Patient reactions to transfers from rural to urban health care institutions
by Judy Diane Schmidt
A thesis submitted in partial fulfillment of the requirements for the degree OF MASTER OF
NURSING
Montana State University
© Copyright by Judy Diane Schmidt (1981)
Abstract:
Patient transfers from rural to urban hospitals are commonplace in Montana. This practice is influenced
by the fact that specialized care and diagnostic equipment are located in the urban hospitals. The
purpose of the study was to determine patient reactions to transfers from rural to urban health care
institutions.
The study had an exploratory descriptive design. Interview questions addressed patient reactions to the
rural health care institution, the transfer process, and the urban health care institution. Questions were
based on the conceptual framework of Parsons' theory of sick role behavior and Wu's theory of patient
needs in relation to illness.
Fourteen patients transferred from rural to urban hospitals were interviewed to determine their
reactions. The data were analyzed using descriptive statistics.
The transferred patients in the study did not express any concerns in regard to the rural hospitals, the
transfer process, or entry into the urban hospitals. Both participants and their families cooperated with
the medical regime, including the decision for transfer. Transfer from the rural to the urban hospital
was viewed as a necessary action in order to regain health.
Results of the study indicated that patients react to rural-to-urban transfers by demonstrating Parsons'
sick role behavior. Concerns for costs, family separation, distance to medical care, length of stay, and
others were expressed. However, these were not expressed unless patients were less seriously ill or
convalescence had begun. Small sample size does not allow corroboration with Wu's theory.
Nurses were frequently identified as major care-givers during all three phases of the rural-to-urban
transfer. This indicates the important role of the nurse in meeting the needs of rural patients in both
rural and urban health care settings. STATEMENT OF PERMISSION TO COPY
In p r e s e n t i n g t h i s t h e s i s in p a r t i a l - f u l f i l l m e n t
of t h e r e q u i r e m e n t s f o r an advanced degree a t Montana S t a t e
U n i v e r s i t y , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y
available for inspection.
I f u r t h e r a g re e t h a t p e rm is si on
f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes'
may be g r a n t e d by my ma jor p r o f e s s o r , o r , in h is a b s e n c e ,
by t h e D i r e c t o r of L i b r a r i e s .
I t i s unde rs too d t h a t any
copying o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain
s h a l l n o t be allow ed w i t h o u t my w r i t t e n pe rm is si o n .
Signature
PATIENT REACTIONS TO TRANSFERS FROM RURAL TO
URBAN HEALTH CARE INSTITUTIONS
BY
JUDY DIANE SCHMIDT
A t h e s i s s ubm itt ed in p a r t i a l f u l f i l l m e n t
o f t h e re qui re m e nts f o r t h e degree
OF
MASTER OF NURSING
Approved:
GfIairpersc^K' G radua te Committee
Head, Major Department
Gra duat e Dean
MONTANA STATE UNIVERSITY
Bozeman, Montana
Jun e, 1981
iii
ACKNOWLEDGEMENTS
I
would l i k e t o t a k e t h i s o p p o r t u n i t y to ex pre ss my
a p p r e c i a t i o n t o s e v e ra l people f o r t h e i r l o y a l t y and su p p o rt
during my work on t h i s t h e s i s .
F i r s t , , I would l i k e t o thank
th e members of my t h e s i s committee. Dr. P a t r i c i a L a r s o n ,
Dr. J a c q u e l i n e Taylor,, and Frances Eakman, f o r t h e i r p a t i e n c e
and a s s i s t a n c e .
A d d i t i o n a l l y , I would l i k e to ex press my
d e e p e s t a p p r e c i a t i o n t o my p a r e n t s and s i s t e r s f o r t h e i r
support.
And f i n a l l y , I would l i k e t o thank my husband^
R ob er t, f o r h i s unwavering encouragement and su p p o rt during
t h e s e two y e a r s .
I d e d i c a t e t h i s work to him.
iv
TABLE OF. CONTENTS
Page
VITA ...................................................................................................................... i i
ACKNOWLEDGEMENTS........................................................... ................................i i i
LIST OF TABLES.......................................................................... ............
. . . vi .
ABSTRACT.....................................................'....................................................... v i i
CHAPTER
1
INTRODUCTION ................................................................................... I
Sta te m e nt o f t h e Problem............... ....................... .......... 1-3
Purpose of t h e S t u d y ......................................................... 3
Basic Assumptions............... ................... *.................. 3-4D e f i n i t i o n o f Terms............................................................. 4-5
2
REVIEW OF THE LITERATURE AND CONCEPTUAL FRAMEWORK••-6
Montana's Health Care System ................................. — 6-11
P a t i e n t Reac tio ns to T r a n s f e r s ....................................... 11-13
. Conceputal Framework......................................................... 13-20
Chapter -Summary......................................................................20-21
3
METHODOLOGY •................................................................................... 22
Research D e s i g n ..................................................................... 22
S e t t i n g and Sample............. *............................'.................. 22-23
Data C o l l e c t i o n I n s t r u m e n t ................................... .......... 23-25
Data C o l l e c t i o n Method .................................................... 25
P i l o t Study .............................................................................25-26
Human R i g h t s ............................................................................ 26
Data A n a l y s i s ............. ............................................................ 27
4
FINDINGS........................................................................................... 28
S c r e e n i ng D a t a ...................... .............................................. .28
Demographic D a t a ................................................ ................... 28-30
Background Data - ................................................................... 30-33
V
CHAPTER '
Page
• P a t i e n t Reactions, to R ura l-t o-U rb an T r a n s f e r s . .33
P a t i e n t Reac tio ns R e l a t i v e t o t h e Rural
Health Care I n s t i t u t i o n .............................................33-34
Summary..................................................................: ...............,34
P a t i e n t Rea ctions R e l a t i v e to th e T r a n s f e r
P r o c e s s .............................
35-39
Summary ..........................................'........................................ 39
P a t i e n t Reac tio ns R e l a t i v e t o the.Urban Health
Care I n s t i t u t i o n .......................................................... .39-43
Summary...........................................
43-44
Data Rel eva nt t o Demographic Data and General
Findings ..............................................................................44-46
Summ ary----- ''......................................................................... 46
Chap ter Summary and D is cu ssi on
......................... 46-49
5
CONCLUSIONS ........................ ............................................. ....50
Conclusions ........................
....50-53
Nursing I m p l i c a t i o n s .................
53-55
L i m i t a t i o n s ..................
55-56
Recommedations f o r Further. S tu dy .....................
56-67
REFERENCES ....................................
58-63
APPENDICES .............................••................................ ................................ * .64
Appendix A - I n t e r v i e w Schedule ................................... .64-66
Appendix B - Approval L e t t e r s .........................................67-70Appendix C - Consent f o r P a r t i c i p a t i o n ........................71-73
vi
LIST' OF TABLES
TABLE
1
2
PAGE
Montana's Po pu la ti o n Ranges and Number of C i t i e s
Within Each Range ...................................................
7
Montana Counties and P e rc e nta ge of Residents Who
Went t o E i t h e r B i l l i n g s ' H o s p i t a l s Between
J u l y and December, 1978 ..........................................
12
3
Demographic Data of P a t i e n t s T r a n s f e r r e d from Rural
to Urban Health Care I n s t i t u t i o n s (-N=IA)...................31
4
P a t i e n t Reac tio ns t o Being Told About th e Rural to-Urban T r a n s f e r .............................
36
Person P erce iv ed as R espons ible f o r P a t i e n t Care
P r i o r t o T r a n s f e r ..........................................
37
Person Percei ved as R espons ible f o r P a t i e n t Care
During t h e T r a n s f e r ..............................
38
r
5
6
7
P a t i e n t Reac tio ns Upon En t er i n g t h e Urban Health
Care I n s t i t u t i o n .......................................................................41
8
Concerns Expressed on En te ri ng Urban Hospital and
Who Handled Them .....................................................................41
9
Concerns Expressed A f t e r Admission to the Urban
Hosp it al and Who Handled Them ....................•...................42
10
F u r t h e r Concerns Expressed Regarding th e R u r a l - t o Urban T r a n s f e r ..................................................
43
v ii
ABSTRACT
P a t i e n t t r a n s f e r s from r u r a l t o urban h o s p i t a l s a r e
commonplace in Montana. This p r a c t i c e i s in f l u e n c e d by the f a c t
t h a t s p e c i a l i z e d c a r e and d i a g n o s t i c equipment a r e l o c a t e d in
t h e urban h o s p i t a l s . The purpose o f th e study was to determine
p a t i e n t r e a c t i o n s to t r a n s f e r s from r u r a l to urban h e a l t h c ar e
institutions.
The s tu dy had an e x p l o r a t o r y d e s c r i p t i v e d e s ig n . I n t e r ­
view q u e s t i o n s a dd re ss ed p a t i e n t r e a c t i o n s to t h e r u r a l h e a l t h
c a r e i n s t i t u t i o n , the t r a n s f e r p r o c e s s , and th e urban h e a l t h ,
c a r e i n s t i t u t i o n . Questions were based on the conceptual frame­
work of Pa rs ons ' theory, of s i c k r o l e b e h a v i o r and Wu1s the ory of
p a t i e n t needs in r e l a t i o n t o i l l n e s s .
Fourteen p a t i e n t s t r a n s f e r r e d from r u r a l to urban h o s p i ­
t a l s were in te r v ie w e d t o determine t h e i r r e a c t i o n s . The data
were analyzed us in g d e s c r i p t i v e s t a t i s t i c s .
The t r a n s f e r r e d p a t i e n t s in t h e stu dy did not e x p re ss any
concerns in re g a rd t o t h e r u r a l h o s p i t a l s , the t r a n s f e r pro ­
c e s s , o r e n t r y i n t o t h e urban h o s p i t a l s .' Both p a r t i c i p a n t s
and t h e i r f a m i l i e s c o ope r at e d with th e medical regime, i n ­
c l u d in g t h e d e c i s i o n f o r t r a n s f e r . T r a n s f e r from t h e r u r a l to
t h e urban h o s p i t a l was viewed as a ne c e s s a ry a c t i o n in o r d e r to
regain health .
R e s u l t s o f th e st udy i n d i c a t e d t h a t p a t i e n t s r e a c t to
r u r a l - t o - u r b a n t r a n s f e r s by dem onst rat ing Pa rs ons ' s i c k r o l e
b e h a v i o r . Concerns f o r c o s t s , fa m ily s e p a r a t i o n , d i s t a n c e t o medical c a r e , l e n g t h of s t a y , and o t h e r s were e x p re s s e d . How­
e v e r , t h e s e were not ex pre sse d u n l e s s p a t i e n t s were l e s s s e r i ­
ous ly i l l or c o nvale sce nce had begun. • Small sample s i z e does
no t allow c o r r o b o r a t i o n with Wu' s t h e o r y .
Nurses were f r e q u e n t l y i d e n t i f i e d as major c a r e - g i v e r s
during a l l t h r e e phases of the r u r a l - t o - u r b a n t r a n s f e r . This
i n d i c a t e s t h e im p o r ta n t r o l e of t h e nurs e in meeting th e needs
of r u r a l p a t i e n t s in both r u r a l and urban h e a l t h c a r e s e t t i n g s .
CHAPTER I
INTRODUCTION
St a te m e nt o f t h e Problem
Nursing i s a p a t i e n t - o r i e n t e d p r o f e s s i o n , p ro v id i n g c a r e
f o r p a t i e n t s w it h v a r i e d dia gnoses and in d i f f e r e n t s e t t i n g s .
With t h e advances in emergency medicine in t h e l a s t deca de ,
p a t i e n t s who have been t r a n s f e r r e d between i n s t i t u t i o n s a r e
numerous and a new c h a l l e n g e to both r u r a l and urban n u r s e s .
In Montana, t r a n s f e r r e d p a t i e n t s from r u r a l t o urban h e a l t h
c a r e i n s t i t u t i o n s a r e commonplace, f o s t e r e d by i t s unique h e a l t h
c a r e system.
Thi s system c o n s i s t s of g e n e r a l i s t s l o c a t e d i n
r u r a l a r e a s and s p e c i a l i s t s in urban a r e a s .
The r u r a l a r e a i s
s erved by medical and n u rs in g g en eral p r a c t i t i o n e r s in s m a l l ,
si m pl y- e qui pp e d h o s p i t a l s .
Both medical and n u r s i n g p r o f e s s i o n a l s
in t h e s e s e t t i n g s must have a broad knowledge and s k i l l base in
o r d e r t o c a r e f o r t h e d i v e r s i t y of p a t i e n t s th e y s e e .
S p e c i a l t y c a r e f o r th e Ea st er n p a r t o f t h e s t a t e i s
l o c a t e d in t h e c i t i e s o f B i l l i n g s and Great. F a l l s .
A large
number o f medical and nur s in g s p e c i a l i s t s , drawn t o Montana
by i t s wide open sp ace s and r e c r e a t i o n a l o p p o r t u n i t i e s , con­
g r e g a t e in B i l l i n g s and Great F a l l s ,
Here the y p r a c t i c e t h e i r
s p e c i a l i z e d s k i l l s , develop p r o f e s s i o n a l n e tw o rk s , and have a c c e ss
2
to c o n t i n u i n g e d u c a ti o n and s p e c i a l i z e d equipment.
Rural p a t i e n t s
from E a s t e r n Montana must be t r a n s f e r r e d to B i l l i n g s and Great
Falls to re c eiv e these sp e c ia liz e d s e rv ic e s .
P a t i e n t s come to
t h e s e s e t t i n g s by s e l f - r e f e r r a l , p h y s i c i a n - r e f e r r a l , o r by.being
t r a n s f e r r e d from r u r a l to urban h o s p i t a l s .
Concern f o r t r a n s f e r r e d p a t i e n t s , e v o l v e d from t h e i n v e s t i ­
g a t o r ' s e x p e r i e n c e in r u r a l h o s p i t a l s , which o f t e n i n c lu d e d
p r e p a r i n g p a t i e n t s f o r t r a n s f e r t o urban h o s p i t a l s and a s s i s t ­
ing p a t i e n t s duri ng t r a n s f e r s .
The problems a s s o c i a t e d with
d i s t a n c e , communications, and t r e a t m e n t p r o t o c o l s have been
i d e n t i f i e d and a r e in t h e p ro c e ss o f being s o l v e d .
The d i s ­
t a n c e s t h e s e pe rsons have t o t r a v e l a r e o f t e n g r e a t , up t o
350 m i l e s in some c a s e s .
Besides t r a v e l l i n g by c a r , a v a r i e t y
of e l a b o r a t e t r a n s p o r t a t i o n systems have developed and a r e used,
f
i n c l u d i n g ground and a i r ambulance s e r v i c e s .
The two urban
h o s p i t a l s in G re at F a l l s and B i l l i n g s have ta ken t h i s d e vel op­
ment one s t e p f u r t h e r by p ro v id i n g s p e c i a l l y equipped a i r p l a n e s
and h e l i c o p t e r s and t r a i n e d medical personnel f o r t r a n s f e r r i n g
p a t i e n t s from r u r a l s e t t i n g s .
E l a b o r a t e communication systems
between h o s p i t a l s and between ambulances a r e u t i l i z e d .
Pro­
t o c o l s o f s p e c i f i c t r e a t m e n t m o d a l i t i e s t o be a d m i n i s t e r e d be­
f o r e and d urin g t r a n s f e r a r e o u t l i n e d and f o l l o w e d .
Of s p e c i a l
i n t e r e s t t o t h e i n v e s t i g a t o r a r e t h e p a t i e n t s who a r e t r a n s f e r r e d
3
to B i l l i n g s .
The medical p r o t o c o l s of t r a n s f e r r i n g p a t i e n t s have been
c a r e f u l l y and d e l i b e r a t e l y devel ope d.
To t h e i n v e s t i g a t o r , con­
s i d e r a t i o n f o r th e p a t i e n t has not been u n d e r t a k e n .
t h e i r r e a c t i o n s t o being t r a n s f e r r e d ?
What a re
Nursing i s a p a t i e n t -
o r i e n t e d p r o f e s s i o n where concern i s f o r t h e t o t a l
p a tie n t, in­
c l u d i n g p h y s i o l o g i c a l , p s y c h o l o g i c a l , and s o c i o - c u l t u r a l f a c t o r s .
R ea c ti o n s o f t r a n s f e r r e d p a t i e n t s toward r u r a l - t o - u . r b a n t r a n s f e r
must be c o n s i d e r e d .
U n d e r s t a n d i n g . o f t h e t r a n s f e r s i t u a t i o n :is
needed i f n u rs e s a r e going t o a d e q u a t e l y c a r e f o r r u r a l p a t i e n t s
and meet t h e i r t o t a l needs.
Purpose o f t h e Study
,
The purpose o f t h e st udy was t o i d e n t i f y p a t i e n t r e a c t i o n s
t o t r a n s f e r s from r u r a l t o urban h e a l t h c a r e i n s t i t u t i o n s in
r e l a t i o n to s i c k r o l e b e h a v io r and t h e e f f e c t s of i l l n e s s and
h o s p i t a l i z a t i o n on b e h a v i o r .
The a c t i o n s of n u r s e s in r u r a l
and urban s e t t i n g s w i l l be a d d re s s e d r e l a t i v e t o t h e s e f i n d i n g s .
Basic Assumptions
Se ve ra l b a s i c assumptions were made r e g a r d i n g t h e s tu dy:
1.
T r a n s f e r s from r u r a l t o urban h e a l t h c a r e i n s t i t u t i o n s
can cause r e a c t i o n s in p a t i e n t s .
2.
Reac tio ns can be e x p re ss e d v e r b a l l y .
4
3.
P a tie n ts are able to v e rb a liz e t h e i r re a c tio n s to
t r a n s f e r a f t e r 12 hours in urban h e a l t h c a r e
institutions.
