An Examination of Telenursing: Description of the Professional Role and Predictors of Role

Home , Advanced practice nurse, Critical care nursing, Nurse anesthetist, Nurse educator, Nurse midwife, Nurse practitioner

An examination of telenursing: Description of the professional role and predictors of role

stress, role ambiguity and role conflict.

Loretta M. Schlachta-Fairchild

Submitted to the Faculty of the School of Graduate Studies

of the Medical College of Georgia in partial fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Date:

November 7, 2000 An examination oftelenursing: Description of the professional role and predictors of role

· stress, role ambiguity and role conflict.

This dissertation is subn:iitted by Loretta. Schlachta~Fair_child ~cl has been examined and approved by an appo~nted co~~ittee of the faculty of the School of.

Graduate Studies of the Medical College of Georgia... --

. . The signatures which app~ar below vetify the·fact that all required changes have been incorporated and that the dissertation has received final appro·val with .reference to

. . ' content, form and accuracy 9f pres~ntatfon. '

This dissertation is therefore in partial ful_fillment of the requirements for the degree of Doctor of Philosophy. ..

Date 3

CHAPTER 3: METHOD ...... p. 37 ·

I. Researchhypotheses ...... · ...... ; ...... p. 38

II. Setting and Sample ...... ·...... p. 41

III. Design ...... ; ...... p. 45

IV. Measurement."...... p. 47

a. Procedures ...... ~ ...... p. 48

b. Instrumentation ...... · ... p. 50

V. Analysis ...... p 58

a. Methods ...... :.; ...... · ...... p. 58

b. Limitations ...... ·...... p. 61

VI.Human Subjects Protection ...... p. 62

CHAPTER 4: FINDINGS...... p. 64

I. Individual Characteris,tics ...... p. 65

II. Professional Role ...... p. 68

III. Work Satisfaction ...... p. 75

IV. Role Strain/Role Stress ...... p. 80

CHAPTER 5: DISCUSSION AND RECOMMENDATIONS ...... _.p. 90

I. . Limitations of Study ...... p. 91

II. Directions for Future Research ...... p. 112

III. Conclusion ...... p. 113

REFERENCES ...... p. 115

ACKNOWLEDGEMENTS

It is with the deepest gratitude that I thank, first and foremost, my loving husband,

Hank and sons Joseph and Henry for all the hours, days and milestones that they provided their love and support to me. I missed many a ball game and many a romp on the lawn with them to complete this goal, and they always supported me unconditionally. To my

Committee Chair, Dr Suzanne Pursley-Crotteau, I owe a great debt of gratitude for her mentorship, kindness and wisdom during this journey. Without her knowledge and support I would not have completed this goal. Dt. Peggy Parks has given of her time, support, mentorship and consultation during this past year. Her guiding li~ht has shown the path when many times the path was too dark for me to see. To my dissertation committee members, my nurse colleagues, my neighbors and friends who have provided insight, wisdom, humor and in~piration, I thank you from the bottom of my heart. A special thanks goes to Jo Ann Klein for her web authorship of the Internet-based

Telenursing Role Survey and for her unending encouragement. And, last, but never least, to my dear friend Beth Buckley for her inspiration to me. as a special friend, a nurse colleague, a fellow student_ and a cancer survivor. Her will and constitution served to inspire me to continue on this journey, as she has continued on her journey, even when at times the path seemed impassable.

Loretta Schlachta-Fairchild

', November 2000 iii

ABSTRACT

An examination of telenursing: Description of the professional role and predictors of role stress, role ambiguity and role conflict.

Telenursing is the use of telehealth technology to deliver nursing care and conduct nursing practice (Schlachta & Sparks, 1999). In response to the rapid adoption of telemedicine technology in he'1:lthcare organizations, telenursing is emerging as a new role, prompting discussion of licensure, malpractice, and credentialing issues within nursing. Role stress associated with new nursing roles such as telenursing impacts individual patients and the larger healthcare organization, causing turnover, burnout, loss of continuity of care and loss of operational expertise. As with many emerging technologies, nurses assume increasingly complex roles and responsibilities. As telemedicine proliferates, the role of nurses in participating in and improving the telemedicine process will take on more pr.ominence. It is important to identify issues related to use and integration of telemedicine into nurses' roles to minimize role stress, encourage telenursing participation and position nursing practice to take advantage of telemedicine technologi~s.

Using the portion of Role Theory, that relates to the impact of Role Set upon

Role· Strain, as a framework this was a descriptive ·research study that identified a current population of 796 telenurses in the U.S., representi!lg 40 states. From this population,

196 telenurses participated in a telephonic or an online, web-based survey during

Summer 2000. The purposes were to 1) Describe a) telenurses' professional role(s) and characteristics and b) U.S. strategies for nursing competence and patient safety iv

2) Measure telenurses' work satisfaction_ and its components, and role stress and its components 3) Predict the relationship between the components of work satisfaction, individual and professional role characteristics, and role stress, role ambiguity and role conflict.

Findings of the Telenursing Role Study indicated that the typical Y2K telenurse is

46 years old, has worked 21 years in nursing and >6 months in her telenursing position.

