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Primary nursing as seen by patients and nurses Konnert, Joanne Norine 1976

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PRIMARY NURSING AS SEEN BY PATIENTS AND NURSES by JOANNE NORINE KONNERT BScN, University of B r i t i s h Columbia, 1971 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER, 1976 fcj Joanne Konnert, 1976 In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make it f ree ly ava i lab le for reference and study. I further agree that permission for extensive copying of th is thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of this thes is for f inanc ia l gain sha l l not be allowed without my written permission. Department of N u r s i n g The Univers i ty of B r i t i s h Columbia 2075 We.sbrook Place Vancouver, Canada V6T 1W5 Date October, 1 Q76 i . ABSTRACT Primary nursing i s a system of d e l i v e r i n g nursing care when one nurse i s responsible and accountable f o r the assessment of the patient's needs as well as the planning, implementing and evaluating of the nursing care throughout the patient's h o s p i t a l i z a t i o n . These a c t i v i t i e s are done i n co l l a b o r a t i o n with the patient and other members of the health team. This system i s a r e l a t i v e l y recent development i n the f i e l d of nursing. There has been l i t t l e research done to e i t h e r describe or evaluate primary nursing, p a r t i c u l a r l y i n the area of psychiatry. This study was an attempt to include both patients and nurses i n such an evaluation. A v a l i d a t e d and r e l i a b l e questionnaire was developed by the author to obtain data r e l a t e d to patients' and nurses 1 perceptions of the occurrence, importance and s a t i s f a c t i o n of s p e c i f i c primary nursing behaviours. The questionnaire was administered to twenty-nine patients and t h e i r primary nurses during the l a s t week of the patient's h o s p i t a l i z a t i o n . Nurses and patients reported that primary nursing behaviours r e l a t e d to discharge had a low occurrence rate. However, they a t t r i b u t e d a high degree of importance to these same behaviours. Both groups reported a low occurrence and importance score for primary nursing behaviours r e l a t e d to family involvement with the primary nurse and the patient's treatment program. Both nurses and patients agreed on the occurrence and importance of most of the primary nursing behaviours. There was less agreement i n the area of s a t i s f a c t i o n . (Thesis Chairman) i i . TABLE OF CONTENTS CHAPTER PAGE I INTRODUCTION 1 THE PURPOSE 2 THE PROBLEM 2 SIGNIFICANCE OF THE STUDY 3 DEFINITIONS . ,.' 6. ASSUMPTIONS 7 HYPOTHESES 8 DATA ANALYSIS - 9 LIMITATIONS 9 DESIGN AND METHODOLOGY 10 Development of the Questionnaire 11 Development of the Patient P r o f i l e . . . . n Administration of the Questionnaire . . . 12 Development of the Chart C h e c k l i s t . . . . 12 DEVELOPMENT OF CHAPTERS 13 II REVIEW OF THE LITERATURE 15 DESCRIPTION OF PRIMARY NURSING 15 Background Related to Primary Nursing . . 15 Models of Primary Nursing 19 EVALUATION OF PRIMARY NURSING 24 Evaluation of Nursing Care 24 Evaluation of Primary Nursing 29 III DESIGN AND METHODOLOGY 36 THE SETTING 36 THE PARTICIPANTS 37 Patients 37 Nurses 38 THE QUESTIONNAIRE 39 THE DESIGN 42 THE CHART CHECKLIST 44 METHODOLOGY 44 IV DATA ANALYSIS AND RESULTS 50 THE PATIENT PROFILE 50 THE CHART CHECKLIST 51 THE QUESTIONNAIRES 53 Hypothesis 1 53 Hypothesis 2 54 Hypothesis 3 55 Hypothesis 4 57 Hypothesis 5 58 Hypothesis 6 60 i i i . V SUMMARY 65 CONCLUSIONS 65 IMPLICATIONS 69 RECOMMENDATIONS 70 BIBLIOGRAPHY 73 APPENDICES Appendix A - Information Given to Primary Nurses 77 Appendix B - Consent Forms 81 Appendix C - Chart C h e c k l i s t 83 Appendix D - Patient P r o f i l e 85 Appendix E - Data from Patient P r o f i l e . . . . 87 Appendix F - Method of C a l c u l a t i n g the S a t i s f a c t i o n Scores 89 Appendix G - Patient Questionnaire 91 Appendix H - Nurse Questionnaire 104 Appendix I - Appendix Tables 115 i v . LIST OF TABLES TABLES PAGE 4.1 Summary of Results from the Chart Checklist 52 4.2 Summary of the Spearman Rank Co r r e l a t i o n C o e f f i c i e n t s f o r Hypotheses 1, 2, 3 56 4.3 Behaviours That Demonstrated S i g n i f i c a n t Differences i n Occurrence 58 4.4 C r i t i c a l Values f or U i n the Mann-Whitney U Test 59 4.5 Behaviours That Demonstrated S i g n i f i c a n t Differences i n Importance 60 4.6 Behaviours That Demonstrated S i g n i f i c a n t Differences i n S a t i s f a c t i o n 62 V. ACKNOWLEDGEMENTS I would l i k e to express my thanks to the members of my Thesis Committee: Dr. Ruth Z i t n i k , Dr. Jack Yensen, and Dr. Tsung-Yi-Lin. Their p r a c t i c a l suggestions and unending support and encouragement I very much appreciated. I would also l i k e to acknowledge my gratitude to the patients and nurses who completed the questionnaires f o r the study. A s p e c i a l thanks to my husband, David, whose i n f i n i t e patience g r e a t l y f a c i l i t a t e d the completion of t h i s t h e s i s . CHAPTER I INTRODUCTION How can nurses best d e l i v e r care to patients? Nursing educators and nursing p r a c t i t i o n e r s have addressed t h i s question within t h e i r respective s e t t i n g s . One answer has been the development of primary nursing. This system of d e l i v e r i n g nursing care i s more than just a revised version of the case method of nursing. The difference l i e s i n the r e s p o n s i b i l i t y and a c c o u n t a b i l i t y of the primary nurse f o r the care he or she gives. The c e n t r a l focus of primary nursing i s the patient. Consequently, i t seems l o g i c a l to include the patient i n any research regarding primary nursing, p a r t i c u l a r l y i f i t i s an evaluative study. Another reason for i n c l u d i n g the patient i s the demand, by consumers, for a voice i n matters pe r t a i n i n g to health care. Melvin Glasser, a physician w r i t i n g about the consumer and health care, stated: "The consumer has now asserted himself as the greatest force f o r promoting change i n the health care f i e l d . Although he looks to the health p r o f e s s i o n a l for t e c h n i c a l guidance, the consumer expects to be part of the decision making process."^ At present, there has been l i t t l e research done to e i t h e r describe or evaluate primary nursing. This i s e s p e c i a l l y true i n psychiatry. M. Glasser, "Consumer Expectations of Health Services", Medicine  i n a Changing Society, eds. L. Corey and S. Saltman, (St. Louis: C.V. Mosby and Co., 1972), p. 29. 2. This study attempted to both describe and evaluate the component of primary nursing. THE PURPOSE The purpose of t h i s study was to devise a t o o l and to gather data regarding the perceptions of patients and primary nurses of the occurrence and importance of s p e c i f i c primary nursing behaviours, and to discover the degree to which they were s a t i s f i e d with primary nursing. This was done i n an attempt to generate research data that would describe and evaluate primary nursing, p a r t i c u l a r l y as i t i s pr a c t i s e d i n a p s y c h i a t r i c s e t t i n g . THE PROBLEM This study addressed i t s e l f to the following questions»• 1. Are the primary nursing behaviours described i n the l i t e r a t u r e c a r r i e d out by nurses i n the h o s p i t a l setting? 2. Do patients and nurses assign the same importance to these primary nursing behaviours? 3. Are nurses and patients s a t i s f i e d with primary nursing as a system of d e l i v e r i n g and re c e i v i n g nursing care? These questions were explored by administering a questionnaire to patients and nurses during the f i n a l week of the patients' h o s p i t a l i z a t i o n . 3. SIGNIFICANCE OF THE STUDY Although primary nursing has been described i n the nursing l i t e r a t u r e for a number of years, there have been few publications describing research done i n t h i s area. Many of the a r t i c l e s about primary nursing contain questions that can only be answered and tested through research. The i n v e s t i g a t o r was unable to discover research that validated that primary nursing, as described i n the l i t e r a t u r e , was a c t u a l l y being p r a c t i s e d . I t i s a common phenomenon that what people say they do and what they a c t u a l l y do are sometimes d i f f e r e n t . Consequently, there seemed to be a need to determine i f patients and nurses perceived the occurrence of the nursing behaviours described i n the l i t e r a t u r e as part of primary nursing. The i n v e s t i g a t o r was able to discover only l i m i t e d data on the perception, by patients and nurses, of the importance of the nursing behaviours that comprise primary nursing. Marram et a l wrote that patients from d i f f e r e n t nursing units (team nursing, f u n c t i o n a l nursing, primary nursing and case method nursing) attached importance to d i f f e r e n t 2 nursing behaviours. These behaviours seemed to r e l a t e more generally to nursing rather than focusing s p e c i f i c a l l y on primary nursing. Perhaps there are primary nursing behaviours that patients and nurses perceive as unimportant and therefore, perhaps, unnecessary. There have been at l e a s t two studies which have looked at s a t i s f a c t i o n with primary nursing. Marram et a l wrote that both patients G. Marram, M. Schlegel, and E. Bevis, Primary Nursing, (St. Louis: C.V. Mosby and Co., 1974), p. 127. and nurses indicated greater s a t i s f a c t i o n with primary nursing than 3 with team, functional or case method nursing. Daeffler's findings indicated a greater degree of s a t i s f a c t i o n with primary nursing as 4 compared to team nursing. A major emphasis i n t h i s study was the involvement of patients i n the evaluation of t h e i r care. As consumers and tax payers i n a society where health care demands a large part of the p r o v i n c i a l and nation a l budget, they are demanding more say i n the area of t h e i r health care. I t i s important that health pr o f e s s i o n a l s , e s p e c i a l l y nurses, respond to these demands. One of the outcomes of t h i s study was the development of a t o o l to te s t patient and nurse s a t i s f a c t i o n with primary nursing. Many of the a r t i c l e s written about primary nursing included the observation that both patients and nurses expressed "great s a t i s f a c t i o n " with primary 5 6 7 nursing. ' ' Marram et a l and Daeffler have s p e c i f i c a l l y examined and measured patient s a t i s f a c t i o n i n r e l a t i o n to primary nursing. Marram looked at the nurses' response as well. D a e f f l e r u t i l i z e d the c h e c k l i s t developed by Abdellah and Levine and expressed the thought that t h i s instrument had l i m i t e d value i n measuring s a t i s f a c t i o n with care. 3 Ibid., p. 132. 4 R. Daeffler, "Patients' Perception of Care under Team and Primary Nursing", Journal of Nursing Administration, V, 3 (1975), pp. 20-26. 5 K.L. Ciske, "Primary Nursing: An Organization That Promotes Pro-f e s s i o n a l P r a c t i c e " , Journal of Nursing Administration, IV, 1 (1974), pp. 28-31. ^ A. Logsdon, "Why Primary Nursing?", Nursing C l i n i c s of North America, XXVIII, 2 (1973), pp. 283-291. 7 M. Manthey, "Primary Nursing i s A l i v e and Well i n the H o s p i t a l " , American Journal of Nursing, LXXIII, 1 (1973), pp. 83-87. Q R. D a e f f l e r , op. c i t . , p. 26. 5. Marram et a l focussed on the d e s c r i p t i o n of the r e s u l t s of t h e i r research and gave l i t t l e data i n terms of t h e i r measurement t o o l s or 9 methodology. I t seems there i s a need to develop v a l i d and r e l i a b l e instruments, which r e f l e c t the process of primary nursing and also provide a l t e r n a t i v e s i n e s t a b l i s h i n g construct v a l i d i t y f o r other t o o l s that might be created to investigate t h i s area. The development of the questionnaire u t i l i z e d i n t h i s study necessitated the i d e n t i f i c a t i o n of the s p e c i f i c behaviours incorporated i n primary nursing. Such an i d e n t i f i c a t i o n could f a c i l i t a t e the comparison of primary nursing with other systems of d e l i v e r i n g nursing care. This might be done by administering the primary nursing questionnaire i n a u n i t that p r a c t i s e d primary nursing and i n a u n i t that u t i l i z e d another nursing approach, such as team nursing, and comparing the r e s u l t s . This study attempted to show which primary nursing behaviours patients and nurses rate as important. This information may have implications f o r the p r a c t i c e o f primary nursing. I t could be viewed as v a l i d a t i o n f or what i s currently being p r a c t i s e d or as a guide for planned change from a d i f f e r e n t system of nursing, such as f u n c t i o n a l nursing, to primary nursing. I t may also give d i r e c t i o n f or planned change within the system of primary nursing. An example would be the elimination of primary nursing behaviours that neither patients nor nurses perceived as important. Marram et a l . , op. c i t . , pp. 125-157. 6. DEFINITIONS The following terms are defined according to t h e i r use i n t h i s i n v e s t i g a t i o n . Primary nursing: a system of d e l i v e r i n g nursing care when one nurse i s responsible and accountable f o r the assessment of the patient's needs as w e l l as the planning, implementing and evaluating of the nursing care throughout the patient's h o s p i t a l i z a t i o n . These a c t i v i t i e s are done i n c o l l a b o r a t i o n with the patient and other members of the health team. Registered nurse: any nurse who i s currently r e g i s t e r e d with the Registered Nurses' Association of B r i t i s h Columbia. Accountable: the nurse's verbal or written j u s t i f i c a t i o n or explanation of h i s or her nursing decisions to the patient, peers and supervisors. Responsible: the nurse's o b l i g a t i o n to assess the patient's needs, and to plan, implement and evaluate the nursing care given throughout the h o s p i t a l i z a t i o n . S a t i s f a c t i o n : an attitud e which can be expressed as the degree of congruence between the occurrence and importance of c e r t a i n nursing behaviours as measured on the questionnaire. P s y c h i a t r i c resident: a medical doctor who i s rec e i v i n g further education and t r a i n i n g to be a p s y c h i a t r i s t . Primary t h e r a p i s t : the person who i s responsible f o r the patient's treatment program while the patient i s i n h o s p i t a l . This person may be a nurse, a s o c i a l worker, a p s y c h i a t r i c resident, a medical student, or a p s y c h i a t r i s t . Associate nurse: a member of the nursing s t a f f who a s s i s t s the primary nurse by giving care to a patient when that patient's primary nurse i s o f f duty. This person may be a reg i s t e r e d nurse or p s y c h i a t r i c a s s i s t a n t . P s y c h i a t r i c a s s i s t a n t : a member of the nursing s t a f f whose main function i s to organize and encourage p a r t i c i p a t i o n i n the a c t i v i t y and recreation program of the h o s p i t a l . Junior care co-ordinator: a primary nurse who has assumed ad d i t i o n a l administrative and teaching r e s p o n s i b i l i t i e s at the ward l e v e l . ASSUMPTIONS I t was assumed that: a. a l l nurses designated as primary nurses within the i n s t i t u t i o n where the study took place would be p r a c t i s i n g primary nursing, because primary nursing was part of the philosophy of the nursing f a c i l i t y ; b. primary nursing can be described by s p e c i f i c observable behaviours; c. primary nursing can be measured through the administration of a questionnaire; d. patients and nurses can and w i l l express s a t i s f a c t i o n or d i s s a t i s f a c t i o n with primary nursing behaviours as measured by a questionnaire. 8. HYPOTHESES Although t h i s was a d e s c r i p t i v e study, i t was possible to i d e n t i f y s i x hypotheses. These were: (1) there i s no c o r r e l a t i o n between the patients' and the nurses' perception of the occurrence of the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire; (2) there i s no c o r r e l a t i o n between the nurses' and the patients' ratings of the importance of the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire; (3) there i s no c o r r e l a t i o n between the nurses' and patients' scores f o r s a t i s f a c t i o n with the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire; (4) there i s no s i g n i f i c a n t difference between the patients' and nurses' perception of the occurrence of each s p e c i f i c primary nursing behaviour included on the s a t i s f a c t i o n questionnaire; (5) there i s no s i g n i f i c a n t d i f f e r e n c e between the pa t i e n t s ' and the nurses' ratings of the importance of each s p e c i f i c primary nursing behaviour.included on the s a t i s f a c t i o n questionnaire; (6) there i s no s i g n i f i c a n t difference between the nurses' and p a t i e n t s 1 scores f o r s a t i s f a c t i o n with each s p e c i f i c primary nursing behaviour included on the s a t i s f a c t i o n questionnaire. 