UBC Theses and Dissertations

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UBC Theses and Dissertations

The clinical nurse specialist in British Columbia Halliday, Shirley Ann Lilly 1983

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THE CLINICAL NURSE SPECIALIST IN BRITISH COLUMBIA by SHIRLEY ANN LILLY HALLIDAY B.N., D a l h o u s i e U n i v e r s i t y , 1971 THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l of N u r s i n g ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1983 © S h i r l e y Ann L i l l y H a l l i d a y , 1983 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of \^( uwV)4A ft The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date $(o /Uttfl \qfo DE-6 (3/81) i i ABSTRACT A l a c k of c l a r i t y c o n c e r n i n g a d e s c r i p t i o n of the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canadian n u r s i n g was the problem a d d r e s s e d i n t h i s t h e s i s . A r o l e enactment view of r o l e t h e o r y and r e p o r t e d r e s e a r c h f i n d i n g s about what c l i n i c a l n u r se s p e c i a l i s t s a c t u a l l y do ( A r a d i n e and Denyes, 1972) were u t i l i z e d as a framework f o r st u d y . A q u e s t i o n n a i r e was deve l o p e d and a m a i l survey was conducted w i t h a s e l f - i d e n t i f i e d group of 147 c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia. Both d e s c r i p t i v e a n a l y s i s and a n a l y s e s of r e l a t i o n s h i p s among v a r i a b l e s were c a r r i e d o u t . G e n e r a l l y s p e a k i n g i t was found t h a t : (1) t h e r e i s s t i l l a l a c k of c l a r i t y about the r o l e i n B r i t i s h C olumbia, (2) the p r i m a r y means by which an i n d i v i d u a l nurse becomes a c l i n i c a l n u r se s p e c i a l i s t i n B r i t i s h Columbia i s t h r o u g h e x p e r i e n c e i n the system, (3) a d e s c r i p t i o n of the r o l e a r t i c u l a t e d i n American n u r s i n g l i t e r a t u r e by A r a d i n e and Denyes (1972) does not f i t the d e s c r i p t i o n r e p o r t e d by the s u b j e c t s , and (4) s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p s e x i s t among some of the v a r i a b l e s examined and e s t i m a t e s of weekly work time r e p o r t e d by the s u b j e c t s . The f i n d i n g s suggest t h e r e i s a need f o r n u r s i n g l e a d e r s i n the a r e a s of e d u c a t i o n and s e r v i c e t o work t o g e t h e r on i s s u e s c o n c e r n i n g the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada. i i i TABLE.OF CONTENTS A b s t r a c t 1 Acknowledgement 2 CHAPTER 1 INTRODUCTION 1 Statement Of The Problem 4 S i g n i f i c a n c e Of The Problem 5 Purposes Of The Study 5 D e f i n i t i o n Of Terms 6 T h e o r e t i c a l Framework 6 Assumptions 9 L i m i t a t i o n s 9 CHAPTER 2 REVIEW OF THE LITERATURE 10 Concept Of The C l i n i c a l Nurse S p e c i a l i s t In American N u r s i n g L i t e r a t u r e 10 E a r l y W r i t i n g s 11 Ro l e Models 13 D i s c u s s i o n s And Research 16 The C l i n i c a l Nurse S p e c i a l i s t In Canadian N u r s i n g L i t e r a t u r e 25 H i s t o r i c a l P e r s p e c t i v e 26 N u r s i n g L i t e r a t u r e About The Role 29 P o s s i b l e E x p l a n a t i o n s For An Observed Gap Ih The L i t e r a t u r e 31 CHAPTER 3 METHODOLOGY 36 S u b j e c t s 36 The I n s t r u m e n t 36 Pro c e d u r e 37 CHAPTER 4 RESULTS 39 P r e s e n t P o s i t i o n '40 Demographic I n f o r m a t i o n 41 Work A c t i v i t y 41 C o n t e x t u a l l y R e l a t e d V a r i a b l e s 44 P r o f e s s i o n a l V a r i a b l e s 50 R e l a t i o n s h i p s Among V a r i a b l e s 54 CHAPTER 5 DISCUSSION 60 D e s c r i p t i o n Of The Rol e As P e r c e i v e d By A S e l f -D e f i n e d Group Of C l i n i c a l Nurse S p e c i a l i s t s In B r i t i s h Columbia 60 Work A c t i v i t y 62 C o n t e x t u a l l y R e l a t e d V a r i a b l e s 64 Job T i t l e 65 New Or E x i s t i n g P o s i t i o n And Presence Or Absence Of Job D e s c r i p t i o n 66 Work S e t t i n g 70 Type Of Appointment 73 P r o f e s s i o n a l V a r i a b l e . . 76 S i m i l a r i t i e s And D i f f e r e n c e s Between The Nurses' D e s c r i p t i o n s And A D e s c r i p t i o n R eported By A r a d i n e And Denyes (1972) 80 S u g g e s t i o n s For The F u t u r e C o n c e r n i n g The C l i n i c a l Nurse S p e c i a l i s t R o l e In Canada 91 i v CHAPTER 6 SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY 95 Summary 95 C o n c l u s i o n s 103 I m p l i c a t i o n s 105 Recommendations For F u r t h e r Study 107 REFERENCES 110 BIBLIOGRAPHY 118 APPENDIX A 124 APPENDIX B 126 APPENDIX C 135 TABLES C.2 - C.9 137 V LIST OF TABLES 1 P r e s e n t P o s i t i o n s Of S u b j e c t s No Longer I d e n t i f y i n g Themselves As C l i n i c a l Nurse S p e c i a l i s t s (Item 1(a)) 40 2 Work A c t i v i t i e s Of S u b j e c t s (Item 7) 42 3 Range And Mean Per c e n t a g e Of E s t i m a t e d Weekly Work Time Devoted To C a t e g o r i e s Of Work A c t i v i t y (Item 7) 43 4 S u b - C a t e g o r i e s And P e r c e n t a g e s For Other C a t e g o r y Of Work A c t i v i t i e s (Item 7) 44 5 C a t e g o r i e s D e r i v e d From S p e c i f i c Job T i t l e s P r o v i d e d By S u b j e c t s (Item 2) 44 6 Summary Of E x p r e s s e d P r e f e r e n c e s For A l t e r n a t e Job T i t l e s (Item 3) 45 7 Length Of Time In P r e s e n t P o s i t i o n (Item 4) 46 8 Types Of Employment S e t t i n g s (Item 8) 47 9 Responses In Other C a t e g o r y For Type Of Appointment (Item 9b) 48 10 B a s i c E d u c a t i o n a l P r e p a r a t i o n In N u r s i n g Of The S u b j e c t s (Item 10) 50 11 P o s t - b a s i c N u r s i n g E d u c a t i o n By Type Of Program, And Minimum, Maximum And Average Number Of Years S i n c e C o m p l e t i o n (Item 11) 50 12 Areas Of Study For D i p l o m a / C e r t i f i c a t e Type Of Programs Completed (Item 11) 52 13 N u r s i n g P o s i t i o n s H e l d By S u b j e c t , By P o s i t i o n , Sequence, Range, And Mean Years H e l d (Item 12) 53 14 Summary Of S i g n i f i c a n t F i n d i n g s For R e l a t i o n s h i p Between C o n t e x t u a l l y R e l a t e d And P r o f e s s i o n a l V a r i a b l e s And E s t i m a t e s Of Pe r c e n t a g e Of Weekly Work Time Devoted To C a t e g o r i e s Of Work A c t i v i t y 56 15 Comparison Of F i n d i n g s For The C o n t e x t u a l l y - R e l a t e d V a r i a b l e Type Of Appointment As D e s c r i b e d By A r a d i n e And Denyes And The P r e s e n t Study 82 16 Comparison Of Work A c t i v i t y Of The C l i n i c a l Nurse S p e c i a l i s t As D e s c r i b e d By A r a d i n e And Deynes (1972) And The F i n d i n g s Of The P r e s e n t Study 87 C.1 L a b e l ( s ) And Pe r c e n t a g e Of Weekly Work Time Re p o r t e d For Other C a t e g o r y Of Work A c t i v i t y (Item 7) 136 C.2 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e Time In P r e s e n t P o s i t i o n 138 C.3 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e New V e r s u s E x i s t i n g P o s i t i o n 140 C.4 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e Job D e s c r i p t i o n 142 C.5 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e Type Of S e t t i n g 144 C.6 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e Type Of Appointment ( U n i t Vs Not U n i t Based) 146 C.7 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e Type Of v i Appointment ( C l i n i c a l , C l i n i c a l - e d u c a t i o n a l , C l i n i c a l - a d m i n i s t r a t i v e , Other) 148 C.8 R e s u l t s Of An A n a l y s i s Of The V a r i a b l e L i n e V e r s u s S t a f f P o s i t i o n 150 C.9 R e s u l t s Of An A n a l y s i s Of The D e r i v e d V a r i a b l e E d u c a t i o n a l P r e p a r a t i o n 152 v i i ACKNOWLEDGEMENT I w i s h t o acknowledge and extend a statement of g r a t i t u d e t o a number of p e r s o n s : my committee members, Dr. M a r i l y n W i llman and Mrs. B e t t y Johnson, f o r t h e i r g u i d a n c e , work, support and unending c a p a c i t i e s t o c h a l l e n g e and extend my t h i n k i n g ; the RNABC Board members f o r p r o v i d i n g a c c e s s t o the s e l f - i d e n t i f i e d group of c l i n i c a l n urse s p e c i a l i s t s ; the i n d i v i d u a l c l i n i c a l nurse s p e c i a l i s t s f o r p r o v i d i n g the i n f o r m a t i o n about t h e m s e l v e s and t h e i r work; my c h i l d r e n , J e f f and Ben, as w e l l as a number of f a m i l y members and f r i e n d s f o r t h e i r v a r i o u s forms of s u p p o r t , encouragement, and c a r i n g t hroughout the work. CHAPTER 1 INTRODUCTION The need f o r s p e c i a l i z a t i o n w i t h i n the h e a l t h c a r e d e l i v e r y system has been c r e a t e d by r a p i d s c i e n t i f i c and t e c h n o l o g i c a l p r o g r e s s , an i n c r e a s e i n the number of s p e c i a l i z e d h e a l t h f a c i l i t i e s , changes i n m e d i c a l p r a c t i c e , and an i n c r e a s e i n the p u b l i c demand f o r h e a l t h s e r v i c e s (Krause, 1977; Smoyak, 1976). S p e c i a l i z a t i o n r e p r e s e n t s a mechanism through which p r o f e s s i o n s can p r o v i d e a h i g h q u a l i t y of s e r v i c e t o the p u b l i c . R o l e s emerge and d e v e l o p as a r e a s of s p e c i a l i z a t i o n d e v e l o p w i t h i n p r o f e s s i o n s . A p r o f e s s i o n must d e f i n e what the s e r o l e s s h o u l d be i n o r d e r t o d i r e c t i t s c o n t r i b u t i o n t o the p u b l i c w e l f a r e . W i t h i n n u r s i n g , the c l i n i c a l nurse s p e c i a l i s t r o l e d e v e l o p e d i n response t o t h i s need f o r s p e c i a l i z a t i o n (Smoyak, 1976; P e p l a u , 1965). T h i s response has o c c u r r e d p r e d o m i n a n t l y i n the U n i t e d S t a t e s . The concept of the c l i n i c a l nurse s p e c i a l i s t was f i r s t d i s c u s s e d by n u r s i n g l e a d e r s i n the 1930's and 1940's (Mayo, 1944; S t e w a r t , 1933) and slow movement toward c l i n i c a l s p e c i a l i z a t i o n f o l l o w e d (Smoyak, 1976; P e p l a u , 1965; N a t i o n a l League For N u r s i n g , 1952). At the p r e s e n t t i m e , the l i t e r a t u r e tends t o su p p o r t a statement made by Smoyak i n 1976 c o n c e r n i n g c l i n i c a l s p e c i a l i z a t i o n : "The i d e a of c l i n i c a l s p e c i a l i z a t i o n , w i t h the i n h e r e n t u n d e r s t a n d i n g of e x c e l l e n c e i n p r a c t i c e , i s v e r y much a c c e p t e d w i t h i n n u r s i n g and i s becoming b e t t e r 1 2 u n d e r s t o o d by consumers, employers, and the o t h e r p r o f e s s i o n s . " (Smoyak, 1976; p. 678). Much has been w r i t t e n about the c l i n i c a l nurse s p e c i a l i s t i n American n u r s i n g l i t e r a t u r e ; however, most of the p u b l i c a t i o n s o c c u r r e d d u r i n g the l a t e 1960's and the e a r l y 1970's, and a c t u a l r e s e a r c h r e l a t i n g t o the r o l e i s l i m i t e d . The concept of c l i n i c a l nurse s p e c i a l i s t i s r e c o g n i z e d i n Canada (Canadian Nurses A s s o c i a t i o n , 1973 and 1972); however, i t has not been f o r m a l l y d e f i n e d (The Canadian Nurse, 1980; Dworkin, 1970).' In s p i t e of t h i s , t h e r e are n u r s e s who i d e n t i f y t hemselves as c l i n i c a l s p e c i a l i s t s ( S t a t s Canada, 1978). N a t i o n a l s t a t i s t i c s i n d i c a t e an i n c r e a s e between 1972 and 1976 i n the number of p o s t - b a s i c programs w i t h a c l i n i c a l f o c u s a v a i l a b l e f o r the p r e p a r a t i o n of n u r s e s . D i p l o m a / c e r t i f i c a t e programs have i n c r e a s e d from 7 t o 11, and master's from 2 t o 10 ( S t a t s Canada, 1978; T a b l e 2 ) . In a d d i t i o n , these s t a t i s t i c s a l s o i n d i c a t e a s l i g h t i n c r e a s e i n the number of g r a d u a t e s from t h e s e programs between 1972 and 1976. From d i p l o m a / c e r t i f i c a t e programs the i n c r e a s e has been from 165 t o 232 g r a d u a t e s , and from master's programs, from 8 t o 17 ( S t a t s Canada, 1978; T a b l e 8 ) . By 1976 each of the p r o v i n c i a l n u r s i n g a s s o c i a t i o n s had i n c l u d e d a work p o s i t i o n e n t i t l e d " c l i n i c a l s p e c i a l i s t " on annual r e g i s t r a t i o n forms ( H e a l t h Manpower S t a t i s t i c s , 1976). The t i t l e , " c l i n i c a l s p e c i a l i s t , " i t seems, t h e n , i s r e c o g n i z e d w i t h i n b oth work s e t t i n g s and the 3 n u r s i n g p r o f e s s i o n . W i t h i n B r i t i s h Columbia the number of n u r s e s i d e n t i f y i n g themselves as " c l i n i c a l s p e c i a l i s t s " has i n c r e a s e d . In 1974 t h e r e was a t o t a l of 60; t h i s number i n c r e a s e d t o a t o t a l of 128 by 1981 ( R o l l c a l l 74, T a b l e 3b.1; R o l l c a l l 81, T a b l e 8 ) . In the 1981-1982 r e g i s t r a t i o n year t h i s t o t a l had i n c r e a s e d t o 148 ( R o l l c a l l Update 82, Table 8 ) . In 1974 the p r o p o r t i o n of " c l i n i c a l s p e c i a l i s t s " r e p r e s e n t e d 0.54% (60/11,182) of the t o t a l r e g i s t e r e d nurse p o p u l a t i o n i n B r i t i s h Columbia. In 1981 the p e r c e n t a g e of s e l f - i d e n t i f i e d " c l i n i c a l s p e c i a l i s t s " had r i s e n t o 0.71 (128/18,067) (see R o l l c a l l 74, t a b l e 3b.1; R o l l c a l l 81, t a b l e 8 ) . Some q u e s t i o n s t h a t need t o be answered so t h a t a d e s c r i p t i o n of the r o l e i n Canada can begin t o be more c l e a r l y a r t i c u l a t e d i n c l u d e : What k i n d of p i c t u r e does the r o l e p r e s e n t now? Can the r o l e be more p r e c i s e l y d e s c r i b e d than the c u r r e n t p i c t u r e r e f l e c t e d i n the l i t e r a t u r e ? Can t r e n d s be i d e n t i f i e d t h a t can be u s e f u l f o r p r o v i d i n g d i r e c t i o n t o the n u r s i n g p r o f e s s i o n ? I s t h e r e such a t h i n g as a Canadian a s p e c t t o the concept of c l i n i c a l nurse s p e c i a l i s t ? What does t h i s l o o k l i k e ? T h i s study was d e s i g n e d t o e x p l o r e the r o l e of a group of n u r s e s engaged i n n u r s i n g p r a c t i c e i n one Canadian p r o v i n c e who i d e n t i f y t h e i r work p o s i t i o n as c l i n i c a l nurse s p e c i a l i s t . 4 Statement of the Problem Nurses are b e i n g p r e p a r e d t o f u n c t i o n i n the c l i n i c a l n urse s p e c i a l i s t r o l e . There a r e nurses who i d e n t i f y t h emselves on annual r e g i s t r a t i o n forms as " c l i n i c a l s p e c i a l i s t . " In B r i t i s h Columbia the number i n t h i s c a t e g o r y has i n c r e a s e d . Because the r o l e of t h e s e n u r s e s has not been d e f i n e d , the n u r s i n g p r o f e s s i o n i n Canada has o n l y a borrowed and s k e t c h y t h e o r e t i c a l base t o draw upon f o r an u n d e r s t a n d i n g of the r o l e and the p r e p a r a t i o n of n u r s e s f o r the r o l e . T h i s t h e o r e t i c a l base i s drawn from the development of n u r s i n g i n another c o u n t r y whose h e a l t h c a r e system i s o r g a n i z e d i n a d i f f e r e n t way. Thus, a p p l i c a t i o n of such u n d e r s t a n d i n g s t o the Canadian s i t u a t i o n can be p r o b l e m a t i c . Because n u r s e s must be a b l e t o f i t i n t o the r o l e , and s i n c e the e d u c a t i o n a l p r o c e s s must h e l p them c a r v e out a n i c h e i n the h e a l t h c a r e system, a c l e a r d e f i n i t i o n of the concept of c l i n i c a l nurse s p e c i a l i s t i s needed by Canadian n u r s i n g . T h e r e f o r e , the problem t o be a d d r e s s e d by t h i s s tudy i s the need f o r a c l e a r d e s c r i p t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e i n Canadian n u r s i n g . The problem w i l l be a d d r e s s e d by a s k i n g p r a c t i c i n g c l i n i c a l n urse s p e c i a l i s t s i n the p r o v i n c e of B r i t i s h Columbia about what they do and the placement of the r o l e i n the employing agency. 5 S i g n i f i c a n c e of the Problem I t i s b e l i e v e d by the r e s e a r c h e r t h a t u t i l i z a t i o n and a c c e p t a n c e of the c l i n i c a l nurse s p e c i a l i s t a r e l i n k e d t o the a b i l i t y t o p r e c i s e l y d e s c r i b e the r o l e . P r o f e s s i o n a l r e s p o n s i b i l i t y r e q u i r e s t h a t t h e r e be a c l e a r d e s c r i p t i o n of the r o l e a r t i c u l a t e d by the n u r s i n g p r o f e s s i o n i n Canada. Without a c l e a r d e s c r i p t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e i s s u e s such as q u a l i t y of c a r e , e d u c a t i o n a l s t a n d a r d s , and c e r t i f i c a t i o n cannot be s a t i s f a c t o r i l y a d d r e s s e d . Purposes of the Study The purposes of t h i s study a r e : 1. t o d e s c r i b e the r o l e of the c l i n i c a l nurse s p e c i a l i s t as p e r c e i v e d by a group of n u r s e s i n B r i t i s h Columbia who i d e n t i f y t h emselves as b e l o n g i n g t o t h i s group; 2. t o i d e n t i f y s i m i l a r i t i e s and d i f f e r e n c e s between the n u r s e s ' d e s c r i p t i o n s and a d e s c r i p t i o n r e p o r t e d by A r a d i n e and Denyes (1972); 3. t o make s u g g e s t i o n s f o r the f u t u r e i n r e l a t i o n t o the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada based on the above f i n d i n g s . 6 D e f i n i t i o n of Terms For the purpose of t h i s study a c l i n i c a l nurse s p e c i a l i s t i s d e f i n e d as a nurse c u r r e n t l y r e g i s t e r e d w i t h the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia (RNABC) who i d e n t i f i e s h e r / h i s work p o s i t i o n as t h a t of c l i n i c a l s p e c i a l i s t by c h e c k i n g Box 23 on the 1981-1982 r e g i s t r a t i o n form. Role i s d e f i n e d as the o v e r t b e h a v i o r of a p a r t i c u l a r i n d i v i d u a l i n a p a r t i c u l a r s e t t i n g ( S a r b i n , 1968; p. 194). T h e o r e t i c a l Framework T h e o r e t i c a l l y t h i s s t u d y was b u i l t on the f i r s t l e v e l r e s e a r c h q u e s t i o n of "what i s ? " ( D i e r s , 1979) and a l i s t of c a t e g o r i e s of a c t i v i t i e s r e p o r t e d by nurse r e s e a r c h e r s ( A r a d i n e ' a n d Denyes, 1972). From a wider p e r s p e c t i v e t h i s s tudy was g u i d e d by r o l e t h e o r y . Deutsch and K r a u s s (1965) i d e n t i f i e d t h r e e d i f f e r e n t c o n c e p t u a l i z a t i o n s r e f l e c t e d i n the l i t e r a t u r e c o n c e r n i n g usage of the term r o l e . These i n c l u d e the n o t i o n s of p r e s c r i b e d r o l e , s u b j e c t i v e r o l e , and ena c t e d r o l e . T h i s l a s t usage was adopted f o r t h i s s t u d y . In t h i s usage, " r o l e c o n s i s t s of the s p e c i f i c o v e r t b e h a v i o r of the occupant of a p o s i t i o n when he i n t e r a c t s w i t h the occupants of' some o t h e r p o s i t i o n " (Deutsch and K r a u s s , 1965; p. 175). E x t e n s i v e t h e o r e t i c a l d i s c u s s i o n of r o l e enactment has been r e p o r t e d by S a r b i n and A l l e n (1968). The model 7 they o u t l i n e can be summarized b r i e f l y by the f o l l o w i n g equat i o n : R o l e depends upon r o l e e x p e c t a t i o n enactment the + i n t e r a c t i o n o f : r o l e l o c a t i o n + r o l e demands + r o l e s k i l l s + r o l e congruence + au d i e n c e e f f e c t . ( S a r b i n and A l l e n , 1968; p. 553) The a n a l y s i s and c o n c e p t s d e s c r i b e d by t h i s model have u t i l i t y , the a u t h o r s s u g g e s t , f o r examining r o l e b e h a v i o r i n r e a l l i f e where " m u l t i p l e r o l e o b l i g a t i o n s impinge s i m u l t a n e o u s l y on the r o l e p e r f o r m e r " ( S a r b i n and A l l e n , 1968; p. 536). W r i t e r s w i t h i n the n u r s i n g p r o f e s s i o n s u p p o r t a p p l i c a b i l i t y of t h i s s u g g e s t i o n t o e x a m i n a t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e ( S t e v e n s , 1976; Georgopoulos and C h r i s t m a n , 1970). S e l e c t e d c o n c e p t s from t h i s l a s t view of r o l e t h e o r y (as d e s c r i b e d by S a r b i n and A l l e n , 1968; and, Deutsch and K r a u s s , 1965), t h e i r d e f i n i t i o n and a p p l i c a b i l i t y i n t h i s study a r e o u t l i n e d as f o l l o w s . R o l e enactment i s d e f i n e d as "the o v e r t b e h a v i o r of a p a r t i c u l a r i n d i v i d u a l i n a p a r t i c u l a r s e t t i n g " ( S a r b i n and A l l e n , 1968; p. 494). A d i m e n s i o n t h a t has p r a c t i c a l u s e f u l n e s s i s concerned w i t h the n o t i o n of i n v o l v e m e n t (time 8 spent i n one r o l e r e l a t i v e t o time spent i n o t h e r r o l e s ) ( S a r b i n and A l l e n , 1968; p. 494). In t h i s study e x a m i n a t i o n of components of r o l e enactment f o r the p o p u l a t i o n of i n t e r e s t was s t r u c t u r e d by r e s e a r c h f i n d i n g s r e p o r t e d by A r a d i n e and Denyes (1972). The d i m e n s i o n of involvement was used by a s k i n g the p o p u l a t i o n of i n t e r e s t t o p r o v i d e e s t i m a t e s of a p e r c e n t a g e of work time devoted t o each of the p r o v i d e d c a t e g o r i e s of work a c t i v i t y . The concept p o s i t i o n / s t a t u s i s d e f i n e d as a r e l a t i o n a l concept used t o r e p r e s e n t a person's l o c a t i o n w i t h i n a " s t a t u s system" (Deutsch and K r a u s s , 1965; p. 174). In t h i s study the p o s i t i o n of i n t e r e s t i s t h a t of the c l i n i c a l nurse s p e c i a l i s t . I n f o r m a t i o n about the p o s i t i o n w i t h i n the employing agency was s o l i c i t e d so t h a t a d e s c r i p t i o n c o u l d be a r t i c u l a t e d of the c o n t e x t u a l background i n which the p o s i t i o n i s e n a c t e d . In a d d i t i o n , t h i s s tudy was a l s o g u i d e d by the u n i t of a n a l y s i s i n h e r e n t i n t h i s view of r o l e t h e o r y . T h i s u n i t of a n a l y s i s c o n s i s t s of (1) a r o l e p e r f o r m e r , (2) a person i n a complementary r o l e , and (3) a t h i r d p e r s o n who o b s e r v e s the p r o c e s s of s o c i a l i n t e r a c t i o n ( S a r b i n and A l l e n , 1968). In t h i s s tudy each respondent was both (1) the r o l e p e r f o r m e r and (2) the person i n the complementary r o l e (Mead, 1934). The t h i r d element was p r o v i d e d by the d a t a - c o l l e c t i n g form. The o b s e r v e r , i n t h i s case the r e s e a r c h e r , i s not p h y s i c a l l y p r e s e n t f o r c o l l e c t i o n of d a t a . The r e s e a r c h e r ' s presence was i n d i r e c t 9 through the d a t a - c o l l e c t i n g form. Assumpt i o n s T h i s study was based on the f o l l o w i n g a s s u m p t i o n s : 1. The c a t e g o r y " c l i n i c a l s p e c i a l i s t " on the RNABC r e g i s t r a t i o n form i s checked by nurses who see themselves and/or whose employers r e c o g n i z e t h e i r work as r e p r e s e n t a t i v e of a s p e c i a l i z e d c l i n i c a l r o l e i n n u r s i n g . 2. Nurses i n B r i t i s h Columbia a r e , i n most ways, r e p r e s e n t a t i v e of the n u r s i n g p o p u l a t i o n i n Canada. 3. Nurses i n the p o p u l a t i o n s u r v e y e d a r e a b l e and w i l l i n g t o p r o v i d e i n f o r m a t i o n about t h e i r s p e c i f i c p r a c t i c e . 4. Nurses i n the p o p u l a t i o n s u r v e y e d w i l l respond h o n e s t l y to items on the d a t a - c o l l e c t i n g form. L i m i t a t i o n s 1. The p o p u l a t i o n was p r e - d e t e r m i n e d by s e l f - r e p o r t s on the RNABC r e g i s t r a t i o n form. T h e r e f o r e , the p o p u l a t i o n may have e x c l u d e d nurses who a r e f u n c t i o n i n g as c l i n i c a l nurse s p e c i a l i s t s as the l i t e r a t u r e would d e f i n e the r o l e but d i d not i d e n t i f y themselves by c h e c k i n g box 23. 2. Data o b t a i n e d by t h i s survey r e s e a r c h p r o v i d e d a d e s c r i p t i o n o n l y of the r o l e of t h i s group i n B r i t i s h Columbia a t the p r e s e n t t i m e . CHAPTER 2 REVIEW OF THE LITERATURE The f i r s t s e c t i o n of the r e v i e w of the l i t e r a t u r e w i l l p r e s e n t an overview of the concept of the c l i n i c a l nurse s p e c i a l i s t as d e s c r i b e d i n American n u r s i n g l i t e r a t u r e . The next s e c t i o n w i l l p r e s e n t a b r i e f review of Canadian l i t e r a t u r e c o n c e r n i n g the c l i n i c a l nurse s p e c i a l i s t . The f i n a l s e c t i o n of t h i s c h a p t e r w i l l p r e s e n t p o s s i b l e e x p l a n a t i o n s suggested i n the l i t e r a t u r e f o r a l a c k of d i s c u s s i o n about the r o l e d u r i n g the pa s t decade. Concept of the C l i n i c a l Nurse S p e c i a l i s t i n American N u r s i n g  L i t e r a t u r e T h i s s e c t i o n w i l l be s u b d i v i d e d i n t o a r e a s e n t i t l e d e a r l y w r i t i n g s , r o l e models, and d i s c u s s i o n s and r e s e a r c h . "The n u r s i n g l i t e r a t u r e from the U n i t e d S t a t e s has had a g r e a t impact on the development of n u r s i n g i n Canada" (Mussallem, 1964; p. 30-31). Because of t h i s , i t i s im p o r t a n t t h a t w r i t i n g s about the c l i n i c a l n urse s p e c i a l i s t r o l e i n t h i s l i t e r a t u r e be examined. 10 11 E a r l y W r i t i n g s The concept of c l i n i c a l nurse s p e c i a l i s t and i t s a p p l i c a t i o n i n the p r a c t i c e of n u r s i n g have been d i s c u s s e d by a number of a u t h o r s ( R e i t e r , 1966; P e p l a u , 1965; Johnson, 1962). Johnson (1962) viewed the c l i n i c a l s p e c i a l i s t as an e x p e r t p r a c t i t i o n e r who, i n c o m b i n a t i o n w i t h a f l o o r / u n i t manager, c o u l d p r o v i d e an a l t e r n a t e p a t t e r n t o t h a t of the head nurse and a means by which d e c i s i o n - m a k i n g r e g a r d i n g p a t i e n t c a r e would be c e n t r a l i z e d a t the c l o s e s t p o i n t t o the p a t i e n t . She viewed n u r s i n g s e r v i c e as r e p r e s e n t a t i v e of a s o c i a l system. She b e l i e v e d the r o l e , i n t h i s o r g a n i z a t i o n a l p o s i t i o n , would r e s u l t i n improvement of the q u a l i t y of c a r e p r o v i d e d t o p a t i e n t s by n u r s e s . P e p l a u (1965) i d e n t i f i e d the p r e p a r a t i o n of c l i n i c a l s p e c i a l i s t s as a most i m p o r t a n t development i n p r o f e s s i o n a l n u r s i n g . She emphasized the need f o r the n u r s i n g p r o f e s s i o n t o make c h o i c e s about the i s s u e of s p e c i a l i z a t i o n w i t h i n the p r o f e s s i o n . U t i l i z i n g a v a i l a b l e knowledge and u n d e r s t a n d i n g about the concept of s p e c i a l i z a t i o n i n g e n e r a l , P e p l a u o u t l i n e d t en c a t e g o r i e s of s p e c i a l t y p r a c t i c e and two models f o r s p e c i a l i z a t i o n from which n u r s i n g c o u l d make c h o i c e s . Each of the p o s s i b i l i t i e s f o r the development of s p e c i a l i z a t i o n i n n u r s i n g d e s c r i b e d by P e p l a u r e f l e c t c e r t a i n s t a t e m e n t s about the d e l i v e r y of h e a l t h c a r e s e r v i c e s t o the p u b l i c . For example, h o s p i t a l s a r e o r g a n i z e d f o r the d e l i v e r y of s e r v i c e s a c c o r d i n g t o age 12 groups and the l e n g t h of i l l n e s s e x p e r i e n c e d by an i n d i v i d u a l . W i t h i n a h o s p i t a l , the d e l i v e r y of s e r v i c e s i s f u r t h e r o r g a n i z e d a c c o r d i n g t o organs and b o d i l y systems, degree of i l l n e s s , f i e l d s of knowledge, and p r o f e s s i o n a l g o a l s . On the one hand th e s e c a t e g o r i e s suggest t h a t , i n d e v e l o p i n g the c l i n i c a l s p e c i a l i s t r o l e , the n u r s i n g p r o f e s s i o n was r e s p o n d i n g t o e v o l v i n g developments w i t h i n the work environment of the h o s p i t a l . On the o t h e r hand, and a t the same t i m e , p r o f e s s i o n a l r e s p o n s i b i l i t y would demand, P e p l a u a r g u e s , t h a t n u r s i n g a r t i c u l a t e d e s c r i p t i o n s of the r o l e s concerned w i t h s p e c i a l i z a t i o n i n n u r s i n g as they c o n t i n u e t o e v o l v e . C l i n i c a l s p e c i a l i s t s , a c c o r d i n g t o P e p l a u (1965), a re g e n e r a l i s t s t r a i n e d w i t h a broad base of i n t e l l e c t u a l c ompetencies who p o s s e s s t h e o r e t i c a l and c l i n i c a l u n d e r s t a n d i n g of the p a t i e n t s / p r o b l e m s w i t h which they work. They s h o u l d a l s o be c o n t r i b u t e r s t o the a v a i l a b l e knowledge i n the p r o f e s s i o n by c o n d u c t i n g r e s e a r c h and p u b l i s h i n g the f i n d i n g s . Another e a r l y w r i t e r , R e i t e r (1966), e x p l o r i n g the meaning she a s s o c i a t e d w i t h the concept of nurse c l i n i c i a n , used the l a b e l i n a g e n e r i c sense t o i n d i c a t e a " s t a t e of b e i n g . " T h i s r e f l e c t s , she m a i n t a i n e d , an a c c u m u l a t i o n of a depth of knowledge and e x p e r i e n c e a p p l i e d i n the p r a c t i c e of n u r s i n g . R e i t e r viewed the r o l e as t h a t of a master p r a c t i t i o n e r who uses a h i g h degree of d i s c r i m i n a t i v e 13 judgement i n the a p p l i c a t i o n of the n u r s i n g p r o c e s s and who i s m o t i v a t e d by a commitment t o the p r o v i s i o n of the h i g h e s t q u a l i t y of n u r s i n g c a r e . These w r i t i n g s r e f l e c t a l e v e l of u n d e r s t a n d i n g t h a t i s a b s t r a c t i n n a t u r e . Johnson, P e p l a u and R e i t e r agree t h a t c l i n i c a l p r a c t i c e i s the f o c u s of the work of the c l i n i c a l s p e c i a l i s t ( i f we equate R e i t e r ' s term nurse c l i n i c i a n t o the o t h e r a u t h o r s ' usage of c l i n i c a l s p e c i a l i s t ) . Assuming t h a t the terms "e x p e r t p r a c t i o n e r , " " i n t e l l e c t u a l c o m p e t e n c i e s " and "master p r a c t i t i o n e r " are r e f e r r i n g t o the same s e t of n o t i o n s , i t then can be s a i d t h a t a l l t h r e e a u t h o r s agree t h a t advanced knowledge and s k i l l s a r e a p a r t of the r o l e . P e p l a u and R e i t e r agree t h a t commitment t o the p r o f e s s i o n i n the form of a d v a n c i n g the knowledge a v a i l a b l e or p r o v i d i n g a h i g h q u a l i t y of n u r s i n g c a r e , i s a p a r t of the r o l e . Johnson does not d i s c u s s t h i s p o i n t e x p l i c i t l y . L a t e r w r i t e r s ( M c P h a i l , 1971; B a r r e t t , 1971) have a r t i c u l a t e d s i m i l a r t h e o r e t i c a l d e f i n i t i o n s . These u n d e r s t a n d i n g s form a t h e o r e t i c a l backdrop f o r i n t e r p r e t i n g the f i n d i n g s of t h i s s t u d y . R o l e Models The f i r s t d e s c r i p t i o n of a r o l e model appears i n the n u r s i n g l i t e r a t u r e i n 1970. Developed by Georgopoulos and C h r i s t m a n (1970), the model was d e r i v e d from a r e v i e w of the l i t e r a t u r e p r i o r t o November, 1965, from p r e v a i l i n g r o l e 1 4 t h e o r y and o r g a n i z a t i o n t h e o r y , and from the i n v e s t i g a t o r s ' e x p e r i e n c e and knowledge of h o s p i t a l s and the h e a l t h f i e l d . F i v e major c l a s s e s of components a r e d e l i n e a t e d by t h i s r o l e model: 1. t r a i n i n g and p r e p a r a t i o n f o r c l i n i c a l p r a c t i c e ; 2. p r o f e s s i o n a l v a l u e s and o r i e n t a t i o n ; 3. c o r e f u n c t i o n s and a c t i v i t i e s of the c l i n i c a l nurse s p e c i a l i s t ; 4. r e l e v a n t r i g h t s and o b l i g a t i o n s of the c l i n i c a l nurse s p e c i a l i s t ; 5. work r e l a t i o n s h i p s w i t h o t h e r s a t the p a t i e n t u n i t l e v e l (Georogoulos and C h r i s t m a n , 1970; p. 1034-1035). The assumptions i d e n t i f i e d by t h e s e a u t h o r s about p r o f e s s i o n a l c h a r a c t e r i s t i c s of c l i n i c a l nurse s p e c i a l i s t s , r o l e s , and n u r s i n g which d i r e c t the s t r u c t u r e of the model i n c l u d e : 1 . the " c l i n i c a l nurse s p e c i a l i s t i s a p r o f e s s i o n a l nurse who has completed a master's l e v e l program f o r s p e c i a l i z a t i o n i n a p a r t i c u l a r n u r s i n g a r e a " (Georgopoulos and C h r i s t m a n , 1970; p. 1033); 2. the r o l e i s "an e x p l i c i t p r o f e s s i o n a l - o r g a n i z a t i o n a l r o l e " w i t h i n a h o s p i t a l system; 3. the r o l e " r e p r e s e n t s a new r o l e model f o r c l i n i c a l l e a d e r s h i p and p r a c t i c e (Georgopoulos and C h r i s t m a n , 1970; p. 1031); 4. p a t i e n t u n i t team l e a d e r s who are c l i n i c a l nurse 1 5 s p e c i a l i s t s can improve the q u a l i t y of p a t i e n t c a r e . A second d e s c r i p t i o n of a r o l e model i s r e p o r t e d by A r a d i n e and Denyes (1972). The model was d e r i v e d from a study of what a group of c l i n i c a l nurse s p e c i a l i s t s p e r c e i v e d themselves as a c t u a l l y d o i n g i n t h e i r work. These r e s e a r c h e r s conducted an e x p l o r a t o r y study of (1) the scope of a c t i v i t i e s , (2) the p r e s s u r e s , and (3) the de v e l o p m e n t a l sequence of a group of c l i n i c a l nurse s p e c i a l i s t s . The sample p o p u l a t i o n c o n s i s t e d of 29 c l i n i c a l nurse s p e c i a l i s t s employed i n h o s p i t a l s which were members of the U n i v e r s i t y H o s p i t a l E x e c u t i v e C o u n c i l 1 . A two day symposium p r o v i d e d the medium f o r d i s c u s s i o n s r e l a t e d t o the i s s u e s i d e n t i f i e d above. Membership i n the d i s c u s s i o n groups was plann e d t o p r o v i d e r e p r e s e n t a t i o n from d i f f e r e n t c l i n i c a l a r e a s , d i f f e r e n t l e n g t h s of e x p e r i e n c e i n c l i n i c a l nurse s p e c i a l i s t p o s i t i o n s , and p a r t i c i p a t i o n from each i n s t i t u t i o n . A composit e l i s t of 122 a c t i v i t i e s was r e c o r d e d i n the language of the c l i n i c a l nurse s p e c i a l i s t s . An independent r e v i e w of t h i s l i s t was made by s i x judges. The review c o n s i s t e d of g r o u p i n g the a c t i v i t i e s i n t o c a t e g o r i e s . There was 100 per cen t agreement among the judges on 28 i t e m s , 83 per cent agreement on 22 i t e m s , and 67 per cen t agreement on 20 i t e m s . The r e m a i n i n g 52 items on which t h e r e was l e s s than 67 h o s p i t a l s i n c l u d e d i n the UHEC a r e the Case Western Reserve U n i v e r s i t y , U n i v e r s i t y of C h i c a g o , I n d i a n a U n i v e r s i t y , U n i v e r s i t y of Iowa, U n i v e r s i t y of M i c h i g a n , U n i v e r s i t y of M i n n e s o t a , U n i v e r s i t y of R o c h e s t e r (New Y o r k ) , and U n i v e r s i t y of W i s c o n s i n ( A r a d i n e and Deynes, 1972, p. 411). 