UBC Theses and Dissertations

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UBC Theses and Dissertations

Role expansion : from speculation to verification MacDonald, Sharon Alice 1978

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ROLE EXPANSION  . . . from SPECULATION  t o VERIFICATION  SHARON ALICE MCDONALD B.Sc.N,, S t . F r a n c i s X a v i e r U n i v e r s i t y , 1974  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N 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 c o n f o r m i n g to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA May, 1978  0  Sharon A l i c e MacDonald, 1978  In p r e s e n t i n g t h i s  thesis  in p a r t i a l  fulfilment of  an advanced degree at the U n i v e r s i t y of the L i b r a r y I further for  this  freely  available  representatives. thesis for  Department of  requirements  Columbia,  I agree  r e f e r e n c e and copying o f  this  fo  that  study. thesis  purposes may be granted by the Head of my Department or It  financial  i s understood that gain s h a l l  written permission.  NURSING  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5  Date  for  agree t h a t p e r m i s s i o n for e x t e n s i v e  scholarly  by h i s of  s h a l l make i t  British  the  MAY, 1978  Columbia  not  copying or  publication  be allowed without my  v  "ABSTRACT  The concept o f r o l e e x p a n s i o n i s p r e s e n t l y a major n u r s i n g issue.  Over t h e p a s t decade, one o f t h e b a s i c problems w i t h i n c o r p o r -  a t i n g t h i s concept i n t o n u r s i n g p r a c t i c e has been d e f i n i n g t h e term 'expanded r o l e .  Many contemporary n u r s i n g a u t h o r s have w r i t t e n  about t h i s p r o b l e m and e x p r e s s e d a need f o r t h e concept t o be c l e a r l y defined.  T h i s s t u d y was an attempt t o e x p l o r e t h e concept  'expanded  r o l e ' o f t h e n u r s e by s u r v e y i n g n u r s e s w o r k i n g i n p s y c h i a t r i c  settings.  Two groups p a r t i c i p a t e d i n t h e s t u d y ; h a l f from a community s e t t i n g and h a l f from a h o s p i t a l  setting,  A q u e s t i o n n a i r e was d e v e l o p e d , by t h e a u t h o r , t o o b t a i n d a t a r e g a r d i n g s p e c i f i c v a r i a b l e s t h a t were thought t o be i n h e r e n t i n , o r strong i n d i c a t o r s o f , r o l e expansion i n nursing.  The q u e s t i o n n a i r e  c o n s i s t e d o f 25 i t e m s and was d i s t r i b u t e d t o a t o t a l sample o f 64 n u r s e s (32 w o r k i n g i n community and 32 employed by a h o s p i t a l ) . I t was found t h a t 51 o f t h e 64 n u r s e s viewed t h e i r r o l e t o be expanded.  I n g e n e r a l , community employed n u r s e s were o l d e r , more  e x p e r i e n c e d and more h i g h l y educated t h a n h o s p i t a l n u r s e s . fundamental d e f i n i t i o n was v e r i f i e d b y d a t a a n a l y s e s .  A broad  Although the  l i t e r a t u r e suggests t h a t graduate l e v e l e d u c a t i o n i s n e c e s s a r y t o f u n c t i o n i n an expanded r o l e , t h i s was not t h e case i n t h i s s t u d y as o n l y 10 n u r s e s had masters degrees.  Committee  Chairman  iii TABLE OF CONTENTS  ,  p A G E  ABSTRACT  1  TABLE OF CONTENTS LIST OF TABLES  1  i i i ,  v  LIST OF FIGURES  vi  ACKNOWLEDGEMENTS  v i i  DEDICATION CHAPTER I  1  Introduction  • • •  1  Statement o f t h e P r o b l e m  3  Purpose o f t h e Study  4  S p e c i f i c O b j e c t i v e s o f t h e Study  4  D e f i n i t i o n o f Terms  4  Assumptions  5  Limitations  6  Overview  6  Chapter I I  •  7  L i t e r a t u r e Review  Chapter I I I  7  .  Methodology Data G a t h e r i n g Instrument  *  1  7  1  7  I  7  Pretest  1  8  Sample S e l e c t i o n  1  8  Implementation  !9  iv PAGE  CHAPTER I V r- RESULTS  22  Introduction  22  Demographic Data  22  Demographic Data - H o s p i t a l Subgroup  25  Demographic Data - Community Subgroup  25  Aggregate C r o s s t a b u l a t i o n R e s u l t s  26  CHAPTER V  30  Discussion of Results  30  Summary  31  Conclusions  -  ; . .  Implications  32 34  BIBLIOGRAPHY  36  APPENDICES  42  Appendix A  Consent Form . . . .  Appendix B - Q u e s t i o n n a i r e  4-3 •  ..44  Appendix C - Method o f C a l c u l a t i n g Decision/Judgement Scores Appendix D - Method o f C a l c u l a t i n g Independence S c o r e s Appendix E - Development o f C l i n i c a l / A d m i n i s t r a t i v e Categories  54 . .  57  59  V LIST OF TABLES  TABLES 4.1  s  Summary o f E d u c a t i o n a l P r e p a r a t i o n by Work L o c a t i o n  4.2  22  Summary o f Age D i s t r i b u t i o n A c c o r d i n g t o 23  Work L o c a t i o n 4.3  Summary o f Y e a r s E x p e r i e n c e  as a R e g i s t e r e d Nurse,  P s y c h i a t r i c Nurse, i n P r e s e n t 4.4  Job by L o c a t i o n . . .  27  C r o s s t a b u l a t i o n R e s u l t s o f Independent F u n c t i o n i n P r e s e n t Job w i t h Expanded R o l e  4.7  26  C r o s s t a b u l a t i o n o f M o n t h l y S a l a r y w i t h Expanded Role  4.6  24  Summary o f Aggregate J o b D e s c r i p t i o n C r o s s t a b u l a t e d w i t h Expanded R o l e  4.5  PAGE  27  Summary o f C r o s s t a b u l a t i o n o f C u m u l a t i v e Independence S c o r e s w i t h Expanded R o l e  29  LIST OF FIGURES  FIGURE  4.1  G r a p h i c Summary o f Independent Treatment D e c i s i o n C r o s s t a b u l a t e d w i t h Expanded R o l e  ACKNOWLEDGEMENTS  I would l i k e to express my sincere thanks to the members of my thesis committee: Dr. Beverlee Cox and Dr. Harry Klonoff. Their support and encouragement were greatly appreciated. I would further l i k e to acknowledge my appreciation to Dr. Elaine Cumming for her suggestions and assistance while developing my questionnaire and to Mr. Peter Tomlinson for his guidance during my computer analysis. To those nurses who completed the questionnaire for the study, I thank you.  )  DEDICATION  I wish to dedicate this thesis to my mother and father. Their love, f a i t h and constant encouragement over the past two years have been appreciated more than I can express. Mom and Dad.  Thanks  CHAPTER I  Introduction The concept of role expansion, as applied to the nursing profession, has, i n the last decade become-a major nursing issue. The development of such a concept resulted from s c i e n t i f i c advances, population growth, the introduction of health insurance programs and the broadened focus of nursing education.  These factors, as well as  the trend toward a time of monetary restraint i n Canada, have led to the realization that there are too few physicians to meet the ever growing demands of the lay public for high quality health care (Lamothe, 1972, l ) .  From this i t became.apparent that there  would have to be a re-evaluation of how health manpower was being utilized.  The nursing profession i s one group who i s addressing this  question.  I t was during this re-evaluation of the roles and functions  of nurses, that nursing experts realized the potential contribution of prepared nurses toward diminishing public demand for acute care. This potential became conceptualized i n terms of "expanded roles" for nurses. Many of today's professional nurses are assuming r e s p o n s i b i l i t i and performing duties that not so very long ago were considered inappropriate for the nurse.  I t i s through this gradual aquisition  and acceptance of new dimensions to nursing care that the concept of role expansion has gained impetus. However, i f role expansion i s to be a process of change, i t w i l l require clear guidelines based on theoretical knowledge, s k i l l i n decision making and f a c i l i t a t i o n of  2 independent judgement t h a t r e f l e c t s t h e uniqueness o f n u r s i n g as a growing p r o f e s s i o n (Lamothe, 1972, 9-19). The  changes i n r o l e p e r c e p t i o n and e x p e c t a t i o n have been o c c u r r i n g  at a r a p i d r a t e . change  I t would appear t h a t i t i s t h e r a t e , r a t h e r t h a n t h e  i t s e l f , t h a t i s c a u s i n g c o n f u s i o n and f r u s t r a t i o n among p h y s i c i a n s ,  the p u b l i c , and n u r s e s , r e g a r d i n g t h e n a t u r e o f t h e new f u n c t i o n s which nurses are a c q u i r i n g .  F o r many n u r s e s t h e changes a r e s t i m u l a t i n g  i n t h a t t h e y b e l i e v e t h e r e i s now o p p o r t u n i t y t o f a s h i o n a new r o l e i n w h i c h n u r s e s w i t h g r e a t e r p r o f e s s i o n a l competence w i l l be more active p a r t i c i p a n t s i n coordinated e f f o r t s t o provide b e t t e r health c a r e (Brown, 1970, l ) .  However, a c c o r d i n g t o Lamothe " i f we a r e n o t  t o p u t t h e c a r t b e f o r e t h e h o r s e , t h e new f u n c t i o n s o f n u r s e s must f i r s t be d e f i n e d , b e f o r e t h e y a r e implemented" (1972, 8 ) . The m u l t i p l i c i t y o f f u n c t i o n s adds t o t h e c o n f u s i o n and c r e a t e s c o n t r o v e r s y f o r t h o s e w i t h i n and o u t s i d e t h e r o l e s . would a s s i s t o t h e r s t o u n d e r s t a n d  A clear set of guidelines  and u t i l i z e , more e f f e c t i v e l y , t h e  expanded r o l e n u r s e ( B o o n e y a n d l K i k u c h i , . ' 1977,  1 0 2 ) . The d i f f i c u l t y  at t h e p r e s e n t t i m e i s t h e l a c k o f c l e a r g u i d e l i n e s r e s u l t i n g i n t h e problem o f c l a r i f y i n g what t h e expanded r o l e e n t a i l s .  U n t i l the  concept "expanded r o l e " c a n be o p e r a t i o n a l l y d e f i n e d , t h e r e cannot be p r o p e r u t i l i z a t i o n o f n u r s i n g manpower w i t h i n an expanded r o l e . K a t h l e e n K i n g (1974) sums i t up n i c e l y .  She s t a t e s ,  " I n r e c e n t y e a r s , a r t i c l e s and s t a t e m e n t s , r e g a r d i n g r o l e expansion,  abound u n t i l t h e  j a r g o n has become j a d e d and one wonders what i s expanded about t h e work o f e i t h e r t h e nurse p r a c t i t i o n e r or a c l i n i c a l nurse s p e c i a l i s t . " (54).  3 Even though i t appears o b v i o u s t h a t t h e n u r s e s ' r o l e always changes i n response t o s o c i e t i e s ' needs, i t s f u n c t i o n s have n e v e r been c l e a r l y d e f i n e d (Lamothe,  1972, 4 ) ,  T h i s whole q u e s t i o n o f  d e f i n i t i o n , t h e n , assumes g r e a t e r i m p o r t a n c e i n l i g h t o f c o n f i r m i n g our u n i q u e c o n t r i b u t i o n , as p r o f e s s i o n a l n u r s e s , t o t h e h e a l t h c a r e d e l i v e r y system. "We  I n t h e words o f A l l e n (1974-), cannot hope f o r b a c k i n g , r e c e i v e  s u f f i c i e n t moral or f i n a n c i a l support, n o r have our b e l i e f s about t h e  expanded  f u n c t i o n s of n u r s i n g understood or taken s e r i o u s l y , u n t i l we can demonstrate w i t h i n a r e s e a r c h framework t h e n a t u r e o f our s e r v i c e s and t h e i r v a l u e t o s o c i e t y . " ( 4 ) . 'Statement o f t h e Problem I n o r d e r t o determine t h e dimensions o f n u r s i n g s e r v i c e s and t h e i r c o n t r i b u t i o n toward meeting t h e needs o f s o c i e t y , w i t h i n a r e s e a r c h framework, we must b e g i n w i t h an o p e r a t i o n a l d e f i n i t i o n o f t h e concept "expanded r o l e " .  A t t h e p r e s e n t t i m e t h e r e i s no  definition  t h a t s a t i s f a c t o r i l y encompasses t h e many new w o r k i n g c a t e g o r i e s t h a t a r e c a l l e d "expanded r o l e s " , ( i . e . c l i n i c a l n u r s e s p e c i a l i s t , nurse t h e r a p i s t , nurse p r a c t i t i o n e r , nurse c o n s u l t a n t ) .  This lack  o f a b a s i c c o r e d e f i n i t i o n i s r e s u l t i n g i n a l a r g e degree o f i n t e r d i s c i p l i n a r y confusion.  I n o t h e r words, how do we d e f i n e t h e  r o l e o f t h e n u r s e so t h a t i t r e f l e c t s t h e fundamental  expanded  similarities  o f f u n c t i o n and purpose r e g a r d l e s s o f t h e w o r k i n g r o l e w h i c h he/she assumes?  4 Purpose o f t h e Study The g e n e r a l purpose o f t h e s t u d y was t o d e v e l o p and e m p i r i c a l l y t e s t a fundamental d e f i n i t i o n o f t h e expanded r o l e o f t h e n u r s e f o r n u r s e s of a l l e d u c a t i o n a l p r e p a r a t i o n s i n v i e w o f s i m i l a r i t i e s i n r o l e f u n c t i o n and c l i n i c a l r e s p o n s i b i l i t i e s as d e s c r i b e d i n t h e literature.  