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UBC Theses and Dissertations

A review of activity recording systems in community health nursing Kretzmar, Philip Terence 1979

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A REVIEW OF ACTIVITY: RECORDING SYSTEMS . IN COMMUNITY HEALTH NURSING by PHILIP TERENCE KRETZMAR B.A., The U n i v e r s i t y o f Cape Town, 1973 B.Sc,  The U n i v e r s i t y o f Cape Town, 1975  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health S e r v i c e s Planning) in THE FACULTY OF GRADUATE STUDIES (The Department of H e a l t h Care and Epidemiology)  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 October 1979  ©  P h i l i p Terence Kretzmar, 1979  In  presenting  an  advanced  the I  Library  further  for  this  thesis  degree shall  agree  at  the University  make  that  by  his representatives.  of  this  written  freely  of  of  Columbia,  British  available  gain  shall  that  the  requirements  reference copying  by t h e Head  i s understood  for financial  for  for extensive  may be g r a n t e d It  fulfilment  of  I agree and this  thesis  o f my D e p a r t m e n t  copying  or  of  University  H ^ M T f f of  British  2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  Ck^ Columbia  th  study.  o  publicatio  n o t be a l l o w e d w i t h o u t  my  permission.  Department The  it  permission  s c h o l a r l y purposes  thesis  in p a r t i a l  EPlE>S*Jl | O t O ^  ii ABSTRACT The  purpose o f t h i s study i s to evaluate  the r o l e of  a c t i v i t y data i n the management of community h e a l t h  nurs-  ing s e r v i c e s . The  study begins by examining what community h e a l t h  nurses do.  P a r t i c u l a r a t t e n t i o n i s given to the manage-  ment s t r u c t u r e i n community h e a l t h n u r s i n g . of i n f o r m a t i o n  The  t h a t i n d i v i d u a l s at d i f f e r e n t l e v e l s i n  the o r g a n i z a t i o n of community h e a l t h n u r s i n g are i n v e s t i g a t e d . a c t i v i t y data.  One  require,  of these kinds of i n f o r m a t i o n i s  Thus, the r o l e t h a t a c t i v i t y data  p l a y f o r those at each o r g a n i z a t i o n a l l e v e l i s Various  kinds  can  explored.  f a c t o r s t h a t can i n f l u e n c e the u s e f u l n e s s  of  a c t i v i t y data are examined. The  conceptual  i n c i a l and one analyzed.  and  f u n c t i o n a l f e a t u r e s of s i x prov-  f e d e r a l a c t i v i t y r e c o r d i n g system are  T h i s i s f o l l o w e d by a more d e t a i l e d study o f  a p a r t i c u l a r system, the A l b e r t a Community Nursing  Acti-  v i t i e s Recording System. In reviewing  the systems analyzed,  the study f i n d s  that a common model f o r a c t i v i t y r e c o r d i n g systems cannot be d e r i v e d .  Objectives  are found to be so vaguely  d e f i n e d t h a t the e v a l u a t i o n of an a c t i v i t y  recording  system i s f o r c e d to r e l y l a r g e l y on the s u b j e c t i v e ings of the systems u s e r s .  Having examined some per-  c e i v e d a l t e r n a t i v e s to c u r r e n t systems, i t i s f e l t a thorough r e v i s i o n of p r e s e n t l y o p e r a t i n g should be undertaken.  feel-  systems  that  iii TABLE OF CONTENTS  P  Abstract  a  g  i i  Table of Contents  i i i  L i s t of Tables L i s t of F i g u r e s  v  Acknowledgements  Information C h a r a c t e r i s t i c s f o r Different Organizational Levels . . . . Information Flows i n an O r g a n i z a t i o n . . What i s A c t i v i t y Recording? Functions Performed by Nurses at D i f f e r e n t L e v e l s i n the O r g a n i z a t i o n . . Operational Control Management C o n t r o l Strategic Planning A c t i v i t y Data and D e c i s i o n Making . . . The Role of A c t i v i t y Data  ' 2.4.1 2.4.2 2.4.3 2.5 2.6  4.2.1  4 5 11  15 21 25 27 28 29 36 39 41  3  3.1 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.3 3.3.1 3.3.2 3.3.3 3.4  4.1 4.2  i  2  2.2 2.3 2.4  Chapter  i  1  What i s Community H e a l t h Nursing?. . . . What Community H e a l t h Nurses Do ... . The Management S t r u c t u r e i n Community H e a l t h Nursing  2.1  Chapter  i  1  1.1 1.2 1.3 Chapter  v  viii  Introduction Chapter  £  The Dynamics of Data T r a n s m i s s i o n Data A c q u i s i t i o n Accuracy Reliability Validity Costs Data Communication F a c t o r s A f f e c t i n g Data Flow Frequency of R e p o r t i n g The Volume o f Data R e p o r t i n g The I n t e r p r e t a t i o n o f Data  . . .  44 44 46 46 51 53 53 54 55 56 60  4 A c t i v i t y Recording Systems i n Canada . . F u n c t i o n a l Features o f A c t i v i t y Recording Systems F e d e r a l Government System  64 65 73  iv  Chapter 4 4.3 4.3.1 4.3.2 4.3.3 4.3.4 4.3.5 4.4 4.4.1 4.5 4.5.1 4.5.2 4.6  (cont.) F u n c t i o n a l Features: D i s c u s s i o n . . . . S e r v i c e s Recorded Non-Client Contact A c t i v i t i e s Data re S e r v i c e R e c i p i e n t s D u r a t i o n o f S e r v i c e s Recorded P l a c e o f S e r v i c e Recorded D i s c u s s i o n o f Systems O b j e c t i v e s . . . O p e r a t i o n a l Features S p e c i a l Features Manitoba The F e d e r a l Government Performance Measurement System Summary o f A c t i v i t y Recording Systems Reviewed  73 73 74 74 76 78 78 82 82 84 84 86  Chapter 5 5.1 5.2 5.3 5.4 5.5 5.5.1 5.5.2 5.5.3 5.6 5.6.1 5.6.2 5.6.3 5.7 5.7.1 5.7.2 5.7.3 5.7.4 5.8 5.8.1 5.8.2 5.8.3 5.8.4 5.8.5 5.8.6  Case Study o f the A l b e r t a Community Nursing A c t i v i t i e s Recording System (A.C.N.A.R.S.) The O r g a n i z a t i o n of Community H e a l t h Services i n Alberta O r g a n i z a t i o n o f Health Agencies . . . . Community Health Nursing i n A l b e r t a . . Background to the I n t r o d u c t i o n o f A.C.N.A.R.S The Need f o r A.C.N.A.R.S P l a n n i n g and Development o f A.C.N.A.R.S. Implementation o f A.C.N.A.R.S The Nurses Report Forms: 1 and 2 . . . Form No. 1 Form No. 2 The Output: Forms 1 and 2 A.C.N.A.R.S. Form No. 1 Section 1 S e c t i o n 2. Time A l l o c a t i o n by Program S e c t i o n s 3 and 4. Group A c t i v i t i e s and I n d i v i d u a l Contacts S e c t i o n 5. Screenings, Assessments and Treatments General D i s c u s s i o n on A.C.N.A.R.S. . . Objectives Assumptions I Acceptance o f the System Recording Data Communication o f Data Usefulness of Systems Data  88 88 89 92 93 93 96 98 99 99 101 102 107 107 107 108 109 109 109 l l 112 114 114 116  V  Chapter 6 6.1 6.2 6.3 6.3.1 6.3.2 6.4 6.4.1 6.4.2 6.4.3 6.5  General D i s c u s s i o n A Common Model . Evaluation Systems Performance The Impact o f A c t i v i t y Data Alternatives No A c t i v i t y Recording S p e c i a l Studies Computerization Conclusions  Bibliography  119 119 120 122 123 124 124 125 127 128 131  vi LIST OF TABLES Table 1.1  1.2  2.1 4.1  Page D i s t r i b u t i o n o f Community H e a l t h Nurses Reported, by P o s i t i o n and by P r o v i n c e , 1975  8  D i s t r i b u t i o n o f Community H e a l t h Nurses Reported, by P o s i t i o n , 1969, 1970, 1971 and 1975  9  The Antony Framework and Information Characteristics  17  F u n c t i o n a l Features o f Recording Systems  68  4.2  Objectives  79  4.3  O p e r a t i o n a l Features o f Systems  83  5.1 6.1  Coding B a s i c C a t e g o r i e s f o r A c t i v i t y Recording.  .  104 121  LIST OF FIGURES Figure 1.1  Page D i s t r i b u t i o n o f P u b l i c H e a l t h Nurses by Academic Q u a l i f i c a t i o n , 1975  10  1.2  Community H e a l t h Agency S t r u c t u r e . . . .  12  2.1  Community H e a l t h Agency Pyramid S t r u c t u r e f o r Management Information Systems  18  2.2  Information Flows i n a System . . . . . .  23  2.3  Information Flows o f a H e a l t h Agency  24  3.1  The Stages o f Data T r a n s m i s s i o n  45  3.2  Model o f C o g n i t i v e S t y l e  61  5.1  The O r g a n i z a t i o n o f Community H e a l t h Services i n A l b e r t a  90  5.2  ...  The O r g a n i z a t i o n o f a T y p i c a l H e a l t h Agency  91  5.3  Nurses Weekly A c t i v i t y Report: Form No. 1  103  5.4  Form No. 2  105  5.5  Report from Form No. 1  106  viii  ACKNOWLEDGEMENTS  I would l i k e to express my s i n c e r e thanks:  to Dr. Charles L a s z l o , D i v i s i o n o f H e a l t h Systems, U.B.C, f o r a very s t i m u l a t i n g and v a l u a b l e l e a r n i n g experience,  to Dr. Morton Warner, Department o f H e a l t h Care and Epidemiology,  U.B.C, and Dr. Jack Yensen, Vancouver  Community C o l l e g e , Langara,  f o r s h a r i n g w i t h me t h e i r  time, knowledge and energy,  to Mrs, Pat Yates, A l b e r t a S o c i a l S e r v i c e s and Community H e a l t h , f o r h e r t i r e l e s s a s s i s t a n c e i n h e l p i n g me l e a r n about A.C.N.A.R.S.,  and to Dr. Annette Research  Stark, D i v i s i o n o f H e a l t h S e r v i c e s  and Development, U.B.C, f o r her comments on  d r a f t s o f t h i s work.  1  INTRODUCTION Community h e a l t h n u r s e s cord  their  this  purpose.  the r o l e  activities  activity  community h e a l t h n u r s i n g There are a c t i v i t y  information.  i n t h e management o f  recording  Numerous c l a i m s  systems i n every spend a  data,  considerable  the required  h a v e b e e n made a b o u t t h e  w h i c h a r e v i e w e d as an im-  e l e m e n t o f t h e i n f o r m a t i o n n e e d s i n community  ful  i n planning,  ing  staffing,  Recording  evaluation,  c o s t i n g s e r v i c e s , determinactivities.  d a t a b e c o m i n g an e n t r e n c h e d  s y s t e m u s e d by n u r s i n g  - do t h e s e  data  play  justified?  item  i n the  management.  a useful role?  about the importance o f a c t i v i t y  Are the  data  really  T h e r e i s a n e e d t o examine t h e v a l i d i t y o f  these  claims.  light  o f the p o t e n t i a l  T h i s need i s e s p e c i a l l y p r e s s i n g f o r the computerization  data  s y s t e m s , and t h e p o s s i b l e p r o l i f e r a t i o n  sary  information. This  as h e l p -  systems have a l s o been c o m p u t e r i z e d , w h i c h has  information But  They a r e r e g a r d e d  and i n o t h e r m a n a g e r i a l  to a c t i v i t y  claims  evaluate  services.  h e a l t h n u r s i n g management.  led  i s to  t i m e and e n e r g y r e c o r d i n g  many u s e s o f a c t i v i t y portant  data  developed f o r  study  .Community h e a l t h n u r s e s  amount o f t h e i r  the country r e -  on f o r m s s p e c i a l l y  The p u r p o s e o f t h i s  o f these  province.  throughout  study  will  focus  on two a s p e c t s  i n the o f these  o f unneces-  of a c i t i v i t y  2  data.  These a r e : 1.  the need f o r a c t i v i t y  2.  the u s e f u l n e s s o f a c t i v i t y  To which  g a i n an u n d e r s t a n d i n g these  in  of the context w i t h i n  data are r e l e v a n t , the study  As a c t i v i t y  special  data.  commences  1 ) by l o o k i n g a t what community h e a l t h  (chapter do.  d a t a , and  nurses  data a r e used a t the managerial  attention  level,  i s g i v e n t o t h e management s t r u c t u r e  community h e a l t h n u r s i n g . E a c h l e v e l w i t h i n an o r g a n i z a t i o n r e q u i r e s p a r t i -  cular  types  of information.  In chapter  amines t h e i n f o r m a t i o n n e e d s o f t h o s e organizational of  the kinds  The at  study  levels  2 t h e s t u d y ex-  at the d i f f e r e n t  o f community h e a l t h n u r s i n g .  o f i n f o r m a t i o n needed i s a c t i v i t y  explores  the r o l e  that a c t i v i t y  each o r g a n i z a t i o n a l l e v e l .  I t also  ential  contribution of activity  making  process.  data  mission. will  3 the study  assesses  i n f l u e n c e the u t i l i t y  f a c t o r s n e e d t o be t a k e n  t h e f u n c t i o n i n g o f an a c t i v i t y act  data, i n  o f data trans-  a t these  of activity  into  the pot-  i n the d e c i s i o n  examines t h e s t a g e s  There are v a r i o u s f a c t o r s  data.  data can p l a y  Having e s t a b l i s h e d the need f o r a c t i v i t y chapter  One  data.  stages  which  These  consideration i n assessing r e c o r d i n g system.  They can  as a g u i d e l i n e f o r a s y s t e m ' s e v a l u a t i o n . In  chapter  4, t h e f e a t u r e s o f s i x p r o v i n c i a l  and one  3  f e d e r a l a c t i v i t y r e c o r d i n g systems are analyzed.  This  a n a l y s i s i n v o l v e s a review of the f u n c t i o n a l and  concep-  t u a l f e a t u r e s o f the systems. Having obtained across  the country,  an overview of r e c o r d i n g  an in-depth  systems  study i s done, i n  5, of the A l b e r t a Community Nursing  Activities  chapter  Recording  System. In c o n c l u s i o n ,  i n chapter  6 , the study addresses i t -  s e l f to some of the major i s s u e s that have been r a i s e d . These are: 1.  i s there a common systems model?  2.  the e v a l u a t i o n o f a c t i v i t y r e c o r d i n g systems,  3.  a l t e r n a t i v e s to r e g u l a r a c t i v i t y r e c o r d i n g ,  4.  computerization.  and  4  CHAPTER 1 1.1  What i s community h e a l t h  nursing?  Community h e a l t h n u r s i n g i s seen as p r o f e s s i o n a l n u r s i n g aimed at s e r v i n g people i n t h e i r u s u a l  environ-  ment o f home, school or work, through organized  commun-  ity effort  (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1966;  1977). The  o b j e c t i v e s o f community h e a l t h n u r s i n g a r e :  1.  To promote h e a l t h and prevent  2.  To p r o v i d e n u r s i n g care f o r the non-hospita-  disease;  l i z e d s i c k and d i s a b l e d , 3.  To e f f e c t c o n t i n u i t y o f care,  4.  To c o n t r i b u t e to v a r i o u s e d u c a t i o n a l programs, and  5.  To be i n v o l v e d i n r e l e v a n t r e s e a r c h . (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1966; 1977).  In a d d i t i o n to i n d i v i d u a l c l i n i c a l l y - o r i e n t e d  care,  community h e a l t h n u r s i n g focuses on group h e a l t h problems w i t h i n a p o p u l a t i o n as a means o f determining  the d i r e c -  t i o n o f c l i n i c a l care s e r v i c e s (Williams, 1977). approach enables priorities, being  This  the p r o v i d e r s o f care t o e s t a b l i s h  and to i d e n t i f y the needs o f the p o p u l a t i o n  served.  I t thus a l s o enables  co-operation  with  other d i s c i p l i n e s i n the community. The ing  community h e a l t h nurse i s a g e n e r a l i s t f u n c t i o n -  as a member o f a m u l t i - d i s c i p l i n a r y team.  To  5  fill  this  r o l e i n a dynamic h e a l t h  the n u r s e s b e l i e v e and  the  services  reassessed,  1.2  and  that  that  discussion  tion  of nurses The  to  Association  i s b a s e d upon (1966, 1977)  work r e q u i r e s  member o f n u r s i n g  and  her  service direct-  to e x e r c i s e  close  enables her  tacts with other  have t h e  disciplines  and  and  switch  She  can  the  the  availability  primarily she  of relevant  services.  some a d m i n i s t r a t i v e ,  the  community  act are  s i t u a t i o n , and  concerned with d i r e c t care  a l s o has  the  the nurse o c c u p i e s  due of  team  most f r e q u e n t  needed s e r v i c e s  understanding of  has  from  workers of a l l i e d  o f t e n unique p o s i t i o n .  a  demands o f  channel through which other to her  As  teams, she  to  c l o s e s t and  c i e s . W i t h i n , t h e team s t r u c t u r e , pivotal,  judgement  a l l community h e a l t h w o r k e r s ,  health nurse w i l l  The  supervision.  t o team member, d e p e n d i n g upon t h e Of  descrip-  s p e c i a l groups.  interdisciplinary  of r o l e that  situation.  the  activities.  1  i n d i v i d u a l s , f a m i l i e s and  flexibility  frequently  do  section  t o make d e c i s i o n s w i t h o u t  leader  n e e d t o be  community h e a l t h n u r s e p r o v i d e s  nature of her  preparation  where n e c e s s a r y .  in this  Canadian P u b l i c Health  and  they provide  adjusted  environment,  educational  What community h e a l t h n u r s e s The  ly  their  care  as  con-  agena a  acquired, knowledge  Although  contact  supervisory  functions, and  6 counselling  responsibilities.  The s u p e r v i s o r of community h e a l t h n u r s i n g the key  interpretive  occupies  r o l e between the d i r e c t o r and  service nursing personnel.  She i s r e s p o n s i b l e to the  d i r e c t o r f o r p l a n n i n g and d i r e c t i n g the a c t i v i t i e s of n u r s i n g and a u x i l i a r y s t a f f i n a s p e c i f i e d area.  She i s  a l s o r e s p o n s i b l e f o r s t a f f development. The d i r e c t o r o f community h e a l t h n u r s i n g i s a member o f the a d m i n i s t r a t i v e team o f the o r g a n i z a t i o n . Inherent  i n the p o s i t i o n o f d i r e c t o r i s d e c i s i o n making  a u t h o r i t y i n r e l a t i o n to the e n t i r e range of n u r s i n g s e r v i c e s under her d i r e c t i o n .  She i s r e s p o n s i b l e f o r the  f u n c t i o n i n g o f 'the s t a f f and programs under her d i r e c t i o n to a c h i e f a d m i n i s t r a t o r as designated by the organization. and  The d i r e c t o r p a r t i c i p a t e s i n p o l i c y  i n determining  planning,  the s h o r t and long range plans f o r the  community h e a l t h n u r s i n g s e r v i c e s o f the o r g a n i z a t i o n . She i n t e r p r e t s community h e a l t h n u r s i n g a c t i v i t i e s to other a d m i n s t r a t i v e  personnel  and the p o l i c y .making board  of the o r g a n i z a t i o n , and to community agencies.  Converse-  l y , she helps the n u r s i n g s t a f f to see t h e i r r o l e s and f u n c t i o n s i n r e l a t i o n to other community  agencies.  The nurse c o n s u l t a n t i s an expert, by reason o f educ a t i o n or experience,  e i t h e r i n the g e n e r a l f i e l d o f  community h e a l t h n u r s i n g , or i n a s p e c i f i c area.  Her  primary purpose i s to promote: the q u a l i t y and development  7  o f the agencies n u r s i n g program.  Her p o s i t i o n i n the  a d m i n i s t r a t i v e h i e r a r c h y o f the o r g a n i z a t i o n w i l l depend upon the s p e c i f i c o r g a n i z a t i o n a l s t r u c t u r e . The d i s t r i b u t i o n o f community h e a l t h nurses by p o s i t i o n and by p r o v i n c e f o r 1975 i s shown i n Table  1.1  (p. 8 ) . T a b l e 1.2  (p. 9) shows the d i s t r i b u t i o n o f commun-  i t y h e a l t h nurses by p o s i t i o n f o r 1969, 1970, 1971 and 1975.  In 1975, 2.2.per cent were d i r e c t o r s or a s s i s t a n t  directors  (122), 7.9 per cent were s u p e r v i s o r s o r a s s i s -  t a n t s u p e r v i s o r s (446), and 1.6 per cent  (90) were  consultants. The d i s t r i b u t i o n o f community h e a l t h nurses by academic q u a l i f i c a t i o n s f o r 1975 i s shown i n F i g u r e 1.1 (p. 10).  Between 1970 and 1975 there was a r e d u c t i o n i n  the percentage  o f r e g i s t e r e d nurses w i t h p u b l i c h e a l t h  c e r t i f i c a t e s from 45.7 per cent to 36.2 per cent. was an i n c r e a s e i n the percentage  of registered  There  nurses  w i t h a b a c c a l a u r e a t e degree, major p u b l i c h e a l t h , from 14.6 per cent t o 19.8 per cent.  There was a l s o an i n c r e a s e  i n r e g i s t e r e d nurses w i t h a b a c c a l a u r e a t e degree o n l y , from 2.8 per cent i n 1970 other c a t e g o r i e s 1975.  to 7.2 per cent i n 1975.  showed l i t t l e  The  change between 1970 and  Table  1.1 D i s t r i b u t i o n o f Community H e a l t h Nurses reported by p o s i t i o n and by P r o v i n c e 1975  Canada  N f l d PEI  NS  NB  QUE.  ONT. • MAN.  SASK ALTA  BC  YUKON"  POSITION 3  1  6  42  4  4  11  5  1  1  6  16  2  2  4  2  -  1  -  1  1  1  1  -  -  -  7 55  9 2  4 -  3 3  4 1  1 1  8  4  8  6  -  -  26  111  14  14  52  37  10  1  -  3  13  9  42  11  23  1  51  2  278  183  384  597  106  90  42  49  95  15  411  272  508  793  136  Director  78  1  Asst. Director (service)  39  4  (education).  5  -  ( g e n e r a l i z e d ) .. ( s p e c i a l i z e d ) ..  28 62  -  Supervisor  290  Asst. Supervisor  156  Asst. Director Consultant Consultant  -  S t a f f Nurse  ( P u b l i c Health)  3,828  71  S t a f f Nurse  (RN)  1,160  33  TOTAL  Source:  5,646  118  1  -  -  24 162 4  2  33 179  60  402  29  503  111  952  1,561 298 2,133  S t a t i s t i c s Canada, Annual S a l a r i e s of P u b l i c Health Nurses. Information Canada, 1975  Ottawa:  1  -  9 Table 1.2 D i s t r i b u t i o n o f Cornmunity H e a l t h Nurses r e p o r t e d by p o s i t i o n , 1969, 1970, 1971 and 1975.  Position  1969  1970  1971  1975  S t a f f nurses  3,744  4,533  4,647  4,988  389  501  548  446  Consultants  40  46  48  90  Directors/Assistant  80  109  123  122  4,253  5,189  5,366  5,646  Supervisors/Assistant Supervisors  Directors  Total  Source:  S t a t i c s Canada. Annual S a l a r i e s o f P u b l i c H e a l t h Nurses. Ottawa: S t a t i s t i c s Canada,  1970, 1971, 1975. "  "  Figure  1.1 D i s t r i b u t i o n of P u b l i c H e a l t h Nurses by Academic Q u a l i f i c a t i o n , 1975 6. 0.9% 7. 0.4% 8. 0.1%  36.2% 19.8%  31.3%  1  R e g i s t e r e d nurse w i t h .public h e a l t h c e r t i f i c a t e  2  R e g i s t e r e d nurse  3  R.N,  w i t h bacc. major p u b l i c h e a l t h  4  R.N,  w i t h bacc.  5  R.N,  w i t h bacc. w i t h p u b l i c h e a l t h c e r t i f i c a t e  6  R.N,  w i t h master's degree, major p u b l i c h e a l t h  7  R.N,  w i t h master's degree, w i t h p u b l i c h e a l t h c e r t i f i c a t e  8  R.N,  w i t h master's degree o n l y  Source:  only  only  S t a t i s t i c s Canada, Annual S a l a r i e s of P u b l i c H e a l t h Nurses. Ottawa: Information Canada, 1975  11 1.3  The management s t r u c t u r e i n community  health  nursing To f a c i l i t a t e an understanding o f the r o l e o f the nurse i n the management o f community h e a l t h s e r v i c e s , the s t r u c t u r e o f a t y p i c a l community h e a l t h agency i s outl i n e d i n Figure somewhat  1.2.  (p. 1 2 ) .  from p r o v i n c e  (This s t r u c t u r e may  vary  to p r o v i n c e ) .  The s i z e o f the community served, and the range of services provided  w i l l determine more e x a c t l y the s t a f f -  i n g o f the agency. nursing and  superviors  The degree o f a u t h o r i t y given to v a r i e s according  t o t h e i r background  experience, and e s p e c i a l l y the management s t y l e o f  the medical o f f i c e r o f h e a l t h , or d i r e c t o r o f the agency. In smaller h e a l t h u n i t s , the d i r e c t o r may be a community h e a l t h nurse. I t i s o f t e n suggested t h a t the a u t h o r i t y i n community n u r s i n g  structure  s e r v i c e s i s much l e s s r i g i d l y ap-  p l i e d than i n h o s p i t a l n u r s i n g  services  The community h e a l t h nurse f u n c t i o n s  (Clark,  1977).  f a r more i n the  r o l e o f independent p r o f e s s i o n a l p r a c t i t i o n e r than as a "physician's  assistant."  degree o f autonomy  She has a much  greater  compared w i t h the h o s p i t a l nurse.  A major reason f o r t h i s i s the p h y s i c a l i s o l a t i o n o f the community nurse, i . e . her s e p a r a t i o n of c e n t r a l c o n t r o l .  from the p o i n t  T h i s i s o l a t i o n , and t h e i r r e l a t i v e  independence (Bristow,  1976), are seen as f a c t o r s  that  12 Figure  1.2  Community H e a l t h A g e n c y  Structure  H e a l t h Agency Board  Director/Medical O f f i c e r of  Senior Public Health Inspector  Other Staff  Nursing Supervisor Administrative Officer  Dental Officer  Public Health Inspectors  Health  Community  Health  Nurses  13 considerably  reduce the p o t e n t i a l f o r c o n f l i c t between  management p e r s o n n e l and nurses a c t i n g as autonomous professionals  ( C l a r k , 1977).  Community h e a l t h nurses i n v o l v e d i n management f i n d themselves f a c i n g some common problems (Stevens, 1976).  1975;  As managers, they are f a c e d w i t h the c o n f l i c t  tween p r o f e s s i o n a l and  administrative roles.  In  their  p r o f e s s i o n a l r o l e they are concerned w i t h p r o v i d i n g optimum . q u a l i t y o f care, w h i l e i n t h e i r  be-  the  administrative  c a p a c i t y they are concerned w i t h f u n c t i o n i n g economica l l y and the goals  efficiently. and  resources  U l t i m a t e l y , they have to balance of the programs they are manag-  ing. The being  nurse as e x e c u t i v e  o f t e n faces  the problem of  i n a p o s i t i o n , o f i n e q u i t a b l e power compared w i t h  many o f those around her' (Stevens, 1975).  