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UBC Theses and Dissertations

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, U n i v e r s i t y o f 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 in THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING  We a c c e p t 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 p r e s e n t i n g t h i s  thesis  an advanced degree at the L i b r a r y s h a l l I  f u r t h e r agree  for  scholarly  by h i s of  the U n i v e r s i t y  make i t  written  thesis  of B r i t i s h for  the requirements  Columbia,  I agree  reference and  f o r e x t e n s i v e copying o f  this  It  for financial  is understood that copying or gain shall  permission.  Nursing  The U n i v e r s i t y o f B r i t i s h  2075 We.sbrook Place Vancouver, Canada V6T 1W5  October,  1 Q76  Columbia  not  for  that  study. thesis  purposes may b e granted b y the Head of my Department  Department of  Date  fulfilment of  freely available  that permission  representatives.  this  in p a r t i a l  or  publication  b e allowed without my  i. ABSTRACT  Primary n u r s i n g i s a system o f d e l i v e r i n g n u r s i n g c a r e when one nurse i s r e s p o n s i b l e and a c c o u n t a b l e f o r t h e assessment o f t h e p a t i e n t ' s needs as w e l l as t h e p l a n n i n g , implementing  and e v a l u a t i n g o f t h e n u r s i n g c a r e  throughout t h e p a t i e n t ' 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 a r e done i n  c o l l a b o r a t i o n w i t h t h e p a t i e n t and o t h e r members o f t h e h e a l t h team. T h i s system i s a r e l a t i v e l y r e c e n t development i n t h e f i e l d o f n u r s i n g . There has been l i t t l e  r e s e a r c h done t o e i t h e r d e s c r i b e o r e v a l u a t e  primary nursing, p a r t i c u l a r l y i n the area o f p s y c h i a t r y . an attempt  T h i s study was  t o i n c l u d e both p a t i e n t s and nurses i n such an e v a l u a t i o n .  A v a l i d a t e d and r e l i a b l e q u e s t i o n n a i r e was developed by t h e author t o o b t a i n d a t a r e l a t e d t o p a t i e n t s ' and nurses o c c u r r e n c e , importance behaviours.  1  perceptions o f the  and s a t i s f a c t i o n o f s p e c i f i c p r i m a r y n u r s i n g  The q u e s t i o n n a i r e was a d m i n i s t e r e d t o twenty-nine  and t h e i r p r i m a r y nurses d u r i n g t h e l a s t week o f t h e p a t i e n t ' s  patients hospitalization.  Nurses and p a t i e n t s r e p o r t e d t h a t p r i m a r y n u r s i n g b e h a v i o u r s t o d i s c h a r g e had a low o c c u r r e n c e r a t e . degree o f importance  However, they a t t r i b u t e d a h i g h  t o these same b e h a v i o u r s .  low o c c u r r e n c e and importance  related  Both groups r e p o r t e d a  score f o r primary nursing behaviours  r e l a t e d t o f a m i l y involvement w i t h t h e p r i m a r y nurse and t h e p a t i e n t ' s treatment program. Both nurses and p a t i e n t s agreed on t h e o c c u r r e n c e and importance o f most o f t h e p r i m a r y n u r s i n g b e h a v i o u r s .  There was l e s s agreement i n t h e  area o f s a t i s f a c t i o n .  ( T h e s i s Chairman)  ii. TABLE OF CONTENTS  CHAPTER I  II  III  IV  PAGE INTRODUCTION THE PURPOSE THE PROBLEM SIGNIFICANCE OF THE STUDY DEFINITIONS . ,.' ASSUMPTIONS HYPOTHESES DATA ANALYSIS LIMITATIONS DESIGN AND METHODOLOGY Development o f t h e Q u e s t i o n n a i r e Development o f t h e P a t i e n t P r o f i l e . . . . Administration o f the Questionnaire . . . Development o f t h e Chart C h e c k l i s t . . . . DEVELOPMENT OF CHAPTERS  1 2 2 3 6. 7 8 9 9 10 11 n 12 12 13  REVIEW OF THE LITERATURE DESCRIPTION OF PRIMARY NURSING Background R e l a t e d t o Primary N u r s i n g Models o f Primary N u r s i n g EVALUATION OF PRIMARY NURSING E v a l u a t i o n o f N u r s i n g Care E v a l u a t i o n o f Primary N u r s i n g  15 15 15 19 24 24 29  . .  DESIGN AND METHODOLOGY THE SETTING THE PARTICIPANTS Patients Nurses THE QUESTIONNAIRE THE DESIGN THE CHART CHECKLIST METHODOLOGY  36 36 37 37 38 39 42 44 44  DATA ANALYSIS AND RESULTS THE PATIENT PROFILE THE CHART CHECKLIST THE QUESTIONNAIRES Hypothesis 1 Hypothesis 2 Hypothesis 3 Hypothesis 4 Hypothesis 5 Hypothesis 6  50 50 51 53 53 54 55 57 58 60  iii.  V  SUMMARY CONCLUSIONS IMPLICATIONS RECOMMENDATIONS  BIBLIOGRAPHY APPENDICES Appendix A - I n f o r m a t i o n Given t o Primary Nurses Appendix B - Consent Forms Appendix C - C h a r t C h e c k l i s t Appendix D - P a t i e n t P r o f i l e Appendix E - Data from P a t i e n t P r o f i l e . . . . Appendix F - Method o f C a l c u l a t i n g t h e S a t i s f a c t i o n Scores Appendix G - P a t i e n t Q u e s t i o n n a i r e Appendix H - Nurse Q u e s t i o n n a i r e Appendix I - Appendix T a b l e s  65 65 69 70 73  77 81 83 85 87 89 91 104 115  iv. LIST OF TABLES  TABLES 4.1  4.2  4.3  4.4  4.5  4.6  PAGE Summary o f R e s u l t s Checklist  from t h e C h a r t 52  Summary o f t h e Spearman Rank Correlation Coefficients f o r Hypotheses 1, 2, 3  56  B e h a v i o u r s That Demonstrated Significant Differences i n Occurrence  58  C r i t i c a l Values f o r U i n the Mann-Whitney U T e s t  59  B e h a v i o u r s That Demonstrated Significant Differences i n Importance  60  B e h a v i o u r s That Demonstrated Significant Differences i n Satisfaction  62  V.  ACKNOWLEDGEMENTS  I would l i k e t o express my thanks t o t h e members o f my T h e s i s Committee:  Dr. Ruth Z i t n i k , Dr. J a c k Yensen, and Dr. T s u n g - Y i - L i n .  T h e i r p r a c t i c a l s u g g e s t i o n s and unending support and encouragement I v e r y much a p p r e c i a t e d . I would a l s o l i k e t o acknowledge my g r a t i t u d e t o t h e p a t i e n t s and nurses who completed A special  t h e q u e s t i o n n a i r e s f o r t h e study.  thanks t o my husband, David, whose i n f i n i t e p a t i e n c e  greatly facilitated  the completion o f t h i s  thesis.  CHAPTER I  INTRODUCTION  How and  can nurses b e s t d e l i v e r care t o p a t i e n t s ?  educators  n u r s i n g p r a c t i t i o n e r s have addressed t h i s q u e s t i o n w i t h i n  respective settings. nursing.  One  T h i s system o f d e l i v e r i n g n u r s i n g c a r e i s more than j u s t  the r e s p o n s i b i l i t y and he o r she The  their  answer has been the development o f p r i m a r y  r e v i s e d v e r s i o n o f the case method o f n u r s i n g .  it  Nursing  The  difference lies  a c c o u n t a b i l i t y o f the primary n u r s e f o r the  in care  gives. c e n t r a l focus o f p r i m a r y n u r s i n g i s the p a t i e n t .  seems l o g i c a l t o i n c l u d e the p a t i e n t i n any  primary nursing, p a r t i c u l a r l y  research  i f i t i s an e v a l u a t i v e  Consequently,  regarding  study.  Another r e a s o n f o r i n c l u d i n g the p a t i e n t i s the demand, by for  a  a v o i c e i n matters p e r t a i n i n g t o h e a l t h c a r e .  consumers,  Melvin Glasser,  p h y s i c i a n w r i t i n g about the consumer and h e a l t h c a r e ,  a  stated:  "The consumer has now a s s e r t e d h i m s e l f as the g r e a t e s t f o r c e f o r promoting change i n the h e a l t h c a r e f i e l d . Although he l o o k s t o the h e a l t h p r o f e s s i o n a l f o r t e c h n i c a l guidance, the consumer expects t o be p a r t o f the d e c i s i o n making p r o c e s s . " ^ At p r e s e n t ,  t h e r e has been l i t t l e r e s e a r c h done t o e i t h e r d e s c r i b e  or evaluate primary nursing.  This i s especially true i n psychiatry.  M. G l a s s e r , "Consumer E x p e c t a t i o n s o f H e a l t h S e r v i c e s " , M e d i c i n e i n a Changing S o c i e t y , eds. L. Corey and S. Saltman, (St. L o u i s : C.V. Mosby and Co., 1972), p. 29.  2. T h i s study attempted  t o both d e s c r i b e and e v a l u a t e t h e component o f  primary n u r s i n g .  THE  PURPOSE  The purpose o f t h i s study was t o d e v i s e a t o o l and t o g a t h e r d a t a r e g a r d i n g t h e p e r c e p t i o n s o f p a t i e n t s and primary nurses o f t h e o c c u r r e n c e and importance to  o f s p e c i f i c primary n u r s i n g b e h a v i o u r s , and  d i s c o v e r t h e degree t o which they were s a t i s f i e d w i t h p r i m a r y n u r s i n g .  T h i s was done i n an attempt t o generate r e s e a r c h d a t a t h a t would d e s c r i b e and e v a l u a t e p r i m a r y n u r s i n g , p a r t i c u l a r l y as i t i s p r a c t i s e d i n a psychiatric  setting.  THE  PROBLEM  T h i s study addressed i t s e l f t o t h e f o l l o w i n g questions»• 1.  Are t h e p r i m a r y n u r s i n g b e h a v i o u r s d e s c r i b e d i n t h e l i t e r a t u r e  c a r r i e d o u t by nurses i n t h e h o s p i t a l 2.  setting?  Do p a t i e n t s and n u r s e s a s s i g n t h e same importance  t o these  primary nursing behaviours? 3.  Are nurses and p a t i e n t s s a t i s f i e d w i t h p r i m a r y n u r s i n g as  a system o f d e l i v e r i n g and r e c e i v i n g n u r s i n g care? These q u e s t i o n s were e x p l o r e d by a d m i n i s t e r i n g a q u e s t i o n n a i r e t o p a t i e n t s and nurses d u r i n g t h e f i n a l week o f t h e p a t i e n t s '  hospitalization.  3. SIGNIFICANCE OF THE  STUDY  A l t h o u g h p r i m a r y n u r s i n g has been d e s c r i b e d i n the n u r s i n g  literature  f o r a number o f y e a r s , t h e r e have been few p u b l i c a t i o n s d e s c r i b i n g r e s e a r c h done i n t h i s area. contain questions The  Many o f the a r t i c l e s about p r i m a r y  t h a t can o n l y be answered and t e s t e d through r e s e a r c h .  i n v e s t i g a t o r was  unable t o d i s c o v e r r e s e a r c h t h a t v a l i d a t e d  t h a t primary n u r s i n g , as d e s c r i b e d i n the l i t e r a t u r e , was practised.  nursing  actually  I t i s a common phenomenon t h a t what p e o p l e say they do  what they a c t u a l l y do are sometimes d i f f e r e n t .  of the nursing behaviours  and  Consequently, t h e r e  seemed t o be a need t o determine i f p a t i e n t s and nurses p e r c e i v e d occurrence  being  the  d e s c r i b e d i n t h e l i t e r a t u r e as p a r t  o f primary nursing. The  i n v e s t i g a t o r was  a b l e t o d i s c o v e r o n l y l i m i t e d d a t a on  p e r c e p t i o n , by p a t i e n t s and n u r s e s , behaviours  o f t h e importance o f the  t h a t comprise p r i m a r y n u r s i n g .  the  nursing  Marram e t a l wrote t h a t  p a t i e n t s from d i f f e r e n t n u r s i n g u n i t s (team n u r s i n g , f u n c t i o n a l n u r s i n g , p r i m a r y n u r s i n g and case method nursing)  attached  importance t o d i f f e r e n t  2 nursing behaviours.  These behaviours  seemed t o r e l a t e more g e n e r a l l y  t o n u r s i n g r a t h e r than f o c u s i n g s p e c i f i c a l l y on p r i m a r y n u r s i n g . t h e r e are primary n u r s i n g b e h a v i o u r s  Perhaps  t h a t p a t i e n t s and nurses p e r c e i v e  as unimportant and t h e r e f o r e , perhaps, unnecessary. There have been a t l e a s t two s a t i s f a c t i o n with primary nursing.  s t u d i e s which have looked  at  Marram e t a l wrote t h a t both p a t i e n t s  G. Marram, M. S c h l e g e l , and E. B e v i s , Primary N u r s i n g , C.V. Mosby and Co., 1974), p. 127.  (St. L o u i s :  and nurses i n d i c a t e d g r e a t e r s a t i s f a c t i o n w i t h primary n u r s i n g than  3 w i t h team, f u n c t i o n a l o r case method n u r s i n g .  Daeffler's  findings  i n d i c a t e d a g r e a t e r degree o f s a t i s f a c t i o n w i t h p r i m a r y n u r s i n g as  4 compared t o team n u r s i n g . A major emphasis i n t h i s study was the e v a l u a t i o n o f t h e i r c a r e .  t h e involvement o f p a t i e n t s i n  As consumers and t a x p a y e r s i n a s o c i e t y  where h e a l t h c a r e demands a l a r g e p a r t o f t h e p r o v i n c i a l and  national  budget, they are demanding more say i n the a r e a o f t h e i r h e a l t h c a r e . I t i s important t h a t h e a l t h p r o f e s s i o n a l s , e s p e c i a l l y n u r s e s , respond t o t h e s e demands. One  o f the outcomes o f t h i s study was  t h e development o f a t o o l t o  t e s t p a t i e n t and nurse s a t i s f a c t i o n w i t h p r i m a r y n u r s i n g .  Many o f the  a r t i c l e s w r i t t e n about p r i m a r y n u r s i n g i n c l u d e d the o b s e r v a t i o n t h a t b o t h p a t i e n t s and nurses expressed " g r e a t s a t i s f a c t i o n " w i t h p r i m a r y  5 nursing. '  6 7 '  Marram e t a l and D a e f f l e r have s p e c i f i c a l l y examined  and measured p a t i e n t s a t i s f a c t i o n i n r e l a t i o n t o p r i m a r y n u r s i n g . Marram l o o k e d a t t h e n u r s e s ' response as w e l l .  Daeffler utilized  c h e c k l i s t developed by A b d e l l a h and L e v i n e and expressed the t h a t t h i s i n s t r u m e n t had l i m i t e d v a l u e i n measuring 3  the  thought  s a t i s f a c t i o n with care.  I b i d . , p. 132.  4 R. D a e f f l e r , " P a t i e n t s ' P e r c e p t i o n o f Care under Team and P r i m a r y N u r s i n g " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V, 3 (1975), pp. 20-26.  5  K.L. C i s k e , "Primary N u r s i n g : An O r g a n i z a t i o n That Promotes P r o f e s s i o n a l P r a c t i c e " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , IV, 1 (1974),  pp. 28-31.  ^ A. Logsdon, "Why Primary N u r s i n g ? " , N u r s i n g C l i n i c s o f N o r t h XXVIII, 2 (1973), pp. 283-291.  America,  7 M. Manthey, "Primary N u r s i n g i s A l i v e and W e l l i n the H o s p i t a l " , American J o u r n a l o f N u r s i n g , LXXIII, 1 (1973), pp. 83-87.  Q  R. D a e f f l e r , op. c i t . , p . 26.  5. Marram e t a l f o c u s s e d  on the d e s c r i p t i o n o f the r e s u l t s o f t h e i r  r e s e a r c h and gave l i t t l e d a t a i n terms o f t h e i r measurement t o o l s or  9 methodology. instruments, provide  I t seems t h e r e i s a need t o develop v a l i d and which r e f l e c t t h e p r o c e s s  reliable  o f p r i m a r y n u r s i n g and  also  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 t h a t might be c r e a t e d t o i n v e s t i g a t e t h i s The  area.  development o f the q u e s t i o n n a i r e u t i l i z e d i n t h i s  study  n e c e s s i t a t e d the i d e n t i f i c a t i o n o f t h e s p e c i f i c b e h a v i o u r s i n primary n u r s i n g .  incorporated  Such an i d e n t i f i c a t i o n c o u l d f a c i l i t a t e  the  comparison o f p r i m a r y n u r s i n g w i t h o t h e r systems o f d e l i v e r i n g care.  nursing  T h i s might be done by a d m i n i s t e r i n g t h e primary n u r s i n g  q u e s t i o n n a i r e i n a u n i t t h a t p r a c t i s e d p r i m a r y n u r s i n g and  in a unit  t h a t u t i l i z e d another n u r s i n g approach, such as team n u r s i n g , comparing t h e  and  results.  T h i s study  attempted t o show which p r i m a r y n u r s i n g  p a t i e n t s and nurses r a t e as important.  behaviours  T h i s i n f o r m a t i o n may  i m p l i c a t i o n s f o r the p r a c t i c e o f p r i m a r y n u r s i n g .  have  I t c o u l d be  viewed  as v a l i d a t i o n f o r what i s c u r r e n t l y b e i n g p r a c t i s e d or as a guide f o r p l a n n e d change from a d i f f e r e n t system o f n u r s i n g , such as f u n c t i o n a l nursing, to primary nursing. change  I t may  a l s o g i v e d i r e c t i o n f o r planned  w i t h i n the system o f p r i m a r y n u r s i n g .  e l i m i n a t i o n of primary nursing behaviours nurses p e r c e i v e d as  Marram e t a l . , op.  important.  c i t . , pp.  125-157.  An  example would be  that neither patients  nor  the  6. DEFINITIONS  The  f o l l o w i n g terms a r e d e f i n e d a c c o r d i n g t o t h e i r use i n t h i s  investigation. Primary n u r s i n g :  a system o f d e l i v e r i n g n u r s i n g c a r e when one  nurse i s r e s p o n s i b l e and a c c o u n t a b l e  f o r t h e assessment o f  the p a t i e n t ' s needs as w e l l as t h e p l a n n i n g , and  implementing  e v a l u a t i n g o f t h e n u r s i n g care throughout the p a t i e n t ' s  hospitalization.  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  w i t h t h e p a t i e n t and o t h e r members o f t h e h e a l t h team. R e g i s t e r e d nurse:  any nurse who i s c u r r e n t l y r e g i s t e r e d w i t h t h e  R e g i s t e r e d Nurses' A s s o c i a t i o n o f B r i t i s h Accountable:  Columbia.  t h e nurse's v e r b a l o r w r i t t e n j u s t i f i c a t i o n o r  explanation o f h i s o r her nursing decisions t o the patient, p e e r s and s u p e r v i s o r s . Responsible:  t h e nurse's o b l i g a t i o n t o a s s e s s t h e p a t i e n t ' s needs,  and t o p l a n , implement and e v a l u a t e  the nursing care  given  throughout t h e h o s p i t a l i z a t i o n . Satisfaction:  an a t t i t u d e which can be expressed  congruence between t h e o c c u r r e n c e nursing behaviours Psychiatric resident: education  as t h e degree o f  and importance o f c e r t a i n  as measured on t h e q u e s t i o n n a i r e . a medical  d o c t o r who i s r e c e i v i n g f u r t h e r  and t r a i n i n g t o 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 p e r s o n who i s r e s p o n s i b l e f o r t h e p a t i e n t ' s  treatment program w h i l e t h e p a t i e n t i s i n h o s p i t a l . may be a nurse, medical  student,  T h i s person  a s o c i a l worker, a p s y c h i a t r i c r e s i d e n t , a or a psychiatrist.  A s s o c i a t e nurse:  a member o f t h e n u r s i n g s t a f f who a s s i s t s t h e  primary nurse by g i v i n g c a r e t o a p a t i e n t when t h a t p a t i e n t ' s p r i m a r y nurse i s o f f d u t y .  T h i s person may be a r e g i s t e r e d  nurse o r p s y c h i a t r i c a s s i s t a n t . Psychiatric assistant:  a member o f t h e n u r s i n g s t a f f whose main  f u n c t i o n i s t o organize  and encourage p a r t i c i p a t i o n i n t h e  a c t i v i t y and r e c r e a t i o n program o f t h e h o s p i t a l . J u n i o r care co-ordinator:  a primary nurse who has assumed  a d d i t i o n a l a d m i n i s t r a t i v e and t e a c h i n g r e s p o n s i b i l i t i e s a t the ward  level.  ASSUMPTIONS  I t was assumed t h a t : a.  a l l nurses designated  as p r i m a r y nurses w i t h i n t h e  i n s t i t u t i o n where t h e study took p l a c e would be p r a c t i s i n g p r i m a r y n u r s i n g , because p r i m a r y n u r s i n g was p a r t o f the philosophy b.  o f the nursing  facility;  p r i m a r y n u r s i n g can be d e s c r i b e d by s p e c i f i c  observable  behaviours; c.  p r i m a r y n u r s i n g can be measured through t h e a d m i n i s t r a t i o n  of a questionnaire; d.  p a t i e n t s and nurses can and w i l l express s a t i s f a c t i o n o r  d i s s a t i s f a c t i o n with primary nursing behaviours by a q u e s t i o n n a i r e .  as measured  8.  HYPOTHESES A l t h o u g h t h i s was a d e s c r i p t i v e study, s i x hypotheses. (1)  These were: t h e r e i s no c o r r e l a t i o n  nurses'  between the p a t i e n t s ' and t h e  p e r c e p t i o n o f t h e occurrence  nursing behaviours (2)  i t was p o s s i b l e t o i d e n t i f y  of the itemized primary  i n c l u d e d on t h e s a t i s f a c t i o n  t h e r e i s no c o r r e l a t i o n  questionnaire;  between the n u r s e s '  and t h e  p a t i e n t s ' r a t i n g s o f the importance o f t h e i t e m i z e d p r i m a r y nursing behaviours (3)  i n c l u d e d on the s a t i s f a c t i o n  t h e r e i s no c o r r e l a t i o n  questionnaire;  between t h e n u r s e s '  s c o r e s f o r s a t i s f a c t i o n w i t h the i t e m i z e d primary behaviours (4)  i n c l u d e d on t h e s a t i s f a c t i o n  and p a t i e n t s ' nursing  questionnaire;  t h e r e 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 t h e p a t i e n t s '  and n u r s e s '  p e r c e p t i o n o f the occurrence  o f each s p e c i f i c  p r i m a r y n u r s i n g b e h a v i o u r i n c l u d e d on t h e s a t i s f a c t i o n questionnaire; (5)  t h e r e 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 p a t i e n t s '  and t h e n u r s e s '  r a t i n g s o f t h e importance o f each s p e c i f i c  primary nursing behaviour.included  on t h e s a t i s f a c t i o n  questionnaire; (6)  t h e r e 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 t h e n u r s e s '  and p a t i e n t s  1  s c o r e s f o r s a t i s f a c t i o n w i t h each s p e c i f i c  p r i m a r y n u r s i n g b e h a v i o u r i n c l u d e d on t h e s a t i s f a c t i o n questionnaire.  9.  DATA ANALYSIS  The  f i r s t t h r e e hypotheses were t e s t e d u s i n g t h e Spearman Rank  Correlation Coefficient.  The  chi-square  Student's t t e s t was  analysis.  The  f o u r t h hypothesis  was  tested using a  used t o  analyse  hypotheses f i v e and s i x .  LIMITATIONS  The p r i m a r y nurses answered the q u e s t i o n n a i r e more than once. To decrease t h e i r f a m i l i a r i t y w i t h the q u e s t i o n n a i r e , the o r d e r o f  the  questions  was  was  a l t e r e d each time t h e primary nurse responded.  done by randomly o r d e r i n g the q u e s t i o n s questionnaires.  Each page o f the q u e s t i o n n a i r e was  ensure t h a t q u e s t i o n s  i n close proximity.  q u e s t i o n n a i r e s which c o n t a i n e d  then checked t o  The  r e s u l t was  the same q u e s t i o n s  the three  in different  order.  assumed t h a t s i n c e t h e r e were o n l y twenty-nine p a t i e n t s , the  nurses would p r o b a b l y times.  different  t e s t i n g the i n t e r n a l consistency of  q u e s t i o n n a i r e were not  I t was  f o r the t h r e e  This  complete the q u e s t i o n n a i r e no more than  I f they d i d respond more than t h r e e t i m e s ,  complete a q u e s t i o n n a i r e which was p e r i o d o f time t h a t had I t was  they would  three still  somewhat u n f a m i l i a r because o f  the  e l a p s e d s i n c e they had p r e v i o u s l y completed i t .  