She has a 27% chance of being an advanced practice nurse, and has at least a baccalaureate degree, and likely a graduate degree. The typical telenurse is white, female, married, and has children .. She works full-time in teleriursing and makes just over $49,000 per year. Telenurse.s work in over 29 practice settings, including web portals, private companies and for telemedicine equipment vendors. They have a host of unique, new titles such as Bioengineering Clinical Nurse Specialist, Telehealth Project

Director and Consumer Information Nurse. Telenurses experience less than average role stress, role ambiguity and role conflict. They also have the same work satisfaction as other hospital-based nurses. The most important factor contributing to telenurses' work satisfaction is autonomy.

Findings of regression analysis were that education level and level of work satisfaction both predict role stress and role ambiguity in telenurses. Higher education levels of telenurses are associated with higher role stress and role ambiguity. Higher levels of work satisfaction of telenurses are associated with lower role stress and role ambiguity. Role ambiguity, level of education and work satisfaction are significant predictors of role conflict in telenurses. V

LIST OF TABLES

Table 1: Summary of Literature Related to Telenursing .... ·...... Appendix F

Table 2: Summary of Literature Related to \1/ork Satisfaction ...... Appendix G

Table 3: Summary of Literature Related to Role Stress ...... Appendix H

Table 4: Summary of Literature Related to Role Conflict

, and Role Ambiguity ...... Appendix I

Table 5: Research Hypotheses ...... p. 38

Table 6: Components ofTelenursinp Role Survey ...... p. 46

Table 7: Telenursing Role Survey Sections and Content...... p. 50

Table 8: Age of Telenurses ...... p. 66

Table 9: Telenurses with Advanced Practice Preparation .... , ...... _ ...... p. 67

Table 10: Employment Status and Salaries of Telenurses ...... " ...... p. 68

Table 11: Work Settings of Telenurses ...... p. 68

Table 12: Role Functions of Telenurses and Percentage of Time Spent in each Role

Function ...... p. 71

Table 13: Types ofTelenursing Role Functions ...... ' ...... p. 72

Table 14: Telenursing Position Titles ...... p. 73

Table 15: Types ofTelemedicine Patients seen by Telenurses ...... p. 75

Table 16: Individual Work Satisfaction Scores of Telenurses ...... _ ...... : ..... p. 77

Table 17: Telenurses Total Work Satisfaction Scores by Quartile ...... p. 78

Table 18: Overall Index of Work Satisfaction for Telenurses as a Group ...... p. 79

Table 19: Role Stress, Role Ambiguity and Role Conflict Scores of Telenurses .... p. 80 vi

Table 20: Pearson Correlations of Study Variables ...... p. 81

Table 21: Summary of Hierarchical Regression Analysis for Variables Predicting Role

A1nbiguity ...... -p. 84

Table 22: Summary of Hierarchical Regression Analysis for Variables Predicting Role

Stress ...... p. 85

Table 23: Summary of Hierarchical Regression Analysis for Predicting Role

Conflict ...... : ...... p. 87

Table 24: Responses to Comfort _with Level of Technical Competence for

Telenursing ...... \ ...... p. 88

Table 25: Comparisons of Studies of Percents of Nurses with Highest Education

Levels ...... p. 94

Table 26: Role Functions Comparison ofTelenurses and Nurses ...... p. 96

Table 27: Index of Work Satisfaction Scores ~f Selected Studies of Nurses ...... p. 103

Table 28: Comparisons of Studies Measuring Role Stress, Role Ambiguity and Role

Conflict of Various Healthcare Groups ...... pp. 106-107 vii

LIST OF FIGURES

Figure I: Role theory: Conceptual-theoretical ---empirical structure of study ...... p. 16

Figure 2: Model for Testing Relationships of Variables and Predicting

Role Stress of Telenurses ...... p. 40

Figure 3: Geographic Representation ofTelenursing Role Study Respondents ...... p. 65 4

Chapter 1

Introduction

Background

Advances in digital and computer technologies are the basis of the technological change that is our economy's prime mover (HBO & Company, 1992). The digital revolution is underway (Office for the Advancement of Telehealth, 1999). Digital data, voice, still images and motion-video can be mixed, matched, melded, transferred, stored and manipulated· by powerful computer systems. The digital revolution enables people to experience unprecedented ways to educate, entertain, inform, transact and interact. In healthcare, scientific and technological advances have transformed the relationships among diagnosis, treatment, patient knowledge and patients' interaction with the healthcare system. Access to advanced technology such as laser surgery or open MRI is the second most important reason why patients visit or enter hospitals and why physicians choose to practice in one hospital versus another (HBO & Company, 1992).

Within this vast and rapidly evolving digital revolution, technology has also served to change nurses' roles in regard to healthcare enterprises.

From the inception of nursing practice, simple and complex technologies have been used to care for the sick. From the poultices of l 800's nursing to .the intraortic balloon pumps of the 1970' s, nurses have incorporated technology as an integral part of nursing care. As Sandelowski ( 1996) points out, though nurses have always used technology, the relationship between nurses and their technological tools has posed a challenge. Nursing leaders of the l 950's, a period when technology was rapidly introduced in inpatient settings, cautioned nurses to remain "nurse therapists rather than 5 nurse technicians" (Abdellah & Strachan, 1959, p. 649). This statement seems to reflect that even in the 1950's, role conflict as a result of incorporating emerging technologies occurred.

Farmer (1978) in a widely cited first effort to describe the relationship of nurses and technology emphasized that technology led to role erosion and role stress as nurses shifted their focus away from patients and placed it on machines and technology.

Nevertheless, the use of technology in nursing has progressed rapidly to the point that entire specialties such as operating room nursing and critical care nursing have evolved around the use of technology.

