you be more speci f ic for me? Informant # 6 T h e y do skil ls like to ta l bed baths, they 'd be pract is ing their c o m m u n i c a t i o n ski l ls , they 'd also be mon i to r ing IV equ ipment , they 'd be able to perform IM injections, g iv ing oral medicat ions . A l so they 'd have a chance to organize their ski l ls and work w i t h set t ing priorities, and I feel those are all impor tant in any sort of nursing educat ion program. S o m e in formants gave curr icular reasons for their se lect ion. Nurs ing models were c o m -monly chosen and expla ined in terms of their use in cu r r icu lum development . 89 Interviewer Informant # 1 5 Interviewer Informant # 2 3 Interviewer Informant # 2 3 W h y do we need to have a nurs ing mode l? It [a nursing model] is a way of o rgan iz ing the content of the program really. I see a model as just a f ramework of the way the mater ia l of a part icular program is taught . Given a part icular [nursing model] f ramework, wh ich course content area wou ld you choose? Y o u might have one university level course and I don ' t know wh ich one of these I wou ld select. It wou ld depend on what you cou ld get. . . I suppose wh ich course cou ld best f it w i th your conceptua l f ramework. So a conceptua l f ramework is really focus ing your who le not ion of the objectives, the course content and the c l in ica l areas. Yes. T h a t wou ld give me di rect ion as to what wou ld be the main threads or strands, or whatever the in phrase is now, and wou ld also direct me in the kinds of nurs ing discipl ine courses wh ich are foundat iona l and then those support courses f rom non -nurs ing . Pedagog ica l Reasons A major concern here was how to best teach a nursing student . It was felt that enhanc ing the mot i va t ion of the student was impor tant , and many respondents gave this reason to support their op in ion that students should have a choice of course content and c l in ica l areas. S o m e in formants discussed the impor tance of student par t ic ipat ion and increasing student interest. Interviewer So why do you th ink the adult learner should be al lowed to pick their own course content? Informant # 5 Because they [the students] wi l l be more highly mot i va ted . T h e y ' l l be c o m m i t t e d to what they are learning, rather than be to ld you have to learn this and th is . . .because somet imes I th ink some of these th ings come back and help us later in life. Interviewer W h a t about genetics? Informant # 1 9 Genet ics is really. . i t 's definitely a specialty for someone who has a personal interest in it. Sequenc ing students ' experiences in terms of m a t c h i n g academic course content w i th c l in ica l experiences was a set of reasons given by some informants . A c l in ica l area might be selected because it helped the student further understand what was taught in the c lassroom set t ing : Interviewer W h y did you choose this [operating room]? Informant # 1 7 O p e r a t i n g room. N o w I really feel any nurse should have at least got ten into the operat ing room once dur ing her nursing main ly because it certainly gives you an awareness of how to get th is person ready, and it cements all that stuff 90 — that theory — even if i t 's just a two -day experience. I th ink i t 's really impor tant . Interviewer How does it cement i t? Informant # 1 7 T o me, you can read it in a book forever but unt i l you get in there and the anaesthetist or the nurse is check ing the w o m a n , asking all those questions, " did you eat, did you th is , d id you that " it really hits home. Not just the book to ld me t h i s . . . . A n d I've not had one come back [from the operat ing room experience] that hasn't said , "I've learned. T h i s has all been cemented . " T h a t ' s the other th ing they wi l l tel l you: "I was amazed , like I d idn ' t really believe that tha t ' s how it was unt i l I saw i t . " A n d I th ink it takes away the fear. Included as pedagogica l reasons are those that relate to the order ing of the student 's courses. Somet imes the in formant said the objective, course content or c l in ica l area was t o o advanced for the student . Other t imes course content wou ld be discarded because it was thought to be t o o elementary. Interviewer A n d why d idn ' t you choose this one? Informant # 2 8 Teach ing correct pr inciples, procedures and techniques to other staff. A g a i n , I wou ld see that as be ing either an ex-perienced pract i t ioner or just a l i tt le above what you wou ld expect of of a beginning R . N . who is learning the principles and procedures herself. Informant # 9 I d idn ' t pick emergency or surgical intensive care because we're deal ing w i t h the beginning student and the d ip loma or baccalaureate student . . . I th ink those areas are more specialty areas and the students really need to have a post basic course to work in those areas.. . t ha t ' s why I d idn ' t include those for that reason, and the same w i t h operat ing r o o m . Interviewer A re you choos ing these [biochemistry, anthropology, and sociology]? Informant # 7 We l l some of these can either be in the program or be pre-requisites. . . These are th ings I th ink are impor tant to have but they cou ld all be done prior to c o m i n g in . B iochemist ry , anthropology, or sociology. . .a lgebra, it has to be taken in high schoo l . In summary, 4 0 % of the t ime, educat iona l reasons were presented by the in formants to just i fy their speci f ic choices concern ing course content , c l in ica l areas and objectives. Such reasons related to a concept ion of what nursing students should know or appreciate, and a concern for how they cou ld best be taught . Inst i tut ional Reasons Inst i tut ional reasons given by interviewees for their choices can be defined in relat ion to the expectat ions and constra ints imposed by the accred i t ing body ( R . N . A . B . C . ) to wh ich the 91 nurse is accountab le , the perceived demands of the present and future workplace (hospita l and c o m m u n i t y ) , and the avai labi l i ty of resources ( t ime, money and access to appropr iate c l in ica l p lacements ) for suppor t ing a program. These reasons (n = 756) represented twenty percent (20 .18%) of the to ta l number of responses. Reasons classif ied in this category include: "the nurse is the most l ikely person in the hospi ta l to do i t . . . " , " i t ' s being imposed on us . . . " , " the hospitals won ' t hire new graduates for that a rea . . . " , "only two to five percent of students wi l l work there as a grad , so why b o t h e r ? " , " in some smal l communi t ies , she may have to do all the work . . . " , " the trend in heal th care is away f rom the hosp i ta l . . . " , " i t ' s on the R . N . e x a m s . . . " , " R . N . A . B . C . requires i t . . . " , "here's where the student p r a c t i s e s — t h e hosp i ta l . . . " , " the decrease in the health care do l la rs . . . " , "we don ' t have the t ime to include t h i s . . . " , "we don ' t have the money. . . " , "there are no faci l i t ies for t h i s . . . " , "we have the c l in ica l faci l i ty for t h i s . . . " , " there is a lack of professional staff to do t h i s . . . " , and "th is wi l l save t ime and money. . . " . Demands of the W o r k p l a c e In the examples that fo l low educators appealed to the demands of the present and future workp lace in just i fy ing their choices. A c o m m o n response was to focus on where the student might be employed after g raduat ion . There was also a focus on the impor tance of the new graduate being able to f i t in w i t h other staff in the inst i tut ion and to work well w i t h people. Interviewer W h y is Emergency your number one choice? Informant # 7 W e l l because I th ink you need to deal w i th emergencies in smal l hospitals, there's go ing to be no one else to deal w i th t h e m except you . Interviewer A n d why do you th ink they [the students] need to have a medica l surgical experience? Informant # 1 9 Because that ' s where c o m m u n i t y college graduates pr imar -ily wi l l be w o r k i n g — in hospitals. T h a t ' s why I've chosen that . Interviewer Cou ld you say why you d idn ' t choose pediatr ics? Informant # 1 1 W h y put everyone th rough that [pediatric] experience when maybe two to five per cent of nurses are go ing to work there when they graduate? T h e demands of the c o m m u n i t y workplace were also presented. For example , some in formants expressed the concern that some pat ients were discharged f rom hospita l sooner t h a n they should be and that they needed c o m m u n i t y resources such as home care services for rehab i l i ta t ion . Nurses had to be prepared to work in the communi ty . 92 Interviewer W h y is menta l health impor tan t? Informant # 3 1 Because the part icular nurse is go ing t o be car ing for i n -d iv iduals who have various types of problems in the acute care set t ing and in the communi ty . T h e perceived demands of the c o m m u n i t y as a future workp lace were also given as a reason by in formants . T h e y believed that the exist ing health care system wou ld be replaced, in part , by home care and c o m m u n i t y centers. Interviewer W h y d id you pick adult day care? Informant # 1 T h e trend is away f rom the hospi ta l . We ' re f ind ing more day care centers for adults such as hospice and so on where we've got t h e m out in the communi ty . They ' re not hospi ta l based and yet there's alot of really good basic nurs ing care that goes on in there. W h e n appea l ing to the perceived demands of the future workplace, some educators discussed how ant ic ipated techno log ica l changes wou ld affect the hospita l workp lace . One such change c o m m o n l y c i ted was computer usage. M a n y in formants felt that computers were go ing to inf luence the workplace and some remarked that computers had already affected their inst i tut ions . Interviewer W h y did you choose in t roduct ion to computers? Informant # 1 C o m p u t e r s — w e l l s imply because they ' re a fact of life. Interviewer It's a fact of life. Y o u mean. . . Informant # 1 They ' re here... There 's a number of hospitals that already have computer i zed systems tota l ly for nurs ing and the en -tire hospi ta l . A l l of the chart ing , etc. is done on a c o m -puter, they have their own codes to go in , everyth ing is done on a computer . . . i f we have students go ing out f rom a nursing program who have had no access to computers in their e lementary and secondary educat ion and we don ' t provide anyth ing in their nursing educat ion , then we really do ing a disservice to the profession. Informant # 2 4 C o m p u t e r s are go ing to be a very impor tant th ing in the future . . .because in the hospita l they ' re using those so rou -t inely as part of their dai ly work and they don ' t have to be a head nurse to use a compute r these days. So many th ings are on the computer these days. Expecta t ions of the A c c r e d i t i n g Body . T h e in formants ' selections were inf luenced, at t imes, by the roles of the accred i t ing body, the R . N . A . B . C . and the nat ional test ing service. R . N . A . B . C . ' s cr i ter ia for program approval include mandatory course requirements. Informant # 1 2 W h a t the R . N . A . B . C . asks essential ly is a certain list of ski l ls she is supposed to have and she is supposed to have the knowledge to wr i te her exams. 93 Informant # 1 9 We l l as long as the R . N . exams have so many quest ions on psychiatry, I see it as another [needed] experience, but in reality I see it as a specialty. Ava i lab i l i t y of Resources A set of reasons used to just i fy select ion of course content , objectives and c l in ica l areas related t o the avai labi l i ty of resources such as t ime, money and access to appropr iate c l in ical fac i l i t ies . T h e lack of such resources was c o m m o n l y given as the reason for not inc lud ing an i tem. Interviewer C a n you say why you d idn ' t want home care? Informant # 1 9 In a two-year program, they [the students] don ' t have t ime to learn c o m m u n i t y experiences. Interviewer So what you're saying is the future of health is out in the communi ty , not in the hospi ta l? Informant # 2 There 's st i l l go ing to be the hospita l but I th ink , for the biggest part, g rowth is go ing to be outs ide of the hospita l because of the health care dol lars, reduct ion in hospita l bed money. Informant # 3 0 Now day care centers for p e d i a t r i c s — i t ' s hard to f ind pe-d iat r ic p lacements. Interviewer C o u l d you say why you've chosen this [pediatric day care]? Informant # 1 1 I don ' t see where i t 's go ing to be possible in the future t o provide every student w i th an inpat ient hospi ta l experience in ped ia t r ics . . .The amount of t ime that it wou ld be, the amount of exposure, access to chi ldren that they wou ld have wou ld probably end up being so m i n i m a l as to not be very useful because we just aren't a d m i t t i n g chi ldren to hospita l if we can possibly avoid it. In summary, twenty percent of the t ime, inst i tut iona l reasons presented by the infor-mants to just i fy their speci f ic choices concern ing course content , c l in ica l areas and objectives related to the present and future demands of the workplace, expectat ions of the accred i t ing body and access to t ime , money and faci l i t ies. C l ient Reasons S o m e reasons were used to just i fy the cur r icu lum in terms of the cl ient or pat ient who wou ld benefit f r om the nurse's services. Three kinds of reasons are comb ined in the category: qual i ty care, cl ient teach ing and cl ient demographics . Reasons w h i c h fal l under this category include: " to help the pat ient . . . " , " to prevent the pat ient f rom being ha rmed . . . " , " to plan the best care for the pat ient . . . " , " the commona l i t y of the health p rob lem. . . " , and "the age 94 of the popu la t ion is increas ing . . . . " C l ient reasons (n = 428) represented eleven percent (11 .4%) of the to ta l number of responses. Qua l i t y Care of the C l ient First was the not ion of the nurse provid ing qual i ty care. In th is category, issues such as pat ient safety, coord inat ion of care, and g iv ing the best care possible were identi f ied as reasons for a part icular select ion: Interviewer Informant # 2 Interviewer Informant # 2 Informant # 5 Interviewer Informant # 5 Interviewer Informant # 1 Interviewer Informant # 3 2 W h y is this impor tan t? Because u l t imate ly i t 's the care of the pat ient tha t ' s the most impor tant — that the pat ient receives qual i ty care. T h e nurse needs to recognize when they ' re not able to provide that . Qua l i ty care? Qua l i t y care, safe care, the best care. Us ing c o m m u n i t y resources to help the pat ient resolve prob-lems. A g a i n , all nurses should be do ing that on a dai ly basis. A n d the reason why they should do it on a dai ly basis? T o enhance the pat ient 's care, of course. A n d why do they have to do this [conduct pat ient care conferences]? A s a method of get t ing everyone do ing the same th ing so that everyone's on the same wave length. . .so that you don ' t have five indiv iduals on various shifts and days go ing in and do ing five different th ings. T h e pat ient , then, receives a better qual i ty of care. W h y is this the most impor tan t? T h a t ' s a pat ient safety issue. A responsible person is not go ing to go in and try and measure pu lmonary wedge pres-sure w i th a S w a n s - G a n z if they don ' t know how. C l ient Teach ing S o m e educators felt that cl ients wanted to take more responsibi l i ty for their own health by being better in formed. Teach ing cl ients was c i ted as a reason, as was the impor tance of the fami l y hav ing inst ruct ion about the illness. It was felt that cl ient teach ing wou ld assist the ind iv idual to return to self care more quickly. Interviewer So you th ink that one of the major aspects of teach ing is to teach other staf f? Informant # 2 W e l l , the major focus would be on teach ing pat ients and family, not only in the hospi ta l , but in the c o m m u n i t y based area too . Interviewer W h y do you th ink students need to have home care? 95 Informant # 9 Pat ients are sent home wi thout being taught some of the skil ls that they need to be taught and fami ly members as wel l . So that people can be managed at home more effec-tively. C l ient Demograph ics Reasons were given in terms of the type of cl ients that students wou ld look after (cl ient demograph ics ) . For example , certain diseases were c i ted as being more c o m m o n than others and in formants often referred to the increasing elderly popu la t ion as reasons for the select ion. Interviewer W h y do you th ink they need psychiatry? Informant # 2 1 P o s t - o p confus ion , what is it? Seventy percent of pat ients on medica l units suffer some degree of de ler ium or con fu -sion in the hospita l as inpat ients . Interviewer C o u l d you say why you chose th is? Informant # 1 6 I th ink part of my decision is based on the f requency of the disease or whatever in the popu lat ion . Interviewer Y o u chose urology because? Informant # 6 It's a fact of life that the age of our popu lat ion is d r a m a t i -cal ly increasing. T h e average age of our pat ients is increas-ing. So a l though most of the urology pat ients wi l l be men, at the moment anyways, and wi l l have speci f ic uro logical problems, there is an increase in w o m e n , female urological pat ients c o m i n g a long. In the last two years [1984-1986] the min i census that they d id and the 1986 larger census that they d id , the average popu lat ion age has gone f rom 28 years to 34 years in C a n a d a , I believe. It was a d ramat ic increase so obviously we're ca tch ing the baby b o o m now — that group is mov ing up in age. Eleven percent of the t ime reasons given by respondents dealt w i t h qual i ty care, cl ient teach ing , and cl ient demographics . T rad i t iona l Reasons T rad i t iona l reasons offered for the selection of objectives, c l in ica l areas and course content involved reference on the part of the interviewee to their own professional experience or educat ion . S u c h reasons include: " M y t ra in ing was like t h a t . . . " , "I th ink back to my own e d u c a t i o n . . . " , "I used to be an emergency nurse and . . . " " M y background has been . . . " , M l d idn ' t need it then and I don ' t need it now. . . " , " T w e n t y years ago when I developed a cu r r i cu lum I inc luded this and I st i l l th ink i t 's re levant . . . " , "I p icked th is because I'm 96 fami l ia r w i t h i t . . . " , "I found it bor ing as a s tudent . . . " , "I thought it wou ld be i n t e r e s t i n g — I'm interested in i t . . . " , "I d idn ' t have this experience and it d idn ' t hurt me one b i t . . . " , and " M y background c louds or influences a lot of what I have to say.; . ." T rad i t iona l reasons (n = 300) represented eight percent of the to ta l number of responses. Th ree kinds of reasons appeared f requent ly in the t rad i t iona l category: past work experience, educat iona l background and lack of experience or educat ion . Past W o r k Exper ience In just i fy ing her choice, an educator may have appealed to her own work experience. A n area was thought to be impor tant because of her past acqua in tance w i t h it on the job . She had often worked as a graduate nurse in the area. Interviewer Now can you tel l me why you chose these? Informant # 4 Emergency is my # 1 choice. I might be a bit biased here w i t h emergency because I a m an emergency nurse. I have had six years of emergency experience and I just f ind it absolutely invaluable to myself as a nurse and I'm drawing heavily on that no matter where I go. Interviewer C a n you say why you chose this [mental health]? Informant # 7 M e n t a l health . I guess it could be first as well because I th ink it runs th rough everything. Psych iat ry is my back -ground and after do ing med -surg for a year and after not hav ing done it for twenty years, the th ing that k ind of got me by that experience was my c o m m u n i c a t i o n ski l ls . M a n y of the pat ients would not know how l itt le knowledge I had somet imes about speci f ic things that I'd never done before but the fact that I cou ld c o m m u n i c a t e well w i t h t h e m over-rode my lack of knowledge. It overrode everyth ing else and I th ink i t 's just a crucia l th ing . Interviewer C o u l d you c o m m e n t on why you th ink medica l and surgical is impor tan t? Informant # 2 1 Because we've always used it. Educat iona l B a c k g r o u n d T h e educat iona l background of the in formant appears to have had an inf luence on her se lect ion . For example , sociology was frequently selected over anthropo logy because the in formant had taken socio logy and not anthropology. One in formant , for example , said that she was p ick ing only the i tems w i th wh ich she was fami l iar or had studied in her program. Informant # 7 I don ' t see nursing models here. Is it here? Interviewer No , it isn ' t . D id you want to include it? Informant # 7 I th ink so. For me, what it gave to me go ing to university, and f ind ing out about models really helped me understand what nursing was- it let me see that when I evaluate the 97 person for these seven needs or these nine behaviours, it let me see that that was what I cou ld do w i thou t any d i rect ion f rom anyone. Informant # 3 O rgan ic chemistry. A l t h o u g h I personally have some or-ganic chemistry, I have always or for many years, regretted that I d idn ' t have more, not because I l iked it, but because there are many th ings happen ing in medic ine the last few years that are very diff icult for me to understand and put together because of my lack of organic chemistry. S o m e in formants discarded selections based on their educat iona l background . For example , Informant # 3 2 Interviewer Informant # 3 2 Interviewer Informant # 3 2 Phys ica l Educat ion goes right out . T h a t always pissed me off-W h a t ? Phys ica l Educat ion? Yes. T h a t they would force you to take it . I mean i t 's not that I ever did poor ly in phys. ed. I've been quite ath let ic . It just pisses me off to no end. First of all because you have to get changed in and out of your clothes for phys. ed. If you want to have a real good phys. ed. course you should be do ing th ings and I just haven't got the t ime when I'm at university. . . . and to have to do it when they tel l you, like in the middle of the day. . . . i t 's just not fun . . . i t 's not rec. It's a human rights th ing . Phys ica l Educat ion? Yes. Te l l ing people that they have to do that . Get in and out of their c lothes and do that sort of stuff. Lack of Exper ience or Educat ion T h e lack of relevant experience or educat ion on the part of the in formant d id inf luence her choices both in select ing or rejecting an i tem. However, in formants felt that their lack of experience w i t h a course or c l in ica l area did not inf luence their abi l i ty to care for ill c l ients. Interviewer Informant # 2 9 Interviewer Informant # 3 2 Informant # 2 6 C a n you say why you chose this [biochemistry]? B iochemistry . I th ink th is . I never took a course in it myself so I speak f rom somebody who doesn' t even for sure know what it is. Bu t biology and chemistry each in their own right seem to have again a broad scient i f ic base upon wh ich nurses learn to understand drugs better, understand the body 's compensatory mechan isms better and theoret ical ly they have more upon wh ich to bui ld a s t rong theory base. So you see it as being. . I see that I d id not have operat ing room as a c l in ica l expe-rience and it d idn ' t hurt me one bit . I, myself, never took an immuno logy course, so i t 's hard for me to say alot about that . E ight percent of the t ime reasons given by respondents dealt w i th their previous pro-fessional experience and educat iona l background . 98 Professional Reasons T h i s category of reasons had to do w i th enhanc ing the status of the nursing profession and of the nurse's professional se l f - image, and c o m m u n i c a t i o n w i t h the publ ic . These reasons (n = 254) represented seven percent (6 .78%) of the to ta l number of responses, and reasons were usually given to just i fy the study of professional issues and the history of nurs ing. Four k inds of reasons were offered as part of this category: the s tatus of the profes-s ion , the professional se l f - image of the nurse, po l i t ica l act ion and c o m m u n i c a t i o n w i th the publ ic . Examples given were: "for the advanc ing of nurs ing theory. . . " , " t o help people see what the profession does . . . " , " to advance the profess ion. . . " , " to give the profession more recogn i t i on . . . " , " to regain the power we once h a d . . . " , " to have a nurse w h o acts in a pro-fessional responsible manner . . . " , " to be able to work w i th the government . . . " and " to have people w h o are better able t o art iculate themselves, whether to supervisors, outs ide groups or government . " Informants f rom the university had more c o m m e n t s in this category than d id other facu l ty (Tab le 5-2) . S t a t u s of the Profession T h e idea of advanc ing the body of nursing knowledge, g iv ing credibi l i ty t o the profession and assist ing the profession to progress were a m o n g the c o m m o n themes in this category. It was bel ieved that an improvement in the status of the profession was necessary. Interviewer You ' re saying nursing models make it ind iv idual ist ic . Informant # 1 0 I'm all for a nurs ing model or ientat ion and not the body system. . . I th ink it makes for a stronger profession. Informant # 7 I th ink research is what helps nursing s tand on its own, helps nursing become a viable profession. . . I th ink we need degrees because all the other professions have it and here we are as nurses w i th probably more responsibi l i ty than diet ic ians, physiotherapists or pharmacists for an ind iv idual , and here we are w i thout degrees. Interviewer How does it go hand in hand w i th professional ism and safety? Informant # 5 W e l l I th ink if you've got a safe nurse, tha t ' s not enough necessarily. Get someone who 's a safe nurse who values the profession and is wi l l ing to do someth ing to enhance that image to make it look a l i tt le better and someone w h o acts in a professional responsible manner . I wish all nurses were like that . 