not f e a s i b l e t o c o n t r o l f o r the p o s s i b l e Hawthorne e f f e c t  o f t h e presence o f t h e i n v e s t i g a t o r .  T h i s may  have i n f l u e n c e d the  n u r s i n g s t a f f t o more c o n s i s t e n t l y and c o n s c i e n t i o u s l y p r a c t i s e the primary nursing behaviours.  However, from d i s c u s s i o n w i t h t h e  staff  10.  conducted p r i o r t o t h e i n t r o d u c t i o n o f t h e r e s e a r c h on t h e u n i t , t h e Hawthorne e f f e c t would appear t o be r e l a t i v e l y i n s i g n i f i c a n t . n u r s i n g s t a f f seemed t o have a good u n d e r s t a n d i n g  The  o f primary nursing  which was v e r y c o n s i s t e n t w i t h t h e l i t e r a t u r e and was i n o p e r a t i o n p r i o r t o the i n t r o d u c t i o n o f the i n v e s t i g a t i o n . The  q u e s t i o n n a i r e was p r e - t e s t e d and u t i l i z e d i n a p s y c h i a t r i c  setting.  T h i s may l i m i t t h e g e n e r a l i z a t i o n o f t h e f i n d i n g s t o p a t i e n t s  and nurses i n o t h e r areas  even though t h e p r i m a r y n u r s i n g  behaviours  i n c l u d e d i n t h e q u e s t i o n n a i r e were n o t s p e c i f i c t o p s y c h i a t r i c n u r s i n g . Another l i m i t a t i o n was t h e time o f t h e y e a r d u r i n g which t h e study was conducted. on v a c a t i o n . primary  During  J u l y and August some o f t h e n u r s i n g s t a f f were  T h i s meant t h a t o c c a s i o n a l l y a p a t i e n t may have had two  nurses.  DESIGN AND METHODOLOGY  The d e s i g n and methodology were t h e v e h i c l e s f o r o p e r a t i o n a l i z i n g the concepts which have been d i s c u s s e d e a r l i e r  i n the chapter.  This  was a d e s c r i p t i v e study which took p l a c e on a twenty-two bed u n i t o f 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 o v e r a t h r e e month p e r i o d o f t i m e . E l e v e n nurses and twenty-nine p a t i e n t s were i n v o l v e d . and  Both t h e p a t i e n t  t h e p r i m a r y nurse were g i v e n a q u e s t i o n n a i r e d u r i n g t h e l a s t week o f  the p a t i e n t ' s h o s p i t a l i z a t i o n .  Each was asked t o i n d i c a t e whether o r n o t  s p e c i f i c primary n u r s i n g b e h a v i o u r s  occurred during the patient's  h o s p i t a l i z a t i o n and t o r a t e t h e importance they a t t a c h e d t o those particular  behaviours.  11.  P r i o r t o the commencement o f the r e s e a r c h , the i n v e s t i g a t o r met w i t h the n u r s i n g s t a f f t o d i s c u s s w i t h them t h e i r understanding p r i m a r y n u r s i n g and how  they p r a c t i s e d i t . As the  study was  conducted, the i n v e s t i g a t o r a l s o monitored the c h a r t s . a c t i o n s were measures o f  Development o f the  these  Questionnaire  f o r p a t i e n t s , one  f o r nurses.  q u e s t i o n n a i r e s were The  whether o r not c e r t a i n primary n u r s i n g b e h a v i o u r s important  being  validity.  In o r d e r t o measure the v a r i a b l e s , two developed; one  Both  of  they were.  The b e h a v i o u r s  d e s c r i b i n g p r i m a r y n u r s i n g , and  questionnaires occurred  were s e l e c t e d from  and  asked how  literature  from the i n v e s t i g a t o r ' s e x p e r i e n c e  w i t h t h i s system o f d e l i v e r i n g n u r s i n g c a r e .  Content v a l i d i t y  e s t a b l i s h e d by s u b m i t t i n g the q u e s t i o n n a i r e t o a p a n e l o f f i v e  was judges,  a l l o f 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 The  approach.  q u e s t i o n n a i r e s were p r e - t e s t e d by a d m i n i s t e r i n g them t o p a t i e n t s  and nurses on a u n i t w i t h i n t h e h o s p i t a l t h a t was study.  R e l i a b i l i t y was  of s t a b i l i t y .  not i n c l u d e d i n the  determined by the t e s t r e - t e s t method, a measure  I n t e r n a l c o n s i s t e n c y was  measured by  including several  q u e s t i o n s which addressed the same i s s u e .  Development o f the P a t i e n t P r o f i l e Previous  r e s e a r c h has  shown t h a t o l d e r p a t i e n t s tend t o r e p o r t more  s a t i s f a c t i o n w i t h n u r s i n g care than do younger p a t i e n t s . " ^  W. Raphael, "Do We Know What P a t i e n t s Think?", o f N u r s i n g S t u d i e s , IV, 3 (1967), p. 214.  Patients  International Journal  12.  who have been n u r s e d under p r i m a r y n u r s i n g seem t o have d i f f e r e n t expectations  o f t h e n u r s i n g care they receive.'''  i f e i t h e r o f these study, and  1  In order t o a s c e r t a i n  two v a r i a b l e s were i n f l u e n c i n g the r e s u l t s o f the  a b r i e f p a t i e n t p r o f i l e was developed i n t h e form o f a c h e c k l i s t  attached  t o the f r o n t of the p a t i e n t s questionnaire. 1  A d m i n i s t r a t i o n o f the Q u e s t i o n n a i r e P r i o r t o the d i s t r i b u t i o n o f the questionnaires, the i n v e s t i g a t o r d i s c u s s e d w i t h t h e s t a f f nurses t h e i r p e r c e p t i o n and p r a c t i c e o f p r i m a r y nursing.  T h i s was done t o ensure v a l i d i t y by e s t a b l i s h i n g the b a s i c  parameters o f primary n u r s i n g i n t h e minds o f t h e nurses and t h e r e b y encouraging i t s p r a c t i c e .  By a g r e e i n g w i t h t h e p r i m a r y n u r s i n g  i d e n t i f i e d from t h e l i t e r a t u r e f o r t h e q u e s t i o n n a i r e , t h e n u r s i n g  behaviours staff  contributed t o the face v a l i d i t y o f the questionnaire. The q u e s t i o n n a i r e was g i v e n t o t h e p a t i e n t d u r i n g the week o f h i s or h e r d i s c h a r g e .  The p a t i e n t ' s primary nurse completed a q u e s t i o n n a i r e  d u r i n g t h i s same time p e r i o d . The  i n v e s t i g a t o r administered  given to p a t i e n t s .  a l l t h e q u e s t i o n n a i r e s t h a t were  T h i s i n c l u d e d a b r i e f d e s c r i p t i o n o f t h e study and  t h e statement t h a t t h e p a t i e n t ' s completion  o f t h e q u e s t i o n n a i r e was  v o l u n t a r y and t h a t he o r she c o u l d withdraw a t any t i m e .  Development o f t h e Chart C h e c k l i s t As an a d d i t i o n a l measurement o f v a l i d i t y , t h e i n v e s t i g a t o r monitored the c h a r t s d u r i n g t h e t h r e e months t h e study was conducted.  Marram e t a l . , op. c i t . , p. 133.  A checklist  13.  was developed from t h e q u e s t i o n n a i r e and i n c l u d e d e l e v e n nursing behaviours chart monitoring  primary  t h a t c o u l d be i d e n t i f i e d through t h e c h a r t i n g .  The  was g r e a t l y f a c i l i t a t e d by t h e f a c t t h a t t h e u n i t was  u s i n g problem o r i e n t e d r e c o r d i n g .  12  DEVELOPMENT OF CHAPTERS This f i r s t  chapter provided  an overview o f t h e study.  I t introduced  the problem o f t h e l a c k o f r e s e a r c h d e s c r i b i n g and e v a l u a t i n g p r i m a r y nursing.  I t d e s c r i b e d t h e development o f a t o o l t o g a t h e r  p a t i e n t s ' and n u r s e s '  p e r c e p t i o n s o f the occurrence  s p e c i f i c primary nursing behaviours nursing.  and importance o f  and t h e i r s a t i s f a c t i o n w i t h  primary  The i n c l u s i o n o f i n p u t from p a t i e n t s r e g a r d i n g t h e e v a l u a t i o n  o f p r i m a r y n u r s i n g was a major The  data about  focus.  second c h a p t e r was a review o f t h e l i t e r a t u r e .  main areas o f i n t e r e s t and r e l e v a n c e .  There were two  The f i r s t was p r i m a r y n u r s i n g as  d e f i n e d and d e s c r i b e d by s e v e r a l authors  and t h e second was t h e  e v a l u a t i o n o f p r i m a r y n u r s i n g by b o t h nurses and p a t i e n t s . Chapter Three d e s c r i b e d the d e s i g n and methodology o f t h e i n v e s t i g a t i o n . The  emphasis was on t h e d e s c r i p t i o n o f t h e q u e s t i o n n a i r e , t h e t e c h n i q u e s  o f t h e d a t a c o l l e c t i o n and t h e methods f o r a n a l y z i n g the d a t a . The  a n a l y s i s and i n t e r p r e t a t i o n o f t h e d a t a were i n Chapter Four.  The  f i n a l c h a p t e r was a summary o f t h e e n t i r e study  i n c l u d i n g the  c o n c l u s i o n s and recommendations which were a r e s u l t o f t h e i n v e s t i g a t i o n .  L. Weed, "Medical Records That Guide and Teach", The New England J o u r n a l o f Medicine, CCLXXVIII, 11 (1968) pp. 593-599.  14.  These f i v e c h a p t e r s  comprise the body o f the study.  a d e s c r i p t i o n o f t h e major r e s e a r c h concepts, those  They i n c l u d e  the o p e r a t i o n a l i s m o f  c o n c e p t s i n t h e d e s i g n and methodology and the i m p l i c a t i o n s o f  t h e r e s u l t s and c o n c l u s i o n s .  15.  CHAPTER I I  REVIEW OF THE  T h i s study was The  LITERATURE  an attempt to d e s c r i b e and e v a l u a t e p r i m a r y  l i t e r a t u r e review f o c u s s e d on two  n u r s i n g and The  areas:  nursing.  a d e s c r i p t i o n o f primary  a d i s c u s s i o n o f the e v a l u a t i o n o f p r i m a r y n u r s i n g .  d e s c r i p t i o n o f p r i m a r y n u r s i n g has  included a b r i e f discussion  o f the background t h a t l e d t o the development o f t h i s system o f d e l i v e r i n g nursing care.  I t a l s o contains a d e s c r i p t i o n o f the  two  major models t h a t are used as frameworks i n o p e r a t i o n a l i z i n g the o f primary The  concepts  nursing.  d i s c u s s i o n o f the e v a l u a t i o n o f p r i m a r y n u r s i n g began w i t h  d e s c r i p t i o n of previous  r e s e a r c h 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 o f measurement i n e v a l u a t i n g n u r s i n g c a r e .  Articles  s t u d i e s r e l a t e d more s p e c i f i c a l l y t o the e v a l u a t i o n o f p r i m a r y were a l s o p r e s e n t e d  and  a  and  nursing  discussed.  DESCRIPTION OF PRIMARY NURSING  Background R e l a t e d t o Primary  Nursing  There appeared t o be a t l e a s t two development o f p r i m a r y n u r s i n g .  The  f o r c e s which c o n t r i b u t e d t o t h e  attempt, by n u r s e s ,  more p r o f e s s i o n a l i n the p r a c t i c e o f n u r s i n g was  t o become  seen as one  G. Marram, M. S c h l e g e l , and E. B e v i s , Primary N u r s i n g , C.V. Mosby S Co., 1974), p. 8.  force.  1  (St. L o u i s :  16.  A second f o r c e was  the d e s i r e o f nurses t o change the b u r e a u c r a c y t h a t 2  is  found i n most i n s t i t u t i o n s m  the b u r e a u c r a t i c the  system c o u l d be  which n u r s e s p r a c t i s e .  A change i n  seen as f a c i l i t a t i n g an i n c r e a s e i n  l e v e l o f s a t i s f a c t i o n o f b o t h nurses and p a t i e n t s w i t h n u r s i n g  T h i s c o u l d be accomplished by d e c r e a s i n g the b u r e a u c r a t i c  care.  the r i g i d i t y t h a t accompanies  system o f management.  Marram, S c h l e g e l and B e v i s d i s c u s s e d  the i s s u e o f p r o f e s s i o n a l i s m  3 i n the opening c h a p t e r  o f t h e i r book, P r i m a r y N u r s i n g .  In t h i s  chapter  they have l i s t e d the e s s e n t i a l i n g r e d i e n t s f o r p r o f e s s i o n a l i s m . the i n g r e d i e n t s i s autonomy, a q u a l i t y they t h i n k i s not abundance i n the p r o f e s s i o n o f n u r s i n g . until  autonomy was  as a way  found i n  These t h r e e a u t h o r s s t a t e d t h a t  t h e i r own 4  adequate s e r v i c e s t o consumers.  needs as a p r o f e s s i o n o r t o  They d e s c r i b e d p r i m a r y  nursing  o f p r o v i d i n g more autonomy by making the nurse r e s p o n s i b l e  a c c o u n t a b l e f o r the n u r s i n g care he o r she  and  gives.  Marlene Kramer i n v e s t i g a t e d t h e e f f e c t s o f exposure t o a  bureaucratic 5  system on the p r o f e s s i o n a l v a l u e s o f r e c e n t c o l l e g i a t e graduate Using  of  i n c o r p o r a t e d i n t o the system o f n u r s i n g p r a c t i c e ,  nurses would be unable t o f u l f i l l  provide  One  the Corwin p r o f e s s i o n a l - b u r e a u c r a t i c r o l e c o n c e p t i o n  and  nurses. role  d e p r i v a t i o n s c a l e s ^ which p r o v i d e d a measure o f the p r o f e s s i o n a l I b i d . , p. 5. I b i d . , pp. 6-9. I b i d . , p. 7.  and  5 M. Kramer, R e a l i t y Shock, pp. 22-23.  (St. L o u i s :  C.V.  Mosby & Co.,  1974),  ^ R. Corwin, "Role C o n c e p t i o n and M o b i l i t y A s p i r a t i o n : A Study i n the F o r m a t i o n & T r a n s f o r m a t i o n o f N u r s i n g I d e n t i t i e s " , (unpublished d o c t o r a l d i s s e r t a t i o n , U n i v e r s i t y o f Minnesota, 1960, Department o f S o c i o l o g y ) c i t e d by M. Kramer, R e a l i t y Shock, (St. L o u i s : C.V. Mosby & Co., 1974), p. 22.  17.  b u r e a u c r a t i c v a l u e s h e l d by the respondent, Kramer t e s t e d the new graduates one month p r i o r t o g r a d u a t i o n , employment.  She r e p o r t e d  and t h r e e and s i x months  after  ". . . a s i g n i f i c a n t i n c r e a s e i n b u r e a u c r a t i c 7  r o l e conception "...  a f t e r exposure t o the employing o r g a n i z a t i o n "  a c o n t i n u a l drop i n the p r o f e s s i o n a l r o l e c o n c e p t i o n  the f i r s t  s i x months a f t e r employment."  and  scales during  Kramer viewed these  results  as an i n d i c a t i o n t h a t some nurses become l e s s p r o f e s s i o n a l w i t h 9 continued  employment.  C i s k e , i n h e r a r t i c l e d e s c r i b i n g the development and implementation o f p r i m a r y n u r s i n g a t the U n i v e r s i t y o f Minnesota H o s p i t a l , d e s c r i b e d i n c r e a s e d p r o f e s s i o n a l i s m on t h e p a r t o f t h e n u r s e as a major g o a l o f primary n u r s i n g .  1 0  She d e s c r i b e d p r i m a r y n u r s i n g as a way ". . . t o  make i t p o s s i b l e t o p r a c t i s e n u r s i n g a t a h i g h e r 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 f o r c e , a d e s i r e t o change the b u r e a u c r a c y , 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 r e p o r t e d t h a t new graduate n u r s e s , working i n h o s p i t a l s e t t i n g s , experience  d i s c r e p a n c i e s between the i d e a l concept o f a nurse  as a student  learned  and t h e i r p e r c e p t i o n o f t h e i r own r o l e performance.  M. Kramer, op. c i t . , p. 22. 8  Ibid.  9 . I b i d . , pg. 23.  K.L. C i s k e , "Primary N u r s i n g : An O r g a n i z a t i o n That Promotes P r o f e s s i o n a l P r a c t i c e " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , IV, 1 (1974), pp. 28-30. 1  0  1  1  I b i d . , p. 28.  12 N. B e r k o w i t z and M. Malone, " 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 " , Forum, V I I , 1 (1968), pp. 50-71.  Nursing  18.  The  authors described  B e r k o w i t z and  t h i s discrepancy  13  Malone suggested t h a t a f a c t o r c o n t r i b u t i n g t o  e x p e r i e n c e o f r o l e d e p r i v a t i o n was hospital.  as r o l e d e p r i v a t i o n .  In o r d e r  the  the r e s t r i c t i v e environment o f  the  t o d e a l w i t h t h i s , Berkowitz and Malone suggested 14  t h a t the i d e a l must be m a i n t a i n e d and nursing  allows  the r e a l i t y changed.  n u r s e s t o f u n c t i o n i n a way  idea of nursing  learned  as n u r s i n g  Primary  that i s s i m i l a r to  the  students.  In an a r t i c l e w r i t t e n about n u r s i n g  and p a t i e n t c a r e ,  L u c i l l e Brown d e s c r i b e d the h o s p i t a l o r g a n i z a t i o n as  Esther  a  ". . . system t h a t tends t o decrease i n i t i a t i v e and m o t i v a t i o n , encourages dependency, f e e l i n g s o f 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 powerf u l and p e r v a s i v e enough t o ' suck.in'many w e l l p r e p a r e d young n u r s e s whom n u r s i n g e d u c a t o r s were c o u n t i n g on t o i n t r o d u c e needed changes. She  described  the  system as t a s k o r i e n t e d r a t h e r than p a t i e n t  oriented.  Her p o i n t o f view i s echoed by Marram, S c h l e g e l and B e v i s , t h e i r book, Primary Nursing."*"^  They d e s c r i b e d  as a system t h a t i s i n f l e x i b l e and  "  I B I D  ->  P-  a system t h a t promotes  17 to maintain o r g a n i z a t i o n a l s u r v i v a l .  61.  "  I b i d . , p.  system  slow t o change, a system t h a t i s  not open t o e x p e r i m e n t a t i o n o r i n n o v a t i o n , s t a b i l i t y i n order  the b u r e a u c r a t i c  in  This  65.  15 E.L. Brown, "Nursing and P a t i e n t Care", The Five S o c i o l o g i c a l E s s a y s , ed., F. D a v i s , (New & Sons Inc., 1 9 6 6 ) , p. 1 9 5 . 16 Marram e t a l . , op. c i t . , pp. 9-14. 17  I b i d . , pp.  17-18.  Nursing Profession, York: John W i l e y  19.  r e s t r i c t e d environment  c r e a t e s c o n f l i c t w i t h i n nurses who  t o respond t o p a t i e n t s as i n d i v i d u a l s . w i t h i n p a t i e n t s who  are t r y i n g  I t creates d i s s a t i s f a c t i o n  are n o t g e t t i n g t h e i r needs as i n d i v i d u a l s  met.  Primary n u r s i n g changes some o f the b u r e a u c r a t i c management by encouraging n u r s e s t o p r o v i d e c o n t i n u i t y o f c a r e , t o take  responsibility  f o r t h e i r n u r s i n g b e h a v i o u r s , and t o respond t o the p a t i e n t as an important  individual.  Models o f Primary N u r s i n g A c c o r d i n g t o t h e l i t e r a t u r e , the concept o f p r i m a r y n u r s i n g i s 18 o p e r a t i o n a l i z e d u s i n g two  d i f f e r e n t models.  a t t h e U n i v e r s i t y o f Minnesota H o s p i t a l .  One  i s the model used  The o t h e r i s used i n  New  York a t the Loeb C e n t e r f o r N u r s i n g and R e h a b i l i t a t i o n and a t t h e Long I s l a n d Jewish General H o s p i t a l .  The main d i f f e r e n c e between these  two models i s i n t h e l e v e l o f p r e p a r a t i o n o f the p e r s o n who p r i m a r y nurse r o l e .  assumes the  A t the U n i v e r s i t y o f Minnesota H o s p i t a l , a p r i m a r y  nurse can be a l i c e n s e d p r a c t i c a l n u r s e .  At the Loeb C e n t e r and the  Long I s l a n d Jewish G e n e r a l , the p r i m a r y nurse must be a r e g i s t e r e d nurse. The term "primary n u r s i n g " f i r s t appeared i n n u r s i n g l i t e r a t u r e i n 1970 w i t h the p u b l i c a t i o n o f an a r t i c l e by Manthey, C i s k e , Robertson 19 and H a r r i s c a l l e d ,  "Primary N u r s i n g " .  d e s c r i b e d p r i m a r y n u r s i n g as i t was  In t h i s a r t i c l e t h e authors  p r a c t i s e d a t the U n i v e r s i t y o f  S. C a r l s o n , book review on Primary N u r s i n g by Marram e t a l . , American J o u r n a l o f N u r s i n g , LXXV, 3 (1975), p. 514. 19 M. Manthey e t a l . , 1 (1970), pp. 65-83.  "Primary N u r s i n g " , N u r s i n g Forum,  XIV,  20.  Minnesota H o s p i t a l . nurse as (1)  Manthey e t a l d e s c r i b e d t h e d u t i e s o f t h e p r i m a r y  assessment o f t h e p a t i e n t , (2)  care p l a n f o r t h e p a t i e n t , (3)  development o f a n u r s i n g  involving the patient i n h i s or her 20  c a r e , and (4)  preparation o f the p a t i e n t f o r discharge.  In o r d e r  t o do t h i s , t h e p r i m a r y nurse c a r e d f o r t h e p a t i e n t each s h i f t t h a t he or she was on duty u n t i l t h e ' p a t i e n t was d i s c h a r g e d .  Another  responsibility,  r e p o r t e d by C i s k e i n h e r a r t i c l e d e s c r i b i n g p r i m a r y n u r s i n g , was " . . . care g i v e r t o care g i v e r communication, b o t h i n t h e n u r s i n g s t a f f ' s 21 d a i l y r e p o r t i n g methods, and between d i s c i p l i n e s . " She a l s o r e p o r t e d t h a t t h e p r i m a r y nurse t r i e d t o h e l p t h e p a t i e n t i d e n t i f y g o a l s i n r e l a t i o n t o how t h e m e d i c a l  c o n d i t i o n might a f f e c t h i s o r h e r l i f e  22 style.  The p r i m a r y nurse might care f o r t h r e e t o s i x p a t i e n t s .  The  assignment o f p a t i e n t s t o p r i m a r y nurses was made on t h e b a s i s o f the i n d i v i d u a l n u r s e ' s a b i l i t y t o g i v e t h e k i n d o f care needed by a 23 patient.  T h i s d e c i s i o n was made by t h e head nurse who a l s o took  i n t o account t h e nurse's i n t e r e s t , p a t i e n t l o a d and s p e c i a l  abilities.  I b i d . , pp. 70-71. 21 K.L. C i s k e , "Primary N u r s i n g : An O r g a n i z a t i o n That Promotes P r o f e s s i o n a l P r a c t i c e " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , IV, 1 (1974), p . 29. 22 Loc. c i t . 23 24  M. Manthey e t a l . , op. c i t . , p . 70. I b i d . , pp. 71-72.  24  21.  Both the Loeb Center and the Long Island Jewish General have based t h e i r philosophy of nursing care on the philosophy of Lydia H a l l , a former d i r e c t o r of nursing at the Loeb Center.  Lydia H a l l  saw  nursing as composed of: " . . . three overriding c i r c l e s , 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 d i s c i p l i n e s , " The f i r s t c i r c l e i s that of nurturing.  Lydia H a l l viewed t h i s  aspect as exclusive to the nursing profession.  She described nurturing  as an interpersonal process which also included " . . . bodily care of patients . . . , "  26  the intimate  In summarizing t h i s aspect of nursing  she wrote: "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  The second c i r c l e i s shared with the medical profession. the tasks delegated to nurses by the medical profession.  I t involves  The main focus 28  i n t h i s part of the nursing process i s " . . .  to avoid paining  ..."  as opposed to the previous goal of comfort. The t h i r d c i r c l e involves the nurse t r e a t i n g the patient as a "whole person".  In order to do t h i s , the nurse must learn to use h i s  or her s e l f therapeutically. This c i r c l e i s shared with a l l professionals. L . H a l l , "Nursing - What Is I t ? " . The Canadian Nurse, LX, 2 (1964), p. 150. 