9. DATA ANALYSIS The f i r s t three hypotheses were tested using the Spearman Rank Co r r e l a t i o n C o e f f i c i e n t . The fourth hypothesis was tested using a chi-square a n a l y s i s . The Student's t t e s t was used to analyse hypotheses f i v e and s i x . LIMITATIONS The primary nurses answered the questionnaire more than once. To decrease t h e i r f a m i l i a r i t y with the questionnaire, the order of the questions was a l t e r e d each time the primary nurse responded. This was done by randomly ordering the questions f o r the three d i f f e r e n t questionnaires. Each page of the questionnaire was then checked to ensure that questions t e s t i n g the i n t e r n a l consistency of the questionnaire were not i n close proximity. The r e s u l t was three questionnaires which contained the same questions i n d i f f e r e n t order. I t was assumed that since there were only twenty-nine p a t i e n t s , the nurses would probably complete the questionnaire no more than three times. I f they did respond more than three times, they would s t i l l complete a questionnaire which was somewhat unfamiliar because of the period of time that had elapsed since they had previously completed i t . I t was not f e a s i b l e to control f o r the possible Hawthorne e f f e c t of the presence of the i n v e s t i g a t o r . This may have influenced the nursing s t a f f to more cons i s t e n t l y and conscientiously p r a c t i s e the primary nursing behaviours. However, from discussion with the s t a f f 10 . conducted p r i o r to the introduction of the research on the uni t , the Hawthorne e f f e c t would appear to be r e l a t i v e l y i n s i g n i f i c a n t . The nursing s t a f f seemed to have a good understanding of primary nursing which was very consistent with the l i t e r a t u r e and was i n operation p r i o r to the introduction of the i n v e s t i g a t i o n . The questionnaire was pre-tested and u t i l i z e d i n a p s y c h i a t r i c s e t t i n g . This may l i m i t the general i z a t i o n of the findings to patients and nurses i n other areas even though the primary nursing behaviours included i n the questionnaire were not s p e c i f i c to p s y c h i a t r i c nursing. Another l i m i t a t i o n was the time of the year during which the study was conducted. During July and August some of the nursing s t a f f were on vacation. This meant that o c c a s i o n a l l y a patient may have had two primary nurses. DESIGN AND METHODOLOGY The design and methodology were the vehicles for o p e r a t i o n a l i z i n g the concepts which have been discussed e a r l i e r i n the chapter. This was a de s c r i p t i v e study which took place on a twenty-two bed unit of a s i x t y - s i x bed p s y c h i a t r i c h o s p i t a l over a three month period of time. Eleven nurses and twenty-nine patients were involved. Both the patient and the primary nurse were given a questionnaire during the l a s t week of the patient's h o s p i t a l i z a t i o n . Each was asked to indicate whether or not s p e c i f i c primary nursing behaviours occurred during the patient's h o s p i t a l i z a t i o n and to rate the importance they attached to those p a r t i c u l a r behaviours. 11. P r i o r to the commencement of the research, the i n v e s t i g a t o r met with the nursing s t a f f to discuss with them t h e i r understanding of primary nursing and how they p r a c t i s e d i t . As the study was being conducted, the i n v e s t i g a t o r also monitored the charts. Both these actions were measures of v a l i d i t y . Development of the Questionnaire In order to measure the v a r i a b l e s , two questionnaires were developed; one f o r patients, one for nurses. The questionnaires asked whether or not c e r t a i n primary nursing behaviours occurred and how important they were. The behaviours were selected from l i t e r a t u r e describing primary nursing, and from the investigator's experience with t h i s system of d e l i v e r i n g nursing care. Content v a l i d i t y was established by submitting the questionnaire to a panel of f i v e judges, a l l of whom had worked i n d i f f e r e n t p o s i t i o n s i n a system which u t i l i z e d a primary nursing approach. The questionnaires were pre-tested by administering them to patients and nurses on a u n i t within the h o s p i t a l that was not included i n the study. R e l i a b i l i t y was determined by the t e s t r e - t e s t method, a measure of s t a b i l i t y . Internal consistency was measured by i n c l u d i n g several questions which addressed the same issue. Development of the Patient P r o f i l e Previous research has shown that older patients tend to report more s a t i s f a c t i o n with nursing care than do younger p a t i e n t s . " ^ Patients W. Raphael, "Do We Know What Patients Think?", International Journal  of Nursing Studies, IV, 3 (1967), p. 214. 12. who have been nursed under primary nursing seem to have d i f f e r e n t expectations of the nursing care they receive.''' 1 In order to ascertain i f e i t h e r of these two variables were i n f l u e n c i n g the r e s u l t s of the study, a b r i e f patient p r o f i l e was developed i n the form of a c h e c k l i s t and attached to the front of the p a t i e n t 1 s questionnaire. Administration of the Questionnaire P r i o r to the d i s t r i b u t i o n of the questionnaires, the i n v e s t i g a t o r discussed with the s t a f f nurses t h e i r perception and p r a c t i c e of primary nursing. This was done to ensure v a l i d i t y by e s t a b l i s h i n g the basic parameters of primary nursing i n the minds of the nurses and thereby encouraging i t s p r a c t i c e . By agreeing with the primary nursing behaviours i d e n t i f i e d from the l i t e r a t u r e f o r the questionnaire, the nursing s t a f f contributed to the face v a l i d i t y of the questionnaire. The questionnaire was given to the patient during the week of h i s or her discharge. The patient's primary nurse completed a questionnaire during t h i s same time period. The i n v e s t i g a t o r administered a l l the questionnaires that were given to patients. This included a b r i e f d e s c r i p t i o n of the study and the statement that the patient's completion of the questionnaire was voluntary and that he or she could withdraw at any time. Development of the Chart C h e c k l i s t As an a d d i t i o n a l measurement of v a l i d i t y , the invest i g a t o r monitored the charts during the three months the study was conducted. A c h e c k l i s t Marram et a l . , op. c i t . , p. 133. 13. was developed from the questionnaire and included eleven primary nursing behaviours that could be i d e n t i f i e d through the charting. The chart monitoring was greatly f a c i l i t a t e d by the fac t that the unit was 12 using problem oriented recording. DEVELOPMENT OF CHAPTERS This f i r s t chapter provided an overview of the study. I t introduced the problem of the lack of research describing and evaluating primary nursing. I t described the development of a t o o l to gather data about patients' and nurses' perceptions of the occurrence and importance of s p e c i f i c primary nursing behaviours and t h e i r s a t i s f a c t i o n with primary nursing. The i n c l u s i o n of input from patients regarding the evaluation of primary nursing was a major focus. The second chapter was a review of the l i t e r a t u r e . There were two main areas of i n t e r e s t and relevance. The f i r s t was primary nursing as defined and described by several authors and the second was the evaluation of primary nursing by both nurses and patients. Chapter Three described the design and methodology of the i n v e s t i g a t i o n . The emphasis was on the desc r i p t i o n of the questionnaire, the techniques of the data c o l l e c t i o n and the methods for analyzing the data. The analysis and i n t e r p r e t a t i o n of the data were i n Chapter Four. The f i n a l chapter was a summary o f the entire study i n c l u d i n g the conclusions and recommendations which were a r e s u l t of the i n v e s t i g a t i o n . L. Weed, "Medical Records That Guide and Teach", The New England Journal of Medicine, CCLXXVIII, 11 (1968) pp. 593-599. 14. These f i v e chapters comprise the body of the study. They include a d e s c r i p t i o n of the major research concepts, the operationalism of those concepts i n the design and methodology and the implications of the r e s u l t s and conclusions. 15. CHAPTER II REVIEW OF THE LITERATURE This study was an attempt to describe and evaluate primary nursing. The l i t e r a t u r e review focussed on two areas: a d e s c r i p t i o n of primary nursing and a discussion of the evaluation of primary nursing. The d e s c r i p t i o n of primary nursing has included a b r i e f discussion of the background that l e d to the development of t h i s system of d e l i v e r i n g nursing care. I t also contains a d e s c r i p t i o n of the two major models that are used as frameworks i n o p e r a t i o n a l i z i n g the concepts of primary nursing. The discussion of the evaluation of primary nursing began with a d e s c r i p t i o n of previous research which u t i l i z e d p a t i e n t s a t i s f a c t i o n as a c r i t e r i o n of measurement i n evaluating nursing care. A r t i c l e s and studies r e l a t e d more s p e c i f i c a l l y to the evaluation of primary nursing were also presented and discussed. DESCRIPTION OF PRIMARY NURSING Background Related to Primary Nursing There appeared to be at l e a s t two forces which contributed to the development of primary nursing. The attempt, by nurses, to become more pr o f e s s i o n a l i n the p r a c t i c e of nursing was seen as one f o r c e . 1 G. Marram, M. Schlegel, and E. Bevis, Primary Nursing, (St. Louis: C.V. Mosby S Co., 1974), p. 8. 16. A second force was the desire of nurses to change the bureaucracy that 2 i s found i n most i n s t i t u t i o n s m which nurses p r a c t i s e . A change i n the bureaucratic system could be seen as f a c i l i t a t i n g an increase i n the l e v e l of s a t i s f a c t i o n of both nurses and patients with nursing care. This could be accomplished by decreasing the r i g i d i t y that accompanies the bureaucratic system of management. Marram, Schlegel and Bevis discussed the issue of professionalism 3 i n the opening chapter of t h e i r book, Primary Nursing. In t h i s chapter they have l i s t e d the e s s e n t i a l ingredients for professionalism. One of the ingredients i s autonomy, a q u a l i t y they think i s not found i n abundance i n the profession of nursing. These three authors stated that u n t i l autonomy was incorporated i n t o the system of nursing p r a c t i c e , nurses would be unable to f u l f i l l t h e i r own needs as a profession or to 4 provide adequate services to consumers. They described primary nursing as a way of providing more autonomy by making the nurse responsible and accountable f o r the nursing care he or she gives. Marlene Kramer inve s t i g a t e d the e f f e c t s of exposure to a bureaucratic 5 system on the p r o f e s s i o n a l values of recent c o l l e g i a t e graduate nurses. Using the Corwin professional-bureaucratic r o l e conception and r o l e deprivation scales^ which provided a measure of the p r o f e s s i o n a l and Ibid., p. 5. Ibid., pp. 6-9. Ibid., p. 7. 5 M. Kramer, Reality Shock, (St. Louis: C.V. Mosby & Co., 1974), pp. 22-23. ^ R. Corwin, "Role Conception and M o b i l i t y A s p i r a t i o n : A Study i n the Formation & Transformation of Nursing I d e n t i t i e s " , (unpublished doctoral d i s s e r t a t i o n , University of Minnesota, 1960, Department of Sociology) c i t e d by M. Kramer, Reality Shock, (St. Louis: C.V. Mosby & Co., 1974), p. 22. 17. bureaucratic values held by the respondent, Kramer tested the new graduates one month p r i o r to graduation, and three and s i x months a f t e r employment. She reported ". . . a s i g n i f i c a n t increase i n bureaucratic 7 r o l e conception a f t e r exposure to the employing organization " and "... a continual drop i n the p r o f e s s i o n a l r o l e conception scales during the f i r s t s i x months a f t e r employment." Kramer viewed these r e s u l t s as an i n d i c a t i o n that some nurses become less p r o f e s s i o n a l with 9 continued employment. Ciske, i n her a r t i c l e describing the development and implementation of primary nursing at the U n i v e r s i t y of Minnesota Hospital, described increased professionalism on the part of the nurse as a major goal of primary n u r s i n g . 1 0 She described primary nursing as a way ". . . t o make i t possible to p r a c t i s e nursing at a higher p r o f e s s i o n a l l e v e l . . i n the h o s p i t a l s e t t i n g . The second force, a desire to change the bureaucracy, was discussed by Berkowitz and Malone i n t h e i r a r t i c l e on i n t r a - p r o f e s s i o n a l c o n f l i c t . They reported that new graduate nurses, working i n h o s p i t a l s e t t i n g s , experience discrepancies between the i d e a l concept of a nurse learned as a student and t h e i r perception of t h e i r own r o l e performance. M. Kramer, op. c i t . , p. 22. 8 9 Ibid. . Ibid., pg. 23. 1 0 K.L. Ciske, "Primary Nursing: An Organization That Promotes Professional P r a c t i c e " , Journal of Nursing Administration, IV, 1 (1974), pp. 28-30. 1 1 Ibid., p. 28. 12 N. Berkowitz and M. Malone, "Intra-Professional C o n f l i c t " , Nursing  Forum, VII, 1 (1968), pp. 50-71. 18. 13 The authors described t h i s discrepancy as r o l e deprivation. Berkowitz and Malone suggested that a factor contributing to the experience of r o l e deprivation was the r e s t r i c t i v e environment of the h o s p i t a l . In order to deal with t h i s , Berkowitz and Malone suggested 14 that the i d e a l must be maintained and the r e a l i t y changed. Primary nursing allows nurses to function i n a way that i s s i m i l a r to the idea of nursing learned as nursing students. In an a r t i c l e written about nursing and patient care, Esther L u c i l l e Brown described the h o s p i t a l organization as a ". . . system that tends to decrease i n i t i a t i v e and motivation, encourages dependency, f e e l i n g s of i n f e r i o r i t y and d i s s a t i s f a c t i o n . The system i s power-f u l and pervasive enough to ' suck.in'many well prepared young nurses whom nursing educators were counting on to introduce needed changes. She described the system as task oriented rather than patient oriented. Her point of view i s echoed by Marram, Schlegel and Bevis, i n t h e i r book, Primary Nursing."*"^ They described the bureaucratic system as a system that i s i n f l e x i b l e and slow to change, a system that i s not open to experimentation or innovation, a system that promotes 17 s t a b i l i t y i n order to maintain organizational s u r v i v a l . This " I B I D - > P- 61. " Ibid., p. 65. 15 E.L. Brown, "Nursing and Patient Care", The Nursing Profession, Five S o c i o l o g i c a l Essays, ed., F. Davis, (New York: John Wiley & Sons Inc., 1 9 6 6 ) , p. 195. 16 Marram et a l . , op. c i t . , pp. 9-14. 17 Ibid., pp. 17-18. 19. r e s t r i c t e d environment creates c o n f l i c t within nurses who are t r y i n g to respond to patients as i n d i v i d u a l s . I t creates d i s s a t i s f a c t i o n within patients who are not getting t h e i r needs as i n d i v i d u a l s met. Primary nursing changes some of the bureaucratic management by encouraging nurses to provide continuity of care, to take r e s p o n s i b i l i t y f o r t h e i r nursing behaviours, and to respond to the patient as an important i n d i v i d u a l . Models of Primary Nursing According to the l i t e r a t u r e , the concept of primary nursing i s 18 operationalized using two d i f f e r e n t models. One i s the model used at the University of Minnesota Ho s p i t a l . The other i s used i n New York at the Loeb Center for Nursing and R e h a b i l i t a t i o n and at the Long Island Jewish General Hospital. The main difference between these two models i s i n the l e v e l of preparation of the person who assumes the primary nurse r o l e . At the University of Minnesota Hospital, a primary nurse can be a licensed p r a c t i c a l nurse. At the Loeb Center and the Long Island Jewish General, the primary nurse must be a registered nurse. The term "primary nursing" f i r s t appeared i n nursing l i t e r a t u r e i n 1970 with the p u b l i c a t i o n of an a r t i c l e by Manthey, Ciske, Robertson 19 and Harris c a l l e d , "Primary Nursing". In t h i s a r t i c l e the authors described primary nursing as i t was p r a c t i s e d at the U n i v e r s i t y of S. Carlson, book review on Primary Nursing by Marram et a l . , American Journal of Nursing, LXXV, 3 (1975), p. 514. 19 M. Manthey et a l . , "Primary Nursing", Nursing Forum, XIV, 1 (1970), pp. 65-83. 20. Minnesota Hospital. Manthey et a l described the duties of the primary nurse as (1) assessment of the patient, (2) development of a nursing care plan for the patient, (3) in v o l v i n g the patient i n h i s or her 20 care, and (4) preparation of the patient f o r discharge. In order to do t h i s , the primary nurse cared f o r the patient each s h i f t that he or she was on duty u n t i l the'patient was discharged. Another r e s p o n s i b i l i t y , reported by Ciske i n her a r t i c l e describing primary nursing, was " . . . care giver to care giver communication, both i n the nursing s t a f f ' s 21 d a i l y reporting methods, and between d i s c i p l i n e s . " She also reported that the primary nurse t r i e d to help the patient i d e n t i f y goals i n r e l a t i o n to how the medical condition might a f f e c t h i s or her l i f e 22 s t y l e . The primary nurse might care f o r three to s i x p a t i e n t s . The assignment of patients to primary nurses was made on the basis of the i n d i v i d u a l nurse's a b i l i t y to give the kind of care needed by a 23 patient. This d e c i s i o n was made by the head nurse who also took 24 into account the nurse's i n t e r e s t , p a t i e n t load and s p e c i a l a b i l i t i e s . Ibid., pp. 70-71. 21 K.L. Ciske, "Primary Nursing: An Organization That Promotes Professional P r a c t i c e " , Journal of Nursing Administration, IV, 1 (1974), p. 29. 22 Loc. c i t . 23 M. Manthey et a l . , op. c i t . , p. 70. 24 Ibid., pp. 71-72. 21. Both the Loeb Center and the Long Island Jewish General have based their philosophy of nursing care on the philosophy of Lydia Hall, a former director of nursing at the Loeb Center. Lydia Hall saw nursing as composed of: " . . . three overriding circles, each denoting one aspect of the [nursing] process as related to the patient, to the supporting sciences, and to the underlying philosophical dynamics. One of these aspects belongs to nursing alone; two are shared with other disciplines," The f i r s t c i r c l e i s that of nurturing. Lydia Hall viewed this aspect as exclusive to the nursing profession. She described nurturing as an interpersonal process which also included " . . . the intimate bodily care of patients . . . ," 2 6 In summarizing this aspect of nursing she wrote: The second c i r c l e i s shared with the medical profession. It involves the tasks delegated to nurses by the medical profession. The main focus 28 in this part of the nursing process is " . . . to avoid paining . . . " as opposed to the previous goal of comfort. The third c i r c l e involves the nurse treating the patient as a "whole person". In order to do this, the nurse must learn to use his or her self therapeutically. This c i r c l e i s shared with a l l professionals. 2 5 L . Hall, "Nursing - What Is It?". The Canadian Nurse, LX, 2 (1964), p. 150. "This exclusive nurturing-aspect of nursing involves the laying on of hands with comfort of the patient as the main interest, and, i f understood, as the main 26 27 Ibid p. 151. 