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 C L I N I C A L NURSE S P E C I A L I S T IN B R I T I S H COLUMBIA by SHIRLEY ANN L I L L Y  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 I N PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N NURSING  in THE FACULTY OF GRADUATE STUDIES (School of Nursing)  We a c c e p t t h i s t h e s i s a s c o n f o r m i n g to the required  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA April, ©  1983  S h i r l e y Ann L i l l y  Halliday,  1983  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may department or by h i s or her  be granted by the head of representatives.  my  It i s  understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be allowed without my  permission.  Department of ^\( uwV)4A ft The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date  DE-6  (3/81)  $(o  /Uttfl  \qfo  written  i i  ABSTRACT A lack of c l a r i t y of  the c l i n i c a l  concerning a description  nurse s p e c i a l i s t i n Canadian  problem addressed  in this thesis.  of the r o l e  n u r s i n g was t h e  A r o l e enactment  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 clinical 1972)  view of  what  n u r s e 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 a n d D e n y e s ,  were u t i l i z e d a s a f r a m e w o r k f o r s t u d y .  q u e s t i o n n a i r e was d e v e l o p e d a n d a m a i l with a s e l f - i d e n t i f i e d specialists  s u r v e y was c o n d u c t e d  g r o u p o f 147 c l i n i c a l  i n B r i t i s h Columbia.  A  nurse  Both d e s c r i p t i v e  analysis  and a n a l y s e s o f 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 out.  G e n e r a l l y s p e a k i n g i t was f o u n d t h a t :  still  a lack  of c l a r i t y  about  the r o l e  (1) t h e r e i s  in British  Columbia,  (2) t h e p r i m a r y means by w h i c h an i n d i v i d u a l n u r s e becomes a clinical  nurse s p e c i a l i s t i n B r i t i s h Columbia  experience  i n the system,  articulated  i n American  D e n y e s (1972) subjects,  (3) a d e s c r i p t i o n  i s through  of t h e r o l e  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 a n d  does not f i t t h e d e s c r i p t i o n  and (4) s t a t i s t i c a l l y  r e p o r t e d by t h e  significant relationships  e x i s t among some o f t h e v a r i a b l e s  examined and e s t i m a t e s of  w e e k l y work t i m e r e p o r t e d by t h e s u b j e c t s .  The  findings  s u g g e s t 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 t h e a r e a s o f education and s e r v i c e the  t o work t o g e t h e r on i s s u e s  r o l e of the c l i n i c a l  concerning  nurse s p e c i a l i s t i n Canada.  iii  TABLE.OF CONTENTS Abstract 1 Acknowledgement 2 CHAPTER 1 INTRODUCTION 1 S t a t e m e n t Of The P r o b l e m 4 S i g n i f i c a n c e Of The P r o b l e m 5 P u r p o s e s Of The S t u d y 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 Limitations 9 CHAPTER 2 REVIEW OF THE LITERATURE 10 C o n c e p t Of The C l i n i c a l N u r s e S p e c i a l i s t I n A m e r i c a n Nursing L i t e r a t u r e 10 Early Writings 11 Role Models 13 D i s c u s s i o n s And R e s e a r c h 16 The C l i n i c a l N u r s e S p e c i a l i s t I n C a n a d i a n N u r s i n g Literature 25 H i s t o r i c a l Perspective 26 N u r s i n g L i t e r a t u r e A b o u t The R o l e 29 P o s s i b l e E x p l a n a t i o n s F o r An O b s e r v e d Gap I h The Literature 31 CHAPTER 3 METHODOLOGY 36 Subjects 36 The I n s t r u m e n t 36 Procedure 37 CHAPTER 4 RESULTS 39 Present 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 Contextually Related Variables 44 Professional Variables 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 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 G r o u p Of C l i n i c a l N u r s e S p e c i a l i s t s I n B r i t i s h Columbia 60 Work A c t i v i t y 62 Contextually Related Variables 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 P r e s e n c e Or A b s e n c e Of J o b D e s c r i p t i o n 66 Work S e t t i n g 70 Type Of A p p o i n t m e n t 73 Professional Variable .. 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 B e t w e e n 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 D e n y e s (1972) 80 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 N u r s e S p e c i a l i s t R o l e I n Canada 91  iv  CHAPTER 6 SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY Summary Conclusions Implications Recommendations F o r F u r t h e r Study REFERENCES BIBLIOGRAPHY APPENDIX A APPENDIX B APPENDIX C TABLES C.2 - C.9  1  95 95 03 105 107 110 118 124 126 135 137  V  L I S T 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 L o n g e r I d e n t i f y i n g T h e m s e l v e s As C l i n i c a l N u r s e S p e c i a l i s t s ( I t e m 1 ( a ) )  40 2 Work A c t i v i t i e s Of S u b j e c t s ( I t e m 7) 42 3 Range And Mean P e r c e n t a g e Of E s t i m a t e d W e e k l y Work Time D e v o t e d To C a t e g o r i e s Of Work A c t i v i t y ( I t e m 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 F o r O t h e r C a t e g o r y Of Work A c t i v i t i e s ( I t e m 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 J o b T i t l e s P r o v i d e d By S u b j e c t s ( I t e m 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 F o r A l t e r n a t e J o b T i t l e s ( I t e m 3) 45 7 L e n g t h Of Time I n P r e s e n t P o s i t i o n ( I t e m 4) 46 8 T y p e s Of Employment S e t t i n g s ( I t e m 8) 47 9 R e s p o n s e s I n O t h e r C a t e g o r y F o r Type Of A p p o i n t m e n t ( I t e m 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 I n N u r s i n g Of The S u b j e c t s ( I t e m 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 P r o g r a m , And Minimum, Maximum And A v e r a g e Number Of Y e a r s S i n c e C o m p l e t i o n ( I t e m 11) 50 12 A r e a s Of S t u d y F o r D i p l o m a / C e r t i f i c a t e Type Of P r o g r a m s C o m p l e t e d ( I t e m 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 , S e q u e n c e , Range, And Mean Y e a r s H e l d ( I t e m 12) 53 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 B e t w e e n 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 P e r c e n t a g e Of W e e k l y Work Time D e v o t e d To C a t e g o r i e s Of Work A c t i v i t y 56 15 C o m p a r i s o n 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 A p p o i n t m e n t As D e s c r i b e d By A r a d i n e And D e n y e s And The P r e s e n t S t u d y 82 16 C o m p a r i s o n Of Work A c t i v i t y Of The C l i n i c a l N u r s e 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 D e y n e s (1972) And The F i n d i n g s Of The P r e s e n t S t u d y 87 C.1 L a b e l ( s ) And P e r c e n t a g e Of W e e k l y Work Time R e p o r t e d F o r O t h e r C a t e g o r y Of Work A c t i v i t y ( I t e m 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 I n Present 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 Existing Position 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 J o b Description 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 Setting 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  vi  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) 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 Staff Position 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 Educational Preparation  148 150 152  vii  ACKNOWLEDGEMENT I wish t o acknowledge and extend a statement of g r a t i t u d e t o a number o f p e r s o n s : my c o m m i t t e e members, Dr. M a r i l y n Willman  and M r s . B e t t y Johnson,  g u i d a n c e , work, s u p p o r t and unending and e x t e n d my t h i n k i n g ;  for their  capacities  t h e RNABC B o a r d members f o r  p r o v i d i n g a c c e s s t o t h e s e l f - i d e n t i f i e d group nurse s p e c i a l i s t s ; for  the individual  clinical  p r o v i d i n g t h e i n f o r m a t i o n about  w o r k ; my c h i l d r e n ,  Jeff  to challenge  f o rtheir  nurse  themselves  and Ben, as w e l l  f a m i l y members a n d f r i e n d s  of c l i n i c a l specialists  and t h e i r  a s a number o f  various  s u p p o r t , encouragement, and c a r i n g throughout  forms o f t h e work.  CHAPTER 1 INTRODUCTION The n e e d f o r s p e c i a l i z a t i o n w i t h i n t h e h e a l t h delivery  s y s t e m h a s been c r e a t e d  technological progress,  care  by r a p i d s c i e n t i f i c a n d  an i n c r e a s e  i n t h e number o f  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 medical p r a c t i c e , and  an i n c r e a s e  (Krause,  i n t h e p u b l i c demand f o r h e a l t h  1977; Smoyak, 1 9 7 6 ) .  Specialization  services  represents  mechanism t h r o u g h w h i c h p r o f e s s i o n s c a n p r o v i d e q u a l i t y of s e r v i c e t o the p u b l i c . as a r e a s o f s p e c i a l i z a t i o n  direct  developed (Smoyak,  leaders and  nursing, the c l i n i c a l  1976; P e p l a u ,  1965).  1952).  welfare. role  i n the United  response has occurred  States.  The c o n c e p t o f t h e  n u r s e 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  i n t h e 1930's a n d 1940's (Mayo, 1944; S t e w a r t ,  1976; P e p l a u , At the present  specialization  specialization: inherent  time,  the l i t e r a t u r e  "The i d e a o f c l i n i c a l  understanding  v e r y much a c c e p t e d  1933)  followed  1965; N a t i o n a l L e a g u e F o r N u r s i n g , tends t o  a s t a t e m e n t made by Smoyak i n 1976 c o n c e r n i n g  the  be i n o r d e r  nurse s p e c i a l i s t  This  s l o w movement t o w a r d c l i n i c a l  (Smoyak,  A  i n r e s p o n s e t o t h i s need f o r s p e c i a l i z a t i o n  predominantly clinical  emerge a n d d e v e l o p  r o l e s should  i t s c o n t r i b u t i o n t o the p u b l i c  Within  a high  develop within professions.  p r o f e s s i o n must d e f i n e what t h e s e to  Roles  a  clinical  specialization,  of e x c e l l e n c e  support  with  in practice, i s  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 c o n s u m e r s , professions."  e m p l o y e r s , and t h e o t h e r  (Smoyak, 1976; the c l i n i c a l  p. 6 7 8 ) .  Much h a s  written  about  nursing  l i t e r a t u r e ; h o w e v e r , most o f t h e  occurred during actual  the l a t e  nurse s p e c i a l i s t i n American  1960's and  c o n c e p t of c l i n i c a l  i n Canada  Nurse,  (Canadian Nurses A s s o c i a t i o n ,  1980;  n u r s e s who  Dworkin,  1970).'  1970's,  and  increase  b e t w e e n 1972  programs w i t h nurses.  defined  (The  1972);  Canadian  In s p i t e of t h i s ,  National and  a clinical  1976  there are  an  post-basic  f o r the  preparation  p r o g r a m s have i n c r e a s e d ( S t a t s Canada,  these s t a t i s t i c s  also  from  1978;  indicate a  i n t h e number o f g r a d u a t e s f r o m t h e s e  p r o g r a m s b e t w e e n 1972  and  programs the i n c r e a s e  h a s been f r o m  1976.  from master's programs,  1978; T a b l e 8 ) .  By  associations  included  had  indicate  i n t h e number o f  f r o m 2 t o 10  In a d d i t i o n ,  increase  statistics  focus a v a i l a b l e  Diploma/certificate  7 t o 11, a n d m a s t e r ' s Table 2).  1973 and  i d e n t i f y t h e m s e l v e s 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).  and  the e a r l y  nurse s p e c i a l i s t i s recognized  h o w e v e r , i t h a s n o t been f o r m a l l y  slight  publications  research r e l a t i n g to the r o l e i s l i m i t e d .  The  of  been  1976  From  diploma/certificate  165 t o 232  graduates,  f r o m 8 t o 17 ( S t a t s  Canada,  each of t h e p r o v i n c i a l  nursing  a work p o s i t i o n e n t i t l e d  "clinical  specialist"  on a n n u a l r e g i s t r a t i o n f o r m s  (Health  Statistics,  1976).  specialist," i t  The  title,  "clinical  seems, t h e n , i s r e c o g n i z e d w i t h i n  Manpower  b o t h work s e t t i n g s and  the  3  nursing  profession.  Within  B r i t i s h C o l u m b i a t h e number o f n u r s e s  identifying  themselves as " c l i n i c a l  increased.  I n 1974 t h e r e was a t o t a l  increased to a t o t a l 3b.1;  Rollcall  year  this total  Table 8 ) .  s p e c i a l i s t s " has o f 60; t h i s  o f 128 by 1981 ( R o l l c a l l  81, Table 8 ) . had i n c r e a s e d  74, T a b l e  I n t h e 1981-1982 r e g i s t r a t i o n t o 148 ( R o l l c a l l U p d a t e 8 2 ,  I n 1974 t h e p r o p o r t i o n o f " c l i n i c a l  represented  0.54% ( 6 0 / 1 1 , 1 8 2 ) o f t h e t o t a l  population  i n B r i t i s h Columbia.  self-identified  "clinical  (128/18,067) ( s e e R o l l c a l l  number  specialists"  r e g i s t e r e d nurse  I n 1981 t h e p e r c e n t a g e o f  specialists"  h a d r i s e n t o 0.71  74, t a b l e 3 b . 1 ; R o l l c a l l 8 1 ,  table 8). Some q u e s t i o n s  t h a t need t o be a n s w e r e d s o t h a t a  d e s c r i p t i o n of the r o l e clearly  articulated  role present  now?  i n Canada c a n b e g i n  i n c l u d e : What k i n d o f p i c t u r e d o e s t h e Can t h e 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 trends  be i d e n t i f i e d  direction  as a C a n a d i a n a s p e c t  designed  i n the l i t e r a t u r e ?  Is there  t o the concept of c l i n i c a l  What d o e s t h i s l o o k  to explore  Can  t h a t c a n be u s e f u l f o r p r o v i d i n g  to the nursing profession?  specialist?  t o be more  like?  This  such a t h i n g nurse  study  was  t h e 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 C a n a d i a n p r o v i n c e work p o s i t i o n a s c l i n i c a l  nurse  who i d e n t i f y  specialist.  their  4  Statement  of the  Nurses  Problem  are being prepared t o f u n c t i o n  nurse s p e c i a l i s t r o l e .  There  i n the  a r e n u r s e s who  identify  t h e m s e l v e s on a n n u a l r e g i s t r a t i o n f o r m s a s specialist."  In B r i t i s h Columbia  c a t e g o r y has  increased.  Because  clinical  "clinical  t h e number i n t h i s the r o l e of t h e s e n u r s e s  h a s n o t been d e f i n e d , t h e n u r s i n g p r o f e s s i o n  i n Canada  o n l y a borrowed  t o draw upon  and  s k e t c h y t h e o r e t i c a l base  f o r an u n d e r s t a n d i n g o f t h e r o l e and nurses f o r the r o l e . the  development  the p r e p a r a t i o n  This theoretical  base  application  of s u c h u n d e r s t a n d i n g s t o t h e C a n a d i a n  c a n be p r o b l e m a t i c .  Because  Thus,  s i n c e t h e e d u c a t i o n a l p r o c e s s must h e l p them  of the c o n c e p t of c l i n i c a l  n e e d e d by C a n a d i a n  nursing.  The  the c l i n i c a l problem  will  clear  nurse s p e c i a l i s t i s  T h e r e f o r e , the problem  a d d r e s s e d by t h i s s t u d y i s t h e need f o r a c l e a r of  situation  n u r s e s must be a b l e t o f i t i n t o  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 definition  from  o f n u r s i n g i n a n o t h e r c o u n t r y whose h e a l t h  i s o r g a n i z e d i n a d i f f e r e n t way.  r o l e , and  of  i s drawn  care system  the  nurse s p e c i a l i s t r o l e  t o be  description  i n Canadian  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  nursing. clinical  nurse 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 what t h e y do and t h e p l a c e m e n t agency.  has  of the r o l e  i n the  about  employing  5  S i g n i f i c a n c e of the It  Problem  i s b e l i e v e d by t h e 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  a c c e p t a n c e of t h e c l i n i c a l the  ability  to p r e c i s e l y d e s c r i b e the r o l e .  responsibility the  nurse s p e c i a l i s t  i s s u e s s u c h as q u a l i t y  and c e r t i f i c a t i o n  The  to  Professional  by t h e n u r s i n g p r o f e s s i o n  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  Purposes  are l i n k e d  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  role articulated  role  and  of t h e  cannot  i n Canada.  nurse  specialist  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 ,  be s a t i s f a c t o r i l y  addressed.  Study  purposes  of t h i s  study a r e :  1. t o d e s c r i b e t h e r o l e o f t h e c l i n i c a l  nurse  specialist  a s p e r c e i v e d by a g r o u p o f n u r s e s i n B r i t i s h  Columbia  who  group;  identify  2. t o i d e n t i f y  t h e m s e l v e s as b e l o n g i n g t o t h i s  s i m i l a r i t i e s and d i f f e r e n c e s b e t w e e n t h e  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 A r a d i n e and D e n y e s  on t h e a b o v e  r e p o r t e d by  (1972);  3. t o make s u g g e s t i o n s f o r t h e f u t u r e r o l e of the c l i n i c a l  in relation  nurse s p e c i a l i s t  findings.  of  i n Canada  to the based  6  D e f i n i t i o n o f Terms For  the purpose of t h i s study  specialist  a clinical  i s d e f i n e d as a nurse c u r r e n t l y  nurse  registered with  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 clinical  s p e c i a l i s t by c h e c k i n g  registration  form.  a particular  individual  1968;  Role  Box 23 on t h e 1981-1982  i s d e f i n e d as t h e o v e r t behavior of in a particular  setting  (Sarbin,  p. 1 9 4 ) .  Theoretical  Framework  Theoretically  t h i s study  was b u i l t on t h e f i r s t  r e s e a r c h q u e s t i o n o f "what i s ? " c a t e g o r i e s of a c t i v i t i e s (Aradine'and study  by r o l e  (Diers,  From a w i d e r  theory.  level  1979) a n d a l i s t o f  r e p o r t e d by n u r s e  Denyes, 1972).  was g u i d e d  identified the  as t h a t of  researchers perspective  D e u t s c h and K r a u s s  this (1965)  three d i f f e r e n t conceptualizations r e f l e c t e d i n  l i t e r a t u r e concerning  usage o f t h e t e r m r o l e .  These  i n c l u d e t h e 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 enacted In  role.  T h i s l a s t u s a g e was a d o p t e d f o r t h i s  t h i s usage, " r o l e c o n s i s t s of t h e s p e c i f i c o v e r t  of t h e occupant of a p o s i t i o n  has  175). Extensive  behavior  when he i n t e r a c t s w i t h t h e  o c c u p a n t s of' some o t h e r p o s i t i o n " p.  study.  (Deutsch  and K r a u s s ,  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  been r e p o r t e d by S a r b i n and A l l e n  (1968).  1965;  enactment  The m o d e l  7  t h e y o u t l i n e c a n be s u m m a r i z e d b r i e f l y  by t h e  following  equat i o n : Role enactment  d e p e n d s upon the interaction of:  role expectation + role location +  r o l e demands + role s k i l l s + r o l e congruence + audience e f f e c t . ( S a r b i n and A l l e n , The  a n a l y s i s and c o n c e p t s  utility, real  where " m u l t i p l e  f o r examining  role obligations  s i m u l t a n e o u s l y on t h e r o l e p e r f o r m e r " 1968;  p.  536).  Writers within  support a p p l i c a b i l i t y  of t h i s  the c l i n i c a l  nurse  Georgopoulos  and C h r i s t m a n ,  this  l a s t view  Allen,  1968;  definition  specialist  and  553)  and  applicability  role behavior i n impinge  ( S a r b i n and  Allen,  the n u r s i n g p r o f e s s i o n suggestion to examination role  (Stevens,  1970).  of r o l e t h e o r y  and, D e u t s c h  p.  d e s c r i b e d by t h i s m o d e l h a v e  the authors suggest,  life  1968;  1976;  Selected concepts  ( a s d e s c r i b e d by S a r b i n Krauss, in this  1965),  of  from and  their  study are o u t l i n e d  as  follows. R o l e e n a c t m e n t i s d e f i n e d as particular Allen,  individual  1968;  usefulness  " t h e o v e r t b e h a v i o r of a  in a particular  p. 4 9 4 ) .  i s concerned  A dimension  setting"  t h a t has  ( S a r b i n and  practical  w i t h t h e n o t i o n of i n v o l v e m e n t  (time  8  spent  i n one  role  relative  ( S a r b i n and A l l e n ,  1968;  t o time spent  p. 4 9 4 ) .  i n other  In t h i s  roles)  study examination  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 D e n y e s ( 1 9 7 2 ) .  The  d i m e n s i o n of i n v o l v e m e n t  u s e d by a s k i n g t h e p o p u l a t i o n o f i n t e r e s t  to provide  e s t i m a t e s o f a p e r c e n t a g e o f work t i m e d e v o t e d t o e a c h t h e p r o v i d e d c a t e g o r i e s o f work a c t i v i t y . position/status  location within a "status  ( D e u t s c h and K r a u s s , 1965; position  of i n t e r e s t  specialist. employing  position  p.  174).  a g e n c y was  solicited  i s enacted.  In a d d i t i o n ,  (2) a p e r s o n  t h i r d p e r s o n who  study the nurse  could  s t u d y was  the  also  i n h e r e n t i n t h i s view of (1) a  1968).  In t h i s  (Mead, 1 9 3 4 ) .  p r o v i d e d by t h e d a t a - c o l l e c t i n g  role  role  i n a c o m p l e m e n t a r y r o l e , and  (1) t h e r o l e p e r f o r m e r and  complementary r o l e  the  i n which  o b s e r v e s the p r o c e s s of s o c i a l  ( S a r b i n and A l l e n , both  this  to  system"  so t h a t a d e s c r i p t i o n  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  performer,  concept  the p o s i t i o n w i t h i n  of the c o n t e x t u a l background  g u i d e d by t h e u n i t o f a n a l y s i s theory.  In t h i s  i s t h a t of t h e c l i n i c a l  I n f o r m a t i o n about  be a r t i c u l a t e d  The  of  i s d e f i n e d as a r e l a t i o n a l concept used  represent a person's  was  (3) a  interaction  study each respondent  was  (2) t h e p e r s o n i n t h e The form.  t h i r d element The  was  observer, in this  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 collection  of d a t a .  The  r e s e a r c h e r ' s p r e s e n c e was  indirect  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 s t u d y was b a s e d on t h e f o l l o w i n g 1. The c a t e g o r y " c l i n i c a l registration  assumptions:  s p e c i a l i s t " on t h e RNABC  f o r m i s c h e c k e d by n u r s e s who s e e  themselves and/or  whose e m p l o y e r s  recognize their  as r e p r e s e n t a t i v e o f a s p e c i a l i z e d  clinical  work  role i n  nursing. 2. N u r s e s  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 o f t h e n u r s i n g p o p u l a t i o n i n Canada. 3. N u r s e s  i n the p o p u l a t i o n surveyed a r e a b l e and w i l l i n g  to p r o v i d e i n f o r m a t i o n about 4. N u r s e s to  their  specific  i n the p o p u l a t i o n surveyed w i l l  i t e m s on t h e d a t a - c o l l e c t i n g  practice.  respond h o n e s t l y  form.  Limitations 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 the  RNABC r e g i s t r a t i o n  form.  on  Therefore, the population  may h a v e e x c l u d e d n u r s e s who a r e f u n c t i o n i n g a s clinical  nurse s p e c i a l i s t s  define the role  as the l i t e r a t u r e  but d i d not i d e n t i f y  would  t h e m s e l v e s by  c h e c k i n g box 2 3 . 2. D a t a  o b t a i n e d by t h i s  description Columbia  survey research provided a  only of the r o l e  at the present time.  of t h i s group  in British  CHAPTER 2 REVIEW OF THE LITERATURE The present  first  an o v e r v i e w  specialist next  section w i l l  s e c t i o n of t h i s  nurse  a brief  review  nurse s p e c i a l i s t .  chapter  present  will  i n the l i t e r a t u r e  Nurse S p e c i a l i s t  The  possible  f o r a l a c k of  d i s c u s s i o n about t h e r o l e d u r i n g t h e past  Concept of t h e C l i n i c a l  The  of Canadian  the c l i n i c a l  suggested  will  i n American nursing l i t e r a t u r e .  present  concerning  explanations  of the l i t e r a t u r e  of the concept of the c l i n i c a l  as d e s c r i b e d  literature final  s e c t i o n of the review  decade.  i n American  Nursing  Literature This section w i l l  be s u b d i v i d e d  into areas  entitled  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 great  nursing literature  i m p a c t on t h e d e v e l o p m e n t o f n u r s i n g  (Mussallem, important role  from t h e U n i t e d S t a t e s has had a  1964; p. 3 0 - 3 1 ) .  Because of t h i s ,  t h a t w r i t i n g s about t h e c l i n i c a l  in this  literature  be e x a m i n e d .  10  i n Canada" i t is  nurse  specialist  11  Early The  concept of c l i n i c a l  application  expert  nurse s p e c i a l i s t  and i t s  i n t h e p r a c t i c e o f n u r s i n g h a v e been  by a number o f a u t h o r s 1962).  Writings  Johnson  ( R e i t e r , 1966; P e p l a u ,  (1962) v i e w e d t h e c l i n i c a l  practitioner  who, i n c o m b i n a t i o n  manager, c o u l d p r o v i d e  1965; J o h n s o n ,  specialist  with a  an a l t e r n a t e p a t t e r n t o t h a t o f t h e  She v i e w e d n u r s i n g system.  s e r v i c e as r e p r e s e n t a t i v e  She b e l i e v e d t h e r o l e ,  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 quality  of care p r o v i d e d  Peplau  (1965) i d e n t i f i e d  to  make c h o i c e s  the preparation  of c l i n i c a l  development i n p r o f e s s i o n a l  outlined  profession  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 t h e  Utilizing  a v a i l a b l e knowledge and  about t h e concept of s p e c i a l i z a t i o n  understanding  i n general,  Peplau  t e n c a t e g o r i e s o f s p e c i a l t y p r a c t i c e a n d two m o d e l s  specialization  f r o m w h i c h 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 specialization certain  nurses.  She e m p h a s i z e d t h e need f o r t h e n u r s i n g  profession.  for  in this  i n improvement o f t h e  t o p a t i e n t s by  s p e c i a l i s t s a s a most i m p o r t a n t nursing.  regarding  w o u l d be c e n t r a l i z e d a t t h e c l o s e s t p o i n t t o  the p a t i e n t . of a s o c i a l  a s an  floor/unit  head n u r s e a n d a means by w h i c h d e c i s i o n - m a k i n g patient care  discussed  f o r the development of  i n nursing described  by P e p l a u  reflect  statements about t h e d e l i v e r y of h e a l t h  services t o the p u b l i c . organized  care  F o r example, h o s p i t a l s a r e  f o r the d e l i v e r y of s e r v i c e s according  t o age  12 groups and t h e l e n g t h individual.  Within  further organized degree of i l l n e s s , goals.  o f i l l n e s s e x p e r i e n c e d by an  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  according fields  t o organs and b o d i l y  of knowledge, and p r o f e s s i o n a l  On t h e one h a n d t h e s e c a t e g o r i e s  developing the c l i n i c a l profession  systems,  specialist  suggest t h a t , i n  r o l e , the nursing  was r e s p o n d i n g t o e v o l v i n g  the  work e n v i r o n m e n t o f t h e h o s p i t a l .  and  a t t h e same t i m e , p r o f e s s i o n a l  developments  within  On t h e o t h e r  hand,  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  nursing  of  s p e c i a l i z a t i o n i n nursing  the r o l e s concerned with  they continue t o Clinical  articulate descriptions as  evolve.  specialists,  generalists trained with  according  to Peplau  a b r o a d base of  (1965), are  intellectual  c o m p e t e n c i e s who p o s s e s s t h e o r e t i c a l a n d 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 They s h o u l d a l s o be c o n t r i b u t e r s in the profession  w h i c h t h e y work.  t o the a v a i l a b l e  by c o n d u c t i n g r e s e a r c h  knowledge  and p u b l i s h i n g t h e  f indings. Another e a r l y w r i t e r , R e i t e r m e a n i n g she a s s o c i a t e d  with  used t h e l a b e l i n a g e n e r i c being."  This  reflects,  (1966), e x p l o r i n g the  the concept of nurse  sense t o i n d i c a t e a " s t a t e of  she m a i n t a i n e d , an a c c u m u l a t i o n o f a  d e p t h of knowledge and e x p e r i e n c e a p p l i e d nursing.  clinician,  R e i t e r viewed the r o l e as t h a t  p r a c t i t i o n e r who u s e s a h i g h  i n t h e p r a c t i c e of of a master  degree of d i s c r i m i n a t i v e  13  judgement i n the i s m o t i v a t e d by quality  of  a p p l i c a t i o n of t h e  nursing  a commitment t o t h e  nursing  p r o v i s i o n of  abstract  i n nature.  