Compared ratings by both nurses and clients of selected community health nursing activities
by Judith Kaye Grogan Gedrose
A thesis submitted in partial fulfillment of the requirements for the degree of Master in Nursing
Montana State University
© Copyright by Judith Kaye Grogan Gedrose (1978)
Abstract:
The purpose of the study was to ascertain if there were differences between the ratings of importance
community health nurses and their clients would assign to the same categories of nursing activities.
These categories of nursing activities were defined as physical care, psychological care, medical care
related and sociological activities.
Two major null hypotheses were generated to facilitate data collection and analysis of the findings.
These were: A. There is no significant difference among categorized groups of selected activities in the
degree of importance attributed to them by clients and/or nurses.
B. There is no significant difference between the degree of importance community health nurses
attribute to categories of selected activities when compared to the level of importance clients attribute
to the same activities.
A hospital-based nursing research study was drawn upon and partially replicated in this study.1 The
Community Health Nursing Activities Tool (CHNAT) was developed as a data collection instrument.
Twenty-five community nurse-client pairs rated the importance of nursing activities as depicted by the
20 items comprising the CHNAT. Data were organized and displayed within these paired relationships
for testing of null hypothesis B. Application of the two-tailed t test led to acceptance of this hypothesis.
When this same test was applied to six associations generated for analysis of hypothesis A, significance
was found.
1White, Marguerite. "Importance of Selected Nursing Activities," Nursing Research, 1972, Vol. 21,
No. I, pp. 4-14.
STATEMENT OF PERMISSION TO COPY
In presenting th is thesis in p a rtia l f u lfillm e n t o f the
requirements fo r an advanced degree a t Montana State U n iv e rs ity ,
I agree th a t the Library shall make i t fr e e ly a v a ila b le fo r
inspection.
I fu rth e r agree th a t permission fo r extensive copying
o f th is thesis fo r scholarly purposes may be granted by my major
professor, o r , in his absence, by the D irecto r of L ib ra rie s .
It
is understood th a t any copying or pu blication o f th is thesis fo r
fin a n c ia l gain shall not be allowed without my w ritte n permission.
COMPARED RATINGS BY BOTH NURSES AND CLIENTS OF
SELECTED COMMUNITY HEALTH NURSING ACTIVITIES
by
JUDITH KAYE GROGAN GEDROSE
A thesis submitted in p a rtia l fu lfillm e n t
o f the requirements fo r the degree
of
Master in Nursing
Approved:
Chaif person & Graduate Committee
Head, Major Department
Graduate Dean
MONTANA STATE UNIVERSITY
Bozeman, Montana
March, 1978
TABLE OF CONTENTS
Page
VITA.
......................................................................................... .
i.i
LIST OF TABLES.......................................................................................................
v ii
LIST OF
FIGURES................................................................................................... ;.
ABSTRACT.......................................................... .........................................................
v iii
ix
CHAPTER
1.
2.
INTRODUCTION...............................................................................................
Statement o f the Problem..................................................................
Need fo r the Study..............................................................................
Objectives o f the S tu d y ........................
Assumptions...................................................................... .................... ,
L im it a t io n s ..............................................................................
D e fin itio n of T e rm s .........................................
2
2
7
7
8
9
REVIEW OF LITERATURE...............................................................................
10'
Sociological Theory Related to the Study and
Application to Community Health Nursing .............................
The Status o f Community Health Nursing: Its
Roles and D uties.........................................................
Public Health A uthorities Discuss Public
Health Nursing............................................. 4..........................
Textbooks Related to Public Health Nursing. . . . . .
Studies Related to the Problem..............................................
Summary...................................................................................................
3.
I
METHODOLOGY ......................................................................
. . . . . .
Procedures fo r Development, V alidation and
P retesting o f the Instrum ent......................................................
Population Defined; Procedures fo r Sampling
and Data C ollection Discussed ..................................................
Chapter Summary . . ............................
12
15
15
18
19
24
27
27
29
30
iv
CHAPTER
4.
;
■
PRESENTATION OF DATA.................................................
32
In tr o d u c tio n .........................................
Null Hypotheses.....................................................
Scoring o f the Instrum ent..............................................................
Presentation o f Data . .....................
Summary...................................................................................................
5.
Page
SUMMARY, FINDINGS, CONCLUSIONSAND RECOMMENDATIONS . . . .
32
33
35
36
51
52
Summary...................................................................................................
F in d in g s ...............................................................................................
Discussion o f Findings ..............................................................
Conclusions and Recommendations..................................................
52
52
55
58
BIBLIOGRAPHY......................... ..................................................................................
61
APPENDICES
A.
EXPERT JUDGE GROUP #1.......................................................... ....
65
L e tte r to Expert Judge Group #1.................................................
In structions and Items Mailed to Expert Judge Group #1 .
B.
C.
EXPERT JUDGE GROUP #2..........................................................
66
67
. . .
70
L e tte r to Expert Judge Group #2............................................. ....
In structions fo r CHNAT Rating and Sorting, Packet . . . .
Category D efin itio n s Appearing on Envelopes
fo r Sorting Procedure # 1 ..........................................................
Revised Items Presented to Expert Judge Group #2
fo r Rating and S o r t in g ......................................................' . .
71
72
EXPERT JUDGE GROUPS #3 AND #4. . ...................................................
78
In structions fo r Sorting Procedure . . . .............................
Revised Category D efin itio n s Appearing on
Envelopes fo r Sorting Procedures #2 and # 3 .....................
Revised Items Presented fo r Sorting
Procedures #2 and # 3 .......................................................... . • •
73
74
79.
80
81
V
APPENDICES
C.
(Continued)
Figure 5.
D.
. Page
Comparison o f Results o f Sorting Procedures
Done to Establish the Degree of V a lid ity ,
o f Placement o f Items Within the Four
Categories o f Community Health Nursing
A c tiv itie s as Defined by the Researcher . . .
PRETESTING WITH NURSING SERVICES CENTER CLIENTS
AND STUDENTS ............................................................................... • . .
Letters to C l i e n t s ..........................................................................
CHNAT Mailed to Nursing Service Center C lients
C lie n ts ' Reactions to Questionnaire Fo rm ..................... . . .
Follow-up Post Card Mailed to Nursing Service
Center C l i e n t s ............................. ................................................
CHNAT D istrib u ted to Nursing Service Center Students . .
Table 9. Results o f P retest o f the CHNAT with
Six (6) Nursing Students o f the Nursing
Services Center Rating the Importance
o f Selected Community Health Nursing
A c t i v i t i e s ................................
Table 10. Results of the Pretest o f the CHNAT with
Sixteen (16) C lients o f the Nursing
Services Center Rating the Importance
o f Selected Community Health Nursing
A c tiv itie s . . . ......................................................
E.
F.
NURSE PARTICIPANTS............................. ' ......................................
82
83
84
85
87
88
89
91
91
92
P a rtic ip a n t Consent Form fo r Nurse P a rtic ip a n ts . . . . .
CHNAT With Revised Directions Used with
Nurse P articip an ts o f the Study..............................................
93
CLIENT PARTICIPANTS. . ...................................................................... '
96
P a rtic ip a n t Consent Form fo r C lients
P a rtic ip a tin g in the S tu d y ..................... .............................
CHNAT with Revised D irections Used with
C lients P a rtic ip a tin g in the S tu d y ............................. . . .
94
97
98
vi
APPENDICES
G.
FORMAT FOR PRESENTING CHNAT TO THE
PROSPECTIVE COMMUNITY HEALTH NURSE SAMPLE.............................
Page
IOO
v ii
LIST OF TABLES
.
:
: ;
Table ■
1.
Page
Tw o-tailed t Test Between Six Associations fo r
Category "Mean Importance Scores" by C lients and
Nurses to Determine Significance o f Differences .................
37
D is trib u tio n o f 25 Community
N urse-C lient "Disagreement Scores".............................................
39
3. . Rank Order of Nursing A c tiv itie s Rated Above a
"Mean Importance Score" o f 2.6 by Nurses.................................
46
2.
4.
5.
6.
7.
Si
9.
10.
Rank Order o f Nursing A c tiv itie s Rated Above a
"Mean Importance Score"of 2.6 by C lie n ts .................................
47
Rank Order of Nursing A c tiv itie s Rated Below a
"Mean Importance Score" o f 2.6 by Nurses.................................
48
Rank Order o f Nursing A c tiv itie s Rated Below a
"Mean Importance Score" o f 2.6 by C l i e n t s .............................
49
Percentage o f Items by Category Receiving a "Mean
Importance Score" o f 2.6 or Above by Nurses and C lients .
51
Percentage o f Items by Category Receiving a "Mean
Importance Score" o f 2.6 or Less by Nurses and C lie n ts . .
51
Results o f Pretest o f the CHNAT with Six (6)
Nursing Students o f the Nursing Services Center
Rating the Importance of Selected
Community Health Nursing A c tiv itie s .....................................
.
91
. .................
91
Results of the P retest of the CHNAT with
Sixteen (16) C lients of the Nursing
Services Center Rating the Importance of
Selected Community Health Nursing A c tiv itie s .
v iii
LIST OF FIGURES
Figure
1.
2.
3.
4.
5.
Page
D is trib u tio n o f 25 Community Nurse-Client
"Disagreement Scores" on Category A
(Physical Care, 5 Item s). ..............................................................
41
D is trib u tio n o f 25 Community Nurse-Client
"Disagreement Scores" on Category B
(Psychological Care, 5 Items) . . : ................................. .... .
42
D is trib u tio n o f 25 Community Nurse-Client
"Disagreement Scores" on Category C
(Medical Care Related, 5 Items) .................................................
43
D is trib u tio n o f 25 Community Nurse-Client
"Disagreement Scores" on Category D
(Sociological Care, 5 Ite m s )..........................................................
44
Comparison o f Results o f Sorting Procedures Done
to Establish the Degree of V a lid ity of Placement
o f Items Within the Four Categories o f Community
Health Nursing A c tiv itie s as Defined by the Researcher. .
82
ix
ABSTRACT
i ■
The purpose o f the study was to ascertain i f there were d i f f e r ­
ences between the ratings o f importance community health nurses and
th e ir c lie n ts would assign to the same categories o f nursing a c t iv it ie s .
These categories o f nursing a c t iv it ie s were defined as physical care,
psychological care, medical care re la te d and sociological a c t iv it ie s .
Two major null hypotheses were generated to f a c i l i t a t e data
c o lle c tio n and analysis o f the fin d in g s . These were:
A. There is no s ig n ific a n t d iffe re n c e among categorized groups
of selected a c t iv it ie s in the degree o f importance a ttrib u te d to them
by c lie n ts and/or nurses.
B. There is no, s ig n ific a n t d iffe re n c e between the degree of
importance community health nurses a ttrib u te to categories o f selected
a c tiv itie s when compared to the level o f importance c lie n ts a ttrib u te
to the same a c t iv it ie s .
A hospital-based nursing research study was drawn upon and
p a r t ia lly re p lic a te d in th is s tu d y .1 The Community Health Nursing
A c tiv itie s Tool (CHNAT) was developed as a data c o lle c tio n instrument.
Tw enty-five community n u rs e -c lie n t pairs rated the importance
o f nursing a c t iv it ie s as depicted by the 20 items comprising the CHNAT.
Data were organized and displayed w ith in these paired relationships
fo r te s tin g o f null hypothesis B. Application of the tw o -ta ile d t te s t
led to acceptance o f th is hypothesis. When th is same te s t was applied
to six associations generated fo r analysis o f hypothesis A, sign ificance
was found.
1W hite, M arguerite. "Importance o f Selected Nursing A c tiv itie s ,"
Nursing Research, 1972, V o l. 21, No. I , pp. 4-14.
INTRODUCTION
Cqmmunity health nursing takes place in a v a rie ty o f settings
and it s p ra c titio n e rs i n it ia t e a m ultitude o f a c t iv it ie s to meet the
goals o f as sis tin g persons with various health needs.
This fa c t con­
trib u te s to the lim ite d amount o f s c ie n tific in ve s tig atio n o f community
health nursing c lin ic a l practice th at now e x is ts .
The uniqueness o f
community health nursing prevents complete u t iliz a t io n o f h o sp ita lbased research and th erefo re necessitates the need fo r it s p ra c titio n e rs
to i n i t i a t e research directed toward v a lid a tin g community health nursing
a c t iv it ie s .
P a rtia l re p lic a tio n o f nursing studies done in hospital
settings is one way o f accomplishing th is goal.
R eplication o f nursing
studies done w ith in a hospital s e ttin g s u b stitu tin g content relevan t to
community health nursing may aid the community health nursing p r a c ti­
tio n e r to more surely p re d ic t the e ffe c ts o f her a c t iv it ie s and enter
in to the theory building th a t is required o f a profession.
Three years o f community health nursing experience, lit e r a t u r e
review , and a p ro ject completed in an undergraduate course by this re ­
searcher have suggested th a t the community health nurse's ro le is often
not viewed in the same frame o f reference by c lie n ts as i t is by the
nurse.
Sociological theory suggests th a t the existence o f divergent
views concerning the roles o f members in te ra c tin g w ith in a group or dyad
may a ffe c t the effectiven ess of the re la tio n s h ip .
Behaviors inherent in roles are p r io r itiz e d by the individual
in accordance with what he values or holds as important to his
2
maintaining optimum functioning.
ences, including education.
Values are determined by l i f e e xp eri­
The community health nurse has an educa­
tio n a l background conducive to her valuing to a high degree the
a c t iv it ie s she in it ia t e s with c lie n ts !
However, the c lie n t with an edu
cational background th a t d iffe rs may a ttrib u te d is s im ila r value to the
same a c t iv it ie s .
I f these divergent views do e x is t, th is c o n flic t may
not allow e ith e r party to meet his goals.
This researcher proposes th a t one way of determining whether or
not these divergent views between community health nurses and c lie n ts
do e x is t is to use survey research techniques which s o li c it ratings of
importance by both nurse and c lie n t r e la tiv e to selected nursing
a c t iv it ie s .
STATEMENT OF THE PROBLEM
The problem o f th is study was to determine and compare the
degree o f importance a ttrib u te d by both nurses and c lie n ts to selected
interventions advocated as meaningful and lik e ly to occur w ithin the
community health n u rs e -c lie n t re la tio n s h ip .
NEED FOR THE STUDY
Nursing, as described by Henderson, is assistin g the p a tie n t to
u t i liz e his po ten tial fo r optimum h ealth .
The nurse substitutes her
physical stren gth, w ill or knowledge, i f th is is lacking in the p a tie n t
3
u n til the p a tie n t can become s e lf - s u f f ic ie n t in meeting his health
needs.
Every member o f the medical team, Henderson continues, must
recognize the p a tie n t as the central fig u re o f the team.
I f the p a tie n t does not understand, accept or p a rtic ip a te in
the program, planned with and fo r him, the e f f o r t o f the
medical team is la rg e ly w asted.■
Henderson's d e fin itio n o f nursing and her concept o f nursing as
assistance required when in divid u als cannot meet th e ir own health needs
is widely accepted.
This is the basis o f nursing's purpose and function
and is re ite ra te d by other nursing a u th o ritie s (Orlando, 1961;
bach, 1964;
Orem, 1971;
Wieden-
Nursing Development Conference Group, 1973).
As nursing has moved into bu ild ing theories to substantiate it s
existence as an independent profession, models fo r nursing practice
which include the p a tie n t as the central fig u re w ithin the model have
been developed (Dumas, Quint, 1969; Rogers, 1970; Roy, Murphy, 1971).
Orovan (1972) stated th a t the p a tie n t can best understand,
respond, p a rtic ip a te and cooperate with the nursing care plan i f the
nurse accurately in te rp re ts the p a tie n t's a ttitu d e s , such as the impor­
tance he a ttrib u te s to the nursing interventions in it ia t e d with him.
Although the nurse
may have considerable
knowledge and
s k ill in
observing and in te rp re tin g her p a tie n t's a ttitu d e s , the observations
^V irg in ia Henderson, The Nature o f Nursing (New York:
C o., 1966), p. 16.
Macmillan
4
and in te rp re ta tio n s are la rg e ly influenced by her own professional
background.
In the discussion o f "What Constitutes C lin ic a l P ra ctice ,"
Baziak (1968) promoted the idea th a t a m ajority o f nurses perceive
aspects o f th e ir ro le th a t require technical s k ills as more important
than care-g ivin g s k ill s .
Therefore, nurses may have d iffe r e n t views
among themselves regarding the importance o f nursing a c tiv it ie s to help
meet th e .p a tie n t's needs.
Several decades ago nursing a u th o ritie s recognized the proposi­
tio n th a t e ffe c tiv e nursing requires inclusion of the p a tie n t in an ac­
tiv e ra th e r than passive r o le .
A s ig n ific a n t number of hospital studies
have been conducted to v a lid a te or re fu te th is hypothesis.
Sociological
theory has been drawn upon to create conceptual frameworks fo r studies
in c lin ic a l nursing r e la tiv e to the p a tie n t as an ac tiv e p a rtic ip a n t in
planning and implementing his care plan.