· Nursing has been and continues to be central in the use of technologies for health care (Sandelowski, 1996). Nurses have relative power and choice in how and whether equipment is used. Nurses inform patients about the use and result aspects of technologies. Nurses in all specialties of practice are required to care for their patients and have the technical knowledge to both manipulate machinery and interpret data, and nurses also take on increasingly varied and complex roles and responsibilities associated with emerging technologies (Barnard, 1996). The combination of technological challenges, managing a changing healthcare delivery system, the nursing shortage, an aging nursing workforce, and work overload causes role stress for nurses.

Role stress is a condition in which role obligations are vague, irritating, difficult, conflicting, or impossible to meet (Hardy & Conway, 1988, p. 165). "Str~ss is everywhere" as procla_imed in the front-page headline of The American Nurse (Trossman,

1999). Stress related to the nursing role is widely acknowledged to be the major cause of attrition and turnover in the nursing profession (Dewe, 1989; Scalzi, 1988; Lees & Ellis, 6

1990; Tyler, Carroll & Cunningham, 1991; Wheeler, 1998). Specifically, role stress, tension, dissatisfaction, physical and mental demands, multiple varied complex situations nurses face, work with gravely ill or dying patients, change in organizational structures, and rapid evolution of technologies have all been implicated in the stress of the nursing role.

It is especially important, therefore, to examine the use and integration of new technology into nurses' roles. It is important because any major change should be accomplished in a purposeful and meaningful manner, not just added to the role of the nurse as another stressor. It is imperative to examine new technology use through the lens of a nursing perspective. Results of this scrutiny will inform the profession about nurses' work with devices, their emerging roles in the healthcare system as a result of technology, the relationship between nurses and other healthcare providers, and the impact of new nursing technology on patients (Sandelowski, 1996; American Nurses

Association, 1998; American Academy of Nursing, 1996).

Sandelowski' s (1996) perspect'ive of technology as an object, i.e. that technology is a tool used by nurses for nursing practice, is a fundamental tenet of the approach of this study. Viewing technology as an object allows focus upon what nurses do and the impact of the technology processes on their role(s), rather than focus upon the technology itself.

Telehealth is a new technology that has received much attention in the last ten years. To date, most of the focus has been on the technical aspects of telehealth. In contrast,

Sandelowski's perspective is to focus on the process and persons, viewing technology as a static entity that is not a focal point of attention. Using Sandelowski's perspective in this study, telehealth is viewed as an object used by nurses for nursing. When technology 7 is viewed as an object, then the advances of telehealth technology are viewed as merely another tool in the toolkit of nurses. The focus then becomes the persons and processes surrounding th~ technology instead of the technology itself. In this study, it is the impact of the use of telehealth technology on nurses' role and role stress that is the focus, not the technology itself.

Telemedicine is defined as the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data and education using interactive audio, visual, and data communications (Kansas Telemedicine Policy Group, 1993). Telehealth is a broader term often interchanged equally with telemedicine and encompassing the same elements of interactivity, education, distance diagnosis, and Internet based health efforts. Typically, telehealth technology includes an exchange via interactive voice and video, where the patient can hear and see the provider, and the provider can hear and se_e the patient. The technology enables a clinical interactfon very similar to a face to face exchange in a clinic or hospital setting. Use of telehealth in healthcare has exploded in the last decade as a potential solution to cost and access to healthcare issues in the United

States and in foreign healthcare delivery systems (Taft & Seitz, 1994; Brennan, 1999;

Moran, 1998).

Telehealth use continues to proliferate (Grigsby et al, 1995). In 1996 there were approximately 100 telehealth programs. As of the date of this research there were over

300 formal institutional programs, with numerous private applications of telehealth technology, such as individual home health agencies. Telehealth technology use continues to accelerate, usually with very little education or formalized training for providers (University of Michigan, 1995). Nurses today are practicing telenursing, using 8

telehealth technology in various settings such as hospital based telehealth centers,

rehabilitation facilities, home health agencies, and disease management companies

(Yensen, 1996; Zickler & Cantor, 1997; Warner, 1996; Lunday, 1997). There are

approximately 2.4 million registered nurses in the United States of America (Division of

Nursing, 1996). A conservative estimate is that ·approximately 600 nurses in the United

States today are practicing telenursing .. Many more telenurses are practicing abroad,

where healthcare reimbursement methods such as socialized medicine provide the

economic structure to readily realize telehealth' s cost reduction and access to care

capabilities.

Telenursing is the use of telehealth technology to deliver nursing care and conduct

nursing practice (Schlachta & Sparks, 1998). There is discussion on how ( or if) the

practice of telenursing changes the scope, licensure, malpractice, ethical and fundamental

tenets of nursing (American Nurses Association, 1997; National Council of State Boards

of Nursing, 1997; Helmlinger & Milholland, 1997; Kjervik, 1997; Tan, 1997).

Telenursing is emerging as a new and controversial role in nursing practice. Nurses

experienced role stress in other relatively new professional nursing roles such as nurse

practitioners, clinical nurse specialists, and case managers. Role stress, in the form of

role conflict and role ambiguity associated with new nursing roles, impacts both

individual nursing practice and the larger healthcare organization (Clawson & Osterweis,

1993; Mezey & McGivern, 1993; Redekopp, 1997; Russell & Hezel, 1994). The extent

· and impact of role stress related to telenursing have yet to be determined, as does the

impact of telehealth as a technology tool for nursing practice. The researcher viewed

telehealth technology for this study as an object, minimizing the technological aspects· 9

and focusing ~n nursing practice and the resultant role issues of telenursing, i.e.

specifically telehealth technology was examined through the lens of a nursing

perspective.

