AN INSTITUTE AS AN EDUCATIONAL EXPERIENCE IN THE CONTIMJING EDUCATION OF A SELECTED POPULATION OF NURSES hy JEAN KIJRSTINE BUCKLAND B.A-Sc, U n i v e r s i t y o f B r i t i s h Columbia, 19^5 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n the Department o f Adul t Education We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE U N i y E R S m OF BRITISH COLUMBIA A p r i l , 1969-In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y of B r i t i s h Columbia, I a g r e e t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and Study. I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g of t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department of The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada ~7 ABSTRACT This study was an effort to evaluate the effectiveness o f a two day institute on "Evaluation of Personnel" as an educational experience i n the continuing education of nurses, to submit to c r i t i c a l analysis a method of evaluation, and to examine the relationship of educational and experiential backgrounds of the participants to the learning which took place subsequent to an observational analysis of the institute. An unstructured interview technique was used three months after i t s completion to e l i c i t subjectively what respondents thought they had learned at the institute. The information was later arranged i n a structured format for compilation, tabulation and analysis, "both by punch card and computer. The socioeconomic back-ground data was gathered through the use of a structured questionnaire at the time of the inteview. A behavioral concept of learning was used throughout. The results revealed that 91$ of the sample indicated that learning had occurred, as they perceived a change in their behavior because they had attended the institute. Further, 76$ perceived a change in knowledge, 62$ in attitude, and jGfo in practice, while over half perceived a change in a l l three areas. The greatest change was perceived by those who were younger, married, had less education (academic and post basic nursing), less experience in nursing, and who were employed i n the l a r g e r agencies. The p e r c e p t i o n o f l i t t l e o r no change was i n d i c a t e d "by those w i t h more education (academic and post b a s i c n u r s i n g ) , more experience i n n u r s i n g , and who were employed i n the s m a l l e r agencies. The comparisons of change t o background f a c t o r s r e v e a l e d t h a t , although none o f the comparisons were c o n s i s t e n t l y s i g n i f i c a n t , t h e re was a p o s i t i v e r e l a t i o n s h i p o f l e a r n i n g w i t h age, b a s i c academic education, post b a s i c n u r s i n g education, years of n u r s i n g experience, and s i z e o f employing agency. M a r i t a l s t a t u s , husband's occupation, p a r e n t a l s t a t u s , income, s o c i a l p a r t i c i p a t i o n , years of head nurse experience, s i z e and type of n u r s i n g u n i t and s i z e o f s t a f f showed some i n t e r e s t i n g comparisons by o b s e r v a t i o n , but the sample proved too s m a l l f o r accurate i n f e r e n c e s to be drawn. The conclusions of the study were t h a t the i n s t i t u t e was e f f e c t i v e as an e d u c a t i o n a l experience f o r c o n t i n u i n g education i n the three aspects o f b e h a v i o r a l l e a r n i n g examined, provided the c r e d i b i l i t y o f the respondents was acceptable. The instrument used was adequate f o r the purpose of i n d i c a t i n g change of behavior w i t h the above p r o v i s o , "but not adequate f o r r e v e a l i n g whether change was r e l e v a n t t o c e r t a i n socioeconomic data. No c l a i m can t h e r e f o r e be made concerning the r e l a t i o n s h i p between t h i s data and l e a r n i n g i n a s i t u a t i o n such as t h i s i n s t i t u t e . TABLE OF CONTENTS Chapter ; page I . • THE PROBLEM, THE RELEVANT RESEARCH, THE STUDY 1 S o c i a l and Occupational Change. 1 Lack o f Leadership 2 Continuing Education f o r Nurses . k E v a l u a t i o n o f Continuing Education: The Utah, WICHE, and Texas St u d i e s . . . . . . . . . . . . . . 5 Relevance o f the Present Study 12 Purpose and Scope o f the Study Ik L i m i t a t i o n s o f the Study ' 15 Footnote References 17 I I . A DESCRIPTION OF THE SAMPLE . . . 21 The P o p u l a t i o n and the Sample 21 C h a r a c t e r i s t i c s o f the Sample . 22 Comparison o f Background Categories 39 Summary 5® Footnote:. References . . 5k I I I . THE INSTITUTE AND U S EVALUATION 56 . . The Learning S i t u a t i o n : Knowledge, A t t i t u d e , P r a c t i c e . . 5& E v a l u a t i o n o f S u p e r v i s o r y T r a i n i n g Programs . . . . 60 The C o n s t r u c t i o n o f the Interview Schedule . . . . . 62 The P i l o t Study 62 The Study . . 63 Compilation o f R e s u l t s . . . . . . . . 6k Footnote References 65 Chapter page IV. RESULTS OF THE STUDY 66 Pe r c e p t i o n o f Change: Knowledge, A t t i t u d e , P r a c t i c e . . . . . . 66 A Comparison o f Pe r c e i v e d Change and Background Data: O v e r a l l Change of Behavior, Knowledge. • Change, A t t i t u d e Change, P r a c t i c e Change . . . . f l Summary 78 V. DISCUSSION AND IMPLICATIONS 80 The. Interviews 80 Expressed Views o f the I n s t i t u t e 8 l Reading 82 The Work S i t u a t i o n and i t s E f f e c t upon Change . . 83 The E f f e c t o f the I n s t i t u t e on the P a r t i c i p a n t s : Adoption o f Innovations, D i f f e r e n t C o g n i t i v e Worlds, D i f f e r e n t E x p e c t a t i o n s , Performance Lags . • 87 Accomplishment o f the Purposes o f the Study . . . 92 Aspects o f the Methodology 9^ D u p l i c a t i o n s 98 Conclusions" • 102 Footnote References 105 BIBLIOGRAPHY . " • • • APPENDIX A Nursing U n i t A d m i n i s t r a t i o n Course APPENDIX B Interview Schedule . .' APPENDIX C Format f o r T a b u l a t i o n o f Data on Change . . . . APPENDIX D Kropp Verner A t t i t u d e S c a l e . . . . . APPENDIX E Learning LIST OF TAELES page I . Comparison o f background categories 52 I I . Comparison of background cate g o r i e s 53 < LIST OF FIGURES Page 1. D i s t r i b u t i o n o f the sample by m a r i t a l and p a r e n t a l s t a t u s . . . . 2k 2. Occupation of husbands on the B l i s h e n Occupational S c a l e 2k 3. D i s t r i b u t i o n o f m a r i t a l s t a t u s o f head nurses i n Canada, B r i t i s h Columbia and the present study . . . . 25 k. Age d i s t r i b u t i o n o f head nurses i n B r i t i s h Columbia and i n the present study 27 5- D i s t r i b u t i o n o f the sample on Chapin's S o c i a l P a r t i c i p a t i o n S c a l e 29 6. D i s t r i b u t i o n o f the sample by b a s i c academic education 30 7. D i s t r i b u t i o n o f the sample by post b a s i c n u r s i n g education 32 8. Post B a s i c n u r s i n g education o f head nurses i n Canada, i n Campion's study and i n the present study 33 9. D i s t r i b u t i o n o f the sample by years o f nursing experience . . 3& 10. D i s t r i b u t i o n o f the sample by years o f head nurse e x p e r i e n c e . . . . . . . . 36 11. D i s t r i b u t i o n o f the sample by s i z e o f employing agency . 37 12. D i s t r i b u t i o n o f the sample by s i z e o f n u r s i n g u n i t . . . 38 13. D i s t r i b u t i o n o f the sample by s i z e o f s t a f f 38 l h . D i s t r i b u t i o n o f the sample by r a t i n g on the Kropp Verner A t t i t u d e S c a l e kO 15. Years o f n u r s i n g experience r e l a t e d t o s i g n i f i c a n t background c a t e g o r i e s : age, and head nurse experience. . kl 16. M a r i t a l s t a t u s r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : post b a s i c n u r s i n g education, years o f head nurse experience and s i z e o f s t a f f k3 page 17• Age related to significant background categories: post basic nursing education and size of staff kh l 8 . Basic academic education related to significant background categories: marital status . . . . . . . . . 1+6 19- Post basic nursing education related to significant background categories: age and size of employing agency hB 20. Years of head nurse experience related to significant background categories: age, marital status, nursing experience and size of staff 21. Size of employing agency related to significant background categories: post basic nursing education . . 51 22. Change in behavior and change in knowledge, attitude and practice - . . . 67 23• Distribution of types of changes within overall change of behavior 68 2h. Change of behavior related to significant background categories: basic academic education and post basic nursing education . 72 25- Change in knowledge related to significant background categories: age, nursing experience and size of employing agency 75 26. Change in attitude related, to significant background categories : post basic nursing education and nursing experience 77 27- Change in practice related to significant background. categories: size of employing agency . . . . . . . . . 79 ACKNOWLEDGMENTS "No man i s an i s l a n d . . . . " This f a m i l i a r q u o t a t i o n o f John Donne i s always a p p l i c a b l e when one attempts a f o r a y i n t o u n f a m i l i a r t e r r i t o r y . The author i s indebted to the many head "nurses who co-operated so w i l l i n g l y and w i t h so much i n t e r e s t i n t h i s study; to t h e i r d i r e c t o r s o f n u r s i n g and su p e r v i s o r s who gave o f t h e i r time, -to arrange i n t e r v i e w s during on-duty hours; t o f e l l o w graduate students who were u n s t i n t i n g i n t h e i r comments, support and c o e r c i o n , as w e l l as i n t h e i r overwhelming advice and donations o f l i t e r a t u r e ; and to. many others at the U n i v e r s i t y and i n the h o s p i t a l s who donated e f f o r t and time t o speed t h i s paper t o completion. S p e c i a l thanks are due to my adviso r y committee, Dr. John Niemi, Dr. Leonard Marsh and Miss' E l i z a b e t h McCann, f o r t h e i r time and pa t i e n c e . . The author i s p a r t i c u l a r l y g r a t e f u l t o Dr. Hew Roberts f o r h i s u n f a i l i n g p o s i t i v e approach to l i f e ' s problems, and t o Mrs. Doris C h r i s t i a n f o r her perseverence i n the face o f a d v e r s i t y . L a s t but not l e a s t , t h i s t h e s i s was p o s s i b l e due t o the f o r -bearance o f my c h i l d r e n d u r i n g . i t s development and f r u i t i o n . CHAPTER I THE PROBLEM, THE RELEVANT RESEARCH, THE STUDY S o c i a l and Occupational Change As the s o c i a l i n s t i t u t i o n s o f our s o c i e t y have become i n c r e a s i n g l y b u r e a u c r a t i c , the need f o r personnel w i t h a d m i n i s t r a t i v e s k i l l s i n the management of people and production has in c r e a s e d . The production e x p l o s i o n of the Second World YJar demonstrated the r e s u l t s 1 of inadequate and inexperienced managerial personnel. I t a l s o demonstrated the e f f e c t s o f t r a i n i n g these people how to supervise and teach t h e i r subordinates. T r a i n i n g u s u a l l y r e s u l t e d i n increased p r o d u c t i o n and decreased turnover o f personnel i n both i n d u s t r y and business.. Nursing, l i k e many p r o f e s s i o n s , has undergone major changes i n the past t w e n t y - f i v e years. Some o f these changes have had i n t e r n a l causes, but many have been i n f l u e n c e d b y - t e c h n i c a l changes i n the medi c a l and paramedical f i e l d s . Although constant changes may make an occupation more i n t e r e s t i n g , they may a l s o c o n s t i t u t e a t h r e a t t o those w i t h f e e l i n g s o f inadequacy i n a s h i f t i n g s i t u a t i o n . Many problems and gene r a l unrest among nur s i n g personnel have been created, causing decreased q u a l i t y o f n u r s i n g s e r v i c e , h i g h turnover o f s t a f f , -References w i l l be c o l l e c t e d at the end o f each chapter. 2 and increased cost i n s t a f f replacement. Lack o f Leadership The graduate nurse has "been educated to g i v e d i r e c t p a t i e n t care r a t h e r than to assime a d m i n i s t r a t i v e d u t i e s and to d i r e c t the 2 work o f o t h e r s , such as are inherent i n the l e a d e r s h i p r o l e . Many-nurses have found themselves i n l e a d e r s h i p and s u p e r v i s o r y p o s i t i o n s w i t h the r e s u l t i n g c o n f l i c t s between'what they learned to do and what they were a c t u a l l y doing i n the everyday work s i t u a t i o n . 3 Approximately 23$ o f nurses i n Canadian gen e r a l h o s p i t a l s were i n p o s i t i o n s o f a s s i s t a n t head nurse or h i g h e r i n 1967-^ The number o f people r e q u i r e d f o r a d m i n i s t r a t i v e f u n c t i o n s has always exceeded the number a v a i l a b l e w i t h the necessary l e a d e r s h i p and s u p e r v i s o r y p r e p a r a t i o n . ^ Various n u r s i n g s t u d i e s have concluded t h a t t w e n t y - f i v e t o t h i r t y - t h r e e percent o f n u r s i n g p o s i t i o n s need as one requirement a baccalaureate or h i g h e r degree.^ Countdown I968 s t a t e d t h a t o f 120,000 r e g i s t e r e d nurses i n Canada i n 19^7} 5$ had a baccalaureate degree i n n u r s i n g , 0.4$ had a h i g h e r degree, 9$ had some c r e d i t s toward a baccalaureate degree, and 8$ had a u n i v e r s i t y diploma o r c e r t i f i c a t e i n nursing. 7 I n 1966, one study reported t h a t , o f one hundred head nurses, f o u r had a degree, twelve had a one year u n i v e r s i t y diploma course i n n u r s i n g , eleven had a h o s p i t a l c l i n i c a l course, and f o u r had completed 8 a correspondence course i n n u r s i n g u n i t a d m i n i s t r a t i o n . (Appendix A ) . I n I967, Mussallem s t a t e d t h a t there was "a c o l o s s a l waste o f n u r s i n g s k i l l s , " which she a t t r i b u t e d t o poor s u p e r v i s i o n and h i g h s t a f f turnover. Lack of preparation caused supervisory personnel uneasiness and f e e l i n g s of inadequacy, which often undermined the s e c u r i t y and confidence of t h e i r subordinates. Lack o f preparation also made t h e i r administrative functioning.inadequate i n many cases. One Canadian study on s t a f f turnover indicated that work load was the l a r g e s t s i n g l e s i g n i f i c a n t f a c t o r involved. The cost of r e p l a c i n g those who leave t h e i r positions involves money, e f f o r t , and time f o r the employing agency and f o r the employees who remain. One American study estimated the personnel processing cost of repla c i n g one 'general s t a f f nurse i n a general h o s p i t a l to be f i v e hundred d o l l a r s . " ^ Since there was an estimated 6l$• turnover rate f o r general s t a f f nurses i n Canada i n 196"7, the 12 implications of the American study are obvious. Turnover rates were l&fo f o r head nurses, iGffc f o r supervisors and 17$ f o r h o s p i t a l nursing d i r e c t o r s i n 1 9 6 6 . ^ The highest turnover of a l l nursing positions was greatest i n h o s p i t a l s o f over 300 beds.-*-*4" The Canadian Nurses Asso c i a t i o n outlined the factors involved i n job s a t i s f a c t i o n which, i t believed, would influence the high.rate o f turnover o f a l l nurses. 1-' These factors included o r i e n t a t i o n pro-cedures, administrative p o l i c i e s , personnel p o l i c i e s , i n s e r v i c e education, s t a f f organization, supervision and evaluation, the opportunity f o r advancement, p a r t i c i p a t i o n i n pr o f e s s i o n a l organizations, and fur t h e r education. A consideration of the q u a l i t y of these factors might a c t u a l l y decrease the turnover r a t e . C o n t i n u i n g Education f o r Nurses Both the Canadian and American Nursing A s s o c i a t i o n s have reported t h a t nurses are asking f o r c o n t i n u i n g education programs t o add to t h e i r , b a s i c knowledge and t o meet t h e i r developing needs Many o f these needs have a r i s e n through changing t e c h n i c a l knowledge, but many have a r i s e n through the promotion o f the nurse i n t o super-v i s o r y p o s i t i o n s f o r which she was not f u l l y prepared. Employing agencies have been i n t e r e s t e d i n updating t h e i r s t a f f members because improved knowledge has u s u a l l y improved the q u a l i t y o f p a t i e n t care. Most h o s p i t a l s have provided i n s e r v i c e education programs f o r v a r i o u s l e v e l s o f workers t o keep them up t o date w i t h changing p r a c t i c e s . A l s o , s t a f f members have u s u a l l y been encouraged t o attend whatever e d u c a t i o n a l courses are a v a i l a b l e . A l a r g e number o f short term t r a i n i n g courses, i n s t i t u t e s , and workshops have been conducted f o r nurses during the past t e n years i n both Canada and the United S t a t e s . No matter how good the b a s i c p r e p a r a t i o n o f the nurse may have been, such courses were considered necessary f o r her t o keep up w i t h current knowledge. Many short courses have been given i n a d m i n i s t r a t i v e and l e a d e r s h i p s u b j e c t s t o enable those without s u f f i c i e n t p r e p a r a t i o n f o r t h e i r p o s i t i o n s to f u n c t i o n more adequately. The courses were-considered stopgaps which would continue o n l y u n t i l enough p r o p e r l y prepared people became a v a i l a b l e . Baccalaureate programs are i n c r e a s i n g across Canada, and s e v e r a l u n i v e r s i t i e s now o f f e r Masters' programs. As graduates from these programs become more numerous, the need f o r s h o r t courses i n a d m i n i s t r a t i o n and l e a d e r s h i p may be expected to decrease except as r e f r e s h e r courses. In the United S t a t e s , over 10,000 nurses, or roughly 15$ o f those e l i g i b l e , attended 300 courses i n management t r a i n i n g between -1 Q i960 and 1963. A nu r s i n g u n i t a d m i n i s t r a t i o n correspondence course has been completed by over 1,500 Canadian head nurses and su p e r v i s o r s s i n c e i t s i n c e p t i o n i n 1960. 1 ^ A summary and e v a l u a t i o n o f t h i s course i s given i n Appendix A. R e c e n t l y the number o f a p p l i c a n t s has exceeded the enrollment c a p a c i t y o f the course. H e r e i n a f t e r t h i s course i s r e f e r r e d t o as the N.U.A. course. E v a l u a t i o n o f Continuing Education Many n u r s i n g and e d u c a t i o n a l groups across the country have i n s t i g a t e d programs o f management t r a i n i n g f o r key personnel i n P0 21 n u r s i n g . ' This has been done i n an e f f o r t to in c r e a s e the u t i l i z a t i o n o f a v a i l a b l e s t a f f through t h e i r improved e f f e c t i v e n e s s as a r e s u l t o f att e n d i n g such programs. From a p r a c t i c a l s t a n d p o i n t , the r e s u l t s have been d i s a p p o i n t i n g to researchers.as improved performance has not op always occurred subsequently. Nursing leaders have f e l t t h a t l i p s e r v i c e r a t h e r than changed performance has r e s u l t e d . ^ B e h a v i o r a l 2k r e s e a r c h e r s , however, regard any change f o l l o w i n g a program as progress. Cheek and Gruenfeld w r i t e , "While management development programs app a r e n t l y f a i l i n t h e i r manifest f u n c t i o n s , they serve a number o f e q u a l l y important l a t e n t f u n c t i o n s ."^ One o f these l a t e n t f u n c t i o n s was the changed.view o f themselves and t h e i r jobs which p a r t i c i p a n t s o f t e n had. With t h i s changed view, the p a r t i c i p a n t was l i k e l y to f u n c t i o n d i f f e r e n t l y on her r e t u r n t o her job , w i t h r e s u l t s which were l i k e l y to "be b e n e f i c i a l t o both h e r s e l f and her employing agency. A speaker at a conference on the p r o f e s s i o n a l nurse t r a i n e e -s h i p program s t a t e d , "There i s no known method of s t a t i s t i c a l l y measuring the q u a l i t y c o n t r i b u t e d by an educated s p i r i t as w e l l as an educated mind. Nor i s i t easy t o assay the i l l i m i t a b l e i n f l u e n c e o f l e a d e r s h i p . " 2 ^ S t u d i e s germaine to the e v a l u 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 a l experiences f o r nurses were reviewed, and are summarised below. The Utah Study. In i960, a r e g i o n a l c o n t i n u i n g education p r o j e c t was s t a r t e d at the U n i v e r s i t y o f Utah C o l l e g e o f Nursing to improve the s k i l l s o f nurses i n a d m i n i s t r a t i v e , s u p e r v i s o r y and teaching p o s i t i o n s . 2 * ^ S i x short conferences were h e l d over a two year p e r i o d w i t h t h i r t y o f the o r i g i n a l t h i r t y - f o u r p a r t i c i p a n t s completing the s e r i e s . The program "was designed t o make changes i n the d i r e c t i o n o f g r e a t e r understanding and more democratic a t t i t u d e s on the p a r t o f p a r t i c i p a n t s . " E v a l u a t i o n o f the program had as i t s o b j e c t i v e determination o f the extent t o which l e a r n i n g and/or a t t i t u d e change took place f o l l o w i n g the ed u c a t i o n a l experiences. The e v a l u a t i o n instruments used were: a) a s p e c i a l t r a i t check l i s t , b) the Helen B. Lenehan Inventory o f Nursing Routines, c) a Superordinate Interview S c a l e , d) a WICHE S u p e r v i s o r R a t i n g S c a l e , and e) a Subordinate R a t i n g S c a l e . The f i r s t two s c a l e s were dis c a r d e d because they were judged as not s e n s i t i v e enough. The l a s t three s c a l e s covered, t o d i f f e r e n t degrees, but g e n e r a l l y , the areas o f e f f i c i e n c y , competence, i n i t i a t i v e , s t r e s s , and 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 . Superordinate and/or subordinate r a t i n g s were obtained on a l l p a r t i c i -pants and on 23 c o n t r o l s u bjects by the same person both before and a f t e r the s e r i e s o f conferences, approximately two years apart. Of the conference p a r t i c i p a n t s , 30$ were evaluated by the superordinates and subordinates as needing l i t t l e o r no t r a i n i n g , and the other I^P were evaluated as needing t r a i n i n g to some extent i n a l l areas. The c o n t r o l group d i d not attend any of the conferences. The conclusions of the study were t h a t the conference p a r t i c i -pants improved w h i l e the c o n t r o l n o n - p a r t i c i p a n t s d i d not. The r e s u l t s were s t r o n g l y suggestive t h a t the conferences were r e s p o n s i b l e f o r the improvements. Of the instruments used, two were judged not s e n s i t i v e enough, one was questioned as being somewhat u n r e l i a b l e , and no s p e c i f i c comments were made concerning the o t h e r s . The WICHE Study. Under the aegis o f the Western I n t e r s t a t e Commission on Higher Education, e i g h t u n i v e r s i t y schools o f n u r s i n g i n P8 twelve western s t a t e s c a r r i e d out seven l e a d e r s h i p t r a i n i n g programs. Each t r a i n e e attended s i x one week conferences over a two year p e r i o d . The major o b j e c t i v e was t o a i d the p a r t i c i p a n t s i n becoming more e f f e c t i v e l e a d e r s , on the assumption t h a t e f f e c t i v e nurse leaders-create a c l i m a t e i n which h i g h q u a l i t y n u r s i n g care can be provided by t h e i r s t a f f s . Using new approaches to l e a r n i n g , i t was hoped t h a t 8 g r e a t e r group awareness and acceptance o f the need f o r change would develop. The aims o f a concurrent research p r o j e c t were to develop instruments f o r e v a l u a t i n g s e l e c t e d a t t i t u d i n a l and b e h a v i o r a l changes, to t e s t the r e l i a b i l i t y o f the instruments developed, and to determine the degree o f change r e s u l t i n g from p a r t i c i p a t i o n i n the c o n t i n u i n g education program. * An experimental group o f hlO nurse l e a d e r p a r t i c i p a n t s and a c o n t r o l group o f U50 nurse l e a d e r n o n - p a r t i c i p a n t s were compared on s e v e r a l research devices and instruments both before and a f t e r the two year program. Overt behavior was measured w i t h a s i t u a t i o n a l e x e r c i s e by three people, and by r a t i n g s c a l e s f o r on-the-job l e a d e r s h i p and i n t e r p e r s o n a l s k i l l by one s u p e r v i s o r and three subordinates. Both groups o f subjects a l s o completed : a) the Nahm Nurse Opinion Inventory, 0) the Todd Personnel R e l a t i o n s Test P a r t I and Pa r t I I . As w e l l as the above, the experimental group, h a l f way through the program, was giv e n a) the B i o g r a p h i c a l Inventory, b) the Re g i s t e r e d Nurse's S e l f D e s c r i p t i o n Scale,' and c) the R e g i s t e r e d Nurse's S a t i s f a c t o r y Achieve-- ment S c a l e . The research r e s u l t s i n d i c a t e d a change i n the d e s i r e d d i r e c t i o n o f expressed a t t i t u d e s and b e l i e f s r e garding l e a d e r s h i p and 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 . However, changes i n behavior to correspond w i t h the a t t i t u d i n a l changes were not c l e a r l y demonstrated. The authors agreed t h a t the p a r t i c i p a n t s had i d e n t i f i e d w i t h more democratic and understanding a t t i t u d e s , but t h a t the pressures o f the day-to-day work s i t u a t i o n were against change. As the seminars o r conferences were o n l y i n t e r r u p t i o n s i n the u s u a l p a t t e r n of work, i t was d i f f i c u l t to break through the b a r r i e r s o f apathy t o o b t a i n p e r s o n a l involvement and commitment. The r o l e s and r e l a t i o n s h i p s i n n u r s i n g have been very ambiguous, and become f u r t h e r complicated by the i n d i v i -dual nurse's p e r c e p t i o n o f her r e s p o n s i b i l i t y f o r n u r s i n g care. They concluded, however, t h a t any movement i n a p o s i t i v e d i r e c t i o n was progress. The r e p o r t s t a t e d t h a t the instruments developed were i n -adequate . The Texas Study. In 1958 an acute shortage o f nurses i n the S t a t e o f Texas p r e c i p i t a t e d a two year survey of nursing needs and r e s o u r c e s A p r o p o s a l f o r improving c o n d i t i o n s through "strengthening the s k i l l s o f those who are now r e s p o n s i b l e f o r d i r e c t i n g the n u r s i n g care o f p a t i e n t s " r e s u l t e d . 