NURSING CURRICULUM: CONTENT NEEDED FOR
HOME HEALTH NURSING CARE
by
PHYLLIS KARMELS, B.S., M.A., M.S.N.
A DISSERTATION
IN
HIGHER EDUCATION
Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of
DOCTOR OF EDUCATION
Approved
December, 1998 '/ Copyright 1998, Phyllis A. Karmels
\ ACKNOWLEDGEMENTS
I wish to dedicate this manuscript to: my mother, Loma McConnel Whiteford, who always encouraged me to be a nurse and to get a good education; my mother-in-law,
Anna Mellville, who was proud of me; and my late husband, Al, who loved me anyway.
In addition, I would like to dedicate this manuscript to my children-Albert, Susan (Ann),
Steven, Wayne, Gary, Theresa, and Michael, all of whom I love anyway.
In addition, I wish to acknowledge the following people, without whom this endeavor would not have come to fruition: Albert Smith, Ph.D., without whom I would not have been able to complete this study. He spent innumerable hours reading and editing this manuscript, as well as advising and counseling me. Susan Pollock, Ph.D., spent hours editing and advising me. She paved the way and encouraged me, especially in matters concerning nursing topics. Corinne Grimes, Ph.D., had endless patience with my amateurish attempts at writing chapters one, two, and three, but through it all she gave me
encouragement when I was ready to give up. Paul Randolph, Ph.D., was most helpful with the statistics. His assistance was invaluable in helping me to select the most
appropriate methods for data analysis. Oliver Hensley, Ph.D., was my first professor of higher education at Texas Tech University. He showed me I could do it, and had so much faith in me that I could not let him down.
I want to thank Carole Wolf for organizing and typing my references. Sue and
Ronald Haas helped me with all phases of my mailouts, from the random selection of respondents, to the sorting and cataloguing of final responses. Sue typed all of my mailing labels. More specifically Sue and Ron helped to: (a) coded the questionnaires, (b)
ii stuffed the envelopes, (c) hcked stamps, and (d) took the envelopes to the post office.
When the returns came in, they assisted me in sorting the responses and mailing the second and third questionnaires.
Marci White, a research student, at Texas Tech University Health Sciences
Center-Permian Basin, School of Nursing (TTUHSC-PB, SON) helped in getting out
letters and surveys and helped me in the data analysis for the first mailout.
Caria Harris, a research student, at TTUHSC-PB, SON who made many of the graphs.
Rosemary Fennemen accompanied me to my proposal presentation and my
defense. She kept me focused and organized throughout these activities. Rosemary would
not let me give up and insisted that I think positively.
I owe a vote of thanks to my co-workers, Gayleen lenatsch, Irma Aguilar,
Dorothy Jackson, Susan Gray, and Mary McClelland, who encouraged me at every step
of the way, and who rejoiced at my progress.
ni TABLE OF CONTENTS
ACKNOWLEDGEMENTS ii
ABSTRACT ix
LIST OF TABLES xi
LIST OF FIGURES xiv
L INTRODUCTION 1
Statement of the Problem 5
Purposes of the Study 6
Research Questions 6
Need for the Study 6
Thesis Statement 8
Assumptions 9
Delimitations 10
Limitations 10
Definitions of Terms 11
Summary 13
IL REVIEW OF THE LITERATURE 15
Introduction 15
History of Nursing Education 15
Early Education of Nurses 15
Nursing Education After WWII 18
Role Conflict 24
iv Reality Shock 25
Nursing in Home Care Settings 31
Higher Education Literature 37
Additional Curriculum Content Needed for Care of the Patient in the Home 38
Summary 42 m. METHODOLOGY 43
Research Design 43
Ethical Considerations 44
Instrument Development: Parti 45
Face Validity 46
First Mailout 47
Preparation for Second Survey 50
Instmment Development: Part II 52
First Mail Back 53
Preparation for Second Mailout 54
Second Mailout 55
Second Mail Back 58
First Delphi Round 58
Procedure for Data Collection 59
Second and Third Rounds 61
Power Analysis 62
Instrument Reliability 63
Instrument Validity 64 Analysis of Data 65
Research Question Number One 65
Research Question Number Two 66
First Round Mailout 67
Returns from the First Round 68
Second Round Mailout 68
Returns from the Second Round 69
Third Round Mailout 69
Returns from the Third Round 70
Further Suggestions and Comments 70
Summary 71
IV. RESULTS 73
Introduction 73
Respondent Background Characteristics 73
Educational Background of the Deans 73
Educational Background of Nursing Directors of Home
Health Agencies 74
Dean's Years of Nursing Experience 75
Nursing Directors' Years of Experience 76
Number of Full-time Undergraduate Students of the Respondents As Reported by the Deans 76
Number of Full-time Nurses Employed in Respondents' Agencies 77
Summary of Respondent Background Characteristics 78
Findings Related to the First Research Question 78
vi Curriculum Content Items Receiving the Highest Mean Ratings by Deans 79
Curriculum Content Items Receiving Mean Ratings Between 4.0 and 4.5 by Deans 81
Curriculum Content Items Receiving Mean Ratings Under 4.0 By the Deans 83
Curriculum Content Items Receiving Mean Ratings Under 4.0
By the Nursing Directors 84
Summary Related to Research Question Number One 85
Findings Related to the Second Research Question 89
Summary Related to Research Question Number Two 90 Summary 91
V. SUMMARY, MAJOR FINDINGS, RECOMMENDATIONS,
AND CONCLUSIONS : 92
Major Findings 97
Concerning Deans' and Nursing Directors' Background 97
Concerning Dean's and Nursing Director's Responses 97
Research Question Number One 99
Highest Ratings by the Deans 102
Highest Ratings by the Nursing Directors 104
Summary 104
Lowest Ratings by the Deans 107 Nursing Directors' Lowest Mean Responses 110
Research Question Number Two Ill
Curriculum Recommendations for Nursing Education 113
vn Recommendations Related to Curriculum 122
Recommendations for Nursing Education 123
Recommendations for Further Research 124
Conclusions 125
Overview 125
REFERENCES '. 127
APPENDICES
A. COVER LETTER AND INSTRUMENT DEVELOPMENT PARTI 137 B. COVER LETTER AND INSTRUMENT DEVELOPMENT PART II 141
C. COVER LETTER AND SURVEY FOR DELPHI ROUND 1 147
D. COVER LETTER AND SURVEY FOR DELPHI ROUND II 154
E. COVER LETTER AND SURVEY FOR DELPHI ROUND III 159
F. REMINDER LETTER TO DEANS OR NURSING DIRECTORS WHO HAVE NOT RETURNED THE SURVEY 165
G. TABLES OF MEAN RESPONSES FROM DEANS AND NURSING DIRECTORS FROM THE FIRST, AND SECOND MAILOUTS 172
H. THIRD ROUND MEAN RESPONSES PER ITEM AND r-VALUE 181
vni ABSTRACT
When nursing education changed from apprenticeship training to college education, many nurses experienced a phenomenon termed "reality shock" because their education had not prepared them to work in hospitals. Changes in the health care system sent patients home to recover from major surgeries and complex medical problems.
Therefore, much of nursing care has moved from the acute care setting to the home.
Caring for these clients in the home requires new competencies as well as established nursing skills. The problem of this research was to determine what curriculum content was needed to prepare nurses for their roles in home health care.
The purposes of this study were : (1) to identify curriculum content needed to prepare nurses for home health care and (2) to make recommendations for the needed curriculum changes to prepare nurses for practice in the home setting. The research questions were: (1) Do deans of baccalaureate schools of nursing and nursing directors of home health care agencies concur with the current health care literature regarding curriculum content needed to prepare graduates to function in the home setting? and (2)
Is there congruence between the perceptions of deans of baccalaureate schools of nursing
and nursing directors of home health care agencies regarding curriculum content needed to prepare graduates to fianction in home health care?
A Delphi technique with three survey rounds was used to collect data from 185
Deans and 152 nursing directors. The study contained a survey questionnaire of 33 curriculum content items, 12 derived from the literature and 21 items from two pilot studies in which curriculum suggestions were made by deans and administrators.
IX Respondents were asked to rate each curriculum content item on a Likert-type scale with
response categories ranging from 0 (highly undesirable) to 5 (essential). The level of
congruence between the two groups was determined by a series of t-tests.
Results indicated that there was agreement between the deans and directors that
11 of the 12 curriculum items derived from the literature were desirable. While there
were statisfically significant differences between the mean responses of the two groups
on 27 of the final 33 curriculum content items, both groups had mean responses of greater
than 3.0 or desirable on 32 of the 33 items. A revised curriculum plan, including these 32
items, was developed to better prepare nurses for home health care. LIST OF TABLES
3.1 Eastern and Western States North of the Mason-Dixon Line 49
3.2 Eastern and Western States .South of the Mason-Dixon Line 49
3.3 Deans' and Nursing Directors' Mean Responses to Original Ten Curriculum Content Items (N=45) 51
3.4 Eastern and Western States North of the Mason-Dixon Line 54
3.5 Eastern and Western States South of the Mason-Dixon Line 54
3.6 Deans' and Nursing Directors' Mean Response Ratings, Mean Differences, and Response Ranges of The Expanded List of Thirty-three Curriculum Content Items (n=91) 56
4.1 Rank Order of the Deans' (n=l 85) Curriculum Content Item Mean Response Ratings Greater Than 4.5, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items 80
4.2 Rank Order of the Deans' (n=185) Curriculum Content Item Mean Response Ratings Between 4.0 and 4.5, Compared to the Nursing Directors' (n=152) Mean Responses Ratings for the Same Items 82
4.3 Rank Order of the Deans' (n=185) Curriculum Content Items Mean Response Ratings Under 4.0, Compared to Nursing Directors' (n=152) Mean Response Ratings for the Same Items 84
4.4 Rank Order of the Nursing Directors' (n=152) Curriculum Content Item Mean Response Ratings Below 4.0, Compared to the Deans' (n=185) Mean Response Ratings for the Same Items 86
4.5 A Comparison of the Deans' (n=185) and Nursing Directors' (n=185) Mean Responses for the Twelve Curriculum Content Items Needed to Prepare Nurses for Work in the Home 88
4.6 Curriculum Content Items Showing Non-significant lvalues, When Deans' (n=185) and Nursing Directors' (n=152) Means Were Compared 90
5.1 Deans' (n=l 85) and Nursing Directors' (n=l 52) Mean Responses to the Twelve Curriculum Content Items Found in the Literature 100
XI 5.2 Rank Order of the Deans' (n=185) Curriculum Content Item Mean Response Ratings Greater Than 4.5, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items 103
5.3 A Comparison of Deans' (n=l 85) Mean Responses with Nursing Directors' (n-152) Mean Responses on Total Thirty-three Curriculum Content Items 104
5.4 Rank Order of the Deans' (n=l 85) Curriculum Content Items Mean Response Ratings Under 4.0, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items 1^8
5.5 Curriculum Content Items Showing Five Not Significant t-values when Deans' (n=185) and Nursing Directors' (n=152) Means were Compared 112
5.6 Basic Nursing Courses with Recommended Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of3.0 or Greater 115
5.7 Practice Management Course with Recommended Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of3.0 or Greater 118
5.8 College of Arts and Sciences Courses with Recommended Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater 119
5.9 College of Liberal Arts and Humanities Courses with Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater 120
5.10 College of Communication Studies Courses with Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater 121
5.11 Law School Courses with Additional Curriculum Content Items Suggested by
the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater 122
G. 1 Means from the First questionnaire Responses Concerning Leadership 173
G.2 Means from the First Questionnaire Responses Concerning Management 173
G. 3 Means from the First Questionnaire Responses Concerning the Individual 174
xn G.4 Means from the First Questionnaire Responses concerning the Aggregate 174
G.5 Means from the First Questionnaire Responses Concerning Communication 175
G.6 Means from the First Questionnaire Responses Concerning Research 175
G.7 Means from the First Questionnaire Responses Concerning Political Issues 176
G.8 Means from the First Questionnaire Responses Concerning Leadership 176
G.9 Means from the Second Questionnaire Responses Concerning Management 177
G. 10 Means for the Second Questionnaire Responses Concerning the Individual 178
G.l 1 Means from the Second Questionnaire Responses Concerning the Aggregate 178
G.12 Means from the Second Questionnaire Responses Concerning Communication.. 179
G. 13 Means from the Second Questionnaire Responses Concerning Research 179
G.l4 Means from the Second Questionnaire Responses Concerning Political Issues ...180
H. 1 Means and ^value from the Third Questionnaire Responses Concerning Leadership 182
H.2 Means and /-value from the Third Questionnaire Responses Concerning Management 183
H.3 Means and /-value from the Third Questionnaire Responses Concerning the Individual 184
H.4 Means and /-value from the Third Questionnaire Responses Concerning the Aggregate 185
H.5 Means and /-value from the Third Questionnaire Responses Concerning Communication 186
H.6 Means and /-value from the Third Questionnaire Responses Concerning Research 186
H.7 Means and /-value from the Third Questionnaire Responses Concerning Political Issues 187
xni LIST OF FIGURES
1.1 Nursing Care Environment as Predicted for Patient's Compensatory Status 3
4.1 Educational Background of Deans (n=216) 74
4.2 Educational Background of Nursing Directors (n=158) 75
4.3 Deans' Years of Nursing Experience (n=215) 75
4.4 Nursing Directors' Years of Nursing Experience (n=152) 76
4.5 Vertical Bars Showing the Number of Schools with the Number of Full-time Students Shown on the Horizontal Axis (n=207) 77
4.6 Vertical Bars Showing the Number of Employees, Horizontal Axis Showing the Number of Agencies employing that Number of Nurses (n=180) 78
XIV CHAPTER I
INTRODUCTION
In a market-driven health care system, much of the nursing care of clients has moved out of the acute care setting into the home. Areas of nursing content required by nurses in home health care are similar to those needed in the acute care facility and yet different, since additional content is required.
Nurses need to plan and manage nursing care in a variety of complex health
situations. They need to provide services in a variety of settings among diverse patient
populations in a rapidly changing health care delivery system. Nursing educators must be
able to prepare their graduates to fimction effectively in the world outside hospitals, under
an assortment of conditions, most of which are not found in smoothly running hospital
units in acute-care settings. In these units, state-of-the-art equipment is immediately
available and the help of experts is only a few steps away.
When nurses care for patients in the hospital, they need not be concerned about
whether the patients are able to get supper that evening or breakfast the next morning
because they routinely feed patients unless scheduled for surgery or for those tests which
require fasting. On the other hand, nutritional counseling at home is different when the
patients do not have the wherewithal to buy or shop for food. Nurses must be able to find
food sources and a delivery source for these patients. In the hospital, the physician orders
medication, the pharmacy delivers it, and the nurse administers it. In the home, nurses must be able to determine if patients or their insurance plans paid for the medication. If not, nurses have to be able to find other sources of payment for medications.
These situations are just two examples of why nursing in the home is different and requires additional nursing content. Hence, fiscal management and teamwork are essential in the home setting. With rare exception, nursing education does not address these concerns. In a market driven economy, patients are routinely sent home as soon as they are stable. At home, they have to fend for themselves or they depend on the home care nurse to help them recover..Course content advocated by the nursing directors in home care agencies and deans of baccalaureate schools of nursing needs to come to a consensus regarding appropriate content areas that enabled the nurse to fimction
effectively in home settings.
Dorthea Orem, an early nurse theorist, developed a theory of nursing which reflected three general aspects of patient care (Marriner-Tomey, 1989). Figure 1.1 uses
those aspects to depict nursing care environments. In Orem's theory, wholly
compensatory meant that the patient could not do anything for himself. Those patients
were usually quadriplegic or comatose. They were often ventilator dependent, meaning
that they could not breathe on their own. Partially compensatory, in Orem's theory, was a
term meaning that the patient could do some things for himself but was dependent on
others for help in some of the activities of daily living. This category covered a broad range of activities in which the patient was partially dependent on others. The self-care category in this theory suggested that the patient could perform all activities of daily living, but may have a knowledge deficit regarding some aspect of his health. For example, a patient who was newly diagnosed as an insulin dependent diabetic may require teaching by the nurse on how to draw up insulin and inject it into himself
Dorthea Orem's theory of nursing (as cited in Fitzpatrick & Whall, 1996), provides a framework for a model which this researcher developed, to visualize where
nursing care takes place in the 21st century and where nurse educators directed the
preparation of nurses for the 21st century. My model (Figure 1.1) depicts the areas in
which nursing care can expect to take place in the fixture.
AGEMGY NURSINQ INTERVEKnON Figure 1.1 Nursing Care Environments as Predicted by Patient's Compensatory Status
As shown, the greater portion of patient care takes place outside the acute care
agency. The upper portion of this model is larger, showing that in the fixture most of the
nursing care of patients could be rendered in home care agencies. The model addresses
the three aspects of patient care: wholly compensatory, partially compensatory, and self c^;e. The concentric circles represent the amount of patient care rendered by the nurse, by others (under the direction of the nurse), or by the patient himself It is expected that in the very near fixtureth e patient will be sent home from the hospital as soon as his or her condition is stable. This shortened hospital stay is represented, in the model, by the amount of the outer circle that appears in the acute care portion of the model.
Only a very small portion of the middle circle extends into the lower part of the model. This part represents patients undergoing surgery or coming into the emergency department for treatment in crisis situations. The smallest circle in Figure 1.1 represents patients who do not need to enter an acute care center. Nurses are involved in providing immunizations or information to keep these people healthy.
Curricula to prepare nursing graduates for expanding care areas could be developed using Orem's model of nursing. The curricula could incorporate content related to the health care demands and the nursing interventions necessary to meet the dynamic changes taking place in nursing care. For example, Orem's theory of health care (as cited in Fitzpatrick and Whall, 1996), is based on two phases of action: estimative and productive. Estimative action involves investigation, reflection, and judgement regarding how the patient's situation can be improved. It is based on decisions regarding the desired goals and outcomes and the means to achieve them. Estimative action is the key element in assessing patients' needs. It is this element that curricula should address in preparing nursing graduates to fimction in home health care agencies. Productive action entails the planning and the implementing of these goals. The need for health services is necessitated by the patient's inability to maintain the amount and quality of self-care that is therapeutic in sustaining life, health, and in recovering from disease or injury, and/or coping with disease or injury.
Statement of the Problem
The problem of nursing in the 21st century is that in a market driven health care system, increasingly, care of the patient will move out of the hospital into the home.
Health care facilities and health insurance companies, in an effort to contain costs, will be sending patients home as soon as they are stable. Many of these patients will be acutely ill or chronically ill. The nurse will need to be able to care for these patients, often, without the benefit of high tech equipment and instant access to colleagues as would have been the case if this care were rendered in a hospital. Caring for these patients in the home requires established nursing skills as well as new and different abilities. The problem of this research was to determine what deans of accredited baccalaureate schools of nursing and nursing directors of home care agencies believed about the curriculum content needed for nurses in the home setting (outside of the acute care agency) in the
21st century. This researcher also determined whether or not deans in this study concurred with current nursing literature and with nurse-administrators of home care agencies as to what curriculum content should be taught in schools of nursing to prepare nurses for their fixturerole s in home health care. Purposes of the Study
The major purposes of this study were to:
1. Identify curriculum content needs to enable the newly graduated nurse to fixnctionth e
home setting.
2. To make recommendations for necessary curriculum changes in order to enable newly
graduated nurse to fixnction in home health.
3. To develop a curriculum plan for those schools of nursing contemplating changes.
Research Ouestions
The research questions for this study were:
1. Do deans of baccalaureate schools of nursing and nursing directors of home health
care agencies concur with the current health care literature regarding curriculum
content needed to prepare graduates to fixnction in the home setting?
2. Is there congruence between the perceptions of deans of baccalaureate schools of
nursing and nursing directors of home health care agencies regarding curriculum
content needed to prepare graduates to fixnction in home health care?
Need for the Study
The rate at which nurses voluntarily left the profession in the 1960s and 1970s was 13% or greater (Kramer, 1979). Such a loss was costly not only for employing agencies but also for the profession. Nurses who had spent years being educated for the profession discovered that nursing was not what they thought it would be (Roach, 1993).
College educated nurses, after WWII, came from an educational background where they
were able to: (a) give holistic care to a single patient, (b) think and make decisions based
on broad concepts and ethical principles, and (c) receive rewards which were based on
their abilities to do so.
When the preparation of nurses changed from an apprenticeship sponsored by
hospitals to the education of nurses in the academic setting, new problems emerged.
Generally hospital supervisors, nurse educators, researchers, and newly graduated nurses
observed a number of phenomena occurring during the period of time when beginning
nurses leave the academic setting and join the ranks of practicing nurses (Kramer, 1979).
The drastic changes in nursing education that occurred when nursing education moved
from the hospital, in the late 1950s and the early 1960s, to the college caused a crisis of
reality shock, which was experienced by new nurses in their transition from college to
work (Benne & Bennis, 1959; Kramer, 1970). Hospital-trained nurses, when they
graduated, merely did the same work and followed the same routine that they did as
students without encoimtering any significant problems.
With changes in health care delivery during this decade, wrought by a market
driven economy, much of the care of patients, in this decade, has occixrred outside the
hospital or other acute care facilities and will continue to do so in the next century. The
nurse who cares for patients outside of the acute care facility, needs the traditional
nursing curriculum content as well as different nursing content in order to be effective
(American Nurses Association [ANA], 1997; Bureau of Labor Statistics, 1994; Cary, 1988; Cavouras & Eddy, 1996). Some major ramifications of not bringing a curriculum into line with the new skills needed in home settings will be: (a) reality shock, (b) loss of nurses from the profession, and (c) less than effective care of the patient.
Thesis Statement
Reality stress in the workplace (Bellinger & McClosky, 1992; Benne & Bennis,
1959; Bernhardt, 1992; Caldwell, 1989; Cummings, 1990; Fiesta, 1990a; Kramer, 1974), encountered by graduates in their first nursing positions, is derived from the differences between school and work expectations for the nurse. For example, tension existed between the need for cost containment and the need for delivery of quality health care. In
order to contain costs, health care insurance planners have been encouraging and paying
for the prevention of illness as a way to reduce the need for treatment (Cary, 1988;
Holloran, 1990). With these changed incentives, health insurance plan representatives are paying for more health care in the home settings. As a result, nurses increasingly practiced in those settings as opposed to acute care agencies. Nursing education needs to revise curricula to address the issues of cost containment and altered practice.
Educational changes are needed to address autonomy and independence within the context of relative isolation in nursing practice as new nurses are confronted with nursing care problems, without the support of other nurses (Cary, 1988). These nurses are expected to provide comprehensive care without much of the sophisticated equipment typically found in acute care settings. Unless nursing education prepared graduates to care for acutely ill patients in the home, nurses could experience reality shock similar to that
8 which had been found in nurses who had graduated from generic baccalaureate schools of nursing, and who felt inadequately prepared for their first positions in nursing (Bronder,
1997; Cary, 1988; Kramer, 1974; Roach, 1993).
This researcher surveyed two groups: (a) the deans of baccalaureate schools of nursing in selected colleges and universities and (b) administrators of nursing in home health agencies, in an effort to determine what content they felt prepared nursing students to fixnction in home settings.
Assumptions
Assumptions undergirding this study are that:
1. The nurse educators responding to this survey are cognizant of the changes in health
care delivery.
2. Nursing directors responding to this survey are realistic in their expectations of
nursing education.
3. The nursing profession uses theories, concepts, and principles for explaining, guiding,
and predicting changes in the health care delivery system.
4. The nursing profession integrates into its knowledge base theories from other
disciplines such as business, sociology, pharmacology, psychology, macro- and
micro-biology, holism, cultural diversity, and chemistry to enhance its commitment to
patients and their families.
5. Curriculum textbooks and nursing literature form the basis for change in
baccalaureate education. 6. Nursing content needs can be validated by both educators and nurse administrators,
regardless of the setting.
7. Nursing educators are cognizant of curriculum content needed by their graduates to
fimction in the home.
Delimitations
This study was delimitated in the following ways:
1. The study looked at only baccalaixreate nursing education.
2. This study was limited to baccalaureate programs in nursing accredited by the
National League of Nursing (NLN), the accrediting body for schools of nursing in the
United States of America.
3. Only a sample of nursing directors of home health agencies are offered the
opportunity to participate.
Limitations
The limitations of this study are listed below:
1. The generalizability of the findings applied only to certain groups of nurse educators
and nursing directors.
2. Observation of nurse educators and nursing directors did not occur.
3. Establishment of revised curricula to include new content is not possible.
10 4. Poor response rates by nurse educators and nursing directors may result in inadequate
curriculum content validation.
5. Nurse educators and nursing directors may present personal biases, with respect to
curriculum recommendations, due to their education, experiences, needs, or other
variables.
6. This study lacked a definitive process that gets curriculum content items translated
back into a curriculum plan. This study also lacked a needs assessment. The pilot
studies were an attempt to cull items from the respondents but there was no attempt to
determine if the need really existed or if the items were just nice to have.
Definitions of Terms
The following theoretical and operational definitions are used for the purpose of this study.
Acute Care Facilities. Those facilities where nurses supply emergent, urgent skilled nursing, and intensive medical and surgical nursing care to clients on a limited hospital stay basis (Kramer, 1978). For this study, that term meant hospital.
Baccalaureate Degree in Nursing. A four-year college or university-based degree in nursing that provides nursing theory, humanities, and behavioral science preparation necessary for the full scope of professional nursing responsibilities. The program of study which integrates the delivery of patient services and monitors patient responses to health care intervention. (ANA, 1995). For this study, the term meant a four-year college course in nursing leading to a bachelor's degree in nursing.
11 Home Health Nurse. A nurse who was involved in meeting the collective needs of the home health agency by "identifying problems and managing interactions within the home itself and between the community and the larger society" (Stanhope & Lancaster,
1996, p. 294). For the purposes of this study, the term meant the bachelor's degree prepared registered a nurse who worked as a nurse in any home health agency.
Congruence. The state of being honest, genuine, and real (Marriner-Tomey,
1989). In that study, it meant agreement on curricular content between deans of baccalaureate schools of nursing and nursing directors of home health care agencies. It meant being in accord.
Content. Elements that make up a course of study (Gaff, 1991). In this study, content referred to and was limited to topics listed in the survey questionnaire.
Course. A planned sequence of activity of a unit of study (Gaff, Ratcliff, &
Associates, 1997). For the purposes of this study, the term meant a specific unit of study on a specific topic.
Curriculum. An undergraduate curriculum was the formal academic experience of students pursuing a baccalaureate degree (Gaff, Ratcliff, & Associates, 1997). For the pixrposes of this study, the term referred to a planned program of courses leading to a bachelor of science degree in nursing.
Curriculum Model. The process for the complete development of a school's plan of study for a particular program such as the school of nursing (Oliva, 1988). For the purposes of this study, the term refers to a diagram that encompasses the curriculum as it
12 relates to courses and nursing topics that enable the nurse to fixnction in the hospital and home.
Dean. The chief academic officer of a college or of a program within a college
(Gaff, Ratchff, & Associates, 1997). For the purposes of this study, the dean was the person responsible for doing or delegating tasks necessary to enable the school of nursing to fixnction.
Home Health Care. "The provision of multi-disciplinary health care to the sick, disabled, and injured in their place of residence" (Bullough & Bullough, 1990, p. 276).
For the purpose of this study, the term meant providing and/or delegating nursing care to an individual and/or family in their place of residence.
Nurse Administrator: A nurse who has considerable executive ability, (Webster's
Ninth New World Dictionary. 1995). For the purpose of this study, the term meant a nurse who assumed the 24-hour responsibility and accountability for hiring, firing, and directing nurses in their agency.
Summary
A high attrition rate occurred among new nurses in the late 1950s due to their inability to make the transition from college to work. This situation was brought about when nursing education moved out of the hospital and into colleges or universities. It has taken more than two decades to resolve the differences between nursing service needs and nursing education (Roach, 1993). At the beginning of the 1990s, because hospital
13 administrators and deans are in greater agreement regarding what new nurses needed to practice successfixlly in hospitals, nursing attrition began to decline (Roach, 1993).
A new era of health care.has emerged in the late 1990s, with an emphasis on cost savings. This new emphasis on cost savings has precipitated a shift of patient care from the hospital to the home. At the same time, the philosophy of health care has shifted from an emphasis on cure to an emphasis on prevention (Cary, 1988). These changes require that nurses working in the home must be cognizant of the cost of equipment and supplies.
