Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The evaluation of a fourteen week continuing education course in critical care nursing Robinson, Ruth Elizabeth 1975

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1975_A8 R62.pdf [ 5.69MB ]
Metadata
JSON: 831-1.0055960.json
JSON-LD: 831-1.0055960-ld.json
RDF/XML (Pretty): 831-1.0055960-rdf.xml
RDF/JSON: 831-1.0055960-rdf.json
Turtle: 831-1.0055960-turtle.txt
N-Triples: 831-1.0055960-rdf-ntriples.txt
Original Record: 831-1.0055960-source.json
Full Text
831-1.0055960-fulltext.txt
Citation
831-1.0055960.ris

Full Text

THE EVALUATION OF A FOURTEEN WEEK CONTINUING EDUCATION COURSE IN CRITICAL CARE NURSING by RUTH ELIZABETH ROBINSON B.S.N., The U n i v e r s i t y of B r i t i s h Columbia, 1970  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  i n the Department of Adult Education  We accept t h i s thesis as conforming to the requested standard  THE UNIVERSITY OF BRITISH COLUMBIA September 1975  In  presenting  this  thesis  an advanced degree at the I  Library shall  f u r t h e r agree  for  scholarly  by h i s of  this  written  make  it  freely available  that permission  It  financial  gain s h a l l  permission.  U n i v e r s i t y of B r i t i s h  2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  Columbia,  Columbia  I agree  r e f e r e n c e and this  not  copying or  for  that  study. thesis  by the Head of my Department  is understood that  Depa rtment The  for  the requirements  f o r e x t e n s i v e copying o f  purposes may be granted  for  fulfilment of  the U n i v e r s i t y of B r i t i s h  representatives. thesis  in p a r t i a l  or  publication  be allowed without my  i.  ABSTRACT  This study reports on an evaluation of the f i r s t of two fourteen week continuing education courses i n c r i t i c a l care nursing.  It  focuses on the thirteen nurses who completed the course, examining trends that might be used as predictors of performance i n continuing education.  The rationale for this approach was that short courses  often i n t e n s i f y a learning experience, and because of time r e s t r i c t i o n s they are presented i n a r e l a t i v e l y structured way.  This p a r t i c u l a r  course was extended i n time and also added a c l i n i c a l learning experience. The study looks at the method and techniques used to determine whether p r i o r knowledge of course participants could a f f e c t these, and whether a structured approach can meet the learning requirements of the course participants. The methodology employed evaluation instruments designed f o r the course which measured performance.  This included a knowledge pretest  and posttest, a c l i n i c a l performance appraisal, and program evaluation questionnaires.  The pretest-posttest design used the same questions  on both tests i n order to measure knowledge gains. administered on the f i r s t day of the course. on the second l a s t day.  The pretest was  The posttest was given  C l i n i c a l performance was assessed on an on-  going basis and a f i n a l assessment and score was determined  i n the l a s t  ii  week of the c o u r s e .  A measure of c o n f i d e n c e was  w i t h each w r i t t e n t e s t by a s k i n g the nurse c o n f i d e n c e i n each answer she s e l e c t e d . measure of b e l i e f i n l o c u s of c o n t r o l  determined  along  to i n d i c a t e her degree o f In a d d i t i o n , a p s y c h o l o g i c a l  (the R o t t e r I-E S c a l e ) ,  a d m i n i s t e r e d a t the b e g i n n i n g o f the course.  T h i s measure  was  determines  the e x t e n t t o which a nurse might take r e s p o n s i b i l i t y f o r her  own  l e a r n i n g , and whether t h a t would u l t i m a t e l y a f f e c t her performance i n a c o n t i n u i n g education course. A n a l y s i s of the d a t a r e v e a l e d c e r t a i n f a c t o r s which a f f e c t e d g a i n s i n knowledge as a r e s u l t of p a r t i c i p a t i o n i n the course, which c o u l d be used as p r e d i c t o r s of performance. age, background work e x p e r i e n c e and  greater gains. n u r s i n g performed  Nurses who  No s i g n i f i c a n t c o r r e l a t i o n s were found  on w r i t t e n t e s t s was  performance s c o r e s . found  Younger nurses  concept achieved  had had more e x p e r i e n c e i n c r i t i c a l  b e t t e r than those who  influenced c l i n i c a l  In p a r t i c u l a r ,  the l o c u s of c o n t r o l  s i g n i f i c a n t l y r e l a t e to knowledge g a i n s .  and  had had  l i t t l e o r no  care  experience.  among these v a r i a b l e s which Confidence  i n answers g i v e n  to p o s i t i v e l y c o r r e l a t e w i t h the a c t u a l  score obtained. The i m p l i c a t i o n s f o r the f i n d i n g s of t h i s study a r e important c o n t i n u i n g e d u c a t i o n course p l a n n e r s .  Based on the  significant  p r e d i c t o r s of performance, s e l e c t i o n of students f o r courses can  be  to  iii  made on these factors.  Age and background experience are known p r i o r  to the course and should be considered when making s e l e c t i o n .  The  pretest performance revealed areas of strength and weakness i n the group and could be used e f f e c t i v e l y for planning the development and emphasis of course content. The locus of control concept deserves further study to determine i t s influence on course outcomes.  The results of t h i s study revealed  that the greater the b e l i e f i n internal control of reinforcement (one i s responsible f o r what happens), the greater the gain achieved i n the course.  Further study as to how or why this influence e x i s t s could  be very h e l p f u l to the f i e l d of continuing education. As a beginning attempt at planning for more e f f e c t i v e continuing education, this study points out s i g n i f i c a n t areas f o r further i n v e s t i gation.  In i t s e l f , i t also has assisted i n the planning f o r the  second course i n c r i t i c a l care nursing, as the evaluation f o r the course revealed areas of weakness i n the presentation used f o r the first  course.  "We d a n c e But  the  'round  i n a r i n g and  secret sits  suppose,  i n t h e m i d d l e and  knows."  Robert  Frost  V  ACKNOWLEDGEMENTS  The author wishes to express appreciation to those people who a s s i s t e d i n the development of the idea, the implementation of the study and i n the preparation of t h i s report.  The members of my  t h e s i s committee - - - Dr. J.E. Thornton, Miss E.K. McCann and Dr. J.B. C o l l i n s - - - each played a s p e c i a l r o l e i n the achievement of the o b j e c t i v e .  Thanks also go to Mrs. Sharon Turnbull, D i r e c t o r ,  Continuing Nursing Education at U.B.C, and Miss M a r i l y n Coordinator  Baines,  of the C r i t i c a l Care Nursing Course, f o r t h e i r assistance  i n the development of the evaluation instruments.  S p e c i a l appreciation  i s expressed to Miss Barbara Lockyer, who provided invaluable assistance i n the typing and e d i t i n g of t h i s report.  And f i n a l l y , the author  wishes to thank Mr. Larry T r u i t t , who made me b e l i e v e i n the f i r s t place that t h i s day would come.  Vancouver, B.C. September 1975  Ruth E. Robinson  vi  TABLE OF CONTENTS  Page ACKNOWLEDGEMENTS TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES  I.  PURPOSE AND SCOPE OF STUDY Introduction A Continuing Education Course i n C r i t i c a l Care Nursing , A D e s c r i p t i o n of the Students Who Attended . . . . Rationale Assumptions and L i m i t a t i o n s Plan of the" Study  II.  SURVEY OF THE LITERATURE Continuing Education i n Nursing Measuring C l i n i c a l Performance Learning Needs External versus I n t e r n a l Control of Reinforcement Program Evaluation Summary  III.  METHODOLOGY Hypotheses Definitions Evaluation Instruments Design of the Study Data C o l l e c t i o n and Analysis  V vi viii ix  1 1 3 4 5 7 9  10 10 12 13 14 17 19  21 22 23 25 30 32  vii  TABLE OF CONTENTS (Continued) Page IV.  ANALYSIS OF DATA  34  General Summary of Program Outcomes Measures of Knowledge Measures of C l i n i c a l Performance Measures of Program E f f e c t i v e n e s s  V.  34 34 51 52  SUMMARY, CONCLUSIONS AND RECOMMENDATIONS  54  Summary Conclusions Recommendations f o r the Second Course Recommendations f o r Further Study  54 56 58 60  ......  BIBLIOGRAPHY AND REFERENCES  62  APPENDICES  66  viii  LIST OF TABLES  Table  Page  LIST OF DATA COLLECTION INSTRUMENTS AND DATES THEY WERE USED  33  SCORES OBTAINED ON PRETESTS FOR EACH OF THREE PRETEST GROUPS  35  PRETEST SCORES AND POSSIBLE RELATED VARIABLES TO EXPLAIN DIFFERENCES BETWEEN 3 PRETEST GROUPS  37  SCORES ON ASSIGNMENTS AND EXAMINATIONS FOR 13 NURSE STUDENTS  39  DIFFERENCE IN RANK FOR EACH OF 13 NURSE STUDENTS WHEN PRETEST SCORE IS INCLUDED AS PART OF FINAL SCORE  40  LIST OF VARIABLES TESTED COMPARING 13 NURSE STUDENTS IN A CRITICAL CARE NURSING COURSE WITH 40 CRITICAL CARE NURSES  42  CORRELATIONS OF VARIABLES TESTED USING COMBINED GROUP OF 13 NURSE STUDENTS AND 40 CRITICAL CARE NURSES  47  GAIN SCORES FROM PRETEST TO POSTTEST FOR 13 NURSE STUDENTS  48  ix.  LIST OF FIGURES Figure  Page MODEL OF COURSE INFLUENCES  B  PERCENTAGE OF CORRECT RESPONSES AND CONFIDENCE IN ANSWERS GIVEN ON 71 ITEM POSTTEST  28  1.  CHAPTER I - PURPOSE AND SCOPE OF THE STUDY  Introduction The h a l f - l i f e of science and technology  a f f e c t i n g nursing care  methods i s now between three and f i v e years, according to Tobin's (47) estimate.  This statement alone can j u s t i f y the need for increased  concern and action i n the area of continuing education for nurses. However, i t appears that the l o g i s t i c a l problems that affect the development of continuing education have not yet been overcome. The National Commission f o r the Study of Nursing and Nursing  Education  has suggested that the problems of continuing education i n nursing may be greater than i n any other profession because of the variety of preservice educational programs used i n the preparation of registered  nurses.^  According to a report from the Western Interstate Commission for Higher Education,the  assumption i s made that " . . . more than 70 per cent  of p r a c t i c i n g nurses may not be pursuing planned programs to increase t h e i r competence as p r a c t i t i o n e r s . " The American Nurses' Association has defined three d i s t i n c t areas of education i n nursing - formal academic study, continuing education and (2)  independent learning. this report.  I t i s the l a t t e r two which are the concern of  From the focus of a p a r t i c u l a r program i n continuing  education, some of the problems inherent i n presenting continuing nursing education are examined, considering both the program i t s e l f and i t s  2.  objective to motivate ongoing independent learning within the course participants. The need f o r preparation of nurses to deal with the technological advances i n medicine which a f f e c t nursing i s c r i t i c a l .  Intensive care  units, coronary care units and emergency departments are faced with challenges every day which demand knowledge and expertise of the nurse. A d d i t i o n a l l y , specialized units such as those f o r patients with burns, renal conditions and neurosurgery require s p e c i a l s k i l l s of the nurse. Formal education and t r a i n i n g programs to prepare nurses i n these areas are minimal.  Most nurses learn "on-the-job", with some help from  inservice education programs, which at best can only provide the minimum for  safety. D i s s a t i s f a c t i o n with this l e v e l of preparation led to the development  of a continuing education course i n c r i t i c a l care nursing at the University of B r i t i s h Columbia.  This was the f i r s t of two courses to be offered, and  concerns expressed not only by the course planners but by many educators both i n nursing and elsewhere suggested the f e a s i b i l i t y of an indepth study of selected problems related to continuing nursing education. This study presents an evaluation of the c r i t i c a l care nursing course, i d e n t i f y i n g trends becoming evident i n planning such courses, using knowledge of the learners themselves as a means of studying what the nature of future courses should be i f they would meet the needs of nurse practitioners.  As preparation for s p e c i a l i z a t i o n i n nursing becomes more important, and i n fact a prerequisite to working i n specialized areas, knowledge about the c h a r a c t e r i s t i c s of nurses which would predict higher performance levels should help to answer whether courses should be more s e l f - d i r e c t e d and facilitating,  or more structured and d i r e c t i v e .  A Continuing Education Course i n C r i t i c a l Care Nursing A post basic course i n C r i t i c a l Care Nursing designed to enable nurses to acquire the theory and c l i n i c a l s k i l l s necessary to provide nursing care to c r i t i c a l l y i l l patients was i d e n t i f i e d as a need i n 1973. An evaluation of two previous short courses i n intensive and coronary care revealed the need f o r a course capable of providing more extensive knowledge i n the f i e l d , and the opportunity to learn c l i n i c a l s k i l l s , neither of which could be s a t i s f i e d by t y p i c a l short courses. As a r e s u l t , a 14-week course was developed and sponsored by the D i v i s i o n of Continuing Nursing Education at the University of B r i t i s h Columbia, i n cooperation with the Registered Nurses' Association of B r i t i s h Columbia, Royal Columbian Hospital, Saint Paul's Hospital and Vancouver General Hospital.  F i n a n c i a l assistance f o r the development  and implementation of the course was provided by B r i t i s h Columbia Hospital Insurance Service, the University of B r i t i s h Columbia School of Nursing, and the Kellogg Project f o r Continuing Education for Health Professionals.  4.  It was the intent of the course to assist nurses i n learning the nursing process i n caring f o r c r i t i c a l l y i l l patients, and importantly to help nurses learn to i d e n t i f y their own learning needs and seek out ways of meeting them. Classroom time was quite formal and d i r e c t i v e i n i t i a l l y , covering content basic to c r i t i c a l care nursing. nurse students were encouraged  As the course developed, the  to be more independent, and were expected  to do more learning on t h e i r own or i n small groups. C l i n i c a l practice was provided concurrently with classroom learning. The nurse students spent two - three days each week i n selected c l i n i c a l areas under the supervision of c l i n i c a l preceptors.  As much as possible,  c l i n i c a l experiences were planned to match what was being taught i n c l a s s . The majority of c l i n i c a l experience time was spent i n intensive care, coronary care and emergency departments.  A Description of the Students Who Attended F i f t e e n nurses were selected representing thirteen smaller communities throughout the province.  Preference i n selection was given  to areas having no easy access to regular continuing nursing education course offerings.  Selection was based on a series of c r i t e r i a pertinent  to the projected course outcomes.  (See Appendix A)  Some of the  c r i t e r i a f o r s e l e c t i o n included p a r t i c i p a t i o n i n continuing nursing education, involvement i n ongoing hospital development a c t i v i t i e s , and  5.  employment i n a h o s p i t a l providing opportunities f o r inservice education and/or s t a f f development.  Nurse applicants were sponsored by their  employers and applications were required from both the nurse applicant and the employer.  Points were given for information obtained from the a p p l i -  cation forms and a t o t a l score was determined  f o r each nurse applicant.  The top 15 scores were accepted f o r the course, with alternates named from the highest score of the remaining applicants.  Application forms  and c r i t e r i a for s e l e c t i o n forms can be found on f i l e at the D i v i s i o n of Continuing Nursing Education, University of B r i t i s h Columbia. The f i f t e e n nurse students represented a v a r i e t y of e x p e r i e n t i a l backgrounds. care areas.  Two were i n supervisory positions responsible f o r c r i t i c a l Four had had no previous work experience i n c r i t i c a l care.  The remainder had some experience, and most of t h e i r preparation had been on-the-job learning.  Rationale This study examines both the s p e c i f i c course on c r i t i c a l care nursing previously described and i t s learners i n order to a r r i v e at some substantiated conclusions that could be used by the course planners to enhance the effectiveness of a second course.  Further, i t became the intent to  project these conclusions i n order to i d e n t i f y trends that might be applicable to continuing nursing education courses i n general. varied analyses this study undertakes  Through  to i d e n t i f y those predictors that  6.  might be used both i n the design of continuing education courses and i n adapting such designs as they are implemented f o r a s p e c i f i c group of learners. To accomplish t h i s task, the study focuses on analyses of the f o l l o w i n g information: 1.  Biographical information about the learners c o l l e c t e d from a p p l i c a t i o n forms.  2.  Formal t e s t s and examinations prepared by course  planners  and designed to e l i c i t knowledge i n l i n e w i t h stated course objectives. 3.  A measure of the confidence nurses have i n t h e i r own answers given on a t e s t of knowledge.  4.  Selected diagnostic t e s t s which were added to the course to e l i c i t other kinds of information about the learners themselves.  This included a t e s t to i d e n t i f y the extent to  which the learners believed i n t h e i r a b i l i t y to c o n t r o l t h e i r own experiences  (the Rotter I-E Scale i s described  in detail later). 5.  A b a t t e r y of evaluation devices which were combined to i d e n t i f y l e v e l s of achievement i n c l i n i c a l performance. These included C r i t i c a l Incident Technique, observations of the c l i n i c a l preceptors and the S l a t e r Nursing Competencies Rating Scale ( a l l to be described l a t e r ) .  7.  The a n a l y s i s was designed to answer questions to which a t t e n t i o n has been given i n previous studies.  little  What i s known about  nurses i n general that might help to p r e d i c t l e a r n i n g gains i n a program of continued learning?  What i s known about program development to help  to achieve greater gains f o r i n d i v i d u a l s who attend?  Is anything r e a l l y  to be gained from continuing nursing education programs which attempt to advance the knowledge and c l i n i c a l  s k i l l s of p r a c t i c i n g nurses?  Figure A shows the development of the analyses used i n t h i s study which were planned to a s s i s t i n answering these questions.  I t represents  inputs to the course, the implementation of the course, and what measurable behaviour changes occurred as a r e s u l t .  Did the course have a p o s i t i v e or  negative e f f e c t on knowledge gains or c l i n i c a l  performance?  And knowing  the r e s u l t s , could the course have been developed d i f f e r e n t l y based on the known inputs f o r a s p e c i f i c group of learners?  Assumptions and L i m i t a t i o n s The study was r e s t r i c t e d to 15 p a r t i c i p a n t s attending the f i r s t of two 14-week continuing education courses i n C r i t i c a l Care Nursing.  As a  r e s u l t , i t was r e s t r i c t e d to the design and experiences provided i n t h i s f i r s t course.  The smallness of the sample was recognized to p o s s i b l y l i m i t  s i g n i f i c a n c e of the r e s u l t s . I t was an assumption i n t h i s study that the nurse students would have basic background knowledge about the areas of c r i t i c a l care nursing pro-  COURSE INPUTS  COURSE OUTPUTS  Biographical Data Attendance at a Continuing  Clinical Performance Abilities  Education Course 1.  Theory Sessions  2.  C l i n i c a l Sessions  Gains/Losses in Performance  Cognitive Styles  FIGURE A. MODEL OF COURSE INFLUENCES  co-  9.  vided i n the course.  This assumption was related to the a b i l i t y and/or  motivation of participants to i d e n t i f y needs, and also to the fact that t h e i r employers supported t h e i r applications and would place them i n c r i t i c a l care areas upon completion of the course. F i n a l l y , the evaluation tools used to measure performance i n the course were approved by a panel of c l i n i c a l experts.  However, r e l i a -  b i l i t y and v a l i d i t y have not yet been tested.  Plan of the Study With the background of the s p e c i f i c course being studied and the learners on whom the research was focussed covered i n Chapter I, a review of the l i t e r a t u r e pertinent to the analysis i s presented i n Chapter I I . The design of the study i s outlined i n Chapter I I I . the findings and the analysis of the data.  Chapter IV presents  This includes not only data  related to the testing of hypotheses, but also other information which i t was f e l t would have influence on course outcomes.  