Purpose

The intent of this study was to examine the professional role and individual

characteristics, work satisfaction, role stress, role ambiguity and role conflict of

telenurses practicin~ in the United States. Using Role Theory as the theoretical

framework, a descriptive study utilizing survey research methods was undertaken. The

focus was on examination of the telenursing role. The purposes of this research were to:

1. Describe a) telenurses' professional role(s) and ind~vidual characteristics

and b) strategies for adherence to the uset competence and patient safety portion of one of the American Nurses Association (ANA) Core Principles on Telehealth

2. Measure a) telenurses' work satisfaction and its components and b) telenurses' role stress, role ambiguity and role conflict

3. Predict the relationship between the components of work satisfaction,

individual and professional role characteristics, and role stress, role ambiguity and role conflict.

Significance

Rapid change in society is occurring with the increased use of computers and

other emerging technologies. This pattern is also occurring in health care and the

burgeoning of technology is driving the growth and changes in healthcare services (Porter

-O-Grady, 1999). As technology proliferates, the evolution of nursing roles will continue

to challenge the profession. Nurses must take the initiative _to examine the impact of technology, particularly telehealth technology to integrate technology into nursing practice in a way that meets the fu.q.damental tenets of nursing (National Center for

Nursing Research, 1993; Dreher, 1996; Warner, 1996; Balas et al, 1997). Jhis involves assessing the impact of proposed guidelines, identifying variables of importance that influence the evolving role of telenursing, and developing a body of knowledge related to telenursing practice (Grigsby et al, 1995; American Academy of Nursing, 1996).

Unless nurses build their own scientific and operational basis of telenursing practice, nursing will be left in a supportive role to physicians and other practitioners.

Until nurses drive the development oftelenursing, roles will be defined/or nurses regarding the use and practice oftelenursing (Quinn, 1974; University of Michigan,

1995). As Porter-0-Grady (1999) stated, "A script for a preferred future for health care is unfolding. The key question is whether nurses are at the table proactively writing the script or at the door lamenting the need to write it" (p. 34). This statement directly applies to telenursing. Nurses are in a unique position to maximize use of telehealth technology, since telehealth's technical aspects are particularly effective for monitoring, educating, mentoring, assessing and supporting patients and families. Examining telenursing provides an opportunity to contribute to the script of future healthcare by describing and defining important aspects relat~d to this emerging role.

During August 1999, a call for comments from Vice President Gore's Joint

Working Group on Telemedicine (Office for the Advancement of Telehealth, 1999) asked the question: Is Telehealth certification necessary for professionals? Because of the newness of telehealth technology, it is being suggested that each profession provide certification for its members for the use oftelehealth technology. Such a question is 11 highly unusual when applied to nursing, especially since the role(s), variables and nature of nursing interventions delivered via telehealth technology are as yet virtually undefined

) (American Academy of Nursing, 1996). Yet the question is being asked, resultant policies are being planned and decisions are currently being mac;le for nurses, not necessarily by nurses experienced in this area. For instance, when the Core Principles of

Telehealth were developed at ANA by an invited group of nurses, this information was taken and published as competencies for telenursing without the consent of the group of nurses who participated in the working session. Furthermore, the group was not representative of telenurses practicing in the arena, therefore the development of competencies by a group of nurses who had very little knowledge of the arena of telenursing is highly problematic.

This researcher began to delineate some of the key variables related to and affecting the emerging role of telenursing. The research plan was to test the portion of

Role Theory that is concerned with the role set. The role set is composed of role behaviors, expectations, competence and the characteristics of the role occupant. The research also tested the relationship of the role set to role strain, role stress and its components, role conflict and role ambiguity. The role occupant in this research was the telenurse. As a test of a portion of Role Theory, the current study was a contribution to the as yet limited body of knowledge of tel_enursing. This knowledge can be utilized by organizations forming or conducting telehealth programs, schools of nursing that prepare students for future nursing practice, and individual nurses who require information related to their current or anticipated practice of telenursing. 12

Theoretical Framework

The theoretic.al basis for this study was Role Theory. Role Theory is a collection of concepts and a group of hypotheses that predict how persons will perform in a given role, or how certain behaviors can be expected to occur (Hardy & Conway, 1988). Role

Theory is a classical theory, virtually unchanged in the years since its articulation, and utilized extensively in the literature related to healthcare and non-healthcare role research. The word "role" was first used in the 1920's and comes from the theatrical arena. Role refers to a part that is played or assigned in a drama. Originally, roles and role performance were studied in the behavioral· sciences. There are two major perspectives from which roles and role theory were studied in behavioral science: structuralism and symbolic interaction. The use of role theory, however, is not limited to the behavioral sciences, and has applicability for health professionals (Hardy & Conway,

1988).

Proponents of structuralism, also termed structural-functional theory, stated that roles occur in society to fill a need for that society. Merton ( 1949) theorized the existence of large-scale systems in human society built by the structuralist perspective.

