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Observation of communication behavior : the development of a research method for use in health care organizations McGill, Mary Elizabeth 1976

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2ISERVATI0N_0F_CgMMUOQATI  f o r ase i n liMLTH_CARE_ORGANIZilIOaS  by  Mary E l i z a b e t h  McGill  Bachelor of Science i n R e h a b i l i t a t i o n , U.B.C., 1965  Submitted  i n p a r t i a l f u l f i l m e n t of the r e g u i r e a e n t s f o r the degree of DOCTOR OF PHILOSOPHY in  THE FACULTY OF COMMERCE AND BUSINESS ADMINISTRATION  He accept t h i s t h e s i s as conforming to the r e q u i r e d standard:  THE UNIVERSITY OF BRITISH COLUMBIA August, 1976 ($) Mary Elizabeth McGill, 1976  In  presenting  this  an a d v a n c e d d e g r e e the I  Library  further  for  shall  agree  thesis  in  at  University  the  make  that  it  partial  freely  permission  his  representatives.  of  this  thesis  for  It  financial  of  of  Columbia,  British  available for  by  the  is understood gain  for  extensive  s c h o l a r l y p u r p o s e s may be g r a n t e d  by  fulfilment  shall  requirements  reference copying of  Head o f  that  not  the  I  agree  and  be a l l o w e d  this  without  Mary E l i z a b e t h M c G l l l  The  of  University  Commerce and. Business Administration of  British  2075 Wesbrook Place Vancouver, Canada V6T 1W5  Date  August 9, 1976  Columbia  thesis or  publication  written permission.  Department  that  study.  my D e p a r t m e n t  copying or  for  my  ABSTRACT  The  objective  Sobert Bales'  of  the  Dissertation  a  ward.  o r g a n i z a t i o n a l , and lack  of  behavior  health care  in  this  on  observing  Saskatchewan. physical  Two  context.  Subjects included families,  and  p r o v i s i o n of  all  all  patients  staff  communication tested  non-participant  in  a  300-bed  in  Southern  chronic two  adult  setting.  wards,  their  d i r e c t or i n d i r e c t  observers  behavior i n - p r o c e s s regarding  the  organizational  position  variance  of the  interaction  sought  for  instrument.  in  study—an  a  the  involved  study  method, r a t h e r  hospital  and on  the  care,  A team of two  were  unit  group,  The  conducted  care  a  patterns.  wards were s e l e c t e d f o r  rehabilitation  the  communication  r e f i n i n g the r e s e a r c h  extended  the  emphasized  actual  specific interaction  and  to adapt  of  literature  A four-month f i e l d study was rehabilitation  review  organizational  focused  than on a n a l y z i n g  for  validate  p a t i e n t communications on  comprehensive  instruments  therefore  to  I n t e r a c t i o n Process A n a l y s i s , and  method f o r a n a l y s i s of s t a f f and hospital  was  the  and  construct  coded  on the wards. relative  context profiles. and  face  in  dyadic  Hypotheses  iaportance  of  explaining  the  Support validity  was of  also the  The  D i s s e r t a t i o n included  t r a i n i n g required technique. subjects  to enable other r e s e a r c h e r s  Procedures  for  providing  were a l s o d e l i n e a t e d , as a c t i v e  considered  c r u c i a l t o the  Partial construct  support  validity  inclusivenass  project's  was of  obtained  given.  A  demonstrated that  multivariate the  observer  of  also  the  participation  was  an  a s p e c t s of  Analysis—the  face  the  validity of  and  d i r e c t i o n s explored The  study  A n a l y s i s has  were given for future  concluded  that  variance  profile,  important  f o r the  but  the  factor.  The  dimension-  observer e f f e c t ,  research. Bales*  Interaction  a d e f i n i t e c o n t r i b u t i o n to make to tne  behavior i n h e a l t h care  Vance F. M i t c h e l l , Thesis Supervisor  was  most s i g n i f i c a n t  impact of o r g a n i z a t i o n a l context v a r i e d with tae A l t e r n a t i v e explanations  the  the independence of  analysis  p o s i t i o n dyad was  was  the  to  Process  explanatory v a r i a b l e f o r the i n t e r a c t i o n particular  feedback  f o r two  of the c a t e g o r i z a t i o n and Evidence  t o employ  the  success.  Interaction  the category f r e q u e n c i e s . also  d e t a i l s of the atetnod and  organizations.  Process study of  iv  TABLE OP CONTENTS  CHAPTER I-  A.  INTRODUCTION  1  B.  RATIONALE  2  C.  BACKGROUND  6  D.  OBJECTIVE  8  E.  LITERATURE BEVIES 1. Role Theory 2. The Communication Process 3. Communication Studies i n Health Care 4. B a l e s ' I n t e r a c t i o n Process A n a l y s i s  9 9 14 17 23  F.  DEVELOPMENT OF HYPOTHESES  42  CHAPTER I I  A.  LOCATION  44  B.  SDBJECTS  46  C.  RESEARCH MODEL  47  D.  STUDY DESIGN  51  E.  METHOD  66  F.  DATA PREPARATION  72  CHAPTER_III  A.  PRELIMINARY ASSESSMENT OF CATEGORY USE  79  B.  RELIABILITY  81  C.  TESTS OF THE HYPOTHESES  85  D.  HOSPITAL FEEDBACK  99  CHAPTER I ?  A.  DISCUSSION 1. Theory 2Method 3. The Research Model 4. U t i l i t y o f the Method  104 104 106 115 116  B.  FUTURE RESEARCH DIRECTIONS  119  C.  CONCLUSIONS  121  BIBLIOGRAPHY APPENDICES A. . R e s u l t s of P i l o t Study B. S t a f f and P a t i e n t Codes C. Submission t o SSHC Management Committee D. P r e s e n t a t i o n t o Department Heads E. S t a f f and P a t i e n t O r i e n t a t i o n Sheet F. Communication P r o f i l e s Presented to Management Committee G- Feedback Information Sheet H. F i n a l Report on Communications Research P r o j e c t  124 135 138 142 151 156 158 170 172  vi  LIST OF TABLES  I  STABILITY OF SUBJECTS BY CATEGORY  II  BALES' NEW IPA—ESTIMATED NORMS AND DIRECTIONAL INDICATORS  39  III  STRENGTH OF PHI VALUES FOR CATEGORY USE BY OBSERVER  80  IV  VARIMAX ROT&TED FACTOR MATRIX—BOTH  87  V  VARIMAX  VI  VARIMAX ROTATED FACTOR MATRIX—STATION FIVE  88  VII  OBLIQUE FACTOR STRUCTURE—BOTH WARDS  88  VIII  OBLIQUE FACTOR STRUCTURE—SECOND WEST  89  IX  OBLIQUE FACTOR STRUCTURE—STATION FIVE  89  X  EIGENVALUE, MAJOR VARIABLE, AND PERCENTAGE OF VARIANCE EXPLAINED FOR EACH FACTOR  90  XI  NUMBER AND DIRECTION OF CO-LOADINGS FOR CATEGORY 6  92  XII  ABSOLUTE AND RELATIVE FREQUENCIES OF CATEGORY 0 BY WEEK  93  XIII  MANOVA—SIGNIFICANT  F-STATISTICS FOR WEEK  95  XIV  MANOVA—SIGNIFICANT  F-STAIISTICS FOR WARD  95  XV  MANOVA—SIGNIFICANT F-STATISTICS FOR DAY, OBSERVER, TIME PERIOD, LOCUS  96  XVI  MANOVA—SIGNIFICANT F-STATISTICS FOR DAY, OBSERVER, DYAD  97  1  INTERACTION BEHAVIOR  HARDS  ROTATED FACTOR MATRIX—SECOND  WEST  28  87  vii  L I S T OF FIGURES  1.  A MODEL OF THE ORGANIZATIONAL  POSITION  2.  BALES' SYSTEM OF CATEGORIES USED IH OBSERVATION AND THEIR MAJOR RELATIONS  25  3.  BASCANA  45  4.  RESEARCH MODEL  47  5.  TIMING OF FIELD STUDY  52  HOSPITAL  6. . SAMPLE PROFILE FROM HOSPITAL FEEDBACK 7.  PHASES OF RESEARCH AND TARGET DATES FOR COMPLETION  12  78 146  viii  ACKNOWLEDGMENTS No man i s an i s l a n d . No man s t a n d s a l o n e .  It  i s hard  t o know where t o b e g i n  acknowledgments people's l i v e s them  for a  have touched  a l l i s impossible.  career  path,  Dr,  Mary  of Occupational faculty  stimulated existing  mine a l o n g  the  be r e c o g n i z e d  at this  and P h y s i c a l Therapy.  So  way--to  many  mention  o f c a r e . , Dr.  that  "extra"  the professions Brock F a h r n i and  o f R e h a b i l i t a t i o n Medicine p a t i e n t and questioned  George S z a s z  broadened  dimensions o f t h e h e a l t h care  R o b e r t McDermit c h a n n e l l e d  my  time.  Dr.  consideration of the t o t a l  other  making  However, a s I have moved a l o n g  o f t h e D.B.C. , S c h o o l  to  when  Dissertation.  Pack e n c o u r a g e d me t o e n t e r  patterns  horizons  end  c e r t a i n i n d i v i d u a l s have p r o v i d e d  impetus which s h o u l d  the  Doctoral  or  this interest  into  my  team, and  communication  research. Between 1967 a n d 1972, teamwork w i t h at  Hascana  objectives, of  Hospital  caused  and s t i m u l a t e d  a broader  understanding  of  U.B.C.  were c r e a t i v e b e c a u s e o f  the  Organizational  Commerce  and  The  past  four  the  the f a c u l t y  Behavior  Business  rethink  organizational  care  particularly  to  and p a t i e n t s my  career  my r e t u r n t o u n i v e r s i t y i n s e a r c h  health  contacts,  research.  me  staff  behavior  years  variety  and  o f study a t of  personal  and g r a d u a t e s t u d e n t s i n  Division  Administration,  of  the  Faculty  of  a n d members o f t h e  ix  Department of Health Care and Epidemiology Medicine. been  Through t h e i r c o n t r i b u t i o n s ,  explored  and  of the F a c u l t y of  new  pathways  have  a multitude of questions r a i s e d f o r the  future. Dissertations Throughout  the  Dr.,  kinds  of  Vance M i t c h e l l , chairman. Dr.  Dean Dyeno of the F a c u l t y of  Crichton  from  Health  Care  M a l l i n s o n , of the Department Simon  many  support. .  development and e x e c u t i o n of the t h e s i s ,  Committee—Dr. and  require  Carl  Commerce,  and  Epidemiology,  of  Communication  Sarndal,  Dr. and  Anne  Dr.,  Tom  Studies  at  F r a s e r U n i v e r s i t y — h a v e a l l played a v i t a l r o l e .  the past  two  years,  f i n a n c i a l support Dr.  Fred  facilitated  I  have  been  fortunate  to  for  For  receive  from a Canada C o u n c i l D o c t o r a l F e l l o w s h i p .  Siller,  of  the  U.B.C.  Faculty  of Commerce,  a Department of Labor student grant to a s s i s t i n  the f i e l d study, and Dr. . Jack Boan, from the U n i v e r s i t y Regina  my  Department  i n t e r i m data  of  of  Economics, obtained computer funding  analysis.  E x c e l l e n t r e s e a r c h a s s i s t a n t s are a r a r e c o a a o d i t y . have  been  fortunate  to  be  associated  f i n e s t — M a r y Brown f o r the p i l o t the  Dissertation  contributions  to  research. the  research  with  mention.  of the  study, and Peter Bowman f o r Both  made  program.  p a t i e n t s at Hascana H o s p i t a l i n the Summer of special  two  I  invaluable  The  staff  1975  and  deserve  l e worked together as a team to t a c k l e a  shared concern f o r the d e l i v e r y of i n t e g r a t e d p a t i e n t c a r e .  X  A D o c t o r a l program requires  constant  cannot  be  encouragement. ,  undertaken Without  parents and f r i e n d s , I would not have this  path.  And  new  and  it  the support of follow  without t h e i r c a r i n g presence,the  terrain  We have  attempted  shared  moments,  Baany  bad, as we have t r a v e r s e d our paths t o g e t h e r .  f a m i l y have p r o v i d e d the m o t i v a t i o n when the  the s t e e p e s t .  It  to  would have been impassable. good  alone.  going  Hy was  I f t h i s r e s e a r c h i s t o be d e d i c a t e d t o anyone  must be to them, f o r they are the f u t u r e . The  c l i m b up the mountain has been e n v i g o r a t i n g . , From  t h i s viewpoint the h o r i z o n i s broad and are  full  of  promise  for  the  ranges  exciting discoveries.  beyond I t i s my  s i n c e r e s t wish t h a t those whose past c o n t r i b u t i o n s have made the present a r e a l i t y w i l l be e x p l o r i n g the f u t u r e  Betty  McGill  Vancouver, June,  terrain.  1976  British  Columbia  able  to  share  with  me  in  1  CHAPTER_I  A.  INTRODUCTION!  Development and v a l i d a t i o n o f a and  analyzing  method  communication behavior  for  observing  o f s t a f f and p a t i e n t s  on a h o s p i t a l ward a r e the o b j e c t i v e s o f t h i s d i s s e r t a t i o n . The  study begins with an examination o f the problems o f  f u n c t i o n a l s p e c i a l i z a t i o n and health  care  organizations.  coordination  observing setting.  team,  but  between  instruments  are  a c t u a l i n t e r a c t i o n behavior Their  members  available for  i n the  organizational  p o t e n t i a l c o n t r i b u t i o n t o an understanding recognized,  thus the r a t i o n a l e f o r the t h e s i s i s developed. Four  key  review—role  methods. seen  are  studies  as  the  in  most  behavior  theoretical  emphasized  the  Sobert Bales*  communication However,  areas theory,  communication  is  o f the  not  of c o o r d i n a t i o n i n h e a l t h c a r e o r g a n i z a t i o n s i s and  today's  Communication i s one aethod of  achieving horizontal coordination treatment  facing  in  the  literature  communication  health  care,  process,  and o b s e r v a t i o n a l  Interact4Qn_Process A n a l y s i s promising in  health  approach care  validation  and  to  studying  organizations. methodological  refinements o f t h i s instrument a r e r e g u i r e d before i n t e r a c t i o n p a t t e r n s can be i n t e r p r e t e d .  (IPA)  specific  2  Eight  hypotheses  IPA and  i t s use on the  issues  raised  the  ward  are  field  and  are  L o c a t i o n and  pilot  described,  variables  logically  from  sample f o r the f o u r -  the  research  operationally  Developmental aspects of the r e s e a r c h are  model defined.  discussed  before  data c o l l e c t i o n i s d e s c r i b e d .  After  summarizing the r e s u l t s of the study, an o u t l i n e  i s given of the process f o r feedback organization.  The  thereby assessed. for  from  researcher.  analysis. study  delineated,  the f i n a l  generated  of t h e present r e s e a r c h f o l l o w s  foregoing  month  hospital  the c o n s t r u c t v a l i d i t y of  i n the l i t e r a t u r e and the r e s u l t s of a  study conducted by the Design  concerning  communication  functional  to  utility  the of  participating the  In d i s c u s s i n g the f i n d i n g s , theory,  observational  method i s  iaplications studies,  and  o r g a n i z a t i o n a l r e s e a r c h are a l s o examined. . The i n v e s t i g a t o r ' s long-term of  methods  which could be used by r e s e a r c h e r s and  h e a l t h care o r g a n i z a t i o n s behavior  B. ,  g o a l i s t o develop  to  observe  their  a  set  staff in  communication  and analyze i t s e f f i c i e n c y and e f f e c t i v e n e s s .  RATIONALE:  "As medical p r a c t i s e has become more s p e c i a l i z e d , i t has become more impersonal .... I t has a l s o become more interdependent .... Since s p e c i a l i z a t i o n c r e a t e s interdependence, it c r e a t e s the need for coordination (Thompson, 1961, p. 4 8 , 5 0 ) . "  3  One the  of the major dilemmas c o n f r o n t i n g o r g a n i z a t i o n s  1970's  is  the  need  opposed to c o o r d i n a t i o n .  for functional specialization T h i s problem was  e a r l y management t h e o r i s t s . , F a y o l that  specialization  p. 6)  inevitably analyses support  emphasized  to by  the  necessity  Lawrence  and  flooney(1937)  and  for  coordination.  Recent  (1967)  (1972)  and  or  through  mechanisms  V e r t i c a l c o o r d i n a t i o n , as (1937),  the  i s generally  of  by the  ideas,  frequently  to Roberts,  O'Reilly,  for  discussed handled  organizational  use of formal a u t h o r i t y and  H o r i z o n t a l c o o r d i n a t i o n i s achieved exchange  Hall  dimensions.  e i t h e r through s t r u c t u r a l approaches such as design  Gulick  the s u b d i v i s i o n of work l e d  Lorsch  Gulick  by many  recognized  Taylor.  have s e v e r a l a l t e r n a t i v e  achieving coordination. by  by  the interdependence of these two  Organizations  20)  as  the n a t u r a l r e s u l t of  advocated that  discussed  (1949, p*  of f u n c t i o n s was  the d i v i s i o n of work d u t i e s (1937,  in  power.  development referred  and  to  as  "communication**. According  Bretton,  and  Porter  (1974), "Communication seems t o t i e organizations together. Consequently, the r e l a t i o n s h i p of various f a c e t s of communication to other processes such as c o o r d i n a t i o n and decision-making appears t o us to have high pay-offs in terms of understanding o r g a n i z a t i o n a l behavior (p. 520) ." However, "communication" as an received  little  researchers  attention  organizational  from  theorists  (Porter & Roberts, 1972).  process  and  has  empirical  4  Because of the e x p o n e n t i a l  growth o f medical  knowledge  during  t h i s century,  p r o v i d e r s of d i r e c t or i n d i r e c t  care  have  forced  been  to  specialize.  organizational structures r e f l e c t this units  such as treatment c e n t r e s  separated  according  adolescent,  adult,  rehabilitation,  all  specialization medical s t a f f ) .  of  level  above  occurs  by  Total  care  (acute,  and/or  disease  psychiatric,  cancer).  types  function  (pediatric,  of  chronic),  of  institutions,  ( n u r s i n g , housekeeping,  Functional s p e c i a l i z a t i o n  dimension o f t o d a y s h e a l t h care Such  patient  arthritis,  the  care  development.  of  geriatric),  (e.g.,  Health  or h o s p i t a l s a r e f r e q u e n t l y  age  activation,  classification Within  to  patient  is  thus  a  key  organizations.  specialization,  however,  necessitates  coordination. The "team approach t o p a t i e n t c a r e " has method  for  disciplines. conceptual Hany  coordinating Considerable  highly  disagreement  have  assumed  o b j e c t i v e ; a number have a  few  i t to  attempted  believe  that  be to  in  exists  an  they  relatively  well-defined  units  a  over team".  organizational  operationalize  S i g n i f i c a n t l y , a r e c e n t study by C r i c h t o n staff  as  specialized  and o p e r a t i o n a l d e f i n i t i o n s of t h e " h e a l t h  authors  concept;  these  evolved  have  succeeded . 1  (1975) found were  the  unable  that to  For a thorough review o f t h i s l i t e r a t u r e , see Warner's (1975) annotated bibliography of h e a l t h care teamwork (p. 1-119).  1  5  e s t a b l i s h the boundaries Hessen's (1958)  o f t h e i r team.  analysis  of  "Hospital  ideology  and  communication between ward p e r s o n n e l " determined t h a t h e a l t h personnel  limited  interaction.  their  They  communications  volume  channeled  the  inter-departmental  majority  within occupational l i n e s .  Hann (1962) r e p o r t e d s i m i l a r perceived  of  patterns  of  findings  information  of  their  Georgopoulos and  in  their  exchange  study  of  i n community  general h o s p i t a l s . D i f f e r i n g behavior been  hypothesized  to  p a t t e r n s of h e a l t h s p e c i a l i s t s create  barriers  to coordination of  p a t i e n t c a r e , but few e m p i r i c a l attempts have been explore  this  dimension.  Researchers  have  have  made  studied  to such  o r g a n i z a t i o n a l v a r i a b l e s as c l i m a t e and l e a d e r s h i p s t y l e s as fierceived developing Dubin  by members. methods  Less  dimension.  many  of  has  been  f o r r e c o r d i n g a c t u a l behavior  (1962), i n "Business  presented  attention  the  behavior early  paid  to  in situ.  b e h a v i o r a l l y - viewed",  s t u d i e s which e x p l o r e d  this  He s t a t e d ,  " I f b e h a v i o r a l s c i e n c e means what i t says, then behavior and the s i t u a t i o n s o f behavior must be the f i r s t level of a n a l y s i s . . . . Perhaps i t would be p r o d u c t i v e of immediate and very substantial advances i f good behavioral scientists rediscovered behavior as t h e i r c e n t r a l datum (p. 11,51)." Kerlinger Deutsch, foundation However,  (1966,  and  Cook  p. .503-525), (1959,  f o r students in  spite  of  and  p.199-234), the  Selltiz, have  Jahoda,  provided  observational  a  method.  of the a v a i l a b i l i t y of such r e f e r e n c e s ,  few r e c e n t e m p i r i c a l s t u d i e s have used o b s e r v a t i o n a l methods  6  to  study  organizations.  This  may  investigations  often  take  the  methodologically  muddy  water.  The  be  because  such  researcher large  into  number  of  u n c o n t r o l l a b l e v a r i a b l e s i n the o r g a n i z a t i o n a l c o n t e x t makes behavioral  studies  prone  to  systematic  error  variance  (Thorndike, 1949, p. 7 5 ) . Measurement o f communication behavior i s a p a r t i c u l a r l y c h a l l e n g i n g task because of t h e absence foundation  a  theoretical  on which t o b u i l d e m p i r i c a l i n v e s t i g a t i o n s .  l a c k o f i n s t r u m e n t a t i o n can dynamic  of  be  a s p e c t s of the process  partly  attributed  The  to the  {Roberts S 0 * R e i l l y ,  1974b).  The amorphous nature o f t h e concept of communication i s a l s o a contributing factor  (Roberts & 0 * R e i l l y ,  1974a).  In summary, t o understand t h e process specialized  departments  of  coordinating  i n h e a l t h care o r g a n i z a t i o n s , more  comprehensive and r e l i a b l e technigues f o r measuring communication developed.  behavior  of  staff  Only i n t h i s way can  interaction  be  patterns to  give  combined a  and  patiants  subjects*  with  their  comprehensive  must  be  perceptions  of  observed  picture  fkctuaj.  of  behavior  the  total  o r g a n i z a t i o n a l communication system.  C.  BACKGROUND:  Between  1967 and 1969 the r e s e a r c h e r conducted a p i l o t  study of " S t a f f communication i n a r e h a b i l i t a t i o n  hospital.  7  and  its  1968)  relation  at Hascana  chronic-care year was coding  to i n t e g r a t i o n of p a t i e n t c a r e " Hospital,  facility  a  in  300-bed  rehabilitation  Eegina, Saskatchewan.  spent attempting t o develop a of  verbal  interactions.  dimension was  how  s t a f f and  method  During  became i n c r e a s i n g l y apparent t h a t  (HcGill,  the  The  for  and first  content  this  period, i t  critical  behavioral  patients interacted, rather  than  what they s a i d , s i n c e the content of t h e i r communication primarily  determined  by the nature of the  E f f o r t s were then focused for  "how"  people  extensive  communicated.  literature  researchers,  the  on developing  search  decision  was  I n t e r a c t i o n Process A n a l y s i s appropriate  dialogue made  (IPA)  that  (1950a)  of  with  other  Robert  Bales'  the  most  were s e v e r a l reasons f o r t h i s c h o i c e .  The  first  which  was  p a r t i a l l y v a l i d a t e d r a t h e r than t o develop a new  second was  Bales'  the  decision  rather  alternatives Analysis,  than  to  Chappie's  to  monitor  i t s content.  three—Flanders' (1949)  the  (1970)  Interaction  extensive  because modification  other two,  the  categories  f o r use i n a  a more comprehensive t h e o r e t i c a l  one. of  Interaction  Chronograph,  would hospital  B a l e s ' c a t e g o r i z a t i o n was  process  at  T h i s narrowed the  (1950a) I n t e r a c t i o n Process A n a l y s i s .  eliminated  an  was  communication  the  result  the d e s i r e to use an e x i s t i n g instrument  least The  the  categories  instrument f o r the s i t u a t i o n . ,  There was  and  problem at hand.  a s e t of  As  was  Flanders' have  foundation.  was  required  setting.  considered  and  Of  to have  8  Bales  1  method, which was developed f o r the s m a l l  laboratory,  reguired  procedures before context.  modification  i t could be  Appropriate  used  of in  data  the  collection  organizational  changes were made, and a p i l o t  was attempted on a l l s i x h o s p i t a l  sards.  Data  wards  of  age  were  (children)  not or  (veterans).  useable  the  because  informality  Analysis  of  the  the  communication  profiles  because  However,  fora  of  for specific  (see  Findings of of  computerizing the p i l o t study data, f u r t h e r the  of p a t i e n t  on t h e other  validity  before  two  of i n t e r a c t i o n patterns  some support f o r the c o n s t r u c t  reguired  from  atmosphere  groups at a p a r t i c u l a r ward l o c a t i o n .  Appendix A ) .  study  ward  f o u r wards i n d i c a t e d that the modified isolate  group  instrument  could  IPA  could  occupational also offered  the  instrument  difficulties  in  validation  was  be comprehensively  assessed.  D.  OBJECTIVE^. The  o b j e c t i v e of the r e s e a r c h  was t o determine  I n t e r a c t i o n Process A n a l y s i s , a general process  s e t o f communication  c a t e g o r i e s , can give r e l i a b l e and v a l i d i n t e r a c t i o n  p r o f i l e s across positions  whether  in  a  broad  spectrum  of  staff  and  patient  a h e a l t h care o r g a n i z a t i o n . , T h i s g o a l was t o  be accomplished by:  9  (a) r e f i n i n g the method of data c o l l e c t i o n f o r use on hospital (b) a s s e s s i n g the construct communication c a t e g o r i z a t i o n .  . validity  of  Bales*  (c) developing and documenting a procedure f o r h e a l t h c a r e p e r s o n n e l t o use the instrument. (d) examining the a d m i n i s t r a t o r s and  E-  theoretical  utility of t h e data f o r h e a l t h care practitioners.  research  and  communication.  had  training  LITERATURE SEVIIII: The present  of  a  evolved  empirical  to  fill  literature  on  gaps  in  the  organizational  S i n c e an i n t e g r a t e d approach to the  problem  measurement d i d not e x i s t , f o u r areas were examined which a  relevant  contribution  to  make:  role  t h e o r y , the  communication process, communication s t u d i e s i n h e a l t h c a r e , and B a l e s ' I n t e r a c t i o n Process a n a l y s i s . are it  discussed  The  first  three  b r i e f l y ; emphasis i s given to the f o u r t h , as  provided the  major  methodological  foundation  for  the  study.  1.  Role_Theory! The  term  " r o l e " has d i f f e r e n t c o n n o t a t i o n s a c r o s s the  s o c i a l s c i e n c e s (Gordon, 1966). conceptually broader—a by  is  r o l e i s a s e t of behaviors e x h i b i t e d  a l l incumbents o f a p a r t i c u l a r s o c i a l p o s i t i o n - - e . g . the  " r o l e " of the nurse. one  I t s p s y c h o l o g i c a l usage  subset  of  S o c i o l o g i s t s g e n e r a l l y view a r o l e  consistent  norms w i t h i n a s o c i a l  as  position.  10  Role thus  governs  particular  incumbent—e.g. the latter,  narrower  types  of  behavior  of  nurse i n t h e " r o l e " of s u p e r v i s o r .  definition  is  used  throughout  the The this  presentation. Bates  (1955-6)  clarifies  the  concepts  "position",  " r o l e " , and "norm": "1. P o s i t i o n : A l o c a t i o n i n a s o c i a l s t r u c t u r e which i s a s s o c i a t e d with a s e t of s o c i a l norms. 2. Role: A p a r t of a s o c i a l p o s i t i o n c o n s i s t i n g of a more or l e s s i n t e g r a t e d or r e l a t e d sub-set of s o c i a l norms which i s d i s t i n g u i s h a b l e from other s e t s of norms forming t h e same p o s i t i o n . 3. Norm: A patterned or commonly expectation. A learned response, held members o f a group (p. 314)."  held behavior i n common by  He maintains t h a t w i t h i n a given c u l t u r e there are a l i m i t e d number  of  different "mother"  roles  which  social could  are  positions. be  shared  combined For  by  i n various  example,  persons  "nurse"  could  "subordinate", "coordinator", The Thomas  contain  "supervisor",  a  number  of  "woman",  £ole  of  i n many p o s i t i o n s :  "nurse", " s o c i a l worker", and "housekeeper". of  the  ways f o r  The  Edition  r o l e s : "mother",  "cleric",  "friend",  " n u r t u r e r " , "medicine d i s p e n s e r " , e t c .  d e f i n i t i o n o f " p o s i t i o n " i s c l a r i f i e d by B i d d l e and  (1966).  They d e s c r i b e i t a s ,  "...a collectively recognized category of persons f o r whom the b a s i s f o r such d i f f e r e n t i a t i o n i s t h e i r common attribute, their common behavior, o r the common r e a c t i o n s o f o t h e r s toward them (p. 29)." The above,  concept of " r o l e , " i n the narrower sense is  not as e a s i l y understood.  i d e n t i f i e d t h r e e o f i t s uses:  discussed  D. J . Levinson  (1959)  11  (a) o r g a n i z a t i o n a l l y given e x p e c t a t i o n s of o t h e r s . (b) the  role  personal r o l e definition—role incumbent p l a c e s upon h i m s e l f .  (c) r o l e b e h a v i o r — a c t u a l  demands—role e x p e c t a t i o n s which  performance.  I t would appear that a u n i f y i n g concept not  a v a i l a b l e to p a r a l l e l " p o s i t i o n " .  of a  particular  identifiable. to  social  In c o n t r a s t ,  ascertain.  reference  The  to  a  expectations, worker  in  or  aides,  overt  it  is be  easily  difficult whether  self-expectations, For  "supervisor"  others'  example, a s o c i a l may  . have  certain  about a p p r o p r i a t e i n t e r a c t i o n b e h a v i o r . be g u i t e  the  f a m i l i e s , which,  different  from  those  d i r e c t o r of s o c i a l s e r v i c e s , in  turn,  A c t u a l r o l e behavior may above  that  expectations,  can  differ  is  hallmarks  must d i s t i n g u i s h  behavior. ,  of  "role"  of the  a s p e c i f i c r o l e may  means  role  e x p e c t a t i o n s may work  is  investigator  role  the  expectations  position  One  of  These  of  social  patients,  from  each  other.  r e f l e c t a combination of a l l of  as w e l l as p e r s o n a l i t y  and  and  the  situational  influences. fiafl£e_l organizational is  added  to  relationship.  depicts  McGill's  position  " s t a f f nurse".  Bates'  conception  Between  the  (1975)  of  personality  aodel  A personality the and  the s e t of  p o s i t i o n a d o t t e d l i n e has  denote a permeable  interface  necessitating)  their  interaction.  for  the core  position-role  e x p e c t a t i o n s of the  allowing  of  role  been drawn t o (and,  indeed,  12 FIGORE_J[ A MODEL OF THE ORGANIZATIONAL POSITION  McGill  suggests  that  p a t i e n t p o s i t i o n there  f o r each r e c o g n i z a b l e  is a  "position-set"  Merton's (1966) d e s c r i p t i o n of " s t a t u s - s e t " of  distinct  and  among s o c i a l systems  hospital  positions  ward,  assigned t o i n d i v i d u a l s both (p. 7 4 ) . "  occupational  Social  Returning to Figure,,,1,  depicted be  social  within  workers  on  a  and  the  (staff  nurse,  but n o t with those  aide).  boundary . r e l a t i o n s h i p s  organizational  between  environment  by the o u t e r l i n e o f the e l l i p s e .  drawn  length  therapist)  i t (electrician, dietary  position  to  f o r example, would have s t a b l e p a t t e r n s o f  physiotherapist,  the  analogous  as a "..•complex  i n t e r a c t i o n with those i n t h e i r p o s i t i o n - s e t  outside  s t a f f or  can be  I t , t o o , should  with a broken l i n e t o i n d i c a t e p e r m e a b i l i t y .  of the i n t e r f a c e between a p o s i t i o n and a environment  can  be  The  particular  c o n s i d e r e d p r o p o r t i o n a l t o the  amount of r e c i p r o c i t y which the incumbent has with o t h e r s i n that p o s i t i o n - s e t . nurse, during the  who  is in  For example, the o u t e r contact  an e i g h t - h o u r s h i f t , hospital  with  boundary  many persons on the ward  would be l o n g e r  administrator,  who  for a  visits  o c c a s i o n a l l y t o converse with t h e head nurse.  than the  that ward  for only  13  Gouldner  (1960)  relationships  examined  within  a  reciprocity  in  exchange  dyad, c o n c l u d i n g t h a t power can  balanced or unbalanced i n the s h o r t - r u n , but i n the w i l l reach e q u i l i b r i u m , complementary  such  as  reciprocity  between o r g a n i z a t i o n a l p o s i t i o n s pharmacist.  Thus  position-set,  it  stable  long-run  While he r e s t r i c t e d h i s a n a l y s i s t o  roles  supervisor/subordinate,  be  may  be  father/son also  such  can  as  be examined  physiotherapist/  postulated  reciprocity  or  that  within  relationships  can  a be  identified, Reciprocities ZiaM£e_l«  When two  proximity  and  the  can  a l s o be examined using the model i n  p o s i t i o n s are placed incumbents  are  r e c i p r o c a l r o l e e x p e c t a t i o n s may conflict  with each other.  in  organizational  reguired  to i n t e r a c t ,  complement, supplement,  For example, given the p o s i t i o n s  " s t a f f nurse" and " n u r s i n g attendant," the r o l e for  or  expectations  s u p e r v i s o r / s u b o r d i n a t e would g e n e r a l l y be complementary.  Those f o r  medication-dispenser/bed-makar  each o t h e r . incumbents  would  supplement  Areas o f p o t e n t i a l c o n f l i c t c o u l d be c r e a t e d i f of  both  positions  were expected  to coordinate  other s t a f f or n u r t u r e the p a t i e n t . Given the above role  expectations  complexities, and  role  context i s a complex task. communication  behavior  undertaken at the l e v e l social  position.  can of  distinguishing  behavior  i n an o r g a n i z a t i o n a l  I n i t i a l analyses therefore the  between  be  of  reciprocal  more f r u i t f u l l y  "collectively  recognized"  14  2•  The  Communication P r o c e s s :  The  communication l i t e r a t u r e has been reviewed on  levels  of  analysis—the  underlying  conversations,  and  group.  d i s c u s s i o n s have focussed  Most  interpretation. paid  to  the  structure  s t u d i e s of the o r g a n i z a t i o n  processes—experience,  encoding,  three  and  of  of  the  on i n t r a - i n d i v i d u a l  decoding,  perception  and  In c o n t r a s t , very l i t t l e a t t e n t i o n has  been  i n t e r - i n d i v i d u a l dimension  of  information  transmission. I n d i v i d u a l communication theory, on  the  (e.g. not  findings  of  Lewin, Sogers), reviewed  develop  a  inclusion  developmental and was  i n depth.  reliable,  ambiguous  dimension  was  a  )  abnormal psychology  therefore  and  non-verbal  to be a p p r o p r i a t e .  P.  useful  was  interaction  was  L i t e r a t u r e d e a l i n g with  only  briefly  to  instrument,  examined  structure of.conversations.  