In the f i n a l Chapter,  a summary of the evaluation of the course i s presented and some conclusions are drawn about this evaluation as i t relates to the t o t a l picture of continuing nursing education.  Recommendations are made f o r the second  course, for future courses and for future research i n evaluation of continuing nursing education courses.  10.  CHAPTER I I - SURVEY OF THE LITERATURE  A review of the l i t e r a t u r e was planned to cover s e v e r a l t o p i c s r e l a t e d to t h i s evaluation study.  I t seemed appropriate to look at  current t h i n k i n g i n continuing education f o r nurses, l o o k i n g both at the need f o r i t and what i t s planning should encompass.  Program evalu-  a t i o n i n general was a l s o considered an area of the l i t e r a t u r e that should be reviewed.  As t h i s course included c l i n i c a l experience f o r the  nurse students, i t was necessary to look at trends i n performance a p p r a i s a l i n nursing.  Readings on l e a r n i n g needs and how to meet them  were done to e x p l a i n i n d i v i d u a l d i f f e r e n c e s among students and how might a f f e c t course outcomes.  this  F i n a l l y , as the study intended to  i d e n t i f y the i n t e r r e l a t i o n s h i p s between achievement, confidence and i n d i v i d u a l d i f f e r e n c e s i n perceived l e v e l s of c o n t r o l (the Rotter I-E Scale), selected l i t e r a t u r e p e r t i n e n t to these measures was  reviewed.  Continuing Education i n Nursing P a r t i c i p a t i o n i n continuing education; programs i s a matter of (33) a t t i t u d e , motivation, and program relevancy.  The concept of l i f e -  long learning i s defeated by the "terminal concept" of most education programs. task.  I n d i v i d u a l s are not geared to l e a r n i n g as a s e l f - d i r e c t e d  M o t i v a t i o n to attend continuing education programs may have  l i t t l e or nothing to do with motivation to engage i n learning.  We  need to know much more about participants i n educational programs before we can determine the extent to which attendance i s equivalent to motivation to learn. Relevance i s an even more valuable concept.  Individuals w i l l  p a r t i c i p a t e and learn i f they see that a program offers opportunity for  them to meet their learning needs.  But what i s not"known, i s .  how able these individuals are to i d e n t i f y their own.'need for^-learning. Programs offered i n the past have been evaluated i n varying degrees of completeness and t e l l us l i t t l e about whether the program has met of  learning needs, i d e n t i f i e d learning needs, or had any degree  relevance i n terms of whether the " r i g h t " people are attending;  whether the d i f f e r e n t needs of graduates of d i f f e r e n t kinds of basic preparation programs are recognized;  (30,16)  Q r  w  j  i e t  j  i e r  payment for continuing education should be the nurse's personal  (22) r e s p o n s i b i l i t y or the r e s p o n s i b i l i t y of her employing agency. The r e a l question always seems to be, "Does continuing education make a d i f f e r e n c e ? "  There are many ways of looking at t h i s question,  (22) although the generally accepted measure i s improved nursing care. Most research on program evaluation i n continuing education has been primarily exploratory.  Those evaluations which have provided  d e t a i l have used techniques which have made the r e s u l t s s p e c i f i c to the course. (33) *t,  12.  Curtis describes several techniques  that have been used i n  continuing education course evaluations, including observations of simulated nurse-patient situations, analysis of process recordings and d i a r i e s , rating achievement of course objectives, s a t i s f a c t i o n ratings such as the Kropp-Verner scale, and Firo-B, which i s a measure of group compatibility.  Measuring C l i n i c a l Performance C l i n i c a l components to continuing education programs have been  (^•5 3X 5 3) provided almost exclusively through inservice education.  '  ''  At the same time, the p o t e n t i a l f o r inservice education to aid i n the development of c l i n i c a l competence has hardly been touched. Evaluation of c l i n i c a l performance requires a great deal of planning and i n s t r u c t i o n .  There are many forms of evaluation i n  existence and some are more successful than others.  The developing  trend i n the l i t e r a t u r e seems to be towards the use of r a t i n g scales. <«.39,21) Standards of nursing care and the use of a nursing audit has current popularity, although i t involves a great deal of preparation time and i t requires t r a i n i n g i n the use of the tool before i t can be e f f e c t i v e .  13.  Learning Needs B i t t e l l and Craig,  (27)  i n reference to industry, stated that  t r a i n i n g needs are determined for various reasons, including: 1.  a s s i s t i n g people to be more productive on their present job and preparing them for advancement;  2.  meeting requirements which w i l l allow people to perform at an optimum l e v e l ;  3.  providing the chance for people to do a good job because they "can", "want to", and " w i l l " ;  4.  making sure that time, money and e f f o r t spent on training i s based on r e a l needs.  Some nursing surveys have been done which ask open-ended questions about " f e l t " learning needs.  Although positions and types of agencies  varied, expressed needs were quite s i m i l a r .  One of the most prominent  needs was that of improving communcation and management s k i l l s . ^ > 2 0 , 1 9 , 1 1 ) Other learning needs that were considered p r i o r i t y were: i n nursing care;  l e g a l aspects of nursing;  newer dimensions  and the changing r o l e of the  nurse. In an Ontario Survey of N e e d s , e m p l o y e r s of nurses i n hospitals and public health agencies i d e n t i f i e d similar things.  They also pointed  out needs for courses to increase teaching s k i l l s , and to provide s p e c i a l i z a t i o n i n nursing, especially i n the areas of intensive care nursing, chronic disease, mental health and r e h a b i l i t a t i o n .  Of p a r t i c u l a r i n t e r e s t to t h i s study was an attempt to i d e n t i f y (34) l e a r n i n g needs of nurses i n two ways.  Price  asked nurses to  report a c r i t i c a l i n c i d e n t encountered the previous year which she considered of extreme s i g n i f i c a n c e and r e l a t e d to her l a c k of preparation. the  Then each was asked to i d e n t i f y the l e a r n i n g need which  nurse thought would best enable her to improve the q u a l i t y of her  nursing care.  P r i c e found that, w h i l e the nurses reported t h e i r  greatest l e a r n i n g needs to be i n d i r e c t p a t i e n t care, most of the c r i t i c a l i n c i d e n t s r e l a t e d to d i r e c t patient care. Related to needs, one of the most frequent requests r e l a t i v e to improving i n s t r u c t i o n a l methods and techniques was more learner (4) participation.  External versus I n t e r n a l Control of Reinforcement One f a c t o r which may a f f e c t the amount of i n f l u e n c e that one person exerts over another i n changing the l a t t e r ' s a t t i t u d e s i s the (37) concept of i n t e r n a l versus e x t e r n a l c o n t r o l of reinforcement. This concept has developed out of s o c i a l l e a r n i n g theory.  Rotter  stated that reinforcements act to strengthen an expectancy that a p a r t i c u l a r behaviour or event w i l l be followed by that same r e i n f o r c e ment i n the future.  The extent to which an i n d i v i d u a l f e e l s that he  controls h i s own destiny and i s the e f f e c t i v e agent i n determining the occurrence of reinforcements i s the extent to which he believes i n  15.  Internal control of reinforcement.  The more an i n d i v i d u a l believes  that forces beyond his control are the influence on reinforcement, the more he believes i n external control of reinforcement.  Such forces  might include fate, chance, powerful others, or the complexity of the  (37) world or i t s u n p r e d i c t a b i l i t y . A number of studies have shown that expectancies are d i f f e r e n t i a l l y affected when tasks are perceived C 2^* 25  35  36  opposed to chance or luck.  as dependent on s k i l l as  ^\ 1)  '  The f i r s t attempt to  measure i n d i v i d u a l differences i n a b e l i e f i n control of reinforcement (35) was  begun by Phares.  a 29-item forced-choice  After several changes, this measure i s scale, including six f i l l e r items.  This scale i s developed to measure a person's expectancy of how  now  generalized  his reinforcements are controlled.  s a t i s f a c t o r y i n t e r n a l consistency,  The scale has  t e s t - r e t e s t r e l i a b i l i t y , convergent  v a l i d i t y , and discriminant v a l i d i t y .  The scale i s most suitable for  investigations of group differences. The i n t e r n a l versus external concept has shown relationships to a v a r i e t y of behaviours, including those i n learning situations(10*24,35,8) conformity s i t u a t i o n s , ^ ^ ' ^  and r i s k taking.  It i s worth comment that Rotter's explanation  of the IE (Internal-  External) control construct included the concept of reward value as  a f f e c t i n g a person's expectancy that a given behaviour w i l l r e s u l t i n an expected reinforcement: Behaviour Potential = f (Expectancy + Reward Value) (26 ^ Jeffrey  i d e n t i f i e s an example of this by suggesting that  a student may have a very i n t e r n a l attitude about studying f o r a course and getting a good grade, but i f the course has l i t t l e reward value to him, he i s unlikely to study for the course. Rotter comments that, t h e o r e t i c a l l y , one would expect some relationship between i n t e r n a l i t y and good adjustment but that the (9)  relationship i s probably quite complex.  Broskowski  noted  that extremely external and extremely i n t e r n a l persons w i l l probably have a greater degree of d i f f i c u l t y i n adjustment than those nearer the center of the continuum.  His j u s t i f i c a t i o n f o r  this prediction i s that extreme externals w i l l not have feelings of  g u i l t or r e s p o n s i b i l i t y , but may have increased d e b i l i t a t i n g  anxiety.  Extreme i n t e r n a l i t y may produce g u i l t and an over-  r i d i n g sense of personal r e s p o n s i b i l i t y , not to mention anxiety in the many fate-controlled or other-controlled situations i n modern l i f e .  17.  Program Evaluation In the foreword to Evaluating Educational Performance.,, J . Thomas Hastings emphasizes that those people involved i n educational measurement must "cease to depend s o l e l y upon the methodologies of psychometrics, and correlation;  rather to adapt and adopt procedures, instrumentation and  l o g i c from sociology, economics, h i s t o r y and elsewhere" i f they are to (48) b e t t e r understand the complexities of education today. . (23) Evaluation-is»noti-ancevent,v- but-rather .ai.process.:. -•HS. ' . I t contributes to a l l aspects of program management by i d e n t i f y i n g needs, measuring achievement, assessing the l e a r n i n g climate, and determining  change.  (13) Cronbach -.. > explained a judgmental strategy f o r evaluation. o u t l i n e d three types of decisions f o r which evaluation i s used: improvement;  decisions about i n d i v i d u a l s ;  He  course  and a d m i n i s t r a t i v e r e g u l a t i o n .  He also i d e n t i f i e d four approaches to evaluation: 1.  Process Studies - to examine what i s happening during i n s t r u c t i o n ;  2.  A t t i t u d e Measures - to e l i c i t f e e l i n g s and b e l i e f s , not j u s t expressions of approval or disapproval; Follow-up Studies - to attempt to observe ultimate educational contributions; P r o f i c i e n c y Measures - to measure student performance by observation or by achievement on w r i t t e n t e s t s .  3. 4.  (32) Merwin  v  .. suggests that there are four considerations t o evaluation:  who (or what) should be evaluated;  who should evaluate;  how evaluations  18.  should be conducted;  and how evaluations can best be Integrated into the  educational process. In a study of the Labour College of Canada, Dickinson and Lamoureux ^-.^ considered f i v e t h e o r e t i c a l units to be c r u c i a l to program evaulation. study was  Their  concerned with educative temporary systems and how useful the pro-  grams were when participants returned to their work s e t t i n g .  Those f i v e  units were: 1.  change i n p a r t i c i p a t i o n behaviour following the educative temporary system;  2.  participant s a t i s f a c t i o n with the design and management of the educative temporary system;  3.  personal goal attainment by participants i n the educative temporary system;.  4.  cognitive achievement within the educative temporary system;  5.  participant attitudes related to the goals of the educative temporary system.  Barclay ^.11 ^ states that a major problem i n implementing new learning strategies i n the schools i s that learning i s influenced by student, teacher, curriculum, parental and other environmental  factors.  As a r e s u l t , when  evaluating behaviours one must not only consider behaviours that relate to achievement, but also to self-competency,  self-management, group i n t e r a c t i o n ,  motivation, and other a f f e c t i v e and s o c i a l variables.  Schulberg and Baker' '' discussed two evaluation models that V  +J  (2Q)  r e l a t e to Knutson's  i d e n t i f i c a t i o n of the categories of evaluation  as being organization oriented and personally oriented. model i s a goal-attainment achievement.  The f i r s t  model, which i s b a s i c a l l y a measure of goal  The second i s a systems model of evaluation.  It i s  concerned with establishing a working model of a s o c i a l unit which i s capable of achieving a goal. Summary This l i t e r a t u r e review points out several important points f o r consideration i n the evaluation of the c r i t i c a l care nursing  course.  The f i r s t i s that attendance at a continuing education course may not necessarily mean desire to learn.  Given the premise that the locus  of control concept may correlate to performance i n the course, the nurse students attending the course may have an i n t e r n a l locus of control, but may have quite separate reasons f o r attending the course. Therefore the implications of the c o r r e l a t i o n may not be answered d i r e c t l y i n the analysis. C l i n i c a l performance evaluations have been researched deal;  a great  however, o b j e c t i v i t y i n such evaluations has never been  s a t i s f a c t o r i l y achieved.  I t should be recognized at the outset  that instruments were selected which i t was hoped would be as objective as possible.  However, the known d i f f i c u l t i e s of c l i n i c a l  20.  performance e v a l u a t i o n presented data  p o t e n t i a l problems w i t h p a r t o f the  analysis. I n d i v i d u a l l e a r n i n g needs a r e always a d i f f i c u l t p a r t o f t h e  d e s i g n of any e d u c a t i o n c o u r s e . needs r e c o g n i z e d by nurses  The l i t e r a t u r e reviewed  i n d i c a t e s t h a t nurses  on l e a r n i n g  attending a continuing  e d u c a t i o n course may have d i f f e r e n t e x p e c t a t i o n s of what the course can o f f e r to them.  Although  t h i s p a r t i c u l a r course was designed  with  i n d i v i d u a l l e a r n i n g needs i n mind, i t was r e c o g n i z e d t h a t the course may  s t i l l not meet the e x p e c t a t i o n s of some of the nurse  students.  21  CHAPTER I I I - METHODOLOGY  The r a t i o n a l e f o r the study was o u t l i n e d i n Chapter I .  The  main focus was to examine a group of students i n a continuing nursing education course, how they performed i n that course and what was known about them as learners and as people that would help to p r e d i c t t h e i r performance.  Factors r e l a t e d to knowledge of the subject, confidence  i n that knowledge, c l i n i c a l performance i n c r i t i c a l care nursing areas, and b e l i e f i n i n t e r n a l - e x t e r n a l locus of c o n t r o l were a l l used to p r e d i c t achievement. The p a r t i c u l a r appeals of the i n t e r n a l - e x t e r n a l locus of c o n t r o l concept i n understanding and e x p l a i n i n g nursing performance i n the l e a r n i n g and performing areas are that:  1) i t helps t o i d e n t i f y the  i n i t i a t i v e that might be taken by a nurse about the care of a c r i t i c a l l y i l l patient;  2) i t may serve as a p r e d i c t o r of a nurse's  confidence i n her/his a b i l i t y to perform a given task;  and 3) i t  may a l s o p r e d i c t a nurse's a b i l i t i e s t o achieve greater gains as a r e s u l t of p a r t i c i p a t i n g i n a continuing education course.  Therefore,  the locus of c o n t r o l concept assumed a c e n t r a l r o l e i n t h i s study.  22.  Hypotheses Based on this rationale, the following hypotheses were proposed. They are expressed as n u l l hypotheses (Ho) and alternate hypotheses (Ha). Testing was performed on the n u l l Hypothesis One  Ho^:  Ha^:  Hypothesis Two  Hypothesis Three  There i s no s i g n i f i c a n t c o r r e l a t i o n between the score obtained on a test of knowledge and the degree of confidence a student has i n the answers given. (i)  Greater confidence i n answers given on a test of knowledge w i l l be associated with lower test scores.  (ii)  Greater confidence i n answers given on a test of knowledge w i l l be associated with higher test scores.  Ho :  There i s no s i g n i f i c a n t c o r r e l a t i o n between the score on a test of knowledge and the b e l i e f i n external control of reinforcement.  2  Ha2:  (i)  Higher scores on knowledge tests r e l a t e to a b e l i e f i n i n t e r n a l control of reinforcement.  (ii)  Higher scores on knowledge tests relate to a b e l i e f i n external control of reinforcement.  Ho :  There i s no s i g n i f i c a n t c o r r e l a t i o n between the degree of confidence i n answers given on a test of knowledge and b e l i e f i n external control of reinforcement.  3  Ha^:  hypotheses.  (i)  A higher degree of confidence i n answers given on a knowledge test relates to a b e l i e f i n i n t e r n a l control of reinforcement.  (ii)  A higher degree of confidence i n answers given on a knowledge test relates to a b e l i e f i n external control of reinforcement.  23.  Hypothesis Four  Ho,  There i s no s i g n i f i c a n t c o r r e l a t i o n between the gain i n score between a knowledge pretest and a posttest and b e l i e f i n e x t e r n a l c o n t r o l of reinforcement.  Ha : ( i )  A greater gain i n score between a knowledge pretest andiposttest r e l a t e s to b e l i e f i n i n t e r n a l c o n t r o l of reinforcement.  4  (ii)  Hypothesis Five  Ho  A greater gain i n score between a knowledge pretest and posttest r e l a t e s to b e l i e f i n external c o n t r o l of reinforcement. There i s no s i g n i f i c a n t c o r r e l a t i o n between the performance of a nurse i n a c r i t i c a l care nursing area and b e l i e f i n e x t e r n a l c o n t r o l of reinforcement.  5'  Ha,.: ( i )  A higher l e v e l of performance of a nurse i n a c r i t i c a l care nursing area r e l a t e s to b e l i e f i n i n t e r n a l c o n t r o l of reinforcement.  (ii)  A higher l e v e l of performance of a nurse i n a c r i t i c a l care nursing area r e l a t e s to b e l i e f i n e x t e r n a l c o n t r o l of reinforcement.  Definitions In order to avoid c o n f l i c t or confusion i n the use of c e r t a i n terms i n the study, the f o l l o w i n g d e f i n i t i o n s were used: (49)  Confidence  -  the b e l i e f one has i n one's own a b i l i t i e s . I t leads to an expressed sense of s e c u r i t y i n knowledge and performance.  Critically i l l  -  r e f e r s to a p a t i e n t w i t h acute problems threatening the f o l l o w i n g l i f e - m a i n t a i n i n g parameters: cardiovascular f u n c t i o n , r e s p i r a t o r y f u n c t i o n , f l u i d - i o n balance, c e n t r a l nervous system r e g u l a t i o n . Such p a t i e n t s as those w i t h traumatic i n j u r i e s ,  24.  severe burns, respiratory f a i l u r e and acute myocardial i n f a r c t i o n require frequent to continuous specialized nursing care.(12) Such care involves complicated technological a b i l i t i e s as w e l l as indepth knowledge on the part of the nurse. the perception of p o s i t i v e and/or negative events as being unrelated to one's own behaviour i n certain situations and therefore beyond personal control. (42) In the context of this study, such factors as the laid-on program, including content, methods and approach appear to the learner to be i n evitable and immutable. the perception of p o s i t i v e and/or negative events as being a consequence of one's own actions and thereby under personal control.(42) The learner perceives the planned program as meeting needs or not, and applies herself to learning the laid-on content only to the extent that i t seems u s e f u l to her. refers to the addition, p r o f i t or advantage achieved as a result of something. (49) It represents the differences measured between the i n i t i a l state of the learner and the end state i n regard to knowledge and c l i n i c a l s k i l l s i n c r i t i c a l care nursing. the has the the  range of understanding or information one about something. (49) In this study, l i m i t s of knowledge are r e s t r i c t e d to understanding of c r i t i c a l care nursing.  