In the structuralist perspective, as institutions and society evolve, the social structures of roles also evolve to fulfill the social need (Hardy & Conway, 1988). Structuralist theorists viewed individual influence and personal effectiveness as limited. In structuralism, the structure of society is the force forming an individual's roles, rather than individuals themselves having influence over the evolution of their own roles.

Structuralism may have certain valid aspects related to environmental forces, namely in this case, technological change and role stress acting to "produce" behavior. However, 13 this framework has limitations for this study and in general. The major limitation of structuralism is the lack of recognition of individuals or small groups to determine the trajectory of new roles in society, such as telenursing.

In contrast, the symbolic interactionist perspective of role theory, derived from the writing and research of social psychologists such as l\1ead (1934) and Blumer (1962), holds that role behavior is a product of the process of interaction of persons, and their interpretation of the behavior of each other as they perf~rm their roles (Hardy & Conway,

1988). The formation of roles in this perspective is a product of the self, self-perception, and the perspective of others who interact with the-person. While societal influences impact the formation of roles in symbolic interactionism, they are not the main driving force. Reciprocal social interaction of individuals, groups, and the structure of society all interact together to form new roles that then further shape society. Symbolic interactionists recognized the power of the individual to create new roles in society, in which language, gestures, and symbols are created and exchanged. In doing so, individuals further define roles.

The symbolic interactionist approach to role theory has taken precedence over structural theory in attempts to explain human behavior (Hardy & Conway, 1988). A reason is that structural-functional theory, while relatively easy to understand, does not account for the large variations in human behavior that occur. In this study, symbolic interactionist theory was used as a framework for the evolving role of tele~ursing.

Symbolic interactionist theory allowed for the impact of the individual in working not only within a role, but also within a group. The individual, taking into account, and being influenced by societal forces, then further creates future roles. 14

The Conceptual Model of Role Theory

Kahn et al ( 1964} defined role as behaviors performed by an individual who occupies a position. Individuals have simultaneous roles, such as parent, citizen, caregiver, and professional, each of which carries its own role expectations. These are

"position-specific norms that identify the attitudes, behaviors, and cognitions required and anticipated" for a person in a specific role (Hardy & Conway, 1988, ·p. 165). Role expectations are part of the role set; the constellation of relationships with the role partners of a particular position (Merton, 1957, p. 369). The role set comprises the role partners of a position, i.e. those who are interacted with during the role episode, as well as the organization in which the role set operates. Kahn (1964) describes a role episode as a three-phased cycle: role sending (role expectations communicated by members of the role set), reaction by the individual in the role, and then the effect of the reaction on the role senders. In the role episode, the role senders should communicate mutually appropriate role expectations to the individual in the role, and observe the individual's role performance, then provide feedback that meets the individual's understanding of what the role should be. Role set direction may or may not be clear, or may be perceived as approval or disapproval by the individual in the role. Thus, as disconnects in the role episode occur, wle stress may begin and build as role episodes occur.

Role stress is a '"condition in which role obligations are vague, irritating, difficult,

conflicting, or impossible to meet" (Hardy & Conway, 1988, p. 165). Role stress is an

external force that produces strain on the internal state of the system - in this case an

individual in the role set. It was an assumption of symbolic interaction and self

actualization theory, and of this study, that individuals actively seek stress to achieve 15

development of interpersonal competence. It was assumed that those individuals in the

role set see role stress and role problems as challenges requiring solutions. Thus, role

stress is not necessarily always abnormal or undesirable, nor does it always result in role

strain (Hardy & Conway, 1988). Role stress is manifested in the individual as role strain.

Role strain is the internalization of role stress. The terms role stress and role strain are

often used interchangeably, and thus inaccurately, in the literature. One cannot measure

role stress, since it is external·to the individual and is located in the general environment.

Role strain, however, can be measured to the extent that a person's internal experience of

role stress can be quantified or reported. For purposes of this study, and in the reported

literature, the term role stress is utilized but in fact actually quantifies and measures role

strain.

Role stress has two components: role conflict and role ambiguity. Role conflict is

the occurrence of two or more sets of pressures such that compliance with one role would

make it more difficult to comply with the other role (Kahn et al, 1964 ). Role ambiguity

. is the lack of clear, consistent and accessible role information (Kahn et al., 1964 ). Role

conflict and role ambiguity are separate constructs within the concept of role stress. Role

conflict and role ambiguity have a direct and summative affect upon role stress. As role

conflict and/or role ambiguity increase, thus role stress increases as well. Persons in the

role set may withhold role information on purpose or innocently; it may not be clearly

articulated or understood, role senders' messages may be conflicting, and thus role

ambiguity and role conflict may occur.

While there are other relationships, models and elements within role theory, this

study, as depicted in Figure 1, tested th~ portion of role theory dealing with the above ,---1 16 L ___ J = Independent Variable

c==:> = Dependent Variable

r------I Role I I 1 1 Theory 1 Roleset I - I I - - - -► Conceptual Model 1------. : Individual : :characteristic~ ~---- _____ J Concepts ,------, r------1 I I ofthe : Wark Satisfaction : : Professional 1 Theory L--~~~~1~~~~~-J ,------i ~~~~~~I~~~~, Measured: :Reported: Reported I IAge Telenursing I Empirical Autonomy Pay IEducation I Functions: l Measures of Measures I • I b I Task Reqts :Total Nursm~ Num · er 1 Role of the· I Org Policies : Experience : Type 1 Ambiguity Concepts I Interaction l IExperience inl &Role

______Prof Status _Jl I1______Telenursin~ _ Figure 1. Role Theory: Conceptual-theoretical-empirical structure of study

Note. From The Relationship of Theory and Research (p. 64), by J. Fawcett, 1999, Philadelphia: F.A. Davis Company. Copyright 1999 by F.A. Davis Company. Adapted with permission obtained (Appendix J) .. 17

mentioned components. Figure I illustrates the portion of the conceptual model of Role

Theory used in this research. The dotted line between Role Set and Role Strain indicates that Role Strain does n_ot always occur. Individuals may experience or actually seek levels of role strain as a stimulation or achallenge, thus the detrimental type of Role

Strain does not occur. Furthermore, depending on the individual, elements of Role Set that would cause Role Strain in one person may not necessarily cause Role Strain in another person.