A secondary purpose was t o u t i l i z e t h e i n f o r m a t i o n o b t a i n e d  t o i d e n t i f y t h e e d u c a t i o n a l gap ( i f one e x i s t s ) between n u r s e s f u n c t i o n i n g i n expanded r o l e s and g e n e r a l d u t y n u r s e s w i t h r e s p e c t t o s t a f f n u r s e p e r c e p t i o n s o f expanded r o l e n u r s e f u n c t i o n s .  S p e c i f i c O b j e c t i v e s of the Study The s p e c i f i c o b j e c t i v e s o f t h i s s t u d y were: 1.  To determine what f u n c t i o n s t h e ^ n u r s e w o r k i n g i n an expanded  r o l e i s c a r r y i n g out. 2.  To determine t h e e d u c a t i o n a l p r e p a r a t i o n o f n u r s e s i n expanded  roles. 3.  To determine whether autonomy and independence  are inherent  i n r o l e expansion. 4.  To determine r o l e p e r c e p t i o n and e x p e c t a t i o n o f expanded  r o l e n u r s e s b y n u r s e s assuming t h i s p o s i t i o n . 5. nursing  To i d e n t i f y a r e a s o f c o n f u s i o n t h a t c o u l d be d i s i p a t e d t h r o u g h education.  D e f i n i t i o n o f Terms Nursing Population:-  those nurses p r e s e n t l y r e g i s t e r e d i n the  5 P r o v i n c e o f B r i t i s h Columbia who  a r e w o r k i n g i n g e n e r a l d u t y and/or  expanded r o l e s i n h o s p i t a l s o r community. Expanded R o l e : l e v e l , who  A r e g i s t e r e d nurse, prepared  at the masters  i s f u n c t i o n i n g beyond t h e t r a d i t i o n a l n u r s e r o l e , i n an  independent o r semi-independent manner i n the a r e a o f c l i n i c a l t h e r a p i s t ( p e r f o r m i n g p s y c h i a t r i c assessment and p s y c h o t h e r a p y ) ,  nurse c o n s u l t a n t ,  team member, l i a i s o n p e r s o n or s o c i a l change agent f o r t h e p u r p o s e s o f c o n t r i b u t i n g h i g h e d u c a t i o n and s k i l l i n the t r e a t m e n t  of the  and o r d i s t r a u g h t p e r s o n o r f a m i l y , o r t h e p r e v e n t i o n o f  illness,  a i d i n g n u r s e s t o cope w i t h ward and p a t i e n t d i f f i c u l t i e s , and and p r e p a r a t i o n f o r p e r s o n s upon t h e i r r e t u r n t o community.  sick  planning Her/his  f u n c t i o n c o u l d a l s o be at t h e e d u c a t i o n a l o r r e s e a r c h l e v e l , depending on h e r / h i s a r e a o f e x p e r t i s e . T r a d i t i o n a l Role:-  Those n u r s e s p r e p a r e d  and/or u n i v e r s i t y programs and who  i n basic hospital  are p r e s e n t l y working general  d u t y i n an e s t a b l i s h e d h o s p i t a l ( e x c l u d i n g s u p e r v i s o r y and a d m i n i s t r a t i v e personnel).  Assumptions The b a s i c assumptions i n t h i s s t u d y were: 1.  t h e concept o f expanded r o l e i s i m p o r t a n t  t o the n u r s i n g  profession; 2.  t h e expanded r o l e e x i s t s , d e s p i t e t h e p r e s e n t  surrounding 3.  i t , b o t h c l i n i c a l l y and c o n c e p t u a l l y ;  confusion  and  a fundamental d e f i n i t i o n can e m p i r i c a l l y be t e s t e d and  i t be v a l i d a t e d , c o u l d a f f e c t t h e h e a l t h c a r e o f Canadians.  should  6 Limitations 1.  Population a)  e x c l u d e s n o n - r e g i s t e r e d n u r s e s and t h o s e w o r k i n g i n s m a l l and/or p r i v a t e l y o p e r a t e d h o s p i t a l s ;  b)  e x c l u d e s a d m i n i s t r a t i v e and s u p e r v i s o r y p e r s o n n e l ;  c)  excludes those working i n h o s p i t a l s or outside the f i e l d of p s y c h i a t r y .  communities  I t appears t h a t t h e  g r e a t e s t d e n s i t y o f n u r s e s w o r k i n g i n expanded r o l e s are w i t h i n a p s y c h i a t r i c / m e n t a l h e a l t h system.  Hence,  f o r t h i s s t u d y , I am l i m i t i n g t h e sample t o t h i s a r e a . 2.  The sample was one o f convenience and g e n e r a l i z a t i o n s t o t h e  l a r g e r n u r s i n g p o p u l a t i o n cannot be made.  Overview A s e l e c t e d l i t e r a t u r e r e v i e w i s p r e s e n t e d i n Chapter I I . Chapter I I I c o n t a i n s a d e s c r i p t i o n o f t h e methodology study.  used i n t h e  Data a n a l y s e s a r e p r e s e n t e d i n Chapter IV. Chapter V  c o n t a i n s c o n c l u s i o n s and i m p l i c a t i o n s o f t h e f i n d i n g s .  7 CHAPTER I I  L i t e r a t u r e Review In recent years the compiled nursing l i t e r a t u r e , d e s c r i b i n g the concept o f r o l e e x p a n s i o n , has become q u i t e voluminous.  There have  been many a t t e m p t s t o d e f i n e t h e term, e x p l a i n i t s o r i g i n and f u t u r e d e s t i n a t i o n , and t o account f o r t h e p r e s e n t needs o f s o c i e t y and t h e n u r s i n g p r o f e s s i o n f o r such a c o n c e p t .  The somewhat b r o a d scope w h i c h  t h e l i t e r a t u r e c o v e r s d e a l s w i t h s p e c u l a t i o n and documentation o f how n u r s e s f u n c t i o n w i t h i n expanded r o l e s ( i . e . t h e r a p i s t , c o n s u l t a n t , nurse s p e c i a l i s t ) .  However, such a c c o u n t s seem t o l a c k o r g a n i z e d  e x p e r i m e n t a l d e s i g n w h i c h would i n d i c a t e , w i t h i n a r e s e a r c h framework, the u n i q u e n a t u r e o f t h e r o l e and f u n c t i o n s o f t h e s e n u r s e s and t h e i r v a l u e t o s o c i e t y and t h e p r o f e s s i o n . One o f t h e major i s s u e s , as d e s c r i b e d i n t h e l i t e r a t u r e , i s t h e problem o f d e f i n i t i o n o f t h e t e r m "expanded r o l e " .  Many a u t h o r s  have w r i t t e n about t h i s problem, and e x p r e s s e d a need f o r t h e concept t o be c l e a r l y d e f i n e d .  The whole i s s u e has been l o o k e d a t from many  p e r s p e c t i v e s , b u t t h e b a s i c c o n c e r n remains t h e same; what i s t h e expanded r o l e o f t h e n u r s e ? The l i t e r a t u r e r e v i e w t o f o l l o w i s s e l e c t i v e o f t h e l a r g e amount o f m a t e r i a l d e a l i n g w i t h t h e problem o f d e f i n i t i o n .  A l t h o u g h some  o f t h e views may appear t o be somewhat m i l i t a n t i n n a t u r e , t h e y e x p r e s s t h e c u r r e n t p o s i t i o n t a k e n b y many o f t h e contemporary n u r s i n g a u t h o r s . I t i s t h e i n t e n t i o n o f t h i s i n v e s t i g a t o r t o determine t h e f u n c t i o n s and c l i n i c a l r o l e o f n u r s e s w o r k i n g i n an expanded r o l e , i n p s y c h i a t r y ,  8 i n t h e hope t h a t a c o r e d e f i n i t i o n o f t h e concept c a n be' e m p i r i c a l l y verified. Contemporary n u r s i n g l i t e r a t u r e c i t e s many f a c t o r s t h a t a r e p e r p e t r a t i n g t h e development o f expanded r o l e s f o r n u r s e s . o f t h e more i m p o r t a n t f a c t o r s i n c l u d e knowledge;  a ) a r a p i d growth o f b i o m e d i c a l  b) broadening nursing education;  demand f o r h e a l t h c a r e ;  Several  c) increased  d ) t h e women's movement; and  public  e ) t h e development  o f p r o f e s s i o n a l r e l a t i o n s h i p s among n u r s e s and o t h e r h e a l t h p r o f e s s i o n a l s ( S e c r e t a r y ' s Committee, 1972, 4-8). However, a c c o r d i n g t o L e w i s ( 1 9 7 2 ) , " . . i f t h e n a t u r e o f an e n l a r g e d  nursing  r o l e i s simply t o extend t h e p h y s i c i a n s ' t h e r a p e u t i c and i l l n e s s - o r i e n t e d s e r v i c e s , t h e n we haven't changed a n y t h i n g ;  we've  simply  d i s t r i b u t e d t h e same o l d work among more p e r s o n s i n t h e same o l d system.  But, i f  t h e n u r s e i s i d e n t i f i e d and used as a p e r s o n with a d i f f e r e n t o r i e n t a t i o n than the physician —  one who p r o v i d e s  k i n d o f h e a l t h care s e r v i c e —  a different t h e n we  have t h e p o t e n t i a l f o r a new p a t t e r n o f h e a l t h manpower and some overdue r e s t r u c t u r i n g of- o u r h e a l t h c a r e d e l i v e r y system." ( 2 1 ) .  Nursing,  i f i t i s t o remain an e s s e n t i a l s o c i a l s e r v i c e ,  must become more a c t i v e i n e s t a b l i s h i n g t h e norms and f u n c t i o n a l g u i d e l i n e s t h a t a r e t o g o v e r n n u r s i n g p r a c t i c e ( D r i s c o l l , 1972, 2 6 ) . As S c h e i n ,  c i t e d by L o u i s e M u r r a y ( 1 9 7 2 ) , s t a t e s , " t h e essence o f  r o l e i n n o v a t i o n i s a r e j e c t i o n o f some o f t h e norms w h i c h g o v e r n t h e p r a c t i c e o f t h e p r o f e s s i o n combined w i t h an i n t e r e s t i n e l u c i d a t i n g  9 the t r u e o r i d e a l r o l e o f t h e nurse p r o f e s s i o n a l i n s o c i e t y " ( 6 0 ) . R o l e , as d e f i n e d i n Theodore S a r b i n ' s R o l e Theory (1968) i s ". . . a n i n t e r n a l l y c o n s i s t e n t s e r i e s o f c o n d i t i o n e d r e s p o n s e s b y one member o f a s o c i a l s i t u a t i o n w h i c h r e p r e s e n t s t h e s t i m u l u s p a t t e r n f o r a s i m i l a r l y i n t e r n a l l y c o n s i s t e n t s e r i e s o f conditioned responses o f t h e o t h e r ( s ) i n t h a t s i t u a t i o n " (488-567).  He f u r t h e r s t a t e s  t h a t a s s o c i a t e d w i t h r o l e a r e r o l e e x p e c t a t i o n s and r o l e p e r c e p t i o n s . I n terms o f r o l e e x p e c t a t i o n s , t h e r e a r e two g e n e r a l k i n d s ; r i g h t s and obligations.  Rights are r o l e expectations i n which the actor of the  r o l e a n t i c i p a t e s c e r t a i n performances f r o m t h e a c t o r o f a r e c i p r o c a l role.  O b l i g a t i o n s are r o l e expectations i n which t h e a c t o r o f a  r o l e a n t i c i p a t e s c e r t a i n performances d i r e c t e d toward t h e a c t o r o f t h e reciprocal role.  When S a r b i n speaks o f r o l e p e r c e p t i o n , he sees  t h i s as an o r g a n i z e d r e s p o n s e o f a p e r s o n t o a s t i m u l i i n a s o c i a l c o n t e x t ; a sequence o f b e h a v i o u r s )  i n w h i c h p e r c e p t u a l r e s p o n s e and  motoric response r e s u l t i n t h e a c t o r performing  actions appropriate  t o h i s l o c a t i o n o f t h e p o s i t i o n s o f s e l f and o t h e r ,  Taken i n t h e c o n t e x t  o f r o l e t h e o r y , t h e n , many o f t h e d i f f i c u l t i e s and c o n t r o v e r s i e s c o n c e r n i n g t h e expanded r o l e f o r t h e n u r s e ,  can b e t t e r be u n d e r s t o o d ,  f o r r o l e change cannot o c c u r i f t h e c l i n i c i a n i s t h e o n l y one t o v i e w her r o l e a s h a v i n g changed.  The g e n e r a l p u b l i c , o t h e r h e a l t h p r o f e s s i o n a l s ,  and p r o f e s s i o n a l n u r s e s themselves must d e v e l o p and m a i n t a i n  similar  p e r c e p t i o n s and e x p e c t a t i o n s o f an advanced c l i n i c a l n u r s e (Moore, 1974,  1 2 7 ) . I n l i g h t o f s o c i e t y ' s c u r r e n t demand f o r improved h e a l t h  c a r e , and t h e a v a i l a b i l i t y o f n u r s e s t o h e l p meet t h i s demand, i t becomes mandatory t o f o r m a l i z e t h e expanded n u r s e ' s r o l e (Walker,  1972, 2 9 ) .  Nursing  i n Canada t o d a y i s e x c i t i n g , but f r u s t r a t i n g and  o f t e n c o n f u s i n g , a s a r e s u l t o f r a p i d e d u c a t i o n a l and r o l e change. As t h e r o l e o f n u r s i n g expands, e d u c a t i o n  expands, and the independent  n a t u r e of the p r o f e s s i o n grows ( H a t t , 1977,  1583).  According  B r i s t o w , e t a l ( 1 9 7 4 ) , " i f we a r e not t o l o s e s i g h t o f our  to  raison  d ' e t r e , we must a d d r e s s o u r s e l v e s t o our p r o f e s s i o n a l b o u n d a r i e s  and  norms i n an e f f o r t t o a c h i e v e l e g i t i m a t e power and a u t h o r i t y " ( 3 1 ) . I n o r d e r t o a c h i e v e t h i s , we must know what we a r e p r e p a r i n g  for i n  terms o f r o l e , f u n c t i o n and purpose and have c l e a r g u i d e l i n e s f o r p r a c t i c e a v a i l a b l e f o r t h e use o f n u r s e s and o t h e r h e a l t h p r o f e s s i o n a l s . A t t h e p r e s e n t t i m e , i n s t e a d o f c l e a r g u i d e l i n e s , we have  confusion  r e s u l t i n g from the interchange  extended  o f terms l i k e expanded and  r o l e ; c l i n i c a l s p e c i a l i s t .andnurse c l i n i c i a n , e t c .  