not this  (Swenson,  Anthropologists  developed the ethnographic method f o r comparative cultures.  In  this  research  technique,  are m e t i c u l o u s l y  and  manner.  analyzed  in  an  objective  the  ethnography  have of  organized observed  S o c i o l o g i s t s have  r e f i n e d the technique f o r a p p l i c a t i o n t o s m a l l e r including  study  the  p r a c t i s e s o f everyday s o c i a l l i f e  Texts on  and  81-114).  The  units,  heavily  of t a n g e n t i a l relevance  considered  1973,  relies  Since the study's o b j e c t i v e was  consistent, of  which  analytical  i n t e r p e r s o n a l communication s e t t i n g . of  communication  edited  by  Sudnow  15  (1972)  and  Turner  conversations "openings",  (1974)  are  shed  considerable  structured.  "sequencing",  f o r " are accomplished  Such  l i g h t on how  issues  as  how  and " t a l k i n g t o " versus " t a l k i n g  are  particularly  relevant  as  they  p r o v i d e a framework i n t o which the communication process can be f i t t e d . ,  fc>) The  organization.  Much  o r g a n i z a t i o n a l communication a  strongly  prescriptive  of  (e.g.  bias.  c o n t r i b u t i o n s have been made.  the  literature  on  Thayer, 1961, 1968) has Few  original theoretical  Roberts e t a l . (1974b)  decry  the l a c k o f t h e o r e t i c a l models f o r i n t e g r a t i n g communication with  other  variables.  Their  d e f i n i t i o n of o r g a n i z a t i o n a l within-organizational, first  communication  Realization  of  another attempt t o bridge (1975),  and  many  Gibb's (1972a,  Interdependence t h i s gap.  other  part  Likert  of  is a  1972b)  theory  Trust  (TORI) i s  (1961),  organization  communication p r i n c i p l e s as a organizational  (interpersonal,  organizational-environmental)  step i n t h i s d i r e c t i o n .  Openness  m u l t i - l e v e l approach t o the  Miles  theorists  their  analyses  use of  c l i m a t e and b e h a v i o r , but have not developed  o r i g i n a l c o n c e p t u a l frameworks. H h i l e recent O'Reilly focused  and on  emphasized research  empirical  Roberts  perceived the  studies  (1974;  Roberts  communication,  incompleteness  programs t o d e s c r i b e  of &  communication  by  O ' R e i l l y , 1974a)  these  researchers  of such data.  The need f o r  organizational  communication  16  behavior  i s recognized,  limited  to  tabulating  but such r e s e a r c h has g e n e r a l l y been the  freguency of v e r b a l or  written  acts. One of  exception  behavioral  i s Rackham and  Honey's (1972)  e v a l u a t i o n of t r a i n i n g i n two  They c o n s i d e r e d  Bales'  approach  but  p r o v i d i n g the d e s i r e d type of data Significant  progress  e d u c a t i o n a l sphere. processes  were  has  Several f i e l d  reported  A s s o c i a t i o n ' s 1961  at  organizations.  rejected  it  as  not  made  in  the  for t r a i n i n g . also  been  s t u d i e s of  communication  American  Psychological  the  "Symposium on conceptual  a n a l y s i s of classroom  discussion  social interaction."  frameworks Two  for  of these are  of p a r t i c u l a r r e l e v a n c e . Lewis  and  Newell  (1962) observed classroom  behaviors  using f o u r t e e n c a t e g o r i e s which seemed t o be an e x t e n s i o n Bales'  dimensions.  They  focused  on  two  major  classifications  of  1962  d e s c r i b e d as a " p r e l i m i n a r y r e p o r t " , but  a r t i c l e was  communicator—sender and  of  receiver.  The no  l a t e r r e f e r e n c e s have been l o c a t e d . Flanders for  (1962, 1970)  analyzing  classroom.  developed an  teacher-pupil  While  his  ten  verbal  observation communication  interaction  categories  scheme in  a are  s p e c i f i c to the e d u c a t i o n a l s e t t i n g ^ h i s method f o r t r a i n i n g observers  has  been w e l l documented.  between s i n g u l a r and  have d e t r a c t e d  studied i n t e r a c t i o n  grouped s o c i a l p o s i t i o n s ("teacher" and  " p u p i l " r e s p e c t i v e l y ) , but to  He  t h i s combination does not  from the u t i l i t y  of the t o o l .  appear  T h i s i s an  17  important f i n d i n g s i n c e many other o r g a n i z a t i o n s types of p o s i t i o n s w i t h i n a s i n g l e Amidon  and  F l a n d e r s ' method number  of  Hough's  (1967)  brought  together  researchers  who  classroom i n t e r a c t i o n behavior. issues  considered  in  their  observer t r a i n i n g , r e l i a b i l i t y , training  programs)  are  have  both  position-set. collection the  have  Many o f the  to  of  a  quantify  methodological  (e.g. research d e s i g n ,  applications  relevant  papers on  experiences  attempted  text  of  to  for  inservice  other o r g a n i z a t i o n a l  contexts.  c  ) The group.  The  major  thrust  of  investigation  communication  behavior has occurred a t t h i s l e v e l .  and  (1966)  Altman's  excellent Chappie's  "synthesis  Small group._research and  critique  of  the  Interaction  Process  McGrath  provided field".  (1949) I n t e r a c t i o n Chronograph and B a l e s '  of  an Both  (1950a)  A n a l y s i s were developed f o r use i n the  s m a l l group l a b o r a t o r y .  3.  Communication,.Studies I n Health  Care : 1  Two t e x t s p a r t i c u l a r l y r e l a t e d t o t h e concerns research  were  The community g e n e r a l h o s p i t a l  of t h e by  Georgopoulos and Mann (1962) and The p s y c h i a t r i c h o s p i t a l as  Two computerized l i t e r a t u r e searches o f t h i s topic have been conducted by t h e r e s e a r c h e r , c o v e r i n g a l l a r t i c l e s c i t e d i n Index.Medicus from 1950 t o the present. 4  18  a s m a l l ..society by C a u d i l l (1958). Georgopoulos function which  of  and  ten  included  administered  Mann  general  analyzed hospitals.  perceived  to  the  the  structure  Their  communication  board  of  and  questionnaire, networks,  trustees,  medical  was staff,  a d m i n i s t r a t o r s , non-medical a d m i n i s t r a t i v e department heads, nurses, of  and  X-Ray and  non-supervisory  authors  1  laboratory nurses was  hospital.  explored He  observation  limits  its  on  collection.  the s o c i a l system of the p s y c h i a t r i c  obtained the  p a t i e n t behavior This  communication  data  the  care  has  organizations  of  as  Caudill*s  using  f i n d i n g s was  the e f f e c t of s t a t u s  the c o n f e r e n c e s .  method  considerable  administrative a modified  on  open r e c o r d i n g of  ethnographic  conferences  sense)  by  camouflaged  a  of  data  promise f o r main  or  an  data.  section in  through  followed  approach  a d j u n c t i v e source of second  his  ward,  using  research i n health  and  and  He a l s o analyzed  (1958)  study  examined  clinical  form of IPA.  the amount and  i n t e r a c t i o n processes lessen  data  The  for observational studies.  Caudill  broader  Interaction  a l s o examined i n depth.  e x c l u s i v e r e l i a n c e on p e r c e p t u a l  usefulness  A  technicians.  role  One  staff  of h i s major (used  in  the  type of p a r t i c i p a t i o n i n the  effects  of  certain  upon the t o t a l h o s p i t a l system. studied  information  exchanges between  observation  techniques  the hospital  were used on two  frequency staff.  of  verbal  Systematic  wards, together  with  19  formal  and  nurses,  informal  i n t e r v i e w s with s e v e n t y - f i v e d o c t o r s ,  dieticians,  non-professional  laboratory  ward p e r s o n n e l .  a b s o l u t e frequency  technicians,  He r e s t r i c t e d h i s data t o  of i n t e r a c t i o n s .  Stevens  (1967)  Wessen's method to a h e a l t h e d u c a t i o n complex. increase  in  lateral  and  applied  She found an  communication which she a t t r i b u t e d t o  the u n i t ' s unique o r g a n i z a t i o n a l s t r u c t u r e . Lum  (1970) assessed  personnel  in  She developed  interaction  patterns  of  nursing  a l a r g e p r i v a t e g e n e r a l h o s p i t a l i a Honolulu. a q u e s t i o n n a i r e which measured the  c o n t e n t , p e r c e i v e d importance,  frequency,  and s a t i s f a c t o r i n e s s of s e l f -  and o t h e r - i n i t i a t e d c o n t a c t s . Wilkinson  (1973)  examined  interaction  patterns  communication channels u s i n g a  sociometric  series  i n t e r v i e w format.  of  guestions  and  b e h a v i o r a l coding was dons. within a t o t a l Werner's  an  The f o c u s  on  of  a  No d i r e c t interaction  institution. (1974)  description  students i n t e r a c t i o n a l s k i l l s " , methodological  was  analysis  and  of  while  "Teaching  medical  interesting  from  s t a n d p o i n t , used content r a t h e r than  a  process  as the b a s i c phenomenon f o r i n v e s t i g a t i o n . Nursing r e s e a r c h e r s have developed  s e v e r a l systems f o r  coding the behavior of students or p r o f e s s i o n a l s i n t e r a c t i n g with  patients. Topf  to  assess  instrument  (1969) formulated a Communication S k i l l s the i n t e r a c t i o n s k i l l s  Checklist  of n u r s i n g s t u d e n t s .  assesses e f f e c t i v e and i n e f f e c t i v e  behaviors  The in  20  e i g h t c a t e g o r i e s , r e l y i n g h e a v i l y on r a t e r s * Johnson eighteen  (1964)  nursing  psychiatric  examined  students  setting.  patient.  The  process  categories.  and  Each  the  interaction  their  patients  student  had  reasons  selection.  Combining content and  instrument  is  considered  by  ten  were  between in  the  with  one  content  and  interacted  o b s e r v a t i o n instrument No  perceptions.  given  for  process dimensions  their in  one  the present r e s e a r c h e r t o be  m e t h o d o l o g i c a l l y unwise. Johnson a l s o observer  in  mentioned  the  room  that,  with  was  evidently  and/or minimized  other  School of Nursing n u r s i n g care t o nurse-patient  (Diers & Leonard, develop  a  nurse,  or  be  other  according  at  the  effect,  to  extensive  the Yale U n i v e r s i t y  1966)  category  i n t e r a c t i o n . , In  sub-categorized  This  the  programs f o r s u b j e c t s .  researchers  (NOSY) a c o n v e r s a t i o n may patient,  (p. 341)."  i n such r e s e a r c h s t u d i e s through  and  of  not a n t i c i p a t e d , should be c o n t r o l l e d  o r i e n t a t i o n and f a m i l i a r i z a t i o n Diers  pressure  the s t u d e n t - t h e r a p i s t and  p a t i e n t d i d a l t e r the i n t e r a c t i o n which  "The  used o b j e c t i v e s of  system  Nurse  studying  Orientation  oriented  towards  person.  Each  the  for  primary  an  System object,  direction  is  emphasis  on  f e e l i n g , t h i n k i n g , or doing. In  McBride's  (1967)  study  of  n u r s i n g approaches t o p a t i e n t s i n p a i n , assess  how  w e l l the independent  to p a t i e n t " was  the  e f f e c t s of t h r e e  NOSY  was  used  v a r i a b l e "nurse's  o p e r a t i o n a l i z e d i n the experiment  to  approach  (see  also  21  D i e r s , Schmidt, McBride, S Davis, 1972). Diers through major  and  Schmidt  transcribing source  had l i t t l e  of  assessed  tape-recorded  e r r o r was  the l o s s of data  conversations.  interactions for  Their  the t r a n s c r i b i n g s e c r e t a r y , who  f a m i l i a r i t y with the context from  were c o l l e c t e d .  need  (1968)  which the  data  T h i s i s not a problem i n s t u d i e s which code  in-process.  coders  to  Nevertheless,  understand  i t emphasizes the  certain  aspects  of  the  o r g a n i z a t i o n under i n v e s t i g a t i o n . . A program of i n t e r a c t i o n r e s e a r c h was (1969)  through  the  Education a t the Sithall's  U n i v e r s i t y of  method  for  d e v e l o p i n g eleven 1970,  p. 328;  Hess, 1973, recorded  Center f o r the  by Hess  Study of  Illinois.  studying  behavioral  initiated  Medical  He  modified  teacher-pupil interaction,  categories  (Heifer  &  Hess,  see a l s o N. C. S c o t t , Donnelly, G a l l a g h e r , &  p. 175  for a slight modification).  behavior  was  p u r p o s e f u l a c t i o n by  "an  the  The  uninterrupted,  student  (Hess,  unit  apparently  1969,  p.  935)."  T h i s i s l e s s p r e c i s e than B a l e s ' d e f i n i t i o n of an " a c t " , requires  additional  interpretation  by  the  observer.  Hess* i n i t i a l study, p a t i e n t i n t e r v i e w s by medical were who  videotaped. received  four  hours  of  designed  a l s o completed  by the r a t e r s ,  were found  was to  to  assessed. be  and In  students  They were l a t e r coded by three p h y s i c i a n s  guestionnaire  reliability  of  more  training  gather and  in  rating.  similar information inter-  and  A was  intra-rater  The i n t e r a c t i o n a n a l y s i s s c o r e s  reliable  than  the  questionnaire  22  results  in  determining  communication Heifer  Heifer  comparing  medical students, mother  of  coded  a  the  fhree  Hess,  actors  seriously  quasi-experimental  &  interviews  resultant  specific  versus  ineffective  behaviors.  (1970;  instrument,  effective  ill  1970) by  communication  with  Hess*  and freshmen  the  role  Five trained  videotapes.  design,  senior  played  child.  modified  Heifer's  use  of  the  observers of  a  actors trained to exhibit  behaviors,  holds  considerable  p o s s i b i l i t i e s f o r other r e s e a r c h e r s . H. C. S c o t t  et  e v a l u a t e a course medical  al.  in  students.  (1973)  used  Hess*  physician-patient relationships  Seventy-six  simulated  videotaped and then coded by two r a t e r s with of over .85.  approach t o  These were compared  for  i n t e r v i e w s were a  reliability  with r a t i n g s by t e n expert  judges of the e f f e c t i v e n e s s o f students* i n t e r v i e w b e h a v i o r . The f i n a l s t u d i e s which were noted by  Howland  and  h i s associates.  were those conducted  E a r l y a r t i c l e s by Howland  (1963a, 1963b, 1963c; Howland S McDowell, 1964)  o u t l i n e d the  development of a g e n e r a l H o s p i t a l Systems Model f o r s t u d y i n g health care behavior. possibilities triad" data  for  These t h e o r e t i c a l r e f e r e n c e s explored  examining  the  "nurse-patient-physician  (1963a, p. 229) and d i s c u s s e d the need f o r b e h a v i o r a l on  article  interaction by  theoretical  processes  Daubenmire aspects  of  and  King  (1964,  p. 295).  (1973)  the r e s e a r c h .  A recent  discussed  Howland  the  (1966)  gave  b r i e f d e t a i l s of the g a t h e r i n g o f t e c h n o l o g i c a l data by  two  23  observers  i n an o p e r a t i n g t h e a t r e , but no i n f o r m a t i o n about  the o b s e r v a t i o n o f i n t e r a c t i o n s . research gathered  They a r e now conducting  program t o t e s t t h e model using o b s e r v a t i o n a l by e x t e n s i v e  v i d e o t a p i n g i n p a t i e n t rooms.  r e p o r t s on t h i s r e s e a r c h should categorization  system  and  a data  Future  be f o l l o w e d to determine the  the  methodological  f i n d i n g s on  videotaping. In summary, f o u r r e s e a r c h e r s — T o p f ,  Johnson, D i e r s , and  H e s s — h a v e developed t h e i r own coding systems the  process  categories desired  of  were  nurse-patient  designed  nursing  behavior,  patterns across  a  positions.  such,  As  to  broad  interaction.  measure  r a t h e r than g e n e r a l spectrum  of  staff  each,  types  of  interaction and  patient  t h e above n u r s i n g c a t e g o r i e s a r e n o t behavior.  B a l e s y Interacti^gn^Process A n a l y s i s ; In 1950, Robert F. Bales  Harvard  Laboratory  development o f behavior  a  of  (IPA)  and  Social  method  h i s associates Relations  i n t h e s m a l l groups l a b o r a t o r y  communicative  behavior  who-to-whom  matrix  researcher  to  by  a  construct  i n d i v i d u a l s and groups.  which,  trained  the  communication  (Bales, 1950a) based  I n t e r a c t i o n Process  employed a s e t o f twelve mutually  a t the  reported  for investigating  on Parsons' P a t t e r n V a r i a b l e s .  of  studying In  specific  appropriate f o r a n a l y s i s of i n t e r - p o s i t i o n  4.  for  Analysis  exclusive categories when  placed  observer,  "interaction  enabled  profiles"  A l l face-to-face verbal  and  in a the for overt  24  non-verbal  i n t e r a c t i o n s were recorded.  Bales  (1950a) s t a t e d  that, "The present s e t of c a t e g o r i e s i s meant to be a g e n e r a l purpose framework f o r o b s e r v a t i o n which can be used to obtain a s e r i e s of standard i n d i c e s regarding the s t r u c t u r e and dynamics of i n t e r a c t i o n i n any small group....,The set of c a t e g o r i e s i s aeant to be completely i n c l u s i v e i n the sense t h a t every act which can be observed can be c l a s s i f i e d i n one p o s i t i v e l y d e f i n e d category (p. 33,35)." The twelve c a t e g o r i e s focus on communicates.  They  are  how  arranged  i n two  are combined i n t o  a  emotional  i s i n the middle, and  content  single,  n e g a t i v e a f f e c t a t the top and categories task  are  paired,  problems  peripheral  of  bottom,  working  problems  has  list.  and of  actor  Neutral  strong p o s i t i v e  and  respectively.  The  outwards from the  r e i n t e g r a t i o n as d e p i c t e d i n F i g u r e While t h i s instrument  social  h i e r a r c h i e s which  mirror-image  communication  emotional  the  evaluation  tension  central to  the  reduction  and  extensively  in  2.  been  used  s m a l l group r e s e a r c h f o r over t w e n t y - f i v e y e a r s , none of the studies support  covered f o r the  by  dimension,  of  areas  categorization, the  original  gives s t a t i s t i c a l Bales*  of  research  o b s e r v e r s " behind  he  the  paper  tape.  For  are  of the  of the  independence  of  category  validation. used  two  to  seven  a one-way s c r e e n , each having  e l e c t r o - m e c h a n i c a l I n t e r a c t i o n Recorder with a moving  theory  concern  interdependence  Each r e q u i r e s f u r t h e r c o n s t r u c t  In Bales* "trained  and  review  validity  Particular  i n c l u s i v e n e s s of the  pairs.  present  construct  communication.  each  the  an  continuously  each communication " a c t "  (simple  25 FIGURE_2 liLISi_SYSTEM_OF_CATEG^RIES USED IN_QBSSHVATIQN AND THEIfi MAJOB RELATIONS  Shows s o l i d a r i t y , r a i s e s o t h e r ' s C l v c s h e l p , riwi'.zvii  j,  Soclalfhotloaal Area i positive  status,  2 Sh',wr, t e n s i o n r»l»*=e. J o k e s , l a u g h s , shows  J Task Arcai Keutral  satisfactioni  Agrees, chows p a s s i v e acceptance, undr.rstar.ds, c o n c u r s , e a s p l l o s i  \  *  Clves s w r t s t ' o n , d i r e c t i o n , l=plyin3 autonomy l o r e t h e r  i  Clvcs or'-ilo^, evaluation, analysis, expresses f e e l i n g , w l s h i  6  C l v r n o r i e n t a t i o n , infornatlon, repeats "clarifies, conilrasi  ?  Asks f o r o r i e n t a t i o n , ' i n f o r c a t l o a r e p e t i t i o n , confirmationi  8  Asfcr, f o r o p i n i o n , e v a l u a t i o n , t r . a l y s l s , expression o f f e e l l n g i  \ 9  ' 10  Soel&ltfcotlonal Area i  *—»  1 a b e d e f  J  Asks f o r s t v - e n t l o n , d i r e c t i o n , p o s s l b l . . vj»ya o f a c t i o n t M s f . T f o j , shows pa.-.sivo r o j e c t l o n , formality, v l t h o l d s help  n  Chows t e n s i o n , asks; f o r h e l p , withdraw out of f i e l d i  12  Shows ant.T-onlsn, d e f l a t e s o t h e r ' s defends o r a s s e r t s s e l f i  status,  KETl 6 i C A •  ftrofcle*s froMer.s JroVloria froVlcns fttoltlcns  o f Corxnunlcatlon of Evaluation of Control of Decision o f Tension Hoducllon  f. A B C D  TroV *na o f R e i n t e g r a t i o n P o s l t i v o Konotlcns Attempted Answers Cuostlons Nc^atlva Reactions  (fxoa B i l o s , 1950-a, p. 9) \  subject-predicate combination the sender category. in  o r an o v e r t n o a - v e r b a l  action)  and r e c e i v e r s e r e r e c o r d e d under t h e a p p r o p r i a t e Because t h e category f r e q u e n c i e s d i f f e r e d  magnitude, those a t t h e extremes  widely  ( i . e . C a t e g o r i e s 1 . and  26  12)  were g i v e n p r i o r i t y over those i n the c e n t r e .  done to i n f l a t e the numbers i n the l e s s freguent to  a  statistically  This  was  categories  s i g n i f i c a n t l e v e l , a p r a c t i s e which i s  c o n s i d e r e d m e t h o d o l o g i c a l l y unsound. Although for  B a l e s o u t l i n e d an e x t e n s i v e  observers,  he  gave  insufficient  training coding  details for  o t h e r s seeking t o use the technigue.  Procedures  most other r e s e a r c h e r s have not been  reported.  exception  is  the  thorough  instructional  r e s e a r c h using typed  transcripts  Mishler  (1968).  and  Waxier  which  program  employed by A  notable  manual  f o r IPA  was  developed  by  Considerable modifications to  t h i s manual are r e g u i r e d f o r i n - p r o c e s s  scoring.  Training  i n IPA i s thus an area which r e g u i r e s f u r t h e r a t t e n t i o n . One  methodological  concern  which  has  thoroughly covered i n the l i t e r a t u r e i s t h a t of B a l e s devoted to was  proposed  for  reliability.  assessing  both  An exhaustive  intra-  and  those  of " u n i t i z i n g , " " c a t e g o r i z i n g , " and  (p.  101).  The f i r s t  communication a c t s , the second  and  receiver  p a r t i c u l a r concern communication.  process  reliability  "attributing"  r e f e r s to d i v i d i n g a conversation  i n a s p e c i f i c category, and the sender  (1950a)  inter-rater  He d i s c u s s e d three key problems o f  as  very  reliability.  an e n t i r e chapter of h i s o r i g i n a l t e x t  " A p p r a i s i n g observer r e l i a b i l i t y . "  separate  been  third  of the message.  during i n - p r o c e s s  into  to p l a c i n g each a c t to  identifying  The f i r s t two monitoring  of  the  are of dyadic  27  For  intra-rater r e l i a b i l i t y  reported  coefficients  categories  (Pearson's r ) .  with  following  the  reliability,  .65  to  .98  f o r the  under  9 (.83);  .85 : Category  10 (.70)..  d i f f e r e n c e was t h a t i n the Northwestern by  recording  one  category  and  groups  as  any  was  at  Harvard.  was determined f o r two t r a i n e d o b s e r v e r s on t h e thus  i n d i c a t i o n of a c t - b y - a c t congruence.  showed higher r e l i a b i l i t y  f o r the  using  of  the  The main  scoring  done  b a s i s o f g r o s s t o t a l s f o r each c a t e g o r y , and give  Harvard.  f o r each speaker's t o t a l  u t t e r a n c e , r a t h e r than one per " a c t " Reliability  For  H e i n i c k e and Bales (1953) compared  used a s l i g h t l y d i f f e r e n t s e t of c a t e g o r i e s .  done  .92,  Category 4(.81);  two s e t s of l a b o r a t o r y s t u d i e s a t Northwestern Each  twelve  The mean f o r the twelve was  values  Category 8 (.65); Category inter-rater  of  ( t e s t - r e t e s t ) , - B a l e s (1953)  larger  unit  Northwestern  analysis.  d i d not  The r e s u l t s observers,  Those f o r t h e Bales  technigue ranged from .90 (Category 2) t o .74 ( C a t e g o r i e s 9 and 7 ) , with a median o f .86. Bales  (1953)  a l s o examined t h e c o n s i s t e n c y o f s u b j e c t  behavior f o r two separate s e t s of s t u d i e s . far  The r e s u l t s  from encouraging, i n s p i t e o f the statement  are  that,  "...the g e n e r a l p i c t u r e of the c o r r e l a t i o n s i n d i c a t e s t h a t a p o s i t i v e r e l a t i o n s h i p e x i s t s between t h e behavior of the same s u b j e c t from one time t o another i n a l l the categories...(which) i s sufficiently good t o g i v e the r e s e a r c h e r some c o n f i d e n c e (p. 568)." T a b l e _ I d u p l i c a t e s h i s f i n d i n g s f o r one o f the s e t s .  28 TABLE_I STABILITI_0F_SJIBJICTS1_IN  Kimber of  pextlcljvintB (ti)  3  5  Buabrr of sesclona  2  2  .w  -.1*  5  4  4  -.62 .93  .67 .91  .53 .9* .70  .26 -.15 •?5  .13 .50 .73  * 5 C  .26 .8?  .79  .83  .80  .79  .90  .84 .91 -.01  -.13 .50 .76  7 e 9  .97 .92 ».03  .39 .27  .86  • .01  .01  .99 .33  .96 .97  .33 .19 .61  10 11 12  -.53 .0? .00  .68 .85 -.25  .69 .78 .96  .97  .99  .96  .85  .92 •  ToUl  • (from tales, 1953. r.  While a l l c a t e g o r i e s except stability  4  2  Category 1  one  5  .23 1.00  .09  .00  .56  able 2-)  1, 4 and 11  had  at  c o e f f i c i e n t above .90, there was no c o n s i s t e n t  p a t t e r n o f high and low c o e f f i c i e n t s a c r o s s a l l groups. differences  in  correlations •accounted  the  (one  p r o f i l e s of s t a b i l i t y  as  high  f o r or minimized  as  -.62)  factors  study  f o r the  The  and the n e g a t i v e  should  either  be  i f the u t i l i t y o f the instrument  i s t o be demonstrated. , No allowance stability  least  was made i a  the  Bales  e f f e c t s of task, time, and other  which may have l e d t o d i f f e r e n t  interaction  patterns  d u r i n g subsequent meetings of t h e same g r o u p . 1  Methods whereby t h e present study handled problem are d i s c u s s e d below, page 41. 1  this  stability  29  Psathas  (1961) compared B a l e s  1  technique of i n - p r o c e s s  s c o r i n g with the use of w r i t t e n and taped p r o t o c o l s .  In the  l a t t e r , the observer focused on non-verbal behavior, r e l y i n g on  the tape  compared  transcripts  the number  f o r verbal  that  total.  in-process  scoring  non-verbal)  missed  acts,  When he c o r r e c t e d the pooled s c o r e s f o r  acts  by  category  C a t e g o r i e s 10 through  corresponded 12.  12,  shows  higher on Category  differences distributions  very c l o s e l y except f o r  These t h r e e c a t e g o r i e s a r e a l l i n  the n e g a t i v e s o c i o - e m o t i o n a l area tension;  and  23% o f t h e pooled  i n number of a c t s , he found t h a t t h e freguency of  Psathas  o f i n - p r o c e s s a c t s per t i a e p e r i o d t o  the number of "pooled" ( v e r b a l plus found  content.  antagonism).  (10, d i s a g r e e s ; 11, In-process  10, while t h e pooled  shows  s c o r i n g was  method  was  higher  f o r . C a t e g o r i e s 11 and 12. Waxier  and  Mishler  review o f IPA r e l i a b i l i t y analysis  of  comparisons  marginal  i s an  (1966) r e p o r t e d t h e most c r i t i c a l problems t o date. differences  important  Their extensive  versus  one f o r t h i s r e s e a r c h .  10,910 a c t s were scored using both  approaches,  disagreed  of  on  the c a t e g o r i z a t i o n  these disagreements categories Thus, of  3 one  disagreement,  into  act-by-act  38.1%.  two  When raters  Over h a l f o f  were due t o i n c o r r e c t c a t e g o r i z a t i o n 5,  hundred  of  5 i n t o 6, 10 i n t o 5, and 10 i n t o 6. and  thirty-two  possible  f o u r c o n t r i b u t e d most of t h e e r r o r s .  types  of  30  In the  an  early  a r t i c l e . Bales  "Statistical  problems of  (1951) summarized some o f small  group  research",  i d e n t i f y i n g f o u r d i f f i c u l t i e s with s c o r i n g : (a) the u n i t o f a n a l y s i s i s not s u f f i c i e n t l y d e f i n e d t h a t a l l observers can come up with the same number of acts. (b) there i s no way o f o b t a i n i n g a " c o r r e c t " answer i n an a b s o l u t e sense, s i n c e a l l s c o r i n g i n v o l v e s human judgment. (c) events cannot be repeated  f o r recount.  (d) the speed with which the i n t e r a c t i o n moves p r e c l u d e s r e c o r d i n g each and every a c t (p. 314). All  of these concerns are extremely  two,  and four can be managed by thorough  with  documentation  act-by-act basis.  of  Number  relevant.  inter-rater three  can  Numbers one,  observer  training  reliability be  resolved  on  an  i n the  l a b o r a t o r y by using v i d e o t a p i n g , but presents major problems i n the o r g a n i z a t i o n a l s e t t i n g . Bales  proceded  to  outline  four  ways  of  analyzing  observations: ( ) Interaction profiles - based on t o t a l meeting, sub-periods and i n d i v i d u a l s . These can be t a b u l a t e d as raw s c o r e s or as percentages of t h e t o t a l i n t e r a c t i o n . a  (b) Sequencing of a c t s - each a c t i s recorded the f i r s t and second number of a p a i r . ui  (c) Phases parts.  -  e.g. d i v i d i n g  twice,  a meeting i n t o three  as  egual  (d) M a t r i c e s - the d i s t r i b u t i o n o f p a r t i c i p a t i o n between members, p l a c i n g the t o t a l number of a c t s in a who-to-whom matrix. Senders can a l s o be arranged i n rank order o f p a r t i c i p a t i o n freguency (p. 315). Most e a r l y r e s e a r c h e r s using IPA emphasized the two  approaches.  Recent work i n the f i e l d has r e l i e d  latter more on  31  the  analysis  of  profiles.  There  has  r e s e a r c h done on sequencing.. T h i s may arduous  nature  of  the  analysis,  examined t w i c e — o n c e as the f i r s t  been  be  very  because  little of t h e  where every a c t must be  a c t of a s e q u e n t i a l  pair,  and once as t h e second. Bales  postulated  interdependent.  that  sequential  By d e a l i n g with a process  acts  of  he reasoned t h a t t h e frequency o f a c t s f a l l i n g  interaction, i n t o any c e l l  would a f f e c t those i n adjacent and p a i r e d c e l l s . mean t h a t s t a n d a r d t e s t s of s t a t i s t i c a l Chi-square  c o u l d not be used.  were  T h i s would  significance  such as  No evidence was found i n t h e  l i t e r a t u r e t o support the assumption  of  interdependence  of  the c a t e g o r y p a i r s . Turning  from  issues  of r e l i a b i l i t y  and s t a t i s t i c s t o  those o f methodology, s t u d i e s were examined which  took  IPA  out o f the s m a l l groups l a b o r a t o r y and i n t o the f i e l d . O'Eourke  (1963)  observed the same three-person f a m i l y  groups at home and i n t h e l a b o r a t o r y . t h a t "The q u a l i t y of i n t e r a c t i o n i n expected  to  vary  as  the  H i s b a s i c premise was social  situational  groups contexts  i n t e r a c t i o n s and the s t r u c t u r e s o f the groups  can  be  o f the  (p. 422).'*  used a n o n - p a r t i c i p a n t observer present i n the room i n  He both  s e t t i n g s , but d i d not d i s c u s s the impact o f the observer (an issue  of  vital  shortened  form  employed.  No  finding  that  concern t o o r g a n i z a t i o n a l r e s e a r c h e r s ) . of  IPA  with  indications the  balance  only  three  of r e l i a b i l i t y between  A  categories  was  were g i v e n .  His  socio-eaotional  and  32  instrumental  interactions  was  f a m i l i a r i t y of the environment  contingent  was  upon  considered  the  particularly  relevant. The  major  f o c u s of the review of f i e l d s t u d i e s was  the use of IPA i n h e a l t h c a r e s e t t i n g s . the  earliest  researcher  Caudill  (1958)  on was  to r e p o r t such a study., H i s work  has been d i s c u s s e d above. Korsch and communication clinic,  Negrete  (1972)  observed  physician-parent  during diagnostic v i s i t s to a large  pediatric  and were a b l e to r e l a t e mutual d i s s a t i s f a c t i o n  the v i s i t t o c e r t a i n types of i n t e r a c t i o n p r o f i l e s Korsch, 1971;  S  M o r r i s , 1969;  Korsch, G o z z i , & F r a n c i s , M. S. Davis  interviews  by  physicians. training  (1968) fourth  Coders or  reliability of  Freemon, Megrete,  used year  profiles  IPA  to  code  were  not  and  interaction  the  matrix.  From  represented behavior. to  forming  this,  ten  (except  a  of that  construction  doctor-to-patient categories  p h y s i c i a n and p a t i e n t were c o r r e l a t e d with themselves,  patient  Bales* i n d i c e s , Davis d i d an  Profiles  twelve  given  In a d d i t i o n to the  of  with  154  students or a t t e n d i n g  extensive factor analysis the  Davis, & Korsch,  worked from tape r e c o r d i n g s ; d e t a i l s  averaged .85).  of  (Francis,  1968).  medical  reliability  interaction  with  twenty-four  factors  were  each by  data.  f o r both  other  and  twenty-four  extracted  which  d i f f e r e n t types of p a t i e n t - d o c t o r communication The study then r e l a t e d these i n t e r a c t i o n  compliance  by  factors  the p a t i e n t , f i n d i n g some p a t t e r n s which  33  helped t o e x p l a i n noncompliance. Conant  (1965) used IPA t o "examine the development  and  nature of the r o l e r e l a t i o n s h i p s of p u b l i c h e a l t h nurses and patients nurses  i n home made  twenty-four  a  visits  total  (p. 304)."  of  Twelve p u b l i c h e a l t h  forty-eight  antepartal patients.  home  was  appropriateness model.  of  Observed  chosen Bales  1  t r a i n e d i n IPA. The  because  of  the  task/emotional  behaviors  were  apparent  problem-solving  related  to  perceived  s a t i s f a c t i o n , as o b t a i n e d by separate i n t e r v i e w s with and  limitations  was  nurses  patients. Conant  from  to  The i n t e r a c t i o n s were tape  recorded and then s c o r e d by two persons instrument  visits  devoted of  considerable  IPA.  time  considering  examining  The e x c l u s i o n o f i n t e r a c t i o n  the coding scheme was d i s c u s s e d . a handicap  to  She  felt  t o be overcome.. D i e r s and Leonard  the dual  the  content  that  this  (1966), i n  o b j e c t i v e o f a s s e s s i n g communication  process versus c o n t e n t , s t a t e d , " I t i s p o s s i b l e t o combine both kinds of c a t e g o r i e s i n one system, but f o r the sake o f t h e mental h e a l t h o f the researcher, i t i s probably b e t t e r t o c o n f i n e any one system t o e i t h e r content or process. I f both k i n d s of categories are i n c l u d e d i n one system, the coder and r e s e a r c h e r are f a c e d with d e c i d i n g whether there i s an important d i f f e r e n c e between, f o r i n s t a n c e , a q u e s t i o n that i s 'supportive' and a statement that is ' unsupportive • (p. .226)." The  researcher  better  to  processes,  do  agrees an  rather  with  accurate than  Diers,  evaluation  attempt  combines process and c o n t e n t .  