2 5  26 29  Ibid. Ibid  27  Ibid  pp. 152-153.  p.  151.  28  Ibid  p.  153.  C a r l s o n , Kaufman and Schwaid d e s c r i b e d an e x p e r i m e n t a l u n i t t h a t was e s t a b l i s h e d a t the Long I s l a n d Jewish G e n e r a l H o s p i t a l i n New 30 York.  The i d e a o r i g i n a t e d w i t h a group o f b a c c a l a u r e a t e n u r s i n g  s t u d e n t s who were about t o graduate.  These s t u d e n t s wanted an  o p p o r t u n i t y t o p r a c t i s e n u r s i n g , as they had been taught, i n a hospital setting.  A f t e r much d i s c u s s i o n between t h e s t u d e n t s , t h e  s t u d e n t s ' t e a c h e r s , and t h e n u r s i n g a d m i n i s t r a t o r s o f the h o s p i t a l , the o p p o r t u n i t y was p r o v i d e d .  The p h i l o s o p h y o f L y d i a H a l l was one  o f t h e b a s i c premises which p r o v i d e d d i r e c t i o n f o r t h e d e l i v e r y o f n u r s i n g care i n t h i s experimental  unit.  The b a c c a l a u r e a t e nurses who p a r t i c i p a t e d i n t h e experiment, o p e r a t e d on t h e i d e a t h a t t h e p r o f e s s i o n a l nurse h e l p e d t o c r e a t e a climate t h a t f o s t e r e d s e l f determination i n the coping behaviour o f 31 the h o s p i t a l i z e d p e r s o n .  In o r d e r t o do t h i s , v i s i t i n g  privileges  were made f l e x i b l e , p a t i e n t s were encouraged t o wear s t r e e t c l o t h e s and t o e a t t o g e t h e r i n a d i n i n g room. involvement  The nurses encouraged t h e  o f t h e p a t i e n t and h i s o r h e r f a m i l y i n the p l a n n i n g and  implementation  o f the n u r s i n g c a r e .  On admission,  t h e p a t i e n t and  f a m i l y were met by a p r o f e s s i o n a l nurse who o r i e n t e d them t o t h e u n i t and took a n u r s i n g h i s t o r y .  Nurses a i d e s were a s s i g n e d t o p r o f e s s i o n a l  n u r s e s as t h e i r a s s i s t a n t s r a t h e r than t o p a t i e n t s as t h e i r n u r s e .  The  s u b j e c t i v e responses o f b o t h p a t i e n t s and nurses were v e r y p o s i t i v e . S. C a r l s o n , R. Kaufman, and M. Schwaid, "An Experiment i n S e l f Determined P a t i e n t Care", N u r s i n g C l i n i c s o f North America, IV, 2 (1969), pp. 495-507. 3  1  I b i d . , p . 498.  As a r e s u l t , the authors r e p o r t e d t h a t the expansion p h i l o s o p h y t o o t h e r n u r s i n g u n i t s i n t h e h o s p i t a l was  of this being  32 considered. The  second  area d e s c r i b e d i n t h e l i t e r a t u r e as i n c o r p o r a t i n g 33  the p h i l o s o p h y o f L y d i a H a l l , was  the Loeb C e n t e r .  The  system o f  n u r s i n g a t Loeb i s not c a l l e d primary n u r s i n g , but many o f the g o a l s are s i m i l a r .  N u r s i n g care p l a n n e d and g i v e n w i t h the p a t i e n t 34  i s the f o c u s o f the n u r s i n g p h i l o s o p h y .  In o r d e r t o meet t h i s  o b j e c t i v e , a l l d i r e c t p a t i e n t c a r e i s g i v e n by r e g i s t e r e d Each nurse works w i t h about e i g h t p a t i e n t s . on the b a s i s o f d i s t r i c t s . comprise  nurses.  Assignments are made  Each nurse has a b l o c k o f rooms which  h i s o r her d i s t r i c t .  I f a p a t i e n t i s admitted t o one  those rooms, t h e nurse knows t h a t p a t i e n t i s h i s o r her  of  responsibility.  Messenger a t t e n d a n t s are a v a i l a b l e t o a s s i s t the nurse but they do give d i r e c t p a t i e n t care. and evenings  individual.  There are the same number o f nurses on days  t o p r o v i d e the n e c e s s a r y n u r s i n g s t a f f t o ensure  ward schedule i s one  not  t h a t a l l o w s the p a t i e n t t o be t r e a t e d as  V i s i t i n g hours are not r e s t r i c t e d .  The nurse  t h a t the an  i s responsible  t o h i s o r her s e l f and t o the p a t i e n t f o r the n u r s i n g c a r e g i v e n . nurse i s not expected t o have t o r e p o r t t o any  The  s p e c i f i c p e r s o n about  the n u r s i n g care g i v e n . A s e n i o r nurse i s a v a i l a b l e f o r c o n s u l t a t i o n 35 w i t h each s t a f f nurse. 32  I b i d . , pp.  500-506.  33 C. Henderson, "Can N u r s i n g Care Hasten Recovery?", American J o u r n a l o f N u r s i n g , LXIV, 6 (1964), p. 80. 34 I b i d . , pp. 80-83. 35 G. A l f a n o , "The Loeb Center f o r N u r s i n g & R e h a b i l i t a t i o n " , N u r s i n g C l i n i c s o f North America, IV, 3 (1969), pp. 487-492.  24. EVALUATION  OF PRIMARY NURSING  E v a l u a t i o n o f N u r s i n g Care E v a l u a t i o n i n v o l v e s an a p p r a i s a l o f t h e congruence between an e x p r e s s e d g o a l and an a c t u a l outcome.  The g o a l o f n u r s i n g  care  always a f f e c t s t h e p a t i e n t , e i t h e r d i r e c t l y o r i n d i r e c t l y . it  Therefore,  seems l o g i c a l t o i n c l u d e t h e p a t i e n t when e v a l u a t i n g n u r s i n g  care.  36 T h i s p o i n t o f view i s supported i n a r e p o r t by Marram.  She  i n v e s t i g a t e d t h e r e l a t i o n s h i p between t h e i n f l u e n c e o f t h e p a t i e n t as the e v a l u a t o r evaluation.  o f c a r e and t h e subsequent importance o f h i s o r h e r Marram found t h a t a l t h o u g h nurses r a t e d o t h e r p e o p l e i n  the h e a l t h c a r e  system ( n u r s i n g s u p e r v i s o r s , head nurses) as more  i n f l u e n t i a l e v a l u a t o r s , t h e p a t i e n t ' s e v a l u a t i o n was r a t e d h i g h e s t i n 37 terms o f importance. Can p a t i e n t s r e a l l y e v a l u a t e t h e i r n u r s i n g care? Marram addressed 38 t h i s q u e s t i o n by d i s t r i b u t i n g a survey q u e s t i o n n a i r e her d i s c u s s i o n o f t h e r e s u l t s , she r e p o r t e d the p a t i e n t ' s e v a l u a t i o n as very  o f p r o v i d i n g comfort and s u p p o r t . patient could evaluate ward management.  t o nurses.  t h a t the n u r s e s r e g a r d e d  important and v e r y 39  sound i n t h e areas  The nurses d i d n o t f e e l t h e  t h e n u r s e s ' performance i n r e c o r d k e e p i n g o r  Marram concluded t h a t n u r s e s view t h e p a t i e n t ' s  e v a l u a t i o n as most v a l i d and important when t h a t e v a l u a t i o n  includes  G. Marram, " P a t i e n t s ' E v a l u a t i o n o f T h e i r Care - Importance t o the Nurse", N u r s i n g Outlook, XXI, 5 (1973), pp. 322-324. Loc. c i t . 38 G. Marram, " P a t i e n t s ' E v a l u a t i o n o f N u r s i n g Performance", N u r s i n g Research, XXII, 2 (1973), pp. 153-157. 39  I b i d . , p. 155.  In  o n l y those t a s k s t h a t t h e p a t i e n t s can see t h e nurse These f i n d i n g s suggest performing  t h a t when nurses  performing."*  are a t the p a t i e n t ' s bedside  t a s k s t h a t a r e v i s i b l e t o the p a t i e n t , nurses  the p a t i e n t as an important  evaluator of nursing  I t appears l o g i c a l and important  u  will  regard  care.  t o nurses t o i n c l u d e t h e  p a t i e n t as an e v a l u a t o r i n a t l e a s t some a s p e c t s o f n u r s i n g c a r e . O b t a i n i n g a measure o f s a t i s f a c t i o n i s one way o f e v a l u a t i n g n u r s i n g care.  T h i s measurement can be e l i c i t e d from both p a t i e n t s and nurses. A b d e l l a h and L e v i n e developed  two v a l i d a t e d c h e c k l i s t s by which 41  they measured p a t i e n t and p e r s o n n e l They a d m i n i s t e r e d short-term,  s a t i s f a c t i o n with nursing care.  t h e p a t i e n t s ' c h e c k l i s t t o 8,666 p a t i e n t s i n s i x t y  g e n e r a l , n o n f e d e r a l , American h o s p i t a l s .  The h i g h e s t  p o s s i b l e score was 150 and, i f a c h i e v e d , would i n d i c a t e g r e a t d i s s a t i s f a c t i o n with the nursing care r e c e i v e d .  The r e s u l t s o f t h e  q u e s t i o n n a i r e i n d i c a t e d most p a t i e n t s were s a t i s f i e d w i t h t h e i r n u r s i n g 42 c a r e . N i n e t y - f i v e p e r c e n t o f t h e s c o r e s were below f i f t y . Only 43 one p e r c e n t had a score o f one hundred o r more. The two areas o f g r e a t e s t d i s s a t i s f a c t i o n were:  (1)  r e s t and r e l a x a t i o n and (2) l a c k  44 of contact with nurses.  S p e c i f i c complaints  included l e v e l o f noise,  b e i n g d i s t u r b e d a t i n c o n v e n i e n t times, n o t s e e i n g the nurse o f t e n  ' " i b i d . , . pp. 153-157. 41 F. A b d e l l a h and E. L e v i n e , "Developing a Measure o f P a t i e n t & P e r s o n n e l S a t i s f a c t i o n w i t h N u r s i n g Care", N u r s i n g Research, V, 3 (1957), pp. 100-108. 42 F. A b d e l l a h and E . L e v i n e , "What P a t i e n t s Say About T h e i r N u r s i n g Care", H o s p i t a l s , XXXI, Nov. 1 (1957), pp. 44-48. 43 ' 4 4 I b i d . , p. 46. I b i d . , p. 46.  26.  enough, f e e l i n g rushed when t h e nurse came, and n o t h a v i n g  the c a l l  45 l i g h t s answered soon enough. Abdellah  and L e v i n e a l s o r e p o r t e d on f a c t o r s t h a t i n f l u e n c e d  46 p a t i e n t s a t i s f a c t i o n with care. sex,  According  t o t h e i r data:  and m a r i t a l s t a t u s i n f l u e n c e d s a t i s f a c t i o n w i t h n u r s i n g  More s p e c i f i c a l l y , p a t i e n t s o v e r s i x t y , males and m a r r i e d  age, care.  patients  r e p o r t e d g r e a t e r s a t i s f a c t i o n t h a n d i d p a t i e n t s under twenty, women  47 (with t h e e x c e p t i o n o f o b s t e t r i c a l p a t i e n t s ) and s i n g l e p a t i e n t s . These same authors found t h a t an i n c r e a s e i n t h e hours o f p r o f e s s i o n a l  48 n u r s i n g care i n c r e a s e d p a t i e n t s a t i s f a c t i o n . difficulty in eliciting critical  They r e p o r t e d no  responses from p a t i e n t s .  D a e f f l e r u t i l i z e d t h e c h e c k l i s t developed by A b d e l l a h and L e v i n e t o e v a l u a t e p a t i e n t s a t i s f a c t i o n when nursed under a team n u r s i n g system i n comparison t o p a t i e n t s a t i s f a c t i o n when nursed under a  49 primary n u r s i n g system.  Again,  t h e r e was no r e p o r t e d  i n e l i c i t i n g c r i t i c a l responses from p a t i e n t s . d i d r e p o r t , " . . . t h e instrument s a t i s f a c t i o n with c a r e . " ^  difficulty  D a e f f l e r , however,  had l i m i t e d v a l u e  f o r measuring  T h i s statement was based on t h e f a c t  t h a t many o f t h e items on t h e c h e c k l i s t emphasized o m i s s i o n s ,  which  51 c r e a t e d t h e f e e l i n g t h a t t h e study was l o o k i n g o n l y f o r c r i t i c i s m . I b i d . , p. 47.  46 F. A b d e l l a h and E . L e v i n e , "What F a c t o r s A f f e c t P a t i e n t s ' Opinions o f T h e i r N u r s i n g Care", H o s p i t a l s , XXXI, Nov. 16 (1957), pp. 61-64.  47  48  I b i d . , pp. 61-62.  I b i d . , p. 64.  49 R. D a e f f l e r , " P a t i e n t s ' P e r c e p t i o n o f Care under Team and P r i m a r y N u r s i n g " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V, 3 (1975), pp. 20-26. 5  0  I b i d . , p. 25.  5  1  I b i d . , p . 25.  The  statement was a l s o based on t h e f a c t t h a t although  some items  were a p p l i c a b l e o n l y t o c e r t a i n p a t i e n t s , they were i n c l u d e d i n the weighted c a t e g o r y  score.  52  study was t h e s u g g e s t i o n  One o f t h e recommendations from D a e f f l e r ' s  t h a t new instruments  p a t i e n t s a t i s f a c t i o n w i t h c a r e be developed.  and methods t o measure  53  N e h r i n g and Geach r e p o r t e d a g r e a t d e a l o f d i f f i c u l t y  i n devising  54 a measurement t o o l t o e v a l u a t e n u r s i n g c a r e . was t h e i r d i f f i c u l t y  i n g e t t i n g p a t i e n t s t o make any c r i t i c a l  about t h e i r n u r s i n g c a r e . success  The major o b s t a c l e comment  N e h r i n g and Geach r e p o r t e d t h a t t h e o n l y  they had was when they used an u n s t r u c t u r e d ,  informal,  55 interview. The f i n d i n g s o f Nehring and Geach were n o t supported  taped  by t h e r e s u l t s 56  o f a study by Moore and Cook which compared two methods o f e v a l u a t i o n . Moore and Cook asked p a t i e n t s t o e v a l u a t e t h e i r p r e - n a t a l n u r s i n g by responding interview.  t o a q u e s t i o n n a i r e and by answering q u e s t i o n s  The same q u e s t i o n s  and t h e i n t e r v i e w . between n e g a t i v e  care  i n an  were i n c l u d e d i n both the q u e s t i o n n a i r e  The r e s u l t s d i d n o t show a s i g n i f i c a n t d i f f e r e n c e  responses t h a t would j u s t i f y  u s i n g one method over  57 the o t h e r . 52  The reason  I b i d . , p. 25.  f o r t h e d i f f e r e n c e between these two s t u d i e s 53  I b i d . , p. 26.  54 V. N e h r i n g and B. Geach, " P a t i e n t s ' E v a l u a t i o n o f T h e i r Care: Why Don't They Complain?", N u r s i n g Outlook, XXI, 5 (1973), pp. 317-321. Ibid. 56 D. Moore and K. Cook-Hubbard, "Comparison o f Methods f o r E v a l u a t i n g the P a t i e n t s ' Response t o N u r s i n g Care", N u r s i n g Research, XXIV, 3 (1975), pp. 202-204. 57 , . , Ibid.  28.  may  l i e i n the methodology.  N e h r i n g and  Geach s t u d i e d h o s p i t a l i z e d  p a t i e n t s whereas Moore and Cook s t u d i e d o u t - p a t i e n t s .  Perhaps t h i s  i n d i c a t e s the p o s s i b l e s i g n i f i c a n c e o f the e f f e c t o f  hospitalization  as a v a r i a b l e i n f l u e n c i n g the p a t i e n t ' s a b i l i t y t o e v a l u a t e h i s o r her  care. E w e l l conducted i n t e r v i e w s w i t h one  i n order to e l i c i t  hundred h o s p i t a l i z e d p a t i e n t s  the p a t i e n t ' s e v a l u a t i o n o f the q u a l i t y o f  the  58 nursing care.  The  i n t e r v i e w s took p l a c e i n the p a t i e n t s ' rooms  d u r i n g the t w e n t y - f o u r hour p e r i o d b e f o r e t h e i r d i s c h a r g e . four percent  o f the p a t i e n t s ' comments were f a v o r a b l e .  s i g n i f i c a n t that f i f t y - f o u r percent suggestions  f o r improving  Eighty-  It  was  o f the p a t i e n t s i n t e r v i e w e d  the n u r s i n g c a r e .  The  suggestions  had  included:  5 "  . . .'greater personal  and  ".  c a r e ' w i t h the means b e i n g  . .'increased bedside  'more p e r s o n n e l ' "  care by p r o f e s s i o n a l n u r s e s " . ^ 1  0  Ewell  noted t h a t none o f t h e p a t i e n t s mentioned t h e p r e v i o u s l y p u b l i s h e d complaints He  o f n o i s y wards, c o l d food and  o t h e r i r r i t a t i n g problems.  suggested t h a t these were not what p a t i e n t s were concerned about  but r a t h e r ".  . . t h e l a c k o f p e r s o n a l care by n u r s i n g s e r v i c e  personnel  the most d i s t u r b i n g f a c t o r t o the p a t i e n t s  The  was  r e s e a r c h done by T o g l i a c o z z o supported  interviewed."  Ewell's f i n d i n g s .  58 C. E w e l l J r . , "What P a t i e n t s R e a l l y T h i n k About T h e i r Care", Modern H o s p i t a l , IX, 2 (1967), pp. 106-108. 5 9  I b i d . , p. 108.  6  0  I b i d . , p. 108.  6 1  Nursing  I b i d . , p.  108.  62 D. L. T o g l i a c o z z o , "The Nurse From the P a t i e n t ' s P o i n t o f View", S o c i a l I n t e r a c t i o n and P a t i e n t Care, eds. J.K. S k i p p e r and R.C. Leonard, (Toronto: J.B. L i p p i n c o t t Co., 1965), pp. 219-227.  T o g l i a c o z z o i n t e r v i e w e d h o s p i t a l i z e d p a t i e n t s and asked what they i d e a l l y expected from a nurse.  E i g h t y - o n e p e r c e n t o f the  responses  s t r e s s e d p e r s o n a l i z e d c a r e as opposed t o f o r t y - f i v e p e r c e n t expected prompt, e f f i c i e n t s e r v i c e and twenty-nine p e r c e n t responded  t h a t they wanted knowledge and t e c h n i c a l  who who  skills.  E v a l u a t i o n o f Primary N u r s i n g Much o f the e v a l u a t i o n o f p r i m a r y n u r s i n g has been based subjective observations.  on  These o b s e r v a t i o n s have p r o v i d e d a back-  ground and f o c u s f o r more s y s t e m a t i c r e s e a r c h t h a t has attempted evaluate In  to  primary n u r s i n g . h e r a r t i c l e d e s c r i b i n g p r i m a r y n u r s i n g a t the U n i v e r s i t y o f  Minnesota H o s p i t a l , C i s k e i n c l u d e d some o f h e r o b s e r v a t i o n s o f the 64 outcomes o f p r i m a r y n u r s i n g .  She r e p o r t e d an i n c r e a s e i n the  enthusiasm o f s t a f f and a f e e l i n g o f accomplishment w i t h the p a r t i c u l p a t i e n t the nurse had worked w i t h . ^ accomplishment was for  T h i s enthusiasm and sense o f  r e f l e c t e d i n a decrease i n t h e r a t e o f t u r n o v e r  both r e g i s t e r e d nurses and l i c e n s e d p r a c t i c a l n u r s e s .  She  reported: AJ d e c r e a s e i n p a t i e n t s t e r e o t y p i n g by nurses as d i f f i c u l t ' , 'demanding', e t c . w i t h c o r r e s p o n d i n g 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 control." 66  63  Ibid.  64  K.L. C i s k e , "Primary N u r s i n g : An O r g a n i z a t i o n That Promotes P r o f e s s i o n a l P r a c t i c e " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , IV, 1 (1974), pp. 28-30. I b i d . , p.  30.  I b i d . , p.  30.  also  30.  C i s k e d e s c r i b e d the g r a t i t u d e o f p a t i e n t s and t h e i r f a m i l i e s a p p r e c i a t e d h a v i n g one nurse i n charge o f the p a t i e n t ' s There were p o s i t i v e comments from nurses who t o the primary n u r s i n g u n i t s .  In r e l a t i o n t o d i s c h a r g e ,  p u b l i c h e a l t h n u r s i n g and n u r s i n g homes who after  discharge.^  case.  were asked t o  d e s c r i b e d b e t t e r communication w i t h community agencies  who  "float"  Ciske  such as  followed p a t i e n t s  7  Logsdon, i n her a r t i c l e d e s c r i b i n g primary n u r s i n g , i n c l u d e d a d i s c u s s i o n o f the advantages and d i s a d v a n t a g e s o f p r i m a r y n u r s i n g . ^ ' Some o f the advantages she d e s c r i b e d were: "Primary n u r s i n g improves the c a r e o f the p a t i e n t by p r o v i d i n g a nurse who w i l l s e t up a r e l a t i o n s h i p t h e p a t i e n t can t r u s t , who w i l l g i v e comprehensive c a r e t h a t g r e a t l y reduces f r a g m e n t a t i o n o f c a r e . Primary n u r s i n g e n l a r g e s the scope o f 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 c a r e o f a p a t i e n t both i n the h o s p i t a l and beyond the w a l l s o f t h e h o s p i t a l . It i s a concept t h a t u t i l i z e s the e d u c a t i o n o f the nurse t o a f a r g r e a t e r e x t e n t , and moves n u r s i n g e d u c a t i o n and n u r s i n g p r a c t i c e c l o s e r together. T h i s concept makes the nurse accountable f o r h e r p r a c t i c e and a l l o w s t h e nurse and o t h e r s t o e v a l u a t e the p r a c t i c e . " 69 A  She  r e p o r t e d t h a t p r i m a r y n u r s i n g enables  the nurse t o 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 w i t h the p h y s i c i a n s i n c e the nurse, w e l l as the p h y s i c i a n , has the p a t i e n t .  I b i d . , p.  as  a g r e a t d e a l o f knowledge r e l a t e d t o  7 0  30.  A. Logsdon, "Why Primary N u r s i n g ? " , N u r s i n g C l i n i c s o f N o r t h America, XXVIII, 2 (1973), pp. 283-291. 6  8  6 9  I b i d . , p. 288.  7  0  I b i d . , p.  288.  31.  Logsdon a l s o r e p o r t e d t h e d i s a d v a n t a g e s as she saw them. major problem was t h e d i f f i c u l t y  some nurses had i n a c c e p t i n g t h e  a u t h o r i t y o f another nurse i n p l a n n i n g care f o r a p a t i e n t . reported d i f f i c u l t y  i n having  One  t h e n i g h t nurse m a i n t a i n  Logsdon  the primary  n u r s i n g r o l e as he o r she had t o have t h e day nurse c a r r y o u t t h e plan. C i s k e attempted t o e l i c i t p a t i e n t s ' e v a l u a t i o n o f p r i m a r y n u r s i n g by m a i l i n g a survey  q u e s t i o n n a i r e t o two hundred p a t i e n t s  72 who had been d i s c h a r g e d  from p r i m a r y and team n u r s i n g u n i t s .  hundred o f t h e q u e s t i o n n a i r e s were r e t u r n e d .  One  The responses o f  p a t i e n t s from each u n i t were compared u s i n g a c h i square a n a l y s i s . The  o n l y s i g n i f i c a n t d i f f e r e n c e r e p o r t e d was t h a t primary n u r s e s  p r o v i d e d more o p p o r t u n i t i e s f o r t h e p a t i e n t t o t a l k about  complaints  73 or problems than d i d n u r s e s from t h e team n u r s i n g u n i t s . Marram, S c h l e g e l and B e v i s have d e s c r i b e d one o f t h e most complete  74 i n v e s t i g a t i o n s o f p r i m a r y n u r s i n g i n t h e i r book, Primary The  authors  utilized  Nursing.  questionnaires that e l i c i t e d the p a t i e n t s ' l e v e l  o f s a t i s f a c t i o n w i t h t h e n u r s i n g care and t h e i r i m p r e s s i o n s nature to  o f t h e n u r s i n g care r e c e i v e d .  The q u e s t i o n n a i r e was  360 p a t i e n t s 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  of the administered nursing  I b i d . , P. 289.  72 K. C i s k e , "Primary N u r s i n g " E v a l u a t i o n " , American J o u r n a l o f N u r s i n g , LXXIV, 8 (1974), pp. 1436-1438. 7 3  I b i d . , pp. 1437-1438.  G. Marram, M. S c h l e g e l , and E. B e v i s , Primary (St. L o u i s : C.V. Mosby & Co., 1974)  Nursing,  32.  approaches were r e p r e s e n t e d :  p r i m a r y n u r s i n g , team n u r s i n g ,  f u n c t i o n a l n u r s i n g and case method n u r s i n g .  These approaches  were r e f l e c t e d on f o u r d i f f e r e n t n u r s i n g u n i t s which were i n c l u d e d i n the  study. ^ 7  To compare p a t i e n t s ' p e r c e p t i o n s on a l l f o u r u n i t s , Marram e t a l asked a l l p a t i e n t s t o l i s t  the t h i n g s they l i k e d about  their  n u r s i n g c a r e and the problems they, as p a t i e n t s , e x p e r i e n c e d .  