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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 University of Cape Town, 1973 B.Sc, The University of Cape Town, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning) i n THE FACULTY OF GRADUATE STUDIES (The Department of Health Care and Epidemiology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1979 © P h i l i p Terence Kretzmar, 1979 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e H e a d o f my D e p a r t m e n t o by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f H ^ M T f f C k ^ E P l E > S * J l | O t O ^ The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 i i ABSTRACT The purpose of 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 health nurs-ing services. The study begins by examining what community health nurses do. P a r t i c u l a r attention i s given to the manage-ment structure i n community health nursing. The kinds of information that individuals at d i f f e r e n t l e v e l s i n the organization of community health nursing require, are investigated. One of these kinds of information i s a c t i v i t y data. Thus, the role that a c t i v i t y data can play for those at each organizational l e v e l i s explored. Various factors that can influence the usefulness of a c t i v i t y data are examined. The conceptual and functional features of s i x prov-i n c i a l and one federal a c t i v i t y recording system are analyzed. This i s followed by a more detailed study of a p a r t i c u l a r system, the Alberta Community Nursing A c t i -v i t i e s Recording System. In reviewing the systems analyzed, the study finds that a common model for a c t i v i t y recording systems can-not be derived. Objectives are found to be so vaguely defined that the evaluation of an a c t i v i t y recording system i s forced to r e l y largely on the subjective f e e l -ings of the systems users. Having examined some per-ceived alternatives to current systems, i t i s f e l t that a thorough r e v i s i o n of presently operating systems should be undertaken. i i i TABLE OF CONTENTS P a g £ Abstract i i Table of Contents i i i L i s t of Tables v i L i s t of Figures v i i Acknowledgements v i i i Introduction 1 Chapter 1 1.1 What i s Community Health Nursing?. . . . 4 1.2 What Community Health Nurses Do . . . . 5 1.3 The Management Structure i n Community Health Nursing 11 Chapter 2 2.1 Information Characteristics for Different Organizational Levels . . . . 15 2.2 Information Flows i n an Organization . . 21 2.3 What i s A c t i v i t y Recording? 25 2.4 Functions Performed by Nurses at Different Levels i n the Organization . . 27 ' 2.4.1 Operational Control 28 2.4.2 Management Control 29 2.4.3 Strategic Planning 36 2.5 A c t i v i t y Data and Decision Making . . . 39 2.6 The Role of A c t i v i t y Data 41 Chapter 3 3.1 The Dynamics of Data Transmission . . . 44 3.2 Data Ac q u i s i t i o n 44 3.2.1 Accuracy 46 3.2.2 R e l i a b i l i t y 46 3.2.3 V a l i d i t y 51 3.2.4 Costs 53 3.3 Data Communication 53 3.3.1 Factors A f f e c t i n g Data Flow 54 3.3.2 Frequency of Reporting 55 3.3.3 The Volume of Data Reporting 56 3.4 The Interpretation of Data 60 Chapter 4 4.1 A c t i v i t y Recording Systems i n Canada . . 64 4.2 Functional Features of A c t i v i t y Recording Systems 65 4.2.1 Federal Government System 73 i v Chapter 4 (cont.) 4.3 Functional Features: Discussion . . . . 73 4.3.1 Services Recorded 73 4.3.2 Non-Client Contact A c t i v i t i e s 74 4.3.3 Data re Service Recipients 74 4.3.4 Duration of Services Recorded 76 4.3.5 Place of Service Recorded 78 4.4 Discussion of Systems Objectives . . . 78 4.4.1 Operational Features 82 4.5 Special Features 82 4.5.1 Manitoba 84 4.5.2 The Federal Government Performance Measurement System 84 4.6 Summary of A c t i v i t y Recording Systems Reviewed 86 Chapter 5 5.1 Case Study of the Alberta Community Nursing A c t i v i t i e s Recording System (A.C.N.A.R.S.) 88 5.2 The Organization of Community Health Services i n Alberta 88 5.3 Organization of Health Agencies . . . . 89 5.4 Community Health Nursing i n Alberta . . 92 5.5 Background to the Introduction of A.C.N.A.R.S 93 5.5.1 The Need for A.C.N.A.R.S 93 5.5.2 Planning and Development of A.C.N.A.R.S. 96 5.5.3 Implementation of A.C.N.A.R.S 98 5.6 The Nurses Report Forms: 1 and 2 . . . 99 5.6.1 Form No. 1 99 5.6.2 Form No. 2 101 5.6.3 The Output: Forms 1 and 2 102 5.7 A.C.N.A.R.S. Form No. 1 107 5.7.1 Section 1 107 5.7.2 Section 2. Time A l l o c a t i o n by Program 107 5.7.3 Sections 3 and 4. Group A c t i v i t i e s and Individual Contacts 108 5.7.4 Section 5. Screenings, Assessments and Treatments 109 5.8 General Discussion on A.C.N.A.R.S. . . 109 5.8.1 Objectives 109 5.8.2 Assumptions I l l 5.8.3 Acceptance of the System 112 5.8.4 Recording Data 114 5.8.5 Communication of Data 114 5.8.6 Usefulness of Systems Data 116 V Chapter 6 6.1 General Discussion 119 6.2 A Common Model . 119 6.3 Evaluation 120 6.3.1 Systems Performance 122 6.3.2 The Impact of A c t i v i t y Data 123 6.4 Alternatives 124 6.4.1 No A c t i v i t y Recording 124 6.4.2 Special Studies 125 6.4.3 Computerization 127 6.5 Conclusions 128 Bibliography 131 v i LIST OF TABLES Table Page 1.1 D i s t r i b u t i o n of Community Health Nurses Reported, by Posit i o n and by Province, 1975 8 1.2 D i s t r i b u t i o n of Community Health Nurses Reported, by Position, 1969, 1970, 1971 and 1975 9 2.1 The Antony Framework and Information Characteristics 17 4.1 Functional Features of Recording Systems 68 4.2 Objectives 79 4.3 Operational Features of Systems 83 5.1 Coding 104 6.1 Basic Categories for A c t i v i t y Recording. . 121 LIST OF FIGURES Figure Page 1.1 D i s t r i b u t i o n of Public Health Nurses by Academic Q u a l i f i c a t i o n , 1975 10 1.2 Community Health Agency Structure . . . . 12 2.1 Community Health Agency Pyramid Structure for Management Information Systems 18 2.2 Information Flows i n a System . . . . . . 23 2.3 Information Flows of a Health Agency ... 24 3.1 The Stages of Data Transmission 45 3.2 Model of Cognitive Style 61 5.1 The Organization of Community Health Services i n Alberta 90 5.2 The Organization of a Typical Health 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 v i i i ACKNOWLEDGEMENTS I would l i k e to express my sincere thanks: to Dr. Charles Laszlo, D i v i s i o n of Health Systems, U.B.C, for a very stimulating and valuable learning experience, to Dr. Morton Warner, Department of Health Care and Epidemiology, U.B.C, and Dr. Jack Yensen, Vancouver Community College, Langara, for sharing with me th e i r time, knowledge and energy, to Mrs, Pat Yates, Alberta Social Services and Community Health, for her t i r e l e s s assistance i n helping me learn about A.C.N.A.R.S., and to Dr. Annette Stark, D i v i s i o n of Health Services Research and Development, U.B.C, for her comments on drafts of this work. 1 INTRODUCTION Community h e a l t h nurses throughout the country r e -cord t h e i r a c t i v i t i e s on forms s p e c i a l l y developed f o r t h i s purpose. The purpose of t h i s study i s to evaluate the r o l e o f these a c t i v i t y data i n the management of community h e a l t h n u r s i n g s e r v i c e s . There are a c t i v i t y r e c o r d i n g systems i n every p r o v i n c e . .Community h e a l t h nurses spend a c o n s i d e r a b l e amount of t h e i r time and energy r e c o r d i n g the r e q u i r e d i n f o r m a t i o n . Numerous claims have been made about the many uses of a c t i v i t y data, which are viewed as an im-p o r t a n t element o f the i n f o r m a t i o n needs i n community h e a l t h n u r s i n g management. They are regarded as h e l p -f u l i n p l a n n i n g , e v a l u a t i o n , c o s t i n g s e r v i c e s , determin-i n g s t a f f i n g , and i n other managerial a c t i v i t i e s . Recording systems have a l s o been computerized, which has l e d to a c t i v i t y data becoming an entrenched item i n the i n f o r m a t i o n system used by n u r s i n g management. But - do these data p l a y a u s e f u l r o l e ? Are the claims about the importance of a c t i v i t y data r e a l l y j u s t i f i e d ? There i s a need to examine the v a l i d i t y o f these c l a i m s . 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 i n the l i g h t o f the p o t e n t i a l f o r the co m p u t e r i z a t i o n o f these data systems, and the p o s s i b l e p r o l i f e r a t i o n o f unneces-sary i n f o r m a t i o n . T h i s study w i l l focus on two aspects o f a c i t i v i t y 2 data. These are: 1 . the need f o r a c t i v i t y data, and 2. the u s e f u l n e s s o f a c t i v i t y data. To g a i n an understanding of the context w i t h i n which these data are r e l e v a n t , the study commences (chapter 1 ) by l o o k i n g at what community h e a l t h nurses do. As a c t i v i t y data are used at the managerial l e v e l , s p e c i a l a t t e n t i o n i s gi v e n to the management 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 . Each 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 -c u l a r types o f i n f o r m a t i o n . In chapter 2 the study ex-amines the i n f o r m a t i o n needs of those at the 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 o f community h e a l t h n u r s i n g . One of the kinds o f i n f o r m a t i o n needed i s a c t i v i t y data. The study explores the r o l e t h a t a c t i v i t y data can p l a y at each o r g a n i z a t i o n a l l e v e l . I t a l s o assesses the pot-e n t i a l c o n t r i b u t i o n o f a c t i v i t y data i n the d e c i s i o n making pro c e s s . 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 data, i n chapter 3 the study examines the stages o f data t r a n s -m i s s i o n . There are v a r i o u s f a c t o r s at these stages which w i l l i n f l u e n c e the u t i l i t y o f a c t i v i t y data. These f a c t o r s need to be taken i n t o c o n s i d e r a t i o n i n a s s e s s i n g the f u n c t i o n i n g o f an a c t i v i t y r e c o r d i n g system. They can act as a g u i d e l i n e f o r a system's e v a l u a t i o n . In chapter 4, the 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 federal a c t i v i t y recording systems are analyzed. This analysis involves a review of the functional and concep-tual features of the systems. Having obtained an overview of recording systems across the country, an in-depth study i s done, i n chapter 5, of the Alberta Community Nursing A c t i v i t i e s Recording System. In conclusion, i n chapter 6 , the study addresses i t -s e l f to some of the major issues that have been raised. These are: 1. i s there a common systems model? 2. the evaluation of a c t i v i t y recording systems, 3. alternatives to regular a c t i v i t y recording, and 4. computerization. 4 CHAPTER 1 1.1 What i s community health nursing? Community health nursing i s seen as professional nursing aimed at serving people i n their usual environ-ment of home, school or work, through organized commun-i t y e f f o r t (Canadian Public Health Association, 1966; 1977). The objectives of community health nursing are: 1. To promote health and prevent disease; 2. To provide nursing care for the non-hospita-l i z e d sick and disabled, 3. To eff e c t continuity of care, 4. To contribute to various educational programs, and 5. To be involved i n relevant research. (Canadian Public Health Association, 1966; 1977). In addition to ind 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 health nursing focuses on group health problems within a population as a means of determining the direc-t i o n of c l i n i c a l care services (Williams, 1977). This approach enables the providers of care to es t a b l i s h p r i o r i t i e s , and to i d e n t i f y the needs of the population being served. It thus also enables co-operation with other d i s c i p l i n e s i n the community. The community health nurse i s a generalist function-ing as a member of a m u l t i - d i s c i p l i n a r y team. To 5 f i l l t h i s r o l e i n a dynamic h e a l t h care environment, the nurses b e l i e v e that t h e i r e d u c a t i o n a l p r e p a r a t i o n and the s e r v i c e s t h a t they p r o v i d e need to be f r e q u e n t l y r e a s s e s s e d , and a d j u s t e d where necessary. 1.2 What community h e a l t h nurses do The d i s c u s s i o n i n t h i s s e c t i o n i s based upon the 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) d e s c r i p -t i o n o f nurses 1 a c t i v i t i e s . The community h e a l t h nurse p r o v i d e s s e r v i c e d i r e c t -l y to i n d i v i d u a l s , f a m i l i e s and s p e c i a l groups. The nature o f her work r e q u i r e s her to e x e r c i s e judgement and to make d e c i s i o n s without c l o s e s u p e r v i s i o n . As a member of n u r s i n g and i n t e r d i s c i p l i n a r y teams, she has f l e x i b i l i t y o f r o l e t h a t enables her to switch from team l e a d e r to team member, depending upon the demands of the s i t u a t i o n . Of a l l community h e a l t h workers, the community h e a l t h nurse w i l l have the c l o s e s t and most frequent con-t a c t s w i t h other d i s c i p l i n e s and workers of a l l i e d agen-c i e s . Within, the team s t r u c t u r e , the nurse occupies a p i v o t a l , and o f t e n unique p o s i t i o n . She can a c t as a channel through which other needed s e r v i c e s are a c q u i r e d , due to her understanding of the s i t u a t i o n , and knowledge of the a v a i l a b i l i t y of r e l e v a n t s e r v i c e s . Although p r i m a r i l y concerned w i t h d i r e c t care c o n t a c t f u n c t i o n s , she a l s o has some a d m i n i s t r a t i v e , s u p e r v i s o r y and 6 counselling r e s p o n s i b i l i t i e s . The supervisor of community health nursing occupies the key int e r p r e t i v e r o l e between the director and service nursing personnel. She i s responsible to the director for planning and d i r e c t i n g the a c t i v i t i e s of nursing and a u x i l i a r y s t a f f i n a sp e c i f i e d area. She i s also responsible for s t a f f development. The director of community health nursing i s a member of the administrative team of the organization. Inherent i n the pos i t i o n of director i s decision making authority i n r e l a t i o n to the entire range of nursing services under her d i r e c t i o n . She i s responsible for the functioning of 'the s t a f f and programs under her direc-tion to a chief administrator as designated by the organ-i z a t i o n . The director participates i n po l i c y planning, and i n determining the short and long range plans for the community health nursing services of the organization. She interprets community health nursing a c t i v i t i e s to other adminstrative personnel and the po l i c y .making board of the organization, and to community agencies. Converse-l y , she helps the nursing s t a f f to see t h e i r roles and functions i n r e l a t i o n to other community agencies. The nurse consultant i s an expert, by reason of edu-cation or experience, either i n the general f i e l d of community health nursing, or i n a s p e c i f i c area. Her primary purpose i s to promote: the quality and development 7 of the agencies nursing program. Her pos i t i o n i n the administrative hierarchy of the organization w i l l de-pend upon the s p e c i f i c organizational structure. The d i s t r i b u t i o n of community health nurses by pos i t i o n and by province for 1975 i s shown i n Table 1.1 (p. 8). Table 1.2 (p. 9) shows the d i s t r i b u t i o n of commun-i t y health nurses by p o s i t i o n for 1969, 1970, 1971 and 1975. In 1975, 2.2.per cent were directors or assistant directors (122), 7.9 per cent were supervisors or a s s i s -tant supervisors (446), and 1.6 per cent (90) were consultants. The d i s t r i b u t i o n of community health nurses by academic q u a l i f i c a t i o n s for 1975 i s shown i n Figure 1.1 (p. 10). Between 1970 and 1975 there was a reduction i n the percentage of registered nurses with public health c e r t i f i c a t e s from 45.7 per cent to 36.2 per cent. There was an increase i n the percentage of registered nurses with a baccalaureate degree, major public health, from 14.6 per cent to 19.8 per cent. There was also an increase i n registered nurses with a baccalaureate degree only, from 2.8 per cent i n 1970 to 7.2 per cent i n 1975. The other categories showed l i t t l e change between 1970 and 1975. Table 1.1 D i s t r i b u t i o n of Community Health Nurses reported by position and by Province 1975 POSITION Director Asst. Director (service) Asst. Director (education). Consultant (generalized) .. Consultant (specialized) .. Supervisor Asst. Supervisor S t a f f Nurse (Public Health) S t a f f Nurse (RN) TOTAL Canada Nf l d PEI NS NB QUE. ONT. • MAN. SASK ALTA BC YUKON" 78 1 1 3 1 6 42 4 4 11 5 39 4 - 1 1 6 16 2 2 4 2 1 5 - - - 1 - 1 1 - 1 1 -28 - - - - - 7 9 4 3 4 1 62 - - - - - 55 2 - 3 1 1 290 8 4 8 6 26 111 14 14 52 37 10 156 1 - 3 13 9 42 11 23 1 51 2 3,828 71 24 162 60 402 1,561 278 183 384 597 106 1,160 33 4 2 29 503 298 90 42 49 95 15 5,646 118 33 179 111 952 2,133 411 272 508 793 136 Source: S t a t i s t i c s Canada, Annual Salaries of Public Health Nurses. Ottawa: Information Canada, 1975 9 Table 1.2 Di s t r i b u t i o n of Cornmunity Health Nurses reported  by position, 1969, 1970, 1971 and 1975. Position 1969 1970 1971 1975 Staff nurses 3,744 4,533 4,647 4,988 Supervisors/Assistant Supervisors 389 501 548 446 Consultants 40 46 48 90 Directors/Assistant Directors 80 109 123 122 Total 4,253 5,189 5,366 5,646 Source: Statics Canada. Annual Salaries of Public Health 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 Public Health Nurses  by Academic Q u a l i f i c a t i o n , 1975 19.8% 6. 0.9% 7. 0.4% 8. 0.1% 36.2% 31.3% 1 Registered nurse with .public health c e r t i f i c a t e 2 Registered nurse only 3 R.N, with bacc. major pu b l i c health 4 R.N, with bacc. only 5 R.N, with bacc. with p u b l i c health c e r t i f i c a t e 6 R.N, with master's degree, major p u b l i c health 7 R.N, with master's degree, with p u b l i c health c e r t i f i c a t e 8 R.N, with master's degree only Source: S t a t i s t i c s Canada, Annual Salaries of Public  Health Nurses. Ottawa: Information Canada, 1975 11 1.3 The management structure i n community health  nursing To f a c i l i t a t e an understanding of the r o l e of the nurse i n the management of community health services, the structure of a t y p i c a l community health agency i s out-l i n e d i n Figure 1.2. (p. 12). (This structure may vary somewhat from province to province). The size of the community served, and the range of services provided w i l l determine more exactly the s t a f f -ing of the agency. The degree of authority given to nursing superviors varies according to t h e i r background and experience, and esp e c i a l l y the management style of the medical o f f i c e r of health, or director of the agency. In smaller health units, the direc t o r may be a community health nurse. It i s often suggested that the authority structure i n community nursing services i s much less r i g i d l y ap-p l i e d than i n hospital nursing services (Clark, 1977). The community health nurse functions far more i n the role of independent professional p r a c t i t i o n e r than as a "physician's assistant." She has a much greater degree of autonomy compared with the hos p i t a l nurse. A major reason for this i s the physical i s o l a t i o n of the community nurse, i . e . her separation from the point of central control. This i s o l a t i o n , and th e i r r e l a t i v e independence (Bristow, 1976), are seen as factors that F i g u r e 1.2 Community H e a l t h Agency S t r u c t u r e 12 Health Agency Board Director/Medical O f f i c e r of Health Senior Public Health Inspector Nursing Supervisor Dental O f f i c e r Other S t a f f Admini-s t r a t i v e O f f i c e r Public Health Inspectors Community Health Nurses 13 considerably reduce the p o t e n t i a l for c o n f l i c t between management personnel and nurses acting as autonomous professionals (Clark, 1977). Community health nurses involved i n management f i n d themselves facing some common problems (Stevens, 1975; 1976). As managers, they are faced with the c o n f l i c t be-tween professional and administrative r o l e s . In t h e i r professional role they are concerned with providing the optimum . quality of care, while i n t h e i r administrative capacity they are concerned with functioning economic-a l l y and e f f i c i e n t l y . Ultimately, they have to balance the goals and resources of the programs they are manag-ing. The nurse as executive often faces the problem of being i n a position,of inequitable power compared with many of those around her' (Stevens, 1975). There are well known s o c i a l and h i s t o r i c a l reasons for t h i s . These re 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 society, and the perception of the nurse as the physician's handmaiden. Much of the changes .that need to be made in this respect are psychological. Nurses i n managerial positions need to be aware of and sensitive to the informal l i n e s of communication i n an organization. "The philosophy and d i r e c t i o n of an organization originate i n informal power groups, rather than i n discussions at formal meetings. Formal meetings tend to c r y s t a l l i z e and authorize thoughts and plans that are generated i n the informal structure" (Stevens, 1975. p. 88). While nurses may occupy positions with authority vested i n them, and attend a l l the o f f i c i a l meetings, Stevens feels that they are often on the out-side of the informal power structure. Where t h i s i s the case, nurses need to be conscious of i t , and work to overcome i t . In t h e i r capacity as managers, community health nurses require information d i f f e r e n t from that they re-quire as c l i n i c a l p r a c t i t i o n e r s . The kinds of informa-tion, and i n p a r t i c u l a r , a c t i v i t y data, required at d i f f e r e n t l e v e l s i n the organization of community nurs-ing services , w i l l now be considered. 