1 6 per c e n t agreement were d i s c u s s e d and coded by two c l i n i c a l nurse s p e c i a l i s t judges who a t t e n d e d the symposium. There was 100 per cent agreement on t h e s e 52 i t e m s . ( A r a d i n e and Denyes, 1972; p. 412). These c a t e g o r i e s of work a c t i v i t y comprise what the r e s e a r c h e r s d e s c r i b e d as the c e n t r a l a c t i v i t i e s of the c l i n i c a l n u r se s p e c i a l i s t r o l e as i t was p e r c e i v e d by the sample. The components of t h i s r o l e model are l e s s w e l l d e v e l o p e d than those d e s c r i b e d i n the Georgopoulos and C h r i s t m a n model. T h i s i s r e l a t e d t o the f o c u s of d a t a c o l l e c t i o n and a n a l y s i s , which d e a l t p r e d o m i n a n t l y w i t h " d e t a i l e d d e s c r i p t i o n s of a c t i v i t i e s , r e s p o n s i b i l i t i e s and p r e s s u r e s e x p e r i e n c e d by p r a c t i c i n g c l i n i c a l nurse s p e c i a l i s t s " ( A r a d i n e and Denyes, 1972; p. 411). The a u t h o r s d i d not e x p l i c i t l y a r t i c u l a t e assumptions u n d e r l y i n g t h i s r o l e model. The r e p o r t e d f i n d i n g s concerned w i t h work a c t i v i t i e s , as o u t l i n e d by A r a d i n e and Denyes, form a b a s i s f o r comparison w i t h the f i n d i n g s of t h i s s t u d y . D i s c u s s i o n s and Research A r e v i e w i n d i c a t e s t h e r e i s a wide range of l i t e r a t u r e about the c l i n i c a l nurse s p e c i a l i s t and e m p i r i c a l r e s e a r c h , a l t h o u g h l i m i t e d i n amount, has p r e d o m i n a n t l y f o c u s e d on the q u e s t i o n of e f f e c t i v e n e s s of the r o l e i n the h o s p i t a l s e t t i n g . The range of d i s c u s s i o n s i n the l i t e r a t u r e can be o r g a n i z e d i n t o the f o l l o w i n g a r e a s : 1 7 1. the e d u c a t i o n a l p r e p a r a t i o n of the c l i n i c a l nurse s p e c i a l i s t (Hellman, 1974; B e r l i n g e r , 1973; M a c P h a i l , 1971; Murphy, 1970); 2. the n a t u r e of the c l i n i c a l nurse s p e c i a l i s t r o l e ( R i s k , 1975; NLN, 1973; P e a r s o n , 1972; B a c k s h e i d e r , 1971; S t u r z l , 1970; Gordon, 1969); 3. the c h a l l e n g e s a s s o c i a t e d w i t h r o l e i m p l e m e n t a t i o n ( B u l l o u g h , 1976; B a r r e t t , 1971; Baker and Kramer, 1970; Love, 1970; R i c h a r d s , 1969); 4. the e f f e c t i v e n e s s of the r o l e ( E h r e n r e i c h and S t e w a r t , 1979; S h a e f e r , 1973; Woodrow and B e l l , 1971; Georgopoulos and Sana, 1971; Georgopoulos and J a c k s o n , 1970; L i t t l e , 1967) ; 5. a c t i v i t i e s of the c l i n i c a l nurse s p e c i a l i s t ( A r a d i n e and Denyes, 1972). D i s c u s s i o n s about p r e p a r a t i o n f o r the c l i n i c a l nurse s p e c i a l i s t r o l e c e n t r e upon whether i t s h o u l d be i n the form of graduate e d u c a t i o n ( M a c P h a i l , 1971; B e r l i n g e r , 1973; Murphy, 1970; P e p l a u , 1965) or a c o m b i n a t i o n of e x p e r i e n c e and on the j o b t r a i n i n g ( B a r r e t t , 1971). The former p o s i t i o n i s s u p p o r t e d by the argument t h a t the c l i n i c a l nurse s p e c i a l i s t r o l e i s an advanced and s p e c i a l i z e d r o l e w i t h i n n u r s i n g p r a c t i c e . The l a t t e r p o s i t i o n i s s u p p o r t e d by a t l e a s t two o b s e r v a t i o n s . These i n c l u d e the f a c t t h a t a r e l a t i v e l y s m a l l number of n u r s e s a r e p r e p a r e d a t the graduate l e v e l f o r the r o l e (Boone and K i k u c h i , 1977; 18 Coombs, 1970), and a q u e s t i o n as t o the a b i l i t y of the e d u c a t i o n a l system t o meet demands f o r p r e p a r i n g n u r s e s i n i n c r e a s i n g numbers f o r the r o l e (CN, 1981; Jenny, 1968). I t s h o u l d be noted t h a t these o b s e r v a t i o n s have been more f r e q u e n t l y a r t i c u l a t e d by n u r s e s who work i n Canada. Research i n t o the r o l e i n d i c a t e s advanced knowledge and depth of u n d e r s t a n d i n g i n a c l i n i c a l s p e c i a l i t y a r e n e c e s s a r y t o f u n c t i o n i n the r o l e (Georgopoulos and Sana, 1971; Georgopoulos and J a c k s o n , 1970). T h i s s u g g e s t s t h a t p r e p a r a t i o n f o r the c l i n i c a l nurse s p e c i a l i s t r o l e may o n l y be a t t a i n a b l e t h rough the p r o c e s s of graduate e d u c a t i o n . The n a t u r e of the r o l e , as r e f l e c t e d by the p r e v i o u s p r e s e n t a t i o n of r o l e models, i s complex and m u l t i f a c e t e d . In a broad sense the l i t e r a t u r e s u rveyed would seem t o support t h i s view. However, d i s c u s s i o n s about t h e n a t u r e of the r o l e seem t o f o c u s p r e d o m i n a n t l y on a s i n g l e a s p e c t of the l a r g e r complex phenomenon of the c l i n i c a l nurse s p e c i a l i s t r o l e . For example, the r o l e has been d e s c r i b e d i n the l i t e r a t u r e i n terms o f : 1. a p r a c t i t i o n e r model ( B a c k s h e i d e r , 1971; Baker and Kramer, 1970; S c u l l y , 1967; Johnson, W i l c o x and M o i d e l , 1967); 2. a change agent model (Gordon, 1969; Loomis, 1968); 3. a c o n s u l t a t i o n model ( B l a k e , 1977; S t e t t e r and Downs, 1974); 4. a s u p e r v i s o r y model f o r n u r s i n g s e r v i c e ( P a r k e s , 1974; 19 F a g i n , 1967); and 5. an i n d i v i d u a l r o l e model f o r n u r s i n g s e r v i c e (Gregory and Lang, 1977; Pearson, 1972; S t u r z l , 1970). C o n s i s t e n c y i s e v i d e n t i n the w r i t i n g s t h a t f o c u s on the f i r s t f o u r of these f i v e broader views of the c l i n i c a l nurse s p e c i a l i s t r o l e . The l a s t view has been c r i t i c i z e d by D i l w o r t h (1970). The b a s i s f o r t h i s i s the ob s e r v e d gap between r o l e model e x p e c t a t i o n s a r t i c u l a t e d by g r a d u a t e s c h o o l s and the e x p e c t a t i o n s and needs of n u r s i n g p r a c t i c e ( D i l w o r t h , 1970). R e s e a r c h i n t o the n a t u r e of the r o l e i s l i m i t e d . Woodrow and B e l l (1971) and A r a d i n e and Denyes (1972) p r o v i d e d e s c r i p t i v e a c c o u n t s of the r o l e as i t was p e r c e i v e d by c l i n i c a l nurse s p e c i a l i s t s w o r k i n g i n a h o s p i t a l s e t t i n g . The former r e s e a r c h e r s u t i l i z e d t h e i r own e x p e r i e n c e s and r e p o r t f r e q u e n c y c o u n t s and r e l a t i v e p e r c e n t a g e s of the number of c o n t a c t s each e x p e r i e n c e d i n f o u r a r e a s of f u n c t i o n , namely, d i r e c t p a t i e n t c a r e , c o n s u l t a t i o n , r e s e a r c h , and t e a c h i n g n u r s i n g p e r s o n n e l . The l a t t e r r e s e a r c h e r s asked a group of c l i n i c a l nurse s p e c i a l i s t s t o use r e c a l l and c u r r e n t e x p e r i e n c e s t o f o r m u l a t e a l i s t of a c t i v i t i e s performed i n t h e i r work. The d a t a i n d i c a t e t h a t the r o l e of the c l i n i c a l nurse s p e c i a l i s t i s a complex and m u l t i f a c e t e d one. A c o l l e c t i o n of a r t i c l e s c o m p i l e d by Lewis i n 1970 p r o v i d e s some i n d i v i d u a l a c c o u n t s of c l i n i c a l nurse 20 s p e c i a l i s t s who have implemented the r o l e . A s i m i l a r c o l l e c t i o n i s a v a i l a b l e f o r Canadian n u r s i n g (Conference on the C l i n i c a l Nurse S p e c i a l i s t , 1973). These ac c o u n t s r e f l e c t an a t t i t u d e of o p t i m i s m about the p o s s i b l e impact of the r o l e on the q u a l i t y and c o n t i n u i t y of p a t i e n t c a r e ( L a g e r s o n , 1973; Simms, 1973; M e l b e r , 1967; Yokes, 1966) and an e x p e r i e n c e of e x c i t e m e n t and s a t i s f a c t i o n r e l a t e d t o the work i t s e l f (Snyder, 1973). In a d d i t i o n , the a c c o u n t s p r o v i d e i n s i g h t s i n t o f r u s t r a t i o n s ( D a r c o v i c h , 1973; Anderson, 1966), d i f f i c u l t i e s (Anderson e t . a l . , 1975; R i s k , 1975), and s t r a t e g i e s u t i l i z e d by a number of c l i n i c a l nurse s p e c i a l i s t s ( B a r r e t t , 1971; R i c h a r d s , 1969) as each implemented a new r o l e . D e s c r i p t i o n s and s t u d i e s of i m p l e m e n t a t i o n of the r o l e have p r e d o m i n a n t l y been from an a d m i n i s t r a t i v e v i e w p o i n t . T h i s p e r s p e c t i v e has f o c u s e d on v a r i a b l e s such as a u t h o r i t y s t r u c t u r e (Kirkman and M i l l e r , 1972; Baker and Kramer, 1970); s t a f f a c c e p t a n c e (Woodrow and B e l l , 1971; Simms, 1966); communication ( B a c k s h e i d e r , 1971); and o t h e r f a c t o r s p e r c e i v e d as e i t h e r f a c i l i t a t i n g or i n h i b i t i n g r o l e i m p l e m e n t a t i o n ( E h r e n r e i c h and S t e w a r t , 1979; S h a e f e r , 1973). At l e a s t two i m p o r t a n t i s s u e s r e l a t e d t o i m p l e m e n t a t i o n of the r o l e warrant a t t e n t i o n . These c o n c e r n the p o s i t i o n of the r o l e i n the a u t h o r i t y s t r u c t u r e of an agency and u t i l i z a t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e by the agency. 21 The l i t e r a t u r e i n d i c a t e s t h e r e i s l i t t l e agreement c o n c e r n i n g the p o s i t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e w i t h i n the a u t h o r i t y s t r u c t u r e of an agency. The advantages and d i s a d v a n t a g e s of the r o l e b e i n g p l a c e d i n a l i n e v e r s u s s t a f f p o s i t i o n have been d i s c u s s e d by a number of w r i t e r s ( C a s t r o n o v o , 1975; P a r k e s , 1974; Cooper, 1973; Kirkman and M i l l e r , 1972; Woodrow and B e l l , 1971; M a c P h a i l , 1971; Baker and Kramer, 1970; L i t t l e , 1967). In g e n e r a l , s u p p o r t f o r the r o l e as a l i n e p o s i t i o n i n an agency i s based on the p o s i t i o n a l a u t h o r i t y i n h e r e n t i n such placement. The n a t u r e of the su p p o r t f o r the r o l e as a s t a f f p o s i t i o n i s based on the r e s u l t i n g g r e a t e r degree of ease w i t h which the c l i n i c a l nurse s p e c i a l i s t can e s t a b l i s h and m a i n t a i n w o r k ing r e l a t i o n s h i p s w i t h s t a f f n u r s e s and o t h e r h e a l t h c a r e p r o f e s s i o n a l s . Another p o s i t i o n r e l a t e d t o the i s s u e of placement of the r o l e w i t h i n the o r g a n i z a t i o n has been a r t i c u l a t e d by Stevens (1976). In her e x a m i n a t i o n of the l a r g e r i s s u e of a c c o u n t a b i l i t y as i t r e l a t e s t o a u t h o r i t y and the c l i n i c a l n urse s p e c i a l i s t r o l e , Stevens makes a d i s t i n c t i o n between two t y p e s of a u t h o r i t y . There i s , she s a y s , a d m i n i s t r a t i v e a u t h o r i t y r e s u l t i n g from the l o c a t i o n i n the h i e r a r c h y i n h e r e n t i n a l i n e p o s i t i o n and t h e r e i s p r o f e s s i o n a l a u t h o r i t y r e s u l t i n g from peer p e r c e p t i o n of the i n d i v i d u a l c l i n i c a l nurse s p e c i a l i s t ' s knowledge and e x p e r t i s e ( t h i s i s u s u a l l y c h a r a c t e r i s t i c of a s t a f f p o s i t i o n ) . The i s s u e of 22 s t a f f v e r s u s l i n e p o s i t i o n , t h e n , can be r e i n t e r p r e t e d i n terms of problems and q u e s t i o n s t h a t a r i s e when the f o c u s of a t t e n t i o n i s r e d i r e c t e d t o the l a r g e r i s s u e of a c c o u n t a b i l i t y of the c l i n i c a l nurse s p e c i a l i s t t o a d i r e c t o r of n u r s i n g s e r v i c e . The c h a l l e n g e , t h e n , f o r r o l e i m p l e m e n t a t i o n r e l a t e d t o placement of the r o l e w i t h i n an o r g a n i z a t i o n a l s t r u c t u r e may l i e i n coming t o terms w i t h the i s s u e of a c c o u n t a b i l i t y . One way t h i s can be done i n v o l v e s the c l i n i c a l nurse s p e c i a l i s t c o n t r a c t i n g w i t h the o r g a n i z a t i o n t o e s t a b l i s h a c c o u n t a b i l i t y ( S t e v e n s , 1976). L i t e r a t u r e c o n c e r n i n g u t i l i z a t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e by an agency s u g g e s t s a c c e p t a n c e or r e s i s t a n c e of s t a f f n urses i s a c r u c i a l v a r i a b l e r e l a t e d t o su c c e s s w i t h i m p l e m e n t a t i o n ( R i s k , 1975; Woodrow and B e l l , 1971; B a c k s h e i d e r , 1971). One p o s s i b l e reason f o r the c e n t r a l i t y of t h i s v a r i a b l e f o r s u c c e s s w i t h i m p l e m e n t a t i o n may l i e i n the f a c t t h a t t h e r e i s o v e r l a p p i n g w i t h many of the r o l e s i n n u r s i n g p r a c t i c e (Baker and Kramer, 1970). T h i s can make i t d i f f i c u l t t o d e l i n e a t e f u n c t i o n s c l e a r l y . Without c l a r i t y i n the d e f i n i t i o n s of r o l e s w i t h i n n u r s i n g p r a c t i c e , i t i s d i f f i c u l t t o d e v e l o p c o l l a b o r a t i o n among nur s e s c o n c e r n i n g p a t i e n t c a r e (Smoyak, 1976; B a c k s h e i d e r , 1971 ) . Rese a r c h s u g g e s t s s t a f f a c c e p t a n c e i s i n f l u e n c e d by the i n c l u s i o n of s t a f f members i n the p l a n n i n g f o r the i n t r o d u c t i o n of the r o l e i n t o an agency ( B a r r e t t , 1971; 23 R i c h a r d s , 1969), and the a d m i n i s t r a t i v e s u pport of n u r s i n g and the o r g a n i z a t i o n f o r the r o l e ( R i s k , 1975; Simms, 1966). T h i s s u p p o r t must be on-going i n n a t u r e (Baker and Kramer, 1970) . The l i t e r a t u r e i n d i c a t e s t h e r e a r e a t l e a s t t h r e e f o c i e v i d e n t i n r e s e a r c h i n t o e f f e c t i v e n e s s of the c l i n i c a l nurse s p e c i a l i s t r o l e . These i n c l u d e : 1. measurement of impact of the r o l e on p a t i e n t c a r e (Georgopoulos and Sana, 1971; Georgopoulos and J a c k s o n , 1970; L i t t l e , 1967); 2. i d e n t i f i c a t i o n of o r g a n i z a t i o n a l f a c t o r s which i n f l u e n c e r o l e i m p l e m e n t a t i o n ( E h r e n r e i c h and S t e w a r t , 1979; A r a d i n e and Denyes, 1972; Woodrow and B e l l , 1971); and, 3. e x p r e s s e d j o b s a t i s f a c t i o n of c l i n i c a l nurse s p e c i a l i s t s ( S h a e f e r , 1973). R e s e a r c h i n t o impact of the r o l e i n d i c a t e s t h a t t h i s was measurable o n l y a f t e r ward r e o r g a n i z a t i o n , which i n c l u d e d removal of n o n - n u r s i n g t a s k s from the c l i n i c a l nurse s p e c i a l i s t r o l e , had been a c h i e v e d (Georgopoulos and C h r i s t m a n , 1970; L i t t l e , 1967). T h i s f i n d i n g draws a t t e n t i o n t o p o t e n t i a l d i f f i c u l t i e s t h a t can be encountered when the r o l e i s implemented i n a h o s p i t a l s e t t i n g . In both s t u d i e s c i t e d the c l i n i c a l nurse s p e c i a l i s t r o l e was viewed as an a l t e r n a t e t o the t r a d i t i o n a l head nurse p a t t e r n f o r the d e l i v e r y of n u r s i n g c a r e s e r v i c e s . Impact of the r o l e was measured i n terms of s p e c i f i c n u r s i n g a c t i v i t i e s , f o r 24 example, "spending more time i n d i r e c t c o n t a c t w i t h p a t i e n t s , p l a n n i n g and a s s e s s i n g , f o c u s i n g more d u r i n g v e r b a l i n t e r a c t i o n s on p a t i e n t ' s p e r c e p t i o n s of h i s w o r l d " ( L i t t l e , 1967); and, the q u a n t i t y and q u a l i t y of i n f o r m a t i o n r e c o r d e d by nurses on the ward kardex system and the i n t e r s h i f t r e p o r t (Georgopoulos and Sana, 1971; Georgopoulos and J a c k s o n , 1970). There i s a c o n t i n u i n g need f o r the n u r s i n g p r o f e s s i o n t o demonstrate impact of the r o l e on p a t i e n t c a r e . The c h a l l e n g e f o r r e s e a r c h e r s would seem t o l i e w i t h the measurement of e f f e c t i v e n e s s . The l i t e r a t u r e does suggest t h a t d e t e r m i n a t i o n of c o s t e f f e c t i v e n e s s as w e l l as measurement of the q u a l i t y of n u r s i n g c a r e s e r v i c e s p r o v i d e d t o the p u b l i c a r e i m p o r t a n t ways of g o i n g about t h i s ( S t e v e n s , 1976). The a c t u a l p r e s s u r e s e x p e r i e n c e d by c l i n i c a l nurse s p e c i a l i s t s have begun t o be s t u d i e d and documented ( E h r e n r e i c h and S t e w a r t , 1979; A r a d i n e and Denyes, 1972; Woodward and B e l l , 1971). These p r e s s u r e s have been c l a s s i f i e d as coming from s e l f , r o l e and the o r g a n i z a t i o n . F u r t h e r r e f i n e m e n t i n d e f i n i t i o n s and r e l a t i o n s h i p s among thes e c l a s s e s of v a r i a b l e s remains t o be d e t e r m i n e d by r e s e a r c h . R e s e a r c h i n t o e x p r e s s e d j o b s a t i s f a c t i o n of the c l i n i c a l nurse s p e c i a l i s t i n a h o s p i t a l s e t t i n g i n d i c a t e s p e r c e p t i o n of a d m i n i s t r a t i v e s u p p o r t by the c l i n i c a l nurse s p e c i a l i s t i s a v a r i a b l e t h a t s i g n i f i c a n t l y i n f l u e n c e s the 25 e x p e r i e n c e of j ob s a t i s f a c t i o n ( S h a e f e r , 1973). T h i s was i n t e r p r e t e d i n l i g h t of the r e l a t i v e newness of the r o l e t o some a g e n c i e s and a need f o r r e a l i s t i c r o l e e x p e c t a t i o n s among c l i n i c a l nurse s p e c i a l i s t s , e s p e c i a l l y i n the b e g i n n i n g phases of r o l e i m p l e m e n t a t i o n ( S h a e f e r , 1973; M a c P h a i l , 1971). Only one study i n the l i t e r a t u r e s u r v e y e d f o c u s e d on a c t i v i t i e s of the c l i n i c a l nurse s p e c i a l i s t i n the work s e t t i n g ( A r a d i n e and Denyes, 1972). D e t a i l s c o n c e r n i n g t h i s study were p r e s e n t e d i n the p r e v i o u s s e c t i o n . Because of the agreement shared by the e x p e r t judges c o n c e r n i n g the l i s t of c a t e g o r i e s of work a c t i v i t i e s i t i s r e a s o n a b l e t o assume t h i s r e p r e s e n t s a v a l i d l i s t of c a t e g o r i e s d e s c r i p t i v e of r o l e enactment of c l i n i c a l nurse s p e c i a l i s t s i n a h o s p i t a l work s e t t i n g . T h i s l i s t of a c t i v i t i e s i s used i n the p r e s e n t study t o s t r u c t u r e r e sponses of the p o p u l a t i o n of i n t e r e s t c o n c e r n i n g r o l e enactment. The C l i n i c a l Nurse S p e c i a l i s t i n Canadian N u r s i n g L i t e r a t u r e T h i s s e c t i o n i s s u b d i v i d e d i n t o l i t e r a t u r e p e r t a i n i n g t o an h i s t o r i c a l p e r s p e c t i v e and more r e c e n t l i t e r a t u r e c o n c e r n i n g the r o l e . 26 H i s t o r i c a l P e r s p e c t i v e A f t e r a r e v i e w of r e l e v a n t Canadian l i t e r a t u r e c o n c e r n i n g the c l i n i c a l nurse s p e c i a l i s t the f o l l o w i n g h i s t o r i c a l a n a l y s i s i s o f f e r e d . In the l a t e 1960's the f e d e r a l government became concerned about the r i s i n g c o s t s of h e a l t h c a r e i n Canada. Numerous s t u d i e s were conducted t o g a t h e r i n f o r m a t i o n about t h i s c o n c e r n ( N a t i o n a l Department of H e a l t h and W e l f a r e , 1970). One s t r a t e g y s u g g e sted i n the Task R e p o r t s on the C o s t s of H e a l t h S e r v i c e s i n Canada concerned i n t r o d u c t i o n of a new r o l e , t h a t of p h y s i c i a n ' s a s s i s t a n t , i n t o the system. An attempt was made t o l i n k the c o n c e p t s of " c l i n i c a l s p e c i a l i s t i n n u r s i n g " and " p r a c t i t i o n e r a s s o c i a t e " i n some of t h e s e r e p o r t s ( N a t i o n a l Department of H e a l t h and W e l f a r e , 1970). From a p o l i t i c a l p e r s p e c t i v e such a s u g g e s t i o n might be somewhat a p p e a l i n g because the concept was p o p u l a r and had some degree of s u c c e s s i n c o u n t r i e s l i k e Sweden, R u s s i a , and the U n i t e d S t a t e s . W ith an u n d e r l y i n g b e l i e f t h a t the many s i m i l a r i t i e s between the U n i t e d S t a t e s and Canada c o u l d r e s u l t i n the same t h i n g s w o r k i n g i n each c o u n t r y , t h i s i d e a had an a p p e a l as a p o s s i b l e s t r a t e g y f o r d e a l i n g w i t h some of the c o n c e r n s w i t h the h e a l t h c a r e system. However, development of the r o l e of p h y s i c i a n ' s a s s i s t a n t r e p r e s e n t e d a s t r a t e g y f o r r e i n t e g r a t i o n i n t o American working s o c i e t y of a l a r g e number of m e d i c a l l y t r a i n e d m i l i t a r y p e r s o n n e l who were r e t u r n i n g from the V i e t Nam war. T h i s s t r a t e g y 27 c e r t a i n l y a p p e a l l e d t o many American p o l i t i c i a n s because i t s i m p l e m e n t a t i o n c o u l d a d d r e s s a number of c o n c e r n s w i t h i n American s o c i e t y . However, s u g g e s t i o n f o r i t s a p p l i c a t i o n t o the Canadian h e a l t h c a r e system was met w i t h o p p o s i t i o n (Canadian Nurses A s s o c i a t i o n , 1 9 7 3 ; 1972; Hacker, 1969). O p p o s i t i o n was spearheaded by the n u r s i n g p r o f e s s i o n ; the ace up i t s s l e e v e , as i t were, was the o u t p o s t n u r s e . T h i s n u r s i n g r o l e had a l o n g h i s t o r y of b e i n g a r e s o u r c e u t i l i z e d t o respond t o the h e a l t h c a r e needs of Canadians l i v i n g i n the n o r t h and i n i s o l a t e d communities i n Newfoundland ( K e i t h , 1971). CNA argued t h a t the o u t p o s t nurse r o l e r e p r e s e n t e d an expanded one f o r n u r s e s and t h e r e were e d u c a t i o n a l r e s o u r c e s a v a i l a b l e t o p r e p a r e n u r s e s f o r such a r o l e (DuGas, 1974). E v e n t u a l l y , the Canadian Nurses A s s o c i a t i o n and the Canadian M e d i c a l A s s o c i a t i o n agreed t h a t e x p a n s i o n of the r o l e of the n u r s e , r a t h e r than i n t r o d u c t i o n of a new r o l e , was a s t r a t e g y t h a t s h o u l d be f o l l o w e d i n Canada (CMA, 1973; CNA, 1973) as the p r o f e s s i o n s worked t o g e t h e r t o respond t o needs o u t l i n e d by p o l i t i c a l l e a d e r s . The c o n c e p t s of " e x p a n s i o n of the r o l e of the n u r s e " and "nurse p r a c t i t i o n e r " were l i n k e d c o n c e p t u a l l y i n t h i s agreement which took the form of a statement of p o l i c y . In the j o i n t statement of p o l i c y a sense of p r i o r i t y was g i v e n t o e x p a n s i o n of the r o l e of the nurse i n the form of the nurse p r a c t i t i o n e r . Thus, i n the e a r l y 1970's i t was not c l e a r i f the concept of the expanded r o l e of the nurse i n 28 Canada c o u l d r e s u l t i n o n l y one r o l e (nurse p r a c t i t i o n e r ) or i f a v a r i e t y of r o l e s was p o s s i b l e (DuGas, 1974; Mu s s a l l e m , 1971 ) . The N a t i o n a l Conference on A s s i s t a n c e t o the P h y s i c i a n (1971) d e f i n e d the concept of "nurse p r a c t i t i o n e r " i n terms of the p r o v i s i o n of a s s i s t a n c e t o the p h y s i c i a n . T h i s group a l s o l i n k e d the concept of " c l i n i c a l nurse s p e c i a l i s t " t o the h o s p i t a l as a work s e t t i n g . I t was c l e a r t h a t b oth c o m p l e m e n t a r i t y of the r o l e s of n u r s e s and p h y s i c i a n s i n the p r o v i s i o n of p r i m a r y c a r e and a p r i o r i t y f o r development of the nurse p r a c t i t i o n e r r o l e were emphasized (CMA, 1973; CNA, 1973; N a t i o n a l Department of H e a l t h and W e l f a r e , 1971). There f o l l o w e d a t t e m p t s t o examine the r o l e of the nurse p r a c t i t i o n e r i n Canada (Boudreau, 1972), e s t a b l i s h m e n t of d e m o n s t r a t i o n p r o j e c t s ( R o t h w e l l , 1976; Cardenas, 1975; S p i t z e r and K e r g i n , 1971; Coombs, 1970), and some e f f o r t s t o a s s e s s p r o g r e s s of the r o l e i n the h e a l t h c a r e system (DuGas and S a n e l t z , 1976; L e F o r t , 1976; DuGas, 1974). Some c o n c l u s i o n s based on these e f f o r t s were the f o l l o w i n g : 1. e f f o r t s were b e i n g made t o p r e p a r e the b a c c a l a u r e a t e nurse f o r the expanded r o l e (DuGas and S a n e l t z , 1976); 2. the h e a l t h c a r e d e l i v e r y system had not changed r a p i d l y enough t o accommodate the expanded r o l e of the nurse i n the h o s p i t a l work s e t t i n g ( R o t h w e l l , 1976); and, 3. the f u t u r e of the nurse p r a c t i t i o n e r i n Canada i s "a mat t e r of whether the market can support i t " ( L e F o r t , 1976; 29 p. 17). Co n c e r n i n g the i s s u e of s p e c i a l i z a t i o n i n n u r s i n g , t h i s h i s t o r i c a l p e r s p e c t i v e s u g g e s t s t h a t a t t e n t i o n had been d i r e c t e d t o the concept of the nurse p r a c t i t i o n e r a t the expense of a t t e n t i o n t o the concept of the c l i n i c a l nurse s p e c i a l i s t . As a r e s u l t , Canadian n u r s i n g l i t e r a t u r e c o n t a i n s a d e f i n i t i o n and d e s c r i p t i o n of the nurse p r a c t i t i o n e r r o l e ( L e F o r t , 1976; S p i t z e r and K e r g i n , 1971) and l i t t l e d i s c u s s i o n about the c l i n i c a l nurse s p e c i a l i s t r o l e . Now t h a t e v i d e n c e i s b e g i n n i n g t o suggest t h a t the nurse p r a c t i t i o n e r r o l e may not be v i a b l e i n the h e a l t h c a r e system, a t l e a s t not i n s o u t h e r n Canada, i t may be time f o r a t t e n t i o n t o s h i f t t o the concept of the c l i n i c a l nurse spec i a l i s t . N u r s i n g L i t e r a t u r e About the Ro l e As mentioned i n the p r e v i o u s s e c t i o n , the concept of the c l i n i c a l nurse s p e c i a l i s t appeared i n Canadian l i t e r a t u r e a t about the same time as d i d the concept of nurse p r a c t i t o n e r (Boudreau, 1972; N a t i o n a l Department of H e a l t h and W e l f a r e , 1971). W i t h i n n u r s i n g l i t e r a t u r e , the i d e a of s p e c i a l i z a t i o n i n n u r s i n g was d i s c u s s e d by the use of a v a r i e t y of t i t l e s , c l i n i c a l nurse s p e c i a l i s t b e i n g one of t h e s e (Anderson e t a l . , 1975; S p i t z e r and K e r g i n 1971; Coombs, 1970). By 1976, the c a t e g o r y " c l i n i c a l s p e c i a l i s t " appeared on p r o v i n c i a l p r o f e s s i o n a l a s s o c i a t i o n r e g i s t r a t i o n 30 forms ( S t a t i s t i c s Canada, 1976). At the Biennium M e e t i n g of the Canadian Nurses A s s o c i a t i o n i n 1972 a r e s o l u t i o n was passed t h a t gave d i r e c t i o n t o the e l e c t e d r e p r e s e n t a t i v e s t o e x p l o r e and d e v e l o p a d e f i n i t i o n f o r