In addition, the nurse working in the home must address concerns regarding how the home-based patient is able to obtain the necessities of living. An added responsibility, for these nurses, involves directing others to care for the patient in the nurse's absence. These new responsibilities of care are best identified by nursing directors working with home- based patients. It would behoove deans of baccalaureate schools of nursing to take their cues from these administrators and address new needs in their curricula. To prevent the exodus of newly graduated nurses from the nursing arena, nurse educators must give fixture nurses the tools they need to practice effectively in the home enviroimient.
Review of Literature contains discussions on the history of nursing education, the problems faced by the student who is not appropriately prepared for the work place, the dichotomy between nursing edupation and nursing service, and suggestions from the literature regarding the nursing content that are needed to care for patients in the 21st century. In Methodology, the author describes the methodology for this study, including the research design, instrument development, sample and population, pilot study, data collection, and data analysis.
14 CHAPTER II
REVIEW OF THE LITERATURE
Introduction
Nursing education went through three major changes in the last one hundred years. Some of these changes caused a conflict between nursing education and nursing service resulting in reality shock, role conflict, and an exodus of nurses from the profession (Kramer & Baker, 1971; Kramer & Schmalenberg, 1978a; Lawrence &
Lawrence, 1987). This chapter contains: (a) a review of the history of nursing education,
(b) a review of selected research on nursing role conflict in work settings, and (c) a review of curriculum content needed for home care of the patient.
History of Nursing Education
Early Education of Nurses
After the Civil War and the Crimean War demonstrated to physicians the effect trained nurses of the nineteenth century had upon disease, American physicians began clamoring for trained nurses to care for their patients. A training school for nursing did not exist until Dr. Marie Zakrzewska opened the first training school for nurses in 1867
(Kalisch & Kalisch, 1995). At that time, the training of nurses resembled an apprenticeship in which nurses spent long hours at the bedside. The training was divided into many branches or services such as obstetrics, pediatrics, medical-surgical, and later mental health (Kalisch & Kalisch, 1995).
15 One textbook written by Isobel Hampton in 1878 cost $2.00 and was 484 pages in length (Kalisch & Kalisch, 1995). The textbook was used for 20 years before any major update was undertaken (Kalisch & Kalisch, 1995). These authors indicated that early nursing students worked 12 to 16 hours a day, seven days a week, with a half day off once a month. These students slept on the wards in order to be readily available for service should the need arise (Baas, 1992; Kalish & Kalisch, 1995; Wuthnow, 1987).
During the depression era, many girls entered the apprenticeship subculture of hospital training schools where the discipline was strict, the hours long, and the work hard
(Wuthnow, 1987). Much of the work was menial and had littie to do with nursing care, such as "washing baby shirts and diapers and hanging them on the fire escape to dry"
(Wuthnow, 1987, p. 219). Early nursing students often cared for 20 to 30 patients a day.
The theory portion of nurses' training prior to 1875 was a one hour weekly lecture given by physicians who contracted to give these lectures. According to Kalisch and Kalisch
(1995), the average day of training lasted 12 to 13.5 hours. A survey of hospital schools of nursing in the last century demonstrated the long days. The total number of clinical hours in one week amounted to seventy-nine hours. The total numbers of class hours in one week amounted to three.
At that time, the training course for nurses was one year in length. These programs are long on practice but short on theory. Pillitteri (1991) wrote about clinical practice days that lasted 12 hours, 7 days a week, with no time off. It was believed that the long hours of practice gave the graduated nurses confidence in their skills and abilities to practice nursing (Pillitteri, 1991).
16 After graduation, the nurse worked: (a) in the home doing private duty, (b) in community health agencies, or (c) worked in associations which practiced in rural areas such as Appalachia (Kalisch & Kalisch, 1995). Home care is a tradition that has been with us for a hundred years (Buhler-Wilkerson, Naylor, Holt, & Rinke, 1998). According to these authors, even the sickest of patients are cared for in the home by nurses. By the
second decade of this century, there were more than 4,000 agencies providing home
based care (Buhler-Wilkerson, Naylor, Holt, & Rinke, 1998). These authors suggested
that care of the patient in the home diminished between 1920 and 1930, as hospitals
became centers of learning and research. However, with changes in the delivery of health
care, in which very sick patients are discharged from the hospital in order to cut the costs,
care of the sick has once again moved back into the home (Cary, 1988).
The first major change in the education of nurses occixrred in 1895. The length of
training by 1895 had been extended to two years. At the turn of the century, another year
was added to the training courses for nursing. Because of the grueling schedule, Isabel
Hampton campaigned to have the workday reduced to eight hours plus class time
(KaHsch &KaUsch, 1995).
Education for nurses in the early years of the 20th century was still apprenticeship
oriented, wherein the needs of the patient prevailed and the educational needs of the
student nurse had to "yield thereto" (Kalisch & Kalisch, 1995, p. 244). In the 1920s,
hospitals controlled schools of nursing. Unprepared instructors (not college educated)
frequently taught sciences and theory in meagerly equipped basement classrooms, at
night, after a hard day's work, covering the barest essentials, or classes are omitted
17 altogether (KaUsch & KaHsch, 1995). PilHtteri (1991) wrote of a nursing supervisor who, after lecturing to student nurses, wrote about her ineptness in her diary: "Poor things, how
I pity them sitting there and listening to my stammering and rambling talk" (p. 275). In the 1930s, students received lectures on anatomy and physiology, microbiology, and nursing arts. Kalisch and Kalisch (1995) indicated that in a total of three years of training, students spent less than 150 hours in the classroom, or less than one hour a week.
The second major change in nursing education occurred with the advent of World
War II (WWII) which created a shortage of nurses. In an effort to expedite the education of nurses, the Army created the Cadet Nurse Corps. These nurses are trained in two years plus a six-month internship. The cadet nurses performed as well as diploma graduates from hospital schools of nursing (Kalisch & Kalisch, 1995). The Cadet Nurse Corps was disbanded shortly after WWII, although the nurse shortage continued (Kalisch & Kalisch,
1995).
In summary, early nursing education was totally on-the-job training. The training consisted of housekeeping chores dedicated to keeping the patient and the environment clean. The hours were long, 12 to 16 hours a day, 7 days a week for 24 months.
Textbooks were almost non-existent. When nurses graduated, they did not work in hospitals but did private duty in the patient's home.
Nursing Education After WWII
Perhaps the most profound change in nursing education occurred after WWII, as a result of the performance of nurses educated in the Cadet Nurse Corps. In 1952, Louise
18 McManus wrote a paper regarding the education of nurses. Ms. McManus conducted a feasibility study to determine if community colleges could educate nurses in two years to perform general nursing duties (Kalisch & Kahsch, 1995). She felt that the repetitive practices utilized by the hospital based schools of nursing were a waste of time and energy. McManus theorized that by moving the education of nursing into the academic arena and shortening the educational process, the nursing shortage would be alleviated.
However, that shorter educational process created a situation whereby nurses would not have the long practice hours that had contributed to their ability to organize their time and to develop good technical skills (Schmalenberg & Kramer, 1979a).
During the time when nurses were educated in hospital-based schools of nursing
(and the learning experience was controlled by these institutions), little difference existed between learning beliefs and practice beliefs. As a result, newly graduated nurses experienced no shock when they began to put their training to work (Schmalenberg &
Kramer, 1979a).
The advantage of apprenticeship training was that these nurses did not complain about the difference between their training and the work place (Kramer & Schmalenberg,
1978b). The transfer of nursing education from an apprenticeship mode to a college mode created a situation in which nurses, upon entering their first job, were placed in unfamiliar situations in which former patterns of behavior were ineffective (Davidhizar & Bowen,
1991). This discrepancy created a shock-like reaction in newly graduated nurses.
College-educated nurses spent years preparing for a position in which their education gave them a feeling of confidence in their ability to care for patients, yet the
19 new nurses found that they were not prepared for the work milieu and that became a source of conflict which resuUed in the shock that neophytes experienced in their first jobs (Beck, 1993; Bernhardt, 1992; Beyer, 1992; Kramer & Schmalenberg, 1978b;
Stacklum, 1982; Watson, 1982; Wierda, 1989). Kramer and Schmalenberg (1978a) coined the term "reality-shock" to mean "the conflict which arose from moving from the familiar subculture of college to the unfamiliar subculture of the work environment"
(p. 1).
Kramer (1979) suggested that the work environment was bureaucratic in nature and that created conflict in role expectations. Owens (1991) identified a number of bureaucratic principles: (a) well defined chain of command, (b) system of rules and procedures to govern the work of the institution, (c) division of labor based on specialization and limited in scope, (d) promotion policies based on technical competencies, and (e) impersonal relationships in dealing with employees and the public.
By this definition, bureaucracy was the antithesis of professionalism. Professionalism
(Kramer & Baker, 1971) was depicted as valuing autonomy from organizational control, responsibility for the whole task, self evaluation of performance, collegial relationships with others, and the willingness to move from one organization to another in seeking the freedom to utilize professional behavior.
The problems of role transformation from student to working professional were not limited to nurses. A search of doctoral dissertations, from 1889 to 1993, revealed that teachers experienced reality shock similar to that of nurses (Bernhardt, 1992; Padilla-
Hajjar, 1985; Pfifferling, 1984; Rand, 1981). In addition to the studies conducted by
20 Kramer (1969, 1974) and Kramer and Schmalenberg (1978b) regarding reality shock among nurses, and Itano, Warren, and Ishida, (1987), studied reality shock and its effect on increased attrition rates of elementary school teachers. From these studies, it would seem that education could do much to alleviate reahty shock if courses were taught which would account for the reality of the work situation.
In 1965, the American Nurses Association (ANA) posited that "education for these who work in nursing should take place in institutions of learning within the general education system of institutions of learning" (1966, p. 516). The authors of this position paper fixrther stated that "minimum preparation for beginning professional nursing practice, at the present time, should be at the baccalaureate level of education in nursing"
(ANA, 1966, p. 515).
The recognition that baccalaureate education was the road to professionalism has led to the creation of a new kind of nurse, the newly graduated nurse, who has theoretical knowledge but limited technical skills (Dodds, Lawrence, & Wearing, 1991). Previously, nurses prepared in hospital-based schools of nursing and working as graduates in these same hospitals needed little orientation because the work experience was an extension of the training experience.
Baccalaureate nursing students had specific objectives and were rewarded for achieving them. The students were expected to provide total patient care, usually, to a single patient. They learned to think in concepts and broad principles of care. They were taught to think of themselves as professionals who were autonomous in their nursing fixnctions and who could make decisions regarding patient care without supervision.
21 Students were taught the ideal of providing holistic, complete patient care, guided by a code of ethics and an appreciation of collegial control (Kramer, 1978).
In the 1960s and 1970s, due to the decrease of clinical experience and the increased complexities of nursing care, graduates of collegiate schools of nursing, it was felt, were underprepared for patient care (Schempp & Rompre, 1986). In 1974,
Schmalenberg and Kramer (1979a) said of the newly graduated nurse "Equipped with a basket of'shoulds' and a paper bag of skills, techniques and role specific behaviors, and because of the lack of pre-socialization into work-related values, the nurse was a prime candidate for massive role conflict" (p. 1). Shead (1991), in her analysis of the nursing literature, revealed that role conflict was both inevitable and a leading contributing factor in causing burnout among nurses. Riggin (1982) noted that role conflict, role strain, and role stress were inevitable because students and new graduates lacked the appropriate cognition, values, and skills to cope with the disparities between the theoretical world of nursing and the real world of nursing. Collegiate education of nurses placed much emphasis and value on individualized, direct care of patients oriented toward knowledge, and empathy.
Upon entering the work world, the new graduate experienced stress due to the unanticipated changes in norms, values, rewards, and sanctions. They merged into the real world of nixrsing and found that many of the role values of the classroom were not operational (Kramer, 1970). In the work world, the student was given implicit objectives related to maintaining the system and caring for several patients and was guided to focus
22 on particulars and interpretations endemic to the hospital (Kramer & Schmalenberg,
1978b). Further, the nursing student who was taught to give total, holistic patient care was now expected to delegate part of that care to others.
Glennon (1983) suggested that when two distinct subcultures clash, such as nursing education and nursing practice, a lack of positive interaction occurs between newly graduated nurses and the staff. The resulting conflict was responsible for the lack of job satisfaction on the part of the nurse. That difference in role definition created confixsion and disillusionment on the part of the nurse. Muff (1982) blamed stress, produced through loss of self-esteem, conflict, and lack of autonomy caused by reality stress, for the high incidence of burnout and the high incidence of dropping out from the profession of nursing.
In summary, nursing education after WWII was moving out of the hospital with its on-the-job mentality and moving into colleges and universities. Nursing education became a science based on theory and research (Marriner-Tomey, 1989). Student nurses no longer had to perform a task over and over to demonstrate that they could perform it
(Kalisch & Kalisch, 1995), and they no longer performed housekeeping chores as part of their education (Blanchard, 1983). Student nurses were educated to care for the whole patient, a philosophy which hospital supervisors deemed wasteftxl (Blanchard, 1983).
This author suggested that hospital supervisors felt that assembly-line division of care was more cost effective. The clash of philosophies created reality shock and role conflict in the newly graduated nurse (Kramer & Schmalenberg, 1978a; Cummings, 1990).
23 Role Conflict
Professionals who must practice in a bureaucratic organization encountered role
conflict. Role conflict existed where there was a disparity between the way neophytes
think a role should be performed and the way their supervisors think the role should be
performed (Kramer & Baker, 1971). At present, baccalaureate nurses are educated for
work in an acute care facility, when, in reality, the majority of nurses will be working in
the home (Clarke & Cody, 1994). This situation was likely to lead to more role conflict in
the fixture, unless nursing education provided the curriculum content needed to prepare
their graduates to work in home'care agencies.
Corwin (1971) investigated the dichotomy between the idealism of nursing as
taught in baccalaureate education and the reality of nursing as practiced in the
bureaucracy of a hospital. Corwin preferred to visualize nursing ideals on a continuum
progressing from "highly bureaucratic at one end to highly professional at the other"
(p. 3). He indicated that, whereas the bureaucratic organization stressed categorical and
routine elements, with tasks being the fijndamental unit of the client situation,
professional nurses focused on unique patient problems, a talent which was essential for the nurse who works outside of an acute care agency.
Corwin (1971) argued that a bureaucracy emphasized standardization, and preservation of files and records, thereby preserving continuity and stability, whereas the professional aspect of nursing stressed autonomy and gave importance to variety and change. Unfortunately, schools of nursing need to change their stand on this aspect of
24 nursing because in home health nursing, third party payers base their reimbursement on
files and records. The philosophy of autonomy and independence focused on holistic care will be a plus in the education of fixturenurse s and should not be tampered with (Corwin
1971).
Reality Shock
Many of the problems that occurred as a resuh of major changes in nursing
education, when nursing education moved out of hospitals with their apprentice-type
training into colleges and the world of academia, centered around the nurses experiencing
reality shock. The phenomenon of reality shock came about when the nurse left the
nurturing environment of college and went to work in the hospital environment. Hospital
bureaucracy was based on the compartmentalism mentality of dividing patient care into
segments, for the sake of efficiency, which thwarted the idealism of holism advocated by
academia.
Early studies of reality shock addressed the identification of problems of neophyte
nurses in acute care facilities. Later studies reflected the development of in-service
programs to ease the transition of the nurse from ideals promulgated by colleges to the realities of the work place through internship and/or mentoring programs (Andersen,
1991; Bellinger & McClosky, 1992; Bell, 1990; Boss, 1985; Bygrave, 1985; Campbell-
Forsyth, 1991; Cantwell, Kahn, Lacey & McLaughlin, 1988; Carrol, 1989; Cummings,
1990; Davidhizar & Bowen, 1991; Glennon, 1983; Habgood, 1986; Horsburgh, 1989;
Hutcherson, 1986; Kramer, 1978; Malloy, White, & Zezutek, 1987; McAlpine & Cargill,
25 1992; McClosky & Grace, 1985; McClosky & McCain, 1987; Meisenhelder, 1981;
Modic & Bowman, 1989; Mooney, Diver, & Schnackel, 1988; Myrick, 1988; Olson,
Gresley & Heater, 1984; Porter-Stubbs and Marriner, 1985; Rittman, 1992; Scheetz,
1989; Weiss, 1984). These programs met with varying degrees of success.
According to Kramer (1970), the first year of work in nursing was distinctive. She identified a particular stress that resulted from the dichotomy that existed between baccalaureate nursing education and service in hospitals. The expectations of beginning nurses were idealistic and unrealistic in light of the idealism of education opposed to the reality of the work of nursing. The difference in expectations of the college, as opposed to the work place, produced role conflict in the nurses. The result of this dichotomy created a crisis which Kramer and Schmalenberg (1978a) termed reality shock.
College faculties tend to teach nursing more idealistically than realistically
(Alhadeff, 1979; Bell, 1990; Benne & Bennis, 1959; Bernstein, 1988; Blanchard, 1983;
Caldwell, 1989; Casfle, 1981; Dyson, 1992; Hollefreund, Mooney, Moore & Jersan,
1981; Kramer & Schmalenberg, 1978a; Miller, 1978; Moessin, 1986; Page, & Arena,
1991; Palluoto, 1993; Pfifferiing, 1984; Smith, 1978; Seuss, Schweitzer, & Wilhams
1982; White, 1979). Nursing ideals center on providing total and holistic patient care and autonomous fimctioning in the profession.
Hospitals and other health care agencies expected the beginning nurse to be a finished product, whereas colleges produced nurses with minimum patient care competencies (Palluoto, 1993). Padilla-Hajjar (1985) noted that beginning workers frequently experienced feelings of shock when they left the supportive environment of
26 higher education, created by supervising instructors, for what she called the indifferent attitude of the workplace.
Other studies found that neophyte nurses entered the work worid with a minimum of technical skills (Alhadeff, 1979; Blanchard, 1983; Boss, 1985; & Dyson, 1992; Focus,
1993). New nurses often did not receive support from the employing agency, which would have aided in their fixrtherdevelopmen t of their essential technical skills, organizational skills, and positive attitudes (Kramer, 1978).
Much research has been done regarding hospital efforts to ease the transition of students into the work of nursing such as establishing internships, extended orientation periods, one-on-one orientation, and preceptorships with specially prepared staff nurses on the unit (Andersen, 1991; Cantwell et al., 1989; Chickerella & Lutz, 1981; Davidhizar and Bowen, 1991; Dobbs, 1984; Glennon, 1983; Hollefreund et al., 1981; Holloran,
Mishkin, & Hanson, 1980; Kramer, 1969, 1970; Lawrence & Lawrence, 1987;
Meisenhelder, 1981; Miller, 1981; Modic & Bowman, 1989; Moessin, 1986; Myrick,
1988; Rittman, 1992; Schmalenberg & Kramer, 1979b; Wandeh, Pierce & Widdowson,
1981). Many research articles focused on college-based efforts designed to smooth the transition of the student into the hospital work world such as work-study, summer and winter courses, collaboration with hospitals for clinical internships, and team leading opportunities (Bell, 1990; Bellinger & McClosky, 1992; Boss, 1985; Dale & Savala,
1990; Dyson, 1992; Friss, 1982; Huckstadt, 1981; Kaspirin & Young, 1984; Porter-
Stubbs & Marriner, 1985; Portnoy, 1980; Scheetz, 1989; Topp & Utter, 1993; Vigen,
1987).
27 wmm^aa
The research findings indicated that preceptorships and internships were effective in reducing reality shock and in easing the transition from academia to work. However, when educators and hospital supervisors overlooked the continuum of pre-service and
staff development education, problems continued and new nurses experienced problems in adjusting (Kramer, 1970). The problem with in-service education was that it had cause
fluctuations in the staffing needs of hospitals and was founded on the agency expectation rather than on well grounded research regarding the opinions or the needs of neophyte
nurses (Gaston, 1981; Meisenhelder, 1981; Modic & Bowman, 1989). The exception was
Kramer and Schmalenberg's (1978b) study on reahty shock and biculturism.
In an early study, Kramer (1969) found that with the advent of the collegiate
education of nurses, agencies, and education have dueled over whose job it was to prepare nurses to fixnction competently from the onset of their careers (Kramer, 1969). A
later researcher found that striving for the mastery of technical skills usually continued beyond the orientation period (Benner, 1984). Benner argued that mastery was rarely
achieved in less than three years of on the job experience. While there was the potential for providing job satisfaction during the orientation period, the lack of job satisfaction led to the exodus of neophyte nurses from the profession and this may have led to the critical nurse shortage (Dodds, Lawrence, & Wearing 1991; Fiesta, 1990a; Friss, 1982; Kramer
& Baker, 1971; McClosky & McCain, 1987).
There were some positive findings, in the literature, regarding the commitment by the profession to bridge the educational gap between the theory of nursing and the reality
28 of nursing (Chickerella & Lutz, 1981; Modic & Bowman, 1989; Myrick, 1988; Rittman,
1992). Studies documented that beginning nurses, who had participated in specialized transition programs, remained in nursing and went on to develop their talents (Cook,
1991; Holloran, Mishkin, & Hanson, 1980; Kaspirin & Young, 1984; McClosky &
McCain, 1987; McGrath & Princeton, 1988; and Meisenhelder, 1981).
The shift of nursing care from the hospital to care of the patient in the home has caused fluctuations in staffing needs of hospitals. Many of the full time employee positions were being deleted either naturally through attrition, by layoffs, or by reducing the hours in which nurses work (Bronder, 1997). Home health agencies were taking up the slack. One has only to read the want ads in the newspaper to know that the nursing shortage has not been relieved.
Blanchard (1983) argued that the best defense against reality shock was clinical competence. He suggested that the greatest flaws in education were the kind and amount of clinical experience provided the students. He felt that, to resolve this dilemma, education and service must collaborate, and that senior nursing students must spend much more time in the clinical area working under conditions that staff nurses face.
Colleges and universities evolved slowly in providing educational changes in response to social changes (Gaff, Ratcliff & Associates, 1997). Gaff, Ratcliff and
Associates (1997) argue that educators were on the threshold of a new millennium and that institutions are creating new leaders and educating these leaders to take their place in building a nation that strives to be a just, democratic society. To carry that thought one step further, nursing and nurses are striving to ensure a physically healthy society. Even
29 though change in universities and colleges evolved slowly, changes in health care
dehvery occurred with supersonic speed. In comparison, higher education, as it involves
nursing and other health care disciplines, may need to consider the needs of the consumer
of health care and the needs of these on the front lines in delivering care and making the
necessary curricular changes as expediently as possible. Gaff, Ratcliff and Associates
(1997) asked the question, "What do students needed to know in order to navigate our
new global reality" (p.l 18). The best way to know what curriculum content was
appropriate was to go directly to these nursing directors whose facilities were providing
care outside the acute care facilities.
Other studies reported that first year nurses entered nursing with a minimum of
technical and organizational competencies (Goldfarb, 1986; Kramer, 1970, 1978;
Lewandowski & Kramer, 1980; Moessin, 1986; Smith, 1978). The neophytes were
criticized severely by the staff and did not receive the support that would have aided in
developing these skills.
Literature and research suggest that bum out and reality shock were the result of
changes in the way nurses were educated in colleges and universities as opposed to the
way nurses were trained on-the-job. When the nurse was trained on the job in the hospital
and was employed by the hospital that trained him/her, there was no dichotomy of philosophy. The student was given a diploma and usually applied for a position in the hospital that trained her/him. On the other hand, the nurse who graduated from a college- based program of nursing often received education in several agencies and his/her philosophy reflected the philosophy of the college or university that educated him/her.
30 Upon employment in a hospital, the newly graduated nurse was often confronted with a
philosophy diametrically opposed to the philosophy imbued in her/him by the college. To
prevent the hemorrhage of nursing from the profession, educators and hospitals devised
ways to help the nurse adjust to the employing agency's ways of caring for patients. The
time and effort to ease the adjustment of the nurse to the work situation was perhaps a
costly and time consuming activity that could have been prevented with more realistic
education and clinical experiences.
Nursing in the 21st century reflected yet another change. In the very near fixture,
few nurses will work in acute care settings. Instead, the graduating nurse will work in the
home. Nurse-educators and nursing-administrators could prevent the loss of nurses to the
profession, decrease role conflict, and reduce reality shock if steps were taken to educate
nurses to fixnction in the home.
Nursing in Home Care Settings
One recent study examined the skills needed by the nurse in a home setting
(Arlton, 1994). Discussed was the concern that The University of Northern Colorado
School of Nursing had regarding the high turnover of nurses in the home setting. In an attempt to alleviate this problem, the nurse educators in this school developed a course that would prepare their graduates to fimction in a rural setting. In this course, students delivered complete patient care without the sophisticated equipment common to acute care facilities. Following the implementation of this course, thirty percent of the
University of Northern Colorado's nursing graduates entered home health nursing. These
31 mmm^a
Students reported more collegial relationships and less confrontation with bureaucracy
than did the students entering acute care facilities.
Because of that study and this research project, nurse-educators and nurse-
administrators may come to an agreement on nursing content suitable for care of the
patient in the home. If this were to happen, much of the role conflict and reality shock
present in nursing education today may be decreased if not eliminated.
The transition in nursing has already shifted from cure to prevention as indicated
by a publication regarding primary nursing care from the Institute of Medicine (Primary
Care, 1996). That philosophical approach to health care means that much of nursing will
take place outside of hospitals. The baby boomers have been and are still approaching
retirement age. The aging process has often accompanied by physical and mental
degeneration. Care of the chronically ill and the dying, accompanied by increased cost of
caring for these patients in the hospital, has caused families and insurance agencies to
seek alternatives to hospital care.
The shift of care has gone from the hospital to the home. Therefore, a greater
demand exists for nurses who can fimction independently and autonomously outside of
an acute care facility. Since these agencies have different expectations, newly graduated
nurses face different stresses without the proximity of staff who can readily support nurses and validate their decisions. Nurses who chose to work outside the hospital are caring for acutely and chronically ill patients. As the population ages, nursing care
32 problems associated with the physical, mental, and social degeneration of the patient have
to be addressed in preparing the student to care for these patients. Nurses have to be
skilled in caring for the dying patient who wants to die at home as well as for patients
who are on ventilators and who need rehabilitation. The high cost of caring for a patient
in the hospital has caused the shift of patient care from the hospital to the home. That
shift prompted Clarke and Cody (1994) to suggest that home-based experiences, in which
students learned about patients and their health in the context of the home offered the best
milieu for students to learn the dynamics of real life nursing. These authors felt that
homes would provide sites in which the student could develop the holistic perspective
needed for independent nursing practice. These authors argued that nursing education
must not continue to "focus on the fraction of the population in hospitals while slighting
knowledge about how it was lived every day" (p. 41). They also felt the priority that
content for all nursing students should be a "portable nursing theory base" (p.41) that can
be taken anywhere. They felt that nursing education should focus on health promotion,
healthy environments, and quality of life. In order to do this, Clark and Cody believed that health care had to begin before illness started. Therefore, nurses had to be educated by placing emphasis on promoting health in the family. That philosophy incorporated safety, hygiene, and environmental issues as well as preventive issues, such as immunizations. Quality of life proponents focused on a myriad of issues from early and consistent prenatal care to death and dying. Not the least of these issues was the availability of and access to health care.
33 tBBHM^Bue
Sharp (1992) wrote about the keynote address given by Dr. Russell G. Mawby of
the W.K.Kellogg Foundation to The Community Partnerships Initiatives Conference.
Mawby foresaw new organizational partnerships in which physicians, nurses, dentists,
medical technicians, and other health professions must be knowledgeable in basic and
clinical sciences. According to Mawby they must be "long-term learners, excellent
communicators, good team players, managers of scarce resources, and health care
visionaries" (p. 14). He indicated that professionals no longer dealt with a patient on a
one-to-one basis. Nor were they segregated from other professionals. He felt that
professionals had to work in concert with other health team members. Mawby believed
that to achieve that, health educators in all health disciplines would have to redirect the
educational and socializational experiences of the students to meet the needs of the
patient who was cared for at home.
According to Cary (1988), the refocus on home health care required that nurses
must position themselves in educational programs that provide the foundations necessary
for quality home care delivery. She indicated that curriculum planners in nursing education needed to critically examine their abilities to prepare graduates to fixnction not only in the areas of technical competence, but also in roles involving health promotion, disease prevention, and risk prevention for communities, families, and patients. Other competencies Cary (1988) mentioned were in areas oft (a) autonomy in nursing practice itself, (b) interdisciplinary delivery modes, (c) client advocacy responsibilities, and (d) cost-effective managed care with nurses submitting documentation for reimbursement from third party payers. She suggested that the integration of these concepts may be
34 taught in the classroom but the practice fixnctions, and nursing roles, can only be initiated
through multiple, progressive Practicum experiences throughout the nurse's education.