15 CHAPTER 2 2.1 Information c h a r a c t e r i s t i c s for d i f f e r e n t  organizational l e v e l s . In assessing the information needs of any i n d i v i -dual i n an organization, i t i s important to know the types of functions they are performing, and the nature of the decisions they face. These functions and deci-sions w i l l a f f e c t the type of information they require. Antony (in Lucas, Clowes and Kaplan, 1974) d i s t i n -guished between three levels of decision making a c t i v i t i e s i n an organization: decision a c t i v i t i e s r e l a t e d to 1. operational control, 2. management control, and 3. strategic planning. Strategic planning, or p o l i c y formation, involves the process of determining organizational objectives, and the means for achieving them. At t h i s l e v e l , a major concern of the planner or p o l i c y maker i s the re-lationship between the organization and i t s environment. Other organizations, their objectives, and how they go about trying to accomplish them are key variables and processes to be taken into account. Those i n positions of management control pursue the objectives set i n strategic planning through a process of 16 resource a l l o c a t i o n , and the monitoring of resource u t i l i z a t i o n . Operational control refers to the process of en-suring that s p e c i f i c tasks are e f f e c t i v e l y and e f f i c i e n t -l y carried out. The three categories, or levels of operation out-l i n e d above, form a continuum; the d i s t i n c t i o n between decision categories, or l e v e l s , i s not clear-cut. The nature of the information required for the d i f f e r e n t types of decisions may d i f f e r widely, as can be seen i n Table 2.1 (p. 17). Adopting the t r a d i t i o n a l view of the agency as a pyramid, the realtionship between the structure of a community health agency and i t s information flows i s i l l u s t r a t e d i n Figure 2.1. (p. 18). Table 2.1 The Antony Framework and Information Characteristics Normative Information Characteristics for Operational Control ManagementCControl Strategic Planning Decisions Decisions Decisions 1. Very detailed data Moderately detailed data. Aggregate data 2. Related to a s p e c i f i c task. Related to achievement of organization's obiectives. Relates to establishing broad p o l i c i e s . 3. Frequently reported Regularly reported Infrequently reported 4. H i s t o r i c a l data H i s t o r i c a l and predictive data. Predictive data 5. Internally generated Mostly i n t e r n a l l y generated. Externally generated 6. Very accurate Accurate within decision bounds. Accurate i n magnitude only•. 7. Repetitive Exception reporting Unique to problem under consideration. 8. Narrow scope Specific and general i n scope Wide scope 9. Current, up to date Mostly medium term Older, showing previous periods Sources: a. Lucas, Henry C , Clowes, Kenneth W.,.and Kaplan, Robert B. "Framework for Information Systems," INFOR Vol. 12, No. 3, October 1974.,, and' b. Keen, Peter G.W., and Scott Morton, Michael S. Decision Support Systems, An Organizational Perspective. Reading, Mass.: Addison - Wesley, 1978. 18 Figure 2.1 Community Health Agency Pyramid Structure for Management  Information System Information used for Agency Administration Director/ 'Plan-V % Supervisoi o Managing -o Information used for Agency and Program a c t i v i t i e s ^Program Information used for patient a c t i v i t i e s Patient Staff Providing care Source: Adapted from Saba, V i r g i n i a K. "A Guide to Understanding Management Information Systems", i n National League for Nursing. State of the  Art i n Management Information Systems for Public He alth/C ommuni ty Health Agencies. Report of the  Conference. New York: National League for Nursing Publication 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 levels of the organization, and to the functioning of any organization, i s that of decision making. To under-stand how and at what stages information may be useful, i t i s necessary to understand the decision making process. A v i t a l contribution towards a taxonomy of decisions, and to our understanding of decision making, has been the work of Simon on human problem solving (Simon, 1960.) Simon distinguishes between two types of decisions -programmed and non-programmed. "Decisions are programmed to the extent that they are r e p e t i t i v e and routine, to the extent that a d e f i n i t e procedure has been worked out for hhandling them ... Decisions are non-programmed to the extent that they are novel, unstructured and consequential." (Simon, 1960. p. 5). In the case of a programmed, or structured decision, a s p e c i f i c procedure can be applied to reach a decision each time the s i t u a t i o n arises. This cannot be done i n the case of non-programmed, or unstructured, decisions. In such cases, there i s no s p e c i f i e d way of dealing with the problem, as i t may not have arisen before, or i t may be so complex or elusive as to warrant special treatment. Few decisions are t o t a l l y programmed (structured) or 20 t o t a l l y non-programmed (unstructured); rather, these are polar types for a continuum of decision making a c t i v i t y . Simon breaks problem solving down into three phases: 1. i n t e l l i g e n c e , 2. design and 3. choice. Intelligence consists of surveying the environment for conditions that c a l l for action. Design involves "inventing, developing and analyzing possible courses of action," (Simon, 1960. p. 2), while choice i s the a c t i v i -ty of selecting a p a r t i c u l a r action from the set of a l -ternatives developed. A f u l l y structured problem i s one i n which a l l three phases are structured, while unstruc-tured problems are those i n which a l l three phases are unstructured. Where only one or two of the phases i s structured, the problem i n i t s entirety i s semi-structured. Considerable work yet remains to be done on an adequate d e f i n i t i o n of "structure", so that the precise meaning conveyed by i t can be c l e a r l y understood. Over time decision techniques do not remain s t a t i c , and the develop-ment of new techniques w i l l tend to add further structure to decision making. Gorry and Scott-Morton have combined the approaches of Antony and Simon to provide a framework which shows that the nature of decisions to be made, or problems to 21 be resolved, w i l l vary within each l e v e l of operation, along the structured to unstructured continuum. Before considering the functions performed by com-munity health nursing directors and supervisors, inform-ation flows i n community health organizations w i l l be examined. This w i l l include a look at what i s meant by a c t i v i t y recording. 2.2 Information flows i n an organization Information provides the means, i n quantitative or descriptive terms, of measuring and describing the functioning and performance of a system. The basic relationship between systems elements and information channels i n complex s o c i a l structures, such as health service organizations, i s i l l u s t r a t e d i n Figure 2.2 (p. 22). From this diagram i t can be seen that information provides a means of measuring the d i f -ference between the objectives, or desired achievements, of a system, and the actual r e s u l t s or output obtained. The information flows and decision making network i n an organization may be viewed as the continuous l i n k i n g mech-anism governing i t s resource flows. A community health agency forms the processing component of the subsystem of the o v e r a l l health system within which i t operates. The inputs and outputs of this system are the same people i n the community. I t i s the objective of the agency that t h e i r health status be Figure 2.2 Information Flows i n a System perceived a l t e r n a t i v e s p r i o r i t i e s pressures, incentives, biases Resources Objectives (Desired achievements) f i n a n c i a l constraints Decision Making Process Decision Transformation Process Outputs Information about output (Perceived achievements) Key Information flows r o Material (service) flows ^ Processes 23 altered by th e i r i n t e r a c t i o n with the agency and i t s personnel. To perform e f f e c t i v e l y i n pursuit of i t s ob-j e c t i v e , the agency needs certain types of information. These are i l l u s t r a t e d i n Figure 2.3 (p. 24), which shows the health agency as the processing unit i n a community health system. From Figure 2.3, the three major types of informa-ti o n the agency i s concerned with are: 1. data about the demographic features of 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 part of t h e i r own assessment of how well they are doing i n pursuit of t h e i r obj ectives, and 3. feedback from people affected by agency a c t i v i t i e s . Ultimately, i t i s the t h i r d type of information, re-lated to the outcome of 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 e f f e c t i v e -ness . A c t i v i t y recording data i s a component of agency generated information that the agency can use i n i t s self-evaluation process. We now examine exactly what i s meant by a c t i v i t y recording and a c t i v i t y data. 24 Figure 2.3 Information flows of a Health Agency Other Health Agencies -5H Community Supplying inputs (people) Receiving outputs (people) Demographic features of s o c i a l environment Follow-up from service r e c i p i e n t s 1 "| , S e l f 1  (evaluation l Community Health Agency (processing people) L- J Source: Adapted from Segal, JoAn S. "Interfaces between Health Agencies and the Library Profession," i n National League for Nursing, State of the Art i n  Management Information Systems for Public Health/" * Community Health Agencies. Report of the Confer r '-fenye. New York: National League for Nursing Publication number 21-1637. 1976. p. 23. 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 practice of noting the a c t i v i t i e s one i s involved i n , during the course of time spent at work, or i n work related a c t i v i t i e s . A c t i v i t y recording and reporting can be quantitative or q u a l i t a t i v e i n nature. In the way i t i s used i n this study, a c t i v i t y recording refers s t r i c t l y to the a c t i v i -t i e s of the service providers. It does not encompass data concerning the recipients of service. With quantitative recording, s t a t i s t i c s are compiled to measure the amount of services provided and the extent of services consumed, as indicated by numbers served. The amount of nursing time u t i l i z e d may also be noted. This kind of recording i s done by the service provider, as she i s the most appropriate person to do so. Descriptive or narrative reporting on a c t i v i t i e s can serve to interpret 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. Such reporting can be done by service providers, as well as by the i r supervisors. Standard d e f i n i t i o n s for the basic units of nursing service are necessary to enable a uniform understanding of the meaning of the measurements performed. Standard d e f i n i t i o n s for non-nursing services, e.g. c l e r i c a l work or continuing education may also be necessary, depending upon the scope of the a c t i v i t y recording. The kind of 26 s t a t i s t i c a l material recorded ought to r e f l e c t the operation of the agency within the framework of 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 require i n t h e i r s t a t i s -t i c a l reporting. The content and frequency of a c t i v i t y recording and reporting w i l l depend on the desires of the p a r t i c u l a r agency. Within the l a s t two decades i n North America, and p a r t i c u l a r l y during the 1970's, there has been a consid-erable growth i n a c t i v i t y recording systems for community health agencies, and i n the refinement of these systems (National League for Nursing, 1974 (a); 1975; 1976; 1978). The advent of advanced data processing technology has lent impetus to this development, and the number of computer-ized systems throughout the continent i s growing rapidly. In the U.S.A., the focus of computerization has been to automate the c l e r i c a l functions related to the f i n a n c i a l operations of the agency. This has not been the case i n Canada, where agencies provide services which do not have to be paid for d i r e c t l y by the service r e c i p i e n t s . B i l l i n g for services i s thus not a major concern of these agencies. Inevitably, the scope and content of a c t i v i t y record-ing over time for community health nurses w i l l show va r i a t i o n i n accordance with the changing scope and focus of community health nursing service. 2 7 An example of an a c t i v i t y recording system can be seen i n section 5.6. 2.4 Functions performed by nurses at d i f f e r e n t levels  i n the organization Many claims have been made about the need for a c t i v i -ty data, and the ways i n which these data can be used (Freeman, 1970; National League for Nursing, 1974(a);. 1976; 1978). These include claims that such data are useful i n the a c t i v i t i e s of planning, evaluation, determining costs or the cost-effectiveness of services, determining s t a f f i n g l e v e l s , measuring productivity, comparing service s t a t i s t i c s , education and various others. The above a c t i v i t i e s are not d i s t i n c t l y separate processes. Indeed, they are most often very c l o s e l y re-lated. They form d i f f e r e n t elements of the continuous i n -teractive process of providing community health services. Planning i s probably the most pervasive a c t i v i t y of a l l , and i s part of a l l a c t i v i t i e s that deal with the future. Evaluation, either e x p l i c i t or i m p l i c i t , i s an inherent part of any planning process. Considerations, such as costs, and e f f i c i e n c y and effectiveness, enter into a l -most a l l a c t i v i t i e s r elated to providing community health nursing service. In the same way, the a c t i v i t i e s performed at any one 28 l e v e l i n the organization are not d i s t i n c t from similar a c t i v i t i e s performed at other l e v e l s . For example, evaluation at any one l e v e l i s i n t e g r a l l y related to evaluation at the other two l e v e l s . 2.4.1 Operational Control At the operational l e v e l , community health nurses provide dir e c t care and other health services to i n d i v i -duals and families i n the community. By keeping a count of the various a c t i v i t i e s they are involved i n , they form the primary source of a c t i v i t y recording data. What use could nurses themselves have of this data they c o l l e c t about their own a c t i v i t i e s ? At the opera-t i o n a l l e v e l , the nurse i s primarily concerned with data concerning the recipients of the service she i s providing. A c t i v i t y data are generally intended for use at a manager-i a l and strategic planning l e v e l , and not at the operation-a l l e v e l i t s e l f . A c t i v i t y data can provide the nurses with an inventory of what they have been doing. It could help them i n plan-ning th e i r d a i l y a c t i v i t i e s . I f they are able to see reports of the a c t i v i t i e s of other nurses, they can com-pare th e i r a c t i v i t i e s with what others are doing. This would enable them to gain a perspective of th e i r role i n comparison with others i n the organization. 29 2.4.2 Management Control At the l e v e l of management control i s the supervisor, and assistant or associate supervisor. Supervisors at a managerial control l e v e l are responsible for seeing that strategic planning and po l i c y decisions are e f f e c t i v e l y and e f f i c i e n t l y translated into action. The function of management control are not separate and d i s t i n c t from the strategic planning process performed at a higher l e v e l . Neither are these functions separate and d i s t i n c t from each other; they are closely i n t e r r e l a t e d . Organizing i s the process, often h i e r a r c h i c a l i n nature, of reducing large quantities of information into structures that can be handled and dealt with conveniently. This involves decision making, as i t involves selecting among perceived alternatives. The management of nursing services involves the determination of what must be done by the group, and the individuals who comprise the group, to accomplish stated goals. "The managerial role requires an a b i l i t y to v i s u a l i z e and project an integrated pattern of action. Organizing i s intimately concerned with people i n a formal structuring of work r o l e s . " (Douglas, 1977. p. 69). Delegation i s a key managerial function. The mana-g e r i a l r o l e c a l l s for a delegator with the experience, knowledge and a b i l i t y to implement the operations over which she has control. Prudent delegation of r e s p o n s i b i l i t y 30 to the appropriate personnel i s the means whereby a mana-ger i s able to maximize the productivity of her available resources. Volante (1974) views the following steps as important for e f f e c t i v e delegation: 1. defining the task to be done, 2. relaying the d e f i n i t i o n of the task, 3. establishing controls and checkpoints to ensure feedback, and 4. establishing a dialogue with those performing the delegated tasks. Organizing^ and delegating inherently involve plan-ning. They require devising projections of how e f f i c i e n t and e f f e c t i v e alternative allocations of resources would be, and then choosing and implementing the perceived best altern a t i v e . Managers need to know the a b i l i t i e s and preferences of t h e i r s t a f f resources to organize and delegate e f f e c t -i v e l y . They also need to monitor t h e i r s t a f f i n the per-formance of th e i r duties. A c t i v i t y data provide an inven-tory of the a c t i v i t i e s performed by each nurse. As such, they act as indicators of the capacities of the nurses. These data add to the manager's knowledge about the a c t i v -i t i t e s of her personnel. But there i s much other informa-tion which the supervisor requires. She needs to know the q u a l i f i c a t i o n s and preferences of her s t a f f , the quality and outcomes of services provided, and the opinions 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 of the many information requirements of supervi-sors .involved i n organizing and delegating work. One of the most important and complex managerial functions i s to determine a s t a f f i n g pattern that w i l l u t i l i z e available s t a f f resources to maximum e f f e c t . There are many factors to be considered. These may vary i n importance, according to the ch a r a c t e r i s t i c s of the community. These factors include the size of the popu-l a t i o n , i t s age d i s t r i b u t i o n , b i r t h rates, morbidity and mortality rates, and health b e l i e f s and practices i n the community. Probably the best single measure of personnel required are the actual needs of the patients and fami-l i e s i n the community. (Roberts, 1963). Professional factors, such as q u a l i f i c a t i o n s and job s p e c i f i c a t i o n s , and service factors, such as nursing standards and person-nel p o l i c i e s , also need to be taken into consideration. St a f f i n g i s a complex issue. "The large amount of time spent i n s t a f f i n g i s .due i^nrpart to. manpower problems, such as shortages and personnel preferences, but i s also greatly due to the lack of conceptualization of the t o t a l -i t y of the program, f a