There  are  w e l l known s o c i a l and h i s t o r i c a l reasons f o r t h i s . These r e l a t e to the t r a d i t i o n a l r o l e of women i n s o c i e t y , and  the p e r c e p t i o n  handmaiden.  of the nurse as the  physician's  Much o f the changes .that need to be made  i n this respect  are  psychological.  Nurses i n managerial p o s i t i o n s need to be aware o f and  s e n s i t i v e to the i n f o r m a l l i n e s of communication i n  an o r g a n i z a t i o n .  "The  philosophy  and  d i r e c t i o n of  an  o r g a n i z a t i o n o r i g i n a t e i n i n f o r m a l power groups, r a t h e r than i n d i s c u s s i o n s  at formal meetings.  Formal meetings  tend to c r y s t a l l i z e and a u t h o r i z e thoughts that are generated 1975. p. 88).  and p l a n s  i n the i n f o r m a l s t r u c t u r e "  (Stevens,  While nurses may occupy p o s i t i o n s w i t h  a u t h o r i t y v e s t e d i n them, and a t t e n d a l l the o f f i c i a l meetings,  Stevens  f e e l s that they are o f t e n on the out-  s i d e o f the i n f o r m a l power s t r u c t u r e .  Where t h i s i s the  case, nurses need to be conscious o f i t ,  and work to  overcome i t . In t h e i r c a p a c i t y as managers, community h e a l t h nurses r e q u i r e i n f o r m a t i o n d i f f e r e n t from t h a t they r e q u i r e as c l i n i c a l p r a c t i t i o n e r s .  The k i n d s o f informa-  t i o n , and i n p a r t i c u l a r , a c t i v i t y data, r e q u i r e d a t d i f f e r e n t l e v e l s i n the o r g a n i z a t i o n o f community n u r s i n g s e r v i c e s , w i l l now be c o n s i d e r e d .  15  CHAPTER 2 2.1  Information  characteristics for different  organizational  levels.  In a s s e s s i n g the i n f o r m a t i o n needs of any  indivi-  dual i n an o r g a n i z a t i o n , i t i s important to know the types of f u n c t i o n s they are performing, and of the d e c i s i o n s they face.  the n a t u r e  These f u n c t i o n s and  sions w i l l a f f e c t the type of i n f o r m a t i o n  they r e q u i r e .  Antony ( i n Lucas, Clowes and Kaplan, 1974) guished  deci-  distin-  between three l e v e l s of d e c i s i o n making  activities  i n an o r g a n i z a t i o n : d e c i s i o n a c t i v i t i e s r e l a t e d to 1.  operational control,  2.  management c o n t r o l , and  3.  s t r a t e g i c planning.  S t r a t e g i c planning, the process and  or p o l i c y formation,  o f determining  involves  organizational objectives,  the means f o r a c h i e v i n g them.  major concern of the planner  At t h i s l e v e l ,  or p o l i c y maker i s the r e -  l a t i o n s h i p between the o r g a n i z a t i o n and  i t s environment.  Other o r g a n i z a t i o n s , t h e i r o b j e c t i v e s , and how  they  about t r y i n g to accomplish them are key v a r i a b l e s processes  a  go  and  to be taken i n t o account.  Those i n p o s i t i o n s of management c o n t r o l pursue o b j e c t i v e s set i n s t r a t e g i c p l a n n i n g  the  through a process  of  16  resource  a l l o c a t i o n , and  the m o n i t o r i n g  of  resource  utilization. O p e r a t i o n a l c o n t r o l r e f e r s to the process  of  s u r i n g that s p e c i f i c tasks are e f f e c t i v e l y and ly carried The  enefficient-  out.  three c a t e g o r i e s , or l e v e l s o f o p e r a t i o n  l i n e d above, form a continuum;  the d i s t i n c t i o n between  d e c i s i o n c a t e g o r i e s , or l e v e l s , i s not c l e a r - c u t . nature types  of the i n f o r m a t i o n r e q u i r e d f o r the of d e c i s i o n s may  i n Table 2.1 Adopting  (p.  out-  d i f f e r widely,  The  different  as can be  seen  17).  the t r a d i t i o n a l view of the agency as a  pyramid, the r e a l t i o n s h i p between the s t r u c t u r e of a community h e a l t h agency and  i t s i n f o r m a t i o n flows i s  i l l u s t r a t e d i n F i g u r e 2.1.  (p.  18).  Table  2.1  The Antony Framework and  Information C h a r a c t e r i s t i c s  Normative Information  Characteristics for  Operational Control Decisions  ManagementCControl Decisions  Strategic Planning Decisions  1. Very d e t a i l e d data  Moderately d e t a i l e d data. R e l a t e d to achievement of o r g a n i z a t i o n ' s obiectives. Regularly reported H i s t o r i c a l and p r e d i c t i v e data. Mostly i n t e r n a l l y generated. Accurate w i t h i n d e c i s i o n bounds. Exception r e p o r t i n g  Aggregate data  2. R e l a t e d to a s p e c i f i c task. 3. F r e q u e n t l y 4. H i s t o r i c a l  reported data  5.  I n t e r n a l l y generated  6.  Very  7.  Repetitive  8.  Narrow scope  accurate  9. Current,  Sources:  a. b.  up  to date  S p e c i f i c and general i n scope Mostly medium term  Relates to e s t a b l i s h i n g broad p o l i c i e s . Infrequently reported P r e d i c t i v e data E x t e r n a l l y generated Accurate i n magnitude only•. Unique to problem under consideration. Wide scope Older, showing previous p e r i o d s  Lucas, Henry C , Clowes, Kenneth W.,.and Kaplan, Robert B. "Framework f o r Information Systems," INFOR V o l . 12, No. 3, October 1974.,, and' Keen, Peter G.W., and Scott Morton, Michael S. D e c i s i o n Support Systems, An O r g a n i z a t i o n a l P e r s p e c t i v e . Reading, Mass.: Addison - Wesley, 1978.  18  F i g u r e 2.1 Community H e a l t h Agency Pyramid S t r u c t u r e f o r Management Information System  Information used f o r Agency A d m i n i s t r a t i o n Director/ 'Plan-V%  Supervisoi  Staff  Source:  o  -o Managing  I n f o r m a t i o n used f o r Agency and Program a c t i v i t i e s ^Program  I n f o r m a t i o n used f o r patient a c t i v i t i e s Patient  P r o v i d i n g care  Adapted from Saba, V i r g i n i a K. "A Guide to Understanding Management I n f o r m a t i o n Systems", i n N a t i o n a l League f o r N u r s i n g . S t a t e o f the A r t i n Management I n f o r m a t i o n Systems f o r P u b l i c He a l t h / C ommuni t y H e a l t h Agencies. Report o f the Conference. New York: N a t i o n a l League f o r Nursing P u b l i c a t i o n number 21-1637, 1976. p. 95.  19  The  a c t i v i t y fundamental to a l l the d i f f e r e n t  l e v e l s o f the o r g a n i z a t i o n , any  organization,  and to the f u n c t i o n i n g o f  i s that o f d e c i s i o n making.  To under-  stand how and at what stages i n f o r m a t i o n may be u s e f u l , it  i s necessary to understand the d e c i s i o n making  process. A v i t a l c o n t r i b u t i o n towards a taxonomy o f d e c i s i o n s , and  to our understanding o f d e c i s i o n making, has been the  work o f Simon Simon  on human problem s o l v i n g (Simon, 1960.)  d i s t i n g u i s h e s between two types o f d e c i s i o n s -  programmed and non-programmed. "Decisions  are programmed to the extent  are r e p e t i t i v e and r o u t i n e , to the extent  t h a t they  that a d e f i n i t e  procedure has been worked out f o r hhandling them ... Decisions  are non-programmed to the extent  novel, unstructured  and c o n s e q u e n t i a l . "  that they are  (Simon,  1960.  p. 5 ) . In the case o f a programmed, o r s t r u c t u r e d d e c i s i o n , a s p e c i f i c procedure can be a p p l i e d to reach a d e c i s i o n each time the s i t u a t i o n a r i s e s .  T h i s cannot be done i n  the case o f non-programmed, o r u n s t r u c t u r e d , In such cases,  there  decisions.  i s no s p e c i f i e d way o f d e a l i n g w i t h  the problem, as i t may not have a r i s e n before,  or i t may  be so complex or e l u s i v e as to warrant s p e c i a l treatment. Few d e c i s i o n s are t o t a l l y programmed  (structured) or  20  t o t a l l y non-programmed ( u n s t r u c t u r e d ) ; p o l a r types f o r a continuum  rather,  these  are  of d e c i s i o n making a c t i v i t y .  Simon breaks problem s o l v i n g down i n t o  three  phases: 1.  intelligence,  2.  design  3.  choice.  and  I n t e l l i g e n c e c o n s i s t s of surveying for conditions "inventing, action,"  that c a l l f o r a c t i o n .  developing and  (Simon,  1960.  analyzing  the  environment  Design  involves  p o s s i b l e courses of  p. 2), w h i l e choice  i s the  activi-  ty of s e l e c t i n g a p a r t i c u l a r a c t i o n from the set o f a l t e r n a t i v e s developed.  A f u l l y s t r u c t u r e d problem i s  i n which a l l three phases are s t r u c t u r e d , w h i l e  unstruc-  tured problems are those i n which a l l three phases unstructured. structured,  Where only one  or two  d e f i n i t i o n of " s t r u c t u r e " , conveyed by  i t can be  ment of new  semi-structured.  done on an adequate  so that the p r e c i s e meaning  c l e a r l y understood.  d e c i s i o n techniques do not  are  of the phases i s  the problem i n i t s e n t i r e t y i s  C o n s i d e r a b l e work y e t remains to be  one  Over time  remain s t a t i c , and  techniques w i l l tend to add  the  further  develop-  structure  to d e c i s i o n making. Gorry and  Scott-Morton have combined the  approaches  o f Antony and Simon to p r o v i d e a framework which shows that the nature of d e c i s i o n s  to be made, or problems to  21 be r e s o l v e d , w i l l vary w i t h i n each l e v e l of along  the s t r u c t u r e d to u n s t r u c t u r e d Before  examined. activity  2.2  continuum.  c o n s i d e r i n g the f u n c t i o n s performed by com-  munity h e a l t h n u r s i n g d i r e c t o r s and a t i o n flows  operation,  supervisors,  inform-  i n community h e a l t h o r g a n i z a t i o n s w i l l  be  T h i s w i l l i n c l u d e a look at what i s meant by recording.  Information  flows  i n an  Information  provides  organization  the means, i n q u a n t i t a t i v e  or d e s c r i p t i v e terms, o f measuring and  d e s c r i b i n g the  f u n c t i o n i n g and performance of a system. The  b a s i c r e l a t i o n s h i p between systems elements  information  and  channels i n complex s o c i a l s t r u c t u r e s , such  as h e a l t h s e r v i c e o r g a n i z a t i o n s , i s i l l u s t r a t e d i n F i g u r e 2.2  (p.  22).  From t h i s diagram i t can be  that i n f o r m a t i o n provides  seen  a means of measuring the  dif-  ference between the o b j e c t i v e s , or d e s i r e d achievements, of a system, and The  the a c t u a l r e s u l t s or output  i n f o r m a t i o n flows  o r g a n i z a t i o n may  and  obtained.  d e c i s i o n making network i n an  be viewed as the continuous l i n k i n g mech-  anism governing i t s resource  flows.  A community h e a l t h agency forms the  processing  component of the subsystem of the o v e r a l l h e a l t h system w i t h i n which i t operates.  The  inputs and  outputs o f  system are the same people i n the community.  this  I t i s the  o b j e c t i v e of the agency t h a t t h e i r h e a l t h s t a t u s  be  Figure  2.2 Information Flows i n a System  Resources  perceived alternatives  priorities pressures, incentives, biases  Objectives (Desired achievements)  financial constraints  Decision Making Process  Decision Transformation Process  Outputs  I n f o r m a t i o n about output (Perceived achievements)  Key Information flows ro  Material Processes  ( s e r v i c e ) flows  ^  23  a l t e r e d by t h e i r i n t e r a c t i o n w i t h the agency and i t s personnel.  To perform e f f e c t i v e l y i n p u r s u i t of i t s ob-  j e c t i v e , the agency needs c e r t a i n types o f i n f o r m a t i o n . These are i l l u s t r a t e d i n F i g u r e 2.3  (p. 2 4 ) , which shows  the h e a l t h agency as the p r o c e s s i n g u n i t i n a community h e a l t h system. From F i g u r e 2.3, the three major types o f informat i o n the agency i s concerned w i t h a r e : 1.  data about the demographic f e a t u r e s o f the community, and i t s s o c i a l environment,  2.  data about i t s own a c t i v i t i e s , gathered by the agency, as p a r t o f t h e i r own assessment o f how w e l l they are doing i n p u r s u i t o f t h e i r obj e c t i v e s , and  3.  feedback from people a f f e c t e d by agency  activities.  U l t i m a t e l y , i t i s the t h i r d type o f i n f o r m a t i o n , r e l a t e d to the outcome o f agency e f f o r t s , which i s most important i n determining the agencies o v e r a l l  effective-  ness . A c t i v i t y r e c o r d i n g data i s a component o f agency generated i n f o r m a t i o n that the agency can use i n i t s s e l f - e v a l u a t i o n process.  We now  examine e x a c t l y what i s  meant by a c t i v i t y r e c o r d i n g and a c t i v i t y  data.  24  Figure  2.3 Information flows o f a H e a l t h Agency  Community Other  Health  Agencies  -5H  Supplying  inputs  (people)  Demographic features of social environment  Receiving outputs (people)  Follow-up from service recipients  "|  1  , Self evaluation  1  (  l  Community H e a l t h Agency (processing  Source:  L- J  people)  Adapted from Segal, JoAn S. " I n t e r f a c e s between H e a l t h Agencies and the L i b r a r y P r o f e s s i o n , " i n N a t i o n a l League f o r Nursing, S t a t e o f the A r t i n Management Information Systems f o r P u b l i c Health/" * Community H e a l t h Agencies. Report o f the C o n f e r '-fenye. New York: N a t i o n a l League f o r Nursing P u b l i c a t i o n number 21-1637. 1976. p. 23. r  25  2.3  What i s a c t i v i t y  recording?  A c t i v i t y recording  i s the p r a c t i c e o f n o t i n g the  a c t i v i t i e s one i s i n v o l v e d i n , d u r i n g  the course o f time  spent at work, or i n work r e l a t e d a c t i v i t i e s . A c t i v i t y recording  and r e p o r t i n g can be q u a n t i t a t i v e  or q u a l i t a t i v e i n n a t u r e .  In the way i t i s used i n t h i s  study, a c t i v i t y r e c o r d i n g  r e f e r s s t r i c t l y t o the a c t i v i -  t i e s o f the s e r v i c e p r o v i d e r s .  I t does not encompass  data concerning the r e c i p i e n t s o f s e r v i c e . With q u a n t i t a t i v e r e c o r d i n g ,  s t a t i s t i c s are compiled  to measure the amount o f s e r v i c e s provided  and the extent  of s e r v i c e s consumed, as i n d i c a t e d by numbers The amount o f n u r s i n g  served.  time u t i l i z e d may a l s o be noted.  This kind of recording  i s done by the s e r v i c e  as she i s the most a p p r o p r i a t e  provider,  person to do so.  D e s c r i p t i v e or n a r r a t i v e r e p o r t i n g on a c t i v i t i e s can serve t o i n t e r p r e t or c l a r i f y the measurements i n the s t a t i s t i c a l report. providers,  Such r e p o r t i n g can be done by s e r v i c e  as w e l l as by t h e i r  supervisors.  Standard d e f i n i t i o n s f o r the b a s i c u n i t s o f n u r s i n g s e r v i c e are necessary to enable a uniform understanding o f the meaning o f the measurements performed.  Standard  d e f i n i t i o n s f o r non-nursing s e r v i c e s , e.g. c l e r i c a l work or c o n t i n u i n g  education may a l s o be necessary, depending  upon the scope of the a c t i v i t y r e c o r d i n g .  The k i n d of  26  s t a t i s t i c a l m a t e r i a l recorded ought to r e f l e c t  the  o p e r a t i o n o f the agency w i t h i n the framework o f i t s p o l i c i e s and programs.  Agencies w i l l vary i n the amount  of d e t a i l and refinement they r e q u i r e i n t h e i r t i c a l reporting.  The  statis-  content and frequency of a c t i v i t y  r e c o r d i n g and r e p o r t i n g w i l l depend on the d e s i r e s o f the p a r t i c u l a r agency. W i t h i n the l a s t two  decades i n North America,  and  p a r t i c u l a r l y d u r i n g the 1970's, there has been a c o n s i d e r a b l e growth i n a c t i v i t y r e c o r d i n g systems f o r community h e a l t h agencies, and i n the refinement of these systems ( N a t i o n a l League f o r Nursing, 1974 The advent  (a); 1975;  1976;  1978).  of advanced data p r o c e s s i n g technology has  lent  impetus to t h i s development, and the number o f computeri z e d systems throughout  the c o n t i n e n t i s growing  rapidly.  In the U.S.A., the focus of c o m p u t e r i z a t i o n has been to automate the c l e r i c a l f u n c t i o n s r e l a t e d to the o p e r a t i o n s o f the agency.  financial  T h i s has not been the case i n  Canada, where agencies p r o v i d e s e r v i c e s which do not have to be p a i d f o r d i r e c t l y by the s e r v i c e r e c i p i e n t s . B i l l i n g f o r s e r v i c e s i s thus not a major concern of these agencies. I n e v i t a b l y , the scope and content of a c t i v i t y r e c o r d ing over time f o r community h e a l t h nurses w i l l show v a r i a t i o n i n accordance w i t h the changing scope and focus of community h e a l t h n u r s i n g s e r v i c e .  27  An  example o f an a c t i v i t y  recording  system can be  seen i n s e c t i o n 5.6.  2.4  Functions  performed by nurses a t d i f f e r e n t l e v e l s  i n the o r g a n i z a t i o n Many claims have been made about the need f o r a c t i v i ty data,  and the ways i n which these data can be used  (Freeman, 1970; N a t i o n a l League f o r Nursing, 1974(a);. 1976; 1978).  These i n c l u d e claims  that such data are u s e f u l  i n the a c t i v i t i e s o f p l a n n i n g ,  evaluation,  determining  costs o r the c o s t - e f f e c t i v e n e s s o f s e r v i c e s , determining staffing  l e v e l s , measuring p r o d u c t i v i t y , comparing  s e r v i c e s t a t i s t i c s , education The  above a c t i v i t i e s  processes. lated.  and v a r i o u s  others.  are not d i s t i n c t l y  Indeed, they are most o f t e n very  separate closely re-  They form d i f f e r e n t elements o f the continuous i n -  t e r a c t i v e process o f p r o v i d i n g community h e a l t h s e r v i c e s . Planning and  i s probably the most p e r v a s i v e  i s part of a l l a c t i v i t i e s  Evaluation,  process.  of a l l ,  that deal w i t h the f u t u r e .  e i t h e r e x p l i c i t or i m p l i c i t ,  p a r t o f any p l a n n i n g  activity  i s an i n h e r e n t  Considerations,  such as  c o s t s , and e f f i c i e n c y and e f f e c t i v e n e s s , enter i n t o a l most a l l a c t i v i t i e s r e l a t e d to p r o v i d i n g community h e a l t h nursing  service.  In the same way, the a c t i v i t i e s performed a t any one  28  l e v e l i n the o r g a n i z a t i o n a r e not d i s t i n c t from a c t i v i t i e s performed  a t other l e v e l s .  similar  F o r example,  e v a l u a t i o n a t any one l e v e l i s i n t e g r a l l y  r e l a t e d to  e v a l u a t i o n at the other two l e v e l s .  2.4.1 O p e r a t i o n a l C o n t r o l At the o p e r a t i o n a l l e v e l , community h e a l t h nurses provide d i r e c t  care and other h e a l t h s e r v i c e s to i n d i v i -  duals and f a m i l i e s  i n the community.  By keeping a count  of the v a r i o u s a c t i v i t i e s they are i n v o l v e d i n , they form the primary  source o f a c t i v i t y r e c o r d i n g data.  What use c o u l d nurses themselves  have o f t h i s  they c o l l e c t about t h e i r own a c t i v i t i e s ? tional  data  A t the opera-  l e v e l , the nurse i s p r i m a r i l y concerned w i t h data  concerning the r e c i p i e n t s Activity  data are g e n e r a l l y intended f o r use a t a manager-  i a l and s t r a t e g i c al level  o f the s e r v i c e she i s p r o v i d i n g .  p l a n n i n g l e v e l , and not a t the o p e r a t i o n -  itself.  Activity  data can p r o v i d e the nurses w i t h an i n v e n t o r y  of what they have been doing. ning t h e i r d a i l y a c t i v i t i e s .  I t c o u l d help them i n p l a n I f they a r e able to see  r e p o r t s o f the a c t i v i t i e s o f other nurses, they can compare t h e i r a c t i v i t i e s w i t h what others are doing.  This  would enable them to g a i n a p e r s p e c t i v e o f t h e i r r o l e i n comparison w i t h others i n the o r g a n i z a t i o n .  29  2.4.2  Management C o n t r o l At the l e v e l o f management c o n t r o l i s the s u p e r v i s o r ,  and  a s s i s t a n t or associate supervisor.  Supervisors  at a  managerial c o n t r o l l e v e l are r e s p o n s i b l e f o r seeing  that  s t r a t e g i c planning and  and p o l i c y d e c i s i o n s are e f f e c t i v e l y  e f f i c i e n t l y translated into action.  management c o n t r o l are not separate s t r a t e g i c p l a n n i n g process Neither  and d i s t i n c t  level. from  they are c l o s e l y i n t e r r e l a t e d .  Organizing nature,  and d i s t i n c t from the  performed a t a higher  are these f u n c t i o n s separate  each other;  The f u n c t i o n o f  i s the process,  o f reducing  often h i e r a r c h i c a l i n  large quantities of information  s t r u c t u r e s that can be handled and d e a l t w i t h  into  conveniently.  T h i s i n v o l v e s d e c i s i o n making, as i t i n v o l v e s s e l e c t i n g among p e r c e i v e d a l t e r n a t i v e s .  The management o f n u r s i n g  s e r v i c e s i n v o l v e s the d e t e r m i n a t i o n  o f what must be done  by the group, and the i n d i v i d u a l s who comprise the group, to accomplish s t a t e d g o a l s .  "The managerial r o l e r e q u i r e s  an a b i l i t y to v i s u a l i z e and p r o j e c t an i n t e g r a t e d p a t t e r n of a c t i o n .  Organizing  i s i n t i m a t e l y concerned w i t h  i n a formal  s t r u c t u r i n g o f work r o l e s . "  people  (Douglas, 1977. p.  69). Delegation  i s a key managerial f u n c t i o n .  The mana-  g e r i a l r o l e c a l l s f o r a d e l e g a t o r w i t h the experience, knowledge and a b i l i t y to implement the o p e r a t i o n s which she has c o n t r o l .  over  Prudent d e l e g a t i o n o f r e s p o n s i b i l i t y  30  to the a p p r o p r i a t e personnel i s the means whereby a manager i s able to maximize the p r o d u c t i v i t y o f her a v a i l a b l e r e s o u r c e s . V o l a n t e (1974) views the f o l l o w i n g steps as important  f o r effective delegation:  1.  d e f i n i n g the task to be done,  2.  r e l a y i n g the d e f i n i t i o n o f the task,  3.  e s t a b l i s h i n g c o n t r o l s and checkpoints to ensure feedback, and  4.  e s t a b l i s h i n g a d i a l o g u e w i t h those  performing  the delegated t a s k s . O r g a n i z i n g ^ and d e l e g a t i n g i n h e r e n t l y i n v o l v e p l a n ning.  They r e q u i r e d e v i s i n g p r o j e c t i o n s o f how e f f i c i e n t  and e f f e c t i v e a l t e r n a t i v e a l l o c a t i o n s o f resources would be, and then choosing and implementing the p e r c e i v e d b e s t alternative. Managers need to know the a b i l i t i e s and p r e f e r e n c e s of t h e i r s t a f f resources t o organize and delegate ively.  effect-  They a l s o need to monitor t h e i r s t a f f i n the per-  formance o f t h e i r d u t i e s .  A c t i v i t y data p r o v i d e an inven-  t o r y o f the a c t i v i t i e s performed by each nurse.  As such,  they a c t as i n d i c a t o r s o f the c a p a c i t i e s o f the nurses. These data add to the manager's knowledge about the a c t i v i t i t e s o f her p e r s o n n e l .  But there i s much other  t i o n which the s u p e r v i s o r r e q u i r e s .  informa-  She needs to know  the q u a l i f i c a t i o n s and p r e f e r e n c e s o f h e r s t a f f , the q u a l i t y and outcomes o f s e r v i c e s p r o v i d e d , and the o p i n i o n s  31  of service r e c i p i e n t s .  A c t i v i t y data are thus only one  element o f the many i n f o r m a t i o n  requirements o f s u p e r v i -  sors . i n v o l v e d i n o r g a n i z i n g and d e l e g a t i n g work. One  o f the most important and complex managerial  functions  i s to determine a s t a f f i n g p a t t e r n that  u t i l i z e a v a i l a b l e s t a f f resources  to maximum e f f e c t .  There are many f a c t o r s to be considered. i n importance, a c c o r d i n g community. lation,  will  These may vary  to the c h a r a c t e r i s t i c s o f the  These f a c t o r s i n c l u d e the s i z e o f the popu-  i t s age d i s t r i b u t i o n , b i r t h r a t e s , m o r b i d i t y and  m o r t a l i t y r a t e s , and h e a l t h b e l i e f s and p r a c t i c e s i n the community.  Probably the best  s i n g l e measure o f p e r s o n n e l  r e q u i r e d are the a c t u a l needs o f the p a t i e n t s and famil i e s i n the community.  (Roberts,  1963).  