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UBC Theses and Dissertations

Attitudes of registered nurses towards consumer rights and nursing independence Green, Florence Grace 1978

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ATTITUDES OF REGISTERED NURSES TOWARDS CONSUMER RIGHTS AND NURSING INDEPENDENCE by F l o r e n c e Grace Green B.Sc.N., U n i v e r s i t y o f Saskatchewan, 1975 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF --SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES THE SCHOOL OF NURSING t We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA APRIL, 19 7 8 (5) F l o r e n c e Grace Green In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t ten pe rm i ss i on . Department o f _jfUj^lc*- ^ < The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e Vancouver, Canada V6T 1WS R O 7 A _ A A « e-ABSTRACT T h i s study i n v e s t i g a t e d the p o s s i b i l i t y t h a t r e g i s t e r e d n urses, working d i r e c t l y w i t h the p a t i e n t , may h o l d a t t i t u d e s towards consumer r i g h t s and n u r s i n g independence which are d i f f e r e n t from those i n the l i t e r a t u r e and those o f nurse l e a d e r s and a c t i v i s t s which are r e f l e c t e d i n the r e s o l u t i o n s on consumer r i g h t s passed a t the Annual Meeting o f the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia i n 1976. The Pankratz and Pankratz (1974) A t t i t u d e S c a l e , con-s i s t i n g of 47 statements, d i v i d e d i n t o three c l u s t e r s : 1) Nursing Autonomy and Advocacy; 2) P a t i e n t R i g h t s ; and 3) R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s wasaadministered by m a i l to a random sample o f r e g i s t e r e d nurses who were members of one of the D i s t r i c t s of the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia, Canada. The sample was s t r a t i f i e d by e d u c a t i o n a l l e v e l and 99.1 percent of 425 s u b j e c t s were con t a c t e d by telephone p r i o r to the d e l i v e r y of the q u e s t i o n n a i r e . A t o t a l of 392 q u e s t i o n n a i r e s (92.23 per c e n t of the complete sample) ->was: r e t u r n e d . A n a l y s i s of v a r i a n c e techniques were used t o t e s t the d i f f e r e n c e between the means when the three c l u s t e r s i n the A t t i t u d e S c a l e (Pankratz and Pankratz 1974) were analyzed by the s i x i n -dependent v a r i a b l e s — a d m i n i s t r a t i v e p o s i t i o n , working hours, experience, w o r k i s e t t i n g , age and e d u c a t i o n . R e s u l t s i n d i c a t e d t h a t nurses i n a d m i n i s t r a t i v e p o s i t i o n s , those w i t h advanced e d u c a t i o n and those who work i n e d u c a t i o n a l or community h e a l t h s e t t i n g s , are more l i k e l y t o score h i g h l y on the Pankratz and Pankratz (1974) A t t i t u d e S c a l e , than are nurses who have not completed a u n i v e r s i t y degree and who work i n a h o s p i t a l s e t t i n g as s t a f f nurses. The a t t i t u d e s expressed suggest t h a t nurses are motivated to accept the p a t i e n t as a p a r t i c i p a t i n g member of the h e a l t h care team but they need support t o assume the r i s k s a s s o c i a t e d with a sel f - i m a g e i n c o r p o r a t i n g p r o f e s s i o n a l autonomy and interdependence. C o n c l u s i o n s reached were t h a t the mean of the t o t a l sample, on a l l three c l u s t e r s , was s u f f i c i e n t l y h i g h t o encourage nurse l e a d e r s t o p r o v i d e a s s e r t i v e l e a d e r s h i p on the i s s u e s of consumer r i g h t s i n h e a l t h c a r e , informed access t o i n f o r m a t i o n by the consumer and n u r s i n g autonomy. Such l e a d e r s h i p would develop r o l e models of consumer advocacy w i t h which s t a f f nurses c o u l d i d e n t i f y . I t i s suggested t h a t by i n c r e a s i n g , wherever p r a c t i c a l , the p a t i e n t ' s p a r t i c i p a t i o n i n d e c i s i o n making and i n h i s own c a r e , a more p r o f e s s i o n a l and more consumer o r i e n t e d s t a f f nurse r o l e c o u l d e v o l v e . TABLE OF CONTENTS Page A b s t r a c t i Table of Contents i i i L i s t of Tables y L i s t of F i g u r e s v i i i Acknowledgement i x CHAPTER I INTRODUCTION 1 Statement o f the Problem . . 4 Purpose o f the Study 7 CHAPTER I I REVIEW OF THE LITERATURE 9 Planned Change: A T h e o r e t i c a l Framework 9 Consumer Rights 23 Access t o Information by Consumers . 41 Nursing Independence as a F a c t o r i n Interdependent P r o f e s s i o n a l A c t i o n . . . . . . 58 The Leadership Role o f the P r o f e s s i o n a l A s s o c i a t i o n . . . . . . . . . 70 CHAPTER I I I METHODOLOGY 81 Method of Data A n a l y s i s ~^ 82 Data C o l l e c t i o n 83 Response Rate . 84 D e f i n i t i o n of Terms 86 Assumptions 8 8 L i m i t a t i o n s 88 i i i CHAPTER IV PRESENTATION AND ANALYSIS OF THE DATA . 90 E d u c a t i o n a l L e v e l o f Respondents . 9 0 Demographic Data 91 Data A n a l y s i s C l u s t e r #1 "Nursing Autonomy and Advocacy". . 97 C l u s t e r #2 " P a t i e n t s R i g h t s " 110 C l u s t e r #3 " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " 119 Summary . . . . . . 129 CHAPTER V CONCLUSIONS 133 Suggestions f o r F u r t h e r Research 140 LIST OF REFERENCES 142 APPENDIX A - Consumer Rights i n Hea l t h Care . . . . . 160 APPENDIX B - Pankratz and Pankratz (1974) A t t i t u d e S c a l e 161 APPENDIX C - S c o r i n g f o r Pankratz and Pankratz (1974) A t t i t u d e S c a l e 165 i v L i s t of Tables 1 Response Rate i n Percentages A c c o r d i n g t o Highest E d u c a t i o n a l L e v e l A t t a i n e d 85 2 Respondents A c c o r d i n g t o E d u c a t i o n a l L e v e l 90 3 C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by " A d m i n i s t r a t i v e P o s i t i o n " , Arranged from Highest Mean to Lowest Mean 9 8 4 A n a l y s i s of V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by " A d m i n i s t r a t i v e P o s i t i o n " 99 5 C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Hours of Work", Arranged from Highest Mean to Lowest Mean 10 0 6 A n a l y s i s o f V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Hours of Work" . . . .10 0 7 C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Experience" Arranged from Highest Mean to Lowest Mean . . . . . . 103 8 A n a l y s i s of V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Experience" 10 3 9 C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by " S e t t i n g " , Arranged from Highest Mean to Lowest Mean . ; 10 5 0 A n a l y s i s o f V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by " S e t t i n g " . . 106 1 C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Age", Arranged from Highest Mean to Lowest Mean . 107 2 A n a l y s i s of V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Age" 10 8 3 C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Education" Arranged from Highest Mean to Lowest Mean 109 v 14 A n a l y s i s of V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" Analyzed by "Education" 110 15 C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by " A d m i n i s t r a t i v e P o s i t i o n " Arranged from Highest Mean to Lowest Mean I l l 16 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by " A d m i n i s t r a t i v e P o s i t i o n " 112 17 C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Hours of Work" Arranged from Highest Mean to Lowest Mean - . 113 18 A n a l y s i s of V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Hours of Work" 114 19 C l u s t e r #2 " P a t i e n t s R i g h t s " Analyzed by "Experience" Arranged from Highest Mean t o Lowest Mean 114 20 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Experience" 115 21 C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by " S e t t i n g " Arranged from Highest Mean to Lowest Mean 116 22 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by " S e t t i n g " 116 23 C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Age" Arranged from Highest Mean to Lowest Mean 117 24 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Age" . 117 25 C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Education" Arranged from Highest Mean to Lowest Mean 118 26 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " Analyzed by "Education" 119 27 C l u s t e r #3 " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by " A d m i n i s t r a t i v e P o s i t i o n " Arranged from Highest Mean to Lowest Mean 120 28 A n a l y s i s o f V a r i a n c e : C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by " A d m i n i s t r a t i v e P o s i t i o n " . . . 121 29 C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Hours o f Work" Arranged from Highest Mean to Lowest Mean 121 v i 30 A n a l y s i s of Variance: C l u s t e r #3 "Re j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Hours of Work" 122 31 C l u s t e r #3 "Re j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Experience" Arranged from Highest Mean to Lowest Mean 12 3 32 A n a l y s i s of Variance: C l u s t e r #3 "R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Experience" 124 33 C l u s t e r #3 "Rejection of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by " S e t t i n g " Arranged from Highest Mean to Lowest Mean 125 34 A n a l y s i s of Variance: C l u s t e r #3 "Re j e c t i o n of N T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by " S e t t i n g " . 125 35 C l u s t e r #3 "Re j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Age" Arranged from Highest Mean to Lowest Mean 126 36 A n a l y s i s of Variance: C l u s t e r #3 "Re j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Age" . . 127 37 C l u s t e r #3 "Re j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Education" Arranged from Highest Mean to Lowest Mean 12 8 38 A n a l y s i s of Variance: C l u s t e r #3 "R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " Analyzed by "Education" 129 39 Scores f o r T o t a l Sample (N = 389) on Each C l u s t e r . . . 132 40 Scores Obtained by Pankratz and Pankratz. (1974) on the Three C l u s t e r s f o r T o t a l Sample w i t h N = 702 . . 132 v i i L i s t of F i g u r e s 1 Frequencies by A d m i n i s t r a t i v e P o s i t i o n N = 389 . . . . 91 2 Frequencies by Hours of Work N = 389 92 3 Frequencies by Years of Experience N = 3 8 9 93 4 Frequencies by Work S e t t i n g 9 4 5 Frequencies by Age of Su b j e c t s N = 389 . . . . . . . . 95 6 Frequencies by Highest E d u c a t i o n a l L e v e l Completed N = 389 96 v i i i ACKNOWLEDGEMENTS I acknowledge the guidance g i v e n t o me i n the w r i t i n g of t h i s t h e s i s by my Committee - Dr. Beverlee Cox and Ms. Pat V a l e n t i n e . S p e c i a l thanks are extended to Ms. S h e i l a T a l l e y f o r her p a t i e n c e and s k i l l i n t y p i n g the t e x t and to those nurses who responded so generously t o my requests f o r t h e i r p a r t i c i p a t i o n i n the p r o j e c t . ix . . . P o s i t i v e h e a l t h i s not something one human being can gi v e t o , or r e q u i r e o f , another. In l a r g e p a r t , i t s attainment must i n c l u d e s e l f - d i r e c t e d , i n t e l l i g e n t , c o n t i n u i n g , p e r s o n a l e f f o r t . Absent t h a t e f f o r t , the h e a l t h s e r v i c e s can onl y i n s u l a t e the i n d i v i d u a l from the more c a t a s t r o p h i c r e s u l t s o f h i s ignorance, s e l f - i n d u l g e n c e , or l a c k of m o t i v a t i o n . P r o v i d e r s of h e a l t h s e r v i c e s must l e a r n i n c r e a s i n g l y t o work w i t h p a t i e n t s r a t h e r than to do t h i n g s to or f o r them. ' J . Douglas Colman H i l l e b o e Memorial L e c t u r e (197.0) x 1 CHAPTER I INTRODUCTION The consumer's i n f l u e n c e on the h e a l t h care system i s i n c r e a s i n g , n e c e s s i t a t i n g a re-examination o f the va l u e s and a t t i t u d e s u n d e r l y i n g the p l a n n i n g o f h e a l t h c a r e systems f o r the f u t u r e . The e x p r e s s i o n o f a t t i t u d e s which accept the p a t i e n t ' s r i g h t to assume more r e s p o n s i b i l i t y f o r the d e c i s i o n s made about h i s own h e a l t h c a r e , p l a c e s emphasis on a need f o r long range p l a n n i n g i n which the i n f l u e n c e o f the consumer has at l e a s t equal p r i o r i t y w i t h t h a t e x e r c i s e d by h e a l t h c a r e workers. In the past , the h e a l t h care system: . . . s e t the boundaries o f i t s s e r v i c e s w i t h i n the d o c t o r ' s o f f i c e o r the h o s p i t a l w a l l s r a t h e r than w i t h i n the best "reach" o f the p a t i e n t . I t d i d not o r i e n t i t s e l f to serve the p a t i e n t where the p a t i e n t w a s — s y m p t o m a t i c a l l y , eco n o m i c a l l y , p s y c h o l o g i c a l l y , or g e o g r a p h i c a l l y (Brown, 1974:5). Dorothy Jean N o v e l l o , P r e s i d e n t o f the N a t i o n a l League f o r Nursing, i n an e d i t o r i a l p u b l i s h e d i n Nursing Outlook, s p e c i f i c a l l y r e c o g n i z e s t h a t n u r s i n g does " . . . a very poor job o f long range p l a n n i n g f o r the p r o f e s s i o n . " (Novello, 1977:243). The main t h r u s t o f her argument i s t h a t , too o f t e n , the p l a n n i n g t h a t i s done i s s t r u c t u r e d around what i s 'good' f o r n u r s i n g and not what i s 'good' f o r the consumer. Pa r t of t h i s syndrome has been an attempt by n u r s i n g , i n common w i t h other s e c t i o n s o f the h e a l t h care b u r e a u c r a c i e s , 2 to d e f i n e the p a t i e n t as a p a s s i v e r e c i p i e n t of t h e i r care and a t t e n t i o n , i n o r d e r to process him more e f f i c i e n t l y through the system (Goffman, 1961; T a y l o r , 1962; F r e i d s o n , 1967; S t r a u s , 1972; Lorber, 1975). The p a s s i v i t y of the p a t i e n t r o l e has been f u r t h e r supported by the concept of the p r o f e s s i o n a l r e l a t i o n s h i p between the r e c i p i e n t of care and the c a r e - g i v e r , as one i n which: . . . the p r o f e s s i o n a l d i c t a t e s what i s good or e v i l f o r the c l i e n t , who has no c h o i c e but to accede to p r o f e s s i o n a l judgement (Greenwood, 1962:206). Times are changing. Mechanic has suggested t h a t h e a l t h care o r g a n i z a t i o n s of the f u t u r e , i n a d d i t i o n to s t r i v i n g f o r a b e t t e r understanding of the b i o l o g i c a l and p s y c h o l o g i c a l needs t h a t underscore the behavior of the s i c k person, must pay a t t e n t i o n t o : . . . the m o t i v a t i o n s and p e r s p e c t i v e s of both p a t i e n t s and h e a l t h care personnel and the c u l t u r a l and p e r s o n a l i n c e n t i v e s t h a t a f f e c t t h e i r behavior (Mechanic, 1975:3). T h i s approach emphasizes the a c t i v e , i n t e r a c t i v e and r e a c t i v e nature o f the human components of the o r g a n i z a t i o n a l system. Malone (1964:48), L e f t o n and Rosengren (1966:802), Georgopoulos (1966:15) and Straus (1972) p o i n t out t h a t the c u l t of e f f i c i e n c y , through c o n t r o l and r e g i m e n t a t i o n , which i s the core of Weber's (1947) i d e a l bureaucracy leads to a d e p e r s o n a l i z i n g process f o r both the s t a f f and the c l i e n t when a p p l i e d , u n a d u l t e r a t e d , t o o r g a n i z a t i o n s t h a t c a t e r to the p h y s i c a l and p s y c h o l o g i c a l needs of i n d i v i d u a l s . 3 . . . People do not n e c e s s a r i l y t h i n k and a c t r a t i o n a l l y ; they t h i n k , a c t and perform i n terms of t h e i r own needs, g o a l s , and motives, whether these be r a t i o n a l o r i r r a t i o n a l , c o nscious or unconscious, and o r g a n i z a t i o n a l l y r e l e v a n t or i r r e l e v a n t (Georgopoulos, 1966:10). The s o c i a l f o r c e s which have r e s u l t e d i n the p a t i e n t e x h i b i t i n g more a s s e r t i v e n e s s i n h i s r e l a t i o n s h i p s w i t h members of the h e a l t h care p r o f e s s i o n s are a t work a l s o on i n d i v i d u a l nurses. The l i k e l i h o o d has i n c r e a s e d t h a t nurses w i l l respond to these f o r c e s by c a s t i n g a s i d e the l a s t v e s t i g e s o f t h e i r 'handmaiden' r o l e i n f a v o r o f more independent and interdependent i n t e r a c t i o n w i t h the p a t i e n t and w i t h other h e a l t h care p r o f e s s i o n a l s . Weick (1969:25) i n a d i s c u s s i o n of o r g a n i z a t i o n a l behavior, supports t h i s p o s i t i o n and t h a t taken by Rosengren and L e f t o n (1969) by arguing t h a t people c a r r y w i t h them, across o r g a n i z a t i o n a l boundaries, the a t t i t u d e s and s e n s i t i v i t i e s which determine t h e i r day-to-day behavior o u t s i d e o f o r g a n i z a t i o n s . The a t t i t u d e s of nurses towards i s s u e s surrounding consumer r i g h t s i n h e a l t h care w i l l a f f e c t t h e i r r e a c t i o n s to changes which p o r t r a y the nurse i n a more independent, expanded r o l e (Shetland, 1971; Boudreau Report, 1972; Murata, 1974; K e l l e r , 1975; Bullough, 1976; K i n l e i n , 1977) and the consumer as an a c t i v e member of the h e a l t h care team (American H o s p i t a l A s s o c i a t i o n , 1972; Consumers' A s s o c i a t i o n of Canada, 1974; L e v i n , 1972; K e l l y , 1976). H e a l t h care p l a n n i n g , which seeks to p r o v i d e maximum b e n e f i t s f o r the consumer of care and to make op t i m a l use of 4 the v a r i o u s l e v e l s of h e a l t h care workers, w i l l b e n e f i t from changes which d e f i n e the p a t i e n t as an a c t i v e p a r t i c i p a n t i n h i s own care--as f a r as i s p r a c t i c a l — o n c e he en t e r s the h e a l t h care system. A y d e l o t t e ' s comment t h a t the problems and i s s u e s of the n u r s i n g p r o f e s s i o n are i n t e r t w i n e d w i t h : . . . the growing awareness of a need f o r the p r o f e s s i o n a l to p r a c t i c e t h a t which i s r e l e v a n t to the c l i e n t , r a t h e r than t h a t which enhances t h e i r own p r o f e s s i o n a l image (Aydelotte, 1972:21). remains as a p p l i c a b l e t o the s i t u a t i o n i n the h e a l t h care system a t the end of the decade as i t was a t the beginn i n g . Statement of the Problem The s o c i a l f o r c e s behind the p u b l i c a t i o n of a P a t i e n t ' s B i l l of Rights by the American H o s p i t a l A s s o c i a t i o n i n 1972, have had a d e f i n i t e impact upon the h e a l t h c a r e system on t h i s Continent. The Consumers' A s s o c i a t i o n of Canada has p u b l i s h e d a Canadian v e r s i o n o f the American document on p a t i e n t r i g h t s which they have t i t l e d "Consumer Righ t s i n H e a l t h Care" (Canadian Consumer, M a r c h / A p r i l , 1974). The R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia, Canada, a t i t s 1976 Annual Meeting, d e c l a r e d i t s p u b l i c support o f the consumer r i g h t s o u t l i n e d by the Consumers' A s s o c i a t i o n of Canada (1974). At the same Annual Meeting, members of the R e g i s t e r e d Nurses' A s s o c i a t i o n o f B r i t i s h Columbia s t a t e d t h e i r support, i n p r i n c i p l e , of the consumer's r i g h t to have informed access to h i s own h e a l t h care r e c o r d so t h a t he i s able to p a r t i c i p a t e knowledgeably i n the d e c i s i o n s 5 made about what happens to him, once he e n t e r s the h e a l t h c a r e system (RNABC News, J u l y 1976:7). The acceptance of the document "Consumer Rights i n H e a l t h C a r e " — b y the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia (RNABC News, J u l y 1976:7) i m p l i e s t h a t r e g i s t e r e d nurses i n B r i t i s h Columbia, as represented by t h e i r p r o f e s s i o n a l a s s o c i a t i o n , b e l i e v e t h a t i t i s time f o r the consumer to adopt a more a c t i v e and independent r o l e i n h i s own h e a l t h care. The R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia has taken a p o s i t i o n which a l i g n s i t w i t h the consumer and which r e c o g n i z e s t h a t : Care t h a t i s d i c t a t e d .no- longer s u i t s today's c l i e n t e l e . The r i g h t to accept, modify or r e f u s e care i s a p a t i e n t ' s p r e r o g a t i v e , j u s t as i t i s of any other consumer (Burgess and Burns, 1973:314). P l a c i n g more emphasis on the p a t i e n t ' s p a r t i c i p a t i o n i n h i s own care, f o r c e s the h e a l t h care worker to e v a l u a t e the s t r e n g t h s of "the person seeking c a r e , along w i t h the p h y s i c a l and p s y c h o l o g i c a l weaknesses which p r e c i p i t a t e d the p a t i e n t ' s e n t r y i n t o the system i n the f i r s t p l a c e . Encouraging the p a t i e n t t o p a r t i c i p a t e — t o the f u l l e s t extent p o s s i b l e — i n the d e c i s i o n making surrounding h i s own h e a l t h c a r e , c a r r i e s w i t h i t the message: . . . Growth enhancement begins by l e t t i n g other persons know t h a t they are capable of a s s i s t i n g i n the s o l u t i o n s of t h e i r own dilemmas (Chapman and Chapman, 1975:24). The o p p o r t u n i t i e s f o r s e l f - g r o w t h i n t h i s s i t u a t i o n are not l i m i t e d to the person seeking h e l p . Nursing has been d e s c r i b e d as: 6 . . . an i n t e r s u b j e c t i v e t r a n s a c t i o n , [which] prese n t s an o c c a s i o n f o r both persons, p a t i e n t and nurse, to experience the process of making r e s p o n s i b l e , c h o i c e s . Through l i v i n g t h i s process i n n u r s i n g s i t u a t i o n s , the nurse develops her own p o t e n t i a l f o r r e s p o n s i b l e choosing (Paterson and Zderad, 1976:17). I f the p o s s i b i l i t y f o r t h i s s o r t of growth i s accepted, r e g i s t e r e d nurses who expect the consumer to be more a s s e r t i v e and independent, would themselves expect t o assume more • autonomy i n t h e i r r e l a t i o n s h i p s w i t h the consumer and w i t h other h e a l t h care workers. Kramer (1972) b e l i e v e s t h a t i f the consumer i s to be accepted as an a c t i v e l y p a r t i c i p a t i n g member of the h e a l t h care team, a t t i t u d i n a l changes must occur which w i l l l e a d to a r e s t r u c t u r i n g of r e l a t i o n s h i p s between h e a l t h care p r o f e s s i o n a l s and consumers. By p e r s o n a l l y r e a f f i r m i n g t h e i r n u r s i n g commitment to the p a t i e n t as a person capable of s e l f - d i r e c t i o n , i n d i v i d u a l nurses w i l l demonstrate some of the c h a r a c t e r i s t i c s of a p a t i e n t advocate. An advocacy model f o r the h e a l t h care system, based on humanistic, p a t i e n t c a r e : . . . s t r o n g l y i m p l i e s a c t i o n and i n t e r a c t i o n of both p a r t i e s i n goal s e t t i n g : i t c a l l s f o r d e f i n i n g i n what circumstances r e s p o n s i b i l i t y can and cannot be taken f o r another. Open communication w i t h p a t i e n t s o r t h e i r r e p r e s e n t a t i v e s concerning power and mutual e x p e c t a t i o n s i s thereby p o s s i b l e w i t h i n such a frame-work (Chapman and Chapman, 1975:61). The adoption of the advocacy r o l e d e s c r i p t i o n by nurses, w i l l n e c e s s i t a t e t h e i r r e j e c t i o n of i t s m i r r o r i m a g e — t h e t r a d i t i o n a l n u r s i n g r o l e — i n which the nurse i s l o a t h to c h a l l e n g e d i r e c t l y the p h y s i c i a n ' s omnipotence or to encourage the p a t i e n t to do so ( S t e i n , 1967). 7 C o l l e c t i v e l y , t h r o u g h i t h e i r p r o f e s s i o n a l A s s o c i a t i o n , r e g i s t e r e d nurses i n B r i t i s h Columbia have shown a w i l l i n g n e s s to accept i n p r i n c i p l e , consumer p a r t i c i p a t i o n i n matters r e l a t i n g t o h e a l t h c a r e . Whether or not i n d i v i d u a l nurses, working d a i l y w i t h the consumers of h e a l t h c a r e , accept the changed a t t i t u d e s and values h i g h l i g h t e d by the concepts behind "consumer r i g h t s , , w i l l a f f e c t n u r s i n g ' s f u t u r e i n t e r a c t i o n w i t h those i t seeks t o help. Purpose of the Study T h i s study attempts to determine i f r e g i s t e r e d nurses, working d i r e c t l y w i t h the p a t i e n t , h o l d d i f f e r e n t a t t i t u d e s towards consumer r i g h t s and nursing'independence than those expressed i n the l i t e r a t u r e and by nurse l e a d e r s and a c t i v i s t s whose work and e f f o r t s are r e f l e c t e d i n the r e s o l u t i o n s on consumers' r i g h t s presented and passed at the Annual Meeting of the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia, i n 1976. I t has been suggested t h a t , although p r o f e s s i o n a l a s s o c i a t i o n s are i d e a l l y , r e p r e s e n t a t i v e of t h e i r membership, i n a c t u a l f a c t : . . . there i s a wide divergence of aims between rank and f i l e members and t h e i r p r o f e s s i o n a l a s s o c i a t i o n s . The personnel of such a s s o c i a t i o n s may be s e l e c t e d from among the avant-garde, the f u t u r e - o r i e n t e d members of the p r o f e s s i o n . They may demand changes i n the p r o f e s s i o n ' s s t a t u s and remain i n s e n s i t i v e to those members whose s e c u r i t y systems are rooted i n the s t a t u s quo (Smith, 1962:219). The key note speaker a t the 197 6 Annual Meeting of the R e g i s t e r e d 8 Nurses' A s s o c i a t i o n of B r i t i s h Columbia, Dr. E l v i Whittaker, d i s c u s s e d the theme "The Oppressed M a j o r i t y " . She suggested: . . . t h a t n u r s e s — m a k i n g up the l a r g e s t group o f h e a l t h c a r e w o r k e r s — a r e kept from r e a l i z i n g t h e i r f u l l p o t e n t i a l as members of the h e a l t h care team (RNABC News, J u l y 1976:13). E l i z a b e t h C a h i l l (a g e n e r a l duty nurse) and a member of a f i v e member panel r e a c t i n g to Whittaker's p r e s e n t a t i o n , commented t h a t one of the ways t h a t g e n e r a l duty nurses are oppressed i s through a l a c k of r e p r e s e n t a t i o n i n the a c t i v i t i e s o f t h e i r p r o f e s s i o n a l a s s o c i a t i o n . C a h i l l s t a t e d t h a t r e p r e s e n t a t i v e s : . . . are o f t e n head nurses or s u p e r v i s o r s who don't work s h i f t s and-can at t e n d more meetings than g e n e r a l duty nurses (RNABC News, J u l y 1976:16). T h i s study asks: 1) Are the a t t i t u d e s of r e g i s t e r e d nurses i n B r i t i s h Columbia towards n u r s i n g autonomy and advocacy, and consumer r i g h t s congruent with the p r o f e s s i o n a l A s s o c i a t i o n ' s p u b l i c d e c l a r a t i o n of support f o r the Canadian Consumers' A s s o c i a t i o n statement on "Consumer Rights i n H e a l t h Care" and t h e i r support, i n p r i n c i p l e , of the p a t i e n t ' s r i g h t to have informed access t o h i s own h e a l t h c a r e r e c o r d (RNABC News, J u l y , 1976)? 2) Does a r e l a t i o n s h i p e x i s t between the p e r s o n a l charac-t e r i s t i c s and background of respondents ( a d m i n i s t r a t i v e p o s i t i o n , hours of work, years of experience, work s e t t i n g , age and education) and a t t i t u d e s expressed about n u r s i n g independence, p a t i e n t advocacy, consumer r i g h t s and r e -j e c t i o n of t r a d i t i o n a l r o l e l i m i t a t i o n s , as measured by the Pankratz and Pankratz A t t i t u d e S c a l e (1974) used i n t h i s study? 9 CHAPTER I I REVIEW OF THE LITERATURE Planned Change: A T h e o r e t i c a l Framework P l a n n i n g f o r change r e q u i r e s an understanding o f change as an i n t e g r a l p a r t o f e x i s t e n c e , r e c o g n i t i o n o f the r a p i d i t y w i t h which a need f o r change p r e s e n t s i t s e l f i n today's s o c i e t y , and an acknowledgement of the complexity o f the i n t e r a c t i o n s t h a t change i n i t i a t e s ( T o f f l e r , 1970). I t i s necessary to achieve a balance i n human p l a n n i n g which allows energy and resources t o be committed to a n t i c i p a t e d changes w h i l e , a t the same time, m a i n t a i n i n g enough leeway so t h a t " u n a n t i c i p a t e d consequences" do not s t r a i n to brea k i n g p o i n t , the human a b i l i t y t o cope (Bennis e t al., 1976:427). Nursing l e a d e r s who t u r n to the l i t e r a t u r e i n order to gaze i n t o the c r y s t a l b a l l o f the f u t u r e , must be i n f l u e n c e d by: 1) the i n c r e a s i n g emphasis on the involvement o f the p u b l i c i n the r e s p o n s i b i l i t y f o r t h e i r own h e a l t h c a r e (Somers, 1971; Lalonde, 1974; Fuchs, 1974; L i t t l e and C a r n e v a l i , 1976; E t z i o n i , 1977) 2) the growth of consumerism as a s o c i a l f o r c e (Annas, 1974 A and B; Stor c h , 1977). 3) the chan g i n g - r o l e o f women i n s o c i e t y (U.S.A. Department of Health, E d u c a t i o n and Welfare. Proceedings o f the  I n t e r n a t i o n a l Conference on Women i n Heal t h , 1975; Polk, 1976; Grissom and Sprengler, 1976)., 10 4) the mounting economic t o l l exacted by the h e a l t h c a r e system, as i t p r e s e n t l y f u n c t i o n s (Hastings, 1972; U p r i c h a r d , 1972; Lalonde, 1974) 5) the e v o l v i n g and expanding r o l e of the nurse p r a c t i t i o n e r (Mauksch, 197 5 and others) 6) the need f o r the d e l i v e r y of a p e r s o n a l i z e d and a c c e p t a b l e h e a l t h care s e r v i c e to a l l the people (Aydelotte, 1972; Howard, et a l . 1975) 7) the s h i f t away from a p r e o c c u p a t i o n w i t h i l l n e s s and a move towards the maintenance of h e a l t h (Reeder, 197 2; Lalonde, 1974) 8) the i n c r e a s i n g p r o l i f e r a t i o n of knowledge and i t s more widespread a b s o r p t i o n by the v a r i o u s l e v e l s of the p o p u l a t i o n (Mussallem, 1970:210; Pettigrew, 1973:136; U.S.A. Dept. of Health, Education and Welfare, p u b l i c a t i o n #HRA-76-14503, 1976:17; Haug, 1976:90) 9) the e s c a l a t i n g s o p h i s t i c a t i o n of medical technology (Brown, 197 0:22; The B.C. P r o f e s s i o n a l Engineer, S p e c i a l Issue: Biomedical E n g i n e e r i n g , J u l y 1976) 10) the p r e d i c t i o n t h a t there w i l l be a d i s p r o p o r t i o n a t e percentage of people, over the age of 65 y e a r s , i n the t o t a l p o p u l a t i o n by the year 2,000 as w e l l as an o v e r a l l growth of p o p u l a t i o n (Lalonde, 1974:60). The l i s t i s not exhaustive nor i s i t arranged i n the order o f importance but, i t c o n t a i n s the p o s s i b i l i t y of enough u n c e r t a i n t y i n the f u t u r e f o r the environment i n which the h e a l t h care system operates, to be c l a s s i f i e d as " t u r b u l e n t " (Emery and T r i s t , 1973). In the r a p i d l y changing world i n which we l i v e , no one can expect any change to evolve without t h a t change i t s e l f being a l t e r e d by o t h e r impinging f o r c e s i n the environment. The " t u r b u l e n t f i e l d " environment i s u n p r e d i c t a b l e because of the complex i n t e r a c t i o n s t a k i n g p l a c e w i t h i n i t , as the r e s u l t of the r a p i d r a t e of change. I t i s not p o s s i b l e to i s o l a t e the t u r b u l e n c e , as coming from t h i s or t h a t p o i n t 11 i n the environment but r a t h e r the whole ' s t u f f o f the environment i s changing, s e t t i n g up w h i r l p o o l s and c u r r e n t s , the e f f e c t s o f which are d i f f i c u l t to p r e d i c t (Emery and T r i s t , 1973:171). S u r v i v a l i n the c o n s t a n t l y changing environment may w e l l hinge upon the e v o l u t i o n of a s e t of common v a l u e s , which w i l l smooth out some of the u n c e r t a i n t i e s i n the t u r -b u l e n t f i e l d . These values become l i k e a l i f e - n e t strung above the c a u s a l t u r b u l e n c e . Provided t h a t the values are rep-r e s e n t a t i v e of oth e r o r g a n i z a t i o n s i n the f i e l d , an i n d i v i d u a l o r g a n i z a t i o n can p e r f e c t i t s a b i l i t y t o adapt, without being threatened with complete d e s t r u c t i o n , as may happen i n an unmodified t u r b u l e n t f i e l d environment (Emery and T r i s t , 1973:173). Most of the changes t h a t have taken p l a c e i n the h e a l t h care f i e l d , over the l a s t 25 yea r s , have been the r e s u l t of e x t e r n a l f o r c e s i n an u n c e r t a i n environment. . ... I f n u r s i n g i s t o maximize i t s p o t e n t i a l e f f e c t i v e n e s s , . . . , i t needs g r e a t e r knowledge than i t has had i n the past of how to p r e d i c t s o c i a l trends e a r l y , and g r e a t e r s k i l l i n p l a n n i n g i n a l l i a n c e , r a t h e r than a t v a r i a n c e , with these trends as they appear (Brown, 1970:3). Change, w i t h i n n u r s i n g , u s u a l l y gains i t s f i r s t s e a l o f approval from the acknowledged l e a d e r s o f the p r o f e s s i o n , expressed v i a pronouncements from the p r o f e s s i o n a l o r g a n i -z a t i o n s , through the medium of the p r o f e s s i o n a l l i t e r a t u r e , by the implementation of i n n o v a t i v e programs of p a t i e n t care i n e d u c a t i o n a l s e t t i n g s or i n s i t u a t i o n s which allow nurses to model a new r o l e i n pion e e r , f r o n t i e r areas. 12 Stevens p o s t u l a t e s t h a t the time l a g between the b i r t h of a new i d e a and i t s g e n e r a l acceptance i s i n t r i n s i c -a l l y t i e d up with the a t t i t u d e s , values and goals of the group a f f e c t e d by the change.(Stevens, 1975:25). Recent r e p o r t s i n the n u r s i n g l i t e r a t u r e agree with the p o s i t i o n taken by Stevens. For example, Jordan and Shipp d e s c r i b e a program a t the U n i v e r s i t y of F l o r i d a , i n which a r e g i s t e r e d nurse pro-v i d e d primary h e a l t h care f o r d i a b e t i c p a t i e n t s . They r e p o r t t h a t the p a t i e n t s and t h e i r f a m i l i e s completely accepted the nurse s p e c i a l i s t . However, nurses (with the e x c e p t i o n o f the f a c u l t y members) e x h i b i t e d r e l u c t a n c e to accept the i n n o v a t i o n . The authors b e l i e v e t h a t n u r s i n g r e a c t e d to a p e r c e i v e d t h r e a t to one of the i n s t i t u t i o n ' s g o a l s — t h e r e c r u i t m e n t of s u f -f i c i e n t s t a f f , a t a time when the supply was low. At the same time, an e x i s t i n g t h r e a t to the i n d i v i d u a l nurse's a b i l i t y to p r o v i d e q u a l i t y n u r s i n g care i n a l r e a d y w e l l d e f i n e d r o l e s , because of the shortage of s t a f f , d i d not make i t easy f o r nurses t o accept the deployment of one of t h e i r number i n t o a new and expanded r o l e (Jordan and Shipp, 1971). R a f f e r t y and Carner who i n i t i a t e d an independent, group n u r s e - c o n s u l t a n t s e r v i c e , a l s o found t h a t some nurses were c r i t i c a l of t h e i r i n n o v a t i o n — v i e w i n g i t as a c h a l l e n g e to the e s t a b l i s h e d s t a t u s quo, although o t h e r c o l l e a g u e s were e n t h u s i a s t i c about the p r o j e c t . ( R a f f e r t y and Carner, 1973:235). Andrew and Yankauer c o n f i r m these impressions. They s t a t e , t h a t : The f r e s h n e s s , the l a c k of precedents, and 13 the l a c k of d e f i n i t i o n s o f these new r o l e s , however, l e a d some nurses and p h y s i c i a n s to r e t r e a t i n t o s t e r e o t y p e d p e r c e p t i o n s of themselves and t h e i r r e s p o n s i b i l i t y f o r the p a t i e n t whenever minor problems or flaws a r i s e i n the new arrangements (Andrew and Yankauer, 1971:508). The s t e r e o t y p e d p e r c e p t i o n s , to which Andrew and Yankauer r e f e r , i n c l u d e a concept o f the p a t i e n t as a p a s s i v e r e c i p i e n t of care and the g i v e r of care as the a u t h o r i t y f i g u r e whose access to knowledge c o n f e r s upon him the r i g h t to make d e c i s i o n s about what i s 'good' f o r the p a t i e n t without n e c e s s a r i l y i n c l u d i n g the p a t i e n t i n the d e c i s i o n making process (Andrew and Yankauer, 1971). Consumer f o r c e s , i n t h i s decade, have d i r e c t e d e n e r g i e s towards e s t a b l i s h i n g a new p e r c e p t i o n of the p a t i e n t as an a c t i v e p a r t i c i p a n t i n the h e a l t h care system, based on the p h i l o s o p h y which s t a t e s : . . . What p a t i e n t s want i s as important i n f o r m u l a t i n g p o l i c y as what p h y s i c i a n s and nurses t h i n k they need (Mullane, 1975:701). The success o r f a i l u r e o f the new image of the p a t i e n t w i l l depend, to a l a r g e e x t e n t , upon how s u c c e s s f u l the consumer i s i n g a i n i n g access to knowledge and i n f o r m a t i o n , both about h i s own h e a l t h care and about the h e a l t h care system i n g e n e r a l . Knowledge as a source of power i s an u n d e r l y i n g theme i n the three s t r a t e g i e s f o r change d e s c r i b e d by Chin and Benne: 1) e m p i r i c a l - r a t i o n a l s t r a t e g i e s , i n which r a t i o n a l s e l f -i n t e r e s t i s the o p e r a t i v e element. Change i s promoted when some group or person can demonstrate to o t h e r s , t h a t the proposed a c t i o n w i l l r e s u l t i n g a i n f o r those a f f e c t e d by the change. 