i l u r e to recognize s i g n i f i c a n t var-iables, and the lack of i n t e l l e c t u a l s k i l l s required i n the construction of the t o t a l program." (Aydelotte, 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 involves r e l y i n g heavily on experience and 32 f a m i l i a r i t y with the f i e l d . It i s by no means a structured or s c i e n t i f i c decision making process. "A variety of models are available for use, but there i s no consistent strategy." (Aydelotte, 1974. p. 5.) Increas-ing the amount of information available w i l l not neces-s a r i l y simplify the problem. For any p a r t i c u l a r s i t u a -tion, the appropriate model needs to be developed, under-stood and s k i l l f u l l y applied. A part of determiningu.s.taf€jfcngsissusing nurse-to-pop-ul a t i o n r a t i o s . These ra t i o s are related to workloads based on the average amount of service an i n d i v i d u a l nurse can provide. Accounts of d a i l y a c t i v i t i e s are seen as "necessary for estimating the amount and type of ser-vices given, and for determining the average amount of service one nurse can provide i n a day or other period of time." (Roberts, 1963. p. 38.). A c t i v i t y data can be used to calculate simple arithmetical means of services provided, and thus form an element of the information requirements i n s t a f f i n g . However, these data can be seen to be merely a small part of a l l the information that i s needed. Supervisors are the key personnel i n performing evaluation. It f a l l s primarily to those i n positions of management control to devise,, implement and monitor the evaluation process. Data to be used i n evaluation may be gathered by nurses at the operational l e v e l , while f i n a l 33 judgement and possibly intepretation may be made at a strategic l e v e l . The range of information needed to perform an eval-uation w i l l vary according to the scope of the evaluation to be done. To provide a perspective on the role of a c t i v i t y data, the range of information needed i n evalua-t i o n w i l l be discussed i n more d e t a i l . Wolf (in National League for Nursing, 1976) describes six classes of information that are necessary to evaluate any program comprehensively. These encompass 1. the i n i t i a l status of those to be helped, 2. the status of those individuals af t e r some period of treatment, or service provision, 3. the objectives of the program, 4. the extent to which the intended program was i n fact carried out, 5. the costs involved, and 6. any supplemental information Supplemental information refers to the views, opinions and impressions of those associated with the program. They should complement the more objective measurement of pre-determined variables, and add a dimension to the perspec-t i v e and understanding of the evaluator. Any evaluation inherently involves the judgement of the evaluator or evaluation team. Those performing an evaluation ought not to delude themselves into thinking 34 that they are engaged i n a purely s c i e n t i f i c process, "or that information necessarily leads to certain conclusions and implications f o r p o l i c y and practice... Evaluation and planning a c t i v i t i e s always involve judgements." (Wolf, i n National League for Nursing, 1976, p. 36). A c t i v i t y data provide an element of information under 4.(above), that can be used i n program evaluation. They act as an inventory of the type and quantity of services provided. However, i t i s evident that many d i f f e r e n t classes of information are necessary i n any evaluation process. While a c t i v i t y data can be used i n evaluation, they are only one element of many contributing to the f i n a l judgement or judgements made. A c t i v i t y data act as an i n d i r e c t measure of the pro- d u c t i v i t y of the nursing s t a f f . Real productivity can not be shown by these s t a t i s t i c s alone. Actual productivity derives from the knowledge, s k i l l and motivation applied by the individuals on the s t a f f . To a large extent, " i t i s on the leadership group that the motivation of s t a f f and the consequent degree of productivity depends." (Aydelotte, 1974. p. 6)./ If the time spent i n a c t i v i t i e s i s noted, a costing of nursing services can be obtained from a c t i v i t y data. But these data give no measure of the effectiveness, or benefit, of the services costed. Other measures are needed to evaluate benefit or effectiveness. There are 35 considerable d i f f i c u l t i e s i n t h i s respect. Effectiveness i n the f i e l d of ^preventive services and health promotion i s hard to calculate. (Shapiro, 1977; K r i s t e i n , 1977). The claim i s sometimes made that a c t i v i t y data can help i n assessing the q u a l i t y of care. To assess quality of care, data concerning the process and outcome of care provided are required. These data elements need to be linked c l e a r l y to those to whom care was given. A c t i v i t y recording c o l l e c t s data on the a c t i v i t i e s of the service, provider. It does not record process, or outcome. As process and outcome measur.esa are essential i n any true determination of quality of care, i t i s evident that a c t i v -i t y data are of minimal help i n assessing q u a l i t y of care. Supervisors are also, responsible for s t a f f development. Continuing education plays a v i t a l r ole i n enabling nurses to keep abreast of the l a t e s t developments, and equipping them to meet t h e i r challenging r o l e i n the community. Such education needs to be directed towards areas where community health nursing i s becoming involved, and t r a i n i n g i s required, or needs to be refreshed. Data obtained from a c t i v i t y recording can provide use-f u l indicators of areas where such education i s necessary. For example, a sharp increase i n cases of c h i l d abuse counselling over a p a r t i c u l a r period may indicate that courses dealing with c h i l d abuse are required. A sharp i n -crease i n work-related accident v i s i t s may indicate that 36 nurses require further i n s t r u c t i o n i n occupational health. Continuing education decisions need to take into account a variety of information. These include the i n t e r e s t s , education and p r i o r t r a i n i n g of s t a f f nurses, planned new programs and changes i n p r i o r i t i e s . A c t i v i t y data are thus only one of a number of data items to be considered. A c t i v i t y data can be used to obtain baseline data for p a r t i c u l a r a c t i v i t e s , and to observe trend data over time. Baseline data, by i t s e l f , i s of l i m i t e d usefulness. It merely indicates a volume of work done. It becomes mean-in g f u l when compared with other data, to obtain trend data or data comparisons. The value of such trend data or com-parative data w i l l depend upon t h e i r interpretation within the context of the s i t u a t i o n . Comparisons' provide l i t t l e insight into or understanding of a si t u a t i o n , unless exam-ined i n connection with s p e c i f i c queries, objectives or related variables. In obtaining comparative data, i t i s most he l p f u l to es t a b l i s h clear objectives beforehand, so that the appropriate data can be gathered. 2.4.3 Strategic planning At the strategic planning or p o l i c y formation l e v e l , i s the director of community health nursing. In budget applications at a strategic planning and po l i c y formation l e v e l , directors need to have information concerning the a c t i v i t i e s of t h e i r community health nurses. 3 7 In budgeting, and developing plans and strategies for t h e i r organization, they also have to take into account informa-ti o n presented by other senior health service managers or o f f i c i a l s . Strategic planning d i f f e r s from planning at other levels i n the organization. The scope and depth of analysis i s broader, while the range of variables involved may also be broader, and less well-defined. The long term time per-spective involved means that there w i l l be a p o t e n t i a l l y greater number of interactions between variables to be considered. One of the normative c h a r a c t e r i s t i c s of information at a strategic planning l e v e l (Table 2.1), i s that predictive data i s required. 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 data. These h i s t o r i c a l data may provide greater insights into the relationships between systems variables than would have been possible without them. While h i s t o r i c a l data are useful as a basis for generating predictive data, they cannot serve as a substitute for predictive data. Evaluation forms a fundamental element of the strategic planning process. Once a plan has been devised and imple-mented, i t needs to be continually monitored to ensure that i t i s progressing as intended. The evaluation process involves the c o l l e c t i o n , analysis and interpretation of information. The process of evaluation has already been described i n section 2 .4. 2 . Directors do not need to be c l o s e l y 38 involved i n this process. They can consult with those actually carrying out the evaluation. But they need to be aware of the results found and judgements indicated, as the f i n a l judgement i n this process often rests i n their hands. Determining s t a f f i n g levels and deciding upon the appropriate s t a f f i s as complex a problem at t h i s l e v e l as at the managerial control l e v e l . While the scope of this a c t i v i t y at a strategic planning l e v e l w i l l be con-siderably broader, similar factors need to be taken into account. A c t i v i t y data can be used at a strategic planning l e v e l to plan and compile the educational programs for community health nurses. Such data w i l l only be .helpful i f they are available to and taken into account by those c o n t r o l l i n g the relevant educational programs. One of the major reasons for gathering a c t i v i t y data i s to provide agency boards or governing bodies with an outline of the a c t i v i t i e s of community health nurses. These data are a means of communicating what services were provided, i . e . the quantity and nature of the work the nurses have been doing. This reporting back to p o l i c y boards or governing bodies i s seen as a way of making nurses more accountable for t h e i r actions. As a c t i v i t y data do not refer to pro-cessess or outcomes of services provided, they can only be 39 used to hold nurses accountable for the type and amount of work done. A c t i v i t y data present an account of how nursing time was u t i l i z e d , and not on the productivity of nurses actions. Further data on processes and outcomes need to be gathered to provide a more comprehensive per-spective on accountability. Unless the members of boards or governing bodies are well versed i n the planning and evaluation process, there may be a tendency to l e t a c t i v i t y data act as a substitute for more meaningful measures of nurses' productivity. 2.5 ".Activity data and decisionmaking How do a c t i v i t y data contribute to the decision making process at the strategic planning level? As directors deal with highly aggregated data, only glaring ommissions or excesses are l i k e l y to receive attention. Examples of these would be no occupational health programs i n a highly i n d u s t r i a l i z e d region, or too many prenatal classes i n a sparsely populated region with a predominantly el d e r l y population. However, such conditions are l i k e l y to be noted and dealt with before being noticed s p e c i f i c a l l y i n a c t i v i t y s t a t i s t i c s . A c t i v i t y data would appear to make l i t t l e contribution at the stage of looking for conditions requiring action. A c t i v i t y data may have some impact at the design stage. The capacities of service providers, and the demand or 40 preferences of consumers, may be infe r r e d from the data. Although a c t i v i t y data are h i s t o r i c a l , they can act as a basis for the predictive data that needs to be generated 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 a t t r a c t i v e -ness of a l l the alternatives developed. A c t i v i t y data w i l l have no impact on choices made i n strategic planning. Thus, the contribution made by a c t i v i t y data i n decision making at the strategic planning l e v e l i s limited. Their primary impact i s at the design stage. At the management control l e v e l , the parameters of the framework within which i n t e l l i g e n c e may be exercised are more c l e a r l y and cl o s e l y defined. Supervisors at this l e v e l function within established p o l i c y guidelines and con^-s t r a i n t s , and with given resources. 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 delegation function, or i n determining s t a f f i n g patterns. The data show what functions nurses are performing. When nurses are inappropriately employed, this may be noted from the data. These data provide a more accurate i n d i c a t i o n to the managers of what nurses are doing than a verbal report may provide. Supervisors may note that th e i r prenatal expert i s involved 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 prenatal group sessions. A c t i v i t y data do not provide a s c i e n t i f i c means of i n d i c a t -ing when action i s required. Supervisors w i l l have to 41 exercise 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 s t a t i s t i c s . In the design phase, a c t i v i t y data give supervisors an idea of the work that th e i r s t a f f are doing. These data may act as a basis for projecting alternative work-loads or work assignments. At this stage, i t i s again evident that objective data cannot replace normative judge-ment . As at the strategic planning l e v e l , a c t i v i t y data have no r e a l contribution to make i n the normative choice phase. In summary, we have seen that these data are of no use at the choice stage. They may be useful i n the i n t e l -ligence phase at the management control l e v e l , while at the design phase they provide supervisors and directors with an h i s t o r i c a l account of nurses 1 a c t i v i t i e s . 2.6 The role of a c t i v i t y data "Data, as i t i s regarded i n planning, i s something l i k e 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 with a c l i n i c a l thermometer, i f something i s to be done with the data, then there must be a diagnosis which requires much more in s i g h t . " (Bergwall, Reeves and Woodside, 1974. p. 158). Planners and management cannot r e l y s o l e l y on objective data. Insight and understanding, and a number of d i f f e r e n t kinds of information are also 42 required. A c t i v i t y data show the type and quantity of services provided and u t i l i z e d i n p a r t i c u l a r areas of need. They can show changes i n patterns of service provision or u t i l i z -ation. They may indicate service p r i o r i t i e s or changes i n p r i o r i t i e s . S t i l l , many other kinds of information are required. For example, i n planning, the demographic features of the population are a v i t a l element of the objective data required. These features include the population size, age d i s t r i b u t i o n , sex r a t i o , . population density, economic status and the l e v e l of health education. Data on the health status of the population are also necessary. There are two approaches that may be used i n planning. F i r s t l y , the epidemiological needs of the population can be i n d e n t i f i e d and p r i o r i z e d . Proceeding from this ordered set of needs, plans could then be developed to use available resources i n the most e f f e c t i v e way to respond to the needs i d e n t i f i e d . A second approach would be to base the develop-ment of a plan on the available resources, and the h i s t o r i c -a l l y demonstrated capacities of such resources. This approach i s more s t a t i c and conservative than the former. In actual-i t y , any planning process w i l l involve a combination of the two approaches. But, a difference i n accent or approach w i l l lead 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. Attaching undue weight and 43 importance to a c t i v i t y data may bias the perspectives of those using the data and thus the o v e r a l l planning process. Relying overly on a c t i v i t y data may lead to planning that i s resource based, and not population based. There are many questions to be answered i n evaluation. These questions r e l a t e to service p r i o r i t i e s , the quality of services provided, and the outcomes observed. I t i s also desirable to know whether services were provided to and used by those i n need of them. Some of this additional information, e.g. the i d e n t i t y of service r e c i p i e n t s , could be obtained by more detailed recording systems. This additional information provides a more comprehensive picture 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 additional informa-tion could be recorded simply, the presentation and i n t e r -pretation of the data gathered would be more complex. Additional information w i l l not i n i t s e l f ensure improve-ment i n the decision making process. Improvement w i l l de-pend upon how such information i s analyzed and interpreted. A c t i v i t y data are one element of many i n the decision making processes of community health nursing directors and supervisors. By themselves, they are of li m i t e d usefulness. However, used i n combination with the other types of inform-ation discussed i n this 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 supervisors and directors. 44 CHAPTER 3 3.1 The dynamics of data transmission There are numerous factors a f f e c t i n g a c t i v i t y data i n i t s flow through an organization. These factors need to be considered and dealt with during the development and implementation of an a c t i v i t y recording system. This chapter examines these factors at three stages of the data transmission process. These stages, i l l u s t r a t e d i n Figure 3.1 (p . 45) , are : 1. data a c q u i s i t i o n , 2. data communication, and 3. data interpretation. 3.2 Data ac q u i s i t i o n There are certain features of a c t i v i t y data which af f e c t the quality of decisions based on these data. The following important aspects of data a c q u i s i t i o n are con-sidered i n this section: 1. accuracy, 2. r e l i a b i l i t y , 3. v a l i d i t y , and 4. cost. 45 Figure 3.1 The Stages of Data Transmission T Data Communication Interpretation of data of data gathering ^ L . Decision making 46 3.2.1 Accuracy Accuracy i s the degree of exactness with which an instrument measures the a c t i v i t i e s i t records. The desired degree of accuracy w i l l depend upon the purpose or purposes for which the data are needed. That i s , i t w i l l depend on what i s to be done with the measurements (Runkel and McGrath, 1972). Where an instrument i s not accurate enough, more items of a similar kind and quality may be added to increase the pr o b a b i l i t y of accurate measurement. (Kerlinger, 1973). An example of this may be seen i n the subject codes of the a c t i v i t y recording system i n Alberta. (Table 5.. 1, p. 104). Subject codes 29, 30, 31 and 32 (smoking, n u t r i t i o n , exer-c i s e / f i t n e s s and obesity) could be grouped under a single subject heading, l i f e s t y l e . Breaking l i f e s t y l e into the areas l i s t e d enables greater accuracy i n measuring a c t i v i -t i e s . 3.2.2 R e l i a b i l i t y " R e l i a b i l i t y can be defined as the r e l a t i v e absence of errors of measurement i n a measuring instrument" (Kerlinger, 1973. p. 443). Measurement error can be i n the form of either a systematic bias or random errors. One element of r e l i a b i l i t y i s the extent to which measurements are repeatable. This aspect i s the a b i l i t y of an instrument to produce the same or similar results for 47 repeated applications of the instrument. There are two kinds of r e l i a b i l i t y related to repeated applications; intra-observer r e l i a b i l i t y , and inter-observer r e l i a b i l i t y . Intra-observer 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 record the same results when a nurse does the same or similar type of work repeatedly. Inter-observer r e l i a b i l i t y i s the a b i l i t y of the instrument to record the same results for the same type of work done by d i f f e r e n t nurses. Differences i n measures between observers may be due to differences i n understanding, differences i n interpreting events, memory lapse or decay, or sloppy measurement. Nurses perform a wide variety of a c t i v i t i e s . Some are s p e c i f i c and c l e a r l y defined. These include immunizations, prenatal classes and screenings. But some a c t i v i t i e s can-not be succinctly described within the available categories of an a c t i v i t y recording system. For example, a nurse may meet with a pregnant woman to discuss family planning. But the discussion may include topics l i k e n u t r i t i o n , f i r s t aid, poisons? smoking or other health services i n the community. In recording this case, the nurse needs to exercise her personal judgement, taking into account her knowledge of the categories 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. (Kerlinger, 1973). These amount to an attempt to reduce the degree of error 48 i n measurement. This can be done by. 1. stating the items of the measuring instrument unambiguously. Ambiguity enables error variance to increase, because individuals are able to interpret the data d i f f e r e n t l y . 