UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

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

Item Metadata

Download

Media
831-UBC_1978_A5_7 M32.pdf [ 2.96MB ]
Metadata
JSON: 831-1.0094258.json
JSON-LD: 831-1.0094258-ld.json
RDF/XML (Pretty): 831-1.0094258-rdf.xml
RDF/JSON: 831-1.0094258-rdf.json
Turtle: 831-1.0094258-turtle.txt
N-Triples: 831-1.0094258-rdf-ntriples.txt
Original Record: 831-1.0094258-source.json
Full Text
831-1.0094258-fulltext.txt
Citation
831-1.0094258.ris

Full Text

ROLE EXPANSION . . . from SPECULATION to VERIFICATION SHARON ALICE MCDONALD B.Sc.N,, S t . F r a n c i s Xavier 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 IN NURSING i n THE FACULTY OF GRADUATE STUDIES School of Nursing We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA May, 1978 0 Sharon A l i c e MacDonald, 1978 In presenting th is thes is in p a r t i a l fu l f i lment of the requirements fo an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make i t f ree l y ava i lab le for reference and study. I fur ther agree that permission for extensive copying of th i s thes is for scho lar l y purposes may be granted by the Head of my Department or by h is representat ives . It is understood that copying or p u b l i c a t i o n of th is thes is for f i n a n c i a l gain sha l l not be allowed without my wri t ten permission. Department of NURSING  The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date MAY, 1978 v "ABSTRACT The concept of r o l e expansion i s p r e s e n t l y a major n u r s i n g i s s u e . Over the past decade, one of the 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 the term 'expanded r o l e . Many contemporary n u r s i n g authors have w r i t t e n about t h i s problem and expressed a need f o r the concept to be c l e a r l y defined. This study was an attempt t o explore the concept 'expanded r o l e ' of the nurse by surveying nurses working i n p s y c h i a t r i c s e t t i n g s . Two groups p a r t i c i p a t e d i n the study; 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 s e t t i n g , A questionnaire was developed, by the author, t o o b t a i n data regarding 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 inherent i n , or strong i n d i c a t o r s of, r o l e expansion i n nu r s i n g . The que s t i o n n a i r e c o n s i s t e d of 25 items and was d i s t r i b u t e d t o a t o t a l sample of 64 nurses (32 working 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 of the 64 nurses viewed t h e i r r o l e t o be expanded. In gene r a l , community employed nurses were o l d e r , more experienced and more h i g h l y educated than h o s p i t a l nurses. A broad fundamental d e f i n i t i o n was v e r i f i e d by data analyses. Although the l i t e r a t u r e suggests t h a t graduate l e v e l education i s necessary to f u n c t i o n i n an expanded r o l e , t h i s was not the case i n t h i s study as only 10 nurses had masters degrees. Committee Chairman i i i TABLE OF CONTENTS p A G E , ABSTRACT 1 1 TABLE OF CONTENTS i i i LIST OF TABLES , v LIST OF FIGURES v i ACKNOWLEDGEMENTS v i i DEDICATION CHAPTER I 1 I n t r o d u c t i o n • • • 1 Statement of the Problem 3 Purpose of the Study 4 S p e c i f i c Objectives of the Study 4 D e f i n i t i o n of Terms 4 Assumptions 5 L i m i t a t i o n s 6 Overview 6 Chapter I I • 7 L i t e r a t u r e Review 7 Chapter I I I . 1 7 Methodology 1 7 Data Gathering Instrument * I 7 P r e t e s t 1 8 Sample S e l e c t i o n 1 8 Implementation !9 i v PAGE CHAPTER IV r- RESULTS 22 I n t r o d u c t i o n 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 Di s c u s s i o n of Re s u l t s 30 Summary 31 Conclusions - ; . . 32 I m p l i c a t i o n s 34 BIBLIOGRAPHY 36 APPENDICES 42 Appendix A Consent Form . . . . 4-3 Appendix B - Questionnaire • ..44 Appendix C - Method of C a l c u l a t i n g Decision/Judgement Scores 54 Appendix D - Method of C a l c u l a t i n g Independence Scores . . 57 Appendix E - Development of C l i n i c a l / A d m i n i s t r a t i v e Categories 59 V LIST OF TABLES TABLES s PAGE 4.1 Summary of Ed 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 22 4.2 Summary of Age D i s t r i b u t i o n According t o Work L o c a t i o n 23 4.3 Summary of Years Experience as a Regis t e r e d Nurse, P s y c h i a t r i c Nurse, i n Present Job by L o c a t i o n . . . 24 4.4 Summary of Aggregate Job D e s c r i p t i o n Crosstabulated w i t h Expanded Role 26 4.5 C r o s s t a b u l a t i o n of Monthly S a l a r y w i t h Expanded Role 27 4.6 C r o s s t a b u l a t i o n R e s u l t s of Independent Funct i o n i n Present Job w i t h Expanded Role 27 4.7 Summary of C r o s s t a b u l a t i o n of Cumulative Independence Scores w i t h Expanded Role 29 LIST OF FIGURES FIGURE 4.1 Graphic Summary of Independent Treatment D e c i s i o n Crosstabulated w i t h Expanded Role ACKNOWLEDGEMENTS I would li 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, faith and constant encouragement over the past two years have been appreciated more than I can express. Thanks Mom and Dad. 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 scientific 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 ut i l i z e d . The nursing profession i s one group who i s addressing this question. It 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 responsibiliti and performing duties that not so very long ago were considered inappropriate for the nurse. It 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 the uniqueness of 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 expe 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 . I t would appear that i t i s the r a t e , r a t h e r than the change i t s e l f , t h a t i s causing confusion 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 nurses, regarding the nature of the new f u n c t i o n s which nurses are a c q u i r i n g . For many nurses the changes are s t i m u l a t i n g i n that they b e l i e v e there i s now opportunity t o f a s h i o n a new r o l e i n which nurses 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 a c t i v e 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 h e a l t h care (Brown, 1970, l ) . However, according t o Lamothe " i f we are not t o put the c a r t before the horse, the new f u n c t i o n s o f nurses must f i r s t be defined, before they are implemented" (1972, 8 ) . The m u l t i p l i c i t y of f u n c t i o n s adds t o the confusion and creates controversy f o r those w i t h i n and outside the r o l e s . A c l e a r set of g u i d e l i n e s would a s s i s t others t o understand and u t i l i z e , more e f f e c t i v e l y , the expanded r o l e nurse (BooneyandlKikuchi,.' 1977, 102). The d i f f i c u l t y at the present time i s the l a c k of 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 the problem of c l a r i f y i n g what the expanded r o l e e n t a i l s . U n t i l the concept "expanded r o l e " can be o p e r a t i o n a l l y d e f i n e d , there cannot be proper u t i l i z a t i o n of n u r s i n g manpower w i t h i n an expanded r o l e . Kathleen King (1974) sums i t up n i c e l y . She s t a t e s , "In recent years, a r t i c l e s and statements, regarding r o l e expansion, abound u n t i l the jargon has become jaded and one wonders what i s expanded about the work of e i t h e r the 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 obvious t h a t the nurses' r o l e always changes i n response to s o c i e t i e s ' needs, i t s f u n c t i o n s have never been c l e a r l y defined (Lamothe, 1972, 4 ) , This whole question of d e f i n i t i o n , then, assumes g r e a t e r importance i n l i g h t of confirming our unique 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 nurses, t o the h e a l t h care d e l i v e r y system. I n the words of A l l e n (1974-), "We cannot hope f o r backing, 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, nor have our b e l i e f s about the 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 research framework the nature of our s e r v i c e s and t h e i r value to s o c i e t y . " ( 4 ) . 'Statement of the Problem I n order to determine the dimensions of 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 the needs of s o c i e t y , w i t h i n a research framework, we must begin 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 of the concept "expanded r o l e " . At the present time there i s no d e f i n i t i o n t h a t s a t i s f a c t o r i l y encompasses the many new working c a t e g o r i e s that are c a l l e d "expanded r o l e s " , ( i . e . c l i n i c a l nurse 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 l a c k of a b a s i c core 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 of i n t e r -d i s c i p l i n a r y confusion. I n other words, how do we define the expanded r o l e of the nurse so t h a t i t r e f l e c t s the fundamental s i m i l a r i t i e s of f u n c t i o n and purpose r e g a r d l e s s of the working r o l e which he/she assumes? 4 Purpose of the Study The general purpose of the study was t o develop 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 of the expanded r o l e of the nurse f o r nurses of a l l e d u c a t i o n a l preparations i n view of 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 described i n the l i t e r a t u r e . A secondary purpose was t o u t i l i z e the i n f o r m a t i o n obtained t o i d e n t i f y the e d u c a t i o n a l gap ( i f one e x i s t s ) between nurses f u n c t i o n i n g i n expanded r o l e s and general duty nurses w i t h respect t o s t a f f nurse perceptions of expanded r o l e nurse f u n c t i o n s . S p e c i f i c Objectives of the Study The s p e c i f i c o b j e c t i v e s of t h i s study were: 1. To determine what f u n c t i o n s the^nurse working i n an expanded r o l e i s c a r r y i n g out. 2. To determine the e d u c a t i o n a l p r e p a r a t i o n of nurses i n expanded r o l e s . 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 ex p e c t a t i o n of expanded r o l e nurses by nurses assuming t h i s p o s i t i o n . 