28 Ibid p. 153. Ibid. 29 Ibid pp. 152-153. Carlson, Kaufman and Schwaid described an experimental u n i t that was established at the Long Island Jewish General Hospital i n New 30 York. The idea o r i g i n a t e d with a group of baccalaureate nursing students who were about to graduate. These students wanted an opportunity to p r a c t i s e nursing, as they had been taught, i n a h o s p i t a l s e t t i n g . A f t e r much discussion between the students, the students' teachers, and the nursing administrators of the h o s p i t a l , the opportunity was provided. The philosophy of Lydia H a l l was one of the basic premises which provided d i r e c t i o n f o r the d e l i v e r y of nursing care i n t h i s experimental unit. The baccalaureate nurses who p a r t i c i p a t e d i n the experiment, operated on the idea that the pr o f e s s i o n a l nurse helped to create a climate that fostered s e l f determination i n the coping behaviour of 31 the h o s p i t a l i z e d person. In order to do t h i s , v i s i t i n g p r i v i l e g e s were made f l e x i b l e , patients were encouraged to wear s t r e e t clothes and to eat together i n a dining room. The nurses encouraged the involvement of the pa t i e n t and hi s or her family i n the planning and implementation of the nursing care. On admission, the patient and family were met by a p r o f e s s i o n a l nurse who oriented them to the u n i t and took a nursing h i s t o r y . Nurses aides were assigned to pr o f e s s i o n a l nurses as t h e i r a ssistants rather than to patients as t h e i r nurse. The subjective responses of both patients and nurses were very p o s i t i v e . S. Carlson, R. Kaufman, and M. Schwaid, "An Experiment i n S e l f -Determined Patient Care", Nursing C l i n i c s of North America, IV, 2 (1969), pp. 495-507. 3 1 Ibid ., p. 498. As a r e s u l t , the authors reported that the expansion of t h i s philosophy to other nursing units i n the h o s p i t a l was being 32 considered. The second area described i n the l i t e r a t u r e as incorporating 33 the philosophy of Lydia H a l l , was the Loeb Center. The system of nursing at Loeb i s not c a l l e d primary nursing, but many of the goals are s i m i l a r . Nursing care planned and given with the patient 34 i s the focus of the nursing philosophy. In order to meet t h i s objective, a l l d i r e c t patient care i s given by registered nurses. Each nurse works with about eight patients. Assignments are made on the basis of d i s t r i c t s . Each nurse has a block of rooms which comprise h i s or her d i s t r i c t . I f a patient i s admitted to one of those rooms, the nurse knows that patient i s h i s or her r e s p o n s i b i l i t y . Messenger attendants are a v a i l a b l e to a s s i s t the nurse but they do not give d i r e c t p a tient care. There are the same number of nurses on days and evenings to provide the necessary nursing s t a f f to ensure that the ward schedule i s one that allows the patient to be treated as an i n d i v i d u a l . V i s i t i n g hours are not r e s t r i c t e d . The nurse i s responsible to h i s or her s e l f and to the patient f o r the nursing care given. The nurse i s not expected to have to report to any s p e c i f i c person about the nursing care given. A senior nurse i s a v a i l a b l e f or consultation 35 with each s t a f f nurse. 32 Ibid., pp. 500-506. 33 C. Henderson, "Can Nursing Care Hasten Recovery?", American  Journal of Nursing, LXIV, 6 (1964), p. 80. 34 Ibid ., pp. 80-83. 35 G. Alfano, "The Loeb Center f o r Nursing & R e h a b i l i t a t i o n " , Nursing C l i n i c s of North America, IV, 3 (1969), pp. 487-492. 24. EVALUATION OF PRIMARY NURSING Evaluation of Nursing Care Evaluation involves an appraisal of the congruence between an expressed goal and an actual outcome. The goal of nursing care always a f f e c t s the patient, e i t h e r d i r e c t l y or i n d i r e c t l y . Therefore, i t seems l o g i c a l to include the patient when evaluating nursing care. 3 6 This point of view i s supported i n a report by Marram. She investigated the r e l a t i o n s h i p between the influence of the patient as the evaluator of care and the subsequent importance of h i s or her evaluation. Marram found that although nurses rated other people i n the health care system (nursing supervisors, head nurses) as more i n f l u e n t i a l evaluators, the patient's evaluation was rated highest i n 37 terms of importance. Can patients r e a l l y evaluate t h e i r nursing care? Marram addressed 38 t h i s question by d i s t r i b u t i n g a survey questionnaire to nurses. In her discussion of the r e s u l t s , she reported that the nurses regarded the patient's evaluation as very important and very sound i n the areas 39 of providing comfort and support. The nurses d i d not f e e l the patient could evaluate the nurses' performance i n record keeping or ward management. Marram concluded that nurses view the patient's evaluation as most v a l i d and important when that evaluation includes G. Marram, "Patients' Evaluation of Their Care - Importance to the Nurse", Nursing Outlook, XXI, 5 (1973), pp. 322-324. Loc. c i t . 38 G. Marram, "Patients' Evaluation of Nursing Performance", Nursing Research, XXII, 2 (1973), pp. 153-157. 39 Ibid., p. 155. only those tasks that the patients can see the nurse performing."* u These findings suggest that when nurses are at the patient's bedside performing tasks that are v i s i b l e to the patient, nurses w i l l regard the patient as an important evaluator of nursing care. I t appears l o g i c a l and important t o nurses to include the patient as an evaluator i n at l e a s t some aspects of nursing care. Obtaining a measure of s a t i s f a c t i o n i s one way of evaluating nursing care. This measurement can be e l i c i t e d from both patients and nurses. Abdellah and Levine developed two validated c h e c k l i s t s by which 41 they measured patient and personnel s a t i s f a c t i o n with nursing care. They administered the patients' c h e c k l i s t to 8,666 patients i n s i x t y short-term, general, n o n f e d e r a l , American h o s p i t a l s . The highest possible score was 150 and, i f achieved, would indicate great d i s s a t i s f a c t i o n with the nursing care received. The r e s u l t s of the questionnaire indicated most patients were s a t i s f i e d with t h e i r nursing 42 care. Ninety-five percent of the scores were below f i f t y . Only 43 one percent had a score of one hundred or more. The two areas of greatest d i s s a t i s f a c t i o n were: (1) re s t and rel a x a t i o n and (2) lack 44 of contact with nurses. S p e c i f i c complaints included l e v e l of noise, being disturbed at inconvenient times, not seeing the nurse often ' " i b i d . , . pp. 153-157. 41 F. Abdellah and E. Levine, "Developing a Measure of Patient & Personnel S a t i s f a c t i o n with Nursing Care", Nursing Research, V, 3 (1957), pp. 100-108. 42 F. Abdellah and E. Levine, "What Patients Say About Their Nursing Care", Hospitals, XXXI, Nov. 1 (1957), pp. 44-48. 43 ' 4 4 Ibid., p. 46. Ib i d . , p. 46. 26. enough, f e e l i n g rushed when the nurse came, and not having the c a l l 45 l i g h t s answered soon enough. Abdellah and Levine also reported on factors that influenced 46 patient s a t i s f a c t i o n with care. According to t h e i r data: age, sex, and ma r i t a l status influenced s a t i s f a c t i o n with nursing care. More s p e c i f i c a l l y , patients over s i x t y , males and married patients reported greater s a t i s f a c t i o n than d i d patients under twenty, women 47 (with the exception of o b s t e t r i c a l patients) and sing l e p a t i e n t s . These same authors found that an increase i n the hours of p r o f e s s i o n a l 48 nursing care increased patient s a t i s f a c t i o n . They reported no d i f f i c u l t y i n e l i c i t i n g c r i t i c a l responses from patients. Daeffler u t i l i z e d the c h e c k l i s t developed by Abdellah and Levine to evaluate patient s a t i s f a c t i o n when nursed under a team nursing system i n comparison to patient s a t i s f a c t i o n when nursed under a 49 primary nursing system. Again, there was no reported d i f f i c u l t y i n e l i c i t i n g c r i t i c a l responses from patients. D a e f f l e r , however, d i d report, " . . . t h e instrument had l i m i t e d value for measuring s a t i s f a c t i o n with c a r e . " ^ This statement was based on the f a c t that many of the items on the c h e c k l i s t emphasized omissions, which 51 created the f e e l i n g that the study was looking only f o r c r i t i c i s m . I b i d . , p. 47. 46 F. Abdellah and E. Levine, "What Factors A f f e c t Patients' Opinions of Their Nursing Care", Hospitals, XXXI, Nov. 16 (1957), pp. 61-64. 47 48 Ibid ., pp. 61-62. Ibid., p. 64. 49 R. Daeff l e r , "Patients' Perception of Care under Team and Primary Nursing", Journal of Nursing Administration, V, 3 (1975), pp. 20-26. 5 0 Ibid., p. 25. 5 1 Ibid., p. 25. The statement was also based on the f a c t that although some items were applicable only to c e r t a i n p a t i e n t s , they were included i n the 52 weighted category score. One of the recommendations from D a e f f l e r ' s study was the suggestion that new instruments and methods to measure 53 patient s a t i s f a c t i o n with care be developed. Nehring and Geach reported a great deal of d i f f i c u l t y i n devising 54 a measurement t o o l to evaluate nursing care. The major obstacle was t h e i r d i f f i c u l t y i n getting patients to make any c r i t i c a l comment about t h e i r nursing care. Nehring and Geach reported that the only success they had was when they used an unstructured, informal, taped 55 interview. The findings of Nehring and Geach were not supported by the r e s u l t s 56 of a study by Moore and Cook which compared two methods of evaluation. Moore and Cook asked patients to evaluate t h e i r pre-natal nursing care by responding to a questionnaire and by answering questions i n an interview. The same questions were included i n both the questionnaire and the interview. The r e s u l t s d i d not show a s i g n i f i c a n t d i f f e r e n c e between negative responses that would j u s t i f y using one method over 57 the other. The reason f o r the differ e n c e between these two studies 52 53 Ibid., p. 25. Ibid ., p. 26. 54 V. Nehring and B. Geach, "Patients' Evaluation of Their Care: Why Don't They Complain?", Nursing Outlook, XXI, 5 (1973), pp. 317-321. Ibid . 56 D. Moore and K. Cook-Hubbard, "Comparison of Methods for Evaluating the Patients' Response to Nursing Care", Nursing Research, XXIV, 3 (1975), pp. 202-204. 57 , . , Ibid. 28. may l i e i n the methodology. Nehring and Geach studied h o s p i t a l i z e d patients whereas Moore and Cook studied out-patients. Perhaps t h i s i ndicates the possible s i g n i f i c a n c e of the e f f e c t of h o s p i t a l i z a t i o n as a v a r i a b l e i n f l u e n c i n g the patient's a b i l i t y to evaluate h i s or her care. Ewell conducted interviews with one hundred h o s p i t a l i z e d patients i n order to e l i c i t the patient's evaluation of the q u a l i t y of the 58 nursing care. The interviews took place i n the patients' rooms during the twenty-four hour period before t h e i r discharge. Eighty-four percent of the patients' comments were favorable. I t was s i g n i f i c a n t that f i f t y - f o u r percent of the patients interviewed had suggestions for improving the nursing care. The suggestions included: 5 " . . .'greater personal care' with the means being 'more personnel'" and ". . .'increased bedside care by p r o f e s s i o n a l n u r s e s 1 " . ^ 0 Ewell noted that none of the patients mentioned the previously published complaints of noisy wards, c o l d food and other i r r i t a t i n g problems. He suggested that these were not what patients were concerned about but rather ". . . the lack of personal care by nursing service personnel was the most d i s t u r b i n g f a c t o r to the patients interviewed." The research done by Togliacozzo supported Ewell's f i n d i n g s . 58 C. Ewell J r . , "What Patients Really Think About Their Nursing Care", Modern Hospital, IX, 2 (1967), pp. 106-108. 5 9 Ibid., p. 108. 6 0 Ibid., p. 108. 6 1 Ibid., p. 108. 62 D. L. Togliacozzo, "The Nurse From the Patient's Point of View", S o c i a l Interaction and Patient Care, eds. J.K. Skipper and R.C. Leonard, (Toronto: J.B. L i p p i n c o t t Co., 1965), pp. 219-227. Togliacozzo interviewed h o s p i t a l i z e d patients and asked what they i d e a l l y expected from a nurse. Eighty-one percent of the responses stressed personalized care as opposed to f o r t y - f i v e percent who expected prompt, e f f i c i e n t service and twenty-nine percent who responded that they wanted knowledge and t e c h n i c a l s k i l l s . Evaluation of Primary Nursing Much of the evaluation of primary nursing has been based on subjective observations. These observations have provided a back-ground and focus for more systematic research that has attempted to evaluate primary nursing. In her a r t i c l e describing primary nursing at the University of Minnesota Hospital, Ciske included some of her observations of the 64 outcomes of primary nursing. She reported an increase i n the enthusiasm of s t a f f and a f e e l i n g of accomplishment with the p a r t i c u l patient the nurse had worked w i t h . ^ This enthusiasm and sense of accomplishment was r e f l e c t e d i n a decrease i n the rate of turnover fo r both re g i s t e r e d nurses and licensed p r a c t i c a l nurses. She also reported: K.L. Ciske, "Primary Nursing: An Organization That Promotes Professional P r a c t i c e " , Journal of Nursing Administration, IV, 1 (1974), pp. 28-30. AJ decrease i n patient stereotyping by nurses as d i f f i c u l t ' , 'demanding', etc. with corresponding decrease i n f r u s t r a t i o n and i n s t a f f / p a t i e n t struggle f o r c o n t r o l . " 66 63 Ibid. 64 Ibid., p. 30. Ibid ., p. 30. 30. Ciske described the gratitude of patients and t h e i r f a m i l i e s who appreciated having one nurse i n charge of the patient's case. There were p o s i t i v e comments from nurses who were asked to " f l o a t " to the primary nursing u n i t s . In r e l a t i o n to discharge, Ciske described better communication with community agencies such as public health nursing and nursing homes who followed patients a f t e r discharge.^ 7 Logsdon, i n her a r t i c l e describing primary nursing, included a discussion of the advantages and disadvantages of primary nursing.^' Some of the advantages she described were: "Primary nursing improves the care of the patient by providing a nurse who w i l l set up a r e l a t i o n s h i p the patient can t r u s t , who w i l l give comprehensive care that greatly reduces fragmentation of care. Primary nursing enlarges the scope of p r a c t i c e by g i v i n g the nurse the r e s p o n s i b i l i t y f o r the care of a patient both i n the h o s p i t a l and beyond the walls of the h o s p i t a l . I t i s a concept that u t i l i z e s the education o f the nurse to a f a r greater extent, and moves nursing education and nursing p r a c t i c e c l o s e r together. This concept makes the nurse accountable f o r her p r a c t i c e and allows the nurse and others to evaluate the p r a c t i c e . " A 69 She reported that primary nursing enables the nurse to e s t a b l i s h a more c o l l a b o r a t i v e r o l e with the physician since the nurse, as well as the physician, has a great deal of knowledge r e l a t e d to the p a t i e n t . 7 0 Ibid ., p. 30. 6 8 A. Logsdon, "Why Primary Nursing?", Nursing C l i n i c s of North  America, XXVIII, 2 (1973), pp. 283-291. 6 9 Ibid., p. 288. 7 0 Ibid., p. 288. 31. Logsdon also reported the disadvantages as she saw them. One major problem was the d i f f i c u l t y some nurses had i n accepting the authority of another nurse i n planning care f o r a patient. Logsdon reported d i f f i c u l t y i n having the night nurse maintain the primary nursing r o l e as he or she had to have the day nurse carry out the plan. Ciske attempted to e l i c i t patients' evaluation of primary nursing by mailing a survey questionnaire to two hundred patients 72 who had been discharged from primary and team nursing units. One hundred of the questionnaires were returned. The responses of patients from each u n i t were compared using a c h i square a n a l y s i s . The only s i g n i f i c a n t d i f f e r e n c e reported was that primary nurses provided more opportunities for the patient to t a l k about complaints 73 or problems than d i d nurses from the team nursing u n i t s . Marram, Schlegel and Bevis have described one of the most complete 74 investigations of primary nursing i n t h e i r book, Primary Nursing. The authors u t i l i z e d questionnaires that e l i c i t e d the patients' l e v e l of s a t i s f a c t i o n with the nursing care and t h e i r impressions of the nature of the nursing care received. The questionnaire was administered to 360 patients i n two d i f f e r e n t h o s p i t a l s . Four d i f f e r e n t nursing Ibid., P. 289. 72 K. Ciske, "Primary Nursing" Evaluation", American Journal of  Nursing, LXXIV, 8 (1974), pp. 1436-1438. 7 3 Ibid., pp. 1437-1438. G. Marram, M. Schlegel, and E. Bevis, Primary Nursing, (St. Louis: C.V. Mosby & Co., 1974) 32. approaches were represented: primary nursing, team nursing, functional nursing and case method nursing. These approaches were r e f l e c t e d on four d i f f e r e n t nursing units which were included i n the study. 7^ To compare patients' perceptions on a l l four units, Marram et a l asked a l l patients to l i s t the things they l i k e d about t h e i r nursing care and the problems they, as patients, experienced. F i f t y -one percent of the patients on the primary nursing unit reported that they l i k e d the fact that the nurse considered the p a t i e n t s ' 76 i n d i v i d u a l i t y . F o r t y - f i v e percent of the patients reported t h i s same experience on the case method nursing unit, 21.5 percent on the 77 team nursing unit and only 15 percent on the f u n c t i o n a l nursing u n i t . A l l of the patients on both the primary nursing unit and the case method nursing unit reported that the nurse gave emotional support, treated the patient as a s p e c i a l person and spent time with the patient. T h i r t y - f i v e percent of the patients on the team nursing u n i t and 42 percent of the patients on the f u n c t i o n a l nursing unit reported that the nurse was more concerned with " . . . other peoples' 78 perceptions and not with what the patients think they need." and that " f i n i s h i n g on time i s more important to JtheJ nurse than good 79 care." None of the patients from the primary nursing unit or the case method unit reported these f i n d i n g s . On a f i v e point scale 7 5 Ibid., pp. 125-147. 