99 Professional Se l f - image T h e need for p romot ing a more posit ive professional image a m o n g nurses was another subcategory. T h e idea that nurses cou ld see themselves as equal to other professions and cou ld feel that they have ident ity w i th a worthwhi le profession was considered to be impor tan t . S o m e in formants felt that the sel f - image of nursing was not as good as it once was, and that nurs ing was not progressing as a profession. Interviewer Informant # 6 Interviewer Informant # Interviewer Informant # Interviewer Informant # Interviewer Informant # 9 W h y d id you choose this [professional issues]? Professional issues. I chose this first because nurses are professionals. I don ' t feel we are recognized as professionals and I th ink we need to educate the students t o be seen as professionals. . . ! th ink we'd see ourselves in a different l i^ht , at a higher level than the average nurse. There 's the aide, the pract ical nurse and most people don ' t th ink of the nurse as a university educated person. So it wou ld elevate the posi t ion in the pub l ic 's eye? Yes and our own. So one of our problems is our image? Definitely. C o u l d you elaborate a bit more? I th ink there are qui te a few nurses that don ' t feel they should be earning more money, they don ' t feel they should be recognized any better. T h e y th ink they ' re just do ing a great job and they ' re satisf ied to just cont inue w i th the way th ings are. T h e y ' l l c o m p l a i n , and you can sit in the cafe-ter ia everyday comp la in ing but noth ing 's ever done about it and they ' re not wi l l ing to change, and I th ink we need people that are in there to change the system because I don ' t th ink nursing's progressing right now. I th ink i t 's go ing backwards. S o m e of the d i lemmas are the ones you just ment ioned? Y e s . . . A n d right now I'm really concerned because I th ink there certainly are alot of people who are certainly get t ing disheartened by it [nursing]; and I th ink we have a real problem right now in nursing, and I th ink i t 's real and I th ink we do a disservice to t h e m to not be upfront and start ta lk ing about some of the very major issues... There 's alot of people that are leaving the profession and there's alot of people saying "I wou ld not want my daughter to become a nurse." T h i s is not what it used to be, and what is it that is m a k i n g the profession so di f f icult? Even those of us who are in it are saying we don ' t really want some of our fami ly to get involved, so what ' s happening to nurs ing right now? Reasons for s tudy ing professional issues inc luded the need for nurses to become more po l i t ica l ly involved, and to be aware of the po l i t ica l context of their profession. Informant #11 I th ink there are aspects of professional issues, how both pol i t ics affects how a profession does its work, and how a 100 profession ought to and can influence the political system in relation to nursing care... Interviewer Why do you have to know that [professional issues]? Informant #16 To have to have an effect politically, in terms of govern-ments, and probably one of the best examples is influencing health care policy. Informant # 1 In a course like professional issues, you would look at what is happening as far as legislation with respect to nursing, with respect to health care, changes, if there are changes, and how you can institute changes, how do you work the government, lobbying... While there was agreement about having professional issues as part of course content, there was considerable disagreement about what those issues should be. Three examples of the range of sugestions follow: Interviewer What do you see as being in professional issues? Informant #12 Right now in B.C.? Government funding, government con-trol, power struggles between other professions, specializa-tion, changes in nursing education, the proposal for the baccalaureate by the year 2000, that kind of thing. Informant #19 I guess what comes to my mind first of all is treatment of AIDS patients, and the rights of patients and the rights of nurses, medications, administering medications, the pa-tient's right to know what he is getting or she is getting,and professional issues in terms of nurses and medications— taking medications themselves, the drug abuse— that kind of stuff has to be addressed, I think in the schools. Those are some of them. Charting is a big one— professional issues in charting. Informant #28 Things like ethics, finding out things too could be con-tinuing education, what is available for them out there, mandatory versus voluntary education so they know what's available. Thirty-one of the thirty-three faculty interviewed chose professional issues as one of the five most important course content areas. Those not choosing this content gave the following reasons: Informant #14 I don't see professional issues as a building block course... my feeling is that professional issues should really just be a natural part of any nursing course... I think it is false to, in my mind, to make them separate courses. Informant #15 I think students are too busy learning what it is that's ex-pected of them, and how they're going to do it and do it safely, to have the energy or the time to look at professional issues. 101 C o m m u n i c a t i o n W i t h T h e P u b l i c C o m m u n i c a t i o n w i t h the publ ic was also a subcategory of professional reasons. In-fo rmants descr ibed the impor tance of being able to c o m m u n i c a t e effectively in various contexts . Interviewer Informant # 1 Informant # 6 W h y do they need to know about publ ic speaking? It probably would not hurt a good number of s tudents w h o are very very shy and have great re luctance to speak in f ront of a class to develop some skil ls in speaking. . . I th ink i t 's someth ing that we need if we want to have people that are able to art iculate themselves well whether t o their supervisors or to outs ide groups or to the government . P u b l i c speaking . I th ink it would help those nurses w h o go on into management and admin is t rat ive posi t ions how to c o m m u n i c a t e at board meetings. In summary, the status of the profession, enhancement of the profession's sel f - image, and the need for effective c o m m u n i c a t i o n w i t h the publ ic compr ised seven percent of all the reasons. A s to what professional issues are impor tant , there was variety in response. Other Reasons Reasons wh ich d id not f it any of the other categories were referred to as 'other ' . These (n = 530) were offered by in formants fourteen percent (14 .15%) of the t ime . Included here were in formants w h o ta lked around i tems but d idn ' t express either a decision or a reason. T h e y wou ld say, " I don ' t know why I th ink this is impor tan t . . . " , or else " i t ' s c r i t i c a l . . . " or " th is is so impor tan t . . . " , but would not go on to say why. Somet imes even when the in formants were pressed to come up w i th a reason for their choices they st i l l were unable to do so. T h e y d idn ' t seem to know why someth ing was impor tant . Interviewer Informant # 6 Informant # 2 Interviewer Informant # 2 Interviewer C o u l d you say why you chose these? " A p p l y i n g research f indings to improve nurs ing care," I th ink they would be do ing that au tomat ica l l y anyways. " P a r t i c i p a t i n g in nursing research" - ! wou ld expect t h e m to do that . " C o n d u c t i n g pat ient care conferences," I wou ld expect them to do that as wel l . P robab ly most of these. I don ' t know what I'm saying. Neither do I. M a y b e we should take that off as my first choice. W h y did I choose these others? We l l I guess out of all of these, tha t ' s what I wou ld say wou ld be the most impor tant to include out of the whole stack. Professional Issues? 102 Informant # 2 Related to nursing, related to health. Interviewer But you're not sure why? Informant # 2 I guess so. I'm not exactly sure why. It sticks out in my mind as being more important than some of the others and it also ties in alot of the others. In summary, this category includes those informants who did not give reasons. They said, "it's critical" or "this is so important," but did not go on to explain why, and those who proffered "I don't know why I think this is important". This category was offered fourteen percent of the time. Basic Preparation for an R.N.: Baccalaureate or Diploma The last part of this chapter deals with the last two questions asked of all informants: "What do you think should be the basic preparation for beginning R.N.'s?" and "How long do you think that preparation should be (in months)?" They were then asked to give a reason or reasons for their opinions. There were widely divergent views on these questions. Most educators (nineteen) were supportive of baccalaureate preparation with four aca-demic years (thirty-two months) as the requirement. Eight felt supportive of the R.N. diploma program; of those, two mentioned a career ladder program, where the student could upgrade from a practical nurse through higher preparation. Six were unwilling to commit themselves to one type of preparation for beginning nurses. Twenty-one infor-mants wanted to lengthen the present program to thirty-two months, one informant to thirty-six months, another to forty-four months and ten wanted the program to remain the same in length or would not specify the length. Of those ten, three would not give a specified length of time, stating that it was dependent on the type of students entering into the program and their previous educational preparation. In this group of ten informants, five were teaching in baccalaureate programs, three in college programs and two in hospital programs. 103 TABLE 5-3 Support for Type of Program RIM Diploma University Unwilling Program Program To Say Frequency 8 19 6 of Choice TABLE 5-4 Support for Length of Program Frequency of choice Lengthen to 32 months 21 Lengthen to 36 months 1 Lengthen to 44 months 1 Stay the same 8 No opinion on length 2 TOTAL 33 Support for Diploma Nursing Programs. A total of eight were supportive of diploma programs although some wanted more research on which program was actually better. Their support for diploma programs was related to perceived changed that advanced education might bring. For example, it was thought that nurses who had degrees would not want to work in the hospital because of limited decision making. The following examples are illustrative of the responses supportive of diploma nursing programs: Interviewer What should be the basic preparation for a beginning nurse? Informant #15 Contrary to what most of my peers feel, I think the basic preparation should be diploma level. I think at the diploma level students learn — the nurses learn to give safe, indi-vidual nursing care and then after they've had some ex-perience, maybe two years, depending on the student — one year may be enough — once they've had that experi-ence, then to go on and get the post basic, to get the de-gree because that's when they have some knowledge base, some understanding — a better base on which to apply 104 Interviewer Informant #15 Informant #19 the theories that they're going to be learning in the higher education...How long should it take to educate a beginning R.N.7...I think it's being done and it's being done quite efficiently in two years. Two academic years or ten months or twelve months or what? Twenty-two, twenty-four months. The other problem with it is that it [a degree program] has not been proven how it will actually help them given a situation in a general hospital...Nurses with their degrees working in a general hospital...they stay there for a period of time and then they are going to go elsewhere because there's very little ability really to make decisions. They can make decisions but they always have to be checked with the doctor. Support for Baccalaureate Nursing Programs Informants (a total of nineteen) in each type of institution were supportive of baccalau-reate nursing education, and four academic years of preparation; the highest percentage of educators supportive of the baccalaureate were for the univerity program. They believed it would help promote the profession, put the nurse on the same level as other health profes-sionals in the hospital and result in their being more respected. Examples of three reasons given to support the baccalaureate follow. First, there was the credibility of the profession. Interviewer What should be the basic preparation for a beginning nurse? Informant # 7 I do think its' a good idea for the BSN because it expands your knowledge about research, about reading in different ways than you would get in a diploma program, and because I think it gives the profession credibility. I think we've got the most responsible jobs, next to the doctor, in the hospi-tal and the least amount of education, and they just don't fit together. However, I don't feel that it has to be done at a university. A second reason for the baccalaureate was the perceived explosion of knowledge relevant to nursing. These informants thought it would take four years to cover all the necessary content. Informant #23 I would have baccalaureate as entry to practice. Interviewer And your reason? Informant #23 There's such a terrific knowledge explosion for one — that about every two to three years you're acquiring new in-formation — and I think that to deal with the complex problems that are facing nurses. I think a baccalaureate gives you the best foundation for that. Interviewer So you're saying a baccalaureate would help with the knowl-edge explosion that there is. 105 Informant # 2 3 I th ink it helps them to prepare to deal w i t h knowledge. It gives them an oppor tun i ty for a style of th ink ing , for approach ing problems, and i t 's not just to acquire a bunch of in format ion , pound facts into people 's heads but to — an oppor tun i ty to learn a manner of acqu i r ing in format ion and apply ing in format ion . A th i rd reason given for the baccalaureate related to the complex i ty of the job and the belief that nurses had more responsibi l i ty in their work than other health care workers. Informant # 1 6 T h e basic preparat ion for a nurse, I strongly believe, should be a baccalaureate in the future because I believe that the complex i ty and the seriousness of the j ob a nurse does re-quires more indepth educat iona l preparat ion in order to be able to handle a job tha t ' s cont inued to escalate, and when you compare us to other professionals such as phys iothera -pists, d iet ic ians, all of t h e m have baccalaureate preparat ion and our job is no less serious. A s a matter of fact , I wou ld argue that i t 's more serious than what they do. However, some saw the government 's lack of fund ing as a barrier to baccalaureate preparat ion. Interviewer Informant # 2 6 Interviewer Informant # 2 6 W h a t should be the basic preparat ion for a beginn ing nurse? W e l l , it wou ld be wonderful if it cou ld be baccalaureate but I just th ink there are t o o many constra ints in that ever happening — the biggest being who is go ing t o f inance th is? A n d when you look at this province and that the number of nurses it produces each year is a th i rd or less of the needs per year. I don ' t see th is provincia l government cough ing up w i th the funds that are required to educate even that th i rd of what ' s required for the baccalaureate level. So a l though I th ink the basic preparat ion should be baccalaureate, I don ' t have m u c h hope that it wi l l be. A n d i t 's most ly because of economic reasons? Yes, most ly economic . Di f f iculty in Dec id ing A few in formants seemed to have di f f iculty c o m m i t t i n g themselves to either one or the other stance. O n e in formant said "I just hope I'm not go ing to be an educator by the year 2000 . " Informant # 1 3 Interviewer Informant # 1 3 I'm look ing at the R . N . as the basic preparat ion but I guess I'm a bit s i t t ing on the fence. T h a t ' s O . K . Because I know that we're a im ing towards baccalaureate as entry to practise but I st i l l don ' t th ink — I'm not all that conv inced that i t 's the best route to go and i t 's perhaps because I th ink there are spots in between. Interviewer How long should it take to educate the beginn ing nurse and what should be the preparat ion? 106 Informant #22 I'm not going to say how long. I refuse to answer that. I really think you can define your terminal objectives and I think it depends on who you are getting into your program, and I don't think you can say that because it depends very much on your objectives and the person you have in the program. Informant #33 But I'm also thinking in terms of there's a split, there's a division very clearly, diploma and baccalaureate, and so what should be the basic preparation for a nurse? There shouldn't be this division. That's what I want to say. If it's diploma, fine, if it's baccalaureate, fine, but there shouldn't be the division. Length of the Program Twenty-one informants wanted to lengthen the program in which they were teaching. The proposed extension varied from two months to a year. For example, whether the present program was twenty-four months or thirty-two months, informants would suggest that an additional two to twelve months would be an improvement. How long should that preparation be? O.K. Probably I would say two years plus another six or nine months. Somewhere along those lines. I think they should tack on another eight months, so thirty-two months. It's hard to know where to draw the line. So I would say you probably need twenty to twenty six months roughly. There's nothing magical about twenty-four, and that preferably should be over a three year period, rather than eleven months a year. The minimum would be thirty-two months. I personally believe that I would like to add a summer program, so probably add on four months to that, so thirty-six months because they need some sort of practical experience which is separate from the university. In summary, when asked about the length and type of educational preparation for nursing education, informants held divergent views. While there was a group of strong supporters for baccalaureate education and four years of preparation, there were also three other groups: those who supported the diploma R.N., those who wanted both and those who wouldn't discuss the issue. Interviewer Informant #28 Informant #20 Informant #16 Informant # 9 107 Discussion of the Findings It is interesting that some informants had difficulty deciding on the selection of course content, clinical areas and objectives. It may be that this reflects, in part, a lack of autonomy in the workplace which affects their ability to feel comfortable making curricular decisions. When presented with a reduced list of options, educators had difficulty keeping the choices to five, sometimes they asked for ten or even wanted to keep all the options. Perhaps this difficulty was due to the perceived role complexity of the nurse; as a consequence, five choices were not seen to cover all the needed curricular content. Sometimes informants, having selected an item, were unable to proffer a reason. Per-haps in the past they had not often been asked to publicly defend their curricular choices. Another explanation may be that the taped interview pressured them to give an immediate response. If more time for thoughtful consideration had occurred, informants might have been able to provide a more thorough justification. It also appears that educators were not as informed about some of the course content or clinical areas as they needed to be in order to make decisions about the selection or rejection of those items. Frequently during the interviews, informants would ask for an explanation of course content labelled, for example, "inorganic chemistry." This lack of information may result in different interpretations about the importance of such course content. It became apparent that different interpretations were given especially to course content labelled professional issues, biochemistry, sociology and anthropology. What one educator described as anthropology, another identified as sociology course content and so on. This is not surprising as labels given to course content such as sociology may sometimes be vague and may actually have been quite different in the educators' university or college preparation. These differences could be attributed, in part, to a professor's area of interest or expertise. It was also not surprising to discover the types of reasons that informants gave. For example, it was expected that educational reasons would be most frequently cited because the informants were all educators. It was also expected that reasons related to the in-stitution should be frequently cited since most students upon graduation are employed in hospitals. Educators, on the whole, gave more importance to institutional expectations than to professional, traditional and client reasons (Table 5-2). However, the low percentage of client reasons was unexpected if it is assumed that a primary purpose in educating nursing 108 students is to assist clients. Professional reasons were provided only 6 % of the time. It is not easy to determine the cause for this low percentage. It might seem that some educators are not interested in professional advances; however, it is more likely that they are so busy ensuring that students receive an adequate education that they may have not focussed on broader professional issues. Professional reasons were important, however, to educators from university settings. They cited professional reasons more often than others. Perhaps they are most interested in promoting the image of nursing and advancing the profession. In contrast, institutional reasons were more frequently cited by college/institute informants who may be concerned about keeping their programs marketable and the class seats full to guarantee continued funding. It is not surprising, however, that educators located in hospital settings were not as concerned about institutional reasons. Students in hospital programs quickly learn the rules of the institution because they are located in the workplace and provide hours of service. Educators here know that their graduates will likely be acceptable to the hospital simply because they have spent time learning to be acceptable. Educators located in hospital settings cited educational, traditional and other reasons most often. Their interest was with ensuring that the student had an adequate theoretical base to complement the practical service requirement of the institution. Because they are working in a more traditional program, their traditional views of nursing education may be more obvious and endorsed without question. However, why hospital educators chose 'other' reasons more frequently is not obvious. One can only speculate that they may believe that the past education they received is still the most relevant and, therefore, may not need to be questionned. The issue of the type and length of preparation was one which was not resolved. Most would like to see a longer program. This perceived need is not too surprising. It seems that educators frequently add new course content while rarely deleting it from a program of studies. However, if the program could be lengthened, there was not agreement about what that length should be. There was added controversy about the type of program. Some educators were quite adamant about the need for the baccalaureate, others preferred the diploma, still others 109 were undecided. Reasons that in formants gave for want ing a baccalaureate as the min ima l educat iona l qua l i f icat ion were related to the complex i ty of the job , the perceived knowledge explos ion , and credibi l i ty of the profession. Those w h o favored the d ip loma program wanted more evidence that the baccalaureate program wou ld actual ly improve nursing pract ice. Moreover , there was concern that nurses wou ld not be content to spend a large percentage of their t ime at the cl ients ' bedside when their educat ion had equ ipped t h e m to do more th ings . S u m m a r y Th i r t y - t h ree in formants were asked to select and rank object ives, course content and c l in ica l areas and provide reasons for their select ion. S o m e of the in formants had di f f i -cu l ty se lect ing , rank ing and g iv ing reasons, whereas others appeared to have no diff iculty. Reasons presented were classif ied by the researcher into six categories: educat iona l , i ns t i tu -t iona l , c l ient , t rad i t iona l , professional and other. Educat iona l reasons were c i ted the most f requent ly and professional reasons the least. It appears that , in general , educators need to spend more t ime just i fy ing curr icular decisions. There were divergent views a m o n g educators regarding the type of program most suited for basic nursing educat ion . S o m e supported the baccalaureate a n d / o r the R . N . d ip loma , and others were undecided. Chapte r S ix wi l l discuss the f indings in l ight of the stake of each stakeholder and the uses of schoo l ing . Further , the chapter gives recommendat ions for basic nursing educat ion programs. 110 C H A P T E R S IX Interpretation of the F indings and Recommendat ions Chapters four and five presented the f indings f rom the quest ionnaire and interview. T h i s chapter discusses these f indings. Pr ior to this discussion an out l ine of l imi tat ions to the s tudy is presented. T h e chapter is organized under headings that relate to the stake of stakeholders, B roudy ' s account of the uses of schoo l ing , and recommendat ions for basic nurs ing educat ion w i th in Br i t ish C o l u m b i a . L imi ta t ions of the S tudy T h e fo l lowing l imi tat ions apply to this study: 1. T h e f ind ings of th is study are restr icted to the popu lat ion under study. Genera l i za -t ions to other popu lat ions should be appl ied w i th caut ion , especial ly w i th reference to the ministry and the R . N . A . B . C . N o C l a i m s are impl ied herein that the views of those surveyed groups express the off icial v iew of any fo rmal stakeholder o rgan iza -t i on . 2. S ince the major ity of the subjects had only one form of c o m m u n i c a t i o n between themselves and the invest igator ( i .e., a letter a c c o m p a n y i n g the instrument and a set of instruct ions for comp le t ing the inst rument ) , their understand ing of the i tems may have var ied. 3. Information was not obta ined w i th regard to the amount of experience that each subject had w i th beginning pract i t ioners f rom each type of nursing educat iona l programs. T h e amount of contact or lack of contact cou ld possibly inf luence their percept ions. 4. T h e quest ionnaire d id not determine whether c l in ica l areas selected as "needed" were needed as an observat ional experience or for actua l nurs ing pract ice. 5. T h e quest ionnaire did not determine the subject 's percept ion of the amount of course content needed for basic nursing educat ion . T h e Stakes of Stakeholders O n e way of interpret ing the f indings f rom the quest ionnaire is to understand each group 's stakes as mani fested in their selection of course content , c l in ica l areas and objectives I l l for basic nurs ing e d u c a t i o n * . T h a t such stakes exist is supported by S h a n t z (1985) who ident i f ied impor tant stakeholders and their stakes in nursing educat ion . W h i l e predominant stakes of stakeholders are inferred; the accounts drawn f rom th is study do not negate the fact that stakeholders at t imes were inconsistent in their rat ings, given what appeared to be their p redominant stakes. For example , the R . N . A . B . C . had the highest overal l rat ing on object ives related to professional act iv i t ies, yet the course content labelled "professional issues" was rated higher by educators . S imi la r discrepancies can be found w i th in other groups. Rather t h a n identify discrepancies found w i th in each group, this sect ion outl ines w h a t appear to be the major stakes revealed in the rat ings proffered. Stakes of Admin i s t ra to rs T h e typ ica l admin is t rator 's stake is related to the maintenance of the inst i tu t ion . S u p -port for this stake is shown by the fact that their rat ings were higher than any other group on seventeen c l in ica l areas found in hospita l sett ings (burn unit , coronary intensive care, emergency, operat ing room, labor and delivery, surgical recovery r o o m , medica l intensive care, newborn intensive care, surgical intensive care, pediatr ic intensive care, dermatology, gynecology, labor and delivery, or thopedics , ophthamology , radiology and uro logy) (Tables 4 -22 , 4 -24 ) . It wou ld seem that they prefer graduates who are experienced in a variety of c l in ica l areas. A n d j u d g i n g by their rat ing of a specia l ized area such as cr i t ica l care, they might prefer new employees capable of work ing in such areas that are chronical ly short -staffed. Hav ing qual i f ied staff could decrease the need for extensive and cost ly inservice or ientat ion programs. A l s o related to the inst i tut iona l stake are rat ings assigned to the category "responds to emergencies" (Tab le 4 -9 ) . Presumably , admin ist rators seem interested in potent ia l employ -ees w h o are able to handle emergencies because this represents an "on the j ob expecta t ion . " Admin i s t ra to rs are managers. A s managers, they seem central ly interested in staff w h o wi l l cooperate w i th in ward routines and hospita l regulat ions, know how the various levels of admin is t ra t ion func t ion , have harmonious work relations and help col leagues in staff shortages. T h i s fac i l i tates a smooth ly run organ izat ion . T h u s it cou ld be expected that the fo l lowing six object ives would be rated higher by admin ist rators than by any other group: "ef f ic ient ly provides care for a group of 4 -6 c l ients ; " "delegates care to staff accord ing * For the purposes of data col lect ion basic nursing educat ion is conf ined to a beginning registered nurse in a hospita l set t ing . 