The concepts of ;Role Theory tested were professional role, individual characteristics, and work satisfaction and the dependent variables were role stress, role ambiguity and role conflict. These concepts were operationalized and linked to empirical measures of work satisfaction, individual characteristics, professional role, and role stress. 18

Research Questions

The purpose and theoretical framework provided a basis for the following research questions:

1. What are the individual and professional role characteristics,

work satisfaction, role stress, roie ambiguity and role conflict of

telenurses?

· 2. What are the relationships among various aspects of

individual and professional role characteristics, work satisfacti6n

· and role stress, role ambiguity and role conflict in telenurses?

3. What predicts role stress, role conflict and role ambiguity of

Telenurses?

4. What are the strategies by which telenurses adhere to the user

competence and patient safety portion of the 11 th Core Principle of

the American Nurses Association Core Principles on Telehealth?

Definition of Terms

American Nurses Association (ANA) Core Principles on Telehealth - a report of the Interdisciplinary Telehealth Standards Working Group, composed of 41 Washington

DC-based professional associations and healthcare organizations. The report describes the roles and responsibilities of the health care profession by proposing 12 standards and guidelines (Appendix A) for the practice of telehealth (American Nurses Association,

1998).

Autonomy - the nature and environment of a job which allows the worker the ability to self-manage his or her work (Pierce, Hazel & Mion, 1996). 19

Interaction - the opportunities and requirements for formal and informal social

and professional contact during the fulfillment of a role (Stamps, 1997). Also

encompasses the component of nurse-physician exchange within the nursing role.

Job Satisfaction - the extent to which employees like their jobs (Stamps, 1997).

Also known as work satisfaction. A function of the degree to which a person's needs are

met by their job. 1

Organizational Policies - constraints or limits imposed upon a role and the

activities of the role by the organization and/or its management (Stamps, 1997).

Pay ...:... the dollar remuneration and fringe benefits received for work done within a role (Stamps, 1997)

Professional Role ..:.... a subset of the role set of a person; the behaviors associated with a profession in society (Schwirian, 1998)

Professional Status - the overall importance felt about the role at the personal level and the importance of the role to the organization and community (Stamps, 1997).

Role - the expected and actual behaviors associated with a position. The more specific term role behavior is also used for the sake of clarity (Hardy & Conway, 1988, p.

165).

Role ambiguity - " .... vagueness, lack of clarity of role expectations"· (Hardy &

Conway, 1988, p. 162). One of two components of role stress, along with role conflict.

Role conflict - role expectations that are incompatible (Hardy & Conway, 1988,

p. 162). Nurses experience role conflic·t when they are caught between their own role ' expectations and what they perceive others expect of them (Pranulis, Renwanz-Boyle, 20

Kontas & Hodson, 1995). One of two components of role stress, along with role ambiguity.

Role expectations - position-specific norms that identify the attitudes·, behaviors and cognitions required and anticipated for a person in a role (Hardy & Conway, 1988, p.

165).

Role set - the constellation of relationships with the role partners of a particular position (Merton, 1957, p. 369). A role set comprises all of a person's role partners. It also comprises characteristics of the person themselves, which contributes to the interactions in the role set.

Role strain - the subjective internal response of the individual when exposed to the demands or pressures of external role stress (Hardy & Conway, 1988, p. 165). Part of the stress-strain dyad. Role strain and role stress are often used interchangeably in the literature and conversation. If a role occupant exposed to stress experiences tension or frustration, this is a condition of role strain (Hardy & Conway, 1988, p. 170). For purposes of this research, role strain is operationalized as role stress, in keeping with the terminology of the instruments and the described literature.

Role stress - an external forte that may produce role strain and is part of the stress-strain dyad (Hardy & Conway, 1988). Role stress manifests itself in the .individual as role strain. The terms role stress and role strain are often used interchangeably in the literature and in conversation. If a problematic condition is one of conflicting, confusing, irritating, or impossible role demands, the condition is one of role stress (Hardy &

Conway, 1988, p. 170). For purposes of this research, the variable tole stress is the operationalized measure of role strain. 21

Task Requirements - the things that must be accomplished as part of a role

(Stamps, 1997).

Telecommunications - the transmission, emission or recepti_on of data or

information, in the form of signs, signals~ writings, images and sounds or any other form,

via wire, radio, visual or other electromagnetic systems (American Nurses Association,

1997) .

. Telehealth - the removal of time and distance barriers for the delivery of health

· care services or related health care activities (American Nurses Association, 1997).

Telehealth as a term is often interchanged with telemedicine.

Telemedicine - the use of electronic information and telecommunications

technologies to provide and support health care when distance separates the participants

.(Field, 1996). Telemedicine as a term is often interchanged with telehealth.