Further, Cary stated that, "Baccalaureate preparation was a minimum standard for
preparing the home health care professional nurse for these fimctions and roles" (p. 343).
She argued that, in acute care agencies, skilled nursing care was ordered by the physician,
but, in home health situations, home care orders were the result of collaborative
discussions by nurses, physicians, and other health professionals.
The effectiveness of home care nursing depended upon delegating responsibilities
for care to family caregivers or home health aides. Student nurses must be taught the legal
and professional obligation for delegating these tasks to non-nurses. Student nurses must
learn to adapt equipment, procedures, and treatment regimens to the clients' needs,
availability of supplies, sanitation, and disposal elements in the home situation (Cary,
1988).
Cary (1988) beheved that all of these skills should be part of the baccalaureate
program. She argued that in addition to the above, home health students should be
required to learn to assess and diagnose clients, plan nursing care, initiate requests for
multiple therapy providers, select and utilize the most efficacious durable medical
equipment and supplies, link clients and care givers to supportive resources, and negotiate and advocate with providers and insurers in order to augment successfixl client outcomes.
In addition, Goodwin (1992) beheved that case management based on the use of critical pathways was an efficient tool to guide home health nursing practice. When nurses' training moved from apprenticeships in hospitals to education within colleges and
35 universities, a phenomenon termed "reality shock" became evident (Kramer, 1974, p. 12).
The dichotomy between the idealism of the college educated nurse and the pragmatism of
the acute care agency was the root of conflict within the newly graduated nurse (Kramer,
1974). This conflict was responsible for the high attrition rate experienced by hospitals
(Malloy, White, and Zezutek, 1987).
Nurses who had undergone reality shock in acute care settings complained of feelings of loneliness and isolation (Kramer, 1978a). These feelings may be magnified in home health settings. Will the different expectations demanded of neophytes in settings other than acute care agencies decrease feelings of reality shock?
Historically, baccalaureate programs of nursing were viewed as having been long on theory but short on the development of their graduates' organizational and technical skills. However, these programs do teach autonomy and holistic patient care. It appears that nursing outside of acute care agencies capitalizes on nurses being able to fixnction autonomously and holistically.
In order to facilitate the ease of transition and reduce or alleviate reality shock in settings outside of acute care agencies, a list of some common curriculum content areas had to be established in order to prepare the neophyte nurse who opts to work outside of the acute care setting (Cary, 1988). This study centered on compiling a list of curriculum content areas enabling the nurse to fixnction in the 21st century. Opinions of deans of schools of nixrsing regarding health care changes and its effect upon curriculum have not appeared in the nursing literature at this writing.
36 In an effort to contain costs, the shift of nursing care from the hospital to the home was taking place. Nursing care in these areas required additional content be included in nurse's education. The literature suggested several areas of content that should be addressed. One aspect of a literature search suggested that nursing education cannot be of such narrow focus that it becomes isolated from other departments in a college or university (Gaff, Ratcliff & Associates, 1997). Nursing must embrace several disciplines if it were to provide a well-rounded education for its graduates.
Higher Education Literature
Gaff, Ratcliff, and Associates (1997) suggested that "connection" was the most important element in the curriculum (p. 380). Although these authors were speaking of the connection between students and teachers, their idea was equally applicable to the connection between education and service. This study provided a way to think of connections between what nursing directors in home care agencies believe should be taught in schools of nursing. Nurse-educators need to connect with nursing directors of home health agencies and seek their input regarding curriculum content which would better prepare their graduates to function in the home.
Many external forces exist that are putting pressure on academic deans, curriculum committees, and department chairs to bring curricula into the 21st century.
Not the least of these are changes in health care delivery from the acute care facility to the home. Gaff, Ratcliff, and Associates (1997) suggested using the mission statement of a college as a point of departure to engage academic leaders and faculty in a discussion of
37 how external influences were impacting their institutions, their curricula, and the faculty's various disciplines. These authors begged the question regarding what types of technology were appropriate for an institution based on the mission statement and the culture of the institution. They suggested the use of forums to make these determinations.
This researcher believed that the findings from the survey and Delphi techniques proposed here will be usefixl in making curriculum decisions. When the survey proposed here was completed, this researcher developed a curriculum plan for fixturenurses , which incorporated the suggested areas of content identified in this study. This proposed plan meets one of the objectives of this research.
Additional Curriculum Content Needed for Care of the Patient in the Home
To function adequately in the home environment, the literature suggested that nurses must have additional curriculum content. The additional content included: (a) case management; (b) the ability to coordinate care with diverse allied health members as well as unlicensed nursing personnel; (c) the ability to assess patient, family needs; and (d) the ability to order and use technology creatively and as cheaply as possible. Nurses must be managers of scarce resources as well as good communicators. Their documentation of care must be such as to be able to collect fees from third party payers, in addition to communicating nixrsing needs and interventions. They had to be grounded in the knowledge of health promotion, disease prevention, and risk prevention. They had to be able to teach well and be comfortable in teaching patients, families, and unlicensed
38 personnel to care for their patients who were undergoing rehabilitation, or patients who
had a chronic disease. Finally, they demand that the nurse be able to care for patients who
were undergoing the physical, mental, and social degeneration of aging and dying.
Curriculum changes require that educators take into consideration content that
both nurse educators and nursing directors of home care agencies concur were necessary\
in preparing graduates to fimction in caring for patients outside the acute care agencies.
This could best happen by bringing the two sides together in some manner.
Ed O'Neill, Pew Memorial Trust executive director, in his keynote address to the
National Faculty Meeting at the National League of Nursing Summit in Chicago,
challenged "nursing practice and nursing education to pull together, thereby creating an
integrated continuum of education and practice" (O'Neill, 1998). At the same meeting,
Langston (1998) challenged nursing deans to conduct faculty meetings without the "ivory
towers" and with a vision of nursing education in its broadest, most inclusive sense.
Gaff (1991) made a stand for interdisciplinary courses to promote all aspects of
diverse specialties. Gaff (1991) suggested that faculty development in colleges and
universities be geared toward making courses available to enhance particular programs
within the college. Taking that thought a step fiirther, it would behoove the departments
of nursing education to collaborate with other departments and programs on the campus
such as the business education departments in the university to offer their students business management and leadership courses. The biology department could be encouraged to offer nursing students courses in microbiology and disease prevention. The sociology education department could offer courses in cultural diversity including
39 methods of obtaining services for the poor and disenfranchised in communities. Such global thinking opens the door for including the non-nursing content suggested in the literature into courses to enable nurses to fixnction outside the hospital setting. It was expected that this Delphi study would form a conduit to these ends. A curriculum model developed, by this researcher, in chapter 5, incorporated the suggested content from this study.
Colleges and universities have an obhgation to take responsibility for preparing their graduates to go where the patients are and to be able to fimction adequately in that setting (Young, 1991). The changed health care delivery system precipitated and profoundly altered the way nursing education prepared nurses.
Curriculum content areas suggested in this review of the literature included:
1. Business and fiscal management (Sharp, 1992).
2. Leadership/management (Cary, 1988).
3. Management of unlicensed assistive personnel in the home setting (Clark & Cody,
1994).
4. Measurable outcomes criteria, e.g., patient satisfaction, recidivism, and or compliance
(Clarke & Cody, 1994).
5. Case management or critical pathways as part of case management (Clark & Cody,
1994).
6. Health maintenance and preventive care (Institute of Medicine, 1996).
7. Care of the patient in the home health agencies such as hospice (Bulloch & Bulloch,
1990).
40 8. Health care in multicultural or under-served populations, i.e. home or community
relevant care (Bulloch & Bulloch, 1990).
9. Communicable epidemiology such as disease surveillance and control (Institute of
Medicine, 1996).
10. Political activism (ANA Position Paper, 1996).
These content areas formed the basis for development of the initial survey
questionnaire used in this study. That instrument is discussed as part of the methodology
reviewed in Chapter III.
In summary, changes in health care delivery required that nursing educators
provide content in the education of nurses that addresses the care of the patient in the
home. These changes in health care delivery were brought about by economics and
reflected attention to ways in which patient care was managed. Emphasis was placed on
prevention as opposed to cure. These changes also required nurses to be fiscally
responsible in the use of supplies and equipment. It called for teamwork in caring for the
acutely ill in the home. Teamwork required good communication skills. Finally, nursing
research needed to study the outcomes of patient care once the curriculum was approved.
As nursing was confronting a rapidly changing health care system, nursing
education and home health care agencies, out of necessity, should form alliances in order
to prepare our nursing students to provide high-quality, cost effective, home based care to patients and their families.
41 TJgL', I iJlJUUfi :^^
Summary
This researcher believed that this study helped to determine the educational content needed to prepare new graduate nurses to work in health care agencies in the home. Four factors pointed to the need for this study: (a) the uniqueness of nursing in these areas outside of the acute care agencies, (b) the paucity of research regarding the preparation of nurses for these areas, and (c) the use of research based on staff development with beginning nurses in agencies outside of the hospital, (at present a search of the literature did not reveal current research on this topic), M. Kramer (personal communication March 19, 1995), and (d) courses in baccalaureate programs which attempt to bridge the transition of neophyte nurses into the world of nursing in homes and communities.
42 CHAPTER III
METHODOGY
The methodology section contained a description of the research methods that
were used in this sttxdy. Addressed in detail were: (a) the general design, (b) instrument
development, (c) preparation for Delphi rounds, (d) procedures for data collection, (e) power analysis, (f) reliability, and (g) data analysis procedures.
Research Design
The data in this survey was collected for the purposes of identifying, critiquing,
and ranking nursing content needed by newly graduated nurses to fimction in nursing outside the acute care facility now and in the 21st century. The survey was based upon a set of curriculum content areas suggested by the literature, nursing educators, and administrators in home health agencies.
This survey used the Delphi survey technique for data collection. The Delphi technique helps stimulate the generation of ideas and promotes guidance by the composition of individual judgements (Delbecq et al., 1975). The Delphi method had been defined as a systematic approach to gathering consensus of conclusions on a specific topic using questionnaires completed sequentially, each round representing the responses and feedback from prior rounds (Delbecq et al., 1975; Nieswiadomy, 1993). The Delphi technique could be used to solicit consensus for the pixrposes of a needs assessment, curricular planning, and research priorities (Chaney, 1987). The representative qualities
43 of the Delphi method were: (a) anonymous work accomplished individually and
independently, (b) pooled judgements, (c) evaluation of ideas, and (d) a mathematical/
statistical procedure used for voting and determining consensus of judgement.
The benefits of the Delphi method included the focus of the expert or the person
m the field on the problem-solving requirement and/or the generation of ideas, as well as
an evaluation of others' ideas (Delbecq et al, 1975). Limitations include the inability to
clarify ideas, which may reduce the effectiveness of the Delphi instrument (Clark, 1997).
Use of the Delphi technique with this study involved validation of responses
through consensus from two groups of nurse experts. Responses were solicited from:
(a) deans who were involved with the baccalaureate education of nurses and (b) nurse-
administrators of home care agencies who hired the nurses who graduated from
baccalaureate schools of nursing.
Ethical Considerations
The identity of respondents was not disclosed. Participants were coded by assigning them a number and a letter. For example, deans received the code DOOl through DlOO and nursing directors of home health agencies received the codes NOOl to
NIOO. The codes were locked in a file cabinet and will remain there until the dissertation has been successfully defended and then will be destroyed. Results were reported in aggregate form. Respondents were asked to return their business cards if they wished to receive a copy of the results. These cards were kept in a separate file and no codes were
44 attached to them. Detailed discussions of how the instrument was developed and how the
final sUidy participants were selected are given in the appropriate sections that follow.
Instrument Development: Part T
The first step in this study consisted of developing an initial letter and survey
instrument and mailing it to 83 individuals. The initial survey instrument consisted of 10
content items culled from the literature as areas of nursing curriculum content deemed
necessary to enable the nurse to practice nursing in a setting outside of the acute care
agency, i.e., the hospital (see Appendix A). Content analysis of a number of journal
articles (see reference list), repoils such as the Pew Report (1996), college of nursing
handbooks, and nursing textbooks provided the initial list of 10 content areas which the
investigator felt should be included in curricula to enable nurses to adapt to nursing
outside the acute care agency.
In addition, the researcher asked the 40 deans, the 40 home health nursing
directors, and the three textbook authors in this first survey to add five nursing content items that the person deemed important to enable nurses to practice in the home setting.
The participants were also asked to provide editorial comments to both the letter and the survey instrument regarding readability, clarity, and congruence of the items with the objectives of the survey. The second step of instrument development (Appendix B) contained revisions made from the ratings of the individual groups of respondents that were compiled from the first survey plus 21 items suggested by the respondents. It must be noted here that many of the first respondents also suggested that some of the 10 items
45 should really be listed as two items. For example, item number one in Appendix A, called
business and fiscal management, became two items, fiscal management (#22) and
business management (#7) in the next mailout (Appendix B). Item #5 in Appendix A,
called case management as part of critical pathways became items # 19 case management
as part of managed care and #20 critical pathways as part of managed care in
Appendix B. This brought the total items in Appendix B to 33 (10+ 2 +21). The 83
participants (see section under first mailout below for the method of selecting
respondents) in the first and second surveys involved in instrument development,
provided editorial comments on face validity factors such as readability, clarity, and
congruence with the objective of the survey.
Face Validity
Face validity, indicates whether a particular instrument looks as if it measured a
designated construct. Though not acceptable as proof of quality, positive face validity it
may have improved acceptance by users of the instrument (Polit & Hungler, 1995).
Individuals such as: (a) Dr. Paul Randolph, from the College of Business Administration
at Texas Tech University (TTU); (b) Dr. Arturo Olivarez Jr., from the Educational
Psychology and Leadership Division; and (c) Dr. Douglas Hubbard, a statistician and
Director of Computer Services at the Texas Tech University Health Sciences Center
(TTUHSC) in Lubbock, as well as, experts in nursing research and nursing education who were on the dissertation committee-Dr. Susan Pollock, Professor and Associate Dean of Research (TTUHSC-SON) and Dr. Corinne Grimes, Assistant Professor and
46 Competency Coordinator (TTUHSC-SON), provided valuable comments to help
establish the face validity of the first draft of the instrument. Revisions were made in
response to comments by these experts after the preparation of each new draft of the
survey instrument.
First Mailout
On June 15, 1997, the first survey questionnaire containing 10 nursing content
items, was mailed to 40 deans, 40 nursing directors, and 3 authors of community health
textbooks, for their validation and feedback. The purpose of this mailout was to see what
the participants wanted to include in nursing curricula.
The nursing directors and deans participating in this first phase of instrument development were selected by virtue of residing in northeastern, southeastern, northwestern, or southwestern states. Forty deans and forty nursing directors were in each of these four geographic regions or quadrants in the United States (see Figure 3.1). For example, Maine and New York were selected because they were two of the largest states in the northeast. Criteria for selecting the deans were that the deans had to preside over an accredited school of baccalaureate nursing listed in the National League for Nursing
(NLN) directory. The quadrants were visualized by dividing a map of the United States of
America into eastern and western regions along the Mississippi river and into northern to southern regions along the Mason-Dixon Line, starting from the Atlantic Ocean and extending the line to the Pacific Ocean. Three directories were used to select the deans and the nursing directors. These'directories were: (a) The State Approved Schools of
47 Nursing R.N. 1995, Division of Research National League of Nursing, New York, N.Y.
for the deans and (b) The 1994-1995 Guide to the N^^tipn's Hosnices and The 1996
National Homecare & Hospice Directory for the nursing directors. The researcher then
selected the first five deans fisted for each of the eight states selected.
The nursing directors were selected by choosing: (a) the first two administrators in
each of the eight selected states, who were mentioned by name in the 1994-1995 Guide to
the Nation's Hospices, and (b)_the first three nursing administrators, who were mentioned
by name, in each of the eight states, from the 1996 National Homecare and Hospice
Directory. The reason for seeking administrators mentioned by name in these directories was that in the event that there were any questions, this researcher would have a person to contact. Thus, there were five deans and five nursing directors selected from each of the
eight states (see Tables 3.1 - 3.2, p. 49).
Three authors of community health and home health textbooks, recognized authorities in the field of home care and community health, were asked to provide feedback on the instrument and the cover letters in addition to participating with this first survey group of 40 deans and 40 nursing directors. The authors were selected because this researcher had selected their textbooks for her community health nursing course and considered them to be authorities on community and home health, and because these three authors agreed to participate on the basis that they could remain anonymous. (It was assumed that the participants who returned the first survey had also agreed to be included in the study.)
48 iWT'yrti.t::. i u...ii<^ r:
Table 3.1 Eastern and Western States North of the Mason-Dixon Line
DEANS NUMBER NURSING DIRECTORS NUMBER New York New York Maine Maine Minnesota Minnesota Washington Washington
Total Deans 20 Total Nursing Directors 20
Table 3.2 Eastern and Western States South of the Mason-Dixon Line
DEANS NUMBER NURSING DIRECTORS NUMBER Alabama 5 Alabama 5 Georgia 5 Georgia 5 California 5 California 5 Texas 5 Texas 5 Total Deans 20 Total Nursing Directors 20
Note. California is considered a southwestern state (Webster's New World Dictionary. 1995).
This first draft of the instrument, used in the survey to establish content validity, was a self-administered, 10-item, survey featuring a Likert response format with six response options: 5 = essential, 4 = highly desirable, 3 = desirable, 2 = neutral or not sure,
1 = undesirable, 0 = highly undesirable (Appendix A). In addition to the 10 items.
49 respondents were requested to write in five areas of nursing content which they deemed
were important (Appendix A).
Preparation for Second Survey
Of the 83 letters and questionnaires sent out to the 40 deans, the 40 nursing directors, and the three community health textbook authors, 45 responses including, these responses of the three authors were received. Deans and nursing directors from each of the eight states selected responded. Of the 40 deans who were sent surveys, 23 deans responded, for a response rate of 58%. Of the 40 nursing directors, 19 responded, which represented a 48% response rate. All three authors responded for a 100% response rate.
The original, 10 survey items were tabulated, means were established, and placed in a table (Table 3.3). It should be noted that the means were calculated by taking all 45 survey responses for each item. The purpose of this step in the process was to determine whether any items should be discarded. It was this researcher's decision that any item with a mean of 3.0 or above (3= "desirable" on the response scale) would be retained. All
10 items had mean responses of 3.0 or above and were retained for further study.
The 200 hand-written responses were then examined. Since none of the respondents knew of any curriculum content items other than the 10 original items on their list and their own suggestions, these write-in items were not rated. The researcher then categorized these 200 plus items into new curriculum content items. From the 200 suggestions, the researcher developed 21 new curriculum content items.
50 Those items were then added to the initial survey of 10 plus two items. The reason only 21 new items were obtained was that many of the respondents suggested essentially the same items. For example, one suggestion was hsted as content on communication; another suggested expertise in giving oral reports. One person suggested that the nurse
Table 3.3 Deans' and Nursing Directors' Mean Responses Ratings to Original Ten Curriculum Items (N=45)
CURRICULUM CONTENT ITEM MEAN RANGE 1. Business & Fiscal Management' 4.50 5.0-3.0 2. Leadership and Management Skills 4.86 5.0-4.0 3. Management of Unlicensed and Assistive 4.60 5.0-4.0 Personnel in the Home
4. Measurable Outcome Criteria e.g., Patient 3.90 5.0-2.0 Satisfaction, Recidivism, and or Compliance
5. Case Management or Critical Pathways as part of 3.90 5.0-1.0 Case Management^
6. Health Maintenance and Preventive Care 4.07 5.0-2.0 7. Care of the Client in the Home 4.46 5.0-3.0
8. Health Care in Multicultural or Under-served 4.40 5.0-3.0 Populations i.e.. Community Relevant Care
9. Communicable Epidemiology 4.07 5.0-2.0
10. Political Activism 3.93 5.0-2.0
Note: Became Business Management (#7) and Fiscal Management (#22) Note: Became Case Management as part of Managed Care (#19) Critical Pathways as Part of Managed Care (#20)
51 should have the ability to explain the rationale of care to a person with a 5th grade education. Another suggested being able to write good nurses notes; another suggested being able to write summaries oif patient needs. Those suggestions were placed in the general curriculum content category "Communication." On the revised 33 items questionnaire these items were included as "Communication: Written (#2)" (see p. 127) and "Communication: Oral (#1)."
Instrument Development: Part II
The original 10 items, plus two, and the 21 items derived from the first set of written suggestions were compiled into a second survey tool with 33 content items.
Because of suggestions from the respondents, some items were reworded for clarity and two of the items became four items leaving only eight unchanged from the first survey.
Eight of the original items stayed the same with minor editing and two of the original items became four items. The original item listed as "business/fiscal management" became "business management (#7)" and "fiscal management (#22)." The item listed as
"case management or critical pathways as part of managed care " became "case management as part of managed care" (#19) and "critical pathways as part of case management" (#20). These items were identified in Table 3.3 on p. 49 by the use of asterisks.
The eight original items and the 4 revised items totaled 12 items. The 21 items suggested by the respondents plus the 12 revised items brought the total number of items up to 33 for the second questionnaire.
52 --'^—^•- — -[wrrmiiri'Tfr'—
The 23 items on the second survey were listed as follows: communication: oral; communication: written; time management, care of the client in the home; pain management, leadership; business management; health maintenance; disease prevention; care of the patient emotionally, legal issues, health care in multicultural populations, measurable outcome criteria; care of the dying patient; management of unlicensed, assistive personnel; working within a team; fixnctioning autonomously in the field, informatics; case management as part of managed care; critical pathways as part of managed care; palliative care; fiscal management; quality assurance; disease surveillance; epidemiology; mediation resolution; rehabilitation nursing; screening for home health; adult learning; research utilization, third party payment; telenursing; and political activism.
First Mail Back
The data collected from the first survey indicated the 45 respondents' judgements on the validity of the first 10 items. These were expanded to 12 items, and placed on a second list. In addition, the panel's suggestions of 21 items were incorporated in the second list of 33 items (Appendix B). This list was placed in a survey format (Appendix
B) and mailed to a new set of 80_deans and 80 nursing directors and the three experts previously mentioned.
53 Preparation for Second Mailout
In this second mailout, four new groups of 40 persons from each of the four
geographical quadrants in the continental United States was devised for a combined total
of 80 deans and 80 nursing directors (Tables 3.4-3.5). The second survey group was to be
Table 3.4 Eastern and Western States North of the Mason-Dixon Line
DEANS NUMBER NURSING DIRECTORS NUMBER
New York 10 New York 10 Maine 10 Maine 10 Washington 10 Washington 10 Minnesota 10 Minnesota 10 Total Deans 40 Total Nursing Directors 40
Table 3.5 Eastern and Western States South of the Mason-Dixon Line
DEANS NUMBER NURSES[G DIRECTORS NUMBER Alabama 10 Alabama 10
Georgia 10 Georgia 10 California 10 California 10
Texas 10 Texas 10
Total Deans 40 Total Nursing Directors 40
54 made up of: (a) nursing deans of NLN accredited baccalaureate schools of nursing, (b)
nursing directors from community health agencies, (c) nursing directors of hospices, and
(d) nursing directors from home health agencies for a total of 80 deans and 80
administrators. This time the researcher started at the end of the directory lists. The
breakdown was as follows: (a) Deans: 20 from the northeast, 20 from the northwest, 20
from the southeast, and 20 from the southwest and (b) Nursing Directors: 20 from the
northeast, 20 from the north west, 20 from the southeast, 20 from the southwest, (see
Tables 3.4-3.5 above).
Second Mailout
The cover letters and revised questionnaires with 33 items were mailed to a new
group of 160 individuals, and the three original experts, along with a self-addressed,
stamped return envelope. The cover letter included a statement regarding the fact that if
anyone wished to have a copy of the results of the survey, the researcher would be glad to
comply with the request to anyone who sent a business card with their completed questionnaire. There were 91 returns out of a possible 163 (56%). Every state was represented. The breakdown of the responses showed that 41 deans out of 80 responded for a response rate of 51% and 47 nursing directors out of 80 responded for a response rate of 59%. All three authors again responded. Each of the 33 items was then ranked according to the mean responses for each item (see Table 3.6).
55 , •- ~-"'r
Table 3.6 Deans' and Nursing Directors' Mean Response Ratings, Mean Differences, and Response Ranges of the Expanded List of Thirty-Three Curriculum Content Items (n=91)
CURRICULUM CONTENT ITEMS Mean: Mean: Difference Range Deans Nursing Directors
1. Communication: Oral 4.72 3.48 1.24 5.0-3.0
2. Communication: Written 3.62 4.90 -1.28 5.0-3.0
3. Time Management 3.60 4.71 -1.11 5.0-2.0 4. Care of the Patient in the Home 3.76 4.90 -1.06 5.0-1.0 5. Pain Management 4.51 4.20 0.31 5.0-2.0 6. Leadership 4.91 3.76 1.21 5.0-2.0 7. Business Management 3.61 4.80 -1.19 5.0-2.0 8. Health Maintenance 4.51 3.52 0.99 5.0-2.0 9. Disease Prevention 5.51 3.42 1.09 5.0-3.0 10. Care of the Patient Emotionally 4.49 3.12 1.37 5.0-2.0 11. Legal Issues 4.44 4.00 0.44 5.0-3.0 12. Health care in Multicultural 4.70 3.50 1.20 5.0-2.0 Populations
13. Measurable Outcome 4.40 3.22 1.18 5.0-2.0 14. Care of the Dying Patient 4.86 3.82 1.04 5.0-2.0
15. Management of unlicensed. 3.24 4.40 -1.16 5.0-1.0 Assistive personnel
16. Working within a Team 3.30 4.31 -1.11 5.0-2.0
17. Functioning Autonomously in 4.00 4.44 -0.44 5.0-2.0 the Field
18. Informatics 4.31 3.33 0.98 5.0-2.0
19. Case Management 3.80 4.80 -1.00 5.0-2.0
56 Table 3.6 Continued.
CURRICULUM CONTENT ITEMS Mean: Mean: Difference Range Deans Nursing Directors
20. Critical Pathways as part of 3.80 4.80 -1.00 5.0-2.0 Managed Care
21. Palhative Care 3.75 4.50 -0.75 5.0-2.0 22. Fiscal Management 3.60 4.80 -1.20 5.0-2.0 23. Quality Assurance 3.48 4.90 -1.42 5.0-2.0 24. Communicable Disease Surveillance 4.13 3.01 1.12 5.0-2.0 25. Epidemiology 4.13 3.01 1.12 5.0-2.0 26. Mediation Resolution 3.22 4.26 -1.04 5.0-2.0 27. Rehabilitation Nursing 4.40 3.10 1.20 5.0-2.0 28. Screening for Home Health 3.51 4.70 -1.19 5.0-2.0 29. Adult Learning 4.78 3.00 1.78 5.0-2.0 30. Research Utilization 4.80 3.35 1.45 5.0-2.0 31. Third Party Payment 3.22 4.78 -1.56 5.0-2.0 32. Telenursing 3.00 4.50 -1.50 5.0-2.0 33. Political Activism 3.51 3.00 0.51 5.0-2.0
The purpose of this step in the study was to: (a) simulate a Delphi round and to assess the strengths and flaws in the use of the expanded survey tool and (b) assess the acceptance and the face validity of the 21 new items, 8 original items, and the 4 revised items. Feedback was also sought regarding the cover letters and instructions that would accompany the mailed instruments in the final study. Analysis of this data provided key direction, particularly for revision of: (a) the insttimient, (b) the individual items
57 ttCBt
comprising the concepttial domain of nursing content, (c) the Delphi method (Delbecq
et al., 1975), and (d) this group survey technique (Borg & Gall, 1989).
Second Mail Back
The 91 rettims from this second mailout in the development of the instrument
examined and ranked according to the mean responses to each item in order to determine
if any items should be discarded because of low mean ratings. The lowest item mean response was 3.5 (see Table 3.6). On the response scale that rating was above 3.0,
meaning the item on the average was desired. This researcher determined that no item
should be discarded at this time.