112 t o their ab i l i t ies ;" "teaches correct pr inciples, procedures and techniques to other staff;" "supervises and checks the work of staff for w h o m responsible;" "are punctua l for work;" and "assists in in i t ia t ing planned change." In m a n a g i n g an o rgan izat ion , admin ist rators wou ld have a stake in m a k i n g sure that legal problems are m in im i zed . In the case of law suits, many indiv iduals , inc lud ing the admin is t ra tors themselves, can be held l iable for pat ient care. C l ient safety and accurate d o c u m e n t a t i o n of cl ient care are impor tant in l ight of the increased number of law suits in health care (Rozovsky 1980, p. 129). In th is respect, admin ist rators gave the highest rat ings to such i tems as: "ensures that the correct med icat ion is g iven" and "transcr ibes or records in format ion on charts, Kardex , or other in format ion sys tem. " Stakes of Educators Educators too , seem to have a stake in cl ient safety. Just as admin is t rators can be held l iable for malpract ice , so can educators a long w i th their current students ; therefore, they wou ld be interested in m i n i m i z i n g the chances of student error and potent ia l legal problems. It is in the interest of educators that students are competent enough to enter the workplace, and that students engage in only those act iv i t ies wh ich are part of the nurses' role. T h i s stance is supported by the high rat ings given by educators to objectives related t o cl ient safety and to legal aspects of nursing (protects pat ient f rom fal ls; ensures a safe env i ronment for pat ients ; supervises pat ient act iv i t ies ; performs tasks w i th in legal l imi ts ; recognizes and reports errors; and monitors t reatments given) . It appears that educators may have a stake in protect ing the student . T h i s stake may be t raced to t imes when hospitals explo i ted student services in exchange for a nurses' t ra in ing p rogram. For example , the 1932 We i r report stated that students were used excessively for service by hospi ta l admin ist rators . Even though this exp lo i tat ion has d imin ished as e d u c a -tors have gained cont ro l of student courses and c l in ica l experiences there may be a sense on the part of educators to protect students f rom the perceived demands of admin ist rators and physic ians. A n o t h e r way to protect the student might be to l imit the number of c l in ica l experiences. T h i s may, in fact , expla in why educators had lower ratings than any other group on fourteen c l in ica l areas. By l im i t ing student learning to those sett ings direct ly under the educator 's con t ro l , there may be less chance of interference f rom other groups. Ano the r explanat ion may be that educators , more than other groups, recognize the l imits on a s tudent 's t ime. A 113 f inal exp lanat ion is that the educators might be most interested in hav ing students prepared as a general ist . Except for the lower rat ings of c l in ica l areas, it appears that educators have a stake in m a i n t a i n i n g the status quo of their work. Items wh ich are presently inc luded in a nursing educat ion cu r r icu lum — for example , the nursing process, g rowth and development , nursing care plans, se l f -d i rected study, cl ient assessment, and cl ient conferences — were given highest rat ings. The i r choices in both the quest ionnaire and interviews reflect their current place of employment . First , (Tab le 6-1) the quest ionnaire reveals that educators teach ing in hospi ta l programs rated the special ized c l in ica l areas higher than other educators (burn unit , coronary intensive care, emergency, medica l intensive care, surgical intensive care, operat ing r o o m and labor and del ivery) ; in hospi ta l based programs, nursing students actual ly spend more t ime in these c l in ica l sett ings than in other types of programs. Second , the quest ionnaire reveled that educators teach ing in a university set t ing rated highly those c l in ica l areas wh ich had a c o m m u n i t y focus: outpat ients , publ ic heal th , menta l heal th , nursery schoo l , home care and industr ia l nursing. Here again , students in univer-sity programs spend more t ime in c o m m u n i t y agencies than do students in other nursing programs. T h i s may account for the higher rat ings assigned by university educators to c o m -muni ty heal th . University educators also rated course content "research methods , " and the object ive, "appl ies research f indings to improve care" higher than the hospi ta l or col lege educators . T h e fact that university educators are often involved in c o n d u c t i n g research may account for their higher rat ings of these areas (Tables 6-2, and 6-3) . T h i r d , the quest ionnaire revealed that educators teach ing in a col lege-based program rated general medic ine , general surgery, and urology higher than d id the other two types of educators . In the current curr icu la in college programs, nursing students spend the greatest proport ion of their c l in ica l experience on general med ica l -surg ica l wards in hospita l sett ings. T h i s may account for the higher rat ings assigned by college educators to general c l in ical areas. Nurse educators , in general , seem interested in computers , as mani fested by high ratings in the quest ionnaires and interviews. S o m e interviewees believed that hospitals wi l l be more compute r i zed in the next decade. There is already an increased demand on them for compute r l iteracy. T h e y are current ly requested to enter exam questions and student scores in the computer , and use mul t ip le choice exams for computer i zed mark ing . Such 114 expectat ions for computer l i teracy may be transferred to their students who wi l l be future compute r users in hospitals . T h a t educators rated teach ing act iv i t ies higher than other groups is understandable. T h e y are al l educators and, as such , their act iv i t ies are main ly related to teach ing . Thus , it is not surpr is ing that al l objectives descr ib ing teach ing act iv i t ies (e.g. teach ing the cl ient and family , ensur ing that inst ruct ion was understood) were given priority. Unl ike admin ist rators , they had the lowest rat ings for the abi l i ty of nurses to assume a leadership role or to take the correct act ion in emergencies. Educators may believe that it is unreal ist ic t o expect a new graduate to cope w i th emergencies. T h i s achievement may come w i t h add i t iona l experience on the job or cont inued educat ion . Table 6-1 Clinical Areas Compared by Type of Educator Group 1 College Educator n=22 Group 2 Hospital Educator n=5 Group 3 University Educator n=6 Fvalue Groups Significantly Different Clinical Areas X X X 1 1 vs vs 2 3 2 vs 3 Burn Unit 1.70 2.94 1.63 8.17* X X Cornary ICU 1.86 3.35 2.00 7.79* X X Clinical Research 1.80 3.30 1.95 9.27* X X Emergency 2.90 4.65 3.09 7.05* X X Extended Care 6.20 5.65 6.65 4.04* X Home Care 3.65 5.45 5.96 22.04* X X Industrial Nursing 1.93 2.47 2.96 4.98* X Labor and Deliver 5.23 6.45 6.24 6.10* X X General Medical 7.00 7.00 6.92 4.86* X Medical ICU 2.72 4.55 2.65 8.27* X X Mental Health 3.98 5.05 5.48 6.75* X Nursery School 2.35 2.95 3.50 3.88* X Surgical ICU 2.54 4.55 2.50 9.85* X X Operating Room 3.55 4.65 3.00 3.78* X Orthopedics 5.84 5.85 4.88 4.27* X Outpatients 3.91 5.20 6.04 16.52* X X Psychiatry 5.77 6.55 6.73 4.83* X Public Health 3.16 5.25 5.39 18.61* X X Rehabitation 5.28 5.15 6.33 5.08* X X General Surgery 6.99 6.85 6.92 4.82* X Urology 5.30 5.20 3.71 8.19* X X TOTAL 83.66 103.06 94.53 MEAN and RANK 3.98 3 4.91 1 4.51 2 * significant beyond the 0.05 level of significance. only those clinical areas with significant disagreement are show in this table. 115 Table 6-2 Objectives Compared by Type of Educator * * Group 1 College Educator n=22 Objectives X Helps patient recognize and 6.31 deal with psychological stress. Observes and correctly assesses 6.59 signs of anxiety or stress. Delegates care within legal limits 5.93 to the nursing staff according to their abilities. Applies research findings to 4.12 improve nursing nursing care. Efficiently provides care to 6.78 to a group of 4-6 clients. TOTAL 29.73 MEAN and RANK 5.95 Group 2 Hospital Educator n=5 X 6.35 6.25 4.72 4.75 5.70 27.77 5.55 Group 3 University Educator n=6 x 6.77 6.92 5.69 5.92 5.83 31.13 6.23 Fvalue 2.86* 5.26* 5.09* 9.79* 15.34* Groups Significantly Different 1 vs 2 1 vs 3 X X 2 vs 3 * significant beyond the 0.05 level of significance. * * only those objectives with significant educator disagreement are shown. Table 6-3 Course Content Compared by Type of Educator * * Group 1 College Educator n=22 Group 2 Hospital Educator n=5 Group 3 University Educator n=6 Fvalue Groups Significantly Different Course Content X X X 1 1 vs vs 2 3 2 vs 3 Algebra 3.38 4.75 3.50 3.25* X Anatomy 6.93 6.95 6.19 11.96* X X Anthropology 3.75 2.95 5.00 8.35* X X Biology 6.28 5.95 5.17 4.21* X Communication 7.00 6.95 7.00 3.40* X Epidemiology 4.79 5.05 6.04 6.62* X History of Nursing 5.05 6.05 6.04 6.62* X X Pharmacology 6.87 6.95 6.58 3.63* X Physics 3.00 2.39 3.80 3.31* X Research Methods 3.18 4.68 5.31 16.97* X X TOTAL 50.23 52.67 54.63 MEAN and RANK 5.02 3 5.27 2 5.46 1 * significant beyond the 0.05 level of significance. * * only those course content areas with significant educator disagreement are shown. 116 Stakes of the R . N . A . B . C . Educators seem t o prefer a longer program for nurses than several groups - but not as long as that proposed by representatives of the R . N . A . B . C . T h e R . N . A . B . C . had the highest expectat ions regarding the type and the length of preparat ion for basic nursing educat ion . Nearly 9 0 % (88 .9%) of t h e m chose the B . S . N , and over two th i rds chose four years as the length for that preparat ion. A longer program could result in nurses having more in fo rmat ion , better credentials and, possibly, greater professional power. Greater professional power is a stake wh ich seems to be central t o the R . N . A . B . C . The i r high rat ings for those objectives wh ich deal w i t h p romot ing the profession (e.g. , "accepts responsibi l i ty for developing and promotes the profession w i th in a chang ing soc ie ty " ) could be related to increasing the prestige of nurs ing. Prest ige in professions may be associated w i th knowledge and research wh ich can i m -prove gives academic status and autonomy. It is l i tt le wonder then , that those objectives and course content rated most highly by the R . N . A . B . C . were related to research (e.g., "appl ies research f indings to improve nurs ing care," "part ic ipates in nurs ing research," and course content "research m e t h o d s " ) . The i r high rat ings of nursing theory course content and objectives (e.g. , "demonstrates knowledge of a nurs ing model when assessing cl ients and prov id ing nurs ing care" ) (Tables 1-23, A p p e n d i x E) is perhaps related to a need for a c o m m o n and recognized theory base upon wh ich t o base pract ice. T h i s theory base cou ld assist in the development of research and the g rowth of nursing as a c l in ica l science, wh ich might increase professional recogni t ion . T h e a im of improved professional recognit ion may also be demonst rated by their high rat ings given to objectives wh ich relate to shar ing in format ion about the cl ient , and to co l laborat ing w i t h physicians and w i th staff f r om other departments . Co l labora t ion may strengthen their recogni t ion of the nursing profession by these groups. Not only does the R . N . A . B . C . want co l laborat ion , but the high rat ing given to course content "nurs ing leadership" identif ies their interest in nurses becoming recognized, thereby increasing their professional status. T h i s interest in leadership might expla in the highest rat ings given t o course content "po l i t ica l science" and "pub l ic speak ing , " presumably to as-sist nurses in becoming both more pol i t ica l ly aware and better able to ar t icu late professional needs when deal ing w i t h other groups or lobby ing w i t h government agencies. A n o t h e r area of interest to the R . N . A . B . C . is qual i ty cl ient care. T h e y had high ratings 117 (above 6.50) for objectives such as "checks that correct med icat ion is given to the right c l i e n t " , "checks for effects of t r ea tment " , and med icat ion . Stakes of Phys ic ians Whereas the R . N . A . B . C . responses reveal an inc l inat ion to increase the role of nurses in med ica l decisions, it is not surpr is ing to f ind that physicians seem incl ined to ma in ta in the status quo w i t h respect to medica l decisions. A t present, nurses appear to have a secondary role, accord ing to some a handmaiden role, in wh ich physicians wou ld like nurses to be more subservient ( M u f f 1982, p. 120) . T h a t physicians are predisposed against change in these role relat ionships could be ind icated , in part, by their assigning the lowest overal l ratings for f i f ty - f ive of e ighty - three objectives, fourteen of th i r ty -e ight c l in ica l areas, and th i r ty -one of forty - f ive course content areas (Tables 1-23, A p p e n d i x E) , and lower rat ings for the type and length of preparat ion than any other group. S o m e of their lower rat ings may be at t r ibuted to their stake in reta in ing the legal author i ty in medica l decis ion mak ing . T h i s may be revealed by g iv ing lower rat ings than any other group on "quest ions orders and decisions by medica l and other professional staff" and "is self d i rected . . . " or lower ratings than any other group given to objectives related to nurses being able to assess c l ient 's learning needs, to provide health care inst ruct ion , to obta in in format ion f rom the family, to discuss t reatment regimes w i t h the c l ient 's family, to have the nurse act as a cl ient advocate , or to have the nurse use c o m m u n i t y resources to help the cl ient resolve dif f icult ies. Rat ings were at t imes as high or higher than any other groups on three objectives ( " takes instant , correct act ion in an emergency s i tua t ion , " "ma in ta ins c a l m and efficient approach under pressure," and "assumes leadership role in crisis s i tuat ion when necessary") and three cr i t ica l care areas (coronary intensive care, emergency, medica l intensive care). P resumab ly they might prefer nurses to funct ion well in cr i t ica l care areas and in emergencies w i thou t needing extensive higher level educat iona l preparat ion. Perhaps their interest is one of hav ing a helpful assistant , able and ready to carry out orders. A l t h o u g h physicians did not have the highest ratings for objectives related to client care, thei r rat ings of objectives such as, "keeps cl ient clean and comfor tab le , " "protects c l ient 's s k i n , " "checks that correct cl ient is given the correct med ica t ion" and "exchanges in fo rmat ion w i t h medica l staff" were a lmost as high as other groups. S u c h rat ings reveal that physic ians a long w i th the other groups seem to have a pr imary interest in well cared 118 for c l ients and being informed about cl ient care. F rom some of the c o m m e n t s found in A p p e n d i x B such as "I have no knowledge of th i s " or " insuff icent contact w i th nurse to k n o w " , it appears that some physicians did not really have an op in ion on what should be conta ined in a program of studies. Perhaps their stake in nurs ing educat ion is not as s t rong as one might expect . Stakes of the M in is t ry T h e ministry had the lowest rat ings of all groups on eighteen object ives, two cl in ical areas and nine course content areas (Tables 1-23, A p p e n d i x E) and the second lowest rat ings on the preparat ion and the length for basic nursing educat ion . T h i s may reflect the min ist ry 's stake in protect ing publ ic fund ing . T h e y seem concerned w i th serving the needs of the pub l ic at m i n i m a l cost . Increased educat iona l requirements often result in increased costs for preservice preparat ion and may result in an increased salary for registered nurses. A second exp lanat ion for their lower rat ings could be occas ioned by a belief that the present roles of nurses seem appropr iate. Suppor t ive of this stance, of ma in ta in ing the status quo, is the observat ion that most of their rat ings of course content , c l in ica l areas and objectives did not vary to extremes. A th i rd exp lanat ion may be that their low ratings relate to their not being well in formed about what a nurs ing educat ion program does or should conta in . T h i s view cou ld be supported by the c o m m e n t s made by some ministry representatives ( A p p e n d i x B ) who admi t ted t o not being well in formed. T h e y had the highest rat ings for two objectives ("appl ies pr inciples of i n fect ion 'cont ro l " and "detects changes in a c l ient 's cond i t ion or s t a t u s " ) , eight c o m m u n i t y c l in ica l areas (e.g. , home care, menta l health , publ ic health , outpat ients , etc . ) and two course content areas (care of ill chi ldren and immuno logy ) . These rat ings seem commensura te w i t h an interest in p r o m o t i n g publ ic health . T h e min ist ry as well as other groups seem concerned about cl ient care. Object ives that related t o cl ient safety, (detects changes in cl ients, prevents in fect ion , mainta ins conf iden -t ial ity, admin isters med icat ion by correct route) and cl ient teach ing (prov id ing health care inst ruct ion ) were a lmost as high as other groups. S ince lower rat ings were assigned to such areas as professional act iv i t ies and nursing research, the ministry seems to be less concerned w i t h act iv i t ies that would promote professional ism in nursing. In summary, it appears that the predominant stakes of stakeholders are as fol lows. 119 Admin i s t ra to rs seem concerned about the needs of the inst i tu t ion , inc lud ing safe and qual i ty care for their cl ients and hav ing a smooth ly run organ izat ion . Educators appear to want to ma in ta in the status quo of the cu r r icu lum and protect the student . The i r interests might be l inked to their place of employment . For example, hosp i ta l -based educators seem more interested in specia l ized c l in ica l experiences for s t u -dents, univers i ty -based educators seem interested in advanc ing research, and col lege-based educators ' interest appears to rest w i th g iv ing the student a general educat ion . T h e R . N . A . B . C . ' s has a central concern for advanc ing nursing. T h i s concern includes prestige, educat ion , research and professional ism in relat ion to improved cl ient care. Phys ic ians are concerned w i th protect ing their doma in of medica l authority. Like others, they are interested in qual i ty cl ient care. T h e min ist ry 's stake seems to be related to protect ing publ ic fund ing . T h e y promote publ ic health and qual i ty cl ient care. There is agreement a m o n g stakeholder about the need for qual i ty pat ient care. Purposes of Schoo l i ng B roudy (1964, 1988) identif ies four purposes of publ ic schoo l ing : associat ive, rep l ica -t ive , interpretive and appl icat ive . Even though he does not d i rect ly refer to these four in terms of a hierarchy, his way of def in ing the terms suggests that appl icat ive use of s c h o o l -ing includes the interpretive, wh ich in tu rn includes the repl icat ive. There is no ind icat ion , however, of the p lacement of assoc ia t ive* uses in that hierarchy. T h e f irst use of schoo l ing is repl icative - where th ings are learned for those operat ions wh ich are f requent ly performed in a wide range of repetit ive s i tuat ions . T h i s use of schoo l ing is exempl i f ied in learning basic reading, wr i t i ng and mathemat ics , in the memor i za t ion of facts , in bak ing a cake, and in count ing a c l ient 's pulse. It is also the most reliable form of schoo l ing because it gives opportun i t ies to overlearn to the point of v i r tual ly f lawless per formance ( B r o u d y 1964, p. 49) . T h i s use of schoo l ing is central for the role learning of routines and ski l ls of a speci f iable nature. Broudy c o m m e n t s on the impor tance of this use of schoo l ing . * B roudy suggests that associat ive uses of schoo l ing are diff icult to understand because " too m u c h depends upon what , in the nature of the case, is highly id iosyncrat ic and uncont ro l lab le , " ( B r o u d y 1964, p. 48) . Because of this , only repl icat ive, interpretive and app l icat ive uses of schoo l ing are discussed in this study. 120 Without a large store of such rote learnings, we are in the position of foreigners ignorant of our own language and who depend on the dictionary for attempts to speak or understand it (1988, p. 13). Broudy's second use of schooling is the interpretive. One is taught to understand a situation and what is necessary to improve it, but may not have the actual ability to do so. For example, a nurse may know that a client needs surgery to stop the post operative hemorrhage but is unable to perform the surgery because of a lack of skill and authority. One actually understands the situation, even if the understanding fails to be implemented by appropriate procedures. The third use of schooling, applicative, is based in part on the replicative and interpretive uses of schooling. Application occurs when things learned are used to solve a problem or analyze an unusual, new or unique situation (Broudy 1964, p. 51). For example, a nurse who has mastered replicative skills and who understands the general principles of managing a person in shock from a bleeding ulcer, should be able to use that knowledge with a person experiencing shock from a post operative hemorrhage. If one is not able to do this, it likely means that he/she has only mastered replicative uses of schooling. Broudy says that applicative uses of schooling require both an understanding of principles and the mastering of procedures that can be replicated with skill. In other words, there are skills that need to be mastered in the care of a bleeding ulcer or a post operative hemorrhage; these skills are necessary but not sufficient to manage similar problems. What is also needed is the ability to apply the principles learned in the care of a person with a bleeding ulcer to a person experiencing shock from a post operative hemorrhage. Broudy says this use of schooling aims at the training of high-level specialists or professionals by combining the acquisition and interpretation of theory with decisions of practice (Broudy 1964, p. 59; 1988, p. 14). Broudy's analysis of uses of schooling is intended for public schooling. In referring to basic nursing education, Broudy's account will be transposed to the "uses of basic nursing education." In applying this framework to the views of stakeholders, there appears to be a predominant use of schooling attributable to each group of stakeholders. While the predominant view will be described most fully, this does not deny that stakeholders appeal to other uses of schooling. The following analysis outlines what appears to be a major focus for each group. 121 Phys ic ians ' Percept ions on Uses of Bas ic Nurs ing Educat ion It wou ld appear that physicians classify the basic use of educat ion by nurses as app l ica -t ive . Phys ic ians gave the highest rat ings to nurses being able to handle emergencies and highest rat ings to nurses needing to work in cr i t ica l care areas. Such rat ings assume that nurses have some repl icat ive skil ls, some interpretive ski l ls and appl icat ive ski l ls . J u d g i n g by their highest rat ings of objectives deal ing w i th emergencies it seems that physicians want nurses w h o can take correct act ion in emergencies and know when to involve physicians ( " takes instant , correct act ion in an emergency" or "assumes a leadership role in a c r is is" ) . W h i l e physicians want nurses to be able to handle emergencies and work in cr i t ical care areas, they are, however, inconsistent in their answers in th is c lass i f icat ion . T h i s is exempl i f ied by their rat ings of the type and the length of educat iona l preparat ion needed for basic nurs ing educat ion wh ich were rated the lowest of all groups. Add i t iona l ly , their overall rat ings regarding the need for objectives, course content and c l in ica l areas were lower than any other group. Because of these low ratings, they have also emphas ized the repl icat ive uses of basic nurs ing educat ion . A p icture emerges in wh ich physicians see the role of the nurses as carry ing out a speci f ic range of tasks, w i t h the abi l i ty to know when to cal l on physicians so that cl ients receive good care. The i r lower rat ings on objectives wh ich relate to nurses quest ion ing medica l orders, d iscussing t reatment w i th cl ients, or teach ing cl ients would identi fy their interest in reta in ing the legal author i ty over cl ients. M in i s t ry ' s Percept ions on Uses O f Bas ic Nurs ing Educat ion Like physic ians, the ministry wou ld also seem to emphasize appl icat ive abi l i t ies. H o w -ever, interpretat ion of their views is di f f icult because they often have neither the highest nor the lowest rat ings on many objectives, course content or c l in ica l areas. M in is t ry of-f ic ials want a nurse w h o can funct ion more in c o m m u n i t y health sett ings w i thout hav ing advanced educat ion . The i r emphasis appears to be more c l in ica l , rat ing eight c l in ica l areas highest, compared w i t h two objectives and two course content areas rated highest. Because they are sensit ive to the chron ic shortage of cr i t ica l care nurses and the need to promote publ ic heal th , it wou ld be natural that ministry off icials rate these areas higher. A focus in c o m m u n i t y health wou ld show the min istry 's regard for the use of basic nurs ing educat ion as app l icat ive , but the min ist ry 's selection of course content and objectives does not reflect a belief that nurses need schoo l ing in this way. 122 T h e min ist ry does not have high rat ings for support course content or in act iv i t ies that wou ld a l low nurses to make central medica l decisions; however, their rat ings were more neutral than other stakeholders. T h u s , it is dif f icult to get a clear p icture of the min ist ry 's views on what uses of schoo l ing they wou ld expect for nurses. Because of their generally lower expectat ions concern ing length and type of educat iona l preparat ion, se lect ion, and their expectat ions of nurses to work as special ists, there is cont rad ic t ion in the way they have emphas ized the uses of basic nursing educat ion . Educators ' Percept ions on Uses O f Bas ic Nurs ing Educat ion W h i l e physicians and the ministry appear to value repl icative and appl icat ive uses of basic nursing educat ion , educators seem to value uses wh ich a l low the student to develop a broader understand ing . T h i s perspective is essential ly interpretive. Educators had the h igh -est rat ings for those objectives wh ich require interpretive abi l i t ies (understand the rat ionale for nurs ing j udgments , assist the student in assessing general pat ient problems, and begin to become sel f -d i rected in learning) . Further, certain support course content areas were given highest rat ings by educators : c o m m u n i c a t i o n , general mathemat ics , immunology , and pathology. Equ ipped w i t h th is type of understanding , the student cou ld become prepared for the roles and responsibi l i t ies of a registered nurse. W h i l e interpret ive abi l i t ies are needed educators also seem to want nurses to have repl icat ive abi l i t ies because their rat ings were a lmost as high as admin ist rators for course content "nurs ing sk i l ls . " Admin is t ra to rs ' rat ing of "nurs ing ski l ls" was 6.98, compared w i t h educators ' rat ing of 6.96. Even though educators want interpretive and repl icative abi l i t ies, their higher rat ings of some c l in ica l areas, such as pos tpar tum, psychiatry, pediatr ics , and well baby nursery suggests some appl icat ive abi l i t ies are needed for basic nursing educat ion . However, their percept ion of the need for app l icat ive abi l i t ies is lower than others since they rated c l in ical areas lower than any other group. It seems then, that educators believe in the impor tance of prepar ing a general ist w h o can , w i t h add i t iona l educat ion and experience, begin to funct ion as a special ist in some area. 123 R. IM.A.B.C. 