These studies seemed to v a l i ­
date the proposition th a t the effectiveness o f nursing procedures
measured in physiological terms were increased when the p a tie n t p a r t i­
cipated in planning and understood the reason fo r and the importance o f
procedures the nurse was p ra c tic in g with him (Dumas, Anderson and
Leonard, 1963;.
Tryon and Leonard, 1965;
Mucahy and Janz, 1973).
Other studies have attempted to a c tiv e ly involve the p a tie n t in
e lic it in g his ra tin g of importance o f the nursing a c t iv it ie s in itia te d
with him in .a primary care s e ttin g .
Some of these studies have also
queried nurses as to the importance they a ttrib u te d to nursing
5
interventions in it ia t e d with p a tie n ts .
Comparison o f the ratings by
patients and nurses have produced findings in d ic a tin g th a t nurses and
patients do a ttrib u te d iffe r e n t ratings o f importance to nursing a c t iv i­
tie s depicted by items d e scrip tive o f physical care, psychological care,
sociological care, medical treatment plans, economic considerations,
s p iritu a l care, p a tie n t education and plans fo r c o n tin u ity o f care or
discharge planning (W hiting, 1958 [as reported by W hite];
Ciesla e t a l . , 1965;
White, 1972;
Sisk and
and Conlee, 1975).
Since community c lie n ts present an extremely varied c o lle c tio n
o f reasons fo r needing nursing assistance, d is tr ib u tiv e care nurses have
had a more independent ro le than episodic care nurses in developing care
plans.
Although physicians' orders and other treatment s p e c ia lis ts '
plans are u t iliz e d , the community health nurse, due to her lack of
proxim ity in the care s e ttin g to these people, is more autonomous in
id e n tify in g and planning c lie n t care.
The c lie n t is the major corrobo­
ra to r fo r th is plan.
Yet p ra c titio n e rs o f community health nursing are mainly guided
by p rin cip le s developed through practice and have done l i t t l e
to v a l i ­
date th e ir unique c lin ic a l practices except through each nurse's own
perception of her a c t iv it ie s ' effectiveness with in d ivid u al c lie n ts
(Mayers, 1975;
Highri t e r , 1977).
Mayers (1975) suggested th a t the home v i s i t is r i t u a l i s t i c .
This seems to in d icate th a t while community health nurses have a large
6
degree o f la titu d e fo r in d iv id u a liz a tio n o f health plan s, they may
a c tu a lly re ly on a re p e rto ire o f practices th a t do not meet certain
needs the c lie n t fe e ls are im portant.
Mayers' study also produced
findings in d ic a tiv e o f community health nurses in the study not sharing
th e ir goals fo r the re la tio n s h ip with the c lie n ts .
th is as the "hidden agenda."
She re fe rred to
This suggests th a t c lie n ts are often not
aware o f those things the nurse sees as important fo r his w elfare and
optimum health statu s.
In one o f two studies conducted r e la tiv e to health needs of
community members, Keith (1976) found th a t public health nurses
emphasized the importance o f interventions re la ted to meeting social
needs o f the e ld e r ly , w hile the e ld e rly respondents ra tin g the same
interventions emphasized a c t iv it ie s th a t would help them maintain
independent functioning by meeting th e ir physiological needs.
In the
second study, Kurtz e t a l . (1974) studied in n e r-c ity residents' and
health decision-makers' perceptions o f health problems and solutions.
Although both groups id e n tifie d s im ila r health problems, the authors
stated th a t there is a resounding "yes" to the question o f a mismatch
in perceptions o f how these problems should be d e a lt w ith .
This researcher proposes th a t there may be differences in the
importance a ttrib u te d to nursing a c t iv it ie s lik e ly to be in it ia t e d in
the community health n u rs e -c lie n t re la tio n s h ip and th a t these d i f f e r ­
ences in ratings o f importance may a ffe c t the effectiveness o f the
7
re la tio n s h ip between them.
Therefore, i t is proposed th a t a d escriptive
study be undertaken, in which both community health c lie n ts and nurses
rate the importance o f selected a c t iv it ie s advocated as meaningful and
lik e ly to occur, to determine i f differences do e x is t.
OBJECTIVES OF THE STUDY
The objectives o f the study were directed towards gathering data
fo r the purpose o f determining whether or not community health nurses
and c lie n ts vary in th e ir ra tin g o f importance of selected community
health nursing a c t iv it ie s th a t may occur w ith in th e ir re la tio n s h ip .
1.
To determine the degree o f importance community health
nurses a ttrib u te to selected, nursing in terven tio n s.
2.
To determine the degree o f importance community health
c lie n ts a ttrib u te to selected nursing in terven tio n s.
3 .. To compare the degree of importance a ttrib u te d to selected
community health nursing interventions when rated by both nurses and
c lie n ts .
ASSUMPTIONS
The assumptions were made in th is study th a t both external and
in tern a l factors may a ffe c t the study.
these assumptions.
The follow ing statements specify
8
External
■
I.
.
.,. .
The assumption is made th a t the effectiveness o f a nurse-
c lie n t re la tio n s h ip may be affected i f the nurse and c lie n t a ttrib u te
d is s im ila r value to the a c t iv it ie s they engage in as a p a ir to meet
the c lie n t's health needs.
Internal
1.
The assumption is made th a t the a c tiv itie s selected fo r
inclusion in the Community Health Nurse A c tiv itie s Tool e lic it e d
responses representative o f data sought.
2.
The assumption is made th a t c lie n ts and nurses responded to
the Community Health Nurse A c tiv itie s Tool in accordance with the per­
ceptual set depicted by the introductory paragraphs preceding the tool
(see Appendices E and F ) .
LIMITATIONS
Findings o f the study were lim ite d to ratings o f importance of
nursing a c t iv it ie s depicted by items o f the Community Health Nursing
A c tiv itie s Tool.
No provision was made fo r respondents to id e n tify
additional a c t iv it ie s or o ffe r q u a lify in g information r e la tiv e to the
items rated.
This study made no attempt to id e n tify the effectiveness of
community health nursing interventions depicted by the items of the
9
Community Health Nursing A c tiv itie s Tool, only th e ir importance as
rated by both sampling populations.
DEFINITION OF TERMS
The terms used fo r the purpose o f th is study were defined from,
th e o re tic a l and operational perspectives.
The follow ing d e fin itio n s
specify these perspectives.
Community Health Nurse
T h e o re tic a l.
A.nurse functioning w ithin a d is tr ib u tiv e se ttin g
Community health nursing is seen as a population-based o b lig a tio n ,
re a liz e d through a m u ltid is c ip lin a ry , e c o lo g ic a lly -o rie n te d e f f o r t
and u t iliz in g concepts and s k ills th a t derive both from generic
f
nursing and from public health p ra c tic e .
O perational.
Registered nurse, employed by the agencies par­
tic ip a tin g in the study.
Therefore the nurses of the study may have
varying educational and e x p e rie n tia l backgrounds depending upon the
q u a lific a tio n s
fo r employment as defined by the p a rtic ip a tin g agencies
Nurses p a rtic ip a tin g in the study are involved in d ire c t services to
c lie n ts .
Community Health C lie n t
T h e o re tic a l.
A person requirin g nursing services to meet his
2Ruth Freeman, Community Health Nursing P ractice (P hiladelph ia:
W. B. Saunders Company, 197 0), p. i i i .
10
health needs outside an episodic care s e ttin g .
O perational.
A person or fam ily drawn purposively from the
case load o f the nurses p a rtic ip a tin g in the study.
selection o f c lie n ts fo r th is study included:
C r ite r ia fo r
( I ) the c lie n t has had
some ongoing contact with a community health nurse (not necessarily the
nurse submitting his name);
understand English;
(2) the c lie n t is a b le 'to read, w rite and
and (3) the c lie n t had given verbal consent to the
community health nurse who submitted his name to be contacted by the
researcher.
I f the main c lie n t w ith in a fam ily was an a d u lt able to
respond e ith e r independently or with the aid of a fam ily member or
other a d u lt, th is a d u lt c lie n t responded to the c lie n t version o f the
Community Health Nursing A c tiv itie s Tool.
I f the main c lie n t w ithin a
fam ily was a c h ild under 18 years o f age, the parent or guardian was
asked to complete the c lie n t version o f the Community Health Nursing
A c tiv itie s Tool.
Importance
T h e o re tic a l.
The value a ttrib u te d to a conceptualization or
action re la te d to human behavior.
Values are an a ttitu d e developed by
a person from l i f e experiences th a t determine how a person has decided
to d ire c t his overt behaviors.
O p eration al.
The subjective view of respondents to the study
instrument items o f the Community Health Nursing A c tiv itie s To ol.
The
respondents were asked to ra te the importance of the items depicting
Tl
nursing a c t iv it ie s on a fiv e -p o in t scale ranging from extremely impor­
ta n t on one end o f the continuum to no importance on the other end of
the continuum.
Nursing A c tiv itie s
T h e o re tic a l.
Overt or covert behaviors of. community health
nurses considered to be essential to meeting c lie n ts ' health needs in
the community health n u rs e -c lie n t re la tio n s h ip .
O perational.
Descriptions o f s p e c ific concrete nursing a c t i­
v itie s (derived from lit e r a t u r e review and v a lid a tio n by expert judges)
to which c lie n t and nurse responded with ratings o f importance.
CHAPTER 2
REVIEW OF LITERATURE
The purpose o f the review o f lit e r a t u r e was to :
( I ) review
sociological theory re la ted to the study and one author's application
o f ro le theory in discussing community health nursing;
(2) consider
the status o f community health nursing, it s roles and d u tie s;
and
(3) review previous studies th a t could give d ire c tio n to the study.
Sociological Theory Related to the Study and Community Health Nursing
"Sociology is the s c ie n tific study o f human in te ra c tio n ."
3
The
in te r a c tio n is t theory o f sociology sees man functioning w ith in a society
and recognizes th a t most behavior o f man is social and involves in t e r ­
action with others.
Sociology is b a s ic a lly a pure science untertaking
research studies to determine the variables th a t contribute to the
orderliness th a t exists w.ithin s o c ie tie s .
However, other d is c ip lin e s ,
including nursing, have attempted to u t i l i z e sociological theory in
th e ir own practices (Vernon, 1965;
Hodges, 1974; B ie rs ta d t, 1974;
and
Anderson, 1974).
T r a d itio n a lly , the main function o f nursing has been "care" and
the medical profession's aim has been "cure."
U ntil several decades ago
the in te ra c tio n process between nurse and p a tie n t was thought an "art"
3Glenn Vernon, Human In te ra c tio n : An Introduction to Sociology
(New York: The Ronald Press Company, 1965), p. 3.
13
ra th e r than a behavior th a t could be learned.
Nurses do p a rtic ip a te in
the diagnostic and therapeutic regimes planned to re lie v e p a tie n ts '
biolo gical d iseq u ilib riu m .
However, these functions are mainly
dependent upon the d ire c tio n o f medical p ra c titio n e rs .
Unless the
c lie n t presents him self fo r care so le ly due to psychological pathology,
the nurse is the d ire c to r o f in te ra c tio n process a c t iv it ie s aimed a t
meeting the c lie n t's s itu a tio n a lly -d e riv e d and emotional needs
(Woolridge, Skipper and Leonard, 1968).
Sociological research has produced data in d ic a tin g th a t there
is always a reciprocal influence on in divid uals taking p art in an in t e r ­
action (B ie rs ta d t, 1974).
These influences have been more f u lly studied
in research re la te d to ro le s .
Roles are e ith e r ascribed or achieved.
The nursing ro le is achieved and to a large extent determined by the
duties assigned to i t by the c lie n ts served by nurses (Freeman, 1970).
This is consistent with the d e fin itio n o f ro le given by F a irc h ild as an
expected behavior o f an individual w ith in a group as defined by the
group (F a ir c h ild , 1970).
Freeman (1970) discusses the "Roles and Functions o f the Com­
munity Health Nurse" (pp. 3 9 -49 ).
The community health nurse's ro le is
determined to a large degree by perceptions of th a t ro le by others.
Freeman states th a t there are inconsistencies in others' view of the
ro le of the nurse.
Program planners, as well as c lie n ts , may ascribe
roles th a t are inconsistent with the community health nurse's
14
c a p a b ilitie s achieved through education. Some of these inconsistencies
. ■t
,
are discussed in the follow ing paragraphs.
Freeman states th a t while the p u b lic's view o f the nurse as a
provider o f personal care to the sick creates acceptance, i t also
delim its the community persons' view of the nurse's p o te n tia l.
Clients
are less lik e ly to view non-tangible services such as health teaching
and emotional support services by the nurse as a valuable component o f
her r o le .
Because a large number o f public health nursing c lie n ts are
poor, the nurse is often viewed as a servant to the poor.
Another ro le described by Freeman is th at o f the " w illin g advodate" (p. 4 0 ).
The nurse is seen as one who can help the c lie n t u t i liz e
services w ith in the confusing maze o f social w elfare programs.
She is
viewed as a means of entry into the medical care system ra th e r than a
person possessing knowledge th a t is separate from the physician. .
Gerald Caplan is quoted by Freeman as coining the phrase "wise
older s is te r" r e la tiv e to the ro le o f the community health nurse.
Since
th is seems to connote a degree of involvement beyond impersonal pro vi­
sion o f s ervice. Freeman states th a t i t may be the most s ig n ific a n t ro le
a ttrib u te d to the community health nurse.
However, even though these
less tan g ib le acts are g re a tly appreciated by c lie n ts , Freeman feels
most c lie n ts do not value them as a
part o f her ro le as a nurse.
Another ro le Freeman discusses is th a t o f "Sensitized Observer"
(p. 4 1 ).
Other members o f the health care team and community c lie n ts
15
equally expect the nurse to observe and report to them any deviation
from expected behavior re la te d to illn e s s , growth and development,
response to drugs and general w e ll-b e in g .
Freeman also proposes th a t the community health nurse is valued
as one who influences decisions and produces change (p. 4 1 ).
No matter
what the obstacles are to health care p ra c tic es , the nurse is expected
to "do something about i t "
(p. 4 2 ).
Freeman's discussion points out th a t much is expected of a
community health nurse, y e t c lie n ts are not lik e ly to perceive non­
tangible acts as a valuable component o f her ro le .
She also promotes
the idea th a t, although community nurses are often involved in a llie d
community service and planning, the scope o f th e ir contributions is
not f u lly understood by others.
Freeman s ta te s .
The degree to which the expectations o f others are congruent
with those o f the nurse h e rs e lf w ill have much to do with the
s a tis fa c tio n she derives from her work.4
The Status of Community Health Nursing;
Its Roles and Duties
Public Health A u th o rities Discuss Public Health Nursing
A 1970 survey o f registered nurses w ithin the United States
determined th a t approximately 51,000, or 7.3%, of those employed were
working w ith in a public health or school se ttin g (W iln er, Walkley and
Goerke, 1973).
^Freeman, op c i t . , p. 43.
16
" P u b lic h e a lth n u rs in g is a s p e c i a l i t y w it h in
b o th p r o f e s s i o n a l
n u r s i n g and t h e b ro a d a re a o f o r g a n iz e d p u b l i c h e a l t h p r a c t i c e .
Nursing is one d ivis io n o f general public health services and i t is
done mainly on a fam ily-centered basis in the home.
In divid uals and
groups are also served by public health nurses in th e ir work and school
s e ttin g as well as in public health centers.
Prevention o f disease and promotion of health are the public
health nurses' main aims.
These are accomplished by methods that
include case fin d in g , emphasis on u t iliz a t io n o f medical care and
health education.
Hanlon (1 9 74 ), in discussing public health nursing services,
reviewed the growth o f th a t s p e c ia lty .
He c ite s prevention o f disease
and ra is in g o f health standards as the primary aims o f public health
nursing.
These aims seem to have prevailed since the f i r s t v is itin g
nurse service was formed by an English p h ila n th ro p is t in 1859.
Professional
Organization Statements Regarding Public Health Nursing
A fte r dissolutio n o f the National Organization fo r Public
Health Nursing and it s incorporation into the National League of Nursing
in 1959,
a statement was issued regarding the practice o f public health
5Danial M iln e r, Rosabelle Walkley and Lenor Goerke, Introduction
to Public H ealth, 6th ed. (New York: MacMillan Publishing, In c ., 1975),
p. 38.
17
nursing.
This statement concurs with the previously-discussed a u th o ri­
tie s (W iln e r, Walkley and Goerke;
Hanlon) th a t public health nursing
has dual aims o f prevention and ra is in g health standards.
I t also de­
fines the jo in t nature o f public health nursing as a blend o f ( I )
professional nursing p ra c tic e ;
o f public h ealth .
and (2) philosophy, content and methods
The NLN statement re ite ra te s W ilner's (W ilner,
Walkley and Goerke) statement th a t the public health nurse's duties are
community-based (Hanlon, 1974, p. 649).
The Public Health Nurses' Section o f the American Nurses'
Association prepared statements o f functions and q u a lific a tio n s fo r
public health nurses (Hanlon, 1974, pp. 649-652).
Functions o f public
health nurses in s t a f f positions are broadly outlined as being:
(I)
assessing, (2) planning, (3) implementing, (4) e valu atin g , and (5)
studying and researching.