Fifty-  one p e r c e n t o f the p a t i e n t s on the p r i m a r y n u r s i n g u n i t r e p o r t e d t h a t they l i k e d the f a c t t h a t the nurse c o n s i d e r e d the p a t i e n t s ' 76 individuality.  F o r t y - f i v e percent o f the p a t i e n t s reported t h i s  same e x p e r i e n c e on the case method n u r s i n g u n i t , 21.5  p e r c e n t on  the 77  team n u r s i n g u n i t and o n l y 15 p e r c e n t on t h e f u n c t i o n a l n u r s i n g u n i t . A l l o f the p a t i e n t s on b o t h the primary n u r s i n g u n i t and the method n u r s i n g u n i t r e p o r t e d t h a t the nurse gave emotional  case  support,  t r e a t e d the p a t i e n t as a s p e c i a l p e r s o n and spent time w i t h the patient. and  T h i r t y - f i v e p e r c e n t o f the p a t i e n t s on t h e team n u r s i n g u n i t  42 p e r c e n t o f the p a t i e n t s on the f u n c t i o n a l n u r s i n g u n i t r e p o r t e d  t h a t the nurse was  more concerned w i t h " . . . o t h e r p e o p l e s ' 78 p e r c e p t i o n s and n o t w i t h what the p a t i e n t s t h i n k they need." that  " f i n i s h i n g on time  and  i s more important t o JtheJ nurse than good  79 care."  None o f the p a t i e n t s from t h e primary n u r s i n g u n i t o r the  case method u n i t r e p o r t e d t h e s e f i n d i n g s . 7 5  77  I b i d . , pp.  125-147.  I b i d . , p. 127.  7  78  6  I b i d . , p.  I b i d . , p. 128.  On a f i v e p o i n t s c a l e 127. 79  I b i d . , p.  128.  33.  t h a t ranged from "extremely s a t i s f i e d " t o "not a t a l l s a t i s f i e d " , 65 p e r c e n t o f the p a t i e n t s from t h e p r i m a r y n u r s i n g u n i t were "extremely s a t i s f i e d " w i t h t h e i r n u r s i n g c a r e as compared t o 40 p e r c e n t from t h e case method u n i t ,  37 p e r c e n t from t h e team 80  n u r s i n g u n i t and 48 p e r c e n t from t h e f u n c t i o n a l n u r s i n g u n i t . In o r d e r t o f u r t h e r i n v e s t i g a t e the outcomes o f p r i m a r y n u r s i n g , Marram e t a l d i d a comparison o f p a t i e n t p e r c e p t i o n s on a s p e c i f i c u n i t , b e f o r e and a f t e r the implementation o f p r i m a r y 81 nursing.  P r i o r t o p r i m a r y n u r s i n g , 42.9 p e r c e n t o f t h e p a t i e n t s  d e s c r i b e d t h e p l e a s a n t n e s s o f the nurse as v e r y important.  After  the implementation o f p r i m a r y n u r s i n g , 44 p e r c e n t d e s c r i b e d t h e 82 "nurse's c o n s i d e r a t i o n o f p a t i e n t i n d i v i d u a l i t y "  as most important.  P r i o r t o p r i m a r y n u r s i n g , o n l y 35 p e r c e n t o f t h e p a t i e n t s  agreed  t h a t the nurse gave e m o t i o n a l support and 30 p e r c e n t agreed t h a t t h e 83 nurse t r e a t e d p a t i e n t s as " . . . s p e c i a l human b e i n g s " . "  After  p r i m a r y n u r s i n g , 75 p e r c e n t o f t h e p a t i e n t s agreed t h a t t h e nurse gave emotional support and 95 p e r c e n t agreed they were t r e a t e d as s p e c i a l people.  Twenty-nine p e r c e n t o f the p a t i e n t s were "extremely  s a t i s f i e d " w i t h t h e n u r s i n g c a r e b e f o r e p r i m a r y n u r s i n g as compared 84 t o 64 p e r c e n t a f t e r t h e implementation o f p r i m a r y n u r s i n g . Marram e t a l a l s o i n v e s t i g a t e d a t o t a l o f 110 n u r s e s  from  primary n u r s i n g u n i t s , team n u r s i n g u n i t s , f u n c t i o n a l n u r s i n g u n i t s 85 80 81 and case method n u r s i n g u n i t s . Ninety percent o f the primary I b i d . , p. 132.  I b i d . , pp. 132-135.  8  2  I b i d . , p. 133.  8  3  I b i d . , p. 133.  8  4  I b i d . , pp. 133-134.  8  5  I b i d . , pp. 137-145.  34. nurses were extremely o r v e r y s a t i s f i e d w i t h t h e way t h e i r work was o r g a n i z e d as compared t o 70 p e r c e n t on t h e case method n u r s i n g u n i t , 52 p e r c e n t on t h e team n u r s i n g u n i t and 43 p e r c e n t on t h e functional nursing u n i t . ^ 8  F e l t o n looked a t i n c r e a s i n g t h e q u a l i t y o f n u r s i n g c a r e by 87 i n t r o d u c i n g t h e system o f primary n u r s i n g on a h o s p i t a l  unit.  T h i s e x p e r i m e n t a l u n i t was a s s i g n e d t o a v a r i e t y o f n u r s e s . Performance o f t h e n u r s i n g care was measured by t h e S l a t e r N u r s i n g 88 89 Competencies S c a l e , t h e Q u a l i t y P a t i e n t Care S c a l e , and t h e 90 Phaneuf N u r s i n g A u d i t .  The mean s c o r e s on each o f t h e s e t h r e e  t o o l s were found t o be h i g h e r on t h e primary n u r s i n g u n i t .  This  f i n d i n g suggests t h a t primary n u r s i n g c o n t r i b u t e d t o i n c r e a s i n g t h e 91 q u a l i t y o f the nursing care given, measured by t h e s e  t o the extent that i t i s  scales.  D a e f f l e r i n v e s t i g a t e d the d i f f e r e n c e s , i f any, i n i d e n t i f i e d o m i s s i o n s i n care as p e r c e i v e d by p a t i e n t s on m e d i c a l - s u r g i c a l 8  ^  I b i d . , p. 141.  87 G. F e l t o n , " I n c r e a s i n g t h e Q u a l i t y o f N u r s i n g Care by I n t r o d u c i n g t h e Concept o f Primary N u r s i n g : A Model P r o j e c t " , N u r s i n g Research, XXIV, 1 (1975), pp. 27-32. 88 D. S l a t e r , The S l a t e r N u r s i n g Competencies S c a l e , ( D e t r o i t : Wayne S t a t e U n i v e r s i t y C o l l e g e o f Nrsg., 1967). 89 M. Wandelt and J . Ager, Q u a l i t y P a t i e n t Care S c a l e , (Detroit: Wayne S t a t e U n i v e r s i t y , C o l l e g e o f N u r s i n g , 1970). 90 M.C. Phaneuf, The N u r s i n g A u d i t : P r o f i l e f o r E x c e l l e n c e , (New York: A p p l e t o n - C e n t u r y - C r o f t s , 1972). 91 G. F e l t o n , 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  c h e c k l i s t developed by Abdellah and Levine.  The findings indicated  that there were more omissions i n care on the team nursing u n i t . difference was  The  s t a t i s t i c a l l y s i g n i f i c a n t only i n the category  related to dietary needs.  Three items that indicated s a t i s f a c t i o n  with care r e f l e c t e d 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 u n i t than from the team nursing u n i t . The l i t e r a t u r e 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 h o s p i t a l i z e d patients, patients from primary nursing units seem to experience more encouragement from t h e i r primary nurse to discuss t h e i r complaints than patients from other kinds of nursing u n i t s . important  Nurses perceive patients as  evaluators of nursing care, p a r t i c u l a r l y i f the patients  are evaluating tasks that have been performed within t h e i r v i s u a l field. nursing.  Both nurses and patients reported s a t i s f a c t i o n with primary I t would seem to be important  to include both nurses and  patients i n an evaluation of the s p e c i f i c 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 I I I  DESIGN AND METHODOLOGY  T h i s study addressed i t s e l f t o t h e problem o f i n v e s t i g a t i n g whether o r n o t c e r t a i n p r i m a r y n u r s i n g b e h a v i o u r s o c c u r r e d d u r i n g a p a t i e n t ' s h o s p i t a l i z a t i o n , how important t h e b e h a v i o u r s were and the degree o f s a t i s f a c t i o n they engendered.  These t h r e e v a r i a b l e s  were measured from b o t h t h e p a t i e n t s * and p r i m a r y n u r s e s view.  1  point of  The d a t a was o b t a i n e d by a d m i n i s t e r i n g a q u e s t i o n n a i r e t o  both p a t i e n t s and nurses d u r i n g t h e l a s t week o f t h e p a t i e n t ' s hospitalization.  THE  SETTING  The h o s p i t a l where t h e study took p l a c e , 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 l o c a t e d i n B r i t i s h Columbia.  There a r e t h r e e  i n - p a t i e n t u n i t s w i t h twenty-two beds each, an o u t - p a t i e n t a r e a and two day care programs.  P a t i e n t s a r e r e f e r r e d from a l l a r e a s o f t h e  p r o v i n c e o f B r i t i s h Columbia, the lower mainland.  w i t h t h e m a j o r i t y o f them coming from  P a t i e n t s can be r e f e r r e d by p s y c h i a t r i s t s ,  g e n e r a l p r a c t i t i o n e r s , o t h e r p r o f e s s i o n a l s , f r i e n d s and s e l f . P r i o r t o admission, a l l p a t i e n t s a r e a s s e s s e d i n t h e o u t - p a t i e n t a r e a t o a s c e r t a i n i f a d m i s s i o n i s warranted o r whether t h e p a t i e n t c o u l d 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 c a r e . Once admission has been d e c i d e d upon, t h e p a t i e n t i s a s s i g n e d t o  37.  whichever u n i t has a v a i l a b l e space.  The wards a r e s t a f f e d by-  r e g 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 . i s made up o f p s y c h i a t r i c r e s i d e n t s  The m e d i c a l  and m e d i c a l s t u d e n t s w i t h a  p s y c h i a t r i s t as t h e c l i n i c a l c h i e f on each o f t h e u n i t s . an o c c u p a t i o n a l t h e r a p i s t and a s o c i a l worker on each u n i t and c o n s u l t a t i o n  services  staff  There i s  in-patient  a r e a v a i l a b l e from t h e department o f  p s y c h o l o g y and d i e t e t i c s . The  organization  the p a t i e n t .  o f t h e u n i t i s c e n t r a l i z e d around t h e c a r e o f  Each p a t i e n t works w i t h a t h e r a p y team c o n s i s t i n g o f a  p r i m a r y t h e r a p i s t and a p r i m a r y n u r s e . most o f t e n  a psychiatric resident,  The p r i m a r y t h e r a p i s t i s  b u t may be a s o c i a l worker o r a  nurse w i t h a g r e a t d e a l o f e x p e r i e n c e i n p s y c h i a t r y . m u l t i - d i s c i p l i n a r y team p r o v i d e i n p u t patient.  Members o f t h e  t o t h e t h e r a p y team and t o t h e  The p a r t i c u l a r u n i t where t h e study was conducted o f f e r s  a variety of therapies group, o c c u p a t i o n a l ,  commonly found i n p s y c h i a t r i c  settings:  and m i l i e u .  THE  PARTICIPANTS  Patients Twenty-nine p a t i e n t s  were i n v o l v e d  were t h i r t e e n men and s i x t e e n women.  with varying  diagnoses.  There  More than, h a l f o f t h e p a t i e n t s  were under t h e age o f f o r t y w i t h t h e m a j o r i t y between twenty-one and t h i r t y y e a r s o f age.  Over h a l f had p r e v i o u s 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 o f which had been a t t h e h o s p i t a l where t h e study took (see Appendix E) questionnaire,  place,  I n o r d e r t o be c o n s i d e r e d e l i g i b l e t o complete t h e  the patient  needed t o be a b l e t o r e a d and w r i t e and t o  38. be o r i e n t e d t o time, p l a c e , and p e r s o n .  No one was  i n c l u d e d i n the  study i f t h e i n v e s t i g a t o r thought t h e y were so d i s t u r b e d a t t h e time of  a d m i s s i o n t h a t they would be unable t o r e c a l l the events o f t h a t  time p e r i o d .  The  Nurses The u n i t where the study took p l a c e had t e n s t a f f n u r s e s ,  j u n i o r care c o - o r d i n a t o r s and a head n u r s e . r e g i s t e r e d nurses registration).  A l l o f the nurses were  (with t h e e x c e p t i o n o f one who  was  awaiting  Four o f the nurses had a b a c c a l a u r e a t e degree,  i n c l u d i n g the head n u r s e .  There was  one male nurse.  been u t i l i z i n g the p r i m a r y n u r s i n g system  The u n i t had  f o r four years.  The p r i m a r y n u r s i n g model p r a c t i s e d by the u n i t s t a f f , was of New  that  the Loeb Center and the Long I s l a n d J e w i s h G e n e r a l H o s p i t a l i n York.  Only r e g i s t e r e d nurses c o u l d a c t as p r i m a r y n u r s e s .  p r i m a r y nurse e i t h e r met hours o f admission.  The  the p a t i e n t on admission o r w i t h i n t w e n t y - f o u r  He o r she was  assessment and c a r e p l a n . was  two  r e s p o n s i b l e f o r an i n i t i a l n u r s i n g  Often, the i n i t i a l  i n t e r v i e w on t h e u n i t  done j o i n t l y w i t h the p a t i e n t , the p r i m a r y nurse and the p r i m a r y  therapist participating.  The p r i m a r y nurse was  also responsible for  the ongoing n u r s i n g c a r e p l a n and f o r h e l p i n g the p a t i e n t p r e p a r e f o r discharge.  I n a d d i t i o n t o t h e p r i m a r y nurse, each p a t i e n t had  a s s o c i a t e nurse who was  o f f duty.  role.  would care f o r the p a t i e n t when the p r i m a r y  an nurse  The p s y c h i a t r i c a s s i s t a n t sometimes f u n c t i o n e d i n t h i s  39.  THE QUESTIONNAIRE  The q u e s t i o n n a i r e was developed p r i m a r i l y i n o r d e r t o t e s t s a t i s f a c t i o n w i t h p r i m a r y n u r s i n g (see Appendix G and H).  In o r d e r  t o do t h a t , t h e i n v e s t i g a t o r u t i l i z e d the format o f the q u e s t i o n n a i r e developed by P o r t e r t o a s s e s s j o b s a t i s f a c t i o n . " ' "  On h i s q u e s t i o n n a i r e  he asks respondents t o i d e n t i f y whether o r n o t a c e r t a i n b e h a v i o u r o c c u r s i n t h e i r j o b , how i m p o r t a n t i t i s and how important i t s h o u l d be. T h i s i n f o r m a t i o n g i v e s a number which r e p r e s e n t s t h e degree o f satisfaction.  F o r t h e purpose o f t h i s study, nurses and p a t i e n t s were  asked o n l y t o i d e n t i f y whether o r n o t a c e r t a i n b e h a v i o u r o c c u r r e d and how important the b e h a v i o u r was. order to  T h i s was f e l t t o be s u f f i c i e n t i n  yield d a t a which was i n accordance w i t h t h e d e f i n i t i o n o f  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 :  Definitions).  In  a d d i t i o n t o y i e l d i n g information r e l a t e d t o s a t i s f a c t i o n , the q u e s t i o n n a i r e a l s o produced  data r e l a t e d t o t h e p a t i e n t s ' and n u r s e s '  p e r c e p t i o n s o f the o c c u r r e n c e and importance  o f those primary n u r s i n g  behaviours represented. The primary n u r s i n g b e h a v i o u r s i n c l u d e d i n t h e q u e s t i o n n a i r e were chosen  from t h e l i t e r a t u r e and t h e i n v e s t i g a t o r ' s e x p e r i e n c e r e l a t e d  to primary nursing.  The b e h a v i o u r s were v a l i d a t e d by s u b m i t t i n g the  q u e s t i o n n a i r e t o a p a n e l o f f i v e judges.  Three o f t h e judges had been  L. P o r t e r , "Job A t t i t u d e s i n Management: Perceived Deficiencies i n Need F u l f i l l m e n t as a F u n c t i o n o f Job L e v e l " , J o u r n a l o f A p p l i e d Psychology, XLVI, 6 (1962), pp. 141-148.  40.  head n u r s e s on u n i t s t h a t p r a c t i s e d p r i m a r y n u r s i n g .  Two o f t h e s e  t h r e e worked i n m e d i c a l s u r g i c a l s e t t i n g s and one worked i n p s y c h i a t r y . Another judge was a n u r s i n g primary nursing  supervisor  and the f i f t h  as a p r i m a r y n u r s e .  i n a hospital that  utilized  judge was a s t a f f nurse who had worked  Each judge was asked t o i n d e p e n d e n t l y r a t e the  v a l i d i t y o f t h e primary n u r s i n g b e h a v i o u r s i n c l u d e d i n t h e q u e s t i o n n a i r e . The  r a t i n g s c a l e was a f i v e p o i n t L i k e r t s c a l e which ranged from  which was h i g h v a l i d i t y , t o one, which was low v a l i d i t y . w i t h a t o t a l score  five,  Behaviours  o f l e s s than seventeen were dropped from the  questionnaire. The  patients' questionnaire  the n u r s e s ' q u e s t i o n n a i r e  c o n s i s t e d o f t h i r t y - s e v e n items and  c o n s i s t e d o f t h i r t y - e i g h t items.  were two s e c t i o n s t o each q u e s t i o n n a i r e .  The f i r s t  There  s e c t i o n tested the  o c c u r r e n c e o f t h e b e h a v i o u r s and respondents were asked t o i n d i c a t e t r u e , f a l s e o r N/A  (not a p p l i c a b l e )  primary nursing behaviour. of the s p e c i f i c behaviours.  f o r the o c c u r r e n c e o f each  specific  The second s e c t i o n d e a l t w i t h t h e importance P a t i e n t s and nurses were asked t o r a t e the  importance o f each p r i m a r y n u r s i n g b e h a v i o u r u s i n g a L i k e r t - t y p e s c a l e . The  method o f c a l c u l a t i n g t h e s a t i s f a c t i o n s c o r e s  i s described i n  Appendix F. Both q u e s t i o n n a i r e s study.  were p r e - t e s t e d on a u n i t not i n c l u d e d i n t h e  The t e s t r e - t e s t method was a p p l i e d t o the q u e s t i o n n a i r e  measure o f s t a b i l i t y .  U s i n g 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 t h a t t h e r e l i a b i l i t y was questionnaire  as a  .75 f o r the p a t i e n t s '  and .79 f o r the n u r s e s ' q u e s t i o n n a i r e .  These  scores  41. were s i g n i f i c a n t a t t h e .05 l e v e l .  The c r i t i c a l v a l u e o f t h e Spearman  Rank C o r r e l a t i o n C o e f f i c i e n t a t t h e .05 l e v e l with a o n e - t a i l e d t e s t and an N o f 7 i s .71.  These r e l i a b i l i t y  s c o r e s o f .75 and .79 i n d i c a t e  t h a t t h e v a r i a t i o n i n s c o r e s between respondents r e f l e c t s d i f f e r e n c e s between responses r a t h e r than b e i n g t h e r e s u l t o f an u n r e l i a b l e o r unstable t e s t i n g Included  process.  i n each q u e s t i o n n a i r e were s e v e r a l p a i r s o f q u e s t i o n s  which t e s t e d t h e same concept. to  These q u e s t i o n s were i n c l u d e d i n o r d e r  determine t h e i n t e r n a l c o n s i s t e n c y o f t h e q u e s t i o n n a i r e .  When t h e  d a t a c o l l e c t i o n was completed, seven p a t i e n t q u e s t i o n n a i r e s and seven nurse q u e s t i o n n a i r e s were randomly s e l e c t e d from t h e sample o f twentyn i n e nurse q u e s t i o n n a i r e s  and twenty-nine p a t i e n t q u e s t i o n n a i r e s .  s e l e c t e d q u e s t i o n n a i r e s were a n a l y z e d  f o r i n t e r n a l c o n s i s t e n c y and t h e  r e s u l t s g e n e r a l i z e d t o t h e r e s t o f t h e sample.  U s i n g t h e 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 t h a t t h e i n t e r n a l for  the nurses'  .80.  The  consistency  q u e s t i o n n a i r e was .90 and f o r t h e p a t i e n t s ' i t was  These s c o r e s were s i g n i f i c a n t a t t h e .05 l e v e l .  These  scores  o f .90 and .80 i n d i c a t e t h a t both p a t i e n t s and nurses a r e responding c o n s i s t e n t l y t o t h e concepts t h a t t h e q u e s t i o n n a i r e i s t e s t i n g . an i n d i v i d u a l ' s performance i s i n c o n s i s t e n t , i t i s p r o b a b l y other  f a c t o r besides  due t o some  the questionnaire.  Because t h e p r i m a r y n u r s e s would be responding  t o the q u e s t i o n n a i r e  more than once, t h r e e n u r s i n g q u e s t i o n n a i r e s were developed. questionnaire  If  Each  c o n t a i n e d t h e same q u e s t i o n s b u t t h e sequence was a l t e r e d .  42.  The o r d e r o f the q u e s t i o n s was page o f the q u e s t i o n n a i r e was the q u e s t i o n s t h a t monitored  determined  by random s e l e c t i o n .  then i n s p e c t e d by  Each  'eye' t o see t h a t  the i n t e r n a l c o n s i s t e n c y o f the  q u e s t i o n n a i r e were spaced a p a r t and d i d not o c c u r on the same page. P r e v i o u s r e s e a r c h has shown t h a t age,  sex and m a r i t a l s t a t u s  i n f l u e n c e the degree o f s a t i s f a c t i o n w i t h n u r s i n g c a r e t h a t a p a t i e n t 2 experiences.  I t has a l s o been demonstrated t h a t p a t i e n t s who  have  had e x p e r i e n c e w i t h p r i m a r y n u r s i n g have d i f f e r e n t e x p e c t a t i o n s about the n u r s i n g c a r e they w i l l r e c e i v e than do p a t i e n t s who  have not  had  3 any e x p e r i e n c e w i t h p r i m a r y n u r s i n g .  In o r d e r t o a s c e r t a i n the  i n f l u e n c e o f t h e s e v a r i a b l e s , a c h e c k l i s t was  added t o the f r o n t o f  the p a t i e n t s ' q u e s t i o n n a i r e f o r each p a t i e n t t o complete b e f o r e responded  One  they  t o the q u e s t i o n n a i r e (see Appendix D). THE DESIGN month p r i o r t o the b e g i n n i n g o f t h e i n v e s t i g a t i o n ,  r e s e a r c h e r met  the  w i t h the n u r s i n g s t a f f t o d i s c u s s t h e i r concept  primary n u r s i n g .  I t was  found t o be congruent  w i t h the  of  literature.  A l l nurses were then g i v e n a b r i e f summary o f the r e s e a r c h d e s i g n  and  a summary o f the concepts o f primary n u r s i n g which were i n c l u d e d i n the q u e s t i o n n a i r e as a focus f o r the second  d i s c u s s i o n (see Appendix A ) .  F. A b d e l l a h and E. L e v i n e , "What F a c t o r s A f f e c t P a t i e n t s ' O p i n i o n s o f T h e i r N u r s i n g Care, H o s p i t a l s , XXXI, (Nov.16, 1957), pp. 61-64.  3 F. D a e f f l e r , " P a t i e n t s ' P e r c e p t i o n o f Care Under Team and Primary N u r s i n g " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V, 3 (1975), pp. 20-26.  43.  T h i s was done t o ensure t h a t p r i m a r y n u r s i n g , t h e independent v a r i a b l e , was b e i n g p r a c t i s e d .  P a t i e n t s who were admitted  d i s c u s s i o n s were c o n s i d e r e d  f o r the research  The q u e s t i o n n a i r e was a d m i n i s t e r e d  sample.  t o p a t i e n t s and nurses  t h e f i n a l week o f t h e p a t i e n t ' s h o s p i t a l i z a t i o n . was avoided Separation  f o l l o w i n g these two  during  The day o f d i s c h a r g e  as a time f o r t h e p a t i e n t t o complete t h e q u e s t i o n n a i r e . anxiety frequently occurs  psychiatric patients.  i n hospitalized patients, especially  I t was f e l t t h a t i t would be d e s i r a b l e t o a v o i d  the i n f l u e n c e o f t h i s s t r e s s . A l l p a t i e n t s and nurses s i g n e d a consent form p r i o r t o r e s p o n d i n g to the questionnaire  (see Appendix B ) .  The i n 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 p a t i e n t q u e s t i o n n a i r e s and o b t a i n e d t h e consent forms from t h e patients.  