's Percept ions on Uses of Bas ic Nurs ing Educat ion T h e percept ions of the R . N . A . B . C . in relat ion to the uses of basic nursing educat ion also seem to be predominant ly interpretive. T h e y were highest in their rat ings of such items as anthropology, genetics, microbiology, pharmacology, physics, physiology, publ ic speaking, sociology, research methods , inorganic chemistry and po l i t ica l science. S u c h course content cou ld prepare students more generally. W h i l e the R . N . A . B . C . places major stress on interpretive abi l i t ies, like educators , their higher rat ings of some c l in ica l areas, such as pos tpa r tum, psychiatry, pediatr ics , and well baby nursery suggests that some appl icat ive abi l i t ies are needed for basic nurs ing educat ion . A l s o l ike educators , their lower ratings of some c l in ica l areas cou ld ind icate less preference for app l icat ive abi l i t ies than interpretive abi l i t ies. Not only does the R . N . A . B . C . prefer app l icat ive and interpret ive abi l i t ies, but there seems to be a need for repl icat ive abi l i t ies for basic nursing educat ion . For example , they rated course content "nurs ing ski l ls" highly as did other groups. Admin i s t ra to rs ' Percept ions on Uses O f Bas ic Nurs ing Educat ion W h i l e educators and the R . N . A . B . C . appear to value schoo l ing for interpretive abi l i t ies, admin is t rators seem to be more interested in special ists . T h e y most often gave a higher rat ing to al l those i tems wh ich were of a c l in ica l app l icat ion . For example , some of the specialty areas cal led "c r i t i ca l care" were rated highest by admin ist rators . A knowledge of specia l ty area requires appl icat ive abi l i t ies. Not only do admin ist rators seem to want appl icat ive abi l i t ies, they also support the need for repl icat ive abi l i t ies. Perhaps admin ist rators prefer nurses to have speci f ic ski l ls, as mani fested by the highest rat ings given by admin ist rators to course content "nurs ing sk i l ls . " Add i t iona l l y , admin ist rators seemingly favor interpretive abi l i t ies in their concept of basic nurs ing educat ion because they had higher rat ings than d id any other group for support course content areas such as biochemistry , f ine arts, organic chemistry, and philosophy. S u c h courses might assist nurses to develop interpretive abi l i t ies. T h u s , admin ist rators seem support ive of nurses hav ing interpretive, as repl icat ive and appl icat ive abi l i t ies. In summary, the major emphases wh ich appeared to stakeholders ' p redominate percep-t ions concern ing the uses of basic nursing educat ion were the fo l lowing : al l want nurses to have repl icat ive abi l i t ies. However, physicians, the ministry and admin ist rators appeared to 124 have more bias toward applicative uses of basic nursing education, than did educators and the R.N.A.B.C. who seemed to emphasize interpretive uses. It appears that physicians and the ministry want a less educated specialist than administrators do, and educators and the R.N.A.B.C. want a more broadly educated generalist. Recommendations for Basic Nursing Education Before turning to recommendations for basic nursing education, it is necessary to review the results of the questionnaire. The data in the questionnaire revealed areas of both agreement and disagreement among and within stakeholder groups. While there was general agreement about the need for most objectives and for nursing course content areas, there was disagreement on the need for particular support course content and clinical areas. Given the areas of agreement and disagreement, the recommendations suggested here will satisfy some stakeholder's wishes at the cost of denying those of others. But the recom-mendations made by the various stakeholders are not necessarily incompatible. The overlap suggests when analyzing the stakeholders' stakes and their views of the uses beginning nurses would make of their basic nursing education that the recommendations forthcoming may, in fact, acceptable to most stakeholders. What follows then, are recommendations for nursing education in British Columbia based on the writer's interpretation of what is practicable and compatible with stakeholders' choices and reasons. In making recommendations for any educational program, there will always be basic skills which are used replicatively. For instance, students learn how to take a patient's temperature, make a bed or change a wound dressing. The nurse is and has been required to perform such skills without error. While the procedure for performing a skill may change (e.g., mercury thermometers have been replaced by electronic sensing devices), there will always be skills a nurse will be required to perform. Thus it would seem fitting that some uses of basic nursing education are replicative. This use of schooling is also consistent with the views of the five groups in this study in that all groups' ratings of course content, objectives and clinical areas revealed the necessity of at least some replicative abilities. Furthermore, the R.N.A.B.C. has established a Task Committee on Nursing Skills to draft a list of skills and degrees of proficiency needed in the performance of these skills for nursing graduates (R .N .A .B .C . March/April 1988 p. 5). While graduate nurses need replicative abilities, Broudy shows that in most life circum-stances one needs to have more than replicative abilities. As Broudy points out, replicative 125 abi l i t ies are wor thwhi le as long as dai ly routines remain relatively constant (1988, p. 12) and that for nurses, repl icat ive uses are likely, in the long te rm, to be comple ted better if the nurse has a background wh ich enables h i m / h e r to use the ski l l into a variety of pract ical contexts . T o develop this background , B roudy argues that one also needs to develop interpretive abi l i t ies. He suggests that the best way to gain interpretive abi l i t ies is by undertak ing general studies (1988, p. 10). A n d , further he wou ld argue for the development of a cu r r i cu lum wh ich includes opt iona l general studies. T h i s type of cu r r i cu lum is seemingly suppor ted by admin ist rators , R . N . A . B . C . and educators because of their higher rat ings of support course content , such as organic chemistry, phi losophy, psychology, etc. W h i l e the need for repl icat ive and interpret ive abii ites seem, thus, to be supported by all groups (pp. 121 -124) , it also seems reasonable that the nurse have some appl icat ive abi l i t ies. T h i s need is revealed, to some extent , in the data , part icular ly those data in wh ich some respondent 's choices favor preparat ion in more specia l ized areas than what current ly exists in basic nurs ing educat ion . A t least three of the stakeholders groups appeared to agree — admin ist rators , ministry and physicians are in favor of select ing c l in ica l areas, wh ich might be considered as prepara-t ion for nurse spec ia l i s ts* . In preparing nursing special ists , it is clear that special ists do not s imply carry out repl icat ive abi l i t ies. It is also clear that whi le they must make interpretive uses of their basic nursing educat ion , they also are expected to solve problems or analyze an unusual , new or unique s i tuat ion ( B r o u d y 1964, p. 51). Further , in nursing, many specialt ies and subspecialt ies have developed. T h i s is, in part, due to advances over the past generat ion in technology and knowledge. M . J . M c G r a w (1988) , in a keynote address to educators in Br i t ish C o l u m b i a , c i ted for ty - three different specialt ies in wh ich nurses are work ing and, hospi ta l admin ist rators often hire new graduates to work on wards wh ich require a knowledge of some sub specialty. Accord ing ly , there appears t o be a need for nursing educat ion to prepare special ists at the basic level. * In using the t e r m special ist , the researcher means abi l it ies wh ich require a m i n i m u m of six to eight months of preparat ion. Because the specialt ies wh ich cou ld be considered for nurs ing are in d ispute, there is clearly need for research to determine the scope of nursing and nature of nurs ing specialt ies. 126 T h u s , any program appropr iate for basic nursing educat ion cou ld include elements in w h i c h the students wou ld acquire repl icat ive, interpretive and appl icat ive abi l i t ies. W h a t B r o u d y says about school curr icu la seems appl icable to basic nursing educat ion : S c h o o l i n g adequate for interpretat ion may not be suff icient for ap -p l ica t ion , whi le some appl icat ive knowledge may be too narrow for interpretive use. Interpretat ional use can be made precise by study, but it does not fo l low that it wi l l au tomat ica l l y shade into app l i ca -t ion (1988, pp. 13, 22). In us ing these categories the focus wi l l be directed first to objectives, then to course content and f inal ly t o c l in ica l areas for a basic nursing educat ion program. O u t of a possible e ighty - three objectives in the quest ionnaire, only nine objectives were rated as less than 5.5. T h u s , there is overal l agreement on seventy- four objectives a m o n g the stakeholders. Secondly, there are many th ings wh ich al l nurses need to know and should be able to do. It can be argued that the specialt ies should be built upon a c o m m o n core cur r icu lum for all basic nurs ing educat ion programs. T h e content for this cu r r icu lum might include those areas considered most needed by stakeholders: nursing skil ls, nurs ing theory, h u m a n needs, legal aspects of nurs ing, professional issues, nursing trends, medica l terminology, nursing leadership, physical assessment and nursing ethics. Hav ing out l ined possible nursing course content areas appropr iate to the p romot ion of the uses of basic nursing educat ion , the discussion wi l l now turn to considerat ion of a f ramework for the support course content . In the quest ionnaire there was overal l agree-ment (overal l mean of 5.5 or greater) on eleven support course content areas: anatomy, biology, c o m m u n i c a t i o n , Eng l ish , human growth and development , microbio logy, nut r i t ion , pathology, pharmacology, physiology, and psychology. These course content areas are all inc luded to a greater or lesser extent in the current Br i t ish C o l u m b i a nursing educat ion cur r icu la . However, also inc luded in the current B . C . curr icu la is course content not given rat ings greater than 5.5 (e.g. , socio logy and physical educat ion ) . Furthermore, there was b ipo lar i zat ion on twenty - three of forty - f ive course content areas. If b ipo lar i zat ion by educators is occur r ing on the support course content and some current ly used support course content is not considered to be needed, it seems to be more appropr iate t o give the student a choice of support course content . S u c h an argument is con f i rmed by Broudy ' s arguments about the need for general studies in educat iona l or voca t iona l programs. G iv ing students choices wou ld enable students to pursue their own areas of greatest 127 interest, and might increase self-directed behaviour. This design could also promote that particular use of schooling which the R.N.A.B .C. and educators seem to most favor - the interpretive use. The student could be presented with a list of options from the sciences and humanities from which he/she would select the a minimum number. For example, in the humanities the students could choose from the following: education, philosophy, anthropology, sociology, psychology, religion, political science, communication, literature, economics, and business administration. In the sciences students could select such things as chemistry, zoology, pharmacology, microbiology, computers, pathology, genetics, im-munology and statistics. Such a varied course selection would recognize the legitimacy of the divergent opinions among knowledgeable stakeholders. It would assist the student in attaining an interpretive background upon which a solid practice could be built. And the student offered such a variety of courses, would develop into somewhat of a generalist. Having outlined a framework in objectives and course content for basic nursing educa-tion, the discussion will be directed to clinical areas most suited to the three uses of basic nursing education. In the questionnaire, ten clinical areas received a rating of 5.5: extended care, gynecology, labor and delivery, general medicine, orthopedics, general surgery, pedi-atrics, postpartum, psychiatry, and well baby nursery. While there is agreement on these ten clinical areas, there was significant disagreement on twenty-seven of the thirty-eight clinical areas and bipolarization of opinion on twenty-nine clinical areas. Furthermore, there was considerable disagreement among educators on the need for particular clinical areas for basic nursing education. In considering the disagreements and agreements, it seems most sensible to have a nurse begin to learn nursing skills on a general medical-surgical ward. A concentrated focus in medicine and surgery would allow a student repeated exposure to those tasks which are completed by individuals on a daily basis. Skills would be more secure with a more intensive grasp of the replicative abilities, before the student proceeds to the interpretive aspects of education. The student would then with repeated exposure, be confident to encounter situations which would call for both replication and interpretation - such as how to recognize post operative complications. The student could have had during this time, experience with observation in several specialties in which interest has been expressed. This observation could serve as a way of assisting the student to determine those areas of specialization in which she/he had the greatest interest. 128 Having spent time acquiring abilities for both replicative and interpretive uses of his/her schooling, the student might then be prepared to begin to assume the advanced complexities of a single specialty. Accordingly, the student would choose a specialty and move to that specialty in the final year of the program. Having discussed general components of a basic nursing eduction program, the dis-cussion will now present inadequacies of the curriculum as proposed. The seventy-four objectives which have received overall agreement appear, on the surface, to meet the needs of stakeholders; however, a more thoughtful consideration reveals at least one major prob-lem. There are not, in the proposed seventy-four objectives, any objectives which provide for the needs of nurse specialists in the current British Columbia basic nursing education curricula, yet three groups of stakeholders' choices reflect a focus on specialties for basic nursing education. Thus, if a curriculum were created which had a specialty focus, specific objectives for specialties would need to be identified. For example, if a nurse were to specialize in gerontology, specific objectives might be the following: 1. Understand theories of aging. 2. Understand developmental tasks of the elderly. 3. Understand physiological changes of the elderly. 4. Understand the aging phenomenon. 5. Recognize specific needs of the elderly. 6. Be able to assess for subtle changes in the elderly. 7. Be able to suitably adapt the elderly's environment. 8. Be able to communicate with the elderly in ways which elderly persons regard as helpful. 9. Be able to use a variety of therapies specifically for the elderly population. 10. Understand the effects of drug therapy on the elderly. 11. Recognize the varieties of accomodation suitable for the elderly. Similar objectives could be developed for each specialty in nursing. A second consideration for specialization is course content. In responses to the ques-tionnaire there was general agreement (overall mean of 5.5 or greater) on fourteen nursing course content areas: care of ill adults, care of ill children, family nursing, gerontology, hu-man needs, legal aspects of nursing, medical terminology, nursing ethics, nursing leadership, 129 nursing skills, nursing theory, nursing trends, professional issues and physical assessment. However, while the questionnaire revealed agreement on the course content areas listed above, the researcher would propose that not every student receive education in all course content areas because some of the nursing course content areas (e.g., gerontology, care of ill children, and family nursing) are quite specialized. If a nurse were to become a geronto-logical specialist, course content in care of ill children might not be appropriate. Instead, it would seem more appropriate for the nurse to enroll in course content that centered around a specialty. If, for example, gerontology is the chosen specialty, relevant course content might be: theories of aging, developmental tasks of the elderly, physiological changes of the elderly, the aging phenomenon, special needs of the elderly, assessing the elderly, therapies related to the elderly, communicating with the elderly, drug therapy and the elderly and accomodation of the elderly. To continue with the gerontology specialty as the example, a nurse choosing this spe-cialty might choose such specialty areas as: a nursing home, an extended care agency, day care for adults, outpatients, an adult group home, a psychogeriatric center, and a multistep facility (e.g., Baycrest in Toronto). These areas, coupled with the academic focus on the gerontology would allow for the integration, application, and immediate employment of the general knowledge learned in the specialty area. In addition, other year-long specialties could be developed. Such specialization would enable development of applicative abilities and would meet the expectations of administrators, physicians and the ministry. Thus, all students would be prepared with core nursing content and skills, support course electives and a general medical-surgical focus. The final year would be reserved for a specialty of the student's choice. In summary, it seems that a desirable nursing education program is one which can produce a nurse who can perform some nursing skills, interpret the results of findings and work as a specialist. In choosing the type and length of program most suitable for basic nursing education, the following argument seems reasonable. While the degree of support for specific aspects of a nursing program differs among the groups, it is clear that overall the respondents gave strong support to a vast array of potential objectives, course content and clinical areas. If, for example, one takes a mean response of 5.5 or higher (on a scale of one to seven) as a strong response and one were to build a program on these, it would have to include 130 seventy-four objectives, twenty-five course content areas and ten clinical areas for basic nursing education. Thus, assuming a typical basic nursing education program had three courses per semester and one clinical area per semester, and assuming there was no return to a clinical area, nor any course content longer than one semester, the program would have to be between eight and nine semesters long. While the baccalaureate program was given strong support by the R . N . A . B . C , other groups were not as strong in their preference for this type and length of program for basic nursing education program. However, in light of the number of program components considered to be needed for basic nursing education by stakeholders, the type of program most suited to this would have to be at least a baccalaureate degree nursing program. Such a program could be four years in length, with core nursing courses, choices of support course content, a solid practical experience in medicine and surgery, followed by the student's choice of a nursing specialty. Such a nursing education program would have the following advantages. Educators in each institution could develop those specialties in which they had expertise and for which their resources were strongest. Administrators should benefit for this program could enable them to hire nurses for specialty areas immediately after graduation. Such a program could help to decrease the chronic shortages found in some specialty areas. And students would benefit, for if they wished to transfer programs, a core curriculum would assist them in transferring between nursing programs. A core curriculum with specialties could also benefit the R.N.A.B.C. by advancing the profession, because if there were core areas of nursing practice and education, it would be easier to conduct nursing research. The ministry could benefit by having community needs met and perhaps by seeing a decrease in the chronic short-staffing of specialty areas. Physicians would benefit not only by having teams of nurses who could perform skills flawlessly in a variety of clinical areas, but, who would also have in-depth abilities to interpret and deal with unusual cases. Summary This chapter has been organized around each stakeholder's stake in nursing education, the beliefs of the stakeholders in relation to the uses of basic nursing education, and the researcher's framework for a curriculum based on the needs of the stakeholders. The recommended program of studies requires the acquisition of replicative, interpretive and applicative abilities. Nursing skills and some core course content areas would be learned 131 for their repl icat ive uses; support courses would seek to promote the interpretive uses of the core content , and the appl icat ive use of schoo l ing wou ld be enhanced th rough specialty content . If admin is t rators ' v iews were considered most central to a cu r r i cu lum, the use of basic nurs ing educat ion wou ld a im at developing appl icat ive abi l i t ies. S ince , admin ist rators want nurses t o be special ists in their place of employment , the program of studies wou ld need to a im not only for a general understanding, but the abi l i ty to apply that understand ing into specia l ty areas. S u c h a program could take four years or more, depending on the required level of app l icat ion expected of the graduate. If physic ians ' v iews were most centra l , the a im would st i l l be for the appl icat ive uses for basic nurs ing educat ion . A program most suited to this wou ld have t o be long enough so that nurses cou ld become special ists and be able to perform tasks w i thou t error. A s imi lar interpretat ion cou ld be given to views expressed by min ist ry off icials. A nurse who works in a cr i t ica l care area or c o m m u n i t y health wou ld again require a program length needed to become a special ist . O n the other hand, it wou ld appear that educators and the R . N . A . B . C . prefer a program wh ich prepares a generalist who is capable of considerable interpretat ion in m a k i n g nursing and medica l decisions. T h e generalist may not know init ia l ly how to perform flawlessly al l the skil ls that were taught , but s h e / h e wou ld have a general understand ing in order to interpret physical signs, s y m p t o m s and to know when to get assistance. T h e type of program most suited to the choices of all the stakeholders would develop bo th generalist and special ist ski l ls and is longer p rogram than most programs current ly offered in Br i t ish C o l u m b i a . T h i s would seem to be a baccalaureate program that inc luded core courses and a choice of support courses that focussed on specialt ies in nursing pract ice. 132 C H A P T E R S E V E N Summary and Conclusions The sixth chapter discussed the findings in light of the stakeholders and Broudy's account of the uses of schooling. In addition, the chapter recommended a type of basic nursing education suitable for British Columbia. This chapter is organized in two sections: summary (purpose, research questions, methodology, findings, and interpretation of the findings) and conclusions (program recommendations, policy implications, and suggestions for further research). Summary Purpose of the Research The purpose of this study was to determine perceptions of five stakeholders in nursing education concerning the need for particular objectives, course content and clinical areas as well as the type and length of educational preparation needed for basic nursing education. In addition, this study outlined some reasons educators gave for their curricular selections. A literature review did not reveal any Canadian studies that specifically addressed stakeholder perceptions about what should be included in a basic nursing education program, nor was any literature found which addressed the reasons educators have for the selections they make. It was intended that data provided by this study could be of use to those in charge of baccalaureate and diploma nursing programs for curriculum planning and even revision. Research Questions and Methodology The following questions guided this study: 1. What differences exist in stakeholder perception regarding the need for particular ob-jectives in a basic nursing education curriculum? 2. What differences exist in stakeholder perception regarding the need for particular course content areas in a basic nursing education curriculum? 3. What differences exist in stakeholder perception regarding the need for particular clinical areas in a basic nursing education curriculum? 4. What differences exist in stakeholder perceptions regarding the educational preparation and the length of preparation for a basic nursing education program? 133 5. W h a t are the reasons offered by nurse educators regarding the select ion of part icular object ives, course content and c l in ica l areas and the type and length of educat iona l p rogram sui table for a basic nursing educat ion program? T h e subjects in this study consisted of 220 educators , 168 admin ist rators , 300 phys i -c ians , 27 representatives f rom the government ministr ies of health and educat ion , and 25 representatives f rom the Registered Nurses Assoc ia t ion of Br i t ish C o l u m b i a ( R . N . A . B . C ) . A l l were mai led a quest ionnaire conta in ing i tems related to 83 objectives, 45 course content and 38 c l in ica l areas. A l l were asked to rate each of the 166 i tems accord ing to a seven-point scale of need. T h e return rate was 6 7 . 6 % . D a t a were analyzed using A N O V A and A N O V A one-way a posterior i contrasts of Tukey analysis of honestly s igni f icant differences. T h e a lpha was set at 0.05. T h e second phase of this study consisted of 33 interviews of nurse educators wh ich were conducted by the invest igator . T h e purpose of th is phase was to determine reasons educators had for their choice of selected objectives, course content , and c l in ica l areas and for the type and length of an educat iona l p rogram. A random sample of educators who had responded to the quest ionnaire was selected. A l l agreed to part ic ipate . Each educator was asked to select the f ive most needed c l in ica l areas, the five most needed course content areas and the f ive most needed objectives f rom a provided list. Fo l lowing their choices, each educator was asked to rank order the list and provide reasons for their selections. T h e interview schedule conta ined eleven questions w i t h for ty -e ight i tems f rom the quest ionnaire. E a c h i tem chosen ful f i l led at least one of two cr i ter ia : either the i tem was one where at least 1 0 % of educators ' responses clustered at the two extremes of the 7 point rat ing scale, or the i tem was chosen because it had an overal l mean located between 3.5 and 5.5. T h e data were ana lyzed , sorted and reduced to categories. Fo l lowing data reduct ion , frequencies for each category were tabu la ted . F ind ings Ma jo r f ind ings of the study are: 1. T h e r e was disagreement a m o n g stakeholders regarding the objectives needed for a basic nurs ing educat ion program. Seventy -s ix of e ighty - three objectives (91%) were rated in s ign i f icant ly different ways by respondents. D isagreement was most pronounced be-tween physic ians and educators and between physicians and admin ist rators , a l though 134 impor tan t d isagreements were also found between educators and admin ist rators , be-tween the ministry and educators, between physicians and the R . N . A . B . C . and between admin is t rators and the ministry. Admin is t ra to rs and educators each had the highest rat ings on th i r ty -one objectives, whi le the R . N . A . B . C . had the highest rat ings on nine object ives. T h e ministry rated two objectives highest and physic ians rated three h igh -est. O n the other hand, physicians suppl ied the lowest rat ings on f i f ty - f ive objectives, compared to the ministry w i th lowest rat ings on eighteen objectives and educators and the R . N . A . B . C . w i th the lowest rat ings on five and four objectives respectively. A t no t ime did admin ist rators supply the lowest ratings. There were f i fteen objectives where ten percent or more of the responses were clustered at the two extremes of the scale. Phys ic ians had b ipolar ized responses on all f i fteen objectives, compared to the ministry w i th b ipolar ized responses on eight objectives, admin ist rators and educators on six, and the R . N . A . B . C . on three objectives. Disagreement in rank order ing occurred on th i r ty -one objectives, whereas ranking agreement occurred w i th three or more groups on sixty objectives. W h i l e the degree of support for speci f ic aspects of a nursing edu -cat ion program differed a m o n g stakeholders, overal l the respondents rated seventy- four objectives 5.5 or higher (on a scale of 1 to 7). In short, whi le there was disagreement as t o the degree of need for these objectives, most objectives were rated needed for basic nurs ing educat ion . 