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Analysis of certain factors in the deffusion of innovations in nursing practice in the public general… Du Gas, Beverly Witter 1969

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The U n i v e r s i t y of B r i t i s h  Columbia  FACULTY OF GRADUATE STUDIES PROGRAMME OF THE FINAL ORAL EXAMINATION FOR THE DEGREE OF DOCTOR OF EDUCATION of BEVERLY WITTER DUGAS B.A., U n i v e r s i t y o f B r i t i s h Columbia M.N., U n i v e r s i t y of Washington TUESDAY, AUGUST 5, 1969, AT 2:30 P.M. IN ROOM 241, GRADUATE STUDIES NEW ADMINISTRATION BUILDING COMMITTEE IN CHARGE Chairman:  J.S. Conway  G. C h r o n i s t e r A. De V r i e s  J . R. M c i n t o s h J . Niemi D. W i l l i a m s  E x t e r n a l Examiner: W i l s o n B. Thiede Department of A d u l t E d u c a t i o n U n i v e r s i t y of W i s c o n s i n Madison, W i s c o n s i n  Research Supervisor:  J . Niemi  AN ANALYSIS OF CERTAIN FACTORS IN THE DIFFUSION OF INNOVATIONS IN NURSING PRACTICE IN THE PUBLIC GENERAL HOSPITALS OF THE PROVINCE OF BRITISH COLUMBIA ABSTRACT L i t e r a t u r e on c o n t i n u i n g e d u c a t i o n f o r members of the h e a l t h p r o f e s s i o n s has s t r e s s e d t h a t u n d e r s t a n d ! of the d i f f u s i o n process i s fundamental to the development of sound e d u c a t i o n a l programs. The p r e s e n t study a n a l y z e s the p r o c e s s of d i f f u s i o n as i t f u n c t i o n s w i t h r e g a r d to changes i n n u r s i n g p r a c t i c e i n e i g h t y - f i v e p u b l i c g e n e r a l h o s p i t a l s of the p r o v i n c e of B r i t i s h C o l u m b i a . Three a s p e c t s of d i f f u s i o n were i n v e s t i g a t e d (1) the f l o w of new i n f o r m a t i o n i n n u r s i n g through the network of h o s p i t a l s ; (2) f a c t o r s a f f e c t i n g the a d o p t i o n of n u r s i n g i n n o v a t i o n s ; and (3) f a c t o r s i n f l u e n c i n g d e l a y i n the a d o p t i o n p r o c e s s , r e j e c t i o n of i n n o v a t i o n s , or t h e i r d i s c o n t i n u a n c e f o l l o w i n g a d o p t i o n . Emphasis was p l a c e d on the c h a r a c t e r i s t i c s of the h o s p i t a l and the r o l e of the D i r e c t o r of N u r s i n g i n the d i f f u s i o n p r o c e s s . R e l a t i v e t o the t h r e e a s p e c t s of d i f f u s i o n s t u d i e d , the f o l l o w i n g were found: (1) There appears t o be a d e f i n i t e process i n v o l v e c i n i n f o r m a t i o n - s e e k i n g by the D i r e c t o r s of N u r s i n g of the h o s p i t a l s i n c l u d e d i n the study and i d e n t i f i a b l e channels of communic a t i o n used by these n u r s e s . (2)  S p e c i f i c c h a r a c t e r i s t i c s of the p o p u l a t i o n tended t o be r e l a t e d t o e a r l i e r and l a t e r a d o p t i o n , and a d i s c e r n i b l e p a t t e r n was e v i d e n t i n the a d o p t i o n of i n n o v a t i o n s by members of the p a r t i c u l a r s o c i a l system under s t u d y .  (3)  F a c t o r s i n f l u e n c i n g d e l a y i n the a d o p t i o n p r o c e s s , r e j e c t i o n or d i s c o n t i n u a n c e of i n n o v a t i o n s were r e l a t e d b o t h t o the nature of the new p r a c t i c e and t o c h a r a c t e r i s t i c s of the i n d i v i d u a l s i n v o l v e d i n making the d e c i s i o n t o adopt or not adopt the i n n o v a t i o n .  C o n c l u s i o n s were drawn as t o the s e r i o u s n e s s of the problem i n v o l v e d i n communicating i n f o r m a t i o n on new ideas and p r a c t i c e s t o nurses i n B r i t i s h Columbia and s u g g e s t i o n s made o f some ways i n which t h i s problem might be r e s o l v e d . Areas i n d i c a t e d f o r f u r t h e r r e s e a r c h i n c l u d e : an i n v e s t i g a t i o n of the f l o w of i n f o r m a t i o n through the s o c i a l network o f nurses w i t h i n a h o s p i t a l ; an a n a l y s i s of the i n - s e r v i c e a s p e c t s of c o n t i n u i n g e d u c a t i o n f o r n u r s e s ; a study of the r o l e of change agents i n t h e n u r s i n g p r o f e s s i o n ; the e x t e n t o f the commercial salesman's i n f l u e n c e on the a d o p t i o n of n u r s i n g i n n o v a t i o n s ; and r e s e a r c h i n t o v a r i o u s a s p e c t s o f c o n t i n u i n g e d u c a t i o n programs f o r n u r s e s , such as a n a l y s i s o f p a r t i c i p a n t s , the e f f e c t i v e n e s s of the s h o r t , c o n t i n u i n g e d u c a t i o n c o u r s e , and the d e s i g n of e f f e c t i v e methods of i n s t r u c t i o n .  GRADUATE STUDIES F i e l d o f Study:  Adult  Education  (Introduction to Adult J . Niemi Education) E d u c a t i o n 514 (Foundations of A d u l t J. Niemi Education) E d u c a t i o n 516 (Mass Media and A d u l t J. Niemi Education) E d u c a t i o n 518 (Methods o f A d u l t C. Verner Education) E d u c a t i o n 583 (Comparative A d u l t H. R o b e r t s Education) E d u c a t i o n 590 ( C u r r e n t Trends i n J. Dennison Higher Education) L. Marsh P s y c h o l o g y 316 (Methods i n Research) A. De V r i e s A g r i c u l t u r a l Economics 403 (The O r g a n i z a t i o n of Rural Sociology) H. R o b e r t s  Educat i o n 412  A N A N A L Y S I S O F C E R T A I N F A C T O R S IN T H E D I F F U S I O N O F I N N O V A T I O N S IN N U R S I N G P R A C T I C E IN T H E PUBLIC G E N E R A L HOSPITALS O F T H E P R O V I N C E O F BRITISH C O L U M B I A  by B E V E R L Y W I T T E R DU GAS B . A . , U n i v e r s i t y of B r i t i s h C o l u m b i a , 1945 M . N . , U n i v e r s i t y of Washington, 1947  A DISSERTATION  S U B M I T T E D IN P A R T I A L F U L F I L M E N T O F  T H E REQUIREMENTS FOR T H E DEGREE O F DOCTOR O F EDUCATION In the F a c u l t y of Education  We accept this d i s s e r t a t i o n as r e q u i r e d standard  conforming^fep7the  T H E UNIVERSITY O F BRITISH C O L U M B I A August,  1969  In  presenting  an  advanced  the I  Library  further  for  degree shall  agree  scholarly  by  his  of  this  written  this  thesis  in  at  University  the  make  that  it  purposes  for  freely  permission may  representatives. thesis  partial  be  It  financial  for  is  British  by  the  understood  gain  Columbia  for  extensive  granted  of  The U n i v e r s i t y o f B r i t i s h V a n c o u v e r 8, Canada  of  available  permission.  Department  f u l f i l m e n t of  shall  reference  Head  be  requirements  Columbia,  copying  that  not  the  of  and  of my  copying  I agree  this  that  Study. thesis  Department or  for  or  publication  allowed without  my  DEDICATION  To my children,  Bud, B a r b a r a ,  David, Daniel  and Eden, w h o s e s u s t a i n i n g e n c o u r a g e m e n t a n d u n f a i l i n g a s s i s t a n c e made the completion of this study possible, work i s affectionately dedicated.  this  i  ABSTRACT  Literature on continuing education for members of the health professions has stressed that understanding of the diffusion process is fundamental to the development of sound educational programs. A review of the literature on diffusion suggests that the theoretical framework that has evolved concerning the transmission of information about new ideas and practices in other disciplines may be applied to nursing.  The present study analyzes the process of diffusion as it functions in regard to changes in nursing practice in a selected segment of Canadian hospitals.  Three aspects of diffusion are investigated:  ( 1 ) the flow of new information in nursing through a network of hospitals; (Z) factors affecting the adoption of new nursing practices; and (3) factors influencing delay in the adoption process, rejection of innovations, or their discontinuance following adoption.  The population consisted of eighty-five public general hospitals in the province of British Columbia.  An analytical survey method was  used and the structured interview technique employed to gather data from the Director of Nursing of each hospital.  ii Data relative to the flow of information were analyzed by calculating frequency and percentage distributions to assess the relative importance of sources of information used by the Directors of Nursing, and flow charts developed to illustrate the transmission of information through the network of hospitals.  Characteristics of the hospitals, of the Directors of Nursing, of the hospital administrators, and of the nursing staffs, with emphasis on the first two, were studied relative to the adoption of nine new practices in nursing. The hospitals were divided into four categories, according to size.  An adoption score for each hospital was computed,  based on the stage in the adoption process reached by the nurses for each of the nine innovations.  Using these scores, the hospitals were  divided into four adopter categories and characteristics of the population related to these.  Frequency and percentage distributions were again used to analyze factors influencing delay, rejection and discontinuance of innovations.  Significant findings in regard to the sources of information used by nurses were (1) the importance of interpersonal communication with colleagues; ( 2 ) the high ranking of continuing education programs as an initial source of new knowledge;  (3) the role of the hospital  supply house salesman in disseminating information to nurses, and (4) the decreasing importance of impersonal sources in later stages of the adoption process.  Two  c y c l e s o f i n f l u e n c e w e r e shown to be o p e r a t i n g i n the flow  o f i n f o r m a t i o n to n u r s e s i n t h e p r o v i n c e ;  the f i r s t d e r i v i n g f r o m the  m a j o r teaching and r e s e a r c h centers i n Vancouver;  the second,  from  the l a r g e r c e n t r a l l y l o c a t e d h o s p i t a l s i n d i s t r i c t s o f the p r o v i n c e .  Four  s e q u e n t i a l steps w e r e i d e n t i f i e d i n the t r a n s m i s s i o n o f i n f o r m a t i o n to nurses i n British Columbia.  The s p e c i f i c c h a r a c t e r i s t i c s of the p o p u l a t i o n w h i c h showed a r e l a t i o n s h i p to adoption included: 1.  size, teaching status, geographic location, and a c c r e d i t a t i o n of the h o s p i t a l ,  2.  age o f the D i r e c t o r of N u r s i n g ,  h e r m a r i t a l status, a c a d e m i c  preparation, professional nursing experience,  extent of  attendance at e d u c a t i o n a l m e e t i n g s , p a r t i c i p a t i o n i n p r o f e s s i o n a l n u r s i n g o r g a n i z a t i o n s , and s u b s c r i p t i o n to n u r s i n g j o u r n a l s . 3.  p r o f e s s i o n a l p r e p a r a t i o n and p r e s t i g e of the h o s p i t a l administrator,  4.  r e l a t i v e age of the n u r s i n g staff.  F a c t o r s i n f l u e n c i n g delay, r e j e c t i o n o r discontinuance  were  s h o w n t o be r e l a t e d b o t h t o c h a r a c t e r i s t i c s o f t h e n e w p r a c t i c e a n d to c h a r a c t e r i s t i c s of the i n d i v i d u a l s i n v o l v e d i n m a k i n g the d e c i s i o n to adopt i n n o v a t i o n s .  F r o m the findings of this study, it is evident that there is a s e r i o u s p r o b l e m in the communication of new i n f o r m a t i o n to n u r s e s employed in public general hospitals in B r i t i s h C o l u m b i a .  The p r o b l e m  is p a r t i c u l a r l y acute in r e g a r d to the n u r s e s in s m a l l hospitals.  It is suggested that a step towards r e s o l u t i o n of this p r o b l e m might be the development of a 'systems' approach to continuing education for n u r s e s .  T h i s approach could effectively u t i l i z e  r e s o u r c e s and facilities throughout the p r o v i n c e and p r o v i d e for c o ordination of a l l educational activities for n u r s e s .  An integral part  of the s y s t e m would be the development of information r e t r i e v a l centers in n u r s i n g to supplement continuing education p r o g r a m s i n the c o m m u n i c a t i o n of scientific i n f o r m a t i o n to n u r s i n g p r a c t i t i o n e r s .  A r e a s suggested for further r e s e a r c h include:  an investigation  of the flow of i n f o r m a t i o n through the s o c i a l network of n u r s e s within a hospital;  an analysis of the i n - s e r v i c e aspects of continuing education  for n u r s e s ;  a study of the r o l e of change agents in n u r s i n g ; the extent  of the c o m m e r c i a l s a l e s m a n ' s influence on the adoption of n u r s i n g innovations;  and r e s e a r c h into v a r i o u s aspects of continuing education  p r o g r a m s for n u r s e s , ness of the short,  such as an analysis of p a r t i c i p a n t s , the  continuing education course,  effective methods of i n s t r u c t i o n .  effective-  and the design of  V  T A B L E O F CONTENTS  CHAPTER I  Page 1  INTRODUCTION 1. S T A T E M E N T O F T H E P R O B L E M II. III.  PURPOSE O F T H E STUDY  4  ASSUMPTIONS  5  IV. P L A N O F T H E S T U D Y  C H A P T E R II  7  V. R E P O R T O F FINDINGS  24  FOOTNOTES  26  REVIEW OF T H E L I T E R A T U R E  29  I. T H E C O M M U N I C A T I O N P R O C E S S  30  II.  E L E M E N T S IN T H E PROCESS  DIFFUSION  in. T H E I N N O V A T I O N - D E C I S I O N PROCESS  C H A P T E R III  1  38  56  FOOTNOTES  59  POPULATION AND PARTICIPANTS  67  I. G E N E R A L I N F O R M A T I O N A B O U T T H E HOSPITALS II.  T H E D I R E C T O R S O F NURSING  68 74  in. T H E N U R S I N G S T A F F S O F T H E HOSPITALS  95  vi  CHAPTER III  Page IV.  V.  POLICIES O F T H E HOSPITALS WITH R E G A R D TO A T T E N D A N C E O F NURSES A T E D U C A T I O N A L MEETINGS  96  T H E NURSES VIEWPOINT ON EQUIPMENT AND PROGRESSIVENESS  97  FOOTNOTES  100  T H E FLOW O F INFORMATION ON N E W NURSING P R A C T I C E S  IV  "  102  SOURCES O F INFORMATION USED, B Y S T A G E S IN T H E A D O P T I O N PROCESS  102  SOURCES O F INFORMATION USED, BY N A T U R E OF ACTIVITY  112  SOURCES O F INFORMATION USED F O R S P E C I F I C INNOVATIONS  128  T H E FLOW O F INFORMATION THROUGH T H E NETWORK O F HOSPITALS  131  FOOTNOTES  157  F A C T O R S R E L A T E D TO ADOPTION  158  I.  CHARACTERISTICS OF T H E HOSPITAL  159  II.  CHARACTERISTICS O F T H E DIRECTOR O F NURSING  172  CHARACTERISTICS O F T H E ADMINISTRATORS  202  C H A R A C T E R I S T I C S O F T H E NURSING STAFF  206  FOOTNOTES  211  I.  II.  III.  IV.  V  III.  IV.  viii  LIST O F T A B L E S TABLE I  II  III  IV  V  VI  VII  VIII  Page P O P U L A T I O N O F H O S P I T A L S I N C L U D E D IN T H E STUDY BY SIZE AND GEOGRAPHIC LOCATION  10  L E V E L OF ACADEMIC PREPARATION OF PARTICIPANTS BY SIZE AND T E A C H I N G STATUS O F THE HOSPITAL  79  POST-BASIC EDUCATIONAL PROGRAMS T A K E N B Y D I R E C T O R S O F NURSING  80  CONTINUING E D U C A T I O N P R O G R A M S A T T E N D E D B Y PARTICIPANTS, B Y SIZE AND TEACHING STATUS O F HOSPITALS  83  A T T E N D A N C EO F PARTICIPANTS AT EDUCATIONAL MEETINGS OUTSIDE T H E P R O V I N C E IN T H E F I V E Y E A R S P R I O R T O T H E STUDY, B Y SIZE AND T E A C H I N G STATUS O F T H E HOSPITAL  84  A T T E N D A N C E OF PARTICIPANTS A T MEETINGS O F T H E L O C A L PROFESSIONAL NURSING ASSOCIATION, B Y SIZE A N D TEACHING STATUS OF T H E HOSPITAL  88  O F F I C E OR C O M M I T T E E M E M B E R S H I P O F P A R T I C I P A N T S IN T H E L O C A L P R O F E S SIONAL NURSING ASSOCIATION, B Y SIZE AND TEACHING STATUS O F T H E HOSPITAL  89  A T T E N D A N C EO F PARTICIPANTS A T MEETINGS O F T H E PROVINCIAL P R O F E S S I O N A L N U R S I N G A S S O C I A T ION, B Y S I Z E AND TEACHING STATUS O F T H E HOSPITAL  90  ix  Page  TABLE IX  X  XI  XII  XIII  XIV  XV  XVI  XVII  XVIII  XIX  XX  O F F I C E OR C O M M I T T E E MEMBERSHIP O F P A R T I C I P A N T S IN T H E P R O V I N C I A L P R O F E S S I O N A L NURSING ASSOCIATION, BY SIZE AND T E A C H I N G STATUS O F T H E HOSPITAL  91  A T T E N D A N C E OF PARTICIPANTS AT MEETINGS OF T H E NATIONAL PROFESSIONAL NURSING ASSOCIATION, B Y SIZE A N D TEACHING STATUS OF T H E HOSPITAL  92  O F F I C E OR C O M M I T T E E M E M B E R S H I P O F P A R T I C I P A N T S IN T H E N A T I O N A L P R O F E S SIONAL NURSING ASSOCIATION, B Y SIZE AND TEACHING STATUS OF T H E HOSPITAL  93  N U M B E R R E C E I V E D O F NURSING J O U R N A L S IN A D D I T I O N T O T H E C A N A D I A N N U R S E B Y PARTICIPANTS, BY SIZE AND T E A C H I N G STATUS O F T H E HOSPITAL  94  SOURCES O F INFORMATION USED BY P A R T I C I P A N T S A T A L L S T A G E S IN T H E ADOPTION PROCESS  102  SOURCES O F INFORMATION USED A T T H E AWARENESS STAGE  105  SOURCES O F INFORMATION USED AT T H E INTEREST STAGE  108  SOURCES O F INFORMATION USED A T T H E EVALUATION STAGE  109  SOURCES O F INFORMATION USED A T T H E TRIAL STAGE  111  SOURCES O F INFORMATION USED A T T H E ADOPTION STAGE  113  SOURCES O F INFORMATION USED BY P A R T I C I P A N T S A T S T A G E S IN T H E ADOPTION PROCESS, ACCORDING TO N A T U R E O F T H E ACTIVITY  114  SPECIFIC SOURCES O F INFORMATION USED BY PARTICIPANTS FOR E A C H INNOVATION  129  X  Page  TABLE XXI  XXII  XXIII  XXIV  XXV  XXVI  XXVII  XXVIII  XXIX  XXX  RANGE, F R E Q U E N C Y AND P E R C E N T A G E DISTRIBUTION O F SCORES O F P A R T I C I PATING HOSPITALS BY A D O P T E R C A T E G O R Y  160  GROUP M E A N ADOPTION SCORES O F H O S P I T A L S IN V A R I O U S A R E A S O F T H E PROVINCE  169  F R E Q U E N C Y A N D P E R C E N T A G E DISTRIBUTION O F P A R T I C I P A N T S IN E A C H A D O P T E R CATEGORY, BY NUMBER OF YEARS OF E X P E R I E N C E IN N U R S I N G  180  O F F I C E - H O L D I N G OR C O M M I T T E E M E M B E R SHIP O F P A R T I C I P A N T S IN L O C A L N U R S I N G ASSOCIATION, BY A D O P T E R C A T E G O R Y  195a  O F F I C E - H O L D I N G OR C O M M I T T E E M E M B E R SHIP O F P A R T I C I P A N T S IN P R O V I N C I A L NURSING ASSOCIATION, B Y A D O P T E R CATEGORY  197  A V E R A G E N U M B E R O F NURSING J O U R N A L S IN A D D I T I O N T O T H E C A N A D I A N N U R S E R E C E I V E D BY PARTICIPANTS, BY A D O P T E R CATEGORY  200  F R E Q U E N C Y AND P E R C E N T A G E O F PARTICIPANTS AT EACH STAGE O F T H E ADOPTION P R O C E S S F O R A L L INNOVATIONS, B Y ADOPTER CATEGORY  215  F R E Q U E N C Y AND P E R C E N T A G E O F PARTICIP A N T S IN E A C H R E S P O N S E S T A T E F O R A L L INNOVATIONS, B Y A D O P T E R C A T E G O R Y  217  F R E Q U E N C Y AND P E R C E N T A G E O F PARTICIP A N T S IN E A C H R E S P O N S E S T A T E F O R A L L INNOVATIONS  218  AUSTRALIAN L I F T : ADOPTIONS  222  xi  Page  TABLE XXXI  BOXING G L O V E MITT RESTRAINTS : ADOPTIONS  224  XXXII  ' C L O S E D G L O V E ' TECHNIQUE : ADOPTIONS  226  XXXIII  SHEEPSKIN P E L T S : ADOPTIONS  228  XXXIV  O P E N VISITING : A D O P T I O N S  230  XXXV  ELIMINATION O F T H E 6 a.m. ROUTINE : ADOPTIONS  TEMPERATURE 232  XXXVI  ELIMINATION O F DRAWSHEETS : ADOPTIONS  234  XXXVII  C O L O R E D DRESSES FOR WORKING WITH CHILDREN : ADOPTIONS  236  XXXVIII  DISPOSABLE SYRINGES : ADOPTIONS  238  XXXIX  S T A T E D REASONS F O R ADOPTION O F INNOVATIONS  242  S T A T E D REASONS F O R ADOPTION, D E L A Y , R E J E C T I O N OR DISCONTINUANCE A L L INNOVATIONS  245  REASONS GIVEN B Y PARTICIPANTS F O R D E L A Y , R E J E C T I O N AND DISCONTINUANCE O F INNOVATIONS, B Y A D O P T E R C A T E G O R Y  249  R E J E C T I O N O F INNOVATIONS B Y P A R T I C I P A N T S A T E A C H S T A G E IN T H E A D O P T I O N PROCESS, BY A D O P T E R C A T E G O R Y  251  XL  XLI  XLII  X L III  F R E Q U E N C Y A N D P E R C E N T A G E DISTRIBUTION O F P E O P L E I N V O L V E D IN T H E D E C I S I O N T O A D O P T INNOVATIONS  252  Xll  LIST O F FIGURES FIGURE 1  2  3  Page MAP O F BRITISH COLUMBIA SHOWING T H E L O C A T I O N O F HOSPITALS I N C L U D E D IN T H E STUDY  11  TROLDAHL'S TWO MODEL  36  CYCLES OF INFLUENCE  WOLPERT'S REGIONAL M O D E L O F INFORMATION DIFFUSION AND A C C E P T A N C E  38  4  A U S T R A L I A N L I F T - P A T T E R N O F ADOPTIONS  5  BOXING G L O V E MITT RESTRAINTS - P A T T E R N O F ADOPTIONS  133  'CLOSED GLOVE' T E C H N I Q U E - P A T T E R N O F ADOPTIONS  134  7  SHEEPSKIN P E L T S - P A T T E R N O F ADOPTIONS  135  8  O P E N VISITING HOURS - P A T T E R N O F ADOPTIONS  136  ELIMINATION O F 6 a. m. T E M P E R A T U R E ROUTINE - P A T T E R N O F ADOPTIONS  137  ELIMINATION O F DRAWSHEETS - P A T T E R N O F ADOPTIONS  138  C O L O R E D DRESSES IN PEDIATRICS - P A T T E R N O F ADOPTIONS  139  DISPOSABLE SYRINGES - P A T T E R N O F ADOPTIONS  140  BRITISH COLUMBIA H O S P I T A L ASSOCIATION DISTRICT O N E ; COMMUNICATION LINKS  145  BRITISH COLUMBIA H O S P I T A L ASSOCIATION DISTRICT TWO : COMMUNICATION LINKS  146  6  9  10  11  12  13  14  15  BRITISH COLUMBIA H O S P I T A L ASSOCIATION DISTRICT T H R E E : COMMUNICATION LINKS  132  147  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT FOUR COMMUNICATION LINKS :  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT F I V E : COMMUNICATION LINKS BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT SIX: COMMUNICATION LINKS BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT S E V E N : COMMUNICATION LINKS BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT EIGHT: COMMUNICATION LINKS DISTRIBUTION O F ADOPTION SCORES P E R C E N T A G E O F HOSPITALS IN E A C H A D O P T E R CATEGORY, BY SIZE O F HOSPITAL P E R C E N T A G E O F L A R G E HOSPITALS IN E A C H A D O P T E R CATEGORY, BY T E A C H I N G STATUS O F HOSPITAL P E R C E N T A G E O F HOSPITALS IN E A C H A D O P T E R CATEGORY, BY GEOGRAPHIC L O C A T I O N O F T H E HOSPITAL: SIX A R E A S O F T H E PROVINCE P E R C E N T A G E O F HOSPITALS IN E A C H A D O P T E R CATEGORY, BY GEOGRAPHIC L O C A T I O N O F T H E HOSPITAL: TWO DIVISIONS O F T H E PROVINCE P E R C E N T A G E O F HOSPITALS IN E A C H A D O P T E R CATEGORY, BY A C C R E D I T A T I O N STATUS O F T H E HOSPITAL PARTICIPANTS IN E A C H A D O P T E R CATEGORY: P E R C E N T A G E MEDIAN A G E OR LESS AND P E R C E N T A G E A B O V E T H E MEDIAN  PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES: P E R C E N T A G E WHO HAD G R A D U A T E D MORE THAN AND LESS THAN THIRTY YEARS AGO P E R C E N T A G E O F PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY CONTINUOUS E M P L O Y M E N T IN NURSING P E R C E N T A G E O F PARTICIPANTS IN E A C H A D O P T E R CATEGORY, BY T E N U R E IN P R E S E N T POSITION P E R C E N T A G E O F PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY M A R I T A L STATUS P E R C E N T A G E O F PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY N U M B E R O F CHILDREN O F PARTICIPANT P E R C E N T A G E O F PARTICIPANTS IN E A C H A D O P T E R CATEGORY, B Y A C A D E M I C L E V E L O F PARTICIPANTS P E R C E N T A G E O F PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY T Y P E O F F U R T H E R E D U C A T I O N A L PROGRAMS TAKEN PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES: P E R C E N T A G E WHO HAD A T T E N D E D NO CONTINUING EDUCATION PROGRAMS AND P E R C E N T A G E WHO HAD A T T E N D E D MORE THAN T H R E E P E R C E N T A G E O F PARTICIPANTS IN E A R L I E R AND L A T E R CATEGORIES, BY L O C A T I O N O F CONTINUING EDUCATION PROGRAMS ATTENDED  X V  FIGURE 37  Page P E R C E N T A G E O F PARTICIPANTS IN E A C H A D O P T E R CATEGORY, BY E X T E N T O F A T T E N D A N C E A T L O C A L PROFESSIONAL NURSING ASSOCIATION MEETINGS  194  P E R C E N T A G E O F PARTICIPANTS IN E A C H A D O P T E R CATEGORY, BY E X T E N T O F A T T E N D A N C E A T PROVINCIAL PROFESSIONAL NURSING ASSOCIATION MEETINGS  196  P E R C E N T A G E O F PARTICIPANTS IN E A C H A D O P T E R CATEGORY, BY E X T E N T O F A T T E N D A N C E A T NATIONAL PROFESSIONAL NURSING ASSOCIATION MEETINGS  199  P E R C E N T A G E O F PARTICIPANTS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY P E R C E P T I O N O F RADICAL CHANGES IN NURSING INTRODUCED IN H O S P I T A L  203  P E R C E N T A G E O F HOSPITALS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY P R E P A R A T I O N O F ADMINISTRATOR  205  P E R C E N T A G E O F HOSPITALS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES, BY ADMINISTRATOR'S A F F I L I A T I O N WITH AMERICAN C O L L E G E O F HOSPITAL ADMINISTRATORS  207  P E R C E N T A G E O F HOSPITALS IN E A R L I E R AND L A T E R A D O P T E R CATEGORIES,BY R E L A T I V E A G E O F T H E NURSING S T A F F  210  44  A U S T R A L I A N LIFT: C U M U L A T I V E ADOPTIONS  223  45  BOXING G L O V E MITT RESTRAINTS : C U M U L A T I V E ADOPTIONS  225  'CLOSED GLOVE' TECHNIQUE: C U M U L A T I V E ADOPTIONS  227  38  39  40  41  42  43  46  SHEEPSKIN P E L T S : C U M U L A T I V E ADOPTIONS O P E N VISITING: C U M U L A T I V E ADOPTIONS ELIMINATION O F 6 a . m . T E M P E R A T U R E ROUTINE: C U M U L A T I V E ADOPTIONS ELIMINATION O F DRAW SHEETS: C U M U L A T I V E ADOPTIONS C O L O R E D DRESSES IN PEDIATRICS: C U M U L A T I V E ADOPTIONS DISPOSABLE SYRINGES: C U M U L A T I V E ADOPTIONS TWO C Y C L E S O F I N F L U E N C E IN NURSING INFORMATION DISSEMINATION IN BRITISH COLUMBIA FOUR STEPS IN T H E DISSEMINATION O F INFORMATION ON NEW P R A C T I C E S TO NURSES IN BRITISH COLUMBIA - A HYPOTHETICAL MODEL  APPENDICES  S T A T I S T I C A L DATA ON HOSPITALS I N C L U D E D IN T H E STUDY T H E INTERVIEW S C H E D U L E 1.  M E T H O D O F ADMINISTRATION  2.  CHOICE O F TOOLS  3.  T H E INSTRUMENT  F R E Q U E N C Y AND P E R C E N T A G E O F PARTICIPANTS WHO HAD ADOPTED, DISCONTINUED AND R E J E C T E D T H E INNOVATIONS, BY A D O P T E R C A T E G O R Y  xviii  ACKNOWLEDGEMENTS  A d o c t o r a l d i s s e r t a t i o n i s the c u l m i n a t i o n of the e f f o r t s of n o t j u s t o n e i n d i v i d u a l , b u t o f m a n y . T h e a u t h o r w i s h e s t o a c k n o w l e d g e w i t h g r a t i t u d e the a s s i s t a n c e o f a l l t h o s e who c o n t r i b u t e d i n v a r i o u s w a y s t o the c o m p l e t i o n o f t h i s s t u d y .  F i r s t , there is Dr. Coolie Verner,  who p r o v i d e d the i n i t i a l  i n s p i r a t i o n , and gave i n v a l u a b l e a s s i s t a n c e i n d e s i g n i n g a n d p l a n n i n g the study.  Then, there i s Dr. John N i e m i ,  w h o w a s the p r i n c i p a l r e s e a r c h  a d v i s e r , a n d gave g e n e r o u s l y of h i s t i m e to p r o v i d e continued  guidance,  encouragement and support while this work was i n progress.  D r . A l c o r n De V r i e s m u s t a l s o b e c r e d i t e d f o r h i s h e l p i n d e v e l o p i n g a l o g i c a l a p p r o a c h to h a n d l i n g t h e d a t a g a t h e r e d d u r i n g t h i s s t u d y and f o r his guidance i n s u m m a r i z i n g  The Dr.  the f i n d i n g s .  a u t h o r w o u l d a l s o l i k e to thank D r . G l e n C h r o n i s t e r ,  Donald W i l l i a m s , a n d Dr.  of t h e d i s s e r t a t i o n c o m m i t t e e .  Stanley Blank, who p a r t i c i p a t e d as m e m b e r s  xix  The  a u t h o r i s a l s o i n d e b t e d t o D r . E v e r e t t M. R o g e r s ,  p e r s o n a l interest and counsel were deeply  The  whose  appreciated.  a s s i s t a n c e of the n u r s e s who p a r t i c i p a t e d i n t h i s  is gratefully acknowledged. Their co-operation,  and hospitality,  study  were  f r e e l y given, and their frank and explicit a n s w e r s to questions i n the interview schedule process  m a d e p o s s i b l e a f a c t u a l and r e a l i s t i c a n a l y s i s o f the  o f i n f o r m a t i o n f l o w t o n u r s e s i n the p r o v i n c e .  The  author w i s h e s to a c k n o w l e d g e a l s o the a s s i s t a n c e o f the  m e m b e r s o f the s t a f f o f t h e R e g i s t e r e d N u r s e s ' A s s o c i a t i o n o f B r i t i s h C o l u m b i a who made a v a i l a b l e facts and f i g u r e s e s s e n t i a l to this The  study.  n u r s i n g c o n s u l t a n t s o f the B r i t i s h C o l u m b i a H o s p i t a l I n s u r a n c e S e r v i c e  a n d the s t a f f o f the B r i t i s h C o l u m b i a H o s p i t a l A s s o c a t i o n a l s o p r o v i d e d m u c h n e e d e d i n f o r m a t i o n a b o u t the h o s p i t a l s i n c l u d e d i n the s t u d y , help i n this r e g a r d i s deeply  and their  appreciated.  It i s i m p o s s i b l e t o l i s t a l l o f the m a n y p e o p l e w h o h e l p e d i n the w o r k that went into t h i s study.  Their invaluable assistance i s  a c k n o w l e d g e d b y the a u t h o r w i t h g r a t e f u l t h a n k s t o a l l .  1  CHAPTER I  INTRODUCTION  C h a n g e h a s b e c o m e so r a p i d t h a t a d j u s t m e n t c a n n o t be l e f t t o t h e n e x t g e n e r a t i o n ; a d u l t s m u s t - n o t o n c e , but c o n t i n u a l l y - t a k e i n , a d j u s t t o , u s e , and m a k e i n n o v a t i o n s i n a s t e a d y s t r e a m of d i s c o v e r y a n d new c o n d i t i o n s . . . . No one w i l l l i v e a l l h i s l i f e i n t h e w o r l d i n t o w h i c h he w a s b o r n , a n d no one w i l l d i e i n t h e w o r l d i n w h i c h he w o r k e d i n h i s maturity. . . . In t h i s w o r l d , no one c a n ' c o m p l e t e an education'.  Dr.  I.  S T A T E M E N T OF  Margaret Mead  THE  PROBLEM  E d u c a t i o n f o r a p r o f e s s i o n c a n no l o n g e r be c o n s i d e r e d  as  l i m i t e d to the b a s i c p r e p a r a t i o n f o r p r a c t i c e i n a f i e l d .  Changes i n  s c i e n t i f i c k n o w l e d g e and t e c h n o l o g y h a v e i n c r e a s e d the  requirements  of p e r s o n a l  c o m p e t e n c e and i n t e n s i f i e d the p r o b l e m of o b s o l e s c e n c e of  2 k n o w l e d g e and s k i l l s i n a l l o c c u p a t i o n s and p r o f e s s i o n s .  The  need for  c o n t i n u o u s r e n e w a l o f l e a r n i n g as a b a s i s f o r p r o f e s s i o n a l p r a c t i c e i n n u r s i n g was  c l e a r l y e x p r e s s e d i n the s t a t e m e n t o f the A m e r i c a n  N u r s e s ' A s s o c i a t i o n to the e f f e c t that:  In n u r s i n g today. . . p r a c t i c e must be based on a continuously expanding and updated body of knowledge. New knowledge pertinent to n u r s i n g care accumulates rapidly; n u r s i n g r e s p o n s i b i l i t i e s grow i n c r e a s i n g l y complex; and changes i n health care concepts and therapies are continuous. ^ The r a p i d i t y with which new  knowledge and technology  are  becoming available i n the health sciences has caused a r e v o l u t i o n i n patterns of patient care, affecting not only n u r s i n g and m e d i c i n e but a l l of the p a r a m e d i c a l p r o f e s s i o n s as well.  One  of the m a j o r p r o b l e m s  today is that of keeping the p r a c t i t i o n e r up-to-date with the latest developments i n h i s field.  The t r a n s f e r of i n f o r m a t i o n f r o m the  scientist w o r k i n g i n r e s e a r c h to the individual p r a c t i s i n g i n the f i e l d i s a matter of m a j o r c o n c e r n for a l l educators, p r o f e s s i o n a l s i n v o l v e d i n health care.  T h i s c o n c e r n was  administrators,  and  4, 5, 6 ' '  s t r o n g l y v o i c e d at the Surgeon-General's  Conference on Health Communications h e l d i n Washington i n 1962, there was  wher  general agreement that s e r i o u s p r o b l e m s exist i n the  communication of scientific i n f o r m a t i o n to p r a c t i t i o n e r s in the health field.  It has been estimated that the total body of knowledge stemming  f r o m r e s e a r c h in the b i o - m e d i c a l sciences has m o r e than doubled i n the past twenty-five years.  T h i s has i n c r e a s e d the complexity  and  manageability of the i n f o r m a t i o n available and intensified the need for m o r e r a p i d and efficient means of communication.  7  3 The  m e m b e r s o f the S u r g e o n - G e n e r a l ' s C o n f e r e n c e stated, i n  t h e i r c o n c l u s i o n s , that:  In t h e f i n a l a n a l y s i s , t h e s o u n d e s t t r a n s f e r o f r e s e a r c h findings to active a p p l i c a t i o n i n health p r a c t i c e takes place i n an educational setting. . . . Thus a broad f r a m e w o r k p r o v i d i n g a purposeful and f o r m a l means for continuing education for physicians and other health p r a c t i t i o n e r s m u s t b e c o m e the b a s i c structure for communication between the frontier of science and the scene of p r a c t i c e i n the health community. . . . T h i s p r o c e s s , c o m p l i m e n t e d by an adequate s y s t e m of r e s o u r c e s f o r m a n a g e m e n t o f the p r o f e s s i o n a l l i t e r a t u r e and s u p p l e m e n t a r y adaptation of storage a n d r e t r i e v a l m e c h a n i s m s would achieve a significant advance i n health communications. ^  N u r s e s a r e acutely a w a r e that they m u s t know m o r e than they l e a r n e d i n their b a s i c n u r s i n g education p r o g r a m s i f they a r e to feel 9  competent i n caring for patients.  It h a s b e e n s a i d t h a t n u r s e s a r e  probably m o r e actively and extensively engaged i n continuing  education  10  than the m e m b e r s o f any other p r o f e s s i o n a l group. number of nurses enrolled in university baccalaureate  In Canada, the programs,  subsequent to i n i t i a l c o u r s e s i n d i p l o m a n u r s i n g s c h o o l s , has m o r e than doubled i n the past five years. ^  The p r o l i f e r a t i o n of w o r k s h o p s ,  institutes, and other short c o u r s e s for n u r s e s inthe past decade has been phenomenal. The  s i t u a t i o n i n n u r s i n g i s s i m i l a r to that i n m e d i c i n e ,  M c L a u g h l i n a n d P e n c h a n s k y r e p o r t that a l l k i n d s of techniques  where  have been  planned, offered, and evaluated i n the development of continuing  education  4  programs.  Y e t , t h e r e i s l i t t l e k n o w l e d g e a v a i l a b l e about the p r o c e s s e s  by w h i c h p h y s i c i a n s l e a r n o f new i n f o r m a t i o n that w i l l help t h e m i n t h e i r 12  p r a c t i c e o r the channels by which this i n f o r m a t i o n i s relayed.  In  d i s c u s s i n g the p r o b l e m of developing m o r e effective means of c o m m u n i c a t i o n to m e m b e r s o f the h e a l t h p r o f e s s i o n s , t h e m e m b e r s o f the S u r g e o n General's  C o m m i t t e e s e v e r a l t i m e s c o n s i d e r e d the q u e s t i o n o f c o m m u n i -  cation v e r s u s education.  T h e y c a m e to the c o n c l u s i o n that:  c o m m u n i c a t i o n and education a r e e l e m e n t s of on e p r o c e s s by which human states of knowledge, attitudes, and behaviour a r e m o d i f i e d and that any a r t i f i c a l s e p a r a t i o n o f the two w i l l i m p e d e t h e p r o g r e s s sought b y a l l . ^  In n u r s i n g , t h e r e h a s b e e n a s i n g u l a r l a c k o f r e s e a r c h o n t h e c o m m u n i c a t i o n o f new i n f o r m a t i o n , o r the d i f f u s i o n o f i n n o v a t i o n s , as the study o f t r a n s f e r o f i n f o r m a t i o n f r o m s c i e n t i s t to p r a c t i t i o n e r h a s been called.  II. P U R P O S E O F T H E  STUDY  It i s t h e p u r p o s e o f t h i s s t u d y to a n a l y z e t h e p r o c e s s o f d i f f u s i o n as i t functions w i t h r e g a r d to changes i n n u r s i n g p r a c t i c e i n a s e l e c t e d segment o f C a n a d i a n h o s p i t a l s , a n d to r e l a t e this to g e n e r a l r e s e a r c h a n d t h e o r y about i n f o r m a t i o n t r a n s m i s s i o n a n d the a c c e p t a n c e of i n n o v a t i o n s . investigated:  T h r e e a s p e c t s o f t h e d i f f u s i o n p r o c e s s w i l l be  5 1.  t h e flow o f i n f o r m a t i o n a b o u t n e w p r a c t i c e s i n n u r s i n g t h r o u g h a  network of hospitals; 2.  f a c t o r s affecting the adoption of n u r s i n g innovations, and  3.  f a c t o r s i n f l u e n c i n g d e l a y i n the adoption p r o c e s s ,  rejection of  new p r a c t i c e s , o r t h e i r discontinuance f o l l o w i n g adoption.  III.  ASSUMPTIONS  P r i o r to d e s i g n i n g a p l a n f o r conducting t h i s study,  certain  assumptions were made: 1.  T h e r e i s a definite and p r e d i c t a b l e p a t t e r n to the diffusion of inno-  v a t i o n s i n the n u r s i n g c o m m u n i t y . the s p e c i f i c channels  It s h o u l d b e p o s s i b l e , t h e n , t o i d e n t i f y  used by nurses  f o r the c o m m u n i c a t i o n of new  i n f o r m a t i o n and to t r a c e the flow of i n f o r m a t i o n through these 2.  channels.  The nature ofnursing innovations w i l l influence their i t i n e r a r y  t h r o u g h the s o c i a l s y s t e m o f n u r s i n g .  C h a r a c t e r i s t i c s o f the i n n o v a t i o n s  as p e r c e i v e d b y t h e D i r e c t o r o f N u r s i n g s h o u l d t h e r e f o r e be c o n s i d e r e d as f a c t o r s i n f l u e n c i n g t h e i r a c c e p t a n c e o r n o n - a c c e p t a n c e b y h o s p i t a l s . 3.  C e r t a i n c h a r a c t e r i s t i c s o f both the h o s p i t a l a n d the  personnel  e m p l o y e d i n a h o s p i t a l a r e r e l a t e d to the adoption of new n u r s i n g p r a c t i c e s . R e l a t i v e to the h o s p i t a l , these i n c l u d e : s i z e , t e a c h i n g status, location, and attainment of c e r t a i n standards  geographic  as e v i d e n c e d b y a c c r e d i -  tation. In r e g a r d to the p e r s o n n e l e m p l o y e d w i t h i n the h o s p i t a l ,  the  p r i n c i p a l i n d i v i d u a l s to be c o n s i d e r e d as f a c t o r s i n f l u e n c i n g a d o p t i o n of n u r s i n g innovations a r e the D i r e c t o r of N u r s i n g , the A d m i n i s t r a t o r of  6 t h e h o s p i t a l , a n d the n u r s i n g s t a f f . T h e  D i r e c t o r o f N u r s i n g i s the  a d m i n i s t r a t i v e h e a d o f the n u r s i n g d e p a r t m e n t o f a h o s p i t a l , and, f o r e , the p r i n c i p a l d e c i s i o n - m a k e r w i t h i n the h o s p i t a l .  there-  w i t h r e g a r d to n u r s i n g p r a c t i c e s  It i s a s s u m e d , t h e r e f o r e , t h a t she p l a y s a k e y  role  i n t h e a d o p t i o n o r r e j e c t i o n o f i n n o v a t i o n s i n n u r s i n g . It s e e m s l o g i c a l to s u p p o s e t h a t c h a r a c t e r i s t i c s o f t h i s i n d i v i d u a l a r e i m p o r t a n t f a c t o r s to be t a k e n i n t o a c c o u n t i n the a c c e p t a n c e o f new  nursing practices.  T h e s e c h a r a c t e r i s t i c s i n c l u d e p e r s o n a l a t t r i b u t e s s u c h a s age, status, and e d u c a t i o n a l attainment, s u c h as y e a r s o f n u r s i n g e x p e r i e n c e ,  marital  as w e l l as p r o f e s s i o n a l q u a l i t i e s a t t e n d a n c e at e d u c a t i o n a l m e e t i n g s ,  p a r t i c i p a t i o n i n p r o f e s s i o n a l n u r s i n g o r g a n i z a t i o n s , and p r o f e s s i o n a l reading habits. The  a d m i n i s t r a t o r i s the e x e c u t i v e h e a d o f the h o s p i t a l . H e  has  o v e r a l l r e s p o n s i b i l i t y f o r m a n a g e m e n t o f a l l d e p a r t m e n t s w i t h i n the h o s p i t a l a n d t h e a u t h o r i t y to m a k e f i n a l d e c i s i o n s c o n c e r n i n g  a l l aspects  of  i t s o p e r a t i o n . It i s a s s u m e d t h a t c h a r a c t e r i s t i c s o f t h e a d m i n i s t r a t o r , s u c h as h i s age,  p r o f e s s i o n a l p r e p a r a t i o n , and p r e s t i g e a m o n g other  admini-  s t r a t o r s w i l l a f f e c t t h e h o s p i t a l ' s a d a p t a b i l i t y t o c h a n g e i n r e g a r d to the n u r s i n g component of patient care. I n t h e f i n a l a n a l y s i s , i t i s t h e n u r s i n g s t a f f o f the h o s p i t a l who  imple-  m e n t i n n o v a t i o n s i n n u r s i n g p r a c t i c e . It i s a s s u m e d t h e n , t h a t c h a r a c t e r i s t i c s o f t h e n u r s e s s u c h as t h e i r age,  w h e r e they had taken t h e i r b a s i c  n u r s i n g p r o g r a m s a n d p o l i c i e s o f t h e h o s p i t a l w i t h r e g a r d to a t t e n d a n c e o f n u r s e s at e d u c a t i o n a l m e e t i n g s , w i l l a l s o i n f l u e n c e the a d a p t a b i l i t y of the h o s p i t a l to c h a n g e s i n n u r s i n g p r a c t i c e .  7  IV. P L A N O F T H E STUDY.  This study was designed to test the above assumptions in the nursing community of British Columbia, specifically among those nurses employed in public general hospitals in the province.  Hospitals in British Columbia are organized and operated under a Provincial Hospital Act.  This Act specifies three types of hospitals:  (1) public hospitals, which are operated as non-profit-making institutions primarily for the care of acute patients,  (2) private hospitals, which  include small public ones operated by industrial concerns principally for their employees, and nursing homes, as well as other privately  * owned and operated hospitals,  (3) rehabilitation,  chronic, and  convalescent hospitals. These are all operated as non-profit making institutions for the care of patients who will benefit from intensive 14 rehabilitative and extended hospital care. The hospitals included in this study were all public hospitals, as designated under the Hospital Act. The population consisted of all of these which provide general acute care for adults and children, including medical, surgical, obstetric and pediatric services, and admit both  The small public hospitals operated by industrial concerns and some of the nursing homes are non-profit making institutions. The remainder of the nursing homes and other privately owned hospital s are operated as business, concerns for profit.  8  male and female patients.  One small hospital, which was operated  as a satellite of another, larger hospital in the same area, was omitted from the study.  The number of public hospitals in British Columbia which offer generalized acute care services is eighty-six. These constitute the majority of hospitals in the province.  Omitting the one hospital which  is operated as a satellite of another, the total population was eighty-five hospitals. The participants in this study were the Directors of Nursing of the hospitals.  In selecting the population to be included in the study, sampling techniques were considered but a number of variables in regard to the hospitals made it difficult to obtain a representative sample. The size, for example, ranges from one hospital with nine beds to one with over 1, 600 beds. As for geographic location, twenty of the hospitals are clustered in the southwest corner of the province where three quarters of the population reside, while the remainder are scattered over the vast territory that comprises British Columbia. Although many hospitals are located in large urban centers, many more are in small rural communities, and some exist in relative isolation in remote parts of the province. The majority of the public general hospitals in the province are community or district hospitals, but a number are run by religious organizations (some as mission hospitals) and these differ from the  9 community-operated ones in financing, administration, and staffing.  Because of the difficulties involved in trying to obtain a sample that would be representative of the population and because the number of public general hospitals in the province is relatively small, the total population was used.  Table 1 shows the population of hospitals included in the study by size of hospital and geographic location.  Categorization of the  hospitals by size corresponds to that used by the British Columbia Department of Health Services and Hospital Insurance for large, 15 medium and small hospitals  with the exception that the small  hospitals were, for purposes of this study, subdivided into two groups; those with a bed capacity of thirty to seventy-four, and those with under thirty beds. Figure 1 is a map of British Columbia showing the location of the hospitals included in the study.  10  TABLE I  P O P U L A T I O N OF HOSPITALS I N C L U D E D IN THE BY SIZE AND  Geographic Location  GEOGRAPHIC  LOCATION  Type C 30-74 beds  6  7  4  -  17  Southern Interior  -  2  7  6  15  Central Interior  1  3  4  6  14  Northern Interior  1  3  7  2  13  Vancouver Island  3  2  7  3  15  Coastal Region  -  3  3  5  11  11  20  32  22  85  Mainland  Totals  Type D U n d e r 30 beds  Total  Type B 75-200 beds  Lower  Type A* 201 b e d s & over  STUDY,  * Six of the Type A h o s p i t a l s operate a s c h o o l of n u r s i n g and are, f o r p u r p o s e s o f t h i s study, d e s i g n a t e d as t e a c h i n g h o s p i t a l s . T h e s e a r e located:  3 i n the L o w e r M a i n l a n d a r e a , 2 on V a n c o u v e r Island, and 1  i n the C e n t r a l I n t e r i o r .  11  Type  C  hospitals  30 to 74 Type under  D hospitals 30  - '  beds  beds.  -  F I G U R E  1.  Map  of B r i t i s h  Showing Hospitals Study.  Columbia  the L o c a t i o n Included  in  of the  12  Sources of Data The Directors of Nursing of the hospitals included in the study were the primary source of data on: (1) characteristics of the hospital, the nursing and administrative personnel, and the community in which the hospital is located, (2) sources of information used in regard to changes in nursing practice, (3) the adoption of innovations in nursing.  Basic statistical information about the hospitals was obtained from the annual reports of the British Columbia Department of Health Services and Hospital Insurance. These reports provide data on bed capacity, daily patient average, staffing and facilities for all hospitals in the province.  Other reports of the Department and the British  Columbia Hospital Association were used for additional background information about the hospitals. The reports were supplemented by personal interviews with members of the nursing consultant staff of the Department and officials of the Hospital Association.  The records of the Registered Nurses' Association of British Columbia provided background data on the nursing community of the Province and also information about continuing educational programs for nurses sponsored by the Association and/or the University of British Columbia.  M e t h o d and  Techniques  An  a n a l y t i c a l s u r v e y m e t h o d was  o f d i f f u s i o n b y w h i c h new  information is transmitted  c o m m u n i t y of B r i t i s h C o l u m b i a .  The  t h e c o m m u n i t y o f g r a d u a t e n u r s e s who h o s p i t a l s o f the p r o v i n c e .  A  u s e d to i n v e s t i g a t e the p r o c e s s  The  i n the  nursing  social s y s t e m under study are  was  e m p l o y e d i n the p u b l i c  u n i t of a n a l y s i s was  s t r u c t u r e d i n t e r v i e w t e c h n i q u e was  general  the h o s p i t a l .  e m p l o y e d to g a t h e r data  f r o m the h e a d o f t h e n u r s i n g s t a f f o f e a c h h o s p i t a l .  C o n s t r u c t i o n of the I n s t r u m e n t An  i n t e r v i e w schedule was  d e s i g n e d to o b t a i n the  i n f o r m a t i o n f r o m the D i r e c t o r s of N u r s i n g . be f o u n d i n A p p e n d i x  The  desired  A c o p y of the s c h e d u l e  may  B.  f i r s t s e c t i o n dealt w i t h c h a r a c t e r i s t i c s of the D i r e c t o r of  N u r s i n g h e r s e l f a n d i n f o r m a t i o n a b o u t t h e h o s p i t a l , the c o m m u n i t y , n u r s i n g staff and a d m i n i s t r a t i v e  The  personnel.  s e c o n d s e c t i o n c o n c e r n e d t h e c h a n n e l s of c o m m u n i c a t i o n  u s e d b y t h e p a r t i c i p a n t s i n l e a r n i n g a b o u t new nursing.  the  i d e a s and p r a c t i c e s i n  F o r t h i s p a r t o f the s t u d y , a l i s t o f p o s s i b l e s o u r c e s o f i n f o r -  m a t i o n t h a t m i g h t be u s e d b y n u r s e s w a s s o u r c e s c i t e d by O r r ,  c o m p i l e d , b a s e d on the l i s t o f  B o e k a n d N e a l as b e i n g u s e d b y p h y s i c i a n s ,  IT  16  s u i t a b l e a d a p t a t i o n to n u r s i n g .  with  '  A d d i t i o n s to t h e l i s t w e r e m a d e  14  d u r i n g the c o u r s e o f t h e s t u d y as the D i r e c t o r s o f N u r s i n g other s o u r c e s they had found helpful.  The  suggested  f i n a l l i s t of s o u r c e s  reported  a s u s e d b y the n u r s e s i s s h o w n i n C h a p t e r I V .  The  t h i r d s e c t i o n of the i n t e r v i e w s c h e d u l e  dealt w i t h the  o f i n n o v a t i o n s i n n u r s i n g p r a c t i c e b y the p a r t i c i p a n t s .  Nursing  adoption  faculty  m e m b e r s a n d t h e s u p e r v i s o r y s t a f f s o f two o f the l a r g e t e a c h i n g h o s p i t a l s i n the L o w e r M a i n l a n d in nursing'.  The  a r e a w e r e c o n s u l t e d as t o 'what i s  l i t e r a t u r e was  a l s o r e v i e w e d to f i n d e x a m p l e s of  c h a n g e s i n n u r s i n g p r a c t i c e w h i c h m i g h t p r o v i d e i n s i g h t i n t o the by w h i c h i n f o r m a t i o n i s t r a n s m i t t e d . F r o m these s o u r c e s , f o u r t e e n i n n o v a t i o n s was  new  compiled  process  a l i s t of  f o r the p u r p o s e o f e x a m i n i n g the  diffusion process.  The  r e s u l t s of s t u d i e s i n other d i s c i p l i n e s s u c h as a g r i c u l t u r e  and e d u c a t i o n , h a v e i n d i c a t e d that the d i f f u s i o n p r o c e s s  u s u a l l y extends  18  o v e r a p e r i o d of y e a r s f o r any s i n g l e innovation.  Therefore,  e x a m p l e s o f c h a n g e s i n n u r s i n g p r a c t i c e w e r e s e l e c t e d to i n c l u d e s o m e which had been introduced i n hospitals i n this P r o v i n c e s e v e r a l years ago as w e l l as s o m e f a i r l y r e c e n t i n n o v a t i o n s . P r e v i o u s r e s e a r c h has  a l s o s h o w n t h a t the c h a r a c t e r i s t i c s o f a n 19  innovation influence its itinerary through a social system. t h r e e types of i n n o v a t i o n s w e r e i n c l u d e d . in nursing techniques;  One  Thus,  set c o n s i s t e d of changes  the s e c o n d , o f c h a n g e s i n n u r s i n g r o u t i n e s ;  and  15 the t h i r d , o f d i s p o s a b l e  equipment.  F i n a l s e l e c t i o n o f the innovations  was based on the following  c r i t e r i a : (1) t h e p r a c t i c e r e p r e s e n t s a c h a n g e o f c o n c r e t e a n d d e m o n s t r a b l e value i n nursing practice;  (2) t h e d e c i s i o n t o a d o p t o r r e j e c t t h e  innovation i s p r i m a r i l y a n u r s i n g m a t t e r rather than the r e s u l t o f changing m e d i c a l practice;  (3) t h e p r a c t i c e i s s u f f i c i e n t l y n o v e l n o t t o  be i n g e n e r a l u s e i n a l l h o s p i t a l s ;  a n d (4) t h e p r a c t i c e i s s u f f i c i e n t l y  g e n e r a l l y applicable as to w a r r a n t i t s u s e i n a l l h o s p i t a l s i n c l u d e d i n the study.  The following items were  selected:  Innovations i n N u r s i n g Techniques 1. T h e A u s t r a l i a n L i f t .  This i s a technique used for lifting  p a t i e n t s u p i n b e d b y t w o n u r s e s u s i n g b o d y m e c h a n i c s . It appears to have originated i n A u s t r a l i a , hence its name, although i t i s also s o m e t i m e s r e f e r r e d to as the New  Zealand  20 lift,  or the 'kiwi  1  lift.  2. B o x i n g G l o v e M i t t R e s t r a i n t s .  These are mitts  m a y be m a d e b y u s i n g g a u z e b a n d a g e s a n d d r e s s i n g or m a y be p u r c h a s e d c o m m e r c i a l l y .  which pads  They are used for  r e s t r a i n i n g confused patients f r o m p u l l i n g out catheters or other tubing without n e c e s s a r i l y r e s t r i c t i n g the m o v e m e n t o f l i m b s o r body. T h e s e have been u s e d f o r  a n u m b e r of years i n the c a r e of n e u r o s u r g i c a l and o p t h a l m i c patients but t h e i r u s e on the g e n e r a l m e d i c a l a n d s u r g i c a l wards and i n intensive care units i s f a i r l y recent. The idea 21 s e e m s to have o r i g i n a t e d i n G r e a t  Britain.  3. T h e ' C l o s e d G l o v e ' T e c h n i q u e i n t h e O p e r a t i n g  Room.  T h i s i s a method of 'gloving' w h i c h p r e c l u d e s touching of the s t e r i l e g l o v e s w i t h b a r e hands a n d a l s o e l i m i n a t e s the 22 need forpowdering gloves.  4. S h e e p s k i n P e l t s f o r S k i n C a r e .  These a r e used under  b e d - r i d d e n patients to a s s i s t i n the p r e v e n t i o n of decubitus ulcers.  They were first used i n Australia.  p e l t s w e r e u s e d but s y n t h e t i c p r o d u c t s w e r e  Initially,  real  subsequently  23 developed  and sold  commercially.  5. T h e U r o l o g y A d a p t o r - p r o t e c t o r .  This i sa small,  disposable i t e m c o n s i s t i n g of a s t e r i l e cover f o r drainage t u b i n g a n d a p l u g f o r a c a t h e t e r . It i s u s e d w h e n c a t h e t e r s are disconnected f r o m drainage tubing for any purpose. T h e i t e m o r i g i n a t e d i n one h o s p i t a l i n t h e U n i t e d S t a t e s as a m e a n s o f r e d u c i n g t h e i n c i d e n c e o f u r i n a r y i n f e c t i o n s in patients with retention catheters. The idea was p i c k e d up b y one of the h o s p i t a l s u p p l y houses, and the i t e m was p r o d u c e d on a c o m m e r c i a l b a s i s . ^  17  Changes in Nursing Routines 1. 'Open' Visiting.  It has been customary in the past for  hospitals to have set visiting hours when friends and relatives might come to see patients.  In recent years, a number of  hospitals have .lifted the restrictions on visiting and allow people to come and go more freely. The openness of the visiting varies, with some hospitals allowing visitors to come anytime between 2 and 8 p . m . and others permitting twentyfour hour open visiting on some nursing units. ^  2. Elimination of the 6 a. m. Temperature Routine.  It has  been traditional in most hospitals to awaken patients in the early morning to take their temperatures before the day staff come on duty. The accuracy of the temperature taken at this time and the necessity for taking the temperatures of all patients every morning have both been questioned and many hospitals are beginning to dispense with the routine.  26  3. Elimination of Drawsheets. A cotton drawsheet has been used traditionally on hospital beds for two reasons; it is easier to change than the bottom sheet and it covers the plastic or rubber drawsheet which serves to protect the mattress.  Today, with the availability of plastic covered  mattresses, the need for either a cotton or a rubber drawsheet  on the b e d s of m o s t p a t i e n t s i s questioned.  Many hospitals  h a v e e l i m i n a t e d d r a w s h e e t s a s a p a r t o f the s t a n d a r d b e d m a k i n g routine, using t h e m only where the need i s indicated.  4. U s e o f C o l o r e d D r e s s e s w h e n w o r k i n g w i t h C h i l d r e n .  27  Many  p s y c h o l o g i s t s and p e d i a t r i c i a n s have long advocated that n u r s e s or other people attending c h i l d r e n i n h o s p i t a l w e a r c o l o r e d dresses  o r s m o c k s i n s t e a d o f the t r a d i t i o n a l w h i t e  Since the n u r s e , o r other attendant,  uniform.  a l w a y s puts on a gown o r  s m o c k over h e r u n i f o r m when giving care to an infant or s m a l l child, the i d e a i s not n e c e s s a r i l y l i m i t e d to u s e i n hospitals which have a separate p e d i a t r i c unit.  It c a n a l s o  be u s e d i n s m a l l h o s p i t a l s w h e r e t h e r e a r e a d u l t s a n d c h i l d r e n o n the s a m e n u r s i n g u n i t .  The  use of Disposable The  Equipment  introduction of disposable equipment has saved a great  m a n y h o u r s o f n u r s i n g t i m e f o r m e r l y spent i n cleaning,  sterilizing,  and r e f u r b i s h i n g . T h e f o l l o w i n g i t e m s w e r e s e l e c t e d as r e p r e s e n t a t i v e o f the w i d e r a n g e o f ' d i s p o s a b l e s ' n o w o n t h e m a r k e t . b o t t l e s , (2) s y r i n g e s , (3) n e e d l e s , toothettes (disposable  (1) drainage  (4) m e d i c i n e c u p s , a n d (5)  toothbrushes).  