2) no r m a t i v e - r e - e d u c a t i v e s t r a t e g i e s where, i n order f o r change to take p l a c e , people have to change t h e i r o l d v a l u e s and adopt new ones. 14 3) power-coercive s t r a t e g i e s , which use economic and p o l i t i c a l power i n order t o achieve g o a l s , t h a t are viewed as d e s i r a b l e , by the change agents (Chin and Benne, 1976:23). Although h e a l t h c a r e p l a n n e r s are, a t pre s e n t , u s i n g a l l t h r e e of these s t r a t e g i e s i n order to produce change w i t h i n the h e a l t h care system, i t i s the e m p i r i c a l - r a t i o n a l approach which has been more p r e v a l e n t i n f a c e - t o - f a c e i n t e r -a c t i o n s between the p r o f e s s i o n a l p r o v i d e r of care and the consumer of care ( P r a t t et a l . 1957; Kane and Kane, 1969; Wilson, 1963; F r e i d s o n , 1972; Powers and Ford, 1976). The p r o f e s s i o n a l i s d e s c r i b e d by these authors as f o r m u l a t i n g a proposed course of a c t i o n f o r the p a t i e n t to f o l l o w t o ensure a g a i n i n h i s h e a l t h s t a t u s . Powers and Ford say: . . . At t h i s p o i n t , the p a t i e n t becomes a p a r t i c i p a n t - o b s e r v e r i n the a f f a i r s of h i s l i f e . . . . He [the p a t i e n t ] i s t o l d , or he i s i n s t r u c t e d , r e g a r d i n g h i s treatment. The p h y s i c i a n teaches or the nurse teaches a l l the p a t i e n t needs t o know. The c a t c h i s , t h a t a l l ~ the p a t i e n t needs to know i s determined by the p r o v i d e r (Powers and Ford, 1976:54). Chin and Benne emphasize t h a t power i s a v i t a l v a r i a b l e i n a l l three s t r a t e g i e s o f change. The d i f f e r e n c e s evolve because o f the way t h a t the power s i t u a t i o n i s handled i n change pr o c e s s e s . In the e m p i r i c a l - r a t i o n a l approach: . . . men of knowledge are l e g i t i m a t e sources of power and the d e s i r a b l e flow of i n f l u e n c e o r power i s from men who know t o men who don'' t know through processes o f educa t i o n and of d i s s e m i n a t i o n of v a l i d i n f o r m a t i o n (Chin and Benne, 1976:39). Greenwood maintains t h a t the assumption of r e s p o n s i b i l i t y f o r the c l i e n t , which p r o f e s s i o n a l a u t h o r i t y c o n f e r s upon the h e a l t h care worker, i s one of the sign s t h a t the c l i e n t i s seeking as he t r i e s t o assess whether or not the r e l a t i o n s h i p 15 w i l l meet h i s needs (Greenwood, 1962:210). The p r o f e s s i o n a l e x e r c i s e s h i s power to d e c i d e what i s " b e s t 1 , i n a p a r t i c u l a r s i t u a t i o n , with the consent of the c l i e n t i n v o l v e d . . . . Although e m p i r i c a l l y t h i s consent may be based on f e a r , ignorance, or h a b i t , i n a broader sense i t i s a consequence of the c l i e n t ' s i m p l i c i t acceptance of the p r o f e s s i o n a l ' s e x p e r t i s e and good w i l l , and the understanding t h a t i n a c c e p t i n g the a u t h o r i t y of the p r o f e s s i o n a l the c l i e n t i n t u r n w i l l be rewarded (Haug and Sussman, 1969:154). Zola (1975) and I l l i c h (1976) r e j e c t the assumption of r e s p o n s i b i l i t y f o r the p a t i e n t by the p r o f e s s i o n a l . I l l i c h a s s e r t s t h a t t h i s s t r a t e g y has r e s u l t e d i n an i n t o l e r a b l e dependency on a medical monopoly—a s i t u a t i o n t h a t he has l a b e l e d "medical i a t r o g e n e s i s " . He d r a m a t i c a l l y i s o l a t e s the unexpected medical consequences of our age and f o r c e s s o c i e t y t o contemplate the d e s t r u c t i v e s p i n - o f f s of medical technology. For I l l i c h , a s e l f - r e l i a n t p o p u l a t i o n i n matters r e l a t i n g to h e a l t h c a r e i s p o s i t i v e l y c o r r e l a t e d w i t h a h i g h l e v e l o f h e a l t h i n the g e n e r a l p o p u l a t i o n . He says: . . . M e d i c a l nemesis i s the experience of people who are l a r g e l y d e p r i v e d of any autonomous a b i l i t y to cope w i t h nature, neighbors, and dreams, and who are t e c h n i c a l l y maintained w i t h i n e n v i r o n -mental, s o c i a l , and symbolic systems ( I l l i c h , 1976:271). I f p a r t i c i p a t i v e p a t i e n t c a r e , based on the p a t i e n t ' s r i g h t " . . . to be r e s p e c t e d as the i n d i v i d u a l w i t h the major r e s p o n s i b i l i t y f o r h i s own h e a l t h c a r e . " (Consumer Rights i n Health Care, 1974) i s to become one of the goals of the h e a l t h care system of the next decade, change w i l l need to take p l a c e w i t h i n a framework s i m i l a r to the one d e s c r i b e d as n o r m a t i v e - r e - e d u c a t i v e . Chin and Benne have i d e n t i f i e d two 16 v a r i a n t s o f t h i s change s t r a t e g y . The f i r s t i s aimed a t h e l p i n g the c l i e n t to improve h i s p r o b l e m - s o l v i n g a b i l i t i e s and the second a t i n c r e a s i n g the p o s s i b i l i t y t h a t the change process w i l l r e s u l t i n the c l i e n t becoming more s e l f - r e l i a n t , more able to cope w i t h the p e r s o n a l c h a l l e n g e s t h a t c o n f r o n t him (Chin and Benne, 1976:34). The use of the n o rmative-re-educative framework f o r change r e q u i r e s a p h i l o s o p h i c a l stance which r e c o g n i z e s the consumer as an i n d i v i d u a l w i t h a s t o r e of untapped, p e r s o n a l , r e s o u r c e s a t h i s d i s p o s a l . Christman, i n an a r t i c l e d i s c u s s i n g the r o l e ambiguity t h a t the p a t i e n t faces when he en t e r s a h o s p i t a l , agrees t h a t most people, as p a t i e n t s , are s t r a n g e r s w i t h i n the h o s p i t a l system. He b e l i e v e s t h a t nurses have a duty to reduce the environmental u n c e r t a i n t y surrounding the p a t i e n t , by c l e a r l y s p e l l i n g out the e x p e c t a t i o n s i n h e r e n t i n the nurse and p a t i e n t r o l e s . T h i s i n c l u d e s an o b l i g a t i o n to i n t e r p r e t the t e c h n i c a l and p r o f e s s i o n a l jargon of the i n s t i t u t i o n , i n such a way t h a t the p a t i e n t i s able to f u n c t i o n as a p a r t i c i p a t i n g member of the h e a l t h care team (Christman, 1967:18). By e s t a b l i s h i n g f r e e and open communication w i t h the consumer, through c a r e f u l e x p l a n a t i o n of a l l the d e t a i l s which, at present, are o n l y a v a i l a b l e to the p r o f e s s i o n a l s t a f f ( i n c l u d i n g f u l l and informed access to h i s own h e a l t h care record) the p a t i e n t i s l i k e l y t o emerge from h i s p e r i o d of h o s p i t a l i z a t i o n , more knowledgeable and s e l f - s u f f i c i e n t i n matters r e l a t i n g to h i s own h e a l t h . 17 . . . The enhanced a b i l i t i e s he has a c q u i r e d to manage h i s own p e r s o n a l h e a l t h may be s u f f i c i e n t to prevent or reduce the p r o b a b i l i t y o f a r e c u r r e n c e of h i s i l l n e s s (Christman 1967:21). Support by the p r o f e s s i o n a l A s s o c i a t i o n of R e g i s t e r e d Nurses' i n B r i t i s h Columbia (1976) of f u l l and informed access by consumers to t h e i r own h e a l t h care r e c o r d i s i n accord w i t h Christman's (1967) t h e s i s and i t i s congruent w i t h the o f t repeated statement by nurses t h a t the p a t i e n t i s the c e n t e r o f t h e i r concern i n the h e a l t h care system. I t a f f i r m s the p o s i t i o n taken by Rogers (1977:12) t h a t the p a r t i c i p a t o r y r e l a t i o n s h i p , between the p r o v i d e r of care and the consumer of ca r e , i s c o n s i d e r e d to be the base upon which t h e r a p e u t i c i n t e r v e n t i o n s w i l l y i e l d o p t i m a l r e s u l t s . C h i n and Benne s t a t e , t h a t : . . . By g e t t i n g the v a l u e s of v a r i o u s p a r t s of the c l i e n t system along w i t h h i s own openly i n t o the arena o f change and by working through value c o n f l i c t s r e s p o n s i b l y , the change agent seeks t o av o i d m a n i p u l a t i o n and i n d o c t r i n a t i o n o f the c l i e n t i n the m o r a l l y r e p r e h e n s i b l e meanings of these terms (Chin and Benne, 1976:33). Focusing on improving access t o i n f o r m a t i o n by the consumer i n order to i n c r e a s e the p r o b a b i l i t y t h a t j o i n t problem s o l v i n g w i l l e v o l v e , i s an approach which f a c i l i t a t e s i n c r e a s e d p e r s o n a l growth and a c t u a l i z a t i o n i n the consumer (Christman, 1967; Chapman and Chapman, 1975; Paterson and Zderad, 1976; Rogers, 1977) as w e l l as continued s e l f - r e n e w a l and change w i t h i n the h e a l t h care p r o f e s s i o n s . Rogers s t a t e s : A person-centred approach, when u t i l i z e d to encourage the growth and development of the p s y c h o t i c , the t r o u b l e d , or the normal i n d i v i d u a l , r e v o l u t i o n i z e s the customary b e h a v i o r s o f members of the h e l p i n g p r o f e s s i o n s (Rogers, 1977:28). 18 In 1961, Dodge conducted a study u s i n g 126 r e g i s t e r e d nurses, l i c e n c e d p r a c t i c a l nurses and n u r s i n g a i d s working i n a 314 bed h o s p i t a l f o r the aged and c h r o n i c a l l y i l l , to t r y t o i s o l a t e whether or not p s y c h o l o g i c a l f a c t o r s of p e r s o n a l inadequacy, are i n v o l v e d i n a person's r e l u c t a n c e to communi-cate f r e e l y and f u l l y w i t h o t h e r s . Dodge d i d not t r y to demonstrate a c a u s a l r e l a t i o n s h i p . Her hypothesis s t a t e d t h a t , the nurse who b e l i e v e d h e r s e l f to be p s y c h o l o g i c a l l y s t r o n g , would be more w i l l i n g t o keep the p a t i e n t informed, than those nurses who p e r c e i v e d themselves to l a c k such s t r e n g t h . The data supported the h y p o t h e s i s , although the r e s u l t s are r e s t r i c t e d because o f the s p e c i f i c type o f p a t i e n t w i t h whom the nurses i n the sample were i n t e r a c t i n g . The use of n o r m a t i v e - r e - e d u c a t i v e s t r a t e g i e s i n managing change does not a v o i d the f a c t t h a t knowledge i s a source of power i n consumer/professional i n t e r a c t i o n but t h i s approach seeks to c o n f i r m t h a t the i n d i v i d u a l to be helped i s capable o f s e l f - d i r e c t i o n . The essence of the s t r a t e g y r e v o l v e s around an understanding t h a t : . . . changes i n normative o r i e n t a t i o n i n v o l v e changes i n a t t i t u d e s , , v a l u e s , s k i l l s and s i g n i f i c a n t r e l a t i o n s h i p s , not j u s t changes i n knowledge, i n f o r m a t i o n , or i n t e l l e c t u a l r a t i o n a l e s f o r a c t i o n and p r a c t i c e (Chin and Benne, 1976:23). I f the n u r s i n g p r o f e s s i o n accepts the r i g h t of the consumer to have access to what i s now t r e a t e d as c l a s s i f i e d i n f o r m a t i o n , a c c o u n t a b i l i t y by the p r o f e s s i o n a l nurse to the consumer of care, becomes more v i s i b l e . Change w i l l have to take p l a c e i n the a t t i t u d e s , v a l u e s , s k i l l s and s i g n i f i c a n t r e l a t i o n s h i p s 19 of both p a r t i e s . Change w i t h i n the e x i s t i n g h e a l t h care system i s being p r e c i p i t a t e d by i n c r e a s i n g c o s t s , as w e l l as by changing valu e s and t e c h n o l o g i c a l i n n o v a t i o n . In an age where i n -f l a t i o n i s a household word, i t comes as no s u r p r i s e to f i n d c o s t s c i t e d as one of the primary reasons f o r e x p l o r i n g d i f f e r e n t approaches to the d e l i v e r y of h e a l t h care s e r v i c e s ( B e r k i , 1973). At p r e s e n t , most of the taxpayer's d o l l a r s f o r h e a l t h care are expended on p h y s i c i a n centered, h o s p i t a l care of a l r e a d y e x i s t i n g i l l n e s s (Lalonde, 1974:12). B e r k i i n an a n a l y s i s o f the impact of the i n t r o d u c t i o n of v a r i o u s types of ' p h y s i c i a n extenders' on the economics o f the h e a l t h care system, d e s c r i b e s the p r e v a i l i n g p a t t e r n of h e a l t h c a r e , with i t s emphasis on s p e c i a l i z a t i o n and d i s e a s e p r o c e s s e s as: . . . a system of f u n c t i o n a l fragmentation i n which the host, the p a t i e n t , i s but a l o s t wanderer i n the strange and complex galaxy of medicine ( B e r k i , 1973:118). He makes the p o i n t t h a t changes i n the h e a l t h care system, r e s u l t i n g from the i n t r o d u c t i o n of new v e r s i o n s of medical manpower, w i l l have s i m i l a r r e s u l t s t o those s p e l l e d out by Emery and T r i s t as o c c u r r i n g i n a ' t u r b u l e n t f i e l d environment'. . . . The consequences . . . l e a d o f f i n ways t h a t become i n c r e a s i n g l y u n p r e d i c t a b l e : they do not n e c e s s a r i l y f a l l o f f w i t h d i s t a n c e , but may at any p o i n t be a m p l i f i e d beyond e x p e c t a t i o n s ; , s i m i l a r l y , l i n e s of a c t i o n t h a t are s t r o n g l y pursued may f i n d themselves attenuated by emergent f i e l d f o r c e s (Emery and T r i s t , 197 3:171). Given the complexity of the i n t e r a c t i o n s i n the h e a l t h 20 care system, the i n c r e a s i n g acceptance o f r e s p o n s i b i l i t y by the Canadian Government f o r the f i n a n c i n g of h e a l t h c a r e , and the s t a t e d o b j e c t i v e s o f the Canadian Government: 1) To reduce mental and p h y s i c a l h e a l t h hazards f o r those p a r t s of the Canadian p o p u l a t i o n whose r i s k s are h i g h , and 2) To improve the a c c e s s i b i l i t y of good mental and p h y s i c a l h e a l t h care f o r those whose pr e s e n t access i s u n s a t i s f a c t o r y (Lalonde, 1974:66). i t i s c l e a r t h a t power-coercive s t r a t e g i e s f o r change w i l l c o n t i n u e to have a s i g n i f i c a n t i n f l u e n c e on the f u t u r e of the h e a l t h care system i n Canada. The power-coercive s t r a t e g i e s o f change are those which b r i n g the f o r c e of economic and p o l i t i c a l p r e ssure to bear i n o r d e r to achieve changes seen as d e s i r a b l e by s t r a t e g i s t s r e s p o n s i b l e f o r the d e l i v e r y o f h e a l t h c a r e . I t i s l i k e l y t h a t a l l three s t r a t e g i e s of change w i l l c o n t i n u e to be important i n the h e a l t h care system. For i n s t a n c e , Chin and Benne emphasize t h a t : . . . normative-re-educative s t r a t e g i e s must be combined wi t h p o l i t i c a l c o e r c i o n , both b e f o r e and a f t e r the p o l i t i c a l a c t i o n , i f the p u b l i c i s t o be adequately informed and d e s i r a b l e and commonly ac c e p t a b l e changes i n p r a c t i c e are to be achieved (Chin and Benne, 1976:42). Changing s o c i a l values suggest t h a t changes w i l l occur i n the i n c i d e n c e of use, w i t h i n the h e a l t h care system, of the three s t r a t e g i e s of change. L i n n , i n a study of the c a r e -cure o r i e n t a t i o n of f a c u l t y and students a t the U n i v e r s i t y of C a l i f o r n i a Schools of Medicine and Nursing, concludes t h a t the medical p r a c t i t i o n e r s of the f u t u r e w i l l more r e a d i l y d i s p l a y i n t e r e s t and concern i n the s o c i a l and p s y c h o l o g i c a l 21 environment a f f e c t i n g the pathology e x h i b i t e d by persons who come to them f o r h e l p . T h i s study suggests t h a t the n u r s i n g and m e d i c a l p r o f e s s i o n s are moving away from a c l e a r c u t dichotomy between care and cure towards a p o s i t i v e acceptance o f both g o a l s by members of each p r o f e s s i o n (Linn, 1975). B l i s s views t h i s p r o g r e s s i o n p o s i t i v e l y because she b e l i e v e s t h a t the average consumer of care i s " . . . very much i n need of both care and cure from a s i n g l e person" ( B l i s s , 1976:13). A d i s p l a y , by young p h y s i c i a n s , of a growing i n t e r e s t i n areas o u t s i d e those covered by the e x c l u s i v e a t t e n t i o n to pathology evinced by the medical model, c o u l d have f a r r e a c h i n g e f f e c t s on the h e a l t h care system. Acc o r d i n g to Cunningham, e d i t o r - a t - l a r g e f o r the j o u r n a l Modern H e a l t h c a r e : . . . i t i s p o s s i b l e t h a t a comparatively s m a l l number of young p h y s i c i a n s i n a few c e n t e r s i n a few areas over a few years c o u l d a c q u a i n t a formidable number of p a t i e n t s w i t h what i t means to be a p a r t n e r , and not a c i p h e r , i n t h e i r own h e a l t h care (Cunningham, 1976:72). F u r t h e r c o n f i r m a t i o n t h a t s o c i a l f o r c e s are changing the h e a l t h care scene can be o b t a i n e d from the o b s e r v a t i o n s made by Haug, sugges t i n g t h a t the acceptance of the use of s p e c i a l knowledge as a source o f power by an e l i t e group i s on the wane. Data gathered from h e a l t h c a r e f a c i l i t i e s i n Great B r i t a i n and the U.S.S.R. confirmed t h a t an i n c r e a s i n g l y s o p h i s t i c a t e d c l i e n t p o p u l a t i o n i s r e j e c t i n g the assumption of p r o f e s s i o n a l a u t h o r i t y by h e a l t h care workers which excludes the c l i e n t from the d e c i s i o n making process (Haug, 1976) . Bertram Brown, the D i r e c t o r of the N a t i o n a l I n s t i t u t e 22 o f Mental Health, speaking at the 1977 World Congress on Mental H e a l t h h e l d i n Vancouver, B r i t i s h Columbia, s t a t e d t h a t the important thread which or d e r s and supports a l l our e f f o r t s i n the p r o v i s i o n o f mental h e a l t h s e r v i c e s i s t i e d up with the values and a t t i t u d e s t h a t govern our l i v e s . . . . An i n d i v i d u a l may accord primacy t o the values a s s o c i a t e d w i t h any number of p e r s o n a l or i n s t i t u t i o n a l i d e n t i t i e s i n h i s or her l i f e . U l t i m a t e l y , however, a common thread must l i n k them a l l l e s t our l i v e s as w e l l as our i n s t i t u t i o n s become c h a o t i c , our go a l s fragmented (Brown, 1977:3). Brown's approach can be e x t r a p o l a t e d to oth e r h e a l t h care s e r v i c e s . I t i s i n accord w i t h the suggestion t h a t a s e t of common va l u e s can be u t i l i z e d to r e s e r v e energy f o r d e a l i n g w i t h the u n c e r t a i n t i e s generated by change (Emery and T r i s t , 1973:173). Although the p a t i e n t , i n t e r m i t t e n t l y , i s extremely dependent upon the p h y s i c i a n ' s e x p e r t i s e and knowledge, at the same time, a p h y s i c i a n without p a t i e n t s l o s e s h i s reason f o r s e t t i n g up i n medical p r a c t i c e ( F r e i d s o n , 1972:214). P a t i e n t s are p r e c i p i t a t i n g a re-examination o f o l d value s by v o i c i n g , through the consumer r i g h t s ' movement, r e j e c t i o n o f the p a s s i v e p a t i e n t r o l e i n f a v o r of one which allows more p a r t i c i p a t i o n by the p a t i e n t i n the d e c i s i o n making processes t h a t go on once he e n t e r s the h e a l t h care system. 23 Consumer Rights The movement towards a more org a n i z e d demand by consumers f o r r e c o g n i t i o n of s p e c i f i e d r i g h t s i n h e a l t h care has not evolved i n a vacuum. I t i s a p a r t o f a general t r e n d i n s o c i e t y , which p l a c e s emphasis on the consumer's ' r i g h t to know'. During the l a s t decade, t h e r e has been a r e - d e f i n i t i o n , w i t h i n the North American l e g a l systems, of the balance of power i n many l e g a l r e l a t i o n s h i p s which were p r e v i o u s l y h e l d to be s a c r o s a n c t — s t a b i l i z e d i n f a v o r of the person h o l d i n g the p u b l i c l y acknowledged a u t h o r i t y i n the i n t e r a c t i o n (Annas and Healey, 1974A-.25). Annas has w r i t t e n a t l e n g t h on the s u b j e c t of p a t i e n t s ' r i g h t s , b a s i n g h i s argument t h a t the h o s p i t a l i s a "Human Rights Wasteland" on the: . . . two fundamental premises: (1) The American medical consumer possesses c e r t a i n i n t e r e s t s , many of which may p r o p e r l y be d e s c r i b e d as r i g h t s , t h a t are not a u t o m a t i c a l l y f o r f e i t e d by e n t e r i n g i n t o a r e l a t i o n s h i p w i t h a d o c t o r or a h e a l t h care f a c i l i t y ; and (2) Most d o c t o r s and h e a l t h care f a c i l i t i e s f a i l ^ to r e c o g n i z e the e x i s t e n c e of these i n t e r e s t s and r i g h t s , f a i l t o p r o v i d e f o r t h e i r p r o t e c t i o n or a s s e r t i o n and f r e q u e n t l y l i m i t t h e i r e x e r c i s e without recourse (Annas, 1974A:11). The t r e n d by p a t i e n t s to a s s e r t t h e i r r i g h t s i n the h e a l t h care system has been tempered by a need to r e t a i n the g o o d w i l l of h e a l t h care p r o f e s s i o n a l s - - a f a c t which i s e v i d e n t i n the wording o f the American H o s p i t a l A s s o c i a t i o n ' s " B i l l o f R i g h t s f o r P a t i e n t s " (1972) which c o n t a i n s p r o p o s a l s " . . . so vague t h a t they are almost meaningless." :\>(Annas, 1974A:21). The document has been d e s c r i b e d as p a t e r n a l i s t i c ( G a y l i n , 1975:22) 24 and i t s authors accused of s i d e s t e p p i n g " . . . c e r t a i n t o p i c s t h a t were sure to i r r i t a t e the medical p r o f e s s i o n . " (Quinn and Somers, 1974:242). The n e c e s s i t y t o c o - e x i s t w i t h a powerful other person or o r g a n i z a t i o n v a r i e s as the a b i l i t y to 'rock the boat' without i n c r e a s i n g the r i s k of s i n k i n g i t , improves. The s o f t p e d a l l i n g of e x p r e s s i o n s o f d i s c o n t e n t , i n power b a l a n c i n g o p e r a t i o n s which i n v o l v e dependency r e l a t i o n s h i p s , i s necessary, i f : . . . a l l the p a r t i c i p a n t s i n the power game know t h a t they w i l l have to l i v e w i t h each other, whatever the r e s u l t s of t h e i r q u a r r e l s , [ t h e r e f o r e ] a minimum of harmony and good f e l l o w s h i p must be maintained, whatever the o p p o s i t i o n of r o l e s ( C r o z i e r , 1964:167). F a c t o r s which decide how easy i t w i l l become f o r the consumer to r e p l a c e more e c o n o m i c a l l y — o r to do without--the s e r v i c e s of h e a l t h care workers, as they p r e s e n t l y e x i s t , w i l l determine ( i n p a r t ) how powerful the consumer movement i n h e a l t h care i s l i k e l y t o become i n the f u t u r e . F o l l o w i n g the p u b l i c a t i o n of the American H o s p i t a l A s s o c i a t i o n ' s statement on P a t i e n t Rights i n 1972 and i t s c i r c u l a t i o n t o the 7,000 members of the A s s o c i a t i o n , many of these i n s t i t u t i o n s put out statements d e c l a r i n g t h a t they were a l r e a d y o p e r a t i n g under a p h i l o s o p h y which i n c o r p o r a t e d the p a t i e n t r i g h t s o u t l i n e d i n the B i l l , (Quinn and Somers, 1974:241). Other responses i n c l u d e d t h a t of the Insurance Commissioner of Pennsylvania, Herbert S. Denenberg. Reacting t o the c a r e f u l l y worded American H o s p i t a l A s s o c i a t i o n ' s B i l l of R i g h t s , Denenberg i s s u e d h i s own " C i t i z e n ' s B i l l o f H o s p i t a l 25 R i g h t s " . T h i s document d i s p l a y e d no tendency to t r e a d l i g h t l y around areas q u e s t i o n i n g a d m i n i s t r a t i v e a u t h o r i t y . I t s t i p u l a t e d t h a t " . . . unnecessary s e r v i c e s should be d i s -continued, and d u p l i c a t i v e , unsafe f a c i l i t i e s should be c l o s e d . " ( H o s p i t a l s JAHA May 26th. 1973:21). The p u b l i c a t i o n of the American H o s p i t a l A s s o c i a t i o n ' s d o c u m e n t — " B i l l of R i g h t s f o r P a t i e n t s " ( 1 9 7 2 ) — i n c r e a s e d the p u b l i c ' s awareness of the s u b j e c t and brought i n t o prominence the r o l e of the p a t i e n t advocate as one way to improve the powerless p o s i t i o n of the p a t i e n t once he e n t e r s the h e a l t h care system (Annas and Healey, 1974B; Quinn and Somers, .1974; K a l i s c h , 1975; K e l l y , 1976). Annas and Healey analyzed the r e s u l t s obtained when h o s p i t a l s i n the U n i t e d S t a t e s of America p r o v i d e d p a t i e n t r e p r e s e n t a t i v e s and i s s u e d pamphlets e x p l a i n i n g the r i g h t s o f p a t i e n t s i n t h e i r h o s p i t a l s . They came to the c o n c l u s i o n t h a t most of these e f f o r t s f a i l e d to p r o v i d e complete i n f o r m a t i o n . For i n s t a n c e , although Massachusetts law allowed p a t i e n t s access to t h e i r own r e c o r d s , the brochure given to p a t i e n t s by the Boston Beth I s r a e l H o s p i t a l d i d not mention t h i s f a c t (Annas and Healey, 1974A:29). An ombudsman-patient-advocate r o l e was i n s t i t u t e d by the Montreal General H o s p i t a l i n t h e i r Emergency S e r v i c e s , on an experimental b a s i s . The advocate, who was a u n i v e r s i t y graduate w i t h s p e c i a l e x p e r t i s e i n psychology and s o c i o l o g y , was a v a i l a b l e as a resource person f o r p a t i e n t s w a i t i n g i n the emergency area. The Montreal General H o s p i t a l a l s o p r o v i d e d 26 a s u g g e s t i o n b o x a n d an i n f o r m a t i o n s h e e t f o r t h e i r p a t i e n t s , c o n t a i n i n g d e t a i l s o f p o l i c i e s a n d p r o c e d u r e s w h i c h m i g h t a f f e c t t h e p a t i e n t as he w a i t e d f o r s e r v i c e . A l t h o u g h t h e o m b u d s m a n - p a t i e n t — a d v o c a t e r o l e was d i s c o n t i n u e d i n 1 9 7 3 , i t was e v a l u a t e d p o s i t i v e l y . A t t h e t i m e t h a t t h e p r o j e c t was r e p o r t e d , i t was s t a t e d t h a t c o n t i n u a t i o n o f t h e r o l e was d e p e n d e n t upon t h e l i f t i n g o f b u d g e t a r y r e s t r a i n t s ( M o r g a n , 1 9 7 3 : 2 6 ) . The n e e d f o r t h e p a t i e n t a d v o c a t e t o be p a i d f r o m a s o u r c e o u t s i d e t h e h o s p i t a l , i n o r d e r t o a v o i d t h e p o s s i b i l i t y t h a t l o w p r i o r i t y w i l l be a s s i g n e d t o t h e r o l e when t h e b u d g e t i s b e i n g c o n s i d e r e d , i s an i m p o r t a n t c o n s i d e r a t i o n i f t h e r o l e i s t o become e s t a b l i s h e d . E x t e r n a l f u n d i n g w o u l d a l s o r e d u c e any t e n d e n c y t h a t t h e a d v o c a t e m i g h t h a v e , t o g i v e f i r s t p r i o r i t y t o t h e m a i n t e n a n c e o f t h e s t a t u s q u o - - p o u r i n g o i l o n t r o u b l e d w a t e r s — i n s t e a d o f l o o k i n g f o r t h e s o u r c e o f p r o b l e m s i n o r d e r t o t r y t o e l i m i n a t e them ( A n n a s , 1 9 7 4 B : 2 3 ) . H o s p i t a l e m p l o y e e s a r e hampered i n t h e r o l e o f p a t i e n t a d v o c a t e i f t h e i r f i r s t l o y a l t y i s t o a d m i n i s t r a t i o n o r t o m e d i c i n e . S p e c i f i c a l l y c o n s i d e r i n g t h e q u a l i f i c a t i o n s o f n u r s e s a s a d v o c a t e s , A n n a s came t o t h e c o n c l u s i o n t h a t t h e y h a v e many o f t h e n e c e s s a r y a t t r i b u t e s r e q u i r e d b y t h e r o l e . H owever, c r u c i a l t o t h e n u r s e ' s s u c c e s s as an a d v o c a t e , i s how she s e e s h e r s e l f a n d how s h e i s v i e w e d b y o t h e r s . . . . F o r e x a m p l e , t h e n u r s e may be s e e n as more c o n c e r n e d w i t h o b t a i n i n g i n f o r m a t i o n f o r t h e d o c t o r t h a n i n h e l p i n g t h e p a t i e n t o b t a i n i n f o r m a t i o n f r o m t h e d o c t o r . I f s o , t h e n u r s e c a n n o t f u n c t i o n e f f e c t i v e l y i n t h i s r o l e ( A n n a s , 1 9 7 4 B : 2 5 ) . 27 Annas and Healey l i s t the f o l l o w i n g powers which they f e e l the p a t i e n t advocate must be abl e to e x e r c i s e , when necessary, on b e h a l f o f the p a t i e n t . They p o i n t out, t h a t : . . . To a l a r g e extent, these powers are rooted i n the r i g h t s t h a t the p a t i e n t possesses and i n c l u d e : -complete access t o medical r e c o r d s and the a u t h o r i t y t o c a l l i n , a t the d i r e c t i o n o f the p a t i e n t , a c o n s u l t a n t to a i d or advise the p a t i e n t ; - a c t i v e p a r t i c i p a t i o n on those h o s p i t a l committees r e s p o n s i b l e f o r m o n i t o r i n g q u a l i t y h e a l t h c a r e , e s p e c i a l l y u t i l i z a t i o n - r e v i e w and p a t i e n t care; -access to support s e r v i c e s f o r a l l p a t i e n t s who request them; - p a r t i c i p a t i o n a t the p a t i e n t ' s request and d i r e c t i o n i n d i s c u s s i o n o f the p a t i e n t ' s case, e s p e c i a l l y before d e c i s i o n s must be made and a l t e r n a t i v e s chosen (Annas and Healey, 1974B:258). Annas and Healey d e s c r i b e the advocate as e x e r c i s i n g " . . . a t the d i r e c t i o n o f the p a t i e n t , powers t h a t belong t o the p a t i e n t . " (Annas and Healey, 1974B: 258). These authors do not s t i p u l a t e t h a t , to the exte n t t h a t he i s abl e , the p a t i e n t should e x e r c i s e these powers f o r h i m s e l f . Hughes e l a b o r a t e s , w i t h a simple statement, the consequences of not making i t c l e a r t h a t the p a t i e n t , where he i s able and w i l l i n g , i s the p i v o t a l p o i n t around which d e c i s i o n s and a l t e r n a t i v e s e v o l v e . He says: . . . In many o f the t h i n g s which people do f o r one another, the f o r can be changed to to by a s l i g h t over-doing o r by a s h i f t of mood (Hughes, 1958:70). The advocacy model put forward by Chapman and Chapman avoids the p o s s i b i l i t y t h a t the power s h i f t i n the advocacy r e l a t i o n s h i p w i l l be i n the wrong d i r e c t i o n , by i n c o r p o r a t i n g the s t i p u l a t i o n t h a t : 28 . . . an a d v o c a c y m o d e l o f h u m a n i s t i c h e l p i n g i m p l i e s t h a t a c t i o n s a r e t a k e n i n b e h a l f o f p a t i e n t s when i t ha s b e e n d e t e r m i n e d t h a t on t h e i r own t h e y o r t h e i r r e p r e s e n t a t i v e s c a n n o t b r i n g t h e n e e d e d r e s o u r c e s t o b e a r on t h e s i t u a t i o n (Chapman and Chapman, 1 9 7 5 : 6 8 ) . R e s e a r c h i n t h e a r e a o f p a t i e n t r i g h t s h a s n o t b e e n e x t e n s i v e l y c o n d u c t e d . An i n t e r e s t i n g s u r v e y , i n t h e f o r m o f a n a t i o n w i d e , p u b l i c p o l l o f 1,513 A m e r i c a n h o u s e h o l d s b y L o u i s H a r r i s and A s s o c i a t e s , I n c . a s k e d s u b j e c t s a b o u t t h e i r f e e l i n g s o n p a t i e n t s ' r i g h t s and A m e r i c a n h e a l t h c a r e . The m a j o r i t y o f r e s p o n d e n t s (7 8 p e r c e n t ) a g r e e d t h a t e v e r y o n e s e e k i n g h e l p f r o m t h e h e a l t h c a r e s y s t e m , h a s a r i g h t t o be t o l d t h e n a t u r e o f h i s i l l n e s s a s w e l l a s t h e d a n g e r s a s s o c i a t e d w i t h i t and t h e r a n g e o f h e l p t h a t he c a n e x p e c t t o r e c e i v e f r o m p r o f e s s i o n a l h e a l t h c a r e w o r k e r s . S e v e n t y -f o u r p e r c e n t s u p p o r t e d t h e p a t i e n t ' s r i g h t t o r e f u s e m e d i c a t i o n s o r t r e a t m e n t , e v e n i f t h e p r o f e s s i o n a l s e e s s u c h b e h a v i o r a s d e t r i m e n t a l t o t h e p a t i e n t ' s w e l l b e i n g . Of t h o s e p o l l e d , 97.2 p e r c e n t s t a t e d t h a t p a t i e n t s s h o u l d r e c e i v e a f u l l e x p l a n a t i o n o f a n y e x p e r i m e n t b e f o r e t h e y w e r e a s k e d t o p a r t i c i p a t e i n i t . A f e e l i n g t h a t h o s p i t a l s and t h e i r p e r s o n n e l w e r e n o t c o m p l e t e l y t r u s t e d , e m e r g e d . F o r t y - o n e p e r c e n t o f t h e s a m p l e f e l t t h a t h o s p i t a l p a t i e n t s do n o t g e t q u a l i t y c a r e a n d 11 p e r c e n t e x p r e s s e d t h e m s e l v e s a s " n o t s u r e " o n t h i s i s s u e ( H a r r i s , 1 9 7 3 ) . The H a r r i s p o l l a g r e e d , i n t h e a r e a s t o do w i t h a c c e s s t o i n f o r m a t i o n , w i t h t h e r e s u l t s o b t a i n e d by M c C l u r e (1975) i n a s t u d y c o n d u c t e d t o i n v e s t i g a t e t h e r e a c t i o n s o f a g r o u p 29 of p a t i e n t s and nurses to the concepts c o n t a i n e d i n the American H o s p i t a l A s s o c i a t i o n ' s " P a t i e n t B i l l of R i g h t s " (1972). McClure's f i n d i n g s i n d i c a t e t h a t nurses and p a t i e n t s v e r b a l l y support the concepts t e s t e d . The r i g h t to i n f o r m a t i o n , e x p l a n a t i o n s before s i g n i n g a consent, and the r i g h t t o be a d v i s e d of any experimental r e s e a r c h were a l l items which were ranked h i g h l y i n importance and which r e c e i v e d strong support from both nurses and p a t i e n t s . The study was conducted i n two l a r g e m e t r o p o l i t a n h o s p i t a l s w i t h a non-random sample of 172 respondents. One o f the h o s p i t a l s was operated by a Board of T r u s t e e s and the other was f i n a n c e d by government funds. R e g i s t e r e d nurse s u b j e c t s were s t a f f nurses employed on medical and s u r g i c a l u n i t s . No i n f o r m a t i o n was i n c l u d e d about the e d u c a t i o n a l s t a t u s o f the s u b j e c t s or whether or not the h o s p i t a l s were used f o r t e a c h i n g purposes. The r e s u l t s o b t a i n e d are r e s t r i c t e d by the non-random nature of the sample and by an acknowledged l a c k of t e s t e d r e l i a b i l i t y and v a l i d i t y o f the r e s e a r c h t o o l used. O v e r a l l , nurses responded more p o s i t i v e l y to the concepts than d i d the p a t i e n t s (McClure, 1975). Pankratz and Pankratz, i n a study which c o n s t r u c t e d and t e s t e d the N u r s i n g A t t i t u d e S c a l e used i n the present study, found t h a t : . . . n u r s i n g l e a d e r s had by f a r the most pro-g r e s s i v e a t t i t u d e s r e g a r d i n g n u r s i n g autonomy and p a t i e n t s ' r i g h t s (Pankratz and Pankratz, 1974:215). The s i x t y - n i n e item q u e s t i o n n a i r e c o n s t r u c t e d by Pankratz and Pankratz measured three s u b - s c a l e s : 1) Nursing Autonomy and Advocacy; 30 2) P a t i e n t R i g h t s ; and 3) R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n s . The q u e s t i o n n a i r e was administered to 702 nurses rep-r e s e n t i n g n u r s i n g l e a d e r s , nurses working i n p s y c h i a t r i c h o s p i t a l s , u n i v e r s i t y t e a c h i n g h o s p i t a l s and community h o s p i t a l s . The nurses working i n community h o s p i t a l s tended to be the most t r a d i t i o n a l i n t h e i r a t t i t u d e s . The m a j o r i t y of these nurses (90 percent) were diploma graduates. Advanced edu-c a t i o n a l p r e p a r a t i o n was found to be p o s i t i v e l y c o r r e l a t e d w i t h a l l t h r e e s u b - s c a l e s " . . . i n d i c a t i n g t h a t nurses w i t h advanced e d u c a t i o n are s t r o n g e r supporters of the autonomous r o l e . " (Pankratz and Pankratz, 1974:214). A c o r r e l a t i o n a l s o e x i s t s between advanced e d u c a t i o n and the answers g i v e n i n the H a r r i s survey to a q u e s t i o n designed to probe how people f e e l about the q u a l i t y of c are i n American h o s p i t a l s . By a s m a l l m a j o r i t y , people s t a t e d t h a t they d i d not f e e l t h a t p a t i e n t s were ne g l e c t e d but, of the people who d i s a g r e e d , the more a f f l u e n t , b e t t e r educated, younger people under t h i r t y , predominated ( H a r r i s , 1973). A review of the circumstances i n which the American H o s p i t a l A s s o c i a t i o n ' s P a t i e n t ' s B i l l o f R i g h t s came i n t o b e i n g i n 1972, r e v e a l s t h a t i t s authors i n c l u d e d h o s p i t a l a d m i n i s t r a t o r s , h o s p i t a l and agency p l a n n i n g c h i e f s , p h y s i c i a n s , a t t o r n e y s and consumers—but no nurses (Quinn and Somers, 1974:240). I t i s obvious t h a t the l a c k of a n u r s i n g r e p r e s e n t a t i v e on t h i s committee d i d not stem from a f a i l u r e by n u r s i n g l e a d e r s h i p to support the concepts behind p a t i e n t r i g h t s and consumer p a r t i c i p a t i o n . 