believing  to  use  of a  that i t i s interaction  scheme  which  34  Conant a l s o r a i s e d q u e s t i o n s o f i n t r a - and reliability.  She  found  that  Bales'  iater-rater  c a t e g o r i e s were not  always mutually e x c l u s i v e . "An act i s not n e c e s s a r i l y e i t h e r completely task or emotional i n nature., I t may c o n t a i n elements o f both and have s e v e r a l purposes and e f f e c t s (p. 308).*' T h i s f i n d i n g , together with her o b s e r v a t i o n t h a t 3  and  11  were r e l a t i v e l y u n d i f f e r e n t i a t e d between p a t i e n t  and nurse b e h a v i o r s , has construct  Categories  validity  considerable  of  the instrument.  importance  for  Hhereas Conant  the saw  these f i n d i n g s as l i m i t a t i o n s , an a l t e r n a t i v e approach would be to b u i l d on B a l e s ' where  appropriate  conceptual  in  the  framework,  light  of  modifying  it  additional empirical  evidence. Conant found t h a t the i n t e r v e n i n g v a r i a b l e of p a t i e n t s ' race  emerged  important  to  in  an  "ex  consider  post  such  facto  analysis."  It  i n t e r v e n i n g v a r i a b l e s , as they  have an important  c o n t r i b u t i o n t o make i n understanding  total interaction  process.  Conant's  final  is  critigue  of  IPA  was  the  r e l a t e d t o the  s c o r i n g of negative s o c i o - e m o t i o n a l c a t e g o r i e s .  She s t a t e d ,  "In the n u r s i n g v i s i t s t h a t were analyzed the showing of t e n s i o n (category 11) sometimes seemed to be r e l a t e d to the s i t u a t i o n or the t o p i c under d i s c u s s i o n r a t h e r than to the r e l a t i o n s h i p of the p a r t i c i p a n t s (p. 3 0 9 ) . " She  seems t o  referring  to  have the  ignored outer  Bales'  to  finding  r e g a r d i n g Category  the instrument's  that  acts  s i t u a t i o n be scored as a c t o r - t o - X  r a t h e r than t o the co-communicator This  requirement  (Bales,  1951a,  p.,185).  11 c o u l d a l s o be  important  construct v a l i d i t y . ,  35  Mishler  ana  relationship  Waxier  (1966,  1968)  questionnaire  They used f a m i l y d i s c u s s i o n s  feedback  and  the  method  d i f f e r e n c e s as t h e b a s i c source o f data. and t r a n s c r i b e d before being  types o f coding the  the  between p a t t e r n s of f a m i l y i n t e r a c t i o n and t h e  presence o f s c h i z o p h r e n i a .  recorded  studied  codes).  procedures These  Sessions  subjected  revealed were tape  to  eleven  (see 1966, p. 69 f o r a summary o f  varied  i n complexity  who-to-whom c a t e g o r i z a t i o n t o B a l e s r a i s e d many q u e s t i o n s  about the  nevertheless  extensive  made  of  of  1  IPA.  from  While the authors  reliability use  of  a simple  of  IPA,  these  data  they in  interpreting their findings. In summary, M. S. Davis, Korsch, and M i s h l e r and Waxier all  employed  IPA  extensively  in  physician-patient  i n t e r v i e w s , and made c o n s t r u c t i v e use o f i t as an e v a l u a t i v e tool.  Conant  was  more  critical,  focused  on o b t a i n i n g s p e c i f i c n u r s i n g care data  on understanding the t o t a l All  of  h e a l t h care profiles health  the  but  her  i n t e r e s t was rather  than  process.  studies  reviewed above which used IPA i n  organizations  found  that  stable  interaction  c o u l d be measured f o r r o l e o r p o s i t i o n groups i n a care  organization . 1  They  therefore  support  the  Whereas these s t u d i e s examined communication between one health p r o f e s s i o n and a s i n g l e type o f p a t i e n t , t h e present r e s e a r c h looked a t the i n t e r a c t i o n network o f a l a r g e r unit--the h o s p i t a l ward. Many s t a f f groups were i n c l u d e d . P a t i e n t s a l s o d i f f e r e d i n type and extent o f d i s a b i l i t y . . 1  36  premise has  that  each  s o c i a l p o s i t i o n w i t h i n the  organization  a c o n s i s t e n t s e t of i n t e r a c t i o n p r o f i l e s . Another focus o f the l i t e r a t u r e review was  which  used  other  as  a  studies  t o o l to f u r t h e r an understanding of  s o c i a l phenomena. F. G.  in  IPA  on  the  Scott  (1962) observed  laboratory.  She  s c o r i n g to determine how  three-generation  used  a  families  modification  of  Bales*  p a t t e r n s o f support between any  affected  by  group  size  and  two  f a m i l y members  were  family  position.  Her  use  the general  emphasis on the a n a l y s i s of i n d i v i d u a l b e h a v i o r .  of " f a m i l y p o s i t i o n " i s a departure from  I t p a r a l l e l s a focus on the o r g a n i z a t i o n a l p o s i t i o n . Hanheim  (1960)  investigated  intergroup  the  relationship  between  focusing  on  intergroup  d i f f e r e n t i a t i o n and  i n v o l v e d two create  IPA.  in  His  The  status two  amount  study  Manheim  employed  the number of negative  socio-emotional  labour-management  analysis  disputes"  p r e d i c t i v e v a l i d i t y of IPA  .  found He  Index of  analyzed Expressive taking  a c t s as a percent  of some  stated.  and  groups communicated  socio-emotional  (1955)  design  (high/low)  (EMB), which i s c a l c u l a t e d by  p o s i t i v e and negative Landsberger's  Bales'  of  manipulated t o  v i a w r i t t e n notes which were l a t e r  M a l i n t e g r a t i v e Behavior  all  perceived  (assigned/emergent).  with each other using  the  t r i a d s which were e x p e r i m e n t a l l y  differences  leadership  conflict.  interaction,  of  acts.„ the  "Mediation of  evidence  of  the  37  " . . . u l t i m a t e s u c c e s s of the s e s s i o n could be p a r t i a l l y p r e d i c t e d from the p a r t i e s ' s t a t e o f mind when they embarked upon t h e s e s s i o n ; the more h o s t i l e their expressed feelings, the l e s s likelihood of success (p. 558)." His  assumption o f e g u a l i t y of p a r t i e s i s g e n e r a l l y not  present i n the h e a l t h team.  According t o P e l l e g r i n o  (1970),  "...the p h y s i c i a n i s the most potent f o r c e i n d e c i s i o n making, not o n l y i n regard t o c a r e o f individual p a t i e n t s but i n regard t o the s e t t i n g o f p o l i c i e s , g o a l s and commitments of the h o s p i t a l (p. 303)." However, some teams appear to egalitarian meetings  or  therefore members  form  used be  to  1  Greater  teams  with  a  more  their  group  approach  perceived  those  predictive  towards  within  Landsberger s  compare  egalitarian  authoritarian.  working  decision-making  conferences.  be to  of  be  might by  perceived validity  their to  be  would  be  expected with the former group, s i n c e each member would  see  an o p p o r t u n i t y t o i n f l u e n c e the outcome of the c o n f e r e n c e . In Behavior each  Bales'  latest  book, P e r s o n a l i t y And  (1970), he expands the twelve c a t e g o r i e s ,  on  three  dimensions  of  He c o n c e p t u a l i z e s t h e s e  dimensions  which  affect  the  plotting  the values s t r u c t u r e of the  individual.  profile.  Interpersonal  three  as  personality  individual's  interaction  They were d e r i v e d from a study o f  sixty  subjects  who: "...met i n twelve groups of f i v e f o r a s e r i e s o f f i v e two-hour meetings, each time with a somewhat different task. There were two i n t e r v i e w i n g and i n f e r e n c e t a s k s , one somewhat f o r m a l i z e d self-analytic task, and two value-dilemma t a s k s based on c a s e s . The data f o r a l l f i v e meetings were pooled f o r each i n d i v i d u a l (p. 391)." E x t e n s i v e f a c t o r a n a l y s e s were performed on f i v e  types  38  of v a r i a b l e s : (a) p e r s o n a l i t y tests.  traits,  measured i n advance by  (b) o b s e r v a t i o n of o v e r t behavior, (c) content classification d u r i n g the groups.  of  using  value  written  IPA. statements  made  (d) r a t i n g s of the i n d i v i d u a l by other group members., (e) guesses by the i n d i v i d u a l of the r a t i n g s he r e c e i v e from o t h e r s (p. 391-392)., The t h r e e these the  data. tendency  dominant  (0)  personality  the  versus  part  of  the  submissive  individual  (D)  pure  leadership  original  hypothesized  others  The  to  were  (F) The  describes  the  feeling.  twelve IPA  c a t e g o r i e s given i n F i g u r e ^ 2 . categorization,  which  to  be d i r e c t i o n a l l y c o n s i s t e n t along  The  only major change i n v o l v e d  ( t e n s i o n r e l e a s e ) and  the  contributes  (B/U),  were r e v i s e d to c r e a t e a new  three dimensions. 2  factor.  (B) the accomplishment of the t a s k at hand.  e x p r e s s i o n of a f f e c t or  was  behavior.  (F/B), i s concerned with whether  t h i r d dimension, " p o s i t i v e / n e g a t i v e "  page 25,  towards  interaction  1  The  from  on  "forward/backward"  retards  derived  f i r s t , "upward/downward" (H/D), r e f e r s to  the i n d i v i d u a l s communication behavior or  were  The  T h i s i s c o n c e p t u a l i z e d as a second,  dimensions  would  Categories  11(shows t e n s i o n ) , although  clarified  developed d i r e c t i o n a l l a b e l s f o r  and  re-named.  each  category,  the  most  Bales based  of then on  f r e q u e n c i e s above or below the median range of i n t e r a c t i o n s , Horms  for  the medians were i n f e r r e d from p r e d i c t e d changes  between the o l d and  the new  schemata but have not  yet  been  39  empirically  verified.  Table_II  gives  the  suggested  interpretation f o r acts i n i t i a t e d .  TABLE_II BALES1_NEW_IPA--BST^ If l o v i  Catecory of Aelo Initialed  Mndiua Ranfio  R  «»»  If Hlf;hi  P  2.6-4,8  I.  Scoas Friendly  2.  Dramatizes  DP  3.  Agrees  NB  8.0-13.6  pj.  *.  Clves Kusccctlon  DB  3.0-7.0  OF  5. C  Clvcs Opinion  B  15.0-22.7  r  Gives Information  U  20.7-31.2  D  KJ  4.0-7.2  N  2.0-3.9  OP P  UB  .6-1.4  DP  P OF P  3.1-5.3  B  3.4-6.0  DB  7. Asks 8. Asks ' 9. Asks 10.  ».  UB .  '  f o r lnforuation f o r Opinion f o r Suceostion  Disagrees Shows Tension  12.  Seems Unfriendly  •  (froo Riles, 1970,  2.4-4.4  H-  p. 96)  ** . These norms are ostlnated by A long process of inference, described l n Appendix 4 , tete3 lower than the Medium Kango shown are c l a s s i f i e d I>ow| r a t e 3 higher than the Kcdlua Panes shown aro c l a s s i f i e d High,  For example, i f an i n d i v i d u a l * s frequency i n Category below  the median range i t r e f l e c t s a negative  (N) tendency.  Conversely, a high p r o p o r t i o n of a c t s i n Category a positive  1 is  1 reflects  (P) value o r i e n t a t i o n .  In d i s c u s s i n g h i s new f o r m u l a t i o n o f the t h e o r y .  Bales  (1970) s t a t e d , "It should be r e c o g n i z e d t h a t s i x t y s u b j e c t s i n twelve groups i s a very s m a l l number f o r such a mountain of data analysis and so many hypotheses., No c l a i m s are made f o r the r e l i a b i l i t y or r e p r e s e n t a t i v e n e s s o f the findings. These problems must be d e a l t with i n the future. The present study, f o r a l l i t s c o m p l i c a t i o n , i s only e x p l o r a t o r y (p. 391)."  40  In  s p i t e of the above c a v e a t s , plus the f a c t  directional which may Bales one  1  hypotheses  or may  new  are based  on p e r s o n a l i t y  that  the  dimensions  not be a p p l i c a b l e at the p o s i t i o n a l  level.  f o r m u l a t i o n i s c o n s i d e r e d p r e f e r a b l e t o the o l d  f o r data c o l l e c t i o n on the h o s p i t a l  ward . 1  5. ,. Summary: The f o l l o w i n g c o n c l u s i o n s emerge from the review of the l i t e r a t u r e on I n t e r a c t i o n Process A n a l y s i s (IPA): (a) No statistical validation t h e o r e t i c a l f o u n d a t i o n s o f IPA.  has  been found f o r the  (b) Acceptable levels of intraand inter-rater reliability can be achieved f o r s c o r i n g of category totals. (c) Act-by-act comparison, while g i v i n g indications of reliability, must be c o n v i n c i n g l y demonstrated i n any IPA study. (d) I t i s e s s e n t i a l t o e s t a b l i s h stability of s u b j e c t interaction behavior, or t o account f o r a major p o r t i o n of i t s v a r i a n c e through s i t u a t i o n a l moderators. (e) Although IPA has been taken out of t h e l a b o r a t o r y , no s t u d i e s were found which measured the impact o f t h i s methodological change. (f) IPA does have t e n t a t i v e i n d i c a t i o n s of predictive validity, h e l p i n g the r e s e a r c h e r t o understand other dimensions of o r g a n i z a t i o n a l b e h a v i o r .  Both period new one Support 1  c a t e g o r i z a t i o n s were assessed during the training of the present study, and the d e c i s i o n made t h a t the was more s u i t a b l e f o r t h i s o r g a n i z a t i o n a l context. f o r t h i s c o n c l u s i o n i s given i n Chapter . II. ?  41  The above  present  research  factors.  The  has been designed t o c o n s i d e r  construct  Process A n a l y s i s was examined. documented,  as  was  the  validity  of  Act-by-act  the  Interaction  reliability  was  t r a i n i n g process whereby t h i s was  achieved. Bales' s t a b i l i t y Firstly,  problem  a l l interactions  was  handled  i n two  ways.  f o r a p a r t i c u l a r p o s i t i o n dyad  were combined, d i s r e g a r d i n g the i n d i v i d u a l except when t h e r e was  only  one  individual  position  incumbent  variations  due  to  on  that  ward.  short-term  Thus,  intra-personal  f a c t o r s such as f a t i g u e , mood-swings, e t c . , were e l i m i n a t e d . By changing a systematic random could  be a c h i e v e d .  Secondly,  issue  contextual  variables.  through  relationship  interaction  the  the  laboratory  project  the  into  stability  confronted of  communication  a  the  intervening to  moderate  dyad and i t s  profile. the  method  out  into various organizational locations.  design,  artifact,  which  were considered  functional  utility  The  should  method  profile  These were hypothesized  between  experimenter  research  variance  measurement  Support was given f o r t a k i n g  of  error  one, i t was suggested t h a t g r e a t e r  stability  the  source o f  of be  in  were  critical  detail.  o f the  Questions t o the  Finally,  the  IPA was a v i t a l focus o f a t t e n t i o n . sufficiently  powerful  f o r broader  i n v e s t i g a t i o n s of o r g a n i z a t i o n a l behavior i f i t i s t o make a s i g n i f i c a n t c o n t r i b u t i o n t o the d i s c i p l i n e .  42  F.  DEVELOPMENT C^_HYPOTHESESi  The  researcher's  Hypothesis  original  intention  i n formulating  1 was t o t e s t two a s p e c t s o f Bales* communication  theory—the  overall  interdependence  category  of  the  independence,  category  pairs.  plus  H1,  as  the i t was  o r i g i n a l l y s t a t e d , d i d not r e f l e c t t h i s i n t e n t i o n : H1 The p a i r e d C a t e g o r i e s interdependent.  ( i . e . 1-12,  2-11,  etc.) are  I t was t h e r e f o r e reformulated as f o l l o w s : Hl-a The p a i r e d C a t e g o r i e s ( i . e . 1-12, 2-11, etc.) are s e q u e n t i a l l y interdependent. H1-.b The r e l a t i v e f r e q u e n c i e s of the twelve are independent., Hypothesis 2 was suggested (see  appendix A ) .  where  categories  by data from the p i l o t  Categories 2 (tension r e l e a s e ) , 6  (gives i n f o r m a t i o n ) , and 11 (shows tension) tended t o in  conjunction  with  others.  They  the  (Categories Conant's  others  to  2  11)  (1965)  and  clarify the  finding  (Category  total  that  supported  6)  interaction  Category  u n d i f f e r e n t i a t e d between p a t i e n t and  occur  were p o s t u l a t e d t o be  a d j u n c t i v e communicative b e h a v i o r s which worked .with  study  nurse  in  concert  and  modify  sequence.  11 was r e l a t i v e l y behaviors  also  t h i s hypothesis.  The formal statement  o f Hypothesis 2 was:  H2 Three o f t h e C a t e g o r i e s (2, 6, and 11) a r e more strongly correlated with t h e others than a r e the remaining n i n e . The  third  hypothesis  also  evolved  from the need t o  43  c o n t r i b u t e t o the c o n s t r u c t v a l i d a t i o n communication the  o f Bales*  theory  of  through an assessment o f the i n c l u s i v e n e s s o f  categorization:  H3 Bales* twelve i n t e r a c t i o n C a t e g o r i e s are i n c l u s i v e of a l l types of v e r b a l communication behavior. The  remaining f i v e hypotheses were designed t o t e s t the  r e s e a r c h model d e s c r i b e d i n d e t a i l i n Chaj3ter_.ilthey assessed s t a b i l i t y o f s u b j e c t behavior of  situational  moderators  organizational l o c i artifact  Together,  (H4), t h e impact  (H5, H6), the e f f e c t o f v a r i o u s  (H7), and the g u e s t i o n  of  experimenter  (H8).  H4 A major independent variable communication p r o f i l e on a h o s p i t a l dyad.  which i n f l u e n c e s the ward i s the p o s i t i o n  H5 Task f a c t o r s have a weaker, but e f f e c t on the i n t e r a c t i o n p r o f i l e s . H6 The c o n t e x t u a l f a c t o r s have a s i g n i f i c a n t e f f e c t , intervening variables.  still  significant,  o f day, week and time do not when c o n t r o l l e d f o r other  H7 The l o c a t i o n of i n t e r a c t i v e locus) has a s t r o n g l y s i g n i f i c a n t the p r o f i l e s of a l l dyads.  behavior mediating  ( i . e . ward, e f f e c t on  H8 The e f f e c t o f a s p e c i f i c observer does not produce v a r i a t i o n i n communication p r o f i l e s . Having developed the r e s e a r c h the  hypotheses,  study method w i l l now be d i s c u s s e d .  details  of  44  CHAPTER I I  A.  LOCATION: In  order  to  f i e l d study was the  South  test  the above hypotheses,  conducted  at Hascana H o s p i t a l , a d i v i s i o n of  Saskatchewan  Saskatchewan.  This  a four-month  Hospital  was  Centre, i n  Regina,  the s i t e of the p i l o t study.  r e s e a r c h e r had been employed by t h a t h o s p i t a l f o r f i v e as  a  p h y s i o t h e r a p i s t and  acceptance  by  the  hospital  (144/614) of the s t a f f who project  were s t i l l  including  researcher, staff.  and  had  during  percent  the  sixteen  of  the  Considerable  twenty  department  interest  heads  expressed by ward and treatment s t a f f  researcher  returned  to  the  pilot  when  the  1974.  wards s e l e c t e d f o r the study were "Second B e s t "  care)  rehabilitation). within  medical  work i n the h o s p i t a l physiotherapy  department i n the summer of  (extended  and  i n the outcome of the  p r o j e c t was  The two  pilot  at Hascana when the present study began,  a s s i s t a n t d i r e c t o r s of n u r s i n g , p l u s the head of the staff.  years gained  Twenty-three  were employed  The  and  "Station  Each  hospital,  ward with  Five"  was  a  commonly  (adult  physical  functional  subsystem  accepted  geographic  boundaries and a s i n g l e " n u r s i n g s t a t i o n " where p a t i e n t care activities  were  coordinated.  h o s p i t a l and the two  F i g u r e 3 g i v e s a map  study wards.  of the  FIGURE WASCANA  SCCOAIO  3  HOSPITAL  wfsT h:  KVVWWWWWWWI _W\\\\N 1  LOCUS  tnn*T  A O O M  fl*TM«OOMS  46  B.  SOBJECTS! The  study  population  was  operationally  defined  as  follows: 1. P a t i e n t :  a  person  wards d u r i n g the study.  who  r e s i d e s on one  of the above  P a t i e n t s v i s i t i n g from other  of  the  h o s p i t a l were excluded.  was  s i x t y - o n e on Second West, and  areas  Maximum p a t i e n t p o p u l a t i o n thirty-three  on  Station  Five. 2. S t a f f s  all  community  and  consultant  physicians  t r e a t i n g p a t i e n t s ; a l l persons employed by the h o s p i t a l provide  direct  or i n d i r e c t  (e.g. housekeeping) s e r v i c e s t o  p a t i e n t s ; i n d i v i d u a l s employed by participate  in  who  other  d i r e c t patient care.  organizations  who  Numbers i n each s t a f f  c l a s s i f i c a t i o n are given i n Appendix B. 3. Volunteer; another  agency,  direction  of  Approximately  a person not employed by the but  the  who  works  coordinator  twenty  volunteers  with of  hospital  patients volunteer  were  active  or  under the services. during  the  who  take  study. 4*  Family: immediate r e l a t i v e s of  responsibility  for  a  his/her well-being.  patient  T h i s number v a r i e d  a c c o r d i n g t o p a r t i c u l a r p a t i e n t s on the wards. Thus, a l l persons i n v o l v e d i n d i r e c t or of  patients  monitored.  care  on a p a r t i c u l a r ward were considered p o t e n t i a l  s u b j e c t s , whether or "team".  indirect  not  Contributions  they of  belonged  to  a  recognized  p a t i e n t s and f a m i l i e s were a l s o  47  C.  RESJAJCH_MODELi. The  and  r e l a t i o n s h i p between  intervening  the independent,  variables i s depicted  dependent,  i n Figure-4.  FIGURE,4 RESEARCH MODEL INDEPENDENT  INTERVENING  DEPENDENT  POSITION  Environmental  Methodological  TaBk  INTERACTION  DYAD  Context  Artifact  Factors  PROFILE  For  purposes o f c a t e g o r i z i n g t h e independent v a r i a b l e ,  the f o l l o w i n g d e f i n i t i o n s were accepted: 1. Position:,  "a  collectively  recognized  category  of  persons f o r whom t h e b a s i s f o r such d i f f e r e n t i a t i o n i s t h e i r common  attribute,  their  common  r e a c t i o n s o f others toward  behavior,  them  (Biddle  &  or  t h e common  Thomas,  1966,  p. 29) ." 2- £atient_Positionj. based  on  regarding  t h e common length  communication  of  a  sub-categorization  reactions  of  staff  of p a t i e n t s ,  towards  h o s p i t a l s t a y , p h y s i c a l m o b i l i t y , and  disability.  3. S j t a f f _ P o s i t i o n j . a c o l l e c t i v e l y recognized staff (e.g.  whose  them  common  attribute  is a  specific  category o f job  title  "housekeeping a i d e " , " d i r e c t o r o f housekeeping").  4. S t a f f .Department;,  a  small  different positions i n a single  group  hospital  of  persons  from  department (e.g.  Maintenance) who p e r c e i v e t h a t on t h e wards they a l l perform  48  similar  communication  patients. one  functions  For example, the one  with  staff  electrician,  and  one  with  plumber,  c a r p e n t e r , e t c . , were a l l c l a s s i f i e d as "maintenance". 5- _?Y.<_di a p a i r of communicators, i d e n t i f i e d by p o s i t i o n  (e.g.  "social worker-physiatrist"). The  dependent  v a r i a b l e , communication, was  t o f a c e - t o - f a c e v e r b a l and o v e r t non-verbal information  of  the  Categories.  freguency For  Intervening  each  dyad,  variables  l a b e l e d "environmental  "time"  of  observation  variable.  The  two  One  into  were  doctor-nurse.  context".  profile.  "Week",  The  first  "day",  "Locus" of  The  and  t o have d i f f e r i n g interaction  another c o n t e x t u a l had  a strong  of those, the " n u r s i n g s t a t i o n " ,  "patient  was  percentaged  were o f t h r e e types.  research.  of  communication  l o c i used i n the p i l o t study  i n c l u d e d i n the present subdivided  a  It  profiles  i t occurred on the ward) was  moderating e f f e c t .  was  and  two  were hypothesized  e f f e c t s on the i n t e r a c t i o n ( i . e . where  Profile,  of B a l e s ' twelve new  g e n e r a t e d — e . g . nurse-doctor  was  transmission  from one person t o another on the ward.  o p e r a t i o n a l i z e d as the I n t e r a c t i o n graph  restricted  was  o t h e r , a "ward walk",  rooms",  "corridors",  and  " c h a r t i n g room". The  intervening  variable  "ward"  s i g n i f i c a n t e f f e c t i n the p i l o t study. was  c a r r i e d out on two  distinction  The  types of ward, making  had  a  present Nagi's  strongly research (1965)  between "impairment" and " d i s a b i l i t y " r e l e v a n t .  49  P a t i e n t s on Second Best a l l had a long-standing or " p a t t e r n long-term  of  behavior  or continued  functional limitations patients  exhibited  a  that  evolves  in  "disability"  situations  of  impairments t h a t are a s s o c i a t e d (p. 103)." range  with  In c o n t r a s t . S t a t i o n f i v e  of  behaviors  from  early  "impairment" through r e c o g n i t i o n of " f u n c t i o n a l l i m i t a t i o n s " to long-standing A  second  produced  by  guantified was  "disability". group  of  intervening  methodological by  the  variables  artifact.  study was  The  that  only  one  the p a r t i c u l a r " o b s e r v e r "  who  recording. The t h i r d type of i n t e r v e n i n g v a r i a b l e , "task  referred  to  the  communication. have  an  task  The  impact  being  accomplished  l i t e r a t u r e suggests  upon  dimension i s  not  categorization The  basis  which  classification basic  was  behavior  characteristic  Therefore,  to  have  Dubin*s systems,  of  every  rules),  which the job gets done),  for  task study. this  (1958)  c l a s s i f i c a t i o n of four  which  he  non-formal  interpersonal relationships).  used  postulated  job—i.e.,  and  general  d u r i n g the  been  ( j o b - s p e c i f i c task a c t i v i t i e s ) , formal organizational  the  scheme f o r t h i s a  to have been developed was  during  the i n t e r a c t i o n p r o f i l e i n the s m a l l  available.  was  factors",  t h a t task parameters  group s e t t i n g , but a s u i t a b l e c l a s s i f i c a t i o n  by  was  informal  technological  (behaviors (the  were  governed  a c t u a l way  (direct  in  voluntary  50  The  above  model,  while u s i n g the t e r n s  and "dependent" v a r i a b l e s , d i d not t e s t the causality  implicit  in  r e l a t i o n s h i p seemed to plausible  to  this be  postulate  a  "independent"  assumptions  of  usage.  The d i r e c t i o n of the  logical  one—it  that  is  not  as  i n t e r a c t i o n p r o f i l e s cause a  p a r t i c u l a r dyad t o i n t e r a c t , p a r t i c u l a r l y  in  the  hospital  s e t t i n g where much o f the i n t e r a c t i o n i s n e c e s s i t a t e d by the task  of  present  patient  care—-but t h i s c o u l d not be t e s t e d i n the  study.  The  researcher  hospital  recognizes  that  communication  objective  of  this  g e n e r a l i z e the contextual  study  was  results.  moderators  the  t o v a l i d a t e a method, not t o  Therefore, was  However,  examined.  only  one  subset  of  The d e c i s i o n t o l i m i t  the scope of the r e s e a r c h model i s e s s e n t i a l i n the  be  a  ward does not occur i n i s o l a t i o n - - i t i s i n f l u e n c e d  by a host of e x t r i n s i c and i n t r i n s i c f a c t o r s .  stages  on  initial  of any r e s e a r c h p r o g r a m — t h e dependent v a r i a b l e must  capable  interaction -assessed.  of with  being other  accurately dimensions  measured can be  before  its  comprehensively  51  D.  STUDY_DESIGN:  1.  Research  Assistance:  Because documentation of t h e t r a i n i n g r e q u i r e d the  technique  was  a  major  objective  of  study,  was  study,  o l d male was s e l e c t e d who had  twenty-two  r e c e n t l y graduated  year  i n Psychology,  field  He had a sound background  i n r e s e a r c h , i n c l u d i n g ethnography, hospitals  f o r the  a  f u l l - t i m e research a s s i s t a n t A  employed  the  t o use  but  no  (as p a t i e n t , s t a f f or v i s i t o r ) .  experience  in  T h i s c h o i c e of a  person with no p r e v i o u s knowledge o f the h e a l t h care - system was  deliberately  extensive  made i n order t o balance the r e s e a r c h e r s 1  involvement  and  reduce  any  bias  which  might  thereby be i n t r o d u c e d .  2-  Development A  of_Methodj.  scenario  of  the f i e l d  study, i n c l u d i n g p r e p a r a t o r y  meetings and f o l l o w - u p s e s s i o n s with t h e h o s p i t a l , i s in  given  F i g u r e 5. Because  developed separately used  many  of  the  methodological  d u r i n g t h e f i e l d study, in  this  f o r the f i n a l  section  each  issue  details is  were  examined  b e f o r e summarizing t h e method  data-collection.  52 FIGURE 5 TIMING OF FIELD STUDY l_ll__.2_L7.i_ ~ p o s s i b i l i t i e s e x p l o r e d f o r conducting the f i e l d study a t Hascana H o s p i t a l 0__.o_J§£_.___l_2_ - p r e s e n t a t i o n made committee o f the SSHC November  12  to  management  1974 - h o s p i t a l commitment obtained  f  January._20-22_._1.975 - p r e l i m i n a r y hospital administration _______7  the  meetings  h e l d with  - ward s t a f f o r i e n t e d t o study  May 20-30 - t r a i n i n g of r e s e a r c h a s s i s t a n t begun; staff o r i e n t a t i o n completed; study e x p l a i n e d to a l l p a t i e n t s June 2-30 - coding system developed for staff patients; part-time ward o b s e r v a t i o n commenced; s t a f f and p a t i e n t s o r i e n t e d as necessary  and new  J u l y 2-15 - f u l l - t i m e ward o b s e r v a t i o n undertaken; periods f i n a l i z e d  time  July  15-16 - frequency study completed  J u l y 21 - August 3 evaluated  Bales'  old  A u g u s t 5 - 7 - "shakedown" of f i n a l August 9-22 - f i n a l data  to f i n a l i z e  vs. new method  loci  formulations  completed  collected  Aug„25- .September 4 - wind-down o f study December 9-19 undertaken  -  first  Fe___a_y_1.0__1.__l 9 76 completed a  )  -  stage  of  second  feedback stage  P r e l i m i n a r y c o n t a c t with h o s p i t a l .  conducting t h e f i e l d  study at Wascana  to hospital of  feedback  Possibilities for  Hospital  were  first  d i s c u s s e d with the a s s i s t a n t e x e c u t i v e d i r e c t o r o f t h e South Saskatchewan  Hospital  Centre  (SSHC) i n the Summer of 1974.  A "Summary and i m p l i c a t i o n s " o f the study  (see  Appendix C)  53  was  prepared  for  submission to the October meeting of  the  SSHC management committee. a f t e r permission participation, the head  of  the the  was  received  researcher medical  met  staff,  a s s i s t a n t d i r e c t o r s of n u r s i n g , service The  department  research  which  the  heads  instrument was hospital  Five  custodial the  in  care  meetings  with the the  and  Hospital's  administrator,  director  and  four  a l l sixteen c l i n i c a l  and  f o r t h r e e days i n January,  1975.  explained,  data  and  the type of  discussed.  wards, they s e l e c t e d Second West and  order and  Hascana  could expect t o r e c e i v e was  Given the choice of two Station  for  to  see  the  contrast  an a c t i v e treatment ward.  was  distributed  to  Appendix D).  The  process  commitment was  s i m i l a r t o H. Levinson's  used  all to  between  a  A summary of  participants  (see  obtain organizational (1972)  approach  to  o b t a i n i n g consent f o r d i a g n o s t i c i n t e r v e n t i o n (p. ,14). P a r t i c u l a r a t t e n t i o n was surrounding Ring,  the i s s u e of "informed consent"  1967).  particularly  Freedom for  only incumbent on  would  initial be  distribution  of  in  exclusion  considerations (Argyris,  or  made e x p l i c i t .  ( i . e . the Persons i n  chose to p a r t i c i p a t e were to on  their  receive  interaction profiles., It  prerogative  to  that  a l l p a t i e n t s were t o be  data,  1968;  withdrawal,  singular positions  t h a t ward), was  feedback  their  of  persons  s i n g u l a r p o s i t i o n s who the  paid to e t h i c a l  decide  the  the o p t i o n of e x c l u s i o n from the d a t a - c o l l e c t i o n .  extent  of given  54  b) S t a f f o r i e n t a t i o n . study  a  one-half  hour  with  a  on the two  summary  given to a l l s t a f f  wards., Each person  F i g u r e ^ , page 25).  were  conducted  individually  Housekeeping,  regular  Physiotherapy).  been informed,  A  communications received permission  policy would  full  Bales  in  1  small  of  the  that  project  Over to this  project  during  s t a f f or by  monitored  the  elected  indicating  of  When a l l persons on  established  be  inclusion.  t h r e e s t a f f members reasons,  was  not  details  for  or  newcomers were b r i e f e d  h o s p i t a l o r i e n t a t i o n f o r new  appointments.  of  l a r g e r meetings were held when department  heads wanted t o g i v e a l l s t a f f an overview  s t a f f had  copy  was  plus  Host  (e.g.  field  a  Afipendix E.  Several  the  plus  (see  groups.  of  sheet,  categorization sessions  beginning  o r i e n t a t i o n was  with p o s s i b l e involvement provided  At the  individual  that  people's  until and  they had  was  excluded  for  had given  the course of the be  the  study, various  a viable a l t e r n a t i v e .  S t a f f i n c o n v e r s a t i o n with a p a t i e n t were reguested  to  ask  the r e s e a r c h e r t o l e a v e i f they c o n s i d e r e d i t a d v i s a b l e . ,  c  )  Patient orientation.  t a i l o r e d to t h e i r l e v e l with given  normal to  brain  explanation. were  understanding.  