5. To i d e n t i f y areas of confusion that could be d i s i p a t e d through n u r s i n g education. D e f i n i t i o n of Terms Nursing P o p u l a t i o n : - 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 Province of B r i t i s h Columbia who are working i n general duty and/or expanded r o l e s i n h o s p i t a l s or community. Expanded Role:- A r e g i s t e r e d nurse, prepared at the masters l e v e l , who i s f u n c t i o n i n g beyond the t r a d i t i o n a l nurse r o l e , i n an independent or semi-independent manner i n the area of c l i n i c a l t h e r a p i s t (performing p s y c h i a t r i c assessment and psychotherapy), nurse c o n s u l t a n t , team member, l i a i s o n person or s o c i a l change agent f o r the purposes of c o n t r i b u t i n g h i g h education and s k i l l i n the treatment of the s i c k and or d i s t r a u g h t person or f a m i l y , or the p r e v e n t i o n of i l l n e s s , a i d i n g nurses to 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 planning and p r e p a r a t i o n f o r persons upon t h e i r r e t u r n t o community. Her/his f u n c t i o n could a l s o be at the e d u c a t i o n a l or research l e v e l , depending on h e r / h i s area of e x p e r t i s e . T r a d i t i o n a l Role:- Those nurses prepared i n b a s i c h o s p i t a l and/or u n i v e r s i t y programs and who are p r e s e n t l y working general duty 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 study were: 1. the concept of expanded r o l e i s important to the n u r s i n g p r o f e s s i o n ; 2. the expanded r o l e e x i s t s , despite the present confusion surrounding i t , both c l i n i c a l l y and c o n c e p t u a l l y ; and 3. 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 should i t be v a l i d a t e d , could a f f e c t the h e a l t h care of Canadians. 6 L i m i t a t i o n s 1. P o p u l a t i o n -a) excludes non-registered nurses and those working i n small and/or p r i v a t e l y operated h o s p i t a l s ; b) excludes a d m i n i s t r a t i v e and sup e r v i s o r y personnel; c) excludes those working i n h o s p i t a l s or communities outside the f i e l d of p s y c h i a t r y . I t appears t h a t the grea t e s t d e n s i t y of nurses working 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 study, I am l i m i t i n g the sample t o t h i s area. 2. The sample was one of convenience and g e n e r a l i z a t i o n s t o the 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 review i s presented 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 of the methodology used i n the study. Data analyses are presented i n Chapter IV. Chapter V contains conclusions and i m p l i c a t i o n s of the f i n d i n g s . CHAPTER I I 7 L i t e r a t u r e Review In recent years the compiled n u r s i n g l i t e r a t u r e , d e s c r i b i n g the concept of r o l e expansion, has become q u i t e voluminous. There have been many attempts to de f i n e the 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 the present needs of s o c i e t y and the nurs i n g p r o f e s s i o n f o r such a concept. The somewhat broad scope which the l i t e r a t u r e covers deals w i t h s p e c u l a t i o n and documentation of how nurses 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 accounts seem t o l a c k organized experimental design which would i n d i c a t e , w i t h i n a research framework, the unique nature of the r o l e and f u n c t i o n s of these nurses and t h e i r value t o s o c i e t y and the p r o f e s s i o n . One of the major i s s u e s , as described i n the l i t e r a t u r e , i s the problem of d e f i n i t i o n of the term "expanded r o l e " . Many authors have w r i t t e n about t h i s problem, and expressed a need f o r the concept t o be c l e a r l y defined. The whole i s s u e has been looked at from many pe r s p e c t i v e s , but the b a s i c concern remains the same; what i s the expanded r o l e of the nurse? The l i t e r a t u r e review t o f o l l o w i s s e l e c t i v e of the l a r g e amount of m a t e r i a l d e a l i n g w i t h the problem of d e f i n i t i o n . Although some of the views may appear t o be somewhat m i l i t a n t i n nature, they express the current p o s i t i o n taken by many of the contemporary n u r s i n g authors. I t i s the i n t e n t i o n of t h i s i n v e s t i g a t o r t o determine the f u n c t i o n s and c l i n i c a l r o l e of nurses working i n an expanded r o l e , i n p s y c h i a t r y , 8 i n the hope that a core d e f i n i t i o n of the concept can be' e m p i r i c a l l y v e r i f i e d . 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 are p e r p e t r a t i n g the development of expanded r o l e s f o r nurses. S e v e r a l of the more important f a c t o r s i n c l u d e a) a r a p i d growth of biomedical knowledge; b) broadening nu r s i n g education; c) increased p u b l i c demand f o r h e a l t h care; d) the women's movement; and e) the development of 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 nurses and other h e a l t h p r o f e s s i o n a l s (Secretary's Committee, 1972, 4-8). However, according t o Lewis (1972), " . . i f the nature of an enlarged n u r s i n g r o l e i s simply t o extend the 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 , then we haven't changed anything; we've simply d i s t r i b u t e d the same o l d work among more persons i n the same o l d system. But, i f the nurse i s i d e n t i f i e d and used as a person w i t h a d i f f e r e n t o r i e n t a t i o n than the p h y s i c i a n — one who provides a d i f f e r e n t k i n d of h e a l t h care s e r v i c e — then we have the p o t e n t i a l f o r a new p a t t e r n of h e a l t h manpower and some overdue r e s t r u c t u r i n g of- our h e a l t h care d e l i v e r y system." (21). 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 the 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 are to govern n u r s i n g p r a c t i c e ( D r i s c o l l , 1972, 26). As Schein, c i t e d by Louise Murray (1972), s t a t e s , "the essence of 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 of some of the norms which govern the p r a c t i c e of the 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 or i d e a l r o l e of the nurse p r o f e s s i o n a l i n s o c i e t y " (60). Role, as defined i n Theodore Sarbin's Role 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 conditioned responses by one member of a s o c i a l s i t u a t i o n which represents the stimulus 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 of conditioned responses of the o t h e r ( s ) i n th 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 are r o l e expectations and r o l e p e r c e p t i o n s . I n terms of r o l e expectations, there are two general k i n d s ; r i g h t s and o b l i g a t i o n s . Rights are r o l e expectations i n which the a c t o r 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 from the a c t o r of a r e c i p r o c a l r o l e . O b l i g a t i o n s are r o l e expectations i n which the a c t o r of 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 the a c t o r of the r e c i p r o c a l r o l e . 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 organized response of a person t o a s t i m u l i i n a s o c i a l context; a sequence of behaviours i n which per c e p t u a l response and ) motoric response r e s u l t i n the act o r performing a c t i o n s appropriate t o h i s l o c a t i o n of the p o s i t i o n s of s e l f and other, Taken i n the context of r o l e theory, then, many of the 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 concerning the expanded r o l e f o r the nurse, can b e t t e r be understood, f o r r o l e change cannot occur i f the c l i n i c i a n i s the only one t o view her r o l e as having changed. The general p u b l i c , other 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 nurses themselves must develop and maintain s i m i l a r perceptions and expectations of an advanced c l i n i c a l nurse (Moore, 1974, 127). In l i g h t of s o c i e t y ' s current demand f o r improved h e a l t h care, and the a v a i l a b i l i t y of nurses to help meet t h i s demand, i t becomes mandatory t o f o r m a l i z e the expanded nurse's r o l e (Walker, 1972, 29). Nursing i n Canada today 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 confusing,as a r e s u l t of r a p i d e d u c a t i o n a l and r o l e change. As the r o l e of n u r s i n g expands, education expands, and the independent nature of the p r o f e s s i o n grows (Hatt, 1977, 1583). According to Bristow, et a l (1974), " i f we are not to l o s e s i g h t of our r a i s o n d'etre, we must address ourselves to our p r o f e s s i o n a l boundaries and norms i n an e f f o r t t o achieve l e g i t i m a t e power and a u t h o r i t y " (31). I n order t o achieve t h i s , we must know what we are preparing f o r i n terms of 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 the use of nurses and other h e a l t h p r o f e s s i o n a l s . At the present time, i n s t e a d of 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 of terms l i k e expanded and extended 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 o p e r a t i o n a l d e f i n i t i o n of "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 the shroud of confusion enveloping the concept at 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 the expanded r o l e of the nurse appears t o be not so much the nurse's a b i l i t y t o f u n c t i o n at a h i g h l e v e l , but the a t t i t u d e s of nurses and p h y s i c i a n s toward a l l o w i n g the nurse 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 t o de Tornyay (1971), "when we t a l k about changing r o l e s , h e l p i n g nurses 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. Changing a t t i t u d e s i s a d i f f e r e n t problem e n t i r e l y " (976). S l i g h t l y more than ten years ago, when nu r s i n g f u n c t i o n s began expanding, few problems, p a r t i c u l a r l y i n the area of r o l e change, were