Each p a t i e n t was t o l d t h a t t h e purpose o f t h e q u e s t i o n n a i r e  was t o g e t i n f o r m a t i o n from p a t i e n t s r e g a r d i n g t h e o c c u r r e n c e nursing behaviours behaviours  were.  i n t h e study,  and how important  they,  of certain  t h e p a t i e n t s , thought  these  They were a l s o t o l d t h a t they d i d n o t have t o p a r t i c i p a t e  and c o u l d withdraw a t any time.  The p r i m a r y nurses a l s o completed a consent form p r i o r t o responding t o the questionnaire.  T h e i r consent form i n c l u d e d p e r m i s s i o n  i n v e s t i g a t o r t o approach t h e p a t i e n t about completing  f o r the  the q u e s t i o n n a i r e .  The primary nurse's q u e s t i o n n a i r e was d i s t r i b u t e d by t h e ward s e c r e t a r y d u r i n g t h e week o f the p a t i e n t ' s d i s c h a r g e . the nurses were completing  I t was assumed t h a t s i n c e  t h e q u e s t i o n n a i r e more than once, they d i d  not need an e x p l a n a t i o n each time they responded. opportunity during the i n i t i a l  They were g i v e n an  discussions of the i n v e s t i g a t i o n to  44. refuse t o p a r t i c i p a t e . the  They c o u l d a l s o withdraw a t any time  during  study.  CHART CHECKLIST  As an a d d i t i o n a l measure o f v a l i d i t y , t h e i n v e s t i g a t o r monitored the c h a r t s on t h e u n i t .  T h i s was done by s e l e c t i n g e l e v e n  behaviours  from t h e n u r s i n g q u e s t i o n n a i r e which, i n t h e i n v e s t i g a t o r ' s o p i n i o n , s h o u l d be r e f l e c t e d i n t h e c h a r t i n g .  These were compiled  checklist  c h a r t s were s e l e c t e d from t h e  (see Appendix C ) .  Fourteen  sample o f p a t i e n t s i n t h e study o f each p r i m a r y nurse i n c l u d e d .  into a  so t h a t t h e r e was a t l e a s t one c h a r t The c h a r t i n g was checked t o see i f  any o f t h e e l e v e n s p e c i f i c behaviours  had been r e c o r d e d .  I t was  assumed t h a t i f t h e b e h a v i o u r was r e p o r t e d i n t h e c h a r t i n g then t h e b e h a v i o u r had o c c u r r e d and t h a t same b e h a v i o u r would be a p p r o p r i a t e l y responded t o i n t h e q u e s t i o n n a i r e .  METHODOLOGY  As mentioned e a r l i e r i n t h e chapter,  t h e impact o f t h e independent  v a r i a b l e o f p r i m a r y n u r s i n g upon p a t i e n t s ' and n u r s e s ' was measured by means o f a q u e s t i o n n a i r e . d a t a r e l a t e d t o p a t i e n t s ' and n u r s e s '  satisfaction  The q u e s t i o n n a i r e y i e l d e d  perception o f the occurrence o f ,  the importance o f , and t h e degree o f s a t i s f a c t i o n w i t h t h e p r i m a r y nursing behaviours  contained  i n the questionnaire.  The purpose o f t h e i n v e s t i g a t i o n was t o generate d a t a t h a t would d e s c r i b e and e v a l u a t e p r i m a r y n u r s i n g .  I n o r d e r t o p r o v i d e some  45.  d i r e c t i o n f o r the i n v e s t i g a t i o n , i n terms o f the d a t a a n a l y s i s , s i x hypotheses of  were proposed.  Each h y p o t h e s i s w i l l be d i s c u s s e d i n terms  the methodology used t o a n a l y s e the d a t a . 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 n u r s e s ' p e r c e p t i o n o f t h e of  occurrence  the i t e m i z e d p r i m a r y n u r s i n g b e h a v i o u r s  i n c l u d e d on the s a t i s f a c t i o n q u e s t i o n n a i r e . In  d e a l i n g w i t h t h i s f i r s t h y p o t h e s i s , the number o f a f f i r m a t i o n s o f  the o c c u r r e n c e o f each matched b e h a v i o u r was  tallied  f o r both p a t i e n t s  4 and n u r s e s .  By a p p l y i n g the Spearman Rank C o r r e l a t i o n  t h e degree o f agreement between the two the p r i m a r y n u r s i n g b e h a v i o u r s was Hypothesis  2.  groups on the o c c u r r e n c e  of  obtained.  There i s no c o r r e l a t i o n between the and t h e p a t i e n t s ' r a t i n g s o f the of  Coefficient,  nurses'  importance  the i t e m i z e d p r i m a r y n u r s i n g b e h a v i o u r s i n -  c l u d e d on t h e s a t i s f a c t i o n q u e s t i o n n a i r e . The a n a l y s i s r e l a t e d t o t h i s h y p o t h e s i s was hypothesis.  s i m i l a r to the  By summing a l l t h e r a t i n g s o f importance  first  t h a t each  nurse  and each p a t i e n t a s s i g n e d t o the s p e c i f i c p r i m a r y n u r s i n g b e h a v i o u r s , an average  s c o r e was  o b t a i n e d which r e f l e c t e d the importance  group a s s i g n e d t o the i t e m i z e d b e h a v i o u r .  F o r example:  y i e l d e d 20 s c o r e s o f 5 and 10 s c o r e s o f 3, t h e average for  t h a t b e h a v i o u r would be 130.  t h a t each  i f a question importance  By a p p l y i n g the Spearman Rank  See Appendix H, T a b l e 7, f o r a l i s t o f the matched b e h a v i o u r s .  score  46. C o r r e l a t i o n C o e f f i c i e n t t o t h i s d a t a i t was t h e degree o f agreement between the two importance  p o s s i b l e to a r r i v e at  groups i n r a t i n g the  o f the primary n u r s i n g b e h a v i o u r s .  Hypothesis  3.  There i s no c o r r e l a t i o n between the n u r s e s ' and p a t i e n t s ' s c o r e s f o r s a t i s f a c t i o n w i t h the i t e m i z e d primary n u r s i n g behaviours i n c l u d e d on the s a t i s f a c t i o n q u e s t i o n n a i r e .  Hypothesis  3 was  hypotheses.  handled  An average  i n a s i m i l a r f a s h i o n as t h e p r e v i o u s s a t i s f a c t i o n score was  two  o b t a i n e d f o r each  behaviour  f o r both p a t i e n t s and n u r s e s .  s c o r e was  o b t a i n e d by summing a l l t h e s a t i s f a c t i o n v a l u e s f o r each  behaviour.  F o r example:  The average  i f a q u e s t i o n y i e l d e d 20 s c o r e s o f  5 s c o r e s o f -3, and 5 s c o r e s o f -5, t h e average would be 60.  satisfaction  satisfaction  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  t o a s c e r t a i n the degree o f agreement between p a t i e n t s and r e l a t e d to the v a r i a b l e o f Hypothesis  4.  +5, score applied  nurses  satisfaction.  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  1  and n u r s e s ' p e r c e p t i o n o f the  o c c u r r e n c e o f each s p e c i f i c primary n u r s i n g behaviour  i n c l u d e d i n the  satisfaction  questionnaire. T h i s h y p o t h e s i s r e l a t e d t o t h e d i f f e r e n c e s between the p a t i e n t s ' n u r s e s ' p e r c e p t i o n o f the o c c u r r e n c e o f the b e h a v i o u r . o f each o f the t h r e e a l t e r n a t i v e s were o b t a i n e d . p a t i e n t s , as a group, may  The  frequencies  F o r example:  answer a s p e c i f i c statement  and  the  w i t h 10 ' t r u e '  47.  responses,  5 ' f a l s e ' responses, and 15 'not a p p l i c a b l e '  responses.  The n u r s e s , as a group, may answer t h a t same statement w i t h 20 responses and 9 ' f a l s e ' responses. t o t h e data t o determine  A c h i - s q u a r e a n a l y s i s was a p p l i e d  i f t h e r e 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 o f t h e responses t o ' t r u e ' , Hypothesis  5.  'true'  ' f a l s e ' , and 'not a p p l i c a b l e ' .  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 t h e p a t i e n t s ' and t h e n u r s e s ' r a t i n g o f t h e importance  o f each s p e c i f i c p r i m a r y n u r s i n g  behaviour included  i n the s a t i s f a c t i o n  questionnaire. To a n a l y s e t h e d a t a r e l a t e d t o t h i s h y p o t h e s i s , a l l t h e responses o f each group r a t i n g t h e importance were added t o g e t h e r .  o f each primary n u r s i n g b e h a v i o u r ,  F o r example:  i f , when r a t i n g t h e importance o f  a s p e c i f i c b e h a v i o u r , t h e p a t i e n t group gave 3 responses o f 1, 4 responses o f 3, 8 responses o f 4 and 14 responses o f 5, each o f t h e s e responses would be t a l l i e d .  A s i m i l a r procedure would o c c u r f o r the  n u r s e s ' response t o t h e same b e h a v i o u r .  A Student's t t e s t was then  a p p l i e d t o t h e d a t a i n o r d e r t o determine which o f t h e b e h a v i o u r s had importance  s c o r e s t h a t 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 t h e two groups.  H y p o t h e s i s 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 t h e n u r s e s ' and p a t i e n t s ' s c o r e s f o r s a t i s f a c t i o n w i t h each s p e c i f i c primary n u r s i n g b e h a v i o u r included i n the s a t i s f a c t i o n questionnaire.  48 . Hypothesis 6 was handled i n a similar fashion as the previous hypothesis. A l l the s a t i s f a c t i o n responses of each group for each s p e c i f i c behaviour were added together.  For example:  i f the nurses' s a t i s f a c t i o n scores  for a s p e c i f i c 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 t e s t was then applied to the  data to see where the nurses' s a t i s f a c t i o n scores were s i g n i f i c a n t l y d i f f e r e n t from the patients' s a t i s f a c t i o n scores f o r each s p e c i f i c primary nursing behaviour. The data generated by t h i s investigation  was either nominal or  ordinal data and therefore only non-parametric s t a t i s t i c s ought to have been used.  I t was recognized that the t t e s t , used to analyse the data  related to hypotheses 5 and 6, i s a parametric t e s t . U t e s t i s the correct test f o r t h i s type of data.  The Mann-Whitney  Due to the ease and  r a p i d i t y with which the t t e s t could be computed by existing computer f a c i l i t i e s , i t was u t i l i z e d i n order to scan the data to see which of the behaviours the two groups rated s i g n i f i c a n t l y d i f f e r e n t .  Data  y i e l d i n g i n s i g n i f i c a n t t r a t i o s would also have yielded s i m i l a r with the Mann-Whitney U t e s t .  results  Conversely, t r a t i o s that were well  above the c r i t i c a l value of t were derived from data which would also generate s i g n i f i c a n t differences i n means using the Mann-^Whitney U t e s t . Those results that were s i g n i f i c a n t with the t t e s t were also computed using the Mann-Whitney U t e s t to ensure that the differences were also s i g n i f i c a n t when using the correct non-parametric analysis which i s less e f f i c i e n t .  49.  T h i s c h a p t e r has i n c l u d e d participants  involved  a d e s c r i p t i o n o f t h e s e t t i n g and the  i n t h e study.  The t o o l s used t o measure t h e  v a r i a b l e o f p r i m a r y n u r s i n g were d e s c r i b e d data a n a l y s i s  and d i s c u s s e d , as was t h e  r e l a t e d t o t h e proposed hypotheses.  50.  CHAPTER IV  DATA ANALYSIS AND  RESULTS  T h i s c h a p t e r d e a l t w i t h the a n a l y s i s o f the d a t a . three  sources o f d a t a :  the q u e s t i o n n a i r e s . p r e s e n t e d and  The  Patient The  There were  the c h a r t c h e c k l i s t s , the p a t i e n t p r o f i l e s ,  The  d a t a from each o f t h e s e t h r e e  sources  Profile  purpose o f the p a t i e n t p r o f i l e was  t o o b t a i n demographic data 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 o f the p a t i e n t s and t h e i r w i t h primary n u r s i n g . s i x t y y e a r s o f age,  Previous  research  twenty y e a r s o f age, single patients.  shown t h a t p a t i e n t s over  1  The  (see Appendix E ) .  of o b s t e t r i c a l p a t i e n t s ) ,  p r o p o r t i o n o f each o f t h e s e c h a r a c t e r i s t i c s not  seen t o i n f l u e n c e the  satisfaction  L e s s than h a l f o f the respondents were male.  o f the respondents were under the age  of sixty.  o f the 29 p a t i e n t s had been p r e v i o u s l y exposed t o p r i m a r y through a p a s t a d m i s s i o n t o the h o s p i t a l where the place.  M a r i t a l s t a t u s was  reported  care than d i d p a t i e n t s under  women (with the e x c e p t i o n  i n the sample o f p a t i e n t s was  A l l but one  has  satisfaction  male p a t i e n t s and p a t i e n t s t h a t are m a r r i e d  greater s a t i s f a c t i o n with t h e i r nursing  scores  was  discussed.  r e l a t e d t o the p a t i e n t i n o r d e r t o see i f t h e r e was  and  and  not  Only  12  nursing  i n v e s t i g a t i o n took  i n c l u d e d on the p r o f i l e but  the i n v e s t i g a t o r , o f the p a t i e n t s ' r e g i s t r a t i o n i n f o r m a t i o n  a check, by indicated  t h a t 16 o f the 29 were unmarried a t the time o f t h e i r h o s p i t a l i z a t i o n .  F. A b d e l l a h and E. L e v i n e , "What F a c t o r s A f f e c t P a t i e n t s ' O p i n i o n s o f T h e i r N u r s i n g Care", H o s p i t a l s , XXXI, Nov. 16 (1957), pp. 61-64.  51.  I t appeared t h a t the degree o f s a t i s f a c t i o n w i t h primary  nursing  would n o t be b i a s e d by the d i s p r o p o r t i o n a t e presence o f any f o u r v a r i a b l e s o f age,  of  these  sex, m a r i t a l s t a t u s , o r p r e v i o u s exposure t o  primary n u r s i n g .  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 t o monitor at l e a s t one  p r i m a r y nurse. T a b l e 4.1).  c h a r t o f each  There were f o u r t e e n c h a r t c h e c k l i s t s completed  The  m a j o r i t y o f the data was  while the p a t i e n t s were s t i l l  c o l l e c t e d from t h e  in hospital.  (see  charts  However, f i v e c h a r t s were  checked r e t r o s p e c t i v e l y . A l l o f the c h a r t s mentioned a d i s c u s s i o n w i t h the p a t i e n t r e g a r d i n g h i s o r her d i s c h a r g e p l a n s .  A l l of  f o u r t e e n c h a r t s had w r i t t e n care p l a n s w i t h i n t e r v e n t i o n s t h a t a t w e n t y - f o u r hour p e r i o d o f time. i n d i c a t e d t h a t t h e primary, nurse had primary t h e r a p i s t .  Eleven  i n medical medical  Only two  the  no  These c h a r t s were monitored  t h a t i n f o r m a t i o n may  records l i b r a r i a n .  charts  contained  Four o f the c h a r t s c o n t a i n e d  t h e p r i m a r y nurse was.  r e c o r d s and  covered  i n t e r v i e w e d the p a t i e n t w i t h  o f the f o u r t e e n c h a r t s a l s o  evaluations of interventions. i n d i c a t i o n o f who  E l e v e n o f the f o u r t e e n  the  have been removed by  the  o f the f o u r t e e n c h a r t s i n d i c a t e d  t h a t the p a t i e n t had been o r i e n t e d t o the u n i t .  T h i s low number  may  r e f l e c t t h e f a c t t h a t the p r i m a r y n u r s e o f t e n asked o t h e r p a t i e n t s t o o r i e n t a t e a new p a t i e n t had  patient.  Two  o f the fourteen charts i n d i c a t e d t h a t  an appointment w i t h the t h e r a p i s t who  her a f t e r d i s c h a r g e .  would f o l l o w him  F i v e charts i n d i c a t e d that e i t h e r the  the or  referring  d o c t o r or the p a t i e n t ' s t h e r a p i s t i n h o s p i t a l would be resuming o r  52. c o n t i n u i n g w i t h t h e p a t i e n t s treatment 1  after discharge.  The r e m a i n i n g  seven c h a r t s c o n t a i n e d no mention o f t h e p a t i e n t s making c o n t a c t w i t h the t h e r a p i s t who would be working w i t h them a f t e r they l e f t  hospital.  E l e v e n o f t h e f o u r t e e n c h a r t s i n d i c a t e d some c o n t a c t w i t h t h e f a m i l y had been d i s c u s s e d .  Of'the  remaining  t h r e e c h a r t s ; one i n d i c a t e d t h a t  f a m i l y c o n t a c t was n o t a p p l i c a b l e , and t h e o t h e r two made no mention o f contacting the family. TABLE 4.1 Summary o f R e s u l t s From t h e C h a r t C h e c k l i s t  Primary N u r s i n g Behaviours Orientation Discussion of discharge plans I n t r o d u c t i o n o f the discharge t h e r a p i s t  Written plans  Charted  Not Charted  2  10  Miscellaneous 2 were r e admitted  14  5  2  2 - had appointment 5 - f o l l o w e d by referring physician or hospital  care  Primary nurse i n d i c a t e d on c h a r t  14  8  4  Evaluation of interventions  11  3  Significant events  14  Interviewed with primary t h e r a p i s t  11  Care p l a n i n d i c a t e d 24 hour i n t e r v e n t i o n s  14  Family contact indicated  11  2  Discussed p o t e n t i a l problems on d i s c h a r g e  14  2  2 indicated elsewhere on ward  3  1 - not a p p l i c a b l e  53. The Q u e s t i o n n a i r e s The d a t a from the q u e s t i o n n a i r e s was the s i x hypotheses  analysed i n r e l a t i o n t o  and consequently t h a t was  how  i t was  presented i n  t h i s chapter. H y p o t h e s i s 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 n u r s e s ' p e r c e p t i o n o f t h e o c c u r r e n c e o f the i t e m i z e d primary n u r s i n g b e h a v i o u r s  included  on t h e s a t i s f a c t i o n q u e s t i o n n a i r e . 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 d a t a r e l a t e d t o the o c c u r r e n c e o f the p r i m a r y n u r s i n g b e h a v i o u r s was The  .82  (see T a b l e  4.2).  c r i t i c a l v a l u e o f 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 a t the 2  .01 l e v e l i s .53.  The  s c o r e o f .82  i n d i c a t e d t h a t t h e r e was  c o r r e l a t i o n between the b e h a v i o u r s t h a t both nurses and r e p o r t e d as o c c u r r i n g .  The n u l l h y p o t h e s i s was  a strong  patients  rejected.  In o r d e r t o compute 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  n e c e s s a r y t o rank the d a t a r e l a t e d t o the o c c u r r e n c e o f t h e p r i m a r y  nursing behaviours.  The a c t o f r a n k i n g t h e d a t a enabled the  investigator  t o see which p r i m a r y n u r s i n g b e h a v i o u r s b o t h nurses and p a t i e n t s r e p o r t e d o c c u r r i n g most f r e q u e n t l y .  Both groups acknowledged t h a t the primary  nurse spent time w i t h the p a t i e n t when the p a t i e n t was  upset.  They a l s o  r e p o r t e d t h a t the p r i m a r y nurse worked w i t h the p a t i e n t every time he o r she was  on day o r a f t e r n o o n s h i f t and t h a t the p r i m a r y nurse gave  clear instructions.  P a t i e n t s and nurses s t a t e d t h a t the p r i m a r y  G. Ferguson, S t a t i s t i c a l A n a l y s i s i n Psychology and E d u c a t i o n , 4th ed., (Toronto: McGraw-Hill Book Company, 1976), p. 495.  nurse  54. encouraged the p a t i e n t t o say what he or she thought h i s o r her were and  problems  t h a t the p r i m a r y nurse gave the p a t i e n t feedback about h i s  or  her p r o g r e s s i n h o s p i t a l . Both p a t i e n t s and  nurses r e p o r t e d  o r i e n t a t e d the p a t i e n t t o the u n i t .  t h a t the primary nurse seldom  The  p a t i e n t s themselves were  encouraged t o o r i e n t a t e newly admitted p e r s o n s .  I t was  felt  that  o r i e n t a t i o n by o t h e r p a t i e n t s f a c i l i t a t e d the  i n t e g r a t i o n and  o f the new  patients reported  p a t i e n t i n t o the ward.  Nurses and  d i s c u s s i o n between the p r i m a r y nurse and a f t e r discharge  occurred  H y p o t h e s i s 2.  the p a t i e n t r e g a r d i n g  w i t h l e s s frequency.  f e l t t h a t the primary nurse was There i s no  adjustment that medication  N e i t h e r p a t i e n t s o r nurses  known t o the p a t i e n t ' s f a m i l y and c o r r e l a t i o n between the n u r s e s '  the p a t i e n t s ' r a t i n g s o f the importance o f  friends. and  the  itemized primary nursing behaviours included the The  satisfaction  questionnaire.  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 d a t a r e l a t e d t o  importance o f the p r i m a r y n u r s i n g b e h a v i o u r s was T h i s s c o r e was It  a l s o s i g n i f i c a n t at the  .01  .87  (see T a b l e  the  4.2).  level for a one-tailed test.  i n d i c a t e d a h i g h degree o f agreement between p a t i e n t s and n u r s e s  the r e l a t i v e importance o f the primary n u r s i n g b e h a v i o u r s . h y p o t h e s i s was  The  on  null  rejected.  B o t h nurses and p a t i e n t s r e p o r t e d  t h a t i t was  the primary nurse t o ask the p a t i e n t f o r a p e r s o n a l his  on  or her problems and  progress i n h o s p i t a l . p r i m a r y nurse and  most important f o r identification  t o g i v e the p a t i e n t feedback on h i s or Both groups f e l t i t was  of  her  most important f o r the  the p r i m a r y t h e r a p i s t t o work c l o s e l y t o g e t h e r  and  55.  for  a l l t h e nurses t h a t worked w i t h t h e p a t i e n t t o understand why  the p a t i e n t was i n h o s p i t a l . Both p a t i e n t s and nurses r e p o r t e d i t was l e s s important t h a t the p a t i e n t ' s f a m i l y and f r i e n d s know t h e p r i m a r y nurse's name.  Both  groups acknowledged i t was l e s s important f o r t h e p r i m a r y nurse t o have c o n t a c t w i t h t h e p a t i e n t ' s f a m i l y o r f o r t h e primary nurse t o be p r e s e n t in  interviews with the primary t h e r a p i s t .  P a t i e n t s and n u r s e s r e p o r t e d  i t was l e s s important f o r t h e p r i m a r y nurse t o o r i e n t a t e t h e p a t i e n t t o the u n i t . Hypothesis 3.  There i s no c o r r e l a t i o n between t h e n u r s e s ' and the p a t i e n t s ' r a t i n g s o f the l e v e l o f importance of  the itemized primary nursing behaviours  included  on t h e q u e s t i o n n a i r e . 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 t h e d a t a r e l a t e d t o t h e s a t i s f a c t i o n w i t h t h e p r i m a r y n u r s i n g b e h a v i o u r s was .33 (see T a b l e 4.2). T h i s score was below the c r i t i c a l v a l u e f o r t h e Spearman Rank C o r r e l a t i o n C o e f f i c i e n t a t t h e .05 l e v e l . to  The reason f o r t h i s seemed t o be r e l a t e d  t h e method o f a r r i v i n g a t t h e s a t i s f a c t i o n s c o r e .  the importance  By m u l t i p l y i n g  s c o r e by both p o s i t i v e and n e g a t i v e v a l u e s i n o r d e r t o  a r r i v e a t t h e s a t i s f a c t i o n s c o r e , the range o f responses was doubled t o i n c l u d e n e g a t i v e as w e l l as p o s i t i v e numbers. r e s u l t e d i n an i n c r e a s e i n v a r i a n c e . to  T h i s i n c r e a s e i n range  Consequently,  i t was v e r y  difficult  d e t e c t t h e c o r r e l a t i o n between t h e two groups on t h e v a r i a b l e o f  satisfaction.  