25.  Evaluation  Instruments  Knowledge Pretest.  A pretest, consisting of multiple choice  questions and completion items, was administered on the f i r s t day of the course.  The questions were based on content to be covered  during the 14 weeks of the course and included a l l subject areas: cardiovascular system, respiratory system, renal system, central nervous system, psychosocial aspects of nursing care, teaching patients and others, administration i n nursing, and s e l f learning. Because i t was assumed that the nurse students would have basic knowledge i n a l l these areas, that some would also have more indepth knowledge because of previous attendance at short courses on c r i t i c a l care nursing, and that some would have work experience i n c r i t i c a l care areas, the purpose of the pretest was to establish the extent to which the nurse students already knew the content to be presented during the course.  This would serve as a baseline from  which knowledge gains could be measured as a r e s u l t of the course. The f i f t e e n nurse students were divided into three groups of f i v e and each group wrote a d i f f e r e n t pretest.  Items on each test  were matched for content, complexity and item types. pretests combined made up the posttest.  The three  This design was used to  measure the gain i n score for the nurse students from pretest to posttest.  For the pretest, the questions were reviewed by a panel  of c l i n i c a l nursing experts, but were not tested f o r v a l i d i t y or reliability.  26.  Confidence Measures.  For each question on the pretest, the nurse  students were asked to indicate their degree of confidence i n their answers;  that i s , a f t e r each question they were asked to indicate  on a scale of 1 - 4 whether: 1 - I have no idea what the answer i s 2 - 1 guessed at my answer 3 - My answer may be right 4 - I am confident my answer i s right A l l confidence responses f o r the t o t a l number of pretest items were then summed.  This measure was used to determine a confidence score  for each nurse student.  The a b i l i t y to perform i n a continuing  education course of the design proposed was measured against the confidence of the nurse student as indicated on the knowledge test.  Knowledge Posttest. (See Appendix B)  The f i n a l examination was  administered on the second l a s t day of the course to 13 nurses completing the course.  The test consisted of items from the three  pretests that were tested for v a l i d i t y and r e l i a b i l i t y by having a group of 40 nurses currently working i n c r i t i c a l care areas write the test.  Item analysis was done, and of the 119 items on the o r i g i n a l  posttest, 71 items were selected for scoring on the f i n a l examination. Forty-eight items were eliminated because of ambiguous stems, confusing d i s t r a c t o r items, more than one right answer for selection, and negative d i f f e r e n t i a l d i s c r i m i n a b i l i t y (that i s , items which s e l e c t i v e l y disadvantaged high performers and advantaged low per-  27.  formers i n the c o n t r o l group of 40 nurses).  The t h i r t e e n nurse  students were asked to answer a l l 119 items, but only the 71 items were counted f o r t h e i r f i n a l mark. Figure B p l o t s the number of correct responses f o r each of the 71 items on the revised p o s t t e s t against the confidence by the whole group of nurses i n that question.  expressed  In a d d i t i o n , the  subject content of each question appears and demonstrates a range of d i f f i c u l t y f o r each subject covered.  I t also shows a O.k-2  c o r r e l a t i o n between high confidence and easier questions and confidence and more d i f f i c u l t questions.  low  This c o r r e l a t i o n w i l l  be discussed i n Chapter IV.  Rotter I-E Scale.  This forced-choice questionnaire, which measures  b e l i e f i n i n t e r n a l versus e x t e r n a l c o n t r o l of reinforcement, has been described i n the l i t e r a t u r e review.  I t was administered on the  morning of the second day of the course. plus s i x f i l l e r items.  The s c a l e has 23 items  Scoring i s based on answers r e f l e c t i n g  b e l i e f i n e x t e r n a l c o n t r o l of reinforcement.  That i s , the higher  the score, the more e x t e r n a l the i n d i v i d u a l i s .  Items i n d i c a t i n g  e x t e r n a l i t y on the scale include the b e l i e f that many of the unhappy things i n people's l i v e s are p a r t l y due to bad luck;  that  the world i s run by the few people i n power and there i s not much the " l i t t l e guy" can do about i t ;  or that many times we might j u s t  4.0  ~287  4*  3.5  £1't  20 t *7 t  sin  2,-C  ti-c  3.0  53-"  *>*  T  <?/-r 2*C  53--I?  w  *' &t.  n-r  il-T  MEAN CONFIDENCE SCORE  9-*  f7-A  HO-h  o 2.5 J  ui-F  SUBJECT CONTENT' LEGEND C-Cardiovascular System R-Respiratory System N-Central Nervous System F-Renal System (Fluid-ion) P-Psychosocial Aspects T-Teaching-Learning A-Administration 65,92,etc. -Test question number  la-r  2.0 \  H  w  H  1.5  20 FIGURE B.  I  T  1  1 4  0  50  :  1 "~  60  1  70  1  1  80  :  r  90 100 PERCENTAGE ANSWERING CORRECTLY PERCENTAGE OF CORRECT RESPONSES AND CONFIDENCE IN ANSWERS GIVEN ON 71 - ITEM POSTTEST ^ • - ~ ... : 3 0  :  29.  as well decide what to do by f l i p p i n g a coin.  Items i n d i c a t i n g  i n t e r n a l i t y on the scale include the b e l i e f that people are lonely because they don't t r y to be f r i e n d l y ; thing as "luck";  that there i s r e a l l y no such  or that people's misfortunes r e s u l t from the  mistakes they make.  The Rotter Scale can be found i n Appendix C.  C l i n i c a l Performance Evaluation.  A number of evaluation tools were  used to assess c l i n i c a l performance.  Those tools included the  C r i t i c a l Incident Technique, (Appendix D) using standards of care for c r i t i c a l l y i l l patients as guidelines, and a summary checklist of performance i n i t i a t i v e .  The f i n a l evaluation tool used was the  standardized Slater Nursing Competencies Rating Scale (Appendix E). A f i n a l grade f o r c l i n i c a l performance was determined by the researcher.  I t was based on a point system applied to the Slater  Scale and other performance evaluation information.  Clinical  performance evaluation was carried out weekly by the c l i n i c a l preceptors.  F i n a l evaluation was carried out during the l a s t  week of the course.  Midterm and F i n a l Evaluation Questionnaires.  These questionnaires  provided information about the nature of the c l i n i c a l  experience,  classroom learning and administrative aspects about the course. Parts of the r e s u l t s obtained from the questionnaires were used to  enhance the r e s u l t s of t h i s study.  As c o n f i d e n t i a l i t y i n  answering the questionnaires was ensured, some information that might otherwise have been h e l p f u l i n t h i s study could not be used.  The questionnaires were lengthy and d e s c r i p t i v e , and  thus  are not included i n the Appendices, but can be found on f i l e at the D i v i s i o n of Continuing Nursing Education at the U n i v e r s i t y of B r i t i s h Columbia.  Questionnaire to Obtain Background Information about P a r t i c i p a n t s . The questionnaire was administered on the f i r s t day of the course. Data c o l l e c t e d included: -  age and sex kind of b a s i c preparation i n nursing l o c a t i o n and name of school (basic preparation) degree and diplomas held and dates received l o c a t i o n and name of school(s) where any post-basic preparation was received t o t a l years working t o t a l time spent working i n c r i t i c a l care area m a r i t a l status number and ages of c h i l d r e n most l i k e l y reasons f o r attending t h i s course  Design of the Study The l i s t of v a r i a b l e s used i n the t e s t i n g of the hypotheses i s as f o l l o w s : Target V a r i a b l e : 1.  Gains i n performance as a r e s u l t of the course.  31.  Predictor Variables: 1.  Age  (in years)  2.  Years worked since graduation (in years)  3.  Years worked i n c r i t i c a l care (in years)  4.  Pretest score  5.  Posttest score  6.  Confidence score on posttest  7.  C l i n i c a l performance score  8.  Rotter I-E Scale score. Data analysis was  carried out on two groups, sometimes j o i n t l y ,  sometimes independently.  The group of 13 nurse,.;students who  the course constituted the experimental group.  completed  The group of 40 c r i t i c a l  care nurses who wrote the posttest and also completed the Rotter I-E Scale and the questionnaire on background information formed the control group. Testing was done on the experimental group and on the experimental and control groups combined.  This yielded information about the experimental  group as a select group of nurses attending a continuing education course, and on the two groups together as a larger population of c r i t i c a l care nurses. »  In addition to the t e s t i n g of the hypotheses,  t h i s study examines  information collected about the participants and attempts to determine trends relevant to continuing nursing education courses of this type. In e f f e c t , each participant's background, contribution and outcome was examined.  32.  Data C o l l e c t i o n and A n a l y s i s Table 1 i d e n t i f i e s a l l instruments used f o r data c o l l e c t i o n . S t a t i s t i c a l a n a l y s i s of the data included c o r r e l a t i o n a l and m u l t i v a r i a t e analysis.  For the 13 nurse students' data a n a l y s i s alone, c o r r e l a t i o n s  were tabulated using the Spearman Rank Order Method of a n a l y s i s .  Pearson  Product Moment c o r r e l a t i o n was used i n c o r r e l a t i o n a l analyses of data combining the 13 nurse students and the c o n t r o l group of 40 nurses. (Both of these are standard computer programs used at the U n i v e r s i t y of B r i t i s h Columbia Computer Center.) Tabulation of r e s u l t s of t e s t s proceeded by means of OMR  Multiple  Choice Examination Answer Cards and the program OMR Mulmark, which tabulated a l l data and were used f o r a l l computer-run programs in. the a n a l y s i s of the data.  (OMR Mulmark i s a l s o a standard program used at  the U n i v e r s i t y of B r i t i s h Columbia Computer Center.) Sigma (z) scores* were tabulated to obtain gain scores between pretest and p o s t t e s t . in pretests.  This was done i n order to e l i m i n a t e d i f f e r e n c e s  Although the three p r e t e s t s were matched f o r content,  complexity and item types, the t e s t s were not pretested f o r v a l i d i t y or r e l i a b i l i t y and therefore i t was not known i n advance whether the t e s t s were i n f a c t equal.  *Formula found i n Best, J . Research i n Education. Englewood C l i f f s , New Jersey: P r e n t i c e - H a l l , Inc., 1970, p. 243.  TABLE 1 - LIST OF DATA COLLECTION INSTRUMENTS AND DATES THEY WERE USED  Data C o l l e c t i o n Instruments  Dates Used  Questionnaire on Background Information  Day 1  Knowledge Pretest  Day 1  Rotter Scale  Day 2  C r i t i c a l Incidents  Daily i n C l i n i c a l Areas  S l a t e r Nursing Competencies Rating Scale  F i n a l Week i n C l i n i c a l Area  Midterm Course Evaluation  Week 10  Knowledge P o s t t e s t  Week 14  F i n a l Course Evaluation  Week 14  34  CHAPTER IV - ANALYSIS OF DATA  General Summary of Program Outcomes The o v e r a l l opportunities and experiences of the course were reported by the majority to be u s e f u l . students completed  the course.  Thirteen of the f i f t e e n nurse  Two withdrew before completion.  One  was asked to leave because i t was f e l t that she was not able to meet the course objectives.  The second l e f t v o l u n t a r i l y , as she f e l t that the  course was not relevant to her p a r t i c u l a r needs. s t a t i s t i c s are based on the thirteen students who  Course evaluation completed  the course.  Measures of Knowledge As the pretests contained questions based on content that would be presented i n the course, i t was not expected that the nurse students would obtain high scores. tests.  Table 2 shows scores obtained on the pre-  (The two nurse students who withdrew from the course were i n  Pretest Group I.)  Although the three pretests were presumably matched  for complexity, t h i s table demonstrates considerable differences among the three groups i n r e s u l t s .  In a pretest s i t u a t i o n , where the students  were grouped randomly, these differences may be explained by the premise that the groups happened to be divided into similar groups of natural a b i l i t y , previous experience or other factors which would c l a r i f y the differences i n scores.  Alternately, i t may be that Pretest Group I I I  35.  TABLE 2 - SCORES OBTAINED. ON PRETESTS FOR EACH OF THREE PRETEST GROUPS  Identification  Pretest Score* (in %)  1 5 8  33 49 33  Pretest Group II  2 4 6 9 13  35 38 28 33 25  Pretest Group I I I  3 7 10 11 12  54 54 41 59 51  Pretest Group I  Pretest Sigma (z) Score  Mean Sigma Score  38.3  - 0.35 + 1.77 - 0.35  + 0.36  31.5  + + + -  0.68 1.16 0.77 0.19 1.26  0  51.8  + + + -  0.31 0.31 1.62 1.08 0.08  0  Pretest Mean Score (in %)  *Because the test was constructed primarily i n multiple choice format, with four alternative answers for each question, a pretest score of 25% should be expected by chance alone. Therefore, a student's on-hand knowledge of the course content should be regarded as the obtained pretest value minus the chance value (25%).  36.  had the e a s i e s t t e s t and Pretest Group I I the most d i f f i c u l t .  Without  v a l i d i t y and r e l i a b i l i t y known f o r the p r e t e s t s , the answer to t h i s question of d i f f e r e n c e s was not immediately known. Table 3 shows some v a r i a b l e s which may have a f f e c t e d the performance of the pretest groups.  Pretest Group I I , with the lowest mean score  on  the pretest (M = 31.5), also had had l e s s previous work experience i n c r i t i c a l care nursing.  Group I I I , (M = 51.8), showed the most previous  experience i n c r i t i c a l care. t h e i r confidence other two groups.  However, i t i s i n t e r e s t i n g to note that  scores on the pretest were considerably lower than the This group may have been more aware of what they  didn't know because of t h e i r experience, and would therefore be l e s s confident i n answers given on the p r e t e s t .  Group I I I also revealed  the most external scores on the Rotter Scale, (M = 11.4), p o s s i b l y supporting the hypothesis  that externals are l e s s confident i n t h e i r  performance (Hypothesis Ha^). Age does not appear to be a notable f a c t o r i n the d i f f e r e n c e s i n pretest scores. On the basis of the information presented i n Table 3, i t may  be  possible to make some p r e d i c t i o n s about needs of the nurse students r e l a t i v e to the development of the course.  Pretest r e s u l t s , as  i n d i c a t o r s of knowledge about c r i t i c a l care nursing already  present,  might p r e d i c t the content that should be presented, or what parts of the subject content should be emphasized.  On the basis of pretest  TABLE 3 - PRETEST SCORES AND POSSIBLE RELATED VARIABLES TO EXPLAIN DIFFERENCES BETWEEN 3 PRETEST GROUPS  Age (Years)  33 49 33 M = 38.1  3.42 3.31 2.77 M = 3.17  34 54 28 M = 39  2 4 6 9 13  35 38 28 33 25 •M = 31.5  3.22 2.36 3.52 3.16 2.86 M = 3.02  27 26 38 26 46 M -• 33  3 7 10 11 12  54 54 41 59 51 M = 51.8  2.55 3.02 2.54 2.92 2.95 M = 2.80  23 27 ' 47 24 22 M = 29  M = 2.2  41.0  2.97  32.5  1.3  Identification  Pretest Group I  Pretest Group I I  Pretest Group I I I  Total Group Means  Years Worked i n Critical Care  Pretest Confidence Mean  1 5 8  Pretest Score ( i n %)  2 1 1  Rotter Score  M - 1.3  4 4 8 M = 5.3  1 0 1 0 0  5 9 11 11 9  M - 0.4  M = 9.0  0 3 5 2 1  15 11 12 10 9  M - 11.4 9.1  Pretest Sigma Score (z score) - 0.35 + 1.77 - 0.35  + + + -  0.68 1.16 0.77 0.19 1.26  + + + -  0.31 0.31 1.62 1.08 0.08  38.  scores, predictions could be made about performance on the posttest. In the interest of drawing some conclusions about what information known p r i o r to a continuing education course might prove useful i n the development and success of the course f o r a p a r t i c u l a r group of learners, trends that evolved i n this p a r t i c u l a r continuing education course i n c r i t i c a l care nursing were reviewed. Table 4 shows a l l scores obtained on tests and assignments throughout the course.  Even though the pretest scores appeared to present  possible s i g n i f i c a n t differences between the three pretest groups, the pretest scores were included i n the c a l c u l a t i o n of the average score f o r each nurse student on a l l written tests and assignments.  Calculation  of the mean score for each nurse student when the pretest score was included showed l i t t l e difference i n r e s u l t s .  not  This i s best shown by  i n d i c a t i n g the rank of each nurse student when the pretest score was and was not included i n the c a l c u l a t i o n of a t o t a l mean score. (See Table 5, page 40.)  Despite differences between Pretest Groups as  shown i n Table 2, Table 5 indicates that pretest scores did not greatly affect the rank for each nurse student.  The mean score of the  differences between ranks i s zero. Mean scores calculated on a l l tests and assignments less pretest scores did, however, show a greater increase i n scores f o r Pretest Group II than f o r either of the other two groups.  (See Table  4.)  TABLE 4 - SCORES ON ASSIGNMENTS AND EXAMINATIONS FOR 13 NURSE STUDENTS  ! Pretest Score (%)  Midterm Test Score (%)  1 5 8  33 49 33  52 68 52  Pretest fy — _ _ . — Group II  2 4 6 9 13  35 38 28 33 25  Pretest ^->__ „ T Group ITIT I  3 7 10 11 12  Identification  Pretest Group I  Total Group Means  Posttest Score (%)  A C CTPMMTTMTC;  :-./0  s  Mean Score (%)  Mean Score Less Pretest (%)  1  2  3  4  5  Total Score  55 77 61  50 75 65  65 75 65  55 65 65  55 55 75  55 55 70  420 519 486  52.5 64.9 60.8 (M=59.4)  55.3 67.1 64.7 (M=62.4) '  75 61 46 70 33  80 69 76 90 54  75 70 65 75 75  85 75 75 75 65  75 60 75 75 65  75 55 75 75 65  75 75 75 75 75  575 503 515 568 457  71.9 62.9 64.4 71.0 58.1 (M=65.7)  77.1 66.4 69.6 76.4 . 61.7 (M=70.2)  54 54 41 59 51  51 71 53 71 73  76 76 63 70 79  55 75 70 70 70  65 85 65 65 75  65 85 70 70 75  70 75 70 75 75  55 75 75 75 75  491 596 507 555 573  61.4 74.5 63.4 69.4 71.6 (M=68.1)  62.4 77.4 66.6 70.9 74.6 (M=70.4)  41  59  71  73  71  70  520  65.1  68.5  .  69  68  VO  40.  TABLE 5 - DIFFERENCE IN RANK FOR EACH OF 13 NURSE STUDENTS WHEN PRETEST SCORE IS INCLUDED AS A PART OF FINAL SCORE  Pretest Group I  Identification  Rank on Total Score  Rank Less Pretest  Difference in Rank  1  13  13  0  c  c. o  •7  /  J 8  11  10  + l - 1  Pretest Group I I  2 4 6 9 13  2 9 7 4 12  2 9 6 3 12  0 0 * - 1 - 1 0  Pretest Group I I I  3 7 10 11 12  10 1 8 5 3  11 1 8 5 4  + 1 0  u 0 + 1  41.  Although  t h e rank of each n u r s e student was  not a f f e c t e d by the p r e t e s t ,  Group I I , h a v i n g the lowest mean p r e t e s t s c o r e , p r o b a b l y a l s o had  the  most d i f f i c u l t p r e t e s t . Seven n u r s e s t u d e n t s r e p o r t e d on the f i n a l q u e s t i o n n a i r e t h a t they f e l t  the f i n a l  i n p r o v i d i n g adequate feedback felt  course e v a l u a t i o n  examination was  not  satisfactory  f o r t h e i r l e a r n i n g needs, w h i l e o n l y  the p r e t e s t and the midterm were u n s a t i s f a c t o r y .  A l l but  student i n c r e a s e d t h e i r s c o r e from midterm to p o s t t e s t .  two  one  The one  nurse  student whose s c o r e dropped o n l y dropped by 1%, whereas i n c r e a s e s i n s c o r e s ranged  from 3% to 30%.  (See T a b l e  4.)  T a b l e 6 i d e n t i f i e s t h e v a r i a b l e s t h a t were t e s t e d f o r both of  nurses.  The  group of 13 nurse s t u d e n t s  the group of 40 c r i t i c a l c a r e nurses s i m i l a r i n many r e s p e c t s .  The  in c r i t i c a l  c a r e n u r s i n g than had  as the c o u r s e was  critical  care.  ( c o n t r o l group) were r e l a t i v e l y  the number of y e a r s worked s i n c e gradu-  c o n t r o l group had had  expected  ( e x p e r i m e n t a l group) and  T h e i r ages, m a r i t a l s t a t u s and number of  c h i l d r e n were s i m i l a r , as was ation.  groups  s i g n i f i c a n t l y more y e a r s of  experience  the e x p e r i m e n t a l group, which was  designed to p r e p a r e the nurses  to be  to work i n  The e x p e r i m e n t a l group showed a more e x t e r n a l mean on  the R o t t e r S c a l e , but not s i g n i f i c a n t l y d i f f e r e n t from the c o n t r o l group. There was  a s i g n i f i c a n t d i f f e r e n c e between the e x p e r i m e n t a l and  control  groups on the s c o r e s o b t a i n e d on the t o t a l p o s t t e s t and the 71 i t e m p o s t test.  The e x p e r i m e n t a l group s c o r e d h i g h e r i n b o t h i n s t a n c e s .  