The implementation phase o f public health
nursing is fu rth e r defined as having comprehensive nursing service as
it s goal.
This nursing component includes:
supervision o f th is when done by others;
( I ) s k ille d care or the
(2) preventative and thera­
peutic treatment under the d ire c tio n o f medical p ra c titio n e rs ;
teaching o f p o sitiv e health measures;.
hazards;
(3)
(4) elim ination o f health
and (5) m aintaining records.
While carrying put the above-named functions the nurse is to
u t i liz e knowledge o f behavior patterns and a ttitu d e s th a t w ill stim ulate
the fam ily to u t i liz e services on th e ir own i n i t i a t i v e .
Corroboration
18
w i t h o t h e r h e a l t h p r o f e s s i o n a l s i s a l s o c i t e d as an i m p o r t a n t f u n c t i o n
w i t h i n t h e im p le m e n t a t io n phase.
The ANA statement again emphasizes th a t public health nursing
occurs w ith in a wide range o f settings and th a t public health nurses
may act on a consultation basis to various groups.
The nurse is also
visu alized as acting as a lia is o n fo r the public health agency with
community groups to promote community health in a v a rie ty o f ways
including the democratic process.
Textbooks Related to Public Health Nursing
Texts reviewed re ite ra te d the foregoing d e fin itio n s and s ta te ­
ments regarding public health nursing (Tinkham and Voorhees, 1972;
Leahy, Cobb and Jones, 1977).
Most nursing texts consider public
health nursing w ith in the la rg e r context o f community health nursing.
Spradley states th a t a c le a r d e fin itio n o f community health nursing is
d i f f i c u l t in th is time o f changing health emphasis and d e liv e ry system.
Public health nursing is one aspect o f community health nursing.
She
goes on to say th a t concepts included in community health nursing
include:
( I ) prevention, (2) the fam ily u n it, and (3) c u ltu re and
community dynamics ( Spradley, 1975, p. v i i ) .
The authors o f community health nursing texts strongly emphasize
19
th a t community health nursing contains practices th a t consider the
c lie n t as a to ta l person liv in g w ith in an environment th a t also shapes
his health status (K a ilin , 1967;
1975;
Freeman, 1970;
Archer and Fleshman,
Leahy, Cobb and Jones, 1977).
Archer and Fleshman (1975) and Freeman (1970) discuss the roles
assumed by community health nurses.
as:
These can be generally outlined
( I ) advocate, (2) c o llab o rato r and team member, (3) consultant,
(4) coordinator and f a c i l i t a t o r , (5) d e liv e re r o f s e rv ic e , and (6)
educator.
Studies Related to the Problem
H ig h rite r (1977) reviewed lit e r a t u r e appearing in Englishw ritte n journals between the years 1972-1976 re la te d to "The Status of
Community Health Nursing Research."
Of those meeting the c r it e r ia fo r
consideration o f H ig h rit e r , HO were reviewed.
She devised a system fo r
categorizing the lit e r a t u r e according to the main purpose o f the study.
Service evaluation studies accounted fo r nearly 40% of the
studies meeting the c r it e r ia fo r inclusion in H ig h rit e r 's review of
community health nursing research.
F ifteen percent (15%) were cate­
gorized as "need assessment" studies.
Orte study w ith in th is group
(K e ith , 1975) is re fe rre d to in the Need For The Study (p. 6 ).
Community health nursing education studies accounted fo r less
than fifte e n percent (15%) of the studies considered.
A ttitu d e studies
20
were e ig h t in number (7%) and fiv e were concerned with nurses' a ttitu d e s
toward various subjects;
none o f these re la te d to the importance a t t r i b ­
uted to th e ir in terv e n tio n s .
The remaining 12% o f the a r tic le s reviewed
were study reviews and a r tic le s re la te d to methodology o f studies.
Mayers (1972) working as a nurse researcher in a large metro­
p o lita n public health agency, undertook several studies to id e n tify
assessment
portion
c r it e r ia fo r
o f the
community health
f ie ld studies
she
nursing
conducted
was
p ra c tic e .
aimed
One
to
id e n tify in g , by p a rtic ip a n t observation, what topics were most f r e ­
quently discussed during home v is it s .
she determined
Of the
A fte r observing 37 home v is it s ,
17 topics had been discussed between c lie n ts and nurses.
17 topical discussions, matters o f medical care plans were d is ­
cussed 26 tim es, general health and physical symptoms were discussed
36 times and personal-em otional-fam ily problems were discussed 22 times.
The remaining topics were defined as personal care techniques, d ie t,
fin a n c ia l problems, social a c t iv it y , c h ild care problems and techniques,
job needs or problems, problems with liv in g conditions, physical a c tiv ­
i t y , housing, b irth c o n tro l, assistance o f attendant, c lo th in g , need
fo r a s s is tiv e devices, and ambulation problems.
These are lis te d in
descending order of occurrence as topics o f discussion in the v is its
observed.
Mayers compared the observed content and process o f the v is its
with the nurses' comments about the v i s i t .
She found th a t the goals
21
stated to the c lie n t represented a d iffe r e n t level o f abstraction than
the ones stated to her as the researcher a f t e r the v i s i t by the nurse
being observed during the v i s i t .
One-half o f the purposes fo r the
n u rse-patient re la tio n s h ip could not be detected from reviewing the
content o f the home v i s i t .
She s ta te d .
One wonders i f nurses might give some thought to sharing th e ir
goals more s p e c ific a lly with th e ir c lie n ts and i f the re latio n sh ip
might be more productive i f c lie n ts were more involved in an
e x p lic it awareness o f the purposes o f the r e la tio n s h ip .'
White (1972) reviewed studies th a t have been done in a hospital
s e ttin g to supposedly determine what p a tie n ts , doctors, the general
public and nurses themselves think a nurse does, should do, is or should
be.
Findings o f these studies have c o n flic te d and have revealed d i f f e r ­
ences in perceptions o f the various groups concerning the ro le o f the
nurse.
White determined th a t patients and personnel have had a very
small degree of p a rtic ip a tio n in the studies and th a t a c t iv it ie s con­
sidered in the studies did not exclusively ceal with nursing a c t iv it ie s .
White describes one study th a t does s o li c it the views o f
patients and personnel;
th a t study was done by Whiting in 1958 fo r the
id e n tific a tio n o f a "generic core o f nursing."
One hundred commonly-
performed nursing a c t iv it ie s were rated according to t h e ir importance by
7Marlene Mayers, "The Therapeutic Ritual in Community Health
Nursing," (unpublished research r e p o r t), p. 9; see also Marlene Mayers,
"Home V is it- - R it u a l or Therapy?" Contemporary Community Nursing,
Barbara Walton Spradley, ed. (Boston: L i t t l e , Brown and Company, 1975).
22
p a tie n ts .
Ratings o f the same a c t iv it ie s were given by personnel and
the ratings o f both groups were compared fo r congruency.
S t a t is t ic a lly
Q
s ig n ific a n t differences were found between the views o f the two groups.
White (1972) questioned the relevance o f comparing generalized
responses such as those evoked in W hiting's study.
She had 100 re g is ­
tered nurses working in. hospitals ra te the importance o f a c tiv itie s
re la te d to 300 p a tie n ts ' care.
She asked th a t the ra tin g be done
according to what the nurse v isu alized as important fo r the p a rtic u la r
p a tie n t, not what had a c tu a lly been done.
When she compared the
responses o f patients and nurses, she found th a t physical comfort mea­
sures were rated more important by the p a tie n ts .
While in W hiting's
(1958) study both nurses and patients rated physical comfort measures
with more than medium importance, in W hite's study patients did rate
them above th is point while nurses rated them below.
White also found th a t the importance fo r the p a tie n t of many
nursing a c t iv it ie s involving psychosocial aspects o f care was overempha­
sized by nurses in the study sample.
This contradicted e a r lie r research
including W hiting 's.
O
W hiting's study o f 1958 was not a v aila b le to th is researcher.
Reference to i t is extracted from W hite's 1972 study. Therefore, the
term "personnel" may in d icate th a t persons other than registered nurses
were also included in the study. However, White states th a t "nurses'"
responses were compared to p a tie n ts ' in her comparison o f findings to
those o f W hiting's study (W hite, 1972, pp. 11-13).
23
White also found th a t nurses and patients placed highest p r io r:
'
■
.
'
'
it y on the nursing a c t iv it ie s th a t implement the physician's plan of
care.
This is consistent with the findings of previous studies White
consulted.
Boyle (1960). attempted to determine the a b il it y o f nursing
students to id e n tify the importance ascribed by patients to certain
aspects o f hospital care by measuring a ttitu d e s .
The resu lts o f th is
study id e n tifie d a need to fin d ways to system atically acquire s k ills
in recognizing p a tie n t a ttitu d e s in the interpersonal re la tio n s h ip .
Conlee (1975) developed a questionnaire to examine nursing care
from the h o sp italized p a tie n t's point o f view by determining which
functions o f the nurse the p a tie n t considered most im portant.
The
re la tio n s h ip of these opinions to demographic variables o f the patients
were analyzed.
Regardless o f the p a tie n t's age, sex, socio-economic
status or e th n ic ity , m edically-prescribed a c tiv itie s o f the nurse were
seen as more important than a c t iv it ie s the nurse c a rrie d out re la ted to
providing an optimum environment, p a tie n t teaching or providing fo r
p a tie n ts ' emotional needs.
Students and th e ir in s tru c to r a t S t. John College (S isk, 1965;
C ie s la , 1965) undertook two studies to determine perceptions of nursing
care from a p a tie n t's view and from a nurse's view.
This was done by
having patients and nurses rate the importance a ttrib u te d to nursing
a c tiv itie s described on a questionnaire.
I
Although d iffe r e n t sets o f
24
a c tiv itie s were presented to the two groups and only c h r o n i c a l ly - ill,
ambulatory patients were considered, both groups indicated th a t they
f e l t meeting the p a tie n t's physical needs was of the greatest importance.
Summary o f Review o f L ite ra tu re
Sociology deals with the s c ie n tific study o f human in te ra c tio n .
While some nursing a c t iv it ie s have an overt technical s k ill aspect, com­
munity health nursing, in p a r tic u la r , is la rg e ly an in te ra c tio n process
between nurse and c lie n t .
Sociological theory, e s p e cia lly in te ra c tio n -
i s t theory and ro le theory, can be drawn upon to study nursing practice
a c t iv it ie s .
Community health nursing is a blend of general nursing practice
and public health p ra c tic e .
Practiced in settings outside the h o s p ita l,
community health nursing attempts to aid persons to meet th e ir needs
considering the person w ith in the la rg e r context o f the community in
which he liv e s ra th e r than in an in s titu tio n a l s e ttin g .
Community health nursing p rin cip le s have mainly been perpetuated
through p ra c tic e .
As nursing in general has begun to bu ild a research
base fo r it s theory, so has community health nursing, but to a lesser
e x ten t.
However, a t th is time some o f it s practices appear to be
r i t u a l i s t i c , which leads to a question of th e ir therapeutic value.
Sociological theory has been applied in hospital-based c lin ic a l
nursing research to study the a ttitu d e s held by nurses and th e ir c lie n ts
toward a c t iv it ie s lik e ly to occur in th e ir professional re la tio n s h ip .
25
These studies have produced data displaying variances in the ra tin g of
importance a ttrib u te d to selected nursing a c t iv it ie s when rated by
nurses and p a tie n ts .
CHAPTER 3
METHODOLOGY
:.
The problem o f th is study was to determine and compare the
degree o f importance a ttrib u te d by both nurses and c lie n ts to selected
interventions advocated as meaningful and lik e ly to occur.
In th is chapter the methodology o f the study is presented in
the follow ing order:
1.
The procedures fo r development, v a lid a tio n and pretesting
of the instrument fo r data c o lle c tio n are defined.
2.
examined;
3.
The population is defined and procedures fo r sampling are
method o f data c o lle c tio n is discussed.
Chapter summary is presented.
Procedures fo r Development, V alid atio n and Pretesting o f the Instrument
fo r Data C ollection
Development o f an Instrument
The instrument fo r c o lle c tin g data consisted o f twenty s ta te ­
ments describing nursing a c t iv it ie s which the respondents were to rate
on a continuum ranging from extreme importance to no importance.
To
select the a c t iv it y statements to be included, lit e r a t u r e was reviewed
to determine interventions purported to be important and often in it ia t e d
in community health nursing p ra c tic e .
Statements o f public health
a u th o ritie s , professional nursing organizations statements, public
health nursing textbooks and re la te d nursing research reports were
27
consulted.
This lit e r a t u r e review focused d ire c tly on n u rs e -c lie n t
in te ra c tio n processes, therefore ad m inistrative and c le r ic a l a c t iv it ie s
o f the nurse are excluded from examination in th is study.
The a c t iv it ie s id e n tifie d from the review o f lit e r a t u r e were
categorized according to four areas o f nursing care th a t are consistent
with defined courses o f study in nursing education.
The decision was
made to perform the data analysis o f the study according to ratings of
the four categories (physical care, psychological care, medical care
re la ted and sociological c a re ).
This is consistent with White's 1972
study as well as other hospital-based studies o f th is type.
The items o f the Community Health Nursing A c tiv itie s Tool
(CHNAT) were developed to id e n tify fiv e items descrip tive o f nursing
in terventions w ith in each o f the four categories.
V a lid ity Studies
Four expert judge groups were asked to perform ra tin g and s o rt­
ing procedures to v a lid a te the items as closely approximating actual
community health nursing practice and v a lid a te the items' placement
w ithin the four categories.
The ratings concerning how closely the
items approximated actual community health nursing practice were done
by th irte e n supervisors o f nursing in public health agencies throughout
Montana.
The sorting procedures regarding v a lid ity o f placement o f
items w ith in the four categories were done by nurses o f varying job
o rie n ta tio n .
28
Items and category d e fin itio n s were revised according to resu lts
of the ra tin g and sorting procedures conducted by the expert judges (see
Appendices A and B).
In the ra tin g procedure, the responses of the
judges were assigned a numerical value from 4 (closely approximating) to
I (not closely approximating) actual p ra c tic e .
Averages were computed
and the items appearing upon the CHNAT fo r the study had a ll been judged
as a t le a s t 80% closely approximative o f actual community health nursing
p ra c tic e .
The v a r ia b ilit y of the expert judge groups conducting the
sorting procedure fo r v a lid ity of item placement w ithin categories was
above the 50% a c c e p ta b ility lim it set by the researcher.
The results
are displayed in Figure 5 (see Appendix C5 p. 8 2 ).
A random drawing determined the sequential order o f placement
of items as accepted from the resu lts o f the expert judging procedures
upon the data c o lle c tio n instrument.
Pretesting o f the Community Health Nursing A c tiv itie s Tool
Sixteen Nursing Service Center c lie n ts and s ix senior nursing
students p a rtic ip a te d in the pretestin g of the CHNAT.
using the tool with these c lie n ts and students were:
Objectives in
( I ) to determine
the mechanical f e a s ib ilit y of the proposed method o f data c o lle c tio n by
m a il;
(2) to determine the c la r it y o f the directions and items o f the
to o l; (3) to ascertain i f v a r ia b ilit y would be displayed w ithin the
29
responses o f c l i e n t s
and s t u d e n t s t o t h e c a t e g o r i z e d ite m s
(see A p p e n d ix
D).
As a re s u lt o f the p retesting the decision was made to re ta in
the items as stated fo r the fin a l form o f the CHNAT.
The decision was
also made to c o lle c t data from pairs o f nurses and c lie n ts rath er than
by group.
The d irection s and introductory paragraphs were changed to
accomodate th is procedural change.
On the CHNAT fo r nurses, the l i s t o f items was preceded by a
paragraph requesting the nurse to in d icate the importance o f each
a c tiv ity fo r the c lie n t whose name was in serted .
On the CHNAT prepared
fo r c lie n ts , the l i s t o f items was preceded by a paragraph requesting
the c lie n t
to in dicate the importance o f each a c t iv it y fo r him (see
Appendices E and F).
Population Defined;
Discussed
Procedures fo r Sampling and Data C ollection
Two communities w ithin Montana were chosen fo r s ite s o f data
c o lle c tio n .
The decision fo r location was based on the a v a ila b ilit y o f
a s u ffic ie n t number o f nurses to expedite data c o lle c tio n and of th e ir
supervisor's agreement to allow them to p a rtic ip a te in the study.
The nurse population was confined to professional nurses engaged
in d ire c t care o f c lie n ts in the community.
On each study day, the
nurses who agreed to p a rtic ip a te were contacted by the researcher (see
Appendix G).
30
The c lie n t sample was drawn from the c lie n t population being
seen by the p a rtic ip a tin g nurses in e ith e r a home v i s i t or c lin ic
s e ttin g .
The c r it e r ia fo r c lie n t selection were as follow s:
( I ) the
c lie n t had had some on-going contact with a community health nurse (not
necessarily the nurse who submitted h is /h e r name);
able to use the English language;
(2 ) the c lie n t was
and (3) the c lie n t had given verbal
consent to the nurse submitting h is /h e r name to be contacted by the
researcher.