Telemedicine (or telehealth) technology - the computers, Internet, televisions,

voice and video systems, and distance learning devices, which, when coupled with

communications lines, enable patient care, education and/or provider contact to occur

over long distances.

Telenurse - in this study, telenurse referred to the nurse who, at the time of the

\ study, worked in a telehealth program, or who worked with telehealth technology.

Telenurse is sometimes referred to in the literature as ·telemedicine nurse' or ·telehealth

nurse'. Telenurse in this study was limited to the nurse who deals with voice and video

(interactive or data) technology, i.e. excludes the population of telephone triage nurses.

Telenursing - the use of telehealth technology to deliver nursing care and conduct

nursing practice (Schlachta & Sparks, 1998). Telenursing encompasses a continuum of 22 nursing to include telephone triage through sophisticated interactive voice ·and video systems whereby patients and providers can see each other as well as hear each other.

User competence - level of technical competence perceived by the telenurse.

Work satisfaction - an affective feeling that depends on the interaction of employees, their personal characteristics, values and expectations with the work environment and the organization. Also known as job satisfaction (Cumbey & Alexander,

1998). 23

Chapter 2

Review of Related Literature

The purpose of this chapter was to provide a summarr of the current state of

knowledge regarding professional role (nursing and telenursing), work satisfaction and its

c9mponents, ·role strain, role stress and its components. Through the following review of

related literature, the paucity of research in telenursing, and the need for this study was

evident. As a new and evolving role, telenursing deserves examination and scrutiny. The

need for research in this area was great, as stated by Lambert and Lambert (1998): "If

nurses are to meet the challenge of the constantly evolving health care system, they must

acquire new skills to meet the many opportunities that lie ahead. To maintain the status

· quo and to assume that current skills will be sufficient for role survival is a mistake." (p.

180)

Professional role

Professional roles are a subset of social roles. Wilensky (1964) described

professions as having four structural features: creation of a full-time occupation;

establishment of a training school; formation of a code of ethics; and formation of

professional associations. In 1968, Hall catalogued five attitudinal attributes of

professional persons: participation in professional organizations; conduct of service to the

public; conduct of self-regulation; a sense of calling to the profession; and autonomy.

Both of the described structural and attitudinal attributes affect the telenurse who is a

professional nurse, primarily by increasing role expectations. 24

Meleis (1975) described four prerequisites for successful role internalization: 1) a mental concept of the role to be assumed 2) viewing the role behaviors and goals as desirable 3) opportunity to perform the role and 4) feedback to reinforce the performance of the role responsibilities. These prerequisites, in concert with the conceptual framework of Role Theory, were considered when selecting the design and variables of the current study.

Research regarding professional roles and role behaviors in nursing is minimal. ·

Sandelowski ( 1996) noted that there is very little research that helps to clarify and articulate what nurses do. The following sectiol1s identify existing research in nursing roles and in telenursing.

Nursing

Clifford (1996) expanded upon the concepts of role theory. She stated that individuals act in such a way so that behavior is adapted in a role set with others until a degree of consensus between the parties occurs. Thus, the way that nurses act is strongly influenced by others. Clifford also pointed out that authors frequently use the word

"role" in an everyday fashion in their titles, without exploring or articulating its theoretical underpinnings. Often-used and interchanged terms in the nursing literature are role conception, role acquisition, role taking, role mastery, role incongruity, role ambiguity, role strain, and role overload. One should be precise in their definition and usage of role terminology in practice and research.

The role of the advanced practke nurse (APN), which evolved over a 30-year period, provided insight into the issue of emerging professional roles in nursing. As occurred in the early days of the APN, no two APN roles were enacted the same due to 25 variable organizations and practice settings. Therefore, working in new nursing roles is creative and challenging at first. As Russell and Hezel { 1994) report, though, there may be too many unexpected aspects to the role leading to frustration and ultimately attrition.

A common concern articulated by APN' s in the past and even today is role confusion or ambiguity (Redekopp, 1997). APN roles still meet with medical resistance, causing role conflict even today, as well as during the course of the evolution of APN roles in the

1970's and 1980's (Inglis & Kjervik, 1993; Sox, 2000). With the social climate of increased autonomy for women combined with the economic climate to reduce healthcare costs, nurse practitioners have finally and collectively achieved the stage of role confirmation in the United States (Andrews, Hanson, Maule, & Snelling, 1999). Role confirmation is positive r.ecognition and support for ~he nurse practitioner role. This was not always the case, and has taken over 30 years of lobbying and struggle to occur

(Sharp, personal conversation, October 1999}. The nurse practitioner role was for a long time considered a deviant (Mezey & McGivern, 1993 ), similar to the current perception of telenursing by some in the nursing profession (Trotter-Betts, personal conversation,

1996; Rau, personal conversation, 2000).

Some descriptive research has been published regarding emerging professional roles during nursing's history.· Using role theory as a framework, Conti (1996) employed both qualitative and quantitative methods, conducted a descriptive study of 58 nurse case managers to identify their role behaviors. After conducting in-depth interviews with four case managers, she identified a list of 16 separate categories of roles fulfilled by case managers. Sending the list to 58 case managers, 82% of the respondents reported fulfilling the following roles: public relator, educator, expeditor, monitor, problem solver, 26

explainer, negotiator, planner, communicator, contactor, recommender, broker,

researcher, assessor, documenter, and coordinator. The majority of the case managers

reported learning the selected roles while on the job. The strength of this study is its

description of professional roles fulfilled by case managers. Nursing roles such as case

management are not usually formalized in the profession for some time. The content and

skills for the new nursing roles are only taught in nursing schools after the role is well

established in practice. The implications of this study are that role stress in the form of

role conflict due to role overload may occur in the acquisition of new nursing roles and

skills.