7 6 Ibid., p. 127. 77 78 79 Ibid., p. 127. Ibid., p. 128. Ibid., p. 128. 33. that ranged from "extremely s a t i s f i e d " to "not at a l l s a t i s f i e d " , 65 percent of the patients from the primary nursing unit were "extremely s a t i s f i e d " with t h e i r nursing care as compared to 40 percent from the case method unit, 37 percent from the team 80 nursing unit and 48 percent from the functional nursing unit. In order to further investigate the outcomes of primary nursing, Marram et a l d i d a comparison of patient perceptions on a s p e c i f i c unit, before and a f t e r the implementation of primary 81 nursing. P r i o r to primary nursing, 42.9 percent of the patients described the pleasantness of the nurse as very important. A f t e r the implementation of primary nursing, 44 percent described the 82 "nurse's consideration of patient i n d i v i d u a l i t y " as most important. P r i o r to primary nursing, only 35 percent of the patients agreed that the nurse gave emotional support and 30 percent agreed that the 83 nurse treated patients as " . . . s p e c i a l human beings". " A f t e r primary nursing, 75 percent of the patients agreed that the nurse gave emotional support and 95 percent agreed they were treated as sp e c i a l people. Twenty-nine percent of the patients were "extremely s a t i s f i e d " with the nursing care before primary nursing as compared 84 to 64 percent a f t e r the implementation of primary nursing. Marram et a l also investigated a t o t a l of 110 nurses from primary nursing units, team nursing u n i t s , functional nursing units 85 and case method nursing u n i t s . Ninety percent of the primary 80 81 Ibid., p. 132. Ibid ., pp. 132-135. 8 2 Ibid ., p. 133. 8 3 Ibid ., p. 133. 8 4 Ibid., pp. 133-134. 8 5 Ibid., pp. 137-145. 34. nurses were extremely or very s a t i s f i e d with the way t h e i r work was organized as compared to 70 percent on the case method nursing unit, 52 percent on the team nursing unit and 43 percent on the functional nursing u n i t . 8 ^ Felton looked at increasing the q u a l i t y of nursing care by 87 introducing the system of primary nursing on a ho s p i t a l u n i t . This experimental unit was assigned to a v a r i e t y of nurses. Performance of the nursing care was measured by the Sl a t e r Nursing 88 89 Competencies Scale, the Quality Patient Care Scale, and the 90 Phaneuf Nursing Audit. The mean scores on each of these three t o o l s were found to be higher on the primary nursing u n i t . T h i s f i n d i n g suggests that primary nursing contributed to increasing the 91 q u a l i t y of the nursing care given, to the extent that i t i s measured by these s c a l e s . D a e f f l e r investigated the differences, i f any, i n i d e n t i f i e d omissions i n care as perceived by patients on medical-surgical 8 ^ Ibid., p. 141. 87 G. Felton, "Increasing the Quality of Nursing Care by Introducing the Concept of Primary Nursing: A Model Project", Nursing Research, XXIV, 1 (1975), pp. 27-32. 88 D. Sla t e r , The S l a t e r Nursing Competencies Scale, (Detroit: Wayne State Un i v e r s i t y College of Nrsg., 1967). 89 M. Wandelt and J . Ager, Quality Patient Care Scale, (Detroit: Wayne State University, College of Nursing, 1970). 90 M.C. Phaneuf, The Nursing Audit: P r o f i l e f o r Excellence, (New York: Appleton-Century-Crofts, 1972). 91 G. Felton, op. c i t . , pp. 30-31. 3.5. units. One of the units used team nursing, the other used primary nursing. The patients' perception of care was measured by the checklist developed by Abdellah and Levine. The findings indicated that there were more omissions in care on the team nursing unit. The difference was s t a t i s t i c a l l y significant only in the category related to dietary needs. Three items that indicated satisfaction with care reflected the nurse's manner, explanation of the care given, and prompt response to the patient's c a l l . These behaviours were reported as occurring by a higher percentage of patients from 93 the primary nursing unit than from the team nursing unit. The literature shows that although there may be some d i f f i c u l t y e l i c i t i n g c r i t i c a l responses from hospitalized patients, patients from primary nursing units seem to experience more encouragement from their primary nurse to discuss their complaints than patients from other kinds of nursing units. Nurses perceive patients as important evaluators of nursing care, particularly i f the patients are evaluating tasks that have been performed within their visual f i e l d . Both nurses and patients reported satisfaction with primary nursing. It would seem to be important to include both nurses and patients in an evaluation of the specific nursing behaviours that comprise primary nursing. Daeffler, "Patients' Perception of Care Under Team and Primary Nursing", Journal of Nursing Administration, V, 3 (1975), pp. 20-26. Ibid., pp. 23-26. 36. CHAPTER III DESIGN AND METHODOLOGY This study addressed i t s e l f to the problem of i n v e s t i g a t i n g whether or not c e r t a i n primary nursing behaviours occurred during a patient's h o s p i t a l i z a t i o n , how important the behaviours were and the degree of s a t i s f a c t i o n they engendered. These three variables were measured from both the patients * and primary nurses 1 point of view. The data was obtained by administering a questionnaire to both patients and nurses during the l a s t week of the patient's h o s p i t a l i z a t i o n . THE SETTING The h o s p i t a l where the study took place, i s a s i x t y - s i x bed p s y c h i a t r i c h o s p i t a l located i n B r i t i s h Columbia. There are three in-p a t i e n t units with twenty-two beds each, an out-patient area and two day care programs. Patients are re f e r r e d from a l l areas of the province of B r i t i s h Columbia, with the majority of them coming from the lower mainland. Patients can be re f e r r e d by p s y c h i a t r i s t s , general p r a c t i t i o n e r s , other professionals, friends and s e l f . P r i o r to admission, a l l patients are assessed i n the out-patient area to as c e r t a i n i f admission i s warranted or whether the patient could b e n e f i t more from an a l t e r n a t i v e program such as day care. Once admission has been decided upon, the pat i e n t i s assigned to 37. whichever u n i t has a v a i l a b l e space. The wards are st a f f e d by-reg i s t e r e d nurses and p s y c h i a t r i c a s s i s t a n t s . The medical s t a f f i s made up of p s y c h i a t r i c residents and medical students with a p s y c h i a t r i s t as the c l i n i c a l c h i e f on each of the u n i t s . There i s an occupational t h e r a p i s t and a s o c i a l worker on each i n - p a t i e n t u n i t and consultation services are a v a i l a b l e from the department of psychology and d i e t e t i c s . The organization of the u n i t i s c e n t r a l i z e d around the care of the p a t i e n t . Each pa t i e n t works with a therapy team c o n s i s t i n g of a primary t h e r a p i s t and a primary nurse. The primary t h e r a p i s t i s most often a p s y c h i a t r i c resident, but may be a s o c i a l worker or a nurse with a great deal of experience i n psychiatry. Members of the m u l t i - d i s c i p l i n a r y team provide input to the therapy team and to the patient . The p a r t i c u l a r u n i t where the study was conducted o f f e r s a v a r i e t y of therapies commonly found i n p s y c h i a t r i c s e t t i n g s : group, occupational, and m i l i e u . THE PARTICIPANTS Patients Twenty-nine patients were involved with varying diagnoses. There were t h i r t e e n men and sixteen women. More than, h a l f of the patients were under the age of f o r t y with the majority between twenty-one and t h i r t y years of age. Over h a l f had previous p s y c h i a t r i c h o s p i t a l i z a t i o n s , twelve of which had been at the h o s p i t a l where the study took place, (see Appendix E) In order to be considered e l i g i b l e to complete the questionnaire, the patient needed to be able to read and write and to 38. be oriented to time, place, and person. No one was included i n the study i f the i n v e s t i g a t o r thought they were so disturbed at the time of admission that they would be unable to r e c a l l the events of that time period. The Nurses The unit where the study took place had ten s t a f f nurses, two junior care co-ordinators and a head nurse. A l l of the nurses were registered nurses (with the exception of one who was awaiting r e g i s t r a t i o n ) . Four o f the nurses had a baccalaureate degree, i n c l u d i n g the head nurse. There was one male nurse. The u n i t had been u t i l i z i n g the primary nursing system for four years. The primary nursing model p r a c t i s e d by the unit s t a f f , was that of the Loeb Center and the Long Island Jewish General Hospital i n New York. Only registered nurses could act as primary nurses. The primary nurse e i t h e r met the p a t i e n t on admission or within twenty-four hours of admission. He or she was responsible f o r an i n i t i a l nursing assessment and care plan. Often, the i n i t i a l interview on the unit was done j o i n t l y with the patient, the primary nurse and the primary t h e r a p i s t p a r t i c i p a t i n g . The primary nurse was also responsible f o r the ongoing nursing care plan and for helping the patient prepare for discharge. In addition to the primary nurse, each patient had an associate nurse who would care for the patient when the primary nurse was o f f duty. The p s y c h i a t r i c a s s i s t a n t sometimes functioned i n t h i s r o l e . 39. THE QUESTIONNAIRE The questionnaire was developed p r i m a r i l y i n order to t e s t s a t i s f a c t i o n with primary nursing (see Appendix G and H). In order to do that, the in v e s t i g a t o r u t i l i z e d the format of the questionnaire developed by Porter to assess job satisfaction."'" On h i s questionnaire he asks respondents to i d e n t i f y whether or not a c e r t a i n behaviour occurs i n t h e i r job, how important i t i s and how important i t should be. This information gives a number which represents the degree of s a t i s f a c t i o n . For the purpose of t h i s study, nurses and patients were asked only to i d e n t i f y whether or not a c e r t a i n behaviour occurred and how important the behaviour was. This was f e l t to be s u f f i c i e n t i n order to yield data which was i n accordance with the d e f i n i t i o n of s a t i s f a c t i o n u t i l i z e d i n t h i s study (see Chapter I: D e f i n i t i o n s ) . In addition to y i e l d i n g information r e l a t e d to s a t i s f a c t i o n , the questionnaire also produced data r e l a t e d to the patients' and nurses' perceptions of the occurrence and importance of those primary nursing behaviours represented. The primary nursing behaviours included i n the questionnaire were chosen from the l i t e r a t u r e and the in v e s t i g a t o r ' s experience r e l a t e d to primary nursing. The behaviours were val i d a t e d by submitting the questionnaire to a panel of f i v e judges. Three of the judges had been L. Porter, "Job Attitudes i n Management: Perceived D e f i c i e n c i e s i n Need F u l f i l l m e n t as a Function of Job Level", Journal of Applied  Psychology, XLVI, 6 (1962), pp. 141-148. 40. head nurses on units that p r a c t i s e d primary nursing. Two of these three worked i n medical s u r g i c a l settings and one worked i n psychiatry. Another judge was a nursing supervisor i n a h o s p i t a l that u t i l i z e d primary nursing and the f i f t h judge was a s t a f f nurse who had worked as a primary nurse. Each judge was asked to independently rate the v a l i d i t y of the primary nursing behaviours included i n the questionnaire. The r a t i n g scale was a f i v e point L i k e r t scale which ranged from f i v e , which was high v a l i d i t y , to one, which was low v a l i d i t y . Behaviours with a t o t a l score of les s than seventeen were dropped from the questionnaire. The patients' questionnaire consisted of thirty-seven items and the nurses' questionnaire consisted of t h i r t y - e i g h t items. There were two sections to each questionnaire. The f i r s t section tested the occurrence of the behaviours and respondents were asked to indi c a t e true, f a l s e or N/A (not applicable) f o r the occurrence of each s p e c i f i c primary nursing behaviour. The second section dealt with the importance of the s p e c i f i c behaviours. Patients and nurses were asked to rate the importance of each primary nursing behaviour using a Likert-type scale. The method of c a l c u l a t i n g the s a t i s f a c t i o n scores i s described i n Appendix F. Both questionnaires were pre-tested on a u n i t not included i n the study. The t e s t r e - t e s t method was applied to the questionnaire as a measure of s t a b i l i t y . Using the Spearman Rank Correlation C o e f f i c i e n t i t was found that the r e l i a b i l i t y was .75 f o r the patients' questionnaire and .79 for the nurses' questionnaire. These scores 41. were s i g n i f i c a n t at the .05 l e v e l . The c r i t i c a l value of the Spearman Rank C o r r e l a t i o n C o e f f i c i e n t at the .05 l e v e l with a one-tailed t e s t and an N of 7 i s .71. These r e l i a b i l i t y scores of .75 and .79 indic a t e that the v a r i a t i o n i n scores between respondents r e f l e c t s differences between responses rather than being the r e s u l t of an u n r e l i a b l e or unstable t e s t i n g process. Included i n each questionnaire were several p a i r s of questions which tested the same concept. These questions were included i n order to determine the i n t e r n a l consistency of the questionnaire. When the data c o l l e c t i o n was completed, seven patient questionnaires and seven nurse questionnaires were randomly selected from the sample of twenty-nine nurse questionnaires and twenty-nine patient questionnaires. The selected questionnaires were analyzed f o r i n t e r n a l consistency and the r e s u l t s generalized to the re s t of the sample. Using the Spearman Rank C o r r e l a t i o n C o e f f i c i e n t , i t was found that the i n t e r n a l consistency for the nurses' questionnaire was .90 and f o r the pa t i e n t s ' i t was .80. These scores were s i g n i f i c a n t at the .05 l e v e l . These scores of .90 and .80 indicate that both patients and nurses are responding c o n s i s t e n t l y to the concepts that the questionnaire i s t e s t i n g . I f an i n d i v i d u a l ' s performance i s inconsistent, i t i s probably due to some other f a c t o r besides the questionnaire. Because the primary nurses would be responding to the questionnaire more than once, three nursing questionnaires were developed. Each questionnaire contained the same questions but the sequence was a l t e r e d . 42. The order of the questions was determined by random s e l e c t i o n . Each page of the questionnaire was then inspected by 'eye' to see that the questions that monitored the i n t e r n a l consistency of the questionnaire were spaced apart and did not occur on the same page. Previous research has shown that age, sex and marital status influence the degree of s a t i s f a c t i o n with nursing care that a patient 2 experiences. I t has also been demonstrated that patients who have had experience with primary nursing have d i f f e r e n t expectations about the nursing care they w i l l receive than do patients who have not had 3 any experience with primary nursing. In order to ascertain the influence of these v a r i a b l e s , a c h e c k l i s t was added to the front of the patients' questionnaire f o r each patient to complete before they responded to the questionnaire (see Appendix D). THE DESIGN One month p r i o r to the beginning of the i n v e s t i g a t i o n , the researcher met with the nursing s t a f f to discuss t h e i r concept of primary nursing. I t was found to be congruent with the l i t e r a t u r e . A l l nurses were then given a b r i e f summary of the research design and a summary of the concepts of primary nursing which were included i n the questionnaire as a focus for the second discussion (see Appendix A). F. Abdellah and E. Levine, "What Factors A f f e c t Patients' Opinions of Their Nursing Care, Hospitals, XXXI, (Nov.16, 1957), pp. 61-64. 3 F. Dae f f l e r , "Patients' Perception of Care Under Team and Primary Nursing", Journal of Nursing Administration, V, 3 (1975), pp. 20-26. 