D e f i n i t i o n o f Terms
The d e f i n i t i o n of terms as used in t h e stu dy a r e as fo ll ows
P a t i e n t - i l l person o f e i t h e r sex between t h e ages
of 18 and 8 0 , who v o l u n t a r i l y o r i n v o l u n t a r i l y i n i t i a l l y
se e ks medical t r e a t m e n t a t a r u r a l h e a l t h c a r e i n s t i t u t i o n
and i s s u b s e q u e n tl y t r a n s f e r r e d t o an urban h e a l t h c a r e
i n s t i t u t i o n f o r s p e c i a l i z e d c a r e o r d i a g n o s t i c p u rp o s e s.
Rea ct ion - a verba l re s p o n s e t o being t r a n s f e r r e d
from r u r a l t o urban h e a l t h ca.re i n s t i t u t i o n s .
T r a n s f e r - t h e t r a n s p o r t i n g o f a p a t i e n t v i a ground,
a i r p l a n e , or h e l i c o p t e r ambulance from a r u r a l t o an
urban h e l a t h c a r e i n s t i t u t i o n f o r s p e c i a l i z e d c a r e o r
d i a g n o s t i c proce dures and t e s t s .
Rural Health Care I n s t i t u t i o n - any h o s p i t a l
f u n c t i o n i n g in a c i t y wit h a p o p u l a t i o n of 2 ,5 00 o r
l e s s and l o c a t e d in E a s te r n and So uth - C e n tr a l Montana
and North ern Wyoming.
*.
Urban Health Care I n s t i t u t i o n - t h e h o s p i t a l s
l o c a t e d in B i l l i n g s , Montana:
B i l l i n g s Deaconess Hospital
. 5
and S t . V i n c e n t ' s H o s p i t a l .
Seriously i l l
patient - a patient transferred a fte r
s t a b i l i z a t i o n from a r u r a l t o an urban h e a l t h c a r e i n s t i ­
tu tio n for specialized care.
Less s e r i o u s l y i l l
patient - a patient transferred
from a r u r a l to an urban h e a l t h c a r e i n s t i t u t i o n f o r
d i a g n o s t i c proce dures and t e s t s and .sub seq ue nt t r e a t m e n t .
CHAPTER 2
REVIEW .OF THE LITERATURE AND CONCEPTUAL FRAMEWORK
Review o f t h e l i t e r a t u r e focus ed on two main a r e a s .
First,
background i n f o r m a t i o n on Montana as a r u r a l s t a t e and i t s h e a lt h
c a r e system was reviewed.
The sec on d, and major emphasis of
t h e l i t e r a t u r e re v ie w , focus ed on how p a t i e n t s r e a c t t o i l l n e s s ,
h o s p i t a l i z a t i o n , and movement i n t o t h e s i c k r o l e .
The l i t e r a t u r e
pro vid ed a co nceptual framework f o r t h e s t u d y based on Wu1s
(1973) t h e o r y o f p a t i e n t needs in r e l a t i o n to i l l n e s s , h o s p i ­
t a l i z a t i o n , and t r e a t m e n t , and P a r s o n s 1 (1958) t h e o r y of s ic k
role behavior.
Montana's Health Care System
Montana i s c o n s id e r e d a r u r a l s t a t e s i n c e 94.3% o f i t s
c i t i e s have p o p u l a t i o n s of 2,500 or l e s s (Copp, 1976; Montana
Department o f Highways, 1979).
Montana's p o p u l a t i o n i s p r e ­
s e n te d in Tabl e I .
Because o f t h i s f a c t , a unique h e a l t h c a r e system has develop­
ed.
E a s t of t h e Rocky Mountains, Montana's h e a l t h c a r e system
c o s i s t s o f a l a r g e r u r a l h e a l t h c a r e system dependent upon two
urban h e a l t h c a r e o r g a n i z a t i o n s o f s p e c i a l i z e d s e r v i c e s l o c a t e d
in B i l l i n g s and Great F a l l s .
I
These s p e c i a l i z e d s e r v i c e s in c lu de
7
Table I . Montana's P o p u la ti o n Ranges and Number of C i t i e s
■ Within Each,Range.
; ____________ • •
!Number or c i t i e s w i t h i n t h i s
P o p u l a t i o n range________________ p o p u l a t i o n r a n g e ...............
1-500
368
501-1,000
41
1 ,0 0 1 - 2 ,0 0 0
29
2 , 0 0 1 - 2 ,5 0 0
6
- 2 , 5 0 1 - 4 ,0 0 0
8
4,000-5,000
6
5, 0 0 0 -1 0 ,0 0 0
' 5
10 ,0 00-15 ,000
2
15 ,0 01-2 0,0 00
I
2 0 ,001 -3 0,0 00
3
6 0 ,0 00- 70,0 00
2
(Montana Department o f Highways, 1979)
.h ig h ly t e c h n i c a l medical and n u r s i n g c a r e and t h e l a t e s t d i a g ­
n o s t i c p ro c e d u r e s and t e s t s .
P a t i e n t s t h a t e n t e r t h e h e a l t h c a r e system in r u r a l a re a s
a r e o f t e n t r a n s f e r r e d to urban a r e a s f o r d i a g n o s t i c proc ed ures
and t e s t s o r s p e c i a l i z e d c a f e .
t i o n s by s e l f - r e f e r r a l ' .
Many a l s o e n t e r urban o r g a n i z a ­
The i n v e s t i g a t o r ' s work in r u r a l h o s p i t a l s
8
revealed a f a i r l y c o n s is te n t p r a c tic e of e i t h e r t r a n s f e r r i n g
p a t i e n t s f o r d i a g n o s t i c pro c e dures and t e s t s , or s t a b i l i z i n g
p a t i e n t s in s e r i o u s c o n d i t i o n and t r a n s f e r r i n g them f o r s p e c i a l i z e d
care.
P a t i e n t s who were t r a n s f e r r e d f o r d i a g n o s t i c rea so ns were
not s e r i o u s l y i l l , bu t were t r a n s f e r r e d t o urban h o s p i t a l s where
s p e c i a l t e s t s and d i a g n o s t i c p ro c e dure s c ould be performed and
s u b se q u e n t t r e a t m e n t a d m i n i s t e r e d .
T r a n s f e r u s u a l l y occu rr ed
a f t e r having s p e n t s e v e r a l days in
the rural h o s p ita l.
S e r i o u s l y i l l p a t i e n t s were s t a b i l i z e d and then t r a n s f e r r e d
from r u r a l t o urban h o s p i t a l s .
This p r a c t i c e f o l l o w s t h e
American C o lle ge o f Surgeons c l a s s i f i c a t i o n system t h a t d e f i n e s
t h e kind s of i n j u r i e s h o s p i t a l s a r e c a p a b l e of h a n d l i n g .
c l a s s i f i c a t i o n system has f o u r l e v e l s .
'The
Level I h o s p i t a l s
hand le s e r i o u s trauma and have some s p e c i a l i s t s .
Level I I I
h o s p i t a l s hand le moderate i n j u r i e s , such as "uncomplicated
i n j u r i e s and c h e s t i n j u r i e s , b u t no n e u r o l o g i c a l , c a r d i a c ,
o r abdominal i n j u r i e s " ( " T r a n s f e r of P a t i e n t s , " ' 1980:140).
Level IV h o s p t i a l s pro vid e s t a b i l i z a t i o n and management o f major
b o d i l y i n j u r i e s fo ll ow e d by th e t r a n s f e r o f t h e p a t i e n t to a
hospital c l a s s i f i e d a t a higher level
C a r e , " ' 1980:227)'.
("New Rules f o r Trauma
According t o t h i s systayi.,Montana's r u r a l
h o s p i t a l s meet t h e req u ir e m e n ts f o r , c l a s s i f i c a t i o n a t Level I I I
o r IV, n e c e s s i t a t i n g t r a n s f e r o f s e r i o u s l y i l l
p a tie n ts to
9
Level I I h o s p i t a l s .
B i l l i n g s ' h o s p i t a l s , t h e urban h e a l t h
c a r e o r g a i n z a t i o n s s e l e c t e d f o r t h i s s t u d y , meet Level I I r e ­
q u i r e m e n t s , alth ough "no formal . d e s i g n a t i o n p ro c e s s f o r h o s p i t a l
c l a s s i f i c a t i o n has been made.in Montana" (Dawson, 1981).
Rural h o s p i t a l s a r e una ble t o p r o v id e ad equ at e c r i t i c a l
c a r e d e l i v e r y f o r s e r i o u s l y . i l l . p a t i e n t s because o f problems
w it h ge ogr ap hy, f i n a n c i n g , and u t i l i z a t i o n , as i d e n t i f i e d by
t h e Montana Health Systems Agency, Ihc.'' ( 1 9 7 9 : 4 - 4 5 ) .
The
d i s t a n c e between h o s p i t a l s in Montana n e c e s s i t a t e s t h e need
f o r small h o s p i t a l s to have t h e c a p a c i t y to t r e a t c r i t i c a l l y
ill
patients.
This s e r v i c e i s l i k e l y t o be pro vided a t a l o s s
to r u r a l h o s p i t a l s .
Because o f low u t i l i z a t i o n t h e r e is
d e c r e a s e d s t a f f p r o f i c i e n c y in t h e a b i l i t y t o p ro vi de c a r e .
Co nti nuing e d u c a ti o n i s needed t o m a i n t a i n s t a f f s k i l l s , y e t
small h o s p i t a l s do not have s t a f f f l e x i b i l i t y t o a ll ow time
f o r t h e s e programs or funding to send s t a f f ,to programs in
d i s t a n t communities (Montana He alth Systems Agency, I n c . ,
1979:4-45).
E l l i s , in a survey o f '36 r e g i s t e r e d nurs es
in Western Montana, i d e n t i f i e d problems r u r a l h o s p i t a l s have
in r e g a r d t o emergency c a r e d e l i v e r y .
These i n c lu d e d s t a f f i n g
pr obl em s, keeping s k i l l s u p - d a t e d . Tack of f a c i l i t i e s , and
l a c k o f equipment (19 80 :4 7).
10
I t has been noted t h a t p r o f e s s i o n a l people with s p e c i a l i z e d
knowledge a r e a t t r a c t e d t o urban r a t h e r tha n r u r a l a r e a s ( H u r l h u r t ,
1975; Mas si nge r, 1976).'
"With i n c r e a s i n g s p e c i a l i s a t i o n , t r a n s f e r
of c r i t i c a l l y i l l p a t i e n t s to s p e c i a l u n i t s i s l i k e l y t o i n c r e a s e "
(Waddell, 1975:1939).
T ransferring p a tie n ts fo r sp ecialized care
and d i a g n o s t i c proce dures and t e s t s i s a l s o r e p o r t e d by Massinger,
I
who s t a t e s t h a t general p r a c t i t i o n e r s in r u r a l a r e a s depend on
urban s p e c i a l i s t s f o r medical s e r v i c e s (1 976: 174) .
The y e ll o w pages of B i l l i n g s ' t e l e p h o n e d i r e c t o r y l i s t
173 medical and s u r g i c a l s p e c i a l i s t s c u r r e n t l y in p r a c t i c e .
(The Mountain S t a t e s Telephone and Te le graph C o . , 1980:468-472).
Medical s e r v i c e s in c l u d e emergency m e d i c i n e , c a r d i o l o g y , endo­
c r i n o l o g y , ne ph ro lo gy , n e u ro lo g y , ophtha lmolo gy, and pulmonary
diseases.
S u r g ic a l s e r v i c e s i n c l u d e a r e a s of c a r d i o v a s c u l a r ,
n e u r o l o g i c a l , o r t h o p e d i c , t h o r a c i c , o p h th a lm o lo g ic , and
p l a s t i c s u r g e r y (The Mountain S t a t e Telephone and Te legraph
C o . , 1 9 8 0 :4 7 2 -6 ) .
Among t h e s p e c i a l t y a r e a s s u p p l i e d by
B i l l i n g s ' h o s p i t a l s a r e a d i a l y s i s u n i t , a burn t r e a t m e n t u n i t ,
two comp ute rize d a x ia l tomogram (C:A :T .) s c a n n e r s , and open
heart surgery.
The a v a i l a b i l i t y o f t h e s e s p e c i a l i z e d s e r v i c e s
i n B i l l i n g s i s a major reaso n f o r many o f t h e r u r a l - t o - u r b a n
transfers.
11
B i l l i n g s ' s p e c i a l i s t s o f f e r t h e i r s e r v i c e s to a broad
ge o g ra p h ic a re a which i n c l u d e s S o u t h - C e n t r a l and E a s te r n Mon­
t a n a and p a r t s of Northern Wyoming.
Data in Table 2 a r e from
Research S e r v i c e s West (1979) and d e p i c t t h e p e r c e n ta g e o f each
c o u n t y ' s r e s i d e n t s d i s c h a r g e d from Mo ntana's r u r a l h o s p i t a l s
between J u l y and December, 1978 and a d m i t t e d to t h e urban h e a l t h
c e n t e r s o f B i l l i n g s Deaconess H o sp i ta l o r S t . V i n c e n t ' s Ho spital
(1 9 7 9 : 1 5 ) .
These c o u n t i e s compose S o u t h - C e n t r a l and E a s te r n
Montana, t h e r u r a l a r e a s s er ved by t h e urban h e a l t h c a r e i n ­
s titu tio n s of B illings.
B illin g s ' h o sp itals receive a s ig n i­
f i c a n t p e r c e n t a g e o f p a t i e n t s from t h e s e su rro undin g c o u n t i e s ,
w ith 28.2% o f S t . V i n c e n t ' s h o s p i t a l , p a t i e n t s and 44% o f B i l l i n g s
Deaconess H os pit al p a t i e n t s being from them (Research S e r v i c e s
West, 1979).
P a t i e n t Reac tio ns t o T r a n s f e r s
Review o f l i t e r a t u r e did not re v e a l any s p e c i f i c s t u d i e s
r e g a r d i n g p a t i e n t r e a c t i o n s to t r a n s f e r s from r u r a l t o urban
health care i n s t i t u t i o n s .
The l i t e r a t u r e ad dre sse d only i n t r a ­
h o s p i t a l and i n t e r - a g e n c y t r a n s f e r s .
Data re g a r d in g i n t r a ­
h o s p i t a l t r a n s f e r s were s p e c i f i c - t o t h e t r a n s f e r r i n g o f p a t i e n t s
in g e ne r al and t r a n s f e r r i n g c o ro na ry c a r e u n i t p a t i e n t s in p a r t i ­
cular.
Se ve ra l s t u d i e s o f i n t r a - h o s p i t a l t r a n s f e r s r e v e a l e d
12
Montana Counties and P e r c e n t a g e of R esi de nts Who went
to e i t h e r B i l l i n g s ' h o s p i t a l s between J u l y and December
1978.
Tabel 2.
Perc e nt ag e
County
County
Percentage
County Pe rcen tag e
Yellowstone
97.4%
Sweet Grass
33.7%
C u st e r
15.5%
Mussel she! I
93.0
Wheat!and
30 .2
Sherida n
10.8
Golden V a lley
71.2
Powder R iv er 29.6
Richland
10.6
Big Horn
62.1
Dawson
19.5
Park
9 .8
Carbon
59.0
Wibaux
18.8
McCone
9.1
Rosebud
54.2
Fal I on
18.7
Roosevelt
8.7
Treasure
49.0
Carter
17.7
Dan iels
8 .3
P e t r o l eum
47.7
Prairie
17.4
Fergus
7.7
Valley
Garfield
15.6
38.9
(Research S e r v i c e s West, 1979:15)
5.9
Stillw ater
c o n t r o v e r s i a l f i n d i n g s with r e p o r t s o f f a v o r a b l e , n e u t r a l , and
d e t r i m e n t a l e f f e c t s on p a t i e n t s ( K o r n f e l d , 1968; Shannon, 1973;
Smith, 1976; Welch, 1977; Tot h, 1980).
Data re g a r d in g i n t e r ­
agency t r a n s f e r s were in r e l a t i o n to t h e e l d e r l y and t h e newborn.
T r a n s f e r r i n g the e l d e r l y was seen as a r i s k with r e p o r t e d i n ­
c r e a s e d m o r t a l i t y r a t e s ( S e li f m a n , 1974; Zweig and Csank, 1975;
B i r r e n and S c h a i e , 1977; H a s s e lk u s , 1978; Fanslow and M a s s e t ,
1979).
T r a n s f e r r i n g th e newborn was r e p o r t e d as having d e f i n i t e
ph ys ic a l b e n e f i t s t h a t had to be weighed a g a i n s t t h e importance
13 .
o f p a r e n t - b a b y bonding (TooTey and Go lds mith, 1977; Young, 1978).
Conceptual. Framework
The l i t e r a t u r e on Wu1s (1974) t h e o r y of p a t i e n t needs in
r e l a t i o n to i l l n e s s , h o s p i t a l i z a t i o n , and t r e a t m e n t , and
Parsons'
(1958) th e o r y of s i c k r o l e b e h a v i o r pro v id e s a conceptual
framework f o r th e s t u d y .
The f o l l o w i n g examination o f t h e l i t e r a ­
tu re addresses the concepts. '
P a t i e n t Needs
'
■
Wu's. (1973) th e o r y o f p a t i e n t needs a d d r e s s e s t h e s t r e s s e s
o f i l l n e s s , h o s p i t a l i z a t i o n , and t r e a t m e n t .
Wu i d e n t i f i e d
h o s p i t a l i z a t i o n and t r e a t m e n t as " s t r e s s o r s t h a t t h e i n d i v i ­
dual may have to deal with in a d d i t i o n to th e i l l n e s s i t s e l f "
( 1 9 7 3 :4 7 ) .