2. stating the instructions c l e a r l y . While ambig-uous instructions increase the error variance, clear and standard instructions tend to reduce errors of measurement. These two steps are c l o s e l y related. While items or categories need to be c l e a r l y stated and explained, ex-p l i c i t instructions are needed as to how items should be recorded. The c l a r i t y and explicitness of instructions for the systems reviewed i n Chapter 4 varies considerably, The system i n Alberta (Chapter 5), contains detailed and e x p l i c i t i n structions. Each nurse i s provided with a 71 page i n s t r u c t i o n manual containing instructions on how to complete the nurses report forms. This includes 8 pages explaining the subject coding. Following the above two steps can improve the r e l i a b i -l i t y of the instrument and thus the q u a l i t y of data measure-ment. But one of the major factors a f f e c t i n g r e l i a b i l i t y i s the conscientiousness with which the nurses complete th e i r a c t i v i t y reports. Once the recording instrument has been re-fined and the instructions c l a r i f i e d , recording d a i l y a c t i -v i t i e s i s a r e l a t i v e l y straightforward task. I t requires 49 a few minutes every day for nurses to keep a log of t h e i r a c t i v i t i e s , and to then transpose these d e t a i l s onto the recording form according to the relevant categories. However, those who have worked with these systems w i l l bear witness to the problem of getting 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 c a r e f u l l y log and record their a c t i v i t i e s as accurately as they can. Others record their a c t i v i t i e s casually, sometimes c l e a r l y overstating or understating the amount of work they are doing. They may make a rough approximation of the work they have done, paying l i t t l e attention to the accuracy of th e i r recording. While i t may not be possible to e n t i r e l y eliminate inaccurate recording, there are ways of improving the quality of data recording. F i r s t l y , the importance of c o r r e c t l y completing t h e i r a c t i v i t y reports can be stressed to nurses. This may rai s e t h e i r l e v e l of conscientiousness and thereby improve the standard of recording. Possibly fthe most e f f e c t i v e way of improving r e l i a b i l -i t y i s some form of data check or control. The nurses' recording can be checked and d i r e c t feedback provided. In this way, unintentional errors or bias could be corrected. Nurses' awareness of the accuracy of t h e i r recording i s l i k e l y to r i s e as they r e a l i z e that t h e i r input i s being checked. They are l i k e l y to apply themselves more 50 studiously to th e i r recording. For example, data checks have been implemented i n some of the health units i n Alberta. Consultants 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 recording i n those health units. 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 estimated? This^i's extremely d i f f i c u l t to e f f e c t i n practice, i n any absolute terms. There are ways i n which an estimate can be obtained, although these are not altogether s a t i s f a c t o r y . The most direct method i s for trained observers to compare thei r own recording of the nurses' a c t i v i t i e s with the recording of the nurses themselves. Error bounds for the data can be established. These error bounds can be applied to the decisions based on these data. However, experimental arrangements such as observation, are l i k e l y to induce re-active e f f e c t s . CCampbell and Stanley, 1963). The experi-mental conditions are l i k e l y to induce the nurses to record the i r a c t i v i t i e s as accurately as possible, i f they know the reason for the observation. Even i f they didn't, th e i r awareness of th e i r a c t i v i t i e s - would be raised, and this would probably lead to improved recording. The only (obviously unfeasible) way i n which nurses could be ob-served without a f f e c t i n g t h e i r recording, would be through t o t a l l y " i n v i s i b l e " observers. Nurses could be given a l i s t of complex a c t i v i t i e s , and asked to record 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 sit u a t i o n . This experiment removes them from the pressures of th e i r r e a l work setting. It i s thus l i k e l y to produce greater inter-observer r e l i a b i l i t y than would similar a c t i v i t i e s i f encountered by the nurses i n t h e i r actual 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 subjective opinions of supervisors. They have an idea of what the i r nurses are doing, and they have access to the a c t i v i t y data recorded. While th e i r opinions may be lacking i n quantitative precision, t h e i r subjective opinions may be the most accurate measures of r e l i a b i l i t y that can be obtained. The accuracy of recording and the r e l i a b i l i t y of measurement w i l l a f f e c t the qu a l i t y of data recorded, and thus the quality of decisions based on these data. The quality of decision making can be improved by improving the quality of the data.' - - -3.2,3 V a l i d i t y According to: Kerlinger (1973) f there are d i f f e r e n t types of v a l i d i t y . The kind of v a l i d i t y relevant to this discussion of a c t i v i t y recording, i s content v a l i d i t y . The content v a l i d i t y of an instrument refers to the adequacy with which a s p e c i f i e d domain of 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 ascertain whether the substance or content of the 52 measure i s representative of the content of the property being sampled. A c t i v i t y recording instruments measure the type and quantity of a c t i v i t i e s performed by nurses. They do not measure the content of the a c t i v i t i e s themselves. Thus, an a c t i v i t y recording instrument can provide p o t e n t i a l l y v a l i d measures of the type of a c t i v i t i e s nurses are involved i n . It cannot act as a v a l i d measure of the a c t i v i t i e s them-selves . Objectives provide guidelines to the use of data c o l -lected, and thus to the types of data required. The content of an a c t i v i t y recording instrument r e f l e c t s what informa-ti o n i s relevant i n terms of the objectives of the recording system. Clearly stated objectives w i l l specify the domain of data to be sampled, while vaguely defined objectives may leave the data domain to be sampled undetermined. When objectives are vaguely defined, the content of the i n s t r u -ment w i l l r e f l e c t the judgement of the instrument's design-ers as to what information i s relevant i n terms of the un-clear l y stated objectives. In such cases, the relevance, content and volume of data to be col l e c t e d may be d i f f i c u l t to establish. Thus, c l e a r l y defined objectives are impor-tant i n determining the content of an instrument, and i n testing for content v a l i d a t i o n . In the absence of c l e a r l y stated objectives, testing for content v a l i d a t i o n becomes a highly subjective process. (The issue of systems 53 objectives i s discussed i n more d e t a i l i n section 4.4.1). 3.2.4 Costs A c t i v i t y data provides an organization with an image of i t s a c t i v i t i e s . The more detailed the image, the great-er the costs involved i n obtaining i t . (Emery, 1971). The more abbreviated the image, the greater the costs (in non-monetary terms) of information foregone. Recording can be costly i n terms of time and nurse e f f o r t . The cost i n materials i s u n l i k e l y to be high. But as the d e t a i l recorded increases, so does the time and e f f o r t required i n recording. Nurses are not s p e c i f i c a l l y trained to perform c l e r i c a l type work, and may do so re-luct a n t l y . The more data that are collected, the more data there are to be presented. More data may mean a loss i n simpli-c i t y i n data presentation. This i s a cost to be considered i n increasing the volume of data c o l l e c t e d . In designing any system, a l l the costs involved need to be taken into account. (Emery, 1971). The trade-off between s i m p l i c i t y and gathering more data, and between di f f e r e n t levels of aggregation and d e t a i l , are among the costs that need to be considered. 3.3 Data communication Nurses at a l l levels within community health 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 such interdependence they need to communicate and u t i l i z e messages. In fact, the managerial and planning functions only become operationalized through communicative a c t i v i t y (Steers, 1977). This section w i l l examine some of the major features of data communication that a f f e c t the communica-tion of a c t i v i t y data. 3.3.1 Factors a f f e c t i n g data flow Possibly the most important factor influencing the transmission of data i s the status hierarchy of the organ-i z a t i o n . (Havelock, 1971). The formal structure of an organization w i l l to a large degree determine the d i s t r i -bution of data to those within and outside of the organiza-tion. (Gibson, Ivancevich and Donnelly, 1976). These channels, downward, upward and horizontal, w i l l a f f e c t the dissemination of a c t i v i t y data throughout an organization. The geographical or physical distance between organiz-ation members and between groups i s also seen as a deter-minant of information exchange. (Havelock, 1971). This i s p a r t i c u l a r l y relevant i n community health nursing, where nurses often cover large distances, and may work i n r e l a -t i v e i s o l a t i o n . There i s also generally a physical separa-tion between d i f f e r e n t organizational l e v e l s . Physical separation i s often a function of the status hierarchy, with the lowest l e v e l s t a f f the most remote geographically. 55 One way of fostering communication i s to routinely convene groups of organization members to discuss relevant items. A c t i v i t y data provide common measures that can act as a basis for such discussions. "Leadership behaviour serves both as a stimulus and a model for much behaviour i n the organization, and for that reason i t i s a major determinant of i n t e r n a l barriers to knowledge dissemination and u t i l i z a t i o n . " (Havelock, 1971. p. 6-26). Leadership behaviour sets a tone which pervades throughout the organization. The director of a health agency i n community health w i l l have a powerful e f f e c t on the style of operation of the supervisor or supervisors i n the agency. The director may also 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 hold nurses accountable for the way they use the i r time at work. These data are thus sometimes regarded as c o n f i d e n t i a l , as i n Alberta (see section 5.5.3). Individuals are sometimes hesitant to share information. They f e e l i t may r e f l e c t negatively on themselves or the functioning of t h e i r group within the organization (Havelock, 1971). These feelings may impede the flow of a c t i v i t y data between units i n the organization, and between the organization and i t s environment. 3,3,2 Frequency of reporting Data can be coll e c t e d and reported either regulary, 56 i r r e g u l a r l y , or not at a l l . There are inherent assump-tions 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 . I f data are regularly collected, this implies that the a c t i v i -t i e s covered by the data need to be constantly monitored, or that data need to be available for constant monitoring or checking. Intermittent data c o l l e c t i o n implies that 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 monitoring. In this case, only i r r e g u l a r checking i s required. Not c o l l e c t i n g any data about certain a c t i v i -t i e s implies that the data are not necessary to monitor these a c t i v i t i e s . It may also mean that the data, even i f acquired, w i l l have minimal or no impact on the decision processes related to these a c t i v i t i e s . It may thus be infe r r e d that those nursing a c t i v i t i e s regularly recorded and reported are regarded as requiring constant monitoring. Or, there may also be a perceived need for such data to be available for monitoring, i n case i t i s required. 3.3.3. The volume of data reporting "Information systems have gained ready acceptance i n the innocent cloak of 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 planning. But herein l i e s one of the most serious dangers of information systems .... I n s e n s i t i v i t y to or a lack of knowledge about the substan-t i v e issues are often washed out of sight 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, Ackhoff stated his b e l i e f that the most important deficiency from which managers suffered was not a lack of relevant information, but an overabundance of irre l e v a n t information. This statement came during a stage of great enthusiasm and technological development i n the f i e l d of management information systems. Ackhoff's claims generated a good deal of controversy. Yet his suggestion that managers suffer from an information over-load has generally remained unchallenged. (Rappaport, i n Davis and Everest, eds., 1976). Whether or not data are necessary depends upon the impact or pot e n t i a l impact they have on actions and. deci-sions. There i s an assumption inherent i n the decision 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. This assumption i s that such data are relevant within the context of some universal decision making model for directors and supervisors. Such a univer-sal model i s an ide a l that does not exist, as there are many i n t e r - i n d i v i d u a l differences a f f e c t i n g decision making. This does not mean that such a universal model i s of no value. As discussed e a r l i e r (section3.2.4), any system must make trade-offs i n determining what information to c o l l e c t . I t must also make trade-offs i n considering how often to c o l l e c t information. In terms of convenience i n 58 c o l l e c t i n g data, i t may be much easier 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 individual's decision making processes. It then becomes the task of the user to apply his or her f i l t r a t i o n or condensation processes to what data are available. Inevitably, this w i l l cause problems, as ... "indeed there i s probably a c r i t i c a l information content, which, i f exceeded, i s l i k e -l y to lead to a deterioration of the usefulness of the summary to the manager". (Ashford, 1975. p.22). The relevance of information, and thus the frequency and volume of data reporting, i s a function of the deci-sion making process. U n t i l the decision making process i s c l e a r l y understood, there i s no l o g i c a l means of determining relevance, and thus the appropriate volume of data report-ing. At present, i t would be unreasonable to claim that a c l e a r l y understood model'of decision making exists for community health nursing supervisors and d i r e c t o r s . Deci-sion making i n this area may be akin to what P i r s i g (1974) sees as q u a l i t y i n writing. It i s something that can clear-l y be seen to e x i s t . 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 analysis. If decision making may be seen to exist, ought i t not to be describable, at least i n terms of the minimum essential information-required to make a systematic decision? The problem here i s adequately defining what i s meant by "systematic". Is a decision systematic because some 59 essential minimum data set was available to the decision maker (in which case systematic i s t a u t o l o g i c a l l y des-cribed)? Or i s decision making systematic due to the structured nature of the i n t e l l i g e n c e , design and choice stages? Simon (section 2.1) feels that there are few decisions or problems which are t o t a l l y structured. Newell and Simon claim that ... "a few, and only a few, gross ch a r a c t e r i s t i c s of the human information processing system are invariant over task and problem solver". (Newell and Simon, 1972. p. 788.). The issue of "systematic" decision making i s indeed complex. The 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 decision making process for supervisors and directors need to be i d e n t i f i e d . An analysis of these features i s beyond the scope of this study. U n t i l this i s done, i t i s not possible to e s t a b l i s h a minimum essential data set for decision making by these individuals. Before the relevance of data can be established, a more comprehensive understanding of the decision making processes of supervisors and directors i s required. In the absence of a comprehensive.model, i t i s s t i l l possible to determine some of i t s elements. These elements may be i d e n t i f i e d through a careful study of the data elements gathered by a c t i v i t y recording systems across Canada. This i s done in Chapter 4. 60 3.4 The interpretation of data Even i f a l l the relevant information for decision making was collected, there i s no assurance that i t would be appropriately used by decision makers. Newell and Simon (section 3.3.3) f e e l that there are only a few ways i n which indi v i d u a l s ' information processing systems are the same, or the same for d i f f e r e n t problems. Decision making strategies are influenced not only by the decision problem and the decision environment, but also by the c h a r a c t e r i s t i c s of the decision maker. Characteris-e s such as i n t e l l e c t u a l a b i l i t y , education, attitudes, c u l t u r a l background and es p e c i a l l y cognitive style w i l l a f f e c t decision making. Individuals gather information through a perceptual process by which the mind organizes the various s t i m u l i i t encounters. What each i n d i v i d u a l perceives as informa-tion i s the r e s u l t of a complex coding process. McKenney and Keen (1974) distinguish two dimensions along which individuals d i f f e r : information gathering and information evaluation (Figure 3.2. p. 61). In gathering information, preceptive thinkers apply concepts to f i l t e r data, while receptive thinkers are more sensitive to the data stimulus i t s e l f . In evaluating information, individuals d i f f e r i n their sequence of analysis of the data available to them. B a r i f f and Lusk (1977) applied cognitive style assess-ment i n the design phase of a "nursing evaluation 61 F i g u r e 3.2 Model of C o g n i t i v e S t y l e Information Evaluation Preceptive \ A « System atic I n t u i t i v e > Receptive f B fl o • H - P ( 8 rH m > Note: Each p o i n t on the g r i d w i l l d e s c r i b e a p a r t i c u l a r c o g n i t i v e s t y l e . For example, 'A' w i l l d e s c r i b e an i n d i v i d u a l who i s s l i g h t l y p r e c e p t i v e i n i n f o r m a t i o n g a t h e r i n g , and h i g h l y s y s t e m a t i c i n i n f o r m a t i o n , e v a l u a t i o n . 'B' i n d i c a t e s someone who i s h i g h l y r e -c e p t i v e i n i n f o r m a t i o n g a t h e r i n g , and h i g h l y . i n -t u i t i v e i n i n f o r m a t i o n e v a l u a t i o n . 62 information system", for a community nursing service i n a large metropolitan USA c i t y . The findings of t h e i r study were i n s t r u c t i v e i n developing reporting formats for data that had been gathered. The individuals i d e n t i f i e d as constituting the deci-sion making network of the organization were tested for cognitive s t y l e . A l l were found to be low i n cognitive complexity. Cognitive complexity involves the processes of: 1 d i f f e r e n t i a t i o n - the number of dimensions extracted from the data, 2. integration - the complexity of the rules for combining structured data, and 3. a r t i c u l a t i o n - the fineness of discrimination. This finding does not mean that users cannot or do not per-form e f f e c t i v e l y . It merely provides a guideline for the designer or developer of user reports as to how such reports ought to be structured. Their findings led to a disaggregation of the former type of report structure, and a consequent increase i n the number of reports. There was also an increase i n the frequency of selected reports, from quarterly to monthly. The designers claim "a pressing need to i d e n t i f y the s p e c i f i c dimensions of reports which are relevant to the various classes of users." ( B a r i f f and Lusk, 1977. p. 827.). B a r i f f and Lusk's findings on cognitive style are probably very applicable to community nursing reporting 63 systems i n Canada. The use of cognitive styles i n inform-ation system design and use i s an area that has been u n t i l recently neglected. (Benbasat and Taylor, 1978). Much further study i s required to c l a r i f y the relationships involved. 