3 0 A Management S k i l l s T r a i n i n g Workshop f o r 'nurse managers' was set up, and i n i 9 6 0 three f i v e day workshops f o l l o w e d by a three day workshop were i n s t i g a t e d over a seventeen month p e r i o d f o r each nurse p a r t i c i p a t i n g . During the f o u r years o f the p r o j e c t , 1 , 7 0 0 nurses, or 2 8 $ of those e l i g i b l e , took p a r t . 3 1 The assumptions u n d e r l y i n g the program were t h a t t r a i n i n g based on changing a t t i t u d e s would l e a d t o changes of behavior, as changing a t t i t u d e s and values are p a r t of o c c u p a t i o n a l s o c i a l i z a t i o n . O ccupational s o c i a l i z a t i o n was d e f i n e d as "a process by which i n d i v i d u a l s s e l e c t i v e l y acquire the s k i l l , knowledge, a t t i t u d e s , v a l u e s , and motives current i n the groups o f which they are, or w i l l become, members."^ The r e p o r t explained t h a t those changing t h e i r o c c u p a t i o n a l 10 r o l e , from bedside n u r s i n g to the s u p e r v i s i o n o f others doing the bedside n u r s i n g , needed to change t h e i r value systems to those o f the work group which they had j o i n e d . The research p r o j e c t method was to gather i n f o r m a t i o n regarding short and long term e f f e c t s o f the program on the p a r t i c i p a n t s and on t h e i r employing agencies. During the t r a i n i n g program, s i x m u l t i - i t e m instruments were used a t v a r i o u s stages. Two were devised s p e c i f i c a l l y f o r measuring i n f o r m a t i o n i n t h i s study, and f o u r were modif i e d from a t t i t u d e s c a l e s developed f o r o t h e r s t u d i e s . The f i r s t i n f o r m a t i o n t e s t was con-s t r u c t e d by the p r o j e c t members but discarded l a t e r , as seven o f the o r i g i n a l f i f t e e n items were judged not d i s c r i m i n a t o r y enough. The second i n f o r m a t i o n t e s t was developed from an a n a l y s i s o f t r a i n i n g p u b l i c a t i o n s and c o n s i s t e d o f 26 items, o f which 1J were found to be s u f f i c i e n t l y d i s c r i m i n a t o r y . The fou r a t t i t u d e s c a l e s were a) the democracy s c a l e , b) the f u n c t i o n a l o r i e n t a t i o n s c a l e , and c) the c o n s i d e r a t i o n and i n i t i a t i n g s t r u c t u r e s c a l e s . The instruments were considered r e l a t i v e l y r e l i a b l e as the c o e f f i c i e n t s r e p o r t e d were com-parable to those reported f o r s i m i l a r s h o r t t e s t s . The study r e v e a l e d a change i n knowledge f o r a l l p a r t i c i -p a n t s , ^ and a change o f a t t i t u d e toward more democratic and f u n c t i o n a l o r i e n t a t i o n s f o r most p a r t i c i p a n t s . These a t t i t u d e s tended to p e r s i s t Ik and i n the p r e d i c t e d d i r e c t i o n . - ' Performance e v a l u a t i o n , o r a change i n p r a c t i c e , was determined through three d i f f e r e n t types o f s p e c i a l sub-studies. These were, e s s e n t i a l l y , a) a P r o f i c i e n c y R a t i n g System used i n the Veterans 11 A d m i n i s t r a t i o n h o s p i t a l s (80 p a r t i c i p a n t s ) , h) the Nurse Management-performance Instrument used i n 8 h o s p i t a l s (hi p a r t i c i p a n t s ) , and c) an i n t e r v i e w and q u e s t i o n a i r e used i n s i x h o s p i t a l s ( l l p a r t i c i -pants) . F o r the l a s t performance e v a l u a t i o n sub-study, c o n t r o l "cases" were matched w i t h the experimental "cases." These "cases" each i n -cluded the p a r t i c i p a n t , one s u p e r v i s o r and two subordinates. The number o f persons given above were those f o l l o w e d throughout the study. Because of t e c h n i c a l d i f f i c u l t i e s , the o r i g i n a l i nterviewees were reduced to these numbers and the samples were not considered as random s e l e c t i o n s o f conference p a r t i c i p a n t s . The attainment o f a t t i t u d e change occurred i n the f i r s t performance e v a l u a t i o n sub-study but there was l i t t l e evidence o f performance change. The second sub-study reported performance im-provement at the lowest l e v e l o f conventional confidence. This group showed s i g n i f i c a n t but low c o r r e l a t i o n s between changed a t t i t u d e s and changed performance. The t h i r d sub-study d i d not prove t h a t improvement occurred, but d i d r e v e a l t h a t the s o c i a l s t r u c t u r e s o f the work group can impede or permit changes and t h a t there was l i t t l e evidence t h a t experimental "cases" would change t h e i r performance more than the c o n t r o l "cases." The r e s u l t s tended t o both support and negate the expected performance change. The r e p o r t then s t a t e d t h a t e v a l u a t i o n o f change and a c t u a l change could be c o n t r a d i c t o r y . In support o f t h i s the authors examined s e l f r e p o r t s o f performance change and r e p o r t s o f changes i n the employing agencies o f the p a r t i c i p a n t s . S e l f r e p o r t s o f performance 12 change v a r i e d from none to many, w i t h areas o f change d i f f e r e n t from those a n t i c i p a t e d . Performance improvement was e v i d e n t l y not g e n e r a l , hut i n s p e c i f i c areas which had been given low p r i o r i t i e s on the o r i g i n a l assessment. Agency changes were reported by over h a l f the d i r e c t o r s employing p a r t i c i p a n t s as e i t h e r new p r a c t i c e s b e i n g i n -s t i t u t e d or e x i s t i n g p r a c t i c e s b e i n g Improved. I n one way or another, a change i n performance occurred f o r most p a r t i c i p a n t s , although the authors s t a t e d t h a t those who were pleased w i t h the conferences may have had i n f l a t e d ideas of the amount of change which a c t u a l l y occurred .35;3^ I n the conclusions o f the study the authors discussed the c o n t r o v e r s i e s which e x i s t over which c r i t e r i a may be accepted as i n d i c a t i v e o f success, and over the l e v e l o f attainment o f these 37 c r i t e r i a b e fore the outcome i s judged as s u c c e s s f u l . 1 From a s o c i a l r e s e a r c h ^ viewpoint, the program was s u c c e s s f u l , determined from both attendance o f i n i t i a l p a r t i c i p a n t s , and t h e i r degree o f s a t i s f a c t i o n w i t h the program. The l a t t e r v a r i e d depending upon the education and experience o f the p a r t i c i p a n t s . The f i n a l statement o f the study i s This r e p o r t has shown c l e a r l y t h a t i t is_ d i f f i c u l t to demonstrate t h a t a management-training program has achieved i t s o b j e c t i v e s , t h a t the t r a i l o f cause and e f f e c t is_ hard to f o l l o w , t h a t c r i t e r i a are hard t o s e l e c t and measure, and t h a t judgment is_ an e s s e n t i a l part-of the process.39 Relevance o f the Present Study -The previous s t u d i e s were concerned w i t h courses o r conferences w h i l e the present study i s concerned w i t h an i n s t i t u t e . 13 An i n s t i t u t e , i n c o n t i n u i n g education terminology on t h i s c o n t i n e n t , i s a one t o three day program o f l e c t u r e s o r p r e s e n t a t i o n s , a l t e r n a t e d w i t h group d i s c u s s i o n s . ^ I n the in e x a c t terminology o f c o n t i n u i n g education, the i n s t i t u t e can a l s o be described as a study-conference, r e f r e s h e r - c o n f e r e n c e , o r short s c h o o l . The p a r t i c i p a n t s u s u a l l y have . a common o c c u p a t i o n a l o r p r o f e s s i o n a l background and gather to add new i n f o r m a t i o n to t h e i r b a s i c knowledge o f a p a r t i c u l a r aspect o f t h e i r f i e l d . I n s t i t u t e s are described as most advantageous f o r the a c q u i s i t i o n o f knowledge r a t h e r than f o r p r a c t i c i n g o r ap p l y i n g i t . Those a t t e n d i n g the i n s t i t u t e s under study h e l d a s s i s t a n t head nurse p o s i t i o n s o r higher i n t h e i r employing agencies. Geitgey d e s c r i b e d a head nurse as the immediate s u p e r v i s o r o f an i n d i v i d u a l ward or c l i n i c a l area. Her s u p e r v i s o r y and e d u c a t i o n a l e f f o r t s are d i r e c t e d t o the gr e a t e r e f f i c i e n c y and b e t t e r performance o f her s t a f f members f o r the improvement o f the n u r s i n g care o f the p a t i e n t s i n her area. The s u p e r v i s i o n and e v a l u a t i o n o f personnel was the su b j e c t of the i n s t i t u t e s . This aspect o f a d m i n i s t r a t i o n has o f t e n been a source o f a n x i e t y , c o n f l i c t , and confusion t o many i n s u p e r v i s o r y p o s i t i o n s , but e s p e c i a l l y t o those without p r e p a r a t i o n because they have not understood the r a t i o n a l e and i m p l i c a t i o n s o f the processes i n v o l v e d . ^ 7 This study was an approach t o the e v a l u a t i o n o f an i n s t i t u t e as an e d u c a t i o n a l experience i n the co n t i n u i n g education o f a sample o f the p a r t i c i p a n t s . The reader w i l l observe t h a t none o f the s t u d i e s Ih reviewed were concerned w i t h an e d u c a t i o n a l experience as i n t e n s i v e as t h i s two day i n s t i t u t e . Purpose and Scope of the Study The purposes o f the present study were: l ) t o evaluate an i n s t i t u t e as an e f f e c t i v e t o o l i n c o n t i n u i n g education f o r nurses, and 2) to s u b j e c t a method of e v a l u a t i o n t o c r i t i c a l a n a l y s i s . E v a l u a t i o n o f the i n s t i t u t e was attempted through l ) a s u b j e c t i v e e v a l u a t i o n by the s e l e c t e d sample o f t h e i r p e r c e p t i o n o f change i n t h e i r own behavior f o l l o w i n g p a r t i c i p a t i o n i n the i n s t i t u t e ; 2) an a n a l y s i s o f perceived change i n knowledge, a t t i t u d e , p r a c t i c e , o r a combination o f these, and 3) an examination of whether d i f f e r e n c e s i n perceived changes were r e l a t e d to d i f f e r e n c e s i n e d u c a t i o n a l and e x p e r i e n t i a l background (g e n e r a l and p r o f e s s i o n a l ) . • • P r o v i s i o n f o r i n c r e a s i n g knowledge and f o r modifying a t t i t u d e s can be i n c l u d e d i n a w e l l designed two day i n s t i t u t e . I nformation about improving p r a c t i c e can be provided, but p r o v i s i o n s f o r a p p l i c a t i o n cannot. The i n s t i t u t e under study was t h e r e f o r e subjected to an o b s e r v a t i o n a l a n a l y s i s i n terms o f knowledge, a t t i t u d e , and relevance t o p r a c t i c e . Summary mention o f the governing f a c t o r s i n t h i s a n a l y s i s i s given i n Chapter I I I . As the a n a l y s i s i s based on the b e h a v i o r a l concept of l e a r n i n g , a review of the l i t e r a t u r e on l e a r n i n g and the f a c t o r s i n f l u e n c i n g i t can be found i n Appendix E. As the m o t i v a t i o n f o r continued l e a r n i n g , and employment I t s e l f , may be conditioned by socioeconomic f a c t o r s such as the need to earn 15 money, a secondary .exploration o f the c o r r e l a t i o n between expressed opinions and s e l e c t e d socioeconomic aspects o f the p a r t i c i p a n t s was undertaken. . The study was e x p l o r a t o r y i n th a t the methodology and r e s u l t s might c o n t r i b u t e to f u r t h e r s t u d i e s i n e v a l u a t i o n from which c o n c e i v a b l y a p p r o p r i a t e instruments and techniques f o r o b j e c t i v e measurement may be developed i n the f u t u r e . The sample used f o r the study was randomly s e l e c t e d from a p o p u l a t i o n c o n s i s t i n g o f those r e g i s t e r e d nurses a t t e n d i n g the i n s t i t u t e who l i v e d w i t h i n a c e r t a i n geographic area. Each nurse was i n t e r v i e w e d i n d i v i d u a l l y by the author, u s u a l l y at the nurse's p l a c e o f work. The i n t e r v i e w s were h e l d over a s i x week p e r i o d s t a r t i n g approximately three months a f t e r completion o f the i n s t i t u t e s The i n t e r v i e w used i n t h i s study c o n s i s t e d o f a) formal questions concerned w i t h socioeconomic and demographic data about the i n d i v i d u a l , and b) a d i s c u s s i o n t o e l i c i t those changes o f behavior perceived by the person as o c c u r r i n g because she had attended one o f the i n s t i t u t e s . L i m i t a t i o n s o f the Study This study was concerned o n l y w i t h the interviewee's p e r c e p t i o n o f any change i n her behavior because she attended the i n s t i t u t e . As w i t h any s u b j e c t i v e study, t h i s one was l i m i t e d by the s u b j e c t i v e a t t r i b u t e s o f the interviewees r e g a r d i n g t h e i r per-c e p t i o n o f t h e i r own behavior, and the impressions o f the i n t e r v i e w e r r e g a r d i n g these statements. Changes may or may not have occurred, although the interviewee may have f e l t t h a t she should show a p o s i t i v e a p p r e c i a t i o n o f the i n s t i t u t e as she had been chosen i n the 16 i n t e r v i e w sample. I n t e r v i e w e r - i n t e r v i e w e e i n t e r a c t i o n could a l s o have a f f e c t e d the outcome o f the study, p a r t i c u l a r l y when the r e c o r d i n g and measurement o f changed behavior was dependent upon un s t r u c t u r e d i n t e r v i e w s . • There was no way of predetermining the composition o f the po p u l a t i o n o r o f p r e t e s t i n g the i n d i v i d u a l ' s unique procedures o f e v a l u a t i n g s t a f f performance before the i n s t i t u t e . I n any event, no standard measures o f s t a f f performance e v a l u a t i o n techniques have yet been e s t a b l i s h e d . . 5 0 >51> 52,53 Apart from p r a c t i c a l d i f f i c u l t i e s , t h e re i s a t h e o r e t i c a l b a s i s f o r the avoidance o f p r e t e s t s o r b a s e l i n e t e s t s i n s t u d i e s o f s u b j e c t i v e e v a l u a t i o n s as d i s t i n c t from o b j e c t i v e measurement o f newly acquired knowledge. When the respondents are aware o f what i s expected, the h a l o e f f e c t i s more i n evidence than would otherwise be the case. 5^ The sample could have been a f f e c t e d p o s i t i v e l y o r n e g a t i v e l y by those respondents who were j u s t completing the N.U.A. course (Appendix A). This was not known before the i n t e r v i e w s . The popu-l a t i o n from which the sample was s e l e c t e d , although g e o g r a p h i c a l l y , l i m i t e d , proved t o be c h a r a c t e r i s t i c o f the p o p u l a t i o n and the pro-f e s s i o n i n major socioeconomic f a c t o r s . The sample, i n c l u d i n g the socioeconomic and demographic i n f o r m a t i o n gathered d u r i n g the i n t e r v i e w s , i s the s u b j e c t o f the next chapter. 17 Footnote References 1 . Marting, E. MA Encyclopedia of Supervisory Training. New York.. Aner ican Management Association. 1 9 6 1 . p. i i i . 2 . Western Interstate Commission for Higher Education. The Effectiveness of a Leadership Program in Nursing. Iknilder, Colorado. 1 9 6 7 . ~ 3 . Arndt, C. Administrative factors in nursing that may inhibit job effectiveness. Journal of Nursing Education. January, I 9 6 8 . 7:33-i-M. k. Canadian Nurses Association. Countdown 1 9 6 8 . Ottawa. 1 9 6 8 . p. 2 6 . 5 . Miller, M.A. Inservice Education for Hospital Nursing Personnel. Department of Hospital Nursing. National League of Nursing. 1 9 5 8 . 6 . Mussallem, H.K. No Lack of Nurses - but a.Shortage of Nursing.. International Nursing Review. I 9 6 8 . 1 5 ( l ) : 3 5 ~ ^ 9 • 7- Canadian Nurses Association, op_. c i t . , p. 1 1 . 8- -. Campion, F.L. A Report on the Project for the Evaluation of the Quality of-Nursing Service. Ottawa. Canadian Nurses As sociation. i960! ' 9> Mussallem, op_. c i t • 1 0 . Dodge, J.S. Why Nurses Leave and What to Do About It. Modern Hospital, i 9 6 0 . 9^(5) : 1 1 6 - 1 2 0 . 1 1 . Melbin, M. and D.L. Taub. The High Cost of Replacing a Nurse. Hospitals. October, 1 9 6 6 . ^ 0 : 1 1 2 - 1 2 2 . 1 2 . Canadian Nurses Association. op_. c i t . , p. 3 ^ -1 3 . Ibid. lU. Ibid. 1 5 . Canadian Nurses Association. Toward Improved Job Satisfaction -A Guide for Employing Agencies. Ottawa. Committee on Nursing Service, i 9 6 0 . 1 6 . I b i d . 18 IT- American. Nurses A s s o c i a t i o n . Avenues f o r Continued Learning. New York. 1967. 18. United S t a t e s Department o f H e a l t h , Education and Welfare. Nurses f o r Leadership. Washington, D.C. P u b l i c H ealth P u b l i c a t i o n 1098. 1963. 19. G o l d f a r b , M. E v a l u a t i o n o f the Extension Course i n Nursing U n i t A d m i n i s t r a t i o n . Canadian Nurse. 1966. 62:59-61. 20. United S t a t e s Department o f H e a l t h , Education and Welfare, op_. c i t . 21. G o l d f a r b , op_. c i t . 22. McLemore, S.E. and R.J. H i l l . Management-training E f f e c t i v e n e s s -A Study o f Nurse Managers. A u s t i n , Texas, Univ. o f Texas, I965. Chapter k. 23- Ruane, K. Pers o n a l Communication. October, 1968. 2h. McLemore, op_. c i t . , p. 12. 25> Cheek, N.H. and L.W. Gruenfeld. A New Look at Management T r a i n i n g . T r a n s a c t i o n . June, 1965- 2:3^-36. 26. United S t a t e s Department o f H e a l t h , Education and Welfare. op_. ' c i t . 27- S e s s i o n s , F. and G.E. V a n S a n t . E v a l u a t i o n s o f Regional C o n t i n u a t i o n E d u c a t i o n a l Conferences. Nursing Research. Winter, 1966. 15:75-79. 28. Western I n t e r s t a t e Commission f o r Higher Education. The E f f e c t i v e n e s s o f a Leadership Program i n Nursing. Boulder, Colorado, 1967. 29- Haskins, D. e t . a l . Survey o f Nursing Needs and Resources i n Texas. Washington, D.C. U.S. Department o f H e a l t h , Education and Welfare. P u b l i c H ealth S e r v i c e . 1958. 30. Haskins, D. e t . a l . A Proposal f o r the Improvement o f Nursing Care' o f P a t i e n t s i n Texas by I n c r e a s i n g the Management S k i l l s o f Key Personnel i n the Nursing S e r v i c e . Texas League f o r Nursing Ne w s l e t t e r. . August, i 9 6 0 . 31. McLemore, op_. c i t . , Chapter 1. 32. S e w e l l , W-H. Some recent Developments i n S o c i a l i z a t i o n Theory and Research. The Annals o f the American Academy o f P o l i t i c a l and S o c i a l S c i e n c e . September, 1963. 349:163-184. 19 33- McLemore, op. c i t . , Chapter 4. . 34. McLemore, op. c i t . , Chapter 5. 35- McLemore, op. c i t . , P- 123-36. McLemore, op. c i t . , P- 136. 37- McLemore, op. c i t . , Chapter 8. 38- I n t h i s paper, " s o c i a l research i n the Texas study, i . e . , 39- McLemore, on. c i t . , p. -151. kO. A d u l t Education A s s o c i a t i o n o f the U.S.A. Conducting Workshops and I n s t i t u t e s . Chicago. 1956. p. 3« kl. Dalhousie U n i v e r s i t y School o f Nursing. I n s t i t u t e on S t a f f Education. H a l i f a x . 196!+. 1+2. Bergevin, P.' et a l . Adult Education Procedures. Greenwich, Conn. Seahury. 196*3 • P- 223-k3. Morgan, B. et a l . Methods i n Adult Education. D a n v i l l e , 111. I n t e r s t a t e . I963• p. 57-s kk. Munger, P.F. e t a l . Guidance I n s t i t u t e s and the P e r s i s t e n c e o f A t t i t u d e s . Personnel Guidance J o u r n a l . I963. 41:1+15-419.' 45. Although those who attended the i n s t i t u t e s were both genera], and p s y c h i a t r i c nurses, o n l y those p a r t i c i p a n t s who were r e g i s t e r e d nurses i n the Province o f B r i t i s h Columbia were considered i n the p o p u l a t i o n o f t h i s study. 46. Geitgey, D.A. A Handbook f o r Head Nurses. P h i l a d e l p h i a . D a v i s . 1961. p..3. 47. Bar abas, M.H. Contemporary Head Nursing. New York. M a c M i l l a n . 1962. p. 32. 48. B a r r e t t , J . Ward. Management and Teaching. New York. Apple ton, Century, C r o f t s . 1949. p. 47. 49. Gorham, W.A. Methods o f Measuring S t a f f Nursing Performance. Nursing Research. I963. 1 2(l):4 - 1 1 . 50. Tate, B.L. E v a l u a t i o n o f C l i n i c a l Performance o f the S t a f f Nurse. Nursing Research. I962. 11:7-9. 20 51. Tate, B.L. A Method for Rating the Proficiency of the Hospital Staff Nurse. New York. National League of Nursing. l$6k 52. Tate, B.L. Test of a Nursing Performance Evaluation Instrument New York"! National League of N u r s i n g . 1 9 6 k . 53 • Gorham, op_. c i t . 5)4. McLemore, op_. ext., p. 123.. CHAPTER I I A DESCRIPTION OF THE SAMPLE The P o p u l a t i o n and.the Sample A two day i n s t i t u t e on "The E v a l u a t i o n o f Personnel" was h e l d twice i n Vancouver, B. C , i n March 1968. • I t was conducted hy Miss K. Ruane o f Winnipeg, under the sponsorship o f the R e g i s t e r e d Nurses A s s o c i a t i o n of B r i t i s h Columbia, and the Department o f Continuing M e d i c a l Education, U n i v e r s i t y o f B r i t i s h Columbia. There were 242 r e g i s t e r e d nurses p a r t i c i p a t i n g i n these i n s t i t u t e s , a l l of whom were employed as a s s i s t a n t head nurses o r h i g h e r . The p o p u l a t i o n f o r the study c o n s i s t e d of those l i v i n g w i t h i n a one-hundred m i l e d r i v i n g radius o f Vancouver, B.C., and was chosen f o r easy a c c e s s i b i l i t y f o r i n t e r v i e w s . The r e s u l t i n g number o f r e g i s t e r e d nurses was 189. From t h i s p o p u l a t i o n of 189, a 35$ sample was chosen from random number t a b l e s , 1 using a l p h a b e t i c a l l y l i s t e d names of p a r t i c i p a n t s . This sample l i s t i n c l u d e d a 25$ study sample and a 10$ a l t e r n a t e l i s t . As the i n t e r v i e w s were h e l d during the summer months when vacations occur, i t was a n t i c i p a t e d t h a t some of the sample might be u n a v a i l a b l e . The f i n a l sample i n c l u d e d o n l y two from the a l t e r n a t e l i s t to replace two who had l e f t B r i t i s h Columbia s i n c e the i n s t i t u t e . Background data were gathered'in order t h a t d i f f e r e n c e s among 22 those comprising the study sample might be i d e n t i f i e d . A s t r u c t u r e d i n t e r v i e w schedule was designed to seek the f o l l o w i n g f a c t s : m a r i t a l s t a t u s , i n c l u d i n g the husband's occupation 3 and p a r e n t a l s t a t u s o f those m a r r i e d ; age; income; s o c i a l p a r t i c i p a t i o n r a t i n g ; b a s i c academic education; non-nursing education; l o c a t i o n o f s c h o o l o f n u r s i n g a s s o c i a t e d w i t h b a s i c n u r s i n g education; year o f graduation; ' type o f h o s p i t a l a s s o c i a t e d w i t h s c h o o l o f n u r s i n g ; amount and type o f post b a s i c n u r s i n g education; years o f n u r s i n g experience; years o f head nurse experience; s i z e o f employing agency; type of n u r s i n g u n i t ; s i z e o f n u r s i n g u n i t ; s i z e o f s t a f f ; and p e r c e p t i o n o f t h e - i n s t i t u t e . ^ The r e s u l t i n g i n t e r v i e w schedule i s i n Appendix B. From the answers t o t h i s schedule obtained during the p i l o t study (discussed i n Chapter III), i t was decided t h a t the questions were s u i t a b l e f o r use as an instrument without change. C h a r a c t e r i s t i c s o f the Sample The data i n t h i s s e c t i o n were derived from the i n t e r v i e w schedule, recorded on punch cards and t a b u l a t e d . This was l a t e r v e r i f i e d by u n i v a r i a t e t a b u l a t i o n s on a computer. The answers to each q u e s t i o n regarding background c h a r a c t e r i s t i c s were combined i n v a r i o u s ways t o s i m p l i f y p r e s e n t a t i o n o f the data. E i t h e r the median s c a l e value or the combination which gave the most s i g n i f i c a n t s t a t i s t i c a l d i f f e r e n c e s i n l a t e r comparisons was used. The data i s presented i n percentages f o r c l a r i t y . Unless otherwise s p e c i f i c a l l y s t a t e d , percentages are o f the t o t a l sample throughout the study. 