the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada. W i t h l e g i t i m a c y thus e s t a b l i s h e d , i t becomes i m p o r t a n t f o r n u r s i n g t o e x e r c i s e i t s p r o f e s s i o n a l r e s p o n s i b i l i t y t o a r t i c u l a t e a d e f i n i t i o n of the r o l e f o r Canadian n u r s i n g . The need f o r c l a r i t y i n a d e f i n i t i o n of the r o l e has been emphasized i n the l i t e r a t u r e s i n c e the time the i s s u e became a p r i o r i t y (Biennium M e e t i n g , 1972). For example, i n 1972, a t a c o n f e r e n c e i n T o r o n t o "the newly emerging r o l e of the master's p r e p a r e d c l i n i c a l nurse s p e c i a l i s t was examined ... The c o n f e r e n c e .... made one t h i n g c l e a r : the r o l e of t h i s nurse s p e c i a l i s t i s not c l e a r l y d e f i n e d or u n d e r s t o o d " (Dworkin,1973; p. 4 0 ) . In 1972 a documentation of i n d i v i d u a l e x p e r i e n c e w i t h the r o l e emphasized the newness of the concept i n Canada and the need "t o e x p l o r e i t s c o n t r i b u t i o n s t o p a t i e n t c a r e " ( R o binson, 1977; p. 3 6 ) . In 1980, a t a N a t i o n a l Forum on N u r s i n g E d u c a t i o n , Baumgart d e s c r i b e d a "growing urgency of s e t t i n g out c l e a r l y the d i f f e r e n c e s i n the r o l e s and competencies of the v a r i o u s t y p e s of n u r s i n g p r a c t i t i o n e r s " (The Canadian Nurse, 1980; p. 16). As l a t e as 1981 t h e r e i s r e f e r e n c e t o the f a c t t h a t graduate e d u c a t i o n of n u r s e s f o r the r o l e of c l i n i c a l nurse s p e c i a l i s t i n v o l v e s p r e p a r i n g them " f o r 31 p o s i t i o n s where t h e r e i s a c o n s i d e r a b l e degree of r o l e -c a r v i n g " i n v o l v e d ( A r p i n , 1981). Each of the above r e f e r e n c e s s u p p o r t s the c l a i m t h a t the r o l e of c l i n i c a l n urse s p e c i a l i s t i s not w e l l d e f i n e d i n Canada. P o s s i b l e E x p l a n a t i o n s f o r an Observed Gap i n the L i t e r a t u r e The above review of the l i t e r a t u r e i n d i c a t e s t h a t t h e r e i s a need f o r f u r t h e r study of the r o l e of the c l i n i c a l n urse s p e c i a l i s t and t h a t l i t t l e has been w r i t t e n about the r o l e i n the l a s t decade. W i t h i n Canada t h i s l a c k of d i s c u s s i o n might be e x p l a i n e d i n a number of ways. The l i t e r a t u r e s u g g ests a t l e a s t t h r e e p o s s i b i l i t i e s : (1) the f o c u s of a t t e n t i o n has been on the r o l e of the nurse p r a c t i t i o n e r , (2) the n a t u r e of the o r g a n i z a t i o n of the p r o f e s s i o n i t s e l f , (3) i n t e r e s t s w i t h i n the p r o f e s s i o n a l group were i n d i r e c t i o n s o t h e r than r o l e development of the c l i n i c a l nurse s p e c i a l i s t . E x p l a n a t i o n of the f i r s t p o s s i b i l i t y was p r e s e n t e d i n the p r e v i o u s s e c t i o n . An a n a l y s i s of the o t h e r two p o s s i b i l i t i e s f o l l o w s . The Canadian Nurses A s s o c i a t i o n i s a f e d e r a t i o n of the ten p r o v i n c i a l a s s o c i a t i o n s . "A f u n c t i o n of the Canadian Nurses A s s o c i a t i o n i s t o f o r m u l a t e p o l i c i e s which w i l l promote a h i g h s t a n d a r d of n u r s i n g s e r v i c e . . . . " ( J e w i t t , 1952; p. 5 0 ) . However, "Canadian l e g i s l a t i o n p r o v i d e s t h a t n u r s i n g a f f a i r s and t h e i r o r g a n i z a t i o n come under p r o v i n c i a l c o n t r o l , w i t h i n the g e n e r a l c a t e g o r y of h e a l t h " ( M ussallem, 32 1964; p. 3 1 ) . Thus, p r o v i n c i a l a s s o c i a t i o n s a r e s e l f g o v e r n i n g u n i t s w i t h powers t h a t come from p r o v i n c i a l l e g i s l a t i v e a c t s . Because of t h i s d i v i s i o n of a u t h o r i t y the Canadian Nurses A s s o c i a t i o n a c t s o n l y i n an a d v i s o r y c a p a c i t y . W i t h t h i s d i v i s i o n of a u t h o r i t y , the power f o r s p e c i f i c a c t i o n r e l a t e d t o development of r o l e s f o r n u r s i n g p r a c t i c e l i e s w i t h i n the j u r i s d i c t i o n of each p r o v i n c i a l n u r s i n g a s s o c i a t i o n . T h e o r e t i c a l l y , t h e n , i t i s p o s s i b l e f o r a v a r i e t y of models f o r c l i n i c a l s p e c i a l i z a t i o n t o d e v e l o p i n Canada. The s p e c i f i c form of any model d e v e l o p e d would be r e l a t e d t o the h e a l t h needs of the p o p u l a t i o n and the h e a l t h c a r e system needs i n a p a r t i c u l a r p r o v i n c e . The c h a l l e n g e f o r both the Canadian Nurses A s s o c i a t i o n and each p r o v i n c i a l n u r s i n g a s s o c i a t i o n t o respond t o p r o v i n c i a l / r e g i o n a l d i f f e r e n c e s i n the h e a l t h c a r e needs of the Canadian p u b l i c and, s i m u l t a n e o u s l y , t o p r o v i d e o p p o r t u n i t y f o r m o b i l i t y w i t h i n n u r s i n g i n the c o u n t r y i s a complex one. T h e r e f o r e , i t i s s u g gested by the r e s e a r c h e r t h a t a d e f i n i t i o n of the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada may c o n s i s t of two l e v e l s : a broad l e v e l d e f i n e d by the n a t i o n a l p r o f e s s i o n a l a s s o c i a t i o n t o g e t h e r w i t h a more s p e c i f i c l e v e l d e f i n e d by each p r o v i n c i a l a s s o c i a t i o n . Such an approach t o d e f i n i n g the r o l e f o r Canadian n u r s i n g would be c o n s i s t e n t w i t h the s t r u c t u r e of the p r o f e s s i o n a l a s s o c i a t i o n , and the s t r u c t u r e of the h e a l t h c a r e system as w e l l as the l a r g e r 33 p o l i t i c a l s t r u c t u r e of the c o u n t r y . A t h i r d p o s s i b l e e x p l a n a t i o n f o r the l a c k of d i s c u s s i o n about the c l i n i c a l nurse s p e c i a l i s t c o n c e r n s o t h e r i n t e r e s t s w i t h i n the p r o f e s s i o n . The l i t e r a t u r e i n d i c a t e s t h a t some of t h e s e i n t e r e s t s have been s t a n d a r d s , a c c r e d i t a t i o n , and c e r t i f i c a t i o n (Adam, 1981; Banning, 1981; F i t z p a t r i c k , 1977; Mussall e m , 1977; Bachand, 1974). A review of the l i t e r a t u r e c o n c e r n i n g t h e s e t o p i c s r e v e a l s t h a t r e l a t i o n s h i p s among thes e i m p o r t a n t i s s u e s and d e f i n i t i o n of the r o l e of the c l i n i c a l nurse s p e c i a l i s t a r e u n s t a t e d . However, the l i t e r a t u r e s u g g e s t s t h a t t h e r e s h o u l d be r e l a t i o n s h i p s among thes e and the r o l e . An u n d e r l y i n g assumption of t h i s s u g g e s t i o n i s the b e l i e f t h a t e d u c a t i o n , e x p e r t i s e , and e x p e r i e n c e of the c l i n i c a l n u r se s p e c i a l i s t can have an impact on the d e l i v e r y of n u r s i n g c a r e s e r v i c e s ( P i a z z a and J a c k s o n , 1978; Mussallem, 1977; Rogers, 1972; P e p l a u , 1965). I f a t t e n t i o n i s d i r e c t e d t o the concept of commitment of a p r o f e s s i o n t o the p u b l i c then some of the s e r e l a t i o n s h i p s b e g i n to become c l e a r . I t i s d e s i r a b l e f o r a p r o f e s s i o n " t o a s s u r e the p u b l i c t h a t s e r v i c e s a r e p r o v i d e d by p r a c t i t i o n e r s who r e c o g n i z e t h e i r r e s p o n s i b i l i t i e s t o p r o v i d e good n u r s i n g c a r e and who have the a b i l i t i e s t o do t h i s " . . . ( K a y and K e r g i n , 1977; p. 8 9 ) . F i v e ways, d e v e l o p e d and used by Canadian n u r s i n g , as w e l l as o t h e r p r o f e s s i o n a l groups, t o p r o v i d e t h i s a s s u r a n c e t o the p u b l i c have been d e s c r i b e d (Kay and K e r g i n , 1977). These a r e : 34 1. the development of a code of e t h i c s f o r d e s c r i b i n g d e s i r a b l e as w e l l as d e v i a n t s t a n d a r d s of b e h a v i o u r t o be f o l l o w e d by members; 2. the s o c i a l i z i n g of s t u d e n t s of the p r o f e s s i o n i n t o "the r o u t i n e s and methods of p e r f o r m i n g p a r t i c u l a r a c t s " (Kay and K e r g i n , 1977; p. 8 9 ) ; 3. the development of s t a n d a r d s t h a t " d e s c r i b e c h a r a c t e r i s t i c s or e n v i r o n m e n t a l c o n d i t i o n s b e l i e v e d t o p e r m i t members t o p r o v i d e s e r v i c e s e f f e c t i v e l y " (Kay and K e r g i n , 1977; p. 8 9 ) ; 4. the e s t a b l i s h m e n t of r e g u l a t i o n s t o "ensure a l l who p r a c t i c e have met minimum s t a n d a r d s of e i t h e r e d u c a t i o n or p r a c t i c e or b o t h " (Kay and K e r g i n , 1977; p. 9 0 ) ; and 5. the maintenance of mechanisms " f o r d e a l i n g w i t h members who a r e a l l e g e d t o have performed a c t s t h a t endanger p a t i e n t s " Kay and K e r g i n , 1977; p. 9 0 ) . I t seems r e a s o n a b l e t o t h i n k movements toward a c c r e d i t a t i o n , q u a l i t y a s s u r a n c e , and c e r t i f i c a t i o n r e p r e s e n t one or more of t h e s e ways f o r a s s u r i n g the p u b l i c about p r a c t i t i o n e r s of the p r o f e s s i o n . Each of the above ways can be viewed as a f o r m a l system d i r e c t e d a t the p r o v i s i o n of such a s s u r a n c e . Each system can f u n c t i o n as a r e g u l a t o r y mechanism concerned w i t h the n o r m a t i v e c o n t r o l of members of the p r o f e s s i o n by the p r o f e s s i o n a l group i t s e l f . The outcomes from each of t h e s e mechanisms are s t a t e m e n t s of s t a n d a r d s . The r e l a t i o n s h i p s , 35 t h e n , among the c l i n i c a l nurse s p e c i a l i s t r o l e and the movements toward a c c r e d i t a t i o n , q u a l i t y a s s u r a n c e , c e r t i f i c a t i o n , and s t a n d a r d s a re suggested by the r e s e a r c h e r t o be l i n k e d t o p r o v i s i o n of a s s u r a n c e t o the p u b l i c about s e r v i c e p r o v i d e d by the n u r s i n g p r o f e s s i o n . To what degree the s e r e l a t i o n s h i p s a r e i n c o r p o r a t e d i n t o p r a c t i c e i s unknown. A c l e a r d e s c r i p t i o n of the r o l e i n Canada would h e l p t o make these l i n k s e x p l i c i t . The above f a c t o r s may have r e s u l t e d i n an absence of d i s c u s s i o n s about and r e s e a r c h i n t o the c l i n i c a l nurse s p e c i a l i s t r o l e i n Canada. I f t h i s i s so, i t i s r e a s o n a b l e t o t h i n k t h a t i t i s time f o r s y s t e m a t i c e x a m i n a t i o n of the r o l e t o b e g i n . As a b e g i n n i n g s t e p , t h i s study was d e s i g n e d t o c o l l e c t d ata c o n c e r n i n g t h e i r r o l e from a s e l f - d e f i n e d group of c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia. CHAPTER 3 METHODOLOGY S u b j e c t s The p o t e n t i a l s u b j e c t p o p u l a t i o n c o n s i s t e d of the 147 members of the RNABC who checked box 23 ( " c l i n i c a l s p e c i a l i s t " ) on the 1981-1982 RNABC r e g i s t r a t i o n form. F i v e of the p o t e n t i a l p o p u l a t i o n were used t o p r e - t e s t the d a t a -c o l l e c t i n g form, r e d u c i n g the number of p o t e n t i a l r e s p o n d e n t s t o 142. The Instrument S i n c e a review of the l i t e r a t u r e d i d not r e s u l t i n the d i s c o v e r y of an i n s t r u m e n t t h a t would f i t the purpose of t h i s s t u d y , a q u e s t i o n n a i r e was dev e l o p e d (see Appendix A ) . The i n s t r u m e n t was c o n s t r u c t e d u s i n g t h r e e s o u r c e s of i n f o r m a t i o n : the c a t e g o r i e s of work a c t i v i t i e s r e p o r t e d by A r a d i n e and Denyes (1972), d e s c r i p t i o n s of the c l i n i c a l n urse s p e c i a l i s t r o l e found i n the l i t e r a t u r e , and i n t e r v i e w s w i t h c l i n i c a l nurse s p e c i a l i s t s p r a c t i c i n g i n B r i t i s h C olumbia. The c o n t e n t of the q u e s t i o n n a i r e can be broken down i n t o t h r e e c a t e g o r i e s : the c a t e g o r i e s of work a c t i v i t i e s d e s c r i b e d by A r a d i n e and Deynes (1972) (Item 7 ) , c o n t e x t u a l l y r e l a t e d v a r i a b l e s (Items 2, 4, 5, 6, 8, and 9 ) , and p r o f e s s i o n a l v a r i a b l e s (Items 10, 11, and 12). In a d d i t i o n , the demographic v a r i a b l e s of age and sex were 36 37 i n c l u d e d . P rocedure A f t e r i n i t i a l development of the q u e s t i o n n a i r e i t was f i e l d t e s t e d f o r c l a r i t y , a p p l i c a b i l i t y of the c a t e g o r i e s of work a c t i v i t i e s t o the work e x p e r i e n c e of the c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h C o lumbia, and the amount of time r e q u i r e d f o r c o m p l e t i o n . The p r e - t e s t sample c o n s i s t e d of f i v e p r a c t i c i n g c l i n i c a l nurse s p e c i a l i s t s . A l i s t of known c l i n i c a l nurse s p e c i a l i s t s i n the Vancouver a r e a was c o m p i l e d and the f i r s t f i v e who were engaged i n n u r s i n g p r a c t i c e , who p e r c e i v e d t hemselves or whose employers p e r c e i v e d them as w o r k ing i n a c l i n i c a l nurse s p e c i a l i s t r o l e , and who agreed t o p a r t i c i p a t e i n the f i e l d t e s t formed the p r e - t e s t sample. Each responded t o the q u e s t i o n n a i r e and then d i s c u s s e d w i t h the r e s e a r c h e r s o u r c e s of d i f f i c u l t y e x p e r i e n c e d . Some s u g g e s t i o n s f o r changes r e l a t e d t o c l a r i t y were made. Four of the f i v e s u b j e c t s gave responses t o each of the c a t e g o r i e s of work a c t i v i t i e s . T h e r e f o r e t h i s i tem (#7) was not a l t e r e d . Each s u b j e c t took l e s s than than 20 minutes t o complete the form. A f t e r r e v i s i o n of the i n s t r u m e n t the q u e s t i o n n a i r e , a l o n g w i t h a l e t t e r of i n t r o d u c t i o n and e x p l a n a t i o n (see Appendix B ) , a s m a l l c a r d 1 , and a stamped a d d r e s s e d envelope f o r r e t u r n of the q u e s t i o n n a i r e were m a i l e d t o each nurse 1 T h i s c a r d c o u l d be used by the s u b j e c t t o r e q u e s t a summary of the f i n d i n g s . 38 who checked box 23. A f o l l o w - u p reminder was m a i l e d t o each s u b j e c t one week l a t e r . The da t a c o l l e c t i o n p e r i o d extended f o r s i x weeks. The procedure used by the RNABC f o r the m a i l i n g does not a l l o w the r e s e a r c h e r d i r e c t a c c e s s t o the names of the s u b j e c t s . RNABC ge n e r a t e d the l i s t of m a i l i n g l a b e l s , a p p l i e d them t o the p r e p a r e d e n v e l o p e s and the f o l l o w - u p r e m i n d e r s , and m a i l e d t h e s e a t the a p p r o p r i a t e t i m e . T h i s p r o c e d u r e would r e s u l t i n those s u b j e c t s i n the p r e - t e s t sample a l s o r e c e i v i n g the r e v i s e d q u e s t i o n n a i r e . T h e r e f o r e , t h e s e f i v e s u b j e c t s were t o l d of t h i s p r o c e d u r e i n the f i e l d t e s t i n g phase and asked not t o respond. Most of the a n a l y s e s of the d a t a were done u s i n g the Midas S t a t i s t i c a l Package. I n d i c a t i o n w i l l be g i v e n i n Chapter 4 whenever o t h e r means of a n a l y s i s were used. CHAPTER 4 RESULTS As o u t l i n e d i n Chapter 3, d a t a were o b t a i n e d from a m a i l e d q u e s t i o n n a i r e sent t o s e l f - i d e n t i f i e d c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia. Of the 147 q u e s t i o n n a i r e s sent o u t , 94 were r e t u r n e d -- 88 from respondents (a r e t u r n r a t e of 6 2 % ) , 4 from the po s t o f f i c e as u n d e l i v e r a b l e and 2 from members of the f i e l d - t e s t s a m p l e 1 . Of the 88, t h r e e were accompanied by notes s u g g e s t i n g a computer e r r o r had r e s u l t e d i n each r e c e i v i n g the form and one was r e t u r n e d unanswered. The r e m a i n i n g 84 formed the r e t u r n sample. Twenty-one (25%) of the r e t u r n e d sample responded "no" t o Item 1 (Are you s t i l l w o r k i n g i n a p o s i t i o n you would c a l l " c l i n i c a l s p e c i a l i s t " ? ) and 63 (75%) responded "yes." T h e r e f o r e , o n l y the 21 s u b j e c t s were i n c l u d e d i n the a n a l y s i s of Item 1 ( a ) ; a l l o t h e r a n a l y s e s were based on the 63 s u b j e c t s who responded a f f i r m a t i v e l y . The r e s u l t s a r e r e p o r t e d under the f o l l o w i n g h e a d i n g s : p r e s e n t p o s i t i o n , demographic i n f o r m a t i o n , work a c t i v i t y , c o n t e x t u a l l y r e l a t e d v a r i a b l e s , p r o f e s s i o n a l v a r i a b l e s , and r e l a t i o n s h i p s among v a r i a b l e s . 1 A note on the f i r s t page of the q u e s t i o n n a i r e i n d i c a t e d t h i s . 39 40 P r e s e n t P o s i t i o n Item 1(a) was concerned w i t h the p r e s e n t work p o s i t i o n of the respondents who no l o n g e r i d e n t i f i e d t h e i r work r o l e as " c l i n i c a l s p e c i a l i s t . " Responses of these 21 s u b j e c t s are summarized i n T a b l e 1. T h i s t a b l e i n d i c a t e s t h a t most T a b l e 1 P r e s e n t P o s i t i o n s of S u b j e c t s No Longer I d e n t i f y i n g Themselves as C l i n i c a l Nurse S p e c i a l i s t s (Item 1(a)) P o s i t i o n s Number of S u b j e c t s A s s i s t a n t s u p e r v i s o r / c o - o r d i n a t o r 2 C l i n i c a l nurse 1 G e n e r a l duty 1 Head nurse 4 Nurse r e s e a r c h a s s i s t a n t 2 P h y s i c i a n ' s o f f i c e 2 Pre-op. t e a c h i n g 1 R e t u r n i n g t o s c h o o l 1 Not working 7 Unemployed =2 R e t i r e d =3 Moved/parenting =2 T o t a l 21 (14/21) of those who no l o n g e r i d e n t i f i e d t h e i r work p o s i t i o n as " c l i n i c a l s p e c i a l i s t " were s t i l l w o r k i n g . Of t h o s e not w o r k i n g , o n l y 2 i n d i c a t e d they were unemployed. 41 Demographic I n f o r m a t i o n Age and sex (Items 13 and 14) were the two demographic v a r i a b l e s l o o k e d a t i n t h i s s t u d y . The age d i s t r i b u t i o n was as f o l l o w s : 5 (8.1%) of the respondents were between 25 and 29 y e a r s of age; 18 (29.0%) were between 30 and 35 y e a r s ; 6 (9.7%) were between 36 and 39 y e a r s ; 15 (24.2%) were between 40 and 45 y e a r s ; 5 (8.1%) were between 46 and 49 y e a r s ; and 13 (21%) were 50 y e a r s or o l d e r . S i x t y (96.8%) of the sample were female and 2 (3.2%) were male. Data from one s u b j e c t were m i s s i n g f o r each of t h e s e i t e m s . Work A c t i v i t y The i n f o r m a t i o n on work a c t i v i t y was d e r i v e d from an a n a l y s i s of the responses t o Item 7 on the q u e s t i o n n a i r e . A summary of the numbers and p e r c e n t a g e s of r e s p o n d e n t s who checked a c a t e g o r y of work a c t i v i t y i s p r e s e n t e d i n T a b l e 2. Each of the c a t e g o r i e s r e p o r t e d by A r a d i n e and Denyes (1972) was d e s c r i b e d by some of the respondents as c h a r a c t e r i s t i c of t h e i r c l i n i c a l nurse s p e c i a l i s t r o l e . The l a r g e s t p e r c e n t a g e (93.5%) of the r e s p o n d e n t s spent some of t h e i r work time i n c o n s u l t a t i v e a c t i v i t i e s . The c a t e g o r i e s a d m i n i s t r a t i o n , e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , p a t i e n t c a r e , p e r s o n a l and p r o f e s s i o n a l growth, p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , community a c t i v i t i e s , and s t a f f development were i d e n t i f i e d by more than 65% of the T a b l e 2 Work A c t i v i t i e s of S u b j e c t s (Item 7) 42 P o s i t i o n s Number of Perc e n t a g e S u b j e c t s of S u b j e c t s A d m i n i s t r a t i o n 47 75. ,8 Community a c t i v i t i e s 41 66. , 1 C o n s u l t a t i o n 58 93. .5 E d u c a t i o n of s t u d e n t s 44 71 . 0 I n t e r d i s i p l i n a r y i n t e r a c t i o n 53 85. .5 P a t i e n t c a r e 53 85. .5 P e r s o n a l and p r o f e s s i o n a l growth 56 90. .3 P l a n n i n g - p o l i c y - s t a n d a r d s -change 48 77, .4 Research 23 37, . 1 S t a f f development 40 64, .5 W r i t i n g f o r p u b l i c a t i o n 21 33, .9 Other 18 29, .0 s u b j e c t s as b e i n g i n c l u d e d among t h e i r work a c t i v i t i e s . L e s s than 40% of the s u b j e c t s i d e n t i f i e d each of the c a t e g o r i e s r e s e a r c h , w r i t i n g f o r p u b l i c a t i o n , and o t h e r as b e i n g p a r t of t h e i r work a c t i v i t i e s . T a b l e 3 p r e s e n t s mean p e r c e n t a g e s and ranges of the e s t i m a t e s of work time on a weekly b a s i s devoted t o each c a t e g o r y as r e p o r t e d i n response t o Item 7. The l a r g e s t amounts of weekly work time were dev o t e d t o the c a t e g o r i e s p a t i e n t c a r e and o t h e r , 37% and 25% r e s p e c t i v e l y . Between 10% and 15% of the e s t i m a t e d weekly work time was devo t e d t o the c a t e g o r i e s a d m i n i s t r a t i o n , community a c t i v i t i e s , and c o n s u l t a t i o n . Less than 10% of the e s t i m a t e d weekly work time was spent on the e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , p e r s o n a l and p r o f e s s i o n a l growth, p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , r e s e a r c h , s t a f f 43 development, and w r i t i n g f o r p u b l i c a t i o n . T a b l e 3 Range and Mean Per c e n t a g e of E s t i m a t e d Weekly Work Time Devoted t o C a t e g o r i e s of Work A c t i v i t y (Item 7) C a t e g o r i e s of Number of Range Mean % Work A c t i v i t y S u b j e c t s Minim. Maxim. of (hours) Weekly Work Time A d m i n i s t r a t i o n 47 1 45 10.4 Commun i t y a c t i v i t i e s 38 1 100 10.1 C o n s u l t a t i o n 55 2 92 15.8 E d u c a t i o n of s t u d e n t s 40 1 40 6.1 I n t e r d i s i p l i n a r y i n t e r a c t i o n 49 1 50 9.6 P a t i e n t c a r e 50 1 80 37.3 P e r s o n a l p r o f e s s i o n a l growth 52 1 50 7.1 P l a n n i n g - p o l i c y -s t a n d a r d s -change 44 1 20 6.9 Res e a r c h 20 1 20 4.6 S t a f f development 37 1 80 8.4 W r i t i n g f o r p u b l i c a t i o n 18 1 40 5.1 Other 1 6 1 80 23.5 T a b l e 4 l i s t s a c a t e g o r i z a t i o n of s p e c i f i c r e s p o n s e s , w i t h an e s t i m a t e of weekly work time devoted t o each c a t e g o r y , p r o v i d e d by the 16 s u b j e c t s who responded t o Item 7 i n the c a t e g o r y " o t h e r . " The average p e r c e n t a g e was 23.5%, w i t h a range of 1% t o 80%. Appendix C (T a b l e C.1) p r o v i d e s a l i s t i n g of the responses t h a t make up the c a t e g o r i e s i n Ta b l e 4. 44 Tab l e 4 S u b - C a t e g o r i e s and P e r c e n t a g e s f o r Other C a t e g o r y of Work A c t i v i t i e s (Item 7) Sub-Category Number Per c e n t a g e o: of Weekly S u b j e c t s work time 1. Research work 1 30% 2. C l e r i c a l 4 2%,5%,8%,N.R. 3. S t a f f programming 3 5%,15%,25% 4. I n f e c t i o n c o n t r o l 2 27%,50% 5. C o u n s e l l i n g / p s y c h o t h e r a p y 2 5%,80% 6. T r a d i t i o n a l n u r s i n g s k i l l s 2 10%,65% 7. P a t i e n t e d u c a t i o n 1 30% 8. Mi s c e l l a n e o u s 3 3%,4%,15% 1N.R. = no response or m i s s i n g d a t a . C o n t e x t u a l l y R e l a t e d V a r i a b l e s The c a t e g o r i e s i n T a b l e 5 were deve l o p e d from the responses t o Item 2 ( s p e c i f i c j o b t i t l e ) . T a b l e 5 i n d i c a t e s t h e r e i s a range of j o b t i t l e s used t o i d e n t i f y t h e r o l e of Tab l e 5 C a t e g o r i e s D e r i v e d from S p e c i f i c Job T i t l e s P r o v i d e d by S u b j e c t s (Item 2) D e r i v e d C a t e g o r i e s Number of S u b j e c t s Community ( h e a l t h / m e n t a l h e a l t h ) nurse 13 E n t e r o s t o m a l t h e r a p i s t 5 I n f e c t i o n c o n t r o l nurse 2 Nurse c l i n i c i a n 22 Nurse p r a c t i t i o n e r 1 Nurse r e s e a r c h e r / r e s e a r c h t e c h n i c i a n 2 S u p e r v i s o r / h e a d n u r s e / a s s i s t a n t head nurse 4 T e a c h i n g / i n s t r u c t o r 4 M i s c e l l a n e o u s 6 No response 4 T o t a l 63 45 thes e r e s p o n d e n t s . The l a r g e s t number of s u b j e c t s , 22 and 13 r e s p e c t i v e l y , were c a t e g o r i z e d as nurse c l i n i c i a n and community n u r s e . Four s u b j e c t s d i d not respond t o t h i s i t e m . Of the s u b j e c t s who responded t o Item 2 by p r o v i d i n g a job t i t l e , most (69%) i n d i c a t e d s a t i s f a c t i o n w i t h the j o b t i t l e . T a b l e 6 p r e s e n t s a summary of a l t e r n a t e j o b t i t l e s p r e f e r r e d by those not s a t i s f i e d w i t h t h e i r p r e s e n t j o b t i t l e . T a b l e 6 Summary of E x p r e s s e d P r e f e r e n c e s f o r A l t e r n a t e Job T i t l e s (Item 3) A l t e r n a t e T i t l e Number of Per c e n t a g e S u b j e c t s of S u b j e c t s C l i n i c a l Nurse S p e c i a l i s t 10 50 Nurse C l i n i c i a n 2 10 Nurse P r a c t i t i o n e r 3 15 S p e c i a l t y Nurse 2 10 Other 2 10 No response 1 5 T o t a l 20 100 Ta b l e 6 i n d i c a t e s t h a t i n response t o Item 3, ten s u b j e c t s (50%) would rename t h e i r w o r k i n g r o l e " c l i n i c a l n urse s p e c i a l i s t . " The two re s p o n d e n t s i n the c a t e g o r y o t h e r would rename t h e i r work r o l e s "nurse c o u n s e l l o r " and " e n t e r o s t o m a l nurse c l i n i c i a n . " T a b l e 7 p r e s e n t s r e s u l t s f o r the l e n g t h of time i n the p r e s e n t p o s i t i o n (Item 4 ) . In g e n e r a l , most of the sample 46 (71%) had worked i n t h e i r p r e s e n t p o s i t i o n f o r more than two y e a r s . F i f t e e n (24.2%) of the s u b j e c t s had worked i n the Ta b l e 7 Length of Time i n P r e s e n t P o s i t i o n (Item 4) Length of Time Number of P e r c e n t a g e S u b j e c t s of S u b j e c t s 0 t o 6 months 3 4.8 7 t o 12 months 6 9.5 13 t o 24 months 9 14.3 25 t o 36 months 15 23.8 > 36 months 29 46.0 No response 1 1.6 T o t a l 63 100.0 p r e s e n t p o s i t i o n between 25 and 35 months and 29 (46.8%) l o n g e r than 36 months. S l i g h t l y more of the p r e s e n t p o s i t i o n s were new p o s i t i o n s and had j o b d e s c r i p t i o n s when they were a c c e p t e d (Items 5 and 6 ) . S p e c i f i c a l l y , 32 (51.6%) of the p r e s e n t p o s i t i o n s were new w h i l e 29 (47.5%) were e x i s t i n g p o s i t i o n s when the s u b j e c t s a c c e p t e d them. T h i r t y - f i v e (57.4%) of the p r e s e n t p o s i t i o n s had a j o b d e s c r i p t i o n when a c c e p t e d w h i l e 26 (42.6%) d i d n o t . Of the 32 new p o s i t i o n s , 14 (43.7%) had a j o b d e s c r i p t i o n , w h i l e 18 (56.3%) were w i t h o u t a j o b d e s c r i p t i o n when the s u b j e c t s a c c e p t e d the p o s i t i o n . Of the 29 e x i s t i n g p o s i t i o n s , 21 (72.4%) had a j o b d e s c r i p t i o n w h i l e 8 (27.6%) were w i t h o u t one. T a b l e 8 p r e s e n t s the r e s u l t s f o r type of employment s e t t i n g (Item 8 ) . Most of the sample (65.1%) worked i n a 47 h o s p i t a l s e t t i n g . Of these 41 s u b j e c t s , most (87.8%) worked i n an a c u t e c a r e h o s p i t a l . Of the 16 s u b j e c t s whose work s e t t i n g was a community based s e r v i c e , most (56.3%) worked i n a community mental h e a l t h agency. T a b l e 8 Types of Employment S e t t i n g s (Item 8) Type of S e t t i n g Number of P e r c e n t a g e S u b j e c t s of S u b j e c t s H o s p i t a l 41 65. 1 N u r s i n g home/home f o r the aged 0 0.0 Community based s e r v i c e s 1 6 25.4 B u s i n e s s / i n d u s t r y P h y s i c i a n ' s o f f i c e / f a m i l y 0 0.0 p r a c t i c e u n i t 2 3.2 Other 3 4.8 No response 1 1 .6 T o t a l 63 100.1 Type of appointment was d e f i n e d i n t h r e e ways (Item 9 a , b , c ) . There was an even d i s t r i b u t i o n of the p r e s e n t p o s i t i o n s between u n i t - b a s e d and not u n i t - b a s e d ; 30 (49.2%) were u n i t - b a s e d w h i l e 31 (50.8%) were n o t . Most of the p r e s e n t p o s i t i o n s (33 or 54.1%) were d e s c r i b e d i n the c a t e g o r y o t h e r , v e r s u s c a t e g o r i e s of c l i n i c a l (17 or 2 7 . 9 % ) , c l i n i c a l - e d u c a t i o n a l (4 or 6.6%), and c l i n i c a l -a d m i n i s t r a t i v e (7 or 11.5%). A t o t a l of 52 or 89.7% of the p r e s e n t p o s i t i o n s were d e s c r i b e d as s t a f f p o s i t i o n s w h i l e 6 or 10.3% were d e s c r i b e d as l i n e p o s i t i o n s . F u r t h e r a n a l y s i s of r esponses t o the c a t e g o r y o t h e r was c a r r i e d out and the r e s u l t s a r e p r e s e n t e d i n T a b l e 9. 48 T a b l e 9 Responses i n Other Category f o r Type of Appointment (Item 9b) S p e c i f i c Response Number of S u b j e c t s 1. Employed by and r e s p o n s i b l e t o a d i v i s i o n ( o u t p a t i e n t ) w i t h i n the h o s p i t a l — not d i r e c t l y r e s p o n s i b l e t o the Department of N u r s i n g . 2 2. Employed by and r e s p o n s i b l e t o M e n t a l H e a l t h f o r p a t i e n t c a r e a c t i v i t i e s and a d m i n i s t r a t i v e a c t i v i t i e s . 6 3. I n d e p e n d e n t l y employed. 1 4. R e s p o n s i b l e t o n u r s i n g s e r v i c e and m u l t i d i s c i p l i n a r y program c o o r d i n a t o r , employed by ambulatory c a r e s e r v i c e s . 2 5. Employed by a group of p h y s i c i a n s . 2 6. A l l of the above ( i . e . c l i n i c a l , c l i n i c a l - e d u c a t i o n a l , c l i n i c a l -a d m i n i s t r a t i v e ) . 3 7. Employed by and r e s p o n s i b l e t o Department of H e a l t h f o r h e a l t h p l a n n i n g and communicable d i s e a s e c o n t r o l . 3 8. Employed by and r e s p o n s i b l e t o department of l a b o r a t o r y m e d i c i n e f o r p a t i e n t c a r e a c t i v i t i e s and a d m i n i s t r a t i v e a c t i v i t i e s . 8 9. Employed by a h o s p i t a l i n B.C., government g r a n t under d i r e c t i o n of c l i n i c a l i n v e s t i g a t i n g f a c i l i t y . 1 10. C l i n i c a l r e s e a r c h : employed by and r e s p o n s i b l e t o department of n u r s i n g f o r funded r e s e a r c h work. 2 1 1 . Employed by B.C. H e a l t h M i n i s t r y and r e s p o n s i b l e t o C e n t r e D i r e c t o r as a s e n i o r mental h e a l t h p r a c t i t i o n e r . 2 49 T a b l e 9 -- C o n t i n u e d S p e c i f i c Response Number of S u b j e c t s 12. C l i n i c a l , s t a f f , and p a t i e n t e d u c a t i o n . 2 13. Employed by h o s p i t a l and r e s p o n s i b l e t o l o n g term c a r e f o r p a t i e n t c a r e , s u p e r v i s i n g n u r s i n g c a r e and e d u c a t i o n of some s t u d e n t s . 1 14. Employed by r e s e a r c h agency, r e s p o n s i b l e t o n u r s i n g , c l i n i c a l , e d u c a t i o n a l , o c c a s i o n a l a d m i n i s t r a t i v e a c t i v i t i e s ( j o i n t a p p o i n t m e n t ) . 1 15. Employed by and r e s p o n s i b l e t o department of food s e r v i c e s f o r p a t i e n t c a r e and a d m i n i s t r a t i v e a c t i v i t i e s . 