An  operational  d e f i n i t i o n o f "expanded r o l e " would g r e a t l y a i d i n e l i m i n a t i n g t h e shroud o f c o n f u s i o n e n v e l o p i n g  t h e concept a t t h i s  time.  I t becomes apparent t h a t a c r i t i c a l i s s u e i n d e f i n i n g t h e expanded r o l e o f t h e n u r s e appears t o be n o t so much t h e n u r s e ' s a b i l i t y t o f u n c t i o n a t a h i g h l e v e l , but t h e a t t i t u d e s of n u r s e s and  physicians  toward a l l o w i n g t h e n u r s e r e a l independence and power i n c l i n i c a l d e c i s i o n making (Heiman and Kempsey, 1976,  587).  According  to  de  Tornyay ( 1 9 7 1 ) , "when we t a l k about changing r o l e s , h e l p i n g n u r s e s t o l e a r n new  s k i l l s i s r e l a t i v e l y easy.  problem e n t i r e l y "  Changing a t t i t u d e s i s a d i f f e r e n t  (976).  S l i g h t l y more t h a n t e n y e a r s ago, when n u r s i n g  functions  began expanding, few problems, p a r t i c u l a r l y i n the a r e a of r o l e change, were a n t i c i p a t e d . incorporated  There was  a g e n e r a l f e e l i n g t h a t t h e s e new  i n t o n u r s i n g were more a p p r o p r i a t e  for their  functions  educational  11 preparation.  However, as time p a s s e d , i t became more and more  evident  t h a t g e n e r a l d u t y n u r s e s d i d n o t see t h e expanded r o l e n u r s e f u n c t i o n i n g any d i f f e r e n t l y from t h e m s e l v e s .  Within that context,  a true r o l e  change c o u l d n o t o c c u r (Moore, 197-4, 1 2 7 ) . Even w i t h b e t t e r  educational  p r e p a r a t i o n , n u r s e s had problems i n t a k i n g on more r e s p o n s i b i l i t y . P a r t o f t h e problem, as s t a t e d e a r l i e r , r e s t s w i t h t h e a t t i t u d e s o f p h y s i c i a n s , t h e p u b l i c and o f n u r s e s t h e m s e l v e s r e g a r d i n g t h e new dimensions b e i n g i n c o r p o r a t e d  i n t o the nursing profession.  But,  perhaps even more i m p o r t a n t t h a t t h e a t t i t u d e s , i s t h e somewhat haphazard a t t e m p t , b y t h e p r o f e s s i o n , t o d e l i n e a t e c l e a r g u i d e l i n e s for  d e f i n i n g t h e r o l e , f u n c t i o n , and c l i n i c a l r e s p o n s i b i l i t i e s o f a  n u r s e p e r f o r m i n g i n an expanded r o l e .  A c c o r d i n g t o Boone and K i k u c h i ( 1 9 7 7 ) ,  " C l e a r e r g u i d e l i n e s would a s s i s t o t h e r s t o u n d e r s t a n d and t o u t i l i z e t h i s p e r s o n more effectively.  Because o f t h e p r e s e n t  ambiguity i n the d e f i n i t i o n s , there i s s t i l l controversy  concerning the n e c e s s i t y ,  the expectations  and t h e p o t e n t i a l o f  the nurse performing w i t h i n t h e context of expanded r o l e . " (102-103). S i n c e n u r s i n g began, i n t h e l a t e 1800's knowledge and e x p e r t i s e has g r e a t l y expanded.  The c l i n i c a l competence n e c e s s a r y f o r p r o f e s s i o n a l  p r a c t i c e has been much g r e a t e r t h a n was a n t i c i p a t e d (Lamothe, 1977, 7 ) . A c c o r d i n g t o Lamothe ( 1 9 7 2 ) , " S i n c e h e a l t h c a r e seems t o f a l l n a t u r a l l y i n t o a form i n w h i c h t h e members o f v a r i o u s d i s c i p l i n e s work i n teams, t h e r o l e and f u n c t i o n s o f each p a r t i c i p a n t  s h o u l d be c l e a r l y l a i d down.  This  w i l l encourage mutual c o o p e r a t i o n  and  w i l l h e l p t o a v o i d p r o l i f e r a t i o n of r o l e s . " (17). I n 1972,  a f u l l s c a l e e f f o r t was made t o l o o k a t t h e  r o l e of the nurse.  expanding  T h i s r e p o r t , put out by the Department o f  National  H e a l t h and W e l f a r e i n t h e f o r m o f t h e Boudreau R e p o r t s t a t e s . . . "The  awareness o f t h e unique c o n t r i b u t i o n  t h a t o t h e r p r o f e s s i o n s can make i n t h e p r o v i s i o n o f h e a l t h c a r e i s , however, becoming more and more w i d e s p r e a d and i s being gradually t r a n s l a t e d i n t o corresponding increased r e s p o n s i b i l i t y  and (4).  autonomy f o r t h e s e p r o f e s s i o n s . "  The  r e p o r t goes on t o s t r e s s t h e i m p o r t a n c e o f d e v e l o p i n g  t h o s e methods  o f h e a l t h c a r e a l r e a d y i n e x i s t e n c e as opposed t o d e v e l o p i n g e n t i r e l y new  c a t e g o r y of h e a l t h p r o f e s s i o n a l .  an  In s p i t e df these  recommendations, we have seen i m p u l s i v e development o f n u r s e p r a c t i t i o n e r programs, p h y s i c i a n a s s i s t a n t programs, c l i n i c a l  nurse  s p e c i a l i s t and t h e r a p i s t programs, a l l of w h i c h have added t o  the  c o n f u s i o n and  c o m p l i c a t i o n o f an expanded r o l e f o r n u r s e s .  o n l y t o l o o k at t h e l i t e r a t u r e t o r e a l i z e t h a t t h e  One  has  educational  p r e p a r a t i o n f o r n u r s e s f o r an expanded r o l e w i d e l y v a r i e s .  However,  no m a t t e r what approach i s used, s u c c e s s i s dependent upon t h e mutual agreement o f b o t h the n u r s e and t h e employing agency as t o t h e r o l e t h e n u r s e w i l l assume (.Boone and Ki.kuchiy.. 1977,  108).  It i s  difficult  t o a c h i e v e mutual agreement when t h e g u i d e l i n e s f o r p r a c t i c e a r e  so  unclear.  How  does a " d e f i n i t i o n " such as t h a t w h i c h appears i n t h e  Boudreau Report (1972) ". . . a n e x t e n s i o n o f t h e p r e s e n t n u r s i n g r o l e , w i t h t h e n u r s e ' s unique s k i l l s i n t h e p r o v i s i o n o f h e a l t h c a r e b e i n g d e v e l o p e d and u t i l i z e d more e f f e c t i v e l y , and t h e n u r s e ' s r o l e i n a s s i s t i n g t h e p h y s i c i a n expanded t h r o u g h i n c r e a s e d d e l e g a t i o n o f t a s k s by p h y s i c i a n s t o s u i t a b l y p r e p a r e d n u r s e s . . ." ( 6 ) , h e l p c l a r i f y a n y t h i n g about t h e new dimensions n u r s e s a r e embarking  on?  I n June o f 1972, R a c h e l Lamothe p r e p a r e d a paper on t h e expanded r o l e o f t h e n u r s e i n w h i c h she emphasized t h e need f o r changes i n t h e r o l e o f n u r s i n g t o meet t h e e v e r i n c r e a s i n g demands o f t h e l a y p u b l i c f o r h e a l t h care (16). and d e f i n i n g t h e new  Lamothe s t r e s s e d t h e need f o r c l a r i f y i n g  f u n c t i o n s w h i c h n u r s e s a r e u n d e r t a k i n g , and a l s o  t h a t i f t h e needs o f s o c i e t y a r e t o be met e f f e c t i v e l y and  efficiently,  u n i v e r s i t i e s and departments o f e d u c a t i o n must agree on t h e t y p e o f education required (19).  More and more s c h o l a r s i n t h e n u r s i n g p r o f e s s i o n  a r e l e a n i n g toward g r a d u a t e p r e p a r a t i o n f o r assuming an expanded r o l e . However, i t s h o u l d be n o t e d t h a t we a r e n o t m e r e l y d e a l i n g w i t h e d u c a t i o n a l programs; we a r e d e a l i n g w i t h p e o p l e whom we a r e t r y i n g t o change and p r e p a r e f o r p r a c t i c e i n new and d i f f e r e n t ways ( W h i t e , 1975, I64).  I n h e r e n t t o t h e development  of r o l e expansion i s increased  autonomy, s e l f - e s t e e m and s o c i a l s u p p o r t ; t h e n u r s e must see h e r s e l f as one who n u t u r e s c l i e n t s and f a m i l i e s r a t h e r t h a n m a i n t a i n i n g a s e r v i c e t o an agency o r i n s t i t u t i o n (Maekemes, 1974, 9 0 ) .  A  crucial  problem w i t h a c h i e v i n g t h i s , i n v o l v e s a m b i g u i t y and r o l e c o n f u s i o n r e s u l t i n g from l a c k o f c l e a r g u i d e l i n e s f o r p r a c t i c e . I n 1976, E d i t h W r i g h t d i d a s u r v e y s t u d y i n w h i c h she a t t e m p t e d t o determine what r e g i s t e r e d n u r s e s thought about t h e expanded r o l e  concept.  She s t a t e d , " I m p l i c i t i n t h e d e c i s i o n t o develop new r o l e s f o r n u r s e s i s t h e a s s u m p t i o n t h a t a new r o l e responds t o a  recognized  need i n t h e h e a l t h c a r e d e l i v e r y and w i l l make a d i f f e r e n c e i n t h e c a r e ultimately delivered." She  (112).  f u r t h e r s t a t e s t h a t " . . . B e f o r e judgements c a n be made about  the u s e f u l n e s s  or f e a s i b i l i t y of preparing  nurses t o f u n c t i o n i n  extended r o l e s , subgroups w i t h i n t h e h e a l t h c a r e system w i l l have s p e c i f i c q u e r i e s and concerns t h a t r e q u i r e a t t e n t i o n . " ( W r i g h t , 1976, 112).  I n o r d e r t o s a t i s f y and/or e l i m i n a t e t h e q u e r i e s and c o n c e r n s ,  t h e n u r s i n g p r o f e s s i o n must be p r e p a r e d w i t h c l e a r g u i d e l i n e s  explaining  b o t h f u n c t i o n and purpose, as w e l l as t h e p o t e n t i a l c o n t r i b u t i o n t h e change has f o r b e t t e r h e a l t h c a r e .  I f we do n o t d e a l c o n s t r u c t i v e l y  and c o l l a b o r a t i v e l y w i t h t h e p r e s e n t problems, n u r s e s w i l l n o t be able t o c l i n i c a l l y  meet t h e c h a l l e n g e  of today's h e a l t h care d e l i v e r y  head on (Moore, 1974, 1 2 7 ) . • F o r many y e a r s n u r s e s i n r u r a l a r e a s o f Western Canada and i s o l a t e d a r e a s o f t h e Canadian N o r t h have f u n c t i o n e d w i t h o u t t h e s e b e i n g d e s i g n a t e d a s such.  i n expanded r o l e s ,  However, emerging s o c i e t a l  and governmental p r e s s u r e s r e l a t e d t o r e d u c i n g  h e a l t h care workers  and t h e need o f s e l e c t e d t y p e s o f p h y s i c i a n s u b s t i t u t e s t o p r o v i d e m e d i c a l c a r e i n remote a r e a s , have t o g e t h e r c r e a t e d a t r e n d t o w a r d greater 1974,  f o r m a l i z a t i o n o f "expanded" r o l e s f o r n u r s e s (Hayes, e t a l . ,  3 4 ) . From t h e l i t e r a t u r e , o f w h i c h t h e r e i s an abundance, i t  becomes apparent t h a t t h e " f o r m a l i z a t i o n " c o n t i n u e s t o l a c k p r e c i s i o n  15 and c l a r i t y w i t h r e s p e c t t o c o m m o n a l i t i e s among a l l expanded r o l e s , and e m p i r i c a l e v i d e n c e t o determine what n u r s e s i n expanded r o l e s a r e r e a l l y doing.  C l a r i t y a l s o t a k e s on s p e c i a l importance h e r e , f o r  p r e p a r i n g a n u r s e t o p e r f o r m i n a more autonomous r o l e , does n o t mean t h a t t h e system w i l l a l l o w her/him t o f u n c t i o n so.  F o r a g r e a t many  y e a r s now t r a d i t i o n has bound t h e r e l a t i o n s h i p between n u r s e s and p h y s i c i a n s t o extreme s u b o r d i n a t i o n - s u p e r o r d i n a t i o n ( B u l l o u g h , 1976, 1478).  A l o n g w i t h r o l e change, t h e r e must be a change i n p r o f e s s i o n a l  s e l f concept s o , t h a t p r o f e s s i o n a l s a r e c o m f o r t a b l e w i t h t h e i r  new  f u n c t i o n s and r e s p o n s i b i l i t i e s , n o t c o n f u s e d o r u n c e r t a i n about t h e change, and d i r e c t l y r e s p o n s i b l e ^tq and f o r t h e patient.,. Expanding our r o l e i s i m p o r t a n t i n l i g h t o f h e a l t h c a r e demands, h e a l t h c a r e c o s t s and economics.  A c c o r d i n g t o Lewis ( 1 9 7 4 ) ,  " I f we a r e t o l o o k f o r w a r d t o b r o a d u n d e r s t a n d i n g and a c c e p t a n c e o f t h e expanded r o l e n u r s e , h a s n ' t t h e t i m e come f o r c o n s i d e r a t i o n o f some b r o a d , n a t i o n a l l y determined s t a n d a r d s and criteria?  F o r y e a r s we have t a l k e d  about t h e l a r g e r c o n t r i b u t i o n t h a t n u r s e s c o u l d make w i t h i n our h e a l t h c a r e s t r u c t u r e g i v e n an o p p o r t u n i t y to p r a c t i c e to t h e i r f u l l  potential.  W i t h t h e concept o f r o l e e x p a n s i o n , n u r s i n g has t h a t o p p o r t u n i t y . " ( 8 9 ) .  What we do t o d a y i n n u r s i n g w i l l be r e f l e c t e d i n t h e f u t u r e (Moore, 1974, 127). what we a r e  The problem, t h e n , becomes one o f v e r i f y i n g v .  preparing forj  who a r e we when  16 we p r a c t i c e i n an expanded r o l e ?  