F o u r of these items,  the drainage bottles, needles,  cups, and toothettes, plus the u r o l o g y adaptor-protector,  medicine  were later  19 e l i m i n a t e d f r o m the l i s t of innovations b e c a u s e i t was felt that undue weight was b e i n g g i v e n to the u s e of d i s p o s a b l e i t e m s .  One  e x a m p l e only, the d i s p o s a b l e s y r i n g e s , was r e t a i n e d as r e p r e s e n t a t i v e of t h e group.  Procedure E a c h of the e i g h t y - f i v e h o s p i t a l s i n c l u d e d i n the study  was  v i s i t e d b y the author and a p e r s o n a l i n t e r v i e w h e l d w i t h the D i r e c t o r of N u r s i n g .  T h e a m o u n t o f t i m e s p e n t i n a n y one h o s p i t a l w a s u s u a l l y  f r o m two to t h r e e h o u r s , i n c l u d i n g the t i m e taken f o r c o m p l e t i o n interview schedule  and a tour of the n u r s i n g units.  of the  B e c a u s e of the  d i s t a n c e s i n v o l v e d i n t r a v e l l i n g to s o m e of the h o s p i t a l s and the d i f f i c u l t y of s c h e d u l i n g v i s i t s to c o i n c i d e w i t h t i m e s when the D i r e c t o r of N u r s i n g w o u l d be a v a i l a b l e f o r i n t e r v i e w , the data g a t h e r i n g e x t e n d e d o v e r a s e v e n a n d one h a l f m o n t h p e r i o d , f r o m J u n e 1, 15,  1 9 6 8 , to J a n u a r y  1 9 6 9 . Since there was a d i f f e r e n c e i n t i m e of s e v e r a l months  b e t w e e n v i s i t s t o t h e v a r i o u s h o s p i t a l s , J u n e 1, c u t - o f f date f o r adoption o f i n n o v a t i o n s .  If adoptions had o c c u r r e d  t h a t date, t h e s t a g e i n t h e a d o p t i o n p r o c e s s be t r i a l ,  r a t h e r than adoption,  I 9 6 8 was u s e d as the after  reached was considered to  to equate w i t h those h e s p i t a l s v i s i t e d  e a r l y i n the study.  The D i r e c t o r s of N u r s i n g of a l l of the h o s p i t a l s w e r e v e r y c o o p e r a t i v e and no r e q u e s t f o r i n t e r v i e w was  refused.  20 Analysis of Data The total population of public general hospitals in the province was used.  The findings represent facts and characteristics of the  population as they were at that particular point in time when the study was undertaken.  Using the data gathered during interview,  three related aspects  of the diffusion process was analyzed; (1) the flow of new information in nursing through the network of public general hospitals in the province; (2) factors affecting adoption, namely, characteristics of the population including both the hospital and the personnel employed within the hospital; and (3) factors influencing delay in the adoption process, rejection of new practices, or their discontinuance following adoption.  The Flow of Information through the Hospitals Data gathered on the sources of information used by the Directors of Nursing were analyzed in four ways, on the basis of; (1) use of sources by stages in the adoption process; (2) use  of  sources by nature of the activity involved in the source; (3) specific sources used for each of the innovations included in the interview schedule;  and (4) the patterns of communication between the hospitals.  In classifying the sources of information by nature of the activity involved in the source, four categories were used;  (1)  impersonal sources, or mass media; (2) participation in short, continuing education programs; (.3) attendance at professional meetings and (4) personal sources, or interpersonal communication.  Frequency and percentage distributions  were calculated to  assess the importance of various sources of information at different stages of the adoption process and also the relative use of each of the four categories of sources. Flow charts were employed to trace the transfer of information about the specific innovations studied and the communication links between hospitals, as reported by the participants  Factors Affecting the Adoption of Innovations Most studies on adoption and diffusion have attempted to assess the relationship between characteristics of a population and adoption of innovations.  Specific characteristics of the participants  are usually correlated with 'innovativeness as determined by an 1  adoption score. Various techniques have been used to arrive at the adoption score depending on the nature and purpose of the study.  The majority of workers have used the concept of adoption or non-adoption as the basis for awarding points to determine adoption  * In computing percentages, the figures were rounded off to the nearest whole number, because the data did not warrant more detailed statistical treatment.  22 scores.  Some have given a bonus for early adoption while others have  . 29 not.  Rogers, Havens and Cartano suggest an 'innovativeness scale  1  using sten scores based on adoption or non-adoption with weighting for earlier adoption of each item and allowance for those innovations which do not apply to a particular respondent.  30  In a recent study done in an urban school system in Western Canada on the relationship between adoption of new practices and characteristics of the principal and the school, Holdoway and Segel used three indices of innovativeness; number of innovations adopted; extent of use of the new practices; and time of adoption, to develop a measure of the tendency towards early adoption.  31  Still other studies have used the degree of adoption concept as the basis for a scale to measure the extent of diffusion of an innovation through a social system.  In this method, points are awarded for  each stage in the adoption process reached by the participants for the various new practices and these points are totalled to give an adoption score for each respondent.  32, 33  Because this study is focused primarily on the diffusion process, that is, the extent to which information about new ideas and practices has spread throughout the community of nurses in the province, rather than the innovativeness of the participants per se, the concept of degree of  adoption was used in calculating the adoption score for the hospitals included in the study.  The stage in the adoption process reached by  the Director of Nursing for each innovation was assessed and points awarded as follows; 0 for non-awareness, 1 for awareness, 2 for interest, 3 for evaluation, 4 for trial, and 5 for adoption.  These points were  totalled to give an adoption score for each hospital.  F r o m the scores thus obtained, the hospitals were divided into four adopter categories following Rogers' suggestion of innovators and early adopters as the top sixteen per cent, early majority, the next thirty-four per cent, late majority, the following thirty-four per cent, 34 and delayed adopters, the lowest sixteen per cent. Specific characteristics of the hospital, the Directors of Nursing, the Administrator, and the nursing staff were studied in relation to adoption, using the adoption score of the hospital as the dependent variable. The technique used to assess relationships between the dependent variable and characteristics of the population was to determine the Group Mean Adoption Score of hospitals possessing specific characteristics and the proportionate distribution of these hospitals in each of the four adopter categories, to discern observable trends.  Factors Influencing Delay, Rejection, and Discontinuance Factors influencing delay in the adoption process, rejection of new practices, or their discontinuance following adoption were analysed  24 in  the f o l l o w i n g m a n n e r ;  innovation-response  F i r s t , the p r o g r e s s t o w a r d s a d o p t i o n a n d the  s t a t e o f t h e p a r t i c i p a n t s f o r a l l o f the i n n o v a t i o n s  w e r e a s s e s s e d to s e e i f t h e r e w e r e d i f f e r e n c e s b e t w e e n categories.  adopter  T h e n , t h e p a t t e r n of a d o p t i o n f o r e a c h o f t h e n i n e i n n o v a t i o n s  w e r e d e t e r m i n e d by p l o t t i n g adoptions a g a i n s t t i m e to see i f t h i s v a r i e d f o r the d i f f e r e n t i t e m s . adoption process,  T h i r d l y , the s t a t e d r e a s o n s f o r d e l a y i n the  r e j e c t i o n or d i s c o n t i n u a n c e of i n n o v a t i o n s w e r e  a n a l y z e d both i n r e l a t i o n to adopter  c a t e g o r y a n d t o the c h a r a c t e r i s t i c s  o f t h e i n n o v a t i o n a s p e r c e i v e d b y the D i r e c t o r s o f N u r s i n g .  P e r c e i v e d c h a r a c t e r i s t i c s of the i n n o v a t i o n s w e r e d e t e r m i n e d b y a n a l y z i n g the r e a s o n s g i v e n b y the D i r e c t o r s o f N u r s i n g f o r a d o p t i o n of the new  p r a c t i c e s , i f these had been a c c e p t e d and put into p r a c t i c e .  F i n a l l y , t h e i n d i v i d u a l s i n v o l v e d i n m a k i n g the d e c i s i o n t o a d o p t the various innovations were identified.  F r e q u e n c y and p e r c e n t a g e d i s t r i b u t i o n s w e r e c a l c u l a t e d f o r a n a l y s i s o f t h e d a t a u s e d i n the f o u r s t e p s o u t l i n e d a b o v e .  In a d d i t i o n ,  g r a p h s w e r e e m p l o y e d to p l o t n u m b e r o f a d o p t i o n s a g a i n s t t i m e ,  to  p r o v i d e a g r a p h i c r e p r e s e n t a t i o n of the data.  V.  R E P O R T OF  FINDINGS  T h i s s t u d y w i l l be r e p o r t e d on i n s i x s e c t i o n s :  C h a p t e r II w i l l d i s c u s s the t h e o r e t i c a l f r a m e w o r k on w h i c h  diffusion studies have been based in other d i s c i p l i n e s , through a review of r e l a t e d l i t e r a t u r e .  Chapter III w i l l be a d e s c r i p t i v e chapter which  discusses  c h a r a c t e r i s t i c s of the graduate n u r s e s employed in the public g e n e r a l hospitals of B r i t i s h C o l u m b i a and the institutions in which they work.  Chapter IV w i l l report, on the analysis of data gathered on the flow of information  on new  n u r s i n g p r a c t i c e s through the network of  hospitals included in the study.  Chapter V w i l l discuss factors r e l a t e d to adoption of innovations in n u r s i n g p r a c t i c e .  Chapter VI w i l l r e p o r t on the analysis of factors r e l a t e d to delay in the adoption p r o c e s s , r e j e c t i o n of new  p r a c t i c e s , or their  discontinuance following adoption.  Chapter VII w i l l present a final s u m m a r y of the findings and d i s c u s s i m p l i c a t i o n s of the study.  26  CHAPTER I  FOOTNOTES  1. M a r g a r e t Mead, quotation cited in The L e a f and the L a m p (Ottawa, The Canadian N u r s e s ' A s s o c i a t i o n , 1968), p. 3. 2. B u r t o n R. C l a r k , "Knowledge, Industry and A d u l t s " S o c i o l o g i c a l Backgrounds of Adult Education, Robert W. Burns, editor, (Chicago: Center for the Study for L i b e r a l Education for Adults, 1964), p. 1. 3. "Avenues for Continued L e a r n i n g , " A m e r i c a n J o u r n a l of N u r s i n g , 67:6:1217-19, (June, 1967), p. 1217. 4. John F. M c C r e a r y , " E d u c a t i o n of Health P e r s o n n e l , " Canadian J o u r n a l of P u b l i c Health, 25:10:124-30, (October 1964). 5. Ruth P e r k i n s Kuehn, "Continuing Education in Nursing, " The J o u r n a l of the A m e r i c a n M e d i c a l A s s o c i a t i o n , 190:554-5, (December 1964). 6. C u r t i s P. M c L a u g h l i n and Roy Penchansky, " D i f f u s i o n of Innovations i n Medicine: A P r o b l e m of Continuing M e d i c a l Education, " J o u r n a l of M e d i c a l Education, 40:437-447, (May 1965). 7. Surgeon-General, U. S. P u b l i c H e a l t h Service, Conference on H e a l t h Communications, November 5-8, 1962 (Washington, D. C. : U. S. P u b l i c Health Service, Department of Health, E d u c a t i o n and Welfare, 1963), p. 1. 8. Ibid. p. 26. 9. "Avenues for Continued L e a r n i n g , " op. cit. pp.  1217-1219-  10. W. H. E l k i n s , "Education i s Continuous, " N u r s i n g Outlook, 61:9:243-45, ( A p r i l 1961), p. 243. 11. Countdown 1968 (Ottawa: The Canadian N u r s e s ' A s s o c i a t i o n , 1969), p. 58."  27 12. M c L a u g h l i n and Penchansky,  op. cit. p. 439.  13. Surgeon-General, op. cit. p. 33. 14. H o s p i t a l Insurance Service, Reference M a t e r i a l on the B r i t i s h C o l u m b i a H o s p i t a l Insurance S e r v i c e for the P e r i o d J a n u a r y 1st, 1949 to J a n u a r y 1st, 1963 ( V i c t o r i a : B r i t i s h C o l u m b i a Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance), p. 2. 15. Report on H o s p i t a l Statistics and A d m i n i s t r a t i o n of the H o s p i t a l A c t for the Y e a r Ended D e c e m b e r 31, 1967 ( V i c t o r i a : B r i t i s h C o l u m b i a Department of Health S e r v i c e s and H o s p i t a l Insurance, 1969), p. 26. 16. R i c h a r d H. D. O r r and Walter E. Boek, A n Annotated B i b l i o g r a p h y of Studies on the Flow of M e d i c a l Information to P r a c t i t i o n e r s (New Y o r k : Institute for the Advancement of M e d i c a l Communication, 1961). 17 H e l e n M. Neal, Better Communication for Better H e a l t h (New Y o r k : National H e a l t h Council, distributed by C o l u m b i a P r e s s , 1966). 18. Infra. Chapter II, pp. 48-50. 19. Infra. Chapter II, pp. 40-42. 20. T h i s technique i s demonstrated i n a f i l m entitled " L i f t i n g and Moving Patients, P a r t 1, " distributed by the Canadian F i l m Institute, Ottawa. 21. F r o m p e r s o n a l c o r r e s p o n d e n c e with D. Rose, Orthopedic Equipment Company, Inc., Bourbon, Indiana, dated M a y 12, 1969. 22. H. L . B r o o k s and V. T. Rockwell, "Simple P r o c e d u r e for p r o c e s s i n g and donning S u r g i c a l Rubber Gloves: C l o s e d Glove Technique, " O R Nursing, 2: 41 (July-August, 1961). 23. "Sheepskin P e l t s for Skin Care, " The Canadian Nurse, 59:11:1059, (November 1963). 24. H a r o l d A. MacKinnon, " U r i n a r y Drainage: The P r o b l e m of A s e p s i s , " A m e r i c a n J o u r n a l of Nursing, 65:8;112 (August 1965).  28 25. E l i z a b e t h Barnes, "Changing H o s p i t a l Attitudes, " International J o u r n a l of H o s p i t a l Studies 1963-66, (Oxford: P e r m a g o n P r e s s ) , pp. 11-16. 26. S h i r l e y B e l l , " E a r l y M o r n i n g T e m p s ? , " A m e r i c a n J o u r n a l of N u r s i n g , 69:4:764-7. (May, 1969.)  Outlook,  27. Ruth P. Strykker, "The 13:4: ( A p r i l , 1965).  E l i m i n a t i o n of Drawsheets, " N u r s i n g  28. "Smocks A l i v e , " A m e r i c a n J o u r n a l of Nursing, 68:2:254 ( F e b r u a r y 1968). 29. E v e r e t t M. R o g e r s and L. E d n a Rogers, "A Methodological A n a l y s i s of Adoption Scales, " R u r a l Sociology, 26:4:325-336 ( D e c e m b e r 1961). 30. E v e r e t t M. Rogers, A. Eugene Havens and David G. Cartane, The C o n s t r u c t i o n of Innovativeness Scales ( M i m e o B u l l e t i n A E 330, A publication f r o m O h i l A g r i c u l t u r a l Department Station R e s e a r c h P r o j e c t H a r c h 166, "The C o m m u n i c a t i o n P r o c e s s and the Adoption of F a r m and Home Practices") 31. E. A. Holdoway and John E. Seger, "The Development of Indices of Innovativeness, " Canadian Education and R e s e a r c h Digest, 8:4:366-79 (December 1968). 32. John M. Welch,"An E v a l u a t i o n of T h r e e Adult Education Methods for D i s s e m i n a t i n g T r a d e Information to M i s s o u r i Restaurant O p e r a t o r s " ( T a l a h a s s i e : unpublished d o c t o r a l dissertation, F l o r i d a State U n i v e r s i t y , 1961). 33. C o o l i e V e r n e r and P e t e r M. Gubbels, The Adoption or Rejection of Innovations by D a i r y F a r m O p e r a t o r s i n the L o w e r F r a s e r V a l l e y (Ottawa; The A g r i c u l t u r a l E c o n o m i c s R e s e a r c h C o u n c i l of Canada, 1967). 34. F r o m p e r s o n a l correspondence dated M a r c h 10, 1969.  with Dr. E v e r e t t M.  Rogers,  29  C H A P T E R II  REVIEW O F T H E L I T E R A T U R E  The effective communication of new ideas and technology has been a major area of interest and the focus of a considerable amount of research in many disciplines in recent years.  The diffusion studies,  as they are called, are concerned specifically with the transmission of new ideas to members of a social system.  A s such, they are now con-  sidered a subset of research in the general field of communication,which includes investigation of the transfer of message units of all kinds from one individual, or group of individuals, to another.  The concept of diffusion as a particular branch of communications has led to a convergence of the theories pertaining to both communication and diffusion.  Studies on the general nature of communi-  cations have contributed substantially to understanding of the process involved in the specific transfer of new knowledge from its source of origin to the members of a particular social system.  30 This chapter w i l l discuss theories and pertinent r e s e a r c h v a r i o u s d i s c i p l i n e s such as a g r i c u l t u r e , m a r k e t i n g , education cine, i n r e g a r d to:  (1) t h e c o m m u n i c a t i o n s p r o c e s s ,  d i f f u s i o n a n d (3) t h e i n d i v i d u a l i n n o v a t i o n . d e c i s i o n  1. T H E C O M M U N I C A T I O N  from  and m e d i -  (2) e l e m e n t s i n  process.  PROCESS  Early Theories M u c h o f o u r k n o w l e d g e o f how new i d e a s a r e t r a n s m i t t e d h a s c o m e f r o m i n v e s t i g a t i o n s o f the i n f l u e n c e o f the m a s s m e d i a i n o u r society.  R e s e a r c h i n t h i s a r e a b e g a n i n t h e 1920's s h o r t l y a f t e r t h e  introduction of radio.  T h e 'model' o f s o c i e t y w h i c h a p p e a r s to have b e e n  p o p u l a r l y h e l d at that t i m e was that o f a l a r g e a t o m i s t i c m a s s of people, e a c h one r e a d y a n d w a i t i n g to r e c e i v e a m e s s a g e f r o m a p o w e r f u l and i n f l u e n t i a l m e d i u m , be i t r a d i o , n e w s p a p e r o r m o t i o n p i c t u r e .  The  m e d i a w e r e s e e n b y s o m e a s g r e a t p o t e n t i a l s o u r c e s o f good,  b y o t h e r s as f o r c e s o f e v i l . widespread.  B e l i e f i n their a l l - p o w e r f u l influence was  T h i s b e l i e f was consistent with the p r e v a i l i n g t h e o r i e s of  s o m e s o c i a l p s y c h o l o g i s t s o f the l a t e n i n e t e e n t h a n d e a r l y t w e n t i e t h c e n t u r i e s who s a w i n t h e t r e n d t o w a r d s u r b a n i z a t i o n a n d i n d u s t r i a l i z a t i o n a probable breakdown of i n t e r p e r s o n a l c o m m u n i c a t i o n and subsequent control of society by a remote, impersonal source.  2  31 The  Two-Step F l o w  Hypothesis  E a r l y m a s s m e d i a r e s e a r c h d u r i n g t h e 1920's a n d concentrated principally in three areas:  1930's  was  audience r e s e a r c h , that i s ,  who  m a d e up t h e n e w s p a p e r - r e a d i n g , r a d i o - l i s t e n i n g , o r m o v i e - g o i n g p u b l i c ; content a n a l y s i s , what s o r t s of m a t e r i a l a p p e a r e d i n the m e d i a ;  and 3  i m p a c t , o r effect, a n a l y s i s , what k i n d of i n f l u e n c e d i d the m e d i a have.  The  f i n d i n g s o f an i m p a c t / e f f e c t a n a l y s i s g a v e the f i r s t i n d i c a -  t i o n of n e e d f o r r e v i s i o n of the p o p u l a r l y h e l d i m a g e of a s i n g l e , s o c i e t y v u l n e r a b l e to p o w e r f u l o u t s i d e i n f l u e n c e s .  A  mass  s t u d y done b y  L a z a r f e l d a n d o t h e r s o n t h e r o l e o f the m a s s m e d i a i n i n f l u e n c i n g v o t i n g b e h a v i o r i n t h e 1940 that the way  P r e s i d e n t i a l c a m p a i g n i n the U n i t e d States r e v e a l e d  an i n d i v i d u a l c a s t h i s v o t e on e l e c t i o n d a y w a s  due m o r e to  t h e i n f l u e n c e o f o t h e r p e o p l e t h a n to a n y m e s s a g e d e l i v e r e d t h r o u g h t h e m a s s m e d i u m of r a d i o . ^  It s h o w e d t o o t h a t s o m e p e o p l e i n a c o m m u n i t y w e r e m o r e influential than their fellows i n persuading way.  These people L a z a r f e l d t e r m e d  F l o w of C o m m u n i c a t i o n " was  1  o t h e r s to v o t e i n a p a r t i c u l a r  o p i n i o n l e a d e r s ' and a " T w o - S t e p  h y p o t h e s i z e d to t h e e f f e c t t h a t :  I n f l u e n c e s s t e m m i n g f r o m the m a s s m e d i a f i r s t r e a c h o p i n i o n l e a d e r s who, i n t u r n , p a s s on w h a t t h e y r e a d a n d h e a r d to t h o s e o f t h e i r e v e r y d a y associates for w h o m they are influential. 1  S i n c e L a z a r f e l d , et a l , p u t f o r t h t h i s i d e a , s t u d i e s h a v e b e e n done o n t h e f l o w o f i n f o r m a t i o n t h r o u g h the c h a n n e l s o f c o m m u n i c a t i o n i n a  32  number of widely differing fields including agriculture, m a r k e t i n g and s p e c i a l interest fields of women.  medicine,  The Two-Step  hypothesis has p r o v i d e d the basic f r a m e w o r k for diffusion r e s e a r c h i n a l l of these areas.  Reports f r o m these studies have c o n f i r m e d that  i n t e r p e r s o n a l r e l a t i o n s h i p s and the p e r s o n a l communications stemming f r o m t h e m are m o r e important than any other items in influencing decision-making.  The Decatur Study of suburban housewives (1945-46) which i n q u i r e d into the r o l e of p e r s o n a l influence i n d e c i s i o n - m a k i n g i n such m a t t e r s as fashions, movie-going,  public a f f a i r s and marketing, showed,  among other things, that people talk most of a l l to people like them7 selves.  T h i s finding R o g e r s and Shoemaker consider one of the b a s i c  p r i n c i p l e s of human communication and they state that: In a free choice situation, when a source can i n t e r a c t with any one of a number of r e c e i v e r s , there i s a tendency for h i m to select a r e c e i v e r who i s most l i k e himself. ^ The t e r m 'homophily' was used by L a z a r f e l d and M e r t o n to d e s c r i b e the degree to which people tend to interact with others of s i m i l a r attributes, beliefs and value system,  education and s o c i a l  status.^  T h i s tendency appears to be important in the adoption of new ideas and p r a c t i c e s .  Coleman, M e n z e l and Katz, r e p o r t i n g on the  findings of a study on the adoption of a new  drug by p h y s i c i a n s (1957)  stated that the extent of a doctor's communications with his colleagues, or, as they put it, his integration into the community of doctors, had a d i r e c t bearing on the time it took h i m to p r e s c r i b e a new drug. ^  In  the Saskatchewan study on the diffusion of innovations among f a r m e r s (1966) it was demonstrated that the most important factor influencing the d e c i s i o n for continued use of a new p r a c t i c e was "talking with other farmers".  Opinion L e a d e r s h i p  - towards a T h e o r y of Influence  Much r e s e a r c h during the 1940's and 1950's was d i r e c t e d towards the people who exert influence i n a s o c i a l culture. T h e s e a r e the people t e r m e d 'opinion l e a d e r s ' by L a z a r f e l d , B e r e l s o n ,  and Gaudet,  and efforts were made to identify these individuals through such t e c h n i ques as s o c i o m e t r i c analysis, the use of k e y informants to name 12 opinion l e a d e r s , and also through self-designating devices.  It was o r i g i n a l l y thought that opinion l e a d e r s acted m o r e o r l e s s as ' gatekeepers ' of information and much r e s e a r c h has gone into identifying the c h a r a c t e r i s t i c s of opinion l e a d e r s in any community. Studies have shown that opinion l e a d e r s a r e to be found on e v e r y l e v e l 13 of society and are v e r y m u c h l i k e the people whom they influence. T h e i r l e a d e r s h i p appears to be r e l a t e d to three f a c t o r s : the p e r s o n i fication of c e r t a i n values held by a p a r t i c u l a r s o c i a l culture, that i s , who they are;  their competence, or, what they know; and their strategic  s o c i a l location , whom they know. ^'  It i s w e l l k n o w n t h a t o p i n i o n l e a d e r s a r e m o r e e x p o s e d  generally  t o t h e m a s s m e d i a t h a n t h e p e o p l e w h o m t h e y i n f l u e n c e ,and a l s o t h e y a r e m o r e s p e c i f i c a l l y exposed to content r e l a t e d to t h e i r p a r t i c u l a r  sphere  of i n f l u e n c e .  How  opinion l e a d e r s exert their influence has also been a matter  of m u c h concern.  The Decatur Study of suburban B o s t o n  housewives  s u g g e s t e d that i n t e r a c t i o n was i n i t i a t e d b y the f o l l o w e r s who sought out  17 acknowledged  leaders foradvice.  A study by M e r t o n of l o c a l and  c o s m o p o l i t a n i n f l u e n t i a l s p r o v i d e s an a l t e r n a t i v e suggestion, that the i n f l u e n t i a l s i n a c o m m u n i t y seek out those l e s s i n f o r m e d a n d use news  18 as a c o m m o d i t y i n e x c h a n g e f o r i n c r e a s e d p r e s t i g e . The informations e e k i n g - s o u g h t r e l a t i o n s h i p i s f e l t t o be t h e e l e m e n t a l s o c i a l s t r u c t u r e through which interpersonal communication  T r o l d a h l puts forth an i n t e r e s t i n g how the i n t e r a c t i o n i s effected.  occurs.  1  19  balance ' t h e o r y to explain  He suggests that new i n f o r m a t i o n , i f  it i s inconsistent with p r e v i o u s knowledge, upsets the i n t e r n a l balance of a person's attitudes and b e h a v i o r p a t t e r n s . The i n d i v i d u a l , i n an attempt to r e s t o r e balance, seeks the o p i n i o n s o f o t h e r s to help h i m e i t h e r to fit the new i n f o r m a t i o n into h i s e x i s t i n g b e h a v i o r a n d v a l u e  .  20  systems o r to r e j e c t it.  It i s i m p o r t a n t , as h a s b e e n b o r n e o u t i n m a n y s t u d i e s , t h a t  21, 22 t h e s o u r c e o f i n f o r m a t i o n be c o n s i d e r e d b o t h c r e d i b l e a n d r e l i a b l e .  T r o l d a h l feels that t h e r e a r e two groups i n any c o m m u n i t y , the f o l l o w e r s and the l e a d e r s .  The f o l l o w e r s seek advice f r o m people like themselves  w h i l e l e a d e r s t e n d to seek t e c h n i c a l l y a c c u r a t e i n f o r m a t i o n  sources,  23 s u c h as p r o f e s s i o n a l i n t e r m e d i a r i e s .  The  Multi-Step The  Flow  o r i g i n a l ' two-step ' flow o f c o m m u n i c a t i o n theory  p o s t u l a t e d b y L a z a r f e l d , et a l h a s u n d e r g o n e m o d i f i c a t i o n o v e r t h e y e a r s as r e s e a r c h h a s s h e d f u r t h e r l i g h t o n the s u b j e c t .  Troldahl  feels now that there i s a one-step flow o f i n f o r m a t i o n and a two-step 24 flow of influence.  H i s m o d e l o f the t w o c y c l e s o f i n f l u e n c e i s  s h o w n i n F i g u r e 2. involved:  R o g e r s suggests,  too, that t h e r e a r e two p r o c e s s e s  one i s the t r a n s f e r o f i n f o r m a t i o n , the s e c o n d i n v o l v e s the 2 5  spread ofinfluence. R e s e a r c h o n the u s e o f i n f o r m a t i o n s o u r c e s h a s s h o w n that information may come f r o m many places.  Followers may become aware  of new k n o w l e d g e f r o m the m a s s m e d i a , f r o m c o m m e r c i a l agents o r a good m a n y other sources i n addition to p e r s o n a l contact with those  v.h i g hv i•n i• n Af l u e n c e .  2  6  '  2  7  W o l p e r t , i n a s t u d y o n the d i s s e m i n a t i o n o f i n f o r m a t i o n t o f a r m e r s i n S w e d e n , p o i n t s o u t t h a t the p r o c e s s o f c o m m u n i c a t i o n i n v o l v e s not o n l y the s i m p l e t r a n s m i s s i o n o f m e s s a g e u n i t s but a l s o  The F i r s t C y c l e of Influence  Professional Intermediaries  Awareness  Mediated Communication  Comprehension  Opinion Leaders  T h e Second C y c l e of Influence Mediated Communication  Awareness  Comprehension e.  Followers  Opinion Leaders F I G U R E 2. T r o l d a h l " s Two C y c l e s of Influence M o d e l  A s shown in W e r l i n g C . T r o l d a h l , " A F i e l d T e s t of a Modified ' T w o - S t e p F l o w of C o m m u n i c a t i o n ' M o d e l , " P u b l i c Opinion Q u a r t e r l y 30:609-623 (Winter 1966-67), p. 614.  37  the social interaction between members of a population.  In tracing the  flow of information on new farm practices over a relatively large area he used a 'multi-step process of diffusion » hypothesis to explain the process.  1.  He found that there were five steps involved:  The information originated in a specific area in Stockholm where teaching and research activities were concentrated.  2.  The information was transferred to central offices in Stockholm for dissemination.  3.  F r o m these central offices, it was sent out to local county agencies.  4.  The information was then directed to the larger farmers in the major agricultural districts. This was not intentional but occurred because these people belonged more to the a g r i cultural associations and also sought out information from the county agent.  5.  There followed an intra-county diffusion through the remainder of the community of farmers.  On the basis of his findings, Wolpert suggested a modified version of the Two-Step Flow model  (Figure 3) showing two stages in  the communication process: 1.  The external flow - - from the experts to the farmers. The  speed of this depends on two factors: a) the potential of membership  EXTERNAL  Regional Diffusion Receipt Rate  PROCESS  Information Accessibility  K  Membership Potential  Information ' Effective Demand  Unit V i a b i l i t y  Area 1  Local Information Vector  Source Credibility  X  Acceptability to Recipient  Local Acceptance Rate  INTERNAL PROCESS F I G U R E 3. W o l p e r t ' s Regional M o d e l of Information Diffusion and A c c e p t a n c e A s shown in J u l i a n Wolpert, " A Regional Simulation M o d e l of Information Diffusion", Opinion Q u a r t e r l y , 30:597-608 (Winter 1966-67), p. 604.  Public '  39  in local agricultural societies;  a n d b ) the d e m a n d f o r i n f o r m a t i o n ,  b a s e d o n t h e n u m b e r o f l a r g e f a r m e r s i n the a r e a .  2. T h e  i n t e r n a l f l o w t h r o u g h the f a r m e r s .  T h i s , he  felt,  d e p e n d e d on t h r e e p r o b a b i l i t y r u l e s : a) t h e l i k e l i h o o d t h a t f a r m e r s w o u l d d i r e c t i n f o r m a t i o n to o t h e r f a r m e r s i n t h e i r own  category  b) t h e l i k e l i h o o d t h a t i n f o r m a t i o n r e c e i v e d w o u l d be believed c) t h e l i k e l i h o o d t h a t l a r g e r f a r m e r s w o u l d n e e d l e s s c o n t a c t w i t h new  information before accepting i t 28  than s m a l l e r  farmers.  It w o u l d a p p e a r , t h e n , t h a t t h e p r o c e s s o f c o m m u n i c a t i o n  can  no l o n g e r be c o n s i d e r e d a s i m p l e t w o - s t e p t r a n s f e r o f i n f o r m a t i o n f r o m e x p e r t to o p i n i o n l e a d e r t o l e s s a c t i v e m e m b e r s o f a c o m m u n i t y . I n s t e a d , one m u s t a c c e p t t h a t t h e r e a r e two involved:  one,  distinct  processes  the t r a n s f e r of i n f o r m a t i o n ( or m e s s a g e u n i t s ) ,  o t h e r , the s p r e a d o f i n f l u e n c e .  the  Instead of a two-step diffusion pattern,  t h e r e i s , r a t h e r a ' m u l t i - s t e p ' flow of c o m m u n i c a t i o n .  II. E L E M E N T S N T  THE  DIFFUSION PROCESS  K a t z d e f i n e d d i f f u s i o n r e s e a r c h as the s t u d y o f " t h e o f an i t e m o v e r t i m e ,  adoption  by units of adoption, l i n k e d together by channels  40  of communication, social structure and a system of values ",  29  Rogers and Shoemaker consider that there are four essential elements in the diffusion process: (1) the innovation, (2) the communication channels (3) the time involved and (4) the social system.  30  (  The Innovation An innovation is defined as an "idea, practice, or object that 31 is perceived as new by an individual. "  The actual length of time  since the idea was first used is not the important aspect.  Rather,  it  is that the individual sees it as a new idea or practice, and, therefore, 32 it is an innovation to him. Fliegel and Kivlin pointed to a lack of research on the v a r i a bility of the innovation as one weakness in the majority of studies on diffusion and suggested that differences in the item which is being transmitted are important variables in its diffusion.  33  The idea that the innovation itself constitutes a variable and that a classification of innovations on the basis of common characteristics should be done was put forth as early as 1922 when Ogburn divided inventions into two categories, material and non-material,  but  the amount of research that has gone into systematically classifying innovations has been limited.  34  41  K a t z suggested one c l a s s i f i c a t i o n for items on the basis of their attributes of communicability, p e r v a s i v e n e s s , r i s k s i n v o l v e d and r e v e r s i 35 bility.  R o g e r s used a c l a s s i f i c a t i o n based on the potential adopter's  p e r c e p t i o n of the new  idea with r e g a r d to: relative advantage over p r e -  v i o u s l y used p r a c t i c e s ;  compatability with existing values and experience;  complexity of the idea; its d i v i s i b i l i t y for t r i a l purposes;  and its  36 communicability.  R o g e r s and Shoemaker now  use the t e r m ' t r i a l -  ability' i n p r e f e r e n c e to ' d i v i s i b i l i t y for t r i a l purposes' and also suggest the w o r d 'observability' be used to denote the v i s i b i l i t y of r e s u l t s of an 37 innovation i n s t e a d of the l e s s p r e c i s e t e r m 'communicability'. Havens (1961) investigated the effect of the subjective definition of a situation by potential adopters on the rate of adoption of a new practice.  farm  T h e y found that when individuals see a situation as p r e s e n t i n g  no alternatives to adoption, acceptance of the innovation  occurs regard-  l e s s of other factors.  B r a n d n e r and K e a r l (19 64) studied the effect of congruence (or s i m i l a r i t y ) with other p r a c t i c e s p r e v i o u s l y adopted on the rate of adoption.  T h e y found this to be h i g h l y significant i n that f a r m e r s  who  had p r e v i o u s l y adopted h y b r i d seed corn adopted h y b r i d sorghum m o r e 39 r a p i d l y than those who  had not.  42  F l i e g a l and K i v l i n i n their study to c o r r e l a t e the rate of adoption of m o d e r n f a r m p r a c t i c e s with the f a r m e r s ' p e r c e p t i o n of the innovation, found that innovations which were the most rewarding and least r i s k y were adopted most r a p i d l y and that d i r e c t contribution of the innovation to the m a j o r occupational interest of the individual enhanced adoption.  On the other hand, high costs were not a brake to  adoption in the r e l a t i v e l y high income l e v e l community studied, nor were complexity of the p r a c t i c e o r p e r v a s i v e n e s s of consequences significant.  In the f i e l d of education, two recent studies a r e noteworthy., C a m a r e n (1966) investigated the attributes of innovations as v a r i a b l e s influencing differentiation i n the s o c i a l i t i n e r a r y of new p r a c t i c e s .  He  found the diffusion of innovations to be the r e s u l t of a complex set of elements, one of which i s the nature of the innovation, its attributes with r e g a r d to costs, d i v i s i b i l i t y , i n t r i n s i c and e x t r i n s i c rewards, 41 p e r v a s i v e n e s s , compatability and l e g i t i m a c y .  Another study by  K o h l (1966) found that the attributes of an innovation were significantly c o r r e l a t e d with c r i t i c a l stages of the adoption p r o c e s s .  Complexity and  d i v i s i b i l i t y were important at the interest stage, as w e l l as compatability with existing p r a c t i c e s and values. The compatability42 factor was the single most significant element at the adoption stage.  Communication  Channels  The O r i g i n a l Source and Agents conveying i n f o r m a t i o n New  ideas may  f r o m an outside source.  originate within a s o c i a l s y s t e m or may  enter  In the case of s c i e n t i f i c or t e c h n o l o g i c a l  information, the source i s u s u a l l y a r e s e a r c h scientist, opinion l e a d e r 43 or change agent.  M i l e s takes the view that an innovation i s a change 44  which i s d e l i b e r a t e l y planned.  A n agent wishing to effect a change  often delegates the task of t r a n s m i t t i n g the m e s s a g e to a s p e c i f i c i n d i v i d u a l c a l l e d a 'change agent , defined by R o g e r s as "a p r o f e s s i o n a l 1  p e r s o n who  attempts to influence decisions i n a d i r e c t i o n he feels i s 45  desirable".  R o g e r s c o n s i d e r s the change agent; to be the link  between two s o c i a l s y s t e m s and feels that the extent of a change agent's p r o m o t i o n a l efforts is d i r e c t l y r e l a t e d to the rate of adoption of an innovation. In f a r m i n g , two types of change agents have been identified, the extension s p e c i a l i s t , and the county a g r i c u l t u r a l agent.  M a n y of the  e a r l y studies i n r u r a l s o c i o l o g y dealt with the r o l e and functions of the county agent. A study by A r m s t r o n g (1959) analyzed county agent 47 activities and the adoption of s o i l - b u i l d i n g p r a c t i c e s , I960 completed a comprehensive  and M c H e n r y i n  analysis of the functions and teaching  methods of the county a g r i c u l t u r a l agent and the extension s p e c i a l i s t . He found that, while the basic function of both was to d i s s e m i n a t e i n f o r m a t i o n on new knowledge, the methods used were different, the  specialist concentrating more on mass media communication, while the county agents emphasized individual contacts.  48  In medicine, the chief research concerning agents in the communication process has been on the role of the 'detail man', or drug salesman, in influencing the adoption of new drugs by physicians.  Much  of the work in this area has been in marketing research by commercial firms interested in the sale of drugs. A comprehensive study of the role of the detail man in affecting decisions of doctors to adopt an 'ethical' innovation was, however, undertaken by Rehder at Stanford 49  University and reported in his doctoral dissertation  (1961).  The drug  salesman appears to be a key link in the communications process of transmitting information about new drugs to practising physicians. It is interesting to note that, in a recent study of the diffusion process in Saskatchewan farming communities, the role of a commercial agent, the farm dealer, in the communications process was noted and it was felt that the influence of this individual should be given more attention in diffusion and adoption studies in agriculture.  50  Troldahl uses the term 'professional intermediaries ' to designate the conveyors of ' technically accurate ' information^iting as examples the county agricultural agent, the scientist and the . ,  commercial agent.  51  45  E i c h h o l z a n d R o g e r s p o i n t to a l a c k o f c h a n g e a g e n t s i n the e d u c a t i o n a l f i e l d to p r o m o t e new diffusion  o f new  i d e a s as one o f the r e a s o n s f o r the  k n o w l e d g e i n the s c h o o l s y s t e m . T h e  slow  school principal  i s p r o b a b l y m o r e a k i n to t h e c o u n t y a g r i c u l t u r a l a g e n t i n p o s i t i o n as a c o m m u n i c a t i o n s l i n k b e t w e e n two E i c h h o l z , i t was  s o c i a l s y s t e m s but, i n a s t u d y d o n e b y  f o u n d t h a t o n l y one out o f f i v e p r i n c i p a l s a c t e d as a  52 change agent.  The  amount of i n f l u e n c e of a d m i n i s t r a t i v e p e r s o n n e l  i n b r i n g i n g about changes i n a s c h o o l s y s t e m was  investigated i n studies  done t h r o u g h t h e D e p a r t m e n t of C u r r i c u l u m a n d T e a c h i n g University's Teachers' College.  It w a s  at C o l u m b i a  found that s c h o o l p r i n c i p a l s  w e r e v e r y i n f l u e n t i a l i n the d i f f u s i o n p r o c e s s ;  supervisors, while having  l e s s d i r e c t a u t h o r i t y than p r i n c i p a l s , often had c o n s i d e r a b l e influence; w h i l e the s c h o o l superintendent,  i n m a n y i n s t a n c e s , h a d the m o s t 53 p o w e r f u l i n f l u e n c e of any single p a r t i c i p a n t . I n n u r s i n g , a d e v e l o p m e n t i n r e c e n t y e a r s h a s b e e n the r i s e o f t h e ' n u r s e c o n s u l t a n t ' w h o s e f u n c t i o n i s t o a d v i s e the s t a f f o f h o s p i t a l s and a g e n c i e s on i m p r o v e d m e t h o d s i n n u r s i n g p r a c t i c e and administration. This individual may  be a t t a c h e d to a p r o f e s s i o n a l  o r g a n i z a t i o n o r g o v e r n m e n t a g e n c y a n d a p p e a r s t o a s s u m e m u c h the s a m e r o l e as t h e e x t e n s i o n s p e c i a l i s t i n a g r i c u l t u r e .  She  might,  t h e r e f o r e , be c a t e g o r i z e d a s a 'change agent', a c c o r d i n g to R o g e r s ' d e f i n i t i o n o f the t e r m , o r a s a ' p r o f e s s i o n a l i n t e r m e d i a r y ' b y An  Wolpert.  e a r l y s t u d y b y F r a z i e r (1953) o u t l i n e d a g u i d e f o r c o n s u l t a n t s i n  the n u r s i n g e d u c a t i o n  field.  The  M e c h a n i s m by w h i c h the M e s s a g e i s  Transmitted  The  channels through which i n f o r m a t i o n i s r e l a y e d have been  the s u b j e c t of a g r e a t d e a l of r e s e a r c h i n a l l d i s c i p l i n e s c o n c e r n e d w i t h diffusion.  P r a c t i c a l l y a l l s t u d i e s h a v e i n c l u d e d a s u r v e y o f how  the  potential adopters  f i r s t h e a r d of i n n o v a t i o n s and the r e l a t i v e i m p o r t a n c e  of v a r i o u s s o u r c e s  of i n f o r m a t i o n i n i n f l u e n c i n g t h e i r d e c i s i o n to adopt  o r not adopt an i n n o v a t i o n .  R o g e r s c a t e g o r i z e d the c h a n n e l s of c o m m u n i c a t i o n into impersonal  sources  Impersonal sources  of i n f o r m a t i o n and p e r s o n a l  two:  communication.  i n c l u d e a l l c o m m u n i c a t i o n s v i a the m a s s m e d i a ,  and c o n s t i t u t e a r a p i d , one-way, and e f f i c i e n t m e a n s of d i s p e n s i n g information.  T h e s e a r e f e l t to be m o s t i m p o r t a n t i n the e a r l y s t a g e s  of the adoption p r o c e s s .  P e r s o n a l communications (or interpersonal)  i m p l y a face-to-face two-way exchange process  which is more likely  55 to i n f l u e n c e b e h a v i o r w h e n j u d g m e n t o f a n i n n o v a t i o n i s b e i n g m a d e .  A n e s s e n t i a l f a c t o r i n the use of i n f o r m a t i o n s o u r c e s i s w h e t h e r the s o u r c e i s both a c c e s s i b l e and r e l i a b l e .  Leuthold mentions  t h a t t h e m o s t s i g n i f i c a n t f i n d i n g o f t h e s t u d i e s done i n S a s k a t c h e w a n o n the t r a n s f e r o f i n f o r m a t i o n to f a r m e r s w a s  that " f a r m e r s '  inter-  p e r s o n a l c o m m u n i c a t i o n w i t h one a n o t h e r i s a m o r e m e a n i n g f u l f a c t o r  56 for c o n t i n u e d use (of an innovation) than any other f a c t o r s t u d i e d " .  47  I n the m e d i c a l field, both i m p e r s o n a l and p e r s o n a l s o u r c e s of i n f o r m a t i o n have been investigated. Caplow and Raymond, i n one of the e a r l i e s t m e d i c a l studies, examined the role p l a y e d by v a r i o u s methods of communication i n p e r s u a d i n g p h y s i c i a n s to adopt a new  pharmaceutical  57 product.  O r r and Boek identify as one of the m a j o r groups of studies  on communication to physicians, those dealing with channels of communication.  T h e y l i s t as communication channels used by p h y s i c i a n s :  post-graduate courses, conferences and meetings,  exhibits, colleagues,  motion p i c t u r e s , sound r e c o r d i n g s , radio, television, journals, detail 58 men, and d i r e c t m a i l . N e a l adds books and publications of 59 i n s u r a n c e and drug companies, also health agencies, to the l i s t . Reports of the studies c o n f i r m the findings of r u r a l sociologists that i m p e r s o n a l communications are important i n the e a r l y stages of the adoption p r o c e s s , while p e r s o n a l contact with p e e r s i s m o r e l i k e l y to affect the d e c i s i o n to adopt i n the later stages. In education, M o r t suggested that the e a r l y slow diffusion p e r i o d for innovations i n educational p r a c t i c e was communication.  i n p a r t due to lack of  Much has been done subsequently to find new  and  i m p r o v e d methods of communicating i n f o r m a t i o n about r e s e a r c h findings in education and a number of p e r i o d i c a l s bearing such titles as Exchange, C e n t r a l Ideas, and Know-How were e s p e c i a l l y designed for this purpose,  62 in addition to the m o r e s c h o l a r l y educational r e s e a r c h journals.  48  O n the subject of channels of communication, the m e m b e r s of the S u r g e o n - G e n e r a l ' s Committee on C o m m u n i c a t i o n s in the Health F i e l d stated that, i n their opinion, continuing education p r o g r a m s p r o v i d e the best means for the c o m m u n i c a t i o n of scientific i n f o r m a t i o n to health practitioners.  In n u r s i n g , there has been a m a r k e d i n c r e a s e in the number of continuing education p r o g r a m s offered, in recent y e a r s .  and m u c h i n t e r e s t in this field  R e s e a r c h undertaken to date, however,  has been  p r i n c i p a l l y c o n c e r n e d with the i n - s e r v i c e aspects of continuing education. One study by N o r r i s (1955) suggested content for an i n - s e r v i c e p r o g r a m for n u r s e t e a c h e r s  64  educational  while another by Straut (1964) r e p o r t e d  on i n c r e a s e d job satisfaction of n u r s e s following p a r t i c i p a t i o n in an i n service program.  65  A recent study by P r i c e (1965) analyzed the  p e r c e i v e d l e a r n i n g needs of n u r s e s in an attempt to a s s e s s content for 66 m-service programs.  Time Rate of Adoption It has been demonstrated that the adoption of new ideas or p r a c t i c e s within a s o c i a l s y s t e m follows a definite and predictable pattern. Initially, there is a slow e a r l y diffusion p e r i o d during which the idea is t r i e d out by a s m a l l group. T h e r e follows a p e r i o d of r a p i d a c c e l e r a t i o n when it is accepted by the m a j o r i t y and culminates in  49  another r e l a t i v e l y slow p e r i o d of time for the few r e m a i n i n g m e m b e r s of the s y s t e m to adopt as w e l l . The diffusion curve often takes on a typical  1  S ' shape when it is plotted on a c u m u l a t i v e basis or follows  the b e l l - s h a p e d c u r v e of n o r m a l distribution when done on a n o n cumulative b a s i s .  67,68,69  T h e amount of time r e q u i r e d for the total p r o c e s s is u s u a l l y a matter of s e v e r a l y e a r s .  In f a r m i n g ,  it has been found that even  r e l a t i v e l y s i m p l e changes m a y take ten or twelve y e a r s f r o m i n i t i a l introduction to total acceptance in a community.  70  T h e e a r l y studies in education showed that change i n the A m e r i c a n school s y s t e m came about even m o r e slowly, with fifty y e a r s elapsing between the insight into a need and the introduction of . 71 a way to meet it.  R o g e r s suggested that a c r i s i s m a y speed up the diffusion 72 p r o c e s s or r e t a r d it, Russian  1  and, certainly,the appearance of the f i r s t  sputnik ' did much to a c c e l e r a t e changes i n the A m e r i c a n 73  school s y s t e m .  M i l e s documents his belief that change is  p r o c e e d i n g m o r e r a p i d l y in education than it did twenty-five y e a r s ago with examples of the adoption of p r o g r a m m e d l e a r n i n g at a faster rate than would have been p r e d i c t e d on a basis of e a r l i e r studies,  and also  the r a p i d p r o l i f e r a t i o n of74 language l a b o r a t o r i e s , and the use of teacher aides and t e a m teaching.  50 It would appear that i n c r e a s e d knowledge on the subject of c o m m u n i c a t i o n and i m p r o v e d techniques that have been developed i n recent y e a r s ,  together with greater contact of the public i n g e n e r a l with  the m a s s m e d i a , have a l l had an effect on the a c c e l e r a t i o n of changes i n our society.  T h e S u r g e o n - G e n e r a l ' s Conference on communications s t r o n g l y e m p h a s i z e d the need for even m o r e r a p i d d i s s e m i n a t i o n of i n f o r m a t i o n on new knowledge and technology to p r a c t i t i o n e r s i n a l l of the health fields.  Individual v a r i a t i o n s i n rate of Adoption The m a j o r i t y of studies dealing with diffusion have attempted to c o r r e l a t e c h a r a c t e r i s t i c s of the potential adopters with the rate at which they accept innovations and put t h e m into p r a c t i c e .  R o g e r s and B e a l i n i t i a l l y divided the adopters into five c a t e gories:  innovators, e a r l y adopters,  e a r l y m a j o r i t y , late m a j o r i t y and  77 laggards.  It has been suggested, and borne out i n v a r i o u s  studies, 78  that the distribution of these groups tends to follow a n o r m a l c u r v e . The t r e n d in p r e v i o u s studies has been to use the M e a n of the ' adoption s c o r e s ' obtained by a population (or sample of a population) and Standard Deviations f r o m the Mean to divide adopters into the  respective  79 categories.  R o g e r s is now of the opinion that the d i v i s i o n should be  51 on a p e r c e n t i l e basis with the innovators and e a r l y adopters  compressed  into one group, c o m p r i s i n g the top sixteen per cent of the s c o r e s .  The  next t h i r t y - f o u r per cent would be the e a r l y m a j o r i t y , while the late m a j o r i t y would include the following t h i r t y - f o u r per cent and the laggards the bottom sixteen per cent.  80  V a r i o u s r e s e a r c h e r s have attempted to identify specific c h a r a c t e r i s t i c s distinguishing each group but their findings have not always 81 been in complete a c c o r d .  T h e r e seems to be a general consensus of  opinion among r u r a l s o c i o l o g i s t s , however,  that there are distinctive  c h a r a c t e r i s t i c s separating the e a r l y f r o m the late adopters in any f a r m i n g community. T h e r e is always a s m a l l group of advance scouts who are w i l l i n g to t r y out a new idea before the r e s t of the m e m b e r s of a community.  T h e s e are the innovators who tend to be m o r e c o s m o -  politan in their r e f e r e n c e groups, are r e f e r r e d to as being ' a little different' by their fellows,  and seek sources of information outside  the c o m m u n i t y to which they belong.  The innovator is not  p a r t i c u l a r l y c o n c e r n e d about the opinion of others in his own l o c a l i t y . The e a r l y adopters tend to be younger, and to have a better s o c i o - e c o n o m i c  that is, not past middle age,  status than others in their  community. T h e y belong to m o r e f o r m a l organizations those c o n c e r n e d with their work.  especially  T h e m a j o r i t y of e a r l y adopters are  acknowledged l e a d e r s in the community and their views are held in respect.  T h e y seek highly creditable sources of information before  t r y i n g out a new p r a c t i c e ,  c o n f e r r i n g with the county agent and  s p e c i a l i s t s f r o m the a g r i c u l t u r a l colleges. T h e i r adoption influences, to a l a r g e extent,  subsequent adoption by the r e m a i n d e r of the  community.  Late adopters,  on the other hand, appear to be m o r e s e c u r i t y  o r i e n t e d than e a r l y adopters.  T h e y u s u a l l y have s m a l l e r land-holdings  and fewer home i m p r o v e m e n t s .  T h e y tend to confine their activities to  1 1 1 i ,i " i i A • 82,83,84,85 p u r e l y l o c a l groups, both s o c i a l l y and o c c u p a t i o n - w i s e .  M e n z e l , K a t z and C o l e m a n , i n their studies of the diffusion of innovations among p h y s i c i a n s ,  r e p o r t m u c h the same findings relative  to p e r s o n a l c h a r a c t e r i s t i c s associated with e a r l y adoption. The innovators among the doctors are emancipated f r o m the l o c a l n o r m s of their m e d i c a l c o m m u n i t y and e a r l y adoption is p o s i t i v e l y c o r r e l a t e d with financial and s o c i a l status,as w e l l as m e m b e r s h i p i n p r o f e s s i o n a l 86 organizations.  In the f i e l d of education,  e a r l y studies confined the a r e a of  r e s e a r c h to the school or school s y s t e m as the unit of analysis for m e a s u r i n g adoption.  Studies were done c o r r e l a t i n g the  of the c o m m u n i t y with the degree of innovativeness particular system.  characteristics  of schools within a  R o s s (1958) found that schools which were most  innovative were ones i n which the teachers attended m o r e meetings and r e a d m o r e widely to find new ideas,  out-of-town  also that the m o r e  innovative school s y s t e m s are to be found in higher income l e v e l communities where there is a greater school tax support.  87  C a r l s o n pointed out the need to take the individual school superintendent into consideration as a k e y factor in influencing change in the school system,  since his approval is r e q u i r e d before a new  88 p r a c t i c e is adopted.  H i s study, and one by Jensen  (1967), indicated  that s o c i a l s t r u c t u r e v a r i a b l e s such as s o c i a l network involvement and status with r e g a r d to other superintendents, prestige,  as evidenced by  p r o f e s s i o n a l i s m and educational attainment, were p o s i t i v e l y 89  c o r r e l a t e d with the r a p i d i t y of adoption of innovations.  Subsequent  studies by P e t e r s o n (1968) and H e n s l e y (1968) have c o n f i r m e d the i m p o r t a n c e of the r o l e p l a y e d by the school superintendent as a p r i n c i p a l 90, 91 'gate-keeper for m a j o r educational innovations. 1  'Innovativeness, ' or tendency to adopt innovations e a r l i e r than other m e m b e r s of a s o c i a l s y s t e m ,  as the t e r m is used above, has in  the past been c o n s i d e r e d to be a single entity.  Recent r e s e a r c h by  Holdaway and Seger suggest that there m a y be three factors i n v o l v e d in the g e n e r a l c h a r a c t e r i s t i c of innovativeness: adopted of any given set,  number of innovations  extent of adoption of the innovations, and  time of adoption. T h e i r study indicates,  as has been found in other  r e s e a r c h , that e a r l y adoption of one innovation does not always ensure e a r l y adoption of a l l others.  92  T h e r e appears to be some shifting  54  within the categories for v a r i o u s types of new ideas although "it is doubtful that an individual who is an innovator for one idea is a l a g g a r d for another idea".  93  T h e Information Spreads T h r o u g h a S o c i a l S y s t e m Information about new ideas and p r a c t i c e s flows through a c o m p l e x s y s t e m of s o c i a l relationships and acceptance of an innovation b y one individual influences the d e c i s i o n to adopt it o r not by other m e m b e r s of a community. R o g e r s states that "in one sense,  adoption  of an innovation m a y be viewed as c o n f o r m i t y to group p r e s s u r e s which become m o r e intense as a higher percentage  of adoption is r e a c h e d for  94 a p a r t i c u l a r innovation i n a s o c i a l system!.'  