1 16. R e s p o n s i b l e t o the d i r e c t o r of H e a l t h Care -- c o n s u l t a n t t o a l l s t a f f . 1 17. R e s p o n s i b l e f o r i n s e r v i c e e d u c a t i o n of g r a d u a t e s t a f f . 1 T a b l e 9 i n d i c a t e s t h a t a l a r g e group of s u b j e c t s (21 out of 33) who i n d i c a t e d type of appointment as o t h e r a re not r e s p o n s i b l e t o n u r s i n g s e r v i c e f o r n u r s i n g c a r e and/or o t h e r a c t i v i t i e s . Some of the departments and p e r s o n s t o whom they a r e r e s p o n s i b l e i n c l u d e : the Department of H e a l t h , Department of L a b o r a t o r y M e d i c i n e , Department of Food S e r v i c e s , and a group of p h y s i c i a n s . 50 P r o f e s s i o n a l V a r i a b l e s As shown i n Table 10, the m a j o r i t y of the s u b j e c t s (48 or 77.4%) r e c e i v e d b a s i c p r e p a r a t i o n i n n u r s i n g i n d i p l o m a programs w h i l e 14 or 22.6% of the s u b j e c t s r e c e i v e d t h i s i n b a c c a l a u r e a t e programs. The type of program most f r e q u e n t l y T a b l e 10 B a s i c E d u c a t i o n a l P r e p a r a t i o n i n N u r s i n g of the S u b j e c t s (Item 10) Type of Program Number of S u b j e c t s P e r c e n t a g e of Sample B a c c a l a u r r e a t e 14 22.2 Diploma 48 76.2 No response 1 1 .6 T o t a l 63 1 00.0 pursued f o r p o s t - b a s i c n u r s i n g e d u c a t i o n was d i p l o m a / c e r t i f i c a t e . T a b l e 11 p r e s e n t s f i n d i n g s r e l a t e d t o p o s t - b a s i c n u r s i n g e d u c a t i o n . T h i s T a b l e i n d i c a t e s t h a t 24 of the s u b j e c t s had pursued p o s t - b a s i c n u r s i n g e d u c a t i o n i n T a b l e 11 P o s t - b a s i c N u r s i n g E d u c a t i o n by Type of Program, and Minimum, Maximum and Average Number of Years S i n c e C o m p l e t i o n (Item 11) Type of Program Number Minimum Maximum Average ( y e a r s ) ( y e a r s ) ( y e a r s ) D i p l o m a / c e r t i f i c a t e 24 0 28 10 B a c c a l a u r e a t e 16 3 25 12 M a s t e r ' s 9 1 13 6 D o c t o r a l 0 - --51 d i p l o m a / c e r t i f i c a t e programs between 1954 and 1982, w i t h the average number of y e a r s s i n c e c o m p l e t i o n b e i n g 10. S i x t e e n of the s u b j e c t s had p u r s u e d p o s t - b a s i c n u r s i n g e d u c a t i o n i n b a c c a l a u r e a t e programs between 1957 and 1979, w i t h an average of 12 y e a r s s i n c e c o m p l e t i o n . Nine respondents had pursued p o s t - b a s i c n u r s i n g e d u c a t i o n i n master's programs between 1969 and 1981, w i t h the average number of y e a r s s i n c e c o m p l e t i o n b e i n g 6. None of the s u b j e c t s had completed d o c t o r a l s t u d i e s . The m a j o r i t y (12/16) of t h e sample who c o mpleted a b a c c a l a u r e a t e program as a p a r t of p o s t - b a s i c n u r s i n g e d u c a t i o n d i d so i n n u r s i n g . Other types of degrees l i s t e d by i n d i v i d u a l s u b j e c t s i n c l u d e d B.A. ( p s y c h o l o g y ) ; B.Sc. ( p s y c h o l o g y ) ; B.A. (not s p e c i f i e d ) ; B.A. ( s o c i o l o g y ) . Of the 9 who had pursued a master's program, 4 d i d so i n n u r s i n g . Other degrees i n c l u d e d : M a s t e r ' s i n H e a l t h S c i e n c e s ; Master of S c i e n c e ; M a s t e r of A r t s ( s o c i o l o g y ) ; Master of A r t s ; and Master of P h i l o s o p h y . A l i s t of a r e a s of study r e p o r t e d by some s u b j e c t s who completed d i p l o m a / c e r t i f i c a t e programs i s p r e s e n t e d i n T a b l e 12. The c a t e g o r i e s most o f t e n s p e c i f i e d were h o s p i t a l / u n i t a d m i n i s t r a t i o n (5/20) and a d m i n i s t r a t i o n and t e a c h i n g ( 3 / 2 0 ) . T a b l e 13 p r e s e n t s the r e s u l t s f o r the number of p o s i t i o n s i n n u r s i n g h e l d by the s u b j e c t s (Item 12). F i n d i n g s a r e p r e s e n t e d as p o s i t i o n s , sequence i n which each 52 T a b l e 12 Areas of Study f o r D i p l o m a / C e r t i f i c a t e Type of Programs Completed (Item 11) Area of Study Number of S u b j e c t s A d m i n i s t r a t i o n and t e a c h i n g 3 C l i n i c a l A r c t i c nurse c o u r s e 1 Coronary c a r e 1 C r i t i c a l c a r e i n s t r u c t o r 1 E n t e r o s t r o m a l t h e r a p y 2 G e n e r a l program f o r p r i m a r y c a r e n u r s i n g 1 H o s p i t a l / u n i t a d m i n i s t r a t i o n 5 I n f e c t i o n c o n t r o l program 1 Midwi f e r y 1 Oncology 1 P e r i n a t a l nurse c l i n i c i a n , n e o n a t a l i n t e n s i v e c a r e 1 R e s p i r a t o r y r e h a b i l i t a t i o n 2 Not r e p o r t e d 4 T o t a l 24 was h e l d by s u b j e c t s , and amount of time i n y e a r s spent i n each p o s i t i o n . Most of the sample had h e l d between one and 4 p o s i t i o n s i n n u r s i n g b e f o r e a c c e p t i n g the p r e s e n t p o s i t i o n of c l i n i c a l nurse s p e c i a l i s t . I t s h o u l d be noted t h a t some of the p o s i t i o n s were h e l d by a respondent more than once, hence a p o s i t i o n may be counted more than once. The sequence of numbers b e g i n s w i t h 1 as the p r e s e n t p o s i t i o n ; 2 r e f e r s t o the p o s i t i o n h e l d p r i o r t o the p r e s e n t p o s i t i o n , 3 r e f e r s t o the p o s i t i o n h e l d b e f o r e 2, and so on, backward from the p r e s e n t . For example, i m m e d i a t e l y p r i o r t o a c c e p t i n g the p r e s e n t p o s i t i o n , 18 of the 59 r e s p o n d e n t s had worked i n the p o s i t i o n of g e n e r a l d u t y / s t a f f nurse f o r a p e r i o d of between 1 and 25 y e a r s w i t h an average of 5 y e a r s . E i g h t respondents had worked i n each of the c a t e g o r i e s of 53 T a b l e 13 N u r s i n g P o s i t i o n s H e l d by S u b j e c t , by P o s i t i o n , Sequence, Range, and Mean Years H e l d (Item 12) POSITION SEQUENCE 1 2 3 4 5 6 7 8 C l i n i c a l nurse spec. No. Rnge Mean 60 2-15 4 A s s i s t a n t or head nurse No. Rnge Mean 4 2-2 2 1 3 2 1-2 1 .5 1 2 0 0 0 A s s o c i a t e or a s s i s t a n t d i r e c t o r No. Rnge Mean 0 0 0 1 1 0 0 0 D i r e c t o r No. Rnge Mean 0 0 2 2-5 3.5 0 0 0 0 G e n e r a l d u t y No. Rnge Mean 18 1-25 5 19 1-15 4.3 12 1-6 2.8 7 2-5 3. 1 9 1-4 2.2 1 2 0 Head nurse No. Rnge Mean 7 3-5 4.5 8 1-10 4.5 0 1 4 I n s t r u c t o r No. Rnge Mean 6 1-8 5.1 4 2-4 2.7 6 2-8 4.5 2 1-3 2 0 0 1 3 O f f i c e n u r s e / comm. h e a l t h nurse No. Rnge Mean 8 1-17 6.7 7 2-19 5.1 3 3-3 3 2 3-12 7.5 0 0 0 P r o f e s s o r No. Rnge Mean 0 1 1 3 0 0 0 0 0 S u p e r v i s o r or c o o r d i n a t o r No. Rnge Mean 8 2-6 3.3 1 5 2 2-5 3.5 1 1 0 2 1-6 3.5 0 Other No. Rnge Mean 8 1-9 3.7 6 1-13 5.6 2 1-3 2 2 2-2 2 1 1 0 0 54 o f f i c e nurse/community h e a l t h n u r s e , s u p e r v i s o r / c o o r d i n a t o r and o t h e r i m m e d i a t e l y p r i o r t o a c c e p t i n g the p r e s e n t p o s i t i o n . S u b j e c t s had worked between 1 and 17 y e a r s i n the p o s i t i o n of o f f i c e nurse/community h e a l t h n u r s e , w i t h an average of 6.7 y e a r s . S u b j e c t s i n the second p o s i t i o n c a t e g o r y ( s u p e r v i s o r / c o o r d i n a t o r ) had worked between 2 and 6 y e a r s , w i t h an average of 3.3 b e f o r e a c c e p t i n g the p r e s e n t p o s i t i o n . S u b j e c t s i n the t h i r d p o s i t i o n c a t e g o r y ( o t h e r ) i n d i c a t e d a range between 1 and 9 y e a r s w i t h an average of 3.7 y e a r s . Table 13 a l s o i n d i c a t e s t h a t n e a r l y a l l the res p o n d e n t s had worked i n the p o s i t i o n c a t e g o r y of g e n e r a l d u t y / s t a f f n u r s e . Many had worked i n the p o s i t i o n c a t e g o r i e s of o t h e r , o f f i c e nurse/community h e a l t h n u r s e , and i n s t r u c t o r . The s m a l l e s t number of respond e n t s had worked i n the p o s t i o n c a t e g o r i e s of a s s o c i a t e / a s s i s t a n t d i r e c t o r , d i r e c t o r and p r o f e s s o r . R e l a t i o n s h i p s Among V a r i a b l e s R e l a t i o n s h i p s between c o n t e x t u a l l y r e l a t e d v a r i a b l e s , the p r o f e s s i o n a l v a r i a b l e , d e r i v e d e d u c a t i o n a l l e v e l 1 , and e s t i m a t e s of weekly work time devoted t o each c a t e g o r y of work a c t i v i t y were examined u s i n g both p a r a m e t r i c and non-p a r a m e t r i c s t a t i s t i c a l t e s t s . I n i t i a l l y , t he ANOVA r e s u l t s 1 The h i g h e s t a c h i e v e d e d u c a t i o n a l l e v e l , d e r i v e d from the s u b j e c t s ' r e p o r t e d e d u c a t i o n a l e x p e r i e n c e , was the o n l y p r o f e s s i o n a l v a r i a b l e examined i n t h i s s e c t i o n . 55 r e v e a l e d a h i g h degree of v a r i a b i l i t y amongst the e s t i m a t e d p e r c e n t a g e s devoted t o some of the work c a t e g o r i e s . S i n c e the number of s u b j e c t s v a r i e s w i t h i n the work c a t e g o r i e s , the v i o l a t i o n of the assumption of e q u a l v a r i a n c e s c o u l d produce m i s l e a d i n g r e s u l t s ( F e r g uson, 1971). Thus, non-p a r a m e t r i c t e s t s , K r u s k a l - W a l l i s rank p r o c e d u r e s , were a l s o used. The l a t t e r a r e not dependent on the v a r i a n c e of the d i s t r i b u t i o n . However, th e s e t e s t s a r e not as p o w e r f u l f o r d e t e c t i n g d i f f e r e n c e s between groups, e s p e c i a l l y when the numbers of o b s e r v a t i o n s a r e s m a l l as i s the case i n some of the f o l l o w i n g a n a l y s e s . The r e s u l t s of both t e s t s a r e p r e s e n t e d i n Appendix C. When both t e s t s i n d i c a t e d s i g n i f i c a n c e , the d i f f e r e n c e was i n t e r p r e t e d as r e a l . When the a n a l y s i s of v a r i a n c e i n d i c a t e d s i g n i f i c a n c e and the K r u s k a l - W a l l i s r e s u l t s approached s i g n i f i c a n c e , the r e s u l t was i n t e r p r e t e d as i n d i c a t i o n of a p o s s i b l e d i f f e r e n c e t h a t may have been p r e s e n t w i t h a l a r g e r sample s i z e . When the K r u s k a l - W a l l i s t e s t i n d i c a t e d s i g n i f i c a n c e and the a n a l y s i s of v a r i a n c e d i d not , t h i s was i n t e r p r e t e d as an i n d i c a t i o n of a d i f f e r e n c e t h a t was l i k e l y r e a l , w i t h the unequal v a r i a n c e s i n the ANOVA " h i d i n g " the d i f f e r e n c e between the means. Appendix C c o n t a i n s a d e s c r i p t i o n of a l l the r e s u l t s , b o t h s t a t i s t i c a l l y s i g n i f i c a n t and n o n s i g n i f i c a n t w h i l e T a b l e 14 p r e s e n t s a summary of s i g n i f i c a n t r e s u l t s . An e x a m i n a t i o n of Ta b l e 14 i n d i c a t e s t h r e e t h i n g s : (1) the c o n t e x t u a l l y r e l a t e d v a r i a b l e s of new or e x i s t i n g 56 T a b l e 14 Summary of S i g n i f i c a n t F i n d i n g s f o r R e l a t i o n s h i p Between C o n t e x t u a l l y R e l a t e d and P r o f e s s i o n a l V a r i a b l e s and E s t i m a t e s of Percentage of Weekly Work Time Devoted t o C a t e g o r i e s of Work A c t i v i t y C ategory V a r i a b l e N M i n . Max. Mean SD Median Avg. Rank A d m i n i s - new 25 1 45 13. 2 1 12. 1 10. 0 26.6 2 t r a t i o n e x i s t i n g 20 1 25 7. 0 6. 8 5. 0 18.5 TOTAL 45 10. 4 10. 5 5. 0 Pat i e n t new 26 1 75 29. 7 1 23. 4 20. 0 20.5 2 c a r e e x i s t i n g 24 1 5 80 45. 6 22. 2 50. 0 30.9 TOTAL 50 37. 3 24. 0 30. 0 Community hosp. 22 1 35 6. 4 8. 8 5. 0 1 5 . 6 2 a c t i v i t y c b s . 1 3 1 1 00 16. 6 26. 5 6. 0 25.0 p o / f p u 0 o t h e r 3 5 20 10. 0 8. 7 5. 0 24.0 TOTAL 38 10. 2 17. 3 5. 0 I n t e r d i s - c l i n i c a l 1 3 2 1 5 5. 5 4. 0 5. 0 16.8 2 i p l i n a r y c l i n - e d 4 8 10 9. 5 1 . 0 10. 0 29.5 i n t e r - c l i n - a d m 7 1 20 7. 0 6. 4 5. 0 19.5 a c t i o n o t h e r 24 1 50 12. 9 10. 8 10. 0 29.3 TOTAL 48 9. 7 8. 8 8. 5 Ad m i n i s - 1 i n e 6 5 45 21 . 7 1 16. 9 15. 0 31 .7 2 t r a t i o n s t a f f 36 1 35 9. 0 8. 4 5. 0 19.7 TOTAL 42 10. 8 10. 7 5. 0 I n t e r d i s - d i p . 34 2 20 8. 1 1 6. 6 8. 0 22.8 i p l i n a r y b acc. 8 1 30 8. 4 6. 2 5. 0 24.3 i n t e r - master 7 3 50 17. 9 15. 3 15. 0 36.0 a c t i o n TOTAL 49 9. 6 8. 8 8. 0 S t a f f d i p . 25 1 20 5. 5 1 4. 7 5. 0 17.4 d e v e l o p - bacc. 6 1 80 24. 3 29. 2 6. 5 26.8 ment master 6 1 10 4. 8 3. 0 5. 0 17.5 TOTAL 37 8. 4 13. 6 5. 0 P i n . P o l . j . d . yes 24 1 20 8. 5 1 6. 2 6. 5 25. 1 Stan d a r d s j . d . no 1 9 1 1 0 4. 7 3. 0 5. 0 18.1 Change TOTAL 43 6. 8 5. 3 5. 0 1 S i g n i f i c a n t d i f f e r e n c e between means a c c o r d i n g t o the one-way ANOVA, p of F s t a t i s t i c < .05 (see t e x t f o r f u r t h e r d e t a i l s ) . 2 S i g n i f i c a n t d i f f e r e n c e between ranks a c c o r d i n g t o the K r u s k a l - W a l l i s s t a t i s t i c , p < .05 (see t e x t f o r f u r t h e r d e t a i l s ) . 57 and l i n e or s t a f f p o s i t i o n were found t o be r e l a t e d t o the amount of e s t i m a t e d time devoted t o the c a t e g o r i e s a d m i n i s t r a t i o n and p a t i e n t c a r e . When the p r e s e n t p o s i t i o n was new when a c c e p t e d , t h i s group of c l i n i c a l nurse s p e c i a l i s t s spent a s i g n i f i c a n t l y l a r g e r amount of e s t i m a t e d weekly work time i n the c a t e g o r y a d m i n i s t r a t i o n (F(1,43)=4.21, p=.046; K-W(1)=4.27, p=.039). When the p r e s e n t p o s i t i o n was a l r e a d y e x i s t i n g , t h i s group of c l i n i c a l nurse s p e c i a l i s t s devoted a s i g n i f i c a n t l y l a r g e r amount of e s t i m a t e d weekly work time t o the c a t e g o r y p a t i e n t c a r e (F(1,48)=6.09, p=.017; K-W(1)=6.27, p=.012). When type of appointment was l i n e as opposed t o s t a f f w i t h i n the employing agency, t h i s group of c l i n i c a l nurse s p e c i a l i s t s d e voted a s i g n i f i c a n t l y g r e a t e r amount of e s t i m a t e d weekly work time t o the c a t e g o r y a d m i n i s t r a t i o n (F(1,40)=8.45, p=.006; K-W(1)=4.89, p=.027); (2) the c o n t e x t u a l l y r e l a t e d v a r i a b l e of presence or absence of a j o b d e s c r i p t i o n and the d e r i v e d p r o f e s s i o n a l v a r i a b l e i n d i c a t e the presence of a p o s s i b l e d i f f e r e n c e f o r the e s t i m a t e s of percentage of weekly work time devoted t o the c a t e g o r i e s p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , and s t a f f development. The a n a l y s i s of v a r i a n c e i n d i c a t e d t h a t t h o s e c l i n i c a l nurse s p e c i a l i s t s w i t h a j o b d e s c r i p t i o n spent a s i g n i f i c a n t l y (F(1,41)=5.91, p=.020; K-W(1)=3.28, p=.070) l a r g e r amount of e s t i m a t e d weekly work time i n the c a t e g o r y p l a n n i n g - p o l i c y -58 standards-change than those w i t h o u t a j ob d e s c r i p t i o n . E x a m i n a t i o n of the e f f e c t of d e r i v e d e d u c a t i o n a l l e v e l on e s t i m a t e s of weekly work time i n d i c a t e d t h a t c l i n i c a l nurse s p e c i a l i s t s w i t h master's l e v e l p r e p a r a t i o n d e v o t e d a s i g n i f i c a n t l y (F(2,46)=4.13, p=.020; K-W(2)=4.91, p=.086) l a r g e r amount of e s t i m a t e d weekly work time t o the c a t e g o r y i n t e r d i s c i p l i n a r y i n t e r a c t i o n than those w i t h b a c c a l a u r e a t e or d i p l o m a l e v e l p r e p a r a t i o n . For the e s t i m a t e d p e r c e n t a g e of weekly work time devoted t o the c a t e g o r y s t a f f development, those c l i n i c a l n u r se s p e c i a l i s t s w i t h b a c c a l a u r e a t e l e v e l p r e p a r a t i o n spent a s i g n i f i c a n t l y (F(2,34)=6.36, p=.005; K-W(2)=3.75, p=.153) g r e a t e r amount of time than those w i t h master's or diploma l e v e l p r e p a r a t i o n ; and (3) the c o n t e x t u a l l y r e l a t e d v a r i a b l e s of s e t t i n g and type of appointment (Item 9b) i n d i c a t e d a l i k e l y r e a l d i f f e r e n c e f o r e s t i m a t e s of weekly work time devoted t o the c a t e g o r i e s community a c t i v i t i e s and i n t e r d i s c i p l i n a r y i n t e r a c t i o n . The K r u s k a l - W a l l i s t e s t i n d i c a t e d t h a t when c l i n i c a l nurse s p e c i a l i s t s worked i n a h o s p i t a l s e t t i n g they spent a s i g n i f i c a n t l y (F(2,35)=1.47, p=.243; K-W(2)=6.41, p=.041) s m a l l e r amount of e s t i m a t e d weekly work time d e v o t e d t o the c a t e g o r y community a c t i v i t i e s than those who worked e i t h e r i n community based s e r v i c e s or t h o s e who i n d i c a t e d they worked i n the c a t e g o r y o t h e r . E x a m i n a t i o n of the i n f l u e n c e of type of appointment (Item 9b) i n d i c a t e d t h a t c l i n i c a l 59 nurse s p e c i a l i s t s who i d e n t i f i e d t y pe as e i t h e r c l i n i c a l -e d u c a t i o n a l or o t h e r spent a s i g n i f i c a n t l y (F(3,44)=2.49, p=.073; K-W(3)=8.14, p=.043) g r e a t e r amount of e s t i m a t e d weekly work time i n the c a t e g o r y i n t e r d i s c i p l i n a r y i n t e r a c t i o n than t h o s e who i d e n t i f i e d type as c l i n i c a l or c l i n i c a l - a d m i n i s t r a t i v e . These f i n d i n g s p e r m i t an i n i t i a l d e s c r i p t i o n t o be made of the c l i n i c a l nurse s p e c i a l i s t r o l e as r e p o r t e d by a group of s e l f - i d e n t i f i e d c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h C olumbia. Such a d e s c r i p t i o n i s p r e s e n t e d i n the next c h a p t e r . In a d d i t i o n , a comparison of the f i n d i n g s i n t h i s s t udy w i t h those of A r a d i n e and Denyes (1972) i s a l s o p r e s e n t e d . CHAPTER 5 DISCUSSION As s t a t e d i n Chapter 1, the purposes of t h i s study were: 1. t o d e s c r i b e the r o l e of the c l i n i c a l nurse s p e c i a l i s t as p e r c e i v e d by a group of nurses i n B r i t i s h Columbia who i d e n t i f y t h emselves as b e l o n g i n g t o t h i s group; 2. t o i d e n t i f y s i m i l a r i t i e s and d i f f e r e n c e s between the n u r s e s ' d e s c r i p t i o n s and a d e s c r i p t i o n r e p o r t e d by A r a d i n e and Denyes (1972); 3. t o make s u g g e s t i o n s f o r the f u t u r e i n r e l a t i o n t o the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada based on the above f i n d i n g s . S p e c i f i c d i s c u s s i o n of the f i n d i n g s i s p r e s e n t e d i n t h r e e s e c t i o n s c o r r e s p o n d i n g t o the s e s t a t e d p u r p o s e s . D e s c r i p t i o n of the R o l e as P e r c e i v e d by a S e l f - D e f i n e d Group  of C l i n i c a l Nurse S p e c i a l i s t s i n B r i t i s h Columbia The d a t a i n d i c a t e t h a t the m a j o r i t y of c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia a r e o l d e r than 40 and r e c e i v e d t h e i r b a s i c n u r s i n g e d u c a t i o n i n d i p l o m a programs. P o s t - b a s i c n u r s i n g e d u c a t i o n may or may not have been pursued by t h i s group. Three or fo u r p o s i t i o n s i n n u r s i n g were h e l d p r i o r t o the ac c e p t a n c e of the p r e s e n t p o s i t i o n . In terms of a l i s t of c a t e g o r i e s of work a c t i v i t y d e s c r i b e d 60 61 i n the l i t e r a t u r e ( A r a d i n e and Denyes, 1972) the l a r g e s t p e r c e n t a g e of weekly work time i s r e p o r t e d l y spent i n p a t i e n t c a r e ; l e s s of the weekly work time i s devoted t o a d m i n i s t r a t i o n , community a c t i v i t i e s , and c o n s u l t a t i o n ; and the l e a s t amount of weekly work time i s devoted t o e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , p e r s o n a l and p r o f e s s i o n a l growth, p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , s t a f f development, r e s e a r c h , and w r i t i n g f o r p u b l i c a t i o n . F u r t h e r m o r e , the m a j o r i t y of c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia r e p o r t e d employment i n a h o s p i t a l s e t t i n g . The most f r e q u e n t l y used j o b t i t l e was nurse c l i n i c i a n . The type of appointment was e v e n l y d i v i d e d between u n i t - b a s e d and not u n i t - b a s e d and was d e s c r i b e d as a s t a f f p o s i t i o n , and by a l a b e l o t h e r when c h o i c e s were p r o v i d e d f o r c l i n i c a l , c l i n i c a l - e d u c a t i o n a l , and c l i n i c a l -a d m i n i s t r a t i v e and o t h e r . C o n t e x t u a l l y r e l a t e d v a r i a b l e s , new v e r s u s e x i s t i n g p o s i t i o n and presence or absence of a job d e s c r i p t i o n when the p r e s e n t p o s i t i o n was a c c e p t e d , were found t o i n f l u e n c e the r e p o r t e d e s t i m a t e s of weekly work time d e v o t e d t o some of the c a t e g o r i e s of work a c t i v i t y , namely a d m i n i s t r a t i o n and p a t i e n t c a r e , and p l a n n i n g - p o l i c y -standards-change r e s p e c t i v e l y . The p r o f e s s i o n a l v a r i a b l e , d e r i v e d e d u c a t i o n a l l e v e l ( h i g h e s t a c h i e v e d e d u c a t i o n a l l e v e l ) , was found t o show a p o s s i b l e d i f f e r e n c e f o r e s t i m a t e s of weekly work time d e v o t e d t o two c a t e g o r i e s of work a c t i v i t y , i n t e r d i s c i p l i n a r y i n t e r a c t i o n and work 62 a c t i v i t y . F u r t h e r s p e c i f i c d i s c u s s i o n r e l a t e d t o t h i s g e n e r a l d e s c r i p t i o n i s p r e s e n t e d under the f o l l o w i n g s u b s e c t i o n s : work a c t i v i t y , c o n t e x t u a l l y r e l a t e d v a r i a b l e s , and p r o f e s s i o n a l v a r i a b l e . Work A c t i v i t y Responses were g i v e n i n terms of a l l of the c a t e g o r i e s d e s c r i b e d by A r a d i n e and Denyes (1972) (see T a b l e 3 ) . T h i s s u g g e s t s t h a t the c a t e g o r y l a b e l s have meaning f o r the group of c l i n i c a l nurse s p e c i a l i s t s s u r v e y e d . The number of c a t e g o r i e s d e r i v e d from the c a t e g o r y o t h e r (Item 7 ) , p r e s e n t e d i n T a b l e 4, s u g g e s t s t h e r e i s a v a r i e t y of meanings a t t a c h e d t o t h e s e c a t e g o r y l a b e l s . For example, i t seems r e a s o n a b l e t o the r e s e a r c h e r t h a t the c a t e g o r i e s c o u n s e l l i n g / p s y c h o t h e r a p y , t r a d i t i o n a l n u r s i n g s k i l l s , and p a t i e n t e d u c a t i o n would f a l l w i t h i n the work a c t i v i t y c a t e g o r y p a t i e n t c a r e . T h e r e f o r e , p r e c i s i o n of the meaning a s s o c i a t e d w i t h each c a t e g o r y l a b e l (among c l i n i c a l nurse s p e c i a l i s t s ) needs t o be f u r t h e r examined by r e s e a r c h . T h i s s u g g e s t i o n i s s i m i l a r t o one made by A r a d i n e and Denyes (1972). The c a t e g o r y of work a c t i v i t y r e c e i v i n g the l a r g e s t amount of weekly work time (37.3%) was p a t i e n t c a r e (see T a b l e 3 ) . T h i s f i n d i n g i s c o n s i s t e n t w i t h the view a r t i c u l a t e d by R e i t e r (1966), P e p l a u (1965), and Johnson (1962) t h a t p a t i e n t c a r e i s the f o c u s of the r o l e . However, the f i n d i n g t h a t most (52 or 89.7%) c l i n i c a l nurse 63 s p e c i a l i s t s a r e i n a s t a f f p o s i t i o n and a s m a l l subgroup (7 or 11.5%) r e p o r t e d type of appointment as c l i n i c a l -a d m i n i s t r a t i v e would seem t o be i n c o n s i s t e n t w i t h Johnson's (1962) view of the r o l e as an a l t e r n a t e t o the t r a d i t i o n a l head nurse p a t t e r n f o r the d e l i v e r y of n u r s i n g c a r e s e r v i c e s i n the h o s p i t a l s e t t i n g . F u r t h e r , the p o s i t i o n t h a t the c l i n i c a l nurse s p e c i a l i s t d e monstrates commitment t o the p r o f e s s i o n by engaging i n r e s e a r c h and p u b l i s h i n g , a r t i c u l a t e d by R e i t e r (1966) and P e p l a u (1965), i s not s u p p o r t e d by the f i n d i n g s of t h i s s t u d y . W h i l e the maximum pe r c e n t a g e of weekly work time r e p o r t e d f o r work c a t e g o r y of r e s e a r c h was 20%, and t h a t f o r w r i t i n g f o r p u b l i c a t i o n was 40%, the mean p e r c e n t a g e s were v e r y low, 4.6% and 5.1% r e s p e c t i v e l y (see Table 3 ) . S p e c u l a t i o n about re a s o n s f o r t h i s f i n d i n g s u g g e s t s t h a t f a c t o r s l i k e type of e d u c a t i o n a l p r e p a r a t i o n and work s e t t i n g might be i n f l u e n c e s . For example, advanced e x p e r i e n c e w i t h the r e s e a r c h p r o c e s s i s common a t the master's l e v e l of p r e p a r a t i o n i n n u r s i n g , u n l i k e b oth the d i p l o m a and b a c c a l a u r e a t e l e v e l s where t h e r e i s u s u a l l y a m i n i m a l amount of c o n t e n t and e x p e r i e n c e r e l a t e d t o r e s e a r c h . In a d d i t i o n , h o s p i t a l s and community s e r v i c e s of a non-academic type and away from l a r g e urban a r e a s f r e q u e n t l y p r o v i d e l i m i t e d emphasis on and s u p p o r t f o r r e s e a r c h a c t i v i t i e s . However, i t can be p o i n t e d out t h a t even when grad u a t e p r e p a r a t i o n was c h a r a c t e r i s t i c of 64 s u b j e c t s , as i n the A r a d i n e and Denyes (1972) study ( a l l s u b j e c t s had master's l e v e l p r e p a r a t i o n i n n u r s i n g ) , involvement i n the c a t e g o r i e s of r e s e a r c h and w r i t i n g f o r p u b l i c a t i o n was r e p o r t e d as low. That s t u d y , however, was c a r r i e d out d u r i n g a time when emphasis on r e s e a r c h and p u b l i c a t i o n was not as g r e a t as a t p r e s e n t . N e v e r t h e l e s s , i t may be t h a t the work s e t t i n g has more t o do w i t h t h i s f i n d i n g than does the l e v e l of e d u c a t i o n a l p r e p a r a t i o n of the s u b j e c t s . Some of the q u e s t i o n s r a i s e d by A r a d i n e and Denyes (1972) i n c l u d e : What v a l u e i s p l a c e d on r e s e a r c h and p u b l i s h i n g by the c l i n i c a l nurse s p e c i a l i s t , employees, and o t h e r s ? What i n f l u e n c e s have t i m e , p r i o r i t i e s , competing p r e s s u r e s , and p r e v i o u s e x p e r i e n c e on r e s e a r c h and w r i t i n g ? Do r e s e a r c h and w r i t i n g r e p r e s e n t d e l a y e d rewards f o r the c l i n i c a l nurse s p e c i a l i s t ? (p. 416) T h i s k i n d of l i m i t e d i n v o l v e m e n t of c l i n i c a l nurse s p e c i a l i s t s i n r e s e a r c h and w r i t i n g f o r p u b l i c a t i o n i s of con c e r n because of the need f o r the n u r s i n g p r o f e s s i o n " t o e v a l u a t e , demonstrate, and a r t i c u l a t e i t s a c t i v i t i e s t o i t s own members, o t h e r p r o f e s s i o n a l s , and consumers" ( A r a d i n e and Denyes, 1972; P. 416). C o n t e x t u a l l y R e l a t e d V a r i a b l e s In t h i s s u b s e c t i o n , d i s c u s s i o n i s p r e s e n t e d p e r t a i n i n g t o the c o n t e x t u a l l y - r e l a t e d v a r i a b l e s : j o b t i t l e , new or e x i s t i n g p o s i t i o n and presence or absence of a j o b d e s c r i p t i o n , work s e t t i n g , and type of appointment. 65 Job t i t l e . T h i s s t u d y found t h a t the most f r e q u e n t l y used j o b t i t l e was nurse c l i n i c i a n (see Table 5 ) . I t i s u n c l e a r why nurses w i t h t h i s j o b t i t l e (nurse c l i n i c i a n ) would check c l i n i c a l s p e c i a l i s t r a t h e r than o t h e r on the RNABC r e g i s t r a t i o n form. T h i s may suggest t h e r e i s a p r e f e r e n c e w i t h i n the p r o v i n c e of B r i t i s h Columbia f o r t h i s t i t l e . A d d i t i o n a l l y , i t i s u n c l e a r why respondents who p r o v i d e d j o b t i t l e s of head n u r s e , community h e a l t h n u r s e , and i n s t r u c t o r (see T a b l e 5) would check box 23 on the RNABC r e g i s t r a t i o n form when t h e s e same c a t e g o r y names a r e p r o v i d e d on t h a t form. A l l of t h i s might suggest t h a t the c a t e g o r y l a b e l " c l i n i c a l s p e c i a l i s t " on the RNABC r e g i s t r a t i o n form may be f u n c t i o n i n g as a c a t c h - a l l c a t e g o r y f o r some n u r s e s . Or t h e s e d i s c r e p a n c i e s may be viewed as s u p p o r t i v e of an assumption of t h i s s t u d y , namely, th e s e n u r s e s and/or t h e i r employers b e l i e v e they p r o v i d e a s e r v i c e t h a t i s d i f f e r e n t than the g e n e r a l l y s h a red u n d e r s t a n d i n g s a s s o c i a t e d w i t h the o t h e r n u r s i n g r o l e s t h a t a r e l i s t e d as o p t i o n s f o r the i n d i c a t i o n of work p o s i t i o n on the RNABC form. I f the r o l e b e i n g implemented by the sample i s t h a t of the c l i n i c a l nurse s p e c i a l i s t , then i t s h o u l d be so named i n the t h i n k i n g of i n d i v i d u a l n u r s e s and i n the everyday w o r k i n g w o r l d by both n u r s e s and o t h e r s i n the h e a l t h c a r e system. As c o n s i s t e n c y and c l a r i t y i n the shared n o t i o n s of the r o l e d e v e l o p , such a d i s c r e p e n c y would be e x p e c t e d t o d i s a p p e a r . 