First Delphi Round
The 33 content items were grouped according to seven general curriculum
categories and placed in a revised survey instrument (Appendix C). The categories were
as follows: (a) Part I: Leadership; (b) Part 2: Management issues such as time
management, business management, fiscal management, management of unlicensed assistive personal in the home setting, case management, critical pathways as part of case management, screening for home health, third party payment, working within a team, and fimctioning autonomously in the field; (c) Part 3: Individual care issues, which include: pain management, care of the patient in the home, care of the patient emotionally, palliative care, care of the dying patient, health maintenance, and rehabilitation nursing;
58 (d) Part 4: Care issues in aggregates such as health care in muhiculttiral populations,
communicable disease, epidemiology, and disease prevention; (e) Part 5:
Communication, which included communication-written, communication-oral,
informatics, telenursing, and adult learning; (f) Part 6: Research, which included the use
of measurable outcome criteria, research utilization, and quality assurance; and (g) Part 7:
Political issues such as mediation resolution, legal issues, and political activism.
Procedure for Data Collection
In the first round of the study, the instrument was sent to 300 nurse-educators
(deans of baccalaureate schools of nursing) and 300 nurse-administrators from home
health agencies. The same directories used to select participants for the development of
the survey were used to select the new participants for the final survey study.
Random selection was used to obtain participants. The researcher counted the
number of schools of nursing in each state. She then made out slips of paper (2" x 2")
with a single number (not digit) written on each slip of paper to equal the number of
schools in each state. For example, Texas had 57 accredited baccalaureate schools of
nursing so the slips of paper were numbered 1 to 57. When the researcher was ready to
select the deans of the baccalaureate schools of nursing for Texas, she put the 57 slips of
papers in a shoebox and asked two people to draw out sic slips of paper. This procedure
occurred state by state until the researcher had selected six numbers from each state.
When the six numbers had been drawn for each state, the researcher selected the first dean by starting with the first school of nursing listed in that state counted down until she
59 .^'^\vrth??^^^•^.•'^r^^r^^ ftceeoT"^ ' ••.g?.^-' reached the lowest number drawn. That dean was selected for the survey. The same procedure was used for the second lowest number drawn and for the third, and so on. That procedure was used until 6 deans from each of the 50 states, also Puerto Rico, St. Thomas in the Virgin Islands, and Washington, D.C. were selected. The exceptions were Alaska, Hawaii, and Montana, each has only one accredited baccalaureate school of nursing. The one dean from each of these schools of nursing were selected. The number of accredited baccalaureate schools of nursing were counted for Puerto Rico, St Thomas in the Virgin Islands, and for Washington, D.C. Slips of paper representing the number of schools in Puerto Rico and Washington, D.C. were placed in a shoebox and five slips of paper from each of these three areas were selected. The same procedure was used to select the nursing directors. The researcher went to the directory for home health and counted the number of agencies listed for that state. It might be 765. Slips of paper numbered from 1 to 765 were placed in a container and the helper was asked to draw five slips of paper. That agency was located as before, and the nurse-administrator of that agency was asked to participate in the survey. This procedure was used in all 50 states, Puerto Rico, St. Thomas in the Virgin Islands, and Washington, D.C. had yielded 300 persons to be contacted. In the pilot study, the researcher selected only agencies that listed the nursing director. However, more than half of the nursing directors had moved on and responses were delayed as the mail was forwarded. In the interest of expediency, the researcher did not limit the selection of home health agencies because the directors' name was not listed. The envelopes were addressed to the present nursing director or designee. 60 Once the 300 deans and 300 administrators were selected, a cover letter, and a copy of the survey with a self-addressed envelope were mailed to them on June, 15, 1998 (Appendix C). Results were then tabulated for each of the two survey groups, and a second Delphi mailing round of the survey was sent out on July 15, 1998 (Appendix D). When these surveys were returned, means for each of the 33 items were tabulated for each person in each of the two groups. Each respondent received a copy of the deans' and nursing directors' means for each item, with their second questionnaire. Each respondent also received a copy of his/her initial response to each of the 33 items and was asked if he/she wished to change his/her response to any of the items. A third round of the survey was mailed on August 15, 1998. This round was sent with the deans' and nursing directors' means as well as the respondents' last response. The participants again had an opportunity to change their responses (Appendix E). Any recipients of the survey who did not return their responses to any of the three rounds, received a reminder letter in an effort to achieve a 100% response for each round (Appendix F). Second and Third Rounds The purpose of the second and third round mailing was to determine, through the Delphi process, the degree of consensus (Morgan & Krueger, 1993) on additional nursing content suggested by the 33 items in the seven categories. 61 Power Analysis Power analysis was done using a table advocated by Krejcie and Morgan (1993) to determine the appropriate sample sizes for this sttidy. It was discovered that with a population of 550 baccalaureate schools of nursing deans, a sample size of 226 within +- .05 was needed to achieve a 95% level of confidence with the results. There were 2,000 home health agencies listed in the directory. Using the same power analysis, a sample size of 368 nurse-administrators within +/- .05% was needed to achieve a 95% level of confidence with the resuhs. Because there was a large difference in the number of baccalaureate schools of nursing deans and nursing directors of home health agencies listed, Krejci and Morgan's (1993) guidelines indicated that the researcher should split the difference in sample size. Therefore, the difference in the sample sizes of 368 and 226 was 142. Splitting the difference of 142 resulted in the number 71. This investigator then added 71 to the sample size of 226 deans of baccalaureate schools of nursing, bringing the sample size up to 297. This investigator then subtracted 71 from 368 home health agencies, suggested bringing the sample size down to 297. Thus, both sample sizes were equal in the final study. However, this researcher decided to send out 300 questionnaires to each group. Fewer than the desired number of responses were obtained for each group. This investigator then sent a reminder letter to the non-respondents and encourage them to complete the appropriate round(s) (see Appendix F). 62 *'^ I I iTirt^. iriinnn>TH>ii' Instrument Reliahihty The split-half reliability method was used in the second stage of the insttimient development. There were 33 questionnaire items, at this stage, therefore odd numbered items exceeded the even numbered items by 1. The split-half reliability coefficient was calculated by permitting the Statistical Analysis System (SAS) to supply the missing data in an effort to compare the data with the calculation for the Pearson Product Moment Correlation Coefficient (r). This method was used because the split-half reliability coefficient underestimates the reliability of a test (Crowl, 1996). The reliability coefficients for the deans' and the nurse-administrators' instrument were corrected for test length by applying the Spearman Brown prophecy formula. The reliability coefficient for the dean's survey of 33 items was 0.81. The reliability coefficient for the nurse- administrator's survey of the 33 items was 0.79. These two high relatively high coefficients represented an adequate level of reliability for use of these two forms of the same instrument in the final Delphi phase of this research. Split-half reliability coefficients were also calculated and corrected for test length after the last Delphi Round. The coefficients of 0.77 for the deans and 0.71 for the nursing directors illustrated a satisfactory level of reliabihty for the deans and nursing directors in the final study. Reliability refers to the "level of internal consistency or stability of the measuring device over time" (Borg & Gall, 1989, p.257). The reliability of an instrument was higher with decreased variability found in repeated measures (SAS Research Guide, 1997). 63 BBHIHB Because reliability was not a stable property of an instrument, it should be estimated with each use of an insttnment (Lynn, 1989; Polit & Hungler, 1995). Perfect reliability was expressed as a coefficient of 1.00; no rehability was expressed as 0.00. In practice, reliability coefficients normally range from 0.0 to 1.00. "For most purposes, reliability coefficients above .70 were considered satisfactory" (Polit & Hungler, 1995, p.349). Instrument Validity There were three types of validity (content, criterion-related, and construct), each of which was used to validate different types of tests (e.g., achievement, aptitude, and personality). The curriculum content of nursing education can be thought of as a population consisting of persons having particular kinds of knowledge and skills. The major purpose of this study was to determine what nursing deans and nurse- administrators of home care agencies believed would be curriculum content needed for nurses working in the home rather than in a hospital. This investigator examined the literature and research related to nursing curriculum content prior to 1998. The researcher then developed a 10-item survey instrument which she felt reflected content that should be added to the nursing curriculum to prepare fiiture nurses for work in the home in the next century. In the instrument development phase of this study, it was clear that the nursing deans and nurse-administrators felt that the current academic content of the curriculum needed to be expanded beyond the 10 content items originally proposed. Determination of the content validity evaluated the "sampling adequacy of the content area being measured" (Polit & Hungler, 1995, p. 354). Content validity was based 64 on judgement, in this case, the adequacy of the nursing education content as judged by the deans and the nursing directors in the instrument development rounds of this sttidy. Therefore, singular instrument validity was a measure of what degree the items were supported by the respondents in the initial two insttnment development mailings and the Delphi rounds. As already reported, the support was high for all 33 items. Analysis of Data Research Ouestion Number One Do deans of baccalaureate schools of nursing and nursing directors of home health care agencies concur with the current health care hterature regarding curriculum content needed to prepare graduates to fimction in the home setting? Analysis Procedures: Content identified in the review of the literature became the first 10 items on the first instrument development survey (Appendix A). The combined responses of the deans, nurse-administrators, and the three experts were then used to calculate mean responses for each of the ten items. All of the means were above 3.0, the rating standard of "desirable" which was set for this study. The responses to these 10 items indicated that the three groups accepted the 10 items from the literature as being valid content items in the preparation of nurses for home care facilities. However, the three groups of respondents in the first phase of the instrument development recommended over 200 more content areas to be covered in the preparation of fiiture home nurses. These 200 plus responses were then grouped into 21 categories for the second phase of instrument development. In the second survey for instrument 65 >:. nxx's) Bwtisiy nnmii>7g.i I 'J :J-:. development, a new group of 91 deans, nurse-administrators, and experts validated all 33 ttems (12 + 21). This group was not given the opportunity to add more items, nor did they attempt to do so. None of the rettims from this second mailout contained suggestions for new curriculum content items. All of their mean responses were above 3.5. Since all of the means were above 3.0, the mean rating standard of "desirable" which was set for this study, it was concluded that the deans, nurse-administrators, and the three experts did only partially concur with the health care literature regarding nursing care curriculum. Had they concurred completely with the first 10 items, they would not have recommended 200 items or supported the 21 new items added to the instrument. The final sttidy determined whether nursing deans and nursing administrators agreed with the content mentioned in the literature (initial 10 items) and the 21 new items. Research Ouestion Number Two Is there congruence between the perceptions of deans of baccalaureate schools of nursing and nursing directors of home health care agencies regarding curriculum content needed to prepare graduates to fimction in home health care? Calculation of means and standard deviations for each item on the instrument, and for each Delphi round, resulted in descriptive information about the responses of each respondent group. The mean was generally considered the most stable measure of central tendency and was the "average of an entire set of scores" (Borg & Gall, 1989, p. 342). It was calculated by adding up a set of scores and dividing the sum by the number of 66 response scores (n=). A mean response of 3.0 or better, on a rating scale of 0 to 5, was used to indicate validity of the item after the third Delphi round. Since there were two groups in this study, a t-test for independent means was used to determine whether or not there were significant differences in the mean responses for the nursing directors and the nurse educators on each of the 33 academic content areas. Overall, congruency was assumed if the majority of the 33 t-tests show no statistically significant differences between the two groups surveyed. First Round Mailout Three hundred invitations to participate in this study went out to deans in the all of these United States, Washington D.C, Puerto Rico, and St. Thomas in the Virgin Islands, on June 15, 1998. Two hundred and eight deans (69%) responded. Forty-nine states were represented, as well as Washington D.C, and Puerto Rico. None of the deans in Hawaii or the Virgin Islands responded. A telephone call to these two places did not produce any positive results. Three letters were returned by the post office as undeliverable. A telephone call went to each of these non-participants, all located in universities. It was revealed that the departments of nursing in these universities closed because there were not enough students to keep the department open. No attempt was made by the researcher to replace these deans with three others. Therefore, the sample size was 297 for deans. A reminder letter went out July 1, 1998 to 89 deans who had not yet responded. Eight returns were received in response to the reminder letter. That brought the total number of responses received from the deans to 216 (72%). 67 I iiiiiii hii iiiiiiiiTfTrii>riinfiiM.iyiiuiiiiM" Three hundred invitations to participate in the sttidy were sent, on June 15, 1998, to 300 nursing directors of home health agencies throughout these United States, Washington D.C, Puerto Rico, and St. Thomas in the Virgin Islands. One hundred and seventy usable responses were received. Nursing directors from every state, Washington D.C, and Puerto Rico responded. Nursing Directors from St. Thomas did not respond. Forty-nine letters were returned by the post office as being undeliverable. Using the lottery system, 49 new agencies were selected from each state represented by the 49 returned letters. In addition to the 49 letters to the new agencies, 81 reminder letters were sent out to nursing directors on July 1, 1998. Ten more nursing directors responded as a result of the reminder letters or the new invitations that went out. The total responses from the nursing directors, for the first Delphi round, were 180 (60%). Returns from the First Round Of the 396 returns, the range of responses for all 33 items was 1 to 5. There were no responses of zero. See Appendix G for the means and range of responses. Second Round Mailout On July 15, the second set of questionnaires was sent out to the deans and nursing directors who had responded to the first questionnaire. Two hundred sixteen (216) questionnaires were sent to deans and 180 questionnaires were sent to nursing directors. The questionnaire contained the 33 original content items in Column I, the mean from the deans responses in column II, the mean from the nursing directors responses in Column 68 .«^^.- inniiiririTTi n III, the responses of the recipient in Column IV, and a blank column in which the recipient was asked to respond again to the content item. The recipient had the option of keeping his/her response the same or changing his/her response. Returns From the Second Round Returns from the second round mailout out were due July 30th. At that time, this researcher received 208 (69%) returns from deans and 164 (55%) returns from nursing directors. Three of the deans and two nursing director respondents wrote that they would not change their answers this time or in the future. See Appendix G for mean responses and range of responses. Third Round Mailout The third round mailout was done on August 15th. Letters and questionnaires were sent to the 208 deans and to the 164 nursing directors who responded to the second round. Again, the questionnaire contained the 33 original content items in Column I the means from the deans responses in Column II, the means from the nursing directors responses in Column III, the responses of the recipient in Column IV, and a blank column in which the recipient was asked to respond again to each content item. The recipient had the option of keeping his/her response to each item the same or changing his/her response to each item. 69 Returns from the Third Round Returns from the third round mailout were due August 30th. At that time, the researcher received 185 (62%) responses from the deans and 152 (51 %) responses from the nursing directors. See Appendix H for mean responses and r-test resuhs. A note from two schools of nursing indicated that the deans who were participating in the research survey from these schools had passed away prior to receiving their third questionnaires. Further Suggestions and Comments Eighty-one (81) nursing directors offered 139 suggestions for additional nursing content and 5 additional comments. The most frequently suggested content item that the nursing directors suggested was that the schools of nursing teach "insurance policy information, such as capitation, fee for service, various insurance reimbursement policies, and how these policies affect approaches to client care, and what restrictions they impose on chent care." This researcher feU that this particular suggestion was covered in content item # 9, which was third-party payment. Fifteen (15) nursing directors made this suggestion. In addition, there were eight suggestions regarding content on managed care. Comments were essentially good luck wishes. One nursing director thanked me for including her in the study. Another told me that she had recently met with the local university on content that they wanted taught to nurses who were seeking employment with them. A telephone call from a home health agency in Vermont suggested that I present my findings to the annual national meeting of Home Care Nurses. Another nursing director told me that I had done an outstanding job of including the basics. 70 •HHEBHIH One hundred and two (102) deans of baccalaureate schools of nursing offered 197 suggestions and three comments. The most frequent suggestion from the deans was that family nursing dynamics/family focused care should be taught; 10 deans suggested this item. Seven (7) deans suggested that reimbursement policies of Medicare, Blue Cross, Medicaid, etc., should be included in the curriculum. This suggestion was covered under nursing content item # 9. Other deans' comments included such things as good luck. One dean wrote that they offer a home health elective. One dean mentioned that it was "one thing to list content and another thing to implement it in the curriculum." One dean indicated that the content identified in the questionnaire was essential for nurses in other areas as well as home care. She fiirther indicated that, hopefiilly, students were able to transfer content from one setting to another, and that when teaching home care the specifics relating to home care need only be emphasized. Summary A 33-item curriculum content questionnaire was developed from the literature and from responses to two pilot studies to investigate what curriculum content items should be added to the curriculum to prepare nurses to work in the home. Invitations to participate in the study were sent to 300 deans and 300 nursing directors randomly selected throughout all 50 states, Washington D.C, Puerto Rico, and St. Thomas in the Virgin Islands. The final number of deans responding was 185 (62%) and the final number of nursing directors responding was 152 (51%). Between the first and third set of 71 responses 31 deans and 29 nursing directors dropped out of the study. Follow up letters elicited few additional responses. One hundred and eighty-three (183) respondents offered suggestions for 336 new curriculum content items and several words of encouragement. Results of this questionnaire will be presented in Section F^, Results, and discussed in Section V, Summary, Major Findings, and Recommendations. 72 CHAPTER IV RESULTS Introduction This chapter contains five sections. The data sections are: (a) background characteristics of the deans and the nursing directors, (b) findings related to research question number one, (c) findings related to research question number two, (d) a summary of the curriculum content suggestions made by the deans and nursing directors and, (e) a chapter summary. Respondent Background Characteristics Educational Background of the Deans The final count of deans responding to the questionnaire was 185. The initial response of deans to the questionnaire was 216. The first questionnaire contained a section on demographic information of both the deans and nursing directors that was not repeated in subsequent mailings. Of the 216 deans of baccalaureate schools of nursing who responded, 200 had doctorates (93%). One hundred twenty-six (126) deans had Ph.D.'s; 56 had Ed.D.'s; 14 had a D.N.Sc./D.N.S.; two deans had a D.P.H. (Doctor of Public Health); 14 deans had Master of the Science of Nursing (M.S.N.) or Master of Arts (M.A.) degrees ; and two deans had a Master of Business Administtation (M.B.A.). Two of the deans, who had master's degrees, wrote that they were working on their doctorates, one of whom was at the dissertation stage (see Figure 4.1). 73 126 140f 12 IOQK 56 80-'' 60-'' QNumber of 40-'' Deans 14 14 20f' 0 :2B^^TCSS^ Ph.D. fe Ed.D. D.N.S. D.P.H.M.S.N.M.B.A. Other Figure 4.1 Educational Background of Deans (n=216). Educational Background of Nursing Directors of Home Health Agencies The fmal count of nursing directors responding to the questionnaire was 152. However, with the initial questionnaire, a section on demographics was included and 180 nursing directors responded. Subsequently, 28 nursing directors did not return responses to the finalquestionnair e leaving only 152 nursing directors in the final data analysis. Of the 180 nursing directors who responded to this question (see Figure 4.2), 35 had a Master of the Science of Nursing degree (M.S.N.); two had a Master of Arts (M.A.) degree; two had a Master of Education (M.Ed.) degree; four had a Master of Public Health (M.P.H.) degree; four had a Master of Public Heahh Administration (M.P.A.) degree; 79 had a Bachelor of Science of Nursing (B.S.N.) degree; eight had a Bachelor of Arts (B.A.); 2 had a Bachelor of Science in Education (B.S. Ed.) degree; 34 had an Associate in Nursing (A.D.N.); and there were 10 respondents who were diploma graduates (they received their R.N. when they passed their state board examination after graduating from a hospital based school of nursing) (see Figure 4.2). 74 O Nursing Directors 79 8 Figure 4.2 Educational Background of Nursing Directors (n = 180). Deans' Years of Nursing Experience Of the 215 deans who answered this question, one dean did not respond. The majority of the 215 deans who answered this question, 142 (66%>), had 26 or more years of nursing experience; 31 (14%)) deans had 21 to 25 years of nursing experience; 25 (12%) deans had 16-20 years of nursing experience; 14 (6%) deans had 11-15 years of nursing experience; two (1%) deans had 6-10 years of nursing experience; one (4%) dean had 1-5 years of experience; and one dean left this question blank (see Figure 4.3). Figure 4.3 Deans' Years of Nursing Experience (n=215). 75 •• \\J.« Nursing Directors' Years of Nursing Experience The majority of nursing directors 70 (39%>) had 26 or more years of nursing experience; 43 (24%) of the nursing directors had 21 to 25 years of nursing experience; 43 (24%) of the nursing directors had 16 to 20 years experience; 16 (9%) of the nursing directors had 11 to 15 years experience in nursing; four (2%) of the nursing directors had 6 to 10 years experience in nursing; and 4 (2%) had 1 to 5 years experience in nursing ( see Figure 4.4). 26+ 21-25 15-20 11-15 6-10 1-5 D Nursing directors •4^ f^ Figure 4.4 Nursing Directors' Years of Nursing Experience. (n=152). Number of Full-time Undergraduate Students Reported by the Deans Each dean was asked how many fiill-time students were in their undergraduate nursing program. The numbers ranged from 8 schools of nursing having 50 or less students to one school of nursing having 1200 fiill-time students in the undergraduate nursing program. The greatest number of schools fell within the range of 101 to 150 76 undergraduate nursing students. There were 33 schools of nursing, as reported by the deans, in that range. Nine deans did not fill in this part of the survey (see Figure 4.5). • Number of Schools >m •-r"' "-."' T^ "7^ Ti T^ gr* ^ ^T* "Tg^ <50 51- 101- 151-201- 251-301- 351-401-501-1000- 100 150 200 250 300 350 400 500 800 1200 Figure 4.5 Vertical Bars Showing the Number of Schools with the Number of Full-time Students Shown on the Horizontal Axis (n=207). Number of Full-time Nurses Employed in Respondents' Agencies One hundred eighty (180) nursing directors answered this question. The majority (51) of the home health agencies employed between 11 and 25 registered nurses. Five agencies reported that there was only one registered nurse (R.N.) in their agency. Two nursing directors indicated that they were the only R.Ns. employed in their agency. The number of registered nurses in the agencies ranged from 1 to 434 (see Figure 4.6). 77 %T jiw ^T*32c:: '-\ Number of Agencies 10 or less 11-25 26-50 51-75 76-100 101-434 Figure 4.6 Vertical Bars Showing the Number of Employees, Horizontal Axis Showing the Number of Agencies Employing that Number of Nurses (n=180). Summary of Respondent Background Characteristics It was found that the deans (143 or 66%) had more years of nursing experience in the 26+ year category than did the nursing directors (70 or 39%). As expected, the deans of baccalaureate schools of nursing reported a higher level of formal education. One hundred and ninety-nine (199) of the 216 deans (93%) responding to the survey had indicated that they had earned doctorates as opposed to the nursing directors who reported none in this category. The greatest number of the nursing directors (49%) had earned bachelors degrees. All 216 of the responding deans had an education beyond the bachelor's degree. Findings Related to the First Research Question 1. Do deans of baccalaureate schools of nursing and nursing directors of home health care agencies concur with the current health care literature regarding curriculum content needed to prepare graduates to fimctions in the home setting? 78 •Curriculum Content Items Receiving the Highest Ratings by Deans The questionnaire used a Likert scale with the following description: Essential =5 ; Highly Desirable =4; Desirable =3; Uncertain or Neutral =2; Undesirable =1; and Highly Undesirable =0). A mean response rating of 4.5 was interpreted to mean that these curriculum content items were "essential" for fiiture curricula. In Table 4.1, the first column contains the list of curriculum content items that the deans rated greater than 4.5. Column 2 contains a list of deans' mean responses to the same items. Column 3 contains the standard deviations for the deans' mean responses. Column 4 contains a list of the nursing directors' mean responses to these items. Column 5 contains the standard deviations for the nursing directors mean responses. The deans' ratings resulted in 14 items having mean responses greater than 4.5 (see Table 4.1). The nursing directors' mean ratings resulted in only seven items having mean responses greater than 4.5. On only two items, numbers 6 and 7, did the nursing directors show a mean rating higher than the deans. It should also be noted that items ranked 1 through 7 received ratings of 4.5 or better by both groups. The first item which the nursing directors rated higher than the deans was "Functioning Autonomously in the Field (#7)." The nursing directors' mean response for this item was 4.91, whereas the deans' mean response for this item was 4.68. The deans rated all but two of the curriculum content items in this study higher than the nursing directors. The average mean response for the 33 items, as rated by the deans, was 4.23. 79 Table 4.1 Rank Order of the Deans' (n=185) Curriculum Content Item Mean Response Ratmgs Greater Than 4.5, Compared to the Nursing Directors' (n=152) Mean Resp Ratmgs for the Same Items. onse Curriculum Content Items Ranked by Deans' Deans SD Nursing SD Mean Responses' Directors 1. Communication: Written #23 4.88 0.37 4.72' 0.55 2. Working Within a Team #10 4.87 0.34 4.66' 0.49 3. Communication: Oral #4 4.86 0.39 4.70' 0.53 4. Case Management as Part of Managed 4.79 0.43 4.53' 0.59 Care #6 5. Care ofthe Patient in the Home #13 4.74 0.51 4.64' 0.52 6. Time Management #2 4.69 0.50 4.74' 0.51 7. Functioning Autonomously in the Field 4.68 0.53 4.91' 0.37 #11 8. Management of Unlicensed Assistive 4.58 0.55 4.35 0.57 Personnel #5 9. Care of the Patient Emotionally # 15 4.58 0.57 4.08 0.71 10. Leadership #1 4.58 0.59 4.44 0.56 11. Health Care in Multicultural Populations #19 4.55 0.64 3.76 0.74 12. Disease Prevention #22 4.54 0.56 3.91 0.72 13. Health Maintenance #7 4.54 0.54 4.22 0.71 14. Measurable Outcome Criteria #28 4.51 0.58 4.37 0.62 Note: The # sign indicates the number ofthe item in the final questionnaire. Note: Nursing directors also rated these items greater than 4.5. 