T h e innovators m a y  stand a little apart f r o m the group and, by v i r t u e of having a higher socio-economic  status, better education and m o r e e x t e r n a l l y o r i e n t e d  outlook,  are f r e e r f r o m the dangers of r i d i c u l e and l e s s 95,96 to group p r e s s u r e s .  susceptible  Once an innovation has been t r i e d out by the e x p e r i m e n t e r s and found s u c c e s s f u l ,  its diffusion through the s o c i a l s y s t e m is l a r g e l y  influenced by the 'opinion l e a d e r s ' who are most representative of the f o r m a l l e a d e r s h i p of the c o m m u n i t y and are those f r o m whom others 97, 98 seek i n f o r m a t i o n and advice.  '  s y s t e m n o r m s on innovativeness  R o g e r s states that the s o c i a l determine the degree of innovativeness  or t r a d i t i o n a l i s m of the opinion l e a d e r s who reflect the g e n e r a l l y h e l d  views of a community.  One of the e a r l y studies in r u r a l sociology,  r e p o r t e d on by  Hoffer and Gibson in 1941 analyzed the r e l a t i o n of s o c i a l factors to s u c c e s s of a g r i c u l t u r a l extension work in four M i c h i g a n c o m m u n i t i e s . The authors concluded that:  No single factor or c i r c u m s t a n c e i n a community situation determines the r e s p o n s i v e n e s s of f a r m e r s to a g r i c u l t u r a l extension p r o g r a m s . Responsiveness is determined, r a t h e r , by a n e t - w o r k of s o c i a l influences and c i r c u m s t a n c e s among which the l e a d e r ship organizations and group m o r a l e among f a r m e r s are v e r y important. T h e s e are affected i n turn by economic conditions and community organizations. ^ 0  L i o n b e r g e r did m u c h r e s e a r c h in the a r e a of s o c i a l and c u l t u r a l values and their relationship to the adoption of innovations.  He  e m p h a s i z e s the need to detect values that operate within a given c o m m u n i t y as influencing both the attitude toward change and the i n t e gration of a new idea or p r a c t i c e into the existing patterns of l i f e .  The studies in Saskatchewan analyzing the diffusion p r o c e s s in different communities p r o v i d e further evidence of this.  It was found  there that differences between communities such as the degree of technological advancement,  ethnicity and time of settlement,  the  educational l e v e l of the community and opportunities for contact with communications m e d i a are a l l factors which have an important  56  influence on the r a p i d i t y with which new ideas and p r a c t i c e s diffused and adopted.  are  102  In n u r s i n g , Coe and B a r n h i l l investigated the s o c i a l of a f a i l u r e i n innovation i n n u r s i n g p r a c t i c e .  dimensions  T h e y found that the d i s t u r -  bance i n s o c i a l s t r u c t u r e of a n u r s i n g unit caused by the introduction of a new method for o r d e r i n g and dispensing medications was a m a j o r factor contributing to the failure of p e r s o n n e l to accept the new 103 practice.  in. T H E INNOVATION-DECISION  Rogers,  PROCESS  B e a l and Bohlen have stated that "for any i n d i v i d u a l  the adoption of a complex new f a r m or home p r a c t i c e s is not a single unit act",  and they pointed out the s i m i l a r i t y between the adoption  p r o c e s s as it applies to f a r m p r a c t i c e s ,  the anthropologists'  concept  of diffusion and some of the l e a r n i n g theories put forth by s o c i a l psychologists.  Wilkenning suggested that there were four stages in the 105 adoption p r o c e s s .  T h e m o s t c o m m o n l y accepted view,  however,  is the five stage concept f i r s t postulated by a panel of r u r a l s o c i o l o g i s t s . T h e s e stages a r e :  57  1.  awareness  - when the individual is f i r s t exposed to the new  idea 2.  interest (or i n f o r m a t i o n ) - the individual is motivated by c u r i o s i t y and interest to seek further i n f o r m a t i o n  3.  evaluation (or application) - ' mental t r i a l ' when the i n d i v i d u a l c o n s i d e r s the r e l a t i v e advantages and d i s advantages of the idea and whether it m a y be useful in his p a r t i c u l a r situation.  4.  t r i a l - the individual experiments w i t h o r t r i e s out, the ;  idea and i n f o r m a t i o n r e g a r d i n g techniques and method is sought 5.  adoption - the idea is evaluated and, if satisfactory, there is a d e c i s i o n for continued u s e ^ ^  T h e r e are m a n y v a r i a t i o n s in the t i m e elapsing between the s u c c e s s i v e stages and s o m e t i m e s there m a y b e n o c l e a r c u t distinction between them. T h e r e appears to be some i n c o n s i s t e n c y amongst r e s e a r c h e r s in differentiating between the stages of t r i a l and adoption. The C o l e m a n - M e n z e l drug study, for example,  used the date of a 107  p h y s i c i a n ' s f i r s t p r e s c r i p t i o n of a new drug as the date of adoption. Lionberger,  on the other hand, uses the t e r m ' t r i a l ' to designate when  a little of the new p r a c t i c e is attempted and r e s e r v e s 'adoption' for 108 "full and continued use" of an innovation. R o g e r s and Shoemaker  also suggest that the fourth stage involves s m a l l - s c a l e t r i a l and indicate that the final stage m a y involve a d e c i s i o n for either adoption or 109 rejection.  T h e y p r e f e r to use the t e r m  innovation-decision  p r o c e s s ' r a t h e r than 'adoption p r o c e s s ' feeling that this allows for both positive or negative decisions.  Other factors mentioned p r e v i o u s l y in  connection with the c h a r a c t e r i s t i c s of innovations,  such as  congruence  and compatability with the existing n o r m s , are influential not only i n the d e c i s i o n to adopt o r not adopt a new idea, but also i n the time taken to r e a c h a d e c i s i o n .  59  C H A P T E R II  FOOTNOTES  1. E v e r e t t M . Rogers and F . F l o y d Shoemaker, Diffusion of Innovations: A C r o s s - C u l t u r a l A p p r o a c h , (New Y o r k : F r e e P r e s s of Glencoe, in print) pp. 17-20. 2. E l i h u K a t z and P a u l L a z a r f e l d , Y o r k : The F r e e P r e s s , 1954), pp. 15-30.  P e r s o n a l Influ-ence,  (New  3. Ibid. pp. 30-32. 4. E v e r e t t M . R o g e r s , Diffusion of Innovations (New Y o r k : The F r e e P r e s s , 1962), pp. 211-14. 5. P a u l L a z a r f e l d , B . B e r e l s o n and H . Gaudet, The People's Choice (fourth edition; New Y o r k : C o l u m b i a U n i v e r s i t y P r e s s , 1954), p. 151. 6. R o g e r s , op. cit. , p.  213.  7. K a t z and L a z a r f e l d ,  op. cit. pp. 150-162.  8. R o g e r s and Shoemaker,  op. cit. , p. 20.  9- R o g e r s and Shoemaker,  ibid.  10. J a m e s C o l e m a n , H e r b e r t M e n z e l and E l i h u K a t z , "The Diffusion of an Innovation among P h y s i c i a n s , " (Sociometry, 20; 253-270, D e c e m b e r , 1957), p. 268. 11. F r a n k O . L e u t h o l d , C o m m u n i c a t i o n and Diffusion of Improved F a r m P r a c t i c e s i n Two N o r t h e r n Saskatchewan F a r m C o m m u n i t i e s (Saskatoon: Canadian Centre for C o m m u n i t y Studies, 1966), p. 146.  60 12. R o g e r s ,  op. cit. , pp. 228-232.  13. E l i h u K a t z , "The Two-Step Flow of C o m m u n i c a t i o n : an U p - t o - D a t e Report on Hypotheses, " P u b l i c Opinion Q u a r t e r l y , 21:61-78 ( Spring 1957) 14. I b i d . , p. 77. 15. R i c h a r d H . Wilcox, "Some Neglected A r e a s of R e s e a r c h on Scientific and T e c h n i c a l C o m m u n i c a t i o n s , " in T h a y e r , L e e ( E d i t o r ) , C o m m u n i c a t i o n , (Washington, Spartan Books, 1966) pp. 361-372. 16. B e r n a r d B e r e l s o n and M o r r i s Janowitz, Reader in P u b l i c Opinion and C o m m u n i c a t i o n , (2nd ed. ; New Y o r k : The F r e e P r e s s , 1966), p. 251. 17. E l i h u K a t z and P a u l F . L a z a r f e l d , P e r s o n a l Influence (New Y o r k : T h e F r e e P r e s s , 1954). 18. W e r l i n g C . T r o l d a h l , " A F i e l d T e s t of a M o d i f i e d " T w o Step F l o w of C o m m u n i c a t i o n s " M o d e l , " P u b l i c Opinion Q u a r t e r l y , 30 609-623(Winter 1966-67). p. 613. :  19. H e r b e r t F . L i o n b e r g e r , Adoption of New Ideas and P r a c t i c e s ( A m e s : The Iowa State U n i v e r s i t y P r e s s , I960), p. 10. 20.  T r o l d a h l , l o c . cit.  21.  Leuthold, op. c i t . , p. 55.  22. C a r l I. Hovland, Irving L . Janis and H a r o l d H . K e l l e y , C o m m u n i c a t i o n and P e r s u a s i o n , (New Haven: Y a l e U n i v e r s i t y P r e s s , 1953), p. 19. 23.  T r o l d a h l , op. c i t . , p. 613.  24. T r o l d a h l , op. c i t . , pp. 613-614. 25.  Rogers,  op. c i t . , pp. 211-214.  26. Robert G . M a s o n , "The Use of Information Sources by Influentials in the Adoption P r o c e s s , " P u b l i c Opinion Q u a r t e r l y , 27:455-456 ( F a l l 1963). 27. •, "The Use of Information Sources in the P r o c e s s of Adoption, " R u r a l Sociology, 29:1:40-52 ( M a r c h 1964)  61 28. J u l i a n Wolpert, " A Regional Simulation M o d e l of Information Diffusion, " P u b l i c O p i n i o n Q u a r t e r l y , 30:597-608 (Winter 1966-67) p. 604. 29. E l i h u K a t z , "Diffusion of Innovations, " in The Obstinate A u d i e n c e , published by the Foundation for R e s e a r c h in Adult B e h a v i o r (Ann A r b o r : B r a u n and B r o o m f i e l d Inc. , 1965), p. 28. 30.  R o g e r s and Shoemaker,  op. cit. , p. 24.  31. Ibid. , p. 25. 32. Ibid. 33. F r e d e r i c k C . F l i e g e l and Joseph E . K i v l i n , "Attributes of Innovations as F a c t o r s i n Diffusion, " T h e A m e r i c a n J o u r n a l of Sociology, 72:235-7, (.November, 1966), p. 235. 34.  F l i e g e l and K i v l i n , l o c . cit.  35. K a t z , 36.  op. cit. , pp. 25-29.  Rogers,  op. c i t . , pp. 121-147.  37. R o g e r s and Shoemaker,  op. c i t . , pp. 28-31.  38. A . E . Havens, "Increasing the Effectiveness Innovativeness," R u r a l Sociology, 30:150-165,(1965).  of P r e d i c t i n g  39. L . B r a n d e r and B . K e a r l , "Evaluation for Congruence as a F a c t o r i n A d o p t i o n - R a t e of Innovations, " R u r a l Sociology, 29:288-303 (1964). 40.  F l i e g e l and K i v l i n , l o c . cit.  41. Reuben J a m e s C a m a r e n , "Innovation as a F a c t o r in Influencing the Diffusion and Adoption P r o c e s s " (unpublished doctoral d i s s e r t a t i o n , T h e U n i v e r s i t y of C a l i f o r n i a , 1966). 42. John W i l l i s K o h l , "Adoption Stages and P e r c e p t i o n s of C h a r a c t e r i s t i c s of E d u c a t i o n a l Innovations" (unpublished doctoral dissertation, U n i v e r s i t y of O r e g o n , 1966). 43.  R o g e r s and Shoemaker,  op. cit. , p. 25.  44. Mathew B . M i l e s , Innovation i n Education (New Y o r k : T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , 1964), p. 14.  62  45.  Rogers,  op. cit. , p.  46.  I b i d . , pp. 261-67.  17.  47. J . B . A r m s t r o n g , "County Agent A c t i v i t i e s and the Adoption of S o i l - B u i l d i n g P r a c t i c e s " (unpublished M a s t e r ' s T h e s i s , U n i v e r s i t y of Kentucky, 1959). 48. Silas L . M c H e n r y , "Functions and T e a c h i n g Methods U t i l i z e d by E x t e n s i o n Specialists and County Agents for the Diffusion of P o u l t r y P r o d u c t i o n Information" (unpublished d o c t o r a l dissertation, P e n n s y l v a n i a U n i v e r s i t y , I960). 49. R. R. Rehder, "The Role of the Detail M a n in the Diffusion and Adoption of an E t h i c a l ( P h a r m a c e u t i c a l ) Innovation within a Single M e d i c a l C o m m u n i t y " (unpublished doctoral dissertation, Stanford U n i v e r s i t y , 1961). 50.  Leuthold, op. cit. , p.  51. T r o l d a h l , 52.  op. cit. , p.  E i c h h o l z and R o g e r s ,  162. 613. op. c i t . ,  p.  315.  53. G o r d o n N . M a c K e n z i e , " C u r r i c u l a r Change: P a r t i c i p a n t s , P o w e r , and P r o c e s s e s , " (in M i l e s ' Innovation in Education, op. c i t . ) pp. 409-13. 54. F r a n c e s F r a z i e r , "Guide for N u r s i n g Education Consultants" (unpublished d o c t o r a l dissertation, New Y o r k , T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , 1953). 55.  Rogers,  op. cit. , pp. 98-105.  56.  L e u t h o l d , op. cit. , p.  146.  57. T h e o d o r e Caplow and John J . R a y m o n d , " F a c t o r s Influencing the Selection of P h a r m a c e u t i c a l P r o d u c t s , " J o u r n a l of M a r k e t i n g 1 9 : 1 : 1 8 - 2 3 , ( J u l y 1954). 58. R i c h a r d H . O r r and Walter E . Boek, A n Annotated B i b l i o graphy on the F l o w of M e d i c a l Information to P r a c t i t i o n e r s (New Y o r k : Institute for the Advancement of M e d i c a l C o m m u n i c a t i o n , 1961). 59. H e l e n N e a l , Better C o m m u n i c a t i o n s for Better Health (New Y o r k : National H e a l t h C o u n c i l , distributed by C o l u m b i a P r e s s , pp. 31-51.  19 66),  63  60. J a m e s C o l e m e n , H e r b e r t M e n z e l and E l i h u K a t z , "The Diffusion of an Innovation among P h y s i c i a n s , " S o c i o m e t r y , 20:253-270, ( D e c e m b e r , 1957). 61. C h a r l e s W i n i c k , "The Diffusion of an Innovation among P h y s i c i a n s in a L a r g e C i t y , " S o c i o m e t r y , 24:384-396 ( 1961). 62. P a u l H . M o r t , "Studies in Educational Innovation f r o m the Institute of A d m i n i s t r a t i v e R e s e a r c h ; an O v e r - V i e w , " (in M i l e s , op. c i t . ) pp. 317-328. 63. S u r g e o n - G e n e r a l , U . S. P u b l i c H e a l t h S e r v i c e , Conference on H e a l t h C o m m u n i c a t i o n s , N o v e m b e r 5-8, 1962 (Washington, D. C . , U . S . P u b l i c Health S e r v i c e , Department of National H e a l t h and W e l f a r e , 1963), p. 26. 64. S. N o r r i s , " P r o p o s a l s for the I n - S e r v i c e Education of C o - o p e r a t i n g T e a c h e r s P a r t i c i p a t i n g in the N u r s i n g Education P r o g r a m s at the U n i v e r s i t y of Minnesota" (unpublished d o c t o r a l dissertation, New Y o r k , T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , 1955). 65. Kathleen M . Straut, " A Study of Changes in Job Satisfaction of N u r s e P r a c t i t i o n e r s following an I n - S e r v i c e E d u c a t i o n a l P r o g r a m " (unpublished d o c t o r a l dissertation, New Y o r k : T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , 1964). 66. E l m i r a M a r y P r i c e , " L e a r n i n g Needs of R e g i s t e r e d N u r s e s " (unpublished d o c t o r a l dissertation, New Y o r k : T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , 1965). 67. H e r b e r t F . L i o n b e r g e r , Adoption of New Ideas and P r a c t i c e s ( A m e s : Iowa, T h e Iowa State U n i v e r s i t y P r e s s , I960), pp. 33-36. 68.  L e u t h o l d , op. c i t . ,  69. R o g e r s ,  p.  op. cit. , p.  142. 41.  70.  L i o n b e r g e r , op. cit. , p.  71.  Mort,  72.  Rogers,  op. c i t . ,  p.  35.  320.  op. cit. , p.  125.  73. Donald W. Johnson " T i t l e III and the D y n a m i c s of E d u c a t i o n a l Change", (in M i l e s , op. c i t . ) pp. 157-182.  64 74.  M i l e s , op. cit. , p.  5-8.  75. L i o n b e r g e r , op. cit. , p. 76.  Surgeon-General, loc.  77. R o g e r s ,  35.  cit.  op. cit. , pp.  148-192.  78. C o o l i e V e r n e r and P e t e r M . Gubbels, T h e Adoption or Rejection of Innovations by D a i r y F a r m O p e r a t o r s in the L o w e r F r a s e r V a l l e y , (Ottawa: A g r i c u l t u r a l R e s e a r c h E c o n o m i c s C o u n c i l , 1967), p. 6. 79. R o g e r s ,  op. cit. , pp.  159-164.  80. Statement by D r . E v e r e t t M . Rogers i n p e r s o n a l correspondence with the author, dated M a r c h 9, 1969. 81. V e r n e r and Gubbels, l o c . 82.  Leuthold, op. cit. , pp.  . 83. R o g e r s ,  op. cit. , pp.  cit.  147. 172-178.  84. H e r b e r t F . L i o n b e r g e r , Adoption of New Ideas and P r a c t i c e s ( A m e s : The Iowa State U n i v e r s i t y P r e s s , I960), pp. 96-106. 85.  V e r n e r and Gubbels, op. cit. , p. 7.  86.  C o l e m a n , M e n z e l and K a t z , l o c .  87.  E i c h h o l z and R o g e r s ,  cit.  op. cit. , pp. 313-314.  88. R i c h a r d O . C a r l s o n , "School Superintendents and the Adoption of M o d e r n Maths : A S o c i a l Structure P r o f i l e " (in M i l e s , op. cit. ) pp. 329-342. 89. L e R o y Jensen, " C h a r a c t e r i s t i c s of Superintendents in Innovative and Non-Innovative School Systems and Interaction with the Iowa Department of P u b l i c Instruction" (unpublished doctoral d i s s e r t a t i o n , A m e s : U n i v e r s i t y of Iowa, 1967). 90. Irving M a u r i c e P e t e r s o n , "Relationships between School Superintendents' P e r s o n a l i t y O r i e n t a t i o n s , P e r c e i v e d Situational P r e s s u r e s , and Innovativeness" (unpublished d o c t o r a l dissertation Rutgers, The State U n i v e r s i t y , 1968).  65 91. O l i v e r Dennis Hensley, " A Study of F a c t o r s Related to the Acceptance of a Cooperative Supplementary E d u c a t i o n a l Service Center authorized under T i t l e III of P L 89-10" (unpublished doctoral d i s s e r t a t i o n , Southern Illinois U n i v e r s i t y , 1968). 92. E . A . Holdoway and John E . Seger, "The Development of Indices of Innovativeness, " Canadian Education and R e s e a r c h Digest, 8:4:366-377 ( D e c e m b e r 1968). 93.  Rogers,  op. cit. , p.  187.  94.  Rogers,  op. cit. , p.  155.  95. M a r v i n A . A n d e r s o n , The Diffusion P r o c e s s ( A m e s : Iowa State U n i v e r s i t y , A g r i c u l t u r a l Extension S e r v i c e Special Report, No. 18, 1957). 96. John N . W e l c h , " A n E v a l u a t i o n of T h r e e Adult E d u c a t i o n Methods for D i s s e m i n a t i n g T r a d e Information to M i s s o u r i Restaurant O p e r a t o r s " (unpublished d o c t o r a l d i s s e r t a t i o n , T a l a h a s s i e : F l o r i d a State U n i v e r s i t y , 1961), p. 28. 97. A n d e r s o n , l o c . cit. , 98.  Rogers,  op. c i t . , pp. 208-211.  99.  Rogers,  op. cit. , pp. 233-236.  100. C . R. Hoffer and D. L . Gibson, The C o m m u n i t y Situation as it Affects A g r i c u l t u r a l Extension W o r k (Special B u l l e t i n 312; E a s t L a n s i n g : M i c h i g a n State College A g r i c u l t u r a l E x p e r i m e n t Station, O c t o b e r , 1941), p. 34. 101.  L i o n b e r g e r , op. cit. , pp. 67-95.  102.  Leuthold, op. c i t . , pp. 87-89.  103. Rodney M . Coe and E l i z a b e t h A . B a r n h i l l , "Social Dimensions of a F a i l u r e in Innovation, " Human O r g a n i z a t i o n , 26:3:149-156, (Fall 1967). 104. George N . B e a l , E v e r e t t M . Rogers and Joe N . Bohlen, " V a l i d i t y of the Concept of Stages in the Adoption P r o c e s s , " R u r a l Sociology, 22:166-168, (1957), p. 166.  105. Eugene A . Wilkenning, A c c e p t a n c e of Improved F a r m P r a c t i c e s in T h r e e C o a s t a l P l a i n Counties, ( T e s t B u l l e t i n No. 98, N o r t h C a r o l i n a A g r i c u l t u r a l E x p e r i m e n t Station, May, 1952.) 106.  Beal,  R o g e r s and Bohlen,  op. c i t . ,  pp. 166-168.  107. H e r b e r t M e n z e l and E l i h u Katz, TSocial Relations and Innovations in the M e d i c a l P r o f e s s i o n : the E p i d e m i o l o g y of a New D r u P u b l i c O p i n i o n Q u a r t e r l y , 19:337-352, (Winter 1955-56). 108.  Lionberger,  op. c i t . ,  109.  R o g e r s and Shoemaker,  110.  Lionberger,  op. c i t . ,  p.  41. op. cit. , pp.  pp. 24-25.  34-35.  67  C H A P T E R III  POPULATION AND PARTICIPANTS  The total number of hospitals in B r i t i s h C o l u m b i a at the beginning of the year 1968 when this study was undertaken was These included ninety public g e n e r a l hospitals, hospitals,  seven contract hospitals,  five public rehabilitation hospitals,  126.*  eight R e d C r o s s Outpost  five F e d e r a l Government hospitals, and one rehabilitation hospital  operated by the P r o v i n c i a l Government.  The population in this study includes a l l of the public g e n e r a l hospitals in the p r o v i n c e , -exclusive of four which offered l i m i t e d s e r v i c e s only and one which was run as a satellite of another l a r g e r hospital.  * T h i s figure c o v e r s a l l of the public and other non-profit making hospitals in the p r o v i n c e .  68  I. G E N E R A L I N F O R M A T I O N A B O U T T H E H O S P I T A L S  O r g a n i z a t i o n and C o n t r o l The hospitals in B r i t i s h C o l u m b i a are o r g a n i z e d and operated under a P r o v i n c i a l H o s p i t a l A c t .  The r e s p o n s i b i l i t y for a d m i n i s t e r i n g  the A c t is vested in the P r o v i n c i a l Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance.  E a c h hospital is operated by its own H o s p i t a l Society.  The  m a j o r i t y of public g e n e r a l hospitals in the p r o v i n c e are community,  or  d i s t r i c t hospitals and any resident of a c o m m u n i t y m a y become a m e m b e r of the Society by paying a one dollar annual fee.  The hospitals  are  managed by B o a r d s of D i r e c t o r s elected f r o m the g e n e r a l m e m b e r s h i p of the H o s p i t a l Society with appointed representation f r o m the P r o v i n c i a l Government and the Regional H o s p i t a l P l a n n i n g B o a r d .  The Hospital  B o a r d is r e q u i r e d to r e p o r t to the m e m b e r s h i p of the H o s p i t a l Society at 2 its annual meeting.  Financing Both the community and the government share in the financing of public general hospitals in the p r o v i n c e . T o facilitate r e g i o n a l planning, development and financing of hospital p r o j e c t s ,  the Regional  H o s p i t a l D i s t r i c t s A c t and the B r i t i s h C o l u m b i a Regional D i s t r i c t s F i n a n c i n g A u t h o r i t y A c t were p a s s e d in 1967.  T h e f o r m e r divides the  p r o v i n c e into twenty-nine large d i s t r i c t s for cooperative  regional  planning while the latter established a P r o v i n c i a l Government authority for the financing of hospital projects s i m i l a r to that used for schools.  3  Under the two D i s t r i c t A c t s and the H o s p i t a l A c t , the P r o v i n c i a l Government makes grants to non-profit organizations to a s s i s t in the construction and equipping of hospitals.  F o r m a j o r construction,  the  G o v e r n m e n t pays to each d i s t r i c t sixty per cent of the costs for an approved hospital project,  after deduction of F e d e r a l Government capital  grants and items which are c o n s i d e r e d the d i s t r i c t ' s r e s p o n s i b i l i t y .  The  F e d e r a l Government's contribution for m a j o r construction is fourteen per cent.  F o r equipment and renovations,  the P r o v i n c i a l Government  contributes t h i r t y - t h r e e and o n e - t h i r d per cent.  The hospitals  are  r e s p o n s i b l e for m a k i n g up the difference between government grants and total costs for m a j o r construction,  renovations and equipment.  case of the community or d i s t r i c t hospitals, revenue is through l o c a l tax levy.  In the  the l a r g e s t source of  4  Money for operating costs of the hospitals comes jointly f r o m the F e d e r a l and P r o v i n c i a l Governments through the F e d e r a l P r o v i n c i a l H o s p i t a l Insurance P l a n .  A d m i n i s t r a t i o n of the funds is by the  P r o v i n c i a l Government which pays an a l l - i n c l u s i v e per d i e m rate to hospitals for the care of patients r e q u i r i n g acute m e d i c a l treatment or active rehabilitation and extended hospital c a r e .  Payments made  70  to hospitals cover a l l but one dollar of the approved per d i e m rate for each hospital. T h e daily rate c o v e r s the cost of a l l r e g u l a r hospital services,  including X - R a y ,  to bed, board,  l a b o r a t o r y and operating r o o m , in addition  and n u r s i n g c a r e .  The patient pays the r e m a i n i n g one dollar a day as c o - i n s u r a n c e under the P r o v i n c i a l H o s p i t a l Insurance scheme.  T h i s fee entitles  the patient to public w a r d accommodation, u s u a l l y in a four to six bed unit, and the use of a l l hospital f a c i l i t i e s .  Patients m a y elect to pay  an additional amount for s e m i - p r i v a t e or private r o o m accommodation 5 at a rate specified b y t h e hospital,  although some hospitals have  dispensed with this, p r e f e r r i n g to allocate beds on a b a s i s of the patient's need rather than his ability to pay. Maintenance of Standards The B r i t i s h C o l u m b i a Department of Health S e r v i c e s and H o s p i t a l Insurance is responsible for the maintenance of standards of hospitals in the p r o v i n c e .  T h e H o s p i t a l Consultative and Inspection  D i v i s i o n of The Department p r o v i d e s public and private hospitals with consultative s e r v i c e s and maintains an inspectional p r o g r a m to ensure that basic standards are met. ^  In addition, hospitals wishing to do so, who meet the criteria,  necessary  m a y apply for national a c c r e d i t a t i o n by the Canadian C o u n c i l  on H o s p i t a l A c c r e d i t a t i o n . T h i s is a voluntary body, governed by a B o a r d  of D i r e c t o r s composed of r e p r e s e n t a t i v e s  f r o m the Canadian H o s p i t a l  A s s o c i a t i o n , the Canadian M e d i c a l A s s o c i a t i o n , L ' A s s o c i a t i o n des M e d e c i n s de Langue F r a n c a i s e and the R o y a l College of P h y s i c i a n s and  7 Surgeons. At the t i m e this r e s e a r c h was in p r o g r e s s ,  t h i r t y - t h r e e of the  hospitals included in the study were a c c r e d i t e d . T h e s e included a l l of the l a r g e hospitals,  eighteen of the m e d i u m - s i z e d hospitals,  the s m a l l hospitals ( f r o m t h i r t y to seventy-four beds),  three of  and one hospital  under t h i r t y beds.  The C o m m u n i t y and the H o s p i t a l The communities in B r i t i s h C o l u m b i a appear to be deeply interested in the hospitals.  A l l but two of the D i r e c t o r s of N u r s i n g  i n t e r v i e w e d felt that the communities supported the hospital and its p o l i c i e s a l l o r most of the t i m e .  P r a c t i c a l l y e v e r y hospital (95 per cent) had at least one Women's A u x i l i a r y with some r e p o r t i n g as m a n y as seven, one for e v e r y s m a l l c o m m u n i t y which the hospital s e r v e d . O n e - h a l f of the participants (56 per cent) said there was also a J u n i o r A u x i l i a r y , or C a n d y - S t r i p e r p r o g r a m , for teen-age volunteers.  In addition,  there were F u t u r e N u r s e s ' Clubs in the high schools in fifty-six communities and these Clubs u s u a l l y had a close l i a i s o n with the hospitals.  The volunteer groups provide m a n y useful s e r v i c e s and amenities for patients and also help to r a i s e funds for the hospital. M u c h of the money they r a i s e goes towards the p u r c h a s e of equipment for which the hospital must pay t w o - t h i r d s of the cost, while the government contributes o n e - t h i r d .  The H o s p i t a l B o a r d O f the eighty-five hospitals included i n this study, the m a j o r i t y were community, or d i s t r i c t , hospitals.  T h e r e m a i n d e r were  operated by p r i v a t e organizations as n o n - p r o f i t - m a k i n g institutions for the care of acute patients.  Eighteen of the p a r t i c i p a t i n g hospitals  were r u n by r e l i g i o u s organizations, six of these as m i s s i o n hospitals.  E a c h hospital had its own H o s p i t a l Society,  in accordance with  the p r o v i s i o n s of the H o s p i t a l A c t , and was managed by a B o a r d of D i r e c t o r s . T h e communities appeared to be a c t i v e l y involved in the management of the hospitals. In addition to the government and, in the case of the hospitals r u n by r e l i g i o u s organizations, representatives,  church  a l l hospitals r e p o r t e d that there were at least two or  three c o m m u n i t y m e m b e r s on the B o a r d s and the m a j o r i t y , (79 per cent) stated that there were m o r e than seven B o a r d m e m b e r s f r o m the community at l a r g e .  M o s t of the D i r e c t o r s of N u r s i n g felt that the community was p r o p e r l y and adequately r e p r e s e n t e d on the H o s p i t a l B o a r d .  O n l y eight  (9 p e r cent) felt that it was not.  The C h a i r m a n of the B o a r d was, l o c a l business or p r o f e s s i o n a l p e r s o n .  in almost a l l instances,  a  Only three hospitals r e p o r t e d  that the C h a i r m a n was a p h y s i c i a n and these were a l l m i s s i o n hospitals.  Under the H o s p i t a l A c t , paid employees are not p e r m i t t e d to be voting m e m b e r s of the H o s p i t a l B o a r d of D i r e c t o r s . almost i n v a r i a b l y attends meetings, however,  The a d m i n i s t r a t o r  as l i a i s o n between the  B o a r d and the hospital staff and frequently acts as S e c r e t a r y to the Bo a r d .  In a p p r o x i m a t e l y o n e - h a l f of the hospitals studied (49 per cent) the D i r e c t o r of N u r s i n g also attended B o a r d meetings on a r e g u l a r b a s i s . In the other half,  she attended by invitation only.  T h e r e were v e r y few doctors on the boards of management of any of the hospitals studied.  F o r t y - s i x (54 per cent) r e p o r t e d that  there were no doctors on the B o a r d ,  t h i r t y - f o u r (40 per cent) that there  was one only, and five (6 per cent) said there were two to three.  The A d m i n i s t r a t o r s The a d m i n i s t r a t o r is the executive head of the hospital.  He  is r e s p o n s i b l e for o v e r a l l management of the hospital plant, p r e p a r a t i o n and a d m i n i s t r a t i o n of the budget,  and s u p e r v i s i o n of a l l departments.  He is, then, in a top p o l i c y and d e c i s i o n - m a k i n g position with r e g a r d to a l l hospital m a t t e r s .  74 The m a j o r i t y of a d m i n i s t r a t o r s of the hospitals included in the study had had u n i v e r s i t y p r e p a r a t i o n in the field of hospital F i f t y - t w o of the participants (61 per cent)  management.  r e p o r t e d that the a d m i n i s t r a t o r  had had s p e c i a l p r e p a r a t i o n in hospital a d m i n i s t r a t i o n .  Fourteen  a d m i n i s t r a t o r s (16 p e r cent) were l o c a l business men (msually accountants) and five (6 per cent) were p h y s i c i a n s . hospitals,  A m o n g the r e m a i n i n g  the D i r e c t o r of N u r s i n g was also the a d m i n i s t r a t o r in two  instances and in the others the a d m i n i s t r a t o r s were m e m b e r s of r e l i g i o u s orders.  In the latter case, these individuals had almost always had  c o u r s e s i n hospital a d m i n i s t r a t i o n .  One of the m e a s u r e s of p r e s t i g e among hospital a d m i n i s t r a t o r s is affiliation in the A m e r i c a n College of H o s p i t a l A d m i n i s t r a t o r s . T h e r e are three degrees of affiliation, nominee,  m e m b e r and fellow,  each  i n d i c a t i n g i n c r e a s i n g status in the organization. T h i r t y - t w o (38 per cent) of the a d m i n i s t r a t o r s of the p a r t i c i p a t i n g hospitals were affiliated with the C o l l e g e .  O f these, nine were employed in l a r g e hospitals,  ten in m e d i u m - s i z e d hospitals,  eleven in hospitals f r o m t h i r t y to seventy-  four beds and two in hospitals under t h i r t y beds.  II. T H E D I R E C T O R S O F N U R S I N G  The D i r e c t o r of N u r s i n g is the head of the n u r s i n g department within a hospital.  She is d i r e c t l y responsible to the a d m i n i s t r a t o r for  75  management of her department and is, n u r s i n g staff of the hospital.  in turn,  r e s p o n s i b l e for the  In the l a r g e hospitals, this m a y involve  as many as fifteen hundred people,  in the s m a l l e s t ,  as few as six to ten.  In the l a r g e h o s p i t a l s , the position is u s u a l l y m a i n l y a d m i n i s t r a t i v e i n function while in the s m a l l e r hospitals of the p r o v i n c e the D i r e c t o r of N u r s i n g m a y be d i r e c t l y involved in patient c a r e .  In the absence of a  qualified p h a r m a c i s t in most of the s m a l l e r hospitals,  she is in charge  of drug supplies, often functions as X - R a y technician, and u s u a l l y a s s i s t s in the operating r o o m on s u r g e r y days.  G e n e r a l Information about the P a r t i c i p a n t s A l l of the D i r e c t o r s of N u r s i n g of the hospitals included in this study were women. A l l stated that they enjoyed n u r s i n g , sixty-nine (81 p e r cent) said ' v e r y m u c h , the r e m a i n d e r 'most of the t i m e ' . 1  T h e m e d i a n age category was f o r t y - f i v e to f o r t y - n i n e y e a r s . T h e r e were only nine p a r t i c i p a n t s under the age of t h i r t y - f i v e (11 per cent) and three (4 p e r cent) over the age of sixty.  T h e r e were an equal  number of single and m a r r i e d women in the group, as w e l l as twelve widows and five who were either separated or d i v o r c e d .  F o r t y (49  p e r cent) had c h i l d r e n , with fourteen of these having three or m o r e .  O n e - h a l f of the p a r t i c i p a n t s (51 per cent) were graduates of B r i t i s h C o l u m b i a schools of n u r s i n g , one f r o m the basic degree c o u r s e at the U n i v e r s i t y of B r i t i s h C o l u m b i a , the r e s t f r o m hospital d i p l o m a  76  schools in the p r o v i n c e .  O f the r e m a i n d e r , another o n e - t h i r d (33 per cent)  of the total group had taken their b a s i c n u r s i n g p r o g r a m s in other p r o v i n c e s in Canada while fourteen (16 per cent) were graduates of schools in other countries.  Professional Experience T w o - t h i r d s of the D i r e c t o r s of N u r s i n g (69 p e r cent) had graduated f r o m their b a s i c n u r s i n g p r o g r a m s m o r e than twenty years ago and had been e m p l o y e d i n n u r s i n g for over twenty y e a r s .  F i f t y - e i g h t per cent  of the total group had w o r k e d continuously in n u r s i n g since graduation, while the r e m a i n d e r had had i n t e r r u p t e d c a r e e r s .  O v e r o n e - h a l f of the participants (59 p e r cent) had m o v e d up to D i r e c t o r of N u r s i n g f r o m other positions in the same hospital. case of the s m a l l hospitals,  In the  this had u s u a l l y been f r o m a staff n u r s e  p o s i t i o n to head of the department.  In the l a r g e r hospitals,  the move  was most often f r o m assistant d i r e c t o r or s u p e r v i s o r . Fifteen of the participants (18 per cent) had been D i r e c t o r s of N u r s i n g in other hospitals p r i o r to accepting their present positions,  two had been teachers of  n u r s i n g , two public health nurses and seven,head  nurses.  The tenure of the D i r e c t o r s of N u r s i n g was short.  The average  length of time the participants had been in their present position was three y e a r s .  O n e - h a l f (49 per cent) r e p o r t e d that they had been appointed  l e s s than three years ago.  The n u r s e s appeared to stay longer in s m a l l e r  77  hospitals.  T h e r e were m o r e D i r e c t o r s with over five years of s e r v i c e  in the same position amongst the m e d i u m and s m a l l hospitals although even i n these cases, the p r o p o r t i o n was l e s s than o n e - q u a r t e r of the total.  No D i r e c t o r of N u r s i n g had been i n her present position m o r e than  twenty y e a r s .  Academic Preparation T h e r e were five D i r e c t o r s of N u r s i n g (6 p e r cent) in the p a r t i c i p a t i n g hospitals who h e l d a m a s t e r ' s degree and thirteen (15 per cent) with a baccalaureate degree.  F o u r t e e n (16 per cent) had f r o m one  to two y e a r s of u n i v e r s i t y work in addition to their b a s i c n u r s i n g p r o g r a m s , while fifty-three of the total eighty-five (62 per cent) had a c a d e m i c p r e p a r a t i o n to the l e v e l of the m i n i m u m r e q u i r e m e n t s for entrance to a school of n u r s i n g . *  A s one would expect,  the D i r e c t o r s of N u r s i n g in the teaching  hospitals were better p r e p a r e d a c a d e m i c a l l y than their colleagues in non-teaching hospitals.  The m a j o r i t y of the n u r s e s holding baccalaureate  or higher degrees were employed in the l a r g e r hospitals,  seven in the  hospitals over 200 beds and seven in the m e d i u m size hospitals (75 to 200 beds).  F o u r were in hospitals f r o m t h i r t y to seventy-four beds.  * In most cases this was Junior M a t r i c u l a t i o n or the equivalent of U n i v e r s i t y E n t r a n c e in B r i t i s h C o l u m b i a .  78 The academic p r e p a r a t i o n of the participants by size of hospital and teaching status of the institution is shown in T a b l e  II. .  P r e p a r a t i o n beyond B a s i c N u r s i n g E d u c a t i o n T a b l e III shows the number of respondents who had p a r t i c i p a t e d in p o s t - b a s i c education p r o g r a m s by type of course taken.  O v e r one-  t h i r d (34 per cent) of the D i r e c t o r s had taken v a r i o u s hospital postgraduate c o u r s e s ,  twenty-five (29 p e r cent) had taken u n i v e r s i t y  certificate c o u r s e s (usually of one year in length),  while  twenty-eight  (33 per cent) had taken, or were c u r r e n t l y e n r o l l e d in, the Canadian N u r s e s ' A s s o c i a t i o n correspondence course on N u r s i n g Unit A d m i n i s tration.  Eight of the n u r s e s who had taken the correspondence  were f r o m m e d i u m - s i z e d hospitals (75 to 200 beds), hospitals with under seventy-five  course  the r e m a i n d e r f r o m  beds.  P a r t i c i p a t i o n in G e n e r a l Adult Education P r o g r a m s A l a r g e number of the p a r t i c i p a n t s , forty i n a l l (47 per cent), had taken n i g h t - s c h o o l or correspondence courses through adult education p r o g r a m s . F o r most,  these had been c o u r s e s of a general  interest nature including such things as typing, sewing and c e r a m i c s , although four r e p o r t e d having taken c o u r s e s for c r e d i t towards a baccalaureate degree in n u r s i n g or some other field.  T A B L E II L E V E L O F ACADEMIC PREPARATION O F P A R T I C I P A N T S , B Y SIZE A N D TEACHING STATUS OF T H E HOSPITAL Hospital  Minimum Requirements  1 - 2 yrs University  Baccalaureate Degree  Master's Degree  Total  Type A Teaching  Non-Teaching  2 40%  Type B  8  1  2  3  6  17%  33%  50%  100%  1  1  1  5  20%  20%  20%  100%  5  6  1 5%  20  25%  30%  100%  4  4 13%  32  40% Type C  24 75%  Type D  19 86%  Totals  53  13%  100%**  3 14% 14  22 100% 35  13  * T y p e A - 201 beds and over, Type B 75-200 beds, Type C 30-74 beds, and Type D under 30 beds * * Percentage figures have been rounded off to the nearest whole number and therefore do not total exactly 100%  T A B L E III POST-BASIC EDUCATIONAL PROGRAMS T A K E N B Y D I R E C T O R S O F NURSING  Type of C o u r s e  Number of Participants  P e r Cent of T o t a l Population  Hospital Post-Graduate  29*  34%  University Certificate  2 5**  29%  Canadian N u r s e s ' A s s o c i a t i o n C o r r e s p o n d e n c e C o u r s e on A d m i n i s t r a t i o n N u r s i n g Unit  28  33%  6 of these participants held a baccalaureate or higher degree.  ** 8 of these participants subsequently attained or higher degree.  a baccalaureate  81 P a r t i c i p a t i o n in Continuing Education P r o g r a m s for N u r s e s The A v a i l a b i l i t y of Continuing E d u c a t i o n P r o g r a m s The R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a is the p r i n c i p a l coordinating body for continuing education p r o g r a m s for n u r s e s i n the p r o v i n c e . T h e p r o f e s s i o n a l n u r s i n g association has,  in the past,  taken m u c h of the r e s p o n s i b i l i t y for o r g a n i z i n g and conducting educational p r o g r a m s for its m e m b e r s through institutes,  workshops  and conferences held i n V a n c o u v e r and i n v a r i o u s r e g i o n a l centers throughout the p r o v i n c e .  M a j o r r e s p o n s i b i l i t y for short, n u r s e s is g r a d u a l l y being a s s u m e d by the  continuing education c o u r s e s for Departments of Continuing  E d u c a t i o n of the F a c u l t y of M e d i c i n e and the School of N u r s i n g of the U n i v e r s i t y of B r i t i s h C o l u m b i a with c o - s p o n s o r s h i p f r o m the n u r s i n g association.  In the five years i m m e d i a t e l y p r i o r to this study, there had been a total of s e v e n t y - s e v e n of these c o u r s e s s p o n s o r e d by the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n a n d / o r the u n i v e r s i t y .  Two s e r i e s of  r e g i o n a l institutes, held in v a r i o u s centers throughout the p r o v i n c e , accounted for a total of forty of these c o u r s e s . seven were held in V a n c o u v e r .  The r e m a i n i n g t h i r t y -  Attendance figures available show  that over 3, 000 n u r s e s attended r e g i o n a l institutes and an equal number attended p r o g r a m s in V a n c o u v e r .  8  82  Attendance at Continuing Education P r o g r a m s A l l but nine of the D i r e c t o r s of N u r s i n g had attended at least one continuing education p r o g r a m for nurses in the five years p r e c e d i n g the study.  O f the ones who had not attended any, six were f r o m s m a l l  hospitals (under seventy-five  beds) and three were employed in m e d i u m -  s i z e d hospitals (75 to 200 beds).  T a b l e IV gives the frequency and  percentage of attendance at continuing education p r o g r a m s by size of hospital and teaching status.  A l l of the D i r e c t o r s of the l a r g e teaching hospitals had been to m o r e than three p r o g r a m s as had a l l but one D i r e c t o r f r o m other l a r g e hospitals.  The p r o p o r t i o n of participants attending m o r e than three  of the short,  continuing education p r o g r a m s steadily d e c r e a s e d as the  s i z e of the h o s p i t a l d e c r e a s e d .  N u r s e s f r o m the l a r g e r hospitals not only attended m o r e educational p r o g r a m s but p r o p o r t i o n a t e l y also went further afield to go to these.  O f the s i x t e e n participants (19 per cent of the total population )  who r e p o r t e d attending educational meetings out of the p r o v i n c e ,  five  were f r o m l a r g e hospitals (46 per cent of the total number of l a r g e hospitals),  six f r o m m e d i u m hospitals (30 per cent),  and five f r o m the  s m a l l e r hospitals (9 per cent).  The number of participants who had attended educational meeting outside the p r o v i n c e in the five years p r i o r to the study is shown in Table  83  T A B L E IV CONTINUING E D U C A T I O N P R O G R A M S A T T E N D E D B Y PARTICIPANTS,  B Y SIZE A N D T E A C H I N G  STATUS O F HOSPITALS  0  N u m b e r of P r ogr ams Attended M o r e than 1 2 3 3  Teaching  -  -  Non-teaching  -  Hospital  *  Total  Type A  1 20%  -  -  -  -  6 100%  6 100%  4 80%  5 100%  Type B  3 15%  3 15%  2 10%  1 5%  11 55%  20 100%  Type C  3 9%  4 13%  5 16%  8 25%  12 38%  32 100% * *  Type D  3 14%  4 18%  7 31%  2 9%  6 27%  22 100%**  Totals  9  12  14  11  39  85  * Type Type Type Type  A B C D  -  201 beds and over 75 - 200 beds 30 - 74 beds under 30 beds  Percentage figures have been rounded off to the nearest whole number and, t h e r e f o r e , do not total exactly 100%  TABLE V A T T E N D A N C E O F PARTICIPANTS A T EDUCATIONAL M E E T I N G S O U T S I D E T H E P R O V I N C E IN T H E F I V E Y E A R S PRIOR T O T H E STUDY, B Y SIZE A N D T E A C H I N G STATUS O F T H E HOSPITAL  *  Hospital ^  Number  P e r c e n t of Total  i  Type A Teaching  4  67%  Non-teaching  1  20%  Type B  6  30%  Type C  3  9%  Type D  2  9%  Totals  16  Type Type Type Type  A B C D -  201 beds and over 75-200 beds 30-74 beds under 30 beds  85  P a r t i c i p a t i o n in P r o f e s s i o n a l N u r s i n g Organizations The authority to control n u r s i n g in Canada is vested in the provinces,  as are other matters pertaining to health.  The R e g i s t e r e d  N u r s e s ' A c t of B r i t i s h C o l u m b i a , which regulates the t r a i n i n g ,  education  and p r a c t i c e of n u r s e s in the p r o v i n c e , is a p e r m i s s i v e r e g i s t r a t i o n act, that is, the nurse m a y or m a y not r e g i s t e r depending on whether wishes to enjoy the p r i v i l e g e s of r e g i s t r a t i o n . hospitals,  she  O n l y in the teaching  and those hospitals which accept n u r s i n g students for c l i n i c a l  experience,  is it m a n d a t o r y that a l l graduate n u r s e s be r e g i s t e r e d .  9  The R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a is the official l i c e n s i n g body for n u r s e s in the p r o v i n c e . 12,011 n u r s e s r e g i s t e r e d in B r i t i s h C o l u m b i a .  In 1968,  O f these,  there were 10,904 were  engaged in n u r s i n g on a full or p a r t - t i m e b a s i s .  R e g i s t r a t i o n in B r i t i s h C o l u m b i a entitles a nurse to m e m b e r s h i p in her l o c a l n u r s i n g association,  the p r o v i n c i a l a s s o c i a t i o n and the  Canadian N u r s e s ' A s s o c i a t i o n . A l l of the D i r e c t o r s of N u r s i n g of the hospitals included in the study were r e g i s t e r e d in the p r o v i n c e . 1968,  A s of  there were forty-two l o c a l chapters of the R e g i s t e r e d N u r s e s '  A s s o c i a t i o n of B r i t i s h C o l u m b i a which were i n c o r p o r a t e d into eight d i s t r i c t s of the A s s o c i a t i o n , plus two d i s t r i c t s in m e t r o p o l i t a n a r e a s i n which the l o c a l chapter and the d i s t r i c t were combined.  In addition, at  the time of the study, there were four l o c a l chapters not i n c o r p o r a t e d into d i s t r i c t s .  86  The l o c a l n u r s i n g chapters u s u a l l y meet on a monthly b a s i s , the d i s t r i c t s two to four times y e a r l y . The p r o v i n c i a l association holds an annual meeting for a l l m e m b e r s ,  while the national n u r s i n g association  meets once e v e r y two years and the International C o n g r e s s e v e r y four years.  In twenty of the hospitals studied  (24 per cent), the participants  r e p o r t e d that they were i n areas not i n c o r p o r a t e d into d i s t r i c t s of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n and sixteen (19 per cent) said there was no l o c a l chapter close enough for them to attend meetings.  Attendance at meetings of the n u r s i n g association and p a r t i c i pation in the organization to the extent of office-holding or committee m e m b e r s h i p at the three l e v e l s , l o c a l , p r o v i n c i a l and national, v a r i e d in d i r e c t relationship to the size of the hospitals.  That is to say,  the  participants f r o m the l a r g e r hospitals were m o r e active in the p r o f e s sional n u r s i n g association than those f r o m s m a l l e r hospitals,  the  degree of p a r t i c i p a t i o n d e c r e a s i n g steadily as the size of the hospital decreased.  T h e r e was one exception to the g e n e r a l t r e n d .  In the case  of the l o c a l chapter meetings, fifty-five per cent of the n u r s e s f r o m the m e d i u m size hospitals (7 5 to 200 beds) r e p o r t e d that they always attended. group.  T h i s was a m u c h higher percentage than that for any other  87 T h e details of attendance and office-holding or committee m e m b e r s h i p of the participants in the p r o f e s s i o n a l n u r s i n g association at the l o c a l , p r o v i n c i a l and national l e v e l s by size of hospital and teaching status are shown in T a b l e s VI through XI on the following pages.  P r o f e s s i o n a l Reading Habits The D i r e c t o r s of N u r s i n g of the hospitals i n c l u d e d in the study r e p o r t e d that they spent anywhere f r o m a couple of hours a week in reading p r o f e s s i o n a l l i t e r a t u r e to one hour a day.  O n l y three (4 per  cent) s a i d they spent l e s s time than this in reading r e l a t e d to their work, while a few stated they s o m e t i m e s spent two hours a day.  B y far the most widely r e a d p r o f e s s i o n a l j o u r n a l is The Canadian Nurse,  official organ of the Canadian N u r s e s ' A s s o c i a t i o n .  Other n u r s i n g  journals r e c e i v e d by the participants v a r i e d in number f r o m none in twenty-five hospitals (4 per cent),  (29 per cent),to five or m o r e in three hospitals  with the s m a l l e r hospitals (those under seventy-five  beds)reporting  the fewest subscriptions to n u r s i n g journals (other than The Canadian Nurse) and the l a r g e teaching hospitals the most.  O n l y eleven participants  (13 per cent) r e c e i v e d N u r s i n g R e s e a r c h , the p r i n c i p a l j o u r n a l r e p o r t i n g on n u r s i n g studies on this  continent.  T a b l e XII shows the detailed breakdown of number of  T A B L E VI A T T E N D A N C E O F PARTICIPANTS A T MEETINGS O F T H E L O C A L P R O F E S S I O N A L NURSING ASSOCIATION, BY SIZE A N D T E A C H I N G STATUS O F T H E H O S P I T A L  Attended *  Hospital  Always  Mostly  Sometimes  Rarely  Meetings Never  No L o c a l Chapter  Totals  Type A Teaching  2 33%  2 33%  2 33%  Non-teaching  2 40%  1 20%  2 40%  11 55% 4 13% 4 18%  5 25% 10 32% 1 5%  4 20% 6  23  20  14  Type B Type C Type D  Type Type Type Type 1-  A B C D  -  -  19%  •  6 100% * *  —  _  a*  -  2 7% 4 18%  5 16% 2  6  7  9%  5 16% 11 . 50%  16  5 100% 20 100% 32 100% * * 22 100%  85  201 beds and over 75-200 beds 30-74 beds under 30 beds  Percentage figures have been rounded off to the n e a r e s t whole number and, therefore, do not total exactly 100%  89  T A B L E VII O F F I C E OR C O M M I T T E E MEMBERSHIP O F P A R T I C I P A N T S IN T H E L O C A L P R O F E S S I O N A L NURSING ASSOCIATION, B Y SIZE A N D T E A C H I N G STATUS O F T H E HOSPITAL  H o l d Office or Committee M e m b e r s h i p a.  Hospital  Currently  Previously  Never  Totals  Type A Teaching  1 17%  Non-teaching  Type C Type D  Totals  * Type Type Type Type  A B C D -  -  6 100%  2 6% 2 9%  3 60% 12 60% 10 31% 3 14%  2 40% 8 40% 20 63% 17 77%  100% 20 100% 32 100% 22 100%  5  33  47  85  -  Type B  5  83%  201 beds and over 75-200 beds 30-74 beds under 30 beds  5  T A B L E VIII A T T E N D A N C E O F PARTICIPANTS A T MEETINGS O F T H E P R O V I N C I A L P R O F E S S I O N A L NURSING ASSOCIATION, BY SIZE A N D TEACHING STATUS O F T H E HOSPITAL  Attend  *  Hospital  Always  Mostly  Sometimes  Meetings Rarely  Never  No L o c a l Chapter  Total  Type A 2 33%  -  -  33%  2 33%  6 100%**  2 40%  1 20%  2 40%  -  -  5 100%  Type B  8 40%  5 25%  3 15%  1 5%  3 15%  20 100%  Type C  3 9%  4 13%  9 28%  4 13%  12 38%  32 100%**  Type D  2  -  6 27%  2 9%  12 55%  22 100%  22  7  27  85  Teaching Non-Teaching  2  9% 17  Totals * Type Type Type Type  A B C D  -  12  201 beds and over 75-200 beds 30-74 beds under 30 beds  * * P e r c e n t a g e figures have been rounded off to the n e a r e s t whole number and, t h e r e f o r e , total e x a c t l y 100%.  do not o  91  T A B L E IX OFFICE OR COMMITTEE MEMBERSHIP O F P A R T I C I P A N T S IN T H E P R O V I N C I A L P R O F E S S I O N A L NURSING ASSOCIATION, B Y SIZE A N D T E A C H I N G STATUS O F T H E HOSPITAL  * Hospital  H o l d Office or C o m m i t t e e M e m b e r s h i p Currently  Previously  Never  Totals  Type A Teaching  3 50%  2 33%  Non-teaching  3 60%  -  Type B  1 5%  Type C  1 17%  6 100%  2 40%  5  6 30%  13 65%  20 100%  -  2 6%  30 94%  32 100%  Type D  1 5%  -  21 95%  22 100%  Totals  8  10  67  85  * T y p e A - 201 beds and over Type B - 75-200 beds Type C - 30-74 beds Type D - under 30 beds  TABLE X A T T E N D A N C E O F PARTICIPANTS AT MEETINGS O FT H E N A T I O N A L P R O F E S S I O N A L NURSING ASSOCIATION, BY SIZE A N DTEACHING STATUS O FT H E HOSPITAL  Attend  * Hospital  Always  Mostly  Sometimes  Meetings Rarely  Never  No L o c a l Chapter  Total  Type A Teaching Non-Teaching Type B  1 17%  3 50%  -  -  1  -  5% Type C  -  -  1 17% 2 40% 4 20%  -  1 17%  6  3 6o£  5 100%  15 7 5%  20 100% 32 100%  1 3%  2 6%  29 91%  100%*  Type D  -  -  1 5%  2 9%  19 86%  22 100%  Totals  2  3  9  4  67  85  * T y p e A - 201 beds and over Type B - 75-200 beds Type C - 30-74 beds Type D - under 30 beds * * Percentage figures have been rounded off to the n e a r e s t whole number and, t h e r e f o r e , do not total exactly 100%  93  T A B L E XI O F F I C E OR C O M M I T T E E MEMBERSHIP O F P A R T I C I P A N T S IN T H E N A T I O N A L P R O F E S S I O N A L NURSING ASSOCIATION, B Y SIZE A N D T E A C H I N G STATUS O F T H E HOSPITAL  H o l d Office or C o m m i t t e e M e m b e r s h i p Hospital *  Currently  Previously  Never  Totals  Type A Teaching  1  -  17%  5 83%  6 100%  -  -  5 100%  5 100%  Type B  -  -  20 100%  20 100%  Type C  -  -  32 100%  32 100%  22 100%  22 100%  84  85  Non-teaching  Type D  1  Totals  *Type Type Type Type  A B C D  -  201 beds and over 75-200 beds 30-74 beds under 30 beds  0  T A B L E XII N U M B E R R E C E I V E D O F NURSING J O U R N A L S IN A D D I T I O N T O T H E C A N A D I A N N U R S E BY PARTICIPANTS, B Y SIZE A N D T E A C H I N G STATUS O F T H E HOSPITAL  N u m b e r of J o u r n a l s  Hospital  0  1  2  3  4  5  Totals  1  2 33% 2 40%  3 50%  6 100%** 5 100%  *  Type A Teaching  -  17% Non-teaching  1 20%  2 40%  -  Type B  1 5%  5 25%  5 2 5%  5 25%  4 20%  Type C  12 37%  11 36%  6 18%  3  -  -  12 55%  6 27%  3 13%  1  —  —  22  5%  25  23  16  10  8  3  85  Type D  Totals  * Type Type Type Type  A B C D  -  9%  20 100% 32 100%  201 beds and over 75-200 beds 30-74 beds under 30 beds  ** P e r c e n t a g e figures have been rounded off to the nearest whole numbe and, therefore, do not total exactly 100%  s u b s c r i p t i o n s to n u r s i n g journals r e p o r t e d by p a r t i c i p a n t s by size of hospital and teaching status.  III. T H E N U R S I N G S T A F F S O F T H E H O S P I T A L S  Most of the graduate n u r s e s employed i n the public g e n e r a l hospitals of the p r o v i n c e at the time of the study were graduates of B r i t i s h C o l u m b i a or other Canadian schools of n u r s i n g .  O n l y one s m a l l  hospital r e p o r t e d a higher p r o p o r t i o n of graduates f r o m countries other than Canada on their staff.  T h i r t y (35 p e r cent) r e p o r t e d that over one-  half of their n u r s e s were f r o m B r i t i s h C o l u m b i a schools, two (2 per cent) that m o r e than t h r e e - q u a r t e r s of their staff were.  In eighteen of  the hospitals (21 p e r cent) the highest p r o p o r t i o n of the n u r s i n g staff were graduates of Canadian schools of n u r s i n g outside B r i t i s h C o l u m b i a , while one participant stated that m o r e than seventy-five per cent of their n u r s e s were f r o m outside the p r o v i n c e .  E x a c t figures on the number of r e g i s t e r e d n u r s e s on the staff were not gathered because this situation v a r i e s f r o m day to day, but in only a v e r y few instances did the D i r e c t o r s of N u r s i n g indicate that there were any n o n - r e g i s t e r e d graduates on their staffs,  and these individuals  were being encouraged to complete their r e g i s t r a t i o n as soon as p o s s i b l e .  