31 The n u r s i n g p r o f e s s i o n , on the North American con-t i n e n t , has a long h i s t o r y of s e n s i t i v i t y t o the needs of the people t h a t n u r s i n g s e r v e s . The N a t i o n a l League f o r N u r s i n g f o r m a l l y i d e n t i f i e d i t s e l f as an o r g a n i z a t i o n concerned w i t h encouraging consumer membership and p a r t i c i p a t i o n i n 1952, when the s t r u c t u r e o f the o r g a n i z a t i o n as we know i t today, emerged (Mauksch, 1971:98). Mauksch sees a need to strengthen even f u r t h e r , the consumer's i n f l u e n c e on the goals and o b j e c t i v e s of the League. I b e l i e v e t h a t i t would not be d i f f i c u l t to envisage the League o f tomorrow as an o r g a n i z a t i o n promoting h e a l t h care r a t h e r than o n l y n u r s i n g ! Thus, i t c o u l d become committed to the support of a l l endeavors d i r e c t e d toward meeting the h e a l t h care needs of the people. As the NATIONAL LEAGUE FOR HEALTH CARE, i t would be a unique o r g a n i z a t i o n i n many ways (Mauksch, 1971:98). In 1959, the N a t i o n a l League f o r Nursing convened a Committee to d r a f t a statement d e a l i n g w i t h the r i g h t s of people as p a t i e n t s . T h i s p u b l i c a t i o n was t i t l e d "What People Can Expect of Modern Nursing S e r v i c e . " In the statement, r e c o g n i t i o n was g i v e n to the f a c t t h a t c o o p e r a t i o n between the consumer and p r o v i d e r of care enhanced the q u a l i t y of n u r s i n g care t h a t c o u l d be p r o v i d e d . However, the-committee i n d e a l i n g w i t h the p a t i e n t ' s r i g h t to be informed, emphasized the commonly accepted f e e l i n g of the day t h a t the p h y s i c i a n was the C a p t a i n of the s h i p . The document s t a t e d t h a t , " . . . w i t h i n the l i m i t s determined by h i s d o c t o r . . . " (Carnegie, 1974:561) i n f o r m a t i o n about the p a t i e n t ' s i l l n e s s would be r e l a y e d to the p a t i e n t or h i s f a m i l y by n u r s i n g . 32 Committee members, r e a c t i n g to the s o c i a l c l i m a t e o f the day, f a i l e d to i d e n t i f y the p h i l o s o p h i c a l b r i d g e which separates the p a t i e n t as the p a s s i v e r e c i p i e n t o f the p r o f e s s i o n a l h e a l t h care worker's concerned care and a t t e n t i o n , from the p a t i e n t — or a member of h i s f a m i l y , where a p p r o p r i a t e — a s the " . . . i n -d i v i d u a l w i t h the major r e s p o n s i b i l i t y f o r h i s own h e a l t h c a r e . " (Canadian Consumers' A s s o c i a t i o n , 1974) . As a r e s u l t , n u r s i n g ' s handmaiden r o l e and the A e s c u l a p i a n a u t h o r i t y o f the p h y s i c i a n ( K a l i s c h , 1975) were perpetuated. The a t t i t u d e t h a t , "The Doctor knows be s t " i s wide-spread i n Western c u l t u r e . A c c o r d i n g to K a l i s c h the p h y s i c i a n ' s A e s c u l a p i a n a u t h o r i t y : . . . stems from a three-pronged power base: the p h y s i c i a n ' s e x p e r t i s e , the p a t i e n t ' s f a i t h i n him and the b e l i e f t h a t he [the p h y s i c i a n ] has almost m y s t i c a l powers ( K a l i s c h , 1975:22). The behavior of the c o n t r i b u t o r s to the p a t i e n t / d o c t o r dyad i s m o d i f i e d by the e x p e c t a t i o n s each has of the oth e r . The p a t i e n t u s u a l l y makes the i n i t i a l moves which e s t a b l i s h the r e l a t i o n s h i p and can, i n most i n s t a n c e s , terminate the a s s o c i a t i o n a t w i l l . However, the balance o f power i n the i n t e r a c t i o n , i s n e a r l y always i n v e s t e d i n the p r o f e s s i o n a l as the u l t i m a t e l y knowledgeable member of the i n t e r a c t i o n (Wilson, 1963:279). Reeder has examined the changing s t a t u s o f people seeking help from h e a l t h c a r e p r o f e s s i o n a l s by an a n a l y s i s o f the l a b e l s a p p l i e d to them i n the l i t e r a t u r e . He maintains t h a t simply by the p r o g r e s s i v e s u b s t i t u t i o n o f ' c l i e n t ' f o r 33 ' p a t i e n t ' and 'consumer' f o r ' c l i e n t ' , changes occur i n the environment which a l t e r the behavior e x h i b i t e d , depending on the l a b e l s used. . . . The s o c i a l c o n s t r u c t i o n o f the r e l a t i o n s h i p becomes r e d e f i n e d by v i r t u e o f the r e a l i t i e s imposed i n the b a r g a i n i n g and n e g o t i a t i n g between c l i e n t -p r a c t i t i o n e r versus consumer-provider (Reeder, 1972:409). L i t t l e and C a r n e v a l i i n the second e d i t i o n o f t h e i r b o o k — N u r s i n g Care P l a n n i n g — p u b l i s h e d i n 1976, pro v i d e con-f i r m a t i o n o f Reeder's p o i n t . They acknowledge the e f f e c t t h a t the changing s t a t u s o f the consumer has had on the format of t h e i r second e d i t i o n . The authors s t a t e i n ^ t h e p r e f a c e to the second e d i t i o n : . . . i n keeping w i t h our v a l u i n g o f the consumer as a p a r t i c i p a n t i n h i s h e a l t h c a r e , at whatever l e v e l i s p o s s i b l e , we opted to c a l l h i s r o l e " c l i e n t " . You w i l l note a l s o t h a t we r e l o c a t e d the c l i e n t and h i s v a l u e s from the end of the chapter on values i n n u r s i n g care p l a n s t o the beginning. T h i s a l s o r e f l e c t s where we are ( L i t t l e and C a r n e v a l i , 1 9 7 6 : v i i i ) . Reeder's t h e s i s suggests t h a t the l a b e l 'consumer' i s a more powerful cue i n i n d u c i n g change i n r o l e behavior than ' c l i e n t ' . The c l i e n t / p r o f e s s i o n a l r e l a t i o n s h i p r e t a i n s many of the i m p l i c a t i o n s of dependency p r e s e n t i n the p a t i e n t / p r o f e s s i o n a l r o l e s . On the other hand: . . . i n consumer-provider r e l a t i o n s h i p s , caveat  emptor i m p l i e s t h a t the consumer has c o n s i d e r a b l y more b a r g a i n i n g power than f o r m e r l y . He may . . . be a b l e to shop i n the market p l a c e o f h e a l t h care (Reeder, 1972:409). The cues generated i n the environment when acute care i s the focus of the medical system, r e s u l t i n the e s t a b l i s h -ment of a s e l l e r ' s market, i n which the p a t i e n t i s seen as a 34 s u p p l i c a n t f o r b e n e f i t s c o n t r o l l e d by powerful p r o f e s s i o n a l s . The swing to p r e v e n t i v e medicine w i t h more emphasis on the maintenance o f h e a l t h has r e s u l t e d i n the formation of a p a r t i a l buyer's market. The consumer has to be convinced t h a t the p r o f e s s i o n a l s have something to o f f e r him i n t h i s area and, consequently, more e f f o r t s are made by p r o f e s s i o n a l s to a t t r a c t the c l i e n t (Echeveste and S c h l a c t e r , 1974). The p u b l i c a t i o n of documents concerned with the r i g h t s of p a t i e n t s i s a t a c i t admission o f the p a t i e n t s ' d i s s a t i s -f a c t i o n with the way t h e i r r i g h t s are r e c o g n i z e d i n the p r e s e n t h e a l t h c a r e system. Rozovsky (1974A:8) has expressed " s u r p r i s e " and K e l l y (1976:26) "sadness" t h a t p a t i e n t s should have t o l a y c l a i m formally- t o p r i n c i p l e s which are a l r e a d y t h e i r s , both l e g a l l y (based on common-law d e c i s i o n s ) and m o r a l l y ( s t a t e d i n the code o f e t h i c s o f both p h y s i c i a n s and n u r s e s ) . Rozovsky pres e n t s three suggestions to Canadian h o s p i t a l a u t h o r i t i e s which he b e l i e v e s , i f implemented, would " . . . safeguard not onl y the p a t i e n t ' s r i g h t s but h i s i n t e r e s t s as w e l l . " (Rozovsky, 1974A:10). They a r e : 1) the a d d i t i o n t o the c u r r i c u l u m i n a l l schools of n u r s i n g and medicine, o f courses i n law as i t a f f e c t s h e a l t h care 2) the c r e a t i o n i n a l l h o s p i t a l p e r s o n n e l , i n c l u d i n g members of the medical s t a f f , o f a s p i r i t o f human responsiveness 3) the esta b l i s h m e n t of systems a u d i t i n g the standards of medi c a l , n u r s i n g and t e c h n i c a l c a r e (Rozovsky, 1974A:10). C u r t i s i n a forum column encouraging p h y s i c i a n - r e a d e r s of M e d i c a l World News to express t h e i r views, r e i n f o r c e s 35 Rozovsky's second su g g e s t i o n . C u r t i s , a p h y s i c i a n , b e l i e v e s t h a t the p r e v a l e n c e of m a l p r a c t i c e l a w s u i t s a g a i n s t p r o f e s s i o n a l h e a l t h care workers, i s the r e s u l t of badly managed communi-c a t i o n w i t h p a t i e n t s . The p h y s i c i a n ' s apparent l a c k of concern f o r them as persons, makes the p a t i e n t s angry enough to sue the p h y s i c i a n i f " . . . an o p p o r t u n i t y or an o p p o r t u n i s t i c a t t o r n e y become a v a i l a b l e . " ( C u r t i s , 1975:110). The viewpoint expressed by C u r t i s i s i n agreement..with t h a t taken by the U.S. Department of H e a l t h , E d u c a t i o n and Welfare S e c r e t a r y ' s Commission on Me d i c a l M a l p r a c t i c e . T h e i r r e p o r t s p e c i f i c a l l y r e c o g n i z e d the l i n k between p a t i e n t care which ignored the human r i g h t s of p a t i e n t s and the i n c i d e n c e of m e d i c a l m a l p r a c t i c e l a w s u i t s . The recommendations of the Commission i n c l u d e d one which s t a t e d : . . . t h a t h o s p i t a l s and ot h e r h e a l t h care f a c i l i t i e s adopt and d i s t r i b u t e statements of p a t i e n t s ' r i g h t s i n a manner which most e f f e c t i v e l y communicates these r i g h t s t o a l l incoming p a t i e n t s (U.S. Department o f Health, E d u c a t i o n and Welfare S e c r e t a r y ' s Commission on Medical M a l p r a c t i c e , 1973:74). Kome (1976:18) w r i t i n g i n the magazine Homemaker's, quotes Ivy D u n n - - D i r e c t o r of Nursing a t the Royal Ottawa H o s p i t a l , O n t a r i o , Canada—where a p r i n t e d b i l l of r i g h t s i s d i s t r i b u t e d to p a t i e n t s , as s t a t i n g t h a t t h i s i n n o v a t i o n r e s u l t e d i n i n c r e a s e d involvement and more work f o r everyone but, she f e e l s t h a t i t i s a p o s i t i v e step i n the r i g h t d i r e c t i o n . I n i t i a l l y , s t a f f a t the Royal Ottawa expressed f e a r s t h a t the H o s p i t a l was i n v i t i n g a rash of l a w s u i t s by i n f o r m i n g p a t i e n t s o f t h e i r r i g h t s , but t h i s has not been the case. 36 The December 7th, 1976 e d i t i o n of The Me d i c a l Post, p u b l i s h e d i n Toronto, Canada, r e p o r t s t h a t the c o u n c i l of the O n t a r i o M e d i c a l A s s o c i a t i o n r e j e c t e d , by a vote of n i n e t y - s i x to seventy-nine, a document c a l l e d " D e c l a r a t i o n of P a t i e n t s ' R i g h t s " , drawn up by the O n t a r i o Medical A s s o c i a t i o n ' s C i t i z e n s ' A d v i s o r y Board and submitted to the c o u n c i l a f t e r being m o d i f i e d by the A s s o c i a t i o n ' s e x e c u t i v e committee and Board of D i r e c t o r s . Dr. Todd, P r e s i d e n t o f the O n t a r i o M e d i c a l A s s o c i a t i o n , d e s c r i b e d the b i l l as "innocuous". I t c o n t a i n e d n o t h i n g t h a t i s not a l -ready accepted by the medical p r o f e s s i o n and incorporated, i n the Canadian M e d i c a l A s s o c i a t i o n ' s code o f e t h i c s . The r i s k o f m a l p r a c t i c e s u i t s was one of the reasons g i v e n by the P r e s i d e n t of the O n t a r i o Medical A s s o c i a t i o n f o r the r e f u s a l o f the c o u n c i l to adopt the b i l l (Medical Post, December 7th, 1976:1, 28). Consumer r i g h t s a s s o c i a t i o n s have been formed across Canada. A t y p i c a l one i s the P a t i e n t s ' Rights A s s o c i a t i o n formed i n Toronto, O n t a r i o . T h i s n o n - p r o f i t o r g a n i z a t i o n has p u b l i s h e d a b o o k l e t c a l l e d the P a t i e n t ' s Rights Manual which enumerates i n d e t a i l the grievance procedures a v a i l a b l e to the p a t i e n t i f he f e e l s t h a t h i s r i g h t s have been ignored or n e g l e c t e d . L i s t e d i n the Manual are the f o l l o w i n g l e g a l r i g h t s o f p a t i e n t s : 1) The r i g h t to medical care i n an emergency 2) The r i g h t to c o n t r o l one's own body 3) The r i g h t to v o l u n t a r y informed consent 4) The r i g h t to decide whether or not to be used f o r r e s e a r c h o r t e a c h i n g purposes (Patient's.  Rights Manual, no date:12). Along w i t h these r i g h t s , the b o o k l e t l i s t s t h ree p a t i e n t r e s p o n s i b i l i t i e s : 1) To f u l l y d i s c l o s e symptoms or c o n d i t i o n s ; 37 2) To f o l l o w medical i n s t r u c t i o n s ; 3) To r e t u r n f o r treatment ( P a t i e n t ' s Rights  Manual, no date:14). The Manual notes t h a t the second r e s p o n s i b i l i t y runs counter to the r i g h t to accept or r e j e c t treatment which i s i n h e r e n t i n the second l e g a l r i g h t — t o c o n t r o l one's own body. . . . The i m p l i c a t i o n here i s t h a t i n a s s e r t i n g your r i g h t to r e f u s e a p a r t i c u l a r treatment your p h y s i c i a n may decide he can no longer t r e a t you adequately hence ask you t o o b t a i n another p h y s i c i a n (which a c t i o n i s w i t h i n h i s l e g a l r i g h t s ) ( P a t i e n t ' s  R i g h t s Manual, no date:14). The P a t i e n t ' s Rights Manual a l s o names three moral or e t h i c a l r i g h t s : 1) The r i g h t to p r i v a c y 2) The r i g h t to normal human c o u r t e s i e s . . . 3) The r i g h t to a second o p i n i o n . . . ( P a t i e n t ' s  Rights Manual, no date:15). The Manual goes on to d i s c u s s r i g h t s which the P a t i e n t s ' R i g h t s A s s o c i a t i o n f e e l s are l e g a l l y i n d i s p u t e and p o i n t s out the con-f l i c t s which e x i s t between the b a s i c l e g a l r i g h t s o r i g i n a l l y l i s t e d and those r i g h t s which the p a t i e n t most o f t e n f e e l s are ignor e d by h e a l t h care p r o f e s s i o n a l s . For i n s t a n c e , the Assoc-i a t i o n b e l i e v e s t h a t the p a t i e n t ' s r i g h t to know the t r u t h i s di s p u t e d and t h a t t h i s c o n f l i c t s w i t h the b a s i c r i g h t o f v o l u n -t a r y , informed consent. The Canadian c o u n t e r p a r t o f the American " P a t i e n t B i l l o f R i g h t s " i s t i t l e d "Consumer Rights i n Hea l t h Care". I t was p u b l i s h e d i n 1974 by the Consumers' A s s o c i a t i o n of Canada and i d e n t i f i e s f o u r major areas i n which Canadian consumers f e e l t h a t t h e i r human r i g h t s are i n jeopardy, once they enter the h e a l t h care system. 38 1) R i g h t t o be i n f o r m e d . 2) R i g h t t o be r e s p e c t e d a s t h e i n d i v i d u a l w i t h t h e m a j o r r e s p o n s i b i l i t y f o r h i s own h e a l t h c a r e . 3) R i g h t t o p a r t i c i p a t e i n d e c i s i o n m a k i n g a f f e c t i n g h i s h e a l t h . 4) R i g h t t o e q u a l a c c e s s t o h e a l t h c a r e ( h e a l t h e d u c a t i o n , p r e v e n t i o n , t r e a t m e n t , a nd r e h a b i l i t a t i o n ) r e g a r d l e s s o f t h e i n d i v i d u a l ' s e c o n o m i c s t a t u s , s e x , ag e , c r e e d , e t h n i c o r i g i n and l o c a t i o n . ( A p p e n d i x A). The f i r s t t h r e e a r e a s r e f l e c t a c o n c e r n w i t h t h e q u a l i t y o f com-m u n i c a t i o n b e t w e e n members o f t h e h e a l t h c a r e p r o f e s s i o n s a n d t h e c o n s u m e r . I t i s r e a s o n a b l e t o assume, t h e r e f o r e , t h a t t h e p u b l i c s e e s a n e e d t o i m p r o v e t h e c o m m u n i c a t i o n t h a t p r e s e n t l y e x i s t s b e t w e e n t h e p a r t i e s . Members o f t h e R e g i s t e r e d N u r s e s ' A s s o c i a t i o n o f B r i t i s h C o l u m b i a , r e p r e s e n t e d by t h e i r p r o f e s s i o n a l a s s o c i a t i o n , h a v e r e c o g n i z e d t h e e x i s t e n c e o f t h i s c o m m u n i c a t i o n gap by s p e c i f i c a l l y q u e s t i o n i n g t h e r i g h t o f p r o f e s s i o n a l s t o d e c l a r e t h a t i n f o r -m a t i o n i n t h e c o n s u m e r ' s h e a l t h c a r e r e c o r d s h o u l d be w i t h h e l d f r o m t h e i n d i v i d u a l c o n s u m e r whom i t d i r e c t l y c o n c e r n s (RNABC  News, 1 9 7 6 : 7 ) . I n f o r m e d a c c e s s t o i n f o r m a t i o n i n c r e a s e s t h e p o s s i b i l i t y t h a t t h e c o n s u m e r ( o r h i s a p p o i n t e d r e p r e s e n t a t i v e ) w i l l be a b l e t o p a r t i c i p a t e i n t e l l i g e n t l y i n t h e d e c i s i o n m a k i n g p r o c e s s e s s u r r o u n d i n g h i s p l a n o f c a r e . S u c h p a r t i c i p a t i o n u t i l i z e s t h e p r i n c i p l e s b e h i n d t h e n o r m a t i v e - r e - e d u c a t i v e s t r a t e g y o f c h a n g e . I n t h i s s t r a t e g y , i n d i v i d u a l s a r e s e e n a s t h e i m p o r -t a n t u n i t o f t h e s o c i a l s y s t e m and c a p a b l e o f t a k i n g s e l f - r e l i a n t a c t i o n t o w a r d s a c c o m p l i s h i n g t h e i r l i f e p o t e n t i a l , p r o v i d e d t h a t t h e e n v i r o n m e n t a l f o r c e s f o s t e r and s u p p o r t t h a t a c t i o n ( C h i n a n d B e n n e, 197 6 : 3 9 ) . R e f e r e n c e s t o t h e r e s p o n s i b i l i t y o f t h e p a t i e n t f o r 39 h i s own h e a l t h a r e i n c r e a s i n g i n t h e l i t e r a t u r e o f t h e s o c i a l s c i e n c e s ( L a l o n d e , 1974; F u c h s , 1974; L i t t l e a n d C a r n e v a l i , 1976; I l l i c h , 1976) a s w e l l a s f i n d i n g e x p r e s s i o n i n t h e e d i t o r i a l s o f d a i l y n e w s p a p e r s , f o r e x a m p l e , The P r o v i n c e , V a n c o u v e r , B r i t i s h C o l u m b i a , 5 t h A u g u s t , 1977. I t i s , h o w e v e r , n o t a new c o n c e p t a l t h o u g h t h e c l i m a t e i n w h i c h i t i s a d v o c a t e d t o d a y endows i t w i t h t h e p o s s i b i l i t y f o r " u n a n t i c i p a t e d c o n -s e q u e n c e s " m i s s i n g i n p r e v i o u s c o n t e x t s . As f a r b a c k a s 1 8 4 7 , when t h e A m e r i c a n M e d i c a l A s s o c i a t i o n a d o p t e d i t s f i r s t c o d e o f e t h i c s , t h e y i n c l u d e d a h e a d i n g o f " O b l i g a t i o n s o f P a t i e n t s t o T h e i r P h y s i c i a n s " w h i c h c o n t a i n e d t h e f o l l o w i n g s t a t e m e n t : . . . The f i r s t d u t y o f a p a t i e n t i s t o s e l e c t a s h i s m e d i c a l a d v i s e r one who h a s r e c e i v e d a r e g u l a r p r o f e s s i o n a l e d u c a t i o n . . . t h e w o r l d o u g h t n o t t o s u p p o s e t h a t k n o w l e d g e i s i n t u i t i v e (New Y o r k M e d i c o -H i s t o r i c a l S o c i e t y , 1 8 6 4 : 4 9 ) . I n 18 47, t h e i m p l i c a t i o n b e h i n d t h e s t a t e m e n t was t h a t t h e p a t i e n t n e e d e d t o p l a c e t h e e n t i r e r e s p o n s i b i l i t y f o r h i s h e a l t h and w e l l b e i n g i n t h e h a n d s o f someone e l s e . The p a t i e n t ' s r e s p o n s i b i l i t y e n d e d f o l l o w i n g h i s c h o i c e o f a c a p a b l e , c o m p e t e n t , p r o f e s s i o n a l p e r s o n a s h i s p h y s i c i a n . The a d v i c e — t o s e l e c t a c o m p e t e n t p h y s i c i a n — r e m a i n s g o od t o d a y , 130 y e a r s l a t e r , b u t t h e e n v i r o n m e n t i n w h i c h t h e modern p a t i e n t f u n c t i o n s i s d i f f e r e n t . I n 1 977, t h e number o f p e r s o n s i n h e a l t h c a r e — o u t s i d e t h e m e d i c a l p r o f e s s i o n — w h o s e b a c k g r o u n d i n c l u d e s a p r o f e s s i o n a l e d u -c a t i o n h a s w i d e n e d . The p a t i e n t h i m s e l f i s b e t t e r e d u c a t e d a n d n o t s o i n c l i n e d t o go a l o n g , w i t h o u t q u e s t i o n , w i t h t h e i d e a t h a t "The D o c t o r knows b e s t " ( W i l s o n , 1 9 6 3 ; Q u i n n and 40 Somers, 197 4; Henig, 1976; Haug, 1976) or w i t h what the h o s p i t a l d i c t a t e s ( T a y l o r , 1962) . The viewpoint of the p h y s i c i a n on consumerism w i l l , of n e c e s s i t y , be more narrowly molded than t h a t of the o r g a n i z e d consumer because of the a u t h o r i t y which the p h y s i c i a n assumes as a r e s u l t of h i s " . . . demonstrated craftsmanship and e x p e r t i s e i n the workplace." (Maddox and Stead, 1974:73). Three key elements i n the s o c i a l i z a t i o n o f p h y s i c i a n s need to be examined i f an understanding of the r e a c t i o n of most p h y s i c i a n s to consumerism i s to be reached. These three elements are: . . . acceptance of u l t i m a t e r e s p o n s i b i l i t y f o r the h e a l t h o f the i n d i v i d u a l p a t i e n t ; the r i g h t o f autonomy to e x e r c i s e p r o f e s s i o n a l judgment about the management o f the i n d i v i d u a l p a t i e n t f o r whom r e s p o n s i b i l i t y i s accepted; and the r e l a t e d r i g h t to c o n t r o l the workplace i n the i n t e r e s t of i n s u r i n g p r o f e s s i o n a l autonomy (Maddox and Stead, 1974:74). Added t o these elements i s a b e l i e f t h a t p a t i e n t behavior i s s t r o n g l y c h a r a c t e r i z e d by dependency, e m o t i o n a l i t y , i r r a t i o n -a l i t y and non-compliance. . . . These' p a t i e n t c h a r a c t e r i s t i c s i n v i t e i f not command a u t h o r i t a t i v e performance by the p h y s i c i a n , thus r e i n f o r c i n g a dominant element i n h i s p e r s p e c t i v e (Maddox and Stead, 1974:75). In 1976, the Saskatchewan R e g i s t e r e d Nurses 1 A s s o c i a t i o n (S.R.N.A.) presented a b r i e f to the Committee on Rights i n R e l a t i o n to H e a l t h Care i n Saskatchewan. The S.R.N.A. supported the document p u b l i s h e d by the Consumers' A s s o c i a t i o n of Canada—"Consumer Rights i n Health Care" (1974) . The b r i e f emphasized t h a t the i n d i v i d u a l ' s r e s p o n s i b i l i t y f o r 41 h e a l t h maintenance goes hand-in-hand wi t h r i g h t s i n h e a l t h care (News B u l l e t i n , S.R.N.A., May 1976:3). I f the h e a l t h care consumer i s to d i s c h a r g e h i s r e s p o n s i b i l i t i e s adequately and e x e r c i s e h i s r i g h t s , as suggested i n the S.R.N.A. b r i e f , informed access to i n f o r m a t i o n about h i s h e a l t h i s e s s e n t i a l . C o u n t e rpoint to t h i s statement i s an assumption that t h e r e a l s o e x i s t s a ' r i g h t to inform' which the consumer i s a s k i n g h e a l t h c a re workers to e x e r c i s e (Fagin, 1975; K e l l y , 1976:32; Bandman and Bandman, 1978). Access to Information by Consumers One of the most frequent arguments advanced a g a i n s t the s u g g e s t i o n t h a t consumers should have ' f u l l and informed access' to t h e i r h e a l t h c a r e r e c o r d s , i s based on the b e l i e f t h a t the average person, without a m e d i c a l background, would be unable to comprehend the i n f o r m a t i o n , even i f i t were f r e e l y a v a i l a b l e . There i s a tendency t o use the p a t i e n t ' s l a c k of s o p h i s t i c a t i o n i n medical matters as an excuse to maintain the p a t i e n t i n a p o s i t i o n o f dependency i n i n t e r -a c t i o n s between h e a l t h care p r o f e s s i o n a l s and consumers of care. Moore and Tumin have examined some of the f u n c t i o n s which ignorance performs i n s o c i a l and p r o f e s s i o n a l s e t t i n g s . They p o i n t out t h a t ignorance i s an unavoidable p a r t of our s o c i a l s t r u c t u r e , s i n c e we do not have access to p e r f e c t knowledge. The e x i s t i n g knowledge—and s p e c i a l i z e d knowledge i n p a r t i c u l a r — i s the base, i n our s o c i e t y , upon which many 42 o f t h e a c c e p t e d p o w e r s t r u c t u r e s d e p e n d . . . . I n many i n s t a n c e s , o f c o u r s e , t h e c o u n t e r p a r t o f i g n o r a n c e o n t h e p a r t o f t h e c o n s u m e r i s s e c r e c y on t h e p a r t o f t h e p o s s e s s o r o f k n o w l e d g e (Moore and T u m i n , 1 9 4 9 : 7 8 8 ) . The m a i n t e n a n c e o f a p r i v i l e g e d s t a t u s i s , t o some e x t e n t , d e p e n d e n t on t h e d i f f e r e n c e t h a t e x i s t s b e t w e e n t h e k n o w l e d g e and s k i l l o f t h e s p e c i a l i s t and t h o s e o f t h e c o n s u m e r . The d i f f e r e n c e i s f u r t h e r m a g n i f i e d when t h e s p e c i a l i s t h a s a c c e s s t o r e f i n e d t e c h n o l o g y n o t commonly a v a i l a b l e t o t h e a m a t e u r . The w o r k o f C r o z i e r (1964) a nd P e t t i g r e w (197 3) e m p h a s i z e s t h a t s t a t u s d i f f e r e n t i a t i o n o f t h i s t y p e i s n o t c o n f i n e d t o t h e p r o f e s s i o n s . C r o z i e r i n a n e m p i r i c a l s t u d y o f two b u r e a u c r a t i c o r g a n i z a t i o n s i n F r a n c e , d e s c r i b e s how t h e m a i n t e n a n c e w o r k e r s i n o ne o f t h e o r g a n i z a t i o n s , e x e r c i s e d p o w e r by t r a d i n g on t h e n e e d t o k e e p t h e m a c h i n e s i n p e r f e c t w o r k i n g o r d e r . T h e i r s t a t u s a s t h e l e g i t i m a t e l y a u t h o r i z e d m e c h a n i c a l e x p e r t s was j e a l o u s l y g u a r d e d a n d t h e i r p o w e r , a s C r o z i e r d e p i c t s i t , h a s many s i m i l a r i t i e s t o t h e power e x e r c i s e d b y p h y s i c i a n s o v e r t h e b o d i l y r e p a i r o f p a t i e n t s . . . . t h e one u n f o r g i v e a b l e s i n o f a m a c h i n e o p e r a t o r i s t o " f o o l a r o u n d " w i t h h e r m a c h i n e . M a i n t e n a n c e a n d r e p a i r p r o b l e m s must be k e p t s e c r e t . No e x p l a n a t i o n i s e v e r g i v e n . . . . T h e s e a n d a l l o t h e r t r i c k s o f t h e t r a d e a r e l e a r n e d t h r o u g h c o m p a n i o n -s h i p on t h e j o b . E v e r y j o b i s done i n d i v i d u a l l y , b u t t h e r e i s a g r e a t d e a l o f s o l i d a r i t y f o r l e a r n i n g p u r p o s e s and w h e n e v e r t h e r e i s a d i f f i c u l t p r o b l e m ( C r o z i e r , 1 9 6 4 : 1 5 3 ) . P a t i e n t s a r e d i s c o u r a g e d f r o m c o n s u l t i n g p r a c t i t i o n e r s o u t s i d e t h e l e g i t i m a t e l y a u t h o r i z e d m e d i c a l s t r u c t u r e — s u c h 43 a c t i o n i s commonly c a l l e d ' f o o l i n g around 1 w i t h quacks. Both the maintenance men i n C r o z i e r ' s b u r e a u c r a t i c s e t t i n g and p h y s i c i a n s are u t i l i z i n g a unique body of knowledge to which they attempt t o c o n t r o l access. The p r a c t i t i o n e r s i n both s i t u a t i o n s r e l y h e a v i l y on peer support to s o l v e unusual problems. P e t t i g r e w i n an i n v e s t i g a t i o n o f the d e c i s i o n making s t r a t e g i e s used w i t h i n a l a r g e B r i t i s h r e t a i l f i r m which made e x t e n s i v e use of computers, l i s t s s i m i l a r d e v i c e s which the computer programmers r e s o r t e d t o , i n o r d e r : . . . to p r o t e c t t h e i r power base and t h e i r o c c u p a t i o n a l i d e n t i t y , . . . The programmers used f o u r main s t r a t e g i e s : (i) norms t h a t denied o u t s i d e r s ' competence ( i i ) p r o t e c t i v e myths ( i i i ) p r o t e c t i o n o f t h e i r knowledge base through c o n t r o l over t r a i n i n g and r e c r u i t m e n t p o l i c i e s (Pettigrew, 1973:150). The use of these d e v i c e s designed to ma i n t a i n a monopoly over s p e c i a l i z e d knowledge i s being questioned (Haug and Sussman, 1969; Haug, 1976). Changes o c c u r r i n g i n the environment have enabled the consumer to become more adept at r e c o g n i z i n g and d e a l i n g w i t h h i s own problems, w i t h the r e s u l t t h a t the consumer i s l e s s dependent upon the s e r v i c e s of the s p e c i a l i s t . In the h e a l t h c a r e f i e l d , the ' d o - i t - y o u r s e l f experience has found e x p r e s s i o n i n the development of women's s e l f - h e l p c l i n i c s i n l a r g e North American c i t i e s ( H a l l , 1974; Dunn e t a l . , 1976) as a by product o f the women's l i b e r a t i o n movement. These c o l l e c t i v e s have p u b l i s h e d manuals, designed to make consumers more f a m i l i a r w i t h how t h e i r bodies work 44 e.g. A Vancouver Women's Hea l t h Booklet (1972), p u b l i s h e d by the Vancouver H e a l t h C o l l e c t i v e and Our Bodies, Ourselves, (1973), put out by the Boston Women's H e a l t h C o l l e c t i v e . Gussow and Tracy have examined the growth of s e l f -h e l p groups over the l a s t 20-30 ye a r s . These authors b e l i e v e t h a t the emergence of these groups c o n s t i t u t e s a s o c i a l movement whose e v o l u t i o n and growth b r i d g e s a gap between the a v a i l a b l e h e a l t h s e r v i c e s and a need i d e n t i f i e d a t the grass r o o t s l e v e l . The gap e x i s t s i n the areas of communication about support s e r v i c e s and access to h e a l t h education (Gussow and Tracy, 1976:407). Experience has shown t h a t many people can assume i n c r e a s e d r e s p o n s i b i l i t y f o r t h e i r own h e a l t h care when giv e n the o p p o r t u n i t y to do so, backed up by adequate access t o the a p p r o p r i a t e technology and knowledge ( F l e g l e , 1977; M e d i c a l World  News, A p r i l 18th 1977; K i n l e i n , 1977). The best known example of e f f e c t i v e p a t i e n t p a r t i c i p a t i o n i n t h e i r own h e a l t h care i s t h a t o f the d i a b e t i c p a t i e n t (King, S p a l d i n g , and Wright, 1974:19; Laugharne and S t e i n e r , 1977). P a t i e n t s , s t a r t i n g a t about s i x years of age can s u c c e s s f u l l y a c q u i r e and make use of a body of s p e c i a l i z e d medical knowledge about diabetes, i n o r d e r to achieve and m a i n t a i n p h y s i c a l w e l l - b e i n g , with a minimum of p r o f e s s i o n a l s u p e r v i s i o n (Leahy, Logan and McArthur, 1975:18). More s o p h i s t i c a t e d , t e c h n o l o g i c a l l y o r i e n t e d examples are the p a t i e n t s who, w i t h the h e l p of t h e i r f a m i l i e s and a v i s i t i n g nurse, manage h i g h l y t e c h n i c a l d i a l y s i s equip-ment a t home ( S c h a f f e r , 1973; Wheeler, 1977). 45 A study done a t North C e n t r a l D i a l y s i s Center i n down-town Chicago, I l l i n o i s , concluded t h a t the disadvantaged m i n o r i t i e s l i v i n g i n t h a t area are as r e s p o n s i v e to s e l f - c a r e d i a l y s i s e d u c a t i o n as more a f f l u e n t groups. The d i f f i c u l t i e s e xperienced i n home d i a l y s i s , on t h i s program, were the r e s u l t of the poor housing c o n d i t i o n s i n which the p a t i e n t s l i v e d and not because of a low p o t e n t i a l f o r s e l f - c a r e . One approach to c o r r e c t i n g t h i s problem has been the e s t a b l i s h m e n t of " l i m i t e d c a r e " d i a l y s i s c e n t e r s i n which p a t i e n t s perform t h e i r own d i a l y s i s under the s u p e r v i s i o n of t r a i n e d p e r sonnel (Medical World News, A p r i l 18th, 1977). A p a t i e n t , Yonnie George, who r e g u l a r l y does her own d i a l y s i s a t New York H o s p i t a l C o r n e l l M e d i c a l Center, e v a l u a t e d very p o s i t i v e l y the " l i m i t e d c a r e " concept. In d e s c r i b i n g her experiences as a p a t i e n t i n another u n i t , where her d i a l y s i s was performed by the s t a f f , she says: . . . I had no c o n t r o l over what was happening. They d i d n ' t even t e l l me my blood p r e s s u r e . When I asked q u e s t i o n s , t h e i r a t t i t u d e was, t h e r e ' s no need f o r me to know. I t would have been b e t t e r f o r me e m o t i o n a l l y i f t h i n g s had been e x p l a i n e d . I r e a l l y f e l t I was j u s t a number there (Medical World  News, A p r i l 18th, 1977:35). A study o f four amputees done by F o o r t i l l u s t r a t e s t h a t the consumer of care i s l o o k i n g f o r the s o r t of support which leads to maximal independence a t each stage of r e -h a b i l i t a t i o n . These amputees, who were an e l i t e group composed of two p h y s i c i a n s , a p s y c h i a t r i s t and a p r o s t h e t i s t , s t r o n g l y a s s e r t e d d u r i n g i n d e p t h i n t e r v i e w s , t h a t : 46 • . . What they wanted was support. T h i s support should be i n the form o f usable i n f o r m a t i o n and q u i t e e x p l i c i t i n s t r u c t i o n s based on f a c t s which they can r e a d i l y grasp and f o l l o w (Foort, 1974:21). In t h i s study, p r o f e s s i o n a l s when transformed i n t o p a t i e n t s , s u f f e r e d from the same sense o f f r u s t r a t i o n and powerlessness as n o n - p r o f e s s i o n a l s ( K a l i s c h , 1975; Med i c a l  World News, A p r i l 18th, 1977) when co n f r o n t e d w i t h t h e r a p e u t i c management techniques which denied them the r i g h t to be i n v o l v e d i n t h e i r own c a r e . The p l e a o f F o o r t ' s s u b j e c t s f o r " . . . u s e f u l and r e l i a b l e i n f o r m a t i o n " (Foort, 1974:22) i s an endorsement o f a statement made by Chin and Benne d u r i n g an a n a l y s i s o f Lewin's c o n t r i b u t i o n to the theory of normative-r e - e d u c a t i v e s t r a t e g i e s o f change. Chin and Benne s t a t e Lewin's (1948) p o s i t i o n , thus: . . . Man must p a r t i c i p a t e i n h i s own r e - e d u c a t i o n i f he i s to be re-educated a t a l l . And r e - e d u c a t i o n i s a normative change as w e l l as a c o g n i t i v e and p e r c e p t u a l change (Chin and Benne, 1976:32). An e m p i r i c a l i n v e s t i g a t i o n i n the Netherlands, found t h a t open communication between the nurse and the p a t i e n t was not a p a r t o f the t h e r a p e u t i c behavior b u i l t i n t o the nurse's r o l e i n n u r s i n g u n i t s o f Dutch g e n e r a l h o s p i t a l s . When open communication was p r e s e n t between s t a f f members and between s t a f f and p a t i e n t s , i t was p o s i t i v e l y c o r r e l a t e d w i t h the p r e v a l e n c e o f t h e r a p e u t i c behavior (Cassee, 1975). Research c a r r i e d out by Skipper, T a g l i a c o z z o and Mauksch (1964) sought t o c l a r i f y the reasons f o r , and the consequences o f , l i m i t e d communication between p a t i e n t s and the people who take care o f them i n h o s p i t a l s . A b e l i e f e x i s t s 47 among p r o f e s s i o n a l s t h a t i n c r e a s e d p a t i e n t involvement i n the p a r t i c u l a r s o f h i s own h e a l t h c a r e , provokes p a t i e n t a n x i e t y , causes unnecessary worry and might, i n f a c t , make the p a t i e n t ' s c o n d i t i o n worse. Skipper e t a l . (1964) make the p o i n t t h a t a n x i e t y i s a normal component of i l l n e s s . Such normal a n x i e t y can be a c a t a l y s t i n h e l p i n g p r o f e s s i o n a l h e a l t h care workers e x p l o r e w i t h the p a t i e n t , the r a m i f i c a t i o n s o f h i s i l l n e s s and the probable e f f e c t s i t w i l l have on h i s f u t u r e l i f e s t y l e . I g n o r i n g the p a t i e n t ' s need f o r i n f o r m a t i o n adds a dimension o f f e a r of the unknown to an a l r e a d y a n x i e t y - l a d e n s i t u a t i o n . Skipper e t a l . (-1964). say that" nurses are more l i k e l y t o i n i t i a t e procedures designed to improve communication w i t h the p a t i e n t than p h y s i c i a n s , because nurses more o f t e n f i n d the experience p e r s o n a l l y s a t i s f y i n g . The authors see the d i f -f e r e n c e s between the s o c i o - c u l t u r a l backgrounds of most p h y s i c i a n s and those o f t h e i r p a t i e n t s , as b a r r i e r s to s a t i s f y i n g communication. Age, i n t e r e s t s , experience and language, combined w i t h an i n a b i l i t y t o c o r r e c t l y estimate the p a t i e n t ' s l e v e l o f medical s o p h i s t i c a t i o n and consequent understanding, a l l a c t to i n h i b i t the s a t i s f a c t i o n t h a t the p h y s i c i a n i s l i k e l y to experience from p e r s o n a l i n t e r a c t i o n with the p a t i e n t . The c o n c l u s i o n s drawn by Skipper e t a l . (1964) support the f i n d i n g s of a study designed by P r a t t , Seligmann and Reader (1957) to expl o r e the communication problems which e x i s t e d between 214 p a t i e n t s and t h e i r p h y s i c i a n s ( e i g h t y - n i n e i n number) i n a medical o u t p a t i e n t s c l i n i c , i n New York. The 48 r e s u l t s r e v e a l e d a b i a s , which caused the p h y s i c i a n s i n t h i s study, to under-rate c o n s i s t e n t l y the p a t i e n t - r e s p o n d e n t s ' knowledge of the e t i o l o g y , symptoms and treatment of ten common d i s e a s e s , even though the demonstrated l e v e l of medical s o p h i s t i c a t i o n among the p a t i e n t s was low. P r a t t e t a l . suggest, t h a t where p r o f e s s i o n a l s s e r i o u s l y under-estimate the consumer's l e v e l o f medical knowledge, they are l e s s l i k e l y t o t h i n k i t worthwhile to spend time e x p l a i n i n g t o the p a t i e n t , the f a c t s about h i s h e a l t h . The f i n d i n g s do not i n d i c a t e t h a t the p a t i e n t s were a s s e r t i v e i n t h e i r s earch f o r i n f o r m a t i o n , but the r e s e a r c h e r s c a u t i o u s l y r e p o r t t h a t " . . . there appeared to be an unformulated, l a t e n t d e s i r e f o r more i n f o r m a t i o n among the m a j o r i t y . " ( P r a t t e t a l . 