The n u l l h y p o t h e s i s was n o t , t h e r e f o r e ,  rejected.  56. Both patients and nurses reported s a t i s f a c t i o n when the primary nurse cared f o r the patient each time he or she was on days or afternoons, when the primary nurse gave the patient feedback about h i s or her progress i n hospital and when the primary nurse encouraged the patient to have input into the treatment plan by asking the patient to i d e n t i f y what he or she thought h i s or her problems were. Behaviours that were less s a t i s f y i n g were related to the primary nurse orientating the patient t o the unit, the primary, nurse explaining the system of primary nursing and the primary nurse discussing with the  patient when to take h i s or her medication a f t e r discharge. I t  must be remembered that due t o 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 scores, 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 could be a r e s u l t 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 s p e c i f i c primary nursing behaviour.  TABLE 4.2 Summary of the Spearman Rank Correlation C o e f f i c i e n t s f o r Hypotheses 1,2,3 Sum of the Differences Squared Hypothesis 1 Occurrence Hypothesis 2 Importance Hypothesis 3 Satisfaction  N  Spearman Rank Correlation Coefficient  241.25  20  .82  172.0  20  .87  894.5  20  .33  57.  H y p o t h e s i s 4.  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 t h e p a t i e n t s ' and n u r s e s ' p e r c e p t i o n o f t h e o c c u r r e n c e o f each s p e c i f i c p r i m a r y n u r s i n g b e h a v i o u r i n c l u d e d i n th» s a t i s f a c t i o n que s t ionna i r e .  Because t h e i n f o r m a t i o n r e l a t e d t o t h i s h y p o t h e s i s was i n t h e form o f frequency d a t a , c h i square was used i n t h e a n a l y s i s .  In o r d e r  f o r t h e r e t o 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 n u r s e s ' and p a t i e n t s ' r e p o r t o f the o c c u r r e n c e o f t h e primary n u r s i n g b e h a v i o u r s ,  3 the  v a l u e o f c h i square needed t o exceed 9.21.  T h i s number  r e p r e s e n t s t h e c r i t i c a l v a l u e o f c h i square a t t h e .01 l e v e l w i t h 2 degrees o f freedom. There were t h r e e b e h a v i o u r s where t h e response o f . t h e n u r s e s and p a t i e n t s 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 T a b l e 4.3. f i r s t primary n u r s i n g b e h a v i o u r r e l a t e d t o g i v i n g c l e a r  The  instructions;  the second, t o g i v i n g feedback t o the p a t i e n t about h i s o r h e r p r o g r e s s i n h o s p i t a l ; and t h e t h i r d , t o encouraging t h e p a t i e n t t o i d e n t i f y what he o r she thought h i s o r h e r problems were. The d i f f e r e n c e s between the two groups on each o f t h e s e t h r e e b e h a v i o u r s was due t o the r e p o r t , by t h e n u r s e s , t h a t t h e b e h a v i o u r s o c c u r r e d 100 p e r c e n t o f t h e time. response o f t h e p a t i e n t s .  T h i s f i g u r e was n o t supported i n t h e  The p r i m a r y n u r s e s may presume t h e y a r e  c a r r y i n g o u t these b e h a v i o u r s w i t h o u t v a l i d a t i n g the o c c u r r e n c e o f them with t h e i r patients.  G. Ferguson, S t a t i s t i c a l A n a l y s i s i n Psychology and E d u c a t i o n , 4th ed., (Toronto: McGraw-Hill Book Company,. 1976), p. 488.  58. TABLE  4.3  Behaviours t h a t Demonstrated S i g n i f i c a n t D i f f e r e n c e s i n Occurrence  Primary N u r s i n g Behaviours  Value o f C h i Square  Degrees o f Freedom  Giving clear instructions  2  9.99  G i v i n g feedback t o the p a t i e n t s re t h e i r progress  2  9.99  Encouraging t h e patients to i d e n t i f y t h e i r own problems  2  Hypothesis  5.  1  9.99  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 p a t i e n t s ' and the n u r s e s ' r a t i n g s o f importance each s p e c i f i c primary n u r s i n g b e h a v i o u r  of  included  i n the s a t i s f a c t i o n q u e s t i o n n a i r e . In o r d e r f o r the d i f f e r e n c e t o be s i g n i f i c a n t , the t e s t v a l u e o f t needed t o exceed t h e c r i t i c a l  v a l u e o f t a t the  tailed test.  m i s s i n g d a t a on some o f the q u e s t i o n n a i r e s  the  degrees  precision,  S i n c e t h e r e was  o f freedom v a r i e d .  the c r i t i c a l  .01 l e v e l f o r a  one-  However, a t an a p p r o p r i a t e l e v e l o f  v a l u e o f t f o r the degrees  o f freedom, which  4 ranged  from 53 t o 56, remained e s s e n t i a l l y  2.40.  See T a b l e 4.4  the c r i t i c a l  v a l u e s o f U i n the Mann-Whitney U t e s t f o r the  values of N  and N  for  corresponding  , where t h e s e v a l u e s 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 E d u c a t i o n , (Toronto: John W i l e y and Sons, I n c o r p o r a t e d , 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 T e s t  Patients N  Nurses  l  N  2  , 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 d i f f e r e n c e s i n the r a t i n g o f importance between nurses and p a t i e n t s were found f o r t h e f o l l o w i n g p r i m a r y n u r s i n g behaviours: (1)  c h e c k i n g the p a t i e n t ' s u n d e r s t a n d i n g  (2)  telling  (3)  encouraging  of instructions,  t h e p a t i e n t how he o r she was p r o g r e s s i n g i n h o s p i t a l , t h e p a t i e n t ' s f a m i l y t o be i n v o l v e d i n t h e  treatment program, (4)  e s t a b l i s h i n g and m a i n t a i n i n g c o n t a c t w i t h the p a t i e n t ' s f a m i l y ,  (5)  p r e p a r i n g t h e p a t i e n t t o d e a l w i t h problems he o r she may encounter  a f t e r discharge.  See T a b l e 4.6 f o r a summary o f the t and U v a l u e s f o r t h e above s i g n i f i c a n t behaviours.  Once a g a i n , a l l o f the d i f f e r e n c e s were due  60.  to  a h i g h e r r a t i n g o f importance  compared w i t h  on the p a r t o f the nurses when  the p a t i e n t s . TABLE  4.5  Behaviours t h a t Demonstated S i g n i f i c a n t D i f f e r e n c e s i n Importance  Primary Nursing Behaviours  Value of t  Degrees of Freedom  Value of U  Checking p a t i e n t ' s understanding o f i n s t r u c t i o n s  55  2.57  150  T e l l i n g p a t i e n t about h i s progress i n h o s p i t a l  56  3.14  225  Encouraging f a m i l y i n v o l v e ment i n program  54  3.55  202  E s t a b l i s h i n g and m a i n t a i n i n g 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 t h e n u r s e s ' and p a t i e n t s ' s c o r e s f o r s a t i s f a c t i o n w i t h each s p e c i f i c primary n u r s i n g b e h a v i o u r included i n the s a t i s f a c t i o n q u e s t i o n n a i r e .  In  o r d e r f o r the d i f f e r e n c e between the two  the t e s t v a l u e o f t needed t o exceed .01 l e v e l f o r a o n e - t a i l e d t e s t .  groups t o be  significant,  the c r i t i c a l v a l u e o f t a t the  These c r i t i c a l v a l u e s have been  cited. 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 between p a t i e n t s and nurses o c c u r r e d f o r the f o l l o w i n g p r i m a r y n u r s i n g b e h a v i o u r s :  61.  (1)  checking the p a t i e n t ' s understanding o f i n s t r u c t i o n s ,  (2)  c o n t a c t i n g and b e i n g known by t h e p a t i e n t ' s f a m i l y and friends,  (3)  e x p l a i n i n g t h e h o s p i t a l program t o t h e p a t i e n t ,  (4)  encouraging t h e involvement o f t h e p a t i e n t ' s  family  i n t h e treatment program, (5)  g i v i n g t h e p a t i e n t feedback r e g a r d i n g h i s o r h e r progress i n h o s p i t a l ,  (6)  working w i t h t h e p a t i e n t whenever t h e p r i m a r y nurse was on days o r evenings.  See T a b l e 4.7 f o r a summary o f t h e t and 13 v a l u e s f o r each o f t h e above s i x b e h a v i o u r s . nurses, as a group, the p a t i e n t s .  As b e f o r e , f o r each o f t h e s e b e h a v i o u r s t h e  r a t e d these b e h a v i o u r s more h i g h l y than d i d  TABLE 4.6 B e h a v i o u r s That Demonstrated S i g n i f i c a n t Differences i n Satisfaction  Degrees of Freedom  Primary Nursing Behaviours  Value of t  Value of U  Checking p a t i e n t ' s understanding o f 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 t i e n t about h i s progress i n h o s p i t a l  56  2.8  268  Encouraging Family i n v o l v e ment  56  3.6  207  E x p l a i n i n g 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 the f a m i l y  56  4.9  233  Working w i t h t h e p a t i e n t when on duty  54  2.4  272  B e i n g known by f a m i l y and f r i e n d s  55  7.1  37  with  From t h e d a t a i t would seem t h a t t h e nurses o v e r - r e p o r t e d the o c c u r r e n c e o f c e r t a i n b e h a v i o u r s , b o t h i n t h e i r c h a r t i n g and i n t h e i r response t o t h e q u e s t i o n n a i r e . d i s c h a r g e i s an example.  P l a n n i n g and d i s c u s s i o n r e l a t e d t o  However, b o t h t h e c h a r t i n g and t h e r e p o r t  o f p a t i e n t s and nurses c o n f i r m e d t h e f a c t t h a t t h e p r i m a r y  nurse  does n o t o r i e n t a t e t h e p a t i e n t t o the u n i t . The d a t a a n a l y s i s r e l a t e d t o H y p o t h e s i s 1 i n d i c a t e d t h a t t h e p r i m a r y nurses seemed t o be i n v o l v e d w i t h t h e i r p a t i e n t s ;  spending  63.  time w i t h t h e p a t i e n t when he o r she was upset, working w i t h the p a t i e n t when on duty, and g i v i n g t h e p a t i e n t feedback r e g a r d i n g h i s or her progress i n h o s p i t a l .  The data a l s o i n d i c a t e d t h a t t h e p r i m a r y  nurse was l e s s i n v o l v e d w i t h t h e p a t i e n t s f a m i l y b u t t h i s was seen 1  by b o t h groups as l e s s  important.  P a t i e n t s and nurses r e l a t e d t h a t i t was important and s a t i s f y i n g f o r t h e p a t i e n t t o be i n v o l v e d i n h i s o r h e r c a r e .  T h i s c o u l d happen  by a s k i n g t h e p a t i e n t what he o r she t h i n k s a r e t h e problems t h a t brought him o r h e r t o h o s p i t a l .  I t could- a l s o happen when t h e p r i m a r y  nurse g i v e s t h e p a t i e n t feedback about h i s o r h e r p r o g r e s s i n h o s p i t a l . Although both p a t i e n t s and n u r s e s r e p o r t e d t h a t i t was important f o r the  p r i m a r y nurse and the p r i m a r y t h e r a p i s t t o work c l o s e l y t o g e t h e r ,  they d i d n o t seem t o see j o i n t i n t e r v i e w i n g as a way o f a c c o m p l i s h i n g this. The s i g n i f i c a n t d i f f e r e n c e between t h e r e p o r t o f t h e o c c u r r e n c e , importance o r s a t i s f a c t i o n o f t h e nurses as compared w i t h t h e p a t i e n t s c o u l d be due t o t h e n u r s e s ' o v e r - r e p o r t i n g . An example might be t h e n u r s e s ' r e p o r t o f t h e o c c u r r e n c e o f such b e h a v i o u r s as g i v i n g i n s t r u c t i o n s o r e x p l a i n i n g primary nursing.  The r e p o r t o f t h e  o c c u r r e n c e o f such b e h a v i o u r s would be t h e p r o f e s s i o n a l l y response.  clear  desirable  The same c o u l d be t r u e f o r the n u r s e s ' importance  rating of  b e h a v i o u r s such as encouraging f a m i l y involvement i n t h e treatment program and p r e p a r i n g t h e p a t i e n t f o r d i s c h a r g e . a l s o be due t o t h e p a t i e n t s ' u n d e r - r e p o r t i n g .  The d i f f e r e n c e c o u l d  Perhaps they a r e u n w i l l i n g  f o r t h e i r f a m i l y t o be i n v o l v e d and consequently r a t e i t as l e s s i m p o r t a n t .  64.  I t seemed t h a t the two major a r e a s o f d i f f e r e n c e were r e l a t e d t o d i s c h a r g e and f a m i l y involvement.  Both p a t i e n t s and n u r s e s r e p o r t e d  l e s s o c c u r r e n c e o f c e r t a i n b e h a v i o u r s r e l a t e d t o these two  areas and  a t t r i b u t e d l e s s importance  involvement.  t o behaviours r e l a t e d to family  Nurses acknowledged t h a t p r i m a r y n u r s i n g b e h a v i o u r s r e l a t e d t o d i s c h a r g e and f a m i l y involvement o c c u r r e d more o f t e n and were more important than d i d the p a t i e n t s .  B o t h t h e s e areas a r e d e s c r i b e d i n t h e 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 p r i m a r y n u r s i n g . The b e h a v i o u r s t h a t y i e l d e d s i g n i f i c a n t d i f f e r e n c e s i n t h e responses o f nurses and p a t i e n t s may satisfying.  have o c c u r r e d and may  have been important  The a n a l y s i s merely shows t h a t , f o r c e r t a i n b e h a v i o u r s ,  t h e responses o f the two groups were s i g n i f i c a n t l y  different.  and  65.  CHAPTER V  SUMMARY  The purpose  o f t h i s study was t o d e v i s e a t o o l and t o c o l l e c t  i n f o r m a t i o n r e l a t e d t o t h e p e r c e p t i o n s o f p a t i e n t s and nurses primary n u r s i n g .  about  The i n v e s t i g a t o r c o n s i d e r e d i t v e r y important t o  i n c o r p o r a t e t h e p e r c e p t i o n s o f p a t i e n t s , as w e l l as n u r s e s , i n t h e e v a l u a t i o n o f primary nursing.  In o r d e r t o accomplish t h i s , a  q u e s t i o n n a i r e was a d m i n i s t e r e d t o twenty-nine p a t i e n t s and t h e i r primary nurses d u r i n g t h e l a s t week o f t h e p a t i e n t ' s  hospitalization.  The q u e s t i o n n a i r e y i e l d e d d a t a r e l a t e d t o t h e o c c u r r e n c e ,  importance  and s a t i s f a c t i o n o f t h e s p e c i f i c p r i m a r y n u r s i n g b e h a v i o u r s .  CONCLUSIONS  The  study was conducted on a p s y c h i a t r i c u n i t and i t i s d i f f i c u l t  t o know how much t h e r e s u l t s can be g e n e r a l i z e d .  F o r example:  one  o f t h e r e s u l t s from t h e q u e s t i o n n a i r e was r e l a t e d t o t h e p r i m a r y n u r s e s o r i e n t a t i n g t h e newly admitted p a t i e n t .  .  ,  B o t h p a t i e n t s and  nurses acknowledged t h a t t h e o r i e n t a t i o n by t h e primary nurse d i d n o t o c c u r and i t was n o t i m p o r t a n t .  One c o u l d deduce t h a t i t was n o t  n e c e s s a r y f o r t h e p r i m a r y nurse t o o r i e n t a t e t h e p a t i e n t and, i n f a c t , she o r he seldom d i d .  P a t i e n t s who had been h o s p i t a l i z e d f o r a p e r i o d  o f time u s u a l l y o r i e n t a t e d p a t i e n t s who were newly a d m i t t e d .  However,  t h i s procedure might o n l y be f e a s i b l e on u n i t s where t h e p a t i e n t  66.  l e n g t h o f s t a y was  l o n g e r and where some p a t i e n t s were  R e h a b i l i t a t i o n a r e a s , extended  c a r e , p s y c h i a t r y and some m e d i c a l u n i t s  are examples o f these t y p e s o f a r e a s . c o n s t r u c t e d i n such a way  ambulatory.  Although the q u e s t i o n n a i r e was  t h a t t h e p r i m a r y n u r s i n g b e h a v i o u r s were  not s p e c i f i c t o p s y c h i a t r y , the g e n e r a l i z a t i o n o f t h e r e s u l t s t o o t h e r n u r s i n g a r e a s may  be somewhat l i m i t e d .  Both nurses and p a t i e n t s were i n h i g h agreement i n t h e i r p e r c e p t i o n o f the o c c u r r e n c e and importance o f the p r i m a r y n u r s i n g b e h a v i o u r s . Where t h e r e were s i g n i f i c a n t d i f f e r e n c e s i n t h e i r p e r c e p t i o n s , i t was due t o h i g h e r r a t i n g s on the p a r t o f the n u r s e s f o r - t h e o c c u r r e n c e , importance  and s a t i s f a c t i o n o f the p r i m a r y n u r s i n g b e h a v i o u r s .  The p a t i e n t s and n u r s e s r e p o r t e d low o c c u r r e n c e s c o r e s f o r b e h a v i o u r s r e l a t e d t o d i s c h a r g e and f a m i l y c o n t a c t . low importance  They a l s o r e p o r t e d  s c o r e s f o r the p r i m a r y n u r s i n g b e h a v i o u r s  w i t h f a m i l y c o n t a c t and involvement.  associated  B o t h groups f e l t p l a n n i n g and  d i s c u s s i o n r e l a t e d t o d i s c h a r g e were v e r y important.  For patients,  t h e i r r e p o r t e d non-occurrence o f t h e s e b e h a v i o u r s r e l a t e d t o d i s c h a r g e and the h i g h importance  they a t t r i b u t e d t o them r e s u 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 n u r s i n g behaviours. The  low o c c u r r e n c e and importance  s c o r e s a t t r i b u t e d by both groups  t o primary n u r s i n g b e h a v i o u r s r e l a t e d t o f a m i l i e s was  unexpected.  F a m i l y involvement was  The  may  o f t e n emphasized on the u n i t .  r e f l e c t the f a c t t h a t many p a t i e n t s d i d n o t have t h e i r  a v a i l a b l e f o r t h i s k i n d o f c o n t a c t and  low s c o r e s families  involvement.  Both p a t i e n t s and n u r s e s r e p o r t e d t h a t t h e p r i m a r y nurse  established  67. a r e l a t i o n s h i p w i t h the p a t i e n t by spending time w i t h the p a t i e n t encouraging the p a t i e n t ' s involvement T h i s was f i r s t met  and  and i n p u t i n t o the c a r e p l a n .  a concern expressed by the n u r s i n g s t a f f when t h e i n v e s t i g a t o r w i t h them t o d i s c u s s t h e study.  They f e l t t h a t one o f t h e  most important a s p e c t s o f primary n u r s i n g was  the r e l a t i o n s h i p  they  formed w i t h t h e i r p a t i e n t s and t h e y 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  o f the b a s i c q u e s t i o n s asked a t the b e g i n n i n g o f t h e  i n v e s t i g a t i o n was:  are p r i m a r y n u r s e s a c t u a l l y p r a c t i s i n g the b e h a v i o u r s  t h a t the l i t e r a t u r e a s c r i b e s t o p r i m a r y nursing?. With a few e x c e p t i o n s , the answer seems t o be  affirmative.  The second q u e s t i o n was  r e l a t e d t o t h e importance  Do p a t i e n t s and n u r s e s a s s i g n t h e same importance behaviours?  of the behaviours.  t o the p r i m a r y n u r s i n g  Again, except f o r a few exceptions,, the answer  was  affirmative. The t h i r d q u e s t i o n was nursing behaviours.  r e 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  T h i s q u e s t i o n was  o n l y p a r t i a l l y answered.  There  were d a t a generated which r e l a t e d t o . t h e s p e c i f i c b e h a v i o u r s b o t h groups r a t e d f o r h i g h and low s a t i s f a c t i o n .  There was  also information related  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 o f the behaviours.  I t was  d i f f i c u l t t o measure any degree  specific  of correlation  between nurses and p a t i e n t s on t h e s a t i s f a c t i o n w i t h t h e p r i m a r y nursing behaviours. An assumption  made a t the b e g i n n i n g o f the i n v e s t i g a t i o n was  that  p a t i e n t s 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 w i t h p r i m a r y  68.  n u r s i n g by responding  to a questionnaire.  t h a t assumption h e l d t r u e .  I t i s d i f f i c u l t t o know i f  Part o f the d i f f i c u l t y l a y i n the construction  o f t h e q u e s t i o n n a i r e and t h e method d e v i s e d t o compute t h e s a t i s f a c t i o n score.  Another c o n t r i b u t i n g f a c t o r was t h e p o s s i b i l i t y o f o v e r - r e p o r t i n g  on t h e p a r t o f t h e n u r s e s .  Were they g i v i n g the p r o f e s s i o n a l l y d e s i r a b l e  response t o some o f t h e statements on t h e q u e s t i o n n a i r e ?  Discussions  w i t h p a t i e n t s i n d i c a t e d t h a t some o f them p e r c e i v e d t h e q u e s t i o n n a i r e as an e v a l u a t i o n o f t h e i r own p r i m a r y n u r s e .  A few o f them commented, " I  gave you a good r e p o r t " , when d i s c u s s i n g the q u e s t i o n n a i r e w i t h t h e nurse i n casual  conversation.  I t i s a l s o d i f f i c u l t t o know how much t h e f a c t t h a t t h e q u e s t i o n n a i r e was g i v e n d u r i n g t h e week o f d i s c h a r g e nurses'  response.  a f f e c t e d b o t h t h e p a t i e n t s ' and  P a t i e n t s may have been very anxious d u r i n g t h i s time  a t t h e thought o f b e i n g d i s c h a r g e d .  T h e i r a n x i e t y may have d i s t o r t e d  t h e i r p e r c e p t i o n o f t h e statements on t h e q u e s t i o n n a i r e o r 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 t h e o t h e r hand, t h e p a t i e n t s may have  been so p l e a s e d t o go home and assumed t h a t t h e s t a f f and t h e h o s p i t a l i z a t i o n had s o l v e d 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 v e r y p o s i t i v e l i g h t . An attempt was made, by the i n v e s t i g a t o r , t o a d m i n i s t e r t h e q u e s t i o n n a i r e t o a s m a l l sample o f p a t i e n t s b e f o r e and a f t e r T h i s was t o a s s e s s t h e e f f e c t , i f any, o f d i s c h a r g e response t o t h e q u e s t i o n n a i r e .  discharge.  on t h e p a t i e n t ' s  The number o f p a t i e n t s r e t u r n i n g t h e  q u e s t i o n n a i r e a f t e r d i s c h a r g e was too /small t o draw any c o n c l u s i o n s from t h e d a t a .  69.  There were f o u r p a t i e n t s who  l e f t the h o s p i t a l i n a very  s t a t e o f mind.  Only one  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 t h a t the  sample may  angry  o f these p a t i e n t s consented t o complete a  have been somewhat skewed w i t h p a t i e n t s who  had  patient  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  I t was  d i s t u r b i n g t o see the  low o c c u r r e n c e s c o r e s  nursing behaviours r e l a t e d to discharge be  and  f o r primary  family contact.  This  may  a f a c t o r i n the h i g h r e - a d m i s s i o n r a t e o f p s y c h i a t r i c p a t i e n t s .  