66 Most of the respondents i n d i c a t e d s a t i s f a c t i o n w i t h t h e i r j o b t i t l e s . T h i s suggests e x i s t e n c e of a degree of agreement between some nur s e s and t h e i r employers about the a p p r o p r i a t e n e s s of the j o b t i t l e s used. However, c o u p l e d w i t h the range of j o b t i t l e s used i n the work p l a c e (see Table 5) the data suggest a p o s s i b l e absence among nurses of a commonly shared u n d e r s t a n d i n g of the t i t l e c l i n i c a l nurse s p e c i a l i s t , a t l e a s t as the l i t e r a t u r e d e f i n e s i t . T h e r e f o r e , the r e s e a r c h e r suggests t h a t i f n u r s e s do not know what a c l i n i c a l nurse s p e c i a l i s t i s and they do know what a head nurse i s , f o r example, then the n u r s i n g p r o f e s s i o n i n Canada has not done i t s job of a r t i c u l a t i n g a d e f i n i t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e w e l l enough. In a d d i t i o n , from the p e r s p e c t i v e of the p r o v i n c e from which the p o p u l a t i o n f o r t h i s s tudy was drawn, the r e s e a r c h e r s u ggests t h a t the c a t e g o r y t i t l e c l i n i c a l nurse s p e c i a l i s t may be a n o n - f u n c t i o n a l one f o r the purposes of the RNABC and t h i s c a t e g o r y might be more a c c u r a t e l y e n t i t l e d nurse c l i n i c i a n . New or e x i s t i n g p o s i t i o n and presence or absence of j o b  d e s c r i p t i o n . The l i t e r a t u r e does not d i s c u s s t h e s e v a r i a b l e s i n r e l a t i o n t o the r o l e of the c l i n i c a l nurse s p e c i a l i s t . However, i t was f e l t by the r e s e a r c h e r t h a t these v a r i a b l e s c o u l d be i m p o r t a n t f a c t o r s w i t h i n the work environment t h a t might a f f e c t r o l e enactment of the c l i n i c a l 67 nurse s p e c i a l i s t . S l i g h t l y more than h a l f of the p r e s e n t p o s i t i o n s (32 or 51.6%) were new ones i n the work s e t t i n g s when a c c e p t e d by the s u b j e c t s . The l e n g t h of time t h a t t h e s e p o s i t i o n s (both new and o l d ) had been h e l d ranged between 2 and 15 y e a r s , w i t h an average of 4 y e a r s (see Tab l e 13). Thus, most of the p r e s e n t p o s i t i o n s h e l d by the s u b j e c t s were c r e a t e d i n the 1970's. I t was i n 1972 t h a t p r i o r i t y w i t h i n the p r o f e s s i o n was d i r e c t e d t o the i s s u e of s p e c i a l i z a t i o n i n n u r s i n g . These f i n d i n g s c l e a r l y i n d i c a t e t h a t i t was a f t e r 1972 when n u r s e s i n B r i t i s h Columbia began t o respond t o the need f o r s p e c i a l i z a t i o n w i t h i n the h e a l t h c a r e system by moving i n t o the r o l e of c l i n i c a l nurse s p e c i a l i s t . T h i s a l s o s u g g e s t s t h a t i t was a f t e r 1972 when v a r i o u s work s e t t i n g s began t o respond t o t h i s need by c r e a t i n g p l a c e s f o r the r o l e w i t h i n t h e i r work s e t t i n g . S l i g h t l y more than h a l f of the p r e s e n t p o s i t i o n s had j o b d e s c r i p t i o n s when they were a c c e p t e d by the r e s p o n d e n t s . T h i s i n d i c a t e s t h a t n u r s i n g p r a c t i c e has been d e a l i n g w i t h the i s s u e of implementing the r o l e . The f i n d i n g t h a t a l a r g e group of c l i n i c a l nurse s p e c i a l i s t s (22 or 42.6%) d i d not have a j o b d e s c r i p t i o n a v a i l a b l e when the p o s i t i o n was a c c e p t e d (see Table C.2) s u g g e s t s t h a t t h i s might be an e a r l y phase f o r n u r s i n g and the h e a l t h c a r e system i n r e s p e c t t o the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n B r i t i s h C olumbia. I f t h i s i s so, c o n t i n u i n g e f f o r t s t o d e v e l o p and implement the r o l e might be l i m i t e d as l o n g as 68 i t remains u n c l e a r l y d e f i n e d . With l a c k of c l a r i t y i n a d e f i n i t i o n of the r o l e , guidance t o n u r s i n g e d u c a t i o n remains u n c l e a r and ways of d e m o n s t r a t i n g the e f f e c t i v e n e s s of the r o l e remain unexamined. When the r e l a t i o n s h i p of these v a r i a b l e s and the e s t i m a t e d p e r c e n t a g e s of time devoted t o each c a t e g o r y of work a c t i v i t y was examined by means of s t a t i s t i c a l a n a l y s e s , some s i g n i f i c a n t d i f f e r e n c e s were found (see T a b l e 14). When the p o s i t i o n was new, c l i n i c a l nurse s p e c i a l i s t s d e voted a s i g n i f i c a n t l y (p < .05) g r e a t e r amount of e s t i m a t e d weekly work time (mean e q u a l l e d 13.2%) t o a d m i n i s t r a t i o n than those whose p o s i t i o n was e x i s t i n g when i t was a c c e p t e d (mean e q u a l l e d 7.0%). A g e n e r a l need f o r becoming f a m i l i a r w i t h a new work environment and/or f i n d i n g out where and how a new r o l e f i t s i n t o the system may e x p l a i n t h i s f i n d i n g . C l a r i f i c a t i o n of a d m i n i s t r a t i v e r e l a t i o n s i s n e c e s s a r y t o s u r v i v a l of r o l e s i n a b u r e a u c r a t i c form of o r g a n i z a t i o n (the reader w i l l r e c a l l t h a t most of the s u b j e c t s (41 or 65.1%) worked i n a h o s p i t a l s e t t i n g ) . In a d d i t i o n , the c l i n i c a l nurse s p e c i a l i s t needs t o e s t a b l i s h c o n t a c t s and c r e d i b i l i t y among her w o r k i n g c o l l e a g u e s because she i s f r e q u e n t l y dependent upon them as so u r c e s of r e f e r r a l s a t a l a t e r time ( A r a d i n e and Denyes, 1972; Woodrow and B e l l , 1971). In o t h e r words, e v e n t u a l e f f e c t i v e i m p l e m e n t a t i o n of the r o l e may depend on the e a r l y a t t e n t i o n of the c l i n i c a l nurse s p e c i a l i s t t o the 69 a d m i n i s t r a t i o n c a t e g o r y of work a c t i v i t y d u r i n g the e a r l y phases of the p o s i t i o n . T h i s e x p l a n a t i o n does not r e a d i l y account f o r the s i t u a t i o n i n which the c l i n i c a l nurse s p e c i a l i s t i s a l r e a d y f a m i l i a r w i t h the work environment because s/he has worked i n i t , but i s c o n f r o n t e d w i t h the t a s k of i m p l e m e n t a t i o n of a s p e c i a l i z e d c l i n i c a l r o l e . I t i s s p e c u l a t e d t h a t the c l i n i c a l nurse s p e c i a l i s t r o l e may b e g i n as c h i e f l y a d m i n i s t r a t i v e because t h a t a s p e c t i s more e a s i l y u n d e r s t o o d and j u s t i f i e d than the c l i n i c a l . When the p o s i t i o n was a l r e a d y i n e x i s t e n c e when a c c e p t e d , c l i n i c a l nurse s p e c i a l i s t s r e p o r t e d t h a t they d e v o t e d a s i g n i f i c a n t l y (p <.02) g r e a t e r amount of weekly work time (mean of 45.6%) t o p a t i e n t c a r e than d i d t h o s e f o r whom the p o s i t i o n was new i n the work s e t t i n g (mean of 29.7%). I n f l u e n c e from a p r e d e c e s s o r and/or on-going i n f l u e n c e s from o t h e r s i n r o l e s t h a t i n t e r a c t w i t h t h a t of the c l i n i c a l nurse s p e c i a l i s t may e x p l a i n t h i s f i n d i n g . For example, i f the u n d e r s t a n d i n g and the e x p e c t a t i o n of the c l i n i c a l nurse s p e c i a l i s t i s t h a t the f o c u s of the r o l e i s p a t i e n t c a r e , t h i s would i n f l u e n c e the n a t u r e of the i n t e r a c t i o n t h a t o c c u r s between v a r i o u s h e a l t h p r o f e s s i o n a l s and the i n d i v i d u a l c l i n i c a l nurse s p e c i a l i s t . In a d d i t i o n , p a t t e r n s of i n t e r a c t i o n c e n t e r e d i n p a t i e n t c a r e a c t i v i t i e s would a l r e a d y be i n o p e r a t i o n once the r o l e has been e s t a b l i s h e d i n an agency. With the c o m b i n a t i o n , e x i s t i n g and w i t h o u t a j o b 70 d e s c r i p t i o n , c l i n i c a l nurse s p e c i a l i s t s devoted a s i g n i f i c a n t l y (p <.01) g r e a t e r amount of e s t i m a t e d weekly work time (mean of 59.6%) t o the c a t e g o r y p a t i e n t c a r e than d i d t h o s e w i t h the o t h e r c o m b i n a t i o n s . T h i s f i n d i n g i s c o n s i s t e n t w i t h a b e l i e f i n , and commitment t o , the c e n t r a l f o c u s of p a t i e n t c a r e a r t i c u l a t e d i n the l i t e r a t u r e by s e v e r a l c l i n i c a l nurse s p e c i a l i s t s (Weeks, 1980; S h r a d e r , 1976; R i s k , 1975; C r o l e y , 1962). C l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia seem t o share t h i s b e l i e f . Work s e t t i n g . F i n d i n g s of t h i s study (see T a b l e 8) a r e c o n s i s t e n t w i t h t h o s e i n d i c a t e d i n the l i t e r a t u r e (Watson, 1973; P e p l a u , 1965). S p e c i f i c a l l y , most of the sample (41 or 65.1%) worked i n a h o s p i t a l s e t t i n g (see T a b l e 8 ) . T h i s i s an e x p e c t e d f i n d i n g i n l i g h t of the f a c t t h a t s p e c i a l i z a t i o n i n the h e a l t h c a r e system i s o r g a n i z e d i n h o s p i t a l s ( Krause, 1977). As e a r l y as 1971, a foreshadow of such a f i n d i n g may be seen i n a l i n k a g e t h a t was made between the concept of the c l i n i c a l nurse s p e c i a l i s t and the h o s p i t a l as a work s e t t i n g f o r the r o l e ( N a t i o n a l Department of H e a l t h and W e l f a r e , 1971). Such a l i n k a g e may have been an e a r l y i n d i c a t i o n t h a t the h o s p i t a l environment i s where the r o l e of the c l i n i c a l nurse s p e c i a l i s t w i l l be implemented i n the h e a l t h c a r e d e l i v e r y system i n Canada. However, the d a t a i n d i c a t e t h a t s e l f - d e f i n e d c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia work i n a v a r i e t y of s e t t i n g s (see Table 8 ) . 71 When the r e l a t i o n s h i p of work s e t t i n g and e s t i m a t e s of p e r c e n t a g e s of weekly work time devoted t o the v a r i o u s c a t e g o r i e s of work a c t i v i t y was examined, a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e was shown o n l y by the K r u s k a l - W a l l i s t e s t (see Table 14). A p o s s i b l e reason f o r the f a i l u r e of the a n a l y s i s of v a r i a n c e t o i n d i c a t e a s i g n i f i c a n t d i f f e r e n c e i s the l a r g e range of e s t i m a t e s f o r weekly work time i n d i c a t e d by the community based s e r v i c e s (cbs) subgroup (1-100%). T h i s produced a much h i g h e r v a r i a n c e w i t h i n t h i s subgroup (26.5) compared t o the o t h e r two subgroups. However, the average rank of the h o s p i t a l s e t t i n g subgroup i s c l e a r l y much lower than the average ranks f o r the o t h e r subgroups. C l i n i c a l nurse s p e c i a l i s t s who worked i n a h o s p i t a l s e t t i n g spent a s i g n i f i c a n t l y (p<.04) s m a l l e r amount of e s t i m a t e d weekly work time (average rank=15.6%) dev o t e d t o community a c t i v i t i e s than d i d those i n e i t h e r community based s e r v i c e s (average rank=25.0%) or those i n the c a t e g o r y o t h e r (average rank=24.0%). T h i s f i n d i n g s u g g e s t s t h a t some a s p e c t s of the c l i n i c a l nurse s p e c i a l i s t r o l e , f o r example, involvement i n community a c t i v i t i e s , may be l i n k e d w i t h the s e t t i n g i n which the r o l e i s implemented. For example, i f a major p o r t i o n of the s e r v i c e s p r o v i d e d by an agency i n v o l v e s community a c t i v i t i e s , t h i s a s p e c t would be e x p e c t e d t o be r e f l e c t e d i n the a c t i v i t i e s t h a t a re implemented t h r o u g h the agency. The i n t e r a c t i v e a s p e c t of the r o l e enactment view 72 of r o l e t h e o r y e x p l a i n s these r e l a t i o n s h i p s ( S a r b i n and A l l e n , 1968; Deutsch and K r a u s s , 1965). Even though r o l e t h e o r y may account f o r t h i s f i n d i n g , as suggested above, t h e r e i s a danger i f a t t e n t i o n i s c o n c e n t r a t e d on s e l e c t e d a s p e c t s or a narrow p e r s p e c t i v e of a complex r o l e . The danger of f o c u s i n g a t t e n t i o n on s e l e c t e d a s p e c t s of a complex r o l e , f o r whatever r e a s o n , i s t h a t the l a r g e r p e r s p e c t i v e can e a s i l y be m i s s e d . T h e r e f o r e , i t i s i m p o r t a n t t h a t t h i s f i n d i n g be i n t e r p r e t e d as a statement about the complex r o l e of the c l i n i c a l nurse s p e c i a l i s t and the p a r t i c u l a r work s e t t i n g of community based s e r v i c e s as opposed t o a statement about the l a r g e r view of the r o l e i n B r i t i s h C o lumbia. I t must be p o i n t e d out t h a t the s u b j e c t s i n the A r a d i n e and Denyes (1972) study worked o n l y i n a h o s p i t a l s e t t i n g yet they r e p o r t e d involvement i n the community a c t i v i t i e s c a t e g o r y . These r e s e a r c h e r s d e s c r i b e d a s h i f t i n the r e p o r t e d involvement of s u b j e c t s i n t h i s c a t e g o r y from low t o moderate l e v e l s by the time two y e a r s had been spent i n the p o s i t i o n . T h i s s h i f t was i n t e r p r e t e d as e v i d e n c e of a movement out from h o s p i t a l u n i t s by c l i n i c a l nurse s p e c i a l i s t s as they a t t e m p t e d t o e x t e n d both the number of p l a c e s and ways i n which they c o u l d share knowledge about the d e l i v e r y of n u r s i n g c a r e w i t h o t h e r s . The involvement of c l i n i c a l nurse s p e c i a l i s t s i n community a c t i v i t i e s r e p o r t e d by b o t h A r a d i n e and' Denyes 73 (1972) and the p r e s e n t study suggest t h a t the v a r i a b l e work s e t t i n g may not be an i m p o r t a n t d e t e r m i n a n t of what a c l i n i c a l nurse s p e c i a l i s t a c t u a l l y does i n p r a c t i c e i n r e l a t i o n t o the c a t e g o r y community a c t i v i t i e s . Or i t may be t h a t the p a r t i c u l a r work s e t t i n g of a l a r g e u n i v e r s i t y h o s p i t a l c e n t e r ( A r a d i n e and Denyes, 1972) i s a s i g n i f i c a n t i n f l u e n c e on the i n v o l v e m e n t of c l i n i c a l nurse s p e c i a l i s t s i n the community a c t i v i t i e s c a t e g o r y . Type of appointment. The l i t e r a t u r e i n d i c a t e s t h a t w r i t e r s a r e d i v i d e d as t o how t o p l a c e the c l i n i c a l nurse s p e c i a l i s t w i t h i n the o r g a n i z a t i o n of the work s e t t i n g ( i . e . , l i n e v e r s u s s t a f f ) . The m a j o r i t y of c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia (52 or 89.7%) r e p o r t e d t h a t they h e l d s t a f f p o s i t i o n s . T h i s can be i n t e r p r e t e d as a statement of how the r o l e f i t s i n t o the h e a l t h c a r e system i n t h i s p r o v i n c e . The b e l i e f a r t i c u l a t e d i n the l i t e r a t u r e t h a t s u p p o r t s t h i s k i n d of a placement m a i n t a i n s t h a t advanced knowledge and s k i l l s a r e the b a s i s of the a u t h o r i t y f o r the c l i n i c a l nurse s p e c i a l i s t (Kirkman and M i l l e r , 1972; Baker and Kramer, 1970). However, t h i s b e l i e f would not seem t o e x p l a i n the s t a f f p o s i t i o n placement r e p o r t e d by these s u b j e c t s because most of them d i d not have graduate l e v e l p r e p a r a t i o n (see T a b l e 11). The s t a f f p o s i t i o n placement r e f l e c t e d i n t h i s s tudy may suggest the presence of what R e i t e r (1966) r e f e r r e d t o as "a s t a t e of b e i n g . " By t h i s she d e s c r i b e d a s i t u a t i o n i n which t h e r e i s r e c o g n i t i o n 74 and a c c e p t a n c e by n u r s e s and o t h e r s of an a c c u m u l a t i o n of a depth of knowledge and e x p e r i e n c e which some nu r s e s a p p l y i n t h e i r p r a c t i c e . A l t h o u g h R e i t e r (1966) d i d not e x p l i c i t l y l i n k t hese i d e a s t o the type of e d u c a t i o n a l p r e p a r a t i o n t h a t such a nurse would r e q u i r e , she d i d d e s c r i b e such a nurse as a master p r a c t i t i o n e r . I f a s t a f f p o s i t i o n placement i s r e f l e c t i v e of such a " s t a t e of b e i n g , " the f i n d i n g i n the p r e s e n t study can be i n t e r p r e t e d as a r e c o g n i t i o n of t h i s s t a t e by both some i n d i v i d u a l n urses and some employers. In l i g h t of the d i s c u s s i o n p r o v i d e d by Stevens (1976) p e r t a i n i n g t o a c c o u n t a b i l i t y and type of appointment of the c l i n i c a l nurse s p e c i a l i s t , t h i s f i n d i n g can a l s o be i n t e r p r e t e d i n the f o l l o w i n g manner. Most of the c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia a r e i n s t a f f p o s i t i o n s . Hence they may be seen as h a v i n g p r o f e s s i o n a l a u t h o r i t y , r e s u l t i n g from peer p e r c e p t i o n of the i n d i v i d u a l c l i n i c a l nurse s p e c i a l i s t ' s knowledge and e x p e r t i s e ( S t e v e n s , 1976). T h i s e x p l a n a t i o n would seem t o be c o n s i s t e n t w i t h the " s t a t e of b e i n g " view d i s c u s s e d by R e i t e r ( 1 9 6 6 ) . The l a t t e r v i e w , t h e n , would appear t o be o p e r a t i v e i n n u r s i n g p r a c t i c e i n B r i t i s h Columbia. When the r e l a t i o n s h i p of t h i s v a r i a b l e and e s t i m a t e s of pe r c e n t a g e s of weekly work time devoted t o each c a t e g o r y of work a c t i v i t y was s u b j e c t e d t o s t a t i s t i c a l a n a l y s e s , a s i g n i f i c a n t d i f f e r e n c e was found (see T a b l e 14). When type of appointment was l i n e , c l i n i c a l nurse s p e c i a l i s t s spent a 75 s i g n i f i c a n t l y (p <.001; p <.03) l a r g e r amount of e s t i m a t e d weekly work time (mean=21.6%; average rank=31.7%) i n a d m i n i s t r a t i o n than d i d those whose p o s i t i o n was s t a f f (mean=9.0%; average r a n k = l 9 . 7 % ) . By d e f i n i t i o n , t h i s t y pe of appointment would be e x p e c t e d t o produce t h i s f i n d i n g and the f i n d i n g demonstrates the e x i s t e n c e of a degree of i n t e r n a l c o n s i s t e n c y i n the q u e s t i o n n a i r e . S l i g h t l y more than h a l f (33 or 54.1%) of the s u b j e c t s d e s c r i b e d type of appointment i n the c a t e g o r y o t h e r . T h i s f i n d i n g i s not c o n s i s t e n t w i t h s t a t e m e n t s t h a t type of appointment f o r c l i n i c a l nurse s p e c i a l i s t s can be c l a s s i f i e d by the c a t e g o r y l a b e l s c l i n i c a l , c l i n i c a l - e d u c a t i o n a l , and c l i n i c a l - a d m i n i s t r a t i v e ( A r a d i n e and Denyes, 1972; B a c k s h e i d e r , 1971). A l a r g e subgroup (21/33) d e s c r i b e d themselves as not r e s p o n s i b l e t o n u r s i n g , e i t h e r p r o f e s s i o n a l l y or o r g a n i z a t i o n a l l y , f o r the a c t i v i t i e s t h a t c o m p r i s e d t h e i r work (see T a b l e 9 ) . T h i s s u g g e s t s t h e r e i s a need f o r the n u r s i n g p r o f e s s i o n t o study t h i s group so t h a t any s p e c i a l needs r e l a t e d t o t h e i r r o l e f u n c t i o n i n g c o u l d be i d e n t i f i e d and, hence, s y s t e m a t i c a l l y a d d r e s s e d . I n d i v i d u a l e f f o r t s at implementing the r o l e of the c l i n i c a l n urse s p e c i a l i s t may be d i f f i c u l t t o a c c o m p l i s h w i t h o u t l e a d e r s h i p and support from the p r o f e s s i o n . In a d d i t i o n t o the l o s s of an o p p o r t u n i t y t o p r o v i d e peer s u p p o r t t o t h e s e n u r s e s , the c o n t r i b u t i o n s , s k i l l s and knowledge of t h e s e n u r s e s may be l o s t t o the n u r s i n g p r o f e s s i o n . 76 When the r e l a t i o n s h i p of the v a r i a b l e type c l i n i c a l , c l i n i c a l - e d u c a t i o n a l , c l i n i c a l - a d m i n i s t r a t i o n , and o t h e r and e s t i m a t e s of p e r c e n t a g e s of weekly work time devoted t o the v a r i o u s c a t e g o r i e s of work a c t i v i t y was s u b j e c t e d t o s t a t i s t i c a l a n a l y s e s , s i g n i f i c a n c e was shown by the K r u s k a l -W a l l i s t e s t (see Table 14). C l i n i c a l nurse s p e c i a l i s t s who i d e n t i f i e d type of appointment as e i t h e r c l i n i c a l -e d u c a t i o n a l or o t h e r spent a s i g n i f i c a n t l y (p <.04) g r e a t e r amount of e s t i m a t e d weekly work time (average rank=29.5% and 29.3% r e s p e c t i v e l y ) devoted t o i n t e r d i s c i p l i n a r y i n t e r a c t i o n than d i d those who i d e n t i f i e d type as c l i n i c a l (average rank=16.8%) or c l i n i c a l - a d m i n i s t r a t i v e (average r a n k = l 9 . 5 % ) . S u b j e c t s i n each of these t y p e s of a p p o i n t m e n t s , c l i n i c a l -e d u c a t i o n a l and o t h e r , would l i k e l y i n t e r a c t d a i l y w i t h p e r s o n n e l from a v a r i e t y of d i s c i p l i n e s . Thus, t h e s e r e s u l t s seem r e a s o n a b l e . P r o f e s s i o n a l V a r i a b l e The l i t e r a t u r e c l e a r l y i n d i c a t e s t h a t advanced knowledge and s k i l l s a re p a r t of the c l i n i c a l nurse s p e c i a l i s t r o l e ( R e i t e r , 1966; P e p l a u , 1965; Johnson, 1962) and t h a t the a p p r o p r i a t e l e v e l of p r e p a r a t i o n f o r the c l i n i c a l nurse s p e c i a l i s t i s the master's degree i n n u r s i n g (Smoyak, 1976; Georgopoulos and C h r i s t m a n , 1970; P e p l a u , 1965). Only f o u r of the s u b j e c t s h e l d a master's degree i n n u r s i n g , a l t h o u g h a t o t a l of n i n e h e l d master's degrees (see 77 T a b l e 11). T h i s may suggest t h a t , a t t h i s time i n B r i t i s h C o l umbia, an e x p e r i e n c e component f o r p r e p a r a t i o n f o r the r o l e may be more h e a v i l y w e i g h t e d than i s an e d u c a t i o n a l component when h i r i n g d e c i s i o n s are made. E x p l a n a t i o n s f o r t h i s a r e u n c l e a r a l t h o u g h s p e c u l a t i o n s u g g e s t s t h a t f a c t o r s l i k e the a v a i l a b i l i t y of m a ster's p r e p a r e d n u r s e s , the l o c a t i o n of h o s p i t a l s , the s u p p o r t i v e s t r u c t u r e s f o r ongoing n u r s i n g r e s e a r c h , and the s t a b i l i t y of such p o s i t i o n s i n n u r s i n g p r a c t i c e might have an i n f l u e n c e . The f i n d i n g s c o n c e r n i n g p o s t - b a s i c p r e p a r a t i o n i n n u r s i n g , t h a t the average number of y e a r s s i n c e c o m p l e t i o n of d i p l o m a / c e r t i f i c a t e programs was 10 w h i l e t h a t f o r c o m p l e t i o n of b a c c a u l a u r a t e and master's programs was 12 and 6 y e a r s r e s p e c t i v e l y , i n d i c a t e t h a t a p a t t e r n f o r e d u c a t i o n a l p r e p a r a t i o n t e n d s t o be w i t h d i p l o m a / c e r t i f i c a t e t y p e s of programs. However, such a p a t t e r n i s i m p o s s i b l e t o c l e a r l y e s t a b l i s h from the d a t a because p o s t - b a s i c p r e p a r a t i o n r e f e r s t o the t y p e s of programs s u b j e c t s pursued a f t e r c o m p l e t i o n of b a s i c n u r s i n g p r e p a r a t i o n . The l a t t e r c o u l d be e i t h e r diploma or b a c c a l a u r e a t e l e v e l s of p r e p a r a t i o n . T h e r e f o r e , i t i s d i f f i c u l t t o make a d e f i n i t e i n t e r p r e t a t i o n of these f i n d i n g s . A d e r i v e d e d u c a t i o n a l v a r i a b l e , the h i g h e s t l e v e l of p r e p a r a t i o n a c h i e v e d , was c a l c u l a t e d . I t was found t h a t 13 (20.9%) of the s u b j e c t s had d i p l o m a l e v e l p r e p a r a t i o n ( b a s i c p r e p a r a t i o n i n n u r s i n g ) , 24 (38.7%) had d i p l o m a / c e r t i f i c a t e 78 l e v e l of p r e p a r a t i o n ( p o s t - b a s i c n u r s i n g p r e p a r a t i o n ) , 16 (25.8%) had b a c c a l a u r e a t e p r e p a r a t i o n and 9 (1.4%) had master's l e v e l p r e p a r a t i o n . The l a t e s t r e p o r t e d n a t i o n a l s t a t i s t i c s i n d i c a t e the f o l l o w i n g p e r c e n t a g e s of n u r s e s a c h i e v i n g v a r i o u s e d u c a t i o n a l l e v e l s : 56.5% from d i p l o m a programs ( b a s i c n u r s i n g e d u c a t i o n ) , 33.3% from d i p l o m a / c e r t i f i c a t e programs ( p o s t - b a s i c n u r s i n g p r e p a r a t i o n ) , 9.1% from b a c c a l a u r e a t e programs, and 1.1% from master's programs (Statement 7, H e a l t h Manpower S t a t i s t i c s , 1976). These f i n d i n g s i n d i c a t e a p a t t e r n of c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n r a t h e r than g r a d u a t e e d u c a t i o n f o r t h i s group of n u r s e s i n B r i t i s h C o lumbia. However, t h i s may s i m p l y r e f l e c t a b a n d - a i d approach t o the i s s u e of l e v e l of p r e p a r a t i o n f o r the c l i n i c a l nurse s p e c i a l i s t r o l e i n Canadian n u r s i n g . The f i n d i n g t h a t 25% of the c l i n i c a l nurse s p e c i a l i s t s who r e c e i v e d the q u e s t i o n n a i r e were no l o n g e r w o r k i n g i n p o s i t i o n s they would i d e n t i f y by c h e c k i n g box 23 (on the RNABC form) s u g g e s t s t h e r e i s a degree of i n s t a b i l i t y r e l a t e d t o t h i s p o s i t i o n w i t h i n the h e a l t h c a r e system a t t h i s t i m e . I f t h i s i s so, t h e r e might seem t o be l i t t l e economic i n c e n t i v e f o r nurses t o pursue graduate e d u c a t i o n i n n u r s i n g i n c l i n i c a l s p e c i a l i z a t i o n a t the p r e s e n t t i m e . S i n c e most of the s u b j e c t s had not pursued g r a d u a t e l e v e l e d u c a t i o n , t h i s f i n d i n g c o u l d a l s o suggest the p r e s e n c e of l i m i t e d support w i t h i n the v a r i o u s work s e t t i n g s c o n c e r n i n g 79 the c l i n i c a l nurse s p e c i a l i s t r o l e . T h i s may be r e l a t e d t o the f i n d i n g t h a t a l a r g e subgroup of the s u b j e c t s (21 out of 33) a re not r e s p o n s i b l e t o n u r s i n g (see T a b l e 9 ) . With a l a c k of su p p o r t and l e a d e r s h i p from n u r s i n g , i t i s r e a s o n a b l e t o t h i n k t h a t i n s t a b i l i t y of p o s i t i o n s might f o l l o w . On the o t h e r hand, w i t h such a l a c k of support and l e a d e r s h i p i t seems r e a s o n a b l e t o t h i n k the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n n u r s i n g i n B.C. remains t o be e s t a b l i s h e d and s u p p o r t e d i n n u r s i n g p r a c t i c e . I t s h o u l d a l s o be noted t h a t the p r e s e n t economic s i t u a t i o n has r e s u l t e d i n major c u t b a c k s i n h o s p i t a l s t a f f i n g and the c l i n i c a l s p e c i a l i s t r o l e may have been a c a s u a l t y i n some p l a c e s . When the r e l a t i o n s h i p of the h i g h e s t l e v e l of e d u c a t i o n a t t a i n e d ( t h e d e r i v e d e d u c a t i o n a l v a r i a b l e ) and e s t i m a t e s of p e r c e n t a g e s of weekly work time d e v o t e d t o the c a t e g o r i e s of work a c t i v i t y was examined, s i g n i f i c a n t d i f f e r e n c e s were demonstrated by the a n a l y s i s of v a r i a n c e t e s t and r e s u l t s a p p r o a c h i n g s i g n i f i c a n c e by the K r u s k a l - W a l l i s t e s t (see Ta b l e 14). The number of s u b j e c t s i n each subgroup found t o be s t a t i s t i c a l l y d i f f e r e n t by the ANOVA was s m a l l (6 and 7 ) . A l a r g e r subgroup s i z e may have r e s u l t e d i n the f i n d i n g of a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e by the K r u s k a l - W a l l i s t e s t as w e l l . T h e r e f o r e , t h e s e r e s u l t s a re i n t e r p r e t e d as o n l y an i n d i c a t i o n of a p o s s i b l e d i f f e r e n c e between the subgroups. C l i n i c a l nurse s p e c i a l i s t s w i t h master's 80 p r e p a r a t i o n spent a s i g n i f i c a n t l y (p <.02) l a r g e r amount of e s t i m a t e d weekly work time (mean=17.9%) devoted t o i n t e r d i s c i p l i n a r y i n t e r a c t i o n than d i d those w i t h b a c c a l a u r e a t e (mean=8.3%) or d i p l o m a p r e p a r a t i o n (mean=8.1%). C l i n i c a l nurse s p e c i a l i s t s w i t h b a c c a l a u r e a t e p r e p a r a t i o n spent a s i g n i f i c a n t l y (p <.001) g r e a t e r amount of e s t i m a t e d weekly work time (mean=24.3%) devo t e d t o s t a f f development than d i d those w i t h master's p r e p a r a t i o n (mean=4.8%) or those w i t h d i p l o m a p r e p a r a t i o n (mean=5.4%). B a c c a l a u r e a t e programs g e n e r a l l y i n c l u d e c o n t e n t r e l a t e d t o p r i n c i p l e s of l e a r n i n g and t e a c h i n g . Given t h a t the s t a f f development c a t e g o r y r e p r e s e n t s a v a r i a t i o n of s i t u a t i o n s f o r a p p l i c a t i o n of such p r i n c i p l e s t h i s f i n d i n g would seem r e a s o n a b l e . S i m i l a r i t i e s and D i f f e r e n c e s Between the Nurses'  D e s c r i p t i o n s and a D e s c r i p t i o n R e p o r t e d by A r a d i n e and  Denyes (1972) When a comparison was made between the r o l e of the c l i n i c a l nurse s p e c i a l i s t as d e s c r i b e d by p a r t i c i p a n t s i n t h i s study and t h a t a r t i c u l a t e d i n the l i t e r a t u r e by A r a d i n e and Denyes (1972), a number of s i m i l a r i t i e s and d i f f e r e n c e s were i d e n t i f i e d . In g e n e r a l , the study groups were s i m i l a r i n t h a t t hey were s e l f - i d e n t i f i e d , s i m i l a r i n terms of age and sex, and s i m i l a r i n the p a t t e r n s of e s t i m a t e d work time devoted t o some c a t e g o r i e s of work a c t i v i t y . The age range 81 of the s u b j e c t s i n the A r a d i n e and Denyes study was 21 t o 51 y e a r s and 25 t o 50 or more y e a r s i n the p r e s e n t s t u d y . A l l the s u b j e c t s i n the A r a d i n e and Denyes study were female and most (60/62) of the s u b j e c t s i n the p r e s e n t study were female. S p e c i f i c d i s c u s s i o n of s i m i l a r i t i e s w i t h the p a t t e r n of e s t i m a t e s of work time devoted t o some c a t e g o r i e s of work a c t i v i t y w i l l f o l l o w a b r i e f d i s c u s s i o n of d i f f e r e n c e s t h a t were obser v e d between f i n d i n g s r e p o r t e d by the A r a d i n e and Denyes and the f i n d i n g s of t h i s s t u d y . A l t h o u g h the study groups were s i m i l a r i n t h a t they were s e l f - i d e n t i f i e d t h e r e were a l s o a number of d i f f e r e n c e s n oted. Nurses who were employed as c l i n i c a l nurse s p e c i a l i s t s i n a group of e i g h t l a r g e t e a c h i n g h o s p i t a l s i n the Midwest of the U n i t e d S t a t e s were i d e n t i f i e d by A r a d i n e and Denyes as t h e i r p o p u l a t i o n of i n t e r e s t . One of the c r i t e r i a , i t seems, f o r employment i n t h i s p o s i t i o n by th e s e a g e n c i e s was the p o s s e s s i o n of a master's degree i n n u r s i n g . Thus, c l i n i c a l nurse s p e c i a l i s t i n the A r a d i n e and Denyes study was o p e r a t i o n a l l y d e f i n e d i n terms of the t i t l e of the work p o s i t i o n as w e l l as p l a c e of employment and l e v e l of e d u c a t i o n a l p r e p a r a t i o n . The p r e s e n t study d e f i n e d the p o p u l a t i o n of i n t e r e s t as b e i n g n u r s e s who i d e n t i f i e d t h e i r work p o s i t i o n as t h a t of c l i n i c a l nurse s p e c i a l i s t t o t h e i r p r o f e s s i o n a l a s s o c i a t i o n . Thus, c l i n i c a l nurse s p e c i a l i s t i n the p r e s e n t s t u d y was o p e r a t i o n a l l y d e f i n e d i n terms of work p o s i t i o n t i t l e a l o n e . 82 In a d d i t i o n , o t h e r o b s e r v e d d i f f e r e n c e s were r e l a t e d t o the c o n t e x t u a l l y - r e l a t e d v a r i a b l e type of appointment, the p r o f e s s i o n a l v a r i a b l e h i g h e s t a c h i e v e d e d u c a t i o n a l l e v e l , the p r e s e n t p o s t i o n , and the p a t t e r n of e s t i m a t e s of work time d e v o t e d t o some c a t e g o r i e s of work a c t i v i t y . T a b l e 15 p r e s e n t s a summary of a comparison of f i n d i n g s about the c o n t e x t u a l l y - r e l a t e d v a r i a b l e type of appointment f o r the s u b j e c t s i n each s t u d y . S u b j e c t s i n the A r a d i n e and Denyes Ta b l e 15 Comparison of F i n d i n g s f o r the C o n t e x t u a l l y - R e l a t e d V a r i a b l e Type of Appointment as D e s c r i b e d by A r a d i n e and Denyes and the P r e s e n t Study Type of Appointment F i n d i n g s R eported by A r a d i n e and Deynes (1972) F i n d i n g s of the P r e s e n t Study Number Per c e n t a g e Number Per c e n t a g e of of of of S u b j e c t s S u b j e c t s S u b j e c t s S u b j e c t s U n i t - b a s e d Not u n i t - b a s e d 23 5 82 18 30 31 49.2 50.8 L i n e p o s i t i o n 17 S t a f f p o s i t i o n 11 61 39 1 0 52 10.3 89.7 C l i n i c a l 16 C l i n i c a l - 6 e d u c a t i o n a l C l i n i c a l - 3 a d m i n i s t r a t i v e Other 3 57 21 1 1 1 1 17 4 7 33 27.9 6.6 11.5 54. 