1957:1283). F i n a l l y , i t emerged from t h i s study, t h a t the p a t i e n t s who had r e c e i v e d the best e x p l a n a t i o n of t h e i r c o n d i t i o n were more l i k e l y to p a r t i c i p a t e i n t h e i r own care more e f f e c t i v e l y . Samora, Saunders and Larson (1962) r e p l i c a t e d a p a r t of the study done by P r a t t et a l . i n 1957, u s i n g the same t h i r t y - s i x item q u e s t i o n n a i r e measuring p a t i e n t knowledge about ten common d i s e a s e s , with s i m i l a r r e s u l t s . Samora e t a l . found t h a t e d u c a t i o n a l l e v e l was the most p o s i t i v e l y c o r r e l a t e d v a r i a b l e a s s o c i a t e d w i t h knowledge about the d i s e a s e s t e s t e d by the r e s e a r c h instrument. These r e s e a r c h e r s concluded t h a t the l e v e l of h e a l t h knowledge shown by the respondents c o n s t i t u t e d a " . . . p o t e n t i a l b a r r i e r to e f f e c t i v e p h y s i c i a n / p a t i e n t communication." (Samora e t a l . 1962:185). 49 A more r e c e n t s t u d y i n A b e r d e e n , S c o t l a n d , b y M c K i n l e y w h i c h e x a m i n e d t h e a c t u a l and p e r c e i v e d u n d e r s t a n d i n g o f women o f l o w s o c i o - e c o n o m i c s t a t u s , u s i n g t h e s e r v i c e s o f a m a t e r n i t y c l i n i c , p r o d u c e d s i m i l a r r e s u l t s t o t h o s e o f P r a t t e t a l . ( 1 9 5 7 ) . M c K i n l e y s p e c i f i c a l l y r e l a t e s h i s f i n d i n g s t o t h e f a c t t h a t p h y -s i c i a n s i m p u t e i g n o r a n c e t o l o w e r s o c i o - e c o n o m i c g r o u p s . He i d e n t i f i e s t h i s t e n d e n c y a s a f u n c t i o n o f t h e s o c i a l d i s t a n c e b e t w e e n t h e p h y s i c i a n a n d h i s p a t i e n t ( M c K i n l e y , 1 9 7 5 ) . M c K i n l e y ' s o b s e r v a t i o n s a l s o showed t h a t p a t i e n t s l e a r n f r o m c o n t i n u e d e x p o s u r e t o t h e m e d i c a l e n v i r o n m e n t . The women who a t t e n d e d t h e m a t e r n i t y c l i n i c r e g u l a r l y and t h o s e who h a d h a d a p r e v i o u s p r e g n a n c y , d i s p l a y e d a b e t t e r u n d e r s t a n d i n g o f t h e m e d i c a l t e r m s t e s t e d , t h a n women h a v i n g t h e i r f i r s t b a b y o r t h o s e who d i d n o t a t t e n d t h e c l i n i c r e g u l a r l y ( M c K i n l e y , 1 9 7 5 ) . T h i s p a r t i c u l a r f i n d i n g m i g h t be t h e r e s u l t o f t h e t e a c h i n g u n d e r t a k e n , o u t s i d e t h e p h y s i c i a n / p a t i e n t r e l a t i o n s h i p , b y o t h e r h e a l t h c a r e w o r k e r s i n m a t e r n i t y c l i n i c s . L i n e h a n i n t e r v i e w e d 450 p a t i e n t s t o t r y t o f i n d o u t wha t p a t i e n t s w a n t t o know b e f o r e d i s c h a r g e f r o m h o s p i t a l . She p r o v i d e s a l i s t o f q u e s t i o n s w h i c h p a t i e n t s s t a t e d t h a t t h e y w a n t e d t o a s k , r a n g i n g f r o m , "What i s w r o n g w i t h me?" " A r e t h e y t e l l i n g me t h e t r u t h ? " t o "What d o e s ' t a k e i t e a s y ' mean?" and " W i l l i t r e c u r ? " ( L i n e h a n 1 9 6 6 : 1 0 6 8 ) . M o s t o f t h e e x a m p l e s o f p a t i e n t ' s q u e s t i o n s a r e c e n t e r e d a r o u n d d i a g n o s e s , p r o g n o s e s , s e l f - c a r e f o l l o w i n g d i s c h a r g e a n d whom t o a s k f o r i n f o r m a t i o n . The f i r s t t h r e e o f t h e s e c a t e g o r i e s a l s o emerge i n r e s e a r c h done b y Dodge (1969) b a s e d on i n t e r v i e w s w i t h 116 50 p a t i e n t s i n a g e n e r a l h o s p i t a l i n New York. The data i n t h i s study, showed a r e l a t i o n s h i p between the p a t i e n t ' s academic accomplishment and the type of i n f o r m a t i o n which he r a t e d as important to him. For example, Dodge suggests: . . . t h a t w hile p a t i e n t s want i n f o r m a t i o n which w i l l c l a r i f y the nature of t h e i r s i t u a t i o n s , they do not concern themselves w i t h t h i n g s which they are unable to understand. Second, . . . the kind of i n -formation sought at v a r i o u s e d u c a t i o n l e v e l s spans a continuum from a d e s i r e f o r simple n o n - f a c t u a l assurance that e v e r y t h i n g w i l l be a l l r i g h t to a d e s i r e f o r i n f o r m a t i o n which i s needed f o r a r r i v i n g a t one's own informed d e c i s i o n r e g a r d i n g h i s t r u e c o n d i t i o n (Dodge, 1969:511) . Three years l a t e r , i n 1972, Dodge r e p o r t e d the r e s u l t s o f f u r t h e r study o f the same s u b j e c t . She asked 139 p a t i e n t s and s i x t y - t w o nurses (both r e g i s t e r e d nurses and p r a c t i c a l nurses) to r a t e the importance t h a t they attached to the p a t i e n t having access to c e r t a i n types of i n f o r m a t i o n . Both the p a t i e n t s and the nurses agreed t h a t knowledge which a f f e c t e d the p a t i e n t ' s a b i l i t y t o perform adequately, both h i s p a t i e n t r o l e and h i s u s u a l s o c i a l r o l e f o l l o w i n g d i s c h a r g e , was " h i g h l y important" (Dodge, 1972). Disagreement between the two groups emerged i n areas concerned with the s p e c i f i c d e t a i l s of the p a t i e n t ' s i l l n e s s . Nurses r a t e d these matters of low importance and the p a t i e n t s i n d i c a t e d t h a t they were anxious t o know these d e t a i l s . Nurses s t r e s s e d the importance of e x p l a i n i n g to p a t i e n t s what was going to happen to them as they went through the v a r i o u s t e s t s and procedures d i c t a t e d by t h e i r p h y s i c i a n s . P a t i e n t s , on the other hand, expressed a need to know the r e s u l t s o f 51 t h e i r t e s t s and procedures, the names of medications they were t a k i n g and what t h e r a p e u t i c r e s u l t s they c o u l d expect from the medical and s u r g i c a l i n t e r v e n t i o n s to which they were sub-j e c t e d (Dodge, 1972). A l l of t h i s i n f o r m a t i o n would be a v a i l a b l e t o the p a t i e n t i f he were granted informed access to h i s own h e a l t h care r e c o r d as proposed i n the r e s o l u t i o n passed at the Annual Meeting o f the R e g i s t e r e d Nurses' A s s o c i a t i o n o f B r i t i s h Columbia i n 1976 (RNABC News, 1976:7). P a t i e n t access to h e a l t h care r e c o r d s i s , however, one o f the most c o n t r o v e r s i a l areas being debated by the proponents o f p a t i e n t r i g h t s and h e a l t h c a r e p r o f e s s i o n a l s . In f o r t y S t a t e s o f the U.S.A., the o n l y sure way a p a t i e n t has of see i n g what i s w r i t t e n i n h i s medical r e c o r d , i s when the r e c o r d i s subpoenaed by the c o u r t , a f t e r the p a t i e n t has f i l e d a m a l p r a c t i c e s u i t (Annas, 1974A:24). A d i s c u s s i o n of: the p a t i e n t ' s p r o p e r t y r i g h t s i n the i n f o r m a t i o n contained i n h i s medical r e c o r d - - i n the Un i t e d S t a t e s of A m e r i c a — i s a v a i l a b l e i n an a r t i c l e by Anthony. He s t a t e s : . . . i t appears t h a t a p a t i e n t has a q u a l i f i e d l e g a l r i g h t to see h i s own r e c o r d but must invoke the j u d i c i a l process o f mandatory i n j u n c t i o n to c l a r i f y t h i s r i g h t on a case-by-case b a s i s with the e x c e p t i o n o f the ten s t a t e s which a l l o w d i r e c t access to re c o r d s by s t a t u t e (Anthony, 1976:90). Shenkin and Warner i n 1973 suggested t h a t l e g i s l a t i o n should be passed i n America r e q u i r i n g h o s p i t a l s to p r o v i d e the p a t i e n t w i t h a "complete and unexpurgated" copy of h i s medical r e c o r d r o u t i n e l y . They s t a t e d t h a t : 52 . . . The r e c o r d would serve as an e d u c a t i o n a l t o o l . P a t i e n t s would c o n s u l t books or m e d i c a l personnel about u n f a m i l i a r words, and thus l e a r n p r o f e s s i o n a l terminology and concepts. F i n a l l y , i n c r e a s e d knowledge would l e a d to more a p p r o p r i a t e u t i l i z a t i o n of p h y s i c i a n s and a g r e a t e r a b i l i t y of p a t i e n t s t o p a r t i c i p a t e i n t h e i r own care (Shenkin and Warner, 1973:689) . Canadian law s t i p u l a t e s t h a t the h o s p i t a l owns the p h y s i c a l p r o p e r t i e s o f which the h e a l t h care r e c o r d i s composed, except i n the P r o v i n c e of Quebec, where th e r e i s no c l e a r cut d e c i s i o n on the matter (Rozovsky, 1974B:65) . Rozovsky (1974B:66) s t a t e s , t h a t a c c o r d i n g t o the few cases t h a t have been be f o r e the c o u r t s i n Canada, the p a t i e n t has a r i g h t of access to h i s h e a l t h care r e c o r d f o r the purpose o f l e a r n i n g what i s happening to him and f o r the purpose of making a copy of the r e c o r d . The P r o v i n c e of Quebec i s once again, a s p e c i a l case. In t h a t p r o v i n c e , a judge may r e f u s e the consumer access to h i s r e c o r d , i f he (the judge) i s of the o p i n i o n t h a t the i n f o r m a t i o n con-t a i n e d i n the r e c o r d , would be harmful to the h e a l t h of the consumer (Rozovsky, 1974:66). The b e l i e f t h a t access, by the p a t i e n t , to the i n -formation i n h i s own h e a l t h care r e c o r d would be d e t r i m e n t a l to h i s recovery, i s commonly advanced as one of the reasons f o r r e f u s i n g the p a t i e n t the r i g h t to read h i s own r e c o r d . Haug's documentation o f her i n f o r m a l i n t e r v i e w s w i t h h e a l t h p r a c t i t i o n e r s i n the U n i t e d Kingdom and the U.S.S.R. r e v e a l e d t h a t the p h y s i c i a n s i n t e r v i e w e d , i n both c o u n t r i e s , were agreed t h a t p a t i e n t s should not be allowed to see t h e i r own h e a l t h care r e c o r d s . 53 . . . For the p a t i e n t ' s own p r o t e c t i o n , the d o c t o r s agreed, t h e r e were some t h i n g s t h a t o n l y they should know (Haug, 1976:92). There was more emphasis p l a c e d on t e a c h i n g p a t i e n t s about h e a l t h , i n the p o l y c l i n i c s of the U.S.S.R. than was e v i d e n t i n the Un i t e d Kingdom. The medical s t a f f i n the U.S.S.R. re c o g n i z e d the i n c o n s i s t e n c y which e x i s t e d i n a t t a c h i n g so much importance t o p a t i e n t e d u c a t i o n i n an environment which s t i l l expected p a t i e n t compliance w i t h the p h y s i c i a n ' s o r d e r s without too many q u e s t i o n s (Haug, 1976). B l o o r and Horobin have a l s o i d e n t i f i e d t h i s dilemma i n t h e i r o b s e r v a t i o n s o f the e x p e c t a t i o n s which B r i t i s h g eneral p r a c t i t i o n e r s have of t h e i r p a t i e n t s . These authors have d e s c r i b e d the s i t u a t i o n as a "double b i n d " f o r the p a t i e n t s , because " . . . the s i c k person i s f i r s t encouraged to par-t i c i p a t e i n and then discouraged from the t h e r a p e u t i c process." (Bloor and Horobin, 1975:277). Des p i t e the c o n f l i c t i n g o p i n i o n s which the t o p i c generates, the l i t e r a t u r e r e p o r t s some s u c c e s s f u l attempts t o all o w the p a t i e n t f u l l and informed access t o h i s own h e a l t h care r e c o r d s (Orovan, 1972; Me d i c a l World News, 1975; Rothwell, 1976; G o l o d e t z et a l . 1976) and to oth e r r e l e v a n t medical i n f o r m a t i o n ( B a r t l e t t et a l . 1973; B l a i r , 1974) . The i n t r o -d u c t i o n , i n t o the s c i e n c e o f medical r e c o r d keeping, of the Problem O r i e n t e d M e d i c a l Record developed by Dr. Lawrence Weed (1969) has opened a door which may e v e n t u a l l y l e a d to b e t t e r access by the consumer t o h i s own h e a l t h c a r e r e c o r d . Weed (1975) advocates u s i n g the p a t i e n t ' s h e a l t h care r e c o r d as the 54 communicating l i n k between the p a t i e n t and a l l o t h e r members of the h e a l t h care team. T h i s author suggests t h a t each p a t i e n t should keep h i s h e a l t h c a r e r e c o r d i n h i s p o s s e s s i o n because i t i s p o s s i b l e t h a t he w i l l be the onl y constant member of the team i n v e s t i g a t i n g and d e a l i n g w i t h h i s i n d i v i d u a l problems over a p e r i o d of time. . . . The p a t i e n t must l e a r n to t h i n k of h i m s e l f as the most important and the most r e s p o n s i b l e of a l l the para-medical workers (Weed, 1975:78). Reports t h a t have emerged from the Medical Center H o s p i t a l i n Vermont, U.S.A., where the Problem Oriented M e d i c a l Record i s used, s t a t e t h a t the p r a c t i c e o f g i v i n g p a t i e n t s a copy of t h e i r h e a l t h care records r o u t i n e l y , has i n c r e a s e d t h e i r c o o p e r a t i o n , r e l i e v e d t h e i r a n x i e t i e s , and has had no harmful s i d e e f f e c t s (Medical World News, 1975; Rothwell, 1976; Gol o d e t z e t a l . 1976). One other u n i t — t h e Given Health Care Center i n B u r l i n g t o n , Vermont—found t h a t , o f e i g h t thousand p a t i e n t s given a carbon copy of t h e i r complete r e c o r d s , 93 per c e n t f e l t t h a t f r e e access t o the i n f o r m a t i o n i n the r e c o r d reduced t h e i r a n x i e t i e s about t h e i r h e a l t h . In a post -d i s c h a r g e e v a l u a t i o n of f i f t y p a t i e n t s o f the p r a c t i c e , about three q u a r t e r s o f the sample r e a c t e d p o s i t i v e l y to the i n n o v a t i o n (Medical World News, January 13, 1975:48). Kitt,, speaking to the members of the Canadian He a l t h Record A s s o c i a t i o n a t t h e i r Annual Meeting, h e l d i n Vancouver, Canada on October 14th 1977, about her experience as the A c t i n g D i r e c t o r o f the Med i c a l Record Department of a S e a t t l e , Washington, h o s p i t a l which has i n s t i t u t e d a p o l i c y f o r the 55 r e l e a s e to the p a t i e n t , on request, o f the i n f o r m a t i o n con-t a i n e d i n h i s c l i n i c a l r e c o r d , noted t h a t : . . . S u r p r i s i n g l y , most p a t i e n t s who are knowledgeable enough to request t h e i r r e c o r d s do not need p h y s i c i a n a s s i s t a n c e f o r f u l l i n t e r p r e t a t i o n of these records ( K i t t , 1977:2). She f e e l s t h a t most p h y s i c i a n s i n the h o s p i t a l a l r e a d y go to c o n s i d e r a b l e t r o u b l e to e x p l a i n to p a t i e n t s what i s happening because of the i n c r e a s e d emphasis on the need f o r informed p a t i e n t consent. As a r e s u l t , the p a t i e n t s are b e t t e r educated i n matters r e l a t i n g to t h e i r own care as w e l l as being aca-d e m i c a l l y more prepared to understand the terminology used i n the r e c o r d . K i t t s p e c u l a t e s t h a t : . . . i f the p h y s i c i a n knows t h a t the p a t i e n t s might have access to the i n f o r m a t i o n [ i n t h e i r r e c ords] t h e r e seems to be more w i l l i n g n e s s to i n f o r m the p a t i e n t s about medical care ( K i t t , P e r s o n a l communication, 1977). The R e g i s t r a r of the C o l l e g e of P h y s i c i a n s and Surgeons of B r i t i s h Columbia, Canada--Dr. W i l l i a m M c C l u r e — s u p p o r t s the e s t a b l i s h m e n t of p o l i c i e s and procedures to a l l o w the p a t i e n t access to h i s own c l i n i c a l r e c o r d . McClure says t h a t he has r e c e n t l y changed h i s mind on t h i s i s s u e . He f o r m a l l y spoke a g a i n s t the p r o p o s a l because he f e l t t h a t the p o t e n t i a l f o r i n c r e a s e d p a t i e n t a n x i e t y was h i g h and because of the danger of an i n f l a t e d r a t e of m a l p r a c t i c e s u i t s a g a i n s t d o c t o r s . McClure r e c o g n i z e s t h a t : . . . d o c t o r s are going to have to t e l l i t l i k e i t i s . . . S o c i e t y i s demanding i t s ' r i g h t s ' and d e c r y i n g medicine's p a t e r n a l i s t i c stance, o f t e n d e s c r i b e d as the 'arrogance o f p h y s i c i a n s ' (McClure, 1977:457). 56 A l o g i c a l p r o g r e s s i o n from a l l o w i n g p a t i e n t s f r e e access to the i n f o r m a t i o n i n t h e i r own h e a l t h care records occurs when s t a f f encourage p a t i e n t s to p a r t i c i p a t e i n com-p i l i n g t h e i r own r e c o r d s . Orovan d e s c r i b e s the s u c c e s s f u l use of such a program i n a s m a l l , short-term, p s y c h i a t r i c u n i t i n Montreal, Canada. P a t i e n t s , i n t h i s u n i t , were asked to c o n t r i b u t e to the Kardex Nu r s i n g Care Plan and to read and c o n t r i b u t e to n u r s i n g o b s e r v a t i o n s about t h e i r behavior. A f t e r a year o f o p e r a t i o n , the program was eval u a t e d as having exceeded the i n i t i a l , o p t i m i s t i c e x p e c t a t i o n s of the s t a f f . In t h i s program, the d o c t o r ' s progress notes were not a v a i l a b l e to the p a t i e n t s , a t the time t h a t the a r t i c l e was w r i t t e n (Orovan, 1972). Authors, w r i t i n g on the law i n the area of the p a t i e n t ' s r i g h t to have access t o the medical i n f o r m a t i o n i n h i s h e a l t h care r e c o r d , tend to ad v i s e h o s p i t a l a d m i n i s t r a t i o n not to encourage the p a t i e n t to e x e r c i s e h i s r i g h t s i n the matter (Rozovsky, I974B; C r e i g h t o n , 1970; Hayt and Hayt, 1972:1094). Rozovsky i n h i s book Canadian H o s p i t a l Law, suggests t h a t " . . . a t l e a s t w h ile the p a t i e n t i s i n h o s p i t a l h i s request f o r access to the r e c o r d be discouraged." (Rozovsky, 1974B:66). He e x p l a i n s h i s advice by m a i n t a i n i n g t h a t d i s c l o s u r e o f such i n f o r m a t i o n may be p s y c h o l o g i c a l l y d e t r i m e n t a l to the p a t i e n t . C r e i g h t o n — a lawyer and a nurse—when commenting upon whether or not the nurse should f e e l f r e e to answer p a t i e n t s ' q u e s t i o n s h o n e s t l y , a d v i s e s a g a i n s t such a t r e n d . 57 . . . When a p a t i e n t d e s i r e s more i n f o r m a t i o n about h i s c o n d i t i o n , i t i s prudent f o r a nurse to suggest t h a t the p a t i e n t c o n s u l t h i s do c t o r (Creighton, 1970:131). She i m p l i e s t h a t a nurse who b e l i e v e s h e r s e l f to be an autono-mous p r o f e s s i o n a l , accountable to the consumer/patient, i s l i k e l y to f i n d h e r s e l f i n t r o u b l e . . . . I f a nurse deports h e r s e l f w i t h d i s c r e t i o n , she w i l l not o n l y a v o i d l e g a l t r o u b l e s a r i s i n g from the wrongful p r a c t i c e o f medicine, but she w i l l a l s o make an important c o n t r i b u t i o n to l e s s e n i n g m a l p r a c t i c e s u i t s a g a i n s t p h y s i c i a n s and surgeons (Creighton, 1970:131). T h i s advice r e f l e c t s a p e r c e p t i o n , commonly h e l d i n the past, o f the nurse i n a h o s p i t a l s e t t i n g , a c t i n g w i t h i n the narrow c o n f i n e s of the p h y s i c i a n ' s a u t h o r i t y (Brown, 1948:47; Corwin and Taves, 1963; Peplau, 1966; Mauksch, 1966; S t e i n , 1967; Annas, 1974B; K a l i s c h and K a l i s c h , 1977) accountable to the p h y s i c i a n and to the i n s t i t u t i o n i n which she works and not d i r e c t l y to the p a t i e n t . K a l i s c h i n a d i s c u s s i o n of her r e a c t i o n s to the p a s s i v e p a t i e n t r o l e which she found h e r s e l f p l a y i n g when unexpectedly h o s p i t a l i z e d , d e s c r i b e s a d i f f e r e n t p e r c e p t i o n o f the nurse. . . . The nurse i s i n a key p o s i t i o n to help both the p a t i e n t and h i s f a m i l y d e a l e f f e c t i v e l y w i t h problems they may be e x p e r i e n c i n g , e i t h e r i n t h e i r r e l a t i o n s h i p w i t h the p h y s i c i a n o r wit h the advic e he has given ( K a l i s c h , 1975:25). K a l i s c h i s d e f i n i n g a r o l e f o r the nurse which comes under the heading o f ' p a t i e n t advocate'. The key i n g r e d i e n t s of the s u c c e s s f u l advocate r o l e i n c l u d e a c c o u n t a b i l i t y to the consumer of c a r e , combined w i t h the a b i l i t y to accept the p a t i e n t as an a c t i v e l y p a r t i c i p a t i n g member o f the h e a l t h care team and the 58 acceptance, by h e a l t h care p r o f e s s i o n a l s , of interdependent p r o f e s s i o n a l a c t i o n based on a s e l f image i n c o r p o r a t i n g p r o f e s s i o n a l competence and independence (Kosik, 1972; Annas, 1974B; K a l i s c h , 1975; Chapman and Chapman, 1975; K e l l y , 1976). Nursing Independence as a F a c t o r i n Interdependent P r o f e s s i o n a l A c t i o n N e a r l y t h i r t y years ago, E s t h e r L u c i l l e Brown i d e n t i f i e d a need f o r n u r s i n g to d e f i n e i t s interdependent a c t i v i t i e s . She ended a chapter, devoted to "The Future Role of the P r o f e s s i o n a l Nurse", i n her Report prepared f o r the N a t i o n a l N u r s i n g C o u n c i l , by q u o t i n g the words of a former Surgeon General of the U n i t e d S t a t e s P u b l i c Health S e r v i c e , Dr. Thomas S. Parram. The n u r s i n g p r o f e s s i o n w i l l make i t s best c o n t r i b u t i o n o n l y when i t i s o r g a n i z e d to work wit h the p u b l i c and to f i n d i t s p l a c e i n the team of a l l i e d p r o f e s s i o n a l groups ( c i t e d i n Brown 1948:100). Progress has been slow but, i n the 1970's, n u r s i n g has shown si g n s of some movement towards t h i s i d e a l . A l o t of energy and r e s o u r c e s have been i n v e s t e d i n a s t r u g g l e t o i d e n t i f y the unique c o n t r i b u t i o n which n u r s i n g has made to the d e l i v e r y o f h e a l t h c a r e (Johnson, 1959; 1961; 1968; and 1975; H a l l , 1964; Henderson, 1969; Roy, 1970; Wiedenbach, 1970; Mauksch and David, 1972; Rogers, 1975) . T h i s need of h e a l t h care workers to d e f i n e t h e i r s p e c i f i c c o n t r i b u t i o n to the d e l i v e r y of h e a l t h c a r e , has been d e s c r i b e d by Chapman and Chapman as: 59 . . . an understandable developmental phase f o r those p r o f e s s i o n a l s seeking p u b l i c i d e n t i t y and autonomy. I t i s s i m i l a r to the phase seen i n the growth and development of c h i l d r e n , of m i n o r i t y groups, and of new c o u n t r i e s (Chapman and Chapman, 1975:1). The n u r s i n g l i t e r a t u r e confirms t h a t n u r s i n g i s n e g o t i a t i n g the developmental stages of dependence and i n -dependence. There i s i n c r e a s i n g evidence t h a t the p r o f e s s i o n i s prepared to accept some of the r e s p o n s i b i l i t i e s a s s o c i a t e d w i t h interdependent r e l a t i o n s h i p s w i t h the consumer ( N o r r i s , 1970; L e v i n , 1972; Kramer, 1972; Quinn and Somers, 1974; Autrey, 197 4; Brandner, 197 4; Malkemes, 1974; K e l l y , 197 6; K i n l e i n , 1977) and w i t h o t h e r h e a l t h c a r e p r o f e s s i o n a l s (Mereness, 1970; L e i n i n g e r , 1971; Boudreau Report, 1972; Lambertson, 1972; Mauksch and Young, 1974; McCormack, 1974; Moore, 1974; Hellman, 1974; Harding et a l . , 1975; E l l i o t t , 1977). At present, n u r s i n g ' s progress towards the e s t a b l i s h -ment of interdependent 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 i s being recorded on both the p l u s and minus s i d e of the l e d g e r . For example, the October, 1977 i s s u e of the American J o u r n a l of  Nursing c a r r i e s a r e p o r t from Chicago, about a grant of $7 65,7 65 from the W.K. K e l l o g g Foundation, to f i n a n c e a three year p r o j e c t — t h e N a t i o n a l J o i n t P r a c t i c e Commission—which w i l l study the problem of e s t a b l i s h i n g j o i n t or c o l l a b o r a t i v e p h y s i c i a n - n u r s e p r a c t i c e i n h o s p i t a l s . The d i r e c t o r of t h i s p r o j e c t i s r e p o r t e d as s a y i n g : . . . We are convinced t h a t t h i s i n c r e a s e d c l i n i c a l c o l l a b o r a t i o n hinges on, f i r s t of a l l , p u t t i n g p r o f e s s i o n a l nurses i n a p o s i t i o n where they can be p r o f e s s i o n a l c o l l e a g u e s of p h y s i c i a n s . And t h a t means t h a t they have f u l l r e s p o n s i b i l i t y and a c c o u n t a b i l i t y to the p a t i e n t (American J o u r n a l of  Nursing, October 1977:1543, 1552). 60 An i n d i c a t i o n t h a t the o b j e c t i v e s of l e a d e r s of the n u r s i n g p r o f e s s i o n , as s t a t e d by A y d e l o t t e (1972:21) and N o v e l l o (1977:243) are s i m i l a r to those of medicine i s con-t a i n e d i n a statement by Harold Gardner, the p h y s i c i a n r e s p o n s i b l e f o r the e s t a b l i s h m e n t o f a s u c c e s s f u l nurse/ p h y s i c i a n j o i n t p r a c t i c e i n Rochester, New York. He says: . . . The important i s s u e i s meeting the needs of the consumer, r a t h e r than p r o t e c t i n g the p r e -r o g a t i v e s of the medical p r o f e s s i o n (American J o u r n a l  of Nursing, September, 1977:1466). The American J o u r n a l of Nursing (August, 1977) c o n t a i n s a n e g a t i v e assessment o f n u r s i n g ' s progress towards independent f u n c t i o n s . The June (1977) meeting of the American M e d i c a l A s s o c i a t i o n House of Delegates: . . . r e a f f i r m e d t h e i r p o s i t i o n t h a t both kinds o f p r a c t i t i o n e r s [ p h y s i c i a n ' s a s s i s t a n t s and nurse p r a c t i t i o n e r s ] should remain under the s u p e r v i s i o n of the p h y s i c i a n and c a l l e d f o r c o n t i n u i n g reimburse-ment by t h i r d p a r t y agencies o n l y to the employing p h y s i c i a n (American J o u r n a l of Nursing, August, 1977:1244). A p o s i t i o n , i n d i r e c t c o n t r a s t to t h i s statement, was taken by L o r e t t a Ford speaking before the House Committee on I n t e r s t a t e and F o r e i g n Commerce's h e a l t h subcommittee i n Washington, D.C.. She s t a t e d t h a t the c l a s s i f i c a t i o n s of p h y s i c i a n ' s a s s i s t a n t s , p h y s i c i a n extenders, p a r a p r o f e s s i o n a l s or m i d l e v e l p r a c t i t i o n e r s were not a c c e p t a b l e to p r o f e s s i o n a l nurses. Ford who was c o - d i r e c t o r of the f i r s t nurse pr a c -t i t i o n e r program a t the U n i v e r s i t y o f Colorado i n 1965, made the p o i n t t h a t : . . . T h i s l a b e l i n g denies the autonomy, a u t h o r i t y , and a c c o u n t a b i l i t y of the p r o f e s s i o n a l nurse . . . With such l a b e l i n g the p h y s i c i a n becomes the c e n t e r of the u n i v e r s e r a t h e r than the p a t i e n t (Ford, 1976:533). 61 The n u r s i n g p r o f e s s i o n , i n the U.S.A., views the p r e s e n t system o f t h i r d p a r t y insurance b e n e f i t s — w h i c h , i n most circumstances, r e f u s e s d i r e c t payment f o r n u r s i n g c a r e -as a d e n i a l of f a c t s which p o i n t to " . . . n u r s i n g p r a c t i c e [as] a d i s t i n c t i v e and unique component o f h e a l t h c a r e . " (Welch, 1975:1847). E f f o r t s to remedy the s i t u a t i o n are under way (Jennings, 1977) . The R u r a l H e a l t h C l i n i c s B i l l HR 8422 was s i g n e d i n t o law by the American Congress on December 13th 1977. The B i l l a u t h o r i z e s d i r e c t re-imbursement of r u r a l nurse p r a c t i t i o n e r s and p h y s i c i a n ' s a s s i s t a n t s under Medicare and Medicaid, p r o v i d e d t h a t the c l i n i c s from which the h e a l t h care workers operate, meet s p e c i f i c h e a l t h standards. In the p a s t , nurse p r a c t i t i o n e r s and p h y s i c i a n ' s a s s i s t a n t s c o u l d o n l y r e c e i v e payment, through Me d i c a i d and Medicare, i f a p h y s i c i a n was p h y s i c a l l y p r e s e n t i n the c l i n i c (American J o u r n a l  of Nursing, January, 1978:8). As a p a r t of n u r s i n g ' s push towards the e s t a b l i s h m e n t of independent s t a t u s , a need to support i n c r e a s e d academic q u a l i f i c a t i o n s f o r p r o f e s s i o n a l nurses i s apparent (Fagin, McClure and S c h l o t f e l d t , 1976). The New York State Nurses' A s s o c i a t i o n convention i n 1975 passed a p r o p o s a l , by m a j o r i t y vote, c a l l i n g f o r a r e v i s i o n of the New York S t a t e ' s E d u c a t i o n Law so t h a t , by 1985, a b a c c a l a u r e a t e degree i n n u r s i n g would be r e q u i r e d for. l i c e n s u r e as a r e g i s t e r e d nurse and an a s s o c i a t e degree i n n u r s i n g to o b t a i n a l i c e n s e as a p r a c t i c a l nurse, i n New York S t a t e (Sims, 1976). A counter p r o p o s a l has been suggested by M c G r i f f i n 62 w h i c h s h e s u g g e s t s t h a t a new l i c e n c e be c r e a t e d f o r a l r e a d y e s t a b l i s h e d b a c c a l a u r e a t e n u r s e s and t h o s e w i t h h i g h e r d e g r e e s " . . . w i t h a c o n t e n t m a j o r i n n u r s i n g . " ( M c G r i f f , 1 9 7 6 : 9 3 2 ) . She p r o p o s e s t h a t t h i s new l i c e n s u r e s h o u l d be r e q u i r e d o f a l l p r o f e s s i o n a l n u r s e s w i s h i n g t o p r a c t i c e a s i n d e p e n d e n t n u r s e s i n t h e S t a t e o f New Y o r k . G r e e n i d g e , Zimmern and K ohnke who h a v e e s t a b l i s h e d a p r i v a t e n u r s i n g g r o u p p r a c t i c e i n New Y o r k C i t y , w o u l d o b v i o u s l y be a f f e c t e d by e i t h e r p r o p o s a l , i f a c c e p t e d and i m p l e m e n t e d . T h e s e n u r s e s b e l i e v e t h a t : . . . a p r i v a t e p r a c t i c e i n n u r s i n g c a n n o t be e q u a t e d w i t h e i t h e r t h e e x t e n d e d o r e x p a n d e d r o l e o f n u r s e s . R a t h e r , we b e l i e v e o u r p r a c t i c e i s t h e f u l f i l l m e n t o f t h e b a s i c r o l e o f n u r s e s - -p r o v i d i n g s e r v i c e s d i r e c t l y t o t h e c l i e n t ( G r e e n i d g e , Zimmern and K o h n k e , 1 9 7 3 : 2 3 1 ) . K e l l e r ( 1 9 7 5 ) , L a n e ( 1 9 7 5 , A l f o r d and J e n s e n (1976) and K i n l e i n (1977) h a v e d e s c r i b e d t h e a d v a n t a g e s and d i s -a d v a n t a g e s a s s o c i a t e d w i t h t h e d e v e l o p m e n t o f i n d e p e n d e n t n u r s e p r a c t i c e s . K e l l e r s p e c i f i c a l l y a s s e r t s t h a t n u r s i n g ' s u n i q u e c o n t r i b u t i o n t o h e a l t h c a r e w i l l be r e c o g n i z e d when n u r s e s a r e i n d i v i d u a l l y more v i s i b l e a nd t h e i r p r o f e s s i o n a l s e r v i c e s a r e more d i r e c t l y a v a i l a b l e t o t h e p u b l i c . She s t a t e s t h a t i n d e p e n d e n t p r a c t i c e s u p p o r t s t h e g r o w t h and a c c e p t a n c e o f a s p i r i t o f i n t e r d e p e n d e n c e among c o n s u m e r s , n u r s e s and o t h e r h e a l t h c a r e p r o f e s s i o n a l s ( K e l l e r , 1 9 7 5 ) . The theme o f h e r a r t i c l e a g r e e s w i t h a s t a t e m e n t made by S z a s z , i n h i s summary o f t h e N a t i o n a l C o n f e r e n c e on A s s i s t a n c e t o P h y s i c i a n s , h e l d i n O t t a w a , C a n a d a , 63 . . . A s s i s t a n c e i s r e q u i r e d not so much to the p h y s i c i a n as t o the consumer, so t h a t he and h i s f a m i l y get more value out of the h e a l t h care system (Szasz, 1971:87). K e l l e r d e s c r i b e s h e r s e l f as a " c l i e n t - e x t e n d e r " r a t h e r than a " p h y s i c i a n - e x t e n d e r " . Her philosophy of care i s s t r u c t u r e d around: . . . p r o v i d i n g the c l i e n t w i t h s p e c i f i c i n f o r -mation and h e l p i n g him wit h the task o f p r o c e s s i n g t h a t i n f o r m a t i o n i n t o o p t i o n s t h a t are accep t a b l e w i t h i n h i s l i f e s t y l e and are a n t i c i p i t o r y [ s i c ] of d a i l y l i f e events ( K e l l e r , 1975:42). K i n l e i n expresses a very s i m i l a r philosophy of care i n her d e f i n i t i o n of n u r s i n g as " . . . a s s i s t i n g the person i n h i s s e l f - c a r e p r a c t i c e s i n regard t o h i s s t a t e of h e a l t h . " ( K i n l e i n , 1977:23). Her independent nurse p r a c t i c e i s based completely on t h i s concept which allows the c l i e n t to i d e n t i f y and make t h e r a p e u t i c use of h i s own s e l f - c a r e p r a c t i c e s . Bayer and Brandner have a l s o r e c o g n i z e d the value of i n t e r -dependent n u r s e / p a t i e n t p r a c t i c e . They p o i n t out, t h a t : As the nurse and the c l i e n t d i s c o v e r the h e a l t h y s t r e n g t h s t o g e t h e r — t h e nurse b r i n g i n g her s p e c i a l knowledge to the process and the c l i e n t c o n t r i b u t i n g h i s own uniqueness and s u r v i v a l a b i l i t y — t h e two can po o l c h o i c e s f o r f u r t h e r h e a l t h enhancement (Bayer and Brandner, 1977:87). The p h i l o s o p h i e s o f these independent nurse p r a c t i t i o n e r s are i n tune with the emergence of a more a s s e r t i v e , more soph-i s t i c a t e d approach by the consumer to h i s own h e a l t h c a r e . The consumer of the f u t u r e w i l l expect to be able to enter the h e a l t h care system, through a v a r i e t y o f channels, a c c o r d i n g to h i s needs. N o r r i s (1970) and L e i n i n g e r (1973 and 1975A) u n d e r l i n e the n e c e s s i t y f o r t h i s s o r t of m u l t i p l e access t o 64 h e a l t h care and they examine i t s c o u n t e r p a r t — h o w the system can be changed to accommodate d i r e c t access to the consumer/ p a t i e n t by h e a l t h care p r o f e s s i o n a l s , o t h e r than p h y s i c i a n s . L e i n i n g e r advocates the development o f an open systems model of h e a l t h care which, i n the f u t u r e , would: . . . p r o v i d e f o r a b r o a d l y conceived h e a l t h assessment p l a n i n which the c l i e n t may have a c h o i c e as to the p r o f e s s i o n a l person he and h i s f a m i l y wish to have h e l p him w i t h h i s h e a l t h problems ( L e i n i n g e r , 1973:174). The e s t a b l i s h m e n t of independent p r i v a t e p r a c t i c e by nurses i s one way of p r o v i d i n g the a l t e r n a t e access to care e n v i s i o n e d by N o r r i s and L e i n i n g e r w i t h advantages to both the consumer and the nurse. However, nurses i n p r i v a t e p r a c t i c e , although t h e i r numbers are growing ( S c h l o t f e l d t , 1977:8) are s t i l l a m i n o r i t y group. For most nurses, i n d e -pendence i s an i l l u s i o n . Nurses do not f i n d i t d i f f i c u l t to extend t h e i r r o l e when t h e i r a c t i v i t i e s meet wi t h the approval of t h e i r medical c o l l e a g u e s and cover areas r e j e c t e d by medicine (Shetland, 1975:112). Under these c o n d i t i o n s , the nurse i s f u n c t i o n i n g as a ' p h y s i c i a n extender' and not as a ' c l i e n t extender' (Rogers, 1975). Nurses, e s p e c i a l l y those remaining w i t h i n the h o s p i t a l s e t t i n g , f ace a d i f f i c u l t task to d i f f e r e n t i a t e themselves from the s t e r e o t y p e d r o l e imposed by t r a d i t i o n and h i s t o r y (Winstead-Fry, 1977) . A c c o u n t a b i l i t y to the p h y s i c i a n and the i n s t i t u t i o n i s deeply imbedded i n the h o s p i t a l environment (Malone, 1964; Johnson, 1971; Anderson e t a l . 