A ll respondents in the study signed a p a rtic ip a n t consent form
before completing the CHNAT (see Appendices E and F ) .
Summary
The problem o f the study was to determine and compare the degree
o f importance a ttrib u te d to interventions advocated as meaningful and
lik e ly to occur w ithin the community health n u rs e -c lie n t re la tio n s h ip .
An instrument fo r c o lle c tio n o f ratings o f importance of commun­
i t y nursing a c t iv it ie s (CHNAT) was developed by the researcher.
V a lid ity te s tin g o f the instrument was done.
Pretesting o f both the
nurse and c lie n t versions was performed.
The tool was used in c o lle c tin g data from tw e n ty -fiv e community
health n u rs e -c lie n t p a irs .
The nurses and c lie n ts were drawn from pur­
posive samples o f the community health nurse and c lie n t population
residing in two m etropolitan areas o f Montana.
31
Data was co llected by the researcher personally d is trib u tin g
the appropriate version o f the CHNAT to both nurses and c lie n ts who had
agreed to p a rtic ip a te in the study.
CHAPTER 4
PRESENTATION OF DATA
Introduction
The problem o f the study was to determine and compare the degree
of importance a ttrib u te d by both nurses and c lie n ts to selected in t e r ­
ventions advocated as meaningful and lik e ly to occur w ith in the com­
munity health n u rs e -c lie n t re la tio n s h ip .
Data were collected from tw e n ty -fiv e pairs of nurses and c lie n ts
regarding 20 items descrip tive o f nursing a c t iv it ie s .
Upon completion
o f data c o lle c tio n , nurse and c lie n t importance ratings o f the twenty
items were organized in th e ir individual and paired relationsh ips and
tabulated.
Importance was described as the value a ttrib u te d to a con­
c e p tu a lizatio n or action re la te d to human behavior.
The nursing a c t i­
v itie s are examples o f behavior illu s t r a t iv e of ph ysical, psychological,
medical care re la te d and sociological needs o f c lie n ts in the community
health nursing care s itu a tio n .
Null hypotheses had been generated to
compare data by category.
The research design was d e s c rip tiv e u t iliz in g a closed-ended
questionnaire method.
The two dependent variables measured were c lie n t
and nurse ratings o f importance o f community health nursing a c t iv it ie s .
This was accomplished by s o lic itin g responses to the Community Health
Nursing A c tiv itie s Tool (CHNAT).
The null hypotheses o f the study
stated th a t there are no differences between nurse ratings o f importance
33
and c lie n t ratings o f importance when considering the same nursing
a c t iv it ie s .
The Montana State U niversity Computer Center and the S ta tis tic s
Laboratory were u t iliz e d to insure accurate computations.
Data were
displayed by non-parametric methods and studied fo r sign ificance by
app licatio n o f the tw o -ta ile d "t" te s t.
The M.S.U. S ta tis tic s Labora­
to ry was consulted fo r accurate in te rp re ta tio n o f the t values.
Null Hypotheses
Two major null hypotheses and ten minor null hypotheses were
generated to f a c i l i t a t e data a n a lysis.
A.
They are as follow s:
There is no s ig n ific a n t d ifferen ce among categorized groups
o f selected a c t iv it ie s in the degree o f importance a t t r i b ­
uted to them by c lie n ts and/or nurses.
1. There is no d ifferen ce in the degree o f importance
a ttrib u te d to physical care a c t iv it ie s as rated by
c lie n ts and/or nurses when compared w ith psychological
care a c t iv it ie s .
2. There is no d ifferen ce in the degree o f importance
a ttrib u te d to physical care a c t iv it ie s as rated by
c lie n ts and/or nurses when compared with medical care
a c t iv it ie s .
3. There is no d ifferen ce in the degree o f importance
34
a ttrib u te d to physical care a c t iv it ie s as rated by
c lie n ts and/or nurses when compared with sociological
care a c t iv it ie s .
4. There is no d iffe re n c e in the degree o f importance
a ttrib u te d to psychological care a c tiv it ie s as rated
by c lie n ts and/or nurses when compared with medical care
a c t iv it ie s .
5. There is no d ifference in the degree o f importance
a ttrib u te d to psychological care a c t iv it ie s as rated by
c lie n ts and/or nurses when compared with sociological
care re la te d a c t iv it ie s .
6. There is no d ifferen ce in the degree o f importance
a ttrib u te d to medical care a c t iv it ie s as rated by
c lie n ts and/or nurses when compared to sociological
a c t iv it ie s .
B.
There is no s ig n ific a n t d ifferen ce between the degree o f
importance community health nurses a ttr ib u te to categories
o f selected a c t iv it ie s when compared to the level of
importance c lie n ts a ttr ib u te to the same categories of
a c t iv it ie s .
I . There is no d ifferen ce in the degree o f importance
a ttrib u te d to physical care a c t iv it ie s by nurses when
35
compared with physical care a c t iv it ie s importanceratings o f c lie n ts .
2. There is no d iffe re n c e in the degree o f importance
a ttrib u te d to psychological care a c t iv it ie s by nurses
when compared with psychological care a c t iv it ie s
importance ratings o f c lie n ts .
3. There is no d ifferen ce in the degree o f importance
a ttrib u te d to medical care re la ted a c t iv it ie s by
nurses when compared with medical care re la te d
a c t iv it ie s importance ratings o f c lie n ts .
4. There is no d ifferen ce in the degree o f importance
a ttrib u te d to sociological care interventions by
nurses when compared with sociological care in t e r ­
vention ratings of c lie n ts .
Scoring o f the Instrument
Each response on the fiv e -p o in t scale fo r ra tin g o f importance
of items was assigned a numerical value.
These values ranged from four
(extremely im p o rta n t).to zero (no importance).
Items with no response
recorded were assigned a value o f zero.
White (1972) discusses her in vestig atio n into the treatment o f
data in th is manner.
Both Edwards (1957, p. 149) and L ik e rt (1932, pp. 25, f . )
describe th is method o f assigning weights to response categories
36
<
Y
on a ttitu d e scales. L ik e rt found th a t scores based on th is
method correlated .99 with the more complicated system o f normal
deviate weighting o f categories.®
Responses of each nurse and each c lie n t were coded according to
category by a system th a t permitted comparison o f each item and o f each
category o f items.
derived:
From the t a llie d CHNAT, the follow ing scores were
( I ) an "importance score" fo r each respondent on each item;
(2) an "importance score" fo r each respondent on each category o f items
was obtained by adding the scores o f a ll the items in the category;
(3) a series o f "disagreement scores" fo r each n u rs e -c lie n t p a ir was
computed by subtracting the nurse's importance score on each category
from th a t o f the c lie n t to whom i t re fe rre d ;
(4) two "mean importance
scores" were computed fo r each a c t iv it y , one based on c lie n t responses
and one derived from nurse responses;
and (5) two "mean importance
scores" were computed fo r each category o f a c t iv it ie s , one based on
c lie n t responses and the other derived from nurse responses.
Presentation o f Data
Table I was constructed in response to the f i r s t major null
hypothesis:
There is no s ig n ific a n t d ifference among categorized groups
o f selected a c t iv it ie s in the degree o f importance a ttrib u te d to them
by c lie n ts and/or nurses.
9Marguerite W hite, "Importance o f Selected Nursing A c tiv itie s ,"
Nursing Research, V o l. 21, No. I , 1973, p. 7.
Table I . Two-Tailed t Test Between Six Associations fo r Category "Mean Importance Scores"
by C lients and Nurses to Determine S ignificance o f Differences
Associa­
tio n No.
Category
to
Category
I
A to B
2.
A to C
3.
A to D
4.
B to C
5.
B to D
6.
C to D
Category
"Mean Importance
Scores"
C lients
Nurses
12.64
to
13.4
12.64
to
14.8
12.64
to
11.64
13.4
to
14.8
13.4
to
11.64
14.8
to
11.64
13.40
to
14.28
13.40
to
15.00
13.40
to
12.00
14.28
to
15.00
14.28
to
12.00
15.00
to
12.00
LEGEND fo r Categories:
C lients
Nurses
.05 .025 .01 .005
.05 .025 .01 .005
t Value
C lients
Nurses
-1.31
-1 .6 9
-3 .6 4
-2 .7 3
1.40
2.08
-2.69
-1 .6 3
*
*
3.30
4,99
*
*
*
4.68
6.00
*
*
*
*
*
*
A = physical care; B = psycho!ogiccaI care;
re la te d ; D = sociological care.
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
C = medical care
* = S ig nificance a t a le v e ls with 24 degrees o f freedom (see Table I T I , Fisher and Yates,
S t a tis tic a l Tables [Massey and Dixon, p. 4 6 4 ]).
38
The ta b le considers the s ix associations between categories as
stated in the minor hypotheses re la te d to the f i r s t major hypothesis.
The tw o -ta ile d t te s t was applied to determine i f the differences be­
tween the "mean importance scores" fo r categories by nurses and c lie n ts
were s ig n ific a n t.
A pplication o f the tw o -ta ile d t te s t produced t values in d ica­
tiv e o f s ig n ific a n t differences between the "mean importance scores"
fo r categories fo r nurses and also fo r c lie n ts .
According to Dixon
and Massey (pp. 119-121), the t te s t is most meaninfgul i f applied when
d iffe re n c e scores are computed and u t iliz e d fo r comparing means.
For
th a t reason the lowest level of sign ificance = .005 a v a ila b le from
Fisher and Yates' S ta tis tic a l Tables (Dixon and Massey, p. 464) was
chosen as the level of sign ificance th a t would be acceptable in th is
study.
These s ix associations produced t values in d ic a tiv e o f s ig n i­
fic a n t differences between the "mean importance scores" fo r categories
as rated by c lie n ts .in three associations and as rated by nurses in two
associations.
These differences w ill be discussed fu rth e r in the fin a l
chapter.
The observations obtained by comparing tw e n ty -fiv e community
health n u rs e -c lie n t "disagreement scores" are presented in Table 2.
Examination of the means, standard deviations and t scores show th a t
nurses and c lie n ts agreed more closely on Category C (medical care
39
Table 2.
Scores"9
D is trib u tio n o f 25 Community Nurse-Client "Disagreement
Nursing
A c tiv itie s
No.
of
Items
Possible
Range of
Scores
Actual
Range of
Scores
Mean
Scores
Standard
Deviation
t Values.
(24 d . f .)■
Category A:
Physical care
5
20 to -20
+8 to -8
.76
4.59
.827
NSc
Category B:
Psychological
care
5
20 to -20
+14 to -9
.88
4.49
.979
NS
5
20 to -20
+7 to -8
.20
3,96
.255
NS
5
20 to -20
+7 to -7
.36
3.37
.535
NS
Category C:
Medical care
related
Category D:
Sociological
care
aComputed by subtracting the nurse's score from.the c lie n t's score.
^ t values determined by consulting Table I I I 9 Fisher and Yates,
S ta tis tic a l Tables (Massey & Dixon, p. 464).
cNot s ig n ific a n t a t a = .05 or less.
40
re la te d ) and Category D (sociological care) items than they did on
Category A (physical care) and Category B (psychological care) a c t iv it y
i terns.
However, application o f the tw o -ta ile d t te s t fo r the comparison
o f the "mean disagreements scores" fo r each category determined no s ig ­
nifican ce a t the a = .05 level set by the researcher.
The most v a r ia b ilit y in n u rs e -c lie n t "disagreement scores" is
found in the ratings o f items descrip tive o f psychological care
a c t iv it ie s .
Figures I , 2, 3 and 4 display the d is trib u tio n o f the nursec lie n t "disagreement scores."
Since the "disagreement scores" were
computed by fin d in g the d ifferen ce between the nurses' score and the
c lie n ts ' paired w ith them, a score o f 0 depicts complete agreement by
the p a ir on items w ith in a category.
A p o sitiv e score displays th at
the nurse's ratings o f items fo r a category was higher;
tiv e score indicates th a t c lie n ts
while a nega­
rated the items in the category more
important than nurses.
Figures 1 , 2 , 3 and 4 depicting v a r ia b ilit y o f "disagreement
scores" fo r n u rs e -c lie n t pairs ratings o f categories display negatively
skewed d is trib u tio n s in Category A (p h y s ic a l) , Category C (medical
care re la te d ) and D (s o c io lo g ic a l).
is p o s itiv e ly skewed.
Category B (psychological care)
7
0
«%
If-
+ Scores
Scores
6
5
4
b 3
1 2
I
O
14
13
12
11
10
9 8 7 6 5 4 3 2 1
0
1
2 3 4 5 6 7 8 9
10
11
12
13
14
# Difference Between Sum Score for Category A
0 Scores = Perfect agreement ( N = I )
+ Scores = Nurse's score was higher (N = 16)
- Scores = C lient's score was higher (N = 8)
Figure I .
D is trib u tio n of 25 N urse-C lient "Disagreement Scores"* on Category A A c tiv itie s
(Physical Care - 5 items)
♦ "D is a g re e m e n t S c o re s " d i f f e r e n c e between n u r s e ' s c a t e g o r y s c o re and p a i r e d c l i e n t ’ s
c a te g o ry s c o re .
Example:
C l i e n t 16
C l i e n t 18
Nurse 18
Nurse 16
+ 2
n r
7
- Scores
6
+ Scores
CO
g 5
4
3
I
2
I
0
14
13
12
U
10
9
8
7
6
5 4
3
2
I
0
I
2
3 4
5
6
7 8
9
10
U
12
13
U
# Difference Between Sum Score for Category B
0 Scores = Perfect agreement ( N = I )
+ Scores = Nurse's score was higher (N = 15)
- Scores = C lient's score was higher (N = 9)
Figure 2. D is trib u tio n of 25 N urse-C lient "Disagreement Scores"* on Category B A c tiv itie s
(Psychological care - 5 Items)
♦ "D is a g re e m e n t S c o re s " d i f f e r e n c e between n u r s e ' s c a t e g o r y s c o re and p a ir e d c l i e n t '
c a te g o ry s c o re .
Exam ple:
C l i e n t 16
C l i e n t 18
Nurse 18
Nurse 16
T T
-
2
7
+ Scores
Scores
to
Z 5
3 4
0
V 3
O
J
M-
12
I
O
14
13
12
n
10
9 8 7 6 5 4 3 2 1
0
1
2
3 4
5
6
7 8
9
10
11
12
13
14
-F i
# Difference Between Sum Score for Category C
0 Scores = Perfect agreement (N = 4)
+ Scores = Nurse's score was higher (N = 12)
- Scores = Client s score was higher (N = 9)
Figure 3. D is trib u tio n o f 25 Nurse-C lient "Disagreement Scores"* on Category C A c tiv itie s
(Medical Care Related - 5 Items)
♦ "D is a g re e m e n t S c o r e s " d i f f e r e n c e between n u r s e ' s c a t e g o r y s c o re and p a i r e d c l i e n t ' s
c a te g o ry s c o re .
E xam ple: C l i e n t 16
C l i e n t 18
Nurse 18
Nurse 16
+ 2
-
2
co
+ Scores
14
13
12
11
10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9
10
11
12
13
14
# Difference Between Sum Score for Category D
0 Scores = Perfect agreement ( N = I )
+ Scores = Nurse's score was higher (N = 14)
- Scores = C lient's score was higher (N = 10)
Figure 4. D is trib u tio n of 25 Nurse-C lient "Disagreement Scores"* on Category D A c tiv itie s
(Sociological care - 5 Items)
♦ "D is a g re e m e n t S c o re s " d i f f e r e n c e between n u r s e ' s c a t e g o r y s c o re and p a i r e d c l i e n t ' s
c a te g o ry s c o re .
Example:
C l i e n t 16
C l i e n t 18
Nurse
18
Nurse 16
+ 2
-
2
45
As, Figure 3 disp lays. Category C (medical care re la te d ) a c tiv ­
it ie s were rated with p e rfe ct agreement by four pairs (16%), while each
o f the other categories display one p a ir (.04%) ra tin g the category
items in p erfect agreement.
The community n u rs e -c lie n t a c t iv it ie s were ranked with those
having a mean "importance score" o f 2.6 or above fo r the nurses being
displayed in Table 3 and c lie n ts being displayed in Table 4.
in
The items
Table. 5 display the rank order of individual a c t iv it y items with
a.mean score o f 2.6 or less and Table 6 being those rated by c lie n ts
with a mean score o f 2.6 or less.
Nurses rated th irte e n items with "importance scores" of 2.6
or above as a mean, while c lie n ts rated only eleven items with scores
averaging 2.6 or above.
Items TO and 12 o f the CHNAT are id e n tifie d
as being the items accounting fo r the d iffe re n c e .
However, the mean
"importance score) fo r items 1 0 .and 12 are 2.64 and 2 .9 6 , re sp ec tiv e ly ,
when rated by nurses compared to 2.32 as the mean score fo r both item s,
10 and 12, when rated by c lie n ts .
This display o f individual items was done to determine i f any
items could be considered "most important" or "le as t im portant."
White
(1972) displayed items in th is way choosing the 2.6 "mean importance
score" as the level fo r describing items as "most im portant."