Professional  f a c t o r s , such as q u a l i f i c a t i o n s and j o b s p e c i f i c a t i o n s , and  s e r v i c e f a c t o r s , such as n u r s i n g  standards and person-  n e l p o l i c i e s , a l s o need to be taken i n t o S t a f f i n g i s a complex i s s u e .  consideration.  "The l a r g e amount o f  time spent i n s t a f f i n g i s .due i^nrpart to. manpower problems, such as shortages and p e r s o n n e l p r e f e r e n c e s ,  but i s a l s o  g r e a t l y due to the l a c k o f c o n c e p t u a l i z a t i o n o f the t o t a l i t y o f the program, f a i l u r e to recognize  significant  var-  i a b l e s , and the l a c k o f i n t e l l e c t u a l s k i l l s r e q u i r e d i n the c o n s t r u c t i o n o f the t o t a l program."  ( A y d e l o t t e , 1974.  p. 4 ) . From the l i t e r a t u r e , i t i s evident  that  determining  s t a f f i n g i n v o l v e s r e l y i n g h e a v i l y on experience and  32  f a m i l i a r i t y w i t h the f i e l d .  I t i s by no means a  s t r u c t u r e d or s c i e n t i f i c d e c i s i o n making process. v a r i e t y of models are a v a i l a b l e f o r use,  but  consistent strategy."  p. 5.)  (Aydelotte,  1974.  there i s no  i n g the amount of i n f o r m a t i o n  a v a i l a b l e w i l l not  s a r i l y s i m p l i f y the problem.  For any  t i o n , the a p p r o p r i a t e stood and  skillfully  "A  Increasneces-  particular situa-  model needs to be developed, underapplied.  A p a r t of determiningu.s.taf€jfcngsissusing nurse-to-population ratios.  These r a t i o s are r e l a t e d to workloads  based on the average amount of s e r v i c e an i n d i v i d u a l nurse can p r o v i d e .  Accounts of d a i l y a c t i v i t i e s are  as "necessary f o r e s t i m a t i n g vices given,  and  (Roberts,  type o f s e r -  f o r determining the average amount of  s e r v i c e one nurse can p r o v i d e time."  the amount and  seen  1963.  i n a day  p. 38.).  or other p e r i o d  A c t i v i t y data can  of  be  used to c a l c u l a t e simple a r i t h m e t i c a l means of s e r v i c e s provided,  and  thus form an element o f the  requirements i n s t a f f i n g .  information  However, these data can be  to be merely a small p a r t of a l l the i n f o r m a t i o n  seen  that i s  needed. Supervisors evaluation.  are the key personnel  i n performing  I t f a l l s p r i m a r i l y to those i n p o s i t i o n s of  management c o n t r o l to devise,, implement and monitor e v a l u a t i o n process.  the  Data to be used i n e v a l u a t i o n may  gathered by nurses at the o p e r a t i o n a l l e v e l , w h i l e  be  final  33  judgement and p o s s i b l y i n t e p r e t a t i o n may strategic The  be made at a  level. range o f i n f o r m a t i o n needed to perform an e v a l -  u a t i o n w i l l vary a c c o r d i n g to be done.  to the scope o f the e v a l u a t i o n  To p r o v i d e a p e r s p e c t i v e on the r o l e of  a c t i v i t y data, the range of i n f o r m a t i o n needed i n evaluat i o n w i l l be d i s c u s s e d i n more d e t a i l . Wolf ( i n N a t i o n a l League f o r Nursing,  1976)  s i x c l a s s e s of i n f o r m a t i o n t h a t are necessary any program comprehensively. 1.  the i n i t i a l  2.  the s t a t u s of those  to  describes evaluate  These encompass  s t a t u s of those  to be  helped,  i n d i v i d u a l s a f t e r some p e r i o d  of treatment, or s e r v i c e p r o v i s i o n , 3.  the o b j e c t i v e s of the program,  4.  the extent  to which the intended program was  fact carried  in  out,  5.  the c o s t s i n v o l v e d ,  6.  any  supplemental  and  information  Supplemental i n f o r m a t i o n r e f e r s to the views, o p i n i o n s impressions  of those a s s o c i a t e d w i t h the program.  and  They  should complement the more o b j e c t i v e measurement of predetermined v a r i a b l e s , and add a dimension to the t i v e and understanding Any  of the  perspec-  evaluator.  e v a l u a t i o n i n h e r e n t l y i n v o l v e s the judgement o f  the e v a l u a t o r or e v a l u a t i o n team.  Those performing  an  e v a l u a t i o n ought not to delude themselves i n t o t h i n k i n g  34  that they are engaged i n a p u r e l y s c i e n t i f i c process, " o r that i n f o r m a t i o n n e c e s s a r i l y leads to c e r t a i n and  i m p l i c a t i o n s f o r p o l i c y and p r a c t i c e . . .  conclusions Evaluation  and p l a n n i n g a c t i v i t i e s always i n v o l v e judgements." (Wolf,  i n N a t i o n a l League f o r Nursing,  1976, p. 36).  A c t i v i t y data p r o v i d e an element o f i n f o r m a t i o n under 4.(above), that can be used i n program e v a l u a t i o n .  They  act as an i n v e n t o r y o f the type and q u a n t i t y o f s e r v i c e s provided.  However, i t i s evident t h a t many d i f f e r e n t  c l a s s e s o f i n f o r m a t i o n are necessary process.  i n any e v a l u a t i o n  While a c t i v i t y data can be used i n e v a l u a t i o n ,  they a r e o n l y one element o f many c o n t r i b u t i n g t o the f i n a l judgement or judgements made. A c t i v i t y data a c t as an i n d i r e c t measure o f the prod u c t i v i t y o f the n u r s i n g s t a f f .  Real p r o d u c t i v i t y can not  be shown by these s t a t i s t i c s alone.  Actual productivity  d e r i v e s from the knowledge, s k i l l and m o t i v a t i o n a p p l i e d by the i n d i v i d u a l s on the s t a f f .  To a l a r g e extent, " i t i s  on the l e a d e r s h i p group t h a t the m o t i v a t i o n o f s t a f f and the consequent degree o f p r o d u c t i v i t y depends." 1974.  (Aydelotte,  p. 6 ) . / I f the time spent  i n a c t i v i t i e s i s noted,  a costing  of n u r s i n g s e r v i c e s can be obtained from a c t i v i t y  data.  But these data g i v e no measure o f the e f f e c t i v e n e s s , o r b e n e f i t , o f the s e r v i c e s costed.  Other measures a r e  needed to evaluate b e n e f i t or e f f e c t i v e n e s s .  There are  35  considerable d i f f i c u l t i e s  i n this respect.  i n the f i e l d of ^ p r e v e n t i v e i s hard to c a l c u l a t e . The  Effectiveness  s e r v i c e s and h e a l t h promotion  (Shapiro, 1977;  Kristein,  1977).  c l a i m i s sometimes made t h a t a c t i v i t y data  help i n a s s e s s i n g the q u a l i t y o f care. of care, data concerning  the process  can  To assess q u a l i t y  and outcome o f  care  p r o v i d e d are r e q u i r e d .  These data elements need to be  l i n k e d c l e a r l y to those  to whom care was  given.  Activity  r e c o r d i n g c o l l e c t s data on the a c t i v i t i e s of the s e r v i c e , p r o v i d e r . I t does not r e c o r d process, process  or outcome.  and outcome measur.esa are e s s e n t i a l i n any  determination  As true  o f q u a l i t y o f care, i t i s evident t h a t a c t i v -  i t y data are of minimal help i n a s s e s s i n g q u a l i t y of care. Supervisors Continuing  are also, r e s p o n s i b l e f o r s t a f f development.  education p l a y s a v i t a l r o l e i n e n a b l i n g nurses  to keep abreast o f the l a t e s t developments, and  equipping  them to meet t h e i r c h a l l e n g i n g r o l e i n the community. education  Such  needs to be d i r e c t e d towards areas where community  h e a l t h n u r s i n g i s becoming i n v o l v e d , and t r a i n i n g i s r e q u i r e d , or needs to be Data obtained  refreshed.  from a c t i v i t y r e c o r d i n g can p r o v i d e use-  f u l i n d i c a t o r s of areas where such education For example, a sharp i n c r e a s e i n cases  i n d i c a t e that  d e a l i n g w i t h c h i l d abuse are r e q u i r e d .  crease i n w o r k - r e l a t e d  necessary.  of c h i l d abuse  c o u n s e l l i n g over a p a r t i c u l a r p e r i o d may courses  is  a c c i d e n t v i s i t s may  A sharp i n -  i n d i c a t e that  36  nurses r e q u i r e f u r t h e r i n s t r u c t i o n i n o c c u p a t i o n a l h e a l t h . C o n t i n u i n g education d e c i s i o n s need to take i n t o a v a r i e t y of i n f o r m a t i o n .  These i n c l u d e the  account  interests,  education and p r i o r t r a i n i n g of s t a f f nurses, planned programs and changes i n p r i o r i t i e s .  new  A c t i v i t y data are  thus  only one o f a number o f data items to be c o n s i d e r e d . A c t i v i t y data can be used  to o b t a i n b a s e l i n e data f o r  p a r t i c u l a r a c t i v i t e s , and to observe B a s e l i n e data, by i t s e l f , merely  t r e n d data over  i s of l i m i t e d u s e f u l n e s s .  i n d i c a t e s a volume o f work done.  time. It  I t becomes mean-  i n g f u l when compared w i t h other data, to o b t a i n t r e n d data or data comparisons.  The value of such t r e n d data or com-  p a r a t i v e data w i l l depend upon t h e i r i n t e r p r e t a t i o n w i t h i n the context of the s i t u a t i o n . i n s i g h t i n t o or understanding  Comparisons' p r o v i d e  little  o f a s i t u a t i o n , u n l e s s exam-  ined i n connection w i t h s p e c i f i c q u e r i e s , o b j e c t i v e s or related variables.  In o b t a i n i n g comparative  data, i t i s  most h e l p f u l to e s t a b l i s h c l e a r o b j e c t i v e s beforehand, that the a p p r o p r i a t e data can be  2.4.3  so  gathered.  Strategic planning At the s t r a t e g i c p l a n n i n g or p o l i c y formation  level,  i s the d i r e c t o r of community h e a l t h n u r s i n g . In budget a p p l i c a t i o n s at a s t r a t e g i c p l a n n i n g and p o l i c y formation l e v e l , d i r e c t o r s need to have i n f o r m a t i o n concerning the a c t i v i t i e s o f t h e i r community h e a l t h nurses.  37  In budgeting, and organization,  developing plans and  strategies for their  they a l s o have to take i n t o account informa-  t i o n presented by other s e n i o r h e a l t h  s e r v i c e managers or  officials. S t r a t e g i c p l a n n i n g d i f f e r s from p l a n n i n g at other l e v e l s i n the o r g a n i z a t i o n .  The  scope and  i s broader, w h i l e the range of v a r i a b l e s be broader, and spective greater  less well-defined.  The  depth of  analysis  i n v o l v e d may  also  long  i n v o l v e d means that there w i l l be  term time per-  a potentially  number o f i n t e r a c t i o n s between v a r i a b l e s  to  be  considered. One  of the normative c h a r a c t e r i s t i c s of i n f o r m a t i o n  a s t r a t e g i c planning l e v e l data i s r e q u i r e d . data.  (Table  2.1),  i s that  at  predictive  A c t i v i t y data are e s s e n t i a l l y h i s t o r i c a l  These h i s t o r i c a l data may  provide greater  insights  i n t o the r e l a t i o n s h i p s between systems v a r i a b l e s have been p o s s i b l e without them. are u s e f u l as a b a s i s  than would  While h i s t o r i c a l  data  f o r g e n e r a t i n g p r e d i c t i v e data, they  cannot serve as a s u b s t i t u t e f o r p r e d i c t i v e data. Evaluation  forms a fundamental element of the  p l a n n i n g process.  Once a p l a n has  mented, i t needs to be it  i s progressing  involves  been d e v i s e d and  strategic imple-  c o n t i n u a l l y monitored to ensure that  as intended.  The  evaluation  the c o l l e c t i o n , a n a l y s i s and  process  i n t e r p r e t a t i o n of  information. The  process of e v a l u a t i o n  i n s e c t i o n 2 .4. 2 .  Directors  has  already  been  do not need to be  described  closely  38  involved i n this process.  They can c o n s u l t w i t h those  a c t u a l l y c a r r y i n g out the e v a l u a t i o n .  But they need to  be aware o f the r e s u l t s found and judgements i n d i c a t e d , as the f i n a l judgement i n t h i s process o f t e n r e s t s i n t h e i r hands. Determining s t a f f i n g l e v e l s and d e c i d i n g upon the a p p r o p r i a t e s t a f f i s as complex a problem at t h i s as at the managerial c o n t r o l l e v e l .  level  While the scope o f  t h i s a c t i v i t y at a s t r a t e g i c p l a n n i n g l e v e l w i l l be  con-  s i d e r a b l y broader, s i m i l a r f a c t o r s need to be taken i n t o account. A c t i v i t y data can be used at a s t r a t e g i c p l a n n i n g l e v e l to p l a n and compile the e d u c a t i o n a l programs f o r community h e a l t h nurses.  Such data w i l l o n l y be .helpful  i f they are a v a i l a b l e to and taken i n t o account by  those  c o n t r o l l i n g the r e l e v a n t e d u c a t i o n a l programs. One  of the major reasons f o r g a t h e r i n g a c t i v i t y  data  i s to p r o v i d e agency boards or governing bodies w i t h an o u t l i n e of the a c t i v i t i e s of community h e a l t h n u r s e s . These data are a means o f communicating what s e r v i c e s were p r o v i d e d , i . e . the q u a n t i t y and nature o f the work the nurses have been doing. T h i s r e p o r t i n g back to p o l i c y boards or governing bodies i s seen as a way for their actions.  o f making nurses more accountable  As a c t i v i t y data do not r e f e r to pro-  cessess or outcomes o f s e r v i c e s p r o v i d e d , they can o n l y be  39  used to h o l d nurses accountable f o r the type and amount of work done.  A c t i v i t y data present an account  n u r s i n g time was u t i l i z e d , o f nurses a c t i o n s .  o f how  and not on the p r o d u c t i v i t y  F u r t h e r data on processes and outcomes  need to be gathered to p r o v i d e a more comprehensive pers p e c t i v e on a c c o u n t a b i l i t y .  Unless the members o f boards  or governing bodies are w e l l v e r s e d i n the p l a n n i n g and e v a l u a t i o n p r o c e s s , there may be a tendency to l e t a c t i v i t y data a c t as a s u b s t i t u t e f o r more meaningful measures o f nurses'  2.5  productivity.  ".Activity data and d e c i s i o n m a k i n g How do a c t i v i t y data c o n t r i b u t e to the d e c i s i o n making  process at the s t r a t e g i c p l a n n i n g l e v e l ? As d i r e c t o r s d e a l w i t h h i g h l y aggregated  data, o n l y  g l a r i n g ommissions or excesses are l i k e l y to r e c e i v e attention.  Examples o f these would be no o c c u p a t i o n a l  h e a l t h programs i n a h i g h l y i n d u s t r i a l i z e d r e g i o n , o r too many p r e n a t a l c l a s s e s i n a s p a r s e l y populated r e g i o n w i t h a predominantly  elderly population.  However, such c o n d i t i o n s  are l i k e l y to be noted and d e a l t w i t h b e f o r e being n o t i c e d specifically in activity statistics. appear to make l i t t l e  A c t i v i t y data would  c o n t r i b u t i o n a t the stage o f l o o k i n g  for conditions requiring  action.  A c t i v i t y data may have some impact The  at the design stage.  c a p a c i t i e s o f s e r v i c e p r o v i d e r s , and the demand or  40  p r e f e r e n c e s of consumers, may Although  be i n f e r r e d from the data.  a c t i v i t y data are h i s t o r i c a l ,  they can a c t as a  b a s i s f o r the p r e d i c t i v e data t h a t needs to be i n developing d i f f e r e n t  alternatives.  Choice w i l l depend on the f e a s i b i l i t y and ness of a l l the a l t e r n a t i v e s developed. have no impact  generated  attractive-  A c t i v i t y data w i l l  on c h o i c e s made i n s t r a t e g i c p l a n n i n g .  Thus, the c o n t r i b u t i o n made by a c t i v i t y data i n d e c i s i o n making at the s t r a t e g i c p l a n n i n g l e v e l i s l i m i t e d . T h e i r primary impact  i s at the d e s i g n stage.  At the management c o n t r o l l e v e l ,  the parameters o f the  framework w i t h i n which i n t e l l i g e n c e may more c l e a r l y and c l o s e l y d e f i n e d .  be e x e r c i s e d are  S u p e r v i s o r s at t h i s  f u n c t i o n w i t h i n e s t a b l i s h e d p o l i c y g u i d e l i n e s and  level  con^-  s t r a i n t s , and w i t h g i v e n r e s o u r c e s . At the i n t e l l i g e n c e stage, a c t i v i t y data may  help i n  the d e l e g a t i o n f u n c t i o n , or i n determining s t a f f i n g p a t t e r n s . The  data show what f u n c t i o n s nurses are performing.  nurses are i n a p p r o p r i a t e l y employed, t h i s may the data.  When  be noted  from  These data p r o v i d e a more accurate i n d i c a t i o n to  the managers of what nurses are doing than a v e r b a l r e p o r t may  provide.  S u p e r v i s o r s may  note t h a t t h e i r p r e n a t a l  expert i s i n v o l v e d i n too much g e r i a t r i c work, or that a g e r i a t r i c nurse i s doing too many p r e n a t a l group s e s s i o n s . A c t i v i t y data do not p r o v i d e a s c i e n t i f i c means o f i n d i c a t i n g when a c t i o n i s r e q u i r e d .  S u p e r v i s o r s w i l l have to  41  e x e r c i s e t h e i r own  i n d i v i d u a l judgement on the a c t i v i t y  statistics. In the design phase, a c t i v i t y data g i v e s u p e r v i s o r s an i d e a of the work t h a t t h e i r s t a f f are doing. data may  These  a c t as a b a s i s f o r p r o j e c t i n g a l t e r n a t i v e work-  loads or work assignments.  At t h i s stage, i t i s again  e v i d e n t t h a t o b j e c t i v e data cannot  r e p l a c e normative  judge-  ment . As at the s t r a t e g i c p l a n n i n g l e v e l ,  activity  data  have no r e a l c o n t r i b u t i o n to make i n the normative c h o i c e phase. In summary, we have seen that these data are of no use at the c h o i c e stage.  They may  be u s e f u l i n the  intel-  l i g e n c e phase at the management c o n t r o l l e v e l , w h i l e a t the design phase they p r o v i d e s u p e r v i s o r s and d i r e c t o r s w i t h an h i s t o r i c a l account of nurses  2.6  The r o l e of a c t i v i t y "Data,  1  activities.  data  as i t i s regarded i n p l a n n i n g , i s something  like  a thermometer; i t w i l l t e l l you the l e v e l of a p a r t i c u l a r phenomenon, but, as w i t h a c l i n i c a l thermometer, i f something i s to be done w i t h the data, then there must be a d i a g n o s i s which r e q u i r e s much more i n s i g h t . " Woodside, 1974.  p. 158).  (Bergwall, Reeves and  Planners and management  r e l y s o l e l y on o b j e c t i v e data.  I n s i g h t and  cannot  understanding,  and a number of d i f f e r e n t k i n d s of i n f o r m a t i o n are a l s o  42  required. A c t i v i t y data show the type and q u a n t i t y o f s e r v i c e s p r o v i d e d and u t i l i z e d i n p a r t i c u l a r areas o f need.  They  can show changes i n p a t t e r n s o f s e r v i c e p r o v i s i o n o r u t i l i z ation.  They may i n d i c a t e s e r v i c e p r i o r i t i e s o r changes i n  priorities.  S t i l l , many other kinds o f i n f o r m a t i o n are  required. For example, i n p l a n n i n g ,  the demographic f e a t u r e s  of the p o p u l a t i o n are a v i t a l element o f the o b j e c t i v e data r e q u i r e d . age  These f e a t u r e s i n c l u d e the p o p u l a t i o n  size,  d i s t r i b u t i o n , sex r a t i o , . p o p u l a t i o n d e n s i t y , economic  s t a t u s and the l e v e l o f h e a l t h education. h e a l t h s t a t u s o f the p o p u l a t i o n are a l s o  Data on the necessary.  There are two approaches t h a t may be used i n p l a n n i n g . Firstly,  the e p i d e m i o l o g i c a l needs o f the p o p u l a t i o n can  be i n d e n t i f i e d and p r i o r i z e d . set o f needs, plans resources  Proceeding  from t h i s  ordered  c o u l d then be developed t o use a v a i l a b l e  i n the most e f f e c t i v e way to respond to the needs  identified.  A second approach would be to base the develop-  ment o f a p l a n on the a v a i l a b l e r e s o u r c e s ,  and the h i s t o r i c -  a l l y demonstrated c a p a c i t i e s o f such r e s o u r c e s .  T h i s approach  i s more s t a t i c and c o n s e r v a t i v e than the former.  In a c t u a l -  i t y , any p l a n n i n g process w i l l i n v o l v e a combination o f the two approaches.  But, a d i f f e r e n c e i n accent  o r approach w i l l  l e a d to p o t e n t i a l l y d i f f e r e n t outcomes, due to the d i f f e r e n t perspectives involved.  A t t a c h i n g undue weight and  43  importance to a c t i v i t y data may  b i a s the p e r s p e c t i v e s of  those u s i n g the data and thus the o v e r a l l p l a n n i n g p r o c e s s . R e l y i n g o v e r l y on a c t i v i t y data may  l e a d to p l a n n i n g t h a t  i s resource based, and not p o p u l a t i o n based. There are many questions to be answered i n e v a l u a t i o n . These questions r e l a t e to s e r v i c e p r i o r i t i e s ,  the q u a l i t y  of s e r v i c e s p r o v i d e d , and the outcomes observed.  It is  a l s o d e s i r a b l e to know whether s e r v i c e s were p r o v i d e d to and used by those i n need of them. Some o f t h i s a d d i t i o n a l i n f o r m a t i o n , e.g.  the  identity  o f s e r v i c e r e c i p i e n t s , c o u l d be o b t a i n e d by more d e t a i l e d r e c o r d i n g systems.  This a d d i t i o n a l information provides  a more comprehensive p i c t u r e of the s i t u a t i o n , but does so at the expense of s i m p l i c i t y .  Even i f a d d i t i o n a l  informa-  t i o n c o u l d be recorded simply, the p r e s e n t a t i o n and  inter-  p r e t a t i o n o f the data gathered would be more complex. A d d i t i o n a l i n f o r m a t i o n w i l l not i n i t s e l f ensure improvement i n the d e c i s i o n making p r o c e s s . pend upon how  de-  such i n f o r m a t i o n i s analyzed and i n t e r p r e t e d .  A c t i v i t y data are one making processes supervisors.  Improvement w i l l  element o f many i n the d e c i s i o n  of community h e a l t h n u r s i n g d i r e c t o r s  and  By themselves,  they are of l i m i t e d u s e f u l n e s s .  However, used i n combination  w i t h the other types of inform-  a t i o n d i s c u s s e d i n t h i s chapter, a c t i v i t y data are h e l p f u l i n some of the a c t i v i t i e s of s u p e r v i s o r s and  directors.  44  CHAPTER 3 3.1  The dynamics of data t r a n s m i s s i o n There are numerous f a c t o r s a f f e c t i n g a c t i v i t y  i n i t s flow through an o r g a n i z a t i o n .  data  These f a c t o r s need to  be c o n s i d e r e d and d e a l t w i t h during the development implementation  o f an a c t i v i t y r e c o r d i n g system.  and  This  chapter examines these f a c t o r s at three stages of the data transmission process. 3.1  3.2  These stages, i l l u s t r a t e d i n F i g u r e  (p . 45) , are : 1.  data a c q u i s i t i o n ,  2.  data communication,  3.  data  and  interpretation.  Data a c q u i s i t i o n There are c e r t a i n f e a t u r e s of a c t i v i t y data which  a f f e c t the q u a l i t y of d e c i s i o n s based on these data. f o l l o w i n g important aspects of data a c q u i s i t i o n are sidered i n this  section:  1.  accuracy,  2.  reliability,  3.  validity,  4.  cost.  and  The con-  45  F i g u r e 3.1 The Stages o f Data T r a n s m i s s i o n  Data gathering  Communication  ^  of data  Interpretation of data  T  L .  Decision  making  46  3.2.1  Accuracy Accuracy i s the degree o f exactness w i t h which an  instrument measures  the a c t i v i t i e s  i t records.  The d e s i r e d  degree o f accuracy w i l l depend upon the purpose or purposes f o r which the data are needed.  That i s , i t w i l l depend  on  what i s to be done w i t h the measurements (Runkel and McGrath,  1972).  Where an instrument i s not accurate enough, more items of a s i m i l a r k i n d and q u a l i t y may be added to i n c r e a s e the p r o b a b i l i t y o f accurate measurement. An example activity  (Kerlinger,  1973).  o f t h i s may be seen i n the s u b j e c t codes o f the  r e c o r d i n g system i n A l b e r t a .  (Table 5.. 1, p. 104).  Subject codes 29, 30, 31 and 32 (smoking, n u t r i t i o n , exerc i s e / f i t n e s s and o b e s i t y ) c o u l d be grouped under a s i n g l e s u b j e c t heading, l i f e s t y l e .  Breaking l i f e s t y l e i n t o the  areas l i s t e d enables g r e a t e r a c c u r a c y i n measuring  activi-  ties .  3.2.2  Reliability "Reliability  of  can be d e f i n e d as the r e l a t i v e  absence  e r r o r s of measurement i n a measuring instrument"  ( K e r l i n g e r , 1973. p. 443).  Measurement e r r o r can be i n  the form o f e i t h e r a systematic b i a s or random e r r o r s . One element o f r e l i a b i l i t y i s the extent to which measurements are r e p e a t a b l e . of  T h i s aspect i s the a b i l i t y  an instrument to produce the same or s i m i l a r r e s u l t s f o r  47  repeated  a p p l i c a t i o n s of the instrument.  