A l l of the l a r g e hospitals and thirteen of the m e d i u m hospitals (65 per cent) r e p o r t e d that their graduate n u r s e s were f a i r l y m i x e d as to  96  age. The s m a l l e s t hospitals indicated, in m o r e instances than any other group, that they had either p r e d o m i n a n t l y younger or older n u r s e s .  IV.  POLICIES O F T H E HOSPITALS  WITH  R E G A R D TO A T T E N D A N C E O F NURSES AT EDUCATIONAL  MEETINGS  In the hospitals s u r v e y e d , the p o l i c y of granting leave of absence with pay for n u r s e s to attend educational meetings and giving financial assistance for expenditures appeared to be f a i r l y w e l l established.  O n l y three hospitals (4 per cent) r e p o r t e d that leave  of absence was not granted, seven (8 per cent) that it was granted sometimes,  or p a r t i a l l y , while seventy-five (88 per cent) stated that  it was r o u t i n e l y given.  A l l but nine hospitals said that the n u r s e s r e c e i v e d money f r o m the hospital to help with expenses for attendance at educational meetings. Two of the nine s a i d the matter had never come up, three said money was never given and four that it was sometimes given.  A l m o s t a l l of the p a r t i c i p a n t s , (91 per cent) stated that they sent n u r s e s to institutes or other educational p r o g r a m s in V a n c o u v e r .  Among  the hospitals outside V a n c o u v e r , the m a j o r i t y (76 per cent) indicated that they sent n u r s e s to r e g i o n a l institutes as w e l l .  In addition to sending n u r s e s away to educational meetings, the m a j o r i t y (69 per cent) of the hospitals r e p o r t e d that they had an i n - s e r v i c e educational p r o g r a m for the n u r s i n g staff.  Many of the  l a r g e r hospitals have one nurse on staff whose p r i n c i p a l r e s p o n s i b i l i t y is i n - s e r v i c e education.  The frequency of educational meetings s e e m e d to v a r y .  One-  t h i r d of the participants (33 per cent) r e p o r t e d that meetings were held once a week or oftener.  Fifteen (18 per cent) said once e v e r y two week  twenty-four (28 per cent) r e p o r t e d monthly meetings, while sixteen (18 per cent) said that educational meetings were held e v e r y once in a while.  V.  T H E NURSES' VIEWPOINT  ON EQUIPMENT  AND PRGGRESSIVENESS  M o s t of the participants (60 per cent) felt that their hospitals were v e r y p r o g r e s s i v e although almost one-half (48 per cent) of the total population said they would like to see m o r e p r o g r e s s and two state that their hospitals were not p r o g r e s s i v e at a l l .  V e r y few  offered an opinion as to who was holding up p r o g r e s s .  The m a j o r i t y of  those who did (eleven, or 12 per cent of the total population) said it was the P r o v i n c i a l Government.  The a d m i n i s t r a t o r was felt to be  r e s p o n s i b l e in two cases and the B o a r d of D i r e c t o r s in one.  98  The hospitals appeared to be well-equipped as far as n u r s i n g was concerned.  T h e m a j o r i t y of the p a r t i c i p a n t s , (68 per cent)  felt they had most of the latest n u r s i n g equipment, indicated that theirs was h o p e l e s s l y out-dated,  although four  and seven said they had  little of the latest.  P r a c t i c a l l y a l l (91 p e r cent) said a l l , or most  of their n u r s i n g staff,  were t r a i n e d to use the latest equipment.  T h e r e s e e m e d to be little difficulty in obtaining needed equipment.  A l m o s t two-thirds of participants (65 per cent) said they had no  p r o b l e m s in this r e g a r d , o n e - q u a r t e r  (24 per cent) said they had a  little difficulty s o m e t i m e s , while ten (12 per cent) r e p o r t e d that they had difficulty most of the t i m e .  Many participants pointed out  that the Women's A u x i l i a r y were v e r y helpful in p u r c h a s i n g new equipment for patient c a r e .  O n l y four participants felt that lack of  equipment was v e r y m u c h of a p r o b l e m in putting new n u r s i n g p r a c t i c e s into effect.  V e r y few indicated that a l l new ideas which were brought to their attention were t r i e d .  The m a j o r i t y (78 per cent) said that some  were and u s u a l l y added a statement to the effect that it depended on the idea and whether it was applicable to their hospital.  99  C H A P T E R III FOOTNOTES  1. 19th Annual Report, J a n u a r y 1st to December 31st, 1967, B r i t i s h C o l u m b i a H o s p i t a l Insurance ( V i c t o r i a , Department of Health S e r v i c e s and H o s p i t a l Insurance, 1968), pp. 38, 39.  vol.  2. B r i t i s h C o l u m b i a Government News ( V i c t o r i a , B . C . , 14, No. 2, M a y , 1966), p. 1.  3. 19th A n n u a l Report of the B r i t i s h C o l u m b i a H o s p i t a l Insurance S e r v i c e , op. cit. , pp. 12, 13. 4. Ibid. , p. 5. I b i d . , pp.  13. 16-19.  6. Ibid. , pp. 30,  31.  7. A B r i e f H i s t o r y of the (Canadian Hospital) A c c r e d i t a t i o n P r o g r a m , unpublished m a t e r i a l on the h i s t o r y of Canadian H o s p i t a l A c c r e d i t a t i o n given to the author by the B r i t i s h C o l u m b i a Hospital Insurance Association. 8. T h e s e figures were c o m p i l e d f r o m r e p o r t s of the minutes of the Annual Meetings of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a , 1963-68 and the Report of the Department of Continuing M e d i c a l Education, F a c u l t y of M e d i c i n e , the U n i v e r s i t y of B r i t i s h C o l u m b i a , 1968. 9. T h e R N A B C , What it is, What it does (pamphlet published by the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a , 1966), p. 8. 10. "Report of the Executive Secretary," R N A B C News (Vancouver, A p r i l / M a y 1969), p. 28.  I  100  C H A P T E R IV T H E F L O W O F I N F O R M A T I O N O N N E W NURSING  PRACTICES  A s d i s c u s s e d i n Chapter II, r e s e a r c h in other d i s c i p l i n e s has shown that there are identifiable channels of c o m m u n i c a t i o n in v a r i o u s s o c i a l s y s t e m s to disseminate i n f o r m a t i o n on new knowledge and technology to m e m b e r s of a community. *  N u r s e s have their own  specific ways of t r a n s m i t t i n g i n f o r m a t i o n about new p r a c t i c e s in n u r s i n g .  In o r d e r to determine the channels used by D i r e c t o r s of N u r s i n g in the hospitals under study, questions were asked during the interview r e g a r d i n g the sources of i n f o r m a t i o n found most helpful at each stage of the adoption p r o c e s s .  T h e n u r s e s were also asked to name the specific  sources they had used for each of the innovations in n u r s i n g p r a c t i c e included in the interview schedule.  A p r e l i m i n a r y l i s t of sources which were thought might be used by the n u r s e s had been c o m p i l e d . *  The participants were asked to  select f r o m the l i s t the sources they had found most helpful or to name  The compilation of the l i s t was d i s c u s s e d in Chapter 1 on page 13, 14  101  others they had used at v a r i o u s stages in the adoption p r o c e s s .  The data gathered was analyzed on the basis of: (1) use of sources by stages in the adoption p r o c e s s ,  (2) use of sources by nature  of the activity involved in the source, (3) use of specific sources for each of the innovations included in the interview schedule,  and (4)  the t r a n s f e r of information about the innovations and c o m m u n i c a t i o n links between hospitals.  I. S O U R C E S O F I N F O R M A T I O N U S E D ,  BY STAGES  IN T H E A D O P T I O N P R O C E S S  T a b l e XIII shows the sources of information r e p o r t e d as used at each stage in the adoption p r o c e s s and the frequency with which these were named by the D i r e c t o r s of N u r s i n g .  Sources named by twenty  or m o r e participants are u n d e r s c o r e d .  T h e r e was a m a r k e d s i m i l a r i t y i n the responses given by participants,  sufficient to indicate that there is a definite p r o c e s s  involved in the seeking of information about new ideas and p r a c t i c e s . T h i s p r o c e s s is c o m m o n to the m a j o r i t y of D i r e c t o r s of N u r s i n g of the public general hospitals of the p r o v i n c e .  The A w a r e n e s s Stage Mason,  T r o l d a h l and others have pointed out that, with f a r m e r s ,  information m a y come f r o m a wide v a r i e t y of sources o r i g i n a l l y .  2  T A B L E XIII:  Stage 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.  S O U R C E S O F I N F O R M A T I O N U S E D B Y P A R T I C I P A N T S A T A L L S T A G E S IN T H E ADOPTION PROCESS Awareness  N u r s i n g staff and other nur ses Doctors Other d i r e c t o r s of n u r s i n g Salesmen-hospital equipment supply house Administrators L i t e r a t u r e f r o m hospital supply houses N u r s i n g journals Institutes H o s p i t a l journals New g r a d u a t e s - C d n schools of N u r s i n g New g r a d u a t e s - B C schools of N u r s i n g Drug s a l e s m e n B . C . H . A . conventions and meetings Films N u r s i n g textbooks M e d i c a l journals R . N . A . B . C . provincial meetings New staff f r o m abroad R. N . A . B . C . News B u l l e t i n  Interest  Evaluation  Trial  Adoption  Total  26  14  72  26  83  221  3_3 40  2_1 66  6_5 12  18 42  71 4  214 164  51 17  34 8  5 55  68 5  68  164 153  5_1 68 5_6 48  50 20 5 9  2 1 2  20 7 2 5  2  45 37 30  6 6  23 2_6 19 2_1  8 3 8 8  2_3 2_1 21  4  2 2  124 98 65 63 53  1 3  48 40  1 2 4  34 31 31 29 25 24 21  T A B L E XIII (Continued)  Stage 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.  Awareness  Patients 9 Previous Experience 16 Hospital Board _ R. N . A . B . C . l o c a l meetings 13 B . C . H . I. S. N u r s i n g Consultant 10 Television programs 8 Newspapers 7 Radio 6 R . N .A. B . C . P u b l i c Health N u r s e Totals  731  Interest  Evaluation  Trial  3 1 5 1  Adoption  Total  8 1 11  21  15 8 7 6 4 1  3 1 282  19 16 15  235  208  258  1714  104  T h i s appears to be true of the n u r s e s also who r e p o r t e d that they r e c e i v e new ideas f r o m m a n y s o u r c e s . of frequency  The most c o m m o n l y named were,  (1) n u r s i n g j o u r n a l s , (2) s a l e s m e n f r o m the hospital  supply houses, (3) institutes and other short, programs,  in orde  continuing educational  (4) l i t e r a t u r e f r o m hospital supply houses, (5) h o s p i t a l  j o u r n a l s , (6) new staff f r o m Canadian schools of n u r s i n g , (other than B r i t i s h C o l u m b i a graduates),  (7) other D i r e c t o r s of N u r s i n g , (8) new  graduates f r o m B r i t i s h C o l u m b i a schools of n u r s i n g , (9) p h y s i c i a n s , (10) drug s a l e s m e n ,  (11) f i l m s , (12) other n u r s e s g e n e r a l l y ,  (13)  attendance at p r o f e s s i o n a l n u r s i n g or hospital a s s o c i a t i o n meetings, (14) new staff f r o m abroad, (15) the News B u l l e t i n of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a , (16) m e d i c a l j o u r n a l s .  It is evident that a new idea m a y come,  then, f r o m any one of a  number of p l a c e s . T a b l e X I V shows the frequency and percentage of s o u r c e s u s e d at the awareness stage of the adoption p r o c e s s .  The Interest Stage Once a D i r e c t o r of N u r s i n g has h e a r d of a new idea and is i n t e r e s t e d in p u r s u i n g it, she seeks additional i n f o r m a t i o n on the subject. were  The five most c o m m o n l y named sources at the interest stage  (1) other D i r e c t o r s of N u r s i n g , (2) l i t e r a t u r e f r o m the hospital  supply houses, (3) s a l e s m e n f r o m the hospital supply houses, doctors,  (5) the n u r s i n g j o u r n a l s .  (4)  105  T A B L E XIV SOURCES O F INFORMATION USED A T T H E AWARENESS STAGE  1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.  Nursing Journals Salesmen - hospital equipment supply houses Institutes L i t e r a t u r e f r o m hospital supply houses Hospital Journals New graduates - Canadian schools of Nursing Other d i r e c t o r s of N u r s i n g New graduates - B . C . Schools of Nursing Doctors Drug salesmen Films N u r s i n g staff and other n u r s e s generally R. N . A . B . C . p r o v i n c i a l meetings B . C . H . A . conventions and meetings New staff f r o m abroad R . N . A . B . C . news bulletin M e d i c a l journals N u r s i n g textbooks Administrator s P r e v i o u s experience R . N . A . B . C . l o c a l meetings B . C . H . I. S. n u r s i n g consultant Patients Television programs Newspapers Radio  Frequency (68)  Per 9  (57) (56) (51) (48)  8 8 7 7  (45) (40)  6 5  (37) (33) (30) (26)  5 5 4 4  (26) (23) (23) (21) (21) (21)  4 3 3 3 3 3 3 2 2 2 1 1 1 1 1  (19) (17) (16) (13) (10) ( ( ( (  9) 8) 7) 6)  731  100%*  P e r c e n t a g e figures have been rounded off to the nearest whole number and therefore do not total exactly 100%.  106 The m o s t usual p r o c e d u r e is for the D i r e c t o r of N u r s i n g to seek i n f o r m a t i o n f r o m others l i k e h e r s e l f who m a y have had experience the innovation, that is,  with  she w i l l write to another D i r e c t o r at a different  hospital; or telephone h e r , to find out m o r e about the new idea. innovation is a new piece of equipment,  If the  she w i l l write for i n f o r m a t i o n  f r o m the hospital supply house, or ask the s a l e s m a n to p r o v i d e her with m o r e detail.  In the s m a l l hospitals p a r t i c u l a r l y , where there is a close  working relationship between the m e d i c a l and n u r s i n g staffs, the doctors are often consulted at this stage.  The journals  m a y be used for  specific reference to information on the new idea and s e v e r a l of the participants mentioned that they would s o m e t i m e s write d i r e c t l y to the author of a j o u r n a l a r t i c l e for additional i n f o r m a t i o n about a new practice.  Other s o u r c e s are also used at the i n t e r e s t stage, although not n a m e d as frequently as the ones above.  The n u r s i n g staff m a y be  questioned to find out i f anyone is f a m i l i a r with the p r a c t i c e f r o m p r e v i o u s experience in other hospitals.  The a d m i n i s t r a t o r m a y be asked  for his opinion, or a request for information m a y be d i r e c t e d to the n u r s i n g consultant staff of the B r i t i s h C o l u m b i a H o s p i t a l Insurance Service, or to the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n .  M e d i c a l journals  and n u r s i n g textbooks m a y be u s e d for additional information.  If there  is to be a continuing education p r o g r a m coming up on the subject, m e m b e r of the staff m a y be sent to it. Sometimes the idea is  a  discussed  107  at a meeting of the D i r e c t o r s of N u r s i n g within their l o c a l B r i t i s h Columbia Hospital Association district.  Information-seeking,  at the interest stage, appears to be d i r e c t e d  and p u r p o s e f u l .  T a b l e . X V shows the frequency and percentage of s o u r c e s  used  at the interest stage of the adoption p r o c e s s .  The E v a l u a t i o n Stage When i n f o r m a t i o n on a new p r a c t i c e has been gathered,  the  idea is evaluated to see i f it would be feasible in the s p e c i a l situation of the p a r t i c u l a r hospital. T h i s appears to be almost e n t i r e l y an i n t e r n a l a s s e s s m e n t with the D i r e c t o r of N u r s i n g consulting with her n u r s i n g staff, the p h y s i c i a n s and the a d m i n i s t r a t o r . Some of the participants mentioned consulting with other D i r e c t o r s of N u r s i n g at this stage, and a few said they contacted the s a l e s m a n f r o m the hospital supply house,  but, by and l a r g e , it is the staff of the h o s p i t a l  who decide whether the idea should be t r i e d in p r a c t i c e .  T a b l e X V I shows the frequency and percentage of s o u r c e s u s e d at the evaluation stage in the adoption p r o c e s s .  T h e T r i a l Stage When  a d e c i s i o n has been made to t r y out something new,  detailed information on the t e c h n i c a l aspects of implementation is  more sought.  108  TABLE XV SOURCES O F INFORMATION USED A T T H E INTEREST STAGE Frequency 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 1.920. 21.  Other D i r e c t o r s of N u r s i n g Information f r o m hospital supply houses Salesmen - hospital equipment supply houses Doctors N u r s i n g journals N u r s i n g staff and other n u r s e s generally H o s p i t a l journals Administrators N u r s i n g textbooks M e d i c a l journals B . C . H . A . conventions and meetings Drug s a l e s m e n New staff - B . C . Schools Institutes New staff - other hospitals in Canada B . C . H . I . S. n u r s i n g consultant Films R.N. A. B . C . New staff f r o m a b r o a d P r e v i o u s experience . Public Health Nurse  P e r cent  (66)  23  (50)  18  (34) (21) (20)  12 7 7  (14) 9) 8) 8) 8) 8) 6) 6) 5) 5) 4) 3) 3) 2)  5 3 3 3 3 3 2 2 2 2 1 1 1 1  ( 1) ( 1)  -  ( ( ( ( ( ( ( ( ( ( ( ( (  282  100% *  • Percentage figures have been rounded off to the nearest whole number and therefore do not total exactly 100%  109  TABLE XVI SOURCES O F INFORMATION USED A T T H E EVALUATION STAGE Frequency 1. 2. 3. 4. 5. 6.  7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.  N u r s i n g staff - other n u r s e s generally Doctors Administrators Other D i r e c t o r s of N u r s i n g Salesmen f r o m hospital supply houses Hospital Board New staff m e m b e r s - B . C . grads Patients Information f r o m hospital supply houses Institutes B . C . H . A . conventions and meetings New staff f r o m hospitals in Canada Nursing journals L o c a l R. N . A . B . C . meetings P r o v i n c i a l R. N . A . B . C . meetings New staff f r o m abroad P r e v i o u s experience R. N . A . B . C . office  (72) (65) (55) (12)  P e r cent  31 28 24 5  ( ( ( (  5) 5) 4) 3)  2 2 2 1  ( ( ( (  2) 2) 2) 2)  1 1 1 1  ( ( ( ( ( (  1) 1) 1) 1) 1) 1)  235  -  100%*  * Percentage figures have been rounded off to the n e a r e s t whole number and therefore do not total exactly 100%  110  If it is a piece of equipment, the s a l e s m a n f r o m the hospital supply house w i l l u s u a l l y give a demonstration for staff m e m b e r s who w i l l be using it.  If the idea is a change in n u r s i n g techniques or routines,  other D i r e c t o r s of N u r s i n g w i l l be consulted.  A staff m e m b e r m a y be  sent to another h o s p i t a l to see the p r a c t i c e i n operation, o r , pondence m a y take the place of a v i s i t . m a y also be used, the p r a c t i c e .  corres-  R e s o u r c e s within the hospital  such as n u r s e s or doctors who are f a m i l i a r with  L i t e r a t u r e f r o m the hospital supply companies m a y  suffice instead of an actual demonstration by the s a l e s m a n .  Some of the  participants mentioned using the n u r s i n g and hospital journals for e x p l i c i t information at the t r i a l stage.  Table* XVLTshows the frequency and percentage of sources used at the t r i a l stage of the adoption p r o c e s s .  The Adoption Stage When a final d e c i s i o n is being made either for full and continued use of an innovation, or its rejection, the evaluation stage.  the same sources are used as at  In actuality, this is also evaluation.  The n u r s i n g  staff p a r t i c u l a r l y those who have t r i e d it, the m e d i c a l staff and the a d m i n i s t r a t o r are consulted.  T h i s time,  after t r i a l use of a new p r a c t i c e . important in of funds,  it is the final a s s e s s m e n t  The a d m i n i s t r a t o r is  cases where adoption of the  especially  innovation involves the outlay  since his a p p r o v a l must be gained before expenditures can be  Ill  T A B L E XVII SOURCES O F INFORMATION USED A T T H E TRIAL STAGE  Frequency 1. 2. '-3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.  Salesmen f r o m hospital equipment supply houses Other D i r e c t o r s of N u r s i n g N u r s i n g staff and other n u r s e s generally Information f r o m hospital supply houses Doctors N u r s i n g j ournals H o s p i t a l journals Administrators N u r s i n g textbooks Drug s a l e s m e n Institutes Films L o c a l R. N . A . B . C . meetings P r o v i n c i a l R . N . A . B . C . meetings B . C . H . A . conventions and meetings New staff - B . C . schools New staff - other Canadian hospitals Patients  P e r cent  (68) (42)  33 20  (26)  13  (20) (18) ( 7) (5) ( 5) ( 4) ( 3) (2) ( 2) ( 1) ( 1) ( 1) ( 1) (1) ( 1)  10 9 3 2 2 2 1 1 1  208  -  100%*  • P e r c e n t a g e figures have been rounded off to the nearest whole number and therefore do not total exactly 100%.  authorized.  S e v e r a l participants mentioned that the H o s p i t a l B o a r d  must also be consulted i f the innovation means a change in hospital p o l i c y or affects c o m m u n i t y r e l a t i o n s .  It was r e p o r t e d by some D i r e c t o r s of N u r s i n g that the opinion of patients m a y be sought before a final d e c i s i o n is made on matters concerning the patients' welfare and a few stated that they consulted with other D i r e c t o r s of N u r s i n g at the final d e c i s i o n - m a k i n g stage.  T a b l e X V I I I shows the frequency and percentage of s o u r c e s used at the adoption stage of the adoption p r o c e s s .  II. S O U R C E S O F I N F O R M A T I O N U S E D , B Y NATURE O F ACTIVITY  The s o u r c e s of i n f o r m a t i o n were divided into four categories a c c o r d i n g to nature of the activity:(l) impers.onal s o u r c e s , m a s s media* (2) attendance at institutes,  that i s ,  workshops and other short,  continuing education programs;(3) attendance at p r o f e s s i o n a l meetings and(4) p e r s o n a l s o u r c e s ,  that i s , i n t e r p e r s o n a l c o m m u n i c a t i o n .  Table X I X shows the frequency and percentage of s o u r c e s used at the five stages of the adoption p r o c e s s by nature of the activity. Sources named by twenty participants or m o r e are u n d e r - s c o r e d .  It is evident that a l l four categories of sources are used  113  T A B L E XVIII  SOURCES O F INFORMATION USED A T T H E ADOPTION STAGE  Frequency 1. 2. 3. 4.  5. 6. 7. 8. 9. 10. 11. 12.  N u r s i n g staff Doctors Administrators Board Patients Other D i r e c t o r s of N u r s i ng N u r s i n g journals Information f r o m hospital supply houses H o s p i t a l journals Drug S a l e s m e n B . C . H . I. S. n u r s i n g consultant P r e v i o u s experience  (83) (77) (68) (11) ( 8) ( 4) ( 2)  Per  cent  32 30 26 4 3 2 1  (  258  100% *  * P e r c e n t a g e figures have been rounded off to the nearest whole number and therefore do not total exactly 100%.  T A B L E XIX  S O U R C E S O F I N F O R M A T I O N U S E D B Y P A R T I C I P A N T S A T S T A G E S IN T H E ADOPTION PROCESS, ACCORDING TO N A T U R E O F T H E ACTIVITY  Awareness  fl  ^  M  rt  h  U  Interest  ^  3  Evaluation  H,  M  • • M  U  f  a  Adoption  2,  ^S)  u  ctf  h  Trial  A  ti  nJ  U •  '  rt  h  U  h  '  O  h  1. I m p e r s o n a l Sources Nursing Journals Information f r o m hospital supply house H o s p i t a l Journals Films ' R. N . A . B . C . news Bulletin Medical Journals N u r s i n g Textbooks Television Programs Newspapers Radio SUB  TOTAL  68_  25  20  51 48_ 2_6  19 17 9  50 9 3  21_ 21 19" 8 7 6  8 8 7 1  _ 8 8 _ _ _  275  3 2 100%*  98  .  .  20  1  33  '.7  18  2  50  51 9  2  67  20 5  1 1  25 25  -  -  52 13 5  3 _  _ 8 8  _ _ _ 100%*  2  -  _ _ _  _  -  4 _  _ _ 3  100%*  _ _ _  10 _  _  _  _  _ _  _ _  38 \  100%*  4  100%  0.5  ro  w  ^ 9£  a O >  OP  »  *  n>  OP  td rJ- >  ' 3' '  O O o p  crq  co  co O o 3 <! tt  ro  OJ  2 •§  3  CL  3 P TO 3 CO  O OP  o CD  o  3 «  >-t o  OJ  OJ  tSJ  W  ft)  X i—i  B"S  o  OP W  <! o 3  (11  <-f  p  3  <-••  - 2  ct>  P  F  3  R. M .  DJ  Hi*  CO CO *-«•  o 3  td  s  ^ 3 a p £ p>  H  cn  o o  w  O <J  tt <-+  DO OJ  •  c+  O  ^  o  ui  to  >  o 3 UI  o o  sa  e  CO CL  T  ^  Frequency-  re Category  > P » 3  CD  CQ CO  Frequency  co  CO  I  U I  CD  H  o o  o o  O O  S3  sa  ro  %  a  CO  Category  Frequency  w  <I p C P  o o  sa  ro  m  UI  O  ro UI  OJ OJ  OJ OJ  OJ OJ  Category  <-t»-••  o 3  sa  ro  OJ  o o  o o  %  o o  Frequency  Category  sa  Frequency  > CL  o  r+  % Category  SIl  o 3  T A B L E X I V (Continued)  13  °  bo 9  13  y  ^  0 «  13  u  Frequency .  U  w  VI  Frequency"  u fa  v •  Frequency  u  Adoption  Trial  Evaluation  Interest  Awareness  Frequency  -  jquency  .  41  -  1  -  25  4  2  77 1  30 -•  Vl fe- b0 «  13  SK • ; Vi.  _^ bo © 13  o  1. P e r s o n a l ' S o u r c e s Salesmen f r o m hospital supply houses New Graduates - Cdn schools of N u r s i n g Other D i r e c t o r s of Nursing New Graduates - B C schools of N u r s i n g Doctors Drug Salesmen N u r s i n g staff and other nurses generally New Staff f r o m abroad Administrators Previous Experience B . C . H . I. S. N u r s i n g Cons Patients Public Health N u r s e . Hospital Board %  SUB  34  20  :5  2  45  13  5  3  2  1  1  12. •  12  66  39  12  5  42  11  6 21 6  4 13 4 ; .  4 65  2  1  1  29  18 3  11 2  32  26  16 3  83 68 1 1  33 27 -  i  8 11  3 ••4 100%*  37 33 30 26 21 17 16 10  ,.  10 9  731  /  8 6  14:'. 2 8  :"' 5 5 3  9 .'. -  TOTAL  GRAND T O T A L  •  8 1 5  1 4  1 • •2 1 .... V.''.. -  100%;,  168  •  279  -  100%*  72 1 55 1 • ':  3  68  -  17  57  24 ' .'.  .- ' . 1  5 -•: I  - ; s'  -  3  .  -  225 .  100%*  165  100%*  254  234  -  208  • -  258  P e r c e n t a g e figures have been rounded off to the n e a r e s t whole number and t h e r e f o r e do not total exactly 100%. - .  117 frequently in the e a r l y stages of the adoption p r o c e s s while, stages of evaluation, t r i a l ,  and final d e c i s i o n - m a k i n g ,  N u r s i n g depend almost e n t i r e l y on p e r s o n a l s o u r c e s .  in the latter  the D i r e c t o r s of The relative  importance of i m p e r s o n a l s o u r c e s thus declines as the potential adopter moves through the innovation-decision p r o c e s s .  T h i s is consistent with  the findings of r u r a l sociologists and r e s e a r c h e r s in the fields of medicine and education.  3  Use of I m p e r s o n a l Sources I m p e r s o n a l sources of information are used most by the D i r e c t o r s of N u r s i n g at the awareness and interest stages of the adoption process. Professional Journals The chief i m p e r s o n a l source is the p r o f e s s i o n a l j o u r n a l , with the n u r s i n g journals outranking the hospital j o u r n a l s , in o r d e r of frequency named, by 42 per cent.  O f the n u r s i n g journals, by far the  most widely r e a d is The Canadian N u r s e , official organ of the Canadian N u r s e s ' A s s o c i a t i o n . A portion of the l i c e n s i n g fee for nurses in B r i t i s h C o l u m b i a pays for a s u b s c r i p t i o n to this j o u r n a l , so that e v e r y R e g i s t e r e d N u r s e in the p r o v i n c e r e c e i v e s it r e g u l a r l y . The m a j o r i t y of participants (89 per cent) r e p o r t e d that they r e a d a l l or most of the a r t i c l e s in it.  O v e r o n e - q u a r t e r (26 per cent) r e c e i v e no other n u r s i n g  journal, while another 26 per cent subscribe to only one other, p e r s o n a l l y or at work.  either  N u r s i n g R e s e a r c h , the p r i n c i p a l journal  r e p o r t i n g r e s e a r c h findings in n u r s i n g on this continent,  is r e c e i v e d by  118 only eleven hospitals in the group under study, the six l a r g e teaching hospitals,  one other l a r g e hospital and four m e d i u m size hospitals  (75-200 beds).  S e v e r a l hospital a d m i n i s t r a t i o n journals are u s u a l l y available to the n u r s i n g staff,  some coming d i r e c t l y to the n u r s i n g office,  while  others are s h a r e d with the a d m i n i s t r a t o r . T h e D i r e c t o r s of N u r s i n g r e p o r t that the hospital journals contain m u c h that is pertinent to n u r s i n g and of p a r t i c u l a r interest to n u r s i n g a d m i n i s t r a t o r s .  The j o u r n a l s were found to be most useful in drawing attention to new ideas,  although there was some indication of their use at the  interest stage and o c c a s i o n a l l y during later stages also.  L i t e r a t u r e f r o m the H o s p i t a l Supply Houses The next most frequently named i m p e r s o n a l source of i n f o r m a t i o n was the l i t e r a t u r e sent out by c o m m e r c i a l f i r m s dealing in hospital equipment. T h i s wasused about equally at the awareness and interest stages, with some r e f e r e n c e to this source again at the t r i a l stage.  T h i s l i t e r a t u r e is chiefly a d v e r t i s i n g m a t e r i a l put out by  companies wishing to sell their p r o d u c t s .  Films F i l m s came eleventh on the l i s t in rank o r d e r of use of a l l s o u r c e s at the awareness stage, being named by twenty-six (31 per cent)  119 of the respondents as being useful in b r i n g i n g new ideas to their attention. M a n y n u r s e s e x p r e s s e d a d e s i r e for m o r e films on new p r a c t i c e s in n u r s i n g and a wish that it were e a s i e r to obtain them.  The suggestion  was made that there be a f i l m l i b r a r y in the province so that available films would be m o r e r e a d i l y a c c e s s i b l e .  Other I m p e r s o n a l Sources Other i m p e r s o n a l sources named by the participants were m e d i c a l journals and n u r s i n g textbooks.  Many D i r e c t o r s of N u r s i n g  indicated that they had started s m a l l n u r s i n g l i b r a r i e s and would like to i n c r e a s e their holdings so that r e f e r e n c e m a t e r i a l would be available to the n u r s i n g staff when needed.  M a s s m e d i a communications,  other than those mentioned above,  were not a c o m m o n source of information for the n u r s e s .  Television,  radio and newspapers apparently provide little that is of p r o f e s s i o n a l interest to the D i r e c t o r s of N u r s i n g although a few mentioned that they o c c a s i o n a l l y came a c r o s s a new idea in a newspaper item,  or on a  t e l e v i s i o n or radio p r o g r a m .  Institutes and other Short, Continuing Education P r o g r a m s T h e r e has been m u c h activity in the a r e a of continuing education p r o g r a m s for nurses in the p r o v i n c e during recent y e a r s . five years i m m e d i a t e l y p r e c e d i n g the study,  In the  a total of t h i r t y - s e v e n short  c o u r s e s for n u r s e s had been offered in the Vancouver a r e a and another  120 forty  r e g i o n a l institutes held in v a r i o u s centers throughout the 4  province.  A l l but nine (11 per cent) of the participants had  attended at least one of these p r o g r a m s and fifty-eight,the  majority,  (68 per cent) had attended three or m o r e . In addition, seventy-seven of the D i r e c t o r s of N u r s i n g (91 per cent) r e p o r t e d that they sent m e m b e r s of their n u r s i n g staff to educational p r o g r a m s in Vancouver while sixty-one of the n u r s e s  from  hospitals outside the Vancouver a r e a (76 p e r cent) said they sent n u r s e s to r e g i o n a l institutes as w e l l .  The p o l i c y of granting leave of absence with p a y for  attendance  at educational meetings appears to be f a i r l y f i r m l y established in the hospitals under study. A l l but three of the participants stated that leave of absence with pay was granted in their hospitals. mentioned, however,  Six  that this was a ' s o m e t i m e s ' matter and one said  that part of the time only was granted as leave with pay.  T h e r e are  u s u a l l y r e s t r i c t i o n s on the number of n u r s e s who m a y attend in ' o n duty' time and others who wish to go,  do so on their own t i m e .  It is also a p o l i c y in s e v e n t y - s i x (89 per cent) of the hospitals for n u r s e s attending educational p r o g r a m s to have some or a l l of their expenses paid by the hospital.  A c e r t a i n amount of the annual budget  of the hospital is allocated for educational purposes but most of the  121 participants stated that there was never enough money to send a l l the n u r s e s they would like to educational p r o g r a m s and the budget,  which  must cover a l l hospital staff, is u s u a l l y depleted long before the end of the y e a r .  The short,  continuing education p r o g r a m , none the l e s s ,  appears  to be an important source of information on new knowledge and technology in n u r s i n g . The nurse who attends is u s u a l l y expected to r e p o r t at a staff meeting on what she l e a r n e d and new ideas are d i s c u s s e d and evaluated with others.  T h e participants cited the continuing e ducation  p r o g r a m s as one of the p r i n c i p a l sources of information at the a w a r e ness stage. A few mentioned that they were also helpful at the interest stage.  If they had h e a r d of something new and there was to be an  institute on the subject,  they would go t h e m s e l v e s or send a staff  m e m b e r to find out m o r e about the idea. Two p a r t i c i p a n t s mentioned the use of continuing education p r o g r a m s at the evaluation and t r i a l stages also.  Attendance at P r o f e s s i o n a l Meetings Attendance at p r o f e s s i o n a l meetings,  s p e c i f i c a l l y the annual  meetings of the P r o v i n c i a l N u r s i n g A s s o c i a t i o n and meetings of the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n , ranked fourteenth and fifteenth on the l i s t of s o u r c e s used at the awareness stage of the adoption process.  It has been the p r a c t i c e of the N u r s i n g A s s o c i a t i o n to set  122 aside a p o r t i o n of their t h r e e - d a y annual meeting for the presentation and d i s c u s s i o n of new ideas in n u r s i n g . Although twenty-seven (32 per cent) of the participants stated that they had never attended an annual meeting of their p r o v i n c i a l n u r s i n g association and another 5 six (7 per cent) s a i d they r a r e l y go,  it appears that those who do  attend feel they gain many new ideas f r o m this s o u r c e . F i g u r e s were not gathered on the number of D i r e c t o r s of N u r s i n g who attended meetings of the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n but it appears that the H o s p i t a l A s s o c i a t i o n conventions and meetings are also c o n s i d e r e d good sources of i n f o r m a t i o n about new ideas in n u r s i n g .  In each A r e a C o u n c i l (district) of the H o s p i t a l  A s s o c i a t i o n , the D i r e c t o r s of N u r s i n g have begun to meet on a r e g u l a r basis to d i s c u s s mutual p r o b l e m s and plan for r e g i o n a l educational p r o g r a m s .  M a n y participants s t r e s s e d the value of the i n f o r m a l exchange with colleagues that takes place at p r o f e s s i o n a l meetings.  S e v e r a l said,  "you can l e a r n m o r e over a cup of coffee with another d i r e c t o r , e s p e c i a l l y if she comes f r o m the same size hospital as you do and has s i m i l a r problems".  The 'getting to know' one another also helps to  facilitate c o m m u n i c a t i o n after the meetings.  Many said they found it  much e a s i e r to c a l l another d i r e c t o r or write to her for i n f o r m a t i o n after chatting i n f o r m a l l y at meetings.  123 Use of P e r s o n a l Sources P e r s o n a l s o u r c e s a r e used by the D i r e c t o r s of N u r s i n g at a l l stages of the adoption p r o c e s s ,  their r e l a t i v e i m p o r t a n c e i n c r e a s i n g  in the l a t e r stages when decisions are being made relative to the t r i a l and continued use of an innovation, or when there is a need for d i r e c t and detailed instructions on implementation of a new p r a c t i c e .  The chief p e r s o n a l sources of i n f o r m a t i o n n a m e d by the p a r t i c i p a n t s i n this study were  (1) other D i r e c t o r s of N u r s i n g , (2)  n u r s i n g staff within the hospital, (3) p h y s i c i a n s ,  (4) a d m i n i s t r a t o r s ,  and (5) s a l e s m e n .  Other D i r e c t o r s of N u r s i n g The importance of communications with other D i r e c t o r s of N u r s i n g is evident f r o m the high ranking of this source at the a w a r e ness (seventh) interest (first),  and t r i a l stages (second), of the adoption  p r o c e s s and is i n a c c o r d with one of the most c o m m o n p r i n c i p l e s of c o m m u n i c a t i o n , n a m e l y , that people interact m o s t l y with others l i k e themselves.  In this respect,  the D i r e c t o r s of N u r s i n g a r e the same  as the m e m b e r s of any other s o c i a l c o m m u n i t y where 'like talks to l i k e ' , * the concept of homophily d i s c u s s e d by R o g e r s and Shoemaker. T h i s was shown to be true i n the e a r l y communications studies on voting behavior of people by L a z a r f e l d and others,  See Chapter II , p. 32  in the N o r t h e r n  for a m o r e complete d i s c u s s i o n of this topic.  124  Saskatchewan studies by Leuthold on f a r m e r s , and in the drug studies by C o l e m a n and M e n z e l on the diffusion of innovations among i  physicians.  6  The N u r s i n g Staff within the H o s p i t a l The n u r s i n g staff within a hospital also p r o v i d e m u c h i n f o r m a t i o n on new ideas and p r a c t i c e s in n u r s i n g . N u r s e s show c o n s i d e r a b l e job m o b i l i t y and their experience i n other hospitals is a useful source of information.  Many participants s a i d they made a habit of q u e s t i o n -  ing e v e r y graduate who came on staff to find out what new things are being t r i e d i n other p l a c e s .  P a r t i c u l a r l y helpful in this r e g a r d are  the recent graduates f r o m B r i t i s h C o l u m b i a and other Canadian schools of n u r s i n g since the teaching hospitals are 'supposed to be up on a l l the latest', a c c o r d i n g to statements made by m a n y of the D i r e c t o r s of Nursing.  The staff were mentioned again at the interest stage, although  they do not figure as p r o m i n e n t l y in this r e g a r d as other s o u r c e s .  When decisions are being made r e l a t i v e to the t r i a l or continued use of an innovation, the n u r s i n g staff is almost i n v a r i a b l y consulted. Seventy-two (85 per cent) of the D i r e c t o r s of N u r s i n g r e p o r t e d that the staff were brought into d i s c u s s i o n s p r i o r to t r i a l use of a new p r a c t i c e and eighty-three (98 per cent) s a i d the n u r s i n g staff were i n v o l v e d in the final d e c i s i o n r e g a r d i n g adoption. The staff m a y also be a s o u r c e of information r e g a r d i n g the details of i m p l e -  125 meriting an innovation, as indicated by use of this source during the t r i a l stage.  The M e d i c a l Staff P h y s i c i a n s were n a m e d as a source of new ideas by t h i r t y - t h r e e (39 p e r cent) of the participants and twenty-one (25 p e r cent) said that when they h e a r d o f something new they would ask the m e d i c a l staff i f they had any i n f o r m a t i o n on the subject.  A g a i n the p h y s i c i a n s were  consulted during the t r i a l stage but their greatest i m p o r t a n c e appeared to be as referents during the evaluation and final d e c i s i o n - m a k i n g stages. Sixty-five (76 per cent) of the participants said the m e d i c a l staff were consulted before an innovation was t r i e d and s e v e n t y - s e v e n (91 per cent) r e p o r t e d that they included the m e d i c a l staff in decisions r e g a r d i n g its continued use.  T h e use of p h y s i c i a n s as a source of i n f o r m a t i o n is m u c h as one would expect since many changes in n u r s i n g p r a c t i c e have about as a r e s u l t of changing m e d i c a l p r a c t i c e .  come  The adoption of  innovations in one field u s u a l l y has d i r e c t or i n d i r e c t i m p l i c a t i o n s for the other.  The A d m i n i s t r a t o r The hospital a d m i n i s t r a t o r , although mentioned by some participants as a source of i n f o r m a t i o n in the e a r l y stages of the adoption p r o c e s s ,  is also most important at the evaluation and adoption  stages.  H i s advice is sought by the m a j o r i t y of D i r e c t o r s of N u r s i n g  ( 6 5 per cent) before innovations are introduced for t r i a l and in eighty per cent of the hospitals ( 6 8 ) it was r e p o r t e d that the a d m i n i s t r a t o r was brought in on the final d e c i s i o n r e g a r d i n g adoption of innovations.  The use of the a d m i n i s t r a t o r as a referent, standable,  again is u n d e r -  since a p p r o v a l by the a d m i n i s t r a t o r is n e c e s s a r y  before  changes in n u r s i n g p r a c t i c e which affect other departments in the hospital, or r e q u i r e an outlay of funds,  can be i m p l e m e n t e d .  Salesmen The r o l e of the c o m m e r c i a l agent, in this case, the f r o m the hospital supply house,  appears to be an important one in the  d i s s e m i n a t i o n of i n f o r m a t i o n about new ideas, to equipment.  salesman  p a r t i c u l a r l y with r e g a r d  Not only does the s a l e s m a n appear second on the l i s t  of s o u r c e s at the awareness stage but he ranks t h i r d at the interest and f i r s t at the t r i a l stages.  The 'detail man' f r o m the hospital  supply house appears to p e r f o r m m u c h the same function in this instance as the drug s a l e s m a n among p h y s i c i a n s ,  o r the r e t a i l s e l l e r  7 of f a r m equipment with the f a r m e r s .  Other p e r s o n a l  sources  Other p e r s o n a l sources of i n f o r m a t i o n named by the participants were  drug s a l e s m e n ,  n u r s i n g consultants  H o s p i t a l Insurance S e r v i c e , patients,  f r o m the B r i t i s h C o l u m b i a  and public health n u r s e s .  127  In m a n y of the s m a l l e r hospitals in the province, there is no qualified p h a r m a c i s t and the D i r e c t o r of N u r s i n g is in charge of drug supplies.  She must, therefore,  be up-to-date on the latest p h a r m a -  ceutical products and the drug s a l e s m a n is v e r y helpful in p r o v i d i n g her with i n f o r m a t i o n on this topic.  The B r i t i s h C o l u m b i a H o s p i t a l Insurance Service offers a consultative s e r v i c e for hospitals in addition to m a k i n g p e r i o d i c inspection t o u r s .  M a n y participants commented on the help they  had r e c e i v e d f r o m the n u r s i n g consultants but few take advantage of the consultative s e r v i c e available.  V i s i t s are initiated,for the most  part, by the Department although they m a y also be made at the hospital's  8 request.  Patients appeared on the l i s t of sources of information used at the awareness and adoption stages p r i n c i p a l l y . Sometimes  patients  are the o r i g i n a l source of a-new idea in n u r s i n g and a few participants s a i d they consulted the patients before adopting a change in n u r s i n g p r a c t i c e that would affect the patients' welfare.  Some of the D i r e c t o r s  of N u r s i n g mentioned that they were inviting suggestions f r o m patients r e g a r d i n g their c a r e while in hospital and had r e c e i v e d many helpful ideas f r o m this s o u r c e .  The d i s t r i c t public health nurse was mentioned in one instance as being helpful in p r o v i d i n g additional information at the interest stage in the adoption p r o c e s s .  128  in. S O U R C E S O F I N F O R M A T I O N U S E D F O R SPECIFIC  Table  XX  INNOVATIONS  shows the l i s t of sources r e p o r t e d as being used by  the p a r t i c i p a n t s for each of the nine innovations included in the i n t e r view schedule,  and the frequency with which these were named.  These  w i l l be d i s c u s s e d under three headings: (1) sources u s e d for changes in n u r s i n g techniques, routines,  (2) sources used for changes in n u r s i n g  and (3) s o u r c e s u s e d for innovations i n v o l v i n g c o m m e r c i a l  products.  Sources u s e d for Changes in N u r s i n g Techniques Information about the n u r s i n g techniques used in this s t u d y a p p e a r e d to  be t r a n s m i t t e d m a i n l y through i n f o r m a l channels of  communication, f r o m n u r s e s to other n u r s e s .  New staff were  r e p o r t e d as being the chief source of i n f o r m a t i o n about the ' A u s t r a l i a n lift', mitt r e s t r a i n t s and the 'closed glove' technique.  Information  about the A u s t r a l i a n lift is being t r a n s m i t t e d by n u r s e s and p h y s i o therapists f r o m A u s t r a l i a a.nd England, although in one hospital it was mentioned that the staff had seen this technique in a f i l m on lifting patients and had subsequently adopted it. The glove technique has been demonstrated in institutes for operating r o o m n u r s e s .  These  institutes had also been an important channel of communication about  T A B L E XX  SPECIFIC SOURCES O F INFORMATION USED B Y PARTICIPANTS F O R E A C H INNOVATIONS Personal  sources >  CO u  Innovation  w OJO SH  I m p e r s o n a l Sources  O  rH  u  •(->  O  H->  J) bO  • rH  Q  m  CO  rH  rj  C  CD  £  CQ  U  W>  CD • rH  P CO CQ  PH  3  fi  O  £ U  c  o  5  •rH  rH  O o  rd rH  a  <  .rH  .2 CD  X  On  «tH  o  H  "H •*->  rH  CO  c bo co o fl  fH  >H  •rH fll  4->  5  >H  C ctf rH  s^  O  18  Boxing Glove Mitt R e s t r a i n t s  24  ' C l o s e d Glove' Technique  49  1  1  Sheepskin P e l t s  43  6  43  Open V i s i t i n g  65  38  6 a. m . T e m p e r a t u r e  56  14  Elimination Drawsheets  65  Colored dresses with c h i l d r e n  40  12  Disposable s y r i n g e s  44  16  CO  CO  rM rH  o o CQ  o £  U  Australian Lift  rj  fj)  HH  19  1  5  29  6  7 47  11  1  6  13  3  43  14  19  44  10  1  47  9  8  Elimination  6 15  71  32  3  22  6 5  2  2  69  4  9  3  98  72  ro i  130 this innovation.  S e v e r a l participants r e p o r t e d that l i t e r a t u r e on the  technique is available f r o m some of the hospital supply houses.  Sources u s e d for Changes in N u r s i n g Routines The changes i n n u r s i n g routines which were investigated during the course of this study appear to have r e c e i v e d m u c h  more publicity  in the n u r s i n g l i t e r a t u r e than the techniques which were selected, and also to have been m o r e widely d i s c u s s e d among n u r s i n g a d m i n i s t r a t o r s . The n u r s i n g staff were again l i s t e d as a p r i n c i p a l source of information about a l l four innovations but a l a r g e number of the D i r e c t o r s of N u r s i n g stated that they had r e a d a r t i c l e s in the n u r s i n g journals about open v i s i t i n g hours, e l i m i n a t i o n of the e a r l y m o r n i n g temperature routine, a nd the use of c o l o r e d d r e s s e s by nurses working in p e d i a t r i c units. These topics had also been d i s c u s s e d with other D i r e c t o r s of N u r s i n g . The e l i m i n a t i o n of drawsheets seems to have come about m a i n l y through n u r s e s t h e m s e l v e s questioning the need for continuing this routine within their own hospitals rather than through i n f o r m a t i o n r e c e i v e d f r o m outside  sources.  Sources used for Innovations Involving C o m m e r c i a l P r o d u c t s In the case of the two innovations involving c o m m e r c i a l products, the use of sheepskin pelts for skin care and the disposable syringes,  the chief sources of information have been the s a l e s m a n and  l i t e r a t u r e f r o m the h o s p i t a l supply houses. A d v e r t i s e m e n t s in the  131 n u r s i n g and hospital journals were also r e p o r t e d as s o u r c e s where the participants either f i r s t h e a r d of the innovation or found out m o r e about it.  S e v e r a l D i r e c t o r s of N u r s i n g said their f i r s t knowledge about the use  of sheepskin pelts came f r o m patients or their r e l a t i v e s who had l e a r n e d of their use e l s e w h e r e . T h e a d m i n i s t r a t o r was also frequently named as a source of information about the disposable  syringes.  IV. T H E F L O W O F I N F O R M A T I O N T H R O U G H T H E NETWORK O F HOSPITALS  In attempting to t r a c e the flow of i n f o r m a t i o n through the network of public general hospitals in the p r o v i n c e , two techniques  were  employed: (1) charts were made showing the pattern of adoption for each of the innovations investigated,  and (2) d i a g r a m s were drawn depicting  the extent of communication between hospitals.  P a t t e r n of Adoption F i g u r e s 4 through 12 show the pattern of adoption of each of the nine innovations investigated in the course of this study.  These  figures show the stage in the adoption p r o c e s s r e a c h e d by each h o s p i t a l a n d / o r the date of adoption of each innovation, by size of hospital and geographic location in the p r o v i n c e . T h e B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n d i s t r i c t s were used as the divisions of geographic location, n u m b e r e d a p p r o x i m a t e l y in o r d e r of distance f r o m V a n c o u v e r .  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 to 8  1  ADOPTED  2  4  3  6  5  1 0  7  8  AUSTRALIAN LIFT- Dates of Adoption or Stage Reached i n the Adoption Process, by Size of Hospital.  9 8 7  •  6  pyj Type A - teaching Q  Type B  |  Type C  [ Type A - Non-  A  Type D  5 FIGURE 4  4  A A  2  0  AO  0  1  m  <1 Trial  o  0 AAAA  o  OO  0 0  Evaluation Interest Awareness  s o  oo  Not Aware  •OOOA  • O A A A A  BSD AAA  OAAO 0 0  noo: u  0 0 0  A  AO A  A  A  0  AAA  oo  A  O  0  nooo U  A A A  OOAAAA  000  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 t o 8  1  ADOPTED  > 10  2  3  4  A  T T  5  BOXING GLOVE MITT RESTRAINTS: Dates of A d o p t i o n o r Stage Reached i n t h e A d o p t i o n P r o c e s s , by S i z e o f H o s p i t a l .  •  A  5  3  l - l T y p e A - Non1—1 teaching 3 V  \\  _\  1  <l  DC 5o  Not aware  T v  P  e  B  ^ 1™* * f i Type D U FIGURE 5  A  \\  \ \ rang bAAp  A  \\  \\ \bo  0  A  0 0 • AA  00  AA  Interest Awareness  O  0  \  \\  \  2  Evaluation  jyjType A - teaching  \  4  Trial  8  .A  8  6  7  B  9  7  6  A • • A O OOA  •AAO •OAO  \ oo O A  A  A  A  oo  00  o 0 A A 00  *A00 AA  A OAOO  O A A 000  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 t o 8  1  ADOPTED  2  4  3  5  10  6  7  8  'CLOSED GLOVE* TECHNIQUE: Dates o f A d o p t i o n o r Stage Reached i n the A d o p t i o n P r o c e s s , by S i z e o f H o s p i t a l .  9 8 7 6  1  5 4  [  :\  ¥  3 2 1  -=1  o oo  •  o  HE  \  teachin Q  ^  \  o \  \  \\ V  1  A  OOO  o  Evaluation  Not aware  AO  Type B T  yp  e  4>A  o o A  AO  AAO  0  OA  AO AAO  0  FIGURE 6  AO OO -A  ^A 0  0  A  AO  A A 0 0  A00  c  Type D  ^  oo A A  Interest Awareness  A  l y p e A - iNon-  O  Trial  O 1 I 1 Type A - t e a c h i A  AO  •  0  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 to 8  1  ADOPTED  10  2  4  3  o  0  o  9 8 7  5  SHEEPSKIN PELTS: Dates of Adoption or Stage Reached i n the Adoption Process, by Size of Hospital. r>, T R i y p e a [ T j T y p e A - teaching vJ QType A -Non£ *ype C  0  A  6 5  •  O  2 1  Evaluation  BQA  L  o^__ -OA0  •  BAA  o A  A  OO  OO AA  <l Trial  I  \  4 3  8  7  6  Til AAO  0  0  ^AO  OA *  AO  f  AO  •AO  0  A O  AO OO  OA  A  A A OA 0 0  CfA  0  A OA  0  Interest Awareness Not aware  0  O 0  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 t o 8  1  ADOPTED  2  4  OO  . 10  O  OO  7  •  A/  •  4 3  0  2  o  Evaluation  A A H—^— AA • O OA  Interest  0  1 * 1 Trial  QType  A - Non teaching  • _•  QType B  A yp T  e  c  FIGURE 8  OType D  A  OO  OO  •  LHAA  A •AO ——V  -AO  A  " "AO  " -  A OAA  0  0  0  AO  AA  AA  OA A  O O A A A O O  00  Awareness Not aware  [jJType A - teaching  )  6 5  Dates o f A d o p t i o n o r Stage Reac hed i n the A d o p t i o n P r o c e s s , by S i z e o f U n c n - t t-a1  E  8  7  OPEN VISITING HOURS:  A  o  6  5  0  o  9 8  3  0  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 t o 8  1  ADOPTED  2  3  4  B  10  6  5  ELIMINATION OF 6 A.M. TEMPERATURE ROUTINE: Dates ot A d o p t i o n o r Stage Reached i n the A d o p t i o n P r o c e s s , by  9  r . . _ _  8  T  TT  _<T  J lie  •  1.-1  UJL nu OJJJ. u<a j..  O  7 6  8  7  B yP ^-u,„„ T  •  [  A  e  [ Type A - Non teaching  5  A  4 3  A  2  •o  OA A  Trial Evaluation  0  o  EDO  A  AO  B Boo  OOA  O  OA  0  AAO  Not aware  o  •AO  e  B  A Type C Q Typ e D  o  FIGURE 9  A  A  o A A  AO  Interest Awareness  A A  A  yp  A A  1  <l  B  T  0 0  A  -o  OO  A A AO  0 0  0  0  A  00  0 0  AO  A  0  AO  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 to 8  1  ADOPTED  10  2  3  4  6  5  7  8  m  9  ELIMINATION OF DRAWSHEETS: P o a r > nor-^  -f n  +-Via  A ^ n n h i  r«n  Dates o f A d o p t i o n o r Stage by S i z e o f H o s p i t a l .  P r n ^ f l o e  8 7  B  BType  6  OA  •  OType B  A - teaching  , , T  y  /XTvoe C P  e  A  " t L " h i n N  g  O^en  5 4  B  2 1  0  B  A  o  <\  o  HQooo O A A  Evaluation Interest  ma.oooo o  00  A A A A A  O  A A A A A A  A  A  OO  O  A A A  000  A  0  A  0  A  000  •  O A A A  O  A  O  •  Awareness Not aware  10  00  3  Trial  FIGURE  OA  • A  0 O  AO  A A A  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 t o 8  10  2  1  ADOPTED  4  3  0  7  6  5  COLORED DRESSES IN PEDIATRICS: Stage Reached i n the A d o p t i o n Hospital.  9 8  [T]Type A - t e a c h i n g  7  •Type A - Non -  Dates o f A d o p t i o n o r P r o c e s s , by S i z e o f  (QType B AType C OType D  teaching  6  FIGURE 11  0  5  0  A  4  A A  A  00  3 2  A  A  O  S A  8  A  .A  0  1 < 1 Trial Evaluation  0  • • • o o mnoo  Interest  A A  Awareness  o  Not aware  A  A A  A  0  m o  o  0  •  A O  O A  A  A  A O  O  O O A  o O  AAA 000  0 0  A O  A  OOO  A O  A A  o  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT 1 t o 8  1  ADOPTED  2  4  3  10  [jjType A - teaching  8 7  D T y P e A  6  m  2 1  o fflCDO OOO  <1 Trial Evaluation Interest Awareness Not aware  7  8  mo A  O • A  ;eac°nin  g  0  T Y P E  B  0*P«°  FIGURE !2  A  5 3  6  DISPOSABLE SYRINGES: Dates o f A d o p t i o n o r Stage Reached i n the A d o p t i o n P r o c e s s , by S i z e o f H o s p i t a l .  9  4  5  0  A  O  OO  A  O  A  •  00  •  00  0  oo  A  A  • A A  A O  • ooo oo  A  A  O  A A A  000  O A  O 0A  A A  A A A  A  0  AAAOOO  OOA OA  A  0  141  Where i n f o r m a t i o n about an innovation w a s r e p o r t e d to have been t r a n s m i t t e d d i r e c t l y f r o m one hospital to another, this is indicated by an a r r o w .  The c h a r t s , with the exception of the ' c l o s e d glove' technique, show little d i r e c t t r a n s m i s s i o n of i n f o r m a t i o n about the specific innovations under study. T h e y do, however,  indicate that, in  instances  where there is systematic diffusion of i n f o r m a t i o n about a new n u r s i n g p r a c t i c e , the rate of adoption appears to be m o r e r a p i d than when diffusion o c c u r s through natural channels.  The ' c l o s e d glove' technique used in the operating r o o m is a case in point. T h i s technique was f i r s t used in B r i t i s h C o l u m b i a eight y e a r s ago in one of the l a r g e teaching hospitals after a staff m e m b e r had seen it demonstrated at an institute for operating r o o m n u r s e s i n another p r o v i n c e . T h e technique, c o n s i d e r e d to be safer than p r a c t i c e p r e v i o u s l y used, was adopted and taught to students.  the Two y e a r s  later it was initiated at another l a r g e teaching hospital, this time having been brought by an operating r o o m n u r s e f r o m E a s t e r n Canada. It was also adopted the same year by two other teaching hospitals,  one  m e d i u m size hospital and one s m a l l one. A s n u r s e s f r o m the teaching hospitals m o v e d to other areas in the p r o v i n c e , they introduced the technique to m o r e hospitals'.  Instructors also began to demonstrate the  the technique at a s e r i e s of institutes for operating r o o m n u r s e s in the  142  p r o v i n c e and the rate of adoption r a p i d l y gained m o m e n t u m . 