Items in
White's study receiving a "mean importance score" o f 1.6 or less were
described as "le a s t im portant."
However, the findings in the present
46
T a b le 3.
Rank O rd e r o f N u r s in g A c t i v i t i e s
ta n c e S c o re " o f 2 .6 by Nurses
Item No.
o f CHNAT
Mean
Category* , Score
Rated Above a "Mean Im p o r­
Abbreviated Item
17
• C
3.32
Explain more f u lly what M.D. has said
20
C
3.32
Inquire about medical treatments and R^
I
C
3.12
Confer with other health professionals
3
D
3.08
Act as the c lie n t's advocate
8
B
3.08
Talk about a m edically-prescribed d ie t
19
A
3.08
P hysically examine the c lie n t
2
A
3.04
Talk with a c lie n t about how body works
6
B
3.00
Aware o f and ta lk about feeling s
9
C
2.96
Suggest the c lie n t see his doctor
12
B
2.95
Praise the c lie n t fo r good practices
13
D
2.87
Are aware o f the c lie n t's fin a n c ia l status
4
B
2.79
ID symptoms of anxiety or depression
10
D
2.64
Encourage c lie n t to ta lk about fam ily
*A = physical care
B = psychological care
C = medical care re la ted
D = sociological care
47
T a b le 4 .
Rank O rd e r o f N u r s in g A c t i v i t i e s
ta n c e S c o r e " o f 2 .6 by C l i e n t s
Rated Above a "Mean im p o r­
Item No
o f CHNAT
Category*
20
C
3.28
Inquires about m edically prescribed R%
I
C
3.20
Confers with other health professionals
19
A
3.04
Physically examines you
4
B
3.04
ID 's symptoms of anxiety or depression
17
C
3.00
Explains doctor more f u lly
8
B
3.00
Talks about m edically prescribed d ie t
13
D
2.96
Is aware o f fin a n c ia l status
9
C
2.95
Suggests you see doctor
3
D
2.76
Acts as your advocate
6
B
2.72
Is aware o f verbal and nonverbal feelings
2
A
2.64
Talks w ith you about how body works
Mean
Score
*A = physical care
B = psychological care
C = medical care re la te d
D = sociological care
Abbreviated Item
48
T a b le 5.. Rank O rd e r o f N u rs in g A c t i v i t i e s
ta n c e S c o re " o f 2 .6 by Nurses
Mean
Score
Rated Below a "Mean Im p o r­
Item No.
on CHNAT
Category*
7
A
2.48
Discuss "basic four" eating habits
18
A
2.44
Show a c lie n t how to do physical a c t iv it y
15
B
2.44
Help c lie n t value habits
16
A
2.36
Plan in making home hazard free
5
C
2.28
Talk about m edically-prescribed d ie t
14
D
1 .84
Give c lie n t information about groups
11
D
1.56
Discuss c h ild spacing and fam ily planning
*A = physical care
B = psychological care
C = medical care re la ted
D = sociological care
Abbreviated Item
49
T a b le 6.
Rank O rd e r o f N u rs in g A c t i v i t i e s
ta n c e S c o re " o f 2 .6 by C l i e n t s
Mean
Score
Rated Below a "Mean Im p o r­
Item No.
on CHNAT
Category*
7
A
2.52
Nurse discusses the "basic four"
C
2.36
Nurse ta lk s about a special d ie t
10
D
2.32
Nurse encourages you to ta lk about fam ily
12
B
2.32
Nurse praises fo r good health practices
15
B
2.32
Nurse helps you value good health habits ,
18
A
2.32
Nurse you how to do physical a c tiv ity
16
A
2.12
Nurse plans with you to make home safe
14
D
1.84
Nurse gives you information about groups
11
D
1.76
Nurse discusses c h ild spacing and fam ily
planning
5'
.
*A = physical care
B = psychological care
C = medical care re la ted
D = sociological care
Abbreviated Item
50
s t u d y a re n o t i n d i c a t i v e o f c l a s s i f y i n g ite m s i n such a way.
O nly one
it e m was r a t e d w i t h a "mean im p o rta n c e s c o r e " o f le s s th a n 1 . 6 .
Tables 7 and 8 display the percentages of items by category
rated above and below a "mean importance score" o f 2 .6 .
Two Category A
items (physical care) were found to have a "mean importance score" th a t
represented 15% o f items being rated more than medium importance.
Both
Category B (psychological care) and Category C (medical care re la te d )
items appeared 4 times (31% o f a ll items) in the more than medium im­
portance or above 2.6 mean score ranking.
Sociological care items
(Category D) appeared 3 or 23% of a ll items in the more than medium
importance ranking.
Summary
Two major null hypotheses were used to guide the c o lle c tio n ,
tab u latio n and analysis o f data obtained from responses given to the
CHNAT.
Since the study is a p a rtia l re p lic a tio n o f W hite's 1972 study,
th a t study was also used as a guide fo r presentation o f and analysis o f
data.
However, a second majdr hypothesis and minor hypotheses allowed
fu rth e r refinem ent.
The findings from the analysis o f data are summarized and d is ­
cussed in Chapter 5.
51
Table 7. Percentage o f Items by Category Receiving a."Mean Importance
Score" o f 2.6 or Above by Nurses and C lients
Percentage
Nurse
Cl ie n t
Category A
Physical care
15
18
Category B
Psychological care
31
37
Category C
Medi cal care re I ated
31
37
Category D
Sociological care
23
18
Table 8. Percentage o f Items by Category Receiving a "Mean Importance
Score" o f 2.6 or Less by Nurses and C lients
Percentage
Nurse
C lie n t
Category A
. Physical care
43
34
Category B
Psychological care
14
22
Category C
Medical care related
14
11
Category D
Sociological care
29
33
CHAPTER 5
SUMMARY, FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
Summary
■
The problem considered in the study was, were there s ig n ific a n t
differences between community health n u rs e -c lie n t importance ratings o f
selected nursing a c tiv itie s ?
The problem was fu rth e r subdivided into
differences between c lie n t and nurse ratings in re la tio n to selected
physical, psychological, medical care re la te d and sociological needs
met through community health nursing a c t iv it ie s .
The questions investigated were:
1.
Are there differences in the degree of importance community
health nurses a ttrib u te to categories o f selected nursing a c tiv itie s ?
2.
Are there differences in the degree of importance community
health c lie n ts a ttrib u te to categories o f selected nursing a c tiv itie s ?
3.
Are there differences when community health nurses' ratings
are compared to c lie n ts ' ratings?
The f i r s t major null hypothesis corresponds to the f i r s t two
questions.
The second major null hypothesis corresponds to the th ird
question.
To fu rth e r re fin e data a n a ly s is , minor null hypotheses were
generated fo r each major null hypothesis.
Findings
The f i r s t major null hypothesis stated th a t there were no d i f ­
ferences among categorized groups of a c t iv it ie s in the degree of
53
importance a ttrib u te d to them by c lie n ts and/or nurses'.
This was fu r -
th e r divided to allow s ix associations between category "mean importance
scores" to be tested fo r sig n ifican ce by the tw o -ta ile d t te s t (see
Table I , p. 3 7 ).
The f i r s t major null hypothesis was accepted.
By ranking the category "mean importance scores," i t was d e te r­
mined th a t both nurses and c lie n ts rated medical care re la te d a c t iv it ie s
as most important.
Psychological care a c t iv it ie s were ranked second
with physical care a c t iv it ie s th ird and sociological care a c tiv itie s
fo u rth .
In the previous chapter, s t a tis t ic a l computations were reported
in terms o f six associations fo r c lie n t and nurse category "mean impor­
tance scores."
The associations were determined by the s ix minor null
hypotheses re la te d to the f i r s t major null hypothesis.
These are as
fo llo w s :
1.
There is no d iffe re n c e in the degree of importance a t t r i b ­
uted to physical care a c tiv it ie s as rated by c lie n ts and/or nurses when
compared with psychological care a c t iv it ie s .
2.
There is no d ifference in the degree of importance a t t r i b ­
uted to physical care a c t iv it ie s as rated by c lie n ts and/or nurses when
compared with medical care a c t iv it ie s .
3.
There is no d iffe re n c e in the degree o f importance a t t r i b ­
uted to physical care a c t iv it ie s as rated by c lie n ts and/or nurses when
compared with sociological care
a c t iv it ie s .
54
4.
There is no d ifferen ce in the degree o f importance a t t r i b ­
uted to psychological care a c t iv it ie s as rated by c lie n ts and/or nurses
when compared with medical care a c t iv it ie s .
5.
There is no d iffe re n c e in the degree of importance a t t r i b ­
uted to psychological care a c t iv it ie s as rated by c lie n ts and/or nurses
when compared with sociological care re la te d a c t iv it ie s .
6.
There is no d ifferen ce in the degree o f importance a t t r i b ­
uted to medical care a c t iv it ie s as rated by c lie n ts and/or nurses when
compared to sociological a c t iv it ie s .
For c lie n ts the associations were determined s ig n ific a n t in
minor hypotheses #2, #5 and #6.
Analysis of nurses' ratings by a p p li­
cation o f the t te s t to category "mean importance scores" determined
s ig n ific a n t differences in minor hypotheses #5 and #6.
In c lie n t associations, s ig n ific a n t differences were found
between a c t iv it ie s d e scrip tive o f:
( I ) physical care ratings being
lower than psychological care ra tin g s ;
(2) psychological care ratings
being rated higher than sociological care ra tin g s ; and (3) medical care
re la te d a c t iv it ie s being rated higher than sociological care a c t iv it ie s .
S ig n ific a n t differences in the associations when considering a c t iv it ie s
as rated by nurses are the same as #2 and #3 lis te d above fo r c lie n ts .
The six association analyses determined th a t there was no s ig ­
n ific a n t d iffe re n c e in the ratings o f the two highest ranked items when
categories were considered by "mean importance scores";
those two
55
categories being medical care re la te d and psychological care a c t iv it ie s .
Likewise, there were no s ig n ific a n t differences between the ratings o f
the two lowest ranked categories--physical care and sociological c a re -in e ith e r nurses' or c lie n ts ' ra tin g s .
The second major null hypothesis s ta tin g th a t there is no s ig ­
n ific a n t d iffe re n c e between the degree o f importance community health
nurses a ttr ib u te to selected a c tiv it ie s when compared to the level o f
importance c lie n ts a ttr ib u te to the same categories o f a c t iv it ie s was
tested and accepted.
No s ig n ific a n t differences were found in associa­
tions between the minor hypotheses u t iliz e d fo r o p era tio n alizin g te s tin g
procedures of the second hypothesis (see Table 2, p. 3 9 . ) .
Discussion o f Findings
Nursing is described as being composed o f independent and
dependent functions.
The dependent functions are delegated by the
physician and re la te d to medical care in it ia t e d regimes.
are nearly always oriented toward e ffe c tin g cure.
These regimes
Independent nurse
functions are more preventative in nature and deal w ith meeting persons'
psychologically-derived
applied
needs.
These
to the community health n u rs e -c lie n t
w ith in the present study.
d e fin itio n s
a c t iv it ie s
were
rated
Since the community health nurse is dealing
with a person residing w ithin the society rath er than in an in s t it u ­
tio n a l s e ttin g , meeting sociological needs related to his health status
also becomes a function o f her r o le .
While th is sociological ro le was
56
rated lower than the other c a teg o ries, i t s t i l l received mean ratings
above medium importance.
The three categories of community health nursing a c tiv itie s
defined as physical care, psychological care and sociological care in
the study contain items descrip tive o f independent nurse functions.
It
is in te re s tin g to note th a t both nurses and c lie n ts in the study sample
rated a il three o f these categories with less importance than dependent
functions.
While community health nurse educators and a u th o ritie s emphasize
the autonomy enjoyed by community health nurses, the findings of data
in
th is
study
sample do not
v e rify
th a t
the c lie n t or the
nurse h e rs e lf view the nurse's ro le as being highly independent.
Freeman (1970) believed
th a t c lie n ts do not perceive non­
tangible supportive acts as valuable as nursing a c tiv ite s directed
toward providing personal care to the s ic k .
This statement by Freeman
was not v e rifie d by findings o f the data collected in the present study.
While ranking o f "mean importance scores" fo r categories showed medical
care re la te d a c t iv it ie s ranked highest, there was no s ig n ific a n t d i f f e r ­
ence in the mean score fo r the psychological care category when the two
were compared.
Freeman also discusses the ro le o f the nurse as being a " w illin g
advocate;"
While the study items do not lend themselves well to a com­
parison o f the d e fin itio n o f th a t r o le , i t is of in te re s t to note th a t
57
nurses rated the item in the study describing the nurse as the c lie n ts '
advocate with a mean score of 3.08 while c lie n ts rated the same item
with a mean score o f 2.76,
Freeman's assertion th a t the community health nurse is expected
to be a "sensitized observer" seems to be confirmed by the study sample
ra tin g s .
Items describing the nurse ph ysically examining the c lie n t,
being aware o f feelin g s and id e n tify in g symptoms o f anxiety or depres­
sion were a ll rated with a mean score above the medium importance ra tin g
by a ll respondents.
While some differences were found between the degree o f impor­
tance nurses and c lie n ts a ttrib u te d to defined categories o f care, no
s ig n ific a n t d iffe re n c e was found when the t te s t was applied to paired
nurses' and c lie n ts ' ratings o f the same categories o f a c t iv it ie s .
It
is a p o s s ib ility th a t the differences found between ratings o f cate­
gories is a re s u lt o f study mechanics.
This is discussed with recom­
mendations fo r Elim ination of th is p o s s ib ility in the Conclusions and
Recommendations.
Study re su lts indicated a high degree of agreement between
c lie n ts and nurses regarding the same nursing a c tiv it ie s in the study
samples.
However, as is discussed in the Conclusions, these findings
are not generalizable to a la rg e r population.
58
Conclusions and.Recommendations
Both in tern a l and external v a lid it y factors a ffe c t drawing con­
clusions other than those considered in the discussion o f the findings
r e la tiv e to the study sample populations.
I t is recommended th a t the
present study and it s resu lts be u t iliz e d fo r conducting a more rig o r­
ous re p lic a tio n .
The follow ing recommendations are made to f a c ili t a t e
such a re p lic a tio n .
Some elements o f the design o f the data c o lle c tio n instrument
lim it conclusions th a t can be drawn and in ferre d from the present study.
While examples o f s p e c ific a c tiv it ie s in the CHNAT items may have
c la r if ie d them, i t is also possible th a t respondents' ratin g s were
influenced by the examples ra th e r than the actual in te n t o f the item.
A recommendation is made to fu rth e r develop the tool so th a t a ll examexamples in items can be elim inated .
S p e c ific a lly , CHNAT items #9, 14,
15, 18 and 19 require fu rth e r fu rth e r s c ru tin y.
This recommendation
o rig in ates from review o f m aterial re la te d to development o f question­
naire items as well as p retest c lie n ts ' comments on the reaction sheet
d is trib u te d with the CHNAT.
Personal d is trib u tio n o f the tool to respondents allowed the
researcher to observe respondent behaviors th a t fu rth e r v e rifie d th is
in tern a l v a lid it y concern.
Other recommendations fo r e lim in atio n of facto rs a ffe c tin g
in tern a l v a lid it y are as. follow s:
59
A.
More extensive lit e r a t u r e content analysis to id e n tify unique
community nurse a c t iv it ie s advocated as essential to an
e ffe c tiv e n u rs e -c lie n t re la tio n s h ip should be done.
1.
These a c t iv it ie s could then be assigned to categories
id e n tifie d and defined from the lit e r a t u r e review.
2.
A s ta tis t ic a l weighting procedure could be used to
determine i f the categories are equally-weighted as
divisions o f nursing care advocated to be meaningful
in an e ffe c tiv e community n u rs e -c lie n t re la tio n s h ip .
This would allow a more v a lid in te rp re ta tio n of the
sig n ifican ce of the ratings assigned to categories.
The assignment o f equal numbers o f a c tiv it ie s to each
category, as was done in the present study, gives the
appearance th at a ll categories are
judged
to be
equal in weight r e la tiv e to th e ir p r io r it ie s fo r an
e ffe c tiv e re la tio n s h ip to occur.
B.
A c tiv ity ra tin g responses could be defined in more s p e c ific
terms than degrees o f importance.
Respondents could be
asked to ra te the item 's as essential or not essential to
meeting the s p e c ific c lie n t 's needs.
The design and methods used in the study r e s t r ic t the external
v a lid ity of the study.
A fte r refinement o f the data c o lle c tio n instrum ent, a much
60
la rg e r sample o f community health nurses and c lie n ts should be drawn to
elim in ate bias th a t is always inherent in c lin ic a l research.
Descrip­
tiv e research regarding variables a ffected by as many extraneous factors
as are present in the n u rs e -c lie n t re la tio n s h ip require an extremely
large number o f sampling u n its .
The selection o f large random samples
of community health nurses and c lie n ts as respondents would make fu rth e r
conclusions possible, leading to v a lid inferences.
The t te s t fo r te s tin g s ig n ifican ce of associations between data
resu lts is appropriate with paired data.