clinical  p r a c t i c e i s the  the  other  that  the  ( i f we authors'  f o c u s of  R e i t e r agree  t h e work of t h e  usage o f c l i n i c a l practioner,"  be  role.  profession  i n the  or p r o v i d i n g the  P e p l a u and  role.  articulated  r e f e r r i n g to  the  said that a l l three  form of a d v a n c i n g the  a h i g h q u a l i t y of n u r s i n g  writers  Assuming  s k i l l s are  a  part  R e i t e r a g r e e t h a t commitment t o  Johnson does not  Later  to  "intellectual  a u t h o r s a g r e e t h a t a d v a n c e d k n o w l e d g e and the  clinical  specialist).  "master p r a c t i t i o n e r " are i t t h e n can  (McPhail,  discuss 1971;  is  that  equate R e i t e r ' s term nurse c l i n i c i a n  same s e t of n o t i o n s ,  of  highest  of u n d e r s t a n d i n g t h a t  J o h n s o n , P e p l a u and  terms "expert  c o m p e t e n c i e s " and  the  who  care.  These w r i t i n g s r e f l e c t a l e v e l  specialist  p r o c e s s and  the  knowledge a v a i l a b l e care,  i s a part  t h i s point  explicitly.  B a r r e t t , 1971)  similar theoretical definitions.  of  have  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 b a c k d r o p 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  this  study.  Role Models The nursing  f i r s t d e s c r i p t i o n of a r o l e model a p p e a r s i n literature  Christman  i n 1970.  the  D e v e l o p e d by G e o r g o p o u l o s  ( 1 9 7 0 ) , t h e m o d e l was  derived  l i t e r a t u r e p r i o r t o November, 1965,  and  f r o m a r e v i e w of  from p r e v a i l i n g r o l e  the  14  t h e o r y and o r g a n i z a t i o n e x p e r i e n c e and Five role  t h e o r y , and  from the  knowledge of h o s p i t a l s  major  classes  investigators'  and t h e h e a l t h  field.  of components a r e d e l i n e a t e d  by  this  model:  1. t r a i n i n g a n d p r e p a r a t i o n 2. p r o f e s s i o n a l  v a l u e s and  3. c o r e f u n c t i o n s  for c l i n i c a l  practice;  orientation;  and a c t i v i t i e s  of t h e c l i n i c a l  nurse  specialist; 4.  relevant  r i g h t s and o b l i g a t i o n s  of t h e c l i n i c a l  nurse  specialist; 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 at the p a t i e n t  ( G e o r o g o u l o s and C h r i s t m a n , 1970; The  assumptions  professional  p.  unit  level  1034-1035).  i d e n t i f i e d by t h e s e a u t h o r s a b o u t  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 w h i c h d i r e c t t h e s t r u c t u r e  of t h e model  include: 1 . the " c l i n i c a l who  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  has c o m p l e t e d a m a s t e r ' s  specialization  2. t h e r o l e  3. t h e r o l e leadership 1970; p. 4. p a t i e n t  a hospital  professional-organizational  system;  " r e p r e s e n t s a new and p r a c t i c e  (Georgopoulos  1033);  i s "an e x p l i c i t  role" within  l e v e l program f o r  in a p a r t i c u l a r nursing area"  and C h r i s t m a n , 1970; p.  r o l e model f o r c l i n i c a l ( G e o r g o p o u l o s and C h r i s t m a n ,  1031); unit  nurse  team l e a d e r s who  are c l i n i c a l  nurse  15  s p e c i a l i s t s can improve A second  the q u a l i t y  The m o d e l was d e r i v e d f r o m a  s t u d y o f what a g r o u p o f c l i n i c a l p e r c e i v e d themselves  nurse  as a c t u a l l y doing  researchers conducted activities,  care.  d e s c r i p t i o n o f 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 ( 1 9 7 2 ) .  of  of p a t i e n t  specialists in their  work.  These  an e x p l o r a t o r y s t u d y o f ( 1 ) t h e s c o p e  (2) t h e p r e s s u r e s , a n d (3) t h e d e 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  specialists.  s a m p l e p o p u l a t i o n c o n s i s t e d o f 29 c l i n i c a l  nurse  The specialists  e m p l o y e d i n h o s p i t a l s w h i c h were members o f t h e U n i v e r s i t y Hospital Executive C o u n c i l .  A two day symposium p r o v i d e d  1  t h e medium f o r d i s c u s s i o n s r e l a t e d t o t h e i s s u e s i d e n t i f i e d above.  M e m b e r s h i p i n t h e d i s c u s s i o n g r o u p s was p l a n n 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 different  lengths of experience  p o s i t i o n s , and p a r t i c i p a t i o n composite language  list  from each  o f 122 a c t i v i t i e s  of the c l i n i c a l  review of t h i s  in clinical  list  nurse  nurse  specialist  institution.  was r e c o r d e d  specialists.  was made by s i x j u d g e s .  c o n s i s t e d of grouping t h e a c t i v i t i e s  areas,  A  i nthe An  independent  The r e v i e w  into categories.  T h e r e was 100 p e r c e n t a g r e e m e n t among t h e j u d g e s on 28 i t e m s , 83 p e r c e n t a g r e e m e n t on 22 i t e m s , and 67 p e r c e n t a g r e e m e n t on 20 i t e m s . The r e m a i n i n g 52 i t e m s on w h i c h t h e r e was l e s s t h a n 67  h o s p i t a l s i n c l u d e d i n t h e UHEC a r e t h e C a s e W e s t e r n R e s e r v e U n i v e r s i t y , U n i v e r s i t y of Chicago, Indiana U n i v e r s i t y , U n i v e r s i t y o f Iowa, U n i v e r s i t y o f M i c h i g a n , U n i v e r s i t y o f M i n n e s o t a , U n i v e r s i t y o f R o c h e s t e r (New Y o r k ) , a n d U n i v e r s i t y o f W i s c o n s i n ( A r a d i n e a n d D e y n e s , 1972, p. 4 1 1 ) .  16  p e r c e n t a g r e e m e n t were d i s c u s s e d and c o d e d by two c l i n i c a l n u r s e s p e c i a l i s t j u d g e s who a t t e n d e d t h e s y m p o s i u m . T h e r e was 100 p e r c e n t a g r e e m e n t on t h e s e 52 i t e m s . ( A r a d i n e and D e n y e s , 1972; p. 4 1 2 ) . T h e s e c a t e g o r i e s o f work a c t i v i t y  comprise  what  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 clinical  nurse  specialist  r o l e as  i t was  the of  the  p e r c e i v e d by  the  sample. The  components of t h i s r o l e model a r e l e s s  well  developed  than those d e s c r i b e d i n the Georgopoulos  Christman  model.  collection  and  This i s related  t o the f o c u s of  ( A r a d i n e and D e n y e s , 1972;  a u t h o r s d i d not e x p l i c i t l y r o l e model.  activities,  The  with  responsibilities  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  this  data  a n a l y s i s , which d e a l t predominantly  " 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 ,  specialists"  and  and  nurse  p. 4 1 1 ) .  a r t i c u l a t e assumptions  reported f i n d i n g s concerned  The underlying w i t h work  as o u t l i n e d by A r a d i n e and D e n y e s , f o r m a b a s i s  for comparison  w i t h the f i n d i n g s of t h i s  D i s c u s s i o n s and A review  study.  Research  i n d i c a t e s t h e r e i s a wide range  about the c l i n i c a l although l i m i t e d  nurse  specialist  i n amount, has  and  setting.  The  range  organized  i n t o the f o l l o w i n g  empirical  predominantly  q u e s t i o n o f e f f e c t i v e n e s s of t h e r o l e  of  i n the  literature research,  f o c u s e d on hospital  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 areas:  the  be  17  1. t h e e d u c a t i o n a l p r e p a r a t i o n o f t h e c l i n i c a l specialist Murphy,  (Hellman,  1974;  Berlinger,  1973;  1975;  NLN,  1970;  Gordon,  1973;  Pearson,  nurse  1972;  specialist role  Backsheider,  (Bullough, 1970;  and  1976;  Barrett,  Richards,  1971;  Baker  1971;  (Risk, Sturzl,  Shaefer,  1973;  S a n a , 1971;  implementation and K r a m e r ,  1970;  1969);  t h e e f f e c t i v e n e s s of t h e r o l e  1979;  1971;  1969);  3. t h e 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  4.  MacPhail,  1970);  2. t h e n a t u r e of t h e c l i n i c a l  Love,  nurse  Woodrow and  Georgopoulos  and  ( E h r e n r e i c h and Bell,  1971;  Jackson,  Stewart,  Georgopoulos  1970;  Little,  1967) ; 5. a c t i v i t i e s Denyes,  of t h e c l i n i c a l  nurse  s p e c i a l i s t (Aradine  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 specialist of  graduate  r o l e c e n t r e upon w h e t h e r i t s h o u l d be education  M u r p h y , 1970; and  Peplau,  ( M a c P h a i l , 1971; 1965)  on t h e j o b t r a i n i n g  position nurse within  and  1971).  of  The  i s an a d v a n c e d and  nursing practice.  by a t l e a s t relatively  two  The  observations.  1973; experience  clinical  specialized  latter position  role  i s supported  These i n c l u d e the f a c t t h a t a  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  l e v e l f o r the r o l e  form  former  i s s u p p o r t e d by t h e a r g u m e n t t h a t t h e  specialist role  graduate  (Barrett,  i n the  Berlinger,  or a combination  nurse  (Boone and K i k u c h i ,  the 1977;  18  Coombs, 1 9 7 0 ) , and a q u e s t i o n a s t o t h e a b i l i t y  of  the  e d u c a t i o n a l s y s t e m 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 t h e r o l e  (CN,  1981;  Jenny,  1968).  It  s h o u l d be n o t e d t h a t t h e s e 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 Research  i n t o the r o l e  i n d i c a t e s advanced  d e p t h 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 necessary to function 1971; G e o r g o p o u l o s preparation  work i n C a n a d a .  i n the r o l e  and  s p e c i a l i t y are  (Georgopoulos and  and J a c k s o n , 1 9 7 0 ) .  f o r the c l i n i c a l  knowledge  Sana,  This suggests  that  n u r s e s p e c i a l i s t r o l e may  only  be a t t a i n a b l e t h r o u g h t h e p r o c e s s o f g r a d u a t e e d u c a t i o n . The  n a t u r e o f t h e r o l e , a s r e f l e c t e d by t h e 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 c o m p l e x and  multifaceted.  In a b r o a d sense t h e l i t e r a t u r e s u r v e y e d would  seem t o  support t h i s view.  t h e n a t u r e of  the  role  the  larger  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  specialist in  However, d i s c u s s i o n s a b o u t  c o m p l e x phenomenon o f t h e c l i n i c a l role.  For example,  a s p e c t of  nurse  t h e r o l e has been d e s c r i b e d  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 K r a m e r , 1970;  model  Scully,  ( B a c k s h e i d e r , 1971;  1967;  Baker  and  J o h n s o n , W i l c o x and M o i d e l ,  1967); 2.  a change agent model  (Gordon,  3.  a c o n s u l t a t i o n model  (Blake,  1969; 1977;  Loomis, Stetter  1968); 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  (Parkes,  1974;  19  Fagin, 5.  1967); and  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  and L a n g , 1977; P e a r s o n , Consistency first  1972; S t u r z l ,  (Gregory  1970).  i s evident i n the writings that  f o c u s on t h e  four of these f i v e broader views of the c l i n i c a l  specialist Dilworth  role.  (1970).  The l a s t v i e w h a s been c r i t i c i z e d The b a s i s f o r t h i s  nurse  by  i s t h e o b s e r v e d gap  b e t w e e n 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 a n d t h e e x p e c t a t i o n s and n e e d s o f n u r s i n g p r a c t i c e (Dilworth,  1970).  Research  i n t o the nature of the r o l e  Woodrow a n d B e l l  i s limited.  (1971) a n d A r a d i n e a n d D e n y e s  (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 o f t h e r o l e a s i t was p e r c e i v e d by c l i n i c a l The  former  report  nurse s p e c i a l i s t s working researchers u t i l i z e d  their  in a hospital  setting.  own e x p e r i e n c e s a n d  f r e q u e n c y counts and r e l a t i v e p e r c e n t a g e s o f t h e  number o f c o n t a c t s e a c h e x p e r i e n c e d i n f o u r a r e a s o f 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 . r e s e a r c h e r s asked a group of c l i n i c a l  The  latter  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  activities  performed  the  i n t h e i r work.  r o l e of the c l i n i c a l  The d a t a i n d i c a t e  nurse s p e c i a l i s t  that  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 o f a r t i c l e s c o m p i l e d by L e w i s 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 o f c l i n i c a l  i n 1970  nurse  20  s p e c i a l i s t s who have i m p l e m e n t e d collection the  i s available  Clinical  f o r Canadian  of o p t i m i s m about  r o l e on t h e q u a l i t y a n d c o n t i n u i t y  (Lagerson,  1973; Simms, 1973; M e l b e r ,  A similar  nursing  Nurse S p e c i a l i s t , 1973).  r e f l e c t an a t t i t u d e the  the r o l e .  ( C o n f e r e n c e on  These a c c o u n t s the possible of patient  impact of care  1967; Y o k e s ,  1966) a n d  an e x p e r i e n c e o f e x c i t e m e n t a n d s a t i s f a c t i o n r e l a t e d work i t s e l f  (Snyder, 1973).  provide insights Anderson,  In a d d i t i o n ,  into frustrations  1966), d i f f i c u l t i e s  the accounts  ( D a r c o v i c h , 1973;  ( A n d e r s o n e t . a l . , 1975; R i s k ,  1 9 7 5 ) , and s t r a t e g i e s  utilized  specialists  (Barrett,  1971; R i c h a r d s , 1969) a s e a c h  implemented  a new  Descriptions  by a number o f c l i n i c a l  and s t u d i e s  of implementation of the r o l e  T h i s p e r s p e c t i v e h a s f o c u s e d on v a r i a b l e s (Kirkman and M i l l e r ,  1970); s t a f f a c c e p t a n c e 1966); communication p e r c e i v e d as e i t h e r implementation 1973).  authority  1972; B a k e r a n d K r a m e r ,  (Woodrow and B e l l ,  1971; Simms,  ( B a c k s h e i d e r , 1971); and o t h e r facilitating  factors  or i n h i b i t i n g r o l e  ( E h r e n r e i c h a n d S t e w a r t , 1979; S h a e f e r ,  A t l e a s t two i m p o r t a n t i s s u e s  p o s i t i o n of the r o l e  agency and u t i l i z a t i o n by t h e a g e n c y .  viewpoint.  such as  related to  implementation of the r o l e warrant a t t e n t i o n . the  nurse  role.  h a v e p r e d o m i n a n t l y been f r o m an a d m i n i s t r a t i v e  structure  t o the  i n the authority  These c o n c e r n  structure  o f an  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  21  The  literature indicates  there  is little  concerning the p o s i t i o n of the c l i n i c a l role within  the authority  structure  agreement  nurse s p e c i a l i s t  o f an a g e n c y .  The  a d v a n t a g e s and d i s a d v a n t a g e s o f t h e r o l e b e i n g p l a c e d line of  v e r s u s s t a f f p o s i t i o n h a v e been d i s c u s s e d by a number  writers  (Castronovo,  Kirkman and M i l l e r , 1971;  1975; P a r k e s ,  placement.  i n an a g e n c y i s  inherent  i n such  nurse s p e c i a l i s t can e s t a b l i s h  maintain working r e l a t i o n s h i p s with care  role within (1976).  accountability  s t a f f n u r s e s and  professionals.  Another p o s i t i o n  Stevens  general,  i s b a s e d on t h e r e s u l t i n g g r e a t e r d e g r e e o f  which the c l i n i c a l  other health  the  In  The n a t u r e o f t h e s u p p o r t f o r t h e r o l e a s a  position  ease w i t h  1971; M a c P h a i l ,  1967).  f o r the r o l e as a l i n e p o s i t i o n  b a s e d on t h e p o s i t i o n a l a u t h o r i t y  staff  1974; C o o p e r , 1973;  1972; Woodrow a n d B e l l ,  B a k e r a n d K r a m e r , 1970; L i t t l e ,  support  and  in a  related  t o the issue  the organization  of placement of  h a s been a r t i c u l a t e d by  In her e x a m i n a t i o n of the l a r g e r as i t r e l a t e s t o a u t h o r i t y  issue of  and t h e c l i n i c a l  n u r s e s p e c i a l i s t r o l e , S t e v e n s makes a d i s t i n c t i o n b e t w e e n two  types of a u t h o r i t y .  authority inherent  usually  r e s u l t i n g from t h e l o c a t i o n  i n the  administrative hierarchy  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  authority clinical  There i s , she s a y s ,  r e s u l t i n g from peer p e r c e p t i o n of t h e i n d i v i d u a l n u r s e s p e c i a l i s t ' s knowledge and e x p e r t i s e  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 ) .  (this i s  The i s s u e o f  22  staff  v e r s u s l i n e p o s i t i o n , t h e n , c a n 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 attention  i s redirected  accountability director  t o the larger  of t h e c l i n i c a l  of nursing  service.  a r i s e when t h e f o c u s o f i s s u e of  nurse s p e c i a l i s t t o a The c h a l l e n g e ,  then, 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 p l a c e m e n t o f t h e r o l e w i t h i n an organizational issue the  structure  may l i e i n c o m i n g t o t e r m s w i t h t h e  of a c c o u n t a b i l i t y .  clinical  organization  One way t h i s c a n be done  nurse s p e c i a l i s t c o n t r a c t i n g to establish accountability  L i t e r a t u r e concerning u t i l i z a t i o n  involves  with the (Stevens,  1976).  of t h e c l i n i c a l  specialist  r o l e by an a g e n c y s u g g e s t s a c c e p t a n c e o r  resistance  of s t a f f nurses i s a c r u c i a l v a r i a b l e  success with 1971;  implementation  Backsheider,  centrality  1971).  the  roles  i n nursing  there i s overlapping  T h i s c a n make i t d i f f i c u l t Without c l a r i t y practice,  reason f o r the  f o r success with  practice  related to  1975; Woodrow a n d B e l l ,  One p o s s i b l e  of t h i s v a r i a b l e  may l i e i n t h e f a c t t h a t  (Risk,  implementation with  (Baker and Kramer,  to delineate  many o f 1970).  functions  clearly.  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  i tisdifficult  nurses concerning patient  to develop c o l l a b o r a t i o n care  nurse  nursing among  (Smoyak, 1976; B a c k s h e i d e r ,  1971 ) . Research suggests s t a f f acceptance i s influenced inclusion  o f s t a f f members i n t h e p l a n n i n g  introduction  of the r o l e  i n t o an a g e n c y  by t h e  f o r the  ( B a r r e t t , 1971;  23  Richards,  1 9 6 9 ) , and  and t h e o r g a n i z a t i o n  the a d m i n i s t r a t i v e f o r the r o l e  T h i s s u p p o r t must be o n - g o i n g  s u p p o r t of  (Risk,  1975;  nursing  Simms,  i n n a t u r e ( B a k e r and  1966).  Kramer,  1970) . The evident  literature  i n d i c a t e s there are at l e a s 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 t h e c l i n i c a l  specialist  role.  These  ( G e o r g o p o u l o s and S a n a , 1970; L i t t l e ,  1971; G e o r g o p o u l o s  of o r g a n i z a t i o n a l  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  and D e n y e s , 1972; Woodrow and B e l l , 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  and J a c k s o n ,  f a c t o r s which  influence  S t e w a r t , 1979;  Aradine  1971);  of c l i n i c a l  and, nurse  measurable  impact of t h e r o l e  only a f t e r  indicates that  ward r e o r g a n i z a t i o n ,  nurse s p e c i a l i s t  attention  this  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 t h e  Christman,  specialists  1973).  Research into was  care  1967);  2. i d e n t i f i c a t i o n  (Shaefer,  nurse  include:  1. measurement of i m p a c t o f t h e r o l e on p a t i e n t  role  three foci  clinical  r o l e , had been a c h i e v e d ( G e o r g o p o u l o s  1970; L i t t l e ,  1967).  This finding  to potential d i f f i c u l t i e s  when t h e r o l e  i s implemented  studies cited  the c l i n i c a l  draws  t h a t c a n be  in a hospital  nurse s p e c i a l i s t  and  encountered  setting. r o l e was  In both viewed  a s an a l t e r n a t e t o t h e t r a d i t i o n a l h e a d  nurse p a t t e r n f o r  the  delivery  Impact  was  measured i n terms of s p e c i f i c  of n u r s i n g c a r e s e r v i c e s .  of the  nursing a c t i v i t i e s ,  role for  24  e x a m p l e , " s p e n d i n g more t i m e i n d i r e c t c o n t a c t patients, planning verbal  i n t e r a c t i o n s on  (Little,  1 9 6 7 ) ; and,  r e c o r d e d by intershift and  report  patient care. with  the  The  patient's perceptions  the  (Stevens, The  challenge  the  p u b l i c are  classified Further  the  role  on  The  to  literature  effectiveness care  as  services  i m p o r t a n t ways of g o i n g  about  1976).  and  as  the  w o u l d seem  q u a l i t y of n u r s i n g  e x p e r i e n c e d by c l i n i c a l  s p e c i a l i s t s h a v e begun t o be  Woodward and  information  Georgopoulos  the  for researchers  of c o s t  world"  need f o r  t o d e m o n s t r a t e i m p a c t of  a c t u a l pressures  (Ehrenreich  S a n a , 1971;  measurement o f e f f e c t i v e n e s s .  t o the  of h i s  q u a l i t y of  There i s a c o n t i n u i n g  w e l l as measurement o f  this  and  during  ward k a r d e x s y s t e m and  does s u g g e s t t h a t d e t e r m i n a t i o n  provided  f o c u s i n g more  ( G e o r g o p o u l o s and  1970).  profession  assessing,  the q u a n t i t y  n u r s e s on  Jackson,  nursing  lie  and  with  Stewart,  Bell,  1971).  s t u d i e d and  1979;  refinement  documented  A r a d i n e and  These p r e s s u r e s  coming from s e l f ,  r o l e and  i n d e f i n i t i o n s and  nurse  Denyes,  1972;  h a v e been the  organization.  r e l a t i o n s h i p s among  t h e s e c l a s s e s o f v a r i a b l e s r e m a i n s t o be  determined  by  research. Research into expressed job s a t i s f a c t i o n clinical  nurse s p e c i a l i s t  of  the  in a hospital setting indicates  perception  o f a d m i n i s t r a t i v e s u p p o r t by  specialist  i s a v a r i a b l e that  the  significantly  clinical  nurse  influences  the  25  experience  of j o b s a t i s f a c t i o n ( S h a e f e r , 1973).  interpreted  i n l i g h t o f t h e r e l a t i v e newness o f t h e r o l e t o  some a g e n c i e s among c l i n i c a l  and a n e e d f o r r e a l i s t i c nurse  Only  expectations  implementation  i nthe  ( S h a e f e r , 1973;  1971). one s t u d y  activities setting  role  specialists, especially  beginning phases of r o l e MacPhail,  i n the l i t e r a t u r e surveyed  of the c l i n i c a l  nurse  ( A r a d i n e and Denyes, 1972).  Details  concerning  i n the previous section.  the agreement shared  by t h e e x p e r t  judges  o f c a t e g o r i e s o f work a c t i v i t i e s  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 descriptive  a hospital  in  the present  work s e t t i n g .  p o p u l a t i o n of i n t e r e s t concerning  The  C l i n i c a l Nurse S p e c i a l i s t This section  Because of  concerning the  of c a t e g o r i e s  This l i s t  study t o s t r u c t u r e  nurse  of a c t i v i t i e s  responses role  specialists i s used  of t h e  enactment.  i n Canadian Nursing  i s subdivided into l i t e r a t u r e  Literature pertaining  t o an h i s t o r i c a l p e r s p e c t i v e a n d more r e c e n t l i t e r a t u r e concerning  the r o l e .  this  i t i s reasonable t o  of r o l e enactment of c l i n i c a l  in  f o c u s e d on  s p e c i a l i s t i n t h e work  s t u d y were p r e s e n t e d  list  T h i s was  26  Historical A f t e r a r e v i e w of c o n c e r n i n g the historical  Perspective  relevant  clinical  Canadian  literature  nurse s p e c i a l i s t  analysis is offered.  In the  the late  f e d e r a l g o v e r n m e n t became c o n c e r n e d a b o u t t h e of h e a l t h c a r e to gather  i n Canada.  information  D e p a r t m e n t of H e a l t h  Welfare,  s u g g e s t e d i n t h e T a s k R e p o r t s on Services that was  i n Canada c o n c e r n e d  of p h y s i c i a n ' s made t o l i n k  nursing" reports  and  the  United  similarities  had  a p p e a l as  the  same t h i n g s  concerns with  development of the a strategy  like  States  the h e a l t h c a r e  Welfare,  might  p o p u l a r and  belief and  that  Canada  system.  the  and  many  could this  idea  some  However,  assistant  war.  be  had  Sweden, R u s s i a ,  trained military  f r o m t h e V i e t Nam  1970).  for dealing with  r o l e of p h y s i c i a n ' s  in  these  represented  f o r r e i n t e g r a t i o n i n t o American working  were r e t u r n i n g  attempt  specialist  i n each country,  strategy  o f a l a r g e number of m e d i c a l l y who  c o n c e p t was  working  a possible  and  role,  An  i n some o f  underlying  between the U n i t e d  i n the  of  W i t h an  Health  such a suggestion  success i n countries  result an  perspective  because the  States.  costs  strategy  system.  "clinical  ( N a t i o n a l Department of H e a l t h  some d e g r e e of  One  i n t r o d u c t i o n o f a new  "practitioner associate"  somewhat a p p e a l i n g  rising  t h e C o s t s of  c o n c e p t s of  From a p o l i t i c a l  the  (National  1970).  a s s i s t a n t , i n t o the  the  1960's  Numerous s t u d i e s were c o n d u c t e d  about t h i s concern and  following  This  society  personnel strategy  27  c e r t a i n l y a p p e a l l e d t o many A m e r i c a n  politicians  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 o f c o n c e r n s American  society.  to the Canadian  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  h e a l t h c a r e s y s t e m was  met  ( C a n a d i a n N u r s e s A s s o c i a t i o n , 1 9 7 3 ; 1972; O p p o s i t i o n was a c e up  spearheaded  with  opposition  Hacker,  1969).  by t h e n u r s i n g p r o f e s s i o n ;  i t s s l e e v e , as i t w e r e , was  nursing  within  r o l e had a l o n g h i s t o r y  the outpost nurse.  of b e i n g a r e s o u r c e  t o r e s p o n d t o the h e a l t h c a r e needs of Canadians t h e n o r t h and (Keith,  i n i s o l a t e d communities  1971).  CNA  educational role  Canada  r o l e , was  (CMA,  1973;  Nurses  Medical A s s o c i a t i o n agreed  a s t r a t e g y t h a t s h o u l d be CNA,  1973)  role  t o prepare nurses f o r such a  e x p a n s i o n of t h e r o l e of t h e n u r s e , r a t h e r t h a n o f a new  and  that  introduction  followed in  as the p r o f e s s i o n s  worked  t o g e t h e r t o r e s p o n d t o n e e d s o u t l i n e d by p o l i t i c a l The  in  t h e r e were  E v e n t u a l l y , the Canadian  A s s o c i a t i o n and t h e C a n a d i a n  utilized  Newfoundland  f o r n u r s e s and  resources a v a i l a b l e  (DuGas, 1 9 7 4 ) .  in  This  living  argued that the outpost nurse  r e p r e s e n t e d an e x p a n d e d one  the  leaders.  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 "  "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  in this  agreement which took the form of a statement of p o l i c y . 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  given  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 . clear  Thus, i n the e a r l y  1970's i t was  In  not  i f the concept of the expanded r o l e of the nurse i n  28  Canada c o u l d  result  if  o f r o l e s was p o s s i b l e  a variety  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  (DuGas, 1974; M u s s a l l e m ,  1971 ) . The  N a t i o n a l C o n f e r e n c e on A s s i s t a n c e t o t h e P h y s i c i a n  (1971) d e f i n e d t h e c o n c e p t o f " n u r s e p r a c t i t i o n e r " of  t h e p r o v i s i o n of a s s i s t a n c e  also linked the  hospital  to the physician.  the concept of " c l i n i c a l a s a work s e t t i n g .  complementarity of t h e r o l e s  nurse p r a c t i t i o n e r  I t was c l e a r  There  that  group  both  of n u r s e s and p h y s i c i a n s  i n the  f o r development  r o l e were e m p h a s i z e d  1973; N a t i o n a l D e p a r t m e n t  This  nurse s p e c i a l i s t " t o  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 the  i n terms  of  (CMA, 1973; CNA,  of H e a l t h and W e l f a r e ,  1971).  f o l l o w e d a t t e m p t s t o examine t h e r o l e of t h e nurse  practitioner  i n Canada  (Boudreau,  1972), e s t a b l i s h m e n t of  demonstration projects  (Rothwell,  1976; C a r d e n a s , 1975;  Spitzer  and K e r g i n ,  1 9 7 1 ; Coombs, 1 9 7 0 ) , a n d some e f f o r t s t o  assess p r o g r e s s of t h e r o l e and S a n e l t z ,  1976; L e F o r t ,  i n t h e h e a l t h c a r e system 1976; DuGas, 1 9 7 4 ) .  (DuGas  Some  c o n c l u s i o n s b a s e d on t h e s e e f f o r t s were t h e 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 t h e b a c c a l a u r e a t e n u r s e f o r t h e expanded  role  2. t h e h e a l t h c a r e d e l i v e r y  (DuGas a n d S a n e l t z ,  system had not changed  enough t o accommodate t h e e x p a n d e d hospital  work s e t t i n g  (Rothwell,  t h e market  rapidly  r o l e of t h e nurse i n t h e 1976); and,  3. t h e f u t u r e o f t h e n u r s e p r a c t i t i o n e r m a t t e r of whether  1976);  i n Canada i s "a  c a n s u p p o r t i t " ( L e F o r t , 1976;  29  p. 1 7 ) . Concerning the i s s u e of s p e c i a l i z a t i o n historical  i n nursing,  this  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 h a d 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 expense of a t t e n t i o n specialist.  