23 Marital status. The sample vas almost equally divided between those who were married (49$) and those who were single (42$) or widowed (9$) • Of those who were married, 59$ bad one or more children. (Figure l ) Of the Canadian head nurses working in hospitals in 1967, 55$ were married, 41$ were single, and 4$ reported another marital status. Of the 653 registered nurses in British Columbia employed as head nurses or assistants i n ¥~}&J, 5^ $ were married, 32$ were, single, and 14$ reported another status.^ Figure 3 shows the marital status of these three groups. As there is no s t a t i s t i c a l l y significant difference, this'comparison can be interpreted to mean that the sample is relatively representative of head nurses in Canada and in British Columbia in marital status. Occupation of husbands. Blishen designed an occupational scale for workers based on socioeconomic and demographic data acquired 8 from census information. This scale ranks occupations from Class 1 for the professional group, to Class 7 for the unskilled laborer. The greater the s k i l l required by an occupation, the higher its prestige, and the higher the social position of those in this occupation. According to this scale, almost a third of Canada's working population is in Class 5> which includes many skilled and semi-skilled trades. Graduate nurses are in Class 2. The occupations of husbands of the married respondents ranged from Class 2 to Class 7> with a median category of Class 4. (Figure 2) This category is below that of nurses .but above that of the general Canadian population. Twenty-seven percent 2k 20 — f -ho 6.0 —1._ 80 —«-•• 100 M M ES3 married s i n g l e widowed i j i l one or more F f f l - L L _ J J _ , J J c h i l d r e n F i g . 1. D i s t r i b u t i o n o f the sample by m a r i t a l .and p a r e n t a l s t a t u s . . . C l a s s 2 C l a s s 3. Cla s s 1+ | Cl a s s 5 Cla s s 6 C l a s s 7 R e t i r e d F i g . . 2. Occupation o f husbands on the B l i s h e n Occupational S c a l e . 2 5 $ 0 - 2 P — • Mo 60 80 100 Canada B r i t i s h Columbia Present Study — 1 H i —? Married S i n g l e Other status F i g . 3- D i s t r i b u t i o n of m a r i t a l s t a t u s o f head nurses i n Cano,da, B r i t i s h Columbia and the present study. 26 o f the husbands were i n the same o c c u p a t i o n a l c l a s s as t h e i r wives. Age_. The age d i s t r i b u t i o n o f the sample ranged from one respondent under 25 years t o three over 60 years, w i t h the median category b e i n g 1+5 t o 49 years. Of the sample, 5^ $ were 45 years o f age o r over. The age d i s t r i b u t i o n o f head nurses i n B r i t i s h Columbia i n 1967 ranged from l e s s than lfo under 25 years to 7$ over 65 years o f age, w i t h the' median category being between 45 and 49 years.^ F i g u r e 4 d e p i c t s the age d i s t r i b u t i o n o f the p r o v i n c i a l head nurses w i t h those i n the present study."" As there i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the two groups, the sample i s r e l a t i v e l y r e p resent-a t i v e o f B r i t i s h Columbia head nurses w i t h regard to age d i s t r i b u t i o n . Income. The gross annual income ranged from $5,000 to $8,999* w i t h 80$ r e c e i v i n g between $6,000 and $6,999 a n n u a l l y . When the annual incomes o f the respondents i n the study are compared t o the s t a t i s t i c s f o r annual incomes f o r nurses i n Canada and B r i t i s h Columbia, those i n the study are average. As the B r i t i s h Columbia f i g u r e s were a l i t t l e h i g h e r (about $300 a year) than the Canadian f i g u r e s , these nurses w i l l now be w e l l above the Canadian average income as c o n t r a c t changes i n B r i t i s h Columbia i n 1968 r a i s e d the b a s i c annual income "by almost $1,500. S o c i a l P a r t i c i p a t i o n . Chapin's S o c i a l P a r t i c i p a t i o n S c a l e measures the degree o f a person's p a r t i c i p a t i o n i n community groups and i n s t i t u t i o n s . 1 1 The extent o f p a r t i c i p a t i o n i s measured by the number 27 *8 0 20 ho 6o 8o —h 100 B r i t i s h Columbia Present Study i+5 o r more years l e s s than years F i g . h. Age d i s t r i b u t i o n o f head nurses i n B r i t i s h Columbia and i n the present s tudy. 28 o f memberships h e l d during the previous year, and the i n t e n s i t y o r degree o f involvement i s measured by attendance at meetings, f i n a n c i a l c o n t r i b u t i o n , committee memberships, and the h o l d i n g o f o f f i c e s . Each o f the component parts counts toward a r a t i n g on Chapin's S c a l e . The higher the r a t i n g , the g r e a t e r the s o c i a l p a r t i c i p a t i o n o f the person. The scores i n the present study ranged from three t o over t h i r t y - f i v e , w i t h an average o f s i x t e e n . ( F i g u r e 5) Chapin s t a t e s t h a t the average score f o r p r o f e s s i o n a l and managerial o c c u p a t i o n a l groups i s 20, o r four p o i n t s above the study average. E a s i c Academic Education. Seven percent o f the sample com-p l e t e d two or more years o f u n i v e r s i t y education, 22$ completed f i r s t year u n i v e r s i t y , 6!+$ graduated from hi g h s c h o o l and 7$ did. not f i n i s h h i g h s c h o o l . ( F i g u r e 6) B a s i c academic education f o r those e n t e r i n g a program o f p r o f e s s i o n a l n u r s i n g education i s c o n t r o l l e d by law i n a l l Canadian p r o v i n c e s , and r e q u i r e s a s a t i s f a c t o r y standing i n c e r t a i n h i g h s c h o o l programs. Those i n the sample w i t h l e s s than h i g h s c h o o l graduation entered schools o f nur s i n g before 1935 > when amendments to re q u i r e d e d u c a t i o n a l standards were made t o the Re g i s t e r e d Nurses Act. o f B r i t i s h Columbia, o r i g i n a l l y passed i n 1918. Non-nursing Education. Eleven percent o f the respondents had taken business o r s e c r e t a r i a l t r a i n i n g , and 16$ had t r a i n i n g i n areas other than n u r s i n g f o l l o w i n g t h e i r b a s i c academic education. S i x t y - f o u r percent had taken noncredit c o n t i n u i n g education courses during the past f i v e years and 87$ hoped to do so i n the f u t u r e . 2 9 to - i 3 0 -2 0 10 llli rm Score of 0 - 1 0 Score of 1 1 - 2 0 Score of over 2 0 1! i l l ! i i i p l l i i i —! F i g . 5- D i s t r i b u t i o n o f the sample on Chapin's S o c i a l P a r t i c i p a t i o n S c a l e . 30 $ o 2.0 ho So So 100 _ ,—,. _ 3 or more years u n i v e r s i t y 2 years u n i v e r s i t y 1 year u n i v e r s i t y h i g h s c h o o l graduation some h i g h school F i g . 6. D i s t r i b u t i o n o f the sample by b a s i c academic education. 31 B a s i c Nursing Education. Forty-seven percent o f the r e -spondents graduated from schools of n u r s i n g i n B r i t i s h Columbia, 40$ i n other parts o f Canada, and 13$ i n Great B r i t a i n . There were no graduates from other c o u n t r i e s represented. The years o f graduation ranged from 1930 t o 1967, w i t h 2 4 $ graduating before 1940, 33$ between 1940 and 1949, 24$ between 1950 and 1959, and 18$ s i n c e i960. A l l respondents graduated from g e n e r a l h o s p i t a l schools o f n u r s i n g . Post B a s i c Nursing Education. T h i r t y - e i g h t percent o f the respondents had no post b a s i c n u r s i n g education, 31$ had completed the n u r s i n g u n i t a d m i n i s t r a t i o n course (Appendix A), 11$ had completed a post graduate h o s p i t a l c l i n i c a l course, and 18$ had at l e a s t one year of u n i v e r s i t y n u r s i n g education. Only one respondent (2$) had a baccalaureate degree i n n u r s i n g . ( F i g u r e 7) A comparison o f head nurses w i t h and without at l e a s t one year of post b a s i c u n i v e r s i t y n u r s i n g education was made between Canadian s t a t i s t i c s as l i s t e d i n Countdown,"^ Campion's S t u d y , ^ and the present study. ( F i g u r e 8) This comparison showed t h a t 12$ o f Canadian head nurses, 16$ o f Campion's respondents and 20$ o f the present sample had one or more years of post b a s i c u n i v e r s i t y n u r s i n g education. As the d i f f e r e n c e s were not s i g n i f i c a n t , the study sample was r e l a t i v e l y r e p r e s e n t a t i v e o f Canadian head nurses, and comparacle to the respondents i n Campion's study regarding post b a s i c u n i v e r s i t y n u r s i n g education. Campion's s t u d y ^ o f n u r s i n g i n Canada provided an i n t e r e s t i n g ' 32 20 ho 6.0 8.0 — f ~ 100 Nursing degree, U n i v e r s i t y diploma. H o s p i t a l c l i n i c a l course N.U.A. course. None. F i g . 7- D i s t r i b u t i o n of the sample by post b a s i c n u r s i n g education. 33 $ o. 2.0 1+0 6o 8o 100 Canada Campion's Study Present Study 1 or more years university nursing education. No university nursing education. 7777} '///A Hospital 'clinical course. | N.U.A. course. Z$ None. Campion's Study TIT Present Study Fig. 8. Post Basic nursing education of head nurses • i n Canada, in Campion's study and in the 'present study. 34 s e t o f s t a t i s t i c s f o r comparison w i t h data i n the present study. F i g u r e 8 shows t h a t 69$ and 38$ of the respondents r e s p e c t i v e l y had no post b a s i c n u r s i n g education, hdp and 31$ had completed the N.U.A. course (Appendix A ) , and 27$ and 31$ had completed a h o s p i t a l c l i n i c a l course or had at l e a s t one year o f post b a s i c u n i v e r s i t y n u r s i n g education. Why the correspondence course was so much more evident i n the present study may be i n t e r p r e t e d s e v e r a l ways. The d i f f e r e n c e s might be due t o the demand f o r education by nurses, the course being r e q u i r e d f o r o r s t r o n g l y suggested by employing agencies t o those unprepared f o r t h e i r head nurse p o s i t i o n s , o r a d i s p r o p o r t i o n a t e number o f past or curr e n t N.U.A. students being at the i n s t i t u t e s because o f t h e i r h i g h i n t e r e s t . During the two years s i n c e p u b l i c a t i o n o f Campion's study, a l a r g e r percent o f the sample had an o p p o r t u n i t y t o complete the course than i n Campion's group. During 1967 and 1968, 12 of the study sample were students i n the N.U.A. course. I f these respondents were r e a l l o c a t e d t o the category of those w i t h no post b a s i c n u r s i n g education, the d i s t r i b u t i o n would become 64$ w i t h no e x t r a education, and 5$ w i t h the course, i n s t e a d o f 38$ and 31$ r e s p e c t i v e l y . These new f i g u r e s were not s i g n i f i c a n t l y d i f f e r e n t from those o f Campion's study. Other n u r s i n g courses, mostly c l i n i c a l , had been taken by 18$ o f the sample during the previous f i v e years. Nursing and Head Nurse Experience. The respondents had . 3 5 nursing experience which ranged from less than five years (7$) to over 35 years (4$). A t o t a l of 67$ of the respondents had more than 15 years of nursing experience. (Figure 9) F i f t y - s i x percent had five or more years experience as a head nurse. ' Only 11$ of the respondents could he considered novices with less than a year of head nurse experience. (Figure 10) Size of Employing Agency. Three of the respondents (7$) worked in health agencies other than hospitals, 53$ worked in hospitals of less than 500 beds, and 40$ worked in larger hospitals. (Figure l l ) Type and Size of Nursing Units. Sixty percent of the re-spondents worked in medical-surgical nursing units. Nine of the respondents (20$) worked in public health agencies or transient patient areas, 33$ worked i n units of less than 30 beds, and 47$ worked in larger units. (Figure 12) Size of Staff. Thirty-eight percent were responsible for personnel numbering less than fifteen, and 62$ were responsible for more. (Figure 13) The head nurse was responsible for the supervision and. evaluation of these staff members unless her supervisor did the reports and/or the interviews. Student nurses were included in a few cases, and the head nurse assisted the instructor i n doing the reports or- did them herself-.— Perception of the Institute. One only answer was e l i c i t e d from each respondent on the Kropp Verner Attitude Scale (Appendix D) 0 20 40 -4-80 — i -15 years or l e s s over 15 years F i g . 9- D i s t r i b u t i o n o f the sample by years o f n ursing experience. i t i|0 — f -Less than 11 year. 1 - 4 years. 5 years and over. F i g . 10. D i s t r i b u t i o n o f the sample by years o f head nurse experience. 0 20 40 —+-6o Not a hos p i t a l ' . 500 or l e s s beds. Over 500 beds F i g . 11. D i s t r i b u t i o n o f the sample by-s i z e o f employing agency. 0 20 )40 60 1 No beds, 30 or l e s s beds. Over 30 beds. F i g . 12. D i s t r i b u t i o n o f the sample by-s i z e o f nursing u n i t . 0 20 —t-ho — f ~ 60 S t a f f o f l e s s than 15. S t a f f o f 15 or more. F i g . 13. D i s t r i b u t i o n o f the sample by s i z e o f s t a f f . 39 which measures the g e n e r a l a t t i t u d e o f the respondent toward an organized 16 e d u c a t i o n a l experience. The median r a t i n g f o r a l l respondents was Item 5> " I t helped me p e r s o n a l l y . " The r a t i n g s are shown i n F i g u r e Ih. Comparison o f Background Categories The v a r i o u s combinations o f each background category were compared w i t h one another. These comparisons were o r i g i n a l l y done on punch cards and l a t e r v e r i f i e d on a computer. A p r o b a b i l i t y o f .05 was chosen as the l e v e l o f s i g n i f i c a n c e , c a l c u l a t e d w i t h the c h i square t e s t when the observed frequency was over f i v e , and w i t h the Kdlomogorov-17 Smirnov t e s t when the observed frequency was s m a l l e r . A l l f i g u r e s showing comparisons i n the t e x t and i n the graphs are at t h i s l e v e l o r l8 b e t t e r , unless otherwise i n d i c a t e d . Ten percent o f the sample, or 4-5 i n d i v i d u a l s , .was a very s m a l l frequency f o r the s t a t i s t i c a l treatment o f observed v a r i a t i o n s , h o w e v e r . ( s e e Tables I and I I , p. 52 and 53) Of the 8 h l t a b l e s which r e s u l t e d from these comparisons 21 showed d i f f e r e n c e s at or above the chosen l e v e l . o f s i g n i f i c a n c e . Some of these added nothing meaningful t o the r e s u l t s o f the study. For example, o f those w i t h over 15 years o f n u r s i n g experience, 73$ were over 4-5 years of age, and 73$ had been head nurses f o r over f i v e y ears. Of those w i t h l e s s than 15 years o f n u r s i n g experience, 7$ were over U5 years of age, and 20$ had been head nurses f o r over f i v e y ears. (Fi g u r e 15) Of the married respondents, 86$ had h i g h s c h o o l graduation or l e s s , 4l$ had been head nurses f o r 5 o r more years, and 82$ were r e s p o n s i b l e f o r s t a f f s o f 15 o r more people. Of the unmarried ho 10 — f -2 0 3 0 Item 1 . i I" Item 2, Item 3 '• Item h. Item 5. Item 6. Item 7. Item 8. Item 1 1 , Item 2 0 . F i g . lU. D i s t r i b u t i o n o f the sample by-r a t i n g on the Kropp Verner A t t i t u d e S c a l e . 41 fi 20 40 60 •-+---• 80 — j _ 100 Over 15 years, 15 or l e s s years. 7 Over 15 years. i i ! ' ! ! I I NI! 15 or l e s s years. inn i i i i i pj^^-^ Less than 45 years. . -. 45 o r more.years. Less than 5 years as head nurse. 5 o r more years as head nurse. i s f! (! I f ] 1» •: 1 1 li-U. F i g . 15. Years o f nursing experience r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : age, and head nurse experience. 1,2 respondents, 57$ had h i g h s c h o o l graduation o r l e s s , 70$ had been head nurses f o r 5 o r more years, and 43$ were r e s p o n s i b l e f o r s t a f f s o f 15 or more people. ( F i g u r e l6) What these d i f f e r e n c e s mean i s d i f f i c u l t , to determine. The d i f f e r e n c e s i n b a s i c academic education may mean t h a t the two groups had d i f f e r e n t career g o a l s , o r t h a t the unmarried group achieved f u r t h e r education l a t e r . At the time o f the i n t e r v i e w s , the respondents were not ,asked f o r d e t a i l s regarding t h e i r education, other than how much they had completed. The d i f f e r e n c e could show a trend'toward career o r i e n t a t i o n s f o r those who remain i n n u r s i n g . The d i f f e r e n c e i n the number o f each group who had been head nurses f o r • over f i v e years would be accounted f o r by fewer o f the more experienced group being married. The r e s p o n s i b i l i t y f o r l a r g e s t a f f s i s an i n t e r e s t i n g d i f f e r e n c e . Whether those who remain i n n u r s i n g g r a d i i a l l y take over s m a l l e r n u r s i n g u n i t s , and t h e r e f o r e s m a l l e r s t a f f s , o r whether they become charge nurses i n more s p e c i a l i z e d areas, again w i t h s m a l l e r s t a f f s , i s p r o b l e m a t i c a l . Of those under 4-5 years o f age, 18$ had completed the N.U.A. course, and 27$ had other post b a s i c n u r s i n g education; 77$ were r e s p o n s i b l e f o r s t a f f s o f 15 or more. Of those over 45 years o f age, 43$ had completed the N.U.A. course, and 37$ had other post b a s i c n u r s i n g education; 48$ were r e s p o n s i b l e f o r s t a f f s o f 15 or more. (Figure 17) As would be surmized, there were s i g n i f i c a n t d i f f e r e n c e s w i t h the year o f graduation, years o f nur s i n g experience, and years as a head nurse. Those who were o l d e r had more n u r s i n g education than the younger group, p o s s i b l y because o f the career and time d i f f e r e n c e s . The 43 of p 0 2 0 40 — f -6 0 Married, Nor married. 8o 100 Hi l l III. Not married. • ! M I' I i'i i I U 1 < • i i ! i i ! ! ! i ! I High school graduation or less Some u n i v e r s i t y . ; _: J . Less than 5 years as head nurse. 5 or more years as head nurse. S t a f f of under 1 5 - . jp l l iS J S t a f f of 15 or more. F i g . l 6 . M a r i t a l status r e l a t e d to s i g n i f i c a n t background categories: post basic nursing education, years of head nurse . experience and s i z e of s t a f f . p 44 0 nrnT I III! 20 1*0 - f — 6o 8o 100 Less than 45 years. x , v ,/ //'//////,• ///////'/A 4-5 o r more years . ! fTTT"; i l l Less than 45 years. 4-5 or more years 1 F u r t h e r post b a s i c education. C\V\N N.U.A. course. ^////'J\ No post b a s i c education. S t a f f o f under 15. S t a f f o f 15 o r more. F i g . IT- Age r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : post b a s i c n u r s i n g education and s i z e o f s t a f f . 1*5 d i f f e r e n c e s i n s i z e o f s t a f f were commented on e a r l i e r w i t h regard to those who were not married. Of those w i t h a score below the median of 11 on the Chapin s c a l e , 32$ graduated from n u r s i n g schools a f t e r 1950, 82$ had more than 15 years o f n u r s i n g experience; and 32$ were r e s p o n s i b l e f o r n u r s i n g u n i t s o f over 30 beds. Of those w i t h a score over the median, 52$ graduated from n u r s i n g schools a f t e r 1950* 52$ had more than 15 years o f n u r s i n g experience, and 6l$ were r e s p o n s i b l e f o r n u r s i n g u n i t s o f over 30 beds. Although these scores appear to be confusing, the t r e n d seems to be t h a t the o l d e r more experienced nurses were among the lower s c o r e r s , and the younger l e s s experienced nurses were among the h i g h e r s c o r e r s . This i s not s u r p r i s i n g when the s o c i e t a l trend i s f o r younger a d u l t s , married or nonmarried, t o be p a r t i c i p a n t s i n community a c t i v i t i e s . Of those who had h i g h s c h o o l graduation or l e s s , 41$ were not married. Of those w i t h more than h i g h s c h o o l graduation, 77$ were.not married. ( F i g u r e 18) I t was mentioned e a r l i e r t h a t career goals would probably d i f f e r between those who were married and those who were not. Again, time of education was not e l u c i d a t e d at the time o f the i n t e r v i e w s . The . r e l a t i o n s h i p between years o f education and m a r i t a l s t a t u s could not be determined from these data. Of those w i t h no post b a s i c nursing education, 71$ were under 4-5 years o f age, and 59$ were employed i n s m a l l e r h o s p i t a l s . Of those who had completed the N.U.A. course, 29$ were under 45, and 43$ were employed i n s m a l l e r h o s p i t a l s . Of those who had f u r t h e r n u r s i n g 46 i o 20 40 6o 8o 100-High sc h o o l graduation or l e s s . . Some u n i v e r s i t y . _j M a rried. Not married. F i g . 18. B a s i c academic education r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : m a r i t a l s t a t u s . ' "" 47 education, 57$ were under 45, and 79$ were employed i n s m a l l e r h o s p i t a l s . .(Figure 19) These d i f f e r e n c e s i n d i c a t e d t h a t those over 45 years o f age have, on the whole, advanced t h e i r education, p a r t i c u l a r l y through 1 the N.U.A. course'. U n i v e r s i t y courses may not have been f e a s i b l e because the l a c k o f i n c e n t i v e , low academic records, f e a r o f attempting anything so unknown, or f i n a n c i a l l i m i t a t i o n s . Those w i t h no post b a s i c education and those w i t h f u r t h e r n ursing education were both found more f r e q u e n t l y i n s m a l l e r h o s p i t a l s . The 7$ i n the p u b l i c h e a l t h agencies would have skewed the r e s u l t s i n the group w i t h more nu r s i n g education, but not s i g n i f i c a n t l y . Geographic d i s t r i b u t i o n would be c o n t r o l l e d t o some extent by the m a r i t a l s t a t u s o f the nurse, and, f o r those married, by the l o c a t i o n o f the husband's place of work, but m a r i t a l s t a t u s was not s i g n i f i c a n t l y d i f f e r e n t f o r those working i n s m a l l e r h o s p i t a l s . Of those w i t h l e s s than . f i v e years o f experience as a head nurse, 35$ were not married, 30$ were over 45 years o f age, 4 0 $ had more than 15 years o f nur s i n g experience, ax\d. 85$ were r e s p o n s i b l e f o r s t a f f s o f over 15- Of those w i t h f i v e o r more years o f head nurse experience, 6 4 $ were not married, 68$ were over 45 years o f age, 88$ had more than 15 years of n u r s i n g experience, and 44$ were r e s p o n s i b l e f o r s t a f f s o f over 15. ( F i g u r e 20) Almost double the number o f those w i t h l e s s experience i n nursing, and as head nurses were i n charge o f l a r g e r s t a f f s than were more experienced head nurses. This was mentioned e a r l i e r r e g arding m a r i t a l s t a t u s . Of those i n s m a l l e r h o s p i t a l s , 37$ had no post b a s i c nursing education, 22$ had completed the N.U.A. course, and 4l$ had f u r t h e r 48 i o ?? §?.. 100 No post b a s i c education. N.U.A. course. F u r t h e r education. F u r t h e r education. Less than 45 years. 45 o r more years. ^y^/y 500 or l e s s beds. 123 Over 500 beds F i g . 19- Post b a s i c n u r s i n g education r e l a t e d t o s i g n i f i c a n t background c a t e g o r i e s : age. and s i z e o f employing agency. 20 60 • — i -80 100 Less than 5 .years. 5 or more years. Less than 5 years.' ! .. • 5 o r more years. 7 / / ' 7 ~ 7 ~ / / / //V. /Z.ZlJYi ////:// ) 5 o r more vears. T Less than 5 years **** J L L L U l L L f e ^ 5 o r niore years .J..JJ. - - s s i i i i i i i i i i i T I I M l E M n i l O f f i M a r r i e d . Not married >J Less than 45 years. U5 or more years. • HH1 Less than 15 years nu r s i n g experience. 15 o r more years nu r s i n g experience. S t a f f o f l e s s . than 15. S t a f f of 15 or * mors F i g . 20. Years o f head nurse experience r e l a t e d t o s i g n i f i c a n t background c a t e g o r i e s : • m a r i t a l ' s t a t u s , age, nu r s i n g experience and s i z e o f s t a f f . 50 n u r s i n g education. Of those i n l a r g e r h o s p i t a l s , 3 9 $ had no post b a s i c n u r s i n g education, U4$ had completed the N.U.A. course, and 17$ had f u r t h e r n u r s i n g education. ( F i g u r e 21) The almost equal r a t i o o f those w i t h no post b a s i c n u r s i n g education i n s m a l l e r and l a r g e r agencies r a i s e s v a r i o u s s p e c u l a t i o n s . The r a t i o could r e s u l t from a h a b i t u a l s t a f f i n g p a t t e r n i n the agencies, o r from the s i t u a t i o n r e l a t i v e to those a v a i l a b l e i n the community f o r employment by the h o s p i t a l . The r a t i o s o f those w i t h f u r t h e r education d i f f e r s between s m a l l e r and l a r g e r h o s p i t a l s . This could r e s u l t from the type o f course i n s t i g a t e d by the agency, i n s i s t e d upon by the agency, o r allowed through l e a v e . o f absence o r payment by the agency. The i n d i v i d u a l at the bottom i n a l a r g e i n s t i t u t i o n perceives o p p o r t u n i t y f o r p e r s o n a l advancement, and w i l l t h e r e f o r e o f t e n be i n t e r n a l l y motivated toward more education. The s t a f f turnover i s g r e a t e r i n the l a r g e r h o s p i t a l s a l s o , which increases the hope o f advancement but a l s o the f e a r o f d i s m i s s a l . The reasons f o r the N.U.A. course i n preference t o , o r i n s t e a d o f , u n i v e r s i t y programs were discussed, e a r l i e r . Summary In t h i s sample which i s r e p r e s e n t a t i v e o f head nurses i n the po p u l a t i o n chosen, and i n B r i t i s h Columbia and Canada i n some areas, there i s no p r o f i l e o f the-typieal-head- nurse-which---is-- apparent-.