There are  two  kinds of r e l i a b i l i t y r e l a t e d to repeated a p p l i c a t i o n s ; intra-observer r e l i a b i l i t y , Intra-observer  and  inter-observer  reliability.  r e l i a b i l i t y denotes the a b i l i t y of the i n -  strument to r e c o r d the same r e s u l t s when a nurse does the same or s i m i l a r type of work r e p e a t e d l y . observer  reliability  Inter-  i s the a b i l i t y of the instrument to  r e c o r d the same r e s u l t s f o r the same type of work done by different  nurses.  D i f f e r e n c e s i n measures between observers  may  be  due  to d i f f e r e n c e s i n understanding, d i f f e r e n c e s i n i n t e r p r e t i n g events,  memory lapse or decay, or sloppy measurement.  Nurses perform a wide v a r i e t y of a c t i v i t i e s . s p e c i f i c and  c l e a r l y defined.  p r e n a t a l c l a s s e s and not be  These i n c l u d e  screenings.  But  Some are immunizations,  some a c t i v i t i e s  can-  s u c c i n c t l y d e s c r i b e d w i t h i n the a v a i l a b l e c a t e g o r i e s  of an a c t i v i t y r e c o r d i n g system.  For example, a nurse  may  meet w i t h a pregnant woman to d i s c u s s f a m i l y p l a n n i n g . the d i s c u s s i o n may poisons?  But  include topics l i k e n u t r i t i o n , f i r s t aid,  smoking or other h e a l t h s e r v i c e s i n the  In r e c o r d i n g t h i s case,  community.  the nurse needs to e x e r c i s e  her  p e r s o n a l judgement, t a k i n g i n t o account her knowledge of the c a t e g o r i e s of the  instrument.  There are d i f f e r e n t ways i n which the r e l i a b i l i t y of a measuring instrument may  be  improved.  ( K e r l i n g e r , 1973).  These amount to an attempt to reduce the degree o f e r r o r  48  i n measurement. 1.  This  s t a t i n g the  can be  done  by.  items of the measuring instrument  unambiguously. to i n c r e a s e ,  Ambiguity enables e r r o r v a r i a n c e  because i n d i v i d u a l s are able  to  i n t e r p r e t the data d i f f e r e n t l y . 2.  s t a t i n g the  instructions clearly.  uous i n s t r u c t i o n s i n c r e a s e c l e a r and  the  While ambig-  error variance,  standard i n s t r u c t i o n s  tend to reduce  e r r o r s of measurement. These two categories plicit  steps are c l o s e l y r e l a t e d .  need to be  c l e a r l y s t a t e d and  i n s t r u c t i o n s are needed as to how  recorded.  The  clarity  for  the  The  system i n A l b e r t a  and  While items or explained,  items should  e x p l i c i t n e s s of  instructions.  considerably,  (Chapter 5), c o n t a i n s d e t a i l e d Each nurse i s p r o v i d e d w i t h a  page i n s t r u c t i o n manual c o n t a i n i n g  i n s t r u c t i o n s on how  complete the nurses r e p o r t  This  explaining  the  subject  ment. the  But  instrument and one  includes  and 71 to  8 pages  coding.  F o l l o w i n g the above two l i t y of the  forms.  be  instructions  systems reviewed i n Chapter 4 v a r i e s  explicit  ex-  steps can  improve the  reliabi-  thus the q u a l i t y of data measure-  of the major f a c t o r s a f f e c t i n g r e l i a b i l i t y i s  c o n s c i e n t i o u s n e s s w i t h which the nurses complete t h e i r  activity f i n e d and vities  reports. the  Once the r e c o r d i n g  instructions c l a r i f i e d ,  i s a r e l a t i v e l y straightforward  instrument has recording task.  It  daily  been r e acti-  requires  49  a few minutes every day a c t i v i t i e s , and  f o r nurses to keep a l o g of  to then transpose  r e c o r d i n g form a c c o r d i n g However, those who  their  these d e t a i l s onto the  to the r e l e v a n t have worked w i t h  categories. these systems  w i l l bear witness to the problem of g e t t i n g nurses to record t h e i r a c t i v i t i e s c o r r e c t l y .  Some nurses  carefully  l o g and r e c o r d t h e i r a c t i v i t i e s as a c c u r a t e l y as they  can.  Others r e c o r d t h e i r a c t i v i t i e s c a s u a l l y , sometimes c l e a r l y o v e r s t a t i n g or u n d e r s t a t i n g doing.  They may  make a rough approximation of the work  they have done, paying their  the amount of work they are  little  a t t e n t i o n to the accuracy  of  recording. While i t may  not be p o s s i b l e to e n t i r e l y  eliminate  i n a c c u r a t e r e c o r d i n g , there are ways of improving quality  of data  Firstly,  recording.  the importance o f c o r r e c t l y  a c t i v i t y r e p o r t s can be  and  their  T h i s may  thereby improve  raise the  of r e c o r d i n g .  P o s s i b l y t h e most e f f e c t i v e way f  of improving  i t y i s some form of data check or c o n t r o l . r e c o r d i n g can be checked and t h i s way,  completing  s t r e s s e d to nurses.  t h e i r l e v e l of c o n s c i e n t i o u s n e s s standard  the  The  reliabil-  nurses'  d i r e c t feedback p r o v i d e d .  u n i n t e n t i o n a l e r r o r s or b i a s c o u l d be  Nurses' awareness of the accuracy  corrected.  of t h e i r r e c o r d i n g i s  l i k e l y to r i s e as they r e a l i z e t h a t t h e i r input i s being checked.  They are l i k e l y to apply  In  themselves more  50  s t u d i o u s l y to t h e i r r e c o r d i n g .  For example, data  checks  have been implemented i n some of the h e a l t h u n i t s i n Alberta.  C o n s u l t a n t s i n the p r o v i n c i a l government f e e l  that these checks have proved e f f e c t i v e i n improving  the  r e l i a b i l i t y of r e c o r d i n g i n those h e a l t h u n i t s . How  can the r e l i a b i l i t y of a c t i v i t y data be  This^i's extremely d i f f i c u l t a b s o l u t e terms.  estimated?  to e f f e c t i n p r a c t i c e , i n any  There are ways i n which an estimate can  be obtained, although these are not a l t o g e t h e r s a t i s f a c t o r y . The most d i r e c t method i s f o r t r a i n e d observers to compare t h e i r own  r e c o r d i n g of the n u r s e s ' a c t i v i t i e s w i t h the  r e c o r d i n g of the nurses themselves. data can be e s t a b l i s h e d .  E r r o r bounds f o r the  These e r r o r bounds can be  to the d e c i s i o n s based on these data.  applied  However, experimental  arrangements such as o b s e r v a t i o n , are l i k e l y to induce r e active effects. mental  CCampbell and S t a n l e y , 1963).  The  experi-  c o n d i t i o n s are l i k e l y to induce the nurses to r e c o r d  t h e i r a c t i v i t i e s as a c c u r a t e l y as p o s s i b l e , i f they know the reason f o r the o b s e r v a t i o n .  Even i f they d i d n ' t , t h e i r  awareness of t h e i r a c t i v i t i e s - would be r a i s e d , and would probably l e a d to improved ( o b v i o u s l y u n f e a s i b l e ) way  recording.  this  The o n l y  i n which nurses c o u l d be  served without a f f e c t i n g t h e i r r e c o r d i n g , would be  obthrough  t o t a l l y " i n v i s i b l e " observers. Nurses c o u l d be g i v e n a l i s t o f complex a c t i v i t i e s , and asked to r e c o r d the a c t i v i t i e s as i f they were i n a  51  r e a l work s i t u a t i o n .  T h i s experiment  removes them from  p r e s s u r e s of t h e i r r e a l work s e t t i n g .  the  I t i s thus l i k e l y  to  produce g r e a t e r i n t e r - o b s e r v e r r e l i a b i l i t y than would s i m i l a r a c t i v i t i e s i f encountered  by the nurses i n t h e i r  a c t u a l work environment. One  of the most p r a c t i c a l estimates of r e l i a b i l i t y  are the s u b j e c t i v e o p i n i o n s of s u p e r v i s o r s .  They have an  i d e a of what t h e i r nurses are doing, and they have access to  the a c t i v i t y data recorded.  While  t h e i r o p i n i o n s may  be  lacking i n q u a n t i t a t i v e p r e c i s i o n , t h e i r subjective opinions may  be the most a c c u r a t e measures of r e l i a b i l i t y t h a t can  be o b t a i n e d . The  accuracy of r e c o r d i n g and the r e l i a b i l i t y  measurement w i l l  of  a f f e c t the q u a l i t y of data recorded,  thus the q u a l i t y of d e c i s i o n s based  on these data.  and  The  q u a l i t y of d e c i s i o n making can be improved by improving q u a l i t y of the data.'  3.2,3  -  -  the  -  Validity A c c o r d i n g to: K e r l i n g e r (1973)  types of v a l i d i t y .  f  there are  The k i n d of v a l i d i t y r e l e v a n t to t h i s  d i s c u s s i o n of a c t i v i t y r e c o r d i n g , i s content The  different  content v a l i d i t y of an instrument  validity. r e f e r s to the  adequacy w i t h which a s p e c i f i e d domain o f content i s sampled.  (Nunnally,  1967).  In content v a l i d a t i o n ,  one  t r i e s to a s c e r t a i n whether the substance or content of the  52  measure i s r e p r e s e n t a t i v e of the content of the p r o p e r t y being sampled. A c t i v i t y r e c o r d i n g instruments measure the type q u a n t i t y of a c t i v i t i e s performed by nurses. measure the content of the a c t i v i t i e s  and  They do not  themselves.  Thus, an  a c t i v i t y r e c o r d i n g instrument can p r o v i d e p o t e n t i a l l y  valid  measures of the type o f a c t i v i t i e s nurses are i n v o l v e d i n . I t cannot a c t as a v a l i d measure of the a c t i v i t i e s themselves . O b j e c t i v e s p r o v i d e g u i d e l i n e s to the use of data c o l l e c t e d , and thus to the types o f data r e q u i r e d .  The  content  of an a c t i v i t y r e c o r d i n g instrument r e f l e c t s what informat i o n i s r e l e v a n t i n terms of the o b j e c t i v e s of the r e c o r d i n g system.  Clearly stated objectives w i l l  s p e c i f y the domain  of data to be sampled, w h i l e vaguely d e f i n e d o b j e c t i v e s leave the data domain to be sampled undetermined.  may  When  o b j e c t i v e s are vaguely d e f i n e d , the content o f the  instru-  ment w i l l r e f l e c t the judgement of the instrument's designers as to what i n f o r m a t i o n i s r e l e v a n t i n terms of the unclear ly stated objectives.  In such cases, the r e l e v a n c e ,  content and volume of data to be c o l l e c t e d may to e s t a b l i s h .  be  difficult  Thus, c l e a r l y d e f i n e d o b j e c t i v e s are impor-  tant i n determining the content of an instrument, and i n t e s t i n g f o r content v a l i d a t i o n .  In the absence of c l e a r l y  s t a t e d o b j e c t i v e s , t e s t i n g f o r content v a l i d a t i o n becomes a highly subjective process.  (The i s s u e of systems  53  objectives i s discussed  3.2.4  i n more d e t a i l i n s e c t i o n 4.4.1).  Costs A c t i v i t y data provides  of i t s a c t i v i t i e s .  an o r g a n i z a t i o n w i t h an image  The more d e t a i l e d the image, the g r e a t -  er the costs i n v o l v e d i n o b t a i n i n g i t . more a b b r e v i a t e d  (Emery, 1971).  the image, the g r e a t e r the c o s t s  monetary terms) o f i n f o r m a t i o n  The  ( i n non-  foregone.  Recording can be c o s t l y i n terms o f time and nurse effort. But  The cost  i n materials  as the d e t a i l recorded  i s u n l i k e l y to be high.  increases,  e f f o r t required i n recording.  so does the time and  Nurses are not s p e c i f i c a l l y  t r a i n e d to perform c l e r i c a l type work, and may do so r e luctantly . The more data t h a t are c o l l e c t e d , the more data are t o be presented.  there  More data may mean a l o s s i n s i m p l i -  c i t y i n data p r e s e n t a t i o n .  T h i s i s a cost to be  considered  i n i n c r e a s i n g the volume o f data c o l l e c t e d . In d e s i g n i n g  any system, a l l the costs i n v o l v e d need  to be taken i n t o account.  (Emery, 1971).  between s i m p l i c i t y and g a t h e r i n g more data, d i f f e r e n t l e v e l s o f aggregation costs t h a t need to be  3.3  The t r a d e - o f f and between  and d e t a i l , are among the  considered.  Data communication Nurses a t a l l l e v e l s w i t h i n community h e a l t h  nursing  54  are interdependent  i n t h e i r work a c t i v i t i e s .  To e f f e c t  interdependence they need to communicate and messages.  utilize  In f a c t , the managerial and p l a n n i n g  functions  only become o p e r a t i o n a l i z e d through communicative (Steers, 1977).  such  activity  T h i s s e c t i o n w i l l examine some of the major  f e a t u r e s of data communication that a f f e c t the communicat i o n of a c t i v i t y  3.3.1  data.  F a c t o r s a f f e c t i n g data  flow  P o s s i b l y the most important f a c t o r i n f l u e n c i n g the transmission ization.  of data i s the s t a t u s h i e r a r c h y of the organ-  (Havelock, 1971).  The  formal  s t r u c t u r e of  an  o r g a n i z a t i o n w i l l to a l a r g e degree determine the  distri-  b u t i o n of data to those w i t h i n and  organiza-  tion.  (Gibson,  Ivancevich  o u t s i d e of the  and Donnelly,  1976).  These  channels, downward, upward and h o r i z o n t a l , w i l l a f f e c t dissemination The  o f a c t i v i t y data throughout an  geographical  the  organization.  or p h y s i c a l d i s t a n c e between o r g a n i z -  a t i o n members and between groups i s a l s o seen as a determinant of i n f o r m a t i o n exchange.  (Havelock, 1971).  This i s  p a r t i c u l a r l y r e l e v a n t i n community h e a l t h n u r s i n g , where nurses o f t e n cover l a r g e d i s t a n c e s , and may tive isolation.  work i n r e l a -  There i s a l s o g e n e r a l l y a p h y s i c a l  t i o n between d i f f e r e n t o r g a n i z a t i o n a l l e v e l s . s e p a r a t i o n i s o f t e n a f u n c t i o n o f the s t a t u s  separa-  Physical  hierarchy,  w i t h the lowest l e v e l s t a f f the most remote g e o g r a p h i c a l l y .  55  One way o f f o s t e r i n g communication i s to r o u t i n e l y convene groups o f o r g a n i z a t i o n members to d i s c u s s r e l e v a n t A c t i v i t y data provide  items.  common measures t h a t can a c t as a  b a s i s f o r such d i s c u s s i o n s . "Leadership behaviour serves both as a stimulus  and a  model f o r much behaviour i n the o r g a n i z a t i o n , and f o r that reason i t i s a major determinant o f i n t e r n a l b a r r i e r s to knowledge d i s s e m i n a t i o n p. 6-26).  and u t i l i z a t i o n . "  (Havelock, 1971.  Leadership behaviour sets a tone which pervades  throughout the o r g a n i z a t i o n .  The d i r e c t o r o f a h e a l t h  agency i n community h e a l t h w i l l have a powerful e f f e c t on the s t y l e o f o p e r a t i o n the agency.  o f the s u p e r v i s o r or s u p e r v i s o r s i n  The d i r e c t o r may a l s o a f f e c t the flow and  u t i l i z a t i o n of a c t i v i t y  data.  A c t i v i t y data could be used to h o l d nurses accountable f o r the way they use t h e i r time a t work.  These data a r e  thus sometimes regarded as c o n f i d e n t i a l , as i n A l b e r t a (see s e c t i o n 5.5.3). share i n f o r m a t i o n .  I n d i v i d u a l s are sometimes h e s i t a n t to  They f e e l i t may r e f l e c t n e g a t i v e l y on  themselves or the f u n c t i o n i n g o f t h e i r group w i t h i n the organization  (Havelock, 1971).  These f e e l i n g s may impede  the flow o f a c t i v i t y data between u n i t s i n the o r g a n i z a t i o n , and between the o r g a n i z a t i o n and i t s environment.  3,3,2  Frequency o f r e p o r t i n g Data can be c o l l e c t e d and r e p o r t e d  either regulary,  56  i r r e g u l a r l y , or not at a l l .  There are i n h e r e n t assump-  t i o n s i n any p a r t i c u l a r frequency of data c o l l e c t i o n . data are r e g u l a r l y c o l l e c t e d , t h i s i m p l i e s t h a t the  If  activi-  t i e s covered by the data need to be c o n s t a n t l y monitored, or that data need to be a v a i l a b l e f o r constant m o n i t o r i n g or checking.  I n t e r m i t t e n t data c o l l e c t i o n i m p l i e s t h a t  the a c t i v i t i e s covered by the data c o l l e c t i o n do not need constant m o n i t o r i n g . is required.  Not  In t h i s case, o n l y i r r e g u l a r  checking  c o l l e c t i n g any data about c e r t a i n  activi-  t i e s i m p l i e s t h a t the data are not necessary to monitor these a c t i v i t i e s .  I t may  a l s o mean that the data, even i f  a c q u i r e d , w i l l have minimal processes r e l a t e d to these I t may  or no impact  on the d e c i s i o n  activities.  thus be i n f e r r e d t h a t those n u r s i n g a c t i v i t i e s  r e g u l a r l y recorded and r e p o r t e d are regarded as r e q u i r i n g constant m o n i t o r i n g .  Or,  there may  a l s o be a p e r c e i v e d  need f o r such data to be a v a i l a b l e f o r m o n i t o r i n g , i n case it  i s required.  3.3.3.  The volume of data r e p o r t i n g  "Information systems have gained ready acceptance  in  the innocent c l o a k o f being the f i r s t and necessary step i n the d i r e c t i o n of r a t i o n a l p l a n n i n g .  But h e r e i n l i e s  of the most s e r i o u s dangers of i n f o r m a t i o n systems I n s e n s i t i v i t y to or a l a c k of knowledge about the  one ....  substan-  t i v e i s s u e s are o f t e n washed out of s i g h t i n the deluge  of  57  d e t a i l e n t h u s i a s t i c a l l y captured".  (Hoss, 1971. p. B663).  In 1967, A c k h o f f s t a t e d h i s b e l i e f that the most important d e f i c i e n c y from which managers s u f f e r e d was not a lack of relevant information, i r r e l e v a n t information. stage o f great  but an overabundance o f  T h i s statement came during a  enthusiasm and t e c h n o l o g i c a l development  i n the f i e l d o f management i n f o r m a t i o n claims  systems.  generated a good deal o f controversy.  suggestion  Ackhoff's  Yet h i s  that managers s u f f e r from an i n f o r m a t i o n  l o a d has g e n e r a l l y remained unchallenged. Davis and E v e r e s t ,  over-  (Rappaport, i n  eds., 1976).  Whether or not data are necessary depends upon the impact or p o t e n t i a l impact they have on a c t i o n s and. d e c i sions.  There i s an assumption inherent  i n the d e c i s i o n to  c o l l e c t any p a r t i c u l a r data item throughout an a c t i v i t y recording  system.  T h i s assumption i s that such data are  r e l e v a n t w i t h i n the context  o f some u n i v e r s a l d e c i s i o n  making model f o r d i r e c t o r s and s u p e r v i s o r s .  Such a u n i v e r -  s a l model i s an i d e a l that does n o t e x i s t , as there are many i n t e r - i n d i v i d u a l d i f f e r e n c e s a f f e c t i n g d e c i s i o n making. T h i s does n o t mean that such a u n i v e r s a l model i s o f no v a l u e .  As d i s c u s s e d  e a r l i e r (section3.2.4),  any  system  must make t r a d e - o f f s i n determining what i n f o r m a t i o n to collect.  I t must a l s o make t r a d e - o f f s i n c o n s i d e r i n g how  o f t e n to c o l l e c t i n f o r m a t i o n .  In terms o f convenience i n  58  c o l l e c t i n g data, i t may  be much e a s i e r to c o l l e c t more  than i s e s s e n t i a l l y necessary i n terms of each i n d i v i d u a l ' s d e c i s i o n making p r o c e s s e s .  I t then becomes the task o f  the user to apply h i s or her f i l t r a t i o n or processes to what data are a v a i l a b l e . w i l l cause problems, as  condensation  Inevitably,  this  ... "indeed there i s probably a  c r i t i c a l i n f o r m a t i o n content, which, i f exceeded, i s l i k e l y to l e a d to a d e t e r i o r a t i o n of the u s e f u l n e s s of the summary to the manager".  (Ashford, 1975.  p.22).  The r e l e v a n c e of i n f o r m a t i o n , and thus the  frequency  and volume of data r e p o r t i n g , i s a f u n c t i o n of the d e c i s i o n making process. c l e a r l y understood,  U n t i l the d e c i s i o n making process i s there i s no l o g i c a l means of determining  r e l e v a n c e , and thus the a p p r o p r i a t e volume o f data r e p o r t ing.  At p r e s e n t , i t would be unreasonable  to c l a i m that a  c l e a r l y understood model'of d e c i s i o n making e x i s t s f o r community h e a l t h n u r s i n g s u p e r v i s o r s and d i r e c t o r s .  Deci-  s i o n making i n t h i s area may  be a k i n to what P i r s i g  sees as q u a l i t y i n w r i t i n g .  I t i s something t h a t can  l y be seen to e x i s t .  (1974) clear-  But, l i k e q u a l i t y , i t i s beyond  l o g i c a l and comprehensive a n a l y s i s . I f d e c i s i o n making may  be seen to e x i s t , ought i t not  to be d e s c r i b a b l e , at l e a s t i n terms o f the minimum e s s e n t i a l i n f o r m a t i o n - r e q u i r e d to make a s y s t e m a t i c d e c i s i o n ? The problem here i s adequately d e f i n i n g what i s meant by "systematic".  Is a d e c i s i o n s y s t e m a t i c because some  59  e s s e n t i a l minimum data set was  a v a i l a b l e to the  maker ( i n which case systematic cribed)?  Or  decision  i s t a u t o l o g i c a l l y des-  i s d e c i s i o n making systematic  due  to  the  s t r u c t u r e d nature of the i n t e l l i g e n c e , design and stages?  Simon ( s e c t i o n 2.1)  f e e l s that there are  choice few  d e c i s i o n s or problems which are t o t a l l y s t r u c t u r e d . and  Simon c l a i m that  ... "a few,  and  only a few,  c h a r a c t e r i s t i c s of the human i n f o r m a t i o n  Simon, 1972. The  p.  The  system  (Newell  and  788.).  i s s u e of " s y s t e m a t i c "  complex.  gross  processing  are i n v a r i a n t over task and problem s o l v e r " .  Newell  d e c i s i o n making i s indeed  basic organizational features  and  universal  s t r u c t u r a l c h a r a c t e r i s t i c s i n the d e c i s i o n making process for supervisors  and  d i r e c t o r s need to be  a n a l y s i s o f these f e a t u r e s study.  identified.  An  i s beyond the scope o f t h i s  U n t i l t h i s i s done, i t i s not p o s s i b l e to e s t a b l i s h  a minimum  e s s e n t i a l data set f o r d e c i s i o n making by  these  individuals. Before the relevance  of data can be e s t a b l i s h e d ,  a  more comprehensive understanding of the d e c i s i o n making processes of s u p e r v i s o r s  and  directors i s required.  In  absence of a comprehensive.model, i t i s s t i l l p o s s i b l e determine some of i t s elements.  These elements may  the to  be  i d e n t i f i e d through a c a r e f u l study of the data elements gathered by a c t i v i t y r e c o r d i n g i s done i n Chapter  4.  systems across  Canada.  This  60  3.4  The  i n t e r p r e t a t i o n of  data  Even i f a l l the r e l e v a n t i n f o r m a t i o n f o r d e c i s i o n making was  c o l l e c t e d , there i s no assurance t h a t i t would  be a p p r o p r i a t e l y used by d e c i s i o n makers.  Newell and  Simon  ( s e c t i o n 3.3.3) f e e l t h a t there are only a few ways i n which i n d i v i d u a l s ' i n f o r m a t i o n p r o c e s s i n g systems are  the  same, or the same f o r d i f f e r e n t problems. D e c i s i o n making s t r a t e g i e s are i n f l u e n c e d not only the d e c i s i o n problem and  the d e c i s i o n environment, but  by the c h a r a c t e r i s t i c s of the d e c i s i o n maker. e s  by also  Characteris-  such as i n t e l l e c t u a l a b i l i t y , education, a t t i t u d e s ,  c u l t u r a l background and  especially cognitive style  will  a f f e c t d e c i s i o n making. I n d i v i d u a l s gather  i n f o r m a t i o n through a p e r c e p t u a l  process by which the mind organizes i t encounters.  the v a r i o u s  stimuli  What each i n d i v i d u a l p e r c e i v e s as  t i o n i s the r e s u l t of a complex coding  process.  McKenney and Keen (1974) d i s t i n g u i s h two along which i n d i v i d u a l s d i f f e r :  informa-  dimensions  information gathering  i n f o r m a t i o n e v a l u a t i o n ( F i g u r e 3.2.  p. 61).  In  and  gathering  i n f o r m a t i o n , p r e c e p t i v e t h i n k e r s apply concepts to  filter  data, w h i l e r e c e p t i v e t h i n k e r s are more s e n s i t i v e to the data stimulus  itself.  