80 Whereas, the average mean response for the 33 items, as rated by the nursing directors, was 4.04. Curriculum Content Items Receiving Mean Ratings Between 4.0 and 4.5 by the Deans Table 4.2 shows the rank order of items that received deans mean response ratings between 4.0 and 4.5. Column 1 contains a listing ofthe curriculum content items. Column 2 contains a Usting ofthe deans' mean responses for these items. Column 3 lists the standard deviations associated with the deans' mean responses. Column 4 lists the nursing directors' mean responses for the curriculum content items in Column 1, and Column 5 lists the standard deviations associated with the nursing directors' mean responses. Note that all ofthe items on this list, received higher mean responses by the deans. It was interesting to note that the greatest difference between the deans' mean response and the nursing directors' mean response here, was in the area of research utilization, number 3. The difference between the two groups mean responses on this item was 0.91, representing almost an entire response category drop on the Likert scale from "Highly Desirable" (4.43) which the deans suggested, to merely "Desirable" (3.52) for the nursing directors. The deans' mean responses for these 13 items were rated between 4.0 and 4.5, (which was considered "Highly Desirable" for this survey). The nursing directors' mean responses for five of these items were between 4.0 and 4.5. 81 Table 4.2 Rank Order ofthe Deans' (n=185) Curriculum Content Item Mean Response Ratmgs Between 4.0 and 4.5, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items. Curriculum Content Items Ranked by Deans' Means: SD Means: SD Responses Deans Nursing Directors 1. Pain Management #12 4.48 0.63 4.09 0.73 2. Care ofThe Dying Patient #16 4.45 0.58 4.17 0.62 3. Research Utilization #29 4.43 0.62 3.52 0.80 4. Quality Assurance #30 4.42 0.57 4.18 0.55 5. Critical Pathways as Part of Managed Care #7 4.41 0.53 4.24 0.71 6. Palliative Care #14 4.41 0.54 4.04 0.66 7. Legal Issues #32 4.32 0.56 3.64 0.67 8. Aduh Learning #27 4.28 0.61 4.11 0.72 9. Screening for Home Health #8 4.23 0.67 4.11 0.76 10. Informatics #25 4.18 0.69 3.64 0.85 11. Rehabilitation Nursing #18 4.11 0.62 3.99 0.68 12. Communicable Disease Surveillance #20 4.09 0.66 3.48 0.73 13. Epidemiology #21 4.04 0.67 3.45 0.66 Note. The # sign shows the number ofthe item on the final questionnaire. 82 Curriculum Content Ttems Receiving Mean Ratings Under 4.0 by the Hpanc Six items received mean response ratings below 4.0 by the deans, whereas, the nursing directors' mean responses rated 13 items below 4.0. Ratings of 3, 2, or 1 on the Likert Scale represented "Desirable (3)," "Neutral or Not Sure (2)", or "Undesirable (1)." Table 4.3 contains the deans' and nursing directors' rating means of these six curriculum content items which received deans' mean response ratings below 4.0. One notes that in this category. The deans' mean responses were higher than the nursing directors' mean responses on four ofthe six items. The nursing directors' mean responses were greater than the deans' mean responses for two items: (a) "Fiscal Management," which the nursing directors' rated as 3.82, whereas the deans' mean response for this item was 3.78 and (b) the "Business Management" item for which the nursing directors' mean response was 3.80, as opposed to the deans' mean response of 3.72 for the same. While not shown, it should also be noted that the only curriculum content item to receive a mean response below 3.0 in this study was "Political Activism," number 33. The nursing directors' mean response to this item was 2.88, which placed the item in the category of "Neutral or Uncertain" on the Likert response scale. The lowest rated curriculum content item by the deans' was "Telenursing," number 6 in Table 4.3. The deans' mean response to this item was 3.53. The nursing directors' mean response to the "Telenursing" item was 3.13, which along with "Mediation Resolution", item number 4, was also rated 3.13, made these two items with the lowest mean response from the nursing directors. 83 '^^v "hWIIOHHMWWwaiUugSSW* Table 4.3 Rank Order ofthe Deans' (n=185) Curriculum Content Items Mean Response Ratmgs Under 4.0, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items. Curriculum Content Items Ranked by Deans' Deans SD Nursing SD Mean Responses. Directors 1. Third-party payment # 9 3.99 0.66 3.78 0.79 2. Fiscal Management # 4 3.78 0.64 3.82 0.83 3. Business Management # 3 3.72 0.64 3.80 0.82 4. Mediation Resolution # 31 3.68 0.71 3.13 0.76 5. Political Activism #33 3.61 0.80 2.88 0.86 6. Telenursing # 26 3.53 0.67 3.13 0.90 Note. The # sign indicates the number ofthe item in the final a uestionilaire . Curriculum Content Items Receiving Mean Ratings Under 4.0 by the Nursing Directors The nursing directors had mean responses under 4.0 on 13 items. The deans had mean responses below 4.0 for six of these curriculum content items. The items receiving mean responses of less than 4.0 by the nursing directors are shown in descending order in column two of Table 4.4. Table 4.4 also shows the deans' mean responses to these same items. The mean responses by the deans were less than the nursing directors' mean responses on only two of these 13 items. The nursing director's mean responses were greater than the deans' mean responses for the items: (a) fiscal management 3.82 versus 84 3.78 and (b) business management 3.80 versus 3.72. The lowest curriculum content mean response by the nursing directors' was for political activism, 2.88. The deans' mean response for this item was 3.61, a difference of .73. The deans' mean response ratings for seven of these 13 items were greater than 4.0. "Health Care in Muhicultural Populations" received a mean response rate by the deans of 4.55, indicating that the curriculum content item was considered "Essential" by the deans. However, this same item received only a 3.76 mean response rating by the nursing directors. The nursing directors gave "Mediation Resolution" and "Telenursing" a mean response rating of 3.13. The only other item that the nursing directors' rated lower was "Political Activism," with a mean response rating of 2.88. Summary Related To Research Ouestion Number One In Table 4.5, Eleven ofthe 12 original curriculum content items were judged by both the deans and nursing directors to be at least "desirable" for inclusion in future curricula. Mean responses by both groups on all 12 items were greater than 3.50 (3.0 was "Desirable" on the Likert scale for this survey). Nine ofthe twelve items achieved mean responses from the deans greater than 4.0, which was a "Highly Desirable" (4.0) on the Likert scale for this survey. It would seem that there was strong agreement with the literature from the deans, who felt strongly that these 12 items should be included in future nursing curricula. 85 'lytMtMMIIMWl II Table 4.4 Rank Order ofthe Nursing Directors' (n=152) Curriculum Content Item Mean Responses Ratings Below 4.0, Compared to the Deans' (n=185) Mean Responses for the Same Items. Curriculum Content Items Ranked by Nursing Nursing SD Deans SD Directors' Mean Responses. Directors 1. Rehabilitation Nursing # 18 3.99 0.68 4.11 0.62 2. Fiscal Management #4 3.82 0.83 3.78 0.64 3. Business Management #3 3.80 0.82 3.72 0.64 4. Third-party payment #9 3.78 0.79 3.99 0.66 5. Health Care in Multicultural Populations 3.76 0.74 4.55 0.64 #19 6. Informatics #25 3.64 0.85 4.18 0.69 7. Legal Issues #32 3.64 0.67 4.32 0.56 8. Research Utilization #29 3.52 0.80 4.43 0.62 9. Communicable Disease Surveillance #20 3.48 0.73 4.09 0.65 10. Epidemiology #21 3.45 0.66 4.04 0.67 11. Telenursing #26 3.13 0.90 3.53 0.67 12. Mediation Resolution #31 3.13 0.76 3.68 0.71 13. Political Activism #33 2.88 0.86 3.61 0.80 Note. The # sign indicates the number ofthe item in the final questionnaire. 86 It should be noted that the mean responses ofthe nursing directors indicated that they also agreed with the literature that at least 11 ofthe 12 items should be included in fiiture curricula. The one item on which the nursing directors did not agree with the literature was item #12, "Political Activism." On that item, the mean response by the nursing directors was 2.88 (2 = Neutral or Unsure on the Likert scale for this survey). The nursing directors' mean responses for seven ofthe items was greater than 4.0, which was "Highly Desirable" on the Likert scale. There was strong agreement by the nursing directors with the Hterature that these items should be included in fiiture nursing curricula. Four ofthe remaining items received mean responses by the directors of greater than 3.0 but less than 4.0. Three (3) was "Desirable" on the Likert scale for this survey. One could conclude that there was at least moderate agreement among the nursing directors with the literature that these items should be included in fiiture nursing curricula. On 9 ofthe 12 mean comparisons in Table 4.5, there was not a consensus or congruence of ratings between the two groups, as indicated by the significant /-values found in 9 ofthe 12 mean comparisons. While congruence was not found in 9 out ofthe 12 mean response comparisons between the two groups, this did not mean that these nine items should not be included in fiiture nursing education curricula. The mean responses by both groups to these nine items still showed that they were at least "Desirable" items for inclusion in fiiture curricula. 87 ; -v^x>;7jie<6a(Baooerr-. Table 4.5 A Comparison ofthe Deans' (n=185) and Nursing Directors' (n=152) Mean Responses for the Twelve Curriculum Content Items Needed to Prepare Nurses for Work in the Home. Curriculum Content Items Deans Nursing /-values Directors 1. Business Management #3 3.72 3.80 -0.88 2 Fiscal Management #4 3.78 3.82 -0.53 3. Leadership #1 4.58 4.44 2.15* 4. Management of Unlicensed 4.58 4.35 3.86** Assistive Personnel #5 . 5. Measurable Outcomes Criteria #28 4.51 4.37 2.17* 6. Case Management as 4.80 4.53 4.69** Part of Managed Care #6 7- Critical Pathways as 4.41 4.24 2.32* Part of Managed Care # 7 8. Health Maintenance #17 4.54 4.22 4.44** 9. Care ofthe Patient in 4.74 4.64 1.60 the Home #13 10. Health Care in Multicultural 4.55 3.76 10.49** Populations #19 11. Communicable Disease 4.09 3.48 8.05** Surveillance #20 12. PoHtical Activism #33 3.61 2.88 8.07** * Significance beyond the 0.05 level ** Significance beyond the 0.01 level Note. The # sign indicates the number ofthe item in the final questionnaire 88 R^m Findings Related to the Second Research Ouestion 2- Is there congruence between the perceptions of deans of baccalaureate schools of nursing and nursing directors of home health care agencies regarding curriculum content needed to prepare graduates to fimction in home health care? Using 33 /-tests to determine whether there were statistically significant differences between the pairs of mean responses ofthe two groups, it was discovered that there was agreement between the two groups on only six curriculum content items. These items were: (a) Time Management, (b) Business Management, (c) Fiscal Management, (d) Screening for Home Health, (e) Care ofthe Patient in the Home, and (f) Rehabilitation Nursing, (see Table 4.6). The /- test on these items three curriculum content items indicated there was not a significant difference between the mean responses ofthe deans and ofthe nursing directors. Therefore, these two groups agreed in their ratings of these six items. The probabilities ofthe calculated /-value for "Time Management" and "Business Management" were greater than 0.05, indicating that there was no statistically significant difference between the two groups. In other words, there was congruence between the groups on these items. Data analyses resulted in 27 statistically significant / values at the 0.05 level, meaning that the two groups differed significantly on 27 ofthe 33 items in terms of their mean responses (see Appendix H for a complete listing of all /-values and their probability levels). 89 IIWWIIIMIMI I Table 4.6 Curriculum Content Items Showing Non-significant /-values When Deans' (n=185) and Nursing Directors' (n=152) Means Were Compared. Curriculum Content Items Showing Means: Means: /-vaues Congruence Deans Nursing Directors 1. Time Management #2 4.99 4.74 -0.88 2. Business Management #3 3.72 3.80 -0.88 3. Fiscal Management #4 3.78 3.82 -0.53 4. Screening for Home Health #8 4.23 4.11 1.48 5. Care ofthe Patient in the Home #13 4.74 4.64 1.60 6. Rehabilitation Nursing #18 4.11 3.99 1.71 * Significance beyond the 0.05 level. The /-test on each of these items indicated there was not a statistically significant difference between groups. ** Significance beyond 0.01 level. Note. The # sign indicates the number ofthe item in the final questionnaire. Summary Related to Research Ouestion Number Two Essentially, there was statistical congruence between the two groups on the mean responses on only six items: (a) Time management, (b) Business management, (c) Fiscal Management, (d) Screening for Home Health, (e) Care ofthe Patient in the Home, and (f) Rehabilitation Nursing. However, while these differences existed, the mean responses of both groups; deans and nursing directors, suggest that at least 27 ofthe 33 curriculum content items should be included in nursing curricula in the fiiture. 90 '"TT^sS Summary The major findings in this chapter were that the deans' mean responses indicated that they moderately or strongly agreed that all 12 items from the literature should be included in fiiture nursing curriculum. The deans also "strongly agreed" (M=4.5 or greater, Essential on the Likert scale) that 14 items ofthe 33 items in the final survey questionnaire should be included in fiiture curricula. They moderately agreed that 13 items (M=4.0 to 4.5, Highly Desirable on the Likert scale) in the final survey questionnaire should be included in fiiture curricula. The deans also agreed (M=3.5 to 4.0, Desirable on the Likert scale) that the remaining 6 items should be included in fiiture nursing curricula. The mean responses ofthe nursing directors indicated that they strongly agreed (M=4.5 or greater. Essential on the Likert scale) that seven items should be included in fiiture curricula. The nursing directors' mean responses also indicated they moderately agreed (M=4.0 to 4.5, "Highly Desirable" on the Likert scale) that 13 ofthe items should be included in fiiture nursing curricula. And finally, the mean responses ofthe nursing directors indicated that they also agreed (M=3.0 to 4.0, "Desirable" on the Likert scale) that 12 items should be included in fiiture nursing curricula and one item they were neutral or unsure (M=2.5 to 3.0) whether or not "Political Activism." That item should not be curriculum content item included in fiiture nursing curricula. 91 IIPPiliiBWI CHAPTER V SUMMARY, MAJOR FINDINGS, RECOMMENDATIONS, AND CONCLUSIONS This section has five components. It contains the summary, major findings, discussion, recommendations, and conclusions. In the past four decades of this century there appears to be a dichotomy between nursing education and nursing service in hospitals. The problem developed when nursing education moved out of hospitals into colleges and universities. College educated nurses now are prepared to fimction primarily in a hospital or an acute care facility, seeing the patient as a whole being, with one nurse attending to all ofthe patient's physical, emotional, and spiritual needs. Hospital supervisors have felt, in more recent times, that it is now more expedient to meet patients' needs by having one nurse perform the same fimction for all patients, while another nurse performs a different task for the entire unit. This clash of ideal and reality may be creating reality shock and leading to a high attrition of nurses from the profession. Nursing care today is moving out ofthe hospitals and into the home, thus requiring additional nursing knowledge in order that the nurse may fimction in the home, as well as in the hospital or acute care facility. This study was an effort to bridge the gap between what nursing directors of home health agencies and what nurse educators (deans of baccalaureate schools of nursing) felt were important additional curriculum content 92 Items to be included in the curriculum to prepare fiiture nurses to fimction in the home, as well as in acute care facilities. A review ofthe literature suggested there were at least 10 curriculum content items needed to prepare fiiture nurses to work in the home. A pilot study containing these 10 curriculum content items was sent to three nursing experts in home and community health agencies as well as to 40 deans of baccalaureate schools of nursing and to 40 nurse administrators across the United States. These pilot groups were asked to rate the 10 items as to whether or not they should be included in fiiture nursing curricula (see Appendix A). The respondents were asked to rate each curriculum content item using a Likert scale with possible response categories ranging from 0 (Highly Undesirable) to 5 (Essential). The 10 items were analyzed for means and ranges and placed on a table (see Appendix A). All 10 items received a mean response of greater than 3.0 (Desirable). The respondents in the pilot study were also asked to add additional curriculum content items that they felt would be needed for nursing curriculum in the fiiture. The pilot respondents recommended a total of 200-curriculum content items which, when categorized, became 21 curriculum content items. In addition, several ofthe respondents felt that two ofthe original 10 items were really four items. Item #1 which was the "Business and Fiscal Management" became items #7 and #22 on the final questionnaire. Item # 5, "Case Management or Critical Pathways as Part of Case Management" became Items #19 and #20 on the final questionnaire (see Appendix B). 93 MfllH^HHHD^SBWHPI The original 12 content items plus the 21 suggested content items were developed into a questionnaire containing 33 content items. This questionnaire used the same Likert scale with six response categories to be used with each ofthe 33 items. This questionnaire was then sent to the original 3 experts, plus 40 different deans of baccalaureate schools of nursing and 40 different nursing directors of home health agencies. The mean responses and ranges were calculated (see Appendix B). All items received a mean response by both groups greater than 3.0 (Desirable); thus, all 33 items were retained for the final Delphi study questionnaire. The 33 items were arranged into categories. There were seven categories, with content concerning: (a) Leadership, (b) Management, (c) the Individual, (d) the Aggregate, (e) Communication, (f) Research, and (g) Political Issues. A power analysis was done using a table advocated by Krejcie and Morgan (1993). It was determined that a sample size of 300 deans and 300 nurse administrators was needed to achieve a confidence level of 95% for the findings in the final study. Three hundred deans of baccalaureate schools of nursing and 300 nursing directors of home health agencies throughout the United States, Washington D.C, Puerto Rico, and St. Thomas in the Virgin Islands were invited in the summer of 1998 to participate in this Delphi survey. Questionnaires containing 33 curriculum content items (see Appendix C), derived from the literature and pilot studies in 1997, were sent to 300 deans of baccalaureate schools of nursing and to 300 nursing directors of home health agencies. Both of these groups were selected randomly for this study. The respondents were asked to rate each item using a Likert scale, 5 (Essential) being high and 0 (Highly Undesirable) being low. The study used the Delphi technique of three rounds to achieve 94 •••^•HH^K^aWMMM^ congruence on the 33 curriculum content items. On two subsequent rounds the respondents were given the deans' mean ratings for each item and the nursing directors mean ratings for each item. A copy ofthe individual's responses and an opportunity to change or retain their rating of each item was also provided in the second and third Delphi rounds. Thirty-three /-tests were carried out between pairs of mean responses (see Appendix H) for the means responses. There were two research questions in the study: 1. Do deans of baccalaureate schools of nursing and nursing directors of home health care agencies concur with the current health care literature regarding curriculum content needed to prepare graduates to fimction in the home setting? The data was analyzed to determine whether the respondents' mean ratings concurred with the 12 items found in the literature. Both groups rated 11 ofthe items greater than 3.0. The mean response ratings from both the deans and the nursing directors indicated that 32 ofthe items should be included in fiiture nursing curricula. The deans' mean responses of 3.0 or greater (desirable on the Likert scale for this study) indicated that they considered that all 33 items should be included in fiiture nursing curricula. The nursing mean responses of 3.0 or greater (desirable on the Likert scale for this study) indicated that they considered that 32 items should be included in fiiture nursing curricula. However, the nursing directors' mean for "Political Activism" was 2.88, 95 Mam KWMIC indicating that they were neutral or uncertain that "Political Activism" should be included in fiiture curriculum. The mean responses from the deans and nursing directors indicated that there was statistical congruence between the groups on only four items: (a) "Time Management," (b) "Business Management," (c) "Screening for Home Health," and (d) "Management of Unlicensed Assistive Personnel." However, there was agreement between both groups that 28 items were desirable as indicated by means greater than 3.0. The nursing directors' mean responses of 2.88 for "Political Activism" indicated that they did not agree with the deans' mean responses regarding this item. 2. Is there congruence between that perceptions of deans of baccalaureate schools of nursing and nursing directors of home health care agencies regarding curriculum content needed to prepare graduates to fimction in home health care? There was statistical congruence on only six items. The were "Time Management" #2 (-0.88), "Business Management" #3 (-0.88), "Fiscal Management" #4 (-0.53), "Screening for Home Health" #8 (1.48) and "Care ofthe Patient in the Home #13 (1.60), "Rehabilitation Nursing" #18 (1.71). However, both groups rated 32 ofthe 33 items greater than 3.0 which was "Desirable" on the Likert scale. So we can say that both groups agreed on all 32 items. The one item on which both groups did not agree was desirable was "Political Activism" #33. Although the deans rated this item greater than 3.0, the nursing directors rated this item 2.88 which was "Uncertain/Neutral" on the Likert scale. 96 Major Findings Concerning Deans' and Nursing Directors' Backgrounds One ofthe major findings was that the deans who responded had more education and more years of nursing experience than the nursing directors. Two hundred ofthe 216 deans who responded were doctoral prepared for their position as dean. The other 16 deans had master's degrees. Two of those deans wrote that they were at the dissertation stage of their doctorates. The highest degree ofthe nursing directors who responded, was a master's degree, none held a doctorate. Forty-seven nursing directors had masters' degrees. The majority of nursing directors had a bachelor's degree, 89% ofthe nursing directors had this degree. Thirty-four nursing directors had an A.D.N., a two-year college degree in nursing. Ten nursing directors had a diploma in nursing, a diploma is offered to the nurse who successfiilly completes a hospital-based program in nursing. The nurse is then permitted to sit for the state board examination for R.N. licensure. The deans also had more years of nursing experience, with a mean of 24+ years of nursing experience, than did the nursing directors who had a mean of 21+ years of nursing experience. Concerning Deans' and Nursing Directors' Responses Overall, the deans tended to rate the items in the questionnaire higher than the nursing directors (29 out of 33) (see Appendix H). A surprising finding was that nursing directors tended to rate most items lower in terms of curricular importance than did the deans. It would seem that areas which vitally affected care ofthe patient in the home (Part 97 Ill- content that concerned the individual and Part IV content that concerned the aggregate 11 items) would have received higher mean response ratings by the nursing directors than by the deans. Perhaps the reason for this phenomenon was based on the deans' educational background. They have to do a lot of reading and must keep their finger on the pulse of patient care issues and trends. In order to guide their organizations, these deans must keep their schools of nursing viable and in touch with current N.L.N. accreditation standards in order to remain open. On this basis, perhaps, the deans placed a greater value on the curriculum content items needed for fiiture nurses to practice nursing in the home than did the nursing directors because they were more in touch with current literature than the nursing directors. On the other hand, nursing directors are restricted by the guidelines dictated by third party payers. If Medicare, Medicaid, or other health insurance agencies do not pay for services such as palliative care etc., the home health agency cannot afford to offer those services. For this reason, nursing directors might not rate "Palliative Care" very high. There were several items on the list of 33 curriculum content items that nursing directors rated lower than the deans. Some of these items referred to individual care, such as: (a) Pain Management, M=4.09; (b) Palliative Care, M=4.04; (c) Care ofthe Dying, M=4.17; (d) Health Maintenance M= 4.22; (e) Rehabihtation Nursing, M=3.99 (see Appendix G) for comparison. 98 From the somewhat higher mean ratings by the nursing directors for such management items as: (a) Time Management, M= 4.74; (b) Case Management as part of Managed Care, M=4.53; (c) Working Within a Team, M=4.66; and (d) Functioning Autonomously in the Field, M=4.91, it would appear that nursing care may have to sacrifice some compassion in favor ofthe economics ("bottom line mentahty") of present day health care delivery (see Appendix G). The nursing directors' seven curriculum content item mean responses for care of the individual did indicate that they feh that these items, with the exception of "Rehabihtation Nursing" (item #8), were "highly desirable" (mean response ratings of greater than 4.0). However, for the management items, the directors rated them as "highly desirable," that is, rated the items closer to 5.0. For example, the nursing directors' mean rating for "Team Management" was M=4.74 and for "Working Within a Team was M=4.66. In addition, there were only four items that the nursing directors rated higher than the deans (see Appendix H). They were: (a) "Time Management," M=4.74; (b) "Business Management," M=3.80; (c) "Fiscal Management," M=3.82; and (d) "Functioning Autonomously in the Field," M=4.91. Research Ouestion Number One Did deans of baccalaureate schools of nursing and nursing directors of home health care agencies concur with the current health care literature regarding curriculum content needed to prepare graduates to fimction in the home setting? 99 Table 5.1 demonstrates that all ofthe 12 items mentioned in the literature received mean responses from the deans of greater than 3.5, indicating that many ofthe deans feh Table 5.1 Deans' (n=185) and Nursing Directors' (n=152) Mean Responses to the Twelve Cumculum Content Items Found in the Literature. Curriculum Content Items Deans Nursing Directors 1. Business Management #3 3.72 3.80 2. Fiscal Management # 4 3.78 3.82 3. Leadership #1 4.58 4.44 4. Management of Unhcensed Assistive Personnel #5 4.58 4.35 5. Measurable Outcome Criteria #28 4.51 4.37 6. Case Management as Part of Managed Care #6 4.80 4.53 7. Critical Pathways as Part of Case Management #7 4.41 4.24 8. Care ofthe Patient in the Home #13 4.74 4.64 9. Health Care in Multicultural Populations #19 4.55 3.76 10. Disease Prevention #22 4.54 3.91 11. Communicable Disease Surveillance #20 4.09 3.48 12. Political Activism #33 3.61 2.88 Note. The # sign indicated the number ofthe item in the final quesjtionnaire . 100 IRIffia that these items were "Desirable" or "Highly Desirable" for use in fiiture nursing curricula. Essentially deans of baccalaureate schools of nursing did concur with current health care literature regarding what curriculum content items should be included in the curriculum in order to prepare nurses to fimction in the home. The information on seven ofthe items received mean responses of greater than 4.5, which indicated that the items were "Essential" or "Highly Desirable," according to the deans. All of these items should clearly be included in fiiture nursing curricula. The nursing directors of home health agencies indicated, by their mean responses, that 11 of the 12 items advocated in the literature were desirable, the exception was the item, "Political Activism," for which the mean response rating by the nursing directors was 2.88 (which was neutral or uncertain on the Likert scale of responses for this study). The nursing directors' mean responses indicted that six of these items were greater than 4.0 meaning they were "Highly Desirable" for inclusion in fiiture nursing curricula. Two ofthe mean responses by the nursing directors were greater than 4.5 which indicated that these items were "Essential" for curriculum content in the preparation for fiiture home health nurses who would be working in the home. Those two items were "Case Management as part of Managed Care," M=4.53, and "Time Management," M=4.74. It would stand to reason that the nursing directors would feel more strongly about these two items. The low means response by the nursing directors for item #33, "Political Activism" M=2.88, indicated that they were neutral or unsure about the need for this curriculum 101 BBMH!