- There i s no c o n c e n t r a t i o n o f any s p e c i f i c c h a r a c t e r i s t i c i n the sample. The s i g n i f i c a n t s t a t i s t i c a l d i f f e r e n c e s are given i n Tables 1 and 2 i n percentages. 51;-i o 2 0 ho 6o — 8 0 100 ~1 500 or - l e s s beds'. Over 500 beds.. | V \ \ \ \ -s F u r t h e r post b a s i c nursing e d u c a t i o n . N.U.A. course. No post b a s i c n u r s i n g education. F i g . 2 1 . S i z e o f employing agency r e l a t e d to s i g n i f i c a n t background categories : . p post b a s i c n u r s i n g education. 52 Agency-s i z e (beds) 500 plus 500 minus. .... Head nurse (years) 5 plus vol _=r 0 0 ; vo 5 minus U N VO Post b a s i c n u r s i n g education f u r t h e r ' j I 1 i N.U.A. course \ \ - . . ._ ! • none ~ 1 — E ! I j B a s i c \ education i i some u n i v e r s i t y m OJ _ H .S. graduation - _ _ ON j I Chapin j S c a l e i i i 11 plus 11 minus j j Age i I i 45 plus 4-5 minus \ . ! M a r i t a l | S t a t u s not married married CO ! CO 1 O o to • r l ft H EH •a w c •H 0 ^ !s O bO bQ A5- i CQ S3 • r H S O i l t—;! 5? I ft i L f N I 5 the socioeconomic data c o l l e c t e d r e v e a l e d t h a t the sample chosen was r e p r e s e n t a t i v e o f head nurses i n Canada and/or B r i t i s h Columbia regarding m a r i t a l s t a t u s , age d i s t r i b u t i o n , income, and post b a s i c n u r s i n g education. Therefore, n e i t h e r the a l p h a b e t i c a l l i s t i n g nor the geo-graphic l i m i t a t i o n s skewed the r e s u l t s . 3. B l i s h e n , B.R. The c o n s t r u c t i o n and use of an o c c u p a t i o n a l c l a s s s c a l e . Canadian J o u r n a l o f Economics and P o l i t i c a l S cience November, 195"o\ 24:519-531. 4. Chapin, F.S. Chapin's S o c i a l P a r t i c i p a t i o n S c a l e . 1952 E d i t i o n I n : D.C. M i l l e r . Handbook o f Research and S o c i a l Measure-ment'. New York. McKay. S o c i a l Science S e r i e s . 1964. 5- Kropp, R.P. and C. Verner. An A t t i t u d e S c a l e Technique f o r E v a l u a t i n g Meetings. Adult Education. Summer, 1957-6. Canadian Nurses A s s o c i a t i o n . Countdown 1968. Ottawa. I968. p 7. P r o v i n c i a l Inventory o f Nurses. B r i t i s h Columbia. 1967. Research U n i t . Ottawa. Canadian Nurses A s s o c i a t i o n . May, I968. Table 7.' B l i s h e n , OJD. c i t . P r o v i n c i a l Inventory of Nurses, op_. c i t . , Table 11. Canadian Nurses A s s o c i a t i o n , op_. c i t . , p. 59-Chapin, op_. c i t . Canadian Nurses A s s o c i a t i o n , op_. c i t . , p. 56. 55 13- Campion, F.L. A Report on the P r o j e c t f o r the E v a l u a t i o n o f the Q u a l i t y o f Nursing S e r v i c e . Ottawa. Canadian Nurses A s s o c i a t i o n . i 9 6 0 ! Ik. Ibid. 15. I b i d . 16. Kropp and Verner, op_. c i t . 17. S i e g e l , S. Honparametric S t a t i s t i c s f o r the B e h a v i o r a l S c i e n c e s . P h i l a d e l p h i a . Saunders. 1965• P- 23-18. A l l other comparisons have been omitted. 19. S i e g e l , op_. c i t . , p. 23-CHAPTER I I I THE INSTITUTE AND ITS EVALUATION Thi s study was an i n v e s t i g a t i o n o f the changes i n behavior pe r c e i v e d by a sample of p a r t i c i p a n t s at the i n s t i t u t e s . Because the interviewees- were asked f o r s u b j e c t i v e e v a l u a t i o n s o f changes i n t h e i r behavior as the r e s u l t o f a s p e c i f i c e d u c a t i o n a l experience, the s t a t e d o b j e c t i v e s o f the i n s t i t u t e were not p e r t i n e n t t o the study. An o b s e r v a t i o n a l a n a l y s i s o f the i n s t i t u t e was made w i t h respect t o new knowledge and i t s p r e s e n t a t i o n , p r o v i s i o n f o r m o d i f i c a t i o n o f a t t i t u d e s , and s p e c i f i c recommendations f o r p r a c t i c e , which were p e r t i n e n t . The Learning S i t u a t i o n Relevant to the purpose o f t h i s study i s an e x p l o r a t i o n o f b e h a v i o r a l l e a r n i n g theory concerning what l e a r n i n g i s and under what circumstances i t occurs. Learning i s d e f i n e d i n the b e h a v i o r a l sciences as a change i n behavior which i s more or l e s s permanent. 1 F o r change to occur there must be a f e l t need f o r change, a c l i m a t e conducive t o change, an o p p o r t u n i t y t o p r a c t i c e the new behavior, and l a t e r reinforcement i f i t i s t o remain a p a r t o f the i n d i v i d u a l ' s p r e p e r t o i r e o f behavior p a t t e r n s . There i s an extensive and growing l i t e r a t u r e on the b e h a v i o r a l measurement o f l e a r n i n g and l e a r n i n g s i t u a t i o n s which has been s t u d i e d by the author. The l e a r n i n g s i t u a t i o n 57 and the f a c t o r s which i n f l u e n c e i t are described i n Appendix E. I t i s obvious t h a t the o p p o r t u n i t y t o p r a c t i c e changed behavior and l a t e r reinforcement cannot be provided i n an i n s t i t u t e . In designing an i n s t i t u t e , however, both the other f a c t o r s and i n f o r -mation p e r t i n e n t t o changing p r a c t i c e should be considered. Knowledge. The i n s t i t u t e was observed f o r the content o f f e r e d and the methods used i n the p r e s e n t a t i o n o f the m a t e r i a l . The s u b j e c t content of the i n s t i t u t e s i n c l u d e d the value and purposes of e v a l u a t i n g s t a f f members, techniques and methods of e v a l u a t i o n , e v a l u a t i o n forms, ambiguous terminology, the d i f f e r e n c e s between ad-m i n i s t r a t i o n and s u p e r v i s i o n , personal f e e l i n g s and b i a s e s , d i r e c t and i n d i r e c t c o u n s e l l i n g , and employee e x p e c t a t i o n s . Each t o p i c was introduced by the speaker and f o l l o w e d by s m a l l group d i s c u s s i o n and/or d i s c u s s i o n s from the f l o o r . The speaker summarized the main p o i n t s which emerged from d i s c u s s i o n . When s m a l l group d i s c u s s i o n s were used, a group re c o r d e r r e p o r t e d the d i s c u s s i o n s and attempted to answer questions from the f l o o r . The l e a r n i n g experiences were provided through v a r i o u s methods of p r e s e n t a t i o n , which i n c l u d e d l e c t u r e s , d i s c u s s i o n s , v a r i o u s audio-v i s u a l media, and p a r t i c i p a t i o n i n problem s o l v i n g . A f i l m , "The Eye o f the Beholder," was shown, d e p i c t i n g e l o q u e n t l y the i n d i v i d u a l c o g n i t i v e worlds of each of the a c t o r s . Two i n s t i t u t e p a r t i c i p a n t s presented a r o l e p l a y i n g sequence, w i t h one p l a y i n g the head nurse and the other an aggressive s t a f f nurse. One of the problems presented was 58 a w r i t t e n case study which gave too l i t t l e i n f o r m a t i o n f o r s o l u t i o n of the problem. Another centered on the terminology f o r e v a l u a t i n g s t a f f ; groups were asked t o designate the terms they would use t o describe various l e v e l s o f performance f o r the same employee group and then t o d e f i n e the terms. The s u b j e c t content and methods of p r e s e n t a t i o n were r e l a t e d t o the past and present work experience of the p a r t i c i p a n t s . The relevance o f both were i n c r e a s i n g l y evident as the p a r t i c i p a n t s became i n v o l v e d i n group d i s c u s s i o n s . D i f f e r e n t approaches and d i f f e r e n t s i t u a t i o n s w i l l o f t e n r e l e a s e s t o r e d i n f o r m a t i o n i n t o the. meaningful or useable realm o f l e a r n e r s . (Appendix E) This meant t h a t a new r e l a t e d n e s s w i t h e x i s t i n g knowledge occurred f o r the i n s t i t u t e p a r t i -c i p a nts . The observer was s a t i s f i e d t h a t the content and i t s p r e s e n t a t i o n were such as to f a c i l i t a t e the l e a r n i n g f o r which the i n s t i t u t e was designed. A t t i t u d e s . Those planning an i n s t i t u t e o r s i m i l a r e d u c a t i o n a l experience a n t i c i p a t e t h a t new knowledge w i l l subsequently be used by the p a r t i c i p a n t s . A study o f the l i t e r a t u r e r eveals t h a t the e f f e c t i v e n e s s of any e d u c a t i o n a l experience may be i n f l u e n c e d by the a t t i t u d e s w i t h which the p a r t i c i p a n t s a r r i v e . (Appendix E) The e d u c a t i o n a l experience should, t h e r e f o r e , be designed so t h a t a t t i t u d e s may be m o d i f i e d during the course of the program. As a t t i t u d e s can be i n f l u e n c e d by the c r e d i b i l i t y o f the communicator i n the p e r c e p t i o n of the l e a r n e r , by the form and manner-o f the p r e s e n t a t i o n o f the m a t e r i a l and by the circumstances o f d e l i v e r y 59 ' (Appendix E), as w e l l as by the involvement o f the i n d i v i d u a l w i t h the m a t e r i a l , these f a c t o r s must be considered. Observation was made o f the types o f p r e s e n t a t i o n and the types o f questions posed f o r s m a l l group d i s c u s s i o n s a t the i n s t i t u t e . The d i s c u s s i o n periods serve s e v e r a l purposes i n such a s e t t i n g : l ) to b r i n g m a t e r i a l i n t o the p r a c t i c a l o r meaningful realm o f the d i s c u s s a n t s , and 2) t o reduce the apathy o f the discussants through involvement as group members. A l l groups have a t h e r a p e u t i c as w e l l as an educative value even when they are not s p e c i f i c a l l y so designed. (Appendix E) The behavior o f the p a r t i c i p a n t s , was observed d u r i n g the s m a l l group d i s c u s s i o n s . There was nothing s p e c i f i c planned at t h i s i n s t i t u t e t o use the coffee or lunch breaks f o r f u r t h e r i n g d i s c u s s i o n , but the observer a l s o l i s t e n e d t o the p a r t i c i p a n t s at these times. The observer was s a t i s f i e d m o d i f i c a t i o n o f a t t i t u d e s was provided f o r i n the design o f the i n s t i t u t e . P r a c t i c e . There was no p r o v i s i o n made at the i n s t i t u t e f o r a change o f p r a c t i c e , but i t s e x p l i c i t purpose was the imparting o f knowledge by which p r a c t i c e s could be m o d i f i e d . The e f f e c t on p r a c t i c e had, t h e r e f o r e , to be determined l a t e r when there had been an o p p o r t u n i t y f o r the p a r t i c i p a n t s to apply some of t h e i r knowledge and a t t i t u d e s i n the p r a c t i c a l s i t u a t i o n . An appropriate i n t e r v a l was t h e r e f o r e allowed t o elapse between the co n c l u s i o n o f the i n s t i t u t e and the c o l l e c t i o n o f data. 6,0 E v a l u a t i o n of S u p e r v i s o r y T r a i n i n g Programs E v a l u a t i o n research i s described by S u t t o n as the extent t o . which the o b j e c t i v e s o f a g i v e n program are achieved by the p a r t i c i -pants.^ K l i n e b e r g s t a t e s t h a t e v a l u a t i o n should be r e s t r i c t e d t o methods which y i e l d evidence t h a t i s " o b j e c t i v e , s y s t e m a t i c , and comprehensive."^ As a d u l t education i s heterogeneous i n i n t e r e s t s , methods, programs and techniques, and as a d u l t educators have such w i d e l y divergent con-cepts of the o b j e c t i v e s of t h e i r e d u c a t i o n a l programs, e v a l u a t i o n research p r o j e c t s have been s c a r c e , divergent and not u s u a l l y comparable. Management and s u p e r v i s o r y t r a i n i n g programs i n business and i n d u s t r y have increased r a p i d l y i n the past twenty years. The theo-r e t i c a l aspect o f e v a l u a t i n g or measuring the e f f e c t i v e n e s s o f these programs was o f i n t e r e s t t o the s o c i a l r esearcher, who s t a t e d t h a t any change was an i n d i c a t i o n o f success and/or progress. F o r p u r e l y p r a c t i c a l reasons, the program d i r e c t o r s were i n t e r e s t e d i n the q u a l i t y o f t h e i r o f f e r i n g s , and the a d m i n i s t r a t o r s o f the' employing agencies were i n t e r e s t e d t e m p o r a l l y and f i n a n c i a l l y i n whether increased pro-d u c t i o n o r performance r e s u l t e d . Attempts to evaluate the r e s u l t s o f these programs have been numerous, but the outcomes have been f r u s t r a t i n g and not always f r u i t f u l . According to McLemore, the l i t e r a t u r e on the research of the e f f e c t i v e n e s s o f these programs i s most v a l u a b l e i n p r o v i d i n g i n f o r m a t i o n about the d i f f i c u l t i e s the researcher w i l l encounter.^ To determine the success of a t r a i n i n g program, Mahler s t a t e s t h a t i s i s necessary to know the o b j e c t i v e s of the program, t o be able 61 ' t o i d e n t i f y and measure r e l e v a n t outcomes, and t o demonstrate a r e l a t i o n s h i p between observed changes and the t r a i n i n g experience.^ However Corb warns t h a t the r e l a t i o n s h i p o f improved performance to 7 e a s i l y measured r e s u l t s i s complex. The major problem areas then i n the e v a l u a t i o n o f a program are those o f the c r i t e r i a t o be measured, and of the a c t u a l i n f e r e n c e between changes and experience. McLemore s t a t e d " i t should be c l e a r . . . t h a t the connecting chain from program o b j e c t i v e t o t r a i n i n g outcome i s not at a l l s imple, and t h a t numerous problems are to be encountered at o every p o i n t along the way.1 Corb adds t h a t the development o f s u i t a b l e c r i t e r i a becomes more d i f f i c u l t "the f u r t h e r removed the t r a i n i n g i s from manual o r manipulative s k i l l s , and the c l o s e r i t approaches the f u n c t i o n s o f c o g n i t i o n , judgment, and per s o n a l e f f e c t i v e n e s s . " ^ Thus, even i f the programs do achieve t h e i r o b j e c t i v e o f improved job performance of the p a r t i c i p a n t s , i t i s seemingly impossible to prove i t . E v a l u a t i v e techniques have not yet been developed to provide o b j e c t i v e proof o f the e f f e c t i v e n e s s o f s u p e r v i s o r y t r a i n i n g programs. The present study was not designed t o e s t a b l i s h or examine o b j e c t i v e " p r o o f s " such as may be used by an employer or e x t e r n a l e v a l u a t o r , but t o examine the r e a c t i o n s o f the p a r t i c i p a n t s (employees) and t h e i r r e l a t i o n s h i p t o the t r a i n i n g program and t o c e r t a i n aspects of the e d u c a t i o n a l and e x p e r i e n t i a l backgrounds o f the p a r t i c i p a n t s . -62. The C o n s t r u c t i o n o f the Interview Schedule The i n i t i a l s tep i n the present study was t o decide how to e l i c i t the i n f o r m a t i o n needed to d i s c o v e r whether o r not the i n s t i t u t e p a r t i c i p a n t s perceived any change i n t h e i r behavior i n e v a l u a t i n g s t a f f because t h e y had attended the i n s t i t u t e . Although the o b j e c t i v e s o f the i n s t i t u t e were known before the event, the experience and p r a c t i c e s o f the p a r t i c i p a n t s were not. The questions devised at t h i s stage were a l l deemed u n s a t i s f a c t o r y . The necessary questions could not be determined on the b a s i s o f the observed a n a l y s i s as each head nurse had a d i f f e r e n t e x p e r i e n t i a l and procedural back-ground. I t was decided t h a t u n s t r u c t u r e d i n t e r v i e w s would be used f o r f o u r or f i v e p a r t i c i p a n t s not i n v o l v e d i n the study sample. From these i n t e r v i e w s p o s s i b l e areas f o r q u e s t i o n i n g would be designated. A f t e r twelve i n t e r v i e w s i t was f u r t h e r decided t h a t an u n s t r u c t u r e d i n t e r v i e w would be;used f o r the study sample. Information was t o be gathered i n the g e n e r a l areas of agency p o l i c i e s r e g a r d i n g e v a l u a t i o n s ; i n d i v i d u a l p r a c t i c e before the i n s t i t u t e ; anything new i n subsequent procedures; any change s i n c e the i n s t i t u t e i n o r i e n t a t i o n , s u p e r v i s i o n , t e a c h i n g , anecdotal notes, e v a l u a t i o n , and i n t e r v i e w s ; and resources from r e a d i n g o r persons, most h e l p f u l w i t h these changes. The P i l o t Study • During the l a t t e r part 1" o f June, almost three months a f t e r the i n s t i t u t e s , the author i n t e r v i e w e d twelve r e g i s t e r e d nurses who had attended the i n s t i t u t e s . These p a r t i c i p a n t s were not among those • 63 s e l e c t e d f o r the study. The inverviews were used t o e l i c i t answers to both the background and change s e c t i o n s o f the i n t e r v i e w schedule. I t was d i f f i c u l t i n each i n t e r v i e w to determine whether each interviewee had a c t u a l l y changed o r whether there was an unconscious need t o express change. There was a l s o the problem o f determining the e v a l u a t i v e behavior o f the i n d i v i d u a l before the i n s t i t u t e as compared w i t h a f t e r . I t was decided at t h i s time t h a t the i n t e r v i e w s would, wherever p o s s i b l e , be conducted at the place o f employment, as there seemed to be a considerable d i f f e r e n c e i n response t o the environment. The i n t e r -views took between one-half and three-quarters o f an hour each. They were, on the whole, apparently r e l a x e d and non-threatening t o the i n t e r -viewees once rapport had been e s t a b l i s h e d . The..-Study During J u l y and e a r l y August, the nurses i n the sample and a l t e r n a t e l i s t s were i n t e r v i e w e d . Arrangements were made through the D i r e c t o r s o f Nursing o f the employing agencies f o r i n t e r v i e w s at times which seemed to be convenient f o r the i n t e r v i e w e e s . In a l l cases, an o f f i c e was provided. The cooperation r e c e i v e d by the author from the employing agencies and the interviewees was e x c e p t i o n a l l y g o o d . ^ Background data was r e a d i l y o b t a i n a b l e from the respondents. The i n s t i t u t e and r e s u l t i n g changes were w i l l i n g l y d i s c u s s e d , but v a r i e d tremendously from i n t e r v i e w t o i n t e r v i e w as the respondent v a r i e d from loquacious to r e t i c e n t . F o r some, the i n s t i t u t e was a form o f 6k • reinforcement o r reassurance o f what they were a l r e a d y doing. F o r o t h e r s , i t was r e l a t i v e l y new m a t e r i a l . In each case the i n t e r v i e w e e 1 s previous procedures and a t t i t u d e s toward e v a l u a t i n g personnel had. t o be determined so t h a t degrees o f l e a r n i n g c o u l d be a s c e r t a i n e d . Judgment or e v a l u a t i o n o f the l e v e l of competence o f the interviewee on her e v a l u a t i v e s k i l l s was not p e r t i n e n t . The p e r t i n e n t f a c t o r was whether she p e r c e i v e d any change i n what she was now doing as a r e s u l t o f having attended the i n s t i t u t e . C o m p i l a t i o n o f R e s u l t s The p e r t i n e n t questions at the i n t e r v i e w s were concerned w i t h how the respondents had supervised, evaluated and inter v i e w e d t h e i r s t a f f members, and whether they p e r c e i v e d any change i n these procedures or methods s i n c e the i n s t i t u t e . They were a l s o questioned about new s t a f f members, r e o r i e n t a t i o n , adjustment t o the u n i t , t e a c h i n g , e v a l u a t i n g , and d i s c u s s i o n o f problem areas. Each respondent was questioned about her philosophy o f e v a l u a t i o n as an ongoing process-, and her reasons f o r e v a l u a t i n g s t a f f members• From the notes made at the i n t e r v i e w s , the patter n s o f e v a l u a t i o n i n each agency were e x t r a c t e d , (p. 83) and the other i n f o r -mation was i n t e r p o l a t e d i n t o a s t r u c t u r e d format. (Appendix C) T h i s format was designed from the i n t e r v i e w notes. As w i l l be obvious, some items were r a r e l y mentioned. I t was decided.'that a l l " ~ cat e g o r i e s would be r e t a i n e d , however, f o r b e t t e r coverage o f the m a t e r i a l . The t a b u l a t i o n s were made re g a r d i n g a p e r c e p t i o n o f no 6HA change or change, and, w i t h the l a t t e r , whether the change was i n knowledge, a t t i t u d e , p r a c t i c e o r t h e i r subcategories.. The seven subcategories o f knowledge, the seven of a t t i t u d e , and the s i x o f p r a c t i c e ( w i t h t h e i r f u r t h e r d i v i s i o n s ) , were not used f i n a l l y f o r comparison purposes, as few s i g n i f i c a n t d i f f e r e n c e s were apparent even between the l a r g e r c a t e g o r i e s . The sample was too s m a l l f o r such f i n e d i v i s i o n s . The r e s u l t s from the t a b u l a t i o n s are given i n the next chapter, as w e l l as s i g n i f i c a n t comparisons o f the changes i n r e l a t i o n to the background data which was presented i n Chapter II.. 65 Footnote References 1. C l a y t o n , T.E. Teaching and Learning. Englewood C l i f f s , N.J. P r e n t i c e H a l l . 1965"! p. U5. 2. Melton, A.W. Categories o f Human Learning. New York. Academic. 1964. p. 316-3. S u t t o n , E.W. A n a l y s i s of Research on S e l e c t e d Aspects o f E v a l u a t i o n i n Adult Education. D o c t o r a l D i s s e r t a t i o n . Ann Arbor. F l o r i d a S t a t e U n i v e r s i t y . U n i v e r s i t y M i c r o -f i l m s . 1966. h. K l i n e b e r g , 0. The Problem o f E v a l u a t i o n . I n t e r n a t i o n a l S o c i a l Science B u l l e t i n . 1955- 7:346-352. 5- McLemore, S.D. and R.J. H i l l . Role change and S o c i a l i z a t i o n i n Nursing. P a c i f i c S o c i o l o g i c a l Review. S p r i n g , I965. 8:21-27-6. Mahler, W.R. E v a l u a t i o n o f Management Developnent Programs. • Personnel. September, 1953- 30: l l6- l l8 . 7> Corb, J.D. How t o Measure the R e s u l t s o f S u p e r v i s o r y T r a i n i n g . Personnel. March, 1956. 32:378-379-8. McLemore, S.D. arid R.J. H i l l . Management-training E f f e c t i v e n e s s A Study o f Nurse Managers . A u s t i n , Texas. Univ. o f Texas. IQ65. Chapter k. 9. Corb, op/-eft'. 10. The author was c o n t i n u a l l y s u r p r i s e d at the i n t e r e s t expressed i n the outcome o f t h i s study, not on l y on the par t of those i n t e r v i e w e d , but by t h e i r s u p e r v i s o r s and d i r e c t o r s o f nu r s i n g who arranged the i n t e r v i e w s , by other nursing-personnel, by non-nursing a d m i n i s t r a t o r s , by the sponsoring agencies, and by those i n v o l v e d i n e d u c a t i o n a l ventures o f a l l k i n d s . CHAPTER IV RESULTS OF THE STUDY P e r c e p t i o n o f Change Of the 1+5 respondents i n the sample, 1+1 or 91$ expressed a p e r c e p t i o n o f change i n t h e i r behavior f o l l o w i n g the i n s t i t u t e . . Those who expressed no p e r c e p t i o n o f change d i d nevertheless s t a t e t h a t the i n s t i t u t e had been a r e a f f i r m a t i o n o f what they were a l r e a d y doing i n e v a l u a t i n g s t a f f members. Three o f these f o u r respondents were s u p e r v i s o r s i n p u b l i c h e a l t h agencies and the f o u r t h was a head nurse i n a medium s i z e d h o s p i t a l . . Where a change i n behavior was perceived, i t occurred w i t h respect t o knowledge, a t t i t u d e , o r p r a c t i c e , o r some combination o f these. S e v e n t y - s i x percent o f the t o t a l respondents perceived a change i n knowledge, 62$ i n a t t i t u d e , and 76$ i n p r a c t i c e . ( F i g u r e 22) F o r t y - n i n e percent o f the respondents perceived a change i n a l l three areas, 11$ i n knowledge and a t t i t u d e , 11$ i n knowledge and p r a c t i c e , 2$ i n a t t i t u d e and p r a c t i c e , 5$ i n knowledge o n l y , and 13$ i n p r a c t i c e o n l y . There were no respondents who perceived a change i n a t t i t u d e o n l y . ( F i g u r e 23) Knowledge. S e v e n t y - s i x percent o f the respondents perceived a change i n behavior i n knowledge. The subcategories o f knowledge change 6? $ 0 20 - Uo 60 80 100 r J : 1 • ~f 1—: : 1 Change.in behavior. Change i n knowledge. Change i n a t t i t u d e . a.. Change i n p r a c t i c e . F i g . 22. Change i n behavior and change i n knowledge, a t t i t u d e and p r a c t i c e . 