a n t i c i p a t e d . There was a general f e e l i n g t h a t these new f u n c t i o n s i n c o r p o r a t e d i n t o n u r s i n g were more appropriate f o r t h e i r e d u c a t i o n a l 11 p r e p a r a t i o n . However, as time passed, i t became more and more evident t h a t general duty nurses d i d not see the expanded r o l e nurse f u n c t i o n i n g any d i f f e r e n t l y from themselves. W i t h i n that context, a t r u e r o l e change could not occur (Moore, 197-4, 127). Even w i t h b e t t e r e d u c a t i o n a l p r e p a r a t i o n , nurses 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 . Part of the problem, as s t a t e d e a r l i e r , r e s t s w i t h the a t t i t u d e s of p h y s i c i a n s , the p u b l i c and of nurses themselves regarding the new dimensions being incor p o r a t e d i n t o the nur s i n g p r o f e s s i o n . But, perhaps even more important t h a t the a t t i t u d e s , i s the somewhat haphazard attempt, by the p r o f e s s i o n , to d e l i n e a t e c l e a r g u i d e l i n e s f o r d e f i n i n g the 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 of a nurse performing i n an expanded r o l e . According t o Boone and K i k u c h i (1977), "C l e a r e r g u i d e l i n e s would a s s i s t others t o understand and t o u t i l i z e t h i s person more e f f e c t i v e l y . Because of the present ambiguity i n the d e f i n i t i o n s , there i s s t i l l c ontroversy concerning the n e c e s s i t y , the expectations and the p o t e n t i a l of the nurse performing w i t h i n the context of expanded r o l e . " (102-103). Since n u r s i n g began, i n the 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 necessary 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 gr e a t e r than was a n t i c i p a t e d (Lamothe, 1977, 7 ) . According t o Lamothe (1972), "Since h e a l t h care seems t o f a l l n a t u r a l l y i n t o a form i n which the members of var i o u s d i s c i p l i n e s work i n teams, the r o l e and f u n c t i o n s of each p a r t i c i p a n t should be c l e a r l y l a i d down. This w i l l encourage mutual cooperation and w i l l help t o avoid 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 to look at the expanding r o l e of the nurse. This r e p o r t , put out by the Department of N a t i o n a l Health and Welfare i n the form of the Boudreau Report s t a t e s . . . "The awareness of the unique c o n t r i b u t i o n t h a t other p r o f e s s i o n s can make i n the p r o v i s i o n of h e a l t h care i s , however, becoming more and more widespread and i s being g r a d u a l l y t r a n s l a t e d i n t o c o r r e s -ponding increased r e s p o n s i b i l i t y and autonomy f o r these p r o f e s s i o n s . " ( 4 ) . The report goes on t o s t r e s s the importance of developing those methods of h e a l t h care a l r e a d y i n existence as opposed to developing an e n t i r e l y new category of h e a l t h p r o f e s s i o n a l . I n s p i t e df these recommendations, we have seen impulsive development of nurse-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 which have added t o the confusion and c o m p l i c a t i o n of an expanded r o l e f o r nurses. One has only t o l o o k at the l i t e r a t u r e to r e a l i z e t h a t the e d u c a t i o n a l p r e p a r a t i o n f o r nurses f o r an expanded r o l e w i d e l y v a r i e s . However, no matter what approach i s used, success i s dependent upon the mutual agreement of both the nurse and the employing agency as t o the r o l e the nurse w i l l assume (.Boone and Ki.kuchiy.. 1977, 108). I t i s d i f f i c u l t t o achieve mutual agreement when the g u i d e l i n e s f o r p r a c t i c e are so u n c l e a r . How does a " d e f i n i t i o n " such as that which appears i n the Boudreau Report (1972) ". . . a n extension of the present n u r s i n g r o l e , w i t h the nurse's unique s k i l l s i n the p r o v i s i o n of h e a l t h care being developed and u t i l i z e d more e f f e c t i v e l y , and the nurse's r o l e i n a s s i s t i n g the p h y s i c i a n expanded through increased d e l e g a t i o n of ta s k s by p h y s i c i a n s to s u i t a b l y prepared nurses . . ." ( 6 ) , help c l a r i f y anything about the new dimensions nurses are embarking on? I n June of 1972, Rachel Lamothe prepared a paper on the expanded r o l e of the nurse i n which she emphasized the need f o r changes i n the r o l e of n u r s i n g t o meet the ever i n c r e a s i n g demands of the l a y p u b l i c f o r h e a l t h care (16). Lamothe s t r e s s e d the need f o r c l a r i f y i n g and d e f i n i n g the new f u n c t i o n s which nurses are undertaking, and a l s o that i f the needs of s o c i e t y are t o be met e f f e c t i v e l y and e f f i c i e n t l y , u n i v e r s i t i e s and departments of education must agree on the type of education r e q u i r e d ( 19). More and more sc h o l a r s i n the n u r s i n g p r o f e s s i o n are l e a n i n g toward graduate p r e p a r a t i o n f o r assuming an expanded r o l e . However, i t should be noted t h a t we are not merely d e a l i n g w i t h e d u c a t i o n a l programs; we are d e a l i n g w i t h people whom we are t r y i n g t o change and prepare 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 (White, 1975, I64) . Inherent to the development of r o l e expansion i s increased autonomy, self-esteem and s o c i a l support; the nurse must see h e r s e l f as one who nutures c l i e n t s and f a m i l i e s r a t h e r than m a i n t a i n i n g a s e r v i c e t o an agency or i n s t i t u t i o n (Maekemes, 1974, 90). A c r u c i a l 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 ambiguity and r o l e confusion r e s u l t i n g from l a c k of 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 Wright d i d a survey study i n which she attempted t o determine what r e g i s t e r e d nurses thought about the expanded r o l e concept. She s t a t e d , " I m p l i c i t i n the d e c i s i o n t o develop new r o l e s f o r nurses i s the assumption that a new r o l e responds t o a recognized need i n the h e a l t h care 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 the care u l t i m a t e l y d e l i v e r e d . " (112). She f u r t h e r s t a t e s t h a t " . . . Before judgements can 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 the h e a l t h care system w i l l have s p e c i f i c queries and concerns that r e q u i r e a t t e n t i o n . " (Wright, 1976, 112). I n order t o s a t i s f y and/or e l i m i n a t e the queries and concerns, the n u r s i n g p r o f e s s i o n must be prepared w i t h c l e a r g u i d e l i n e s e x p l a i n i n g both f u n c t i o n and purpose, as w e l l as the p o t e n t i a l c o n t r i b u t i o n the change has f o r b e t t e r h e a l t h care. I f we do not deal 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 the present problems, nurses w i l l not be able t o c l i n i c a l l y meet the challenge of today's h e a l t h care d e l i v e r y head on (Moore, 1974, 127). • For many years nurses i n r u r a l areas of Western Canada and i s o l a t e d areas of the Canadian North have funct i o n e d i n expanded r o l e s , without these being designated as such. However, emerging s o c i e t a l and governmental pressures r e l a t e d t o reducing h e a l t h care workers and the need of s e l e c t e d types of p h y s i c i a n s u b s t i t u t e s to provide medical care i n remote areas, have together created a t r e n d toward grea t e r f o r m a l i z a t i o n of "expanded" r o l e s f o r nurses (Hayes, et a l . , 1974, 34). From the l i t e r a t u r e , of which there i s an abundance, i t becomes apparent t h a t the " f o r m a l i z a t i o n " continues to 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 respect t o commonalities among a l l expanded r o l e s , and e m p i r i c a l evidence to determine what nurses i n expanded r o l e s are r e a l l y doing. C l a r i t y a l s o takes on s p e c i a l importance here, f o r preparing a nurse to perform i n a more autonomous r o l e , does not mean tha t the system w i l l a l l o w her/him t o f u n c t i o n so. For a great many years now t r a d i t i o n has bound the r e l a t i o n s h i p between nurses and p h y s i c i a n s t o extreme su 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 lough, 1976, 1478). Along w i t h r o l e change, there must be a change i n p r o f e s s i o n a l s e l f concept so,that p r o f e s s i o n a l s are comfortable 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 , not confused or u n c e r t a i n about the 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 the patient.,. Expanding our r o l e i s important i n l i g h t of h e a l t h care demands, h e a l t h care costs and economics. According t o Lewis (1974), " I f we are t o look forward t o broad understanding and acceptance of the expanded r o l e nurse, hasn't the time come f o r c o n s i d e r a t i o n of some broad, n a t i o n a l l y determined standards and c r i t e r i a ? For years we have t a l k e d about the l a r g e r c o n t r i b u t i o n t h a t nurses could make w i t h i n our h e a l t h care s t r u c t u r e g iven an opportunity t o p r a c t i c e t o t h e i r f u l l p o t e n t i a l . With the concept of r o l e expansion, nu r s i n g has t h a t o p p o r t u n i t y . " (89). What we do today 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 the f u t u r e (Moore, 1974, 127). The problem, then, becomes one of v e r i f y i n g v . what we are preparing f o r j who are 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 than not, t h a t i f n u r s i n g doesn't define the r o l e , other 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 us. In the words of -Joan . . G i l c h r i s t , as c i t e d .by Kathleen King (1974): "We should not be content to 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 which i n c l u d e s research, l e a r n i n g , 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." (55). Martha Rogers (1972) has summed i t up n i c e l y . ". . . i t i s nur s i n g knowledge t h a t nurses b r i n g t o the j o i n t c o l l a b o r a t i o n of a range of h e a l t h p r o f e s s i o n a l s ; i t i s nur s i n g knowledge that 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 nursing's,:^ body of s c i e n t i f i c knowledge th a t guides nu r s i n g p r a c t i c e . Nursing i s s o l e l y r e s p o n s i b l e f o r i t s own a c t s . Only out of mutual sharing and respect among h e a l t h d i s c i p l i n e s can there a r i s e a nature and q u a l i t y of 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 provide on i t s own." (4-4). In c o n c l u s i o n then, i f the concept of r o l e expansion 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 cut d e f i n i t i o n of the r o l e and fu n c t i o n s must be developed i n the near f u t u r e . The time 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 challenge of the day by 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 the p r a c t i c e of an expanded r o l e nurse. 