^^ content item in the fiiture preparation of nurses to work in the home. It was, and still is, this researcher's opinion that being politically active in your professional organization is one way nurses, in general and home health nurses in particular can effect change. Perhaps with enough pressure on health care insurance payers, we nurses can persuade health insurance companies to pay for compassionate care such as "Palliative Care" for the dying patient. "Business and Fiscal Management" items were rated only slightly less than 4.0 (Highly Desirable) but greater than 3.5 by both groups. This indicated that both groups still feh that this content should be included in fiiture curricula. In summary, both groups were very positive about the 10 (later 12) literature derived curriculum content items in this study. Highest Ratings bv the Deans The deans rated 14 items with mean responses greater than 4.5 (see Table 5.2). Items whose means were greater than 4.5 strongly indicated that the deans considered these items to be "Essential" content in the curriculum. Nursing directors rated only seven of these items greater than a mean of 4.5. The items with mean responses under 4.5 for the nursing directors, but above 4.5 for the deans were as follows: "Management of Unlicensed Assistive Personnel" #8, M=4.58 and M=4.35; "Care ofthe Patient Emotionally" #9, M=4.59 and M=4.08; "Leadership" #10, M=4.58 and M=4.44; "Health Care in Multicultural Populations" #11, M=4,55 and M=3.76; "Disease Prevention" #12, M=4.54 and M=3.91; "Health 102 Maintenance" #13, M=4.54 and M=4.22; "Measurable Outcome Criteria" #14, M=4.51 and M=4.37 (see Table 5.2). Table 5.2 Rank Order ofthe Deans' (n=185) Curriculum Content Item Mean Response Ratings Greater Than 4.5, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items. Curriculum Content Items Ranked by Deans' Deans SD Nursing SD Mean Responses' Directors 1. Communication: Written #23 4.88 0.37 4.72' 0.55 2. Working Within a Team #10 4.87 0.34 4.66' 0.49 3. Communication: Oral #24 4.86 0.39 4.70' 0.49 4. Case Management as Part of Managed 4.80 0.43 4.53' 0.59 Care #6 5. Care ofthe Patient in the Home #13 4.74 0.51 4.64' 0.52 6. Time Management #2 4.69 0.50 4.74' 0.51 7. Functioning Autonomously in the Field 4.68 0.53 4.91' 0.37 #11 8. Management of Unlicensed Assistive 4.58 0.55 4.35 0.57 Personnel #5 9 Care of the Patient Emotionally # 15 4.58 0.57 4.08 0.71 10. Leadership #1 4.58 0.59 4.44 0.56 11. Health Care in Multicultural Populations #19 4.55 0.64 3.76 0.74 12. Disease Prevention #22 4.54 0.56 3.91 0.72 13. Health Maintenance #7 4.54 0.54 4.22 0.71 14. Measurable Outcome Criteria #28 4.51 0.58 4.37 0.62 Note: Nursing directors also rated these items greater than 4.5. Note: The # sign indicates the number ofthe item in the final cmestio r inaire. 103 ^IHAM Table 5.3 Contains the 33 curriculum content items in the final survey. Looking at all of the mean responses ofthe items one can see that the deans' tended to rate most items somewhat higher than did the nursing directors Highest Ratings bv the Nursing Directors "Functioning Autonomously" in the Field was the highest rated item by the nursing directors (see Table 5.3). The mean response rating by the nursing directors for this item was 4.91. The majority of nursing directors responding (146) rated this item as "Essential" (5 on the Likert scale). The six remaining nursing directors rated this item with a 4.75, 4.5, 4.0, or 3.0. The nursing directors rated only seven ofthe curriculum content items greater than 4.5 on Table 5.3, which was just 1/2 ofthe number of items rated greater than 4.5 by the deans. The curriculum content items rated greater than 4.5 by the nursing directors compared to the deans ratings ofthe same items in descending order by nursing directors' mean responses were: "Functioning Autonomously in the Field" #1, M= 4.91 and M=4.68; "Time Management" #2, M=4.74 M= 4.69; "Communication: Written" #3, M=4.72 and M=4.88; "Communication: Oral" #4, M=4.70 and M=4.86; "Working within a Team" #5, M=4.66 and M=4.87; "Care ofthe Patient in the Home" #6, M=4.64 and M=4.87; and "Case Management as Part of Managed Care" #7, M=4.53 and M=4.80. Summary The deans' mean responses tended to be somewhat higher than the nursing directors' means responses. This was the pattern throughout the analysis as you can see by 104 I 11 liHiiuiiiini 11 iiiMi m II 11 IN 11 Table 5.3 A Comparison of Deans' (n=185) Mean Responses with Nursing Directors' (n=152) Mean Responses on Total Thirty-three Curriculum Content Items. Curriculum Content Items Deans SD Nursing SD Directors 1. Communication: Written #23 4.88 0.37 4.72' 0.55 2. Working Within a Team #10 4.87 0.34 4.66' 0.49 3. Communication: Oral #24 4.86 0.39 4.70' 0.49 4. Case Management as Part, of Managed 4.80 0.43 4.53' 0.59 Care #6 5. Care of the Patient in the Home # 13 4.74 0.51 4.64' 0.52 6. Time Management #2 4.69 0.50 4.74' 0.51 7. Functioning Autonomously In the Field #11 4.68 0.53 4.91' 0.37 8. Management of Unlicensed Assistive 4.58 0.55 4.35 0.57 Personnel #5 9. Care of the Patient Emotionally # 15 4.58 0.58 4.08 0.56 10. Leadership #1 4.58 0.59 4.44 0.71 11. Health Care in Multicultural Populations #19 4.55 0.64 3.76 0.74 12. Disease Prevention #22 4.54 0.54 3.91 0.72 13. Health Maintenance #17 4.54 0.54 4.22 0.71 the comparisons in Table 5.3. As previously mentioned, perhaps the deans do more reading ofthe latest literature because their schools viability depends on it, or perhaps they have special insights, by reason of their education, which allows them to see the 105 vm Table 5.3 Continued. Curriculum Content Items Deans SD Nursing SD Directors 14. Measurable Outcome Criteria #28 4.51 0.58 4.37 0.62 15. Pain Management #12 4.48 0.63 4.09 0.73 16. Care ofthe Dying Patient #16 4.45 0.58 4.17 0.62 17- Research Utihzation #29 4.43 0.62 3.52 0.80 18. Quality Assurance #30 4.42 0.54 4.18 0.55 19. Critical Pathways as Part of Case 4.41 0.54 4.24 0.71 Management #7 20. Palliative Care #14 4.41 0.55 4.04 0.70 21. Legal Issues #32 4.32 0.56 3.64 0.67 22. Aduh Learning #27 4.28 0.61 4.11 0.72 23. Screening for Home Health #8 4.23 0.67 4.11 0.76 24. Informatics #25 4.18 0.70 3.64 0.90 25. Rehabilitation Nursing #18 4.11 0.62 3.99 0.68 26. Communicable Disease Surveillance #20 4.09 0.65 3.48 0.73 27. Epidemiology #21 4.04 0.70 3.45 0.79 28. Third-party payment #9 3.99 0.66 3.78 0.79 29. Fiscal Management #4 3.78 0.64 3.82 0.83 106 Table 5.3 Continued. Curriculum Content Items Deans SD Nursing SD Directors 30. Business Management #3 3.72 0.64 3.80 0.82 31. Mediation Resolution #31 3.68 0.71 3.13 0.80 32. Political Activism #33 3.61 0.80 2.88 0.86 33. Telenursing #26 3.53 0.67 3.13 0.90 Note^ Indicates that the nursing directors mean responses were also greater than 4.5. Ngtei The # sign indicates the number ofthe items in the final questionnaire value of a particular curriculum content item. Nursing directors would tend to look at an Item and be concerned about whether health insurance companies would pay for such a service. Another possible explanation, for the lower ratings by the nursing directors would be that if the home health agency cannot offer a service because it could not be paid for, the nursing directors would then not see much point in rating that item as "Essential" for the curriculum. One could probably conclude that the items receiving the highest mean responses by the deans should be included in fiiture nursing curricula. Lowest Ratings bv the Deans Six items received mean ratings by the deans below 4.0. For ranking and comparison purposes with the nursing directors' mean responses (see Table 5.4). The deans mean response ratmgs for "Third-Party Payment" was 3.99. Very close to a 4.0. 107 Most deans felt that this item was "Highly Desirable." However, enough deans felt it was less than "Highly Desirable" to bring the mean down below 4.0. The nursing directors .Table 5.4 Rank Order ofthe Deans' (n=185) Curriculum Content Items Mean Response Ratings Under 4.0, Compared to the Nursing Directors' (n=152) Mean Response Ratings for the Same Items. Curriculum Content Items Ranked by Deans' Deans SD Nursing SD Mean Responses. Directors 1. Third-party payment # 9 3.99 0.66 3.78 0.79 2. Fiscal Management # 4 3.78 0.64 3.82 0.83 3. Business Management # 3 3.72 0.64 3.80 0.82 4. Mediation Resolution #31 3.68 0.71 3.13 0.76 5. Political Activism # 33 3.61 0.80 2.88 0.86 6. Telenursing # 26 3.53 0.67 3.13 0.90 Note. The # sign indicates the number ofthe item in the final questionnaire. rated this item with a 3.78. Since nursing directors must deal with Medicare, Medicaid, and other health insurance payers, it seems rather surprising that this item would not be a greater priority for them and be ranked closer to Essential. One explanation could be that they feel it would be better taught in orientation or out in the field after graduation. Several nursing directors wrote in their suggestions that nurses should have two years of 108 •BMSSlMiHIil^HBINi hospital experience before working in home health. That may not always be feasible, since patients are sent home as soon as they are stable, often the day of surgery. Hospitals have downsized to the point of having very few R.N.s in the patient-care employee mix (Langston, 1998). The deans, on the average, ranked Telenursing last, below Political Activism, although both items were rated greater than 3.5 by the deans. There might be some legal implications for giving patients advice over the telephone which may be why deans ranked this item as low as they did, i.e., 3.53, their lowest mean response. The deans' mean response for "Fiscal Management" was also below 4.0. This item had a mean response of 3.78 by the deans and 3.82 from the nursing directors. The two groups may be thinking that management of a patient's health care resources can be complex and might be better left to the business manager ofthe home health agency. Dealing with expensive equipment such as a ventilator would give credence to this notion. Nevertheless, "Fiscal Management" could also include finding the resources to pay for prescription drugs not covered by the patient's insurance plan. Alternatively, instructions on how to find the cheapest way to purchase the drug rather than the expensive drug that may be ordered by the physician. Fiscal management would also teach the patient to plan by using mail-order pharmacies and getting several months supply ofthe drug at cheaper prices. It would seem to the researcher that "Fiscal Management" would be an important item to include in the curriculum. The responses indicated that the deans' mean response to "Business Management" was 3.72 ("Desirable"). Perhaps, the deans were less enchanted with this item, thinking 109 wmmm that this item would probably fit better into a master's program. Or perhaps they felt "Business Management" would benefit only those nurses who would own or manage home health agencies. Even though Cary (1988) suggested that nurses needed to be educated in "Business Management," it does seem like an umbrella course that could address "Time Management," "Fiscal Management," "Mediation Resolution," "Third- Party Payment," and "Management for Unlicensed Assistive Personnel." Nursing Directors' Lowest Mean Responses It was surprising that nursing directors did not rate "Health Care in Multicultural Populations" (M=3.76), higher. One explanation could be that the respondents' home health agencies served just one zone or neighborhood, and that zone was homogenous in ethnic or cultural composition. The deans who used agencies over a broad geographic area, which may encompass many ethnic and cultural diverse populations, therefore, could have been looking at the broader picture when rating this item. The nursing directors' mean responses for "Telenursing" was only 3.13. It would seem that nursing directors would have rated this item higher because one would think that nurses in the field would frequently have to give advice over the telephone regarding health care issues. "Mediation Resolution" was another curriculum content item that had a relatively low mean response rating by the nursing directors. It would seem that this curriculum content item would be usefiil in dealing with nursing staff. 110 Research Ouestion Number Two Is there congruence between the perceptions of deans of baccalaureate schools of nursing and nursing directors of home health care agencies regarding curriculum content needed to prepare graduates to fimction in home health care? At first glance, it would seem that there was congruence between the two groups regarding what curriculum content items they perceived to be important in preparing nurses ofthe fiiture. But a comparison ofthe 33 means for both groups demonstrated that while the two groups felt at least 32 ofthe 33 items were "desirable", "very desirable" or "essential" for fiittire curricula, the two groups did differ significantly on the degree of "desirability" that they placed on 27 ofthe 33 items. (Six items showed non-significant /- values) (see Table 5.5). A /-test was used to determine whether the differences between the 33 mean responses ofthe two groups were different. Statistically, significant differences were found between the two groups in 27 ofthe 33 comparisons (see Appendix H). Only five comparisons ofthe mean responses were statistically significant beyond the 0.05 level. The six items for which the two groups did not differ significantiy are listed in Table 5.5. These five items were: (a) "Time Management," (b) "Business Management," (c) Fiscal Management, (d) "Screening for Home Health," (e) "Care for the Patient in the Home, and (f) Rehabilitation Nursing. Ill Table 5.5 Curriculum Content Items Showing Five Not Significant /-values when Deans' (n=185) and Nursing Dfrectors' (n-152) Means were Compared. Curriculum Content Items Deans SD Nursing SD /- Directors values 1. Time Management # 2 4.69 0.50 4.74 0.51 -0.88 2. Business Management #3 3.72 0.64 3.80 0.82 -0.88 3. Fiscal Management #4 3.78 0.64 3.82 0.83 -0.53 4. Screening for Home Health #8 4.23 0.67 4.11 0.76 1.48 5. Care ofthe Patient in the Home 4.74 0.51 4.64 0.52 1.60 #13 6. Rehabilitation Nursing #18 4.11 0.62 3.99 0.68 1.71 Note. The # sign indicates the number of the items in the f inal questior inaire. While a statistically significant difference was found between the groups' mean responses to 27 items, their mean response ratings of 3.0 or better on these items and the six in Table 5.5 suggested that 32 ofthe 33 curriculum content items should still be included m fiiturecurriculu m designs (see Appendix H) for means and /- values for all 33 items). 112 MHBHaBBwmm Curriculum Recommendations for Nursing Education One ofthe purposes of this study was to make recommendations for necessary curriculum changes to enable the newly graduated nurse to fimction in home health. To this purpose, the following suggestions were made to accommodate additional curriculum content items, which were recommended by the mean responses ofthe deans and nursing directors. Cary (1988) indicated that nurses must take the position that educational programs need to provide the basis necessary for quality home delivery of patient care. Cary (1998) challenged nurses to learn to co-operate with other health care workers to form a team to deliver health care in the home. She also charged nurses to be managers of scarce resources. Sharp (1992) suggested that nurses and nurse educators be "Health Care Visionaries" (p.l 13). In keeping with the recommendations by Sharp (1992) and Cary (1988), and in tight ofthe stt-ong positive responses by both the deans and the nursing directors in this study, new curriculum content items should be offered which reflect these responses. It may be no coincidence that the oval track on which Romans raced their chariots was called a curriculum (Oliva, 1988). One could think of nursing education as a tract cutting across many professional fields. The nursing discipline has many components to its curriculum. Many other disciplines often impact these components in the endeavor to provide the nursing student with a broad basis of education in the 21st century. To that purpose, this study examined 33 curriculum content items in seven categories. It was not the purpose of this research to develop paradigms for each ofthe 33 items in order to place them in one particular part ofthe curriculum. It was beyond the 113 scope of this research to develop the ideal curriculum that could meet the needs of all of the schools of baccalaureate nursing education in this countty. However, one ofthe purposes of this sttidy was to develop a curriculum plan. It is expected that this plan will provide food for nursing educators and nursing directors throughout the United States and Puerto Rico who feh the curriculum content items would be needed to educate the nurse who would be working in the home. Six tables were developed to offer suggestions on where some curriculum content items could fit specific course (see Tables 5.6-5.11). Table 5.6 lists basic nursing courses on the left side and recommended curriculum content items for those courses on the right side. Some curriculum content items could be placed in several courses. It would also be reasonable that each item might not represent a fiill-semester course; thus, the researcher has addressed the curriculum content items in several ways. Metaphorically, one could visualize them as threads forming a tapestry in the education ofthe nurse. The threads may be different in color, thickness, length, and texture as they weave in and out of various courses. The following paragraphs describe how content items could fit into specific nursing courses. Therefore all 33 content items are incorporated in existing nursing education curriculum. "Care ofthe Patient in the Home" #16 was placed in a Gerontics course, because the elder most frequently need to be cared for in the home. Children are often cared for in the home as well as clients of varying ages with post-operative, post-trauma, and myriad medical problems. 114 l.^lXlLfc**W^^'l • ' M *^'i •• • • Canng for the patient in the home has given rise to events that caring for the patient in a hospital does not address. For example, when a nurse cares for the patient in the home, that nurse must be cognizant of a patient's needs, such as tt-ansportationt o the store, money to purchase food, and the ability and means to prepare food safely. Table 5.6 Basic Nursing Courses with Recommended Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater. Basic Nursing Courses Curriculum Content Items Health and Wellness, Concepts in Health Care ofthe Patient in the Home #13, Care Assessment, Gerontics, Care ofthe Patient ofthe Dying #16, Palliative Care #24, with Medical or Surgical Problems, Screening for Home Health #8, Case Maternal Child Health Management as Part of Managed Care #8, Critical Pathways as Part of Case Management #7, Rehabilitation #18, Pain Management #12 Psychiatric Nursing Care ofthe Patient Emotionally #15 Health Teaching Adult Learning #27 Community Health Nursing Communicable Disease Surveillance #20 Epidemiology #21, Disease Prevention #22 Issues and Trends in Nursing Mediation Resolution #31 Research Research Utilization #29 Measurable Outcomes Criteria #28 Although the researcher placed care ofthe patient in the home in a Gerontics course as a curriculum content item, it needs to be a thread in all ofthe basic nursing courses. For example, a pregnant woman on bedrest, because of premature labor, may be cared for in the home with a good outcome if the nurse had been adequately prepared for home health care. 115 Items like "Pain Management" could be appropriately taught in "Care ofthe Patient with Medical Problems" under which oncology (patients suffering from cancer) or bums could fall. It could also be taught in a gerontics course that could deal with patients with arthritis or broken bones from falls or in care ofthe postoperative patients who have surgical wounds. "Pain Management" could be a thread throughout most courses. "Palliative Care" #24 could also be a thread throughout all age groups, because people in all age groups have debilitating diseases from which there is no hope for recovery. "Care ofthe Patient Emotionally" #15, while a primary focus of Psychiatric Nursing is a thread through all basic courses. People with chronic illnesses and those who have suffered trauma need emotional support. "Care ofthe Dying" #16 apphes to chents of all ages. This particular curriculum content item could also be a thread transcending most other basic courses. "Adult Learning" #27 is a curriculum content item that could be emphasized in Health Teaching, but carried as a thread throughout all nursing care of aduhs. "Communicable Disease Surveillance" #20, "Epidemiology" #21, and "Disease Prevention" #22 could be introduced as a microbiology course taught by the science department. These courses could then be emphasized in Community Health Nursing and used as a thread throughout the nursing courses. "Mediation Resolution" #31 could be addressed in Issues and Trends in Nursing. Kahsch and Kalisch (1991) referred to nursing groups forming unions to mediate such items as staffing, wages, and sending nurses to work in units unfamiliar to their areas of experience and expertise. With changes in staffing due to economics practiced by 116 hospitals, health insurance companies, and other employing agencies, this topic could lend itself to issues and trends. "Research Utilization" #29 could be taught in a research course, but should also be a part ofthe content in every course. For example, the sttident could be expected to read research articles on problems facing drug-addicted mothers and focus on how research could be used to help these mothers. "Measurable Outcomes Criteria" #28 should be addressed m all courses, but the basics may also be offered in a research course. Table 5.7 addressed curriculum content items which need to be included in management courses. The school of nursing, in collaboration with the school of business, could offer nurses a course such as practice management which would include items such as "Leadership" #1, "Time Management" #2, "Business Management, #3, "Fiscal Management" #4, "Management of Unhcensed Assistive Personnel" #5, Third-Party Payment" #9, "Working Within a Team" #10, "Functioning Autonomously in the Field" #11, "Quality Assurance" #30, and "Mediation Resolution" #31. "Mediation Resolution" #31 was mentioned as a curriculum content item that could be offered in Issues and Trends; however, that item could also be fiirther addressed in the aforementioned course on practice management for nurses. 117 Table 5.7 Practice Management Course with Recommended Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater. Business Administration Curriculum Content Items identified as needed for Home Health Care Practice Management Leadership #1, Time Management #2, Business Management #2, Fiscal Management #4, Management of Unlicensed Assistive Personnel #5, Third Party Payment #9, Working Within a Team #10, Functioning Autonomously in the field #11, Measurable Outcomes Criteria #28, Quality Assurance #30, Mediation Resolution #31 Table 5.8 reflects content that may be offered by the department of arts and sciences that are taken by nursing students usually as prerequisites. As previously mentioned, "Communicable Disease Surveillance" #20, "Epidemiology" #21, and "Disease Prevention" #22 could be taken as part of a course in microbiology and then could serve as threads throughout all clinical courses. A nutrition course might have served as a conduit for teaching "Health Maintenance" #17 and might use principles of 118 OTW^xarHBBsimaB Table 5 8 College of Arts and Sciences Courses with Recommended Additional Cumculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater. Science Department Additional Curriculum Content Items Identified as Needed for Home Health Care Microbiology, Nutrition, Pharmacology Communicable Disease Surveillance #20, Epidemiology #21, Disease Prevention #22, Aduh Learning #27, Health Mainenance #17, Pain Management #12 Note, Right hand column Indicates additional curriculum content items listed in the survey and the number ofthe item as it appeared in the final survey. A pharmacology course might have a segment on "Pain Management" #12 which could be woven as a thread throughout all courses that are designed to provide learning experiences when the students care for patients who have pain. The sociology department could offer content on "Health Care in Muhicultural Populations" #19 (see Table 5.9). An ahemative, that may be found in large colleges or universities, is to place this content in a course on Communication Studies (COMS) such as one that is offered at the university with which the researcher is associated (see Table 5.10). 119 ^EH mnoaei Table 5.9 College of Liberal Arts and Humanities Courses with Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 ^ Greater. Arts and Humanities Department Additional Curriculum Content Items Courses Identified as Needed for Home Health Care Language Arts Communication: Written #23, Communication Oral #24, Informatics #25, Telenursing #26 Sociology Department Health Care in Muhicultural Populations #19 Psychology Department Care ofthe Patient Emotionally #15 "Adult Learning" #27 in teachmg nurses how to present nuttitional theory to adult patients. Communication Sttidies (COMS) has many components at this university and may collaborate with the school of nursing to address content concerning "Adult Education" #27 in their course on Communication and Instruction and Teaching. A COMS department offering a course in Communication in Health Care could include the curriculum content items "Communication: Written" #23, "Communication: Oral" #24, Informatics" #25, and "Telenursing" #26. Intercultural communication could contain curriculum content related to "Health Care in Multicultural Populations" #19. Even though the nursing directors mdicated by thefr low mean response rates that "Political Activism" #33 was not an item that they feh should be in a nursing curriculum, the deans' mean response rate indicated that they considered this content desirable. 120 m&^ "Political Activism" #33 may be offered as an elective by the COMS department under the auspices of their course on Political Campaign Communication. This curriculum content item may also be included in the Issues and Trends in Nursing course ofthe basic nursing curriculum. The language arts department of any college could Table 5.10 College of Communication Sttidies Courses with Additional Curriculum Content Items Suggested by the Deans' and Nursing Directors' Mean Responses of 3.0 or Greater. Courses in Communication Studies (COMS) (TTU Undergraduate Catalogue, 1997,1998) Courses In Communication Studies Additional Curriculum Content Identified as Needed for Home Health Care Political Campaign Communication Pohtical Activism # 33 (received a mean Elective response rating of greater than 3.0 by deans, however, nursing directors' mean response rating was 2.88, therefore it is suggested that it may be an elective). Intercultural Communication Health Care in Multicultural Populations #19 (may also be subsumed in a sociology course). Communication in Instruction and Aduh Learning #27 Teaching Communication in Health Care Communication: Written #23 (may be subsumed by the English department). Communication: Oral # 24 (may be subsumed by the English department). Informatics # 24 (may be subsumed by the English department). Telenursing #26 (may be subsumed by the English department). Note. Right hand column indicates additional curriculum content items listed in the survey and the number ofthe item as it appeared in the final survey. 121 0*^^saa^i**i^'*~KB-a collaborate with the school of nursing to provide curriculum content regarding "Communication: Written" #23, "Communications: Oral" #34, "Informatics" #23, and "Telenursing" #26. "Legal Issues" #32 and "Mediation Resolution" #31 could be content items taught in collaboration with the law school of any large college or university. Table 5.11 illustrates that "Legal Issues" #32 could be content included in a course on laws governing health care. "Mediation Resolution" #31 could be content included in a course taught on labor law. Each of these curriculum content items could be offered as a single class taught by a guest lecturer from the law school. Table 5.11 Law School Courses with Additional Curriculum Content Items Suggested by the Deans" and Nursing Directors' Mean Responses of 3.0 or Greater. Law School Courses in Law Additional Curriculum Content Identified as Needed for Home Health Care Laws Governing Health Care Legal Issues #32 Labor Law Mediation Resolution #31 Recommendations Related to Curriculum Nursing needs to examine course offerings in other departments within the college or university to enrich their educational programs of nursing in order to provide their students with the curriculum content items recommended by this study. Nursing educators need to invite nursing directors of home health agencies located in their areas to 122 participate in making necessary curricular changes so that their sttidents will be better able to fimction in the home health care setting. Recommendations for Nursing Education Five recommendations emerged for nursing education as a resuh of this sttidy: 1. Consider the findings from this research sttidy in baccalaureate curricular planning. 2. Request school of business to incorporate management courses to include curriculum content items as suggested by the findings of this survey. 3. Form organizational partnerships with other members ofthe health care team. 4. Collaborate with nursing services in the community to develop curricula that could effectively prepare the newly graduated nurse to work m the home. 5. Collaborate with other departments in the college or university to develop a nursing program that reflects broad academic preparation for nursing students. Support for these recommendations was also provided by Cary (1998) who suggested the need for nursing education to include business management, fiscal management, time management, management of unlicensed assistive personnel, measurable outcomes, case management, critical pathways, health maintenance, disease prevention, multicultural health care, and disease surveillance. Sharp (1992) identified "new organizational partnerships in which physicians, nurses, dentists, medical technicians, and other health professions must be knowledgeable m basic and clinical sciences (p. 14). Nurses in the fiittire must be "long-term learners" (see Aduh Learning 123 #27), excellent communicators (see Communication: Written and Oral #23 & #24), and good team players (see Working Within a Team #10). Recommendations for Further Research Six recommendations for fiirther research are suggested: 1. There needs to be a qualitative research sttidy regardmg the reason why nursing directors' mean responses to such items as "Care ofthe Dying (M= 4.17) and "Palliative Care" (M=4.04) received lower mean responses than "Functioning Autonomously in the Field" (M=4.91) and "Time Management" (M= 4.74). 2. Further define curriculum content items as to placement in the curriculum, i.e., whether or not a fiiUcours e should be devoted to "Business Management." Also, what other content mentioned in this study could be included in a course such as "Time Management?" 