1968,  eight y e a r s after its i n i t i a l use,  B y June,  one-half of the hospitals had  adopted the technique and another thirteen were in the t r i a l p r o c e s s . The p r a c t i c e is now starting to be discontinued by some of those who initiated its use because newer and better techniques have been i n t r o duced. Significantly, eighteen of the participants were s t i l l unaware of the innovation at the time this study was undertaken despite the d i s s e m i n a t i o n of information on it through o r g a n i z e d channels.  A l l but  one of these were f r o m s m a l l hospitals.  E v e n m o r e r a p i d are the instances where s p r e a d of i n f o r m a t i o n about an innovation has been firms.  systematically  c a r r i e d out by c o m m e r c i a l  The adoption of sheepskin pelts for u s i n g under b e d - r i d d e n  patients i l l u s t r a t e s this. T h e i r adoption was v e r y slow and sporadic i n i t i a l l y . T h e y were introduced m a i n l y by patients or staff m e m b e r s who had seen t h e m u s e d elsewhere. did help to prevent decubitus u l c e r s .  It was g e n e r a l l y felt that the pelts It was,  however,  a p r o b l e m to  keep t h e m clean and l a u n d e r i n g had to be done by hand. Once the c o m m e r c i a l f i r m s had developed a synthetic product that was m a c h i n e washable and a d v e r t i s e d this widely through l i t e r a t u r e and their s a l e s men, the pace of adoption a c c e l e r a t e d r a p i d l y . Within the next five and one-half years, hospitals.  there were sixty-two adoptions among the public general  T h e D i r e c t o r s of N u r s i n g r e p o r t e d that the s a l e s m e n f r o m  the hospital supply houses and the l i t e r a t u r e sent out by the company  143 were their chief sources of i n f o r m a t i o n .  O n l y one participant f r o m  a v e r y s m a l l isolated hospital r e p o r t e d that she had never h e a r d of this product. T h e adoption of disposable syringes shows m u c h the same pattern.  These have had extensive a d v e r t i s i n g i n the p r o f e s s i o n a l  j o u r n a l s and through l i t e r a t u r e sent to hospitals by the supply houses and by the s a l e s m e n .  S e v e r a l participants mentioned that the supply  companies would come in and do a cost analysis s u r v e y to help hospitals decide whether the use of disposable syringes would in fact save money.  T h e disposable syringes were f i r s t used six years p r i o r  to the date this r e s e a r c h was undertaken, i n one l a r g e teaching hospital and one s m a l l hospital in the p r o v i n c e . T h e i r adoption by other hospitals shows a gradual i n c r e a s e until by 1968,  forty of the  total eighty-five hospitals had adopted them fully and another t h i r t y eight were i n the t r i a l p r o c e s s with the m a j o r i t y of these planning to go into f u l l - s c a l e use shortly. T h e r e were no participants who had not h e a r d of disposable  syringes.  The r e m a i n d e r of the innovations, boxing glove mitt r e s t r a i n t s ,  the 'Australian lift', the  open v i s i t i n g , e l i m i n a t i o n of the 6 a . m .  t e m p e r a t u r e routine, and elimination of drawsheets show a m u c h slower rate of adoption. Some of them, it is true, are f a i r l y recent in their introduction to the p r o v i n c e and are, therefore,  in the e a r l y  slow diffusion p e r i o d , but s e v e r a l have been in use in hospitals in  144  B r i t i s h C o l u m b i a for m a n y y e a r s .  The number of participants who  a r e unaware of some of the newer p r a c t i c e s would appear to indicate that l a c k of communication is an important factor in the slowness of diffusion of innovations.  M o s t of the participants interviewed  e x p r e s s e d considerable interest in l e a r n i n g m o r e about p r a c t i c e s they had not h e a r d of p r i o r to the study and were anxious to hear of other new ideas being t r i e d in v a r i o u s hospitals.  C o m m u n i c a t i o n between H o s p i t a l s The d i a g r a m s showing the extent of communications between hospitals were based on answers given by the participants to questions on which hospitals they wrote to (or otherwise c o n f e r r e d with) r e g a r d i n g new ideas and p r a c t i c e s in n u r s i n g . T h i s was done if they had indicated other D i r e c t o r s of N u r s i n g as a source of information at any stage in the adoption p r o c e s s .  T h e s e d i a g r a m s are shown i n F i g u r e s l 3 through 20 on the following pages.  E a c h figure depicts c o m m u n i c a t i o n links between hospitals within a d i s t r i c t and to outside centers.  The B r i t i s h C o l u m b i a  H o s p i t a l A s s o c i a t i o n D i s t r i c t s were again used, n u m b e r e d a p p r o x i m a t e l y in o r d e r of distance f r o m the large metropolitan a r e a of V a n c o u v e r .  The graphic representation i l l u s t r a t e s s e v e r a l points:  145  Province '  /Other /parts /  / P r n v i nr./  Outside  Province  /Other / parts/Province  /  Other p a r t s Province  Other p a r t s Province  Other p a r t s Province  Outside Province  Other part Province Other p a r t s  Province  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT ONE: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and Between I n d i v i d u a l H o s p i t a l s and Outside Centers.  D O  Type A T  yp  e  B  A  Type C  O  Type D  FIGURE 13  146  Other p a r t s o f Province  Vancouver  Vancouver  Vancouver  7  Vancouver Plus out of Province  Vancouver  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT TWO: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and Outside Centers.  Vancouver  • Type A OType B A yp T  e  c  FIGURE 14  147  Vancouver Plus out of |Province  Vancou Other p a r t s ef-,Province  Vancouver Plu out o f Province  Other p a r t s of Province Vancouver  |—|Type  0 A 0  T  y  p  Type C Type D  Vancouver  Vancouver  Vancouver  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT THREE: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and O u t s i d e C e n t e r s . FIGURE  15  148  Vancouver  ouver  0_ther d i s t r i c t Vancouv  ut of Province Other  Other d i s t r i c t  •  Other d i s t r i c t  Type A  QType B  /\Type C 0  Type D  district  Other d i s t r i c t BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT FOUR: Communication between H o s p i t a l s w i t h i n t h e D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and Outside Centers. FIGURE  16  149  (jType  B  /\Type  C  o  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT FIVE: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and O u t s i d e C e n t e r s .  Type D FIGURE  17  i  150  /\ [  Type C j Type D  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT SIX: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and Outside Centers.  FIGURE  18  151  Vancouver  Outside of Province  Vancouver  Vancouver  Other  Other  district  Vancouver  district  Vancouver  Vancouver  • O  Type A T  A 0  yp  e  B  Type C T  yp  e  Vancouver  Other  district  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT SEVEN: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and O u t s i d e C e n t e r s .  D  FIGURE  19  152  Outside Province  Vancouver  Vancouver  OType B A 0  C  T y  p  e  Vancouver  Vancouver  BRITISH COLUMBIA HOSPITAL ASSOCIATION DISTRICT EIGHT: Communication between H o s p i t a l s w i t h i n the D i s t r i c t and between I n d i v i d u a l H o s p i t a l s and O u t s i d e C e n t e r s .  D  FIGURE  -20  153  1.  B y far, the most c o m m o n l y used referents are the l a r g e  teaching hospitals in the L o w e r Mainland,  although teaching hospitals in  other parts of the p r o v i n c e also r e c e i v e many queries as well as v i s i t o r s f r o m s m a l l e r , non-teaching institutions in their l o c a l area. T h i r t y - f i v e of the participants stated that they wrote to one or m o r e of the teaching hospitals in the L o w e r M a i n l a n d for i n f o r m a t i o n concerning innovations in n u r s i n g p r a c t i c e .  Many mentioned that they would often  send a n u r s e to one of the teaching hospitals i f they wanted to l e a r n about such matters as setting up an intensive c a r e unit or an i n t r a venous s e r v i c e .  T h i s is not to say that these institutions have a m o n o -  p o l y on new ideas.  As can be seen f r o m the figures showing patterns by a i  tion, (Chapt. V . pp- 132-140) the i n i t i a l use of a new p r a c t i c e m a y be in other areas of the p r o v i n c e and in s m a l l e r hospitals,  but it is the  teaching institutions which are expected to have the latest i n f o r m a t i o n .  2.  T h e amount of communication between hospitals within  a d i s t r i c t d e c r e a s e s as the distance f r o m Vancouver i n c r e a s e s .  T h i s can  be explained i n l a r g e p a r t , by the longer distances between hospitals and t r a n s p o r t a t i o n p r o b l e m s in the m o r e s p a r s e l y settled areas of the province.  It is m u c h e a s i e r for D i r e c t o r s of N u r s i n g of hospitals in  Vancouver and the L o w e r M a i n l a n d to get together for meetings or to d i s c u s s matters by telephone than it is in n o r t h e r n parts of the p r o v i n c e , for example,  where t r a v e l l i n g is difficult i n the winter months, o r on the  coast, where some hospitals are a c c e s s i b l e only by s m a l l plane o r lengthy  154  f e r r y journey.  Some participants in isolated communities said they  had no contact with other D i r e c t o r s of N u r s i n g .  If they wished  information they would write to the teaching hospitals.  3.  T h e r e is some indication that c e r t a i n hospitals  represent  the opinion l e a d e r s h i p within a d i s t r i c t , as evidenced by the number of other hospitals seeking i n f o r m a t i o n f r o m them. m a i n l y the l a r g e r hospitals in r e g i o n a l centers,  T h e s e appear to be although this is not  always the case. In m a n y of the d i s t r i c t s , however,  it is the one or  two l a r g e r hospitals which take the lead in o r g a n i z i n g educational p r o g r a m s for n u r s e s in the a r e a . The l a r g e r centers u s u a l l y have better established i n - s e r v i c e educational p r o g r a m s and, i n c r e a s i n g l y , an i n s e r v i c e c o - o r d i n a t o r and they w i l l often invite nurses f r o m n e a r b y hospitals to participate i n p r o g r a m s put on for their own staff.  4.  T h e r e is some indication also, that there are two cycles  of influence operating amongst the hospitals.  The f i r s t is the influence  exerted by the l a r g e , teaching hospitals who r e c e i v e i n f o r m a t i o n f r o m s o u r c e s outside the p r o v i n c e and participate actively in the educational p r o g r a m s for n u r s e s sponsored by the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n and the Departments of Continuing M e d i c a l and N u r s i n g Education of the U n i v e r s i t y of B r i t i s h C o l u m b i a .  The second cycle of influence involves use of the l a r g e r hospitals i n r e g i o n a l centers throughout the p r o v i n c e as referents by the  155  s m a l l e r hospitals in a d i s t r i c t .  M a n y participants f r o m the s m a l l  hospitals r e m a r k e d that "the (educational) p r o g r a m s in V a n c o u v e r a l l s e e m g e a r e d to the big hospital".  Although some of the continuing  education p r o g r a m s offered in V a n c o u v e r have been s p e c i f i c a l l y planned for n u r s e s f r o m s m a l l hospitals,  many of the D i r e c t o r s of N u r s i n g s e e m  to feel that what is said in V a n c o u v e r is not applicable to their  situations  in the r u r a l parts of the p r o v i n c e . T h e y therefore turn to the l a r g e r hospitals in their own a r e a or to hospitals of comparable size in other p a r t s of the p r o v i n c e .  In addition, the v e r y s m a l l hospitals have  p r o b l e m s in getting n u r s e s away to educational p r o g r a m s in V a n c o u v e r . It is difficult to r e l e a s e staff for the t i m e r e q u i r e d for t r a v e l l i n g and the prograrrijand the expense involved soon depletes the budgetary allowance for education.  T h e y can m o r e e a s i l y send staff to l o c a l p r o g r a m s  s p o n s o r e d either by the p r o f e s s i o n a l n u r s i n g association or by the r e g i o n a l center hospital itself, which many participants felt to be m u c h m o r e beneficial to them.  Sources of Information and Adopter C a t e g o r y B e c a u s e of the m a r k e d s i m i l a r i t y of sources of information r e p o r t e d as used by a l l participants in this study, there is little distinction that can be made between sources used by e a r l y versus late adopters.  The one point of differentiation is the m o r e cosmopolitan nature  of referent hospitals u s e d by the i n n o v a t o r - e a r l i e r adopter  group who  seek i n f o r m a t i o n f r o m places outside the p r o v i n c e , in other parts of  156  Canada and the United States.  T h i r t e e n of the e a r l i e r adopters used sources outside B r i t i s h C o l u m b i a for i n f o r m a t i o n on new ideas and p r a c t i c e s , only four of the l a t e r adopters.  as c o m p a r e d with  157  C H A P T E R IV  FOOTNOTES  1. Supra,  Chapter II, pp. 46-48  2. Supra,  Chapter TJ, p p . 43-46  3. Supra,  Chapter II, pp. 46-48  4. F r o m minutes of the Annual Meetings of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a , 1962-68. 5. F o r detailed tables on attendance at p r o f e s s i o n a l meetings See Chapter III, p 83 and Chapter V , pp.. 85-91. 6.  Supra,  Chapter II, pp. 32-33  7. Supra,  Chapter II, pp.43-44  8. F r o m d i s c u s s i o n s with the N u r s i n g Consultant Staff of the B r i t i s h C o l u m b i a H o s p i t a l Insurance S e r v i c e , and p e r s o n a l correspondence f r o m E . Nordlund, dated M a r c h 7, 1969  158  CHAPTER V  FACTORS R E L A T E D TO ADOPTION  P r e v i o u s r e s e a r c h has indicated that c h a r a c t e r i s t i c s of a population are r e l a t e d to the acceptance o r rejection of new ideas and technology. ^  T h e factors studied in the present r e s e a r c h included  c h a r a c t e r i s t i c s of:  (1) the hospital, (2) the D i r e c t o r s of N u r s i n g ,  (3) the a d m i n i s t r a t o r and (4) the n u r s i n g staff.  T h e s e factors were  examined by d e t e r m i n i n g the Group Mean Adoption Scores of hospitals p o s s e s s i n g specific c h a r a c t e r i s t i c s and the proportionate distribution of these hospitals in the four adopter c a t e g o r i e s . * the categories were c o m p r e s s e d into two,  In some instances,  e a r l i e r and later adopters,  to point up differences i n the c h a r a c t e r i s t i c s of those who initiate changes e a r l i e r , as opposed to those who are slower to accept innovations.  * See Chapter I, pp. 21-23 for a detailed d e s c r i p t i o n of the method of p r o c e d u r e used in computing the adoption s c o r e , and d i v i s i o n of the hospitals into adopter categories.  159 The individual adoption s c o r e s for the total population of hospitals ranged f r o m a low of 15 to a high of 41. The Mean Score for a l l hospitals was 29, with a Standard Deviation of 6.  The range, frequency and percentage distribution of s c o r e s of the p a r t i c i p a t i n g hospitals,  by adopter category,  are shown in T a b l e X X I .  F i g u r e 21 shows the frequency distribution of s c o r e s of the hospitals in graph f o r m .  I. C H A R A C T E R I S T I C S O F T H E H O S P I T A L  A s d i s c u s s e d i n Chapter II, studies i n education have indicated a r e l a t i o n s h i p between factors such as size of school d i s t r i c t and income l e v e l of the community, and the adoption of educational changes in a 2 school s y s t e m . nursing,  In the absence of previous r e s e a r c h in the field of  some of the distinctive c h a r a c t e r i s t i c s of hospitals which  might influence their adaptability to changes in n u r s i n g p r a c t i c e were investigated.  T h e s e factors were (1) size of hospital (2) status of  a teaching institution (3) geographic location, and (4) the meeting of c e r t a i n standards as evidenced by a c c r e d i t a t i o n . Size U s i n g rated bed capacity as the c r i t e r i o n of size, the hospitals were divided into four groups, as outlined in Chapter I. Type A , 201 beds and over;  Type B , 75 to 200 beds;  Type D, under 30 beds.  3  Type C , 30 to 74 beds,  and  160  T A B L E XXI  RANGE,  F R E Q U E N C Y A N D P E R C E N T A G E DISTRIBUTION  O F SCORES O F PARTICIPATING HOSPITALS BY ADOPTER CATEGORY  Adopter Category-  Range of S c o r e s *  N u m b e r of Hospitals  P e r Cent of T o t a l Population  Innovators and E a r l y Adopters  37 to 41  13  16  Early Majority  30 to 36  30  34  Late Majority  24 to 29  29  34  Delayed A d o p t e r s  15 to 23  13  16  TOTAL  15 to 41  85  100%  M a x i m u m Score P o s s i b l e M i n i m u m Score P o s s i b l e Mean Score Standard Deviation  45 0 29 6  162 F i g u r e 22 shows the percentage distribution of innovators and e a r l y adopters,  e a r l y m a j o r i t y , late m a j o r i t y and delayed adopters  among the Type A , B , C , and D hospitals and the Group Mean Adoption Score of each typeA l l of the Type A hospitals were in either the i n n o v a t o r - e a r l y adopter or e a r l y m a j o r i t y categories and thus among the e a r l i e r adopters, while T y p e s B , C , and D had hospitals in a l l four  categories.  The p r o p o r t i o n of hospitals of each type i n the i n n o v a t o r - e a r l y adopter category d e c r e a s e d steadily as the hospitals became while the percentage  of delayed adopters i n c r e a s e d ,  smaller  with the  hospitals having the l a r g e s t number of participants in this  smallest  category.  The M e a n Scores of the groups show the same t r e n d with Type A having the highest Group M e a n Score, and Type D the lowest.  C o n t r a r y to the general t r e n d of d e c r e a s i n g adaptability with d e c r e a s i n g s i z e , the Type C hospitals (30 to 74 beds) had a higher p r o p o r t i o n in the two combined e a r l i e r adopter categories than the l a r g e r Type B hospitals, same.  and the M e a n Score of both groups was the  T h i s seems a little s u r p r i s i n g at first since the hospital of  74 to 200 beds is frequently the l a r g e s t hospital in a d i s t r i c t and the most influential, a c c o r d i n g to the number of s m a l l e r hospitals information f r o m it.  The finding is, however,  seeking  consistent  with that of M e n z e l and K a t z in the m e d i c a l field who  investigated  the adoption of new drugs by physicians and r e p o r t e d that:  163  Type A  Type B  Type C  Type D  201 beds and over  75-200 beds  30-74 beds  under 30 beds  Score  FIGURE 22:  P e r c e n t a g e o f h o s p i t a l s i n each a d o p t e r c a t e g o r y , by s i z e of h o s p i t a l .  164 . . . the s o c i o m e t r i c stars are among the last to adopt the drug; but when they finally do, a l l other m e m b e r s except the r e a l diehards fall in line immediately. 4  Status of the H o s p i t a l as a T e a c h i n g Institution The operation of a n u r s i n g school in conjunction with a hospital would s e e m to be a l o g i c a l impetus to keeping up with changes in n u r s i n g p r a c t i c e . T h i s is borne out in the findings f r o m this study. Of the six teaching hospitals in the p r o v i n c e , a l l but one were in the i n n o v a t o r - e a r l y adopter category and this one ranked in the e a r l y m a j o r i t y group. The Mean Adoption Score of the teaching hospitals was c o n s i d e r a b l y higher than that of any other single group.  A c o m p a r i s o n of percentages of teaching and non-teaching l a r g e hospitals (Type A) in each adopter category is shown in F i g u r e 23.  Geographic L o c a t i o n of the H o s p i t a l A c c e s s i b i l i t y to information s o u r c e s has been shown to be a 5 factor influencing the adoption of innovations.  The p r i n c i p a l  s o u r c e s of new i n f o r m a t i o n in n u r s i n g for the p r o v i n c e of B r i t i s h C o l u m b i a appear to be in Vancouver where the two l a r g e s t teaching hospitals,  the u n i v e r s i t y , and the office of the p r o v i n c i a l n u r s i n g  association are located.  It stands to r e a s o n that the greater the  distance of a hospital f r o m V a n c o u v e r , the fewer are its opportunities to l e a r n of new ideas and p r a c t i c e s in n u r s i n g , and one would expect the rate of adoption of innovations to be slower.  T h i s would, indeed,  165  Type A  Type A  Teaching  Non-teaching  17  Score  FIGURE 23:  P e r c e n t a g e o f l a r g e h o s p i t a l s i n each a d o p t e r c a t e g o r y by t e a c h i n g s t a t u s of h o s p i t a l .  166  s e e m to be the case.  F i g u r e 24 shows the percentage distribution of p a r t i c i p a n t s in each of the adopter categories by location of the hospital a c c o r d i n g to n a t u r a l geographic boundaries. T h e s e locations are n u m b e r e d a p p r o x i m a t e l y in o r d e r of the distance f r o m V a n c o u v e r . F i g u r e 25 shows the d i s t r i c t s c o m p r e s s e d into two groups, the f i r s t c o m p r i s i n g hospitals in the L o w e r M a i n l a n d and V a n c o u v e r Island A r e a s , there is the greatest density of population, the second,  where  a l l others.  While both e a r l y and late adopters were found in a l l parts of the p r o v i n c e , the g e n e r a l t r e n d was for the e a r l i e r adopters to be in the m o r e populous regions,  where c o m m u n i c a t i o n is e a s i e r ,  l a t e r adopters in the m o r e s p a r s e l y settled r e g i o n s .  and the  T h e Group M e a n  Adoption Score of hospitals located in m o r e r u r a l areas was c o r r e s pondingly lower than that of hospitals i n the L o w e r M a i n l a n d or on Vancouver Island.  F o r a m o r e detailed analysis of the factor of geographic location, the hospitals were divided into groups by: (1) n a t u r a l boundaries ( a s above),  (2) organization into d i s t r i c t s of the B r i t i s h C o l u m b i a H o s p i t a l  Association,  and (3) d i v i s i o n by i n c o r p o r a t e d d i s t r i c t s of the R e g i s t e r e d  N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a .  The Mean Adoption Scores of hospitals in each d i s t r i c t , a c c o r d i n g to these three groupings,  are shown in T a b l e XXII, the d i s t r i c t s  1  Lower Mainland  Vancouver Island  FIGURE 24:  i  I n t e r i o r and C o a s t a l Regions  1  Percentage of hospitals i n each adopter category, by geographic l o c a t i o n of the h o s p i t a l : 6 areas of the province.  FIGURE 25:  P e r c e n t a g e of h o s p i t a l s i n each a d o p t e r c a t e g o r y , by g e o g r a p h i c l o c a t i o n o f the h o s p i t a l : 2 d i v i s i o n s of the p r o v i n c e .  169  T A B L E XXII G R O U P M E A N A D O P T I O N S C O R E S O F H O S P I T A L S IN VARIOUS A R E A S O F T H E P R O V I N C E  L o c a t i o n byN a t u r a l Geographic Boundaries N o . of Hospitals  L o c a t i o n by R . N . A. B. C. District  L o c a t i o n by B . C . H . I. S. District  Adoption Score  No. of Hospitals  Adoption Score  N o . of Hospitals  Adoption Score  1  17  33  1  10  32_  1  7  3_3  2  15  31_  2  10  32.  2  11  32.  3  14  27  3  15  i i  3  3  35.  4  15  29  4  14  27  4  9  34  5  13  29  5  8  27  5  11  29  6  11  25  6  7  31  6  5  29  7  10  30  7  6  28  8  11  26  8  5  32  9  3  27  1.0  5  30  20  25  Not in D i s t r i c t  Note: S c o r e s of hospitals on the L o w e r M a i n l a n d and Vancouver are  underlined  Island  again n u m b e r e d a p p r o x i m a t e l y in o r d e r of i n c r e a s i n g distance f r o m V a n c o u v e r . T h e Group Mean Adoption Scores of hospitals in d i s t r i c t s on the L o w e r M a i n l a n d and V a n c o u v e r Island are u n d e r s c o r e d . It is interesting to note that some d i s t r i c t s s e e m e d to be m o r e innovative than others even though their apparent a c c e s s i b i l i t y to information s o u r c e s in the V a n c o u v e r a r e a is l e s s .  But, perhaps the most s i g -  nificant finding is that hospitals in areas not i n c o r p o r a t e d into d i s t r i c t s of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n had a m u c h lower Group M e a n Adoption Score, 2 5, than any others.  T h i s is again  consistent with the findings of w o r k e r s i n other fields where  sbcio-  m e t r i c ties and p a r t i c i p a t i o n in p r o f e s s i o n a l organizations have been shown to be important v a r i a b l e s in the diffusion and acceptance of 6 new p r a c t i c e s .  A c c r e d i t a t i o n of H o s p i t a l s In o r d e r to be a c c r e d i t e d by the Canadian C o u n c i l of H o s p i t a l Accreditation,  a hospital must meet high standards in r e l a t i o n to a l l  facets of its operation, including the n u r s i n g component. this r e s e a r c h was in p r o g r e s s ,  A t the time  t h i r t y - t h r e e of the total eighty-five  hospitals included in the study were a c c r e d i t e d .  F i g u r e 26 shows a c o m p a r i s o n of hospitals in the four adopter categories a c c o r d i n g to their a c c r e d i t a t i o n status at the time of the study. T h e m a j o r i t y of the a c c r e d i t e d institutions (two-thirds) were  171  FIGURE 26:  Percentage of hospitals i n each adopter category, by a c c r e d i t a t i o n status of the h o s p i t a l .  172  amongst the e a r l i e r adopters while a m i n o r i t y were in the later adopter c a t e g o r i e s .  The r e v e r s e is true of the n o n - a c c r e d i t e d  hospitals and the M e a n Scores of a c c r e d i t e d and n o n - a c c r e d i t e d hospitals reflect the same t r e n d .  The meeting of c e r t a i n standards in r e l a t i o n to their o v e r a l l operation thus appears to be a factor in a hospital's acceptance of new ideas and p r a c t i c e s in n u r s i n g , as evidenced by a higher rate of adoption of n u r s i n g innovations.  II. C H A R A C T E R I S T I C S O F T H E D I R E C T O R O F N U R S I N G  R e s e a r c h by other w o r k e r s has indicated a positive c o r r e l a t i o n between p e r s o n a l c h a r a c t e r i s t i c s of the superintendent of a school 7 d i s t r i c t , and adaptability of a school s y s t e m .  Because each of the  public g e n e r a l hospitals included in this study functions as an autonomous institution operated by its own H o s p i t a l Society, the D i r e c t o r of N u r s i n g a s s u m e s m u c h the same r o l e as the superintendent of a school d i s t r i c t . She is the p r i n c i p a l d e c i s i o n - m a k e r with r e g a r d to n u r s i n g p r a c t i c e s within the hospital, as the school superintendent is in r e g a r d to educational p r a c t i c e s within his d i s t r i c t . It is l o g i c a l to suppose,  then,  that c h a r a c t e r i s t i c s of the D i r e c t o r of N u r s i n g m a y be a factor in the adoption or r e j e c t i o n of innovations in n u r s i n g . The c h a r a c t e r i s t i c s studied were (1) age,  (2) p r o f e s s i o n a l n u r s i n g experience,  status, (4) educational attainment,  (3) m a r i t a l  (5) p a r t i c i p a t i o n in p r o f e s s i o n a l  173  n u r s i n g organizations,  (6) p r o f e s s i o n a l reading habits, and (7) perception  of the p r o g r e s s i v e n e s s  of the h o s p i t a l in which she was employed.  Age as a factor i n adoption A g e , per se,  as a factor influencing the adoption of new ideas g  and p r a c t i c e s ,  is a c o n t r o v e r s i a l one i n the l i t e r a t u r e .  In this study,  the m e d i a n age category of the participants was f o r t y - f i v e to forty-nine years,  c o n s i d e r a b l y higher than the average age for a l l n u r s e s in 9  Canada, which is thirty-two y e a r s .  O n l y nine D i r e c t o r s of N u r s i n g  in the hospitals studied were under t h i r t y - f i v e years of age. ^ c o m p a r i s o n of the data relative to age and adopter category,  For  the  p a r t i c i p a n t s were divided into two groups, those in the median age category or below,  and those above the median.  F i g u r e 27 shows the percentage of participants in each adopter category who were i n the median age group or younger and the percentage above the median. The late m a j o r i t y group had the greatest p r o p o r t i o n of older n u r s e s with a p p r o x i m a t e l y t w o - t h i r d s of the participants in this category being above the median age.  T h e delayed adopters had the  next highest percentage of their group in the older age b r a c k e t s , although it should be noted that they also had some of the  youngest.  P a r t i c i p a n t s in the e a r l i e r adopter categories were p r e d o m i n a n t l y younger on the whole than the later adopters.  T h i s finding is consistent  174  Median ages  Ah°ve  or Below  .InnovatorE^rly Adopter  23 Percentage  Early Majority  30 Percentage  Late Majority  66 Percentage  Deljstyed Adopters  46  Median age category 45-49 years.  Percentage  Median ages or below  Above median age  FIGURE 27:  Participants i n each adopter category: Percentage median age or less and Percentage above the median.  175 with R o g e r s ' generalization that " e a r l i e r adopters are younger in age than l a t e r  adopters."^  Professional Nursing Experience C l o s e l y r e l a t e d to the factor of age is the number of years the p a r t i c i p a n t had been engaged in p r o f e s s i o n a l n u r s i n g p r a c t i c e .  Data  were gathered on three factors relative to time involvement in n u r s i n g : (1) date of the p a r t i c i p a n t ' s graduation f r o m her basic program, graduation,  nursing  (2) whether she had w o r k e d in n u r s i n g continuously since and (3) number of years in n u r s i n g altogether.  These  factors were then studied i n r e l a t i o n to the adopter category of the hospitals i n which the n u r s e s were employed.  Date of Graduation f r o m B a s i c N u r s i n g P r o g r a m A s one would expect f r o m the data on age,  the m a j o r i t y of  participants had graduated f r o m their b a s i c n u r s i n g p r o g r a m s m o r e than twenty years ago.  The median category for date of graduation  for the total population was twenty to t h i r t y y e a r s .  T h e same t r e n d was  found in r e l a t i o n to date of graduation f r o m basic n u r s i n g p r o g r a m as with age of the p a r t i c i p a n t s . The p r o p o r t i o n of n u r s e s who had graduated m o r e than t h i r t y years ago, that is, before those in the m e d i a n category,  was greater in the later adopter group than among  e a r l i e r adopters.  F i g u r e 28 shows the percentage of e a r l i e r and l a t e r adopters who graduated l e s s than, and m o r e than t h i r t y years ago.  176  Graduated l e s s than 30 y e a r s ago  more than 30 y e a r s  Earlier Adopters Percentage  Later Adopters Percentage  __3  Graduated l e s s than 30 y e a r s ago.  FIGURE 28:  Graduated 30 o r more y e a r s ago.  P a r t i c i p a n t s i n e a r l i e r and l a t e r a d o p t e r c a t e g o r i e s : P e r c e n t a g e who had g r a d u a t e d more t h a n and l e s s than t h i r t y y e a r s ago.  177  Continuous E m p l o y m e n t in N u r s i n g O n l y a little over one half (forty-nine or 58 per cent) of the D i r e c t o r s of N u r s i n g who p a r t i c i p a t e d in this study had had u n i n t e r rupted c a r e e r s in the p r o f e s s i o n .  Many had been away f r o m n u r s i n g  for v a r y i n g p e r i o d s of time because of m a r r i a g e and f a m i l y responsibilities,  r e t u r n i n g to work after their c h i l d r e n were in  school or c i r c u m s t a n c e s were such that they had to support t h e m s e l v e s and their f a m i l y .  Whether a p a r t i c i p a n t had w o r k e d in n u r s i n g continuously since graduation or not, appears to have some b e a r i n g on h e r keeping up-to-date with c u r r e n t developments in the field. The m a j o r i t y of n u r s e s who had w o r k e d continuously were in the e a r l i e r adopter groups whereas the biggest percentage of those with i n t e r r u p t e d c a r e e r s were among the l a t e r adopters.  The M e a n Adoption Score of  the continuously employed group is c o r r e s p o n d i n g l y higher (32) than that of the group who had been out of n u r s i n g for a p e r i o d of time (26).  The percentage of e a r l i e r and later adopters among participants who had w o r k e d in n u r s i n g continuously since graduation and those with i n t e r r u p t e d c a r e e r s is shown in F i g u r e 29  T o t a l N u m b e r of Y e a r s in N u r s i n g The total number of years a p a r t i c i p a n t had worked in n u r s i n g did not appear to be as c l o s e l y r e l a t e d to adopter category as date of  178  FIGURE 29:  Percentage of participants i n e a r l i e r and l a t e r adopter categories, by continuous employment i n nursing.  179 graduation. T h e m a j o r i t y had been i n the field for over twenty years and the m e d i a n category for the total population was twenty to twentynine y e a r s ,  which is consistent with the m e d i a n category for date of  graduation f r o m b a s i c n u r s i n g p r o g r a m . A l l adopter categories showed a f a i r l y wide range of participants with differing lengths of experience in n u r s i n g , although there were no n u r s e s with l e s s than five years of experience among the innovator and e a r l y adopters, and there was a higher p r o p o r t i o n of n u r s e s who had been e m p l o y e d i n n u r s i n g m o r e than t h i r t y years among the l a t e r adopters.  T h e Mean Adoption Score (25)  of the n u r s e s who had w o r k e d the longest was lower than that of other groups.  The frequency and percentage distribution of total number of y e a r s i n n u r s i n g by adopter category is shown i n T a b l e XXIII.  Tenure The mean turnover rate of D i r e c t o r s of Nur sing employed i n 12 public g e n e r a l hospitals i n Canada is 17.41.  F o u r t e e n of the  p a r t i c i p a n t s i n this study (16 per cent) hadbeen i n their p r e s e n t p o s i t i o n l e s s than one year, so the population i n this r e g a r d would appear to be f a i r l y representative of the national average.  In this study the m e d i a n length  of time a nurse had been i n her present position as d i r e c t o r was three to five y e a r s .  T A B L E XXIII  F R E Q U E N C Y A N D P E R C E N T A G E D I S T R I B U T I O N O F P A R T I C I P A N T S IN EACH ADOPTER CATEGORY, BY NUMBER O F YEARS O F EXPERIENCE IN N U R S I N G  N u m b e r of Y e a r s in N u r s i n g  L e s s than 5  15 - 19  20 - 29  More than 30  Total  10 - 14  2 25%  1 7%  2 17%  7 18%  1 13%  13  5-9  Adopter CategoryInnovators and E a r l y Adopters  -  E a r l y Majority  1 33%  2 25%  6 43%  6 50%  13 33%  2 25%  30  Late M a j o r i t y  2 67%  2 25%  5 36%  2 17%  15 38%  3 38%  29  2 14%  2 17%  5 13%  2 25%  13  14 100%  12  40  8  85  100%**  100%**  100%**  2 25%  Delayed Adopters  TOTALS  3  8  GROUP M E A N ADOPTION SCORE  100%  100%  * Median Category  .  3<0 30_ 28_ 28 25_ 27 * * P e r c e n t a g e s have been rounded off to the n e a r e s t whole number and therefore, do not total exactly 100%.  181  The percentage distribution of participants in each adopter category,  by tenure in present position is shown in F i g u r e 30.  The group with six to ten years of tenure had the highest percentage of innovators and e a r l y adopters while both this group and those who had been in their positions l e s s than one year, had the l a r g e s t o v e r a l l p r o p o r t i o n of e a r l i e r adopters.  T h e r e were no participants in  the delayed adopter category in either of these two groups while their Group M e a n Adoption S c o r e s were also higher than those of participants in other categories of tenure.  T h e participants with eleven to twenty years in the same position had the lowest percentage of e a r l i e r adopters and the lowest Group Mean Adoption S c o r e .  These findings would s e e m to indicate that a new D i r e c t o r of N u r s i n g introduces a number of changes during her f i r s t year and, again, after she feels secure in her position, of tenure.  following five years  T h o s e who r e m a i n in the same position m o r e than ten  years would appear to be l e s s adaptable to change.  M a r i t a l Status and N u m b e r of C h i l d r e n T h e r e were an equal number of m a r r i e d and single participants (40 per cent of each) in the population as well as seventeen (20 per cent) who were widowed,  separated or d i v o r c e d . The single nurses were thus  182  1-2 years  3-5 years 18  25  cu 60 ni  CD 00 CO 4-1  <u 00 cfl  u c  c  4J  c <u o  cu o u <u  CU U  U  <U  u  (U  PH  41  '29  Group 21 Mean Adoption Score  Innovator ggj  XEarly  Adopters  '. Early Majority  FIGURE 30:  ^  m  j  o  x  ±  t  y  Delayed A d o p t e r s  Percentage of participants i n each adopter category, by tenure i n present position.  183  in the m i n o r i t y but their p r o p o r t i o n of e a r l i e r adopters was as shown in F i g u r e 31.  F o r comparison purposes,  greater,  the total population  was divided into two groups, the single n u r s e s and a l l others.  F o r t y p a r t i c i p a n t s , almost one half of the total population (47 per cent) had c h i l d r e n .  In relating this factor to adopter category,  the findings are consistent with those in r e g a r d to m a r i t a l status. The n u r s e s without c h i l d r e n were p r e d o m i n a n t l y in the e a r l i e r adopter group, whereas the m a j o r i t y of those with c h i l d r e n were among the later adopters.  A c o m p a r i s o n of the percentage of e a r l i e r and later  adopters among the participants who had c h i l d r e n and those who did not is shown in F i g u r e 32. Educational Attainment In this study,  a l l of the p a r t i c i p a n t s had complete d a b a s i c  p r o g r a m in an approved school of n u r s i n g . T h i r t y - t w o (38%) had additional u n i v e r s i t y p r e p a r a t i o n , the extent v a r y i n g f r o m one year of studies to attainment of a m a s t e r ' s degree.  A number had taken  post-graduate c l i n i c a l courses or other educational p r o g r a m s including c o r r e s p o n d e n c e and n i g h t - s c h o o l c o u r s e s ,  and a l l but  nine  attended at l e a s t one short continuing education p r o g r a m for n u r s e s in the past five y e a r s . Academic Achievement With r e g a r d to a c a d e m i c achievement as m e a s u r e d by number of years of school completed or degree obtained, the r e l a t i o n s h i p  184  Married Widowed Separated Divorced  or  Earlier  Adopters  10  oo!  |  cS  c  |  Later  Adopters  o r-l  cu  PH  Group Mean Adoption Score  31  FIGURE  31:  P e r c e n t a g e o f p a r t i c i p a n t s i n e a r l i e r and c a t e g o r i e s , by m a r i t a l s t a t u s .  later  No Children  Children  36  FIGURE 32:  Percentage of participants i n e a r l i e r and l a t e r adopter categories, by number of c h i l d r e n of participant.  186  between education and adoption appears to be significant in the findings f r o m this study.  T h e percentage of innovators and e a r l y adopters i n c r e a s e d steadily as the a c a d e m i c l e v e l r o s e .  T h e group with the least a c a d e m i c  p r e p a r a t i o n ( m i n i m u m r e q u i r e m e n t s for entrance to a school of nursing) had the lowest percentage of innovators and e a r l y adopters and a m a j o r i t y of this group were among the later adopters. The participants who had completed one to two years of u n i v e r s i t y showed an equal distribution of e a r l i e r and l a t e r adopters while the m a j o r i t y of those holding baccalaureate degrees and a l l of those with m a s t e r ' s degrees were in the two e a r l i e r adopter  categories.  13  The Group M e a n Adoption Scores follow the same t r e n d with the l e a s t a c a d e m i c a l l y p r e p a r e d n u r s e s having the lowest s c o r e and the best educated ones the highest.  F i g u r e 33 shows the percentage  distribution of participants in each adopter category by highest a c a demic l e v e l of the D i r e c t o r of N u r s i n g .  P o s t - B a s i c Educational P r o g r a m s Twenty-nine of the participants had taken post-graduate c l i n i c a l c o u r s e s in n u r s i n g . T h i s did not appear to be a factor in adoption,  since  there were an almost equal number of e a r l i e r and later adopters among the group. Detailed  tables outlining number of participants who had  taken post-graduate hospital c o u r s e s were given in Chapter III.  14  187  University Entrance  Adoption  1-2 yrs. University  Baccalaurete Masters Degree Degree  Score  FIGURE 33:  P e r c e n t a g e of p a r t i c i p a n t s i n each a d o p t e r c a t e g o r y , by academic l e v e l o f p a r t i c i p a n t s .  188  O n the other hand, the twenty-five nur ses who had taken certificate  c o u r s e s at a u n i v e r s i t y ,  teaching and s u p e r v i s i o n ,  such as w a r d a d m i n i s t r a t i o n ,  or public health n u r s i n g were preponderantly  among the e a r l i e r adopters, so this would appear to be one educational experience contributing to e a r l y adoption of innovations.  15  Another twenty-eight of the D i r e c t o r s of N u r s i n g had taken the Canadian N u r s e s ' A s s o c i a t i o n C o r r e s p o n d e n c e C o u r s e on N u r s i n g Unit A d m i n i s t r a t i o n . T h i s  did not appear to be r e l a t e d to the adoption  s c o r e h u t w a s more c l o s e l y a s s o c i a t e d with the size of the hospital, since the m a j o r i t y of those who had taken this c o u r s e were f r o m the smaller  hospitals (under seventy-five beds).  G e n e r a l Adult Education C o u r s e s A l m o s t one half of the participants had p a r t i c i p a t e d in general adult education p r o g r a m s , either through night school or  correspondence 17  study.  M o s t of the c o u r s e s taken were of a g e n e r a l i n t e r e s t nature.  A slightly higher p r o p o r t i o n of the n u r s e s who had taken adult education p r o g r a m s were in the e a r l i e r adopter category,  the ratio of e a r l i e r to  later adopters being 23:16. The p r o p o r t i o n of e a r l i e r and later adopters among the participants by p a r t i c i p a t i o n in p o s t - b a s i c educational p r o g r a m s is shown in F i g u r e 34.  189  Hospital Postgraduate Courses  General Adult Education Courses  University Certificate Courses  ^\^\ cu  Earlier  Adopters  cu  00 ctf •u  00 Ctf  4J  a cu o u  ci  cu CJ  u  cu  Later  Adopters  CU PH  Pi  Group 28 Mean A d o p t i o n Score  FIGURE 34:  30  31  P e r c e n t a g e of p a r t i c i p a n t s i n e a r l i e r and l a t e r c a t e g o r i e s , by type o f f u r t h e r e d u c a t i o n a l programs t a k e n .  190  Continuing Education P r o g r a m s in N u r s i n g A l l but nine of the participants had attended at least one institute, workshop or other short continuing education p r o g r a m for n u r s e s . O f the nine who had attended no educational p r o g r a m s , seven were in the l a t e r adopter group, while the m a j o r i t y of those who attended the l a r g e s t number of short courses (more than three) were among the e a r l i e r adopters.  P e r h a p s the most significant finding, however,  i n r e l a t i o n to the l o c a t i o n of the c o u r s e s attended.  is  It would appear  that the m o r e widely afield the nurse t r a v e l l e d to attend courses that would keep her up-to-date with c u r r e n t developments in her greater  was  practices.  profession,the  the tendency towards e a r l i e r adoption of new ideas and  T h i s is again i n agreement with the findings of w o r k e r s in  other fields who have consistently shown a r e l a t i o n s h i p between e a r l y adoption and the use of cosmopolitan sources of i n f o r m a t i o n .  18  F i g u r e 35 shows a c o m p a r i s o n of e a r l i e r and later adopters among p a r t i c i p a n t s who had attended  no short continuing education  p r o g r a m s in the past five years and those who had been to m o r e than three,  while F i g u r e 36 shows the percentage of e a r l i e r and l a t e r  adopters by location of c o u r s e s  attended.  P a r t i c i p a t i o n in P r o f e s s i o n a l N u r s i n g Organizations P r i o r r e s e a r c h has indicated that e a r l y adopters tend to belong to m o r e f o r m a l organizations than late adopters.  19  191  Number o f c o u r s e s a t t e n d e d More than 3  Nil  Earlier cu  Adopters  cu  60 c. 4J  60 cd 4J  a cu o n cu  c  CU  o u cu  Later  Adopters  PH  Group 26 Mean A d o p t i o n Score  FIGURE 35:  31  P a r t i c i p a n t s i n e a r l i e r and l a t e r a d o p t e r c a t e g o r i e s : P e r c e n t a g e who had a t t e n d e d no c o n t i n u i n g e d u c a t i o n programs and percentage who had a t t e n d e d more than three.  192 L o c a t i o n o f Programs Outside Province  Local & .Vanrrnnvpr  Vancouver nnl y  Earlier 0) 60 n)  60 ct!  u C  CD 60  CJ  a)  IH  Group25 Mean Adoption Score  FIGURE 36:  C!  CD  J-l  CD  CD  P-<  28  Latex Adopters  O  U  CD PM  P-i  4J  CD CJ  <u o  o u  CD 60 ni  4J Cl  4-1  CD  Adopters  PH  30  33  P e r c e n t a g e o f p a r t i c i p a n t s i n e a r l i e r and l a t e r c a t e g o r i e s , by l o c a t i o n o f c o n t i n u i n g e d u c a t i o n programs a t t e n d e d .  193  In o r d e r to analyze the relationship between adoption and p a r t i c i p a t i o n in p r o f e s s i o n a l n u r s i n g organizations,  data were collected  on two aspects of p a r t i c i p a t i o n , attendance at meetings and officeholding, or committee m e m b e r s h i p ,  at the l o c a l , p r o v i n c i a l and  national l e v e l s of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n . in the p r o f e s s i o n a l n u r s i n g association  Participation  was r e l a t e d to adopter category 20  of the hospitals i n which the nurses were employed.  A t the L o c a l L e v e l Twenty of the hospitals included in this study were i n areas not i n c o r p o r a t e d into d i s t r i c t s of the p r o v i n c i a l n u r s i n g association.  Four  of these had a l o c a l n u r s i n g chapter in the community, however,  leaving  a total of sixteen participants with no l o c a l meetings to attend. The p r o p o r t i o n of e a r l i e r adopters was low among those who r a r e l y or never attended meetings of a l o c a l chapter of the n u r s i n g organization (including those with no meetings to attend) and the m a j o r i t y of these participants were later adopters.  O n the other hand, the p r o p o r t i o n s  were r e v e r s e d among those who attended always,  most of the time,  or  s o m e t i m e s . The percentage of participants i n each adopter category, by extent of attendance at l o c a l n u r s i n g association meetings is shown in F i g u r e 37. The Group Mean Scores also declined with d e c r e a s i n g attendance at p r o f e s s i o n a l meetings, the lowest score belonging to  194  Attend Meetings Always  Sometiroes  Mostly  No Local  Qhapfpr  16  cu  cu  M  M(  U C  JJ  cfl C  CU  cu  u  u  o  o  cu  36  CU PM  PH  '. "42  39  Group 30 Mean A d o p t i o n Score  30  Innovator E a r l y Adopter  Early  FIGURE 37:  Majority  /^/^  Late M a j o r i t y  Delayed A d o p t e r s  P e r c e n t a g e o f p a r t i c i p a n t s i n each a d o p t e r c a t e g o r y , by e x t e n t o f a t t e n d a n c e a t l o c a l p r o f e s s i o n a l n u r s i n g a s s o c i a t i o n meetings.  195  the group who had no l o c a l chapter in their a r e a .  Rather  s u r p r i s i n g l y , the group with the highest Mean Adoption Score and greatest p r o p o r t i o n of e a r l i e r adopters were the participants who stated they attended l o c a l chapter meetings s o m e t i m e s , but not on a regular basis.  With r e g a r d to holding office in the n u r s i n g association at the local level,  the most significant finding is the v e r y s m a l l number  of p a r t i c i p a n t s in the delayed adopter category who had ever h e l d a leadership position.  It is this group also who had the lowest  p r o p o r t i o n attending meetings. The numbers in each adopter category c u r r e n t l y holding, or who have held an office at the l o c a l l e v e l are shown i n T a b l e 24.  At the P r o v i n c i a l L e v e l Again,  at the p r o v i n c i a l l e v e l ,  those who attend Annual  Meetings of the A s s o c i a t i o n were among the e a r l i e r adopters and the p r o p o r t i o n of e a r l i e r adopters went steadily downward as r e p o r t e d attendance at the Annual Meetings of the A s s o c i a t i o n d e c r e a s e d .  The  same t r e n d was evident in the M e a n Adoption Score for the groups, as c a t e g o r i z e d by degree of attendance.  T h i s m a y be seen i n F i g u r e 38.  R e l a t i v e l y few of the D i r e c t o r s of N u r s i n g had p a r t i c i p a t e d in the p r o v i n c i a l n u r s i n g association to the extent of holding office or  195a  T A B L E XXIV OFFICE-HOLDING OR C O M M I T T E E MEMBERSHIP O F P A R T I C I P A N T S IN L O C A L N U R S I N G  ASSOCIATION,  BY ADOPTER CATEGORY  Adopter Source  Innovatore a r l y adopter  E a r l y majority  Late majority  Delayed adopters  Currently hold  Previously held  Never held  20%  7 17%  5 11%  1 20%  12 40%  17 36%  100%  3 60%  11 33%  15 32%  29 100%  3 10%  10 21%  13 100%  1  -  Totals  13 100% 30  Totals  5  33  47  85  GROUP M E A N  28  31  29  100%  Attend Meetings Mostly  Always  Sometimes  8  12  Rarely  Never  13  77,  24 cu  CD 60 cS  cu  60 CO  u c  <u  u CJ  4-1  4J  C CU  0)  o u  p-l  60 CO  CU  46  C  o  58  tl  CU PM  • 32  3  18 Group 31 Mean Adoption Score  Innovator E a r l y Adopter  Early Majority  FIGURE 38:  '//  a  Late M a j o r i t y  Delayed A d o p t e r s  P e r c e n t a g e of p a r t i c i p a n t s i n each a d o p t e r c a t e g o r y , by e x t e n t of a t t e n d a n c e a t p r o v i n c i a l p r o f e s s i o n a l n u r s i n g a s s o c i a t i o n meetings.  197  committee m e m b e r s h i p . but four were e a r l i e r  O f the eighteen (21 per cent) who had, a l l  adopters.  The details of frequency and percentage distribution of participants holding office or committee m e m b e r s h i p by adopter c a t e g o r y are shown i n T a b l e X X V  TABLE  XXV  OFFICE-HOLDING OR C O M M I T T E E MEMBERSHIP O F P A R T I C I P A N T S IN P R O V I N C I A L N U R S I N G  ASSOCIATION  BY ADOPTER CATEGORY  Currently  Previously  Never  hold  held  held  4 50%  2 20%  7 10%  13 100%  Early majority  4 50%  4 40%  22 33%  30 100%  Late majority  _  4 40%  25 37%  29 100%  Delayed adopters  -  -  13 20%  13  Innovator e a r l y adopter  Total Group Mean Adoption Score  8  10  67  37  31  29  Total  100%  198  At the National L e v e l The overwhelming m a j o r i t y of D i r e c t o r s of N u r s i n g of the public general hospitals in this p r o v i n c e have never attended a biennial meeting of the Canadian N u r s e s ' A s s o c i a t i o n . e a r l i e r adopters.  Once again, those who had were  O n l y one participant r e p o r t e d that she c u r r e n t l y  holds an office in the national organization and there were no others who had held one p r e v i o u s l y .  The percentage of participants in each adopter category,  by  extent of attendance at the biennial meetings of the p r o f e s s i o n a l n u r s i n g association,  is shown in F i g u r e 39.  P r o f e s s i o n a l Reading Habits of the D i r e c t o r s of N u r s i n g P r o f e s s i o n a l reading habits of the participants were  investigated  under four headings: (1) extent of reading of The Canadian N u r s e (official j o u r n a l of the Canadian N u r s e s ' A s s o c i a t i o n ) , journals r e c e i v e d other than the Canadian N u r s e , Nursing Research;  (2) number of  (3) s u b s c r i p t i o n to  and (4) amount of time spent in p r o f e s s i o n a l reading.  A s mentioned e a r l i e r , a l l participants r e c e i v e T h e Canadian N u r s e journal.  Seventy-five of the total eighty-five d i r e c t o r s involved i n the  study r e p o r t e d that they r e a d a l l or most of the a r t i c l e s in it. The r e m a i n d e r stated that they r e a d some. therefore,  The Canadian N u r s e would,  appear to be an important source of information for a l l  rather than a point of differentiation between e a r l i e r and later adopters.  22  Attend Meetings Mostly  Some times.  .Ttarply  60  36  nj  4J  a  cu o u  CU PH  34  M3 29  Mean 33 Adoption Score Innovator Early' Adopter  I  FIGURE 39:  |  Later Adopters  Early Majority  y^/,  Delayed Adopi t e r s  P e r c e n t a g e o f p a r t i c i p a n t s i n each a d o p t e r c a t e g o r y , by e x t e n t o f a t t e n d a n c e a t n a t i o n a l p r o f e s s i o n a l nursing a s s o c i a t i o n meetings.  200  With r e g a r d to the number of n u r s i n g journals r e c e i v e d byp a r t i c i p a n t s , the data revealed an interesting finding in that the number of journals r e c e i v e d d e c r e a s e category.  p r o p o r t i o n a t e l y with adopter  The average number of journals r e c e i v e d by participants  (in addition to T h e Canadian Nurse) in each adopter category is shown in T a b l e  XXVI  TABLE  XXVI  A V E R A G E N U M B E R O F N U R S I N G J O U R N A L S IN A D D I T I O N TO T H E CANADIAN NURSE R E C E I V E D B Y P A R T I C I P A N T S , BY ADOPTER CATEGORY  N u m b e r of J o u r n a l s Innovator E a r l y adopter  3  Early majority  2  Late majority  1  Delayed A d o p t e r s  0  A s for s u b s c r i p t i o n to the p r i n c i p a l j o u r n a l r e p o r t i n g r e s e a r c h dingins on this continent,  only eleven "participants r e p o r t e d r e c e i v i n g  N u r s i n g R e s e a r c h , either at work or p e r s o n a l l y . A l l but two of these were e a r l i e r adopters.  201  The amount of time spent i n p r o f e s s i o n a l reading does not appear to be different between e a r l i e r and later adopters. A l m o s t a l l of the participants r e p o r t e d that they spent anywhere f r o m a couple of h o u r s a week to one hour a day in reading r e l a t e d to their work, with only three stating that they spent l e s s time than this.  P e r c e p t i o n of P r o g r e s s i v e n e s s  of the H o s p i t a l s  In o r d e r to a s s e s s the p a r t i c i p a n t s ' p e r c e p t i o n of the p r o g r e s s i v e ness of the hospitals in which they worked, questions were asked r e g a r d i n g the number of r a d i c a l changes in n u r s i n g introduced in the past five y e a r s .  T h e d i r e c t o r s were also asked i f they felt their  hospital was p r o g r e s s i v e ,  as p r o g r e s s i v e as they thought it should be,  and, i f not, who was holding up p r o g r e s s .  ^  The r e s p o n s e s to these questions p r o v i d e d some interesting findings.  T h e n u r s e s ' perceptions ooincided f a i r l y a c c u r a t e l y with  the hospitals' adoption s c o r e s in r e g a r d to number of new p r a c t i c e s introduced recently.  Those who felt there had been quite a few  were p r e d o m i n a n t l y in the e a r l i e r adopter categories, s a i d there had been a few, later adopters. were,  changes  while those who  or not too many, were m o s t l y among the  The participants who s a i d there had been none at a l l ,  with only one exception,  in the later adopter categories.  