17 CHAPTER I I I Methodology-This study was conducted through the use of a q u e s t i o n n a i r e which was completed by nurses working i n a community or 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 data, obtained from responses t o the q u e s t i o n n a i r e , were analysed to determine what r o l e perceptions, expectations and f u n c t i o n s are inherent t o a nurse working i n an "expanded" r o l e . Data Gathering Instrument The questionnaire (see Appendix B) u t i l i z e d i n t h i s d e s c r i p t i v e study was developed 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 stionnaire development, as p a r t of the r e s e a r c h process. I t 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 respondents' p e r c e p t i o n of t h e i r r o l e , and l e v e l of 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 expansion. The t o o l c o n s i s t e d of three p a r t s ; part one of demographic data used t o determine whether v a r i a b l e s such as age, education, years of experience, e t c . , e f f e c t r o l e p e r c e p t i o n and l e v e l of f u n c t i o n i n g ; p a r t two c o n s i s t e d of h y p o t h e t i c a l / s t i u a t i o n a l items as i n d i c a t o r s of how nurses can or would r e a c t i n t h e i r r e s p e c t i v e work areas; p a r t three was composed of open ended response items f o r purposes of e l i c i t i n g the t r u e p e r c e p t i o n of how nurses see themselves 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 job 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 contained a t o t a l of twentyr-five (25) items. The p r i v a c y of subjects was ensured by anonymity of study p a r t i c i p a n t s . 18 P r e t e s t The questionnaire was p r e t e s t e d u t i l i z i n g t e n nurses working 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 reasons f o r the p r e t e s t were:-r 1. t o determine whether the questions were c l e a r and unambiguous; 2. to determine whether the items were d e s c r i m i n a t i n g between 'expanded' r o l e nurses and general s t a f f nurses w i t h i n p s y c h i a t r y ; and 3. to determine whether the questionnaire e l i c i t e d the necessary i n f o r m a t i o n f o r determining 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 of the concept 'expanded' r o l e . As a r e s u l t c f the p r e t e s t , format of the q u e s t i o n n a i r e was a l t e r e d , two questions were e l i m i n a t e d and two questions were added. Sample S e l e c t i o n A convenience sample was obtained from those persons working w i t h i n an 'expanded' r o l e who attended the Q u a l i t y Assurance Conference he l d at the Burnaby Mental H e a l t h Centre. They were contacted by t h i s i n v e s t i g a t o r , and 35 persons volunteered t o p a r t i c i p a t e i n the study. A second group of 35 persons was obtained from the n u r s i n g s t a f f at Health Sciences Centre H o s p i t a l . • 19 Implementation  Phase I: Through a search of the l i t e r a t u r e , a d e f i n i t i o n r e f l e c t i n g the s i m i l a r b a s i c components of f u n c t i o n was developed, f o r the expanded r o l e of the nurse. From t h i s d e f i n i t i o n , a que s t i o n n a i r e was developed t o r e f l e c t the concept i n question. Phase I I : The questionnaire was mailed out t o those persons who had been contacted through the Burnaby Mental Health Centre. Of the 35 mailed out t h e ^ r e t u r n was 91$ or 32 qu e s t i o n n a i r e s . The same number, 32, of questionnaires was completed by the nu r s i n g s t a f f at Health Sciences Centre r e s u l t i n g i n a t o t a l sample of 64 s u b j e c t s . A l l p a r t i c i p a n t s r e c e i v e d the same qu e s t i o n n a i r e . Due t o the nature of the sample s e l e c t i o n and the f a c t the study was r e s t r i c t e d t o the f i e l d of 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 regarding the 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 co n v e r t i n g the i n f o r m a t i o n i n t o numerical values were e s t a b l i s h e d . Part 2 dealt w i t h s i t u a t i o n a l items designed t o e l i c i t a beh a v i o u r a l response i n d i c a t i n g the k i n d of judgement nurses u t i l i z e i n a given s i t u a t i o n . The f o l l o w i n g c r i t e r i a were employed t o convert t h i s data i n t o numerical scores. 1, I f the response r e f l e c t e d s y n t h e s i s of the presented data 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 the 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 the response 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 , the respondent was awarded a score of +1. I f response t o the item r e f l e c t e d 2 of the 3 c r i t e r i a , the nurse was given +2; and i f only one ( o r none) of the c r i t e r i a was accounted f o r , the nurse was awarded a +3. A f t e r each item i n P a r t 2 was scored i n t h i s manner, the numerical values were t o t a l l e d which r e s u l t e d i n a cumulative judgement/ d e c i s i o n score. These scores ranged from +6 which i n d i c a t e d h i g h q u a l i t y decision/judgement to +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 / judgement a c t i v i t y . (For example, see Appendix C). Part 3 of the data gathering instrument contained 3 questions u t i l i z e d as i n d i c a t o r s of independent f u n c t i o n i n g . These questions ( l , 2 and 4) were a l s o converted t o numerical values. The procedure used t o change the data to amenable form f o l l o w s : 1. a response r e f l e c t i n g the most autonomous f u n c t i o n was awarded +1; 2. a response i n d i c a t i n g a team approach was assigned +2; and 3. a response r e f l e c t i n g dependent f u n c t i o n was assigned ' +3 or +4 (dependent upon the number of a v a i l a b l e o p t i o n s ) . Once the values were assigned to each item, they were t o t a l l e d t o achieve a cumulative independence score. These scores 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 low independence. (For example, see Appendix D). Phase IV: Method of Analyses The data obtained from the questionnaire was analysed by u t i l i z i n g the S t a t i s t i c a l Package f o r the S o c i a l Sciences ( V e r s i o n 7) computer program. Analyses c o n s i s t e d of. two phases: 1) frequency 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 d e s c r i p t i o n , e d u c a t i o n a l p r e p a r a t i o n , years experience, age, monthly s a l a r y , decision/judgement, independence, job p e r c e p t i o n , time spent, expanded r o l e and l o c a t i o n of p r a c t i c e ) w i t h the c a l c u l a t i o n of s t a t i s t i c s i n terms of mean, median, mode, standard d e v i a t i o n , variance and range; and 2) c r o s s t a b u l a t i o n s of a l l v a r i a b l e s ' w i t h s u b j e c t s ' p e r c e p t i o n of being i n an expanded r o l e , as the dependent v a r i a b l e , y i e l d i n g c h i squared values as an i n d i c a t o r of st r e n g t h of r e l a t i o n s h i p s and the 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 ( h e r e a f t e r c a l l e d Pearson's R) as an i n d i c a t o r of the d i r e c t i o n of the r e l a t i o n s h i p , should 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 to e x i s t w i t h these two t e s t s i f at a 0.05 l e v e l of s i g n i f i c a n c e . Both phases of analyses were performed on the sample group as a whole (64 cases) and on each group ( h o s p i t a l - 32 cases and community 32 cases) se p a r a t e l y . 22 CHAPTER IV RESULTS I n t r o d u c t i o n This study was designed 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 education 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 nurses, who s u b j e c t i v e l y view themselves t o be working i n expanded r o l e s , and general duty s t a f f nurses employed i n a h o s p i t a l s e t t i n g . A l l respondents are: c u r r e n t l y working i n the f i e l d of p s y c h i a t r y . Demographic Data The sample c o n s i s t e d of 64 r e g i s t e r e d nurses; 32 working i n community s e t t i n g s and 32 employed by a h o s p i t a l . Data analyses showed t h a t community nurses had a t t a i n e d higher 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). Table 4.1 Summary of Education P r e p a r a t i o n - According t o Work L o c a t i o n i n Raw Scores L o c a t i o n H o s p i t a l Community T o t a l Diploma 16 16 32 Degree 16 6 . 