1975). Christman s t a t e s t h a t the development of autonomous n u r s i n g s t a f f s 65 r e q u i r e s the acceptance of " n e w - l i f e s t y l e s " f o r nurses, i n c l u d i n g the concept o f f e e - f o r - n u r s i n g - s e r v i c e w i t h i n the i n s t i t u t i o n a l s e t t i n g . . . . Whether the p a t i e n t pays d i r e c t l y or not i s b e side the p o i n t : the p a t i e n t can determine from the b i l l p r e c i s e l y those s e r v i c e s which nurses have performed (Christman, 1976:42). Christman d e s c r i b e s an autonomous n u r s i n g s t a f f i n an i n s t i t u t i o n , as one prepared to accept p r o f e s s i o n a l r e s -p o n s i b i l i t y f o r t h e i r n u r s i n g p r a c t i c e d i r e c t l y . In t h a t p r o c e s s , nurses w i l l be expected to accept the r i s k s of l e g a l and p r o f e s s i o n a l m a l p r a c t i c e which emerge. Nurses seeking autonomy i n the i n s t i t u t i o n a l s e t t i n g must org a n i z e i n o r d e r : . . . e x p l i c i t l y t o permit: 1) the e x p r e s s i o n of c l i n i c a l s e l f - d i r e c t i o n among nurses; 2) the f u l f i l l m e n t of t h e i r r e s p o n s i b i l i t i e s to p a t i e n t s ; and 3) the acceptance of a f t e r - t h e - e v e n t s a n c t i o n s r a t h e r than before-the-event c o n t r o l s over p r a c t i c e (Christman, 1976:39). Implementation of the t h i r d p o i n t means the abandonment of a l l r i t u a l i z e d and r o u t i n i z e d p a t t e r n s of care as w e l l as the e l i m i n a t i o n o f the p r e s e n t l y p r e v a l e n t , h i e r a r c h i a l s t r u c t u r e used to monitor the q u a l i t y o f n u r s i n g care d e l i v e r e d to the p a t i e n t . The "new l i f e s t y l e s " (Christman, 1976) i n c l u d e a system o f s t a f f and p r a c t i c e p r i v i l e g e s , c o n t r o l l e d by nurses, s i m i l a r to the system used by medicine. Although he acknow-ledges the d i f f i c u l t i e s which the change to t h i s system w i l l generate, Christman b e l i e v e s t h a t they w i l l decrease as nurses demonstrate t h e i r competence i n p r o f e s s i o n a l p r a c t i c e . One of 66 the advantages l i s t e d i s lowered turnover because o f i n c r e a s e d work s a t i s f a c t i o n . Status w i l l abide i n f u l l s t a f f membership as so much energy i s devoted to becoming competent enough to earn f u l l s t a t u s (Christman, 1976:42). New l i f e s t y l e s imply a new i d e n t i t y . Deloughery and Gebbie, i n a chapter devoted to p r o f e s s i o n a l i s m , agree w i t h Chapman and Chapman (1975) t h a t a developmental process i s i n v o l v e d i n a c q u i r i n g p r o f e s s i o n a l i d e n t i t y . They make the assumption t h a t nurses have something to c o n t r i b u t e to the system: . . . based on [ t h e i r ] knowledge of and concern f o r the i n d i v i d u a l person's h e a l t h needs. Such a stage o f c o n t r i b u t i o n and interdependence can o n l y be reached a f t e r proceeding through the stages of s o c i a l i z a t i o n (dependence), p r o f e s s i o n a l i z a t i o n (independence) and i n t e g r a t i o n ( i d e n t i t y ) (Deloughery and Gebbie, 1975:135). Malkemes i n an examination of the r e s o c i a l i z a t i o n p rocess which accompanies the adoption of an expanded r o l e by the nurse, s t i p u l a t e s t h a t t h e r e i s more to the t r a n s f o r m a t i o n than the a c q u i s i t i o n o f new knowledge and s k i l l s . C r u c i a l to the success of the nurse p r a c t i t i o n e r i n r e a l i t y , i s a change i n her concept of h e r s e l f as accountable to an i n s t i t u t i o n , to t h a t of a c c o u n t a b i l i t y t o her c l i e n t . Malkemes d e f i n e s the nurse p r a c t i t i o n e r as a nurse: . . . who i s i n d i r e c t c o n t a c t w i t h c l i e n t s and f a m i l i e s ; i s accountable o n l y to the c l i e n t ; who works i n t e r d e p e n d e n t l y w i t h o t h e r s i n d e l i v e r i n g h e a l t h s e r v i c e s to c l i e n t s ; who becomes an advocate f o r the c l i e n t s ; and who i s c o n f i d e n t i n her a b i l i t y to p r a c t i c e i n the p r a c t i t i o n e r r o l e (Malkemes, 1974:90). The l a s t a t t r i b u t e which Malkemes d e s c r i b e s — " c o n f i d e n c e " — 67 w i l l i n f l u e n c e the p e r c e p t i o n s which other h e a l t h care p r o f e s s i o n a l s and the consumers of care have of the expanded n u r s i n g r o l e . I t i s a product of a r e s o c i a l i z a t i o n model which aims to teach p r o b l e m - s o l v i n g techniques i n three phases. In the f i r s t phase, i t i s assumed t h a t the p r a c t i t i o n e r students b r i n g w i t h them-into . the -program, " a degree of m o t i v a t i o n f o r change i n themselves and i n t h e i r n u r s i n g p r a c t i c e . " (Malkemes, 1974:92). Students are en-couraged to examine i n depth t h e i r p r e v i o u s l y h e l d a t t i t u d e s about h e a l t h s e r v i c e s and t h e i r r o l e i n the h e a l t h care system. Malkemes r e f e r s to t h i s stage as "dependent". She s t a t e s t h a t i t r e s u l t s i n a l o t o f student a n x i e t y and f r u s t r a t i o n , w i t h an i n c r e a s e d d e s i r e to t r y out the new nurse r o l e , even though some of the student a n x i e t y can be a t t r i b u t e d t o f e e l i n g s o f u n c e r t a i n t y surrounding t h e i r own assessment of t h e i r a b i l i t y to f u n c t i o n adequately i n the nurse p r a c t i t i o n e r r o l e (Malkemes, 1974). The second phase begins a t the h e i g h t of the nurse's i n s e c u r i t y . The emphasis changes to interdependent problem s o l v i n g w i t h f a m i l i e s and i n c r e a s i n g o p p o r t u n i t y to p r a c t i c e , w i t h f a c u l t y support, the nurse p r a c t i t i o n e r r o l e , " . . . h e l p i n g to e s t a b l i s h i t more f i r m l y as the nurse's i d e n t i t y . " (Malkemes, 1974:92). The t h i r d phase c o n s i s t s of a p e r i o d o f experience o f the nurse p r a c t i t i o n e r r o l e under the p r e c e p t o r -s h i p o f a p h y s i c i a n . Independent problem s o l v i n g i s the nucleus o f t h i s phase. The nurse has an o p p o r t u n i t y t o demon-s t r a t e her competence and to experience the s a t i s f a c t i o n of 68 e s t a b l i s h i n g h e r s e l f as a capable, independent, p r o f e s s i o n a l . These ex p e r i e n c e s stand the nurse i n good stead when she moves out of the student r o l e . The nurse, at the end of the program, i s " . . . a b l e to f u n c t i o n i n t e r d e p e n d e n t l y , w h i l e making sound independent judgments about c a r e . " (Malkemes, 1974:93). T h i s developmental approach to the education o f nurse p r a c t i t i o n e r s r e c o g n i z e s and attempts to remedy, one of the handicaps imposed by the dependent s t a t u s of the t r a d i t i o n a l nurse r o l e . In b u r e a u c r a t i c s e t t i n g s : . . . The nurse has been de l e g a t e d a d m i n i s t r a t i v e a u t h o r i t y and a c c o u n t a b i l i t y , but has not been granted r e s p o n s i b i l i t y f o r her own p a t i e n t s over an extended p e r i o d of time. R e s p o n s i b i l i t y has been f i x e d by p h y s i c a l l o c a t i o n , r o u t i n e s , and circumstances, w i t h c l i e n t s as temporary charges (Maas, 1976:39). I t , t h e r e f o r e becomes d i f f i c u l t f o r the nurse to p r o j e c t h e r s e l f as a competent, independent, p r o f e s s i o n a l g i v i n g i n d i v i d u a l i z e d , q u a l i t y p a t i e n t care. A dilemma e x i s t s f o r n u r s i n g which has been d e s c r i b e d by F r e i d s o n (1970:66) as a s t r u g g l e to escape from the narrow c o n f i n e s of medical domination i n a b u r e a u c r a t i c environment. Sheahan supports F r e i d s o n ' s view o f the s i t u a t i o n i n h o s p i t a l s , by s t a t i n g : . . . o n l y the p h y s i c i a n , c l i n i c a l l y speaking, makes p r o f e s s i o n a l d e c i s i o n s i n the h o s p i t a l , and, t h e r e f o r e , he alone f u n c t i o n s i n a p r o f e s s i o n a l c a p a c i t y (Sheahan, 1972:441). I f nurses are to break f r e e from the c o n s t r a i n t s of t h e i r dependent s t a t u s , they must f i r s t examine c l o s e l y o l d a t t i t u d e s and v a l u e s and cease to p l a y what Sheahan (1972) 69 has c a l l e d "the game of the name". H o s p i t a l a u t h o r i t i e s who p l a y t h i s game delude themselves i n t o t h i n k i n g t h a t the employment of a nurse wearing a p r o f e s s i o n a l l a b e l r e s u l t s , a u t o m a t i c a l l y , i n ' p r o f e s s i o n a l n u r s i n g c a r e ' , without r e c o g n i z i n g t h a t the environment i n which the nurse f u n c t i o n s i s the oth e r s i d e o f the equation. I t i s a b a s i c p r e r e q u i s i t e f o r the smooth t r a n s i t i o n of n u r s i n g i n t o areas which r e q u i r e acceptance of i n c r e a s i n g p r o f e s s i o n a l and consumer interdependence, f o r nurses i n i n t e r a c t i o n s w i t h o t h e r s , t o d i s p l a y a t t i t u d e s which are conducive to the development o f a s a t i s f a c t o r y c l i m a t e f o r change. The s o c i a l i z a t i o n o f the student i n t o the n u r s i n g p r o f e s s i o n i s pro f o u n d l y a f f e c t e d by the r o l e models t h a t they encounter i n the p r a c t i c e s e t t i n g . Christman speaking on a panel p r e s e n t a t i o n sponsored by the N a t i o n a l J o i n t P r a c t i c e Commission at the American Nurses' Convention i n A t l a n t i c C i t y , s a i d : . . . you can't change the s o c i a l i z a t i o n of the student i n t o t h e i r p r o f e s s i o n u n t i l you change the s t r u c t u r e under which nurses p r a c t i c e and the way they p r a c t i c e because t h a t ' s what students l e a r n . . . . As soon as nurses move i n t o becoming c l i n i c i a n s and do primary care w i l l i n g l y and take these a c c o u n t a b i l i t y r o l e s , the students w i l l be co-opted by the r o l e o f s o c i a l i z a t i o n and i t ' s not a problem (Christman, 1976:61). T h i s statement acknowledges t h a t the s e r v i c e environment c o n t a i n s "consequences" which n u r s i n g educators have tended, i n the p a s t , to ig n o r e , thus t r a n s f o r m i n g what should have been " a n t i c i p a t e d consequences" i n t o " u n a n t i c i p a t e d consequences". 70 The Leadership Role of the P r o f e s s i o n a l A s s o c i a t i o n The p r o f e s s i o n a l a s s o c i a t i o n i s one of the f o r c e s i n the e x t e r n a l environment which has the p o t e n t i a l to p r o v i d e support to the p r o f e s s i o n a l nurse as she enacts the p r o f e s -s i o n a l r o l e w i t h i n h e a l t h care f a c i l i t i e s or i n independent nurse p r a c t i c e (Merton, 1958). L a b e l l e , speaking t o the f i n a l p l e n a r y s e s s i o n o f the 16th Quadrennial Congress of the I n t e r n a t i o n a l C o u n c i l of Nurses, s t a t e d : . . . C o l l e c t i v e l y nurses at the l e v e l o f the i n s t i t u t i o n s and p r o f e s s i o n a l a s s o c i a t i o n s f o s t e r a c c o u n t a b i l i t y through the development of codes of e t h i c s , standards o f p r a c t i c e f o r e n t r y i n t o the p r o f e s s i o n and e v a l u a t i o n c r i t e r i a . For i n d i v i d u a l nurses a c c o u n t a b i l i t y means a n s w e r a b i l i t y and r e s p o n s i b i l i t y f o r outcomes of n u r s i n g a c t i o n s . . . (The Canadian Nurse, August 1977:39). A l i g n e d w i t h the p r o f e s s i o n a l a s s o c i a t i o n as t r e n d s e t t e r s and change agents are those l e a d e r s i n n u r s i n g who are a c t i v e i n the f i e l d s o f n u r s i n g e d u c a t i o n and n u r s i n g s e r v i c e a d m i n i s t r a t i o n . As l e a d e r s i n t h e i r p r o f e s s i o n a l a s s o c i a t i o n s and i n h e a l t h care f a c i l i t i e s they have m u l t i p l e i n p u t i n t o the change process and access t o the machinery of power from d i f f e r i n g a n g l e s . In an address to the Saskatchewan R e g i s t e r e d Nurses' A s s o c i a t i o n Annual Meeting i n 1975, i n Saskatoon, Marion J a c k s o n — n u r s i n g a d m i n i s t r a t o r — m a d e the o b s e r v a t i o n : . . . t h a t the m a j o r i t y of those who serve on C o u n c i l or i t s Committees tend to be i n management p o s i t i o n s i n e i t h e r n u r s i n g s e r v i c e or n u r s i n g e d u c a t i o n (Jackson, 1975:1). ( 71 Jackson s t a t e d t h a t , i n her p e r s o n a l experience, as her a d m i n i s t r a t i v e s t a t u s i n c r e a s e d so d i d her a c t i v e i n v o l v e -ment i n the p r o f e s s i o n a l A s s o c i a t i o n . She suggested t h a t the A s s o c i a t i o n should make more e f f o r t to r e c r u i t grass r o o t s members as r e p r e s e n t a t i v e s on the C o u n c i l and Committees of the A s s o c i a t i o n . She recommended t h a t s t a f f nurses be given p a i d time o f f to a t t e n d p r o f e s s i o n a l meetings (Jackson, 1975). The r e s u l t s o f a random survey of 7,500 readers con-ducted by the American J o u r n a l of Nursing i n 1970, which had a response r a t e of 40 p e r c e n t , agree w i t h Jackson's (1975) experience. The survey showed t h a t the respondents b e l i e v e d t h a t t h e i r p r o f e s s i o n a l a s s o c i a t i o n was not r e p r e s e n t a t i v e of a c r o s s s e c t i o n o f members or p o t e n t i a l members. The p u b l i s h e d r e p o r t of the survey, s t a t e s : The m a j o r i t y of the respondents b e l i e v e ANA speaks f o r the e l i t e groups i n n u r s i n g — d e g r e e h o l d i n g a d m i n i s t r a t o r s and educators (American J o u r n a l of  Nursing, A p r i l , 1970:813). The survey r e s u l t s support a statement by Corwin and Taves i n 1963, t h a t the m a j o r i t y of nurses are not a c t i v e l y engaged i n t h e i r p r o f e s s i o n a l o r g a n i z a t i o n as members. Corwin and Taves (1963) and Smith (1962) s t a t e t h a t , i n common wit h ot h e r u n d e r - p r i v i l e g e d groups, there e x i s t s i n n u r s i n g , a d i v i s i o n between persons at the grass r o o t s l e v e l and those i n l e a d e r s h i p p o s i t i o n s . In c o u n t r i e s where membership i n the p r o f e s s i o n a l n u r s i n g o r g a n i z a t i o n i s v o l u n t a r y , i t i s obvious to anyone who cares to study the membership f i g u r e s , t h a t the a s s o c i a t i o n 72 l a c k s t h e a u t h o r i t y t h a t i t m i g h t w i e l d , b e c a u s e i t r e p r e s e n t s o n l y a s m a l l p e r c e n t a g e o f t h e t o t a l m e m b e r s h i p . F o r e x a m p l e , i n 1 9 7 3 , a c c o r d i n g t o t h e 1976 e d i t i o n o f F a c t s A b o u t N u r s i n g , 14.4 p e r c e n t o f t h e t o t a l number o f r e g i s t e r e d n u r s e s i n t h e U.S.A. b e l o n g e d t o t h e A m e r i c a n N u r s e s ' A s s o c i a t i o n . E v e n i n c o u n t r i e s w h e r e m e m b e r s h i p i n t h e p r o f e s s i o n a l a s s o c i a t i o n i s m a n d a t o r y , i f t h e n u r s e w i s h e s t o p r a c t i c e a s a r e g i s t e r e d p r o f e s s i o n a l n u r s e , t h e power o f 100 p e r c e n t m e m b e r s h i p i s i l l u s o r y . N u r s e members a c t a s a s i l e n t m a j o r i t y on many i s s u e s ( Z i l m , 1 9 6 9 : 3 4 ) . Bowman and C u l p e p p e r h a v e s u g g e s t e d t h a t n u r s i n g a s s o c i a t i o n s t a k e p o s i t i o n s o n i s s u e s b u t f a i l t o f o l l o w up w i t h c o n s t r u c t i v e , a s s e r t i v e a c t i o n . C o n s e q u e n t l y , " . . . t h e y t e n d t o r e f l e c t t h e n e g a t i v e image o f t h e i r members." (Bowman a n d C u l p e p p e r , 1 9 7 4 : 1 0 5 5 ) . W i t h o u t t h e s u p p o r t , c o m m i t -ment and p a r t i c i p a t i o n o f t h e m a j o r i t y o f t h e members o f t h e p r o f e s s i o n , t h e r e a l i t y o f t h e s i t u a t i o n may be t h a t t h e " t a k i n g o f p o s i t i o n s " i s t h e h i g h e s t l e v e l a t w h i c h t h e a s s o c i a t i o n c a n e f f e c t i v e l y f u n c t i o n . N u r s e s , i n t h e p a s t , h a v e i g n o r e d t h e p o t e n t i a l s t r e n g t h and power i n h e r e n t i n b e i n g s e c o n d o n l y t o t h e p a t i e n t i n n u m e r i c a l s t r e n g t h w i t h i n t h e h e a l t h c a r e s y s t e m . Bowman and C u l p e p p e r d e s c r i b e t h e b e g i n n i n g s o f c h a n g e s w h i c h r e f l e c t an a w a r e n e s s o f t h e s t r e n g t h t o be f o u n d i n u n i t y . T hey s a y t h a t : . . . common c o n c e r n s a b o u t p a t i e n t a d v o c a c y , s t a n d a r d s o f p r a c t i c e , c o n t i n u i n g e d u c a t i o n , c e r t i f i c a t i o n , a c c o u n t a b i l i t y and o t h e r i s s u e s c o n -s t i t u t e w h a t c a n be c a l l e d s u p e r o r d i n a t e g o a l s f o r t h e p r o f e s s i o n (Bowman and C u l p e p p e r , 1 9 7 4 : 1 0 5 5 ) . 73 I f t h e i s s u e s i d e n t i f i e d by Bowman an d C u l p e p p e r a r e r e a l l y a r a l l y i n g p o i n t f o r c h a n g e , i t i s i m p e r a t i v e t h a t t h e p r o f e s s i o n a l n u r s i n g o r g a n i z a t i o n s g a i n a s e n s e o f t h e i r members' w i l l i n g n e s s t o s u p p o r t a s s e r t i v e a c t i o n s i n t h e s e a r e a s . A s s e r t i v e a c t i o n by n u r s e l e a d e r s i s , a c c o r d i n g t o L e i n i n g e r t h e v a r i a b l e w h i c h i s most p r o d u c t i v e o f r e s u l t s i n t o d a y ' s s o c i e t y . L e i n i n g e r ' s p o r t r a i t o f a n e f f e c t i v e n u r s e l e a d e r i s a c o u n t e r image o f t h e p a s s i v e , d e p e n d e n t n u r s e r o l e . She s a y s t h a t l e a d e r s o f t h e n u r s i n g p r o f e s s i o n : . . . must be n o t o n l y p o l i t i c a l l y and i n t e l l e c t u a l l y a s t u t e , b u t t h e y m u s t be g o o d r i s k - t a k e r s , f a i r l y a g g r e s s i v e , a c t i v e p u r s u e r s o f i s s u e s , and a l e r t t o a l t e r n a t i v e s t r a t e g i e s i n p u r s u i t o f an o b j e c t i v e . T h ey must h a v e s t r o n g e g o s , a p o s i t i v e s e n s e o f p e r s o n a l i d e n t i t y , a n d a d e t e r m i n a t i o n t o p r e s e r v e d e s i r a b l e p r o f e s s i o n a l v a l u e s ( L e i n i n g e r , 1 9 7 5 B : 6 3 ) . L e i n i n g e r s a y s t h a t t h e s e l e a d e r s h i p q u a l i t i e s a r e n e e d e d t o c o p e w i t h a c o m p l e x e n v i r o n m e n t i n w h i c h c o n f r o n t a t i o n and n e g o t i a t i o n a r e i n c r e a s i n g l y u s e d a s t e c h n i q u e s o f o r g a n i -z a t i o n a l c h a n g e ( L e i n i n g e r , 1 9 7 5 B ) . F o r a l e a d e r , s u c h a s L e i n i n g e r d e s c r i b e s , t o make a s i g n i f i c a n t i m p a c t , she m u s t f o r m a c o a l i t i o n w i t h f o l l o w e r s whose a t t i t u d e s and v a l u e s s u s t a i n and r e n e w t h e e n e r g i e s e x p e n d e d by t h e l e a d e r . N o v e l l o s t a t e s t h a t n u r s i n g i s w e l l endowed w i t h s t r o n g , i n n o v a t i v e l e a d e r s b u t , she b e l i e v e s t h a t t h e r e i s a n e e d t o d e v e l o p : . . . an a t t i t u d e among n u r s e s w h i c h f o s t e r s s u c h l e a d e r s and w h i c h w e l c o m e s t h e c h a l l e n g e s t h a t t h e y r a i s e . The d e s t i n y o f o u r p r o f e s s i o n i s d e p e n d e n t upon s u c h l e a d e r s h i p . And d e s t i n y i s a m a t t e r o f c h o i c e , n o t c h a n c e ( N o v e l l o , 1 9 7 7 : 2 4 3 ) . 74 E v e n i f s t r o n g s u p p o r t e x i s t s f o r an a s s e r t i v e , d y n a m i c l e a d e r , r i p p l e s a n d waves w i l l be c r e a t e d a s c h a n g e o c c u r s ( L e i n i n g e r , 1 9 7 5 B : 6 7 ) . O p p o s i t i o n f r o m t h e r a n k and f i l e m e m b e r s h i p o f p r o f e s s i o n a l o r g a n i z a t i o n s t o s i t u a t i o n s i n v o l v i n g p r o f e s s i o n a l c h a n g e h a s b e e n e x a m i n e d by S m i t h who a t t r i b u t e s i t t o f e e l i n g s o f i n s e c u r i t y a r o u s e d by t h e p r o p o s e d c h a n g e . He s a y s : . . . They [members] may f e e l c o m f o r t a b l e h a v i n g a c h i e v e d s u c c e s s o r r e c o g n i t i o n on t h e b a s i s o f t h e i r p r e s e n t s k i l l s . D r a s t i c c h a n g e s i n t h e s y s t e m may i n v i t e new c o m p e t i t i o n o r r e q u i r e new c o u r s e s o f e d u c a t i o n and t r a i n i n g ( S m i t h , 1 9 6 2 : 2 2 1 ) . T h e r e i s a t e n d e n c y t o v i e w r e s i s t a n c e t o c h a n g e a s a d e f e a t i s t m e chanism. K l e i n i n an e f f o r t t o i s o l a t e t h e r e a s o n s f o r , a n d t h e a d v a n t a g e s t o b e g a i n e d f r o m r e s i s t a n c e t o c h a n g e , h a s p a i d a t t e n t i o n t o t h e phenomena. He s u p p o r t s S m i t h (1962) by s t a t i n g t h a t r e s i s t a n c e t o c h a n g e " . . . may h a v e a s i t s f i r s t f u n d a m e n t a l o b j e c t i v e t h e d e f e n s e o f s e l f - e s t e e m , com-p e t e n c e and autonomy." ( K l e i n , 1 9 7 6 : 1 1 9 ) . Added t o t h i s , K l e i n c i t e s t h e " . . . f r e q u e n t a l i e n a t i o n o f t h e p l a n n e r s o f c h a n g e f r o m t h e w o r l d o f t h o s e f o r whom t h e y a r e p l a n n i n g . . . ." ( K l e i n , 1976:119) a s a p r i m e c a u s e o f t h e r e s i s t a n c e t o c h a n g e . G r o u p s who o p p o s e p l a n n e d c h a n g e (by r a d i c a l a l t e r n a t i v e s o r by v i g o r o u s * s u p p o r t o f t h e s t a t u s quo) a r e i m p o r t a n t f o r c e s whose i n v o l v e m e n t i n t h e c h a n g e p r o c e s s w i l l , i n some i n s t a n c e s , - l e a d t o : . . . t h e d e v e l o p m e n t o f more a d e q u a t e p l a n s and t o t h e a v o i d a n c e o f some h i t h e r t o u n f o r s e e n c o n -s e q u e n c e s o f t h e p r o j e c t e d c h a n g e ( K l e i n , 1 9 7 6 : 2 3 ) . R e s i s t a n c e t o c h a n g e i s n o t c o n f i n e d w i t h i n t h e g r o u p s whose members a r e m o s t d i r e c t l y a f f e c t e d b y i t . S t r o n g 75 o b j e c t i o n s may be g e n e r a t e d by p o w e r f u l o t h e r g r o u p s i n t h e e n v i r o n m e n t who f e e l t h e m s e l v e s t h r e a t e n e d b y t h e i m p l i c a t i o n s t h a t t h e c h a n g e p r o d u c e s ( S m i t h , 1 9 6 2 ) . The r e s u l t i n g c o n f l i c t i s o f t e n v i e w e d a s d e s t r u c t i v e b u t , i n f a c t , i t c a n be a r a l l y i n g p o i n t f o r a c t i o n . C o n f l i c t p r e c i p i t a t e s t h e u s e o f s t r a t e g i e s w h i c h w i l l i n c r e a s e t h e d r i v e t o w a r d s a c c e p t a n c e o f new c o n c e p t s o r t h e r e i n f o r c e m e n t o f o l d v a l u e s ( F i l l e y , 1 9 7 4 ) . C h a n g e s t h a t p o r t r a y t h e p a t i e n t a s a more p o w e r f u l c o n s u m e r o f c a r e , a r e t h r e a t e n i n g t o t h e p r o f e s s i o n a l ' s s e l f -c o n c e p t . N u r s e s , i n p a r t i c u l a r , a r e a f f e c t e d b e c a u s e t h e i r e v e r y d a y a c t i v i t i e s b r i n g them i n t o c l o s e p r o x i m i t y t o t h e c o n s u m e r f o r l o n g p e r i o d s o f t i m e . E v e n i f t h e r e s u l t s o f t h e i n t e r a c t i o n do n o t i m p l y a n e g a t i v e e v a l u a t i o n o f n u r s i n g c a r e , t h e y may c o n t a i n p a t i e n t b e h a v i o r t h a t t h e n u r s e c l a s -s i f i e s as "d e m a n d i n g " o r " u n c o o p e r a t i v e " ( V a c h o n , 1 9 7 6 : 4 2 ) . Consumer d i s s a t i s f a c t i o n e x p r e s s e d i n f a c e - t o - f a c e i n t e r a c t i o n i s h a r d t o h a n d l e . I t r e q u i r e s a h i g h l e v e l o f m a t u r i t y and ego s t r e n g t h t o h e a r w h a t t h e p a t i e n t i s r e a l l y s a y i n g . V a c h o n r e v i e w s some o f t h e r e p e r c u s s i o n s b e i n g e x -p e r i e n c e d b y n u r s e s b e c a u s e o f t h e i n c r e a s i n g s t r e s s i n t h e " c l i e n t e n v i r o n m e n t " . She i d e n t i f i e s t h e s t r e s s a s e m e r g i n g f r o m new v a l u e s and c o n c e p t s r e l a t i n g t o t h e s t a t u s o f p e o p l e who s e e k h e l p f r o m h e a l t h c a r e p r o f e s s i o n a l s . T h i s a u t h o r s t a t e s t h a t g r o u p a c t i o n t o d e v e l o p m e c h a n i s m s t o d e a l w i t h s t r e s s i n t h e e x t e r n a l e n v i r o n m e n t i s more s u c c e s s f u l t h a n i n d i v i d u a l a t t e m p t s t o c o p e w i t h s i t u a t i o n ( V a c h o n , 1 9 7 6 : 4 2 ) . 76 Her a r t i c l e suggests t h a t the a c t i o n taken by R.N.A.B.C. members to endorse the p u b l i c a t i o n "Consumer Rights i n Health Care" (1974) and the r i g h t , i n p r i n c i p l e , of the consumer to f u l l and informed access to i n f o r m a t i o n (RNABC WPWR, J u l y 1976) w i l l strengthen the attempts of i n d i v i d u a l nurses i n B r i t i s h Columbia, to p r o v i d e n u r s i n g care based on the concept of the consumer as a p a r t i c i p a t i n g member of the h e a l t h care team. Leaders who demonstrate an a b i l i t y t o n e g o t i a t e s u c c e s s -f u l l y the r i s k s i n v o l v e d i n p o l i t i c a l a c t i o n w i l l i n f l u e n c e the s e l f - i m a g e the average nurse-has of h e r s e l f , as capable o f i n i t i a t i n g the change pro c e s s . Mullane s t a t e s : . . . Nurses, who spend 24 hours each day with h o s p i t a l p a t i e n t s ( p h y s i c i a n s average about 10 minutes per p a t i e n t out of 24 hours) and who are the r e c i p i e n t s of the f e a r s and concerns p a t i e n t s h e s i t a t e to review w i t h t h e i r p h y s i c i a n s , owe to those p a t i e n t s g r e a t e r i n s i s t e n c e upon being heard (Mullane, 1975:701). Although c o l l e c t i v e a c t i o n i s important, t h e r e i s no doubt t h a t the i n d i v i d u a l — w h e t h e r w i t h i n the c o l l e c t i v e or o u t s i d e i t — i s r e s p o n s i b l e f o r t r a n s l a t i n g the i d e a l s of the p r o f e s s i o n i n t o r e a l i t y (Merton, 1958; Lysaught, 1970; L e v i n , 1972; Kramer, 1974; Christman, 1976; Jackson, 1976). Duke concludes the summary of her i n v e s t i g a t i o n i n t o the a b i l i t y of the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia to c o n t r o l n u r s i n g p r a c t i c e i n the P r o v i n c e of B r i t i s h Columbia, by s t a t i n g : . . . The power to c o n t r o l n u r s i n g p r a c t i c e i n h e r e n t i n the A s s o c i a t i o n or p r o f e s s i o n a l r o l e i s dependent on the members themselves. When they are a c t i v e l y i n v o l v e d i n promoting i n t e r e s t s of the p r o f e s s i o n , the a s s o c i a t i o n r o l e i s more powerful and i n f l u e n t i a l i n c o n t r o l l i n g n u r s i n g p r a c t i c e (Duke, 1976:32). 77 I n d i c a t i o n s e x i s t t h a t t h e i n t e r e s t s a n d v a l u e s o f t h e n u r s i n g p r o f e s s i o n a r e i n t e r d e p e n d e n t w i t h , t h o s e o f t h e c o n -sumer o f h e a l t h c a r e a n d t h a t n u r s i n g i s p r e p a r e d t o s t r u c t u r e i t s f u t u r e p l a n s , as Brown a d v i s e d i n 1970 " . . . i n a l l i a n c e , r a t h e r t h a n a t v a r i a n c e , w i t h [ t h e ] t r e n d . . . ." (Brown, 1 9 7 0 : 3 ) . U n d e r t h e s e c i r c u m s t a n c e s , t h e r o l e o f t h e p r o -f e s s i o n a l a s s o c i a t i o n s i s t o p r o v i d e l e a d e r s h i p w h i c h w i l l r e - f o c u s and r e i n t e g r a t e t h e e f f o r t s o f members t o a c h i e v e n u r s i n g ' s p r i m a r y t a s k — t h e d e l i v e r y o f q u a l i t y n u r s i n g c a r e w h i c h i s p r o d u c t i v e o f a h i g h i n d e x o f c o n s u m e r s a t i s f a c t i o n . Summary S o c i a l v a l u e s a n d a t t i t u d e s w h i c h p r e v i o u s l y s u p p o r t e d t h e c o n c e p t o f a d e p e n d e n t , p a t i e n t r o l e c o u n t e r b a l a n c e d b y t h a t o f a p o w e r f u l , p r o f e s s i o n a l , a u t h o r i t y f i g u r e i n t h e i n t e r a c t i o n b e t w e e n h e a l t h c a r e w o r k e r s and c o n s u m e r s o f h e a l t h c a r e , i s b e i n g c h a l l e n g e d . T h i s c h a n g e i s a p a r t o f a g e n e r a l t r e n d w h i c h r e c o g n i z e s t h e r i g h t o f t h e i n d i v i d u a l t o h a v e a c c e s s t o i n f o r m a t i o n - - p r e v i o u s l y c a r e f u l l y g u a r d e d b y t h o s e w i t h t h e n e c e s s a r y p o w e r — i n o r d e r t h a t t h e c o n s u m e r may e x e r c i s e more c o n t r o l o v e r t h e c o m p l e x d e c i s i o n s t h a t a r e an i n c r e a s i n g l y p r o m i n e n t p a r t o f o u r c o n s t a n t l y c h a n g i n g e n v i r o n m e n t . F o r many p a t i e n t s — e s p e c i a l l y t h o s e who a r e c r i t i c a l l y i l l — d e p e n d e n c y i s a n i n e v i t a b l e a n d n e c e s s a r y s t a t e w h i c h c o n -t r i b u t e s s i g n i f i c a n t l y t o t h e i r c h a n c e s o f s u r v i v a l . D e p e n d e n c y c a r r i e d t o e x t r e m e s , h o w e v e r , c a n r e s u l t i n t h e s i c k r o l e b e -c o m i n g s a t u r a t e d w i t h f e e l i n g s o f p o w e r l e s s n e s s . 78 The t r e n d by c o n s u m e r s t o q u e r y t h e s t e r e o t y p e o f t h e p a s s i v e l y d e p e n d e n t p a t i e n t a s r e l e v a n t i n t o d a y ' s s o c i e t y i s s u p p o r t e d b y t h e p r e s e n t p o l i t i c a l c l i m a t e i n Canada- The s p i r a l l i n g c o s t s o f h e a l t h c a r e h a v e r e s u l t e d i n an i n c r e a s e d g o v e r n m e n t a l f o c u s on m e a s u r e s d e s i g n e d t o r e d u c e s e l f i m p o s e d r i s k s , i n v e s t i g a t e e n v i r o n m e n t a l p r o b l e m s a nd e x t e n d o u r know-l e d g e o f human b i o l o g y ( L a l o n d e , 1 9 7 4 ) . T h e r e i s an i n c r e a s i n g e m p h a s i s on t h e p r e v e n t i o n o f i l l n e s s ( L a l o n d e , 1974) and on t h e n e e d t o p r o v i d e c a r e , b a s e d on t h e i n t e r d i s c i p l i n a r y h e a l t h t e a m c o n c e p t ( H a s t i n g s , 1 9 7 2 : 3 6 3 ) . L e v i n (1972:2008) h a s s u g g e s t e d t h a t by d e l i b e r a t e l y s e e k i n g t o c h a n g e t h e r e l a t i o n s h i p b e t w e e n t h e c o n s u m e r o f c a r e and p r o f e s s i o n a l n u r s e s , t h e n u r s i n g p r o f e s s i o n c o u l d c a r v e a n i c h e f o r i t s e l f — i n c o a l i t i o n w i t h t h e c o n s u m e r — w i t h b e n e f i t s t o b o t h p a r t i e s . The h i d d e n d a n g e r o f t h i s p r o p o s a l i s t h a t i t c o u l d i n c r e a s e t h e d e p e n d e n c y e x p e r i e n c e d b y t h e p a t i e n t s o n c e t h e y e n t e r t h e h e a l t h c a r e s y s t e m , u n l e s s h e a l t h c a r e w o r k e r s a r e p r e p a r e d t o g i v e h i g h p r i o r i t y t o t h e c o n s u m e r s ' r i g h t t o p a r t i c i p a t e a c t i v e l y i n t h e d e c i s i o n s made a b o u t t h e i r own h e a l t h c a r e . Consumer i n s i g h t s i n t o t h e i r p e r s o n a l d i s e a s e s and h e a l t h m a i n t e n a n c e s y s t e m s may p r o v i d e c l u e s w i t h r e g a r d t o b e h a v i o r r e i n f o r c e m e n t t h a t c a n c o n t r i b u t e t o t h e c o n s u m e r ' s s e l f - h e l p c a p a b i l i t y . ( L e v i n , 1 9 7 2 : 2 0 0 9 ) . I n c r e a s e d p u b l i c a w a r e n e s s o f t h e i s s u e s i n h e r e n t i n c o n s u m e r r i g h t s i n h e a l t h c a r e h a s h i g h l i g h t e d t h e c o n c e p t o f a c c o u n t a b i l i t y t o t h e c o n s u m e r b y i n d i v i d u a l h e a l t h c a r e p r o f e s s i o n a l s . T r a n s l a t i n g t h e r h e t o r i c o f c o n s u m e r r i g h t s a n d 79 a c c o u n t a b i l i t y f r o m a v a l u e p o s i t i o n i n t o m e c h a n i s m s w h i c h w i l l become p a r t o f p r o f e s s i o n a l r e a l i t y r e q u i r e s commitment t o c h a n g e a t a l l l e v e l s o f t h e h e a l t h c a r e s y s t e m . C h r i s t m a n s a y s t h a t : . . . i f p r o f e s s i o n a l p e r s o n s d e s i r e t h e r i g h t s a n d p r i v i l e g e s o f p r o f e s s i o n a l s t a t u s , t h e y a l s o s h o u l d be w i l l i n g t o w i t h s t a n d t h e o b l i g a t i o n s a n d a c c o u n t -a b i l i t y o f t h a t s t a t u s . ( C h r i s t m a n , 1 9 6 7 : 2 1 ) . One o f t h e p r o f e s s i o n a l o b l i g a t i o n s upon w h i c h C h r i s t m a n p l a c e s e m p h a s i s i s p a t i e n t e d u c a t i o n . T e a c h i n g p a t i e n t s how t o e v a l u a t e t h e c a r e t h a t t h e y r e c e i v e f r o m i n d i v i d u a l members o f t h e h e a l t h c a r e team a l l o w s t h e p a t i e n t s ' e x p e c t a t i o n s o f t h e h e a l t h w o r k e r s ' r o l e , as w e l l a s t h e i r own c o n t r i b u t i o n t o t h e t h e r a p e u t i c p r o c e s s , t o be more r e a l i s t i c and more a p p r o p r i a t e ( C h r i s t m a n , 1 9 6 7 : 2 1 ) . H e a l t h c a r e w o r k e r s i n d i r e c t c o n t a c t w i t h t h e c o n s u m e r h a v e t h e p o t e n t i a l t o c o n t r i b u t e t o t h e p a t i e n t ' s f e e l i n g s o f s e l f - w o r t h i n ways w h i c h " . . . a c t a s p o s i t i v e i n f l u e n c e s on a c c e l e r a t i n g t h e movement t h r o u g h t h e r e h a b i l i t a t i o n p h a s e " ( C h r i s t m a n , 1 9 6 7 : 2 0 ) . The r e v e r s e i s , o f c o u r s e , a l s o t r u e . P l a n n e d c h a n g e b y n u r s i n g l e a d e r s w h i c h r e c o g n i z e s and s u p p o r t s t h e e f f o r t s o f i n d i v i d u a l n u r s e s t o r e i n f o r c e a n d u p h o l d t h e r i g h t s o f t h e c o n s u m e r , c o u l d d e v e l o p a m o d e l o f p a t i e n t c a r e i n w h i c h t h e p a t i e n t : . . . w i l l become i n v o l v e d t o a g r e a t e x t e n t a s a h e l p f u l and k n o w l e d g e a b l e p e r s o n i n t h e p l a n n i n g and management o f h i s i l l n e s s a n d t h e s p e c i f i c e l e m e n t s o f . h i s c a r e . ( C h r i s t m a n , 1 9 7 6 : 1 8 ) . I n h e r e n t i n s u c h a c h a n g e p r o c e s s i s a p h i l o s o p h y w h i c h c o n f e r s i n c r e a s e d s t a t u s on t h e p a t i e n t as a p e r s o n c a p a b l e o f s e l f 80 d i r e c t i o n and a c o r r e s p o n d i n g d e c r e a s e i n t h e t e n d e n c y t o i n s i s t on an o m n i s c i e n t and o m n i p o t e n t r o l e f o r h e a l t h c a r e p r o f e s s i o n a l s . 81 CHAPTER I I I METHODOLOGY The s t u d y i s n o n - e x p e r i m e n t a l a n d e x p l o r a t o r y i n n a t u r e . A q u e s t i o n n a i r e ( P a n k r a t z and P a n k r a t z , 1974) d e s i g n e d t o m e a s u r e t h e a t t i t u d e s o f r e g i s t e r e d n u r s e s t o w a r d s N u r s i n g Autonomy a nd A d v o c a c y , P a t i e n t s ' R i g h t s a n d R e j e c t i o n o f T r a d i t i o n a l N u r s i n g R o l e L i m i t a t i o n s , was a d m i n i s t e r e d by m a i l . A c o m p u t e r l i s t o f t h e names a nd a d d r e s s e s o f r e g i s t e r e d n u r s e s , who w e r e members o f a D i s t r i c t o f t h e R e g i s t e r e d N u r s e s ' A s s o c i a t i o n o f B r i t i s h C o l u m b i a , C a n a d a a t t h e t i m e o f t h e s u r v e y , was o b t a i n e d f r o m t h e C o u n c i l o f t h a t A s s o c i a t i o n . The l i s t i n c l u d e d t h e b a s i c e d u c a t i o n a l q u a l i f i c a t i o n s o f members a nd t h e h i g h e s t e d u c a t i o n a l l e v e l a t t a i n e d by e a c h p e r s o n . The P a n k r a t z a n d P a n k r a t z (1974) A t t i t u d e S c a l e c o n t a i n s t h r e e c l u s t e r s o r s u b - s c a l e s , i s o l a t e d by EC TRY S y s t e m C l u s t e r and F a c t o r A n a l y s i s . ( T r y o n and B a i l e y , 1 9 6 6 ) . P a n k r a t z and P a n k r a t z (1974) i n d e v e l o p i n g t h e A t t i t u d e S c a l e , a d m i n i s t e r e d i t t o a t o t a l o f 7 02 n u r s e s u b j e c t s . T h e y o b t a i n e d r e l i a b i l i t y c o - e f f i c i e n t s f o r C l u s t e r #1 o f .93; f o r C l u s t e r #2 o f .81; and f o r C l u s t e r #3 o f .81 ( P a n k r a t z a n d P a n k r a t z 1 9 7 4 : 2 1 3 ) . The d a t a f r o m t h e 7 02 s u b j e c t s i n t h e P a n k r a t z a n d P a n k r a t z (1974) s t u d y , was a l s o a n a l y z e d u s i n g a p r i n c i p a l c o m p o n e n t s f a c t o r a n a l y t i c a p p r o a c h ( P i n n e a u e t a l . 1966) w i t h 82 s i m i l a r r e s u l t s t o t h o s e o b t a i n e d by t h e BC TRY S y s t e m C l u s t e r and F a c t o r A n a l y s i s , t h u s s u p p o r t i n g t h e v a l i d i t y o f t h e s u b - s c a l e s ( P a n k r a t z a n d P a n k r a t z 1974:215). The r e s u l t s showed t h a t h i g h s c o r e s o n t h e t h r e e s u b - s c a l e s ( i n d i c a t i n g p o s i t i v e r e s p o n s e s t o N u r s i n g Autonomy a n d A d v o c a c y , P a t i e n t R i g h t s a n d R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s ) w e r e : . . . a s s o c i a t e d w i t h e d u c a t i o n , l e a d e r s h i p , a c a d e m i c s e t t i n g a n d n o n - t r a d i t i o n a l s o c i a l c l i m a t e ( P a n k r a t z a n d P a n k r a t z , 1974:211). M e t h o d o f D a t a A n a l y s i s The d a t a w e r e a n a l y z e d u s i n g t h e c o m p u t e r s o c i a l s c i e n c e p r o g r a m SPSS ( N i e e t a l . 