The  Group Mean Adoption Scores show the same t r e n d and reflect the progressiveness  of the hospitals as p e r c e i v e d by the n u r s e s .  The  202  p r o p o r t i o n of e a r l i e r and later adopters in each group a c c o r d i n g to p e r c e p t i o n of p r o g r e s s i v e n e s s  of the hospital is shown in F i g u r e 40.  When asked d i r e c t l y if they thought their hospital was progressive, adopters.  only two answered "not at a l l " and these were l a t e r  T h e r e m a i n d e r said, "very p r o g r e s s i v e " or " f a i r l y  p r o g r e s s i v e " with only slight v a r i a t i o n s among the adopter  categories.  F o r t y - o n e participants (48 per cent) said they would like to see m o r e p r o g r e s s and these participants too, were found in a l l categories. 25 V e r y few offered an opinion as to who was holding up p r o g r e s s .  III. C H A R A C T E R I S T I C S '-OF T H E A D M I N I S T R A T O R  In the o r g a n i z a t i o n a l setup of B r i t i s h C o l u m b i a hospitals,  the  a d m i n i s t r a t o r is r e s p o n s i b l e for o v e r a l l operation of the institution. He is the l i a i s o n between the staff and the B o a r d of D i r e c t o r s , his u s u a l r o l e being s e c r e t a r y to the B o a r d in most hospitals,  rather  than a voting m e m b e r . A s noted p r e v i o u s l y , the a d m i n i s t r a t o r ' s a p p r o v a l is needed before expenditures can be made, it being his 26 r e s p o n s i b i l i t y to a d m i n i s t e r the total budget for the hospital. One might expect, then, that this individual is also a factor to be taken into account in the adoption of innovations within the hospital. C h a r a c t e r i s t i c s of the a d m i n i s t r a t o r s investigated in r e l a t i o n to adoption were (1) p r e p a r a t i o n , (2) age,  and (3) prestige among  203  R a d i c a l Changes i n N u r s i n g  Q u i t e a few  Some  A few  None a t a l l  EaTlie'r A d o p t e r s  Later Adopters Group31 Mean Adoption Score  FIGURE 40:  P e r c e n t a g e o f p a r t i c i p a n t s i n e a r l i e r and l a t e r a d o p t e r c a t e g o r i e s , by p e r c e p t i o n o f r a d i c a l changes i n n u r s i n g introduced i n h o s p i t a l .  204 colleagues,  as evidenced by affiliation with the A m e r i c a n College of  Hospital Administrators.  The m a j o r i t y of hospital a d m i n i s t r a t o r s (65 per cent) in the eighty-five hospitals had had p r e p a r a t i o n in hospital a d m i n i s t r a t i o n .  A s evident in F i g u r e 41, the a d m i n i s t r a t o r ' s p r e p a r a t i o n in the field of hospital a d m i n i s t r a t i o n appeared to have an effect on the r a p i d i t y of adoption of innovations in n u r s i n g p r a c t i c e within the hospital.  T h e m a j o r i t y of the t r a i n e d hospital a d m i n i s t r a t o r s were  in hospitals which were e a r l i e r adopters,  while the l a r g e s t p r o p o r t i o n  of these not s p e c i f i c a l l y p r e p a r e d in the field were employed in hospitals in the l a t e r adopter group. The Group M e a n Adoption Score of the hospitals without t r a i n e d a d m i n i s t r a t o r was also lower.  In this study, the a d m i n i s t r a t o r ' s age did not show a significant relationship to adoption.  P r e s t i g e of the a d m i n i s t r a t o r , however,  as  evidenced by his affiliation with the A m e r i c a n College of H o s p i t a l Administrators,  did appear to have an influence on adaptability of  the hospital i n r e g a r d s to changes in n u r s i n g p r a c t i c e . a d m i n i s t r a t o r s who were nominees,  members,  M o s t of the  or fellows of the  College were in hospitals i n the e a r l i e r adopter categories,  and their  Group Mean Adoption s c o r e was c o r r e s p o n d i n g l y higher than that of hospitals in which the a d m i n i s t r a t o r was not affiliated with the association.  The p r o p o r t i o n of e a r l i e r and later adopters among  205 Administrator  Prepared in Hospital Administration  No S p e c i f i c Preparation  u cu  •U Cu  o <5 cu Earlier  cu  tater  60  Adopters  Adopters  a <u o  S-l cu  PM  u  CU  4J  Cu O  T) <ti  >» r-l  u  cS  w  Group 32 Mean Adoption Score  FIGURE 41:  26  P e r c e n t a g e of h o s p i t a l s i n e a r l i e r and a d o p t e r c a t e g o r i e s , by p r e p a r a t i o n o f administrator.  later  206  hospitals in which the a d m i n i s t r a t o r s were affiliated with the A m e r i c a n College of H o s p i t a l A d m i n i s t r a t o r s c o m p a r e d with hospitals where the a d m i n i s t r a t o r was not so affiliated,  and the Group Mean Adoption  S c o r e s of the two groups of hospitals are shown in F i g u r e 42.  IV. C H A R A C T E R I S T I C S O F T H E N U R S I N G S T A F F  The n u r s i n g staff are undoubtedly important in the adoption of new ideas and p r a c t i c e s i n n u r s i n g . A s d i s c u s s e d in the previous chapter on sources of i n f o r m a t i o n used by the D i r e c t o r s of N u r s i n g , the n u r s e s frequently b r i n g new ideas with them when they move f r o m one h o s p i t a l to another and also when they r e t u r n f r o m educational meetings.  The n u r s i n g staff are almost without exception,  when new ideas are evaluated for t r i a l or adoption.  consulted  27  The c h a r a c t e r i s t i c s of the n u r s i n g staff investigated in r e l a t i o n to adoption were (1) r e l a t i v e age of the staff, taken their b a s i c n u r s i n g p r o g r a m ,  (2) where the n u r s e s had  and (3) p o l i c i e s of the hospital in  r e g a r d to attendance of n u r s i n g staff at educational meetings.  Since the overwhelming m a j o r i t y of the D i r e c t o r s of N u r s i n g r e p o r t e d that the nurses on their staff were p r e d o m i n a n t l y graduates of either B r i t i s h C o l u m b i a or other Canadian schools of n u r s i n g , the location of basic n u r s i n g p r o g r a m appears to be a c h a r a c t e r i s t i c c o m m o n to the total population, between hospitals.  rather than a basis for c o m p a r i s o n  207  Administrator  Nominee Member Fellow ACHA  Not Affiliated w i t h ACHA  Adoption Score  FIGURE 42:  P e r c e n t a g e o f h o s p i t a l s i n e a r l i e r and l a t e r a d o p t e r c a t e g o r i e s , by a d m i n i s t r a t o r ' s a f f i l i a t i o n w i t h American College of H o s p i t a l A d m i n i s t r a t o r s .  208  The p o l i c i e s of granting leave of absence with pay, and a s s i s t i n g n u r s e s with the expenses involved in attending,  appear to be  f i r m l y established in p r a c t i c a l l y a l l of the hospitals included in the 28 study.  Implementation of the p o l i c i e s ,  that is, how m a n y n u r s e s  are able to attend educational meetings and the extent of financial assistance,  does v a r y f r o m hospital to hospital.  The influence of  the extent of attendance of the n u r s i n g staff at educational meetings on acceptance of new n u r s i n g p r a c t i c e s might be a fruitful a r e a for further research. O f the three factors investigated,  then, relative age of the  n u r s i n g staff is the only one where there appears to be any point of differentiation between the hospitals r e g a r d i n g e a r l y and late adoption of n u r s i n g innovations.  It would seem, f r o m the findings, that a m i x e d  age group amongst the n u r s e s e m p l o y e d by a h o s p i t a l is m o r e conducive to adaptability to change than either a p r e d o m i n a n t l y older or younger staff.  T h e r e was a higher p r o p o r t i o n of e a r l i e r adopters among the hospitals r e p o r t i n g  that their n u r s e s were f a i r l y m i x e d as to age,  in institutions where the staff consisted of m o s t l y younger or older nurses. higher.  The Group Mean Adoption Score was also proportionately  than  F i g u r e 43 shows the percentage of e a r l i e r and later adopter among p a r t i c i p a t i n g hospitals,  by relative age of the n u r s i n g staff.  Nursing Staff  Predominantly Predominantly F a i r l y Young Middle aged mixed  41 61  * ,  *  Early  Percentage  * •. * "  Percent age  62  •  . *.  Majority  Later Adopters  #  •  27 Mean Adoption Score P  FIGURE 43:  27  .' • • •  31  P e r c e n t a g e o f h o s p i t a l s i n e a r l i e r and l a t e r a d o p t e r c a t e g o r i e s by r e l a t i v e age o f the nursing staff.  211  CHAPTER V  FOOTNOTES  1. Supra, Chapter II, pp. 50-54. 2. Supra,  Chapter II, pp. 52-53.  3. Supra, Chapter I, pp. 9, 10 4. H e r b e r t M e n z e l and E l i h u K a t z , "Social Relations and Innovations in the M e d i c a l P r o f e s s i o n : The E p i d e m i o l o g y of a New D r u g " (The P u b l i c Opinion Q u a r t e r l y , 29:4:337-352, Winter 1955-56) p. 351. 5. Supra, Chapter II, pp. 36-38 6. Supra, Chapter II, pp. 51-53 7. Supra,  Chapter II, p. 53  8. C o o l i e V e r n e r and P e t e r M . Gubbels, T h e Adoption or Rejection of Innovations by D a i r y F a r m O p e r a t o r s in the L o w e r F r a s e r V a l l e y , A Report published by the A g r i c u l t u r a l E c o n o m i c s R e s e a r c h C o u n c i l of Canada (printed in Canada, June, 1967), p. . 7 . 9- Countdown 1968 (Ottawa, 1969) pp. 8, 9.  T h e Canadian N u r s e s '  Association,  10. Supra, Chapter III, p. 7 5 11. E v e r e t t M . R o g e r s , The F r e e P r e s s , 1962), p.172. 12. Countdown, 13.  Diffusion of Innovations (New Y o r k ;  1968, op. cit. , p. 34.  Cf. Chapter III, pp. 77-79.  14.  Supra, Chapter III, p . 80  15.  Ibid.  16.  Ibid.  17.  Ibid.  18. Supra,  Chapter II, pp.  51, 52  19.  Ibid.  20.  C f . Chapter III, pp.  21.  Supra,  Chapter V , p. 169  22.  Supra,  Chapter III, p. 87  23.  Ibid.  24.  Supra, Chapter III, pp. 97-99  25.  Ibid.  26.  Supra, Chapter I I I , pp. 73-74  27.  Supra, Chapter I V , pp. 124-125  28.  Supra, Chapter III , pp. 96-97  85-94  213  C H A P T E R VI  FACTORS INFLUENCING DELAY, AND  REJECTION,  DISCONTINUANCE  R o g e r s and Shoemaker define the i n n o v a t i o n - d e c i s i o n p r o c e s s as  "the mental p r o c e s s through which an individual p a s s e s f r o m f i r s t  knowledge of an innovation to a d e c i s i o n to adopt or reject and to 1 c o n f i r m a t i o n of this decision. "  T h e time r e q u i r e d for the p r o c e s s  and the ultimate d e c i s i o n to adopt or not adopt a new p r a c t i c e v a r i e s for different innovations and with different i n d i v i d u a l s . In n u r s i n g , the d e c i s i o n to adopt or r e j e c t a change in n u r s i n g p r a c t i c e often involves a number of people and the innovation must be viewed i n the light of the p a r t i c u l a r situation in each h o s p i t a l .  In  analyzing the factors influencing delay in the adoption p r o c e s s ,  rejection  of innovations,  necessary  or their discontinuance following adoption, it is  then, to consider both the individuals involved and the nature of the innovation.  The analysis r e p o r t e d on in this chapter deals with four aspects of the adoption p r o c e s s investigated during the course of the study:  214  (1) the p r o g r e s s towards adoption and the i n n o v a t i o n - r e s p o n s e of the p a r t i c i p a n t s for the new p r a c t i c e s ; for each of the nine innovations; delay,  rejection,  state  (2) the pattern of adoption  (3) the stated reasons for adoption,  and discontinuance of the innovations;  and (4) the  i n d i v i d u a l s i n v o l v e d i n m a k i n g the d e c i s i o n to adopt the v a r i o u s practices.  I. P R O G R E S S T O W A R D S A D O P T I O N A N D INNOVATION RESPONSE  STATE  Information about the innovations i n c l u d e d i n the study had been available i n the p r o v i n c e for a n u m b e r of y e a r s and a l l of the p r a c t i c e s had been u s e d in at l e a s t one h o s p i t a l for a m i n i m u m of six years p r i o r to the study.  S t i l l , a l a r g e number of p a r t i c i p a n t s r e p o r t e d being  unaware of m a n y of them.  O n the average,  each h o s p i t a l had adopted  3. 4 of the nine new p r a c t i c e s and was unaware of  1.5.  T a b l e X X V I I shows the i n c r e a s i n g p r o g r e s s towards adoption f r o m the delayed adopters to the i n n o v a t o r - e a r l y adopter group.  P e r h a p s the  most significant figure i n the table is the high percentage of p a r t i c i p a n t s i n the delayed adopter category who were not aware of new p r a c t i c e s . Forty  p e r cent of p a r t i c i p a n t s in this category who were unaware  of the innovations i n c l u d e d in this study is c o n s i d e r a b l y higher than the percentage in any other adopter category.  215  T A B L E XXVII FREQUENCY AND P E R C E N T A G EO F PARTICIPANTS A T EACH S T A G E O F T H E ADOPTION PROCESS F O R A L L INNOVATIONS,  Adopter Category-  EarlyAdopter Innovator  BY ADOPTER CATEGORY  Early-  Late  Delayed  Majority  Majority  Adopter  Total  Stage Reached Not A w a r e  3 3%  27 10%  52 20%  47 40%  129 17%  Awareness  4 3%  22 8%  30 12%  14 12%  70 9%  Interest  2  5 2%  10 4%  1  2%  1%  18 2%  Evaluation  12 10%  32 12%  27 10%  11 9%  82 11%  Trial  35 30%  62 23%  61 23%  16 14%  174 23%  Adoption  61 52%  122 45%  81 31%  28 24%  292 38%  TOTALS  117 100%  270 100%  261 100%  117 100%  765 100%  216  T h e frequency and percentage of respondents i n each innovation response state, that is, rejection,  adoption, continuing with the adoption p r o c e s s ,  discontinuance, and not aware, for a l l innovations is shown  in T a b l e XXVIII.  T h e r e is again, as one would expect,  a d e c r e a s i n g number of  adoptions as the table proceeds f r o m the i n n o v a t o r - e a r l y adopters to the delayed adopters, and also a d e c r e a s i n g percentage in the continuing state. T h e high p r o p o r t i o n of delayed adopters who were not aware of new p r a c t i c e s is evident,  as indicated also in Table X X V I I .  The one point  of difference which shows up in this table is the greater p r o p o r t i o n of delayed adopters who had r e j e c t e d innovations.  Detailed tables of frequency and percentage of respondents in each response state for each innovation, and frequency and percentage distribution of respondents who had adopted, rejected, discontinued, or were unaware of each innovation are shown in T a b l e X X I X .  F i v e of the innovations had been adopted by m o r e than forty per cent of the hospitals included in the study.  T h e s e innovations were,  in o r d e r of number of adoptions, (1) sheepskin pelts; glove technique';  (3) open v i s i t i n g ;  (2) the 'closed  (4) disposable s y r i n g e s ;  and  (5) e l i m i n a t i o n of the 6 a . m . t e m p e r a t u r e routine.  The p r a c t i c e s with the least number of adoptions included two  217  T A B L E XXVIII FREQUENCY AND P E R C E N T A G E O F PARTICIPANTS IN E A C H R E S P O N S E S T A T E F O R A L L I N N O V A T I O N S ,  BY  ADOPTER CATEGORY  Adopter Category-  Early Adopter Innovator  Early Majority  Late Majority  Delayed Adopter  Total  Stage Reached Not A w a r e  3 3%  27. 10%  52 20%  47 40%  129 17%  Adoption  59 50%  119 44%  80 31%  27 23%  285 37%  Continuing  43 37%  104 39%  107 41%  25 21%  279 36%  Rejection  10 8%  17 6%  21 8%  17 15%  65 9%  Discontinuance  2 2%  3  1  1  7  1%  -  1%  1%  117 100%  270 100%  261 100%  117 100%  765 100%  Totals  T A B L E XXIX  F R E Q U E N C Y A N D P E R C E N T A G E O F P A R T I C I P A N T S IN E A C H R E S P O N S E S T A T E F O R A L L INNOVATIONS  Response State  Adoption  Continuing  Rejection  Discontinued  Not A w a r e  Total  Innovation Australian Lift  10 12%  24 28%  2 2%  -  49 58%  85 100%  13 15%  36 42%  2 2%  -  34 40%  85 100% *  ' C l o s e d Glove' Technique  41 48%  17 20%  7 8%  2 2%  18 21%  85 100%*  Sheepskin P e l t s  65 76%  10 12%  6 7%  3 4%  1 1%  85 100%  Open V i s i t i n g  46 54%  24 28%  12 14%  2 2%  1 1%  85 100%*  38 45%  27 32%  12 14%  0  8 9%  85 100%  15 18%  61 72%  9 11%  85 100%*  Boxing Glove Mitt Restraints  E l i m i n a t i o n of 6 a. m . Temperatures  E l imination of D r a w sheets  T A B L E X X I X (Continued)  Response State  Adoption  Continuing  Rejection  Discontinued  Not A w a r e  Total  Innovation C o l o r e d D r e s s e s with Children  17 20%  40 47%  19 22%  -  9 11%  85 100%  Disposable Syringes  40 47%  40 47%  5 6%  -  -  85 100%  TOTAL  285 37%  279 36%  65 8%  7 1%  129 17%  765 100%*  Percentage figures have been rounded off to the nearest whole number and, therefore, total exactly 100%.  do not  220 techniques,  the A u s t r a l i a n L i f t and the boxing glove mitt r e s t r a i n t s ,  and two routines, the e l i m i n a t i o n of drawsheets and the use of c o l o r e d d r e s s e s for working with c h i l d r e n .  T h e r e were v e r y few rejections of  any of the new p r a c t i c e s except in the case of the use of c o l o r e d d r e s s e s when w o r k i n g with c h i l d r e n . T h i s innovation, up to the time the study was undertaken, had had m o r e rejections (nineteen) than adoptions (seventeen). sixty-five,  T h e total number of rejections for a l l p r a c t i c e s was  which r e p r e s e n t s eight per cent of the total possible adoptions.  T w e l v e hospitals had rejected open v i s i t i n g and another twelve,  the  e l i m i n a t i o n of the 6 a . m . t e m p e r a t u r e routine. The ' c l o s e d glove' technique was r e j e c t e d by seven hospitals, the sheepskin pelts by six, and the disposable syringes by five. Two rejections of the ' A u s t r a l i a n L i f t ' and two rejections of the disposable syringes accounted for the r e m a i n d e r of the sixty-five r e j e c t i o n s .  T h e r e were even fewer discontinuances of new p r a c t i c e s following their adoption. The total number of discontinuances was seven,  which  is two per cent of the total number of adoptions. T h r e e hospitals had discontinued use of the sheepskin pelts.  Two had discontinued the ' c l o s e d  glove' technique, and two had c u r t a i l e d v i s i t i n g hours subsequent to e a r l i e r adoption of open v i s i t i n g .  II.  T H E P A T T E R N O F ADOPTIONS  A s d i s c u s s e d in Chapter II, numerous studies have indicated  221  that there is a definite and predictable pattern to the diffusion of innovations in any s o c i a l s y s t e m .  2  In addition to collecting data f r o m the D i r e c t o r s of N u r s i n g on the stage in the i n n o v a t i o n - d e c i s i o n p r o c e s s r e a c h e d for e a c h innovation, those D i r e c t o r s , who had adopted, were asked for the date the p r a c t i c e was f i r s t u s e d on a full scale in their hospital. F r o m this information, it was p o s s i b l e to tabulate the number of adoptions per year on both a cumulative and n o n - c u m u l a t i v e b a s i s .  C u m u l a t i v e adoptions were then  plotted on a graph to determine i f there was a d i s c e r n i b l e pattern.  The graphs of cumulative adoptions and tables showing number of adoptions per year, together with the number of participants i n each stage of the d e c i s i o n - m a k i n g p r o c e s s p r i o r to adoption for each innovation are shown on the following pages in F i g u r e s 44 through 52 and T a b l e s  X X X through X X X V I I I .  It is evident f r o m the graphs that the adoptions take on the 3 t y p i c a l '.'S'-shaped curve when plotted on a cumulative b a s i s . a m a r k e d difference  T h e r e is  in the sharpness of the curves indicating a m o r e  r a p i d rate of adoption of some innovations than others.  The most r a p i d  diffusion appears to have taken place in the case of the c l o s e d glove technique,  the sheepskin pelts for skin care, open v i s i t i n g hours and  the use of disposable s y r i n g e s .  E l i m i n a t i o n of the 6 a . m .  temperature  routine had a v e r y slow e a r l y diffusion p e r i o d but the rate of adoptions  222  TABLE XXX  N o . of P a r t i c i p a n t s in Stages P r i o r to Adoption Trial  10  AUSTRALIAN LIFT  Year  :  N o . Adopting per Year  ADOPTIONS  Cumulative Adoptions  1958 o r p r i o r  Evaluation  1  1959  Interest  2  I960  Awareness  13  1961  1  Not A w a r e  49  1962  1  1963  1  1964  1  1965  4  5  1966  3  8  1967  8  1968  10  223 i i T l_!  ":.I..r. TJX  --!-!••il±  .LI. LL  -!_i..J.  I [  80  -I-hi-"  "i:iiL  TTTT  .LL  i i  J.J.  T l '• !  75  I  ..L !..  70  i  J.L.L Tl-L  J_._  .LLLj. M LL. Ti i i TT  65  ! i  i i  T  i i I i M l_ T"i_q: 1" r i "i  ... --,-j-  TTTT  r  60  I  J.J..J. i I  55  J_L  _i_L  50  I I  TT  I _!_ 1 T  I_I  J..U--  i_ i J I i L_U i"! I I  40  I I I  Til"  45  .LIT J i i Ti  30 T  iJ  X±±  i r  45  M i l  J.IMT J I I l_ -i-rr "i _i_ r  i" iI  IT  _!. .!.  "IT  d:  I I i I  rrjii.  25  i _i _ i i i i  i  i I  TT IT  i i i  20  I I I ' I !  TI ni I  •I  i i  25 i I i  I I I ! I  10 i i I i i i  i i  !_| I_l  J-jlLI  • •-rn 1958  _|_!_L  !_) I !  T-T 1959 I960  .i L U . .! L L !  i i  1961  J  i I I i  J_U_L.i  I J..|. I I !  r i n •  i i  _L il  J_U_!  HI  I I I I.. M .  i :  _!.'!..LI'J i i  19 62  FIGURE  44:  i I I  "i"  i li-:T  1963 1964 AUSTRALIAN  196 5 196 6 LIFT;  CUMULATIVE ADOPTIONS  n i'-Ff-.  "i  1967 1968  I  i !  i  i i '  224  TABLE  BOXING G L O V E MITT  XXXI  :  N o . of P a r t i c i p a n t s i n Stages P r i o r to Adoption Trial  22  Year  1958 o r p r i o r  RESTRAINTS  ADOPTIONS  No. Adopting per Year  5  Cumulative Adoptions  5  Evaluation  1959  5  Interest  I960  5 5  Awareness  15  1961  Not A w a r e  34  1962  1  6  1963  2  8 8  1964 1965  1  9  1966  1  10  1967  2  12  1968  1  13  226  TABLE  XXXII  'CLOSED GLOVE'  TECHNIQUE  : ADOPTIONS N o . of P a r t i c i p a n t s in Stages P r i o r to Adoption Trial  13  Year  N o . Adopting per Year  Cumulative Adoptions  1958 o r p r i o r  Evaluation  3  1959  Interest  1  I960  1  1  Awareness  7  1961  _  1  Not A w a r e  18  1962  5  6  1963  1  7  1964  4  11  1965  9  20  1966  11  31  1967  5  36  1968  7  43  227  TABLE  XXXIII  N o . of P a r t i c i p a n t s i n Stages P r i o r to Adoption Trial  10  SHEEPSKIN P E L T S  Year  1958 o r p r i o r  :  ADOPTIONS  N o . Adopting per Year  Cumulative Adoptions  2  2  Evaluation  4  1959  -  2  Interest  _  I960  1  3  Awareness  2  1961  1  4  Not A w a r e  i  1962  2  6  1963  14  20  1964  11  31  1965  9  40  1966  14  54  1967  6  60  1968  8  68  229  -- - —- - —— - -- - --- - -- - - - -- i 80 - - ----  _  ...  i  _  - - - --  -  -  !  -- -  --  -  -  —---  i  1  I  -  T. . . . .  ....  1 i  i i 1  "i  --  - I1  1  - 1 1  --  -  -  [  -  1  i  -—  -  A f  \ i  |  -  -  -  -  1  1 ' 1 i 1  -  1  -  i  _  --  1  -  -  -  -  ---  -  -  i  i  -  -  --  1  --  -  n~ —  I  1  --  j 1  L_ 1  i -- - J_. 1 - .J... 1  1  -  1 1  i  -  | '  J._L J_.L  " \  _ , .  .  1 1  50  1 1  . . _  ~r  1  60 - i  -- - - --  - -- -  -  --  ...  --  -- - - - -- 70 -  _ | _  ...  i i  i  j  i  - Vc  i — —_ - - - — --- - - - _L1i 1 I -- T r -_L.L I - 1 i _!.... _ F -tI - —- -- - -- - i - -i I i i i — — -- -- 1 i i M 1M r 1 _ 11 I i - -i r — - ---— |I - -i " F t " -- -- - i 1 I ~r 1 — i li  _  _ L .  'l  "1  -- - - - - -  f  i  i  -  1  40  i  i  r  -  i  <  l  I\J.-  -  -  -  -  i i  i  if  i  30 1 1  --  -  -  --  / -  /j  - --  -  ~  -  i  10  ...  -— - --  1  M  _  -1 -I  --  -  -  -  _  M I -H-  1958  --  - -- -  ii  I  1  IL. -- T  i"  !  ~i T"  I  I [I  ! 1 !  -  --  -  -1  -  i  —- -  -  -- 1 1  - 1-ic- ---  _  J._.  :  i  I  i  -  -—  - - ——  -  _..L. 1  47:  -  -  l  1962  FIGURE  - - - -- - - -ii  —- -  _  |  1963  1964  SHEEPSKIN  _  -  —  ---  -'-!— i |_!_  1965  1 I  i  1 _ i  -  ,  1 !  --  --  -  1 |  ]  -  i  •M  1  1  --  —  ; i i i i  1 1 l  1  i  i  -  -  -  1  -  _  ...  -  -  -  i /  -  1  1  -- •-  \J  - - r r rI I I I I I960 1961  l | II  1959  -  -  i 1 1 1 i  -  L  -  !  -  - -  --- - -  /1  20  i i 1  -  1  -  i •:  I  1966  PELTS:  CUMULATIVE ADOPTIONS  —- -  — --  I •  1967  1 —j-  - --  M  M  -—  '  - _ ! _ L . M J  ~rr  ....  1 ! I 1  |  -j  i 1 1  -_ I  ! M  " I I I  |  1968  n i .!  !  '"  -  i ;  230  TABLE  XXXIV  No. o f P a r t i c i p a n t s i n Stages P r i o r to Adoption  O P E N VISITING  12  Evaluation  20  ADOPTIONS  No. A d o p t i n g per Year  Cumulative Adoptions  3  3  1959  2  5  Year  Trial  :  1958  or prior  Interest  2  I960  3  8  Awareness  2  19 61  3  11  Not A w a r e  1  1962  1  12  1963  6  18  1964  6  24  '  1965  .6  30  1966  8  38  1967  4  42  1968  6  48  231 1  --  - —-  —-  -- - - - - -1  - -  80  T I i  l l  -fl-  -  -—  -  -  i  —  -  --  -- - - — -- -  1  —- —- --- -  -- - - - --- --  ...  -  :  -  -  -  -  -  -  1 •  i i•  i  -  i - Ui  i  I I  - -  -  -  1  --  T  I i  1  I  i  --  -  i  1  I  i i  50  1  -  -  -  i i  -  i  i  -  !  -  ! i  -  -  -  1  ji  -  -  1  —  I-  ---  i  -  *1  1  -  -  ——--  -- -  1  20  1 1  -  r -  --  -  -  --  i 1 i f  —  /  - -  /I  - -i -  - -  1 1!  I \  1 _  —  -- i ----  -  1  M  --  r  1  i I  -  ... - -  M  1 1i  1  1  i  i ! i  -  1  i  T  _ ii _  i i  T\~  _ -J.I..  _  -  ;  1  1  r  1958  1  1959 I960  1  J_ i i  1 ; 1 i |  -  -_ L  i - - i _j_  1  1 i t "~... 1  1 1  r  T TL i  T •-  -  i  - --  1 1  — ]~ \ I ~ ! ._!_ i ' TL T " vT T - T U " ._!_ . . . i n " I T T "i l~ •j T' T|T " i r T . J T L TL.i'T i ! 'Tl' "1 i i i ! 1~" "'! i r i 10 i i. . .IL L 1 1! 1 i I i M i l i I !. - ± r | : " TI!i I"1 I1 11 1L ' V! 1 ..!.j __L .!.. I M I :• i ; T JT i j_ ! i ! ! i: ! 1 : M M ! i i i 1 -!_ i J T i L LiTj . TlT .... J.T i ''i1 1i H i 1 T i I! 1I ! ] i . i i i f' 1 i i 1i i i - i" I 11 i i J T J _ ... i J._ J. i I •!- i 1 1 1 i - _ T!T Ti.J.". ! i " "1 i ' A J... | - i i _L. ._ -- - i | i i ; 1 1 T T T T '. r Lr Lr j _ i ..... j J . . I IT i 1 1 j. . i ..!.. . 1.. j VT. \_ j Ti • Ji I M i l I II i I Ii I M M ir' : |_j _ M : "M V i _T i I ii i i ..... i 'i " i i i i  j -i ji l  i  1 r _ _ - i - 1 T 1T "T1 ~ " 1 i( ~i~ T i i i M _.U_. - i1 - j j" ; • ~/\ . J . T - - 1 i 1 i —T i" T i ;•" i 1 1 -- T - / - J _ 1 i 1 - I •{-•!- i _ _. .... r\~ "T r T H_j_ i I  /\ 1  i  1  1  i I I  _i  I  -  i i  T i  1  --  -  -  I  -  --  1  1  i  -  1  -  -  i  1  1  - -  i  -T -  1  -  -  'I  -  _L -  30  1  -  I  i  1 1  I I  |  --  i  --  1  40  —'  L J_i  1  I  -  TL1  1  -  i  i  1  -  - --  -  -:  T  - - - ---  1  -  -  I  -  1  --  I i  i  —  - -- -  -  -  -  -  ...  |  i -- -- -- I - -- -  -- -  I  i  1 ... - - —- - - - - - - -  - - --- -  -- -- -  i  -60  - --  -  -  1  - - --  _  ! 1 1 ! 1 1 1 I T  l  -- 70  i  i  I  - - - - -t-H - -  11  - - _ --  -  1 1 1  --  1  ;  1961 1962 1963 1964 1965 "1966  FIGURE 48: OPEN VISITING : CUMULATIVE ADOPTIONS  1  (  i 1  ... | i i i I i i  —  r  ;  ;  TiT.jTT.  TjT! T ! i ! • i j *r \"\" I ! i i i >" i i i":" i i .!..!.. . .J_U_i_ ! I -I .1 ! - L . i L i . '; T L.! T • i i ' l l i  •  1  M L !  M _  j '!  1967 1968  "l "  232  TABLE  XXXV  E L I M I N A T I O N O F T H E 6 a. m . T E M P E R A T U R E ROUTINE ADOPTIONS :  N o . of P a r t i c i p a n t s i n Stages P r i o r to Adoption Trial Evaluation  12 14  Year  N o . Adopting per Year  1958 o r p r i o r  Cumulative Adoptions  -2  1959  2  Interest  I960  3  Awareness  1961  3  Not A w a r e  1962  2  5  1963  1  6  1964  9  15  1965  7  22  1966  4  26  1967  5  31  1968  7  38  233 -—  _  -  - - -  l!  -  -  -  -  -  -  --  - --!i  -  80  -  -  -  i - -  -  - -  - -  -  i  -  - _i  --  - _!_ i1  r  -|-  1  -  -  -  ...L. J . - i :i: i  -  —  -  1  •1  - -_ i  60  -  r  -  1  -  i  i  -  -  -  -  40  TFF __ _i_. i i t  j  t-i  1  n _  1  i  j  i i j i "T"  .1  -  -  1  20  -  - -  10  -  ..L - J .1. 1  -—  --  i_U_  - - -  -  -- -  I L  1  -  --  I  ---  j'_L  -  1 1  i  1 -- j  i i i '  ll  _  -  t  —  -  —  II  -  r  .i  L L _ i  +  - -H -  -  _L|._.L J...!_L  -  1959 I960  FIGURE 49:  --  -—  --  I  ..!._ 1  i  J_. --  TL "  -  i  1 1  ...  ._!—  -  i  i i i i i  i i i i  j _n  --  i i i  -  i  —  1  -  -  -  i i  -  -  " h -1  i i  ! 1 1  !  -  -  ....  1  j  -  -  i  -  _  i i  -  •i i i i  -  77 _ ! . _ . i i i i  i  1 ' ' i 1 - Ii ii '  1  -  1  /  -  ?  1  -  —  1  -  "i 1 j"  -  1  L.I..-  1 1  -  -  -  1 1  J //  i  1  - I . J . - I . 1 •. / M M -\-/- -  - --  -  - -  1 1  --  •IJICJI  7  ' M "  l-l  i i  -  -j-  7'7 i.:!._  i  J_|_:  J . • _ _1_U  -  "\~  |i  ...  i  run M Ti  -  - -  i i i i _L  ." l ~I  -  1 1  --  -j-  " I i i —  i.. i i  TV  !  -  -  fi "  1  i  i  M ._L  -  -  —-  f f  | i M  _L  1961 1962 1963 1964 1965 1966 1967 1968 ELIMINATION OF 6 A.M. TEMPERATURE ROUTINE: CUMULATIVE ADOPTIONS  M  n i" i  I I T i i •  - -  r  -  i i _.LL.LL. r-LLLL M 1 I •  1  -- -- I  i i"i  ;  --  i • i  i  I I _L M . _ L  i  i  -  i r.i_. _LJ_  ;  i  ! Ll I ' M M . . . . .1 -  !  -  1 1  :  "*T  -  -J-H -  -  -  --  -  -  -  - —  -  -  --  -  -  -  -  -  "i ' ; "  ._1I'.L i l •I  i  -  -  -  -—  —  - -  ! 1 1 -1 1 11 - 7i "JT • y — - - - - I I ! ' y\ <'! 7J_1_ 1 - - -}1 i i 1 1 I 1 1 I _| l ) /"' '•" L L L J._ — M i | — _L17 — — T J 7 > r.!.I_DI - - -- ~j_| j / i , •• i M M  i I I l- lH i- i I •! i1 i 1 " iI 1i  1958  — —  --  -  ........  ~'\"  -  --  -  1 1 1  -  i  -  -  - _ -  -  -  —  i 1 i 1 i i i i  ......... .....  1  !  1 .1...  -  i M i i" n . ! i. j i i i  i i i i1 - .1 M l i 11 i ! i i M M  i  1  1  r ~r'r _i t _J__  I  --  M | - i I ! C • I 1 I  — —  - - -  1  1 1  _ -  1I —  —  1  I M i l  . L l  30  '  -  L L -. ...L.M._ . | _ U _ I i 1 J_t_J_. Iii L I 1 ! i i i 1 1 i i i i i i .!_ 1 i 1 . j... 1  |  i  rfFi  -  -  1—  -  - -  z  TTT"—  -I- 71.7 III.  L_l._ 1 _ ! _ ! . _  -  ; 1  M M  .  r |  —  1 -  l i M ..LL.! . j .  7  1  1  1  J..LL  -  -  i \• i "i i L •[-]"]" 1 i I J _!_ I -  —  -  -  [J  ! > l i .. . . .  1  i i  50  1!  _— - i  - -  -  ..Li..!. i i""ii I I .... ..^ i i i 1 i i i  :R:RT  --  -  1  1  -  -  -- -  !  70  :U:!:.L  .1  —  "i ~ I  i l l ! :  —  ..!_  j'lj. '  -  1  - -  1  -  -  —  - -  -  --  -— 1 -  1  234 /  TABLE  XXXVI  N o . of P a r t i c i p a n t s in Stages P r i o r to Adoption Trial Evaluation  54  ELIMINATION O F DRAWSHEETS : ADOPTIONS  Year  N o . Adopting per Year  1958 or p r i o r  Cumulative Adoptions  1  1959  1  Interest  I960  1  Awareness  1961  1  2  Not A w a r e  1962  2  4  1963  2  6  2  6  1964 1965  2  8  1966  2  10  1967  3  13  1968  2  15  235 j  i _ L.  T  i  -L  r  '"  i_  .. I 1..i "TT"  -  i i r "i ! 1 j l • ir r; "ii  _i _!_!_!._. |  :  _|_! "i  80  '  75  _ _  r  i i -  65 _.!_  j  :i_r  i i . j. . i _ i i i -  4 f! -  -  i  ! 1  55  -  H-  50  - -  -  _ ' r  "1 '  —  m  -{—{—1—4~  —  r  —  -  n rr  1  ri n  1  |  1  1 ; • : i ! ! 1  _ ! . -I._!_ 1 " i r: i ..ill -~r "I'M "i" rl. "S. \. 1 i " L _ " i~T i"' i i T r r ... .... j j • "" i f i i i ! " i i i i ! i 1T I 1 i i 1 i i l i i i _ ...L_ - i -j-j-j- _L " i ... :.J_L . - l i l 1 --ii 1 l i i _L ._LL._ - ._!„ 11 ~" 1 1 i i . .L.L ..... - - - _. - ! - - |-|• i i i i T ni M i l 1 1 1 ._ j_. - - 11 -j— _ lL.II _ L . L L L __ !~ 1 I _ - J _ i i_!_!_ rr- -i 1 ... 1 1 1 1 lil _U.J. r r h i 1 1 I 1 j _ J _ r" i i -j-|-L- T i M i l T" M i l 1 i 1 1 1 1 1 1 i i i _ - j - - - _!_!_.!_ -i i 1 M i l i 1 i-ji 1 l i M | i i TV i i M l ! - j i i i 1 i i "i i l l s "i i 1 ; 1 i i i i _ _l_ 1 l 1 1 i i i - - I | 1 1 i i i 1 i i 1 1 1 1 1 l i l l ... - - - i ~hn~r i ~ir i 1 1 1... M M rTi i i i i i ! 1 M M 1 M i l I I 1 1i 1 i i I i 1 1 1 i 1 1  " !-.. _L.  —  --  -  -  "i 1  i i 1 i i j *i r ij  i  i 1 1i "T"i""T ... .. ..  i  -  _.L  1  ..LL  T-F T ' :.ji i  M  i  60  -  i >i I T T T M i l _!—T __.!_. i i ! _L i  i l ! i l l ! ... . _ . 1 | _ _  70  I  "i"  M  rJ t _1_ -fl" _  " i ri  1  :  1 1 !  .n._i.r  i .."":......  - - - 1  -  ! 1  1  45  -  II  -  1  1 1 1 1 1  1  1  1  1 1  1 1 M I  1 1  1  1  40  1  1  ' M M M M  I !  1  1  35  I  -  1 1 i 1  -  30  1 1  —  -  25  ! -  -  1  -  1  -  -  20  i  - - - -  -  15  s  - - -  T  i I  10  -  .J I i  1  i  1958  :p  —  -  I t ' : I I I !  1959  -  -i- - 1 1  1 I 1 _!_ - - i 1i 1 i i1 _ _ J Li. i  — -  -  - - -  -  --  -  - -  -  _  l -•  - -  -  -  -  1L  -  -  1  -  -  1 i 1  i  - - - "i r  1  _LL r  |  -  -  i  - -  I  r  "i  l i L  "i i •I  "  ri i _i_ -  i~  -  -  i  —  1  -  -  1 1 -  -- r  -  i .....  "  i  -  1  1 - -}i i I! i 1 i i i I  r  - i i i i  1  -  i  1 1  i  J  L.  1  -  -  1 1  1 l  ~r i  rr i [ i i  1  • j i  -  in  1 1  - -  1  1  —- —i --  -- -  ——-  -  - -  -  I  1  -  -  :  j1 ||  ~r  -  i i - i i _.L i _ i i - —1~ i i .i i  i  i !  1 1  i 1 1 1 1 ! 1 ; i I  ! 1  M M M i l  r i i1 i i1 i 1 i - !  1  i  i I  1 !  M i l  M i r ! i i ! 1 - 1 i i -H Mi l Ml i 1 I 1 - 1 11 M M I 1 1 1 1  —  I I  1  ! i i i 1 i 1 _M__ - i i i ' "i 1 i "  -—  I960 1961 1962 1963 1964 1965 1966 1967 1968 FIGURE 50: ELIMINATION OF DRAW SHEETS : CUMULATIVE ADOPTIONS  !  TABLE  XXXVII C O L O R E D DRESSES F O R W O R K I N G WITH CHILDREN ADOPTIONS :  N o . of P a r t i c i p a n t s in Stages P r i o r to Adoption  Year  Trial  10  Evaluation  24  Cumulative Adoptions  1  1  1959  -  1  5  I960  _  1  Awareness  20  1961  _  1  Not A w a r e  9  1962  2  3  1963  2  5  1964  2  7  1965  4  11  1966  4  15  1967  1  16  1968  1  17  Interest  1958 or p r i o r  No. Adopting per Year  237 I  'r i ""I 1 1 - -- - - -T i _ I T... —- _ _ - ... - - 1 - -- i - i .J_.j_.j_ - 1 - -... -- - - —- — - - - - ... -- -- - _ i 1 1 ..... 1 j j j i _..L 1 T T .. 1 " ... 1 — - i i ..... - ... - — — - —i — — - ~ T -- - _ _ i IIj -[_ -- •- 1 -- j 1 i P ! i 1 i ! 1 1 _i_L.L_ 1 ' 1 — — - — — i _L IFF— — ... —L _ Li _ - 1 Tcr! I | I ! 1 Ti I I • i I M III - —-M M i —l~' - | - -- - nii - - -- - - - -- 1 - i — i • - T~ - 1 ! i i i—i—' I 1 1 r 1  J-.L.L  Iff  _  •  —  T V  ~H  _  i 1  -  -  - l --  -  I-  -  -  I  --  i ~j~  ~\" T  --  1  I  -  1  1  III'  -  -  I  -  i "]' i  --  i i i  i  ]  ' "T i l  I  1 !  I i  -  20  -  i 1  1  - -  I  i i  _L T 10 T T  -  -  1  i  -  -  1  -- -  1  1  i I i.i !! 1M i. i i i ii I T !i J  "1958  1959  _ -  -  — -=  1 !! i! M 1 1T " 1 I iI  -  -  -  !  --- --  i  ...  .  L  L  I  j  -  —-  . 1 . M i l  i i  -  ii -  i / i  -  ... -  -...  i  4 i  ui  _L.L. " .. 1 "1 ...  i1 i - t !'•" i I i" i""- Ill — ——IL — ! • 1 i .i ! ~r I  I i  1 :  i  1  -I i_i  i  -  i  i  i  /  -  -- -  -  1 1 1  1  ~rr  1  1  i  1  """ll  ...L —1 i  1  i  l M M 1  1  1.  J J .  1  -  -  -  ........  i:  --  1  ...  I ' M I '. !  i 1  I"'  -—  1  1 ...!.. I i i !  - ILi 1  -  -  i I !  -  -  I  .1.... 1  1  -  r  Il_  1 :  -j-.  i  - Ji .  1  _L. l  -  |  1  -"i  -j-  !  p  1  IL  - ....  ~  —-— - i — —-  1 1  --  -  i i I  1 -  -  1 1  i  - -  -  1  -  i i i  --  I  I  1 |  --  ...  j  i I I :  M M "Ti 1 i 1 i  1  -  1  -  1  i I 1 1 1 M i l m 1 M M 1 P l i j  I  1  1  i I  i |  1  _ L .  - --  T i  -  30  --  !  M M I1  - -  ---  t  1  l  1  1  1  -  i  r  i 1 i j  r r  40  1  j 1 1r --  1 1  -  i' 1 1  1  1  -r-  1  I  1  --  1 1 1  1 1  1  I  1 1  T T  1 1  i  1  -  i I  ...  !  -  11  - - ......  i  i l I I 1  i  --  --  i I  M M I 1  — 1  j  M  _L_  I  M M T~  i  l  '  M M  _!_ " i 'i i __L _L_ i i i -i IL.!_L.L - I ITi M M Ij_|_ "i i i -- - -... T _j_ ILL i i - .... "i' .... ..... . j . . . ... "1 ii M :" " T ....... -  M l  --  M  —-  "" I  I'  I960 1961 1962 1963 " 1964 1965 1966 1967 FIGURE 51: COLORED DRESSES IN PEDIATRICS : CUMULATIVE ADOPTIONS  ' I  V i i  1968  238  T A B L E XXXVIII  N o . of P a r t i c i p a n t s in Stages P r i o r to Adoption Trial Evaluation  DISPOSABLE SYRINGES : ADOPTIONS  Year  38 7  Interest  N o . Adopting per Year  1958 o r p r i o r  Cumulative Adoptions  -  1959 I960  Awareness  -  1961  Not A w a r e  -  1962  2  2  1963  2  4  1964  6  10  1965  8  18  1966  14  32  1967  2  34  1968  6  40  240 has a c c e l e r a t e d r a p i d l y in the past five y e a r s .  Some of the other p r a c t i c e s ,  such as the boxing glove mitt  r e s t r a i n t s , the elimination of drawsheets,  and the use of c o l o r e d  d r e s s e s when w o r k i n g with c h i l d r e n show a much slower rate of adoption, although a l l of these have been in use in some hospitals in the p r o v i n c e for m o r e than ten y e a r s .  The A u s t r a l i a n L i f t technique is a m o r e recent innovation and its graph of adoptions i l l u s t r a t e s the v e r y slow e a r l y diffusion p e r i o d of an innovation.  It is evident f r o m the tables and graphs that the diffusion of any single innovation through the network of public general hospitals in the p r o v i n c e extends over a p e r i o d of s e v e r a l y e a r s . In the case of the sheepskin pelts,  which have had the greatest number of adoptions  of any of the innovations studied, the p r o c e s s has taken ten years for these to be used in eighty per cent of the hospitals p a r t i c i p a t i n g in the study. T h i s technique has p r o b a b l y r e a c h e d its saturation point and nine participants r e p o r t e d that it had been r e j e c t e d or discontinued in favor of newer p r a c t i c e s .  E v e n in the case of the innovations which have had the most r a p i d rate of adoption, as for example, the p r o c e s s is slow.  the 'closed glove' technique,  It had been six years since this was first  introduced in the p r o v i n c e and only fifty-orte per cent of the  respondents  241  had adopted it by June, 1968.  A t this time, the hospital in which it was  f i r s t u s e d r e p o r t e d that the p r a c t i c e was now being discontinued because of i m p r o v e d techniques, while eighteen respondents (21 per cent) r e p o r t e d that they had s t i l l not h e a r d of it.  III. R E A S O N S F O R A D O P T I O N ,  DELAY,  DISCONTINUANCE  AND REJECTION  Some of the innovations were adopted r e l a t i v e l y quickly, took longer to diffuse through the hospitals, or discontinued subsequent to adoption.  some  and others were r e j e c t e d  The p a r t i c i p a n t s were asked  to state the reasons for adoption (if the p r a c t i c e had been put into use),  the reasons for a delay of m o r e than two years in the adoption  process,  and the reasons for r e j e c t i o n or discontinuance of the  practice.  Reasons for Adoption The reasons stated by the D i r e c t o r s of N u r s i n g for adoption of each of the nine new p r a c t i c e s are shown in Table X X X I X . These reasons give an indication of the dominant c h a r a c t e r i s t i c s of the innovation as p e r c e i v e d by the p a r t i c i p a n t s .  F r o m T a b l e 39 it can be seen that the p r i n c i p a l reason for adopting an innovation was either safety of the patient, that is, innovation was c o n s i d e r e d a better or ' s a f e r  1  the  technique than that  T A B L E XXXIX S T A T E D REASONS F O R A D O P T I O N O F INNOVATIONS  Innovation  N o . * of Adoptions  Safety of Patients  Comfort of Patients  Australian Lift  10  Boxing Glove Mitt Restraints  13  13  Technique  43  13  Sheepskin P e l t s  68  68  Open V i s i t i n g  48  45  E l i m i n a t i o n of 6 a. m . Temperatures  38  35  E l i m i n a t i o n of Drawsheets  15  15  Use of C o l o r e d D r e s s e s with c h i l d r e n  17  17  Time Saving  Labor Saving  Money Saving  Other  1  ' C l o s e d Glove'  Disposable Syringes  4  35  26  1  2 35  37  N u m b e r of reasons given for adopting some innovations is greater than the number of adoptions. The r e a s o n for this is that some participants gave m o r e than one r e a s o n for adopting some items.  243  p r e v i o u s l y used, syringes,  or comfort of the patient.  One i t e m , the disposable  was r e g a r d e d as having time and l a b o r - s a v i n g advantages  as well as safety features.  T h u s , the innovations could be divided into  two groups on the b a s i s of p e r c e i v e d c h a r a c t e r i s t i c s .  The f i r s t group  contained the items c o n s i d e r e d p r i n c i p a l l y safety m e a s u r e s , second,  and the  the p r a c t i c e s adopted m a i n l y for the comfort of the patient.  F o r analysis of data, the disposable s y r i n g e s , s afety component,  because of their l a r g e  were included with the group of safety m e a s u r e s .  T h i s d i v i s i o n of the innovations on the b a s i s of p e r c e i v e d c h a r a c t e r i s t i c s is consistent with the o r i g i n a l categorization of new practices. items,  The techniques were a l l c o n s i d e r e d to be p r i m a r i l y safety  while the routines were adopted m o r e for the comfort of the  patient than for any other r e a s o n .  Reasons for Delay, Rejection, or Discontinuance In questioning the n u r s e s r e g a r d i n g a delay in the adoption p r o c e s s for the v a r i o u s innovations, had to be taken into account.  the f a l l a b i l i t y of human m e m o r y  While the participants could r e m e m b e r ,  with what appeared to be a fair degree of a c c u r a c y , when a new p r a c t i c e had been introduced in their hospital, the date when they had f i r s t h e a r d of it was often vague.  The source was r e m e m b e r e d , but not the exact  date. F o r this reason, the v a l i d i t y of data on the exact length of time spent in the adoption p r o c e s s is questionable and, therefore, r e p o r t e d on h e r e .  not  244 It was evident,  however,  that some innovations were adopted  m u c h m o r e q u i c k l y than others as, technique,  for example,  the ' c l o s e d glove'  which the m a j o r i t y of participants indicated had been put  into use as soon as they,  or their operating r o o m n u r s e s ,  had h e a r d  about it. When the participants indicated that a fair length of time had elapsed between awareness and the stage r e a c h e d in the adoption process,  data on the reasons why the innovation had not been put into  effect e a r l i e r , were gathered.  The reasons for delay, r e j e c t i o n ,  or discontinuance were  c a t e g o r i z e d under the following headings: (1) relative advantage, (2) compatability with existing p r a c t i c e s ,  (3) complexity,  d i v i s i b i l i t y , (5) c o m m u n i c a b i l i t y , (6) situational factors,  (4) and (7)  o v e r - r u l i n g of a n u r s i n g d e c i s i o n . T h e reasons were analyzed in t e r m s of the dominant c h a r a c t e r i s t i c s of the innovation p e r c e i v e d by the nurses as d e r i v e d f r o m the p r i n c i p a l r e a s o n for adoption, and also in r e l a t i o n to adopter category.  B y p e r c e i v e d c h a r a c t e r i s t i c s of the innovations T a b l e X L shows the stated reasons for adoption v i s - a - v i s the r e a s o n s given for delay,  rejection,  or discontinuance for a l l innovations.  It is evident that a close relationship exists between the reasons  given  by some participants for adopting an i t e m and the reasons given by others for delay in the adoption p r o c e s s ,  rejection of an innovation,  TABLE  XL  S T A T E D REASONS F O R ADOPTION, A L L INNOVATIONS  Reason stated for* Australian Lift T o t a l adoptions 12% Mitt Restraints T o t a l adoptions 15%  Adoption  10  13  Glove Technique T o t a l adoptions 51%  43  Sheepskin Pelts T o t a l adoptions 80%  68  Disposable Syringes 40 T o t a l Adoptions 47%  DELAY,  R E J E C T I O N OR DISCONTINUANCE  Delay  Rejection  -  Discontinuance  -  Safety of Patient Labor-saving Time-saving  6 3 1  Communicability Situational Relative advan.  14 4 2  Safety of Patient C o m f o r t of " Time-saving  13 1 1  Relative Advan. Situational Communicability  15 6 5  Safety of Patient  43  Relative Advan. Communicability Situational Over -ruling  4 6  Relative Advan. Situational Complexity  31 6 5  5 1  3  -  -  Relative A d v a n . Situational  57 3  4 1  Safety of Patient C o m f o r t of " Safety of Patient Time-saving Labor-saving C o m f o r t of Patient Money-saving  68 26 35 35 37 1 2  -  2  -  2 2 2 2 1  -  1 1  -  -  TABLE  XL  (Continued) Adoption  Reason stated for* Open V i s i t i n g T o t a l adoptions 56% Elimination 6 a. m . temps T o t a l adoptions 45% E l i m i n a t i o n of Drawsheets T o t a l adoptions 18< Colored Dresses with C h i l d r e n T o t a l adoptions 20%  Reasons for:  48  38  Compatability Situational Relative A d v . Complexity  15 10 8 4  4 2 2  C o m f o r t of Patient 35 4 Time-saving 1 Labor-saving 2 Safety of Patient  Compatability Over -ruling Relative A d v . Situational  10 8 2 1  3 8  C o m f o r t of Patient 15  • Compatability Relative A d v . Situational  30 12 8  -  Situational Compatability Relative A d v . Complexity Over-ruling  24 7 7 4 1  12  C o m f o r t of Patient 45 2 Time-saving 1 Convenience  15 C o m f o r t of Patient 17 Labor-saving 2 17  Rejection  Delay-  Discontinuance  -  1  -  4 2 1  2  -  -  -  -  -  Reasons stated for adoption do not equal total number of adoptions because participants in some instances indicated m o r e than one r e a s o n for adopting an item.  tv  247  or its discontinuance after adoption.  C e r t a i n attributes of the  innovation i t s e l f such as its c o m m u n i c a b i l i t y or relative advantage appear to be m o r e important in the case of the techniques. C o m p a t a b i l i t y with existing p r a c t i c e s and situational factors were m o r e important i n the case of the routines.  N u r s i n g decisions to  adopt an innovation were o v e r - r u l e d m o r e frequently in the case of c e r t a i n innovations than others.  C o m m u n i c a b i l i t y was the most frequently given r e a s o n for delay,  r e j e c t i o n or discontinuance of three of the n u r s i n g techniques,  the A u s t r a l i a n L i f t ,  the B o x i n g Glove Mitt r e s t r a i n t s ,  and the ' c l o s e d  glove' technique. Relative advantage was the r e a s o n most c o m m o n l y given in r e l a t i o n to the sheepskin pelts and the disposable In the case of both of the last two items,  syringes.  costs were given as the  m a j o r factor to be c o n s i d e r e d in relative advantage of the innovation, by a number of the participants (eight in the case of the sheepskin pelts,  t h i r t y - e i g h t for the disposable  syringes).  With the open v i s i t i n g , the p r i n c i p a l r e a s o n given for delay, r e j e c t i o n , or discontinuance was compatability with existing routines. Situational factors were next highest on the l i s t of r e a s o n s .  The biggest  factor in r e j e c t i o n of the e l i m i n a t i o n of the 6 a. m . t e m p e r a t u r e routine was o v e r - r u l i n g of a n u r s i n g d e c i s i o n to adopt it. C o m p a t a b i l i t y with existing routines was the second most important r e a s o n .  248 Reasons by Adopter C a t e g o r y Table X L I • shows the frequency and percentage of reasons for delay, r e j e c t i o n , or discontinuance of innovations,  by adopter category.  the c h a r a c t e r i s t i c s of the innovation, such as its r e l a t i v e over other p r a c t i c e s ,  advantage  its compatability with existing routines,  c o m m u n i c a b i l i t y , or complexity, T h i s was also evident in T a b l e X L .  Overall;  outweigh a l l the other reasons  its given.  The late m a j o r i t y group and the  delayed adopters tended to s t r e s s situational factors m o r e than the e a r l i e r adopters d i d . T h e situation was u s u a l l y stated in t e r m s of the size of the hospital, type of cases admitted, or nature of the community in which the hospital was located.  Reasons by Stages in the Adoption P r o c e s s One important factor to consider is the stage in the adoption p r o c e s s when rejection o c c u r s . Is the new p r a c t i c e given  sufficient  consideration before the idea is rejected,, or it is d i s m i s s e d before being  investigated fully? T a b l e X L I I l i s t s the number and percentage  of rejections which o c c u r r e d at each stage in the adoption p r o c e s s , by adopter category.  Although there were v e r y few rejections of any of the p r a c t i c e s in this study,  it appears that, in most instances,  the innovation had  been given c a r e f u l consideration before being d i s m i s s e d as unsuitable for use in a hospital. The m a j o r i t y of rejections,  fifty of the total  249  TABLE  XLI  REASONS GIVEN B Y PARTICIPANTS F O R D E L A Y , R E J E C T I O N A N D DISCONTINUANCE O F INNOVATIONS, BY ADOPTER CATEGORY Adopter Reason Stated  Early Adopter Innovator  Early Majority  C at e g o r y Late Majority  Delayed Adopters  Tota:  39%  56 43%  59 41%  21 40%  160 41%  Compatability  8 13%  37 28%  21 15%  10 19%  76 20%  Communicability  9 15%  7 5%  11 8%  2 4%  29 7%  Complexity  9 15%  3 2%  1 2%  13 3%  Situational F a c t o r s  6 10%  24 18%  36 2 5%  16 30%  82 21%  5 8%  6 5%  14 10%  3 6%  28 7%  130 100%*  144 100%*  53 100%*  Relative Advantage  Over-ruling  Total  24  61 100%  -  388 100"/  * P e r c e n t a g e figures have been rounded off to the n e a r e s t whole number and, therefore, do not total exactly 100%  250 sixty-five (77 percent), had o c c u r r e d at either the evaluation or t r i a l stages. A m o n g the i n n o v a t o r - e a r l y adopter group, there were no rejections at the awareness stage, and only one at the  interest  stage. The delayed adopters tended to d i s m i s s new p r a c t i c e s a little m o r e frequently when they f i r s t h e a r d about them, but, even with this group, the m a j o r i t y of rejections, (72 p e r cent),  twelve of the total seventeen  o c c u r r e d during the l a t e r stages of the adoption p r o c e s s .  IV. P E O P L E I N V O L V E D IN D E C I S I O N - M A K I N G  If an innovation had been put into use in a hospital,  the  p a r t i c i p a n t s were asked who had been involved in m a k i n g the decision to adopt it.  In a number of instances,  the new p r a c t i c e had been  introduced p r i o r to the appointment of the c u r r e n t D i r e c t o r of N u r s i n g , and this i n f o r m a t i o n was not available. T h e s e instances, constituted a v e r y s m a l l percentage of the c a s e s .  however,  The data were  analyzed on the basis of number and percentage of times each individual, or group of individuals, was involved in the d e c i s i o n to adopt the innovations.  T a b l e XLIII shows the frequency and percentage of t i m e s the D i r e c t o r of N u r s i n g , the n u r s i n g staff, the m e d i c a l staff, administrator,  the  and the H o s p i t a l B o a r d were involved in making the  decision to adopt each of the nine new p r a c t i c e s .  In no instance were  individuals outside of the hospital r e p o r t e d as being involved in m a k i n g  251  TABLE  XLII  R E J E C T I O N O F INNOVATIONS B Y P A R T I C I P A N T S A T E A C H S T A G E IN T H E A D O P T I O N P R O C E S S , BY A D O P T E R CATEGORY Adopter Stage in the Adoption P r o c e s s  Early Adopter Innovator  Early Majority  4  Awareness  24%  Category Late Majority  5 24%  Delayed Adopters  Total  5 29%  14 22%  Interest  1 10%  1 2%  Evaluation  5 50%  10 59%  10 48%  8 47%  33 51%  Trial  4 40%  3 18%  6 30%  4 24%  17 26%  Total  10 100%  17 100%*  21 100%*  17 100%  65 100%  P e r c e n t a g e figures have been rounded off to the nearest whole number and, therefore, do not total exactly 100%  TABLE  XLIII  F R E Q U E N C Y A N D P E R C E N T A G E DISTRIBUTION O F P E O P L E I N V O L V E D IN T H E D E C I S I O N T O A D O P T INNOVATIONS  Innovation  Australian Lift  B o x i n g Glove Mitts  Director of Nursing 8  Nursing Staff  80%  10 100%  13 100%  13 100%  Personnel Medical AdminisStaff trator  Hospital Board  32** 8 6%  37 100%  6 16%  Sheepskin P e l t s  59** 100%  52 88%  7 12%  21 35%  Open V i s i t i n g  42** 100%  39 93%  26 62%  30 71%  25 60%  E l i m i n a t i o n of 6 a. m . 33** 100% Temperatures  27 82%  20 61%  5 15%  2 6%  ' C l o s e d Glove' Technique  E l i m i n a t i o n of Drawsheets  15 100%  15 100%  1 9%  1 9%  C o l o r e d D r e s s with Children  17 100%  15 88%  1 6%  4 24%  Disposable Syringes  40 100%  37 93%  13 33%  34 8 5%  2 5%  Totals  259 98%  245 92%  74 28%  95 36%  29 11%  253  TABLE  XLIII  (Continued)  In 13 instances the D i r e c t o r s of N u r s i n g indicated that they were s o l e l y r e s p o n s i b l e for introducing new p r a c t i c e s . T h e s e were 'closed glove' technique (2) sheepskin pelts (2) e l i m i n a t i o n of 6 a . m . t e m p e r a t u r e s (1) c o l o r e d d r e s s e s (1) and disposable syringes (2).  **  M i s s i n g data.  254  the final d e c i s i o n to adopt an innovation.  T h e r e were v e r y few instances,  only thirteen in a l l , in which  the D i r e c t o r of N u r s i n g indicated that she,  alone, was r e s p o n s i b l e  for m a k i n g the d e c i s i o n to adopt a new p r a c t i c e .  O n the other hand,  there were v e r y few cases (2 per cent) in which she was not involved. O f the seven instances i n which the participants said the decision to adopt an innovation had been made solely by the n u r s i n g staff,  two  were adoption of the A u s t r a l i a n L i f t as a technique for m o v i n g patients,  and the other five involved the use of the ' c l o s e d glove'  technique in the operating r o o m .  The n u r s i n g staff were r e p o r t e d as being consulted in the d e c i s i o n to accept new p r a c t i c e s in ninety-two per cent of the c a s e s . T h e m e d i c a l staff were brought into decisions r e g a r d i n g open v i s i t i n g hours and the e l i m i n a t i o n of the e a r l y m o r n i n g t e m p e r a t u r e routine (61 per cent) m o r e than at any other time,  although they were also  consulted in r e g a r d to the use of the disposable syringes (33 per cent) the ' c l o s e d glove' technique (16 per cent) and the use of sheepskin pelts (12 per cent).  The a d m i n i s t r a t o r was involved in the d e c i s i o n to adopt disposable s y r i n g e s in eighty-five per cent of the cases,  and was also  important in the d e c i s i o n to introduce open v i s i t i n g (71 per cent of the cases). T h e sheepskin pelts,  which involve costs,  also brought the  a d m i n i s t r a t o r into the d e c i s i o n - m a k i n g p r o c e s s in r e g a r d to their use,  t h i r t y - f i v e percent of the t i m e .  T h e a d m i n i s t r a t o r was again  consulted in some of the decisions r e g a r d i n g the use of c o l o r e d d r e s s e s for working with c h i l d r e n (24 per cent of the cases) and in a few instances i n r e g a r d to e l i m i n a t i o n of the 6 a. m .  temperature.  The H o s p i t a l B o a r d became involved in the d e c i s i o n - m a k i n g p r o c e s s r e g a r d i n g open v i s i t i n g in sixty p e r cent of the c a s e s .  This  is to be expected since the v i s i t i n g hours of a hospital affect community relations and m a y , in fact,  involve a change in hospital p o l i c y . T h e  B o a r d was also consulted i n two instances (6 per cent) involving the e l i m i n a t i o n of the 6 a. m . temperature routine.  256  C H A P T E R VI  FOOTNOTES  1. E v e r e t t M . Rogers and F . F l o y d Shoemaker, Diffusion of Innovations: a c r o s s - c u l t u r a l approach. (New Y o r k , F r e e P r e s s of Glencoe, i n print), p. 34. 2.  Supra, Chapter II, pp. 48-50  3. Ibid.  257  C H A P T E R VII  SUMMARY A N D IMPLICATIONS  It has been the purpose of this study to investigate the diffusion of innovations in n u r s i n g p r a c t i c e in a selected segment of Canadian hospitals.  L i t e r a t u r e on continuing education for m e m b e r s of the health professions has s t r e s s e d that understanding of the p r o c e s s of diffusion is one of the most important factors to be c o n s i d e r e d in the development of effective educational p r o g r a m s .  O f p r i m e i m p o r t a n c e is the p r o c e s s  by which new i n f o r m a t i o n is t r a n s m i t t e d and the factors which cause some ideas to be accepted i n p r a c t i c e and others to be rejected.  Studies on the diffusion of innovations have been done in such d i v e r s e fields as a g r i c u l t u r e , education, m a r k e t i n g , and m e d i c i n e . A review of the l i t e r a t u r e suggests that the t h e o r e t i c a l f r a m e w o r k that has evolved r e g a r d i n g the t r a n s m i s s i o n of i n f o r m a t i o n about new knowledge and technology in other d i s c i p l i n e s m a y be equally applicable in n u r s i n g . O f p a r t i c u l a r r e l e v a n c e are theories concerning the flow of information  258  through a s o c i a l s y s t e m ,  elements in the diffusion p r o c e s s ,  and the  nature of the individual i n n o v a t i o n - d e c i s i o n p r o c e s s .  