I t has been s a i d , more o f t e n t h a n  n o t , t h a t i f n u r s i n g doesn't d e f i n e t h e r o l e , o t h e r h e a l t h p r o f e s s i o n a l s w i l l do i t f o r u s . King  I n t h e words o f -Joan . . G i l c h r i s t , as c i t e d .by K a t h l e e n  (1974): "We should n o t be c o n t e n t t o f o l l o w along d i r e c t i o n s determined by others but  should n e g o t i a t e our p o s i t i o n from  a base w h i c h i n c l u d e s r e s e a r c h ,  learning,  a d m i n i s t r a t i o n and above a l l n u r s i n g p r a c t i c e knowledge." ( 5 5 ) .  M a r t h a Rogers (1972) has summed i t up n i c e l y . ". . . i t i s n u r s i n g knowledge t h a t n u r s e s b r i n g t o t h e j o i n t c o l l a b o r a t i o n o f a range o f h e a l t h p r o f e s s i o n a l s ; i t i s n u r s i n g knowledge t h a t adds new dimensions t o human s a f e t y and human s e r v i c e ; and i t i s n u r s i n g ' s , : ^ body o f s c i e n t i f i c knowledge t h a t g u i d e s nursing p r a c t i c e .  Nursing  i ssolely  r e s p o n s i b l e f o r i t s own a c t s .  Only  out o f mutual s h a r i n g and r e s p e c t among h e a l t h d i s c i p l i n e s c a n t h e r e a r i s e a n a t u r e and q u a l i t y o f h e a l t h s e r v i c e s t h a t no s i n g l e d i s c i p l i n e can p r o v i d e on i t s own." (4-4). I n c o n c l u s i o n t h e n , i f t h e concept o f r o l e e x p a n s i o n i s t o l i v e a l o n g , h e a l t h y l i f e , a c l e a r c u t d e f i n i t i o n o f t h e r o l e and f u n c t i o n s must be d e v e l o p e d i n t h e near f u t u r e .  The t i m e has come,  and n u r s i n g must meet^the p r o f e s s i o n a l c h a l l e n g e  o f t h e day b y a c t i v e l y  . p a r t i c i p a t i n g i n the p r e p a r a t i o n o f g u i d e l i n e s t o govern t h e p r a c t i c e o f an expanded r o l e n u r s e .  17 CHAPTER I I I  MethodologyT h i s s t u d y was w h i c h was  conducted t h r o u g h t h e use o f a q u e s t i o n n a i r e  completed by n u r s e s w o r k i n g i n a community o r h o s p i t a l  s e t t i n g , i n the f i e l d of p s y c h i a t r y .  Aggregate d a t a ,  obtained  from r e s p o n s e s t o t h e q u e s t i o n n a i r e , were a n a l y s e d t o determine what r o l e p e r c e p t i o n s , e x p e c t a t i o n s and f u n c t i o n s are i n h e r e n t t o a n u r s e w o r k i n g i n an "expanded" r o l e .  Data G a t h e r i n g The s t u d y was  Instrument  q u e s t i o n n a i r e (see Appendix B) u t i l i z e d  i n this descriptive  d e v e l o p e d by t h i s i n v e s t i g a t o r , i n c o n s u l t a t i o n w i t h  experts  i n q u e s t i o n n a i r e development, as p a r t o f t h e r e s e a r c h p r o c e s s . was  designed t o e l i c i t s p e c i f i c i n f o r m a t i o n regarding  It  respondents'  p e r c e p t i o n o f t h e i r r o l e , and l e v e l o f c l i n i c a l f u n c t i o n i n g as i n d i c a t o r s of r o l e e x p a n s i o n .  The t o o l c o n s i s t e d o f t h r e e p a r t s ; p a r t one  demographic d a t a used t o determine whether v a r i a b l e s s u c h as education, years of experience, o f f u n c t i o n i n g ; p a r t two as i n d i c a t o r s o f how a r e a s ; p a r t t h r e e was  of  age,  e t c . , e f f e c t r o l e p e r c e p t i o n and  consisted of h y p o t h e t i c a l / s t i u a t i o n a l  level items  n u r s e s can o r would r e a c t i n t h e i r r e s p e c t i v e work composed o f open ended r e s p o n s e i t e m s f o r  p u r p o s e s o f e l i c i t i n g t h e t r u e p e r c e p t i o n o f how  n u r s e s see t h e m s e l v e s  f u n c t i o n i n g i n r e l a t i o n - t o education, experience  and j o b d e s c r i p t i o n .  The q u e s t i o n n a i r e c o n t a i n e d a t o t a l o f t w e n t y r - f i v e ( 2 5 ) The p r i v a c y o f s u b j e c t s was  items.  ensured by anonymity o f s t u d y p a r t i c i p a n t s .  18  Pretest The q u e s t i o n n a i r e was p r e t e s t e d u t i l i z i n g t e n n u r s e s w o r k i n g i n p s y c h i a t r y i n community and h o s p i t a l s e t t i n g s . the  The r e a s o n s f o r  p r e t e s t were:r  1.  t o determine whether t h e q u e s t i o n s were c l e a r and unambiguous;  2.  t o determine whether t h e i t e m s were d e s c r i m i n a t i n g between  'expanded' r o l e n u r s e s and g e n e r a l s t a f f n u r s e s w i t h i n p s y c h i a t r y ; and 3.  t o determine whether t h e q u e s t i o n n a i r e e l i c i t e d  the necessary  i n f o r m a t i o n f o r d e t e r m i n i n g r o l e perception'.and r o l e f u n c t i o n f o r v a l i d a t i n g a d e f i n i t i o n o f t h e concept 'expanded' r o l e . As a r e s u l t c f t h e p r e t e s t , format o f t h e q u e s t i o n n a i r e was a l t e r e d , two q u e s t i o n s were e l i m i n a t e d and two q u e s t i o n s were added.  Sample S e l e c t i o n A convenience sample was o b t a i n e d from t h o s e p e r s o n s w o r k i n g w i t h i n an 'expanded' r o l e who a t t e n d e d t h e Q u a l i t y A s s u r a n c e h e l d a t t h e Burnaby M e n t a l H e a l t h C e n t r e .  Conference  They were c o n t a c t e d by  t h i s i n v e s t i g a t o r , and 35 p e r s o n s v o l u n t e e r e d t o p a r t i c i p a t e i n the study. A second group o f 35 p e r s o n s was o b t a i n e d from t h e n u r s i n g s t a f f at H e a l t h Sciences Centre H o s p i t a l .  •  19  Implementation  Phase I : Through a s e a r c h o f t h e l i t e r a t u r e , a d e f i n i t i o n  reflecting  t h e s i m i l a r b a s i c components o f f u n c t i o n was d e v e l o p e d , f o r t h e expanded r o l e o f t h e n u r s e .  From t h i s d e f i n i t i o n , a q u e s t i o n n a i r e  was developed t o r e f l e c t t h e concept i n q u e s t i o n . Phase I I : The q u e s t i o n n a i r e was m a i l e d out t o t h o s e p e r s o n s who had been c o n t a c t e d t h r o u g h t h e Burnaby M e n t a l H e a l t h C e n t r e .  Of t h e 35  m a i l e d out t h e ^ r e t u r n was 91$ o r 32 q u e s t i o n n a i r e s . The same number, 32, o f q u e s t i o n n a i r e s was completed b y t h e n u r s i n g s t a f f a t H e a l t h Sciences Centre r e s u l t i n g o f 64 s u b j e c t s .  A l l participants  i n a t o t a l sample  r e c e i v e d t h e same q u e s t i o n n a i r e .  Due t o t h e n a t u r e o f t h e sample s e l e c t i o n  and t h e f a c t t h e s t u d y  was r e s t r i c t e d t o t h e f i e l d o f p s y c h i a t r y , g e n e r a l i z a t i o n s cannot be made r e g a r d i n g t h e t o t a l n u r s i n g p o p u l a t i o n .  Phase I I I : P r i o r t o data c o l l e c t i o n , c r i t e r i a f o r converting the i n f o r m a t i o n i n t o n u m e r i c a l v a l u e s were e s t a b l i s h e d . P a r t 2 d e a l t w i t h s i t u a t i o n a l items d e s i g n e d b e h a v i o u r a l response i n d i c a t i n g i n a given situation.  1,  t h e k i n d o f judgement n u r s e s u t i l i z e  The f o l l o w i n g  t h i s data i n t o numerical  to e l i c i t a  c r i t e r i a were employed t o c o n v e r t  scores.  I f t h e response r e f l e c t e d  synthesis of the presented  d a t a r e s u l t i n g i n a c l i n i c a l l y sound judgement, and  20 2.  i f t h e response was  i n d i c a t i v e of accepting r e s p o n s i b i l i t y  f o r one's own a c t i o n s , and 3.  i f t h e response  t h e respondent was  i n d i c a t e d autonomous c l i n i c a l f u n c t i o n ,  awarded a s c o r e o f +1.  I f response  r e f l e c t e d 2 o f t h e 3 c r i t e r i a , t h e nurse was one ( o r none) o f t h e c r i t e r i a was a +3.  accounted  A f t e r each i t e m i n P a r t 2 was  t o the item  g i v e n +2; and i f o n l y f o r , t h e n u r s e was  awarded  s c o r e d i n t h i s manner, t h e  n u m e r i c a l v a l u e s were t o t a l l e d w h i c h r e s u l t e d i n a c u m u l a t i v e judgement/ d e c i s i o n score.  These s c o r e s ranged from +6 w h i c h i n d i c a t e d h i g h  q u a l i t y decision/judgement judgement a c t i v i t y .  t o +16 r e f l e c t i n g low q u a l i t y d e c i s i o n /  ( F o r example, see Appendix C ) .  Part 3 of the data g a t h e r i n g instrument contained 3 questions u t i l i z e d as i n d i c a t o r s o f independent f u n c t i o n i n g . These q u e s t i o n s (l,  2 and 4) were a l s o c o n v e r t e d t o n u m e r i c a l v a l u e s .  The  procedure  used t o change t h e d a t a t o amenable f o r m f o l l o w s : 1.  a response awarded  r e f l e c t i n g t h e most autonomous f u n c t i o n was  +1;  2.  a response  i n d i c a t i n g a team a p p r o a c h was  a s s i g n e d +2;  3.  a response r e f l e c t i n g dependent f u n c t i o n was  and  assigned  +3 o r +4 (dependent upon t h e number o f a v a i l a b l e o p t i o n s ) . Once t h e v a l u e s were a s s i g n e d t o each i t e m , t h e y were t o t a l l e d t o a c h i e v e a c u m u l a t i v e independence s c o r e .  These s c o r e s ranged from  +3 i n d i c a t i n g h i g h independent f u n c t i o n i n g t o +10 r e f l e c t i n g independence.  low  ( F o r example, see Appendix D).  Phase IV:  Method o f A n a l y s e s  The d a t a o b t a i n e d f r o m t h e q u e s t i o n n a i r e was  analysed  by  u t i l i z i n g t h e S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s ( V e r s i o n 7)  '  computer program. 1) educational  Analyses consisted  of. two phases:  f r e q u e n c y d i s t r i b u t i o n s on a l l v a r i a b l e s ( j o b preparation,  description,  y e a r s e x p e r i e n c e , age, monthly s a l a r y ,  d e c i s i o n / j u d g e m e n t , independence, j o b p e r c e p t i o n ,  t i m e s p e n t , expanded  r o l e and l o c a t i o n o f p r a c t i c e ) w i t h t h e c a l c u l a t i o n o f s t a t i s t i c s i n terms o f mean, median, mode, s t a n d a r d d e v i a t i o n , v a r i a n c e and r a n g e ; and 2)  crosstabulations  of a l l variables'with  subjects'  perception  o f b e i n g i n an expanded r o l e , as t h e dependent v a r i a b l e , y i e l d i n g c h i squared v a l u e s as an i n d i c a t o r o f s t r e n g t h and  of relationships  t h e Pearson's Rank Order C o r r e l a t i o n C o e f f i c i e n t  (hereafter  c a l l e d Pearson's R) as an i n d i c a t o r o f t h e d i r e c t i o n o f t h e r e l a t i o n s h i p , s h o u l d one e x i s t .  A s i g n i f i c a n t r e l a t i o n s h i p was h e l d t o e x i s t  t h e s e two t e s t s i f a t a 0.05 l e v e l o f s i g n i f i c a n c e .  with  B o t h phases  of a n a l y s e s were performed on t h e sample group as a whole (64 c a s e s ) and  on each group ( h o s p i t a l - 32 cases and community 32 c a s e s )  separately.  22 CHAPTER I V RESULTS  Introduction T h i s s t u d y was d e s i g n e d t o determine whether s p e c i f i e d  demographic,  f u n c t i o n a l , and e d u c a t i o n v a r i a b l e s would d i f f e r e n t i a t e between community n u r s e s , who s u b j e c t i v e l y v i e w t h e m s e l v e s t o be w o r k i n g i n expanded r o l e s , and g e n e r a l d u t y s t a f f n u r s e s employed i n a h o s p i t a l setting.  A l l respondents  are: c u r r e n t l y w o r k i n g i n t h e f i e l d o f p s y c h i a t r y .  Demographic Data The sample c o n s i s t e d o f 64 r e g i s t e r e d n u r s e s ; 32 w o r k i n g i n community s e t t i n g s and 32 employed b y a h o s p i t a l .  Data a n a l y s e s  showed t h a t community n u r s e s had a t t a i n e d h i g h e r e d u c a t i o n a l p r e p a r a t i o n than h o s p i t a l nurses (see Table 4.1).  T a b l e 4.1 Summary o f E d u c a t i o n P r e p a r a t i o n -  A c c o r d i n g t o Work L o c a t i o n i n Raw S c o r e s  Location Hospital  Community  Total  32 22  Diploma  16  16  Degree  16  6  0  10  10  32  32  64  Masters Total n = 64  .  23 Frequency d i s t r i b u t i o n demonstrated t h a t o f t h e group o f 64, 31 ( 4 8 % ) worked as s t a f f n u r s e s , 10 (16%) 16 (25%)  as c l i n i c a l n u r s e  specialists,  as n u r s e t h e r a p i s t s and 7 (11$) as head n u r s e / c o n s u l t a n t s .  The mean age o f t h e group was 33 y e a r s .  More d e t a i l e d a n a l y s e s showed  t h a t community n u r s e s were o l d e r t h a n h o s p i t a l employees ( s e e T a b l e 4.2). I n terms o f e x p e r i e n c e , i t was found t h a t n u r s e s w o r k i n g i n t h e community had n o t o n l y more g e n e r a l e x p e r i e n c e , but had worked i n p s y c h i a t r y l o n g e r t h a n h o s p i t a l n u r s e s ( s e e T a b l e 4.3).  