1975). F r e q u e n c i e s w e r e c a l c u l a t e d f o r a l l s u b j e c t s f r o m t h e d e m o g r a p h i c d a t a s u p p l i e d by t h e r e s p o n d e n t s . The s c o r e s o f a l l s u b j e c t s w e r e c o m p u t e d a c c o r d i n g t o t h e m e t h o d o f s c o r i n g o u t l i n e d i n A p p e n d i x c on page 165 f o r t h e P a n k r a t z and P a n k r a t z (1974) A t t i t u d e S c a l e w h i c h p r o d u c e s s c o r e s on t h r e e s u b - s c a l e s o r c l u s t e r s . The s u b - s c a l e s a r e l a b e l e d : 1) N u r s i n g Autonomy and A d v o c a c y , 2) P a t i e n t s ' R i g h t s , and 3) R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s . The sum, mean, s t a n d a r d d e v i a t i o n a n d v a r i a n c e o f t h e t o t a l s a m p l e , on e a c h s u b - s c a l e i n t h e P a n k r a t z and P a n k r a t z (1974) A t t i t u d e S c a l e , was c o m p u t e d and t h e n t h e sum, mean, s t a n d a r d d e v i a t i o n a n d v a r i a n c e a c c o r d i n g t o t h e s c o r e s o b t a i n e d by s i x g r o u p s d e f i n e d by t h e s i x i n d e p e n d e n t v a r i a b l e s : 83 1) A d m i n i s t r a t i v e p o s i t i o n , 2) F u l l time, p a r t time or i n a c t i v e s t a t u s , 3) Years of experi e n c e , 4) Work s e t t i n g , 5) Age, and 6) E d u c a t i o n . An a n a l y s i s o f v a r i a n c e was a l s o performed on each sub-s c a l e o f the A t t i t u d e S c a l e (Pankratz and Pankratz, 1974) broken down by the demographic, independent v a r i a b l e s named above. The F score o b t a i n e d was i n t e r p r e t e d using an alpha of 0.05. The s t a t i s t i c a l n u l l h y p o t h e s i s t e s t e d was t h a t , when each o f the three sub-scales was analyzed by each of the s i x independent v a r i a b l e s : M, = M_ = M_ . . . = M * Data C o l l e c t i o n A random sample s t r a t i f i e d by h i g h e s t e d u c a t i o n a l l e v e l o b t a i n e d , was drawn from the l i s t of members s u p p l i e d by the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia, Canada. Eighty-two percent of the sample h e l d a n u r s i n g diploma; f i f t e e n p e rcent h e l d a b a c c a l a u r e a t e degree; and three percent h e l d a Master's degree or h i g h e r . An N of 425 s u b j e c t s was sought, r e p r e s e n t i n g 10 percent of the t o t a l membership of the d i s t r i c t of the R e g i s t e r e d Nurses' A s s o c i a t i o n o f B r i t i s h Columbia, from which the sample was s e l e c t e d . * M^ = mean of f i r s t group; M^ = mean of second group; M^ = mean of t h i r d group and M n = mean of f i n a l group. 84 N i n e t y - n i n e p o i n t one p e r c e n t o f t h e 425 s u b j e c t s w e r e c o n t a c t e d p e r s o n a l l y b y t h e r e s e a r c h e r t h r o u g h a t e l e p h o n e c a l l , p r i o r t o t h e d e l i v e r y o f t h e q u e s t i o n n a i r e b y m a i l , i n o r d e r t o d e t e r m i n e t h e i r w i l l i n g n e s s t o p a r t i c i p a t e i n t h e s t u d y . S u b j e c t s f o r whom a t e l e p h o n e number was n o t a v a i l a b l e — w i t h t h e e x c e p t i o n o f f o u r s u b j e c t s — w e r e d r o p p e d f r o m t h e s t u d y a n d a s u b s t i t u t e was c h o s e n , a t random, f r o m t h e p o p u l a t i o n . A s u b s t i t u t e was a l s o c h o s e n , a t random, f o r t h o s e p e r s o n s c o n -t a c t e d who d i d n o t w i s h t o be i n c l u d e d i n t h e s t u d y . F o u r weeks a f t e r t h e l a s t q u e s t i o n n a i r e was m a i l e d , a s e c o n d t e l e p h o n e c o n t a c t was a t t e m p t e d t o t h o s e s u b j e c t s l i s t e d a s n o t r e t u r n i n g t h e c o m p l e t e d q u e s t i o n n a i r e . I f t h i s c a l l was u n s u c c e s s f u l b e c a u s e t h e s u b j e c t was n o t a t home, i t was n o t r e p e a t e d . No f u r t h e r e f f o r t was made t o c o n t a c t s u b j e c t s who d i d n o t r e s p o n d t o t h i s f i r s t r e m i n d e r . S u b j e c t s who r e t u r n e d q u e s t i o n n a i r e s w i t h o u t a n s w e r i n g a l l t h e q u e s t i o n s o r whose a n s w e r s r a i s e d q u e r i e s i n t h e m i n d o f t h e r e s e a r c h e r , w e r e c o n t a c t e d a s e c o n d t i m e and a s k e d t o c l a r i f y t h e i r a n s w e r s . T h r e e o f t h e s e s u b j e c t s w e r e n o t a v a i l a b l e b y t e l e p h o n e a t t h i s t i m e a n d t h e i r q u e s t i o n n a i r e s w e r e e x c l u d e d f r o m t h e a n a l y s i s o f t h e d a t a . R e s p o n s e R a t e T h i r t y - t w o n u r s e s ( o r 7 p e r c e n t o f t h e s a m p l e ) d i d n o t w i s h t o p a r t i c i p a t e i n t h e s t u d y . T h e r e f o r e , a t o t a l o f 457 c o m p l e t e d phone c a l l s was made t o o b t a i n t h e d e s i r e d number (425) o f r e s p o n d e n t s . The r e t u r n r a t e , one month a f t e r t h e l a s t 85 q u e s t i o n n a i r e was mailed, amounted to 382 q u e s t i o n n a i r e s or 88.88 percent o f the t o t a l sample. F o l l o w i n g a telephone reminder to those a v a i l a b l e s u b j e c t s who had not re t u r n e d t h e i r q u e s t i o n n a i r e s , ten s u b j e c t s (or 23.25 percent) out of a t o t a l of f o r t y - t h r e e non-respondents, r e t u r n e d t h e i r q u e s t i o n n a i r e s . The t o t a l response r a t e was, t h e r e f o r e , i n c r e a s e d by 3.35 p e r c e n t t o 392 q u e s t i o n n a i r e s , or 92.23 percent of the t o t a l sample. Of the f o u r s u b j e c t s to whom q u e s t i o n n a i r e s were mailed, without a p r i o r telephone c a l l , two ret u r n e d t h e i r q u e s t i o n n a i r e w i t h i n a reasonable time, one was r e t u r n e d by the post o f f i c e because i t was not d e l i v e r a b l e and one q u e s t i o n n a i r e was never r e t u r n e d . Table 1 Response Rate i n Percentages A c c o r d i n g to Highest E d u c a t i o n a l L e v e l A t t a i n e d E d u c a t i o n a l L e v e l Response Rate Percent Diploma i n Nursing B a c c a l a u r e a t e Degree Master's or Higher Degree 93.45 91. 8 76. 92 86 D e f i n i t i o n o f Terms R e g i s t e r e d Nurse A nurse who i s a member of the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia. His or her b a s i c n u r s i n g education may be a t the diploma l e v e l or the n u r s i n g degree l e v e l . N u r s i n g Autonomy The degree o f independence i n the work s i t u a t i o n t h a t r e g i s t e r e d nurses p e r c e i v e t h a t they have o r , t h a t they would be w i l l i n g to e x e r c i s e , i f the o p p o r t u n i t y presented i t s e l f . I t i s measured, i n t h i s study., by C l u s t e r #1 i n the Nursing A t t i t u d e S cale (Pankratz and Pankrats, 1974) which i s used as the data g a t h e r i n g instrument. High s c o r e s on the sub-scale i n d i c a t e a p o s i t i v e a t t i t u d e towards assuming an autonomous n u r s i n g r o l e . P a t i e n t Advocacy A measure o f how f l e x i b l y the nurse responds i n i n t e r -a c t i o n w i t h i n d i v i d u a l p a t i e n t s and of how w i l l i n g she i s to take a c t i o n on b e h a l f o f the p a t i e n t i f h i s r i g h t s are i n jeopardy and he (or a member o f h i s family) i s unable to remedy the s i t u a t i o n . I t i s measured, i n t h i s study, by C l u s t e r #1 i n the Nursing A t t i t u d e S c a l e (Pankratz and Pankratz, 1974) i n which i t c o - e x i s t s w i t h the measure of Nursing Autonomy. High scores on t h i s s u b - s c a l e suggest a w i l l i n g n e s s on the p a r t of the nurse to adopt a p a t i e n t advocate r o l e and to accept the r i g h t of the p a t i e n t to be i n c l u d e d i n the 87 d e c i s i o n m a k i n g p r o c e s s e s s u r r o u n d i n g h i s h e a l t h c a r e so t h a t h i s s e l f - c a r e p o t e n t i a l i s i m p l e m e n t e d t o t h e f u l l e s t e x t e n t p o s s i b l e . P a t i e n t R i g h t s R e f e r s t o t h e c o n c e p t s c o n t a i n e d i n t h e document t i t l e d "Consumer R i g h t s i n H e a l t h C a r e " , p u b l i s h e d by t h e C o n s u m e r s ' A s s o c i a t i o n o f C a n a d a i n 1974 ( A p p e n d i x A ) . I n t h i s s t u d y , a t t i t u d e s t o w a r d s P a t i e n t R i g h t s a r e m e a s u r e d by C l u s t e r #2 i n t h e N u r s i n g A t t i t u d e S c a l e ( P a n k r a t z and P a n k r a t z , 1 9 7 4 ) . T h i s s u b - s c a l e t a p s t h e d e g r e e o f i n d e p e n d e n c e t h a t t h e n u r s e i s p r e p a r e d t o c o n c e d e t o t h e c o n s u m e r , i n m a t t e r s r e l a t i n g t o h i s own c a r e a n d t r e a t m e n t . S t a t e m e n t s s u c h a s : " I b e l i e v e a p a t i e n t h a s a r i g h t t o h a v e a l l h i s q u e s t i o n s a n s w e r e d f o r h i m . " a r e d e s i g n e d t o p r o b e t h e n u r s e ' s a t t i t u d e s t o w a r d s t h e c o n s u m e r ' s r i g h t t o h a v e i n f o r m e d a c c e s s t o i n f o r m a t i o n a b o u t h i s c o n d i t i o n . H i g h s c o r e s on t h i s s u b - s c a l e , r e f l e c t a c c e p t a n c e o f t h e c o n s u m e r ' s r i g h t t o be an a c t i v e p a r t i c i p a n t on t h e h e a l t h c a r e t e a m, when d e c i s i o n s a r e b e i n g made t h a t i n v o l v e h i s h e a l t h and w e l l b e i n g . T r a d i t i o n a l N u r s i n g R o l e The t r a d i t i o n a l n u r s i n g r o l e p l a c e s t h e n u r s e i n a p o s i t i o n i n w h i c h s h e i s d e p e n d e n t upon t h e p h y s i c i a n f o r d i r e c t i o n i n h e r i n t e r a c t i o n w i t h t h e c o n s u m e r a n d , i n w h i c h , s h e i s u n w i l l i n g t o d i s a g r e e w i t h t h e p h y s i c i a n ' s d e c i s i o n s . I t i s m e a s u r e d by C l u s t e r #3 i n t h e N u r s i n g A t t i t u d e S c a l e ( P a n k r a t z and P a n k r a t z , 1974) i n t h i s s t u d y . H i g h s c o r e s on t h i s s u b - s c a l e i n d i c a t e a t t i t u d e s w h i c h r e j e c t t h e t r a d i t i o n a l 88 n u r s i n g r o l e and i t s a s s o c i a t e d b e h a v i o r s . N u r s e s s c o r i n g h i g h l y o n t h i s m e a s u r e w o u l d be e x p e c t e d t o s e e t h e m s e l v e s a s an e x t e n s i o n o f t h e p a t i e n t ' s i n t e r e s t s a n d n o t s i m p l y a t t h e p a t i e n t ' s b e d s i d e t o c a r r y o u t t h e p h y s i c i a n ' s o r d e r s . A s s u m p t i o n s 1) C o n s u m e r s o f h e a l t h c a r e c a n a d o p t a r e s p o n s i b l e and k n o w l e d g e a b l e r o l e i n t h e i r h e a l t h c a r e and t h e y a r e w i l l i n g t o do s o . 2) The q u a l i t y o f n u r s i n g c a r e w i l l i m p r o v e a s n u r s e s r e c o g n i z e a n d s u p p o r t t h e p a t i e n t ' s p o t e n t i a l f o r t h e r a -p e u t i c s e l f - c a r e p r a c t i c e s . •3) N u r s e s a r e c a p a b l e o f a d o p t i n g more i n d e p e n d e n t r o l e s i n h e a l t h c a r e w i t h t h e e m p h a s i s o n a c c o u n t a b i l i t y t o t h e p a t i e n t / c o n s u m e r . 4) A s e l e c t m i n o r i t y o f t h e t o t a l m e m b e r s h i p o f any p r o -f e s s i o n a l o r g a n i z a t i o n i s a c t i v e i n f o r m u l a t i n g and p r o m o t i n g t h e s t r a t e g i e s w h i c h d e t e r m i n e t h e d i r e c t i o n i n w h i c h t h e p r o f e s s i o n w i l l move. L i m i t a t i o n s 1) S u b j e c t s may n o t e x p r e s s t h e i r t r u e r e a c t i o n s t o t h e s t a t e m e n t s l i s t e d i n t h e N u r s i n g A t t i t u d e S c a l e ( P a n k r a t z and P a n k r a t z , 1 9 7 4 ) . 2) S u b j e c t s ' a t t i t u d e s , a s e x p r e s s e d i n t h i s s t u d y , may n o t c o r r e s p o n d t o t h e i r b e h a v i o r when c o n f r o n t e d w i t h a c t u a l s i t u a t i o n s r e q u i r i n g a b e h a v i o r a l r e s p o n s e . 3) The s u r v e y a p p r o a c h , u s e d i n t h i s s t u d y t o c o l l e c t d a t a , a l l o w s l i m i t e d c o n t r o l o v e r e x t r a n e o u s v a r i a b l e s . 4) The p o p u l a t i o n s a m p l e d , i n t h i s s t u d y , i s c o m p r i s e d o f r e g i s t e r e d n u r s e s l i v i n g and w o r k i n g i n a m e t r o p o l i t a n a r e a o f a l a r g e c i t y . T h e i r a t t i t u d e s t o w a r d s t h e q u e s t i o n s a s k e d may d i f f e r f r o m t h o s e o f r e g i s t e r e d n u r s e s l i v i n g a n d w o r k i n g i n l e s s u r b a n i z e d a r e a s . 5) A t i m e l a g , o f a p p r o x i m a t e l y one y e a r , e x i s t s b e t w e e n t h e a c c e p t a n c e by R.N.A.B.C. members o f t h e r e s o l u t i o n s p u t f o r w a r d a t t h e 1976 A n n u a l M e e t i n g o f R.N.A.B.C. and t h e 89 c o l l e c t i o n o f d a t a f o r t h i s s t u d y . I t i s l i k e l y t h a t a t t i t u d e s h a v e n o t r e m a i n e d s t a t i c i n t h i s p e r i o d . 90 CHAPTER IV PRESENTATION AND ANALYSIS OF DATA E d u c a t i o n a l L e v e l o f Respondents The random sample to whom the q u e s t i o n n a i r e was sent was s t r a t i f i e d by the h i g h e s t l e v e l of education obtained. Of the nurses i n the s t r a t i f i e d sample 82 percent h e l d a diploma i n nu r s i n g ; 15 percent h e l d a b a c c a l a u r e a t e degree, and 3 percent h e l d a Master's degree or hi g h e r . The d i s c r e p a n c y between the percentages, a c c o r d i n g to the e d u c a t i o n a l l e v e l of the s u b j e c t s who r e t u r n e d t h e i r q u e s t i o n n a i r e s and the s t r a t i f i e d sample to whom the q u e s t i o n n a i r e s were sent, i s the r e s u l t of two t h i n g s . 1) S u b j e c t s who h e l d a diploma i n n u r s i n g had a higher r a t e o f response (Table 1) than e i t h e r o f the othe r two groups. 2) The computer l i s t from which the random s t r a t i f i e d sample was s e l e c t e d , contained the names of some nurses who were d e s c r i b e d as having a b a c c a l a u r e a t e degree when, i n f a c t , they were s t i l l p u r suing t h a t o b j e c t i v e . They had obtained r e g i s t r a t i o n a f t e r the f i r s t two years of the ba c c a l a u r e a t e program i n n u r s i n g a t the U n i v e r s i t y o f B r i t i s h Columbia. One s u b j e c t who was l i s t e d as h o l d i n g a ba c c a l a u r e a t e degree had completed a Master's degree. The re t u r n e d q u e s t i o n -n a i r e s were checked a g a i n s t the computer l i s t i n t h i s area. Whenever a d i s c r e p a n c y was noted, the s i t u a t i o n was c l a r i f i e d w i t h the nurse i n q u e s t i o n by telephone. Table 2 Respondents A c c o r d i n g t o E d u c a t i o n a l L e v e l NUMBER PERCENT EDUCATIONAL LEVEL (N=389) Sample P o p u l a t i o n Diploma i n Nursing 323 83.0 82.0 B a c c a l a u r e a t e Degree 56 14.4 15.0 Master's or Higher Degree 10 2.6 3.0 T o t a l 389 100.0 100. 0 91 D e m o g r a p h i c D a t a 300 CO LU U z UJ o LU <_ 200 100 • ^ NURSE PRACTITIONER COMMUNITY HEALTH NURSE SUPERVISOR OR ADMIN. NURSE HEAD NURSE IH STAFF NURSE TEACHER OTHER F i g u r e 1 F r e q u e n c i e s b y A d m i n i s t r a t i v e P o s i t i o n N = 389 The d e m o g r a p h i c d a t a o b t a i n e d f r o m t h e s a m p l e i s d i s p l a y e d i n F i g u r e s o n e t o s i x . The e i g h t n u r s e s who r e s -p o n d e d t o t h e c a t e g o r y " N u r s e P r a c t i t i o n e r " , i n F i g u r e 1, we r e a s e l f - s e l e c t e d g r o u p . No f o r m a l d e f i n i t i o n was a t t a c h e d t o t h e c a t e g o r y b y t h e r e s e a r c h e r i n t h i s s t u d y and n u r s e s may d e f i n e t h e n u r s e p r a c t i t i o n e r r o l e i n a v a r i e t y o f ways. The c a t e g o r y " O t h e r " , i n F i g u r e 1 i n c l u d e s t h i r t y - s i x i n a c t i v e n u r s e s a s w e l l a s n u r s e s e n g a g e d i n P r i v a t e D u t y N u r s i n g and t h o s e n o t p r e s e n t l y w o r k i n g i n n u r s i n g , a l l o f whom r e t a i n t h e i r r e g i s t r a t i o n a s n u r s e s . 92 The m a j o r i t y o f n u r s e s i n t h i s s a m p l e (55.8 p e r c e n t ) w e r e e m p l o y e d a s s t a f f n u r s e s . C a n a d i a n s t a t i s t i c s show t h a t i n 1973, 118,897 n u r s e s w e r e e m p l o y e d i n n u r s i n g a n d o f t h e s e n u r s e s , 75 p e r c e n t w e r e w o r k i n g a s s t a f f n u r s e s ( C o u n t d o w n , 1974:8). 300 r co 200 UJ U Z UJ =5 o UJ " 100 HJ FULL TIME f l PART TIME • INACTIVE F i g u r e 2 F r e q u e n c i e s b y H o u r s o f Work N = 389 I n t h i s s a m p l e 21.6 p e r c e n t o f t h e r e s p o n d e n t s w ere e m p l o y e d p a r t t i m e . Of t h e 118,8 97 n u r s e s e m p l o y e d i n C a n a d a , 28 p e r c e n t w e r e e m p l o y e d p a r t t i m e . The g r e a t e s t p r o p o r t i o n o f n u r s e s who w o r k p a r t t i m e i n C a n a d a a r e e m p l o y e d a s s t a f f n u r s e s . 93 to UJ U Z LU o UJ 140 p 120 l -100 80 60 40 20 fp-0 _ \ UNDER 5 YEARS [~1 6-10 YEARS 11-15 YEARS OVER 15 YEARS F i g u r e 3 F r e q u e n c i e s b y Y e a r s o f E x p e r i e n c e N = 389 94 co LU U z LU o 300 r 200 100 HOSPITAL • COMMUNITY • EDUCATION n OTHER F i g u r e 4 F r e q u e n c i e s b y Work S e t t i n g N = 389 M o s t o f t h e r e g i s t e r e d n u r s e s i n t h i s s a m p l e w o r k e d i n a h o s p i t a l s e t t i n g (72.5 p e r c e n t ) . The s t a t i s t i c s c o l l e c t e d by t h e C a n a d i a n N u r s e s ' A s s o c i a t i o n i n 1973 showed t h a t 83 p e r c e n t o f t h e n u r s e s w o r k i n g i n C a n a d a w e r e e m p l o y e d i n h o s p i t a l : o r o t h e r i n s t i t u t i o n s ( C o u n t d o w n , 1 9 7 4 : 8 ) . 95 to UJ U Z LU o LU 160 140 120 100 80 60 40 20 0 H UNDER 20 YEARS g 21-30 YEARS [""] 31-40 YEARS ^ 41-50 YEARS 51-60 YEARS OVER 60 YEARS F i g u r e 5 F r e q u e n c i e s b y A g e o f S u b j e c t s N = 389 The c a t e g o r y " U n d e r 20 y e a r s " i n F i g u r e 5, w h i c h c o n t a i n e d o n l y t h r e e s u b j e c t s was m e r g e d w i t h t h e c a t e g o r y "21-30 y e a r s " f o r t h e p u r p o s e s o f a n a l y s i s . The number o f s u b j e c t s i n e a c h age g r o u p i n t h i s s t u d y , i s a p p r o x i m a t e l y e q u a l t o t h e number o f n u r s e s i n s i m i l a r age g r o u p s i n t h e t o t a l p o p u l a t i o n o f n u r s e s i n C a n a d a ( C o u n t d o w n , 1 9 7 4 : 1 7 ) . 96 co uj U 350 i -300 250 200 O £ 150 100 50 • DIPLOMA BACCALAUREATE DEGREE M.S.N. OR HIGHER F i g u r e 6 F r e q u e n c i e s b y H i g h e s t E d u c a t i o n a l L e v e l C o m p l e t e d N ! =•• 389 The c a t e g o r y " O t h e r " w h i c h a p p e a r e d i n t h e q u e s t i o n -n a i r e u s e d i n t h i s s t u d y u n d e r t h e h e a d i n g " H i g h e s t E d u c a t i o n a l Q u a l i f i c a t i o n C o m p l e t e d " , was m e r g e d w i t h t h e c a t e g o r y " D i p l o m a " i n F i g u r e 6, f o r t h e p u r p o s e s o f a n a l y s i s . The c a t e g o r y " O t h e r " c o n t a i n e d e i g h t e e n s u b j e c t s o r 4.6 p e r c e n t o f t h e t o t a l s a m p l e . By r e f e r e n c e t o t h e c o m p u t e r l i s t f r o m w h i c h t h e s a m p l e was d r a w n , i t was f o u n d t h a t t h e m a j o r i t y o f s u b j e c t s i n t h e c a t e g o r y " O t h e r " h a d c r e d i t s i n c o n t i n u i n g e d u c a t i o n b u t d i d n o t h o l d a U n i v e r s i t y d e g r e e . One s u b j e c t who ma r k e d " O t h e r " was r e c l a s s i f i e d a s " M a s t e r s o r H i g h e r D e g r e e " . 97 Data A n a l y s i s C l u s t e r #1 "Nursing Autonomy and Advocacy" The a n a l y s i s o f C l u s t e r #1 "Nursing Autonomy and Advocacy" by the independent v a r i a b l e " A d m i n i s t r a t i v e P o s i t i o n " (Table 3) produced means which ranged from 93.13 (teachers) to 81.13 ( s t a f f nurses) r e f l e c t i n g a tendency f o r nurses h o l d i n g l e a d e r s h i p p o s i t i o n s to p r o f e s s p o s i t i v e a t t i t u d e s towards n u r s i n g autonomy and advocacy, as measured i n t h i s study. The r e s u l t i s congruent w i t h the r e s u l t s o b t a i n e d when the C l u s t e r "Nursing Autonomy and Advocacy" was analyzed by the independent v a r i a b l e "Highest L e v e l of Educa t i o n Completed" (Table 13:109') • Although most of the groups were too small to a l l o w con-c l u s i o n s to be drawn about i n d i v i d u a l groups, the l a r g e s t group ( s t a f f nurses N = 217) was the only group w i t h a mean below the mean of the t o t a l sample. T h i s f i n d i n g c onfirms t h a t o f Pankratz and Pankratz who found t h a t nurses i n l e a d e r s h i p p o s i t i o n s were very p o s i t i v e i n the e x p r e s s i o n of t h e i r a t t i t u d e s towards n u r s i n g autonomy and p a t i e n t r i g h t s (Pankratz and Pankratz, 1974:215). Teachers, community h e a l t h nurses and s t a f f n u rses--w i t h i n which group occur both the h i g h e s t and the lowest means— had the lowest v a r i a t i o n w i t h i n the groups (standard d e v i a t i o n s of 10.79, 10.98 and 10.88 r e s p e c t i v e l y ) . Nurses w i t h i n these groups were more agreed i n the a t t i t u d e s t h a t they h o l d , about the amount of independence t h a t they—:and t h e i r p a t i e n t s — should e x e r c i s e w i t h i n t h e i r i n d i v i d u a l r o l e s , than was the case w i t h other c a t e g o r i e s . 98 Nurses who p l a c e d themselves i n the category o f "Nurse P r a c t i t i o n e r " had the second h i g h e s t mean of 89.13 but showed the widest v a r i a n c e i n t h e i r s c o r e s . The s i z e o f the group (N = 8) and the f a c t t h a t the term "Nurse P r a c t i t i o n e r " may have a wide v a r i e t y of meanings t o i n d i v i d u a l nurses, meant t h a t i t was d i f f i c u l t to draw meaningful c o n c l u s i o n s from the data obtained from t h i s group. Table 3 C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by " A d m i n i s t r a t i v e P o s i t i o n " , arranged from h i g h e s t mean to lowest > mean CATEGORY LABEL SUM MEAN S.D. * VAR.** N g, "5 Teacher 2142.00 93.13 10.79 116.39 23 5.9 Nurse P r a c t i t i o n e r 713. 00 89. 13 18. 76 351. 84 8 2. 1 S u p e r v i s o r or A d m i n i s t r a t i v e Nurse 2201. 00 88. 04 13. 83 191. 29 25 6. 4 Head Nurse 2244. oo 86. 30 11. 52 132. 62 26 6. 7 Community He a l t h Nurse 3015. 00 86. 14 10. 98 120. 66 35 9. 0 Other 4556. 00 82 . 84 13. 56 183. 92 55 14. 1 S t a f f Nurse 17606. 00 81. 13 10. 88 118. 45 217 55. 8 T o t a l Sample 32477. 00 83. 49 12. 14 147. 27 389 100. 0 *Standard D e v i a t i o n **Variance An a n a l y s i s o f v a r i a n c e (Table 4) performed on the two v a r i a b l e s "Nursing Autonomy and Advocacy" and " A d m i n i s t r a t i v e P o s i t i o n " produced an F of 5.561. The r e s u l t i n d i c a t e d t h a t a r e l a t i o n s h i p e x i s t e d between the two v a r i a b l e s which was s i g -n i f i c a n t a t w e l l below the 0.05 l e v e l . The hypothesis t h a t 99 the means were d i f f e r e n t i n t h i s sample was accepted. Table 4 A n a l y s i s of V a r i a n c e C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by " A d m i n i s t r a t i v e P o s i t i o n " SOURCE SUM OF SQUARES MEAN DF* SQUARE F SIG.** Between Groups 4590.278 6 765.046 5.561 0.0000 Wit h i n Groups 52548.920 382 137.563 ETA = 0.2834 ETA SQUARED = 0.0803 *Degrees of Freedom * * S i g n i f i c a n c e L e v e l The a n a l y s i s of C l u s t e r #1 "Nursing Autonomy and Advocacy" by "Hours of Work" r e s u l t e d i n a l o g i c a l o r d e r i n g of the means (Table 5). Nurses working f u l l time produced scores w i t h the h i g h e s t mean (84.91) and i n a c t i v e nurses scored the lowest mean (79.72). Nurses engaged f u l l time i n n u r s i n g can be expected to respond more p o s i t i v e l y to s t a t e -ments which p o r t r a y the nurse as an independent p r o f e s s i o n a l , because such s t a t u s i s more p r o d u c t i v e of work s a t i s f a c t i o n and f e e l i n g s of s e l f esteem (Bullough, 1974; Maas e t a l . 1975; Brandner, 1974) . Both p a r t time and i n a c t i v e nurses produced scores which r e s u l t e d i n means below the mean of the t o t a l sample (83.49). These nurses are l e s s l i k e l y to be as exposed to the concept of n u r s i n g autonomy and advocacy and i t s p o s s i b l e i n f l u e n c e on the f u t u r e of the n u r s i n g p r o f e s s i o n , than nurses working f u l l time i n the p r o f e s s i o n . 100 Table 5 C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Hours of Work" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S.D. VARIANCE N Q, "O F u l l Time 22840. 00 84.91 11.92 142.17 269 69. 2 Pa r t Time 6767. 00 80.56 12. 02 144.42 84 21. 6 I n a c t i v e 2870. 00 79.72 12.28 150.78 36 9. 3 T o t a l Sample 32477. 00 83.49 12.14 147.27 389 100. 0 An a n a l y s i s of v a r i a n c e on C l u s t e r #1 "Nursing Autonomy and Advocacy" and the independent v a r i a b l e "Hours of Work" showed t h a t the ob t a i n e d F of 6.179 was s i g n i f i c a n t a t the 0.0023 l e v e l (Table 6) and t h e r e f o r e , the hypothesis t h a t the means o f the sample were were d i f f e r e n t was accepted. The r e s u l t s suggested t h a t a r e l a t i o n s h i p e x i s t e d between the two v a r i a b l e s , "Nursing Autonomy and Advocacy" and "Hours of Work" i n t h i s study. Table 6 A n a l y s i s o f V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Hours,of Work" SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 1772.597 2 886.298 6 .179 0.0023 Within Groups 55366.601 386 143.437 ETA = 0.1761 ETA SQUARED = 0.0310 Subjects with 11-15 years experience o b t a i n e d the h i g h e s t mean when C l u s t e r #1 "Nursing Autonomy and Advocacy" was analyzed by the v a r i a b l e "Experience" (Table 7). These s u b j e c t s completed t h e i r b a s i c n u r s i n g e d u c a t i o n , p r i o r to 101 t h e t i m e t h a t t h e e x p a n d e d r o l e o f t h e n u r s e was b e g i n n i n g t o r e c e i v e a t t e n t i o n i n t h e n u r s i n g l i t e r a t u r e ( F o r d and S i l v e r , 1967; S k i n n e r , 1968; S i l v e r and D u n c a n , 1969; N a t i o n a l C o n f e r e n c e on A s s i s t a n c e t o t h e P h y s i c i a n , 1 9 7 1 ) . T h i s r e s u l t r e f l e c t s t h e f a c t t h a t , w i t h i n c e r t a i n l i m i t s , a c c u m u l a t e d e x p e r i e n c e l e a d s t h e n u r s e t o a c q u i r e a s e l f c o n c e p t b a s e d on h e r a b i l i t y t o f u n c t i o n w i t h c o n f i d e n c e and a s s u r a n c e i n h e r r o l e . As h e r e x p e r t i s e a n d s e l f c o n f i d e n c e i n c r e a s e , s h e i s more l i k e l y t o s u p p o r t p o s i t i v e a t t i t u d e s t o w a r d s s t a t e m e n t s p o r t r a y i n g t h e n u r s e a s an a utonomous p r o f e s s i o n a l a c c o u n t a b l e t o t h e c l i e n t , e s p e c i a l l y a s t h i s a t t r i b u t e h a s become more v a l u e d i n t h e n u r s i n g c u l t u r e . S u c h a n u r s e h a s p r o g r e s s e d , a t l e a s t p a r t way, t h r o u g h t h e r e s o c i a l i z a t i o n p r o c e s s d e s c r i b e d by Malkemes (1974) a s a p r e r e q u i s i t e f o r t h e s u c c e s s f u l a d o p t i o n o f t h e n u r s e p r a c t i t i o n e r r o l e . A t t h e same t i m e , t h i s g r o u p o f n u r s e s h a v e b e e n e x -p o s e d t o f o r c e s i n t h e e n v i r o n m e n t w h i c h h a v e p l a c e d i n c r e a s i n g e m p h a s i s on t h e n e e d f o r c o n t i n u i n g n u r s i n g e d u c a t i o n . C o n -f i r m a t i o n o f t h i s s t a t e m e n t i s c o n t a i n e d i n t h e f a c t t h a t t h e g r o u p i n c l u d e d f i v e o u t o f t h e t e n p e o p l e i n t h e t o t a l s a m p l e who h e l d a M a s t e r s d e g r e e o r h i g h e r . V a r i a n c e w i t h i n t h e g r o u p w i t h 11-15 y e a r s e x p e r i e n c e was w i d e r t h a n t h a t i n t h e g r o u p s w i t h l e s s e x p e r i e n c e , i n a c c o r d w i t h t h e t r a n s i t i o n a l p r o f i l e o f t h e r e s o c i a l i z a t i o n p r o c e s s ( M a l k e m e s , 1 9 7 4 ) . The two g r o u p s o f n u r s e s i n t h e s a m p l e , w i t h u n d e r 5 y e a r s e x p e r i e n c e and f r o m 6-10 y e a r s e x p e r i e n c e , h a d v e r y s i m i l a r means o f 84.96 and 84.67 r e s p e c t i v e l y . The s t a n d a r d 102 d e v i a t i o n of these groups i n d i c a t e d t h a t t h e i r scores were more c l o s e l y c l u s t e r e d than e i t h e r of the groups w i t h more expe r i e n c e . A change i n the b a s i c s o c i a l i z a t i o n of the nurse to her r o l e — both as a nurse and as a woman—has occu r r e d i n the l a s t ten y e a r s . More emphasis i s now p l a c e d , i n b a s i c n u r s i n g e d u c a t i o n a l programs, on the r o l e of the nurse as a member of the h e a l t h care team. T h i s i s r e f l e c t e d i n the a t t i t u d e s of the groups with l e s s than 10 years experience towards statements which p o r t r a y the nurse as e x e r c i s i n g independent judgement i n her i n t e r a c t i o n s w i t h p a t i e n t s and other h e a l t h care p r o f e s s i o n a l s . The group w i t h over 15 years experience showed the widest v a r i a t i o n i n scores and the lowest mean of 80.60 which was below the mean of the complete sample. The group c o n s i s t e d of 126 s u b j e c t s (32.4 p e r c e n t of the sample) and i n c l u d e d 110 diploma nurses, twelve b a c c a l a u r e a t e degree nurses and f o u r nurses h o l d i n g a Masters or h i g h e r degree. Because the group with over 15 years experience was twice as l a r g e as the 11-15 year group the e f f e c t of academic p r e p a r a t i o n was d i l u t e d . The group w i t h over 15 years experience contained 12.7 percent w i t h a b a c c a l a u r e a t e degree or h i g h e r as compared to 20.3 percent i n the group with 11-15 years experience. Added to t h i s , the group'with the most n u r s i n g experience has been exposed, f o r a longer p e r i o d of time, to a n u r s i n g c u l t u r e which accepted the t r a d i t i o n a l r o l e of the nurse as the norm. 103 Table 7 C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Experience" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S.D. V a r i a n c e N Q, "O 11-15 years 5441. 00 85. 02 13. .09 171. 48 64 16. .5 Under 5 years 9006. 00 84. 96 10. .30 106. 04 106 27 . . 2 6-10 years 7874. 00 84. 67 10. . 00 100. 05 93 23. .9 Over 15 years 10156. 00 80. 60 13. .98 195. 52 126 32. .4 T o t a l Sample 32477. 00 83. 49 12. . 14 147. 27 389 100. .0 The a n a l y s i s of v a r i a n c e performed on the C l u s t e r "Nursing Autonomy and Advocacy" by the v a r i a b l e "Experience" (Table 8) r e s u l t e d i n an F of 3.596 which i s - s i g n i f i c a n t at below the s t a t e d alpha f o r t h i s study (0.05). T h e r e f o r e , the hypothesis t h a t the means were d i f f e r e n t i n t h i s sample was accepted. The i n d i c a t i o n s are t h a 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 e x i s t s between C l u s t e r #1 "Nursing Autonomy and Advocacy" and the independent v a r i a b l e "Experience". Table 8 A n a l y s i s of V a r i a n c e , C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Experience" SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 1557.539 3 519. 180 3.596 0.0138 Wit h i n Groups 55581.659 385 144. 368 ETA = 0.1651 ETA SQUARED = 0.027 3 The o r d e r i n g of the means when C l u s t e r #1 "Nursing Autonomy and Advocacy" was analyzed by the independent v a r i a b l e " S e t t i n g " (Table 9) lends support to the f i n d i n g s of Pankratz and Pankratz 104 (1974) t h a t academic and n o n - t r a d i t i o n a l s e t t i n g s f o s t e r the growth o f a t t i t u d e s which value n u r s i n g autonomy and advocacy. The group, working i n an e d u c a t i o n a l s e t t i n g i n t h i s sample, was composed of eighteen nurses, evenly d i v i d e d between nurses h o l d i n g diploma, b a c c a l a u r e a t e and master '~s degree or h i g h e r . The nurses holdingmaster-'^s or higher degrees working i n e d u c a t i o n a l s e t t i n g s r e p r e s e n t e d 60 per c e n t of the ten nurses i n the master 1 s and h i g h e r group i n the s t r a t i f i e d sample. -—-The nurses working i n a h o s p i t a l s e t t i n g were the l a r g e s t group—282 or 72.5 percent o f the complete sample. The mean of t h i s group (82.62) was below the mean of the t o t a l sample. The b u r e a u c r a t i c s t r u c t u r e of the modern h o s p i t a l h e a l t h care f a c i l i t y does not encourage independent n u r s i n g a c t i o n (Malone, 1964; Mauksch, 1965; S t e i n , 1967; Kramer, 1974; Bullo u g h , 1976). People f i n d i t hard to t o l e r a t e i n c o n s i s t e n c y between t h e i r a t t i t u d e s and t h e i r everyday behavior. Research has shown t h a t people tend to a l t e r t h e i r o p i n i o n s and a t t i t u d e s to conform w i t h t h e i r behavior e s p e c i a l l y i f the behavior i s rewarded ( F e s t i n g e r and C a r l s m i t h , 1959). Nurses working i n a community s e t t i n g i n t h i s study, had the second h i g h e s t mean of 8 6.74.' The f o r t y - t h r e e s u b j e c t s i n t h i s group represented 11.1 percent of the t o t a l sample. They i n c l u d e d seventeen nurses w i t h a b a c c a l a u r e a t e degree and one with a masters or high e r degree (41.86 pe r c e n t o f t h i s stratum of the t o t a l sample). The b a s i c n u r s i n g e d u c a t i o n o f t w e n t y - f i v e nurses (or 58.1 percent) i n t h i s group was a t the diploma i n n u r s i n g l e v e l . Reference to the o r i g i n a l computer 105 l i s t from which the sample was drawn, i n d i c a t e d t h a t nine of these t w e n t y - f i v e nurses h e l d a b a s i c n u r s i n g diploma o n l y and seventeen h e l d a d i p l o m a / c e r t i f i c a t e i n a s p e c i a l t y area or u n i v e r s i t y c r e d i t s i n c o n t i n u i n g e ducation. I t was not p o s s i b l e t o d e f i n e the e d u c a t i o n a l s t a t u s of the group more p r e c i s e l y from the a v a i l a b l e d ata. The r e s u l t s suggest t h a t the s e t t i n g i n which the nurse p r a c t i c e s i s an important v a r i a b l e i n determining how the nurse w i l l r e a c t to statements designed to probe her a t t i t u d e s towards the dependent v a r i a b l e "Nursing Autonomy and Advocacy" i n t h i s study. Table 9 C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by " S e t t i n g " arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S .D. VARIANCE N Q. E d u c a t i o n 1668. 00 92. 67 11 .46 131. 41 18 4. 5 Community 3730. 00 86. 74 12 .55 157 . 39 43 11. 1 H o s p i t a l 23301. 00 82. 62 11 .77 138. 52 282 72. 5 Other 3778 . 00 82. 13 12 . 57 157. 89 46 11. 8 T o t a l Sample 32477.00 83.49 12.14 147.27 389 100.0 The i n d i c a t i o n t h a t a r e l a t i o n s h i p e x i s t e d between C l u s t e r #1 and the independent v a r i a b l e " S e t t i n g " was confirmed by an F of 5.299 which was s i g n i f i c a n t a t the 0.0014 l e v e l (Table 10). The h y pothesis t h a t the means obtained i n t h i s sample were d i f f e r e n t was accepted. 106 Table 10 A n a l y s i s o f V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by " S e t t i n g " SOURCE •SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 2265.890 3 755.297 5 .299 0.0014 W i t h i n Groups 54873.308 385 142.528 ETA = 0.1991 ETA SQUARED = 0.0397 The means of the groups showed decrease w i t h age when C l u s t e r #1 "Nursing Autonomy and Advocacy" was analyzed by the indepen-dent v a r i a b l e "Age" (Table 1 1 ) . The under 30 years group had the h i g h e s t means of a l l groups ( 8 5 . 6 4 ) . The next two g r o u p s — aged 31-40 and 41-50 y e a r s — p r o d u c e d very s i m i l a r means (84.41 and 84.32) to each other and to the group p r e c e d i n g them i n Table 11. Then there was a s i x p o i n t drop i n the mean of su b j e c t s between 51-60 years t o 78.12 and a twelve p o i n t drop i n the mean obtained by s u b j e c t s over 60 years o f age. The p a t t e r n i s c o n s i s t e n t w i t h changes which have oc c u r r e d over time i n the educa t i o n o f nurses. S o c i a l f o r c e s i n the external" environment, such as the l i b e r a l i z i n g e f f e c t of the women's movement on a predominantly -female work -force and the i n c r e a s i n g exposure of nurses—who are both consumers and p r o v i d e r s o f h e a l t h c a r e — t o the arguments of the p a t i e n t s ' r i g h t s movement, are a l s o r e f l e c t e d i n the o r d e r i n g of the means a c c o r d i n g t o age group. 107 The standard d e v i a t i o n s i n Table 11 show t h a t the group w i t h the h i g h e s t mean and the group w i t h the lowest mean ( i . e . the youngest and the o l d e s t age groups) have the lowest v a r i a t i o n i n s c o r e s — 1 0 . 