22 Masters 0 10 10 T o t a l 32 32 64 n = 64 23 Frequency d i s t r i b u t i o n demonstrated t h a t of the group of 64, 31 (48%) worked as s t a f f nurses, 10 (16%) as c l i n i c a l nurse s p e c i a l i s t s , 16 (25%) as nurse t h e r a p i s t s and 7 (11$) as head nurse/consultants. The mean age of the group was 33 years. More d e t a i l e d analyses showed tha t community nurses were o l d e r than h o s p i t a l employees (see Table 4.2). I n terms of experience, i t was found t h a t nurses working i n the community had not only more general experience, but had worked i n p s y c h i a t r y longer than h o s p i t a l nurses (see Table 4.3). Table 4.2 Summary of Age D i s t r i b u t i o n According t o Work L o c a t i o n i n Column Percent L o c a t i o n Age H o s p i t a l Community 19 - 30 59.4 34.4 31 - 40 34.4 37.5 41 - 50 6.2 21.9 51 - 60 0.0 6.2 T o t a l 100.0$ 100.0$ x. = 30 year s x. = 36 years Table 4.3 Summary of Years Experience as, an R.N.; P s y c h i a t r i c Nurse, and i n Present Job, by L o c a t i o n i n Raw Scores L o c a t i o n H o s p i t a l Community Years Experience R.N. Psych. Pr. Job R.N. Psych. Pr. Job 1 - 2 7 15 26 1 3 9 3 - 5 8 9 4 4 5 16 6 - 1 0 10 6 6 10 15 7 11 - 15 4 2 2 9 5 0 16 + 3 0 0 8 4 0 T o t a l 32 32 32 32 32 32 n = 64 P a r t i c i p a n t s i n the study 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 of employment. The average s a l a r y of the 64 nurses was $1442/month; f o r the community group i t was $1563/month and f o r h o s p i t a l employees $1321/month. Of the t o t a l group of 64, 36 (56$) perceived themselves t o be working c l i n i c a l l y and 28 (44$) viewed t h e i r jobs as a d m i n i s t r a t i v e (see Appendix E ) . I n terms of r o l e expansion, 51 (80$) saw themselves working i n an expanded r o l e and 13 (20$) d i d not. I n summary, the group c o n s i s t e d of 64 r e g i s t e r e d nurses ranging i n age from 25 years t o 60 years. They had v a r y i n g years of experience and e d u c a t i o n a l p r e p a r a t i o n . I n general,community nurses were o l d e r and had more experience, w i t h higher e d u c a t i o n a l p r e p a r a t i o n than 25 h o s p i t a l nurses. A l l respondents f e l l i n t o e i t h e r c l i n i c a l or a d m i n i s t r a t i v e areas of p r a c t i c e . The sample was composed of 32 h o s p i t a l nurses and 32 community nurses. Demographic Data - H o s p i t a l Subgroup The h o s p i t a l subgroup were a l l prepared at a non masters l e v e l and 19 (59.4$) nurses were under 30 years of age. Of t h i s group 30 (93.8$) saw themselves working as s t a f f nurses and 2 (6,2%) as nurse t h e r a p i s t s . In terms of work experience, 81.3% of t h i s group had been i n t h e i r present jobs 2 years or l e s s ; 75$ had 5 years or l e s s p s y c h i a t r i c n u r s i n g experience and 65.6$ had 9 years or l e s s general experience as a r e g i s t e r e d nurse. Data showed t h a t 81.3$ or 26 nurses earned l e s s than $1400/month. Demographic Data - Community Subgroup The group of community nurses was composed of 32 respondents, 10 of which were prepared at the masters l e v e l . Of the remaining 22, 6 h e l d Baccalaureate degrees and 16 had diplomas i n n u r s i n g . I n terms of job d e s c r i p t i o n , 15 (46.9$) nurses viewed themselves as nurse t h e r a p i s t s , 10 (31.3$) saw themselves as c l i n i c a l nurse s p e c i a l i s t , 1 (3.1$) as a s t a f f nurse and 6 (18.7$) as a head nurse/consultant. Community employees were o l d e r w i t h 21 (63.3$) respondents being over 31 years of age. Work h i s t o r y of community nurses was longer as 16 (58.3$) had g r e a t e r than 9 years experience as a r e g i s t e r e d nurse; 24 (75.0$) had more than 5 years p s y c h i a t r i c n u r s i n g experience; and 24 (75.0$) had been i n t h e i r present jobs 3 or more years. The s a l a r y f o r t h i s group was higher w i t h 25 (78.1$) nurses earning more than $1400/month. I n terms of r o l e expansion, 30 (93.8$) nurses viewed t h e i r r o l e s as expanded and 2 (6.3$) d i d not. Aggregate C r o s s t a b u l a t i o n R e s u l t s A l l v a r i a b l e s discussed i n the preceding s e c t i o n s were t r e a t e d as independent^variables and c r o s s t a b u l a t e d w i t h data r e g a r d i n g expanded r o l e . Of the 64- nurses, 51 (79.7$) perc e i v e d t h e i r jobs t o be an expanded r o l e . Table 4.4 Summary of Aggregate Job D e s c r i p t i o n Crosstabulated w i t h Perceived Expanded Role Expanded Role Job D e s c r i p t i o n Yes o Abs. Value C o l . PCT Abs. Value C o l . PCT S t a f f Nurse 20 39.2 11 84.6 S p e c i a l i s t 9 17.6 1 7.7 Therapist 15 29.4 1 7.7 Consultant/ Head Nurse 7 13.8 0 0.0 T o t a l 51 100.0 13 100.0 x 2 = 8.80 P < .06 Table 4.4 showed the r e s u l t s of the c r o s s t a b u l a t i o n of job 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 not s t a t i s t i c a l l y s i g n i f i c a n t although i t showed th a t s t a f f nurses were much l e s s l i k e l y to view t h e i r r o l e s as expanded. Table 4.5 C r o s s t a b u l a t i o n of Monthly S a l a r y w i t h Perceived Role Expansion Expanded Role S a l a r y Yes No Abs. Value C o l . PCT Abs. Value C o l . PCT l e s s $1399/month 22 43.1 11 84.6 $1400/month or more 29 56.9 2 15.4 T o t a l 51 100.0 13 100.0 x 2 = 5.57 P < .02 Table 4.5 demonstrated the r e s u l t s of the cr.Psstabulation of s a l a r y w i t h perceived expanded r o l e . The r e l a t i o n s h i p appeared t o have s i g n i f i c a n c e but s i n c e community employees make more money, much of the v a r i a b i l i t y was taken up by the nature o f the community group. Table 4.6 C r o s s t a b u l a t i o n R e s u l t s of Independent Function i n Present Job w i t h Perceived Expanded Role Expanded Role Independence Yes No Abs. Value C o l . PCT Abs. Value C o l . PCT Without C o n s u l t i n g 21 41.2 1 7.7 Team Approach 20 39.2 3 23.1 R o u t i n e l y Consult 10 19.6 9 69.2 T o t a l 51 100.0 13 100.0 x 2 = 12.77 P < .002 The strongest r e l a t i o n s h i p which r e s u l t e d from data analyses appeared i n Table 4.6. This showed t h a t nurses who view t h e i r r o l e s as expanded e x e r c i s e much g r e a t e r independence i n terms of working autonomously, without c o n s u l t i n g a p h y s i c i a n , than nurses who do not view t h e i r r o l e s as expanded. f i g u r e 4.1 Graphic Summary of Independent Treatment D e c i s i o n Crosstabulated w i t h Expanded Role Per Cent of Independent Treatment D e c i s i o n 100 75 50 25 1 5 10 15 20 25 Number of Nurses i n Expanded Role X = 6.83 P < .08 Figure 4.1 g r a p h i c a l l y represented the percentage of time t h a t nurses alone decide on the treatment f o r t h e i r p a t i e n t s / c l i e n t s , The graph showed t h a t , i n g e n e r a l , nurses e i t h e r decide 75-100$ of the time or l e s s than 25$ of the time on p a t i e n t treatment. Data analyses showed that of those nursesvwho per c e i v e d themselves t o be i n expanded r o l e s , 22 (45%) independently planned 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 those nurses who d i d not per c e i v e t h e i r r o l e as expanded 10 (76$) decided on treatment l e s s than 25$ of the time. Table 4.7 Summary of Cumulative Independence Scores Crosstabulated w i t h Perceived Role Expansion Expanded Role Independence Yes No Abs. Value C o l . PCT Abs. Value C o l . PCT High Ind. 31 60.8 2 15.4 Low Ind. 20 39.2 11 84.6 T o t a l 51 100.0 13 100.0 x 2 = 6.82 P < .009 The data which appeared i n Table 4.7 demonstrated that n e a r l y 4 times as many nurses, who achieved high cumulative independence scores, viewed t h e i r r o l e s as expanded and more than twice as many respondents, who achieved low 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 of 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 expansion showed th a t 58.8$ of those 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 in nursing. However, when the data obtained from the two groups, separately, were examined, i t was found that much of the occurring va 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 -tional definition of staff nurse was different for hospital and community nurses and hence two totally different groups would emerge. As a result, staff nurses were much less l i k e l y to view their roles as expanded, than community employees. The trend, i n the literature, 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 va 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 during data analyses 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 those nurses 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 time performing a d m i n i s t r a t i v e t a s k s . T h i s was not c o n s i s t e n t l y the case. Many of these persons spent as much time c a r i n g f o r p a t i e n t s as the c l i n i c a l l y o r i e n t e d group. This 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 the d i f f i c u l t y i n detaching oneself from p a t i e n t s by very nature of a h o s p i t a l ward s e t t i n g . The data demonstrated by Figure 4.1 represented an unexpected r e l a t i o n s h i p . Nurses were found t o decide p a t i e n t care at the two extremes; e i t h e r 75-100$ of the time or l e s s than 25$ of the time. One could speculate 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 are not conducive t o h i g h degrees of independent f u n c t i o n i n g , h o s p i t a l nurses f a l l i n t o the l e s s than 25$ category. Conversely, community agencies 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. This 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 scores compared to h o p s i t a l nurses. Community nurses had a~ more autonomous r o l e which probably r e s u l t e d i n higher self-esteem and confidence 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 of t h i s study 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 to be inherent i n , or strong i n d i c a t o r s o f , r o l e expansion i n the hope t h a t a fundamental d e f i n i t i o n could be v e r i f i e d . From data c o l l e c t e d from '65 nurses, i t was found t h a t the s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p s t h a t occurred could be accounted f o r by the nature of the two groups. Community nurses presented d i f f e r e n t l y than h o s p i t a l nurses which could be the r e s u l t of the i n s t i t u t i o n a l h i e r a r c h y i n which h o s p i t a l employees work. Conclusions Since the sample was small (n = 64) and one of convenience, g e n e r a l i z a t i o n s were l i m i t e d to 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 general, community nurses are older-, more experienced, b e t t e r educated and f u