T r a n s f e r s made w i t h i n t h e h o s p i t a l a r e seen as a
potential additional s tr e s s .
"Not only must they I earn t o a d j u s t
t o a s i n g l e ward b u t in t o d a y ' s h o s p i t a l s i t is n o t uncommon to
have t o a d j u s t to s e v e r a l a r e a s .
This f r e q u e n t movement and
change o f environments can become an added s t r e s s f o r many
p a t i e n t s " (Wu, 1973:67).
P a t i e n t needs in r e l a t i o n t o s t r e s s e s of i l l n e s s , h o s p i ­
t a l i z a t i o n , and t r e a t m e n t t o which Wu r e f e r s a r e o p e r a t i o n a l i ­
zed in t h e s tu d y as p a t i e n t c o n c e r n s .
These in c l u d e con cerns
a bou t c o s t s , fa m ily s e p a r a t i o n , f e a r o f t h e unknown, and modes
14
o f t r a n s p o r t a t i o n used t r a n s f e r r i n g p a t i e n t s .
Costs a s s o c i a t e d with medical c a r e i n c r e a s e w it h t r a n s f e r .
Added expenses of t h e t r a n s p o r t a t i o n t o t h e second medical f a c i l i t y ,
s p e c i a l i z e d c a r e , arid t h e c o s t o f m ote ls and meals f o r family,
members, as well as m a i n t a i n i n g p a r t o f t h e fa m i l y in t h e home,
may be co nce rns of t r a n s f e r r e d p a t i e n t s .
Locke r e p o r t e d t h a t
p a t i e n t t r a n s f e r s t o urban a r e a s f o r s p e c i a l i z e d c a r e can cause
emotional and economic p r o b l e m s . ( 1 9 7 8 : 2 3 ) .
Wu i s in agreement .
s t a t i n g t h a t " f a c t o r s o t h e r th a n t h o s e t h a t i n i t i a t e d t h e i l l - .
ne ss p r o c e s s can s i g n i f i c a n t l y i n f l u e n c e i t s c o u rs e s and o u t ­
come.
For example, f i n a n c i a l w o r r i e s could slow down and
impede f u l l re c ove ry " ( 1 9 7 3 :1 2 ) .
:
In a d d i t i o n to f i n a n c i a l c o n c e r n s , p a t i e n t s have concerns
a bo ut s e p a r a t i o n .
H o s p i t a l i z a t i o n means s e p a r a t i o n of p a t i e n t s
from f a m i l y and f r i e n d s , s u p p o r t systems u t i l i z e d in everyday
l i f e and times of c r i s i s (Cap!an, 1964; Wu, 1973).
l e a v e s p a t i e n t s f e e l i n g i s o l a t e d and h e l p l e s s .
S e p a r a ti o n
When p a t i e n t s
a r e t r a n s f e r r e d and h o s p i t a l i z a t i o n : i s a t a d i s t a n c e from the
f a m i l y home, t h e e f f e c t s o f s t r e s s , may be more s e v e r e .
Trans­
f e r r e d p a t i e r i t s a r e t e m p o r a r i l y c u t o f f from a l l p r e v io u s
. systems o f s u p p o r t . ' " I t i s t h e s im u lt a n e o u s r u p t u r e o f a
whole ra nge o f e x i s t i n g r e l a t i o n s h i p s t h a t makes r e l o c a t i o n
.15
p s y c h o l o g i c a l l y t a x i n g f o r many"; ( T o f f I e r , 1970:103.).
As a consequence o f h o s p i t a l i z a t i o n , s o c i a l c o n t a c t s a re
lim ited.
S e p a r a t i o n n o t only a f f e c t s : p a t i e n t s , b u t f a m il y and
f r i e n d s as w e l l .
These s i g n i f i c a n t o t h e r s must r e a d j u s t t h e i r
l i v e s ( Capla n , 1964:115).
T r a n s f e r r e d p a t i e n t s a r e c ar ed f o r a t d i s t a n t h o s p i t a l s
which f u r t h e r a c c e n t u a t e s t h e s e p a r a t i o n - f r o m f a m il y and
friends.
Most people in t h e E a s t e r n h a l f o f t h e . U n i t e d . S t a t e s
a r e w i t h i n 100 m ile s of h e a l t h c a r e f a c i l i t i e s .
This i s not
t h e c a s e in t h e Western p a r t o f t h e United S t a t e s (Massinger
and W h it in g , 1976).
H o s p ita liz a tio n .a t considerable distance
from home was i d e n t i f i e d by V oli cer , in two . s t u d i e s o f s t r e s s f u l
e v e n ts a s s o c i a t e d with h o s p i t a l i z a t i o n , as being a h i g h l y s t r e s s
f u l e v e n t ( V o l i c e r , 1973; 1974).
In c o n t r a s t , Snyder, in a
s t u d y o f 15 home d i a l y s i s p a t i e n t s in Western Montana, found
t h a t d i s t a n c e s up to 900 m il e s were d e f i n e d as bei ng c l o s e
and c o n v e n i e n t in terms of t r a v e l t o h e a l t h c a r e f a c i l i t i e s
( 1 9 79 :1 00) .
V arious f e a r s may be o f concern f o r t r a n s f e r r e d p a t i e n t s .
T r a n f e r t o t h e urban h o s p i t a l s i n . a l l
probability indicates
t h e s e r i o u s n e s s o f t h e h e a l t h problem. ' P a t i e n t s may be
f r i g h t e n e d when faced with t h e . p r o s p e c t o f t r a n f e r to urban
■16
h o s p i t a l s with a l l i t s i m p l i c a t i o n s o f s e r i o u s i l l n e s s .
Along with f e a r a s s o c i a t e d : w i t h . t h e meaning of being t r a n s ­
f e r r e d comes' t h e f e a r o f going to: u n f a m i l i a r p l a c e s with un­
f a m i l i a r people r e s p o n s i b l e f o r p a t i e n t c a r e and l i f e .
Hasselkus
d i s c u s s e s Markus' c o n c e p ts o f . r e l o c a t i o n , in t h a t r e l o c a t i o n
i n c l u d e s " f i r s t , t h e d e p r i v a t i o n of f a m i l i a r cues and e n v i r o n ­
mental s u p p o r t s ; and s e c o n d , t h e need t o . c o p e with new s e t s of
s t i m u l i in an u n f a m i l i a r environment" ( 1 9 78: 632) :
T r a n s p o r t a t i o n modes may ,a ls o be o f concern t o t r a n s f e r r e d
patients.
I f p a t i e n t s a r e t o be t r a n s f e r r e d more than 100
m i l e s , an a i r ambulance s e r v i c e , e i t h e r fi x e d -w in g o r h e l i ­
c o p t e r , i s recommended ( Hensl e r , e t a l . , 1976; McCombs., 1978).
D i f f e r e n t modes of t r a n s p o r t a t i o n used in t r a n s f e r s and th e
importance of ve rbal and w r i t t e n communication between th e
t r a n s f e r r i n g h o s p i t a l s and t h e r e c e i v i n g h o s p i t a l s a r e well
documented in t h e l i t e r a t u r e (Goodman, 19.75; H u r l b u r t , 1975;
Cowper-Smit h , 1976; Hensle r , e t a l . , 1976; S h i r c o f e , 1976; Edlich
e t a l . , 1978; Locke, 1978; McCombs, 1978; Norland, 1978; Fanslow
and M a s s e t , 1979).
V o l i c e r , in two s t u d i e s w ith a t o t a l of 263 p a t i e n t s , i d e n t i
fi.ed some of t h e same c oncer ns o u t l i n e d above.
.Events a s s o c i a t e d
w ith h o s p i t a l i z a t i o n t h a t were c o n s i d e r e d as h ig h l y s t r e s s f u l .
17
i n c lu d e d "admission f o r :l i f e - t h r e a t e n i n g i l l n e s s , in a d e q u a te
i n s u r a n c e t o cover h o s p i t a l i z a t i o n , ad mission f o r s u r g e r y , un­
dia gn os ed a i l m e n t a t time o f a d m i s s i o n , and h o s p i t a l i z a t i o n
a t c o n s i d e r a b l e d i s t a n c e from home" ( V o l i c e r , 1974:237).
Other
e v e n t s c o n s i d e r e d l o w - s t r e s s e v e n t s in c lu d e d "admission f o r
d i a g n o s t i c t e s t s o n l y , ho t h a v i n g , v i s i t o r s , being c a r e d f o r by
u n f a m i l i a r p h y s i c i a n s , and ! i s o l a t i o n from f r i e n d s " ( V o l i c e r ,
1974:237).
Smith, in a s tu d y o f 320 p a t i e n t s , found t h a t
t r a n s f e r i t s e l f was not i d e n t i f i e d as a s t r e s s f u l e ven t of
h o s p i t a l i z a t i o n (1 97 6: 192 ).
Summary
From t h e review o f t h e l i t e r a t u r e on p a t i e n t ne ed s ,
o p e r a t i o n a l i z e d as. p a t i e n t c oncer ns in t h i s s t u d y , s e v e r a l
a r e a s of concern were i d e n t i f i e d and s u p p o r t e d .
How p a t i e n t s
r e a c t t o t r a n s f e r s from r u r a l t o urban h e a l t h c a r e i n s t i t u t i o n s
can be de mo nstrated by v e r b a l i z a t i o n o f t h e s e concerns.
Sick Role Behavior
P a r s o n s ' (1958) t h e o r y of s i c k r o l e be h a v io r pro v id e s
a n o t h e r p e r s p e c t i v e f o r t h e con cep tua l framework o f t h i s s tu d y .
The works o f Parsons' and Wu's i n t e g r a t i o n of th e e f f e c t s of
i l l n e s s on p a t i e n t b e h a v i o r p r o v id e t h e b a s i s f o r t h e fo ll o w i n g
d i s c u s s i o n of s i c k r o l e b e h a v i o r .
•18
Parsons d e f i n e s i l l n e s s as a ! " s o c i a l l y i n s t i t u t i o n a l i z e d
r o l e - t y p e , " ' d i s t u r b i n g t h e c a p a c i t y o f an i n d i v i d u a l f o r normallyex pe c te d t a s k or r o l e performance; (1 9 5 8 :1 7 6 ) .
I l l n e s s i s viewed
as a c r i s i s , something i n t e r r u p t i n g t h e normal flow of e v e n t s .
I l l n e s s caus es changes in a person t h a t make f u n c t i o n i n g a t
an optimal phy si cal and p s y c h o l o g i c a l c a p a c i t y im p o s s i b l e (Wu,
1973) .
'
According to P a r s o n s ' d e s c r i p t i o n o f s i c k r o l e b e h a v i o r ,
t h e p a t i e n t "can not be ' h e l d r e s p o n s i b l e 1 f o r t h e i n c a p a c i t y "
( 1 9 5 8 :1 7 6 ) , bu t does have two o b l i g a t i o n s t o f u l f i l l .
First,
t h e p a t i e n t has an o b l i g a t i o n " to t r y t o ' g e t w e l l ' and c o o p er at e
w it h o t h e r s t o t h i s end.
(1 9 5 8 :1 7 7 ) .
To be i l l .is i n h e r e n t l y uYideAXsiabZo.
The p a t i e n t has t h e o b l i g a t i o n to Ae.e.k comp&t&nt
he£p and t o c o o p e r a te w it h competent a g en c ie s in t h e i r a t t e m p t s
t o he lp him g e t w e l l " (1 9 5 8 :1 7 7 ) .
In o r d e r t o f a c i l i t a t e
r e c o v e r y , t h e p a t i e n t in t h e s i c k r o l e i s e x e m p t ." t o v a ry in g
ways and f o r va ryi ng p e r i o d s a cc o rd in g t o t h e n a t u r e of th e
i l l n e s s , from h is normal r o l e a n d . t a s k o b l i g a t i o n s " ( P a r s o n s ,
19 58:17 6).
Withdrawal from normal a d u l t a c t i v i t i e s and c o n c e n t r a ­
t i o n on g e t t i n g well i s e x p e c t e d . . The p a t i e n t i s preoccu pie d
w it h i l l n e s s (Wu,- 1973:16 0).
Re gre s s io n o c c u r s , and i s c h a r a c t e r i z e d by e g o c e n t r i c i t y ,
19
c o n s t r i c t i o n o f i n t e r e s t s , dep end en cy , and h y p o c h o n d r i a s i s , e s ­
p e c i a l l y in t h o s e s e r i o u s l y o r a c u t e l y i l l
(Wu, 1973:16 0).
The
p a t i e n t , who now i s exempt from a d u l t r e s p o n s i b i l i t i e s , i s con­
cerned w it h s e l f and with what i s happening w i t h i n t o t h e p o i n t
of hypochondriasis.
egocentricity.
O u ts id e i n t e r e s t s a r e reduced because of
Much e n e r g y : i s needed t o deal with t h e i l l n e s s ,
l e a v i n g l i t t l e energy f o r o t h e r " a c t i v i t i e s (Wu, 1973.)
The p a t i e n t becomes depend en t upon o t h e r s , p a r t i a l Iy because
o f t h e i l l n e s s and p a r t i a l l y be ca us e o f t h e e g o c e n t r i c i t y and
co n strictio n of in te r e s ts .
Compliance and c o o p e r a t i o n with the
p r e s c r i b e d medical regime i n f l u e n c e r e c o v e r y (Wu, 1973).
As t h e i l l n e s s becomes l e s s s e v e r e and l e s s demanding, th e
p a t i e n t g r a d u a l l y resumes a dul’t r e s p o n s i b i l i t i e s with a broadened
scope o f i n t e r e s t s .
More energy f o r o u t s i d e a c t i v i t i e s and
th o u g h t s i s a v a i l a b l e (Wu, 1973 :1 63) .
No two people r e a c t t o . i l l n e s s and h o s p i t a l i z a t i o n in
t h e same manner. . P e r c e p t i o n s an i n d i v i d u a l has r e g a r d i n g i l l ­
ne ss and t o s p i t a l . j z a t i o n a r e i n f l u e n c e d by a mi xtu re o f i n t e r n a l
and e x t e r n a l f a c t o r s . . Personal v a r i a b l e s t h a t i n f l u e n c e s i c k
ro le behavior include " p e r s o n a lity , so cial s t a t u s , occupation,
e d u c a t i o n , a ge, and sex" (Wu, '1973:166)'.
Other v a r i a b l e s t h a t
i n f l u e n c e s i c k r o l e b e h a v i o r a r e " t h e n a t u r e of t h e i l l n e s s ,
20
s o c i a l r o l e norms, i n t e r a c t i o n w it h . r e l e v a n t o t h e r s , t h e h o s p i t a l
c u l t u r e , and t h e medical c a r e sy st e m " (Wu, 1973:1975).
Today's
medical c a r e system encourages a d o p t i o n o f s i c k r o l e b e h a v i o r
by t h e p a t i e n t .
P a t i e n t p e r c e p t i o n s a bout h o s p i t a l i z a t i o n and
t r e a t m e n t a r e i n f l u e n c e d by p e r c e p t i o n s and r o l e e x p e c t a t i o n s
o f c a r e - g i v e r s (Wu, 1973; Orem, 1973).
On t h e o t h e r hand, t o d a y ' s
s o c i a l r o l e norms a r e changing w it h advances o f th e prosumer
movement.
With many people t a k i n g r e s p o n s i b i l i t y f o r t h e i r own
h e a l t h , s i c k r o l e b e h a v i o r may be i n f l u e n c e d ( T o f f l e r , 1980).
Summary
Adopting s i c k r o l e b e h a v i o r i s an ex pected a c t i v i t y f o r a
person who i s i l l .
s ee ki ng h e l p .
The p a t i e n t e n t e r s t h e h e a l t h c a r e system
In o r d e r t o g e t w e l l , c o o p e r a t i o n w it h th e
medical team i s n e c e s s a r y .
To f a c i l i t a t e t h i s c o o p e r a t i o n , the
p a t i e n t i s t e m p o r a r i l y exempt from n o r m a l l y - e x p e c t e d , d a y - t o day a c t i v i t i e s and d u t i e s .
R esponsibility fo r illn e s s is
no t t h e p a t i e n t ' s , b u t , to. r e g a i n h e a l t h , t h e p a t i e n t i s t o
do what must be done t o g e t w e l l .
Chap ter SUmMiary
Montana i s a r u r a l s t a t e w it h a unique h e a l t h c a r e system
c o n s i s t i n g of a l a r g e r u r a l a r e a - d e p e n d e n t upon urban o r g a n i ­
zations for specialized services.
S c a tte re d , lim ited services
21
c r e a t e a common e v e n t in M o n t a n a ' s . h e a l t h c a r e system: . t r a n s f e r r i n g
p a t i e n t s from r u r a l to urban h o s p i t a l s .
P a t i e n t r e a c t i o n s to
r u r a l - t o - u r b a n t r a n s f e r s may be i n f l u e n c e d by p a t i e n t con cerns
a n d / o r s i c k r o l e b e h a v i o r , and may.be e l i c i t e d as p a t i e n t s e n t e r
t h e h e a l t h c a r e system a t t h e r u r a l h e a l t h c a r e i n s t i t u t i o n ,
d ur in g t h e t r a n s f e r p r o c e s s , o r a t t h e urban h e a l t h c a r e i n ­
stitution.
The purpose o f t h i s s tu dy.w as t o de te r m in e how p a t i e n t s .
r e a c t t o t r a n s f e r s from r u r a l t o urban h e a l t h c a r e i n s t i t u t i o n s .
Review o f t h e l i t e r a t u r e and t h e co n ce p tu a l framework s e t t h e
pa ra me te rs o f t h e s t u d y .