In e v a l u a t i n g i n f o r m a t i o n , i n d i v i d u a l s  d i f f e r i n t h e i r sequence o f a n a l y s i s of the data a v a i l a b l e to them. B a r i f f and Lusk (1977) a p p l i e d c o g n i t i v e s t y l e ment i n the design phase of a " n u r s i n g  evaluation  assess-  61  Figure  3.2 Model  of Cognitive  Style  Preceptive  Information Evaluation  fl o  • H  -P  «  \  A Intuitive  System a t i c  (8  >  rH  Receptive  m >  B  f  Note:  E a c h p o i n t on t h e g r i d w i l l cognitive  style.  i n d i v i d u a l who gathering,  describe  F o r example,  is slightly  a particular  'A' w i l l  preceptive  and h i g h l y s y s t e m a t i c  describe  an  i n information  i n information,  e v a l u a t i o n . 'B' i n d i c a t e s someone who ceptive  i n information  gathering,  tuitive  i n information  evaluation.  i s highly re-  and h i g h l y . i n -  62  information  system", f o r a community n u r s i n g  large metropolitan  USA  city.  The  service i n a  findings of t h e i r  study  were i n s t r u c t i v e i n d e v e l o p i n g r e p o r t i n g formats f o r data that had The  been gathered. i n d i v i d u a l s i d e n t i f i e d as c o n s t i t u t i n g the  deci-  s i o n making network of the o r g a n i z a t i o n were t e s t e d f o r cognitive style. complexity. 1  A l l were found to be  Cognitive  complexity i n v o l v e s  in cognitive the processes of:  d i f f e r e n t i a t i o n - the number of dimensions extracted  2.  low  from the  data,  i n t e g r a t i o n - the complexity of the r u l e s f o r combining s t r u c t u r e d data,  3.  a r t i c u l a t i o n - the f i n e n e s s  and  of d i s c r i m i n a t i o n .  T h i s f i n d i n g does not mean that users cannot or do not form e f f e c t i v e l y .  I t merely p r o v i d e s a g u i d e l i n e f o r  designer or developer of user r e p o r t s ought to be  as to how  such  the reports  structured.  T h e i r f i n d i n g s l e d to a d i s a g g r e g a t i o n type of r e p o r t  s t r u c t u r e , and  number of r e p o r t s .  There was  frequency of s e l e c t e d r e p o r t s , The  per-  of the  former  a consequent i n c r e a s e a l s o an i n c r e a s e  i n the  i n the  from q u a r t e r l y to monthly.  designers c l a i m "a p r e s s i n g need to i d e n t i f y the  dimensions of r e p o r t s which are r e l e v a n t c l a s s e s of u s e r s . "  to the  ( B a r i f f and Lusk, 1977.  p.  various 827.).  B a r i f f and Lusk's f i n d i n g s on c o g n i t i v e s t y l e probably v e r y a p p l i c a b l e to community n u r s i n g  specific  are  reporting  63  systems i n Canada.  The  use  of c o g n i t i v e  a t i o n system design and  use  i s an area that has  recently neglected.  (Benbasat and  f u r t h e r study i s r e q u i r e d involved.  s t y l e s i n inform-  Taylor,  to c l a r i f y  the  been u n t i l  1978).  Much  relationships  64  CHAPTER 4 4.1  Activity  r e c o r d i n g systems i n Canada  T h i s chapter c o n t a i n s an a n a l y s i s o f a c t i v i t y ing  systems f o r community h e a l t h nurses i n s i x p r o v i n c e s  across Canada.  The f e d e r a l government system f o r occupa-  t i o n a l h e a l t h nurses i s a l s o reviewed<. the  record-  The purpose o f  a n a l y s i s i s to o b t a i n an overview of c u r r e n t Canadian  practices. D e t a i l e d i n f o r m a t i o n on the d i f f e r e n t systems  was  r e q u i r e d to perform t h i s  analysis.  was  to a l l the p r o v i n c i a l d i r e c t o r s o f  sent i n August 1978,  public/community h e a l t h n u r s i n g to H e a l t h and Welfare Canada.  Accordingly, a l e t t e r  (except f o r A l b e r t a ) ,  and  A f t e r b r i e f l y o u t l i n i n g the  t o p i c o f the proposed study, the l e t t e r requested information  on: 1.  the r e p o r t i n g or r e c o r d i n g system f o r p u b l i c / community h e a l t h n u r s i n g a c t i v i t i e s i n the province,  2.  the o b j e c t i v e s o f the system,  3.  the process of development  4.  the output generated by the system, and  5.  how  o f the system,  the roiitput of the system i s used.  R e p l i e s w i t h i n f o r m a t i o n were r e c e i v e d from B r i t i s h Columbia, New  Brunswick, Manitoba and O n t a r i o .  Informa-  t i o n from A l b e r t a had a l r e a d y been made a v a i l a b l e . October, 1978,  a follow-up l e t t e r was  sent to those  In  65  p r o v i n c e s which had not responded. c e i v e d from P r i n c e Edward I s l a n d .  Information The M e d i c a l  Branch of H e a l t h and Welfare Canada s u p p l i e d  was  re-  Services  information  on the system used by community h e a l t h nurses working i n occupational health.  Newfoundland, Nova S c o t i a ,  chewan and Quebec d i d not The  the  information: the f u n c t i o n a l f e a t u r e s of the systems were examined.  2.  information.  f o l l o w i n g framework i s a p p l i e d to analyze  available 1.  supply  Saskat-  These f e a t u r e s i n c l u d e :  a.  services  recorded,  b.  n o n - c l i e n t contact  c.  data re s e r v i c e r e c i p i e n t s ,  d.  d u r a t i o n o f s e r v i c e s recorded,  e.  p l a c e o f s e r v i c e recorded.  The  conceptual  and  system are l i s t e d .  activities,  and  o p e r a t i o n a l f e a t u r e s of each The  s t a t e d o b j e c t i v e s of  the  systems are examined. 3.  The  s p e c i a l f e a t u r e s of the a v a i l a b l e systems are  discussed.  4.2.  Functional features of a c t i v i t y The  r e c o r d i n g systems  f u n c t i o n a l f e a t u r e s of the systems a v a i l a b l e f o r  t h i s study  are summarized i n Table 4.1  (pp. 68-72). T h i s t a b l e  i s based on i n f o r m a t i o n made a v a i l a b l e by the f e d e r a l and , p r o v i n c i a l governments. l i s t e d below.  The  information provided i s  66  Alberta All  forms and documented m a t e r i a l r e l a t i n g  system were made a v a i l a b l e f o r t h i s  British  to this  study.  Columbia  1.  Monthly Report o f S e l e c t e d S t a t i t i c s  2.  Summary o f Monthly S t a t i s t i c a l Report  3.  Home Care  4.  D i s c u s s i o n o f P.H. 56 (Monthly Report).  5.  Computer Programming o f Home  Program  (Nursing). (Nursing),  - P a t i e n t Summary.  Care  Statistics.  Manitoba 1.  R e g i o n a l P u b l i c H e a l t h Nursing S t a t i s t i c s .  S e l e c t e d Reasons 2.  f o r Service.  S e l e c t e d Reasons  f o r S e r v i c e from R e g i o n a l Summary  Sheet (3 pages). 3. cal  Revised P u b l i c H e a l t h N u r s i n g S e r v i c e s  Systems.  New Brunswick 1.  D a i l y S e r v i c e Record.  2.  Statistical  3.  Code f o r S e r v i c e Record.  4.  Guide t o D a i l y S e r v i c e Record.  Record (2 pages).  Statisti-  67  Ontario 1.  Community H e a l t h Resources.  Report o f weekly  activities. 2.  Monthly Summary.  3.  C.H.A.R.I.S.  4.  The Community H e a l t h Resources Report o f Weekly  Nursing a c i t i v i t y  sybsystem.  activity. 5. System  Community H e a l t h A c t i v i t y Resources I n f o r m a t i o n (C.H.A.R.I.S.)  C l e r i c a l Procedures.  P r i n c e Edward 1.  D a i l y Report.  2.  Immunization  3.  Monthly and Annual S t a t i s t i c a l  Statistics. Summary.  P u b l i c Health Nursing. -  * T  H e a l t h and Welfare Canada 1.  H e a l t h U n i t S t a t i s t i c a l Report (A).  2.  H e a l t h U n i t S t a t i s t i c a l Report (T).  3.  Performance Measurement System.  Health F a c i l i t y .  Public  Service  Table  4.1 F u n c t i o n a l Features  1.  Services  recorded  Alta  of Recording Systems B.C.  a  Immunizations Rubella  X  Smallpox  .c  Polio  X  Man. N.B.  X  X  c  X  b  Ont.  PEI  b  a X  c  ,c  X  X  Polio  (Salk)  c  Polio  (Sabin)  c  .c c  .c  Diphtheria  :c  :c  Tetanus  c  c  Typhoid  c  Quad  c  c  Measles  X  X  Cholera  X  X  Influenza  X  X  DPT  X  DT  X  Mumps  c 'c X  Triad  X  Biad  X  MMR  X  Pertusis  X  Schick  X  Rabies  X  Typhus  X  Immune Serum G l o b u l i n Plague Other  d  X  X X  X  Key on page 72  Fd.Gvt.  69  Slta  Services i n schools  B.C.  d  Conference  with  staff  d  Conference  with  students  X  Man. :b  N.B. X  Ont. e  Fd.Gvt.  PEI d  d"  Inspections Counselling  X  No. r e f e r r e d by t e a c h e r  X  Recommended f o r e x c l u s i o n  d  Defects corrected  d  Screening  f  ,d  Vision  X  Hearing  X  Communicable  Disease  Developmental  .f f  f  X  f  .f  X X  X X  Schick  X  P.K.U.  X  Pediculosis  X  Other  X  Expectant  .d  C h i l d Health  parent/prenatal  d  X  Family planning  X  X  d  ,d X  d  Conference  Clinics  f  X  Tuberculin  Groups/classes  d  d  X  b  b,d  X  .d  X  X  X  X  X  Geriatric  . :.d  X  X  d  X  b  d  d  X  X  Chest Other  X  Communicable d i s e a s e  d  d  VD  X  X  TB  X  X  Mental  Health/illness  X  X  d  X  d  X  d  g X  d•  X  Key on Page 72  X  70  Man. d  Alta a  B.C. .a  X  X  X  . d  X  Postnatal  X  X  New i n f a n t  X  Home Care Home assessment/ reassessment  N.B. X  d  Ont.  PEI  X  X  General Expectant prenatal  parent/  H e a l t h promotion Chronic  disease  X  Lifestyle  X  X  X  X  X  X  X  X  X  ••d  X  X  X  d  Safety/occupation health  g  X  Drugs/alcohol  X  X  Public  X  d,g  relations  Followup  X  Handicapped/ Special Services  X  ChildrAbuse  X  Poison C o n t r o l  X  Retirement  X  Social Services  X  Treatment  X  d  F i r s t Aid  X  General  X  Health  Infant & preschool assessment  ..-a  Infectious hepatitis  X  Episodic  X  care  Mental r e t a r d a t i o n  X  Child  care  X  Adult  care  X  Growth & development  g  Public health  X  Key on page 72  Fd.Gvt.  71  General  (cont.) ;  Nursing  Alta  B.C.  Man.  care  N.B.  Ont.  X  Preschool  class  X  Geriatric  care  X  Medical  X  Surgical  X  Conception/ contraception  X  education  g  X  Registration of preschool c h i l d r e n  g  Non-communicable disease  X  Local options  2.  X  X  N o n - c l i e n t contact  activities  Meetings  d  Liasons  d  Hospital  Inservice  education  X  Team/case c o n f e r e n c e  d  X  X  X  liason  Supervision/training  Fd.Gvt.  X  N u r s i n g home programs  Parent  PEI  X  X  X  X  X  X  X  X  X  X X  X  X  X  Others  Daycare c e n t r e s  X  Community agency  X  X  Nurse attachment  X  Mass media  X  Service  activities  X  O f f i c e management  d  X  Clerical  X  X  Key  on page 72  X  X  72 2.  Non c l i e n t contact a c t i v i t i e s ^ (cont.) Alta. Travel  B.C.  Man.  X  N.B.  X  X  Home v i s i t i n g  :e  Number o f homes  Absence  visited  X  contacts  Fd.Gvt. X  X  Mileage noted  Telephone  PEI  Ont.  e  X  X  e  X  from work  d  d  X  .h  Data r e s e r v i c e r e c i p i e n t s Age  X  h  h  h  Sex  X  X  X  D u r a t i o n o f s e r v i c e s recorded . X  5.  X  X  Name  4.  h  X  . .h  X  X  :f  f  Place of service recorded h  Key. a.  Separate form  b.  Single l i n e  c.  Shows r e i n f o r c i n g s e r i e s  d.  More d e t a i l e d breakdown g i v e n  e.  Time a l l o c a t i o n noted  f.  Recorded under school  gh.  Group a c t i v i t i e s / c l a s s e s For  some  entry  activities  activities only  X  73  4.2.1  F e d e r a l government system As the f e d e r a l government system i s f o r the a c t i v i t i e s  of nurses performing a s p e c i a l i s t f u n c t i o n , these s e r v i c e s are l i s t e d s e p a r a t e l y .  The H e a l t h U n i t S t a t i s t i c a l Report  groups the a c t i v i t i e s o f nurses as f o l l o w s :  4.3.  4.3.1  1.  h e a l t h assessment,  2.  counselling,  3.  treatment,  4.  referrals - disposals,  5.  h e a l t h education  6.  o f f i c e management.  and l i a s o n ,  Functional features: discussion  Services From Table  recorded 4.1 i t i s evident  t h a t there are many under-  l y i n g s i m i l a r i t i e s i n the s e r v i c e s recorded r e c o r d i n g systems.  S e r v i c e s recorded  provinces are: 1.  immunizations,  2.  school h e a l t h s e r v i c e s ,  3.  screenings,  4.  groups/classes,  5.  c h i l d health  6.  clinics,  7.  communicable  conferences,  disease,.  by the p r o v i n c i a l  i n at l e a s t  four  74  8.  mental h e a l t h / i l l n e s s ,  9.  home care,  10.  prenatal/postnatal,  11.  new i n f a n t .  Home care may be presented  as a"separate  program w i t h i t s  own i n f o r m a t i o n system, as i n B.C. and A l b e r t a . The  community h e a l t h n u r s i n g programs i n the d i f f e r e n t  provinces have t h e i r own p a r t i c u l a r emphases.  Yet from  Table 4.1 i t can be seen t h a t the m a j o r i t y o f a c t i v i t i e s i n which nurses a r e i n v o l v e d are common to a l l p r o v i n c e s .  4.3.2  Non—client  contact  activities  There are d i f f e r e n c e s between the p r o v i n c e s terminology  i n the  a p p l i e d to non c l i e n t contact a c t i v i t i e s ' .  a c t i v i t i e s are g e n e r a l l y measured i n terms o f the time  These spent  on them. These data convey no i n f o r m a t i o n a t a l l about contact n u r s i n g a c t i v i t i e s .  They do p r o v i d e a p e r s p e c t i v e  of the d i s t r i b u t i o n o f nurses' time, over the f u l l  client  a c t i v i t i e s or of nursing  spectrum o f a c t i v i t i e s  i n which they are  involved.  4.3.3  Data r e s e r v i c e r e c i p i e n t s S e r v i c e r e c i p i e n t s may be noted a c c o r d i n g to t h e i r : 1.  name,  75  1.  2.  sex, and/or  3.  age.  Name o f r e c i p i e n t ( s ) Recording  the name o f i n d i v i d u a l contacts i s the c l e a r -  est way of i d e n t i f y i n g s e r v i c e r e c i p i e n t s .  But t h i s  informa-  t i o n i s " l o s t " i n the aggregation o f data.  At the manager-  i a l o r s t r a t e g i c p l a n n i n g l e v e l , knowing the names o f s e r v i c e r e c i p i e n t s has no p a r t i c u l a r advantages over a simpler identification 2.  Sex  process.  :  Recording  the sex of s e r v i c e r e c i p i e n t s may be approp-  r i a t e f o r the o c c u p a t i o n a l h e a l t h a c t i v i t i e s o f f e d e r a l government nurses.  Knowing the sex o f r e c i p i e n t s o f p r o v i n -  c i a l n u r s i n g s e r v i c e s i s u s e f u l i n cases o f o c c u p a t i o n a l h e a l t h , and i n r e c o r d i n g attendances planning classes.  a t p r e n a t a l and f a m i l y  Knowing the sex r a t i o o f attendance a t  these c l a s s e s could enable more a p p r o p r i a t e p r e p a r a t i o n and presentation of material. 3.  Age  groupings  The age groupings  used i n the p r o v i n c e s vary,  although  there appears to be an u n d e r l y i n g s e t of age spans. are: 1.  infant:  0-1  year  (up to 364 days),,  2.  preschool:  1-5  years,  3.  school:  6-18  4.  adult:  years,  19 - 64 years,  These  76  5.  geriatric:  65 + years.  G e n e r a l l y , there are a g r e a t e r number o f age spans, w h i l e some p r o v i n c e s use age groupings spans.  t h a t c u t across  these  Manitoba has a number o f o v e r l a p p i n g age c a t e g o r i e s  which v a r y a c c o r d i n g t o the nature o f the p o p u l a t i o n b e i n g served.  The age groups are s e t to i d e n t i f y s e r v i c e r e c i p -  i e n t s as c l e a r l y as d e s i r e d . Age  groupings  are the most common way o f i d e n t i f y i n g  t a r g e t groups o r p o p u l a t i o n s by whom s e r v i c e s a r e r e c e i v e d . The  f i n e r the d i s t i n c t i o n between age c a t e g o r i e s , the more  c l e a r l y the i d e n t i t y o f s e r v i c e r e c i p i e n t s i s d i s t i n g u i s h e d . T h i s f i n e r d i s t i n c t i o n between age c a t e g o r i e s enables a c l o s e r comparison to be made between the needs o f a t a r g e t p o p u l a t i o n , and the type and q u a n t i t y o f s e r v i c e s p r o v i d e d to that p o p u l a t i o n .  4.3.4  D u r a t i o n o f s e r v i c e s recorded " D i s t i n c t i o n should be made between data which are r e -  g u l a r l y summarized and r e p o r t e d and data obtained by a s p e c i a l study or survey.  For example, an agency may need  d e t a i l e d i n f o r m a t i o n on the d i s t r i b u t i o n o f t o t a l n u r s i n g time f o r a s s e s s i n g emphases, f o r work measurement, and f o r cost a n a l y s i s . estimate.  A sample time study w i l l p r o v i d e a good  I t i s u s u a l l y n o t necessary or a d v i s a b l e to  c o l l e c t such i n f o r m a t i o n on a continuous League f o r Nursing,  b a s i s " (National  1962. p. 6.). Only B.C. and Manitoba  77  do not r e c o r d any data about time spent i n a c t i v i t i e s . Nurses may same f u n c t i o n .  take d i f f e r e n t amounts of time to perform the Or, they may  spend the same amount of time i n  an a c t i v i t y , and perform d i f f e r e n t l y . spent i n a c t i v i t i e s may  V a r i a t i o n s i n time  be due to the n u r s e s ' q u a l i f i c a t i o n s ,  the r e s o u r c e s a v a i l a b l e , the c h a r a c t e r i s t i c s of s e r v i c e p i e n t s and/or  reci-  other f a c t o r s .  S u p e r v i s o r s and d i r e c t o r s r e q u i r e a sound knowledge of the amount of time needed f o r d i f f e r e n t a c t i v i t i e s mining s t a f f i n g l e v e l s and s t a f f i n g p a t t e r n s .  i n deter-  They a l s o need  to know how much time nurses are a c t u a l l y spending i n t h e i r various a c t i v i t i e s .  Knowledge about the average times r e -  q u i r e d f o r p a r t i c u l a r a c t i v i t i e s i s a c q u i r e d through ience i n the community h e a l t h n u r s i n g f i e l d . of v a r i a t i o n s from average work times develops w i t h experience i n the  exper-  An understanding inherently  field.  Time spent i n a c t i v i t i e s  i s an i n d i c a t o r of the o v e r a l l  d i s t r i b u t i o n of n u r s i n g time.  I t i s not an i n d i c a t i o n o f  p r o c e s s , outcome or e f f e c t i v e n e s s .  Due  to v a r i a t i o n s i n  these f a c t o r s , time spent i s not an a c c u r a t e i n d i c a t o r of efficiency. Due  to t e c h n o l o g i c a l developments and changes i n proce-  dures, e d u c a t i o n and emphasis, the time spent i n d i f f e r e n t a c t i v i t i e s w i l l vary over time.  The time spent i n perform-  i n g a p a r t i c u l a r a c t i v i t y i s very u n l i k e l y to vary much i n the s h o r t or medium term.  D i r e c t o r s and s u p e r v i s o r s need to  78  be  aware o f any changes t h a t  only  intermittent recording  regular ies  do o c c u r . o f nursing  and c o m p r e h e n s i v e r e c o r d i n g  i s t h u s an u n n e c e s s a r y  For their  time i s r e q u i r e d .  o f time  feature  purposes,  spent  of activity  The  in activit-  recording  systems.  4.3.5.  Place  of service  Many a c t i v i t i e s , services, the  office  take p l a c e  recorded  by t h e i r v e r y  nature,  e.g. s c h o o l  i n a p a r t i c u l a r l o c a t i o n , e.g. s c h o o l ,  o r a t home.  T h e p l a c e where s e r v i c e s  are provided  is  g e n e r a l l y n o t r e c o r d e d , and may t h u s be i n f e r r e d n o t t o  be  relevant.  4.4.  Discussion  o f systems  objectives  Although the wording o f the o b j e c t i v e s uses o f t h e systems v a r i e d ,  there  T h e s e c a n be s e e n i n T a b l e 4.2 Objectives  c a n be s t a t e d  and  intended  were some common o b j e c t i v e s .  (p. 7 9 ) . i n d i f f e r e n t ways.  For the  p u r p o s e s o f measurement, o b j e c t i v e s n e e d t o b e o p e r a t i o n a l l y defined.  Measurement i s i n v o l v e d  whether o r n o t o b j e c t i v e s not  be u n a m b i g u o u s l y  c a n n o t be m e a s u r e d .  i n the process o f evaluating  h a v e b e e n met.  I f objectives  translated into operational Whether o r n o t o b j e c t i v e s  t h e n becomes a l t o g e t h e r  a matter of s u b j e c t i v e  terms,  canthey  are being  met  judgement.  J u d g e m e n t s on a s y s t e m ' s p e r f o r m a n c e i n m e e t i n g i t s o b j e c t i v e s may d i f f e r  according  to i n d i v i d u a l s ' perspectives  on a c t i v i t y  79 A l t a \ B.C.\  ManJ  N.B./  Ont./ P E I / Fd.Gvt,  T a b l e 4.2 Obj e c t i v e s 1.  To p r o v i d e d a t a which can be used as a b a s i s f o r r e q u e s t i n g f u n d i n g for services.  2.  X  X  To p r o v i d e d a t a t o a s s i s t i n d e t e r mining s t a f f i n g p a t t e r n s / c a s e l o a d s .  X  X  3.  To p r o v i d e d a t a t o a s s i s t i n p r o gram p l a n n i n g  X  4.  To compile s t a t i s t i c s f o r s e l e c t e d n u r s i n g s e r v i c e s by a u n i f o r m method  5.  X  X  X  X  X  X  To p r o v i d e uses w i t h d a t a f o r companies  X  X  6.  To p r o v i d e d a t a t o a s s i s t i n p r o gram e v a l u a t i o n  X  7.  To p r o v i d e d a t a f o r annual r e p o r t s o r i n response t o s p e c i a l r e q u e s t s re s e r v i c e s  8. 9. 10.  11.  X  X  To p r o v i d e d a t a t o measure the e x t e n t o f programs  X  X  To p r o v i d e d a t a t o a s s i s t i n d e t e r m i n i n g the c o s t / c o s t - e f f e c t i v e n e s s o f programs  X  X  To p r o v i d e d a t a f o r e v a l u a t i n g effort  To measure and d e s c r i b e the output o f the n u r s i n g s e r v i c e  12.  To a n a l y z e s t a t i s t i c s c o l l e c t e d by p r o v i n c e , r e g i o n and h e a l t h u n i t / department  13.  To p r o v i d e c o n s u l t a n t s w i t h d a t a t o monitor a c t i v i t i e s  14.  To p r o v i d e a b a s i s f o r d e c i s i o n maki n g i n community h e a l t h n u r s i n g activities  15.  To p r o v i d e d a t a t o a s s i s t i n management  16.  X  To p r o v i d e d a t a f o r an o p e r a t i o n a l performance measurement system  X  X  X  X  X  X  X  X  80  recording. O b j e c t i v e 2 i n Table 4.2  does not c l a r i f y how  data are to be used i n determining s t a f f i n g . of determining s t a f f i n g i n s e c t i o n 2.4.2 nature o f t h i s task.  Family needs was  activity  The d i s c u s s i o n  o u t l i n e d the complex i d e n t i f i e d as the major  f a c t o r r e q u i r e d i n determining s t a f f i n g .  More than any  f a c t o r , the need prevalence o f a p o p u l a t i o n w i l l  other  determine  the s e r v i c e s and s t a f f i n g r e q u i r e d . A c t i v i t y data are an i n v e n t o r y of s e r v i c e s p r o v i d e d . are not an i n d i c a t o r of what was  needed, how  They  needs were  met,  what s e r v i c e s were i n s u f f i c i e n t , or which were e x c e s s i v e . These judgements r e q u i r e more comprehensive i n f o r m a t i o n . formation i s needed about the p o p u l a t i o n to be served,  In-  the  s e r v i c e s being p r o v i d e d , and the c h a r a c t e r i s t i c s of s e r v i c e providers.  A c t i v i t y data may  but t h i s w i l l depend upon how  be used i n determining  much and what other data are  available.  I t w i l l a l s o depend on the s t a f f i n g  being used,  and how  are made e x p l i c i t ,  they are a p p l i e d .  methodologies  Unless these  there i s no c l e a r way  whether o b j e c t i v e 2 i s being  staffing,  factors  of determining  met.  O b j e c t i v e 3 i s s t a t e d i n s i m i l a r l y vague and n o n o p e r a t i o n a l terms.  Unless the process of program p l a n n i n g i s more e x p l i -  c i t l y d e s c r i b e d , there i s no way o b j e c t i v e 3 i s being Requesting  o f measuring whether or not  met.  funding f o r s e r v i c e s r e q u i r e s p r e d i c t i v e  about s e r v i c e s to be p r o v i d e d .  P r o j e c t e d s e r v i c e s may  data be  81  based on h i s t o r i c a l data from a c t i v i t y r e c o r d i n g . for  funding  need to be based on p r o j e c t e d  Requests  s e r v i c e s , and  not  on the h i s t o r i c a l data used to o b t a i n these p r o j e c t i o n s . Objective  1 i s thus s t a t e d i n an i n a p p r o p r i a t e  and  non-  o p e r a t i o n a l manner. On  the other hand, o b j e c t i v e s 4 and  5 are s t a t e d i n such  terms t h a t t h e i r achievement can be measured.  However,  whether or not o b j e c t i v e s are achieved does not r e l a t e to whether or not  the system's output w i l l be u s e f u l .  ample, the system may f o r use how  s a t i s f y o b j e c t i v e 5,  i n comparisons.  and provide  exdata  But no g u i d e l i n e s are given as  or what kinds of comparisons are to be made.  such as 4,.'i5ctor 13,  For  to  Objectives  are s t a t e d i n such simple terms as to  of no v a l u e i n determining the u s e f u l n e s s  of the  be  data  gathered by the system. An example o f an o b j e c t i v e t h a t can be measured i s o b j e c t i v e 16 i n T a b l e 4.2.  operationally  The  o p e r a t i o n a l per-  formance measurement system used by the f e d e r a l government i s c l e a r l y o u t l i n e d i n the Health  and Welfare Canada p u b l i c a t i o n ,  Performance Measurement System. data that are r e q u i r e d .  