3. Conduct fiirther research regarding competencies and skills needed by nurses in the fiiture. For example, what level of competency is needed to "Function Autonomously in the Field," as opposed to "Working Within a Team?" This research concentrated on content items but these items need to be fiirther defined as competencies. 4. A qualitative study is needed to define such broad terms as fiscal management, third- party payment, telenursing, and health maintenance. 5. Further investigation could identify objectives needed for the curriculum content items suggested by this study. 124 HBaai^—wwaeai^BaiwMw^^p 6. Another Delphi sttidy might address competencies and rank them for consideration in a new curriculum. Conclusions In conclusion, nursing deans and the nursing directors were in agreement on 32 of the 33 curriculum content items that needed to be included in fiittire baccalaureate nursmg curricula. Less agreement was found related to the relative degree of item importance between these two groups. The seven highest rated items by the deans coincided with the seven highest rated items by the nursing directors. The deans' mean response ratings of greater than 4.0, "Highly Desirable," included 27 items, whereas the nursing directors' mean response ratings greater than 4.0 included only 18 items. Overview This research began with a search ofthe literature for curriculum content that would be appropriate to prepare the nurse to be able to care for patients m the home. One ofthe problems of nursing in the 21st century is created by the consideration that in a market-driven health care system, care ofthe patient has moved out ofthe hospital into the home. Health care facihties and health insurance companies, in an effort to contain costs, have begun sending patients home as soon as they are stable. Many of these patients are acutely ill or chronically ill. The nurse ofthe fiiture needs to be able to care for these patients without the benefit of high technologic equipment and immediate 125 access to colleagues as would be the case if this care were rendered in a hospital. Caring for these patients in the home requires the traditionally estabhshed skills for use in hospitals as well as different abilities. This sttidy attempted to determine what deans of accredited baccalaureate schools of nursing and nursing directors of home care agencies believed the curriculum content should be for nurses in the home settmg in the 21st centtiry. An additional purpose of this research included an attempt to determine whether deans of baccalaureate schools of nursing concurred with current nursing literature and with nursing dfrectors of home care agencies as to what curricular content should be taught in schools of nursing in the fiittire. Nursing directors and deans suggested areas of content that they feh would benefit nursing in the 21st century. Deans of baccalaureate schools of nursing added several suggestions that were educationally good ideas, but did not always reflect the same content needs suggested by the nursmg directors. Essentially deans of baccalaureate nursing education and directors of nursing service were in agreement regarding 32 ofthe 33 curriculum content items. However, nursing directors in home health service rated some areas, such as care ofthe dying and pain management, relatively lower than the deans and they placed a higher priority on "Management of Unlicensed Assistive Personnel" and Fiscal Management." This researcher sees many different groups benefiting from this study, particularly fiiture nurses. It is hoped that recommendations from this study will provide a starting point for bringing about change m nursing education in the fiiture. 126 REFERENCES "1996" National homecare and hospice directory. 8th ed. Washington, D.C: National Association for Home Care. Alhadeff, G. (1979). Anxiety in a new graduate. American Journal of Nursing. 79^30). 687-688. American Nurses Association (A.N.A.) (1995). Nursing Facts. American Nurses Association. A.N. A. (1966). Position paper on nursing education. Kansas City, MO. 8-11. A.N. A. (1997). Nursing trends and issues. American Nurses Association. 2. Kansas City, MO. ANA Registered (1994). Registered professional nurses and unlicensed assistive personnel. ANA. Washington, D.C: American Nurses Publishing Co. Andersen, S. L. (1991). Preceptor teaching stt-ategies: Behaviors that facihtate role transition in senior nursing students. Joumal of Nursing Staff Development. 6. 171-175. Arlton, D. (1994). The rural nursing practicum. Nursing Outlook. 32. 204-206. Baas, L. S. (1992). An analysis ofthe writings of Janet Geister and Mary Roberts regarding the problems of private duty nursing. Joumal of Professional Nursing. 8. 176-183. Baccalaureate education in nursing: Information about N.L.N.-accredited baccalaureate programs. (1995). New York, NY: National League for Nursing. Beck, C. T. (1993). Nursing students' initial clinical experience: A phenomenological study. International Joumal of Nursing Studies. 30. 489-497. Bell, E. A. (1990). Antidote for reality shock. Joumal of Nursing Education. 19. 4-6. Bellinger, S. R. & McClosky, J. C. (1992). Are preceptors for orientation of new nurses effective? Joumal of Professional Nursing. 8, 321-327. Benne, K. D., & Bennis, W. (1959). Role confiision and conflict in nursing: What is real nursing? The American Joumal of Nursing. 59. 380-383. 127 Benner, P. (1984). From novice to ^ypprt Menlo Park, CA: Addison-Wesley Bernhardt, J. C. (1992). Bridging the pap: A sttidv in participation in preceptorship expenences and role sociahzation outcomes of newlv licensed registered nurses Doctoral dissertation. University of Texas at Austin. Bernstein, J. L. (1988). Don't quh nursing...consider the ahematives! AD Nurse. Nov/Dec. 30-32. Beyer, J. E .S. (1992). Role expectations and coping stt-ategies of baccalaureate nursing sttidents. Doctoral dissertation. University of Nebraska, Lincoln. Blanchard, S. L. (1983). The discontinuity between school and practice. Nursing Management. 14^ 41-47. Borg, W. R., & Gall, M. D. (1989) Educational Research (5th ed.). White Plains, NY: Longman. Boss, L. A. S. (1985). Teaching for clinical competence. Nurse Educator. 10. 8-12. Bronder, E. (1997). Nursing trends and issues. American Nurses Association 2. 5-8. Buhler-Wilkerson, K., Naylor, M. D., Hoh, S. W., & Rinke, L. T. (1998). Integrating research, education and practice. Nursing Outlook. 46. 77-80. Bullough, B., & Bullough, V. (1990). Nursing in the community. Philadelphia: C.V. Mosby Company. Bureau of Labor Statistics (BLS) (1994). National industtr-occupational mattix. Employment by industry and occupation, 1994 and projected 2005 ahematives: registered nurses. Washington DC: Department of Labor. Bygrave, D. (1985). The shock of ttansition. Nursing Times. 8. 32-33. Caldwell, C. L. (1989). The things they didn't tell you in nursing school. The Kansas Nurse. 64. 3-4. Campbell-Forsyth, L. (1991). First experiences shape nursing practice. Florida Nurse 3 12-13. Cantwell, E. R., Kahn, M. H., Lacey, M. R., & McLaughlin, E. F. (1989). Survey of current hospital preceptorship programs in the greater Philadelphia area. Joumal of Nursing Staff Development. 9. 225-230. 128 ^^Ei»««i^^S Carroll, T. L. (1989). Role deprivation in baccalaureate nursing sttidents pre and post cumculum revision. Joutnal of Nursing Education, 9S, 134-139. Cary, A. H. (1988). Preparation for professional practice: What do we need? Nursing Clinics of North America^ 7^, 341-351. Castle, J. (1981). "That's not the way we do things around here," American Joumal of Nursing. 13.48. Cavouras, C. & Eddy, L. (1996). Developing your nursing career: A working guide. ANA, (1997). Chaney, H. S. (1987). Needs assessment: A Delphi approach. Joumal of Nursing Staff Development. 8, 48-53. Chickerella, B. G., & Lutz, W. J. (1981). Professional nuttirance: Preceptorships for undergraduate nursing sttidents. American Joumal of Nursing. (January). Clark, D. L. (1997). High school seniors react to their teachers and their schools. Phi Deha Kappan. 3. 503-509. Clarke, P. N., & Cody, W. K. (1994) Nursing theory-based practice in the home and community: The cmx of professional nursing education. Advances in Nursing Science. 17.41-53 Cook, S. H. (1991). Mind the theory/practice gap in nursing. Joumal of Advanced Nursing. 16. 1462-1469. Corwin, R. G. (1971). The professional employee: A study of conflict in nursing roles. The American Joumal of Sociology. 11. 604-615. Crowl, T. K., (1996). Fundamentals of educational research Qnd ed.). Madison, WI: Brown and Benchmark. Cummings, S.P. (1990). Socialization to nursing: The effect of a summer nurse extemship program on role conception of baccalaureate nursing students. Doctoral dissertation, Clemson University, 1991. Dissertation Abstracts Intemational. 52/01. Dale, M. L. & Savala, S. M. (1990). A new approach to the senior practicum. Nursing Connections, 3, 27-31 129 Davidhizar, R. & Bowen, M. (1991). Helping the new nurse adjust to the OR environment. Today's OR Nurse. 23. 18-21. Delbecq, A. L., Van de Van, A. H., & Gustafson, D. H. (1975). Group techniques for program planning: A guide to nominal group and Delphi processes. Glenview, IL: Scott, Foresman and Company. Dobbs, K. K. (1984). The senior preceptorship as a method for anticipatory socialization of baccalaureate student nurses (role transitition, reality shock). Doctoral dissertation. University of Alabama, 1985. Dissertation Absfa-acts hitemational. 45/12. Dodds, A. E. Lawrence, J. A. & Wearing, A. J. (1991). What makes nursing satisfying: A comparison of college students' and registered nurses' views. Joumal of Advanced Nursing. 16.741-753. Dyson, J. (1992). The importance of practice. Nursing Times. 8. 44-46. Fiesta, J. (1990a). The nursing shortage: Whose liabihty problem? Part I. Nursing Management. 21. 24-25.. Fiesta, J. (1990b). The nursing shortage: Whose liabihty problem? Part II. Nursing Management. 2. 22-23. Fitzpatrick, J. &haU, A. (1996). Conceptual models of nursing: analysis and application. (3rd Ed.) Stamford, CT: Appleton and Lange. Focus (1993). Sociahzation transformation: The passage from caregiver to educator. Joumal of Nursing Staff Development. 9. 155-159. Friss, L. (1982). Why RNs quit: The need for management reappraisal ofthe "propensity to leave" Hospital & Health Services Administtation, Nov/Dec. 28-44. Gaff, J. G. (1991). New life for the college curriculum. San Francisco, CA: Jossey-Bass. Gaff, J. G., Ratchff, J. L., & Associates, (1997). Handbook ofthe undergraduate curriculum: A comprehensive guide to purposes, stmctures. practices, and change. San Francisco, CA: Jossey-Bass. Gaston, S. K. (1981). An analysis of role preparation, conception, deprivation, and strain and professional behavior in novice and experienced nurse educators. Doctoral dissertation, Kansas State University, 1981. Dissertation Absfracts Intemational. 42(01). 130 1^ Glennon, T. K. (1983). An additive model to promote biculttirahsm. Nursing Management. 14nv 28-31. Goldfarb, S. (1986). Reality shock for OR nurses. Today's OR Nurse. 8. 21-23. Goodman, C. M. (1986). The Delphi Technique: A critique. Joumal of Advanced Nursing. 1987. 12^ 729-734. Goodwin, D. (1992). Critical pathways in home health care. Joumal of Nursing Administration. 22. 35-40. Habgood, M .K. (1981). Preventing reality shock: One AD program's plan. Nursing & Health Care. 6n V 74-75. Hollefreund, B. Mooney, V.M., Moore, S., & Jersan, J. (1981). Implementing a reality shock program. The Joumal of Nursing Administration. January. 16-20. Holloran, L. (1990). Health care changes leave nurses in ttansition. The Hartford Courant. May 30. 21-24. Holloran, S. D., Mishkin, B. H., & Hanson, B. L. (1980). Biculttiral training for new graduates. The Joumal of Nursing Administration. 1. 17-24. Horsburgh, M. (1989). Graduate nurses' adjusttnent to initial employment: Natural field work. Joumal of Advanced Nursing. 14. 610-617. Huckstadt, A. (1981). Work/sttidy: A bridge to practice. American Joumal of Nursing. 4. 726-28 Hutcherson, A. H. (1986). Bridging the gap between education and practice: A cooperative effort between education and service...from student to graduate. AD Nurse. 1.19-23. Itano, J. K., Warren & J., Ishida, D. N., (1987). A comparison of role conceptions and role deprivation of baccalaureate students in nursing participating in a preceptorship or a ttaditional clinical program. Joumal of Nursing Education. 26. 69-73 KaHsch, P. A., & Kahsch, B. J. (1995). The advance of American nursing (3rd. ed.). Baltimore: Lippincott Kasprisin, C. A., & Young, W. B. (1984). Nurse intemship program reduces ttimover, raises committnent. Nursing & Health Care. March. 137-140. 131 Keppel, G. (1991). Design and Analysis: A Researcher's Handbook Englewood Chffs N.J.: Prentice Hall. Krejcie, R. V., Morgan, D. W., (1993). Determining sample size for research activities. Educational and Psychological Measurement. 1970^ 30, 607-610. Kramer, M. (1969). College graduate nurses in medical center hospitals: Muttial challenge or duel. Nursing Research 3^ 196-210. Kramer, M. (1970). Role conceptions of baccalaureate nurses and success in hospital nursing. Nursing Research. 19. 428-438. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis: C.V. Mosby. Kramer, M. (1978). Bicultural ttaining and new graduate role transition. Nursing Digest. 2, (Winter) Kramer, M. (1979). Collegiate graduate nurses in medical center hospitals: Mutual challenge or duel. Nursing Research. 18. 196-210. Kramer, M. & Baker, C. (1971). The exodus: Can we prevent it? Joumal of Nursing Administtation. Mav/June. 15-30. Kramer, M. & Schmalenberg, C. E. (1978 a). Conflict: The cutting edge of growth Nursing Digest. 6. 59-65. Kramer, M., & Schmalenberg, C. E. (1978 b). Dreams and reality: Where do they meet? Nursing Digest. 7. 49-57. Langston, N. (1998, September). NLN UPDATE [on-line serial], 19. Available E-mail: NLNUPDATE@nhiorg. Lawrence, R. M., & Lawrence, S. A. (1987). The nurse and job related sttess: Responses, tteatment, and self-dependency. Nursing Forum, 23. 45-51. Lewandowski, L. A., & Kramer, M. (1980). Role ttansformation of special care unit nurses: A comparative study. Nursing Research. 29. 170-179. Lynn, M. R. (1989). Instrument reliability and validity: How much needs to be published? Heart and Lung. 12.421 -423 Malloy, C, White, J. F., & Zezutek, P. (1987). Nursing service and education - winners! Nurse Educator. 12. 5-6. 132 XKi**nv^^Ba Marriner-Tomey, A. (1989). Nursing theorists and their work St. Louis: The C.V. Mosby Company. McAlpine, L., & Cargill, G. (1992). Effects of summer employment on sttident nurses: Imphcations for recmittnent and retention of staff nurses. Canadian Joumal of Nursing Administtation. 5, 23-27. McClosky, J. C, & Grace, H. K. (Eds.). (1985). Current issues in nursinp (2nd ed.). Boston: Blackwell Scientific Publications. McClosky, J. C, & McCain, B. E. (1987). Satisfaction, commitment and professionahsm of newly employed nurses. Image. 19. 20-23. McGrath, B. J., & Princeton, J. C. (1988). Evaluation of a clinical preceptor program for new graduates - eight years later. The Joumal of Continuing Education in Nursing. 18,133-136. Meisenhelder, J. B. (1981). The .new graduate socialization. The Joumal of Continuing Education in Nursing. 12. 16-22. Miller, S. (1981). Our power to become. Heart & Lung. 10. 423-430. Modic, M. B., & Bowman, C. (1989). Developing a preceptor program: What are the ingredients? Joumal of Nursing Staff Development. March/April. 78-83. Moessin, J. (1986). Do nurses eat their young? Nursing 86. March. 52-53. Mooney, V. A., Diver, B., & Schnackel, A .A. (1988). Developing a cost-effective clinical preceptorship program. Joumal of Nursing Administration. IS(\). 31-36. Morgan , D. L., & Krueger, R. A. (1993). When to use focus groups and why. In D. L. Morgan (Ed.), Successfiil focus groups (pp. 3-19). Newbury Park, NJ: Sage. Muff, J. (1982). Socialism, sexism, and stereotyping: Women's issues in nursing. St. Louis: C.V. Mosby. Myrick, F. (1988). Preceptorship: A viable alternative clinical teaching sttategy? Joumal of Advanced Nursing. 13. 588-591. Nieswiadomy, R. M. (1993). Foundations of nursing research (2nd ed.). Norwalk, CT: Appleton & Lange. Oliva, P. (1988). Developing the curriculum (2nd ed.). Boston: Littie Brown & Co. 133 -L Olson, R .K., Gresely, R. S., & Heater, B. S. (1984). The effects of an undergraduate clinical intemship on the self-concept and professional role mastery of baccalaureate nursing sttidents. Joumal of Nursing Education. 23. 105-108. O' Neill, E. (1998, September). NLNUPDATE.[On-lme serial] 19. Available E-Mail- NLNUPDATE@nhiorg. Owens, R. G. (1991). Organizational behavior in education (4th ed.). Englewood Cliffs NJ: Prentice Hall. PadiUa-Hajjar, R. V. (1985). A disttict-wide program of induction for beginning teachers in large, urban school distticts in Texas. Doctoral dissertation. University of Texas at Austin. Dissertation Abstracts Intemational. Page, N. E., & Arena, D. M. (1991). Practical sttategies for CNS role implementation. Clinical Nurse Sneciahst. 5, 43-48. Palluotto, E. D. (1993). The compiling of a preceptor manual following a survey of nurses' perceptions of a preceptor program. Unpublished masters thesis, Bellarmine College, 1994. Masters Abstracts Intemational. 32/03. Pew Report (1996) Pfifferling, J. H. (1984). Viewpoint: The role ofthe educational setting in preventing bumout. Family & Community Service. 6. 68-75. Pillitteri, A. (1991). Documenting Lystra Gretter's student experiences in nursing: A 100- year comparison with today. Nursing Outlook. 11. 273-279. Polit, D. F., & Hungler, B. P. (1995). Nursing research. (5th ed.). Philadelphia: J. B. Lippincott. Porter-Stubbs, L., & Marriner, A. (1985). Work-study elective courses. Nurse Educator. 57,31-35. Portnoy, F. L. (1980). RN students analyze their experiences. Nursing Outlook. 56. 112- 115. Primary care: America's health in a new era (1996). Institute of Medicine. March. Rand, J. M. H. (1981). Role deprivation and reality shock experiences and the nurse practitioner, (unpubhshed doctoral dissertation, Syracuse University, 1981). Dissertation Absttacts Intemational. 42/05. 134 •*N«m Richardson, G. (Ed.). (June 1997). Bulletin of Texas Tech University: Undergraduate Catalog 1997-1998. (Available from Texas Tech University, Lubbock, Texas 79409). Riggin, O. Z. (1982). Role theory for nursing practice. Concepts for Advanced Nursing Practice. St. Louis: C.V. Mosby. Rittman, M. R. (1992). Preceptor development programs: An interpretive approach. Joumal of Nursing Education. 31. 367-370. Roach, J. A. (1993). Focus. Joumal of Nursing Staff Development. 9. 155-159. Scheetz, L. J. (1989). Baccalaureate nursing student preceptorship programs and the development of clinical competence. Joumal of Nursing Education. 28. 29-35. Schempp. C. M., & Rompre, R. M. (1986). Transition programs for new graduates: How effective are they? Joumal of Nursing Staff Development. Fall, 150-156. Schmalenberg, C. & Kramer, M. (1979a). Coping with reality shock. Wakefield, MA: Nursing Resources. Schmalenberg, C. & Kramer, M. (1979b). Biculttiral training: A cost-effective program. The Joumal of Nursing Administration. Dec. 10-16. Sharp, N. (1992). Community partnerships in health professions education. Nursing Management. 23. 14-15. Shead, H. (1991). Role conflict in student nurses: Towards a positive approach for the 1990s. Joumal of Advanced Nursing. 16. 736-740. Smith, K. M. (1978). Discrepancies in the role-specific values of head nurses and nursing educators. Nursing Digest. Wmter 25(2). 67-74. Stacklum, M. M. (1982). Changes in role conception and role deprivation among baccalaureate student nurses following psychiatric and medical clinical experiences. Unpublished doctoral dissertation, Columbia University Teachers College, (1982). Dissertation Absttacts Intemational, 43/05. Stanhope, M., Lancaster, J. (1996). Community health nursing (4th ed.). Philadelphia: C.V. Moseby: State Approved Schools of Nursing R.N. 1995. New York: Division of Research National League of Nursing. 135 mm Suess, L. R., & Schweitzer, B. J., & Williams, CA. (1982). Nursing students with expenment with reality. Nurse Educator. March/April, 28-33. Topp, R., & Utter, D. (1993). Developing a reciprocal program between sttident nurse organizations and hospitals. Imprint. 40. 63-65. Vigen, K.V. (1987). Clinical preceptorships in nursing education: A model for role transition. Unpubhshed doctoral dissertation. University of Minnesota, (1987). Dissertation Abstracts Intemational. 48/01. Wandeh, M. A., Pierce, P. M., & Widdowson, R. R. (1981). Why nurses leave nursing and what can be done about it. American Joumal of Nursing. Jan, 72-77. Watson, A. B. (1982). Professional socialization ofthe registered nurse as measured by attittides and problem identification skills. Unpublished doctoral dissertation, University of Cahfomia, San Francisco, (1983). Dissertation Abstracts Intemational. 43/10. Webster's ninth new worid dictionary (1995). Springfield, MA: Miriam-Webster Inc. Weiss, S. J. (1984). The effect of transition modules on new graduate apphcations. Research in Nursing and Health. 7. 51-59. White, E. E. D. (1979). Where are students in the conflict between "real" and "ideal" nursing practice? Occupational Health Nursing. August, 14-15. Wierda, L. (1989). B.S.N, sttidents find a way to lessen the severity of reality shock. Nursing Fomm, 24. 11-14. Wuthnow, S. (1987). Our mothers' stories: The recollection of depression-era nursing students interviewed in the Philadelphia oral history project. Nursing Outlook.38. 218-222. Young, L. (1991). Expected competencies of new graduate nurses as perceived by new graduates, head nurses and nursing supervisors. Unpublished masters thesis, Bellarmine College, (1992). Master's Abstract Intemational. 0/04. 136 "K'lWlLlilMMFWilIflrJ.V APPENDIX A COVER LETTER ESrSTRUMENT DEVELOPMENT PARTI 137 Phyllis Karmels 4903 Canadian Ave Midland, Texas 79707 June 15,1997 Dear I am a doctoral candidate working on my Ed.D. from Texas Tech University. I plan to conduct a survey of 300 deans of accredited baccalaureate schools of nursing and 300 nursing directors throughout the United States as part of my dissertation. I am asking you to be a part of my pilot study. I would be most appreciative if you would lend me your expertise in developing my survey tool. My survey contains ten curriculum content areas suggested in the literature that newly graduated baccalaureate nurses will need in their first position as a nurse caring for patients and their families in the home. I am sending to you a copy ofthe survey. I am asking you to make comments and suggestions regarding the readability ofthe survey tool. Next, please look at the content ofthe survey tool, rate the content according to the directions and comment. In addition to the content mentioned, please add five more areas of curriculum content which you feel should be included in the national curriculum survey. I appreciate your taking time to review the enclosures and respond to them. Please respond by 7/15/97. I have enclosed a stamped, self-addressed envelope for your convenience. If you prefer, you may fax me your responses at 915-335-5169 or telephone me at 915-335-5155. Sincerely yours. Phylhs Karmels, R.N., C, Ma Ed., M.S.N. 138 Questionnaire Please place an "X" in the column to the right ofthe content area which describes how you rate the content's importance to nursing in the 21$t century. Key: E=Essential, HD=Highly Desirable, D= Desirable, N=Neutral or Not sure, U=UndesirabIe, HU= Highly Undesirable. Curriculum Content Items E HD D N U HU 5 4 3 2 1 0 1. Business and fiscal management. (#7 & 22)* 2. Leadership and management skills. (# 6)* 3. Management of unlicensed and assistive personnel in the home setting.(#15)* • 4. Measurable outcome criteria, eg., patient satisfaction, recividism, and/or compliance. (#3)* 5. Case management or critical pathways as part of case management. (#19 & 20)* 6. Health maintenance and preventive care.(#9)* 7. Care ofthe client in the home. (#4)* 8. Health care in multicultural or under- served populations, i.e., community relevant health care. (#12)* 9. Communicable epidemiology such as" disease surveillance and control. (#24)* 10. Political activism. (#33)* * Location of items in the second mailout. Please add 5 other areas of content that you deem necessary or important to be included in baccalaureate nursing curriculum for the 21st century. 1. 2. 3. 4. 5. 139 Table A.l Deans' and Nursing Directors' Mean Response Ratings to Original 10 Items (n=45) CURRICULUM CONTENT ITEM MEAN RANGE 1. Business & Fiscal Management * 4.50 5.0-3.0 2. Leadership and Management Skills 4.86 5.0 - 4.0 3. Management of Unlicensed and Assistive 4.60 5.0-4.0 Personnel in the Home 4. Measurable Outcome Criteria e.g., Patient 3.90 5.0-2.0 Satisfaction, Recividism, and or Compliance 5. Case Management or Critical Pathways as part of 3.90 5.0-1.0 Case Management ** • 6. Health Maintenance and Preventive Care 4.07 5.0-2.0 7. Care ofthe Client in the Home 4.46 5.0-3.0 8. Health Care in Multicultural or Under-served 4.40 5.0-3.0 Populations i.e.. Community Relevant Care 9. Communicable Epidemiology 4.07 5.0-2.0 10. Political Activism 3.93 5.0-2.0 * Became Business Management (#7) and Fiscal Management (#22) ** Became Case Management (#19) Critical Pathways as Part of Case Management (#20) 140 APPENDIX B COVER LETTER AND ESrSTRUMENT DEVELOPMENT PART II 141 Phyllis Karmels 4903 Canadian Ave. Midland, Texas 79707 Home phone (915) 520-6172 Work phone (915) 335-5155 July 30, 1997 Dear Dean, Nurse-Administrator or Designee My name is Phyllis Karmels. I am a doctoral candidate working on my Ed.D. at Texas Tech University. The focus of my dissertation is on curriculum content which deans of baccalaureate schools of nursing deem necessary in order to prepare nurses to practice nursing in the home in the 21st century. My study has been approved by the Institutional Review Board at Texas Tech. As part of my study, I have selected, at random, deans of NLN accredited baccalaureate schools of nursing throughout the continental United States. In addition to these deans, I have selected nursing administrators from hospice, community health agencies, and home health agencies to participate in my study. The content that you see listed in the 33 items in the survey has been culled from the literature and from responses to a prior survey, as important content for nurses to have in order to enable them to fimction outside the acute care agency. If you wish a copy ofthe results of my fmal study, please indicate this on your retum or enclose your business card and I will forward a copy to you as soon as the study is finished. I would appreciate it if you would look over the letter and the survey sent to you and add comments to either missive. I am especially interested in knowing that the directions on the survey are easily read and understandable. Please retum the survey by August 15th, 1997. Thank you for your valuable time in furthering my education. Sincerely yours. Phyllis Karmels, R.N., C, Ma.Ed., M.S.N. 142 •-%*VW^>„iimW^^» Instrument Development Part II Please place an "X" in the column to the right ofthe content area which describes how you rate the content s miportance to nursing in the 21st century. Key: E=Essential, HD=Highly Desirable, D= Desirable, N=Neutral or Not sure, U=UndesirabIe, HU= Highly Undesirable. CURRICULUM CONTENT ITEMS E HD D N U HU 5 4 3 2 1 0 1. Communication: Oral 2. Communication Written 3. Time Management 4. Care ofthe Client in the Home 5. Pain Management 6. Leadership 7. Business Management 8. Health Maintenance 9. Disease Prevention 10. Care of the Patient Emotionally 11. Legal Issues 12. Health care in a Multicultural or Under-served Populations 13. Measurable Outcome Criteria e.g. Patient Satisfaction, Recividism 14. Care of the Dying Patient 15. Management of Unlicensed, Assistive Persoimel 16. Working Within a Team 17. Functioning Autonomously in the Field 143 Instrument Development Part II, Continued CONTENT CURRICULUM ITEM E HD D N U HU 5 4 3 2 1 0 18. Informatics 19. Case Management as part of Managed Care 20. Critical Pathways as Part of Managed care 21. Palliative Care 22. Fiscal Management 23. Quality Assurance 24. Commimicable Epidemiology, Disease Surveillance, and Control 1 25. Epidemiology 26. Mediation Resolution 27. Rehabilitation Nursing 28. Screening for Home Health 29. Adult Learning 30. Research Utilization 31. Third-party payment 32. Telenursing 33. Political Activism 144 lULIJJWi liiU!il_.lii—'i'*i III I'l I II I I I ' i> >i'iim I I I I lf!u I ^ ^"f "''/."^ pursing Directors' Mean Response Ratings, Mean Differences, and Response Ranges of the Expanded List of 33 Cumculum Content Items (N=91) CURRICULUM CONTENT ITEMS Mean: Mean Difference Range Deans Nursing Directors 1. Communication: Oral 4.72 3.48 1.24 5.0-3.0 2. Communication: Written 3.62 4.90 1.28 5.0-3.0 3. Time Management 3.60 4.71 1.11 5.0-2.0 4. Care of the Patient in the Home 3.76 4.90 1.06 5.0- 1.0 5. Pain Management 4.51 4.20 0.31 5.0-2.0 6. Leadership 4.91 3.76 1.21 5.0-2.0 7. Business Management 3.61 4.80 1.19 5.0-2.0 8. Health Maintenance 4.51 3.52 0.99 5.0-2.0 9. Disease Prevention 5.51 3.42 1.09 5.0-3.0 10. Care of the Patient Emotionally 4.49 3.12 1.37 5.0-2.0 11. Legal Issues 4.44 4.00 0.44 5.0-3.0 12. Health care in Multicultural 4.70 3.50 1.20 5.0-2.0 Populations 13. Measurable Outcome 4.40 3.22 1.18 5.0-2.0 14. Care of the Dying Patient 4.86 3.82 1.04 5.0-2.0 15. Management of Unlicensed Assistive 3.24 4.40 1.16 5.0- 1.0 Personnel 16. Working within a Team 3.30 4.31 1.11 5.0-2.0 17. Functioning Autonomously in the 4.00 4.44 0.44 5.0-2.0 Field 18. Informatics 4.31 3.33 0.98 5.0-2.0 145 :.7;s!g;^>^-^.