I f the p a t i e n t s have not been informed o f such t h i n g s as m e d i c a t i o n a f t e r discharge  and  l i t t l e d i s c u s s i o n has  a c t i v i t i e s and p r e p a r a t i o n  taken p l a c e  about p o s t - h o s p i t a l  f o r p o s s i b l e problems, t h e y may  f e e l and  i l l - e q u i p p e d t o handle the t r a n s i t i o n from h o s p i t a l t o home. f a m i l y has  not been i n v o l v e d w i t h the p a t i e n t d u r i n g h i s o r  h o s p i t a l i z a t i o n , they may  n o t g i v e t h e support and  p a t i e n t needs on d i s c h a r g e . and  I f the her  encouragement the  I t i s s i g n i f i c a n t to note that both p a t i e n t s  nurses r a t e d the p r i m a r y n u r s i n g b e h a v i o u r s a s s o c i a t e d w i t h  as h i g h l y i m p o r t a n t .  Perhaps the a c t u a l d i s c h a r g e  minimum o f communication between d i s c i p l i n e s . n u r s e may  It  is difficult  discharge  takes place with a  Consequently, the  n o t have s u f f i c i e n t time o r i n f o r m a t i o n  p a t i e n t prepare f o r  be  primary  to a c t u a l l y help  the  discharge. t o e x p l a i n the  low  scores  f o r the importance  occurrence of primary nursing behaviours r e l a t e d to family contact  and and  70.  involvement.  As  s t a t e d e a r l i e r , these  low s c o r e s may  be a  reflection  o f the - u n a v a i l a b i l i t y o f the p a t i e n t ' s f a m i l y f o r involvement contact.  I t i s conceivable  the occurrence  or  t h a t because t h e f a m i l y i s u n a v a i l a b l e ,  o f and' importance a t t r i b u t e d t o t h e b e h a v i o u r s  decreases.  Perhaps, h o s p i t a l i z a t i o n i s a time t o focus on t h e p a t i e n t and  family  involvement should have l e s s emphasis.  RECOMMENDATIONS  There seemed t o be  some l i m i t a t i o n s i n terms o f the  questionnaire.  Perhaps another method o f a r r i v i n g a t the s a t i s f a c t i o n s c o r e s might be devised.  In a d d i t i o n t o t h e q u e s t i o n n a i r e ,  be o b t a i n e d through i n t e r v i e w s .  f u r t h e r i n f o r m a t i o n might  A l t h o u g h t h i s i s a time consuming  method of d a t a c o l l e c t i o n ,  i t may  information.  a r e angry o r upset may-be more amenable t o  P a t i e n t s who  y i e l d more a c c u r a t e  and  complete  an i n t e r v i e w as compared t o a q u e s t i o n n a i r e . The  q u e s t i o n n a i r e c o u l d be  b e f o r e and any  after discharge.  administered  In t h i s way  t o a sample o f p a t i e n t s  i t would be p o s s i b l e t o d e t e c t  d i f f e r e n c e s i n response which might.be due  anxiety r e l a t e d to  discharge.  Because the study was o f the r e s u l t s i s l i m i t e d . another a r e a ,  low occurrence  behaviours  done on a p s y c h i a t r i c u n i t , t h e g e n e r a l i z a t i o n The  such as a m e d i c a l  f i n d i n g s o f t h i s study The  t o the i n f l u e n c e o f  i n v e s t i g a t i o n c o u l d be d u p l i c a t e d i n ward, i n o r d e r t o c o n f i r m . o r  negate  the  i n r e l a t i o n t o o t h e r areas o f n u r s i n g . o f and  importance a t t r i b u t e d t o p r i m a r y  a s s o c i a t e d w i t h f a m i l y involvement was  unexpected.  nursing This  area  /  71. might be'the f o c u s i n a subsequent The  low o c c u r r e n c e o f primary  s h o u l d be remedied.  investigation. nursing behaviours  related to discharge  In o r d e r t h a t a l l s t a f f are aware o f t h e p a t i e n t ' s  d i s c h a r g e d a t e , i t s h o u l d be d e c i d e d a t l e a s t one week b e f o r e and p o s t e d where b o t h t h e p a t i e n t and s t a f f can s e e . A d i s c h a r g e c h e c k l i s t might be added t o t h e c h a r t .  I t could i n c l u d e behaviours  such as d i s c u s s i o n o f  m e d i c a t i o n and d i s c u s s i o n o f p o s s i b l e p o s t - h o s p i t a l a c t i v i t i e s t h e p a t i e n t s h o u l d o r c o u l d engage i n . note when t h e b e h a v i o u r  The p a t i e n t and t h e nurse, t o g e t h e r , c o u l d  has taken p l a c e .  The c h e c k l i s t would h e l p  focus  the a t t e n t i o n o f b o t h the p a t i e n t and t h e primary nurse on t h e p r e p a r a t i o n of the p a t i e n t f o r discharge. The author p l a n s t o meet w i t h t h e n u r s i n g s t a f f a t t h e h o s p i t a l where t h e study took p l a c e i n o r d e r t o d i s c u s s t h e f i n d i n g s . expressed  i n t e r e s t i n h a v i n g t h i s feedback when they  the study.  The nurses  f i r s t met t o d i s c u s s  In a d d i t i o n t o d i s c u s s i n g the r e s u l t s , i t i s hopeful that the  nurses might have some i d e a s about how t o i n s t i t u t e changes p e r t i n e n t t o the f i n d i n g s .  F o r example:  how t o improve t h e d i s c h a r g e p l a n n i n g .  The  recommendations made e a r l i e r i n t h i s c h a p t e r a r e s u g g e s t i o n s t h a t t h e s t a f f c o u l d implement. The  However, they might have b e t t e r a l t e r n a t i v e s .  p o s s i b i l i t y e x i s t s t h a t , as p r i m a r y n u r s i n g i s implemented i n  o t h e r h o s p i t a l s i n t h e c i t y , t h e t o o l c o u l d be used as an e v a l u a t i v e measure.  T h i s would enable t h e i n v e s t i g a t o r t o see i f t h e r e s u l t s  from  t h i s study a r e s i m i l a r t o t h e d a t a generated when t h e t o o l i s u t i l i z e d in other nursing areas.  72.  T h i s study has attempted t o d e s c r i b e and e v a l u a t e p r i m a r y n u r s i n g p a r t i c u l a r l y as i t o c c u r s on a p s y c h i a t r i c u n i t .  I t has v a l i d a t e d  most o f t h e p r i m a r y n u r s i n g b e h a v i o u r s o c c u r and b o t h p a t i e n t s 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 o f p a t i e n t s i n t h e e v a l u a t i o n o f t h e i r c a r e .  that  72A .  BIBLIOGRAPHY  73. BIBLIOGRAPHY  BOOKS AND  ESSAYS  Brown, E. L. "Nursing and P a t i e n t Care", The N u r s i n g P r o f e s s i o n , F i v e S o c i o l o g i c a l E s s a y s , F. D a v i s , e d i t o r . New York: John Wiley & Sons I n c o r p o r a t e d , 1966. Campbell, W. G. Form and S t y l e i n T h e s i s W r i t i n g . Houghton M i f f l i n Company, 1969.  New  York:  Ferguson, G. A. S t a t i s t i c a l A n a l y s i s i n Psychology and E d u c a t i o n . 4 t h ed. T o r o n t o : McGraw-Hill Book Company, 1976. G l a s s e r , M. "Consumer E x p e c t a t i o n s o f H e a l t h S e r v i c e s " , M e d i c i n e i n a Changing World, L. Corey and S. Saltman, editors. 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. T o r o n t o : McGraw-Hill Book Company, 1952. Kramer, M. 1974.  R e a l i t y Shock.  St. Louis:  C.V. Mosby and Company,  Marram, G., M. S c h l e g e l and E. B e v i s . Primary St. L o u i s : C.V. Mosby and Company, 1974. Phaneuf, M. C. New York:  Nursing.  The N u r s i n g A u d i t : P r o f i l e f o r Excellence. Appleton-Century-Crofts, 1972.  Shaw, M. E. and J . M. Wright. S c a l e s f o r t h e Measurement o f Attitudes. New York: McGraw-Hill Book Company, 1967. S l a t e r , D. The S l a t e r N u r s i n g Competencies S c a l e . D e t r o i t : Wayne S t a t e U n i v e r s i t y , C o l l e g e o f N u r s i n g , 1967. T o g l i a c o z z o , D. L. "The Nurse From the P a t i e n t ' s P o i n t o f View", S o c i a l I n t e r a c t i o n and P a t i e n t Care, J.K. S k i p p e r and R.C. Leonard, e d i t o r s . T o r o n t o : J.B. L i p p i n c o t t Company, 1965. Tuckman, B. W. C o n d u c t i n g E d u c a t i o n a l Research. New H a r c o u r t , Brace, J o v a n o v i c h I n c o r p o r a t e d , 1972.  York:  Wandelt, M. and J . Ager. Quality P a t i e n t Care S c a l e . D e t r o i t : Wayne S t a t e U n i v e r s i t y , C o l l e g e o f N u r s i n g , 1970.  74. BIBLIOGRAPHY  (Contd.)  PERIODICALS A b d e l l a h , F. and E. L e v i n e . "Developing A Measure o f P a t i e n t & P e r s o n n e l S a t i s f a c t i o n With N u r s i n g Care", N u r s i n g Research, V, 3 (1957), 100-108. A b d e l l a h , F. and E. L e v i n e . "What F a c t o r s A f f e c t P a t i e n t s ' Opinions o f T h e i r N u r s i n g Care?", H o s p i t a l s , XXXI, (November, 1957), 61-64. A b d e l l a h , F. and E. L e v i n e . "What P a t i e n t s Say About T h e i r N u r s i n g Care", H o s p i t a l s , XXXI, (November, 1957), 44-48. A l f a n o , G. "The Loeb Center f o r N u r s i n g and R e h a b i l i t a t i o n " , N u r s i n g C l i n i c s o f N o r t h America, IV, 3 (1969), 487-492. Bakke, K. "Primary N u r s i n g : P e r c e p t i o n s o f a S t a f f Nurse", American J o u r n a l o f N u r s i n g , LXXIV, 8 (1974), 1432-1434. B e r k o w i t z , N. and M. Malone. "Intra-Professional N u r s i n g Forum, V I I , 1 (1968), 50-71.  Conflict",  C a r l s o n , S. Book review on Primary N u r s i n g by Marram, G. and o t h e r s , American J o u r n a l o f N u r s i n g , LXXV, 3 (1975), 514. C a r l s o n , S., R. Kaufman and M. Schwaid. "An Experiment i n S e l f Determined P a t i e n t Care", N u r s i n g C l i n i c s o f N o r t h America, IV, 2 (1969), 495-507. C i s k e , K. L. "Primary N u r s i n g : An O r g a n i z a t i o n t o Promote Professional P r a c t i c e " , Journal o f Nursing Administration, IV, 1 (1974), 28-3 . .Ciske, K. L. "Primary N u r s i n g : E v a l u a t i o n " , American J o u r n a l of N u r s i n g , LXXIV, 8 (1974), 1436-1438. D a e f f l e r , R. " P a t i e n t s ' P e r c e p t i o n o f Care Under Team and Primary N u r s i n g " , J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V, 3 (1975), 20-26. E w e l l , C. "What P a t i e n t s R e a l l y T h i n k About T h e i r N u r s i n g Modern H o s p i t a l , IX, 2 (1967), 106-108. F e l t o n , G. "Increasing the Quality of Nursing Care by Introducing the Concept of Primary Nursing: A Model P r o j e c t " , Nursing Research, XXIV, 1 (1975), 27-32.  Care",  75.  BIBLIOGRAPHY  (Contd.)  PERIODICALS H a l l , L. " N u r s i n g - What I s I t ? " , The Canadian 2 (1964), 150-154.  Nurse, LX,  Henderson, C. "Can N u r s i n g Care Hasten Recovery?", J o u r n a l o f N u r s i n g , LXIV, 6 (1964), 80-82. Kramer, M. and M. Manthey. "Dialogue on Primary N u r s i n g Forum, IX, 4 (1974), 356-379.  American  Nursing",  Logsdon, A. "Why Primary N u r s i n g ? " , N u r s i n g C l i n i c s o f N o r t h America, XXVIII, 2 (1973), 283-291. Manthey, M. "Primary N u r s i n g i s A l i v e and W e l l i n t h e H o s p i t a l " , American J o u r n a l o f N u r s i n g , L X X I I I , 1 (1973), 83-87. Manthey, M. and o t h e r s . 1 (1970), 65-83.  "Primary N u r s i n g " , N u r s i n g Forum, XIV,  Marram, G. " I n n o v a t i o n on 4 Tower West: What Happened?", American J o u r n a l o f N u r s i n g , L X X I I I , 5 (1973), 814-816. Marram, G. " P a t i e n t s ' E v a l u a t i o n o f N u r s i n g Performance", N u r s i n g Research, XXII, 2 (1973), 153-157. Marram, G. " P a t i e n t s ' E v a l u a t i o n o f T h e i r Care: Importance To The Nurse", N u r s i n g Outlook, XXI, 5 (1973), 322-324. Moore, D. and K. Cook-Hubbard. "Comparison o f Methods f o r E v a l u a t i n g t h e P a t i e n t s ' Response t o N u r s i n g Care", N u r s i n g Research, XXIV, 3 (1975), 202-204. Mundinger, M. "Primary N u r s i n g : Role E v o l u t i o n " , N u r s i n g Outlook, XXI, 10 (1973), 642-645. Munson, F. C. and S. S. Meda. "An Instrument N u r s i n g S a t i s f a c t i o n " , N u r s i n g Research, 159-166.  f o r Measuring XXIII, 2 (1974),  N e h r i n g , V. and B. Geach. " P a t i e n t s ' E v a l u a t i o n o f T h e i r Care: Why Don't They Complain?", N u r s i n g Outlook, XXI, 5 (1973), 317-321. Page, M. "Primary N u r s i n g : P e r c e p t i o n s o f a Head Nurse", American J o u r n a l o f N u r s i n g , LXXIV, 8 (1974), 1435-1436.  76. BIBLIOGRAPHY  (Contd.)  PERIODICALS P o r t e r , L. "Job A t t i t u d e s i n Management: P a r t 1. P e r c e i v e d 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 F u n c t i o n o f Job L e v e l " , J o u r n a l o f A p p l i e d Psychology, XLVI, 6 (1962), 375-384. P o r t e r , L. "Job A t t i t u d e s i n Management: P a r t 2. P e r c e i v e d Importance o f Needs as a F u n c t i o n o f Job L e v e l " , J o u r n a l o f A p p l i e d Psychology, XLVII, 1 (1963), 141-148. Raphael, W. "Do We Know What P a t i e n t s T h i n k ? " , I n t e r n a t i o n a l J o u r n a l o f N u r s i n g S t u d i e s , IV, 3 (1967), 209-223. R i e v e , J . "Primary N u r s i n g In a P s y c h i a t r i c S e t t i n g " , Alumni Magazine, L X X I I I , 2 (1976), 20-21. R i s s e r , N. "Development o f an Instrument t o Measure P a t i e n t S a t i s f a c t i o n With Nurses and N u r s i n g Care i n P r i m a r y Care S e t t i n g s " , N u r s i n g Research, XXIV, 1 (1975), 45-51. Robinson, A. M. "Primary Care N u r s i n g a t Two T e a c h i n g H o s p i t a l s " , R. N., XXXVII, 4 (1974), 31-34. S c h l e g e l , M. " I n n o v a t i o n on 4 Tower West: How?", American J o u r n a l o f N u r s i n g , L X X I I I , 6 (1973), 811-813. Weed, L. " M e d i c a l Records That Guide and Teach", The New England J o u r n a l o f M e d i c i n e , CCLXXVIII, 11 (1968) 593-599.  76A .  APPENDICES  77.  APPENDIX A  78. APPENDIX A  PRIMARY NURSING  Primary n u r s i n g i s a system o f d e l i v e r i n g n u r s i n g c a r e . system one nurse i s r e s p o n s i b l e and accountable  In t h i s  f o r the assessment o f  the p a t i e n t ' s needs and t h e p l a n n i n g and e v a l u a t i o n o f t h e n u r s i n g throughout t h e p a t i e n t ' s h o s p i t a l i z a t i o n .  care  These a c t i v i t i e s a r e done i n  c o l l a b o r a t i o n w i t h t h e p a t i e n t and t h e o t h e r members o f t h e h e a l t h team. According  t o t h e l i t e r a t u r e , the p r i m a r y nurse performs t h e  f o l l o w i n g 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 t o h i s o r her primary p a t i e n t s : 1.  o r i e n t a t e s t h e p a t i e n t t o t h e u n i t and t h e h o s p i t a l .  This  could  i n c l u d e an e x p l a n a t i o n o f h o s p i t a l p o l i c i e s , t h e ward program, and p r i m a r y n u r s i n g ; 2.  assesses The  t h e p a t i e n t t o e s t a b l i s h an immediate p r i o r i t y o f needs.  i d e n t i f i c a t i o n and d i s c u s s i o n o f problems s h o u l d be done  j o i n t l y w i t h t h e p a t i e n t , (when a p p r o p r i a t e ) ; 3.  assumes r e s p o n s i b i l i t y f o r n u r s i n g ' s  c o n t r i b u t i o n t o the care plan.  T h i s i n c l u d e s keeping t h e p l a n c u r r e n t , e v a l u a t i n g t h e n u r s i n g measures, c o - o r d i n a t i n g t h e p l a n o f care f o r t h e p a t i e n t , and making r e f e r r a l s t o o t h e r 4.  disciplines;  works w i t h t h e p r i m a r y t h e r a p i s t i n j o i n t i n t e r v i e w s and d i s c u s s i o n s o f t h e care p l a n ;  5.  communicates w i t h o t h e r s t a f f members about t h e care p l a n .  This  i n c l u d e s d i s c u s s i o n w i t h o t h e r d i s c i p l i n e s such as o c c u p a t i o n a l therapy,  c h a r t i n g , and d i s c u s s i o n s w i t h t h e a s s o c i a t e  nurse;  79.  6.  g i v e s c a r e t o p r i m a r y p a t i e n t s whenever on duty - v i t a l s i g n s , treatments,  7.  medications,  preparation f o r tests;  p l a n s t h e c a r e t o be g i v e n when t h e primary nurse i s n o t on duty - 24 hour r e s p o n s i b i l i t y ;  8.  s u p e r v i s e s p a t i e n t and f a m i l y t e a c h i n g f o r such t h i n g s as medications,  s i g n s and symptoms o f t h e p a t i e n t ' s  illness,  h o s p i t a l i z a t i o n , and d i s c h a r g e ; 9.  co-ordinates  t h e p a t i e n t ' s d i s c h a r g e , i n c l u d i n g p l a n n i n g and  d i s c u s s i n g i t w i t h t h e p a t i e n t about two weeks p r i o r t o d i s c h a r g e as w e l l as i n t r o d u c i n g t h e d i s c h a r g e t h e r a p i s t , i f and when appropriate; 10.  seeks s u p e r v i s i o n o r feedback from p e e r s when a p p r o p r i a t e .  80.  APPENDIX A  SUMMARY OF RESEARCH  Primary n u r s i n g i s a system o f d e l i v e r i n g n u r s i n g care when one nurse i s r e a p o n s i b l e and a c c o u n t a b l e  f o r t h e assessment o f t h e p a t i e n t ' s  needs and t h e p l a n n i n g and e v a l u a t i o n o f t h e n u r s i n g c a r e throughout the p a t i e n t ' 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 a r e done i n c o l l a b o r a t i o n  w i t h t h e p a t i e n t and o t h e r members o f t h e h e a l t h team.  Although t h i s  model o f d e l i v e r i n g n u r s i n g care i s f e l t t o i n c r e a s e p a t i e n t w i t h n u r s i n g c a r e , t h e r e has been l i t t l e The proposed study w i l l  this.  which c h a r a c t e r i z e p r i m a r y  A q u e s t i o n n a i r e w i l l be a d m i n i s t e r e d  p r i o r t o discharge will  r e s e a r c h done t o e v a l u a t e  i n v e s t i g a t e t h e degree o f p a t i e n t and nurse  s a t i s f a c t i o n with the n u r s i n g behaviours nursing.  satisfaction  from h o s p i t a l .  be g i v e n t o t h e p a t i e n t ' s  t o t h e p a t i e n t t h e week  At t h e same t i m e , a s i m i l a r  questionnaire  nurse.  SAMPLE  The  s u b j e c t s w i l l be twenty-nine p a t i e n t s who have been h o s p i t a l i z e d  on t h e same ward and t h e i r p r i m a r y n u r s e s .  The i n v e s t i g a t o r w i l l  t h e p a t i e n t and t h e nurse t o a d m i n i s t e r t h e q u e s t i o n n a i r e .  contact  81.  APPENDIX B «  82.  APPENDIX B  CONSENT FORM - NURSE I , t h e undersigned, agree t o p a r t i c i p a t e i n t h e r e s e a r c h d e s c r i b i n g primary n u r s i n g . involved.  I understand the p r o c e d u r e s  I consent t o have t h e q u e s t i o n n a i r e g i v e n t o my  patient. I understand t h a t I may withdraw from t h e study a t any time.  Signature Date  CONSENT FORM I, t h e undersigned, agree t o p a r t i c i p a t e i n t h e research d e s c r i b i n g primary nursing. procedures  I understand t h e  involved.  I understand t h a t I may withdraw from t h e study a t any  time.  Signature Date Witness  83.  84.  APPENDIX C  CHART CHECKLIST  - date - nurse - patient Orientation Discuss discharge plans Introduce d i s c h a r g e t h e r a p i s t Written care plans Primary nurse chart  i n d i c a t e d on  Evaluations charted S i g n i f i c a n t events Interviewed with therapist  charted  primary  C a r e p l a n i n d i c a t e d 24 hour interventions Family c o n t a c t i n d i c a t e d Mention o f d i s c u s s i o n o f p a t i e n t ' s problems on discharge  85.  APPENDIX D  P l e a s e i n d i c a t e which o f t h e f o l l o w i n g statements apply t o you by p l a c i n g a check mark >/ i n t h e a p p r o p r i a t e space. 1.  Male  2.  Age:  Female under  51 - 60  20  21 - 30  61 - 70  31 - 40  over  71  41 - 50 T3  3.  Have you had a p r e v i o u s 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 ?  > H  M Yes 4.  a  No  I f t h e answer t o q u e s t i o n 3 was p r e v i o u s h o s p i t a l i z a t i o n was.  "Yes", p l e a s e i n d i c a t e where your  Health Sciences Centre Hospital L i o n ' s Gate H o s p i t a l Riverview H o s p i t a l St. Paul's H o s p i t a l St. Vincent's H o s p i t a l Shaughnessy H o s p i t a l Surrey Memorial H o s p i t a l Vancouver G e n e r a l Other  (specify)  Hospital  8 H  ir H  1  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 Hospitalization Yes  P r e v i o u s Admissions to t h i s Hospital  -  12  17  No  -  12  89.  APPENDIX F  90.  APPENDIX F  METHOD OF CALCULATING THE  SATISFACTION SCORES  In o r d e r t o get a measure o f s a t i s f a c t i o n , i n d i c a t e d the b e h a v i o u r had o c c u r r e d was response  a response  g i v e n a v a l u e o f +1,  which i n d i c a t e d the b e h a v i o u r d i d not o c c u r was  v a l u e o f -1, and a p p l i c a b l e was  a response  F o r example:  "Your primary nurse  the ward", would be g i v e n a v a l u e o f +1. the statement,  a  given a  which i n d i c a t e d the b e h a v i o u r was  g i v e n a v a l u e o f 0.  " t r u e " t o t h e statement,  which  a response  showed you  A response  not of  around  of "true" to  "Your f a m i l y had no c o n t a c t w i t h your p r i m a r y  would be g i v e n a v a l u e of -1.  nurse",  By m u l t i p l y i n g the v a l u e g i v e n f o r  the o c c u r r e n c e o f the b e h a v i o u r  i n p a r t one o f the q u e s t i o n n a i r e ,  w i t h t h e r a t i n g o f importance a s s i g n e d i n p a r t two  of the  q u e s t i o n n a i r e , a n u m e r i c a l i n d i c a t o r o f s a t i s f a c t i o n c o u l d be arrived at. example:  Each behaviour  was  treated individually.  t h e f i r s t q u e s t i o n i n p a r t one  and two  For  o f the p a t i e n t  questionnaire i s : 1.  "Your primary nurse  showed you around the ward."  I f a p a t i e n t responded " f a l s e " f o r o c c u r r e n c e q u e s t i o n n a i r e and a s s i g n e d the b e h a v i o u r i n p a r t two  i n p a r t one o f the  a v a l u e o f 4 f o r importance  o f t h e q u e s t i o n n a i r e , t h e p a t i e n t would r e c e i v e a  s a t i s f a c t i o n s c o r e o f -4.  The  c o u l d go from +5 t o -5 w i t h +5 indicating least  satisfaction.  range o f s c o r e s measuring  satisfaction  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  91.  APPENDIX G  P l e a s e i n d i c a t e which of the f o l l o w i n g statements a p p l i e s to by p l a c i n g a check mark s/ i n the a p p r o p r i a t e space. 1.  Male  2.  Age:  3.  Have you had  Female _ _ under 20  51 - °0  21 -  30  61 - 70  31 -  l±o  over 71  *U  50  -  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  k.  you  ...  No  I f the answer to q u e s t i o n 3 was "yes", please your p r e v i o u s h o s p i t a l i z a t i o n was.  i n d i c a t e where  H e a l t h S c i e n c e s Centre H o s p i t a l L i o n ' s Gate H o s p i t a l  ,  Riverview H o s p i t a l St. P a u l ' s H o s p i t a l St. V i n c e n t ' s H o s p i t a l Shaughnessy H o s p i t a l Surrey Memorial H o s p i t a l Vancouver General H o s p i t a l Other ( s p e c i f y )  ,  INSTRUCTIONS On t h e next few pages a r e a s e r i e s o f statements may o r may n o t d e s c r i b e t h e r e l a t i o n s h i p you had w i t h primary nurse. the statements  P l e a s e i n d i c a t e by c i r c l i n g  which your  True o r F a l s e  which a p p l y t o the c a r e you r e c e i v e d .  