T h r e e r e l a t e d aspects of diffusion were investigated in the c o u r s e of this study:  the flow of information about  through a network of hospitals;  new n u r s i n g p r a c t i c e s  factors r e l a t e d to adoption;  influencing delay in the adoption p r o c e s s ,  and factors  r e j e c t i o n of innovations,  or  their discontinuance following adoption.  I.  METHOD AND PROCEDURE  The population consisted of 85 hospitals in the P r o v i n c e of B r i t i s h C o l u m b i a . T h e s e constituted a l l of the public hospitals which p r o v i d e g e n e r a l i z e d acute care s e r v i c e s and included the m a j o r i t y of hospitals in the p r o v i n c e . The participants were the D i r e c t o r s of N u r s i n g of the h o s p i t a l s .  A n a n a l y t i c a l s u r v e y method was u s e d to investigate the diffusion of nine innovations in  n u r s i n g p r a c t i c e in the hospitals under  study. The unit of analysis was the hospital, and a s t r u c t u r e d  interview  technique was employed to gather data f r o m the D i r e c t o r of N u r s i n g of each hospital.  F o r analysis of data, the hospitals were divided into four groups, a c c o r d i n g to size: (1) Type A , consisting of hospitals with a rated bed capacity of 201 or over;  (2) Type B , of 75 to 200 beds;  259  (3) Type C , of 30 to 74 beds;  and (4) Type D, of under 30 beds.  Data were gathered on the sources of i n f o r m a t i o n used by the D i r e c t o r s of N u r s i n g at each stage of the adoption p r o c e s s ,  and on the  specific s o u r c e s used for i n f o r m a t i o n about the innovations included i n the interview schedule. T h e sources were c a t e g o r i z e d as: (1) impersonal sources,  (2) attendance at continuing education p r o g r a m s ,  (3) attendance at p r o f e s s i o n a l meetings,  and (4) p e r s o n a l s o u r c e s .  F r e q u e n c y and percentage distributions were calculated to a s s e s s the r e l a t i v e importance of v a r i o u s sources at different stages in the adoption p r o c e s s , sources.  and also the r e l a t i v e use of the four categories of  F l o w charts were developed to t r a c e the t r a n s m i s s i o n of  i n f o r m a t i o n about the specific innovations studied and, also, the general pattern of c o m m u n i c a t i o n between hospitals.  In analyzing factors r e l a t e d to the adoption of innovations, the dependent v a r i a b l e was an adoption s c o r e of the hospital computed on the basis of the stage in the adoption p r o c e s s r e a c h e d by the D i r e c t o r of N u r s i n g for each of the nine new p r a c t i c e s . T h e s c o r e s were r a n k o r d e r e d and then the hospitals were divided into four adopter categories: i n n o v a t o r - e a r l y adopter, e a r l y m a j o r i t y , late m a j o r i t y , and delayed adopters.  260  The factors influencing delay in the adoption p r o c e s s , of new p r a c t i c e s ,  rejection  or their discontinuance following adoption were  analyzed by (1) a s s e s s i n g the stage in the adoption p r o c e s s r e a c h e d by the p a r t i c i p a n t s and their innovation-response state for a l l innovations; (2) d e t e r m i n i n g the pattern of adoption for each new p r a c t i c e ; (3) r e l a t i n g the stated reasons for delay,  rejection,  to the p a r t i c i p a n t s ' p e r c e p t i o n of the innovations, stated r e a s o n s for adopting the p r a c t i c e .  and  or discontinuance  as evidenced by their  F i n a l l y , the individuals  i n v o l v e d i n m a k i n g the d e c i s i o n to adopt innovations were identified.  II.  T H E FINDINGS  The r e s u l t s of this study are consistent with the findings of r e s e a r c h in other d i s c i p l i n e s on the diffusion of innovations.  They  suggest that n u r s e s are v e r y m u c h l i k e the m e m b e r s of any other group with r e g a r d to the way they t r a n s m i t i n f o r m a t i o n about new ideas and p r a c t i c e s .  T h e r e appears to be a definite p r o c e s s involved i n  i n f o r m a t i o n - s e e k i n g by the D i r e c t o r s of N u r s i n g of the hospitals i n c l u d e d in the study, by n u r s e s .  and identifiable channels of c o m m u n i c a t i o n used  Specific c h a r a c t e r i s t i c s of the population tended to be  r e l a t e d to e a r l i e r and later adoption, and a d i s c e r n i b l e pattern was evident in the adoption of innovations by m e m b e r s of the p a r t i c u l a r s o c i a l s y s t e m under study. F a c t o r s influencing delay in the adoption process,  r e j e c t i o n or discontinuance of innovations were r e l a t e d both  261  to the nature of the p r a c t i c e ,  as p e r c e i v e d by the n u r s e s ,  and the  c h a r a c t e r i s t i c s of individuals involved in making the d e c i s i o n to adopt or not adopt the new p r a c t i c e s .  The findings w i l l be r e p o r t e d on under three headings: (1) the flow of i n f o r m a t i o n through the hospitals; adoption;  and (3) factors influencing delay,  (2) factors r e l a t e d to  rejection,  and d i s c o n t i n u -  ance.  The F l o w of Information T h r o u g h the H o s p i t a l s G e n e r a l Sources of Information The D i r e c t o r s of N u r s i n g of the hospitals i n this study showed a m a r k e d s i m i l a r i t y in the s o u r c e s of information they used at v a r i o u s stages in the adoption p r o c e s s .  The p r i n c i p a l sources r e p o r t e d as used,  in o r d e r of frequency named at a l l stages, were (1) the n u r s i n g staff within the hospital;  (2) p h y s i c i a n s ; (3) other D i r e c t o r s of N u r s i n g ;  (4) s a l e s m e n f r o m the hospital supply houses and drug companies; (5) h o s p i t a l a d m i n i s t r a t o r s ; h o s p i t a l journals;  (6) p r o f e s s i o n a l n u r s i n g , m e d i c a l and  (7) l i t e r a t u r e f r o m c o m m e r c i a l f i r m s ;  (8) attendance  at p r o f e s s i o n a l meetings; (9) p a r t i c i p a t i o n i n continuing education programs;  (10) f i l m s ;  (11) the news bulletin of the p r o v i n c i a l n u r s i n g  a s s o c a t i o n ; (12) n u r s i n g textbooks;  and (13) n u r s i n g  consultants.  New i n f o r m a t i o n m a y come o r i g i n a l l y f r o m any one of a  262 number of s o u r c e s , journal;  as for example:  an a r t i c l e in a p r o f e s s i o n a l  c o n v e r s a t i o n with another D i r e c t o r of N u r s i n g ; p a r t i c i p a t i o n  i n an institute or workshop;  attendance at a p r o f e s s i o n a l meeting;  the v i s i t of a representative of one of the hospital supply houses or l i t e r a t u r e sent out by the company; government n u r s i n g consultant;  the p e r i o d i c v i s i t of the p r o v i n c i a l  a patient; a f i l m ;  or a book.  If the n u r s e is interested in the idea and wishes to pursue it, she w i l l contact another D i r e c t o r of N u r s i n g to ask her about the new practice,  request the s a l e s m a n to f u r n i s h her with further details,  or  write d i r e c t l y to the company for additional l i t e r a t u r e .  Once the information has been gathered, the D i r e c t o r then consults with her colleagues within the hospital, the n u r s i n g and m e d i c a l staff,  and the a d m i n i s t r a t o r , to see if the innovation would  be suitable for use in their p a r t i c u l a r hospital.  When detailed i n f o r m a t i o n is r e q u i r e d r e l a t i v e to implementation of the innovation, and it involves a piece of equipment, the  salesman  f r o m the hospital supply house w i l l u s u a l l y a s s i s t by p r o v i d i n g a demonstration for the staff. routines or techniques,  If the innovation involves a change in  a nurse m a y be sent to another hospital to  see the p r a c t i c e in operation. If neither of these two alternatives feasible,  written information m a y suffice.  is  In the final stage of d e c i s i o n - m a k i n g , it is again the staff within the hospital who are consulted.  The n u r s i n g staff, the p h y s i c i a n s ,  and the a d m i n i s t r a t o r were a l l r e p o r t e d as involved in deciding whether an innovation is to be accepted or rejected.  In addition, i f the new p r a c t i c e  r e q u i r e s a change in hospital p o l i c y , or affects community relations, the H o s p i t a l B o a r d of D i r e c t o r s must also give their sanction.  Sources used by Nature of the A c t i v i t y Involved in the Source With r e g a r d to the categories of s o u r c e s investigated,  four  findings are significant: 1.  O f p r i m a r y importance is the r o l e of p e r s o n a l c o m m u n i c a t i o n  with colleagues.  O t h e r D i r e c t o r s of N u r s i n g were n a m e d as the p r i n c i -  p a l outside referents for i n f o r m a t i o n and advice on new ideas and p r a c t i c e s i n n u r s i n g , while the staff within the h o s p i t a l , the n u r s e s , physicians,  and the a d m i n i s t r a t o r were the chief consultants  the  when  decisions were being made r e l a t i v e to t r i a l or continued use of an innovation.  In addition, i n f o r m a l c o m m u n i c a t i o n with other n u r s e s at  p r o f e s s i o n a l meetings was r e p o r t e d as a valuable source contributing to knowledge about new ideas in n u r s i n g .  2.  Continuing education p r o g r a m s are an important i n i t i a l  source of i n f o r m a t i o n on new knowledge and technology in n u r s i n g . T h e s e ranked t h i r d in o r d e r of a l l s o u r c e s named at the awareness stage in the adoption p r o c e s s .  264  3.  The role of the c o m m e r c i a l agent, in this case, the  salesman  f r o m the hospital supply house, was found to be significant in drawing the D i r e c t o r of Nur sing s attention to new items, 1  p r o v i d i n g additional  i n f o r m a t i o n at the interest stage, and furnishing technical a s s i s t a n c e at the t r i a l stage of adoption.  4.  A s has been found i n other studies, i m p e r s o n a l sources of  i n f o r m a t i o n were used most frequently in the e a r l y stages of the adoption p r o c e s s ,  d e c r e a s i n g in relative importance as the D i r e c t o r of  N u r s i n g p r o c e e d e d through the stages of i n n o v a t i o n - d e c i s i o n .  The  n u r s i n g j o u r n a l s , l i t e r a t u r e f r o m the hospital supply companies,  hospital  journals and f i l m s were the chief i m p e r s o n a l s o u r c e s r e p o r t e d by the nurses,  with the n u r s i n g journals ranking f i r s t in o r d e r of a l l s o u r c e s  n a m e d at the awareness stage.  Specific Sources of Information U s e d for the Innovations With r e g a r d to the specific s o u r c e s of information used for the nine innovations investigated in the course of this study,  personal  c o m m u n i c a t i o n through i n f o r m a l channels was r e p o r t e d m o r e frequently than any other source for a l l of the new p r a c t i c e s .  The one  exception  was in the case of c o m m e r c i a l p r o d u c t s . The s a l e s m e n and l i t e r a t u r e f r o m the hospital supply houses, as well as advertisements  in the  n u r s i n g and hospital j o u r n a l s , were cited as the chief s o u r c e s of i n f o r m a t i o n for these.  265  In addition to p e r s o n a l communication, the short,  continuing  education course was named as an important source of i n f o r m a t i o n about the ' c l o s e d glove' technique and the ' A u s t r a l i a n lift'.,  Also,  a  number of the participants r e p o r t e d that they had r e a d j o u r n a l a r t i c l e s about m a n y of the innovations.  The P a t t e r n of Information F l o w Except in the case of one innovation, (the 'closed glove' technique),  there was little d i r e c t t r a n s f e r of information f r o m one  hospital to another r e p o r t e d about the nine innovations studied.  In t r a c i n g  the c o m m u n i c a t i o n links between hospitals,  evident  however,  it became  that two c y c l e s of influence are operating within the network of public g e n e r a l hospitals in the p r o v i n c e .  T h e f i r s t c y c l e of influence derives f r o m V a n c o u v e r , where the l a r g e teaching and r e s e a r c h centers are located. and the u n i v e r s i t y ,  T h e hospitals here,  conduct m a n y studies on new n u r s i n g p r a c t i c e s and  also r e c e i v e i n f o r m a t i o n f r o m s o u r c e s outside the p r o v i n c e . T h e second cycle of influence operates within a d i s t r i c t where some hospital's appear to function as opinion l e a d e r s for other hospitals in the a r e a . The opinion l e a d e r s are u s u a l l y the l a r g e r , r e g i o n a l center hospitals which have taken the lead in developing educational p r o g r a m s for n u r s e s in the d i s t r i c t and are used as referents by the s m a l l e r hospitals.  Thus,  it  appears that T r o l d a h l ' s 'Two C y c l e of Influence' theory* is as applicable  The F i r s t C y c l e of Influence Professional Intermediaries  Awareness Comprehension  N u r s i n g consultants Staff of the R e g i s t e r e d Nurses' Association Influence C o m m e r c i a l agents Outside experts  .Advice Seeking D i r e c t o r s of N u r s i n g of l a r g e r , c e n t r a l l y located hospitals  Mediated Communication  P r o f e s s i o n a l journals Continuing education programs P r o f e s s i o n a l meetings V i s i t s to other hospitals C o m m e r c i a l literature F i l m s , Books  The Second C y c l e of Influence Me diated Communication  Awareness Comprehension  D i r e c t o r s of N u r s i n g , of s m a l l e r hospitals I  Followers  Regional Institutes D i s t r i c t conferences C o m m e r c i a l agents / A d v i c e Seeking Opinion L e a d e r s IN>  F I G U R E 53  T W O C Y C L E S O F I N F L U E N C E IN N U R S I N G I N F O R M A T I O N D I S S E M I N A T I O N IN B R I T I S H C O L U M B I A  267  in n u r s i n g as it is in f a r m i n g . The p r o f e s s i o n a l i n t e r m e d i a r i e s in n u r s i n g (the agents t r a n s m i t t i n g new information) identified in this study include consultants f r o m the B r i t i s h C o l u m b i a H o s p i t a l Insurance S e r v i c e , the staff  of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n ,  agents of the hospital supply houses, and outside experts.  commercial Communication  is mediated (or transmitted) through p r o f e s s i o n a l j o u r n a l s , continuing education p r o g r a m s , p r o f e s s i o n a l meetings, a r r a n g e d v i s i t s to other hospitals,  commercial literature, films,  and books.  * A d i a g r a m m a t i c representation,  based on T r o l d a h l s model, 1  of the two c y c l e s of influence operating in the n u r s i n g c o m m u n i t y of B r i t i s h Columbia,  as indicated in the findings f r o m this study, is shown  in F i g u r e 53. Steps i n the P r o c e s s of Information D i s s e m i n a t i o n about New Nursing Practices In s u m m a r i z i n g the findings in r e g a r d to flow of information about new knowledge and technology through the hospitals included in this study,  four sequential steps a r e apparent. T h e s e are s i m i l a r to the  five steps d e s c r i b e d by W o l p e r t in the dissemination of information to 2  f a r m e r s in Sweden.  * T r o l d a h l ' s m o d e l is shown on page 37 of Chapter II, Review of the Literature.  268  1.  The focal point for i n f o r m a t i o n about new n u r s i n g knowledge  appears to be V a n c o u v e r . centers are situated, in the p r o v i n c e .  H e r e the m a j o r teaching and r e s e a r c h  as well as the one u n i v e r s i t y school of n u r s i n g  The l a r g e s t number of continuing education p r o g r a m s  for n u r s e s are held i n V a n c o u v e r , and experts are drawn here f r o m other parts of Canada and the United States to give short c o u r s e s on s p e c i a l i z e d topics i n n u r s i n g . The headquarters of the p r o v i n c i a l n u r s i n g a s s o c i a t i o n is also located in V a n c o u v e r .  2.  The c o - o r d i n a t i n g body for new i n f o r m a t i o n in n u r s i n g appears  to be the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a . The p r o f e s s i o n a l a s s o c i a t i o n has taken m u c h of the r e s p o n s i b i l i t y for o r g a n i z i n g and conducting continuing education p r o g r a m s for n u r s e s in the p r o v i n c e with a s s i s t a n c e f r o m the Departments of Continuing M e d i c a l and N u r s i n g E d u c a t i o n of the U n i v e r s i t y of B r i t i s h C o l u m b i a . In addition, the D i r e c t o r s of N u r s i n g S e r v i c e and N u r s i n g E d u c a t i o n of the A s s o c i a t i o n consolidate requests by n u r s e s in the p r o v i n c e for educational c o u r s e s and provide consultative  s e r v i c e s for d i s t r i c t s  wishing to develop their own p r o g r a m s .  3.  Information is d i s s e m i n a t e d to the l a r g e r hospitals in the  province.  In B r i t i s h C o l u m b i a , there are no s p e c i f i c a l l y designated  r e g i o n a l centers for the dissemination of i n f o r m a t i o n in n u r s i n g which p a r a l l e l the County A g r i c u l t u r a l agencies mentioned by Wolpert as  269  operating i n f a r m i n g d i s t r i c t s in Sweden.  3  Instead,  information  seems to flow m o r e d i r e c t l y to the l a r g e r hospitals within an a r e a . T h i s is p r o b a b l y due to s e v e r a l factors.  T h e s e hospitals are able to  send m o r e of their staff to educational p r o g r a m s in V a n c o u v e r .  The  D i r e c t o r s of N u r s i n g of the l a r g e r hospitals are u s u a l l y better p r e p a r e d a c a d e m i c a l l y than the nurses in s m a l l e r hospitals.  T h e y tend to seek  i n f o r m a t i o n through s u b s c r i p t i o n to m o r e p r o f e s s i o n a l journals and go further afield to obtain i n f o r m a t i o n than their counterparts in the smaller hospitals.  It is the D i r e c t o r s of N u r s i n g of the l a r g e r  hospitals who take an active part i n the p r o f e s s i o n a l n u r s i n g a s s o c i a t i o n . T h e y attend m o r e meetings and are also m o r e involved in holding office or c o m m i t t e e - m e m b e r s h i p from smaller  4.  in the organization than the n u r s e s  hospitals.  Information spreads through the r e m a i n d e r of h o s p i t a l s .  A s indicated p r e v i o u s l y , there is u s u a l l y one l a r g e r hospital in an a r e a which a s s u m e s a leading role in t r a n s m i t t i n g i n f o r m a t i o n to s m a l l e r hospitals in the d i s t r i c t . T h e l a r g e r hospitals u s u a l l y have better o r g a n i z e d i n - s e r v i c e educational p r o g r a m s for their own staff and w i l l often invite nurses f r o m other hospitals to join them for educational meetings. Regional institutes are u s u a l l y held in the l a r g e r hospitals.  The D i r e c t o r s of N u r s i n g of these hospitals are also used  as referents by the D i r e c t o r s of s m a l l e r hospitals in the surrounding area.  270  A hypothetical model i l l u s t r a t i n g the four steps in the diffusion of innovations i n n u r s i n g in the province is depicted in F i g u r e 54.  F a c t o r s Related to Adoption C h a r a c t e r i s t i c s of the population which it was felt might influence the adoption of innovations in n u r s i n g p r a c t i c e were i n v e s t i gated.  T h e s e included c h a r a c t e r i s t i c s of the hospital,  of the D i r e c t o r  of N u r s i n g , of the a d m i n i s t r a t o r , and of the n u r s i n g staff. P a r t i c u l a r emphasis was p l a c e d on the f i r s t two.  The H o s p i t a l a. Size of the hospital appeared to be a significant factor in the adoption of changes in n u r s i n g p r a c t i c e . A l l of the l a r g e hospitals were in the two e a r l i e r adopter c a t e g o r i e s , while the s m a l l e s t hospitals (those under 30 beds) had the highest p r o p o r t i o n of delayed adopters.  A general t r e n d of  d e c r e a s i n g adaptability with d e c r e a s i n g size was  evident  both f r o m the proportionate distribution of e a r l i e r and later adopters among hospitals of different s i z e s and also f r o m their Group Mean Adoption S c o r e s .  Significantly,  the  Group Mean Adoption Score of the hospitals under 30 beds was the only one below the population mean.  STEP 1 Vancouver  STEP 2 Vancouver  T e a c h i n g and r e s e a r c h hospitals U n i v e r s i t y School of N u r s i n g  STEP 3 D i s s e m i n a t i o n to L a r g e r Hospitals in D i s t r i c t  STEP 4 Diffusion T h r o u g h the R e m a i n i n g H o s p i t a l s  L a r g e r Hospital  Smaller Hospital  Registered Nurses' As sociation British Columbia  Outside s o u r c e s : experts f r o m Canada and the United States  FIGURE  54  F O U R S T E P S IN T H E D I S S E M I N A T I O N O F I N F O R M A T I O N O N N E W P R A C T I C E S T O N U R S E S IN B R I T I S H C O L U M B I A A HYPOTHETICAL MODEL -0  272  b. T e a c h i n g Status of the hospital also s e e m e d to have a b e a r i n g on e a r l y adoption of innovations in n u r s i n g p r a c t i c e . A l l of the teaching hospitals but one were in the i n n o v a t o r e a r l y adopter category, m a j o r i t y group.  and this one was in the e a r l y  T h e Group Mean Adoption Score of the  teaching hospitals was c o n s i d e r a b l y higher than that of any other single group of hospitals.  c. A c c e s s i b i l i t y to Information Sources was  also r e l a t e d  to adoption. Although e a r l i e r and later adopters were found in a l l parts of the p r o v i n c e , the g e n e r a l t r e n d was for the hospitals in the L o w e r M a i n l a n d and on V a n c o u v e r Island,  in  areas c l o s e l y adjacent to the p r i n c i p a l teaching and r e s e a r c h centers i n V a n c o u v e r , to be among the e a r l i e r adopters,  while  those in a r e a s further r e m o v e d had a higher p r o p o r t i o n of l a t e r adopters.  The Group Mean Adoption Score of hospitals  in the L o w e r M a i n l a n d and on Vancouver Island was c o r r e s p o n d i n g l y higher than that of hospitals in other parts of the p r o v i n c e .  d. A c c r e d i t a t i o n of the hospital was another factor which s e e m e d to have a bearing on i t 3 adaptability to change in r e g a r d to n u r s i n g p r a c t i c e .  A higher p r o p o r t i o n of a c c r e d i t e d  hospitals were e a r l i e r adoptervs,  and they had a higher Group  27 3  M e a n Adoption Score than n o n - a c c r e d i t e d hospitals.  The D i r e c t o r of N u r s i n g a. Age i n this study, was r e l a t e d to adoption in that p a r t i c i p a n t s in the e a r l i e r adopter categories were p r e d o m i n antly younger on the whole than the later adopters.  The  m e d i a n age category of participants was 45 to 49 y e a r s . The m a j o r i t y of e a r l i e r adopters were in the m e d i a n age category o r younger, while a high percentage of those in l a t e r adopter categories were above the m e d i a n . The late m a j o r i t y group had the highest percentage of older n u r s e s , and the delayed adopters the next l a r g e s t group of n u r s e s above the m e d i a n age  category.  b. P r o f e s s i o n a l N u r s i n g E x p e r i e n c e was also shown to have a r e l a t i o n s h i p to adoption of innovations.  T h e m a j o r i t y of  p a r t i c i p a n t s had graduated f r o m their basic n u r s i n g p r o g r a m s m o r e than twenty years p r i o r to the study and had been a c t i v e l y engaged in n u r s i n g for over 20 y e a r s . A little m o r e than one half (58 per cent) had had uninterrupted c a r e e r s ,  while  the r e m a i n d e r had been out of n u r s i n g for a p e r i o d of t i m e and then r e t u r n e d to their p r o f e s s i o n .  T h o s e with u n i n t e r -  rupted c a r e e r s appeared to have kept m o r e up-to-date on c u r r e n t p r a c t i c e s than those who had been out of n u r s i n g for  274 a while.  T h e r e were m o r e e a r l i e r adopters among the  n u r s e s who had worked in n u r s i n g continuously,  their  Group M e a n Adoption Score being higher than that of nurses with i n t e r r u p t e d c a r e e r s .  Date of graduation f r o m the basic n u r s i n g p r o g r a m appeared to be m o r e c l o s e l y related to the adoption of innovations than the total number of years in the p r o f e s s i o n .  O f the n u r s e s  who had graduated m o r e than 30 years ago, m o r e were i n the l a t e r adopter groups than among the n u r s e s who had graduated i n the median category (20 to 29 years ago) or later.  With r e g a r d to tenure,  it was found that the participants who  had been in their present positions 6 to 10 years had the greatest number of innovators and e a r l y adopters,  while  the group with l e s s than one year of tenure had the next highest percentage in the e a r l i e r adopter Proportionately  categories.  m o r e later adopters were found among the  n u r s e s who had been in their positions 11 to 20 years than in any other group.  c. M a r i t a l Status and N u m b e r of C h i l d r e n were also found to be r e l a t e d to adoption. Although the single nurses were  275 in the m i n o r i t y in this p a r t i c u l a r study, their p r o p o r t i o n of e a r l i e r adopters was greater and their Group Mean Adoption Score higher than those who were not single.  The  same t r e n d was found with r e g a r d to participants without children,  as opposed to those with c h i l d r e n .  d. E d u c a t i o n a l Attainment in this study,  was  significantly  r e l a t e d to adoption of innovations. (i) a c a d e m i c p r e p a r a t i o n . T h e r e appeared to be a close relationship between a c a d e m i c p r e p a r a t i o n of the participants and e a r l y adoption of innovations.  T h e p r o p o r t i o n of  innovators and e a r l y adopters and also the Group M e a n Adoption Score i n c r e a s e d steadily as the a c a d e m i c l e v e l of the D i r e c t o r s of N u r s i n g r o s e .  (ii) post basic educational p r o g r a m s .  Twenty-nine participants had  taken hospital post-graduate c o u r s e s in n u r s i n g , university courses,  twenty-five  and twenty-eight had taken, or were  c u r r e n t l y e n r o l l e d in the Canadian N u r s e s ' A s s o c a t i o n c o r r e s p o n d e n c e course on N u r s i n g Unit A d m i n i s t r a t i o n . O f the three p r o g r a m s , the u n i v e r s i t y certificate course was the only one which showed a close relationship to e a r l y adoption of innovations.  T h e r e was a higher p r o p o r t i o n of e a r l i e r  adopters amongst these nurses than in the general population,  276  and they also had a higher Group Mean Adoption Score.  (iii) g e n e r a l adult education c o u r s e s .  F o r t y - t w o of the  participants had taken adult education c o u r s e s of a g e n e r a l nature. T h e r e was a slightly higher p r o p o r t i o n of e a r l i e r adopters among this group than in the general population, and they also had a higher Group Mean Adoption Score than the population mean.  (iv) p a r t i c i p a t i o n in continuing education p r o g r a m s for n u r s e s Attendance at continuing education p r o g r a m s showed a close relationship to e a r l y adoption of new n u r s i n g p r a c t i c e s , this p a r t i c u l a r study.  in  The participants who had attended the  l a r g e s t number of institutes, workshops or other educational p r o g r a m s in the five years p r i o r to the study were predomin= antly among the e a r l i e r adopters,  while the m a j o r i t y of  those who had attended none were in the late m a j o r i t y or delayed adopter c a t e g o r i e s . T h e r e was a significant  difference  in the Mean Adoption Scores of these two groups, also,  with  those who had not been to any educational p r o g r a m s having a s c o r e c o n s i d e r a b l y below the population m e a n .  The location of the courses attended also appeared to be a factor influencing adoption. Seventy-five per cent of those who had been to educational meetings outside the p r o v i n c e  277  were e a r l i e r adopters,  and the M e a n Adoption Score of  this group was well above the total population mean.  e.  P a r t i c i p a t i o n in P r o f e s s i o n a l N u r s i n g O r g a n i z a t i o n s  also showed a close relationship to adoption.  N u r s e s who  p a r t i c i p a t e d in their p r o f e s s i o n a l organizations showed a tendency to adopt new ideas and p r a c t i c e s m o r e r e a d i l y than those who did not p a r t i c i p a t e . T h e p r o p o r t i o n of e a r l i e r adopters and the Group Mean Adoption Score i n c r e a s e d steadily with the extent of p a r t i c i p a t i o n i n the p r o f e s s i o n a l n u r s i n g association,  as evidenced by attendance at meetings  and office-holding or committee m e m b e r s h i p in the o r g a n ization.  T h i s finding was true of p a r t i c i p a t i o n at the l o c a l ,  p r o v i n c i a l and national l e v e l s of the p r o f e s s i o n a l n u r s i n g association.  T h e m a j o r i t y of participants who r e p o r t e d that  they did not attend meetings of their p r o f e s s i o n a l were later adopters.  association  In line with this finding, hospitals in  the areas where the n u r s e s were not i n c o r p o r a t e d into d i s t r i c t s of the p r o v i n c i a l n u r s i n g a s s o c i a t i o n had the lowest Group M e a n Adoption Score of a l l of the groups of hospitals when analysis was done on a basis of geographic l o c a t i o n .  f. P r o f e s s i o n a l Reading Habits showed a r e l a t i o n s h i p to adoption in only one facet.  A l l participants r e c e i v e d The Canadian N u r s e  j o u r n a l which is the official j o u r n a l of the national nursing association,  and most participants r e p o r t e d that they r e a d  it r e g u l a r l y . A significant  finding i n r e l a t i o n to p r o f e s s i o n a l reading  habits was that the number of n u r s i n g journals r e p o r t e d as s u b s c r i b e d to by the participants c o r r e s p o n d e d c l o s e l y to adopter category. ed  T h e i n n o v a t o r - e a r l y adopter group r e c e i v -  an average of three n u r s i n g journals i n addition to the  Canadian N u r s e ; the e a r l y m a j o r i t y , two; the late m a j o r i t y , one; and the delayed adopters,  none.  T h e amount of time  spent i n p r o f e s s i o n a l reading and the extent of reading of T h e Canadian N u r s e was a p p r o x i m a t e l y the same for a l l adopter categories and, therefore,  not significantly r e l a t e d  to adoption.  g.  T h e p a r t i c i p a n t s ' perception tf the p r o g r e s s i v e n e s s of  the hospitals i n which they were employed, as evidenced by their indication of the number of r a d i c a l changes i n n u r s i n g introduced i n the past five y e a r s ,  coincided f a i r l y a c c u r a t e l y  with the adoption s c o r e of the hospital.  T h e r e was a higher  p r o p o r t i o n of e a r l i e r adopters among those who stated that there had been quite a few changes, and a higher p r o p o r t i o n of later adopters among those who said that there had been  few or none at a l l .  A n s w e r s to d i r e c t questions on whether  the hospital was p r o g r e s s i v e did not show a r e l a t i o n s h i p to the adoption s c o r e of the hospital.  The Administrator  a.  Specific p r e p a r a t i o n i n hospital a d m i n i s t r a t i o n on the part  of the a d m i n i s t r a t o r appeared to be a factor, i n influencing adaptability of the hospital to changes i n n u r s i n g p r a c t i c e .  A  higher p r o p o r t i o n of e a r l i e r adopters and a higher G r o u p M e a n A d o p t i o n Score were found among hospitals with p r e p a r e d a d m i n i s t r a t o r s than among hospitals where the a d m i n i s t r a t o r had not had specific p r e p a r a t i o n i n the field.  b«  A g e of the a d m i n i s t r a t o r did not show a significant c o r -  r e l a t i o n with adoption. however,  T h e age categories u s e d in this study,  c o v e r e d a wide range, and it is possible that a m o r e  sensitive instrument might r e v e a l differences i n r e g a r d to this characteristic.  c.  Prestige,  as indicated by affiliation with the A m e r i c a n  C o l l e g e of H o s p i t a l A d m i n i s t r a t o r s , did, however, r e l a t i o n s h i p to e a r l y adoption.  show a  T h e percentage of e a r l i e r  adopters and the G r o u p M e a n A d o p t i o n S c o r e s of hospitals  280 whose a d m i n i s t r a t o r s were either nominees,  members,  or  fellows of the a s s o c i a t i o n were m u c h above the g e n e r a l population n o r m s and significantly higher than hospitals in which the a d m i n i s t r a t o r was not so affiliated.  T h e N u r s i n g Staff  T h r e e c h a r a c t e r i s t i c s of the n u r s i n g staff were in r e g a r d to adoption:  investigated  (1) r e l a t i v e age of the staff; (2) location of  the schools of n u r s i n g where they had taken their b a s i c n u r s i n g education p r o g r a m s ; and (3) p o l i c i e s of the hospitals with r e g a r d to attendance of staff at educational meetings.  Of these three f a c t o r s ,  the only one which showed a r e l a t i o n s h i p to adoption of innovations was r e l a t i v e age.  It would appear that a f a i r l y m i x e d age group of  n u r s e s is m o r e conducive to adaptability i n r e g a r d to changing n u r s ing p r a c t i c e s than either a predominantly younger or older n u r s i n g staff.  P r o p o r t i o n a t e l y m o r e e a r l i e r adopters and a c o r r e s p o n d i n g l y  higher A d o p t i o n Score were found i n hospitals where the n u r s i n g staff were r e p o r t e d as f a i r l y m i x e d i n age, younger or older n u r s e s .  than i n hospitals with either  T h e other two factors a p p e a r e d to be  c h a r a c t e r i s t i c s of the total population r a t h e r than factors influencing adoption.  A l l but one hospital r e p o r t e d that the m a j o r i t y of its n u r s -  ing staff were graduates of Canadian schools of n u r s i n g . a v e r y few participants  A l l but  stated that the p o l i c i e s of granting leave of  281  absence with pay for n u r s e s to attend educational meetings and the granting of some f i n a n c i a l a s s i s t a n c e towards expenses i n attending these, were established p o l i c i e s i n their hospitals.  F a c t o r s Influencing D e l a y , R e j e c t i o n and Discontinuance  In analyzing factors influencing delay i n the adoption p r o c e s s , r e j e c t i o n of innovations,  or their discontinuance following adoption,  both the individuals involved i n making decisions to adopt or not adopt innovations were c o n s i d e r e d , as w e l l as the c h a r a c t e r i s t i c s of the innovation itself.  Stages i n the A d o p t i o n P r o c e s s R e a c h e d by P a r t i c i p a n t s and Innovation-Response State for a l l Innovations.  On the a v e r a g e ,  each hospital had adopted 3. 4 of the nine new  p r a c t i c e s and was unaware of 1. 5.  F i v e of the innovations, had been  adopted by m o r e that forty percent of the hospitals included i n the study.  T h e s e were the sheepskin pelts,  open v i s i t i n g , disposable s y r i n g e s , t e m p e r a t u r e routine. Lift,  the  1  c l o s e d glove'  technique,  and e l i m i n a t i o n of the 6 a. m,  T h e r e m a i n i n g four innovations, the A u s t r a l i a n  the boxing glove mitt r e s t r a i n t s , the e l i m i n a t i o n of drawsheets,  and the uses of c o l o r e d d r e s s e s for working with c h i l d r e n , had been adopted by a c o n s i d e r a b l y s m a l l e r number of hospitals.  T h e r e were  282 r e l a t i v e l y few rejections of any of the new p r a c t i c e s except one, the use of c o l o r e d d r e s s e s for working with c h i l d r e n , which up to the time this study was undertaken, had had m o r e rejections than, adoptions.  The  total n u m b e r of rejections for a l l innovations was sixty-five (8 per cent of the number of possible adoptions). discontinuances,  T h e r e were even fewer  l e s s than three per cent of a l l adoptions that had  taken place. A s one might expect, there was a higher percentage of innovators and e a r l y adopters, and a l s o the e a r l y m a j o r i t y group, who had either adopted, or were i n the state of continuing with the adoption p r o c e s s , for a l l innovations.  T h e numbers d e c r e a s e d proportionately among  the l a t e r adopters.  One highly significant finding was the l a r g e  number of delayed adopters who were unaware of many of the new practices.  T h e delayed adopters a l s o had a higher percentage  of r e j e c t i o n of innovations than any other. W h e r e rejections had o c c u r r e d , these were usually i n the later stages of the adoption p r o c e s s ,  a fact which suggests that most ideas a r e  given a f a i r evaluation before being d i s m i s s e d as unsuitable for a p a r t i c u l a r hospital.  Only i n the one instance where there were m o r e  rejections than adoptions was there any indication that the idea had not been fully explored before r e j e c t i o n .  283 T h e P a t t e r n of Adoptions of Innovation^;  When adoptions were plotted against t i m e , cumulative adoptions a s s u m e d the t y p i c a l ' S  1  the graph of  shaped curve  d e s c r i b e d by many other w o r k e r s i n the field of diffusion r e s e a r c h . T h e r e was a m a r k e d difference i n the sharpness of the c u r v e s for the different innovations,  showing a m o r e r a p i d rate of adoption  of some of the new p r a c t i c e s than others. reached a  higher peak of adoption a l s o ,  Some innovations indicating a m o r e  complete  acceptance of some new i t e m s than others.  T h e most r a p i d rate of adoption had o c c u r r e d i n cases where there had been a s y s t e m a t i c d i s s e m i n a t i o n of i n f o r m a t i o n about the innovation through continuing education c o u r s e s ,  a d v e r t i s i n g by the  c o m m e r c i a l f i r m s , or publicity through the journals and other literature.  E v e n i n the case of innovations with the most r a p i d rate of diffusion,  however,  it was evident that the i t i n e r a r y of any single  innovation through the community of hospitals a considerable lenght of time.  i n the province takes  T h e shortest p e r i o s of time for any  of the new p r a c t i c e s to be adopted by m o r e than forty per cent of the population was six y e a r s .  T h i s p a r t i c u l a r case  involved use of  284 the  1  c l o s e d glove' technique i n the operating r o o m ,  A t the time  this r e s e a r c h was i n p r o g r e s s , the h o s p i t a l which had been the e a r l i e s t adopter of this technique r e p o r t e d that the p r a c t i c e was c u r r e n t l y being discontinued because of i m p r o v e d techniques. M e a n w h i l e , one fifth of the population had s t i l l not h e a r d of it.  Stated Reasons for A d o p t i o n , D e l a y , R e j e c t i o n , or Discontinuance  In analyzing the r e a s o n s given for adoption of the v a r i o u s innovations, the new p r a c t i c e s were found to divide into two categories:  major  those concerned p r i m a r i l y with the safety of the patient,  and those adopted p r i n c i p a l l y for the patient s c o m f o r t . 1  of the innovations into  1  This division  safety i t e m s ' and ' comfort m e a s u r e s  1  paralleled  the o r i g i n a l categorization of the new p r a c t i c e s into n u r s i n g techniques, n u r s i n g r o u t i n e s , and disposable i t e m s .  T h e techniques were  c o n s i d e r e d chiefly safety i t e m s , while the routines were adopted m a i n l y for the comfort of the patient.  T h e disposable s y r i n g e s were  r e p o r t e d as having time and l a b o r - s a v i n g advantages over p r e v i o u s l y used s y r i n g e s , but, for purposes of analysis, the disposable ones were c l a s s i f i e d with the techniques, because of the number of n u r s e s who gave as one of the chief reasons for adoption, that they p r o v i d e d a better or  1  safer'  technique.  T h e most frequently given reasons for delay, discontinuance or r e j e c t i o n pertained to attributes of the innovation, with its  285  r e l a t i v e advantage over p r e v i o u s l y used p r a c t i c e s being the most important c o n s i d e r a t i o n .  Other c h a r a c t e r i s t i c s ,  such as an i t e m ' s  c o m m u n i c a b i l i t y or complexity, were a l s o frequently named as for not adopting some of the techniques (safety i t e m s ) .  reasons  Compatibility  with existing p r a c t i c e s was the most frequently given r e a s o n for delay, r e j e c t i o n or discontinuance of the routines (comfort  measures).  Situational factors were given as a r e a s o n by delayed adopteds, m o r e than any other adoptor group for non-acceptance of new nursing routines.  T h e reasons were u s u a l l y stated i n t e r m s of size  of the hospital or the community situation.  In the case of only one  i t e m did a significant number of participants r e p o r t that a n u r s i n g d e c i s i o n to adopt an innovation had been o v e r - r u l e d .  This practice  i n v o l v e d e l i m i n a t i o n of the 6 a. m . t e m p e r a t u r e routine.  The Decision-Makers  In the section of the study dealing with sources of i n f o r m a t i o n , it was r e p o r t e d that the nursing staff of the h o s p i t a l , the physicians and the a d m i n i s t r a t o r were the p r i n c i p a l consultants of the D i r e c t o r of N u r s i n g when decisions were being made r e l a t i v e to t r i a l or continued use of an innovation.  T h i s finding was borne out i n the  286 i n d i v i d u a l s , r e p o r t e d as being involved i n making the d e c i s i o n to adopt the nine new p r a c t i c e s included i n the interview schedule.  In only a v e r y few instances it was stated that the D i r e c t o r of N u r s i n g was solely r e s p o n s i b l e for the adoption of any of the nine innovations.  In a l m o s t a l l c a s e s , the n u r s i n g staff were brought into the  decision-making process.  T h e physicians were frequently consulted,  when the new p r a c t i c e might affect other departments of the hospitals* and,  where costs were i n v o l v e d , the a d m i n i s t r a t o r was a l s o brought  into the d e c i s i o n - m a k i n g p r o c e s s .  In the case of the one change i n  n u r s i n g routines which affected c o m m u n i t y relations (open visiting) , the B o a r d of D i r e c t o r s were a l s o i n v o l v e d .  It a p p e a r s , then, that the D i r e c t o r of N u r s i n g plays a key r o l e in the adoption of innovations of n u r s i n g p r a c t i c e within a hospital, but d e c i s i o n s a r e s e l d o m made i n an a u t h o r i t a r i a n m a n n e r .  Rather,  they a r e made i n consultation with her colleagues.  III.  IMPLICATIONS  The m e m b e r s of the S u r g e o n - G e n e r a l s C o n f e r e n c e on 1  C o m m u n i c a t i o n s i n the H e a l t h F i e l d suggested that the most  effective  means for communicating new i n f o r m a t i o n to m e m b e r s of the health p r o f e s s i o n s i s through a broad f r a m e w o r k of continuing education  287 programs.  T h e s e p r o g r a m s , supplemented by adequate management  of the p r o f e s s i o n a l l i t e r a t u r e , and i m p r o v e d methods for the storage and r e t r i e v a l of i n f o r m a t i o n , would, they felt, go a long way towards r e s o l v i n g the p r o b l e m of communicating scientific i n f o r m a t i o n to health . . 4 practitioners.  T h e findings f r o m this study indicate that there i s , indeed, a s e r i o u s p r o b l e m i n the c o m m u n i c a t i o n of i n f o r m a t i o n about new ideas and p r a c t i c e s to n u r s e s i n the P r o v i n c e of B r i t i s h C o l u m b i a . T h e p r o b l e m is p a r t i c u l a r l y acute i n r e g a r d to the n u r s e s employed i n s m a l l h o s p i t a l s , where there is m i n i m a l contact with other hospitals and other n u r s e s .  T h e i m p l i c a t i o n s of this study w i l l be d i s c u s s e d under three headings, based p a r t l y on the r e c o m m e n d a t i o n s of the S u r g e o n G e n e r a l ' s Conference: (1) T h e development of a s t r u c t u r e of continuing education p r o g r a m s for n u r s e s i n the p r o v i n c e ; (2)  the  setting up of i n f o r m a t i o n - r e t r i e v a l centers for n u r s i n g ; and (3) the u t i l i z a t i o n of existing c o m m u n i c a t i o n channels.  288 A Structure of Continuing E d u c a t i o n P r o g r a m s  Although the number of continuing education p r o g r a m s for n u r s e s i n the p r o v i n c e has been g r e a t l y expanded i n recent y e a r s , it is obvious that many n u r s e s ,  p a r t i c u l a r l y f r o m s m a l l e r hospitals  a r e not able to take advantage of these to the extent that is d e s i r a b l e . With a s m a l l  staff, it is difficult to r e l e a s e n u r s e s for the time  r e q u i r e d to t r a v e l to, and attend, Vancouver.  courses,  e s p e c i a l l y those held i n  T h e l i m i t e d budget of s m a l l hospitals a l s o prevents them  f r o m sending as many n u r s e s as they would like to educational p r o g r a m s , e s p e c i a l l y if there are. long distances involved i n t r a v e l l i n g and expensive t r a n s p o r t a t i o n costs. b a s e d institutes,  T h e development of m o r e r e g i o n a l l y -  conferences and workshops would appear to be an  i m p o r t a n t step i n b r i n g i n g i n f o r m a t i o n about new p r a c t i c e s to m o r e n u r s e s throughout the p r o v i n c e .  A plan to i n c r e a s e the number of  p r o g r a m s given i n r e g i o n a l centers is c u r r e n t l y being i m p l e m e n t e d by the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n i n conjunction with the U n i v e r sity of B r i t i s h C o l u m b i a .  In addition, as the proposed s y s t e m of community colleges for the p r o v i n c e develops,  it is evident that these institutions w i l l be in  an i d e a l position to provide l e a d e r s h i p in the field of continuing education for n u r s e s in their l o c a l i t y . in C a s t l e g a r , for example,  T h e S e l k i r k C o m m u n i t y College  is planning to initiate a n u r s i n g education  289 p r o g r a m i n the near future.  It is anticipated that, as future  r e g i o n a l colleges a r e developed,  nursing education w i l l be i n -  c o r p o r a t e d into the p r o g r a m offerings of these institutions. the community s e r v i c e function  As  becomes a recognized responsi-  b i l i t y of r e g i o n a l colleges, these n u r s i n g p r o g r a m s should s e r v e the continuing education needs of the p r o f e s s i o n a l n u r s e .  It is  suggested that extension c o u r s e s for n u r s e s , both i n the f o r m of short, one to three day p r o g r a m s , and evening c o u r s e s of extended length, should be integrated into the c u r r i c u l a r  offerings  of the colleges f r o m their inception.  One suggestion for the effective u t i l i z a t i o n of present and potential r e s o u r c e s i n the p r o v i n c e i s the development of a 1  systems  1  a p p r o a c h to continuing education for n u r s e s .  The  U n i v e r s i t y of B r i t i s h C o l u m b i a , as the institution with a h i s t o r y of providing continuing education i n remote a r e a s ,  might be the l o g i c a l  c o - o r d i n a t i n g body, with r e s p o n s i b i l i t y for o v e r a l l management of continuing education p r o g r a m s for n u r s e s in the p r o v i n c e . 1  This  s y s t e m s ' a p p r o a c h could u t i l i z e the f a c i l i t i e s and staff of colleges  and other educational institutions to develop a s t r u c t u r e of continuing education for the n u r s i n g p r o f e s s i o n i n B r i t i s h C o l u m b i a .  290 In addition to making p r o v i s i o n for continuing education classes, for n u r s e s ,  c o n s i d e r a t i o n should be given to expanding  opportunities for i n d i v i d u a l study for the n u r s e s in i s o l a t e d a r e a s of the p r o v i n c e .  It is suggested that correspondence c o u r s e s and  p r o g r a m m e d l e a r n i n g i n v a r i o u s subject a r e a s would provide the n u r s e s i n s m a l l hospitals with the opportunity to per sue their studies and keep up with c u r r e n t developments i n their f i e l d . T h e popularity of the Canadian N u r s e s ' A s s o c i a t i o n correspondence c o u r s e on N u r s i n g Unit A d m i n i s t r a t i o n , p a r t i c u l a r l y among the n u r s e s employed i n s m a l l hospitals,  is indicative of the need felt  by many n u r s e s i n l e a d e r s h i p positions to i m p r o v e their q u a l i f i c a tions.  B o t h i n d i v i d u a l and group c o u r s e s could be offered on a  c r e d i t and n o n - c r e d i t b a s i s for n u r s e s wishing tjo continue their education on a p a r t - t i m e b a s i s .  Information R e t r i e v a l C e n t e r s for N u r s i n g  C o n s i d e r a t i o n might be given to the development of a national i n f o r m a t i o n - r e t r i e v a l center for the n u r s i n g p r o f e s s i o n i n Canada, s i m i l a r to the E d u c a t i o n Information R e t r i e v a l Center (ERIC) for A d u l t E d u c a t i o n at the U n i v e r s i t y of S y r a c u s e i n New Y o r k .  ERIC  functions not only as a r e p o s i t o r y for p r o f e s s i o n a l l i t e r a t u r e on A d u l t E d u c a t i o n but, a l s o , as a d i s p e r s a l center for the d i s t r i b u t i o n  2S of i n f o r m a t i o n to p r a c t i t i o n e r s in the f i e l d .  T h e l i b r a r y at E R I C  contains holdings which include a l l available publications on A d u l t Education:  j o u r n a l s , texts, d e s c r i p t i v e studies and abstracts of  r e s e a r c h studies (including theses and dissertations) , as w e l l as details of c o u r s e s and p r o g r a m s offered i n b i b l i o g r a p h i e s on specific topics.  the field and annotated  T h e Center d i s p e r s e s i n f o r m a -  tion on l i t e r a t u r e available through a monthly publication of a c c e s sions to the l i b r a r y and s p e c i a l publications reviewing r e s e a r c h i n v a r i o u s subject a r e a s .  E R I C w i l l a l s o f u r n i s h , on request,  copies  of annotated b i b l i o g r a p h i e s and p r o g r a m s offerings i n A d u l t E d u c a tion to individuals who wish these, and a l s o provide X e r o x copies on short m a t e r i a l s , o r m i c r o f i c h e copies of theses and d i s s e r t a t i o n s at cost.  Since the Canadian N u r s e s ' A s s o c i a t i o n a l r e a d y has an e x c e l l ent l i b r a r y at National Office i n Ottawa, and has become the m a j o r r e p o s i t o r y for n u r s i n g studies i n Canada, this l i b r a r y might well s e r v e as the nucleus for an i n f o r m a t i o n - r e t r i e v a l center for the profession.  In addition to developing s e r v i c e s such as those p r o -  vided by E R I C , the n u r s i n g center might a l s o have a l i b r a r y of f i l m film-strips,  tapes, r e c o r d i n g s and other a u d i o v i s u a l m a t e r i a l s on  n u r s i n g subjects.  It would be important to have a catalogue of the  292  holdings, d e s c r i b i n g what is a v a i l a b l e , with supplements to the catalogue i s s u e d at r e g u l a r i n t e r v a l s .  A c c e s s i o n s to the i n f o r m a t i o n -  r e t r i e v a l center could be published in T h e Canadian N u r s e , as a c c e s sions to the l i b r a r y at N a t i o n a l Office a r e c u r r e n t l y , or through i n d e pendent bulletins.  F r o m the national center, i n f o r m a t i o n could be d i s p e r s e d to n u r s e s throughout the country.  T h e center would serve as an i m p o r t -  ant s o u r c e of i n f o r m a t i o n for the p r o v i n c i a l n u r s i n g a s s o c i a t i o n s .  The  R e g i s t e r e d N u r s e s ' A s s o c i a t i o n of B r i t i s h C o l u m b i a has a s m a l l l i b r a r y of j o u r n a l s , texts and r e p o r t s of studies i n its p r o v i n c i a l office i n V a n c o u v e r and, probably, s i m i l a r l i b r a r i e s exist i n other p r o v i n c i a l n u r s i n g associations  offices a c r o s s the country.  l i b r a r i e s a r e often m i s s i n g v i t a l m a t e r i a l , however,  These small such as books  and essential studies that a r e no longer a v a i l a b l e , or a r e too costly for the p r o v i n c i a l l i b r a r i e s to a c q u i r e .  T h e r e s o u r c e s of a national  center would provide a valuable supplement to the m a t e r i a l available i n the p r o v i n c e s .  In addition, hospitals and other health agencies, as well as individual nurses,  could take advantage of the s e r v i c e s of a national  i n f o r m a t i o n - r e t r i e v a l center ot obtain i n f o r m a t i o n they cannot get locally.  M a n y hospitals maintain a s m a l l n u r s i n g l i b r a r y of their  own, but these u s u a l l y contain only a s m a l l number of journals and a few n u r s i n g textbooks.  It has been demonstrated i n many other  studies,  as w e l l as i n the present one, that a c c e s s i b i l i t y to i n f o r m a -  tion s o u r c e s is an important factor in adaptability to change.  The  need for r e a d i l y a c c e s s i b l e r e f e r e n c e m a t e r i a l for n u r s e s working i n hospitals w i l l have to be i n t e r p r e t e d to both hospital a d m i n i s t r a t o r s and government authorities i n charge of financiang for hospitals.  It  is suggested that money for s u b s c r i p t i o n to p r o f e s s i o n a l j o u r n a l s and a l s o money for the purchase of up-to-date  nursing texts should be  a l l o c a t e d as a r e g u l a r part of the h o s p i t a l ' s annual budget.  U t i l i z a t i o n of E x i s t i n g C o m m u n i c a t i o n Channels for N u r s e s i n B r i t i s h Columbia  A number of channels of c o m m u n i c a t i o n used by n u r s e s i n the p r o v i n c e were identified i n the findings f r o m this study.  It might be  i n ' o r d e r to suggest, at this point, ways i n which these channels might be u t i l i z e d m o r e effectively to t r a n s m i t new i n f o r m a t i o n to n u r s e s .  T h e n u r s i n g j o u r n a l s were r e p o r t e d as the most frequently u s e d source of i n f o r m a t i o n i n f i r s t drawing the n u r s e s ' attention to new ideas and p r a c t i c e s .  T h e Canadian N u r s e , which is the most  widely r e a d j o u r n a l i n the p r o v i n c e , is frequently the only n u r s i n g j o u r n a l r e c e i v e d i n many hospitals-  Its influence i s ,  therefore,  294 considerable.  A t the present t i m e , T h e Canadian N u r s e  contains  two features which a r e p a r t i c u l a r l y helpful i n disseminating new information.  One feature concerns new products for use in n u r s -  i n g , the other, news items about innovations i n n u r s i n g p r a c t i c e , or news f r o m a l l i e d p r o f e s s i o n s .  It is possible that these features  might be expanded, or supplements to the j o u r n a l , r e p o r t i n g on n u r s i n g studies and experiments with new techniques,  routines,  or  staffing patterns, be published at r e g u l a r i n t e r a v l s .  P r o b a b l y the most important channel for the c o m m u n i c a t i o n of new ideas and techniques in n u r s i n g i s , however, c o m m u n i c a t i o n with colleagues.  interpersonal  T h i s was brought out i n the find-  ings both on s o u r c e s of i n f o r m a t i o n used by the n u r s e s , and on f a c t o r s r e l a t e d to adoption of innovations.  