The  TABLE 6 - LIST OF VARIABLES TESTED COMPARING 13 NURSE STUDENTS IN A CRITICAL CARE NURSING COURSE WITH 40 CRITICAL CARE NURSES  Grand standard deviation  Possible range  Actual range  Grand mean  Age i n y e a r s  0 - ?  22 - 54  30.2  Marital status*  1-2  1 - 2  1.39  -  Number o f children  0 - ?  0 - 5 '  0.7  Years worked since graduation  0 - ?  1-23  Years worked i n critical care  0 - ?  0 -  Rotter score  0-23  0-16  Raw s c o r e on p o s t t e s t  0 -100  Adjusted s c o r e on 71 p o s t t e s t items  0 -100  Confidence i n answers given  7fc--284  7.2  Experimental mean (N = 13)  Control mean (N = 40)  Significant difference E v s . C v _'.  32.5  29.4  0.18  1.53  1.34  0.20  1.4  1.2  0.5  0.14  7.2  5.2  7.1  7.2  0.89  3.3  2.8  1.3  3.9  0.002  8.7  3.3  .9-1  8.6  0.67-  30 - 76  54.8  8.7  61.8  52.5  0.0006  27 - 90  63.4  12.1  71.1  60.9  0.007  12'  140--264 „>  * 1 " S i n g l e , separated, 2 = Married.  51.2  d i v o r c e d o r widowed  222  -204  0.08  43.  e x p e r i m e n t a l group c o u l d be expected been r e a d i n g and Confidence was  t o s c o r e h i g h e r because they  s t u d y i n g the s u b j e c t content throughout  the c o u r s e .  h i g h e r f o r the e x p e r i m e n t a l group, and a l t h o u g h  d i f f e r e n c e between the groups was might be expected  f o r two  not s i g n i f i c a n t , t h i s h i g h e r  reasons.  had  the confidence  F i r s t , as they s c o r e d h i g h e r on  the  t e s t s , the e x p e r i m e n t a l group would l i k e l y have more c o n f i d e n c e i n what they knew.  The c o n t r o l group, on the o t h e r hand, may  what they don't  know, and  be more aware of  t h e r e f o r e be l e s s sure of the answers they  gave. One  of the q u e s t i o n s o r i g i n a l l y posed was  whether the c o n f i d e n c e a  nurse has i n her answers t o q u e s t i o n s on a t e s t of knowledge has relationship  t o how  she performs  on t h a t t e s t .  any  That i s , does a h i g h  degree o f c o n f i d e n c e mean t h a t the nurse w i l l s c o r e h i g h e r on a knowledge t e s t about c r i t i c a l  care?  For the 13 n u r s e s t u d e n t s i n t h e c o u r s e , the c o r r e l a t i o n t h e i r c o n f i d e n c e and  t h e i r s c o r e on a t e s t of knowledge was  (Spearman r h o ) .  T h i s i s not s i g n i f i c a n t a t the  the c o r r e l a t i o n  c o e f f i c i e n t between c o n f i d e n c e and  t o t a l group of 53 nurses was  0.36  s i g n i f i c a n t a t the  (see T a b l e 6 ) .  .01 l e v e l  .05 l e v e l .  between 0.25 However,  t e s t s c o r e f o r the  (Pearson Product Moment), which i s Thus, the more c o n f i d e n c e  the nurses have about t h e i r answers, the h i g h e r the knowledge s c o r e likely  earned.  This r e s u l t ,  n u l l h y p o t h e s i s Ho  1  f o r the group o f 53 n u r s e s , r e j e c t s  and a c c e p t s the a l t e r n a t e h y p o t h e s i s Ha^  the  ( i i ) that  44.  there i s a s i g n i f i c a n t p o s i t i v e correlation between confidence and the knowledge score. The confidence indicated  i n each answer on the posttest was corre-  lated with the percentage of people answering the question c o r r e c t l y . (See Figure B, page 28.) 0.42  As might be expected, the c o r r e l a t i o n  was  (Pearson Product Moment), p o s i t i v e and s i g n i f i c a n t at the .01 l e v e l .  If a question i s r e l a t i v e l y easy, i t seems l o g i c a l that most nurses w i l l answer the question correctly and w i l l have a high degree of confidence i n their answer.  What becomes interesting i s why  some questions were  not answered correctly by the majority, but high confidence was i n the answer given.  expressed  Question #14, which asked the nurse to interpret  signs of cardiovascular changes, i s an example of t h i s , where the mean confidence score was  3.3,  (above the mean confidence for the whole t e s t ) ,  while only 40% answered the question c o r r e c t l y .  Alternately,  #56, which asked for understanding about the implications  Question  of subcutaneous  emphysema after surgery i n infants, was answered c o r r e c t l y by 91% of the nurses, but the confidence expressed was only 2.4, which was the confidence scores on 87% of the t e s t .  lower  than  Even though these questions  were included after the item analysis was completed, something about the nature of the question caused a d i s p a r i t y between confidence and  accuracy.  The knowledge test scores might also have been affected by the locus of control concept.  If the nurses scored higher on the test, were they  more i n t e r n a l or external i n t h e i r b e l i e f i n control of reinforcement?  • 45,  For the group of 13 nurse students the Spearman rho c o r r e l a t i o n - 0.1,  while for the 53 nurses, the Pearson r c o r r e l a t i o n was  Neither c o r r e l a t i o n i s s i g n i f i c a n t and  was  -  0.07.  therefore the n u l l hypothesis  must be accepted, that b e l i e f i n i n t e r n a l or external control of reinforcement does not s i g n i f i c a n t l y r e l a t e to performance on a knowledge test.  The negative d i r e c t i o n of the c o r r e l a t i o n would suggest that  high scores are more related to i n t e r n a l b e l i e f .  At the same time, the  lack of significance between these two variables might support the concept developed by Broskowski i n Chapter Two,  that those nearer the center  of the continuum of the i n t e r n a l - external locus of control would adjust better to a given s i t u a t i o n . Since confidence was control concept was  a predictor of test scores but the locus of  not, i t was  then asked whether high confidence  a predictor of i n t e r n a l i t y or externality, or vice versa. tion was  not s i g n i f i c a n t for either group, (N = 13, rho = -  was  This c o r r e l a 0.29;  N = 53, r = - 0.19), but the negative d i r e c t i o n suggests that high confidence i s more related to i n t e r n a l s .  The question of confidence  and i n t e r n a l i t y i s d i f f i c u l t to predict within the confines of methods used to test the variables i n t h i s study. personal and  the  Confidence as a  independent expression of a b i l i t y , and not r e s t r i c t e d to  feelings about knowledge of test question content, might reveal more interesting r e s u l t s when correlated with the locus of control concept score.  Whether such a measure exists and could be used was  vestigated  i n t h i s study.  not i n -  46.  Table 7 shows the c o r r e l a t i o n matrix for a l l variables tested f o r both groups of nurses.  Significance at the .01 and .05 l e v e l s i s noted.  Other than correlations which have already been discussed i n r e l a t i o n to the hypotheses  tested, there are other s i g n i f i c a n t correlations which are  of p o t e n t i a l i n t e r e s t .  The performance on the test of knowledge of  c r i t i c a l care nursing correlated more p o s i t i v e l y with years worked since graduation than years worked i n c r i t i c a l care.  This may be due to the  fact that the subject content of the posttest demanded more general knowledge and judgment about nursing than s p e c i f i c knowledge about c r i t i c a l care nursing.  I t i s also i n t e r e s t i n g to note that age correlated nega-  t i v e l y with posttest scores.  As the age of the nurse increased, her  score on the posttest decreased.  Detailed discussion follows, but i t  suggests that older nurses adapt less w e l l to the r e s t r i c t i o n s imposed by a multiple choice examination for testing knowledge.  It may also mean  that older nurses know l e s s , but more support would have to be offered to that supposition than this c o r r e l a t i o n alone. Referring back to the 13 nurse students i n the course, the next step was to look at the performance of these nurses at the end of the course and compare i t to what we knew about them at the beginning of the course. If a nurse i s more external or i n t e r n a l i n her b e l i e f i n control of reinforcement, does she improve more s i g n i f i c a n t l y as a r e s u l t of a learning experience?  If the answer to this i s yes, why  i s i t so?  Table 8 shows the  gain scores between pretest and posttest for each nurse student.  The table  separates the students into t h e i r o r i g i n a l pretest groups to indicate group differences.  TABLE 7 - CORRELATIONS OF VARIABLES TESTED USING COMBINED GROUP OF 13 NURSE STUDENTS AND 40 CRITICAL CARE NURSES  Age i n years  Marital status  Number of children  Years worked since graduation  Years worked i n critical care  Rotter score  Score on 119 posttest items  Score on 71 posttest items  Confidence score  Age i n y r s .  1.00  Marital status  0.17**  1.00  Number of children  0.65**  0.47**  1.00  Years worked since graduation  0.76**  0.21  0.59**  1.00  Years worked i n critical care  0.22  - 0.06  0.23  0.45**  Rotter score  - 0.19  0.02  - 0.07  - 0.06  - 0.17  Score on 119 p o s t t e s t items  - 0.27*  - 0.30*  - 0.45**  - 0.36**  - 0.35**  - 0.06  1.00  Score on 71 p o s t t e s t items  - 0.27*  - 0.36**  - 0.47**  - 0.37**  - 0.28*  - 0.07  0.96**  1.00  Confidence score  - 0.09  - 0.03  - 0.15  - 0.04  - 0.03  - 0.19  0.41**  0.36**  1.00  -  -.0.03  - 0.17  0.47  0.49  0.56  Gain .score***  0.08,._7\  • S i g n i f i c a n t at r . „ 05  , - 0.18 -."  " S i g n i f i c a n t at r.-, 01  -0.06-  1.00  -  0.00  1.00  ***Gain scores are based on computations f o r 15 nurse students only  TABLE 8 - GAIN SCORES FROM PRETEST TO POSTTEST FOR 13 NURSE STUDENTS  Identification  Pretest Score (%)  Posttest Score (%)  Gain Score (%)  Gain z Score  1 5 8  33 49 33  55 77 61  22 28 28  - 1.18 - 1.16 - 0.65  Pretest Group I I  2 4 6 9 13  35 48 28 33 25  80 69 76 90 54  45 21 48 57 29  + 0.05 - 1.37 +.1.23 + 1.60 - 0.41  Pretest Group I I I  3 7 10 11 12  54 54 41 59 • 51  76 '76 63 70 79  22 22 22 11 28  + + + +  71.1  29.0  Pretest Group I  Total Group Means  41.0  0.05 0.05 1.12 1.15 0.81  49.  C a l c u l a t i o n of c o r r e l a t i o n s between gain scores and b e l i e f i n c o n t r o l of reinforcement revealed some unusual r e s u l t s .  The c o r r e l a t i o n  c o e f f i c i e n t between these two v a r i a b l e s using the gain score i n percentage revealed a c o r r e l a t i o n - 0.15, (Spearman rho), which i s not s i g n i f i c a n t . However, using gain z scores, the c o r r e l a t i o n c o e f f i c i e n t became - 0.61 (Spearman rho).  That i s , the more i n t e r n a l the i n d i v i d u a l , the greater  was the gain i n score from pretest to p o s t t e s t .  This c o r r e l a t i o n of  - 0.61 i s s i g n i f i c a n t at the .05 l e v e l . The most l i k e l y explanation f o r t h i s d i f f e r e n c e i n c o r r e l a t i o n s may be the d i f f e r e n c e i n o r i g i n a l p r e t e s t s .  A c t u a l gain scores expressed as  a percentage do not n e c e s s a r i l y r e f l e c t s i g n i f i c a n t changes, p r i m a r i l y because higher pretest scores had l e s s opportunity to make s i g n i f i c a n t gains to the p o s t t e s t .  The z scores, on the other hand, attempt to  eliminate the d i f f e r e n c e s between groups, and are therefore l i k e l y to be a b e t t e r r e f l e c t i o n of gain than are gain scores expressed as percentages. I t •. seems . that * nurses who have a greater b e l i e f i n i n t e r n a l c o n t r o l of reinforcement apply themselves more to the l e a r n i n g at hand, and work harder to perform b e t t e r i n the course.  I t might a l s o suggest  that i n t e r n a l s have a greater motivation to do b e t t e r i n the course as a r e s u l t of pretest performance.  50.  When a l l e l e v e n v a r i a b l e s t e s t e d f o r 53 nurses i n T a b l e 6 (page 42) a r e used j o i n t l y t o p r e d i c t t h e amount o f g a i n from p r e t e s t t o p o s t t e s t f o r 13 n u r s e s t u d e n t s ,  the s t a t i s t i c s are considerably  The  s i n g l e best  and  accounts f o r about 31% o f t h e p r e d i c t a b i l i t y o f g a i n s c o r e s .  second b e s t  p r e d i c t o r of nurses' gain scores  more encouraging.  predictor  (and indeed t h e o n l y other  s i g n i f i c a n t ) i s the p o s t t e s t s c o r e .  i s confidence  The  one s t a t i s t i c a l l y  Taken t o g e t h e r ,  d i c t o r v a r i a b l e s accounted f o r 41% o f t h e n u r s e s ' g a i n The  itself  t h e s e two p r e scores.  f a c t t h a t a p o s t t e s t s c o r e i s a b e t t e r p r e d i c t o r than any o f  the p r e t e s t s c o r e s  i s encouraging.  That suggests t h a t i t i s t h e  e f f e c t i v e n e s s o f the course c o n t e n t , r a t h e r than t h e s t u d e n t ' s p r i o r knowledge, t h a t i s t h e d e c i s i v e f a c t o r .  I n s h o r t , how f a r t h e l e a r n e r  went i n the c o u r s e made more d i f f e r e n c e than t h e p o i n t from which she started. The  o n l y o t h e r v a r i a b l e s t h a t approached s i g n i f i c a n c e as p r e d i c t o r s  of g a i n were age and the number o f y e a r s worked i n c r i t i c a l c a r e , b u t both f e l l j u s t s l i g h t l y s h o r t of t h e .05 l e v e l o f s i g n i f i c a n c e .  The  other v a r i a b l e c r i t i c a l t o t h i s study, R o t t e r ' s measure o f i n t e r n a l i t y , e x h i b i t s a p a r t i a l c o r r e l a t i o n with gain scores the l e v e l needed f o r s i g n i f i c a n c e .  o f 0.15 - - - f a r from  51.  Measures of C l i n i c a l Performance Several d i f f i c u l t i e s were encountered  i n the use of the evaluation  instruments selected to measure c l i n i c a l performance i n the course. Some of the d i f f i c u l t y was probably related to the lack of c l i n i c a l teaching experience of the clinicalppreceptors.  Some d i f f i c u l t y was  also due to the ambiguity of the instruments and the lack of opportunity for practice with the instruments by the c l i n i c a l preceptors. Differences were encountered  i n the scores obtained by the nurse  students according to the c l i n i c a l preceptor who evaluated the performance.  Discussion with the c l i n i c a l preceptors about the Slater  Nursing Competencies Rating Scale revealed a lack of s u f f i c i e n t understanding about the meaning"of the terms used f o r rating (e.g. "best nurse", "poorest nurse", e t c . ) . Despite these d i f f i c u l t i e s , f i n a l c l i n i c a l performance r e s u l t s were considered representative of the performance of each nurse student. Recognizing the l i m i t a t i o n s of the subjective evaluation that was carried out, the researcher reviewed a l l evaluation materials on each nurse student, including a score calculated from the results of the Slater Scale.  The group was then ranked from 1 (best performance) to 13 „  (poorest performance).  Spearman rho correlations were carried out on  t h i s ranking. The relationship between c l i n i c a l performance and b e l i e f i n control of reinforcement was of no s i g n i f i c a n c e .  (rho = - 0.28).  The d i r e c t i o n  of the c o r r e l a t i o n , however, suggests that^betiter;-performance i s _ f  .52-.  seen i n more internal nurses.  Correlation of c l i n i c a l performance  with confidence again showed no significance (rho = - 0.16).  The  d i r e c t i o n suggests i n t h i s instance, however, that c l i n i c a l performance i s associated with lower confidence.  Comparison of c l i n i c a l performance  with posttest score showed a Spearman rho c o r r e l a t i o n of  0.38.  Thus i t seems that c l i n i c a l performance does not have significance i n r e l a t i o n to other knowledge about the nurse students i n the course. A larger group, however, may begin to show stronger correlations which would support the concept that c l i n i c a l performance could be used as a predictor for performance i n a continuing education course.  Alternately,  Rotter scores and confidence i n answers on a knowledge test may predictors of performance i n c r i t i c a l care nursing.  be  These appear to be  areas f o r further investigation, using more refined tools for measurement of performance.  Measures of Program Effectiveness Midterm and f i n a l evaluation questionnaires provided, primarily, confirmation of problems or d i f f i c u l t i e s already i d e n t i f i e d informally. The design of the course was considered.satisfactory, and content presentations were reported as p o s i t i v e .  It was pointed out by some  students that there would have been an advantage to having more resource people available for s p e c i f i c content areas. Other than problems related to the lack of appropriate learning experiences i n one c l i n i c a l area, the c l i n i c a l experience was good.  53.  Several students i d e n t i f i e d a need f o r more experience i n s p e c i f i c c l i n i c a l areas related  to t h e i r needs.  A s i g n i f i c a n t result of the questionnaires was the i d e n t i f i c a t i o n of the need f o r more pre-course preparation by the students.  A list  of reading requirements and the i d e n t i f i c a t i o n of resource text books to be used during the course was considered to be most important. This was not done f o r the f i r s t course.  Some students also reported  that a more similar background experience would have made the teaching task easier and the learning experience more valuable. The course length was generally considered satisfactory, -although i t was f e l t that more c l i n i c a l time, together with more p r i o r preparation of the students by pre-reading, would have made the t o t a l experience more worthwhile.  54  CHAPTER V - SUMMARY, CONCLUSIONS AND RECOMMENDATIONS  This report has presented the results of the performance of 13 nurses attending the f i r s t of two 14-week continuing education courses i n c r i t i c a l care nursing.  The evaluation of the course has brought to  l i g h t several pieces of information which should prove useful i n planning the second course and indeed future courses which include c l i n i c a l and classroom learning experiences.  Summary The major focus of the study was on the gains achieved by the nurses as a r e s u l t of attending the course.  S p e c i f i c measures of gain were  tested to determine achievement i n the areas of knowledge and performance. Factors which were f e l t to be predictors of performance were also tested. Analysis of the results revealed c e r t a i n gains s p e c i f i c to the p a r t i c u l a r course and possibly gains that could be predicted f o r future courses. Figure A (page 8) represented a model of the intent of the study. It was found that there were indeed c e r t a i n pieces of information that could be obtained about nurses p r i o r to a course which could predict performance i n the course.  Selection of students for t h i s course was  based on what were considered to be important c r i t e r i a  (see Appendix A).  However, other factors were found to be just as important i f not more so.  55.  Age and the number of years worked i n c r i t i c a l care nursing became s i g n i f i c a n t predictors of performance.  Both of these factors, although  not considered i n need of weighting f o r selection, were known p r i o r to the course and may have played a part i n the selection process. A pretest given to the students on the f i r s t day of the course also helped to i d e n t i f y areas of strength and weakness i n the knowledge each nurse had about c r i t i c a l care nursing.  The test, made up of questions  based on content to be presented i n the course, could w e l l have been used to plan for individualized learning experiences for the nurses. A posttest administered at the end of the course provided important information about gains achieved i n the course.  The posttest consisted  of questions that had been on the pretest, and therefore gave a s i g n i ficant measure of increases i n knowledge as a r e s u l t of attendance at the course.  Also, by measuring confidence i n answers given on the test,  predictions could be made as to whether confidence i s a predictor of performance on a knowledge t e s t . The internal-external locus of control concept  (Rotter I-E Scale)  was chosen f o r t h i s study because i t was considered a predictor of c l i i i c a l performance a b i l i t y , confidence i n performance and gain.  The  The r e s u l t s have shown that i t was indeed a s i g n i f i c a n t predictor of gain, but not s t a t i s t i c a l l y s i g n i f i c a n t for confidence or c l i n i c a l performance.  Neither was i t a s i g n i f i c a n t predictor of testis scores.  Because the test group was very small (N = 13), and because there were  56.  c o r r e l a t i o n a l a n a l y s e s which were n o t s i g n i f i c a n t f o r t h e e x p e r i m e n t a l group b u t were f o r the e x p e r i m e n t a l  and c o n t r o l groups combined, f u r t h e r  t e s t i n g i s needed o f t h e s e v a r i a b l e s u s i n g l a r g e r groups. F i v e hypotheses were s t a t e d and t h e a n a l y s i s of t h e r e s u l t s has revealed the f o l l o w i n g p o s i t i v e  findings:  G r e a t e r c o n f i d e n c e i n answers g i v e n on a knowledge test w i l l r e l a t e to higher scores. (Ha^ ( i i ) ) A g r e a t e r g a i n i n s c o r e between a knowledge p r e t e s t and p o s t t e s t r e l a t e s t o b e l i e f i n i n t e r n a l c o n t r o l of r e i n f o r c e m e n t . (Ha^ ( i ) )  Conclusions E v a l u a t i o n o f a 14-week c o n t i n u i n g e d u c a t i o n course i n c r i t i c a l c a r e n u r s i n g has demonstrated some p o s i t i v e f i n d i n g s .  