20 —t— ho —i— 60 Change i n knowledge, a t t i t u d e and p r a c t i c e . Change i n knowledge and a t t i t u d e , Change i n knowledge and p r a c t i c e . .Change i n a t t i t u d e and p r a c t i c e . Change i n knowledge o n l y . Change i n p r a c t i c e o n l y . F i g . 23. D i s t r i b u t i o n o f types o f changes w i t h i n o v e r a l l change o f behavior. 69 i n d i c a t e d by the respondents were: 47$ - B e t t e r understanding o f the reasons f o r e v a l u a t i o n . 29$ - B e t t e r understanding o f d i s c u s s i n g e v a l u a t i o n s . 27$ - An awareness t h a t others i n s i m i l a r p o s i t i o n s have s i m i l a r problems. 22$ - B e t t e r understanding of r e c o r d i n g or w r i t i n g e v a l u a t i o n s . 13$ - R e c a l l and r e a f f i r m a t i o n of previous knowledge. 9$ - B e t t e r understanding o f p r e p a r a t i o n o f e v a l u a t i o n s . 9$ - An awareness t h a t there are other points o f view besides one 1s own. 156$ - T o t a l As can be seen, the percentages i n the above l i s t t o t a l 156$. T h i s was because many o f the respondents i n d i c a t e d more than one sub-category o f change i n knowledge. Two percent chose f i v e c a t e g o r i e s , 9$ chose f o u r , 17$ chose t h r e e , 9$ chose two and 39$ chose o n l y one. There was no p e r c e p t i o n o f change i n knowledge by 24$ of the respondents. A t t i t u d e . S i x t y - t w o percent o f the respondents perceived a . change o f behavior i n a t t i t u d e . This category was f u r t h e r s u b d i v i d e d . The sub-categories o f a t t i t u d e change i n d i c a t e d by the respondents were: kOfo - D i f f e r e n t philosophy about e v a l u a t i o n s . 38$ - More confidence i n doing e v a l u a t i o n s now. 24$ - E v a l u a t i o n s are e a s i e r to do now. l8$ - An awareness t h a t there are other points o f view besides one's' own. TO 9$ - More confidence in a b i l i t y to f i l l head nurse position now. 7$ - Expectations are now two-way. 4$ - Different feeling about interviews. 140$ - Total • As the percentages in this l i s t total l40$, i t can again be seen that more than one category was chosen by some respondents. Four percent chose four subcategories, 24$ chose three, l8$ chose two, and. l6$ chose one. There was no perception change i n attitude by 38$ of the respondents. Practice. Seventy-six percent of the respondents perceived a change of behavior i n practice. The subcategories of practice change indicated by the respondents were: 44$ - Interview practice. 29$ - Supervisory practice. 29$ - Preparing, writing, evaluation reports. 24$ - Anecdotal notes. 20$ - Orientation practice, ^ 2$ - Teaching practice. 148$ - Total As the percentages In this l i s t t o tal 148$, i t can again be seen that some respondents chose more than one subcategory. Seven percent chose four, 22$ chose three, 13$ chose two, and 33$ chose one. There was no perception of change in practice by 24$ of the respondents. Tl A Comparison o f P e r c e i v e d Changes and Background Data The l e v e l o f s i g n i f i c a n c e and i t s c a l c u l a t i o n i n t h i s s e c t i o n were obtained s i m i l a r l y t o t h a t described i n Chapter I I . A . 0 5 p r o b a b i l i t y was the l e v e l o f s i g n i f i c a n c e chosen. Although 290 comparisons were made between the perceived changes and the background data, o n l y e i g h t of the comparisons showed s i g n i f i c a n t d i f f e r e n c e s . In summary, change of behavior was perceived d i f f e r e n t i a l l y by those w i t h d i f f e r e n t b a s i c academic education and by those w i t h d i f f e r e n t post b a s i c n u r s i n g education. Knowledge changes were, p e r c e i v e d d i f f e r e n t i a l l y by those i n d i f f e r e n t age c a t e g o r i e s , by those w i t h d i f f e r e n t amounts of n u r s i n g experience, and by those employed i n d i f f e r e n t s i z e d agencies. A t t i t u d e changes were perc e i v e d d i f f e r e n t i a l l y by those w i t h d i f f e r e n t post b a s i c n u r s i n g education and by those w i t h d i f f e r e n t amounts o f n u r s i n g experience. P r a c t i c e changes were perc e i v e d d i f f e r e n t i a l l y by those i n d i f f e r e n t s i z e d h o s p i t a l s . F i v e o f the background categories c o r r e l a t e d s i g n i f i c a n t l y w i t h change, i . e . , those of age, b a s i c academic education, post b a s i c n u r s i n g education, years o f n u r s i n g experience, and s i z e o f employing agency. Of these f i v e , post b a s i c n u r s i n g education, years o f n u r s i n g experience, and s i z e o f agency were s i g n i f i c a n t l y d i f f e r e n t w i t h respect t o two areas o f change. None were s i g n i f i c a n t l y d i f f e r e n t c o n s i s t e n t l y . O v e r a l l Change o f Behavior. In the comparison of the o v e r a l l change o f behavior w i t h background data, o n l y two comparisons were s i g n i f i c a n t l y d i f f e r e n t . ( F i g u r e 2k) The comparison o f those w i t h no 0 20 40 60 80 100 1 — — . 1 „ „ j . High school graduation or l e s s . Some u n i v e r s i t y . Mo post b a s i c n u r s i n g education. N.U.A. course. F u r t h e r post b a s i c n u r s i n g education. -F i g . 24. Change of behavior r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : b a s i c academic education and post b a s i c nursing... education. 73: post b a s i c n u r s i n g education, those who had completed (or were completing) the N.U.A. course, and those w i t h f u r t h e r n u r s i n g education, r e v e a l e d t h a t 91$, 100$ and 79$ r e s p e c t i v e l y perceived an o v e r a l l change of behavior; and comparison o f those w i t h h i g h s c h o o l graduation o r l e s s and those w i t h more,'revealed t h a t 97$ and 77$ r e s p e c t i v e l y p e r c e i v e d an o v e r a l l change o f behavior. Most change i n the f i r s t grouping was perceived by those w i t h the N.U.A. course. Twelve o f the 17 respondents i n t h i s group were students during 1967 or 1968, which was unforeseen before t h i s study, was done, and no b a s i s f o r d i f f e r e n t i -a t i o n was e s t a b l i s h e d . These respondents were d e l i g h t e d w i t h the reinforcement o f t h e i r course by the i n s t i t u t e , but were not abl e , o f course, t o d i s t i n g u i s h which i n f l u e n c e d t h e i r changed behavior the most or i n which areas. Those w i t h ho post b a s i c n u r s i n g education p e r c e i v e d a g r e a t e r change w i t h respect t o knowledge and a t t i t u d e than the other two groups. This could be due to the g r e a t e r amount o f new in f o r m a t i o n or the d i f f e r e n t p o i n t s o f view t o which they were exposed as compared w i t h the other groups. Those completing the N.U.A. course p e r c e i v e d a gr e a t e r change i n o v e r a l l behavior, p o s s i b l y as they were-having more r e c e n t l y . a c q u i r e d i n f o r m a t i o n r e i n f o r c e d . The fewest changes were perc e i v e d i n a l l areas by those who had completed f u r t h e r n u r s i n g education. This was i n t e r e s t i n g i n view of the f a c t t h a t the data on t h i s group r e v e a l s t h a t more than h a l f had h i g h s c h o o l graduation o r l e s s , were s i n g l e , were over 45 years o f age, and had graduated i n schools o f nu r s i n g o u t s i d e B r i t i s h Columbia. 74 Three-quarters o f the group had more than 15 years o f experience, t w o - t h i r d s had been head nurses more than f i v e y e a r s , and t h r e e -quarters worked i n s m a l l agencies- This group ranked low (at l l ) on the Chapin S o c i a l P a r t i c i p a t i o n S c a l e . Knowledge Change. The present study i n d i c a t e s a p e r c e p t i o n o f change i n knowledge f o r 76$ o f the respondents. Of these, 79$ a l s o p e r c e i v e d a change i n a t t i t u d e , and 79$ a l s o perceived a change i n p r a c t i c e . Fewer o f the o l d e r than o f the younger respondents perceived a change i n knowledge (6l$ and 91$ r e s p e c t i v e l y ) . Those w i t h l e s s and more n u r s i n g experience perceived a s i g n i f i c a n t d i f f e r e n c e i n knowledge change (93$ and 67$ r e s p e c t i v e l y ) . ( F i g u r e 25) As those under 4-5 years o f age were g e n e r a l l y those w i t h l e s s n u r s i n g experience, these d i f f e r e n t i a l perceptions could be expected. Whether the d i f f e r e n c e was due t o l e a r n i n g what was necessary on the job, o r whether those who were o l d e r and more experienced were l e s s w i l l i n g t o change was not determinable. The o l d e r respondents might have perceived l e s s change as they were al r e a d y u s i n g much o f the m a t e r i a l presented a t the i n s t i t u t e . They a l s o had, on the whole, more b a s i c academic education,'more experience i n n u r s i n g and more experience i n head nurse p o s i t i o n s . They might a l s o have formed c o g n i t i v e c o n f i g u r a t i o n s which were not amenable t o changes, and t h e r e f o r e they could not see the relevance o f the new m a t e r i a l to t h e i r personal performance. A comparison o f those i n s m a l l e r and l a r g e r agencies r e v e a l e d 75 ! | L _ _ 6 0 8 0 100 Less than 45 years.. 45 o r more years, 15 or l e s s years of n u r s i n g experience. Over 15 years o f nursing experience. As 500 or l e s s beds. Ay Over 500 beds F i g . 2 5 - Change i n knowledge r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : age, n u r s i n g experience and s i z e o f employing agency. 1& t h a t 67$ and 89$ r e s p e c t i v e l y perceived a change w i t h respect to knowledge. This could he due to the d i f f e r e n c e i n the communication patte r n s i n the d i f f e r e n t s i z e d i n s t i t u t i o n s . The communication channels tend t o be more open and e a s i e r t o use i n s m a l l e r u n i t s , and more clo s e d and t h e r e f o r e more d i f f i c u l t i n l a r g e r u n i t s . Communication i s o f t e n more d i f f i c u l t i n a n u r s i n g u n i t o f a l a r g e h o s p i t a l than i n a s m a l l h o s p i t a l . The d i f f e r e n c e s i n communication patt e r n s are the r e s u l t o f d i f f e r e n c e s i n the v i s i b i l i t y of communicants, i n the number o f communicants i n v o l v e d , and i n the number o f contacts w i t h each o t h e r . The s m a l l e r the group, the e a s i e r the communication p a t t e r n u s u a l l y i s . A t t i t u d e Change. The present study i n d i c a t e d t h a t 68$ o f the respondents perceived a change i n a t t i t u d e . Of these, 96$ a l s o per-ceived a change i n knowledge and 82$ i n p r a c t i c e . S i g n i f i c a n t d i f f e r e n c e s i n a t t i t u d e change were perceived by those w i t h l e s s than 15 years o f n u r s i n g experience and by those w i t h more (80$ and 53$ r e s p e c t i v e l y ) . D i f f e r e n t i a l perceptions were a l s o i n d i c a t e d by 82$, 50$ and 50$ r e s p e c t i v e l y o f those w i t h no post b a s i c n u r s i n g education, those w i t h the N.U.A. course, and those w i t h f u r t h e r n u r s i n g education. (Figure 26) Obviously from these f i g u r e s , the respondents w i t h l e s s experience and l e s s post b a s i c n u r s i n g edu-c a t i o n were l e s s aware o f the philosophy and reasoning behind some o f the m a t e r i a l presented at the i n s t i t u t e . Those w i t h more experience— and more education were l e s s aware o f those f e e l i n g s which the former -group found were changed. 7:7 20 ho 60 8o •-4~ 100 No post b a s i c n u r s i n g education. N.U.A. course. F u r t h e r post b a s i c nursing education. 15 or l e s s years o f n u r s i n g experience. Over 15 years o f nursing experience. F i g . 26. Change i n a t t i t u d e r e l a t e d t o s i g n i f i c a n t background c a t e g o r i e s : post b a s i c n u r s i n g education and n u r s i n g experience. P r a c t i c e Change. In the present study, 78$ of the respondents i n d i c a t e d a change i n p r a c t i c e , although the ha l o e f f e c t may have p e r t a i n e d . Of these, 79$ a l s o p e r c e i v e d a change i n knowledge, and 68$ i n a t t i t u d e . A d i f f e r e n t i a l p e r c e p t i o n o f change i n p r a c t i c e was i n d i c a t e d by those i n s m a l l e r o r l a r g e r agencies (67$ and 89$ r e s p e c t i v e l y ) . ( F i g u r e 27) Whether or not t h i s change was due to the communication patte r n s mentioned e a r l i e r , was again d i f f i c u l t t o assess. I t was a n t i c i p a t e d t h a t the b e t t e r q u a l i f i e d nurses would be employed i n the l a r g e r i n s t i t u t i o n s , but t h i s c e r t a i n l y was not the case w i t h the study sample. The anonymity and d i f f i c u l t communication patterns i n the l a r g e r . i n s t i t u t i o n might make i t more p o s s i b l e f o r a head nurse to be unaware o f what her compatriots are doing. This would be l e s s l i k e l y to occur i n a s m a l l e r i n s t i t u t i o n . Summary F o l l o w i n g the i n s t i t u t e , 91$ o f the respondents i n the sample perceived a change o f behavior and 9$ d i d not. Of a l l respondents, 76$ perceived a change i n knowledge, 62$ i n a t t i t u d e , and 76$ i n p r a c t i c e . Almost h a l f the respondents perceived a change o f behavior i n a l l three areas. Comparisons o f change w i t h background c a t e g o r i e s showed s i g n i f i c a n t c o r r e l a t i o n s with, regard to. age, b a s i c academic education, post b a s i c n u r s i n g education, years o f n u r s i n g experience, and s i z e o f employing agency. None were s i g n i f i c a n t l y d i f f e r e n t c o n s i s t e n t l y . 79 hp 6.0 80 _4_ 100 500 o r l e s s beds. Over 500 beds l~ F i g . 27- Change i n p r a c t i c e r e l a t e d to s i g n i f i c a n t background c a t e g o r i e s : s i z e o f employing agency. CHAPTER V DISCUSSION AND IMPLICATIONS The p a r t i c i p a n t s i n t h i s study were described i n Chapter I I , the methodology used i n Chapter I I I , and the r e s u l t s o f the study and comparisons o f change w i t h background i n Chapter IV. I t was f e l t t h a t an i t e m i z e d summary, chapter by chapter would be meaningless and waste-f u l . o f the reader's time. This chapter i s , t h e r e f o r e , devoted to d i s c u s s i o n o f the study as a whole, i n c l u d i n g some aspects o f the i n t e r views and work context which were not subjected to s t a t i s t i c a l t r e a t -ment: to an assessment o f the methodology and i t s r e s u l t a n t conclusions and to the s e v e r a l types o f i m p l i c a t i o n s a r i s i n g therefrom, some o f which are i n t e r p o l a t e d i n the t e x t . The Interviews The i n t e r v i e w i t s e l f posed a premonitory t h r e a t to some of the nurses, as they appeared to f e e l t h a t i t s purpose was to examine how much they had learned at the i n s t i t u t e , o r how e f f i c i e n t they were i n e v a l u a t i n g t h e i r s t a f f s . In each appointment f o r an i n t e r v i e w , i t was s t r e s s e d t h a t nothing needed to be prepared f o r the i n t e r v i e w . Nevertheless, some had c a r e f u l l y reviewed t h e i r notes, others had brought t h e i r notes before o r a f t e r having reread them, w h i l e s t i l l o thers apologized f o r not having had time to read them. Some were able to quote almost verbatim from these notes, and were d i s a p p o i n t e d , 3i but a l s o r e l i e v e d , t h a t they were not to be examined. •• I t was apparently a r e l i e f to many t h a t t h e i r p a r t i c i p a t i o n i n the study would remain anonymous. Quite a number were i n t e r e s t e d i n d i s c u s s i n g s p e c i f i c problems they had encountered, and. t r i e d t o t u r n the i n t e r v i e w i n t o a t u t o r i a l . Personal and f a m i l y problems, s u p e r v i s o r and subordinate problems were a l l i n c l u d e d . Obviously there was a degree o f apprehension o r f e a r i n v o l v e d i n the a n t i c i p a t i o n o f the i n t e r v i e w s on the p a r t of some o f the i n t e r v i e w e e s . When t h i s was r e l i e v e d , there was an a n x i e t y to discuss problems which may have been the cause o f the u n d e r l y i n g f e e l i n g s o f i n s e c u r i t y . Most were very i n t e r e s t e d i n what the i n t e r v i e w e r hoped t o di s c o v e r , and i n e d u c a t i o n a l ventures i n gen e r a l . Many, e s p e c i a l l y i n the younger age groups,-were hoping t o take f u r t h e r formal education, and some were s t a r t i n g formal courses i n the near f u t u r e . The i n s t i t u t e a p p a r e n t l y served as an impetus t o some and an encouragement to o t h e r s . Expressed Views o f the I n s t i t u t e The i n s t i t u t e was enjoyed and accepted by the p a r t i c i p a n t s as i n d i c a t e d by both end-of-meeting questionnaires presented by the sponsors at the time o f the i n s t i t u t e s , and by the Kropp Verner A t t i t u d e S c a l e presented t o the respondents during the i n t e r v i e w s . The median choice on the l a t t e r s c a l e was h i g h on the p o s i t i v e o r acceptance s i d e . Some of the respondents expressed the o p i n i o n t h a t s i m i l a r , i n s t i t u t e s should be h e l d every few years so they might be kept up-to-date i n p r a c t i c e , even though the m a t e r i a l might not be new. 82 They f e l t the reassurance and r e a f f i r m a t i o n o f t h e i r current p r a c t i c e s were very encouraging, and gave them more confidence t o t r y new p r a c t i c e s and to encourage t h e i r subordinates to change. Comments heard at the i n s t i t u t e v e r i f i e d the c r e d i b i l i t y o f the speaker i n the o p i n i o n o f the p a r t i c i p a n t s , and the p r a c t i c a l i t y o f the m a t e r i a l they were being given. C r i t i c i s m s were concerned w i t h the p h y s i c a l environment regarding n o i s e , heat and a c o u s t i c s . Reading Previous t o the i n s t i t u t e , a short b i b l i o g r a p h y was sent t o each r e g i s t r a n t . On the end-of-session q u e s t i o n n a i r e s used by the sponsors, those a t t e n d i n g i n d i c a t e d t h a t they had read at l e a s t one re f e r e n c e . At the i n s t i t u t e , a book e x h i b i t and book l i s t p e r t a i n i n g t o the i n s t i t u t e t o p i c s a t t r a c t e d considerable a t t e n t i o n from those a t t e n d i n g . Order forms were completed by some f o r p e r s o n a l copies o f the e x h i b i t e d and l i s t e d books. I t was not p o s s i b l e t o o b t a i n d e t a i l s o f the o r d e r s . At the i n t e r v i e w s , the respondents were questioned about t h e i r r e a d i n g . On the whole, most o f them d i d not read v e r y much. Few f e l t they had read more because they had attended the i n s t i t u t e . Those who d i d , d i d not f e e l they had gained a p p r e c i a b l y . The m a j o r i t y ^ of those who expressed an increase i n t h e i r reading a t t r i b u t e d the-cause to the N.U.'-A. correspondence course f o r which reading was r e q u i r e d . 83 ' Many appeared t o continue reading a f t e r completion o f the course. The main source o f i n f o r m a t i o n appeared to he the Canadian Nurse, t h e o f f i c i a l organ o f the Canadian Nurses A s s o c i a t i o n which a l l r e g i s t e r e d nurses r e c e i v e as par t o f t h e i r r e g i s t r a t i o n . Many of the n u r s i n g j o u r n a l s mentioned to the respondents were.unknown t o them. Obviously, t h i s i n s t i t u t e d i d not change the reading h a b i t s o f the p a r t i c i p a n t s . The Work S i t u a t i o n and i t s E f f e c t upon Change The s i t u a t i o n s i n which the respondents f u n c t i o n v a r i e d markedly from agency t o agency, and from department to department, even w i t h i n the same agency. From the i n f o r m a t i o n gathered at the time o f the i n t e r v i e w s , the p o l i c i e s o f the seventeen agencies represented by the respondents were e x t r a c t e d and analyzed. Of the seventeen agencies represented by the respondents i n \ t h i s study, nine r e q u i r e d r e g u l a r reports on s t a f f members, u s u a l l y a f t e r the f i r s t three o r s i x months, then an n u a l l y o r b i a n n u a l l y , and at the t e r m i n a t i o n o f employment. Four agencies r e q u i r e d a r e p o r t at the end of the i n i t i a l p r o b a t i o n a r y p e r i o d , but d i d not enforce r e p o r t s t h e r e a f t e r . Three agencies had forms a v a i l a b l e but d i d not enforce any r e g u l a r p o l i c y o f e v a l u a t i o n . The seventeenth agency d i d not have any p o l i c y o f e v a l u a t i n g or i n t e r v i e w i n g s t a f f members at the time o f the i n s t i t u t e . W i t h i n s e v e r a l o f the l a r g e r h o s p i t a l s , the p a t t e r n o f e v a l u a t i o n was i n c o n s i s t e n t , apparently dependent upon the depart-mental s u p e r v i s o r r a t h e r than upon the a d m i n i s t r a t i v e p o l i c y o f the 8k department o f n u r s i n g . The m a j o r i t y o f head nurses prepared r e g u l a r e v a l u a t i o n r e p o r t s in'these h o s p i t a l s w i t h the support and encourage-ment o f t h e i r s u p e r v i s o r s . The evaluations were a l s o v a r i o u s l y done by the head nurse and her. s u p e r v i s o r , by the s u p e r v i s o r w i t h i n c i d e n t r e p o r t s prepared by the head nurse, o r by the s u p e r v i s o r without reference to the head nurse. Programs f o r r e g u l a r i n t e r v i e w s w i t h s t a f f members v a r i e d as g r e a t l y . The i n t e r v i e w s were u s u a l l y conducted by the person preparing the r e p o r t (head nurse o r s u p e r v i s o r ) , although they were a l s o conducted by the s u p e r v i s o r w i t h a report prepared by the head nurse, o r f o l l o w i n g an i n t e r v i e w o f the s t a f f member by the head nurse In s e v e r a l instances head nurses s t a t e d t h a t reports were r e g u l a r l y changed by the su p e r v i s o r a f t e r the head nurse had int e r v i e w e d the s t a f f member, but before the r e p o r t was sent on t o the personnel f i l e s In three i n s t a n c e s , respondents s t a t e d t h a t reports had disappeared a f t e r disagreement between the su p e r v i s o r and head nurse about the assessment o f the s t a f f member. Reports were u s u a l l y seen and signed by the. r a t e e , although o c c a s i o n a l l y a r e p o r t on poor performance o r a s p e c i f i c i n c i d e n t was f i l e d i n the personnel f i l e without the ratee being aware o f i t s e x i s t e n c e . This p r a c t i c e was reported i n h o s p i t a l s o f v a r y i n g s i z e s . The m a j o r i t y o f the respondents had c o n t r o l over s t a f f e v a l u a t i o n s and in t e r v i e w s w i t h the support o f t h e i r s u p e r v i s o r s . I n other cases, the head nurses had accepted t h e i r s i t u a t i o n s without p r o t e s t , pleased that t h e i r s u p e r v i s o r r e l i e v e d them o f the onerous 8 5 t a s k . Another group o f head nurses r e s o l v e d t h e i r dilemma by-h o l d i n g r e g u l a r " d i s c u s s i o n s " w i t h t h e i r s t a f f members. Most o f the respondents expressed t h e i r g r a t i f i c a t i o n and a p p r e c i a t i o n o f the tremendous h e l p they r e c e i v e d from t h e i r s u p e r v i s o r s through guidance, support and encouragement t o c a r r y out t h e i r head nurse f u n c t i o n s . As one o f the l a t t e r group expressed i t , " I can h a r d l y w a i t f o r her to get back from her v a c a t i o n . " She had c o l l e c t e d pages o f data to f o l l o w through on some s t a f f education ideas she and her s u p e r v i s o r had p r e v i o u s l y d i s c u s s e d . During the course o f conducting the i n t e r v i e w s f o r t h i s study, seven s u p e r v i s o r s o f respondents came to meet the i n t e r v i e w e r , e i t h e r t o di s c u s s the r e s u l t s o f the i n s t i t u t e , or t o ask f o r reading o r c o n s u l t a n t references f o r s p e c i f i c areas o f e v a l u a t i o n o r super-v i s i o n o f s t a f f . Only f o u r o f the head nurses s p e c i f i c a l l y mentioned having r e c e i v e d e v a l u a t i o n r e p o r t s at any time themselves, although q u i t e a number s t a t e d t h a t they would appreciate being evaluated by t h e i r s u p e r v i s o r s . At the time o f the i n t e r v i e w s , new e v a l u a t i o n forms had been designed i n two agencies by the head nurses i n a committee o f the whole, new forms were being planned i n two agencies, and a format was under c o n s i d e r a t i o n f o r the agency w i t h no previous form. I n other agencies, the head nurses had had many i n f o r m a l d i s c u s s i o n s on the format t h e y used f o r e v a l u a t i o n s , i t s uses and i t s i n t e r p r e t a t i o n . 