to p a t i e n t s were Some  patients  communication a b i l i t y r e c e i v e d a l l i a f o r m a t i o n  staff,  (e.g. with  of  Explanations  oriented  including damage)  the were  two  handouts.. given  a  Others  simplified  A number of p a t i e n t s on the c h r o n i c c a r e  ward  through a s t a f f member i n t e r p r e t i n g i n t h e i r  55  first  language  normal  (e.g.  receptive  often  reguired  German,  ability several  Ukrainian).  Patients  with  but severe e x p r e s s i v e impairment discussions  before  having  the  o p p o r t u n i t y t o have a l l t h e i r q u e s t i o n s answered. Only  one  a f t e r two being  patient  requested  weeks of being  "left  out."  to  omitted,  Uhen  told  questioned that  request,  he  s a i d e x a s p e r a t e d l y , "Oh,  demanded  to  be  patient  with  observed  paranoid  suggestion of the New  from  be excluded,  this  was  was  did  not  receive  completed.  Host  e x p l a n a t i o n of the study by one this  was  not  possible,  information to t h e i r  d) T r a i n i n g . during  the  he  was  at h i s  One  excluded  own and  other  at  the  the o r i e n t a t i o n  until  staff.  patients  this  he,  th,en!",  p o i n t on.  t h e i r second day on the ward, and were after  was  t h a t was  that  tendencies  why  and  of  patients  not  families the  observers.  (1950a),  to r e l a y  The f i r s t  placed  the  the  reading with  on  training  s t e p i n the r e t r a i n i n g of the  r e s e a r c h e r and the i n i t i a l f a m i l i a r i z a t i o n of  Analysis  Hhere  families.  study.  was  until  were given an  were asked  A major emphasis was  assistant  observed  of  Bales  emphasis  1  the  research  I n t e r a c t i o n Process on  the  Appendix,  " D e f i n i t i o n s of the c a t e g o r i e s (p.,177-195)," Tapes  of  radio  i n t e r v i e w s and " o p e n - l i n e " shows were  then used, t o g e t h e r with e x t e n s i v e d i s c u s s i o n , t o consensus  on  how  a  establish  p a r t i c u l a r a c t should be coded.  This  56  method of t r a i n i n g was h e l p f u l  f o r improving  a b i l i t y , but not f o r u n i t i z i n g i n t o separate  categorizing  ( i . e . dividing conversations  acts).  M i s h l e r and Waxier*s (1968) " I n t e r a c t i o n Code Book" was useful  as  a  s t a r t i n g point f o r the l a t t e r .  The o b s e r v e r s  then moved to an i n t e n s i v e one-week study o f E n g l i s h grammar handbooks i n order t o be a b l e versus  complex  to  guickly  identify  simple  sentences, c l a u s e s versus phrases, e t c .  the end o f t h i s p e r i o d , d e c i s i o n s about u n i t i z i n g were to  facilitate  At made  i n - p r o c e s s s c o r i n g (as opposed t o Waxier and  H i s h l e r ' s f o c u s on t a p e - t r a n s c i p t s ) . The o b s e r v a t i o n a l method focused Only  those  non-verbal  interactions  on  verbal  which  were o v e r t and  e a s i l y c l a s s i f i a b l e i n t o a p a r t i c u l a r category anger) aspects  were on  recorded.  The  the r e c e p t i o n  impact  of  the  of  (e.g. s m i l e ,  other  verbal  behavior.  non-verbal message  is  recognized—e.g.  support, m o d i f i c a t i o n , or n e g a t i o n o f t h e  manifest c o n t e n t .  However, c o n s i d e r a b l e  interpretation  is  g e n e r a l l y r e g u i r e d t o a s s i g n such behavior t o one of t h e IPA categories.  This  of  expectancy  observer  i s time-consuming and a p o t e n t i a l bias.  Therefore  only  source simple  non-verbal a c t s were c a t e g o r i z e d . During  the t r a i n i n g  p e r i o d , a c a r e f u l comparison was  made between B a l e s ' o l d and new one  was used f o r t h e f i r s t  the new one f o r t h e second  categorizations.  The o l d  h a l f of the t r a i n i n g p e r i o d , and half.  57  The f o r two  f i n a l s e l e c t i o n was reasons.  directional  The  f i r s t was  indicators  example, when there was Category  4  (gives  The  4,  modified  on  or  the  forward  an  one  found  the  act  For  belonged  in  5 (gives o p i n i o n ) , the  basis  of  ascendance  (0),  t a s k movement ( F ) , Category  f o r s e l e c t i n g the new  Category 2 (dramatizing)  v e r s i o n was  appeared  meaningful type of i n t e r a c t i o n behavior than was  new  helpful i n categorizing.  suggestion)  versus  second reason  very  the  t h a t the observers  doubt whether  d e c i s i o n c o u l d be made Category  made i n f a v o r of  to  5.  t h a t the  be  a  more  on the h o s p i t a l ward  the o l d Category 2 ( t e n s i o n r e l e a s e ) .  Because Category 2 i n c l u d e d a s i g n i f i c a n t p r o p o r t i o n of dramatizing  about  "out-group" a c t i v i t i e s  ( i . e . not r e l a t e d  t o the ward), these a c t s were coded s e p a r a t e l y "M".  This  approach  method  because  co-communicator.  was  chosen  over  it  preserved  the  It  was  as  Bales*  Category  "sender^-to-X"  identity  of  also a useful d i s t i n c t i o n  the during  the feedback t o the h o s p i t a l s t a f f . A f t e r the new sections  on  categorization  "Definitions  of  (p. 99-135) and Appendix 4, categories"  (p. 471-491)  i n t e r p e r s o n a l behavior observer collated. was  The  the  been  of  Bales*  of  the  the  interaction  (1970) _fersona_iJ:y_and  studied  points.  selected,  interaction categories"  "Revision  were  made notes on key  had  exhaustively.  These were d i s c u s s e d  Each and  r e s u l t i n g twelve-page summary i n p o i n t form  r e - r e a d every evening  d u r i n g the f i n a l  data c o l l e c t i o n t o ensure r e g u l a r i t y of  three  coding.  weeks  of  58  e  )  Reliability*  dimension was These  s  were  The  major  the use of the selected  resembled  monitored  the wards.  on  the  the  Taping  on  types  of  tapes.  two-party  interchange  being  The h o s p i t a l r e f u s e d to allow  had been used b r i e f l y  assurances  had a  of  this  making  any  reliability  data i d e n t i c a l to the study m a t e r i a l i m p o s s i b l e .  intra-rater r e l i a b i l i t y . and  radio  variety  t a p i n g of c o n v e r s a t i o n s on the premises, checks  f o r assessing  above-mentioned  because  conversations  avenue  very  i n the p i l o t study  Although  extensive  to e s t a b l i s h explanations  had been provided t o s t a f f , t h i s t a p i n g  upsetting  effect  on  communication  had  patterns,  r e d u c i n g t r u s t i n the r e s e a r c h team f o r s e v e r a l weeks. Using  the  radio-taped  e i g h t y " a c t s " was without  coded  interruption.  conversations,  simultaneously This  number  m a j o r i t y of c o n v e r s a t i o n s on the sixty was  acts*  duration.  ward  was  of  observers  chosen because a  were  of  less  than  T h e r e f o r e , the e i g h t y - a c t c r i t e r i o n  a c t - b y - a c t and consensus reached It  aaximum  both  was  considered s u f f i c i e n t l y rigorous.  category.  by  a  repeated  The  tape  was  on the " c o r r e c t "  a  third  time, with  replayed unit  and  freguent  i n t e r r u p t i o n s , i n order t h a t the observers c o u l d check t h e i r o r i g i n a l coding and  determine the number of " c o r r e c t "  and the number of e r r o r s i n c a t e g o r i z i n g and "missed" was  then  correct  a c t s and  " e x t r a " ones).  made f o r each observer acts  E r r o r s were  as also  a  percent  subdivided  acts,  unitizing  (both  A rough r e l i a b i l i t y  check  by expressing the number of into  of  the t o t a l number of a c t s . those  of  categorizing  59  versus  unitizing.  This  procedure  provided the o b s e r v e r s  with feedback on t h e i r types o f mistakes, the  the  final  three  guided  weeks o f data c o l l e c t i o n , a t  l e a s t two e i g h t y - a c t r e l i a b i l i t y  checks were made a t the end  each day's o b s e r v a t i o n s to monitor the o b s e r v e r s ' minimum  reliability.  One  week  after  collection,  six  conversations  and end  the  three  of  intra-rater  f)  first  weeks  the  conclusion  of  data  from the b e g i n n i n g , middle, were  recoded  to  establish  reliability.  S t a f f p o s i t i o n coding.  developed f o r a l l s t a f f digit  A  three-digit  positions  and  was g e n e r a l l y e i t h e r a " I "  on whether the p o s i t i o n was s i n g u l a r per  thus  learning process. During  of  and  ward) o r grouped  ("0") .  code  departments.  was The  or a "0", depending  (i.e.  °1"  incumbent  The l a s t two d i g i t s were then  a l l o c a t e d a c c o r d i n g t o p o s i t i o n o r department. Three grouped codes were a l s o used, each b e g i n n i n g with a "2"; 260 = group o f s t a f f 261 = group of p a t i e n t s 262 = group o f s t a f f and p a t i e n t s In  a d d i t i o n , when a s t a f f group c o n s i s t e d  position, position  the  last  two  digits  used  entirely were  of  one  those o f t h a t  (e.g. a group of s t a f f nurses was coded "200").  Hherever p o s s i b l e , the  nursing  directors,  department  heads, and o t h e r s i n g u l a r p o s i t i o n s were coded with t h e l a s t  60  two  digits  of  o t h e r department  a i d e s were coded " 0 1 0 ; the  director  M  "110"}.  members (e.g. housekeeping of  housekeeping  Appendix B g i v e s the complete s t a f f  g) P a t i e n t p o s i t i o n c o d i n g . , considered to received  influence  the  was  code.  Three  factors  communications  sent  were to  and  by p a t i e n t s — l e n g t h o f stay on t h a t ward, p h y s i c a l  m o b i l i t y , and communication  impairment.  Thus  each  patient  was  assigned a t h r e e - d i g i t code, one number f o r each f a c t o r  (see  Ap.pendix_B) . The a c t u a l c o d i n g procedure v a r i e d with the  £i=Sath_of_Stay.  was c a l c u l a t e d f o r each p a t i e n t on the f i r s t  day o f every week. coded  by  physical  the  M o b i l i t y f o r p a t i e n t s on Second  researchers  according  to  m o b i l i t y over the p r e v i o u s week.  their  both  wards remained i n the same m o b i l i t y  u n l e s s t h e i r l e v e l changed example, but who to  for  more  a p a t i e n t of code "4"  cannot t r a n s f e r from bed  West was observed  On S t a t i o n F i v e ,  t h i s was done i n c o n s u l t a t i o n with nursing s t a f f . on  dimension.  than  Patients  classification one  day..  For  (moves f r e e l y about the ward  to  wheelchair  independently)  developed pneumonia and was c o n f i n e d t o bed was recoded a " 0 " ; a bedridden p a t i e n t of code «Q*» who l e f t her  room  once per week t o make a telephone c a l l was not recoded. Initially assistant  the  directors  communication  research of  impairment  team  nursing .  d i s c u s s e d with ward s t a f f , who  This  worked  to  code  with each  classification  disagreed with  a  the  two  patient s 1  was then number  of  61  the  patients'  codes.  Because t h e c r i t i c a l  staff-patient  c o m m u n i c a t i o n was  £__£___!__  patient a b i l i t y ,  °f  classification working with department and  on  this  them. because  availability  c o n s i d e r e d t o be i t was  dimension  Nursing  determinant  was  decided should as  staff's  that  patient  be done by  staff  the  classifying  o f c o n s i s t e n t c o n t a c t with  a l l patients  f o r coding.  chosen  the  of  Hethods d i f f e r e d  on  the  two  wards:  __£2__«_il__  Once  :  per  the f i n a l  data c o l l e c t i o n ,  attendant  working  each  patient  This  assessment,  but  the  end  of  tabulated, for  was  the the  patient  to  of  six  to  be  a l l  many p a t i e n t s on  and  expressive  an  individual  "code™  code  communication  ability had  ward  Instead,  nursing  staff  of on  the the  beginning  final ward  met  data  ability  was  used.  those  changed  a " s t r o k e " and  t h e above method o f c l a s s i f i c a t i o n the  final  recoded.  rehabilitation  at  were  the  Because the communication  the  At  assigned-  during  rapidly,  (including  classified  e x p r e s s i v e modes o b t a i n e d  this  no l o n g e r s p e a k would be Station Five:  nursing  perceptions  a communication  unless  to  consultation did occur.  weeks,  retained  and  patients  m a r k e d l y . . F o r e x a m p l e , a p a t i e n t who could  nurse  receptive  r e c e p t i v e and  data-collection  staff  intended  sometimes  e a c h p a t i e n t , and  The  every  with a group  according  impairment.  week f o r s i x weeks p r i o r  of  of  changing  c o u l d not every  week  collection)  for fifteen  to  be  a l l  twenty  62  minutes, d i s c u s s e d the p a t i e n t s , and reached a on t h e i r communication impairment. then used f o r the remainder of  a  marked  change  These  values  were  of the week, except i n cases  as mentioned  were coded the day a f t e r  consensus  above.  New  t h e i r a r r i v a l by the  patients admitting  and/or s e n i o r nurse. While  i t i s r e c o g n i z e d that t h i s d i f f e r e n c e i n methods  between the two wards i s  not  ideal,  e x i g e n c i e s which the r e s e a r c h e r was on the two and  it  was  one  of  the  forced to accept.  wards were accustomed t o f u n c t i o n i n g  Staff  differently,  s i n c e they were being reguested to take time from  busy  schedule  flexibility  to in  e f f i c i e n t l y and  do  the  their  weekly  method  of  maintained  they  accomplishing  needed it  most  effectively.  h) Day _and t i m e s e l e c t i o n . were  coding,  their  on  Since  weekends,  the  only five  minimal  staff  weekdays (Monday  through Friday) were s e l e c t e d f o r i n t e n s i v e study. During the e a r l y weeks of o b s e r v a t i o n i t was that  peak  occurred  periods  of  between  0800  one-and-one-half-hour chosen 1200,  to  provide  inter-disciplinary and  1430  time p e r i o d s  within  hours. this  Three  span  were  staff  to  hours.  T h i s s e l e c t i o n of day and time nursing  communication  optimum c o v e r a g e — 0 8 0 0 to 0930, 1030  and 1300 t o 1430  between  determined  during  and  excluded  communication  immediately  change o f s h i f t , and a l s o c o n v e r s a t i o n s between  after nurses  the and  63  patients  or  families  inter-disciplinary At  in  evenings  i n t e r a c t i o n was  and  feedback  on  shift  communication a t t h i s time was four  days  following  shift  changes on both  weekends, but  given p r i o r i t y .  the o u t s e t of the r e s e a r c h ,  requested  on  nursing  changes,  as  administration they f e l t  poor. , To meet t h i s  that  request,  the study were used to code a l l t h r e e wards.  These  data  were  tabulated  s e p a r a t e l y and presented a f t e r the second feedback s e s s i o n . .  1) Choice_of l o c i , of  T h i s was  accomplished through  a number of s i t e s on the wards d u r i n g the f i r s t  of  observation,  communication  plus  an  frequency  intensive  at  various  2-day  trial  s i x weeks study  locations.  of  Decisions  made were: (i)  n u r s i n g s t a t i o n - the i s s u e was  the It  separate  i n n e r D e d i c a t i o n s / s e r v i c e area from the outer desk. was  two,  decided t o keep t h i s as as  frequency  interdependent, and  whether t o  then  in  one both  locus  rather  areas  was  than often  A c o n v e r s a t i o n would begin i n one  move t o the o t h e r , or might be conducted  part with  one person i n each, ( i i ) c h a r t i n g room - freguency here v a r i e d markedly the time and day, as the room was conferences sufficient  and  patient  communication  i n c l u s i o n as a l o c u s . was  also  used  clinics. occurred  During to  A f u r t h e r pragmatic  with  for  staff  a  week,  warrant  its  consideration  that the i n c l u s i o n of one lower-freguency  l o c u s gave  64  the observer the o p p o r t u n i t y t o s i t f o r f i v e minutes out of  every  thirty  and  record  in  f a s h i o n — a welcome r e s p i t e from  a  the  more  continuous  w h i l e s t a n d i n g or walking at the other (iii)  corrido£S -  the two  reasons  loci,  for subdividing differed  nursing  station,  crosspiece divided  (see  into  limbs  charting  of  The  side  and  impressions  differed  The two with  Patients  "North" and "South."  low  was  one  the  those made t o  early of  on  care the  nursing the two one  station limbs  weeks  of  on  the  separate  end were missed  corridors  the i f the  start  time. the  c h a r t i n g room a t the j u n c t i o n of  could  o c c u r r i n g i n the o t h e r .  of  observer  more compact, L-shaped, with  and  and  Although one c o u l d walk the  (see F i g u r e 3 ) .  corridor  From  South,  at the o t h e r or had h i s hack turned at the S t a t i o n F i v e was  in  coamunication  levels.  l e n g t h o f e i t h e r c o r r i d o r i n 4 5 seconds, at  were  on the South s i d e  mobility in  from  t h e r e f o r e the d e c i s i o n was  conversations  the  and e l e v a t o r a t the  o b s e r v a t i o n , i t seemed t h a t p a t t e r n s North  and  teams on the North s i d e had p a t i e n t s  a l l communication  ethnographic  "H,"  page 4 5 ) .  F i g u r e 3,  f o u r "teams".  two  the  room,  mostly bedridden p a t i e n t s  skills.  into  on  H-shaped, with p a t i e n t rooms down  the outer s i d e s of both  on  coding  wards: Second Best was  had  leisurely  T h e r e f o r e , the  observer  not see i f c o n v e r s a t i o n s were Because  of  this,  corridors  were s u b d i v i d e d i n t o "North" and " E a s t " f o r t h i s ward.  65  (iv)  rooms -  adjacent ()  these  were  used  accordiag  to t h e i r  corridors.  s o l a r i u m - t h i s was  v  divided  during  excluded  the day except  because i t  f o r overflow  was  of  rarely  conferences  or c l i n i c s from the c h a r t i n g room. (vi)  s e r v i c e rooms^bathSP.QI§<.,§tc.  these areas were i n c l u d e d with To  improve  reliability,  - conversations  "corridors." rules  were  Bade s p e c i f y i n g  i n c l u s i o n / e x c l u s i o n of c o n v e r s a t i o n s between boundaries  of the ward, e t c .  aware of the boundaries  in  loci,  at  the  While s t a f f and p a t i e n t s were  on each ward, they  seldom  made  an  it  was  obvious e f f o r t to t a l k o u t s i d e the a r e a .  j) planned wards  Week.  In  the  original  for  a  two-week  period. ,  after a  recognized  each l o c u s was  that  out  of  communicators family)  design,  t h a t complete data would be c o l l e c t e d from  wards every day.  minutes  research  (e.g.  could  twenty-five  every  come,  minutes  trial  to r e c t i f y  two  Observers would a l t e r n a t e of  this  system,  being covered  thirty.  it  f o r only  Infrequent  or  was five brief  p h y s i c i a n , o c c u p a t i o n a l t h e r a p i s t , or communicate, that  the  and  leave  observer was  t h i s , i t was  the loci.  missed.  decided to have two  on the ward at the same time, but spaced three T h i s meant t h a t coverage was  during  at other  Thus, much i n t e r - d i s c i p l i n a r y communication was order  the  In  observers  loci  apart.  provided f o r a p a r t i c u l a r l o c u s  f i v e minutes out of f i f t e e n , r a t h e r than out of  thirty.  66  Consequently,  the  assessed, s i n c e one  variable  ward was  "week" could not be  fully  covered f o r one week, and  then  both observers moved t o the other ward.  k) Task .design. proposed  One  f o r the r e s e a r c h  researcher  recognizes  of  the  was that  "task this  moderator, i t could not be t e s t e d observers without  had this  therefore later  reached additional  made  date,  to  when  intervening  their  design." may  be  during  maximum  variable.  variables While  a  significant  the  study.,  recording The  the  The  capacity  decision  was  leave e x p l o r a t i o n of t h i s v a r i a b l e to a fewer  contextual  factors  were  being  monitored.  E.  METHOD! The  final  method f o r data c o l l e c t i o n evolved from  f o r e g o i n g d e c i s i o n s (see F i g u r e 5, "shakedown"  of the procedure  August 5 through was  7.  was conducted  A  three-day  on S t a t i o n  The o n l y a d d i t i o n a l problem  Five,  encountered  t h a t of exact s y n c h r o n i z a t i o n of both o b s e r v e r s ' watches  with the ward c l o c k . of  page 52) .  the  stop  watches.  The only s o l u t i o n to t h i s was Held  they  were  watches which had  no  use  i n the palm of the l e f t hand, and  o n l y c l i c k e d at the beginning and end of each period,  the  more  previously  obtrusive been  concern f o r s t a f f or p a t i e n t s . .  used,  than and  ninety-minute the o r d i n a r y were  not  a  67  The  study  was  designed  to spend the week of August  on Second West and the week of August 18 However, f o r two on  the observers switched  reasons.  Station  following  on  Station  wards f o r one  on  Thursday  Thursday, because  staff  August  14,  of v a c a t i o n s .  shutdown  being h e l d  but  not  the  Second, s i n c e a  possible  general  secondary  p i c k e t i n g by an e x t e r n a l party i n v o l v e d i n a l a b o r  d i s p u t e , the ward s w i t c h was  was  Five,  day each week  F i r s t , a r e g u l a r conference was  Five  11  imminent  due  made i n order t o have one  to  day's  f i n a l data on S t a t i o n F i v e f o r comparison with the shakedown data.  Thus,  each  week's  data  were  composed of Monday,  Tuesday, Wednesday and F r i d a y on one ward, and  Thursday  on  the o t h e r . Each  week's  o r i e n t a t i o n of patient  new  observation staff,  classification  was  hours' p r a c t i s e o b s e r v a t i o n subjects. finer  Extensive  patients, also was  on and  Sunday,  with  families.  The  revised, done  to  and one  or  familiarize  two new  r e l i a b i l i t y checks were a l s o made and  p o i n t s of coding were d i s c u s s e d . Observations  during 1030  began  and  b e h a v i o r s was at  to the next  1300  t o 1430  hours).  A  time  conducted  sampling  employed, with f o u r minutes and t h i r t y  of  seconds  each l o c u s , and t h i r t y seconds allowed f o r moving one.  Data were recorded d i r e c t l y coding  F r i d a y were  the p r e v i o u s l y d i s c u s s e d time p e r i o d s (0800 t o 0930,  t o 1200  spent  from Monday through  forms.  The  onto e i g h t y - c o l u a a  intervening  Fortran  v a r i a b l e s were e n t e r e d i n  68  columns  one  through  sixteen  before  period  began.  Then,  observation  s t a r t e d , i n t e r a c t i o n was immediately to  whom  (using  when  ninety-minute a  conversation  recorded as w_o  speaks  t h e p o s i t i o n codes) and how (an a c t - b y - a c t  Bales c a t e g o r i z a t i o n ) . simultaneous  the  The process was s i m i l a r t o  translation.  that  For example, the seguence:  DOCTOfi  TO  Smith?  Do yon t h i n k we can stop the I.V.?  NORSE  :  Good  morning.  How i s Mrs.  NORSE TO DOCTOR : She had a good n i g h t , but restless  of  she's  today.  would be recorded as f o l l o w s : 040 000 In  : 189: 56-  t h e above  example, t h e doctor  asked f o r an o p i n i o n ("8") nurse  (000) d i d not  and  M  not  examined  phenomenon  The  was  T h i s could be a  sequencing  i n the  suggestion  ("1 ) and M  ( 9")«  The  ,,  r e t u r n t h e g r e e t i n g , gave an o p i n i o n  ("5") and i n f o r m a t i o n {"6 ). communication.  a  (040) g r e e t e d ,  data  consistent,  would show a h i g h e r percentage  breakdown i n  a s p e c t s of i n t e r a c t i o n were  analysis. the  However,  profile  i f  the  f o r doctor-nurse  o f C a t e g o r i e s 1,  8,  and  9.  The nurse-doctor p r o f i l e would have a d e f i c i t o f Category 1, and  peaks f o r 5 and 6.  Such p r o f i l e comparisons c o u l d then  be f o l l o w e d by random o r s e l e c t i v e examination Two l i n e s of conversation—one  the coding  sheet  were  used  f o r each  f o r each person's u t t e r a n c e s — m o v i n g  l e f t t o r i g h t as t h e d i a l o g u e progressed. nurse  o f seguences.  from  F o r example, i f a  was t a l k i n g t o a n u r s i n g a t t e n d a n t , t h e coding  might  69  look l i k e  this: 000 : 167 001 :  In  36 66444 4165122  3  3  1-  t h i s case, the c o n v e r s a t i o n began with three a c t s by the  nurse  COOO") , f o l l o w e d by f i v e  by  the  nursing  attendant  ("001"), then two by t h e nurse, e t c . When  no  communications were o c c u r r i n g at a p a r t i c u l a r  l o c u s , the observers used the back o f t h e r e c o r d ethnographic Loci  were  coding  sheet  to  impressions.  rotated  systematically  in  the  following  order: 0 = nursing station 2 = S. c o r r i d o r s (Second West) or N. c o r r i d o r s ( S t a t i o n Five) 3 = S. ,rooms (Second West) o r N. rooms ( S t a t i o n Five) 1 = c h a r t i n g room 4 = N. c o r r i d o r s (Second West) or E. c o r r i d o r s ( S t a t i o n Five) 5 = N. rooms (Second West) or E. rooms ( S t a t i o n Five) Each day Monday  at  observers  began  at  successive  "0" and "1," Tuesday at 2 n  n  days'  observations  and "5" o n l y reached  (e.g.  and "4") i n o r d e r t o  o b t a i n as comprehensive coverage as p o s s i b l e . five  loci  Because  only  were completed per ward, l o c i "3"  the s t a r t i n g p o s i t i o n  whereas t h e o t h e r s d i d so twice  once  per  week,  (once f o r each o b s e r v e r ) .  70  Depending  on  the  r e g u i r e d to c i r c u l a t e potential  locus,  in  order  conversations.  c h a r t i n g room they s a t conversations  observers to  As  in  a  remain  monitor  sites  it  a  conversation  the  where  all  In the n u r s i n g s t a t i o n ,  they  was  possible  simultaneously were  unless  ignored  until  one the  c o r r i d o r s , the observers conversation  was  they commenced. walking  from  when  above,  location  move  i t began.  At both  code  had  a very r a p i d pace.  initial  two  one  these  conversations  was  Others  complete.  placed themselves c e n t r a l l y  In  when no  o c c u r r i n g , and moved to communications as Monitoring  room  to  in  room  rooms  in  reguired  order  to  Because other c o n v e r s a t i o n s c o u l d  observers  switched  terminated  or reached first,  immediately  to  coverage.  occurred  to  in  p o s i t i o n e d themselves c e n t r a l l y and c o u l d to  sometimes  accessible  discussed  central  c o u l d be heard.  were  to  a  new  room  a d u r a t i o n of  when one  continuous  provide  egual  not  seen,  a  be  conversation  minute,  whichever  i n order t o a v o i d o v e r r e p r e s e n t a t i o n of  one  p a i r of communicators. Because of the obvious c a r e f u l c o n s i d e r a t i o n was control  (Rosenthal  presence of the  research  given t o g u e s t i o n s of a r t i f a c t  and Rosnow, 1969).  weeks  of  the  project.  However, a f t e r two  weeks of part-time o b s e r v a t i o n , the s t a f f became to  the presence of the observer.  and  Sechrest's  and  The observers had  d e f i n i t e impact on the ward communication s t r u c t u r e early  team,  in  a  the  to three  accustomed  Webb, Campbell, Schwartz,  (1966) d i s c u s s i o n of Dnobtrusiye  measures  was  71  c a r e f u l l y s t u d i e d f o r ways t o reduce the r e a c t i v i t y method,  but  applicableArgyris'  their  suggestions  Instead,  (1968)  the  were  researcher  approach  to  not  the  particularly  elected  minimizing  of  to  the  follow  "Unintended  conseguences of r i g o r o u s r e s e a r c h " by b u i l d i n g i n m o t i v a t i o n factors  for  developing  the  meaningful  Throughout examination that  subject  the  which  study,  recorded.  the observer's were  they  reassurance Having  another I t was who  by  to  were  open  patients  soon  realized  c o u l d be t r a c e d t o them as positions  On  Sundays, were  and  interactions  apprehension, when  available  ward to  and  thus  activities give f u r t h e r  explanations.  the  ethnographic  said  coded  observers  and  and  sheets  T h i s f u r t h e r reduced impact.  minimal,  organization,  data  S t a f f and  i n d i v i d u a l s , s i n c e only were  the  participation.  by s u b j e c t s .  nothing  and  observer  impressions  record  in  the  constantly,  noting  c o n v e r s a t i o n breaks,  means of reducing the o b t r u s i v e n e s s of  the  was  method.  f e l t t h a t s u b j e c t s were l e s s l i k e l y t o n o t i c e someone  w r i t e s c o n t i n u o u s l y than one I t had been suggested  video-tape  and/or  collection  to  does so  t h a t a combination  interviews  assess  who  1  of  audio-tape,  be used a f t e r the major data  subjects'  o b t r u s i v e n e s s of the method .  intermittently.  perceptions  T h i s was  of  the  not p o s s i b l e because  This suggestion was made at a workshop of the O r g a n i z a t i o n a l Behavior D i v i s i o n of the U.B.C. Faculty of Commerce. 1  72  of  time  staff  and  limitations.  However,  p a t i e n t s during  and  informal discussions  a f t e r the study i n d i c a t e d t h a t  they became g u i t e comfortable communicating i n the of  observers  and  personal  except lives.  A r e l a t i v e l y high freguency of  a c t s during the  subjects  were  able  occasion  arose.  to  discussions  with  of  negatively  when  to  open  communication  was  feedback on t h e i r i n t e r a c t i o n p a t t e r n s . , explained  i n p u t of data to the study.  In other  words,  the  "3")  data and  keypunched,  their was  possible  h e l p f u l feedback.  from the developmental three  the f i n a l t h r e e weeks ( " 5 " , " 6 " , visually  then r e o r g a n i z e d manner,  1  as  data  DA___P___AH_TIO__  All and  During  onus  placed on the s t a f f to communicate as "normally" as they wished to r e c e i v e a c c u r a t e ,  the  that the  which s t a f f would r e c e i v e c o u l d only be as accurate  F.  the  s t a f f , a t h i r d f a c t o r which they  o r i e n t a t i o n s e s s i o n s , the r e s e a r c h e r  if  negative  month o f J u l y i n d i c a t e d t h a t  communicate  mentioned as c o n t r i b u t i n g promise  presence  when d i s c u s s i n g t h e i r home s i t u a t i o n s  socio-emotional  In  with  the  examined  for  by a s p e c i a l computer  seguential  T h i s program was  m a t e r i a l was  weeks  ("1 ,"2", n  " 7 " ) were  and  errors, corrected, program . 1  In  and this  t r a n s f e r r e d t o a form  developed by L.. Chen.  73  s u i t a b l e f o r f u r t h e r a n a l y s i s , condensing  13,684  cases  of  raw data t o 10,654. These  data were f u r t h e r v e r i f i e d before being  i n t o two major f i l e s weeks  (one f o r weeks 1 t o 3;  other  Bent, 1975). process  in  observer  order  t o e l i m i n a t e not only keypunching  initial  errors  visual  editing,  (such as miscoding  f o r one d a y ) .  M  (Nie, H u l l , Jenkins, S t e i n b r e n n e r ,  but  errors  also  logical  s e n d e r / r e c e i v e r "005" as  Ethnographic data provided c o n s i d e r a b l e  a s s i s t a n c e f o r f i n d i n g the l a t t e r  errors.  As d i s c u s s e d above (page 30), Bales o u t l i n e d f o u r a n a l y z i n g i n t e r a c t i o n d a t a — p r o f i l e s , sequencing  phases,  and  matrices.  interaction one  profiles  for  calculated  the  (the  of acts,  For each c e l l i n the matrix,  were  receiver.  freguency  created  some  concern  Percentaged  profiles  were  of each category converted t o a  for ipsativity  s i n c e there i s a weak mathematical twelve  percentages—i.e.  decrease. were  that  two  d e t e r m i n e d — o n e f o r the sender,  percent of the t o t a l i n t e r a c t i o n s ) t o s t a n d a r d i z e the This  ways  In the present study a who-to-whom  p o s i t i o n matrix was used.  and  &  C o n s i d e r a b l e time was r e g u i r e d f o r the e d i t i n g  missed i n the  of  for  5 t o 7) using the Statistical„_ac_ages f o r _ t h e _ s p c i a l  s c i e n c e s . V e r s i o n 6.02  "003  the  compiled  ( H i c k s , 1970),  interdependence  of  when one i n c r e a s e s , another  However, i n d i c a t i o n s from the t h i s interdependence  data.  pilot  study  would be minimal.  the must data  Matrices  and p r o f i l e s were t a b u l a t e d f o r each o b s e r v a t i o n p e r i o d , and the moderating  situational variables  noted.  74  Complete sequencing of a c t s was not examined because of the magnitude of the data-handling problem. information  was  available  specific  questions  example,  if  from  during  the  the  However,  raw  data  feedback  this  t o answer  process.  For  the i n t e r a c t i o n p r o f i l e s f o r a p a r t i c u l a r  dyad  showed a p o t e n t i a l source o f communication i n c o n s i s t e n c y , random  or  selected  sample  a  of t h e i r i n t e r a c t i o n s c o u l d be  analyzed s e q u e n t i a l l y . When Bales and Strodtbeck problem-solving  groups,  "qualitatively  (1951) examined the phases of  they  different  defined  sub-periods  phases  within  a  total  continuous p e r i o d of i n t e r a c t i o n i n which a  group  from  involving  initiation  t o completion of a problem  decision  (p. 485)-"  group,  movement  They found t h a t f o r occurred  over  time  proceeds group  pr;oble.m-so ivjnq i  from  £iaM£e_2,  The group c o n c u r r e n t l y had an i n c r e a s e of  both  positive  (see  of  evaluation  i n the r e l a t i v e freguency  control  problems  communicaton through page 25).  