2 4 and 10.36 r e s p e c t i v e l y . Of the eleven nurses i n the "over 60" bracket, f i v e (45.5 percent) were i n a c t i v e . Although the group was s m a l l , the f i g u r e s show t h a t the m a j o r i t y of the "over 60" s u b j e c t s i n t h i s study have r e t a i n e d a c t i v e membership i n the work p l a c e . Table 11 C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Age" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S.D • VARIANCE N Q. *o Under 30 years 12161. 00 85.64 10. 24 104.98 142 36. 5 31-40 years 9285. 00 84.41 . 11. 73 137.51 110 28. 3 41-50 years 6240. 00 84.32 12. 14 147.32 74 19. 0 51-60 years 4062. 00 78.12 13. 97 195.20 52 13. 4 Over 60 years 729. 00 66. 27 10. 36 107.42 11 2. 8' T o t a l Sample 32 477. 00 83.49 12. 14 147.27 389 100. 0 A sharp d i v i s i o n i n the a t t i t u d e s expressed by those s u b j e c t s under f i f t y years of age and those over f i f t y was e v i d e n t i n t h i s study. The a n a l y s i s of v a r i a n c e produced an F of 10.357 which was s i g n i f i c a n t a t w e l l below the 0.05 l e v e l (Table 12) i n d i c a t i n g t h a t a r e l a t i o n s h i p e x i s t s between the a t t i t u d e s expressed by s u b j e c t s on the t o p i c of "Nursing Autonomy and Advocacy" (as measured i n t h i s study) and age group. The hypothesis t h a t the means were d i f f e r e n t was accepted. 108 Table 12 A n a l y s i s of V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Age" SUM OF MEAN SOURCE SQUARES DF SQUARE F SIG. Between Groups 5564.218 4 1391.055 10.357 0.0000 Wit h i n Groups 51574.980 384 134.310 ETA = 0.3121 ETA SQUARED = 0.097 4 The category "Other", which was merged with the category "Diploma" when the v a r i a b l e "Nursing Autonomy and Advocacy" was analyzed by the independent v a r i a b l e "Education" (Table 13), c o n t a i n e d e i g h t e e n s u b j e c t s w i t h a mean of 7 8.78 and a standard d e v i a t i o n of 13.06. The r e s u l t s d e p i c t e d i n Table 13 support the f i n d i n g s of Pankratz and Pankratz (1974) t h a t exposure to programs of h i g h e r education makes nurses more p o s i t i v e i n t h e i r a t t i t u d e s to statements p o r t r a y i n g the nurse as an autonomous p r o f e s s i o n a l . The impact of education as a s o c i a l i z i n g process has a l s o been demonstrated i n a study by Bullough and Sparks (1975:691) which i n d i c a t e d t h a t students are s o c i a l i z e d to accept the v a l u e s of f a c u l t y members, c u r r i c u l u m content or both. Schmahl, 1966; T o r r e s , 1974; Malkemes, 1974 and Januska e t a l . 1974 a l l s t r e s s t h a t e d u c a t i o n i s one p a r t of a complex r e -s o c i a l i z a t i o n process which must take p l a c e b e f o r e nurses can f u n c t i o n comfortably as independent h e a l t h care p r o f e s s i o n a l s . Support f o r the f i n d i n g s i n the p r e s e n t study i s a l s o forthcoming from a review of the backgrounds of nurses who have t r a n s l a t e d t h e i r a t t i t u d e s about n u r s i n g independence 109 i n t o very v i s i b l e behavior by s e t t i n g up independent nurse p r a c t i c e s . Those nurses who have p u b l i s h e d accounts of t h e i r experiences i n independent p r a c t i c e have a l l pursued t h e i r e d ucation beyond the b a c c a l a u r e a t e degree i n n u r s i n g (Greenidge e t a l . 1973; Lane, 1975; K e l l e r , 1975 and K i n l e i n , 1977) . The means were ordered i n step w i t h the h i g h e s t l e v e l of e d u c a t i o n a t t a i n e d by the s u b j e c t s i n t h i s study. Those persons h o l d i n g a master's degree or hig h e r scored the h i g h e s t mean (97.20) and those with a diploma i n n u r s i n g , the lowest (81.46). The standard d e v i a t i o n s r e v e a l e d t h a t nurses w i t h i n c r e a s e d education are more agreed w i t h i n t h e i r group on the s u b j e c t o f a t t i t u d e s towards "Nursing Autonomy and Advocacy" as measured by t h i s study, than are nurses who h o l d a diploma i n n u r s i n g . The wider standard d e v i a t i o n among diploma nurses (11.67) may r e f l e c t a s t a t e o f t r a n s i t i o n i n a t t i t u d e s w i t h i n t h i s group. Table 13 C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Education" arranged from highest.mean to lowest mean CATEGORY LABEL SUM MEAN S. D. VARIANCE N o. Masters or Higher Degree 972. 00 97.20 7. 96 63.29 10 2.6 Baccalaureate Degree 5192. 00 92.71 9. 30 86.46 56 14.4 Diploma i n Nursing 26313. 00 81.46 11. 67 136.17 323 83 T o t a l Sample 32477.00 83.49 12.14 147.27 389 100.0 110 The F which r e s u l t e d from the a n a l y s i s o f v a r i a n c e was 31.283 (Table 14) s i g n i f i c a n t a t the 0.0000 l e v e l . I t has t h e r e f o r e been demonstrated t h a t a r e l a t i o n s h i p e x i s t s between the C l u s t e r "Nursing Autonomy and Advocacy" and "Education" i n t h i s study. The hypothesis t h a t the means were d i f f e r e n t , when C l u s t e r #1 was analyzed by the independent v a r i a b l e "Education", was accepted.. Table 14 A n a l y s i s of V a r i a n c e : C l u s t e r #1 "Nursing Autonomy and Advocacy" analyzed by "Education" SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 7969.829 2 3984.914 31.283 0.0000 Wit h i n Groups 491.69.369 386 127.382 ETA = 0.3735 ETA SQUARED = 0.1395 C l u s t e r #2 " P a t i e n t R i g h t s " The means o f the C l u s t e r " P a t i e n t s ' R i g h t s " were arranged i n the same order as the C l u s t e r "Nursing Autonomy and Advocacy" on the v a r i a b l e - - " A d m i n i s t r a t i v e P o s i t i o n " . Teachers had the h i g h e s t mean of 62.87 and s t a f f nurses the lowest of 58.32 (Table 15). The standard d e v i a t i o n s were much sma l l e r and c l o s e r t ogether i n the a n a l y s i s o f t h i s c l u s t e r , than was the case i n C l u s t e r #1. The h i g h e s t and the lowest means are w i t h i n 4.55 p o i n t s of one another i n Table 15, whereas, i n Tab l e 3: 9§> - C l u s t e r #1 "Nursing Autonomy and Advocacy" broken down by " A d m i n i s t r a t i v e P o s i t i o n " — there was a d i f f e r e n c e of 12 p o i n t s . T h e r e f o r e , there was more o v e r a l l agreement on the s u b j e c t of a t t i t u d e s towards the I l l C l u s t e r " P a t i e n t R i g h t s " compared with the agreement expressed about "Nursing Autonomy and Advocacy" on t h i s v a r i a b l e . I t i s argued t h a t the v a r i a n c e was s m a l l e r on t h i s C l u s t e r because the nurse i s exposed to d i s c u s s i o n of the t o p i c from s e v e r a l s i d e s — f r o m the n u r s i n g c u l t u r e and from the e x t e r n a l environment i n which she i s both a nurse and a consumer. The concepts behind the P a t i e n t s ' Rights movement are not i n c o n f l i c t w i t h the image, which n u r s i n g f o s t e r s , of the nurse as a p r o f e s s i o n a l who s p e c i a l i z e s i n i n d i v i d u a l i z e d p a t i e n t care. There i s apt to be l e s s c o n f l i c t i n v o l v e d i n e x p r e s s i n g a t t i t u d e s t h a t are valued by the p r o f e s s i o n — a n d which concern a l e s s powerful o t h e r — t h a n i s i n h e r e n t i n a s i t u a t i o n c a l l i n g f o r a d e c l a r a t i o n of independence from powerful a u t h o r i t y f i g u r e s . Table 15 C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by " A d m i n i s t r a t i v e P o s i t i o n " arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S. D. VARIANCE N Q. *o Teacher 1446. 00 62. 87 3. 97 15.75 23 5. 9 Nurse P r a c t i t i o n e r 500. 00 62.50 5. 88 34.57 8 2. 1 S u p e r v i s o r or Admin-i s t r a t i v e Nurse 1539. 00 61. 56 4. 55 20.67 25 6. 4 Head Nurse 1563. 00 60.12, 4. 84 2 3.39 26 6. 7 Community Health Nurse 2101. 00 60. 03 5. 26 27.68 35 9. 0 Other 3232. 00 58.76 5. 77 33.26 55 14. 1 S t a f f Nurse 12656. 00 58. 32 5. 41 29.29 217 55. 8 T o t a l Sample 23037.00 59.22 5.44 29.62 389 100.0 112 The a n a l y s i s of v a r i a n c e w i t h an F of 4.503 i s s i g -n i f i c a n t a t below the 0.05 l e v e l (Table 16) which confirms t h a t the r e l a t i o n s h i p i n d i c a t e d between the C l u s t e r " P a t i e n t s ' Rights" and " A d m i n i s t r a t i v e P o s i t i o n " i s not a chance one and, t h e r e f o r e , the hypothesis t h a t the means were d i f f e r e n t was accepted. The F obtained on t h i s C l u s t e r i s s m a l l e r , w i t h the same degrees of freedom, than the F of 5.561 ob t a i n e d f o r C l u s t e r #1 on the same independent v a r i a b l e (Table 4 : .99) . Table 16 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by " A d m i n i s t r a t i v e P o s i t i o n " SUM OF MEAN SOURCE SQUARES DF SQUARE F SIG. Between Groups 759.247 6 126.541 4.503 0.0002 Wi t h i n Groups 10733.741 382 28.099 ETA = 0.2570 ETA SQUARED = 0.0661 The a n a l y s i s of C l u s t e r #2 by "Flours o f Work" produced means t h a t were c l o s e together over the three c a t e g o r i e s w i t h standard d e v i a t i o n s which showed t h a t the scores were c l o s e l y c l u s t e r e d around the mean, w i t h i n each category, as w e l l as w i t h i n the complete sample (Table 17). 113 Table 17 C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by "Hours of Work" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S.D. VARIANCE N O, F u l l time 15973.00 59.38 5.58 31.18 269 69.2 P a r t Time 4948.00 58.90 5.03 25.34 84 21.6 I n a c t i v e 2116.00 58.78 5.38 28.92 36 9.3 T o t a l Sample 23037.00 59.22 5.44 29.62 389 100.0 The a n a l y s i s of v a r i a n c e w i t h an F of 0.374 (Table 18), confirmed t h a t any d i f f e r e n c e s which emerged were the r e s u l t of chance and the hypothesis t h a t the means were equal was accepted. E t a squared i s approaching zero (0.0019) which sup-p o r t s the r e s u l t of the obtained F. T h i s r e s u l t does not support the suggestion made by S t o r c h , t h a t : . . . Because of the i n c r e a s e d o p p o r t u n i t i e s f o r l a y c o n t a c t which p a r t time nurses g e n e r a l l y have, they are f r e q u e n t l y more attuned to l a y -t h i n k i n g (Storch, 1977:158). The f o r c e of consumerism over r i d e s the o c c u p a t i o n a l b a r r i e r s c r e a t e d by the n u r s i n g r o l e . At the same time, modern nurses working f u l l time, have r e j e c t e d the .suggestion t h a t they have a c l o i s t e r e d , r e s t r i c t e d viewpoint, by a c t i v e l y seeking community involvement (Freeman, 1970:111; Robischon, 1971:410-413; Leahy e t a l . , 1972:4-5). 114 Table 18 A n a l y s i s of V a r i a n c e : analyzed by "Hours of C l u s t e r #2 Work" " P a t i e n t s ' R i g h t s " SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 22.203 2 11.102 0.374 0.6885 Wit h i n Groups 11470.784 38 6 29.717 ETA = 0.0440 ETA SQUARED = 0.0019 Conformity of a t t i t u d e was once again e v i d e n t when C l u s t e r #2 " P a t i e n t s ' R i g h t s " was analyzed a c c o r d i n g to the v a r i a b l e "Experience" (Table 19). There was only 0.37 d i f f e r e n c e between the h i g h e s t and the lowest mean. Table 19 C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by "Experience" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S . D. VARIANCE N o, "5 Under 5 years 6296.00 59.40 5. 19 26. 91 106 27. 2 6-10 years 5515.00 .59.30 5. 41 29. 32 93 23. 9 11-15 years 3788.00 59.19 5. 40 29.17 64 16. 5 Over 15 years 7438.00 59. 03 5. 74 32. 99 126 32. 4 T o t a l Sample 23037.00 59.22 5. 44 29.62 389 100. 0 The F of 0.094 (Table 20) suggested t h a t no r e l a t i o n -s h i p e x i s t e d between the a t t i t u d e s expressed about C l u s t e r #2 " P a t i e n t s ' R i g h t s " and the independent v a r i a b l e "Experience". T h i s r e s u l t was s i g n i f i c a n t a t the 0.9632 l e v e l , w e l l above the alpha of 0.05 s e t f o r t h i s study. T h e r e f o r e , the hypothesis t h a t the means were equal was accepted. The e t a squared was near t o zero (0.0007) and i t confirmed the f i n d i n g . 115 T a b l e 20 A n a l y s i s o f V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " a n a l y z e d b y " E x p e r i e n c e " SUM OF MEAN SOURCE SQUARES DF SQUARE F S I G . B e t w e e n G r o u p s 8. 436 3 2.812 .0. 094 0.9632 W i t h i n G r o u p s 11484.551 385 29.830 ETA = 0.0271 ETA SQUARED = 0.0007 When t h e C l u s t e r " P a t i e n t s ' 1 R i g h t s " was a n a l y z e d b y t h e v a r i a b l e " S e t t i n g " ( T a b l e 2 1 ) , t h e two h i g h e s t means o f 62.72 and 6 0.33 w e r e r e s p e c t i v e l y o b t a i n e d b y n u r s e s w o r k i n g i n e d u -c a t i o n a l a n d c o m m u n i t y s e t t i n g s . The e d u c a t i o n a l s e t t i n g i s u s u a l l y e x p e c t e d t o p r o v i d e o p p o r t u n i t i e s f o r t r e n d s e t t i n g a c t i v i t i e s i n r e s p o n s e t o s o c i a l f o r c e s s u c h a s t h e p a t i e n t s ' r i g h t s movement. The c o m m u n i t y s e t t i n g p l a c e s more e m p h a s i s on t h e p a t i e n t s ' s e l f c a r e a c t i v i t i e s a n d i t i s t h e r e f o r e more p r o -d u c t i v e o f n u r s i n g a t t i t u d e s w h i c h v a l u e t h e p a t i e n t ' s d e c i s i o n m a k i n g p o w e r s , t h a n i s u s u a l l y t h e c a s e i n t h e h o s p i t a l s e t t i n g . The s t a n d a r d d e v i a t i o n s o b t a i n e d i n d i c a t e more u n i -f o r m i t y i n t h e a t t i t u d e s e x p r e s s e d b y r e s p o n d e n t s t o t h i s C l u s t e r " P a t i e n t s ' R i g h t s " t h a n was a p p a r e n t i n C l u s t e r #1 " N u r s i n g Autonomy and A d v o c a c y " when a n a l y z e d u s i n g t h e same v a r i a b l e " S e t t i n g " ( T a b l e 9 : 1 0 5 ) . The r e s u l t may r e f l e c t t h e f a c t t h a t t h e r i g h t s o f p a t i e n t s h a v e a l w a y s b e e n g i v e n a t l e a s t l i p s e r v i c e , i n s u c h c o n c e p t s a s ' p a t i e n t c e n t e r e d c a r e ' , w h e r e a s , n u r s e autonomy i s a c o n f l i c t r i d d e n i n n o v a t i o n i m p l y i n g t h a t t h e n u r s e m u s t a c c e p t more r i s k s t h a n s h e h a s b e e n s o c i a l i z e d t o a c c e p t . 116 Table 21 C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by " S e t t i n g arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S.D. VARIANCE N % Edu c a t i o n 1129. 00 62. 72 4. 43 19. 62 18 4. 5 Community 2594. 00 60. 33 5. 25 27. 56 43 11. 1 H o s p i t a l 16625. 00 58. 95 5. 46 29. 81 282 72. 5 Other 2689. 00 58. 46 5. 39 2 9'. 01 46 11. 8 T o t a l Sample 23037. 00 59. 22 5. 44 29. 62 389 100. 0 The F of 3.677, which was s i g n i f i c a n t at below the 0.05 l e v e l (Table 22), suggested t h a t a r e l a t i o n s h i p does e x i s t between the s e t t i n g i n which a nurse p r a c t i c e s and the a t t i t u d e s t h a t she expressed on t h e - s u b j e c t of p a t i e n t s ' r i g h t s . The hypothesis t h a t the means were d i f f e r e n t i n t h i s study, was accepted. Table 22 A n a l y s i s of V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by " S e t t i n g " SUM OF MEAN SOURCE SQUARES DF SQUARE F SIG. Between Groups 320.120 3 106.707 3.677 0.0123 Wit h i n Groups . 11172.867 385 29.020 . ETA = 0.1669 ETA SQUARED = 0.027 9 C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed-by the independent v a r i a b l e "Age" produced very s i m i l a r means f o r groups up to 60 years of age (Table 23). The scores of s u b j e c t s over 40 years o f age r e s u l t e d i n means which were below the mean of the t o t a l sample (59.22). 117 Table 2 3 C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by "Age" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL Under 30 years 8507. 00 59. 91 5.10 25. 97 142 36. 5 41-50 years 4377. 00 59. 15 5.64 31.80 74 19. 0 31-40 6495. 00 59. 05 5.44 29.60 110 28 . 3 51-60 years 3045. 00 58. 56 6. 01 36.13 52 13. 4 Over 60 years 613. 00 55. 73 4.61 21.22 11 2. 8 T o t a l Sample 23037. 00 59. 22 5.44 29.62 389 100. 0 The obtained F of 1. 943 (Table 24) i n d i c a t e d t h a t no r e l a t i o n s h i p e x i s t e d between the two v a r i a b l e s " P a t i e n t s ' R i g h t s " and "Age" as measured i n t h i s study. The computed F was s i g n i f i c a n t a t above the 0.05 l e v e l . The hyp o t h e s i s t h a t the means were equal was accepted. An E t a squared of 0.0198 supported the r e s u l t of the obtained F. Table 24 A n a l y s i s of V a r i a n c e : analyzed by "Age" C l u s t e r #2 " P a t i e n t s ' R i g h t s " SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 228.031 4 '57. 008 1.943 0.1026 Wi t h i n Groups 11264.956 384 29.336 ETA = 0.1409 ETA SQUARED = 0. 0198 The category "Other" which was merged with the c a t e -gory "Diploma" i n Table 25, co n t a i n e d eighteen s u b j e c t s w i t h a mean of 58.89 and a standard d e v i a t i o n of 6.61. The means d i s p l a y e d i n Table 25 ranged from 62.20 f o r respondents w i t h a Master's degree or h i g h e r , through 61.79 f o r nurses w i t h a 118 baccalaureate degree to 58.68 f o r those subjects w i t h a diploma i n n ursing. The f a c t t h a t the means were c l o s e together and the standard d e v i a t i o n s were w i t h i n + 6 points of the mean i n d i c a t e that there was a considerable amount of conformity i n the a t t i t u d e s expressed by subjects about statements contained i n the C l u s t e r " P a t i e n t s ' R i g h t s " , when analyzed according to the v a r i a b l e "Education". The o r d e r i n g of the means from lowest to highest w i t h i n c r e a s i n g education supports the f i n d i n g s of Pankratz and Pankratz (1974). Table 2 5 C l u s t e r #2 " P a t i e n t s ' Rights" analyzed by "Education" arranged from highest mean to lowest mean CATEGORY LABEL SUM MEAN S. D. VARIANCE N g, o Master's or Higher Degree 622.00 62.20 5. 96 35. 51 10 2. 6 Baccalaureate Degree 3460.00 61.79 4. 60 21.12 56 14 . 4 Diploma i n Nursing 18955.00 58.68 5. 42 2 9.38 323 83. 0 T o t a l Sample 23037.00 59.22 5.44 29.62 389 100.0 Although the means are c l o s e together, they are s i g -n i f i c a n t l y d i f f e r e n t at w e l l below the 0.05 l e v e l . The a n a l y s i s of variance r e s u l t e d i n an F of 9.703, s i g n i f i c a n t at 0.0001 (Table 26). A r e l a t i o n s h i p has, t h e r e f o r e , been demon-s t r a t e d between the C l u s t e r " P a t i e n t s ' Rights" and the v a r i a b l e "Education" i n t h i s study. The hypothesis t h a t the means were d i f f e r e n t was accepted. 119 Table 26 A n a l y s i s of V a r i a n c e : C l u s t e r #2 " P a t i e n t s ' R i g h t s " analyzed by "Education" SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 550.169 2 275.085 9.703 0.0001 Wit h i n Groups 10942.818 386 28.349 ETA = 0.218 8 ETA SQUARED = 0.047 9 C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n s " The order i n t o which the groups f a l l i s s l i g h t l y d i f -f e r e n t i n the a n a l y s i s o f C l u s t e r #3 by " A d m i n i s t r a t i v e P o s i t i o n " (Table 2 7)- from the order which emerged when the pr e v i o u s two C l u s t e r s were analyzed u s i n g the same v a r i a b l e (Tables 3:98; and 15:111). However, the category "Teacher" had the h i g h e s t mean and " S t a f f Nurse" the lowest mean on a l l t h r e e C l u s t e r s , so t h a t , o v e r a l l , the groups are congruent. The means of the groups "Other" (49.82) and " S t a f f Nurse" (49.58) are both below the mean of t o t a l sample which was 50.47 i n Table 27. The o r d e r i n g of the means d i s p l a y e d i n Table 27 i s l o g i c a l and supports the r e s u l t s obtained by Pankratz and Pankratz where the three C l u s t e r s were c o r r e l a t e d with " . '. . advanced edu-c a t i o n , l e a d e r s h i p , academic s e t t i n g and n o n - t r a d i t i o n a l s o c i a l c l i m a t e . . . " " (Pankratz and Pankratz, 1974:215). S t a f f nurses p r a c t i s i n g i n a h o s p i t a l s e t t i n g are, by the nature of the environment i n which they work, l e s s l i k e l y t o be able t o take i n n o v a t i v e approaches to p a t i e n t care o u t s i d e the r o l e d e f i n i t i o n s e s t a b l i s h e d by the h o s p i t a l . 120 The f i n d i n g t h a t the groups "Supervisor or A d m i n i s t r a t i v e Nurse" and "Head Nurse", i n t h i s study, scored the t h i r d and. f o u r t h h i g h e s t means r e s p e c t i v e l y , may i n d i c a t e t h a t the p o t e n t i a l f o r change e x i s t s i n the h o s p i t a l environment. Although the " S t a f f Nurse" group had the lowest mean, t h a t does not n e c e s s a r i l y suggest t h a t t h e i r a t t i t u d e s towards the C l u s t e r " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " are n e g a t i v e . On the c o n t r a r y , the mean score of 4 9.58 rep r e s e n t e d approx-imate l y 77 percent o f a t o t a l p o s s i b l e score of s i x t y - f i v e . Table 27 C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n s " analyzed by " A d m i n i s t r a t i v e P o s i t i o n " arranged from h i g h e s t mean to. lowest mean CATEGORY' LABEL SUM MEAN S. D. VARIANCE N Q, *o Teacher 1260.00 54.78 5. 24 27.45 23 5. 9 Community Health Nurse 1830.00 52.29 6. 01 36.09 35 9. 0 Sup e r v i s o r or A d m i n i s t r a t i v e Nurse 1299.00 51.96 5. 27 27.79 25 6. 4 Head Nurse 1340.00 51.54 5. 93 35.2:2 26 6. 7 Nurse P r a c t i t i o n e r 406.00 50.75 9. 21 84.79 8 2:. .1 Other 2740.00 49. 82 6. 54 42.74 55 14. 1 S t a f f Nurse 10758.00 49.58 5. 97 35.68 217 55. 8 T o t a l Sample 19633.00 50. 47 6. 18 38.18 389 100. 0 The a n a l y s i s of v a r i a n c e , w i t h an F of 3.759 (Table 28), suggests t h a t the r e l a t i o n s h i p between C l u s t e r #3 and " A d m i n i s t r a t i v e P o s i t i o n " i s not one t h a t occurs by chance. I t i s s i g n i f i c a n t a t below the 0.05 l e v e l and t h e r e f o r e , the 121 hypothesis t h a t the means i n t h i s study were d i f f e r e n t was accepted. Table 28 A n a l y s i s of V a r i a n c e : C l u s t e r #3 " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " analyzed by " A d m i n i s t r a t i v e P o s i t i o n " SUM OF MEAN SOURCE SQUARES DF SQUARE F SIG. Between Groups 825.755 6 137.626 3.759 0.0012 With i n Groups 13987.155 382 36.616 ETA = 0.2361 ETA SQUARED = 0.0557 A n a l y s i s of C l u s t e r #3 by the independent v a r i a b l e "Hours of Work" (Table 29) produced means t h a t w e r e . a l l very c l o s e together. Standard d e v i a t i o n s o f w i t h i n j_ 6.18 of the mean of the t o t a l sample i n d i c a t e d t h a t s u b j e c t s ' scores were c l u s t e r e d around the mean f a i r l y c l o s e l y . Table 29 C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n s " analyzed by "Hours of Work" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S. D. VARIANCE N o, "o F u l l Time 13704. 00 50.94 6. 15 37.87 269 69. 2 I n a c t i v e 1790. 00 49.72 5. 40 29.12 36 9. 3 Pa r t Time 4139. 00 49. 27 6. 44 41. 50 84 21. 6 T o t a l Sample 19633. 00 50.47 6. 18 38.18 389 100. 0 122 The a n a l y s i s of va r i a n c e , w i t h an F of 2.653 (Table 30) showed that the d i f f e r e n c e between these means i s not s i g -n i f i c a n t at the 0.05 l e v e l . The hypothesis t h a t the means were equal was accepted i n d i c a t i n g t h a t no r e l a t i o n s h i p e x i s t s between C l u s t e r #3 and the v a r i a b l e "Hours of Work". Table 30 A n a l y s i s of Variance: C l u s t e r #3 "R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " analyzed by "Hours of Work" SOURCE SUM OF SQUARES DF MEAN SQUARE F SIG. Between Groups 200.822 2 100.411 2.i 553 0.0718 Within Groups 14612.088 386 37.855 ETA = 0.1164 ETA SQUARED = = 0.0136 The means i n Table 31 when C l u s t e r #3 was analyzed by the v a r i a b l e "Experience" decreased as years of experience increased. The f i r s t three g r o u p s — f r o m under 5 years up to 15 years experience—were s i m i l a r w i t h a 0.61 d i f f e r e n c e between the highest and the lowest mean. Then a wider gap of 2.64 p o i n t s separated the group w i t h below 15 years experience from the group w i t h over 15 years experience. This grouping i n d i c a t e s t h a t the changing e d u c a t i o n a l and s o c i a l scenes are having some impact on the a t t i t u d e s of nurses when they are asked to de f i n e the nursing r o l e . 123 Although the order which emerged i n Table7:103 when C l u s t e r #1 "Nursing Autonomy and Advocacy" was analyzed by the v a r i a b l e "Experience" was d i f f e r e n t , t here was the same p a t t e r n as i n Table 3 1 — v e r y s i m i l a r means f o r the groups under 15 years experience and then a drop of 4.07 p o i n t s s e p a r a t i n g the under 15 years from the over 15 years experience group. Table 31 C l u s t e r #3 " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " analyzed by "Experience" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S. D. VARIANCE N a *6 Under 5 years 5479. 00 51. 69 5. 39 29. 05 106 27. 2 6-10 years 4779. 00 51. 39 5. 66 32. 07 93 23. 9 11-15 years 3270. 00 51. 09 6. 00 36. 05 64 16. 5 Over 15 years 6105. 00 48.45 6. 79 46.14 126 32. 4 T o t a l Sample 19633. 00 50.47 6. 18 38.18 38 9 100. 0 The a n a l y s i s , of v a r i a n c e produced an F o f 7.070 (Table 32) which was s i g n i f i c a n t a t w e l l below the 0.05 l e v e l and r e s u l t e d i n the acceptance o f the hypothesis t h a t the means obtained were d i f f e r e n t . The i n d i c a t i o n e x i s t s t h a t a r e l a t i o n s h i p between the v a r i a b l e "Experience" and C l u s t e r #3, i n t h i s study, does not occur by chance. 124 T a b l e 32 A n a l y s i s o f V a r i a n c e : C l u s t e r #3 " R e j e c t i o n o f . T r a d i t i o n a l R o l e L i m i t a t i o n s " a n a l y z e d by " E x p e r i e n c e " SOURCE SUM OF SQUARES DF MEAN SQUARE F S I G . B e t w e e n G r o u p s 773.467 3 257.822 7 .070 0.0001 W i t h i n G r o u p s 14039.443 385 36.466 i ETA = 0.2285 ETA SQUARED = 0.0522 The o r d e r i n w h i c h t h e means emerge when t h e C l u s t e r #3 i s a n a l y z e d b y t h e i n d e p e n d e n t v a r i a b l e " S e t t i n g " ( T a b l e 33) s u p p o r t s t h e s u g g e s t i o n t h a t t h e e n v i r o n m e n t i n w h i c h t h e n u r s e p r a c t i c e s i s a n i m p o r t a n t v a r i a b l e i n s h a p i n g a t t i t u d e s a b o u t t h e n u r s e r o l e . N u r s e s w o r k i n g i n an e d u c a t i o n a l s e t t i n g s c o r e d t h e h i g h e s t mean, f o l l o w e d b y t h o s e n u r s e s w o r k i n g i n a c o m m u n i t y h e a l t h s e t t i n g . N u r s e s who p r a c t i c e d i n t h e h o s p i t a l s e t t i n g p r o d u c e d s c o r e s w i t h a mean b e l o w t h a t o f t h e t o t a l s a m p l e o f 50.47. S u p p o r t f o r r e j e c t i n g t r a d i t i o n a l r o l e s w as, h o w e v e r , s t r o n g . The mean o f t h e t o t a l s a m p l e (50.47) i n T a b l e 3 3 , r e p r e s e n t s 77.6 p e r c e n t o f t h e p o s s i b l e s c o r e f o r C l u s t e r #3. A l l t h r e e c l u s t e r s p r o d u c e d t h e same o r d e r i n g o f t h e means when a n a l y z e d a c c o r d i n g t o t h e i n d e p e n d e n t v a r i a b l e " S e t t i n g " . 125 T a b l e 33 C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " a n a l y z e d b y " S e t t i n g " a r r a n g e d f r o m h i g h e s t mean t o l o w e s t mean CATEGORY LABEL SUM MEAN S .D. VARIANCE N Q. "o E d u c a t i o n a l 955.00 53.06 6 .28 39.47 18 4. 5 Community 2245.00 52. 21 6 .01 36.12 43 11 . 1 H o s p i t a l 14168.00 50. 24 6 . 02 36.22 282 72. 5 O t h e r 2265.00 49.24 6 .85 46. 94 46 11. 8 T o t a l S a mple 19633.00 50.47 6 .18 38.18 389 100. 0 The F o b t a i n e d f r o m an a n a l y s i s o f v a r i a n c e ( T a b l e 34) p e r f o r m e d o n t h e s e d a t a i s 2.968 w h i c h was s i g n i f i c a n t a t b e l o w t h e 0.05 l e v e l . T h e r e f o r e a r e l a t i o n s h i p h a s b e e n s u g g e s t e d i n t h i s s t u d y , b e t w e e n t h e C l u s t e r " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " a n d t h e v a r i a b l e " S e t t i n g " . The h y p o t h e s i s t h a t t h e means i n t h i s s a m p l e w e r e d i f f e r e n t was a c c e p t e d . T a b l e 34 A n a l y s i s o f V a r i a n c e : C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " a n a l y z e d by " S e t t i n g " SOURCE SUM OF SQUARES DF MEAN SQUARE F S I G . B e t w e e n G r o u p s 334.877 3 111.626 2.968 0.0319 W i t h i n G r o u p s 14478.033 385 37 .605 ETA = 0.1504 ETA SQUARED = 0.022 6 The means d i s p l a y e d i n T a b l e 35 d e p i c t t h e s c o r e s o b t a i n e d when C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " was a n a l y z e d b y t h e i n d e p e n d e n t v a r i a b l e "Age". The p a t t e r n i s s i m i l a r t o t h e one t h a t emerged ( T a b l e 11:10 7 ) . 126 when C l u s t e r #1 "Nursing Autonomy, and Advocacy" was analyzed by age groups. In Table 35, the means of groups under 50 years o f age show a d i f f e r e n c e of 1.79 p o i n t s . Then a gap of 3.88 appears between the lowest mean of the under 50 group and the mean of the 51-60 age group, f o l l o w e d by a f u r t h e r drop of 5.88 p o i n t s i n the mean of the over 60 group. There was, t h e r e f o r e , a d e f i n i t e d i v i s i o n between the under 50 and the over 50 age groups. The p a t t e r n i s an expected one s i n c e most of the s t r e s s on the need f o r n u r s i n g to adopt a more i n -dependent image has emerged over the l a s t 10-15 y e a r s . Table 35 C l u s t e r #3 " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " analyzed by "Age" arranged from h i g h e s t mean to lowest mean CATEGORY LABEL SUM MEAN S .D. VARIANCE N Q. "O Under 2 0 years t o 30 years 7420.00 52. 25 5 . 22 27.30 142 36.5 31-40 years 5590.00 50.82 5 .75 33.07 110 28. 3 41-50 years 3734.00 50.46 5 . 37 28. 85 74 19. 0 51-60 years 2438.00 46. 88 7 .14 51.01 52 13.4 Over 60 years 451.00 41.00 7 .29 53.20 11 2.8 T o t a l Sample 19633.00 50. 47 6 .18 38.18 389 100. 0 The a n a l y s i s of v a r i a n c e (Table 36) supports the suggestion t h a t a r e l a t i o n s h i p was p r e s e n t between the C l u s t e r " R e j e c t i o n of T r a d i t i o n a l Role L i m i t a t i o n s " and "Age" i n t h i s study. An F of 16.034 was o b t a i n e d which was s i g n i f i c a n t a t w e l l below the 0.05 l e v e l . The hypothesis t h a t the means obtained were d i f f e r e n t was accepted f o r t h i s sample. 12 7 T a b l e 36 A n a l y s i s o f V a r i a n c e : C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " a n a l y z e d by "Age" SOURCE SUM OF SQUARES DF MEAN SQUARE F S I G . B e t w e e n G r o u p s 2119.987 4 529.997 16.034 0.0000 W i t h i n G r o u p s 12692.923 384 33.054 ETA = 0.37 8 3 ETA SQUARED = 0.14 31 The c a t e g o r y " O t h e r " , w h i c h was merged w i t h t h e c a t e -g o r y " D i p l o m a i n N u r s i n g " ( T a b l e 37) f o r t h e p u r p o s e s o f a n a l y s i s , c o n t a i n e d e i g h t e e n s u b j e c t s w i t h a mean o f 48.00 a nd a s t a n d a r d d e v i a t i o n o f 6.50. C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " a n a l y z e d by t h e i n d e p e n d e n t v a r i a b l e " E d u c a t i o n " r e s u l t e d i n an i n c r e a s e i n means w i t h i n c r e a s i n g e d u c a t i o n a l s t a t u s . T h i s r e s u l t was i n a c c o r d w i t h t h e r e s u l t s o b t a i n e d i n t h e a n a l y s i s o f a l l t h r e e C l u s t e r s w i t h t h e v a r i a b l e " E d u c a t i o n " . S t a n d a r d d e v i a t i o n s d i s p l a y e d i n T a b l e 37 showed t h a t n u r s e s w i t h a M a s t e r ' s o r h i g h e r d e g r e e w e r e more a g r e e d i n t h e i r a t t i t u d e s a b o u t t h e n a t u r e o f t h e n u r s i n g r o l e t h a n w e r e n u r s e s w i t h l e s s e d u c a t i o n a l p r e p a r a t i o n . The r e s u l t s a g r e e w i t h t h o s e o b t a i n e d by P a n k r a t z a n d P a n k r a t z .(1974) who c o n c l u d e d t h a t e d u c a t i o n was a p o w e r f u l v a r i a b l e i n s h a p i n g t h e a t t i t u d e s t h a t n u r s e s e x p r e s s e d a b o u t t h e t r a d i t i o n a l n u r s i n g r o l e . 128 T a b l e 37 C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s a n a l y z e d by " E d u c a t i o n " a r r a n g e d f r o m h i g h e s t mean t o l o w e s t mean CATEGORY LABEL SUM MEAN S. D. VARIANCE N O, "5 M a s t e r ' s o r H i g h e r D e g r e e 546.00 54.60 4. 03 16.27 10 2. 6 B a c c a l a u r e a t e D e g r e e 3047.00 54.41 5. 08 25.77 56 14. 4 D i p l o m a i n N u r s i n g 16040.00 49. 66 6. 10 37. 26 323 83. 0 T o t a l S a mple 19633.00 50.47 6. 18 38.18 389 100. 0 The F o b t a i n e d when an a n a l y s i s o f v a r i a n c e was p e r -f o r m e d was 17.825 ( T a b l e 3 8 ) . T h i s r e s u l t was s i g n i f i c a n t a t w e l l b e l o w t h e 0.05 l e v e l a n d c o n f i r m s t h a t a r e l a t i o n s h i p e x i s t e d b e t w e e n t h e v a r i a b l e " E d u c a t i o n " a n d C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " i n t h i s s t u d y . The h y p o t h e s i s t h a t t h e means o b t a i n e d w e r e d i f f e r e n t was a c c e p t e d . T a b l e 38 A n a l y s i s o f V a r i a n c e : C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " a n a l y z e d b y " E d u c a t i o n " SOURCE SUM OF SQUARES DF MEAN SQUARE F S I G . B e t w e e n G r o u p s W i t h i n G r o u p s 1252.418 13560.492 2 386 626.209 17 35.131 .825 0.0000 ETA = 0.2908 ETA SQUARED = 0.0845 129 Summary The m a j o r i t y o f t h e r e s u l t s o b t a i n e d i n t h e s e r i e s o f a n a l y s i s o f v a r i a n c e t e s t s , p e r f o r m e d i n t h e p r e s e n t s t u d y , w e r e s i g n i f i c a n t a t b e l o w t h e 0.05 l e v e l . The r e s u l t s w h i c h w e r e n o t s i g n i f i c a n t a t t h e 0.05 l e v e l w e r e t h o s e o b t a i n e d when t h e C l u s t e r #2 " P a t i e n t s ' R i g h t s " was a n a l y z e d by t h e i n d e p e n d e n t v a r i a b l e s " H o u r s o f Work", " E x p e r i e n c e " and "Age" a n d when C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " was a n a l y z e d by " H o u r s o f Work". The p r e s e n t s t u d y i n d i c a t e d t h a t n u r s e s i n a d m i n i s -t r a t i v e p o s i t i o n s , t h o s e w i t h a d v a n c e d e d u c a t i o n and t h o s e who w o r k i n e d u c a t i o n a l o r c o m m u n i t y h e a l t h s e t t i n g s a r e more l i k e l y t o s c o r e h i g h l y o n t h e P a n k r a t z and P a n k r a t z (1974) A t t i t u d e S c a l e — d e s i g n e d t o m e a s u r e a t t i t u d e s t o t h e t h r e e C l u s t e r s : 1) N u r s i n g Autonomy and A d v o c a c y ; 2) P a t i e n t s ' R i g h t s ; and 3) R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s ; t h a n a r e n u r s e s w o r k i n g i n a h o s p i t a l s e t t i n g a s s t a f f n u r s e s and who h a v e n o t c o m p l e t e d a u n i v e r s i t y d e g r e e . Y e a r s o f n u r s i n g e x p e r i e n c e was shown t o p r o d u c e two s e p a r a t e g r o u p s i n r e l a t i o n t o C l u s t e r #1 " N u r s i n g Autonomy an d A d v o c a c y " and C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " . S u b j e c t s w i t h 15 y e a r s o r l e s s e x p e r i e n c e had t h e h i g h e s t means i n b o t h C l u s t e r s and f o r m e d one g r o u p . S u b j e c t s w i t h o v e r 15 y e a r s e x p e r i e n c e h a d l o w e r means and f o r m e d a n o t h e r g r o u p . No s u c h g r o u p i n g o f t h e means o c c u r r e d 130 when C l u s t e r #2 " P a t i e n t s ' R i g h t s " was a n a l y z e d by t h e v a r i a b l e " E x p e r i e n c e " The r e s u l t s o b t a i n e d when C l u s t e r #1 " N u r s i n g Autonomy and A d v o c a c y " and C l u s t e r #3 " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " w e r e a n a l y z e d by t h e v a r i a b l e "Age" d e m o n s t r a t e d a d i c h o t o m y b e t w e e n t h e a t t i t u d e s e x p r e s s e d by s u b j e c t s u n d e r 50 y e a r s o f age and t h o s e o v e r 50 y e a r s . The r e s u l t i s c o n -g r u e n t w i t h t h e r e s u l t s o b t a i n e d when t h e s e two c l u s t e r s w e r e a n a l y z e d by t h e v a r i a b l e " E x p e r i e n c e " . A n a l y s i s o f t h e C l u s t e r #2 " P a t i e n t s ' R i g h t s " and t h e v a r i a b l e "Age" showed v e r y l i t t l e v a r i a t i o n among t h e means. The m a j o r i t y o f r e s p o n d e n t s i n t h i s s t u d y p r o f e s s p o s i -t i v e a t t i t u d e s t o w a r d s a l l t h r e e c l u s t e r s t e s t e d by t h e P a n k r a t z and P a n k r a t z (1974) A t t i t u d e S c a l e . H owever, a c o m p a r a t i v e e x a m i n a t i o n o f t h e means and s t a n d a r d d e v i a t i o n s o b t a i n e d o n t h e t h r e e c l u s t e r s ( T a b l e 39.) r e v e a l e d t h a t t h e a t t i t u d e s o f t h e r e s p o n d e n t s w e re more homogeneous o n C l u s t e r #2 " P a t i e n t s ' R i g h t s " t h a n o n e i t h e r o f t h e o t h e r two c l u s t e r s . T h i s r e s u l t i s i l l u s t r a t e d when t h e r e s p o n s e s t o i n d i v i d u a l s t a t e m e n t s i n t h e c l u s t e r a r e e x a m i n e d . F o r e x a m p l e , i n r e s p o n s e t o t h e s t a t e m e n t , " I b e l i e v e a p a t i e n t h a s a r i g h t t o h a v e a l l h i s q u e s t i o n s a n s w e r e d f o r h i m . " 91.5 p e r c e n t o f t h e t o t a l s a m p l e m a r k e d e i t h e r STRONGLY AGREE (60.9 p e r c e n t ) o r AGREE (30.6 p e r c e n t ) . Q u e s t i o n number 19, w h i c h s t a t e d , " I f e e l p a t i e n t s s h o u l d be t o l d t h e m e d i c a t i o n s t h e y a r e t a k i n g . " d r e w a r e s p o n s e o f STRONGLY AGREE, o f 54.5 p e r c e n t and AGREE, o f 4 0.1 p e r c e n t f r o m t h e t o t a l s a m p l e . A t t h e same t i m e , 131 t h e C l u s t e r " P a t i e n t s ' R i g h t s " p r o d u c e d t h e l o w e s t mean f o r t h e t o t a l s a m p l e when means were e x p r e s s e d a s a p e r c e n t a g e o f t h e h i g h e s t p o s s i b l e s c o r e o n e a c h C l u s t e r ( T a b l e 3 9 ) . C l u s t e r #1 " N u r s i n g Autonomy and A d v o c a c y " c o n t a i n s s t a t e m e n t s w h i c h t a p t h e n u r s e ' s a t t i t u d e s t o w a r d s h e r own r i g h t t o i n d e p e n d e n t p r o f e s s i o n a l a c t i o n and h e r w i l l i n g n e s s t o s u p p o r t t h e p a t i e n t ' s e f f o r t s t o g a i n more c o n t r o l o v e r w h a t h a p p e n s t o h i m w i t h i n t h e h e a l t h c a r e s y s t e m . An e x a m i -n a t i o n o f . t h e means and s t a n d a r d d e v i a t i o n s i n T a b l e 39, p r o -v i d e s e v i d e n c e o f a c o m p a r a t i v e l y w i d e v a r i a n c e i n r e s p o n s e s , t o s t a t e m e n t s i n C l u s t e r #1. T h i s i s an e x p e c t e d r e s u l t i n an a r e a u n d e r g o i n g d r a m a t i c c h a n g e s a s a r e s u l t o f s h i f t i n g s o c i e t a l a t t i t u d e s t o w a r d s t h e i m p o r t a n c e o f c o n s u m e r b e h a v i o r i n h e a l t h c a r e a nd t h e n e e d t o make more e f f i c i e n t u s e o f a v a i l a b l e h e a l t h c a r e w o r k e r s . The t h i r d C l u s t e r — " R e j e c t i o n o f T r a d i t i o n a l R o l e L i m i t a t i o n s " — p r o d u c e d means and s t a n d a r d d e v i a t i o n s w h i c h show t h a t n u r s e s , i n t h i s s t u d y , r e j e c t a t t i t u d e s r e m i n i s c e n t o f t h e d e p e n d e n t , t r a d i t i o n a l n u r s e . r o l e . F o r e x a m p l e 88 p e r c e n t o f t h e t o t a l s a m p l e a g r e e d t h a t , " I f I am n o t s a t i s f i e d w i t h t h e d o c t o r ' s a c t i o n I w o u l d p u r s u e t h e i s s u e . " T h i s s t a t e m e n t i m p l i e s t h a t n u r s e s a r e p r e p a r e d t o t a k e a s s e r t i v e a c t i o n on t h e i r own o r o n t h e p a t i e n t ' s b e h a l f , i f n e c e s s a r y . S u b j e c t s w e r e p r e p a r e d t o s u p p o r t t h i s s t a t e m e n t w h e r e t h e e m p h a s i s i s o n t h e i r s e n s e o f d i s s a t i s f a c t i o n w i t h t h e p h y s i c i a n and t h e y w e r e n o t p r e p a r e d t o g i v e a s i m i l a r s t a t e -ment m a j o r i t y s u p p o r t , when t h e e m p h a s i s was p l a c e d o n t h e 132 p a t i e n t ' s d i s s a t i s f a c t i o n w i t h the p h y s i c i a n and the s t a t e -ment was s p e c i f i c a l l y l i n k e d w i t h the p a t i e n t advocate r o l e . Table 39 Scores f o r T o t a l Sample (N = 389) on each C l u s t e r MEAN AS A % OF HIGHEST POSSIBLE SCORE ON EACH CLUSTER LABELS MEAN S.D. SUB-SCALE Nursing Autonomy 83.49 12.14 64.3 P a t i e n t s ' Rights 59.22 5.44 60.4 R e j e c t i o n o f T r a d i t i o n a l Role L i m i t a t i o n 50. 