a t the  t o t h e concept of the c l i n i c a l  As a r e s u l t , C a n a d i a n  nursing  nurse  literature  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 t h e nurse practitioner and  little  role.  role  (LeFort,  1976; S p i t z e r a n d K e r g i n ,  d i s c u s s i o n about the c l i n i c a l  Now  nurse  1971)  specialist  that evidence i s beginning t o suggest that the  nurse p r a c t i t i o n e r  r o l e may n o t be v i a b l e  i n the health care  s y s t e m , a t l e a s t n o t i n s o u t h e r n C a n a d a , i t may be t i m e f o r attention  to shift  t o t h e concept of t h e 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 t h e R o l e As m e n t i o n e d the  clinical  i n the p r e v i o u s s e c t i o n , the concept of  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 a b o u t t h e same t i m e a s d i d t h e c o n c e p t o f nurse p r a c t i t o n e r  (Boudreau,  H e a l t h and W e l f a r e , 1971). idea of s p e c i a l i z a t i o n of t i t l e s ,  Within nursing l i t e r a t u r e , the  i n n u r s i n g was d i s c u s s e d by t h e u s e  of  a variety  of  these (Anderson e t a l . ,  Coombs, 1 9 7 0 ) .  1972; N a t i o n a l D e p a r t m e n t o f  clinical  nurse s p e c i a l i s t  b e i n g one  1975; S p i t z e r a n d K e r g i n 1971;  By 1976, t h e c a t e g o r y " c l i n i c a l  a p p e a r e d 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  specialist" registration  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 Association direction  i n 1972 a r e s o l u t i o n  t o the e l e c t e d  develop a d e f i n i t i o n specialist  was  Nurses  passed that  gave  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  f o r the r o l e of the c l i n i c a l  i n Canada.  With legitimacy  nurse  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 professional  responsibility  of t h e r o l e f o r  Canadian the  to a r t i c u l a t e a d e f i n i t i o n  nursing.  The  need f o r c l a r i t y  r o l e h a s been e m p h a s i z e d  i n the l i t e r a t u r e  t i m e t h e i s s u e became a p r i o r i t y For  example,  emerging  in a definition since  (Biennium Meeting,  the 1972).  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 " t h e  r o l e of the m a s t e r ' s p r e p a r e d c l i n i c a l  s p e c i a l i s t was thing clear:  examined  ...  The  c l e a r l y d e f i n e d or understood " (Dworkin,1973;  newly  nurse  c o n f e r e n c e ....  the r o l e of t h i s nurse s p e c i a l i s t  made  one  i s not p. 4 0 ) .  1972 a d o c u m e n t a t i o n o f i n d i v i d u a l e x p e r i e n c e w i t h t h e emphasized "to  t h e newness o f t h e c o n c e p t  I n 1980,  the  a t a N a t i o n a l Forum on N u r s i n g  the  the d i f f e r e n c e s  1980;  fact  clinical  p.  16).  As  setting  i n t h e r o l e s and c o m p e t e n c i e s  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 "  Nurse,  role  (Robinson,  E d u c a t i o n , Baumgart d e s c r i b e d a " g r o w i n g u r g e n c y o f out c l e a r l y  In  i n Canada and t h e n e e d  explore i t s c o n t r i b u t i o n s to patient care"  1977; p. 3 6 ) .  of  l a t e as  1981  (The  Canadian  there i s reference to  t h a t g r a d u a t e e d u c a t i o n of n u r s e s f o r t h e r o l e nurse s p e c i a l i s t  of  i n v o l v e s p r e p a r i n g them " f o r  of  31  p o s i t i o n s where t h e r e carving"  involved  references  The  (Arpin,  s u p p o r t s the  nurse s p e c i a l i s t  Possible  i s a considerable  claim  i s not  Explanations  1981).  above r e v i e w of  that  role  i n the  the  that  l a s t decade.  discussion  m i g h t be  literature  suggests at  practitioner, profession  (2)  the  itself,  (3)  the  role-  above  r o l e of  clinical  i n Canada.  literature  i n the  Literature  indicates that  r o l e of  the  little  has  Within  Canada t h i s  explained  f o c u s of a t t e n t i o n has  the  the  O b s e r v e d Gap  i s a need f o r f u r t h e r s t u d y of n u r s e s p e c i a l i s t and  E a c h of  well defined  f o r an  d e g r e e of  clinical  been w r i t t e n a b o u t lack  l e a s t three  possibilities:  been on  r o l e of  n a t u r e of  the  the  the  The (1)  the  nurse  organization  interests within  the  of  i n a number o f ways.  the  there  of  the  professional  g r o u p were i n d i r e c t i o n s o t h e r t h a n r o l e d e v e l o p m e n t o f clinical  nurse s p e c i a l i s t .  Explanation  possibility  was  presented  i n the  a n a l y s i s of  the  o t h e r two  possibilities  The ten  Nurses A s s o c i a t i o n  "A  the  i s a federation  function  of  s t a n d a r d of  1952;  However, " C a n a d i a n l e g i s l a t i o n  nursing  50).  a f f a i r s and  c o n t r o l , w i t h i n the  the  service  their organization general  of  the  Canadian  i s to formulate p o l i c i e s which nursing  An  follows.  promote a h i g h p.  first  previous section.  Canadian Nurses A s s o c i a t i o n  provincial associations.  of  the  will  ...."(Jewitt, provides  that  come u n d e r p r o v i n c i a l  c a t e g o r y of h e a l t h "  (Mussallem,  32  1964; p. 3 1 ) .  Thus,  provincial associations  governing units with legislative  acts.  powers t h a t  Because  are  self  come f r o m p r o v i n c i a l  of t h i s d i v i s i o n of a u t h o r i t y  Canadian Nurses A s s o c i a t i o n  acts  only  i n an  the  advisory  capacity. 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 , action lies  r e l a t e d t o development  within  the j u r i s d i c t i o n  association.  The  related  of each p r o v i n c i a l  for clinical  t o the h e a l t h  needs  of t h e p o p u l a t i o n  i n a p a r t i c u l a r province.  association  differences  it  i n the h e a l t h  nursing  c a r e needs  i n the country  i s a complex  with  association  together with  the r o l e f o r Canadian nursing  the s t r u c t u r e  structure  of the p r o f e s s i o n a l  of the h e a l t h  public  for mobility one.  Therefore,  a d e f i n i t i o n of the  by t h e  by e a c h p r o v i n c i a l a s s o c i a t i o n .  defining  health  challenge  n u r s e s p e c i a l i s t i n Canada may  two l e v e l s : a b r o a d l e v e l d e f i n e d  defined  The  of t h e C a n a d i a n  i s s u g g e s t e d by t h e r e s e a r c h e r t h a t  professional  and t h e  be  to respond to p r o v i n c i a l / r e g i o n a l  r o l e of the c l i n i c a l of  for a  and e a c h p r o v i n c i a l  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 within  nursing  s p e c i a l i z a t i o n to develop i n  both the Canadian Nurses A s s o c i a t i o n  nursing  practice  s p e c i f i c f o r m o f any m o d e l d e v e l o p e d w o u l d  c a r e s y s t e m needs for  of r o l e s f o r n u r s i n g  T h e o r e t i c a l l y , then, i t i s possible  v a r i e t y of models Canada.  t h e power f o r s p e c i f i c  consist  national  a more s p e c i f i c l e v e l Such an a p p r o a c h t o w o u l d be  consistent  association,  c a r e s y s t e m a s w e l l as t h e  and  the  larger  33  political  s t r u c t u r e of t h e c o u n t r y .  A t h i r d possible explanation about t h e c l i n i c a l  nurse s p e c i a l i s t concerns other  within the profession. of  f o r the l a c k of d i s c u s s i o n  The l i t e r a t u r e  indicates that  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 ,  certification Mussallem,  (Adam, 1981; B a n n i n g ,  1977; B a c h a n d , 1 9 7 4 ) .  concerning these t o p i c s reveals these important clinical  literature  these and t h e r o l e . suggestion  A review of the l i t e r a t u r e that  that  e x p e r i e n c e of t h e c l i n i c a l  If  of the r o l e of the  1978; M u s s a l l e m ,  However, t h e  be r e l a t i o n s h i p s among  assumption of t h i s  education,  e x p e r t i s e , and  nurse s p e c i a l i s t  i m p a c t on t h e d e l i v e r y o f n u r s i n g Jackson,  r e l a t i o n s h i p s among  should  An u n d e r l y i n g  i s the b e l i e f  a c c r e d i t a t i o n , and  are unstated.  suggests that there  some  1981; F i t z p a t r i c k , 1977;  i s s u e s and d e f i n i t i o n  nurse s p e c i a l i s t  interests  care  c a n h a v e an  services  1977; R o g e r s ,  ( P i a z z a and  1972; P e p l a u ,  1965).  a t t e n t i o n i s d i r e c t e d t o t h e c o n c e p t o f commitment  of a p r o f e s s i o n  t o t h e p u b l i c t h e n some o f t h e s e  r e l a t i o n s h i p s b e g i n t o become c l e a r .  I t i s desirable fora  profession  services are provided  "to assure the p u b l i c that  by p r a c t i t i o n e r s who r e c o g n i z e provide  good n u r s i n g  this"...(Kay and  care  and K e r g i n ,  described  responsibilities to  a n d who have t h e a b i l i t i e s 1977; p. 8 9 ) . F i v e ways,  u s e d by C a n a d i a n n u r s i n g ,  groups, t o provide  their  as w e l l as other  t o do  developed  professional  t h i s a s s u r a n c e t o t h e p u b l i c h a v e been  (Kay and K e r g i n ,  1977).  These a r e :  34  1. t h e d e v e l o p m e n t o f a c o d e o f 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 followed  to  by members;  2. t h e s o c i a l i z i n g  of s t u d e n t s of t h e p r o f e s s i o n  into  r o u t i n e s and m e t h o d s o f p e r f o r m i n g p a r t i c u l a r a c t s " Kergin,  1977;  p.  believed  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 "  4.  p.  (Kay  and  "describe  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  1977;  "the  89);  3. t h e d e v e l o p m e n t o f s t a n d a r d s t h a t  Kergin,  be  to  (Kay  and  89);  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 h a v e met  minimum s t a n d a r d s o f e i t h e r e d u c a t i o n o r  p r a c t i c e or both"  (Kay and  Kergin,  1977;  p.  90);  5. t h e m a i n t e n a n c e of m e c h a n i s m s " f o r d e a l i n g who  a r e a l l e g e d t o have p e r f o r m e d  p a t i e n t s " Kay It  and K e r g i n ,  the  p.  that  endanger  90).  certification  t h e s e ways f o r a s s u r i n g  r e p r e s e n t one  o r more  t h e p u b l i c a b o u t p r a c t i t i o n e r s of  profession. E a c h of t h e a b o v e ways c a n be v i e w e d  as a f o r m a l  d i r e c t e d a t t h e p r o v i s i o n of s u c h a s s u r a n c e . can  w i t h members  seems r e a s o n a b l e t o t h i n k movements t o w a r d 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 of  1977;  acts  and  f u n c t i o n as a r e g u l a t o r y  normative  mechanism c o n c e r n e d  c o n t r o l o f members o f t h e p r o f e s s i o n  p r o f e s s i o n a l group i t s e l f . mechanisms a r e s t a t e m e n t s  Each  The  outcomes from each  of s t a n d a r d s .  system  with  by  system  the  the of  these  The r e l a t i o n s h i p s ,  35  t h e n , among t h e c l i n i c a l movements t o w a r d certification, t o be l i n k e d service  assurance,  and s t a n d a r d s a r e s u g g e s t e d  to provision  of assurance  by t h e r e s e a r c h e r  to the public  A clear  description  above f a c t o r s  discussions specialist  To what d e g r e e  of t h e r o l e  i n Canada w o u l d  explicit.  may have r e s u l t e d  i n an a b s e n c e o f  about and r e s e a r c h i n t o t h e c l i n i c a l role  that  to begin.  about  are incorporated into practice i s  h e l p t o make t h e s e l i n k s  role  quality  p r o v i d e d by t h e n u r s i n g p r o f e s s i o n .  unknown.  to think  s p e c i a l i s t r o l e and t h e  accreditation,  these r e l a t i o n s h i p s  The  nurse  i n Canada.  i t i s time  nurse  I f t h i s i s so, i t i s reasonable  f o r systematic examination  of the  As a b e g i n n i n g s t e p , t h i s s t u d y was d e s i g n e d  to c o l l e c t data concerning t h e i r r o l e group of c l i n i c a l  nurse  from a  specialists in British  self-defined Columbia.  CHAPTER 3 METHODOLOGY  Subjects 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 o f t h e 147  members o f t h e RNABC who c h e c k e d box 23 specialist")  on t h e 1981-1982 RNABC r e g i s t r a t i o n  of t h e p o t e n t i a l p o p u l a t i o n collecting  ("clinical  form, reducing  form.  Five  were u s e d t o p r e - t e s t t h e d a t a -  t h e number o f 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 Since a review  discovery  of the l i t e r a t u r e d i d not r e s u l t  o f an i n s t r u m e n t  t h i s study,  a questionnaire  The i n s t r u m e n t  t h a t would f i t the purpose of was d e v e l o p e d  was c o n s t r u c t e d  using  (see Appendix A ) .  three sources  i n f o r m a t i o n : t h e c a t e g o r i e s o f work a c t i v i t i e s Aradine  a n d Denyes  nurse s p e c i a l i s t  (1972),  role  B r i t i s h Columbia.  of  reported  by  d e s c r i p t i o n s of the c l i n i c a l  found i n the l i t e r a t u r e ,  interviews with c l i n i c a l  i n the  and  nurse s p e c i a l i s t s p r a c t i c i n g i n  The c o n t e n t  o f t h e q u e s t i o n n a i r e c a n be  b r o k e n down i n t o t h r e e c a t e g o r i e s : t h e c a t e g o r i e s o f work activities  described  contextually and  by A r a d i n e  a n d Deynes ( 1 9 7 2 ) ( I t e m 7 ) ,  r e l a t e d v a r i a b l e s ( I t e m s 2, 4, 5, 6, 8, and 9 ) ,  p r o f e s s i o n a l v a r i a b l e s ( I t e m s 10, 11, and 1 2 ) .  addition,  In  t h e d e m o g r a p h i c v a r i a b l e s o f age a n d s e x were 36  37  included. Procedure After field  initial  development of the q u e s t i o n n a i r e  tested for c l a r i t y , a p p l i c a b i l i t y  work a c t i v i t i e s t o t h e work e x p e r i e n c e specialists required  i n B r i t i s h C o l u m b i a , and  for completion.  The  nurse s p e c i a l i s t s  compiled  and  the  p r a c t i c e , who  first  t h e amount o f  them as w o r k i n g  role,  who  and  clarity to  item  (#7)  was  researcher  altered.  t h a n 20 m i n u t e s t o c o m p l e t e t h e After along  revision  of t h e  w i t h a l e t t e r of  five  1  of d i f f i c u l t y  s u b j e c t s gave  to responses  Therefore than  form. the  questionnaire,  explanation  a stamped a d d r e s s e d  r e t u r n o f t h e q u e s t i o n n a i r e were m a i l e d the  formed  questionnaire  sources  i n t r o d u c t i o n and  T h i s c a r d c o u l d be u s e d by summary o f t h e f i n d i n g s .  test  Each s u b j e c t took l e s s  instrument  A p p e n d i x B ) , a s m a l l c a r d , and  1  was  f o r changes r e l a t e d  Four of the  not  known  specialist  field  e a c h o f t h e c a t e g o r i e s of work a c t i v i t i e s .  this  for  i n the  Each responded t o the  Some s u g g e s t i o n s  were made.  of  of  were e n g a g e d i n n u r s i n g  i n a c l i n i c a l nurse  then d i s c u s s e d w i t h the  experienced.  A list  i n the Vancouver area  agreed to p a r t i c i p a t e  the p r e - t e s t sample.  time  t h e m s e l v e s o r whose e m p l o y e r s  perceived and  of  of t h e c l i n i c a l n u r s e  p r e - t e s t sample c o n s i s t e d  f i v e who  perceived  was  of the c a t e g o r i e s  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 . clinical  it  subject  (see envelope  to each nurse  to request  a  38  who c h e c k e d box 2 3 .  A f o l l o w - u p reminder  s u b j e c t one week l a t e r . for  was m a i l e d  The d a t a c o l l e c t i o n  t o each  p e r i o d extended  s i x weeks. The  procedure  u s e d by t h e RNABC f o r t h e m a i l i n g d o e s  not a l l o w t h e r e s e a r c h e r d i r e c t subjects.  RNABC g e n e r a t e d  the l i s t  a p p l i e d them t o t h e p r e p a r e d reminders, procedure  t o t h e names o f t h e  of m a i l i n g  envelopes  and t h e f o l l o w - u p  would r e s u l t  i n those  the revised questionnaire.  phase and asked  Chapter  Therefore, i n the f i e l d  not t o respond.  Most o f t h e a n a l y s e s Midas S t a t i s t i c a l  This  subjects i n the pre-test  f i v e s u b j e c t s were t o l d o f t h i s p r o c e d u r e  testing  labels,  and m a i l e d t h e s e a t t h e a p p r o p r i a t e t i m e .  sample a l s o r e c e i v i n g these  access  Package.  o f t h e d a t a were done u s i n g t h e Indication w i l l  be g i v e n i n  4 whenever o t h e r means o f a n a l y s i s were u s e d .  CHAPTER 4 RESULTS As o u t l i n e d  i n C h a p t e r 3, d a t a were o b t a i n e d f r o m a  mailed questionnaire specialists  sent t o s e l f - i d e n t i f i e d  i n B r i t i s h Columbia.  clinical  nurse  Of t h e 147 q u e s t i o n n a i r e s  s e n t o u t , 94 were r e t u r n e d -- 88 f r o m r e s p o n d e n t s  (a r e t u r n  r a t e of 6 2 % ) , 4 from t h e p o s t o f f i c e as u n d e l i v e r a b l e and 2 f r o m members o f t h e f i e l d - t e s t were a c c o m p a n i e d resulted  Twenty-one Item  Of t h e 8 8 , t h r e e  t h e f o r m a n d one was r e t u r n e d  The r e m a i n i n g 84 f o r m e d  the return  sample.  (25%) of t h e r e t u r n e d sample responded  1 (Are you s t i l l  "clinical  1  by n o t e s s u g g e s t i n g a c o m p u t e r e r r o r h a d  i n each r e c e i v i n g  unanswered.  sample .  working i n a p o s i t i o n you would  s p e c i a l i s t " ? ) a n d 63 ( 7 5 % ) r e s p o n d e d  T h e r e f o r e , o n l y t h e 21 s u b j e c t s were i n c l u d e d a n a l y s i s of Item  demographic  call  "yes." i nthe  1 ( a ) ; a l l o t h e r a n a l y s e s were b a s e d on t h e  63 s u b j e c t s who r e s p o n d e d a f f i r m a t i v e l y . r e p o r t e d under  "no" t o  The r e s u l t s a r e  the following headings: present p o s i t i o n ,  i n f o r m a t i o n , work a c t i v i t y ,  contextually  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  related among  variables.  A n o t e on t h e f i r s t page o f t h e q u e s t i o n n a i r e this. 1  39  indicated  40  Present  Position  Item of  1(a) was  the respondents  as " c l i n i c a l are  concerned who  w i t h t h e p r e s e n t work  no l o n g e r i d e n t i f i e d  specialist."  summarized i n T a b l e  1.  their  This table  role  i n d i c a t e s t h a t most  Positions  Identifying (Item 1(a)) Number o f Subjects  Assistant supervisor/co-ordinator C l i n i c a l nurse General duty Head n u r s e Nurse r e s e a r c h a s s i s t a n t Physician's office Pre-op. t e a c h i n g Returning to school Not w o r k i n g Unemployed =2 Retired =3 Moved/parenting =2  2 1 1 4 2 2 1 1 7  Total  p o s i t i o n as " c l i n i c a l  work  R e s p o n s e s o f t h e s e 21 s u b j e c t s  Table 1 P r e s e n t P o s i t i o n s o f S u b j e c t s No L o n g e r Themselves as C l i n i c a l Nurse S p e c i a l i s t s  ( 1 4 / 2 1 ) o f t h o s e who  position  21  no l o n g e r i d e n t i f i e d specialist"  their  were s t i l l  work  working.  Of  t h o s e n o t w o r k i n g , o n l y 2 i n d i c a t e d t h e y were u n e m p l o y e d .  41  Demographic I n f o r m a t i o n Age  and  sex  (Items  13 and  v a r i a b l e s looked at i n t h i s as f o l l o w s :  18  (29.0%)  ( 9 . 7 % ) were b e t w e e n 36 and  13  study.  The  demographic  age d i s t r i b u t i o n  was  5 ( 8 . 1 % ) o f t h e r e s p o n d e n t s were b e t w e e n 25  29 y e a r s o f a g e ;  40 and  14) were t h e two  were b e t w e e n 30 and 39 y e a r s ; 15 ( 2 4 . 2 % )  45 y e a r s ; 5 ( 8 . 1 % ) were b e t w e e n 46 and  ( 2 1 % ) were 50 y e a r s o r o l d e r .  s a m p l e were f e m a l e and  Sixty  35 y e a r s ; 6 were b e t w e e n  49 y e a r s ; and  (96.8%)  2 ( 3 . 2 % ) were m a l e .  and  of  Data  the  from  one  s u b j e c t were m i s s i n g f o r e a c h o f t h e s e i t e m s .  Work  Activity The  i n f o r m a t i o n on work a c t i v i t y was  derived  from  an  a n a l y s i s o f t h e r e s p o n s e s t o I t e m 7 on t h e q u e s t i o n n a i r e . summary o f t h e numbers and p e r c e n t a g e s o f r e s p o n d e n t s checked  was of  d e s c r i b e d by some o f t h e r e s p o n d e n t s a s their  who  a c a t e g o r y o f 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  E a c h o f t h e 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 D e n y e s  clinical  percentage  (93.5%)  nurse s p e c i a l i s t  role.  The  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 ,  The  2.  (1972)  characteristic largest  o f t h e r e s p o n d e n t s s p e n t some o f  work t i m e i n c o n s u l t a t i v e a c t i v i t i e s .  A  their  categories  interdisciplinary  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 , c o m m u n i t y a c t i v i t i e s , and staff  development  were i d e n t i f i e d by more t h a n 65% o f  the  Table 2 Work A c t i v i t i e s o f S u b j e c t s Positions  s u b j e c t s as being than  Percentage of S u b j e c t s  47 41 58 44  75.,8 66. , 1 93..5 71 . .0  53 53  85..5 85..5  56  90..3  48 23 40 21 18  77,.4 37,. 1 64,.5 33,.9 29,.0  i n c l u d e d among t h e i r work  activities.  40% o f t h e s u b j e c t s i d e n t i f i e d each o f t h e  categories research, writing being p a r t of t h e i r Table  ( I t e m 7)  Number o f Subjects  Administration Community a c t i v i t i e s Consultation E d u c a t i o n of s t u d e n t s Interdisiplinary interaction Patient care P e r s o n a l and p r o f e s s i o n a l growth Planning-policy-standardschange Research S t a f f development Writing for publication Other  Less  42  work  f o r p u b l i c a t i o n , and o t h e r as  activities.  3 p r e s e n t s mean p e r c e n t a g e s  e s t i m a t e s o f work t i m e on a w e e k l y category as r e p o r t e d i n response amounts o f w e e k l y  and ranges  b a s i s devoted  t o Item  work t i m e were d e v o t e d  7.  of the t o each  The l a r g e s t  t o the c a t e g o r i e s  p a t i e n t c a r e a n d o t h e r , 37% a n d 2 5 % r e s p e c t i v e l y . 10% a n d 15% o f t h e e s t i m a t e d w e e k l y  Between  work t i m e was d e v o 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 consultation.  Less  t i m e was s p e n t  on t h e e d u c a t i o n o f s t u d e n t s ,  interdisciplinary growth,  than  10% o f t h e e s t i m a t e d w e e k l y  interaction,  work  p e r s o n a l and p r o f e s s i o n a l  planning-policy-standards-change, research,  staff  43  development, and w r i t i n g  for publication.  Table 3 Range a n d Mean P e r c e n t a g e o f E s t i m a t e d W e e k l y Work Time D e v o t e d t o C a t e g o r i e s o f Work A c t i v i t y ( I t e m 7) C a t e g o r i e s of Work A c t i v i t y  Number o f Subjects  Administration Commun i t y activities Consultation Education of students Interdisiplinary i n t e r a c t ion Patient care Personal professional growth Planning-policystandardschange Research S t a f f development Writing for publication Other  Table  Range Minim. Maxim. (hours)  Mean % of Weekly Work Time  47  1  45  10.4  38 55  1 2  100 92  10.1 15.8  40  1  40  6.1  49 50  1 1  50 80  9.6 37.3  52  1  50  7.1  44 20 37  1 1 1  20 20 80  6.9 4.6 8.4  18 16  1 1  40 80  5.1 23.5  4 l i s t s a categorization  w i t h an e s t i m a t e o f w e e k l y  of s p e c i f i c  work t i m e d e v o t e d  responses,  t o each  c a t e g o r y , p r o v i d e d by t h e 16 s u b j e c t s who r e s p o n d e d t o I t e m 7 i n the category  "other."  The a v e r a g e p e r c e n t a g e  2 3 . 5 % , w i t h a r a n g e o f 1% t o 8 0 % . provides a l i s t i n g categories  i n Table  of t h e responses 4.  was  Appendix C (Table t h a t make up t h e  C.1)  Table 4 S u b - C a t e g o r i e s a n d P e r c e n t a g e s f o r O t h e r C a t e g o r y o f Work A c t i v i t i e s ( I t e m 7) Sub-Category  Number of Subjects  R e s e a r c h work Clerical S t a f f programming Infection control Counselling/ psychotherapy 6. T r a d i t i o n a l n u r s i n g skills 7. P a t i e n t e d u c a t i o n 8. M i s c e l l a n e o u s 1. 2. 3. 4. 5.  1  N.R.  1 4 3 2  44  P e r c e n t a g e o: Weekly work t i m e 30% 2%,5%,8%,N.R. 5%,15%,25% 27%,50%  2  5%,80%  2 1 3  10%,65% 30% 3%,4%,15%  = no r e s p o n s e o r m i s s i n g d a t a .  Contextually Related Variables The  categories  i n T a b l e 5 were d e v e l o p e d f r o m t h e  r e s p o n s e s t o Item 2 ( s p e c i f i c t h e r e i s a range of j o b t i t l e s  job t i t l e ) . used  Table 5  to identify  indicates  t h e r o l e of  Table 5 C a t e g o r i e s D e r i v e d f r o m S p e c i f i c J o b T i t l e s P r o v i d e d by S u b j e c t s ( I t e m 2) Derived Categories Community ( h e a l t h / m e n t a l h e a l t h ) nurse Enterostomal therapist I n f e c t i o n c o n t r o l nurse Nurse c l i n i c i a n Nurse p r a c t i t i o n e r Nurse r e s e a r c h e r / r e s e a r c h technic ian Supervisor/head nurse/ a s s i s t a n t head n u r s e Teaching/instructor Miscellaneous No r e s p o n s e Total  Number o f S u b j e c t s 13 5 2 22 1 2 4 4 6 4 63  45  these respondents.  The l a r g e s t number o f s u b j e c t s , 22 a n d  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 a s n u r s e c l i n i c i a n community n u r s e .  Four  and  s u b j e c t s d i d not respond t o t h i s  item. Of t h e s u b j e c t s who r e s p o n d e d job  title,  title.  t o I t e m 2 by p r o v i d i n g a  most ( 6 9 % ) i n d i c a t e d s a t i s f a c t i o n  T a b l e 6 p r e s e n t s a summary  p r e f e r r e d by t h o s e n o t s a t i s f i e d  with the job  of a l t e r n a t e  job t i t l e s  with t h e i r present job  title. Table 6 Summary o f 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 J o b T i t l e s ( I t e m 3) Alternate Title  Number o f Subjects  Percentage of S u b j e c t s  C l i n i c a l Nurse Specialist 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 No r e s p o n s e  10 2 3 2 2 1  50 10 15 10 10 5  Total  20  100  Table 6 i n d i c a t e s that subjects  (50%) would  nurse s p e c i a l i s t . " o t h e r would  i n r e s p o n s e t o I t e m 3, t e n  rename t h e i r w o r k i n g r o l e The two r e s p o n d e n t s  rename t h e i r work r o l e s  "enterostomal nurse  i n the category  "nurse c o u n s e l l o r " and  clinician."  Table 7 presents r e s u l t s present p o s i t i o n  "clinical  (Item 4 ) .  f o r the l e n g t h of time i n the  I n g e n e r a l , most o f t h e s a m p l e  46  (71%) h a d w o r k e d i n t h e i r p r e s e n t p o s i t i o n years.  Fifteen  f o r more t h a n  ( 2 4 . 2 % ) o f t h e s u b j e c t s had w o r k e d i n t h e  Table 7 L e n g t h o f Time i n P r e s e n t P o s i t i o n L e n g t h o f Time  (Item  4)  Number o f Subjects  Percentage of S u b j e c t s  0 7 13 25  t o 6 months t o 12 months t o 24 months t o 36 months > 36 months No r e s p o n s e  3 6 9 15 29 1  4.8 9.5 14.3 23.8 46.0 1.6  Total  63  100.0  present p o s i t i o n longer than  b e t w e e n 25 a n d 35 months a n d 29  were new  and had j o b d e s c r i p t i o n s when t h e y were  (Items 5 and 6 ) . positions  when t h e s u b j e c t s a c c e p t e d present positions  them.  positions  T h i r t y - f i v e (57.4%) of t h e  had a j o b d e s c r i p t i o n  26 ( 4 2 . 6 % ) d i d n o t . a job description,  accepted  S p e c i f i c a l l y , 32 ( 5 1 . 6 % ) o f t h e p r e s e n t  were new w h i l e 29 ( 4 7 . 5 % ) were e x i s t i n g  description  (46.8%)  36 m o n t h s .  S l i g h t l y more o f t h e p r e s e n t p o s i t i o n s positions  when a c c e p t e d  Of t h e 32 new p o s i t i o n s ,  while  14 ( 4 3 . 7 % ) h a d  w h i l e 18 ( 5 6 . 3 % ) were w i t h o u t a j o b  when t h e s u b j e c t s a c c e p t e d t h e p o s i t i o n .  29 e x i s t i n g p o s i t i o n s ,  21  Of t h e  ( 7 2 . 4 % ) had a j o b d e s c r i p t i o n  w h i l e 8 ( 2 7 . 6 % ) were w i t h o u t o n e . T a b l e 8 p r e s e n t s t h e r e s u l t s f o r t y p e o f employment setting  two  (Item 8 ) .  Most of t h e sample  (65.1%) worked i n a  47  hospital  setting.  Of  these  hospital.  41  s u b j e c t s , most  Of  the  i n an a c u t e  care  s e t t i n g was  a community b a s e d s e r v i c e , most  i n a community mental h e a l t h  16 s u b j e c t s whose work (56.3%) worked  agency.  