^gauUUUi. W11. Table B.l Continued CURRICULUM CONTENT ITEMS Mean: Mean: Difference Range Deans Nursing Directors 19. Case Management 3.80 4.80 1.00 5.0-2.0 20. Critical Pathways as part of 3.80 4.80 1.00 5.0-2.0 Managed Care 21. Palliative Care 3.75 4.50 0.75 5.0-2.0 22. Fiscal Management 3.60 4.80 1.20 5.0-2.0 23. Quality Assurance 3.48 4.90 1.42 5.0-2.0 24. Communicable Disease Surveillance 4.13 3.01 1.12 5.0-2.0 25. Epidemiology 4.13 3.01 1.12 5.0-2.0 26. Mediation Resolution 3.22 4.26 1.04 5.0-2.0 27. Rehabilitation Nursing 4.40 3.10 1.20 5.0-2.0 28. Screening for Home Health 3.51 4.70 1.19 5.0-2.0 29. Adult Learning 4.78 3.00 1.78 5.0-2.0 30. Research Utilization 4.80 3.35 1.45 5.0-2.0 31. Third-party payment 3.22 4.78 1.56 5.0-2.0 32. Telenursing 3.00 4.50 1.50 5.0-2.0 33. Political Activism 3.51 3.00 0.51 5.0-2.0 146 mhn I |i |i I III 1 I Biwwm 11 11 I APPENDIX C COVER LETTER AND SURVEY FOR DELPHI ROUND I 147 June 15, 1998 Dear Nursing Director, The purpose of my letter is to invite you to participate in a three part, national curriculum study. The focus of this study is on the preparation of nurses who will work in the home m the 21st century. You will be one of 300 deans of baccalaureate schools of nursing and 300 nursing directors of home health agencies specially selected for this national investigation. This study has been approved by the Texas Tech University Institutional Review Board (IRB) project #97435. Enclosed with this letter is a 33-item questionnaire that has been developed with the help of 120 deans and 120 nursing directors over the last year. In this study, you will be asked to complete the original, and two more brief questionnaires. Would you please take 10 or 15 minutes now to complete the enclosed survey, indicating what curriculum content you feel is needed in baccalaureate schools of nursing to prepare students for work in the home? Please retum your completed questionnaire in the pre-addressed, stamped envelope by JUNE 30th. If you wish, you may fax your reply to me. My fax number is (915) 335-5169. Your responses will be held in "strict confidence." No names or institutions will be used in any future reports. After I receive all of your responses, I will send to you the other directors' and the deans' mean responses for each ofthe 33 items, as well as a copy of your first set of responses. You will then be given the opportunity to change your responses to the curriculum content items. A third questionnaire will be mailed to you later this summer for any fmal changes you may wish to make in any ofthe thirty-three item responses. If you would like a summary ofthe final result of this study, please enclose your business card and I will send a copy to you. Thank you in advance for your assistance in this study. Sincerely, Phyllis Karmels R.N., C, Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 148 III! I I ii I I June 15,1998 Dear Dean, The purpose of my letter is to invite you to participate in a three part, national curriculum study. The focus of this study is on the preparation of nurses who will work in the home in the 21st century. You will be one of 300 deans of baccalaureate schools of nursing and 300 nursing directors of home health agencies specially selected for this national investigation. This study has been approved by the Texas Tech University Institutional Review Board (IRB) project #97435. Enclosed with this letter is a 33-item questionnaire that has been developed with the help of 120 deans and 120 nursing directors over the last year, hi this study, you will be asked to complete the original and two more brief questionnaires. Would you please take 10 or 15 minutes now to complete the enclosed survey, indicating what curriculum content you feel is needed in baccalaureate schools of nursing to prepare students for work in the home? Please retum your completed questionnaire in the pre-addressed, stamped envelope by JUNE 30th. If you wish, you may fax your reply to me. My fax number is (915) 335-5169. Your responses will be held in "strict confidence": No names or institutions will be used in any future reports. After I receive all of your responses, I will send to you the other deans' and the nursing directors' mean responses for each ofthe 33 items, as well as a copy of your first set of responses. You will then be given the opportunity to change your responses to the items. A third questionnaire will be mailed to you later this summer for any final changes you may wish to make in any ofthe thirty-three item responses. If you would like a summary ofthe final resuh of this study, please enclose your business card and I will send a copy to you. Thank you in advance for your assistance in this study. Sincerely, Phylhs Karmels R.N., C, Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 • Office Phone (915) 335-5155 149 SECTION li BACKGROUND INFORMATION 1. Your Title: 2. Years of Nursing Experience: (Check one ofthe options listed). 1-5 years 6-10 years 11-15 years 16-20 years 21-25 years_ 26 or more years . 3. Educational Background (Check all that apply): B.S.N. MSN Ph.D. BA- M.A. Ed.D. Other (please specify) 4. For Deans: Number of full time equivalent students in your program 5. For Home Health Nursing directors: Number of registered nurses employed in your agency . Comments (optional): Please list any additional content areas that you think should be included in curricula designed to prepare nurses to work in the home in the 21st century. 1. 2. 3. 4. '' Thank you for your time in completing this, the first ofthe three questionnaires. Please mail your completed questionnaire in the pre-addressed, stamped envelope by June 1998. Phyllis Karmels TTUHSC-PB 800 West 4th Street Odessa, Texas 79763 150 :tsv?^f Code QUESTIONNAIRE # 1 DIRECTIONS: Please place an "X" in the column to the right of each curriculum content item which descnbes how you would rate each item in terms of its essential nature in preparing nurses for work in home health care agencies in the 21st century. Response Key: (5) E=Essential, (4) HD=Highly Desirable, (3)D= Desirable, (2) N=Neutral or Not sure, U=Undesu-able, HU= Highly Undesirable. CURRICULUM CONTENT ITEMS E HD D N U HU 5 4 3 2 1 0 Part I: CONTENT DEALING WITH LEADERSHIP 1. Leadership Part II: CONTENT DEALING WITH MANAGEMENT 2. Time Management 3. Business Management 4. Fiscal Management 5. Management of Unlicensed Assistive, Personnel in the Home 6. Case Management as part of Managed Care 7. Critical Pathways as part of Case Management 8. Screening for Home Health 9. Third-party payment 10. Working Within a Team 11. Functioning Autonomously in the Field (OVER) 151 ""•—"""^rVMllil II imi»H[l|i|l nil QUESTIONNAIRE # 1 CnntimiPH Part III: CONTENT DEALING WITH THE INDIVIDUAL 12. Pain Management 13. Care ofthe Patient in the Home 14. Care ofthe Patient Emotionally 15. Palliative Care 16. Care ofthe Dying Patient 17. Health Maintenance 18. Rehabilitative Nursing 19. Health Care in Multicultural Populations 20. Communicable Disease Surveillance 21. Epidemiology 22. Disease Prevention Part V: CONTENT CONCERNING COMMUNICATION 23. Communication: Written 24. Communication: Oral 25. Informatics 26. Telenursing 27. Adult Learning Part VI: CONTENT CONCERNING RESEARCH 28. Measurable Outcome Criteria 29. Research Utilization 30. Quality Assurance 152 «lllU«^iiirfk!lU^ QUESTIONNAIRE # 1 Continued Part VII: CONTENT CONCERNING POLITICAL ISSUES 31. Mediation Resolution 32. Legal Issues 33. Political Activism Thank you for your time and attention. Please retum your survey in the enclosed envelope or fax it to me at (915) 335 5169 by June, 30th Phyllis Karmels TTUHSC SON 800 W. 4th Street Odessa, Texas 79763 153 • I II !••••• n in • APPENDIX D COVER LETTER AND SURVEY FOR DELPHI ROUND II 154 MUUU July 15, 1998 Dear Dean, Thank you for responding to round one of this three-round Delphi study. Enclosed is the second round questionnaire for this survey. The first column ofthe enclosed questionnaire contains the list ofthe 33 items that appeared in your first round questionnaire. The second column in the questionnaire contains the mean responses from the all ofthe who responded to the survey. The third column contains the mean responses from all ofthe nursing directors who responded to the survey. The fourth column contains your first responses to each ofthe 33 items. The fifth column is blank. In this column, please rate each item again as to how "essential" or "unessential" you feel that this curriculum content item is in preparing nurses to function in home health agencies in the next century. You may change your responses or keep them the same as they were in the first round. I have enclosed a pre-addressed, stamped envelope for your convenience in returning your completed questionnaire to me You may also fax your second set of responses to me at my office at Texas Tech University Health Sciences Center-PB. The fax number is 915-335-5169. Please respond by July 30,1998. Thank you for your valuable time in completing this second survey. Sincerely, Phylhs Karmels R.N.,C.,M.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 155 HUB i»ma • ^•••" IITfc Code QUESTIONNATRF Ml DIRECTIONS: The first column below, contains the 33 content items ofthe survey. The second column contams the deans' mean responses to each item. The third column contains the nursing directors' mean responses for each item. The fourth column contains your response to each ofthe 33 items. Again, please wnte your response to each item in the last (5th) column which describes how you would rate each item m terms of its essential nature in preparing nurses for work in the home in the 21st century. Response Key: (5) E = Essential, (4) HD = Highly Desirable, (3) D = Desirable, (2) N = Neutral or Not sure (1) U = Undesirable, (0) HU = Highly Undesirable. I n III IV V CURRICULUM CONTENT ITEM Mean: Mean: Your Your Deans Nursing Responses: Responses Directors 1st Round This Round Part I: CONTENT CONCERNING LEADERSHIP 1. Leadership 4.46 4.15 Part II: CONTENT CONCERNING MANAGEMENT 2. Time Management 4.63 4.67 3. Business Management 3.65 3.61 4. Fiscal Management 3.71 3.60 5. Management of Unlicensed 4.55 4.29 Assistive Personnel in the Home. 6. Case Management as part of 4.65 4.51 Managed Care 7. Critical Pathways as part of 4.31 4.24 Management 8. Screening for Home Health 4.33 4.15 9. Third-party payment 4.01 3.56 10. Working within a team 4.81 4.53 11. Functioning Autonomously in the 4.77 4.81 Field 156 — "-T"r • n Ii aiirfin Mt-m - r X,. "•.-^ •A.'^^.^ (OVER) QUESTIONNAIRE #2 Continued Part III: CONTENT CONCERNING THE INDIVIDUAL 12. Pain Management 4.75 4.09 13. Care ofthe Patient in the Home 4.79 4.53 14. Care ofthe Patient Emotionally 4.73 4.19 15. Palliative Care 4.48 3.89 16. Care of the Dying Patient 4.38 4.04 17. Health Maintenance 4.48 4.10 18. Rehabilitation Nursing 4.27 3.88 Part IV: CONTENT CONCERNING THE AGGREGATE 19. Health Care in Multicultural 4.53 3.63 Populations 20. Communicable Disease 4.31 3.51 Surveillance 21. Epidemiology 4.29 3.31 22. Disease Prevention 4.56 3.78 Part V: CONTENT CONCERNING COMMUNICATION 23. Communication: Written 4.86 4.56 24. Communication: Oral 4.90 4.58 25. Informatics 4.17 3.64 26. Telenursing 3.72 3.26 27. Adult Learning 4.20 4.04 157 .^, ,-r^^ QUESTIONNATRF U7 Continued Part VI: CONTENT CONCERNING RESEARCH 28. Measurable Outcome Criteria 4.44 4.28 29. Research Utilization 4.37 3.41 30. Quality Assurance 4.36 4.19 Part VII: CONTENT CONCERNESIG POLITICAL ISSUES 31. Mediation Resolution 3.70 3.25 32. Legal Issues 4.39 3.75 33. Political Activism, 3.58 2.82 Thank you for your time and attention. Please mail your responses by July 30,1998, or fax your response to me. My fax number is (915) 335- 5169: Phyllis Karmels, R.N.,C., M.Ed., M.S.N. TTUHSC-SON 800 West 4th St. Odessa, TX 79763 158 ^w^Mt ^vujLii'jLLuuamimmirm APPENDIX E COVER LETTER AND SURVEY FOR ROUND III 159 August 15, 1998 Dear Dean, Thank you for responding to my first and second questionnaires. Enclosed is the Third Delphi round ofthe survey. The first column contains the list of 33 items in the order in which they appeared in the first and second rounds. The second column contains the mean responses from all the deans who responded in round II. The third column contains the mean responses from all ofthe nursing directors in round II. The fourth column contains your responses in round 2. The 5th column is blank. Please use this column to again, rate your responses either by changing them or keeping them the same. The rating choices are the same as before. I have enclosed a stamped, pre-addressed envelope for your convenience. Please mail your response August 30th, 1998. This is the last survey you will receive. Thank you for your valuable time in participating in this study, for completing this survey, and for furthering my education. Sincerely yours, Phylhs Karmels, R.N.,C., Ma.Ed., M.S.N. 4903 Canadian Ave. Midland, TX 79707 Home Phone (915) 520-6172 Work Phone (915) 335-5155 160 1^ August 15, 1998 Dear Nursing Director, Thank you for responding to my first and second questionnaires. Enclosed is the Third Delphi round ofthe survey. The first column contains the list of 33 items in the order in which they appeared in the first and second rounds. The second column contains the mean responses from all the deans who responded in round II. The third column contains the mean responses from all ofthe nursing directors in round II. The fourth column contains your responses in round 2. The 5th column is blank. Please use this column to again, rate your responses either by changing them or keeping them the same. The rating choices are the same as before. I have enclosed a stamped, pre-addressed envelope for your convenience. Please mail your response August 30th J998. This is the last survey you will receive. Thank you for your valuable time in participating in this study, for completing this survey, and for frirthering my education. Sincerely yours, Phyllis Karmels, R.N.,C., Ma.Ed., M.S.N. 4903 Canadian Ave. Midland, TX 79707 Home Phone (915) 520-6172 Work Phone (915) 335-5155 161 Code Questionnaire #3 Below IS a copy ofthe means from all ofthe responses. The second column reflects the mean responses for the deans, the third column reflects the mean responses for the nursing directors. The fourth column contams your responses to each item in the second questionnaire. DIRECTIONS: The fifth columns is blank. In this column please rate each item again, keeping or changing your response as you wish. Response Key: (5) E=Essential, (4) HD=Highly Desirable, (3)D= Desirable, (2) N=Neutral or Not sure, U=Undesirable, HU= Highly Undesirable. I II III IV V CURRICULUM CONTENT ITEMS Mean: Mean: Your Your Deans Nursing Response: Responses: Directors 2nd Round This Round Part I: CONTENT CONCERNING LEADERSHIP 1. Leadership Part II: CONTENT CONCERNESTG MANAGEMENT 2. Time Management 3. Business Management 4. Fiscal Management 5. Management of Unlicensed Assistive Personnel in the Home 6. Case Management as part of Managed Care 7. Critical Pathways as part of Managed Care 8. Screening for Home Health 9. Third-party payment 10. Working within a Team (OVER) 162 Questionnaire #3 Continued 11. Functioning Autonomously in the Field Pat III: CONTENT CONCERNING THE INDIVIDUAL 12. Pain Management 13. Care ofthe Patient in the Home 14. Care ofthe Patient Emotionally 15. Palliative Care 16. Care of the Dying Patient 17. Health Maintenance 18. Rehabilitation Nursing Part IV: CONTENT CONCERNING THE AGGREGATE 19. Health Care in Multicultural Populations 20. Communicable Disease Surveillance 21. Epidemiology 22. Disease Prevention Part V: CONTENT CONCERNESfG COMMUNICATION 23. Communication: Written 24. Communication: Oral 25. Informatics 26. Telenursing 27. Aduh Learning 163 MPvmnr^ QUESTIONNAIRE #3 Continued Response Key: (5) E=Essential, (4) HD=Highly Desirable, (3)D= Desirable, (2) N=Neutral or Not sure, U=Undesirable, HU= Highly Undesirable. I II III IV V CURRICULUM CONTENT ITEMS Mean: Mean: Your Your Deans Nursing Responses: Responses: Directors 2nd Round This Round Part VI: CONTENT CONCERNING RESEARCH 28. Measurable Outcome Criteria 29. Research Utilization 30. Quality Assurance Part VII: CONTENT CONCERNING POLITICAL ISSUES 31. Mediation Resolution 32. Legal Issues 33. Political Activism Thank you for your time and attention. If you wish a copy ofthe final Results pleas enclose your business card with your responses. Please mail your responses by July 30,1998, or fax your response to me. My fax number is (915) 335-5169: Phyllis Karmels, R.N.,C., Ma.Ed., M.S.N. TTUHSC-SON 800 West 4th St. Odessa, TX 79763 Work Phone (915) 335-5155 Home Phone (915) 520-6172 164 ^^^^f^muimmjMa APPENDIX F REMINDER LETTER TO DEANS OR NURSING DIRECTORS WHO HAVE NOT RETURNED THE SURVEY 165 •UJHBW«n«EJI July 1, 1998 Dear Dean, Two weeks ago I sent to you the first of three rounds of questionnaires that you will receive in my national study. To date I have not received your first set of responses. This study is designed to examine the curriculum content needed for graduates ofthe baccalaureate program in nursing to enable them to function in home health care. Feedback is being solicited from 300 nurse educators and 300 nursing directors in home care settings throughout the United States. Your response is very important to this study. A 100% response is needed for this study, in all three rounds to be successful. I would appreciate it if you would take a few minutes now, to complete the questionnaire and send it back to me by July 10th, 1998 in the pre- addressed, stamped envelope which has been enclosed for your convenience. If you wish, you may fax your reply to me. The fax number is (915) 335-5169. (Please disregard this letter if you have recently mailed in your completed questionnaire.) Thank you for participating in this study. Sincerely, Phyllis Karmels, R.N.,C., Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 166 I ••Bi< 11* II • • I I I I • July 1, 1998 Dear Nursing Director, Two weeks ago I sent to you the first of three rounds of questionnaires that you will receive in my national study. To date I have not received your first set of responses. This study is designed to examine the curriculum content needed for graduates ofthe baccalaureate program in nursing to enable them to fimction in home health care. Feedback is being solicited from 300 nurse educators and 300 nursing directors in home care settings throughout the United States. Your response is very important to this study. A 100% response is needed for this study, in all three rounds to be successfiil. I would appreciate it if you would take a few minutes now, to complete the questionnaire and send it back to me by July 10th, 1998 in the pre- addressed, stamped envelope which has been enclosed for your convenience. If you wish, you may fax your reply to me. The fax number is (915) 335-5169. (Please disregard this letter if you have recently mailed in your completed questionnaire.) Thank you for participating in this study. Sincerely, Phyllis Karmels, R.N.,C., Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 167 August 1, 1998 Dear Dean, Recently, I sent to you the second set of three rounds of questionnaires that you will receive in this national study. Thank you for responding to the first round. However, to date I have not received your responses to the second round of this national study. This study is designed to examine curriculum content needed by nursing graduates to prepare nurses to function in home health care. Feedback is being solicited from 300 nurse educators and 300 nursing directors in home care settings throughout the United States. Your response is very important to this study. A 100% response is needed for this study to be successfiil. I would appreciate it if you would take a few minutes, now, to complete the survey and send it back to me no later than August 10th, 1998, in the pre-addressed, stamped envelope, which you received earlier. (Contact me if you have misplaced the questionnaire and I will send you another one.) If you wish, you may fax your responses to me. The fax number is (915) 335-5169. (Please disregard this letter if you have recently mailed in your completed questionnaire.) Thank you for participating in this study. Sincerely, Phylhs Karmels, R.N.,C., Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 168 BUnnff'^me WV * • J ^^^\gan r> I August 1, 1998 Dear Nursing Director, Recently, I sent to you the second set of three rounds of questionnaires that you will receive in this national study. Thank you for responding to the first round. However, to date I have not received your responses to the second round of this national study. This study is designed to examine curriculum content needed by nursing graduates to prepare nurses to fimction in home health care. Feedback is being solicited from 300 nurse educators and 300 nursing directors in home care settings throughout the United States. Your response is very important to this study. A 100% response is needed for this study to be successfiil. I would appreciate it if you would take a few minutes, now, to complete the survey and send it back to me no later than August 10th, 1998, in the pre-addressed, stamped envelope, which you received earlier. (Contact me if you have misplaced the questionnaire and I will send you another one.) If you wish, you may fax your responses to me. The fax number is (915) 335-5169. (Please disregard this letter if you have recently mailed in your completed questionnaire.) Thank you for participating in this study. Sincerely, Phyllis Karmels, R.N.,C., Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 169 September 1, 1998 Dear Nursing Director, Recently, I sent to you the third and final set of three rounds of questionnaires that you will receive in this national study. Thank you for responding to my first and second questionnaires that are part of a national survey. However, to date I have not received your responses to the third round of this national study. This study is designed to identify curriculum content needed by nursing graduates to prepare nurses to fimction in home health care. Feedback is being solicited from 300 nurse educators and 300 nursing directors in home care settings throughout the United States. Your response is very important to this study. A 100% response is needed for this study to be successfiil. I would appreciate it if you would take a few minutes, now, to complete the survey and send it back to me no later than September 15,1998, in the pre-addressed, stamped envelope, which you received earlier. (Contact me if you have misplaced the questionnaire and I will send you another one.) If you wish, you may fax your responses to me. The fax number is (915) 335-5169. (Please disregard this letter if you have recently mailed in your completed questionnaire.) Thank you for participating in this study. Sincerely, Phyllis Karmels, R.N.,C., Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 170 ri*"'nil niflffBnrwpifWfff September 1, 1998 Dear Dean, Recently, I sent to you the third and final set of three rounds of questionnaires that you will receive in this national study. Thank you for responding to my first and second questionnaires that are part of a national survey. However, to date I have not received your responses to the third round of this national study. This study is designed to identify curriculum content needed by nursing graduates to prepare nurses to fimction in home health care. Feedback is being solicited from 300 nurse educators and 300 nursing directors in home care settings throughout the United States. Your response is very important to this study. A 100% response is needed for this study to be successfiil. I would appreciate it if you would take a few minutes, now, to complete the survey and send it back to me no later than September 15,1998, in the pre-addressed, stamped envelope, which you received earlier. (Contact me if you have misplaced the questionnaire and I will send you another one.) If you wish, you may fax your responses to me. The fax number is (915) 335-5169. (Please disregard this letter if you have recently mailed in your completed questionnaire.) Thank you for participating in this study. Sincerely, Phylhs Karmels, R.N.,C., Ma.Ed., M.S.N. Doctoral Student, Higher Education Program and Assistant Professor of Nursing Home Phone (915) 520-6172 Office Phone (915) 335-5155 171 ?:i! iiH APPENDIX G TABLES OF MEAN RESPONSES FROM DEANS AND NURSING DIRECTORS FROM THE FIRST AND SECOND, MAIL OUTS 172 I II II I llilNIWWWWflWHIIII IlllPlimHlliil I Table G.l Means from the First Questionnaire Responses Concerning Leadership Curriculum Content Items Deans Nursing Range Directors Oto5 1. Leadership 4.46 4.15 4 to 5 Table G.2 Means from the First Questionnaire Responses Concerning Management Curriculum Content Items Deans Nursing Range Directors Oto5 2. Time Management 4.63 4.15 4 to 5 3. Business Management 3.65 3.61 2 to 5 4. Fiscal Management 3.71 3.60 2 to 5 5. Management of Unlicensed 4.55 4.29 3 to 5 Assistive Personnel 6. Case Management as Part of 4.65 4.51 4 to 5 Managed Care 7. Critical Pathways as Part .of Case 4.31 4.24 3 to 5 Management 8. Screening for Home Health 4.33 4.15 2 to 5 9. Third-party payment 4.01 3.56 2 to 5 10. Working Within a Team 4.81 4.53 4 to 5 11. Functioning Autonomously in 4.77 4.81 3 to 5 the Field 173 r rrmriBir'n •^jnjSU Table G.3 Means from the First Questionnaire Responses Concerning the Individual Curriculum Content Items Deans Nursing Range: Directors Oto5 12. Pain Management 4.75 4.09 3 to 5 13. Care of The Patient in the Home 4.79 3.89 3 to 5 14. Palliative Care 4.48 3.89 2 to 5 15. Care ofthe Patient Emotionally 4.73 3.88 2 to 5 16. Care ofthe Dying Patient 4.38 4.04 3 to 5 17. Health Maintenance 4.48 4.10 3 to 5 18. Rehabilitation Nursing 4.27 3.88 2 to 5 Table G.4 Means from the First Questionnaire Responses Concerning the Aggregate Curriculum Content Items Deans Nursing Range Directors Oto5 19. Health Care in Multicultural 4.53 3.63 3 to 5 Populations 20. Communicable Disease 4.31 3.51 2 to 5 Surveillance 21. Epidemiology 4.29 3.31 2 to 5 22. Disease Prevention 4.56 3.78 2 to 5 174 iiii<>i>iniiiii iiiiPiHiifD'ii ii rr I" " -' ''— Table G.5 Means from the First Questionnaire Responses Concerning Communication Curriculum Content Items Deans Nursing Range Directors Oto5 23. Communication: Written 4.86 4.56 3 to 5 24. Communication: Oral 4.90 4.58 3 to 5 25. Informatics 4.17 3.64 lto5 26. Telenursing 3.72 3.26 lto5 27- Adult Learning Principles 4.20 4.04 3 to 5 Table G.6 Means from the First Questionnaire Responses Conceming Research Curriculum Content Items Deans Nursing Range Directors Oto5 28. Measurable Outcome Criteria 4.44 4.28 2 to 5 29. Research Utilization 4.37 3.41 lto5 30. Quality Assurance 4.36 4.19 3 to 5 175 I "I •iiiiuMPdiyiPi'rn f I' ^.^m^ m mm TJJfcBii» •••> • MJi ^^.-ta Table G.7 Means from the First Questionnaire Responses Conceming Political Issues Curriculum Content Items Deans Nursing Range Directors Oto5 31. Mediation Resolution 3.70 3.25 lto5 32. Legal Issues 4.39 3.75 2 to 5 33. Political Activism 3.58 2.82 lto5 Table G.8 Means from the Second Questionnaire Responses Conceming Leadership Curriculum Content Items Deans Nursing Range Directors Oto5 1. Leadership 4.53 4.35 3 to 5 176 eceffiiiBaa fc^ ^ 1» w •• m ^"^j Table G.9 Means from the Second Questionnaire Responses Conceming Management Curriculum Content Items Deans Nursing Range Directors Oto5 2. Time Management 4.85 4.74 3 to 5 3. Business Management 3.73 3.66 2 to 5 4. Fiscal Management 3.74 3.62 2 to 5 5. Management of Unlicensed 4.61 4.56 3 to 5 Assistive Personnel 6. Case Management as part of 4.66 4.50 3 to 5 Managed Care 7. Critical Pathways as Part of Case 4.39 4.38 3 to 5 Management 8. Screening for Home Health 4.31 4.18 3 to 5 9. Third-party payment 3.87 3.63 2 to 5 10. Working Within a Team 4.91 4.83 4 to 5 11. Functioning Autonomously in the 4.71 4.96 4 to 5 Field 177 M^^itf'WlHgc »T I ILB,IW>i>W*^W^:MM>Wy Table G.IO Means for the Second Questionnaire Responses Conceming the Individual Curriculum Content Items Deans Nursing Range Directors Oto5 12. Pain Management 4.68 4.24 2 to 5 13. Care ofthe Patient in the Home 4.82 4.69 3 to 5 14. Palliative Care 4.45 4.02 2 to 5 15. Care of the Patient Emotionally 4.60 4.26 2 to 5 Table G.l 1 Means from the Second Questionnaire Responses Conceming the Aggregate Curriculum Content Items Deans Nursing Range Directors Oto5 16. Care ofthe Dying Patient 4.47 4.10 2 to 5 17. Health Maintenance 4.52 4.14 2 to 5 18. Rehabilitation Nursing 4.05 3.93 2 to 5 19. Health Care in Multicultural Populations 4.55 3.76 2 to 5 20. Communicable Disease Surveillance 4.12 3.59 2 to 5 21. Epidemiology 4.06 4.20 2 to 5 22. Disease Prevention 4.47 4.25 2 to 5 178 I^IHTIf illl^iiiJdBanTi'iilr 111 • ^^••.••a Wiifc I Table G.12 Means from the Second Questionnaire Responses Conceming Communication Curriculum Content Items Deans Nursing Range Directors Oto5 23. Communication: Written 4.90 4.67 4 to 5 24. Communication: Oral 4.82 4.72 4 to 5 25. Informatics 4.33 3.78 2 to 5 26. Telenursing 3.70 3.15 lto5 27. Adult Leaming 4.19 4.03 2 to 5 Table G.l3 Means from the Second Questionnaire Responses Conceming Research Curriculum Content Items Deans Nursing Range Directors Oto5 28. Measurable Outcome Criteria 4.42 4.36 2 to 5 29. Research Utihzation 4.43 3.35 2 to 5 30. Quality Assurance 4.34 4.26 3 to 5 179 ^ -^^ - i>!»»juw»iy_— -^ Table G.l4 Means from the Second Questionnaire Response Conceming Political Issues Curriculum Content Items Deans Nursing Range Directors Oto5 31. Mediation Resolution 3.54 3.34 Oto5 32. Legal Issues 4.29 3.62 2 to 5 33. Political Activism 3.55 3.46 1 to5 180 P *>lll|i|IIIIIIIIIIIIHIIilP I III II I I liliN|ill|lilll|i l|i»l|| stssa Mfc » ^ » < • • . •.•*J1^ APPENDIX H THIRD ROUND MEAN RESPONSES PER ITEM AND r-VALUES 181 -Jf'J.klLlM\\n IWHIIMII LiimuMjui jijBge^g^aaBB—ia ^saMl Table H 1 Means and /-value from the Third Questionnaire Responses Conceming Leadership Curriculum Content Deans Nursing /-value Directors 1. Leadership 4.58 4.44 2.15* * < .05. 182 .« " I l|IWi' Curriculum Content Items Deans Nursing /-value Director 2. Time Management 4.69 4.74 -0.88 3. Business Management 3.72 3.80 -0.88 4. Fiscal Management 3.78 3.82 -0.53 5. Management of Unlicensed 4.58 4.35 3.86** Assistive Personnel 6. Case Management as 4.80 4.53 4.69** Part of Managed Care 7. Critical Pathways as Part 4.41 4.24 2.32* of Case Management 8. Screening for Home Health 4.23 4.11 1.48 9. Third-Party Payment 3.99 3.78 2.64** 10. Working Within a Team 4.87 4.66 4.54** 11. Functioning Autonomously 4.68 4.91 -4.60** in the Field * <.05. **<.01. 183 Table H 3 Means and /-value from the Third Questionnaire Responses Conceming the Individual Curriculum Content Items Deans Nursing /-value Directors 12. Pain Management 4.48 4.09 5.11** 13. Care ofthe Patient in the 4.74 4.64 1.60 Home 14. Palliative Care 4.41 4.04 5.47** 15. Care ofthe Patient 4.58 4.08 7.06** Emotionally 16. Care ofthe Dying Patient 4.45 4.17 4.25** 17. Health Maintenance 4.54 4.22 4 44** * <.05. **<.01. 184 I iiiiiiii«iiiniiiiiiii II II II iiir iiiirir Table H 4 Means and /-value from the Third Questionnaire Responses Conceming the Aggregate Curriculum Content Items Deans Nursing /-value Directors 18. Rehabilitation Nursing 4.11 3.99 1.71 19. Health Care in Multicultural 4.55 3.76 10.49** Populations 20. Communicable Disease 4.09 3.48 8.05** Surveillance 21. Epidemiology 4.04 3.45 8.01** 22. Disease Prevention 4.54 3.91 8.79** * <.05. **<.01. 185 —T'-LJuiMlai* ^.VUIUILBC Table H 5 Means and /- value from the Third Questionnaire Response Conceming Communication Curriculum Content Items Deans Nursing /-value Director 23. Communication: Written 4.88 4.72 2.94** 24. Communication: Oral 4.86 4.7 3.20** 25. Informatics 4.18 3.64 6.26** 26. Telenursing 3.53 3.13 4.47** 27. Adult Leaming 4,28 4.11 2.28* * <.05. **<.01. Table H 6 Means and /-value from the Third Questionnaire Responses Conceming Research Curriculum Content Items Deans Nursing /-value Director 28. Measurable Outcome 4.51 4.37 2.17* Criteria 29. Research Utilization 4.43 3.52 11.49** 30. Quality Assurance 4.42 4.18 3.90** * <.05. **<.01. 186 I III' r--| I Table H 7 Means and /-value from the Third Questionnaire Responses Conceming Political Issues Curriculum Content Items Deans Nursing /-value Director 31. Mediation Resolution 3.68 3.13 6.74** 32. Legal Issues 4.32 3.64 9.96** 33. Political Activism 3.61 2.88 8.07** **<.01, 187 8SB5Bi plijjij- it!-»'j'j'-j^- '•' jr, J^^*r-.fty