Some  statements may n o t be a p p l i c a b l e t o you and i f t h a t i s so p l e a s e i n d i c a t e by c i r c l i n g  N/A.  There a r e no " r i g h t " o r "wrong" answers and i t i s v e r y important t h a t you be v e r y s t r a i g h t f o r w a r d when responding to  the questions.  The q u e s t i o n n a i r e s w i l l remain anonymous  and n e i t h e r you n o r your nurse w i l l be i d e n t i f i e d by name.  1. OCCURRENCE  BEHAVIOUR 1.  Your primary nurse showed you around the ward.  T  F  N/A  2.  Your primary nurse spent time with you when you were upset.  T  F  N/A  3.  Your primary nurse prepared you f o r any problems you might have a f t e r l e a v i n g the h o s p i t a l .  T  F  N/A  4.  You were taught by your primary nurse t o observe your r e a c t i o n to treatment.  T  F  N/A  5.  Your f a m i l y had no c o n t a c t w i t h your primary nurse.  T  F  N/A  6.  Your primary nurse knew you v e r y w e l l .  T  F  N/A  7.  You knew when your primary nurse was on days off.  T  F  N/A  8.  You and your primary nurse t a l k e d about your problems.  T  F  N/A  9.  Your primary nurse answered your q u e s t i o n s .  T  F  N/A  10. Together, you and your p r i m a r y nurse d i s c u s s e d whether or n o t the treatment was working.  T  F  N/A  11. Your primary nurse e x p l a i n e d primary n u r s i n g to you.  T  F  N/A  10  2. OCCURRENCE  BEHAVIOUR 12.  An e x p l a n a t i o n o f t h e h o s p i t a l program was g i v e n to you by your primary nurse.  T  F  N/A  13»  Your primary nurse e x p l a i n e d the reason f o r any t e s t s t h a t you had,  T  F  N/A  1^.  Your primary nurse l i s t e n e d to your  T  F  N/A  15•  Your primary nurse seldom t a l k e d with your visitors.  T  F  N/A  16.  Your primary nurse worked w i t h you whenever she was on days o r evenings.  T  F  N/A  17.  Every nurse t h a t worked w i t h you seemed to know why you were i n h o s p i t a l .  T  F  N/A  18.  You were g i v e n i n c o r r e c t e x p l a n a t i o n s o f procedures by your primary nurse.  T  F  N/A  19•  Your primary nurse d i s c u s s e d with you the problems you would be working on d u r i n g your hospitalization.  T  F  N/A  Your t h e r a p i s t and your primary nurse worked together.  T  F  N/A  20.  problems.  3OCCURRENCE  BEHAVIOUR 21.  Your primary nurse encouraged your f a m i l y t o be i n v o l v e d i n the treatment program.  T  F  N/A  22.  Your primary nurse was seldom present i n interviews.  T  F  N/A  23.  Yourwere g i v e n c l e a r i n s t r u c t i o n s by your primary nurse.  T  F  N/A  2k.  You d i s c u s s e d your d i s c h a r g e p l a n s with your primary nurse.  T  F  N/A  25•  You understood the reason f o r your symptoms.  T  F  N/A  26.  Your primary nurse encouraged thought your problems were.  T  F  N/A  27.  Your r e l a t i v e s t a l k e d about your progress with your -primary nurse.  T  F  N/A  28.  You r e c e i v e d no e x p l a n a t i o n o f h o s p i t a l p o l i c i e s .  T  F  N/A  29.  Your primary nurse t r e a t e d you l i k e an i n d i v i d u a l .  T  F  N/A  30.  Your primary nurse t o l d you how she thought you were doing.  T  F  N/A  you to say what you  OCCURRENCE  31.  Your f a m i l y and f r i e n d s knew your primary nurse.  T  F  N/A  32.  You never knew which nurse was going to he working w i t h you from one s h i f t to the next.  T  F  N/A  33*  You d i s c u s s e d w i t h your p r i m a r y nurse the e f f e c t of the treatment you were r e c e i v i n g .  T  F  N/A  3^.  Your primary nurse checked on your understanding of i n s t r u c t i o n s .  T  F  N/A  35.  Your primary nurse a d v i s e d you about posthospital activities.  T  F  N/A  36.  Your primary nurse e x p l a i n e d r o u t i n e procedures.  T  F  N/A  37.  Your primary nurse d i s c u s s e d your t a k i n g m e d i c a t i o n a t home a f t e r d i s c h a r g e .  T  F  N/A  INSTRUCTIONS On the next few pages you w i l l be asked t o r a t e how important  the d e s c r i b e d n u r s i n g behaviours are to you.  P l e a s e i n d i c a t e t h e importance by c i r c l i n g any one o f the f i v e numbers w i t h 5 b e i n g v e r y important, important  and 1 b e i n g n o t important  3 being somewhat  at a l l .  Once again, there are no " r i g h t " or "wrong" responses.  1. IMPORTANCE  BEHAVIOUR Not  Very  Important  Important  HOW IMPORTANT IS I T TO YOU THAT: 1.  Your primary nurse shows you around the ward? 1  2.  3»  k-.  5.  Your primary nurse spends time w i t h you when you are upset? Your primary nurse p r e p a r e s you f o r any problems you might have a f t e r l e a v i n g the h o s p i t a l ? Your primary nurse teaches you to observe your r e a c t i o n t o treatment? Your f a m i l y has c o n t a c t w i t h your primary nurse?  6.  Your primary nurse knows you w e l l ?  7.  You know when your primary nurse i s on days o f f ?  8.  You can t a l k w i t h your primary nurse about your problems?  9-  Your primary nurse answers your q u e s t i o n s ?  1  1  1  2 2  2  2  3  ^  5  *  5  *  5  Ur  5  h  5  ^  5  h  5  4  5  3  3  3  1  2  3  1  2  3  1  2  3  1  2  3  2. BEHAVIOUR  HOW IMPORTANT IS IT TO YOU THAT:  IMPORTANCE Not Important  Very Important  10.  Together, you and your primary nurse d i s c u s s whether or n o t your treatment i s working?  2  3  ^  5  11.  Your primary nurse e x p l a i n s primary n u r s i n g to you?  2  3  ^  5  12.  An e x p l a n a t i o n o f the h o s p i t a l program i s g i v e n to you by your primary nurse?  2  3  ^  5  13-  Your primary nurse e x p l a i n s the reason f o r any t e s t s t h a t you have?  2  3  ^  5  Ik.  Your primary nurse l i s t e n s to your problems?  2  3  ^  5  15«  Your primary nurse t a l k s w i t h your v i s i t o r s ?  2  3  ^  5  16.  Every nurse t h a t works w i t h you seems to know why you a r e i n h o s p i t a l ?  2  3  ^  5  1?.  Your primary nurse works w i t h you whenever he or she i s on day o r evening s h i f t ?  2  3  ^  5  18.  You a r e g i v e n e x p l a n a t i o n s o f procedures by your primary nurse?  2  3  ^  5  3IMPORTANCE  BEHAVIOUR  HOW 19.  Not-  Very  Important  Important  IMPORTANT IS IT TO YOU THATs Your primary nurse d i s c u s s e s w i t h you the problems you w i l l be working on d u r i n g your ho spi t a l i z a t i on?  1  2  3  k  5  20.  Your t h e r a p i s t and your primary nurse work together?  1  2  3  k  5  21.  Your primary nurse encourages your f a m i l y to be i n v o l v e d i n the treatment program?  1  2  3  k  5  22.  Your primary nurse i s present i n i n t e r v i e w s  1  3  k  5  23«  You a r e g i v e n c l e a r i n s t r u c t i o n s by your primary nurse?  1  2  3  k  5  2k.  You d i s c u s s your d i s c h a r g e p l a n s with your primary nurse?  1  2  3  k  5  25.  You understand the reason f o r your  26.  Your primary nurse encourages you to say what you t h i n k your problems are?  symptoms  2  k.  IMPORTANCE  BEHAVIOUR Not  Very  Important  Important  HOW IMPORTANT IS IT TO YOU THAT: 27-  Your r e l a t i v e s t a l k about your p r o g r e s s w i t h your primary nurse?  1  2  3  k  5  1  2  3  k  5  1  2  3  k  5  28.  You r e c e i v e an e x p l a n a t i o n o f h o s p i t a l p o l i c i e s ?  29.  Your primary nurse t r e a t s you like, an i n d i v i d u a l ?  30.  Your primary nurse t e l l s you how she/he t h i n k s you a r e doing?  1  2  3  k  5  31.  Your f a m i l y and f r i e n d s know your primary nurse?  1  2  3  k  5  32.  You know which nurse i s going to be working w i t h you from one s h i f t to t h e next?  1  2  3  k  5  33*  You d i s c u s s w i t h your primary nurse the e f f e c t of the treatment you a r e r e c e i v i n g ?  1  2  3  k  5  3k.  Your primary nurse checks on your understanding of his/her i n s t r u c t i o n s ?  1  2  3  ^  5  35•  Your primary nurse a d v i s e s you about posthospital activities?  1  2  3  ^  5  5. IMPORTANCE  BEHAVIOUR  HOW  IMPORTANT IS IT TO YOU THAT:  Not Important  36,  Your primary nurse e x p l a i n s r o u t i n e procedures?  22  37.  Your primary nurse d i s c u s s e s your t a k i n g m e d i c a t i o n a t home a f t e r d i s c h a r g e ?  2  Very Important  3  5  k  3  ^  5  104.  APPENDIX H  NURSE - INSTRUCTIONS On the next few pages a r e a s e r i e s o f statements may o r may n o t d e s c r i b e the r e l a t i o n s h i p you had w i t h individual patient. the statements  which  this  P l e a s e i n d i c a t e by c i r c l i n g True or F a l s e  which a p p l y to your care o f t h i s s p e c i f i c p a t i e n t .  Some statements may n o t be a p p l i c a b l e and i f t h a t i s so, p l e a s e i n d i c a t e by c i r c l i n g N/A. There a r e no " r i g h t " or "wrong" answers and i t i s v e r y important to  t h a t you be v e r y s t r a i g h t f o r w a r d when responding  the questions.  The q u e s t i o n n a i r e s w i l l remain anonymous  and n e i t h e r you nor your p a t i e n t w i l l be i d e n t i f i e d by name.  BEHAVIOUR  ;  OCCURRENCE  1.  You o r i e n t a t e d the p a t i e n t to the p h y s i c a l setting.  T  F  N/A  2.  You  T  F  N/A  3-  You had no others.  T  F  N/A  4.  You  worked c l o s e l y w i t h the primary t h e r a p i s t .  T  F  N/A  5.  You was  spent time w i t h the p a t i e n t when he or upset.  T  F  N/A  6.  You d i s c u s s e d w i t h the p a t i e n t the plans.  T  F  N/A  7.  You i n t r o d u c e d the p a t i e n t to the discharge t h e r a p i s t p r i o r to the p a t i e n t ' s discharge from the ward.  T  F  N/A  8.  You d i s c u s s e d w i t h the p a t i e n t the purpose of the m e d i c a t i o n he or she was t a k i n g .  T  F  N/A  9-  You gave r e p o r t to the next s h i f t about t h i s patient.  T  F  N/A  10.  You  T  F  N/A  explained  the system of primary n u r s i n g ;  c o n t a c t w i t h the p a t i e n t ' s  wrote your c a r e p l a n s  on the  significant  she  discharge  chart.  BEHAVIOUR  11.  A l l s t a f f knew t h a t you were the primary nurse f o r this patient.  12.  You c h a r t e d  13.  You d i d n o t ask the p a t i e n t f o r h i s o r her i d e n t i f i c a t i o n o f h i s o r h e r problems.  1^.  You asked t h i s p a t i e n t what he/she thought was c o n t r i b u t i n g to h i s / h e r improvement.  15-  You looked a f t e r t h i s p a t i e n t every time you were on days o r evenings.  16.  You c h a r t e d any s i g n i f i c a n t events which w i t h the p a t i e n t d u r i n g your s h i f t .  17•  You were r e s p o n s i b l e this patient.  18.  You d i d n o t r e f e r the p a t i e n t to other p r o f e s s i o n a l s .  19.  You a d v i s e d activities.  20.  You gave c l e a r i n s t r u c t i o n s .  your e v a l u a t i o n  o f your i n t e r v e n t i o n s .  f o r the n u r s i n g  the p a t i e n t about  occurred  careplan f o r  post-hospital  3BEHAVIOUR  21.  The p a t i e n t ' s f a m i l y and/or f r i e n d s knew your name. . .  22.  You t a l k e d w i t h the p a t i e n t to check h i s or her understanding o f your t e a c h i n g .  23.  You e x p l a i n e d  the h o s p i t a l program.  2Ur.  You e x p l a i n e d  the reason f o r any s p e c i a l t e s t s .  25.  You gave the p a t i e n t feedback about how you thought he or she was doing.  26.  You seldom i n t e r v i e w e d primary t h e r a p i s t .  27.  You d i s c u s s e d w i t h the p a t i e n t the p a r t i c i p a t i o n of h i s or her f a m i l y i n the treatment p l a n .  28.  You answered any q u e s t i o n s about the c a r e p l a n .  29.  Your c a r e p l a n i n d i c a t e d i n t e r v e n t i o n s to be used over a Zk hour p e r i o d o f time.  30.  I t was c l e a r l y i n d i c a t e d on the c h a r t t h a t you were the primary nurse f o r t h i s p a t i e n t .  the p a t i e n t w i t h the  t h e a s s o c i a t e nurse had  k.  OCCURRENCE  BEHAVIOUR  31.  You informed the p a t i e n t when you would not be working w i t h him o r her.  T  F  N/A  32.  Together, you and the p a t i e n t evaluated the n u r s i n g care p l a n .  T  F  N/A  33.  You knew when t o seek s u p e r v i s i o n with patient's careplan.  T  F  N/A  3k.  You d i s c u s s e d w i t h the p a t i e n t how he/she thought they were doing.  T  F  N/A  35«  You d i s c u s s e d t h e c a r e p l a n w i t h the a s s o c i a t e nurse.  T  F  N/A  36.  You d i s c u s s e d w i t h the p a t i e n t when to take the medication p r e s c r i b e d at discharge.  T  F  N/A  37>  You d i s c u s s e d w i t h the p a t i e n t the problems he or she may encounter a f t e r l e a v i n g the h o s p i t a l .  T  F  N/A  38.  You seldom asked f o r peer feedback during your care o f t h i s p a t i e n t .  T  F  N/A  this  NURSE - INSTRUCTIONS On the next few pages you w i l l he asked to r a t e how important  the d e s c r i b e d n u r s i n g behaviours are to you i n  order f o r you to g i v e good primary n u r s i n g care.  Please  i n d i c a t e the importance by c i r c l i n g any one of the f i v e numbers, w i t h 5 b e i n g v e r y important, important,  and 1 being n o t important  3 being somewhat at a l l .  Once again, t h e r e are no " r i g h t " or "wrong" responses.  IMPORTANCE  BEHAVIOUR  Not; Important  HOW IMPORTANT IS IT TO YOU THAT:  Very Important  1.  You o r i e n t a t e the p a t i e n t to the p h y s i c a l setting?  1  2  3  2.  You e x p l a i n the system of primary n u r s i n g ?  1  2  3  ^  5  3.  You have contact w i t h the p a t i e n t ' s s i g n i f i c a n t others?  1  2  3  ^  5  Ur.  You work c l o s e l y w i t h the primary t h e r a p i s t ?  1  2  3  ^  5  5.  You spend time w i t h the p a t i e n t when he or she i s upset?  1  2  3  ^  5  6.  You d i s c u s s w i t h the p a t i e n t the discharge plans?  1  2  3  ^  5  7.  You i n t r o d u c e the p a t i e n t to the discharge t h e r a p i s t p r i o r t o the p a t i e n t ' s discharge from the ward?  1  2  3  ^  5  8.  You d i s c u s s w i t h the p a t i e n t the purpose of the m e d i c a t i o n he or she i s taking?  1  2  3  ^  5  9.  You g i v e r e p o r t to the next s h i f t about patient?  1  2  3  ^  5  this  ^  5  2. IMPORTANCE  BEHAVIOUR  Not Important  HOW IMPORTANT IS IT TO YOU THAT:  Very Important  1  2  3  k-  5  A l l s t a f f know t h a t you are the primary nurse for this patient?  1  2  3  k-  5  12.  You c h a r t your e v a l u a t i o n o f your i n t e r v e n t i o n s ?  1  2  3  k-  5  13.  You ask the p a t i e n t f o r h i s or her i d e n t i f i c a t i o n of h i s o r h e r problems?  1  2  3  k-  5  Ik-.  You ask the p a t i e n t what he/she t h i n k s i s c o n t r i b u t i n g to h i s / h e r improvement?  1  2  3  kr  5  15.  Every time you a r e on days or evenings you look a f t e r t h i s p a t i e n t ?  1  2  3  k  5  16.  You c h a r t any s i g n i f i c a n t events which with the p a t i e n t d u r i n g your s h i f t ?  1  2  3  k-  5  17.  You are r e s p o n s i b l e f o r the n u r s i n g for this patient?  1  2  3  *k  18.  You r e f e r t h e p a t i e n t to other p r o f e s s i o n a l s ?  10.  You w r i t e your c a r e p l a n s  11.  on the chart?  occur  careplan  1  2  3  ^  '  5 5  3. IMPORTANCE  BEHAVIOUR  19•  You a d v i s e the p a t i e n t about activities?  20. 21.  22.  Very Important  Not Important  HOW IMPORTANT IS IT TO YOU THAT:  post-hospital  1  2  3  ^  5  You give c l e a r i n s t r u c t i o n s ?  1  2  3  ^  5  The p a t i e n t ' s f a m i l y and/or f r i e n d s know your name?  1  2  3  ^  5 r(jO  You t a l k w i t h the p a t i e n t to check h i s or her understanding o f your teaching?  1  2  3  23.  You e x p l a i n the h o s p i t a l program?  1  2  3  2k-.  You e x p l a i n the reason f o r any s p e c i a l t e s t s ?  1  2  3  ^  5  25-  You give the p a t i e n t feedback t h i n k he o r she i s doing?  1  2  3  ^  5  You i n t e r v i e w the p a t i e n t w i t h the primary therapist?  1  2  3  ^  5  You d i s c u s s w i t h the p a t i e n t the p a r t i c i p a t i o n of h i s o r her f a m i l y i n the treatment plan?  1  2  3  ^  5  26.  27.  about how you  ^ ^  5 -  5  IMPORTANCE  BEHAVIOUR  HOW IMPORTANT IS IT TO YOU THAT:  28.  You answer any q u e s t i o n s has about t h e careplan?  29.  the a s s o c i a t e nurse  Very Important  Not Important  1  2  3  Your c a r e p l a n i n d i c a t e s i n t e r v e n t i o n s to be used over a 2k- hour p e r i o d o f time?  1  2  3  30.  I t i s c l e a r l y i n d i c a t e d on the chart that you are the p r i m a r y nurse f o r t h i s p a t i e n t ?  1  2  3  k-  5  31.  You inform the p a t i e n t when you w i l l n o t be working w i t h him o r her?  1  2  3  k  5  32.  Together, you and the p a t i e n t evaluate the n u r s i n g careplan?  1  2  3  k-  5  33*  You know when t o seek s u p e r v i s i o n w i t h the p a t i e n t ' s careplan?  1  2  3  k-  5  3k-.  You d i s c u s s w i t h the p a t i e n t how he/she t h i n k s they a r e doing?  1  2  3  k-  5  35-  You d i s c u s s the c a r e p l a n w i t h the a s s o c i a t e nurse?  1  2  3  k-  5  36.  You d i s c u s s w i t h the p a t i e n t when to take the m e d i c a t i o n p r e s c r i b e d a t discharge?  1  2  3  k-  5  5  k-  ^  5  5. IMPORTANCE  BEHAVIOUR  Not Important  HOW IMPORTANT IS IT TO YOU THAT:  37.  You d i s c u s s w i t h the p a t i e n t the problems he or she may encounter a f t e r l e a v i n g the h o s p i t a l ?  38.  You ask f o r peer feedback d u r i n g care of t h i s p a t i e n t ?  Very Important  your 5  115.  APPENDIX I  116.  APPENDIX TABLE 1 Frequency o f P a t i e n t Responses f o r Occurrence o f the Primary N u r s i n g B e h a v i o u r s  Patient's  Question Number 1 2 3 4 * 5 6 7 8 9 10 11 12 13 14 *15 16 17 *18 19 20 21 *22 23 24 25 26 27 *28 29 30 31 *32 33 34 35 36 37  '  True 15 ' 24 19 19 12 19 19 25 25 20 15 21 18 24 13 24 24 ' • 1 23 22 13 8 26 19 22 28 9 3 27 24 8 11 21 22 17 22 16  Responses N/A 5 2 3 4 5 2 2 2 3 5 6 5 10 3 10 2 1 2 2 4 6 2  False 9 3 7 6 12 8 8 2 1 4 8 3 1 2 6 3 4 26 4 3 10 19 3 4 4  6 3 1 10 3  10 23 2 5 13 17 4 3 4 1 7  * Q u e s t i o n s which were n e g a t i v e l y  8 1 4 4 8 6 6  phrased.  117.  APPENDIX TABLE 2 Frequency o f Nurse Responses f o r t h e Occurrence o f t h e Primary N u r s i n g B e h a v i o u r s  Question Number 1 2 * 3 4 5 6 7 8 9 10 11 12 *13. 14 15 16 17 *18 19 20 21 22 23 24 25 *26 27 28 29 30 31 32 33 34 35 36 37 *38  Nurse's True 13 24 7 27 28 25 4 22 29 29 28 27  Responses N/A 7 3 1  False 9 2 21 2 1 3 9 1  1 16 6  -  -  1  -  2  -  29  29 28 29 29 4 24 29 18 29 25 18 29 13 22 28 24 28 27 24 29 29 22 13 27 4  -  -  21 4  4 1  -  -  1  7  4  -  -  1 1  3 10  -  -  16 2  5 1 2 1  3  2 4  -  -  -  1  7 5 2 25  * Q u e s t i o n s which were n e g a t i v e l y  11  -  phrased.  118. APPENDIX TABLE 3 Frequency of Patient Ratings of Importance of Primary Nursing Behaviours  Question Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37  Rating of Importance 1 2 1 2 2 10 2 -  1 4 3 1  -  10 2  -  2 1 1 12 1 3 1 9 3 -  -  12 2 -  1 3 3  2 4  -  2 1 2  1 1 1 1 5 -  2 -  1 4 1 1 1 1 2 3 1 2 3 2 3 3 1 1  3 8 1 4 1 1 3 6 1 3 2 6 3 2 5 8 5 5 1 2 6 5 4 1 2 5  1 4 2 3 3 5 2  4 5 5 2 8 3 4 8 3 4 4 6 9 5 4 4 5 6 6 6 3 4 5 6 7 4 3 1 7 2 10 4 6 5 8 6 7 3  5 10 21 20 15 11 20 11 25 22 20 12 13 20 23 4 14 18 14 21 23 10 12 17 17 21 23 10 11 27 18 8 13 20 15 15 13 19  119.  APPENDIX TABLE 4 Frequency o f Nurse R a t i n g s o f Importance o f Primary N u r s i n g B e h a v i o u r s  Question Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38  R a t i n g o f Importance 1 5  1 -  1  1  1  -  2 1 1 1  2  -  2 4 -  -  -•  1 1  -  -  -  2 1 2  -  -  -  1 -  . 2 -  1  3 6 3 6 1 1  6 1 3 4 1  1 1  6 4 1 4 1 4  3 4 3 1 3 3 1 2 4 2  4  4 7 8 2 3 7 4 14 5 4 2 8 7 3 4 3 3 7 4 8 4 13 4 7 6 1 12 2 5 8 5 7 8 2 3 7 3 1 7  5 10 17 19 25 21 25 7 22 22 27 17 21 26 24 25 26 22 16 17 24 7 24 18 23 28 13 22 21 18 20 17 20 24 26 18 22 28 17  120. APPENDIX TABLE 5 Frequency o f P a t i e n t R a t i n g s o f t h e S a t i s f a c t i o n w i t h Primary N u r s i n g B e h a v i o u r s  Question Number 1 2 3 4 5 6 7. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37  Satisfaction -5 2 2 3 3 1 4 1  -  1 2  -  2 1 1 1 1 • 1  -4 , 2 1  -  -  -  3 1  1  1  1  1  1  1  2 3 3 3 2  -  5  -  -  1 2 1 1 1 1  -  1  -  -  1 1 1 2  -  -2 2  2 1 1 3  -  -  -3 , 1  1  1 1 2  1 2 2  -  -  1 1 1  -  -  5  2  2 1  -  -  -  -  2  1  -  1  -  2  1 1 2  2  -  -  -  1 3  -  -  2  1 1  -1 1  1  6  1  2 1  5 2  -  1 1 8 1  -  2 3 3 3 7 2  -  6 1  4 4 1 11 4  -  -  1  -  9  -  -  1  1  1  0 5 2 3 5 6 2 2 1 2 6 6 5 11 2 11  9 2 3 5 9 7 8  Ratings 1  1 1 2  1 1 3  -  -  2 1  -  3 4 1 3 1  1  -  2  1  -  1 4 1 3 2 4 4 2  -  -  -  2  2  -  -  -  1 2 2  -  1 1  -  1  4 7 3 3 2 3 3 2  1 2 3  -  -  2  1  -  -  2  -  1 1 1 1 1  1 2 2 1 1 2  1  -  -  -  4 , 3 3 1 6 2 2 5 3 3 3 4 6 5 3 2 5 4 6 4 1 3 3 5 6 4 3  6 2 9 2 4 3 7 3 7 2  5 7 18 14 8 8 15 9 21 20 13 7 6 10 20  12 16 12 18 18 9 11 16 11 16 21 5 10 25 15 2 8 17 12 10 11 10  121.  APPENDIX TABLE 6 Frequency o f Nurse R a t i n g s o f S a t i s f a c t i o n w i t h Primary N u r s i n g B e h a v i o u r s  Question Number i  i 2 3 4 5 6 7 •8 9 10 •11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38  Satisfaction -5 , 1 3  -  1  -  2  1 1 2  -  -  2  . -  -  1  -  2  2 1  -  2  -  2 2 1 2 1  -4 , 1 1  -  1 1 1 2 1 1  -  -  -3 , 2 1 1 1 1  4  -  -  -  -  -  1  -  1  -  -  -  -  -  2  1  -  -  -  -  1  -1 2  -  1 1 2 2  -  -  -  -  -2 ,  -  1 2 1  -  -  -  -  2  -  -  1  -  -  -  -  -  -  -  1  1 1  -  -  -  1  1  -  0 , 3 1 1 3  -  1 7 3  -  4 3 3 1 1  3 3 1 2 2  3 4  -  2  -  1  -  3 2 2  -  1 2  -  -  -  -  -  -  -  -  -  -  -  -  7 7 4  1  2 2  -  -  2  3  -  -  1  -  -  -  Ratings  4 2 1 1  1 ,  -  -  -  -  -  -  -  -  2 , 1  -  1  -  3 , 2 1 2 1  -  -  -  1 1  2 2 3 2  1  -  -  3 1  -  1 4 1  -  1  -  -  -  -  2 1 1  -  -  -  1 1  1 2 3  -  -  -  2 1 1  -  -  -  3 1 2 2  -  4 , 6 4 2 2 6 3 3 37 4 6 2 2 3 1 1 2 3 7 7 7 6 6 2 3 10 1 3 4 7 3 4 1 4 4 3 2 3  5 11 18 22 21 20 24 13 22 17 21 13 22 24 19 26 28 19 18 17 13 17 22 17 22 26 12 22 17 16 21 17 20 26 22 18 15 13 16  122. APPENDIX TABLE 7  Matched B e h a v i o u r s From Nurses' and P a t i e n t s ' Q u e s t i o n n a i r e  Patient Questionnaire Number  Nurse Que s t ionn a i r e Number  1  1  2  5  3  37  5  3  7  31  11  2  12  23  13  24  17  15  20  4  21  27  22  26  23  20  24  6  26  13  30  25  31  21  34  22  35  36  36  19  

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