Table  4.2  Summary o f Age D i s t r i b u t i o n A c c o r d i n g t o Work L o c a t i o n i n Column P e r c e n t Location Age  Hospital  Community  19 - 30  59.4  34.4  31 - 40  34.4  37.5  41 - 50  6.2  21.9  51 - 60  0.0  6.2  Total  100.0$  100.0$  x. = 30 y e a r s  x. = 36 y e a r s  T a b l e 4.3 Summary o f Y e a r s E x p e r i e n c e a s , an R.N.; P s y c h i a t r i c Nurse, and i n P r e s e n t Job, b y L o c a t i o n i n Raw S c o r e s Location Community  Hospital Years Experience  1 - 2  3  -  5  6-10 11 - 15 16 + Total  R.N.  Psych.  P r . Job  R.N.  Psych.  P r . Job  7  15  26  1  3  9  8  9  4  4  5  16  10  6  6  10  15  7  4 3  2  2  9  5  0  0  0  8  4  0  32  32  32  32  32  32  n = 64  P a r t i c i p a n t s i n t h e s t u d y were found t o have somewhat l a r g e s a l a r y d i f f e r e n c e s i n accordance w i t h t h e i r l o c a t i o n o f employment. The average s a l a r y o f t h e 64 n u r s e s was $1442/month; f o r t h e community group i t was $1563/month and f o r h o s p i t a l employees $1321/month. Of t h e t o t a l group o f 64, 36 ( 5 6 $ ) p e r c e i v e d t h e m s e l v e s t o be w o r k i n g c l i n i c a l l y and 28 ( 4 4 $ ) viewed t h e i r j o b s as a d m i n i s t r a t i v e ( s e e Appendix E ) .  I n terms o f r o l e e x p a n s i o n , 51 ( 8 0 $ ) saw t h e m s e l v e s  w o r k i n g i n an expanded r o l e and 13 ( 2 0 $ ) d i d n o t . I n summary, t h e group c o n s i s t e d o f 64 r e g i s t e r e d n u r s e s r a n g i n g i n age from 25 y e a r s t o 60 y e a r s . and e d u c a t i o n a l p r e p a r a t i o n .  They had v a r y i n g y e a r s o f e x p e r i e n c e  I n general,community  n u r s e s were o l d e r  and had more e x p e r i e n c e , w i t h h i g h e r e d u c a t i o n a l p r e p a r a t i o n t h a n  25  h o s p i t a l nurses. administrative  A l l respondents f e l l i n t o e i t h e r c l i n i c a l or  areas of p r a c t i c e .  The sample was  composed o f 32  h o s p i t a l n u r s e s and 32 community n u r s e s .  Demographic Data - H o s p i t a l Subgroup The h o s p i t a l subgroup were a l l p r e p a r e d a t a non m a s t e r s l e v e l and 19 (59.4$) n u r s e s were under 30 y e a r s o f age.  Of t h i s group  30 (93.8$) saw themselves w o r k i n g as s t a f f n u r s e s and 2 (6,2%) nurse t h e r a p i s t s .  I n terms o f work e x p e r i e n c e , 81.3%  as  o f t h i s group  had been i n t h e i r p r e s e n t j o b s 2 y e a r s o r l e s s ; 75$ had 5 y e a r s o r l e s s p s y c h i a t r i c n u r s i n g e x p e r i e n c e and 65.6$ had 9 y e a r s o r l e s s g e n e r a l e x p e r i e n c e as a r e g i s t e r e d n u r s e .  Data showed t h a t 81.3$  or  26 n u r s e s earned l e s s t h a n $1400/month.  Demographic Data - Community Subgroup The group o f community n u r s e s was  composed o f 32  10 o f w h i c h were p r e p a r e d a t t h e masters l e v e l .  respondents,  Of t h e r e m a i n i n g  22, 6 h e l d B a c c a l a u r e a t e degrees and 16 had diplomas i n n u r s i n g . I n terms o f j o b d e s c r i p t i o n , 15 (46.9$) n u r s e s viewed themselves  as  n u r s e t h e r a p i s t s , 10 (31.3$) saw t h e m s e l v e s as c l i n i c a l n u r s e s p e c i a l i s t , 1 (3.1$) as a s t a f f n u r s e and 6 (18.7$) as a head n u r s e / c o n s u l t a n t . Community employees were o l d e r w i t h 21 (63.3$) r e s p o n d e n t s over 31 y e a r s o f age.  Work h i s t o r y o f community n u r s e s was  being longer  as 16 (58.3$) had g r e a t e r t h a n 9 y e a r s e x p e r i e n c e as a r e g i s t e r e d n u r s e ; 24 (75.0$) had more t h a n 5 y e a r s p s y c h i a t r i c n u r s i n g e x p e r i e n c e ; and 24 (75.0$) had been i n t h e i r p r e s e n t j o b s 3 o r more y e a r s .  The  s a l a r y f o r t h i s group was h i g h e r w i t h 25 (78.1$) n u r s e s e a r n i n g  more t h a n $1400/month.  I n terms o f r o l e expansion,  30 (93.8$) n u r s e s  viewed t h e i r r o l e s as expanded and 2 (6.3$) d i d n o t . Aggregate C r o s s t a b u l a t i o n R e s u l t s A l l v a r i a b l e s discussed i n the preceding as i n d e p e n d e n t ^ v a r i a b l e s expanded r o l e .  s e c t i o n s were t r e a t e d  and c r o s s t a b u l a t e d w i t h d a t a  Of t h e 64- n u r s e s ,  regarding  51 (79.7$) p e r c e i v e d t h e i r j o b s t o  be an expanded r o l e .  T a b l e 4.4 Summary o f A g g r e g a t e Job D e s c r i p t i o n C r o s s t a b u l a t e d w i t h P e r c e i v e d Expanded R o l e Expanded R o l e Job D e s c r i p t i o n  Yes Abs.  S t a f f Nurse Specialist Therapist Consultant/ Head Nurse Total x  2  = 8.80  Value  o Col.  PCT  Abs.  Value  Col.  PCT  84.6  20  39.2  11  9  17.6  1  7.7  15  29.4  1  7.7  7  13.8  0  0.0  51  100.0  13  100.0  P < .06  T a b l e 4.4 showed t h e r e s u l t s o f t h e c r o s s t a b u l a t i o n o f j o b d e s c r i p t i o n w i t h perceived r o l e expansion.  The r e l a t i o n s h i p was n o t  s t a t i s t i c a l l y s i g n i f i c a n t a l t h o u g h i t showed t h a t s t a f f n u r s e s were much l e s s l i k e l y t o v i e w t h e i r r o l e s as expanded.  T a b l e 4.5 C r o s s t a b u l a t i o n o f Monthly S a l a r y w i t h Perceived Role Expansion Expanded R o l e Salary  No  Yes Abs. V a l u e  C o l . PCT  C o l . PCT  Abs. V a l u e  l e s s $1399/month  22  43.1  11  84.6  $1400/month o r more  29  56.9  2  15.4  Total  51  100.0  13  100.0  x  2  = 5.57  P <  .02  T a b l e 4.5 demonstrated t h e r e s u l t s o f t h e c r . P s s t a b u l a t i o n o f s a l a r y w i t h p e r c e i v e d expanded r o l e .  The r e l a t i o n s h i p appeared t o  have s i g n i f i c a n c e b u t s i n c e community employees make more money, much o f t h e v a r i a b i l i t y was t a k e n up by t h e n a t u r e o f t h e community group. T a b l e 4.6 C r o s s t a b u l a t i o n R e s u l t s o f Independent  Function  i n P r e s e n t Job w i t h P e r c e i v e d Expanded R o l e Expanded R o l e No  Yes  Independence  Abs. V a l u e  C o l . PCT  Abs. V a l u e  C o l . PCT  Without Consulting  21  41.2  1  7.7  Team  20  39.2  3  23.1  Routinely Consult  10  19.6  9  69.2  Total  51  100.0  13  100.0  x  2  Approach  = 12.77  P < .002  The s t r o n g e s t r e l a t i o n s h i p w h i c h r e s u l t e d from d a t a a n a l y s e s appeared i n T a b l e 4.6.  T h i s showed t h a t n u r s e s who v i e w t h e i r r o l e s  as expanded e x e r c i s e much g r e a t e r independence autonomously,  i n terms o f w o r k i n g  w i t h o u t c o n s u l t i n g a p h y s i c i a n , t h a n n u r s e s who do n o t  v i e w t h e i r r o l e s a s expanded.  f i g u r e 4.1 G r a p h i c Summary o f Independent Treatment  DecisionCrosstabulated  w i t h Expanded R o l e  100  Per Cent o f  75  Independent Treatment  50  Decision 25  1  5  10  15  20  25  Number o f Nurses i n Expanded Role X  = 6.83  P < .08  F i g u r e 4.1 g r a p h i c a l l y r e p r e s e n t e d t h e p e r c e n t a g e o f t i m e t h a t nurses alone decide on t h e treatment f o r t h e i r p a t i e n t s / c l i e n t s , The graph showed t h a t , i n g e n e r a l , n u r s e s e i t h e r d e c i d e 75-100$ o f t h e t i m e o r l e s s t h a n 25$ o f t h e t i m e on p a t i e n t t r e a t m e n t .  Data a n a l y s e s showed t h a t o f t h o s e nursesvwho p e r c e i v e d t h e m s e l v e s t o be i n expanded r o l e s , 22 ( 4 5 % ) i n d e p e n d e n t l y p l a n n e d f o r t h e i r p a t i e n t s ' / c l i e n t s ' care.  Of t h o s e n u r s e s who d i d n o t p e r c e i v e t h e i r  r o l e a s expanded 10 (76$) d e c i d e d on t r e a t m e n t l e s s t h a n 25$ o f t h e time.  T a b l e 4.7 Summary o f C u m u l a t i v e Independence S c o r e s Crosstabulated w i t h Perceived Role Expansion Expanded R o l e No  Yes  Independence  Abs. V a l u e  C o l . PCT  Abs.  Value  C o l . PCT  High Ind.  31  60.8  2  15.4  Low  20  39.2  11  84.6  51  100.0  13  100.0  Ind.  Total x  2  = 6.82  P < .009  The d a t a w h i c h appeared i n T a b l e 4.7 demonstrated t h a t n e a r l y 4 t i m e s as many n u r s e s , who a c h i e v e d h i g h c u m u l a t i v e  independence  s c o r e s , viewed t h e i r r o l e s a s expanded and more t h a n t w i c e as many r e s p o n d e n t s , who a c h i e v e d l o w independence  scores, perceived t h e i r '  r o l e s t o be non expanded. F i n a l l y , l o c a t i o n o f employment c r o s s t a b u l a t e d w i t h p e r c e i v e d r o l e e x p a n s i o n showed t h a t 58.8$ o f t h o s e i n d i v i d u a l s who viewed t h e i r r o l e s as expanded were employed i n a community s e t t i n g .  CHAPTER V  Discussion of Results The preceding chapter demonstrated several s t a t i s t i c a l l y significant relationships that are important i n terms of defining role expansion i n nursing.  However, when the data obtained from the  two groups, separately, were examined, i t was found that much of the occurring v a r i a b i l i t y could be accounted for by the nature of the individual groups. For example, i n terms of job description, i n s t i t u t i o n a l definition of staff nurse was different for hospital and community nurses and hence two t o t a l l y different groups would emerge. As a result, staff nurses were much less l i k e l y to view t h e i r roles as expanded, than community employees.  The trend, i n the l i t e r a t u r e ,  was for nurses assuming expanded roles to be prepared at the masters level.  The data indicated that only 10 persons held masters degrees  and a l l others were prepared at a non masters level. In terms of independent functioning, there was a s t a t i s t i c a l l y significant relationship with role expansion. By the very nature of working i n community, nurses obtain greater independence and have less need to consult with the physician.  This may account for the  high v a r i a b i l i t y which occurred. On the whole, analyses of the data showed that community employed nurses were older, had more experience and were more highly educated than hospital nurses. This would account for the strong perception of role expansion which occurred i n the community subgroup, as compared to the hospital group.  An i n t e r e s t i n g f i n d i n g t h a t appeared d u r i n g d a t a a n a l y s e s was i n the c l i n i c a l vs. a d m i n i s t r a t i v e o r i e n t a t i o n t o p r a c t i c e .  I t was  expected t h a t t h o s e n u r s e s who viewed t h e i r r o l e s as a d m i n i s t r a t i v e would spend most o f t h e i r t i m e p e r f o r m i n g a d m i n i s t r a t i v e t a s k s . was not c o n s i s t e n t l y t h e case.  Many o f t h e s e p e r s o n s  This  spent as much  t i m e c a r i n g f o r p a t i e n t s as t h e c l i n i c a l l y o r i e n t e d group.  T h i s was  p a r t i c u l a r l y n o t i c e a b l e i n the h o s p i t a l nurses which probably i n d i c a t e s t h e d i f f i c u l t y i n d e t a c h i n g o n e s e l f from p a t i e n t s by v e r y n a t u r e o f a h o s p i t a l ward s e t t i n g . The d a t a demonstrated relationship. extremes;  by F i g u r e 4.1 r e p r e s e n t e d an  unexpected  Nurses were found t o d e c i d e p a t i e n t c a r e a t t h e two  e i t h e r 75-100$ o f t h e time o r l e s s t h a n 25$ o f t h e t i m e .  One c o u l d s p e c u l a t e t h a t s i n c e h o s p i t a l s e t t i n g s a r e n o t c o n d u c i v e t o h i g h degrees o f independent t h e l e s s t h a n 25$ c a t e g o r y .  f u n c t i o n i n g , h o s p i t a l nurses f a l l  into  C o n v e r s e l y , community a g e n c i e s were on  a more e q u a l i t y b a s i s and t h e r e f o r e r e q u i r e more independence and freedom i n d e c i s i o n making.  T h i s would a l s o r e s u l t i n community  employees a c h i e v i n g h i g h t o t a l independence s c o r e s compared t o h o p s i t a l nurses.  Community n u r s e s had a~ more autonomous r o l e  which  p r o b a b l y r e s u l t e d i n h i g h e r s e l f - e s t e e m and c o n f i d e n c e i n assuming greater r e s p o n s i b i l i t y f o r p a t i e n t care.  Summary The purpose o f t h i s s t u d y was t o t e s t s p e c i f i e d v a r i a b l e s t h a t were thought t o be i n h e r e n t i n , o r s t r o n g i n d i c a t o r s o f , r o l e  expansion  i n t h e hope t h a t a fundamental  From  d e f i n i t i o n c o u l d be v e r i f i e d .  