However, use o f more sophis­
tic a te d s t a tis t ic a l procedures such as analysis o f variance would lend
much support to data analysis o f the proposed re p lic a tio n study.
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APPENDIX A
66
Montana State University
SCHOOL OF
Dear
I
S
o
a
a
a
C o m m u n ity
Bozem an, M o n ta n a 5 9 7 1 5
N U R S IN G
H e a lth
A ugust
N u rs in g
11,
T e l. 4 0 6 - 9 9 4 - 0 2 1 1
1977
P ra c titio n e r:
am a g r a d u a t e s t u d e n t i n C o m m u n ity H e a l t h N u r s i n g a t M o n t a n a S t a t e U n i v e r s i t y
c h o o l o f N u rs in g .
I am w r i t i n g t o a s k y o u r a s s i s t a n c e i n e s t a b l i s h i n g t h e d e g r e e
f v a l i d i t y i n q u e s t i o n s I am p r o p o s i n g t o u s e i n a r e s e a r c h s t u d y .
The q u e s tio n s
re m a in ly b a s e d u p o n a r e v ie w o f C o m m u n ity H e a lt h N u r s in g l i t e r a t u r e .
I have
tte m p te d t o in c lu d e q u e s t io n s t h a t a re i n c l u s i v e o f m o s t C o m m u n ity H e a lt h N u r s in g
c t iv i t i e s a d v o c a te d b y a u th o rs and b a s ic a lly a p p lic a b le to any age c li e n t .
S in c e th e ite m s h a v e b e e n c o n s tr u c te d m a in ly fro m l i t e r a t u r e r e v ie w , I n e e d a
c r i t i q u e o f th e m b y e x p e r t C o m m u n ity H e a lt h N u r s in g p r a c t i t i o n e r s r e l a t i v e to th e
q u e s tio n s ' d e g re e o f a p p ro x im a tio n to a c tu a l d a ily p r a c tic e .
As a d a ily p ra c ­
t i t i o n e r o f C o m m u n ity H e a lt h N u r s in g , y o u a re s u c h an e x p e r t .
S in c e C o m m u n ity
H e a lth N u rs in g i s a s p e c ia lt y , we n e e d re s e a rc h e f f o r t s d ir e c t e d a t v a lid a t in g o u r
u n iq u e p r a c t ic e s .
I h o p e th a t yo u w i l l a s s is t me in t h is e f f o r t .
Som e h o s p it a l s t u d ie s h a v e b
o f im p o rta n c e th e y h o ld f o r
p ro fe s s io n a l r e la tio n s h ip .
N u rs in g A c t i v i t i e s , " N u rs in g
o f t h is ty p e a llo w n u rs in g p
tio n s th e y may i n it ia t e w i ll
k in d a llo w s th e n u rs e to in d
a d v a n ta g e .
e e n done w h e re p a tie n ts and n u rs e s e a ch r a te d th e le v e l
c e r t a in n u rs in g a c ts t h a t m ay h a ve o c c u rre d d u rin g t h e ir
(S e e W h ite , M a r g u e r ite U ., " Im p o rta n c e o f S e le c te d
R e se a rch . S a n u a ry -F e b ru a ry , 1972, pp , 4 -1 3 ).
S tu d ie s
r a c titio n e r s to b e tte r p re d ic t how v a rio u s in te rv e n ­
be re c e iv e d by som e c lie n t s .
A p re d ic tio n o f th is
iv id u a liz e h e r c a re and use h e r s k ills to th e b e s t
S in c e a s tu d y o f t h i s ty p e h a s n o t b e e n d o n e i n th e C o m m u n ity H e a lt h N u r s in g s e t t in g ,
I w o u ld l i k e t o c o n d u c t o n e .
The q u e s tio n s I h a ve com posed to be p re s e n te d to n u rs e c l i e n t p a ir s f o r r a t in g a s to le v e l o f im p o rta n c e a re on th e f o llo w in g p a g e s .
I am a s k i n g y o u r a s s i s t a n c e i n t h r e e a r e a s :
F ir s t, on th e a tta c h e d li s t i n g o f
n u r s in g a c t i v i t i e s , ju d g e e a c h ite m a s to how c lo s e ly i t a p p ro x im a te s n u r s in g in t e r ­
v e n t io n s i n i t i a t e d d a i l y i n C o m m u n ity H e a lt h N u r s in g p r a c t i c e .
The in s tr u c tio n s a re
a t th e to p o f th e C o m m u n ity H e a lth N u r s in g A c t i v i t i e s T o o l.
A t th e end o f th e
q u e s tio n s to be r a t e d , y o u w i l l f in d a sp a ce w h e re y o u c a n com m e nt o r a d d ite m s t h a t
y o u b e lie v e s h o u ld be in c lu d e d .
T h i s i s t h e s e c o n d t h i n g I am a s k i n g y o u t o d o .
T he t h i r d m a tte r I w o u ld l i k e y o u to co m m e n t o n i s w h e th e r o r n o t y o u f e e l th e ite m s
a s s ta te d a re a c c e p ta b le an d u n d e rs ta n d a b le to th e m a jo r ity o f c li e n t s yo u w o rk w ith .
I f y o u h a v e c o m m e n ts r e l a t e d to t h is , p le a s e p la c e th e m in th e m a rg in a re a .
Y ou r c o o p e ra tio n is s in c e r e ly a p p re c ia te d .
P le a s e r e t u r n th e
c o m m e n ts i n th e s e lf- a d d r e s s e d , s ta m p e d e n v e lo p e p r o v id e d .
Y o u rs
q u e s tio n s
w ith
your
tr u ly ,
3udy G e d ro se , R .N ., B .5 .N .
29 G la c ie r C o u rt
B o ze m a n , M o n ta n a
59715
3 u d y G e d ro s e is c u r r e n t ly r e g is t e r e d a s a f u l l tim e s tu d e n t in
P ro g ra m .
Any a s s is ta n c e and c o o p e ra tio n y o u c a n g iv e h e r w i ll
th e M a s te r o f N u rs in g
be a o p re c ia te d .
- 1J f-
Anna
M.
Shannon,
R .N .,
i* I - i i
D.N.S.
.~7 { ' / a
,
67
C O M M U N IT Y
HEALTH
A C T IV IT IE S
In s tru
you in
s c a le
c o n s tr
ite m s
c tio n s :
O udg
it ia t e d a ily
to in d ic a te y
u c tio n o f th e
you fe e l a re
P h y s ic a l
I.
F a re
e e a c h i t e m a s t o h o rn c l o
i n y o u r c o m m u n ity h e a lt h
o u r ju d g m e n t.
C o m m e n ts r
ite m ca n be m ade in th e
p e r tin e n t is p ro v id e d a t
fts o e c ts
o f
The n u rse p h y s ic a lly
ta k e b lo o d p re s s u re ,
C o m m u n ity
H e a lth
N U R S IN G
TOOL
s e ly i t a p p ro x im a
n u rs in g p r a c tic e .
e la t iv e to th e u n
m a rg in s .
A space
th e e n d o f th e ite
N u rs in g
te s in te rv e n tio n s
M a rk an X on th e
d e rs ta n d e b ility and
fo r a d d itio n o f
m s t o be ju d g e d .
P ra c tic e :
e x a m in e s th e c l i e n t o r a f a m il y
ch e ck th e m ovem ent in a p a in fu l
m em ber
lim b .
C lo s e ly
N ot
A p p ro x im a tin g
C lo s e ly
to
see
a ra sh ,
JL_______ I________ I_________I_________L
2.
The
new
n u rse
baby,
show s a c lie n t how to do a p h y s ic a l a c t iv it y such as b a th in g
a p p ly in g a s a lv e , c h a n g in g a d r e s s in g , o r a d ju s t in g a b ra c e .
C lo s e ly
N ot
A p p ro x im a tin g
C lo s e ly
3.
The
h im
n u rs e ta lk s w ith
and o th e r fa m ily
flo s e ly
,
a c lie n t
m e m b e rs.
about
how
he
can
m ake
h is
,
N ot
I_______________I_____________ I_______________I
The
and
I
w ith
a c lie n t
,
re g a rd in g
,
th e
N ot
A p p ro x im a tin g
5.
fo r
,
C lo s e ly
N u rse d is c u s s e s n u t r it io n
h e a lth fu l e a tin g h a b its .
jjllo s e ly
s a fe r
___________ !_
A p p ro x im a tin g
4.
hom e
a
"b a s ic
fo u r
fo o d s "
^I*
C lo s e ly
The n u rs e ta lk s w ith a c lie n t
go od h e a lth o r in r e la tio n to
a b o u t how h is o r h ie
a s p e c ific d is e a s e .
C lo s e ly
c h ild 's
body
w o rks
in
N ot
I
_____________I______________I_______________ L
A p p ro x im a tin g
-
C lo s e ly
P s y c h o lo g ic a l
A s p e c ts
o f
I.
p ra is e s
th e
The
n u rse
C o m m u n ity
c lie n t
H e a lth
fo r
good
N u rs in g
h e a lth
P ra c tic e :
p ra c tic e s
he
is
C lo s e ly
N ot
Approximating
Closely
a lre a d y
u s in g .
68
2
2.
Thg n u rs e e n c o u ra g e s th e c lie n t to
lif e
and th e s ta te o f h is h e a lth .
ta lk
about
h is
fe e lin g s
c o n c e rn in g
C lo s e ly
Not
I
*
I
t
I
A p p ro x im a tin g
3.
C lo s e ly
The n u rs e t r i e s to d e te rm in e th e c l i e n t ' s u s u a l l i v i n g p a tt e r n b y d is ­
c u s s in g t h i s w ith h im a n d h e lp s h im m ake a d ju s tm e n ts i f th e y a re n e c e s s a ry
fo r h is h e a lth .
N ot
C lo s e ly
I
I
A p p ro x im a tin g
A.
!
I
I
C lo s e ly
The n u rs e h e lp s th e
in h is li f e
nou' a n d
c lie n t
in th e
s e e h o rn g o o d
fu tu re .
h e a lth
p ra c tic e s
I
I
I
The n u rs e le ts th e
r e a lly u n d e rs ta n d s
c lie n t know , th ro u g h
how th e c lie n t fe e ls
spe ech and a c tio n s , th a t she
about h is lif e
and h e a lth .
N ot
I
I
I
I
I
A p p ro x im a tin g
C a re
C lo s e ly
R e la re c
The n u rse
ab ou t h is
A s p e c ts
e x p la in s
h e a lth .
m o re
o f
C o m m u n ity
fu lly
H e a lth
s o m e th in g
th e
N u rs in g :
c lie n t's
d o c to r
C lo s e ly
I
I
I
is ta k in g
a c tin g in
I
I
I
A p p ro x im a tin g
C lo s e ly
The n u rs e ta lk s w ith
p r e s c r ib e d f o r h im .
Approxinecirg
o r o th e r tr e a t­
th e e x p e c te d way
N ot
I
C lo s e ly
t
h im
I
C lo s e ly
3.
to ld
C lo s e ly
T he n u rs e in q u ir e s a b o u t th e m e d ic in e s th e c l i e n t
m e n ts he i s p r a c t i c in g a t hom e to se e i f th e y a re
I
has
Not
I
A p p ro x im a tin g
2.
h e lp fu l
C lo s e ly
C lo s e ly
I.
be
i
l
A p p ro x im a tin g
M e d ic a l
w ill
Not
C lo s e ly
5.
h is
th e
c lie n t
about
a
s p e c ia l
d ie t
th e
d o c to r
has
N ot
I
I
I
—I____
Closely
69
3
4.
The n u rs e s u g g e s ts th e c lie n t
p re v e n ta tiv e m e a su re s su ch as
see h is d o c to r a b o u t a h e a lth p ro b le m
im m u n iz a tio n s o r a y e a r ly c h e c k -u p .
C lo s e ly
I
I
)
I
A p p ro x im a tin g
The n u rse
fe s s io n a l
C lo s e ly
s u g g e s ts th e c lie n t d is c u s s r e f e r r a l to a n o th e r h e a lth
such as a m e n ta l h e a lth w o rk e r o r a s o c ia l w o rk e r w ith
C lo s e ly
I
I
1.
The
p ro h is d o c to r
N ot
I
I
I
A p p ro x im a tin g
S o c ia l
fo r
N ot
I
5.
or
C a re
C lo s e ly
a s p e c ts
n u rse
o f
d is c u s s e s
C o m m u n ity
c h ild
H e a lth
s p a c in g
N u rs in g
and
P ra c tic e :
fa m ily
p la n n in g
w ith
th e
c lie n t.
C lo s e ly
N ot
A p p ro x im a tin g
C lo s e ly
I
2.
The n u rs e g iv e s th e c lie n t in fo rm a tio n
W e ig h t W a tc h e rs , A lc o h o lic s A n o n y m o u s ,
p e rs o n a l g ro w th g ro u p .
a b o u t g ro u p s he
P re p a ra tio n fo r
m ig h t jo in , s u c h
C h ild h o o d o r a
N ot
C lo s e ly
I
I
I
I
I
A p p ro x im a tin g
3.
C lo s e ly
The n u rs e e n c o u ra g e s th e c lie n t
f a m ily m e m b e rs a n d . f r ie n d s .
to
ta lk
about
how
he
g e ts
I
I
I
w ith
The n u rse
w ith h im .
C lo s e ly
d is c u s s e s
th e
fin a n c ia l
im p lic a tio n
o f
th e
c lie n t's
h e a lth
ca re
N ot
C lo s e ly
<
I
I
I
I
C lo s e ly
A p p ro x im a tin g
The n u rs e d is c u s s e s h is liv in g
m ig h t a f f e c t h is h e a lth .
a rra n g e m e n ts
w ith
th e
c lie n t
and
how
C lo s e ly
N ot
Approximating
Closely
A d d itio n a l
o th e r
I
I
A p p ro x im a tin g
5.
a lo n g
Not
C lo s e ly
4.
as
ite m s
and
c o m m e n ts :
(U se
re v e rs e
o f
th is
sheet
i f
Total length of employment as a Community Health Nurse
needed)
th is
APPENDIX B
71
Montana State University---------------------------Bozeman, Montana 59715
Tel. 406-994-0211
September 11, 1977
Dear Community Health Nursing Practitioner:
I am a graduate student in Community Health Nursing at Montana State University
School of Nursing. I am writing to ask your assistance in establishing the degree
of v a lid ity in items I am proposing to use in a research study. I am also asking
your help in judging the correctness of placement of the questions within four (4)
major categories descriptive of Community Health Nursing a c tiv itie s . The task
takes approximately 15 minutes.
Since the items have been constructed mainly from lite ra tu re review, I need a
critique of them by expert Community Health Nursing P racticitioners, such as
you. Being a daily p ractitio ner, you are an expert regarding how closely the
items I have constructed actually approximate your daily practice.
Some hospital studies have been done where patients and nurses each rated the
level of importance they hold for certain nursing acts that may have occurred
during th e ir professional relationship. Studies of this type allow nursing
practitioners to better predict how various interventions they may in itia te w ill
be received by some c lie n ts . The uniqueness of Community Health Nursing practice
precludes direct transfer of hospital based nursing research studies to the com­
munity setting. Therefore, I would lik e to conduct a similar study within a
Community Health Nursing agency u tiliz in g items within the questionnaire descrip­
tive of Community Health Nursing a c tiv itie s . The items you are being asked to
judge are a basis for development of the questionnaire to be used when both
nurses and clients w ill be asked to rate the importance of a c tiv itie s that may
have occurred.
Analysis of the data received through the questionnaire w ill be done by group­
ing various items into four (4) major categories descriptive of Community Health
Nursing a c tiv itie s . The categories are: Physical Care Related Aspects, Psycho­
logical Care Related Aspects, Medical Care Related Aspects and Sociological Care
Related Aspects. I have placed the items within the categories I feel are most
descriptive of th e ir major in ten t. I am asking you to conduct a task sim ilar to
a Q-Sort to determine the v a lid ity of my placement of the items within the cate­
gories.
Enclosed you w ill find a packet containing the materials to perform the judging
of the items as to how closely they approximate your daily practice and to per­
form the task sim ilar to a Q-Sort for establishing the placement of the items in
the four main categories. The instructions are on the front of this packet.
We, as Community Health Nursing Practitioners, need research that is apropos to
our unique practices. Your time in helping me accomplish this is greatly appre­
ciated.
Yours tfu ly ,
Judy3Getirose, R.N., B.S.N.
************
Judy Gedrose is currently registered as a fu ll-tim e student in the Master of
Nursing program. Any assistance and cooperation you can give her w ill be appre-
ciated-
___
Anna M. Shannon, R.N., D.N.5.
72
COMMUNITY HEALTH NURSING
ACTIVITIES TOOL
PACKET
INSTRUCTIONS: Within th is
s lip s . Each one ca rrie s a
Nursing a c t iv it y . You w ill
each envelope you w ill see
categories I have selected
Nursing.
packet you w ill fin d tw enty-three (23) item
statement d escriptive o f a Community Health
also fin d four (4) yellow envelopes. On
the d e fin itio n o f one of the four (4) major
as being illu s t r a t iv e of Community Health
To conduct the ta s k , please follow these steps:
1. Lay out the four (4) envelopes on a f l a t surface in fro n t
o f you.