I t has a l s o  r e v e a l e d areas o f weakness i n p l a n n i n g such c o u r s e s , and t h i s study has i d e n t i f i e d some o f t h e s e weaknesses and how they c o u l d be improved t o achieve a b e t t e r r e s u l t .  F u r t h e r , p r i o r knowledge about course  parti-  c i p a n t s can p r e d i c t performance c a p a b i l i t i e s and can u s e f u l l y a f f e c t t h e program d e s i g n f o r a s p e c i f i c group o f s t u d e n t s .  I n the course  just  completed, s e v e r a l f a c t o r s have been i d e n t i f i e d which might have improved the course f o r t h i s group o f l e a r n e r s .  F o r i n s t a n c e , knowledge about  the v a r i e d e x p e r i e n t i a l backgrounds o f t h e nurse s t u d e n t s c o u l d have a f f e c t e d the c l i n i c a l l e a r n i n g experiences had  to i n d i v i d u a l students.  and t h e v a l u e those  experiences  A l t h o u g h n o t d i r e c t l y r e f l e c t e d by c o u r s e  57.  r e s u l t s , the d i f f i c u l t y learning was students.  i n adjusting to the concept of s e l f - d i r e c t e d  stated as a problem more frequently by the older nurse Although i t was attempted  to give attention to i n d i v i d u a l  needs, the group also had to function as a unit i n order to accomplish the task i n the time allowed.  The two students who withdrew from the  course both suffered from this need to conform to group norms, as they seemed to have greater and more i n d i v i d u a l needs than most of the other nurse students. The d i f f i c u l t i e s  encountered with the c l i n i c a l performance evalu-  ation instruments have already been discussed i n Chapter IV.  The need  to develop i n t e r - r a t e r r e l i a b i l i t y and more objective instruments became evident early i n this program.  It also seemed important to  concentrate on the assessment of each nurse as she came into the program and to attempt to plan for c l i n i c a l experiences that would be most b e n e f i c i a l to her.  Changes were made i n the course f o r some students  to provide for s p e c i a l learning experiences, but i t was  evident i n the  f i n a l course evaluation that this was not s u f f i c i e n t and that more could have been done to meet more i n d i v i d u a l needs. The data analyses reported i n this study have p a r t i c u l a r l y i d e n t i f i e d factors which can a f f e c t achievement p o t e n t i a l i n a continuing education course. -  Those factors, more s p e c i f i c a l l y , are: age previous experience i n c r i t i c a l care nursing confidence b e l i e f i n locus of control (Rotter I-E Scale) pretest score on course content.  58.  Many times throughout the course i t became evident that d i f f e r e n t approaches to evaluation would have revealed more s i g n i f i c a n t r e s u l t s . Information collected about the nurse students on observation was i n valuable i n assessing and understanding their a b i l i t i e s , but was not documented i n any way that could be used i n the data analysis.  Although  this became a f r u s t r a t i n g s i t u a t i o n f o r the evaluation of the f i r s t course, i t helped a great deal i n making recommendations for the second and any subsequent courses. Gains i n knowledge have c l e a r l y been demonstrated as a r e s u l t of attendance at a continuing education course.  This i s encouraging and  supports the concept of a course such as the 14-week course described i n this study.  The more that can be determined through further study  as to what factors can allow for optimum gain,tthe better such courses w i l l become.  Recommendations f o r the Second Course Selection of students for such courses may be one of the most important factors to consider, based on evaluation of the 15 nurses who began this p a r t i c u l a r course, problems that arose, and what was known about the nurses prior to the commencement of the course.  There were  s i m i l a r i t i e s i n the two nurses who withdrew from the course. older (45 and 54 years).  Both were  Both had very i n d i v i d u a l learning needs which  apparently could not be met, even though the t o t a l class number was small.  59.  Background experience i n c r i t i c a l care nursing also seemed to a f f e c t learning performance i n the course.  The v a r i e t y of backgrounds presented  d i f f i c u l t y i n s e t t i n g out course material i n the depth required and at the pace of learning that was set early i n the course.  On f i n a l evaluation,  some nurses commented on the need to engage i n extensive i n d i v i d u a l study i n order to keep up with the material being presented i n c l a s s . Twelve of the 13 students completing the course f e l t that the course objectives were relevant to t h e i r learning needs.  With respect to the  evaluation instruments used, d i f f i c u l t i e s encountered  i n the f i r s t course  resulted i n the following recommendations for the second course: 1.  Content and structure of the written examination should be refined for the second course.  Major d i f f i c u l t i e s with the pretest and  posttest appeared to be ambiguity within the structure of the questions, and confusion i n the selection of d i s t r a c t o r items. 2.  C l i n i c a l evaluation instruments should be revised i n order to make them easier to use for the c l i n i c a l preceptors.  Clinical  preceptors were recognized to have a b i l i t y i n i d e n t i f y i n g problems and planning learning experiences.  However, the differences  between the preceptors i n t h e i r a b i l i t y to document observations objectively has already been discussed.  I t i s recommended that  i n future, one course evaluator be used to keep documentation about the c l i n i c a l performance of the nurse students.  This does  not solve the problem of i n t e r - r a t e r differences, but would give  60.  more consistent r e s u l t s f o r the next course u n t i l more objective instruments and more preceptor t r a i n i n g were a v a i l a b l e . 3.  Attempts should be made to plan c l i n i c a l learning experiences around the needs of each nurse and with consideration of the current experiences available i n the c l i n i c a l areas.  Recommendations f o r Further Study This study has revealed information which can prove useful i n the development of future courses i n continuing nursing education.  I t has  hopefully presented some explanation f o r the differences i n nurse student performance i n a continuing education course that can be used to plan more e f f e c t i v e l y for meeting i n d i v i d u a l learning needs of nurses attending such a course. Most importantly, this study may be useful to others i n determining needs f o r further study about nurses and t h e i r p a r t i c i p a t i o n i n continuing education.  I t has only touched the surface of planning and providing  learning experiences to maintain competence. go.  There i s a long way yet to  As mentioned in^the introduction to this report, the l o g i s t i c a l  problems that affect the development of continuing education are s t i l l not overcome.  However, the design of the 14-week c r i t i c a l care nursing  course, -and the evaluation of the nurses attending, have taken a f i r s t step i n v ( d e a l i n g with the problem.  61.  Based on the results of the hypotheses tested in this study, recommendations for further study in certain areas of learning for nurses in continuing education courses are: 1.  to examine the relationship between a nurse's belief in locus of control and her ability to perform in a directive or non-directive continuing education course;  2.  to examine the relationship between a nurse's belief in locus of control and performance in c l i n i c a l nursing areas;  3.  to study factors related to past experience and age to determine their relationship to different abilities to perform in a continuing education course. The needs of the future are increasing at a greater rate than the  problems of the past are being solved.  Although this sounds depressing,  studies such as reported here and those recommended can clarify issues which have been hidden or unknown barriers to successful continuing education programs, not only in nursing but hopefully in other professional disciplines as well.  Greater sensitivity to the individual and more  alert tuning to differences between individuals, together with s k i l l f u l application of known scientific methods for obtaining such data,  suggest  a challenging and f r u i t f u l future to those engaged i n this v i t a l educational f i e l d .  This report and its implications should provide a guide  for others in dealing with the problems and finding some solutions.  62.  BIBLIOGRAPHY AND REFERENCES  1. An Abstract f o r A c t i o n ; Report on the National Commission f o r the Study of Nursing and Nursing Education, New York: The McGraw-Hill Book Co., 1970. 2. American Nurses' A s s o c i a t i o n : Avenues f o r Continued Kansas C i t y , Mo.: The A s s o c i a t i o n , 1967.  Learning,  3. Alfano, G. "The Loeb Center f o r Nursing and R e h a b i l i t a t i o n " . Nursing C l i n i c s of North America, Sept. 1969, pp. 487-493. 4. Anderson, J . and P a r e i g i s , J . Continuing Nursing Education Survey. Pennsylvania State U n i v e r s i t y , Department of Nursing, June - A p r i l , 1968-69. 5. A r g y r i s , C. Diagnosing Human Relations i n Organization: A Case Study of a H o s p i t a l . New Haven: Yale U n i v e r s i t y Press, 1956. 6.  Balch, P. and Ross, A.W. " P r e d i c t i n g Success i n Weight Reduction as a Function of Locus of C o n t r o l : A Unidimensional and M u l t i dimensional Approach". Journal of Consulting and C l i n i c a l Psychology, February 1975, p. 119.  7.  Barclay, J.R. "Needs Assessment", i n Walberg, H.J. (ed.) Evaluating Educational Performance, Berkley, C a l . : McCutchan P u b l i s h i n g Co., 1974.  8.  Bass, B.A., O l l e n d i c k , T.H. and Vuchinich, R.E. "Study Habits as a Factor i n the Locus of Control - Academic Achievement R e l a t i o n s h i p " , P s y c h o l o g i c a l Reports, June 1974, p. 906.  9.  Broskowski, A. "A Review of the I n t e r n a l - E x t e r n a l Control of Reinforcement", Unpublished Manuscript, Indiana U n i v e r s i t y , 1966.  10.  B i a l e r , I . "Conceptualization o f Success and F a i l u r e i n Mentally Retarded and Normal C h i l d r e n " . Journal of P e r s o n a l i t y , 29: 1961, pp. 303-320.  11.  Continuing Education f o r Nurses: A Study of the Need f o r Continuing Education f o r RNs i n Ontario. Toronto: School o f Nursing and the D i v i s i o n on U n i v e r s i t y Extension, U n i v e r s i t y of Toronto, 1969.  12. Course Announcement, C r i t i c a l Care Nursing Course, The U n i v e r s i t y of B r i t i s h Columbia School of Nursing, 1974.  63.  13.  Cronbach, Lee J . "Course Improvement through Evaluation", i n Worthen, B.R. and Sanders, J.R. Educational Evaluation: Theory and P r a c t i c e , Belmont, C a l . : Wadsworth P u b l i s h i n g Co., 1973.  14.  Crowne, D.P. and L i v e r a n t , S. "Conformity under Varying Conditions of Personal Commitment". Journal of Abnormal and S o c i a l Psychology, 66: 1963, pp. 547-555.  15.  C u r t i s s , F. et a l . Continuing Education i n Nursing. Boulder, Colorado: Western I n t e r s t a t e Commission on Higher Education, 1969.  16.  "Do Beginning Jobs f o r Beginning Graduates D i f f e r ? " Journal of Nursing, Sept. 1969, pp. 1903-1907.  17.  Dickinson, G. and Lamoureux, M.E. Systems", unpublished r e p o r t .  18.  Dubin, S. and Marlow, H. Supervisory Training Needs of H o s p i t a l Personnel i n Pennsylvania Nursing Service and Nursing Education. Pennsylvania State U n i v e r s i t y , 1965.  19.  Dubin, S. et a l . Correspondence Courses as an Educational Method i n H o s p i t a l s . Pennsylvania State U n i v e r s i t y and the H o s p i t a l Research and Educational Trust of the American H o s p i t a l A s s o c i a t i o n , 1967.  20.  F l a h e r t y , J . An Enquiry i n t o the Need f o r Continuing Education f o r RNs i n the Province of Ontario. U n i v e r s i t y of Toronto, Master's Thesis, 1965.  21.  Glaser, W.A. and McVey, F.A. "Evaluation of Performance i n P u b l i c Health Nursing". Nursing Research, Winter 1961, pp. 32-37.  22.  Henry, R. (ed.) Ends and Means: The National Conference on Continuing Education i n Nursing. New York: Syracuse U n i v e r s i t y P u b l i c a t i o n s i n Continuing Education, 1971.  23.  H o s p i t a l Research and Education Trust. Education. Chicago: The Trust, 1970.  24.  James, W.H. I n t e r n a l vs. E x t e r n a l Control of Reinforcement as a Basic V a r i a b l e i n Learning Theory. Unpublished d o c t o r a l d i s s e r t a t i o n , Ohio State U n i v e r s i t y , 1957.  25.  James, W.H. and R o t t e r , J.B. " P a r t i a l and 100% Reinforcement Under Chance and S k i l l Conditions". Journal of Experimental Psychology, 55: 1958, pp. 397-403.  American  "Evaluating Educative Temporary  Training and Continuing  64  26.  J e f f r e y , B. " I n t e r n a l ' E x t e r n a l C o n t r o l o f Reinforcement: A C r i t i c a l Summary and S y n t h e s i s o f the L i t e r a t u r e " , U n i v e r s i t y o f Utah, Department o f Psychology, May 1970.  27.  Johnson, R. "Determining T r a i n i n g Needs", i n C r a i g , R. and B i t t e l l , L. (ed.) The T r a i n i n g and Development Handbook. New York: McGraw-Hill Book Co.  28.  Knutson, A.L. " E v a l u a t i o n f o r What?" P r o c e e d i n g s o f the R e g i o n a l I n s t i t u t e o f N e u r o l o g i c a l l y Handicapping C o n d i t i o n s i n C h i l d r e n , h e l d a t the U n i v e r s i t y o f C a l i f o r n i a , B e r k l e y , June 1961.  29.  L i v e r a n t , S. and S c o d e l , A. " I n t e r n a l and E x t e r n a l C o n t r o l as Determinants o f D e c i s i o n Making under C o n d i t i o n s o f R i s k " . P s y c h o l o g i c a l Reports, 7: 1960, pp. 59-67.  30.  Lysaught, J . ( D i r e c t o r ) . A b s t r a c t f o r A c t i o n : Commission f o r the Study o f N u r s i n g and N u r s i n g New York: M c G r a w - H i l l Book Co., 1970.  31.  M c C l e l l a n , M. " S t a f f Development i n A c t i o n " . o f N u r s i n g , Feb. 1968, pp. 288-300.  32.  Merwin, J.C. " H i s t o r i c a l Review o f Changing Concepts o f E v a l u a t i o n " , i n T y l e r , R.W. (ed.) E d u c a t i o n a l E v a l u a t i o n : New R o l e s , New Means, Chicago: U n i v e r s i t y of Chicago P r e s s , 1969.  33.  Nakamoto, J . and Verner, C. C o n t i n u i n g E d u c a t i o n i n the H e a l t h P r o f e s s i o n s : A Review o f the L i t e r a t u r e P e r t i n e n t t o North America. Syracuse: The ERIC C l e a r i n g h o u s e on A d u l t E d u c a t i o n , 1973.  34.  P r i c e , E. " L e a r n i n g Needs^ o f R e g i s t e r e d NujrsesV Teachers C o l l e g e , D o c t o r i a l D i s s e r t a t i o n , Columbia U n i v e r s i t y , 1967.  35.  Phares, E . J . "Expectancy Changes i n S k i l l and Chance S i t u a t i o n s " , J o u r n a l of Abnormal and S o c i a l Psychology, 54: 1957, pp. 339-342.  36.  Phares, E . J . " P e r c e p t u a l Threshold Decrements as a F u n c t i o n o f S k i l l and Chance E x p e c t a n c i e s " . J o u r n a l of Psychology, 53: 1962, pp. 399-407.  37.  Phares, E . J . " I n t e r n a l - E x t e r n a l C o n t r o l as a Determinant o f Amount of S o c i a l I n f l u e n c e E x e r t e d " . J o u r n a l o f P e r s o n a l i t y and S o c i a l Psychology, V o l . 2, No. 5, 1965, pp. 642-647.  38.  Ramey, I.G. " S e t t i n g Nursing Standards and E v a l u a t i n g Care". J o u r n a l o f Nursing A d m i n i s t r a t i o n , May - June 1973, pp. 27-35.  National Education.  American J o u r n a l ,  65.  39.  Rosen, A. and Abraham, G.D. " E v a l u a t i o n of a Procedure f o r A s s e s s i n g the Performance of S t a f f Nurses". N u r s i n g Research, S p r i n g 1963, pp. 78-82.  40.  R o t t e r , J.B. S o c i a l L e a r n i n g and C l i n i c a l Englewood C l i f f s : P r e n t i c e - H a l l , 1954.  41.  R o t t e r , J.B., L i v e r a n t , S. and Crowne, D.P. "The Growth and E x t i n c t i o n of E x p e c t a n c i e s i n Chance C o n t r o l l e d and S k i l l e d Tests". J o u r n a l of Psychology, 52: 1961, pp. 161-177.  42.  R o t t e r , J.B., Seeman, M. and L i v e r a n t , S. "Internal vs. External C o n t r o l of Reinforcements: A Major V a r i a b l e i n Behaviour Theory", i n Washburn, N.F. (ed.) D e c i s i o n s , Values and Groups, V o l . 2. London: Pergamon P r e s s , 1962, pp. 473-516.  43.  Schulberg, H.C. and Baker, F. "Program E v a l u a t i o n Models and the Implementation o f Research F i n d i n g s " . American J o u r n a l of P u b l i c H e a l t h , V o l . 58, No. 7, J u l y 1968, pp. 1248-1255.  44.  Second Annual Report, C o n t i n u i n g E d u c a t i o n i n N u r s i n g . University of B r i t i s h Columbia H e a l t h S c i e n c e s Centre, School of N u r s i n g , 1969-1970.  45.  Skinner, G. "What do P r a c t i c i n g Nurses Want to Know?" J o u r n a l of N u r s i n g , August 1969, pp. 1662-1664.  46.  Tate, B. " E v a l u a t i n g the Nurse's C l i n i c a l Performance". N u r s i n g Outlook, Jan. 1962, pp. 35-37.  47.  T o b i n , H.M., Yoder, P.S., H u l l , P.K. and C l a r k , B.S. The Process of S t a f f Development, S a i n t L o u i s : The C V . 1974.  Psychology.  American  Mosby  Co.,  48.  Walberg, H.J. (ed.) E v a l u a t i n g E d u c a t i o n a l Performance: a Sourcebook of Methods, Instruments and Examples, B e r k l e y , C a l . : McCutchan P u b l i s h i n g Co., 1974.  49.  Webster's^New World* D i c t i o n a r y 7 o f the"-.American^Language. New York^-The World P u b l i s h i n g .Co..,.'li§57., ; •; ]>.  50.  Western I n t e r s t a t e Commission f o r Higher E d u c a t i o n : C o n t i n u i n g E d u c a t i o n i n N u r s i n g , Boulder, C o l o . : The Commission, 1967.  -• "  66.  APPENDICES  APPENDIX CRITERIA  A  67.  FOR S t i EC T J O r ^ F ^ P ART IC I PA NT S FOR TH E C R I T I C A L CARE COUR S E  Criteria  Va I ue  Has c u r r e n t  B r i t i s h Columbia nursing  Employed  hospital  by  i n need o f  registration.  critical  8.0  care nursing  staff.  Has had o n e y e a r of r e c e n t ( 1 9 7 2 - 1 9 7 - 1 ) f u l l I imo n u r s i n g experience g i v i n g d i r e c t c a r e in a c u t e c a r e s e t t i n g s , e . g . medicine and/or s u r g e r y , emergency, P . A . R . , c o r o n a r y and intensive care.  Has p a r t i c i p a t e d i n c o n t i n u i n g and i n d e p e n d e n t l e a r n i n g , e . g . over the past f i v e y e a r s .  7.5  •  7.0  education (including inservice r e a d i n g ) on a r e g u l a r b a s i s  Has b e e n i n v o l v e d i n o n g o i n g h o s p i t a l d e v e l o p m e n t a l a c t i v i t i e s ( e . g . n u r s i n g p o l i c y and p r o c e d u r e c o m m i t t e e s ; p a t i e n t c a r e commit I c e s . )  E m p l o y e d by a h o s p i t a l w_ith s u p p o r t i v e p r o f e s s i o n a l a n d technical rcsx::~ces (e.g. p h y s i c i a n s , p h y s i o t h e r a p i s t s , laboratory t e c h n i c i a n s , laboratory equipment, m o n i t o r i n g equipment, r e s p i r a t o r y equipment.)  3,5  E m p l o y e d by a h o s p i t a l w h i c h p r o v i d e s o p p o r t u n i t i e s i n s e r v i c e education and/or s t a f f development.  5.0  for  Total  42.5  -APPENDIX B*  CRITICAl CAPE ?-TKSIN'C Knowlrdi-c test  arti  The folloving questions a selection o f multiple choice sr.d, completion Iters. ' The questions arc designed to help you dctcrsls. vhat your learning r.ccds arc in c r i t i c a l care r.ureir.^. PART I:  Multiple choice Questions^  For each c u l t i p l e choice question, select che answer which i c s t completes the statement or encuers the question. Circle the l e t t e r of your chosen answer, PART II:  Correction cuc-itt:ns  These itcr.s <"5k you co f i l l in the appropriate answer. answer in tho space provided.  V r l t e your  Scoring i s based or. the nur.bcr of right answers, eo fee sure t o answer every question.  X  -In addition, you crc acted co indicate your decree cf cor.fidtsce in your answer. After each question, please c i r c l e the word chit besc doscrlbcs how cure you are of your sx.awcr. e.g.  Hov cure are Ko idea  you?  Cuesscd  Pretty 6\;re  s' *—* (Confident])  If you arc confident char  Questions eliminated from 71 item posttest are marked c o r r e c t answer f o r each multiple choice question i s ^ c i r c l e d  Ihe  69.  TJ  TJ  n  o t_>  O  j:  ts  i:  i:  u  O  (J  'J  u  t*  I.  i.  rv  P.  c  Ii.  l  rl -/  .  -*  i  vs (I  PJ  T-  y  u  i  y.  u  «J  -.  V*  w  -4  r. 3  *:  -J  rl  3  <.-.  -i  Cl "J J , : .i: " i: r. O  co o  J  vi  u  -j U  v> *i  r* 'J  O  o  c.  5s  ci  t! Cl  • c i  .  J  Cl V> Vi 3 C (4  rt  -  3 o Ps 01 Vi rt  X  TJ  ci Cl 3 (J  rt <u  ,c  TJ  i: o 3 '* tl V?  <  u  T» c n  £H4  13.  