to  a  as  key  and  to  negative  reactions. Phases  were  two reasons. hospital  ward  interaction" ramifications the  problem  interactions  not  assessed i n the present r e s e a r c h f o r  The f i r s t is in  was t h a t ongoing communication on  not i d e n t i c a l t o a "continuous p e r i o d of  which  a  problem  is  identified,  e x p l o r e d , and a s o l u t i o n reached. is  solved  over  reason was t h a t , as  a  an  through extended  discussed  a  number  above  More o f t e n  of  p e r i o d of time. (page 3 7 ) ,  its  discrete The  second  a  "group  75  d e c i s i o n " i s r a r e l y , i f e v e r , made i n the medical c o n t e x t . The two and  major data s e t s were grouped a c c o r d i n g t o dyad,  interaction  combination. than f i f t y dyad  profiles  calculated  Those with l e s s than f i v e time p e r i o d s or l e s s  a c t s were e l i m i n a t e d  pair  f o r each who-to-whom  (unless  i n which the other h a l f met  the remaining p r o f i l e s were examined  they  completed  these c r i t e r i a ) ,  for  a and  consistency  over  time. These reasons.  two  sets  The f i r s t  categorization  were  was  not d i r e c t l y comparable f o r two  that  system,  weeks  and  1-3  weeks  used  Bales  5-7, the new. , T h i s  have r e s u l t e d i n major d i f f e r e n c e s i n Category 2, and differences  in  ipsativity  of  several the  others.  percentaged  Because  profiles,  c o n t r i b u t e d an unknown v a r i a n c e t o the two The  second,  of  a  conditioning circulation temperatures  sets.,  and more s i g n i f i c a n t a l t e r a t i o n , o c c u r r e d  two-storey (except because in  weak  changes  which  being monitored d u r i n g the s t u d y — t h e weather.  Hospital,  may  minor  the  these  because of an u n a n t i c i p a t e d i n t e r v e n i n g v a r i a b l e not  old  1  the  in of  frame  building,  certain ward  first  had  offices)  design.  70%,  unbearable f o r s t a f f and p a t i e n t s  wards  Hascana no  air  and l i t t l e a i r  Therefore,  week i n J u l y reached 38  C e l s i u s , and humidity was over  was  when degrees  quickly  became  (and o b s e r v e r s ! ) .  Working  and l i v i n g under such c o n d i t i o n s , tempers f l a r e d g u i c k l y  and  tension l e v e l s rose. Interestingly,  the  o b s e r v a t i o n a l instrument  proved  76  sufficiently climate.  t o p i c k up t h e s e c h a n g e s i n e m o t i o n a l  When t h e p r o f i l e s  examined,  the  were a l m o s t lower.  sensitive  percentages  double  the  percentages, categories directly  and  compared.  were  patient-to-staff  interactions.  interdependence  freguencies  and  the  two  The i m p o r t a n c e  of  of  the  sets  the  other ten  could  not  of the a l t e r a t i o n  be  i n the  weather  will  d i s c u s s e d i n Chapter IV. Chi-sguare  through  the  statistics  12, and f o r  profiles., two  Both data  sets,  over  split-half  checks  "nurse-nurse" the second  time  and  special data  were  giving  for  10,  some  (greater also  on  f o r Categories 1  forty-six  of  indication  of  the  profile  on t h e 3-10 a n a l y s i s ) .  done  on  the  major  acts  Station  f o r the hospital.  data s e t with greater than  Five) 1  o f 3 0 9 — 1 1 8 f o r Second were  plotted,  These formed  Graphed  T h i s program was w r i t t e n  within  results.  (a t o t a l  computer p r o g r a m .  Two  profiles  "nurse attendant-nurse a t t e n d a n t "  f o r t h e second  p e r i o d s and f i f t y 191  through  s e t , with s i m i l a r  Profiles  and  3  were c a l c u l a t e d  a n a l y s e s showed a c o n s i s t e n t p a t t e r n a c r o s s  stability  1  were  when t e a p e r a t u r e s  p r o f i l e s corresponding to fluctuations i n the be  set  staff-to-staff,  relative  were l o w e r e d  data  f o r most  mathematical  the  July  o f a c t s i n C a t e g o r i e s 11 a n d 12  was c o n s i s t e n t  staff-to-patient, of  the  t h o s e f o r August,  This finding  Because  for  using  the basic  five west  another feedback  p r o f i l e s f o r both p a i r s  f o r t h e s t u d y by P. Cahoon.  of a  77  dyad  (e.g. n u r s e - d o c t o r ,  and doctor-nurse) sere reduced i n  s i z e and t r a n s f e r r e d t o a s i n g l e sheet of gives  an  example  of  the  sheet  written  instructions Department  staff  p a r t i c i p a t i n g i n the study.  was  for heads  to  accompany  their  s t a f f , accompanied  position  Sets of  and  staff  A single information  the  interpretation  received  _i__r__6  p r o f i l e s f o r one dyad.  p r o f i l e s were compiled f o r each department  paper.  profile (see  s e t s , with A__e,ndix_G).  c o p i e s of a l l p r o f i l e s of t h e i r  by t a b l e s g i v i n g the exact v a l u e s f o r t h e  graphs. The f i n a l t h r e e weeks"  divided  into  t h r e e days* "shakedown" on S t a t i o n F i v e and f i v e days*  final  data  for  each  p e r i o d s or l e s s together  with  ward. than those  ("900"), or p a t i e n t s staff-to-staff the hypotheses.  data  data  were  then  A l l dyads with l e s s than f i v e one  hundred  involving  acts  groups  were  eliminated,  ("260", e t c . ) ,  ("300" through "659").  The  time  self  regaining  were used f o r the s t a t i s t i c a l t e s t s o f  VflSCBNfi H0SP1TM. C O W U N I C B T r W PROFILE PERCENTAGE OF ACTS IH EACH CATEGORY FOR  WSCJWq HOSPITAL CCmUNJCATIW PRCFJ1.E PERCENTAGE OF RCTS -H ERCH CATEGORY FOR SECOND WEST  GENERAL PRRCTITIOl'JER TO REGISTERED NURSE  CATEGCRT  PERIODS^ B C T S =  79  CHAPTER  A.  PRELIMINARY ASSESSMENT OF CATEGORY  When  the  coefficients to  ill  data  had  been  edited  USE;  and  collated.  were c a l c u l a t e d on every ward/week  determine  differential  category  usage  for  Phi  combination the  two  observers. Phi  i s a measure of a s s o c i a t i o n s i m i l a r t o C h i - s g u a r e .  I t t e s t s the d i f f e r e n c e between two is  independent  of  the  categorical ratings  sample s i z e  (N).  value of - 1 . 0 0 and a maximum of + 1 . 0 0 .  but  I t has a minimum  The optimum value i s  0.00.  r e p o r t s P h i c o e f f i c i e n t s g r e a t e r than ± 0 . 0 9 ,  _________  and mean v a l u e s (X) f o r the two weeks 1 - 3 , a  value  sets  by  ward.  ten out o f s e v e n t y - e i g h t Phi c o e f f i c i e n t s of  .10  ±  ; f o r weeks 5 - 7 ,  were at or beyond t h i s T e s t s of hypothesis  data  the  that  seven out of f i f t y - t w o  of  Phi  (i.e.  can be obtained from  t h a t N times Phi-sguare eguals Chi-sguare.  small.  be  rejected  in  a l l cases  the  null  the knowledge  However, because  o f the l a r g e sample s i z e i n t h i s study, the n u l l would  reached  level.  significance Phi=0)  For  hypothesis  even though P h i i s very  T h i s would be e n t i r e l y an e f f e c t of the l a r g e sample  s i z e , and not a r e f l e c t i o n of any s t r o n g a s s o c i a t i o n .  80  TABLE_III STRENGTH OF PHI VALUES FOB CATEGORY USE-BY OBSERVER CatO 2W  Cl  C2  cr.  C3  C4  C5  C6  C8  C7  CIO  C9  Cll .21  .11  .10  1  .12  35  z  .20  .10  65  .12  2W  i) J  .11  2W  - t* •  .13  .1'*  .11  S5  •  .11  zv  123  .!5|  .11  S5  (2W)  5  C12  r  35 .10  2V  *  6  .12  .10  .1?  S5  • '-5  :i2  2¥ 7 • 13  S5  .ii  2W  X 56?  S5 • NO DATA WERE COLLECTED FOB 2K IN KEEK 5  J . A. Davis conventions  (1971) has o u t l i n e d  f o r describing  between two nominal "Yule*s  Q. **  an  arbitrary  the s t r e n g t h o f the a s s o c i a t i o n  v a r i a b l e s as measured by  According  to  set of  the  statistic  h i s c r i t e r i a , Q v a l u e s between  ± .01 t o .09 should be i n t e r p r e t e d as a " n e g l i g i b l e p o s i t i v e or n e g a t i v e a s s o c i a t i o n " , and those i n t h e range .10 t o as  a  "low  .29  a s s o c i a t i o n " . , Since P h i i s s i m i l a r t o Q, i t i s  reasonable t o use these c r i t e r i a when i n t e r p r e t i n g t h e above findings. association  There was t h e r e f o r e between  overall  o b s e r v e r s on e i t h e r ward.  only  a  category  negligible use  by  or low the two  81 /  B.,  RELIABILITY!  Hany o f the communication s t u d i e s Pearson  by W. A. S c o t t  appropriate  Since  have  used  R t o assess i n t e r - and i n t r a - r a t e r r e l i a b i l i t y .  discussed only  reviewed  IPA  (1955, p. ,323), t h i s  when d e a l i n g  is a  nominal  considered  inappropriate.  to  standard  use  Richardson 20. tested  by  (percentage (1960),  and  measures  The taped r e l i a b i l i t y alternate  act-by-act Scott's  use  of  is  data. R  was  Consequently, i t was not p o s s i b l e  reliability  two  statistic  with i n t e r v a l o r r a t i o  categorization,  As  as  were  therefore  statistics—Cohen's  agreement Pi  data  such  with  (marginal  chance  agreement  Kuder  Kappa removed)  with chance  removed) (1955) . Two approaches were used because a s i n g l e s t a t i s t i c not  available  in-process addition  for  handling  act-by-act  agreement f o r  s c o r i n g , where e r r o r s o f u n i t i z i n g a r e to  extensively  those by  categorizing  of  categorizing.  Waxier  errors,  and but  found  in  Cohen's Kappa, used  Hishler  when  is  (1966),  adapted  to  handles  account f o r  u n i t i z i n g e r r o r s i t underestimates the r e l i a b i l i t y . , In both i n s t a n c e s , one of Cohen's a s s u m p t i o n s — i . e . no  criterion  comparison—was Nevertheless, act-by-act research  f o r correctness violated the  by  importance  which the  of  r e l i a b i l i t y during the  that  can  there  be  used f o r  reliability  obtaining training  a  is  data.  measure o f  stages  of the  n e c e s s i t a t e d the use of Kappa a t t h a t time. , During  82  the  final  data a n a l y s i s , an assessment of marginal  t o t a l s was form. for  d e s i r a b l e , s i n c e the data were t o be used  P i was  account  c o n s i s t e n t d i f f e r e n c e s between o b s e r v e r s .  designed  for  reliability nominal ranges  index  use  in  of  research  agreement,  "to  was  neasure  the  of c l a s s i f y i n g a l a r g e number of responses  scale  c a t e g o r i e s (W.  from 0.00  t o 1.00,  proportions  and assumes t h a t the  data.  p. 321)."  It  distribution  where P  0  P  e  T h i s assumption  was  not  met  P i i s c a l c u l a t e d by the f o r m u l a :  P±  I = observed  percent agreement  •= percent agreement expected on the b a s i s of chance  Cohen's Kappa was nominal  A. S c o t t , 1955,  into  over c a t e g o r i e s f o r the p o p u l a t i o n i s known  by the r e l i a b i l i t y  following  inter-coder  survey  and i s egual f o r both r a t e r s .  of  i n that  t h e r e f o r e used, even though i t d i d not  S c o t t ' s P i , an  of  category  a l s o designed f o r s t a t i s t i c a l  data, but on an a c t - b y - a c t b a s i s .  testing  I t makes the  assumptions:  (a) u n i t s are  independent  (b) judges operate  independently  (c) c a t e g o r i e s are independent, exhaustive According t o B a l e s ' theory met  by  of the  mutually e x c l u s i v e , and  communication, data,  with  these  assumptions  were  the  contaminating  i n f l u e n c e of s e g u e n t i a l interdependence.  three  possible  83  T h i s s t a t i s t i c i s used i n s i t u a t i o n s where t h e r e i s c r i t e r i o n f o r correctness.  no  The formula i s :  Po - R l - Pc where P  0  P  c  = p r o p o r t i o n o f u n i t s i n which the judges agreed = p r o p o r t i o n of u n i t s f o r which agreement i s expected by chance  It  i s c a l c u l a t e d from the a c t u a l d i s t r i b u t i o n of assignment  of a c t s t o N c a t e g o r i e s by two o b s e r v e r s ,  r e s u l t i n g i n an  N  by N matrix. Although  the  formulae  for  very s i m i l a r , "Pc" and «pe" a r e Pi,  "Pe"  is  a c t s assigned  the two s t a t i s t i c s appear  defined  differently.  For  the sguared mean d i f f e r e n c e between the t o t a l t o each category  by t h e two r a t e r s :  P.. * P.  a  P*  where P  fl  P  6  +  X  Pa  1  =  __  P^ +  =  C  P<- +.....+P*  0  0  •  6  6  In c o n t r a s t , the "Pc" f o r Kappa i s d e f i n e d as the p r o p o r t i o n of a c t s expected t o be assigned  t o a p a r t i c u l a r c e l l by both  observers  on the b a s i s of chance, given  totals,  i.e.  the  differing  joint probability  proportions:  (P,.)(P..) p where P = P„ = P.  of  the  marginal marginal  84  Pi s t a t i s t i c s  f o r the t h r e e weeks of August  3  to  22,  i n c l u s i v e , were: August  3 - 7 10 - 15 17 - 22  .91 .73 .71  overall r e l i a b i l i t y  f o r t h r e e weeks was .86  R e l i a b i l i t y using Kappa was c a l c u l a t e d i n two ways; 1. c a t e g o r i z i n g e r r o r s only August  3 - 7 10 - 15 17 - 22  .66 .71 .61  overall reliability  .67  2. c a t e g o r i z i n g p l u s u n i t i z i n g e r r o r s August  3 - 7 10 - 15 17 - 22  .58 .57 .48  overall r e l i a b i l i t y Given difficult Since of  the  study  category  appropriate are  deterioration will  in  the  t o draw c o n c l u s i o n s about  the  These  variation  .56  the  figures,  the  consider  within  figures  for Pi  are  data. profiles  the  most  a t the present stage of a n a l y s i s .  acceptable  across  i t is  reliability  data were analyzed as percentaged  totals, to  above  the  range,  although  t h r e e weeks should be noted  the (and  be d i s c u s s e d i n Chapter I V ) . The  original  objective  of  using  Kappa  during  the  developmental stages of the r e s e a r c h to monitor the progress of of  achieving act-by-act r e l i a b i l i t y the  lack  of s u i t a b i l i t y  could not be met because  of the s t a t i s t i c .  T h i s was an  85  u n a n t i c i p a t e d problem.  The study  has  therefore  uncovered  the need f o r f u t u r e dialogue with s t a t i s t i c i a n s t o develop a suitable  measure  of  s c o r i n g of i n t e r a c t i o n  act-by-act r e l i a b i l i t y f o r in-process data.  Intra-rater r e l i a b i l i t y for  was determined by P i t o be  .80  the r e s e a r c h e r , and .86 f o r t h e r e s e a r c h a s s i s t a n t .  e x p l a n a t i o n f o r t h i s d i f f e r e n c e w i l l be presented  C.  An  below.  _E_L_S_OF__HE__YP  It  will  be r e c a l l e d t h a t t h e f i r s t  p a r t of Hypothesis  1  was: Hl-a  The p a i r e d C a t e g o r i e s  sequentially After  ( i . e . 1-12, 2-11, e t c . ) are  interdependent.  the  data were c o l l a t e d , the researcher  t h a t Hl-a c o u l d o n l y be assessed the  data.  As  previously  by s e q u e n t i a l  realized  analysis  d i s c u s s e d , t h i s i s an  extremely  time-consuming and arduous task which could not be the  present  study.  This  hypothesis  was  of  done  therefore  in not  tested. The next two hypotheses were examined together; Hl-b The r e l a t i v e f r e g u e n c i e s of the twelve are independent.  categories  H2 Three o f t h e C a t e g o r i e s ( 2 , 6, and 11) a r e more strongly c o r r e l a t e d with the o t h e r s than are the remaining n i n e .  86  These  hypotheses  sere  tested  f a c t o r analyses on three subsets ward  aggregated  by day,  components  analysis  communalities. obligue  was  twelve,  oblimin)  with no  each category  Bales.  rotations,  Category 6  The  assume  of  that  provided  Bales'  new  Bales'  t o g e t h e r on the f a c t o r s .  (varimax)  and  o r t h o g o n a l i t y of  the set  to determine whether factor.  varimax  rotated  factor  o r t h o g o n a l i t y as c o n c e p t u a l i z e d  IPA  (which w i l l be d i s c u s s e d  indication  principal  number of f a c t o r s was  g i v e the  A l l three a n a l y s e s  orthogonality  case,  both orthogonal  would l o a d on a separate  which  data—each  dyad, p l u s a combined  In each  minimum Eigenvalue,  T_bles_I______a____I matrices,  final  used, with i t e r a t i o n s to e s t a b l i s h  v a r i a b l e s c o u l d be v e r i f i e d . at  a s e r i e s o f R-type  the  and  dyad.  By performing  (direct  of  observer  a n a l y s i s of ward, observer,  by  new  strong support categories. . below),  categories thus  there  for  by the  Excluding was  no  tended  to  load  confirmed  in  this  three  Hl-b  was  the  assumption  of  o r t h o g o n a l i t y , the  rotations  summarized  in  Tables - V i l l , - - y i l l - i and, IX  analysis. Removing obligue showed was  a  and  weak interdependence of some c a t e g o r i e s , but  minimal.  tended  to  .29  In g e n e r a l , varimax l o a d i n g s  when  single  supported  of  .10  to  i n c r e a s e on the o b l i g u e s t r u c t u r e t o between the  orthogonality  These values were s t i l l the  r  dominant  Hypothesis  low,  was  .19 .20  lifted.  r e l a t i v e t o the high l o a d i n g o f  variable.  1-b. ,  restriction  this  This  analysis  further  87 ________ VARIMAX VARIABLE  P  FACTOR 1  FACTOR 3  FACTOR 2  ROTATED FACTOR MATRIX—BOTH  FACTOR U  FACTOR 5  FACTOR 6  FACTOR 7  FACTOR 8  WARDS  FACTOR 9  FACTOR 10 FACTOR 11 FACTOR 12  .98  1  P2  -.9*  P3  • 95 .97  ?4  -A3  P6  -.1*1  -.36  • 50  .96  P7  .95  P8 P9  • 93  .21  -.22  P5  .96  P 10  • 96 .96  P 11  -.91 '  -.21  P 12  -23  (K • kk)  ONLY FACTOR LOADINGS > .20 ARE REPORTED  _______ VARIMAX VARIABLE  P  1  P  2  FACTOR 1  FACTOR 2  FACTOR 3  ROTATED FACTOR MATRIX—SECOND  FACTOR 4  FACTOR 5  FACTOR 6  FACTOR 7  FACTOR 8  FACTOR 9  -.97  0  -.97 .97  P4  • 97  P5 P6  .38  -.23  -.U2  pe  -.25  • 50  -.21  .97  P7 -  .22  .96 .99  P9  .  .21*  10  p 11 P  f w c r o n 1 0 FACTOR 1 1 FACTOR 1 2  -.96  P3  P  WEST  .98 .99  12  (if - ne)  ONLY FACTOR LOADINGS > .20 ARE REPORTED  -95  88 TABLE_VI VABIHAX ROTATED FAG TO g M AT R I S TATIQ N FIVE VARIABLE  FACTOR 1  PI  FACTOR 2  FACTOR 3  FACTOR 4  FACTOR 6  FACTOR 5  FACTCR 7  FACTOR 8  FACTOR 9  FACTOR 10 FACTOR 11 FACTOR 12  .86  P2  .97 .7*  J J  .79  P» .78  PS  .90  P6 P7  .85  .69  P8 .71  P9  •37  P 10 .66  pil P  •38  12  (R - 160)  ONLY FACTOR LOADINGS > .20 AND REPORTED  TABLE VII QBLI0.UE_FACTOR_STROC^ VARIABLE FACTOR 1  p1  • 33  P2  .27  P3 P»  FACTOR 2  FACTOR 4  FACTOR 5  FACTOR 6  FACTOR 7  .28  P6  .1.00  .28  -.36  -1.00  .22  -.23  • 33  .27  P9 -.99  P 10  .28  .99  .21  •31  .31  • 36  • 99 -.26  .28 .21  -.24 -1.00  -.30  • 36  .23  .28  - 4 5  1.00  -.28  P 11  -1.00  -.26  .24  P7  • 35  .27  • 35 • 36  FACTOR 10 FACTOR 11 FACTOR 12  .24 -1.00  •33  FACTOR 9  .22  -1.00  -.30  P 12  FACTOR 8  -1.00  .27  P5  P8  FACTOR 3  1.00  • 36 • 36  33  (I - 44)  ONLY FACTOR LOADINGS > .20 ARE REPORTED  TABLE_VIII OBLIQUE FACTOR STRUCTURE—SECOND BEST VARIABLE  FACTOR  1  FACTOR  FACTOR  2  3  FACTOR  4  FACTOR  5  "ACTOR 6  FACTOR  FACTOR  10 F A C T O R  11 F A C T O R  -1.00  .23  12  .22  .22  -1.00  .29  .23  -1.00  .21 -1.00  .26  P6 -1.00  P7  9  .26  .24 .21  FACTOR  .24  -1.00  P3 P4  .21  .25  1.00  .46 1.00  P9 P 10  8  -1.00  .25  P2  P8  FACTOR  .29  P1  P5  7  -.21  1.00  P 11  1.00 -  P 12  .21  .46 .21 1.00  (H - 118)  ONLY FACTOR LOADINGS > . 2 0 ARE REPORTED  TABLE_IX QBLI<20E_FACTO RESTRUCTURE VARIABLE!  11  FACTOR  1  FACTOR  2  FACTOR 3  FACTOR 4  -1.00 .22  .23  7  FACTOR 8  FACTOR  9  FACTOR  10 F A C T O R  -.21  .76  .82  -.23  -95  11 F A C T O R  •  -.81  P5 P6  FACTOR  -.28  P3 P4  FACTOR 6  -.88  .26  P2  FACTOR 5  .28  -.20  • 31 -.25  -.26 .88  P7 -.70  P8 -.72  P9  • 38  P 10 .67  P 11  -.49  P 12 (N - 160)  ONLY FACTOR LOADINGS > .20 ARE REPORTED  12  90  The c l a r i t y whether  o f these f i n d i n g s r a i s e d  the f a c t o r  s t r u c t u r e was a c t u a l l y as simple  appeared, o r c o u l d  this  particular  was t h e l a c k  concern  the guestion  be  a  statistical  of  as i t  artifact?  o f an obvious  A  order f o r  v a r i a b l e l o a d i n g s on t h e f a c t o r s . Tabie_X g i v e s the major v a r i a b l e l o a d i n g s .  Eigenvalues,  and p r o p o r t i o n s o f t h e v a r i a n c e e x p l a i n e d , f o r each  of the  t h r e e data s e t s . TABLE .X EIG___AL_____AJO__V FOR EACH FACTOR—WARDS  SEPARATE AND COMBINED ST/ ITI0N FIVE  SE( 30ND WEST  BC TK WARES % VARIANCE  EIGENVALUE  VARIABLE  % VARIANCE  EIGENVALUE  VARIABLE  % VARIANCE  EIGENVALUE  VARIABLE  1  2.17  P9  18.2  1.88  P2  15-7  1.41  re  21.0  2  1.87  71  15.6  1.50  P4  12.5  1.19  PI  17.8  3  1.68  P3  14.1  1.44  F3  12.0  .82  P7  12.2  4  1.19  r?  10.0  1.27  Pll :  10.6  • 72  P5  ]0.7  5  1.13  pi  9.5  1.08  PI  9.0  .69  P3  10.2  6  1.04  P10  8.7  .99  P7  8.3  • 57  P9  8.4  P4  8.1  FACTOR  7  .89  P3  7.5  .97  16  8.1  .5'*  8  .69  Pll  5-8  .89  P5  7.4  .43  9  • 55  I>4  4.6  .74  P12  6.2  .37  Pll  5-6  10  .42  P12  3-5  .73  10  6.1  .18  P12  2.7  11  .32  P5  2.6  .50  P10  4.1  •03  P6  12  -0.00  •0.0  •0.00  -23  •0.0  6.3  P10  • 5  -3.6  When t h e v a r i a b l e / f a c t o r r e l a t i o n s h i p was examined more closely,  some  8, and 12 loaded combined  wards.  c o n s i s t e n c y emerged. i n this  order  on  C a t e g o r i e s 2, 3, 7, 1, the f a c t o r s  o f the  T h i s r e l a t i o n s h i p was a l s o e v i d e n t on t h e  Second West f a c t o r s , except t h a t P7 and P1  were  reversed.  91  The  Station  otherwise  Five  the  Therefore,  factors  order  only  had  P3  confirmed  Categories  and  the  4,  5  P1  reversed*  other  #  two  but  analyses.  9,  10,  and  is  believed  11  loaded  randomly. The l a c k of occurred  because  would account all  total  consistency  t h e r e was  are  have  no s i n g l e dominant f a c t o r which  f o r most of the data  Eigenvalues  to  relatively  variance.  In  Table  close  in  magnitude.  s i n g l e f a c t o r makes a major c o n t r i b u t i o n  to  the  X. No  explained  variance. Hypothesis  H2,  p i l o t study data by two  (see Appendix A), was  information)  of the f a c t o r s , and Second  Category weakly data.  west  loaded moderately weakly  data.  or  moderately  Categories  p a t t e r n was When  to  supported  3  with  their  the  to -50)  on three  11 and  5  also  factors  12. had  by  ward and  6  on f o u r  others  combined  with C a t e g o r i e s 2  direction  of  the  a l l f a c t o r s but one  the r e v e r s e d i r e c t i o n 6  11 and  hierarchy).  to .29)  Using  and  (.30  Category  in  data. 4,  and  On the Second West a  moderate-to-weak  Category  6.  No  such  found i n the varimax a n a l y s i s f o r S t a t i o n F i v e . the  examined,  Category  (.20  6 loaded moderately  contribution  3, 4,  partially  out of the three varimax f a c t o r a n a l y s e s .  (gives  the  which evolved from the a n a l y s i s of the  was 12  to  varimax  loadings  (Table^IV, F a c t o r 10)  the  other  variable.  was  were i n  That  n e g a t i v e l y a s s o c i a t e d with C a t e g o r i e s  is. 1,2,  (those at the extremes of the c a t e g o r i z a t i o n  Examination  of  the  obligue  factor  structure  92  revealed  a  similar  but accentuated  p a t t e r n because of the  g e n e r a l i n c r e a s e i n the f a c t o r l o a d i n g s . TableXI Category 6's  summarizes co-loadings  the  number  without  and  regard  direction  of  f o r t h e i r magnitude.  TABLE_XI N0MBER_M2_2IRECTION_OF_C Direction  reverse  c?  C9  C8  Rotation  Cl  C2  C3  Ch  C5  varimax  2  2  1  2  1  oblique  7  3  2  6  1  3  2  total  9  5  3"  8  2  3  2  oblique  1  2  k  2  5  1  total  1  2  4  2  6  1  Cll  C12  2  1  2  if  . 2  2  6  3  CIO  varimax same  In  general,  Category  with C a t e g o r i e s association  6  9,  -  -  1  had a strong negative a s s o c i a t i o n  1, 2, 4, 8, and  with  1  10, and  11, 12.,  and  a  weak  negative  I t had a strong p o s i t i v e  a s s o c i a t i o n with Category 5 (the c e n t r a l , task dimension giving  opinions).  Findings  for  Categories  3 and  of  7 were  ambiguous. It  therefore  categorization,  appears  that,  using  of  itself.  However, C a t e g o r i e s  2 and  dimension  one  been  refined  to  unigue types of i n t e r a c t i o n  the  in  11, which under  the o l d system a l s o appeared to be a d j u n c t i v e , have new  new  Category 6 remains an adjunct t o most o t h e r  communication behaviors, r a t h e r than a unique and  Bales*  in  the  p o i n t where they emerge as  behavior.  93  The  oblique  determine  rotations  whether  l o a d i n g along the  any  were  further  examined  to  t r e n d s were e v i d e n t towards f a c t o r s  directional  dimensions  hypothesized  Bales t o c o r r e l a t e with each of the new c a t e g o r i e s .  by  No such  p a t t e r n emerged. Hypothesis 3 was s t a t e d as f o l l o w s : H3 B a l e s twelve i n t e r a c t i o n C a t e g o r i e s are i n c l u s i v e of a l l t y p e s of v e r b a l communication behavior. 1  T h i s h y p o t h e s i s was t e s t e d i n f o r m a l l y by the number acts  coded  into  a  t h i r t e e n t h category  Table XII g i v e s the t o t a l number of a c t s  of  ("0 not c o d a b l e ) . ,,=  in  this  residual  c a t e g o r y by week, p l u s t h e i r c o n t r i b u t i o n s t o t h e percentage profiles.  TABLE XII ABSOLUTE S RELATIVE, FREQUENCY OF CATEGORY ,0-BX MEEK  CATEGORY 0 - ABSOLUTE FREQUENCY CATEGORY 0 - PERCENT OF TOTAL TOTAL ACTS  This  hypothesis  was  WEEK 1  WEEK 2  WEEK 3  WEEK 5  WEEK 6  WEEK ?  24  170  40  220  406  470  .40 %  1.68 %  1.80 %  2.16 %  2.62 %  2.85 %  5.901  10,094  2,223  10,178  15.504  16,511  not" submitted  s i g n i f i c a n c e using Chi-sguare f o r the above  (page 80),  but  the  to  a  same  formal t e s t of reasons  given  data appear t o support H3.  maximum v a l u e f o r Category  0 i s 2.8% o f the  all  The s l i g h t but steady i n c r e a s e i n  staff  and p a t i e n t s .  total  acts  The by  94  percentages  between  weeks  1  and 7  likely  reflects  an  observer f a t i g u e f a c t o r . Hypotheses Multivariate  4,  6,  Analyses  data-handling program Los  Angeles'  7, and 8 were t e s t e d by a s e r i e s o f of  Variance  (MANOVA).  used was the U n i v e r s i t y o f C a l i f o r n i a ,  BMD:X63,  a  MANOVA  program  which a l l o w s f o r  unbalanced design and unegual c e l l f r e g u e n c i e s . program  The  limitations,  only  t h e main  effects  o b t a i n e d — i n t e r a c t i o n e f f e c t s were grouped  with  Because  of  could  be  the error  term. A s e r i e s o f p a r t i a l l y complete MANOVA's was executed t o examine  combinations  intervening  of the f o l l o w i n g  variables:  position  dyad,  independent week,  and  day,  time  p e r i o d , ward, l o c u s , and o b s e r v e r .  1.  Week: Although  this  v a r i a b l e c o u l d not be r i g o r o u s l y  tested  from the f i n a l data, some i n d i c a t i o n o f i t s impact c o u l d gained  by  comparing  t h r e e days' data from S t a t i o n F i v e i n  the i n i t i a l "shakedown" week with the same t h r e e the  f i n a l data s e t .  A subset o f twenty-one  both weeks was s e l e c t e d , each with a minimum periods two  be  and one hundred a c t s .  days  from  dyads common t o of five  time  Data were then aggregated i n  ways: WEEK by DAY by OBSERVES by LOCUS  ("WDOL")  WEEK by OBSERVER by DyAD  ("WODy")  95  after profiles  aggregation, Were  of independent coded,  and  assessed.  category  calculated  f o r each  and i n t e r v e n i n g  their  totals  and  percentage  combination.  A l l levels  variables  were  then  e f f e c t on t h e dependent v a r i a b l e  The s i g n i f i c a n c e  l e v e l of  dummy profile  the F - S t a t i s t i c s f o r  the main e f f e c t s i s given i n Table..XIII,.  TABLE_XIII aANpJA-^SIGNI^FIC^HCE OF F-STATISTICS .FQa^MSIK TOOL  VODy  Veck  .001  .001  Day'  ns  Observer  <  .001  ns  Locuo  .001  Dyad N-70  2-  .001  K-83  Wardi Again, a subset o f 11 dyads common t o both wards d u r i n g  the  final  data  c o l l e c t i o n was used, with the same minimum  freguency c r i t e r i a .  F i n d i n g s a r e summarized in° Table XIV.  TABLE_XIV MAHOVA--SIGNIFICANCE OF,F-STATISTICS FOE-WARD VdDOL Yard  na  Har  .005  Observer  .001  Locus  .025  VdODy .05  .01  .001  Dyad K-113  96  3-  Day. Observer, Time Period,_Locus: Two  analyses  variables—one  for  o u t l i n e d above. the  analysis,  were each  completed  for  ward—using  these  intervening  the minimum  In order t o reduce the number of the  time  criteria cells  in  of day was reduced t o t h r e e major  "time p e r i o d s " — 0 8 0 0 t o 0930, 1030 t o 1200,  and  hours f o r f i n d i n g s on these f o u r v a r i a b l e s , see  1300  to  1430  Tabi___V.  TABLE XV MANOVA—SIGNIFICANCE OF F-STATISTICS FOR ' DAY. OBSERVES, TIME PERIOD. LOCOS DOTL(2tf)  D0T_(S5)  fey  •05  •005  Observer  .001  .001  ns  ns  .05  • 05  K-165  N-133  i'lme Ferloc Locus  Very s i m i l a r p a t t e r n s were o b t a i n e d on the but "day" was l e s s s i g n i f i c a n t on Second  Best.  two  wards,  Implications  of t h i s w i l l be d i s c u s s e d below.  4.  Day, Observer, Dyad: The  two  most s i g n i f i c a n t  analysis—i.e. dyad.  Here  v a r i a b l e s from the p r e c e d i n g  day and o b s e r v e r — w e r e  then  combined  with  an i d e n t i c a l p a t t e r n emerged f o r the two wards  (see Table_XVI).  97 TABLE XVI A—SIGNIFICANCE OF F-STATISTICS  D0Dy(2W)  D0Dy(S5)  .025  .025  Oboervor  .005  .001  Dyad  .001  .001  H-no  N-160  One q u e s t i o n r a i s e d by the above a n a l y s e s d i f f e r e n t ' patterns  ones.  Two  separate  MANOVA's  e i t h e r or both  members  grouped  positions,  were s i n g u l a r .  one  Results  were  wards.  On  Station  F i v e , a majority  f o r t h e d i f f e r e n t N's i n v o l v e d ,  patterns  on  the  of the p o s i t i o n s  were s i n g u l a r ; on Second Hest, most were grouped.  not  were  and  complicated by d i f f e r i n g d i s t r i b u t i o n s o f p o s i t i o n s two  whether  f o r each ward—one on a l l freguent p r o f i l e s where  both members of the dyad were where  was  of s i g n i f i c a n c e might emerge f o r grouped  r o l e s versus s i n g u l a r performed  FOR  Allowing  of s i g n i f i c a n c e d i d  appear t o d i f f e r markedly i n the two types of a n a l y s i s ,  with one  exception.  On  both  wards,  locus  reached  the  p < .001  l e v e l f o r s i n g u l a r r o l e s , and was only s i g n i f i c a n t  between p < .10 and p < .05 f o r grouped r o l e s . Summarizing  the  findings  relevant  to  Hypotheses  4  through 8, the f o l l o w i n g assessments can be made: H4 The major independent v a r i a b l e which i n f l u e n c e s the communication p r o f i l e i n a h o s p i t a l ward i s the p o s i t i o n dyad. T h i s was s t r o n g l y  supported (p < .001). i n a l l a n a l y s e s .  98  H5 Task f a c t o r s have a weaker, but e f f e c t on the i n t e r a c t i o n p r o f i l e s .  still  significant,  T h i s c o u l d not be t e s t e d , f o r reasons s t a t e d above.  H6 The c o n t e x t u a l f a c t o r s o f day, week and time do not have a s i g n i f i c a n t e f f e c t , when c o n t r o l l e d f o r other intervening variables. . Results Day three  v a r i e d according t o t h e p a r t i c u l a r v a r i a b l e .  was not s i g n i f i c a n t i n the HDOL a n a l y s i s , when only  days'  generally effect  data  were  used.  s i g n i f i c a n t between was  accentuated  on  and  Station  Five,  from  clinics  conferences,  leaves,  team  from  p < .05  consistently varied and  day  Apart  to  day  that,  i t was  p < .01.  This  where - events  because  preparation  of  weekly  f o r weekend  admissions, discharges, e t c .  Week was h i g h l y s i g n i f i c a n t . . T h i s u n a n t i c i p a t e d i s discussed  effect  below under "observer."  Time p e r i o d  was c o n s i s t e n t l y not s i g n i f i c a n t .  H7 The l o c a t i o n of i n t e r a c t i v e behavior (i.e..ward, locus) has a s t r o n g l y s i g n i f i c a n t mediating e f f e c t on the p r o f i l e s of a l l dyads. T h i s p r e d i c t i o n was p a r t i a l l y Hard was i n c o n c l u s i v e — i t was  upheld. significant  beyond  the  p < .05 l e v e l when t h e data were analyzed one way; t h e other way, i t was not s i g n i f i c a n t . Locus, with t h e e x c e p t i o n of the "week" a n a l y s i s fewer and  dyads  and  days), was s i g n i f i c a n t a t between p < .05  p < .025, s u p p o r t i n g t h i s p a r t o f t h e  observed  (using  difference  hypothesis.  between s i n g u l a r and grouped  The  positions  99  i s understandable, s i n c e s e v e r a l of worked  mainly  at  the n u r s i n g  the  single  s t a t i o n (e.g.  incumbents  senior  nurse,  ward c l e r k ) .  H8 The e f f e c t o f a s p e c i f i c observer does v a r i a t i o n i n communication p r o f i l e s . This  hypothesis  explanations  D.  was  definitely  produce  refuted.  f o r t h i s f i n d i n g are d i s c u s s e d  Possible  i n Chapter _ I V .  HOSPITAL FEEDBACK:  As p a r t of the r e s e a r c h e r ' s it  not  was agreed t h a t o b j e c t i v e  patterns  could  administrators.  be provided  commitment to the h o s p i t a l ,  information  on  t o s t a f f , department heads, and  The h o s p i t a l was aware from the o u t s e t  the method was not s u f f i c i e n t l y r e f i n e d to from  "bad"  communication,  communication p r i n c i p l e s . mirror  which  communication  communication  would  except What  reflect  as  could to  the  separate  related be  to  that  "good" general  provided  was  participants  their  patterns.  The process o f i n i t i a l feedback which the s u b j e c t s researcher  agreed  upon  was  would r e c e i v e r e s u l t s before l a t t e r , i n turn, singular researcher, profiles.  a  before  positions  as f o l l o w s : b a s i c l e v e l  and staff  t h e i r department heads, and the  the  would  and would be given  administration. meet the  Persons  individually  with  master  of  copy  in the  their  100  A  series  of one-half  groups of s t a f f feedback-  Each  i n f o r m a t i o n and her/his  during staff  ranged  was  Staff  the  sheets, plus a l l  up  to  graphs  only one  twenty-nine thoroughly  emphasized t h a t the  of  the two  their to  discrepancies  go  "bad".  