1 study i n d i c a t e d t h e i r p r e s e n t p o s i t i o n s were u n i t - b a s e d (23 or 82% of the s u b j e c t s ) , l i n e p o s i t i o n s (17 or 6 1 % ) , and c h a r a c t e r i z e d by the l a b e l c l i n i c a l (16 or 5 7 % ) . In 83 c o n t r a s t , s u b j e c t s i n the p r e s e n t study i n d i c a t e d t h e i r p r e s e n t p o s i t i o n s were e q u a l l y d i v i d e d between u n i t - b a s e d (30 or 48.2%) and not u n i t - b a s e d (31 or 50.8 % ) , p r e d o m i n a n t l y s t a f f p o s i t i o n s (52 or 89.7%), and c h a r a c t e r i z e d by the l a b e l o t h e r (33 or 54.1%) A l a r g e subgroup (21/33) of these l a t t e r s u b j e c t s was not r e s p o n s i b l e p r o f e s s i o n a l l y or o r g a n i z a t i o n a l l y t o n u r s i n g s e r v i c e (see T a b l e 9 ) . S t a t i s t i c a l a n a l y s i s of the r e l a t i o n s h i p between type of appointment, s p e c i f i c a l l y l i n e v e r s u s s t a f f and c l i n i c a l v e r s u s c l i n i c a l - e d u c a t i o n a l v e r s u s c l i n i c a l - a d m i n i s t r a t i v e v e r s u s o t h e r , and e s t i m a t e s of weekly work time devoted t o c a t e g o r i e s of work a c t i v i t y f o r the s u b j e c t s i n the p r e s e n t s t u d y suggest t h e s e v a r i a b l e s d i d i n f l u e n c e r o l e enactment of the c l i n i c a l nurse s p e c i a l i s t (see T a b l e 14). These s p e c i f i c r e l a t i o n s h i p s were not examined by A r a d i n e and Denyes i n t h e i r s tudy as a l l the s u b j e c t s worked i n the same type of s e t t i n g . Thus, the f i n d i n g s r e p o r t e d by A r a d i n e and Denyes may be a statement about the i n t e r a c t i o n of the complex r o l e of the c l i n i c a l nurse s p e c i a l i s t and the p a r t i c u l a r work s e t t i n g of a l a r g e u n i v e r s i t y t e a c h i n g h o s p i t a l r a t h e r than a d e f i n i t i v e statement of a wider view of the r o l e . The most s t r i k i n g d i f f e r e n c e c o n c e r n i n g the p r o f e s s i o n a l v a r i a b l e h i g h e s t l e v e l of e d u c a t i o n was t h a t a l l s u b j e c t s i n the A r a d i n e and Denyes st u d y had master's p r e p a r a t i o n i n n u r s i n g and a l l had r e c e i v e d t h e i r 84 p r e p a r a t i o n i n the e a r l y 1970's. In c o n t r a s t , i n the p r e s e n t study 4 s u b j e c t s had master's p r e p a r a t i o n i n n u r s i n g and 3 of these had r e c e i v e d t h a t p r e p a r a t i o n i n the l a t e 1970's. More s p e c i f i c e x a m i n a t i o n of the p r o f e s s i o n a l v a r i a b l e l e v e l of e d u c a t i o n r e v e a l e d t h a t 10 (36%) of the s u b j e c t s i n the A r a d i n e and Denyes study r e c e i v e d t h e i r b a s i c n u r s i n g e d u c a t i o n i n a b a c c a u l e a u r a t e program compared t o the 14 (22.6%) of the s u b j e c t s i n the p r e s e n t study who r e c e i v e d t h e i r b a s i c t r a i n i n g i n such a program. E i g h t e e n (64%) of the s u b j e c t s i n the A r a d i n e and Denyes study and 48 (77.4%) of the s u b j e c t s i n the p r e s e n t study r e c e i v e d t h e i r b a s i c n u r s i n g e d u c a t i o n i n d i p l o m a programs. Thus, the p a t t e r n of p u r s u i n g graduate e d u c a t i o n i n n u r s i n g i s s t r i k i n g l y d i f f e r e n t between the two groups of s u b j e c t s . D i f f e r e n c e s r e l a t e d t o the p r e s e n t p o s i t i o n were concerned w i t h the l e n g t h of time i n the p o s i t i o n and the s e t t i n g i n which the p o s i t i o n was e n a c t e d . For s u b j e c t s i n the A r a d i n e and Denyes s t u d y , e x p e r i e n c e w i t h the c u r r e n t p o s i t i o n ranged from one t o 6 y e a r s w i t h h a l f the s u b j e c t s h a v i n g had 2 y e a r s e x p e r i e n c e . F u r t h e r m o r e , both e x p e r i e n c e i n the p r e s e n t p o s i t i o n and r e c a l l of e x p e r i e n c e from w o r k i n g i n s i m i l a r p o s i t i o n s were used as the s o u r c e of d a t a i n t h e i r s t u d y . In c o n t r a s t , i n t h i s s t u d y , the y e a r s of s u b j e c t s ' e x p e r i e n c e i n the c u r r e n t p o s i t i o n ranged between l e s s than one year and 15 y e a r s , w i t h 4 the mean number of y e a r s of e x p e r i e n c e . In a d d i t i o n , o n l y d e s c r i p t i o n of 85 e x p e r i e n c e i n the p r e s e n t p o s i t i o n was used as a source of d a t a i n the p r e s e n t s t u d y . A l l s u b j e c t s i n the A r a d i n e and Denyes study were employed i n a l a r g e u n i v e r s i t y t e a c h i n g h o s p i t a l s e t t i n g . In c o n t r a s t , 41 (65%) of the s u b j e c t s i n the p r e s e n t study worked i n a h o s p i t a l s e t t i n g , the s i z e and type u n s p e c i f i e d . I t i s r e a s o n a b l e t o assume t h a t some of t h e s e 41 s u b j e c t s were employed i n a u n i v e r s i t y t e a c h i n g h o s p i t a l s e t t i n g i n B r i t i s h Columbia. However, i t i s not n e c e s s a r i l y the case t h a t such a s e t t i n g i s comparable t o the work s e t t i n g s of the s u b j e c t s i n the A r a d i n e and Denyes s t u d y . E v i d e n c e of the l a t t e r can be found i n the c l a s s i f i c a t i o n of the m e t r o p o l i t a n and n o n - m e t r o p o l i t a n r e g i o n a l h o s p i t a l d i s t r i c t s p r o v i d e d by the B r i t i s h Columbia M i n i s t r y of H e a l t h . The m e t r o p o l i t a n c a t e g o r y i n c l u d e s a wide range of communities from Vancouver t o s e v e r a l of the G u l f I s l a n d s . In 1975, the r a t i o of n o n - m e t r o p o l i t a n t o m e t r o p o l i t a n c l i n i c a l nurse s p e c i a l i s t s was .30 (13:44) ( R o l l c a l l 75, T a b l e 3b.1). In 1980 t h i s r a t i o had r i s e n t o .36 (34:94) ( R o l l c a l l Update 80, T a b l e 8 ) , and i n 1982 t h i s r a t i o was .48 (48:100) ( R o l l c a l l Update 82, T a b l e 8 ) . T h i s i n d i c a t e s t h a t the r a t e of the p r o p o r t i o n of c l i n i c a l nurse s p e c i a l i s t p o s i t i o n s i n n o n - m e t r o p o l i t a n r e g i o n a l h o s p i t a l d i s t r i c t s has been i n c r e a s i n g . Thus, i t seems un r e a s o n a b l e t o assume t h a t most of the s u b j e c t s i n t h i s s tudy worked i n the u n i v e r s i t y t e a c h i n g h o s p i t a l s i n the m e t r o p o l i t a n a r e a s of 86 B r i t i s h C o lumbia. D i f f e r e n c e s and s i m i l a r i t i e s between the A r a d i n e and Denyes study and the p r e s e n t study r e l a t e d t o the p a t t e r n of e s t i m a t e s of work time d e v o t e d t o c a t e g o r i e s of work a c t i v i t y w i l l now be d i s c u s s e d . T a b l e 16 p r e s e n t s a summary of the work a c t i v i t y p a t t e r n s found i n the two s t u d i e s . L e v e l I d e s i g n a t e s e s t i m a t e s of "a g r e a t d e a l of t i m e " i n d i c a t e d by s u b j e c t s i n the A r a d i n e and Denyes st u d y and e s t i m a t e s g r e a t e r than 20% i n d i c a t e d by s u b j e c t s i n the p r e s e n t s t u d y . L e v e l I I d e s i g n a t e s e s t i m a t e s of "moderate amount of t i m e " and between 11 and 19 p e r c e n t i n d i c a t e d by s u b j e c t s i n each of the r e s p e c t i v e s t u d i e s . L e v e l I I I d e s i g n a t e s e s t i m a t e s of " s m a l l amount of t i m e " i n the A r a d i n e and Denyes st u d y and 10 p e r c e n t or l e s s of the e s t i m a t e d work time i n t h i s s t u d y . E x a m i n a t i o n of T a b l e 16 i n d i c a t e s t h a t the c a t e g o r i e s of p a t i e n t c a r e , c o n s u l t a t i o n , community a c t i v i t i e s , r e s e a r c h and w r i t i n g f o r p u b l i c a t i o n a r e d e s c r i b e d i n a s i m i l a r manner by the s u b j e c t s i n each of the s t u d i e s . Each group of c l i n i c a l nurse s p e c i a l i s t s i n d i c a t e d they devoted a l a r g e r amount of e s t i m a t e d work time t o p a t i e n t c a r e than they d i d t o c o n s u l t a t i o n and community a c t i v i t i e s ; and they spent a l a r g e r amount of e s t i m a t e d work time on the l a t t e r c a t e g o r i e s than on r e s e a r c h and w r i t i n g f o r p u b l i c a t i o n . T a b l e 16 a l s o i n d i c a t e s t h a t the s u b j e c t s i n t h i s s tudy d e s c r i b e d t h e i r work a c t i v i t i e s i n a d i f f e r e n t manner than T a b l e 16 Comparison of Work A c t i v i t y of the C l i n i c a l Nurse S p e c i a l i s t as D e s c r i b e d by A r a d i n e and Deynes (1972) and the F i n d i n g s of the P r e s e n t Study L e v e l A r a d i n e and Deynes Study P r e s e n t Study I - p a t i e n t c a r e - s t a f f development - i n t e r d i s c i p l i n a r y i n t e r a c t i o n - p l a n n i n g - p o l i c y -standards-change - p a t i e n t c a r e I I - p e r s o n a l and p r o f e s s i o n a l growth - c o n s u l t a t i o n -community a c t i v i t i e s - e d u c a t i o n of s t u d e n t s -admini s t r a t i o n - c o n s u l t a t i o n -community a c t i v i t i e s I I I - a d m i n i s t r a t i o n - r e s e a r c h - w r i t i n g f o r p u b l i c a t i o n - i n t e r d i s c i p l i n a r y i n t e r a c t i o n - r e s e a r c h - w r i t i n g f o r p u b l i c a t i o n - s t a f f development - p e r s o n a l and p r o f e s s i o n a l growth - e d u c a t i o n of s t u d e n t s - p l a n n i n g - p o l i c y -standards-change d i d the s u b j e c t s i n the A r a d i n e and Denyes (1972) s t u d y . The d i f f e r e n c e i s i n terms of the e s t i m a t e s of amounts of time d e v o t e d t o many of the c a t e g o r i e s of work a c t i v i t y (note e s p e c i a l l y L e v e l s I and I I I ) . The work a c t i v i t y as o u t l i n e d by the s u b j e c t s i n the A r a d i n e and Denyes (1972) study c o n s i s t e d of a g r e a t d e a l of time devoted t o p a t i e n t c a r e , s t a f f development, i n t e r d i s c i p l i n a r y i n t e r a c t i o n , and p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e . In c o n t r a s t , t h i s s tudy found t h a t c l i n i c a l n u r se s p e c i a l i s t s i n B r i t i s h Columbia 88 spent the l a r g e s t amount of e s t i m a t e d work time devoted t o p a t i e n t c a r e . C l i n i c a l nurse s p e c i a l i s t s , a c c o r d i n g t o A r a d i n e and Denyes, spent a moderate amount of work time i n the c a t e g o r i e s p e r s o n a l and p r o f e s s i o n a l growth, c o n s u l t a t i o n , community a c t i v i t i e s , and e d u c a t i o n of s t u d e n t s . T h i s study found t h a t c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia spent a s i m i l a r l e v e l of work time d e v o t e d t o a d m i n i s t r a t i o n , c o n s u l t a t i o n , and community a c t i v i t i e s . L a s t l y , i n the A r a d i n e and Denyes study c l i n i c a l nurse s p e c i a l i s t s devoted the l e a s t time t o a d m i n i s t r a t i o n , r e s e a r c h , and w r i t i n g f o r p u b l i c a t i o n . In c o n t r a s t , t h i s study found t h a t c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia devoted the l e a s t amount of e s t i m a t e d weekly work time t o i n t e r d i s c i p l i n a r y i n t e r a c t i o n , r e s e a r c h , w r i t i n g f o r p u b l i c a t i o n , s t a f f development, p e r s o n a l and p r o f e s s i o n a l growth, e d u c a t i o n of s t u d e n t s , and p l a n n i n g -p o l i c y - s t a n d a r d s - c h a n g e . These f i n d i n g s c l e a r l y suggest the r o l e model d e s c r i b e d i n the l i t e r a t u r e by A r a d i n e and Denyes (1972) does not f i t the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n B r i t i s h C olumbia. These d i f f e r e n c e s may be accounted f o r by a number of f a c t o r s : type of work s e t t i n g , p r e p a r a t i o n f o r the r o l e , and the p l a c e of the r o l e w i t h i n the h e a l t h c a r e system. For example, a l l s u b j e c t s i n the A r a d i n e and Denyes study worked i n a l a r g e u n i v e r s i t y t e a c h i n g h o s p i t a l s e t t i n g . In a d d i t i o n , a l l of the s u b j e c t s h e l d the master's degree i n 89 n u r s i n g . I t seems r e a s o n a b l e t o expect t h a t the c o n t e x t u a l l y - r e l a t e d v a r i a b l e of work s e t t i n g and the e d u c a t i o n v a r i a b l e may i n f l u e n c e s p e c i f i c r o l e enactment of the c l i n i c a l nurse s p e c i a l i s t . In a l a r g e u n i v e r s i t y t e a c h i n g h o s p i t a l , i n t e r a c t i o n w i t h a v a r i e t y of h e a l t h c a r e p r o f e s s i o n a l s and on-going s t a f f development would seem t o be two examples of work more l i k e l y t o be e x p e c t e d of the c l i n i c a l nurse s p e c i a l i s t . Some a d d i t i o n a l support f o r the b e l i e f t h a t type of s e t t i n g may i n f l u e n c e r o l e enactment i s p r o v i d e d by t h i s s t u d y . S t a t i s t i c a l a n a l y s i s of the r e l a t i o n s h i p s between type of s e t t i n g and the e s t i m a t e s of weekly work time devoted t o work a c t i v i t y i n d i c a t e d the p o s s i b i l i t y t h a t d i f f e r e n c e s i n s e t t i n g i n f l u e n c e d the work time (see T a b l e 14 and i t s accompanying d i s c u s s i o n ) . More s p e c i f i c a l l y , i n t h e i r d i s c u s s i o n A r a d i n e and Denyes suggested t h a t the amount of time devoted t o f o u r c a t e g o r i e s of work a c t i v i t y , p e r s o n a l and p r o f e s s i o n a l growth, community a c t i v i t i e s , e d u c a t i o n of s t u d e n t s , and c o n s u l t a t i o n changed over time f o r c l i n i c a l nurse s p e c i a l i s t s . T h i s study found e v i d e n c e t o suggest t h a t s h i f t s i n the e s t i m a t e d amounts of time devoted t o community a c t i v i t i e s and c o n s u l t a t i o n o c c u r r e d f o r the sample. C l i n i c a l nurse s p e c i a l i s t s i n the A r a d i n e and Denyes s t u d y i n d i c a t e d they spent l e s s time i n the c a t e g o r y p e r s o n a l and p r o f e s s i o n a l growth, and more time i n the o t h e r c a t e g o r i e s , w i t h t h e s e s h i f t s a t t a i n i n g s t a b i l i t y w i t h i n t h r e e y e a r s . 90 By c o n t r a s t , i n t h i s study c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h Columbia i n d i c a t e d more time spent i n the c a t e g o r i e s c o n s u l t a t i o n and community a c t i v i t i e s w i t h an i n c r e a s e of time i n the p o s i t i o n . I t must be p o i n t e d out t h a t the s h i f t s r e p o r t e d by the s u b j e c t s i n the A r a d i n e and Denyes study were c a t e g o r i e s of work a c t i v i t y f o r the same group of s u b j e c t s over t i m e . In c o n t r a s t , s u b j e c t s i n the p r e s e n t study were asked t o i n d i c a t e the l e n g t h of time i n the p r e s e n t c l i n i c a l nurse s p e c i a l i s t p o s i t i o n as w e l l as e s t i m a t e s of work time devoted t o the v a r i o u s c a t e g o r i e s of work a c t i v i t y . Thus, d i f f e r e n t groups of c l i n i c a l nurse s p e c i a l i s t s , c l a s s i f i e d by l e n g t h of time i n the p r e s e n t p o s i t i o n , were used i n the p r e s e n t s t u d y t o examine e v i d e n c e f o r a de v e l o p m e n t a l sequence a s s o c i a t e d w i t h r o l e i m p l e m e n t a t i o n t h a t was suggested by A r a d i n e and Denyes. When the e f f e c t of time i n the r o l e on e s t i m a t e d p e r c e n t a g e s of time devoted t o each c a t e g o r y of work a c t i v i t y was s u b j e c t e d t o s t a t i s t i c a l a n a l y s e s , no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s were r e p o r t e d f o r the s u b j e c t s i n the p r e s e n t s t u d y (see Ta b l e C . 2 ) . T h i s f i n d i n g does not su p p o r t the s u g g e s t i o n made by A r a d i n e and Denyes of the e x i s t e n c e of a d e v e l o p m e n t a l sequence f o r c l i n i c a l nurse s p e c i a l i s t s as they implement the r o l e . I t may be t h a t t h i s s u g g e s t i o n i s a p p l i c a b l e on an i n d i v i d u a l l e v e l , but i s not a s i g n i f i c a n t f a c t o r on the l a r g e r l e v e l of how 91 c l i n i c a l nurse s p e c i a l i s t s spend t h e i r work time as a f u n c t i o n of time spent i n the p o s i t i o n . Or i t may be t h a t the d e v e l o p m e n t a l sequence suggested by A r a d i n e and Denyes i s o n l y a p p l i c a b l e t o c l i n i c a l nurse s p e c i a l i s t s who work i n a l a r g e u n i v e r s i t y t e a c h i n g h o s p i t a l s e t t i n g . S u g g e s t i o n s f o r the F u t u r e C o n c e r n i n g the C l i n i c a l Nurse  S p e c i a l i s t Role i n Canada To the e x t e n t t h a t t h e s e f i n d i n g s from n u r s e s i n B r i t i s h Columbia are r e p r e s e n t a t i v e of n u r s i n g p r a c t i c e i n Canada the f o l l o w i n g s u g g e s t i o n s c o n c e r n i n g the r o l e i n Canadian n u r s i n g can be i d e n t i f i e d . V a r i a t i o n s r e f l e c t e d i n the f i n d i n g s of t h i s study i n d i c a t e t h a t the c l i n i c a l nurse s p e c i a l i s t r o l e remains t o be p r e c i s e l y d e s c r i b e d by the n u r s i n g p r o f e s s i o n i n Canada. The f i n d i n g s t h a t a l a r g e subgroup (21 out of 33 s u b j e c t s ) were not r e s p o n s i b l e o r g a n i z a t i o n a l l y t o n u r s i n g , o n l y 4 of the s u b j e c t s had gradu a t e l e v e l p r e p a r a t i o n i n n u r s i n g , and t h a t a range of jo b t i t l e s was used i n the work s e t t i n g s u p p o r t t h i s v i e w . However, the s e f i n d i n g s do p r o v i d e some s u g g e s t i o n s f o r the f u t u r e of the r o l e i n Canadian n u r s i n g . I t seems unr e a s o n a b l e t h a t a nurse i n a s p e c i a l i z e d c l i n i c a l r o l e i n an agency s h o u l d be r e s p o n s i b l e and a c c o u n t a b l e t o an e n t i t y o t h e r than n u r s i n g . Among o t h e r t h i n g s , the n u r s i n g p r o f e s s i o n i s m i s s i n g an o p p o r t u n i t y t o p r o v i d e peer support t o i n d i v i d u a l nurses who a r e engaged i n 92 the p r o c e s s of implementing a s p e c i a l i z e d r o l e i n n u r s i n g p r a c t i c e . In a d d i t i o n , the p r o f e s s i o n i s m i s s i n g an o p p o r t u n i t y t o a r t i c u l a t e t o nurses as w e l l as t o members of o t h e r h e a l t h c a r e d i s c i p l i n e s and the p u b l i c a d e s c r i p t i o n of t h i s r o l e as i t emerges and d e v e l o p s i n n u r s i n g . T h e r e f o r e , i t i s suggested t h a t n u r s i n g s e r v i c e s h o u l d work toward g e t t i n g the c l i n i c a l nurse s p e c i a l i s t p o s i t i o n e s t a b l i s h e d w i t h i n the o r g a n i z a t i o n a l framework of n u r s i n g . I t i s i m p e r a t i v e t h a t guidance be p r o v i d e d t o a l l l e v e l s of n u r s e s i n an agency, c l i n i c a l nurse s p e c i a l i s t s , and o t h e r s w i t h i n the h e a l t h c a r e system about how t h i s s p e c i a l i z e d n u r s i n g r o l e can be u t i l i z e d t o a f f e c t the q u a l i t y of p a t i e n t c a r e . I t i s i m p o r t a n t t h a t e x p l i c i t r e l a t i o n s h i p s between the r o l e of the c l i n i c a l nurse s p e c i a l i s t and o t h e r n u r s i n g r o l e s and i s s u e s t h a t a r e of concern t o t h e p r o f e s s i o n (such as q u a l i t y of c a r e , s t a n d a r d s and c e r t i f i c a t i o n ) be a r t i c u l a t e d by the n u r s i n g p r o f e s s i o n . Nurses engaged i n n u r s i n g p r a c t i c e must speak i n a s t r o n g c l e a r v o i c e about the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada. Such a s t r o n g v o i c e , i t i s s u g g e s t e d , needs t o f o c u s on the i s s u e of l e v e l of p r e p a r a t i o n r e q u i r e d by the nurse f o r t h i s r o l e . C l e a r l y , the l i t e r a t u r e i n d i c a t e s t h a t g r a d u a t e l e v e l e d u c a t i o n i n n u r s i n g i s r e q u i r e d t o p r e p a r e a nurse f o r t h i s r o l e . The f i n d i n g t h a t 25% of the r e s p o n d e n t s who r e t u r n e d the q u e s t i o n n a i r e were no l o n g e r w o r k i n g i n a p o s i t i o n they 93 would i d e n t i f y as t h a t of a c l i n i c a l nurse s p e c i a l i s t p o i n t s t o y e t another s u g g e s t i o n f o r the f u t u r e of the r o l e i n Canada. I t may be i m p o r t a n t f o r the p r o f e s s i o n t o examine the f o r c e s which c o n t r i b u t e t o the apparent i n s t a b i l i t y of the r o l e i n n u r s i n g p r a c t i c e . T h i s i n f o r m a t i o n may prove v a l u a b l e i n d e f i n i n g the r o l e . Once a c l e a r and d e f i n i t i v e p o s i t i o n has been taken by the n u r s i n g p r o f e s s i o n c o n c e r n i n g p r e p a r a t i o n f o r the c l i n i c a l nurse s p e c i a l i s t r o l e , i t i s suggested t h a t a movement toward a s s u r i n g the p u b l i c about the l e v e l of p r e p a r a t i o n , s t a b i l i t y , and the range of a c t i v i t i e s t h a t can be e x p e c t e d of t h i s s p e c i a l i z e d c l i n i c a l r o l e s h o u l d b e g i n . F i n a l l y , i t i s suggested t h a t a c l e a r v o i c e from the n u r s i n g p r o f e s s i o n i n su p p o r t of c o n s i s t e n c y i n the use of l a b e l s and j o b t i t l e s t o d e s c r i b e n u r s i n g r o l e s i s needed. I t would seem t o o n l y add t o the s t a t e of c o n f u s i o n i n the minds of i n d i v i d u a l n u r s e s and the c o l l e c t i v e t h i n k i n g of the p r o f e s s i o n , as w e l l as t o a s i m i l a r c o n f u s i o n t h a t seems t o e x i s t i n the t h i n k i n g of employers and consumers, when d i f f e r e n t j o b t i t l e s a r e used t o r e f e r t o the same phenomenon. As a r e s u l t of such a s t a t e of c o n f u s i o n i t might be d i f f i c u l t , i f not i m p o s s i b l e , f o r the p r o f e s s i o n t o make a statement about any one r o l e , l e t a l o n e a whole system of n u r s i n g r o l e s , t h e i r r e l a t i o n s h i p t o each o t h e r , and t h e i r r e l a t i o n s h i p t o the h e a l t h c a r e system. S p e c i a l i z a t i o n i n h e a l t h c a r e i s w i t h us f o r a v a r i e t y 94 of r e a s o n s . With a c l e a r d e f i n i t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e and on-going r e s e a r c h t o i n v e s t i g a t e a c t u a l r o l e i m p l e m e n t a t i o n and development i t s h o u l d be p o s s i b l e f o r the n u r s i n g p r o f e s s i o n i n Canada t o i n t e g r a t e the "what i s " w i t h "what s h o u l d be" where the r o l e of the c l i n i c a l nurse s p e c i a l i s t i s c o n c e r n e d . The next c h a p t e r p r e s e n t s a summary of the f i n d i n g s of t h i s s t u d y . T h i s forms the b a s i s from which the major c o n c l u s i o n s , i m p l i c a t i o n s , and s u g g e s t i o n s f o r f u r t h e r r e s e a r c h a r e drawn. CHAPTER 6 SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY Summary A t t e n t i o n has been drawn t o the f a c t t h a t , a l t h o u g h t h e r e a r e nur s e s who i n Canada i d e n t i f y themselves as c l i n i c a l nurse s p e c i a l i s t s , the n u r s i n g p r o f e s s i o n i n Canada has o n l y a borrowed and s k e t c h y t h e o r e t i c a l base t o draw upon f o r an u n d e r s t a n d i n g of the r o l e and p r e p a r a t i o n of nurs e s f o r the r o l e . The l a c k of s t u d i e s w i t h i n Canadian n u r s i n g c o n c e r n i n g the r o l e was a s t i m u l u s f o r t h i s s t u d y . R o l e t h e o r y and r e p o r t e d r e s e a r c h f i n d i n g s about what c l i n i c a l nurse s p e c i a l i s t s do ( A r a d i n e and Denyes, 1972) were s e l e c t e d as the framework f o r the study of c l i n i c a l nurse s p e c i a l i s t s i n B r i t i s h C o lumbia. These o f f e r e d an i n t e r a c t i o n a l p e r s p e c t i v e t o the stu d y of the r o l e and the c o n t e x t i n which i t i s enacted as w e l l as an o p p o r t u n i t y t o b u i l d on a v a i l a b l e n u r s i n g knowledge. T h i s study was d e s i g n e d t o 1. g a t h e r i n f o r m a t i o n about c l i n i c a l nurse s p e c i a l i s t s and what they do i n t h e i r work i n the p r o v i n c e of B r i t i s h C olumbia; 2. i d e n t i f y s i m i l a r i t i e s and d i f f e r e n c e s between the nurses* d e s c r i p t i o n s and a d e s c r i p t i o n r e p o r t e d by A r a d i n e and Denyes (1972); 95 96 3. make s u g g e s t i o n s f o r the f u t u r e i n r e l a t i o n t o the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canada based on the above f i n d i n g s . The s u b j e c t s were s e l f - i d e n t i f i e d , i n t h a t o n l y those n u r s e s who d e s c r i b e d t h e i r work p o s i t i o n as c l i n i c a l nurse s p e c i a l i s t on the a n n u a l RNABC r e g i s t r a t i o n form were c o n t a c t e d . A q u e s t i o n n a i r e was c o n s t r u c t e d t h a t i n c l u d e d t h r e e c a t e g o r i e s : the c a t e g o r i e s of work a c t i v i t i e s d e s c r i b e d by A r a d i n e and Denyes ( 1 9 7 2 ) 1 ; c o n t e x t u a l l y r e l a t e d v a r i a b l e s : s p e c i f i c j o b t i t l e , l e n g t h of time i n the p r e s e n t p o s i t i o n , new or e x i s t i n g p o s i t i o n and presence or absence of a j o b d e s c r i p t i o n when the p r e s e n t p o s i t i o n was a c c e p t e d , type of work s e t t i n g , and type of appointment; and p r o f e s s i o n a l v a r i a b l e s : type of b a s i c n u r s i n g e d u c a t i o n , type of p o s t - b a s i c n u r s i n g e d u c a t i o n , and p r e v i o u s work e x p e r i e n c e w i t h i n the n u r s i n g p r o f e s s i o n p r i o r t o a c c e p t i n g the p r e s e n t c l i n i c a l nurse s p e c i a l i s t p o s i t i o n . Q u e s t i o n n a i r e s were m a i l e d t o 147 persons and a t o t a l of 63 was u s a b l e f o r purposes of a n a l y s e s . Both d e s c r i p t i v e a n a l y s i s and a n a l y s e s of r e l a t i o n s h i p s among the v a r i a b l e s were c a r r i e d o u t . The f i n d i n g s a r e d i v i d e d i n t o f o u r main a r e a s : d e s c r i p t i o n s of work a c t i v i t y , c o n t e x t u a l l y - r e l a t e d 1These c a t e g o r i e s i n c l u d e a d m i n i s t r a t i o n , community a c t i v i t i e s , c o n s u l t a t i o n , e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , p a t i e n t c a r e , p e r s o n a l and p r o f e s s i o n a l growth, p l a n n i n g - p o l i c y - s t a n d a - r d s - c h a n g e , r e s e a r c h , s t a f f development, w r i t i n g f o r p u b l i c a t i o n , and o t h e r . 97 v a r i a b l e s , p r o f e s s i o n a l v a r i a b l e s , and s t a t i s t i c a l a n a l y s e s of r e l a t i o n s h i p s of c e r t a i n of the s e v a r i a b l e s w i t h the work time p e r c e n t a g e s r e p o r t e d by the s u b j e c t s . Each of the c a t e g o r i e s d e s c r i b e d by A r a d i n e and Denyes (1972) was l i s t e d by a t l e a s t some of the s u b j e c t s as b e i n g a p p l i c a b l e t o t h e i r work. The c a t e g o r y r e c e i v i n g the l a r g e s t p ercentage (93.5) of responses was c o n s u l t a t i o n . The c a t e g o r i e s of a d m i n i s t r a t i o n , e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , p a t i e n t c a r e , p e r s o n a l and p r o f e s s i o n a l growth, p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , community a c t i v i t i e s , and s t a f f development were i d e n t i f i e d by more than 65% of the s u b j e c t s . Less than 40% of the s u b j e c t s i d e n t i f i e d the c a t e g o r i e s of r e s e a r c h , w r i t i n g f o r p u b l i c a t i o n and o t h e r as i n c l u d e d among t h e i r work a c t i v i t i e s . The range of work a c t i v i t i e s p r o v i d e d by those s u b j e c t s under the c a t e g o r y o t h e r was q u i t e v a r i e d , f o r example, c o u n s e l l i n g / p s y c h o t h e r a p y , t r a d i t i o n a l n u r s i n g s k i l l s , r e s e a r c h work, c l e r i c a l , and i n f e c t i o n c o n t r o l . These f i n d i n g s i n d i c a t e t h a t the c a t e g o r y l a b e l s d e s c r i b e d by A r a d i n e and Denyes (1972) had r e l e v e n c e f o r the s u b j e c t s , but t h a t a v a r i e t y of meanings i s a t t a c h e d t o them. The l a r g e s t amounts of weekly work time r e p o r t e d by the s u b j e c t s were spent i n the c a t e g o r i e s p a t i e n t c a r e (37%) and o t h e r ( 2 3 . 