The fo c us o f th e s t u d y was on r u r a l
p a t i e n t s ' movement from w e l l n e s s t o i l l n e s s , i n c o r p o r a t i n g '
t h e framework o f p a t i e n t con cerns and s i c k r o l e b e h a v i o r .
CHAPTER 3
METHODOLOGY
The purpose o f t h e s tu d y was t o d e t e r m i n e p a t i e n t r e a c t i o n s
t o t r a n s f e r s from r u r a l t o urban h e a l t h c a r e i n s t i t u t i o n s .
In
t h i s c h a p t e r methodology o f t h e s t u d y i s p r e s e n t e d .
' Research Design
The s tu dy was an e x p l o r a t o r y d e s c r i p t i v e desi gn a d d r e s s in g
t h e q u e s t i o n , "What a r e p a t i e n t r e a c t i o n s t o t r a n s f e r s from
r u r a l t o urban h e a l t h c a r e i n s t i t u t i o n s ? " The st ud y u t i l i z e d
a s t r u c t u r e d i n t e r v i e w developed by t h e i n v e s t i g a t o r .
When
l i t t l e i s known on a t o p i c , perso nal i n t e r v i e w s a r e powerful
methods o f s e c u r i n g i n f o r m a t i o n ( P o l i t . a n d Hungler, 1978:203).
I n t e r v i e w d a ta p ro vid e depth and q u a l i t y w it h o p p o r t u n i t i e s
f o r v e r i f i c a t i o n ( K e r l i n g e r , 1973).
S in c e i n t e r v i e w s c h e d u le s
■r e g a r d i n g p a t i e n t r e a c t i o n s t o r u r a l - t o - u r b a n t r a n s f e r s were
n o t a v a i l a b l e , one was developed a d d r e s s i n g p a t i e n t con cerns
and s i c k r o l e b e h a v io r e x p e r ie n c e d by p a t i e n t s w hil e in r u r a l
h e a l t h c a r e i n s t i t u t i o n s , duri ng t h e t r a n s f e r p r o c e s s , and
upon e n t r y i n t o urban h e a l t h c a r e i n s t i t u t i o n s .
S e t t i n g ' a n d Sample
Montana i s a r u r a l s t a t e with only two urban a r e a s .
23
B i l l i n g s and G reat F a l l s , p ro v id i n g s p e c i a l i z e d medical c a r e f o r
Ea st er n and So ut h - C e n tr a l Montana. : Because o f th e i n v e s t i g a t o r ' s
i n t e r e s t , B i l l i n g s Deaconess H osp i ta l and S t . V i n c e n t ' s H o s p i t a l ,
l o c a t e d in B i l l i n g s , were s e l e c t e d to. r e p r e s e n t th e urban h e a l t h
care i n s t i t u t i o n s .
Both h o s p i t a l s r e c e i v e a l a r g e number of
p a t i e n t s from s u rr o u n d in g r u r a l c o u n t i e s (Research S e r v i c e s
West, 1979).
These h o s p i t a l s house s p e c i a l i z e d u n i t s and e q u i p ­
ment wit h medical and n u r s i n g s p e c i a l i s t s from m a n y . f i e l d s
s e r v i n g them.
The t a r g e t p o p u l a t i o n were p a t i e n t s who had been t r a n s f e r r e d
from r u r a l h o s p i t a l s t o t h e s e B i l l i n g s ' h o s p i t a l s .
Other c r i t e r i a
t h a t had t o be met f o r p a t i e n t s t o be c o n s i d e r e d f o r p a r t i c i ­
p a t i o n in th e s tu d y were in r e l a t i o n t o age a n d . p l a c e o f r e s i ­
dence.
P a r t i c i p a n t s s e l e c t e d f o r t h e s tu d y were between th e
ages o f 18 and 80,. a l e r t , o r i e n t e d , c o h e r e n t , and r e p r e s e n t i n g
a v a r i e t y of medical d i a g n o s e s . ' P a t i e n t s who were s e l e c t e d
were from a r u r a l a r e a with a p o p u l a t i o n o f 2,500 or l e s s
w ith a f u n c t i o n i n g h o s p i t a l .
P a t i e n t s of e i t h e r s e x , and
any r a c e , r e l i g i o n , o c c u p a t i o n , ' o r e d u c a t i o n a l le v el were
e l i g i b l e f o r p a r t i c i p a t i o n in t h e s t u d y .
' D ata'C o ! I e c tio n ' Instrument
A s t r u c t u r e d i n t e r v i e w was developed by th e i n v e s t i g a t o r
to e l i c i t p a tie n t re a ctio n s to ru ra l-to -u rb a n . t r a n s f e r s .
■24
Q ue sti ons r e l a t e d t o t h e r u r a l h e a l t h c a r e i n s t i t u t i o n , th e
t r a n s f e r p r o c e s s , and t h e urban h e a l t h c a r e i n s t i t u t i o n .
Que stions a d d r e s s i n g demographic and background d a t a , as
well as r e a c t i o n s t o r u r a l - t p - u r b a n t r a n s f e r s in r e l a t i o n to
p a t i e n t concerns and s i c k r o l e b e h a v i o r were asked. . Demographic
questions e l i c i t e d information regarding age, sex, m arital s t a t u s , o c c u p a t i o n , town of r e s i d e n c e , y e a r s a t t h a t r e s i d e n c e ,
d i a g n o s i s , and r u r a l and urban a dm is si on d a t e s .
Que stion s
s p e c i f i c a l l y a d d r e s s i n g t h e r u r a l h e a l t h c a r e i n s t i t u t i o n , th e
t r a n s f e r p r o c e s s , and t h e urban h e a l t h c a r e i n s t i t u t i o n made
up t h e major p a r t o f t h e i n t e r v i e w .
Appendix A c o n t a i n s t h e
data c o l l e c t i o n instrument.
V a l i d i t y of t h e d a t a c o l l e c t i o n i n s t r u m e n t was a s s e s s e d
through p i l o t i n t e r v i e w s .
The pre sum ption was held t h a t each
p a r t i c i p a n t h a d . f a c e v a l i d i t y as an in f o r m a n t (Brink and Wood,
1978:123) and t h a t s e l f - r e p o r t would be t r u t h f u l .
To a s s e s s t h e i n s t r u m e n t ' s r e l i a b i l i t y , two q u e s t i o n s
a d d r e s s i n g t h e same concept were p r e s e n t e d d i f f e r e n t l y by
rewording t h e q u e s t i o n s .
With e v e r y i n t e r v i e w , th e same
q u e s t i o n s were asked in th e same o r d e r in o r d e r to reduce
i n v e s t i g a t o r b i a s and : " i h s u r e . - c o m p a r a b i l i t y of r e s p o n se s"
(Pol i t and ' liu ngle r, 1978:326).
Each p a r t i c i p a n t was giv en
.25
t h e o p p o r t u n i t y to g i v e ' a d d i t i o n a l ,i n f o r m a t i o n a t th e end o f .
the interview .
Data C o l l e c t i o n Method
Data f o r t h e s tu d y were c o l l e c t e d ;between Janu ary 9 , '1981 and
Febru ary 4 , 1981.
Using th e c r i t e r i a o u t l i n e d f o r t h e s t u d y , HO
p a t i e n t s were s c r e e n e d .
were i n t e r v i e w e d .
O n l y '14 . p a t i e n t s ' met th e c r i t e r i a and
The remainder s c r e e n e d were e i t h e r too i l l
t o p a r t i c i p a t e , were in B i l l i n g s by s e l f - r e f e r r a l o r p h y s i c i a n r e f e r r a l , o r did not meet t h e c r i t e r i a o f age.
I n t e r v i e w s were he ld in t h e p a t i e n t ' s h o s p i t a l room and
r e q u i r e d from 3 0 . t o 60 minutes f o r c o m p l e t i o n , with an aver age
time o f 30 m in u te s .
I n t e r v i e w s were h e l d '12 t o 72 hours a f t e r
t h e p a t i e n t ' s ad mission to t h e urban h e a l t h c a r e i n s t i t u t i o n .
Verbatim r e c o r d i n g of t h e d a t a was done a t th e time of th e
i n t e r v i e w by t h e i n v e s t i g a t o r .
P i l o t Study
A p i l o t s tu d y with a sample o f f o u r p a t i e n t s was f i r s t
conducted t o a s s e s s t h e adequacy o f t h e i n t e r v i e w and t o i d e n t i f y
I
,
problems t h a t may be en cou nte red or a r e a s of i n q u i r y which may
have been o ve rl oo ke d.
As a r e s u l t o f t h i s p i l o t s t u d y , a d d i ­
t i o n a l q u e s t i o n s were added r e g a r d i n g o c c u p a t i o n , m a r i t a l
s t a t u s , and how p a t i e n t s planned t o r e t u r n home.
P atien t's
26
o c cu pa tio n and m a r i t a l s t a t u s were d i s c u s s e d by p a r t i c i p a n t s
o f t h e p i l o t s tu d y and i n d i c a t e d a n . i n f l u e n c e on th e p a t i e n t s '
r e a c t i o n s to t r a n s f e r s .
The q u e s t i o n a d d re ss in g , th e r e t u r n - t r i p
home was added as t h e i n v e s t i g a t o r b e l i e v e d t h i s may be an a re a
of concern f o r t r a n s f e r r e d p a t i e n t s . ' R e s u l t s o f t h i s p i l o t stu dy
with t h e s e f o u r p a t i e n t s a r e in c l u d e d in t h e o v e r a l l f i n d i n g s
of t h e s t u d y because p a t i e n t s s p o n t a n e o u s l y provided t h e i n ­
v e s t i g a t o r w it h t h i s i n f o r m a t i o n .
Human R ig hts
- .
P r o v i s i o n s were made in t h e s t u d y f o r p r o t e c t i o n o f th e
p a r t i c i p a n t s ' human r i g h t s .
The human r i g h t s committees o f
Montana S t a t e U n i v e r s i t y School o f N u rs in g , B i l l i n g s Extended
Campus, B i l l i n g s Deaconess H o s p i t a l , and S t . V i n c e n t ' s Hosp it al
reviewed t h e s tu d y and g r a n t e d approval f o r conducting i t .
Copies o f t h e l e t t e r s o f approval a r e found in Appendix B.
Signed
c o n se n t f o r p a r t i c i p a t i o n in t h e s t u d y was r e c e i v e d from each
participant.
A copy of t h e c o n s e n t form i s in Appendix C.
Each p a t i e n t ' s c a p a b i l i t y t o p a r t i c i p a t e in t h e s t u d y was
a s s e s s e d by t h e h o s p i t a l u n i t ' s head nurs e and t h e i n v e s t i g a t o r .
Each p a r t i c i p a n t r e c e i v e d v e rb a l and w r i t t e n e x p l a n a t i o n of
t h e s tu d y and a s s u r a n c e o f anonymity and c o n f i d e n t i a l i t y .
rf
■27
Data Anal ysi s
Upon completion o f t h e d a t a c o l l e c t i o n , da ta were summarized,
c a t e g o r i z e d and t a b u l a t e d .
P e r t i n e n t demographic d a ta were
c r o s s - t a b u l a t e d with t h e g en eral f i n d i n g s .
Data a r e p r e s e n t e d
in t a b l e s us in g numerical f r e q u e n c i e s '. a n d in n a r r a t i v e form in
t h e f o ll o w i n g c h a p t e r .
CHAPTER.' 4
FINDINGS AND DISCUSSION
The s tu d y was an e x p l o r a t o r y d e s c r i p t i v e survey of 14
p a t i e n t s 1 r e a c t i o n s to t r a n s f e r s from r u r a l t o urban h e a l t h
c a r e i n s t i t u t i o n s r e l a t i v e t o co nce rn s and s i c k r o l e b e h a v i o r .
Data was g a t h e r e d by an i n t e r v i e w de vel oped by th e i n v e s t i g a t o r .
The r e s u l t s were an aly ze d with t h e f i n d i n g s and d i s c u s s i o n
p r e s e n t e d in t h i s c h a p t e r .
Screen ing Data
One hundred and t e n p e r s o n s w it h r u r a l a d d re ss e s h o s p i t a l ­
iz ed in two B i l l i n g s h o s p i t a l s were i d e n t i f i e d by th e i n v e s t i g a t o r .
Of t h e s e 110, only 14 had been t r a n s f e r r e d from r u r a l h o s p i t a l s .
The g r e a t m a j o r i t y (n=85) were s e l f - r e f e r r e d or p h y s i c i a n r e f e r r e d w it h s u b s e q u e n t h o s p i t a l ad m is si o n f o r d i a g n o s t i c
p r o c e d u r e s , t e s t s , and s u r g e r y .
The r e m a in de r ( n = l l ) were e i t h e r
too i l l t o p a r t i c i p a t e o r did n o t meet t h e age c r i t e r i o n .
Demographic Data
The d a t a r e p o r t e d were
patients.
c o l l e c t e d from t h e s e 14 t r a n s f e r r e d
These p a r t i c i p a n t s in c l u d e d a r e p r e s e n t a t i o n of
males (n=8) and fema les (n=6), who were e i t h e r employed
(n=7) o r r e t i r e d ( n = 7 ) .
All were a l e r t , o r i e n t e d , and co-
29
.
h e r e n t . . The m a j o r i t y ( n = l l ) were' '43 y e a r s of age or o l d e r .
Six p a r t i c i p a n t s l i v e d 200 or more ;miTes from B i l l i n g s ; th e
remaining e i g h t l i v e d from '53' t o . TOOTmiTes from B i l l i n g s .
The
m a j o r i t y (n=10) were m a r r i e d . ' . E i g h t p a r t i c i p a n t s had l i v e d a t
t h e i r p r e s e n t r u r a l r e s i d e n c e 32 :years or more; th e remaining
s i x had m a in ta in e d t h e i r p r e s e n t r u r a l r e s i d e n c y f o r seven
y e a r s or l e s s .
P a r t i c i p a n t s had dia gno ses o f e i t h e r s e r i o u s i l l n e s s ( n=9)
o r l e s s s e r i o u s i l l n e s s ■(n=5)..:. D e te r m in a t io n of s e r i o u s and
l e s s s e r i o u s d ia gno se s was based upon r e a s o n s f o r t r a n s f e r and
l e n g t h of time b e f o r e t r a n s f e r from t h e r u r a l h o s p i t a l .
For
example, t h e p a r t i c i p a n t who s u f f e r e d a head i n j u r y and m u l t i ­
pl e f r a c t u r e s was d e f i n e d as having a s e r i o u s d i a g n o s i s .
Rural -
t o - u r b a n t r a n s f e r was i n s t i t u t e d f o r t h i s p a t i e n t immediately
a f t e r s t a b i l i z a t i o n due to th e need f o r t h e s p e c i a l i z e d c a r e
o f a n e u r o l o g i s t , o r t h o p e d i c su rg e o n , and i n t e n s i v e c a r e
m o n it o r in g .
Another p a r t i c i p a n t who had oneside d p a r e s t h e s i a
was d e f i n e d as having a l e s s s e r i o u s d i a g n o s i s .
This p a t i e n t ' s
t r a n s f e r took p l a c e a f t e r se v e n .d a y s o f . r u r a l h o s p i t a l i z a t i o n .
The d i a g n o s t i c proc ed ures and s o p h i s t i c a t e d t e s t i n g n e c e s s a r y to
deter mine t h e cause o f t h e p a r e s t h e s i a was only a v a i l a b l e in
urban h o s p i t a l s e t t i n g s .
30
The m a j o r i t y of p a r t i c i p a n t s ' ( n'=9)■ had s p e n t l e s s tha n two
days in th e r u r a l h o s p i t a l b e f o r e t r a n s f e r ; s p e n t f i v e o r l e s s
days in t h e urban h o s p i t a l b e f o r e being i n t e r v i e w e d ; and had
seven or more t o t a l s i c k days, .''Teble 3 p r e s e n t s t h e s p e c i f i c
demographic d a ta on a l l '14 p a r t i c i p a n t s . .
■ Background,Data
Background d a t a were g a t h e r e d i n r e l a t i o n to th e r u r a l
h e a l t h c a r e i n s t i t u t i o n and th e t r a n s f e r p ro c e s s t o f a c i l i t a t e
p a r t i c i p a n t - i n v e s t i g a t o r r a p p o r t and g a i n background i n f o r m a t i o n
r e g a r d i n g th e b a s i s f o r t h e r u r a l - t o - u r b a n t r a n s f e r as p e r c e iv e d
by t h e p a r t i c i p a n t s .
Appendix A c o n t a i n s t h e for mat o f th e
interview .
Rural Health Care I n s t i t u t i o n
Background d a t a r e g a r d i n g problems t h a t brought p a r t i c i p a n t s
to r u r a l h o s p i t a l s and means of g e t t i n g t h e r e were a d d r e s s e d .
The g r e a t m a j o r i t y o f t h e p a r t i c i p a n t s (n=12) d e s c r i b e d t h e
problem t h a t l e d t o r u r a l h o s p i t a l adm is sio n with symptomology,
f o r example, "I was coughing up a l o t o f b lo o d ."
Others used
common d i a g n o s t i c t e r m s , such as "I had a h e a r t a t t a c k . "
P a r t i c i p a n t s were bro ug ht t o r u r a l h o s p i t a l s e i t h e r by a c a r
d r i v e n by t h e p a r t i c i p a n t ' s s p o u s e , a r e l a t i v e , or thems elve s
(n-10) or by l o c a l ambulance ( n - 4 ) .