2. There was disagreement a m o n g stakeholders regarding the course content areas needed for a basic nurs ing educat ion program. Forty of forty - f ive (88 .8%) course content areas were rated in s igni f icant ly different ways by respondents. D isagreement was most pro-nounced between physicians and educators and between physicians and admin ist rators , a l though impor tan t d isagreements were also found between educators and admin is t ra -tors, between the ministry and educators, and between admin is t rators and the ministry. Admin i s t ra to rs and the R . N . A . B . C . had the highest rat ings on eighteen and seventeen course content areas respectively. Educators had the highest rat ings on seven course content areas. T h e ministry rated two content areas highest. Phys ic ians rated no course content areas highest; however, they suppl ied the lowest rat ings on th i r ty -one course content areas. T h e ministry rated nine course content areas lowest whi le edu -cators and the R . N . A . B . C . had the lowest rat ings on one and two course content areas respectively. A t no t ime did admin ist rators supply the lowest rat ings for course c o n -135 tent areas. There were twenty-three course content areas where ten percent or more of the responses clustered at the two extremes of the seven-point rating scale. The ministry had bipolarized responses on fifteen content areas. Physicians had bipolarized responses on twelve content areas, educators had eleven, administrators had ten, and the R.N.A.B.C. had eight. Disagreement in rank ordering also occurred on eleven con-tent areas, whereas ranking agreement with three or more groups occurred on eleven content areas. While the degree of support for specific aspects of a nursing program differed among the groups, overall the respondents rated twenty-five course content areas 5.5 or higher (on a scale of 1 to 7): anatomy, biology, care of ill adults, care of ill children, commu-nication, English, family nursing, gerontology, human growth and development, human needs, legal aspects, medical terminology, microbiology, nursing ethics, nursing leader-ship, nursing skills, nursing theory, nursing trends, nutrition, pathology, pharmacology, physical assessment, physiology, professional issues and psychology. Thus, five stake-holders agreed that twenty-five course content areas were needed for basic nursing education. The disagreement occurred most commonly over the degree of need. 3. There was disagreement among stakeholders regarding the clinical areas needed for a basic nursing education program. Twenty-six of thirty-eight (68.4%) clinical areas were shown to be rated in significantly different ways by respondents. Disagreement was most pronounced between physicians and educators and between administrators and ed-ucators, however there were also disagreements between administrators and physicians, between the R.N.A.B.C. and physicians, and between the R.N.A.B.C. and administra-tors. Administrators had the highest ratings on fifteen clinical areas. R.N.A.B.C. had the highest on nine, the ministry had the highest on eight, and physicians had the high-est on five. Educators had only one clinical area rated highest but fifteen times they gave the lowest ratings. Lowest ratings were also proffered by physicians on fourteen clinical areas, by the R.N.A.B.C. on five and by administrators on one clinical area. There were twenty-nine clinical areas where ten percent or more responses clustered at the two extremes of the scale. The ministry had bipolarized responses on twenty-four clinical areas. These responses were compared to the R.N.A.B.C. who had bipolarized responses on twenty-two clinical areas, physicians and administrators with twenty clin-ical areas, and educators with nineteen clinical areas. Disagreement in rank ordering 136 occur red on ten c l in ica l areas, whereas ranking agreement w i th three or more groups occur red on eighteen c l in ica l areas. W h i l e the degree of support for specif ic c l in ica l areas differed a m o n g groups, overal l , respondents rated ten c l in ica l areas 5.5 or higher (on a scale of 1 to 7) : extended care, gynecology, labor and delivery, general medicine, or thopedics , general surgery, ped i -atr ics , pos tpa r tum, psychiatry, and well baby nursery. T h u s , f ive stakeholders agreed that ten c l in ica l areas were needed for basic nursing educat ion . T h e disagreement occur red most c o m m o n l y over the degree of need. 4. T h e r e were s igni f icant differences a m o n g the groups in their views on the length and type of program for basic nursing educat ion . For example , support for the B . S c . N . and four years of preparat ion was given by 8 9 % of the R . N . A . B . C . compared w i t h educators at 6 5 % , admin ist rators at 5 9 % , the ministry at 3 0 % and physicians at 1 8 % . Phys ic ians were in d isagreement the most - they disagreed w i th three other groups in their ratings over the length and type of educat iona l preparat ion. 5. Reasons that educators gave for selection of part icular objectives, course content and c l in ica l areas inc luded ( in order of f requency) : educat iona l , i ns t i tu t iona l , c l ient , t r ad i -t iona l , professional and other. Reasons given by educators f rom university schools of nurs ing differed f rom those given by hospi ta l -based educators . Co l lege -based educa -tors advanced categories of reasons that differed f rom those of both university -based and hospi ta l -based educators. For example , univers i ty -based educators stressed profes-s ional reasons; hosp i ta l -based educators stressed educat iona l and t rad i t iona l reasons; and col lege-based educators stressed inst i tut iona l and cl ient reasons. A t t imes (14%) educators had di f f iculty presenting reasons, perhaps because they may be unaccustomed to offering just i f icat ions for curr icular decisions. Interpretat ion of the F ind ings 1. S o m e of the differences a m o n g the five stakeholders arise f r o m the stake each group has in nurs ing educat ion . A l l stakeholders appeared to have a stake in prov id ing good care to cl ients. T h e differences in stakes were found to be as fo l lows. Phys ic ians seem to have a stake in ma in ta in ing the status quo in nursing educat ion . The i r stake also appears to rest w i th ma in ta in ing contro l over medica l decisions regarding cl ients. T h e R . N . A . B . C . seems interested in ob ta in ing a larger role in dec i s ion -mak ing for nurses, 137 whereas admin ist rators have a stake in m a k i n g certain that the inst i tut ion operates smooth ly . M in i s t r y off icials have a stake in publ ic health and seem interested in those areas w i t h a current shortage of nursing personnel (e.g., cr i t ica l care nursing) . E d u c a -tors ' stakes relate to ma in ta in ing the status quo of the current cu r r i cu lum, protect ing the student f rom exp lo i tat ion and m a k i n g certain that students are competent to prac-tise in the c l in ica l set t ing . 2. Phys ic ians chose the course content , c l in ica l areas and objectives wh ich seem to require more appl icat ive uses, and to a lesser extent , interpretive and repl icat ive uses of basic nurs ing educat ion . Phys ic ians appear to value a nurse who has ski l ls and w h o can handle emergencies, as well as one who can funct ion in cr i t ica l care areas w i thout extensive educat iona l preparat ion. M in is t ry off icials agree. T h e y too , appear to value simi lar uses for basic nurs ing educat ion . T h e y seem to want a nurse w h o can work in cr i t ica l care areas, in publ ic health , but w i thout extensive educat iona l preparat ion. These views are in contrast w i th educators and the R . N . A . B . C . w h o selected i tems wh ich seem to relate t o the interpretive uses of basic nursing educat ion , and w i t h a lesser emphasis on appl icat ive and repl icative uses. Admin is t ra to rs , like physic ians and the ministry, selected items that lend more to appl icat ive uses for basic nurs ing educat ion , w i t h a lesser emphasis on repl icative and interpretive uses. T h u s , educators and the R . N . A . B . C . want a nurse who can practise as a generalist, whereas admin ist rators , the ministry and physicians stressed the need for a special ist w h o can apply what she has learned in speci f ic c l in ica l sett ings. In consider ing stakeholders ' uses of basic nursing educat ion , it therefore seems appropr iate to consider a cu r r i cu lum wh ich focusses on repl icat ive, interpret ive and appl icat ive uses. Conc lus ions P r o g r a m R e c o m m e n d a t i o n s 1. In m a k i n g recommendat ions for basic nursing educat ion , the f irst area to consider is that of object ives. It makes sense to choose at least those objectives wh ich are consistent w i t h the select ions of stakeholders, their stakes and their uses of basic nurs ing educat ion . T o th is end, the seventy- four objectives receiving an overal l respondent rat ing of 5.5 or greater should be seriously considered for a basic nurs ing educat ion program. But in add i t ion , there should be objectives developed wh ich wou ld give a specialty focus to 138 the curriculum. This specialty focus seems to be at least consistent with the choices of clinicial areas by administrators, physicians and the ministry. 2. The second consideration is related to course content areas for basic nursing education. Those areas which were rated as being most needed by the stakeholders were: nursing skills, nursing theory, human needs, legal aspects of nursing, professional issues, nursing trends, medical terminology, nursing leadership, physical assessment and nursing ethics. This core content should be included in a nursing program. But, in addition, there should be content that would deal with the beginning specialty. 3. Selection of appropriate support course content areas for basic nursing education is difficult because of the degree of disagreement found among and within groups of stakeholders. Because of this disagreement, it seems reasonable to allow students to make choices from a list of options in the sciences and humanities. By allowing students to have choices, the interpretive uses of basic nursing education which call for a general education may be enhanced. 4. In choosing clinical areas for basic nursing education, it seems appropriate to give students a solid basis in general medical-surgical nursing on general medical-surgical wards in hospital settings. This would allow the nurse to develop the replicative and interpretive uses of basic nursing education. Having mastered the essential principles of nursing, the student could then proceed to the applicative uses of basic nursing education by pursuing a specialty of the student's choice. 5. In choosing the type and length of program most suitable for basic nursing education, the following argument seems reasonable. While the degree of support for specific aspects of a nursing program differs among the groups, it is clear that overall the respondents gave strong support to a vast array of potential objectives, course content and clinical areas. If, for example, one takes a mean response of 5.5 or higher (on a scale of one to seven) as a strong response and one were to build a program on these, it would have to include seventy-four objectives, twenty-five course content areas and ten clinical areas for basic nursing education. Assuming a typical basic nursing education program had three courses per semester and one clinical area per semester, and assuming there was no return to a clinical area nor any course content longer than one semester, the program would have to be between eight and nine semesters 139 long. While the baccalaureate program was given stronger support by the R . N . A . B . C , other groups were not as strong in their preference for this type and length of program for basic nursing education program. However, in light of the number of program components considered necessary for basic nursing education by stakeholders, the type of program that would incorporate them would be a baccalaureate degree program. Such a program could be four years in length, with core nursing courses, choices of support course content, a solid practical experience in medicine and surgery, followed by the student's choice of a nursing specialty. Alternate Recommendations The author realizes that the data collected from these groups of stakeholders could support other potential curricular recommendations: 1. One might argue that a suitable program for basic nursing education is one which would actually include all those components considered "needed" by the stakeholder groups. Such a program of studies could include the 74 objectives, 25 course content areas and 10 clinical areas rated 5.5 or higher by the stakeholders. Assuming that all these curricular components were included, the program would have to be longer than any of the existing programs in British Columbia. If, for example, a program had three courses per semester and one clinical area per semester, and, assuming there was no return to a clinical area, nor any course content longer than one semester, the program would have to be between nine and ten academic semesters in length. Such a program may not be economically feasible. 2. A second type of basic nursing education program which might be considered is based on the amount of disagreement revealed in the study. The disagreement found between and among the stakeholders group may demonstrate, in part, a lack of understanding amongst stakeholders about the most appropriate curricular components. For this reason, it might be most suitable to let one group, for example, the R . N . A . B . C , or the nurse educators decide on the necessary curricular components for a program. Having only one group make the decisions might result in the development of a more unified program, but it may not, in fact, reflect the values of the other stakeholder groups. 3. A third option to reconsider is also based on the amount of disagreement amongst and within the stakeholder groups. Owing to the extent of disagreement, it might be ad-140 vantageous to retain the three types of programs currently offered in British Columbia. Such an option could allow stakeholders to retain their interest in the continued de-velopment of different programs. This increased development might result in further diversity in nursing education. And this diversity could impede the development of the profession of nursing. 4. A fourth option which might be used is again based on the extent of disagreement amongst and within the stakeholder groups. Such disagreement could be handled by retaining the three types of programs currently offered in British Columbia until consensus is reach amongst and within the stakeholder groups. If consensus could be reached, a better program might emerge. However, recognizing that consensus may be an impossibility, the development of this option may never materialize. Having identified five options for basic nursing education, the author holds that the first proposal is reasonable, has at least the support inferred from the data, and given current financial and professional assumptions, is practicable. Policy Implications 1. The conclusions drawn in this study provide direction for the major policy issue related to nursing education-the preparation of nurses for basic nursing. This study lends support to the argument that basic nursing education be at the baccalaureate level. 2. The conclusions drawn from this study provide direction for implementing a core cur-riculum across the province. This would assist employers in understanding the nurse's abilities at graduation, clarify the capabilities of the graduate nurse to other health care workers, and increase the student's transferability. A core curriculum could as-sist faculty to more clearly articulate and justify the purposes of nursing education to themselves and to others. A core curriculum would also provide a good basis for the conduct of research in the areas of practice and education. 3. Curricula for specialty areas in nursing education need to be further developed and refined. At present, there seems to be confusion as to what constitutes a nursing specialty. 4. There needs to be a mechanism for ensuring that stakeholders work more closely to-gether and identify each other's needs through both formal and informal channels. 141 5. The present structure of the registration examinations would need to be changed to accomodate the nursing specialties. Suggestions for Further Research 1. Clarification of the essential components of a nursing specialist practice should be made. If specialist preparation is designed to have students begin work in one area of nursing, with a particular type of client and set of problems, then research into the development of objectives, course content and clinical learning experiences are necessary. The appropriate range of actual nursing specialties needs to be clarified. 2. Research could be conducted which investigates how curricular decisions are made. Such research would assist understanding of who makes these decisions, the kinds of curricular decisions made, and where and when such decisions are made. 3. Owing to the differing levels of expectation among administrators, educators, physi-cians, the ministry and the R.N.A.B.C, it might be helpful to conduct research on a job analysis of the work setting of a nurse. Such an analysis might help to resolve conflicts in hospital settings to the benefit of all stakeholders. 4. It might be profitable to conduct a similar study with a national population. This survey might also determine whether there is variation across provinces or whether the findings in other Canadian provinces match those of British Columbia. While the word "chaos" to describe nursing education is used by some authors, it was the perceived disagreement amongst stakeholders which provided the author's motive for this study. This study provides a foundation for understanding stakeholder perceptions of basic nursing education. 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"Role Incongruency Among Associate Degree Nurses: Perceptions of Nursing Educators, Associate Degree Nurses, Doctors, and Nursing Administrators." Ed.D. Dissertation, University of Kentucky, 1982. Worthen, Blaine and Sanders James; Educational Evaluation: Alternate Approaches and  Guidelines. New York: Longman Inc., (1988). Zabawski, Pauline. "Diploma Nurse - Baccalaureate Nurse: Is There a Difference?" A report  on a Descriptive study of College programs and the Generic B.S.N Program for the  Ministry of Education. August 1983. 151 APPENDIX A March 27, 1987 Dear Nurse Administrator: I am currently studying towards a doctoral degree at the University of British Columbia. The objectives of my research are to identify certain conceptions of nursing education which are justifiable. Interest in this study has developed as a result of my involvement in nursing education over the past thirteen years in Alberta, British Columbia ana Australia. During this time, it has become increasingly apparent to me that nursing education is preparing nurses for a diversity of roles within the field of nursing and yet this diversity is not clearly understood at the conceptual level. It is my understanding that you are/have been involved in nursing education as an educator, administrator, as a member of a governing body or as a member of the medical staff. I would therefore like to invite your participation in this study. Although there have been numerous studies that deal with objectives, one benefit to this study is that it not only includes objectives, but it also ex-tends to include course content and clinical areas. A second benefit to be derived from this study includes finding out the perceptions of people both from within and outside nursing who make nursing education decisions. A third benefit to this study is to determine the reasons for viewing cer-tain objectives, course content and clinical areas as being more important than other objectives, course content and clinical areas from those people within and outside nursing. Your cooperation is vital to the study's outcome. Your participation in-cludes the completion of a questionnaire. Approximately 20 minutes will be needed to complete the questionnaire. Additionally a few individuals may be interviewed. This interview, randomly selected, is a follow-up to the questionnaire which will attempt to determine the reasons why certain objectives, course content and clinical areas were chosen as being more 161 N u r s i n g E d u c a t i o n Survey The purpose of this study is to determine your perceptions regarding the degree to which certain objectives, course content and clinical areas are needed for BEGINNING NURSES. The following groups will be asked to respond: Nurse Administrators, Nurse Educators, Physicians, Ministry Officials, and representatives from the Provincial Nursing As-sociation. Although there have been numerous studies that deal with nursing objec-tives, one benefit to this study is that this study not only includes ob-jectives, but it also extends to include course content and clinical areas that might be part of a nursing education curriculum. A second bene-fit includes finding out the perceptions of people both from within nurs-ing and outside nursing education who make nursing education decisions about the necessity of certain objectives, course content and clinical ar-eas needed for BEGINNING NURSES. A third benefit to this study is to determine the reason for viewing certain objectives, course content and clinical areas as being more important than other objectives, course con-tent and clinical areas from those people both within and outside nursing. Your cooperation is vital to the study's outcome. Your participation in-cludes the completion of a questionnaire. Approximately 20 minutes will be needed to complete the questionnaire. Additionally, a few individuals may be interviewed. This interview, randomly selected, is a follow-up to the questionnaire which will attempt to determine the reasons why certain objectives, course content and clinical areas were chosen as being more important than other objectives, course content and clinical areas. If se-lected, the interview will not take longer than an additional 30 minutes of your time, at a time which is mutually convenient. If the questionnaire is completed, it will be assumed that consent has been given. You may be assured of complete confidentiality. The questionnaire has an identification number for mailing purposes only. This is so that I can check your name off the mailing list when your questionnaire is returned. Your name will never be placed on the questionnaire. Ques-tionnaires will be coded and stored in the computer. Information from the interviews will be transcribed and available only for the use of the re-searcher. Data may eventually be made available with the identification deleted to other research groups. You do have the right to refuse to par-ticipate or to withdraw from the study at any time. Refusal to participate will in no way affect employment status. 163 Consent Form Nursing Education Survey The purpose of this study is to determine your perceptions regarding the degree to which certain objectives, course content and clinical areas are needed for BEGINNING NURSES. The following groups will be asked to respond: Nurse Administrators, Nurse Educators, Physicians, Ministry Of-ficials, and representatives from the Provincial Nursing Associa-tion. Although there have been numerous studies that deal with objectives, one benefit to this study is that this study not only includes objectives, but it also extends to include course content, and clinical areas. A second benefit to be derived from this study includes finding out the perceptions of people both from within nursing and outside nursing who make nursing education decisions. A third benefit to this study is to determine the reasons for viewing certain objectives, course content and clinical areas as being more important than other objectives, course content and clinical areas from those people both within and outside nursing. Your cooperation is vital to the study's outcome. Your participation in-cludes the completion of a questionnaire. Approximately 20 minutes will be needed to complete the questionnaire. Additionally, a few individuals may be interviewed. This interview, randomly selected, is a follow-up to the questionnaire which will attempt to determine the reasons why cer-tain objectives, course content and clinical areas were chosen as being more important than other objectives, courses content and clinical ar-eas. If selected, the interview will not take longer than an additional 30 minutes of your time, at a time which is mutually convenient. If the questionnaire is completed, it will be assumed that consent has been given. You may be assured of complete confidentiality. The questionnaire has an identification number for mailing purposes only. This is so that I may check your name off the mailing list when your questionnaire is returned. Only the researcher will have access to the raw data. Ques-tionnaires will be coded and stored in the computer. Information from the interviews will be transcribed and available only to the researcher. Questionnaires may eventually be made available with the identification deleted to other research groups. You do have the right to refuse to par-ticipate or to withdraw from the study at any time. Refusal to participate will not in any way affect employment status. Results of the research will be available to those who request it. You may receive a summary of the results by printing your name and address on the back of the envelope. 165 N u r s i n g E d u c a t i o n Survey The questionnaire is in five parts. Part One consists of identifying the clinical areas that might be part of a Nursing curriculum. Part Two includes identifying the degree to which certain objectives describ-ing Nursing activities and knowledge are needed. Part Three identifies courses/course content for possible inclusion in a Nursing curriculum. Part Four asks two questions regarding the level of Nurse and type of education required for a BEGINNING NURSE. Finally, the last part re-quests some demographic information. Instructions for the Quest ionnaire The following questionnaire includes objectives/course content/clinical areas that might be included in basic nursing education. Please indi-cate your views as to whether EACH one is needed for BEGINNING NURSES*. For example, circle a seven (7) if you think that this objec-tive is definitely NEEDED for the BEGINNING NURSE or circle a one (1) if you think that the objective is NOT NEEDED for the BEGINNING NURSE*. If you don't know whether or not it is needed, circle a zero (0). 1. Gives a report to team members at the end of the shift. 1 2 3 4 5 6 7 The number circled indicates that this objective is definitely needed for the BEGINNING NURSE. *Beginning RN in a hospital setting (ie: New Graduate Nurse) 166 Part O n e - Cl in ica l Areas T h e following are clinical areas for possible inclusion in basic nursing education. Please indicate your views as to whether E A C H O N E is needed for B E G I N N I N G N U R S E S . For example, circle a seven (7) if you view the particular clinical area as definitely N E E D E D for a BEGINNING N U R S E , or circle a one (1) if it is N O T If you don't know whether or not it is needed, circle i zero (0) for D O N T K N O W . 1. Burn Unit 1 2 3 4 5 6 7 0 2. Cardiovascular-thoracic Surgery 1 2 3 4 5 6 7 0 3. Clinical Research Unit 1 2 3 4 5 6 7 0 4. Coronary Intensive Care 1 2 3 4 5 6 7 0 5. Day Care Centers (Adults) 1 2 3 4 5 6 7 0 6. Day Care Centers (Pediatrics) 1 2 3 4 5 6 7 0 7. Dermatology 1 2 3 4 5 6 7 0 8. Emergency Room 1 2 3 4 5 6 7 0 9. Extended Care 1 2 3 4 5 6 7 0 10. Gynecology 1 2 3 4 5 6 7 0 11. Home Care 1 2 3 4 5 6 7 0 12. Industrial Nursing 1 2 3 4 5 6 7 0 13. Labor and Delivery 1 2 3 4 5 6 7 0 14. Medical (General) 1 2 3 4 5 6 7 0 15. Medical Intensive Care 1 2 3 4 5 6 7 0 16. Mental Health (Outpatient) 1 2 3 4 5 6 7 0 17. Neurology 1 2 3 4 5 6 7 0 18. Neurosurgery 1 2 3 4 5 6 7 0 19. Newborn Intensive Care 1 2 3 4 5 6 7 0 20. Nursery School 1 2 3 4 5 6 7 0 21. Orthopedics 1 2 3 4 5 6 7 0 22. Surgical (General) 1 2 3 4 5 6 7 0 23. Surgical Intensive Care 1 2 3 4 5 6 7 0 167 24. Surgical Recovery Room 1 2 3 4 5 6 7 0 25. Operating Room 1 2 3 4 5 6 7 0 26. Ophthamology 1 2 3 4 5 6 7 0 27. Outpatient/Community Clinics 1 2 3 4 5 6 7 0 28. Pediatrics 1 2 3 4 5 6 7 0 29. Pediatric Intensive Care 1 2 3 4 5 6 7 0 30. Physician's Offices 1 2 3 4 5 6 7 0 31. Plastic Surgery 1 2 3 4 5 6 7 0 32. Postpartum 1 2 3 4 5 6 7 0 33. Psychiatry (In Patient) 1 2 3 4 5 6 7 0 34. Public Health 1 2 3 4 5 6 7 0 35. Radiology 1 2 3 4 5 6 7 0 36. Rehabilitation 1 2 3 4 5 6 7 0 37. Urology 1 2 3 4 5 6 7 0 38. Well Baby Nursery 1 2 3 4 5 6 7 0 39. Other (specify) Part T w o - Course Objectives The following are objectives for possible inclusion in basic nursing education. Please indicate your views as to whether EACH ONE is needed for BEGINNING NURSES. For example, circle a seven (7) if you view the particular objective as definitely NEEDED for a BEGINNING NURSE, or circle a one (1) if it is NOT NEEDED. If you don't know whether or not it is needed, circle zero (0) for DONT KNOW. 1. Adapts care to individual patient needs. 1 2 3 4 5 6 7 0 2. Fulfills responsibility to patient and others. 1 2 3 4 5 6 7 0 168 3. Questions orders and decisions by medical and other professional staff. 1 2 3 4 5 6 7 0 4. Acts as patient advocate in obtaining appropriate medical, psychiatric or other help. 1 2 3 4 5 6 7 0 5. Recognizes, corrects and reports own errors. 1 2 3 4 5 6 7 0 6. Analyzes and changes own behavior in order to maintain therapeutic relationship with patient. 1 2 3 4 5 6 7 0 7. Evaluates whether patient's requirements for nursing care were met. 1 2 3 4 5 6 7 0 8. Uses community resources to help patient resolve problems. 1 2 3 4 5 6 7 0 9. Assesses patient learning needs in relation to disability. 1 2 3 4 5 6 7 0 10. Provides health care instruction or inform-ation to patients, family or significant other. 1 2 3 4 5 6 7 0 11. Ensures that instruction is understood. 1 2 3 4 5 6 7 0 12. Encourages patient or family to make informed decisions about accepting care or adhering to treatment regime. 1 2 3 4 5 6 7 0 13. Helps patient recognize and deal with psychological stress. 1 2 3 4 5 6 7 0 14. Avoids creating or increasing anxiety or stress. 1 2 3 4 5 6 7 0 15. Conveys acceptance, respect and trust to patient. 1 2 3 4 5 6 7 0 16. Facilitates relationship of family, self or significant other with patient. 1 2 3 4 5 6 7 0 17. Maintains confidentiality of patient information. 1 2 3 4 5 6 7 0 18. Stimulates, motivates patient or enables him/her to achieve self care and independence. 1 2 3 4 5 6 7 0 19. Keeps patient clean and comfortable. 