The  copies over  of the  onus  the  and  to  In the  first  or  two  pairs  of  how  researcher's  was  material.  profiles  discuss  possible  assist  the  second met  received  placed  on  They  their  on  week  of  were  own,  to  examine  would r e t u r n i n  four  to  a plan of  data. the  December  feedback,  i n d i v i d u a l l y with each department head. the same b a s i c p r e s e n t a t i o n as t h e i r  In most i n s t a n c e s , t h i s was  or  causes and s o l u t i o n s .  h o s p i t a l t o formulate  a c t i o n using the communication  researcher  for  p o s i t i o n s t o examine t h i s dimension.  They were t o l d t h a t the r e s e a r c h e r weeks  the  discussed,  p r e f e r a b l y with a group of t h e i r co-workers, and  six  December  not to assess whether d i s c r e p a n c i e s i n the p a i r e d  kept  encouraged  of  the l a y o u t of the p r o f i l e s and  p r o f i l e s were "good" or incumbents  held f o r small  r e c e i v e d c o p i e s of  i n f o r m a t i o n sheet was  i n t e r p r e t them., I t was  role  week  participant  f o c u s i n g on understanding to  first  In some cases, t h i s was  dyads; i n o t h e r s , i t The  the  p a t i e n t coding  position.,  profiles.  hour meetings was  followed  d i s c u s s i o n of guestions r a i s e d by the  by  a  more  the They  staff.  detailed  profiles.  At the end of the f i r s t feedback p e r i o d , the  researcher  h e l d a two-hour meeting with t h r e e members of t h e management committee  of  the  South Saskatchewan H o s p i t a l Centre,  plus  101  the a d m i n i s t r a t i v e c o o r d i n a t o r reviewing  the  p r o f i l e s was  view, might have  the  data  administrative  the o r i g i n a l mandate was  present  i t to the s t a f f and  sought from the committee on  and  of  future  elicit  input.  They  as many suggestions  s t a f f during the next feedback v i s i t stringencies), Development Education)  and  p o i n t of  implications  guidance was  researcher  After  which, from the r e s e a r c h e r ' s  future  Since  and  format  Hospital.  method of data c o l l e c t i o n , a s e l e c t e d s e t of  presented  Appendix F ) .  of i a s c a n a  only t o  collect  administration,  the  desirability  reguested as p o s s i b l e  (keeping  that  the  from  the  i n mind budget  i n v o l v e the s o o n - t o - b e - e s t a b l i s h e d  Department  (formerly  as h e a v i l y as p o s s i b l e .  then take over r e s p o n s i b i l i t y f o r  (see  Nursing  Staff  Inservice  S t a f f Development c o u l d implementing  any  action  a r i s i n g out of the study., The  second  two-week  feedback  u n t i l February at the reguest It  session  in  administrator  (the  third  just learned  Because of  unrest  emphasis  maximizing the staff  and  the  hospital,  effectiveness  and  of  i n three months)  impending c u t s i n s t a f f p o s i t i o n s . throughout  postponed  of the h o s p i t a l a d m i n i s t r a t o r .  began s l o w l y , as department heads had  change  was  efficiency  programs r a t h e r than developing  new  the was of  a and  general  shifted to existing  areas.  102  The met  researcher  with the  departments:  heads  and and/or  Dietary,  Practitioners  and  the d i r e c t o r of s t a f f development supervisors  Therapy,  S o c i a l Work,  and Speech  the  following  Housekeeping, M e d i c a l S t a f f  Consultants),  Occupational  of  fifursing  Physiotherapy, and Hearing.  (General  (both  Pharmacy,  wards),  Psychology,  At each n e e t i n g , the  department members present were asked: (a) What a d d i t i o n a l work had they or their staff done with the communication feedback s i n c e mid-December? (b) Did they see any need f o r a c t i o n ? I f s o , what had they already done? What should be suggested f o r the future? (c) What type of help would they l i k e , e i t h e r from the r e s e a r c h e r or from S t a f f Development, f o r : - g e n e r a l s t a f f members? - s u p e r v i s o r s and/or department heads? Four major inter-department  were d i s c u s s e d :  (a) low communication by a l l s t a f f with patients with moderate to severe impairment ( i . e . "aphasia")  Station Five communication  (b) f u n c t i o n i n g of team conferences on S t a t i o n F i v e (c) d e s i r e of department heads and/or s u p e r v i s o r s f o r some t r a i n i n g i n how to help s t a f f communicate more effectively (d) g e n e r a l s t a f f ' s wish f o r communication. With  the  r e l a t e d to  exception the  of  specific  number  information one,  interaction  on  effective  these i s s u e s were not profiles,  but  r a i s e d by the department heads as r e l e v a n t concerns.  were  103  In  addition,  a  number of i n t r a y d e p a r t m e n t a l problems  were d i s c u s s e d . , These g e n e r a l l y  focused  on  the  specific  communication p r o f i l e s f o r t h a t department., Examples of t h e concerns  which were r a i s e d a r e :  (a) low communication of dietary a i d e s with p a t i e n t s with communication impairment (aphasics) (b) s t r o n g communication r o l e of d i e t i c i a n with Station Five p a t i e n t s on an experimental program o f t h e r a p e u t i c diets (c) n u r s e - p h y s i c i a n friendly)  imbalance  of  Category  1  (seems  (d) low communication o f c l i n i c a l pharmacists with a l l p a t i e n t s , e s p e c i a l l y aphasics (e) frequency of negative emotional r e a c t i o n s ( t e n s i o n , unfriendliness) from p a t i e n t to physiotherapy attendant on Second West A c t i o n was taken on most of these  concerns.  In  some  c a s e s , the r e s e a r c h e r acted as a d i r e c t r e s o u r c e , conducting classes  for  department heads and s t a f f .  I n o t h e r s , only a  n e u t r a l c a t a l y s t was needed t o enable the department members to  solve  their  administrative  own  problems.  support  and/or  a d d i t i o n a l emphasis i n the f i n a l committee  (see  Appendix H  Issues  which  required  decision-making  were given  report  management  to  the  f o r d e t a i l s of concerns  raised,  c o n c l u s i o n s reached, and a c t i o n taken during the two  weeks).  104  CHAPTER IV  A.  DISCUSSION!  The f i n d i n g s o f the study areas  of  concern—theory,  the u t i l i t y  1.  can  be  divided  into  four  method, the r e s e a r c h model, and  of the method.  Theory: The c o n s t r u c t v a l i d i t y o f any  first  be  Bales*  performed  original was  premise  the  supported  concerning  (gives  opinion)  c o n v e r s a t i o n a l seguence. associated  with  the  (Categories  leadership  categories  by the f a c t o r data.,  Category  are  analyses  Seguential  (gives  frequently  12),  of  6  intermingled i n a  However, Category  and  information)  I t appears t h a t C a t e g o r i e s  expression 1  6  6 i s negatively  p o s i t i v e and negative  giving  suggestions  or  (Category 4 ) , and s e e k i n g o p i n i o n s (Category 8 ) .  Thus i n f o r m a t i o n - g i v i n g tends t o be done i n these  are  o f the category p a i r s could not be a s s e s s e d .  merit f u r t h e r i n t e r p r e t a t i o n .  affect  that  on t h e present and p i l o t study  Findings  5  must  or u t i l i t y .  strongly  interdependence  and  measure  e s t a b l i s h e d before c o n s i d e r a t i o n i s g i v e n t o such  f a c t o r s as r e l i a b i l i t y  orthogonal  empirical  other f i v e dimensions.  communication  behaviors  are  isolation  from  L i k e w i s e , when the f i v e  other  exhibited,  the  amount  of  105 i n f o r m a t i o n provided While  i s reduced.  the d i r e c t i o n a l i n d i c a t o r s of the new  were h e l p f u l t o the observers  categories  i n d e c i d i n g where a p a r t i c u l a r  a c t should be placed i n the i n t e r a c t i o n a l space, evidence d i r e c t i o n a l l o a d i n g s was Since the new of  factor  analyses.  c a t e g o r i z a t i o n i s s t i l l i n the embryonic  development,  necessary  not found i n the  considerable  construct  or  data.  present  The  whether  they are more r e l e v a n t t o  research guestions  the  the  level  comparative and  of  the  organizational  perceptual  validity  of  the  behavior  position.,  c o n t r a s t i n g s t u d i e s are necessary  is  actual  d i r e c t i o n a l hypotheses f o r i n t e r p r e t i n g i n t e r a c t i o n at  stage  validation  t o determine i f these dimensions i n f l u e n c e  behavxor,  of  Other  to further  examine t h i s i s s u e . The  study  validity.  data a l s o showed strong i n d i c a t i o n s  Empirical  variations  r e f l e c t e d " r e a l " events o c c u r r i n g were was  described hot, and  the  in  the ward atmosphere was  profiles  socio-emotional  had acts.  on S t a t i o n F i v e i s  interaction  during  by the ethnographic  of  the  profiles  study  which  data., When the weather described  as  "tense",  proportion  of  negative  a  higher  The  s t a t i s t i c a l s i g n i f i c a n c e of  associated  face  with  the  observation  "day" that  d i f f e r e n t events happened on t h a t ward on s p e c i f i c days., Second  West,  between one  day  v a r i a b l e "day" Ho  where and had  strong  there was the  little  next  observable d i f f e r e n c e  (including  weekends),  only a minimal impact on the patterns  of  On  variation  the  profiles. were  noted  106  ethnographically  w i t h i n days a c r o s s the time periods  by the study, and time was not a s i g n i f i c a n t analysis  of  singular  communicators  assistant  variance.  director  communications singular  to  versus  The  duties  (ward  of  clerk,  nursing)  factor  senior  station.  profiles  found  i n the  three of the main nurse,  restricted  the n u r s i n g  grouped  of  spanned  and  many of t h e i r Comparisons  of  t h a t " l o c u s " was  h i g h l y s i g n i f i c a n t f o r the s i n g u l a r cases. The  above  research,  findings,  could  make  a  development o f a "theory  2.  i f  substantiated  significant  by  future  contribution  t o the  o f o r g a n i z a t i o n a l communication."  Method! Turning  should  from i s s u e s o f t h e o r e t i c a l r e l e v a n c e ,  be focused  on t h e  methodological  attention  concerns  examined  d u r i n g the study. The  most  important  finding  concerning  method was  that  determining  p a t t e r n s o f communication.  .the_ position ,dyad - plays a dominant-role i n :  t h a t "each s o c i a l p o s i t i o n w i t h i n consistent  the r e s e a r c h  the  The  basic  organization  s e t of i n t e r a c t i o n p a t t e r n s " was upheld.  premise has a There  are s e v e r a l i m p l i c a t i o n s a r i s i n g from t h i s f i n d i n g . The  f i r s t i s that the f u n c t i o n a l p o s i t i o n ,  as  defined  above, i s an important focus f o r the study o f o r g a n i z a t i o n a l behavior.  This  area  of  concern  has  researchers  i n t h e f i e l d , who have tended t o  i n d i v i d u a l , the group or t h e o r g a n i z a t i o n .  been  n e g l e c t e d by focus  on the  107  An e x t e n s i v e review o f the use of " r o l e " and " p o s i t i o n " in  the  o r g a n i z a t i o n a l l i t e r a t u r e over the past f i v e  (McGill,  1975)  has  shown  that  these  concepts  considerable  p o t e n t i a l f o r b r i d g i n g the gap between  and  approaches  "micro"  D. J . Levinson  (1959),  p e r s o n a l i t y , and setting",  to in  social  the a  study  seminal  structure  in  of  'role*)  is  have "macro"  organizations.  article  on  "Role,  the o r g a n i z a t i o n a l  suggests t h a t one of the "most a l l u r i n g  (of the concept  years  i t s double  qualities  reference  to  the  i n d i v i d u a l and t o t h e c o l l e c t i v e matrix.... The o r g a n i z a t i o n provides  a  s i n g u l a r l y u s e f u l arena f o r the development and  a p p l i c a t i o n of r o l e theory  (p. 1 7 0 ) . H e  has thereby i s s u e d  a d u a l c h a l l e n g e to O r g a n i z a t i o n a l B e h a v i o r i s t s — - t o an  develop  i n t e g r a t i v e t h e o r y of o r g a n i z a t i o n a l r o l e s , and t o apply  t h i s framework to e m p i r i c a l a n a l y s e s o f behavior. Three Hickson  other  (1966)  works  reiterated  recognized  the  Levinson* s  potential  challenge.  u t i l i t y of r o l e  t h e o r y f o r o r g a n i z a t i o n a l a n a l y s e s , but focused only on r o l e s p e c i f i c i t y . , Katz and Kahn  (1966) suggested  that r o l e  was,  "...the major means f o r l i n k i n g the i n d i v i d u a l and organizational l e v e l s of r e s e a r c h and theory; i t i s at once the b u i l d i n g block of s o c i a l systems and the summation of the reguirements with which such systems c o n f r o n t t h e i r members as i n d i v i d u a l s (p.,197)." However, they only explored the integrative (1971)  theme  suggested  individual (p. 252) ."  and  role-taking  episode.  then l a y dormant u n t i l Lichtman that, the  "roles social  do  more  than  structure—they  The  and Hunt  link  the  unite  them  108  Levinson's  dual  s y s t e m a t i c attempts a  conceptual  organization. and  has  not  been  met. , Few  have been made t o develop r o l e theory as  link  between  the  individual  A p p l i c a t i o n s of r o l e theory  empirical  rigor.  challenge  analyses  of  are  and t h e  disjointed,  these concepts vary g r e a t l y i n  Future work i n t h i s area h o l d s c o n s i d e r a b l e  promise,  and should be given p r i o r i t y by o r g a n i z a t i o n a l r e s e a r c h e r s . The second  implication i s that  organizational interactive  behavior  behavior  individuals.  It  understanding  of  i s e n r i c h e d by the examination o f  of  was  the  dyads  the  as  well  who-to-whom  as  that  combination  i n f l u e n c e d the i n t e r a c t i o n s , not t h e p o s i t i o n  of which  incumbent  in  isolation. A stable  third  implication  behavior  patterns  i s linked can  be  to  the f i n d i n g t h a t  identified  for  the  incumbents  of p a r t i c u l a r o r g a n i z a t i o n a l p o s i t i o n s . ,  Whereas  Bales found  little  groups,  the  s t a b i l i t y f o r i n d i v i d u a l s across  present study demonstrated s t a b i l i t y f o r p o s i t i o n dyads  across  a  time  span  of  eight  weeks  and  a  variety  of  situations. Given  the  above,  contributions to the f i e l d  one  by  studying  functional  position.  the  study's  significant  of o r g a n i z a t i o n a l behavior should  be t o emphasize t h e wealth of gained  of  understanding  organizations  at  the  which  can  be  level  of t h e  109  The other major methodological f i n d i n g of the study t h a t , while a c c e p t a b l e reliability of  of  intra-  and  inter-rater  c o u l d be achieved on data u n r e l a t e d t o the  type  o r g a n i z a t i o n being s t u d i e d , the p a r t i c u l a r observer had a  strongly  significant  profiles. for  levels  was  T h i s was  effect  on  the  ward  interaction  not a n t i c i p a t e d , and i s a major  f u t u r e use of the method.  There  are  at  concern  least  three  p o s s i b l e e x p l a n a t i o n s f o r the c o n s i s t e n t s i g n i f i c a n c e of the variable  "observer".  The  first  observers.  is  the  backgrounds  of the  two  The study design purposely employed persons  d i f f e r i n g exposures minimize  divergent  any  with  to t h i s type of o r g a n i z a t i o n i n order t o  observer "expectancy  effect."  The  researcher  i s s t i l l of t h e o p i n i o n t h a t the c h o i c e of an a s s i s t a n t no  exposure  to the h e a l t h c a r e system was  with  j u s t i f i e d at the  time from the p o i n t of view of study design and r i c h n e s s ethnographic d a t a . whether  However, the c r u c i a l g u e s t i o n now  arises  an o b s e r v a t i o n a l team can f u n c t i o n e f f e c t i v e l y  such d i v e r g e n t backgrounds.  This  factor  is  of  with  particularly  suspect as a c o n t r i b u t o r to the "observer e f f e c t " because of the  reasonably  taped m a t e r i a l . element  during  high One  reliability would  "in  a t t a i n e d on the " n e u t r a l "  suspect  process"  that  coding  the is  interpretive stronger  than  Current s t u d i e s of o r g a n i z a t i o n a l c l i m a t e suggest  that  anticipated.  a p a r t i c u l a r type of o r g a n i z a t i o n develops a unigue c l i m a t e . It  would  therefore  seem reasonable t o p o s t u l a t e t h a t some  110  a s p e c t s of t h a t c l i m a t e are only who to  have its  accessible  to  "insiders"  experienced i t s impact and have becoae s e n s i t i z e d subtleties.  An  "outsider"  who  has  not  been  s o c i a l i z e d i n t o a p a r t i c u l a r organizational climate  may  ongoing  than  behavior  "insider."  from  different  perspective  I t i s important t o r e c o g n i z e  of the o r g a n i z a t i o n While  a  the  that  above  approach to study design has  by o r g a n i z a t i o n a l r e s e a r c h e r s ,  significant  concern  in  the  c o n s u l t a t i o n f o r many years. "Journal  group  and  authors (Gibb,  organizational to  was  the  i t has  of  an  view  not  yet  been  a  organizational  entire  issue  of  devoted to the t o p i c o f  consultation.  Several  m u l t i p l e r o l e s of the  1959; fi. L i p p i t t , 1959;  G. L. L i p p i t t  field  In 1959,  of S o c i a l Issues"  referred  an  i s correct a p r i o r i .  been explored  the  neither  view  Seashore 6 Van  of  the  consultant  Egmond, 1959).  (1959) emphasized t h a t ,  "A c o n s u l t a n t r e l a t e s to a c l i e n t group i n terms of i t s previous background and h i s t o r y , and must work w i t h i n the dimensions of t h a t s i t u a t i o n (p. 50)." According detachment (p. 17)." are  to H.  is  Levinson  impossible  (1972), "Pure in  the  objectivity  behavioral  He maintains t h a t procedures f o r data  similar,  regardless  assistance—the  of  who  In  either  leader  1975  Managerial  Academy  of  Consultation  collection  case  Management  for  or the  becomes "embedded i n the o r g a n i z a t i o n a l process The  sciences  i n i t i a t e s the reguest  organizational  consultant/researcher.  or  meetings  the  researcher (p. 24).' included  1  a  D i v i s i o n at which s e v e r a l speakers  111  considered  the r e l a t i v e merits of in-house  consultants. approach had favor  of  Fitzgerald  (1975)  i t s advantages.  the  in-house  One  versus  emphasized of  the  approach was  that  main  that f a m i l i a r i t y a  evaluation  proposed  the  feasability  Conversely, the o u t s i d e c o n s u l t a n t  of was  each  points  o r g a n i z a t i o n a l i n t r i c a c i e s c o u l d l e a d to of  external  more  in with  realistic actions.  seen t o have  a  more  i m p a r t i a l viewpoint, a d e f i n i t e asset i n some s i t u a t i o n s . The  organizational  considerable between  attention  involvement and  change l i t e r a t u r e has to  achieving  (Bennis,  Benne, S Chin,  6  1970).  Argyris'  marginal r o l e of the c o n s u l t a n t emphasized parties  the  by  behavioral  a  discrepancy  consultant  and  of  versus  trust  suggested  client.  that  that these  optimum  balance  detachment i n the c o n s u l t a n t - c l i e n t  relationship Greiner,  an  a l s o devoted  1969;  (1969)  Dalton,  discussion  i s particularly  of  the  germane.  He  i n e f f i c i e n c i e s created  f o r both  between  of  the  values  Huse (1975) a l s o explored of  Lawrence,  impersonality  should  be  the  the impact  (p. 312-313) and  balanced  to  meet  the  p a r t i c u l a r needs of the o r g a n i z a t i o n a l system. Whereas  most  of the methodological l i t e r a t u r e  focuses  on the need t o c o n t r o l "expectancy b i a s " , perhaps i t i s time for organizational phenomenon.  In  researchers other  to  begin  to  ma____  words, i n o b s e r v a t i o n a l s t u d i e s  degree of r e s e a r c h e r  s o c i a l i z a t i o n should  be matched to  objectives  research.  main  of  the  f i n d i n g s unaffected  this  If  the  focus  the the  i s on  by o r g a n i z a t i o n a l c l i m a t e or m i l i e u , the  112  r e s e a r c h team should context. the  If,  c o n s i s t of novices t o  interactive  same  effects  of  socialization  composition design,  a  of the  should  as  study  of  variables  be exposed to some of  participants.  team  a i i k i n  should  Thus,  reflect  the  the study  approach has been a l l u d e d t o by Suchman (1967) i n  comparison  "scientific" alterations  of  evaluative  research. in  evaluation have  set  r a t h e r than impinge upon i t .  This his  particular  on the other hand, the o b j e c t i v e i s to study  o r g a n i z a t i o n s , then r e s e a r c h e r s the  that  not  been  design  mentioned.  research  studies.  the It  integrative studies,  evaluative,  be  approach  c o n t r i b u t i o n s t o an  are  considered  reguired  is  a  development eliminated,  to  be  for  researcher  strong  implicit versus  T h i s e v a l u a t i v e b i a s may  research  theoretical,  would  which  only  or  or the other approach i s somehow  balanced  whether  has  other d i s c u s s i o n s of " a p p l i e d "  t h a t one  should  he  There  " b e t t e r " i n an a b s o l u t e sense. hindering  noaevaluative  D e s i r e a b l e c r i t e r i a f o r the  assumption i n t h i s and "basic"  However,  research  studies.  versus  and  organizational replaced  by  an  methodology im which a l l  empirical,  assessed  overall  of  be  on  the  applied, basis  understanding  of  of how  or their  people  behave i n o r g a n i z a t i o n s . Recent  discussions  d e f i n i t e c o n t r i b u t i o n to summarized follows:  this  of  "action  this  synthesis  r e s e a r c h " have made a  concern.  of r e s e a r c h  Huse and  (19 75)  has  c o n s u l t a t i o n as  113  " . . . a c t i o n r e s e a r c h i s a c y c l i c a l process which focuses on s e v e r a l main i s s u e s : j o i n t c o l l a b o r a t i o n between client and change agent, heavy emphasis on data gathering and preliminary diagnosis prior to a c t i o n planning and implementation, careful evaluation of results before a c t i o n i s taken, and the development of new b e h a v i o r a l s c i e n c e knowledge which can be a p p l i e d i n other o r g a n i z a t i o n a l s e t t i n g s , as opposed to the application of e x i s t i n g b e h a v i o r a l s c i e n c e knowledge (p. 103) ." A second r i v a l hypothesis f o r the that  each  observer  conversations  to  may  code.  have It  towards  the  researcher's  hospital  background  in  patient  end  of  rooms  and  procedures  as bathing and  research  assistant  did  the  above  the  study  during that  the  coding  of  c u b i c l e s d u r i n g such  dressing,  not f e e l comfortable  whereas  the  importance  s e l e c t i v i t y cannot be assessed  at  of  the  e n t e r i n g such  However, s i n c e p a t i e n t data were excluded analysis,  is  selected  apparent  facilitated  treatment  situations.  effect  differentially became  discussions  conversations  observer  this  from  observer  present.  The t h i r d e x p l a n a t i o n f o r the impact of the observer i s an i n t e r a c t i o n between "week" and "observer." noted  from  the  It  will  be  r e l i a b i l i t y data t h a t the r e s e a r c h e r ' s  own  r e l i a b i l i t y d e c l i n e d over the f i n a l three-week rapidly  than d i d the r e s e a r c h a s s i s t a n t ' s .  the e f f e c t of f a t i g u e on limited of  a  judgment  and  funding, the r e s e a r c h e r was clerical  throughout  the  assistant study.  In  in  period  T h i s was  speed.  more likely  Because  of  r e g u i r e d t o do the work  evenings  and  on  weekends  a d d i t i o n , during the f i n a l  two  weeks of data c o l l e c t i o n s t a f f c a l l e d upon the r e s e a r c h e r t o  114  s e t t l e i s s u e s not d i r e c t l y connected study.  with the  observational  T h i s meant t h a t " r e s t " breaks between coding p e r i o d s  were v i r t u a l l y n o n e x i s t e n t . One  very important caveat f o r f u t u r e r e s e a r c h which the  fatigue  explanation  adequate  clerical  Because  of  the  underscores  assistance degree  of  is  for  mental  the  observational  At the o u t s e t of the present study, i t observational  overtaxed. was  type  of  such f i n d i n g s similar  research.  should  studies.  recognized  The observer e f f e c t  d i s c u s s e d above e x e m p l i f i e s the type of problem this  studies.  s t u d i e s " o f t e n take the r e s e a r c h e r i n t o  m e t h o d o l o g i c a l l y muddy water (page 6 ) . "  by  of  a c u i t y demanded, i t i s  p a r t i c u l a r l y important t h a t o b s e r v e r s not be  that  importance  not  encountered  However, i t i s important  prevent  future  that  undertaking  of  Rather, they should be c o n s i d e r e d as  new  types of o b s t a c l e s t o be overcome by c a r e f u l and  systematic  investigations. The r e l i a b i l i t y can  be  achieved w i t h i n a two-month t r a i n i n g p e r i o d .  the t r a i n i n g is  f i n d i n g s i n d i c a t e t h a t P i v a l u e s of  believed  Since  program was being r e f i n e d a t the same time, that  a  f o u r - t o six-week p e r i o d would now  s u f f i c i e n t t o achieve t h i s l e v e l . t r a i n i n g time has yet to be  .85  it be  However, t h i s e s t i m a t e of  verified.  Act-by-act assessment of  in-process  scoring  was  not  p o s s i b l e because of s t a t i s t i c a l l i m i t a t i o n s .  I t s importance  during  underestimated.  the  training  Confidence cannot  process s h o u l d not be  be achieved i n marginal s c o r e s d u r i n g  the  11.5  final  data  analysis  unless the preceding process has  monitored on an a c t - b y - a c t b a s i s . available,  the  percentage  of  considering  chance, i s the  is  researcher's unitizing  i m p e r a t i v e that  as soon as  U n t i l such a s t a t i s t i c i s  method  and  of  monitoring.  categorizing  best a v a i l a b l e  errors,  the  without  alternative.  It  i t be superseded by a s u i t a b l e  statistic  of  for  IPA  study.  This  possible.  Documentation in-process  scoring  m a t e r i a l has  the  was  one  training  procedure  o b j e c t i v e of the  been c o l l e c t e d , but a d d i t i o n a l time i s  to produce a s u c c i n c t t r a i n i n g manual., The document  been  was  reguired  need f o r such  re-emphasized by the study, and  a  t h i s work w i l l  r e c e i v e high p r i o r i t y i n the near f u t u r e .  3.  The  Research Model:  The  two  most s i g n i f i c a n t e f f e c t s i n the r e s e a r c h  ( p o s i t i o n dyad and The was  observer) have already  contextual  anticipated.  f a c t o r "day"  had  On  I t i s encouraging to f i n d  Station  discussed.  a greater  between v a r i a t i o n i n i n t e r a c t i o n p a t t e r n s events.  been  a  and  model  impact than relationship  regular  weekly  F i v e , d i f f e r e n t weekly c o n f e r e n c e s on  p a r t i c u l a r days brought d i f f e r e n t communicators to the Behavior i n these meetings, after,  varied  discussed.  T h i s was  communication, of the  with the  a  and  on  the  ward  persons present and  r e f l e c t e d i n the  observed  f u r t h e r i n d i c a t i o n of the  instrument f o r  this  type  of  the  ward.  before  and  t o p i c s being patterns  of  appropriateness  analysis.  It  seems  116  sufficiently  sensitive  i n the p a t t e r n s considerable behavior  of  to i d e n t i f y consistent daily  interaction,  potential  for  and  therefore  monitoring  staff  shifts  may and  have  patient  changes over time.  The  type  of  communication  ward  was  behavior  are necessary  a  doubtful  i n t h i s study.  to ascertain  if  determinant  Further  consistent  of  comparisons  patterns  emerge  a c r o s s h e a l t h care o r g a n i z a t i o n s . The  effect  moderated by singular  of  the  locus  on  positions  communicators,  the communication matrix i s  of  whose  i n t e r a c t i o n , are excluded,  the  communicators.  p o s i t i o n s r e s t r i c t s i t e s of  l o c a t i o n within  only a minor r o l e i n i n f l u e n c i n g behavior The  non-significance  methodologically, hypersensitive. moderators  as i t The  of  time  indicates  the  plays  patterns.  period that  ward  i s encouraging  the  tool  is  not  a b i l i t y t o d i s t i n g u i s h minor from major  is  important  organizational  behavior.  4•  Hhen  in  any  instrument  f o r measuring  Utility_Of_The_Method: The study  IPA, fallen  while  of i n t e r p e r s o n a l and  in  somewhat  disappointment i t s l a c k of  vogue into  in  the  group  1950's and  disfavor  because  phenomena  using  e a r l y *60's, has of  researchers'  with the f i n d i n g s . . Many c r i t i c i s m s f o c u s  conceptual  richness.  This  was  one  of  on the  reasons f o r B a l e s ' a d d i t i o n o f d i r e c t i o n a l dimensions to the instrument.  However  it  can  be  argued  that the l a c k of  117 i n t e r p r e t i v e power l i e s i n the uses made of the t o o l , than the c a t e g o r i z a t i o n i t s e l f . , Perhaps at level the  rather  the i n d i v i d u a l  of a n a l y s i s i t i s l a c k i n g i n usefulness.„ However, a t positional  level  i t appears  to  have  considerable  i n t e r p r e t i v e power, while r e t a i n i n g s u f f i c i e n t g e n e r a l i t y t o be used across a wide spectrum. If  the  above f i n d i n g s a r e v e r i f i e d i n f u t u r e s t u d i e s ,  the method c o u l d play a v i t a l r o l e i n monitoring patterns  of  health  would be monitoring chronic many  to  care  delivery.  institutions  organizational  An example o f i t s use  a l t e r a t i o n s i n the focus  rehabilitation,  a  today.  difficult  An  from  transition facing measure  to  for  patterns  health  care  and p r a c t i t i o n e r s . S i m i l a r use c o u l d a l s o be  organizational  i n t e r n a l and/or assess  care  feedback on a c t i v e versus c u s t o d i a l  administrators with  of  objective  o f care would be o f s i g n i f i c a n t a s s i s t a n c e  made  changes i n  external  development programs, observers  could  be  A team o f trained  to  the u n i t ' s i n t e r a c t i o n p a t t e r n s , to diagnose areas o f  breakdown, and t o monitor e f f o r t s t o improve c o o r d i n a t i o n o f patient  care.  One  of the major methodological  the c o s t of such r e s e a r c h . study cost  The method used i n the  present  i s both time-consuming and expensive i n terms of t h e of  demanded  the of  research hospital  consideration for where  drawbacks, however, i s  team. staff  research  However, and  little  patients,  i n health  care  an  time  was  important  organizations  the p r i c e o f s t a f f time i s high because o f t h e degree  118  of p r o f e s s i o n a l i z a t i o n . procedures,  the  assessing  in-process  Further  development  refinements  of  a  of  training  suitable s t a t i s t i c f o r  act-by-act  reliability,  and  s t r e a m l i n i n g of methods f o r c o l l a t i n g and a n a l y z i n g the data should  contribute  studies.  Future  to  a  reduction  i n the expense o f such  r e s e a r c h i n the use o f the technique  c a r e f u l l y a s s e s s t h e c o s t f a c t o r and the  cost/benefit  ratio  (a  attempt  to  controversial  should  determine  topic  i n the  economics o f h e a l t h c a r e ) . Considerable and  time was spent  implementing  participating  the  method  hospital.  As  , r e p o r t to the a d m i n i s t r a t o r considered  i n the  during the study  two  can  communication  with  be  feedback seen  to  the  from the f i n a l  (Appendix H). some of the i s s u e s feedback  p e r i p h e r a l l y r e l a t e d t o the study low  for  developing  sessions  data.  aphasic  were  Others,  only  such as t h e  p a t i e n t s on S t a t i o n F i v e ,  were a d i r e c t r e s u l t o f t h i s i n p u t . Most s t a f f r e a c t e d p o s i t i v e l y t o the i n i t i a l When had  the f i n d i n g s d i f f e r e d s u f f i c i e n t confidence  from t h e i r own p e r c e p t i o n s ,  i n the v a l i d i t y  examine d i s c r e p a n c i e s between the two sources  researcher  others  of  five  stated  they to  and t o of  t o the  t h a t t h e f i n d i n g s were not v a l i d because they had  not communicated f r e e l y when All  group  perceptions,  data  critically  one  own  the  and  Only  their  of  guestion  information.  reassess  feedback.  said  that  the  observers  were  present.  they had communicated normally, and  t h e r e f o r e the data deserved c a r e f u l c o n s i d e r a t i o n .  119  S e v e r a l s t a f f groups took a c t i o n as initial  feedback  (e.g.  Physiotherapy,  Others r e g u i r e d more time with their  interpretations.  d u r i n g the  second  a  the  result Speech  researcher  of  the  Therapy). to  clarify  They decided on a course of a c t i o n  phase.  