31
Table 3. Demographic Data o f P a t i e n t s T r a n s f e r r e d from Rural to
___________ Urban Health Care I n s t i t u t i o n s (N=14).__________________
Sex
Age
M a r it a l s t a t u s
Working s t a t u s
Diagnosis
Ma
19
Sb
Employed
S Ic
F
W
76
Reti fed
LSI
M
S
Employed
47
SI
M
M
72
Reti red
SI
M
M
32
Employed
SI
F
M
Employed
61
SI
F
M
62
Reti red
SI
F
W
Ret i red
SI
71
F
M
65
Reti red
LSI
M
M
43
Employed
LSI
M
M
Employed
LSI
35
M
M
Employed
SI
55
F
81
W
Reti red
LSI
M
M
66
Reti red
SI
aM=male ; F=female; 0S=S ingle ; W=widowed; M=married; cS I = s e r io u s
i l l n e s s , LSI=I ess s e r i o u s i l l n e s s .
Rural r e s i d e n c y Miles t r a n s f e r r e d Rural S t a y d Urban Sta y0Sick days0
8 Days
0 Days
8 Days
60 Miles
7 Years
4
81
0
4
Si
21
93
0
21
43
81
0
2
2
72
8
I
32
340
7
17
10
53
7
40
2
I
I
100
4
2
I
I
308
40
8
15
209
7
45
3
2
I
306
43
15
5
210
10
3
7
5
2
283
Ii
9
2
81
7
3i
10
9
I
60
65
5.5 Days 8 .8 Days
162.4 Miles
3 . 3 Days
Means-28.8 Years
dRural Stay=Uays a t r u r a l h o s p i t a l b e f o r e t r a n s f e r ; 0Urban stay=
days a t urban h o s p i t a l b e f o r e i n t e r v i e w ; c Sick days=tota1 s i c k days.
32
T h e ' T r a n s f e r Pr oce ss
Several r e a s o n s f o r t h e t r a n s f e r s , as pe rc ei ve d by th e
p a r t i c i p a n t s ' , were r e p o r t e d .
The' need t o be under t h e c a r e o f .
a s p e c i a l i s t was r e p o r t e d t h e m o s t . f r e q u e n t l y ( n = 5 ) .
For
example, one p a r t i c i p a n t s t a t e d , :" I- n e e d ed to g e t to my h e a r t
doctor."
Other r e a s o n s f o r t h e t r a n s f e r s inc lu de d t h e need
t o g e t a b e t t e r equipped f a c i l i t y ( n = 4 ) , t h e need f o r t h e
performance o f s p e c i a l t e s t s in o r d e r t o det ermi ne " th e r o o t
o f t h e problem" ( n = 3 ) , and t h e p e r c e p t i o n t h a t th e p r e ­
c a r i o u s n e s s o f t h e p a r t i c i p a n t ' s p h y s ic a l c o n d i t i o n n e c e s s i t a t e d
the t r a n s f e r (n=2).
For example, in r e s p o n s e t o t h e q u e s t i o n ,
"Why were you t r a n s f e r r e d ? " one p a r t i c i p a n t re s ponded, "They
were worr ie d a bo ut hemorrhaging on t h e b r a i n . "
Various modes of t r a n s p o r t a t i o n were used in th e t r a n s f e r
p r o c e s s , with c om bin at ion s o f d i f f e r e n t modes used in some
transfers.
Local r u r a l ambulance s e r v i c e s were r e p o r t e d as
being used t h e most in r u r a l - t o - u r b a n t r a n s f e r s ' ( n = 5 ).
Other
modes u t i l i z e d i n c l u d e d l o c a l a i r ambulance s e r v i c e s ( n=3) ,
c a r s (n=2), and B i l l i n g s ' h e l i c o p t e r s and a i r ambulances
(n=2).
Combinations of d i f f e r e n t modes in c lu d e d a B i l l i n g s
a i r ambulance w it h a h e l i c o p t e r . a n d a l o c a l ambulance w it h
a B i l l i n g s Advanced C a r d i a c - L i f e Su pport (A.C iL. S. ) ambulance.
' 33.
which were u t i l i z e d a f t e r one p a r t i c i p a n t re f u s e d to g e t in
a Billings h elico p ter.
' Patient' ReactionsVto',Ruhal TtdrUrban Transfers
•
P a t i e n t r e a c t i o n s t o t r a n s f e r s from r u r a l t o urban h o s p i t a l s
a r e p r e s e n t e d in r e l a t i o n t o t h e :r u r a l h e a l t h c a r e i n s t i t u t i o n ,
■the t r a n s f e r p r o c e s s , and t h e urban h e a l t h c a r e i n s t i t u t i o n .
P a r t i c i p a n t s ' r e a c t i o n s t o each o f t h e s e a r e p r e s e n t e d in t h e
fo ll o w i n g pages.
P a t i e n t R ea c tio ns R e l a t i v e ' , t o ' t h e . , R u r a l Health Care I n s t i t u t i o n
The r u r a l h e a l t h c a r e . i n s t i t u t i o n was a d d re ss e d as one area
o f i n f l u e n c e on p a t i e n t r e a c t i o n s t o r u r a l - t o - u r b a n t r a n s f e r s .
Questions were asked t o e l i c i t r e a c t i o n s in r e l a t i o n t o p a t i e n t
concerns and s i c k r o l e b e h a v i o r .
The m a j o r i t y of t h e p a r t i c i p a n t s (n=12) remembered t h e i r
e n t r y to t h e r u r a l h e a l t h c a r e i n s t i t u t i o n and c l e a r l y r e c a l l e d
t h e .events t h a t f o l l o w e d .
Responses i n c lu d e d th e f o l l o w i n g ,
"They put me on t h e emergency room t a b l e , s t a r t e d an I . V . ,
gave me Oxygen, and wheeled me in f o r X - r a y s ."
One p a r t i c i p a n t
had vague remembrance o f t h e c i r c u m s t a n c e s su rro un din g t h e
e n t r a n c e to t h e rur al, h o s p i t a l s . N o doubt t h i s was due t o t h e
s ev e re myocardial . . i n f a r c t i o n t h e p a r t i c i p a n t was e x p e r i e n c i n g .
Another could not remember a n yth in g a bout t h e r u r a l h o s p it a l, .
34
even though "I guess I was t e l l i n g pe ople my name, m y . p l l e r g i e s ,
and who to cal I ."
Twelve p a r t i c i p a n t s knew a t l e a s t one p e rs o n , nurs e or
p h y s i c i a n , who c a r e d f o r them i n i t i a l l y in t h e r u r a l h o s p i t a l ,
with 9 i n d i c a t i n g th e y knew "everyone" ( n u r s e s , p h y s i c i a n s ,
a i d e s , and ambulances a t t e n d a n t s ) .
As one p a r t i c i p a n t s t a t e d ,
"In a small town, everyone knows ev erybody ."
Most p a r t i c i p a n t s (n=10). r e p o r t e d n o t having any concerns
entering the ru ral h o s p i t a l .
O the rs r e p o r t e d concerns in r e l a t i o n
t o p a i n , d i a g n o s i s , where t o go f o r s p e c i a l i z e d c a r e , and n e g a t i v e
f e e l i n g s toward t h e r u r a l h o s p i t a l due t o problems en cou nte red with
pre vi ous a d m i s s i o n s .
from t h e p a i n . "
One p a r t i c i p a n t s a i d , "I j u s t wanted r e l i e f
Another a s k e d , "What's t h e m a t t e r with me?"
While a n o t h e r s t a t e d . , "I d i d n ' t know Where t o go ( f o r s p e c i a l i z e d
care)."
These co nce rns were handled by n u r s e s , r e l a t i v e s , or
were l e f t , unanswered.
Summary
On e n t e r i n g t h e r u r a l h o s p i t a l , most p a r t i c i p a n t s r e p o r t e d
not having any c o n c e r n s .
They remembered t h e i r e n t r y to th e
r u r a l h o s p i t a l and were a b l e t o d e s c r i b e t h e events t h a t
fo ll ow e d.
The p a r t i c i p a n t s , in g e n e r a l , knew a t l e a s t one
person who c a r e d f o r them i n i t i a l l y in t h e r u r a l h o s p i t a l .
35
.
P a t i e n t ,.Reactio n s ' Rel a t i Ve t o : t h e ^ T ra n sf e r Process
The t r a n s f e r p ro c e s s was a d d r e s s e d :as a n o t h e r a r e a o f
i n f l u e n c e on p a t i e n t r e a c t i o n s to r u r a l - t o - u r b a n t r a n s f e r s .
Again, q u e s t i o n s were :asked t o r . e l i c i t ' r e a c t i o n s in r e l a t i o n
,
t o p a t i e n t con cerns a n d , s i c k r o l e b e h a v i o r .
Various r e a c t i o n s were ;el i c i t e d .from t h e p a r t i c i p a n t s
when t h e y were t o l d t h a t th e y were .being " t r a n s f e r r e d .
Half. . •
o f the p a r t i c i p a n t s b e l i e v e d t h e . t r a n s f e r was n e c e s s a ry and
were w i l l i n g t o go.
As one p a r t i c i p a n t , s t a t e d , "I wanted
t o . f i g u r e o u t what was wrong::with me."
The o t h e r h a l f had
mixed r e a c t i o n s . " S e v e ra l d i d n ' t want t o be t r a n s f e r r e d , but
wanted e i t h e r t o s t a y in t h e r u r a l h o s p i t a l o r go to a n o t h e r
urban h o s p i t a l o t h e r th a n t h o s e . i n B i l l i n g s .
One p a r t i c i p a n t
wanted t o be t r a n s f e r r e d t o . G r e a t . F g l l s as fa m ily members l i v e d
there.
Qrily two p a r t i c i p a n t s were .-frightened when t o l d a bout
being t r a n s f e r r e d .
me.
One s t a t e d , " I t s c a r e d t h e h e ll ou t o f .
I j u s t knew I was going t o kick t h e b u c k e t ; "
s a i d , "I d i d n ' t know i t was t h a t s e r i o u s . ".
Another
Another p a r t i c i ­
pan t r e p o r t e d n o t being t o l d :about t h e t r a n s f e r , bu t t h a t
knowledge o f being t r a n s f e r r e d t o - B i l l i n g s ' w a s gained when
"I heard the' ( a m b u l a n c e ) , s i r e n g o i n g . "
P a t i e n t r e a c t i o n s to
' 36.
being t o l d about t h e t r a n s f e r t o t h e urban h o s p i t a l a r e p r e s e n t e d
in Table 4.
Table 4. P a t i e n t R e a c ti o n s t o Being Told About th e R u r a l - t o ___________Urban T r a n s f e r .
, ,_______ ._______ •_____________ ,
______
Patient reactions
....................
Seen as a n e c e s s a r y a c t i o n .
Number of res ponse s
7
S t a t e d did no t want t o go
3
Were s u r p r i s e d / s c a r e d
2
Not t o l d / d i d n o t remember
. . : . :______
2_____________________
The m a j o r i t y o f p a r t i c i p a n t s ' (n=9) r e p o r t e d not having any
concerns upon bei ng t o l d t h a t t h e t r a n s f e r was sc h e d u le d .
Concerns
r e p o r t e d were i n r e g a r d t o c o s t s o f t h e t r a n s f e r and s p e c i a l i z e d
c a r e , the e s t i m a t e d l e n g t h o f time t h a t would be s p e n t in th e
urban h o s p i t a l , and wh e th er s u r g e r y would be r e q u i r e d .
One p a r t i ­
c i p a n t r e p o r t e d , "I t o l d them I wanted t o go t o Great F a l l s ,
b u t they d i d n ' t l i s t e n t o me."
For t h e p a r t i c i p a n t who voiced
them, p h y s i c i a n s d i s c u s s e d t h e co nce rns o f s u rg e ry and l e n g t h
of stay.
I t was r e p o r t e d t h a t no one d i s c u s s e d c o s t s o r t h e
d e c i s i o n on where t o be t r a n s f e r r e d with t h e p a r t i c i p a n t s who
voic ed t h e s e c o n c e r n s .
. Being in v o lv e d in a t r a n s f e r p re v io u s t o t h i s p a r t i c u l a r
one was r e p o r t e d b y :e i g h t p a r t i c i p a n t s . . Those who had not been
37
invol ve d in p re v io u s t r a n s f e r s did not v o ic e any concern r e ­
ga rdi ng t h a t i n e x p e r i e n c e .
Nurses were i d e n t i f i e d by s i x ' p a r t i c i p a n t s as pe rsons
responsible fo r t h e i r care before.being tra n s fe rre d .
Physi­
c i a n s were seen as r e s p o n s i b l e f o r : f i v e o f th e t r a n s f e r s .
hysband" and t h e p a r t i c i p a n t w e r e . a l s o i d e n t i f i e d .
"My
Persons
p e rc ei v e d as r e s p o n s i b l e f o r p a t i e n t c a r e p r i o r to t r a n s f e r
a r e p r e s e n t e d in Ta b le 5. '
Table 5. Person P e r c e i v e d . a s R e s p o n s ib le f o r P a t i e n t Care P r i o r
___________ t o T r a n s f e r .
______________________ _________________
C a r e - g i v e r i d e n t i f i e d ________________ Number of re s p o n se s
Nurse
6
Physician
5
Spouse or o t h e r f a m i l y member
2
__________Did n o t remember________________________ I____________________
P r e p a r a t i o n f o r t r a n s f e r was seen by most p a r t i c i p a n t s in
r e g a r d s to p h y s i c a l c a r e ( n=5) and s p e c i f i c t r e a t m e n t s (n=7).
This p r e p a r a t i o n in c l u d e d a d m i n i s t r a t i o n of m e d ic at io n s and i n t r a ­
venous f l u i d s , e x p l a n a t i o n s , and g e t t i n g th e p a r t i c i p a n t s dre sse d
appropriately fo r tr a n s fe r.
Nurses were p e r c e iv e d as t h e ones
doing p a t i e n t c a r e by f o u r o f t h e p a r t i c i p a n t s .
Other i d e n t i f i e d
as being in vol ve d in p a t i e n t p r e p a r a t i o n inc lud ed p h y s i c i a n s
38. ■
(n =3 ) , emergency medical t e c h n i c i a n s (E. M. T. ) ( n = 2 ) , fa m i l y members
( n=2)
and t h e p a r t i c i p a n t .
In d e s c r i b i n g t h e t r i p from th e r u r a l h o s p i t a l t o t h e
urban h o s p i t a l , most p a r t i c i p a n t s ..responded by d e s c r i b i n g the,
ph y s ic a l en vironment ( n - 1 2 ) .
The t r i p was "smooth," o ve r
"rough r o a d s , " and " l i k e a n y . o t h e r a i r p l a n e r i d e . "
As
mentioned p r e v i o u s l y , a l l m ode s' of t r a n s p o r t a t i o n , gro und,
f i x e d - w i n g , and h e l i c o p t e r , w e r e . u t i l i z e d .
Nurses and EJM.T.'s were i d e n t i f i e d . a s t h e main pe rsons
r e s p o n s i b l e f o r p a t i e n t c a r e during th e t r a n s f e r (n= 8) .
Other
l i s t e d as r e s p o n s i b l e i n c lu d e d r e l a t i v e s and t h e p a r t i c i p a n t .
In one c a s e , t h e c a r e was sh ared by a n u rs e and an E.M.T.
Persons p e r c e i v e d as r e s p o n s i b l e f o r p a t i e n t c a r e d u ri n g th e
t r a n s f e r a r e p r e s e n t e d in T a b l e '6.
Table 6.
Person P e r c e i v e d as Responsible f o r P a t i e n t Care During
' the Transfer.
Care-giver id e n tif ie d
Nurse
■ ■
Number of r e s p o n s e s
4
E.M.T.
4
Relative
3
Did n o t remember
2
Participant
I
-*
39
The g e n e r a l r e a c t i o n o f th e p a r t i c i p a n t s towards t h e
t r a n s f e r p r o c e s s was p o s i t i v e :
t h i n g was handled ve ry w e l l . "
ab out t h e t r a n s f e r p r o c e s s .
:As .one p a r t i c i p a n t s t a t e d , "Every­
E i g h t p a r t i c i p a n t s had no concerns
Concerns r e p o r t e d were in re g a rd to
who was d r i v i n g t h e ambulance,:' t h e a d d i t i o n a l c o s t o f t h e t r a n s f e r ,
t h e w e a t h e r c o n d i t i o n s , and "What1s happening t o me?"
Summary
Va rio us r e a c t i o n s t o being t o l d a bout t h e impending t r a n s f e r
were r e p o r t e d w ith h a l f of the p a r t i c i p a n t s b e l i e v i n g t h e t r a n s f e r
was n e c e s s a r y in o r d e r to g e t w e l l .
The o t h e r h a l f r e p o r t e d not
wanting t o be t r a n s f e r r e d , being s c a r e d , and not being t o l d .
The m a j o r i t y o f t h e p a r t i c i p a n t s d id n o t have any a d d i t i o n a l
co ncerns a f t e r being t o l d t h a t t h e t r a n s f e r was s c h e d u l e d .
Most p a r t i c i p a n t s did n o t have any concerns r e g a r d i n g th e
tra n s fe r process.
Nurses were i d e n t i f i e d as major c a r e - g i v e r s
p r i o r t o t h e t r a n s f e r and in p r e p a r a t i o n f o r t h e t r a n s f e r ,
wit h n u r s e s and E .M .T .' s s h a r in g p a t i e n t c a r e d urin g t h e t r a n s f e r .
In g e n e r a l , r e a c t i o n t o t h e t r a n s f e r p ro c e s s was p o s i t i v e .
P a t i e n t R e a c ti o n s R e l a t i v e t o t h e Urban Health Care I n s t i t u t i o n
Urban h e a l t h c a r e i n s t i t u t i o n s were t h e t h i r d a r e a address ed
in t h e s t u d y w it h q u e s t i o n s f o c u s in g on e l i c i t i n g r e a c t i o n s in
r e l a t i o n t o p a t i e n t concerns and s i c k r o l e b e h a v i o r .