T h i s system i d e n t i f i e s  Objective  16 thus provides  of an o b j e c t i v e which r e l a t e s to a c l e a r l y d e f i n e d which i n t u r n determines e x a c t l y what data are  operationally  the model process,  required.  To act as r e a l i s t i c g u i d e l i n e s to the use of the o b j e c t i v e s need to be c l e a r l y and  the  data,  defined.  Only once t h i s i s done i s i t f e a s i b l e to determine i f the  82  data being gathered are adequate to perform the f u n c t i o n s f o r which they are intended.  Most of the o b j e c t i v e s i n Table  4.2  are s t a t e d i n such broad and n o n o p e r a t i o n a l terms, t h a t i t i s not p o s s i b l e to even i n v e s t i g a t e i f the data being are adequate i n terms of these o b j e c t i v e s . some o b j e c t i v e s , adequate data may objectives.  gathered  In the case of  be gathered to meet the  But these o b j e c t i v e s are s t a t e d i n such vague  terms t h a t the u s e f u l n e s s of the gathered data remains questionable.  4.4.1  O p e r a t i o n a l ^ !e a t u r e s Table 4.3  (p. 83) c o n t a i n s o p e r a t i o n a l f e a t u r e s o f  systems t h a t are o f i n t e r e s t .  I t shows the r e g u l a r i t y w i t h  which: 1.  forms are completed,  2.  r e p o r t s are  and  compiled.  I t d i s t i n g u i s h e s between:  4.5  3.  manual and computer systems, and shows the  4.  units  (areas) by which data are  compiled.  Special features There are d i f f e r e n c e s and v a r i a t i o n s between the systems  examined.  Other  than the c o m p u t e r i z a t i o n of the A l b e r t a and  Ontario systems, there are o n l y two be unique.  These are:  f e a t u r e s t h a t appear to  83  Table  Alta.  4.3  /B.C. /Man.  /N.B. /Ont. / P E I /Fd.Gvt.  O p e r a t i o n a l Features o f Systems 1.  Forms  completed:  weekly  Reports  X  compiled;  Weekly X  X  year-to-date  X  X  X  X  Computerized  X  X  X X  X  compiled:  by o f f i c e / h e a l t h  unit  X  by r e g i o n by p r o v i n c e  Note:  X  X  Manual t a b u l a t i o n  Data  X X  other  4.  X  X  monthly  3.  X  X  X  X  monthly  2.  X  X  daily  Table 4.3 was may  X  X  X  X  X  X  X X X  X  compiled from data submitted.  be c e r t a i n omissions i n the t a b l e , e.g.  There data  compiled by r e g i o n , as c e r t a i n o p e r a t i o n a l f e a t u r e s may  not have been e x p l i c i t y d e a l t w i t h i n a v a i l a b l e  information.  84  1.  the method o f r e c o r d i n g type of s e r v i c e and s e r v i c e r e c i p i e n t s i n Manitoba, and  2.  the f e d e r a l government method of c a l c u l a t i n g performance measurement i n d i c a t o r s .  4.5.1  Manitoba For each s u b j e c t grouping, the most a p p r o p r i a t e  age  spans are used to c l e a r l y i d e n t i f y the s e r v i c e r e c i p i e n t s . T h i s system c o n t a i n s the l a r g e s t number of age spans.  It i s  a l s o the o n l y system w i t h these o v e r l a p p i n g age c a t e g o r i e s . I n d i v i d u a l c o n t a c t s are recorded a c c o r d i n g to whether the c o n t a c t was care nature.  o f a h e a l t h promotion or d i r e c t n u r s i n g  T h i s system i s the only one to d i s t i n g u i s h i n  t h i s way between h e a l t h promotion and d i r e c t n u r s i n g care.  4.5.2  The f e d e r a l government performance measurement system The d e s c r i p t i o n o f the system g i v e n i n t h i s s e c t i o n i s  based on the H e a l t h and Welfare Canada document, Performance Measurement System. Investment time i s viewed as r e s o u r c e u t i l i z a t i o n i n the p r o d u c t i o n o f an accomplishment.  Although each accomp-  lishment w i l l not have the same investment time, i t i s f e l t that an average investment time per accomplishment  can be  85  determined.  T h i s f a c t o r i s c o n s i d e r e d the w e i g h t i n g f a c t o r  i n determining the monthly weighted  workload.  Performance measurment i n d i c a t o r s can be c a l c u l a t e d f o r e f f i c i e n c y , e f f e c t i v e n e s s and percentage investment.  Effic-  i e n c y i n d i c a t o r s measure the r a t i o of accomplishment  produced  to the investment time consumed i n t h e i r p r o d u c t i o n . e.g.  „ .. , r-r.. . t o t a l weighted workload Operational e f f i c i e n c y = i investment t  o  t  a  E f f e c t i v e n e s s r e l a t e s to how w e l l one i s a c h i e v i n g set g o a l s . e.g.  „ , .ce . . Operational effectiveness =  accomplishments *_ obj e c t i v e s .  T h i s r a t i o o b v i o u s l y cannot be c a l c u l a t e d i n the absence o f quantifiable  objectives.  Percentage investment i n d i c a t o r s can be c a l c u l a t e d f o r major s e c t i o n s o f o c c u p a t i o n a l h e a l t h n u r s i n g .  These  indica-  t o r s permit management to determine the l e v e l s o f investment f o r each o f the areas concerned.  Investment  a l l o c a t i o n great-  er than or l e s s than a predetermined v a r i a n c e range can i n d i cate that some management d e c i s i o n i s r e q u i r e d .  I t i s stated  that these i n d i c a t o r s g i v e a t a n g i b l e f i g u r e to what i n the past has been an i n t a n g i b l e gut  feeling.  The l o g i c i n h e r e n t i n the above statement needs to be explored. The d e s c r i p t i o n o f the performance measurement system i m p l i e s that determining a v a r i a n c e range f o r percentage  86 investment i n d i c a t o r s makes the management process more r a t i o n a l , or s c i e n t i f i c .  T h i s i s not so.  A v a r i a n c e range  does put concrete bounds around some c a l c u l a t e d But a v a r i a n c e range can o n l y be determined from  average. intuition,  knowledge from experience, or what i s r e f e r r e d to as i n t a n g i b l e gut f e e l i n g .  There i s no s c i e n t i f i c method o f s e t t i n g  such v a r i a n c e ranges without the express judgement of the i n d i v i d u a l s e t t i n g the range.  In s e t t i n g l i m i t s ,  the i n d i v i d -  u a l must apply h i s or her understanding of the s i t u a t i o n ,  an  act as a d i a g n o s t i c i a n . S i m i l a r l y , e f f i c i e n c y and e f f e c t i v e n e s s i n d i c a t o r s p r o v i d e measures r e l a t i n g to s e r v i c e p r o v i s i o n , but  individ-  u a l judgement i s i n h e r e n t l y i n v o l v e d i n i n t e r p r e t i n g measures.  may  these  I t i s f a l l a c i o u s to assume that any degree of  i n t r i c a t e or e l a b o r a t e c a l c u l a t i o n can e l i m i n a t e the essenti a l l y judgemental nature of the i n t e r p r e t a t i o n of a c t i v i t y statistics.  4.6  Summary of a c t i v i t y r e c o r d i n g systems reviewed The o b j e c t i v e s , o p e r a t i o n a l aspects and s e l e c t e d  feat-  ures of a c t i v i t y r e c o r d i n g systems across Canada have been reviewed. As o u t l i n e d i n Chapter 2, the need f o r these systems i s to p r o v i d e data a t the management and s t r a t e g i c p l a n n i n g levels.  Thus, the i n t e n t of such systems i s to gather data  to meet these needs.  The o b j e c t i v e s may  be seen as a more  87  concrete  expression of  Generally, and  the  to assess  whether  the  essential  The the  argued was  system  for  They  systems.  systems  cannot  are  be  translated  This being  the  i f these  objectives  a r e b e i n g met,  gathered be  are  case,  or  i t i s not  expressed  distribution  time  spent  or  appropriate. i n terms  or not  even  are  objectives  gathered.  in particular  o f n u r s e s , was  feas-  It is that  i f appropriate data are being  f o r d a t a oh  vaguely  activities,  discussed. spent  in  It  was  activit-  unnecessary. outputs  and  were examined.  the the  the  t h a t the r e g u l a r r e c o r d i n g of time  The  with  of  these  d e f i n a b l e to measure whether  need time  of  terms.  that objectives  a r e b e i n g met,  ies  objectives  data being  operationally  and  intent  nonoperationally defined.  i n t o measurable ible  the  data,  and  of  Whatever  the  federal  calculations  government are  i t i s e v i d e n t t h a t t h e r e a r e no  individual  interpret  workings  judgement of  work w i t h these  the person  data.  who  performed  substitutes must  finally  88  CHAPTER 5 5.1  Case study o f the A l b e r t a community n u r s i n g  activites  r e c o r d i n g system (ACNARS). In a d d i t i o n to the overview o f the systems  presented  i n Chaper 4, i t i s i l l u s t r a t i v e and i n f o r m a t i v e t o examine a s p e c i f i c system i n g r e a t e r d e t a i l . helps  to p r o v i d e  An in-depth  study  a more comprehensive i n s i g h t i n t o the i s s u e s  that have been d i s c u s s e d . Community Nursing  In t h i s Chapter, the A l b e r t a  A c t i v i t i e s Recording System (A.C.N.A.R.S.)  w i l l be examined i n d e t a i l .  The d i s c u s s i o n i s based on a l l  a v a i l a b l e system s documentation, o f f i c i a l government o f 1  A l b e r t a p u b l i c a t i o n s , and my  personal  observations  during  May to August, 1978.  5.2  The o r g a n i z a t i o n o f community h e a l t h s e r v i c e s i n A l b e r t a There are twenty-nine g e o g r a p h i c a l  r e s p o n s i b i l i t y f o r community h e a l t h . as L o c a l Boards o f H e a l t h  i n Calgary  areas i n A l b e r t a with  These areas a r e known and Edmonton, and as  H e a l t h U n i t s i n the remaining twenty-seven j u r i s d i c t i o n s . Each one o f these h e a l t h agencies i s autonomous, being r e s p o n s i b l e to a l o c a l board made up o f r e p r e s e n t a t i v e s o f the communities w i t h i n i t s j u r i s d i c t i o n .  Board members are  appointed  from the e l e c t e d r e p r e s e n t a t i v e s on m u n i c i p a l  councils.  U n t i l 1973, h e a l t h agencies r e c e i v e d e i g h t y  cent o f t h e i r funding  per-  from the p r o v i n c i a l government and  89  twenty per cent from the m u n i c i p a l governments i n t h e i r A f t e r March 1973, the p r o v i n c i a l government assumed funding o f the h e a l t h  total  agencies.  T h i s funding mechanism g i v e s r i s e to an anomalous ation.  area.  situ-  H e a l t h agency o f f i c i a l s are r e s p o n s i b l e to a l o c a l  board f o r program d i r e c t i o n and emphasis.  The h e a l t h agency  board must i n t u r n j u s t i f y that program d i r e c t i o n and emphasis to the p r o v i n c i a l government i n order to o b t a i n  funds.  The c o n s u l t a n t s employed by L o c a l H e a l t h S e r v i c e s i n the Department o f S o c i a l S e r v i c e s and Community Health, have a r e s p o n s i b i l i t y to g i v e advice t h a t , i f f o l l o w e d , ought to r e s u l t i n the e f f e c t i v e and e f f i c i e n t  spending o f p u b l i c  However, because o f the autonomy o f the l o c a l h e a l t h the c o n s u l t a n t s have no a u t h o r i t y to enforce t h e i r  funds.  agencies,  advice.  The r e l a t i o n s h i p d e s c r i b e d i s o u t l i n e d i n F i g u r e  5.1.  (p. 90).  5.3  O r g a n i z a t i o n o f H e a l t h Agencies F i g u r e 5.2  (p. 91) o u t l i n e s the o r g a n i z a t i o n o f a t y p i -  c a l h e a l t h agency. Most h e a l t h agencies of h e a l t h , who board.  are d i r e c t e d by a medical  i s d i r e c t l y r e s p o n s i b l e to the h e a l t h agency  In a few agencies,  directors.  officer  Reporting  nurses have been appointed  as  to the d i r e c t o r are a n u r s i n g s u p e r v i -  sor, s e n i o r p u b l i c h e a l t h i n s p e c t o r , d e n t a l o f f i c e r s , and an administrative o f f i c e r .  Some h e a l t h agencies  have other  9,0  F i g u r e 5.1 The O r g a n i z a t i o n o f Cornmunicty H e a l t h Services i n Alberta  Minister  Community  T Consul|ation  Health  Services  IF I Program Justification  H e a l t h Agency  Health  Agency  Board  9 1  F i g u r e 5.2 The O r g a n i z a t i o n o f a T y p i c a l H e a l t h Agency  H e a l t h Agency Board  Director/Medical of Health  Senior Public Health Inspector  Senior  Nursing  Speech Therapist  Supervisor  Other, e.g. Nutritionist Den.Officer  Administrative Officer  Public  Officer  Community  Health  Health  Inspectors  Nurses  Speech Therapist  92  professionals health  s u c h as  speech p a t h o l o g i s t s , n u t r i t i o n i s t s  educators.  The  nursing  supervisor  o r more s t a f f n u r s e s who The  i s i n turn responsible  may  be  supervisor  and  experience,  the  agency.  a g e n c y may nursing  will  and  vary,  according  Thus, the n u r s i n g  limited  the h e a l t h  agency.  common t o a l l l o c a l h e a l t h 1.  m a t e r n a l and  2.  school  3.  communicable  health,  family planning  the  health.  In keeping w i t h  the  province  before  this  time).  t h e most  major n u r s i n g fall  f o r nurses  are  nutrition  a philosophy  areas  family and  of:  p r o g r a m was  this  been o p e r a t i n g program,  mental  s e r v i c e s to  implemented  the  life  general  of prevention,  in providing  ( i t had In  visible  programs,  i n t o the  o f h a n d i c a p p e d c h i l d r e n and  Home C a r e  i n 1978  the  control.  clinics,  b e c o m i n g more i n v o l v e d The  t o manage  and  fitness,  citizens.  health  health,  disease  registry  d i r e c t o r of  i n a given  i s probably The  Other areas of involvement education,  background  the  t o how  the  authority.  agencies,  child  of  to  in Alberta  community h e a l t h n u r s e  employee o f  to her  supervisor  have c o m p l e t e d i s c r e t i o n as  Community h e a l t h n u r s i n g  one  located i n several sub-offices.  t h e management s t y l e  program, or o n l y  The  are  for  degree o f independence i n d e c i s i o n making g i v e n  nursing  5.4  and  nurses senior  throughout  i n some a g e n c i e s  local health  agency  93 c o - o r d i n a t e s a program o f d i r e c t n u r s i n g care i n the home, a c c o r d i n g to treatment All  p r e s c r i b e d by a p h y s i c i a n .  community h e a l t h nurses  a r e members o f the p r o v i n -  c i a l n u r s i n g a s s o c i a t i o n , which l i c e n s e s them to p r a c t i c e . There i s a S o c i e t y o f Community H e a l t h Nurses. a c t s as a spokesman f o r the nurses,  arranges  This society  f o r continuing  education, r e a c t s to documents and developments i n the h e a l t h care f i e l d ,  and prepares  p o s i t i o n s and b r i e f s on b e h a l f o f  community h e a l t h nurses.  S i m i l a r l y , there i s a S o c i e t y o f  Community H e a l t h Nursing  Supervisors.  Each p r o v i n c i a l c o n s u l t a n t i n community h e a l t h n u r s i n g has r e s p o n s i b i l i t y f o r c o n s u l t i n g to a number o f h e a l t h u n i t s i n a g i v e n g e o g r a p h i c a l area. ist  Each ^ c o n s u l t a n t i s a s p e c i a l -  i n a t l e a s t one p a r t i c u l a r f i e l d ,  care, p r e - s c h o o l o r g e r i a t r i c care.  such as m a t e r n a l - c h i l d The c o n s u l t a n t s a l s o  r e p r e s e n t the i n t e r e s t s o f community h e a l t h n u r s i n g to nursing  educators,  p r o f e s s i o n a l groups, other government  depart-  ments , other p r o v i n c e s and s p e c i a l groups which may be charged w i t h developing province-wide  5.5  5.5.1  standards  o f care.  Background to the i n t r o d u c t i o n o f A.C.N.A.R.S.  The need f o r A.C.N.A.R.S. P r i o r to A.C.N.A.R.S., nurses were u s i n g the P u b l i c  H e a l t h Nurses' Report form t o r e c o r d t h e i r d a i l y The  activities.  s t a t e d purposes o f the r e p o r t p r o v i d e an i n s i g h t  into  94  the i n t e n t o f t h i s form. 1.  The purposes were:  to p r o v i d e a r e c o r d o f p u b l i c h e a l t h n u r s i n g s e r v i c e s and t o g i v e a b a s i s f o r compiling t o t a l s o f s e r v i c e by area,  2.  to p r o v i d e f o r a v a l i d a p p r a i s a l o f the program and to a s s i s t i n p l a n n i n g ,  3.  to p r o v i d e f a c t u a l i n f o r m a t i o n which may then be used when r e p o r t i n g to l o c a l Boards o f H e a l t h , and  4.  to p r o v i d e  i n f o r m a t i o n to the s u p e r v i s o r which  w i l l a s s i s t her to guide and evaluate each nurse. One  o f the f e a t u r e s o f the form was t h a t a d d i t i o n a l informa-  t i o n c o u l d be recorded under a s e c t i o n c a l l e d Remarks. I t i s evident t h a t the r e p o r t was intended  to gather  data t h a t c o u l d be used , p r i m a r i l y i n managerial c o n t r o l . To a l e s s e r extent,  the data c o u l d a l s o be used i n s t r a t e g i c  p l a n n i n g and p o l i c y formation. i z e d throughout the p r o v i n c e ,  Reporting was not standardand data were not gathered by  the Department f o r the p r o v i n c e as a whole. The  r e p o r t was intended as a r e c o r d o f d i r e c t s e r v i c e s  to the community. nurses had spent  I t was n o t intended t h e i r time each day.  as a r e c o r d o f how Some h e a l t h u n i t s  f e l t t h a t the form was adequate, but there was g e n e r a l l y s t r o n g f e e l i n g t h a t the r e p o r t was inadequate to meet i t s i n tended purposes.  I t was unpopular i n many agencies,  been d i s c o n t i n u e d i n at l e a s t one h e a l t h u n i t .  and had  Complaints  95 about the form were d i r e c t e d at i t s complexity,  the wide  v a r i e t y of i n t e r p r e t a t i o n s p o s s i b l e f o r d i f f e r e n t items,  and  the time needed to complete the form on a monthly b a s i s . form was not be  a l s o i n f l e x i b l e as to what s e r v i c e s c o u l d or  The  could  reported.  The  h e a l t h u n i t n u r s i n g records  w i t h reviewing  record-keeping  committee was  mechanisms i n use, working t o -  wards the s t a n d a r d i z a t i o n o f r e c o r d s , type and  entrusted  and  identifying  the  amount of i n f o r m a t i o n t h a t should be r e p o r t e d  l o c a l h e a l t h s e r v i c e s f o r management purposes.  The  to  nurses  r e p o r t form f o r p u b l i c h e a l t h nurses f e l l w i t h i n t h e i r  juris-  diction . During the summer of 1976,  the n u r s i n g records  committee  completed a review o f a l l p r o v i n c i a l n u r s i n g records community h e a l t h nurses.  According  input from h e a l t h u n i t s and  for  to the committee,  the  the c i t y boards of h e a l t h  cated c l e a r l y t h a t the nurses r e p o r t form was  indi-  i n need of  major r e v i s i o n .  The members of the committee f e l t t h a t a  new  necessary.  approach was  They p e r c e i v e d  a need f o r a  more p r e c i s e t o o l f o r g a t h e r i n g n u r s i n g program At t h a t time (1976), the development of an system f o r l o c a l h e a l t h s e r v i c e s was Department.  A new  information  under d i s c u s s i o n i n the  r e p o r t i n g format was  the scope of t h i s development.  statistics.  seen to f a l l  within  96  5.5.2  P l a n n i n g and development  o f A.C.N.A.R.S.  The need f o r a new approach having been  identified,  three members o f the n u r s i n g r e c o r d s committee  visited  Toronto i n January, 1977, to l e a r n about the O n t a r i o n u r s i n g activities  system.  The O n t a r i o system was regarded as one  which c o u l d be used as a model f o r the system i n A l b e r t a . The n u r s i n g records committee 1977,  r e s o l v e d i n February,  that a computerized n u r s i n g a c t i v i t i e s  reporting  system based on the O n t a r i o model be developed and i n t r o duced as soon as p o s s i b l e .  A r e p o r t on the v i s i t  to O n t a r i o  i d e n t i f i e d the i s s u e s that would have to be d e a l t w i t h . r e p o r t a l s o noted the uses o f the system, p o t e n t i a l  The  problems  that might be encountered, and a broad time frame f o r the development,  t e s t i n g and implementation o f the system.  The  p r o p o s a l f o r the envisaged system was to be c i r c u l a t e d to various f i e l d personnel.  I t was hoped that t h e i r  would be an important input i n the development  feedback  and m o d i f i c a -  t i o n o f the system. During the f i r s t h a l f o f 1977, new r e p o r t forms were developed by the committee.  Although the O n t a r i o system  was i n i t i a l l y used as a model,  some o f the f e a t u r e s o f the  new form were q u i t e d i f f e r e n t from the O n t a r i o  model.  The i n t e n t o f the system was to p r o v i d e data that could be used i n managerial c o n t r o l and s t r a t e g i c p l a n n i n g .  While  there a r e broad statements o f i n t e n t , there does n o t appear to  be any documented evidence o f c l e a r l y s t a t e d and d e t a i l e d  o b j e c t i v e s f o r the system.  There was no documented evidence  97  c o n t a i n i n g g u i d e l i n e s o f how the data gathered could be used to achieve The  the purposes f o r which the system was  form was developed i n a format t h a t would allow f o r  the computerization was  intended.  considered  o f the data gathered.  Computerization  to be time saving, and thus cost saving.  There  i s no evidence t h a t t h i s assumption was t e s t e d , or that any type o f s u b s t a n t i v e was  c o s t - b e n e f i t a n a l y s i s was performed.  It  a l s o f e l t t h a t the computer r e p o r t s t h a t c o u l d be  produced would make the r e p o r t i n g system a more powerful tool. At the same time as forms were being d e t a i l e d i n s t r u c t i o n manual, was  drawn up.  covering  developed, a  the use o f the system,  T h i s i n v o l v e d d e c i d i n g upon s u b j e c t  categories,  d e f i n i n g these s u b j e c t c a t e g o r i e s , and d e s c r i b i n g i n d e t a i l how the forms were to be completed. plicitly, validity.  with  T h i s process  the problems o f accuracy,  d e a l t im-  r e l i a b i l i t y and  A t no time do these i s s u e s appear to have been  s p e c i f i c a l l y mentioned or e x p l i c i t l y ,  d e a l t with.  R e g i o n a l meetings were h e l d throughout the province i n June, 1977, f o r medical o f f i c e r s o f h e a l t h , and f o r s u p e r v i sors and d i r e c t o r s o f community h e a l t h n u r s i n g .  T h i s was to  f a m i l i a r i z e them w i t h the proposed forms, and o b t a i n feedback.  The f i r s t  their  f i e l d t e s t i n g o f the new form and  i n s t r u c t i o n manual was done i n the Wetoka H e a l t h U n i t and Edmonton during September, 1977. The d i f f i c u l t i e s and concerns encountered were noted, and m o d i f i c a t i o n s were made  98  to the form and the r e c o r d i n g manual. field  trials,  i n November, 1977,  in 5 health units.  Field  preceded by one  trials,  further  incorporated.  Implementation  o f A.C.N.A.R.S.  In those h e a l t h u n i t s where f i e l d h e l d , a one day i n t e n s i v e workshop was i n the u n i t .  day's  f o r the p a r t i c i p a t i n g f i e l d  A f t e r the second s e r i e s o f f i e l d  r e v i s i o n s were  5.5.3  took p l a c e i n Edmonton and  t e s t i n g was  i n t e n s i v e i n - s e r v i c e education staff.  The second s e r i e s o f  T h i s was  t e s t i n g had not been h e l d f o r a l l nurses  f o l l o w e d by one to two weeks p r a c t i c e  i n completing the forms.  A.C.N.A.R.S. was  introduced  in a l l  h e a l t h u n i t s , and both c i t y l o c a l boards o f h e a l t h , from the f i r s t week o f January,  1978.  The three month p e r i o d , January to March, 1978, was f o r seen as a debugging p e r i o d , during which e r r o r s would have to be c o r r e c t e d .  A h i g h e r r o r r a t e was  expected, although ex-  p e c t a t i o n s were not expressed i n q u a n t i t a t i v e . t e r m s . the f i r s t month o f f u l l o p e r a t i o n , the computer r e p o r t . c l i n e d considerably, a f t e r March,  Thereafter,  During  114 e r r o r s were l i s t e d on the number o f e r r o r s de-  to a monthly average of l e s s than 20,  1978.  I n i t i a l l y , monthly, q u a r t e r l y and annual computer r e p o r t s were produced and c i r c u l a t e d .  Each h e a l t h u n i t and  board o f h e a l t h r e c e i v e d a copy o f t h e i r own  city  statistics.  Copies o f the data f o r a l l h e a l t h agencies are kept by L o c a l  99  Health Services.  The  s t a t i s t i c s o f each h e a l t h u n i t are r e -  garded as c o n f i d e n t i a l . T h i s c o n f i d e n t i a l i t y of t i o n was  informa-  an express c o n d i t i o n by some h e a l t h u n i t s f o r t h e i r  involvement i n the r e p o r t i n g system.  