Table 8 T y p e s of Employment S e t t i n g s Type of S e t t i n g  (Item  Number of Subjects  8)  Percentage of S u b j e c t s  Hospital 41 N u r s i n g home/home f o r the aged 0 Community b a s e d s e r v i c e s 16 Business/industry 0 Physician's office/family practice unit 2 Other 3 No r e s p o n s e 1  65. 1  Total  100.1  a,b,c).  T h e r e was  present category  3.2 4.8 1 .6  defined  i n t h r e e ways ( I t e m  an even d i s t r i b u t i o n  p o s i t i o n s between u n i t - b a s e d were u n i t - b a s e d  0.0 25.4 0.0  63  Type of a p p o i n t m e n t was  while  31  and  not  ( 5 0 . 8 % ) were n o t .  other, versus  administrative  11.5%).  10.3%  (7 o r  A total  p o s i t i o n s were d e s c r i b e d a s were d e s c r i b e d as  r e s u l t s are presented  other  of  staff  i n Table  9.  was  (49.2%)  in  the  the  (17 o r  27.9%),  clinical52  o r 89.7%  of  the  positions while  line positions.  of r e s p o n s e s t o the c a t e g o r y  30  M o s t of  c a t e g o r i e s of c l i n i c a l  9  present  p o s i t i o n s (33 o r 54.1%) were d e s c r i b e d  (4 o r 6 . 6 % ) , and  present  of the  unit-based;  clinical-educational  or  (87.8%) worked  Further  c a r r i e d out  6  analysis and  the  48  Table 9 R e s p o n s e s i n O t h e r C a t e g o r y f o r Type o f A p p o i n t m e n t ( I t e m 9b) Specific  Response  Number o f Subjects  1. E m p l o y e d by and r e s p o n s i b l e t o a d i v i s i o n (outpatient) 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 to the Department of N u r s i n g .  2  2. E m p l o y e d by a n d r e s p o n s i b l e t o Mental Health f o r p a t i e n t care 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 activities.  6  3. I n d e p e n d e n t l y  1  employed.  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 , e m p l o y e d by a m b u l a t o r y c a r e s e r v i c e s .  2  5. E m p l o y e d by a g r o u p o f p h y s i c i a n s .  2  6. A l l o f t h e a b o v e ( i . e . c l i n i c a l , clinical-educational, c l i n i c a l administrative) .  3  7. E m p l o y e d by a n d 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 control.  3  8. E m p l o y e d by a n d 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 medicine 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 administrative activities.  8  9. E m p l o y e d 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 : e m p l o y e d 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 . E m p l o y e d 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 m e n t a l 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 Specific  Number o f Subjects  Response  12.  Clinical,  13.  E m p l o y e d by h o s p i t a l a n d r e s p o n s i b l e to long term care 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 o f some s t u d e n t s .  1  14.  E m p l o y e d by r e s e a r c h a g e n c y , responsible to nursing, c l i n i c a l , educational, occasional administrative a c t i v i t i e s (joint appointment).  1  15.  E m p l o y e d by a n d 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 activities.  1  16.  Responsible t o the d i r e c t o r of Health C a r e -- c o n s u l t a n t t o a l l s t a f f .  1  17.  Responsible f o r inservice of g r a d u a t e s t a f f .  1  staff,  and p a t i e n t  education.  education  2  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 g r o u p o f s u b j e c t s (21 out  o f 33) who i n d i c a t e d t y p e o f a p p o i n t m e n t a s o t h e r a r e  not  responsible  other  to nursing  activities.  service f o r nursing  care  and/or  Some o f t h e d e p a r t m e n t s and p e r s o n s t o  whom t h e y a r e r e s p o n s i b l e Department of L a b o r a t o r y  i n c l u d e : t h e Department of H e a l t h , 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  Professional As  Variables  shown i n T a b l e  10,  t h e m a j o r i t y of t h e  o r 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 programs w h i l e baccalaureate  14 o r 22.6% programs.  Basic Educational  Type o f  The  the type  Table Preparation (Item  Program  in nursing  subjects received this o f p r o g r a m most  10 in Nursing 10)  Number of Subjects  of t h e  22.2 76.2 1 .6  Total  63  1 00.0  diploma/certificate. post-basic  Table  nursing education.  s u b j e c t s had  education  11 p r e s e n t s  frequently  Subjects  was findings related  to  This Table i n d i c a t e s that  24  pursued post-basic  nursing education  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 P r o g r a m , and Minimum, Maximum and A v e r a g e Number o f Y e a r s S i n c e C o m p l e t i o n ( I t e m 11) Type o f P r o g r a m  Number  Diploma/ certificate Baccalaureate Master's Doctoral  24 16 9 0  in  Percentage of Sample  14 48 1  nursing  (48  i n diploma  Baccalaurreate Diploma No r e s p o n s e  pursued f o r post-basic  of the  of  subjects  Minimum Maximum A v e r a g e (years) (years) (years) 0 3 1 -  28 25 13 --  10 12 6  in  51  d i p l o m a / c e r t i f i c a t e p r o g r a m s b e t w e e n 1954 a v e r a g e number of y e a r s of the  s u b j e c t s had  baccalaureate a v e r a g e of  programs between  pursued post-basic  1982,  being  10.  with  the  Sixteen  pursued post-basic nursing education  12 y e a r s  b e t w e e n 1969  since completion  and  1957  and  since completion. nursing education  1979,  with  in  an  Nine respondents  had  i n master's programs  and  1981,  w i t h t h e a v e r a g e number o f  since completion  being  6.  None o f t h e  subjects  years  had  completed d o c t o r a l s t u d i e s . The  majority  baccalaureate education by  Of  d i d so  in nursing.  subjects  (psychology);  the  9 who  s a m p l e who  completed a  p r o g r a m as a p a r t o f p o s t - b a s i c  individual  B.Sc.  ( 1 2 / 1 6 ) of t h e  had  Other types  i n c l u d e d B.A.  B.A.  (not  nursing  of d e g r e e s  listed  (psychology);  specified);  B.A.  (sociology).  p u r s u e d a m a s t e r ' s p r o g r a m , 4 d i d so  in  nursing.  Other degrees i n c l u d e d : Master's i n  Sciences;  M a s t e r 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 ) ;  M a s t e r of A r t s ; and of study  r e p o r t e d by  M a s t e r of P h i l o s o p h y . some s u b j e c t s who  Health  A list  of  areas  completed  d i p l o m a / c e r t i f i c a t e programs i s presented  in Table  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 administration  ( 5 / 2 0 ) and  a d m i n i s t r a t i o n and  teaching  (3/20). T a b l e 13 p r e s e n t s positions  the  r e s u l t s f o r t h e number o f  i n n u r s i n g h e l d by  F i n d i n g s are presented  the  subjects  (Item  12).  as p o s i t i o n s , s e q u e n c e i n w h i c h e a c h  Areas  T a b l e 12 f o r D i p l o m a / C e r t i f i c a t e Type o f C o m p l e t e d ( I t e m 11)  of Study  A r e a of  Study  3 1 1 1 2 1 5 1 1 1 1 2 4  Total h e l d by  each  4 positions  24  s u b j e c t s , and  position.  Programs  Number o f Subjects  A d m i n i s t r a t i o n and t e a c h i n g C l i n i c a l A r c t i c nurse course Coronary care C r i t i c a l care i n s t r u c t o r Enterostromal therapy G e n e r a l program f o r p r i m a r y care nursing Hospital/unit administration I n f e c t i o n c o n t r o l program Midwi f e r y Oncology P e r i n a t a l nurse c l i n i c i a n , neonatal intensive care Respiratory rehabilitation Not r e p o r t e d  was  52  amount o f t i m e  Most o f t h e s a m p l e had  i n y e a r s spent  h e l d b e t w e e n one  i n n u r s i n g before a c c e p t i n g the present  of  c l i n i c a l nurse  specialist.  of  t h e p o s i t i o n s were h e l d by a r e s p o n d e n t  h e n c e a p o s i t i o n may  be c o u n t e d  I t s h o u l d be n o t e d  and  position  t h a t some  more t h a n  more t h a n o n c e .  in  once,  The  s e q u e n c e o f numbers b e g i n s w i t h 1 a s t h e p r e s e n t p o s i t i o n ;  2  r e f e r s to the p o s i t i o n h e l d p r i o r  3  t o the p r e s e n t p o s i t i o n ,  r e f e r s t o t h e p o s i t i o n h e l d b e f o r e 2, and from the p r e s e n t .  For example, immediately  a c c e p t i n g the present p o s i t i o n , worked i n the p o s i t i o n 1 and  Eight  had  backward  prior  to  18 o f t h e 59 r e s p o n d e n t s  of g e n e r a l d u t y / s t a f f  p e r i o d o f between respondents  so o n ,  nurse  25 y e a r s w i t h an a v e r a g e  worked i n each  had  for a  of 5 y e a r s .  of the c a t e g o r i e s of  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 , Range, a n d Mean Y e a r s H e l d ( I t e m 12) POSITION 2  3  4  5  6  7  8  1  1  0  0  0  2 1  0  0  0  Clinical nurse spec.  No. 60 Rnge 2-15 Mean 4  Assistant or head n u r s e  No. Rnge Mean  4 2-2 2  3  2 1-2 1 .5  Associate or assistant di rector  No. Rnge Mean  0  0  0  Director  No. Rnge Mean  0  Head  Sequence,  SEQUENCE 1  General  53  duty  nurse  Instructor  0  2 2-5 3.5  0  0  0  0  9 1-4 2.2  1  0  2  2 1-3 2  0  0  2 3 3-3 3-12 3 7.5  0  0  0  No. Rnge Mean  18 19 1-25 1-15 5 4.3  12 1-6 2.8  7 2-5 3. 1  No. Rnge Mean  7 8 3-5 1-10 4.5 4.5  0  1  No. Rnge Mean  6 1-8 5.1  O f f i c e n u r s e / No. comm. h e a l t h Rnge nurse Mean Professor  1  No. Rnge Mean  4 2-4 2.7  7 8 1-17 2-19 6.7 5.1 0  1  6 2-8 4.5  1 3  0  0  0  0  0  2 2-5 3.5  1  0  2 1-6 3.5  0  2 1-3 2  2 2-2 2  1  0  0  13  S u p e r v i s o r o r No. coordinator Rnge Mean  8 2-6 3.3  Other  8 6 1-9 1-13 3.7 5.6  No. Rnge Mean  4  1 5  1  1  54  office and  nurse/community h e a l t h nurse,  other  immediately  position. position  Subjects  prior  years,  to accepting  had worked between  the present  1 a n d 17 y e a r s  of o f f i c e nurse/community h e a l t h nurse,  a v e r a g e o f 6.7 y e a r s . category  supervisor/coordinator  Subjects  w i t h an  i n the second p o s i t i o n  ( 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  w i t h an a v e r a g e o f 3.3 b e f o r e  position.  Subjects  i n the t h i r d  i n d i c a t e d a range between 3.7 y e a r s .  Table  accepting  duty/staff  nurse.  the present  p o s i t i o n category  1 and 9 y e a r s  (other)  w i t h an a v e r a g e o f  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 t h e  r e s p o n d e n t s had worked i n t h e p o s i t i o n c a t e g o r y  of general  Many h a d w o r k e d i n t h e 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 and  i n the  instructor.  nurse,  The s m a l l e s t number o f r e s p o n d e n t s h a d  worked i n t h e 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 estimates  1  o f w e e k l y work t i m e d e v o t e d t o e a c h c a t e g o r y  work a c t i v i t y parametric  l e v e l , and  were e x a m i n e d u s i n g b o t h p a r a m e t r i c  statistical  tests.  of  and non-  I n i t i a l l y , t h e ANOVA  results  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 f r o m t h e 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 t h e 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 . 1  55  revealed  a high degree of v a r i a b i l i t y  amongst  the estimated  p e r c e n t a g e s d e v o t e d t o some o f t h e work c a t e g o r i e s . the  number o f s u b j e c t s  the  v i o l a t i o n of the assumption of equal v a r i a n c e s  produce m i s l e a d i n g parametric used.  distribution.  numbers the  However,  the  was  of variance  of v a r i a n c e  means.  indicated  a larger  test indicated  that  Appendix C c o n t a i n s  difference  sample s i z e .  that  When t h e  s i g n i f i c a n c e and t h e a n a l y s i s  was l i k e l y  real,  with  a s an i n d i c a t i o n t h e unequal  the difference  a description  between t h e  of a l l the  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  14 p r e s e n t s a summary o f 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 o f T a b l e (1)  When  s i g n i f i c a n c e and t h e  as i n d i c a t i o n of a p o s s i b l e  i n t h e ANOVA " h i d i n g "  Table  as r e a l .  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  r e s u l t s , both s t a t i s t i c a l l y while  indicated  was i n t e r p r e t e d  d i d n o t , t h i s was i n t e r p r e t e d  of a d i f f e r e n c e variances  a s i s t h e c a s e i n some o f  When b o t h t e s t s  may h a v e been p r e s e n t w i t h Kruskal-Wallis  of t h e  The r e s u l t s o f b o t h t e s t s a r e  the difference  interpreted  also  these t e s t s a r e not as powerful f o r  i n A p p e n d i x C.  Kruskal-Wallis  Thus, non-  b e t w e e n g r o u p s , e s p e c i a l l y when t h e  following analyses.  analysis  1971).  could  r a n k p r o c e d u r e s , were  of o b s e r v a t i o n s a r e small  significance,  categories,  a r e n o t d e p e n d e n t on t h e v a r i a n c e  differences  presented  t h e work  r e s u l t s (Ferguson,  tests, Kruskal-Wallis  The l a t t e r  detecting  varies within  Since  the contextually  14 i n d i c a t e s t h r e e  related variables  things:  o f new o r e x i s t i n g  T a b l e 14 Summary o f 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 o f P e r c e n t a g e o f W e e k l y Work Time D e v o t e d t o C a t e g o r i e s o f Work A c t i v i t y M i n . Max.  Mean  SD  56  Category  Variable  N  Administration  new existing TOTAL  25 20 45  1 1  45 25  13. 2 7. 0 10. 4  1  12. 1 6. 8 10. 5  10. 0 5. 0 5. 0  26.6 18.5  2  Pat i e n t care  new existing TOTAL  26 24 50  1 15  75 80  29. 7 45. 6 37. 3  1  23. 4 22. 2 24. 0  20. 0 50. 0 30. 0  20.5 30.9  2  Community activity  hosp. cbs. po/fpu other TOTAL  22 13 0 3 38  1 1  35 1 00  6. 4 16. 6  8. 8 26. 5  5. 0 6. 0  15. 6 25.0  5  20  10. 0 10. 2  8. 7 17. 3  5. 0 5. 0  24.0  Interdis- clinical iplinary clin-ed interclin-adm act ion other TOTAL  13 4 7 24 48  2 8 1 1  15 10 20 50  5. 5 9. 5 7. 0 12. 9 9. 7  4. 0 1 .0 6. 4 10. 8 8. 8  5. 0 10. 0 5. 0 10. 0 8. 5  16.8 29.5 19.5 29.3  Administration  1 ine staff TOTAL  6 36 42  5 1  45 35  21 . 7 9. 0 10. 8  16. 9 8. 4 10. 7  15. 0 5. 0 5. 0  31 . 7 19.7  Interdis- dip. i p l i n a r y bacc. intermaster action TOTAL  34 8 7 49  2 1 3  20 30 50  8. 1 8. 4 17. 9 9. 6  6. 6 6. 2 15. 3 8. 8  8. 0 5. 0 15. 0 8. 0  22.8 24.3 36.0  Staff development  dip. bacc. master TOTAL  25 6 6 37  1 1 1  20 80 10  5. 5 24. 3 4. 8 8. 4  1  4. 7 29. 2 3. 0 13. 6  5. 0 6. 5 5. 0 5. 0  17.4 26.8 17.5  P i n . P o l . j . d . yes S t a n d a r d s j . d . no Change TOTAL  24 19 43  1 1  20 10  8. 5 4. 7 6. 8  1  6. 2 3. 0 5. 3  6. 5 5. 0 5. 0  25. 1 18.1  1  1  Median Avg. Rank  S i g n i f i c a n t d i f f e r e n c e b e t w e e n means a c c o r d i n g way ANOVA, p o f F s t a t i s t i c < .05 ( s e e t e x t f o r details). S i g n i f i c a n t d i f f e r e n c e between r a n k s a c c o r d i n g K r u s k a l - W a l l i s s t a t i s t i c , p < .05 ( s e e t e x t f o r details).  2  2  2  1  t o t h e onefurther  2  to the further  57  and  l i n e o r s t a f f p o s i t i o n were f o u n d t o be r e l a t e d t o t h e  amount o f e s t i m a t e d t i m e d e v o t e d t o t h e c a t e g o r i e s administration  and p a t i e n t  care.  When t h e 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 g r o u p o f c l i n i c a l specialists weekly  nurse  s p e n t a s i g n i f i c a n t l y l a r g e r amount o f e s t i m a t e d  work t i m e i n t h e c a t e g o r y  (F(1,43)=4.21,  administration  p=.046; K-W(1)=4.27, p = . 0 3 9 ) .  When t h e  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 g r o u p o f clinical  nurse s p e c i a l i s t s  amount o f e s t i m a t e d w e e k l y care  (F(1,48)=6.09,  of appointment  devoted a s i g n i f i c a n t l y  larger  work t i m e t o t h e c a t e g o r y  p=.017; K-W(1)=6.27, p = . 0 1 2 ) .  was l i n e a s o p p o s e d t o s t a f f  employing agency, t h i s group of c l i n i c a l  patient  When t y p e  within the  nurse  specialists  d e v o t e d a s i g n i f i c a n t l y g r e a t e r amount o f e s t i m a t e d w e e k l y work t i m e t o t h e 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 = . 0 2 7 ) ; (2) t h e 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 o r absence  of a j o b d e s c r i p t i o n a n d t h e d e r i v e d i n d i c a t e t h e presence of a p o s s i b l e  professional difference  variable  f o r the  e s t i m a t e s o f p e r c e n t a g e o f w e e k l y work t i m e d e v o t e d t o t h e categories planning-policy-standards-change, interdisciplinary analysis  i n t e r a c t i o n , and s t a f f  of variance indicated  specialists  with  (F(1,41)=5.91,  that  a jobdescription  development.  those c l i n i c a l  The  nurse  spent a s i g n i f i c a n t l y  p=.020; K-W(1)=3.28, p=.070) l a r g e r amount o f  e s t i m a t e d w e e k l y work t i m e  i n the category  planning-policy-  58  standards-change  than those w i t h o u t a j o b 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 e s t i m a t e s of weekly specialists  larger  work t i m e  w i t h master's  significantly  of d e r i v e d e d u c a t i o n a l l e v e l indicated that c l i n i c a l  amount o f e s t i m a t e d w e e k l y  or  diploma  of  weekly  p=.086)  work t i m e t o t h e c a t e g o r y  interaction  than those w i t h b a c c a l a u r e a t e  level preparation.  For the estimated percentage  work t i m e d e v o t e d  development, those c l i n i c a l  t o the category nurse  (F(2,34)=6.36,  staff  specialists  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  of  nurse  l e v e l p r e p a r a t i o n devoted a  ( F ( 2 , 4 6 ) = 4 . 1 3 , p=.020; K-W(2)=4.91,  interdisciplinary  on  with  significantly  p=.005; K-W(2)=3.75, p=.153) g r e a t e r amount  time than those w i t h master's  or diploma  level  p r e p a r a t i o n ; and (3) t h e c o n t e x t u a l l y of for  appointment  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  ( I t e m 9b) i n d i c a t e d a l i k e l y  e s t i m a t e s of weekly  community a c t i v i t i e s Kruskal-Wallis test specialists  work t i m e d e v o t e d  significantly  (F(2,35)=1.47,  setting  i n community based  of  nurse  they spent a  work t i m e d e v o t e d  t h a n t h o s e who w o r k e d  s e r v i c e s o r t h o s e who i n d i c a t e d  worked i n t h e c a t e g o r y o t h e r . type of appointment  The  p=.243; K-W(2)=6.41, p=.041)  s m a l l e r amount o f e s t i m a t e d w e e k l y c a t e g o r y community a c t i v i t i e s  interaction.  t h a t when c l i n i c a l  worked i n a h o s p i t a l  difference  to the categories  and i n t e r d i s c i p l i n a r y indicated  real  to the either  they  Examination of the i n f l u e n c e  ( I t e m 9b) i n d i c a t e d t h a t  clinical  59  nurse  specialists  who  identified  t y p e as e i t h e r  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  clinical-  (F(3,44)=2.49,  p=.073; K-W(3)=8.14, p=.043) g r e a t e r amount o f e s t i m a t e d weekly  work t i m e i n t h e c a t e g o r y  interaction  t h a n t h o s e who  interdisciplinary  identified  type as c l i n i c a l  or  clinical-administrative. T h e s e f i n d i n g s p e r m i t an of  the c l i n i c a l  of  self-identified clinical  Columbia. chapter.  initial  nurse s p e c i a l i s t  role  description  a s r e p o r t e d by a  nurse s p e c i a l i s t s  Such a d e s c r i p t i o n  next  of the f i n d i n g s  in this  s t u d y w i t h t h o s e o f A r a d i n e and D e n y e s ( 1 9 7 2 ) i s a l s o presented.  group  in British  i s presented i n the  In a d d i t i o n , a comparison  t o be made  CHAPTER 5 DISCUSSION As  stated  i n Chapter  1, t h e p u r p o s e s o f t h i s  study  were: 1. t o d e s c r i b e  2.  the role  of t h e c l i n i c a l  nurse  specialist  as p e r c e i v e d  by a g r o u p o f n u r s e s i n B r i t i s h C o l u m b i a  who i d e n t i f y  themselves as b e l o n g i n g  to identify  to this  group;  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 t h e  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 A r a d i n e and Denyes 3.  (1972);  t o make s u g g e s t i o n s f o r t h e f u t u r e role on  Specific  of the c l i n i c a l  to the  i n Canada b a s e d  t h e above f i n d i n g s . d i s c u s s i o n of t h e f i n d i n g s i s p r e s e n t e d  Description  of the Role as P e r c e i v e d  of C l i n i c a l Nurse S p e c i a l i s t s data  specialists received  in relation  nurse s p e c i a l i s t  sections corresponding t o these stated  The  by  indicate that  Post-basic  purposes.  by a S e l f - D e f i n e d  basic  nursing  nursing  education  p u r s u e d by t h i s g r o u p . were h e l d p r i o r  the majority  education  of c l i n i c a l  nurse  t h a n 40 a n d  i n diploma  programs.  may o r may n o t h a v e been  Three or four p o s i t i o n s i n n u r s i n g  t o the acceptance of the present  In terms of a l i s t  Group  i n B r i t i s h Columbia  i n B r i t i s h Columbia a r e older  their  i n three  of categories 60  o f work a c t i v i t y  position. described  61  in  the l i t e r a t u r e  ( A r a d i n e and D e n y e s , 1972) t h e l a r g e s t  p e r c e n t a g e o f w e e k l y work t i m e i s r e p o r t e d l y p a t i e n t c a r e ; l e s s of the weekly  work t i m e i s d e v o t e d 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 , the of  spent i n  and c o n s u l t a t i o n ;  and  l e a s t amount o f w e e k l y work t i m e i s d e v o t e d t o e d u c a t i o n students, 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 d e v e l o p m e n t , r e s e a r c h , and w r i t i n g  for publication.  Furthermore, the m a j o r i t y of c l i n i c a l in  B r i t i s h Columbia  setting.  r e p o r t e d employment  The most f r e q u e n t l y u s e d  clinician.  The t y p e o f a p p o i n t m e n t  nurse  specialists  in a hospital  job t i t l e  was  nurse  was e v e n l y d i v i d e d  b e t w e e n u n i t - b a s e d a n d n o t u n i t - b a s e d and was d e s c r i b e d a s a staff  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  provided  for clinical,  clinical-educational,  a d m i n i s t r a t i v e and o t h e r . new v e r s u s e x i s t i n g job  Contextually  and  related  clinicalvariables,  p o s i t i o n and p r e s e n c e or absence of a  d e s c r i p t i o n when t h e 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 t h e r e p o r t e d e s t i m a t e s of weekly t i m e d e v o t e d t o some o f t h e c a t e g o r i e s o f work  work  activity,  n a m e l y a d m i n i s t r a t i o n a n d 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  respectively.  derived educational level),  level  The p r o f e s s i o n a l  variable,  (highest achieved educational  was f o u n d 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 a c t i v i t y ,  work t i m e d e v o t e d t o two c a t e g o r i e s o f  interdisciplinary  i n t e r a c t i o n a n d work  62  activity.  Further specific  general description  d i s c u s s i o n related to  i s p r e s e n t e d under the  s u b s e c t i o n s : work a c t i v i t y , and  professional  d e s c r i b e d by A r a d i n e  and  nurse  Denyes (1972) (see T a b l e  i n Table  4,  suggests  (Item  labels.  This group  number o f 7),  there i s a variety  of  For example, i t  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  counselling/psychotherapy, t r a d i t i o n a l p a t i e n t education would f a l l category patient care.  s p e c i a l i s t s ) n e e d s t o be is similar  nursing s k i l l s ,  w i t h i n t h e work  Therefore, precision  a s s o c i a t e d w i t h each category  suggestion  The  the category other  meanings a t t a c h e d t o these c a t e g o r y seems r e a s o n a b l e  3).  l a b e l s have meaning f o r t h e  s p e c i a l i s t s surveyed.  c a t e g o r i e s d e r i v e d from presented  Activity  i n t e r m s o f a l l of t h e c a t e g o r i e s  t h a t the c a t e g o r y  clinical  variables,  variable.  R e s p o n s e s were g i v e n  of  following  contextually related  Work  suggests  this  label  t o one  activity of t h e  (among c l i n i c a l  f u r t h e r e x a m i n e d by  and  meaning nurse  research.  made by A r a d i n e and  This  Denyes  (1972). The  category  amount o f w e e k l y Table  3).  of work a c t i v i t y work t i m e  This finding  a r t i c u l a t e d by R e i t e r  ( 3 7 . 3 % ) was  the  largest  p a t i e n t care  i s c o n s i s t e n t w i t h the  (1966), Peplau  (1962) t h a t p a t i e n t c a r e t h e f i n d i n g t h a t most  receiving  view  ( 1 9 6 5 ) , and  Johnson  i s the f o c u s of the r o l e .  (52 o r 89.7%) c l i n i c a l  (see  nurse  However,  63  s p e c i a l i s t s are or  in a staff  11.5%) r e p o r t e d  type  p o s i t i o n and  a s m a l l subgroup  of a p p o i n t m e n t a s  a d m i n i s t r a t i v e w o u l d seem t o be  clinical-  inconsistent with  Johnson's  (1962) view of the  r o l e a s an a l t e r n a t e t o t h e  head nurse p a t t e r n  f o r t h e d e l i v e r y of n u r s i n g c a r e  i n the h o s p i t a l s e t t i n g . clinical  Further,  n u r s e s p e c i a l i s t d e m o n s t r a t e s commitment t o  the  supported  by R e i t e r ( 1 9 6 6 ) and  by  the  publishing,  Peplau  f i n d i n g s of t h i s  r e s e a r c h was  20%,  and  that  (see T a b l e  low,  s e t t i n g m i g h t be experience  type  baccalaureate  m i n i m a l amount o f c o n t e n t  frequently provide  4.6%  and  finding  was  5.1%  suggests  i s common a t  l e v e l s where t h e r e and  experience  the  H o w e v e r , i t can was  the  is usually a  r e l a t e d to  community s e r v i c e s of  away f r o m l a r g e u r b a n  e v e n when g r a d u a t e p r e p a r a t i o n  work  i n nursing, u n l i k e both  l i m i t e d e m p h a s i s on and  activities.  and  of  example, advanced  I n a d d i t i o n , h o s p i t a l s and  a non-academic type  research  For  research process  m a s t e r ' s l e v e l of p r e p a r a t i o n d i p l o m a and  f o r work c a t e g o r y  o f e d u c a t i o n a l p r e p a r a t i o n and  influences.  w i t h the  W h i l e t h e maximum  3).  S p e c u l a t i o n about reasons f o r t h i s factors like  i s not  for writing for publication  t h e mean p e r c e n t a g e s were v e r y  respectively  (1965),  study.  p e r c e n t a g e o f w e e k l y work t i m e r e p o r t e d  research.  services the  articulated  that  traditional  the p o s i t i o n t h a t  p r o f e s s i o n by e n g a g i n g i n r e s e a r c h and  40%,  (7  areas  support  be p o i n t e d  characteristic  for  out of  that  64  s u b j e c t s , as i n the Aradine (all  a n d D e n y e s (1972)  study  s u b j e c t s had m a s t e r ' s l e v e l p r e p a r a t i o n i n  nursing), writing  involvement  i n t h e c a t e g o r i e s of r e s e a r c h and  f o r p u b l i c a t i o n was r e p o r t e d a s l o w .  That  study,  h o w e v e r , was c a r r i e d o u t d u r i n g a t i m e when e m p h a s i s on r e s e a r c h a n d p u b l i c a t i o n was n o t a s g r e a t a s a t p r e s e n t . Nevertheless, with this  i t may be t h a t t h e work s e t t i n g h a s more t o do  finding  than does t h e l e v e l  p r e p a r a t i o n of the s u b j e c t s . by A r a d i n e  of e d u c a t i o n a l  Some o f t h e q u e s t i o n s  raised  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 a n d 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 others? What i n f l u e n c e s h a v e t i m e , p r i o r i t i e s , c o m p e t i n g p r e s s u r e s , a n d 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 a n d w r i t i n g ? Do r e s e a r c h a n d w r i t i n g represent delayed rewards f o r the c l i n i c a l nurse specialist? ( p . 416) This k i n d of l i m i t e d specialists concern  involvement  of c l i n i c a l  i n r e s e a r c h and w r i t i n g  nurse  for publication  because of t h e need f o r t h e 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 , d e m o n s t r a t e , and a r t i c u l a t e  its activities  own members, o t h e r p r o f e s s i o n a l s , a n d c o n s u m e r s " and  i s of  to i t s  (Aradine  D e n y e s , 1972; P. 4 1 6 ) .  Contextually Related Variables In to  this  subsection, d i s c u s s i o n i s presented p e r t a i n i n g  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 :  e x i s t i n g p o s i t i o n and p r e s e n c e  job t i t l e ,  new o r  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 , a n d t y p e o f a p p o i n t m e n t .  65  used  Job t i t l e .  T h i s s t u d y f o u n d t h a t t h e most  job t i t l e  was n u r s e c l i n i c i a n ( s e e T a b l e 5 ) .  