Al I of
• 40
the p a r t i c i p a n t s e n t e r e d t h e , u r b a n h e a l t h c a r e i n s t i t u t i o n .as
" d i r e c t a d m i t s " b y p a s s i n g t h e emergency ward and being taken
d i r e c t l y t o t h e pro pe r medical u n i t f o r a d m is si on.
On a d ­
m is si on t o t h e medical u n i t , p a r t i c i p a n t s were o r i e n t e d by
nurs es ( n = 7 ) , p h y s ic i an s ' (n=5), r e l a t i v e s ( n = l ) , o r not
oriented a t a ll
(n=2).
Va rie d r e a c t i o n s t o admission to t h e urban h o s p i t a l
were r e p o r t e d .
Half of t h e p a r t i c i p a n t s were "happy t o be in a
pl a ce where I can g e t help and g e t b e t t e r . "
They e x p r e s s e d t h a t
th e y were f i n a l l y g e t t i n g t o th e h o s p i t a l where th e y co uld
c o n c e n t r a t e on g e t t i n g w e l l .
Others had v a r i o u s r e s p o n s e s .
Two p a r t i c i p a n t s were "so s i c k , i t d i d n ' t m a t t e r " where th e y
were.
Two o t h e r s were concerned a bout the mselves w it h one
s t a t i n g , "AlI I was concerned a bout was me."
Another responded
w i t h , "I knew i t was a' s t r a n g e e nv ir o n m e n t. "
P a tie n t reactions
upon e n t e r i n g t h e urban h e a l t h c a r e i n s t i t u t i o n a r e p r e s e n t e d
in Tabl e 7.
Most p a r t i c i p a n t s (n=10) did not have any co nce rn s on
e n t e r i n g t h e urban h o s p i t a l .
Of t h e co ncerns e x p r e s s e d by
o t h e r s , t h o s e of 3 p a r t i c i p a n t s were in rega rd to t h e i r
ph y s ic a l c o n d i t i o n s and were a d d r e s s e d by t h e i r urban p h y s i c i a n s .
For example, one p a r t i c i p a n t a sk e d , "What's going to happen to
1
1N
41
Table 7.
P a t i e n t R eactions Upon E n t e r i n g t h e Urban He alth Care
. . Institution.
Reaction
Happy t o be a t urban h o s p i t a l
me?"
Number o f res pons e s
7
Did not m a t t e r where th e y were
2
S elf-concern
2
P hys ic al environment s t r a n g e
I
P hys ic al e n v i ro n m e n t/ d id not m a t t e r
I
S u r p r i s e d t o be a t urban h o s p i t a l
I
Concerns e xpr ess ed by t h e p a r t i c i p a n t s on e n t e r i n g th e
urban h o s p i t a l and who handled t h e s e co ncerns a r e p r e s e n t e d in
Table 8 .
;
Tabl e 8 .
Concerns Expressed on E n t e r i n g Urban H o sp i ta l and Who
. Handled Them.
Concern s/ ha ndl ed by
None
Physical co n d itio n /p h y sic ian
Phys ic al c o n d i t i o n / r e l a t i ve
Number of re s p o n s e s
10
3
f .I
The m a j o r i t y o f t h e p a r t i c i p a n t s (n=10) had n e v e r p r e v i o u s l y
been p a t i e n t s in t h e urban h e a l t h c a r e i n s t i t u t i o n .
None of
t h e p a r t i c i p a n t s knew any of t h e peop le who cared f o r them in
t h e urban h o s p i t a l .
N e i t h e r o f t h e s e f a c t o r s e l i c i t e d any
42
concern from t h e p a r t i c i p a n t s .
A f t e r t h e i r admission t o t h e urban h o s p i t a l , f i v e p a r t i c i ­
p a n ts were concerned a bout t h e i r p h y s ic a l . c o n d i t i o n a n d / o r diagnosis
and what had to be done " t o remedy i t . "
these concerns.
Physicians a d d re ssed '
Other con cerns were e x p r e s s e d and a r e p re s e n te d
i n Tabl e 9.
Tabl e 9. Concerns Expressed A f t e r Admission t o t h e Urban
___________ Ho spital and Who Handled Them.______________■ ■■
Concern s/ ha ndl ed by________ Number of re s p o n s e s
Phys ical c o n d i t i o n / p h y s i c i a n
5
None
4
Length of s t a y / p h y s i c i a n
2
Costs/nurse
I
Job and f a m i l y / n u r s e
I
Loneli ness/1 e f t unanswered
I
H al f of t h e p a r t i c i p a n t s had no f u r t h e r co nce rns t o sh are
a t t h e end of t h e i n t e r v i e w .
Concerns e x p re s s e d by t h e o t h e r
h a l f in c l u d e d t h e s t a t e m e n t s o f "The ro a ds s u r e were r o u g h . " ,
" I t ' s to o bad I have t o come a l l t h i s way f o r t e s t s . " , and
" I' m s u r e th a n k fu l I have i n s u r a n c e . ".
Concerns e x p r e s s e d a t
t h e end of th e i n t e r v i e w r e g a r d i n g t h e r u r a l - t o - u r b a n t r a n s f e r
a r e p r e s e n t e d in Table 10.
43
Table 10. F u r t h e r Concerns Expressed Regarding t h e R u r a l - t p . . . .______ Urban . T r a n s f e r , ______________ .
________________
Concerns
None
..
..
Number of re s p o n se s'
7
Phys ical c o n d i t i o n
2
Road c o n d i t i o n s
2
D is ta nc e t o mediqal c a r e
I
Family s e p a r a t i o n .
I
D is ta nc e to medical c a r e / c d s t s
■'
'
' •
■I
None o f t h e p a r t i c i p a n t s had any co nce rns r e g a r d i n g t h e i r
r e t u r n t r i p home".
T h i r t e e n p a r t i c i p a n t s ex pected to r e t u r n
home by c a r d r iv e n by a f a m il y member.
One ex pec te d t o r e t u r n
home by a i r p l a n e .
Summary
On e n t e r i n g t h e urban h o s p i t a l , a l l p a r t i c i p a n t s were
a d m i t t e d d i r e c t l y to a medical u n i t .
The main r e a c t i o n t o
t h e urban admission was a f e e l i n g t h a t now they could " g e t
down t o t h e b u s i n e s s o f g e t t i n g w e l l . "
They did not have
ainy co nce rns on e n t e r i n g th e urban h o s p i t a l , even though
most of them had
never been p a t i e n t s t h e r e b e f o r e and none
o f them knew any of t h e people who were c a r i n g f o r them.
The most f r e q u e n t concern r e p o r t e d by th e p a r t i c i p a n t s
44
a f t e r ad mis sion to t h e urban h o s p i t a l was in r e g a r d s to t h e i r
physical con d itio n .
i t c ou ld be remedied.
They wanted t o know what was wrong and how
None o f t h e p a r t i c i p a n t s had any concerns
r e g a r d i n g t h e i r r e t u r n - t r i p home.
The p a r t i c i p a n t s i d e n t i f i e d n u r s e s as th e main peop le r e ­
s p o n s i b l e f o r t h e i r o r i e n t a t i o n t o t h e i r s u r r o u n d in g s and t o
what was happening to them on a dmi ssi on t o t h e urban h o s p i t a l .
P h y s i c i a n s were i d e n t i f i e d as t h e pe ople who handled t h e i r
c o nce rn s r e g a r d i n g phy s ic a l c o n d i t i o n , d i a g n o s i s , and t r e a t ­
ment.
Data R el ev a nt to Demographic Data .and General Findings
The p e r t i n e n t f i n d i n g s in r e l a t i o n to t h e t a b u l a t i o n of
demographic d a t a with g en eral f i n d i n g s of t h e s tu dy were in
r e g a r d to d i s t a n c e t r a n s f e r r e d and d i a g n o s i s .
Eig ht p a r t i ­
c i p a n t s were t r a n s f e r r e d l e s s than 100 m i l e s in o r d e r to
a r r i v e a t t h e urban h o s p i t a l and were t r a n s p o r t e d mainly
by l o c a l ground ambulance s e r v i c e s .
Othe rs were t r a n s p o r t e d
by c a r , h e l i c o p t e r , and t h e comb ina tio n of a l o c a l ambulance
w it h a B i l l i n g s A.C.L..S. ambulance.
Emergency medical
t e c h n i c i a n s were r e p o r t e d as t h e pe rs on s r e s p o n s i b l e f o r
c a r e of h a l f (n=7) o f t h e p a r t i c i p a n t s d uri ng t h e s e t r a n s f e r s .
Others r e p o r t e d as being r e s p o n s i b l e f o r p a t i e n t c a r e '
45
i n c lu d e d nurs es and f a m il y members.
Six p a r t i c i p a n t s were t r a n s f e r r e d more than 200 m il e s in
o r d e r to a r r i v e a t t h e urban h o s p i t a l and were t r a n s p o r t e d by
both r u r a l and urban a i r a m b u la n c e ^ s e r v ic e , in f i v e o f t h e s ix
transfers,.
Nurses were i d e n t i f i e d .as t h e persons r e s p o n s i b l e
f o r t h e c a r e o f h a l f of t h e p a r t i c i p a n t s during t h e s e l on g­
distance t r a n s f e r s .
Of t h e : s i x who were t r a n s f e r r e d more than
200 m i l e s , t h r e e were t r a n s f e r r e d more th a n 300 m ile s by lo c al
o r B i l l i n g s a i r ambulances and r e l a t i v e s were i d e n t i f i e d as
t h e pe rsons r e s p o n s i b l e f o r p a t i e n t c a r e in two o f t h e t h r e e .
transfers.
P a r t i c i p a n t s who were d e f i n e d a s b e in g s e r i o u s l y i l l
e x p re s s e d l e s s con cerns than t h o s e d e f i n e d as being l e s s
seriously i l l .
Less s e r i o u s l y i l l
p a r t i c i p a n t s e x p re ss e d con­
c e r n s r e g a r d i n g c o s t s , l e n g t h of s t a y , t h e p o s s i b i l i t y of .
s u r g e r y , l o n e l i n e s s , fa m il y s e p a r a t i o n , and d i s t a n c e t o
medical c a r e .
Many of t h e s e a r e t h e same concerns i d e n t i f i e d
by V o l i c e r (1973; 1974) in her s t u d i e s o f s t r e s s f u l e v e n ts of
hospitalization.
S e r i o u s l y i l l p a r t i c i p a n t s d id not v o i c e concerns u n t i l
a f t e r t h e e i g h t h day of urban h o s p i t a l i z a t i o n .
From one to
e i g h t days a f t e r t h e i r urban a d m i s s i o n , t h e i r main concern was
46
t h e i r ph ys ic a l c o n d i t i o n . . Then, a f t e r t h e e i g h t h day, concerns
r e g a r d i n g f a m ily s e p a r a t i o n , ' c o s t s , l e n g t h of s t a y a t t h e urban
h o s p i t a l , and d i s t a n c e to medical c a r e were e x p r e s s e d .
'
Summary
P e r t i n e n t f i n d i n g s . i n r e l a t i o n to t h e t a b u l a t i o n of
demographic d a ta with g e ner al - f i n d i n g s of t h e study were in
r e g a r d t o d i s t a n c e t r a n s f e r r e d and d i a g n o s i s .
Differences
in t h e modes of t r a n s p o r t a t i o n and medical personnel used
du rin g t r a n s f e r were i d e n t i f i e d a c c o r d i n g to d i s t a n c e t r a n s ­
ferred .
Less s e r i o u s l y i l l
p a r t i c i p a n t s r e c a l l e d having con cerns
s h o r t l y a f t e r urban a d m i s s i o n . ; " S i m i l a r concerns were voiced
by s e r i o u s l y i l l
p a r t i c i p a n t s a f t e r t h e e i g h t h day o f urban
hospitalization.
C hap te r Summary a n d - D is c u s s i o n
The purpose o f t h e s tu d y was t o de te rm in e p a t i e n t
r e a c t i o n s t o t r a n s f e r s - f r o m .r u r a l t o urban h e a l t h c a r e i n ­
stitutions.
Data were p r e s e n t e d in f o u r s e c t i o n s :
screening
d a t a , demographic d a t a , background d a t a , and p a t i e n t r e a c t i o n s
t o r u r a l - t o - u r b a n t r a n s f e r s in r e l a t i o n t o t h e r u r a l h e a l t h
c a r e i n s t i t u t i o n , t h e t r a n s f e r p r o c e s s , and t h e urban h e a l t h
care i n s t i t u t i o n .
47
One hundred and t e n p a t i e n t s were s cr ee ned f o r t h e s t u d y with
only 14 meeting t h e s t u d y ' s c r i t e r i a .
The m a j o r i t y of th o s e
sc r e e n e d had come t o t h e urban h o s p i t a l by s e l f - r e f e r r a l or
physician-referral.
I n ' g e n e r a l , p a r t i c i p a n t s did not have any
co ncerns in re g a r d t o t h e r u r a l h e a l t h c a r e i n s t i t u t i o n .
These
f i n d i n g s s u g g e s t t h a t t h i s la c k of concern was due to t h e p a r t i ­
c i p a n t s ' p e r c e p t i o n of t h e s e r i o u s or emergency n a t u r e o f . t h e i r
problems.
Because o f t h i s p e r c e p t i o n , p a r t i c i p a n t s saw a need
t o go t o t h e r u r a l h o s p i t a l f o r c a r e .
Lack of concerns a l s o
may have been due to being c ar ed f o r by f a m i l i a r p e o p l e , t h u s ,
f a c i l i t a t i n g f u l f i l l m e n t o f t h e s i c k r o l e o b l i g a t i o n s of
s ee ki ng he lp and c o o p e r a t i n g , as d e s c r i b e d by Parsons' (195 8) .
The p a r t i c i p a n t s did no t have any c o n c e r n s , i n re g a r d
to the t r a n s f e r process.
I t i s r e a s o n a b l e to assume from t h e s e
f i n d i n g s t h a t s i c k r o l e b e h a v io r was being de m onst rate d.
Parti­
c i p a n t s were c o o p e r a t i n g with t h e p r e s c r i b e d medical regime,
which i n c lu d e d being t r a n s f e r r e d , in o r d e r to g e t w e l l .
Fa m il ie s o f t h e p a r t i c i p a n t s a l s o i n d i c a t e d s i c k r o l e b e h a v io r
wit h t h e i r c o o p e r a t i o n w it h t h e d e c i s i o n f o r t r a n s f e r .
Once
t h e p a r t i c i p a n t s had adopted t h e s i c k rtiTe, i n t e r e s t s were
r e s t r i c t e d and e g o c e n t r i c i s m de vel op e d.
Pr eo c c up at io n
w it h i l l n e s s reduced i n t e r e s t s t o s e l f and away from o u t s i d e
48
activities.
T r a n s f e r s from r u r a l t o urban h o s p i t a l s were seen
as n e c e s s a r y a c t i o n s in t h e p a r t i c i p a n t s ' p l i g h t t o g e t w e l l .
Nurses were f r e q u e n t l y i d e n t i f i e d :as th e persons r e ­
s p o n s i b l e f o r p a t i e n t c a r e b e f o r e t h e t r a n s f e r and f o r p r e p a r in g
p a t i e n t s f o r t r a n s f e r . ' P a t i e n t c a r e d uri ng most t r a n s f e r s was
t h e r e s p o n s i b i l i t y o f n urs e s or emergency medical t e c h n i c i a n s .
On ad mis sion t o t h e urban h o s p i t a l , a l l of the p a r t i c i ­
pa nts were taken d i r e c t l y ' t o a .m e d i c a l u n i t .
The p a r t i c i p a n t s
b e l i e v e d t h a t once the y w e r e . a t t h e urban h o s p i t a l t h e
pro ce ss o f g e t t i n g well co uld b e g i n .
T h e i r main conce rn was
t h e i r ph y s ic a l c o n d i t i o n or d i a g n o s i s and t r e a t m e n t .
None
were concerned a bout t h e i r r e t u r n t r i p home. •
These f i n d i n g s i n d i c a t e c o n t i n u a t i o n o f s i c k r o l e b e h a v io r
i n t o t h e urban h e a l t h c a r e i n s t i t u t i o n .
Regression c o n ti n u e d
and t h e h y p o c h o n d ri a s is Wu (1973) d e s c r i b e d became e v i d e n t
in th e e g o c e n t r i c i t y e x p re ss e d by t h e p a r t i c i p a n t s .
Most
energy was c o n c e n t r a t e d on i l l n e s s and i t s remedy.
Lack o f concern e x p re ss e d on adm is sio n to th e urban
h o s p i t a l may have been due t o t h e p a r t i c i p a n t s ' : b e l i e f t h a t
th e y were in competent hands..
Al s o , t h e p a r t i c i p a n t s ' pre vio us
e x p e r ie n c e with h o s p i t a l i z a t i o n . m a y have made s u rr o u n d in g s
and people l e s s s t r a n g e and more p r e d i c t a b l e .
For t h o s e who
had never been h o s p i t a l i z e d p r e v i o u s l y , e xper ie nc e drawn from
... v
49
h o s p i t a l v i s i t s , t e l e v i s i o n programs, o r movies may have added
to t h e i r p e r c e p t i o n s (.Wu, 1973')..
Nurses were i d e n t i f i e d as t h e p e r s o n s r e s p o n s i b l e f o r ■
o r i e n t i n g p a r t i c i p a n t s d uri ng t h e i r a d m is s io n .
Physicians
were r e c ogn iz e d as t h e :person who hand led t h e i r concern r e g a r d i n g
d i a g n o s i s and t r e a t m e n t .
D i f f e r e n c e s in modes o f . t r a n s p o r t a t i o n and who gave
p a t i e n t c a r e d uri ng t r a n s f e r were note d in r e l a t i o n t o d i s ­
ta n c e s t r a n s f e r r e d .