1 2 3 4 5 6 7 0 20. Helps patient maintain or regain normal body functions. 1 2 3 4 5 6 7 0 21. Efficiently provides care for a group of four to six patients. 1 2 3 4 5 6 7 0 169 22. Applies principles of infection control. 1 2 3 4 5 6 7 0 23. Protects patient's skin and mucous membranes from injurious material. 1 2 3 4 5 6 7 0 24. Uses positioning or exercises to prevent injury or the complications of immobility. 1 2 3 4 5 6 7 0 25. Avoids using injurious technique in administering and managing intrusive or other potentially traumatic/treatments. 1 2 3 4 5 6 7 0 26. Protects patient from falls or other contact injuries. 1 2 3 4 5 6 7 0 27. Supervises patient's activities. 1 2 3 4 5 6 7 0 28. Ensures safe environment for patient. 1 2 3 4 5 6 7 0 29. Checks correctness, condition and safety of medication being prepared. 1 2 3 4 5 6 7 0 30. Ensures that correct medication or care is given to the right patient and that patient takes or receives it. 1 2 3 4 5 6 7 0 31. Adheres to schedule in giving medication, treatment or test. 1 2 3 4 5 6 7 0 32. Administers medication by correct route, rate or mode. 1 2 3 4 5 6 7 0 33. Checks patient's readiness for medication, treatment, surgery or other care. 1 2 3 4 5 6 7 0 34. Checks to ensure that those tests or measurements that the nurse is responsible for are done correctly. 1 2 3 4 5 6 7 0 35. Monitors patient infusions and inhalations. 1 2 3 4 5 6 7 0 36. Checks for and interprets effect of medication, treatment or care and takes corrective action if needed. 1 2 3 4 5 6 7 0 37. Detects changes in a patient's condition or status. 1 2 3 4 5 6 7 0 38. Investigates or verfies patient's complaints or problems 1 2 3 4 5 6 7 0 39. Uses alarms and signals on automatic equipment as an adjunct to personal assessment. 1 2 3 4 5 6 7 0 170 40. Observes and correctly assesses signs of anxiety or behavioral stress. 1 2 3 4 5 6 7 0 41. Observes and correctly assesses physical signs, symptoms or findings and intervenes appropriately. 1 2 3 4 5 6 7 0 42. Correctly assesses severity or priority of patient's condition and gives or obtains needed care. 1 2 3 4 5 6 7 0 43. Is able to explain the reason for nursing judgments. 1 2 3 4 5 6 7 0 44. Uses understanding of developmental stages to aid in interpreting of patient symptoms. 1 2 3 4 5 6 7 0 45. Anticipates the need for crisis care. 1 2 3 4 5 6 7 0 46. Takes instant, correct action in an emergency situation. 1 2 3 4 5 6 7 0 47. Maintains calm and efficient approach under pressure. 1 2 3 4 5 6 7 0 48. Assumes leadership role in crisis situation when needed. 1 2 3 4 5 6 7 0 49. Checks data sources for orders and other inform-ation about patient. 1 2 3 4 5 6 7 0 50. Obtains information from patient and family. 1 2 3 4 5 6 7 0 51. Transcribes or records information on charts, Kardex.or other information system. 1 2 3 4 5 6 7 0 52. Exchanges information with nursing staff and other departments. 1 2 3 4 5 6 7 0 53. Exchanges information with medical staff. 1 2 3 4 5 6 7 0 54. Cooperates with ward routines and hospital regulations. 1 2 3 4 5 6 7 0 55. Knows the administrative organization and functioning of the institution at various levels. 1 2 3 4 5 6 7 0 56. Knows the functions and responsibilities of each member of the health care team. 1 2 3 4 5 6 7 0 57. Adheres to a nursing code of ethics. 1 2 3 4 5 6 7 0 58. Works together with other nursing staff. 1 2 3 4 5 6 7 0 171 59. Helps other staff members with work during staff shortage. 1 2 3 4 5 6 7 0 60. Obtains assistance when situation requires additional help, more skilled personnel or greater resources. 1 2 3 4 5 6 7 0 61. Develops and modifies patient care plan. 1 2 3 4 5 6 7 0 62. Includes doctor, other staff or agencies in planning care. 1 2 3 4 5 6 . 7 0 63. Implements patient care plan 1 2 3 4 5 6 7 0 64. Conducts patient care conferences. 1 2 3 4 5 6 7 0 65. Contributes constructively to patient care conferences. 1 2 3 4 5 6 7 0 66. Updates nursing knowledge by attending inservice workshops. 1 2 3 4 5 6 7 0 67. Teaches correct principles, procedures and techniques of patient care to other staff. 1 2 3 4 5 6 7 0 68. Supervises and checks the work of staff for whom she is responsible. 1 2 3 4 5 6 7 0 69. Performs tasks, with legal limits, that cannot be delegated to other staff. 1 2 3 4 5 6 7 0 70. Identifies own behaviour that interferes with leadership. 1 2 3 4 5 6 7 0 71. Delegates care, within legal limits, to the nursing staff according to their abilities. 1 2 3 4 5 6 7 0 72. Assists in initiating planned change. 1 2 3 4 5 6 7 0 73. Is punctual for work. 1 2 3 4 5 6 7 0 74. Is self directed: takes initiative and goes ahead on own. 1 2 3 4 5 6 7 0 75. Recognizes own ability to deal with patient or situation and obtains substitute. 1 2 3 4 5 6 7 0 76. Demonstrates knowledge of a nursing model when assessing patients and providing nursing care. 1 2 3 4 5 6 7 0 77. Understands and uses a variety of nursing models in 172 providing nursing care. 1 2 3 4 5 6 7 0 78. Adapts nursing model learned in nursing program to fit with the hospital nursing model. 1 2 3 4 5 6 7 0 79. Applies research findings to improve nursing care. 1 2 3 4 5 6 7 0 80. Participates in nursing research. 1 2 3 4 5 6 7 0 81. Accepts responsibility for developing and pro-moting the profession within a changing society 1 2 3 4 5 6 7 0 82. Accepts responsibility for self directed, personal and professional growth. 1 2 3 4 5 6 7 0 83. Evaluates the present and emerging roles of the professional nurse in relation to trends in health care. 1 2 3 4 5 6 7 0 84. Other (specify) : Part Three - Course Content The following is possible content for inclusion in basic Nursing education. Please indicate your views as to whether EACH ONE is needed for BEGINNING NURSES. For example, circle a seven (7) if you view the particular course as definitely NEEDED for a BEGINNING NURSE, or circle a one (1) if it is NOT NEEDED. If you don't know whether or not it is needed, circle zero (0) for DONT KNOW. 1. Abnormal Psychology 1 2 3 4 5 6 7 0 2. Algebra 1 2 3 4 5 6 7 0 3. Anatomy 1 2 3 4 5 6 7 0 4. Anthropology 1 2 3 4 5 6 7 0 5. Biochemistry 1 2 3 4 5 6 7 0 6. Biology 1 2 3 4 5 6 7 0 7. Care of III Adults 1 2 3 4 5 6 7 0 8. Care of III Children 1 2 3 4 5 6 7 0 9. Communication 1 2 3 4 5 6 7 0 173 10. English 1 2 3 4 5 6 7 0 11. Epidemiology 1 2 3 4 5 6 7 0 12. Family Nursing 1 2 3 4 5 6 7 0 13. Fine Arts 1 2 3 4 5 6 7 0 14. General Math 1 2 3 4 5 6 7 0 15. Genetics 1 2 3 4 5 6 7 0 16. Gerontology 1 2 3 4 5 6 7 0 17. History of Nursing 1 2 3 4 5 6 7 0 18. Human Growth & Development 1 2 3 4 5 6 7 0 19. Human Needs 1 2 3 4 5 6 7 0 20. Immunology 1 2 3 4 5 6 7 0 21. Introduction to Computers 1 2 3 4 5 6 7 0 22. Inorganic Chemistry 1 2 3 4 5 6 7 0 23. Legal Aspects of Nursing 1 2 3 4 5 6 7 0 24. Medical Terminology 1 2 3 4 5 6 7 0 25. Microbiology 1 2 3 4 5 6 7 0 26. Nursing Ethics 1 2 3 4 5 6 7 0 27. Nursing Leadership 1 2 3 4 5 6 7 0 28. Nursing Skills 1 2 3 4 5 6 7 0 29. Nursing Theory 1 2 3 4 5 6 7 0 30. Nursing Trends 1 2 3 4 5 6 7 0 31. Nutrition 1 2 3 4 5 6 7 0 32. Organic Chemistry 1 2 3 4 5 6 7 0 33. Pathology 1 2 3 4 5 6 7 0 34. Pharmacology 1 2 3 4 5 6 7 0 174 35. Philosophy 1 2 3 4 5 6 7 0 36. Physical Assessment 1 2 3 4 5 6 7 0 37. Physical Education 1 2 3 4 5 6 7 0 38. Physics 1 2 3 4 5 6 7 0 39. Physiology 1 2 3 4 5 6 7 0 40. Political Science 1 2 3 4 5 6 7 0 41. Professional Issues 1 2 3 4 5 6 7 0 42. Psychology 1 2 3 4 5 6 7 0 43. Public Speaking 1 2 3 4 5 6 7 0 44. Research Methods 1 2 3 4 5 6 7 0 45. Sociology 1 2 3 4 5 6 7 0 46. Other (specify) Part Four - Level/Education of R . N . The following two questions ask you to respond to the length and type of education needed for the beginning R.N. 1. How long should it take to educate a beginning R.N. (after high school). academic years. 2. What should be the required basic preparation for a beginning R.N.? a. Diploma-Hospital b. Diploma-College/lnstitute c. B.S.N. d. M.S.N. e. Ph.D. f. Other (specify) 175 Part Five - D e m o g r a p h i c D a t a Nurse Educator Confidential Please circle the letter or fill in the blank with the answer that BEST applies to you: This information is needed for statistical purposes only, and confidentiality is assured. 1. Your Sex. a. Male b. Female 2. Your Age: years old 3. Highest level of education attained in Nursing. a. R.N. Diploma b. B.S.N. c. M.S.N. d. Ph.D. /Ed.D. /D.S.N. e. Other (specify) 4. Highest level of education attained in other than Nursing. a. B .A . /B .Ed . /B .Sc . b. M.A. /M.Ed. /M.Sc . /M.P .A . c. Ph.D. /Ed.D. d. Other (specify) 5. Basic Nursing education program. a. Hospital Nursing program b. College Nursing program c. Baccalaureate Nursing program d. Other (specify) 6. Your present position. a. Instructor hospital program b. Instructor college program c. Instructor baccalaureate program d. Instructor graduate nursing program e. Other (specify) 7. Number of years in present position. years 8. Types of nursing programs you have taught in (Circle as many as are appropriate). a. Hospital diploma b. College diploma c. Baccalaureate degree d. Graduate degree e. Other (specify) 176 9. Areas in which you have had clinical experience (Circle as many as apply). a. Medical b. Surgical c. Pediatrics d. Obstetrics e. Psychiatry f. Other (specify) 10. Approximately how many beds are in the hospital in which you work? beds. 11. Approximately how may students graduate from your program each year? students. 177 Part Five - D e m o g r a p h i c D a t a Nurse Administrator Confidential Please circle the letter or fill in the blank with the answer that BEST applies to you. This information is needed for statistical purposes only, and confidentiality is assured. 1. Your Sex. a. Male b. Female 2. Your Age: years. 3. Highest level of education attained in Nursing. a. R.N. Diploma b. B.S.N. c. M.S.N. d. Ph.D. /Ed.D. /D.S.N. e. Other (specify) 4. Highest level of education attained in other than Nursing. a. B .A . /B .Ed . /B .Sc . b. M.A. /M.Ed. /M.Sc . /M.P .A . c. Ph.D. /Ed.D. d. Other (specify) 5. Your basic Nursing education program. a. Hospital Nursing program b. College Nursing program c. Baccalaureate Nursing program d. Other (specify) 6. Years in your present position. years. 7. Your present position. a. Head Nurse b. Supervisor/Coordinator c. Director/Assistant Director d. Other (specify) 8. Have you taught in a Nursing program? a. Yes (circle types of programs involved with) HOSPITAL COLLEGE UNIVERSITY b. No 178 9. Areas in which you have had clinical experience (Circle as many as apply). a. Medical — . b. Surgical c. Pediatrics d. Obstetrics e. Psychiatry f. Other (specify) 10. Which Nursing education program (if any) is involved in clinical practice in the agency where you are employed? (Circle as many as apply) a. There are no nursing education programs in the agency where I am employed b. Hospital programs c. College programs d. Bacclaureate programs e. Other (specify) 11. Approximately how may beds are there in the hospital where you are employed? .beds 179 Part Five - Demographic Data Physicians Confidential Please circle the letter or fill in the blank with the answer that BEST applies to you. This information is needed for statistical purposes only, and confidentiality is assured. 1. Your Sex. a. Male b. Female 2. Your Age: years 3. Highest level of education attained. a. M.D. b. Fellowship c. Other (specify) 4. In what area of medicine are you currently practising? a. General Practice b. General Surgery c. Internal Medicine d. Pediatrics e. Psychiatry f. Obstetrics and Gynecology g. Other (specify) 5. Number of years in present position. i years. 6. Have you ever been involved in teaching in Nursing program? a. Yes (circle types of programs involved with) HOSPITAL COLLEGE UNIVERSITY b. No 7. Are you aware of the differences in the three types of Nursing programs? a. Not aware b. Somewhat aware c. Aware d. Very aware 8. Which Nursing education program (if any) is involved in clinical practice in the agency where you practice (Circle as may as apply)? a. There are no nursing education programs in the agency where I practice b. Hospital programs c. College programs d. University degree e. Other (specify) : f. I don't know which programs are involved. 180 9. Approximately how may beds are there in the hospital in which you PRIMARILY practice? beds 10. Did your basic medical education program contain information on the different types of Nursing education programs? a. Yes (Please enlarge) b. No 181 Part Five - Demographic Data RNABC Representative Confidential Please circle the letter or fill in the blank with the answer that BEST applies to you. This information is needed for statistical purposes only, and confidentiality is assured. 1. Your Sex. a. Male b. Female 2. Age : years 3. Highest level of education attained in Nursing. a. R.N. Diploma b. B.S.N. c. M.S.N. d. Ph.D./Ed.D./D.S.N. e. Other (specify) 4. Highest level of education attained in other than Nursing. a. B.A./B.Ed./B.Sc. b. M.A./M.Ed./M.Sc./M.P.A. c. Ph.D./Ed.D. d. Other (specify) 5. Are you a Nurse? a. Yes (please circle Basic Education Received) Hospital Nursing Program College Nursing Program Baccalaureate Nursing Program Other(specify) . b. No 6. Your present position. a. Staff Head Nurse b. Nursing Service Administrator c. Nursing Educator d. Nursing Education Administrator e. Other (specify) 7. Number of years in your present position. yea rs 8. Have you ever been involved in teaching in a Nursing program? a. Yes (circle types of programs involved with) HOSPITAL COLLEGE UNIVERSITY b. No 182 9. Areas in which you have had clinical experience (Circle as many as apply). a. Medical b. Surgical c. Pediatrics d. Obstretrics e. Psychiatry f. Other (specify) 183 Part Five - Demographic Data Ministry Official Confidential Please circle the letter or fill in the blank with the answer that B E S T applies to you. This information is needed for statistical purposes only, and confidentiality is assured. 1. Your Sex. a. Male b. Female 2. Your Age : years 3. Are you a Nurse? a. Yes (please circle appropriate answer) Basic Nursing Education Received Hospital RN Diploma College RN Diploma University Other(specify) b. No 3. Highest level of education attained in Nursing. a. R .N . Diploma b. B . A . / B . E d . / B . S c . c. M . A . / M . E d . / M . P . A . / M . S c . d. P h . D . / E d . D . / D . S . N . e. Other (specify) 4. Your present position (Please specify) 5. Years in your present position. yea rs 6. Have you ever been involved in teaching in a Nursing program? a. Yes (circle types of programs involved with) H O S P I T A L C O L L E G E U N I V E R S I T Y b. No 7. Have you ever worked in a hospital? a. Yes (please specify type of employment) b. No 184 8. Are you aware of the differences in the three types of Nursing programs? a. Not aware b. Somewhat aware c. Aware d. Very aware 185 i" have not received a response to a questionnaire titled Nursing Educa-tion Survey sent to you approximately four weeks ago. It is very important that I receive your response to this questionnaire. As you may have misplaced it, I have enclosed a second copy of the questionnaire, with instructions and a self addressed stamped envelope for your convenience. Your return of the questionnaire prior to May 25, 1987 would greatly assist me in the completion of my research. Thank you for your participation in nursing education research. Yours truly, Sharon Frissell Doctoral Candidate 186 Dear Nurse Administrator: In April and in May I mailed envelopes to you requesting your partic-ipation in my doctoral dissertation study entitled Nursing Education Survey. Each envelope contained a letter of invitation, a copy of the question-naire and a self-addressed stamped envelope. Because the response rate is still insufficient to ensure an adequate sample, I am forwarding this last request. I realize that you are very busy and that this sort of re-quest creates an additional burden, but I do hope that you will consider it favorably before June 20, 1987. Your perception of nursing education is thought to be important and worthy of study. If you have already completed the questionnaire, thank you for your assistance. Please for-give this third communication. If not, this note is a reminder that your individual response is important in providing a balanced study. Thank you for your involvement in nursing education research. Yours truly, Sharon Frissell Doctoral Candidate University of British Columbia 187 Dear Nurse Educator: In April and in May I mailed envelopes to you requesting your partic-ipation in my doctoral dissertation study entitled Nursing Education Survey. Each envelope contained a letter of invitation, a copy of the question-naire and a self-addressed stamped envelope. Because the response rate is still insufficient to ensure an adequate sample, I am forwarding this last request. I realize that you are very busy and that this sort of re-quest creates an additional burden, but I do hope that you will consider it favorably before June 20, 1987. Your perception of nursing education is thought to be important and worthy of study. If you have already completed the questionnaire, thank you for your assistance. Please for-give this third communication. If not, this note is a reminder that your individual response is important in providing a balanced study. Thank you for your involvement in nursing education research. Yours truly, Sharon Frissell Doctoral Candidate University of British Columbia 188 Dear Physician: In April and in May I mailed envelopes to you requesting your partic-ipation in my doctoral dissertation study entitled Nursing Education Survey. Each envelope contained a letter of invitation, a copy of the question-naire and a self-addressed stamped envelope. Because the response rate is still insufficient to ensure an adequate sample, I am forwarding this last request. I realize that you are very busy and that this sort of re-quest creates an additional burden, but I do nope that you will consider it favorably before June 20, 1987. Your perception of nursing education is thought to be important and worthy of study. If you have already completed the questionnaire, thank you for your assistance. Please for-give this third communication. If not, this note is a reminder that your individual response is important in providing a balanced study. Thank you for your involvement in nursing education research. Yours truly, Sharon Frissell Doctoral Candidate University of British Columbia 189 Dear Ministry Official: In April and in May I mailed envelopes to you requesting your partic-ipation in my doctoral dissertation study entitled Nursing Education Survey. Each envelope contained a letter of invitation, a copy of the question-naire and a self-addressed stamped envelope. Because the response rate is still insufficient to ensure an adequate sample, I am forwarding this last request. I realize that you are very busy and that this sort of re-quest creates an additional burden, but I do hope that you will consider it favorably before June 20, 1987. Your perception of nursing education is thought to be important and worthy of study. If you have already completed the questionnaire, thank you for your assistance. Please for-give this third communication. If not, this note is a reminder that your individual response is important in providing a balanced study. Thank you for your involvement in nursing education research. Yours truly, Sharon Frissell Doctoral Candidate University of British Columbia 190 Dear RNABC Representative: In April and in May I mailed envelopes to you requesting your partic-ipation in my doctoral dissertation study entitled Nursing Education Survey. Each envelope contained a letter of invitation, a copy of the question-naire and a self-addressed stamped envelope. Because the response rate is still insufficient to ensure an adequate sample, I am forwarding this last request. I realize that you are very busy and that this sort of re-quest creates an additional burden, but I do hope that you will consider it favorably before June 20, 1987. Your perception of nursing education is thought to be important and worthy of study. If you have already completed the questionnaire, thank you for your assistance. Please for-give this third communication. If not, this note is a reminder that your individual response is important in providing a balanced study. Thank you for your involvement in nursing education research. Yours truly, Sharon Frissell Doctoral Candidate University of British Columbia 191 A P P E N D I X B Demographic Data Presented in this appendix are the demographic data for the respondents in the study. This section reports data obtained from nurse educators, nurse service administrators, physi-cians, ministry officials and representatives from the Registered Nurses Association of British Columbia ( R . N . A . B . C ) . There was a total response rate of nearly sixty-eight percent (67.6%) for the five respondent groups involved in the first part of the study. Seventy-two percent (72.3%) of the educators surveyed returned the questionnaire of which one hundred and fifty nine were usable. There was an eighty-two percent (82.1%) response rate for ad-ministrators, a fifty-four percent (54%) response rate for physicians, nearly a seventy-eight percent return rate (77.8%) for the ministry and an eighty percent response rate for the R.N.A.B.C. To summarize, seven hundred and forty questionnaires were mailed to the five respondent groups with five hundred returned (Table 1). Not every question was responded to by every participant, thus making the totals different on some questions. Nurse Educators (Educators) Tables 2 and 3 show that the typical educator who responded had taught for eight years and was presently teaching in a college diploma program that graduated an average of eighty-six (85.5) students every year. Teaching experience ranged from one to greater than twenty-one years. Most educators (62.3%) had attained a minimum of a B.S.N., twenty-six percent (25.8%) a M.S.N, and eighteen percent (18.2%) had attained a master's degree in other than nursing (Table 4 and Table 5). TABLE 1 Responses to Questionnaires RESPONDENTS Number Mailed Number Returned Percent Returned Number Usable Educators 220 159 72.3 159 Administrators 168 138 82.1 134 Physicians - 300 162 54.0 156 R.N.A.B.C. 25 20 80.0 20 Ministry 27 21 77.8 21 TOTAL 740 500 67.6 490 192 A l t h o u g h most educators (62 .3%) were teach ing in a college sett ing , the major ity ( 59 .7%) had also taught in a hospita l p rogram. O n l y twenty - f ive percent (24 .5%) had taught in a baccalaureate program and eleven percent (11 .3%) in a graduate nursing pro-g r a m . A l m o s t seventy percent of all educators (69 .8%) had at one t ime taught in a college program (Tables 6 and 7) . TABLE 2 Years of Teaching Experience NUMBER OF YEARS Number of Faculty Percent Mean St.Dev. Mode No response 4 2.5 8.00 4.55 6.00 1-5 40 25.5 6-10 71 45.2 11-15 '37 23.3 16-20 6 3.8 over 21 1 0.6 TOTAL 159 100.0 TABLE 3 Size of Program by Number of Graduates NUMBER OF STUDENTS Frequency Percent Mean St.Dev. Mode No response 8 5.0 85.56 45.54 100 1-25 5 3.1 26-50 33 20.8 51-100 61 38.4 101-150 45 28.3 greater than 151 7 4.4 TOTAL 159 100.0 193 TABLE 4 Highest Level of Education in Nursing Attained by Educators Frequency Percent No response 3 1.9 R.N. 8 5.0 B.S.N. 99 62.3 M.S.N. 41 25.8 Ph.D./D.S.N. 1 0.6 Other 7 4.4 TOTAL 159 100.0 TABLE 5 Level of Education Attained in Other Than Nursing Frequency Percent None 108 67.9 B.A. /B.Ed. /B.Sc. 4 2.5 M.A. /M.Ed/M.Sc/M.P.A. 29 18.2 Ph.D./Ed.D. 6 3.8 Other 12 7.5 TOTAL 159 100.0 TABLE 6 Type of Program In Which Educator Is Teaching Frequency Percent No response 2 1.3 Hospital 20 12.6 Diploma College 99 62.3 Diploma University 16 10.1 Baccalaureate Graduate 10 6.3 Other (RPN) 12 7.5 TOTAL 159 100.0 194 TABLE 7 Types of Programs in Which Educator Has Taught Frequency Percent Hospital 95 59.7 Dipjoma College 111 69.8 Diploma University 39 24.5 Baccalaureate Graduate 18 11.3 Program Other 21 13.2 Programs (LPN, RPN) TOTAL 159 100.0 From Table 8, clinical experience for educators was predominantly medical (86.2 per-cent). TABLE 8 Areas of Clinical Experience For Educators CLINICAL AREA Frequency Percent Medicine 137 86.2 Obstetrics 62 39.0 Pediatrics 80 50.3 Psychiatry 42 26.4 Surgery 130 81.8 Other 79 49.7 The size of the hospital where these worked with students varied greatly depending on location of the school (Tables 9 and 10). TABLE 9 Number of Hospital Beds Where Educators Practice Number Maximum Beds Minimum Beds Mean St. Dev. of beds 1500 75 367.25 345.574 195 TABLE 10 Number of Hospital Beds Where Educators Worked With Students NUMBER OF Frequency Percent BEDS No response 49 30.8 51-100 2 1.3 101-200 8 5.0 210-300 15 9.4 301-400 29 18.2 401-500 14 8.8 501-600 8 5.0 601-700 5 3.1 701-800 10 6.3 801-900 4 2.5 901-1000 10 6.3 1001 and over 5 3.1 TOTAL 159 100.0 From Tables 11 through 14 the typical educator was a female, forty-three years old and had graduated from a hospital nursing program. Less than four percent (3.8%) graduated from a college diploma program, yet that is where most teach. TABLE 11 Gender of Educator Frequency Percent No response 3 1.9 Male 6 3.8 Female 150 94.3 TOTAL 159 100.0 TABLE 12 Age of Educator Minimum Age Maximum Age Mean St. Dev. AGE 28 66 43.05 7.69 196 TABLE 13 Age of Educator Frequency Percent No response 5 3.1 26-30 years 5 3.1 31-35 years 16 10.1 36-40 years 38 23.9 41-45 years 47 29.6 46-50 years 26 16.4 51-55 years 10 6.3 over 56 years 12 7.5 TOTAL 159 100.0 TABLE 14 Basic Nursing Education for PROGRAM Frequency Percent No response 2 1.3 Hospital Diploma 99 62.3 College Diploma 6 3.8 University Baccalaureate (Generic) 49 30.8 Other 3 1.9 TOTAL 159 100.0 Mode 40.00 Nurse Service Administrators (Administrators) Tables 15 through Tables 18 contain data from administrators. The average adminis-trator was female, aged forty-five years and had not taught in a nursing education program. TABLE 15 Gender of Administrator Frequency Percent No response 5 3.7 Male 7 5.2 Female 122 91.1 TOTAL 134 100.0 197 TABLE 16 Age of Administrator Minimum Age Maximum Age Mean St. Dev. AGE 29 60 45.05 7.32 TABLE 17 Frequency and Age of Administrator AGE (in years) Frequency Percent No response 9 6.7 26-30 4 3.0 31-35 7 5.2 36-40 25 18.7 41-45 31 23.1 46-50 28 20.9 51-55 22 16.4 56 and 8 6.0 over TOTAL 134 100.0 TABLE 18 Types of Nursing Programs In Which Administrators Have Taught Frequency Percent Have not Taught in 85 63.4 a Nursing program Have Taught in 45 33.6 a Nursing program No response 4 3.0 Hospital program 32 23.9 College program 17 12.7 University program 19 14.2 All administrators had extensive clinical experience. Most administrators had experience in all specialty areas (Table 19). 