u n c l e a r why n u r s e s w i t h t h i s j o b t i t l e would  check  clinical  RNABC r e g i s t r a t i o n preference within title.  and  registration  t h e p r o v i n c e of B r i t i s h Columbia  check  nurse,  box 23 on t h e RNABC  A l l of t h i s might  "clinical  suggest  that the  s p e c i a l i s t " on t h e RNABC  f o r m may be f u n c t i o n i n g a s a c a t c h - a l l  category  Or t h e s e d i s c r e p a n c i e s may be v i e w e d a s  their  i s different  of t h i s  employers  s t u d y , namely,  than the g e n e r a l l y shared  options f o r the i n d i c a t i o n I f the role  b e i n g implemented  the c l i n i c a l  nurse  in  the thinking  of i n d i v i d u a l  understandings  that a r e l i s t e d as  o f work p o s i t i o n  of  these  b e l i e v e they p r o v i d e a s e r v i c e  associated with the other nursing roles  form.  who  o f head n u r s e , community h e a l t h  s u p p o r t i v e o f an a s s u m p t i o n  that  for this  i t i s u n c l e a r why r e s p o n d e n t s  form.  some n u r s e s .  nurses and/or  there i s a  f o r m when t h e s e same c a t e g o r y names a r e  category l a b e l registration  (nurse c l i n i c i a n )  T h i s may s u g g e s t  ( s e e T a b l e 5) w o u l d  p r o v i d e d on t h a t  for  form.  job t i t l e s  instructor  I ti s  s p e c i a l i s t r a t h e r t h a n o t h e r on t h e  Additionally,  provided  frequently  on t h e RNABC  by t h e s a m p l e i s t h a t  s p e c i a l i s t , then  i t s h o u l d be so named  nurses and i n t h e everyday  w o r k i n g w o r l d by b o t h n u r s e s a n d o t h e r s i n t h e h e a l t h system.  As c o n s i s t e n c y a n d 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 disappear.  care  be e x p e c t e d t o  66  Most of the r e s p o n d e n t s their  job t i t l e s .  indicated satisfaction  with  T h i s s u g g e s t s e x i s t e n c e of a degree employers  of  a g r e e m e n t b e t w e e n some n u r s e s and  their  about  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.  w i t h t h e r a n g e of j o b t i t l e s u s e d  i n t h e work p l a c e ( s e e  the  However, c o u p l e d  T a b l e 5) t h e d a t a s u g g e s t a p o s s i b l e a b s e n c e  among n u r s e s o f  a commonly s h a r e d u n d e r s t a n d i n g o f t h e t i t l e  clinical  specialist,  nurse  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 .  Therefore, the researcher suggests that know what a c l i n i c a l  nurse s p e c i a l i s t  what a h e a d n u r s e i s , f o r e x a m p l e ,  i f n u r s e s do  not  i s and t h e y do  know  then the n u r s i n g  profession  i n Canada has n o t done i t s j o b o f a r t i c u l a t i n g  definition  of the c l i n i c a l  enough.  In a d d i t i o n ,  nurse s p e c i a l i s t  the p o p u l a t i o n f o r t h i s  researcher  suggests that the category t i t l e  the  RNABC a n d  entitled New  variables  The  nurse  f o r the purposes  of  be more a c c u r a t e l y  l i t e r a t u r e does not d i s c u s s  However, i t was  t h a t might  felt  nurse  by t h e r e s e a r c h e r t h a t  important f a c t o r s w i t h i n  affect  of j o b  these  t o the r o l e of the c l i n i c a l  t h e s e v a r i a b l e s c o u l d be environment  clinical  p o s i t i o n and p r e s e n c e o r a b s e n c e  in relation  specialist.  drawn, the  clinician.  or e x i s t i n g  description.  s t u d y was  be a n o n - f u n c t i o n a l one t h i s c a t e g o r y might  nurse  well  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  s p e c i a l i s t may  role  a  r o l e enactment  t h e work  of the  clinical  67  nurse s p e c i a l i s t . positions  S l i g h t l y more t h a n h a l f o f t h e p r e s e n t  (32 o r 51.6%) were new ones i n t h e work  when a c c e p t e d by t h e s u b j e c t s . these p o s i t i o n s  (both  Table  that  ranged  w i t h an a v e r a g e o f 4 y e a r s ( s e e  1 3 ) . T h u s , most o f t h e p r e s e n t p o s i t i o n s h e l d by t h e  subjects  were c r e a t e d  priority  w i t h i n the profession  specialization that  The l e n g t h o f t i m e  new a n d o l d ) h a d been h e l d  b e t w e e n 2 a n d 15 y e a r s ,  settings  i n t h e 1970's.  i n nursing.  I t was i n 1972 t h a t  was d i r e c t e d t o t h e i s s u e o f  These f i n d i n g s c l e a r l y  indicate  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 C o l u m b i a began  t o r e s p o n d t o t h e need f o r s p e c i a l i z a t i o n w i t h i n t h e h e a l t h care  s y s t e m by m o v i n g i n t o t h e r o l e o f c l i n i c a l  specialist. various  This  a l s o suggests that  nurse  i t was a f t e r 1972 when  work s e t t i n g s began t o r e s p o n d t o t h i s n e e d by  creating places  f o r t h e 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 t h a n h a l f o f t h e p r e s e n t p o s i t i o n s h a d j o b d e s c r i p t i o n s when t h e y were a c c e p t e d by t h e r e s p o n d e n t s . This the  indicates that  nursing  issue of implementing the r o l e .  l a r g e group of c l i n i c a l not  p r a c t i c e h a s been d e a l i n g  with  The f i n d i n g t h a t a  nurse s p e c i a l i s t s  (22 o r 42.6%) d i d  h a v e 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 t h e p o s i t i o n was  accepted  ( s e e T a b l e C.2) s u g g e s t s t h a t t h i s m i g h t be an  e a r l y phase f o r n u r s i n g respect  and t h e h e a l t h c a r e  t o t h e r o l e of the c l i n i c a l  B r i t i s h Columbia.  If this  system i n  nurse s p e c i a l i s t i n  i s so, continuing  efforts to  d e v e l o p a n d i m p l e m e n t t h e r o l e m i g h t be l i m i t e d a s l o n g a s  68  it  remains  unclearly defined.  definition  With lack of c l a r i t y  of the r o l e , guidance  ina  to nursing education  r e m a i n s u n c l e a r a n d ways o f d e m o n s t r a t i n g t h e e f f e c t i v e n e s s of t h e r o l e  remain  unexamined.  When t h e r e l a t i o n s h i p o f t h e s e v a r i a b l e s a n d t h e e s t i m a t e d percentages of time devoted work a c t i v i t y  t o each c a t e g o r y of  was e x a m i n e d by means o f 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 f o u n d  When t h e p o s i t i o n was new, c l i n i c a l devoted a s i g n i f i c a n t l y e s t i m a t e d weekly  (see T a b l e 1 4 ) .  nurse  ( p < .05) g r e a t e r amount o f  work t i m e  (mean e q u a l l e d  a d m i n i s t r a t i o n t h a n t h o s e whose p o s i t i o n it  specialists  was a c c e p t e d (mean e q u a l l e d  7.0%).  13.2%) t o was e x i s t i n g  A g e n e r a l need f o r  b e c o m i n g f a m i l i a r w i t h a new work e n v i r o n m e n t o u t where a n d how a new r o l e explain  this  relations  finding.  Clarification  form of o r g a n i z a t i o n  t h a t most o f t h e s u b j e c t s  finding  of a d m i n i s t r a t i v e ina  (the reader w i l l  recall  (41 o r 65.1%) w o r k e d i n a h o s p i t a l  In a d d i t i o n , the c l i n i c a l  to 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 c o l l e a g u e s because  and/or  i n t o t h e s y s t e m may  i s necessary t o s u r v i v a l of r o l e s  bureaucratic  setting).  fits  when  nurse s p e c i a l i s t  needs  among h e r w o r k i n g  s h e i s f r e q u e n t l y d e p e n d e n t upon them a s  sources of r e f e r r a l s a t a l a t e r  time  1972;  In other words, e v e n t u a l  Woodrow a n d B e l l ,  effective  1971).  ( A r a d i n e and Denyes,  i m p l e m e n t a t i o n o f t h e r o l e may d e p e n d on t h e 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 category  o f work a c t i v i t y  p h a s e s of t h e p o s i t i o n . account f o r the specialist  b e c a u s e s/he t a s k of  has  begin  w o r k e d i n i t , but  accepted,  justified  p o s i t i o n was  clinical  already  (p <.02)  Influence  new  the c l i n i c a l  nurse s p e c i a l i s t  and  the  reported  established  and  be  i n an  may  i s more  they weekly  than d i d those  and/or  (mean of on-going  finding.  the e x p e c t a t i o n focus  for  of  of the  nature  of  of For  the  role i s  the  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 nurse s p e c i a l i s t .  interaction centered  would a l r e a d y  that  explain this  i s t h a t the  individual clinical  p a t t e r n s of  role  g r e a t e r amount o f  t h i s would i n f l u e n c e the  that occurs  It  in r o l e s that interact with that  example, i f the understanding  interaction  role.  clinical.  i n t h e work s e t t i n g  n u r s e s p e c i a l i s t may  patient care,  the  i n e x i s t e n c e when  from a p r e d e c e s s o r  i n f l u e n c e s from o t h e r s  clinical  than the  (mean o f 45.6%) t o p a t i e n t c a r e  whom t h e p o s i t i o n was 29.7%).  with  nurse s p e c i a l i s t  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 work t i m e  i s confronted  a d m i n i s t r a t i v e because t h a t aspect  u n d e r s t o o d and  When t h e  readily  nurse  of a s p e c i a l i z e d c l i n i c a l  t h a t the c l i n i c a l  as c h i e f l y  easily  i n which the c l i n i c a l  early  f a m i l i a r w i t h t h e work e n v i r o n m e n t  implementation  is speculated  the  T h i s e x p l a n a t i o n does not  situation  i s already  during  in operation  In a d d i t i o n ,  i n p a t i e n t care  once the  r o l e has  activities been  agency.  With the combination,  e x i s t i n g and  without  a  job  70  description, clinical significantly work t i m e did  (p <.01)  nurse s p e c i a l i s t s devoted a g r e a t e r amount o f e s t i m a t e d w e e k l y  (mean o f 59.6%) t o t h e c a t e g o r y p a t i e n t c a r e t h a n  those w i t h the other c o m b i n a t i o n s .  consistent with a belief  i n , and commitment t o , t h e  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 several c l i n i c a l 1976; in  Risk,  C r o l e y , 1962).  B r i t i s h Columbia  or  P e p l a u , 1965).  i s an e x p e c t e d f i n d i n g  hospitals  in light  ( K r a u s e , 1977).  the  be s e e n  indication  specialists  ( s e e T a b l e 8)  setting  of the f a c t  1971, a f o r e s h a d o w  (National  S u c h a l i n k a g e may  nurse s p e c i a l i s t  i n the h e a l t h care d e l i v e r y  will  system  the  h a v e been i s where  be i n Canada.  specialists  work i n a v a r i e t y  (see Table 8 ) .  and  Department  self-defined clinical  settings  of  made  However, t h e d a t a i n d i c a t e t h a t i n B r i t i s h Columbia  This  i s organized in  that the h o s p i t a l environment  r o l e of the c l i n i c a l  (41  that  nurse s p e c i a l i s t  f o r the r o l e  are  (Watson,  (see Table 8 ) .  i n a l i n k a g e t h a t was  H e a l t h and W e l f a r e , 1 9 7 1 ) .  implemented  study  As e a r l y a s  h o s p i t a l a s a work s e t t i n g  an e a r l y  nurse  i n the l i t e r a t u r e  between the c o n c e p t of the c l i n i c a l  of  Shrader,  belief.  i n the h e a l t h c a r e system  s u c h a f i n d i n g may  by  S p e c i f i c a l l y , most o f t h e s a m p l e  65.1%) w o r k e d i n a h o s p i t a l  specialization  Clinical  F i n d i n g s of t h i s  c o n s i s t e n t with those i n d i c a t e d 1973;  (Weeks, 1980;  seem t o s h a r e t h i s  Work s e t t i n g .  central  i n the l i t e r a t u r e  nurse s p e c i a l i s t s  1975;  This finding i s  of  nurse  71  When t h e r e l a t i o n s h i p o f work s e t t i n g a n d e s t i m a t e s o f p e r c e n t a g e s of weekly  work t i m e d e v o t e d  c a t e g o r i e s o f work a c t i v i t y  to the various  was e x a m i n e d , a  statistically  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 t h e K r u s k a l - W a l l i s test  (see Table  14). A p o s s i b l e  reason  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 difference time  i s t h e l a r g e range  within  (1-100%).  this  subgroups. setting  T h i s produced  subgroup  services (cbs)  a much h i g h e r v a r i a n c e  rank of t h e h o s p i t a l  i s c l e a r l y much l o w e r t h a n t h e a v e r a g e  ranks f o r the other subgroups. who w o r k e d i n a h o s p i t a l  setting  Clinical  nurse  spent a  ( a v e r a g e rank=15.6%) d e v o t e d  services  rank=25.0%) o r those i n t h e c a t e g o r y o t h e r  clinical  This finding  nurse s p e c i a l i s t  community a c t i v i t i e s , which  the role  work  agency.  (average  (average  role,  f o r example, involvement i n  may be l i n k e d w i t h t h e s e t t i n g i n F o r example, i f a major  p o r t i o n o f t h e s e r v i c e s p r o v i d e d by an a g e n c y  reflected  than  s u g g e s t s t h a t some a s p e c t s o f t h e  i s implemented.  community a c t i v i t i e s ,  time  t o community a c t i v i t i e s  t h o s e i n e i t h e r community based  rank=24.0%).  specialists  significantly  (p<.04) s m a l l e r amount o f e s t i m a t e d w e e k l y  did  work  ( 2 6 . 5 ) c o m p a r e d t o t h e o t h e r two  However, t h e a v e r a g e  subgroup  significant  of e s t i m a t e s f o r weekly  i n d i c a t e d by t h e c o m m u n i t y b a s e d  subgroup  f o r the f a i l u r e of  t h i s a s p e c t would  i n the a c t i v i t i e s  involves  be e x p e c t e d t o be  t h a t a r e implemented  through the  The i n t e r a c t i v e a s p e c t o f t h e r o l e e n a c t m e n t  view  72  of  r o l e theory e x p l a i n s these r e l a t i o n s h i p s  Allen,  1968;  t h e o r y may  D e u t s c h and K r a u s s , 1965).  account  t h e r e i s a danger  for this  The  danger  a complex r o l e ,  selected  role.  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 o f f o r whatever  important that t h i s  the  role  above,  i s c o n c e n t r a t e d on  p e r s p e c t i v e of a complex  p e r s p e c t i v e can e a s i l y  about  and  Even t h o u g h  f i n d i n g , as s u g g e s t e d  i f attention  a s p e c t s or a narrow  (Sarbin  reason, i s that the  be m i s s e d .  f i n d i n g be  Therefore, i t i s  i n t e r p r e t e d as a  the complex r o l e of the c l i n i c a l  t o a statement about  British  Columbia.  statement  nurse s p e c i a l i s t  p a r t i c u l a r work s e t t i n g o f c o m m u n i t y b a s e d  opposed  larger  and  services  as  the l a r g e r view of the r o l e i n  I t must be p o i n t e d o u t t h a t t h e s u b j e c t s i n t h e A r a d i n e and D e n y e s (1972) yet  t h e y r e p o r t e d i n v o l v e m e n t i n t h e community  category. reported to the  study worked o n l y i n a h o s p i t a l  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  setting  activities i n the  i n v o l v e m e n t 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  m o d e r a t e l e v e l s by t h e t i m e two y e a r s had been s p e n t i n position.  movement o u t  This s h i f t  was  from h o s p i t a l  i n t e r p r e t e d as e v i d e n c e o f a  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 a s t h e y a t t e m p t e d t o e x t e n d b o t h t h e number o f p l a c e s and ways i n w h i c h the  delivery The  they c o u l d  of n u r s i n g c a r e w i t h  involvement of c l i n i c a l  community a c t i v i t i e s  share knowledge  about  others. nurse s p e c i a l i s t s i n  r e p o r t e d by b o t h A r a d i n e and' D e n y e s  73  (1972) and  the present study suggest that the v a r i a b l e  s e t t i n g may  n o t be an  work  i m p o r t a n t d e t e r m i n a n t o f what a  clinical  n u r s e 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  relation  t o the c a t e g o r y community a c t i v i t i e s .  t h a t t h e p a r t i c u l a r work s e t t i n g o f a l a r g e h o s p i t a l c e n t e r ( A r a d i n e and D e n y e s , 1972) i n f l u e n c e on t h e i n v o l v e m e n t o f c l i n i c a l in  The  w r i t e r s a r e d i v i d e d a s t o how specialist (i.e.,  within  line  specialists  be  university is a  nurse  versus s t a f f ) .  significant specialists  s t a t e m e n t o f how  the r o l e  this province.  The  that supports t h i s  for  The  T h i s c a n be fits  belief  articulated  i n the  maintains that  p o s i t i o n placement  reflected  what R e i t e r  this  (1966)  would  The  s t u d y may  staff  1972;  not  r e p o r t e d by  most o f them d i d n o t h a v e  in this  authority  ( K i r k m a n and M i l l e r ,  seem t o e x p l a i n t h e s t a f f  11).  system  literature  s k i l l s a r e the b a s i s of the  (see T a b l e  nurse  i n t o the h e a l t h care  However, t h i s b e l i e f  placement  setting  i n t e r p r e t e d as a  B a k e r and K r a m e r , 1 9 7 0 ) .  level preparation  nurse  (52 o r 89.7%) r e p o r t e d t h a t  nurse s p e c i a l i s t  these s u b j e c t s because  that  m a j o r i t y of c l i n i c a l  k i n d of a placement  k n o w l e d g e and  the c l i n i c a l  indicates  to p l a c e the c l i n i c a l  i n B r i t i s h Columbia positions.  advanced  literature  t h e o r g a n i z a t i o n o f t h e work  they h e l d s t a f f  of  i t may  the community a c t i v i t i e s c a t e g o r y . Type o f a p p o i n t m e n t .  in  Or  graduate  position  suggest the  presence  r e f e r r e d t o a s "a s t a t e o f b e i n g . "  she d e s c r i b e d a s i t u a t i o n  By  i n which there 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 a n d o t h e r s o f an a c c u m u l a t i o n o f a d e p t h o f k n o w l e d g e a n d e x p e r i e n c e w h i c h some n u r s e s a p p l y i n their link  practice.  Although Reiter  (1966) d i d n o t e x p l i c i t l y  these ideas t o t h 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  such a nurse would a master  require,  practitioner.  reflective  she d i d d e s c r i b e such a nurse as  If a staff  p o s i t i o n placement i s  of such a " s t a t e of b e i n g , " t h e f i n d i n g i n t h e  p r e s e n t s t u d y c a n be i n t e r p r e t e d state  as a r e c o g n i t i o n  by b o t h some i n d i v i d u a l n u r s e s a n d some In l i g h t of t h e d i s c u s s i o n  pertaining clinical  (1976)  positions.  i n B r i t i s h Columbia  Most o f t h e c l i n i c a l are i n staff  Hence t h e y may be seen a s h a v i n g  authority,  of t h e  f i n d i n g c a n a l s o be  i n t h e f o l l o w i n g manner.  nurse s p e c i a l i s t s  professional  r e s u l t i n g from peer p e r c e p t i o n of t h e i n d i v i d u a l  nurse s p e c i a l i s t ' s 1976).  consistent  knowledge and e x p e r t i s e  T h i s e x p l a n a t i o n would  with the "state  Reiter(1966). operative  employers.  p r o v i d e d by S t e v e n s  nurse s p e c i a l i s t , t h i s  (Stevens,  of t h i s  t o a c c o u n t a b i l i t y and type of appointment  interpreted  clinical  that  seem t o be  o f b e i n g " v i e w d i s c u s s e d by  The l a t t e r v i e w , t h e n , w o u l d  i n nursing practice  inBritish  appear  t o be  Columbia.  When t h e r e l a t i o n s h i p o f t h i s v a r i a b l e a n d e s t i m a t e s o f p e r c e n t a g e s o f w e e k l y work t i m e d e v o t e d t o e a c h c a t e g o r y o f 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 significant  difference  of a p p o i n t m e n t  was f o u n d  was l i n e , c l i n i c a l  (see Table  analyses, a 1 4 ) . When t y p e  nurse s p e c i a l i s t s  spent a  75  significantly weekly  (p <.001; p <.03)  work t i m e  administration  (mean=21.6%; a v e r a g e  appointment  rank=31.7%) i n  t h a n d i d t h o s e whose p o s i t i o n was  (mean=9.0%; a v e r a g e of  l a r g e r amount o f e s t i m a t e d  rank=l9.7%).  would  be e x p e c t e d  the f i n d i n g demonstrates  staff  By d e f i n i t i o n , t o produce  this  this  type  finding  the e x i s t e n c e of a degree  and  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 t h a n h a l f  (33 o r 54.1%) o f t h e s u b j e c t s  d e s c r i b e d type of appointment finding  i n the category o t h e r .  i s not c o n s i s t e n t w i t h statements t h a t  appointment  for c l i n i c a l  nurse  clinical-administrative Backsheider, themselves  1971).  classified  clinical-educational,  ( A r a d i n e and D e n y e s ,  A l a r g e subgroup  or o r g a n i z a t i o n a l l y ,  t h e i r work  1972;  (21/33) d e s c r i b e d  f o r the a c t i v i t i e s  (see Table 9 ) .  t h a t any  special  needs r e l a t e d t o t h e i r  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  I n d i v i d u a l e f f o r t s at implementing n u r s e s p e c i a l i s t may l e a d e r s h i p and  be d i f f i c u l t  support  role  lost  addressed. clinical  to accomplish without  t h e l o s s o f an o p p o r t u n i t y t o p r o v i d e p e e r  be  so  functioning  the r o l e of the  from the p r o f e s s i o n .  nurses, the c o n t r i b u t i o n s ,  that  This suggests there 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 s t u d y t h i s group  n u r s e s may  and  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  professionally comprised  t y p e of  s p e c i a l i s t s c a n be  by t h e c a t e g o r y l a b e l s c l i n i c a l ,  This  s k i l l s and  In a d d i t i o n  to  support to these  knowledge of  to the n u r s i n g p r o f e s s i o n .  these  76  When t h e r e l a t i o n s h i p clinical-educational,  of the v a r i a b l e  statistical  analyses, significance  Wallis  (see Table  14).  was  Clinical  type of appointment  other  work t i m e d e v o t e d  v a r i o u s c a t e g o r i e s o f work a c t i v i t y was  identified  clinical,  c l i n i c a l - a d m i n i s t r a t i o n , and  e s t i m a t e s of p e r c e n t a g e s of weekly  test  type  shown by t h e nurse  as e i t h e r  29.3%  respectively)  t h a n d i d t h o s e who  work t i m e  devoted  to the  subjected to Kruskal-  specialists  who  clinical-  e d u c a t i o n a l o r o t h e r s p e n t a s i g n i f i c a n t l y (p <.04) amount o f e s t i m a t e d w e e k l y  and  (average  greater  rank=29.5%  and  to 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  i d e n t i f i e d t y p e 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  rank=l9.5%).  S u b j e c t s i n each of t h e s e t y p e s of a p p o i n t m e n t s ,  clinical-  e d u c a t i o n a l and  o t h e r , would  p e r s o n n e l from a v a r i e t y results  likely  of d i s c i p l i n e s .  these  Variable  literature clearly indicates  k n o w l e d g e and specialist and  Thus,  seem r e a s o n a b l e .  Professional The  interact daily with  that  advanced  s k i l l s are p a r t of the c l i n i c a l  role  (Reiter,  1966;  P e p l a u , 1965;  nurse Johnson,  1962)  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 t h e  clinical  nurse  (Smoyak, 1976; 1965).  Only  s p e c i a l i s t i s the master's Georgopoulos  and C h r i s t m a n ,  degree  in nursing  1970;  Peplau,  f o u r of the s u b j e c t s h e l d a master's  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  degree  degrees  in (see  77  Table  11).  T h i s may  C o l u m b i a , an r o l e may  suggest t h a t , at t h i s  experience  time i n  component f o r p r e p a r a t i o n  be more h e a v i l y w e i g h t e d t h a n i s an  component when h i r i n g d e c i s i o n s a r e made. t h i s are unclear like  although  the a v a i l a b i l i t y  location  supportive  nursing  r e s e a r c h , and  nursing  p r a c t i c e m i g h t h a v e an  stability  findings concerning  of b a c c a u l a u r a t e  types  of programs.  clearly  preparation  10 w h i l e  types  because  that  for 12  and  for  i s impossible  of p r o g r a m s s u b j e c t s  of b a s i c n u r s i n g p r e p a r a t i o n .  Therefore,  to  post-basic  e i t h e r diploma or b a c c a l a u r e a t e  preparation.  completion  m a s t e r ' s p r o g r a m s was  However, s u c h a p a t t e r n  r e f e r s t o the  a f t e r completion c o u l d be  since  in  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  e s t a b l i s h from the d a t a  preparation  the  of s u c h p o s i t i o n s i n  post-basic  and  nurses,  r e s p e c t i v e l y , i n d i c a t e that a pattern  educational preparation  for  influence.  o f d i p l o m a / c e r t i f i c a t e p r o g r a m s was  6 years  educational  s t r u c t u r e s for ongoing  n u r s i n g , t h a t t h e a v e r a g e number of y e a r s  completion  the  speculation suggests that f a c t o r s  of h o s p i t a l s , t h e  The  for  Explanations  of m a s t e r ' s p r e p a r e d  the  British  i t is difficult  The  levels  pursued latter  of  t o make a  definite  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 preparation achieved, (20.9%) of the preparation  was  calculated.  s u b j e c t s had  i n n u r s i n g ) , 24  I t was  level  of  found t h a t  diploma l e v e l preparation  13  (basic  ( 3 8 . 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 ( 2 5 . 8 % ) had  (post-basic nursing preparation),  baccalaureate  p r e p a r a t i o n and  master's l e v e l p r e p a r a t i o n . statistics  i n d i c a t e the  The  reported  (basic nursing  levels:  education),  56.5%  33.3%  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 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  1976).  from nursing  p r o g r a m s , and  simply  specialist  role  i n Canadian  finding  p o s i t i o n s they  t h a t 25%  f o r the c l i n i c a l  of the c l i n i c a l  would i d e n t i f y  RNABC f o r m ) s u g g e s t s t h e r e  this  graduate  nurse  were no  nurse  longer  by c h e c k i n g  box  If this  23  nursing  education, limited  this  support  the  system at  i s s o , t h e r e m i g h t seem t o be  in c l i n i c a l  S i n c e most of t h e  (on  in  i s a d e g r e e of i n s t a b i l i t y  economic i n c e n t i v e f o r nurses t o pursue graduate in  specialists  working  to 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 care  time.  the  nursing.  r e c e i v e d the q u e s t i o n n a i r e  related  r a t h e r than  of  r e f l e c t a band-aid approach to  i s s u e of l e v e l of p r e p a r a t i o n  who  Manpower  f o r t h i s g r o u p of n u r s e s i n B r i t i s h C o l u m b i a .  H o w e v e r , t h i s may  The  1.1%  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  continuing p r o f e s s i o n a l education education  nurses  from diploma  f r o m m a s t e r ' s p r o g r a m s ( S t a t e m e n t 7, H e a l t h Statistics,  had  national  f o l l o w i n g p e r c e n t a g e s of  achieving various educational programs  latest  9 (1.4%)  16  specialization  s u b j e c t s had  not  little education  at the p r e s e n t  pursued graduate  time. level  f i n d i n g c o u l d a l s o suggest the presence w i t h i n t h e v a r i o u s work s e t t i n g s  of  concerning  79  the  clinical  nurse s p e c i a l i s t  the  finding that a large  33)  are not responsible  to nursing  reasonable t o think that On t h e o t h e r  leadership clinical  T h i s may be r e l a t e d t o  subgroup of t h e s u b j e c t s  l a c k of s u p p o r t and l e a d e r s h i p  follow.  role.  (see  hand, w i t h  i t is  such a l a c k of support and  i n nursing  e s t a b l i s h e d and supported i n n u r s i n g a l s o be n o t e d t h a t  With a  of p o s i t i o n s might  i t seems r e a s o n a b l e t o t h i n k  nurse s p e c i a l i s t  Table 9).  from n u r s i n g ,  instability  (21 o u t o f  the r o l e of the  i n B.C. r e m a i n s t o be practice.  I t should  t h e p r e s e n t economic s i t u a t i o n has  resulted  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  clinical  specialist  and t h e  r o l e may have been a c a s u a l t y  i n some  places. When t h e r e l a t i o n s h i p o f t h e h i g h e s t attained  (the d e r i v e d  educational  level  of  education  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 o f w e e k l y work t i m e d e v o t e d t o t h e c a t e g o r i e s o f work a c t i v i t y  was e x a m i n e d , s i g n i f i c a n t d i f f e r e n c e s were  d e m o n s t r a t e d by t h e a n a l y s i s o f 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 t h e K r u s k a l - W a l l i s Table be  14).  The number o f s u b j e c t s  statistically  t e s t (see  i n each subgroup found t o  d i f f e r e n t by t h e ANOVA was s m a l l  (6 a n d 7 ) .  