64 CHAPTER 4 4.1 A c t i v i t y recording systems i n Canada This chapter contains an analysis of a c t i v i t y record-ing systems for community health nurses i n six provinces across Canada. The federal government system for occupa-t i o n a l health nurses i s also reviewed<. The purpose of the analysis i s to obtain an overview of current Canadian practices. Detailed information on the d i f f e r e n t systems was required to perform this analysis. Accordingly, a l e t t e r was sent i n August 1978, to a l l the p r o v i n c i a l directors of public/community health nursing (except for Alberta), and to Health and Welfare Canada. After b r i e f l y o u t l i n i n g the topic of the proposed study, the l e t t e r requested informa-tio n on: 1. the reporting or recording system for public/ community health nursing a c t i v i t i e s i n the province, 2. the objectives of the system, 3. the process of development of the system, 4. the output generated by the system, and 5. how the roiitput of the system i s used. Replies with information were received from B r i t i s h Columbia, New Brunswick, Manitoba and Ontario. Informa-tio n from Alberta had already been made available. In October, 1978, a follow-up l e t t e r was sent to those 65 provinces which had not responded. Information was re-ceived from Prince Edward Island. The Medical Services Branch of Health and Welfare Canada supplied information on the system used by community health nurses working i n occupational health. Newfoundland, Nova Scotia, Saskat-chewan and Quebec did not supply information. The following framework i s applied to analyze the available information: 1. the functional features of the systems were examined. These features include: a. services recorded, b. non-client contact a c t i v i t i e s , c. data re service r e c i p i e n t s , d. duration of services recorded, and e. place of service recorded. 2. The conceptual and operational features of each system are l i s t e d . The stated objectives of the systems are examined. 3. The s p e c i a l features of the available systems are discussed. 4.2. Functional features of a c t i v i t y recording systems The functional features of the systems available for this study are summarized i n Table 4.1 (pp. 68-72). This table i s based on information made available by the federal and , p r o v i n c i a l governments. The information provided i s l i s t e d below. 66 Alberta A l l forms and documented material r e l a t i n g to this system were made available for this study. B r i t i s h Columbia 1. Monthly Report of Selected S t a t i t i c s (Nursing). 2. Summary of Monthly S t a t i s t i c a l Report (Nursing), 3. Home Care Program - Patient Summary. 4. Discussion of P.H. 56 (Monthly Report). 5. Computer Programming of Home Care S t a t i s t i c s . Manitoba 1. Regional Public Health Nursing S t a t i s t i c s . Selected Reasons for Service. 2. Selected Reasons for Service from Regional Summary Sheet (3 pages). 3. Revised Public Health Nursing Services S t a t i s t i -c a l Systems. New Brunswick 1. Daily Service Record. 2. S t a t i s t i c a l Record (2 pages). 3. Code for Service Record. 4. Guide to Daily Service Record. 67 Ontario 1. Community Health Resources. Report of weekly a c t i v i t i e s . 2. Monthly Summary. 3 . C.H.A.R.I.S. Nursing a c i t i v i t y sybsystem. 4. The Community Health Resources Report of Weekly a c t i v i t y . 5. Community Health A c t i v i t y Resources Information System (C.H.A.R.I.S.) C l e r i c a l Procedures. Prince Edward 1. Daily Report. 2. Immunization S t a t i s t i c s . 3 . Monthly and Annual S t a t i s t i c a l Summary. Public Health Nursing. - * T Health and Welfare Canada 1. Health Unit S t a t i s t i c a l Report (A). 2. Health Unit S t a t i s t i c a l Report (T). 3 . Performance Measurement System. Public Service Health F a c i l i t y . Table 4.1 Functional Features of Recording Systems A l t a B.C. Man. N.B. Ont. PEI Fd.Gvt. 1. Services recorded Immunizations a X X b b a Rubella X c X X Smallpox . c X ,c c P o l i o X X P o l i o (Salk) c .c P o l i o (Sabin) 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 c DT X ' c Mumps X T r i a d X Biad X MMR X Pertusis X Schick X Rabies X Typhus X Immune Serum Globulin d X Plague X Other X X Key on page 72 69 Slta B.C. Man. N.B. Ont. PEI Fd.Gvt. Services i n schools d : b X e Conference with s t a f f d d Conference with students X Inspections d" Counselling X No. re f e r r e d by teacher X Recommended for exclusion d Defects corrected d Screening ,d f d d f V i s i o n X . f X f Hearing X f X f Communicable Disease X . f Developmental X X Tuberculin X X Schick X P.K.U. X Pediculosis X X Other X Groups/classes . d , d d X . :.d Expectant parent/prenatal X d X X X X C h i l d Health Conference d b d b d C l i n i c s b,d X . d X d Family planning X X X G e r i a t r i c X X Chest X Other X X d Communicable disease d d X X d VD X X g d TB X X X Mental H e a l t h / i l l n e s s X d • X X Key on Page 72 70 A l t a B.C. Man. N.B. Ont. PEI Fd.Gvt. Home Care a .a d X X Home assessment/ reassessment X X d X General Expectant parent/ prenatal X . d X X X X Postnatal X X X X X New inf a n t X X X X Health promotion X ••d X Chronic disease X X L i f e s t y l e d g Safety/occupation health X Drugs/alcohol X X Public r e l a t i o n s X d,g Followup X X Handicapped/ Special Services X ChildrAbuse X Poison Control X Retirement X S o c i a l Services X Treatment d F i r s t Aid X General Health X Infant & preschool assessment ..-a Infectious h e p a t i t i s X Episodic care X Mental retardation X C h i l d care X Adult care X Growth & development g Public health X Key on page 72 71 General (cont.) ;- A l t a B.C. Man. N.B. Ont. PEI Fd.Gvt. Nursing care X Nursing home programs X Preschool cl a s s X G e r i a t r i c care X Medical X S u r g i c a l X Conception/ contraception X Parent education X g Registration of pre-school children g Non-communicable disease X Local options X X 2. Non-client contact a c t i v i t i e s Meetings d X d Liasons d X X Hospital l i a s o n X X Inservice education X X X X X X Team/case conference X X X X Supervision/training X X X Others Daycare centres X Community agency X X Nurse attachment X Mass media X Service a c t i v i t i e s X O f f i c e management X d X X C l e r i c a l X X Key on page 72 72 2. Non c l i e n t contact  a c t i v i t i e s ^ (cont.) Travel Mileage noted Home v i s i t i n g Number of homes v i s i t e d Telephone contacts Absence from work Data re service rec A l t a . B.C. Man. N.B. Ont. PEI Fd.Gvt. X X X X X :e e X X X X e d d ipients Age Sex Name X h h X .h h h X X X X X 4. Duration of services recorded . X X . .h X X 5. Place of service recorded h X :f f Key. a. Separate form b. Single l i n e entry c. Shows rei n f o r c i n g series d. More detailed breakdown given e. Time a l l o c a t i o n noted f. Recorded under school a c t i v i t i e s g- Group a c t i v i t i e s / c l a s s e s only h. For some a c t i v i t i e s 73 4.2.1 Federal government system As the federal government system i s for 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 function, these services are l i s t e d separately. The Health Unit S t a t i s t i c a l Report groups the a c t i v i t i e s of nurses as follows: 1. health assessment, 2. counselling, 3. treatment, 4. r e f e r r a l s - disposals, 5. health education and liason, 6. o f f i c e management. 4.3. Functional features: discussion 4.3.1 Services recorded From Table 4.1 i t i s evident that there are many under-lying s i m i l a r i t i e s i n the services recorded by the p r o v i n c i a l recording systems. Services recorded i n at least four provinces are: 1. immunizations, 2. school health services, 3. screenings, 4. groups/classes, 5. c h i l d health conferences, 6. c l i n i c s , 7. communicable disease,. 74 8. mental h e a l t h / i l l n e s s , 9. home care, 10. prenatal/postnatal, 11. new infant. Home care may be presented as a"separate program with i t s own information system, as i n B.C. and Alberta. The community health nursing 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 that the majority of a c t i v i t i e s i n which nurses are involved are common to a l l provinces. 4.3.2 Non—client contact a c t i v i t i e s There are differences between the provinces i n the terminology applied to non c l i e n t contact activities'. These a c t i v i t i e s are generally measured i n terms of the time spent on them. These data convey no information at a l l about c l i e n t contact nursing a c t i v i t i e s . They do provide a perspective of the d i s t r i b u t i o n of nurses' a c t i v i t i e s or of nursing time, over the f u l l spectrum of a c t i v i t i e s i n which they are involved. 4.3.3 Data re service recipients Service recipients may be noted according to t h e i r : 1. name, 75 2. sex, and/or 3. age. 1. Name of recipient(s) Recording the name of i n d i v i d u a l contacts i s the clear-est way of i d e n t i f y i n g service r e c i p i e n t s . But th i s informa-tion i s " l o s t " i n the aggregation of data. At the manager-i a l or str a t e g i c planning l e v e l , knowing the names of ser-vice recipients has no p a r t i c u l a r advantages over a simpler i d e n t i f i c a t i o n process. 2. Sex : Recording the sex of service recipients may be approp-r i a t e for the occupational health a c t i v i t i e s of federal government nurses. Knowing the sex of recipients of provin-c i a l nursing services i s useful i n cases of occupational health, and i n recording attendances at prenatal and family planning classes. Knowing the sex r a t i o of attendance at these classes could enable more appropriate preparation and presentation of material. 3. Age groupings The age groupings used i n the provinces vary, although there appears to be an underlying set of age spans. These are: 1. infant: 0 - 1 year (up to 364 days),, 2. preschool: 1 - 5 years, 3. school: 6 - 1 8 years, 4. adult: 19 - 64 years, 76 5. g e r i a t r i c : 65 + years. Generally, there are a greater number of age spans, while some provinces use age groupings that cut across these spans. Manitoba has a number of overlapping age categories which vary according to the nature of the population being served. The age groups are set to i d e n t i f y service re c i p -ients as c l e a r l y as desired. Age groupings are the most common way of i d e n t i f y i n g target groups or populations by whom services are received. The f i n e r the d i s t i n c t i o n between age categories, the more c l e a r l y the i d e n t i t y of service recipients i s distinguished. This f i n e r d i s t i n c t i o n between age categories enables a closer comparison to be made between the needs of a target population, and the type and quantity of services provided to that population. 4.3.4 Duration of services recorded " D i s t i n c t i o n should be made between data which are re-gularly summarized and reported and data obtained by a special study or survey. For example, an agency may need detailed information on the d i s t r i b u t i o n of t o t a l nursing time f o r assessing emphases, fo r work measurement, and for cost analysis. A sample time study w i l l provide a good estimate. It i s usually not necessary or advisable to c o l l e c t such information on a continuous basis" (National League for Nursing, 1962. p. 6.). Only B.C. and Manitoba 77 do not record any data about time spent i n a c t i v i t i e s . Nurses may take d i f f e r e n t amounts of time to perform the same function. 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 . Variations i n time spent i n a c t i v i t i e s may be due to the nurses' q u a l i f i c a t i o n s , the resources available, the c h a r a c t e r i s t i c s of service r e c i -pients and/or other factors. Supervisors and directors require a sound knowledge of the amount of time needed for d i f f e r e n t a c t i v i t i e s i n deter-mining s t a f f i n g levels and s t a f f i n g patterns. They also need to know how much time nurses are a c t u a l l y spending i n th e i r various a c t i v i t i e s . Knowledge about the average times re-quired for p a r t i c u l a r a c t i v i t i e s i s acquired through exper-ience i n the community health nursing f i e l d . An understanding of variations from average work times develops inherently with experience i n the f i e l d . Time spent i n a c t i v i t i e s i s an indicator of the o v e r a l l d i s t r i b u t i o n of nursing time. It i s not an i n d i c a t i o n of process, outcome or effectiveness. Due to variations i n these factors, time spent i s not an accurate indicator of e f f i c i e n c y . Due to technological developments and changes i n proce-dures, education 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-ing 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 short or medium term. Directors and supervisors need to 78 be aware o f any changes t h a t do occur. For t h e i r purposes, o n l y i n t e r m i t t e n t r e c o r d i n g o f n u r s i n g time i s r e q u i r e d . The r e g u l a r and comprehensive r e c o r d i n g of time spent i n a c t i v i t -i e s i s thus an unnecessary f e a t u r e o f a c t i v i t y r e c o r d i n g systems. 4.3.5. P l a c e o f s e r v i c e r e c o r d e d Many a c t i v i t i e s , by t h e i r very nature, e.g. sch o o l s e r v i c e s , take p l a c e 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 , the o f f i c e or at home. The p l a c e where s e r v i c e s are p r o v i d e d i s g e n e r a l l y not recorded, and may thus be i n f e r r e d not to be r e l e v a n t . 4.4. D i s c u s s i o n of systems o b j e c t i v e s Although the wording of the o b j e c t i v e s and intended uses of the systems v a r i e d , there were some common o b j e c t i v e s . These can be seen i n Tab l e 4.2 (p. 79). O b j e c t i v e s can be s t a t e d i n d i f f e r e n t ways. For the purposes of measurement, o b j e c t i v e s need to be o p e r a t i o n a l l y d e f i n e d . Measurement i s i n v o l v e d i n the process o f e v a l u a t i n g whether or not o b j e c t i v e s have been met. I f o b j e c t i v e s can-not be unambiguously t r a n s l a t e d i n t o o p e r a t i o n a l terms, they cannot be measured. Whether or not o b j e c t i v e s are being met then becomes a l t o g e t h e r a matter of s u b j e c t i v e judgement. Judgements on a system's performance i n meeting i t s o b j e c t i v e s may d i f f e r a c c o r d i n g to i n d i v i d u a l s ' p e r s p e c t i v e s on a c t i v i t y 79 A l t a \ B.C.\ ManJ N.B./ Ont./ PEI/ Fd.Gvt, Table 4.2  Obj e c t i v e s 1. To provide data which can be used as a basis f o r requesting funding for services. 2. To provide data to a s s i s t i n deter-mining s t a f f i n g patterns/case loads. 3. To provide data to a s s i s t i n pro-gram planning 4. To compile s t a t i s t i c s f o r selected nursing services by a uniform method 5. To provide uses with data f o r companies 6. To provide data to a s s i s t i n pro-gram evaluation 7. To provide data f o r annual reports or i n response to s p e c i a l requests re services 8. To provide data f o r evaluating e f f o r t 9. To provide data to measure the extent of programs 10. To provide data to a s s i s t i n deter-mining the cost/cost-effectiveness of programs 11. To measure and describe the output of the nursing service 12. To analyze s t a t i s t i c s c o l l e c t e d by province, region and health u n i t / department 13. To provide consultants with data to monitor a c t i v i t i e s 14. To provide a basis for decision mak-ing i n community health nursing a c t i v i t i e s 15. To provide data to a s s i s t i n management 16. To provide data f o r an operational performance measurement system X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 80 recording. Objective 2 i n Table 4.2 does not c l a r i f y how a c t i v i t y data are to be used i n determining s t a f f i n g . The discussion of determining s t a f f i n g i n section 2.4.2 outlined the complex nature of this task. Family needs was i d e n t i f i e d as the major factor required i n determining s t a f f i n g . More than any other factor, the need prevalence of a population w i l l determine the services and s t a f f i n g required. A c t i v i t y data are an inventory of services provided. They are not an indicator of what was needed, how needs were met, what services were i n s u f f i c i e n t , or which were excessive. These judgements require more comprehensive information. In-formation i s needed about the population to be served, the services being provided, and the c h a r a c t e r i s t i c s of service providers. A c t i v i t y data may be used i n determining s t a f f i n g , but this w i l l depend upon how much and what other data are available. It w i l l also depend on the s t a f f i n g methodologies being used, and how they are applied. Unless these factors are made e x p l i c i t , there i s no clear way of determining whether objective 2 i s being met. Objective 3 i s stated i n s i m i l a r l y vague and nonoperational terms. Unless the process of program planning i s more e x p l i -c i t l y described, there i s no way of measuring whether or not objective 3 i s being met. Requesting funding for services requires predictive data about services to be provided. Projected services may be 81 based on h i s t o r i c a l data from a c t i v i t y recording. Requests for funding need to be based on projected services, and not on the h i s t o r i c a l data used to obtain these projections. Objective 1 i s thus stated i n an inappropriate and non-operational manner. On the other hand, objectives 4 and 5 are stated i n such terms that t h e i r achievement can be measured. However, whether or not objectives are achieved does not r e l a t e to whether or not the system's output w i l l be useful. For ex-ample, the system may s a t i s f y objective 5 , and provide data for use i n comparisons. But no guidelines are given as to how or what kinds of comparisons are to be made. Objectives such as 4,.'i5ctor 13, are stated i n such simple terms as to be of no value i n determining the usefulness of the data gathered by the system. An example of an objective that can be operationally measured i s objective 16 i n Table 4.2. The operational per-formance measurement system used by the federal government i s c l e a r l y outlined i n the Health and Welfare Canada publication, Performance Measurement System. This system i d e n t i f i e s the data that are required. Objective 16 thus provides the model of an objective which relates to a c l e a r l y defined process, which i n turn determines exactly what data are required. To act as r e a l i s t i c guidelines to the use of the data, objectives need to be c l e a r l y and operationally defined. Only once this 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 functions for which they are intended. Most of the objectives i n Table 4.2 are stated i n such broad and nonoperational terms, that i t i s not possible to even investigate i f the data being gathered are adequate i n terms of these objectives. In the case of some objectives, adequate data may be gathered to meet the objectives. But these objectives are stated i n such vague terms that the usefulness of the gathered data remains questionable. 4.4.1 Operational^! eatures Table 4.3 (p. 83) contains operational features of systems that are of in t e r e s t . It shows the r e g u l a r i t y with which: 1. forms are completed, and 2. reports are compiled. It distinguishes between: 3. manual and computer systems, and shows the 4. units (areas) by which data are compiled. 4.5 Special features There are differences and variations between the systems examined. Other than the computerization of the Alberta and Ontario systems, there are only two features that appear to be unique. These are: 83 Table 4.3 A l t a . /B.C. /Man. /N.B. /Ont. / P E I /Fd.Gvt. Operational Features of Systems 1. Forms c o m p l e t e d : d a i l y weekly monthly 2. Reports compiled; Weekly monthly year-to-date other 3. Manual tabulation Computerized 4. Data compiled: by o f f i c e / h e a l t h unit by region by province X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Note: Table 4.3 was compiled from data submitted. There may be cert a i n omissions i n the table, e.g. data compiled by region, as cert a i n operational features may not have been e x p l i c i t y dealt with i n available information. 