O ve rall , local: s e r v i c e s were u t i l i z e d '
in most t r a n s f e r s with n u r s e s and E.M JT .' s in a t t e n d a n c e o f
the p a tie n t.
Concerns r e p o r t e d were vo ic ed by l e s s s e r i o u s l y i l l
participants.
S e r i o u s l y i l l p a r t i c i p a n t s did not vo ic e
concerns u n t i l a f t e r t h e e i g h t h day o f urban h o s p i t a l i z a t i o n ,
and they then had many of th e. sam e c o n c e rn s as voiced by t h e
less seriously i l l .
These f i n d i n g s s u p p o r t Wu's (1973) r e p o r t t h a t as i l l n e s s
becomes l e s s s e v e r e and l e s s demanding, p a t i e n t s g r a d u a l l y
resume a d u l t r e s p o n s i b i l i t i e s and t h e i r scope of i n t e r e s t
br oa de ns .
More energy i s a v a i l a b l e f o r o u t s i d e th ou g h ts and
a c t i v i t i e s , which could be i n t e r p r e t e d as concerns f o r c o s t s ,
l e n g t h o f , s t a y , and t h e . o t h e r c o n c e rn s r e p o r t e d by t h e p a r t i c i p a n t s
CHAPTER 5
CONCLUSIONS
The purpose o f t h e s tu d y was t o de te r m in e p a t i e n t r e a c t i o n s
t o t r a n s f e r s from r u r a l to urban h e a l t h c a r e i n s t i t u t i o n s .
Con­
c l u s i o n s t h a t were d e r i v e d from t h e s t u d y a r e p r e s e n t e d in t h i s
c h a p t e r along w it h n u rs in g i m p l i c a t i o n s , recommendations f o r
f u r t h e r s t u d y , and l i m i t a t i o n s o f t h e s t u d y .
Conclusions
Montana i s a r u r a l s t a t e .
S p e c i a l i z e d medical c a r e e a s t
of th e Rocky Mountains is l o c a t e d i n two c i t i e s .
Of t h e HO
p a t i e n t s s c r e e n e d f o r t h i s s t u d y , t h e g r e a t m a j o r i t y came
t o urban h o s p i t a l s by s e l f - r e f e r r a l
or p h y s ician -referral.
A small number (N=14)' came on a more emergency b a s i s , t r a n s ­
f e r r e d d i r e c t l y from r u r a l h o s p i t a l s t o urban c e n t e r s because
o f t h e i r need f o r immediate or s p e c i a l i z e d c a r e .
The l a r g e
number of r e f e r r a l s may i n d i c a t e an a d a p t a t i o n t o Montana's
unique h e a l t h c a r e system.
In t h e s t u d y , p a t i e n t s t r a n s f e r r e d from r u r a l , h o s p i t a l s
to B i l l i n g s ' h o s p i t a l s de mo nst rat ed s i c k r o l e b e ha vio r as
a r e a c t i o n t o be ing t r a n s f e r r e d .
They demonstrated c o o p e r a ­
t i o n with h e a l t h c a r e p r o f e s s i o n a l s ^ withdrawal from a d u l t
51
r e s p o n s i b i l i t i e s , and e g o c e n t r i c i s m .
Sick r o l e b e h a v i o r began
wit h e n t r y to t h e r u r a l h o s p i t a l where medical he lp was f i r s t
sought.
I t c o n ti n u e d on through t h e t r a n s f e r pro c e ss and i n t o
t h e urban h e a l t h c a r e i n s t i t u t i o n s .
Cooperation with p r o f e s ­
s i o n a l s , an a s p e c t o f s i c k r o l e b e h a v i o r , inc lu de d a c c e p ta n c e o f
transfer.
Withdrawal from a d u l t r e s p o n s i b i l i t i e s was i n d i c a t e d
when no concerns were vo ic ed in r e g a r d to t h e r u r a l h e a l t h c a r e
i n s t i t u t i o n and t r a n s f e r p r o c e s s .
Upon e n t e r i n g t h e urban
h o s p i t a l , p a t i e n t e g o c e n t r i c i s m was de m onst rate d.
were r e s t r i c t e d t o d i a g n o s i s and t r e a t m e n t .
Interests
During t h e e n t i r e
pro c e ss o f t r a n s f e r , p a t i e n t s depended on nurses and o t h e r s
f o r c a r e and e x p l a n a t i o n s .
Very l i t t l e concern was e xpre ss ed
regarding the p a r t i c i p a n t s ' fa m ilie s .
Findi ngs from t h e s tu d y s u p p o r t P a rs o n s ' (1958) t h e o r y
of s i c k r o l e b e h a v i o r .
These r u r a l p a t i e n t s demo nst rat ed
s i c k r o l e b e h a v i o r b e gin ni ng with t h e e n t r y i n t o a r u r a l
h o s p i t a l , d uri ng t h e t r a n s f e r p r o c e s s , and c o n t i n u i n g i n t o
t h e e a r l y days o f urban h o s p i t a l i z a t i o n .
After th is p eriod,
t h e r u r a l p a t i e n t began t o move o u t o f t h e s i c k r o l e ,
The
p a t i e n t s in t h e s t u d y were in agreement wi th S m i th 's (1976)
f i n d i n g t h a t t r a n s f e r between h e a l t h c a r e s e t t i n g s i s n o t
p e rc e iv e d as a s t r e s s f u l e v e n t .
52
When i l l n e s s became l e s s demanding o r with l e s s s e r i o u s
i l l n e s s , t h e s e r u r a l p a t i e n t s tended t o de m onst rate l e s s
sick ro le behavior.
Adu lt r e s p o n s i b i l i t i e s were resumed and
con cerns were e x p r e s s e d .
At t h i s p o i n t t h e r u r a l p a t i e n t s
begin to e x p r e s s c oncer ns r e l a t e d t o t h e i r i l l n e s s and
associated fa c to rs .
Concerns r e g a r d i n g c o s t s , l e n g t h o f s t a y ,
d i s t a n c e t o medical c a r e , f a m i l y s e p a r a t i o n , th e p o s s i b i l i t y
of s u r g e r y , and l o n e l i n e s s were e xpre ss ed by t h e l e s s s e r i o u s l y
ill patients.
A f t e r t h e e i g h t h day of urban h o s p i t a l i z a t i o n ,
the s e r io u s ly i l l
cerns.
p a t i e n t s v e r b a l i z e d many o f t h e same con­
S e v e ra l o f t h e s e c o n c e r n s , c o s t s , d i s t a n c e , f a m il y
s e p a r a t i o n , and s u r g e r y , have a l s o been^i d e n t i f i e d by V o l i c e r
(1973;1974) i n s t u d i e s o f s t r e s s f u l e v en ts a s s o c i a t e d w it h
h o s p i t a l i z a t i o n with p a t i e n t s in an E a s te r n h e a l t h c a r e s e t t i n g .
Wu1s (1973) t h e o r y o f p a t i e n t n e e d s , o p e r a t i o n a l i zed to
p a t i e n t c o nce rn s f o r c o s t s , fa m ily s e p a r a t i o n , f e a r o f t h e
unknown, and modes o f t r a n s p o r t a t i o n , were v e r b a l i z e d
by t h e s t u d y ' s p a r t i c i p a n t s .
Due t o t h e sm al ln es s o f t h e
sample, t h e s i g n i f i c a n c e of p a t i e n t concerns r e l a t e d t o
p a t i e n t r e a c t i o n s . i n r u r a l - t o - u r b a n t r a n s f e r s can n o t be
de te rm in e d.
A r e l a t i o n s h i p between p a t i e n t s co nce rn s and
diagnosis is in d ic a te d .
Less s e r i o u s l y i l l p a t i e n t s
53
e xp re ss ed co ncerns s h o r t l y a f t e r urban h o s p i t a l i z a t i o n ^
Seriously i l l
p a t i e n t s d id not e x p re s s concerns u n t i l a f t e r .
'
t h e e i g h t h day o f urban h o s p i t a l i z a t i o n .
Nursing I m p l i c a t i o n s
Nurses were f r e q u e n t l y i d e n t i f i e d as major c a r e - g i v e r s to
p a t i e n t s e x p e r i e n c i n g t r a n s f e r from r u r a l t o urban h o s p i t a l s .
Nurses c a r e d f o r p a t i e n t s i n t h e r u r a l h o s p i t a l , were in volv e d
in p a t i e n t p r e p a r a t i o n f o r t r a n s f e r , c ar ed f o r p a t i e n t s during
t r a n s f e r , and o r i e n t e d p a t i e n t s upon e n t e r i n g t h e urban h o s p i t a l s .
They c o n ti n u e d t o be t h e major c a r e - g i v e r s in th e urban h e a l t h
care s e ttin g .
Rural and urban n u r s e s ap pea r t o be in p o s i t i o n s t o
influence the behavior of tra n s fe rre d p a tie n ts .
Nurses in
r u r a l s e t t i n g s need t o promote communication between h o s p i t a l s
and c o o r d i n a t i o n o f p a t i e n t c a r e .
Nurses in urban s e t t i n g s
need t o r e c o g n i z e t h e l o s s of f a m il y s u p p o rt with t r a n s f e r r e d
patients.
These p a t i e n t s a r e used t o being in f a m i l i a r
s e t t i n g s and may n o t know anyone in t h e urban s e t t i n g , a
s i t u a t i o n d i s t u r b i n g t o many p a t i e n t s .
I n i t i a t i o n Of
o r i e n t a t i o n programs and s u r r o g a t e s u p p o r t system o r g a n i z a t i o n s
f o r r u r a l p a t i e n t s i n urban h e a l t h c a r e s e t t i n g s may h e l p .
Nurses in both s e t t i n g s must be aware of th e i n f l u e n c e
-1N
54
o f s i c k r o l e b e h a v i o r on p a t i e n t r e a c t i o n s t o r u r a l - t o - u r b a n
transfers.
P e r c e p t i o n s o f i l l n e s s a r e not only i n f l u e n c e d
by p a t i e n t s ' b e l i e f s , b u t a l s o by p e r c e p t i o n s o f t h o s e
who a d m i n i s t e r p a t i e n t c a r e (Wu, 1973).
Knowing t h i s , nurs e s
must be aware o f p a t i e n t b e h a v i o r de mo nstrated in r u r a l - t o - u r b a n
transfers.
I t i s n e c e s s a r y to no te both t h e dependent s i c k r o l e
b e h a v i o r and t h e e v e n tu a l emergence from e g o c e n t r i c i s m t o
awareness and e x p r e s s i o n o f c o n c e r n s .
•
By acknowledging t h e s e
as normal r e a c t i o n s t o both p a t i e n t s and t h e i r f a m i l i e s ,
n ur s e s w i l l a i d p a t i e n t s in coping b e t t e r with t h e i r i l l n e s s
and movement towards r e c o v e r y .
Rec ognit ion o f t h e s e f a c t o r s
w i l l a i d n urs e s i n t h e i r a ss e ss m e n t of p a t i e n t r e a d i n e s s f o r
t e a c h i n g and d i s c h a r g e p la n n i n g .
Even though a m a j o r i t y o f t h e p a r t i c i p a n t s i d e n t i f i e d
nu rs es as major c a r e - g i v e r s in t h e r u r a l and urban s e t t i n g s ,
emergency medical t e c h n i c i a n s (E.M.T.) were a l s o i d e n t i f i e d
as being r e s p o n s i b l e f o r c a r e o f p a t i e n t s during t r a n s f e r s
of l e s s th a n 100 m i l e s .
F u r t h e r i t was found t h a t r e l a t i v e s
were o f t e n i d e n t i f i e d as being r e s p o n s i b l e f o r p a t i e n t c a r e
when t r a n s f e r s were more than 300 m i l e s .
I t i s pro ba bly
a p p r o p r i a t e f o r E .M .T .1s t o be in charg e of p a t i e n t c a r e
d u ri n g t r a n s f e r , but d e l e g a t i n g c a r e o f p a t i e n t s d u ri n g
(9
55
t r a n s f e r t o r e l a t i v e s i s no t a p p r o p r i a t e .
Nurses, or
E . M . T . ' s , sho uld be u t i l i z e d in t h e s e t r a n s f e r s as r e l a t i v e s
a r e e m o t i o n a l l y in vol ve d with t h e p a t i e n t and not t r a i n e d
f o r such r e s p o n s i b i l i t y .
■
The q u a l i t y of c a r e given d u ri n g
■
t r a n s f e r was n o t a d d re s s e d in t h i s s tu d y .
Limitations
- .
The time c r i t e r i o n proved to be ve ry l i m i t i n g .
.
p a t i e n t s were too i l l
•
Several
t o be i n t e r v i e w e d w i t h i n 72 hours of
t h e i r a dm is si on t o urban h o s p i t a l and were l o s t from t h e s tu d y
However, whenever p o s s i b l e , t h e s e p a t i e n t s were i n t e r v i e w e d
a t a l a t e r date.
This may have e f f e c t e d t h e r e s u l t s s i n c e
p a r t i c i p a n t s u t i l i z e d r e c a l l t o p r o v id e t h e d a ta f o r t h e stud y
I n t e r v i e w s were conducted up t o 21 days a f t e r urban a d m is s io n .
Interview s a re considered
an a p p r o p r i a t e means f o r d a ta
c o l l e c t i o n in an e x p l o r a t o r y d e s c r i p t i v e d e si g n .
Limitations
of t h e i n t e r v i e w f o r t h i s s tu d y i n c lu d e d the f o l l o w i n g :
t h e g r e a t m a j o r i t y of q u e s t i o n s focus ed on p a t i e n t c o n c e r n s ;
p r o v i s i o n s f o r fo l l o w - u p q u e s t i o n s were not provided i n t h e
i n t e r v i e w , s c h e d u l e ; and t h e c o n s e n t form was to o long f o r
many o f t h e p a r t i c i p a n t s t o read and had to be read by th e
investigator.
E x t e n s i v e t e s t s of r e l i a b i l i t y and v a l i d i t y were n o t
56
conducted on the- i n t e r v i e w t o o l .
In t h i s type of study using
p a t i e n t s as i n f o r m a n t s , r e l i a b i l i t y o f th e in s t r u m e n t v a r i e s ■
g r e a t l y w ith mood, physica l c o n d i t i o n , o r environmental f a c t o r s
su rro und in g p a t i e n t s (Brink and,Wood, 1978; P o l i t and Hungle r ,
1978).
Even though c o n t r o l s f o r t h e s e v a r i a b l e s were pro vid e d,
they were not c omp le tely c o n t r o l l e d and may have i n f l u e n c e d
t h e r e s u l t s of th e s tu d y .
Recommendations f o r F u r t h e r Study
Due to t h e small sample s i z e , r e s u l t s o f t h e stud y can
not be g e n e r a l i z e d .
R e p l i c a t i o n of th e st ud y i s recommended
us in g a l a r g e r sample.
The p r e s e n t i n t e r v i e w survey tool
r e q u i r e s f u r t h e r re f i n e m e n t and v a l i d a t i o n p r i o r t o f u r t h e r
us e.
To broaden t h e focus of th e s t u d y , a comparison of
r e a c t i o n s to t r a n s f e r o r t r a n s p o r t o f th o s e who were
p h y s i c i a n - r e f e r r e d , s e l f - r e f e r r e d , and t r a n s f e r r e d from r u r a l
h o s p i t a l s should be un derta ken .
In t h i s s t u d y , p a t i e n t s who re g a in ed co n sc io u s n es s a f t e r
urban admission were o r i e n t e d by r e l a t i v e s or not o r i e n t e d a t
all.
I n v e s t i g a t i o n of how comatose p a t i e n t s a re o r i e n t e d
i s a n o t h e r area to be i n v e s t i g a t e d .
I n v e s t i g a t i n g r e a c t i o n s ' of f a m i l i e s of p a t i e n t s who
were t r a n s f e r r e d i s a n o t h e r im p o r ta n t a re a f o r f u r t h e r st udy ,
57
Spouses and s i g n i f i c a n t o t h e r s a r e so invol ve d in r u r a l - t o urban t r a n s f e r s t h a t t h e i r r e a c t i o n s need to be a d d r e s s e d .
R eac tio ns of n u rs e s t o r u r a l - t o - u r b a n t r a n s f e r s i s a n o t h e r area
for fu r th e r study.
The i n v e s t i g a t o r noted d i f f e r e n t r e a c ti o n ' s
from r u r a l and urban n u rs e s invol ve d in p a t i e n t t r a n s f e r s ,
i n c l u d i n g r e l i e f , d i s i n t e r e s t , and c once rn .
Another a r e a
f o r f u r t h e r i n v e s t i g a t i o n may be th e examination o f t h e
f a c i l i t a t i o n o f s i c k r o l e b e h a v io r by f a m il y and h e a l t h c a r e
p ro fe s sio n a ls , including nurses.
A ls o, where do co ncerns
o r i g i n a t e , fr o m t h e p a t i e n t , f a m i l y , or h e a l t h c a r e p r o f e s s i o n a l s ?
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Handbook of th e Psychology o f Aging.
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New York:
B ri nk , Pamela J . and Wood, Marilyn J .
1978
Basic Steps in Planning Nursing Research.
S c i t u a t e , M as sa c h u se tt s : Duxbury P r e s s .
BushnelI , Marilyn E.
1979
" I n s t i t u t i o n s in T r a n s i t i o n . "
P s y c h i a t r i c Care 17:260-5.
Van
North
. .
^
P e r s p e c t i v e s in
Cap!an, Gerald
1964
P r in c i p le ' s o f P r e v e n t a t i v e P s y c h i a t r y .
Basic Books.
New York:
Copp, James H.