2. Remove the staple holding the twenty-three (23) item slip s
so you can consider each separately.
3. Judge each item as to how closely i t approximates in t e r ­
ventions you i n i t i a t e d a ily in your Community Health Nursing
p ra c tic e.
4. Mark an X on the fo u r-p o in t scale below the item to
in d icate your judgment o f each item from Closely Approxi- ■
mating to Not Closely.
5. Place the item s lip w ith in one ( I ) of the four (4) envelopes
provided to in d icate your judgment o f which major category
o f Community Health Nursing practice the item illu s t r a te s .
6. Repeat th is process fo r a ll twenty-three (23) items.
When you have completed the judging o f the items and placed them a ll
w ithin a category envelope, in s e rt them in the stamped, self-addressed
envelope provided and return them by mail to me. Thank you!
73
CATEGORY DEFINITIONS APPEARING ON ENVELOPES
FOR SORTING PROCEDURE #1 BY EXPERT JUDGE GROUP #2
PHYSICAL CARE RELATED ASPECTS:
The items w ithin th is category depict
interventions th a t are nursein it ia t e d to f a c i l i t a t e the c lie n t
meeting his basic physiological and
safety needs.
PSYCHOLOGICAL CARE RELATED ASPECTS:
This category includes items des­
c r ip tiv e of nursing interventions
th a t are in it ia t e d in an e f f o r t to
.
promote individual c lie n t growth.
These are usually in tan g ib le and
occur as a communication process
between nurse and c lie n t r e la tiv e to
emotions, values and goals.
MEDICAL CARE RELATED ASPECTS:
This category includes items r e la tiv e
to interventions usually in itia te d by
or re la ted to other health profes­
sion als.
SOCIOLOGICAL CARE RELATED ASPECTS:
This category contains items d e p ict­
ing in te ra c tio n process interventions
concerning the c lie n t 's relationsh ips
with others and his l i f e as a social
being.
74
The n u rs e i s
th e
aware o f th e c l i e n t s
c l i e n t r e c e iv e
h is
f i n a n c i a l s t a t u s and a tte m p ts t o
h e lp
h e a lt h c a re i n th e m ost c o s t e f f i c i e n t m an n e r.
N ot
C lo s e ly
I
A p p r o x im a tin g
I
J
! _
2
J
I
C lo s e ly
4
5
The n u rs e shows a c l i e n t how t o do a p h y s ic a l a c t i v i t y
su ch as b a t h in g a
new b a b y , a p p ly in g a s a lv e , c h a n g in g a d r e s s in g o r a d ju s t in g a b r a c e .
C lo s e ly
I _______
A p p r o x im a tin g
I
I
I
2
N ot
I
C lo s e ly
4
5
The n u rs e s u g g e s ts th e c l i e n t see h is d o c t o r a b o u t a h e a lt h p ro b le m o r f o r
p r e v e n t a t iv e m easures su ch as im m u n iz a tio n o r a y e a r ly c h e c k -u p .
Not
C lo s e ly
I
I
A p p r o x im a tin g
I
I
2
The n u rs e g iv e s t h e
I
C lo s e ly
I
4
5
c l i e n t in f o r m a t io n a b o u t g ro u p s he m ig h t j o i n ,
su ch
as W e ig h t W a tc h e rs , A lc o h o lic s Anonym ous, P r e p a r a tio n f o r C h ild b e a r in g o r
a p e rs o n a l g ro w th g ro u p .
C lo s e ly
N ot
I
A p p r o x im a tin g
I
I
I
2
r e la tio n t o
C lo s e ly
4
5
The n u rs e t a l k s w i t h a c l i e n t a b o u t how h is
good h e a lt h o r i n
I
o r h is c h i l d 1's body w o rk s i n
a s p e c i f i c d is e a s e .
C lo s e ly
N ot
I
A p p r o x im a tin g
I
I
I
2
The n u rs e e x p la in s more f u l l y
I
^
|
C lo s e ly
3
s o m e th in g t h e
c lie n t 's
d o c t o r has t o l d
him
a b o u t h is h e a lt h .
C lo s e ly
.
Not
I
A p p r o x im a tin g
I
2
___
5
C lo s e ly
I
75
The n u rs e e n c o u ra g e s th e c l i e n t t o t a l k a b o u t how he g e ts a lo n g w i t h
o t h e r f a m il y members and f r i e n d s .
Not
C lo s e ly
I
I
J
A p p r o x im a tin g
I
J
2
4
3
w it h a c l i e n t r e g a r d in g th e
The n u rs e d is c u s s e s n u t r i t i o n
I
C lo s e ly
" b a s ic f o u r
fo o d s " and h e a l t h f u l e a t in g h a b it s .
N ot
C lo s e ly
I
A p p r o x im a tin g
I
I
..................
I
I
C lo s e ly
2
The n u rs e s u g g e s ts th e
4
3
c l i e n t d is c u s s r e f e r r a l t o
I
a n o th e r h e a lt h p r o f e s s -
io n a l s u c h as a m e n ta l h e a lt h w o rk e r o r a s o c ia l w o rk e r w it h h is d o c t o r .
Not
C lo s e ly
I
I
A p p r o x im a tin g
'
I
I
^
^
C lo s e ly
I
3
The n u rs e i d e n t i f i e s
symptoms o f p ro b le m s su ch as a n x ie t y o r d e p re s s io n
t h a t s h o u ld be r e p o r t e d t o th e c l i e n t ' s
to
d o c t o r and may le a d t o
re fe rra l
a m e n ta l h e a lt h w o r k e r o r a m e d ic a l s o c ia l w o r k e r .
Not
C lo s e ly
I
I
I
C lo s e ly
I p p r o x im a t in g
The n u rs e i s
aware o f v e r b a l o r n o n - v e r b a l e x p re s s io n s o f f e e lin g s th e
c l i e n t may d is p la y r e g a r d in g h is
e n c o u ra g e s t h e
c lie n t t o ta lk c
life
and th e
s ta te
o f h is h e a lt h and
about th e s e .
C lo s e ly
N ot
I
A p p ro x im a tin g
JL
J-
C lo s e ly
76
The n u rs e p r a is e s th e
c l i e n t f o r good h e a lt h p r a c t ic e s
he i s
a lr e a d y u s in g .
N ot
Closely
I
A p p r o x im a tin g
I
.
I
2
The n u rs e t a l k s w i t h th e
I
i
5
I
C lo s e ly *
4
c l i e n t a b o u t a s p e c ia l d i e t th e d o c t o r has p r e s c r ib e d
f o r h im .
C lo s e ly
N ot
I
A p p ro x !m a tin g
I
I
I
I
2
C lo s e ly
4
5
I
The nurse discusses his living arrangements with the client and how this
might affect his health.
Closely
Not
Approximating
J-
^
I
Closely
The nurse discusses the clients current living arrangements with him and
I
z
how this may affect the clients and his families health.
N ot
Closely
I
A p p r o x im a tin g
I
I
L_
2
I
Closely
4
5
The nurse talks with a client about ways he can make his home safer for
himself and other family members.
Closely
Not
I
Approximating
I
I
i
2
I
5
I
Closely
4
The nurse inquires about the medicines the client is taking or other treatments
he is practicing at home to see if these procedures are producing the expected
results.
Closely
Not
I_
_
_
_
_
_
-L
Approximating
I
1
I
Closely
4
77
The n u rs e e n c o u ra g e s th e
life
and th e
s ta te
c lie n t to t a lk
a b o u t h is f e e lin g s
c o n c e rn in g h is
o f h is h e a lt h .
C lo s e ly
Not
i
A p p r o x im a tin g
I
C lo s e ly
4
5
The n u rs e d is c u s s e s c h i l d
s p a c in g and f a m i l y p la n n in g w it h th e
c lie n t .
C lo s e ly
A
p
Not
p
r
o
x
1
The n u rs e t r i e s
t h is
i
m
a
t
i
n
g
to
C
l
o
s
)
2
d e te rm in e th e c l i e n t ' s
l
y
4
u su a l liv in g
w i t h him and h e lp s him make a d ju s tm e n ts i f
e
p a t t e r n b y d is c u s s in g
t h e y a re n e c e s s a ry f o r h is
h e a lt h .
C lo s e ly
Not
I
I
A p p r o x im a tin g
I
__ I
i
I
C lo s e ly
2
The n u rs e l e t s th e
4
5
c l i e n t know, th r o u g h h e r sp e e ch and a c t io n s , t h a t she has
an u n d e r s ta n d in g o f how he f e e ls a b o u t h is
life
and h is h e a lt h .
C lo s e ly
Not
I
I
A p p r o x im a tin g
I
I
I
I
C lo s e ly
2
The n u rs e p h y s ic a lI y exam ines th e
4
5
c l i e n t o r a f a m il y member t o
see a r a s h ,
ta k e a b lo o d p re s s u re o r c h e c k th e movement i n a p a i n f u l lim b .
O lo s e l'
Not
I
I
I
A p p r o x im a tin g
I
I
C lo s e ly
2
The n u rs e h e lp s t h e
4
5
c l i e n t see how good h e a lt h p r a c t ic e s w i l l be h e l p f u l t o
h im now and i n th e f u t u r e .
C lo s e ly
I p p ro x im a t^ n g
Not
-L
I
I
__,.U
^
C lo s e ly
APPENDIX C
79.
COMMUNITY HEALTH NURSING
ACTIVITIES TOOL
PACKET
INSTRUCTIONS: Within th is packet you w ill fin d tw enty-three (23) item
s lip s .
Each one ca rrie s a statement d escriptive o f a Community Health
Nursing a c t iv it y . You w ill also fin d four (4) yellow envelopes. On
each envelope you w ill see the d e fin itio n o f one of the four (4) major
categories I have selected as being illu s t r a t iv e o f Community Health
Nursing.
To conduct the ta s k, please follow these steps:
1. Lay out the four (4) envelopes on a f l a t surface in fro n t o f
you.
2. Remove the staple holding the twenty-three (23) ite n slip s
so you can consider each separately.
3. Place each item s lip w ith in one ( I ) o f the four (4)
envelopes provided to in d icate your judgment^ o f which major
category o f Community Health Nursing p ractive the item
illu s t r a te s .
4. Repeat th is process fo r a ll twenty-three (23) items.
When you have completed placing a ll the items w ithin a category
envelope, return a ll the envelopes to me. Thank you!
80
CATEGORY DEFINITIONS APPEARING ON ENVELOPES
FOR SORTING PROCEDURES #2 AND #3
BY EXPERT JUDGE GROUPS #3 AND #4
PHYSICAL CARE RELATED ASPECTS:
The items w ithin th is category depict
interventions th a t are nursein it ia t e d to f a c i l i t a t e the c lie n t
meeting his basic physiological and
safety needs.
PSYCHOLOGICAL CARE RELATED ASPECTS:
This category includes items des­
c r ip tiv e of nursing interventions
th a t are introduced in an e f f o r t to
promote individual c lie n t growth.
These are usually in tan g ib le and,
occur as a communication process
between nurse and c lie n t r e la tiv e to
emotions, values and goals.
MEDICAL CARE RELATED ASPECTS:
This category includes items r e la tiv e
to interventions usually in it ia t e d by
or re la te d to other health profes­
sion als.
SOCIOLOGICAL CARE RELATED ASPECTS:
This category contains items d ep ict­
ing in te ra c tio n process interventions
concerning the c lie n t's relationships
with others and his l i f e as a social
being.
81
IC
The nurse explains more f u lly something the c lie n t's doctor has to ld
him about his health.
2C
The nurse inquires about the medicines the c lie n t is taking or other
treatments he is p racticin g a t home, under the d ire c tio n o f a physi­
c ia n , to see i f these procedures are producing the expected re s u lts .
SC The nurse ta lk s with the c lie n t about a special d ie t the doctor has
prescribed fo r him.
4C
The nurse suggests the c lie n t see his doctor about a health problem
or fo r preventative measures such as immunizations or a yearly
checkup.
SC
The nurse confers with other health professionals and coordinates
her in terventions with th e irs in helping the c lie n t meet his needs.
ID
The nurse discusses c h ild spacing and fam ily planning with the
c lie n t .
2D
The nurse gives the c lie n t inform ation about groups he might jo in ,
so th a t the c lie n t can meet a health need o f his own through s o c ia l­
iz a tio n with others.
3D
The nurse encourages the c lie n t to ta lk about how he gets along
with other fam ily members and frie n d s .
4D
The nurse is aware o f the c lie n t's fin a n c ia l status and attempts
to help the c lie n t receive health care in the most cost e f f ic ie n t
manner.
5D
The nurse acts as the c lie n t's advocate in helping him use e x is tin g
community services he is e lig ib le fo r .
The nurse discusses his liv in g arrangements with the c lie n t and how
th is might a ffe c t his health.
The nurse suggests the c lie n t discuss re fe rra l to another health
professional such as a mental health worker or a social worker
with his doctor.
82
Percentage o f Items
Sorted in Agreement
With Researcher's
Placement o f Items
Within the Four
Categories
Physical
Care
Aspects
Psychological
Care
Aspects
Medical
Care-Related
Aspects
Sociological
Care
Related
I nno/
I UU/o
QC
Q
A
yu
Q
C
oD
PA
7C
/D
7A
/U
C
C
DO
CA
DU
*
--
X
X
X
X
•A ..
\"
" ......
X
X
\
C
C
Db
\
X
»
“
- -e ___________ -
CU
A
D
/I40C
LEGEND:
Expert Judge Group #2 =
Expert Judge Group #3 =
Expert Judge Group #4 =
Figure 5. Comparison o f Results o f Sorting Procedures Done to Establish
the Degree of V a lid ity of Placement of Items Within the Four Categories
of Community Health Nursing A c tiv itie s as Defined by the Researcher
APPENDIX D
84
Montana State University
Bozeman, Montana 59715
Tel. 406-994-0211
School of Nursing
Nursing Services Center
Dear Nursing Services Center Client:
Community Health Nursing is a joint venture between the nurse and client. As
nurses we value meeting each individual’s health needs. We do this by communicating
fith each client and following physicians' treatment plans, as well as utilizing
nursing authorities' advice as found in textbooks and nursing organizations' guide­
lines .
One way of determining if we are meeting this goal is to ask you to rate the
activities likely to occur when a Nursing Services Center nurse visits you ag to
their importance for you.
Tudy Gedrose is a graduate student here at the School of Nursing. She has developed
he enclosed, Community Health Nursing Activities Tool, and we feel that your
participation in responding to it could be of benefit to our maintaining a high
quality service. Your responses will also allow her to test the workability of
'he tool.
The study you are being asked to participate in is designed to measure the degree
of agreement regarding the importance of selected nursing activities when rated by
both nurses and clients. Participation in this study will require you to respond
to statements describing nursing activities a Community Health Nurse may initiate
with you and rate these activities as to the importance you feel they have.
The tabulation of the results of the ratings of the statements will be made
according to grouping of activities into categories set by the researcher. There­
fore, you are assured complete anonymity and confidentiality. The tool is to be
returned directly to the researcher, not to the Nursing Services Center, in the
stamped, self-addressed envelope provided you. The reaction sheet following the
CHNAT is for the researcher's use in improving the tool. If you make comments on
the reaction sheet, return it to the researcher with your completed CHNAT.
tour participation in this study is greatly appreciated and we hope it will
jILimate:y benefit you, the client. The study will be completed in mid-March 1978.
If you would desire knowing more about the study upon its completion, the researcher
ould be nappy to provide you with more information.
Yours truly,
Nancy K. Chandler, R.N., M.N.
Nursing Services Center
1 /9 /7 8
85
COMMUNITY HEALTH NURSING
ACTIVITIES TOOL
DIRECTIONS: The statements below describe some activities a Nursing Services Center
nurse may have done with you. Perhaps some have been done and some have not. You
probably consider some more important than others. You are being asked to rate each
statement, regardless of whether or not it was done, according to importance for you
Read the statements, then place an X in the box after the statement that best
describes how important the nursing activity is to you.
EXAMPLE:
The nurse talks with you about how you can
make your home safer.
Medium Slight No
Extreme Very
Impor­ Impor­ Impor­ Impor­ Impor­
tance
tant
tance tance tance
" The nurse confers with other health profes­
sionals and coordinates her interventions
with theirs in helping you meet your needs.
2. The nurse talks with you about how your or
your child's body works in good health or in
relation to a specific disease.
3. The nurse acts as your advocate in helping
you use existing community services you are
eligible for.
4. The nurse identifies symptoms of problems
such as anxiety or depression and takes
appropriate action in directing you towards
dealing with these problems.
5. The nurse talks with you about a special diet
the doctor has prescribed for you.
6. The nurse is aware of verbal or nonverbal
expressions of feelings you may display
regarding your life and the state of your
health and she encourages you to talk about
this.
7. The nurse discusses nutrition with you
regarding the "basic four foods" and health­
ful eating habits.
8. The nurse lets you know, through her speech
and actions that she has an understanding of
how you feel about your life and health.