A l a r g e r s u b g r o u p s i z e may have r e s u l t e d i n t h e f i n d i n g o f a statistically t e s t as w e l l . only  s i g n i f i c a n t d i f f e r e n c e by t h e K r u s k a l - W a l l i s Therefore,  these r e s u l t s a r e i n t e r p r e t e d as  an i n d i c a t i o n o f a p o s s i b l e d i f f e r e n c e b e t w e e n t h e  subgroups.  Clinical  nurse s p e c i a l i s t s with  master's  80  preparation  spent a s i g n i f i c a n t l y  e s t i m a t e d w e e k l y work t i m e interdisciplinary  ( p <.02)  (mean=17.9%) d e v o t e d t o  interaction  than d i d those  baccalaureate  (mean=8.3%) o r d i p l o m a  (mean=8.1%).  C l i n i c a l nurse s p e c i a l i s t s  preparation of  spent a s i g n i f i c a n t l y  e s t i m a t e d w e e k l y work t i m e  development  l a r g e r amount o f  with  preparation with baccalaureate  ( p <.001) g r e a t e r amount  (mean=24.3%) d e v o t e d  than d i d those w i t h master's  preparation  (mean=4.8%) o r t h o s e w i t h d i p l o m a p r e p a r a t i o n B a c c a l a u r e a t e programs g e n e r a l l y principles  for  of such p r i n c i p l e s  to  Given that the s t a f f  category represents a variation  application  (mean=5.4%).  include content related  o f l e a r n i n g and t e a c h i n g .  development  to staff  this  of  situations  finding  would  seem  reasonable.  Similarities  and D i f f e r e n c e s B e t w e e n t h e 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 a n d Denyes  (1972)  When a c o m p a r i s o n clinical this  was made b e t w e e n t h e r o l e  nurse s p e c i a l i s t  a s d e s c r i b e d by p a r t i c i p a n t s i n  study and t h a t a r t i c u l a t e d  and Denyes  ( 1 9 7 2 ) , a number  were i d e n t i f i e d .  i n the l i t e r a t u r e  In g e n e r a l , the study groups  s e x , and s i m i l a r  by A r a d i n e  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  i n t h a t t h e y were s e l f - i d e n t i f i e d , and  of the  similar  were  similar  i n t e r m s o f age  i n t h e p a t t e r n s o f e s t i m a t e d work  d e v o t e d t o some c a t e g o r i e s o f work a c t i v i t y .  The age  time range  81  of  t h e s u b j e c t s i n t h e A r a d i n e a n d Denyes s t u d y was 21 t o 51  y e a r s and 25 t o 50 o r more y e a r s i n t h e p r e s e n t s t u d y . A l l t h e s u b j e c t s i n t h e A r a d i n e and Denyes s t u d y were f e m a l e most  (60/62) of t h e s u b j e c t s i n t h e p r e s e n t study  female.  Specific  discussion  work a c t i v i t y  will  follow a brief  d i f f e r e n c e s t h a t were o b s e r v e d  t o some c a t e g o r i e s  d i s c u s s i o n of  b e t w e e n f i n d i n g s r e p o r t e d by  t h e A r a d i n e and D e n y e s and t h e f i n d i n g s o f t h i s Although  t h e s t u d y g r o u p s were s i m i l a r  self-identified noted.  Nurses  specialists  study.  i n t h a t they  were  t h e r e were a l s o a number o f d i f f e r e n c e s who were e m p l o y e d a s c l i n i c a l  nurse  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  t h e M i d w e s t o f t h e U n i t e d S t a t e s were i d e n t i f i e d and Denyes a s t h e i r p o p u l a t i o n o f i n t e r e s t . criteria,  were  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 o f e s t i m a t e s o f work t i m e d e v o t e d of  and  i t seems, f o r employment  nurse  specialist  One o f t h e  in this position  a g e n c i e s was t h e p o s s e s s i o n o f a m a s t e r ' s Thus, c l i n i c a l  by A r a d i n e  by  these  degree i n n u r s i n g .  i n t h e A r a d i n e and Denyes  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 t e r m s o f t h e t i t l e  of the  work p o s i t i o n a s w e l l a s p l a c e o f employment a n d l e v e l o f educational preparation.  The p r e s e n t s t u d y d e f i n e d t h e  p o p u l a t i o n o f i n t e r e s t a s b e i n g n u r s e s who work p o s i t i o n a s t h a t o f c l i n i c a l professional association. in  nurse  identified  specialist  Thus, c l i n i c a l  nurse  their  to their  specialist  t h e 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 t e r m s o f  work p o s i t i o n  title  alone.  82  In a d d i t i o n , o t h e r observed d i f f e r e n c e s the  contextually-related  professional the  variable  were r e l a t e d t o  type of appointment, the  variable highest achieved educational  present postion,  and t h e p a t t e r n  t i m e d e v o t e d t o some c a t e g o r i e s  level,  o f e s t i m a t e s o f work  o f 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 o f a c o m p a r i s o n o f f i n d i n g s a b o u t t h e contextually-related subjects  variable  i n each study.  type of appointment f o r t h e  S u b j e c t s i n t h e A r a d i n e a n d Denyes  T a 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 Variable Type o f A p p o i n t m e n t a s D e s c r i b e d by A r a d i n e a n d Denyes a n d the P r e s e n t Study Type o f Appointment  Findings Reported by A r a d i n e a n d Deynes (1972)  F i n d i n g s of the Present Study  Number of Subjects  Percentage of Subjects  Number of Subjects  Percentage of Subjects  Unit-based Not u n i t - b a s e d  23 5  82 18  30 31  49.2 50.8  Line p o s i t i o n Staff position  17 11  61 39  10 52  10.3 89.7  Clinical Clinicaleducational Clinicaladministrative Other  16 6  57 21  17 4  27.9 6.6  3  1 1  7  11.5  3  1 1  33  54. 1  study or  indicated  t h e i r present positions  82% of t h e s u b j e c t s ) ,  characterized  line positions  by t h e l a b e l c l i n i c a l  were u n i t - b a s e d (23 (17 o r 6 1 % ) , a n d  (16 o r 5 7 % ) . I n  83  contrast,  s u b j e c t s i n the present  study  indicated  their  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 b e t w e e n u n i t - b a s e d (30 o r 48.2%) and n o t u n i t - b a s e d (31 o r predominantly  staff  positions  50.8%),  (52 o r 8 9 . 7 % ) ,  and  c h a r a c t e r i z e d by t h e l a b e l o t h e r  (33 o r 54.1%) A  subgroup (21/33) of t h e s e l a t t e r  s u b j e c t s was n o t  responsible 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 service  (see Table  9).  Statistical  and c l i n i c a l  to nursing  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 a p p o i n t m e n t , versus staff  large  specifically  versus c l i n i c a l - e d u c a t i o n a l  line versus  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 o f weekly  work t i m e d e v o t e d  t o c a t e g o r i e s o f work a c t i v i t y f o r  the s u b j e c t s i n the present study suggest did  influence  specialist  these  r o l e enactment of the c l i n i c a l  (see Table  14).  These s p e c i f i c  variables  nurse relationships  were n o t e x a m i n e d by A r a d i n e a n d Denyes i n t h e i r all  study as  t h e s u b j e c t s w o r k e d i n t h e same t y p e o f s e t t i n g .  t h e f i n d i n g s r e p o r t e d by A r a d i n e a n d Denyes may statement clinical  about the i n t e r a c t i o n nurse  specialist  a large university definitive  be a  of the complex r o l e of t h e  a n d t h e p a r t i c u l a r work s e t t i n g o f  teaching hospital  statement  Thus,  r a t h e r than a  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 t h e professional variable highest level all  o f e d u c a t i o n was t h a t  s u b j e c t s i n t h e A r a d i n e a n d D e n y e s s t u d y had  preparation  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  master's  84  preparation present and  i n the e a r l y  study  1970's.  In c o n t r a s t , i n the  4 s u b j e c t s had m a s t e r ' s  3 of t h e s e had  preparation in nursing  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 examination  1970's.  More s p e c i f i c  variable  l e v e l of e d u c a t i o n  subjects  i n t h e A r a d i n e and D e n y e s s t u d y r e c e i v e d t h e i r  basic nursing education to the  14  professional  r e v e a l e d t h a t 10  (36%)  of  the  i n a b a c c a u l e a u r a t e program compared  (22.6%) of the s u b j e c t s i n the p r e s e n t  received their (64%)  of the  late  basic training  study  i n such a program.  who  Eighteen  o f t h e s u b j e c t s i n t h e A r a d i n e and D e n y e s s t u d y and  (77.4%) of the s u b j e c t s i n the p r e s e n t basic nursing education  i n diploma  p a t t e r n of p u r s u i n g graduate strikingly different  study  received their  programs.  education  b e t w e e n t h e two  Thus,  setting  w i t h t h e l e n g t h of t i m e  i n which  t h e p o s i t i o n was  the  in nursing i s  g r o u p s 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 to the present p o s i t i o n concerned  were  i n t h e p o s i t i o n and enacted.  For  the  subjects in  t h e 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  position  from  ranged  h a v i n g had  one  to 6 years with half  2 years experience.  i n t h e p r e s e n t p o s i t i o n and working  in similar  in t h e i r subjects'  study.  the s u b j e c t s both  of e x p e r i e n c e  experience from  p o s i t i o n s were u s e d a s t h e s o u r c e  In c o n t r a s t , i n t h i s  experience  l e s s t h a n one  Furthermore,  recall  y e a r s of e x p e r i e n c e .  of  study, the years  i n the c u r r e n t p o s i t i o n  y e a r and  48  ranged  data of  between  15 y e a r s , w i t h 4 t h e mean number o f In a d d i t i o n , only 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 t h e p r e s e n t p o s i t i o n was data  i n the present All  s u b j e c t s i n t h e A r a d i n e and D e n y e s s t u d y  contrast,  41  (65%)  worked i n a h o s p i t a l It  teaching hospital  setting.  setting,  t h e s i z e and  type  that  unspecified.  teaching hospital  such a s e t t i n g  the l a t t e r  can  be  m e t r o p o l i t a n and districts Health.  clinical Table  the  case  found  i n the c l a s s i f i c a t i o n  of  Evidence of  of  the  hospital  p r o v i d e d by t h e B r i t i s h C o l u m b i a  Ministry  The  in  i s c o m p a r a b l e t o t h e work s e t t i n g s  non-metropolitan regional  communities 1975,  setting  However, i t i s n o t n e c e s s a r i l y  t h e s u b j e c t s i n t h e A r a d i n e and Denyes s t u d y .  of  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 f r o m V a n c o u v e r t o s e v e r a l of t h e G u l f  of  Islands.  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 nurse  3b.1).  (Rollcall  s p e c i a l i s t s was I n 1980  this  .30  (13:44) ( R o l l c a l l  r a t i o had  U p d a t e 80, T a b l e 8 ) , and  r i s e n t o .36  i n 1982  this  This  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  positions  in non-metropolitan  been i n c r e a s i n g .  regional hospital  T h u s , i t seems u n r e a s o n a b l e  t h a t most of t h e s u b j e c t s i n t h i s university  teaching hospitals  75,  (34:94)  ratio  ( 4 8 : 1 0 0 ) ( R o l l c a l l U p d a t e 82, T a b l e 8 ) .  has  study  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  B r i t i s h Columbia.  .48  were  of t h e s u b j e c t s i n t h e p r e s e n t  were e m p l o y e d i n a u n i v e r s i t y  In  of  study.  employed i n a l a r g e u n i v e r s i t y In  used as a s o u r c e  was  indicates specialist  districts t o assume  study worked i n the  i n the m e t r o p o l i t a n areas  of  86  British  Columbia.  D i f f e r e n c e s and s i m i l a r i t i e s Denyes s t u d y and t h e p r e s e n t  study  e s t i m a t e s o f work t i m e d e v o t e d activity  will  Table  between t h e A r a d i n e  r e l a t e d t o t h e p a t t e r n of  t o c a t e g o r i e s o f work  now be d i s c u s s e d .  16 p r e s e n t s a summary o f t h e work  p a t t e r n s found  and  i n t h e two s t u d i e s .  e s t i m a t e s o f "a g r e a t d e a l o f t i m e "  activity  Level I designates i n d i c a t e d by s u b j e c t s i n  t h e A r a d i n e a n d Denyes s t u d y and e s t i m a t e s g r e a t e r t h a n i n d i c a t e d by s u b j e c t s i n t h e p r e s e n t  study.  20%  Level II  d e s i g n a t e s e s t i m a t e s o f " m o d e r a t e amount o f t i m e " a n d b e t w e e n 11 a n d 19 p e r c e n t the r e s p e c t i v e s t u d i e s . " s m a l l amount 10 p e r c e n t  of time"  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 i n t h e A r a d i n e and D e n y e s s t u d y and  o r l e s s o f t h e e s t i m a t e d work t i m e  Examination of  i n d i c a t e d by s u b j e c t s i n e a c h o f  of T a b l e  in this  study.  16 i n d i c a t e s t h a t t h e c a t e g o r i e s  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 s i m i l a r manner  by t h e s u b j e c t s i n e a c h o f t h e s t u d i e s .  group of c l i n i c a l l a r g e r amount  f o r publication are described i n a  nurse  specialists  o f e s t i m a t e d work t i m e  Each  i n d i c a t e d they devoted to patient care  than  t h e y d i d t o c o n s u l t a t i o n a n d c o m m u n i t y a c t i v i t i e s ; and spent  a l a r g e r amount  o f e s t i m a t e d work t i m e on t h e l a t t e r  c a t e g o r i e s t h a n on r e s e a r c h a n d w r i t i n g Table  they  for publication.  16 a l s o i n d i c a t e s t h a t t h e s u b j e c t s i n t h i s  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  study  i n a d i f f e r e n t manner  than  a  T a b l e 16 C o m p a r i s o n of Work A c t i v i t y of t h e C l i n i c a l N u r s e S p e c i a l i s t a s D e s c r i b e d by A r a d i n e and Deynes (1972) and t h e F i n d i n g s of t h e P r e s e n t S t u d y Level  A r a d i n e and D e y n e s Study  Present  I  -patient care - s t a f f development -interdisciplinary interact ion -planning-policystandards-change  -patient  - p e r s o n a l and p r o f e s s i o n a l growth -consultat ion -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 ion  -administration  -interdisciplinary interaction -research -writing for publication - 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 -planning-policystandards-change  II  III  The  and  care  -consultat ion -community a c t i v i t i e s  -research -writing for publication  d i d the s u b j e c t s i n the A r a d i n e  Study  D e n y e s (1972)  study.  d i f f e r e n c e i s i n t e r m s of t h e e s t i m a t e s of amounts o f  time devoted  t o many o f t h e c a t e g o r i e s o f work  ( n o t e e s p e c i a l l y L e v e l s I and o u t l i n e d by  I I I ) . The  the s u b j e c t s i n the A r a d i n e  activity  work a c t i v i t y and  Denyes  s t u d y c o n s i s t e d of a g r e a t d e a l of t i m e d e v o t e d care, staff  development, i n t e r d i s c i p l i n a r y  planning-policy-standards-change. found  that c l i n i c a l  nurse  (1972)  to patient  interaction,  In c o n t r a s t , t h i s  specialists  as  in British  and  study  Columbia  88  s p e n t t h e l a r g e s t amount patient care.  Clinical  o f e s t i m a t e d work t i m e d e v o t e d t o nurse s p e c i a l i s t s ,  according to  A r a d i n e a n d D e n y e s , s p e n t a m o d e r a t e amount 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  c o n s u l t a t i o n , community a c t i v i t i e s , students. in  growth,  and e d u c a t i o n o f  T h i s study found t h a t c l i n i c a l  B r i t i s h Columbia  spent a s i m i l a r  o f work t i m e i n  nurse  specialists  l e v e l o f 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 c o m m u n i t y activities. clinical  Lastly,  nurse s p e c i a l i s t s devoted the l e a s t  administration, contrast, this in  r e s e a r c h , and w r i t i n g  writing  for publication,  p r o f e s s i o n a l growth,  staff  time t o  nurse  d e v o t e d t h e l e a s t amount  work t i m e t o i n t e r d i s c i p l i n a r y  study  for publication.  study found t h a t c l i n i c a l  B r i t i s h Columbia  weekly  i n t h e A r a d i n e and D e n y e s  In  specialists  of e s t i m a t e d  interaction, research,  development,  p e r s o n a l and  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 -  policy-standards-change.  These f i n d i n g s c l e a r l y  suggest the  r o l e m o d e l d e s c r i b e d i n t h e l i t e r a t u r e by A r a d i n e a n d Denyes (1972) does not f i t t h e r o l e of t h e c l i n i c a l specialist  in British  Columbia.  T h e s e d i f f e r e n c e s may factors: the  nurse  be a c c o u n t e d  f o r by a number o f  t y p e o f 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 ,  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.  and  For  example, a l l s u b j e c t s  i n t h e A r a d i n e a n d Denyes s t u d y w o r k e d  in  teaching hospital  a large university  setting.  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  In degree i n  89  nursing.  I t seems r e a s o n a b l e t o e x p e c t 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 o f work s e t t i n g and e d u c a t i o n v a r i a b l e may the c l i n i c a l  influence  nurse s p e c i a l i s t .  specific  the  r o l e enactment of  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 p r o f e s s i o n a l s and o n - g o i n g be two  d e v e l o p m e n t w o u l d seem t o  e x a m p l e s o f work more l i k e l y  clinical belief  staff  nurse s p e c i a l i s t .  that  study.  t o be e x p e c t e d o f  the  Some a d d i t i o n a l s u p p o r t f o r t h e  t y p e o f s e t t i n g may  p r o v i d e d by t h i s  care  i n f l u e n c e r o l e enactment i s  Statistical  a n a l y s i s of the  r e l a t i o n s h i p s b e t w e e n t y p e o f s e t t i n g and t h e e s t i m a t e s o f w e e k l y work t i m e d e v o t e d t o work a c t i v i t y possibility time  that differences  (see Table  14 and  categories  i n s e t t i n g i n f l u e n c e d t h e work  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 , Denyes s u g g e s t e d t h a t  i n d i c a t e d the  in their  discussion Aradine  t h e amount o f t i m e d e v o t e d t o  of work a c t i v i t y ,  growth, community a c t i v i t i e s ,  p e r s o n a l and  shifts  four  professional  e d u c a t i o n o f 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 specialists.  and  nurse  T h i s study found evidence to suggest  that  i n t h e e s t i m a t e d amounts o f t i m e d e v o t e d t o c o m m u n i t y  activities Clinical  and c o n s u l t a t i o n o c c u r r e d f o r t h e  nurse s p e c i a l i s t s  sample.  i n t h e A r a d i n e and Denyes s t u d y  i n d i c a t e d t h e y s p e n t l e s s t i m e i n t h e 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 g r o w t h , and more t i m e with  i n the o t h e r  these s h i f t s a t t a i n i n g s t a b i l i t y  categories,  within three years.  90  By c o n t r a s t , British  in this  Columbia  study c l i n i c a l  nurse  i n d i c a t e d more t i m e s p e n t  c o n s u l t a t i o n and community a c t i v i t i e s time  specialists in i n the categories  w i t h an i n c r e a s e o f  i n the position. I t must be p o i n t e d o u t t h a t t h e s h i f t s  subjects  i n t h e A r a d i n e a n d D e n y e s s t u d y were c a t e g o r i e s o f  work a c t i v i t y contrast,  f o r t h e same g r o u p o f s u b j e c t s o v e r t i m e .  specialist  i n the present c l i n i c a l  p o s i t i o n a s w e l l a s e s t i m a t e s o f work  nurse  time  t o t h e v a r i o u s c a t e g o r i e s o f work a c t i v i t y .  different  groups of c l i n i c a l  by l e n g t h o f t i m e  nurse  sequence a s s o c i a t e d w i t h r o l e  percentages  of time devoted  fora  developmental  implementation  t h a t was  i n t h e r o l e on e s t i m a t e d t o e a c h c a t e g o r y o f work  was s u b j e c t e d t o s t a t i s t i c a l  statistically subjects  classified  by A r a d i n e a n d D e n y e s .  When t h e e f f e c t o f t i m e  activity  specialists,  Thus,  i n t h e p r e s e n t p o s i t i o n , were u s e d i n t h e  p r e s e n t s t u d y t o examine e v i d e n c e  suggested  In  s u b j e c t s i n t h e p r e s e n t s t u d y were a s k e d t o  i n d i c a t e t h e l e n g t h of time  devoted  r e p o r t e d by t h e  significant  a n a l y s e s , no  d i f f e r e n c e s were r e p o r t e d f o r t h e  i n the present study  (see Table C.2).  This  finding  d o e s n o t s u p p o r t t h e s u g g e s t i o n made by A r a d i n e a n d D e n y e s of  t h e e x i s t e n c e of a developmental  nurse  s p e c i a l i s t s as they  that t h i s but  sequence f o r c l i n i c a l  implement t h e r o l e .  I t may be  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  i s not a s i g n i f i c a n t  f a c t o r on t h e l a r g e r  level  level, o f how  91  clinical  nurse s p e c i a l i s t s  f u n c t i o n of time spent  s p e n d t h e i r work t i m e a s a  i n the position.  Or i t may be t h a t  t h e d e v e l o p m e n t a l s e q u e n c e s u g g e s t e d by A r a d i n e i s only applicable to c l i n i c a l a large u n i v e r s i t y teaching  Suggestions Specialist To  f o r the Future Role  and Denyes  n u r s e s p e c i a l i s t s who work i n  hospital setting.  Concerning the C l i n i c a l  Nurse  i n Canada  the extent  that these  f i n d i n g s from nurses i n  B r i t i s h Columbia a r e 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 t h e f o l l o w i n g s u g g e s t i o n s  concerning  C a n a d i a n n u r s i n g c a n be i d e n t i f i e d . the  f i n d i n g s of t h i s  specialist  study  the role i n  Variations reflected in  i n d i c a t e that the c l i n i c a l  r o l e r e m a i n s t o be p r e c i s e l y d e s c r i b e d  n u r s i n g p r o f e s s i o n i n Canada.  nurse  by t h e  The f i n d i n g s t h a t a l a r g e  s u b g r o u p (21 o u t o f 33 s u b j e c t s ) were n o t r e s p o n s i b l e organizationally  to nursing, only  graduate l e v e l preparation  4 of t h e s u b j e c t s had  i n n u r s i n g , and t h a t a range of  j o b t i t l e s was u s e d i n t h e work s e t t i n g However, t h e s e  f i n d i n g s do p r o v i d e  f u t u r e of the r o l e It clinical  i n Canadian  support  some s u g g e s t i o n s  view. f o r the  nursing.  seems u n r e a s o n a b l e t h a t a n u r s e i n a s p e c i a l i z e d role  accountable  i n an a g e n c y s h o u l d  t o an e n t i t y  other  be r e s p o n s i b l e a n d  than n u r s i n g .  things, the nursing profession i s missing provide  this  peer support  Among  other  an o p p o r t u n i t y t o  t o i n d i v i d u a l n u r s e s who a r e e n g a g e d i n  92  the process practice.  of  In a d d i t i o n , the p r o f e s s i o n  opportunity other  implementing a s p e c i a l i z e d role  to a r t i c u l a t e  r o l e as  Therefore,  nursing  i s missing  an  t o n u r s e s as w e l l as t o members of  h e a l t h c a r e d i s c i p l i n e s and  of t h i s  in  i t emerges and  the p u b l i c a d e s c r i p t i o n  develops in nursing.  i t i s suggested that nursing  toward g e t t i n g the c l i n i c a l  service should  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 t h e o r g a n i z a t i o n a l framework o f It  i s imperative  n u r s e s i n an within  t h a t g u i d a n c e be p r o v i d e d  agency, c l i n i c a l  the h e a l t h care  nursing  r o l e can  patient care. between the nursing  I t i s important  certification)  the q u a l i t y  of c o n c e r n t o  of c a r e ,  be a r t i c u l a t e d by  of  the  standards nursing  and  i n Canada. focus  on  the  r o l e of the c l i n i c a l  and  profession.  nurse  strong  specialist  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 i s s u e of  nurse f o r t h i s  role.  level  nurse f o r t h i s  of p r e p a r a t i o n  C l e a r l y , the  graduate l e v e l education  The  other  the  N u r s e s e n g a g e d i n n u r s i n g p r a c t i c e must speak i n a c l e a r v o i c e about the  others  this specialized  nurse s p e c i a l i s t  issues that are  ( s u c h as q u a l i t y  and  of  that e x p l i c i t r e l a t i o n s h i p s  r o l e of t h e c l i n i c a l  r o l e s and  profession  to a f f e c t  nursing.  to a l l l e v e l s  nurse s p e c i a l i s t s ,  s y s t e m a b o u t how  be u t i l i z e d  work  in nursing  r e q u i r e d by  literature  the  indicates that  i s required to prepare a  role.  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  returned  t h e q u e s t i o n n a i r e were no  longer  working 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 to yet another suggestion Canada.  nurse s p e c i a l i s t  f o r the f u t u r e of t h e r o l e i n  I t may be i m p o r t a n t  f o r t h e p r o f e s s i o n t o examine  the  forces which c o n t r i b u t e to the apparent  the  role  valuable  points  i n nursing p r a c t i c e .  This  i n s t a b i l i t y of  i n f o r m a t i o n may  prove  i n d e f i n i n g the r o l e .  Once a c l e a r a n d d e f i n i t i v e p o s i t i o n h a s been t a k e n the  nursing profession concerning  f o r the  clinical  nurse s p e c i a l i s t  movement  toward a s s u r i n g t h e p u b l i c about t h e l e v e l of  preparation,  stability,  be e x p e c t e d o f t h i s Finally,  role,  preparation  i t i s suggested that a  and t h e range of a c t i v i t i e s  specialized clinical  role should  i t i s suggested that a c l e a r voice  nursing p r o f e s s i o n i n support l a b e l s and j o b t i t l e s  of c o n s i s t e n c y  to describe nursing  r o l e s i s needed.  their  i f not i m p o s s i b l e ,  roles, their  f o r the p r o f e s s i o n t o  l e t alone  a whole  r e l a t i o n s h i p t o each  r e l a t i o n s h i p to the h e a l t h care  Specialization  when  of such a s t a t e of c o n f u s i o n i t  make a s t a t e m e n t a b o u t any one r o l e , system of n u r s i n g  seems  a r e u s e d t o r e f e r t o t h e same  As a r e s u l t  m i g h t be d i f f i c u l t ,  and  that  i n t h e t h i n k i n g of e m p l o y e r s and consumers,  phenomenon.  i n the  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  job t i t l e s  begin.  i n t h e use of  minds of i n d i v i d u a l n u r s e s and t h e c o l l e c t i v e  different  t h a t can  from t h e  I t w o u l d seem t o o n l y a d d t o t h e s t a t e o f c o n f u s i o n  to e x i s t  by  i n h e a l t h care  other,  system.  i s w i t h us f o r a v a r i e t y  94  of  reasons.  specialist role  With a c l e a r d e f i n i t i o n r o l e and  implementation  on-going and  of t h e c l i n i c a l  research to i n v e s t i g a t e  development  i t s h o u l d be  t h e 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 t h e  is"  w i t h "what s h o u l d be" where t h e r o l e of t h e specialist The  actual  possible  for  nurse  nurse  "what  clinical  i s concerned.  n e x t c h a p t e r p r e s e n t s a summary of t h e f i n d i n g s  t h i s study.  T h i s forms the b a s i s from which  conclusions,  i m p l i c a t i o n s , and  research are  drawn.  the major  suggestions for  further  of  CHAPTER 6 SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY  Summary A t t e n t i o n h a s been drawn t o t h e f a c t t h a t , t h e r e a r e n u r s e s who i n Canada i d e n t i f y clinical has  nurse  specialists,  although  themselves as  t h e n u r s i n g p r o f e s s i o n i n Canada  o n l y a borrowed and sketchy t h e o r e t i c a l  b a s e t o draw  upon f o r an u n d e r s t a n d i n g o f t h e r o l e a n d p r e p a r a t i o n o f nurses  f o rthe role.  The l a c k o f 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 t h e r o l e was a s t i m u l u s f o r t h i s  study.  R o l e t h e o r y a n d r e p o r t e d r e s e a r c h f i n d i n g s a b o u t what clinical  nurse  s p e c i a l i s t s do ( A r a d i n e a n d D e n y e s , 1972)  were s e l e c t e d a s t h e f r a m e w o r k f o r t h e s t u d y o f c l i n i c a l nurse  specialists  i n B r i t i s h Columbia.  T h e s e 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 t h e s t u d y of t h e r o l e and t h e context  i n which  i t i s e n a c t e d a s w e l l a s 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 k n o w l e d g e . T h i s s t u d y 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 t h e y do i n t h e i r work i n t h e p r o v i n c e o f B r i t i s h Columbia; 2. i d e n t i f y  s i m i l a r i t i e s a n d d i f f e r e n c e s between t h e 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 Denyes  (1972); 95  r e p o r t e d by A r a d i n e a n d  96  3. make s u g g e s t i o n s of t h e c l i n i c a l  f o r the future i n r e l a t i o n  nurse s p e c i a l i s t  t o the role  i n Canada b a s e d on t h e  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 , who d e s c r i b e d specialist  i n that only  t h e i r work p o s i t i o n a s c l i n i c a l  on t h e a n n u a l RNABC r e g i s t r a t i o n  contacted.  