3  S CI > n >.. ••'  3 M « u Vi C  0  'J  H  -j  ci -j  u o « ij "J  — u tl e»  -1 (J '.1 t3  Ps ti vl rj rj U vi 3 1% <t  TJ CI u c c» »i w  n 11 o "-J  il -J TJ CI  pi  *a vi O r-»  O » 3 vt  "  'j O T>  ^  a)  ©  T T ll Vt »* rt  u tl  M CI > ci  •rl ot rl O CI •I « (fl ll -j « v. u ti CI £ -j VI CO r: t;  vi cj CI Vi Vi 3 C U  »  O  -J  •  o n •r4  ^  tl ll Vi O.TJ  o*»>»  n  TJ  t i -^J fj u  ot rv.  (.1  l l If l l I ll. 1  rt ci o 'U «^ -H  rl  .CI -i > 11 CI -.1 l l  Ul "3 « P. V 3 tj O c x: a M CI  ftliif111 f 1  Cl v. 3 w s.  a  o o 3 "« K *i  T l •• CI e s i u - v i O U -4 3 " t» '.1 O Cl :j •j v> o 3 P. C C  o » v« -J  V. O 3 O r-l vi u> C. V> *-l 5s vl Ct : i 4 <J vi rt n 3 c v. ,< I. w C [J O -rl p " 4i• >, i) Q ./J Cl Ss ftl rt *vt U ' J u 4J U -r-t ll rj II "° TJ ° ^: ci s Cl O rt W W Ss T J 41 « * -n « u TJ G '1 v. O rj Vt U <H Vi Hi O VI rt If CI ti - « 01 O CI' VI - i -o VI ' • i; vi CI "J Cl vi TJ >l i t -rt , t> i ci TJ Ci nH >M •** ^) ,o i )• •.i Cl v< U 33 CI CI d CI (W CT *i vi u o ao vc 4i J.J "H .r: jr: <fl l& rt .,4*) a o u O. TJ Vt Cl cl  a 'JO SI vi u 1 •-« M vi O J  HI ii rt  1  IJ CJ  vi tl  O  ti CI TJ •rt  Ss r-l  jr. o rt O U 'JI U U OO tUl 3 o O t-1) -I ' l rH r-i 3I C. -O l) |) <y CI o n I Cl Cl O U Cl (fl r-4 Ii CJ »1 *l ,U M  a cj  V.  14  CI  o  u  rO  cj  a  „ 3  Tl . CI II TJ  TJ  vi M TJ  'i  > vi v» j : ,< ;: 1. u (J -j -« 01: O ,n U  n  >  o  IJ  41  »•  TJ  CI  ••J  tj o  I  i!  •j  tiJ >o o  !•  n "a  TJ  CI v.  a  LJ  i rl r-H  u  *J  I:*  n  14 >*  •J  Jt o <) li  t l tt 'J It Vi J  «  w  1  CI  tl  T*  M  t:  ft >* v> il Ct TJ  ij  u  o 3  • >* 5S ni M Vl 0  >  Z*  <«  o  'n o C -4  (fl Cl  TJ  Si CJ vi • ^ tj o t: vi a CI rt r-l v. a ja VI • TJ u S > 5s» o 0 »H -I  rt -i vt Vi  O C ll 10 -» -»l rt ^ CI "J CI U 1. 3 r: i- 11 v* o "» ( J CI  TJ  I  ^  rt  0 v* 3 n U CI tt  3 O is  TJ  CV  o tt rt ci M O  4  TH  >1  t>-  TI  VI t* e» CI M t< 3 P« v>  TJ Cl 14  1  8 rt  n  O  rt  <•  ci O Ti V. Tl  cv  CO  Pi I *'  «  *lHl  -5. 'J  c  • H • II l * •• U O *•*  «i 1-1 CI Vi CI O IJ O O CI  Vt rj  TJ  T • li  TJ  O  p«  r: I" t o ••• "  ii  v.  ' ^  . l-i r:  t'  O  i) i i  ; rj c v. - i j ;  2t ' - ' -> ** T. . ) » • [ : • ' » t-i ') t(  u  , J  c *.  -i  o n *< -  -rH u  "  w.i:  >  w-  ct  o  -i  ij  > u U u  >;  r-  •j i i  ii  O  TJ  r: c  i) >> r-t ti H :> c o>: j=  L: o I: 10 o r. ;:  -I  ll r i Q  H  r  •a u  ii.>o -I rH  O o :i '••  >/t o </"\  Ci  •  TJ  >:  v. j: v. ui  t  t:  i. 3 ••} r% jr. . A j. ;: -,j i : -1 r. ;-*. - - i >: w V 0 j " J ;•: 1; u u :. ct •r' r-i 3 c • ^ ^ .. >  TJ  -I j;  ll  rt 1.  O J>  •  • _-T  v. Cl 3 Vi 3 tl ti »l ,C "J 3 1*4 I,  <l U IS II. O !•  vi rj  ra w  • T J «M. || Vt -vi IJ  TI  ci  -J  *  . ij ii" " -j  '*  o -1  ~*  ^  -1 Cl ^ 0. o ti  3 o rs ci  TJ  n  L  |  X " ii rt I* 'J o »• o rjvl M  o • > •.•» »' o C J ci -ri v i > :  xt\  3 !• o -t« o .1: vt |1 U (7|  .  1  rt rt  n  •  rl  * * V r-l rt <sj  ^^PI  ll o Vl  r-o ii  uv: ,' o >> il  rS VI Cl Cl Vt Vi 3 Pt Ul  -J  he: >• <> *' •' u • i 3  ci t i ui <a  11  'A rt  ci .1: !• <) 0 t: JT:  : i .1: fl 11 -i ti 11  0 l i .-j i v 1. ^ rj  6  ©  1/  (J ti M  b  v» •* >i v .:: 'fl 1. w c if -1 -A 11 ti  rt  'j  l-J a TJ v. »i  •!  r-i u 1. r. -J vi !• U IV Vi  o  » -1  ci --t  -i ,ii - 1  Cl .1 3  st  v r-i  v. T J 3 •j  •J  "•j  u  ?S  5-»  vi Ct ti l l ti 3 Pi M  v i rt ti U I* 3 t: •"J  •i  t< rv ti O O  -1 r: O "I 1  f l  d  cj  »; rt  r: o o ti n. • -  t:  J  •  o  II Vi Cl 3 **  -) n ci j: 'j o j: 14 •* II iJ VI « ll -I O 1: -t Oil t l rt -J 41 ij -I C VI t< "J O r t X T J j: j 3 ti n •) <J rt -1 o o 1: ^ .. j : H <J -J >. !; :> -1 u»" -t ifl •.( ;l 11 ci : --' -,( <i .1 --i **i 'J 1: .1 u -1 'ji >) -1 ci -J c TJ u -J -1 r. c ;i j *j •! -1 « »• ..: tr- n -t A J . 1 t. :» -j w .j 11 ft is. :i '* -J »• >. 1 J ^: iv t. .* f J-. ..1 ; » fx, tfl •)  rs o il  J:  ti  n o -1 v  1: p.  ->  'J ' I li rj -1 a rt ci ci ^: o  13 - 1 i ' rt  H .1:  o  '1  TJ  TJ ci ci •J .  • 01  r*i  X ti rv 11 o u  «c. yi  *J  (t 11 '/ m  -.1  3 O  •1  > rrv rt c It  c/ o j-: 41  f 'j >>  (1 u1 ti ci 0. .1: w J : !•• II II vl  tt :l *  ti  <« I  TJ  ; -i i i  w  13.  \ 16* '  S t r e s s t-nhancer. r . o d l u a r e t e n t i o n t h r o u g h tho role.ire o f c o r t i c o t r o p i n froa t h e ' anterior lcbo of thu p i t u i t a r y gland. C o r t i c o t r o p i n a c t s on t h e a d r e n a l c o r t e x to i n c r e a s e s e c r e t i o n , p r i m a r i l y , o f t A.  <9 This ICC t r a c i n g  2.  pacemaker  ^TD  atrial  acetylcholine. D. How s u r e a r e y o u ?  i s an example o f :  ventricular tachycardia.  Ko . idea  rhyth=.  ventricular  Ecu  sure  fibrillation.  Digitalis toxicity A result of:  o r e you? Pretty  li.  A.  Cucsscd  Confident  A.  char.ro t h e d i a g n o s i s ,  a.  discontinue  arrange  scrum potassium  D.  scrua sodiu- increase.  No idea  f o re l e c t i v e c a r d i o v e r s i o n .  Pretty sure  Cuesscd  D.  pace a p a t i e n t i n v e n t r i c u l a r tachycardia.  A.  0.5 - 1.5 = £ q / l .  s.  i : c riq/i.  C.  7.25 - 7.40 c E q / 1 ,  (3^  3.5 - 5.0 a £ q / l .  Eav  cur* a r e you?  Ko idea  Guessed  Pretty sura  sure Arc  Confidant  you?  Cuessed  Pretty sura  Pretty sure  n a t be ccr.ee r r h y t h m i s r.c r Confident  D.  Confidant  s k i n v a r a and f l u s h e d .  B.  drop i n c e n t r a l venous  21.  Cuesscd  Cuessed  pressure. ire;,-:r.a :s a . i ^ y e a r - c l c r-ir. wr.c a d - l ; t o d t o tho c c r c r . i r y care ur.it f.irctlon. i-'-j h a s t-:cn p a i n - f r e e f a r ti:e l.-:r.t £ he-.::.-,, h.is c r 1 c r . c o i -z  How s u r e a r c y o u ? idea  you; ro t t y  a l l o f the above.  Pretty sure  this Jchas  i n s t r u c t M r . Jc-hnscr. n o t t o do a n y n.ore e x e r c i s e s " t o d a y .  ide  oliguria. D.  izecciateiy. wt why. t h *  :or  o f c a r d i o g e n i c shock i n c l u d e :  A.  ©  shocks.  p r o v i d e emergency l i g h t i n g i n t h e e v e n t o f a power f a i l u r e .  No idea  Syspcorns  Confident  :  i s normally:  Cuesscd  the p h y s i c i a n  l n w s t l ; , . u c t o ii p a c r . r Isn't w  How s u r e a r  C.  Confident  notify  -do n o t h i n g , a s t h i s i s a normal sinus rhythm.  Ko idea  generator -is t o ;  produce s a a l l voltage  Eov Sorua potassium  Pretty sure  to observe.  Your best- act ten I s t o : A.  How s u r e a r c y o u ?  I m p r o v e t h e p u l s e when i t i s v c a k .  digitalis.  edr.inlcter p r e c o r d i a l shock.  D.  20.  The purpose o f a p u l s e A.  administer p r e c o r d i a l thuzp.  B.  increase.  a r c you? Guessed  your  A.  continue  o f t e n develops A S  C.  How- s u r e a r e y c u ?  15.  Confidant  serua potassium d e p l e t i o n .  How c u r e  18.  digitalis.  ccr.tinuc o r i n c r e a s e  idea  Pretty sure  scrua eodiu= d e p l e t i o n .  (^}  A patient exhibits atrial fibrillatloa c n h i s SCC s t r i p . I f he h a s been h c s p i t a l i z e d :e r . a r y e c a r d i a l i n f a r c t i c r . and has been c i g i t a l i z e d , i t is reasonable to anticipate that tho treatment f o r t h i s arrhythmia would te t o :  D.  Cuesscd  When y o u s e c t h i s ZCC t r a c i n g , f i r s t a c t i o n s h o u l d be t o :  fibrillation.  2.  idea  glucocorticoids, norepinephrine,  C.  A.  (r.incrnlocor t I c o l d o .  Confident  H r . J o h n s o n was a d m i t t e d t o t h e c o r o n a r y c a r e u n i t 3 days n r o . At that tin.c, a d e f i n i t e c" i .if.r.o*.; i:v o i i n f e r i o r ir.yoc a r d i a l i n f a r c t i o n wa:» r,.ade. Subs e q u e n t l y , a t r a n s v o r . o u s tiir.'pornry p a c e r.r.kcr was i n s e r t e d b e c a u s e o f :r . i r k e d s i n u b b r a d y c a r d i a and - l i d h y p o t e n s i o n . E f f e c t i v e pacir.;; h a s b e e n - r . i n t i i r . e d f o r the l a s t 3 d a y s , and : : r . J o h n s o n ' s v i t a l s i g n s have been r.orr.al. A recent check c: t h e pacemaker demonstrated t h a t i t was s e t a t a r a t e o : 75 b e a t s p e r r . i n u t c , 2.5 c-.il l i a s . p u r o a o n dc-.a;.d p a c i n g . Kr. Johnstone has j u s t r x v f i n i s h e d s l i d a c t i v e e x e r c i s e o f h i s l e f t upper c x trcoity, prescribed to caintain c o b i l i t y  cation.  Ko r.cw c a l l r . y : u i r . t : h i s  Ycu n o t i c e t h a t h i s r.cr.itcr ce-octs a ccccr.d-de;;:*ec a t r l e v e r . : r i c u i a r b l c c k . a potential  problem?  E.  an a c t u a l ( r e a l )  C.  a possible (probable)  prcblcn? problem?  T>. n o p r a b l c a ? Kow c u r e Ko idea  o  a r e ya-u? Cuessed  Pretty sure  Confident  71. tl  •>  •j it -  •J  .>:  >:  --J  rt  »• iv, li  >i J;  i.  ti O U  >-t  U  1  rj  1.  r|  '1  !}  i  ^  '•C .t:  —  ^  j it <J  •-•  l  t  o  -  c  *u  -« •J c  -<  •J  o  —  r: i : o  o  -« ET  u .1 r+ .3  (J  O  •Pv • •  O  c c,  1. r c  <«-» < •-( > >  >  C»  O  c c  »-4 M >  CI u  O c  U  ^ ffl  «~<  <1 ffl ^« ^ r: c v. U  c  <g u U  >  ^  v<  c U  -u U  u e.  V : u  *3  T  X  '*.  <a u tl  c «,  «-  c « rj  v. U  t. 3 O  ,!  :l n o tl o ;, j : " >; a w .i  C  cJ  •-•  v.  (J  O  J  -1 . -1  -t  O -J  -'- -<  3  -•  3  I.  ^3  o -»  o J-J  •J  'J  *' 'J li  >  (V. 3  'J li ;l <J  ->J ^  O  O  N  1* n ty  •** o  o .r:  t:  i iJ '* x  i: i  l i •<> n  ii i:  '-!  o  "J u  O  ~<  r.  u  a  —_  o .  "9"  a  U  u  -  1  vi  P.  .  x  "  J  n  io  c  >i  «  ti  i:  ti  K  o  t.  u  ll  ii  n  «  u  Q  x  a  -U  o  J >  '•:  ^  u  f:i  M  ii-'i ii  o i . :i o U <•• ' c  u u  'J n  ii:  «  w  u  '•• ci  vt  rr  .... o C s>  LI  J  C t:  3  i;  "  ^  -»  O  u  .> M  o  • M  -, i  .i  »J IJ  II  -I  ll  ;l  o  I.  i:  •> .-j  n  >i  x  o t.  F  x  < J  u  n ;i i. ij  r:  it  X  ,; J .j u t  o  v. ;< c i: -* W J  t . .-j .4 y J X \1 ^ ,i -rj ij O O r< l i v1 rl 13^ 13 <*4  <  ta  -  y  . i ' ii  R  u ii u  >» u i)  -;  o  v.  »: u  o  O  U  >» u n ut '1 ii i: l. ;l o J .» i i -j w •: O ll it « y o :J o o ij  'j  u  i-  u  y.  o • •  l. :>  -y  •• -1  >* J  -•  rj  "  t. . <J |] '> i i i : .<  i>  •J  i:  «  a  m  <•  9  M  &  is TJ (Z  S)^-tO  •>"->  '» Xt  C «  ft k.  X •J U *4 « J  -*  •o t; «-* Ct 1  fJ c o  C  r«  -3 ^ (3 o • £ 'J  c  u  •  •a  1u C o  n  tl  il t:  'J  n. j : i v»  w M U  (J  l*J o  c  i  O  w o 01 M  *«  d.  Ij 3  ^  H  o o. O  M  o  a  x ^ u ta &<  4J  -  o \m  <a u 3  u  3  a  tu i_>  o  <a  «l  O >,  -a  o  >» *i  '« -O  g  o»  rt ta U  >!ft. • V* 1 »-H  H  io  U l*  C»  —« <s u -H  13 u  : > (9  VI  oOo  o  ^*  a  & u ci ct u  k. 3 O ' rH  >» *U 3  O  o u c  -n ct  »H  o  •-< -o >su '5 r~* >ri H 3 LI . LI ki rH X Vi | CI O •*« f 'S X. Ll C *• * t l C M r-l ri rH -H ^; v> n u u o . 3 CI c •« - * c o. « •  y <*  ta  u  M  o  3  o c *-«  "a  JS a tj  O u  O  n ca  o  %z «  tl S Q  M  y  *J a  o  ii u  « n.  JC  /"<v  < \cn\  CJ  M  3  F-  3  o  <w in  5s  a U i9  o 3  rj •  ci o-rto • o o w 3  l;  o  I U  V*  ti :J <u o II  0  C  «  3  *  *-» i: «  ii w u  o  a:  • 5 "-fiP C O ' • *• o Js  e d  O _T r-< U  •J U  rj  CI  CI ka tl  c o  o jC  r« n (X o W O «'C > Ll - i >. C C Cu rH • J « r. n o JT  " •* , zO u  v c 13 »H  co v  c u t . ~* -< L. c  M O >. [i  n-j^  It  (J  •*< t-l M  « U <*  CI  O L«  k. CI o u n ct  li « u O xx  O 4 a jti «J u 1rt. .G O 1> V. -r« O  « Ll  jz  ct •J>  -t •9 Vt Ll •rt  • n  rfi  "V 3 a cj  <J  COrH (I CI  0  4  Ll  «i j3 CI Ll  i>  .fl  1. Ll r. 3 o. o rj ii il Ll ••H n ig1 O ti 1 n) n . «U • CI  j*  n  U Q  a 4 -Vt Ut >» J rj •  9  (S rt  O  t0  o n  L* o  d  •SO \: ji  CI tt « 'j  cCiI  U Vt  c ^: 4 u  3 ^  rt  CI  rj -O  ^ o  < <^  U  O  U  ci  «  -J 3 S3  «  U ki Vi 3  •J  ' R  1?  O  "* « nL> u w 1  o» **4  CO  L*  J  ci r:  O M 3  <D  0  'i;  M  ul  o  rj o O ~J  M  i  ft LI o 'j >** f» • r(  rs  k u  ( I I .  O i k .  U  <~i 'J u u  *J  • C»  >  -.1  u  ll (»  o  i:  J;  ',3  H  JJ  >*  u  -u  m  •»< 3 O  Ss  .  it .»  (1 o  >t  TJ  IJ «.«  <1  tt  - ' ii  y  II  M  (.  • *-*  3  c- o  w  T  j  -J o >,  r;  o  U  a.  I.  -j  ••  -t  « ^  n  ,\  ^: o  >» -  1;  (J.  ii  ll CJ  ui o .>.  t*  -J  •J <y t:  •it  ti  II  «.»  ii  s*>  !  ^4  .Eov jure arc you? No idea ^ ;.  Cuessed  Pretty sure  neglectful of the grief and rournlng process. •  Confident  v  ^  How sure are you?  codeine 32 r g . for pain. E.  ccdcir.e 120 tig. for pain.  C.  corphir.e 10 eg. for pain.  D.  no eedicatioa for pain,  Ko idea ,  Eov sure are you? idea 33.  Cuessed  Pretty sure  S.  . Confident  B.  outbursts of crying.  C.  talking cons tan ly about past  D.  a l l of the abova.  How sure are you? Ko idea Cuessed  /tj  aroused by efferent endings i n the viscera.  D.  arcused by afferent endings i n the viscera.  i 41. '  Pretty sure  £ X 39. K i s s R. i s a p a t i e n t in che ICU. She i s 19 years o l d and WOJ Involved i n a s c t c r c y c l c accident w i t h her b o y f r i e n d , Ke has a f r a c t u r e d fer-ur. She has r u l t l p l c f r a c t u r e s . Two days ago, her r i g h t l e g was a r p j t a t e d above the knee due to gar.rr<:.-.e. Since the surgery she h a i been q u i e t e r than u s u a l and very c c c r e r a c i v e v i t h the nurses. The nurses have rcr.air.cti c h e e r f u l and t a l k a t i v e and p r o v i d e d as auch reassurance as p a s s i b l e . T h e i r approach to Kiss R. was: . A. 3.  bathed dally to prevent skin breakdown.  the boat under the circumstances. poor beca-sa Kiss St.. Is not talkative.  C.  both of the above.  D.  none of the above.  42.  Cuesscd  Pretty sure  44.  sodiux depletion.  an increase i n the c o l l o i d osmotic pressure f r o a 6 z.i. H£. to 26 Kga decrease i n the t i s s u e pressure f r o a +7 nr.. Ilg. to - 7 an. Hg.  Cuesscd  Pretty sure  cardiac f l a c c i d i t y .  3.  r e s p i r a t o r y a r r e s t in tetany.  C.  cardiac  D.  hyperventilation.  irritability.  45. ^*  Guessed  E.  todius excess. potassiun depletion.  D.  potassiua axcoss.  less of scdiur: ar.i i n c r e a s e i n blcud r c t a s s i u r . . C.  decreased c a p i l l a r y p e m c a b i l i t y .  D,  r i s e i n fc l o r d volume.  How cure arc you? Ko idea 47. JO  Guessed  Pretty 'swre  Confident  Miss Closer.. 22 years e l d , vas a c r - i t t c d to the turn u n i t w i t h sc c c r . i - s c rree bu:r.s over 4C\ cf hcr^bady and f a c e .  durir.?, \,i>z convalescent p c r i c C v t u l d uast concern the nurse? A.  rer.oval of the n i r r o r f r c a t h e r c c a .  3.  requesting each of her v i s i t e r s  to  crying and s a y i n g , ' V - y d i d t h i s happen to  Lie?"  r e f u s i n g zo see v i s i t o r s . •  How sure arc you? Confident  •'0 idea  X.  Which of the f o l l o w i n g s i g n s and syuptoas c f hypoglycemia r o s t represents the need for i c v e d i u t c action? . A.  Ccnfident  chock.  ^Tj) Pretty cure  Pretty sure  F l u i d s h i f t s zrc a gre.-.t danger i n the p a t i e n t w i t h c u : n s . Which a : tha f o l l o w i n g would be- o r r . i c t e d to cccur?. A. increa.'.ed. f l u i d .'.hiftc A l t e r 2 hay.':;, v i i l c h r e s u l t i a i r r e v t r i i b l e  C.  Eow sure are you? Ko idea  Guessed  Confident  C\ic<ic,ci  C.  slight increase In systolic pressure.  &.  nuabneas about tho south.  •«.(42.cont'd).  Pretty sure  res v c u - d se r a  A.  reduce p r o t e i n i n t a k e so as cot to - overtax the k i d n e y s .  £•  l i r . i t c a l o r i c intake sa as to d e crease tha work of the body. ...(48  \  Confident  4 3 , . To r - : i n t a i n Miss Cibccr.'s (Question 47) of th iaportant?  cveatir.g. incontinence of urine.  C.  46.  &  The r.;sc s e r i o u s e f f e c t o f hypocalcemia, clinically, is: (T}  Confident -  Th? presenting syrr.ptor-s of a new patient i n the unit arc fatigue, nusclc weakness, rusclo c r a r p s , headache and . vertigo. The skin shows .oss of turgor and you cannot detect a peripheral pulse. These synptocs are c o s o a signs of:  C.  Ko idea  How 6ure ore you? Ko idea  an increase i n t i s s u e pressure fror. - 7 s.t. Hg. to -r7 =.= . V:g.  Kov sure are you?  oriented to date, tine and place. Confident  Ko idea  Confident  B.  D.  Confident  Regardless of their physical status, a l l patients i n a c r i t i c a l care unit should be: A.  Eov sure are you?  Pretty sure  Vrctty sure  a reduction i n the c o l l o i d osmotic pressure f r o a 23 -jr.. HG. to - • 6 S.T.. i!g.  experiences.  transmitted by branching, nonmyelinated, finely beaded naked nerve endings.  Cuessed  Confident  restlessness.  caused by degeneration of the d i s t a l portion of the nerve.  Ko' idea  Cuesscd  How sure are you?  Guessed  Edcr-.i that aecor.p.'.nles a severe burn ia a r e s u l t of the accumulation c f I n t e r s t i t i a l f l u i d as the end r e s u l t of hypop r o c ; i r . o ; i a . This accumulation takes place btjc.Tuse of che a l t e r a t i o n of a p r i - a r y f a c t o r of c a p i l l a r y dyr.aaica, na=ely:  43* Pretty sure  Sensory deprivation ia demonstrated In such behaviours as:  Keferred pain i s : A.  Ko idea  t o v because Miss R. knew that people s t i l l cared about har aven though she had lost her leg.  0.  A patient with a head Injury under observation cay be given:  37*  How sure Arc you?  cont'd)..-  ro  73.  1. u i  4J  r-t a  d  < a D. O. d  n ^: o  SL3  J  v»;  %  « t ^:  rt o o  -a o i< u • r: • f• « rf 'J 1 <  ue  Il U 1.1 n o (-* W i t  <.! a  O  Q  W  U  a  O  -j  J t<  r t <1  o r-4  • r: r:  u  V-  .r.  U ['•  y a •i:  -<:. (PU  Q  tt  ii  j- « Z ^ -ti & » ^ i ^- -Jfci  ss  o  w  •9 -.1  O it - I O -rt O W 0)  u  u  ->1  O  > 11  II  3  o  0  oi o a a  sf O. <  PI  i: ,c <ov ) ° q  O  0  o  O «  d  •i  rt  -J -**  ' 13  <3  ,t  t: *M O o  «  *J  > *4  o  n  e  o  t:  J :  t;  •  il  n  CI  o  *«  CI  n•  P  •J a  i ) -»  U  u  « - l i i* l i  J  ;i  wn  U  *J  I* •!» 'J  ^ u O o  w o o ' J .r: »• >> oi i i  d  '*  O ">J v . •»<  rt o » ^ a o4i: o Ti^, 'J u o « * u » o 1 o •u ^ ? | |J u r\ 5  r. •  o  t«•  •i *» •  «J ' U It  3l  <7»  rl  4  n o  tVi!  -t «  <s>  I)  n  ri  in  ct  )«  • U  *M  J U r-l i« n14 ri >.  O 4 >t l» O iO: i •l  <i >  ti n.-1  --t  'J l l '.j <>  u» .•:  d  <i i:  O O CI 1. t . ci It .» ct -J  14  M  • <o  o ct  u n  rt r*>  .< »-l rH  "ti. .<  :>  ifl  X  u  •1  vt -* (1 i* J •  ri  rt  \*  Pi  ^:  H o ct i< ' j i f l - . i n * i ->i o  d ci i t  3  to H ci i t  o u.( t: i t  fl  J  rv i l  3  - • * -J  2 ii !•!;•!?:•  14 d  -.1 •* <J <J  O O  •4 u  •.1  ci tj c\  «i  i ii iv O i II  i  vl  U  4  u "tJ \ : :t t: et rj •! i: -* ^: a n n «J  t>. O o \\  V  »«  J*  CJ ?  «  t< *» o r. '=; o  (J  -»  1. O "'J n ' j k> 'J Li *J 3 O. > it• C -«J C H  « U  **  rj o  r-  - J  o  *•  0  CI  of or  rJ  c -« w « i ti nt4 T ••'a' 'j u c 5 « '* .. iiIi e\ o i: . c «H a ^1 \j c :i  -o  J :  I»  ,11 nj . t :>  0  It •  (>  r\  •  ;» •! j y o 0)  r  a  ti ii o  cr  ^» i  <J  1, •»« •j t .  i> £ . •  6u  W  o.  <•' o  (3  »  3  u  ,r. o o o ct  to  d t< ci  •i  s  d  IJ  rt  (  n  M H  O -o  o  A  a  «  3  3 3  74.  t e l l M r s . A. t h a t i t d w r . r . ' t r a t t e r it" h e r husband dees r e p o r t the n u r s i n g care to h o s p i t a l a d m i n i stration.  C.  D.  a s k M r s . A. i f she thicks her caro has  Eov  been  sure  No idea  73.  How  are  poor.  No idea  , 75. *  you?  Guessed  Pretty sure  Confidant  Ir. w o r k i n g w i t h p a t i e n t s who h a v a i n j u r i e s w-hlch r c c t i l t i n p e r m a n e n t d l * a ' ; i l i i y , i t i s cost important t h a t the n u r s e : accept the p a t i e n t ' s psychoi c ^ i c a l and p h y s i c a l l i r - i t a 2.  r e : a i h cn c p t i n i s t i c and c h e e r f u l a p p r o a c h no n a t t e r w h a t t h e patient's behaviour.  C.  t e l l the p a t i e n t and h i s f a n i l y hcv to deal w i t h acceptance of the, d i s a b i l i t y .  How  sure No idea  7i.  are  Guessed  •Sensory d e p r i v a t i o n has cause:  been known  to  1.  no a d v e r s e e f f e c t s c n t h e p a t i e n t ' s a b i l i t y t o cope w i t h h i s i l l n e s s .  2.  acute psychotic r e a c t i o n followed b y c e r . : i r . u a t i o r . of d e l u s i o n s for s e v e r a l days.  3.  depression a n d anxiety for a period of several weeks.  severe  A.  1, 2, 3.  3.  1, 2.  C.  1, 3.  Q  2. 3.  Pretty sure  A.  accepting.  3.  .analysing.  D,  evaluating.  How  sure are  1  Ccnfideat  A,  p r o v i d e p a i n r e l i e f b e f o r e the e x e r c i s e s , and e n c o u r a g e h e r w h i l e she i s d o i n g the e x e r c i s e s .  B.  r a k e h e r do t h e e x e r c i s e s f o r a l o n g e r p e r i o d co t h a t her cough i s -rorc p r o d u c t i v e and she r e a i i r e s the v a l u e o f che cxe r c i s c s .  Pretty sure  Confident  S e l e c t the n u r s i n g c l which w i l l beet p r e p a r e Mr. B. ( s e e o e s t i o n 75) for crutch walking with braces. o ; i  A.  E,  the p a t i e n t w i l l a s s i s t the n u r s e ' i r . d o i n g p a s s i v e and a c t i v e e x e r c i a e s o f h i s e r r s and l e g s . M r . 2. w i l l do 10 p u s h u p s e v e r y h o u r d u r i n g the day. M r . 3. w i l l do 10 p u s h u p s w i t h h i s h a n d s U t i n e s a d a y f o r one week.  D.  How  t h e r.ursc w i l l doing  supervise  3 types of  active  the  patient  exercises  f o r his arr.s twica a day tor 10 =inutes.  How sura ara you? Ko ' Pretty idea Cuesscd sure  Confident  sure Ko Idea  78.  arc  ur.«!e rr; r .-ind M r s . prt<h\crr..  B.  understand her  husband's  of  and  D.  sure  c-n  fcelia;s  Snlth.  you? Pretty sure  Cuessed  When a p a r Ii-r.c d e c s n e t a c c e p t Irip, h i s  illness,  ir.portar.t- t h a t A.  the  S.  t  fCJ  appear to  nursing  tell  h i r . t h a : he  live  with i t .  be  Confident  be  i t i s *icst  r.ot f o r c e h i r . t o do does net want t o  staff:  anything  he  do. has  to l o a m  to  (  consistent  in their  ajpraach  with hir_. *  T>.  