86 In-two agencies, v e r b a l i n t e r v i e w s at the t e r m i n a t i o n o f employment were being replaced by r e g u l a r r e p o r t s and i n t e r v i e w s i n s t i g a t e d by the head nurses. S p e c i f i c plans f o r l i b r a r i e s were underway i n three agencies, s t a r t e d i n one s i n c e the i n s t i t u t e , and given an impetus by the i n s t i t u t e i n the other two. In summary, s i x t e e n o f the seventeen agencies represented by the respondents i n t h i s study had some system of r a t i n g o r e v a l u a t i n g employees. There was l i t t l e s t a n d a r d i z a t i o n w i t h i n o r between h o s p i t a l s i n the methods or sched u l i n g o f e v a l u a t i o n . In seven o f the agencies a stimulus o r impetus toward change was reported t o have occurred because o f the I n s t i t u t e . Four o f the respondents expressed a . f e e l i n g o f unworthiness or inadequacy i n t h e i r head nurse p o s i t i o n s . They seemed to f e e l t h a t they had been an i n t e g r a l part o f t h e i r s t a f f s and resented being r e -garded as s u p e r i o r i n any way. These same head nurses had d i f f i c u l t y w i t h s t a f f r e p o r t s as they f e l t e v a l u a t i o n was an infringement on pe r s o n a l p r i v a c y . I f performance i s considered one's own bu s i n e s s , and not the business o f the person r e s p o n s i b l e f o r the n u r s i n g care o f the p a t i e n t s on the u n i t , the -head nurse r o l e i s o b v i o u s l y n e i t h e r appreciated nor understood. O b v i o u s l y these he rid nurses d i d not b e n e f i t from the i n s t i t u t e , even though they p e r c e i v e d changes i n t h e i r b e havior. They needed a-d i f f e r e n t type o f e d u c a t i o n a l experience, perhaps t h e r a p e u t i c i n nature, or p o s s i b l y they should be r w e r t e d t o bedside n u r s i n g . 87 Some of the head nurses expressed s u r p r i s e t h a t t h e i r sub-o r d i n a t e s would l i k e i n s t r u c t i o n i n u n f a m i l i a r procedures and r o u t i n e s i n the nur s i n g u n i t . They expressed the view t h a t t e a c h i n g o f subordin-ates meant b e l i t t l i n g t h e i r competence, as they were graduate nurses. These head nurses a l s o f e l t t h a t personal acceptance by t h e i r s t a f f s would d i m i n i s h i f they i n d i c a t e d a need f o r the subordinate to l e a r n something new. This viewpoint i s c o n t r a d i c t o r y to the r a t i o n a l e o f e v a l u a t i o n as an ongoing process f o r p e r s o n a l and p r o f e s s i o n a l growth and t o the concept o f c o n t i n u i n g education. P o s s i b l y planned head nurse, d i s c u s s i o n s on tea c h i n g w i t h i n the agencies could a l t e r t h i s viewpoint. Of the respondents who expressed no p e r c e p t i o n of change as a r e s u l t o f a t t e n d i n g the i n s t i t u t e , three were not employed i n h o s p i t a l s e t t i n g s . Of the respondents who p e r c e i v e d change, most f e l t they could i n s t i g a t e some changes r e g a r d l e s s o f t h e i r work s i t u a t i o n , although others f e l t t h a t nothing v e r y much could be done. Some s e t t i n g s impede changes t h a t need t o be made, w h i l e others f a c i l i t a t e them. Whether the opi n i o n s expressed by the respondents r e f l e c t a q u a l i t y o f these respondents, or o f the work s i t u a t i o n s , was not revealed by t h i s study. The E f f e c t o f the I n s t i t u t e on the P a r t i c i p a n t s . Ninety-one percent o f the i n s t i t u t e p a r t i c i p a n t s p e r c e i v e d change as the r e s u l t o f atte n d i n g the i n s t i t u t e . These were the s p e c i f i c t a b u l a t e d changes i n t h i s study, but other e x p l i c i t and i m p l i c i t changes a l s o occurred. These l a t t e r changes i n c l u d e d the adoption o f i n n o v a t i o n s , the acceptance o f d i f f e r e n t c o g n i t i v e worlds, the acceptance o f d i f f e r e n t e x p e c t a t i o n s , and r e m o t i v a t i o n . 88 As the respondents i n d i c a t e d p e r c e p t i o n of a considerable amount of change, they must have f e l t a need t o change. Whether these f e e l i n g s were present before the i n s t i t u t e , were engendered through the i n s t i t u t e process, o r were i n d i c a t i o n s o f a w i l l i n g n e s s t o please at the time of the i n t e r v i e w , i s a matter o f s p e c u l a t i o n . Whichever was behind the i n d i c a t e d changes however, the i n s t i t u t e seemed to h e l p some o f the respondents f e e l more adequate i n t h e i r p o s i t i o n s through a reinforcement of c urrent performance, or through changes which gave them more s e c u r i t y i n t h e i r performance. The responses i n d i c a t e d t h a t the engendered changes were congruent w i t h the behavior which they f e l t they needed. Those who perceived no change as a r e s u l t o f a t t e n d i n g the i n s t i t u t e were, g e n e r a l l y , those w i t h more post b a s i c n u r s i n g education, more n u r s i n g experience, and more head nurse experience, and who were not employed i n h o s p i t a l s e t t i n g s . These f a c t o r s i n d i c a t e t h a t change might not occur because performance already conformed to recommended p r a c t i c e , or because there seemed no personal advantage to change. The g r e a t e s t p e r c e p t i o n o f change was seemingly perceived by younger head nurses, those i n l a r g e r agencies, and those who had l e s s ba.sic academic education, l e s s post b a s i c n u r s i n g education or l e s s n u r s i n g experience. F u r t h e r research would be needed t o v a l i d a t e t h i s , however. A s i g n i f i c a n t l y g r e a t e r change i n o v e r a l l behavior and i n a t t i t u d e was perceived by those w i t h l e s s post b a s i c n u r s i n g education than by those w i t h more; i n knowledge and a t t i t u d e by those w i t h l e s s n u r s i n g experience than by those w i t h more; i n knowledge and p r a c t i c e "by those employed i n l a r g e r agencies than by those i n s m a l l e r ones; and i n 89 o v e r a l l behavior by those w i t h l e s s b a s i c academic education than by those w i t h more,and by those who were younger than by those who were o l d e r . I n t e r e s t i n g l y , the r e l a t i o n s h i p s expected when the study s t a r t e d were t h a t g r e a t e r change would occur f o r the younger, l e s s educated, and l e s s experienced head nurse, e s p e c i a l l y i n the s m a l l e r agencies. As the r e s u l t s show, these expectations were o n l y p a r t i a l l y r e a l i z e d . The most s u r p r i s i n g r e s u l t was the expr e s s i o n o f gre a t e r change by those i n the l a r g e r agencies. A l s o , those w i t h l e s s head nurse experience d i d not perceive as s i g n i f i c a n t a change i n behavior as those w i t h l e s s n u r s i n g experience. Otherwise, the r e s u l t s f o l l o w e d the expected p a t t e r n and s u b s t a n t i a t e d the r e s u l t s o f other s t u d i e s . The trends i n change which became apparent i n the study were i n three g e n e r a l areas, each o f which i n c l u d e d many of the subcategories used i n the t a b u l a t i o n s . These general areas were those o f adoption o f i n n o v a t i o n , d i f f e r e n t c o g n i t i v e worlds, and d i f f e r e n t e x p e c t a t i o n s . Adoption o f Innovations• Some of the respondents reported t h a t the i n s t i t u t e had g i v e n them a b e t t e r understanding o f i n f o r m a t i o n they a l r e a d y had, but which they had not p r e v i o u s l y used. The adoption o f new ideas i s seldom spontaneous, as the adopter has to t r y them out, understand t h e i r use, a s s i m i l a t e them i n t o previous c o g n i t i v e p a t t e r n s , see them as d e s i r a b l e to him p e r s o n a l l y , and see them as meaningful i n h i s s o c i a l context. In the group process o f the work s i t u a t i o n , the adopter has to f e e l he w i l l r e c e i v e the approval o f h i s subordinates and 90 ' s u p e r i o r s f o r h i s new s t y l e o f behavior before he i s w i l l i n g t o change h i s behavior patterns f u l l y . . Many of the respondents described the incr e a s e d cooperation and i n t e r a c t i o n o f t h e i r s t a f f members i n response t o t h e i r changed behavior. This response would probably increase the p o s s i b i l i t y o f the new behavior being adopted permanently. D i f f e r e n t C o g n i t i v e Worlds. The number o f respondents who expressed s u r p r i s e t h a t other people had d i f f e r e n t p o i n t s o f view from t h e i r own was r a t h e r d i s c o n c e r t i n g . The d i f f e r e n c e s between p a t i e n t s are c o n t i n u a l l y s t r e s s e d i n n u r s i n g , although seemingly t h i s knowledge d i d not t r a n s f e r to d i f f e r e n c e s between subordinates. This aspect was mentioned i n d i f f e r e n t ways by a quarter o f the respondents during i n t e r v i e w s . Both the f i l m and the" case study at the i n s t i t u t e were commented on by respondents i n the context o f e f f o r t s to understand sub-o r d i n a t e s through a l l o w i n g them to express t h e i r f e e l i n g s about s i t u a t i o n s . E v i d e n t l y these respondents had p r e v i o u s l y presented one p o i n t o f view -t h e i r own - and expected cooperation from the subordinate. D i f f e r e n t E x p e c t a t i o n s . Some o f the respondents were d i s -concerted t o d i s c o v e r t h a t not o n l y d i d they have expectations o f t h e i r s t a f f members, but t h a t s t a f f members had expectations o f them. T h i s was expressed q u i t e v o c i f e r o u s l y i n d i s c u s s i o n s at the i n s t i t u t e , but seldom mentioned i n i n d i v i d u a l i n t e r v i e w s . Some respondents had found t h a t t h e i r changed beh a v i o r regarding s u p e r v i s i o n , e v a l u a t i o n and i n t e r v i e w - d i s c u s s i o n s was accepted r e a d i l y by s t a f f members, t h a t d i s -cussions were two-way more than f o r m e r l y , and t h a t they were more-comfortable i n d i s c u s s i o n s as they f e l t more secure and adequate i n t h e i r . 91 own performance. More democratic a t t i t u d e s appear t o have been-formed by these respondents. I f the head nurse has c e r t a i n f i x e d expectations or c o g n i t i v e sets before she i n t e r v i e w s members o f her s t a f f as t o e x a c t l y what she i s going t o say, p l a n , execute, do, etc:-, spontaneity and f l e x i b i l i t y are l o s t . When a head nurse develops more democratic a t t i t u d e s toward • human r e l a t i o n s , i n t e r v i e w s may be u n p r e d i c t a b l e , but a b e t t e r rapport f o r ongoing i n t e r a c t i o n u s u a l l y develops. Apparently, the i n s t i t u t e was e f f e c t i v e i n t h i s r e s p e c t , but i t would not be p o s s i b l e to place a q u a n t i t a t i v e value on the r e s u l t s . Performance Lags. For each person doing r e p e t i t i v e t a s k s , the maintenance o f a s a t i s f a c t o r y l e v e l o f accomplishment tends to l a g . Performance lag s may be diminished, or at l e a s t a r r e s t e d , through r e -m o t i v a t i o n o f the i n d i v i d u a l . E v a l u a t i o n o f s t a f f can accomplish t h i s t o some extent i f the ratee grants c r e d i b i l i t y to the r a t e r , and i f the r a t e e f e e l s he i s improving. Workshops and i n s i t u t e s , l e c t u r e s and con-ferences o c c a s i o n a l l y serve t h i s purpose a l s o , as p a r t i c i p a n t s from d i f f e r e n t o r g a n i z a t i o n s d i s c o v e r how others o f s i m i l a r s t a t u s f e e l about t h e i r problems and s a t i s f a c t i o n s , t h e i r various methods of problem, s o l v i n g , and t h e i r d i f f e r e n t p o i n t s o f view. P r o f e s s i o n a l exchange of experiences may s t i m u l a t e a person and make him f e e l more adequate to d e a l w i t h a f r u s t r a t i n g s i t u a t i o n . The most f r e q u e n t l y expressed view of the i n s t i t u t e was t h a t the interviewee f e l t she had learned nothing new, but t h a t i t was r e a s s u r i n g to know she was going i n the r i g h t d i r e c t i o n . Even those who 92 i n d i c a t e d t h a t they had perceived no change s t a t e d t h a t the i n s t i t u t e had r e a f f i r m e d what they were doing. The m a t e r i a l had acted l i k e 'a shot i n the arm', as one respondent put i t . This r e a f f i r m a t i o n or r e -assurance b o l s t e r e d confidence to c a r r y on as the person gained a f e e l i n g o f "togetherness" of both s a t i s f a c t i o n s and problems. The f e e l i n g o f inadequacy to cope w i t h problems o f t e n diminishes w i t h the knowledge t h a t others have shared and t a c k l e d s i m i l a r s i t u a t i o n s i n other agencies. Inasmuch as the i n s t i t u t e s p e c i f i c a l l y catered f o r group a c t i v i t i e s , i t may be considered s u c c e s s f u l i n p r o v i d i n g r e a f f i r m a t i o n . There seemed t o be l i t t l e d i f f e r e n c e i n the amount o f change between the respondents i n agencies w i t h or without standardized p o l i c i e s f o r e v a l u a t i o n s and i n t e r v i e w s . The changes i n o v e r a l l p o l i c y i n seven of the agencies represented i n the study had occurred l a r g e l y at the i n s t i g a t i o n o f those who had attended the i n s t i t u t e , although o f t e n a l l the head nurses were i n v o l v e d . However, changes i n personal performance were l i k e l y to conform to group consensus. As the turnover o f head nurses i n h o s p i t a l s i n Canada averages 16$ annually, changes are i n e v i t a b l e . The d i f f i c u l t y o f i n s t i g a t i n g and m a i n t a i n i n g change i n an agency not o n l y i n v o l v e s changes i n the p r a c t i c e o f c u r r e n t s t a f f , but adequate o r i e n t a t i o n o f new s t a f f . This a l l leads one to surmize t h a t t h i s would i n v o l v e i n t r a i n s t i t u t i o n a l c o n t i n u i n g education, as w e l l as i n t e r i n s t i t u t i o n a l c o n t i n u i n g education and r e g u l a r programs i n both.areas f o r r e m o t i v a t i o n . Accomplishment o f the Purposes o f the Study . From the l i t e r a t u r e reviewed i n Chapters I and I I I , i t was 93 obvious t h a t the present study d i d not meet the c r i t e r i a necessary f o r e f f e c t i v e r e s e a r c h . The l i t e r a t u r e r e p e a t e d l y emphasized t h a t p o s i t i v e research r e s u l t s r e v e a l the extent t o which the o b j e c t i v e s of a .given program are achieved by the p a r t i c i p a n t s when measured by methods which are o b j e c t i v e , systematic and comprehensive. This study d i d not t r y t o assess o b j e c t i v e l y the way p a r t i c i p a n t s met the o b j e c t i v e s o f the program. The data was i n t r o s p e c t i v e and s u b j e c t i v e ; the method, though systematic, was p a r t l y i m p r e s s i o n i s t i c , and r e s t r i c t e d . The r e l a t i o n s h i p o f improved performance t o e a s i l y measured r e s u l t s d i s -cussed i n the l i t e r a t u r e was s a i d t o be complex, and c e r t a i n l y i n t h i s study the r e l a t i o n s h i p cannot be proved. The study showed improvement occurred, but i t was measured i n the p e r c e p t i o n o f the respondent about her own performance, and i s t h e r e f o r e l i m i t e d by the i n t r o s p e c t i v e s k i l l o f the respondents and t h e i r p r o f e s s i o n a l i n t e g r i t y . When the per-formance t o be measured i s i n the f i e l d o f c o g n i t i o n , judgment and p e r s o n a l e f f e c t i v e n e s s , o b j e c t i v e measures are not a v a i l a b l e . The s u b j e c t i v e p e r c e p t i o n o f the respondents could p o s s i b l y have been measured against the judgments o f t h e i r immediate s u p e r v i s o r s , but these would a l s o have been s u b j e c t i v e e v a l u a t i o n s . P o s s i b l y the o n l y r e l i a b l e r e s u l t s i n terms o f work s i t u a t i o n s were l a t e n t r a t h e r than manifest. Any value attached to.the r e s u l t a n t conclusions t h e r e f o r e r e s t s on two c r e d i b i l i t y f a c t o r s inherent i n the methodology, which i s discussed i n the next s e c t i o n . Aspects o f the Methodology The purposes o f the study were t o evaluate the i n s t i t u t e as an e f f e c t i v e t o o l i n c o n t i n u i n g education, and to s u b j e c t t o c r i t i c a l a n a l y s i s a method of e v a l u a t i o n . The f i r s t purpose could be considered to have been met i f the r e s u l t s can be accepted on the s u b j e c t i v e b a s i s on which they were obtained, i . e . , i f the phrase " p r o f e s s i o n a l i n t e g r i t y " i s accepted as a v a l u e , even though i t i s not s t a t i s t i c a l l y e s t a b l i s h e d . In t h i s study, the opinions of the respondents were accepted at a h i g h l e v e l o f c r e d i b i l i t y . Whether n u r s i n g i s c l a s s e d as a p r o f e s s i o n or as a t e c h n i c a l t r a i n i n g i s s t i l l a c o n t r o v e r s i a l i s s u e , but h o s p i t a l p r a c t i c e i s dependent upon the a t t i t u d e o f people toward t h e i r work and upon t h e i r acceptance o f r e s p o n s i b i l i t y . The work o f a nurse t h e r e f o r e cannot be compared t o the work of a person i n i n d u s t r y where pr o d u c t i o n can be measured. I n the examination o f the e f f e c t i v e -ness o f c o n t i n u i n g education on the work o f a nurse, the w r i t e r sees no reason f o r not r e l y i n g on the p r o f e s s i o n a l i n t e g r i t y o f the respondents. In a d d i t i o n , h i g h c r e d i b i l i t y was accepted, p a r t l y because the respondents as a whole expressed the o p i n i o n t h a t they had learned nothing new at the i n s t i t u t e , and p a r t l y because o f the impressions r e c e i v e d by the i n t e r v i e w e r , to which f u r t h e r reference i s made below. The i n s t i t u t e was designed, t o educate the p a r t i c i p a n t s , , not t o change i n s t i t u t i o n s . I f the perceived changes o f the respondents were not r e f l e c t e d i n I n s t i t u t i o n a l changes, t h i s d i d not d i m i n i s h the e f f e c t i v e n e s s o f the i n s t i t u t e . Apparently, however, i n s t i t u t i o n a l change was e f f e c t e d i n seven o f the I n s t i t u t i o n s represented. Although 95 t h i s was not an i n t e n t i o n of the i n s t i t u t e , i t tends to support the c r e d i b i l i t y o f the s u b j e c t i v e responses. I f each respondent i n t h i s study had chosen each of the c a t e g o r i e s used i n t a b u l a t i n g the r e s u l t s , $00 changes would have been i n d i c a t e d . The t o t a l number o f changes perceived however, was 468, o f which 169 were i n knowledge, 146 i n a t t i t u d e , and 153 i n p r a c t i c e . For those respondents who perceived change, t h i s i n d i c a t e d approximately 12 changes f o r each. S t a t i s t i c s such as these are somewhat meaningless, except t h a t they i n d i c a t e a trend toward change. VThen l e a r n i n g i s d e f i n e d as a change i n behavior, the t r e n d toward change can be considered as a d e f i n i t e and p o s i t i v e outcome o f an e d u c a t i o n a l experience. Perceived change was i d e n t i f i e d and a t t r i b u t e d to the i n s t i t u t e by the respondents. However, the study provided no evidence t o show t h a t the i n s t i t u t e was de f a c t o r e s p o n s i b l e f o r the changes which were pe r c e i v e d . The method used i n the study d i d not allow f o r the d i s c r i m i n a t i o n o f confounding v a r i a b l e s . . To provide such evidence would r e q u i r e an o b j e c t i v e p r e t e s t to e s t a b l i s h a b a s e l i n e . Although p r e t e s t i n g was not p o s s i b l e f o r reasons mentioned p r e v i o u s l y , such a b a s e l i n e could, however, o n l y have been e s t a b l i s h e d f o r a sub-sequent change i n knowledge. I n view of the l a c k o f u n i f o r m i t y o f i n s t i t u t i o n a l p r a c t i c e s as r e v e a l e d i n the study," such a t e s t would be meaningless i n terms of the b e h a v i o r a l concept o f l e a r n i n g used i n the study. The i n s t i t u t e was designed to increase knowledge, but i t was a l s o designed t o modify a t t i t u d e s and to change p r a c t i c e through these f a c t o r s . There was a second c r e d i b i l i t y f a c t o r inherent i n the method used, i . e . , the i n t e r v i e w e r . The acceptance o f i n f o r m a t i o n s u p p l i e d by 96 the respondents, which became the raw data of the study, as c r e d i b l e or otherwise was a judgment o f the i n t e r v i e w e r , who, u s i n g an u n s t r u c t u r e d i n t e r v i e w technique, formed impressions w h i l e r e c o r d i n g statements. I n the design of the study t h i s f a c t o r was h e l d as a constant throughout: one research worker performed the o b s e r v a t i o n a l a n a l y s i s o f the i n s t i t u t e , a l l i n t e r v i e w s , and a l l compilations and s t a t i s t i c a l treatments o f the data. A growing body of research leads the educator t o b e l i e v e t h a t s o c i a l and economic f a c t o r s i n l i f e experience i n f l u e n c e the l e a r n i n g processes o f students. How f a r such f a c t o r s i n f l u e n c e the p r o f e s s i o n a l c o n t i n u i n g education o f nurses has not been e s t a b l i s h e d . How f a r , i f at a l l , they a p p l i e d t o a c o n t i n u i n g education program as short as a two day i n s t i t u t e f o r head nurses was a second p a r t of t h i s study. I f t h e i r i n f l u e n c e was s i g n i f i c a n t , the r e s u l t s would be o f value i n the planning o f f u t u r e i n s t i t u t e s and i n the s e l e c t i o n o f p a r t i c i p a n t s . I t was s t a t e d (Chapter I I ) t h a t no s p e c i f i c p r o f i l e o f the p a r t i c i p a n t s i n t h i s study emerged. The ' t y p i c a l ' head nurse was not d i s c e r n a b l e from the data c o l l e c t e d on the backgrounds of the r e -spondents . I t was noted (Chapter IV) t h a t the few s i g n i f i c a n t r e s u l t s r e l a t i n g l e a r n i n g t o the background categories i n v o l v e d those o f age, education, experience, and s i z e o f employing agency, confirming what would appear t o be common sense e x p e c t a t i o n s . That these are the o n l y f a c t o r s , however, cannot be concluded from the present study. As a research t o o l , the instrument used was inadequate to the 97 e x p l o r a t i o n undertaken. F o r example, o f those 45 years o f age or l e s s , 5$ o f the sample i n d i c a t e d no change i n behavior. This 5$ a c t u a l l y represented o n l y one person, w h i l e the other 95$ represented 21 persons. A much l a r g e r sample, perhaps a t o t a l p o p u l a t i o n , would be necessary, to supply the numbers necessary f o r v a l i d r e s u l t s , whether these proved negative o r p o s i t i v e . The examination o f a t o t a l p o p u l a t i o n to determine change a f t e r a two day i n s t i t u t e would not be economically d e f e n s i b l e , e s p e c i a l l y as i t would probably prove impossible to d i s t i n g u i s h change a t t r i b u t a b l e t o the i n s t i t u t e from t h a t a t t r i b u t a b l e t o recent c o n t i n u i n g education i n other forms, except at the l e v e l o f knowledge. Fa c t o r s other than the i n s t i t u t e which might i n f l u e n c e change would t h e r e f o r e have to be i d e n t i f i e d , i s o l a t e d and measured. Apart from the expense of such research i t i s d o u b t f u l whether r e l i a b l e d i s c r i m i n a t o r y measures e x i s t f o r the purpose. P r o v i n c i a l s t a t i s t i c s on n u r s i n g s t a t e t h a t there were 653 r e g i s t e r e d nurses employed as head nurses i n B r i t i s h Columbia i n 1967-One o f the l a r g e r h o s p i t a l s , which employs approximately 8$ o f the p r o v i n c i a l head nurse p o p u l a t i o n , had an i n s e r v i c e e d u c a t i o n a l program during 1967-8 on communication, which i n c l u d e d both e v a l u a t i n g and i n t e r -v iewing p e r s o n n e l . 