A questionnaire  was c o n s t r u c t e d  those  nurse  f o r m were that  included  t h r e e c a t e g o r i e s : t h e c a t e g o r i e s o f work  activities  described  contextually  by A r a d i n e  a n d Denyes ( 1 9 7 2 ) ; 1  related variables: specific present  position,  job t i t l e ,  l e n g t h of time i n the  new o r e x i s t i n g p o s i t i o n a n d p r e s e n c e o r  a b s e n c e o f a j o b d e s c r i p t i o n when t h e p r e s e n t accepted,  type  o f work s e t t i n g , a n d t y p e  p r o f e s s i o n a l v a r i a b l e s : type type  of p o s t - b a s i c  experience the p r e s e n t  was u s a b l e  of appointment; and  of b a s i c n u r s i n g  nursing education,  p o s i t i o n was  education,  and p r e v i o u s  within the nursing profession p r i o r clinical  Questionnaires  nurse s p e c i a l i s t  were m a i l e d  work  to accepting  position.  t o 147 p e r s o n s a n d a t o t a l  f o r purposes of analyses.  a n a l y s i s and a n a l y s e s  o f 63  Both d e s c r i p t i v e  o f r e l a t i o n s h i p s among t h e 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 areas:  nurses  f o u r main  d e s c r i p t i o n s o f 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  These 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 , education of students, 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, planning-policy-standa-rds-change, 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 other. 1  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 of r e l a t i o n s h i p s o f c e r t a i n time percentages  analyses  o f t h e s e v a r i a b l e s w i t h t h e work  r e p o r t e d by t h e s u b j e c t s .  E a c h o f t h e 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 ( 1 9 7 2 ) was l i s t e d  by a t l e a s t  applicable to their l a r g e s t percentage  work.  some o f t h e s u b j e c t s a s b e i n g  The c a t e g o r y  (93.5) of responses  receiving the was c o n s u l t a t i o n .  The c a t e g o r i e s o f a d m i n i s t r a t i o n , e d u c a t i o n interdisciplinary  a n d Denyes  of students,  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,  planning-policy-standards-change,  community a c t i v i t i e s ,  and s t a f f  by more t h a n subjects  d e v e l o p m e n t were  65% o f t h e s u b j e c t s .  identified  Less  than  40% of t h e  t h e 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 a n d o t h e r a s i n c l u d e d among t h e i r activities.  The r a n g e o f work a c t i v i t i e s  s u b j e c t s under t h e c a t e g o r y  r e s e a r c h work, c l e r i c a l ,  but  a n d Denyes  p r o v i d e d by  traditional  and i n f e c t i o n  These f i n d i n g s i n d i c a t e t h a t t h e c a t e g o r y by A r a d i n e  work those  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 , skills,  identified  (1972) had r e l e v e n c e  nursing control.  labels  described  f o r the subjects,  t h a t a v a r i e t y o f m e a n i n g s i s a t t a c h e d t o them. The l a r g e s t amounts o f w e e k l y work t i m e  s u b j e c t s were s p e n t other  (23.5%).  were s p e n t activities,  r e p o r t e d by t h e  i n the categories patient care  Lesser percentages,  (37%) and  b e t w e e n 10% a n d 15%,  i n t h e 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 and c o n s u l t a t i o n .  Percentages  o f l e s s t h a n 10%  98  o f w e e k l y work t i m e were d e v o t e d of s t u d e n t s ,  interdisciplinary  p r o f e s s i o n a l growth,  to the c a t e g o r i e s  education  i n t e r a c t i o n , p e r s o n a l and  planning-policy-standards-change,  r e s e a r c h , s t a f f d e v e l o p m e n t , and w r i t i n g  for publication.  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 t h e v i e w s a r t i c u l a t e d by R e i t e r ( 1 9 6 6 ) , Johnson  Peplau  (1962) i n t e r m s o f p a t i e n t c a r e b e i n g  the r o l e .  However, i t i s s e e n a s b e i n g  the view t h a t c l i n i c a l  nurse  to their  inconsistent with  demonstrating  profession (Reiter,  1966; P e p l a u ,  A s s u m i n g t h e e s t i m a t e s o f work t i m e subjects  i n both the Aradine  significant  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 a s a p a r t i c u l a r means o f commitment  t h e f o c u s of  s p e c i a l i s t s devote  amounts o f t h e i r work a c t i v i t y  present  (1965) and  a n d Denyes  i n d i c a t e d by t h e (1972) s t u d y and t h e  study a r e 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 t h e  e s t i m a t e d amounts o f work t i m e d e v o t e d planning-policy-standards-change, administration, education  staff  of s t u d e n t s ,  to the c a t e g o r i e s development, interdisciplinary  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 g r o w t h . i n t e r p r e t e d as a f a i l u r e Aradine  1965).  a n d Denyes  This  was  o f t h e r o l e d e s c r i p t i o n p r o v i d e d by  (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  specialist  role  in British  Columbia. Despite position  the f a c t  that a l l subjects indicated their  on t h e RNABC f o r m t o be t h a t o f c l i n i c a l  nurse  work  99  s p e c i a l i s t , a r a n g e of b e i n g used i n the job  title  work s e t t i n g .  ( 2 2 / 6 3 ) was  a preferred  title  s p e c i f i c job  within  m e a n i n g of  Most of position years.  the  nursing  the  The  a v e r a g e number of  (21  or  subject,  job d e s c r i p t i o n s . subjects  as  14  M o s t of  the  l a t e 1970's.  p r e s e n c e of  evidence that  of  the  nursing  i m p l e m e n t a t i o n of  a fairly  p o s i t i o n was  unclearly  large  or  the  existing  setting,  the  51.6%)  when a c c e p t e d  new  positions  This  health  of  had  the  was  care system.  a j o b d e s c r i p t i o n was practice the  is dealing  role.  s u b g r o u p of  interpreted  defined  Most of  4.  (32  the  the  i n the subjects  majority  of  as  these  or  with  the  issue  subjects  or  p r a c t i c e area at (41  interpreted  finding  evidence that  the  to  In  However, the  h a v e 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 t h e  a c c e p t e d was  15  e v i d e n c e of a response i n B r i t i s h Columbia  as  that  the  2 to  present p o s i t i o n s  need f o r s p e c i a l i z a t i o n i n t h e  addition,  a r a n g e of  ( 4 3 . 7 % ) of  i n the  clarity  subjects.  years i n the  the  British  a l a c k of  job d e s c r i p t i o n s  Most of  were c r e a t e d  interpreted  not  only  as  these p o s i t i o n s  72.4%) had but  in  be  been i n t h e i r p r e s e n t  when t h e y were a c c e p t e d .  positions  the  had  f o r more t h a n 2 y e a r s , w i t h  were new  the  practice  (71%)  used  A l t h o u g h t h i s may  r o l e among t h e  subjects  actually  most f r e q u e n t l y  interpreted  S l i g h t l y more t h a n h a l f of  by  The  nurse c l i n i c i a n .  C o l u m b i a , t h i s f i n d i n g was about the  t i t l e s was  (22  46%)  position role  did was  is  t h i s time.  65.1%) w o r k e d i n a  ( 8 7 . 8 % ) i n an  acute  hospital care  100  hospital.  Of  ( 2 5 . 4 % of  t h o s e not  a l l the  working  community m e n t a l h e a l t h  can  be  view that  the  (or  16)  agency. r o l e of  Peplau,  1965).  the  interpreted  as  specialization hospitals  (Krause,  health  1977).  finding  A l t h o u g h the  variety  t h e r e may  located The  solely  the  or  i d e n t i f i e d as (17  large  s u b g r o u p (21  fact  r o l e of  w i t h the  "state  of  r o l e d e s c r i b e d by  a  i n the  or  (33  unit-based or  by  most  out  of  (31  54.1%) as  to  future.  were e v e n l y d i s t r i b u t e d  other  or  between 50.8%),  opposed  to  27.9%), c l i n i c a l - e d u c a t i o n a l  (4  (52 33)  t h i s was  or of  1 1 . 5 % ) , and  89.7%) of the  the  were  (1966).  the  as  used  A  the  not other  being  clinical  or  described  subjects.  s u b j e c t s who  interpreted  b e i n g " v i e w of Reiter  in  setting  r e s p o n s i b l e to n u r s i n g f o r n u r s i n g c a r e and/or A l l of  clinical  hospital  category other to d e s c r i b e t h e i r p o s i t i o n  activities.  the  in  for t h i s role  not  the  that  implemented  o r c l i n i c a l - a d m i n i s t r a t i v e (7 o r  staff positions  most of  a trend  49.2%) and  types c l i n i c a l  6.6%) as  (30  that  be  present positions  unit-based primarily  i n the  settings  care system i s o r g a n i z e d  t h e o r e t i c a l l y be  settings,  consistent  further  w i t h the  n u r s e s p e c i a l i s t can of  in a  nurse s p e c i a l i s t  clinical  s e t t i n g was  being consistent i n the  s e e n as  clinical  16  based  them w o r k i n g  T h i s was  The  s u b j e c t s worked i n a h o s p i t a l  be  of  i m p l e m e n t e d i n a w i d e r a n g e of  ( W a t s o n , 1973;  setting,  s u b j e c t s ) worked i n community  a g e n c i e s / s e r v i c e s w i t h 56.3%  w i t h the  in a hospital  consistent  specialist  101  The basic  majority  (48 o r 76.2%) of t h e  nursing education  i n d i p l o m a p r o g r a m s and  o r 22.2%) i n b a c c a l a u r e a t e (33.3%) s u b j e c t s baccalaureate  years  since completion  It  master's i n nursing.  findings, basic  but  rest  A total  of  9 of  The  p r o g r a m s , and  48  the  10  12 y e a r s  for  i n t e r p r e t a t i o n of  i s a trend f o r s u b j e c t s to pursue  l e v e l s of p r e p a r a t i o n  (most  years  f o r master's programs.  t o make a d e f i n i t i v e  there  4 of  a v e r a g e number of  of p r o g r a m s ,  6 years  (14  pursued  of p o s t - b a s i c p r o g r a m s was:  d i p l o m a / c e r t i f i c a t e types  is difficult  g r o u p had  their  to obtain master's degrees, with only  being  baccalaureate  the  S i x t e e n of the  i n the diploma prepared  these  for  programs.  level preparation.  s u b j e c t s went on  sample r e c e i v e d  these post-  frequently  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, t h e reported had  f i n d i n g s here are  by A r a d i n e  and  master's preparation A career  s u b j e c t s had prior  category  Denyes (1972) where a l l t h e  subjects  in nursing.  h e l d b e t w e e n one  Nearly  of g e n e r a l  the present a l l of t h e  and  p o s i t i o n of c l i n i c a l s u b j e c t s had  nurse  worked i n  Many had  nurse/community h e a l t h nurse  and  least  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 , professor.  the  worked i n  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  d i r e c t o r , and  the  4 positions in nursing  d u t y / s t a f f nurse.  the p o s i t i o n s of o f f i c e  number of  those  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 o f  to accepting  specialist.  i n marked c o n t r a s t t o  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  statistical  tests  were u s e d t o e x a m i n e r e l a t i o n s h i p s b e t w e e n c o n t e x t u a l l y related variables,  the p r o f e s s i o n a l v a r i a b l e  derived  e d u c a t i o n l e v e l , and t h e work t i m e 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 o r e x i s t i n g p o s i t i o n , appointment  ( l i n e or s t a f f ; c l i n i c a l ,  clinical-administrative,  setting,  clinical-educational,  o r o t h e r ) and p r e s e n c e o r a b s e n c e  o f a j o b d e s c r i p t i o n , were f o u n d t o r e l a t e the p e r c e n t a g e s of weekly  type of  significantly  work t i m e i n t h e work  to  activity  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 activities,  interdisciplinary  policy-standards-change. education l e v e l  i n t e r a c t i o n , and p l a n 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  derived  (diploma, b a c c a l a u r e a t e , or master's)  f o u n d t o r e l a t e t o t h e p e r c e n t a g e s o f w e e k l y work  was  time  i n d i c a t e d by t h e s u b j e c t s f o r t h e c a t e g o r i e s interdisciplinary  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 d e m o n s t r a t e d p a r a m e t r i c and n o n - p a r a m e t r i c  tests  by b o t h  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 o r e x i s t i n g p o s i t i o n a n d l i n e o r s t a f f placement.  When t h e p r e s e n t p o s i t i o n was new,  nurse s p e c i a l i s t s  the c l i n i c a l  s p e n t a l a r g e r amount o f e s t i m a t e d work  time i n the category a d m i n i s t r a t i o n  (mean=13.2%;  average  r a n k = 2 6 . 6 % ) t h a n 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 rank=l8.5%).  However, when t h e 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 ,  this  1 03  group of c l i n i c a l  n u r s e s p e c i a l i s t s s p e n t a l a r g e r amount o f  e s t i m a t e d work t i m e i n t h e c a t e g o r y p a t i e n t (mean=45.6%; a v e r a g e specialists  i n new  rank=20.5%).  rank=30.9%) than d i d the c l i n i c a l  positions  T h i s was  (mean=29.7%;  interpreted  g e n e r a l need of the c l i n i c a l c o n t a c t s and c r e d i b i l i t y role  i s new  reflect  care  average  as b e i n g r e l a t e d t o a  nurse s p e c i a l i s t to e s t a b l i s h  among w o r k i n g c o l l e a g u e s when t h e  t o an a g e n c y .  In a d d i t i o n ,  t h i s seems t o  a common u n d e r s t a n d i n g b e t w e e n t h e c l i n i c a l  specialist  nurse  a n d an e m p l o y i n g a g e n c y  that  patient  nurse  care i s the  focus 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 w o u l d  be a n t i c i p a t e d , when t h e p r e s e n t p o s i t i o n  a line position, clinical  nurse s p e c i a l i s t s spent a  amount o f e s t i m a t e d w e e k l y activities  work t i m e i n  (mean=21.7%; a v e r a g e  p o s i t i o n was  a staff position  was  larger  administrative  r a n k = 3 1 . 7 % ) t h a n when t h e  (mean=9.0%;  average  rank=19.7%).  Conclusions Based  on t h e f i n d i n g s o f t h i s s t u d y t h e  c o n c l u s i o n s c a n be 1.  The  clinical large  drawn:  r o l e model o u t l i n e d  does not a c c u r a t e l y  following  by A r a d i n e and D e n y e s  d e s c r i b e the p r e s e n t r o l e of  nurse s p e c i a l i s t i n B r i t i s h Columbia.  p e r c e n t a g e of t h e s u b j e c t s  categories  o f work a c t i v i t y  indicated  applied  that  (1972) the  While a the  to their positions,  the  1 04  e s t i m a t e s o f t h e p e r c e n t a g e s o f w e e k l y work t i m e were much l o w e r t h a n t h o s e d e s c r i b e d by A r a d i n e a n d D e n y e s f o r t h e categories staff  development,  interdisciplinary  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 . credence t o the b e l i e f  This finding  t h a t t h e r e may be a C a n a d i a n  to  t h e concept of c l i n i c a l  to  what d e g r e e  care d e l i v e r y  nurse s p e c i a l i s t .  system, the s e t t i n g  way i n w h i c h t h e r o l e d e v e l o p s .  2.  There  of  clarity  I t i sunclear  f o r the role  shape  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 about  range of a c t u a l absence  the c l i n i c a l job t i t l e s  education pursued p r i o r specialist  used  role.  i n v a r i o u s work  The  settings,  f o r 26 ( 4 2 . 6 % ) o f t h e  i n the type of p o s t - b a s i c  t o acceptance of a c l i n i c a l  p o s i t i o n , and t h e f i n d i n g t h a t  responsible organizationally evidence.  nurse s p e c i a l i s t  of a j o b d e s c r i p t i o n  subjects, the v a r i a b i l i t y  nursing nurse  21 ( 3 3 . 8 % ) a r e n o t  to nursing constitutes  this  T h i s i s t h o u g h t t o be r e l a t e d t o a l a c k o f  among n u r s e s a b o u t  nurse s p e c i a l i s t 3.  aspect  i n which the r o l e i s  the  clarity  lends  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  e n a c t e d , and t h e e d u c a t i o n a l p r e p a r a t i o n  the  interaction,  role  t h e development  i n Canadian  of the c l i n i c a l  nursing.  The r o u t e by w h i c h an i n d i v i d u a l n u r s e becomes a  clinical consist  nurse s p e c i a l i s t  i n B r i t i s h Columbia  seems t o  of b e i n g w i t h i n t h e system f o r a w h i l e and r e c e i v i n g  recognition  forprofessional  Although t h i s  knowledge and e x p e r i e n c e .  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 ( 1 9 6 6 ) ,  inconsistent with writings indicating preparation  f o r the c l i n i c a l  nurse s p e c i a l i s t  the master's degree i n n u r s i n g and  Christman,  1970;  indicates there are prepared Kikuchi,  Peplau,  i s a gap  (Smoyak, 1976;  1965).  Coombs, 1970)  t h a t the c l i n i c a l s p e c i a l i z e d one  This  and  the  nurse s p e c i a l i s t  for  preparation  should  role  who  (Boone  theoretical  role  and  agreement  i s an a d v a n c e d  t o the e s t a b l i s h m e n t f o r the  by  s u c h a gap of  be  Georgopoulos  and  r e q u i r i n g graduate l e v e l preparation.  i n Canada t o b r i d g e  " s t a t e of b e i n g "  role  of  conclusion  f o r the  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 profession  level  b e t w e e n t h e number o f n u r s e s  at the graduate l e v e l  1977;  t h a t the  i t is  the  and  A  nursing  move f r o m a  formal  requirements  role.  Implications These c o n c l u s i o n s nursing  s e r v i c e and  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  nursing education.  The  most  important  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 t h e profession concerning  b o t h a d e s c r i p t i o n of the  nurse s p e c i a l i s t  i n C a n a d i a n n u r s i n g and  to  the  role.  role  Because f u l f i l l m e n t  the e m p i r i c a l world it  i s of c r u c i a l  s e r v i c e and  of  reality,  of a r o l e  the  education  a r t i c u l a t e what t h i s  work t o g e t h e r role  i s t o be  clinical  issues related  is attained in  researcher  importance that nursing  nursing  believes  leaders  to determine i n Canadian  from  that  both  and  nursing.  106  The Aradine  first and  c o n c l u s i o n , t h a t the  D e n y e s (1972) d i d n o t  r o l e of the c l i n i c a l has  service leaders  suggestions to  about the  Canadian n u r s i n g .  between n u r s i n g being  in B r i t i s h  service.  In  i n Canada s h o u l d  role that arise  particular, be wary of  should  nursing education  clinical provide  T h i s c o n c l u s i o n a l s o has  education.  Continuing  efforts  n u r s e s p e c i a l i s t s a c t u a l l y do direction  to nursing educators  c u r r i c u l a at the master's l e v e l clinical The  nurse s p e c i a l i s t  role,  role  implications for  t o d e t e r m i n e what i n t h e i r work  i s a l a c k of  i s a need f o r a  t h e c o n c e p t and For  each r e l e v a n t  specialist  i n C a n a d i a n n u r s i n g a s t a n d must be  of  of the  clarity strong the  r o l e of the c l i n i c a l taken  nurse on  what  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 the p r o f e s s i o n can  role. be  I n d i v i d u a l nurses preparing  s e n s i t i z e d e a r l y to the  demands o f a s p e c i a l i z e d r o l e w i t h i n t h e  When t h i s  can  issue  t h e c o n c e p t and  and  the  r o l e of  concerning  is acceptable  goal  in  f o r the p r e p a r a t i o n  i n d i c a t e s that there  nurse s p e c i a l i s t .  on-going  i n Canada.  from n u r s e s c o n c e r n i n g  clinical  be  studies  f o r development  second c o n c l u s i o n , that there  about the  applying  w i t h the  t h e d e v e l o p m e n t of a d e s c r i p t i o n of t h e  nursing  the  Columbia,  from American  Instead, dialogue  s e r v i c e and  Canadian n u r s i n g .  voice  accurately predict  nurse s p e c i a l i s t  implications for nursing  nursing  r o l e m o d e l o u t l i n e d by  i s coupled  with strong  for :  requirements profession.  l e a d e r s h i p and  support  from  1 07  nursing  s e r v i c e , i t w o u l d be r e a s o n a b l e  different the  s e t of f i n d i n g s should  this  to anticipate a study  be r e p e a t e d i n  future. 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 t h e s y s t e m  to  be t h e p r i m a r y  way i n w h i c h a n u r s e becomes a  nurse s p e c i a l i s t  i n B r i t i s h Columbia, again  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 about p r e p a r a t i o n  for this  should  continue  Professional  to reflect  responsibility  clinical  has i m p l i c a t i o n s  from n u r s i n g  specialized clinical  seems u n r 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  seems  leadership  role.  in this  It  study  t h e s t a t e of t h e a r t . 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 t h e r e l a t e d d e c i s i o n s i n t h e a r e a s of p r a c t i c e and e d u c a t i o n . leadership coupled direct  I t i s only through the e x e r c i s e of  with r a t i o n a l planning  t h a t n u r s i n g can  i t s c o n t r i b u t i o n to the p u b l i c welfare.  r e q u i r e s agreement t h a t advanced e d u c a t i o n essential  in fulfilling  This  i n nursing i s  t h e mandates of p r o f e s s i o n a l  practice.  Recommendations f o r F u r t h e r  Study  On t h e b a s i s o f t h e c o n c l u s i o n s a n d i m p l i c a t i o n s o f t h i s study, 1.  i t i s recommended t h a t :  A study  be c o n d u c t e d t o e x a m i n e t h e b e l i e f s a n d  that nursing concerning 2.  leaders  i n s e r v i c e and e d u c a t i o n  the c l i n i c a l  The p r e s e n t  study  nurse s p e c i a l i s t  be r e p e a t e d  role  i n other  stands  hold i n Canada.  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  groups of s e l f - d e f i n e d c l i n i c a l 3.  A s t u d y be c o n d u c t e d  clinical 4.  in c u r r i c u l a  in  7.  out t o examine the c o n t e n t  B r i t i s h Columbia  clinical  who  nurse  specialists  a r e n o t r e s p o n s i b l e t o n u r s i n g be  out t o determine e x p l a n a t i o n s f o r t h i s  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  future  included  role.  which the c l i n i c a l in  i n Canada.  F u r t h e r s t u d y of t h e g r o u p o f c l i n i c a l  carried 6.  specialists.  designed t o prepare nurses f o r the  nurse s p e c i a l i s t 5.  nurse  f o r other  t o examine the j o b d e s c r i p t i o n s of  nurse s p e c i a l i s t s  A s t u d y be c a r r i e d  are c o n s i s t e n t  finding.  of the h o s p i t a l s i n  nurse s p e c i a l i s t s  a r e e m p l o y e d be  sought  studies.  A s t u d y o f o u t c o m e s o f work a c t i v i t y  specialists  be c o n d u c t e d  of c l i n i c a l  nurse  ( 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 c o n d u c t e d  clinical  nurse s p e c i a l i s t s  describe their 9.  a t t a c h t o the t i t l e  be c o n d u c t e d  time i n the p o s i t i o n  c a t e g o r i e s o f work The  to  nurse  t o examine t h e i n f l u e n c e of  length  on t h e t i m e s p e n t i n t h e v a r i o u s  activity.  v a l u e of t h i s  beginning e f f o r t clinical  used  that  jobs.  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  specialists of  t o examine the p r e c i s e meaning  study r e s t s  i n i t s contribution to a  c o n c e r n i n g knowledge of the r o l e  nurse s p e c i a l i s t  i n Canadian  nursing.  of  the  I t i s hoped  that the stimulate  findings w i l l further  p r o v i d e food f o r thought  study.  and  1 10  REFERENCES  Adam, E. 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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 . Williamson (Ed.). Current perspectives in nursing e d u c a t i o n : The c h a n g i n g s c e n e V o l . 1 , S t . L o u i s : CV. Mosby, 1 9 7 6 , 95-118. L e g o , S. The o n e - t o - o n e n u r s e - p a t i e n t Perspectives i n P s y c h i a t r i c Care,  relationship. 1980, 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 n u r s e s p e c i a l i s t , New Y o r k : A m e r i c a n J o u r n a l of N u r s i n g Company, 1 9 7 7 . Littlefield, Nursing  The  N. The p s y c h i a t r i c n u r s e as c h a n g e a g e n t . C l i n i c s of N o r t h A m e r i c a , 1979, 14:2, 373-383.  Logan, J . The e x p a n d e d r o l e o f t h e h a n d m a i d e n . Canadian Nurse, 1980, 7 6 : 1 , 34-35.  The  M a u k s c h , H.O. The o r g a n i z a t i o n a l c o n t e x t o f n u r s i n g practice. I n 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 Y o r k : J o h n W i l e y , 1966, 109-137. 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 . Nursing A d m i n i s t r a t i o n Q u a r t e r l y , 1979, 4sJ_ 67-78. r  1 22  M u l l a n e y , J.W., F o x , R.A., L i s t o n , M.F. C l i n i c a l n u r s e s p e c i a l i s t and s o c i a l w o r k e r : C l a r i f y i n g t h e r o l e s . N u r s i n g O u t l o o k , 1974, 2 2 : 1 1 , 712-718. M u r p h y , J . & S c h m i t z , M. The c l i n i c a l n u r s e 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 . Journal of N u r s i n g A d m i n i s t r a t i o n , 1979, 9, 2 9 - 3 1 . Nurse  p r a c t i t i o n e r s — The n a t i o n a l N u r s e , 1978, 7 4 : 4 , 13-23.  picture.  The C a n a d i a n  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 process. N u r s i n g O u t l o o k , 1977, 2 5 , 3 7 4 - 3 7 7 .  P e p l a u , H.E. The p s y c i a t r i c n u r s e -- A c c o u n t a b l e ? To whom? F o r w h a t ? 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 a r e , 1980, X V I 1 1 , 128-134. P e t e r s o n , S. The P s y c h i a t r i c n u r s e s p e c i a l i s t i n a g e n e r a l hospital. 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. (Eds.). specialist: Interpretations, C e n t u r y - C r o f t s , 1973.  The c l i n i c a l n u r s e New Y o r k : A p p l e t o n -  Richards, J.F. Integrating a c l i n i c a l s p e c i a l i s t into a hospital service. N u r s i n g O u t l o o k , 1969, 1 7 : 3 , 23-25. R o a c h , M.S. The n u r s i n g r o l e a n d t h e p r o b l e m o f implementation. N u r s i n g P a p e r s , 1974, 6:2, 2 8 - 2 9 . R o l l c a l l 77, A s t a t u s r e p o r t of h e a l t h p e r s o n n e l i n t h e province of B r i t i s h Columbiai Report of the D i v i s i o n of H e a l t h S e r v i c e s R e s e a r c h a n d D e v e l o p m e n t , #R:5, U . B . C , 1977. R o l l c a l l 75, A s t a t u s r e p o r t of h e a l t h p e r s o n n e l i n t h e province of B r i t i s h Columbia. Report of t h e D i v i s i o n of H e a l t h S e r v i c e s R e s e a r c h a n d D e v e l o p m e n t , #R:1, U . B . C , 1975. S p i t z e r , W.O. & K e r g i n , D . J . The n u r s e p r a c t i t i o n e r : C a l l i n g a spade. O n t a r i o M e d i c a l R e v i e w , 1 9 7 1 , 38, 165-166. S t e v e n s , B . J . The c h a n g i n g h e a l t h s c e n e : Impact problems f o r n u r s i n g . J o u r n a l of Nursing A d m i n i s t r a t i o n , 1974, 4:3, 2 0 - 2 3 .  on a n d  1 23  T r u d e a u , P.E. The p r a c t i c e a n d t h e o r y o f f e d e r a l i s m . I n F. V a u g h a n , e t . a l . ( E d s . ) . Contemporary i s s u e s i n Canadian p o l i t i c s , Scarborough, O n t a r i o : P r e n t i c e - H a l l o f Canada L t d . , 1 9 7 0 , 2 - 2 1 . U n i v e r s i t y s c h o o l s of n u r s i n g i n Canada. Nurse, 1 9 7 0 , 6 6 : 4 , 4 1 - 5 1 .  The C a n a d i a n  V a u g h a n , B.A. Role f u s i o n , d i f f u s i o n and c o n f u s i o n . Nursing C l i n i c s of North America, 1 9 7 3 , 8 : 4 , 7 0  3 - 7 1 3 .  W i l l i a m s o n , J.A. ( E d . ) . Current perspectives i n nursing e d u c a t i o n V o l . j _ , S t . L o u i s : The C.V. Mosby Company, 1 9 7 6 .  W i n s t e a d - F r y , P. The n e e d t o d i f f e r e n t i a t e a n u r s i n g s e l f . American J o u r n a l of Nursing, 1 9 7 7 , J _ 7 , 1 4 5 2 - 1 4 5 4 . W r i g h t , E. R e g i s t e r e d concept. Nursing  nurses' opinions Research, 1 9 7 6 ,  on an e x t e n d e d 2 5 : 2 ,  1 1 2 - 1 1 4 .  