Only  one  department  made  no  attempt t o use the feedback d a t a . While  the  p a t i e n t data have not y e t been s u b j e c t e d t o  e x t e n s i v e m u l t i v a r i a t e a n a l y s i s , v i s u a l examination patient-to-staff  profiles  a c r o s s one or more o f the example,  the  nurse's  shows three  considerable  patient  interaction  vary most with t h e i r communication  of  the  variation  dimensions. ,  For  with p a t i e n t s tended t o impairment,  whereas  the  o c c u p a t i o n a l t h e r a p i s t ' s d i f f e r e d mainly by l e n g t h o f s t a y . From  the  f o r e g o i n g , i t can be seen t h a t the study d i d  have value f o r h o s p i t a l s t a f f at s e v e r a l l e v e l s . guestion care.  to  be  asked  is  The  the r e s u l t a n t impact on  next  patient  T h i s e f f e c t i v e n e s s dimension can only be assessed  longitudinal  studies,  which  are  by  s t r o n g l y recommended f o r  f u t u r e phases of the r e s e a r c h .  B,  FUTORE RESEARCH DIRECTIONS:  During the i n i t i a l examination number  of  the  literature,  a  of a r t i c l e s were reviewed which had i m p l i c a t i o n s f o r  future research.  120  In  relation  to  the  development  organizational  communication,  Georgopoulos and  Mann  (1962)  many  of of  could  be  a the  relationship  between  Transactional Analysis 1971)  should  be  (Berne,  longitudinal  Talland  designs  a p p l i e d IPA  discussion  combination  Stanley's  in  future  In a d d i t i o n ,  James  &  those  of  Jongeward,  to the problem of  groups.  (1963)  with  explore  The  one  the  use  such as t h a t employed by  Hess (1969) a l s o holds c o n s i d e r a b l e used i n  of  and  f u t u r e s t u d i e s should  research  (1955), who  therapeutic  concepts  1964;  findings  explored.  Methodologically, of  Bales*  of  tested  convergent and d i s c r i m i n a n t v a l i d a t i o n o f IPA. the  theory  analyzing  s i m u l a t i o n approach of  promise, p a r t i c u l a r l y i f  or  more  guasi-experimental  of  Campbell  designs  to  and  test for  causal relationships. In f u t u r e r e s e a r c h coordinator  in  models, i n t e r a c t i o n as a  organizations  should  horizontal  be s t u d i e d i n c o n c e r t  with other phenomena such as  leadership.  type  has a s i g n i f i c a n t c o n t r i b u t i o n  of  c a t e g o r i z a t i o n , IPA  t o make to such i n v e s t i g a t i o n s . example,  i s hypothesized  dimension.  Therefore  understanding (1960) should  could of  findings  Category  other  measures  an  of  important  organizational the  of  4,  the  for  to be almost purely a " l e a d e r s h i p "  play  on  new  s t u d i e s of convergent and  v a l i d i t y , using t h i s and leadership,  The  Because  effects  discriminant  organizational role  integration. of s t a t u s and  a l s o be h e l p f u l i n f u t u r e investigations.„  in  the  Manheim's leadership  121  The should  effectiveness be  a  major  other  organizational  concern  u t i l i t y , of the method. and  of  nursing  communication  i n f u t u r e examinations  of the  Here the work of N. C. S c o t t researchers  helpful.  For example, comparisons  relative  validity  and  utility  should could of IPA  be  (1973)  particularly  be  made  of  the  and NOSY i n s e v e r a l  d i f f e r e n t s e t t i n g s and a c r o s s a v a r i e t y of p o s i t i o n s .  This  would a s s i s t r e s e a r c h e r s t o determine tine a p p r o p r i a t e degree of  category s p e c i f i c i t y  for i n t e r a c t i o n research i n various  h e a l t h care c o n t e x t s . The  foregoing  possibilities  for  discussion future  in  no  research  way in  o b s e r v a t i o n o f o r g a n i z a t i o n a l communication. intended  to  r e s e a r c h may in  C.  suggest  exhausts the  field  Bather, i t  a number of ways i n which the  is  raised  study.  CONCLUSIONS! The m e t h o d o l o g i c a l o b j e c t i v e s of the present study,  outlined  above  (page 8),  have  been  met.  demonstrated that communication behavior can be  The study  the observer, as determined  socialization, intervening  is  variable.  believed  as has  consistently  measured i n the o r g a n i z a t i o n a l c o n t e x t . , The p e r c e p t u a l of  of  present  s t i m u l a t e others t o e x p l o r e the concerns  the r a t i o n a l e of t h i s  the  set  Jby exposure to o r g a n i z a t i o n a l to  function  as  a  major  122  Bales' I n t e r a c t i o n Process  A n a l y s i s can be r e f i n e d f o r  use  i n the o r g a n i z a t i o n a l environment.  As long as s u b j e c t s  are  fully  objectives  research,  aware and  of  the  nature  have achieved  data  collection  does not o v e r l y d i s r u p t the  The method used  One such instrument  with  keyboard  calculator  recorder. battery  in  the  study  connected  i s now to  available,  a c a s e t t e tape  However, i t has s e v e r a l d r a w b a c k s — s i z e , life,  cost,  and d i f f i c u l t y o f s e r v i c i n g .  weight, I f such  d e v i c e s are used i n f u t u r e r e s e a r c h , t h e i r p o t e n t i a l on s u b j e c t apprehension should The  construct  be c a r e f u l l y  validity  of  IPA  impact  assessed.,  i s partially  upheld.  Eleven of the twelve c a t e g o r i e s a r e c l e a r l y demonstrated be  independent  hypothesis behavior is  dimensions  o f communication b e h a v i o r .  t h a t Category 6 i s an  i s s t r o n g l y supported.  low,  giving  some support  c a t e g o r i z a t i o n i s exhaustive. the  category  validation  of  for  might be improved by the use of e l e c t r o n i c  tabulation devices. a  o f the  some degree o f commitment, t h e  presence o f a r e c o r d i n g observer organizational milieu.  and  pairs these  could  communication  t o B a l e s ' c o n t e n t i o n t h a t the S e q u e n t i a l interdependence o f  findings  the development of a theory  The  Freguency o f uncodable a c t s  not  r e s e a r c h using the instrument  adjunctive  to  be  assessed.  i s recommended  i s t o make a  Further  i f empirical  contribution to  of o r g a n i z a t i o n a l communication.  123  Implications are e x c i t i n g . researcher  is  f o r the f i e l d  As  a  result  of  significantly  long-term g o a l expressed on page There  the  present  closer  to  2  of  Behavior  study,  the  realizing  the  this  Dissertation.  i s promise t h a t methods can be developed f o r t r a i n i n g  organizational researchers analyze result  of O r g a n i z a t i o n a l  communication in  more  and/or  members  behavior.  efficient  use  Such of  our  to  observe  awareness health  and  should manpower  resources,  and e v e n t u a l l y l e a d t o more e f f e c t i v e i n t e g r a t i o n  of p a t i e n t  care.  124  BIBLIOGRAPHY Amidon, E. 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J r . , Introduction^tp... i n t e r p e r s o n a l / r e l o t i o n s , Glenview, 1 1 1 . , S c o t t Foresman, 1973 :  Sydiaha, D., " B a l e s ' Interaction Process Analysis of personnel selection interviews". J o u r n a l of A p p l i e d Ps_cholo__, 1961, V. 45(6), P. 393-401 T a l l a n d , G. A., "Task and interaction process; Some c h a r a c t e r i s t i c s o f t h e r a p e u t i c group d i s c u s s i o n " , J o u r n a l o f _bn_______n__Social_Ps^ , 1955, V. 50, P. ,105-109 Thayer, L. O., A d m i n i s t r a t i v e cp^muBic§tign, Homewood, 1 1 1 . , I r w i n , 1961 ~ Thayer, L, 0., Commuqication a n d c o m m u n i c a t i o n s y s t g m s _ i n o r g a n i z a t i o n a l management and i n t e r p e r s p n a i _ r e l a t _ o n s , Homewood, 1 1 1 . , I r w i n , 1968 :  Thompson, V- A., a o d e r n _ p r q a n i z a t i q n .  New York, Knopf, 1961  Thorndike, R. L., Personnel s e l e c t i o n ; .Test and measurement techniques, Hew York, Wiley, 1949 Topf, M., "A behavioral c h e c k l i s t f o r estimating the development o f communication skills", Journal^pf.N u r s i n q Education, 196 9, V. 8(4), P. 29-34 Turner, R. (Ed.), Ethnpmethpdolpgy__Selected Harmondsworth, England, Penguin Education, 1974  readings.  Warner, M. M. , An a.nnp.tat^d_b ib_4agsa_fel-_i-feaa^fe_gft£^ tea_wor^_and_health_.cent , Vancouver, U. B. C. Faculty of Medicine, Department of Health Care and Epidemiology, P r o j e c t TEAM, 1975 i  Waxier, N. E., & M i s h l e r , E. G., "Scoring and r e l i a b i l i t y problems i n I n t e r a c t i o n Process A n a l y s i s : A methodological note", Sociometry,, 1966, V. 29(1), P . 28-40 Webb, E., Campbell, D. T., Schwartz, R. D., & S e c h r e s t , L., Onpb/trusive_measures;. Ngnreac^iye r e ^ e ^ r c h i n t h e s o c i a l s c i e n c e s , Chicago, Rand-McNally, 1966  134  Werner, A., S Schneider, J - H . , "Teaching medical students interactional skills". New England J o u r n a l o f Medicine, 1974, V. 290(22), P. 1232-1237 Wessen, A. F., " H o s p i t a l i d e o l o g y and communication between ward p e r s o n n e l " , i n Jaco, E. G. (Ed.), P a t i e n t s , . p h y s i c i a n s afld_illnej;si_Sguxcebo science_and .medicine, Glencoe, I l l 7 , Free Press7~19587~P. 448-468 W i l k i n s o n , G. s . , " I n t e r a c t i o n p a t t e r n s and s t a f f response to p s y c h i a t r i c i n n o v a t i o n s " . J o u r n a l o f Health and S o c i a l Behavior, 1973, ¥.,14(4), P. 323-329  135  APPENDIX A RESULTS OF PILOT.STUDY  The  following  the 1967-69 p i l o t  is  a summary of r e l e v a n t f i n d i n g s  study  conducted  Wascana H o s p i t a l i n Regina, The  reliability  the  researcher  at  Saskatchewan.  of  adeguately documented.  by  from  the  IPA  instrument  was  not  T h i s c o n s t i t u t e d a major f l a w i n the  study. When examining multiple  the data  correlations  validity,  the  were a l l found to be below .20,  with  the e x c e p t i o n of Category receiver.  In  a  that  series  interaction.  All  they  construct  6 f o r sender, and 2, 6 and  C a t e g o r i e s except 2, 6 and indicating  for  of  R-type  11  were  loading  c a t e g o r i e s had low E i g e n v a l u e s — i . e . The  specific  orthogonal,  independent on  for  analyses, a l l  relatively  represented  factors  factor  11  the  types  other  of nine  none were predominant.  order of the f a c t o r s v a r i e d with the data s e t  (sender versus r e c e i v e r ) and the type of r o t a t i o n . C a t e g o r i e s 2 and five  of  moderately of  the  11 loaded moderately  factors  for  the  (.20  receiver,  on seven of the sender's f a c t o r s .  to  .39)  and  6  In  both  on  loaded sets  data, the main l o a d i n g s f o r these three v a r i a b l e s were on  the f i r s t t h r e e f a c t o r s .  136  Categories  2,  c o n c e p t u a l l e v e l from to  6 and 11 were f e l t t o be on a d i f f e r e n t the other n i n e .  postulated  be a d j u n c t i y e e g ^ m ^ n i c ^ t i y e behaviors working i n c o n c e r t L  with t h e o t h e r s t o c l a r i f y and  They were  (Cat. 6) and  modify  (Cats. .  2  11) the t o t a l i n t e r a c t i o n seguence. Because o f the data arrangement, the interdependence o f  B a l e s ' category p a i r s c o u l d not be thoroughly examined. , With  r e s p e c t t o m e t h o d o l o g i c a l a r t i f a c t , the e f f e c t o f  the observer was d e f i n i t e l y higher on  the f i r s t  day, but  t h i s was not t e s t e d f o r l e v e l of s i g n i f i c a n c e .  In t h e p i l o t  project  in  observer  communications  e v a l u a t e the maximum impact  of  were  the  coded  method.  order t o  These  values  were i n f l a t e d s i n c e a l l observer i n t e r a c t i o n s were r e c o r d e d , whereas  only  communicators. minimal  a  time sampling  A f t e r the f i r s t  was  taken  f o r other  day, the observer had only a  e f f e c t on the ward p r o f i l e i n C a t e g o r i e s  However,  Categories  1  and  2  showed  3  t o 10.  a definite  observer  e f f e c t as sender, and 1, 2 and 11 as r e c e i v e r .  The observer  t h e r e f o r e i n c r e a s e d the s o c i o - e m o t i o n a l aspects of t h e  ward  profiles. When  the r e s u l t s  were t e s t e d f o r concurrent  validity  u s i n g a u n i v a r i a t e ANOVA, one of the major f i n d i n g s was t h a t the who-to-whom f i r s t significant. use  the  role  order i n t e r a c t i o n  effect  was  highly  T h i s l e d t o the suggestion t h a t f u t u r e s t u d i e s dyad,  rather  r e c e i v e r , as t h e independent  than  an  variable.  isolated  sender o r  137  Significant effects effects of  f o r "day".  inadeguate  the a one.  but  this  ethnographic  was  a  could  to five atypical not  material.  key v a r i a b l e ,  r e s u l t of i n t e r a c t i o n moderate  and  minimal  I t was p o s t u l a t e d that t h e weak "day"  were mainly a t t r i b u t a b l e  sixteen,  "locus"  e f f e c t s were found f o r "ward"  be  days  out  v e r i f i e d because o f  For  some  categories,  but t h i s was c o n s i d e r e d t o be  o f a s t r o n g "who-to-whom"  effect,  "task design" e f f e c t , and a weaker "pure l o c u s "  138  APPEJ_____  ______M_____________I_ STAFF POSITION AND DEPARTMENT CODES-  ______ OOO 001 002 003 004 005 006  —  —  Grouped P o s i t i o n s  Total N  s t a f f nurse n u r s i n g attendant n u r s i n g student s e n i o r nurse nursing supervisor nursing administration n u r s i n g i n s e r v i c e education  41 40 20 3 8 2 3 8 14 2 13 5  010 011 012 013 015  -  —  housekeeping a i d e houseman housekeeping s u p e r v i s o r d i e t a r y aide porter  020 021 022 023 024 025 026 027 028 -029  -  laboratory technician o c c u p a t i o n a l therapy orthopaedic a p p l i a n c e s pharmacy physiotherapist physiotherapy i n t e r n e physiotherapy attendant medical s o c i a l worker speech and hearing X-ray  3 18 7 6 25 2 13 5 4 2  C.S.R. aide maintenance medical records purchasing and s t o r e s security a d m i t t i n g and switchboard  3 7 5 3 5 13  030 031 032 034 036 037  —  —  — —  -  —  040 041 042 043  —  050 051 052 053 054  —  -  —  -  general p r a c t i t i o n e r physiatrist orthopaedic surgeon other medical s p e c i a l i s t family volunteer clergy r e s e a r c h observer admin i s t r a t i o n  8 3  2 2  139  Code # 100 101 102 105 110 113 114  S in qu1ar Pos i t io n s  --—  —  a s s i s t a n t d i r e c t o r of nursing ward c l e r k WIA&S n u r s i n g i n s t r u c t o r d i r e c t o r of n u r s i n g a s s i s t a n t d i r e c t o r o f housekeeping food s e r v i c e s s u p e r v i s o r dietician  121 127  —  d i r e c t o r of o c c u p a t i o n a l therapy p e r s o n a l s e r v i c e s worker  131 133 134 135  —  d i r e c t o r of maintenance o u t p a t i e n t c l i n i c attendant s u p e r v i s o r of purchasing driver  154 155 156 157 158  _  -— -  —  barber hairdresser h e a l t h nurse psychologist V.O.N.  140  PATIENT POSITION.CODES  LENGTH_OF_STAY: 3=2  to 7 days  4 = 8 t o 30 days 5 = 31 t o 90 days 6 = 91+ days  MOBILITY: 0 = s t a y s i n own room a l l the time, except appointments (e.g. X-Eay)  f o r special  1 = up i n wheelchair out of room; cannot p r o p e l s e l f 2 = propels independent  chair  short  distances;  transfers  not  3 = p r o p e l s c h a i r short d i s t a n c e s ; t r a n s f e r s independent 4 = moves f r e e l y independent 5 = moves f r e e l y ;  (chair  or  walking);  transfers  not  t r a n s f e r s independent  COMMUNICATION_IMPAIRMENT: 0 = severe impairment  receptive  impairment;  severe  expressive  1 = moderate r e c e p t i v e impairment; severe e x p r e s s i v e (or v i c e versa) 2 = moderate  r e c e p t i v e impairment; moderate  3 = s l i g h t r e c e p t i v e impairment; severe v i c e versa)  expressive  4 = s l i g h t r e c e p t i v e impairment; moderate v i c e versa) 5 = s l i g h t r e c e p t i v e impairment; s l i g h t  expressive (or  e x p r e s s i v e (or  expressive  6 = no r e c e p t i v e impairment; severe e x p r e s s i v e  141  7 = no r e c e p t i v e impairment; 8 = no versa)  moderate e x p r e s s i v e  r e c e p t i v e impairment;  s l i g h t e x p r e s s i v e (or v i c e  9 = no r e c e p t i v e impairment; no e x p r e s s i v e  Communication  impairment i s d e f i n e d as f o l l o w s ;  RECEPTIVE: severe = understands l e s s than 10% of what i s her/him  said  to  moderate = understands 10% t o 50% of what i s s a i d slight = understands gets confused)  51%  t o 90% of what i s s a i d (or  none = understands more than 90% o f what i s s a i d EXPRESSIVE: severe = unable t o express d e s i r e s i n any manner moderate = a b l e difficulty  to  express  slight staff  to  express most d e s i r e s e a s i l y t o a l l  =  able  some  desires,  but  with  none = normal e x p r e s s i v e a b i l i t y Note: Communication English.  code i s based on p a t i e n t s s k i l l 1  in  142  APPENDIX C SUBMISSION ..TOSSHC MANAGEMENT COMMITTEE October 2, 1974 SUMMARY AND IMPLICATIONS of a £!0£OSEp_DOCTOR_OF_PH^ in  ORGA_IZA_IO__L_BE__yj[0___Np__  INTRODUCTION The  following  presentation  o u t l i n e s a study i n h e a l t h  team communication t o be conducted rehabilitation  hospital  by  hospital  by  a  Canadian  and Miss Betty M c G i l l , a.S-R-  b r i e f i s prepared t o e l i c i t project  jointly  i n t e r e s t i n and support f o r  Boards and A d m i n i s t r a t o r s .  The the  The b a s i c  study has been designed by Miss M c G i l l as a part o f a Ph.D. dissertation i n Organizational the  University  project  will  o f B r i t i s h Columbia. be  plus  Care  at  The f i n a l design o f the  worked out i n c l o s e c o n s u l t a t i o n  participating unit. the  Behavior and Health  The h o s p i t a l w i l l be asked  with t h e  to  provide  s i t e f o r the f i e l d study and p a r t i c i p a t i o n o f i t s s t a f f , a  s m a l l o f f i c e f o r the use o f t h e r e s e a r c h team.  r e s e a r c h e r w i l l assume r e s p o n s i b i l i t y f o r o b t a i n i n g  The  funding,  c a r r y i n g put the a c t u a l study, and i n t e r p r e t i n g the  results  t o the h o s p i t a l . The  intent  o f t h e r e s e a r c h i s t o develop a method f o r  observing and a n a l y z i n g departments  communicate  how  hospital  staff  from  with each other and with  various patients.  143  T h i s w i l l be achieved  by a four-month f i e l d  Summer of  team  1975.  A  of  two  communication p a t t e r n s w i t h i n and  observers  the  hospital  analyzed field  Administration  (approximately  study).  The  will  F i n d i n g s w i l l be  as  soon  f o u r months a f t e r  end  of  t h e s i s of the r e s e a r c h e r w i l l  relevance  for  are the  f o c u s on  the a c t u a l method f o r observing communication p a t t e r n s , its  two  given  as the data the  the  record  between d i s c i p l i n e s on  wards of the p a r t i c i p a t i n g h o s p i t a l . to  study d u r i n g  f u t u r e s t u d i e s i n h e a l t h care and  and other  organizations. The  present o u t l i n e focuses on the  research,  the  study  participating hospital. being reviewed, and analysis  of  researcher's  design,  and  Relevant  rationale  for  the  implications  for  the  literature  is  currently  t e c h n i c a l d e t a i l s of r e s e a r c h method and  results  have  met  with  Thesis  Committee.  the  information  is  a v a i l a b l e i n the second d r a f t of the r e s e a r c h p r o p o s a l .  The  Canada C o u n c i l has expressed  This  approval of the  support f o r the p r o j e c t through  g r a n t i n g the r e s e a r c h e r a D o c t o r a l F e l l o w s h i p .  RATIONALE Health confronted patient  organizations  of  by a dilemma i n the  care.  In  order  to  the  1970's are i n c r e a s i n g l y  provision cope  with  of  high  the e x p l o s i o n of  knowledge, the h e a l t h d i s c i p l i n e s have had to become specialized. field  Keeping  pace  with  developments  r e g u i r e s t h a t the medical/paramedical  guality  highly  in his  own  s p e c i a l i s t spend  l e s s time l e a r n i n g about f i n d i n g s i n other areas. resulted  This  has  i n high c a l i b r e care f o r s p e c i f i c problems, but a t  the expense  of  integration  of  the  needs  of  the  total  patient. Within  the  past  ten  years,  the  problem  of how  to  c o o r d i n a t e the team of h e a l t h s p e c i a l i s t s has been d i s c u s s e d with  increasing  administrators. a  "team  freguency  by  health  planners  H o s p i t a l s which have attempted to implement  approach  to  patient  c a r e " have met  degrees of success, but the f i n d i n g s from one g e n e r a l l y been t r a n s f e r a b l e to o t h e r s . field  has  The reasons health  focused why  with  i t i s difficult  specialists  u n i t have  not  Most research i n the  have  been  to  coordinate  a  team  of  given l i t t l e a t t e n t i o n , and  for objectively  measuring  h_ow  information  re.  p a r t i c u l a r team i s f u n c t i o n i n g .  a  Recognizing  that  communication  of  P a t i e n t care p r o v i d e s a v i t a l l i n k f o r c o o r d i n a t i o n various  disciplines,  aspect of teamwork. people concern  the  proposed  study  of  the  f o c u s s s on  this  I t begins from the b a s i c  premise  say.  other  that  communicate i n a h o s p i t a l s e t t i n g i s of g r e a t e r  f o r the development of an e f f e c t i v e team  a s s e s s i n g how with  varying  on the r e s u l t s of i n e f f e c t i v e teamwork.  ways have not been developed  they  and  It  then  develops  a  persons from v a r i o u s staff  ___eraction_Process_An^  and  with  method  than  what  for  objectively  disciplines  communicate  patients.  Robert  Bales*  an o b s e r v a t i o n scheme  which has been widely used i n s m a l l group s t u d i e s ,  will  be  145  modified  f o r use on h o s p i t a l wards, at the n u r s i n g  i n team meetings, and a t other l o c a t i o n s . to  develop a simple  While  diagnosis  data-gathering  flexible  to  of  is  allow  expected  transfer  o r g a n i z a t i o n s w i t h i n and o u t s i d e the h e a l t h The care  study should t h e r e f o r e g i v e  the  is be  communication  w i l l be r e s t r i c t e d to  wards of a s i n g l e h o s p i t a l , the method sufficiently  intention  method, so t h a t h o s p i t a l s t a f f c o u l d  t r a i n e d i n i t s use f o r ongoing problems.  The  station,  to  to  two be  other  field., field  of  health  a d m i n i s t r a t i o n a d i a g n o s t i c t o o l which can be used not  only by the p a r t i c i p a t i n g h o s p i t a l and r e s e a r c h e r s ,  but a l s o  by other a d m i n i s t r a t o r s and r e s e a r c h e r s seeking  to  identify  i n their organizations.  This, i n  communication  breakdowns  t u r n , c o u l d be the f i r s t step towards changes i n p a t t e r n s of providing  care,  to  the  i n d i v i d u a l p a t i e n t and  eventual  benefit  of  both  the  span a period of two  years  the g e n e r a l s o c i e t y .  STUDY DESIGN The (see  projected  study  will  _______7). In Phase A, the emphasis w i l l be on f i n a l i z a t i o n of  research proposal study. Phase  and  s e l e c t i o n of the s i t e  for  the  Phase B i n v o l v e s the a c t u a l g a t h e r i n g of d a t a , C  will  h o s p i t a l , and  analyze  the  field while  the r e s u l t s , provide feedback t o the  prepare the f i n a l  thesis.  146 FIG_RE_7 £H_SES_QF_RESE4iC__4_D_T_RG_T PHASE__  PHASE_B  _______  1. e x p l o r e a l t e r n a t i v e s for f i e l d s i t e  October 31,1974  2. approach sources of funding  November  3. c o n f e r with Adminstration of h o s p i t a l t o f i n a l i z e f i e l d study  January  4. meet with h o s p i t a l A d m i n i s t r a t o r s and Department heads t o schedule study  March 21  1. begin f i e l d  May  study  30 30,1975  1  2. o r i e n t h o s p i t a l s t a f f and p a t i e n t s t o study; f a m i l i a r i z e r e s e a r c h e r s with wards; researcher t r a i n i n g  June 30  3. gather t r i a l data; t e s t computer programs  July  4. gather f i n a l  August 31  data  1. analyze r e s u l t s 2. communicate f i n d i n g s hospital 3. prepare i n i t i a l for publication  to  article  31  December  15  February  15,1976  August 31  Phase_A focuses on the s e l e c t i o n of a h o s p i t a l f o r field  study.  project.  T h i s i s the most c r i t i c a l  aspect of the e n t i r e  Minimal c r i t e r i a f o r c o n s i d e r a t i o n  1. h o s p i t a l Board of D i r e c t o r s '  are:  consent to the  project  2. top level Administrators* and Medical w i l l i n g n e s s t o be committed to the study 3. support and i n t e r e s t of a m a j o r i t y of Nursing being a f o c a l concern  the  Directors'  Department  Heads,  147  4. an care  inpatient  unit,  p h y s i c a l r e h a b i l i t a t i o n or extended  5. a d u l t p a t i e n t  population  6. minimum of two choice  wards; more would be d e s i r a b l e ,  7. r e l a t i v e l y or temporary)  stable  8. reasonable l e n g t h  s t a f f i n g patterns of p a t i e n t  study  are e s s e n t i a l .  ( i . e . few  allow  part-time  stay  In order t o achieve maximum o r g a n i z a t i o n a l support and  to  potential  of  the  study,  w i l l i n g n e s s t o p a r t i c i p a t e i n the  Based on a 1969  pilot  study u s i n g  proposed method i n a southern Saskatchewan h o p s i t a l , b e l i e v e d that the develop  considerable  Administration patterns  on  problems and sufficiently could  of  h o s p i t a l can research  i n t e r e s t i n the p r o j e c t .  the two for  data on  The  planning.  If  h e l p f u l t o the u n i t , one the  use  communication  of  the  method  problems.  In  gain r e c o g n i t i o n i n the f i e l d  will  communication present  findings  or more s t a f f  the  is  hospital  wards, f o r use i n d i a g n o s i s of  future  it  participating hospital  w i l l receive extensive  be t r a i n e d i n  diagnosis  all  members of the  the  for  are  members ongoing  addition, of  health  the care  through an acknowledgement of i t s p a r t i c i p a t i o n i n  p u b l i c a t i o n of r e s u l t s , should t h i s be  desired  by  the  Board. Phase B, f o u r months. researchers observing  the a c t u a l f i e l d study, w i l l span a p e r i o d It (Hiss  will  involve  McGill  communication  and  behavior  a  team  another on  the  of  two  of  full-time  graduate selected  student) wards.  148  Choice of the l a t t e r w i l l be done j o i n t l y by the r e s e a r c h e r s and  the h o s p i t a l  Administrator.  The  two o b s e r v e r s  r e c o r d how s t a f f and p a t i e n t s communicate a t d i f f e r e n t on the wards. during  Generally  they  will  work  sites  s e p a r a t e l y , but  r e l i a b i l i t y checks they w i l l observe j o i n t l y .  the observer w i l l patients ongoing  minimize  during  h i s i n t e r a c t i o n s with  the d a t a - g a t h e r i n g ,  will  Since  staff  and  interference  with  ward r o u t i n e s i s expected t o be minimal.  A major key t o the success o f t h e method w i l l be  staff  and p a t i e n t openness and w i l l i n g n e s s t o communicate i n t h e i r accustomed  manner  relationship research will  of  team  trust  must  be  the  spent  be  of  an  study  to  groups  between  two  and p a t i e n t s .  meetings one  larger  unit,  i t may  orientation for a l l staff meeting),  In a small  with  a l l staff  hour  of  each  possible  to  do  and staff  a  In  general  (15-30 minutes at a r e g u l a r  staff  p l u s d e t a i l e d e x p l a n a t i o n s f o r persons on the two  study wards. or  be  the  months  member*s time w i l l be r e g u i r e d f o r formal o r i e n t a t i o n ) . a  A  C o n s i d e r a b l e time  the f i r s t  staff  (approximately  observer.  established  during  h o s p i t a l , t h i s w i l l involve patient  presence  and persons on the wards.  therefore  explaining  i n the  P a t i e n t s w i l l be o r i e n t e d e i t h e r  i n groups.  The o b s e r v a t i o n scheme and the type of data  gathered  will  ensuring  anonymity of a l l p a r t i c i p a n t s .  be  thoroughly  made a t any time i n the study communicator.  individually  Staff  explained,  to  means f o r  No attempt  identify  classifications  plus  an  w i l l be  individual  with only one member  149  will  be  grouped  communicators  to  ensure  confidentiality.  Other  w i l l be i d e n t i f i e d by t h e i r o c c u p a t i o n a l r o l e  {e.g. nurse, housekeeper, p a t i e n t ) . Because c o n s i d e r a b l e time w i l l observations  and  training  of  be  the  spent  second  r e s e a r c h team w i l l r e g u i r e some space  on  practise  observer,  (however small)  could allow freedom of d i s c u s s i o n d u r i n g the f i e l d In  £hase_C,  the  data  will  be analyzed.  B e f o r e any  back  t o the p a r t i c i p a t i n g h o s p i t a l .  fully  informed o f , t h e . r e s e a r c h f i n d i n g s before any  thesis  hospital  will  be  w i l l be i d e n t i f i e d  determined  by  be f e d  They,/will^t^erelore•be  presentation or .publication of the r e s u l t s . the  which  study.  f u r t h e r work i s done on the t h e s i s , the r e s u l t s w i l l  which  the  the  The  extent  to  i n the r e s e a r c h e r ' s  hospital  Board  or  Administration. Time  has  a l s o been allowed f o r p r e p a r a t i o n of some of  the r e s u l t s f o r p u b l i c a t i o n . stable  I f the  study  can  method f o r measuring communication behavior  h o s p i t a l s e t t i n g , then the r e s e a r c h e r w i l l have obligation  date,  researchers,  a  a  within a definite  t o share the r e s u l t s with o t h e r s i n the f i e l d o f  H o s p i t a l A d m i n i s t r a t i o n and later  develop  Health  Care  fiesearch.  At  a  r e s u l t s w i l l be communicated t o a d m i n i s t r a t i v e for  possible  implementation  in  other  organizational contexts.  _______ Implications  of the proposed  study a r e e x c i t i n g .  If a  150  method can  be developed whereby an untrained  taught to  objectively  behavior,  the  tool  measure  and  observer  analyze  can be used i n i n v e s t i g a t i o n s of I t might a l s o be  for  Development  and  hospital  to  Organizational enabling  a  be  communication  factors influencing patient care.  programs,  can  Inservice  other  adapted Education  monitor  its  own  communication p a t t e r n s , and  to a d j u s t a c c o r d i n g l y when those  found  to  to  patient  be  detrimental  care  are  speculations  at  effective  uncovered. the present  implemented, and  i t s findings  "speculations"  can  be  While  and/or these  efficient are  mere  time, i f the proposed study i s are  significant,  transferred  to  then  the  such  realm  of  "possibilities". The  potential  uses  of  risks  the  proposed  considerable.  The  been considered  by the r e s e a r c h e r ' s  method  are  inherent i n i t s development have T h e s i s Committee.  It is  t h e i r o p i n i o n , as w e l l as t h a t of the r e s e a r c h e r ,  that  scales  favor  of  supported  by  of  judgment  attempting  the  evidence  from  indicates  I.P.A.  the  researcher,  be  This  above  two  challenging  weighted  decision  mentioned  identified  ensuing  and  heavily  communication  can  The  exciting  hospital  project.  that  disciplines  are  years  in  pilot  patterns using should  period,  but a l s o f o r A d m i n i s t r a t o r s  involved  is  in  study of  a  modified therefore  not  only  and  staff  the  which  specific form of be  an  for  the  of  the  t h i s p r e l i m i n a r y attempt to diagnose  the "communication d i s o r d e r " of a complex o r g a n i z a t i o n .  151  APPENDIX D PRESENTATION TO DEPARTMENT HEADS January 21, 1975 M1SC__A_HOSPITAL E_SEA_C__ST__Y in HEALTH_T_A__COMHOSICATIpN  £2S£QSE; The purpose o f t h e study method  f o r observing  and  i s to analyzing  communicate o r a l l y with each other their  develop how  and  and  test  hospital  with  a  staff  p a t i e n t s and  families. The  high  degree of s p e c i a l i z a t i o n of today's  departments has l e d t o i n c r e a s e d patient  care,  communication.  accompanied  problems by  i n coordinating  greater  He are o f t e n not aware  of  hospital  difficulty where  these communication breakdowns a r e o c c u r r i n g .  and  in why  Therefore, i t  i s important t o observe a c t u a l communication behavior on t h e hospital  ward.  Our  ultimate  aim  i s to  achieve  more  e f f e c t i v e and e f f i c i e n t use of h o s p i t a l personnel, r e s u l t i n g i n a higher standard of p a t i e n t c a r e .  ST_DY_DESIG__ 1.  When: - May t o August, 1975 ( i n c l u s i v e ) - The f i r s t two months w i l l be spent t r a i n i n g the two observers, f a m i l i a r i z i n g ward s t a f f and p a t i e n t s with the study, and noting communication i n s p e c i f i c areas.  152  The how  second two w i l l i n v o l v e g a t h e r i n g i n f o r m a t i o n r e . s p e c i f i c groups communicate on the wards.  - Most o b s e r v a t i o n s w i l l be done between 0800 and 1700 hrs., but some time w i l l a l s o be spent on the wards i n the e a r l y morning and evening. 2.  What: - He w i l l focus on how people communicate r a t h e r than on what they are s a y i n g .  orally,  - The recording scheme c o n s i s t s of twelve c a t e g o r i e s (see attached l i s t ) . Each time someone communicates with someone e l s e , the process w i l l be coded i n t o one or more of the c a t e g o r i e s . Only the coded information w i l l be r e c o r d e d . , - Telephone c o n v e r s a t i o n s ward end only (plus n o t i n g r e c e i v e d the c a l l ) .  will be i n c l u d e d from the which department sent or  - No w r i t t e n communication w i l l be examined. 3.  Where: - Two wards of s t u d i e d — S t a t i o n Five (extended care) .  4.  