1 In March of 1968, over h a l f the employed head nurses i n B r i t i s h Columbia (other than the 8$ mentioned) p a r t i c i p a t e d i n the i n s t i t u t e s on personnel e v a l u a t i o n h e l d i n Vancouver, V i c t o r i a , and P r i n c e George. The study sample o f 4-5 respondents was approximately 7$ o f the t o t a l p o p u l a t i o n o f p r o v i n c i a l head nurses, o r 14$ o f those" 98 a t t e n d i n g a l l the i n s t i t u t e s . I f these respondents are i n any way r e p r e s e n t a t i v e o f the head nurses i n B r i t i s h Columbia (and the study r e v e a l e d t h a t they were), then the c l a i m t h a t changes could have occurred d u r i n g the ensuing year i s v a l i d . The study, however, revealed t h a t change i n p r a c t i c e i s s u b j e c t to i n s t i t u t i o n a l p o l i c y . A c l a i m t h a t considerable changes have, i n f a c t , occurred beyond the s i t u a t i o n s ' s t u d i e d cannot t h e r e f o r e be v a l i d l y made. The l i m i t a t i o n s o f the study were o u t l i n e d i n Chapter I and o n l y c o n f i r m a t i o n o f those f a c t o r s brought out i n the study i s mentioned here. The r e s u l t s were p o s s i b l y skewed by the i n c l u s i o n o f those i n p u b l i c h e a l t h agencies, those i n t r a n s i e n t p a t i e n t areas, those i n s u p e r v i s o r y p o s i t i o n s above the l e v e l o f head nurse, and those c u r r e n t l y e n r o l l e d i n the N.U.A. course. A b e t t e r s e l e c t i o n o f a sample by e d u c a t i o n a l and e x p e r i e n t i a l background might have prevented t h i s p o s s i b i l i t y . The study sample was a 25$ random s e l e c t i o n of a p o p u l a t i o n o f 189 r e g i s t e r e d nurses, and was too s m a l l f o r any s t a t i s t i c a l l y s i g n i f i c a n t i n f erences t o be drawn. Conclusions A number of conclusions were i n t r i n s i c to the study. C e r t a i n conclusions e x t r i n s i c t o the study but inherent i n the data are l i s t e d i n paragraphs 5> 6, 7 a ^ d ih below. While these conclusions are not r e l e v a n t to the e v a l u a t i o n o f the i n s t i t u t e , they are r e l e v a n t to the purposes f o r which i t was organized, and t h e r e f o r e to c o n t i n u i n g education 99 f o r nurses. A c c o r d i n g l y , they have been in c l u d e d here. 1. The i n s t i t u t e was s u c c e s s f u l as determined by the enjoyment o f the p a r t i c i p a n t s and by t h e i r p e r c e p t i o n of. change i n ways f o r which the i n s t i t u t e was designed. 2. The i n s t i t u t e was w e l l designed as the l e v e l o f p o s i t i v e r e s u l t s was h i g h , and and as i t provided the m a t e r i a l which the p a r t i c i p a n t s needed t o change t h e i r behavior i n d i r e c t i o n s which they f e l t were congruent w i t h t h e i r work s i t u a t i o n . 3- Through i n f l u e n c i n g the p a r t i c i p a n t s , the i n s t i t u t e s a f f e c t e d i n s t i t u t i o n a l p o l i c y i n over kOfo o f the agencies represented. Although t h i s was not an i n t e n t i o n o f the i n s t i t u t e , i t i s p r a c t i c a l evidence o f i t s success as an instrument i n c o n t i n u i n g education. •h. The i n s t i t u t e s t i m u l a t e d a g r e a t e r awareness o f the need f o r c o n t i n u i n g education, p r o f e s s i o n a l h e l p o r consultant s e r v i c e s , and f o r i n t r a i n s t i t u t i o n a l education. 5. As the study showed a r e l a t i o n s h i p o f l e a r n i n g t o education and experience, an i n s t i t u t e should be based on a problem census and s e l e c t i o n o f p a r t i c i p a n t s should match i n s t i t u t e o b j e c t i v e s . 6. There is . a need f o r r e c u r r i n g i n t e r v a l - o f - t i m e s u b j e c t i v e e v a l u a t i o n s such as t h i s study, though not n e c e s s a r i l y w i t h more than a r i t h m e t i c treatment o f r e s u l t s . Through these, e v a l u a t i o n of past-o f f e r i n g s would occur, and recommendations f o r other e d u c a t i o n a l o f f e r i n g s would a r i s e . 7. To reach s i g n i f i c a n t conclusions of g e n e r a l a p p l i c a t i o n about the r e l a t i o n s h i p o f socioeconomic data t o l e a r n i n g , there needs-to be a-much l a r g e r sample (perhaps a t o t a l population) than was used i n t h i s .study.. 100 . f 8. The i n s t i t u t e apparently served as an impetus t o some p a r t i -c i p a n t s and an encouragement to others toward f u r t h e r formal education. 9- The i n s t i t u t e d i d not change the .reading h a b i t s o f the p a r t i c i p a n t s . 10. Many head nurses reported t h a t t h e i r changed behavior l e d t o increased cooperation and i n t e r a c t i o n w i t h s t a f f members, and t h a t i n t e r v i e w s were two-way more than they had been "before the i n s t i t u t e . .11.. Some head nurses showed more democratic a t t i t u d e s toward human r e l a t i o n s , and i n d i c a t e d b e t t e r rapport w i t h s t a f f members i n i n t e r a c t i o n s a f t e r the i n s t i t u t e . 12. Group d i s c u s s i o n s were apparently h e l p f u l i n p r o v i d i n g r e -a f f i r m a t i o n o f procedures f o r some respondents. 13• The methodology used was the o b j e c t i v e study of s u b j e c t i v e data; i n t h i s case, a s t a t i s t i c a l refinement of a process commonly used by p r o f e s s i o n a l a d m i n i s t r a t o r s of c o n t i n u i n g education programs. Although no s t a t i s t i c a l computation could be attempted, i t was concluded t h a t i n s t i t u t i o n a l p o l i c y changes recorded i n the r e s u l t s supported the assumption o f a h i g h c r e d i b i l i t y o f the data. I t was a l s o concluded t h a t i f no r e l i a b i l i t y i s accorded p r o f e s s i o n a l statements by p r o f e s s i o n a l persons concerning t h e i r p r o f e s s i o n a l work (arguable as a b a s i c assumption i n the o r g a n i z a t i o n o f much medical and e d u c a t i o n a l a c t i v i t y ) f u t u r e s t u d i e s u s i n g s u b j e c t i v e data should s t a r t from and conclude at o b j e c t i v e l y determined p o i n t s . Ih. The study provided a number of recommendations u s e f u l i n work s i t u a t i o n s and c o n t i n u i n g education of nurses, as discussed i n s e c t i o n s A and B o f the I m p l i c a t i o n s . I t was concluded t h a t these recommendations, 101 r a i s e d d i r e c t l y "by the p a r t i c i p a n t s and exceeding the l i m i t s o f data needed f o r computation, were a p o s i t i v e value o f a methodology u s i n g u n s t r u c t u r e d i n t e r v i e w s f o r the c o l l e c t i o n o f s u b j e c t i v e data. I m p l i c a t i o n s The i m p l i c a t i o n s which a r i s e from the study are i n three areas: A) the work s i t u a t i o n , B) f u r t h e r e d u c a t i o n a l programs, and C) f u r t h e r research A. The work s i t u a t i o n . 1. The need of many o f the respondents f o r reassurance and i n -creased sources o f i n f o r m a t i o n to answer questions became apparent during t h i s study. Many expressed t h e i r d e s i r e f o r o p p o r t u n i t i e s t o di s c u s s p e r s o n a l l y the va r i o u s problems they encountered d a i l y , and problems i n v o l v e d i n s u p e r v i s i n g and e v a l u a t i n g a c o n s t a n t l y changing s t a f f . P o s s i b l y i t i n e r a n t n u r s i n g consultants could h e l p i n s t i t u t e p a r t i c i p a n t s through i n d i v i d u a l t u t o r i a l i n s t r u c t i o n to r e c a l l f o r -g o t t e n m a t e r i a l o r t o e l u c i d a t e misunderstood p r i n c i p l e s given a t an i n s t i t u t e . This i s r i g h t f u l l y the job o f the s u p e r v i s o r , but she might a l s o b e n e f i t from the s e r v i c e s o f such a c o n s u l t a n t . The expense i n v o l v e d would be g r e a t , but the b e n e f i t s might be w e l l worthwhile, p a r t i c u l a r l y I f a l a r g e p r o p o r t i o n o f head nurses are without adequate, p r e p a r a t i o n . 2. The need was a l s o revealed f o r d i s c u s s i o n s w i t h i n agencies on the e v a l u a t i o n process, w i t h p a r t i c u l a r emphasis on those aspects 102 r e l e v a n t t o the needs o f the s p e c i f i c head nurses and su p e r v i s o r s i n -volved . 3- Many head nurses expressed the d e s i r e f o r personal .evaluations by t h e i r s u p e r v i s o r s . These should be p a r t o f an ongoing process. h. There should be increased l i b r a r y resources a v a i l a b l e t o nurses w i t h i n t h e i r employing agencies. 5. There needs t o be more emphasis w i t h i n agencies on the concept o f c o n t i n u i n g education f o r a l l nurses. 6. There should be more emphasis on the need f o r teaching o f subordinates and f o r encouraging t h e i r continued l e a r n i n g . 7- When head nurses express f e e l i n g s o f inadequacy or unworthiness d i s p r o p o r t i o n a t e to t h e i r p o s i t i o n s , they hould be given s p e c i a l -e d u c a t i o n a l programs o r p o s s i b l y be r e v e r t e d t o bedside n u r s i n g . T h e i r continued expressions o f inadequacy would tend to undermine the con-f i d e n c e o f t h e i r s t a f f s . 8. A l l members of a work group should be i n c l u d e d i n the planning and implementing o f changes f o r t h a t group. O r i e n t a t i o n o f new s t a f f members should i n c l u d e the implemented changes. B. F u r t h e r e d u c a t i o n a l programs. 1. The l a c k o f p r e p a r a t i o n o f many o f the head nurses i n the sample (and o f head nurses i n B r i t i s h Columbia and Canada) i n d i c a t e d an i n -creased need f o r i n s t i t u t e s o f the type d i s c u s s e d i n t h i s study. A s t a t i s t i c a l r e l a t i o n s h i p was demonstrated between the formal p r e p a r a t i o n o f the respondent and her p e r c e p t i o n o f change. 103 2. The r e p e t i t i o n o f i n s t i t u t e s at s u i t a b l e i n t e r v a l s was i m p l i e d by the responses o f those who perceived few o r no changes, yet f e l t t h a t b e n e f i t accrued from the i n s t i t u t e through r e a f f i r m a t i o n o f current performance. 3• The data revealed t h a t the l e s s experienced head nurses had d i f f i c u l t y i n r e t a i n i n g a l l they had le a r n e d i n the i n t e n s i v e two day i n s t i t u t e . a n d t h a t , . w h i l e t h e i r p r a c t i c e changed s i g n i f i c a n t l y , i t tended not t o reach the l e v e l made p o s s i b l e by the i n s t i t u t e . The n e c e s s i t y f o r repeat i n s t i t u t e s o r pr o g r e s s i v e e d u c a t i o n a l programs was th e r e f o r e i m p l i e d . h. Some method needs t o be found t o encourage and support admini-s t r a t o r s i n the upgrading o f t h e i r s t a f f s . 5- The study revealed t h a t changes occurred in p r a c t i c e but w i t h -out any knowledge o f how or why they occurred. I t i s i m p l i e d t h a t i n s t i t u t e s on the process o f change o r on the adoption o f innovations would be v a l u a b l e f o r s e n i o r a d m i n i s t r a t i v e s t a f f . 6. The use o f i n s t i t u t e s o r i n t e r i n s t i t u t i o n a l group s e s s i o n s , t u t o r i a l s , o r conferences should be an i n t e g r a l p a r t o f correspondence course education. The N.U.A. course i s an e x c e l l e n t example o f t h i s . The process has a l s o been standardized f o r E x t e r n a l (correspondence) S t u d i e s by the U n i v e r s i t y o f New England, Armidale, New South Wales, A u s t r a l i a , (see i t s calendar) 104 C. F u r t h e r research. 1. Other than t h a t the p a r t i c i p a n t s should he head nurses, no s e l e c t i v e process was used f o r admission to the i n s t i t u t e under study. The i n s t i t u t e was designed i n advance o f any study o f the needs of the p a r t i c i p a n t s , i . e . , t h e i r needs were assumed. E v a l u a t i o n s t u d i e s o f ed u c a t i o n a l o f f e r i n g s should continue to a i d i n the planning o f f u t u r e o f f e r i n g s and i n the s e l e c t i o n o f p a r t i c i p a n t s so t h a t needs and pre s e n t a t i o n s may be matched. 2. The c r e d i b i l i t y s i t u a t i o n d i s c u s s e d i n t h i s study i m p l i e s a need f o r a s i m i l a r study w i t h the a d d i t i o n o f a c o n t r o l group and the predetermination o f e v a l u a t i o n p r a c t i c e s f o r both groups, so t h a t the e f f e c t o f the i n s t i t u t e could be more n e a r l y a s c e r t a i n e d q u a n t i t a t i v e l y . 3. A study o f a t t i t u d e and p r a c t i c e change f o l l o w i n g d i f f e r i n g forms o f c o n t i n u i n g education i s i m p l i e d , e.g., i n s t i t u t e , workshop, correspondence course, e t c . h. A study o f h o s p i t a l s e t t i n g s i s i n d i c a t e d t o i d e n t i f y those f a c t o r s which f a c i l i t a t e o r dete r change. 5- A study o f p r o f e s s i o n a l o p i n i o n r e l a t e d t o a given s e t of f a c t s i s i m p l i e d t o e s t a b l i s h the c r e d i b i l i t y o f p r o f e s s i o n a l o p i n i o n . 6. A study i s i n d i c a t e d t o determine the best way to increase the reading h a b i t s o f nurses. 7. To e s t a b l i s h the r e l a t i o n s h i p o f background data t o l e a r n i n g , s i m i l a r s t u d i e s i n e v a l u a t i o n would appear to need a p r o p o r t i o n a l l y g r e a t e r sample o f the p o p u l a t i o n . 8. 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Winter, 1$66. 14:75-79-S e w e l l , W.H. "Some recent developments i n s o c i a l i z a t i o n theory and research.". The Annals o f the American Academy o f P o l i t i c a l and S o c i a l S c i e n c e . September, 1963• 349:l63-19l« 112 Tate, B.L. " E v a l u a t i o n o f c l i n i c a l performance o f the s t a f f nurse." Nursing Research. 1962 • 11:7-9-T h i s t l e t h w a i t e , D. " A t t i t u d e and s t r u c t u r e as f a c t o r s i n the d i s t o r t i o n o f reasoning." J o u r n a l o f Abnormal and S o c i a l Psychology. 1950. 45:Mi2-U5o\ Whitaker, J . "The changing r o l e o f the p r o f e s s i o n a l nurse i n the h o s p i t a l . " American J o u r n a l o f Nursing. I 9 6 2 . 62(2)165-67. MISCELLANEOUS Belyea, E.L-. Personal Interview. June, 1968. Canadian Nurses A s s o c i a t i o n . Research U n i t . " P r o v i n c i a l Inventory o f Nurses, B r i t i s h Columbia, 1967." Ottawa, Canadian Nurses A s s o c i a t i o n , May, 1968. Mimeographed. Nelson, J . "Role P e r s o n a l i t y C o n f l i c t i n t h e Team Leader Role." Unpublished Masters' T h e s i s . Los Angeles, U n i v e r s i t y o f C a l i f o r n i a , I966. R o e t h l i s b e r g e r , F . J . " B a r r i e r s and Gateways to Communication. P a r t I I . " Education 516• Mimeographed. Undated. Rogers, C.R. " B a r r i e r s and Gateways to Communication. P a r t I . " Education 5l6. Mimeographed. Undated. Ruane, K. Pe r s o n a l Communication. October, 1968. Su t t o n , E.W. " A n a l y s i s o f Research on S e l e c t e d Aspects o f E v a l u a t i o n i n Adult Education." Unpublished D o c t o r a l D i s s e r t a t i o n . T a l l a h a s s e e , F l o r i d a S t a t e U n i v e r s i t y , I966. APPENDICES 114 APPENDIX A THE NURSING UNIT ADMINISTRATION CORRESPONDENCE COURSE (THE N.U.A. COURSE) The Canadian Nurses A s s o c i a t i o n and the Canadian H o s p i t a l A s s o c i a t i o n have j o i n t l y sponsored an extension o r correspondence course i n Nursing U n i t A d m i n i s t r a t i o n f o r head nurses i n Canada s i n c e i 9 6 0 . The course i s described by i t s sponsors as an i n s e r v i c e type of program designed "to d e f i n e the f u n c t i o n s o f a d m i n i s t r a t i o n • a n d to show how these may be c a r r i e d out i n the management o f the n u r s i n g u n i t . " I t i s p r i m a r i l y designed f o r those who have been promoted i n t o s u p e r v i s o r y p o s i t i o n s without adequate p r e p a r a t i o n and are unable to attend a u n i -v e r s i t y to upgrade t h e i r s k i l l s . I n I966 an e v a l u a t i o n of t h i s course was done w i t h the aims o f evalxiating whether the purpose o f the course was being met, examining the e f f i c i e n c y o f the method, and forming guide l i n e s f o r f u t u r e a c t i o n . Information was gathered i n personal i n t e r v i e w s across the country from the t u t o r s who marked the l e s s o n s , graduates o f the course, e n t e r i n g students, h o s p i t a l a d m i n i s t r a t i v e personnel, and n u r s i n g and u n i v e r s i t y c o n s u l t a n t s . The r e s u l t s showed t h a t the course i s w e l l known and w e l l thought o f by h o s p i t a l personnel. Graduates have been the best p u b l i c r e l a t i o n s t o o l . Cooperation f o r students to attend the a s s o c i a t e d work-115 shops i s h i g h , although most students pay t h e i r own expenses. Many changes have "been suggested f o r the course and f o r employing h o s p i t a l s by the graduates and students. The course s t i m u l a t e d more reading f o r i t s students, and a l s o suggestions by the students f o r other s t a f f . APPENDIX B INSTITUTE INTERVIEW Name No. Marital Status 1. Single 2. Married 3. Widowed, divorced or separated If married, husband's occupation Number of children 1. 0-5 years 2. 6 - 10 3. 11-15 4. 15 or over Age 1. under 25 years 2. 25 - 29 3. 30 - 34 4. 35 - 39 5. 40-44 6. 45 - 49 7. 50 - 54 8. 55 - 59 9. 60-65 Gross annual salary 1. under $3000 2. 3000 - 3999 3. 4000 - 4999 4. 5000 - 5999 5. 6000 - 6999 6. 7000 - 7999 7. 8000 - 8999 8. 9000 or over 117 Names of organizations belonged to in past year, excluding church membership but including church organizations. Total Score Name of Organization Atten-dance Finan-cial con-tribution Member of Com-mittee Offices Held 1. 2. 3. 4. 5. 6. 7. 8. Total (XI) (X2) (X3) (X4) (X5) Score 0 I - 5 6-10 II - 15 16 - 20 21 - 25 26 - 30 31 - 35 Over 35 8. What was the highest grade of school you completed? 1. Some high school 2. Junior matriculation or high school graduation 3. Senior matriculation or first year university 4. 2 years university 5. 3 years university 6. over 3 years university 9. Where did you take your basic nursing course ? 1. B.C. 2. Canada (other than B. C.) 3. United States 4. Great Britain 5. Other, specify. 10. Year of graduation 1. 1920 - 1929 2. 1930 - 1939 3. 1940 - 1949 4. 1950 - 1959 5. 1960 - 1967 118 11. What type of hospital or institution was your course associated with? 12. Post basic nursing education (give year). 1. None 2. CNA Correspondence course inward administration 3. University diploma course in a. public health nursing b. administration c. supervision d. teaching e. psychiatry-f. other, specify. 4. University degree(s) a. degree(s) b. specialty 5. Other, specify 13. In the past five years, have you taken any nursing courses not covered in the previous question? 14. What post high school training have you had other than nursing? 1. None 2. Business 3. Secretarial 4. University degree, specify field 5. Other, specify 15. In the past five years have you taken any non-nursing courses? 16. Are you interested in further courses in adult education? 17. How many years of experience have you had in nursing? 18. For how many years have you been a head nurse? 1. 2. None Course Institution 1. Yes 2. No 1. Yes 2. No 119 19. What is the approximate bed count of your hospital? 20. What type of nursing unit are you working on? • 21. What is the bed count of the nursing unit? 22. What number of personnel does your unit have? . 23. Kropp Verner attitude scale score. 24. What did you learn that was new at the Institute ? How have you changed your evaluative procedure since the Institute ? APPENDIX C STRUCTURED FORMAT FOR PERCEIVED CHANGE I . No change I I . Change A. Knowledge 1. Reawareness o f previous knowledge. 2 . B e t t e r understanding o f the reasons f o r e v a l u a t i o n . 3 - B e t t e r understanding o f p r e p a r a t i o n o f e v a l u a t i o n s . k. B e t t e r understanding o f r e c o r d i n g o r w r i t i n g e v a l u a t i o n s . .5. B e t t e r understanding o f di s Q c s s i n g e v a l u a t i o n s . 6. Others have s i m i l a r problems. J. There are other p o i n t s o f view besides one's own. B. A t t i t u d e . 1. D i f f e r e n t f e e l i n g about i n t e r v i e w s . 2. D i f f e r e n t philosophy about e v a l u a t i o n s . . ' 3 - Evaluations are e a s i e r to do now. h. More confidence i n doing e v a l u a t i o n s . 5- Expectations are now two way. 6. There are other p o i n t s o f view besides one's own. 7- More confidence i n a b i l i t y t o f i l l p o s i t i o n . 121 P r a c t i c e 1. S u p e r v i s i o n a) more observant o f s t a f f performance. b) more explanations and reasons to s t a f f . c) more d i p l o m a t i c and t a c t f u l . d) problems d e a l t with,immediately. 2. Teaching a) t e a c h i n g planned on observations o f performance. 3• O r i e n t a t i o n a) now doing o r i e n t a t i o n s . b) planning new o r i e n t a t i o n . c) o u t l i n e s expectations and/or job d e s c r i p t i o n s . d) more time spent w i t h new s t a f f members. e) o r i e n t a t i o n more s p e c i f i c and more d e t a i l e d . k. Anecdotal notes a) anecdotal notes now c o l l e c t e d . b) more anecdotal notes kept. c) anecdotal notes more s p e c i f i c and o b j e c t i v e . d) c o l l e c t s anecdotal notes w r i t t e n by other s t a f f . e) c o l l e c t s and records comments on s t a f f by doctors and p a t i e n t s . 5- E v a l u a t i o n r e p o r t s a) more o b j e c t i v e . b) more f u t u r e o r i e n t e d . c) more c a r e f u l i n d e s c r i b i n g behavior. d) e a s i e r because more con f i d e n t o f f a c t s . e) more head nurse d i s c u s s i o n s o f e v a l u a t i o n . 122 6. Interviews a) more regular.. b) more frequent. c) more i n f o r m a l . d) more two way d i s c u s s i o n s . e) more p r i v a t e and more planned. f ) more p r a i s e .and encouragement g i v e n . g) more s p e c i f i c . • h) more o b j e c t i v e . i ) e a s i e r because reports are b e t t e r , j ) e a s i e r because f a c t s are a v a i l a b l e . APPENDIX D THE KROPP VERNER ATT HUD S SCALE From the statements "below, which most c l o s e l y describes your o p i n i o n of the I n s t i t u t e on E v a l u a t i o n which you attended? 1. I t was one of the most rewarding experiences I have ever had. 2. E x a c t l y what I wanted. 3- I hope we can have another one i n the near f u t u r e . k. I t provided the k i n d o f experience t h a t I can apply to my own s i t u a t i o n . 5. I t helped me p e r s o n a l l y . 6. I t solved some problems f o r me. 7- I t h i n k i t served i t s purpose. 8, I t had some m e r i t s . 9. I t was f a i r . 10. I t was n e i t h e r very good nor very poor. 11. I was m i l d l y d i s a p p o i n t e d . 12• I t was not e x a c t l y what I needed. 13• I t was too g e n e r a l . Ik. I d i d not take any new ideas away. 15. I t d i d n ' t h o l d my i n t e r e s t . 16. I t was much too s u p e r f i c i a l . 17. I l e f t d i s s a t i s f i e d . 124 18. I t was very p o o r l y planned. 19- I d i d n ' t l e a r n a t h i n g . 20. I t was a complete waste o f time. APPENDIX E THE LEARNING SITUATION Learning i s d e f i n e d i n - t h e b e h a v i o r a l sciences as a change i n behavior which i s more or l e s s permanent. 1 The d e f i n i t i o n i s a p p l i c a b l e t o knowledge, a t t i t u d e and s k i l l s , although o n l y knowledge can be o b j e c t i v e l y measured. I f new behavior i s to be l e a r n e d , the l e a r n e r must have knowledge about t h i s new behavior, a t t i t u d e s which are p o s i t i v e toward t h i s new behavior, and a s i t u a t i o n where he can p r a c t i c e or u s e - i t . A c q u i s i t i o n o f new behavior i s , t h e r e f o r e , dependent upon l e a r n i n g , a need t o change, a c l i m a t e conducive f o r l e a r n i n g , and approval o f the co-members of one's groups. Knowledge Knowledge i s the a c q u i s i t i o n o f f a c t s about one's world, and the frames of reference o r c o g n i t i v e c o n f i g u r a t i o n s which the i n d i v i d u a l develops to keep h i s i n f o r m a t i o n c l a s s i f i e d , systematized, or l o g i c a l l y 2 sequenced. Our c o g n i t i v e world i s constructed on.what we t h i n k , b e l i e v e , and expect. Hence, "the responses of the i n d i v i d u a l t o persons and t h i n g s are shaped by the way they look t o him--his c o g n i t i v e world. As each person has a d i f f e r e n t e x p e r i e n t i a l background, each has a d i f f e r e n t c o g n i t i v e world. An e g o c e n t r i c assumption t h a t 'our' c o g n i t i v e world i s the same as t h a t o f others leads to confusion and d i f f i c u l t i e s h i n i n t e r a c t i o n s , communication and understanding. 