T h e s e findings suggest  that m o r e opportunity should be p r o v i d e d for nurses to get together to d i s c u s s  mutual p r o b l e m s and exchange i n f o r m a t i o n about new  ideas i n n u r s i n g .  Of p a r t i c u l a r i m p o r t a n c e is the need for a p r i m -  a r y r e f e r e n c e group for the D i r e c t o r s of N u r s i n g , to allow them to meet with others like t h e m s e l v e s who hold l e a d e r s h i p positions in the n u r s i n g community.  A beginning has been made i n this r e g a r d  i n the r e g i o n a l meetings of D i r e c t o r s of N u r s i n g i n v a r i o u s d i s t r i c t s of the p r o v i n c e .  T h e r e i s a need top, though, for n u r s e s f r o m the  295 s m a l l e r hospitals to meet and exchange ideas with n u r s e s f r o m l a r g e hospitals.  A parent body is r e q u i r e d to co -ordinate these  meetings on a p r o v i n c i a l b a s i s .  The Registered Nurses' A s s o c i a -  tion would appear to be the l o g i c a l organization to a c c o m p l i s h this purpose.  A precedent has been set i n this r e g a r d by other  groups of nurses with s p e c i a l i z e d functions,  such as the operating  r o o m n u r s e s and the occupational health n u r s e s , who have their own sections within the n u r s i n g a s s o c i a t i o n .  It seems feasible  that  the D i r e c t o r s of N u r s i n g might a l s o have their own section.  T h e development of a p a r t i c u l a r section of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n for D i r e c t o r s of N u r s i n g might a l s o e n c o u r age m o r e D i r e c t o r s to take an active part i n the business of the association.  Attendance at p r o f e s s i o n a l meetings was found to be  a significant factor i n learning about c u r r e n t developments i n nursing.  It seems a p p r o p r i a t e to suggest, then, that m o r e D i r e c t o r s  be encouraged to p a r t i c i p a t e d a c t i v e l y i n their p r o f e s s i o n a l association.  Since it is the n u r s e s f r o m the l a r g e r hospitals who  attend m o r e meetings and s e r v e on m o r e c o m m i t t e e s ,  it might be  p r o p o s e d that c o n s i d e r a t i o n be given to including r e p r e s e n t a t i v e s f r o m the s m a l l e r hospitals when names a r e being suggested for office,  or committees f o r m e d .  P a r t i c u l a r effort should be d i r e c t -  ed towards drawing the n u r s e s f r o m hospitals i n a r e a s not  296 i n c o r p o r a t e d into d i s t r i c t s of the a s s o c i a t i o n into active p a r t i cipation i n the organization.  The r o l e of change agents, s p e c i f i c a l l y delegated with the task of disseminating new i n f o r m a t i o n in n u r s i n g , is one which bears consideration.  T h e p r o f e s s i o n a l i n t e r m e d i a r i e s identified  i n this study included the n u r s i n g consultants f r o m the B r i t i s h C o l u m b i a H o s p i t a l Insurance S e r v i c e , the staff of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n , c o m m e r c i a l agents, and outside  experts.  Whether these individuals see t h e m s e l v e s as agents for the diffusion of i n f o r m a t i o n about innovations i n n u r s i n g is not c l e a r but, c e r t a i n l y , change agents a r e v e r y m u c h needed i n the p r o f e s s i o n .  A s d i s c u s s e d e a r l i e r i n the study, the c o m m e r c i a l r e p r e s e n tative of the hospital supply house is an important source of i n f o r m a tion used by D i r e c t o r s of N u r s i n g ,  The systematic  dissemination  of i n f o r m a t i o n about new products by these individuals has been b a s e d l a r g e l y on the findings of r e s e a r a c h i n the field of m a r k e t i n g . T h i s s y s t e m a t i c diffusion appears to have a close r e l a t i o n s h i p to the rate of adoption of innovations, which those who a r e i n t e r e s t e d i n instigating changes in n u r s i n g might do w e l l to study.  T h e consultative s e r v i c e s  offered by the n u r s i n g staff of the  297  H o s p i t a l Insurance S e r v i c e a r e c u r r e n t l y not being used to the extent that they might by the D i r e c t o r s of N u r s i n g i n the p r o v i n c e . T h i s may be due to l a c k of knowledge on the part of the n u r s e s about the a v a i l a b i l i t y of s e r v i c e s ,  or to an insufficient number of consult-  ants to meet the needs of a l l hospitals.  Many n u r s e s indicated to  the author that they wished the nursing consultant would make m o r e frequent v i s i t s ,  but few s e e m e d to r e a l i z e that a s s i s t a n c e with p a r t i -  cular p r o b l e m s could be requested f r o m the D e p a r t m e n t .  It might be  i n o r d e r , then, to suggest that i n c r e a s e d publicity of s e r v i c e s a v a i l able by the n u r s i n g consultants would be helpful, and, a l s o , that the staff might be enlarged so that hospitals could be v i s i t e d m o r e frequently.  T h e D i r e c t o r s of N u r s i n g S e r v i c e and N u r s i n g E d u c a t i o n of the R e g i s t e r e d N u r s e s ' A s s o c i a t i o n might also be c o n s i d e r e d as potential change agents i n n u r s i n g .  T h e position of D i r e c t o r of N u r s i n g S e r v i c e  i s a new one, which has only recently been f i l l e d .  In the past,  the  D i r e c t o r of N u r s i n g E d u c a t i o n has been p r i m a r i l y concerned with the planning and o r g a n i z a t i o n of continuing education p r o g r a m s for n u r s e s . Since the u n i v e r s i t y i s now a s s u m i n g m u c h of the r e s p o n s i b i l i t y for continuing education for n u r s e s i n the p r o v i n c e , it is possible to  298  envisage the D i r e c t o r s of N u r s i n g S e r v i c e and N u r s i n g E d u c a t i o n m o r e i n the r o l e of change agents i n the future, their r e s p o n s i b i l i t i e s p r i m a r i l y concerned with d i s s e m i n a t i n g new i n f o r m a t i o n to individuals engaged i n n u r s i n g s e r v i c e and n u r s i n g education i n the province.  IV.  AREAS  FOR FURTHER  RESEARCH  T h i s study was a b r o a d p r e l i m i n a r y examination of the p r o c e s s of diffusion of innovations i n n u r s i n g p r a c t i c e .  It  has concerned  i t s e l f p r i m a r i l y with the t r a n s m i s s i o n of i n f o r m a t i o n f r o m outside s o u r c e s to the D i r e c t o r s of N u r s i n g employed i n hospitals i n the p r o v i n c e of B r i t i s h C o l u m b i a .  It is hoped that the findings r e p o r t e d  h e r e m a y provide some insight into the p r o c e s s by which i n f o r m a t i o n about new ideas and p r a c t i c e s is c o m m u n i c a t e d to m e m b e r s of the nursing profession.  It is a l s o hoped that these findings w i l l be u s e -  ful to those involved in planning continuing education p r o g r a m s for n u r s e s , and to these i n t e r e s t e d i n devising adequate storage and r e t r i e v a l m e c h a n i s m s for the vast amount of l i t e r a t u r e that i s r a p i d l y accumulating i n the p r o f e s s i o n .  299 In the conduct of this study, many a r e a s where r e s e a r c h i s needed have been indicated.  A l o g i c a l subject for a study to f o l l o w - this one is an i n v e s t i gation of the p r o c e s s by-which i n f o r m a t i o n about new n u r s i n g p r a c t i c e s i s d i s s e m i n a t e d to the nurses within the h o s p i t a l . questions that might be asked a r e :  Some of the  How does i n f o r m a t i o n about new  n u r s i n g p r a c t i c e s f i l t e r down f r o m the D i r e c t o r of N u r s i n g , to the s u p e r v i s o r y staff, hospital?  to the g e n e r a l duty n u r s e s on the wards of the  What channels a r e there for the exchange of i n f o r m a t i o n  about new n u r s i n g p r a c t i c e s between n u r s e s working i n different departments of a hospital? Who a r e the opinion l e a d e r s within the n u r s i n g staff?  How do they exert their influence?  What factors i n -  fluence i n d i v i d u a l n u r s e s to accept innovations or to r e j e c t them?  A n a n a l y s i s of the i n - s e r v i c e aspects of continuing education for n u r s e s i n h o s p i t a l s i i n B r i t i s h C o l u m b i a might also be useful. T h e m a j o r i t y of D i r e c t o r s of N u r s i n g of the hospitals included i n this study indicated that they had some f o r m of i n - s e r v i c e educational p r o g r a m for the n u r s i n g staff but there a r e s e v e r a l questions i n r e g a r d to i n - s e r v i c e p r o g r a m s that r e m a i n unanswered.  A n investi-  gation of the types of p r o g r a m s offered might r e v e a l answers to such questions as:  What i n - s e r v i c e educational p r o g r a m s a r e presently  300  available?  T o w a r d s what objectives a r e they d i r e c t e d ? How w e l l  do they f u l f i l l the needs of the n u r s i n g staff?  A n a n a l y s i s of the r o l e of the change agent in n u r s i n g might profitably be undertaken. following questions:  Such an a n a l y s i s might answer the  Who, i n the n u r s i n g community is best  suited for the r o l e of change agent? What c h a r a c t e r i s t i c s should this i n d i v i d u a l have?  What a r e the most effective mehtods to be  employed by individuals who have the specific r e s p o n s i b i l i t y for instigating changes i n n u r s i n g ?  T h e extent of the c o m m e r c i a l s a l e s m a n  1  s influence in affect-  ing decisions to adopt nursing innovations would a l s o appear to be important.  T h e s a l e s m a n f r o m the hospital supply house is a  frequently used source of i n f o r m a t i o n on new p r a c t i c e s i n n u r s i n g , as r e v e a l e d i n the  findings  f r o m this study, but how m u c h influence  does he a c t u a l l y have in decisions r e g a r d i n g the adoption of i n n o v a tions?  What m e t h o d s a r e employed by this i n d i v i d u a l i n his  atic diffusion of i n f o r m a t i o n about n u r s i n g innovations?  system-  C o u l d these  methods be u t i l i z e d by n u r s e s to disseminate i n f o r m a t i o n they wished to t r a n s m i t ?  30  T h e r e are many m o r e p o s s i b i l i t i e s for r e s e a r c h on the subject of continuing education courses for n u r s e s .  A n analysis  of the p a r t i c i p a n t s in continuing education p r o g r a m s might r e v e a l factors which influence some n u r s e s to take advantage of courses offered while others are apathetic about attending. p r o g r a m s do the n u r s e s feel they need?  What type of  W h i c h methods and t e c h -  niques are best suited for use in continuing education p r o g r a m s ? How effective are the short, continuing education p r o g r a m s in b r i n g i n g about changes in knowledge, who attend?  attitudes or behaviour of thos  302  CHAPTER  VII  FOOTNOTES  1.  S u p r a , Chapter II, pp. 35,  2.  S u p r a , Chapter II, pp. 3 5 -  3.  Ibid.  4.  S u p r a , Chapter I, p.  3.  36. 38.  303  BIBLIOGRAPHY  A.  Barnett, H . G . Innovation: M c G r a w - H i l l , 1953.  BOOKS  the B a s i s of C u l t u r a l Change. New Y o r k :  B e r e l s o n , B e r n a r d and M o r r i s Janowitz, Reader in P u b l i c Opinion and C o m m u n i c a t i o n . Second edition. New Y o r k : The F r e e P r e s s , 1966. Hovland, C a r l I. , Irving L . Janis, and H a r o l d H . K e l l e y . C o m m u n i c a t i o n and P e r s u a s i o n . New H a v e n and London: Y a l e U n i v e r s i t y P r e s s , K a t z , E l i h u and P a u l F . L a z a r s f e l d . P e r s o n a l Influence. New Y o r k : The F r e e P r e s s , 1964. L a z a r f e l d , P . , B . 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N u r s i n g and R i t u a l i s t i c P r a c t i c e . M a c M i l l a n Company, 1967.  New Y o r k :  304 B.  PUBLICATIONS O F T H E GOVERNMENT, LEARNED SOCIETIES, A N D O T H E R ORGANIZATIONS  A n d e r s o n , M a r v i n A . The Diffusion P r o c e s s . A g r i c u l t u r a l Extension Service Special Report, No. 18, M a r c h , 1957. A m e s : Iowa State University, 1957. B i s h o p , R. and Coughenour. Discontinuance of F a r m Innovations. Department Series A . E . 361, Department of A g r i c u l t u r a l E c o n o m i c s and R u r a l Sociology. Columbus: Ohio State U n i v e r s i t y , 1964. B r i t i s h C o l u m b i a Government News. Government of B r i t i s h C o l u m b i a ,  14:2, M a y , 1966. 1966.  Victoria:  B r i t i s h C o l u m b i a H o s p i t a l Insurance S e r v i c e . Nineteenth Annual Report, J a n u a r y 1st to December 31st, 1967. B r i t i s h C o l u m b i a H o s p i t a l Insurance. 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"The Diffusion of an Innovation among P h y s i c i a n s in a L a r g e City, " S o c i o m e t r y , 24:384-396, 1961. Wolpert, J . " A Regional Simulation M o d e l of Information Diffusion, " P u b l i c O p i n i o n Q u a r t e r l y , 34(4):597-608, Winter, 1966-67.  D.  E S S A Y S A N D A R T I C L E S IN C O L L E C T I O N S  Bohlen, Joe M . "The Adoption and Diffusion of Ideas in A g r i c u l t u r e , " Our Changing R u r a l Society, P e r s p e c t i v e s and T r e n d s . James H . Copp, editor, A m e s , Iowa: Iowa State U n i v e r s i t y P r e s s , 1964. p.268. C a r l s o n , R i c h a r d O . "School Superintendents and the Adoption of M o d e r n Maths: A S o c i a l Structure P r o f i l e , " in M i l e s , Innovation in E d u c a t i o n . New Y o r k : T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , 1964. pp. 329-342. E i c h h o l z , G e r a r d and E v e r e t t M . R o g e r s . 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"Some Neglected A r e a s in R e s e a r c h on Scientific and T e c h n i c a l C o m m u n i c a t i o n s , " in T h a y e r , L e e ( E d . ), C o m m u n i c a t i o n . Washington: Spartan Books, 1966, pp. 361-372.  E.  UNPUBLISHED MATERIALS  A l l e y n e , E . P a t r i c k . "Interpersonal Communications and the Adoption of Innovations among S t r a w b e r r y G r o w e r s in the L o w e r F r a s e r V a l l e y . " Unpublished M a s t e r ' s T h e s i s , The U n i v e r s i t y of B r i t i s h C o l u m b i a , V a n c o u v e r , 1968. A r m s t r o n g , J . B . "County Agent A c t i v i t i e s and the Adoption of S o i l B u i l d i n g P r a c t i c e s . " Unpublished M a s t e r ' s t h e s i s , The U n i v e r s i t y of Kentucky, Lexington, 1959B r e i v o g e l , W m . F . "The Relationship of Selected V a r i a b l e s and the Introduction of E d u c a t i o n a l Innovations in New J e r s e y P u b l i c School D i s t r i c t s . " Unpublished d o c t o r a l d i s s e r t a t i o n , Rutgers, The State U n i v e r s i t y , New B r u n s w i c k , N . J . , 1967. C a m a r e n , Reuben J a m e s . "Innovation as a F a c t o r Influencing the Diffusion and Adoption P r o c e s s . " Unpublished doctoral d i s s e r t a t i o n , The U n i v e r s i t y of C a l i f o r n i a , B e r k e l e y , 1966. C h i l d s , John W i l l i a m s . " A Study of the B e l i e f Systems of A d m i n i s t r a t o r s and T e a c h e r s i n Innovative and Non-Innovative School D i s t r i c t s . " Unpublished d o c t o r a l dissertation, M i c h i g a n State U n i v e r s i t y , E a s t L a n s i n g , 1965. C h r i s t i a n s e n , J a m e s E d w a r d . "The Adoption of Educational Innovations among T e a c h e r s of V o c a t i o n a l A g r i c u l t u r e . " Unpublished doctoral d i s s e r t a t i o n , The Ohio State U n i v e r s i t y , C o l u m b u s , 1965. F r a z i e r , F r a n c e s . "Guide for N u r s i n g E d u c a t i o n a l Consultants. " Unpublished doctoral dissertation, C o l u m b i a U n i v e r s i t y , New Y o r k , 1952. F r e u n d , L o u i s A . "Investigation of the Significance of H e a d N u r s e Attitudes and T e a c h i n g Methods in Change P r o c e d u r e s . " Unpublished M a s t e r ' s T h e s i s , Washington U n i v e r s i t y , St. L o u i s , M o . , 1965.  312  F u l k s , Danny G r e y s o n . "The U t i l i z a t i o n of P e r i o d i c a l L i t e r a t u r e by Selected P u b l i c School Superintendents. " Unpublished doctoral d i s s e r t a t i o n , T h e U n i v e r s i t y of T e n n e s s e e , M e m p h i s , 1968. Hage, J e r a l d T h o r e . "Organizational Response to Innovation: A C a s e Study of a C o m m u n i t y H o s p i t a l . " Unpublished doctoral dissertation, C o l u m b i a U n i v e r s i t y , New Y o r k , 1963. Hanson, John Ofsthus. " A D e s c r i p t i v e Study of B a s i c Data and the Educational Innovations F o u n d in T w e n t y - T w o Selected N o r t h Dakota S m a l l Schools. " Unpublished doctoral d i s s e r t a t i o n , T h e U n i v e r s i t y of N o r t h Dakota, G r a n d F o r k s , 1966. H a r r e l l , Roger L e o n . " A P r o c e s s M o d e l for Educational Change - - its Development and Use as an Evaluative Instrument. " Unpublished doctoral dissertation, The U n i v e r s i t y of New M e x i c o , Albuquerque, 1967. H a v e n s , A . E . "Social P s y c h o l o g i c a l F a c t o r s A s s o c i a t e d with the Differential Adoption of New Techniques by M i l k P r o d u c e r s . " Unpublished d o c t o r a l dissertation, U n i v e r s i t y of Ohio, C o l u m b u s , 1962. H e n s l e y , O l i v e r Dennis. " A Study of F a c t o r s Related to the Acceptance and Adoption of a Cooperative Supplementary E d u c a t i o n a l Service Center A u t h o r i z e d under T i t l e III of P . L . 89-10. " Unpublished d o c t o r a l dissertation, Southern Illinois U n i v e r s i t y , Carbondale, 1968. Hughes, L a r r y Wayne. "The O r g a n i z a t i o n a l C l i m a t e F o u n d in C e n t r a l A d m i n i s t r a t i v e Offices of Selected H i g h l y Innovative and N o n Innovative School D i s t r i c t s in the State of O h i o . " Unpublished d o c t o r a l d i s s e r t a t i o n , The Ohio State U n i v e r s i t y , C o l u m b u s , 1965. Jacobs, Jan Wayne. " L e a d e r s h i p , Size and Wealth as Related to C u r r i c u l a r Innovations in the Junior H i g h School. " Unpublished d o c t o r a l dissertation, The U n i v e r s i t y of M i c h i g a n , A n n A r b o r , 1965. Jensen, L e R o y . " C h a r a c t e r i s t i c s of Superintendents in Innovative and Non-Innovative School Systems and Interaction with the Iowa Department of P u b l i c Instruction. " Unpublished doctoral dissertation, The U n i v e r s i t y of Iowa, A m e s , 1967. K i n g e n b e r g , A l l e n Jay. " A Study of Selected A d m i n i s t r a t i v e B e h a v i o r among A d m i n i s t r a t o r s f r o m Innovative and Non-Innovative P u b l i c School D i s t r i c t s . " Unpublished doctoral dissertation, M i c h i g a n State U n i v e r s i t y , E a s t L a n s i n g , 1966.  313  K o h l , John W i l l i s . "Adoption Stages and P e r c e p t i o n s of C h a r a c t e r i s t i c s of E d u c a t i o n a l Innovation. " Unpublished doctoral dissertation, The U n i v e r s i t y of O r e g o n , Eugene, 1966. L a M a r , Ronald V i c t o r . "In-Service Education Needs Related to the Diffusion of an Innovation. " Unpublished doctoral dissertation, The U n i v e r s i t y of C a l i f o r n i a , B e r k e l e y , 1966. L a Plant, J a m e s Clayton. "School D i s t r i c t Innovativeness and Expectations for the School B o a r d Role. " Unpublished doctoral dissertation, The U n i v e r s i t y of W i s c o n s i n , M a d i s o n , 1966. L e e , W m . B . " A Study of the Educational Opinions of Selected T e a c h e r s and A d m i n i s t r a t o r s . " Unpublished doctoral dissertation, - M i c h i g a n State U n i v e r s i t y , E a s t L a n s i n g , 1967. M c H e n r y , Silas L . " F u n ctions and T e a c h i n g Methods U t i l i z e d by Extension S p e c i a l i s t s and County Agents for the Diffusion of P o u l t r y P r o d u c t i o n Information. " Unpublished doctoral dissertation, The P e n n s y l v a n i a State U n i v e r s i t y , State College, P e n n . , I960. M o r e t o n , R o s s E l w e n . "The Diffusion of C e r t a i n Instructional Innovations in the P u b l i c Schools of M i s s o u r i , 1958-1966. " Unpublished d o c t o r a l dissertation, The U n i v e r s i t y of M i s s o u r i , C o l u m b i a , 1968. M u r r a y , J . S. "Educational Innovations. " P a p e r presented at the F o u r t h Canadian Conference on E d u c a t i o n a l R e s e a r c h , T o r o n t o , Ont. 1966. N o r r i s , S. " P r o p o s a l s for the I n - S e r v i c e Education of C o - o p e r a t i n g T e a c h e r s P a r t i c i p a t i n g in the N u r s i n g Education P r o g r a m s at the U n i v e r s i t y of Minnesota. " Unpublished doctoral dissertation, T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , New Y o r k , 1955. P e t e r m a n , L l o y d E d w a r d . "The Relationship of I n - S e r v i c e Education to the Innovativeness of the C l a s s r o o m T e a c h e r in Selected P u b l i c Secondary Schools in M i c h i g a n . " Unpublished doctoral dissertation, The U n i v e r s i t y of M i c h i g a n , Ann A r b o r , 1966. P r i c e , E l m i r a M a r y . " L e a r n i n g Needs of R e g i s t e r e d N u r s e s . " Unpublished d o c t o r a l dissertation, T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , New Y o r k , 1965. P e t e r s o n , Irving M a u r i c e . "Relationships between School Superintendents P e r s o n a l i t y O r i e n t a t i o n s , P e r c e i v e d Situational P r e s s u r e s , and Innovativeness. " Unpublished doctoral dissertation, Rutgers, The State U n i v e r s i t y , New B r u n s w i c k , 1968.  314  Render, R. R. "The Role of the Detail M a n in the Diffusion and Adoption of an E t h i c a l P h a r m a c e u t i c a l Innovation within a Single M e d i c a l C o m m u n i t y . " Unpublished doctoral dissertation, Stanford U n i v e r s i t y , Stanford, C a l i f o r n i a , 1961. R u k e r , P a u l M i l t o n , J r . "Relationship of Selected F a c t o r s to T e a c h e r s ' Readiness to Change. " Unpublished doctoral dissertation, The U n i v e r s i t y of F l o r i d a , G a i n s e v i l l e , 1968. Sanderson, M . E . " A d m i n i s t r a t i o n of I n - S e r v i c e Education P r o g r a m s in H o s p i t a l N u r s i n g S e r v i c e . " Unpublished d o c t o r a l dissertation, T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , New Y o r k , I960. Smith, Duane Ronald. " A Study of E l e m e n t a r y T e a c h e r s ' Attitudes T o w a r d B e l i e f s About, and Use of Newer Instructional M a t e r i a l s . " Unpublished doctoral dissertation, The U n i v e r s i t y of P i t t s b u r g , P i t t s b u r g h , P e n n s y l v a n i a , 1966. Straut, Kathleen M . " A Study of Changes in Job Satisfaction of N u r s e P r a c t i t i o n e r s following an I n - S e r v i c e Education P r o g r a m . " Unpublished doctoral dissertation, T e a c h e r s ' College, C o l u m b i a U n i v e r s i t y , New Y o r k , 1964 V a n A l f e n , C u r t i s N i c h o l a s . " A Study to Develop an Instrument M e a s u r i n g the P e r c e p t i o n of E d u c a t o r s and T e a c h e r s as it Relates to Innovative T r a n s i t i o n a l or T r a d i t i o n a l Educational E n v i r o n m e n t s . " Unpublished doctoral dissertation, The U n i v e r s i t y of Utah, Salt L a k e City, 1967. W e l c h , John M . " A n Evaluation of T h r e e Adult Education Methods for D i s s e m i n a t i n g T r a d e Information to M i s s o u r i Restaurant O p e r a t o r s . " Unpublished d o c t o r a l dissertation, F l o r i d a State U n i v e r s i t y , T a l l a h a s s i e , 1961. Wygal, B e n j a m i n Raymond. " P e r s o n a l C h a r a c t e r i s t i c s and Situational P e r c e p t i o n s of Junior College Instructors as Related to Innovativeness. " Unpublished doctoral dissertation, The U n i v e r s i t y of T e x a s , A u s t i n , 1966.  315  O T H E R SOURCES  " L i f t i n g and M o v i n g Patients - P a r t I in H o s p i t a l " f i l m d i s t r i b u t e d by Canadian F i l m Institute, 1762 C a r l i n g Avenue, Ottawa. P e r s o n a l c o r r e s p o n d e n c e with E . Nordlund, dated M a r c h 7,  1969  P e r s o n a l c o r r e s p o n d e n c e with D r . E v e r e t t M . R o g e r s dated M a r c h 10, 1969. P e r s o n a l c o r r e s p o n d e n c e with D. Rose, O r t h o p e d i c Equipment C o m p a n y Inc. , Bourbon, Indiana, dated M a y 12, 1969.  APPENDICES  Rated Bed C a p a c i t y , Statistics  D a i l y P a t i e n t Occupancy and S t a f f i n g  of H o s p i t a l s  Included  i n the Study Staff  Rated bed Capacity  Bassinets  Daily Patient Occupancy  Grad.  N u r s i n g 1S t a f f Stud Other  Other  Total  1,880.4 521.3 327.4 578.1 402.1 474.0 206.8 112.7 143.4 141.5 143.5  4,099.4 1,309.4 703.6 1,435.0 991.5 1,160.6 535.7 264.1 363.7 368.7 325.0  145.7 109.3 126.2 96.9 71.0 69.1 96.2  299.4 252.0 282.8 235.3 181.9 160.6 203.7  Type A - 201 Beds and over 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.  1634 512 485 482 448 434 270 256 243 242 225  137 62 72 39 48 51 45 47 69 43 43  1,489.71 494.68 342.3 497.58 373.66 419.61 213.33 159.55 228.3 216.89 179.19  968.0 357.7 230.4 338.7 251.6 250.0 136.0 94.3 135.5 126.5 107.3  493.3 280.0  -  243.4 107.7 256.7 115.4  -  -  757.7 222.4 145.4 274.8 230.1 179.9 77.5 57.1 84.8 100.7 74.2  Type B - 75 t o 200 beds 12. 13. 14. 15. 16. 17. 18.  180 164 163 146 132 126 121  31 22 20 27 29 27 32  174.25 131.58 142.04 152.11 109.78 95.78 61.9  109.15 88.2 100.4 75.9 65.1 62.7 61.9  —  -  --  44.2 54.5 56.2 62.5 45.8 28.18 45.6  (continued) Staff Rated Bed Capacity  Bassinets  117 113 111 109 106 103 100 94 91 88 85 85 78  20 29 28 25 14 17 29 30 26 12 19 14 12  19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. Type C -  30 t o 74 Beds  32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.  74 72 70 67 66 63 61 56 54 54 50  21 18 12 18 5 8 12 14 16 12 4  Daily Patient Occupancy  Nursing S t a f f Grad. Stud. Other  88.73 75.28 85.17 91.3 79.81 98.63 89.72 73.42 80.51 81.87 69.83 72.9 74.6  58.2 40.9 50.3 48.3 44*4 60.8 46.8 46.9 40.0 54.6 31.0 48.9 34.7  62.64 58.75 58.25 61.89 50.98 50.07 47.05 46.92 47.95 58.19 31.66  31.9 35.4 27.7 34.9 26,7 21.7 13.2 26.7 27.2 24.3 14.1  -  -  -  -  —  Other  Total  21.9 24.7 23.0 37.6 23.6 38.5 39.0 27.0 25.8 28.5 29.0 27.6 26.3  80.6 66.3 75.0 82.4 65.7 66.2 70.6 66.5 56.2 62.0 55.1 61.8 56.0  160.7 131.9 148.3 168.3 133.7 165.5 156.4 140.4 122.0 145.1 115.1 138.3 117.0  24.6 22.6 16.0 19.5 27.3 18.5 18.8 15.2 12.7 22.9 10.1  50.9 48.1 47.4 41.8 47.1 36.1 30.5 40.2 34.1 43.4 30.3  107.4 106.1 91.1 96.2 101.1 76.3 62.5 82.1 70.0 90.6 54.5  (continued) Staff Rated bed Capacity 4344. 45. 46. 47. 48. ' 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63.  50 45 45 44 43 43 43 41 40 37 37 35 33 33 33 31 31 30 30 30 30  .  Bassinets  12 8 8 15 10 7 8 8 4 10 8 10 12 2 9 7 8 12 6 8 4  D a i l y Patient Occupancy  Nursing S t a f f Grad. Stud. Other  Other  Total  40.41 23.33 44.85 49.87 35.24 33.92 31. 21 27.25 40.15 31.62 33.81 31.92 30.34 29.01 20.61 19.28 8.14 23.39 24.27 28.92 25.77  25.3 14.4 16.1 22.9 18.4 14.0 15.8 12.8 20.1 14.0 16.8 15.3 13.0 20.9 9.0 8.6 5.8 12.9 11.5 12.4 13.1  5.2 5.6 5.0 4.3 9.4 10.0 7.0  30.0 24.2 33.3 35. 2 25.8 24.3 28.0 20. 2 41.4 22.9 27.2 26.0 20.2 20.0 16.2 16.7 8.4 18.8 18.6 18.3 22.6  70.2 49.9 69.5 73 .3 57.2 45.3 52.3 39.4 77.2 46.9 54.1 50.1 47.6 40.9 30.4 30.9 19.2 36.0 39.5 40.7 42.7  22.68 10.71 16.53  8.5 6.1 8.8  4.7 5.0 3.3  15.3 9.4 14.7  28.5 20.5 26.8  -  13.9 11.3 20.1 15.2 13.0 7.0 8.5 6.4 15.7 10.0 10.1 8.8 14.4  -  Type D - Under 30 beds 64. 65. 66.  28 27 26  4 4 2  -  (continued) Staff Rated Bed Capacity 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85.  26 25 25 25 25 24 24 21 21 21 21 21 21 19 18 17 16 15 9  Bassinets  5 4 5 2 6 6 6 3 6 10 2 4 6 2 8 2 5 1 2  Daily Patient Occupancy 15.08 15.12 24.37 11.61 18.57 21.7 21.32 8.14 15.93 10.07 9.92 16.46 13.96 6.59 22.92 14.53 11.13 10.17 3.38  Nursing S t a f f Grad. Stud. Other 7.1 7.4 10.7 5.8 9.3 12.4 6.5 4.2 6.4 4.9 5.7 8.8 7.7 4.8 8.1 6.5 5.9 5.5 3.5  -• -  5.0 5.9 9.9 9.5 6.2 8.1 8.3 3.2 4.9 5.4 2.5 4.6 3.9 2.7 8.6 4.0 2.5  3.3 1.3  Other  Total  13.7 12.9 16.4 13.2 13.4 15.8 15.9 8.2 8.9 11.1 7.8 13.4 9.7 6.4 13.9 8.7 4.1 7. 7 .3  25.8 26.2 37.0 28.5 28.9 36.3 30.7 15.6 20.2 21.4 16.0 26.8 21.3 13.9 30.6 19.2 12.5 16.5 5.1  321  APPENDIX B  T H E INTERVIEW S C H E D U L E  I.  M E T H O D O F ADMINISTRATION  A s t r u c t u r e d interview  technique was employed to obtain  i n f o r m a t i o n f r o m the D i r e c t o r s of N u r s i n g of the hospitals included i n the study.  The instrument used as a basis for conducting the interview  and for r e c o r d i n g data was the Interview Schedule. The construction of the schedule was d e s c r i b e d in Chapter I, pages 13 to 19. A standard format for conducting the interview was developed and used throughout the s e r i e s of v i s i t s to the eighty-five  hospitals.  The first section of the interview schedule concerned i n f o r m a t i o n about the D i r e c t o r s of N u r s i n g , the hospital, the community, the a d m i n i s t r a t i v e p e r s o n n e l and the n u r s i n g staff.  T h e questions in this  section were asked in the f o r m in which they appear in the schedule and data were r e c o r d e d d i r e c t l y as the i n f o r m a t i o n was given.  The second section of the schedule dealt with sources of i n f o r m a t i o n used by the D i r e c t o r s of N u r s i n g at each stage of the adoption p r o c e s s . In a d m i n i s t e r i n g this section,  the author handed each participant a c a r d  which contained a l i s t of possible sources which it was felt might be u s e d by n u r s e s .  T h e c o m p i l a t i o n of this l i s t was d e s c r i b e d on pages 13  and 14 of Chapter I.  T h e participant was asked to select f r o m the l i s t  322  s o u r c e s she had found most helpful or to name others she had used c at v a r i o u s stages in the adoption p r o c e s s (as outlined in the on page 11 of the schedule).  A free choice was given and the participants  were i n s t r u c t e d that they could name as many, or as few, wished.  questions  as they  In addition, if a participant gave 'other D i r e c t o r s of N u r s i n g '  as a source at any stage,  she was asked to name the hospital she wrote  to, or otherwise communicated with, c o n c e r n i n g new p r a c t i c e s in n u r s i n g . T h i s i n f o r m a t i o n was l a t e r used to trace the communication links between hospitals.  In a d m i n i s t e r i n g the t h i r d section of the Interview Schedule concerning the adoption of innovations, the questions in l e s s t e c h n i c a l t e r m s . developed. innovations.  it was n e c e s s a r y to r e p h r a s e Again, a standard format was  E a c h participant was handed a c a r d containing the l i s t of T h e following question was asked about each innovation:  A r e you using this p r a c t i c e , or have you used it in your hospital? If the p a r t i c i p a n t answered "yes", one s e r i e s of questions was asked, if "no", an alternative s e r i e s was used. A.  In the case of an affirmative answer,  the following questions were  used:  1.  When did you start using this p r a c t i c e in your hospital?  2.  T o what extent are you using it now?  3.  When did you f i r s t hear about it?  4.  Where did you first hear of it?  5.  Did it take you long to start using this after you h a r d first h e a r d about it?  323  If a delay of two years or m o r e was indicated, the next question was: 6.  Why did it take so long?  Then, 7.  A r e you continuing to use this p r a c t i c e ?  If not, 8.  Why are you not using it now?  Then, 9.  Who made the d e c i s i o n to use this p r a c t i c e ?  and 10.  Why did you decide to use it?  Finally, 11.  Where else did you get i n f o r m a t i o n about this p a r t i c u l a r practice?  B.  If the participant gave a negative answer to the f i r s t  question, indicating that the p r a c t i c e had never been used in her hospital,, the following question was asked:  Have you h e a r d of this p r a c t i c e ? If the answer was "no, " no further questions were asked about this innovation.  If the respondent answered "yes", the following were asked: 1.  When did you first hear about it?  2.  Where did you hear about it?  324  3.  Have you done anything about this p r a c t i c e , that is, have you t r i e d to get m o r e information on it, or have you d i s c u s s e d it •with anyone ?  4.  Have you c o n s i d e r e d using it in this hospital?  If the participant indicated that the p r a c t i c e had been rejected for use in their hospital, the question was asked: 5.  Why did you decide not to use it h e r e ?  Similarly,  i f the p a r t i c i p a n t stated that she was interested in the  idea but had not p r o c e e d e d beyond the interest, stage,  she was asked  6.  Why has there been a delay?  evaluation,  or t r i a l  Finally, 7.  What other s o u r c e s of information have you used in r e g a r d to this p r a c t i c e ?  The i n f o r m a t i o n gathered f r o m the D i r e c t o r s of N u r s i n g was r e c o r d e d on the Interview Schedule in the f o r m in which the questions appear in pages 13ato 15c of the Schedule.  325  •2.  CHOICE O F TOOLS  The innovations in nursing practice investigated during the course of this study were the tools used to determine how information is transmitted in the nursing community. The manner in which the specific practices were selected was described in Chapter I on pages 14 and 15. The initial list of fourteen items was compiled following discussions with teachers and supervisors of the nursing staffs of two of the large hospitals in the Lower Mainland area.  Many of the innovations suggested by  the nurses were ones which had come about as a result of changing medical practice.  Only those innovations which were considered to be primarily in  the realm of nursing practice were included. Relatively neutral, rather than highly controversial items were chosen, which could be used in both rural and urban hospitals.  In the initial  selection of items, D r . Coolie Verner with his background of experience in diffusion-adoption studies and his knowledge of rural sociology, was of invaluable assistance. The list of fourteen innovations in nursing practice was subsequently evaluated by the author's dissertation committee, which included a physician, a statistician, and experts in the field of education.  The Committee  recommended using only one "disposable" item rather than the six which were  326  on the original list.  It was felt that using the six commercial items would  be a duplication of effort and it was preferable to focus the study on behavioral changes in regard to professional and administrative aspects of nursing practice.  3.  INTERVIEW SCHEDULE  Respondent' s Name: Name o f H o s p i t a l : L o c a t i o n of H o s p i t a l : Bed C a p a c i t y o f H o s p i t a l : (1967) Number of Graduate Nurse S t a f f : Telephone Number: Code Number o f H o s p i t a l : Record o f V i s i t : Date  Comments:  Time  328  H e l l o , I'm Mrs. B e v e r l y DuGas. I am conducting a study f o r the U n i v e r s i t y of B r i t i s h Columbia. I would l i k e to have your a s s i s t a n c e i n t h i s by answering some questions. Please answer these q u e s t i o n s as c l e a r l y and as h o n e s t l y as you can. THIS INFORMATION IS FOR THE PREPARATION OF STATISTICAL REPORTS ONLY AND IS STRICTLY CONFIDENTIAL  1. What i s your 1. 2.  3.  J+.  5. 6.  21-2I4.  25-30  31 -314-  35-39  ko-kk  7.  So-Sh  9.  60  8.  age?  55-60  or over  2. What i s your m a r i t a l s t a t u s ?  3.  1. 2. 3. LL. 5.  single married widowed separated divorced  How  many c h i l d r e n do you have?  1.  none  2.  1 - 2  3.  3 - h  LL.  5 or more  LL. What was  5.  the h i g h e s t year you completed  i n school?  1. U n i v e r s i t y Entrance 2. f i r s t year u n i v e r s i t y 3. second year u n i v e r s i t y LL. u n i v e r s i t y degree i n n u r s i n g 5. u n i v e r s i t y degree other than n u r s i n g 6. master's degree Where d i d you take your b a s i c n u r s i n g course? 1. 2.  3.  diploma s c h o o l of n u r s i n g i n B.C. the U.B.C. School of N u r s i n g diploma s c h o o l of n u r s i n g o u t s i d e B.C.  but i n Canada  329  2. Q u e s t i o n £ continued 14-.  5.  6. 7. 8. 9. 6.  7.  u n i v e r s i t y s c h o o l of n u r s i n g o u t s i d e U.K. U.S.A. Europe Asia other  B.C.  Have you taken any h o s p i t a l post-graduate courses i n n u r s i n g ? 1.  yes  2.  no  I f so, which course or courses d i d you  1. operating nursing 2. obstetric nursing 3. Pediatric nursing [j.. P s y c h i a t r i c n u r s i n g 5. Neuro s u r g i c a l n u r s i n g : 6. other 8. Have you taken any c e r t i f i c a t e 1. yes 2. no  take?  courses at a U n i v e r s i t y ?  9. I f you answered "yes" to number 8, what course or courses d i d you take?  10.  11.  1. ward a d m i n i s t r a t i o n 2. t e a c h i n g 3o t e a c h i n g and s u p e r v i s i o n li. public health nursing 5. course i n c l i n i c a l s u b j e c t 6. other Have you taken the C.N.A. course on Ward A d m i n i s t r a t i o n ? 1 .  yes  2.  no  Have you taken n i g h t s c h o o l or correspondence 1. 2. 3. li.  courses?  courses l e a d i n g to a degree i n n u r s i n g courses l e a d i n g to a degree o t h e r than n u r s i n g g e n e r a l i n t e r e s t courses none  330  3. 12.  Do you enjoy n u r s i n g ? 1. 2. 3. li. 5.  13.  yes, v e r y much yes, most of the time about average not a l l the time not at a l l  When d i d you graduate  from your s c h o o l . o f n u r s i n g ?  c l a s s i f i c a t i o n of response T. l e a s than 5 years ago 2. 5-9 years ago 3. 10 - 11+ years ago k-' 1 5 - 1 9 years ago 5. 2 0 - 2 9 years ago 6. II4..  15»  over 30 years  ago  Have you worked i n n u r s i n g c o n t i n u o u s l y s i n c e 1. 2.  yes no  How  many years have you worked i n n u r s i n g  graduation?  altogether?  c l a s s i f i c a t i o n of response 1. l e s s than 5 y e a r s 2. 5-9 years 3. 10 - 1I4. y e a r s h.. 1 5 - 1 9 years 5. 20 - 29 years 6. over 30 years 16.  How  l o n g have you been i n your p r e s e n t p o s i t i o n ?  c l a s s i f i c a t i o n of response 1. l e s s than one year 2. one to two years 3. three t o f i v e y e a r s I4.. s i x to ten years 5. e l e v e n to twenty years 6. more than twenty y e a r s 17.  What p o s i t i o n d i d you h o l d immediately position? 1. 2. 3. li. 5. 6. 7.  D i r e c t o r of Nursing at another Supervisor Head Nurse S t a f f Nurse P u b l i c H e a l t h Nurse Instructor Other ( s p e c i f y )  b e f o r e you took  hospital  this  331  k. 18. Where was t h i s p o s i t i o n ? 1. i n a l a r g e h o s p i t a l i n B. C. 2. i n a s m a l l h o s p i t a l i n B. C. 3. i n a l a r g e h o s p i t a l i n another p a r t of Canada LL. i n a s m a l l h o s p i t a l i n another p a r t of Canada 5. i n a h o s p i t a l i n another country 6. other ( s p e c i f y ) 19.  Do you a t t e n d the l o c a l c h a p t e r meetings 1. 2. 3. LL. 5.  always most of the time s ome t ime s rarely never  20. Have you h e l d - or do you h o l d - an o f f i c e chapter? 1.  2.  3.  22.  the.Annual Meetings of the R.N.A.B.C?  always most of the time sometimes rarely never  Have you h e l d - or do you h o l d - an o f f i c e nursing association? 1.  2. 3.  2. 3.  of the C.N.A?  always most o f the time sometimes rarely never  2LL. Have you h e l d - or do you h o l d 1.  i n the p r o v i n c i a l  yes, c u r r e n t l y h o l d an o f f i c e y e s , but not now no  23. Do you a t t e n d the b i e n n i a l meetings 1. 2. 3. LL. 5.  i n the l o c a l  yes, c u r r e n t l y h o l d one y e s , but not now no, I have never h e l d an o f f i c e  21. Do you a t t e n d 1. 2. 3. LL. 5.  of the R.N.A.B.C?  yes, c u r r e n t l y hold y e s , but not now no  - an o f f i c e i n the C.N.A?  an o f f i c e  332  5. 25.  Have you attended any n u r s i n g i n s t i t u t e s , workshops, or s h o r t e d u c a t i o n a l programs i n the past f i v e years?  1.  2.  yes no  I f you answered "yes" to the p r e v i o u s which ones you attended. a)  b )  question, please  c)  27. Where was  the  course  to the r e g i o n a l  institutes?  yes no  Do nurses get leave of absense with pay meetings ( i n s t i t u t e s ) ? 1. 2. 3. ii.  31.  or other' e d u c a t i o n a l  yes no  29. Do you send nurses  1. 2.  attended  held?  Do you send nurses to i n s t i t u t e s meetings h e l d i n Vancouver?  1. 2.  30.  (s)  specify  d)  26. C l a s s i f i c a t i o n of number of courses 1 . none 2. one 3. two ' . three 5. more than three  28.  other  routinely sometimes no L/A g i v e n L/A but without  to attend  pay  Do nurses r e c e i v e money from the h o s p i t a l to attend meetings ? yes, always sometimes never  educational  educational  333 6.  32. Who i s the A d m i n i s t r a t o r 1. 2. 3. LL.  o f the H o s p i t a l ?  a physician a l o c a l business man a trained administrator other  33- What i s h i s (her) approximate age? 1. 2. 3. LL. 3LL.  under 35 y e a r s 3D - 50 years over 50 years over 60 years  I S he (she) a member of the H o s p i t a l Board? 1.  2.  yes no  35. Have there been any r a d i c a l changes i n your h o s p i t a l w i t h regard to n u r s i n g technique w i t h i n the l a s t f i v e 1. 2.  3.  LL.  years?  y e s , q u i t e a few some, but not too many a few none at a l l  36. Do you have any I n - S e r v i c e E d u c a t i o n a l Program f o r the nursing staff? 1.  2.  yes no  37. How o f t e n do you h o l d meetings i n order t o b r i n g your u p t o date on the l a t e s t n u r s i n g techniques? 1. 2. 3. L|.. 38.  staff  once a week every two weeks once a month every once i n a w h i l e  Do you r e c e i v e much i n f o r m a t i o n from the R.N.A.B.C? 1. y e s , a l l i n f o r m a t i o n r e c e i v e d i s from the R.N.A.B.C? 2. y e s , but not a l l 3. some LL . none  334  7. 39.  Do y o u r e c e i v e much o f t h e i n f o r m a t i o n m e n t i o n e d i n t h e p r e v i o u s q u e s t i o n f r o m s o u r s e s o t h e r t h a n the R . N . A . B . C ? 1.  2.  3. li.  yes, e n t i r e l y y e s , but not a l l s ome none  i|0. A r e a l l pressed 1. 2.  3. li.  t h e new i d e a s w h i c h a r e b r o u g h t t o y o u r into service?  yes, a l l y e s , most s ome none  111 . Do you f e e l y o u h a v e in nursing? 1. 2.  y e s , most some  3.  a  li.  none,  of  the  latest  up-to-date  equipment  used  it  little most  equipment  is  1x2. Is y o u r s t a f f t r a i n e d t o use 1. y e s , a l l the s t a f f 2. y e s , most o f t h e s t a f f 3. some o f t h e s t a f f l+. a few o f t h e s t a f f 5.  attention  none  of  the  staff  is  hopelessly the  familiar  latest  outdated n u r s i n g equipment?  w i t h the  latest  equipment  2+3• Is i t d i f f i c u l t t o o b t a i n t h e l a t e s t e q u i p m e n t ? 1. 2. 3. l±. 5. ijii.  not at a l l not too d i f f i c u l t , but s t i c k y at times most o f t h e time a l l o f the time i t i s i m p o s s i b l e t o o b t a i n new e q u i p m e n t  Do y o u f i n d t h a t a l a c k o f e q u i p m e n t p r e v e n t s new t e c h n i q u e s i n t o p r a c t i c e ? 1.  2.  3. li.  not at a l l yes, a b i t yes, quite a b i t i t is impossible to equipment  you from  do a n y t h i n g new w i t h o u t  putting  the p r o p e r  335  8. LL£. D O you t h i n k your h o s p i t a l i s p r o g r e s s i v e ? 1. 2. 3. LL6.  I S your h o s p i t a l as p r o g r e s s i v e  1. 2.  3. I4.7.  very p r o g r e s s i v e f a i r l y progressive not p r o g r e s s i v e at a l l  If be 1. 2. 3. LL. 5. 6. 7. 8.  as you t h i n k i t should be?  yes i t i s p r o g r e s s i v e , but I would l i k e t o see more not at a l l your h o s p i t a l i s not as p r o g r e s s i v e as you t h i n k i t should i n n u r s i n g , who i s h o l d i n g up p r o g r e s s ? F e d e r a l Government P r o v i n c i a l Government M u n i c i p a l Government the H o s p i t a l Board of D i r e c t o r s the H o s p i t a l A d m i n i s t r a t o r R.N.A.B.C. our H o s p i t a l i s p r o g r e s s i v e I don't know  LL8. I S the chairman o f the Board a member o f the m e d i c a l profession?  1.  2.  yes no  LL9. Are you a member of the Board?  1.  2. 50.  yes no  How many d o c t o r s  are on the Board?  c l a s s i f i c a t i o n o f response 1 . one 2. two - three 3. f o u r - seven LL. more than seven 51. How many members of the community o t h e r than doctors the Board of D i r e c t o r s ? 1.  2. 3. LL. 5.  none one two - three f o u r - seven more than seven  are on  336 9.  52. Do you t h i n k t h a t the community i s p r o p e r l y and adequately represented? 1 . yes 2. no  53.  Does the community support 1. 2. 3. li. 5.  the h o s p i t a l and i t s p o l i c i e s ?  yes, supnort i t most o f the time does not support or approve i t oppose i t n o t known  5J+. Does the h o s p i t a l have a Women's A u x i l l i a r y ?  1.  2.  3.  yes no n o t an o r g a n i z e d group, but v o l u n t e e r s come i n t o h e l p  55. Does the h o s p i t a l have a C a n d y - S t r i p e r o r other v o l u n t e e r s e r v i c e program f o r teen-age g i r l s i n the community?  1. 2. 3. 56.  no not an o r g a n i z e d group, but some do come i n t o h e l p  Do the h i g h schools i n your community have a Future Club? 1. 2. 3. l±.  57.  yes-  y e s , most o f them some of them none of them never heard of them  Is your n u r s i n g 1. 2. 3.  1.  staff:  predominantly middle aged f a i r l y mixed  58. What percentage of Nursing?  2. 3.  Nurses'  0% - 25% 25% - 5o% 5o% - 75% 75% - 100%  young  o f your s t a f f  are graduates  o f B.C. Schools  10. 59. Graduates of Canadian Schools of N u r s i n g (other than B.C.  1. 2. 3. Li. 60.  British  1. 2. 3. LL.  61.  0$ - 25$ 25$ - 50% $0% - 100$ 75$ - 100$  0% - 25$ 25$ - 50% 50$- 75$ 75$ - 100$  Other  1. 2. 3. LL.  - 25$ 25'^ - 50$ 50$ - 75$ 75$ - 100$ 0%  62. Do you r e a d The Canadian Nurse? 1. 2. 3. LL. 5.  yes, r e g u l a r l y r e a d every a r t i c l e r e a d most o f the a r t i c l e s i n i t look at some a r t i c l e s r a r e l y l o o k at i t never open i t  63. Which n u r s i n g j o u r n a l s , b e s i d e s The Canadian Nurse do you receive ? a.  b.  c.  d.  e.  c l a s s i f i c a t i o n o f response Number o f j o u r n a l s r e c e i v e d .  1. 1 2. 2 3. 3 5. 5  oli. Is N u r s i n g Research among the j o u r n a l s l i s t e d as r e c e i v e d  1. 2.  yes no  338  11 . 65. How much time, on the average, do you spend i n p r o f e s s i o n a l reading? 1. 2. 3. ii. 5. 6.  one hour a day one h a l f an hour a day a c o u p l e of hours a week one hour a week one h a l f hour a week o c c a s i o n a l l y p i c k up a j o u r n a l and read i t  THE NEXT QUESTIONS WILL DEAL WITH SOURCES OF INFORMATION ABOUT IMPROVED PRACTICES. (Hand the respondent the l i s t  of sources of i n f o r m a t i o n )  On t h i s card are a number o f sources o f i n f o r m a t i o n where you might l e a r n about improved n u r s i n g p r a c t i c e s . In answering the next few q u e s t i o n s , I want you to g i v e me the numbers and/or the l e t t e r s of the sources of i n f o r m a t i o n which a p p l y . 66 -  70  What source or sources have you found to be most u s e f u l i n f i n d i n g out about new or improved p r a c t i c e s which can be used i n your h o s p i t a l ?  71 -  76  When you have found an item about a new o r improved p r a c t i c e which i n t e r e s t s you, to which source or sources do you go f o r f u r t h e r i n f o r m a t i o n on how you can p o s s i b l y use i t i n your h o s p i t a l ?  77 -  82  When you have r e c e i v e d i n f o r m a t i o n on a new or improved p r a c t i c e , which source or sources do you use to h e l p you e v a l u a t e the i n f o r m a t i o n a c q u i r e d i n the l i g h t of e x i s t i n g c o n d i t i o n s i n t o which the p r a c t i c e wouid have to f i t ?  83 - 88  A f t e r you have weighed the i n f o r m a t i o n a v a i l a b l e , what source or sources do you use i n f i n d i n g i n f o r m a t i o n on how t o apply the p r a c t i c e ?  339  12. When y o u have f o u n d o u t how t o a p p l y t h e p r a c t i c e s , w h i c h s o u r c e o r s o u r c e s do you use i n d e c i d i n g whethe o r not to adopt the p r a c t i c e ?  340  13. INFORMATION ON NURSING  PRACTICES  To c o m p l e t e t h e i n t e r v i e w , I w o u l d l i k e t o a s k some q u e s t i o n s i n r e l a t i o n t o t h e n u r s i n g p r a c t i c e s t h a t a r e l i s t e d on the Innovations i n Nursing card. Are y o u u s i n g t h i s this hospital? a.  b.  practice?  c.  If  yes,  d.  when was  it  first  a r e y o u aware o f  a.  e.  I.  What s t e p s 1. 5.  II.  c.  d.  have you t a k e n i n r e g a r d to  n o t aware trial  2. 6.  awareness adoption  this 3«  You became aware o f t h i s p r a c t i c e i n l e n g t h o f t i m e b e t w e e n a w a r e n e s s and t h e adoption process? 1. 2. 3. l±.  now aware l e s s t h a n one y e a r one two y e a r s  in  e.  I f you are not u s i n g t h i s p r a c t i c e , when d i d y o u become aware o f i t ? b.  used  5. 6. 7. 8.  it?  If  practice?  interest  I4..  . What was t h e stage reached i n  three years four years f i v e years s i x years  yes,  v. 10.  evaluation  the  seven years more t h a n seven years  What r e a s o n w o u l d y o u g i v e f o r s p e n d i n g more t h a n two y e a r s t r y i n g t o d e c i d e w h e t h e r o r n o t t o use t h i s p r a c t i c e ? a.  • b. c. d. e.  341  1 . Australian lift  101  1  2  b. M i t t restraints  113  %  3  125  1  2 3  1 2 3  I*  5  5  6  7 8 9  7 8 9  10  6 10  5  7 8 9  10  1U/9  3  \  \  6  138  1  2 3  ll5  6 7 8 9  19  1  2  3  5  126  1  e. u r o l o g y adaptor protector  2  6  k  6  137  3  5  1114-  1  d. sheepskin pelts  2  6  6  1 2  2  c . glove technique  3  3  102  1  3A  6  150  1  2 3  li 5  6  7 8 9  10  342  III.  C l a s s i f i c a t i o n of the r e a s o n f o r a delay of more than two years between awareness and the stage reached i n r e g a r d to t h i s p r a c t i c e .  1. z.  3.  l+. 5.  situational factor o v e r - r u l i n g of n u r s i n g d e c i s i o n  6.  r e l a t i v e advantage compatibility complex!ty divisibility communicability  7. 8. 9. 10.  IV. Which of the following, d e s c r i b e s your p o s i t i o n i n r e g a r d to this practice? 1. 2. 3. ii.  c o n t i n u i n g with the a d o p t i o n process rejection adoption discontinuance  What reason would you g i v e f o r r e j e c t i n g o r d i s c o n t i n u i n g this practice? a. b. c. d. e. V.  C l a s s i f i c a t i o n o f the r e a s o n f o r r e j e c t i n g or d i s c o n t i n u i n g the p r a c t i c e . 1. 2. 3. U. 5.  r e l a t i v e advantage compatability complexity divisibility communicability  , I'  ., .. ., situational factor o v e r - r u l i n g of n u r s i n g d e c i s i o n  ^*  I f the p r a c t i c e has been adopted, adopt i t ? a.  b.  c.  who made the d e c i s i o n to d.  e.  343  b. M i t t restraints  Australian lift  103  IV  10li  1 2 3  1  11$  115  6  6  9  9  1  0  116  3 I*.  105  1 2 u3  1 2 3 a,  6 7 8  9  10  127 id(  117  101 2 3 1*. 1 2 3 1+ 6 7 8  9  10  1 1  d. sheepskin pelts 139 >jy  2 3  *  2  v  1  c. glove technique  ! 9 101 2 3  II4.0  1  2 3 U 5 6 7 8  9  10  151  •  2 3  6  6  9  9  101  152  1 10 2 3 14.  153  1 2 3  3  k 1IL1  1  2 3  2  It-  129  •  t  6  128  1  e. u r o l o g y adaptor protector  1 2 3 Ij-  5 6 7 8  9 10  \ 6 7 8  9  10  344  15.  VI. C l a s s i f i c a t i o n of p e r s o n n e l r e s p o n s i b l e f o r making d e c i s i o n to adopt the p r a c t i c e . 1. 2. 3. LL.  D i r e c t o r of Nursing Nursing s t a f f Medical s t a f f Hospital administrator  V I I . I f the p r a c t i c e has f o r adopting i t ? 1. 2. 3. LL.  5. 6.  H o s p i t a l board other  been adopted, what reason  time s a v i n g labour saving money-saving comfort of the p a t i e n t  5. 6. 7.  the  would you  give  s a f e t y of the p a t i e n t administrative order other  V I I I . Look at the sources of i n f o r m a t i o n on the c a r d and t e l l me the numbers of the sources of i n f o r m a t i o n that you used i n r e l a t i o n to t h i s p r a c t i c e .  345  15A  a. A u s t r a l i a n lift  VI  /II.  106  b. M i t t restraints  1  118  2  3  S  4  VIII 108 109 110 111  112  B  119  1  2 3  .  -  l  1  6  1  2  1  d. s h e e p s k i n pelts 1LL2  2  3  6  107  130  1  2 I  c. glove techniques  3  '  .  l  S  l  131  3  1514. 1  2  2  5  6  2  1 3  .  1  e. u r o l o g y adaptor protector  3  I 4 . I 1 .  5  6  114-3  1  2  6  1  55  1  2  3  3  3  \  \  \  \  5  6  6  6  6  6  7  7  7  7  7  120  132  ]hk  121  133  ]^f—  123  136  114-8  122 12li  13a 135ZZ  ^  }56  Ml  \H  160.  346  13INFORMATION ON NURSING PRACTICES To c o m p l e t e t h e i n t e r v i e w , I w o u l d l i k e t o a s k some q u e s t i o n s i n r e l a t i o n t o t h e n u r s i n g p r a c t i c e s t h a t a r e l i s t e d on the Innovations i n Nursing card. Are y o u u s i n g t h i s this hospital? a.  b.  practice?  c.  If  yes,  when was  d.  it  first  a r e y o u aware o f  a.  e.  I.  What s t e p s 1. 5.  II.  c.  d.  have y o u t a k e n i n r e g a r d t o  n o t aware trial  2. 6.  in  e.  I f you are not u s i n g t h i s p r a c t i c e , when d i d y o u become aware o f i t ? b.  used  awareness adoption  this 3«  You became aware o f t h i s p r a c t i c e i n l e n g t h o f t i m e b e t w e e n a w a r e n e s s and t h e adoption process?  it?  If  practice?  interest  !+.  . What was t h e stage reached i n  1.  now aware  5.  three  years  2. 3. J+.  l e s s t h a n one y e a r one two y e a r s  6. 7. 8.  four years f i v e years s i x years  yes,  v. 10.  seven  evaluati  the years  more t h a n seven years  What r e a s o n w o u l d y o u g i v e f o r s p e n d i n g more t h a n two y e a r s t r y i n g t o d e c i d e w h e t h e r o r n o t t o use t h i s p r a c t i c e ? a.  b. c. d. e.  347  1 3B  open v i s i t i n g hours  161  1  g.elimination 6:00 a.m. temperature  173  h.  185  elimination of drawsheets  1  i .  colored dresses paediatrics  1  197  2  2  k  k  k  k  6  6  6  6  3  1 2  2  3  5  162  1  of  3  5  171+  1  2  3  5  186  1  5  198 1  2  2  k  k  k  k  6 7 8 9 10  6 7 8 9 10  6 7 8 9 10  6 7 8 9 10  3  5  3  5  3  5  2  3  5  348  1k. III.  C l a s s i f i c a t i o n o f the r e a s o n f o r a delay of more than two years between awareness and the stage reached i n r e g a r d to t h i s p r a c t i c e .  1.  2. 3.  k-  5.  6.  r e l a t i v e advantage compatibility complexity divisibility cominunic a b i l i t y  situational factor o v e r - r u l i n g of n u r s i n  7.  8.  9. 10.  IV. Which o f the f o l l o w i n g d e s c r i b e s your p o s i t i o n i n r e g a r d to this practice? 1. 2. 3. k.  c o n t i n u i n g with the a d o p t i o n process rejection adoption discontinuance  What reason would you g i v e f o r r e j e c t i n g o r d i s c o n t i n u i n g this practice? a. b. c. d. e. V.  C l a s s i f i c a t i o n o f the r e a s o n f o r r e j e c t i n g or d i s c o n t i n u i n g the p r a c t i c e . 1. 2. 3. U. 5.  r e l a t i v e advantage compatability complexity divisibility communicability  6. 7.  8.  situational factor o v e r - r u l i n g of n u r s i n g d e c i s i o n  9. 10.  I f the p r a c t i c e has been adopted, adopt i t ? a.  b.  c.  who made the d e c i s i o n to  a.  e.  349 11LB. f.  open v i s i t i n g hours  III.  163 1 2 3  g.  175  k  5 6 7 8 9 10  IV. I6I4.  V. 165  1  2 3  1  2  3 1+ 5 6 7 8 9 10  e l i m i n a t i o n of a.m. temperature  elimination of drawsheets  6:00  1  2 3  187  k  k  9 10  9 10  5 6 7 8  176  1  2  1  2 3  k  5 6 7 8 9 10  199  5 6 7 8  188  1  2  3  177  1 2 3  i. colored dresses paediatrics  1  2 3 H-  5 6 7 8 9 10  2 3 U5 6 7 8  9 10 200  3 1+-  189  1  1  2 3  201  1 2 3 1* 5 6 7 8 9 10  350  15.  VI. C l a s s i f i c a t i o n of p e r s o n n e l r e s p o n s i b l e f o r making d e c i s i o n to adopt the p r a c t i c e . 1. 2. 3. LL.  D i r e c t o r of Nursing Nursi