84 1. the method of recording type of service and service recipients i n Manitoba, and 2. the federal government method of ca l c u l a t i n g performance measurement indicators. 4.5.1 Manitoba For each subject grouping, the most appropriate age spans are used to c l e a r l y i d e n t i f y the service recipients. This system contains the largest number of age spans. It i s also the only system with these overlapping age categories. Individual contacts are recorded according to whether the contact was of a health promotion or d i r e c t nursing care nature. This system i s the only one to distinguish i n this way between health promotion and d i r e c t nursing care. 4.5.2 The federal government performance measurement  system The description of the system given i n this section i s based on the Health and Welfare Canada document, Performance Measurement System. Investment time i s viewed as resource u t i l i z a t i o n i n the production of 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. This factor i s considered the weighting factor i n determining the monthly weighted workload. Performance measurment indicators can be calculated for e f f i c i e n c y , effectiveness and percentage investment. E f f i c - iency indicators measure the r a t i o of accomplishment produced to the investment time consumed i n th e i r production. „ . . , r-r.. . t o t a l weighted workload e.g. Operational e f f i c i e n c y = t o t a i investment Effectiveness relates to how well one i s achieving set goals. „ , .ce . . accomplishments e.g. Operational effectiveness = *_ obj ectives. This r a t i o obviously cannot be calculated i n the absence of quantifiable objectives. Percentage investment indicators can be calculated for major sections of occupational health nursing. These indica-tors permit management to determine the levels of investment for each of the areas concerned. Investment a l l o c a t i o n great-er than or less than a predetermined variance range can i n d i -cate that some management decision i s required. It i s stated that these indicators give a tangible figure to what i n the past has been an intangible gut f e e l i n g . The l o g i c inherent i n the above statement needs to be explored. The description of the performance measurement system implies that determining a variance range for percentage 86 investment indicators makes the management process more r a t i o n a l , or s c i e n t i f i c . This i s not so. A variance range does put concrete bounds around some calculated average. But a variance range can only be determined from i n t u i t i o n , knowledge from experience, or what i s referred to as intang-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 of setting such variance ranges without the express judgement of the i n dividual setting the range. In setting l i m i t s , the i n d i v i d -ual must apply his or her understanding of the s i t u a t i o n , an act as a diagnostician. S i m i l a r l y , e f f i c i e n c y and effectiveness indicators may provide measures r e l a t i n g to service provision, but i n d i v i d -ual judgement i s inherently involved i n interpreting these measures. It 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 elaborate c a l c u l a t i o n can eliminate the essent-i a l l y judgemental nature of the inte r p r e t a t i o n of a c t i v i t y s t a t i s t i c s . 4.6 Summary of a c t i v i t y recording systems reviewed The objectives, operational aspects and selected feat-ures of a c t i v i t y recording systems across Canada have been reviewed. As outlined i n Chapter 2, the need for these systems i s to provide data at the management and strategic planning l e v e l s . Thus, the intent of such systems i s to gather data to meet these needs. The objectives may be seen as a more 87 c o n c r e t e e x p r e s s i o n o f t h e i n t e n t o f t h e s e s y s t e m s . G e n e r a l l y , t h e o b j e c t i v e s o f t h e s y s t e m s a r e v a g u e l y a n d n o n o p e r a t i o n a l l y d e f i n e d . T h e y c a n n o t be t r a n s l a t e d i n t o m e a s u r a b l e t e r m s . T h i s b e i n g t h e c a s e , i t i s n o t f e a s -i b l e t o a s s e s s i f t h e s e o b j e c t i v e s a r e b e i n g met, o r e v e n w h e t h e r t h e d a t a b e i n g g a t h e r e d a r e a p p r o p r i a t e . I t i s e s s e n t i a l t h a t o b j e c t i v e s be e x p r e s s e d i n t e r m s t h a t a r e o p e r a t i o n a l l y d e f i n a b l e t o m e a s u r e w h e t h e r o r n o t o b j e c t i v e s a r e b e i n g met, o r i f a p p r o p r i a t e d a t a a r e b e i n g g a t h e r e d . The n e e d f o r d a t a o h t i m e s p e n t i n p a r t i c u l a r a c t i v i t i e s , a n d t h e t i m e d i s t r i b u t i o n o f n u r s e s , was d i s c u s s e d . I t was a r g u e d t h a t t h e r e g u l a r r e c o r d i n g o f t i m e s p e n t i n a c t i v i t -i e s was u n n e c e s s a r y . The o u t p u t s a n d w o r k i n g s o f t h e f e d e r a l g o v e r n m e n t s y s t e m w e r e e x a m i n e d . W h a t e v e r c a l c u l a t i o n s a r e p e r f o r m e d w i t h t h e d a t a , i t i s e v i d e n t t h a t t h e r e a r e no s u b s t i t u t e s f o r t h e i n d i v i d u a l j u d g e m e n t o f t h e p e r s o n who must f i n a l l y i n t e r p r e t a n d w o r k w i t h t h e s e d a t a . 88 CHAPTER 5 5.1 Case study of the Alberta community nursing a c t i v i t e s  recording system (ACNARS). In addition to the overview of the systems presented i n Chaper 4, i t i s i l l u s t r a t i v e and informative to examine a s p e c i f i c system i n greater d e t a i l . An in-depth study helps to provide a more comprehensive insight into the issues that have been discussed. In this Chapter, the Alberta Community Nursing 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 discussion i s based on a l l available system 1 s documentation, o f f i c i a l government of Alberta publications, and my personal observations during May to August, 1978. 5.2 The organization of community health services i n Alberta There are twenty-nine geographical areas i n Alberta with r e s p o n s i b i l i t y for community health. These areas are known as Local Boards of Health i n Calgary and Edmonton, and as Health Units i n the remaining twenty-seven j u r i s d i c t i o n s . Each one of these health agencies i s autonomous, being responsible to a l o c a l board made up of representatives of the communities within i t s j u r i s d i c t i o n . Board members are appointed from the elected representatives on municipal councils. U n t i l 1973, health agencies received eighty per-cent of t h e i r funding from the p r o v i n c i a l government and 89 twenty per cent from the municipal governments i n the i r area. After March 1973, the p r o v i n c i a l government assumed t o t a l funding of the health agencies. This funding mechanism gives r i s e to an anomalous s i t u -ation. Health agency o f f i c i a l s are responsible to a l o c a l board for program d i r e c t i o n and emphasis. The health agency board must i n turn 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 obtain funds. The consultants employed by Local Health Services i n the Department of Social Services and Community Health, have a r e s p o n s i b i l i t y to give advice that, i f followed, ought to re-sul t i n the e f f e c t i v e and e f f i c i e n t spending of public funds. However, because of the autonomy of the l o c a l health agencies, the consultants have no authority to enforce their advice. The rela t i o n s h i p described i s outlined i n Figure 5.1. (p. 90). 5.3 Organization of Health Agencies Figure 5.2 (p. 91) outlines the organization of a t y p i -c a l health agency. Most health agencies are directed by a medical o f f i c e r of health, who i s d i r e c t l y responsible to the health agency board. In a few agencies, nurses have been appointed as directors. Reporting to the dire c t o r are a nursing supervi-sor, senior public health inspector, dental o f f i c e r s , and an administrative o f f i c e r . Some health agencies have other F i g u r e 5.1 The Org a n i z a t i o n of Cornmunicty Health Services i n A l b e r t a 9,0 M i n i s t e r Community H e a l t h S e r v i c e s T C o n s u l | a t i o n IF I P r o g r a m H e a l t h A g e n c y J u s t i f i c a t i o n H e a l t h A g e n c y B o a r d 9 1 Figure 5.2 The Organization of a T y p i c a l Health Agency Health Agency Board Director/Medical O f f i c e r of Health Senior Public Health Inspector Nursing Supervisor Senior Speech Therapist Admini-s t r a t i v e O f f i c e r Other, e.g. N u t r i -t i o n i s t Den.Officer Public Health Inspectors Community Health Nurses Speech Therapist 92 p r o f e s s i o n a l s such 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 and h e a l t h educators. The n u r s i n g s u p e r v i s o r i s i n t u r n r e s p o n s i b l e f o r one or more s t a f f nurses who may be l o c a t e d i n s e v e r a l s u b - o f f i c e s . The degree o f independence i n d e c i s i o n making gi v e n to the n u r s i n g s u p e r v i s o r w i l l vary, a c c o r d i n g to her background and experience, and the management s t y l e of the d i r e c t o r of the agency. Thus, the n u r s i n g s u p e r v i s o r i n a g i v e n h e a l t h agency may have complete d i s c r e t i o n as to how to manage the n u r s i n g program, or o n l y l i m i t e d a u t h o r i t y . 5.4 Community h e a l t h n u r s i n g i n A l b e r t a The community h e a l t h nurse i s probably the most v i s i b l e employee of the h e a l t h agency. The major n u r s i n g programs, common to a l l l o c a l h e a l t h agencies, f a l l i n t o the areas o f : 1. maternal and c h i l d h e a l t h , 2. s c h o o l h e a l t h , and 3. communicable d i s e a s e c o n t r o l . Other areas o f involvement f o r nurses are f a m i l y l i f e e d u cation, f a m i l y p l a n n i n g c l i n i c s , n u t r i t i o n and g e n e r a l f i t n e s s , the r e g i s t r y of handicapped c h i l d r e n and mental h e a l t h . In keeping w i t h a p h i l o s o p h y o f p r e v e n t i o n , nurses are becoming more i n v o l v e d i n p r o v i d i n g s e r v i c e s to s e n i o r c i t i z e n s . The Home Care program was implemented throughout the p r o v i n c e i n 1978 ( i t had been o p e r a t i n g i n some agencies b e f o r e t h i s t i m e ) . In t h i s program, the l o c a l h e a l t h agency 93 co-ordinates a program of di r e c t nursing care i n the home, according to treatment prescribed by a physician. A l l community health nurses are members of the provin-c i a l nursing association, which licenses them to practice. There i s a Society of Community Health Nurses. This society acts as a spokesman for the nurses, arranges for continuing education, reacts to documents and developments i n the health care f i e l d , and prepares positions and b r i e f s on behalf of community health nurses. Si m i l a r l y , there i s a Society of Community Health Nursing Supervisors. Each p r o v i n c i a l consultant i n community health nursing has r e s p o n s i b i l i t y for consulting to a number of health units i n a given geographical area. Each ^consultant i s a s p e c i a l -i s t i n at least one p a r t i c u l a r f i e l d , such as maternal-child care, pre-school or g e r i a t r i c care. The consultants also represent the interests of community health nursing to nurs-ing educators, professional groups, other government depart-ments , other provinces and special groups which may be charged with developing province-wide standards of care. 5.5 Background to the introduction of A.C.N.A.R.S. 5.5.1 The need for A.C.N.A.R.S. Pr i o r to A.C.N.A.R.S., nurses were using the Public Health Nurses' Report form to record t h e i r d a i l y a c t i v i t i e s . The stated purposes of the report provide an insight into 94 the intent of this form. The purposes were: 1. to provide a record of public health nursing services and to give a basis for compiling to t a l s of service by area, 2 . to provide for a v a l i d appraisal of the program and to a s s i s t i n planning, 3. to provide factual information which may then be used when reporting to l o c a l Boards of Health, and 4. to provide information to the supervisor which w i l l a s s i s t her to guide and evaluate each nurse. One of the features of the form was that additional informa-t i o n could be recorded under a section c a l l e d Remarks. It i s evident that the report was intended to gather data that could be used , primarily i n managerial control. To a lesser extent, the data could also be used i n strategic planning and p o l i c y formation. Reporting was not standard-ized throughout the province, and data were not gathered by the Department for the province as a whole. The report was intended as a record of di r e c t services to the community. It was not intended as a record of how nurses had spent t h e i r time each day. Some health units f e l t that the form was adequate, but there was generally strong f e e l i n g that the report was inadequate to meet i t s i n -tended purposes. It was unpopular i n many agencies, and had been discontinued i n at least one health unit. Complaints 95 about the form were directed at i t s complexity, the wide vari e t y of interpretations possible for d i f f e r e n t items, and the time needed to complete the form on a monthly basis. The form was also i n f l e x i b l e as to what services could or could not be reported. The health unit nursing records committee was entrusted with reviewing record-keeping mechanisms i n use, working to-wards the standardization of records, and i d e n t i f y i n g the type and amount of information that should be reported to l o c a l health services for management purposes. The nurses report form for public health nurses f e l l within their j u r i s -d i c t i o n . During the summer of 1976, the nursing records committee completed a review of a l l p r o v i n c i a l nursing records for community health nurses. According to the committee, the input from health units and the c i t y boards of health i n d i -cated c l e a r l y that the nurses report form was i n need of major r e v i s i o n . The members of the committee f e l t that a new approach was necessary. They perceived a need for a more precise tool for gathering nursing program s t a t i s t i c s . At that time (1976), the development of an information system for l o c a l health services was under discussion i n the Department. A new reporting format was seen to f a l l within the scope of this development. 96 5.5.2 Planning and development of A.C.N.A.R.S. The need for a new approach having been i d e n t i f i e d , three members of the nursing records committee v i s i t e d Toronto i n January, 1977, to learn about the Ontario nursing a c t i v i t i e s system. The Ontario system was regarded as one which could be used as a model for the system i n Alberta. The nursing records committee resolved i n February, 1977, that a computerized nursing a c t i v i t i e s reporting system based on the Ontario model be developed and i n t r o -duced as soon as possible. A report on the v i s i t to Ontario i d e n t i f i e d the issues that would have to be dealt with. The report also noted the uses of the system, pote n t i a l problems that might be encountered, and a broad time frame for the development, testing and implementation of the system. The proposal for the envisaged system was to be ci r c u l a t e d to various f i e l d personnel. It was hoped that t h e i r feedback would be an important input i n the development and modifica-t i o n of the system. During the f i r s t h a l f of 1977, new report forms were developed by the committee. Although the Ontario system was i n i t i a l l y used as a model, some of the features of the new form were quite d i f f e r e n t from the Ontario model. The intent of the system was to provide data that could be used i n managerial control and strategic planning. While there are broad statements of intent, there does not appear to be any documented evidence of c l e a r l y stated and detailed objectives for the system. There was no documented evidence 97 containing guidelines of how the data gathered could be used to achieve the purposes f o r which the system was intended. The form was developed i n a format that would allow for the computerization of the data gathered. Computerization was considered to be time saving, and thus cost saving. There i s no evidence that this assumption was tested, or that any type of substantive cost-benefit analysis was performed. It was also f e l t that the computer reports that could be produced would make the reporting system a more powerful t o o l . At the same time as forms were being developed, a detailed i n s t r u c t i o n manual, covering the use of the system, was drawn up. This involved deciding upon subject categories, defining these subject categories, and describing i n d e t a i l how the forms were to be completed. This process dealt im-p l i c i t l y , with the problems of accuracy, r e l i a b i l i t y and v a l i d i t y . At no time do these issues 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 , dealt with. Regional meetings were held throughout the province i n June, 1977, for medical o f f i c e r s of health, and for supervi-sors and directors of community health nursing. This was to f a m i l i a r i z e them with the proposed forms, and obtain t h e i r feedback. The f i r s t f i e l d testing of the new form and ins t r u c t i o n manual was done i n the Wetoka Health Unit and Edmonton during September, 1977. The d i f f i c u l t i e s and concerns encountered were noted, and modifications were made 98 to the form and the recording manual. The second series of f i e l d t r i a l s , i n November, 1977, took place i n Edmonton and i n 5 health units. F i e l d testing was preceded by one day's intensive in-service education for the p a r t i c i p a t i n g f i e l d s t a f f . After the second series of f i e l d t r i a l s , further revisions were incorporated. 5.5.3 Implementation of A.C.N.A.R.S. In those health units where f i e l d t e sting had not been held, a one day intensive workshop was held for a l l nurses i n the unit. This was followed by one to two weeks practice i n completing the forms. A.C.N.A.R.S. was introduced i n a l l health units, and both c i t y l o c a l boards of health, from the f i r s t week of January, 1978. The three month period, January to March, 1978, was for-seen as a debugging period, during which errors would have to be corrected. A high error rate was expected, although ex-pectations were not expressed i n quantitative.terms. During the f i r s t month of f u l l operation, 114 errors were l i s t e d on the computer report. Thereafter, the number of errors de-cli n e d considerably, to a monthly average of less than 20, afte r March, 1978. I n i t i a l l y , monthly, quarterly and annual computer reports were produced and c i r c u l a t e d . Each health unit and c i t y board of health received a copy of th e i r own s t a t i s t i c s . Copies of the data for a l l health agencies are kept by Local 99 Health Services. The s t a t i s t i c s of each health unit are re-garded as c o n f i d e n t i a l . This c o n f i d e n t i a l i t y of informa-tion was an express condition by some health units for t h e i r involvement i n the reporting system. I f the data were con-f i d e n t i a l , health units would not be subject to p o t e n t i a l l y unfavourable comparisons with other units. Local Health Services also receive a copy of province wide t o t a l s . A f t e r the f i r s t s i x months of operation, the nursing records committee decided to discontinue the monthly reports. This was done i n response to requests by f i e l d personnel, who f e l t that they were being swamped by a mass of data too large for them to handle. During A p r i l , 1978, a workshop was held for directors of l o c a l health agencies, and directors and supervisors of community health nursing. This workshop covered the i n t e r -pretation and u t i l i z a t i o n of computer reports, especially those from A.C.N.A.R.S. 5.6 The nurses report forms: 1 and 2  5.6.1 Form ho. 1 The nurses weekly a c t i v i t i e s report (Figure 5.3, p. 103) consists of f i v e sections. In the f i r s t section, on i d e n t i f i c a t i on, the year, week and sheet number are noted. This section i s also used to i d e n t i f y : - the agency, 100 - the o f f i c e / s u b - o f f i c e , - the nurses function, - her c l a s s i f i c a t i o n (educational preparation), and - i n d i v i d u a l i d e n t i f i c a t i o n . Section 2 records time a l l o c a t i o n by program; the time recorded i s actually noted according to the age group of service r e c i p i e n t s . There are 6 age groups. Time spent i n t r a v e l , selected l o c a l options, c l e r i c a l work and tr a i n i n g others i s also recorded. Time data are the only new data gathered; the other sections are a l l adaptations of informa-ti o n previously gathered. The number of home v i s i t s i s recorded. Section 3 records data on group a c t i v i t i e s : - the age code of the group, - number of persons i n the group, - the subject, and - the time spent (including preparation time) i n the group a c t i v i t y . In section 4, i n d i v i d u a l contacts, either i n person or by phone, are recorded according to the subject dealt with, and the age of the i n d i v i d u a l contacted. In the f i f t h section, screenings, assessments and treat-ments are recorded according to: - age group, - the number within the age group screened, assessed or tested, and 101 - the number of those screened for whom further action i s required. The age and subject coded for the d i f f e r e n t sections are shown on the reverse of the report form (Table 5.1, p. 104). 