d a t a c o l l e c t e d from '65 n u r s e s , i t was found t h a t t h e s t a t i s t i c a l l y  s i g n i f i c a n t r e l a t i o n s h i p s t h a t o c c u r r e d c o u l d be a c c o u n t e d f o r by t h e n a t u r e o f t h e two groups.  Community n u r s e s p r e s e n t e d d i f f e r e n t l y  t h a n h o s p i t a l n u r s e s w h i c h c o u l d be t h e r e s u l t o f t h e i n s t i t u t i o n a l h i e r a r c h y i n w h i c h h o s p i t a l employees work.  Conclusions S i n c e t h e sample was  s m a l l ( n = 6 4 ) and one o f c o n v e n i e n c e ,  g e n e r a l i z a t i o n s were l i m i t e d t o community and h o s p i t a l employees i n the f i e l d of p s y c h i a t r y .  I n g e n e r a l , community n u r s e s a r e older-, more  e x p e r i e n c e d , b e t t e r educated and f u n c t i o n more  autonomously.  A t t h e b e g i n n i n g o f t h i s s t u d y f i v e s p e c i f i c o b j e c t i v e s were constructed.  These o b j e c t i v e s were o n l y p a r t i a l l y f u l f i l l e d  from i n a d e q u a c i e s i n h e r e n t i n t h e q u e s t i o n n a i r e .  I t was  resulting  difficult  t o determine whether a l l t h e f u n c t i o n s o f expanded r o l e n u r s e s were elicited.  I t was found t h a t n u r s e s i n expanded r o l e s do i n t a k e  assessments, t h e r a p y ( i n d i v i d u a l , group and f a m i l y ) , m a r r i a g e  coun-  s e l l i n g , m o n i t o r m e d i c a t i o n s and p l a n t r e a t m e n t f o r e m o t i o n a l l y i l l patients. A n o t h e r o b j e c t i v e d e a l t w i t h e d u c a t i o n a l p r e p a r a t i o n and t h e expanded r o l e n u r s e .  M a s t e r s e d u c a t i o n was t h e e x c e p t i o n r a t h e r t h a n  t h e r u l e , but i n g e n e r a l , community n u r s e s were b e t t e r educated  and  hence f e l t more p r e p a r e d f o r t h e i r assumed r o l e . A  f u r t h e r a r e a o f i n t e r e s t was an attempt t o determine  whether autonomy and independence  were i n h e r e n t t o r o l e e x p a n s i o n .  T h i s would seem t o be so, a l t h o u g h by v e r y n a t u r e o f h o s p i t a l v s . community employment, c o n c l u s i o n s here wer e made w i t h c a u t i o n . 7  I t was t h e hope o f t h e a u t h o r t h a t n u r s e s ' r o l e e x p e c t a t i o n and r o l e p e r c e p t i o n c o u l d be e x t r a p o l a t e d from t h e i r d e f i n i t i o n o f present jobs.  T h i s p r o c e s s was  s u b j e c t i v e and t h e r e f o r e n o t a r e a l i s t i c  method o f a t t a i n i n g t h i s i n f o r m a t i o n .  As a r e s u l t , t h e i n v e s t i g a t i o n  was not r e f i n e d a d e q u a t e l y and t h i s o b j e c t i v e was n o t  met.  L a s t l y , i t was hoped t h a t a r e a s o f u n c l e a r e x p e c t a t i o n c o u l d be d e l i n e a t e d so t h a t changes i n n u r s i n g e d u c a t i o n c o u l d be recommended. I t was found t h a t many n u r s e s were u n c l e a r as t o what t h e t e r m 'expanded r o l e ' means, which was expected a t t h e onset o f t h e s t u d y . I t was a l s o found t h a t r o l e e x p a n s i o n was viewed i n terms o f l o c a t i o n o f employment, w h i c h need not be t h e c a s e .  One o f t h e s t r i k i n g f i n d i n g s  was t h a t h o s p i t a l n u r s e s do n o t seem t o know whether t h e j o b s t h e y a r e p e r f o r m i n g d e s i g n a t e an expanded r o l e o r a r e s i m p l y t r a d i t i o n a l f o r the p s y c h i a t r i c s e t t i n g .  T h i s was.-shown by t h e v a r i a t i o n i n  r e s p o n s e , by h o s p i t a l s t a f f , t o whether t h e y p e r c e i v e d t h e i r r o l e t o be expanded o r n o t . I n terms o f v e r i f y i n g t h e fundamental d e f i n i t i o n developed at t h e onset o f t h e s t u d y , t h e i n v e s t i g a t i o n succeeded, w i t h a minor change.  S i n c e 54 o f t h e 64 n u r s e s i n t h e s t u d y were p r e p a r e d  a t a non masters l e v e l , need f o r masters e d u c a t i o n was not v a l i d a t e d . However, at t h e p r e s e n t t i m e t h e r e a r e not enough n u r s e s p r e p a r e d a t t h e g r a d u a t e l e v e l t o f i l l t h e p o s i t i o n s r e q u i r i n g a masters  degree.  Hence t h e s e p o s i t i o n s a r e b e i n g f i l l e d w i t h i n d i v i d u a l s p r e p a r e d a t a non masters  level.  34 Implications An underlying premise i n expanded r o l e s f o r nurses i s that these professionals are providing a better consumer and s o c i a l service.  In  order to determine the impact that expanded r o l e nurses are having with the consumer, there needs to be development of outcome scales designed to measure the e f f e c t s of services rendered by expanded r o l e nurses on behalf of the consumer. Further, the study indicated that there was  a cognitive dissonance  among h o s p i t a l employees i n terms of r o l e perception and r o l e enactment. Research designed to e l i c i t those variables that are e f f e c t i n g t h i s would g r e a t l y a i d i n c l a r i f y i n g the p o s i t i o n of a h o s p i t a l nurse functioning i n an expanded r o l e . The present trend i s toward graduate preparation f o r nurses performing  i n expanded r o l e s .  Since only 10 nurses i n t h i s  study  held a masters degree, further research into standardized educational preparation i s warranted.  This would have to be i n terms of comparing  the l e v e l of c l i n i c a l function (both t h e o r e t i c a l and p r a c t i c a l ) of a nurse prepared at a masters l e v e l and a nurse prepared at a non masters l e v e l , both of whom are assuming expanded r o l e s . A r e p l i c a t i o n of t h i s study, u t i l i z i n g more r e f i n e d measurement techniques, complimented by d a i l y work logs and personal interviews, would greatly a i d i n further c l a r i f y i n g the functions of expanded r o l e nurses, both within and outside the f i e l d of psychiatry. The number of nurses performing  i n expanded r o l e s with graduate  preparation i s very l i m i t e d at t h i s time.  To help eliminate t h i s  problem, greater government funding f o r nurses desiring higher would be needed.  education  This would mean that nurses could return to u n i v e r s i t y  35 f r e e of f i n a n c i a l worry.  To f u r t h e r enhance t h i s , development o f  programs f o r o u t l y i n g d i s t r i c t s would a l l o w n u r s e s t o c o n t i n u e  their  .education on a p a r t - t i m e b a s i s . N u r s i n g e d u c a t i o n a t t h e g r a d u a t e l e v e l s h o u l d be d e s i g n e d clinical  s p e c i a l i z a t i o n w i t h emphasis p l a c e d on u t i l i z i n g  r o l e t h e o r y and t h e o r i e s o f change, as n u r s e s p e r f o r m i n g a r e t o be t h e change agents f o r the p r o f e s s i o n . n u r s e s must be p r e p a r e d  and  toward  understanding  i n t h i s capacity  A l s o , expanded r o l e •  to evaluate t h e i r c o n t r i b u t i o n to p a t i e n t  c a r e , as w e l l as t o t h e p r o f e s s i o n . I n terms o f n u r s i n g p r a c t i c e , perhaps t h e most i m p o r t a n t a t i o n i s q u a l i t y care.  consider-  A t t h e p r e s e n t t i m e , t h e most q u a l i f i e d n u r s e s  a r e s i t u a t e d i n community s e t t i n g s , r e s u l t i n g i n t o o few r o l e models i n hospitals.  I n o r d e r t o h e l p r e - d i s t r i b u t e a v a i l a b l e manpower, h o s p i t a l  n u r s i n g d i r e c t o r s would have t o a c t i v e l y i n v o l v e t h e m s e l v e s i n o r g a n i z a t i o n a l changes d i r e c t e d toward a l l o w i n g g r e a t e r f l e x i b i l i t y and for  n u r s e s assuming an expanded r o l e w i t h i n an i n s t i t u t i o n .  freedom  This could  a l s o be f a c i l i t a t e d by c o - o p e r a t i o n between n u r s i n g a s s o c i a t i o n s and h o s p i t a l a d m i n i s t r a t o r s i n c l e a r l y d e l i n e a t i n g the f u n c t i o n s of advanced c l i n i c a l n u r s e - w o r k i n g i n a h o s p i t a l .  I t i s evident, that  h o s p i t a l a d m i n i s t r a t i o n s would have t o be w i l l i n g t o p r o v i d e support t o a n u r s e w o r k i n g i n an expanded r o l e w i t h i n an The  an  strong  institution.  s u r v e y i n d i c a t e d t h a t n u r s e s do have the p o t e n t i a l t o f u n c t i o n  i n expanded r o l e s g i v e n t h e f l e x i b i l i t y and autonomy i n h e r e n t i n the community s e t t i n g .  I f the present  s t r u c t u r e o f i n s t i t u t i o n s can  be  r e o r g a n i z e d t o a l l o w t h e same f l e x i b i l i t y and autonomy, t h e n n u r s e s employed by i n s t i t u t i o n s , i n expanded r o l e s , c o u l d be u t i l i z e d their f u l l  potential.  to  36  BIBLIOGRAPHY  37 BIBLIOGRAPHY PERIODICALS A s h l e y , - J o Ann. " N u r s i n g and E a r l y Feminism."' A m e r i c a n J o u r n a l o f • N u r s i n g , 75, No. 9 ( 1 9 7 5 ) , U 6 5 - H 6 7 . Awtrey, J a n e t S h e a l y . "Teaching t h e Expanded R o l e . " 22, No. 2 ( 1 9 7 4 ) , 98-102.  Nursing Outlook, ~~  Beletz, Elaine. " I s N u r s i n g ' s P u b l i c Image Up t o Date." O u t l o o k , 22, No. 7 ( 1 9 7 4 ) , 432-435.  Nursing  Bergman, Abraham. " P h y s i c i a n ' s A s s i s t a n t s Belong i n t h e N u r s i n g P r o f e s s i o n . " A m e r i c a n J o u r n a l o f N u r s i n g , 71, No. 5 ( 1 9 7 1 ) , 975-977. Bowman, Rosemary A., and Rebecca C. Culpepper. "Power: Rx f o r Change." American J o u r n a l o f N u r s i n g , 74, No. 6 ( 1 9 7 4 ) , 1053-1056. B u l l o u g h , Bonnie. " I n f l u e n c e s on R o l e E x p a n s i o n . " o f N u r s i n g , 76, No. 9 ( 1 9 7 6 ) , 1476-1481.  American Journal  B u l l o u g h , Bonnie, and V e r n B u l l o u g h . "A C a r e e r Ladder i n N u r s i n g ; Problems and P r o s p e c t s . " American J o u r n a l o f N u r s i n g , 71, No. 10 ( 1 9 7 1 ) , 1938-1943. C h r i s t y , T e r e s a E. "New P r i v i l e g e s , New - N u r s i n g 73, Nov. 1973, 8-11.  C h a l l e n g e s , New  Responsibilities."  De Tornyay, Rheba. "Expanding The Nurse's R o l e Does Not Make Her a P h y s i c i a n ' s A s s i s t a n t . " A m e r i c a n J o u r n a l o f N u r s i n g , 71, No. 5 ( 1 9 7 1 ) , 974-976. D r i s c o l l , Veronica. "Liberating Nursing P r a c t i c e . " 20, No. 1 ( 1 9 7 2 ) , 24-28.  Nursing Outlook,  Du Gas, B e v e r l y W i t t i e r . " N u r s i n g ' s Expanded R o l e i n Canada." N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 9, No. 3 ( 1 9 7 4 ) , 523-533. E d e l s t e i n , Ruth Greenberg. "Equal R i g h t s f o r Women: P e r s p e c t i v e s . " " A m e r i c a n J o u r n a l o f N u r s i n g , 71, No. 2 ( 1 9 7 1 ) , 294-297. E l l i o t t , Jo E l e a n o r , Ingeborg Mauksch, and Rosamond G a b r i l l s o n . "Nurses and N u r s i n g ' s I s s u e s . " A m e r i c a n J o u r n a l o f N u r s i n g , 75, No. 10 ( 1 9 7 5 ) , 1848-1859.  v  BIBLIOGRAPHY ( c o n f . ) PERIODICALS F a g i n , C l a i r e M. "Nurses' R i g h t s . " 75, No. 1 (1975,-),82-85.  American J o u r n a l o f N u r s i n g ,  F a g i n , C l a i r e , and M c C l u r e F a g i n . "Can We B r i n g Order Out o f t h e Chaos o f N u r s i n g E d u c a t i o n ? " A m e r i c a n J o u r n a l o f N u r s i n g , 76, No. 1 (1976),98-102. F l y n n , B e v e r l y C. "Study Documents R e a c t i o n s t o Nurses i n Expanded R o l e s . " H o s p i t a l s , 49 ( 1 9 7 5 ) , 81-83. Ford, L o r e t t a . "Nursing. . .Evolution or Revolution?" Nurse, 64, No. 1 ( 1 9 7 1 ) , 32-37. Freeman, R u t h B. " P r a c t i c e as P r o t e s t . " 71, No. 5 ( 1 9 7 1 ) , 918-921.  Canadian  American J o u r n a l o f N u r s i n g , |  Georgopoulas, B a s i l S., and J o s e p h i n e M, Sana. " C l i n i c a l Nursing S p e c i a l i z a t i o n and I n t e r s h i f t Report B e h a v i o r . " A m e r i c a n J o u r n a l o f N u r s i n g , 71, No. 3 ( 1 9 7 1 ) , 538-545. Grace, Mary J o . "The P s y c h i a t r i c Nurse S p e c i a l i s t and M e d i c a l S u r g i c a l P a t i e n t s . " American J o u r n a l o f N u r s i n g , 74, No. ( 1 9 7 4 ) , 481-483. ~"  3  Grissum, M a r l e n e . "How You Can Become a R i s k Taker and a R o l e B r e a k e r . " N u r s i n g 76, Nov. 1976, 11-14. H a t t , J a c q u e l i n e Ross. "Updating C h e r r y Ames." A m e r i c a n J o u r n a l o f N u r s i n g , 77, No. 10 ( 1 9 7 7 ) , 1580-1583. Hawkins, Norman G. " I s There a S c h o o l Nurse R o l e ? " o f N u r s i n g , 71, No 4 ( 1 9 7 1 ) , 744-750.  