g i v e him r e a d i n g t - a t c r i a l about h i s i l l n e s s s o t h a t h« c a ; l e a r n by h i r . & c l f a t h i s ovn r a t e . sure are ycu?  Ko idea  Confident  M r s . S m i t h i s a p a t i e n t i n t h e TCU who was a d r i u c d t o t h e ICU a f t r r t a k i n g a n o v e r d e s e of b a r b i t u r a t e s . Discussions w i t h h e r h u s b a n d r e v e a l t h a t .".re. S m i t h i s an a l c o h o l i c , and she h.-.i; b e e n i n s i s t i n g l a t e l y ch.tt s h e wantr. t o h a v e h e r ir.other co:re co l i v e w i t h t h e f a r a l l y t o c a r e f o r h e r s e l f a n d h e r two sr.:-11 c h i l d r e n , b e c a u s e she i a o f t e n u n a b l e to be r e s p o n s i b l e f o r h e r c h i l d r e n due to h e r i l l n e s s . Her husband has refused to a g r e e to t h i s , and as a r e s u l t t h e Siaichs a r c h a v i n g c a r i o u s l a a r i t a i p r o b lem. Mrs. S s i c h ' s c o n d i t i o n haa b c e a critical, but i t a p p e a r s now that hor  are  Ko idea  How Pretty sure  her  feelings  hostility,  ask the d o c t o r i f p s y c h i a t r i c h e l p c o u l d be a r r a n g e d f o r M r s . 5-rich.  How  79.  Sr.ith's e r c t i c r . a l  frustration  toward Mrs.  ycu?  Guessed  A.  recognise  f i n d c u t w h a t M r s . Ercu-n k n o w s a b o u t h e r emphysema and h e l p h e r to understand the i r . p l i c a t i o n a I f she d o e s n ' t e x e r c i s e , c e l l h e r t h a t s h e h a s t o do t h e e x e r c i s e s o r she w i l l pet pneuc o n i a , and e x p l a i n t h a t a b d o m i n a l b r e a t h i n g r.i<;ht h e l p r e l i e v e pain afterwards.  you?  Cuessed  c o n d i t i o n h..:;. * t a h i I i n-C. lz c r i e r .to p l a n f o r c c : ->'.•:;<• n u r s i n p c i r e f c r H r o . I ' . T i i h , th<- n u r s e r.ur. 1 f i r t t :  >!ia.. B r o w n i n a 3? y e n * o l d wrn.m who lin*; b e e n a p . . t i e : i t I n t h e i C U t o r 3 dayii. She w.ir. I r . v o l v o d i n j c a r A c c i d e n t .ind ha. " 3 f r a c t u r e d r i b s , a c o n pound f r a c t u r e o f h e r rlf.ht a m nnd a badly bruised hip. Mr:i. l i r u w n ' s i n j u r i e s h a v e b e e n c o m p l i c a t e d by t h o f a c t t h a t s h e has cr.-physcn-.i, Deep b r e a t h i n g and c o u g h i n g e x e r c i s e r h a v a b e e n o r d e r e d q.2.h. Mrs. Brown has been uncooperative and b c c o r . e s u p s e t w h e n r h e k n o w s i t i s t i n e t o do t h o exercises. The n u r s e ' s b e s t a c t i o n i s to:  valuing.  76.  .Confident  • 77. "  you?  Cuesscd  No idea  you? Pretty sure  are  Mr. B., a 25 y e a r o l d p r o f e s s i o n a l b a s e b a l l p l a y e r , w.ir. I n v o l v e d i n a severe automobile accident, lie was admitted to h o s p i t a l , p.ir.ilyrod i r o n t h e n e c k down. Mr. B. h a s g r a d u a l l y r o r y i i n r d t o t a l f u n c t i o n c f the upper ' extremities. In order to understand and a c c e p t h i s d i s a b i l i t y , Mr. 5. r.eeds t o d e v e l o p a p o s i t i v e a t t i t u d e . T i c f i r s t s t e p i n t h i s d e v e l o p m e n t is k n o w n ns r e c e i v i n g . The s e c o n d stage i s responding. What is the third stage?  •  kr.ov t h e cor-n.ur.ity r e s o u r c e s t h a t provide s e r v i c e to people with handicaps.  0.  sure  30.  Cuesscd  Which o f NCT  is A.  the  Pretty . sure  following characteristics  true of  learning?  r e s u l t s i n a change i a occurs  Confidtat  behaviour,  naturally.  p r o d u c e s a r e l a t i v e l y permanent  C.  change. D.  c a n ' t be  directly  Kov  sure  you?  Ko- . idea  ara  Cuesscd  observed.  Pretty sure  VJ1 Confident  31.  Learning Is an experience which occur* inside the learner ar.d i s activated by:  Hew sure ore you7 No • idea  the lo.irr.or. 3.  tha teacher.  C.  the environment.  D.  a l l of the above.  X.  No idea  Guessed  Pretty sure  free the ur.kr.o--T. to the f a m i l i a r .  C.  at a speed greater than the students would like in order to keep then interested. at a slower pace for children than for adults.  53.  Guessed  Pretty sure  £6,  Confident  2.  after the f a n i i y has been t o l d . when they have recovered and are ready to ga hone.  W  C.  r.or.thly.  D.  yearly.  No idea  Guessed  Pretty sure  Confidant  adult learninjt  increase,  C.  arc d i f f i c u l t , to i d e n t i f y .  D.  Pretty sure  Leamins that i s reinforced i a ; A.  rezenbercd forever.  3.  less l i k e l y to recur.  (5T) D.  nore l i k e l y to racur. the o i l y £ c c i kind of Icanvinj.  Pretty sure  Confident  2.  Incentives motivate 1 c - rr. 1 z ; .  3*  Learning is nost effective whan individual is ready to l o a m , thi n , vhcr. ho feels a need to knew coiothir.£.  <£>  Confident  give constant and irtnediate feedback of r e s u l t s . reinforce successes And punish failures.  D.  none of the above. Pretty sura  Confidant  :  » 2. 1,  3-  2.  restate cor.ir.cntn and aak pertinent questions.  C.  1,  j.  ar.ume the role of fin expert on the topic.  D.  2,  3.  Uow uure -are you? No idea  cake brief sur.?.arics cf areas of  Cucsscd  Pretty sure  92. Confident  A.  resentrcnt at the way the change was introduced..  C.  expressed concerns chst nursing  0.  cc_.plair.es of lack of understanding  How sure ore you? No Idea  CuesBed  Pretty sure  Confident  Pretty sure  Confident  The sost i:.  p a r t factor to conaide i n the estivation cf a patient i s h i s  C. ^)  a£c and occupatica. role i n family and society. l i f e i i r e values and attitudes.  Hc-w bure arc you? No idea 93.  Cucssed  Pretty sure - Confident  A standard of care can best be defined as a:  care standards would deteriorate. of che way the eye ton would work.  Cuc-Socd  £ . - dia^r.osic and pror^-.osis.  A system called "primary nursing" was introduced by a head r.urr.c to the R.H. staff on hor ur.it. She oncour.ti-red izsizzcr.ee to the change in r.ar.y forsa, Vhich of the follovir.s is an unreasonable expression -of rcsistar.ee?  apathy towards the entire cystea.  X  c  3.  A. 90.  withhold results of learning for 3 days.  Guessed  Cutascd  Eow jure are you?  A useful way to help adults i s to:  No idc«  k  direct discussion toward tho purpc-ie.  No .idea  C.  Lf.'ii'ni • : •> ,' rcpiiri;:; th.1t the i.-.civi '>;1 I-.: in a c: c>;c:-cnt1.il i*-a.!Ir.ef.;., ( i . e . he has h experiences that n.Vt:e h i - ready le.irn what i s debited),  1.  csreer.ent or dis acre cn'-cnt.  Slow sure are you? Bi.  ^Cj  are affected by i l l n e s s .  A.  i t doesn't natter who taachca then.  3.  How sure are you?  87*  D.  which of the frtl ' . ' . v . - ! . - ? ir." h.i-,:c principles ot r..>:.v,,:icr.?  A &ood group leader ia one who does not:  £9.  Confident  B.  Cuessed  doctors. s-ilesr.cn.  A.  decline.  Ko idea  £. C.  91.  How sure are you?  e Pretty sure  fron;  otlicr nurses.  No idea  A.  vr.cn they indicate willingness to learn.  Ecw sure are ycu?  Cucsscd  Uith advancing abilities:  frcr: the f i r s t day they are ad_u.ttcd. :c hcspical.  C.  fo)  weekly.  ^)  A i l patier.es should be taught'about their i l l n e s s : A.  daily.  B.  No idea  He- sure are you? No idea  Confident  Kow sure are you?  Che f a n i l i a r to the unknown, 5.  0.  (T) Confident  Learning tasks should proceed:  62*  Nurses probably learn better QC^  Educational contact between a patient's physician and the responsible curses should occur;  8S,  Ecw cure are ycu?  Cuossed  SS. Pretty sure  criterion. 3.  £03l.  C.  principle.  0,  cotivc.  ' Kow sure arc you? No Idea  Cues&cd  Pretty sura.  Confident  77.  " o -J u  ™  f-i  "6-  n  c->  u n  J3  3  <* 14  >' U C\ O  H a u _o  i: o f O <*< li e c w c a tl _•; j -o t  «  "  M  C- O  (j  U u - *"• w «3  5 5  *  o  C  t« O  c •-•rt w« w iy* 00 n r -« W O  3*  to  X  •*  3 <  1 >  M  Ss  u  U  3  2  u  I* P*  o r3  J c  O J=  3  *-»  Ci  w  "°  «J  °*  >M  ct  3  TJ CJ W 3  o  <J O H  °  n  •J -H C  is n  •? b  3 •  «  n. ij ^  J  o i  >• U  i 'j I  o u ;  n i, 6 5 y o ( P  S3 *t s  8"  SSg S a ii  S  "3  o  H o>u * Q  3  -c a a .rt * *J — « n 3  Ci  ii _< Ji -i w c  S  2» ~  3 P„  s  2fi s  i g &> «  c  u  S£ g "  « 2~* 3 5  g - ' i i J! S'sJ ? r  s  -> * C r. S U <J U <;  r l 14 1  2 5^  o_2  i v "M  U  O 14  At  j  all  *  ii  U  II s  v  (a)  0)  3 O  r*. > »• c  •a u n u  CI  > o -a  o W  rt  C -rt t» 'uj  O >» V V* (1  ^ >*J19 uO ou ** TJ "u c< ta C  X  C "o 3 ~* at "ro • o u > >*. « O Ci l i £j «  0  U i. 3 ia  x:  *•o « o  3  rt w  a)  o  -3  78.  ° s-  vt at  m  ill III  .« VI > " o 4J  all  U  o  o  VI  •u c  o  tj r-(  -H  O  vi  u  >  O rj  mm  « <N V. Cl <*  •3 a  5^  •>.'• i  "  .  (J  -TJ '* 1 H  M  I V. ^  i  "  n o 3 TJ  o V  2 3 " -3 rv u  u-  a  v.  L' I Cl  VI  ct  v> «* v> Vt  a;  ^1)  3  : <0 u  •i 8  i "i °i i <i)  79  «* 14 O  w o 13  4 3  iu >  It o a *o  l*t rH O *  o o  3 w  :J  u  rH 11 O  —  u C  *4 Co  . "5.  o a.  t« c* >«  »J  u  -< c  X O. U -4 rH X  o  •»  r  .5 •b  3  •>* ta«« 3  O  •3  -O  U  > IT),v*-S 'J w ct. ii -C  sloth d cou  Wi u 3  >, L*  rj  *M  i:  01X u  O  3 U  rj  o (Ju  r« O.  3O  (*• T J  rH  <0  <L)  fi-  a  2 O  3  8 3-  3 3  O >*  U ti Id  I* '»  O  a •»  w  u 3  I  APPENDIX C  80  OBSERVATION GUIDELINES  The f o l l o w i n g items are provided as g u i d e l i n e s to observation of performance. C r i t i c a l i n c i d e n t s should be w r i t t e n w i t h these standards i n mind. To each question the observer should be able to answer:  Yes - the student d i d t h i s (or accounted  for i t ) .  No  - the student d i d not i n d i c a t e c o n s i d e r a t i o n f o r t h i s .  ?  - I don't know whether the student d i d o r d i d not consider this.  N/A - This was not a p p l i c a b l e to the s i t u a t i o n .  GUIDELINES FOR CRITICAL INCIDENTS  Q  1 •  THE PATIENT WITH A DEFICIENCY IN CARDIOVASCULAR FUNCTION A.  Patient 1.  Assessment  Has the nurse taken into account - medical history? - consultants' reports? - nursing history?  ,  2.  Have r e s u l t s of laboratory and r a d i o l o g i c a l examinations been taken i n t o account?  3.  Has the nurse assessed the patient's status? a) The patient has optimum pump a c t i o n - urinary output? - heart sounds? - a r t e r i a l blood pressure? - c e n t r a l venous pressure? - jugular v e i n pressure? - pulses - peripheral? - apical? - pain? - cerebral perfusion? - breath sounds? - ECG - arrhythmias? - conduction defects? - ST segments T wave changes? - drug effects? b). The patient has optimum blood volume - a l l items i n (a)? - temperature? - thirst? - s k i n turgor and colour? c) The patient has optimum vascular tone - a l l items i n (a) and (b)? - l e v e l of consciousness? - s k i n temperature?  B.  C.  D.  Problem I d e n t i f i c a t i o n  32,  1.  Has the nurse c o r r e c t l y i d e n t i f i e d those items i n assessment which are abnormal?  2.  Has the nurse c o r r e c t l y i d e n t i f i e d the problems ( p o t e n t i a l , a c t u a l , p o s s i b l e ) which can or have r e s u l t e d from the f i n d i n g s ?  3.  Has the nurse c o r r e c t l y i d e n t i f i e d those problems which are priority? ( i . e . has she/he ranked the problems?),  4.  Has the nurse produced a problem l i s t which o u t l i n e s h e r / h i s findings?  Goal S p e c i f i c a t i o n 1.  Has the nurse proposed a p l a n of n u r s i n g care?  2.  Has she included a l l r e l e v a n t data?  3.  Has she o u t l i n e d nursing goals?  4.  Has she suggested an approach to goal achievement?  Nursing Approach 1.  W i t h i n the scope of nursing p r a c t i c e , has the nurse provided care which w i l l meet n u r s i n g goals? , a) B a s i c care to p a t i e n t s . ' b) The p a t i e n t has optimum pump a c t i o n i) p r o p h y l a c t i c therapy - I.V. route e s t a b l i s h e d and/or maintained? - volume and e l e c t r o l y t e c o n t r o l ? - drug therapy as ordered? - oxygen and v e n t i l a t i o n ? - p o s i t i o n i n g of p a t i e n t ? - c o n t r o l of a c t i v i t y and r e s t ? - c o n t r o l of environment - noise? - visitors? - lights? - e l e c t r i c a l hazards? i i ) emergency treatment Cardiac a r r e s t - f i r s t a i d r e s u s c i t a t i o n - p r e c o r d i a l thump? - ventilation? - c a r d i a c massage? - e s t a b l i s h I.V. route? - drug therapy - prepared? - instituted? - a s s i s t p h y s i c i a n i n c a r d i a c pacing? ... - defibrillation? Acute Pulmonary Edema - p o s i t i o n i n g patient? - oxygen and v e n t i l a t i o n ? - e s t a b l i s h I.V. route?  - drug therapy - prepared? - instituted? 5» - r o t a t i n g tourniquets? Cardiogenic Shock - p o s i t i o n i n g patient? - oxygen and v e n t i l a t i o n ? - e s t a b l i s h I.V. route? - drug therapy - prepared? - instituted? Cardiac Tamponade Acute - hemodynamic support? - immediate n o t i f i c a t i o n of surgeon? - preparation f o r s u r g i c a l intervention? Subacute - preparation f o r p e r i c a r d i a l tap? c) The p a t i e n t has optimum blood volume, i ) treatment f o r hypovolemia - obtains specimen for group and match? - appropriate f l u i d intake? - appropriate position? i i ) treatment f o r hypervolemia - appropriate f l u i d intake? - drug therapy - prepared? - instituted? - r o t a t i n g tourniquets? - phlebotomy as ordered? d) The p a t i e n t has optimum vascular tone. i ) Has the nurse c a r r i e d out i n t e r v e n t i o n measures to provide adequate pump support? (See #1, D) i i ) Has the nurse c a r r i e d out i n t e r v e n t i o n measures to provide adequate volume control? i i i ) Has the nurse implemented - drug therapy - prepared? - instituted? - p o s i t i o n i n g of patient? - oxygen and v e n t i l a t i o n ? - temperature c o n t r o l - patient? - environment? 8  E.  Evaluation 1.  Has the nurse indicated that she has assessed her care by - reassessing the patient? - s e l e c t i n g new goals? - s e l e c t i n g new approaches? - j u s t i f y i n g continuation of approach?  GUIDELINES FOR CRITICAL INCIDENTS II.  84.  THE PATIENT WITH A DEFICIENCY IN RESPIRATORY FUNCTION A.  Patient  1.  Has the nurse taken i n t o account - medical h i s t o r y ? - consultants' reports? - nursing history?  2.  Have r e s u l t s of laboratory and r a d i o l o g i c a l examinations been taken i n t o account?  3.  Has the nurse assessed the patient's status? a) The patient has a patent airway - free from obstruction (mechanical or p h y s i o l o g i c a l ) ? b) The p a t i e n t has optimum v e n t i l a t i o n - breathing movements? - breath sounds? - r e s p i r a t o r y rate? - flaring nostrils? - indrawing of i n t e r c o s t a l muscles? - secretions (nature and amount)? - patient's colour - restlessness? - euphoria? - l e v e l of consciousness? - pain? c)  Assessment  '  The p a t i e n t has optimum a l v e o l a r c a p i l l a r y d i f f u s i o n - a l l items i n (b)? - nature of cough  B.  Problem I d e n t i f i c a t i o n  1.  Has the nurse c o r r e c t l y i d e n t i f i e d those items i n assessment are abnormal?  2.  Has the nurse c o r r e c t l y i d e n t i f i e d the problems ( p o t e n t i a l , a c t u a l , possible) which can or have r e s u l t e d from the findings?  3.  Has the nurse c o r r e c t l y i d e n t i f i e d those problems which are p r i o r i t y ? ( i . e . has she/he ranked the problems?)  4.  Has the nurse produced a problem l i s t which o u t l i n e s her/his findings?  C.  Goal S p e c i f i c a t i o n  1.  Has the nurse proposed a plan of nursing care?  2.  Has she included a l l relevant data?  3.  Has she o u t l i n e d nursing goals?  4.  Has she suggested an approach to goal  achievement?  which  Nursing Approach 1.  /  85. •  Within the scope of nursing p r a c t i c e has the nurse taken measures to ensure a) Basis care has been given? b) The patient has a patent airway - positioned the patient? - loosened and removed secretions by appropriate means: - moisture? - i n s p i r e d gas hydration? - deep breathing? - coughing? - physiotherapy? - removal - manually? - by suction? - prevented a s p i r a t i o n : - of vomitus? - use of g a s t r i c suction? ^ - i n f l a t i o n of cuff of t r a c h e a l tube i f i n use? - g a s t r i c feed: - positioned properly? - administered properly? - f o r patients with tracheal tube maintained - patency? - suction? - c o r r e c t p o s i t i o n of tube? - appropriate moisture - p a t i e n t hydration - i n s p i r a t o r y gas hydration - minimal cuff i n f l a t i o n - supplies f o r i n t e r v e n t i o n i n the event of accidental decannulation c) The p a t i e n t has optimum v e n t i l a t i o n - emergency v e n t i l a t i o n ? - used equipment f o r - a s s i s t e d mechanical v e n t i l a t i o n ? - c o n t r o l l e d mechanical v e n t i l a t i o n ? r - maintenance of function of thoracotomy tubes? - patency? • - seal? - maintenance of function of chest suction apparatus? d) The patient has optimum a l v e o l a r c a p i l l a r y d i f f u s i o n - physiotherapy? - clapping? - vibration? - deep breathing and coughing? - postural draining? provided supportive therapy for pulmonary edema? - position? - oxygen? -  I.V.?  -  medication?  t  - p r o v i d e d oxygen t h e r a p y by 86. - r e c o g n i z i n g a l t e r e d PG^? - i n t e r p r e t i n g b l o o d gas a n a l y s i s ? - d i f f e r e n t i a t e d between problems o f v e n t i l a t i o n and d i f f u s i o n ? - a d m i n i s t e r i n g oxygen c o r r e c t l y ? - used l o w e s t c o n c e n t r a t i o n o f 0^ t o m a i n t a i n s a f e PO^ l e v e l s ? - used m o i s t u r i z e d C^? - c o n t i n u o u s t h e r a p y e s s e n t i a l to m a i n t a i n safe P 0 2 level? - p r e v e n t e d h a z a r d s o f 0^ t h e r a p y ? - prevented sustained h i g h blood l e v e l s of 0 2 ? - p r e v e n t e d h i g h 0^ c o n c e n t r a t i o n f o r patients with chronic r e s p i r a t o r y acidosis? - prevented f i r e hazards?  Evaluation 1.  Has the n u r s e i n d i c a t e d t h a t she has a s s e s s e d - r e a s s e s s i n g the p a t i e n t ? - s e l e c t i n g new g o a l s ? - s e l e c t i n g new approaches? - j u s t i f y i n g c o n t i n u a t i o n o f approach?  her  care  by  GUIDELINES FOR CRITICAL INCIDENTS IV.  THE PATIENT WITH A DISTURBANCE IN THE CENTRAL NERVOUS SYSTEM  87.  A.  Patient  Assessment  1.  Has the n u r s e taken i n t o - medical history? - consultants' reports? - nursing history?  2.  Have r e s u l t s o f l a b o r a t o r y and r a d i o l o g i c a l e x a m i n a t i o n s been t a k e n i n t o account?  3.  Has a)  B.  Problem  1.  Has are  2.  Has the n u r s e c o r r e c t l y i d e n t i f i e d the problems ( p o t e n t i a l , p o s s i b l e ) w h i c h can o r have r e s u l t e d from the f i n d i n g s ?  3.  Has the n u r s e c o r r e c t l y i d e n t i f i e d t h o s e problems w h i c h a r e p r i o r i t y ? ( i . e . has she/he ranked the problems?)  4.  Has  account  the n u r s e a s s e s s e d the p a t i e n t ' s s t a t u s ? The p a t i e n t has optimum l e v e l o f c o n s c i o u s n e s s , autonomic motor s e n s o r y and i n t e l l e c t u a l f u n c t i o n s - n e u r o l o g i c a l v i t a l s i g n s t a k e n to measure i n t r a c r a n i a l p r e s s u r e ? - a r o u s e d p a t i e n t by v o i c e and/or touch? - a s s e s s e d l e v e l o f c o n s c i o u s n e s s - o r i e n t a t i o n as t o p e r s o n , t i m e , place? - checked p u p i l s i z e and r e a c t i o n ? - a s s e s s e d p a t i e n t ' s r e s p o n s e to a u d i t o r y and v i s u a l s t i m u l a t i o n ? - blood pressure, pulse, respiration? - temperature? - motor f u n c t i o n ? - hand g r i p ? - arm and l e g movement? - nervous system i n t e g r i t y ? - bladder functions? - s p e c i a l senses? - speech? - a b i l i t y to reason? - memory? - s w a l l o w i n g - gag r e f l e x ? - CSF d r a i n a g e ? - headache? - vomiting? - seizures? - pattern? - duration? - p r e s e n c e o r absence o f i n c o n t i n e n c e ? - p r e s e n c e o r absence o f aura? Identification  the n u r s e c o r r e c t l y abnormal?  identified  t h o s e items i n assessment  the n u r s e produced a problem l i s t w h i c h o u t l i n e s h e r / h i s  which  actual,  findings?  C.  Goal  Specification  .  88 • 1.  Has  the  nurse  2.  Has  she  included  a l l  3.  Has  she  outlined  nursing  4.  Has  she  suggested  D.  Nursing  1.  Within ensure  an  a plan  of  relevant  nursing  care?  data?  goals?  approach  to  goal  achievement?  Approach the scope that  been  practice,  has  the  nurse  b)  The p a t i e n t has optimum l e v e l o f c o n s c i o u s n e s s , sensory and i n t e l l e c t u a l f u n c t i o n s - promptly reported changes?  taken  patient  autonomic  disability?  special consideration position? hearing? -  verbal  for  the  unconscious  patient?  stimuli?  Evaluation Has  the  nurse  indicated the  measures  to  given?  i d e n t i f i e d and prevented p o t e n t i a l hazards? - i n a p p r o p r i a t e a n a l g e s i a and s e d a t i o n ? - environmental factors? -  E.  has  nursing  Basic  -  care  of  a)  -  1.  proposed  that  -  reassessing  -  s e l e c t i n g new  goals?  -  s e l e c t i n g new  approaches?  -  justifying  she  has  assessed her  patient?  continuation  of  approach?  care  by  motor,  " V ^ L X T O S  III.  tun CRITICAL INCIDENTS  THE  PATIENT WITH A DEFICIENCY IN RENAL FUNCTION  A.  P a t i e n t Assessment  1.  