5.6.2 Form no. 2 The second form, which has 4 sections, i s for c l i n i c attendance, tuberculosis control, and immunization (Figure 5.4 p. 105). The f i r s t section, as i n form no. 1, i f for i d e n t i f i c a -t i o n . There i s additional room to i d e n t i f y the c l i n i c . The second section records c l i n i c attendance by: - age, - persons immunized, - persons not immunized, - those 'new', and - t o t a l attendance for a.m., p.m. or evening. Recording i n the l a s t 2 categories i s optional. In section 3, for tuberculosis control, mantoux screen-ing i s recorded - by grade, - by age, - by number tested, and - the number of p o s i t i v e reactors, for both no BGG and previous BCG. BCG records note the age and number vaccinated: 102 Section 4 records the following data on immunizations: - the age of persons immunized, - the immunizing agent, and - the number of doses administered. Schick testing and immune serum globulin are also re-corded i n th i s section. 5.6.3 The output: forms 1 and 2 Once the data have been computer coded, a variety of reports can be produced for each section. Data can be ag-gregated, or disaggregated, according to the categories by which they have been collected. For example, data gathered i n section 3 of form no. 1 can be used to produce reports show-ing the number of persons attending group a c t i v i t i e s and time i n group a c t i v i t i e s : 1. by o f f i c e , age, and subject, 2. by age and subject, 3. by subj ect, 4. by o f f i c e , function, age and subject, 5. for each i n d i v i d u a l nurse. Similar reports can be produced for each section; an example of the reports produced i s shown i n Figure 5.5 (p. 106). Sim i l a r l y , the data gathered by form no. 2 can be aggre-gated or disaggregated according to the categories by which the data are collected. A variety of reports can be produced for each of the sections of this form. (These reports were 103 Figure 5.3 B S C H 140 /dlberra S O C I A L S E R V I C E S A N D C O M M U N I T Y H E A L T H NURSES WEEKLY ACTIVITIES REPORT 1 1 I I 1 I 1 I I I I T I M E A L L O C A T I O N B Y P R O G R A M Office Use Only 21 22 Mon. Tues. Wed. Thurs. Fri. Infant | Early Preschool | Late Preschool | School | Adult | Geriatric | Travel * -,,. | Local Option 1 | 2 • | Clerical | Training Others | No. of Homes Visited I I I I I | YEAR WEEK SHEET 1.0. No. III. G R O U P A C T I V I T I E S 44 21 S C R E E N I N G S . A S S E S S M E N T S . T R E A T M E N T S **> Persons! Age 21 No. of Persons Subject Hours 27 1 | I | 1 | 1 | 1 | I | 1 | 1 | i | i | i | i | i | i | i | i | i | i | IV. I N D I V I D U A L C O N T A C T S Age 21 Subject 23 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | I Age 21 Subject 23 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 1 104 T a b l e 5.1 - 5 -CODING C O D E 1 - A G E : ( T A R G E T P O P U L A T I O N ) C O D E II - S U B J E C T A In fant (to 1 year ) 1 0 P r e n a t a l B E a r l y P r e s c h o o l (1 y e a r to 4 . 5 y e a r s ) 11 N e o n a t a l 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) 1 2 P o s t n a t a l D G r a d e s 1 - 6 1 3 W e l l C h i l d E G r a d e s 7 - 9 1 4 P a r e n t i n g F G r a d e s 1 0 - 1 2 1 5 O b s e r v a t i o n (at r isk ) G S p e c i a l E d u c a t i o n 1 6 H a n d i c a p p e d / S p e c i a l S e r v i c e s H A d u l t ( G e n e r a l ) 1 7 C h i l d A b u s e 1 A d u l t ( O c c u p a t i o n a l H e a l t h ) 1 8 P o i s o n C o n t r o l J G e r i a t r i c ( 6 5 - 7 4 ) 1 9 F a m i l y P l a n n i n g K G e r i a t r i c ( 7 5 +) 2 0 F a m i l y L i f e E d u c a t i o n L M i x e d A g e s 21 U n w a n t e d P r e g n a n c y 2 2 C o m m u n i c a b l e D i s e a s e C O D E III • S C R E E N I N G . A S S E S S M E N T 2 3 T B A N D T R E A T M E N T T Y P E S 2 4 V D A A u d i o 2 5 C h r o n i c D i s e a s e B B l o o d P r e s s u r e 2 6 M e n t a l I l l n e s s C C o m m u n i c a b l e D i s e a s e 2 7 M e n t a l H e a l t h D D e v e l o p m e n t a l 2 8 A l c o h o l / D r u g s H H e a l t h A s s e s s m e n t P P a r a s i t e s 2 9 S m o k i n g 3 0 N u t r i t i o n S S p e e c h 31 E x e r c i s e / F i t n e s s V V i s i o n 3 2 O b e s i t y E B a t h 3 3 S a f e t y F C a t h e t e r i z a t i o n 3 4 R e t i r e m e n t G D r e s s i n g J E n e m a 3 5 O t h e r L i f e s t y l e K F o o t C a r e 3 6 S o c i a l S e r v i c e s L H e m o g l o b i n 3 7 H o m e C a r e A s s e s s m e n t s M I r r i ga t ion 3 8 H o m e C a r e R e a s s e s s m e n t s 3 9 T r e a t m e n t N O r a l M e d i c a t i o n 4 0 F i r s t A i d R P a r e n t e r a l M e d i c a t i o n T S u t u r e R e m o v a l 4 1 F o l l o w u p U T h e r a p e u t i c E x e r c i s e 4 2 G e n e r a l H e a l t h W U r i n a l y s i s 4 3 P u b l i c I n f o r m a t i o n / C o n s u m e r I n f o r m a t i o n 4 4 - 5 0 L o c a l O p t i o n s Y L o c a l O p t i o n Z L o c a l O p t i o n (JAN/78) S S C H 1 4 0 8 II A G E C U N C A T T E N D A N C E parson* not 0 • 1 yr. f rom 1 ft. to 2 yr. other early preschool ( 1st* preschool school ago edutt geriatric TOTAL A M . P .M. E V E N . 1 1 1 T E A R •*«EK SHEET 1 0 Wo 2,0! JL_L T U B E R C U L O S I S C O N T R O L S C R E E N I N G ( M A N T O U X ) A G E No. tasted No. po«. raac lo r t no B C G h a d B C G g r a d e 1 I I I g r a d e 6 I I I g r a d e 9 | I I g r a d e 1 2 I I I A G E C O D E * no. ta t tad no. poa. roaelora no B C G had B C G I I I I I I I " uaa a a a coda, nurs ing a c t m t l a a raport form I M M U N I Z A T I O N C O D E : D O S E S G I V E N a tat . 2nd . 3 r d REINFORCING = fl D I P H T H E R I A 2nd 3rd R T E T A N U S POLIO ISALK) 1st 2nd 3rd R 2nd 3rd R • I M M U N I Z A T I O N A G E P O L I O ( S A B I N ) BUM L LA INflAJ-S M A L L P O X TYPHOID R A B I E S — P R E E X P O S U R E I M M U N E S E R U M G L O B U L I N i n 2nd R one dose one dose EHIA H I Ind 3rd 2nd 3rd R «- bf.a*. control "i'.T ©thor 6 7 infant 0 to 1 yr. P 7 3 BO 1 1 i 68 from 1 yr. to 2 yr. 74 1 B l 1 i 6 9 other preschool 7 5 1 6 2 1 ! 1 1 7 0 school age 76 1 8 3 1 ! ! 1 1 71 adult 77 1 1 84 1 ( 1 i 17 geriatric i , 7 B 1 8 5 1 • ! c H C D O 2! O N > O AY 04, 1978 PAGE COMMUNITY NURSING ACTIVITIES SYSTEM 5A NO. OF SERVICES AND REFERRALS FROM SECTION V BY OFFICE, AGE AND SUBJECT FOUR WEEKLY • I T « , W E E K 0 5 - ° 8 817 04 SUBJECT SEEN REFERRED DEVELOPMENTAL SCRN 7 1 HEALTH ASSESSMENT 13 VISION SCREENING 2 22 1 LATE PRESCHOOL AUDIO SCREENING 50 9 DEVELOPMENTAL SCRN 20 HEALTH ASSESSMENT 13 SPEECH SCREENING 2 VISION SCREENING 56 24 141 33 GRADES 1 - 6 AUDIO SCREENING 45 4 DEVELOPMENTAL SCRN 6 1 PARASITES SCREENING 2 5 VISION SCREENING 53 9 106 16 AU0IO SCREENING 1 1 VISION SCREENING 15 4 16 5 ADULT (GENERAL) AUDIO SCREENING 13 1 BLOOD PRESSURE SCRN 4 17 1 GERIA (65-74) BLOOD FRESSURE SCRN 18 18 GERIA (75 +) BLOOD PRESSUPE SCRN 7 PARENTERAL MEDIC 1 8 328 56 ,402 221 1978 PAGE COMMUNITY NURSING ACTIVITIES SYSTEM 5A NO OF SERVICES AND REFERRALS FROM SECTION V BY OFFICE, AGE AND SUBJECT FOUR WEEKLY WEEK 05-08 SUBJECT SEEN REFERRED BLOOD PRESSURE SCRN 1 DRESSING i HEALTH ASSESSMENT 11 5 14 5 EARLY PRESCHOOL COMM DISEASE SCRN 2 1 HEALTH ASSESSMENT 5 2 HEMOGLOBIN 1 LATE PRESCHOOL AUDIO SCREENING 3 DEVELOPMENTAL SCRN 3 HEALTH ASSESSMENT 3 SPEECH SCREENING 1 VISION SCREENING 3 GRADES 1 - 6 AUDIO SCREENING COMM DISEASE SCRN DRESSING HEALTH ASSESSMENT ORAL MEDICATION PARENTERAL MEDIC GRADES 7 - 9 AUDIO SCREENING BLOOD PRESSURE SCRN HEALTH ASSESSMENT ADULT (GENERAL) BLOOD PRESSURE SCRN 8 DRESSING 1 HEALTH ASSESSMENT 12 7 HEMOGLOBIN 3 ORAL MEDICATION 4 2 PARENTERAL MEDIC 4 URINALYSIS 2 2 ADULT (OCC H) AUDIO SCREENING 1 1 GERIA (65-74) HEALTH ASSESSMENT J GERIA (75 +) BLOOD PRESSURE SCRN 2 URINALYSIS 1 11 107 not available at the time of this study). 5.7 A.C.N.A.R.S. Form no. 1 5.7.1 Section 1 Due to the way nurses are i d e n t i f i e d , data can be produced according to the d i f f e r e n t features of the i d e n t i -f i e r . Data can be reported by: - agency, - o f f i c e / s u b - o f f i c e , - function, - c l a s s i f i c a t i o n , or - i n d i v i d u a l . 5.7.2. Section 2. Time a l l o c a t i o n by program Upon the introduction of A.C.N.A.R.S., this section was regarded as a p a r t i c u l a r l y novel feature. It was f e l t that the data from this section would be of great use to supervi-sors and dire c t o r s . This section appears to be inappropriately named. Time a l l o c a t i o n i s actually recorded according to the age of pop-ul a t i o n served, and some other non-client 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 c l e a r l y directed at those within the p a r t i c u l a r age categories used i n this section. I f any program i s aimed at 108 a population that bridges the age spans used, this section cannot measure time a l l o c a t i o n by program. I f a number of programs are directed at any of the defined populations, then this section i s unable to measure the time allocated to i n -dividual programs. Instead, i n such cases, i t measures the time allocated to a number of programs. Time a l l o c a t i o n by age of population served may be an inte r e s t i n g feature, but i t i s not a p a r t i c u l a r l y h e l p f u l quantitative indicator of service delivered. As pointed out i n section 4 . 3 . 4 , a c t i v i t i e s may vary i n the time they require, and nurses may vary i n the time they require to perform a c t i -v i t i e s . Time spent on d i f f e r e n t age groups may bear no r e a l r elationship to services performed, outcomes obtained, and the effectiveness or even e f f i c i e n c y of nurses. One may pos-tulate some p o s i t i v e c o r r e l a t i o n between time spent and effectiveness, but the true rel a t i o n s h i p i s presently well beyond c a l c u l a t i o n . This section does provide a neat reporting format. But the relationship between the data reported and processes, outcomes and programs i s so indeterminate, that the data are of very l i t t l e use. 5 . 7 . 3 . Sections 3 and 4 . Group a c t i v i t i e s and ind i v i d u a l  contacts. These sections provide data very similar to data produced by the other systems examined. 109 5.7.4. Section 5. Screenings, assessments and treatments This section also notes where further action i s required. Much of the data i n this section i s gathered by other systems. Yet this section provides a compact means of recording the above a c t i v i t y types within the same section. As reports from form no. 2 were not available at the time of this study, this form i s not reviewed. 5.8. General discussion on A.C.N.A.R.S.  5.8.1 Objectives The need for a new recording form and a new approach was i d e n t i f i e d i n summer, 1976. (section 5.5.1). Yet, no clear and detailed objectives appear to have been stated as guidelines to what data the form should c o l l e c t , or how the data may be used. A report following the v i s i t to Ontario i n January, 1977, stated the uses of the system as: A. Local l e v e l 1. program planning 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. inservice planning based on program needs, 5. reporting to boards on services, functions, s t a f f u t i l i z a t i o n , 6. u t i l i z a t i o n of services. 110 B. Department l e v e l 1. budget allocation,, 2. define inservice and educational needs related to programs, 3. program needs, 4. research data and planning, 5. consultant information, 6. reporting to government oh services and functions 7. data to promote changes i n university/college programs to meet service and professional needs, 8. data to stimulate professional associations (standards, conferences, research). The output of the system could be used as a tool i n most of the above a c t i v i t i e s . Yet a c t i v i t y data are only one element among the many needed for the above process. Many other relevant information sources are required. The report did not define how the above processes were to be performed, or the nature of the information required. The need for c l e a r l y defined objectives was noted i n a memorandum on the development proposal for a health unit program information system. The memorandum was sent during May, 1976, by a consultant i n Local, Health Services. It stated that ... " i f the objectives of each program are not defined we can hardly deal with a management information system, but rather should conceptualize at the l e v e l of descriptive analysis." I l l 5.8.2 Assumptions Information on a c t i v i t y recording was requested and received (with one exception) from a l l the other provinces. It was decided to develop the forms using the system i n Ontario as a model. In the report on the v i s i t to Ontario, the a p p l i c a b i l i t y of the Ontario system to the Albertan 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 health authorities agreeing with two assumptions. These were that: 1. i t i s necessary for management purposes at both the p r o v i n c i a l and l o c a l levels to routinely c o l l e c t , tabulate and report comparable s t a t i s t i c s on the nursing services provided by each Alberta l o c a l 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 nursing services at a s u f f i c i e n t l e v e l of d e t a i l to meet management needs through a t r a d i t i o n a l manual reporting system (even i f standardized across the province), and therefore some comput-erized reporting system i s necessary. These two assumptions are fundamental to the system as i t was developed. Even though there was some wariness i n certain quarters about the introduction of a computerized system, these assumptions do not appear to have been ser-iously evaluated at any stage. Routine c o l l e c t i o n , tabulation and reporting of nursing 112 s t a t i s t i c s had been carried out i n Alberta and the other provinces for many years. As pointed out i n section 3.3.2, the routine reporting of nursing a c t i v i t i e s implies that these a c t i v i t i e s require constant monitoring. The t r a n s i t i o n to a computerized system was a major innovation, and a substantial change i n operating procedures. The rationale for a computerized system was that i t would be time saving, and more cost e f f i c i e n t i n the long run. As pointed out i n section 5.5.2, these claims do not appear to have been analyzed during the development of the system. Neither does the f e a s i b i l i t y of a computerized as opposed to a manual tabulation system appear to have been investigated. A computerized system involves time and costs during i t s development, planning and implementation stages. It also has a greater need for data control c l e r i c a l s t a f f time. In the l i g h t of these factors, the cost argument needs to be c a r e f u l l y evaluated i n introducing a computerized system. 5.8.3. Acceptance of the system One of the major problems i d e n t i f i e d i n introducing the new system was that of obtaining acceptance for i t from f i e l d and managerial s t a f f at the l o c a l l e v e l . This was based upon the advice of those f a m i l i a r with the system i n Ontario; f i e l d support for the system was c r u c i a l . This would involve overcoming a negative attitude towards computer systems based on two less than successful systems introduced for other programs. 1 1 3 A very r e a l e f f o r t was made to involve f i e l d s t a f f i n the development process as much as possible. This was also done to a l l a y fears that the time record would be used as a supervisory t o o l . The p o s i t i v e p o t e n t i a l of the system was strongly emphasized. The savings i n l o c a l s t a f f time presently spent c a l c u l a t i n g s t a t i s t i c s , was stressed. The process of system development produced two e f f e c t s . F i r s t l y , i t sought and managed to obtain the support of f i e l d personnel. This was due i n large part to the high-l y i n t e r a c t i v e nature of 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 that t h e i r input was regarded as valuable. It also raised the general l e v e l of awareness concerning a c t i v i t y recording. The second e f f e c t was, despite some skepticism, to create high expectations of the p o t e n t i a l of the system. This was an almost inevitable reaction to the enthusiasm and i n t e r a c t i o n generated. By constantly stressing the poten-t i a l of the system, the b e l i e f was created that the system would be very h e l p f u l to supervisors and directors i n a number of v i t a l tasks. I t may have been that, with the mystical power of a computerized system somewhat obscuring the issues, some managerial s t a f f were led to expect more from the system than what i t was i n fact capable of delivering. Enthusiasm i n developing- a system i s a p o s i t i v e asset. But i t must be kept i n mind that, unless the enthusiasm and expectations can be shown to be warranted, disillusionment and negative feelings may r e s u l t . 114 5.8.4 Recording data The i n s t r u c t i o n manual for the nurses report form was extensively detailed to enable the recording of a c t i v i t i e s to be as accurate as possible. The issues 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 dealt with e x p l i c i t -l y . Yet the extensive d e t a i l of the instructions serve to increase 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 report form). The intensive one day 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 nurses with the form. The one to two weeks practice with the form was intended to develop and improve th e i r recording a b i l i t y . As noted i n section 5.5.3, errors decreased sharply i n number after the f i r s t month of operation of A.C.N.A.R.S. I t was found that feedback to nurses with indications of incorrect recording increased their awareness of th e i r record-ing, as well as improving t h e i r accuracy. This feedback can be provided through some kind of data check i n the l o c a l health agency, before forms are forwarded to Local Health Services. 5.8.5. Communication of data As pointed out i n section 3.3.1, the status hierarchy of an organization w i l l be possibly the major factor a f f e c t -ing the flow of data through i t . A feature of the data flow process i s the rule that a l l correspondence to health unit personnel from Local Health Services must be directed 115 v i a the director of the agency. This can give the director the power that c e r t a i n data may p o t e n t i a l l y contain. The director thus has some influence and control over the flow of a c t i v i t y data between Community Health Services and his or her nursing supervisor. The degree of communication, both within and between health units, i s l i k e l y to be a function of the leadership  s t y l e of the director (see section 3.3.1). The nurse supervisor and her st y l e of operation w i l l be fundamentally affected by the style of the director. The amount of com-parison of program s t a t i s t i c s , and programs and services themselves, which i s actually affected between health units, depends a great deal on the director's leadership s t y l e . It was agreed that the input from a l l health units, and the r e s u l t i n g output, was to be regarded as co n f i d e n t i a l . This was done to a l l a y fears that other health units would obtain data that might r e f l e c t negatively on the health unit concerned. The i n i t i a t i v e for comparing data thus rests with the health units themselves. The cognitive s t y l e of supervisors and directors was taken into account i n developing output formulas for the data gathered. The format of data reports was developed by the nursing records committee, which was composed predomin-antly of nursing supervisors. Input was also obtained from other f i e l d personnel. 