198 TABLE 19 Areas in Which Administrators Have Had Clinical Experience Clinical Frequency Percent Area Medical 109 81.3 Obstetrics 82 61.2 Pediatrics 82 61.2 Psychiatry 52 38.8 Surgical 117 87.3 Other 91 67.9 The majority of administrators have been involved with nursing education programs. Most of the involvement (62.7%) was with college programs (Table 20). TABLE 20 Administrator's Involvement in Clinical Practice of Nursing Education Programs Frequency Percent No programs 36 26.9 Hospital program 13 9.7 College program 84 62.7 Baccalaureate 30 22.4 Other 24 17.9 Table 22 shows that most administrators are employed in hospitals with bed capacities of fewer than 200. The average bed capacity is 224 (Table 21). Most administrators (82.1%) received their nursing education in hospital diploma programs (Table 23). Many administrators (48.5%) hold the R.N. as the highest level of education in nursing (Table 24). TABLE 21 Beds In Hospitals of Administrators Minimum Beds Maximum Beds Mean St.Dev. NUMBER OF BEDS 2 1800 224.51 291.125 199 TABLE 22 Number of Hospital Beds Where Administrators Work NUMBER OF BEDS Frequency Percent No response 5 3.7 1-50 41 30.6 51-100 21 15.7 101-200 21 15.7 201-300 11 8.2 301-400 8 6.0 401-500 6 4.5 501-600 12 9.0 601-700 0 0.0 701-800 2 1.5 801-900 2 1.5 901-1000 2 1.5 over 1001 3 2.2 TOTAL 134 100.0 TABLE 23 Basic Nursing Education Program For Administrator T Y P E OF PROGRAM Frequency Percent No response 3 2.2 Hospital 110 82.1 College 10 7.5 Baccalaureate 10 7.5 Other 1 0.7 TOTAL 134 100.0 TABLE 24 Highest Level of Education in Nursing Attained by Administrator HIGHEST LEVEL OF Frequency Percent EDUCATION No response 4 3.0 R.N. 65 48.5 B.S.N. 37 27.6 M.S.N. 14 10.4 Other 14 10.4 TOTAL 134 100.0 200 Most administrators did not have degrees in other than nursing (Table 25) and had worked for one to five years in their present position with the average being 5.5 years (Table 26). TABLE 25 Highest Level of Education Attained in 1 Nursing By Administrator DEGREE Frequency Percent None 89 66.4 B.A. /B.Ed. /B.Sc. 3 2.2 M.A. /M.Ed. /M.Sc. /M.P.A. 3 2.2 Ph.D./Ed.D. 1 0.7 Other 38 28.4 TOTAL 134 100.0 TABLE 26 Years Administrators Had Been in Present Position YEARS Frequency Percent Mean St. Dev. Mode No response 5 3.7 5.55 5.74 1.00 1-5 years 75 56.0 6-10 years 41 30.6 11-15 years 9 6.7 16-20 years 1 0.7 21 and over 3 2.2 TOTAL 134 100.0 Physicians Of the hundred and sixty two questionnaires returned by physicians, nineteen were returned with few or no comments. Comments returned with unanswered questionnaires included: "I have no knowledge of this...", "Insufficient contact with nurses to know..." and "I don't have the temperament for completing this kind of stuff...." Two physicians wrote letters. Said one, "I am, with sadness, returning your nursing education survey not completed. When one puts things in the form of a survey like this, the form of question to a large extent determines the answer. The answers that I would give would not fit with your questionnaire. I am dismayed at the education of nurses as I see it... I think there is a need for a rethinking of nursing much more fundamental than the questions in your questionnaire would indicate..." Four physicians asked nurses to complete the form. These four questionnaires were not used. 201 TABLE 27 Responding Physician's Area of Medical Practice GENERAL AREA Frequency Percent No response 23 14.7 General Practice 58 37.2 General Surgery 8 5.1 Gynecology 9 5.8 Internal Medicine 10 6.4 Pediatrics 4 2.6 Psychiatry 4 2.6 Other (Anesthesiology, 40 25.6 Radiology, Laboratory, Pathology, etc.) TOTAL 156 100.0 The areas of medical practice with the greatest number of physicians (37.2%) were in general practice and the 'other' category (25.6%) General Surgery, Internal Medicine, and Gynecology were quite evenly distributed (Table 27). From Tables 28 and 29, it can be seen that the average physician was male (70.5%) and had practised ten (10.23) years who responded the most frequently to the questionnaire. The number of beds in the hospitals at which physicians practised ranged from less than twenty to over one thousand (Table 30), the average 308 (Table 30). Over half (57.1%) of the physicians practiced in hospitals with over three hundred beds (Table 31). Years in TABLE 28 Practice of Physician! YEARS IN PRACTICE Frequency Percent Mean St.Dev. no response 25 16.0 10.23 9.83 1-5 years 38 24.4 6-10 years 32 20.5 11-15 years 20 12.8 16-20 years 21 13.5 21-25 years 6 3.8 26-30 years 7 4.5 31-35 years 4 2.6 36-40 years 2 1.3 41 and over 1 0.6 TOTAL 156 100.0 Mode Median 0.0 8.00 202 No response Male Female TOTAL TABLE 29 Gender of the Physician Frequency 23 110 23 156 Percent 14.7 70.5 14.7 100.0 Number of beds TABLE 30 Beds in Hospitals at Which Physicians Practice Maximum Beds Minimum Beds Mean 20 1000 308.17 St. Dev. 228.159 TABLE 31 Frequency and Percent of Beds in Hospitals at Which Physicians Practice NUMBER OF BEDS no response 1-50 51-100 101-200 201-300 301-400 401-500 501-600 601-700 701-800 801-900 901-1000 Missing TOTAL Frequency 32 1 4 14 15 58 19 2 0 4 3 3 1 156 Percent 20.5 0.6 2.6 9.0 9.6 37.2 12.2 1.3 0.0 2.6 1.9 1.9 0.6 100.0 Mode 0.0 203 The average age of the physician was forty-four years of age (Table 32), the youngest physician twenty-six and the eldest seventy-one (Table 40). Approximately one third (35.3%) of the physicians were specialists, attaining a fellowship (Table 33). TABLE 32 Age of Physician Minimum Age Maximum Age Mean St. Dev. Mode AGE 26 71 44.16 10.90 34.00 TABLE 33 Highest Level of Education Attained by Physicians DEGREE Frequency Percent No response 24 15.4 M.D. 67 42.9 Fellowship 55 35.3 Other 10 6.4 TOTAL 156 100.0 Physicians were asked to respond to a question that asked how aware they were of the differences among the three types of nursing education programs. Table 34 reveals that 52.5% were either not aware or only somewhat aware of the differences in the three programs, whereas 32.1% stated that they were either aware or very aware of the differences. TABLE 34 Awareness of Physicians of the Differences in Preparation of the Three Types of Nursing Education Programs Degree of Awareness Frequency Percent No response 24 15.4 Not aware 20 12.8 Somewhat aware 62 39.7 Aware 38 24.4 Very Aware 12 7.7 TOTAL 156 100.0 Table 35 reveals that 78.8% of the physicians said that their medical curriculum had not provided them with knowledge of the different nursing education programs. 204 TABLE 35 Response of Physicians to Whether Medical Curriculum Provided Knowledge Concerning Types of Nursing Education Programs RESPONSES Frequency Percent no response 23 14.1 no 123 78.8 yes 9 5.8 TOTAL 155 100.0 Physicians were also asked whether any nursing education programs were engaged in clinical practice in the hospital where they practised. From Table 36, nine percent said there were no nursing education programs, 23.1% said that hospital programs were involved in clinical practice where they worked, 59.6% said that college programs were involved and 10.9% said that the baccalaureate program was involved. More than one third (34.0%) have been involved with teaching in nursing programs, 27.6% in hospital nursing programs, 8.3% in college programs, and 8.3% have been involved in university baccalaureate programs (Tables 37 and 38). TABLE 36 Responses of Physicians to the Type of Nursing Education Programs that Involve Clinical Practice in the Hospital Where They Work T Y P E OF Frequency Percent PROGRAM No programs 14 9.0 Hospital Diploma 36 23.1 College Diploma 93 59.6 University 17 10.9 Don't Know 7 4.5 Other programs 4 2.6 TABLE 37 Physician's Involvement in Teaching Nursing Programs INVOLVEMENT Frequency Percent IN TEACHING No response 24 15.4 Yes 53 34.0 No 79 50.6 205 TABLE 38 Type of Nursing Program Physicians Have Been Involved in Teaching T Y P E OF PROGRAM Hospital Diploma College Diploma University Baccalaureate Frequency 43 13 13 Percent 27.6 8.3 8.3 Representatives from the Registered Nurses Association (R.N.A.B.C. ) Even though the sample was small (twenty-five), the return rate was high (80%). The average representative was female, nearly forty-four years old (43.6) and had been in the present position for an average of 5.5 years (Tables 39, 40, 41 and 42). TABLE 39 Gender of R.N.A.B.C. Representative Frequency Percent No response 1 5.0 Female 16 80 Male 3 15 TOTAL 20 100.0 TABLE 40 Age of R.N.A.B.C. Representative AGE (in years) Frequency Percent Mode no response 1 5.0 40.0 1-20 1 5.0 21-25 0 0.0 26-30 0 0.0 31-35 0 0.0 36-40 6 30.0 41-45 7 35.0 46-50 1 5.0 51-55 3 15.0 56 and over 1 5.0 TOTAL 20 100.0 206 TABLE 41 Age of the R.N.A.B.C. Representative Minimum Age Maximum Age Mean St. Dev. AGE 20 63 43.6 9.04 TABLE 42 Years Representative Has Been In Present Position YEARS Frequency Percent Mean St.Dev. Mode no response 1 5 5.5 4.27 3.0 1-2 years 3 15 3-5 years 8 40 6-9 years 5 25 10 years and over 3 15 TOTAL 20 100 Most (85%) of the representatives were nurses (Table 43). TABLE 43 Identification of Whether or not the R.N.A.B.C. Representative is a Nurse ARE YOU A Frequency Percent NURSE no response 1 5 Yes 17 85 No 2 10 TOTAL 20 100.0 More than one third (35%) had attained a B.S.N, in nursing; 20% a master's degree in nursing and 30% percent an R.N. diploma. While 45% did not have any other education than nursing, 20% had earned a master's degree in other than nursing (Tables 44 and 45). TABLE 44 Highest Level of Education in Nursing Attained by R.N.A.B.C. Representative DIPLOMA/ DEGREE Frequency Percent No response 2 10 R.N. 6 30 B.S.N. 7 35 M.S.N. 4 20 Ph.D./D.S.N. 0 0 Other 1 5 TOTAL 20 100.0 207 TABLE 45 Highest Level of Education Attained in Other Than Nursing by R.N.A.B.C. Representative DEGREE Frequency Percent No reponse 1 5 None 9 45 B.A. /B.Ed. /B.Sc. 2 10 M.A. /M.Ed. /M.P.A. /M.Sc. 4 20 Ph.D. 0 0 Other 4 20 TOTAL 20 100.0 Clinical preparation of the R.N.A.B.C. representative was extensive, with medicine and surgery the areas most frequently mentioned (Table 46). TABLE 46 Areas In Which R.N.A.B.C. Representative Has Had Clinical Experience CLINICAL AREA Frequency Percent Medicine 14 70 Obstetrics 6 30 Pediatrics 9 45 Psychiatry 7 35 Surgery 14 70 Other 13 65 From Tables 47 and 48, the majority of R.N.A.B.C. representatives (70%) had taught in a nursing education program, 40% were involved with college based programs, 30% with university programs, and 30% with hospital programs. 208 TABLE 47 R.N.A.B.C.'s Involvement in Teaching in Nursing Programs INVOLVEMENT IN Frequency Percent TEACHING No response 1 S Yes 14 70 No 5 25 TABLE 48 Type of Nursing Program R.N.A.B.C. Representative Has Taught T Y P E OF PROGRAM Frequency Percent No programs 5 25 Hospital Diploma 6 30 College Diploma 8 40 University Baccalaureate 6 30 R.N.A.B.C. respondents were all involved in teaching or administrative positions in the province: forty percent of the representatives were administrators and fifteen percent were educators (Table 49). When this was the case, to prevent duplication of responses from the same person, names of these people were struck from either the nursing service administrator list or the nurse educator list. TABLE 49 Present Position of R.N.A.B.C. Representative POSITION Frequency Percent No response 1 5 Head Nurse 2 10 Nursing Service 5 25 Administrator Nurse Educator 3 15 Educational Administrator 1 5 Other 8 40 TOTAL 20 100.0 209 Ministry Officials (Ministry) Even though the population was small (twenty-seven), the return rate was high (77.8%). Some of the respondents stated their background did not assist them to properly complete the questionnaire. Said one, "I completed the questionnaire to the best of my ability but we both recognize that the detailed nature of most of the questions did not correspond with my background. I want to emphasize that neither college administrators nor ministry staff are major contributors to defining the content of nursing programs." Another respondent who refused to complete the questionnaire telephoned with reasons: "I do not have the expertise in content to be able to make curricular decisions about what content should be included. I rely on content experts to do that — they advise me on this decision...! set an overall parameter — what I can say is that I have an overall budget of X million dollars and then a group of people assist in generating weights. If I get a question, such as, "will we fund a three year program in nursing education," the answer is "no, we don't fund it, you must decrease the content but we don't decide on the content that is to be decreased — that is the work of the content experts." From Tables 50 through 53, the average ministry official was equally likely to be male or female aged forty-five years. Most ministry officials (66.7%) had been in the present position from one to four years, an average of four years. TABLE 50 Gender of Ministry Official Frequency Percent No response 1 4.8 Male 9 42.9 Female 11 52.4 TOTAL 21 100.0 TABLE 51 Age of Ministry Official Minimum Age Maximum Age Mean St. Dev. AGE 32 60 45.0 8.42 210 TABLE 52 Frequency and Percent of Ages of Ministry Official AGE (in years) Frequency Percent No response 4 19 31-35 4 19 36-40 1 4.8 41-45 5 23.8 46-50 4 19 51-56 1 4.8 56 and over 2 9.5 TOTAL 21 100.0 TABLE 53 Years Ministry Official Had Been in Present Position YEARS IN POSITION Frequency Percent Mean St.Dev. Mode No response 4 9.5 4.0 3.95 1.0 less than 1 year 3 14.3 I- 5 years 11 52.4 6-10 years 3 14.3 II- 15 years 2 9.5 TOTAL 21 100.0 From Tables 54 through 57, ten officials were R.N.'s. Of the ten that were nurses (47.6%), seven had received their basic nursing education in a hospital and three were educated at a university rather than a college. The highest level achieved in nursing was a master's degree (9.5%), whereas three (14.3%) had master's degrees in other than nursing. TABLE 54 Identification of Whether or not the Ministry Official is a Nurse ARE YOU A Frequency Percent NURSE Yes 10 47.6 No 11 52.4 TOTAL 21 100.0 2 1 1 T Y P E OF PROGRAM Hospital Diploma College Diploma University Degree TABLE 55 Basic Education Program for Ministry Officials Who Are Nurses Frequency Percent 33.3 0.0 19.3 TABLE 56 Highest Level of Education Attained by Ministry Officials DEGREE Frequency Percent No response 8 38.4 R.N. 0 0.0 B.S.N. 2 9.5 M.S.N. 2 9.5 M.A/M.Ed/M.P.A. 3 14.3 Ph.D. 2 9.5 M.D. 2 9.5 Other 2 9.5 TOTAL 21 100.0 While information about education levels was not specifically requested of officials who were not nurses, four respondents volunteered this information. Two were medical doctors and two were educated at the Ph.D. level (Table 56). Two had taught nursing in a hospital, three at a college, college, and two at a university (Table 58). TABLE 57 Number of Ministry Officials That Have Taught In Nursing Programs HAVE YOU TAUGHT IN A NURSING EDUCATION PROGRAM Frequency Percent No response 2 9.5 Yes 5 23.8 No 14 66.7 TOTAL 21 100.0 212 TYPES OF PROGRAMS Hospital Diploma College Diploma University Baccalaureate TABLE 58 Types of Nursing Programs in Which Ministry Officials Have Taught Frequency 2 3 2 Percent 9.5 14.3 9.5 From Table 59, 61.9% had worked in a hospital. TABLE 59 Ministry Official Employed In a Hospital Setting EVER WORKED Frequency Percent IN A HOSPITAL? Yes 13 61.9 No 8 38.1 TOTAL 21 100.0 When ministry officials were asked asked how aware they were of the differences in preparation of the three types of nursing education programs, a majority (71.5%) were either aware or very aware of the differences whereas a small percent (9.5%) said they were only somewhat aware (Table 60). TABLE 60 Awareness of Ministry Officials of the Differences in Preparation of the Three Types of Nursing Education Programs DEGREE OF AWARENESS Frequency Percent No response 4 19.0 Not aware 0 0.0 Somewhat aware 2 9.5 Aware 3 14.3 Very Aware 12 57.2 TOTAL 21 100.0 The present positions occupied by this group were varied: five of the respondents were at the level of consultant, five were directors, one was an assistant director, one was a coordinator, two were deans, two were analysts, two were adminstrators, two did not give a response as to their position and one was an assistant deputy minister. 213 APPENDIX C TABLE 1 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA BURN UNIT NOT NEEDED NEEDED 1 2 3 4 S 6 7 MEAN ST.DEV. EDUCATOR 64.2 7.9 13.2 9.3 2.0 2.0 1.3 1.88 1.40 ADMINISTRATOR 38.8 8.5 13.2 15.5 10.9 1.6 11.6 3.02 2.06 PHYSICIAN 31.0 16.7 10.3 21.4 11.9 1.6 7.1 3.00 1.84 R.N.A.B.C. 47.1 5.9 11.8 17.6 11.8 0.0 5.9 2.65 1.90 MINISTRY 35.0 15.0 25.0 10.0 0.0 5.0 10.0 2.80 1.96 OVERALL MEAN 2.60 TABLE 2 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA CARDIOVASCULAR THORACIC NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 37.1 6.0 10.6 19.9 7.9 7.9 10.6 3.22 2.11 ADMINISTRATOR 39.8 7.8 7.0 16.4 10.2 5.5 13.3 3.19 2.20 PHYSICIAN 35.9 18.0 12.5 11.7 15.6 0.8 5.5 2.77 1.81 R.N.A.B.C. 41.2 11.0 5.9 17.6 11.8 11.8 0.0 2.82 1.91 MINISTRY 36.8 15.8 10.5 10.5 21.1 5.3 0.0 2.79 1.78 OVERALL MEAN 3.05 TABLE 3 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA CLINICAL RESEARCH NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 58.8 12.4 9.8 9.2 5.9 2.6 1.3 2.03 1.52 ADMINISTRATOR 54.3 10.9 13.2 9.3 8.5 0.0 3.9 2.22 1.66 PHYSICIAN 54.3 19.7 10.2 10.2 2.4 0.8 2.4 1.98 1.41 R.N.A.B.C. 66.7 5.6 5.6 11.1 0.0 11.1 0.0 2.06 1.76 MINISTRY 40.0 25.0 15.0 10.0 5.0 0.0 5.0 2.35 1.63 OVERALL MEAN 2.09 214 TABLE 4 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA CORONARY INTENSIVE CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 56.1 9.7 9.7 10.3 9.0 2.6 2.6 2.25 1.70 ADMINISTRATOR 19.8 3.8 11.5 13.0 12.2 9.9 29.8 4.43 2.26 PHYSICIAN 10.5 6.0 9.8 15.0 20.3 18.8 19.5 4.63 1.90 R.N.A.B.C. 44.4 22.2 11.1 5.6 5.6 5.6 5.6 2.44 1.89 MINISTRY 20.0 5.0 10.0 25.0 25.0 5.0 10.0 3.85 1.89 OVERALL MEAN 3.64 TABLE 5 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA DAY CARE ADULT NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 13.5 6.8 6.8 20.3 20.3 12.2 20.3 4.45 1.97 ADMINISTRATOR 20.2 4.7 10.9 17.1 13.2 6.2 27.9 4.29 2.22 PHYSICIAN 9.8 9.1 8.3 23.5 18.2 9.8 21.2 4.45 1.90 R.N.A.B.C. 17.6 0.0 0.0 23.5 17.6 11.8 29.4 4.76 2.14 MINISTRY 20.0 5.0 10.0 15.0 20.0 15.0 15.0 4.15 2.10 OVERALL MEAN 4.40 TABLE 6 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA DAY CARE PEDIATRICS NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 15.6 8.2 6.1 18.4 20.4 10.2 21.1 4.35 2.05 ADMINISTRATOR 23.4 3.9 10.9 18.0 17.2 3.9 22.7 4.04 2.19 PHYSICIAN 10.6 6.8 9.8 23.5 18.2 9.1 22.0 4.47 1.91 R.N.A.B.C. 29.4 0.0 5.9 23.5 11.8 11.8 17.6 3.94 2.27 MINISTRY 20.0 0.0 15.0 15.0 15.0 20.0 15.0 4.25 2.09 OVERALL MEAN 4.24 215 TABLE 7 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA DERMATOLOGY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 34.5 12.8 12.8 21.6 12.2 3.4 2.7 2.85 2.05 ADMINISTRATOR 20.2 7.0 12.4 20.2 10.9 7.0 22.5 4.05 1.86 PHYSICIAN 12.2 16.8 19.1 24.4 9.9 5.3 12.2 3.70 1.40 R.N.A.B.C. 33.3 5.6 11.1 16.7 16.7 5.6 11.1 3.39 2.12 MINISTRY 5.6 11.1 5.6 27.8 33.3 5.6 11.1 4.33 1.93 OVERALL MEAN 3.53 TABLE 8 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA EMERGENCY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 31.8 11.7 9.1 11.0 19.5 9.7 7.1 3.32 2.05 ADMINISTRATOR 7.6 0.8 4.6 9.2 9.9 9.9 58.0 5.75 1.85 PHYSICIAN 3.7 0.0 3.0 2.2 8.9 20.7 61.5 6.21 1.39 R.N.A.B.C. 22.2 0.0 11.1 16.7 22.2 11.1 16.7 4.17 2.12 MINISTRY 5.0 10.0 0.0 10.0 15.0 15.0 45.0 5.45 1.93 OVERALL MEAN 4.99 TABLE 9 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA EXTENDED CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 1.3 0.0 1.9 5.0 14.5 15.7 61.4 6.25 1.17 ADMINISTRATOR 1.5 0.0 2.3 10.0 6.9 11.5 67.7 6.26 1.29 PHYSICIAN 6.8 0.8 2.3 13.5 23.3 16.5 36.8 5.42 1.69 R.N.A.B.C. 0.0 0.0 0.0 11.1 11.1 16.7 61.1 6.28 1.07 MINISTRY 0.0 0.0 5.0 10.0 25.0 15.0 45.0 5.85 1.26 OVERALL MEAN 6.00 216 TABLE 10 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA GYNECOLOGY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 5.4 1.3 4.0 10.1 21.5 19.5 38.3 5.52 1.64 ADMINISTRATOR 0.8 0.8 0.8 6.9 10.7 6.9 73.3 6.40 1.16 PHYSICIAN 1.5 0.0 2.2 14.1 21.5 17.0 43.7 5.80 1.32 R.N.A.B.C. 0.0 0.0 0.0 0.0 11.1 22.2 66.7 6.56 0.70 MINISTRY 0.0 0.0 0.0 21.1 15.8 26.3 36.8 5.79 1.18 OVERALL MEAN 5.91 TABLE 11 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA HOME CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 14.5 7.5 9.4 17.0 17.0 12.6 22.0 4.40 2.05 ADMINISTRATOR 18.8 1.6 10.2 20.3 18.8 4.7 25.8 4.36 2.11 PHYSICIAN 10.7 8.4 9.2 29.8 13.0 7.6 21.4 4.34 1.91 R.N.A.B.C. 16.7 5.6 11.1 5.6 22.2 5.6 33.3 4.61 2.27 MINISTRY 10.0 5.0 0.0 30.0 15.0 10.0 30.0 4.85 1.95 OVERALL MEAN 4.40 TABLE 12 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA INDUSTRIAL NURSING NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 53.9 13.2 13.2 11.2 5.3 0.7 2.6 2.13 1.53 ADMINISTRATOR 47.7 11.5 15.4 13.1 8.5 1.5 2.3 2.37 1.61 PHYSICIAN 30.2 20.9 17.1 22.5 7.0 1.6 0.8 2.63 1.44 R.N.A.B.C. 60.0 6.7 6.7 13.3 6.7 6.7 0.0 2.20 1.74 MINISTRY 25.0 25.0 15.0 25.0 0.0 5.0 5.0 2.85 1.69 OVERALL MEAN 2.38 217 TABLE 13 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA LABOR AND DELIVERY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 5.8 3.9 2.6 12.3 12.3 12.9 50.3 5.61 1.81 ADMINISTRATOR 3.1 0.8 0.8 5.3 10.7 7.6 71.8 6.30 1.39 PHYSICIAN 2.2 1.5 1.5 8.9 15.6 18.5 51.9 5.97 1.40 R.N.A.B.C. 5.6 5.6 16.7 0.0 16.7 22.2 33.3 5.16 1.95 MINISTRY 10.0 0.0 0.0 0.0 5.0 25.0 60.0 6.05 1.82 OVERALL MEAN 5.92 TABLE 14 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA GENERAL MEDICINE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 0.0 1.3 98.7 6.99 0.11 ADMINISTRATOR 0.0 0.0 0.0 0.0 1.5 0.0 98.5 6.97 0.25 PHYSICIAN 0.7 0.0 0.0 1.5 3.7 13.3 80.7 6.70 0.77 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 0.0 100.0 7.0 0.0 MINISTRY 0.0 0.0 0.0 0.0 0.0 10.0 90.0 6.9 0.31 OVERALL MEAN 6.90 TABLE 15 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA MEDICAL INTENSIVE CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 38.5 6.4 10.9 16.7 15.4 5.8 6.4 3.07 1.98 ADMINISTRATOR 13.4 2.4 4.7 16.5 18.1 14.2 30.7 4.89 2.02 PHYSICIAN 6.7 4.4 6.7 18.5 17.8 18.5 27.4 5.01 1.80 R.N.A.B.C. 38.9 16.7 5.6 5.6 11.1 5.6 16.7 3.17 2.38 MINISTRY 25.0 10.0 5.0 10.0 20.0 20.0 10.0 3.90 2.19 OVERALL MEAN 4.19 218 TABLE 16 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA MENTAL HEALTH (OUTPATIENT) NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 16.3 4.6 7.2 18.3 20.9 10.5 22.2 4.43 2.04 ADMINISTRATOR 18.0 5.5 8.6 20.3 15.6 8.6 23.4 4:30 2.11 PHYSICIAN 6.8 5.3 11.3 21.8 19.5 13.5 21.8 4.70 1.78 R.N.A.B.C. 16.7 11.1 11.1 16.7 16.7 11.1 16.7 4.06 2.09 MINISTRY 5.0 0.0 20.0 30.0 20.0 0.0 25.0 4.60 1.70 OVERALL MEAN 4.46 TABLE 17 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA NEUROLOGY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 12.3 1.9 8.4 24.7 19.5 14.3 18.8 4.55 1.86 ADMINISTRATOR 7.8 2.3 3.9 14.0 19.4 8.5 44.2 5.37 1.87 PHYSICIAN 6.8 12.1 15.2 22.7 19.7 11.4 12.1 4.19 1.73 R.N.A.B.C. 0.0 0.0 11.1 22.2 16.7 11.1 38.9 5.44 1.50 MINISTRY 10.0 0.0 5.0 35.0 35.0 0.0 15.0 4.45 1.60 OVERALL MEAN 4.71 TABLE 18 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA NEUROSURGERY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 18.5 6.0 9.9 25.8 17.9 9.9 11.9 3.96 1.92 ADMINISTRATOR 14.1 5.5 10.2 17.2 14.8 10.2 28.1 4.56 2.09 PHYSICIAN 17.7 17.7 13.8 21.5 14.6 6.9 7.7 3.49 1.82 R.N.A.B.C. 27.8 11.1 5.6 11.1 22.2 5.6 16.7 3.72 2.27 MINISTRY 15.0 15.0 20.0 15.0 30.0 0.0 5.0 3.50 1.67 OVERALL MEAN 3.97 219 TABLE 19 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA NEWBORN INTENSIVE CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 56.4 13.5 7.7 9.0 6.4 4.5 2.6 2.19 1.70 ADMINISTRATOR 27.9 9.3 6.2 16.3 17.1 4.7 18.6 3.74 2.22 PHYSICIAN 21.2 12.1 15.2 19.7 12.9 7.6 11.4 3.59 1.97 R.N.A.B.C. 44.4 11.1 5.6 16.7 11.1 5.6 5.6 2.78 2.01 MINISTRY 25.0 25.0 15.0 15.0 0.0 10.0 10.0 3.10 2.02 OVERALL MEAN 3.10 TABLE 20 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA NURSERY SCHOOL NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 46.4 9.9 9.9 12.6 8.6 6.0 6.6 2.72 1.99 ADMINISTRATOR 55.2 9.6 12.8 8.0 4.0 4.0 6.4 2.34 1.87 PHYSICIAN 38.5 17.2 12.3 13.9 9.8 2.5 5.7 2.70 1.82 R.N.A.B.C. 56.3 6.3 12.5 6.3 6.3 12.5 0.0 2.38 1.89 MINISTRY 35.0 15.0 15.0 20.0 10.0 0.0 5.0 2.75 1.74 OVERALL MEAN 2.59 TABLE 21 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA ORTHOPEDICS NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 3.2 1.3 1.9 11.7 18.8 21.4 41.6 5.72 1.48 ADMINISTRATOR 0.0 0.8 2.3 7.6 3.8 16.0 69.5 6.40 1.10 PHYSICIAN 2.2 2.2 7.5 17.2 26.1 14.2 30.6 5.27 1.53 R.N.A.B.C. 0.0 0.0 0.0 11.1 27.8 11.1 50.0 6.00 1.14 MINISTRY 0.0 0.0 0.0 25.0 40.0 20.0 15.0 5.25 1.01 OVERALL MEAN 5.78 220 TABLE 22 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA GENERAL SURGERY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 0.0 3.8 96.2 6.96 0.19 ADMINISTRATOR 0.0 0.0 0.0 0.8 1.5 0.8 96.9 6.93 0.37 PHYSICIAN 0.0 0.0 2.2 3.7 5.2 15.6 73.3 6.51 0.92 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 0.0 100. 7.00 0.00 MINISTRY 0.0 0.0 0.0 0.0 5.0 10.0 85.0 6.80 0.52 OVERALL MEAN 6.82 TABLE 23 CORSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA SURGICAL INTENSIVE CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 42.9 7.7 8.3 14.1 15.4 5.8 5.8 2.92 2.00 ADMINISTRATOR 19.7 0.8 4.7 20.5 18.1 7.9 28.3 4.54 2.16 PHYSICIAN 14.3 7.5 12.0 20.3 19.5 10.5 15.8 4.18 1.93 R.N.A.B.C. 38.9 16.7 5.6 16.7 11.1 5.6 5.6 2.83 1.98 MINISTRY 25.0 5.0 20.0 10.0 10.0 20.0 10.0 3.75 2.15 OVERALL MEAN 3.77 TABLE 24 CROSS TABLUATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA SURGICAL RECOVERY ROOM NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 14.2 5.8 9.7 15.5 16.1 14.2 24.5 4.54 2.07 ADMINISTRATOR 4.7 0.0 2.3 12.5 10.9 11.7 57.8 5.91 1.60 PHYSICIAN 9.0 9.0 9.7 15.7 17.2 11.2 28.4 4.70 1.99 R.N.A.B.C. 16.7 5.6 11.1 11.1 16.7 16.7 22.2 4.44 2.18 MINISTRY 10.0 0.0 10.0 10.0 15.0 15.0 40.0 5.25 2.00 OVERALL MEAN 5.00 221 TABLE 25 CROSS TABULATIONS BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA OPERATING ROOM NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 28.2 7.1 10.3 16.7 16.7 8.3 12.8 3.63 2.11 ADMINISTRATOR 4.7 3.1 3.9 14.7 13.2 8.5 51.9 5.62 1.77 PHYSICIAN 6.0 5.2 8:2 15.7 17.2 9.0 38.8 5.15 1.89 R.N.A.B.C. 22.2 0.0 5.6 16.7 11.1 11.1 33.3 4.61 2.35 MINISTRY 15.0 5.0 15.0 5.0 15.0 20.0 25.0 4.60 2.19 OVERALL MEAN 4.72 TABLE 26 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA OPHTHAMOLOGY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 20.9 7.8 9.8 26.8 15.7 9.2 9.8 3.75 1.91 ADMINISTRATOR 10.7 2.3 9.9 16.8 13.7 6.9 39.7 5.00 2.04 PHYSICIAN 13.7 20.6 11.5 29.0 10.7 6.1 8.4 3.54 1.76 R.N.A.B.C. 27.8 11.1 11.1 11.1 11.1 11.1 16.7 3.67 2.30 MINISTRY 5.3 5.3 21.1 26.3 21.1 5.3 15.8 4.32 1.66 OVERALL MEAN 4.07 TABLE 27 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA OUTPATIENTS NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 10.9 7.7 10.3 22.4 12.8 10.3 25.6 4.52 2.00 ADMINISTRATOR 12.5 4.7 10.2 15.6 19.5 6.3 31.3 4.69 2.06 PHYSICIAN 11.4 5.3 9.8 18.2 15.9 14.4 25.0 4.65 1.98 R.N.A.B.C. 11.8 0.0 0.0 11.8 29.4 17.6 29.4 5.18 1.88 MINISTRY 5.0 10.0 5.0 15.0 25.0 15.0 25.0 4.90 1.83 OVERALL MEAN 4.65 222 TABLE 28 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA PEDIATRICS NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 1.3 0.0 2.6 4.5 10.4 11.7 69.5 6.36 1.19 ADMINISTRATOR 1.5 0.8 1.5 3.8 6.1 5.3 80.9 6.52 1.19 PHYSICIAN 1.5 0.7 0.7 6.7 11.1 20.0 59.3 6.22 1.22 R.N.A.B.C. 0.0 0.0 11.1 5.6 0.0 16.7 66.7 6.22 1.40 MINISTRY 0.0 0.0 0.0 0.0 5.0 40.0 55.0 6.50 0.61 OVERALL MEAN 6.36 TABLE 29 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA PEDIATRIC INTENSIVE CARE NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 60.9 7.7 10.9 9.0 7.1 2.6 1.9 2.09 1.62 ADMINISTRATOR 27.1 3.1 9.3 21.7 12.4 7.8 18.6 3.87 2.18 PHYSICIAN 19.4 10.4 15.7 26.1 9.7 6.7 11.9 3.64 1.91 R.N.A.B.C. 61.1 0.0 11.1 16.7 5.6 0.0 5.6 2.28 1.84 MINISTRY 30.0 15.0 15.0 20.0 5.0 15.0 0.0 3.00 1.81 OVERALL MEAN 3.09 TABLE 30 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA PHYSICIAN'S OFFICES NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 57.9 7.9 13.2 9.2 6.6 2.6 2.6 2.17 1.65 ADMINISTRATOR 55.9 4.7 11.8 11.0 9.4 1.6 5.5 2.40 1.86 PHYSICIAN 33.1 10.5 16.5 20.3 9.8 3.8 6.0 2.99 1.83 R.N.A.B.C. 55.6 5.6 11.1 5.6 11.1 5.6 5.6 2.50 2.04 MINISTRY 20.0 25.0 20.0 20.0 5.0 5.0 5.0 3.00 1.69 OVERALL MEAN 2.53 223 TABLE 31 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA PLASTIC SURGERY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 44.8 9.1 14.9 9.7 7.1 7.1 7.1 2.75 2.00 ADMINISTRATOR 33.3 9.5 10.3 13.5 11.1 10.3 11.9 3.38 2.18 PHYSICIAN 21.5 18.5 18.5 23.8 10.0 0.0 7.7 3.13 1.71 R.N.A.B.C. 35.3 23.5 11.8 5.9 11.8 5.9 5.9 2.76 1.95 MINISTRY 31.6 5.3 26.3 10.5 10.5 10.5 5.3 3.16 1.95 OVERALL MEAN 3.06 TABLE 32 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA POSTPARTUM NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 1.3 0.0 1.3 3.2 8.3 8.3 77.6 6.53 1.07 ADMINISTRATOR 1.5 0.8 0.0 2.3 6.9 3.8 84.7 6.63 1.06 PHYSICIAN 3.0 3.7 8.9 9.6 17.0 11.1 46.7 5.54 1.72 R.N.A.B.C. 0.0 0.0 5.6 0.0 5.6 22.2 66.7 6.44 1.04 MINISTRY 0.0 0.0 0.0 10.0 10.0 20.0 60.0 6.30 1.03 OVERALL MEAN 6.25 TABLE 33 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA PSYCHIATRY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 3.8 2.5 3.2 3.8 8.9 11.5 66.2 6.11 1.60 ADMINISTRATOR 1.5 0.8 0.8 7.6 6.1 8.4 74.8 6.40 1.24 PHYSICIAN 2.3 1.5 5.3 18.0 22.6 15.0 35.3 5.44 1.51 R.N.A.B.C. 5.6 0.0 5.6 0.0 16.7 5.6 66.7 6.06 1.70 MINISTRY 5.0 0.0 10.0 10.0 15.0 15.0 45.0 5.55 1.76 OVERALL MEAN 5.97 224 TABLE 34 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA PUBLIC HEALTH NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 23.4 6.5 9.7 17.5 18.8 4.5 19.5 3.94 2.15 ADMINISTRATOR 18.6 3.1 13.2 14.7 15.5 5.4 29.5 4.40 2.20 PHYSICIAN 11.3 6.8 9.8 27.1 14.3 8.3 22.6 4.41 1.94 R.N.A.B.C. 17.6 0.0 5.9 17.6 23.5 11.8 23.5 4.59 1.09 MINISTRY 10.0 15.0 0.0 15.0 15.0 15.0 30.0 4.75 2.15 OVERALL MEAN 4.27 TABLE 35 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA RADIOLOGY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 59.5 9.8 11.1 12.4 4.6 1.3 1.3 2.02 1.47 ADMINISTRATOR 45.2 7.9 12.7 17.5 7.1 4.8 4.8 2.67 1.86 PHYSICIAN 38.9 20.6 17.6 10.7 7.6 1.5 3.1 2.44 1.58 R.N.A.B.C. 47.1 17.6 11.8 17.6 0.0 0.0 5.9 2.29 1.69 MINISTRY 42.1 10.5 0.0 21.1 10.5 5.3 10.5 3.05 2.20 OVERALL MEAN 2.38 TABLE 36 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA REHABILITATION NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 3.9 1.3 5.8 12.9 24.5 15.5 36.1 5.44 1.S9 ADMINISTRATOR 6.9 0.8 1.5 19.2 13.1 14.6 43.8 5.50 1.76 PHYSICIAN 9.8 7.6 10.6 18.2 20.5 9.1 24.2 4.56 1.93 R.N.A.B.C. 0.0 0.0 11.8 5.9 17.6 23.5 41.2 5.76 1.39 MINISTRY 5.0 5.0 10.0 10.0 20.0 10.0 40.0 5.25 1.89 OVERALL MEAN 5.20 225 TABLE 37 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA UROLOGY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 10.4 0.6 7.1 14.3 22.1 18.8 26.6 5.00 1.85 ADMINISTRATOR 4.7 3.1 3.9 14.7 8.5 7.8 57.4 5.72 1.79 PHYSICIAN 9.8 9.1 11.4 23.5 18.2 10.6 17.4 4.32 1.86 R.N.A.B.C. 0.0 0.0 16.7 11.1 22.2 16.7 33.3 5.39 1.50 MINISTRY 5.0 5.0 5.0 30.0 25.0 10.0 20.0 4.75 1.65 OVERALL MEAN 5.01 TABLE 38 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR CLINICAL AREA WELL BABY NURSERY NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 1.9 1.3 2.5 7.0 6.4 11.5 69.4 6.27 1.37 ADMINISTRATOR 2.3 2.3 0.0 9.2 6.2 5.4 74.6 6.29 1.43 PHYSICIAN 6.8 1.5 7.6 17.4 14.4 12.9 39.4 5.27 1.83 R.N.A.B.C. 0.0 0.0 5.9 0.0 11.8 17.6 64.7 6.35 1.11 MINISTRY 5.3 0.0 0.0 5.3 10.5 10.5 68.4 6.21 1.55 OVERALL MEAN 5.99 TABLE 39 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ADAPTS CARE TO INDIVIDUAL PATIENT NEEDS" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 1.3 4.4 94.3 6.93 0.30 ADMINISTRATOR 0.0 0.0 0.0 0.0 3.1 6.2 90.8 6.87 0.41 PHYSICIAN 0.0 0.7 0.0 3.7 11.2 10.4 73.9 6.52 0.92 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 5.9 94.1 6.94 0.24 MINISTRY 0.0 0.0 0.0 5.0 5.0 15.0 75.0 6.60 0.82 OVERALL MEAN 6.78 226 EDUCATOR ADMINISTRATOR PHYSICIAN R.N;A.B.C. MINISTRY OVERALL MEAN TABLE 40 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "FULFILLS RESPONSIBILITY TO PATIENT AND OTHERS" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.84 0.0 0.0 0.8 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.0 1.6 2.3 0.0 5.0 5 0.0 1.6 3.8 6.3 10.0 6 4.6 2.3 11.5 0.0 15.0 NEEDED MEAN 7 95.4 94.6 81.5 93.8 70.0 6.95 6.89 6.71 6.87 6.50 ST.DEV. 0.21 0.46 0.76 0.50 0.88 TABLE 41 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "QUESTIONS ORDERS AND DECISIONS BY MEDICAL AND OTHER PROFESSIONAL STAFF" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 1.9 9.0 10.3 78.8 6.66 0.72 ADMINISTRATOR 0.8 0.0 0.8 6.2 11.6 12.4 68.2 6.37 1.08 PHYSICIAN 8.3 4.5 10.5 23.3 14.3 15.0 24.1 4.72 1.86 R.N.A.B.C. 0.0 0.0 0.0 12.5 12.5 12.5 62.5 6.25 1.13 MINISTRY 5.0 0.0 5.0 20.0 15.0 10.0 45.0 5.50 1.73 OVERALL MEAN 5.95 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 42 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ACTS AS PATIENT ADVOCATE IN OBTAINING APPROPRIATE MEDICAL PSYCHIATRIC OR OTHER HELP" NOT NEEDED 1 2 0.0 4.7 8.3 0.0 10.5 5.70 0.0 0.0 4.5 0.0 0.0 3 1.3 2.3 9.8 0.0 10.5 4 2.5 11.7 20.3 17.6 10.5 5 12.7 14.1 24.1 11.8 15.8 6 17.2 10.9 14.3 17.6 10.5 NEEDED 7 66.2 56.3 18.8 52.9 42.1 MEAN 6.44 5.88 4.65 6.05 5.21 ST.DEV. 0.90 1.60 1.76 1.20 2.04 227 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 43 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "RECOGNIZES, CORRECTS AND REPORTS OWN ERRORS" NOT NEEDED 1 2 0.0 0.0 0.7 0.0 0.0 6.84 0.0 0.0 0.7 0.0 0.0 3 0.0 0.8 0.0 0.0 0.0 4 0.0 0.8 2.9 0.0 0.0 5 0.0 0.0 7.4 0.0 5.0 6 1.3 3:8 8.8 11.8 0.0 NEEDED 7 98.7 94.7 79.4 88.2 95.0 MEAN 6.98 6.90 6.59 6.88 6.90 ST.DEV. 0.11 0.47 0.97 0.33 0.45 TABLE 44 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ANALYZES AND CHANGES OWN BEHAVIOUR IN ORDER T O MAINTAIN THERAPEUTIC RELATIONSHIP WITH PATIENT" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.6 0.0 0.0 1.3 8.3 10.2 79.6 6.65 0.81 ADMINISTRATOR 0.8 0.0 0.0 6.2 7.0 10.1 76.0 6.52 1.00 PHYSICIAN 0.0 0.0 4.6 7.6 13.0 19.1 55.7 6.13 1.18 R.N.A.B.C. 0.0 0.0 0.0 0.0 23.5 11.8 64.7 6.41 0.88 MINISTRY 0.0 0.0 0.0 5.0 20.0 10.0 65.0 6.35 0.99 OVERALL MEAN 6.45 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN NOT NEEDED 1 0.0 0.8 2.3 0.0 0.0 6.49 TABLE 45 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "EVALUATES WHETHER PATIENT'S REQUIREMENTS FOR NURSING CARE WERE MET" NEEDED 2 0.0 0.0 2.3 0.0 0.0 3 0.0 0.8 2.3 0.0 0.0 4 0.6 0.8 13.2 0.0 10.0 5 3.8 6.9 8.5 23.5 10.0 6 7.5 9.2 19.4 5.9 5.0 7 88.1 81.7 51.9 70.6 75.0 MEAN 6.83 6.67 5.89 6.47 6.45 ST.DEV. 0.50 0.85 1.52 0.87 1.05 228 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 46 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "USES COMMUNITY RESOURCES TO HELP PATIENT RESOLVE PROBLEMS" NOT NEEDED 1 2 1.3 7.0 9.7 0.0 0.0 5.30 1.3 2.3 5.2 0.0 5.0 3 3.2 4.7 6.0 0.0 5.0 4 12.2 12.5 22.4 5.9 15.0 5 28.2 25.8 14.2 52.9 30.0 6 14.7 11.7 9.7 17.6 10.0 NEEDED 7 39.1 35.7 32.8 23.5 35.0 MEAN 5.65 5.26 4.86 5.58 5.40 ST.DEV. 1.36 1.78 1.98 0.93 1.50 TABLE 47 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ASSESSES PATIENT LEARNING NEEDS IN RELATION TO DISABILITY" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 1.3 10.3 13.5 75.0 6.62 0.72 ADMINISTRATOR 1.5 0.8 3.1 3.1 13.0 19.1 59.5 6.20 1.26 PHYSICIAN 7.7 3.1 4.6 24.6 16.9 13.8 29.2 4.98 1.81 R.N.A.B.C. 0.0 0.0 0.0 5.9 11.8 29.4 52.9 6.29 0.92 MINISTRY 0.0 5.0 5.0 5.0 15.0 15.0 55:0 5.95 1.50 OVERALL MEAN 5.99 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 48 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "PROVIDES HEALTH CARE INSTRUCTION OR OTHER INFORMATION TO . PATIENTS, FAMILY OR SIGNIFICANT OTHERS" NOT NEEDED 1 2 0.0 1.5 6:6 0.0 0.0 6.11 0.0 0.0 3.7 0.0 0.0 3 0.0 1.5 6.6 0.0 10.0 4 0.0 5.4 16.2 5.9 5.0 5 8.2 9.2 19.9 17.6 15.0 6 11.9 10.8 13.2 29.4 10.0 NEEDED 7 79.9 71.5 33.8 47.1 60.0 MEAN 6.71 6.39 5.13 6.17 6.05 ST.DEV. 0.61 1.18 1.82 0.95 1.39 229 TABLE 49 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBEJECTIVE "ENSURES THAT INSTRUCTION IS UNDERSTOOD" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.6 5.1 11.4 82.9 6.76 0.56 ADMINISTRATOR 1.5 0.8 0.8 1.5 6.9 9.9 78.6 6.55 1.09 PHYSICIAN 2.2 1.5 3.7 11.1 15.6 14.1 51.9 5.85 1.50 R.N.A.B.C. 0.0 0.0 0.0 0.0 18.8 18.8 62.5 6.43 0.81 MINISTRY . 