'
1976
" D i v e r s i t y of Rural S o c i e t y and Health N e e d s ."
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■ R. ( E d s . ) , Rural Health S e rv ic e s: - O r g a n i z a t i o n ,
D e l i v e r y , and Use. Ames: Iowa S t a t e U n i v e r s i t y P r e s s .
Cowper-Smith, Frances
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"RAF f l i e s home t h e s i c k . "
Nursing M ir ro r 142:55-8.
Dawson, Drew
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Emergency Medical S e r v ic e s D i r e c t o r , Personal
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E d l i c h , Richard F . , Haynes, Boyd W., Larkham, Nancy, A ll e n ,
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Mil ton I .
1978
"Emergency Department Tr ea tm e nt, T r ia g e and T r a n s f e r
P r o t o c o l s f o r t h e Burn P a t i e n t . " Journal o f th e
American College of Emergency P hys ic ia ns 7:1 52-8 .
E l l i s , Daniel J .
1980
A D e s c r i p t i v e Survey of Rural Emergency Room Nurses'
Knowledge and Role P e r c e p ti o n of Advanced Cardiac Life
S uppor t. Unpublished m a s t e r ' s t h e s i s , Montana S t a t e
University.
60
Fans!ow, Cath leen and M a s s e t5 Evelyn
1979
"Building S t a f f Rapport Between I n s t i t u t i o n s ."
American Jou rnal of Nursing 79:1441-2.
Goodman5 Joy
1975
" S p e c i a l i s t in P a t i e n t T r a n s f e r . "
Emergency Nursing 1:17-19.
Journal of
H a s s e l k u s 5 B e t ty R is t ee n
. 1978
" R e lo c a tio n S t r e s s and t h e E l d e r l y . " The American
Journal of Occupational Therapy 32:631-6.
-
H a s s i n g e r 5 Edward W.
1976
"Pathways of Rural People to Health S e r v i c e s . "
pp. 164-187 in H a s s i n g e r 5 Edward W. and W h i t i n g 5
Larr y R. ( E d s . ) , Rural Health S e r v i c e s : O r g a n iz a ti o n s
D e l i v e r y , and Use.- Ames: Iowas S t a t e U n i v e r s i t y
Press.
H a s s i n g e r 5 Edward W. and W h it in g , Larry R . , Eds.
1976
Rural Health S e r v i c e s : O r g a n i z a t i o n 5 D e l i v e r y , and Use.
Ames: Iowa S t a t e U n i v e r s i t y P r e s s .
H e n s l e r 5 Eugene C ., Johnson, Alexander C . , a n d . Zy d l o 5 S t a n l e y
1976
"Air T r a n s p o r t : How to move a p a t i e n t f a r and f a s t . "
P a t i e n t Care 10:112-6.
H u r l b u r t 5 Ward B.
1975
"Health Care Programs f o r S c a t t e r e d P o p u l a t i o n s . "
P ubl i c Health Reviews 4:297-325. .
K e r l i n g e r 5 Fred N.
1973
Foundations o f Behavioral Research.,
- R in e h a r t and Winston5 Inc.
New. York: H olt ,
K or nf e ld, Donald S . , Maxwell, T e r e s i t a 5 and Momrow5 Dawn.
1968
"Psy cho log ical Hazards of th e I n t e n s i v e Care U nitNursing Care A s p e c ts ." Nursing C l i n i c s of North
America 3:4 1-5 1.
Locke, S. Jack
1978
"Emergency P a t i e n t T r a n s p o r t in Rural A r e a s . "
Nurse P r a c t i t i o n e r 3:23+.
61
McCombs, Carolyn M.
1978
"Air Ambulance S e r v i c e s : New Horizons f o r Emergency
.N urs in g." Jou rnal of Emergency Nursing 4 : 2 1 - 3 . .
Montana Department o f Highways
1979
The O f f i c i a l Montana 1979 Highway Map.
H.M. Gousha Company.
Montana Health Systems Agency, Inc.
1979
Montana Health Systems Plan. Helena:
Health and Environmental S c ie n c e s .
Helena, Montana:
Department of
The Mountain S t a t e s Telephone and Telegraph Company
1980
B i l l i n g s and S o u t h e a s t e r n Montana Telephone D i r e c t o r y .
Mountain B e l l , pp. 468-476.
N e rl and, E l a in e
1978
" P a t i e n t T r a n s f e r Form Provides C o n t i n u i t y of C a r e . "
H o s p i t a l s 52:151-2+.
"New Rules f o r Trauma C a r e . "
,19 80
Emergency Medicine 12:227.
Orem, Dorothea E.
1971
Nursing: Concepts of P r a c t i c e .
Hill Book Company.
New York: McGraw-
Parsons, T a lc o tt
1958
" D e f i n i t i o n s o f Health and H i n e s ' s in th e L i g h t of
American Values and Social S t r u c t u r e . " Pp. 165-187
in J a c o , E.G. ( E d . ) , P a t i e n t , Ph y s ic ia n s and I l l n e s s . .
New York: Free P r e s s .
Pol i t , Denise and Hungle r , B e r n a d e tt e •
1978
Nursing R e s e a r c h : P r i n c i p l e s and Methods.
J . B . L i p p i n c o t t Company.
Research S e r v ic e s West
1979
Planning Data Book.
Hospital.
Philadelphia
B i l l i n g s : B i l l i n g s Deaconess
S e l i f m a n 5 Martin E.
_
1974
"Submissive Death: Giving Up On L i f e . " Psycholgoy
Today 23:80-85.
Shannon, V a l e r i e J .
1973
- "The t r a n s f e r pro c e ss :\ A n area o f concern f o r t h e .
CCU'n u r s e . " Heart and Lung 2:364-67.
S h i r c o r e 5 Richard S.
'
1976
" P a t i e n t management on t h e r o a d . "
143:45-46.
Nursing M irr or
S m i t h 5 Mary C o l e t t e
1976 ■" P a t i e n t Responses to Being T r a n s f e r r e d during
H o s p i t a l i z a t i o n . " Nursing Research 25:192-6.
Sn y d e r5 Teresa E l i z a b e t h .
1979
A Study of t h e I n i t i a l Problems Encounterd by Home
D i a l y s i s P a t i e n t s R el ate d t o th e Proximity to t h e
Home T r a in i n g C en te r. Unpublished m a s t e r ' s t h e s i s ,
Montana S t a t e U n i v e r s i t y .
T o f f l e r 5 Alvin
1970
Future Shock. New York: Random House I n c .
1980
The Th ir d Wave. New York: William Morrow and Company,
Inc.
T o o l e y 5 William H. and Goldsmith, Jay
1977
"Neonatal T r a n s p o r t : A D i s c u s s i o n . "
22:1138-45.
R e s p i r a t o r y Care
T o t h 5 Jean
1980
" E f f e c t of S t r u c t u r e d P r e p a r a t i o n f o r T r a n s f e r on
P a t i e n t Anxiety on Leaving Coronary Care U n i t . "
Nursing Research 29:28-34.
" T r a n s f e r of P a t i e n t s . "
1980
Emergency Medicine 12:140.
V o l i c e r 5 Beverly J .
1973
"Perceiv ed S t r e s s Levels of Events A sso c ia te d with the
Experience of H o s p i t a l i z a t i o n . " Nursing Research
22:491-97.
j
63
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V o l i c e r 5 Beverly J .
1974
" P a t i e n t P e r c e p t i o n s o f S t r e s s f u l Events A ss oc ia te d
With H o s p i t a l i z a t i o n . " Nursing Research 23:235-38.
Waddell, Gordon
1975
"Moving th e c r i t i c a l Iy i l l . "
Nursing Times 71:1937-39.
Welch, Benjamin
1977
"Some C o n s id e r a ti o n s Before Using th e A eria l Ambulance.
Jou rnal of t h e American Co!l e g e o f Emergency P h y s i c i a n s .
■ 6:1 55-57.
Wu, Ruth
1973
Behavior and I l l n e s s .
P r e n tic e -H a ll, Inc.
Englewood C l i f f s , New J e r s e y :
Young, Diony
,
1978
Bonding-How P a re n ts Become Attached To T h e i r Baby.
Minneapolis: I n t e r n a t i o n a l C h i l d b i r t h Education
Association.
Zweig, J . P . and Csank, J . Z .
1975
" E f f e c t s of R el o ca ti o n on C h r o n i c a l l y 111 G e r i a t r i c
P a t i e n t s of a Medical Un it: M o r t a l i t y R a t e s ."
Journal of t h e American G e r i a t r i c s So c ie ty 23:132-136.
<
APPENDIX'A
65
P a t i e n t Reac tio ns to T r a n s f e r s from Rural to Urban Health Care
Institutions
P a t i e n t I n t e r v i e w Guide (Case #_______ )
"Sex
(Optional)
Occupation
(Optional)
Age
(Optional)
Mari tal S t a t u s
(Optional)
Town o f Residence________________
Length of time a t t h a t r e s i d e n c e
Diagnosis_________________________
Admission Date ( R u r a l )___________
(Urban)___________
Today's Date_____.________________________________________________
A.
Introduction
1.
Purpose
2.
Rights
a.
30-60 minute i n t e r v i e w
b.
No s p e c i a l r i s k s / b e n e f i t s
c.
V oluntary p a r t i c i p a t i o n ■
d.
Confidentiality/anonymity
e.
V olu nte er t o be in te rv ie w e d ?
i.
Sign c onse nt
i i . Copy with p a r t i c i p a n t
B.
Rural Health Care I n s t i t u t i o n
1.
What problem brought you to t h e _______________ H osp it al ?
2.
Who brou ght you to the ______________________
Hosp it al ?
3.
What do you remeber about e n t e r i n g t h a t H o sp i ta l ?
4.
Did you know any of t h e people who cared f o r you?
5.
Did you have any q u e s t i o n s or concerns on e n t e r i n g
t h a t H o s p i t a l ? How were they handled and by whom?
6.
What was your r e a c t i o n when you were t o l d you were
being t r a n s f e r r e d ? •
7.
Did you have any o t h e r q u e s t i o n s or concerns a f t e r
you were t o l d ab out t h e t r a n s f e r ? How were they
handled and by whom?
6 6
C.
The T r a n s f e r
1.
Why were you t r a n s f e r r e d ?
2.
How were you t r a n s f e r r e d ?
3.
Who was r e s p o n s i b l e f o r your c a r e b e f o r e t h e t r a n s f e r ?
4.
How were you pre pared f o r th e t r a n s f e r and by whom?
5.
Describe y o u r t r i p he re .
6.
Who was r e s p o n s i b l e f o r your c a r e during yo ur t r a n s f e r ?
7.
How were t h i n g s handled in th e t r a n s f e r pro ce ss?
8.
What was yo ur imp ressi on of t h e t r a n s f e r pro ce ss?
9.
Did you have any q u e s t i o n s or concerns about your
t r a n s f e r ? How were t h e s e handled?
10.
Have you been involved in an ambulance t r a n s f e r b e fo re ?
D.
Urban Health Care I n s t i t u t i o n
1.
Describe yo ur e n t r y i n t o t h i s H o s p i t a l . What do you
remember about e n t e r i n g t h i s H o s p i t a l ? When did you
f i r s t r e a l i z e you were he re and who o r i e n t e d you
to what did happen/was happening?
2.
What was you r i n i t i a l r e a c t i o n on e n t e r i n g t h i s
Hospital ( o r when you f i r s t r e a l i z e d you were
■ • h e re )?
3.
Did you have any q u e s t i o n s or concerns on e n t e r i n g
t h i s H o s p i t a l ? How were th e y handled and by
whom?
4.
Have you been a p a t i e n t in t h i s Hospital be for e?
5.
Did you know any of t h e people who car ed f o r you?
6.
Did you have any a d d i t i o n a l concerns or q u e s ti o n s
a f t e r you were a dmi tte d? How were th e y handled
and by whom?
7.
How w i l l you r e t u r n t o your home?
8.
Are t h e r e any o t h e r t h i n g s about your t r a n s f e r I
h a v e n ' t asked about t h a t you would l i k e to d i s c u s s ?
APPENDIX B
68
Approval L e t t e r from MSU School of Nursing - B il li n g s Extended Campus
SCHOOL OF NURSING
BILLINGS EXTENDED CAMPUS
EM C CAMPUS BOX 5 74.
BILLINGS. M O N TA N A 59101
Judy Schmidt, R.N., Graduate Student
- School of Nursing
Montana State University
Dear Ms. Schmidt:
Your research proposal, "Patient Reactions to Transfers from Rural
to Urban Settings", was reviewed and approved for protection of
human subjects on November 12, 1980.
Al I consent forms will be
secured and held in a locked file in this office for three years.
Best wishes for a successful study.
Sincerely,
Ruth Vanderhorst, R.N., M.S.,
Education Director
RV/dk
a
. ... '
S O n?
\ / ^ ‘ X , _ r,
69 ■
Approval l e t t e r from S t. Vincent's Hospital
V inCViii
H O S p irO l
1233 North 30th Street
P.O .B ox 2505
Billings, Montana 59103 ■
406-657-7000
•
December 11, 1980
Judy Schmidt, R.N.
P o s t Office Box 654
Roundup, Montana 59072
Dear Judy:
The Research Review Committee has approved your research " P a t i e n t Reactions
to Trans fers from Rural to Urban Health Care I n s t i t u t i o n s " .
As discussed per phone, your research will" occur between mid January and
extend int o February as needed. Also, the Head Nurse meeting will be sched­
uled f o r December 19, 1980 a t 0930 enabling you to share your research pro­
j e c t and goals.
We are looking forward to p a r t i c i p a t i n g in t h i s study.
S in c e re ly ,
Lorraine Reinhardt, R.N.
A s s i s t a n t D ire ct or of Nursing Service
LR/jb
70
Approval L e t t e r from B i l l i n g s Deaconess Hospital
"G-3 D Z A C O H E S S HOSPITAL
Decanber 26, 1980
Judy D. Schmidt, RN
P.O. Box 654 '
Roundup, Montana 59073
Dear Judy:
After committee review and your consideration of our suggestion,
the Research Cormittee of Billings Deaconess Hospital grants
permission to conduct data collection for your study at Deaconess.
The unit supervisors have a copy of the abstract and enclosed
you will find a list of key people for each nursing unit. It
wauld be helpful to present a copy of this letter to the unit
staff prior to interviewing any patient.
We will be looking forward to receiving the results of your study
and utilizing the material to improve our services to patients and
their'families.
<3-1 Y V C T - O l X 7
Sue T. Cable, RN
Chairperson, Research Committee
STC:ch
enc
'APPENDIX'C
11
Con1Sent t o A c t as a P a r t i c i p a n t
• in th e study e n t i t l e d :
P a t i e n t Reactions to T r a n s f e r s
from Rural to Urban Health Care I n s t i t u t i o n s
The purpose of t h e s t u d y , as e x p la i n e d to me by Judy Schmidt,
a r e g i s t e r e d nurs e in th e g r a d u a te program a t t h e Montana S t a t e
U n i v e r s i t y School o f N ur si ng , :is t o - e x p l o r e t h e p a t i e n t ' s needs
in a r u r a l - t o - u r b a n t r a n s f e r .
To p a r t i c i p a t e in t h e . s t u d y , I w i l l ta k e p a r t in an i n t e r ­
view a ski ng q u e s ti o n s a b o u t 'my r e a c t i o n s t o my t r a n s f e r from a
r u r a l to an, urban h e a l t h c a r e i n s t i t u t i o n .
The i n t e r v i e w w il l
r e q u i r e ab ou t 30 to 60 minutes of my time.
I will p a r t i c i p a t e
in th e s tu dy a t my c o nve ni e nc e. '
I have t h e r i g h t to st o p the
i n t e r v i e w a t any time because of f a t i g u e , t r e a t m e n t s , or nursing •
c a r e and c o n t i n u e on when' I choose.
stu dy a t any time.
I can withdraw from the
My d e c i s i o n to p a r t i c i p a t e , not to p a r t i ­
c i p a t e , or my d e c i s i o n to withdraw from th e study w i l l be kept
c o n f i d e n t i a l and w il l n o t i n f lu e ce my c a r e and t r e a t m e n t .
My
r e p l i e s w i l l be k e p t c o n f i d e n t i a l and a l l in fo rm at io n w il l be
coded to p r o t e c t my anonymity.
The in f or m at io n I g iv e w i l l
be d e s tr o y e d a f t e r the d a ta i s analyzed and t a b u l a t e d , and
th e r e s u l t s o f the stu dy w il l be sh ared with o t h e r nurses
■ j
7 3
through p u b l i c a t i o n .
There w i l l be no b e n e f i t to me p e r s o n a l l y from p a r t i c i p a t i n g
in t h e s t u d y , but th e i n fo r m a t io n gained from th e s tu dy may help
nurs es provid e b e t t e r p a t i e n t c a r e in th e f u t u r e .
There w il l be
l i t t l e or no r i s k in p a r t i c i p a t i n g in th e st udy .
I , t h e r e f o r e , ag re e to p a r t i c i p a t e in the study " P a t i e n t .
Rea ctions to T r a n s f e r s from Rural to Urban Health Care I n s t i t u ­
tions."
I f I have any q u e s t i o n s re g a rd in g t h i s s t u d y , I may
c o n t a c t Judy Schmidt by c a l l i n g (406)-323-1758 c o l l e c t .
S i g n a t u r e _________________________
Date
»
MONTANA STATE UNIVERSITY LIBRARIES
stks N378.Sch533@Theses
RL
Patient reactions to transfers from rura
3 1762 00112241 3
N3 7 8
Sch533
cop.2
DATE
Schmidt, J u d y D
Patient reactions to
transfers from rural to
urban health care insti
tutions
IS S U E D TO
Sik 533
aop