I f the data were con-  f i d e n t i a l , h e a l t h u n i t s would not be s u b j e c t to p o t e n t i a l l y unfavourable comparisons w i t h other u n i t s .  Local  Health  S e r v i c e s a l s o r e c e i v e a copy of p r o v i n c e wide t o t a l s . A f t e r the f i r s t records  s i x months of o p e r a t i o n ,  committee decided  to d i s c o n t i n u e  T h i s was  done i n response to requests  who  that they were being  felt  the  nursing  the monthly r e p o r t s .  by f i e l d  personnel,  swamped by a mass of data  too  l a r g e f o r them to handle. During A p r i l ,  1978,  a workshop was  of l o c a l h e a l t h agencies,  and  community h e a l t h n u r s i n g .  held for directors  d i r e c t o r s and  supervisors  T h i s workshop covered the  of  inter-  p r e t a t i o n and u t i l i z a t i o n o f computer r e p o r t s , e s p e c i a l l y those from A.C.N.A.R.S.  The nurses r e p o r t forms: 1 and  5.6 5.6.1  Form ho. The  2  1  nurses weekly a c t i v i t i e s r e p o r t  (Figure 5.3,  p. 103)  c o n s i s t s of f i v e s e c t i o n s . In the f i r s t and  s e c t i o n , on i d e n t i f i c a t i on,  sheet number are noted.  identify: - the agency,  the year, week  T h i s s e c t i o n i s a l s o used to  100 - the o f f i c e / s u b - o f f i c e , - the nurses f u n c t i o n , - her c l a s s i f i c a t i o n - individual  ( e d u c a t i o n a l p r e p a r a t i o n ) , and  identification.  S e c t i o n 2 r e c o r d s time a l l o c a t i o n by program; the recorded i s a c t u a l l y noted service recipients.  a c c o r d i n g to the age group of  There are 6 age groups.  Time spent i n  t r a v e l , s e l e c t e d l o c a l o p t i o n s , c l e r i c a l work and others i s a l s o recorded. gathered;  training  Time data are the only new  the other s e c t i o n s are a l l adaptations o f  t i o n p r e v i o u s l y gathered.  time  data informa-  The number o f home v i s i t s i s  recorded. S e c t i o n 3 records data on group - the age  activities:  code of the group,  - number of persons  i n the group,  - the s u b j e c t , and - the time spent  ( i n c l u d i n g p r e p a r a t i o n time) i n  the group a c t i v i t y . In s e c t i o n 4, i n d i v i d u a l c o n t a c t s , e i t h e r i n person  or  by phone, are recorded a c c o r d i n g to the s u b j e c t d e a l t with, and the age of the i n d i v i d u a l  contacted.  In the f i f t h s e c t i o n , s c r e e n i n g s , assessments and  treat-  ments are recorded a c c o r d i n g t o : - age  group,  - the number w i t h i n the age group screened, or t e s t e d , and  assessed  101  - the number o f those screened f o r whom f u r t h e r action i s required. The age and s u b j e c t coded f o r the d i f f e r e n t  sections  are shown on the r e v e r s e o f the r e p o r t form (Table 5.1, p. 104).  5.6.2  Form no. 2 The second form, which has 4 s e c t i o n s , i s f o r c l i n i c  attendance, t u b e r c u l o s i s c o n t r o l , and immunization 5.4  p. 105). The f i r s t  tion.  (Figure  s e c t i o n , as i n form no. 1, i f f o r i d e n t i f i c a -  There i s a d d i t i o n a l room t o i d e n t i f y the c l i n i c . The second s e c t i o n r e c o r d s c l i n i c attendance by: - age, - persons immunized, - persons not immunized, - those 'new', and - t o t a l attendance f o r a.m.,  p.m. or evening.  Recording i n the l a s t 2 c a t e g o r i e s i s o p t i o n a l . In s e c t i o n 3, f o r t u b e r c u l o s i s c o n t r o l , mantoux screening i s recorded - by grade, - by age, - by number t e s t e d , and - the number o f p o s i t i v e r e a c t o r s , f o r both no BGG and p r e v i o u s BCG. BCG r e c o r d s note the age and number v a c c i n a t e d :  102 S e c t i o n 4 r e c o r d s the f o l l o w i n g data on immunizations: - the age o f persons  immunized,  - the immunizing agent, and - the number o f doses a d m i n i s t e r e d . Schick t e s t i n g and immune serum g l o b u l i n are a l s o r e corded i n t h i s  5.6.3  section.  The output: forms 1 and 2 Once the data have been computer  coded, a v a r i e t y o f  r e p o r t s can be produced f o r each s e c t i o n .  Data can be ag-  gregated, o r d i s a g g r e g a t e d , a c c o r d i n g to the c a t e g o r i e s by which they have been c o l l e c t e d .  For example,  data gathered i n  s e c t i o n 3 o f form no. 1 can be used t o produce r e p o r t s showi n g the number o f persons a t t e n d i n g group a c t i v i t i e s and time i n group  activities:  1.  by o f f i c e , age, and s u b j e c t ,  2.  by age and s u b j e c t ,  3.  by subj e c t ,  4.  by o f f i c e , f u n c t i o n , age and s u b j e c t ,  5.  f o r each i n d i v i d u a l nurse.  S i m i l a r r e p o r t s can be produced f o r each s e c t i o n ; an example o f the r e p o r t s produced i s shown i n F i g u r e 5.5 (p. 106). S i m i l a r l y , the data gathered by form no. 2 can be aggregated or d i s a g g r e g a t e d a c c o r d i n g to the c a t e g o r i e s by which the data are c o l l e c t e d .  A v a r i e t y o f r e p o r t s can be produced  f o r each o f the s e c t i o n s o f t h i s form.  (These r e p o r t s were  103 F i g u r e 5.3  B S C H 140  NURSES WEEKLY ACTIVITIES REPORT  /dlberra  SOCIAL SERVICES AND COMMUNITY HEALTH  YEAR TIME ALLOCATION Mon.  WEEK  BY PROGRAM Tues.  Wed.  Thurs.  Fri.  Office Use Only 21 22  |  Infant Early Preschool  |  Late Preschool  | |  Adult  |  Geriatric  | * -,,.  1  |  2  |  •  Age 21  I  I  SCREENINGS.  I  I  I  ASSESSMENTS.  No. of Persons  1 1 1 1 I  1 1 i i i i i i i i i  |  Training Others  Persons!  GROUP  |  Clerical  **>  III.  |  Travel  No. of Homes Visited  1.0. No.  I  School  Local Option  SHEET  | 44  i 21  TREATMENTS  1 1I I 1 I 1 I I ACTIVITIES  Subject  IV.  Hours  Age 21  INDIVIDUAL Subject 23  I  I  CONTACTS Age 21  Subject 23  |  |  | | | | | | |  | | |  | |  | |  | |  | |  |  |  | | | |  | |  |  |  27  | | | | | | | | | |  |  |  |  |  |  |  | |  |  | | | | | |  | |  | |  |  | | | | | |  |  |  |  |  |  |  | | | | |  |  | |  |  | | |  |  | | | | I  | | |  |  | |  |  | | |  | 1  104 Table  5.1  -5-  CODING C O D E 1- AGE: (TARGET  POPULATION)  C O D E II - S U B J E C T  A  Infant (to 1 year)  10  Prenatal  B  E a r l y P r e s c h o o l (1 y e a r t o 4 . 5 y e a r s )  11  Neonatal  C  L a t e P r e s c h o o l ( 4 . 5 y e a r s t o G r a d e 1)  12  Postnatal  D  Grades 1 - 6  13 Well  E  Grades 7 - 9  14  F  Grades 10 - 12  1 5 O b s e r v a t i o n (at r i s k )  G  Special Education  16  H  Adult (General)  1  Adult (Occupational  J  Geriatric (65 - 74)  19  Family  K  G e r i a t r i c ( 7 5 +)  20  Family Life Education  L  Mixed Ages  21  Unwanted  22  Communicable  Health)  C O D E III • S C R E E N I N G . A S S E S S M E N T AND TREATMENT TYPES A  Audio  B  Blood Pressure  C  Communicable  D  Developmental  H  Health Assessment  P  Parasites  S  Speech  V  Vision  E  Bath  F  Catheterization  G  Dressing  J  Enema  K  Foot  L M  Care  Hemoglobin Irrigation  N  Oral Medication  R  Parenteral Medication  T  Suture  U  Therapeutic Exercise  W  Urinalysis  Removal  Y  Local  Option  Z  Local  Option  Parenting  Handicapped/Special Services  17  Child  18  Poison Control  Abuse  Planning  Pregnancy Disease  23 TB 24 V D 25  Disease  Child  Chronic  Disease  26  Mental  Illness  27  Mental  Health  28  Alcohol/Drugs  29  Smoking  30  Nutrition  31  Exercise/Fitness  32  Obesity  33  Safety  34  Retirement  35  Other  36  Social Services  Lifestyle  37  Home Care A s s e s s m e n t s  38  Home Care  39  Treatment  40  First A i d  41  Followup  Reassessments  42  General  43  Public Information/Consumer  44-50  Local  Health Information  Options  (JAN/78)  S S CH  1408  II  CUNC  TOTAL  ATTENDANCE  AM.  parson* not  A G E  1  P.M.  1  TEAR  1 0 Wo  1  2,0! TUBERCULOSIS SCREENING  0 • 1 yr. f r o m 1 ft. to 2 yr. other early preschool  •*«EK S H E E T  EVEN.  CONTROL  H  CD  (MANTOUX) N o . po«. raaclort no had BCG BCG  No. tasted  AGE  c  JL_L  AGE CODE*  no. poa. roaelora no had BCG BCG  no. tattad  grade 1  (  1st* preschool  grade 6  school ago  grade 9  edutt  grade 1 2  I  I  I  I  I  I  I  I  I  |  I  I  I  I  I  I  I  I  I  " u a a a a a c o d a , n u r s i n g a c t m t l a a raport f o r m  geriatric  IMMUNIZATION  CODE: D O S E S G I V E N a tat. 2nd. 3rd  R E I N F O R C I N G = fl DIPHTHERIA  2nd  R  1st  2nd  O  POLIO ISALK)  TETANUS  3rd  3rd  R  2nd  3rd  R  2! O  •  N >  IMMUNIZATION POLIO AGE  67  68  infant 0 to 1 yr. f r o m 1 yr. to 2 yr.  in  BUM L LA  (SABIN)  2nd  R  one dose  one dose  INflAJEHIA  SMALLPOX  P  TYPHOID HI  Ind  RABIES —  3rd  2nd  PRE  «-  R  70 71  17  preschool s c h o o l age  BO  1  74  1  Bl  1  75  1  62  1  ! !  76  adult geriatric  77  i ,  bf.a*. control  73  other 69  IMMUNE S E R U M GLOBULIN  EXPOSURE  3rd  7B  1  1  83  1  1  84  1  1  85  1  1  "i'.T  ©thor  i  i  (  •  !  1  1  1  1  1  i  !  O  AY 04, 1978 PAGE COMMUNITY NURSING A C T I V I T I E S SYSTEM 5A NO. OF SERVICES AND REFERRALS FROM S E C T I O N V BY O F F I C E , AGE AND SUBJECT FOUR WEEKLY • I T 817  «, 04  SUBJECT  DEVELOPMENTAL SCRN HEALTH ASSESSMENT V I S I O N SCREENING LATE  SEEN  7 13 2 22  W  GRADES  1 1  K  0  5  - °  WEEK 05-08  8  SUBJECT  BLOOD PRESSURE SCRN DRESSING HEALTH ASSESSMENT EARLY  50 20 13 2 56 141  9  24 33  1 - 6  AUDIO SCREENING DEVELOPMENTAL SCRN PARASITES SCREENING V I S I O N SCREENING  E  REFERRED  PRESCHOOL  AUDIO SCREENING DEVELOPMENTAL SCRN HEALTH ASSESSMENT SPEECH SCREENING VISION SCREENING  E  1978 PAGE COMMUNITY NURSING A C T I V I T I E S SYSTEM 5A NO OF S E R V I C E S AND REFERRALS FROM SECTION V BY O F F I C E , AGE AND S U B J E C T FOUR WEEKLY  45 6 2 53 106  4 1 5 9 16  1 15 16  1 4 5  13 4 17  1  ADULT (GENERAL) AUDIO SCREENING BLOOD PRESSURE SCRN GERIA  18 18  1 2  3 3 3 1 3  1 - 6  AUDIO SCREENING COMM D I S E A S E SCRN DRESSING HEALTH ASSESSMENT ORAL MEDICATION PARENTERAL MEDIC GRADES  7 - 9  ADULT ( G E N E R A L )  ( 7 5 +)  BLOOD PRESSUPE SCRN PARENTERAL MEDIC  2 5 1  AUDIO SCREENING BLOOD PRESSURE SCRN HEALTH ASSESSMENT  (65-74)  BLOOD FRESSURE SCRN GERIA  1  5 5  PRESCHOOL  AUDIO SCREENING DEVELOPMENTAL SCRN HEALTH ASSESSMENT SPEECH SCREENING V I S I O N SCREENING GRADES  AU0IO SCREENING V I S I O N SCREENING  1 i 11 14  REFERRED  PRESCHOOL  COMM D I S E A S E SCRN HEALTH ASSESSMENT HEMOGLOBIN LATE  SEEN  7 1 8 328 ,402  56 221  BLOOD PRESSURE SCRN DRESSING HEALTH ASSESSMENT HEMOGLOBIN ORAL MEDICATION PARENTERAL MEDIC URINALYSIS ADULT  (OCC H)  AUDIO SCREENING GERIA  8 1 12 3 4 4 2  1 1  (65-74)  HEALTH ASSESSMENT  J  GERIA ( 7 5 +) BLOOD PRESSURE SCRN URINALYSIS  2 1  7 2 2 11  107  not  available  5.7  a t the time o f t h i s  A.C.N.A.R.S.  5.7.1  study).  Form no. 1  Section 1 Due  to the way nurses a r e i d e n t i f i e d , data can be  produced a c c o r d i n g to the d i f f e r e n t fier.  f e a t u r e s o f the i d e n t i -  Data can be r e p o r t e d by: - agency, -  office/sub-office,  -  function,  - c l a s s i f i c a t i o n , or -  individual.  5.7.2.  S e c t i o n 2.  Time a l l o c a t i o n by program  Upon the i n t r o d u c t i o n  o f A.C.N.A.R.S., t h i s s e c t i o n  regarded as a p a r t i c u l a r l y n o v e l f e a t u r e . the  data from t h i s s e c t i o n  I t was f e l t  was  that  would be o f great use to s u p e r v i -  sors and d i r e c t o r s . This section allocation ulation  appears to be i n a p p r o p r i a t e l y named.  i s actually  Time  r e c o r d e d a c c o r d i n g to the age o f pop-  served, and some other n o n - c l i e n t contact a c t i v i t i e s  Time a l l o c a t i o n by program i s only measured where programs are  clearly directed  at those w i t h i n the p a r t i c u l a r age  c a t e g o r i e s used i n t h i s s e c t i o n .  I f any program i s aimed at  108 a p o p u l a t i o n t h a t b r i d g e s the age spans used, cannot measure time a l l o c a t i o n by program.  this  section  I f a number o f  programs are d i r e c t e d a t any o f the d e f i n e d p o p u l a t i o n s , then t h i s s e c t i o n i s unable d i v i d u a l programs.  to measure the time a l l o c a t e d to i n -  Instead, i n such cases, i t measures the  time a l l o c a t e d to a number o f programs. Time a l l o c a t i o n by age o f p o p u l a t i o n served may be an i n t e r e s t i n g f e a t u r e , but i t i s not a p a r t i c u l a r l y quantitative indicator of service delivered. in section 4 . 3 . 4 ,  helpful  As p o i n t e d out  a c t i v i t i e s may vary i n the time they r e q u i r e ,  and nurses may vary i n the time they r e q u i r e to perform vities .  acti-  Time spent on d i f f e r e n t age groups may bear no r e a l  r e l a t i o n s h i p to s e r v i c e s performed,  outcomes obtained, and  the e f f e c t i v e n e s s o r even e f f i c i e n c y o f nurses. One may post u l a t e some p o s i t i v e c o r r e l a t i o n between time spent and e f f e c t i v e n e s s , but the t r u e r e l a t i o n s h i p i s p r e s e n t l y w e l l beyond c a l c u l a t i o n . T h i s s e c t i o n does p r o v i d e a neat r e p o r t i n g format.  But  the r e l a t i o n s h i p between the data r e p o r t e d and processes, outcomes and programs i s so indeterminate, t h a t the data are of very l i t t l e use.  5.7.3.  S e c t i o n s 3 and 4 .  Group a c t i v i t i e s and i n d i v i d u a l  contacts. These s e c t i o n s p r o v i d e data very s i m i l a r to data by the other systems examined.  produced  109  5.7.4.  Section  This  5.  Screenings, assessments and  treatments  s e c t i o n a l s o notes where f u r t h e r a c t i o n i s r e q u i r e d .  Much o f the data i n t h i s s e c t i o n i s gathered by other systems. Yet  t h i s s e c t i o n p r o v i d e s a compact means of r e c o r d i n g  the  above a c t i v i t y types w i t h i n the same s e c t i o n . As r e p o r t s  from form no.  2 were not  of t h i s study, t h i s form i s not  5.8.  time  reviewed.  General d i s c u s s i o n on A.C.N.A.R.S.  5.8.1  Objectives The  was  a v a i l a b l e at the  need f o r a new  recording  i d e n t i f i e d i n summer, 1976.  c l e a r and  a new  ( s e c t i o n 5.5.1).  approach Yet,  as  to what data the form should c o l l e c t , or how  the  be used.  A r e p o r t f o l l o w i n g the v i s i t  to O n t a r i o  i n January,  s t a t e d the uses of the system as: A.  no  d e t a i l e d o b j e c t i v e s appear to have been s t a t e d  guidelines data may  form and  Local  level  1.  program p l a n n i n g  and  monitoring,  2.  s t a f f a l l o c a t i o n , monitoring r a t i o s ,  3.  budgeting,  4.  i n s e r v i c e planning  5.  r e p o r t i n g to boards on s e r v i c e s ,  based on program needs,  staff utilization, 6.  u t i l i z a t i o n of s e r v i c e s .  functions,  1977,  110  B.  Department  level  1.  budget a l l o c a t i o n , ,  2.  d e f i n e i n s e r v i c e and e d u c a t i o n a l needs r e l a t e d to programs,  3.  program needs,  4.  r e s e a r c h data and p l a n n i n g ,  5.  consultant  6.  r e p o r t i n g to government oh s e r v i c e s and  information,  functions 7.  data to promote changes i n u n i v e r s i t y / c o l l e g e programs to meet s e r v i c e and p r o f e s s i o n a l needs,  8.  data to s t i m u l a t 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 (standards,  The output  conferences,  research).  o f the system could be used as a t o o l i n  most o f the above a c t i v i t i e s .  Yet a c t i v i t y data a r e o n l y  one element among the many needed f o r the above Many other r e l e v a n t i n f o r m a t i o n sources  are required.  r e p o r t d i d not d e f i n e how the above processes performed, or the nature  process. The  were to be  o f the i n f o r m a t i o n r e q u i r e d .  The need f o r c l e a r l y d e f i n e d o b j e c t i v e s was noted i n a memorandum on the development p r o p o s a l f o r a h e a l t h u n i t program i n f o r m a t i o n system.  The memorandum was sent  May, 1976, by a c o n s u l t a n t i n Local, H e a l t h S e r v i c e s . stated that  during It  ... " i f the o b j e c t i v e s o f each program are n o t  d e f i n e d we can h a r d l y d e a l w i t h a management i n f o r m a t i o n system, but r a t h e r should c o n c e p t u a l i z e descriptive analysis."  a t the l e v e l o f  Ill  5.8.2  Assumptions I n f o r m a t i o n on a c t i v i t y r e c o r d i n g was  received I t was  (with one exception) from a l l  requested and  the other p r o v i n c e s .  decided to develop the forms u s i n g the system i n  O n t a r i o as a model.  In the r e p o r t on the v i s i t  to O n t a r i o ,  the a p p l i c a b i l i t y o f the O n t a r i o system to the A l b e r t a n s i t u a t i o n was  seen to depend upon both l o c a l and p r o v i n c i a l  h e a l t h a u t h o r i t i e s a g r e e i n g w i t h two assumptions.  These  were t h a t : 1.  i t i s n e c e s s a r y f o r management purposes at both the p r o v i n c i a l and l o c a l l e v e l s to r o u t i n e l y c o l l e c t , t a b u l a t e and r e p o r t comparable  statistics  on the n u r s i n g s e r v i c e s p r o v i d e d by each A l b e r t a local health authority. 2.  i t i s not f e a s i b l e to produce these s t a t i s t i c s  on  n u r s i n g s e r v i c e s at a s u f f i c i e n t l e v e l o f d e t a i l to meet management needs through a t r a d i t i o n a l manual r e p o r t i n g system (even i f s t a n d a r d i z e d across the p r o v i n c e ) , and t h e r e f o r e some compute r i z e d r e p o r t i n g system i s n e c e s s a r y . These two assumptions are fundamental to the system as i t was  developed.  Even though there was  some wariness i n  c e r t a i n q u a r t e r s about the i n t r o d u c t i o n o f a computerized system, these assumptions do not appear to have been  ser-  i o u s l y e v a l u a t e d at any stage. Routine c o l l e c t i o n , t a b u l a t i o n and r e p o r t i n g o f n u r s i n g  112  s t a t i s t i c s had been c a r r i e d out i n A l b e r t a and provinces  f o r many y e a r s .  these a c t i v i t i e s r e q u i r e constant  The  i m p l i e s that  monitoring.  t r a n s i t i o n to a computerized system was  i n n o v a t i o n , and  other  As p o i n t e d out i n s e c t i o n 3.3.2,  the r o u t i n e r e p o r t i n g of n u r s i n g a c t i v i t i e s  The  the  a major  a s u b s t a n t i a l change i n o p e r a t i n g  r a t i o n a l e f o r a computerized system was  be time saving, and more c o s t e f f i c i e n t  procedures.  t h a t i t would  i n the long run.  p o i n t e d out i n s e c t i o n 5.5.2, these claims do not to have been analyzed  As  appear  d u r i n g the development of the system.  N e i t h e r does the f e a s i b i l i t y o f a computerized as opposed to a manual t a b u l a t i o n system appear to have been i n v e s t i g a t e d . A computerized system i n v o l v e s time and c o s t s during i t s development, p l a n n i n g and has  implementation stages.  It also  a g r e a t e r need f o r data c o n t r o l c l e r i c a l s t a f f  time.  In  the l i g h t of these f a c t o r s , the c o s t argument needs to be c a r e f u l l y evaluated  5.8.3. One the new  i n i n t r o d u c i n g a computerized system.  Acceptance of the  system  of the major problems i d e n t i f i e d system was  t h a t of o b t a i n i n g acceptance f o r i t from  f i e l d and managerial s t a f f at the l o c a l based upon the advice o f those Ontario; f i e l d  support  systems based on two  level.  This  was  f a m i l i a r w i t h the system i n  f o r the system was  would i n v o l v e overcoming a n e g a t i v e  f o r other programs.  i n introducing  crucial.  This  a t t i t u d e towards computer  l e s s than s u c c e s s f u l systems  introduced  113  A very r e a l e f f o r t was the development process  made to i n v o l v e f i e l d  as much as p o s s i b l e .  staff in  T h i s was  also  done to a l l a y f e a r s t h a t the time r e c o r d would be used as a supervisory t o o l . was  The p o s i t i v e p o t e n t i a l o f the system  s t r o n g l y emphasized.  p r e s e n t l y spent The  process  Firstly,  The  savings  i n l o c a l s t a f f time  c a l c u l a t i n g s t a t i s t i c s , was  stressed.  o f system development produced two  i t sought and managed to o b t a i n the  of f i e l d personnel.  T h i s was  l y i n t e r a c t i v e nature  due  effects. support  i n l a r g e p a r t to the h i g h -  o f the development process.  This  i n t e r a c t i o n gave f i e l d workers the f e e l i n g t h a t t h e i r  input  was  level  regarded  as v a l u a b l e .  of awareness concerning The  activity  second e f f e c t was,  create high expectations T h i s was  I t a l s o r a i s e d the g e n e r a l recording.  d e s p i t e some s k e p t i c i s m ,  to  of the p o t e n t i a l o f the system.  an almost i n e v i t a b l e r e a c t i o n to the enthusiasm  i n t e r a c t i o n generated.  By c o n s t a n t l y s t r e s s i n g the poten-  t i a l o f the system, the b e l i e f was  c r e a t e d that the system  would be very h e l p f u l to s u p e r v i s o r s and number of v i t a l  tasks.  and  I t may  directors in a  have been t h a t , w i t h  m y s t i c a l power of a computerized  the  system somewhat obscuring  the i s s u e s , some managerial s t a f f were l e d to expect more from the system than what i t was  i n f a c t capable  of d e l i v e r i n g .  Enthusiasm i n developing- a system i s a p o s i t i v e a s s e t . But  i t must be kept i n mind t h a t , u n l e s s  the enthusiasm  and  expectations  can be shown to be warranted, d i s i l l u s i o n m e n t  and n e g a t i v e  f e e l i n g s may  result.  114  5.8.4  Recording The  data  i n s t r u c t i o n manual f o r the nurses r e p o r t form  was  e x t e n s i v e l y d e t a i l e d to enable the r e c o r d i n g of a c t i v i t i e s to be as accurate as p o s s i b l e .  The  i s s u e s of r e l i a b i l i t y  and v a l i d i t y do not appear to have been d e a l t w i t h ly.  explicit-  Yet the e x t e n s i v e d e t a i l of the i n s t r u c t i o n s serve to  i n c r e a s e the p o t e n t i a l r e l i a b i l i t y and v a l i d i t y of the instrument  (the nurses r e p o r t form).  The  i n t e n s i v e one  a c c l i m i t i z a t i o n workshops were intended to f a m i l i a r i z e w i t h the form. was  The  one  to two weeks p r a c t i c e w i t h the  day nurses  form  intended to develop and improve t h e i r r e c o r d i n g a b i l i t y . As noted  i n s e c t i o n 5.5.3, e r r o r s decreased  sharply i n  number a f t e r the f i r s t month of o p e r a t i o n o f A.C.N.A.R.S. was  found t h a t feedback  It  to nurses w i t h i n d i c a t i o n s of  i n c o r r e c t r e c o r d i n g i n c r e a s e d t h e i r awareness of t h e i r r e c o r d i n g , as w e l l as improving be p r o v i d e d through  t h e i r accuracy.  T h i s feedback  some k i n d o f data check i n the  h e a l t h agency, b e f o r e forms are forwarded  can  local  to L o c a l H e a l t h  Services.  5.8.5.  Communication o f data  As p o i n t e d out i n s e c t i o n 3.3.1, the s t a t u s h i e r a r c h y of an o r g a n i z a t i o n w i l l be p o s s i b l y the major f a c t o r i n g the flow of data through i t .  affect-  A f e a t u r e of the data  flow process i s the r u l e t h a t a l l correspondence u n i t personnel from L o c a l H e a l t h S e r v i c e s must be  to h e a l t h directed  115  v i a the d i r e c t o r o f the agency.  T h i s can give the d i r e c t o r  the power t h a t c e r t a i n data may p o t e n t i a l l y c o n t a i n .  The  d i r e c t o r thus has some i n f l u e n c e and c o n t r o l over the flow of a c t i v i t y data between Community H e a l t h or her n u r s i n g The  S e r v i c e s and h i s  supervisor.  degree o f communication, both w i t h i n and between  h e a l t h u n i t s , i s l i k e l y t o be a f u n c t i o n o f the l e a d e r s h i p s t y l e o f the d i r e c t o r (see s e c t i o n 3.3.1).  The nurse  s u p e r v i s o r and her s t y l e o f o p e r a t i o n w i l l be fundamentally a f f e c t e d by the s t y l e o f the d i r e c t o r .  The amount o f com-  p a r i s o n o f program s t a t i s t i c s , and programs and s e r v i c e s themselves, which i s a c t u a l l y a f f e c t e d between h e a l t h u n i t s , depends a g r e a t d e a l on the d i r e c t o r ' s l e a d e r s h i p  style.  I t was agreed t h a t the input from a l l h e a l t h u n i t s , and the r e s u l t i n g output, was to be regarded as c o n f i d e n t i a l . T h i s was done to a l l a y f e a r s that other h e a l t h u n i t s would o b t a i n data that might r e f l e c t n e g a t i v e l y on the h e a l t h u n i t concerned.  