43. This was done to ensure that primary nursing, the independent v a r i a b l e , was being p r a c t i s e d . Patients who were admitted following these two discussions were considered f o r the research sample. The questionnaire was administered to patients and nurses during the f i n a l week of the patient's h o s p i t a l i z a t i o n . The day of discharge was avoided as a time for the patient to complete the questionnaire. Separation anxiety frequently occurs i n h o s p i t a l i z e d patients, e s p e c i a l l y p s y c h i a t r i c p a t i e n t s . I t was f e l t that i t would be desirable to avoid the influence of t h i s s t r e s s . A l l patients and nurses signed a consent form p r i o r to responding to the questionnaire (see Appendix B). The in v e s t i g a t o r d i s t r i b u t e d a l l the patient questionnaires and obtained the consent forms from the patients. Each patient was t o l d that the purpose of the questionnaire was to get information from patients regarding the occurrence of c e r t a i n nursing behaviours and how important they, the patients, thought these behaviours were. They were also t o l d that they did not have to p a r t i c i p a t e i n the study, and could withdraw at any time. The primary nurses also completed a consent form p r i o r to responding to the questionnaire. Their consent form included permission f o r the inve s t i g a t o r to approach the patient about completing the questionnaire. The primary nurse's questionnaire was d i s t r i b u t e d by the ward secretary during the week of the patient's discharge. I t was assumed that since the nurses were completing the questionnaire more than once, they did not need an explanation each time they responded. They were given an opportunity during the i n i t i a l discussions of the i n v e s t i g a t i o n to 44. refuse to p a r t i c i p a t e . They could also withdraw at any time during the study. CHART CHECKLIST As an a d d i t i o n a l measure of v a l i d i t y , the inv e s t i g a t o r monitored the charts on the unit. This was done by s e l e c t i n g eleven behaviours from the nursing questionnaire which, i n the investigator's opinion, should be r e f l e c t e d i n the charting. These were compiled i n t o a ch e c k l i s t (see Appendix C). Fourteen charts were selected from the sample of patients i n the study so that there was at l e a s t one chart of each primary nurse included. The charting was checked to see i f any of the eleven s p e c i f i c behaviours had been recorded. I t was assumed that i f the behaviour was reported i n the charting then the behaviour had occurred and that same behaviour would be appropriately responded to i n the questionnaire. METHODOLOGY As mentioned e a r l i e r i n the chapter, the impact of the independent var i a b l e of primary nursing upon pa t i e n t s ' and nurses' s a t i s f a c t i o n was measured by means of a questionnaire. The questionnaire y i e l d e d data r e l a t e d to pat i e n t s ' and nurses' perception of the occurrence of, the importance of, and the degree of s a t i s f a c t i o n with the primary nursing behaviours contained i n the questionnaire. The purpose of the i n v e s t i g a t i o n was to generate data that would describe and evaluate primary nursing. In order to provide some 45. d i r e c t i o n f or the i n v e s t i g a t i o n , i n terms of the data a n a l y s i s , s i x hypotheses were proposed. Each hypothesis w i l l be discussed i n terms of the methodology used to analyse the data. Hypothesis 1. There i s no c o r r e l a t i o n between the patients' and the nurses' perception of the occurrence of the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire. In dealing with t h i s f i r s t hypothesis, the number of affirmations of the occurrence of each matched behaviour was t a l l i e d for both patients 4 and nurses. By applying the Spearman Rank Co r r e l a t i o n C o e f f i c i e n t , the degree of agreement between the two groups on the occurrence of the primary nursing behaviours was obtained. Hypothesis 2. There i s no c o r r e l a t i o n between the nurses' and the p a t i e n t s ' ratings of the importance of the itemized primary nursing behaviours i n -cluded on the s a t i s f a c t i o n questionnaire. The analysis r e l a t e d to t h i s hypothesis was s i m i l a r to the f i r s t hypothesis. By summing a l l the ratings of importance that each nurse and each patient assigned to the s p e c i f i c primary nursing behaviours, an average score was obtained which r e f l e c t e d the importance that each group assigned to the itemized behaviour. For example: i f a question y i e l d e d 20 scores of 5 and 10 scores of 3, the average importance score for that behaviour would be 130. By applying the Spearman Rank See Appendix H, Table 7, f o r a l i s t of the matched behaviours. 46. C o r r e l a t i o n C o e f f i c i e n t to t h i s data i t was possible to a r r i v e at the degree of agreement between the two groups i n r a t i n g the importance of the primary nursing behaviours. Hypothesis 3. There i s no c o r r e l a t i o n between the nurses' and patients' scores for s a t i s f a c t i o n with the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire. Hypothesis 3 was handled i n a s i m i l a r fashion as the previous two hypotheses. An average s a t i s f a c t i o n score was obtained for each behaviour for both patients and nurses. The average s a t i s f a c t i o n score was obtained by summing a l l the s a t i s f a c t i o n values f o r each behaviour. For example: i f a question yielded 20 scores of +5, 5 scores of -3, and 5 scores of -5, the average s a t i s f a c t i o n score would be 60. The Spearman Rank C o r r e l a t i o n C o e f f i c i e n t was applied to ascertain the degree of agreement between patients and nurses r e l a t e d to the v a r i a b l e of s a t i s f a c t i o n . Hypothesis 4. There i s no s i g n i f i c a n t difference between the patients 1 and nurses' perception of the occurrence of each s p e c i f i c primary nursing behaviour included i n the s a t i s f a c t i o n questionnaire. This hypothesis r e l a t e d to the differences between the p a t i e n t s ' and nurses' perception of the occurrence of the behaviour. The frequencies of each of the three a l t e r n a t i v e s were obtained. For example: the patients, as a group, may answer a s p e c i f i c statement with 10 'true' 47. responses, 5 ' f a l s e ' responses, and 15 'not applicable' responses. The nurses, as a group, may answer that same statement with 20 'true' responses and 9 ' f a l s e ' responses. A chi-square analysis was applied to the data to determine i f there was any s i g n i f i c a n t d i f f e r e n c e s i n the frequency of the responses to 'true', ' f a l s e ' , and 'not app l i c a b l e ' . Hypothesis 5. There i s no s i g n i f i c a n t difference between the patients' and the nurses' r a t i n g of the importance of each s p e c i f i c primary nursing behaviour included i n the s a t i s f a c t i o n questionnaire. To analyse the data re l a t e d to t h i s hypothesis, a l l the responses of each group r a t i n g the importance of each primary nursing behaviour, were added together. For example: i f , when r a t i n g the importance of a s p e c i f i c behaviour, the pa t i e n t group gave 3 responses of 1, 4 responses of 3, 8 responses of 4 and 14 responses of 5, each of these responses would be t a l l i e d . A s i m i l a r procedure would occur f o r the nurses' response to the same behaviour. A Student's t t e s t was then applied to the data i n order to determine which of the behaviours had importance scores that were s i g n i f i c a n t l y d i f f e r e n t f o r the two groups. Hypothesis 6. There i s no s i g n i f i c a n t d i f f e r e n c e between the nurses' and patients' scores for s a t i s f a c t i o n with each s p e c i f i c primary nursing behaviour included i n the s a t i s f a c t i o n questionnaire. 48 . Hypothesis 6 was handled in a similar fashion as the previous hypothesis. A l l the satisfaction responses of each group for each specific behaviour were added together. For example: i f the nurses' satisfaction scores for a specific behaviour were 2 responses at -5, 3 responses at -1, 5 responses at 0, 5 responses at +4, and 14 responses at +5, each of these responses would be t a l l i e d . A t test was then applied to the data to see where the nurses' satisfaction scores were significantly different from the patients' satisfaction scores for each specific primary nursing behaviour. The data generated by this investigation was either nominal or ordinal data and therefore only non-parametric stat i s t i c s ought to have been used. It was recognized that the t test, used to analyse the data related to hypotheses 5 and 6, i s a parametric test. The Mann-Whitney U test i s the correct test for this type of data. Due to the ease and rapidity with which the t test could be computed by existing computer f a c i l i t i e s , i t was ut i l i z e d in order to scan the data to see which of the behaviours the two groups rated significantly different. Data yielding insignificant t ratios would also have yielded similar results with the Mann-Whitney U test. Conversely, t ratios that were well above the c r i t i c a l value of t were derived from data which would also generate significant differences in means using the Mann-^Whitney U test. Those results that were significant with the t test were also computed using the Mann-Whitney U test to ensure that the differences were also significant when using the correct non-parametric analysis which i s less efficient. 49. This chapter has included a d e s c r i p t i o n of the s e t t i n g and the p a r t i c i p a n t s involved i n the study. The t o o l s used to measure the vari a b l e of primary nursing were described and discussed, as was the data analysis r e l a t e d to the proposed hypotheses. 50. CHAPTER IV DATA ANALYSIS AND RESULTS This chapter dealt with the a n a l y s i s of the data. There were three sources of data: the chart c h e c k l i s t s , the patient p r o f i l e s , and the questionnaires. The data from each of these three sources was presented and discussed. The Patient P r o f i l e The purpose of the patient p r o f i l e was to obtain demographic data r e l a t e d to the patient i n order to see i f there was any r e l a t i o n s h i p between c e r t a i n c h a r a c t e r i s t i c s of the patients and t h e i r s a t i s f a c t i o n with primary nursing. Previous research has shown that patients over s i x t y years of age, male patients and patients that are married reported greater s a t i s f a c t i o n with t h e i r nursing care than did patients under twenty years of age, women (with the exception of o b s t e t r i c a l p a t i e n t s ) , and single p a t i e n t s . 1 The proportion of each of these c h a r a c t e r i s t i c s i n the sample of patients was not seen to influence the s a t i s f a c t i o n scores (see Appendix E). Less than h a l f of the respondents were male. A l l but one of the respondents were under the age of s i x t y . Only 12 of the 29 patients had been previously exposed to primary nursing through a past admission to the h o s p i t a l where the i n v e s t i g a t i o n took place. M a r i t a l status was not included on the p r o f i l e but a check, by the i n v e s t i g a t o r , of the patients' r e g i s t r a t i o n information indicated that 16 of the 29 were unmarried at the time of t h e i r h o s p i t a l i z a t i o n . F. Abdellah and E. Levine, "What Factors A f f e c t Patients' Opinions of Their Nursing Care", Hospitals, XXXI, Nov. 16 (1957), pp. 61-64. 51. It appeared that the degree of s a t i s f a c t i o n with primary nursing would not be biased by the disproportionate presence of any of these four variables of age, sex, marital status, or previous exposure to primary nursing. The Chart C h e c k l i s t The i n v e s t i g a t o r attempted to monitor at l e a s t one chart of each primary nurse. There were fourteen chart c h e c k l i s t s completed (see Table 4.1). The majority of the data was c o l l e c t e d from the charts while the patients were s t i l l i n h o s p i t a l . However, f i v e charts were checked r e t r o s p e c t i v e l y . A l l of the charts mentioned a discussion with the patient regarding h i s or her discharge plans. A l l of the fourteen charts had written care plans with interventions that covered a twenty-four hour period of time. Eleven of the fourteen charts indicated that the primary, nurse had interviewed the patient with the primary t h e r a p i s t . Eleven of the fourteen charts also contained evaluations of interventions. Four of the charts contained no i n d i c a t i o n of who the primary nurse was. These charts were monitored i n medical records and that information may have been removed by the medical records l i b r a r i a n . Only two of the fourteen charts indicated that the patient had been oriented to the u n i t . This low number may r e f l e c t the f a c t that the primary nurse often asked other patients to orientate a new patient. Two of the fourteen charts indicated that the patient had an appointment with the t h e r a p i s t who would follow him or her a f t e r discharge. Five charts indicated that either the r e f e r r i n g doctor or the patient's t h e r a p i s t i n h o s p i t a l would be resuming or 52. continuing with the p a t i e n t 1 s treatment a f t e r discharge. The remaining seven charts contained no mention of the patients making contact with the t h e r a p i s t who would be working with them a f t e r they l e f t h o s p i t a l . Eleven of the fourteen charts indicated some contact with the family had been discussed. Of'the remaining three charts; one indicated that family contact was not applicable, and the other two made no mention of contacting the family. TABLE 4.1 Summary of Results From the Chart C h e c k l i s t Primary Nursing Behaviours Charted Not Charted Miscellaneous Orientation 2 10 2 were re-admitted Discussion of discharge plans 14 Introduction of the discharge t h e r a p i s t 5 2 2 - had appointment 5 - followed by r e f e r r i n g physician or h o s p i t a l Written care plans 14 Primary nurse indicated on chart 8 4 2 indicated elsewhere on ward Evaluation of interventions 11 3 S i g n i f i c a n t events 14 Interviewed with primary therapist 11 3 Care plan ind i c a t e d 24 hour interventions 14 Family contact indicated 11 2 1 - not applicable Discussed p o t e n t i a l problems on discharge 14 2 53. The Questionnaires The data from the questionnaires was analysed i n r e l a t i o n to the s i x hypotheses and consequently that was how i t was presented i n t h i s chapter. Hypothesis 1. There i s no c o r r e l a t i o n between the p a t i e n t s ' and the nurses' perception of the occurrence of the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire. The Spearman Rank C o r r e l a t i o n C o e f f i c i e n t for the data r e l a t e d to the occurrence of the primary nursing behaviours was .82 (see Table 4.2). The c r i t i c a l value of the Spearman Rank C o r r e l a t i o n C o e f f i c i e n t at the 2 .01 l e v e l i s .53. The score of .82 indicated that there was a strong c o r r e l a t i o n between the behaviours that both nurses and patients reported as occurring. The n u l l hypothesis was rejected. In order to compute the Spearman Rank Co r r e l a t i o n C o e f f i c i e n t , i t was necessary to rank the data r e l a t e d to the occurrence of the primary nursing behaviours. The act of ranking the data enabled the i n v e s t i g a t o r t o see which primary nursing behaviours both nurses and patients reported occurring most frequently. Both groups acknowledged that the primary nurse spent time with the patient when the patient was upset. They also reported that the primary nurse worked with the patient every time he or she was on day or afternoon s h i f t and that the primary nurse gave c l e a r i n s t r u c t i o n s . Patients and nurses stated that the primary nurse G. Ferguson, S t a t i s t i c a l Analysis i n Psychology and Education, 4th ed., (Toronto: McGraw-Hill Book Company, 1976), p. 495. 54. encouraged the patient to say what he or she thought h i s or her problems were and that the primary nurse gave the patient feedback about h i s or her progress i n h o s p i t a l . Both patients and nurses reported that the primary nurse seldom orientated the patient to the u n i t . The patients themselves were encouraged to orientate newly admitted persons. I t was f e l t that o r i e n t a t i o n by other patients f a c i l i t a t e d the i n t e g r a t i o n and adjustment of the new patient into the ward. Nurses and patients reported that discussion between the primary nurse and the patient regarding medication a f t e r discharge occurred with less frequency. Neither patients or nurses f e l t that the primary nurse was known to the patient's family and f r i e n d s . Hypothesis 2. There i s no c o r r e l a t i o n between the nurses' and the patients' ratings of the importance of the itemized primary nursing behaviours included on the s a t i s f a c t i o n questionnaire. The Spearman Rank C o r r e l a t i o n C o e f f i c i e n t f o r the data r e l a t e d to the importance of the primary nursing behaviours was .87 (see Table 4.2). This score was also s i g n i f i c a n t at the .01 l e v e l f o r a one-tailed t e s t . I t indicated a high degree of agreement between patients and nurses on the r e l a t i v e importance of the primary nursing behaviours. The n u l l hypothesis was rejected. Both nurses and patients reported that i t was most important for the primary nurse to ask the patient f o r a personal i d e n t i f i c a t i o n of his or her problems and to give the patient feedback on h i s or her progress i n h o s p i t a l . Both groups f e l t i t was most important for the primary nurse and the primary t h e r a p i s t to work c l o s e l y together and 55. fo r a l l the nurses that worked with the patient to understand why the patient was i n h o s p i t a l . Both patients and nurses reported i t was l e s s important that the patient's family and friends know the primary nurse's name. Both groups acknowledged i t was less important for the primary nurse to have contact with the patient's family or for the primary nurse to be present i n interviews with the primary t h e r a p i s t . Patients and nurses reported i t was l e s s important for the primary nurse to orientate the patient to the u n i t . Hypothesis 3. There i s no c o r r e l a t i o n between the nurses' and the patients' ratings of the l e v e l of importance of the itemized primary nursing behaviours included on the questionnaire. The Spearman Rank Co r r e l a t i o n C o e f f i c i e n t for the data r e l a t e d to the s a t i s f a c t i o n with the primary nursing behaviours was .33 (see Table 4.2). This score was below the c r i t i c a l value for the Spearman Rank C o r r e l a t i o n C o e f f i c i e n t at the .05 l e v e l . The reason for t h i s seemed to be r e l a t e d to the method of a r r i v i n g at the s a t i s f a c t i o n score. By mul t i p l y i n g the importance score by both p o s i t i v e and negative values i n order to a r r i v e at the s a t i s f a c t i o n score, the range of responses was doubled to include negative as we l l as p o s i t i v e numbers. This increase i n range resu l t e d i n an increase i n variance. Consequently, i t was very d i f f i c u l t to detect the c o r r e l a t i o n between the two groups on the va r i a b l e of s a t i s f a c t i o n . The n u l l hypothesis was not, therefore, rejected. 