0.0 0.0 5.0 5.0 10.0 10.0 70.0 6.35 1.18 OVERALL MEAN 6.41 TABLE 50 CROSS TABULATION BY PROFESSSION PERCENTAGE ANSWERING FOR OBJECTIVE "ENCOURAGES PATIENT OR FAMILY TO MAKE INFORMED DECISIONS ABOUT ACCEPTING CARE OR ADHERING T O TREATMENT REGIME" EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN NOT NEEDED 1 2 0.0 2.3 7.4 5.9 0.0 6.00 0.0 0.8 1.5 0.0 0.0 3 0.0 3.1 6.7 0.0 10.0 4 2.5 4.7 15.6 5.9 10.0 5 10.8 12.4 17.8 0.0 25.0 6 19.1 11.6 14.8 35.3 20.0 NEEDED 7 67.5 65.1 36.3 52.9 35.0 MEAN 6.51 6.19 5.24 6.11 5.60 ST.DEV. 0.79 1.38 1.82 1.54 1.35 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 51 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "HELPS PATIENT DEAL WITH PSYCHOLOGICAL STRESS" NOT NEEDED 1 2 0.0 2.3 2.2 0.0 5.0 5.96 0.0 0.8 2.9 0.0 0.0 3 0.6 3.1 5.9 0.0 5.0 4 2.5 6.2 16.2 5.9 25.0 5 14.6 18.5 17.6 23.5 15.0 6 19.0 13.1 19.9 29.4 5.0 NEEDED 7 63.3 56.2 35.3 41.2 45.0 MEAN 6.41 6.01 5.44 6.05 5.40 ST.DEV. 0.88 1.41 1.56 0.97 1.76 230 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 52 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "AVOIDS CREATING OR INCREASING ANXIETY OR STRESS" NOT NEEDED 1 2 1.3 0.0 0.7 0.0 5.0 6.52 0.0 0.0 0.0 0.0 0.0 3 0.7 0.0 2.9 0.0 0.0 4 2.6 3.1 6.6 11.8 5.0 5 6.0 4.7 7.4 5.9 15.0 6 13.2 10.1 12.5 23.5 15.0 NEEDED 7 76.2 82.2 69.9 58.8 60.0 MEAN 6.56 6.71 6.36 6.29 6.10 ST.DEV. 1.00 0.70 1.17 1.05 1.52 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 53 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CONVEYS ACCEPTANCE, RESPECT AND TRUST TO PATIENT" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.81 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.0 1.5 2.3 0.0 0.0 5 0.6 2.3 9.1 0.0 10.0 6 2.5 3.8 17.4 11.8 10.0 NEEDED 7 96.8 92.4 71.2 88.2 80.0 MEAN 6.96 6.87 6.57 6.88 6.70 ST.DEV. 0.22 0.50 0.75 0.33 0.66 TABLE 54 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "FACILITATES RELATIONSHIP OF FAMILY, SELF OR SIGNIFICANT OTHER WITH PATIENT" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 1.9 0.0 1.3 3.8 12.8 14.7 65.4 6.31 1.20 ADMINISTRATOR 0.0 0.0 3.1 4.6 11.5 13.0 67.9 6.38 1.06 PHYSICIAN 5.4 1.5 10.0 11.5 17.7 13.8 40.0 5.36 1.77 R.N.A.B.C. 0.0 0.0 5.9 11.8 23.5 17.6 41.2 5.76 1.30 MINISTRY 5.0 0.0 10.0 15.0 10.0 25.0 35.0 5.40 1.73 OVERALL MEAN 6.00 231 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 55 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "MAINTAINS CONFIDENTIALITY OF PATIENT INFORMATION" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.95 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.0 0.0 0.7 0.0 0.0 5 0.0 0.0 2.2 5.6 0.0 6 1.9 0.0 5.9 0.0 0.0 NEEDED 7 98.1 100.0 91.2 94.4 100.0 MEAN 6.98 7.00 6.88 6.88 7.00 ST.DEV. 0.14 0.00 0.45 0.47 0.00 TABLE 56 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "STIMULATES, MOTIVATES PATIENT OR ENABLES HIM/HER T O ACHIEVE SELF CARE AND INDEPENDENCE" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 1.3 10.9 19.9 67.9 6.54 0.74 ADMINISTRATO 0.0 0.0 0.0 3.8 5.3 15.3 75.6 6.62 0.76 PHYSICIAN 0.0 0.7 2.9 5.9 15.4 19.9 55.1 6.16 1.14 R.N.A.B.C. 0.0 0.0 0.0 5.6 16.7 22.2 55.6 6.27 0.96 MINISTRY 0.0 0.0 0.0 10.0 30.0 15.0 45.0 5.95 1.10 OVERALL MEAN 6.42 TABLE 57 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "KEEPS PATIENT CLEAN AND COMFORTABLE" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.6 1.3 3.8 94.3 6.91 0.37 ADMINISTRATOR 0.0 0.0 0.0 0.8 2.3 3.1 93.9 6.90 0.43 PHYSICIAN 0.0 0.0 0.0 1.5 5.9 13.3 79.3 6.70 0.65 R.N.A.B.C. 0.0 0.0 0.0 0.0 5.6 0.0 94.4 6.88 0.47 MINISTRY 0.0 0.0 0.0 0.0 5.0 5.0 90.0 6.85 0.49 OVERALL MEAN 6.85 232 TABLE 58 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "HELPS PATIENT MAINTAIN OR REGAIN NORMAL BODY FUNCTIONS" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 1.9 12.1 86.0 6.84 0.42 ADMINISTRATOR 0.0 0.0 0.8 0.0 1.5 6.2 91.5 6.87 0.48 PHYSICIAN 0.7 0.7 0.7 3.7 14.2 11.2 68.9 6.38 1.10 R.N.A.B.C. 0.0 0.0 0.0 0.0 5.6 22.2 72.2 6.67 0.59 MINISTRY 0.0 0.0 0.0 0.0 10.0 10.0 80.0 6.70 0.66 OVERALL MEAN 6.70 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 59 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "EFFICIENTLY PROVIDES CARE FOR A GROUP OF FOUR TO SIX PATIENTS" NOT NEEDED 1 2 1.3 0.8 2.5 0.0 0.0 6.45 0.6 0.8 0.8 0.0 0.0 3 0.0 0.0 2.5 0.0 0.0 4 2.6 0.8 6.6 11.1 0.0 5 11.6 1.5 15.6 5.6 21.1 6 10.3 8.5 13.1 5.6 21.1 NEEDED 7 73.5 87.7 59.0 77.8 57.9 MEAN 6.48 6.78 6.07 6.50 6.37 ST.DEV. 1.08 0.80 1.41 1.04 0.83 TABLE 60 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "APPLIES PRINCIPLES OF INFECTION CONTROL" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 0.0 6.9 93.1 6.93 0.25 ADMINISTRATOR 0.0 0.0 0.0 0.8 2.3 2.3 94.7 6.90 0.42 PHYSICIAN 0.0 0.7 0.0 3.0 6.7 14.1 75.6 6.60 0.84 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 5.6 94.4 6.94 0.24 MINISTRY 0.0 0.0 0.0 0.0 0.0 0.0 100.0 7.00 0.00 OVERALL MEAN 6.83 233 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 61 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "PROTECTS PATIENT'S SKIN AND MUCOUS MEMBRANES FROM INJURIOUS MATERIAL" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.78 0.0 0.0 1.5 0.0 0.0 3 0.0 0.0 0.7 0.0 0.0 4 0.6 0.0 2.2 0.0 0.0 5 0.0 3.1 10.3 5.6 5.3 6 5.1 3.8 14.7 5.6 15.0 NEEDED 7 94.3 93.1 70.6 88.9 78.9 MEAN 6.93 6.90 6.48 6.83 6.73 ST.DEV. 0.32 0.39 0.99 0.51 0.56 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 62 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "USES POSITIONING OR EXERCISES T O PREVENT INJURY OR THE COMPLICATIONS OF IMMOBILITY" NOT NEEDED 1 0.0 0.0 0.7 0.0 0.0 6.68 2 0.0 0.0 0.7 0.0 0.0 3 0.0 0.8 1.5 0.0 0.0 4 0.0 0.8 4.4 0.0 0.0 5 2.5 3.1 14.7 5.6 5.0 6 5.7 6.2 15.4 5.6 20.0 NEEDED MEAN 7 91.8 89.2 62.5 88.9 75.0 6.89 6.82 6.28 6.83 6.70 ST.DEV. 0.38 0.59 1.15 0.52 0.57 TABLE 63 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "AVOIDS USING INJURIOUS TECHNIQUE IN ADMINISTERING AND MANAGING INTRUSIVE OR OTHER POTENTIALLY TRUAMATIC TREATMENTS" EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN NOT NEEDED 1 2 0.6 0.0 1.5 0.0 0.0 6.79 0.0 0.0 0.0 0.0 0.0 3 0.6 0.0 0.0 0.0 0.0 4 0.0 2.3 1.5 0.0 0.0 5 0.6 3.1 7.4 5.6 0.0 6 1.9 3.1 14.0 5.6 10.0 NEEDED 7 96.1 91.4 75.7 88.9 90.0 MEAN 6.90 6.84 6.58 6.83 6.90 ST.DEV. 0.61 0.59 0.96 0.51 0.31 2 3 4 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 64 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "PROTECTS PATIENT FROM FALLS OR OTHER CONTACT INJURIES" NOT NEEDED 1 2 0.0 0.0 1.5 0.0 0.0 6.75 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 1.5 0.0 0.0 4 0.0 1.5 3.0 0.0 5.0 5 0.6 3.8 11.1 11.1 0.0 6 1.9 2.3 15.6 0.0 5.0 NEEDED MEAN 7 97.5 92.4 67.4 88.9 90.0 6.97 6.86 6.39 6.78 6.80 ST.DEV. 0.21 0.54 1.12 0.65 0.70 TABLE 65 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "SUPERVISES PATIENT'S ACTIVITIES" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.7 0.7 0.0 5.9 9.2 11.2 72.4 6.45 1.06 ADMINISTRATOR 0.0 0.0 0.0 4.8 6.3 10.3 78.6 6.62 0.81 PHYSICIAN 3.0 2.2 7.4 14.8 23.7 9.6 39.3 5.40 1.63 R.N.A.B.C. 0.0 0.0 0.0 11.1 11.1 16.7 61.1 6.28 1.07 MINISTRY 0.0 0.0 0.0 10.5 15.8 15.8 57.9 6.21 1.08 OVERALL MEAN 6.17 TABLE 66 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ENSURES SAFE ENVIRONMENT FOR PATIENT" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 1.9 3.8 94.3 6.92 0.33 ADMINISTRATOR 0.0 0.0 0.0 1.5 1.5 4.6 92.3 6.87 0.48 PHYSICIAN 2.2 0.7 2.2 8.8 13.2 13.2 59.6 6.08 1.40 R.N.A.B.C. 0.0 0.0 0.0 0.0 5.6 0.0 94.4 6.89 0.47 MINISTRY 0.0 0.0 0.0 10.0 5.0 10.0 75.0 6.50 1.00 OVERALL MEAN 6.64 235 EDUCATOR ADMINISTRATOR PHYSICIAN RNABC MINISTRY OVERALL MEAN TABLE 67 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CHECKS CORRECTNESS, CONDITION AND SAFETY OF MEDICATION BEING PREPARED" NOT NEEDED 1 0.0 0.0 0.7 0.0 0.0 6.900 2 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.7 0.0 0.0 4 0.0 0.8 3.0 0.0 0.0 5 0.0 0.0 2.2 0.0 0.0 6 0.0 0.0 9.0 0.0 5.0 NEEDED 7 100.0 99.2 84.3 100.0 95.0 MEAN 7.00 6.98 6.70 7.00 6.95 ST.DEV. 0.00 0.26 0.87 0.00 0.22 TABLE 68 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ENSURES THAT CORRECT MEDICATION OR CARE IS GIVEN TO THE RIGHT PATIENT AND THAT PATIENT TAKES OR RECEIVES IT" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 0.0 0.0 100.0 7.00 0.00 ADMINISTRATOR 0.0 0.0 0.0 0.0 0.0 0.0 100.0 7.00 0.00 PHYSICIAN 0.0 0.0 0.0 2.2 1.5 5.9 90.4 6.84 0.54 RNABC 0.0 0.0 0.0 0.0 5.6 5.6 88.9 6.83 0.51 MINISTRY 0.0 0.0 0.0 0.0 0.0 0.0 100.0 7.00 0.00 OVERALL MEAN 6.95 EDUCATOR ADMINISTRATOR PHYSICIAN RNABC MINISTRY OVERALL MEAN TABLE 69 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ADHERES TO SCHEDULE IN GIVING MEDICATION, TREATMENT OR TEST" NOT NEEDED NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.75 0.0 0.0 0.7 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 1.9 0.8 0.7 5.6 0.0 5 1.9 2.3 14.0 5.6 5.0 6 7.7 3.8 12.5 5.6 5.0 7 88.4 93.1 72.1 83.3 90.0 MEAN 6.82 6.89 6.53 6.67 6.86 ST.DEV. 0.55 0.43 0.85 0.84 0.49 236 EDUCATOR ADMINISTRATOR PHYSICIAN RNABC MINISTRY OVERALL MEAN TABLE 70 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ADMINISTERS MEDICATION BY CORRECT ROUTE, RATE OR MODE" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.96 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.0 0.0 0.7 0.0 0.0 5 0.0 0.0 1.5 5.6 0.0 6 0.0 0.0 6.6 5.6 0.0 7 100.0 100.0 91.2 88.9 100.0 NEEDED MEAN 7.00 7.00 6.88 6.83 7.00 ST.DEV. 0.00 0.00 0.42 0.51 0.00 TABLE 71 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CHECKS PATIENT READINESS FOR MEDICATION, TREATMENT, SURGERY OR OTHER CARE" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.6 0.6 3.8 12.7 82.3 6.75 0.62 ADMINISTRATOR 0.0 0.0 0.0 2.3 3.8 5.4 88.5 6.80 0.62 PHYSICIAN 1.5 0.7 0.7 5.2 13.4 14.9 63.4 6.27 1.22 RNABC 0.0 0.0 0.0 0.0 5.6 16.7 77.8 6.72 0.57 MINISTRY 0.0 0.0 0.0 5.0 5.0 5.0 85.0 6.70 0.80 OVERALL MEAN 6.62 TABLE 72 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CHECKS TO ENSURE THAT THOSE TESTS OR MEASUREMENTS THAT T H E NURSE IS RESPONSIBLE FOR ARE DONE CORRECTLY" EDUCATOR ADMINISTRATOR PHYSICIAN RNABC MINISTRY NOT NEEDED 1 2 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.7 0.0 0.0 4 0.6 0.8 2.2 5.6 0.0 5 0.6 0.8 6.7 0.0 0.0 6 5.0 4.6 11.1 16.7 10.0 NEEDED 7 93.7 93.9 78.5 77.8 90.0 MEAN 6.92 6.92 6.61 6.67 6.90 ST.DEV. 0.36 0.37 0.91 0.77 0.31 OVERALL MEAN 6.82 237 EDUCATOR ADMINISTRATOR PHYSICIAN RNABC MINISTRY OVERALL MEAN TABLE 73 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "MONITORS PATIENT INFUSIONS AND INHALATIONS" NOT NEEDED 1 2 0.0 0.0 2.2 0.0 0.0 6.75 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.0 23 6.7 0.0 5.0 5 0.6 1.5 4.4 11.1 0.0 6 3.8 6.1 12.6 11.1 10.0 NEEDED 7 95.5 90.1 74.1 77.8 85.0 MEAN 6.95 6.84 6.45 6.67 6.75 ST.DEV. 0.25 0.55 1.19 0.69 0.72 TABLE 74 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CHECKS FOR AND INTERPRETS EFFECT OF MEDICATION, TREATMENT OR CARE AND TAKES CORRECTIVE ACTION IF NEEDED" EDUCATOR ADMINISTRATOR PHYSICIAN RNABC MINISTRY OVERALL MEAN NOT NEEDED 1 2 0.0 0.0 1.5 0.0 0.0 6.58 0.0 0.0 0.7 0.0 0.0 3 0.0 0.0 2.2 0.0 0.0 4 1.3 3.8 8.9 0.0 0.0 5 1.3 1.5 14.8 0.0 15.0 6 13.2 7.6 14.1 11.1 10.0 NEEDED 7 84.3 87.0 57.8 88.9 75.0 MEAN 6.80 6.78 6.08 6.89 6.60 ST.DEV. 0.51 0.66 1.33 0.32 0.75 TABLE 75 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "DETECTS CHANGES IN A PATIENT'S CONDITION OR STATUS" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 2.5 10.1 87.4 6.85 0.42 ADMINISTRATOR 0.0 0.0 0.0 0.8 4.6 7.6 87.0 6.80 0.54 PHYSICIAN 0.0 0.0 0.0 2.2 8.1 14.0 75.7 6.63 0.73 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 16.7 83.3 6.83 0.38 MINISTRY 0.0 0.0 0.0 0.0 0.0 10.0 90.0 6.90 0.31 OVERALL MEAN 6.78 238 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 76 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "INVESTIGATES OR VERIFIES PATIENT'S COMPLAINTS OR PROBLEMS" NOT NEEDED 1 2 0.0 0.0 2.2 0.0 0.0 6.54 0.0 0.0 0.7 0.0 0.0 3 0.0 0.0 2.2 0.0 0.0 4 0.0 3.1 8.1 5.6 0.0 5 2.5 7.6 14.7 5.6 10.0 6 11.9 9.9 14.7 5.6 10.0 NEEDED MEAN 7 85.5 79.4 57.4 83.3 80.0 6.83 6.65 6.05 6.67 6.70 ST.DEV. 0.44 0.75 1.39 0.84 0.66 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 77 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "USES ALARMS AND SIGNALS ON AUTOMATIC EQUIPMENT AS AN ADJUNCT TO PERSONAL ASSESSMENT" NOT NEEDED 1 2 3.3 0.8 0.7 0.0 0.0 6.34 0.0 0.0 0.7 0.0 0.0 3 2.0 0.8 3.0 6.3 0.0 4 3.3 3.2 6.7 0.0 5.3 5 13.2 6.3 11.1 12.5 15.8 6 10.5 10.3 18.5 12.5 15.8 NEEDED 7 67.8 78.6 59.3 68.8 63.2 MEAN 6.26 6.60 6.19 6.38 6.37 ST.DEV. 1.38 0.95 1.23 1.15 0.96 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 78 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "OBSERVES AND CORRECTLY ASSESSES SIGNS OF ANXIETY OR BEHAVIOURAL STRESS" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.35 0.0 0.0 1.5 0.0 0.0 3 0.6 0.0 1.5 0.0 0.0 4 0.0 4.6 10.3 0.0 10.0 5 9.5 8.5 20.6 16.7 15.0 6 17.1 18.5 24.3 27.8 25.0 NEEDED 7 72.8 68.5 41.9 55.6 50.0 MEAN 6.61 6.51 5.90 6.39 6.15 ST.DEV. 0.71 0.84 1.19 0.78 1.04 239 TABLE 79 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "OBSERVES AND CORRECTLY ASSESSES PHYSICAL SIGNS, SYMPTOMS OR FINDINGS AND INTERVENES APPROPRIATELY" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.6 0.0 0.0 3.8 19.0 76.6 6.70 0.64 ADMINISTRATOR 0.0 0.0 0.8 1.5 6.1 10.7 80.9 6.69 0.72 PHYSICIAN 1.5 3.0 3.7 11.1 11.1 14.8 54.8 5.91 1.51 R.N.A.B.C. 0.0 0.0 0.0 0.0 5.6 27.8 66.7 6.61 0.82 MINISTRY 0.0 0.0 0.0 0.0 20.0 20.0 60.0 6.40 0.82 OVERALL MEAN 6.45 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 80 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CORRECTLY ASSESSES SEVERITY OR PRIORITY OF PATIENT'S CONDITION AND GIVES OR OBTAINS NEEDED CARE" NOT NEEDED 1 2 0.0 0.0 3.0 0.0 0.0 6.48 0.0 0.0 0.7 0.0 0.0 3 0.0 0.8 2.2 5.6 0.0 4 0.0 1.5 6.7 0.0 5.0 5 6.4 6.1 14.9 11.1 15.0 6 15.9 14.5 14.2 16.7 20.0 NEEDED MEAN 7 77.7 77.1 58.2 66.7 60.0 6.71 6.65 6.05 6.39 6.35 ST.DEV. 0.58 0.73 1.44 1.09 0.933 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 81 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "IS ABLE TO EXPLAIN T H E REASON FOR NURSING JUDGMENTS" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.61 0.0 0.0 0.8 0.0 0.0 3 0.0 0.0 0.8 0.0 0.0 4 0.0 2.3 8.3 0.0 5.0 5 3.1 6.9 14.4 5.6 10.0 6 7.5 9.9 17.4 22.2 15.0 NEEDED 7 89.3 80.9 58.3 72.2 70.0 MEAN 6.86 6.69 6.22 6.67 6.50 ST.DEV. 0.43 0.70 1.10 0.59 0.89 TABLE 82 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "USES UNDERSTANDING OF DEVELOPMENTAL STAGES T O AID IN INTERPRETING OF PATIENT SYMPTOMS" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.0 7.0 17.2 75.8 6.69 0.60 ADMINISTRATOR 0.0 0.0 0.8 7.6 14.5 16.0 61.1 6.29 1.03 PHYSICIAN 3.4 4.2 7.6 13.4 30.3 7.6 33.6 5.20 1.67 R.N.A.B.C. 0.0 0.0 5.6 0.0 11.1 22.2 61.1 6.33 1.08 MINISTRY 0.0 0.0 0.0 15.0 20.0 20.0 45.0 5.95 1.15 OVERALL MEAN 6.13 TABLE 83 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ANTICIPATES THE NEED FOR CRISIS CARE" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 1.3 3.9 19.0 25.5 50.3 6.20 0.97 ADMINISTRATOR 0.0 0.0 0.0 3.1 11.6 14.0 71.3 6.53 0.82 PHYSICIAN 1.5 2.3 2.3 9.8 17.4 18.9 47.7 5.87 1.41 R.N.A.B.C. 0.0 0.0 5.9 0.0 23.5 5.9 64.7 6.24 1.20 MINISTRY 5.0 0.0 0.0 5.0 15.0 30.0 45.0 5.95 1.47 OVERALL MEAN 6.19 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 84 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "TAKES INSTANT, CORRECT ACTION IN AN EMERGENCY SITUATION" NOT NEEDED 1 2 0.0 1.5 0.0 0.0 0.0 6.37 1.3 0.0 0.7 0.0 0.0 3 0.6 0.0 0.7 0.0 0.0 4 6.5 3.1 3.7 0.0 5.0 5 18.7 12.2 6.7 16.7 10.0 6 21.3 12.2 14.1 27.8 25.0 NEEDED 7 51.6 71.0 74.1 55.6 60.0 MEAN 6.13 6.45 6.55 6.39 6.40 ST.DEV. 1.10 1.07 0.92 0.78 0.88 241 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 85 CROSS TABULATION BY PROFESSION PERCENTAGE ANSERING FOR OBJECTIVE "MAINTAINS CALM AND EFFICIENT APPROACH UNDER PRESSURE" NOT NEEDED 1 2 1.3 0.8 0.0 0.0 0.0 6.31 0.0 0.0 0.0 0.0 0.0 3 1.3 1.5 1.5 0.0 0.0 4 8.4 1.5 2.3 0.0 5.0 5 16.1 15.3 11.3 22.2 10.0 6 24.5 11.5 15.0 27.8 35.0 NEEDED 7 48.4 69.5 69.9 50.0 50.0 MEAN 6.05 6.43 6.50 6.28 6.30 ST.DEV. 1.19 1.03 0.89 0.83 0.86 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 86 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "ASSUMES LEADERSHIP ROLE IN CRISIS SITUATION WHEN NEEDED" NOT NEEDED 1 2 4.5 5.4 2.2 0.0 5.0 5.51 3.9 2.3 0.7 0.0 0.0 3 5.8 2.3 2.2 5.6 0.0 4 14.9 12.4 6.0 5.6 5.0 5 27.9 24.8 21.6 44.4 45.0 6 10.2 10.1 13.4 22.2 20.0 NEEDED 7 24.7 42.6 53.7 22.2 25.0 MEAN 5.11 5.50 5.99 5.50 5.45 ST.DEV. 1.62 1.70 1.38 1.09 1.39 TABLE 87 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CHECKS DATA SOURCES FOR ORDERS AND OTHER INFORMATION ABOUT PATIENT" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 0.0 0.0 0.6 1.9 9.7 87.7 6.85 0.46 ADMINISTRATOR 0.0 0.0 1.6 3.1 2.3 8.5 84.5 6.71 0.79 PHYSICIAN 1.5 1.5 0.0 12.8 14.3 21.1 48.9 5.95 1.33 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 16.7 83.3 6.83 0.38 MINISTRY 0.0 0.0 0.0 0.0 15.0 20.0 65.0 6.50 0.76 OVERALL MEAN 6.53 242 TABLE 88 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "OBTAINS INFORMATION FROM PATIENT AND FAMILY" NOT NEEDED 1 2 EDUCATOR 0.0 0.0 ADMINISTRATOR 0.0 0.8 PHYSICIAN 1.5 1.5 R.N.A.B.C. 0.0 0.0 MINISTRY 0.0 0.0 OVERALL MEAN 6.41 TABLE 89 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "TRANSCRIBES OR RECORDS INFORMATION ON CHARTS, KARDEX OR OTHER INFORMATION SYSTEM" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.6 0.0 0.0 1.3 5.0 8.2 84.9 6.74 0.75 ADMINISTRATOR 0.0 0.0 0.0 0.0 1.5 3.8 94.7 6.93 0.31 PHYSICIAN 3.0 0.0 2.2 10.4 16.3 14.1 54.1 5.96 1.44 R.N.A.B.C. 0.0 0.0 0.0 0.0 5.6 5.6 88.9 6.83 0.51 MINISTRY 0.0 0.0 0.0 5.0 10.0 10.0 75.0 6.55 0.89 OVERALL MEAN 6.56 TABLE 90 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "EXCHANGES INFORMATION WITH NURSING STAFF AND OTHER DEPARTMENTS" NOT NEEDED 1 2 EDUCATOR 0.0 0.0 ADMINISTRATOR 0.0 0.0 PHYSICIAN 0.7 0.0 R.N.A.B.C. 0.0 0.0 MINISTRY 0.5 0.0 OVERALL MEAN 6.61 NEEDED 3 4 5 6 7 MEAN ST.DEV. 0.0 1.3 4.4 8.8 85.5 6.79 0.58 0.0 0.8 6.1 9.9 82.4 6.72 0.73 4.4 14.8 17.8 17.0 43.0 5.69 1.46 0.0 0.0 5.6 22.2 72.2 6.67 0.59 0.0 10.0 20.0 15.0 55.0 6.15 1.09 NEEDED 3 4 5 6 7 MEAN ST.DEV. 0.0 1.3 3.8 11.4 83.5 6.77 0.57 0.0 2.3 2.3 6.9 88.5 6.82 0.58 0.7 6.0 17.2 16.4 59.0 6.24 1.10 0.0 0.0 0.0 11.1 88.9 6.89 0.32 0.0 0.0 10.0 20.0 65.0 6.30 1.42 243 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 91 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "EXCHANGES INFORMATION WITH MEDICAL STAFF" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 5.0 6.61 0.0 0.0 0.0 0.0 0.0 3 0.0 0.8 0.0 0.0 0.0 4 3.8 3.8 3.7 0.0 5.0 5 5.1 6.1 7.4 0.0 10.0 6 13.3 10.7 17.0 16.7 20.0 NEEDED 7 77.8 78.6 71.9 83.3 60.0 MEAN 6.65 6.63 6.57 6.83 6.15 ST.DEV. 0.75 0.83 0.79 0.38 1.50 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 92 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "COOPERATES WITH WARD ROUTINES AND HOSPITAL REGULATIONS" NOT NEEDED 1 2 0.0 0.0 0.7 0.0 0.0 6.62 0.0 0.0 0.7 0.0 0.0 3 0.0 0.0 0.7 0.0 0.0 4 2.6 0.0 7.5 0.0 0.0 5 4.5 3.1 14.9 5.6 5.0 6 10.3 6.1 17.2 11.1 15.0 NEEDED MEAN 7 82.7 90.8 58.2 83.3 80.0 6.73 6.88 6.19 6.78 6.75 ST.DEV. 0.67 0.41 1.17 0.55 0.55 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 93 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "KNOWS THE ADMINISTRATIVE ORGANIZATION AND FUNCTIONING OF T H E INSTITUTION AT VARIOUS LEVELS" NOT NEEDED 1 2 4.5 3.9 9.6 0.0 5.0 5.20 0.6 0.0 4.4 0.0 5.0 3 5.1 3.1 11.1 0.0 10.0 4 16.6 7.0 25.9 11.8 20.0 5 27.4 21.7 18.5 41.2 30.0 6 21.0 14.7 8.1 17.6 5.0 NEEDED 7 24.8 49.6 22.2 29.4 25.0 MEAN 5.24 5.85 4.53 5.65 4.80 ST.DEV. 1.52 1.50 1.85 1.06 1.74 244 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 94 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "KNOWS THE FUNCTIONS AND RESPONSIBILITIES OF EACH MEMBER OF THE HEALTH CARE T E A M " NOT NEEDED 1 2 0.0 1.5 3.7 0.0 0.0 5.94 0.0 0.8 0.7 0.0 0.0 3 1.3 1.5 4.4 0.0 5.0 4 5.8 8.4 12.6 5.6 5.0 5 24.4 14.5 20.7 50.0 20.0 6 20.5 16.8 14.1 11.1 25.0 NEEDED 7 48.1 56.5 43.7 33.3 45.0 MEAN 6.08 6.10 5.63 5.72 6.00 ST.DEV. 1.03 1.30 1.57 1.02 1.17 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.83 0.0 0.0 0.0 0.0 0.0 TABLE 95 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE 'ADHERES TO A NURSING CODE OF ETHICS" 3 0.0 0.0 0.7 0.0 0.0 4 0.0 0.0 3.0 0.0 0.0 5 0.6 0.0 7.5 5.6 5.0 6 6.4 3.8 12.7 5.6 10.0 7 93.0 96.2 76.1 88.9 85.0 NEEDED MEAN 6.92 6.96 6.60 6.83 6.80 ST.DEV. 0.29 0.19 0.81 0.51 0.52 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 96 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "WORKS TOGETHER WITH OTHER NURSING STAFF" NOT NEEDED 1 2 0.0 0.0 0.0 0.0 0.0 6.77 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.6 0.0 3.0 0.0 0.0 5 5.1 2.3 5.9 0.0 15.0 6 6.4 4.6 20.0 11.1 15.0 NEEDED MEAN 7 87.9 93.1 71.1 88.9 70.0 6.82 6.91 6.59 6.89 6.55 ST.DEV. 0.54 0.36 0.74 0.32 0.76 245 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 97 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "HELPS OTHER STAFF MEMBERS WITH WORK DURING STAFF SHORTAGE" NOT NEEDED 1 2 5.3 0.0 0.0 5.9 0.0 6.25 0.0 0.8 0.0 0.0 0.0 3 1.3 0.0 2.2 0.0 0.0 4 7.9 4.6 8.2 17.6 5.0 5 13.9 5.4 9.0 11.8 20.0 6 16.6 8.5 20.1 11.8 25.0 NEEDED 7 55.0 80.8 60.4 52.9 50.0 MEAN 5.95 6.63 6.28 5.76 6.20 ST.DEV. 1.57 0.88 1.07 1.72 0.95 TABLE 98 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "OBTAINS ASSISTANCE WHEN SITUATION REQUIRES ADDITIONAL HELP, MORE SKILLED PERSONNEL OR GREATER RESOURCES" EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN NOT NEEDED 1 2 1.3 0.0 0.0 0.0 0.0 6.74 0.0 0.0 0.0 0.0 0.0 3 0.0 0.0 0.0 0.0 0.0 4 0.0 1.5 1.5 0.0 5.0 5 1.9 1.5 11.9 5.6 10.0 6 7.6 4.6 15.6 11.1 20.0 NEEDED 7 89.2 92.4 71.1 83.3 65.0 MEAN 6.81 6.88 6.56 6.78 6.45 ST.DEV. 0.76 0.48 0.76 0.55 0.89 TABLE 99 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "DEVELOPS AND MODIFIES PATIENT CARE PLAN" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 0.0 ' 0.0 0.0 0.0 6.4 15.4 78.2 6.72 0.58 ADMINISTRATOR 0.8 0.0 0.8 3.1 13.0 13.0 69.5 6.44 1.00 PHYSICIAN 5.3 5.3 6.1 22.0 17.4 15.9 28.0 5.01 1.76 R.N.A.B.C. 0.0 0.0 0.0 0.0 0.0 22.2 77.8 6.78 0.43 MINISTRY 0.0 0.0 0.0 15.0 0.0 30.0 55.0 6.25 1.07 OVERALL MEAN 6.13 246 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 100 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "INCLUDES DOCTOR, OTHER STAFF OR AGENCIES IN PLANNING CARE" NOT NEEDED 1 2 0.7 0.8 3.8 0.0 0.0 6.10 0.0 0.0 0.8 0.0 0.0 3 1.3 1.5 6.9 0.0 0.0 4 4.6 9.2 6.9 0.0 10.0 5 17.6 14.6 9.9 44.4 20.0 6 24.8 13.8 12.2 16.7 15.0 NEEDED 7 51.0 60.0 59.5 38.9 55.0 MEAN 6.17 6.18 5.93 5.94 6.15 ST.DEV. 1.06 1.19 1.64 0.94 1.09 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN NOT NEEDED 1 2 0.0 0.8 2.3 0.0 0.0 6.53 0.0 0.0 1.5 0.0 0.0 TABLE 101 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "IMPLEMENTS PATIENT CARE PLAN" 3 0.0 0.8 3.1 0.0 0.0 4 0.0 3.1 10.7 0.0 0.0 5 1.9 1.5 18.3 5.6 10.0 6 6.5 6.9 15.3 11.1 15.0 NEEDED 7 91.6 87.0 48.9 83.3 75.0 MEAN 6.90 6.73 5.82 6.78 6.65 ST.DEV. 0.36 0.86 1.48 0.55 0.67 TABLE 102 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CONDUCTS PATIENT CARE CONFERENCES" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 2.6 1.3 5.2 10.4 27.9 18.2 34.4 5.52 1.47 ADMINISTRATOR 6.3 0.8 3.9 16.4 24.2 14.1 34.4 5.31 1.68 PHYSICIAN 12.4 7.0 11.6 23.3 17.1 7.0 21.7 4.33 1.96 R.N.A.B.C. 5.6 0.0 5.6 11.1 50.0 22.2 5.6 4.88 1.32 MINISTRY 5.0 0.0 5.0 25.0 30.0 20.0 15.0 4.95 1.47 OVERALL MEAN 5.07 247 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 103 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "CONTRIBUTES CONSTRUCTIVELY TO PATIENT CARE CONFERENCES" NOT NEEDED 1 2 0.6 0.0 1.5 0.0 0.0 6.25 0.0 0.0 1.5 0.0 0.0 3 0.0 0.8 7.7 0.0 0.0 4 1.9 3.1 13.1 0.0 10.0 5 9.6 6.9 23.8 22.2 20.0 6 15.4 11.5 14.6 11.1 25.0 NEEDED 7 72.4 77.9 37.7 66.7 45.0 MEAN 6.56 6.63 5.51 6.44 6.05 ST.DEV. 0.87 0.81 1.50 0.86 1.05 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 104 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "UPDATES NURSING KNOWLEDGE BY ATTENDING INSERVICE WORKSHOPS" NOT NEEDED 1 2 1.3 0.0 0.7 0.0 0.0 6.53 0.0 0.0 0.7 0.0 0.0 3 0.6 0.8 1.5 0.0 0.0 4 1.9 0.0 5.2 0.0 5.0 5 8.4 0.0 16.4 11.8 20.0 6 12.3 6.9 16.4 23.5 25.0 NEEDED 7 75.5 91.5 59.0 64.7 50.0 MEAN 6.55 6.88 6.21 6.53 6.20 ST.DEV. 1.00 0.46 1.17 0.72 0.95 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 105 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "TEACHES CORRECT PRINCIPLES, PROCEDURES AND TECHNIQUES OF PATIENT CARE TO OTHER STAFF" NOT NEEDED 1 2 9.8 8.5 10.4 11.1 20.0 5.04 2.6 3.1 2.2 5.6 5.0 3 3.9 1.6 6.7 11.1 5.0 4 15.7 18.6 17.9 22.2 5.0 5 26.1 18.6 13.4 33.3 25.0 6 12.4 13.2 8.2 11.1 10.0 NEEDED 7 29.4 36.4 41.0 5.6 30.0 MEAN 5.01 5.21 5.10 4.17 4.60 ST.DEV. 1.85 1.86 2.02 1.65 2.30 248 TABLE 106 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJECTIVE "SUPERVISES AND CHECKS THE WORK OF STAFF FOR WHOM SHE IS RESPONSIBLE" NOT NEEDED NEEDED 1 2 3 4 5 6 7 MEAN ST.DEV. EDUCATOR 4.5 0.6 2.6 5.8 20.6 20.0 45.8 5.81 1.53 ADMINISTRATOR 5.4 0.0 1.5 5.4 11.5 10.0 66.2 6.12 1.58 PHYSICIAN 2.2 0.7 3.7 9.7 13.4 10.4 59.7 6.01 1.47 R.N.A.B.C. 0.0 0.0 0.0 11.8 35.3 11.8 41.2 5.82 1.13 MINISTRY 5.0 0.0 5.0 5.0 15.0 15.0 55.0 5.90 1.65 OVERALL MEAN 5.96 EDUCATOR ADMINISTRATOR PHYSICIAN R.N.A.B.C. MINISTRY OVERALL MEAN TABLE 107 CROSS TABULATION BY PROFESSION PERCENTAGE ANSWERING FOR OBJE