126 By the time- a person i s an a d u l t , he has u s u a l l y developed complex c o g n i t i v e s t r u c t u r e s which he uses as anchors f o r any new m a t e r i a l w i t h which he i s presented. These s t r u c t u r e s are concepts, which form as the person o r g a n i z e s , groups, and systematizes h i s knowledge. Harvey defines a concept as a mode o f relatedness between the i n d i v i d u a l 5 and h i s w o r l d . When the person i s presented w i t h new m a t e r i a l , he accepts and s t o r e s i t i n h i s memory. I f the m a t e r i a l has no r e l a t i o n -s h i p t o anything he has s t o r e d b e f o r e , he i s l i k e l y to d i s c a r d i t , but i f i t i s r e l a t e d t o previous concepts, he adds i t to h i s previous cog-n i t i v e c o n f i g u r a t i o n s by modifying these, o r adding to them. On the whole, we do not l i k e to change things too d r a s t i c a l l y as t h i s would destroy our r e l a t i o n s h i p w i t h "our" world. We are more l i k e l y to d i s t o r t the i n f o r m a t i o n we have received so t h a t i t w i l l f i t our preconceived concepts, even though these may have been formed w i t h too l i t t l e i n f o r -mation. . (This w i l l be f u r t h e r discussed under A t t i t u d e s ) Human beings d i s l i k e ambiguity o r gaps i n knowledge, and tend to bend or f i l l i n what they a l r e a d y 'know' w i t h f a n t a s i e s and imagi n a t i o n . I f nothing i s presented t o amend t h i s , the person may have f a u l t y concepts about many subj e c t s . New i n f o r m a t i o n w i l l change these concepts o n l y i n so f a r as the i n d i v i d u a l i s w i l l i n g t o accept new ideas and change h i s c o g n i t i v e p a t t e r n s . U s u a l l y concepts form from simple to complex, from concrete to a b s t r a c t , and from d i s c r e t e t o sys t e m a t i c . E d u c a t i o n a l o f f e r i n g s should 6 1 8 be based on a s i m i l a r sequence. ' ' The i n d i v i d u a l a l s o s t r i v e s f o r a l o g i c a l c o n sistency i n t h i s process o f c o g n i t i v e p a t t e r n i n g . This does not always occur, however, because o f changes which are c o n s t a n t l y t a k i n g 127 p l a c e i n ourselves arid i n our world. The concepts one holds are r e -i n f o r c e d and mo d i f i e d c o n t i n u a l l y by the r e a c t i o n s o f those around us 9 as we seek t h e i r approval o f our a c t i o n s . As a person develops m a t u r i t y , there i s a development o f l o g i c a l i n t e r r e l a t e d n e s s between h i s v a r i o u s concepts, g i v i n g h i s p e r s o n a l i t y an i n t e g r a t i o n o f values and knowledge."^ Concept formation and change occur r e a d i l y f o r the i n t e g r a t e d o r 'open' person, s i n c e he can examine m a t e r i a l r e a d i l y . When a l a c k o f i n t e r -r e latedness leads to compartmentalization o f concepts, r i g i d i t y and a 'closed' p e r s o n a l i t y d e v e l o p . 1 1 As concept formation and change are b a s i c t o problem s o l v i n g , the open person i s more l i k e l y t o seek a l t e r n a t i v e 12 pathways when an apparent s o l u t i o n i s not tenable. A t t i t u d e s A t t i t u d e s are the emotional components o f the f a c t s which a person s t o r e s , o r the " f e e l i n g tone" about these ideas o r c o n c e p t s . ^ They become a par t o f c o g n i t i v e c o n f i g u r a t i o n s as these develop through-Ih out childhood and adulthood. A t t i t u d e s w i l l have a decided i n f l u e n c e on what a person can accept or use t o a l t e r c o g n i t i v e p a t t e r n s . S h e r i f s t a t e s t h a t an a t t i t u d e i s not a p o i n t on a continuum, but r a t h e r a range 15 o f l a t i t u d e o f acceptance. A t t i t u d e s d e f i n e what a person i s and what he i s not. H a l l o r a n ' d e s c r i b e s a t t i t u d e s as being our major equipment f o r d e a l i n g w i t h r e a l i t y , and, as such, they r e f l e c t our s t y l e o f o p e r a t i o n i n coping w i t h problems and i n s i m p l i f y i n g complex s i t u a t i o n s l6 so we can d e a l w i t h them. A t t i t u d e s are learned along w i t h knowledge, and are b u i l t i n t o c o g n i t i v e concepts as these form. The g r e a t e s t source of i n f l u e n c e on a t t i t u d e formation i s the 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 one 128 IT has vrith important or s i g n i f i c a n t o t h e r s . 1 Thus, those i n our groups at work o r at home, w i l l have a decided e f f e c t on how we f e e l about l 8 t h i n g s and persons. A t t i t u d e s toward any new m a t e r i a l add new dimensions to whether or not a person can ' l e a r n ' the m a t e r i a l . I f new m a t e r i a l i s w i t h i n the ' l a t i t u d e o f acceptance', i t w i l l . b e handled as described on page 126, modifying or adding to e x i s t i n g c o g n i t i v e c o n f i g u r a t i o n s . However, i f the m a t e r i a l i s o u t s i d e h i s range o f acceptance, the person w i l l e i t h e r r e j e c t i t completely as meaningless to him, or he w i l l change i t i n some way to make i t acceptable. This i s how people ' t w i s t f a c t s ' or d i s t o r t r e asoning."^ A t t i t u d e s have degrees o f emotional e f f e c t f o r the i n d i v i d u a l a l s o , because they are p a r t o f a concept t h a t i s more o r l e s s meaningful to t h a t i n d i v i d u a l . When a concept i s very meaningful, i t i s w e l l p r o t e c t e d w i t h defense mechanisms. Such a concept i s considered a ' c e n t r a l concept', and has a low range o f acceptance f o r change. The most c e n t r a l concept f o r most people i s t h a t o f s e l f . When new i n -formation p e r t a i n s to a c e n t r a l concept, i t w i l l be accepted i f i t con-firms h i s concepts, but r e j e c t e d i f i t does not. A l e s s meaningful concept has l e s s emotional content, and i s not so r e a d i l y defended. Such a concept i s considered a p e r i p h e r a l concept, and has a wide range o f acceptance f o r change. Thus, the person w i t h most of h i s concepts i n the p e r i p h e r a l sphere Is more r e a d i l y i n f l u e n c e d than the person w i t h a P I PP great number o f c e n t r a l concepts .c-J->^ 129 P r a c t i c e S k i l l s are ways o f behaving i n coordinated, smooth, p r e c i s e p a t t e r n s as responses to the s t i m u l i o r cues of a s i t u a t i o n . ^ 3 P r a c t i c e i s u s u a l l y defined as the r e p e t i t i o n o f learned sequences of behavior u n t i l the p a t t e r n i s automatic or has become a h a b i t . C o n f u s i n g l y , i n n u r s i n g , p r a c t i c e i s used to denote the person ' p r a c t i c i n g ' n u r s i n g or working as a graduate nurse. Her s k i l l s are accepted as a l r e a d y acquired, although 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 k i l l s never become auto-ma t i c . Thus i n t h i s paper the term p r a c t i c e has been used to denote the acquired s k i l l r a t h e r than the a c q u i s i t i o n o f i t . In the a c q u i s i t i o n o f a new s k i l l , the i n d i v i d u a l s t a r t s from a background o f many alr e a d y e x i s t i n g , h i g h l y developed general and s p e c i f i c s k i l l s . Each a d u l t has hundreds o f these s k i l l s , each s k i l l w i t h i t s own background o f c o g n i t i v e p a t t e r n i n g . ^ As a person begins a new r o u t i n e , he t r i e s one o f h i s e x i s t i n g h a b i t p a t t e r n s . From h i s i n t e r n a l feedback o f ' f e e l ' and the responses of h i s environment, he w i l l adjust the p a t t e r n he t r i e d , or t r y another. His o r i g i n a l r e p e r t o i r e -of responses and h a b i t s i n f l u e n c e t h i s markedly. Performance d u r i n g the l e a r n i n g o f a s k i l l can be d e s c r i b e d as 27 passing through the stages o f c o g n i t i o n , f i x a t i o n and automation. ' The c o g n i t i v e stage i s the e a r l y stage, during which the person acquires the knowledge necessary f o r him to perform the behavior f o r which he i s s t r i v i n g . This stage i s one o f confusion as the person makes many e r r o r s o f wrong responses, or r i g h t responses at the wrong time. He has-to l e a r n the s t i m u l i o r cues i n h i s environment which are r e l e v a n t and i r r e l e v a n t t o h i s task.2® . G r a d u a l l y he l e a r n s to match appropriate cues 130 and responses as h i s i n f o r m a t i o n processing improves and h i s c o g n i t i v e c o n f i g u r a t i o n s develop. F i x a t i o n i s . the stage during which he r e f i n e s h i s responses through f u r t h e r s e l e c t i o n .and d i s c r i m i n a t i o n . This i s the po l o n g e s t p e r i o d i n l e a r n i n g a. s k i l l . y G r a d u a l l y there are decreasing e r r o r s and i n c r e a s i n g l y smooth, p r e c i s e and accurate responses. At t h i s p o i n t automation or h a b i t patterns have been e s t a b l i s h e d . ( F i t t s describes a c o g n i t i v e set or h a b i t as the -preparation i n advance f o r the. p r o b a b i l i t i e s or contingencies c h a r a c t e r i z i n g a c e r t a i n s i t u a t i o n . ) ^ S k i l l l e a r n i n g t h e r e f o r e i s a gradual s h i f t i n the f a c t o r s t r u c t u r e of. the s k i l l s as u n i t s become l a r g e r and c o g n i t i v e sets or h a b i t s develop. The d i s c o n t i n u i t y of movement i s lessened, and c o n t i n u i t y becomes smooth. -The Need to Change Often a s a t i s f a c t o r y and acceptable degree of competence i n o l d patterns of behavior makes a person u n w i l l i n g to r e l i n q u i s h the s e c u r i t y h i s competence gives him f o r the u n t r i e d and u n c e r t a i n r e a c t i o n s the new behavior may produce. The new behavior seems l e s s necessary or important t o him than to someone who does not have s a t i s f y i n g patterns o f behavior. For l e a r n i n g t o occur, the person must d e s i r e a change o r something must be done to induce him to f e e l a need to change. For some, e x t r i n s i c rewards may be s u p p l i e d through promotion, increased pay, encouragement, p r a i s e or other means which are meaningful to the l e a r n e r . For o t h e r s , the i n t r i n s i c g r a t i f i c a t i o n o f l e a r n i n g alone i s enough. Role p r e s c r i p t i o n s provide some of the major motivations to change. Role i s defined as "the p a t t e r n o f wants and g o a l s , b e l i e f s , . 131 f e e l i n g s , a t t i t u d e s , values and ac t i o n s which members o f a community expect would c h a r a c t e r i z e the t y p i c a l occupant o f a p o s i t i o n . Roles p r e s c r i b e the behavior expected o f people i n standard s i t u a t i o n s . " A p o s i t i o n i s defined as "a category or place i n a system o f s o c i a l c l a s s i f i c a t i o n . . . recognized by a community. Each i n d i v i d u a l occupies m u l t i p l e p o s i t i o n s , a s s o c i a t e d w i t h each of which i s i t s role."^3 Merton s t a t e s t h a t the i n d i v i d u a l behaves i n " r e g u l a r r o l e performance as a' l o g i c a l consequence o f the system o f sanctions imposed on those who f a i l t o meet, and rewards those who do meet, the expectations o f ••34 s o c i e t y . There are always i n c o m p a t i b i l i t i e s w i t h i n one r o l e , and 35 i n c o m p a t i b i l i t i e s between r o l e s . The way an i n d i v i d u a l behaves i n h i s r o l e s r e f l e c t s both h i s p e r s o n a l i t y and the incompatible and con-f l i c t i n g demands and expectations o f others . Role c o n f l i c t s are solved through the person's d e c i s i o n s regarding the importance o f ' o t h e r s ' e x p e c t a t i o n s , and the punishments he may r e c e i v e f o r noncompliance. When the r o l e i s not c l e a r l y d e f i n e d , as o f t e n happens, the person has f u r t h e r c o n f l i c t s w i t h which to contend. The c o n f l i c t s and i n c o m p a t i b i l i t i e s i n a r o l e cause much pressure on the incumbent o f a p o s i t i o n . When a person i s new t o the p o s i t i o n , the va r i o u s a t t r i b u t e s o f the r o l e can be both confusing and c o n f l i c t i n g . When s o l u t i o n s are not w i t h i n s i g h t , the incumbent may re a c t w i t h the behavior o f her o l d p o s i t i o n , becoming more and more d i s -36 3T s a t i s f i e d as t h i s behavior f a i l s to r e s o l v e her c o n f l i c t s . ' Some, of the problems are s o c i e t a l commonalities, such as those f o r anyone i n a s i m i l a r p o s i t i o n ; some are o r g a n i z a t i o n a l w i t h incongruent a u t h o r i t y 132 and r e s p o n s i b i l i t y i n the p o s i t i o n ; and some are personal when the i n d i v i d u a l cannot r e s o l v e incongruent personal and r o l e g o a l s . Within.the n u r s i n g p r o f e s s i o n , there are o f t e n a d d i t i o n a l pressures a r i s i n g from d i r e c t i n g the work o f others i n s t e a d o f doing a c t u a l p a t i e n t c a r e . 3 9 ^ e n u r s e who has r i s e n t o a head nurse p o s i t i o n has t o conform t o the norms o f h e r new r o l e and d i s s a s s o c i a t e h e r s e l f from the group which she has l e f t . F o r her new r o l e she has t o l e a r n the v a l u e s , a t t i t u d e s and behaviors o f the head nurse group, and how these d i f f e r from those she le a r n e d d u r i n g her o c c u p a t i o n a l s o c i a l -i z a t i o n i n becoming a s t a f f n u r s e . ^ This change r e q u i r e s major changes i n s e l f concept f o r many nurses w i t h considerable i n s e c u r i t y u n t i l the 4l 42 4-3 44 new r o l e a t t r i b u t e s are lear n e d . ' ' ' The a b i l i t y t o make , adjustments and the e x p e r i e n t i a l background o f the i n d i v i d u a l determine the f a c i l i t y and ease w i t h which she adjusts.^5>46,47 Regardless o f the e x t r i n s i c o r i n t r i n s i c m o t i v a t i o n , however, the person must d e s i r e the change. He has t o perc e i v e the change as u s e f u l t o him, and adaptable to h i s past experience and h i s present, s o c i a l system. By t h i s i t i s meant, t h a t he has t o r e a l i z e the use or meaningfulness o f the new behavior to him through being able t o r e l a t e i t to what has happened to him i n t h e past, and through h i s per-c e p t i o n o f the a c c e p t a b i l i t y o f the new behavior t o those i n h i s s o c i a l groups. Whatever engenders a f e e l i n g o f a need to change, the person t r i e s to acquire the i n f o r m a t i o n he needs f o r the new behavior and t o develop the a t t i t u d e s he needs t o adopt i t . These are o f t e n i n f l u e n c e d by the clim a t e i n which the new m a t e r i a l i s presented. 133 Climate f o r Learning The l e a r n e r needs a c l e a r p i c t u r e o f the behavior or knowledge which he i s t o a c q u i r e , and an o p p o r t u n i t y t o p r a c t i c e any change f o r reinforcement o f the new behavior. Information can be presented i n many ways ard under many d i f f e r e n t circumstances. Some of the ways which have been found conducive t o l e a r n i n g were discovered through classroom kg experiments, y others were discovered through research i n t o p u b l i c o p i n i o n , and much has been learned through t r i a l and e r r o r . Freedom from t h r e a t , permission to v e n t i l a t e f e e l i n g s , emotional support, and an o p p o r t u n i t y to g a i n i n s i g h t i n t o one's f e e l i n g s about the sub j e c t under c o n s i d e r a t i o n have been found to enable l e a r n i n g to occur. The degree o f each o f these r e q u i r e d by any one i n d i v i d u a l w i l l be dependent upon h i s knowledge and a t t i t u d e s , and by the amount o f change 52 d e s i r e d . M i l d a n x i e t y i s necessary f o r l e a r n i n g t o occur as complacency, 53 apathy, and d i s i n t e r e s t i n change are c h a r a c t e r i s t i c o f minimal a n x i e t y . Excess a n x i e t y , however, leads to the a c t i v a t i o n o f defense mechanisms and hence decreased communication and l e a r n i n g . ^ Often the c r e d i b i l i t y o f the communicator i n the pe r c e p t i o n o f the l e a r n e r , the form' and manner o f the p r e s e n t a t i o n , and the circumstances 55 56 57 o f the d e l i v e r y have pronounced e f f e c t s on the l e a r n e r . ' The E f f e c t o f S m a l l Groups Man Is a s o c i a l being and . . . i s dependent upon others t o a considerable degree. He has l i v e d , played, worshipped,-worked, and has been educated i n groups throughout h i s 13k e x i s t e n c e . The worst punishment which s o c i e t y can i n f l i c t upon him i s the l i v i n g death o f i s o l a t i o n . . . . The c o n t i n u i t y o f mankind has been p r i m a r i l y - t h r o u g h s m a l l groups: i t cannot endure without them.-5 A person's membership i n any group depends upon how w e l l h i s a s p i r a t i o n s and o b j e c t i v e s are congruent w i t h those he perceives as the 59 norms o f h i s group. The more he p a r t i c i p a t e s i n forming group con-sensus, the more i n v o l v e d h i s membership becomes. With g r e a t e r i n -volvement, there i s more conformity, l i k i n g , s e c u r i t y . When group approval i s not apparent, the member may experience f r u s t r a t i o n and con-60 f l i c t . A work s i t u a t i o n i s p a r t i c u l a r l y v u l n e r a b l e i n t h i s respect as changes i n personnel b r i n g changes i n group membership and group norms. A new group member w i l l o f t e n conform to patterns which previous group members have found comfortable and s a t i s f y i n g , i n order t o g a i n acceptance. On the opposite extreme, a l a c k o f defined..expectations may r e s u l t i n f r u s t r a t i o n and c o n f l i c t f o r a l l group members . ^ > ^ The s u c c e s s f u l worker, who 'was w e l l accepted w i t h i n h i s work group may f e e l cut o f f from h i s former a s s o c i a t e s when he i s promoted to a s u p e r v i s o r y p o s i t i o n . He i s now expected to conform t o the behavior o f h i s new group and former co-workers expect l e a d e r s h i p from him. Adjustment t o a new r o l e i s e a s i e r w i t h a w e l l organized p l a n o f o r i e n t a t i o n , and encouragement and support as needed. -5 I t i s the r e s p o n s i b i l i t y o f the s u p e r v i s o r y person to p l a n f o r changes i n the work group. Unless he gains h i s subordinates' cooperation, l i t t l e w i l l happen. Cooperation i s f a c i l i t a t e d by mutual planning o f o b j e c t i v e s and d i s c u s s i o n s o f accomplishments. The m o t i v a t i o n to change 135 is often the result of the group process and is most effective when i t is engendered and reinforced within the growp.^'^'^'^'^ Conferences, workshops, institutes or other meetings of those in similar positions i n different agencies, stimulate and encourage the potentials for "learning, reorientation, and creative thinking" 69 already present i n those who attend. Group process is definitely a factor at such gatherings, and can be used constructively to influence change. The social system of each small group possesses a structure of interaction or a relational system, a system of customary behavior and . 70 a system of values. These systems are interdependent and thus enhance and support each other. A social system exists in a certain environment, and changes in either are reciprocal. The relational system is one of interpersonal relationships b u i l t upon" responsiveness, understanding and sensitivity to others. The customary behavior and the value system govern how group members should behave and f e e l . Personal l i f e satisfaction . . . depends upon our communion with people . . . . Society can only be understood through communication; i t can only stay together as a society by proper communication . . . . Dialogue . . .begins i n an act of f a i t h : the assumption that those who converse speak in honesty for the purpose of reaching understanding, and with generosity toward each other . . . . Dialogue demands that we earn the right to be heard by lending our ears to what others have to say. The only way we can get another person's idea of ourselves and.our projects is by listening to him t a l k J 1 Communication is the process of a sender encoding and trans-72 mitting a message which is received and decoded by a receiver.' When there is no blockage, the recipient understands the message which the 136 sender meant him to r e c e i v e . The composite parts of the process i n c l u d e a s i m i l a r : language symbolism, the emotional component of the message to e i t h e r the sender or the r e c e i v e r , the nonverbal aspects of the communication sent, the a t t i t u d e s engendered i n the r e c e i v e r , and the 73•74 75 relevance o f the m a t e r i a l t o the r e c e i v e r . ' Communication and i n t e r a c t i o n are i n s e p a r a b l e . Much i n t e r -a c t i o n i s spontaneously evolved and each encounter leads to f e e l i n g s on a continuum between acceptance and r e j e c t i o n . The prime m o t i v a t i o n i n any i n t e r a c t i o n i s the v a l i d a t i o n and p r o t e c t i o n of the s e l f . Past experience w i l l determine the q u a l i t y o f an i n d i v i d u a l ' s response and the extent to which he perceives other persons, events, and s i t u a t i o n s as 76 t h r e a t s . This p e r c e p t i o n i n f l u e n c e s the a c t i v a t i o n o f h i s defense mechanisms and hence h i s a b i l i t y to communicate. In t h r e a t e n i n g s i t u a t i o n s , which can occur f o r anyone, the person may not p e r c e i v e the i n f o r m a t i o n which i s a v a i l a b l e , he may m i s i n t e r p r e t i t to b r i n g i t i n t o l i n e w i t h e x i s t i n g concepts, o r he may r e c e i v e the i n f o r m a t i o n adequately but be 77 unable t o respond through ignorance o r f e a r . ' 1 Communication i s increased when the s u b j e c t i s important to the group, when the group i s cohesive, when f r i e n d s h i p s e x i s t i n the group, and when the group i s s m a l l . VJlth i n c r e a s i n g membership i n a group, there i s i n c r e a s i n g h e t e r o g e n e i t y o f ideas and decreasing i n d i v i d u a l 7 8 p a r t i c i p a t i o n and involvement. In very l a r g e groups, the 'anonymity 79 8 0 phenomenon 1, or a l i e n a t i o n from group membership may occur. E i t h e r o f these may l e a d t o a l a c k o f expectations o f performance, and a l a c k o f r e s p o n s i b i l i t y and p a r t i c i p a t i o n i n group endeavour. 137 P r e s e n t a t i o n o f New M a t e r i a l When the o b j e c t i v e s o f a p r e s e n t a t i o n or l e c t u r e appear to be congruent w i t h the worker's per s o n a l o b j e c t i v e s , he i s more r e c e p t i v e t o the new i n f o r m a t i o n . As meaningfulness i s evident, he can r e l a t e i t to e a r l i e r experience through the r e o r g a n i z a t i o n o f h i s e x i s t i n g concepts. The r e t r a i n e e i s q u i t e a d i f f e r e n t i n d i v i d u a l than the-young t r a i n e e . Our experience w i t h t h i s group shows them to" be . . . f a r more h i g h l y motivated, r e a l i s t i c , i n s i g h t f u l , r e s p o n s i b l e , and g e n e r a l l y more s t a b l e . T h e i r goals are g e n e r a l l y f i x e d , long-range i n nature, job o r i e n t e d , and they are f a r more s t r o n g l y committed t o these goals than are the younger students .81 Many o f the courses o r l e c t u r e s which people attend do not present 'new' m a t e r i a l but r a t h e r i n f o r m a t i o n which the person had e a r l i e r r e c e i v e d and s t o r e d . The ' r e f r e s h e r ' course tends to b r i n g i n t o 82 consciousness t h i s ' f o r g o t t e n ' m a t e r i a l . I f the m a t e r i a l i s presented i n a d i f f e r e n t context or from a d i f f e r e n t p o i n t o f view i t becomes r e l a t e d more mean i n g f u l l y to e x i s t i n g . c o n c e p t s . I n t h i s way the person w i l l be more l i k e l y t o use it.^3;84 P e r s o n a l growth i s dependent upon the i n c o r p o r a t i o n o f the new w i t h the o l d , or i n b r i n g i n g i n t o meaningful focus p r e v i o u s l y learned i n f o r m a t i o n . • At an i n s t i t u t e where s m a l l group d i s c u s s i o n s are employed, an i n d i v i d u a l tends to become i n v o l v e d i n the group process. In so doing, he expresses h i s ideas and thoughts t o group:members, and rec e i v e s feed-back from them. The approval or d i s a p p r o v a l inherent i n group p a r t i c i p a t i o n may a l t e r h i s f e e l i n g o f a need to change. W i t h i n the s m a l l group the person o f t e n d i s c o v e r s t h a t h i s major problems are those common to h i s p o s i t i o n . These problems may be the s o c i e t a l commonalities mentioned e a r l i e r , o r they may be o f o r g a n i z a t i o n a l o r i g i n , o n l y extant i n h i s 138 • employing agency, or o n l y i n a s p e c i f i c type o f agency. The group may give the person f e e l i n g s o f adequacy and competency which were l a c k i n g e a r l i e r as he was not aware t h a t others shared the same problems. He may a l s o f i n d t h a t h i s own pers o n a l s o l u t i o n s are deemed adequate by h i s peers. The group may, on the other hand, make him r e a l i z e - t h a t there are b e t t e r ways of s o l v i n g problems than those he had been u s i n g and motivate him to t r y new beha v i o r s . The i n t e r a c t i o n s and communication patterns w i t h i n a s m a l l group can have a major i n f l u e n c e on the group members. 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