Has the n u r s e taken i n t o a c c o u n t - medical history? - consultants' reports? - nursing history?  2.  Have r e s u l t s o f l a b o r a t o r y i n t o account?  3.  Has a)  b)  and  r a d i o l o g i c a l examinations been  t h e n u r s e a s s e s s e d the p a t i e n t ' s s t a t u s ? The p a t i e n t has optimum body w a t e r volume - volume o f w a t e r g a i n known? - volume o f w a t e r l o s s known? - urine - g a s t r o i n t e s t i n a l - vomiting - suction - diarrhea - wound d r a i n a g e - hemorrhage - perspiration - hyperventilation - ascites - burns - d a i l y weight? - c e r e b r a l signs? - headache? - twitching? convulsions? - coma? - mucous membrane? - thirst? The  p a t i e n t ' s body f l u i d s have optimum s a l i n e c o n t e n t ?  - s a l i n e gain? - gastrointestinal? - parenteral? - renal? - s a l i n e loss? - urine? - gastrointestinal? - hemorrhage? - perspiration? - plasma e x t r a v a s a t i o n ? - s i g n s o f plasma volume change? - hemodynamic?  c)  The  89.  - - e x t r a c e l l u l a r f l u i d ? (CVP, JVD, BP, urine) - edema? - s k i n turgor? - sunken e y e b a l l s ? p a t i e n t ' s body p o t a s s i u m i s a t optimum l e v e l  taken  -  potassium -  -  potassium -  d)  gain?  gastrointestinal? parenteral? renal? loss?  -  mental  gastrointestinal? renal? state?  -  muscle  tone?  The p a t i e n t h a s optimum a c i d - b a s e - observed for acidosis? -  renal failure? hypoventilation?  -  gastrointestinal diarrhea?  small intestine fluid pancreatic fistula?  -  excess  -  gastrointestinal - emesis? -  -  alkali  Problem  intake? loss?  Identification  Has the n u r s e c o r r e c t l y which are abnormal?  2.  Has  the  actual,  nurse  correctly  possible)  which  identified  those  identified  the  can  or  have  Has the n u r s e c o r r e c t l y i d e n t i f i e d priority? ( i . e . has she/he ranked Has the n u r s e findings?  items  in  problems  resulted  assessment  (potential,  from  the  findings  those problems which problems? )  are  the  produced  a problem  l i s t  which  proposed  a plan  nursing  outlines  her/his  Specification  1.  Has  the  nurse  2.  Has  she  included  a l l  3.  Has  she  outlined  nursing  4.  Has  she  suggested  Nursing .  acids?  potassium?  1.  Goal  of  loss?  gastric suction? hyperventilation?  - low body mental state? convulsions? headache?  -  4.  loss?  HCO^  - metabolic production observed for alkalosis?  -  balance  hypoxia?  -  -  3.  "  an  relevant  of  care?  data?  goals?  approach  to  goal  achievement?  Approach'  Within  the  scope  of  nursing  practice,  has  the  nurse  taken  measures to ensure a) Basic care to patients 91 • b) The patient has optimum body water volume - planned f l u i d requirements according to route of intake? - d i s t r i b u t e d f l u i d intake over an appropriate period of time? - i n i t i a t e d and/or monitored - parenteral therapy? - g a s t r i c feedings? - dialysis? - re-evaluated water requirements and reported same? c) The patient's body f l u i d s have optimum s a l i n e content - implemented and maintained administration of s a l i n e as prescribed? - transmitted data which i n d i c a t e d a change of orders? - adjusted the administration of s a l i n e according to assessed needs? d) The patient's body potassium i s at optimum l e v e l - implemented and maintained intake of potassium as prescribed? - d i s t r i b u t e d intake over an appropriate period of time? - performed or a s s i s t e d with procedures to c o n t r o l body potassium? - parenteral therapy? - g a s t r i c feedings? - dialysis? - drugs? •e) The patient has optimum acid-base balance - implemented and maintained v e n t i l a t i o n to achieve 0^ and l e v e l s within the patient's normal range? - correct cause of a c i d base disturbance? - administered prescribed medications? Evaluation 1.  Has the nurse indicated that she has assessed her care by - reassessing the patient? - s e l e c t i n g new goals? - s e l e c t i n g new approaches? - j u s t i f y i n g continuation of approach?  GUIDELINES FOR CRITICAL INCIDENTS  92. PSYCHOSOCIAL ASPECTS A.  Patient Assessment  1.  Has the nurse assessed the patient's psychological status?  2.  Have socio-demographic factors been considered?  B.  Problem I d e n t i f i c a t i o n  1.  Has the nurse c o r r e c t l y i d e n t i f i e d those items i n assessment which ar abnormal?  2.  Has the nurse c o r r e c t l y i d e n t i f i e d the problems ( p o t e n t i a l , a c t u a l , possible) which can or have resulted from the findings?  3.  Has the nurse c o r r e c t l y i d e n t i f i e d those problems which are p r i o r i t y ? ( i . e . has she/he ranked the problems?)  4.  Has the nurse produced a problem l i s t which o u t l i n e s her/his findings  C.  Goal S p e c i f i c a t i o n  1.  Has the nurse porposed a plan of nursing care?  2.  Has she included a l l relevant data?  3.  Has she outlined nursing goals?  4.  Has she suggested an approach to goal achievement?  D.  Nursing Approach  1.  Within the scope of nursing meet nursing goals? a) The patient has optimum b) The patient experiences c) The patient experiences  p r a c t i c e , has the nurse provided care to psychosocial r e a c t i o n to i l l n e s s ? optimal e f f e c t from the environment? beginning process of r e h a b i l i t a t i o n ?  E.  Evaluation  1.  Has the nurse indicated that she has assessed her care by - reassessing the patient? - s e l e c t i n g new goals? - s e l e c t i n g new approaches? - j u s t i f y i n g continuation of approach?  APPENDIX D  m STATE UNIVERSITY  Page  Lege of Nursing  Date  1  of  7  93. pages  SLATER NURSING COMPETENCIES RATING SCALE ;e being rated:  Rater (name or No.)"  JHO-SOCIAL: INDIVIDUAL Actions directed toward meeting psychoneeds of individual patients. 1. Gives f u l l attention to patients . . . . 2. Is a receptive listener  . . . . . . . .  3. Approaches patient in a kind, gentle and friendly manner 4.  Responds in a therapeutic manner to patient's behavior  5. Recognizes anxiety in patient and takes appropriate action . . . . , 6.  Gives explanation and verbal reassurance when needed  7.  Offers companionship to patient without becoming involved in a non-therapeutic way  8. Considers patient as a member oil a family and of a society 9. Is alert to patient's spiritual needs  E:  10.  Identifies individual needs expressed through behavior and initiates actions to meet them  11,  Accepts rejection or ridicule and continues effort to meet needs . ,  12.  Communicates belief in the worth and dignity of man  13.  Utilizes healthy aspects of patient's personality  To facilitate identification, Best, Average, and Poorest Nurse co utnns are those with the parens marking spaces.  vrieht  f c ) 1967 COIIPPP  n f Nurqino  SLATER NCRS  14.  15.  16.  17.  18.  Creates an atmosphere of mutual t r u s t , acceptance, and respect, rather than showing concern for power, prestige, and authority  ( )  Is well informed about current events and common i n t e r e s t s that can be shared with patient  ( )  Chooses appropriate conversation  ( )  topics for  Offers purposeful experiences and a c t i v i t i e s that w i l l help the patient to p a r t i c i p a t e and communicate with others  ( )  Conducts h e r s e l f with same professional demeanor when caring for an unconscious or non-oriented patient as when caring for a conscious patient  ( )  PSYCHO-SOCIAL: GROUP Actions directed toward meeting psycho-social needs of patients as members of groups. 19.  Conveys warmth and i n t e r e s t i n group s i t u a t i o n s with patients  ( )  20.  Helps groups of patients accept necessary l i m i t s . t o freedom ( )  21.  Encourages patients to p a r t i c i p a t e i n planning t h e i r own group l i v i n g experiences  ( )  Delegates r e s p o n s i b i l i t y to patients according to t h e i r c a p a b i l i t i e s ....  ( )  Proposes a c t i v i t i e s appropriate to i n t e r e s t s and needs of various patients w i t h i n group  ( )  22.  23.  24.  Changes a c t i v i t i e s to meet p r i o r i t y needs i n group, even though i t would be easier to continue with a c t i v i t y already begun ( )  25.  Structures a c t i v i t i e s for the purpose of helping patients vent t h e i r emotions i n a s o c i a l l y acceptable way  ( )  SLATER NCRS  26.  27.  28.  P a r t i c i p a t e s i n group a c t i v i t i e s without dominating the s i t u a t i o n . . . .  ()  Gives praise and recognition for achievement according to i n d i v i d u a l ' s needs and with reepect f o r others i n the group . .  ( )  Conducts a c t i v i t i e s with enthusiasm and without emphasizing i n d i v i d u a l • competition  ( )  Converses with patients during group activities  ( )  30.  Shares time with a l l patients i n group' .  ( )  31.  Guides group discussion when t h i s i a desirable  ( )  29.  #  PHYSICAL Actions directed toward meeting physical needs of patients 32.  33.  34.  35.  36.  Adapts nursing procedureo to maet neads of i n d i v i d u a l patients f o r d a i l y hygiene and f o r treatment  ( )  Attends to d a i l y hygenic needs for c l e a n l i n e s s and acceptable appearance  .  ( )  U t i l i z e s nursing procedures as media f o r communication and i n t e r a c t i o n with patients  ( )  I d e n t i f i e s physical aymptom3 and physical changes  ( )  Recognizes physical d i s t r e s s and actfc to provide r e l i e f for the patient  ( )  37.  Encourages patient to observe adequate rest and exercise .' ( )  38.  Encourages patient to take adequate d i e t  ()  39.  Recognizes and reports behavioral and p h y s i o l o g i c a l changes that are due • to drugs  ( )  SLATER NCRS  40.  Adjusts expectations o f patient's behavior according to the e f f e c t the d r u g has on t h e p a t i e n t . . .  41.  Demonstrates u n d e r s t a n d i n g o f both m e d i c a l and s u r g i c a l a s e p s i s . . .  42.  Recognizer- h a z a r d s t o p a t i e n t s a f e t y and takes appropriate a c t i o n t o maintain a s a f e environment and t o g i v e p a t i e n t f e e l i n g o f being safe  43.  C a r r i e s o u t s a f e t y measures developed t o p r e v e n t p a t i e n t s from harming themselves or others '. .  44.  C a r r i e s out e s t a b l i s h e d technique f o r s a f e a d m i n i s t r a t i o n o f m e d i c a t i o n s and parenteral fluids . . . . .  GENERAL A c t i o n s t h a t may be d i r e c t e d toward meeting e i t h e r p s y c h o - s o c i a l o r p h y s i c a l needs o f p a t i e n t s , o r b o t h a t once. 45.  U t i l i z e s patient  46.  Involves f o r care  p a t i e n t and f a m i l y i n p l a n n i n g and t r e a t m e n t s  47.  Protects  s e n s i t i v i t i e s o f the p a t i e n t  48.  Encourages p a t i e n t t o a c c e p t dependence/ independence as a p p r o p r i a t e t o h i s condition  49.  U t i l i z e s resources w i t h i n the m i l i e u to provide patient with opportunities f o r problem s o l v i n g  50.  A l l o w s p a t i e n t freedom o f c h o i c e i n d e t a i l s o f d a i l y l i v i n g whenever p o s s i b l e and w i t h i n p a t i e n t ' s a b i l i t y t o make choice  51.  teaching  opportunities  E n c o u r a g e s p a t i e n t t o take p a r t i n a c t i v i t i e s o f d a i l y l i v i n g that w i l l stimulate h i s p o t e n t i a l f o r positive  Page  SLATER NCRS  53.  5  of  Adapts nursing care to patient's level and pace of development  ( )  ( )  Provides for diversional and treatment activities appropriate to patient's capabilities and needs  ( )  ( )  ( )  Allows for slow or unskilled performance without showing annoyance or impatience.  ( )  ( )  ( )  Establishes nursing care goals within the framework of the therapist's plan o f care  ( )  ( )  ( )  Adapts to and works with varied approaches to treatment  ( )  ( )  ( )  58.  Relates with patient within the framework of the therapeutic plan  ( )  ( )  ( )  59.  Watchfulness is carried out in an unobtrustive manner , . . . .  ()  ( )  ( )  Responds appropriately to emergency situations  ( )  ( )  ( )  Communicates ideas, facts, feelings, and concepts clearly in speech  ( )  ( )  ( )  Communicates ideas, facts, feelings, and concepts clearly in writing  ( )  ( )  ( )  Establishes a well-developed nursing care plan  ( )  ( )  ( )  Gives accurate reports, verbal/written, of patient behavior, including behavior that involved interaction with herself .  ( )  ( )  ( )  Participates freely in ward patient care conferences  ( )  54.  55. 56.  57.  60.  ,  ( )  COMMUNICATION  Communications on behalf of patients 61. 62. 63. 64.  65.  ()  ( )  7  pages  _ _  ____  ATER NCRS  P a  \  8  •  ,  .  ^  \  \  \  \  \  \f> \ o \ A \ P \o \ *. \ <1 \ ^ X C X X  \ £  \  \\  \ < p \  V  66.  67.  JL  e  \ *  \  Communicates effectively and establishes \ \ good relationships with other disciplines ( ) Attends to patient's needs through use of referrals, both to departments in the hospital as agency and to other community agencies ( )  W  \  < i \ f l  _Z_ P S  o f  a  ^  .  e s  98.  \ ^* \ \ ^ X *^ X \ *sr X O X X  >»  \  1*  X  \ ^ \ * \ s \ fl \  X  X  Y*\ \^  X P X ^ X ^ X  \  v A \  A  \  ( )  ( )  ( )  ( )  X  \  \  ,  ROFESSIONAL  Actions directed toward f u l f i l l i n g responsibilities of a nurse in a l l facets and varieties of patient care situations. Is self-directing: takes i n i t i a t i v e and goes ahead on own  ( )  ( )  ( )  Makes decisions willingly and appropriately  ( )  ( )  ( )  Makes decisions that reflect both knowledge of facts and good judgment . .  ( )  ( )  ( )  Gives verbal evidences of good insight into deeper problems and needs of patients  ( )  ( )  ( )  Contributes as nurse member of medical team to planning and evaluating care . .  ( )  ( )  ( )  Spends time with patients, rather than with other nurses or hospital personnel.  ( )  ( )  ( )  74.  Reliable: follows through with responsibilities  ( )  ( )  ( )  .  75.  Stays with assigned patients, or knows where and how they are  ( )  ( )  ( )  .  ( )  ( )  ( )  ( )  ( )  ( )  68. 69. 70. 71.  72. 73.  •  76.  Impresses others with sincerity of interest and nursing effort  77.  Gives continued interest and encouragement to various-level programs, whether directed to care of patients of her immediate concern or institution-wide programs  [  Page  ER NCRS  78.  Participates  79.  Avails  self  in of  staff  meetings  opportunities  for  learning 80.  Is  a good  follower  cooperative) 81.  Is  a good  82.  Is  helpful  83.  Cooperates hospital  84.  Accepts  (helpful,  .  leader to  (constructive)  ward  with  personnel  ward  routines  .  authority .  situations .  .  .,  .  .  . . . . . . . and  regulations  understanding  .  with  7  of  APPENDIX E  100. THE ROTTER SCALE Instructions This i s a questionnaire to find out the way in which certain important events in our society affect different people. Each item consists of a pair of alternatives lettered a or b. Please select the one statement of each pair (and only one) which you more strongly believe to be the case as far as you're concerned. Be sure to select the one you actually believe to be more true rather than the one you think you should choose or the one you would like to be true. This i s a measure of personal belief; obviously there are no right or wrong answers. Your answers to the items on this questionnaire are to be recorded in the box to the l e f t of your choice. For example, i f you choose (a) as the statement that i s more true, place an X in the box to the l e f t of the (a) statement.  Please answer these items carefully but do not spend too much time on any one item. Be sure to find an answer for every choice. Select the statement you believe to be more true and place an X i n the box to the l e f t of i t . In some neither believe to each by your  instances you may discover that you believe both statements or one. In such cases, be sure to select the one you more strongly to be the case as far as you're concerned. Also try to respond item independently when making your choice; do not be influenced previous choices.  1. Q  a. Children get Into trouble because their parents punish them too much.  I I b. The trouble with most children nowadays is that their parents are too easy with them. 2  -  CZ3 ' a  Many of the unhappy things in people's lives are partly due to bad luck.  I I b. People's misfortunes result from the mistakes they make.  - 2101 .  3. £^3 a. One of the major reasons why we have wars is because people don't take enough interest in p o l i t i c s . | | b. There w i l l always be wars, no matter how hard people try to prevent them. a . In the long run people get the respect they deserve in this world.  A.  j | b. Unfortunately, an individual's worth often passes unrecognized no matter how hard he tries. a . The idea that teachers are unfair to students i s nonsense.  5. |T[]  I b. Most students don't realize the extent to v/hich their marks are influenced by accidental happenings.  |  a . Without the right breaks one cannot be an effective leader.  6.  | | b. Capable people who f a i l to become leaders have not taken advantage of their opportunities. a . No matter how hard you try some people just don't like you.  7. |  | b. People who can't get others to like them don't understand how to get along with others.  8. j^Jl ' a  Heredity plays the major role in determining one's personality.  | | b. It is one's experiences in l i f e which determine what they're like. 9. [3  >  a  I have often found that what Is going to happen w i l l happen.  j | b. Trusting to fate has never turned out as well for me as making a decision to take a definite course of action. a . In the case of the well prepared student there is rarely i f ever such a thing as an unfair test. | | b. Many times exam questions tend to be so unrelated to course work that studying is really useless.  10. [^]  11.  a. Becoming a success is a matter of hard work, luck has l i t t l e or nothing to do with i t . | | b. Getting a good job depends mainly on being in the right place at the right time.  - 3102.  12.  [~] a. The average c i t i z e n can have an influence i n government decisions. |  13.  | b. This world i s run by the few people i n power, and there i s not much the l i t t l e guy can do about i t .  \~_) a* When I make plans, I am almost c e r t a i n that I can make them work. |  14.  | b. I t i s not always wise to plan too f a r ahead because many things turn out to be a matter of good or bad fortune anyhow.  (~] a. There are c e r t a i n people who are just no good. |  15.  | b. There i s some good i n everybody.  [~  a. In my case getting what I want has l i t t l e or nothing to do with luck.  |  16.  | b. Many times we might just as w e l l decide what to do by f l i p p i n g a coin.  L_ f  17.  | b. Getting people to do the r i g h t thing depends upon a b i l i t y , luck has l i t t l e or nothing to do with i t .  L_ |  18.  a. Who gets to be the boss often depends on who was lucky enough to be i n the r i g h t place f i r s t .  a. As f a r as world a f f a i r s are concerned, most o f us are the victims of forces we can neither understand, nor c o n t r o l . | b. By taking an active part i n p o l i t i c a l and s o c i a l a f f a i r s the people can c o n t r o l world events.  Q |  a. Most people don't r e a l i z e the extent to which t h e i r l i v e s are c o n t r o l l e d by accidental happenings. | b. There r e a l l y i s no such thing as "luck".  19.  a. One should always be w i l l i n g to admit mistakes. j  20.  | b. I t i s u s u a l l y best to cover up one's mistakes.  [~ |  a« I t i s hard to know whether or not a person r e a l l y l i k e s you, | b. How many friends you have depends upon how n i c e a person you are.  - 4 -  103.  21.  t^] I  22.  D  a. In the long run the bad things that happen to us are balanced by the good ones. | b. Most misfortunes are the r e s u l t of l a c k o f a b i l i t y , ignorance, l a z i n e s s , or a l l three. a. With enough e f f o r t we can wipe out p o l i t i c a l corruption.  { | b. I t i s d i f f i c u l t f o r people to have much c o n t r o l over the things p o l i t i c i a n s do i n o f f i c e . 23.  Q  a. Sometimes I can't understand how teachers a r r i v e a t the grades they give.  \ | b. There i s a d i r e c t connection between how hard I study and the grades I get. 24.  Q |  25.  27.  | b. A good leader makes i t clear to everybody what t h e i r jobs are. a. Many times I f e e l that I have l i t t l e i n f l u e n c e over the things that happen to me.  |  26.  a. A good leader expects people to decide f o r themselves what they should do.  ]~]  | b. I t i s impossible for me to believe that chance or luck plays an important r o l e i n my l i f e . a. People are lonely because they don't t r y to be f r i e n d l y .  |  | b. There's not much use In trying too hard to please people, i f they l i k e you, they l i k e you.  Q  a. There i s too much emphasis on a t h l e t i c s i n high school.  | | b. Team sports are an excellent way to b u i l d character. 28.  29.  Q  a. What happens to me i s my own doing.  |  | b. Sometimes I f e e l that I don't have enough c o n t r o l over the d i r e c t i o n my l i f e i s taking.  Q  a. Most of the time I can't understand why p o l i t i c i a n s behave the way they do.  | | b. In the long run the people are responsible f o r bad government on a n a t i o n a l as w e l l as on a l o c a l l e v e l .  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0055960/manifest

Comment

Related Items