5 % ) . L e s s e r p e r c e n t a g e s , between 10% and 15%, were spent i n the c a t e g o r i e s a d m i n i s t r a t i o n , community a c t i v i t i e s , and c o n s u l t a t i o n . P e r c e n t a g e s of l e s s than 10% 98 of weekly work time were devoted t o the c a t e g o r i e s e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , p e r s o n a l and p r o f e s s i o n a l growth, p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , r e s e a r c h , s t a f f development, and w r i t i n g f o r p u b l i c a t i o n . T h i s p a t t e r n i s i n t e r p r e t e d as b e i n g c o n s i s t e n t w i t h the views a r t i c u l a t e d by R e i t e r (1966), P e p l a u (1965) and Johnson (1962) i n terms of p a t i e n t c a r e b e i n g the f o c u s of the r o l e . However, i t i s seen as b e i n g i n c o n s i s t e n t w i t h the view t h a t c l i n i c a l nurse s p e c i a l i s t s devote s i g n i f i c a n t amounts of t h e i r work a c t i v i t y t o r e s e a r c h and w r i t i n g f o r p u b l i c a t i o n as a p a r t i c u l a r means of d e m o n s t r a t i n g commitment t o t h e i r p r o f e s s i o n ( R e i t e r , 1966; P e p l a u , 1965). Assuming the e s t i m a t e s of work time i n d i c a t e d by the s u b j e c t s i n both the A r a d i n e and Denyes (1972) s t u d y and the p r e s e n t study are comparable, a d e s c r i p t i v e comparison of the r e s u l t s i n d i c a t e d t h a t t h e r e were d i f f e r e n c e s i n the e s t i m a t e d amounts of work time devoted t o the c a t e g o r i e s p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e , s t a f f development, a d m i n i s t r a t i o n , e d u c a t i o n of s t u d e n t s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , and p e r s o n a l and p r o f e s s i o n a l growth. T h i s was i n t e r p r e t e d as a f a i l u r e of the r o l e d e s c r i p t i o n p r o v i d e d by A r a d i n e and Denyes (1972) t o a c c u r a t e l y p r e d i c t a d e s c r i p t i o n of the c l i n i c a l nurse s p e c i a l i s t r o l e i n B r i t i s h C o lumbia. D e s p i t e the f a c t t h a t a l l s u b j e c t s i n d i c a t e d t h e i r work p o s i t i o n on the RNABC form t o be t h a t of c l i n i c a l nurse 99 s p e c i a l i s t , a range of s p e c i f i c job t i t l e s was a c t u a l l y b e i n g used i n the work s e t t i n g . The most f r e q u e n t l y used j o b t i t l e (22/63) was nurse c l i n i c i a n . A l t h o u g h t h i s may be a p r e f e r r e d t i t l e w i t h i n n u r s i n g p r a c t i c e i n B r i t i s h C o lumbia, t h i s f i n d i n g was i n t e r p r e t e d as a l a c k of c l a r i t y about the meaning of the r o l e among the s u b j e c t s . Most of the s u b j e c t s (71%) had been i n t h e i r p r e s e n t p o s i t i o n f o r more than 2 y e a r s , w i t h a range of 2 t o 15 y e a r s . The average number of y e a r s i n the p o s i t i o n was 4. S l i g h t l y more than h a l f of t h e s e p o s i t i o n s (32 or 51.6%) were new when they were a c c e p t e d . Most of the e x i s t i n g p o s i t i o n s (21 or 72.4%) had j o b d e s c r i p t i o n s when a c c e p t e d by the s u b j e c t , but o n l y 14 (43.7%) of the new p o s i t i o n s had j o b d e s c r i p t i o n s . Most of the p r e s e n t p o s i t i o n s of the s u b j e c t s were c r e a t e d i n the l a t e 1970's. T h i s was i n t e r p r e t e d as e v i d e n c e of a response i n B r i t i s h Columbia t o the need f o r s p e c i a l i z a t i o n i n the h e a l t h c a r e system. In a d d i t i o n , the presence of a j o b d e s c r i p t i o n was i n t e r p r e t e d as e v i d e n c e t h a t n u r s i n g p r a c t i c e i s d e a l i n g w i t h the i s s u e of the i m p l e m e n t a t i o n of the r o l e . However, the f i n d i n g t h a t a f a i r l y l a r g e subgroup of the s u b j e c t s (22 or 46%) d i d not have a j o b d e s c r i p t i o n a v a i l a b l e when the p o s i t i o n was a c c e p t e d was i n t e r p r e t e d as e v i d e n c e t h a t the r o l e i s u n c l e a r l y d e f i n e d i n the p r a c t i c e a r e a at t h i s t i m e . Most of the s u b j e c t s (41 or 65.1%) worked i n a h o s p i t a l s e t t i n g , the m a j o r i t y of t h e s e (87.8%) i n an a c u t e c a r e 100 h o s p i t a l . Of those not w o r k i n g i n a h o s p i t a l s e t t i n g , 16 (25.4% of a l l the s u b j e c t s ) worked i n community based a g e n c i e s / s e r v i c e s w i t h 56.3% (or 16) of them w o r k i n g i n a community mental h e a l t h agency. T h i s was seen as c o n s i s t e n t w i t h the view t h a t the r o l e of the c l i n i c a l nurse s p e c i a l i s t can be implemented i n a wide range of c l i n i c a l s e t t i n g s (Watson, 1973; P e p l a u , 1965). The f i n d i n g t h a t most of the s u b j e c t s worked i n a h o s p i t a l s e t t i n g was f u r t h e r i n t e r p r e t e d as b e i n g c o n s i s t e n t w i t h the f a c t t h a t s p e c i a l i z a t i o n i n the h e a l t h c a r e system i s o r g a n i z e d i n h o s p i t a l s ( K r a u s e , 1977). A l t h o u g h the r o l e of the c l i n i c a l n urse s p e c i a l i s t can t h e o r e t i c a l l y be implemented i n a v a r i e t y of s e t t i n g s , t h e r e may be a t r e n d f o r t h i s r o l e t o be l o c a t e d s o l e l y i n the h o s p i t a l s e t t i n g i n the f u t u r e . The p r e s e n t p o s i t i o n s were e v e n l y d i s t r i b u t e d between u n i t - b a s e d (30 or 49.2%) and not u n i t - b a s e d (31 or 5 0.8%), p r i m a r i l y i d e n t i f i e d as o t h e r (33 or 54.1%) as opposed t o the t y p e s c l i n i c a l (17 or 2 7 . 9 % ) , c l i n i c a l - e d u c a t i o n a l (4 or 6.6%) or c l i n i c a l - a d m i n i s t r a t i v e (7 or 11.5%), and d e s c r i b e d as s t a f f p o s i t i o n s by most (52 or 89.7%) of the s u b j e c t s . A l a r g e subgroup (21 out of 33) of the s u b j e c t s who used the c a t e g o r y o t h e r t o d e s c r i b e t h e i r p o s i t i o n were not r e s p o n s i b l e t o n u r s i n g f o r n u r s i n g c a r e and/or o t h e r a c t i v i t i e s . A l l of t h i s was i n t e r p r e t e d as b e i n g c o n s i s t e n t w i t h the " s t a t e of b e i n g " view of the c l i n i c a l s p e c i a l i s t r o l e d e s c r i b e d by R e i t e r (1966). 101 The m a j o r i t y (48 or 76.2%) of the sample r e c e i v e d t h e i r b a s i c n u r s i n g e d u c a t i o n i n diploma programs and the r e s t (14 or 22.2%) i n b a c c a l a u r e a t e programs. S i x t e e n of the 48 (33.3%) s u b j e c t s i n the diploma p r e p a r e d group had pursued b a c c a l a u r e a t e l e v e l p r e p a r a t i o n . A t o t a l of 9 of the s u b j e c t s went on t o o b t a i n master's de g r e e s , w i t h o n l y 4 of these b e i n g master's i n n u r s i n g . The average number of y e a r s s i n c e c o m p l e t i o n of p o s t - b a s i c programs was: 10 y e a r s f o r d i p l o m a / c e r t i f i c a t e t y p e s of programs, 12 y e a r s f o r b a c c a l a u r e a t e programs, and 6 y e a r s f o r m aster's programs. I t i s d i f f i c u l t t o make a d e f i n i t i v e i n t e r p r e t a t i o n of t h e s e f i n d i n g s , but t h e r e i s a t r e n d f o r s u b j e c t s t o pursue p o s t -b a s i c l e v e l s of p r e p a r a t i o n (most f r e q u e n t l y d i p l o m a / c e r t i f i c a t e programs) r a t h e r than master's programs. However, the f i n d i n g s here are i n marked c o n t r a s t t o those r e p o r t e d by A r a d i n e and Denyes (1972) where a l l the s u b j e c t s had master's p r e p a r a t i o n i n n u r s i n g . A c a r e e r p a t t e r n v a r i a b l e i n d i c a t e d t h a t most of the s u b j e c t s had h e l d between one and 4 p o s i t i o n s i n n u r s i n g p r i o r t o a c c e p t i n g the p r e s e n t p o s i t i o n of c l i n i c a l nurse s p e c i a l i s t . N e a r l y a l l of the s u b j e c t s had worked i n the c a t e g o r y of g e n e r a l d u t y / s t a f f n u r s e . Many had worked i n the p o s i t i o n s of o f f i c e nurse/community h e a l t h nurse and i n s t r u c t o r , w h i l e the p o s i t i o n c a t e g o r i e s w i t h the l e a s t number of s u b j e c t s were a s s o c i a t e / a s s i s t a n t d i r e c t o r , d i r e c t o r , and p r o f e s s o r . 1 02 Both p a r a m e t r i c and n o n - p a r a m e t r i c s t a t i s t i c a l t e s t s were used t o examine r e l a t i o n s h i p s between c o n t e x t u a l l y -r e l a t e d v a r i a b l e s , the p r o f e s s i o n a l v a r i a b l e d e r i v e d e d u c a t i o n l e v e l , and the work time p e r c e n t a g e s e s t i m a t e d by the s u b j e c t s . In g e n e r a l , the c o n t e x t u a l l y - r e l a t e d v a r i a b l e s , new or e x i s t i n g p o s i t i o n , s e t t i n g , t y pe of appointment ( l i n e or s t a f f ; c l i n i c a l , c l i n i c a l - e d u c a t i o n a l , c l i n i c a l - a d m i n i s t r a t i v e , or o t h e r ) and presence or absence of a j o b d e s c r i p t i o n , were found t o r e l a t e s i g n i f i c a n t l y t o the p e r c e n t a g e s of weekly work time i n the work a c t i v i t y c a t e g o r i e s of a d m i n i s t r a t i o n , p a t i e n t c a r e , community a c t i v i t i e s , i n t e r d i s c i p l i n a r y i n t e r a c t i o n , and p l a n n i n g -p o l i c y - s t a n d a r d s - c h a n g e . The p r o f e s s i o n a l v a r i a b l e d e r i v e d e d u c a t i o n l e v e l ( d i p l o m a , b a c c a l a u r e a t e , or m a s t e r ' s ) was found t o r e l a t e t o the p e r c e n t a g e s of weekly work time i n d i c a t e d by the s u b j e c t s f o r the c a t e g o r i e s i n t e r d i s c i p l i n a r y i n t e r a c t i o n and s t a f f development. S i g n i f i c a n t d i f f e r e n c e s were demonstrated by both p a r a m e t r i c and n o n - p a r a m e t r i c t e s t s f o r the c o n t e x t u a l l y r e l a t e d v a r i a b l e s new or e x i s t i n g p o s i t i o n and l i n e or s t a f f placement. When the p r e s e n t p o s i t i o n was new, the c l i n i c a l nurse s p e c i a l i s t s spent a l a r g e r amount of e s t i m a t e d work time i n the c a t e g o r y a d m i n i s t r a t i o n (mean=13.2%; average rank=26.6%) than when i t was a l r e a d y e x i s t i n g when a c c e p t e d (mean=7.0%; average r a n k = l 8 . 5 % ) . However, when the p r e s e n t p o s i t i o n was a l r e a d y i n e x i s t e n c e when i t was a c c e p t e d , t h i s 1 03 group of c l i n i c a l nurse s p e c i a l i s t s spent a l a r g e r amount of e s t i m a t e d work time i n the c a t e g o r y p a t i e n t c a r e (mean=45.6%; average rank=30.9%) than d i d the c l i n i c a l nurse s p e c i a l i s t s i n new p o s i t i o n s (mean=29.7%; average rank=20.5%). T h i s was i n t e r p r e t e d as b e i n g r e l a t e d t o a g e n e r a l need of the c l i n i c a l nurse s p e c i a l i s t t o e s t a b l i s h c o n t a c t s and c r e d i b i l i t y among wo r k i n g c o l l e a g u e s when the r o l e i s new t o an agency. In a d d i t i o n , t h i s seems t o r e f l e c t a common u n d e r s t a n d i n g between the c l i n i c a l nurse s p e c i a l i s t and an employing agency t h a t p a t i e n t c a r e i s the f o c u s of a l r e a d y e x i s t i n g p o s i t i o n s . As would be a n t i c i p a t e d , when the p r e s e n t p o s i t i o n was a l i n e p o s i t i o n , c l i n i c a l nurse s p e c i a l i s t s spent a l a r g e r amount of e s t i m a t e d weekly work time i n a d m i n i s t r a t i v e a c t i v i t i e s (mean=21.7%; average rank=31.7%) than when the p o s i t i o n was a s t a f f p o s i t i o n (mean=9.0%; average rank=19.7%). C o n c l u s i o n s Based on the f i n d i n g s of t h i s s t u d y the f o l l o w i n g c o n c l u s i o n s can be drawn: 1. The r o l e model o u t l i n e d by A r a d i n e and Denyes (1972) does not a c c u r a t e l y d e s c r i b e the p r e s e n t r o l e of the c l i n i c a l nurse s p e c i a l i s t i n B r i t i s h Columbia. W h i l e a l a r g e p e r c e n t a g e of the s u b j e c t s i n d i c a t e d t h a t the c a t e g o r i e s of work a c t i v i t y a p p l i e d t o t h e i r p o s i t i o n s , the 1 04 e s t i m a t e s of the p e r c e n t a g e s of weekly work time were much lower than those d e s c r i b e d by A r a d i n e and Denyes f o r the c a t e g o r i e s s t a f f development, i n t e r d i s c i p l i n a r y i n t e r a c t i o n , and p l a n n i n g - p o l i c y - s t a n d a r d s - c h a n g e . T h i s f i n d i n g l e n d s credence t o the b e l i e f t h a t t h e r e may be a Canadian a s p e c t to the concept of c l i n i c a l nurse s p e c i a l i s t . I t i s u n c l e a r to what degree the f a c t o r s of the o r g a n i z a t i o n of the h e a l t h c a r e d e l i v e r y system, the s e t t i n g i n which the r o l e i s e n a c t e d , and the e d u c a t i o n a l p r e p a r a t i o n f o r the r o l e shape the way i n which the r o l e d e v e l o p s . 2. There i s some e v i d e n c e t o i n d i c a t e t h a t t h e r e i s a l a c k of c l a r i t y about the c l i n i c a l nurse s p e c i a l i s t r o l e . The range of a c t u a l j o b t i t l e s used i n v a r i o u s work s e t t i n g s , the absence of a j o b d e s c r i p t i o n f o r 26 (42.6%) of the s u b j e c t s , the v a r i a b i l i t y i n the type of p o s t - b a s i c n u r s i n g e d u c a t i o n pursued p r i o r t o ac c e p t a n c e of a c l i n i c a l nurse s p e c i a l i s t p o s i t i o n , and the f i n d i n g t h a t 21 (33.8%) a r e not r e s p o n s i b l e o r g a n i z a t i o n a l l y t o n u r s i n g c o n s t i t u t e s t h i s e v i d e n c e . T h i s i s thought t o be r e l a t e d t o a l a c k of c l a r i t y among nurses about the development of the c l i n i c a l nurse s p e c i a l i s t r o l e i n Canadian n u r s i n g . 3. The r o u t e by which an i n d i v i d u a l nurse becomes a c l i n i c a l nurse s p e c i a l i s t i n B r i t i s h Columbia seems t o c o n s i s t of b e i n g w i t h i n the system f o r a w h i l e and r e c e i v i n g r e c o g n i t i o n f o r p r o f e s s i o n a l knowledge and e x p e r i e n c e . A l t h o u g h t h i s i s seen as p o s s i b l y b e i n g r e f l e c t i v e of a 105 " s t a t e of b e i n g " view d e s c r i b e d by R e i t e r (1966), i t i s i n c o n s i s t e n t w i t h w r i t i n g s i n d i c a t i n g t h a t the l e v e l of p r e p a r a t i o n f o r the c l i n i c a l nurse s p e c i a l i s t r o l e s h o u l d be the master's degree i n n u r s i n g (Smoyak, 1976; Georgopoulos and C h r i s t m a n , 1970; P e p l a u , 1965). T h i s c o n c l u s i o n i n d i c a t e s t h e r e i s a gap between the number of n u r s e s who a r e p r e p a r e d a t the graduate l e v e l f o r the r o l e (Boone and K i k u c h i , 1977; Coombs, 1970) and the t h e o r e t i c a l agreement t h a t the c l i n i c a l nurse s p e c i a l i s t r o l e i s an advanced and s p e c i a l i z e d one r e q u i r i n g g r a d u a t e l e v e l p r e p a r a t i o n . A s t r o n g c o n s i s t e n t v o i c e must be p r o v i d e d by the n u r s i n g p r o f e s s i o n i n Canada t o b r i d g e such a gap and move from a " s t a t e of b e i n g " t o the e s t a b l i s h m e n t of f o r m a l r e q u i r e m e n t s f o r p r e p a r a t i o n f o r the r o l e . I m p l i c a t i o n s These c o n c l u s i o n s r a i s e c e r t a i n i m p l i c a t i o n s f o r both n u r s i n g s e r v i c e and n u r s i n g e d u c a t i o n . The most i m p o r t a n t seems t o be a need f o r s t r o n g l e a d e r s h i p w i t h i n the n u r s i n g p r o f e s s i o n c o n c e r n i n g b oth a d e s c r i p t i o n of the c l i n i c a l n urse s p e c i a l i s t r o l e i n Canadian n u r s i n g and i s s u e s r e l a t e d t o the r o l e . Because f u l f i l l m e n t of a r o l e i s a t t a i n e d i n the e m p i r i c a l w o r l d of r e a l i t y , the r e s e a r c h e r b e l i e v e s t h a t i t i s of c r u c i a l importance t h a t n u r s i n g l e a d e r s from both s e r v i c e and e d u c a t i o n work t o g e t h e r t o d etermine and a r t i c u l a t e what t h i s r o l e i s t o be i n Canadian n u r s i n g . 106 The f i r s t c o n c l u s i o n , t h a t the r o l e model o u t l i n e d by A r a d i n e and Denyes (1972) d i d not a c c u r a t e l y p r e d i c t the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n B r i t i s h C o lumbia, has i m p l i c a t i o n s f o r n u r s i n g s e r v i c e . In p a r t i c u l a r , n u r s i n g s e r v i c e l e a d e r s i n Canada s h o u l d be wary of a p p l y i n g s u g g e s t i o n s about the r o l e t h a t a r i s e from American s t u d i e s t o Canadian n u r s i n g . I n s t e a d , d i a l o g u e s h o u l d be on-going between n u r s i n g s e r v i c e and n u r s i n g e d u c a t i o n w i t h the g o a l b e i n g the development of a d e s c r i p t i o n of the r o l e i n Canadian n u r s i n g . T h i s c o n c l u s i o n a l s o has i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n . C o n t i n u i n g e f f o r t s t o d etermine what c l i n i c a l nurse s p e c i a l i s t s a c t u a l l y do i n t h e i r work can p r o v i d e d i r e c t i o n t o n u r s i n g e d u c a t o r s f o r development of c u r r i c u l a a t the master's l e v e l f o r the p r e p a r a t i o n of the c l i n i c a l n u r se s p e c i a l i s t i n Canada. The second c o n c l u s i o n , t h a t t h e r e i s a l a c k of c l a r i t y about the r o l e , i n d i c a t e s t h a t t h e r e i s a need f o r a s t r o n g v o i c e from n u r s e s c o n c e r n i n g the concept and r o l e of the c l i n i c a l n u r se s p e c i a l i s t . For each r e l e v a n t i s s u e c o n c e r n i n g the concept and the r o l e of the c l i n i c a l n u r se s p e c i a l i s t i n Canadian n u r s i n g a s t a n d must be taken on what i s a c c e p t a b l e t o the n u r s i n g p r o f e s s i o n r e l a t e d t o development of t h i s r o l e . I n d i v i d u a l nurses p r e p a r i n g f o r : the p r o f e s s i o n can be s e n s i t i z e d e a r l y t o the r e q u i r e m e n t s and demands of a s p e c i a l i z e d r o l e w i t h i n the p r o f e s s i o n . When t h i s i s c o u p l e d w i t h s t r o n g l e a d e r s h i p and s u p p o r t from 1 07 n u r s i n g s e r v i c e , i t would be r e a s o n a b l e t o a n t i c i p a t e a d i f f e r e n t s e t of f i n d i n g s s h o u l d t h i s study be r e p e a t e d i n the f u t u r e . The t h i r d c o n c l u s i o n , l o n g e v i t y w i t h i n the system seems to be the p r i m a r y way i n which a nurse becomes a c l i n i c a l n urse s p e c i a l i s t i n B r i t i s h C olumbia, a g a i n has i m p l i c a t i o n s r e l a t e d t o a need f o r a s t r o n g v o i c e from n u r s i n g l e a d e r s h i p about p r e p a r a t i o n f o r t h i s s p e c i a l i z e d c l i n i c a l r o l e . I t seems unr e a s o n a b l e t h a t f i n d i n g s d e s c r i b e d i n t h i s study s h o u l d c o n t i n u e t o r e f l e c t the s t a t e of the a r t . P r o f e s s i o n a l r e s p o n s i b i l i t y demands t h a t n u r s i n g make i t s c h o i c e s and implement the r e l a t e d d e c i s i o n s i n the a r e a s of p r a c t i c e and e d u c a t i o n . I t i s o n l y t h r o u g h the e x e r c i s e of l e a d e r s h i p c o u p l e d w i t h r a t i o n a l p l a n n i n g t h a t n u r s i n g can d i r e c t i t s c o n t r i b u t i o n t o the p u b l i c w e l f a r e . T h i s r e q u i r e s agreement t h a t advanced e d u c a t i o n i n n u r s i n g i s e s s e n t i a l i n f u l f i l l i n g the mandates of p r o f e s s i o n a l p r a c t i c e . Recommendations f o r F u r t h e r Study On the b a s i s of the c o n c l u s i o n s and i m p l i c a t i o n s of t h i s s t u d y , i t i s recommended t h a t : 1. A study be conducted t o examine the b e l i e f s and s t a n d s t h a t n u r s i n g l e a d e r s i n s e r v i c e and e d u c a t i o n h o l d c o n c e r n i n g the c l i n i c a l nurse s p e c i a l i s t r o l e i n Canada. 2. The p r e s e n t study be r e p e a t e d i n o t h e r p r o v i n c e s of 108 Canada t o d i s c o v e r i f the r e s u l t s a r e c o n s i s t e n t f o r o t h e r groups of s e l f - d e f i n e d c l i n i c a l nurse s p e c i a l i s t s . 3. A s t u d y be conducted t o examine the j o b d e s c r i p t i o n s of c l i n i c a l nurse s p e c i a l i s t s i n Canada. 4. A s t u d y be c a r r i e d out t o examine the c o n t e n t i n c l u d e d i n c u r r i c u l a d e s i g n e d t o p r e p a r e n u r s e s f o r the c l i n i c a l n urse s p e c i a l i s t r o l e . 5. F u r t h e r study of the group of c l i n i c a l n u r se s p e c i a l i s t s i n B r i t i s h Columbia who a r e not r e s p o n s i b l e t o n u r s i n g be c a r r i e d out t o determine e x p l a n a t i o n s f o r t h i s f i n d i n g . 6. I n f o r m a t i o n c o n c e r n i n g the s i z e of the h o s p i t a l s i n which the c l i n i c a l nurse s p e c i a l i s t s a r e employed be sought i n f u t u r e s t u d i e s . 7. A s t u d y of outcomes of work a c t i v i t y of c l i n i c a l nurse s p e c i a l i s t s be conducted ( e . g . , p a t i e n t c a r e and c o s t outcomes). 8. A s t u d y be conducted t o examine the p r e c i s e meaning t h a t c l i n i c a l nurse s p e c i a l i s t s a t t a c h t o the t i t l e used t o d e s c r i b e t h e i r j o b s . 9. A p r o s p e c t i v e study of a group of c l i n i c a l nurse s p e c i a l i s t s be conducted t o examine the i n f l u e n c e of l e n g t h of time i n the p o s i t i o n on the time spent i n the v a r i o u s c a t e g o r i e s of work a c t i v i t y . The v a l u e of t h i s s t u d y r e s t s i n i t s c o n t r i b u t i o n t o a b e g i n n i n g e f f o r t c o n c e r n i n g knowledge of the r o l e of the c l i n i c a l nurse s p e c i a l i s t i n Canadian n u r s i n g . I t i s hoped t h a t the f i n d i n g s w i l l p r o v i d e food f o r thought and s t i m u l a t e f u r t h e r s t u d y . 1 10 REFERENCES Adam, E. CNA's s t a n d a r d s f o r n u r i n g p r a c t i c e : An i n t e r p r e t a t i o n . The Canadian Nurse, 1 9 8 1 , 7 7 : 8 , 3 2 - 3 4 . Anderson, J . e t . a l . The expanded r o l e of the n u r s e : Independent p r a c t i t i o n e r or p h y s i c i a n ' s a s s i s t a n t ? The  Canadian Nurse, 1 9 7 5 , 7J_, 3 4 - 3 5 . A r a d i n e , C R . & Denyes, M.J. A c t i v i t i e s and p r e s s u r e s of c l i n i c a l nurse s p e c i a l i s t s . N u r s i n g R e s e a r c h , 1 9 7 2 , 2M, 4 1 1 - 4 1 8 . A r p i n , K.E. J o i n t - a p p o i n t m e n t s : S t r e n g t h i n g the c l i n i c a l p r a c t i c e component i n n u r s i n g e d u c a t i o n programmes. N u r s i n g P a p e r s , 1 9 8 1 , J_3, 9 - 1 4 . Bachand, M. Wanted: A d e f i n i t i o n of n u r s i n g p r a c t i c e . The  Canadian Nurse, 1 9 7 4 , 7 0 : 5 , 2 6 - 2 9 . Back t o b a s i c s , n u r s i n g e d u c a t o r s f a c e up t o needs of the e i g h t i e s . The Canadian n u r s e , 1 9 8 0 , 7 6 , 1 6 - 2 0 . B a c k s h e i d e r , J . The c l i n i c a l nurse s p e c i a l i s t as a p r a c t i t i o n e r . N u r s i n g Forum, 1 9 7 1 , X, 3 5 9 - 3 7 7 . Baker, C. & Kramer, M. 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The  Canadian Nurse, 1980, 7j6, 36-39. Watson, J . The c l i n i c a l nurse s p e c i a l i s t . O n t a r i o M e d i c a l  Review, 1973, 40, 326-327. Weeks, H. Ro l e of the c l i n i c a l s p e c i a l i s t i n the p e d i a t r i c i n t e n s i v e c a r e u n i t . C u r r e n t P r a c t i c a l P e d i a t r i c  N u r se, 1980, 3, 225-239. W i t t e r duGas, B. N u r s i n g ' s expanded r o l e i n Canada: I m p l i c a t i o n s of the j o i n t CMA-CNA statement of p o l i c y . N u r s i n g C l i n i c s of N o r t h A m e r i c a , 1974, 9:3 , 532-533. Woodrow, M. & B e l l , J.A. C l i n i c a l s p e c i a l i z a t i o n : C o n f l i c t between r e a l i t y and t h e o r y . J o u r n a l of N u r s i n g  A d m i n i s t r a t i o n , 1971, 1:6, 23-28. W r i g h t , B.L. The nurse c o n s u l t a n t . An independent p r a c t i c e s e t t i n g . The Canadian Nurse, 1981, 7J7 , 34-36. Yokes, J.A. The c l i n i c a l s p e c i a l i s t i n c a r d i o v a s c u l a r n u r s i n g . American J o u r n a l of N u r s i n g , 1966, 6j6, 2667-2670. 118 BIBLIOGRAPHY Anderson, E.M., Leonard, B . J . , Y a t e s , J.A. E p i g e n e s i s of the nurse p r a c t i t i o n e r r o l e . American J o u r n a l of  N u r s i n g , 1974, 74:10, 1812-1816. Anderson, M. The c l i n i c a l nurse s p e c i a l i s t i n a s t a f f p o s i t i o n : Sources of a u t h o r i t y . In P. Channings & R. M a r k e l (Eds.) The c l i n i c a l nurse s p e c i a l i s t : A  symposium, Monograph #1, S e r i e s 75, I n d i a n a p o l i s : Sigma Theta Tau, 1976, 1-7. A n d r i a n o s , A.F., Swain, C.R. I n t e r f a c i n g the r o l e of a p s y c h i a t r i c nurse s p e c i a l i s t w i t h a h o s p i t a l emergency room s e t t i n g . J o u r n a l of P s y c h i a t r i c N u r s i n g , 1979, 17:4, 24-27. Anonsen, D.C. The expanded r o l e i n n u r s i n g . N u r s i n g  P a p e r s , 1974, 6j_2, 50-53. American Nurses' A s s o c i a t i o n . Statements of p s y c h i a t r i c and  mental h e a l t h n u r s i n g p r a c t i c e , American Nurses' A s s o c i a t i o n : D i v i s i o n of P s y c h i a t r i c and M e n t a l H e a l t h N u r s i n g , 1976, 5-6, 15-19. B a t c h e l o r , G.M., e t a l . Nurse p r a c t i t i o n e r s i n p r i m a r y c a r e : Impact of an i n t e r d i s c i p l i n a r y team on a t t i t u d e s of a r u r a l p o p u l a t i o n . Canadian M e d i c a l A s s o c i a t i o n  J o u r n a l , 1975, 112:12, 1415-1420. Beeber, L.S. Should the c l i n i c a l nurse s p e c i a l i s t be f r e e of a d m i n i s t r a t i v e r e s p o n s i b i l i t y ? P e r s p e c t i v e s i n  P s y c h i a t r i c C are, 1980, XVI11:6, 250;264-266. B e n f e r , B.A. D e f i n i n g the r o l e and f u n c t i o n of the p s y c h i a t r i c nurse as a member of the team. P e r s p e c t i v e s i n P s y c h i a t r i c C are, 1980, XVI11:4, 166-177. B e n f e r , B.A. C l i n i c a l s u p e r v i s i o n as a support system f o r the c a r e g i v e r . P e r s p e c t i v e s i n P s y c h i a t r i c C are, 1979, XVI1:1, 13-17. B e n n i s , W.G., et a l . The p l a n n i n g of change, 3 r d . ed. New York: H o l t , R i n e h a r t & W i n s t o n , 1976. 119 B e r d i e , D.R., Anderson, J.F. Q u e s t i o n n a i r e s : Design and use , Metuchen, New J e r s e y : The Scarecrow P r e s s , I n c . , 1974. B i d d l e , B., Thomas, E. ( E d s . ) . Role t h e o r y : Concepts and  r e s e a r c h , New York: John W i l e y & Sons, I n c . , 1966. B r a d l e y , L.O. Standards i n h e a l t h c a r e . H o s p i t a l  A d m i n i s t r a t i o n i n Canada, 1972, 23-24. Brown, B.G. E x p l o r a t i o n of the "expanded r o l e " of the nurse i n a p r i m a r y c a r e s e t t i n g . N u r s i n g P a p e r s , 1974, 6:2, 41-49. Brown, E.L. N u r s i n g f o r the f u t u r e , New York: R u s s e l l Sage F o u n d a t i o n , 1948. B u l l o u g h , B. I n f l u e n c e s on r o l e e x p a n s i o n . American  J o u r n a l of N u r s i n g , 1976, 76:9, 1476-1481. B u l l o u g h , B. I s the nurse p r a c t i t i o n e r r o l e a source of i n c r e a s e d work s a t i s f a c t i o n ? N u r s i n g R e s e a r c h , 1974, 23:1, 14-19. Burdge, L. The c l i n i c a l nurse s p e c i a l i s t -- 5. The r o l e of the c l i n i c a l n u r s i n g o f f i c e r . N u r s i n g Times, 1978, 31, 1299-1300. B u r k e t t , G.L. e t . a l . A c o m p a r a t i v e study of p h y s i c i a n s ' and n u r s e s ' c o n c e p t i o n s of the r o l e of the nurse p r a c t i t i o n e r . American J o u r n a l of P u b l i c H e a l t h , 1978, 68, 1090-1096. C a s s i d y , J.T. The advanced n u r s i n g p r a c t i t i o n e r : A dilemma f o r s u p e r v i s o r s . J o u r n a l of N u r s i n g A d m i n i s t r a t i o n , 1975, 5j_6, 40-42. Chambers, K.W., Wast, A.E. Assessment of the r o l e of the f a m i l y p r a c t i c e nurse i n urban m e d i c a l p r a c t i c e s . Canadian J o u r n a l of P u b l i c H e a l t h , 1978, 69:6, 459-468. C h r i s t m a n , L. S p e c i a l i s m and g e n e r a l i s m i n c l i n i c a l n u r s i n g . H o s p i t a l s , 1967, 41:1, 83-86. C h r i s t m a n , L. The I n f l u e n c e of s p e c i a l i z a t i o n on the n u r s i n g p r o f e s s i o n . N u r s i n g S c i e n c e , 1965, 3:6, 446-453. 120 C r i c h t o n , A. H e a l t h p o l i c y making: Fundamental i s s u e s i n the U.S., Canada, Gr e a t B r i t a i n , A u s t r a l i a , Ann A r b o r , M i c h i g a n : H e a l t h A d m i n i s t r a t i o n P r e s s , 1981. D a v i s , A . J . , Underwood, P. R o l e , f u n c t i o n , and d e c i s i o n making i n community mental h e a l t h . N u r s i n g R e s e a r c h , 1976, 25:4, 256-258. D e w i t t , K. S p e c i a l t i e s i n n u r s i n g . American J o u r n a l of  N u r s i n g , 1900, J_, 14-17. D i e r s , D. Research i n n u r s i n g p r a c t i c e , T o r o n t o : J.B. L i p p i n c o t t Company, 1979. Dyson, R. Changes i n p r o f e s s i o n a l r o l e s -- I m p l i c a t i o n s f o r the f u t u r e . Canadian J o u r n a l of P s y c h i a t r i c N u r s i n g , 1973, 14:1, 14-16. Edwards, J . C l i n i c a l s p e c i a l i s t s a r e not e f f e c t i v e -- Why? S u p e r v i s o r Nurse, 1971, 6:8, 38-47. E l l i s , B. F u t u r e e v o l u t i o n of n u r s i n g r o l e s c o n t i n g e n t on l e g i s l a t i o n . H o s p i t a l s , 1978, 52:3, 81-82. Emory, C.W. B u s i n e s s r e s e a r c h methods, Georgetown, O n t a r i o : I r w i n - D o r s e y L i m i t e d , 1980. E r i c k s o n , F. Nurse s p e c i a l i s t s f o r c h i l d r e n . N u r s i n g  O u t l o o k , 1968, J_6, 34-36. F i t z p a t r i c k , L. A c a t a l o g u e of s p e c i a l i n t e r e s t groups. The Canadian Nurse, 1979, 75:6, 9~16;50. G i l c h r i s t , J . C o l l a b o r a t i o n , not c o m p e t i t i o n ( e d i t o r i a l ) . The Canadian Nurse, 1978, 74:4, 38-39. G l a s s , H.P., W i n k l e r , S.J., & Degner, L.F. Statements on the expanded r o l e of the nu r s e . N u r s i n g P a p e r s , 1974, 6:2, 10-14. Hacker, C.L. A new c a t e g o r y of h e a l t h c a r e worker f o r Canada? The Canadian Nurse, 1969, 65:1, 38-43. Hardy, M. E. & Conway, M. E. Role t h e o r y : P e r s p e c t i v e s f o r h e a l t h p r o f e s s i o n a l s , New York: A p p l e t o n - C e n t u r y -C r o f t s , 1978. 121 Hayes, P., F i e l d , P.A., M c C l u r e , R.E., N i s k a l a , H. & S t i n s o n , S. The expanded r o l e of the n u r s e : A p o s i t i o n paper. N u r s i n g P a p e r s , 1 9 7 4 , 6 : 2 , 3 4 - 3 6 . H u t c h i n s o n , D.J. C e r t i f i c a t i o n : a new impetus t o c o n t i n u i n g e d u c a t i o n . J o u r n a l of C o n t i n u i n g E d u c a t i o n i n N u r s i n g , 1 9 7 3 , 4 : 5 , 3 - 4 . J a c k s o n , B.S. The r o l e of the p s y c h i a t r i c nurse s p e c i a l i s t i n c a r i n g f o r the i n s t i t u t i o n a l i z e d aged. J o u r n a l of  P s y c h i a t r i c N u r s i n g , 1 9 7 9 , 1 7 : 1 1 , 2 1 - 2 3 . J a c k s o n , M.M. ( E d . ) . C l i n i c a l nurse s p e c i a l i s t symposium, Ann A r b o r , M i c h i g a n : The U n i v e r s i t y of M i c h i g a n , 1 9 7 2 . K e l l e r , N.S. The n u r s e ' s r o l e : I s i t expanding or s h r i n k i n g ? N u r s i n g O u t l o o k , 1 9 7 3 , 2J_, 2 3 6 - 2 4 0 . K i n g , K. Expanded r o l e ? Expanded r e c o g n i t i o n , expanded o p p o r t u n i t y ? N u r s i n g P a p e r s , 1 9 7 4 , 6 : 2 , 5 4 - 5 6 . K i n s e l l a , C R . Who i s the c l i n i c a l nurse s p e c i a l i s t ? H o s p i t a l s , 1 9 7 3 , 4 7 : 1 1 , 7 2 - 8 0 . Kramer, M. E d u c a t i o n l p r e p a r a t i o n f o r nurse r o l e s . In J . W i l l i a m s o n ( E d . ) . C u r r e n t p e r s p e c t i v e s i n n u r s i n g  e d u c a t i o n : The c h a n g i n g scene V o l . 1 , S t . L o u i s : C V . Mosby, 1 9 7 6 , 9 5 - 1 1 8 . Lego, S. The one-to-one n u r s e - p a t i e n t r e l a t i o n s h i p . P e r s p e c t i v e s i n P s y c h i a t r i c Care, 1 9 8 0 , X V I I I , 6 7 - 8 9 . L e w i s , E.P. The c l i n i c a l nurse s p e c i a l i s t , New York: The American J o u r n a l of N u r s i n g Company, 1 9 7 7 . L i t t l e f i e l d , N. The p s y c h i a t r i c nurse as change agent. N u r s i n g C l i n i c s of N o r t h A m e r i c a , 1 9 7 9 , 1 4 : 2 , 3 7 3 - 3 8 3 . Logan, J . The expanded r o l e of the handmaiden. The  Canadian Nurse, 1 9 8 0 , 7 6 : 1 , 3 4 - 3 5 . Mauksch, H.O. The o r g a n i z a t i o n a l c o n t e x t of n u r s i n g p r a c t i c e . In F. D a v i s (Ed.) The n u r s i n g p r o f e s s i o n :  F i v e s o c i o l o g i c a l e s s a y s , New York: John W i l e y , 1 9 6 6 , 1 0 9 - 1 3 7 . M o r r i s , K.H. & S c h w e i s s e r , J.A. C l i n i c a l nurse s p e c i a l i s t r o l e c r e a t i o n : An a c h i e v a b l e g o a l . N u r s i n g  A d m i n i s t r a t i o n Q u a r t e r l y , 1 9 7 9 , 4sJ_ r 6 7 - 7 8 . 