9. The nurse suggests you see your doctor about
a health problem or for preventative measures
such as immunizations.
10. The nurse encourages you to talk about how
you get along with other family members and
friends.
11. The nurse discusses child spacing and family
planning with you.
12. The nurse praises you for good health
practices you are already using.
CONTINUED ON BACK OF THIS SHEET
86
COMMUNITY HEALTH NURSING ACTIVITIES TOOL - Page 2
Medium Slight IjIo
Extreme Very
Impor­ Impor­ Imporr Impor­ Impor­
tance tance tance
tance
tant
13. The nurse is aware of your financial status
and attempts to help you receive health care
in the most cost efficient manner.
14. The nurse gives you information about groups
you might join, so that you can meet a
health need of your own through socialization
with others.
15. The nurse helps you see how valuing habits
such as exercise, no smoking and consuming
a moderate diet, will be beneficial to your
life now and in the future.
16. The nurse plans with you and assists you in
making your home an area free from hazards
that could cause bodily harm to you or other
persons.
17. The nurse explains more fully something your
doctor has told you about your health.
18. The nurse shows you how to do a physical
activity such as bathing a new baby,
applying a salve, changing a dressing or
adjusting a brace.
19. The nurse physically examines you or a family
member to see a rash, take your blood
pressure, or check the movement in a limb you
find painful.
20. The nurse inquires about the medicine you are
taking or other treatments you are practicing
at home, under the direction of a physician,
to see if these procedures are producing the
expected results.
87
CLIENT'S REACTIONS TO QUESTIONNAIRE
After you have filled out the questionnaire, COMMUNITY HEALTH NURSING ACTIVITIES'
TOOL, please comment on the following:
I.
Do you feel the questionnaire describes some of the activities that have taken
place when the nurses from the Nursing Services Center or any other community
health nurse has visited you? If not, please explain what has taken place
during visits to you from a nurse.
2.
Are the items on the questionnaire understandable? If not, which ones did you
find hard to understand? Please explain how the ones you have listed, if any,
could be improved?
3.
Are there any words used in the items (questions) that you do not understand or
had to look up or guess? If so., what were they? Could you suggest words that
might be more common to most community health clients to replace the ones you
found difficult? If you can, explain.
4.
Since the collection of data is a pre-test to check on the understandability of
the items of the questionnaire and the ease with which clients will be able to
use it, I would appreciate any comments you wish to make about it. How long
did it take you to rate all the items. Did you enjoy doing it? Do you feel it
could lead to findings that can improve community, health nursing services you
receive?
88
FOLLOW-UP POST CARD SENT TO NURSING SERVICE CENTER CLIENTS
January 23, 1978
Within the past 1 -1 /2 weeks, you should have
received a questionnaire from the Nursing Services
Center. I f you did receive i t and have not returned
i t , please check one o f the follow ing responses and
return th is card:
_____ I plan to return i t .
_____ I did not have time to respond to i t .
_____ I saw no value in responding to the questionnaire.
_____ Other (Comments)
Since the tool w ill be used w ithin a la rg e r study,
I would sincerely appreciate your comments.
Yours t r u ly .
Judy Gedrose, Researcher
89
COMMUNITY HEALTH NURSING
ACTIVITIES TOOL
DIRECTIONS: The following twenty (20) items are descriptive of Community Health
Nurse activities. You may have done some of them with clients you worked with during
the past week. I would like you to consider the clients you worked with during the
past week as a composite. Then, regardless of whether or not you were able to carry
out the procedure, rate it as to the degree of importance it holds for the clients
you have worked with. Mark your judgment of importance with an X in the appropriate
square following each item.
EXAMPLE:
You suggest the client discuss referral to
another health professional such as a mental
health worker or a social worker with his/her
doctor.
I. You confer with other health professionals
and coordinate your interventions with theirs
in helping the client meet his/her needs.
2. You talk with a client about how his/her or
his/her child's body works in good health or
in relation to a specific disease.
3. You act as the client's advocate in helping
him/her use existing community services
he/she is eligible for.
4. You identify symptoms of problems such as
anxiety or depression and take the appropri­
ate action in directing the client towards
dealing with these problems.
5. You talk with the client about a special diet
the doctor has prescribed for him/her.
6. You are aware of verbal and nonverbal
expressions of feelings the client may dis­
play regarding his/her life and the state of
his/her health and encourage the client to
talk about this.
7. You discuss nutrition with a client regarding
the "basic four foods" and healthful eating
habits.
8. You let the client know, through speech and
actions, that you have an understanding of
how he/she feels about his/her life and
health.
9. You suggest the client see his/her doctor
about a health problem or for preventative
measures such as immunizations or a yearly
check-up.
10. You encourage the client to talk about he/she
gets along with other family members and
friends.
Extreme Very
Medium Slight No
Impor­ Impor­ Impor­ Impor­ Impor­
tant
tance tance tance
tance
X
CONTINUED
90
COMMUNITY HEALTH NURSING ACTIVITIES TOOL - Page 2
Extreme Very
Medium Slight No
Impor­ Impor­ Impor­ Impor­ Impor­
tance
tant
tance tance tance
11. You discuss child spacing and family planning
with the client.
12. You praise the client for good health
practices he/she is already using.
13. You are aware of the client's financial
status and attempt to help the client
receive health care in the most cost
efficient manner.
14. You give the client information about groups
he/she might join, so the client can meet a
health need of his/her own through socializa­
tion with others.
15. You help the client see how valuing habits
such as exercise, not smoking and consuming
a moderate diet, will be beneficial to his/
her life now and in the future.
16. You plan with and assist the client in making
his/her home an area free from hazards that
could cause bodily harm to him/her or other
persons.
17. You explain more fully something the client's
doctor has told him/her about his/her health.
18. You show a client how to do a physical
activity such as bathing a new baby, applying
a salve, changing a dressing or adjusting a
brace.
19. You physically examine the client or a family
member to see a rash, take a blood pressure,
or check the movement in a limb the client
finds painful.
20. You inquire about the medicines the client is
taking, or other treatments he/she is prac­
ticing at home, under the direction of a
physician, to see if these procedures are
producing the expected results.
91
T a b le 9. R e s u lt s o f P r e t e s t o f th e CHNAT w i t h S ix ( 6 ) N u r s in g S tu d e n ts
o f t h e N u r s in g S e r v ic e s C e n te r R a t in g t h e Im p o rta n c e o f S e le c te d
Community H e a lt h N u rs in g A c t i v i t i e s
Nursing A c tiv itie s
Al I A c tiv itie s
Category A:
Physical Care
Category B:
Psychological Care
Category C:
Medical Care Related
Category D:
Sociological Care
No.
of
Items
Possible
Range of
Scores
Actual
Range of
Scores
20
80 to 0
71 to 45
5
20 to 0
18 to 11
15.17
5
20 to 0
18 to 12
16.00
5
20 to 0
18 to 12
15.17
5
20 to 0
17 to 10
13.67
Mean
Scores
Table 10. Results o f the P retest o f the CHNAT with Sixteen (16) C lients
of the Nursing Services Center Rating the Importance of Selected
Community Health Nursing A c tiv itie s
Nursing A c tiv itie s
A ll A c tiv itie s
Category A:
Physical Care
Category B:
Psychological Care
Category C:
Medical Care Related
Category D:
Sociological Care
Possible
Range of
Scores
Actual
Range of
Scores
20
80 to 0
75 to 29
5
20 to 0
19 to 8
13.2
5
20 to 0
19 to 6
12.33
5
20 to 0
19 to 8
13.73
5
20 to 0
18 to 7
12.13
No.
of
Items
Mean
Scores
APPENDIX E
93
PARTICIPANT CONSENT
The study you are being asked to participate in is designed to
measure the degree of agreement regarding importance of selected nursing
activities between clients and Community Health Nurses.
Participation in this study will require you to respond to
statements describing nursing activities you may or may not have initi­
ated with a client who has been chosen to be your partner in this study*
You will be asked to rate the importance of the statements as you feel
they apply to the named client (family). This study makes no attempt
to determine the quality of care being provided by any individual nurse
participating in the study. You will be identified only through com­
posite scores of all participants relative to the categories of items
depicting four (4) aspects of Community Health Nursing.
If you agree to participate, please sign the following state­
ment .
Judy Gedrose, Researcher
I, __________________________________, state that I understand what is
(Print Name)
required of me as a participant in the above-described study and agree
to take part in this research study.
94
COMMUNITY HEALTH NURSING
ACTIVITIES TOOL
DIRECTIONS: The following twenty (20) items are descriptive of Community Health
Nurse activities. You may have done some with the client who has been selected
as your partner for this study. I would like you to consider
and his/her family whom you have recently worked with. Regardless of whether or
not you were able to carry out the activity, rate each item as to the degree of
importance you feel it holds for the client or his/her family named above.
Mark your judgment of importance with an "X" in the appropriate square following
each item.
EXAMPLE:
You suggest the client discuss referral to
another health professional such as a mental
health worker or a social worker with his/her
doctor.
I. You confer with other health professionals
and coordinate your interventions with theirs
in helping the client meet his/her needs.
2. You talk with a client about how his/her or
his/her child's body works in good health or
in relation to a specific disease.
3. You act as the client's advocate in helping
him/her use existing community services
he/she is eligible for.
4. You identify symptoms of problems such as
anxiety or depression and take the appropri­
ate action in directing the client towards
dealing with these problems.
5. You talk with the client about a special diet
the doctor has prescribed for him/her.
6. You are aware of verbal and nonverbal
expressions of feelings the client may dis­
play regarding his/her life and the state of
his/her health and encourage the client to
talk about this.
7. You discuss nutrition with a client regarding
the "basic four foods" and healthful eating
habits.
8. You let the client know, through speech and
actions, that you have an understanding of
how he/she feels about his/her life and
health.
9. You suggest the client see his/her doctor
about a health problem or for preventative
measures such as immunizations or a yearly
check-up.
10. You encourage the client to talk about he/she
gets along with other family members and
friends.
Extreme Very
Medium Slight No
Impor­ Impor­ Impor­ Impor­ Impor­
tance
tant
tance tance tance
X
CONTINUED
95
COMMUNITY HEALTH NURSING ACTIVITIES TOOL - Page 2
Extreme Very
Medium Slight No
Impor­ Impor­ Impor­ Impor­ Impor­
tance
tant
tance tance tance
11. You discuss child spacing and family planning
with the client.
12. You praise the client for good health
practices he/she is already using.
13. You are aware of the client's financial
status and attempt to help the client
receive health care in the most cost
efficient manner.
14. You give the client information about groups
he/she might join, so the client can meet a
health need of his/her own through socializa­
tion with others.
15. You help the client see how valuing habits
such as exercise, not smoking and consuming
a moderate diet, will be beneficial to his/
her life now and in the future.
16. You plan with and assist the client in making
his/her home an area free from hazards that
could cause bodily harm to him/her or other
persons.
17. You explain more fully something the client's
doctor has told him/her about his/her health.
18. You show a client how to do a physical
activity such as bathing a new baby, applying
a salve, changing a dressing or adjusting a
brace.
19. You physically examine the client or a family
member to see a rash, take a blood pressure,
or check the movement in a limb the client
finds painful.
20. You inquire about the medicines the client is
taking, or other treatments he/she is prac­
ticing at home, under the direction of a
physician, to see if these procedures are
producing the expected results.
APPENDIX F
97
PARTICIPANT CONSENT
The study you are being asked to participate in is designed to
measure the degree o f agreement regarding importance of selected nursing
activities between clients and Community Health Nurses.
Participation in this study will require you to respond to
statements describing nursing activities a Community Health Nurse may
initiate with you and rate these statements as to the importance you
feel they have.
It will take approximately ten minutes to complete the
questionnaire. Your answers will be held in complete anonymity and you
will not be identified in any manner.
If you agree to participate, please sign the following state­
ment .
Judy Gedrose, Researcher
I, ____________________ _______________ , state that I understand what is
(Print name)
required of me as a participant in the above-described study and agree
to take part in this research study.
(Signature)
98
COMMUNITY HEALTH NURSING
ACTIVITIES TOOL
DIRECTIONS: The statements below describe some activities or topics a
nurse may have done or discussed with you.
Perhaps some have been done and some have not. You probably consider some more
important than others. You are being asked to rate each statement, regardless
of whether or not it was done, according to the importance the activity or topic
has for you. Read the statements, then place an "X" in the box after the state­
ment that best describes how important the nursing activity is for you or your
________ ______ _____________
family.
Extreme Very
Medium Slight No
Impor­ Impor­ Impor­ Impor­ Impor­
EXAMPLE:
tance
tance tance tance
tant
The nurse talks with you about how you can
make your home safer.
X
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
The nurse confers with other health profes­
sionals and coordinates her interventions
with theirs in helping you meet your needs.
The nurse talks with you about how your or
your child's body works in good health or in
relation to a specific disease.
The nurse acts as your advocate in helping
you use existing community services you are
eligible for.
The nurse identifies symptoms of problems
such as anxiety or depression and takes
appropriate action in directing you towards
dealing with these problems.
The nurse talks with you about a special diet
the doctor has prescribed for you.
The nurse is aware of verbal or nonverbal
expressions of feelings you may display
regarding your life and the state of your
health and she encourages you to talk about
this.
The nurse discusses nutrition with you
regarding the "basic four foods" and health­
ful eating habits.
The nurse lets you know, through her speech
and actions that she has an understanding of
how you feel about your life and health.
The nurse suggests you see your doctor about
a health problem or for preventative measures
such as immunizations.
The nurse encourages you to talk about how
you get along with other family members and
friends.
The nurse discusses child spacing and family
planning with you.
The nurse praises you for good health
practices you are already using.
CONTINUED ON BACK OF THIS SHEET
99
COMMUNITY HEALTH NURSING ACTIVITIES TOOL - Page 2
Medium Slight IjJo
Extreme Very
Impor­ Impor­ Imporr Impor­ Impor­
tance
tant
tance tance tance
13. The nurse is aware of your financial status
and attempts to help you receive health care
in the most cost efficient manner.
14. The nurse gives you information about groups
you might join, so that you can meet a
health need of your own through socialization
with others.
15. The nurse helps you see how valuing habits
such as exercise, no smoking and consuming
a moderate diet, will be beneficial to your
life now and in the future.
16. The nurse plans with you and assists you in
making your home an area free from hazards
that could cause bodily harm to you or other
persons.
17. The nurse explains more fully something your
doctor has told you about your health.
18. The nurse shows you how to do a physical
activity such as bathing a new baby,
applying a salve, changing a dressing or
adjusting a brace.
19. The nurse physically examines you or a family
member to see a rash, take your blood
pressure, or check the movement in a limb you
find painful.
20. The nurse inquires about the medicine you are
taking or other treatments you are practicing
at home, under the direction of a physician,
to see if these procedures are producing the
expected results.
APPENDIX G
101
FORMAT FOR PRESENTING COMMUNITY HEALTH NURSING ACTIVITIES TOOL
TO PROSPECTIVE COMMUNITY HEALTH NURSE SAMPLE
I have formulated a to o l--th e Community Health Nursing A c tiv i­
tie s Tool.
I t contains 20 items descrip tive o f Community Health Nursing
a c t iv it ie s .
I would lik e to have 25 nurses and c lie n ts ra te the impor­
tance o f the a c t iv it ie s , using a 5 response scale varying from extremely
important to no importance.
When I have collected the completed CHNATs,
I w ill compare the ratings o f the items according to categories of
nursing care which are:
( I ) physical care re la te d , (2 ) psychological
care re la te d , (3) medical care re la te d , and (4) sociological care
re la te d .
I would lik e you to see the p a rtic ip a n t consent form and the tool —
I f you agree to p a r tic ip a te , th is is what I would need to have you
do:
1.
Select the names o f the la s t four c lie n ts you have seen th a t
meet the follow ing c r it e r i a :
contact with a
( I ) the c lie n t has had some on-going
Community Health Nurse (not necessarily you);
(2) the
c lie n t is able to read and understand English, able to w rite ;
(3) the
c lie n t w ill give verbal consent to you fo r me to contact them about
responding to the to o l.
2.
I w ill draw one o f the c lie n ts fo r contacting.
102
3.
For c o n fid e n tia li t y , I would lik e you to phone or personally
contact the person chosen from your caseload and say the follow ing:
The (agency p a rtic ip a tin g ) nursing department
has agreed to p a rtic ip a te in a research study
being, conducted by a nurse-researcher from
Bozeman.
She has asked me to draw a name from
the people I am seeing, and when I did t h is ,
I drew your name.
The researcher has a ques­
tio n n a ire th a t takes about 10 minutes to complete.
You are under no o b lig atio n to f i l l
i t out.
If
you would be in terested in f i l l i n g out a question­
naire fo r her study, I w ill l e t you speak with
her to make arrangements fo r her to contact you.
WTAM STATE
VWIVERSirf
7 6 2 1 0 0 1380 3 9
N378
G268
cop. 2
Gedrose, J u d ith K
Compared, r a tin g s by
both nurses and c lie n ts
o f s e le c te d community
h e a lth nursing a c t i v i t i e s
DATE
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