47 6.18 77.6 The f i n d i n g s i n t h i s study support the r e s u l t s r e p o r t e d by Pankratz and Pankratz (1974) and the means expressed as a percentage of the t o t a l p o s s i b l e scores (Tables 39 and 40) are very s i m i l a r i n both s t u d i e s . Table 40 Scores obtained by Pankratz and Pankratz (1974) on the three C l u s t e r s f o r t o t a l sample with N = 702 CLUSTER LABELS MEAN S.D. MEAN EXPRESSED AS % OF HIGHEST POSSIBLE SCORE ON 3 SUB-SCALES Nursing Autonomy 84.6 16.6 65.1 P a t i e n t s ' Rights 56. 6 6.1 57.8 R e j e c t i o n o f the T r a d i t i o n a l Role L i m i t a t i o n 50. 2 7.3 77.2 133 CHAPTER V CONCLUSIONS The r e s u l t s o f t h i s s t u d y s u g g e s t t h a t , a l t h o u g h n u r s e s i n a d m i n i s t r a t i v e p o s i t i o n s , e d u c a t o r s a n d t h o s e n u r s e s w o r k i n g i n e d u c a t i o n a l a n d co m m u n i t y h e a l t h s e t t i n g s , s c o r e d h i g h e s t on a l l t h r e e c l u s t e r s i n t h e P a n k r a t z a n d P a n k r a t z (1974) A t t i t u d e S c a l e , t h e mean o f t h e t o t a l s a m p l e o n t h e t h r e e c l u s t e r s i s s u f f i c i e n t l y h i g h t o p r o v i d e f i r m s u p p o r t f o r a s s e r t i v e l e a d e r s h i p on t h e i s s u e s o f c o n s u m e r r i g h t s i n h e a l t h c a r e , i n f o r m e d a c c e s s t o i n f o r m a t i o n by t h e c o n s u m e r , and n u r s i n g autonomy, and a d v o c a c y . A t t h e l e v e l o f t h e p r o f e s -s i o n a l a s s o c i a t i o n , n u r s i n g l e a d e r s who p r o m o t e t h e r i g h t s o f c o n s u m e r s i n h e a l t h c a r e by a s s e r t i v e i n t e r a c t i o n w i t h c o n s u m e r g r o u p s , g o v e r n m e n t r e p r e s e n t a t i v e s a n d o t h e r h e a l t h c a r e w o r k e r s c o u l d d e v e l o p r o l e m o d e l s o f c o n s u m e r a d v o c a c y w i t h w h i c h t h e i n d i v i d u a l n u r s e , w o r k i n g w i t h t h e c o n s u m e r o f c a r e , c a n i d e n t i f y . The f i n d i n g s i n d i c a t e t h a t t h e h o s p i t a l s e t t i n g i s t h e l e a s t p r o d u c t i v e o f p o s i t i v e a t t i t u d e s t o w a r d s t h e t h r e e c l u s t e r s a n d t h a t t h e s t a t u s o f s t a f f n u r s e w i t h i n t h e h o s p i t a l s e t t i n g r e f l e c t s a s i m i l a r s i t u a t i o n . I f n u r s e s v a l u e t h e c o n c e p t s i n h e r e n t i n n u r s i n g i n d e p e n d e n c e , c o n s u m e r r i g h t s and a d v o c a c y a n d , i f t h e n u r s i n g p r o f e s s i o n i s t o g i v e s u b -s t a n c e t o t h e m y t h t h a t t h e p a t i e n t i s t h e i r ' r e a s o n f o r b e i n g ' , 134 t h e s e f a c t s m e r i t s e r i o u s c o n s i d e r a t i o n . The n u r s i n g p r o f e s s i o n , a s a p a r t o f t h e r e v o l t a g a i n s t t h e a p p r e n t i c e s h i p s y s t e m o f n u r s i n g e d u c a t i o n , t r a n s f e r r e d t h e m a j o r r e s p o n s i b i l i t y f o r t h e s o c i a l i z a t i o n o f t h e n u r s e t o h e r r o l e , t o n u r s i n g e d u c a t o r s . R e s p o n s i b i l i t y f o r t h e w o r k p l a c e a s a s o c i a l i z i n g f o r c e was a b d i c a t e d , a l t h o u g h i t i s w e l l known t h a t t h e w o r k p l a c e e x e r t s a p o w e r f u l i n f l u e n c e upon w o r k e r s ( G o f f m a n , 1961:4; C h r i s t m a n , 1 9 7 6 : 6 1 ; T r e a t and K r a m e r , 1977; M i l l e r , 1 9 7 7 : 2 8 ) . The r e a l i t y t h a t t h e n u r s i n g p r o f e s s i o n must f a c e i s t h a t most n u r s e s w o r k i n h o s p i t a l s e t t i n g s w h i c h a r e " . . . w o r k c e n t e r e d and a c t i o n o r i e n t e d " a c c o r d i n g t o T h e i s and H a r r i n g t o n (1968:1481) and w h i c h H a a s e d e s c r i b e s a s : . . . b u r e a u c r a t i c s t r u c t u r e s o r g a n i z e d a r o u n d t h e p e r f o r m a n c e o f t a s k s and b a s e d p e c u l i a r l y o n an i n d u s t r i a l m o d e l t h a t d e a l s i n p r o d u c t s and p r o f i t a b l e o u t c o m e s ( H a a s e , 1 9 7 6 : 8 0 7 ) . Change w i t h i n t h e s e s e t t i n g s r e q u i r e s a " . . . c l a r i f i c a t i o n a n d r e c o n s t r u c t i o n o f v a l u e s . . . " ( C h i n and B e n n e , 1976:33) w h i c h i s t h e f u l c r u m u p o n w h i c h t h e n o r m a t i v e - r e - e d u c a t i v e c h a n g e p r o c e s s r e s t s . T h i s r e s e a r c h e r a g r e e s w i t h H a s s e n p l u g who h a s s t a t e d t h a t i t i s n e c e s s a r y t o c o n c e n t r a t e on t h e p r o b l e m s t h a t t h e s t a f f n u r s e f a c e s i n d e l i v e r i n g n u r s i n g c a r e t o t h e c o n s u m e r , i n o r d e r t o i n s u r e t h a t t h e p r i m a r y t a s k o f n u r s i n g i s a c c o m p l i s h e d t o t h e s a t i s f a c t i o n o f b o t h n u r s e s and c o n s u m e r s . 135 . . . I t seems i m p e r a t i v e t h a t we h e l p [ s t a f f ] n u r s e s s t r e n g t h e n t h e i r p r e p a r a t i o n , s h i f t t h e i r a c c o u n t a b i l i t y f r o m p h y s i c i a n s and i n s t i t u t i o n s t o c l i e n t s , a nd become c o n t r i b u t i n g members o f t h e i r p r o f e s s i o n a l o r g a n i z a t i o n , whose g o a l s i n c l u d e i m p r o v e m e n t o f n u r s i n g p r a c t i c e and n u r s i n g e d u -c a t i o n and g r e a t e r s a y i n t h e d e l i v e r y o f h e a l t h c a r e s e r v i c e s ( H a s s e n p l u g , 1 9 7 7 : 4 3 6 ) . The e m e r g e n c e o f t h e c o n s u m e r r i g h t s i n t h e h e a l t h c a r e movement c a r r i e s w i t h i t a message t h a t t h e c o n s u m e r c o n -s i d e r s h i m s e l f and h i s r e a c t i o n s t o be i m p o r t a n t i n t h e p r o c e s s e s o f " c u r e and c a r e " . From i t a r i s e s a n e e d t o c l a r i f y t h e v a l u e t h a t t h e p r o f e s s i o n a l h e a l t h c a r e w o r k e r p l a c e s o n t h e p a t i e n t . How t h e p a t i e n t t h i n k s , f e e l s and a c t s - - h i s s t r e n g t h s a s w e l l a s h i s w e a k n e s s e s — p r o v i d e a b a s i s f o r c h a n g e w i t h i n t h e h e a l t h c a r e s y s t e m . A t p r e s e n t , t h e s y s t e m v a l u e s t e c h n i q u e s and i n t e r v e n t i o n s e x t e r n a l t o t h e p a t i e n t w h i c h c a n be a p p l i e d , a d m i n i s t e r e d o r o t h e r w i s e m a n i p u l a t e d by someone e l s e . I t i s r a r e f o r t h e h e a l t h c a r e w o r k e r t o e x a m i n e c a r e f u l l y t h e p o t e n t i a l f o r h e a l t h t h a t t h e p a t i e n t b r i n g s w i t h h i m , a l o n g w i t h h i s d i s e a s e d o r g a n o r s y s t e m , i n t o t h e h o s p i t a l s e t t i n g . E v e n when t h e p a t i e n t e n t e r s t h e h o s p i t a l i n d e s p e r a t e n e e d o f a c u t e c a r e , a p o t e n t i a l f o r h e a l t h c o n t i n u e s t o e x i s t , a l t h o u g h i t may h a v e t o be e x p r e s s e d by t h e t h o u g h t s , f e e l i n g s and a c t i o n s o f f a m i l y members o r , i n e x t r e m e c a s e s , b y t h e a c t i o n s o f p r o f e s s i o n a l h e a l t h c a r e w o r k e r s . S h e l a g h R o s e , a s o c i a l w o r k e r , w r i t i n g a b o u t h e r e x p e r i e n c e s a s a p a t i e n t , s u g g e s t s t h a t t h e d i f f e r i n g a t t i t u d e s e x p r e s s e d b y c o m m u n i t y h e a l t h n u r s e s a n d h o s p i t a l n u r s e s h a v e t h e i r o r i g i n s i n t h e p a t i e n t p r o f i l e . The h o s p i t a l p a t i e n t 136 i s t y p i c a l l y a c c e p t e d a s d e p e n d e n t w h e r e a s , t h e p e r s o n s e e k i n g h e l p i n t h e c o m m u n i t y s e t t i n g more o f t e n r e t a i n s h i s m o b i l i t y and i n d e p e n d e n c e a nd he i s t r e a t e d a s more i n t e l l i g e n t t h a n h i s h o s p i t a l c o u n t e r p a r t ( R o s e , 1 9 7 0 ) . A h o s p i t a l e n v i r o n m e n t w h i c h e n c o u r a g e s t h e maximum p o s s i b l e p a r t i c i p a t i o n b y t h e c o n s u m e r ( o r , w h e r e a p p r o p r i a t e , h i s f a m i l y ) i n h i s own c a r e w o u l d e n c o u r a g e c h a n g e w i t h i n a f r a m e w o r k o f n o r m a t i v e - r e - e d u c a t i v e s t r a t e g i e s ( C h i n and Benne, 1 9 7 6 ) . The c h a n g e w o u l d c r e a t e a more d e m a n d i n g , p r o f e s s i o n a l l y o r i e n t e d s t a f f n u r s e r o l e . R e s o c i a l i z a t i o n , on a l a r g e s c a l e , i s n e e d e d t o make s u c h a r o l e a r e a l i t y . I n t e r a c t i o n s a i m e d a t e x p l o r i n g t h e c o n s u m e r ' s p o t e n t i a l t o c o n t r i b u t e t o d e c i s i o n m a k i n g a n d t o s e l f - c a r e , a s s e s s i n g a c c u r a t e l y when r e s p o n s i b i l i t y must be assumed b y t h e h e a l t h c a r e w o r k e r , w o u l d become a s . i m p o r t a n t a s t h e s k i l l s n e c e s s a r y t o p e r f o r m h i g h l y t e c h n i c a l t a s k s . The s t a f f n u r s e r o l e w o u l d e x p a n d t o i n c l u d e t h a t o f h e a l t h e d u c a t o r w o r k i n g w i t h t h e c o n s u m e r t o s e t r e a l i s t i c s e l f - c a r e g o a l s , t e a c h i n g t h e s k i l l s n e c e s s a r y t o a c h i e v e t h o s e g o a l s a n d o f f e r i n g s u p p o r t a nd f e e d b a c k as t h e p a t i e n t t r i e s o u t h i s new s k i l l s a n d r e s p o n s i b i l i t i e s . The c o n c e p t r e c o g -n i z e s t h a t t h e r e comes a t i m e i n t h e e v o l u t i o n o f t h e p a t i e n t ' s p r o g r e s s t o w a r d s h e a l t h when t h e n e e d f o r i n t e r d e p e n d e n t p a t i e n t / n u r s e i n t e r a c t i o n assumes p r i o r i t y o v e r t h e n e e d f o r p a t i e n t / p h y s i c i a n o r p h y s i c i a n / n u r s e i n t e r a c t i o n . A t one e n d . o f a c o n t i n u u m i n C l u s t e r #1 o f t h e P a n k r a t z a n d P a n k r a t z (1974) A t t i t u d e S c a l e a r e s t a t e m e n t s a b o u t n u r s i n g 137 autonomy, which s p e c i f i c a l l y tap the s u b j e c t ' s a t t i t u d e s towards independent n u r s i n g p r a c t i c e and the assumption by nurses of l e g a l r e s p o n s i b i l i t y f o r p r o f e s s i o n a l n u r s i n g a c t i o n s . At the other end of the continuum i s a statement, which por-t r a y s the nurse as a p r o f e s s i o n a l h e a l t h care worker a c c e p t i n g the r e s p o n s i b i l i t y f o r the i n i t i a t i o n o f p u b l i c h e a l t h r e f e r r a l s on b e h a l f of the p a t i e n t . In the l a t t e r case, the v a s t m a j o r i t y of respondents (98.5 percent) had no d i f f i c u l t y i n a c c e p t i n g the statement (49.4 p e r c e n t marked STRONGLY AGREE and 49.1 percent marked AGREE). As might be expected, responses t o , "I should be a b l e to go i n t o p r i v a t e p r a c t i c e l i k e a d o c t o r i f I wish." r e s u l t e d i n 4 4.2 percent of the t o t a l sample r e j e c t i n g the statement (15.4 percent STRONGLY DISAGREE and 28.8 percent DISAGREE) and 27.5 percent marking UNDECIDED. T h i s r e s u l t i s probably p a r t l y due to the l a c k of b e h a v i o r a l models i n t h i s a r ea. L e v i n has s t a t e d : . . . a t t i t u d e s are d i f f i c u l t to change i n a vacuum. Some a c t u a l behavior, a p r a c t i c a l a c t i v i t y , w i l l have to take p l a c e — s o m e t r i a l s which w i l l reduce embarrassment and r e p l a c e i t w i t h t r u s t based on experience w i t h p r a c t i c a l and mutual b e n e f i t s (Levin, 1972:2010). Most nurses do not know c o l l e a g u e s who have s e t up i n independent n u r s i n g p r a c t i c e and t h e i r f a m i l i a r i t y with the model i s c o n f i n e d to r e p o r t s i n the l i t e r a t u r e . However, the f a c t t h a t 2 8.3 percent of the t o t a l sample accepted the statement, shows t h a t nurses have gi v e n thought to the model as a f u t u r e p o s s i b i l i t y f o r some members of the n u r s i n g p r o f e s s i o n . 138 The s t a t e m e n t t h a t , " N u r s e s s h o u l d be h e l d s o l e l y l e g a l l y r e s p o n s i b l e f o r t h e i r own a c t i o n s a nd n o t e x p e c t t o come u n d e r t h e u m b r e l l a o f t h e d o c t o r o r h o s p i t a l i n a m a l -p r a c t i c e s u i t . " i s t h e u l t i m a t e i n a c c o u n t a b i l i t y t o t h e c o n s u m e r . I t d e s c r i b e s a s i t u a t i o n w h i c h i s c l o s e r t o t h e r e a l i t y o f n u r s i n g p r a c t i c e i n t h e 1 9 7 0 ' s i n C a n a d a t h a n i s t h e m o d e l o f i n d e p e n d e n t n u r s e p r a c t i c e . H o w e v e r , i t a s k s f o r a r e a c t i o n t o a s i t u a t i o n w h i c h w o u l d h a v e t o be a c c e p t e d b e f o r e i n d e p e n d e n t n u r s e p r a c t i c e c o u l d become a r e a l i t y . R e s u l t s i n d i c a t e t h a t t h e m a j o r i t y o f n u r s e s i n t h i s s t u d y a r e n o t r e a d y t o a c c e p t l e g a l r e s p o n s i b i l i t y f o r t h e i r a c t i o n s . F o r t y f f o u r p o i n t f i v e p e r c e n t o f t h e r e s p o n d e n t s r e j e c t e d t h e s t a t e -ment (13.1 p e r c e n t STRONGLY DISAGREE and 31.4 p e r c e n t D I S A G R E E ) . The number o f p e r s o n s who w e r e UNDECIDED d r o p p e d t o 21.9 p e r c e n t a s c o m p a r e d t o 27.5 p e r c e n t who e x p r e s s e d u n c e r t a i n t y i n r e s p o n s e t o t h e s t a t e m e n t a b o u t i n d e p e n d e n t n u r s e p r a c t i c e . R o l e m o d e l s o f i n d e p e n d e n t n u r s e p r a c t i c e i n t h e l i t e r a t u r e p l a c e g r e a t e m p h a s i s o n t h e r o l e o f t h e n u r s e as a p a t i e n t a d v o c a t e ( K e l l e r , 1975; K i n l e i n , 1 9 7 7 ) . N u r s e s , i n t h i s s t u d y , d i d n o t i d e n t i f y w i t h t h e r o l e o f p a t i e n t a d v o c a t e i f i t s p e c i f i c a l l y c o n t a i n e d a r e j e c t i o n o f t h e p h y s i c i a n ' s a u t h o r i t y . More r e s p o n d e n t s d i s a g r e e d (39.6 p e r c e n t ) w i t h t h e s t a t e m e n t , " I am t h e b e s t p e r s o n i n t h e h o s p i t a l t o be t h e p a t i e n t ' s a d v o c a t e i f he d i s a g r e e s w i t h t h e d o c t o r . " t h a n a g r e e d (34.9 p e r c e n t ) . T w e n t y - f i v e p o i n t f o u r p e r c e n t m a r k e d UNDECIDED f o r t h i s s t a t e m e n t w h i c h may be i n d i c a t i v e o f t h e t r a n s i t i o n a l s t a t e o f a t t i t u d e s a b o u t t h e p h y s i c i a n a s t h e 139 symbol of u l t i m a t e a u t h o r i t y i n the h e a l t h care system. When the s u b j e c t s were asked to respond) to the s i m p l e r s t a t e m e n t — " P a t i e n t s can expect me to stand up f o r them."— i n d e c i s i o n dropped to 8.2 percent. E i g h t y - e i g h t p o i n t nine p e r c e n t of the respondents checked agreement wi t h the statement (31.6 percent marked STRONGLY AGREE and 57.3 percent marked AGREE). The f i r s t statement p l a c e s two values i n c o m p e t i t i o n with one another and c r e a t e s dissonance f o r the nurse who has been s o c i a l i z e d to value the i n d i v i d u a l i t y of the p a t i e n t and at the same time to accept the p h y s i c i a n as the person "who knows best" what i s good f o r the p a t i e n t . R e c o g n i t i o n by nurses, of t h i s s o r t of dissonance " . . . among t h e i r most c h e r i s h e d v a l u e s " (Pankratz and Pankratz, 1974:212) may r e s u l t i n the d i s c a r d i n g of o l d value systems i n f a v o r of v a l u e s more i n accord with autonomous r o l e s . The nurse-advocate r o l e needs c a r e f u l examination by l e a d e r s of the n u r s i n g p r o f e s s i o n . Chapman and Chapman's model of humanistic advocacy, c o n t a i n s — a s an i n t r i n s i c p a r t of the h e l p i n g p r o c e s s — a n emphasis on h e a l t h w o r k e r / p a t i e n t p a r t i c i p a t i o n i n d e c i s i o n making which i s i n tune with an approach to planned change based on Chin and Benne's (1976) normative-re-educative s t r a t e g i e s f o r change. Chapman and Chapman say: . . . Helpers deserve h i g h value and r e s p e c t , j u s t as do p a t i e n t s . They must be l i s t e n e d to as i n d i v i d u a l s as w e l l as groups and a s s i s t e d i n every growth-enhancing way to know and a c t u a l i z e themselves more br o a d l y (Chapman and Chapman, 1975:49). 140 The adoption o f the advocacy r o l e by nurses c a r r i e s w i t h i t s p e c i f i c r i s k s f o r i n d i v i d u a l nurses. K e l l y has faced the r e a l i t y o f the s i t u a t i o n by commenting: . . . We have encouraged the nurse to be autonomous, to make independent d e c i s i o n s w i t h i n her scope of p r a c t i c e , t o c o n s i d e r h e r s e l f as accountable t o the p a t i e n t . But, i f she does indeed p r a c t i c e i n t h i s f a s h i o n and, as a r e s u l t , f i n d s h e r s e l f i n p e r s o n a l and p r o f e s s i o n a l d i f f i c u l t y , are th e r e support systems a v a i l a b l e to her? ( K e l l y , 1976:32). The a t t i t u d e s expressed i n t h i s study i n d i c a t e t h a t nurses are motivated to accept the p a t i e n t as a p a r t i c i p a t i n g member of the h e a l t h care team but they need support t o assume the r i s k s a s s o c i a t e d with a se l f - i m a g e i n c o r p o r a t i n g p r o f e s s i o n a l autonomy and interdependence. Suggestions f o r F u r t h e r Research R e c o g n i t i o n of the antecedents of change which are enmeshed i n the presen t emphasis on consumer r i g h t s i n h e a l t h care has to be melded wi t h a r e c o g n i t i o n t h a t " . . . human behavior i s l i k e a centip e d e , s t a n d i n g on many l e g s . " (Bennis e t a l . 1976:6). A t t i t u d e s , although important elements i n pl a n n i n g f o r change, are not n e c e s s a r i l y transformed i n t o c orresponding behavior i n given s i t u a t i o n s . The r e s u l t s o b t a i n e d i n t h i s study suggest the need to i n v e s t i g a t e the nature of the i n t e r a c t i o n s t h a t occur, i n r e a l i t y , between the consumers of care and h e a l t h care workers and to i s o l a t e the e f f e c t t h a t v a r i o u s environments i n the h e a l t h care system have upon these r e l a t i o n s h i p s . Inherent i n t h i s approach i s a need to d e f i n e the support systems t h a t are 141 a v a i l a b l e t o r e g i s t e r e d n u r s e s who, i n t h e p r o c e s s o f a c t i -v a t i n g t h e i d e a l s o f t h e p r o f e s s i o n , f i n d t h a t t h e r e a l i t i e s o f t h e w o r k p l a c e e x e r t p o w e r f u l i n f l u e n c e s w h i c h c a n p r o v e t o be o v e r w h e l m i n g t o t h e i n d i v i d u a l n u r s e . I n c r e a s e d e m p h a s i s on t h e c o n s u m e r ' s e v a l u a t i o n o f t h e h e a l t h c a r e s y s t e m c o u l d r e s u l t i n i n n o v a t i v e a p p r o a c h e s t o t h e d e l i v e r y o f h e a l t h c a r e . R e s e a r c h i s n e e d e d t o d e v e l o p i n s i g h t i n t o how t o f o s t e r t h e p a t i e n t ' s s e l f - c a r e p o t e n t i a l a s a t h e r a p e u t i c r e s o u r c e w h i l e s t i l l s u p p o r t i n g t h e p a t i e n t ' s l e g i t i m a t e n e e d f o r d e p e n d e n c y as i t o c c u r s . S t u d i e s demon-s t r a t i n g t h e e f f e c t s o f an e n v i r o n m e n t w h i c h d e v e l o p s t h e p a t i e n t ' s a b i l i t i e s t o a c t i v e l y p a r t i c i p a t e i n h i s own h e a l t h c a r e c o m p a r e d t o one i n w h i c h t h e p a t i e n t i s e x p e c t e d t o be c o m p l i a n t and p a s s i v e w o u l d p r o v i d e c l a r i f i c a t i o n o f e n v i r o n -m e n t a l i n f l u e n c e s a n d d i r e c t i o n i n l o n g r a n g e p l a n n i n g f o r t h e f u t u r e o f t h e h e a l t h c a r e s y s t e m . 142 L i s t o f References A l f o r d , Dolores Marsh, and Janet M o l l Jensen. 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W i n s t e a d - F r y , P a t r i c i a . "The Need t o D i f f e r e n t i a t e a N u r s i n g S e l f , " A m e r i c a n J o u r n a l o f N u r s i n g 77 ( S e p t e m b e r , 1 9 7 7 ) , 1452-54. Z i l m , G l e n n i s . " N u r s i n g A s s o c i a t i o n s : A r e They C o m i n g o r G o i n g ? " The C a n a d i a n N u r s e 65 ( S e p t e m b e r , 1 9 6 9 ) , 32-35. Z o l a , I r v i n g K e n n e t h . " M e d i c i n e a s a n I n s t i t u t i o n o f S o c i a l C o n t r o l , " I n A S o c i o l o g y o f M e d i c a l P r a c t i c e , pp. 1 7 0 - 8 5 . E d i t e d by C a r o l i n e C o x , and A d r i a n n e Mead. L o n d o n : C o l l i e r - M a c M i l l a n , 1975. APPENDIX A CONSUMER RIGHTS I N HEALTH CARE CONSUMERS » ASSOCIATION OF CANADA 1974 159a 160 CONSUMER RIGHTS I N HEALTH CARE I R i g h t t o be i n f o r m e d 1 - a b o u t p r e v e n t i v e h e a l t h c a r e i n c l u d i n g e d u c a t i o n on n u t r i t i o n , b i r t h c o n t r o l , d r u g u s e , a p p r o p r i a t e e x e r c i s e 2 - a b o u t t h e h e a l t h c a r e s y s t e m i n c l u d i n g t h e e x t e n t o f g o v e r n m e n t i n s u r a n c e c o v e r a g e f o r s e r v i c e s , s u p p l e m e n t a r y i n s u r a n c e p l a n s , t h e r e f e r r a l s y s t e m t o a u x i l i a r y h e a l t h a n d s o c i a l f a c i l i t i e s a n d s e r v i c e s i n t h e - c o m m u n i t y 3 - a b o u t t h e i n d i v i d u a l ' s own d i a g n o s i s a n d s p e c i f i c t r e a t m e n t p r o g r a m i n c l u d i n g p r e s c r i b e d s u r g e r y a n d m e d i c a t i o n , o p t i o n s , e f f e c t s a n d s i d e e f f e c t s 4 - a b o u t t h e s p e c i f i c c o s t s o f p r o c e d u r e s , s e r v i c e s and p r o f e s s i o n a l f e e s u n d e r t a k e n o n b e h a l f o f t h e i n d i v i d u a l c o n s u m e r I I R i g h t t o be r e s p e c t e d a s t h e i n d i v i d u a l w i t h t h e m a j o r r e s p o n s i b i l i t y f o r h i s own h e a l t h c a r e - r i g h t t h a t c o n f i d e n t i a l i t y o f h i s h e a l t h r e c o r d s be m a i n t a i n e d - r i g h t t o r e f u s e e x p e r i m e n t a t i o n , undue p a i n f u l p r o l o n -g a t i o n o f h i s l i f e o r p a r t i c i p a t i o n i n t e a c h i n g p r o g r a m s - r i g h t o f a d u l t t o r e f u s e t r e a t m e n t , r i g h t t o d i e w i t h d i g n i t y I I I R i g h t t o p a r t i c i p a t e i n d e c i s i o n m a k i n g a f f e c t i n g h i s h e a l t h - t h r o u g h c o n s u m e r r e p r e s e n t a t i o n a t e a c h l e v e l o f g o v e r n -ment i n p l a n n i n g a n d e v a l u a t i n g t h e s y s t e m o f h e a l t h s e r v i c e s , t h e t y p e s a nd q u a l i t i e s o f s e r v i c e a n d t h e c o n d i t i o n s u n d e r w h i c h h e a l t h s e r v i c e s a r e d e l i v e r e d - w i t h t h e h e a l t h p r o f e s s i o n a l s a n d p e r s o n n e l i n v o l v e d i n h i s d i r e c t h e a l t h c a r e I V R i g h t t o e q u a l a c c e s s t o h e a l t h c a r e ( h e a l t h e d u c a t i o n , p r e v e n t i o n , t r e a t m e n t a nd r e h a b i l i t a t i o n ) r e g a r d l e s s o f t h e i n d i v i d u a l ' s e c o n o m i c s t a t u s , s e x , a g e , c r e e d , e t h n i c o r i g i n a n d l o c a t i o n - r i g h t t o a c c e s s t o a d e q u a t e l y q u a l i f i e d h e a l t h p e r s o n n e l - r i g h t t o a s e c o n d m e d i c a l o p i n i o n - r i g h t t o p r o m p t r e s p o n s e i n e m e r g e n c i e s APPENDIX B PANKRATZ AND PANKRATZ (1974) ATTITUDE SCALE 160a 161 PANKRATZ AND PANKRATZ (1974) ATTITUDE SCALE NURSING QUESTIONNAIRE I D E N T I F I C A T I O N I w o u l d l i k e t o know w h a t y o u t h i n k a b o u t t h e s e s t a t e m e n t s . F o r e a c h o p i n i o n s t a t e m e n t , p l a c e a number i n t h e b o x t o t h e r i g h t o f t h e q u e s t i o n t h a t c o r r e s p o n d s m o s t c l o s e l y , t o how y o u r e a c t t o t h e s t a t e m e n t . STRONGLY AGREE ="1; AGREE = 2; UNDECIDED = 3; DISAGREE = 4; an d STRONGLY DISAGREE = 5. P l e a s e a n s w e r e v e r y q u e s t i o n . T h e r e a r e no r i g h t o r w r o n g a n s w e r s . 1) I f e e l t h a t p a t i e n t s s h o u l d p l a n t h e i r own a c t i v i t i e s . 2) I h a v e f u l f i l l e d my r e s p o n s i b i l i t y when I r e p o r t a c o n d i t i o n t o a p h y s i c i a n . 3) I w o u l d f e e l f r e e t o t r y new a p p r o a c h e s t o p a t i e n t s ' c a r e w i t h o u t t h e " p e r m i s s i o n " o f a n a d m i n i s t r a t i v e n u r s e . 4) I f e e l f r e e t o recommend n o n - p r e s c r i p t i o n m e d i c a t i o n . 5) I f I r e q u e s t e d a p s y c h i a t r i c c o n s u l t f o r a p a t i e n t , I. w o u l d f e e l o u t o f b o u n d s . 6) I b e l i e v e a p a t i e n t h a s a r i g h t t o h a v e a l l h i s q u e s t i o n s a n s w e r e d f o r h i m . 7) I f I am n o t s a t i s f i e d w i t h t h e d o c t o r ' s a c t i o n I w o u l d p u r s u e t h e i s s u e . 8) I am t h e b e s t p e r s o n i n t h e h o s p i t a l t o be t h e p a t i e n t ' s a d v o c a t e i f he d i s a g r e e s w i t h t h e d o c t o r . 9) I f a p a t i e n t i s a l l o w e d t o k e e p a l o t o f p e r s o n a l i t e m s , i t becomes m o r e , t r o u b l e t h a n i t i s w o r t h . 10) I . d o n ' t a n s w e r t o o many q u e s t i o n s o f t h e p a t i e n t b e c a u s e t h e d o c t o r may h a v e a n o t h e r p l a n i n m i n d . 11) I f e e l t h e d o c t o r i s f a r b e t t e r t r a i n e d t o make d e c i s i o n s t h a n I . 12) I w o u l d n e v e r c a l l a p a t i e n t ' s f a m i l y a f t e r d i s c h a r g e . 162 P a t i e n t s s h o u l d n o t h a v e a n y r e s p o n s i b i l i t y i n a h o s p i t a l . P a t i e n t s s h o u l d be p e r m i t t e d t o go o f f t h e i r u n i t a n d e l s e w h e r e i n t h e h o s p i t a l . I f a p a t i e n t a s k s why h i s m e d i c a t i o n i s c h a n g e d , I w o u l d r e f e r h i m t o h i s d o c t o r . I f a p o l i c y c h a n g e a f f e c t s p a t i e n t c a r e , I w a n t t o u n d e r s t a n d why t h e c h a n g e i s n e c e s s a r y . P a t i e n t s s h o u l d be e n c o u r a g e d t o show t h e i r f e e l i n g s . I s h o u l d be a b l e t o go i n t o p r i v a t e p r a c t i c e l i k e a d o c t o r i f I w i s h . I f e e l p a t i e n t s s h o u l d be t o l d t h e m e d i c a t i o n s t h e y a r e t a k i n g . , I s h o u l d h a v e a r i g h t t o know why a c h a n g e . i s n e c e s s a r y B e f o r e i t . i s a c c e p t e d . P a t i e n t s s h o u l d b e t o l d t h e i r d i a g n o s i s . I f I make c o n v e r s a t i o n w i t h t h e p a t i e n t , t h e r e i s no n e e d t o e x p l a i n p r o c e d u r e s a nd t r e a t m e n t s b e f o r e t h e y a r e s t a r t e d . I g e n e r a l l y know more a b o u t t h e . p a t i e n t t h a n t h e d o c t o r . P a t i e n t s i n a h o s p i t a l h a v e a r i g h t t o s e l e c t t h e t y p e o f t r e a t m e n t s o r c a r e t h e y w i s h . I f I d i s a g r e e w i t h t h e . d o c t o r , I k e e p i t t o m y s e l f . I f e e l t h e p a t i e n t h a s a r i g h t t o e x p e c t me, a s a n u r s e , t o e f f e c t i v e l y u t i l i z e my t i m e i n i m p r o v i n g my s k i l l s by t a k i n g a d v a n t a g e o f e d u c a t i o n a l o p p o r t u n i t i e s o f f e r e d . . I w o u l d f e e l c o m f o r t a b l e i n a u t h o r i z i n g a p a t i e n t t o l e a v e t h e u n i t t o go t o a n o t h e r p a r t o f t h e h o s p i t a l . The p a t i e n t h a s a r i g h t t o e x p e c t me t o r e g a r d h i s p e r s o n a l n e e d s t o h a v e p r i o r i t y o v e r m i n e . I f e e l t h e p a t i e n t h a s a r i g h t t o r e f u s e c a r e . I t s h o u l d be t h e d o c t o r who d e c i d e s i f t h e p a t i e n t c a n a d m i n i s t e r h i s own d r u g s . I w o u l d n e v e r r e f u s e t o c a r r y o u t a d o c t o r ' s o r d e r . 163 32) I f e e l t h a t p a t i e n t s s h o u l d be i n f o r m e d a s t o what c o n s t i t u t e s q u a l i t y h e a l t h c a r e . 33) The p a t i e n t h a s a r i g h t t o e x p e c t me t o a c c e p t h i s s o c i a l c u l t u r a l c o d e a n d t o c o n s i d e r i t s i n f l u e n c e o n h i s way o f l i f e . 3 4) P a t i e n t s s h o u l d be p e r m i t t e d t o . w e a r w h a t t h e y w a n t . 35) I w o u l d n e v e r i n t e r a c t w i t h a p a t i e n t on a f i r s t name b a s i s . 36) I r a r e l y g i v e i n t o p a t i e n t p r e s s u r e . 37) N u r s e s s h o u l d be h e l d s o l e l y l e g a l l y r e s p o n s i b l e f o r t h e i r own a c t i o n s a n d n o t e x p e c t t o come u n d e r t h e u m b r e l l a o f t h e d o c t o r o r h o s p i t a l i n a m a l p r a c t i c e s u i t . 38) D o c t o r s m u s t d e c i d e w h a t n u r s e s c a n and c a n n o t do i n t h e d e l i v e r y o f h e a l t h c a r e . 39) I t i s t h e p r e r o g a t i v e o f t h e n u r s e t o d e c i d e w h e t h e r o r n o t t o w e a r a u n i f o r m . 40) I w o u l d g i v e t h e p a t i e n t h i s d i a g n o s i s i f he a s k s . 41) I t s h o u l d be t h e n u r s e ' s d e c i s i o n when t o t a l k t o t h e t e r m i n a l p a t i e n t a b o u t h i s c o n d i t i o n . 42) I t h i n k t h a t i t i s my r e s p o n s i b i l i t y t o i n i t i a t e p u b l i c h e a l t h r e f e r r a l s on p a t i e n t s . 43) ' I f e e l t h a t I s h o u l d s u g g e s t t o p a t i e n t s , f a m i l y , a n d d o c t o r a n y c o m m u n i t y r e s o u r c e s t h a t I know a r e a v a i l a b l e . 44) P a t i e n t s c a n e x p e c t me t o s p e a k up f o r them. 45) I w o u l d n e v e r a s k a p a t i e n t a b o u t h i s o r h e r s e x u a l l i f e . 46) I w o u l d t a l k v e r y l i t t l e t o p a t i e n t s a b o u t t h e i r p a s t . 47) I r a r e l y a s k a p a t i e n t a p e r s o n a l q u e s t i o n . 16 4 FOR THE REMAINING QUESTIONS, PLEASE PLACE THE CODE NUMBER I N THE ANSWER BOX, WHICH. CORRESPONDS TO THE CORRECT ANSWER TO THE QUESTION. EXAMPLE - I f y o u a r e a Community H e a l t h N u r s e , P l a c e t h e number 2 i n t h e b o x . CODE 48) A r e y o u a -N u r s e P r a c t i t i o n e r ? 1 Community H e a l t h N u r s e ? . 2 S u p e r v i s o r o r A d m i n i s t r a t i v e N u r s e ? 3 Head N u r s e ? 4 S t a f f N u r s e ? 5 T e a c h e r ? 6 O t h e r ? 7 49) Do y o u wo r k -F u l l t i m e ? 1 P a r t t i m e ? 2 I n a c t i v e ? 3 50) How many y e a r s o f e x p e r i e n c e do y o u h a v e a s a R e g i s t e r e d N u r s e ? U n d e r 5 y e a r s ? 1 6-10 y e a r s ? 2 11-15 y e a r s ? 3 o v e r 15 y e a r s ? 4 51) Do y o u wo r k i n -a H o s p i t a l ? 1 a Community s e t t i n g ? 2 E d u c a t i o n a l s e t t i n g ? 3 o t h e r ? 4 52) Age -u n d e r 20 y e a r s ? 1 21-30 y e a r s ? 2 31-40 y e a r s ? 3 41-50 y e a r s ? 4 51-60 y e a r s ? 5 o v e r 60 y e a r s ? 6 53) H i g h e s t e d u c a t i o n a l q u a l i f i c a t i o n c o m p l e t e d -D i p l o m a ? 1 B a c c a l a u r e a t e d e g r e e ? 2 G r a d u a t e d e g r e e ? 3 O t h e r ? 4 APPENDIX C SCORING FOR PANKRATZ AND PANKRATZ (1974) ATTITUDE SCALE 164a 165 S c o r i n g f o r t h e P a n k r a t z a nd P a n k r a t z (1974) A t t i t u d e S c a l e E a c h s u b j e c t was g i v e n one t o f i v e p o i n t s o n e a c h s t a t e m e n t . The p o i n t s w e r e a s s i g n e d s o t h a t ' S t r o n g l y A g r e e 1 = one p o i n t up t o ' S t r o n g l y D i s a g r e e ' = 5 p o i n t s . Some s t a t e m e n t s c o n t r i b u t e d p o s i t i v e l y and some n e g a t i v e l y t o t h e s c a l e s c o r e s . T h e r e f o r e , some i t e m s w e r e r e v e r s e d b y s u b -t r a c t i n g f r o m a g i v e n c o n s t a n t — t h a t c o n s t a n t b e i n g s i x p o i n t s f o r e a c h r e v e r s e d s t a t e m e n t . E X A M P L E — o n S c a l e I I I , t h e s u b j e c t ' s s c o r e on s t a t e m e n t number s e v e n c o n t r i b u t e d o n l y one p o i n t , i f t h e s u b j e c t c h e c k e d ' S t r o n g l y D i s a g r e e ' ( s i x m i n u s f i v e = o n e ) . The p r o c e d u r e t o o b t a i n s c o r e s o n t h e t h r e e s c a l e s i s as f o l l o w s : SCALE I - H i g h e s t p o s s i b l e s c o r e i s 130. 1) Add t h e s c o r e s o n t h e f o l l o w i n g 15 i t e m s : 1, 3, 4, 8, 14, 18, 2 3 , 24, 2 7 , 34, 37, 39, 40, 4 1 , 42 S u b t r a c t t h e t o t a l s c o r e o n t h e s e i t e m s f r o m 90. 2) Add t h e p r e c e d i n g r e s u l t s t o .the t o t a l s c o r e on t h e f o l l o w i n g e l e v e n i t e m s : 5, 9, 10, 1 1 , 12, 1 5 , 30, 36, 38, 45, 46 SCALE I I - H i g h e s t p o s s i b l e s c o r e i s 98. Add t h e s c o r e s on t h e f o l l o w i n g 14 i t e m s : 6, 16, 17, 19, 20, 2 1 , 26, 28, 29, 32, 33, 34, 4 3 , 44 S u b t r a c t t h e t o t a l s c o r e on t h e s e i t e m s f r o m 84. SCALE I I I - H i g h e s t p o s s i b l e s c o r e i s 65. 1) S u b t r a c t t h e s u b j e c t ' s s c o r e o n i t e m number s e v e n f r o m s i x . 2) Add t h e p r e c e d i n g r e s u l t s t o t h e t o t a l s c o r e o f t h e f o l l o w i n g t w e l v e i t e m s . 2, 5, 10, 1 1 , 1 3 , .22, 25, 3 1 , 35, 45, 46, 47. 

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