American Journal.  Heiman, E l l i o t t M., and Mary K. Dempsey. "Independent B e h a v i o r o f Nurse P r a c t i t i o n e r s : A S u r v e y o f P h y s i c i a n and Nurse A t t i t u d e s . American J o u r n a l o f P u b l i c H e a l t h , 66, No. 6 ( 1 9 7 6 ) , 587-589. H o c k i n g , Irma L., R u t h S. H a s s a n e i n , and S r . R.T. Bahr. "The W i l l i n g n e o f P s y c h i a t r i c Nurses t o Assume t h e Extended R o l e . " N u r s i n g R e s e a r c h , 25 ( 1 9 7 6 ) , 44-48. K e l l y , L u c i e Young. " N u r s i n g P r a c t i c e A c t s . " N u r s i n g , 74, No. 7 ( 1 9 7 4 ) , 1310-1319.  American J o u r n a l o f  Lambersten, E l e a n o r . " P e r s p e c t i v e s on t h e P h y s i c i a n ' s A s s i s t a n t . " N u r s i n g O u t l o o k , 20," No. 1 ( 1 9 7 2 ) , 32-36.  39 -BIBLIOGRAPHY ( c o n t . ) PERIODICALS L e w i s , E d i t h , P., ed. "The Nurse P r a c t i t i o n e r : P r e p a r a t i o n and P r a c t i c e . " N u r s i n g O u t l o o k , 22, No. 2 ( 1 9 7 4 ) , 65-127. L e w i s , E d i t h , P., ed. "A R o l e By Any Name." 22, No. 2 ( 1 9 7 4 ) , 89.  Nursing Outlook,  L e w i s , E d i t h , P., ed. "A Nurse I s A Nurse, Or I s She?" O u t l o o k , 20, No. 1 (1972), 21.  Nursing  L i n n , Lawrence S. " E x p e c t a t i o n v s . R e a l i z a t i o n i n t h e Nurse P r a c t i t i o n e r R o l e . " N u r s i n g O u t l o o k , 23, No. 3 ( 1 9 7 5 ) , 166-171. Maas, M e r i d e a n , J a n e t Specht, and Ada J a c o x . "Nurse Autonomy. . . R e a l i t y Not R h e t o r i c . " American J o u r n a l o f N u r s i n g , 75, No. 12 ( 1 9 7 5 ) , 2201-2208. ' Malkemes, L o i s D. " R e s o c i a l i z a t i o n : A Model f o r Nurse P r a c t i t i o n e r P r e p a r a t i o n . " N u r s i n g O u t l o o k , 22, No. 2 ( 1 9 7 4 ) , 90-94. Meldman, J . Monte, B e r n a r d Newman, Donna S c h a l l e r , and P a u l P e t e r s o n . " P a t i e n t s ' Responses t o N u r s e - P s y c h o t h e r a p i s t s . " ' A m e r i c a n J o u r n a l o f N u r s i n g , 71, No. 6 ( 1 9 7 1 ) , 1150-1151. Moore, Ann C. "Nurse P r a c t i t i o n e r : R e f l e c t i o n s on The R o l e . " N u r s i n g O u t l o o k , 22, No. 1 ( 1 9 7 4 ) , 124-127. Murphy, J u a n i t a F. "Role E x p a n s i o n o r R o l e E x t e n s i o n . " -Forum, 9, No. 4 (1970), 380-389.  Nursing  Murray, L o u i s e B. "A Case f o r Independent Group N u r s i n g P r a c t i c e . " N u r s i n g O u t l o o k , 20, No. 1 ( 1 9 7 2 ) , 60-63~. R a j a b a l l y , Mohamed H. " N u r s i n g E d u c a t i o n : Another Tower o f B a b e l ? " Canadian Nurse, 70, No. 9 ( 1 9 7 7 ) , 30-31. Rogers, M a r t h a E. " N u r s i n g : To Be o r Not To Be?" N u r s i n g 20, No. 1 ( 1 9 7 2 ) , 42-46. S c h i e n , E.H. "Role I n n o v a t o r and H i s E d u c a t i o n . " 73, No. 33 ( 1 9 7 0 ) , 50-56.  Outlook.  Technology Review,  S e c r e t a r y ' s Committee. " E x t e n d i n g t h e Scope o f N u r s i n g P r a c t i c e . " N u r s i n g O u t l o o k , 20, No. 1 (1972), 46-52.  BIBLIOGRAPHY ( c o n f . ) - PERIODICALS S t r o z i e r , " V i r g i n i a , and D a v i d W i l l i a m s . " E v o l u t i o n o f a R o l e : P e d i a t r i c Nurse C l i n i c i a n . " S u p e r v i s o r Nurse, Feb. 1975, 30-37. ~" v  Walker, E l i z a b e t h . "Primex. . .The F a m i l y Nurse P r a c t i t i o n e r Program. N u r s i n g O u t l o o k , 20, No. 1 ( 1 9 7 2 ) , 28-31. White, Martha S. " P s y c h o l o g i c a l C h a r a c t e r i s t i c s o f t h e Nurse P r a c t i t i o n e r . " N u r s i n g O u t l o o k , 23, No. 3 ( 1 9 7 5 ) , 160-165. Wright, E d i t h . " R e g i s t e r e d Nurses' O p i n i o n s on an Extended Concept." N u r s i n g R e s e a r c h , 25 ( 1 9 7 6 ) , 112-114.  Role  BIBLIOGRAPHY ( c o n t . )  BOOKS and ESSAYS  A l l e n , Moyra, ed. N u r s i n g P a p e r s . P r e s s , Summer 1974-.  Montreal:  McGill University  Boone, M a r g a r e t , and June K i k u c h i : "The C l i n i c a l Nurse S p e c i a l i s t " i n I s s u e s i n Canadian N u r s i n g , e d i t e d by B e t s y L a Sor and M. Ruth E l l i o t t . O n t a r i o : P r e n t i c e H a l l o f Canada, L t d . , 1977. Browing, Mary H., and S m i t h R. L e w i s . "The Expanded R o l e o f t h e Nurse." Contemporary N u r s i n g S e r i e s . New Y o r k : The American J o u r n a l o f N u r s i n g Company, 1973. Brown, E s t h e r L u c i l l e . N u r s i n g R e c o n s i d e r e d - A Study o f Change. T o r o n t o : J.B. L i p p i n c o t t Company, 1970. Canada — Department o f N a t i o n a l H e a l t h and W e l f a r e : Report o f t h e Committee o f Nurse P r a c t i t i o n e r s . Ottawa, 1972. Canada — Department o f N a t i o n a l H e a l t h and W e l f a r e : P r o g r e s s Report P r e p a r a t i o n o f Nurses f o r an Expanded R o l e i n Canadian H e a l t h S e r v i c e s ^ Ottawa, 1975. Lamothe, R a c h e l . "The Expanding R o l e o f t h e Nurse." Nurses's A s s o c i a t i o n . June, 1972. Lucas, E l i z a b e t h , ed. Nurses and H e a l t h Care. Sons, L t d . , 1976. Modern Languages A s s o c i a t i o n o f A m e r i c a . ed. 1970.  Canadian  Hereford:  Adams and  The MLA S t y l e Sheet.  2nd  S a r b i n , Theodore. "Role Theory." Handbook o f S o c i a l P s y c h o l o g y . M a s s a c h u s e t t s : Addison-Wesley P u b l i s h i n g Co., 1968.  42  APPENDICES  APPENDIX A  -SUBJECT CONSENT FORM As p a r t i a l c o m p l e t i o n f o r a M a s t e r s Degree i n N u r s i n g , I am d o i n g a r e s e a r c h s t u d y concerned w i t h comparing t h e p e r c e i v e d r o l e , f u n c t i o n and purpose o f t h e n u r s e p e r f o r m i n g i n an expanded r o l e as d e s c r i b e d i n t h e l i t e r a t u r e , and t h e i r practice.  actual  Should y o u p a r t i c i p a t e i n t h i s s t u d y , i t would  r e q u i r e about 15 minutes o f y o u r t i m e on one o c c a s i o n o n l y . A l l i n f o r m a t i o n i s kept c o n f i d e n t i a l and w i l l be used f o r t h i s study only. s t u d y a t any t i m e .  You have t h e r i g h t t o w i t h d r a w f r o m t h e P l e a s e check one o f t h e o p t i o n s below and  p l a c e y o u r s i g n a t u r e i n t h e s u p p l i e d space.  1.  I agree t o p a r t i c i p a t e  2.  I do n o t want t o p a r t i c i p a t e  Subject Signature  Researcher;  Sharon MacDonald MSN I I  APPENDIX B  ———  - Instruction  P l e a s e Read C a r e f u l l y : rOn t h e pages t o f o l l o w i s a q u e s t i o n n a i r e c o n c e r n i n g t h e expanded r o l e o f t h e n u r s e .  Many o f t h e i t e m s r e f e r t o p a r t i c u l a r  s i t u a t i o n s and may n o t a p p l y t o your p a r t i c u l a r j o b .  I n answering  t h e s e i t e m s p l e a s e imagine y o u r s e l f i n t h e p o s i t i o n d e s c r i b e d and r e s p o n d t h e way you p r o b a b l y would a c t . to e l i c i t s p e c i f i c information.  Each i t e m has been d e s i g n e d  Because t h e i t e m s a r e s h o r t , you  may  f e e l - y o u want t o know more about t h e s i t u a t i o n d e s c r i b e d ; however, p l e a s e r e s p o n d t h e way you would a c t i n r e l a t i o n t o your p r e s e n t j o b . There a r e no r i g h t o r wrong answers!  The q u e s t i o n n a i r e i s  d e s i g n e d t o determine what i s happening i n your j o b s , and n o t i n an ideal situation.  I t i s n o t n e c e s s a r y t o p u t y o u r name on t h e  q u e s t i o n n a i r e ; i t has been coded p r i o r t o d i s t r i b u t i o n i n o r d e r t o i d e n t i f y your p l a c e o f work. study.  O n l y aggregate d a t a w i l l be used i n t h i s  I would l i k e t o thank you f o r y o u r t i m e and c o - o p e r a t i o n .  Sharon A. MacDonald  -Part Gnerr-  1.  What j o b d e s c r i p t i o n do y o u c u r r e n t l y have?  ( I f more t h a n one  a p p l i e s , p l e a s e i n d i c a t e t h e p e r c e n t o f time devoted t o each.)  2.  1.  s t a f f nurse  2.  clinical  specialist  3.  clinical  therapist  4.  c l i n i c a l consultant  5.  clinical  6.  other/specify "  instructor ......  ( a ) What i s y o u r h i g h e s t e d u c a t i o n a l p r e p a r a t i o n ? ( P l e a s e c i r c l e one) 1.  diploma  2.  degree  3.  masters  4.  other/specify  (b)  ^  '  s  Have y o u a t t e n d e d any s p e c i a l t y t r a i n i n g c o u r s e s ?  1.  Yes ( p l e a s e s p e c i f y )  2.  No  years  3.  How o l d a r e you?  4.  How l o n g have y o u worked as a n u r s e ?  years  months  5.  How l o n g have you worked i n p s y c h i a t r y ? -  6,  How l o n g have y o u worked a t y o u r p r e s e n t x  years  x  '  -  years job?  months  7.  What i s your c u r r e n t monthly s a l a r y ?  8.  P l e a s e r a n k o r d e r t h e f o l l o w i n g i n accordance t o how y o u see y o u r s e l f working i n your present important,  months  j o b . ( i . e . #1 would be most  #2 n e x t e t c . )  a.  an educator  "  b.  a co^-ordinator  c.  a consultant  ' ^>  d.  a clinical liaison  '  e.  an a d m i n i s t r a t o r  f.  a therapist  g.  other/specify  v v v  v  vvv  v  ' ' ' ^' v . s  '  v  Part-'Two: -  T h i s s e c t i o n o f seven q u e s t i o n s p r e s e n t s y o u w i t h h y p o t h e t i c a l s i t u a t i o n s i n w h i c h y o u a r e asked t o i n d i c a t e y o u r most a p p r o p r i a t e action. 9.  P l e a s e c i r c l e 'your most a p p r o p r i a t e r e s p o n s e f o r each s i t u a t i o n .  A new p a t i e n t i s a d m i t t e d t o h o s p i t a l .  A f t e r a d m i s s i o n you f i n d  h e r t e a r f u l and s i t t i n g a l o n e i n h e r room.  You a r e most l i k e l y t o  1.  c a l l her doctor  2.  spend some t i m e t a l k i n g t o h e r  3.  g i v e h e r a l i t t l e more t i m e t o a d j u s t t o h o s p i t a l and c a l l back l a t e r  47 10,  John, a 25 y e a r o l d man, i s b e i n g r e f e r r e d f o r p s y c h i a t r i c assessment. abusive.  11.  He i s d e s c r i b e d as b e i n g h o s t i l e and p h y s i c a l l y  You a r e 'mast'-lively t o  1.  p e r f o r m t h e assessment y o u r s e l f ,  2.  p e r f o r m t h e assessment b u t have someone e l s e p r e s e n t ,  3.  have a more a p p r o p r i a t e p e r s o n a s s e s s  John.  You a r e s e e i n g a depressed woman who y o u f e e l i s a h i g h s u i c i d e r i s k a l t h o u g h outward s u i c i d a l i d e a t i o n i s n o t p r e s e n t .  You  f i r m l y b e l i e v e t h a t t h i s woman s h o u l d be h o s p i t a l i z e d , b u t t h e p s y c h i a t r i s t on t h e team does n o t agree w i t h you.  You a r e most  likely to  12,  1.  i n s i s t t h e woman be h o s p i t a l i z e d .  2.  a b i d e b y t h e p s y c h i a t r i s t ' s judgement,  3.  other/specify "  You have seen a p a t i e n t a t t h e r e q u e s t o f t h e f a m i l y d o c t o r and have made recommendations f o r t r e a t m e n t .  L a t e r you d i s c o v e r t h a t  t h e f a m i l y d o c t o r has i g n o r e d your recommendations and asked a 'colleague o f y o u r s t o see t h e p a t i e n t . psychiatrist.  The c o l l e a g u e i s a  You a r e most l i k e l y t o  1.  t r y t o f o r g e t about t h e i n c i d e n t .  2.  r e q u e s t a meeting w i t h t h e f a m i l y d o c t o r and d i s c u s s t h e i n c i d e n t w i t h him.  3.  d i s c u s s t h e i n c i d e n t w i t h the p s y c h i a t r i s t .  4.  other/specify  48 13.  You have assessed pregnancy,  a t e e n a g e r who i s d e p r e s s e d as a r e s u l t o f  H e r p a r e n t s have t o l d h e r t o g e t o u t o f t h e home.  You recommend o u t p a t i e n t treatment for the family.  f o r h e r as w e l l as c o u n s e l l i n g  S e v e r a l days l a t e r y o u a r e n o t i f i e d t h a t t h i s  p a t i e n t i s admitted t o h o s p i t a l w i t h a s u i c i d e attempt.  You  a r e 'mosfr-Iikely t o 1,  d i r e c t t h e case t o y o u r s u p e r v i s o r .  2,  i n i t i a t e a r e v i e w o f y o u r p r e v i o u s assessment.  3,  do n o t h i n g , as y o u p r o b a b l y c o u l d n ' t have p r e v e n t e d t h e i n c i d e n t anyway,  14.  A j u n i o r s t a f f member i s t a l k i n g t o a young man who i s i n h o s p i t a l because o f s e x u a l l y d e v i a n t b e h a v i o u r .  