The i n i t i a t i v e f o r comparing data thus r e s t s with  the h e a l t h u n i t s themselves. The  c o g n i t i v e s t y l e o f s u p e r v i s o r s and d i r e c t o r s was  taken i n t o account i n developing data gathered.  The format o f data r e p o r t s was developed by  the n u r s i n g records antly of nursing other  field  output formulas f o r the  committee, which was composed predomin-  supervisors.  personnel.  Input was a l s o obtained  from  116  5.8.6  Usefulness During  o f systems  data  the summer o f 1978, I undertook an  e v a l u a t i o n o f the A.C.N.A.R.S. system i n compiling  guide-  l i n e s to the use o f the data produced by the system. work i n c l u d e d a s e r i e s o f f i e l d v i s i t s , o f h e a l t h , and to three h e a l t h u n i t s . w i t h medical  This  to both c i t y boards D i s c u s s i o n s were h e l d  o f f i c e r s o f h e a l t h , s u p e r v i s o r s and d i r e c t o r s  of community h e a l t h n u r s i n g , n u r s i n g c o n s u l t a n t s and members of the n u r s i n g records  committee.  Many s t r a i g h t f o r w a r d ways i n which the data c o u l d be used were i d e n t i f i e d .  For example, i f o b j e c t i v e s are s e t  f o r a program, i n terms o f the q u a n t i t y o f s e r v i c e to be provided, A.C.N.A.R.S. provides  the means f o r measuring  whether or n o t o b j e c t i v e s have been met. provides  A.C.N.A.R.S.  data t h a t can be s t u d i e d f o r trends i n p a t t e r n s  of s e r v i c e p r o v i s i o n .  The data can g i v e an i n d i c a t i o n o f  changes i n emphases, p r i o r i t i e s or s e r v i c e u t i l i z a t i o n .  The  data may a c t as an i n d i r e c t i n d i c a t o r o f demand f o r c e r t a i n services. Comparisons o f data from A.C.N.A.R.S. can only r e v e a l i n d i c a t o r s of trends.  They can i n no way i n d i c a t e what  of a c t i o n s or d e c i s i o n s are necessary.  Appropriate  type  action  can only be undertaken once a t o t a l p e r s p e c t i v e o f a s i t u a t i o n has been As 2.6),  obtained.  i n d i c a t e d by Bergwall,  Reeves and Woodside ( s e c t i o n  one cannot i n t e r p r e t a c c u r a t e l y measured  activities  117 without  an understanding  o f t h e i r context.  ments o f a c t i v i t i e s a r e n o t i n themselves without  an o v e r a l l understanding  other hand, an understanding  Accurate measurea basis f o r action,  o f the s i t u a t i o n .  On the  o f the s i t u a t i o n may be a s u f f i -  c i e n t b a s i s f o r a c t i o n , without any a c c u r a t e measurements of activities.  While A.C.N.A.R.S. can p r o v i d e a c c u r a t e measure-  ments o f a c t i v i t i e s to complement an understanding  of a s i t -  u a t i o n , i t can i n no way p r o v i d e the understanding  that i s  so necessary i n the o v e r a l l d i a g n o s t i c process. It  i s perhaps because o f r a i s e d e x p e c t a t i o n s i n t h i s  r e g a r d t h a t I found a c e r t a i n degree o f f r u s t r a t i o n among those i n v o l v e d w i t h the system and i t s output.  While  not a l t o g e t h e r n e g a t i v e , many o f those I spoke to were skept i c a l o f the u s e f u l n e s s o f the system.  They were e l u s i v e  when asked f o r concrete examples o f how the data was being used, or c o u l d be used.  There was g e n e r a l l y very p o s i t i v e  f e e l i n g on the u s e f u l n e s s o f data i n r e p o r t i n g back to boards.  But, a t a l l l e v e l s , people i n d i c a t e d they were un-  a b l e t o f i n d much use f o r the data, o t h e r than t o r e p o r t to boards or other agencies, and to p r o v i d e a q u a n t i t a t i v e i n ventory o f n u r s i n g work  performed.  W i t h i n Community H e a l t h S e r v i c e s , i t was f e l t  that  A.C.N.A.R.S. p r o v i d e d v a l u a b l e b a s e l i n e data on a p r o v i n c e wide b a s i s , which had n o t been a v a i l a b l e beforehand. also strongly f e l t  I t was  that A.C.N.A.R.S. a c t s as an awareness  r a i s i n g mechanism, by making nurses more aware o f the  118  activities  they are performing.  as an e d u c a t i o n a l  tool.  In t h i s way  too,  i t acts  While t h i s i s t r u e , i t i s d i f f i c u l t  to say to what extent i t i s so. When being used i n a n a l y z i n g  s e r v i c e s provided,  data are more u s e f u l i f seen i n the context of s t a t e d and  o p e r a t i o n a l l y defined  objectives.  the  clearly In any  further  development o f A.C.N.A.R.S., i t would appear to be v i t a l o b j e c t i v e s be not  c l e a r l y and  operationally defined.  done, the process of development may  T h i s could  lack  l e a d to a " c a r t - b e f o r e - t h e - h o r s e "  In t h i s case, a f t e r w e l l - i n t e n t i o n e d ments are made, the users may  and  that  If this i s  direction. type o f  good l o o k i n g  be hard pressed to f i n d  s p e c i f i c ways i n which the data o b t a i n e d can be used.  situation. refine-  119  CHAPTER 6  6.1  General  discussion  In t h e p r e v i o u s recording cular, was  the general  a few o u t s t a n d i n g  5.  c o u l d be d e r i v e d Secondly,  ation  consider that  Finally,  final  recording  t o round  systems.  a t t h e i s s u e o f w h e t h e r a common m o d e l  examine t h e g e n e r a l  problem o f a c t i v i t y I will  In this  from t h e systems examined i n c h a p t e r  I shall  systems  analysis of a  i s s u e s w i l l be c o n s i d e r e d  our d i s c u s s i o n o f Canadian a c t i v i t y I look  In p a r t i -  recording  an in-depth  s y s t e m was made i n c h a p t e r  Firstly,  6.2  4, w h i l e  of activity  i n detail.  examination of a c t i v i t y  the t o p i c o f chapter  chapter,  most a s p e c t s  s y s t e m s have b e e n d i s c u s s e d  particular  out  chapters,  recording  and a l l i m p o r t a n t  systems e v a l u a t i o n .  a l t e r n a t i v e methods o f o b t a i n i n g  i s presently  gathered  4.  Thirdly, the inform-  through a c t i v i t y  a summary o f t h e f i n d i n g s o f t h i s  recording.  work w i l l be made.  A common m o d e l The  concept  recording lities  o f a common m o d e l assumes t h a t  systems have e s s e n t i a l and i d e n t i f i a b l e  i n objectives, organization,  commonalities  do e x i s t ,  provinces.  Furthermore,  and o p e r a t i o n .  a model system c o u l d  o f community h e a l t h n u r s i n g  standard  activity  activity  f o r the evaluation of e x i s t i n g  I f such  form t h e b a s i s  recording  such a model c o u l d  commona-  in all  also provide  systems.  a  120  In chapter ing  4, p r o v i n c i a l and f e d e r a l a c t i v i t y  systems were examined i n d e t a i l .  can a  record-  Based upon t h i s a n a l y s i s ,  model Canadian system be derived? . . ' At f i r s t  glance,  the p o s s i b i l i t i e s  look  promising.  R e f e r r i n g to Table 4.1 we can see t h a t the m a j o r i t y o f a c t i v i t i e s on which data a r e c o l l e c t e d a r e common to a l l systems. These a c t i v i t i e s f a l l i n t o the b a s i c c a t e g o r i e s g i v e n i n Table  6.1 (p. 121) . However, c l o s e r a n a l y s i s o f the i n f o r m a t i o n i n chapter  4 shows t h a t , d e s p i t e s i m i l a r i t i e s , systems a r e s u b s t a n t i a l . are i n a l l cases vaguely  d i f f e r e n c e s between  In p a r t i c u l a r , systems o b j e c t i v e s defined.  Thus, the data items c o l -  l e c t e d , the methods o f data c o l l e c t i o n , the o r g a n i z a t i o n used to  o b t a i n the data and the u t i l i z a t i o n of the i n f o r m a t i o n  c o l l e c t e d are s u b s t a n t i a l l y d i f f e r e n t from one a c t i v i t y ing  system t o another.  record-  These d i f f e r e n c e s make each system  unique to such an extent  that a meaningful  common model can-  n o t be d e r i v e d .  6-3  Evaluation The  o b j e c t i v e o f e v a l u a t i o n i s to examine how w e l l a  system i s doing what i t i s supposed to do.  With a c t i v i t y r e -  c o r d i n g systems, there are two q u i t e d i f f e r e n t aspects considered.  The f i r s t  system i t s e l f ,  i s the performance o f the r e c o r d i n g  and the second i s the imp ac t o f the data  produced by the system.  to be  121  Table  6.1 Basic Categories f o r A c t i v i t y 1.  Immunizations.  2.  School h e a l t h s e r v i c e s .  3.  Screenings.  4.  Groups and/or c l a s s e s .  5.  C h i l d h e a l t h conferences.  6.  M a t e r n a l care ( p r e n a t a l • (postnatal.  7.  Infant care.  8.  Clinics.  9.  Meetings/liasons.  10.  Communicable d i s e a s e s .  11.  Mental  health/illness.  12.  Health  promotion.  13.  Home  14.  Family p l a n n i n g .  15.  T o t a l home v i s i t s .  Recording  assessments/reassessments.  122  The  explicit  c a l c u l a t i o n of the c o s t s o f the  system i s a l s o an important c o n s i d e r a t i o n . of these c o s t s would be: n u r s i n g  The main elements  time spent i n r e c o r d i n g ,  costs o f s u p p l i e s , data p r o c e s s i n g a d m i n i s t r a t i v e overhead.  recording  expenditures  The performance and  and  the  impact  should  be weighted a g a i n s t c o s t s , to d e r i v e a measure of the  cost-  e f f e c t i v e n e s s of a system.  6.3.1  Systems performance When e v a l u a t i n g the performance of an a c t i v i t y  record-  ing  system, one wants to know whether the system i s c o l l e c t -  ing  the a p p r o p r i a t e  data, as w e l l as the q u a l i t y o f  data  collected. For every r e c o r d i n g system, one fy  should be able to s p e c i -  a minimum e s s e n t i a l data s e t , c o n s i s t i n g of those  items which are necessary f o r the system to f u l f i l l tives.  For the systems s t u d i e d i n chapter  difficult  problem.  As was  4,  data i t s objec-  t h i s presents  a  shown then, systems o b j e c t i v e s are  g e n e r a l l y so vaguely d e f i n e d t h a t i t i s not p o s s i b l e to d e r i v e from them a minimum e s s e n t i a l data s e t . have to form t h e i r own  Thus, e v a l u a t o r s  judgements on the adequacy of  c o l l e c t e d , or r e l y on the s u b j e c t i v e o p i n i o n o f  may  data  supervisors  and d i r e c t o r s . Data q u a l i t y i s a f f e c t e d by the accuracy of data r e c o r d i n g . 3.2.2  and  3.2.3.  to estimate  and  reliability  These f a c t o r s were d i s c u s s e d i n s e c t i o n s As  accuracy  i n d i c a t e d then, i t may and r e l i a b i l i t y  not be p o s s i b l e  i n absolute  terms.  An  123  assessment of these  f a c t o r s may  thus  j u d g e m e n t o f t h o s e most c l o s e l y  h a v e t o be  involved with  These would i n c l u d e d i r e c t o r s ,  based  the  s u p e r v i s o r s and  on  the  system.  the  nurses  themselves.  6.3.2  The  impact  The  of a c t i v i t y  impact  of data  systems i s the r e a l  a number o f f a c t o r s were r e v i e w e d n e e d t o be The  activity  that these  o f s u p e r v i s o r s and  influencing  i n s e c t i o n s 3.3  explicitly  this  and  impact  From s y s t e m s o b j e c t i v e s , formance parameters, p a c t o f the data.  one  3.4.  these  directors.  There  evaluation process. by w h a t e v e r means  o u g h t t o be  is  able to d e r i v e per-  difficult  activity  d a t a and  These p r o c e s s e s effect  cannot  Thus, i t i s extremely  be  terms.  the  difficult  so u n s t r u c t u r e d and d a t a on  T h e r e f o r e , no  them c a n n o t  vague-  to  fulfilled. I t i s ex-  causal connections  t h e outcome o f d e c i s i o n m a k i n g  im-  obtained  more f u n d a m e n t a l p r o b l e m .  to i d e n t i f y  are  of a c t i v i t y  the  However, o b j e c t i v e s a r e g e n e r a l l y so  There i s another,  are  significant.  w h i c h c o u l d be m e a s u r e d t o a s s e s s  statements.  are  They  measure whether systems o b j e c t i v e s are i n d e e d b e i n g  tremely  deci-  These f a c t o r s a l l  of the data  d e f i n e d that performance parameters  from  the  effectiveness.  c o n s i d e r e d i n any  whether the  recording  d a t a h a v e on  evaluators t r y to e s t a b l i s h ,  available,  ly  s u p p l i e d by  effect  s i o n making p r o c e s s e s  data  between  processes.  undefined,  that  the  be m e a s u r e d i n o b j e c t i v e  o b j e c t i v e measures or  performance  124  parameters  f o r the  impact  of a c t i v i t y  T h u s , i t becomes n e c e s s a r y data  t h e m s e l v e s how recording.  tions  the  of  The  impact  of  t h i s way,  curate  the  such data.  evaluators  perspective  o f how  their  are  be s p e c i f i e d .  the users the  data are  able  claims  or  by  percep-  carefully disclaimers. t h e most  truly  are  to  acthose  intended.  Alternatives  r h a v e i n d i c a t e d t h a t no common m o d e l c a n be from those trying and  the  their  to o b t a i n data  of  produced  T h e y must be  u s e f u l the  f o r whom i t i s p r i m a r i l y  6.4  can  answers t h e y g i v e  cross-examined, to s u b s t a n t i a t e In  to ask  h e l p f u l they f i n d  activity  data  I h a v e a l s o shown t h e  to o b j e c t i v e l y evaluate  the  ative  studied.  impact  of a c t i v i t y  to consider  the  data.  derived  difficulty  performance of a At  this  stage,  some a l t e r n a t i v e s t o r e g u l a r  in  system,  i t is  imper-  activity  recording.  6.4.1  No The  activity ing  any In  activity first,  and  recording. activity the  recording most o b v i o u s What a r e  abandon  i m p l i c a t i o n s of not  collect-  data?  absence of a c l e a r u n d e r s t a n d i n g o f  making p r o c e s s e s  of  to e s t a b l i s h the  effect  The  the  a l t e r n a t i v e , i s to  d i r e c t o r s and of having  i n t u i t i v e knowledge t h a t  supervisors, t o do w i t h o u t  supervisors  and  the  decision  i t is difficult activity  data.  d i r e c t o r s have  125  of the a c t i v i t i e s of t h e i r nurses would not be much.  affected  However, the more r e f i n e d measure t h a t a c t i v i t y  g i v e to t h i s knowledge would be  data  lost.  A c t i v i t y data are p a r t i c u l a r l y h e l p f u l i n communications between h e a l t h s e r v i c e p r o v i d e r s .  Communications between  community h e a l t h nurses and others i n v o l v e d i n h e a l t h care provision i s v i t a l , understanding  f o r each p a r t y to convey to the other an  of what they are doing.  Such communication i s  fundamental to the r a t i o n a l o r g a n i z a t i o n and o p e r a t i o n of h e a l t h care s e r v i c e s .  Furthermore,  i t increases i n  importance  as the scope of community h e a l t h n u r s i n g programs grow, and the complexity of the o r g a n i z a t i o n a l environment i n c r e a s e s . A c t i v i t y data p r o v i d e q u a n t i t a t i v e means of communicat i o n that can be adequately understood by a l l p a r t i e s .  No  other data c o u l d f i l l  Thus,  due  t h i s r o l e i n q u i t e the same way.  to the communication needs between the v a r i o u s p a r t s of  the h e a l t h care system, some a c t i v i t y data are indeed necessary. 6.4.2  Special studies S p e c i a l s t u d i e s may  be designed and s t r u c t u r e d to c o l l e c t  whatever p a r t i c u l a r data are r e q u i r e d .  For example, they  c o l l e c t data on nurses' q u a l i f i c a t i o n s ,  interests  may  and  o p i n i o n s , data on the content of n u r s i n g a c t i v i t i e s , or informa t i o n on the outcome o f s e r v i c e s p r o v i d e d . S p e c i a l s t u d i e s have t h e i r l i m i t a t i o n s .  " I t i s very  p o r t a n t to r e c o g n i z e t h a t .... s p e c i a l s t u d i e s are r e a l l y  im-  126  sample surveys and  t h e r e f o r e s u b j e c t to the c a u t i o n that  t h e i r r e s u l t s are only estimates ( N a t i o n a l League f o r Nursing,  of the t r u e  1977,  p. 23).  values". P a r t i c u l a r at-  t e n t i o n must be g i v e n to the survey design and  the time when  the study i s done, to ensure t h a t the sample obtained p r e s e n t a t i v e of the r e a l  i s re-  situation.  S p e c i a l s t u d i e s r e q u i r e s t a f f o r i e n t a t i o n to the method o f the study.  F a m i l i a r i z i n g nurses w i t h the instrument to  be used i s time consuming.  Accuracy and r e l i a b i l i t y may  be problems i n short term sampling, due f a m i l i a r i t y and  experience  to nurses'  also  l a c k of  w i t h the forms i n v o l v e d .  Using  t r a i n e d o u t s i d e r s would overcome t h i s problem, but would be prohibitively costly.  A l l these f a c t o r s need to be  con-  s i d e r e d when weighing the r e l a t i v e c o s t and b e n e f i t f a c t o r s o f such s t u d i e s . The  representativeness  of a study w i l l depend, among  other t h i n g s , on the p r e d i c t i v e v a l i d i t y of the study method. P r e d i c t i v e v a l i d i t y c o u l d be t e s t e d by simultaneously forming a c t i v i t y r e c o r d i n g and i n g the r e s u l t s .  s p e c i a l s t u d i e s , and  per-  compar-  I f t h e i r p r e d i c t i v e v a l i d i t y i s high  enough, s p e c i a l s t u d i e s c o u l d be used f o r r e p o r t i n g purposes, and  c o u l d p o s s i b l y r e p l a c e the more t r a d i t i o n a l and  blished activity statistics  from a c t i v i t y  esta-  recording.  I f s p e c i a l s t u d i e s have w e l l d e f i n e d o b j e c t i v e s , are a p p r o p r i a t e l y designed to f u l f i l l  and  these o b j e c t i v e s , they  are p o t e n t i a l l y a more f l e x i b l e t o o l than r e g u l a r  activity  127  r e c o r d i n g systems. v i a b l e and  U n d e r t h e s e c o n d i t i o n s , t h e y may  be  a  appealing a l t e r n a t i v e to regular recording  systems. 6.4.3  Computerization T h e r e seems t o be a t e n d e n c y ,  practice,  i n t h e l i t e r a t u r e and  t o assume t h a t c o m p u t e r i z a t i o n o f e x i s t i n g  systems  will  r e s o l v e t h e i r c u r r e n t p r o b l e m s and  inadequacies.  this  sense,  as a  different present  computerization i s regarded  development, g i v i n g r i s e  it  In  qualitatively  t o an a l t e r n a t i v e  to  practices.  A computerized ual  in  system,  system  i s much more p o w e r f u l t h a n a man-  i n t e r m s o f t h e q u a n t i t y and v a r i e t y o f  can produce.  output  I t i s m o s t u s e f u l as a means o f r e d u c i n g  a v o i d i n g t e d i o u s manual m a n i p u l a t i o n s o f d a t a .  or  However,  w h i l e c o m p u t e r i z a t i o n i s most advantageous i n t h e s e r e s p e c t s , it  i s n o t a s u b s t a n t i a l l y d i f f e r e n t means o f c o l l e c t i n g  tivity  data.  In essence,  m a n u a l and  computerized  r e c o r d i n g s y s t e m s f u n c t i o n i n much t h e same The  key  to o b t a i n i n g data that w i l l  d e c i s i o n making l i e s Initially,  one  w a n t s t o do.  activity  way.  h a v e an i m p a c t  i n the p r o c e s s of systems  d i c a t o r o f t h e t y p e and  amount o f d a t a t o be  procedure.  one  a c t as an i n collected.  C o m p u t e r i z a t i o n d o e s n o t do away w i t h t h e n e e d t o f o l l o w the above  on  development.  needs t o e s t a b l i s h c l e a r l y what i t i s Clearly defined objectives w i l l  ac-  carefully  128  The  importance o f data on d e c i s i o n making i s a func-  t i o n of the d e c i s i o n making processes  of s u p e r v i s o r s and  d i r e c t o r s , and not of the q u a n t i t y and v a r i e t y of data produced.  While c o m p u t e r i z a t i o n o f a c t i v i t y data may  affect  q u a n t i t y and v a r i e t y of r e p o r t s produced, i t w i l l not a f f e c t the d e c i s i o n making processes  6/5  directly  of data u s e r s .  Cone l u s ions T h i s study has  collection.  focused on two  aspects of a c t i v i t y  data  These are  1.  the need f o r a c t i v i t y data,  2.  the u s e f u l n e s s of these  As shown i n s e c t i o n 2.4, data.  the  and  data.  there i s a need f o r a c t i v i t y  However, these data p l a y a l i m i t e d r o l e i n the func-  t i o n s performed by d i r e c t o r s and  supervisors.  k i n d s of i n f o r m a t i o n are a l s o r e q u i r e d .  Many other  In most cases,  these  other types o f i n f o r m a t i o n are o f g r e a t e r importance than  ac-  t i v i t y data.  The o n l y f u n c t i o n where a c t i v i t y data appear to  be of primary  importance i s t h a t of r e p o r t i n g n u r s i n g  ties  to boards,  activi-  government o f f i c i a l s and other h e a l t h care  workers. As i t i s e v i d e n t from the d i s c u s s i o n of s e c t i o n 4.4.1, many o f the systems' o b j e c t i v e s are s t a t e d i n vague and o p e r a t i o n a l terms.  non-  T h e r e f o r e , the data t h a t need to be  c o l l e c t e d c o u l d not be i d e n t i f i e d .  I t was  thus not p o s s i b l e  to v e r i f y whether the data being c o l l e c t e d were a p p r o p r i a t e  129  or  adequate t o e n a b l e t h e systems t o f u l f i l l  tives. not  Unless objectives  Poorly unstructured  to the process defined  guidelines.  of defining objectives  clearly. o f the  n a t u r e o f the d e c i s i o n making p r o c e s s e s management.  the features  s y s t e m may h a v e l i t t l e  and f u n c t i o n i n g  established,  o f the recording  e f f e c t on t h e u s e f u l n e s s  o f t h e system.  A more t h o r o u g h u n d e r s t a n d i n g o f t h e d e c i s i o n m a k i n g of how  d i r e c t o r s and s u p e r v i s o r s  i n com-  I f t h e ways i n w h i c h  d a t a a r e t o be u s e d a r e n o t c l e a r l y  then r e f i n i n g  t h e y do  Attention  o b j e c t i v e s may be a r e f l e c t i o n  munity h e a l t h n u r s i n g activity  objec-  are operationally defined,  a c t as d e f i n i t e d a t a c o l l e c t i o n  must be g i v e n  their  i s required  processes  t o i d e n t i f y where and  t h e d a t a may be u s e d . Special  than r e g u l a r studies  studies activity  can c o l l e c t recording  a broader range o f data  systems.  a r e a p o t e n t i a l l y more f l e x i b l e  such present  activity  recording  Therefore  and u s e f u l t o o l  a r e cheaper than r e c o r d i n g  c o s t - e f f i c i e n t way o f o b t a i n i n g commended studies  that  The  systems,  activity  the p r e d i c t i v e v a l i d i t y  be f u r t h e r  I f special t h e y a r e a more  data.  I t i s thus r e -  and c o s t s  of special  investigated.  analysis presented  i n t h i s work i m p l i e s  thorough r e v i s i o n o f presently, operating systems i s n e c e s s a r y . of p r e s e n t l y  than  s y s t e m s , i f t h e y c a n be shown  to have a s a t i s f a c t o r y p r e d i c t i v e v a l i d i t y . studies  these  The r e l e v a n c e  g a t h e r e d data need  activity  and p o t e n t i a l  t o be r e a s s e s s e d .  that  a  recording usefulness I believe  130  t h a t such a review would l e a d to changes i n some o f the current p r a c t i c e s . activities.  An example i s that o f n o t i n g the d u r a t i o n o f  In the context  o f the d i s c u s s i o n i n s e c t i o n 4.3.  4, t h i s f e a t u r e ought to be d i s c o n t i n u e d . Even more d r a s t i c a c t i o n may be warranted i n some cases. For example, the a c t i v i t y r e c o r d i n g system used by the Vancouver H e a l t h Department was r e c e n t l y d i s c o n t i n u e d . p a r t i c u l a r a c t i o n would seem to be i n l i n e w i t h i n d i c a t i o n s o f t h i s study,  This  some o f the  t h a t much o f the time and energy  spent on a c t i v i t y r e c o r d i n g i s n o t worthwhile. In summary, t h i s examination o f the fundamental concepts and  f u n c t i o n i n g o f a c t i v i t y r e c o r d i n g i n d i c a t e s a reassessment  of the commitment to a c t i v i t y r e c o r d i n g systems i n community h e a l t h n u r s i n g i s needed.  I t i s b e l i e v e d t h a t such r e a s s e s s -  ment w i l l l e a d to major changes i n the c o l l e c t i o n and use o f activity  data.  131  BIBLIOGRAPHY  Ackhoff, R u s s e l l L. "Management M i s i n f o r m a t i o n Systems". Management S c i e n c e , V o l . 14, No. 4, December 1967. pp. B147 - 156. 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