n c t i o n more autonomously. At the beginning of t h i s study 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 only p a r t i a l l y f u l f i l l e d r e s u l t i n g from inadequacies inherent i n the q u e s t i o n n a i r e . I t was d i f f i c u l t to determine whether a l l the f u n c t i o n s of expanded r o l e nurses were e l i c i t e d . I t was found t h a t nurses i n expanded r o l e s do i n t a k e assessments, therapy ( i n d i v i d u a l , group and f a m i l y ) , marriage coun-s e l l i n g , monitor medications and p l a n treatment f o r e m o t i o n a l l y i l l p a t i e n t s . Another 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 the expanded r o l e nurse. Masters education was the exception r a t h e r than the r u l e , but i n g e n e r a l , community nurses were b e t t e r educated and hence f e l t more prepared f o r t h e i r assumed r o l e . A f u r t h e r area of i n t e r e s t was an attempt t o determine whether autonomy and independence were inherent to r o l e expansion. This would seem t o be so, although by very nature of h o s p i t a l vs. community employment, conclusions here wer7e made w i t h c a u t i o n . I t was the hope of the author t h a t nurses' 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 could 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 of present jobs. This process was s u b j e c t i v e and t h e r e f o r e not a r e a l i s t i c method of 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 , the i n v e s t i g a t i o n was not r e f i n e d adequately and t h i s o b j e c t i v e was not met. L a s t l y , i t was hoped that areas of 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 education could be recommended. I t was found t h a t many nurses were unclear as to what the term 'expanded r o l e ' means, which was expected at the onset of the study. I t was a l s o found that r o l e expansion was viewed i n terms of l o c a t i o n of employment, which need not be the case. One of the s t r i k i n g f i n d i n g s was that h o s p i t a l nurses do not seem to know whether the jobs they are performing designate an expanded r o l e or are simply 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 . This was.-shown by the v a r i a t i o n i n response, by h o s p i t a l s t a f f , t o whether they perceived t h e i r r o l e t o be expanded or not. In terms of v e r i f y i n g the fundamental d e f i n i t i o n developed at the onset of the study, the i n v e s t i g a t i o n succeeded, w i t h a minor change. Since 54 of the 64 nurses i n the study were prepared at a non masters l e v e l , need f o r masters education was not v a l i d a t e d . However, at the present time there are not enough nurses prepared at the graduate l e v e l to f i l l the p o s i t i o n s r e q u i r i n g a masters degree. Hence these p o s i t i o n s are being f i l l e d w i t h i n d i v i d u a l s prepared at a non masters l e v e l . 34 Implications An underlying premise i n expanded roles for nurses i s that these professionals are providing a better consumer and social service. In order to determine the impact that expanded role nurses are having with the consumer, there needs to be development of outcome scales designed to measure the effects of services rendered by expanded role nurses on behalf of the consumer. Further, the study indicated that there was a cognitive dissonance among hospital employees in terms of role perception and role enactment. Research designed to e l i c i t those variables that are effecting this would greatly aid i n clarifying the position of a hospital nurse functioning i n an expanded role. The present trend is toward graduate preparation for nurses performing i n expanded roles. Since only 10 nurses in this 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 level of c l i n i c a l function (both theoretical and practical) of a nurse prepared at a masters level and a nurse prepared at a non masters level, both of whom are assuming expanded roles. A replication of this study, u t i l i z i n g more refined measurement techniques, complimented by daily work logs and personal interviews, would greatly aid i n further clarifying the functions of expanded role nurses, both within and outside the f i e l d of psychiatry. The number of nurses performing i n expanded roles with graduate preparation i s very limited at this time. To help eliminate this problem, greater government funding for nurses desiring higher education would be needed. This would mean that nurses could return to university 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 of 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 nurses t o continue t h e i r .education on a part-time b a s i s . Nursing education at the graduate l e v e l should be designed toward c l i n i c a l s p e c i a l i z a t i o n w i t h emphasis placed on u t i l i z i n g and understanding r o l e theory and t h e o r i e s of change, as nurses performing i n t h i s c a p a c i t y are to be the change agents f o r the p r o f e s s i o n . A l s o , expanded r o l e • nurses must be prepared t o evaluate t h e i r c o n t r i b u t i o n t o p a t i e n t care, as w e l l as t o the p r o f e s s i o n . In terms of n u r s i n g p r a c t i c e , perhaps the most important consider-a t i o n i s q u a l i t y care. At the present time, the most q u a l i f i e d nurses are 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 too few r o l e models i n h o s p i t a l s . In order t o help 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 to a c t i v e l y i n v o l v e themselves 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 freedom f o r nurses 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 . T his could a l s o be f a c i l i t a t e d by co-operation 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 an advanced c l i n i c a l nurse-working i n a h o s p i t a l . I t i s evident, t h a t 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 to be w i l l i n g t o provide strong support t o a nurse working i n an expanded r o l e w i t h i n an i n s t i t u t i o n . The survey i n d i c a t e d t h a t nurses 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 given the f l e x i b i l i t y and autonomy inherent i n the community s e t t i n g . I f the present s t r u c t u r e of i n s t i t u t i o n s can be reorganized t o a l l o w the same f l e x i b i l i t y and autonomy, then nurses employed by i n s t i t u t i o n s , i n expanded r o l e s , could be u t i l i z e d t o t h e i r f u l l p o t e n t i a l . 36 BIBLIOGRAPHY 37 BIBLIOGRAPHY PERIODICALS Ashley,-Jo Ann. "Nursing and E a r l y Feminism."' American J o u r n a l of • Nursing, 75, No. 9 (1975), U 6 5 - H67. Awtrey, Janet Shealy. "Teaching the Expanded Role." Nursing Outlook, 22, No. 2 (1974), 98-102. ~~ B e l e t z , E l a i n e . " I s Nursing's P u b l i c Image Up t o Date." Nursing  Outlook, 22, No. 7 (1974), 432-435. Bergman, Abraham. "Physician's A s s i s t a n t s Belong i n the Nursing P r o f e s s i o n . " American J o u r n a l of Nursing, 71, No. 5 (1971), 975-977. Bowman, Rosemary A., and Rebecca C. Culpepper. "Power: Rx f o r Change." American J o u r n a l of Nursing, 74, No. 6 (1974), 1053-1056. Bullough, Bonnie. "Influences on Role Expansion." American J o u r n a l  of Nursing, 76, No. 9 (1976), 1476-1481. Bullough, Bonnie, and Vern Bullough. "A Career Ladder i n Nursing; Problems and Prospects." American J o u r n a l of Nursing, 71, No. 10 (1971), 1938-1943. C h r i s t y , Teresa E. "New P r i v i l e g e s , New Challenges, New R e s p o n s i b i l i t i e s . " - N u r s i n g 73, Nov. 1973, 8-11. De Tornyay, Rheba. "Expanding The Nurse's Role Does Not Make Her a P h y s i c i a n ' s A s s i s t a n t . " American J o u r n a l of Nursing, 71, No. 5 (1971), 974-976. D r i s c o l l , Veronica. " L i b e r a t i n g Nursing P r a c t i c e . " Nursing Outlook, 20, No. 1 (1972), 24-28. Du Gas, B e v e r l y W i t t i e r . "Nursing's Expanded Role i n Canada." Nursing C l i n i c s of North America, 9, No. 3 (1974), 523-533. E d e l s t e i n , Ruth Greenberg. "Equal Rights f o r Women: P e r s p e c t i v e s . " "American J o u r n a l of Nursing, 71, No. 2 (1971), 294-297. E l l i o t t , Jo Eleanor, Ingeborg Mauksch, and Rosamond G a b r i l l s o n . "Nurses and Nursing's Issues." American J o u r n a l of Nursing, 75, No. 10 (1975), 1848-1859. v BIBLIOGRAPHY (conf. ) PERIODICALS Fagin, C l a i r e M. "Nurses' R i g h t s . " American J o u r n a l of Nursing, 75, No. 1 (1975,-),82-85. Fagin, C l a i r e , and McClure Fagin. "Can We B r i n g Order Out of the Chaos of Nursing Education?" American J o u r n a l of Nursing, 76, No. 1 (1976),98-102. Flynn, Beverly C. "Study Documents Reactions t o Nurses i n Expanded Roles." H o s p i t a l s , 49 (1975), 81-83. Ford, L o r e t t a . "Nursing. . . E v o l u t i o n or R e v o l u t i o n ? " Canadian  Nurse, 64, No. 1 (1971), 32-37. Freeman, Ruth B. " P r a c t i c e as P r o t e s t . " American J o u r n a l of Nursing, 71, No. 5 (1971), 918-921. | Georgopoulas, B a s i l S., and Josephine 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 Behavior." American  Jo u r n a l of Nursing, 71, No. 3 (1971), 538-545. Grace, Mary Jo. "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 of Nursing, 74, No. 3 (1974), 481-483. ~" Grissum, Marlene. "How You Can Become a R i s k Taker and a Role Breaker." Nursing 76, Nov. 1976, 11-14. Hatt, Jacqueline Ross. "Updating Cherry Ames." American J o u r n a l  of Nursing, 77, No. 10 (1977), 1580-1583. Hawkins, Norman G. "Is There a School Nurse Role?" American Journal. of Nursing, 71, No 4 (1971), 744-750. Heiman, E l l i o t t M., and Mary K. Dempsey. "Independent Behavior of Nurse P r a c t i t i o n e r s : A Survey of 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 of P u b l i c Health, 66, No. 6 (1976), 587-589. Hocking, Irma L., Ruth S. Hassanein, and Sr. R.T. Bahr. "The W i l l i n g n e of P s y c h i a t r i c Nurses t o Assume the Extended Role." Nursing  Research, 25 (1976), 44-48. K e l l y , L u c i e Young. "Nursing P r a c t i c e A c t s . " American J o u r n a l o f  Nursing, 74, No. 7 (1974), 1310-1319. Lambersten, Eleanor. "Perspectives on the P h y s i c i a n ' s A s s i s t a n t . " Nursing Outlook, 20," No. 1 (1972), 32-36. 