116 5.8.6 Usefulness of systems data During the summer of 1978, I undertook an evaluation of the A.C.N.A.R.S. system i n compiling guide-l i n e s to the use of the data produced by the system. This work included a series of f i e l d v i s i t s , to both c i t y boards of health, and to three health units. Discussions were held with medical o f f i c e r s of health, supervisors and directors of community health nursing, nursing consultants and members of the nursing records committee. Many straightforward ways i n which the data could be used were i d e n t i f i e d . For example, i f objectives are set for a program, i n terms of the quantity of service to be provided, A.C.N.A.R.S. provides the means for measuring whether or not objectives have been met. A.C.N.A.R.S. provides data that can be studied for trends i n patterns of service provision. The data can give an ind i c a t i o n of changes i n emphases, p r i o r i t i e s or service u t i l i z a t i o n . The data may act as an i n d i r e c t indicator of demand for certain services. Comparisons of data from A.C.N.A.R.S. can only reveal indicators of trends. They can i n no way indicate what type of actions or decisions are necessary. Appropriate action can only be undertaken once a t o t a l perspective of a situa-tion has been obtained. As indicated by Bergwall, Reeves and Woodside (section 2.6), one cannot interpret accurately measured a c t i v i t i e s 117 without an understanding of th e i r context. Accurate measure-ments of a c t i v i t i e s are not i n themselves a basis for action, without an o v e r a l l understanding of the si t u a t i o n . On the other hand, an understanding of the s i t u a t i o n may be a s u f f i -cient basis for action, without any accurate measurements of a c t i v i t i e s . While A.C.N.A.R.S. can provide accurate measure-ments of a c t i v i t i e s to complement an understanding of a s i t -uation, i t can i n no way provide the understanding that i s so necessary i n the o v e r a l l diagnostic process. It i s perhaps because of raised expectations i n this regard that I found a certa i n degree of f r u s t r a t i o n among those involved with the system and i t s output. While not altogether negative, many of those I spoke to were skep-t i c a l of the usefulness of the system. They were elusive when asked for concrete examples of how the data was being used, or could be used. There was generally very p o s i t i v e f e e l i n g on the usefulness of data i n reporting back to boards. But, at a l l l e v e l s , people indicated they were un-able to f i n d much use for the data, other than to report to boards or other agencies, and to provide a quantitative i n -ventory of nursing work performed. Within Community Health Services, i t was f e l t that A.C.N.A.R.S. provided valuable baseline data on a province-wide basis, which had not been available beforehand. It was also strongly f e l t that A.C.N.A.R.S. acts as an awareness r a i s i n g mechanism, by making nurses more aware of the 118 a c t i v i t i e s they are performing. In this way too, i t acts as an educational t o o l . While this i s true, 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 analyzing services provided, the data are more useful i f seen i n the context of c l e a r l y stated and operationally defined objectives. In any further development of A.C.N.A.R.S., i t would appear to be v i t a l that objectives be c l e a r l y and operationally defined. I f this i s not done, the process of development may lack d i r e c t i o n . This could lead to a "cart-before-the-horse" type of s i t u a t i o n . In this case, aft e r well-intentioned and good looking r e f i n e -ments are made, the users may be hard pressed to f i n d s p e c i f i c ways i n which the data obtained can be used. 119 CHAPTER 6 6.1 General d i s c u s s i o n In the p r e v i o u s chapters, most aspects o f a c t i v i t y r e c o r d i n g systems have been d i s c u s s e d i n d e t a i l . In p a r t i -c u l a r , the g e n e r a l examination of a c t i v i t y r e c o r d i n g systems was the t o p i c o f chapter 4, w h i l e an in-dept h a n a l y s i s o f a p a r t i c u l a r system was made i n chapter 5. In t h i s f i n a l chapter, a few ou t s t a n d i n g i s s u e s w i l l be considered to round out our d i s c u s s i o n o f Canadian a c t i v i t y r e c o r d i n g systems. F i r s t l y , I look at the i s s u e of whether a common model c o u l d be d e r i v e d from the systems examined i n chapter 4. Secondly, I s h a l l examine the ge n e r a l and a l l important problem o f a c t i v i t y r e c o r d i n g systems e v a l u a t i o n . T h i r d l y , I w i l l c o n s i d e r a l t e r n a t i v e methods of o b t a i n i n g the inform-a t i o n t hat i s p r e s e n t l y gathered through a c t i v i t y r e c o r d i n g . F i n a l l y , a summary o f the f i n d i n g s o f t h i s work w i l l be made. 6.2 A common model The concept of a common model assumes t h a t a c t i v i t y r e c o r d i n g systems have e s s e n t i a l and i d e n t i f i a b l e commona-l i t i e s i n o b j e c t i v e s , o r g a n i z a t i o n , and o p e r a t i o n . I f such commonalities do e x i s t , a model system c o u l d form the b a s i s of community h e a l t h n u r s i n g a c t i v i t y r e c o r d i n g i n a l l p r o v i n c e s . Furthermore, such a model c o u l d a l s o p r o v i d e a standard f o r the e v a l u a t i o n of e x i s t i n g systems. 120 In chapter 4, p r o v i n c i a l and federal a c t i v i t y record-ing systems were examined i n d e t a i l . Based upon this analysis, can a 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. Referring to Table 4.1 we can see that the majority of a c t i v i -t i e s on which data are col l e c t e d are common to a l l systems. These a c t i v i t i e s f a l l into the basic categories given i n Table 6.1 (p. 121) . However, closer analysis of the information i n chapter 4 shows that, despite s i m i l a r i t i e s , differences between systems are substantial. In p a r t i c u l a r , systems objectives are i n a l l cases vaguely defined. Thus, the data items c o l -lected, the methods of data c o l l e c t i o n , the organization used to obtain the data and the u t i l i z a t i o n of the information col l e c t e d are subst 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 record-ing system to another. These differences make each system unique to such an extent that a meaningful common model can-not be derived. 6-3 Evaluation The objective of evaluation i s to examine how well a system i s doing what i t i s supposed to do. With a c t i v i t y re-cording systems, there are two quite d i f f e r e n t aspects to be considered. The f i r s t i s the performance of the recording system i t s e l f , and the second i s the imp ac t of the data produced by the system. 121 Table 6.1 Basic Categories for A c t i v i t y Recording 1. Immunizations. 2. School health services. 3. Screenings. 4. Groups and/or classes. 5. Child health conferences. 6. Maternal care (prenatal • (postnatal. 7. Infant care. 8. C l i n i c s . 9. Meetings/liasons. 10. Communicable diseases. 11. Mental h e a l t h / i l l n e s s . 12. Health promotion. 13. Home assessments/reassessments. 14. Family planning. 15. Total home v i s i t s . 122 The e x p l i c i t c a l c u l a t i o n of the costs of the recording system i s also an important consideration. The main elements of these costs would be: nursing time spent i n recording, costs of supplies, data processing expenditures and the administrative overhead. The performance and impact should be weighted against costs, to derive a measure of the cost-effectiveness of a system. 6.3.1 Systems performance When evaluating 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 appropriate data, as well as the q u a l i t y of data col l e c t e d . For every recording system, one should be able to speci-fy a minimum esse n t i a l data set, consisting of those data items which are necessary for the system to f u l f i l l i t s objec-t i v e s . For the systems studied i n chapter 4, this presents a d i f f i c u l t problem. As was shown then, systems objectives are generally so vaguely defined that i t i s not possible to derive from them a minimum essential data set. Thus, evaluators may have to form th e i r own judgements on the adequacy of data collected, or r e l y on the subjective opinion of supervisors and d i r e c t o r s . Data qu a l i t y i s affected by the accuracy and r e l i a b i l i t y of data recording. These factors were discussed i n sections 3.2.2 and 3.2.3. As indicated then, i t may not be possible to estimate accuracy and r e l i a b i l i t y i n absolute terms. An 123 assessment of these f a c t o r s may thus have to be based on the judgement of those most c l o s e l y i n v o l v e d w i t h the system. These would i n c l u d e d i r e c t o r s , s u p e r v i s o r s and the nurses themselves. 6.3.2 The impact o f a c t i v i t y data The impact of data s u p p l i e d by a c t i v i t y r e c o r d i n g systems i s the r e a l e f f e c t t h a t these data have on the d e c i -s i o n making processes o f s u p e r v i s o r s and d i r e c t o r s . There are a number o f f a c t o r s i n f l u e n c i n g t h i s e f f e c t i v e n e s s . They were reviewed i n s e c t i o n s 3.3 and 3.4. These f a c t o r s a l l need to be e x p l i c i t l y c o n s i d e r e d i n any e v a l u a t i o n process. The e v a l u a t o r s t r y to e s t a b l i s h , by whatever means are a v a i l a b l e , whether the impact of the data i s s i g n i f i c a n t . From systems o b j e c t i v e s , one ought to be able to d e r i v e per-formance parameters, which c o u l d be measured to assess the im-pact of the data. However, o b j e c t i v e s are g e n e r a l l y so vague-l y d e f i n e d t h a t performance parameters cannot be obtained from these statements. Thus, i t i s extremely d i f f i c u l t to measure whether systems o b j e c t i v e s are indeed being f u l f i l l e d . There i s another, more fundamental problem. I t i s ex-tremely d i f f i c u l t to i d e n t i f y the c a u s a l connections between a c t i v i t y data and the outcome of d e c i s i o n making processes. These processes are so u n s t r u c t u r e d and undefined, t h a t the e f f e c t o f a c t i v i t y data on them cannot be measured i n o b j e c t i v e terms. T h e r e f o r e , no 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 data can be s p e c i f i e d . Thus, i t becomes necessary to ask the users of the data themselves how h e l p f u l they f i n d the data produced by a c t i v i t y r e c o r d i n g . The answers they g i v e are t h e i r percep-t i o n s of the impact of such data. They must be c a r e f u l l y cross-examined, to s u b s t a n t i a t e t h e i r claims or d i s c l a i m e r s . In t h i s way, the e v a l u a t o r s are a b l e to o b t a i n the most ac-c u r a t e p e r s p e c t i v e of how u s e f u l the data t r u l y are to those f o r whom i t i s p r i m a r i l y intended. 6.4 A l t e r n a t i v e s r h a v e i n d i c a t e d t h a t no common model can be d e r i v e d from those s t u d i e d . I have a l s o shown the d i f f i c u l t y i n t r y i n g to o b j e c t i v e l y evaluate the performance of a system, and the impact of a c t i v i t y data. At t h i s stage, i t i s imper-a t i v e to c o n s i d e r some 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 . 6.4.1 No a c t i v i t y r e c o r d i n g The f i r s t , and most obvious a l t e r n a t i v e , i s to abandon a c t i v i t y r e c o r d i n g . What are the i m p l i c a t i o n s o f not c o l l e c t -i n g any a c t i v i t y data? In the absence of a c l e a r understanding of the d e c i s i o n making processes of d i r e c t o r s and s u p e r v i s o r s , i t i s d i f f i c u l t to e s t a b l i s h the e f f e c t of having to do without a c t i v i t y data. The i n t u i t i v e knowledge t h a t s u p e r v i s o r s and 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 affected much. However, the more refined measure that a c t i v i t y data give to this knowledge would be l o s t . 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 health service providers. Communications between community health nurses and others involved i n health care provision i s v i t a l , for each party to convey to the other an understanding of what they are doing. Such communication i s fundamental to the r a t i o n a l organization and operation of health care services. Furthermore, i t increases i n importance as the scope of community health nursing programs grow, and the complexity of the organizational environment increases. A c t i v i t y data provide quantitative means of communica-tio n that can be adequately understood by a l l parties. No other data could f i l l this role i n quite the same way. Thus, due to the communication needs between the various parts of the health care system, some a c t i v i t y data are indeed necessary. 6.4.2 Special studies Special studies may be designed and structured to c o l l e c t whatever p a r t i c u l a r data are required. For example, they may 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 and opinions, data on the content of nursing a c t i v i t i e s , or inform-ation on the outcome of services provided. Special studies have t h e i r l i m i t a t i o n s . " I t i s very im-portant to recognize that .... special studies are r e a l l y 126 sample surveys and therefore subject to the caution that t h e i r r e s u l t s are only estimates of the true values". (National League for Nursing, 1977, p. 23). P a r t i c u l a r at-tention must be given to the survey design and the time when the study i s done, to ensure that the sample obtained i s re-presentative of the r e a l s i t u a t i o n . Special studies require s t a f f orientation to the method of the study. F a m i l i a r i z i n g nurses with the instrument to be used i s time consuming. Accuracy and r e l i a b i l i t y may also be problems i n short term sampling, due to nurses' lack of f a m i l i a r i t y and experience with the forms involved. Using trained outsiders would overcome th i s problem, but would be p r o h i b i t i v e l y costly. A l l these factors need to be con-sidered when weighing the r e l a t i v e cost and benefit factors of such studies. The representativeness of a study w i l l depend, among other things, on the predictive v a l i d i t y of the study method. Predictive v a l i d i t y could be tested by simultaneously per-forming a c t i v i t y recording and s p e c i a l studies, and compar-ing the r e s u l t s . 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, special studies could be used for reporting purposes, and could possibly replace the more t r a d i t i o n a l and esta-blished a c t i v i t y s t a t i s t i c s from a c t i v i t y recording. If special studies have well defined objectives, and are appropriately designed to f u l f i l l these objectives, 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 regular a c t i v i t y 127 r e c o r d i n g systems. Under t h e s e c o n d i t i o n s , they may be a v i a b l e and a p p e a l i n g a l t e r n a t i v e t o r e g u l a r r e c o r d i n g systems. 6 . 4 . 3 C o m p u t e r i z a t i o n There seems t o be a tendency, i n the l i t e r a t u r e and i n p r a c t i c e , 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 w i l l r e s o l v e t h e i r c u r r e n t problems and i n a d e q u a c i e s . I n t h i s sense, c o m p u t e r i z a t i o n i s r e g a r d e d as a q u a l i t a t i v e l y d i f f e r e n t development, g i v i n g r i s e t o an a l t e r n a t i v e t o p r e s e n t p r a c t i c e s . A c o m p u t e r i z e d system i s much more p o w e r f u l t h a n a man-u a l system, i n terms o f t h e q u a n t i t y and v a r i e t y o f o u t p u t i t can produce. I t i s most u s e f u l as a means o f r e d u c i n g o r 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 . 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 , i t 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 ac-t i v i t y d a t a . I n e s s e n c e , manual and c o m p u t e r i z e d a c t i v i t y r e c o r d i n g systems f u n c t i o n i n much the same way. The key t o o b t a i n i n g d a t a t h a t w i l l have an impact on d e c i s i o n making l i e s i n t h e p r o c e s s o f systems development. I n i t i a l l y , one needs t o e s t a b l i s h c l e a r l y what i t i s one wants t o do. C l e a r l y d e f i n e d o b j e c t i v e s w i l l a c t as an i n -d i c a t o r o f t h e type and amount o f d a t a t o be c o l l e c t e d . C o m p u t e r i z a t i o n does n o t do away w i t h the need t o c a r e f u l l y f o l l o w the above p r o c e d u r e . 128 The importance of data on decision making i s a func-ti o n of the decision making processes of supervisors and dir e c t o r s , and not of the quantity and variety of data pro-duced. While computerization of a c t i v i t y data may a f f e c t the quantity and va r i e t y of reports produced, i t w i l l not d i r e c t l y a f f e c t the decision making processes of data users. 6/5 Cone lus ions This study has focused on two aspects of a c t i v i t y data c o l l e c t i o n . These are 1. the need for a c t i v i t y data, and 2. the usefulness of these data. As shown i n section 2.4, there i s a need for a c t i v i t y data. However, these data play a li m i t e d role i n the func-tions performed by directors and supervisors. Many other kinds of information are also required. In most cases, these other types of information are of greater importance than ac-t i v i t y data. The only function where a c t i v i t y data appear to be of primary importance i s that of reporting nursing a c t i v i -t i e s to boards, government o f f i c i a l s and other health care workers. As i t i s evident from the discussion of section 4.4.1, many of the systems' objectives are stated i n vague and non-operational terms. Therefore, the data that need to be col l e c t e d could not be i d e n t i f i e d . It was thus not possible to v e r i f y whether the data being c o l l e c t e d were appropriate 1 2 9 or adequate to enable the systems to f u l f i l l t h e i r objec-t i v e s . Unless o b j e c t i v e s are o p e r a t i o n a l l y d e f i n e d , they do not a c t as d e f i n i t e data c o l l e c t i o n g u i d e l i n e s . A t t e n t i o n must be g i v e n to the process of d e f i n i n g o b j e c t i v e s c l e a r l y . P o o r l y d e f i n e d o b j e c t i v e s may be a r e f l e c t i o n of the u n s t r u c t u r e d nature o f the d e c i s i o n making processes i n com-munity h e a l t h n u r s i n g management. I f the ways i n which a c t i v i t y data are to be used are not c l e a r l y e s t a b l i s h e d , then r e f i n i n g the f e a t u r e s and f u n c t i o n i n g o f the r e c o r d i n g system may have l i t t l e e f f e c t on the u s e f u l n e s s of the system. A more thorough understanding of the d e c i s i o n making processes of d i r e c t o r s and s u p e r v i s o r s i s r e q u i r e d to i d e n t i f y where and how the data may be used. S p e c i a l s t u d i e s can c o l l e c t a broader range of data than r e g u l a r a c t i v i t y r e c o r d i n g systems. T h e r e f o r e these s t u d i e s are a p o t e n t i a l l y more f l e x i b l e and u s e f u l t o o l than such present a c t i v i t y r e c o r d i n g systems, i f they can 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 . I f s p e c i a l s t u d i e s are cheaper than r e c o r d i n g systems, they are a more c o s t - e f f i c i e n t way of o b t a i n i n g a c t i v i t y data. I t i s thus r e -commended t h a t the p r e d i c t i v e v a l i d i t y and co s t s o f s p e c i a l s t u d i e s be f u r t h e r i n v e s t i g a t e d . The a n a l y s i s presented i n t h i s work i m p l i e s t h a t a thorough r e v i s i o n o f presently, o p e r a t i n g a c t i v i t y r e c o r d i n g systems i s necessary. The r e l e v a n c e and p o t e n t i a l u s e f u l n e s s of p r e s e n t l y gathered data need to be re a s s e s s e d . I b e l i e v e 130 that such a review would lead to changes i n some of the cur-rent practices. An example i s that of noting the duration of a c t i v i t i e s . In the context of the discussion i n section 4.3. 4, this feature ought to be discontinued. Even more dra s t i c action may be warranted i n some cases. 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