1 22 M u l l a n e y , J.W., Fox, R.A., L i s t o n , M.F. C l i n i c a l nurse s p e c i a l i s t and s o c i a l worker: C l a r i f y i n g the r o l e s . N u r s i n g O u t l o o k , 1974, 22:11, 712-718. Murphy, J . & S c h m i t z , M. The c l i n i c a l nurse s p e c i a l i s t : Implementing the r o l e i n a h o s p i t a l s e t t i n g . J o u r n a l  of N u r s i n g A d m i n i s t r a t i o n , 1979, 9, 29-31. Nurse p r a c t i t i o n e r s — The n a t i o n a l p i c t u r e . The Canadian  Nurse, 1978, 74:4, 13-23. Oda, D. S p e c i a l i z e d r o l e development: A t h r e e phase p r o c e s s . N u r s i n g O u t l o o k , 1977, 25, 374-377. P e p l a u , H.E. The p s y c i a t r i c nurse -- A c c o u n t a b l e ? To whom? For what? P e r s p e c t i v e s i n P s y c h i a t r i c C are, 1980, XVI11, 128-134. P e t e r s o n , S. The P s y c h i a t r i c nurse s p e c i a l i s t i n a g e n e r a l h o s p i t a l . N u r s i n g O u t l o o k , 1969, J_7, 56-58. R i e h l , J . & McVay, J.W. ( E d s . ) . The c l i n i c a l nurse  s p e c i a l i s t : I n t e r p r e t a t i o n s , New York: A p p l e t o n -C e n t u r y - C r o f t s , 1973. R i c h a r d s , J.F. I n t e g r a t i n g a c l i n i c a l s p e c i a l i s t i n t o a h o s p i t a l s e r v i c e . N u r s i n g O u t l o o k , 1969, 17:3, 23-25. Roach, M.S. The n u r s i n g r o l e and the problem of i m p l e m e n t a t i o n . 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N u r s i n g R e s e a r c h , 1 9 7 6 , 2 5 : 2 , 1 1 2 - 1 1 4 . 1 24 APPENDIX A 125 Dear Colleague, As a nurse, and as a student i n the Master of Science i n Nursing program at the University of B r i t i s h Columbia, I am aware that an issue of importance to our profession i s the role of the c l i n i c a l nurse s p e c i a l i s t . I want to examine, i n a master's thesis, the practice of the c l i n i c a l nurse s p e c i a l i s t i n B r i t i s h Columbia. You have received t h i s package because of assistance I have re-ceived from the p r o v i n c i a l association. The nature of that assistance has been a s t a f f member at RNABC r e t r e i v i n g from the computer a l i s t of names of nurses who checked box 23 ( c l i n i c a l s p e c i a l i s t ) on the current r e g i s t r a t i o n form and l a b e l l i n g and mailing the stuffed envelopes I have prepared. You can a s s i s t me by completing the data-collecting form that accompanies t h i s l e t t e r . Completion requires 2 0 - 3 0 mintues of your time. An addressed stamped envelope i s provided f o r return of the form. Return of the completed form w i l l be assumed to indicate your consent to part i c i p a t e i n the study. Your anonymity i s assured as a r e s u l t of the procedure I have followed with RNABC. Your name w i l l not appear on the data-collecting form. I f you are interested i n receiving feedback i n the form of a summary of findings and recommendations from t h i s study, please indicate t h i s by recording your name and mailing address on the small card i n t h i s package. I f you decide to participate i n the study, I urge you to respond to each item on the data-collecting form. There are no r i g h t or wrong responses. I seek to describe the practice i n which you engage based on your perceptions and experience i n your present position. In a n t i c i p a t i o n of your decision to participate I want to thank you for your contribution to my study. I f you decide not to pa r t i c i p a t e , I want to thank you f o r considering the p o s s i b i l i t y . I w i l l appreciate your returning the form i n either case. Sincerely, Shirley Halliday, BN (graduate student, University of B r i t i s h Colimbia) 1 26 APPENDIX B 127 DATA - COLLECTING FORM Survey of the Pr a c t i c e of C l i n i c a l Nurse S p e c i a l i s t s i n B r i t i s h Columbia Introduction Approximately 20-30 minutes of your time w i l l be required for completion of t h i s form. You are free to decline to respond to any item. There are no consequences to your doing so. The return of the completed form to the researcher w i l l be assumed to i n -dicate your consent to p a r t i c i p a t e i n th i s study. GENERAL INSTRUCTION As a basis for your responses to each item, please use your present job experience. 128 When you completed the RNABC r e g i s t r a t i o n fee form you i n d i c a t e d that your work p o s i t i o n was that of " c l i n i c a l s p e c i a l i s t " by checking box 23. At the present time are you s t i l l working i n a p o s i t i o n you would i d e n t i f y as " c l i n i c a l s p e c i a l i s t " ? YES NO I f your response i s NO would you: a) please i n d i c a t e what kind of work you are doing b) STOP at t h i s p o i n t . Do not complete the form. Please r e t u r n i t to the researcher i n the envelope that has been provided. What i s your s p e c i f i c job t i t l e ? I f you think your job t i t l e i s d e s c r i p t i v e of your work please skip to item 4. I f i t i s u n s a t i s f a c t o r y how would you rename i t ? Which of the f o l l o w i n g best applies c l i n i c a l nurse s p e c i a l i s t nurse c l i n i c i a n nurse p r a c t i t i o n e r s p e c i a l t y nurse other: please s p e c i f y How long have you worked i n your present p o s i t i o n w i t h t h i s t i t l e ? 0 - 6 months 7 - 1 2 months 1 3 - 2 4 months 25 - 36 months longer than 36 months At the time you accepted your p o s i t i o n was i t new? e x i s t i n g ? When you accepted your present p o s i t i o n d i d a job d e s c r i p t i o n e x i s t f o r i t ? YES NO 1 2 9 7. The f o l l o w i n g c a t e g o r i e s have been defined by nurse researchers (Aradine and Denyes) as c h a r a c t e r i s t i c of the p r a c t i c e of the c l i n i c a l nurse s p e c i a l i s t . Please check YES f o r each category that a p p l i e s to your p r a c t i c e and estimate the percentage of your work time on a weekly b a s i s devoted to each category you have checked. Your estimates should t o t a l 100%. At l e a s t one example i s provided f o r eacl category i n order to a s s i s t you i n responding. Percentage estimate CATEGORY* YES of weekly work time a d m i n i s t r a t i o n eg., p a r t i c i a p t e i n p o l i c y making decisons provide c l i n i c a l s u p e r v i s i o n to n u r s i n g s t a f f b) community a c t i v i t i e s eg., c o n t r i b u t e to the p o l i t i c a l process that a f f e c t s h e a l t h care provide formal and i n f o r m a l programs w i t h defined objec-t i v e s f o r groups i n the community c) c o n s u l t a t i o n eg., provide p a t i e n t centered c o n s u l t a t i o n to h e a l t h team members d) education of students eg., p a r t i c i p a t e i n edu c a t i o n a l programs f o r students e) i n t e r d i s c i p l i n a r y i n t e r a c t i o n eg., c o l l a b o r a t e w i t h members of the h e a l t h team i n p r a c t i c e o r i e n t e d research i n v o l v e a l l s t a f f i n p l a n -n i n g p a t i e n t care f) p a t i e n t care eg., u t i l i z e d i r e c t i o n of a nurs i n g model when im-plementing the n u r s i n g process continued 130 7. (continued) ... Percentage estimate CATEGORY of weekly work time % g) personal and p r o f e s s i o n a l growth eg., assume r e s p o n s i b i l i t y f o r s e l f development p a r t i c i p a t e i n p r o f e s s i o n a l a c t i v i t i e s h) planning-policies-standards-change eg., c o n t r i b u t e new and a l t e r n a t e p a t t e r n s to n u r s i n g care p a r t i c i p a t e i n developing standards f o r nursing care i ) research eg., a s s i s t n u r s i n g s t a f f and others to become f a m i l i a r w i t h n u r s i n g research c o l l a b o r a t e w i t h nurse researchers i n planning and conducting n u r s i n g research j ) s t a f f development eg., a s s i s t n u r s i n g s t a f f to be-come informed i n nursing theory and research k) w r i t i n g f o r p u b l i c a t i o n eg., c o l l a b o r a t i n g w i t h other members of the h e a l t h team i n w r i t i n g f o r p u b l i c a t i o n 1) other please s p e c i f y : % % % % 100 % *These cate g o r i e s have been taken from the work of Aradine,CR. & Denyes,M.J. A c t i v i t i e s and Pressures of C l i n i c a l Nurse S p e c i a l i s t s . Nursing Research, 19 21, 411-418. What i s the type of s e t t i n g i n which you work? Please check one maj major type appears i n upper case p r i n t . a) HOSPITAL: i f yes, i s i t a ( n ) : acute care h o s p i t a l ? extended care h o s p i t a l ? r e h a b i l i t a t i o n h o s p i t a l ? other? please s p e c i f y : b) NURSING HOME/HOMES FOR THE AGED c) COMMUNITY BASED SERVICES i f yes, i s i t a ( n ) : community mental h e a l t h agency? community h e a l t h agency? home c a r e / v i s i t i n g care agency? other? please s p e c i f y : d) BUSINESS/INDUSTRY e) PHYSICIAN'S OFFICE/FAMILY PRACTICE UNIT f) OTHER please s p e c i f y : 9. Given the f o l l o w i n g d e f i n i t i o n s what i s the type of appointment you hold a) Please check one of the f o l l o w i n g which a p p l i e s to your p o s i t i o n . TYPE DEFINITION unit-based a p o s i t i o n i n which you car r y primary r e s p o n s i b i l i t y f o r a defined geographic area w i t h i n the agency/setting not unit-based a p o s i t i o n i n which your primary r e s p o n s i b i l i t y i s not bound by a defined geographic area 132 9.(continued) b) Please check one of the f o l l o w i n g which a p p l i e s to vour p o s i t i o n . TYPE c l i n i c a l c l i n i c a l & educa-t i o n a l DEFINITION employed by & r e s p o n s i b l e to the department of n u r s i n g s e r v i c e f o r nu r s i n g care a c t i v i t i e s employed by & r e s p o n s i b l e to the department of nursing s e r v i c e and a department o f nursing education f o r nursing care a c t i v i t i e s and education of nur s i n g students r e s p e c t i v e l y c l i n i c a l & a d m i n i s t r a t i v e employed by & resp o n s i b l e to the department of nursing s e r v i c e f o r p a t i e n t care a c t i v i -t i e s as w e l l as a d m i n i s t r a t i v e a c t i v i t i e s other please s p e c i f y : c) Please check the one of the f o l l o w i n g which a p p l i e s to your p o s i t i o n . TYPE DEFINITION l i n e p o s i t i o n a p o s i t i o n i n which you have "power by v i r t u e of the o r g a n i z a t i o n a l p o s i t i o n " ; you have " r e s p o n s i b i l i t y f o r the a c t i o n s and the management of other employees" s t a f f p o s i t i o n a p o s i t i o n i n which you have power and i n f l u e n c e that r e s u l t s from knowledge and e x p e r t i s e ; you do not have r e s p o n s i b i l i t y f o r the a c t i o n s of others 10. What i s your b a s i c educational p r e p a r a t i o n i n nursing? baccalaureate program diploma program 133 11. Your post-basic nursing education consisted of which of the following? I f you require more space for your response please write on the page opposite t h i s one. TYPE of PROGRAM YEAR of COMPLETION dipl o m a / c e r t i f i c a t e area of study: baccalaureate nursing: other: master's nursing: other: doctoral nursing: other: 12. What positions i n nursing have you held? Please i n d i c a t e a l l positions you have had, i n a numbered sequence, and the approximate time, i n years, for each positi< POSITION APPROXIMATE SEQUENCE TIME i n YEA'. assistant head nurse associate/assistant d i r e c t o r d i r e c t o r general duty/staff nurse head nurse i n s t r u c t o r o f f i c e nurse/community health nurse professor supervisor/co-ordinator your present p o s i t i o n other please specify: 134 1 3 . Your age i s l e s s than 25 years 2 5 - 2 9 years 30 - 35 years 36 - 3 9 years 4 0 - 4 5 years 46 - 49 years 5 0 years and greater 1 4 . Your sex i s female male THANK YOU FOR COMPLETING THIS. 1 35 APPENDIX C 1 36 T a b l e C.1 L a b e l ( s ) and P e r c e n t a g e of Weekly Work Time Re p o r t e d f o r Other C a t e g o r y of Work A c t i v i t y (Item 7) S u b j e c t L a b e l used by S u b j e c t P e r c e n t a g e Category of weekly i n work time T a b l e 2 i n d i c a t e d 1 a. Data c o l l e c t i o n and 10 1 review b. F o l l o w - u p 15 1 c. Research l i a i s o n 5 1 2 C l e r i c a l 5 2 3 a. S u r v e i l l a n c e of i n f e c t i o n 27 4 b. S t a t i s t i c s 2 2 4 P a t i e n t e d u c a t i o n 30 7 5 S u r v e i l l a n c e of i n f e c t i o n 50 4 C o n t r o l 6 O r i e n t a t i o n programs 15 3 7 a. T r a d i t i o n a l n u r s i n g 10 6 s k i l l s b. C l e r i c a l 8 2 8 a. S u p e r v i s e v o l u n t e e r s 1 8 b. P u b l i c r e l a t i o n s 3 8 9 S u p p l i e s N.R.1 2 10 T r a v e l time 3 8 11 a. S e t t i n g up programs 5 3 b. Committee work 15 8 12 C o o r d i n a t e s e r v i c e s on N.R. 3 b e h a l f of i n d i v i d u a l p a t i e n t 13 P r o v i d i n g p s y c h o t h e r a p y 80 5 14 C o u n s e l l i n g 5 5 15 a. C l a s s g i v i n g 5 3 b. O r i e n t a t i o n t o new s t a f f 20 3 16 A d m i n i s t e r i n g chemotherapy 65 6 Average 23.5 N.R. = No re s p o n s e . 1 37 TABLES C.2 - C.9 These t a b l e s p r e s e n t a l l the r e s u l t s found f o r the a n a l y s e s of the i n f u e n c e of the c o n t e x t u a l l y r e l a t e d v a r i a b l e s and the p r o f e s s i o n a l v a r i a b l e d e r i v e d e d u c a t i o n a l l e v e l on the e s t i m a t e s of weekly work time r e p o r t e d f o r each c a t e g o r y of work a c t i v i t y . Two a n a l y s e s were done on each v a r i a b l e : an ANOVA t o t e s t f o r d i f f e r e n c e s between means, and a K r u s k a l - W a l l i s t e s t f o r d i f f e r e n c e s i n average rank. Where s i g n i f i c a n t d i f f e r e n c e s were found the mean i s f l a g g e d by a 1 (p<.05, ANOVA) or the average rank i s f l a g g e d by 2 (p<.05, K-W s t a t i s t i c ) . F u r t h e r d e t a i l s about the n a t u r e of the s i g n i f i c a n t d i f f e r e n c e s a r e p r e s e n t e d i n the t e x t of Chapter 4. 1 38 Table C.2 R e s u l t s of an A n a l y s i s of the V a r i a b l e Time i n P r e s e n t P o s i t i o n C a tegory Time i n N Min. Max. Mean SD Median Avg. Job Rank (months) Admini s- 0--6 3 5 20 10. 0 8. 6 5. 0 25. 6 t r a t i o n 7--12 4 5 20 1 1 . 2 6. 2 10. 0 29. 3 1 3-24 5 5 20 10. 4 5. 7 10. 0 28. 7 25--35 1 4 1 45 10. 2 12. 9 3. 5 19. 3 > 36 19 1 40 10. 4 1 1 . 2 5. 0 22. 3 TOTAL 45 10. ,4 10. 5 5. .0 Commun i t y o--6 1 5 5 5. ,0 -- 5. 0 19. ,0 A c t i v i t y 7--12 3 5 5 5. ,0 0. .0 5. ,0 19. ,0 1 3-24 5 1 5 4. ,2 1. ,1 5. ,0 15. ,9 25--35 10 1 35 1 1 . 2 13. .2 5. ,0 19. ,4 > 36 19 1 100 12. ,2 22. ,4 5. ,0 20. ,5 TOTAL 38 10. . 1 17. ,2 5. ,0 C o n s u l t - 0 -6 3 5 10 8. ,3 2. ,8 10. .0 21 . , 1 at i o n 7 -12 5 5 1 5 10. .0 5. .0 10. ,0 25. . 1 1 3 -24 9 5 92 19. .2 27. ,9 10. ,0 27. .2 25 -35 1 4 3 60 18. .6 16. .3 1 1 . ,0 31 . 9 > 36 24 2 60 15. .0 14. , 1 10. .0 27, .4 TOTAL 55 15. .8 16. .6 10. ,0 Educat i o n 0 -6 0 of 7 -12 3 5 1 0 6. .6 2, .8 5. .0 28, .5 S t u d e n t s 1 3 -24 5 1 5 3. .4 2. . 1 5. .0 16, .8 25 -35 12 1 25 6, .8 7, .8 4, .5 20, . 1 > 36 20 1 40 6, . 1 8, .4 5, .0 20, .4 TOTAL 40 6, .0 7, .3 5, .0 I n t e r d i s - 0 -6 3 10 20 13, .3 5, .7 10, .0 36, .3 c i p l i n a r y 7 -12 5 5 1 5 8 .0 4, .4 5, .0 25 .4 I n t e r - 1 3 -24 5 5 21 8 .2 7, . 1 5, .0 23 .6 a c t i o n 25 -35 1 4 1 22 7. .4 7, . 1 4, .0 20 .7 > 36 22 2 50 1 1 .0 10 .9 10, .0 26 .8 TOTAL 49 9 .5 8 .7 8, .0 P a t i e n t 0 -6 3 20 60 43 .3 20 .8 50, .0 29 .5 Care 7 -12 4 5 58 28 .2 21 .9 25 .0 21 . 1 1 3 -24 8 1 80 42 .6 30 .2 50 .0 27 .3 25 -35 1 5 7 80 35 .4 21 .6 25 .0 25 .2 > 36 20 5 80 37 .5 25 .3 32 .0 25 .2 TOTAL 50 37 .3 24 .0 30 .0 1 39 Table C.2 — C o n t i n u e d C a t e g o r y Time i n N Min. Max. Mean SD Median Avg. Job Rank (months) P e r s o n a l + 0--6 2 5 10 7. .5 3. 5 7. 5 33. 7 P r o f e s s - 7--12 4 5 20 8. .7 7. .5 5. 0 31 . 3 i o n a l 1 3-24 9 1 1 3 6. .3 3. 8 5. 0 27. 3 Growth 25--35 1 4 1 1 4 5. 0 3. 6 4. 5 20. 7 > 36 23 1 50 8. .4 10. , 1 5. 0 28. 1 TOTAL 52 7. , 1 7. ,4 5. 0 P l a n n i n g 0 -6 3 5 1 0 8. ,3 2. ,8 10. ,0 30. , 1 P o l i c y 7--12 5 1 20 9. ,2 7. ,9 5. ,0 25. , 1 St a n d a r d s 13' -24 7 1 1 5 6. ,4 5. ,0 5. ,0 21 . ,1 Change 25 -35 1 5 1 20 5. ,7 5. ,5 4. ,0 18. ,3 > 36 1 4 1 20 7. , 1 4. ,7 6. ,0 24. ,7 TOTAL 44 6. ,8 5. ,2 5. ,0 Rese a r c h 0 -6 0 7 -12 2 5 5 5. .0 0. .0 5. ,0 13. ,5 1 3 -24 3 1 20 8. .6 10. .0 5. ,0 12. ,5 25 -35 5 1 2 1 . .6 .6 2. ,0 7. ,3 > 36 1 0 1 1 5 4. .8 4, .6 3. ,5 10. .9 TOTAL 20 4. .6 5, .0 2. .0 S t a f f 0 -6 2 10 20 15. .0 7. .0 15. .0 32. .2 Develop- 7 -12 3 5 10 8. .3 2. .8 10. .0 ' 26, .5 ment 1 3 -24 5 1 30 9. .0 12, . 1 5, .0 17, .9 25 -35 1 1 1 1 4 4, .9 3, .8 3, .0 16, .9 > 36 1 6 1 80 9, .8 19, .3 5, .0 17, .7 TOTAL 37 8, .4 13, .5 5, .0 Wr i t i n g 0 -6 0 f o r 7 -12 2 5 5 5, .0 0, .0 5, .0 12, .5 P u b l i c a - 1 3 -24 3 1 5 2 .3 2 .3 1 , .0 7, .5 t i o n 25 -35 5 1 9 2, .6 3, .5 1 , .0 7, .4 > 36 8 1 40 7, .7 13, .2 3, .5 10, .8 TOTAL 18 5 . 1 9 .0 1 , .5 Other 0 -6 0 7 -12 4 1 50 22 .7 20 .6 20 .0 8 . 1 13 -24 4 5 29 16 .0 1 2 .8 15 .0 8 .3 25 -35 4 3 65 25 .5 29 . 1 17 .0 8 .7 > 36 4 2 80 30 .0 34 .2 19 .0 8 .7 TOTAL 1 6 23 .5 23 .4 19 .0 1 40 Tab l e C.3 R e s u l t s of an A n a l y s i s of the V a r i a b l e New Vers u s E x i s t i n g P o s i t i o n C a t e g o r y Type of P o s i t i o n N Min. Max. Mean SD Median Avg. Rank A d m i n i s - new 25 1 45 1 3 . 2 1 12.1 10.0 26.6 2 t r a t i o n e x i s t i n g 20 1 25 7.0 6.8 5.0 18.5 TOTAL 45 10.4 10.5 5.0 Communi t y new 20 1 100 11.4 21.9 5.0 20.2 A c t i v i t y e x i s t i n g 18 1 35 8.7 10.4 5.0 18.7 TOTAL 38 10.1 17.2 5.0 C o n s u l t - new 28 2 92 17.6 18.3 11.5 30.5 a t i o n e x i s t i n g 27 5 60 13.9 14.8 10.0 25.3 TOTAL 55 15.8 16.6 10.0 E d u c a t i o n new 19 1 25 6.8 6.3 5.0 23.5 of e x i s t i n g 21 1 40 5.2 8.2 4.0 17.7 S t u d e n t s TOTAL 40 6.0 7.3 5.0 I n t e r d i s -c i p l i n a r y n e w 25 1 50 10.5 10.9 5.0 25. 1 I n t e r - e x i s t i n g 24 1 22 8.5 5.7 9.5 24.8 A c t i o n TOTAL 49 9.5 8.7 8.0 P a t i e n t new 26 1 75 29.7 1 23.4 20.0 20.5 2 Care e x i s t i n g 24 15 80 45.-6 22.2 50.0 30.9 TOTAL 50 37.3 24.0 30.0 Pe r s o n a l + P r o f e s s - new 26 1 1 5 6.2 3.5 5.0 27 . 1 i o n a l e x i s t i n g 26 1 50 8.1 9.9 5.0 25.8 Growth TOTAL 52 7.1 7.4 5.0 P l a n n i n g . P o l i c y new 25 1 16 6.6 • 4.5 5.0 22.6 Sta n d a r d s e x i s t i n g 19 1 20 7.2 6.2 5.0 22.2 Change TOTAL 44 6.8 5.2 5.0 Res e a r c h new 1 1 1 20 4.0 5.5 2.0 9.5 e x i s t i n g 9 5 15 5.2 4.7 5.0 11.6 TOTAL 20 4.6 5.0 2.0 S t a f f new 20 1 30 7.9 7.8 5.0 19.8 Develop- e x i s t i n g 17 1 80 9.0 18.4 5.0 18.0 ment TOTAL 37 8.4 13.5 5.0 141 Ta b l e C.3 — C o n t i n u e d C a t e g o r y Type of P o s i t i o n N Min. Max. Mean SD Median Avg. Rank W r i t i n g f o r new 9 1 9 3.2 2.9 1 .0 8.8 P u b l i c a - e x i s t i n g 9 1 40 7.0 12.5 2.0 10.1 t i o n TOTAL 18 5.1 9.0 1 .5 Other new 9 1 50 17.6 16.4 18.0 7.5 e x i s t i n g - 7 3 80 31.1 29.9 20.0 9.7 TOTAL 1 6 23.5 23.4 19.0 1 42 Ta b l e C.4 R e s u l t s of an A n a l y s i s of the V a r i a b l e Job D e s c r i p t i o n C a t e g o r y Job D e s c r i p t . N Min. Max. Mean SD Median Avg. . Rank A d m i n i s - yes 27 1 40 10.5 9.5 7.0 22.8 t r a t i o n no 17 1 45 10.7 12.2 5.0 21.9 TOTAL 44 10.6 10.5 5.0 Community yes 23 1 35 8.6 9.5 5.0 20. 1 A c t i v i t y no 1 5 1 1 00 12.4 25.2 5.0 18.5 TOTAL 38 10.1 17.2 5.0 C o n s u l t - yes 31 2 92 16.0 19.0 10.0 27.3 a t i o n no 23 3 35 13.5 9.8 12.0 27.6 TOTAL 54 15.0 15.6 10.0 Educat i o n yes 23 1 40 6.0 7.9 5.0 20.6 of no 17 1 25 6.1 6.6 5.0 20.3 S t u d e n t s TOTAL 40 6.0 7.3 5.0 I n t e r d i s -c i p l i n a r y yes 28 1 21 8.4 5.3 10.0 24. 1 I n t e r - no 20 1 50 11.5 11.9 5.0 24.9 Act i o n TOTAL 48 9.7 8.7 8.5 P a t i e n t yes 27 1 80 32.7 21 .6 25.0 22.5 Care no 22 5 80 43.4 26.7 50.0 27.9 TOTAL 49 37.5 34. 1 30.0 P e r s o n a l + P r o f e s s - yes 30 1 50 8.4 9.3 5.0 28.0 i o n a l no 22 1 10 5.4 3.0 5.0 24.3 Growth TOTAL 52 ?' 1 7.4 5.0 P l a n n i n g P o l i c y yes 24 1 20 8.5 1 6.2 6.5 25. 1 S t a n d a r d s no 19 1 1 0 4.7 3.0 5.0 18.1 Change TOTAL 43 6.8 5.3 5.0 Rese a r c h yes 1 2 1 15 4.5 4.1 3.5 11.2 no 8 1 20 4.6 6.5 1 .5 9.3 TOTAL 20 4.6 5.0 2.0 S t a f f yes 20 1 80 11.0 17.6 5.0 20.9 Develop- no 16 1 20 5.2 5.5 3.0 15.4 ment TOTAL 36 8.4 13.7 5.0 1 43 Table C.4 -- C o n t i n u e d C a t e g o r y Job D e s c r i p t . N Min. Max. Mean SD Median Avg. Rank W r i t i n g f o r yes 1 2 1 40 6.0 11.0 1 .0 9.2 P u b l i c a - no 6 1 6 3.3 2.2 3.5 10.0 t i o n TOTAL 18 5. 1 9.0 1 .5 Other yes 10 3 80 27.6 25.9 22.5 9.5 no 6 1 50 16.8 18.8 11.5 6.8 TOTAL 1 6 23.5 23.4 19.0 1 44 Tab l e C.5 R e s u l t s of an A n a l y s i s of the V a r i a b l e Type of S e t t i n g Category Type of S e t t i n g N Min. Max. Mean SD Median Avg. Rank Admini s- hosp 32 1 45 10.5 10.5 5.0 23.0 t r a t i o n cbs 9 3 40 10.4 12.2 5.0 22.2 po/fpu 1 5 5 5.0 -- 5.0 19.5 o t h e r 3 3 20 11.0 8.5 10.0 26.0 TOTAL 45 10.4 10.5 5.0 Community hosp 22 1 35 6.3 8.7 5.0 15.6 A c t i v i t y cbs 1 3 1 1 00 16.6 26.5 6.0 25.0 po/fpu 0 o t h e r 3 5 20 10.0 8.6 5.0 24.0 TOTAL 38 10.1 17.2 5.0 C o n s u l t - hosp 36 3 92 17.2 8.6 5.0 29.8 a t i o n cbs 1 4 5 35 11.6 9.6 10.0 23.4 po/fpu 2 5 30 17.5 17.6 17.5 29.2 o t h e r 3 2 40 17.3 20.0 10.0 26. 1 TOTAL 55 15.8 16.6 10.0 E d u c a t i o n hosp 27 1 40 6.2 8.7 5.0 19.1 of cbs 1 0 2 1 o 4.7 2.8 4.5 20.6 S t u d e n t s po/fpu 0 o t h e r 3 5 •10 8.3 2.8 10.0 32.0 TOTAL 40 • 6.0 7.3 5.0 I n t e r d i s- hosp 33 1 50 8.5 9.3 5.0 22. 1 c i p l i n a r y c b s 1 2 2 30 12.0 7.4 5.0 31.4 I n t e r - p o/fpu 1 20 20 20.0 — 20.0 44.0 A c t i o n o t h e r 3 2 10 7.3 4 .6 10.0 23.6 TOTAL 49 9.5 8.7 8.0 P a t i e n t hosp 34 1 80 36.0 24.6 25.0 24.8 Care cbs 1 2 5 80 41.6 23.3 50.0 27.7 po/fpu 1 60 60 60.0 -- 60.0 40.5 o t h e r 3 5 50 26.6 22.5 25.0 19.1 TOTAL 50 37.3 24.0 30.0 Personal+ hosp 35 1 50 7.2 8.8 5.0 24.9 P r o f e s s - cbs 1 3 3 10 6.7 3.0 5.0 29.3 i o n a l p o/fpu 1 5 5 5.0 — 5.0 25.0 Growth o t h e r 3 5 1 5 8.3 5.7 5.0 33.0 TOTAL 52 7.1 7.4 5.0 1 45 Ta b l e C.5 — C o n t i n u e d C a t e g o r y Type of S e t t i n g N M i n . Max. Mean SD Median Avg. Rank P l a n n i n g hosp 33 1 20 6.7 5.5 5.0 21.9 P o l i c y cbs 8 3 20 8.0 5.3 7.0 26.0 Stand a r d s po/fpu 1 5 5 5.0 — 5.0 19.5 Change o t h e r 2 5 5 5.0 0.0 5.0 19.5 TOTAL 44 6.8 5.2 5.0 Research hosp 13 1 20 5.4 5.8 5.0 11.3 cbs 5 1 9 3.0 3.3 2.0 9.0 po/fpu o t h e r 2 1 5 3.0 2.8 3.0 8.7 TOTAL 20 4.6 5.0 2.0 S t a f f hosp 27 1 80 9.9 15.6 5.0 19.9 Develop- cbs 8 2 5 4.0 1 .4 5.0 16.1 ment po/fpu o t h e r 2 1 10 5.5 6.3 5.5 17.0 TOTAL 37 8.4 13.5 5.0 W r i t i n g hosp 1 3 1 40 6.0 10.5 2.0 10.7 f o r cbs 3 1 5 2.3 2.3 1 .0 7.5 P u b l i c a - po/fpu t i o n o t h e r 2 1 5 3.0 2.8 3.0 8.7 TOTAL 18 5.1 9.0 1 .5 Other hosp 1 4 1 65 21.0 18.7 19.0 8.3 cbs 2 3 80 41.5 54.4 41 .5 9.5 po/fpu o t h e r TOTAL 16 23.5 23.4 1 46 Tab l e C.6 R e s u l t s of an A n a l y s i s of the V a r i a b l e Type of Appointment ( U n i t vs Not U n i t Based) Categ o r y Type of N Min. Max. Mean SD Median Avg. P o s i t i o n Rank A d m i n i s - u n i t 21 1 45 11.0 12.6 5.0 21.0 t r a t i o n n o t - u n i t 23 1 35 10.0 8.5 5.0 23.8 TOTAL 44 10.5 10.6 5.0 Community u n i t 1 5 1 100 16.8 25.3 5.0 23.7 A c t i v i t y n o t - u n i t 22 1 30 6.0 6.6 5.0 15.7 TOTAL 37 10.3 17.4 5.0 C o n s u l t - u n i t 27 2 60 12.5 11.7 10.0 25.4 a t i o n n o t - u n i t 27 5 92 17.4 18.7 10.0 29.5 TOTAL 54 15.0 15.6 10.0 E d u c a t i o n u n i t 18 1 40 7.5 10.4 4.5 18.7 of n o t - u n i t 21 1 10 5.0 2.7 5.0 21.0 S t u d e n t s TOTAL 39 6.1 7.4 5.0 I n t e r d i s-c i p l i n a r y u n i t 24 1 50 9.9 10.7 9.0 23.4 I n t e r - n o t - u n i t 24 1 22 9.5 6.4 8.5 25.5 A c t i o n TOTAL 48 9.7 8.7 8.5 P a t i e n t u n i t 26 5 80 38.6 24.9 28.0 25.5 Care n o t - u n i t 23 1 80 36.5 23.7 38.0 24.3 TOTAL 49 37.6 24. 1 30.0 Pe r s o n a l + P r o f e s s - u n i t 25 1 50 8.2 9.7 5.0 27.3 i o n a l n o t - u n i t 26 1 20 6.3 4.5 5.0 24.7 ^Growth TOTAL 51 7.2 7.5 5.0 P l a n n i n g P o l i c y u n i t 22 1 20 7.7 6.5 6.0 22.8 St a n d a r d s n o t - u n i t 21 1 16 6.0 3.6 5.0 21.9 Change TOTAL 43 6.9 5.3 5.0 Research u n i t 9 1 7 3.2 2.4 2.0 8.7 n o t - u n i t 10 1 20 6.2 6.5 3.5 11.5 TOTAL 19 4.7 5. 1 2.0 S t a f f u n i t 20 1 30 7.9 7.8 5.0 19.8 Develop- n o t - u n i t 17 1 80 9.0 18.4 5.0 18.0 ment TOTAL 37 8.4 13.5 5.0 1 47 Ta b l e C.6 -- C o n t i n u e d Category Type of P o s i t i o n N Min. Max. Mean SD Median Avg. Rank W r i t i n g f o r u n i t 9 1 9 3.2 2.9 3.0 8.8 P u b l i c a - n o t - u n i t 9 1 40 7.0 12.5 1 .5 10.1 t i o n TOTAL 18 5.1 9.0 1 .5 Other un i t 9 1 50 17.6 16.4 16.5 7.5 n o t - u n i t 7 3 80 31.1 29.9 27.0 9.7 TOTAL 1 6 23.5 23.4 19.0 1 48 Tab l e C.7 R e s u l t s of an A n a l y s i s of the V a r i a b l e Type of Appointment ( C l i n i c a l , C l i n i c a l - e d u c a t i o n a l , C l i n i c a l - a d m i n i s t r a t i v e , O ther) C a t e g o r y Type of A p p o i n t . N Mi n . Max. Mean SD Median Avg. Rank A d m i n i s - c l i n 1 3 1 35 10. 4 1 1 . 1 5. 0 21 . 0 t r a t i o n c l i n - e d 3 4 1 5 8. 0 6. 0 5. 0 22. 1 c l i n - a d 6 2 45 16. 6 15. 9 15. 0 27. 5 o t h e r 22 2 40 8. 5 8. 7 5. 0 22. 0 TOTAL 44 10. 2 10. 5 5. 0 Community c l i n 8 2 5 4. 2 1 . 3 5. 0 15. 8 A c t i v i t y c l i n - e d 4 1 5 2. 0 2. ,0 1 . ,0 7. 2 c l i n - a d 3 5 10 6. 6 2. ,8 5. ,0 22. 1 o t h e r 22 1 1 00 14. 5 21 . ,8 5. ,0 21 . 8 TOTAL 37 10. ,2 17. ,5 5. ,0 C o n s u l t - c l i n 1 7 5 60 18. ,5 17. ,6 10. ,0 31 . ,6 a t i o n c l i n - e d 4 10 30 20. ,5 1 1 . ,0 21 . ,0 39. ,5 c l i n - a d 6 3 1 5 8. ,0 4. .4 7. ,5 19. , 1 o t h e r 27 2 92 14. ,4 18. , 1 10. ,0 24. ,9 TOTAL 54 15. ,4 16. .6 10. ,0 Educat i o n c l i n 9 1 40 7. .3 12. .3 5. .0 18. ,8 of c l i n - e d 4 4 5 4. ,7 < .5 5. .0 22. ,7 S t u d e n t s c l i n - a d 5 1 20 6. .6 7. .7 5. .0 20. .5 o t h e r 21 1 25 5. .4 5, .4 5. .0 19. .8 TOTAL 39 5. .9 7. .4 5, .0 I n t e r d i s - c l i n 1 3 2 1 5 5, .5 4, .0 5, .0 16. .8 2 c i p l i n a r y c l i n - e d 4 8 10 9. .5 1 , .0 10, .0 29, .5 I n t e r - c l i n - a d 7 1 20 7, .0 6, .4 5, .0 19, .5 Act i on o t h e r 24 1 50 12, .9 10, .8 10, .0 29, .3 TOTAL 48 9, .7 8, .8 8, .5 P a t i e n t c l i n 16 5 80 46, .0 27, .5 50, .0 29, .3 Care c l i n - e d 4 1 5 51 34, .0 19 . 1 35, .0 22, .7 c 1 i n - a d 7 5 75 38, .5 28 .2 25 .0 24, .8 o t h e r 22 1 70 32, .4 19 .5 27 .5 22, .2 TOTAL 49 37, .9 23 .8 30 .0 Pe r s o n a l + c l i n 1 4 1 50 8 .0 1 2 .6 5 .0 22 .8 P r o f e s s - c l i n - e d 4 2 5 4 .0 1 .4 4 .5 17 .7 i o n a l c l i n - a d 7 1 20 7 .0 6 .3 5 .0 25 .7 Growth o t h e r 26 1 20 7 . 1 4 .2 5 .0 29 .0 TOTAL 51 7 . 1 7 .5 5 .0 149 T a b l e C.7 -- C o n t i n u e d C a t e g o r y Type of N Min. Max. Mean SD Median Avg. A p p o i n t . Rank P l a n n i n g c l i n 1 5 1 1 5 6. , 1 4. ,2 5. ,0 21 . ,3 P o l i c y c l i n - ed 3 2 20 8. ,6 9. ,8 4. ,0 21 . ,5 Stand a r d s c l i n - ad 7 1 20 7. ,8 7. ,3 4. ,0 21 . 8 Change o t h e r 18 1 20 6. ,7 4. ,8 5. ,5 22. ,7 TOTAL 43 6. ,8 5. ,3 5. ,0 Research c l i n 4 1 7 3. ,5 3. ,0 3. ,0 9. , 1 c l i n - ed 2 2 5 3. ,5 2. , 1 3. ,5 10. ,7 c l i n - ad 3 1 1 1 . ,0 0. ,0 1 . ,0 4. ,0 o t h e r 10 1 20 6. ,6 6. .3 5. ,0 12. ,0 TOTAL 19 4. ,7 5. . 1 2. .0 S t a f f c l i n 1 1 1 30 8. .4 9. . 1 5. .0 19. .0 Develop- c l i n - ed 2 5 8 6. .5 2. . 1 6. .5 21 . 7 ment c l i n - ad 5 1 20 5. .6 8. . 1 3, .0 13. . 1 o t h e r 18 1 80 9. .7 17. .8 5, .0 19. .3 TOTAL 36 8. .6 13. .7 5, .0 W r i t i n g c l i n 3 1 6 2. .6 2, .8 1 , .0 7, .8 f o r c l i n - ed 1 1 1 1 , .0 -- 1 , .0 4, .5 P u b l i c a - c l i n - ad 1 1 1 1 , .0 -- 1 , .0 4, .5 t i o n o t h e r 1 2 1 40 6. .7 10, .7 5, .0 10, .0 TOTAL 17 5, .3 9, .2 2, .0 Other c l i n 4 1 65 18, .2 31 , .2 3, .5 5, .8 c l i n - ed 1 30 30 30, .0 30, .0 13, .0 c l i n - ad 3 5 25 15, .0 10, .0 15, .0 7, .6 o t h e r 8 3 80 28, .6 25, .5 22, .5 9, .5 TOTAL 1 6 23, .5 23, .4 19, .0 1 50 Table C.8 R e s u l t s of an A n a l y s i s of the V a r i a b l e L i n e V e r s u s S t a f f P o s i t i o n C a t e g o r y Type of P o s i t i o n N Min. Max. Mean SD Median Avg. Rank A d m i n i s - l i n e 6 5 45 21 .7 1 16.9 15.0 31 .I 2 t r a t i o n s t a f f 36 1 35 9.0 8.4 5.0 19.7 TOTAL 42 10.8 10.7 5.0 Community l i n e 3 1 5 3.6 2.3 5.0 13.5 A c t i v i t y s t a f f 33 1 100 11.0 18.4 . 5.0 18.9 TOTAL 36 10.4 17.7 5.0 C o n s u l t - l i n e 5 5 43 18.6 18.8 5.0 25. 1 a t i o n s t a f f 46 2 92 15.4 17.1 10.0 26.0 TOTAL 51 15.7 17.1 10.0 E d u c a t i o n l i n e 4 1 20 9.0 8.2 7.5 23.7 of s t a f f 33 1 40 5.8 7.5 5.0 18.4 S t u d e n t s TOTAL 37 6.1 7.5 5.0 I n t e r d i s -c i p l i n a r y l i n e 6 1 50 1 1 . 8 18.9 4.0 18.4 I n t e r - s t a f f 40 1 22 8.9 5.9 8.5 24.2 A c t i o n TOTAL 46 9.2 8.4 8.0 P a t i e n t l i n e 6 5 30 19.8 8.3 20.0 14.8 Care s t a f f 41 1 80 39.8 24.7 50.0 25.3 TOTAL 50 37.3 24.0 30.0 P e r s o n a l + P r o f e s s - 1 i n e 6 1 20 8.3 6.5 7.0 29.0 i o n a l s t a f f 43 1 50 7.0 7.8 5.0 24.4 Growth TOTAL 49 7.2 7.6 5.0 P l a n n i n g P o l i c y l i n e 6 1 20 7.3 7. 1 5.5 21.1 St a n d a r d s s t a f f 36 1 20 6.8 5.1 5.0 25.5 Change TOTAL 44 6.8 5.2 5.0 Res e a r c h l i n e 2 1 2 1 .5 0.7 1 .5 6.0 s t a f f 15 1 20 5.0 5.6 2.0 9.4 TOTAL 20 4.6 5.0 2.0 S t a f f l i n e 5 1 5 2.6 1 .5 2.0 10.5 Dev e l o p - s t a f f 30 1 80 9.5 14.8 5.0 19.2 ment TOTAL 35 5.0 151 T a b l e C.8 — C o n t i n u e d Category Type of P o s i t i o n N M i n . Max. Mean SD Median Avg. Rank W r i t i n g f o r 1 i n e 2 1 9 5.0 5.6 5.0 10.0 P u b l i c a - s t a f f 1 4 1 40 5.0 10.2 1 .0 8.2 t i o n TOTAL 1 6 5.0 9.6 1 .0 Other 1 i n e 3 4 18 12.3 7.3 15.0 6.3 s t a f f 1 3' 1 80 26.3 25.3 25.0 9.0 TOTAL 1 6 23.5 23.4 19.0 1 52 Tab l e C.9 R e s u l t s of an A n a l y s i s of the D e r i v e d V a r i a b l e E d u c a t i o n a l P r e p a r a t i o n Cat e g o r y L e v e l of N Min. Max. Mean SD Median Avg. Educat i o n Rank Admini s- diplo m a 34 1 45 10.6 10.6 5.0 23.3 t r a t i o n bacc 5 1 35 15.2 14.3 10.0 27.3 master 6 2 10 5.0 2.7 5.0 17.5 TOTAL 44 10.4 10.5 5.0 Community di p l o m a 27 1 35 7.2 8.2 5.0 18.8 Act i v i t y bacc 4 1 1 00 27.7 48.2 5.0 19.8 master 7 1 35 11.4 11.7 5.0 21.8 TOTAL 38 10.1 17.2 5.0 C o n s u l t - d i p l o m a 38 2 60 16.1 14.7 10.5 28.8 a t i o n bacc 8 5 30 11.8 8.4 10.0 26.3 master 9 5 92 18.0 27.9 10.0 25.7 TOTAL 55 15.8 16.6 10.0 Educat i o n d i p l o m a 28 1 40 6.7 8.5 5.0 21.0 of bacc 5 1 1 0 5.0 3.2 4.5 21.2 S t u d e n t s master 7 1 10 4. 1 3.0 4.0 17.7 TOTAL 40 6.0 7.3 5.0 I n t e r d i s - d i p l o m a 34 1 30 8.1 1 6.6 8.0 22.8 c i p l i n a r y b a c c 8 2 20 8.4 6.2 5.0 24.3 I n t e r - master 7 3 50 17.9 15.3 15.0 36.0 A c t i o n TOTAL 49 9.6 8.8 8.0 Pat i e n t d i p l o m a 35 1 80 36.8 25. 1 25.0 25. 1 Care bacc 8 5 75 43.8 26.8 50.0 29.0 master 7 1 5 50 32.4 14.1 30.0 23. 1 TOTAL 50 37.3 24.0 30.0 Per s o n a l + d i p l o m a 37 1 50 8.1 8.5 5.0 28.6 P r o f e s s - bacc 7 1 5 3.8 1 .9 5.0 18.8 i o n a l master 8 1 10 5.3 3.1 5.0 23.4 Growth TOTAL 52 7.1 7.4 5.0 P l a n n i n g d i p l o m a 32 1 20 6.5 4.8 5.0 22. 1 P o l i c y bacc 6 1 1 6 8.0 6.6 8.0 23.9 Stand a r d s master 6 1 20 7.5 6.7 6.5 23.0 Change TOTAL 44 6.8 5.2 5.0 153 T a b l e C.9 — C o n t i n u e d C a t e g o r y L e v e l of Educat i o n N Mi n . Max. Mean SD Median Avg. Rank Rese a r c h diploma 13 1 20 5.3 6.0 3.0 10.6 bacc 4 1 7 3.7 2.7 2.0 11.0 master 3 1 5 2.6 2.0 2.0 9.0 TOTAL 20 4.6 5.0 2.0 S t a f f d iploma 25 1 20 5.5 1 4.7 5.0 17.4 Develop- bacc 6 1 80 24.3 29.2 6.5 26.8 ment master 6 1 10 4.8 3.0 5.0 17.5 TOTAL 37 8.4 13.6 5.0 W r i t i n g d iploma 1 1 1 40 6.5 11.4 3.5 10.0 f o r bacc 3 1 6 2.6 2.8 1 .0 8.5 P u b l i c a - master 4 1 5 3.0 2.3 3.0 8.7 t i o n TOTAL 18 5.1 9.0 1 .5 Other diploma 9 2 65 27.2 20.2 27.0 9.7 bacc 4 1 20 7.7 8.3 5.0 5.2 master 3 3 80 33.6 40.8 18.0 9.0 TOTAL 1 6 23.5 23.4 19.0 

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