39 -BIBLIOGRAPHY (cont.) PERIODICALS Lewis, 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 . " Nursing Outlook, 22, No. 2 (1974), 65-127. Lewis, E d i t h , P., ed. "A Role By Any Name." Nursing Outlook, 22, No. 2 (1974), 89. Lewis, E d i t h , P., ed. "A Nurse I s A Nurse, Or I s She?" Nursing  Outlook, 20, No. 1 (1972), 21. Li n n , Lawrence S. "Expectation vs. R e a l i z a t i o n i n the Nurse P r a c t i t i o n e r Role." Nursing Outlook, 23, No. 3 (1975), 166-171. Maas, Meridean, Janet Specht, and Ada Jacox. "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 of Nursing, 75, No. 12 (1975), 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 . " Nursing Outlook, 22, No. 2 (1974), 90-94. Meldman, J . Monte, Bernard Newman, Donna S c h a l l e r , and Paul Peterson. " P a t i e n t s ' Responses to Nurse-Psychotherapists." ' American  Jo u r n a l of Nursing, 71, No. 6 (1971), 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 Role." Nursing Outlook, 22, No. 1 (1974), 124-127. Murphy, J u a n i t a F. "Role Expansion or Role Extension." Nursing  -Forum, 9, No. 4 (1970), 380-389. Murray, Louise B. "A Case f o r Independent Group Nursing P r a c t i c e . " Nursing Outlook, 20, No. 1 (1972), 60-63~. R a j a b a l l y , Mohamed H. "Nursing Education: Another Tower of Babel?" Canadian Nurse, 70, No. 9 (1977), 30-31. Rogers, Martha E. "Nursing: To Be or Not To Be?" Nursing Outlook. 20, No. 1 (1972), 42-46. Schien, E.H. "Role Innovator and His Education." Technology Review, 73, No. 33 (1970), 50-56. Secretary's Committee. "Extending the Scope of Nursing P r a c t i c e . " Nursing Outlook, 20, No. 1 (1972), 46-52. BIBLIOGRAPHY (conf.) - PERIODICALS S t r o z i e r , " V i r g i n i a , and David W i l l i a m s . " E v o l u t i o n of a Role: P e d i a t r i c Nurse C l i n i c i a n . " v Supervisor Nurse, Feb. 1975, 30-37. ~ " Walker, E l i z a b e t h . "Primex. . .The Family Nurse P r a c t i t i o n e r Program. Nursing Outlook, 20, No. 1 (1972), 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 of the Nurse P r a c t i t i o n e r . " Nursing Outlook, 23, No. 3 (1975), 160-165. Wright, E d i t h . "Registered Nurses' Opinions on an Extended Role Concept." Nursing Research, 25 (1976), 112-114. BIBLIOGRAPHY (cont. ) BOOKS and ESSAYS A l l e n , Moyra, ed. Nursing Papers. Montreal: M c G i l l U n i v e r s i t y Press, Summer 1974-. Boone, Margaret, 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 Issues i n Canadian Nursing, e d i t e d by Betsy La Sor and M. Ruth E l l i o t t . Ontario: P r e n t i c e H a l l of Canada, L t d . , 1977. Browing, Mary H., and Smith R. Lewis. "The Expanded Role of the Nurse." Contemporary Nursing S e r i e s . New York: The American Journa l of Nursing Company, 1973. Brown, Esther L u c i l l e . Nursing Reconsidered - A Study of Change. Toronto: J.B. L i p p i n c o t t Company, 1970. Canada — Department of N a t i o n a l Health and Welfare: Report of the  Committee of Nurse P r a c t i t i o n e r s . Ottawa, 1972. Canada — Department of N a t i o n a l H ealth and Welfare: Progress Report  P r e p a r a t i o n of Nurses f o r an Expanded Role i n Canadian H e a l t h  Se r v i c e s ^ Ottawa, 1975. Lamothe, Rachel. "The Expanding Role of the Nurse." Canadian  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 Health Care. Hereford: Adams and Sons, L t d . , 1976. Modern Languages A s s o c i a t i o n of America. The MLA S t y l e Sheet. 2nd ed. 1970. S a r b i n , Theodore. "Role Theory." Handbook of S o c i a l Psychology. Massachusetts: 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 completion f o r a Masters Degree i n Nursing, I am doing a research study concerned w i t h comparing the perceived r o l e , f u n c t i o n and purpose of the nurse performing i n an expanded r o l e as described i n the l i t e r a t u r e , and t h e i r a c t u a l p r a c t i c e . Should you p a r t i c i p a t e i n t h i s study, i t would r e q u i r e about 15 minutes of your time on one occasion only. 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. You have the r i g h t to withdraw from the study at any time. Please check one of the options below and place your signature i n the 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 not want t o p a r t i c i p a t e Subject Signature Researcher; Sharon MacDonald MSN I I APPENDIX B - I n s t r u c t i o n ——— Please Read C a r e f u l l y : r-On the pages t o f o l l o w i s a questionnaire concerning the expanded r o l e of the nurse. Many of the items 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 not apply t o your p a r t i c u l a r j ob. I n answering these items please imagine y o u r s e l f i n the p o s i t i o n described and respond the way you probably would a c t . Each item has been designed to 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 . Because the items are short, you may f e e l - y o u want t o know more about the s i t u a t i o n described; however, please respond the way you would act i n r e l a t i o n to your present j o b . There are no r i g h t or wrong answers! The qu e s t i o n n a i r e i s designed t o determine what i s happening i n your j o b s , and not i n an i d e a l s i t u a t i o n . I t i s not necessary t o put your name on the qu 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 order to i d e n t i f y your place of work. Only aggregate data w i l l be used i n t h i s study. I would l i k e t o thank you f o r your time and co-operation. Sharon A. MacDonald -Part Gnerr-1. What job d e s c r i p t i o n do you c u r r e n t l y have? ( I f more than one a p p l i e s , please i n d i c a t e the per cent of time devoted to each.) 1. s t a f f nurse 2. c l i n i c a l s p e c i a l i s t 3. c l i n i c a l t h e r a p i s t 4. c l i n i c a l c onsultant 5. c l i n i c a l i n s t r u c t o r 6. o t h e r / s p e c i f y " ...... 2. ( a ) What i s your highest e d u c a t i o n a l preparation? (Please c i r c l e one) ^ 1. diploma 2. degree 3. masters 4. o t h e r / s p e c i f y ' s (b) Have you attended any s p e c i a l t y t r a i n i n g courses? 1. Yes (please s p e c i f y ) 2. No 3. How o l d are you? years 4. How long have you worked as a nurse? years months 5. How long have you worked i n p s y c h i a t r y ? - years months 6, How long have you worked at your present job? x x years ' - months 7. What i s your current monthly s a l a r y ? 8. Please rank order the f o l l o w i n g i n accordance t o how you see y o u r s e l f working i n your present job. ( i . e . #1 would be most important, #2 next e t c . ) a. an educator " v v v b. a co^-ordinator v c. a consultant ' vvv^> d. a c l i n i c a l l i a i s o n ' e. an a d m i n i s t r a t o r v' ' ' f. a t h e r a p i s t '^ s v . g. o t h e r / s p e c i f y ' v Part-'Two: -This s e c t i o n of seven questions presents you 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 which you are asked t o i n d i c a t e your most appropriate a c t i o n . Please c i r c l e 'your most appropriate response f o r each s i t u a t i o n . 9. A new p a t i e n t i s admitted t o h o s p i t a l . A f t e r admission you f i n d her t e a r f u l and s i t t i n g alone i n her room. You are most l i k e l y to 1. c a l l her doctor 2. spend some time t a l k i n g t o her 3. give her a l i t t l e more time t o adjust 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 year o l d man, i s being r e f e r r e d f o r p s y c h i a t r i c assessment. He i s described as being h o s t i l e and p h y s i c a l l y abusive. You are 'mast'-lively t o 1. perform the assessment y o u r s e l f , 2. perform the assessment but have someone e l s e present, 3. have a more appropriate person assess John. 11. You are seeing a depressed woman who you f e e l i s a high s u i c i d e r i s k although outward s u i c i d a l i d e a t i o n i s not present. You f i r m l y b e l i e v e t h a t t h i s woman should be h o s p i t a l i z e d , but the p s y c h i a t r i s t on the team does not agree w i t h you. You are most  l i k e l y t o 1. i n s i s t the woman be h o s p i t a l i z e d . 2. abide by the p s y c h i a t r i s t ' s judgement, 3. o t h e r / s p e c i f y " 12, You have seen a p a t i e n t at the request of the f a m i l y doctor and have made recommendations f o r treatment. L a t e r you dis c o v e r t h a t the f a m i l y doctor has ignored your recommendations and asked a 'colleague of yours t o see the p a t i e n t . The colleague i s a p s y c h i a t r i s t . You are most l i k e l y t o 1. t r y t o f o r g e t about the i n c i d e n t . 2. request a meeting w i t h the f a m i l y doctor and discuss the i n c i d e n t w i t h him. 3. d i s c u s s the 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. o t h e r / s p e c i f y 48 13. You have assessed a teenager who i s depressed as a r e s u l t of pregnancy, Her parents have t o l d her t o get out of the home. You recommend ou t p a t i e n t treatment f o r her as w e l l as c o u n s e l l i n g f o r the f a m i l y . S e v e r a l days l a t e r you are n o t i f i e d that t h i s p a t i e n t i s admitted to h o s p i t a l w i t h a s u i c i d e attempt. You are 'mosfr-Iikely t o 1, d i r e c t the case t o your s u p e r v i s o r . 2, i n i t i a t e a review of your previous assessment. 3, do nothing, as you probably couldn't have prevented the 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 of s e x u a l l y deviant behaviour. As they are t a l k i n g , you n o t i c e t h a t the 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 the a c t i o n s and conversation of t h i s p a t i e n t . You are most l i k e l y t o 1. intervene and support the j u n i o r s t a f f member. 2. discu s s the f e e l i n g s and r e a c t i o n s of the j u n i o r s t a f f member at a l a t e r time. 3. ask the p a t i e n t i f you could j o i n them, and then d i r e c t the conversation i n a d i f f e r e n t d i r e c t i o n . 