As t h e y a r e t a l k i n g ,  you n o t i c e t h a t t h e j u n i o r s t a f f member i s g e t t i n g more and more d i s t r e s s e d by t h e a c t i o n s and c o n v e r s a t i o n o f t h i s p a t i e n t . You a r e most l i k e l y t o 1.  i n t e r v e n e and support  2.  d i s c u s s t h e f e e l i n g s and r e a c t i o n s o f t h e j u n i o r s t a f f member a t a l a t e r  3.  t h e j u n i o r s t a f f member.  time.  a s k t h e p a t i e n t i f y o u c o u l d j o i n them, and t h e n d i r e c t the conversation i n a d i f f e r e n t  15.  direction.  S t a f f members on an i n p a t i e n t u n i t a r e angry and u p s e t b y t h e behaviour  of a disruptive attention-seeking patient.  asked t o h e l p them cope w i t h t h e s i t u a t i o n .  You a r e  You a r e most l i k e l y t o  1,  a s s e s s t h e p a t i e n t y o u r s e l f and make s p e c i f i c recommendations.  2.  meet w i t h s t a f f , e x p l o r e t h e i r f e e l i n g s about t h e p a t i e n t and h e l p them d e a l w i t h them.  3,  meet w i t h s t a f f and e x p l o r e t h e c i r c u m s t a n c e s the p a t i e n t ' s  4.  surrounding  behaviour.  suggest how s t a f f c o u l d t r y t o work t h e p r o b l e m o u t t h e m s e l v e s .  Part-Three;^  The f o l l o w i n g 9 q u e s t i o n s d e a l w i t h s p e c i f i c d e t a i l s o f y o u r e v e r y day work, 1.  2,  P l e a s e c i r c l e t h e most a p p l i c a b l e r e s p o n s e .  I n your present j o b you u s u a l l y 1.  a c t independently without consulting a p h y s i c i a n ,  2.  r o u t i n e l y consult a physician.  3.  Both 1 & 2  I n y o u r c l i n i c a l p r a c t i c e , who u s u a l l y t a l k s t o p a t i e n t s  first  Cother t h a n t h e r e c e p t i o n i s t ) ? 1.  the p s y c h i a t r i s t .  2.  y o u r s e l f and p s y c h i a t r i s t ,  3.  you alone.  4.  o  t  h  e  r  /  s  p  e  w  c  e  Of t h e p a t i e n t s y o u saw l a s t week, i n how many o f t h e cases d i d  2.  50 -  74$ o f c a s e s  3.  25 -  49$ o f c a s e s  4.  l e s s t h a n 25$ o f c a s e s  ^  '  4.  75 T 100$ o f cases  ?  y  How many p a t i e n t s d i d y o u see l a s t  1.  k  f  3.  you a l o n e d e c i d e what t r e a t m e n t s h o u l d be?  e  i  v  v  50 5,  Compared t o o t h e r f u l l t i m e members o f t h e h e a l t h c a r e team, y o u r patient load i s  6.  1,  about t h e same,  2,  comparatively  higher,  3.  comparatively  lower.  4.  other/specify  Rank o r d e r t h e f o l l o w i n g ( l ,  '  2, 3, etc',) a c c o r d i n g  ' on t h e  a v e r a g e , you spend y o u r t i m e d o i n g d u r i n g a normal day.  ( l - most;  6 = least)  1.  d i r e c t p a t i e n t contact  2.  c h a r t s and/or paperwork"''  3.  administrative duties  4.  t e a c h i n g and/or s u p e r v i s i o n  6,  t o what,  x  ^  v  ' 5.  '  v  '  v x v  '  " v -'  consultant other/specify"  ' ' '  x  ' '  W i t h s p e c i f i c r e f e r e n c e t o your d a i l y p r a c t i c e , d e f i n e y o u r present job?  Do you c o n s i d e r y o u r s e l f t o be w o r k i n g i n an  1. 2.  yes no  expanded role'-'?  Do you f e e l t h a t your academic and c l i n i c a l t r a i n i n g has p r e p a r e d you t o assume t h e r o l e you a r e p r e s e n t l y w o r k i n g i n ? I f so, how?  I f n o t , why not? •  P l a c e any f u r t h e r comments, h e r e ,  APPENDIX C  C a l c u l a t i o n o f C u m u l a t i v e Judgement/Decision  Scores  The d a t a o b t a i n e d from P a r t I I o f t h e q u e s t i o n n a i r e were c o n v e r t e d t o n u m e r i c a l v a l u e s on t h e b a s i s o f t h e f o l l o w i n g 1.  criteria:  t h e response must have r e f l e c t e d s y n t h e s i s o f t h e a v a i l a b l e d a t a r e s u l t i n g i n a c l i n i c a l l y sound judgement;  2.  t h e response must have been i n d i c a t i v e o f a c c e p t i n g r e s p o n s i b i l i t y f o r ones' own a c t i o n s ;  3.  and  t h e response must have r e f l e c t e d autonomous f u n c t i o n .  A response t h a t encompassed a l l t h r e e o f t h e c r i t e r i a  was  awarded +1; compliance w i t h 2 o f t h e 3 c r i t e r i a r e s u l t e d i n +2; one ( o r none) o f t h e c r i t e r i a r e s u l t e d i n awarding +3. i t e m was  and  When each  s c o r e d , t h e t o t a l a c h i e v e d on t h e 6 i t e m s was t a k e n r e s u l t i n g  i n a cumulative judgement/decision score.  The s c o r e s ranged from  i n d i c a t i n g h i g h q u a l i t y j u d g e m e n t / d e c i s i o n t h r o u g h t o +16 low q u a l i t y j u d g e m e n t / d e c i s i o n a c t i v i t y .  reflecting  The example t o f o l l o w  demonstrates t h e p r o c e d u r e .  10.  John, a 25 y e a r o l d man, assessment. abusive.  +1  +6  i s being referred f o r p s y c h i a t r i c  He i s d e s c r i b e d as b e i n g h o s t i l e and p h y s i c a l l y  You a r e most l i k e l y t o  1.  p e r f o r m t h e assessment but have someone e l s e p r e s e n t .  2,  p e r f o r m t h e assessment y o u t s e l f .  3.  have a more a p p r o p r i a t e p e r s o n a s s e s s John.  v  55 11.  You a r e s e e i n g a d e p r e s s e d woman whom y o u f e e l i s a h i g h s u i c i d e r i s k a l t h o u g h outward s u i c i d a l i d e a t i o n i s n o t p r e s e n t .  You  f i r m l y b e l i e v e t h a t t h i s woman s h o u l d be h o s p i t a l i z e d , b u t t h e p s y c h i a t r i s t on t h e team does n o t agree w i t h you.  You a r e  most l i k e l y t o  +2  12.  1.  insist  t h e woman be h o s p i t a l i z e d .  2.  a b i d e b y the p s y c h i a t r i s t ' s judgement.  3.  other/specify  _  You have seen a p a t i e n t a t t h e r e q u e s t o f t h e f a m i l y d o c t o r and have made recommendations f o r t r e a t m e n t .  Later you discover that  . t h e f a m i l y d o c t o r h a s i g n o r e d y o u r recommendations and asked a c o l l e a g u e o f y o u r s t o see t h e p a t i e n t . psychiatrist. 1.  The c o l l e a g u e i s a  You a r e most l i k e l y t o  r e q u e s t a meeting w i t h t h e f a m i l y d o c t o r and d i s c u s s t h e i n d i c e n t w i t h him.  +413.  2.  d i s c u s s t h e i n c i d e n t w i t h the p s y c h i a t r i s t .  3.  t r y t o f o r g e t about t h e i n c i d e n t .  You have a s s e s s e d pregnancy.  a t e e n a g e r who i s depressed as a r e s u l t o f  H e r p a r e n t s have t o l d h e r t o g e t o u t o f t h e home.  You recommend o u t p a t i e n t t r e a t m e n t for the family.  f o r h e r a s w e l l as c o u n s e l l i n g  S e v e r a l days l a t e r y o u a r e n o t i f i e d t h a t t h i s  p a t i e n t i s admitted t o h o s p i t a l w i t h a s u i c i d e attempt.  You  a r e most l i k e l y t o  +2  1.  i n i t i a t e a r e v i e w o f y o u r p r e v i o u s assessment.  2.  d i r e c t t h e case t o y o u r s u p e r v i s o r .  3.  do n o t h i n g , as y o u p r o b a b l y c o u l d n ' t have p r e v e n t e d t h e i n c i d e n t anyway.  56  14.  A junior s t a f f member i s t a l k i n g to a young man who i s i n hospital because of sexually deviant behaviour.  As they are talking, you  notice that the junior s t a f f member i s getting more and more distressed by the actions and conversation of t h i s patient. You are most l i k e l y to 1.  discuss the feelings and reactions of the junior s t a f f member at a l a t e r time.  +2  2.  ask the patient i f you could j o i n them, and then direct the conversation i n a d i f f e r e n t d i r e c t i o n .  3.  intervene and support the junior s t a f f member.  Staff members on an inpatient unit are angry and upset by the behaviour of a disruptive attention-seeking patient. asked to help them cope with the situation.  You are  You are most l i k e l y  to 1.  meet with s t a f f , explore t h e i r feelings about the patient and help them deal with them.  1.  meet with s t a f f and explore the circumstances surrounding the patient's behaviour.  2.  assess the patient yourself and make s p e c i f i c recommendations.  3.  suggest how s t a f f could t r y to work the problem out themselves.  Total Judgement/Decision  Score  =  +12  APPENDIX D C a l c u l a t i o n o f C u m u l a t i v e Independence S c o r e s  Data o b t a i n e d from P a r t I I I ( q u e s t i o n s 1, 2 and 4 ) were c o n v e r t e d t o n u m e r i c a l v a l u e s on t h e b a s i s o f t h e f o l l o w i n g 1.  criteria;  a response r e f l e c t i n g t h e most autonomous c l i n i c a l  function  was a s s i g n e d +1; 2.  a response r e f l e c t i n g a team approach was awarded +2;  and  3.  a response i n d i c a t i n g a dependent mode o f f u n c t i o n i n g a c h i e v e d a +3 ( o r +4 depending on t h e number o f a v a i l a b l e options).  A f t e r each i t e m was s c o r e d , a c u m u l a t i v e independence s c o r e was o b t a i n e d by t o t a l l i n g t h e v a l u e s a s s i g n e d t o t h e i n d i v i d u a l i t e m s . These s c o r e s ranged from +3 r e f l e c t i n g a h i g h l e v e l o f independent f u n c t i o n i n g t h r o u g h t o +10 i n d i c a t i n g a low l e v e l o f independent functioning.  The example t h a t f o l l o w s demonstrates t h e p r o c e d u r e  w i t h r e s p o n s e s i n a s c e n d i n g o r d e r b e g i n n i n g a t t h e independent end of t h e continuum ( r e s p o n s e #1 i s t h e most i n d i c a t i v e o f independent function).  1.  I n y o u r p r e s e n t j o b you u s u a l l y  +1 1",  2,  act independently without consulting a physician.  2.  a c t i n d e p e n d e n t l y b u t c o n s u l t t h e p h y s i c i a n a t own  3,  r o u t i n e l y consult a physician.  discretion.  I n y o u r c l i n i c a l p r a c t i c e , who u s u a l l y t a l k s t o p a t i e n t s pother than the r e c e p t i o n i s t ) ? 1.  +2 2. 3.  you a l o n e . y o u r s e l f and p s y c h i a t r i s t . the p s y c h i a t r i s t .  first  58 4. Of the patients you saw last week, in how many of the cases did you alone decide what treatment should be? 1. 2. +3 3. 4.  75 - 100$ of cases 50 - 74$ of cases 25 - 49$ of cases less than 25$ of cases  Total Independence Score = +6  I  APPENDIX E  Development o f C l i n i c a l / A d m i n i s t r a t i v e C a t e g o r i e s  There were 3 i t e m s on t h e q u e s t i o n n a i r e d e s i g n e d t o determine t h e p r a c t i c e o r i e n t a t i o n o f t h e respondent. Part 1  Question 8  Part 3  Question 6  Part 3  Question 7  These were:  Part 1 Question 8 P l e a s e r a n k o r d e r t h e f o l l o w i n g i n accordance t o how y o u see y o u r s e l f w o r k i n g i n your p r e s e n t j o b . a.  educator  b.  co-ordinator  c.  consultant  '  d.  clinical liaison  '  e.  administrator  f.  therapist  v  -  v  N  v  ' v  To o b t a i n r e s p o n d e n t s o r i e n t a t i o n , t h e s e c a t e g o r i e s were c o l l a p s e d i n t h e f o l l o w i n g way: 1)  a respondent w i t h 2 o f a, c, o r f i n t h e i r f i r s t 2 r a n k o r d e r s was c l a s s i f i e d as pure  2)  clinical;  a l l o t h e r c o m b i n a t i o n s were c l a s s i f i e d as a d m i n i s t r a t i v e . A l t h o u g h t h e r e were some mixed respondents ( i . e . a, e i n f i r s t 2 r a n k s ) t h e s e were n o t pure c l i n i c a l and hence were c l a s s i f i e d as a d m i n i s t r a t i v e o r i e n t a t i o n .  Part 3 Question  6  Rank o r d e r the f o l l o w i n g a c c o r d i n g t o what, on t h e a v e r a g e , you spend y o u r time d o i n g d u r i n g a normal  day.  ( l = most,* 6 = l e a s t ) 1.  d i r e c t p a t i e n t contact  2.  c h a r t s and paperwork  3.  administrative duties  4.  t e a c h i n g and/or s u p e r v i s i o n  5.  consultant  6.  other/specify  _____  To o b t a i n r e s p o n d e n t s o r i e n t a t i o n on t h i s i t e m , he/she must have had 2 o f r e s p o n s e s 1, 2 o r 4 i n t h e i r t o p 2 r a n k o r d e r s f o r p u r e clinical.  A l l o t h e r combinations  Part 3 Question  were c o n s i d e r e d a d m i n i s t r a t i v e .  7  With s p e c i f i c reference t o your d a i l y p r a c t i c e , d e f i n e your present  job?  T h i s i t e m was  used as a r e l i a b i l i t y check f o r o r i e n t a t i o n s o b t a i n e d  i n P a r t 1, Q u e s t i o n 8 and P a r t 3 Q u e s t i o n i.e.  6.  I f a respondent- had a c l i n i c a l o r e i n t a t i o n t o q u e s t i o n 8  and  a l s o on q u e s t i o n 6, t h e i r d e f i n i t i o n o f t h e i r j o b s h o u l d comply w i t h this.  F o r " t h e most p a r t , t h i s was  so.  

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