Wascana Hospital will be ( r e h a b i l i t a t i o n ) and Second West  Who: - To the g r e a t e s t extent p o s s i b l e , the study w i l l be anonymous, i n t h a t persons p a r t i c i p a t i n g will be identified by the department (e.g. Purchasing) or p o s i t i o n (e.g. Nurse attendant) to which they belong. - Persons who are the s o l e occupant of a p o s i t i o n (e.g. Ward Clerk) or the s o l e r e p r e s e n t a t i v e of a department (e.g. Social Service) on a ward w i l l have the o p t i o n of being i d e n t i f i e d or being grouped with o t h e r s . They are s t r o n g l y encouraged t o allow t h e i r p o s i t i o n to be identifiable i n the data-gathering stage, with the o p t i o n of d e c i d i n g l a t e r the extent of d i s t r i b u t i o n of i n f o r m a t i o n r e . t h e i r communication p a t t e r n s . - A l l ward communications of the f o l l o w i n g groups w i l l be recorded: - p a t i e n t s - a l l persons r e s i d e n t on the studied - physicians wards  -  those  wards  t r e a t i n g p a t i e n t s on the  being study  153  - staff - a l l emplyees o f Hascana H o s p i t a l who provide direct or i n d i r e c t c a r e t o p a t i e n t s on t h e two wards - persons employed by other organizations who participate i n direct p a t i e n t care on the wards (e.g. barber, h a i r d r e s s e r , c l e r g y ) - f a m i l y - communication with s t a f f only - volunteers - guestionable - v i s i t o r s w i l l be excluded 5.  How: - There w i l l be a team of two f u l l - t i m e observers. Generally one w i l l work on each ward, but they w i l l o c c a s i o n a l l y work together during t r a i n i n g p e r i o d s . - Each observer w i l l use a s t e n o g r a p h e r s notebook and pencil, or a mechanical punch which r e c o r d s t h e i n f o r m a t i o n i n a form which can be d i r e c t l y fed into the computer without r e - c o d i n g . 1  NOTE: used.  at  no  time  w i l l a tape-recording  d e v i c e be  - He w i l l r e c o r d i n t h e notebook who speaks t o whom and how, phrase by phrase. - e.g.,  the seguence:  DOCTOE TO NORSE : Good morning. How i s Mrs. Smith? Do you t h i n k we can d i s c o n t i n u e t h e IV? NORSE TO DOCTOR : She had a good n i g h t , but s h e ^ r e s t l e s s today. would be recorded 040 000  as f o l l o w s :  : 189: 56-  - Some g e n e r a l c a t e g o r i e s f o r the type of content will be developed and w i l l a l s o be noted (e.g. p a t i e n t c a r e , s t a f f concern, a d m i n i s t r a t i o n ) . - I t can be seen from t h e above example t h a t no i n d i v i d u a l s t a f f member (except as noted above) can be identified from the r e c o r d s o f t h e observers, nor can what they have s a i d be t r a c e d .  154  ________ After analyzed computer  the at  data  the  have  been  University  of  gathered, British  programs are being prepared.  they  -ill  Columbia,  The r e s u l t s  be  -here  sill  be  fed back t o the h o s p i t a l approximately four months a f t e r the c o n c l u s i o n of the study. determined  by  the  The exact feedback process M i l l  hospital  A d m i n i s t r a t i o n and  be  Department  Heads. Two t y p e s of i n f o r m a t i o n w i l l be provided: 1. Comparative: a) by department - comparison of the a b s o l u t e volume of ward communication f o r each department in each c a t e g o r y , and of the p r o f i l e s g i v i n g the percentage of communications i n each c a t e g o r y . b) Y ward - comparison of absolute and percentage communications, broken down by day and time b  2- l _ i r s of communicators: a) a b s o l u t e and percentage profiles f o r within -department communication (e.g. nurse to nurse, nurse attendant to ward c l e r k ) b) a b s o l u t e and percentage profiles f o r between -department communication (e.g. housekeeping to maintenanace) c) a b s o l u t e and percentage p r o f i l e s f o r communication between s t a f f of each department and patients,;;. a,-nd; .thgir • families. i:  The comparative s t a t i s t i c s department versus l i g h t patterns.  heads  to  should h e l p  up  general  communication  p r o f i l e s of s p e c i f i c p a i r s of communicators  should help the members of the two groups t o i d e n t i f y of  potentially  the  i d e n t i f y times and l o c a t i o n s of heavy  volume, and to p i c k The  (#1, above)  more or l e s s e f f e c t i v e communication.  areas They  155  should then be  better  able  to  determine  possible  steps  toward improvement of t h e i r methods of communicating., If  the  i n f o r m a t i o n provided i s found to be h e l p f u l t o  the v a r i o u s groups w i t h i n heads,  and  the  administrators—it  t r a i n s e v e r a l s t a f f members might  then  this  would use  then the  way  the  and  January 20 and  21,  with  is  senior  Adminstrators  during A p r i l ,  Wascana  a  them,  and  measure  summary of p r e s e n t a t i o n s made by  researcher,  Department 1975.  all 1975.  communication.  effort.  foregoing  McGill,  meetings  method.  h o s p i t a l c o u l d begin t o aore e f f e c t i v e l y  the r e s u l t s of t h a t  Betty  be p o s s i b l e t o  be a breakdown i n  diagnose i t s problems, attempt t o s o l v e  The  department  be a b l e to examine a d d i t i o n a l areas where s t a f f  or p a t i e n t s f e e l t h e r e may In  to  hospital—staff,  staff  These  to  five  groups  of  Heads o f Wascana H o s p i t a l on will  directly  be  followed  involved  i n the  up  by  study  156  __________ _TAFF_AH__P__I__T_0_I____TX___S_EE_• I____SA_HOSPIT_L C0_M_NI____O_S_R_SEA_CH_PR_J_C_  _M_i  The purpose o f the study i s t o develop a way of h e l p i n g h o s p i t a l s t a f f understand how, they communicate with other s t a f f and p a t i e n t s .  WHERE; S t a t i o n F i v e and Second West WHEN: May 5 t o August 31, 1975 WHO: Betty M c G i l l and Peter Bowman w i l l be the r e s e a r c h e r s . _2_i  H  w i l l be o b s e r v i n g how s t a f f and p a t i e n t s communicate at different l o c a t i o n s on t h e two wards--ewg. a t Nursing desk, i n p a t i e n t rooms., Generally one researcher will work on each ward, but sometimes we w i l l observe together t o check our r e l i a b i l i t y . Host of the study w i l l be done between 0800 and 1700 hours, but some time w i l l a l s o be spent i n the e a r l y morning and evening. e  WHAT: S t a f f w i l l be i d e n t i f i e d by t h e i r job t i t l e o n l y . No names w i l l be used. P a t i e n t s w i l l be grouped a c c o r d i n g to t h e communication demands which they place on the staff. A c o n v e r s a t i o n w i l l be coded, phrase by phrase, using twelve c a t e g o r i e s o f _ow people communicate--for example, give o r ask f o r i n f o r m a t i o n , agree o r disagree. We w i l l not note what i s being said. Only the coded information o f who speaks to w_om-and how w i l l be recorded.  157  For example, t h e c o n v e r s a t i o n : DOCTOR TO NURSE : Good morning., How i s Mrs. Smith? Do you t h i n k we can stop the IV? NURSE TO DOCTOR : She had a good n i g h t , but she's r e s t l e s s today. would be recorded  RESULTS:  040 : 000 :  18956-  after  being  as f o l l o w s :  analyzed,  the  results  d i s c u s s e d with a l l persons who have p a r t i c i p a t e d . be  able  to  will  be  They  will  see " p r o f i l e s " of how the nurse and d o c t o r , o r  nurse attendant  and p a t i e n t , communicate,  and t o l e a r n where  t h e i r s t r e n g t h s and weaknesses  i n communication  For  P r o f i l e of Housekeeping aide  example, the Communication  to P a t i e n t might look l i k e 1 2 3 4 5 6 7 8 9 10 11 12  this:  may l i e .  VRSCflHS HOSPITAL COMMUNICATION PROFILE PERCENTRGE OF RCTS ]M EACH CATEGORY FOR STATIOM FIVE REG-STEREO NURSE  PER!0D5=  flCTS=  T f l  25. 150.  CCCUPaTIOHffl. THRflPY  0  1  2  M  3  4 5 6 CATEGORY  7  8  9  J  K  L  WSCRNfl HOSPITAL COWUNIOTNON PROFILE PERCENTRGE CF ACTS IN ERCH CATEGORY FOR STATION FIVE REGISTERED NIRSE TO PHTStOTHERSPIST  3  1  2  H  PERIOOS= ACTS:  3  4 S 6 CATEGORY  7  B  9  J  28. 203.  K  L  WRSCRNA HOSPITAL COMMUNICATION PROFILE PERCENTAGE PF ACTS IN EACH CATEGORY FOR " ._ ta a  STATION FIVE REGISTERED NURSE TO SOCIAL WORKER  PERIODS: ACTS-  IN  CATEGORY  VRSCAMA HOSPITAL COMMUNICATION PROFILE PERCENTAGE OF ACTS IN EACH CATEGORY FOR 10. 124.  STATION FIVE SOCIAL WORKER TO REGISTERED NURSE  PER1005= «CT5=  10. 92.  WSCANS HOSPITAL COHHWICRTIO* PROFILE PERCENTAGE OF ACTS IN EACH CATEGORY FOR  WSCANA HOSPITAL CCfWUCATtON PROFILE PERCENTAGE Of RCTS IN EACH CATEGORY FOR SECOND VEST  0  1  2  M  3  4  5  CATEGORY  6  7  B  8  J  K  L  32.00  28.00-  WASCANA HOSPITAL COMMUNICATION PROFILE PERCENTAOS OF ACTS IN EACH CATEGORY FOR STATION FIVE FT STAY 2-T OAYS  PERIODS* ACTS"  WASCANA HOSPITAL COMMUNICATION PROFTLB PERCENTAGE OF ACTS IN EACH CATEGORY FOR 32.00  28. »S.  . TO REGISTERED NURSE  28.00  24.00-  24.00  20.00-  20.00  STATION FIVE REGISTERF.O NURSE  PERIODS" ACTS*  TO PT STAY 2-7 OAYS  **  •* *  X OF ACTS  % OF ACTS 16.00-  * *  16.00*  « *  28. 250.  *  •• •  « * *  12.00  12.00  *  • • #•  • .00  * •  8.00  * * * *  * • * 4.00  • • * •  *  • 0  *>  1  2  M  • 3  4 5 6 CATEGORY  7  m  m  * *  « *  *  •  4.00  *  •  *  *  •* 8  9  J  *  •  • ** *•  •  *•' •  •  *  ****************************** 4 5 6 CATEGORY  cr.  32.00-  28.00-  MASCANA HOSPITAL COMMUNICATION PROFUt PERCENTAGE OF ACTS XN EACH CATEGORY FOX STATION FIVE REGISTERED NURSE  PERIODS" ACTS"  TO PT STAY 2-7 CAYS  40.00  78. 761.  VASCANA HOSPITAL COHMUNICATION PROFIlff PERCENTAGE OF ACTS IN EACH CATEGORY FOR STATION FIV8 FT STAY 2-7 OAYS TO REGISTERED NURSE  35.00  24.00*  30. 00  20.00-  25. CO  PERIOOS" ACTS*  78. 392.  t OF ACTS  t OF ACTS  •*  16.00*  * *  20.00-  ** *  • *  12.00*  •  * *  #  15.00  «  •  8.00*  • 4.00*-  10.00  *  * * * *#  *  *  *  "  •  3.00  • •  *  • • < « •  * *  •• *  ,00»***»**«*****»* ***»«***«****•*****•«***»#***•**••***•**»••«•  100*  rt  F  3  4 5 6 CATEGORY  0  I  2  M  3  4 5 6 CATEGORY  7  8  9  J  .  K  L  WASCANA HOSPITAL COMMUNICATION PROFILE PERCENTAGE OF ACTS IN EACH CATEGORY FOR 32.00-  28.00*  SECOND WEST REGISTERED NURSE  PERIODSACTS-  TO PT COMNUNICATION-2  WASCANA HOSPITAL COMMUNICATION PROFILE PERCENTAGE OF ACTS IN EACH CATEGORY FOR  40.00-  SECONO WEST PT COMMUNICATION**  21. 180. 39.00  24.00-  30.00  20.00-  25.00  PERIODSACTS-  TO REGISTERED NURSE  -21. **62.  *  t OP *'  * OF ACTS *  *•  16.00  • *  20.00  •  *  •  *  *  12.00-  *  13.00-  * •  10.00-  •  **  • *  8.00-  *  4.00•  « * •*  #  5.00-  *  *  *  •*•  *  «  *  •  •  »  *  ' * *  m  •  *  •  •  mm  **  •  • ** ** .OO******************************  .00* 4 5 6 CATEGORY  ***•••*«••«•**»*•*• •***•*•»  CATEGORY  6  7  8  9  CO  WASCANA HOSPITAL COMMUNICATION PROFILE PERCENTAGE OF ACTS IN EACH CATEGORY FOR 64.00-  SECONO WEST REGISTERED NURSE  96.00-  PERIODS" ACTS'  TO PT COMMUNICATIONS  8.  58*  48.00-  40.00-  *  O F A CTS 32.00  24.00-  16.00-  * * 8.00«  • *  * *  *  ***  *  «» •  *  •  **«  * *•**  * *  • 00* 4  3  CATEGORY  6  _  170  APPENDIX G FEEDBACK_INFO_M_IO__S_EET _ASCMi_aO_£I2_____I__NICAlI £_PLANATIO__OF_CO___N_  1. At the top l e f t - h a n d c o r n e r o f each graph, t h e ward and two communicators are g i v e n . The f i r s t person i s the speaker, the second i s the l i s t e n e r . 2. At the top r i g h t - h a n d c o r n e r , two numbers a r e : g i v e n . "Periods" i s the number o f d i f f e r e n t 5-minute time p e r i o d s when these two persons were t a l k i n g . "Acts" i s the t o t a l number o f communications. G e n e r a l l y , one a c t i s egual to a simple sentence. 3. Across the bottom o f the graph, the numbers and letters stand f o r the 14 d i f f e r e n t types of c a t e g o r i e s i n t o which a l l communications were coded; not codable Cat 0 seems f r i e n d l y 1 dramatizes r e . work 2 dramatizes r e . non-work M agrees, l i s t e n s 3 4 - gives suggestions, leads 5 gives opinions 6 gives information  L - seems u n f r i e n d l y K - shows t e n s i o n J 9 8 7  -  disagrees seeks s u g g e s t i o n s seeks o p i n i o n s seeks i n f o r m a t i o n  4. The numbers down the l e f t - h a n d s i d e g i v e : t h e ; percentage o f the speakers*s a c t s which were i n a p a r t i c u l a r c a t e g o r y . Note that t h i s s c a l e may d i f f e r from one graph t o another.  Suggestions f©reinterpreting  a_Pair_Of_£_g£___s  1. Compare the number o f a c t s f o r each speaker., F o r example, i f NORSE t o PATIENT has 570 a c t s , and PATIENT t o NORSE has 220, then the nurse communicated twice as much t o the p a t i e n t as he d i d t o her.  171  2. Look a t t h e o v e r a l l shape of t h e two p r o f i l e s . they s i m i l a r ? Where do they d i f f e r ?  Where a r e  3. Examine the frequency of s p e c i f i c categories. For example, are the percentages of Cat. ,1's equal f o r DIETARY AIDE t o PATIENT versus PATIENT t o DIETARY AIDE? 4. Look f o r marked e g u a l i t i e s o r i n e q u a l i t i e s between p a i r s o f c a t e g o r i e s on each p r o f i l e . , ( i . e . . 1-L; 2+8-K; 3-J; 4-9; 5-8; 6-7) e.g. and  DOCTOR t o NORSE - high 5 (giving opinion) NURSE t o DOCTOR - low 8 (seeking opinion)  versus and  DOCTOR t o NURSE - high 5 NURSE t o DOCTOR - high 8  5. Relate each p a i r of p r o f i l e s t o what you know about the work you do on the ward. Which f i n d i n g s are easy t o explain? Which a r e n ' t ? 6. Discuss what you've l e a r n e d with Compare your p r o f i l e s with t h e i r s . ,  other  staff  members.  7. Write down any guestions which you have, or p o i n t s which you'd l i k e t o d i s c u s s f u r t h e r .  (Note: T h i s sheet was accompanied by a copy of p o s i t i o n code given i n _2_endijc_B.)  the p a t i e n t  172  A__E_DI__H IIMAL_SISQRl_o__Gg____i_ATig_s_^ February To:  Hr. ,R. Osiowy, Administrator, Wascana H o s p i t a l , Eegina, Saskatchewan  He:  Depart-ental_ffqllow-UB^^  28,  1976  During my ten-day s t a y i n Regina, meetings were held with the f o l l o w i ng Wascana H o s p i t a l Department Heads and A s s i s t a n t D i r e c t o r s of Nursing: - M. Lindberg, C Spooner S t a f f Development - R. Osiowy, A. T a t a r i n o f f Administration - G. P e r n i s i e , P Skaien Dietary - M. Kaplunsky Housekeeping Haintenanace - R. Beebe - c . M i l l e r , M. Cook, G. De-ay Nursing - F. Richardson O c c u p a t i o n a l Therapy - F. Ford Porters a l l staff Pharmacy - L. Johnson Physiotherapy - D. Leland Psychology - A. Sloan S o c i a l Work - D. Rackley Speech and Hearing C. Spooner attended a m a j o r i t y of the above meetings. M. Lindberg and the S t a f f Development I n s t r u c t o r s a l s o attended s e s s i o n s with the two A.D.N.*s. At each meeting, persons present were asked: 1. What a d d i t i o n a l work they or t h e i r s t a f f had done with the communication feedback s i n c e mid-December? 2. Did they see any need f o r a c t i o n ? I f so, what had they a l r e a d y done? What should be suggested f o r the f u t u r e ? 3. What type of help would they l i k e , e i t h e r from myself d u r i n g my s t a y , or from S t a f f Development i n the future, for: - g e n e r a l s t a f f members? - s u p e r v i s o r s and/or department heads?  173  I__§_^§E___l__tal_2_ob_ems 1  -  were d i s c u s s e d as f o l l o w s :  Problem: low communication by s t a f f with a p h a s i c p a t i e n t s on S t a t i o n F i v e D i s c u s s i o n : T h e r a p i s t s f e l t t h a t they do t h i s when the p a t i e n t i s i n the department f o r treatment., Nursing believed t h a t more communication occurs i n evenings when p a t i e n t s are on the ward. However, i n s p i t e of these f a c t o r s , most s t a f f r e c o g n i z e d t h i s as a problem. Mt_2___a_en: Most s t a f f b e l i e v e d t h a t being aware of t h i s d e f i c i t was h e l p i n g them t o overcome: i t through individual effort. D. Rackley (Speech T h e r a p i s t ) i s now p r o v i d i n g more support t o the team by a t t e n d i n g clinics and g i v i n g suggestions r e . s p e c i f i c p a t i e n t s . T h i s was a p p r e c i a t e d by s e v e r a l departments. Suggestions; Several departments reguested Staff Development classes on practical suggestions f o r communicating with the aphasic p a t i e n t ; This was discussed with Ms. Rackley and a f i r s t session for p r o f e s s i o n a l s t a f f was scheduled f o r Thursday, February 26, at 15:30 h r s .  2»  Problem: team conferences on S t a t i o n F i v e were not felt by some p a r t i c i p a n t s t o be functioning e f f e c t i v e l y as they might  as  D i s c u s s i o n : Informal d i s c u s s i o n s were held with s e n i o r nurses, o c c u p a t i o n a l t h e r a p i s t s , p h y s i o t h e r a p i s t s and social workers from both teams. I t seemed t h a t i t was mainly the S e n i o r Nurses who were d i s s a t i s f i e d with present f u n c t i o n i n g . Action^Taken: A. Balon, S t a f f Development I n s t r u c t o r f o r t h a t ward, and I s a t i n on one conference f o r each team. We then met with the f o u r s e n i o r nurses and Mrs. Demay t o d i s c u s s how. they, i n t h e i r present r o l e as c o o r d i n a t o r of the c o n f e r e n c e s , might improve their e f f e c t i v e n e s s and e f f i c i e n c y . 3»  Problem: d e s i r e of Department Heads and/or S u p e r v i s o r s f o r some t r a i n i n g i n how t o help s t a f f communicate more effectively A______X_l£.§2.'• Four one-and-one-half-hour s e s s i o n s on " E f f e c t i v e Communication" were conducted f o r Department Heads and S u p e r v i s o r s during my second week at Wascana. T o p i c s covered were: - understanding the communication process - a s s e s s i n g communication e f f e c t i v e n e s s using the twelve Study c a t e g o r i e s - improving l i s t e n i n g s k i l l s  174  Attendance a t these c l a s s e s was as f o l l o w s : 2M§§___Feb_l7 A. Balon M. Cook L. Golby M. Kaplunsky C. L i u P. Skaien (2) H. Lindberg  15 :00_;_o_16_30_hrs_ S t a f f Development Second West Physiotherapy C l i n i c a l S u p e r v i s o r Housekeeping D i e t a r y Interne Dietician Pharmacy S.S.H.C. S t a f f Development  ______________ E. B e i t e l G. Demay J . Kletke B. McCudden C. Spooner A. T a t a r i n o f f  lli20_to_13__0__rs_ Personnel Station Five S t a f f Development Health Nurse S t a f f Development Administration 15__0_to_16_30_hrs. Outpatient C l i n i c s Dietary Speech & Hearing Speech 6 Hearing Pharmacy  y  F. Ford G. P e r n i s i e E. Small M..Hunter (3)  15x00_to_16_30_hrs. H e d i c a l Records Security O c c u p a t i o n a l Therapy Senior O.T.*s S o c i a l Work ( s u b s t i t u t e )  ____________  D. Jones P. Hatwiy F. Richardson (3) A. Sloan r  All persons present participated actively in d i s c u s s i o n s . I n a d d i t i o n t o the above, a separate onehour class was held with a l l the Senior P h y s i o t h e r a p i s t s and L. Johnson, f o c u s i n g on their s p e c i f i c concerns. 4.  Problem: g e n e r a l s t a f f wanted t o know more about e f f e c t i v e commnication 4__i2__2_ll§ .s assess i n t e r e s t i n t h i s t o p i c , and provide a model f o r f u t u r e S t a f f Development sessions, I conducted f i v e h a l f - h o u r c l a s s e s . P a r t i c i p a t i o n was as f o l l o w s : n  Tues._ Feb_  T  o  17 - 13:30 h r s . 22:00  (5) (12)  Feb. v_18 - '15:30  (5)  Thurs. _Feb. , 1 9 - 1 3 : 3 0 18:45  (4) (16)  _____  175  Suggestions; I n a d d i t i o n t o t h e above, o p p o r t u n i t i e s f o r f o l l o w - u p f o r g e n e r a l s t a f f e x i s t through; a) i n d i v i d u a l o r departmental education by Department Heads and A.D.N.'s b) o r i e n t a t i o n o f new s t a f f by s t a f f Development c) f o l l o w - u p c l a s s e s on " E f f e c t i v e S t a f f Development  Communications"  by  In addition t o the above, t h e f o l l o w i n g ___£_-_§E___S__i_l_£_2_l§l§ were d i s c u s s e d d u r i n g the meetings with i n d i v i d u a l Department Heads: Dietary: 1.  Concern: low communication o f D i e t a r y Aides with a l l patients Discussion: Ideally, s t a f f f e l t t h a t i f they had more Aides they c o u l d spend more time communicating with patients. However, given present l i m i t a t i o n s , t h i s problem cannot be a l l e v i a t e d .  2.  Concern: Aides showed low communication with confused or aphasic p a t i e n t s D i s c u s s i o n : D i e t a r y Aides suggested that a brief d i s c u s s i o n with P. Skaien, e i t h e r bi-weekly or monthly, giving them more i n f o r m a t i o n r e . p a t i e n t s , would h e l p them t o make b e t t e r use o f the time they do have : with these p a t i e n t s . A c t i o n Taken: a) P. Skaien will hold b r i e f i n f o r m a l meetings with Aides from each ward t o give them suggestions r e . communication with certain patients and an e x p l a n a t i o n of why the p a t i e n t i s on a p a r t i c u l a r d i e t . Emphasis w i l l be placed on the p a t i e n t ' s present communication ability and d i e t r a t h e r than h i s / h e r d i s a b i l i t y or history. G. P e r n i s i e w i l l inform staff of this at t h e i r next meeting, and d i s c u s s t h e i r r e s p o n s i b i l i t i e s re. c o n f i d e n t i a l i t y . b) S t a f f Development w i l l conduct a twenty^minute c l a s s f o r n o n - p r o f e s s i o n a l s t a f f ( D i e t a r y , Housekeeping) on Reality Orientation and general approaches to communication with such p a t i e n t s .  176  3)  Concern: s t r o n g communication r o l e of D i e t i c i a n S t a t i o n F i v e p a t i e n t s on t h e r a p a e u f i c d i e t s  with  D i s c u s s i o n : The communication p r o f i l e s of the D i e t i c i a n on Station Five during the pilot project on Therapaeutic D i e t s showed t h a t a c o n s t r u c t i v e r o l e was being filled i n seeking patient input (opinions, suggestions) re. their diets. Recent e l i m i n a t i o n of t h i s s e r v i c e cannot help but cause a d e t e r i o r a t i o n i n the g u a l i t y of t o t a l care o f f e r e d t o the p a t i e n t s on t h a t ward. Suggestion: I would strongly recommend that this service be made a v a i l a b l e to p a t i e n t s on a l l wards as soon as p o s s i b l e . P r o f i l e s supporting t h i s suggestion are a v a i l a b l e from P. Skaien. Housekeeping: 1.  £2S£___* t e n s i o n and u n f r i e n d l i n e s s between Housekeeping Aides and Housemen on Second Best Discussion: B . Kaplunski has h e l d meetings with h i s staff~and~supervisors re., this issue. They f e l t part of this problem was a c o n f l i c t over job d u t i e s , which has been somewhat a l l e v i a t e d by compiling the job evaluations. Suggestion: I spent c o n s i d e r a b l e time d i s c u s s i n g t h i s c o n f l i c t with H. Kaplunski and h i s two Supervisors. Thay f e e l t h a t the major cause of t h i s c o n f l i c t , which i s present throughout the Department, i s the l a r g e wage spread between the two classifications (H..Aide = $3.22/hr.; Houseman = $4.04), and t h a t i f t h i s spread were reduced i t would be p o s s i b l e t o get increased p r o d u c t i v i t y from the female s t a f f . ,  2.  Concern: low m o t i v a t i o n l a c k o f p r i d e i n work  of Housekeeping employees; :  -isS-S-iSSa d d i t i o n t o t h e low wages of H. Aides, there are only two steps t o the salary scale. T h e r e f o r e , t h e r e i s no i n c e n t i v e t o long-term employees to maintain a high l e v e l of p r o d u c t i v i t y . . . Compounding this problem i s the f a c t that on most wards. Housekeeping staff receive little or no r e c o g n i t i o n from other departments f o r a job w e l l donei , I  n  Suggestion: a) The S u p e r v i s o r s recommended more steps on the s a l a r y s c a l e t o allow r e c o g n i t i o n f o r l o n g - s e r v i c e employees.  177  b) S t a f f Development w i l l encourage ward s t a f f t o thank and p r a i s e Housekeeping s t a f f f o r jobs w e l l done. , T h i s i s already being done by t h e S t a t i o n s 5-6 Nursing staff, and was f e l t t o c o n t r i b u t e t o t h e i r being considered the most popular s i t e s f o r s t a f f t o work. c) S t a f f Development will also emphasize this communication r o l e t o new employees during o r i e n t a t i o n , and by example on the wards. d) S t a f f Development w i l l conduct bi-weekly s e s s i o n s with s u p e r v i s o r s t o improve t h e i r e f f e c t i v e n e s . I_rsing_-_Second__est: 1  «  Concern^ between R.N. and G.P, on Category 1, Seems F r i e n d l y (R.N. = 3%; G.P. = 20%) there ; i s an imbalance Suggestion: Balanced communication should be s t r e s s e d during O r i e n t a t i o n . T h i s c o u l d a l s o be pointed out t o present s t a f f as part o f a general s e s s i o n on e f f e c t i v e communication. However, i t was not f e l t that staff would be w i l l i n g t o attend such a c l a s s at present. .  2.  Concern: low p a r t i c i p a t i o n by 28 and 2E Nursing in Inservice classes  staff  D i s c u s s i o n : T h i s concern arose from the d i s c u s s i o n o f #1, above, r a t h e r than from t h e study feedback. , I t i s c o n s i d e r e d a major problem. Suggestion: a) Involvement of H. Cook, as a resource person f o r c l a s s e s ( s t a f f a r e p r e s e n t l y not making maximum use o f her knowledge and e x p e r i e n c e ) . b) I n s t i t u t e a reguirement that a l l h o s p i t a l s t a f f p a r t i c i p a t e i n a c e r t a i n number o f s t a f f development classes per year (e.g. 6) . ,. A p r e v i o u s Mascana system of each s t a f f member having h i s or her own educational card, on which such p a r t i c i p a t i o n was checked o f f , i s recommended. S t a f f would thus assume responsibility for deciding which c l a s s e s were of most r e l e v a n c e t o them, and of a t t e n d i n g t h e y e a r l y reguirement^ This recommendation is now being considered by S t a f f Development.  178  _u_sin____Station_Fi_e: 1.  Concern: Senior Nurse  over-dramatizes  A _ i i 2 B i Awareness of t h i s tendency provided through the December feedback seems t o have a l l e v i a t e d the problem. Her communication i s now - perceived to be more functional. 2.  Concern: a l l h e a l t h team members a r e low on seeking the professional opinion of t h e i r own and other disciplines A c t i o n : Nurses have d i s c u s s e d t h i s as a group with G. Demay, and have agreed t o make an e f f o r t t o c o r r e c t t h i s problem.  3.  Concern: low communication  with a p h a s i c s  Suggestion: In a d d i t i o n t o the general p o i n t s d i s c u s s e d on page 1, the nurses requested t h a t the c l a s s e s by D. Rackley be conducted at 15:30 h r s . i f p o s s i b l e , as evening s t a f f have the g r e a t e s t communication with patients. A c t i o n : The c l a s s has been scheduled a c c o r d i n g l y . O c c u p a t i o n a l Therapy: no i n t r a - d e p a r t m e n t a l i s s u e s were discussed; low communication with d y s p h a s i c s i s aggravated by l a c k of s t a f f and l a c k . of Senior O c c u p a t i o n a l T h e r a p i s t on S t a t i o n F i v e . Pharmacy: 1.  Concern: low communication  with a l l p a t i e n t s  D i s c u s s i o n : Pharmacists f e e l t h a t t h e i r education does not prepare them s u f f i c i e n t l y f o r communication with patients, whether with or without the additional problem of a p h a s i a . A c t i o n : They reguested t h a t a l l „ f i v e members of the department p a r t i c i p a t e i n the l o n g e r s e s s i o n s on " E f f e c t i v e Communications" f o r Department Heads. 2.  Concern: low communication  with a p h a s i c s  Suggestion: C l a s s e s by D. Rackley be h e l d at the end o f the morning or afternoon so t h a t s t a f f can p a r t i c i p a t e .  179  Physiotherapy1-  Concern: frequency of negative emotional r e a c t i o n s (tension, unfriendliness) from patient to Behab. Attendant on 28 Discussion: The Senior Therapists, when d i s c u s s i n g t h i s , f e l t t h a t a t l e a s t part of the cause of t h i s might be t h a t attendants were working t o o f a s t . A c t i o n : The department has already implemented a s e r i e s of weekly c l a s s e s f o r Rehab. Attendants t o review basic techniques and d i s c u s s t h e use of Reality Orientation.  2.  Concern: l a c k o f communication between P h y s i o t h e r a p i s t and Registered Nurse on Second Hest (no s i g n i f i c a n t profile) A c t i o n : L. Johnson w i l l work with t h e Senior Physio, in that area t o t r y t o i n c r e a s e t h i s communication. Staff Development w i l l reinforce the need for communication with other departments during O r i e n t a t i o n and through follow-up on t h e wards.  3. ,  Concern: l a c k o f communication between and p a t i e n t on 29 Action: deficit.  4.  L. Johnson  will  make  staff  Physiotherapist aware  of  Concern: P h y s i o t h e r a p i s t s a r e somewhat lower on Category 1 (seems f r i e n d l y ) than a r e the departments with whom they a r e communicating  this  other  Discussion: Because s t a f f a r e working under very heavy pressures a t the moment, i t was not f e l t t o be a p p r o p r i a t e t o d i s c u s s t h i s i s s u e d i r e c t l y with thenu Action: This was handled by d i s c u s s i n g Communication" with t h e s e n i o r t h e r a p i s t s .  "Effective  Psychology: Although she r e c e i v e d no d i r e c t feedback from the study, I have kept Ms. Leland informed on the feedback process f o r two reasons. The f i r s t i s that she has a d e f i n i t e i n t e r e s t i n t h i s area, s i n c e her Master's t h e s i s was on T e a c h e r - P u p i l Communication. The second i s t h a t she i s a p o t e n t i a l resource f o r a l l Hospital departments on t h i s t o p i c ( i n c l u d i n g S t a f f Development f o r c l a s s e s ) .  180  S o c i a l .Work: 1.  Concern: how t o provide communication s t i m u l a t i o n f o r p a t i e n t s on 2W Suggestion: I n c r e a s e the use o f v o l u n t e e r s through: a) A. Sloan p r o v i d i n g g r e a t e r support t o the P e r s o n a l Services worker, (G. M c C l e l l a n d has been c a r r y i n g an e x c e p t i o n a l l y heavy l o a d f o r many y e a r s , and i s needing increased professional support to maintain her effectiveness). b) More d i r e c t c o n t a c t with v o l u n t e e r s by A. Sloan, Close l i a i s o n between A. ,Sloan and G, M c C l e l l a n d i s necessary to the above two suggestions. . I t i s t h e r e f o r e c r i t i c a l f o r the P e r s o n a l S e r v i c e s Worker t o remain w i t h i n the wascana Department of S o c i a l Work. Given this a d m i n i s t r a t i v e arrangement, the above s u g g e s t i o n s a r e f e a s i b l e with present s t a f f i n g .  2-  Concern:  low communication with new p a t i e n t s on S5  Action: S o c i a l Workers a r e now a s k i n g f o r n o t i f i c a t i o n from Admitting when a new p a t i e n t arrives, and f o r notice from t h e Ward when t h e r e i s a d i s c h a r g e . They w i l l a l s o be encouraged t o see the p a t i e n t s more i n t h e i r f i r s t week on the ward. . S_eech_and ^Hearing: 1.  Concern: low communication with other departments on Station Five Action; D. Backley i s attempting to participate i n S t a t i o n F i v e c l i n i c s on a bi-weekly basis. The team discuss her p a t i e n t s f i r s t , so t h a t r e d u c t i o n i n treatment time i s minimized. , She has a l s o been phoning the ward with suggestions r e . s p e c i f i c p a t i e n t s . Suggestion: D. Backley will attempt t o a t t e n d ward planning conferences every two t o three weeks, t o provide a l l s t a f f with suggestions on patient communication. While t h i s w i l l s l i g h t l y decrease her d i r e c t treatment s t a t i s t i c s , Ms. Backley f e e l s i t w i l l provide b e t t e r o v e r - a l l c a r e f o r p a t i e n t s because s t a f f will be able t o c o o r d i n a t e t h e i r approaches t o the p a t i e n t ' s communication d i s a b i l i t y .  2.  Concern; need t o a s s i s t p a t i e n t s t o improve t h e i r communication s k i l l s Suggestion: Ms. Backley w i l l d i s c u s s with Ms. Demay the p o s s i b i l i t y o f making language m a t e r i a l s a v a i l a b l e on the ward f o r evenings and weekends.  181  _______: The above a r e the major areas o f concern which were uncovered d u r i n g my v i s i t . Most Department Heads expressed a definite interest i n following through on the i n i t i a l feedback from the Communication Study. As you w i l l note from the above, some a c t i o n has been taken to r e s o l v e most of the problems and concerns i d e n t i f i e d by the Study. While most of the problems can be r e s o l v e d a t the departmental l e v e l , I f e e l t h a t s e v e r a l have emerged which require Administrative support and/ o r d e c i s i o n making. These are as f o l l o w s : Dietary (#3); Housekeeping (all); Nursing - Second Best (#2); S o c i a l Work (#1); Speech and Hearing (#1). Throughout a l l of the d i s c u s s i o n s , i t was evident t h a t Wascana s t a f f a t a l l l e v e l s are aware o f the importance o f communication, and of maximizing i t s e f f e c t i v e n e s s i n times of s t a f f i n g p r e s s u r e s . I b e l i e v e that the impetus of the study has helped t o focus a t t e n t i o n on t h i s problem, and on c o n s t r u c t i v e s o l u t i o n s , and hope t h a t t h i s concern will continue i n the f u t u r e . Thank you f o r your i n t e r e s t i n the the study.  Respectfully  B.  HcGILL  Subaitted,  (SIGNED)  Betty M c G i l l , Research P r o j e c t  Director  

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