role  1 24  APPENDIX A  125  Dear Colleague, As a nurse, and as a student i n the Master o f Science i n Nursing program a t the U n i v e r s i t y o f B r i t i s h Columbia, I am aware t h a t an i s s u e of importance t o our p r o f e s s i o n i s the r o l e o f the c l i n i c a l nurse s p e c i a l i s t . I want t o examine, i n a master's t h e s i s , the p r a c t i c e o f 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 o f assistance I have r e ceived from the p r o v i n c i a l a s s o c i a t i o n . The nature o f t h a t assistance has been a s t a f f member a t RNABC r e t r e i v i n g from the computer a l i s t o f names o f 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 m a i l i n g the s t u f f e d envelopes I have prepared. You can a s s i s t me by completing the d a t a - c o l l e c t i n g form t h a t accompanies t h i s l e t t e r . Completion requires 2 0 - 3 0 mintues o f your time. An addressed stamped envelope i s provided f o r r e t u r n o f the form. Return of the completed form w i l l be assumed t o i n d i c a t e your consent t o p a r t i c i p a t e i n the study. Your anonymity i s assured as a r e s u l t o f the procedure I have followed w i t h RNABC. Your name w i l l not appear on t h e d a t a - c o l l e c t i n g form. I f you are i n t e r e s t e d i n r e c e i v i n g feedback i n the form o f a summary o f f i n d i n g s and recommendations from t h i s study, please i n d i c a t e t h i s by recording your name and m a i l i n g address on the s m a l l card i n t h i s package. I f you decide t o p a r t i c i p a t e i n the study, I urge you t o respond to each i t e m on the d a t a - c o l l e c t i n g form. There are no r i g h t o r wrong responses. I seek t o describe the p r a c t i c e i n which you engage based on your perceptions and experience i n your present p o s i t i o n . In a n t i c i p a t i o n o f your d e c i s i o n t o p a r t i c i p a t e I want t o thank you f o r your c o n t r i b u t i o n t o my study. I f you decide n o t t o p a r t i c i p a t e , I want t o 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 r e t u r n i n g the form i n e i t h e r case.  Sincerely, S h i r l e y H a l l i d a y , BN (graduate student, U n i v e r s i t y of B r i t i s h Colimbia)  1 26  APPENDIX B  127  DATA - COLLECTING FORM  Survey o f the P r a c t i c e o f 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 o f your time w i l l be r e q u i r e d o f t h i s form.  f o r completion  You a r e f r e e to d e c l i n e t o respond t o any item. T h e r e a r e no to your doing s o .  consequences  The r e t u r n o f the completed form t o the r e s e a r c h e r w i l l be assumed to i n d i c a t e your consent to p a r t i c i p a t e i n t h i s study.  GENERAL INSTRUCTION As a b a s i s f o r your responses to each item, p l e a s e use your p r e s e n t j o b experience.  128 When you completed t h e RNABC r e g i s t r a t i o n f e e form you i n d i c a t e d t h a t your work p o s i t i o n was t h a t o f " 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. A t t h e p r e s e n t time a r e 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 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 y o u : a) p l e a s e i n d i c a t e what k i n d o f work you a r e d o i n g  b) STOP a t t h i s p o i n t . Do n o t complete t h e form. P l e a s e r e t u r n i t t o t h e r e s e a r c h e r i n t h e envelope t h a t has been p r o v i d e d . What i s your s p e c i f i c j o b t i t l e ?  I f you t h i n k your j o b t i t l e i s d e s c r i p t i v e o f your work p l e a s e s k i p t o i t e m 4. I f i t i s u n s a t i s f a c t o r y how would y o u rename i t ? Which o f t h e f o l l o w i n g b e s t a p p l i e s 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 specify How l o n g have you worked i n your p r e s e n t p o s i t i o n w i t h t h i s t i t l e ? 0 - 6 months 7-12  months  1 3 - 2 4 months 25 - 36 months l o n g e r than 36 months At t h e time you a c c e p t e d your p o s i t i o n was i t new? existing?  When you a c c e p t e d y o u r p r e s e n t p o s i t i o n d i d a j o b d e s c r i p t i o n e x i s t f o r i t ? YES NO  129  7. The f o l l o w i n g c a t e g o r i e s have been d e f i n e d by n u r s e r e s e a r c h e r s ( A r a d i n e and Denyes) as c h a r a c t e r i s t i c o f t h e p r a c t i c e o f t h e c l i n i c a l nurse s p e c i a l i s t . P l e a s e check YES f o r each c a t e g o r y t h a t a p p l i e s t o your p r a c t i c e and e s t i m a t e t h e percentage o f your work time on a weekly b a s i s devoted t o each c a t e g o r y you have checked. Your e s t i m a t e s s h o u l d t o t a l 100%. A t l e a s t one example i s p r o v i d e d f o r eacl c a t e g o r y i n o r d e r t o a s s i s t you i n r e s p o n d i n g . Percentage e s t i m a t e CATEGORY* YES o f weekly work time  administration eg., p a r t i c i a p t e i n p o l i c y making d e c i s o n s provide c l i n i c a l supervision 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 t o t h e 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 p r o v i d e f o r m a l and i n f o r m a l programs w i t h d e f i n e d o b j e c 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., p r o v i d e p a t i e n t c e n t e r e d c o n s u l t a t i o n to h e a l t h team members  d) e d u c a t i o n o f s t u d e n t s eg., p a r t i c i p a t e i n e d u c a t i o n a l programs f o r s t u d e n t s 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 o f t h e h e a l t h team i n p r a c t i c e oriented research involve a l l staff i n planning 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 o f a n u r s i n g model when i m plementing the n u r s i n g process  continued  130  7. ( c o n t i n u e d )  ... Percentage estimate of weekly work time  CATEGORY  %  g) p e r s o n a l 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 participate i n professional activities 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 c a r e p a r t i c i p a t e i n developing standards f o r n u r s i n g care  i)  research eg., a s s i s t n u r s i n g s t a f f and o t h e r s to become f a m i l i a r with nursing research c o l l a b o r a t e with nurse r e s e a r c h e r s i n p l a n n i n g and conducting nursing 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 t o become informed i n n u r s i n g t h e o r y and r e s e a r c h 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 o t h e r members o f the h e a l t h team in writing for publication  1)  other please s p e c i f y :  % % % % 100  %  *These c a t e g o r i e s have been t a k e n from the work o f 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 o f 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 , 19 21, 411-418.  What i s t h e t y p e o f s e t t i n g i n w h i c h you work? P l e a s e 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 c a r e h o s p i t a l ? rehabilitation hospital? other? please specify: 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 c a r e agency? other? please specify: d) BUSINESS/INDUSTRY e) PHYSICIAN'S OFFICE/FAMILY PRACTICE UNIT f ) OTHER please specify:  9. Given t h e f o l l o w i n g d e f i n i t i o n s what i s t h e type o f appointment you h o l d a) P l e a s e check one o f t h e f o l l o w i n g w h i c h a p p l i e s t o your p o s i t i o n . TYPE  DEFINITION  unit-based  a p o s i t i o n i n w h i c h you c a r r y p r i m a r y 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 u n i t - b a s e d  a p o s i t i o n i n w h i c h your p r i m a r y r e s p o n s i b i l i t y i s n o t bound by a d e f i n e d geographic a r e a  132  9.(continued) b) P l e a s e check one o f t h e f o l l o w i n g which a p p l i e s t o v o u r p o s i t i o n . TYPE  DEFINITION  clinical  employed by & r e s p o n s i b l e t o t h e department of 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 activities  c l i n i c a l & educational  clinical & administrative  employed by & r e s p o n s i b l e t o t h e department o f n u r s i n g 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 e d u c a t i o n o f n u r s i n g s t u d e n t s r e s p e c t i v e l y employed by & r e s p o n s i b l e t o t h e department of n u r s i n g 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 specify:  c) P l e a s e check t h e one o f t h e f o l l o w i n g w h i c h a p p l i e s t o your p o s i t i o n . TYPE  DEFINITION  line position  a p o s i t i o n i n which you have "power by v i r t u e o f t h e 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 t h e a c t i o n s and t h e management o f o t h e r employees"  staff position  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 t h a t 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 for the actions of others  10. What i s y o u r 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 ? baccalaureate  program  d i p l o m a program  133 11. Your 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 c o n s i s t e d o f which o f the f o l l o w i n g ? I f you r e q u i r e more space f o r your response p l e a s e w r i t e on the page o p p o s i t e t h i s one. TYPE o f PROGRAM  YEAR o f COMPLETION  diploma/certificate area o f study: baccalaureate nursing: other: master's nursing: other: doctoral nursing: other:  12. What p o s i t i o n s i n n u r s i n g have you held? P l e a s e i n d i c a t e a l l p o s i t i o n s you have had, i n a numbered sequence, and the approximate time, i n y e a r s , f o r each positi< POSITION  APPROXIMATE SEQUENCE  a s s i s t a n t head nurse associate/assistant director director g e n e r a l d u t y / s t a f f nurse head nurse instructor o f f i c e nurse/community h e a l t h nurse professor supervisor/co-ordinator your p r e s e n t p o s i t i o n other please s p e c i f y :  TIME i n YEA'  134  1 3 . Your age i s l e s s than 25 y e a r s 25 -  2 9 years  30 -  3 5 years  36 -  3 9 years  40 -  4 5 years  46 -  49 years  5 0 y e a r s and g r e a t e r  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 ) a n d P e r c e n t a g e o f W e e k l y Work Time R e p o r t e d f o r O t h e r C a t e g o r y o f Work A c t i v i t y ( I t e m 7) Subject  1  2 3 4 5 6 7 8 9 10 11 12 13 14 15 16  L a b e l u s e d by S u b j e c t  a. D a t a c o l l e c t i o n a n d review b. F o l l o w - u p c. R e s e a r c h l i a i s o n Clerical a. S u r v e i l l a n c e o f i n f e c t i o n b. S t a t i s t i c s Patient education S u r v e i l l a n c e of i n f e c t i o n Control O r i e n t a t i o n programs a. T r a d i t i o n a l n u r s i n g skills b. C l e r i c a l a. S u p e r v i s e v o l u n t e e r s b. P u b l i c r e l a t i o n s Supplies Travel time a. S e t t i n g up p r o g r a m s b. C o m m i t t e e work C o o r d i n a t e s e r v i c e s on behalf of i n d i v i d u a l patient Providing psychotherapy Counselling a. C l a s s g i v i n g b. O r i e n t a t i o n t o new s t a f f A d m i n i s t e r i n g chemotherapy Average  N.R.  Percentage of w e e k l y work t i m e indicated  = No  response.  Category in Table 2  10  1  15 5 5 27 2 30 50  1 1 2 4 2 7 4  15 10  3 6  8 1 3 N.R. 3 5 15 N.R.  2 8 8 2 8 3 8 3  1  80 5 5 20 65 23.5  5 5 3 3 6  1 37  TABLES C.2 - C.9 These t a b l e s p r e s e n t a l l t h e r e s u l t s found f o r t h e analyses  of the infuence  of the c o n t e x t u a l l y  related  v a r i a b l e s and t h e 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 level  on t h e e s t i m a t e s  educational  o f w e e k l y work t i m e r e p o r t e d  c a t e g o r y o f work a c t i v i t y .  Two a n a l y s e s  were done on e a c h  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 b e t w e e n and  a Kruskal-Wallis  test for differences  f o r each  means,  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 f o u n d t h e mean i s f l a g g e d by  a  1  (p<.05, ANOVA) o r t h e a v e r a g e r a n k  (p<.05, K-W the  statistic).  Further  by  2  d e t a i l s about t h e n a t u r e of  s i g n i f i c a n t differences are presented  C h a p t e r 4.  i s flagged  i n the t e x t of  1 38  Results  T a b l e C.2 o f an A n a l y s i s o f t h e V a r i a b l e Time i n P r e s e n t Position  Category  Time i n Job (months)  N  M i n . Max.  A d m i n i strat ion  0--6 7--12 1 3-24 25--35 > 36 TOTAL  3 4 5 14 19 45  5 5 5 1 1  20 20 20 45 40  Commun i t y Activity  o--6 7--12 1 3--24 25--35 > 36 TOTAL  1 3 5 10 19 38  5 5 1 1 1  5 5 5 35 100  Consultat ion  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  3 5 9 14 24 55  5 5 5 3 2  10 15 92 60 60  Educat i o n of Students  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  0 3 5 12 20 40  5 1 1 1  10 5 25 40  Interdisciplinary Interaction  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  3 5 5 14 22 49  10 5 5 1 2  20 15 21 22 50  Patient Care  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  3 4 8 15 20 50  20 5 1 7 5  60 58 80 80 80  Mean  SD  10. 0 1 1 .2 10. 4 10. 2 10. 4 10.,4  8. 6 6. 2 5. 7 12. 9 1 1 .2 10. 5  5. 0 10. 0 10. 0 3. 5 5. 0 5..0  25. 6 29. 3 28. 7 19. 3 22. 3  -5.,0 5.,0 0..0 4.,2 1.,1 13..2 1 1 .2 . 12.,2 22.,4 10.. 1 17.,2  5. 0 5.,0 5.,0 5.,0 5.,0 5.,0  19.,0 19.,0 15.,9 19.,4 20.,5  2.,8 5..0 27.,9 16..3 14., 1 16..6  10..0 10.,0 10.,0 1 1 ,0 . 10..0 10.,0  21 ,. 1 25.. 1 27..2 31 .9 . 27,.4  2,.8 2.. 1 7,.8 8,.4 7,.3  5..0 5..0 4,.5 5,.0 5,.0  28,.5 16,.8 20,. 1 20,.4  13,.3 8 .0 8 .2 7..4 1 1.0 9 .5  5,.7 4,.4 7,. 1 7,. 1 10 .9 8 .7  10,.0 5,.0 5,.0 4,.0 10,.0 8,.0  36,.3 25 .4 23 .6 20 .7 26 .8  43 .3 28 .2 42 .6 35 .4 37 .5 37 .3  20 .8 21 .9 30 .2 21 .6 25 .3 24 .0  50,.0 25 .0 50 .0 25 .0 32 .0 30 .0  29 .5 21 . 1 27 .3 25 .2 25 .2  8.,3 10..0 19..2 18..6 15..0 15..8 6..6 3..4 6,.8 6,. 1 6,.0  Median Avg. Rank  1 39  T a b l e C.2 — Category  Continued Time i n Job (months)  N  M i n . Max.  Mean  SD  Median Avg. Rank  Personal+ Professional Growth  0--6 7--12 1 3--24 25--35 > 36 TOTAL  2 4 9 14 23 52  5 5 1 1 1  10 20 13 14 50  7..5 3. 5 7..5 8..7 3. 8 6..3 5. 0 3. 6 8..4 10., 1 7., 1 7.,4  Planning Policy Standards Change  0 -6 7--12 13'-24 25 -35 > 36 TOTAL  3 5 7 15 14 44  5 1 1 1 1  10 20 15 20 20  8.,3 9.,2 6.,4 5.,7 7., 1 6.,8  2.,8 7.,9 5.,0 5.,5 4.,7 5.,2  10.,0 5.,0 5.,0 4.,0 6.,0 5.,0  Research  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  0 2 3 5 10 20  5 1 1 1  5 20 2 15  5..0 8..6 1 .6 . 4..8 4..6  0..0 10..0 .6 4,.6 5,.0  5.,0 5.,0 2.,0 3.,5 2..0  Staff Development  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  2 3 5 1 1 16 37  10 5 1 1 1  20 10 30 14 80  15..0 8..3 9..0 4,.9 9,.8 8,.4  7..0 2..8 12,. 1 3,.8 19,.3 13,.5  Wr i t i n g for Publicat ion  0 -6 7 -12 1 3-24 25 -35 > 36 TOTAL  0 2 3 5 8 18  5 1 1 1  5 5 9 40  Other  0 -6 7 -12 13 -24 25 -35 > 36 TOTAL  0 4 4 4 4 16  1 5 3 2  50 29 65 80  5,.0 2 .3 2,.6 7,.7 5. 1 22 .7 16 .0 25 .5 30 .0 23 .5  0,.0 2 .3 3,.5 13,.2 9 .0  7. 5 5. 0 5. 0 4. 5 5. 0 5. 0  33. 7 31 .3 27. 3 20. 7 28. 1 30., 1 25., 1 21 . ,1 18.,3 24.,7  13.,5 12.,5 7.,3 10..9  15..0 32..2 10..0 ' 26,.5 5,.0 17,.9 3,.0 16,.9 5,.0 17,.7 5,.0 5,.0 1 .0 , 1 .0 , 3,.5 1 .5 ,  20 .6 20 .0 1 2 .8 15 .0 29 . 1 17 .0 34 .2 19 .0 23 .4 19 .0  12,.5 7,.5 7,.4 10,.8  8. 1 8 .3 8 .7 8 .7  1 40  Results  T a b l e C.3 o f an A n a l y s i s o f t h e V a r i a b l e New V e r s u s Posit ion M i n . Max.  Category  Type o f Position  N  Administration  new existing TOTAL  25 20 45  1 1  45 25  Communi t y new existing Activity TOTAL  20 18 38  1 1  100 35  new existing TOTAL  28 27 55  2 5  E d u c a t i o n new existing of TOTAL Students  19 21 40  Interdisc iplinarynew Interexisting TOTAL Action  Mean  SD  Existing  Median Avg. Rank  1 3 . 2 12.1 6.8 7.0 10.5 10.4  10.0 5.0 5.0  26.6 18.5  11.4 8.7 10.1  21.9 10.4 17.2  5.0 5.0 5.0  20.2 18.7  92 60  17.6 13.9 15.8  18.3 14.8 16.6  11.5 10.0 10.0  30.5 25.3  1 1  25 40  6.8 5.2 6.0  6.3 8.2 7.3  5.0 4.0 5.0  23.5 17.7  25 24 49  1 1  50 22  10.5 8.5 9.5  10.9 5.7 8.7  5.0 9.5 8.0  25. 1 24.8  new existing TOTAL  26 24 50  1 15  75 80  29.7 45.-6 37.3  23.4 22.2 24.0  20.0 50.0 30.0  20.5 30.9  Personal+ Professional Growth  new existing TOTAL  26 26 52  1 1  15 50  6.2 8.1 7.1  3.5 9.9 7.4  5.0 5.0 5.0  Planning Policy Standards Change  new existing TOTAL  25 19 44  1 1  16 20  6.6 • 4.5 7.2 6.2 6.8 5.2  . 5.0 5.0 5.0  Research  new exist ing TOTAL  1 1 9 20  1 5  20 15  4.0 5.2 4.6  5.5 4.7 5.0  2.0 5.0 2.0  9.5 11.6  Staff Development  new existing TOTAL  20 17 37  1 1  30 80  7.9 9.0 8.4  7.8 18.4 13.5  5.0 5.0 5.0  19.8 18.0  Consultation  Patient Care  1  1  2  2  27 . 1 25.8  22.6 22.2  141  T a b l e C.3 — Category Writing for Publication Other  Continued Type o f Position  N  M i n . Max.  new existing TOTAL  9 9 18  1 1  9 40  3.2 7.0 5.1  2.9 12.5 9.0  new existing TOTAL  9 -7 16  1 3  50 80  17.6 31.1 23.5  16.4 29.9 23.4  Mean  SD  Median Avg. Rank 1 .0 2.0 1 .5 18.0 20.0 19.0  8.8 10.1 7.5 9.7  1 42  Results  o f an A n a l y s i s  T a b l e C.4 of t h e V a r i a b l e Job D e s c r i p t i o n Median Avg. . Rank  Mean  SD  40 45  10.5 10.7 10.6  9.5 12.2 10.5  7.0 5.0 5.0  22.8 21.9  1 1  35 1 00  8.6 12.4 10.1  9.5 25.2 17.2  5.0 5.0 5.0  20. 1 18.5  31 23 54  2 3  92 35  16.0 13.5 15.0  19.0 9.8 15.6  10.0 12.0 10.0  27.3 27.6  yes no TOTAL  23 17 40  1 1  40 25  6.0 6.1 6.0  7.9 6.6 7.3  5.0 5.0 5.0  20.6 20.3  yes no TOTAL  28 20 48  1 1  21 50  8.4 11.5 9.7  5.3 11.9 8.7  10.0 5.0 8.5  24. 1 24.9  yes no TOTAL  27 22 49  1 5  80 80  32.7 43.4 37.5  21 .6 26.7 34. 1  25.0 50.0 30.0  22.5 27.9  Personal+ Professional Growth  yes no TOTAL  30 22 52  1 1  50 10  8.4 5.4  9.3 3.0 7.4  5.0 5.0 5.0  28.0 24.3  Planning Pol icy Standards Change  yes no TOTAL  24 19 43  1 1  20 10  8.5 4.7 6.8  6.2 3.0 5.3  6.5 5.0 5.0  25. 1 18.1  Research  yes no TOTAL  12 8 20  1 1  15 20  4.5 4.6 4.6  4.1 6.5 5.0  3.5 1 .5 2.0  11.2 9.3  Staff Development  yes no TOTAL  20 16 36  1 1  80 20  11.0 5.2 8.4  17.6 5.5 13.7  5.0 3.0 5.0  20.9 15.4  M i n . Max.  Category  N Job Descript.  Administration  yes no TOTAL  27 17 44  1 1  Community Activity  yes no TOTAL  23 15 38  Consultation  yes no TOTAL  Educat ion of Students Interdisciplinary InterAct ion Patient Care  ?'  1  1  1 43  T a b l e C.4 -- C o n t i n u e d Category Writing for Publication Other  N Job Descript.  M i n . Max.  yes no TOTAL  12 6 18  1 1  40 6  yes no TOTAL  10 6 16  3 1  80 50  Mean  6.0 3.3 5. 1 27.6 16.8 23.5  SD  11.0 2.2 9.0 25.9 18.8 23.4  Median Avg. Rank 1 .0 3.5 1 .5 22.5 11.5 19.0  9.2 10.0 9.5 6.8  1 44  T a b l e C.5 R e s u l t s o f an A n a l y s i s o f t h e V a r i a b l e Type o f S e t t i n g Category  Type o f Setting  N  M i n . Max.  A d m i n i st r a t ion  hosp cbs po/fpu other TOTAL  32 9 1 3 45  1 3 5 3  Community h o s p Activity cbs po/fpu other TOTAL  22 13 0 3 38  Consultat ion  hosp cbs po/fpu other TOTAL  Median Avg. Rank  Mean  SD  45 40 5 20  10.5 10.4 5.0 11.0 10.4  10.5 12.2 -8.5 10.5  5.0 5.0 5.0 10.0 5.0  23.0 22.2 19.5 26.0  1 1  35 1 00  6.3 16.6  8.7 26.5  5.0 6.0  15.6 25.0  5  20  10.0 10.1  8.6 17.2  5.0 5.0  24.0  36 14 2 3 55  3 5 5 2  92 35 30 40  17.2 11.6 17.5 17.3 15.8  8.6 9.6 17.6 20.0 16.6  5.0 10.0 17.5 10.0 10.0  29.8 23.4 29.2 26. 1  Education hosp cbs of Students po/fpu other TOTAL  27 10 0 3 40  1 2  40 1o  6.2 4.7  8.7 2.8  5.0 4.5  19.1 20.6  •10  8.3 6.0  2.8 7.3  10.0 5.0  32.0  I n t e r d i s- h o s p c iplinarycbs Interpo/fpu Action other TOTAL  33 12 1 3 49  1 2 20 2  50 30 20 10  8.5 12.0 20.0 7.3 9.5  9.3 7.4 4 .6 8.7  5.0 5.0 20.0 10.0 8.0  22. 1 31.4 44.0 23.6  Patient Care  hosp cbs po/fpu other TOTAL  34 12 1 3 50  1 5 60 5  80 80 60 50  36.0 41.6 60.0 26.6 37.3  24.6 23.3 -22.5 24.0  25.0 50.0 60.0 25.0 30.0  24.8 27.7 40.5 19.1  Personal+ Professional Growth  hosp cbs po/fpu other TOTAL  35 13 1 3 52  1 3 5 5  7.2 6.7 5.0 8.3 7.1  8.8 3.0  5.0 5.0 5.0 5.0 5.0  24.9 29.3 25.0 33.0  5 •  50 10 5 15  —  —  5.7 7.4  1 45  T a b l e C.5 —  Continued SD  Type o f Setting  N  Planning Pol icy Standards Change  hosp cbs po/fpu other TOTAL  33 8 1 2 44  1 3 5 5  20 20 5 5  6.7 8.0 5.0 5.0 6.8  —  Research  hosp cbs po/fpu other TOTAL  13 5  1 1  20 9  2 20  1  27 8 2  Staff Development  hosp cbs po/fpu other TOTAL  M i n . Max.  Mean  Category  0.0 5.2  5.0 7.0 5.0 5.0 5.0  21.9 26.0 19.5 19.5  5.4 3.0  5.8 3.3  5.0 2.0  11.3 9.0  5  3.0 4.6  2.8 5.0  3.0 2.0  8.7  1 2  80 5  9.9 4.0  15.6 1 .4  5.0 5.0  19.9 16.1  1  10  5.5  6.3  5.5  17.0  8.4  13.5  5.0  37  5.5 5.3  Median Avg. Rank  Writing for Publication  hosp cbs po/fpu other TOTAL  13 3  1 1  40 5  6.0 2.3  10.5 2.3  2.0 1 .0  10.7 7.5  2 18  1  5  3.0 5.1  2.8 9.0  3.0 1 .5  8.7  Other  hosp cbs po/fpu other TOTAL  14 2  1 3  65 80  21.0 41.5  18.7 54.4  19.0 41 .5  8.3 9.5  23.5  23.4  16  1 46  Results  T a b l e C.6 o f an A n a l y s i s o f t h e V a r i a b l e Type o f A p p o i n t m e n t ( U n i t v s Not U n i t B a s e d ) Median Avg. Rank  Mean  SD  45 35  11.0 10.0 10.5  12.6 8.5 10.6  5.0 5.0 5.0  21.0 23.8  1 1  100 30  16.8 6.0 10.3  25.3 6.6 17.4  5.0 5.0 5.0  23.7 15.7  27 27 54  2 5  60 92  12.5 17.4 15.0  11.7 18.7 15.6  10.0 10.0 10.0  25.4 29.5  Education unit of not-unit TOTAL Students  18 21 39  1 1  40 10  7.5 5.0 6.1  10.4 2.7 7.4  4.5 5.0 5.0  18.7 21.0  I n t e r d i sciplinaryunit Internot-unit TOTAL Action  24 24 48  1 1  50 22  9.9 9.5 9.7  10.7 6.4 8.7  9.0 8.5 8.5  23.4 25.5  unit not-unit TOTAL  26 23 49  5 1  80 80  38.6 36.5 37.6  24.9 23.7 24. 1  28.0 38.0 30.0  25.5 24.3  Personal+ Professional ^Growth  unit not-unit TOTAL  25 26 51  1 1  50 20  8.2 6.3 7.2  9.7 4.5 7.5  5.0 5.0 5.0  27.3 24.7  Planning Policy Standards Change  unit not-unit TOTAL  22 21 43  1 1  20 16  7.7 6.0 6.9  6.5 3.6 5.3  6.0 5.0 5.0  22.8 21.9  Research  unit not-unit TOTAL  9 10 19  1 1  7 20  3.2 6.2 4.7  2.4 6.5 5. 1  2.0 3.5 2.0  8.7 11.5  Staff Development  unit not-unit TOTAL  20 17 37  1 1  30 80  7.9 9.0 8.4  7.8 18.4 13.5  5.0 5.0 5.0  19.8 18.0  Category  Type o f Position  N  Administration  unit not-unit TOTAL  21 23 44  1 1  Community u n i t Activity not-unit TOTAL  15 22 37  Consultation  unit not-unit TOTAL  Patient Care  M i n . Max.  1 47  T a b l e C.6 -- C o n t i n u e d Category Writing for Publication Other  Type o f Posit ion  N  M i n . Max.  Mean  SD  unit not-unit TOTAL  9 9 18  1 1  9 40  3.2 7.0 5.1  2.9 12.5 9.0  un i t not-unit TOTAL  9 7 16  1 3  50 80  17.6 31.1 23.5  16.4 29.9 23.4  Median Avg. Rank 3.0 1 .5 1 .5 16.5 27.0 19.0  8.8 10.1 7.5 9.7  1 48  T a b l e C.7 R e s u l t s o f an A n a l y s i s o f t h e V a r i a b l e Type o f A p p o i n t m e n t (Clinical, Clinical-educational, Clinical-administrative, Other) Median  Avg. Rank  1 1 .1 6. 0 15. 9 8. 7 10. 5  5. 0 5. 0 15. 0 5. 0 5. 0  21 . 0 22. 1 27. 5 22. 0  4. 2 2. 0 6. 6 14. 5 10.,2  1 .3 2.,0 2.,8 21 . ,8 17.,5  5. 0 1 ,0 . 5.,0 5.,0 5.,0  15. 8 7. 2 22. 1 21 . 8  60 30 15 92  18.,5 20.,5 8.,0 14.,4 15.,4  17.,6 1 1 ,0 . 4..4 18., 1 16..6  10.,0 21 . ,0 7.,5 10.,0 10.,0  31 . ,6 39.,5 19., 1 24.,9  1 4 1 1  40 5 20 25  7..3 4.,7 6..6 5..4 5..9  12..3 .5 7..7 5,.4 7..4  5..0 5..0 5..0 5..0 5,.0  18.,8 22.,7 20..5 19..8  13 4 7 24 48  2 8 1 1  15 10 20 50  5,.5 9..5 7,.0 12,.9 9,.7  4,.0 1 .0 , 6,.4 10,.8 8,.8  5,.0 10,.0 5,.0 10,.0 8,.5  16.. 8 29,.5 19,.5 29,.3  clin clin-ed c1in-ad other TOTAL  16 4 7 22 49  5 15 5 1  80 51 75 70  46,.0 34,.0 38,.5 32,.4 37,.9  27,.5 19 . 1 28 .2 19 .5 23 .8  50,.0 35,.0 25 .0 27 .5 30 .0  29,.3 22,.7 24,.8 22,.2  clin clin-ed clin-ad other TOTAL  14 4 7 26 51  1 2 1 1  50 5 20 20  5 .0 4 .5 5 .0 5 .0 5 .0  22 .8 17 .7 25 .7 29 .0  Mean  SD  35 15 45 40  10. 4 8. 0 16. 6 8. 5 10. 2  2 1 5 1  5 5 10 1 00  17 4 6 27 54  5 10 3 2  Educat i o n c l i n clin-ed of clin-ad Students other TOTAL  9 4 5 21 39  Interdis- clin c i p l i n a ry c l i n - e d Interclin-ad other A c t i on TOTAL Patient Care  Personal+ Professional Growth  M i n . Max.  Category  Type o f Appoint.  N  Administration  cl in clin-ed clin-ad other TOTAL  13 3 6 22 44  1 4 2 2  Community c l i n clin-ed Activity clin-ad other TOTAL  8 4 3 22 37  clin clin-ed clin-ad other TOTAL  Consultation  <  8 .0 1 2.6 1 .4 4 .0 7 .0 6 .3 7. 1 4 .2 7. 1 7 .5  2  149  T a b l e C.7 -- C o n t i n u e d Category  Type o f Appoint.  N  M i n . Max.  Mean  SD  Median Avg. Rank  Planning clin c l i n - ed Pol i c y S t a n d a r d s c l i n - ad other Change TOTAL  15 3 7 18 43  1 2 1 1  15 20 20 20  6., 1 8.,6 7.,8 6.,7 6.,8  4.,2 9.,8 7.,3 4.,8 5.,3  5.,0 4.,0 4.,0 5.,5 5.,0  21 . ,3 21 . ,5 21 . .8 22.,7  Research  clin c l i n - ed c l i n - ad other TOTAL  4 2 3 10 19  1 2 1 1  7 5 1 20  3.,5 3.,5 1 ,0 . 6.,6 4.,7  3.,0 2., 1 0.,0 6..3 5.. 1  3.,0 3.,5 1 ,0 . 5.,0 2..0  9., 1 10.,7 4.,0 12.,0  Staff Development  clin c l i n - ed c l i n - ad other TOTAL  1 1 2 5 18 36  1 5 1 1  30 8 20 80  8..4 6..5 5..6 9..7 8..6  9.. 1 2.. 1 8.. 1 17..8 13..7  5..0 6..5 3,.0 5,.0 5,.0  19..0 21 .7 . 13.. 1 19..3  Writing for Publicat ion  clin c l i n - ed c l i n - ad other TOTAL  3 1 1 12 17  1 1 1 1  6 1 1 40  2..6 1 .0 , 1 .0 , 6..7 5,.3  2,.8  1 .0 , 1 .0 , 1 .0 , 5,.0 2,.0  7,.8 4,.5 4,.5 10,.0  Other  clin c l i n - ed c l i n - ad other TOTAL  4 1 3 8 16  1 30 5 3  65 30 25 80  18,.2 30,.0 15,.0 28,.6 23,.5  3,.5 30,.0 15,.0 22,.5 19,.0  5,.8 13,.0 7,.6 9,.5  ---  10,.7 9,.2 31 .2 , 10,.0 25,.5 23,.4  1 50  Results  T a b l e C.8 o f an A n a l y s i s o f t h e V a r i a b l e L i n e V e r s u s Position  Category  Type o f Position  N  M i n . Max.  Mean  SD  Staff  Median Avg. Rank  Administration  line staff TOTAL  6 36 42  5 1  45 35  21 .7 9.0 10.8  16.9 8.4 10.7  Community Activity  line staff TOTAL  3 33 36  1 1  5 100  3.6 11.0 10.4  2.3 5.0 18.4 . 5.0 17.7 5.0  13.5 18.9  Consultation  line staff TOTAL  5 46 51  5 2  43 92  18.6 15.4 15.7  18.8 17.1 17.1  5.0 10.0 10.0  25. 1 26.0  Education of Students  line staff TOTAL  4 33 37  1 1  20 40  9.0 5.8 6.1  8.2 7.5 7.5  7.5 5.0 5.0  23.7 18.4  Interdisciplinary InterAction  line staff TOTAL  6 40 46  1 1  50 22  11.8  8.9 9.2  18.9 5.9 8.4  4.0 8.5 8.0  18.4 24.2  line staff TOTAL  6 41 50  5 1  30 80  19.8 39.8 37.3  8.3 24.7 24.0  20.0 50.0 30.0  14.8 25.3  Personal+ Professional Growth  1 ine staff TOTAL  6 43 49  1 1  20 50  8.3 7.0 7.2  6.5 7.8 7.6  7.0 5.0 5.0  29.0 24.4  Planning Policy Standards Change  line staff TOTAL  6 36 44  1 1  20 20  7.3 6.8 6.8  7. 1 5.1 5.2  5.5 5.0 5.0  21.1 25.5  Research  line staff TOTAL  2 15 20  1 1  2 20  1 .5 5.0 4.6  0.7 5.6 5.0  1 .5 2.0 2.0  6.0 9.4  Staff Development  line staff TOTAL  5 30 35  1 1  5 80  2.6 9.5  1 .5 14.8  2.0 5.0 5.0  10.5 19.2  Patient Care  1  15.0 5.0 5.0  31 .I 19.7  2  151  T a b l e C.8 — Category Writing for Publicat ion Other  Continued Type o f Position  N  M i n . Max.  Mean  SD  Median Avg. Rank  1 ine staff TOTAL  2 14 16  1 1  9 40  5.0 5.0 5.0  5.6 10.2 9.6  5.0 1 .0 1 .0  10.0 8.2  1 ine staff TOTAL  3 1 3' 16  4 1  18 80  12.3 26.3 23.5  7.3 25.3 23.4  15.0 25.0 19.0  6.3 9.0  1 52  Results  T a b l e C.9 o f an A n a l y s i s o f t h e D e r i v e d Preparat ion  Variable  Educational  Median Avg. Rank  Mean  SD  45 35 10  10.6 15.2 5.0 10.4  10.6 14.3 2.7 10.5  5.0 10.0 5.0 5.0  23.3 27.3 17.5  1 1 1  35 1 00 35  7.2 27.7 11.4 10.1  8.2 48.2 11.7 17.2  5.0 5.0 5.0 5.0  18.8 19.8 21.8  38 8 9 55  2 5 5  60 30 92  16.1 11.8 18.0 15.8  14.7 8.4 27.9 16.6  10.5 10.0 10.0 10.0  28.8 26.3 25.7  Educat i o n diploma of bacc master Students TOTAL  28 5 7 40  1 1 1  40 10 10  6.7 5.0 4. 1 6.0  8.5 3.2 3.0 7.3  5.0 4.5 4.0 5.0  21.0 21.2 17.7  I n t e r d i s - diploma ciplinarybacc Intermaster Action TOTAL  34 8 7 49  1 2 3  30 20 50  8.1 8.4 17.9 9.6  6.6 6.2 15.3 8.8  8.0 5.0 15.0 8.0  22.8 24.3 36.0  Pat i e n t Care  diploma bacc master TOTAL  35 8 7 50  1 5 15  80 75 50  36.8 43.8 32.4 37.3  25. 1 26.8 14.1 24.0  25.0 50.0 30.0 30.0  25. 1 29.0 23. 1  Personal+ diploma Professbacc master ional Growth TOTAL  37 7 8 52  1 1 1  50 5 10  8.1 3.8 5.3 7.1  8.5 1 .9 3.1 7.4  5.0 5.0 5.0 5.0  28.6 18.8 23.4  Planning diploma bacc Pol i c y Standards master TOTAL Change  32 6 6 44  1 1 1  20 16 20  6.5 8.0 7.5 6.8  4.8 6.6 6.7 5.2  5.0 8.0 6.5 5.0  22. 1 23.9 23.0  Category  L e v e l of N Educat ion  M i n . Max.  A d m i n i stration  diploma bacc master TOTAL  34 5 6 44  1 1 2  Community d i p l o m a Act i v i t y bacc master TOTAL  27 4 7 38  Consultation  diploma bacc master TOTAL  1  153  T a b l e C.9 —  Continued  Category  L e v e l of N Educat i o n  Research  diploma bacc master TOTAL  13 4 3 20  1 1 1  20 7 5  5.3 3.7 2.6 4.6  6.0 2.7 2.0 5.0  3.0 2.0 2.0 2.0  10.6 11.0 9.0  Staff Development  diploma bacc master TOTAL  25 6 6 37  1 1 1  20 80 10  5.5 24.3 4.8 8.4  1  4.7 29.2 3.0 13.6  5.0 6.5 5.0 5.0  17.4 26.8 17.5  Writing for Publication  diploma bacc master TOTAL  1 1 3 4 18  1 1 1  40 6 5  6.5 2.6 3.0 5.1  11.4 2.8 2.3 9.0  3.5 1 .0 3.0 1 .5  10.0 8.5 8.7  Other  diploma bacc master TOTAL  9 4 3 16  2 1 3  65 20 80  27.2 7.7 33.6 23.5  20.2 8.3 40.8 23.4  27.0 5.0 18.0 19.0  9.7 5.2 9.0  M i n . Max.  SD  Mean  Median Avg. Rank  

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