15. S t a f f members on an i n p a t i e n t u n i t are angry and upset by the behaviour of a d i s r u p t i v e a t t e n t i o n - s e e k i n g p a t i e n t . You are asked to help them cope w i t h the s i t u a t i o n . You are most l i k e l y t o 1, assess the 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 , explore t h e i r f e e l i n g s about the p a t i e n t and help them de a l w i t h them. 3, meet w i t h s t a f f and explore the circumstances surrounding the p a t i e n t ' s behaviour. 4. suggest how s t a f f could t r y to work the problem out themselves. P a r t - T h r e e ; ^ The f o l l o w i n g 9 questions deal w i t h s p e c i f i c d e t a i l s of your every day work, Please c i r c l e the most a p p l i c a b l e response. 1. In your present job you u s u a l l y 1. a c t independently without c o n s u l t i n g a p h y s i c i a n , 2. r o u t i n e l y consult a p h y s i c i a n . 3. Both 1 & 2 2, In your 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 f i r s t Cother than the 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 c i f y ' 3. How many p a t i e n t s d i d you see l a s t w e e k ? ^ v v 4. Of the p a t i e n t s you saw l a s t week, i n how many of the cases d i d you alone decide what treatment should be? 1. 75 T 100$ of cases 2. 50 - 74$ of cases 3. 25 - 49$ of cases 4. l e s s than 25$ of cases 50 5, Compared t o other f u l l t i m e members of the h e a l t h care team, your p a t i e n t l o a d i s 1, about the same, 2, comparatively higher, 3. comparatively lower. 4. o t h e r / s p e c i f y ' ' 6. Rank order the f o l l o w i n g ( l , 2, 3, etc',) according t o what, ^v x ' on the average, you spend your time doing during 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 v' ' ' 2. charts and/or paperwork"'' ' v x v 3. a d m i n i s t r a t i v e d u t i e s ' 4. teaching and/or s u p e r v i s i o n ' 5. consultant " vx -' 6, o t h e r / s p e c i f y " ' ' With s p e c i f i c reference to your d a i l y p r a c t i c e , d e fine your present job? Do you consider y o u r s e l f t o be working i n an expanded role'-'? 1. yes 2 . no Do you f e e l that your academic and c l i n i c a l t r a i n i n g has prepared you to assume the r o l e you are p r e s e n t l y working i n ? I f so, how? I f not, why not? • Place any f u r t h e r comments, here, APPENDIX C C a l c u l a t i o n of Cumulative Judgement/Decision Scores The data obtained from Part I I of the questionnaire were converted t o numerical values on the b a s i s of the f o l l o w i n g c r i t e r i a : 1. the response must have r e f l e c t e d s y n t h e s i s of the a v a i l a b l e data 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. the response must have been i n d i c a t i v e of a c c e p t i n g respon-s i b i l i t y f o r ones' own a c t i o n s ; and 3. the 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 three of the c r i t e r i a was awarded +1; compliance w i t h 2 of the 3 c r i t e r i a r e s u l t e d i n +2; and one ( o r none) of the c r i t e r i a r e s u l t e d i n awarding +3. When each item was scored, the t o t a l achieved on the 6 items was taken r e s u l t i n g i n a cumulative judgement/decision score. The scores ranged from +6 i n d i c a t i n g h i g h q u a l i t y judgement/decision through t o +16 r e f l e c t i n g low q u a l i t y judgement/decision a c t i v i t y . The example t o f o l l o w demonstrates the procedure. 10. John, a 25 year o l d man, i s being r e f e r r e d f o r p s y c h i a t r i c assessment. He i s described as being h o s t i l e and p h y s i c a l l y abusive. You are most l i k e l y t o +1 1. perform the assessment but have someone e l s e present. 2, perform the assessment y o u t s e l f . v 3. have a more appropriate person assess John. 55 11. You are seeing a depressed woman whom you f e e l i s a high s u i c i d e r i s k although outward s u i c i d a l i d e a t i o n i s not present. You f i r m l y b e l i e v e that t h i s woman should be h o s p i t a l i z e d , but the p s y c h i a t r i s t on the team does not agree w i t h you. You are most l i k e l y t o 1. i n s i s t the woman be h o s p i t a l i z e d . +2 2. abide by the p s y c h i a t r i s t ' s judgement. 3. o t h e r / s p e c i f y _ 12. You have seen a p a t i e n t at the request of the f a m i l y doctor and have made recommendations f o r treatment. L a t e r you discover t h a t . the f a m i l y doctor has ignored your recommendations and asked a colleague of yours t o see the p a t i e n t . The colleague i s a p s y c h i a t r i s t . You are most l i k e l y to 1. request a meeting w i t h the f a m i l y doctor and discuss the i n d i c e n t w i t h him. 2. d i s c u s s the 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- 3. t r y t o for g e t about the i n c i d e n t . 13. You have assessed a teenager who i s depressed as a r e s u l t of pregnancy. Her parents have t o l d her t o get out of the home. You recommend o u t p a t i e n t treatment f o r her as w e l l as c o u n s e l l i n g f o r the f a m i l y . S e v e r a l days l a t e r you are 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 are most l i k e l y to 1. i n i t i a t e a review o f your previous assessment. +2 2. d i r e c t the case t o your s u p e r v i s o r . 3. do nothing, as you probably couldn't have prevented the in c i d e n t anyway. 56 14. A junior staff member i s talking to a young man who i s i n hospital because of sexually deviant behaviour. As they are talking, you notice that the junior staff member i s getting more and more distressed by the actions and conversation of this patient. You are most l i k e l y to 1. discuss the feelings and reactions of the junior staff member at a later time. +2 2. ask the patient i f you could join them, and then direct the conversation i n a different direction. 3. intervene and support the junior staff member. Staff members on an inpatient unit are angry and upset by the behaviour of a disruptive attention-seeking patient. You are asked to help them cope with the situation. You are most l i k e l y to 1. meet with staff, explore their feelings about the patient and help them deal with them. 1. meet with staff and explore the circumstances surrounding the patient's behaviour. 2. assess the patient yourself and make specific recommendations. 3. suggest how staff could try to work the problem out themselves. Total Judgement/Decision Score = +12 APPENDIX D C a l c u l a t i o n of Cumulative Independence Scores Data obtained from Part I I I (questions 1, 2 and 4) were converted t o numerical values on the b a s i s of the f o l l o w i n g c r i t e r i a ; 1. a response r e f l e c t i n g the most autonomous c l i n i c a l f u n c t i o n was assigned +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 of f u n c t i o n i n g achieved a +3 ( o r +4 depending on the number of a v a i l a b l e o p t i o n s ) . A f t e r each item was scored, a cumulative independence score was obtained by t o t a l l i n g the values assigned to the i n d i v i d u a l items. These scores ranged from +3 r e f l e c t i n g a h i g h l e v e l of independent f u n c t i o n i n g through t o +10 i n d i c a t i n g a low l e v e l of independent f u n c t i o n i n g . The example t h a t f o l l o w s demonstrates the procedure w i t h responses i n ascending order beginning at the independent end of the continuum (response #1 i s the most i n d i c a t i v e of independent f u n c t i o n ) . 1. In your present job you u s u a l l y +1 1", act independently without c o n s u l t i n g a p h y s i c i a n . 2. act independently but consult the p h y s i c i a n at own d i s c r e t i o n . 3, r o u t i n e l y c o nsult a p h y s i c i a n . 2, I n your 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 f i r s t pother than the r e c e p t i o n i s t ) ? 1. you alone. +2 2. y o u r s e l f and p s y c h i a t r i s t . 3. the p s y c h i a t r i s t . 58 4. Of the patients you saw last week, in how many of the cases did you alone decide what treatment should be? 1. 75 - 100$ of cases 2. 50 - 74$ of cases +3 3. 25 - 49$ of cases 4. less than 25$ of cases Total Independence Score = +6 I APPENDIX E Development of C l i n i c a l / A d m i n i s t r a t i v e Categories There were 3 items on the questionnaire designed to determine the p r a c t i c e o r i e n t a t i o n of the respondent. These were: Part 1 Question 8 Part 3 Question 6 Part 3 Question 7 Part 1 Question 8 Please rank order the f o l l o w i n g i n accordance to how you see y o u r s e l f working i n your present job. a. educator b. co-ordinator v  c. consultant ' d. c l i n i c a l l i a i s o n ' e. a d m i n i s t r a t o r v-v f . t h e r a p i s t N' v To o b t a i n respondents o r i e n t a t i o n , these c a t e g o r i e s were c o l l a p s e d i n the f o l l o w i n g way: 1) a respondent w i t h 2 of a, c, or f i n t h e i r f i r s t 2 rank orders was c l a s s i f i e d as pure c l i n i c a l ; 2) a l l other combinations 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 . -Although there were some mixed respondents ( i . e . a, e i n f i r s t 2 ranks) these were not 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 order the f o l l o w i n g according t o what, on the average, you spend your time doing during 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. a d m i n i s t r a t i v e d u t i e s 4. teaching and/or s u p e r v i s i o n 5. consultant 6. o t h e r / s p e c i f y To o b t a i n respondents o r i e n t a t i o n on t h i s item, he/she must have had 2 of responses 1, 2 or 4 i n t h e i r top 2 rank orders f o r pure c l i n i c a l . A l l other combinations were considered a d m i n i s t r a t i v e . Part 3 Question 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 fine your present job? This item 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 obtained i n Part 1, Question 8 and Part 3 Question 6. i . e . 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 question 8 and a l s o on question 6, t h e i r d e f i n i t i o n of t h e i r job should comply w i t h t h i s . For"the most p a r t , t h i s was so. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0094258/manifest

Comment

Related Items