56. Both patients and nurses reported satisfaction when the primary nurse cared for the patient each time he or she was on days or afternoons, when the primary nurse gave the patient feedback about his or her progress in hospital and when the primary nurse encouraged the patient to have input into the treatment plan by asking the patient to identify what he or she thought his or her problems were. Behaviours that were less satisfying were related to the primary nurse orientating the patient to the unit, the primary, nurse explaining the system of primary nursing and the primary nurse discussing with the patient when to take his or her medication after discharge. It must be remembered that due to the method of arriving at the satisfaction scores, satisfaction or dissatisfaction could be a result of the occurrence or non-occurrence of the behaviour or. i t could also be due to the importance or lack of importance attributed to a specific primary nursing behaviour. TABLE 4.2 Summary of the Spearman Rank Correlation Coefficients for Hypotheses 1,2,3  Sum of the Differences Squared N Spearman Rank Correlation Coefficient Hypothesis 1 Occurrence 241.25 20 .82 Hypothesis 2 Importance 172.0 20 .87 Hypothesis 3 Satisfaction 894.5 20 .33 57. Hypothesis 4. There i s no s i g n i f i c a n t difference between the pat i e n t s ' and nurses' perception of the occurrence of each s p e c i f i c primary nursing behaviour included i n th» s a t i s f a c t i o n que st ionna i re. Because the information r e l a t e d to t h i s hypothesis was i n the form of frequency data, c h i square was used i n the an a l y s i s . In order for there to be a s i g n i f i c a n t d i f f e r e n c e between the nurses' and pat i e n t s ' report of the occurrence of the primary nursing behaviours, 3 the value of c h i square needed to exceed 9.21. This number represents the c r i t i c a l value of chi square at the .01 l e v e l with 2 degrees of freedom. There were three behaviours where the response of.the nurses and patients were s i g n i f i c a n t l y d i f f e r e n t as shown i n Table 4.3. The f i r s t primary nursing behaviour re l a t e d to giving c l e a r i n s t r u c t i o n s ; the second, to giving feedback to the patient about h i s or her progress i n h o s p i t a l ; and the t h i r d , to encouraging the patient to i d e n t i f y what he or she thought h i s or her problems were. The differences between the two groups on each of these three behaviours was due to the report, by the nurses, that the behaviours occurred 100 percent of the time. This figure was not supported i n the response of the pat i e n t s . The primary nurses may presume they are carrying out these behaviours without v a l i d a t i n g the occurrence of them with t h e i r p a t i e n t s . G. Ferguson, S t a t i s t i c a l Analysis i n Psychology and Education, 4th ed., (Toronto: McGraw-Hill Book Company,. 1976), p. 488. 58. TABLE 4.3 Behaviours that Demonstrated S i g n i f i c a n t Differences i n Occurrence Primary Nursing Behaviours Degrees of Freedom Value of Chi Square Giving c l e a r i n s t r u c t i o n s 2 9.99 Giving feedback to the patients re t h e i r progress 2 1 9.99 Encouraging the patients to i d e n t i f y t h e i r own problems 2 9.99 Hypothesis 5. There i s no s i g n i f i c a n t d i f f e r e n c e between the patients' and the nurses' ratings of importance of each s p e c i f i c primary nursing behaviour included i n the s a t i s f a c t i o n questionnaire. In order for the diff e r e n c e to be s i g n i f i c a n t , the t e s t value o f t needed to exceed the c r i t i c a l value of t at the .01 l e v e l for a one-t a i l e d t e s t . Since there was missing data on some of the questionnaires the degrees of freedom varied. However, at an appropriate l e v e l of p r e c i s i o n , the c r i t i c a l value of t f o r the degrees of freedom, which 4 ranged from 53 to 56, remained e s s e n t i a l l y 2.40. See Table 4.4 f o r the c r i t i c a l values of U i n the Mann-Whitney U t e s t f o r the corresponding values of N and N , where these values were the numbers i n each group. E. Minium, S t a t i s t i c a l Reasoning i n Psychology and Education, (Toronto: John Wiley and Sons, Incorporated, 1970), p. 444. 59. TABLE 4.4 C r i t i c a l Values f o r U i n the Mann-Whitney U Test Patients N l Nurses N2 , C r i t i c a l Values For U 26 29 515 27 29 534 28 28 534 28 29 552 29 29 570 S i g n i f i c a n t differences i n the r a t i n g of importance between nurses and patients were found f o r the following primary nursing behaviours: (1) checking the patient's understanding of i n s t r u c t i o n s , (2) t e l l i n g the patient how he or she was progressing i n h o s p i t a l , (3) encouraging the patient's family to be involved i n the treatment program, (4) e s t a b l i s h i n g and maintaining contact with the patient's family, (5) preparing the patient to deal with problems he or she may encounter a f t e r discharge. See Table 4.6 for a summary of the t and U values f o r the above s i g n i f i c a n t behaviours. Once again, a l l of the differences were due 60. to a higher r a t i n g of importance on the part of the nurses when compared with the p a t i e n t s . TABLE 4.5 Behaviours that Demonstated S i g n i f i c a n t Differences i n Importance  Primary Nursing Behaviours Degrees of Freedom Value of t Value of U Checking patient's under-standing of i n s t r u c t i o n s 55 2.57 150 T e l l i n g patient about h i s progress i n h o s p i t a l 56 3.14 225 Encouraging family involve-ment i n program 54 3.55 202 E s t a b l i s h i n g and maintaining family contact 54 2.87 215 Preparing patient for discharge 55 2.71 301 Hypothesis 6. There i s no s i g n i f i c a n t d i f f e r e n c e between the nurses' and patients' scores for s a t i s f a c t i o n with each s p e c i f i c primary nursing behaviour included i n the s a t i s f a c t i o n questionnaire. In order f o r the diff e r e n c e between the two groups to be s i g n i f i c a n t , the t e s t value of t needed to exceed the c r i t i c a l value of t at the .01 l e v e l for a o n e - t a i l e d t e s t . These c r i t i c a l values have been c i t e d . S i g n i f i c a n t differences i n s a t i s f a c t i o n between patients and nurses occurred f o r the following primary nursing behaviours: 61. (1) checking the patient's understanding of i n s t r u c t i o n s , (2) contacting and being known by the patient's family and friends, (3) explaining the h o s p i t a l program to the patient, (4) encouraging the involvement of the patient's family i n the treatment program, (5) g i v i n g the pa t i e n t feedback regarding h i s or her progress i n h o s p i t a l , (6) working with the pa t i e n t whenever the primary nurse was on days or evenings. See Table 4.7 for a summary of the t and 13 values for each of the above s i x behaviours. As before, f o r each of these behaviours the nurses, as a group, rated these behaviours more highly than did the pa t i e n t s . TABLE 4.6 Behaviours That Demonstrated S i g n i f i c a n t Differences i n S a t i s f a c t i o n Primary Nursing Behaviours Degrees of Freedom Value of t Value of U Checking patient's under-standing of i n s t r u c t i o n s 56 3.5 245 T e l l i n g p a tient about h i s progress i n h o s p i t a l 56 2.8 268 Encouraging Family involve-ment 56 3.6 207 Explaining the h o s p i t a l program 54 2.4 318 E s t a b l i s h i n g contact with the family 56 4.9 233 Working with the patient when on duty 54 2.4 272 Being known by family and friends 55 7.1 37 From the data i t would seem that the nurses over-reported the occurrence of c e r t a i n behaviours, both i n t h e i r charting and i n t h e i r response to the questionnaire. Planning and discussion r e l a t e d to discharge i s an example. However, both the charting and the report of patients and nurses confirmed the f a c t that the primary nurse does not orientate the patient to the uni t . The data analysis r e l a t e d to Hypothesis 1 indicated that the primary nurses seemed to be involved with t h e i r patients; spending 63. time with the patient when he or she was upset, working with the patient when on duty, and g i v i n g the patient feedback regarding h i s or her progress i n h o s p i t a l . The data also i n d i c a t e d that the primary nurse was less involved with the p a t i e n t 1 s family but t h i s was seen by both groups as less important. Patients and nurses re l a t e d that i t was important and s a t i s f y i n g f o r the patient to be involved i n h i s or her care. This could happen by asking the pa t i e n t what he or she thinks are the problems that brought him or her to h o s p i t a l . I t could- also happen when the primary nurse gives the patient feedback about h i s or her progress i n h o s p i t a l . Although both patients and nurses reported that i t was important f o r the primary nurse and the primary th e r a p i s t to work c l o s e l y together, they d i d not seem to see j o i n t interviewing as a way of accomplishing t h i s . The s i g n i f i c a n t difference between the report of the occurrence, importance or s a t i s f a c t i o n of the nurses as compared with the patients could be due to the nurses' over-reporting. An example might be the nurses' report of the occurrence of such behaviours as gi v i n g c l e a r i n s t r u c t i o n s or explaining primary nursing. The report of the occurrence of such behaviours would be the p r o f e s s i o n a l l y desirable response. The same could be true f o r the nurses' importance r a t i n g of behaviours such as encouraging family involvement i n the treatment program and preparing the patient f o r discharge. The dif f e r e n c e could also be due to the patients' under-reporting. Perhaps they are unw i l l i n g for t h e i r family to be involved and consequently rate i t as l e s s important. 64. It seemed that the two major areas of d i f f e r e n c e were r e l a t e d to discharge and family involvement. Both patients and nurses reported l e s s occurrence of c e r t a i n behaviours r e l a t e d to these two areas and a t t r i b u t e d l e s s importance to behaviours related to family involvement. Nurses acknowledged that primary nursing behaviours r e l a t e d to discharge and family involvement occurred more often and were more important than did the patients. Both these areas are described i n the l i t e r a t u r e as important c h a r a c t e r i s t i c s o f primary nursing. The behaviours that yielded s i g n i f i c a n t differences i n the responses of nurses and patients may have occurred and may have been important and s a t i s f y i n g . The analysis merely shows that, f o r c e r t a i n behaviours, the responses of the two groups were s i g n i f i c a n t l y d i f f e r e n t . 65. CHAPTER V SUMMARY The purpose of t h i s study was to devise a t o o l and to c o l l e c t information r e l a t e d to the perceptions of patients and nurses about primary nursing. The i n v e s t i g a t o r considered i t very important to incorporate the perceptions of pati e n t s , as well as nurses, i n the evaluation of primary nursing. In order to accomplish t h i s , a questionnaire was administered to twenty-nine patients and t h e i r primary nurses during the l a s t week of the patient's h o s p i t a l i z a t i o n . The questionnaire y i e l d e d data re l a t e d to the occurrence, importance and s a t i s f a c t i o n of the s p e c i f i c primary nursing behaviours. CONCLUSIONS The study was conducted on a p s y c h i a t r i c unit and i t i s d i f f i c u l t to know how much the r e s u l t s can be generalized. For example: one of the r e s u l t s from the questionnaire was rela t e d to the primary . , nurses o r i e n t a t i n g the newly admitted patient. Both patients and nurses acknowledged that the o r i e n t a t i o n by the primary nurse d i d not occur and i t was not important. One could deduce that i t was not necessary f o r the primary nurse to orientate the patient and, i n f a c t , she or he seldom did. Patients who had been h o s p i t a l i z e d for a period of time usually orientated patients who were newly admitted. However, t h i s procedure might only be f e a s i b l e on units where the patient 66. length of stay was longer and where some patients were ambulatory. R e h a b i l i t a t i o n areas, extended care, psychiatry and some medical u n i t s are examples of these types of areas. Although the questionnaire was constructed i n such a way that the primary nursing behaviours were not s p e c i f i c to psychiatry, the g e n e r a l i z a t i o n of the r e s u l t s to other nursing areas may be somewhat l i m i t e d . Both nurses and patients were i n high agreement i n t h e i r perception of the occurrence and importance of the primary nursing behaviours. Where there were s i g n i f i c a n t differences i n t h e i r perceptions, i t was due to higher ratings on the part of the nurses for-the occurrence, importance and s a t i s f a c t i o n of the primary nursing behaviours. The patients and nurses reported low occurrence scores for behaviours r e l a t e d to discharge and family contact. They also reported low importance scores f o r the primary nursing behaviours associated with family contact and involvement. Both groups f e l t planning and discussion r e l a t e d to discharge were very important. For patients, t h e i r reported non-occurrence of these behaviours r e l a t e d to discharge and the high importance they a t t r i b u t e d to them resu l t e d i n low s a t i s f a c t i o n f o r these s p e c i f i c primary nursing behaviours. The low occurrence and importance scores a t t r i b u t e d by both groups to primary nursing behaviours r e l a t e d to f a m i l i e s was unexpected. Family involvement was often emphasized on the u n i t . The low scores may r e f l e c t the f a c t that many patients did not have t h e i r f a m i l i e s a v a i l a b l e f o r t h i s kind of contact and involvement. Both patients and nurses reported that the primary nurse established 67. a r e l a t i o n s h i p with the patient by spending time with the patient and encouraging the patient's involvement and input i n t o the care plan. This was a concern expressed by the nursing s t a f f when the i n v e s t i g a t o r f i r s t met with them to discuss the study. They f e l t that one of the most important aspects of primary nursing was the r e l a t i o n s h i p they formed with t h e i r patients and they hoped t h i s c h a r a c t e r i s t i c would be acknowledged i n the study. One of the basic questions asked at the beginning of the i n v e s t i g a t i o n was: are primary nurses a c t u a l l y p r a c t i s i n g the behaviours that the l i t e r a t u r e ascribes to primary nursing?. With a few exceptions, the answer seems to be a f f i r m a t i v e . The second question was r e l a t e d to the importance of the behaviours. Do patients and nurses assign the same importance to the primary nursing behaviours? Again, except f o r a few exceptions,, the answer was af f i r m a t i v e . The t h i r d question was re l a t e d to the s a t i s f a c t i o n . w i t h the primary nursing behaviours. This question was only p a r t i a l l y answered. There were data generated which r e l a t e d to.the s p e c i f i c behaviours both groups rated f o r high and low s a t i s f a c t i o n . There was also information re l a t e d to s i g n i f i c a n t d i f f e r e n c e s i n s a t i s f a c t i o n scores of the s p e c i f i c behaviours. I t was d i f f i c u l t to measure any degree of c o r r e l a t i o n between nurses and patients on the s a t i s f a c t i o n with the primary nursing behaviours. An assumption made at the beginning of the i n v e s t i g a t i o n was that patients and nurses can and w i l l express t h e i r s a t i s f a c t i o n with primary 68. nursing by responding to a questionnaire. I t i s d i f f i c u l t to know i f that assumption held true. Part of the d i f f i c u l t y lay i n the construction of the questionnaire and the method devised to compute the s a t i s f a c t i o n score. Another contributing factor was the p o s s i b i l i t y of over-reporting on the part of the nurses. Were they g i v i n g the p r o f e s s i o n a l l y desirable response to some of the statements on the questionnaire? Discussions with patients indicated that some of them perceived the questionnaire as an evaluation of t h e i r own primary nurse. A few of them commented, "I gave you a good report", when discussing the questionnaire with the nurse i n casual conversation. I t i s also d i f f i c u l t to know how much the fact that the questionnaire was given during the week of discharge affected both the pa t i e n t s ' and nurses' response. Patients may have been very anxious during t h i s time at the thought of being discharged. Their anxiety may have d i s t o r t e d t h e i r perception of the statements on the questionnaire or t h e i r view of t h e i r h o s p i t a l i z a t i o n . On the other hand, the patients may have been so pleased to go home and assumed that the s t a f f and the h o s p i t a l i z a t i o n had solved a l l t h e i r problems. Consequently, they may have viewed t h e i r h o s p i t a l i z a t i o n i n a very p o s i t i v e l i g h t . An attempt was made, by the in v e s t i g a t o r , to administer the questionnaire to a small sample of patients before and a f t e r discharge. This was to assess the e f f e c t , i f any, of discharge on the patient's response to the questionnaire. The number of patients returning the questionnaire a f t e r discharge was too /small to draw any conclusions from the data. 69. There were four patients who l e f t the h o s p i t a l i n a very angry state of mind. Only one of these patients consented to complete a questionnaire. As a r e s u l t , the p o s s i b i l i t y e x i s t s that the patient sample may have been somewhat skewed with patients who had very p o s i t i v e f e e l i n g s towards t h e i r h o s p i t a l i z a t i o n . IMPLICATIONS It was d i s t u r b i n g to see the low occurrence scores for primary nursing behaviours r e l a t e d to discharge and family contact. This may be a f a c t o r i n the high re-admission rate of p s y c h i a t r i c p a t i e n t s . I f the patients have not been informed of such things as medication a f t e r discharge and l i t t l e discussion has taken place about post-hospital a c t i v i t i e s and preparation f o r possible problems, they may f e e l and be i l l - e q u i p p e d to handle the t r a n s i t i o n from h o s p i t a l to home. I f the family has not been involved with the patient during h i s or her h o s p i t a l i z a t i o n , they may not give the support and encouragement the patient needs on discharge. I t i s s i g n i f i c a n t to note that both patients and nurses rated the primary nursing behaviours associated with discharge as highly important. Perhaps the actual discharge takes place with a minimum of communication between d i s c i p l i n e s . Consequently, the primary nurse may not have s u f f i c i e n t time or information to a c t u a l l y help the patient prepare f o r discharge. I t i s d i f f i c u l t to explain the low scores for the importance and occurrence of primary nursing behaviours r e l a t e d to family contact and 70. involvement. As stated e a r l i e r , these low scores may be a r e f l e c t i o n of the -unavailability of the patient's family for involvement or contact. I t i s conceivable that because the family i s unavailable, the occurrence of and' importance a t t r i b u t e d to the behaviours decreases. Perhaps, h o s p i t a l i z a t i o n i s a time to focus on the patient and family involvement should have l e s s emphasis. RECOMMENDATIONS There seemed to be some l i m i t a t i o n s i n terms of the questionnaire. Perhaps another method of a r r i v i n g at the s a t i s f a c t i o n scores might be devised. In addition to the questionnaire, further information might be obtained through interviews. Although t h i s i s a time consuming method of data c o l l e c t i o n , i t may y i e l d more accurate and complete information. Patients who are angry or upset may-be more amenable to an interview as compared to a questionnaire. The questionnaire could be administered to a sample of patients before and a f t e r discharge. In t h i s way i t would be possible to detect any differences i n response which might.be due to the influence of anxiety r e l a t e d to discharge. Because the study was done on a p s y c h i a t r i c u n i t , the g e n e r a l i z a t i o n of the r e s u l t s i s l i m i t e d . The i n v e s t i g a t i o n could be duplicated i n another area, such as a medical ward, i n order to confirm.or negate the findings of t h i s study i n r e l a t i o n to other areas of nursing. The low occurrence of and importance a t t r i b u t e d to primary nursing behaviours associated with family involvement was unexpected. This area / 71. might be'the focus i n a subsequent i n v e s t i g a t i o n . The low occurrence of primary nursing behaviours r e l a t e d to discharge should be remedied. In order that a l l s t a f f are aware of the patient's discharge date, i t should be decided at le a s t one week before and posted where both the patient and s t a f f can see. A discharge c h e c k l i s t might be added to the chart. I t could include behaviours such as discussion of medication and discussion of possible post-hospital a c t i v i t i e s the patient should or could engage i n . The patient and the nurse, together, could note when the behaviour has taken place. The c h e c k l i s t would help focus the attention of both the pa t i e n t and the primary nurse on the preparation of the patient f o r discharge. The author plans to meet with the nursing s t a f f at the h o s p i t a l where the study took place i n order to discuss the f i n d i n g s . The nurses expressed i n t e r e s t i n having t h i s feedback when they f i r s t met to discuss the study. In a d d i t i o n to discussing the r e s u l t s , i t i s hopeful that the nurses might have some ideas about how to i n s t i t u t e changes pertinent to the fi n d i n g s . For example: how to improve the discharge planning. The recommendations made e a r l i e r i n t h i s chapter are suggestions that the s t a f f could implement. However, they might have better a l t e r n a t i v e s . The p o s s i b i l i t y e x i s t s that, as primary nursing i s implemented i n other h o s p i t a l s i n the c i t y , the t o o l could be used as an evaluative measure. This would enable the in v e s t i g a t o r to see i f the r e s u l t s from t h i s study are s i m i l a r to the data generated when the t o o l i s u t i l i z e d i n other nursing areas. 72. This study has attempted to describe and evaluate primary nursing p a r t i c u l a r l y as i t occurs on a p s y c h i a t r i c u n i t . I t has validated that most of the primary nursing behaviours occur and both patients and nurses agree on t h e i r importance. A most s i g n i f i c a n t r e s u l t has been the i n c l u s i o n of patients i n the evaluation of t h e i r care. 72A . BIBLIOGRAPHY 73. BIBLIOGRAPHY BOOKS AND ESSAYS Brown, E. L. "Nursing and Patient Care", The Nursing Profession, Five S o c i o l o g i c a l Essays, F. Davis, e d i t o r . New York: John Wiley & Sons Incorporated, 1966. Campbell, W. G. Form and Style i n Thesis Writing. New York: Houghton M i f f l i n Company, 1969. Ferguson, G. A. S t a t i s t i c a l Analysis i n Psychology and Education. 4th ed. Toronto: McGraw-Hill Book Company, 1976. Glasser, M. "Consumer Expectations of Health Services", Medicine i n a Changing World, L. Corey and S. Saltman, ed i t o r s . St. Louis: C.V. Mosby and Company, 1972. Goode, W. J. and P. K. Hatt. Methods i n S o c i a l Research. Toronto: McGraw-Hill Book Company, 1952. Kramer, M. Re a l i t y Shock. St. Louis: C.V. Mosby and Company, 1974. Marram, G., M. Schlegel and E. Bevis. Primary Nursing. St. Louis: C.V. Mosby and Company, 1974. Phaneuf, M. C. The Nursing Audit: P r o f i l e f o r Excellence. New York: Appleton-Century-Crofts, 1972. Shaw, M. E. and J . M. Wright. Scales f o r the Measurement of  Attitu d e s . New York: McGraw-Hill Book Company, 1967. Slat e r , D. The S l a t e r Nursing Competencies Scale. D e t r o i t : Wayne State U n i v e r s i t y , College of Nursing, 1967. Togliacozzo, D. L. "The Nurse From the Patient's Point of View", So c i a l Interaction and Patient Care, J.K. Skipper and R.C. Leonard, e d i t o r s . Toronto: J.B. L i p p i n c o t t Company, 1965. Tuckman, B. W. Conducting Educational Research. New York: Harcourt, Brace, Jovanovich Incorporated, 1972. Wandelt, M. and J. Ager. Quality Patient Care Scale. D e t r o i t : Wayne State U n i v e r s i t y , College of Nursing, 1970. 74. BIBLIOGRAPHY (Contd.) PERIODICALS Abdellah, F. and E. Levine. "Developing A Measure of Patient & Personnel S a t i s f a c t i o n With Nursing Care", Nursing  Research, V, 3 (1957), 100-108. Abdellah, F. and E. Levine. "What Factors A f f e c t Patients' Opinions of Their Nursing Care?", Hospitals, XXXI, (November, 1957), 61-64. Abdellah, F. and E. Levine. "What Patients Say About Their Nursing Care", Hospitals, XXXI, (November, 1957), 44-48. Alfano, G. "The Loeb Center f o r Nursing and R e h a b i l i t a t i o n " , Nursing C l i n i c s of North America, IV, 3 (1969), 487-492. Bakke, K. "Primary Nursing: Perceptions of a S t a f f Nurse", American Journal of Nursing, LXXIV, 8 (1974), 1432-1434. Berkowitz, N. and M. Malone. "Intra-Professional C o n f l i c t " , Nursing Forum, VII, 1 (1968), 50-71. Carlson, S. Book review on Primary Nursing by Marram, G. and others, American Journal of Nursing, LXXV, 3 (1975), 514. Carlson, S., R. Kaufman and M. Schwaid. "An Experiment i n S e l f -Determined Patient Care", Nursing C l i n i c s of North America, IV, 2 (1969), 495-507. Ciske, K. L. "Primary Nursing: An Organization to Promote Professional P r a c t i c e " , Journal of Nursing Administration, IV, 1 (1974), 28-3 . .Ciske, K. L. "Primary Nursing: Evaluation", American Journal  of Nursing, LXXIV, 8 (1974), 1436-1438. D a e f f l e r , R. "Patients' Perception of Care Under Team and Primary Nursing", Journal of Nursing Administration, V, 3 (1975), 20-26. Ewell, C. "What Patients Really Think About Their Nursing Care", Modern Hospital, IX, 2 (1967), 106-108. Felton, G. "Increasing the Quality of Nursing Care by Introducing the Concept of Primary Nursing: A Model Project", Nursing Research, XXIV, 1 (1975), 27-32. 75. BIBLIOGRAPHY (Contd.) PERIODICALS H a l l , L. "Nursing - What Is I t ? " , The Canadian Nurse, LX, 2 (1964), 150-154. Henderson, C. "Can Nursing Care Hasten Recovery?", American  Journal of Nursing, LXIV, 6 (1964), 80-82. Kramer, M. and M. Manthey. "Dialogue on Primary Nursing", Nursing Forum, IX, 4 (1974), 356-379. Logsdon, A. "Why Primary Nursing?", Nursing C l i n i c s of North  America, XXVIII, 2 (1973), 283-291. Manthey, M. "Primary Nursing i s A l i v e and Well i n the Hospital", American Journal of Nursing, LXXIII, 1 (1973), 83-87. Manthey, M. and others. "Primary Nursing", Nursing Forum, XIV, 1 (1970), 65-83. Marram, G. "Innovation on 4 Tower West: What Happened?", American Journal of Nursing, LXXIII, 5 (1973), 814-816. Marram, G. "Patients' Evaluation of Nursing Performance", Nursing Research, XXII, 2 (1973), 153-157. Marram, G. "Patients' Evaluation of Their Care: Importance To The Nurse", Nursing Outlook, XXI, 5 (1973), 322-324. Moore, D. and K. Cook-Hubbard. "Comparison of Methods f o r Evaluating the Patients' Response to Nursing Care", Nursing Research, XXIV, 3 (1975), 202-204. Mundinger, M. "Primary Nursing: Role Evolution", Nursing  Outlook, XXI, 10 (1973), 642-645. Munson, F. C. and S. S. Meda. "An Instrument for Measuring Nursing S a t i s f a c t i o n " , Nursing Research, XXIII, 2 (1974), 159-166. Nehring, V. and B. Geach. "Patients' Evaluation of Their Care: Why Don't They Complain?", Nursing Outlook, XXI, 5 (1973), 317-321. Page, M. "Primary Nursing: Perceptions of a Head Nurse", American Journal of Nursing, LXXIV, 8 (1974), 1435-1436. 76. BIBLIOGRAPHY (Contd.) PERIODICALS Porter, L. "Job Attitudes i n Management: Part 1. Perceived D e f i c i e n c i e s i n Need F u l f i l l m e n t as a Function of Job Level", Journal of Applied Psychology, XLVI, 6 (1962), 375-384. Porter, L. "Job Attitudes i n Management: Part 2. Perceived Importance of Needs as a Function of Job Level", Journal of Applied Psychology, XLVII, 1 (1963), 141-148. Raphael, W. "Do We Know What Patients Think?", International  Journal of Nursing Studies, IV, 3 (1967), 209-223. Rieve, J. "Primary Nursing In a P s y c h i a t r i c Setting", Alumni Magazine, LXXIII, 2 (1976), 20-21. Risser, N. "Development o f an Instrument to Measure Patient S a t i s f a c t i o n With Nurses and Nursing Care i n Primary Care Settings", Nursing Research, XXIV, 1 (1975), 45-51. Robinson, A. M. "Primary Care Nursing at Two Teaching Hospitals", R. N., XXXVII, 4 (1974), 31-34. Schlegel, M. "Innovation on 4 Tower West: How?", American  Journal of Nursing, LXXIII, 6 (1973), 811-813. Weed, L. "Medical Records That Guide and Teach", The New England Journal of Medicine, CCLXXVIII, 11 (1968) 593-599. 76A . APPENDICES 77. APPENDIX A 78. APPENDIX A PRIMARY NURSING Primary nursing i s a system of d e l i v e r i n g nursing care. In t h i s system one nurse i s responsible and accountable for the assessment of the patient's needs and the planning and evaluation of the nursing care throughout the patient's h o s p i t a l i z a t i o n . These a c t i v i t i e s are done i n col l a b o r a t i o n with the patient and the other members of the health team. According to the l i t e r a t u r e , the primary nurse performs the following s p e c i f i c a c t i v i t i e s i n r e l a t i o n to h i s or her primary patients: 1. orientates the patient to the u n i t and the h o s p i t a l . This could include an explanation of h o s p i t a l p o l i c i e s , the ward program, and primary nursing; 2. assesses the patient to e s t a b l i s h an immediate p r i o r i t y o f needs. The i d e n t i f i c a t i o n and discussion of problems should be done j o i n t l y with the patient, (when appropriate); 3. assumes r e s p o n s i b i l i t y f o r nursing's c o n t r i b u t i o n to the care plan. This includes keeping the plan current, evaluating the nursing measures, co-ordinating the plan of care for the patient, and making r e f e r r a l s to other d i s c i p l i n e s ; 4. works with the primary t h e r a p i s t i n j o i n t interviews and discussions of the care plan; 5. communicates with other s t a f f members about the care plan. This includes discussion with other d i s c i p l i n e s such as occupational therapy, charting, and discussions with the associate nurse; 79. 6. gives care to primary patients whenever on duty - v i t a l signs, treatments, medications, preparation f o r t e s t s ; 7. plans the care to be given when the primary nurse i s not on duty - 24 hour r e s p o n s i b i l i t y ; 8. supervises patient and family teaching for such things as medications, signs and symptoms of the patient's i l l n e s s , h o s p i t a l i z a t i o n , and discharge; 9. co-ordinates the patient's discharge, i n c l u d i n g planning and discussing i t with the patient about two weeks p r i o r to discharge as well as introducing the discharge t h e r a p i s t , i f and when appropriate; 10. seeks supervision or feedback from peers when appropriate. 80. APPENDIX A SUMMARY OF RESEARCH Primary nursing i s a system of d e l i v e r i n g nursing care when one nurse i s reaponsible and accountable f o r the assessment of the patient's needs and the planning and evaluation of the nursing care throughout the patient's h o s p i t a l i z a t i o n . These a c t i v i t i e s are done i n c o l l a b o r a t i o n with the patient and other members of the health team. Although t h i s model of d e l i v e r i n g nursing care i s f e l t to increase patient s a t i s f a c t i o n with nursing care, there has been l i t t l e research done to evaluate t h i s . The proposed study w i l l investigate the degree of patient and nurse s a t i s f a c t i o n with the nursing behaviours which characterize primary nursing. A questionnaire w i l l be administered to the patient the week p r i o r to discharge from h o s p i t a l . At the same time, a s i m i l a r questionnaire w i l l be given to the patient's nurse. SAMPLE The subjects w i l l be twenty-nine patients who have been h o s p i t a l i z e d on the same ward and t h e i r primary nurses. The i n v e s t i g a t o r w i l l contact the patient and the nurse to administer the questionnaire. 81. APPENDIX B « 82. APPENDIX B CONSENT FORM - NURSE I, the undersigned, agree to p a r t i c i p a t e i n the research describing primary nursing. I understand the procedures involved. I consent to have the questionnaire given to my patient. I understand that I may withdraw from the study at any time. Signature Date CONSENT FORM I, the undersigned, agree to p a r t i c i p a t e i n the research describing primary nursing. I understand the procedures involved. I understand that I may withdraw from the study at any time. Signature Date Witness 83. 84. APPENDIX C CHART CHECKLIST - date - nurse - patient Orientation Discuss discharge plans Introduce discharge t h e r a p i s t Written care plans Primary nurse ind i c a t e d on chart Evaluations charted S i g n i f i c a n t events charted Interviewed with primary th e r a p i s t Careplan indicated 24 hour interventions Family contact indicated Mention of discu s s i o n of patient's problems on discharge 85. APPENDIX D Please in d i c a t e which of the following statements apply to you by p l a c i n g a check mark >/ i n the appropriate space. 1. Male 2. Age: Female under 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 over 71 3. Have you had a previous p s y c h i a t r i c h o s p i t a l i z a t i o n ? Yes No 4. I f the answer to question 3 was "Yes", please indicate where your previous h o s p i t a l i z a t i o n was. Health Sciences Centre Hospital Lion's Gate Hospital Riverview Hospital St. Paul's Hospital St. Vincent's Hospital Shaughnessy Hospital Surrey Memorial Hospital Vancouver General Hospital Other (specify) T3 > H M a 8 H ir1 H 15 o H X oo 87. APPENDIX E 88. APPENDIX E DATA FROM PATIENT PROFILE SHEET Sex Male 13 Female 16 Age i n Years under 20 1 51 - 60 5 21 - 30 10 61 - 70 _1 31 - 40 _5 over 71 0 41 - 50 7 Previous P s y c h i a t r i c H o s p i t a l i z a t i o n  Yes - 17 No - 12 Previous Admissions to t h i s Hospital 12 89. APPENDIX F 90. APPENDIX F METHOD OF CALCULATING THE SATISFACTION SCORES In order to get a measure of s a t i s f a c t i o n , a response which indicated the behaviour had occurred was given a value of +1, a response which indi c a t e d the behaviour d i d not occur was given a value of -1, and a response which indicated the behaviour was not applicable was given a value of 0. For example: a response of "true" to the statement, "Your primary nurse showed you around the ward", would be given a value of +1. A response of "true" to the statement, "Your family had no contact with your primary nurse", would be given a value of -1. By m u l t i p l y i n g the value given for the occurrence of the behaviour i n part one of the questionnaire, with the r a t i n g of importance assigned i n part two of the questionnaire, a numerical i n d i c a t o r of s a t i s f a c t i o n could be arr i v e d at. Each behaviour was treated i n d i v i d u a l l y . For example: the f i r s t question i n part one and two of the patient questionnaire i s : 1. "Your primary nurse showed you around the ward." I f a patient responded " f a l s e " f o r occurrence i n part one of the questionnaire and assigned the behaviour a value of 4 for importance i n part two of the questionnaire, the patient would receive a s a t i s f a c t i o n score of -4. The range of scores measuring s a t i s f a c t i o n could go from +5 to -5 with +5 i n d i c a t i n g most s a t i s f a c t i o n and -5 i n d i c a t i n g l e a s t s a t i s f a c t i o n . 91. APPENDIX G Please indicate which of the following statements applies to you by placing a check mark s/ i n the appropriate space. 1. Male Female _ _ 2. Age: under 20 51 - °0 21 - 30 61 - 70 31 - l±o over 71 *U - 50 3. Have you had a previous psychiatric hospitalization? Yes ... No k. I f the answer to question 3 was "yes", please indicate where your previous h o s p i t a l i z a t i o n was. Health Sciences Centre Hospital , Lion's Gate Hospital , Riverview Hospital St. Paul's Hospital St. Vincent's Hospital Shaughnessy Hospital Surrey Memorial Hospital Vancouver General Hospital Other ( specify) INSTRUCTIONS On the next few pages are a series of statements which may or may not describe the re l a t i o n s h i p you had with your primary nurse. Please indicate by c i r c l i n g True or False the statements which apply to the care you received. Some statements may not be applicable to you and i f that i s so please indicate by c i r c l i n g N/A. There are no " r i g h t " or "wrong" answers and i t i s very important that you be very straightforward when responding to the questions. The questionnaires w i l l remain anonymous and neither you nor your nurse w i l l be i d e n t i f i e d by name. 1. BEHAVIOUR  1. Your primary nurse showed you around the ward. 2. Your primary nurse spent time with you when you were upset. 3. Your primary nurse prepared you for any problems you might have a f t e r leaving the hospital. 4. You were taught by your primary nurse to observe your reaction to treatment. 5. Your family had no contact with your primary nurse. 6. Your primary nurse knew you very well. 7. You knew when your primary nurse was on days o f f . 8. You and your primary nurse talked about your problems. 9. Your primary nurse answered your questions. 10. Together, you and your primary nurse discussed whether or not the treatment was working. 11. Your primary nurse explained primary nursing to you. OCCURRENCE T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A 10 2. BEHAVIOUR  12. An explanation of the ho s p i t a l program was given to you by your primary nurse. 13» Your primary nurse explained the reason for any tests that you had, 1^. Your primary nurse l i s t e n e d to your problems. 15• Your primary nurse seldom talked with your v i s i t o r s . 16. Your primary nurse worked with you whenever she was on days or evenings. 17. Every nurse that worked with you seemed to know why you were i n ho s p i t a l . 18. You were given incorrect explanations of procedures by your primary nurse. 19• Your primary nurse discussed with you the problems you would be working on during your h o s p i t a l i z a t i o n . 20. Your therapist and your primary nurse worked together. OCCURRENCE T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A 3-BEHAVIOUR 21. Your primary nurse encouraged your family to be involved i n the treatment program. 22. Your primary nurse was seldom present i n interviews. 23. Yourwere given clear i n s t r u c t i o n s by your primary nurse. 2k. You discussed your discharge plans with your primary nurse. 25• You understood the reason f o r your symptoms. 26. Your primary nurse encouraged you to say what you thought your problems were. 27. Your r e l a t i v e s talked about your progress with your -primary nurse. 28. You received no explanation of hospital p o l i c i e s . 29. Your primary nurse treated you l i k e an i n d i v i d u a l . 30. Your primary nurse t o l d you how she thought you were doing. OCCURRENCE T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A 31. Your family and friends knew your primary nurse. 32. You never knew which nurse was going to he working with you from one s h i f t to the next. 33* You discussed with your primary nurse the effect of the treatment you were receiving. 3^. Your primary nurse checked on your understanding of i n s t r u c t i o n s . 35. Your primary nurse advised you about post-ho s p i t a l a c t i v i t i e s . 36. Your primary nurse explained routine procedures. 37. Your primary nurse discussed your taking medication at home af t e r discharge. OCCURRENCE T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A INSTRUCTIONS On the next few pages you w i l l be asked to rate how important the described nursing behaviours are to you. Please indicate the importance by c i r c l i n g any one of the f i v e numbers with 5 being very important, 3 being somewhat important and 1 being not important at a l l . Once again, there are no "right" or "wrong" responses. 1. BEHAVIOUR  HOW IMPORTANT IS IT TO YOU THAT: 1. Your primary nurse shows you around the ward? 2. Your primary nurse spends time with you when you are upset? 3» Your primary nurse prepares you for any problems you might have afte r leaving the hospital? k-. Your primary nurse teaches you to observe your reaction to treatment? 5. Your family has contact with your primary nurse? 6. Your primary nurse knows you well? 7. You know when your primary nurse i s on days off? 8. You can tal k with your primary nurse about your problems? 9- Your primary nurse answers your questions? IMPORTANCE Not Important 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Very Important ^ 5 * 5 * 5 Ur 5 h 5 ^ 5 h 5 4 5 2. BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 10. Together, you and your primary nurse discuss whether or not your treatment i s working? 11. Your primary nurse explains primary nursing to you? 12. An explanation of the hos p i t a l program i s given to you by your primary nurse? 13- Your primary nurse explains the reason for any tests that you have? Ik. Your primary nurse l i s t e n s to your problems? 15« Your primary nurse t a l k s with your v i s i t o r s ? 16. Every nurse that works with you seems to know why you are i n hospital? 1?. Your primary nurse works with you whenever he or she i s on day or evening s h i f t ? 18. You are given explanations of procedures by your primary nurse? IMPORTANCE Not Very Important Important 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 2 3 ^ 5 3-BEHAVIOUR HOW IMPORTANT IS IT TO YOU THATs 19. Your primary nurse discusses with you the problems you w i l l be working on during your ho spi t a l i z a t i on? 20. Your therapist and your primary nurse work together? 21. Your primary nurse encourages your family to be involved i n the treatment program? 22. Your primary nurse i s present i n interviews 23« You are given clear i n s t r u c t i o n s by your primary nurse? 2k. You discuss your discharge plans with your primary nurse? 25. You understand the reason f o r your symptoms 26. Your primary nurse encourages you to say what you think your problems are? IMPORTANCE Not-Important 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Very Important k 5 k 5 k 5 k 5 k 5 k 5 k. BEHAVIOUR  HOW IMPORTANT IS IT TO YOU THAT: 27- Your r e l a t i v e s talk about your progress with your primary nurse? 28. You receive an explanation of hos p i t a l p o l i c i e s ? 29. Your primary nurse treats you like, an individual? 30. Your primary nurse t e l l s you how she/he thinks you are doing? 31. Your family and friends know your primary nurse? 32. You know which nurse i s going to be working with you from one s h i f t to the next? 33* You discuss with your primary nurse the effect of the treatment you are receiving? 3k. Your primary nurse checks on your understanding of his/her ins t r u c t i o n s ? 35• Your primary nurse advises you about post-ho s p i t a l a c t i v i t i e s ? IMPORTANCE Not Important 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 Very Important 3 k 5 3 k 5 3 k 5 3 k 5 3 k 5 3 k 5 3 k 5 3 ^ 5 3 ^ 5 5. BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 36, Your primary nurse explains routine procedures? 37. Your primary nurse discusses your taking medication at home af t e r discharge? IMPORTANCE Not Very Important Important 22 3 k 5 2 3 ^ 5 104. APPENDIX H NURSE - INSTRUCTIONS On the next few pages are a series of statements which may or may not describe the relationship you had with t h i s i n d i v i d u a l patient. Please indicate by c i r c l i n g True or False the statements which apply to your care of t h i s s p e c i f i c patient. Some statements may not be applicable and i f that i s so, please indicate by c i r c l i n g N/A. There are no "r i g h t " or "wrong" answers and i t i s very important that you be very straightforward when responding to the questions. The questionnaires w i l l remain anonymous and neither you nor your patient w i l l be i d e n t i f i e d by name. BEHAVIOUR ; OCCURRENCE 1. You orientated the patient to the physical setting. T F N/A 2. You explained the system of primary nursing; T F N/A 3- You had no contact with the patient's s i g n i f i c a n t others. T F N/A 4. You worked c l o s e l y with the primary therapist. T F N/A 5. You spent time with the patient when he or she was upset. T F N/A 6. You discussed with the patient the discharge plans. T F N/A 7. You introduced the patient to the discharge therapist p r i o r to the patient's discharge from the ward. T F N/A 8. You discussed with the patient the purpose of the medication he or she was taking. T F N/A 9- You gave report to the next s h i f t about t h i s patient. T F N/A 10. You wrote your careplans on the chart. T F N/A BEHAVIOUR 11. A l l s t a f f knew that you were the primary nurse for t h i s patient. 12. You charted your evaluation of your interventions. 13. You did not ask the patient f o r his or her i d e n t i f i c a t i o n of h i s or her problems. 1^. You asked t h i s patient what he/she thought was contributing to his/her improvement. 15- You looked af t e r t h i s patient every time you were on days or evenings. 16. You charted any s i g n i f i c a n t events which occurred with the patient during your s h i f t . 17• You were responsible f o r the nursing careplan f o r t h i s patient. 18. You did not r e f e r the patient to other professionals. 19. You advised the patient about post-hospital a c t i v i t i e s . 20. You gave clear i n s t r u c t i o n s . 3-BEHAVIOUR 21. The patient's family and/or friends knew your name. . . 22. You talked with the patient to check his or her understanding of your teaching. 23. You explained the h o s p i t a l program. 2Ur. You explained the reason f o r any special tests. 25. You gave the patient feedback about how you thought he or she was doing. 26. You seldom interviewed the patient with the primary therapist. 27. You discussed with the patient the p a r t i c i p a t i o n of h i s or her family i n the treatment plan. 28. You answered any questions the associate nurse had about the careplan. 29. Your careplan indicated interventions to be used over a Zk hour period of time. 30. I t was c l e a r l y indicated on the chart that you were the primary nurse for t h i s patient. k. BEHAVIOUR  31. You informed the patient when you would not be working with him or her. 32. Together, you and the patient evaluated the nursing care plan. 33. You knew when to seek supervision with t h i s patient's careplan. 3k. You discussed with the patient how he/she thought they were doing. 35« You discussed the careplan with the associate nurse. 36. You discussed with the patient when to take the medication prescribed at discharge. 37> You discussed with the patient the problems he or she may encounter aft e r leaving the hospital. 38. You seldom asked for peer feedback during your care of t h i s patient. OCCURRENCE T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A T F N/A NURSE - INSTRUCTIONS On the next few pages you w i l l he asked to rate how important the described nursing behaviours are to you i n order f o r you to give good primary nursing care. Please indicate the importance by c i r c l i n g any one of the f i v e numbers, with 5 being very important, 3 being somewhat important, and 1 being not important at a l l . Once again, there are no "right" or "wrong" responses. BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 1. You orientate the patient to the physical setting? 2. You explain the system of primary nursing? 3. You have contact with the patient's s i g n i f i c a n t others? Ur. You work c l o s e l y with the primary therapist? 5. You spend time with the patient when he or she i s upset? 6. You discuss with the patient the discharge plans? 7. You introduce the patient to the discharge therapist p r i o r to the patient's discharge from the ward? 8. You discuss with the patient the purpose of the medication he or she i s taking? 9. You give report to the next s h i f t about t h i s patient? IMPORTANCE Not; Important 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 Very Important 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 2. BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 10. You write your careplans on the chart? 11. A l l s t a f f know that you are the primary nurse for t h i s patient? 12. You chart your evaluation of your interventions? 13. You ask the patient for h i s or her i d e n t i f i c a t i o n of h i s or her problems? Ik-. You ask the patient what he/she thinks i s contributing to his/her improvement? 15. Every time you are on days or evenings you look a f t e r t h i s patient? 16. You chart any s i g n i f i c a n t events which occur with the patient during your s h i f t ? 17. You are responsible for the nursing careplan for t h i s patient? 18. You r e f e r the patient to other professionals? IMPORTANCE Not Very Important Important 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3 3 k-k-k-k-kr k k-5 5 5 5 5 5 5 1 2 3 *k ' 5 1 2 3 ^ 5 3. BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 19• You advise the patient about post-hospital a c t i v i t i e s ? 20. You give clear instructions? 21. The patient's family and/or friends know your name? 22. You talk with the patient to check his or her understanding of your teaching? 23. You explain the h o s p i t a l program? 2k-. You explain the reason for any special tests? 25- You give the patient feedback about how you think he or she i s doing? 26. You interview the patient with the primary therapist? 27. You discuss with the patient the p a r t i c i p a t i o n of h i s or her family i n the treatment plan? IMPORTANCE Not Important 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 Very Important 3 ^ 5 3 ^ 5 3 ^ 5 r-(jO 3 ^ 5 3 ^ - 5 3 ^ 5 3 ^ 5 3 ^ 5 3 ^ 5 BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 28. You answer any questions the associate nurse has about the careplan? 29. Your careplan indicates interventions to be used over a 2k- hour period of time? 30. I t i s c l e a r l y indicated on the chart that you are the primary nurse f o r t h i s patient? 31. You inform the patient when you w i l l not be working with him or her? 32. Together, you and the patient evaluate the nursing careplan? 33* You know when to seek supervision with the patient's careplan? 3k-. You discuss with the patient how he/she thinks they are doing? 35- You discuss the careplan with the associate nurse? 36. You discuss with the patient when to take the medication prescribed at discharge? IMPORTANCE Not Important 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 Very Important 3 k- 5 3 ^ 5 3 k- 5 3 k 5 3 k- 5 3 k- 5 3 k- 5 3 k- 5 3 k- 5 5. BEHAVIOUR HOW IMPORTANT IS IT TO YOU THAT: 37. You discuss with the patient the problems he or she may encounter a f t e r leaving the hospital? 38. You ask for peer feedback during your care of t h i s patient? IMPORTANCE Not Very Important Important 5 115. APPENDIX I 116. APPENDIX TABLE 1 Frequency of Patient Responses f o r Occurrence of the Primary Nursing Behaviours  Question Patient's Responses Number True False N/A 1 15 ' 9 5 2 24 3 2 3 19 7 3 4 19 6 4 * 5 12 12 5 6 19 8 2 7 19 8 2 8 25 2 2 9 25 1 3 10 20 4 5 11 15 8 6 12 21 3 5 13 18 1 10 14 24 2 3 *15 13 6 10 16 24 3 2 17 24 4 1 *18 ' ' • 1 26 2 19 23 4 2 20 22 3 4 21 13 10 6 *22 8 19 2 23 26 3 -24 19 4 6 25 22 4 3 26 28 - 1 27 9 10 10 *28 3 23 3 29 27 2 -30 24 5 -31 8 13 8 *32 11 17 1 33 21 4 4 34 22 3 4 35 17 4 8 36 22 1 6 37 16 7 6 * Questions which were negatively phrased. 117. APPENDIX TABLE 2 Frequency of Nurse Responses f or the Occurrence of the Primary Nursing Behaviours  Question Number Nurse's Responses True False N/A 1 13 9 7 2 24 2 3 * 3 7 21 1 4 27 2 -5 28 1 -6 25 3 1 7 4 9 16 8 22 1 6 9 29 - -10 29 - -11 28 1 -12 27 - 2 *13. - 29 -14 29 - -15 28 1 -16 29 - -17 29 - -*18 4 21 4 19 24 4 1 20 29 - -21 18 7 4 22 29 - -23 25 1 3 24 18 1 10 25 29 - -*26 13 16 -27 22 2 5 28 28 - 1 29 24 3 2 30 28 - 1 31 27 2 -32 24 4 1 33 29 - -34 29 - -35 22 7 -36 13 5 11 37 27 2 -*38 4 25 -* Questions which were negatively phrased. 118. APPENDIX TABLE 3 Frequency of Patient Ratings of Importance of Primary Nursing Behaviours  Question Number Rating of Importance 1 2 3 4 5 1 2 4 8 5 10 2 1 - 1 5 21 3 2 - 4 2 20 4 2 - 1 8 15 5 10 2 1 3 11 6 - 1 3 4 20 7 2 2 6 8 11 8 - - 1 3 25 9 - - 3 4 22 10 1 1 2 4 20 11 4 1 6 6 12 12 3 1 3 9 13 13 1 - 2 5 20 14 - 1 - 4 23 15 10 5 5 4 4 16 2 - 8 5 14 17 - - 5 6 18 18 2 2 5 6 14 19 1 - 1 6 21 20 1 - 2 3 23 21 12 1 - 4 10 22 1 4 6 5 12 23 - 1 5 6 17 24 - 1 4 7 17 25 3 1 - 4 21 26 1 1 1 3 23 27 9 2 2 1 10 28 3 3 5 7 11 29 - - - 2 27 30 - 1 - 10 18 31 12 2 1 4 8 32 2 3 4 6 13 33 - 2 2 5 20 34 3 3 8 15 35 1 3 3 6 15 36 3 1 5 7 13 37 3 1 2 3 19 119. APPENDIX TABLE 4 Frequency of Nurse Ratings of Importance of Primary Nursing Behaviours  Question Rating of Importance Number 1 2 3 4 5 1 5 1 6 7 10 2 - 1 3 8 17 3 1 1 6 2 19 4 - - 1 3 25 5 - - 1 7 21 6 - - - 4 25 7 - 2 6 14 7 8 1 - 1 5 22 9 - - 3 4 22 10 - - - 2 27 11 - - 4 8 17 12 - - 1 7 21 13 - - - 3 26 14 - - 1 4 24 15 - - 1 3 25 16 - - - 3 26 17 - - - 7 22 18 1 2 6 4 16 19 - - 4 8 17 20 - - 1 4 24 21 1 4 4 13 7 22 - - 1 4 24 23 - - 4 7 18 24 - - - 6 23 25 - - 1 28 26 - 1 3 12 13 27 -• 1 4 2 22 28 - - 3 5 21 29 - 2 1 8 18 30 - 1 3 5 20 31 - 2 3 7 17 32 - - 1 8 20 33 - 1 2 2 24 34 - - - 3 26 35 . - - 4 7 18 36 2 - 2 3 22 37 - - - 1 28 38 - 1 4 7 17 120. APPENDIX TABLE 5 Frequency of Patient Ratings of the S a t i s f a c t i o n with Primary Nursing Behaviours  Question Number S a t i s f a c t i o n Ratings -5 -4 , -3 , -2 -1 0 1 2 3 4 , 5 1 2 2 1 2 1 5 - 1 4 3 7 2 2 1 - - - 2 - - 1 3 18 3 3 - 1 - 1 3 1 - 3 1 14 4 3 2 - - - 5 1 - 1 6 8 5 1 1 1 2 6 6 2 1 - 2 8 6 4 1 2 - - 2 - - 1 2 15 7. 1 3 2 - 1 2 - 2 4 5 9 8 - - - - - 1 - - 1 3 21 9 1 - - - - 2 - - 3 3 20 10 2 - - - - 6 1 1 2 3 13 11 - 3 1 1 2 6 1 - 4 4 7 12 2 1 - - 1 5 3 - 4 6 6 13 1 - - - - 11 - - 2 5 10 14 1 1 - - - 2 - - 3 20 15 1 - - 5 5 11 - - 4 2 -16 1 - 1 - 2 - - - 7 5 12 17 • 1 1 1 - - 2 - - 3 4 16 18 - - 1 - - 3 2 2 3 6 12 19 1 1 - - 1 3 - - - 4 18 20 - 2 - - 1 3 - - 2 1 18 21 - 1 - - 8 7 - 1 - 3 9 22 1 1 2 2 1 2 - 2 3 3 11 23 1 1 1 - - - - 2 3 5 16 24 1 1 - 1 - 4 - - 2 6 11 25 2 - - - 1 4 1 - - 4 16 26 - - - - - 1 1 1 1 3 21 27 1 - - 2 6 11 - - 2 - 5 28 - 1 1 - 1 4 2 1 3 6 10 29 2 - - - - - - - - 2 25 30 3 1 - 1 - - - - - 9 15 31 3 1 - 1 9 9 - - 1 2 2 32 3 2 2 2 - 2 2 1 2 4 8 33 2 - - - - 3 - 1 2 3 17 34 - 1 2 - - 5 - 1 1 7 12 35 - 3 - 1 - 9 - 1 1 3 10 36 - - 1 - - 7 - 1 2 7 11 37 5 - 1 1 1 8 1 - - 2 10 121. APPENDIX TABLE 6 Frequency of Nurse Ratings of S a t i s f a c t i o n with Primary Nursing Behaviours  Question S a t i s f a c t i o n Ratings Number i -5 , -4 , -3 , -2 , -1 0 , 1 , 2 , 3 , 4 , 5 i 1 1 2 - 2 3 - 1 2 6 11 2 3 1 1 - - 1 - - 1 4 18 3 - - 1 - - 1 - 1 2 2 22 4 - 1 1 - - 3 - - 1 2 21 5 1 1 1 - - - - - - 6 20 6 - 1 - - - 1 - - - 3 24 7 2 2 - 1 1 7 - - - 3 13 •8 - 1 - - - 3 - - - 3 - 22 9 1 1 - - - - - 1 2 7 17 10 1 - - - - - - 1 2 4 21 •11 2 - - - 1 4 - - 3 6 13 12 - - - - - 3 - - 2 2 22 13 - - - - - 3 - - - 2 24 14 - - 2 - - 1 - 1 3 3 19 15 - - - - - 1 - - 1 1 26 16 - - - - - - - - - 1 28 17 2 1 1 - - 3 - - 1 2 19 18 . - 1 - - - 3 - - 4 3 18 19 - 2 1 - - 1 - - 1 7 17 20 - 2 2 2 - 2 - 1 - 7 13 21 - - 1 - - 2 - - 2 7 17 22 - - - - - - - - 1 6 22 23 - 1 1 - - 3 - - 1 6 17 24 1 - - - - 4 - - - 2 22 25 - - - - - - - - - 3 26 26 2 4 - 1 - - - - - 10 12 27 - - 1 - - 3 - 1 1 1 22 28 2 - 1 - 1 2 - 1 2 3 17 29 1 2 - 1 - 2 - - 3 4 16 30 - - 1 - - - - - - 7 21 31 - 1 2 - - 4 - - 2 3 17 32 2 - - - - 2 - - 1 4 20 33 - - - - - 1 - - 1 1 26 34 2 - - - - 1 - - - 4 22 35 2 2 - - - - - - 3 4 18 36 1 2 - - - 7 - - 1 3 15 37 2 - 2 1 - 7 - - 2 2 13 38 1 3 - - - 4 - - 2 3 16 122. APPENDIX TABLE 7 Matched Behaviours From Nurses' and Patients' Questionnaire Patient Questionnaire Number  1 2 3 5 7 11 12 13 17 20 21 22 23 24 26 30 31 34 35 36 Nurse Que s t ionn a i r e Number 1 5 37 3 31 2 23 24 15 4 27 26 20 6 13 25 21 22 36 19 

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