In 1983, the ANA published Standards for School Nursing Practice to reduce role ambiguity in the expanding role of school nurse. Parsons and Felton, (1992) studied the impact of a training program based on the standards on 98 southeast U.S. school nurses' job satisfaction and role ambiguity. Using Role Theory as a framework, Parsons and

Felton administered Bullough's Job Satisfaction and Role Performance Scales and a self developed demographic instrument, before, upon completion of a 9-month school nurse training program, and 9 months after completion. Findings confirmed that the training program on standards for school nursing positively impacted role performance (F=7 .15,

df=50, p <. 01) and intrinsic job satisfaction (F=6.65, df=50, p <. 01). Although role

performance continued to improve 9 months after course completion, the attrition rate of

44% of subjects is a weakness of the study. Despite this weakness, it may be indicated

that specific training in the role expectations of new roles may reduce role ambiguity and

increase job satisfaction. 27

Brennan, Moore and Smyth (1991) conducted a study on the impact of technology on 22 caregivers of Alzheimer's patients who used an Internet discussion group for support from each other and from nurses. Although this study focused on the caregivers and did not use interactive voice and video (telehealth) technology, the role of the nurse in this process is briefly described as clinical expert and group facilitator (American

Academy of Nursing, 1996). Some of the functions of the nursing roles included overseeing the computer network, maintaining and updating clinical content in the network's electronic encyclopedia, visiting participants to install the computer terminal, providing initial and ongoing computer training to caregivers, answering caregivers questions and facilitating communications. An implication of this work is that emerging nursing roles such as the role described in this study may indicate futuristic opportunities for nurses.

Telenursing

The American Academy of Nursing (1996) described telenursing and telehealth as a new model for delivery of community based healthcare services and communication.

Their report was intended to focus the nursing community's attention on the use of electronic networks. Although they do not report any data or studies, The American

Academy of Nursing (AAN) defined the role of telenursing as electronic linking of schools, libraries, childcare, neighborhood and senior center,s to strengthen public health services. The AAN further described the telenursing role as an expansion of staff nursing practice to increase effectiveness of teaching/training with in-home clients and other patients in the community. 28

Telenursing is not a new role for nurses. There is documented evidence of

existence of the role of telenurses for more than 25 years in the li~erature. There is,

however, scant detail relating to the specifics of the telenursing role. The earliest

reference to the role of telenurse was by Quinn in 1974. She described her roles as a

nurse in a hospital-based telehealth center as being ·technician, scheduler, patient

educator, staff educator, coordinator and physician support resource in the conduct of

medical teleconsultations. In her anecdotal report of her experience with her job as

telehealth nurse, she also expressed great excitement regarding the promise of the

practice of nursing using telehealth in the future.

Empirical eviden~e of the practice and perceptions of nurses in telehealth is

severely limited. Table 1. at Appendix F details the studies and published articles which

directly or indirectly refer to telenursing roles. Early descriptions of telehealth programs

in the l 970's and l 980's alluded to nurses actively participating in telehealth work. Few

specifics are offered. Later studies begin to report data from active participation of

nurses and even telenurse-impacted patient outcomes.

The only reported study to date of telenursing roles, responsibilities and practices

was conducted in 1996 by Horton, who published her findings in 1997. She conducted a

self-developed, mailed survey with a convenience sample of 130 telenurses in the United

States and achieved a 56 percent response rate of 74 telehealth nurses. Telenurses were

identified by Horton after contacting the telehealth programs listed on the Telemedicine \ Information Exchange, an, internet-based resource for telehealth. Face or content validity

of the survey was stated to be achieved via a pretest ·with telehealth nurses, however no

data are provided. This is a weakness of the study. 29

In Horton's study, roles were defined to include perceived job responsibilities.

While 3 8 percent of the respondents worked full time in telehealth, 67 percent reported that more than one nurse was working at the telehealth site. Roles described for the telehealth nurses included clinical nurse, administrator, nurse educator, technician and "I don't know". Fifty-one percent of the respondents(# 27) reported their role as that of a

"nurse". Five nurses reported their role was solely nurse educator. Nine nurses described their role as only administrative. Four nurses reported their role as solely technician. Four nurses answered that their role included all categories. One nurse answered "I don't know". Twenty-one percent of nurses identified their roles as other, which included program evaluators, researchers, nurse practitioners, consultants, clinical nurse specialists and scheduler.

In this study, only 35 percent of nurses had a job description. Twenty-eight percent of respondents indicated that specific actions related to telehealth were expected but not included in their job description. Of note, 20 percent of the nurses indicated that they reported to no one. Twenty-one percent reported to a physician.

When asked to provide other written comments, 21 nurses wrote comments that were categorized into five themes: satisfaction, nurses, specific nursing actions, roles and technology. Respondents reported their nursing role as being a) undefined b) fraught with political turmoil, and c) without recognition or part in decision making. Role frustration related to a "lack of specific expectations" (p. 10) was also reported.

Horton ( 1997) called for a redefinition of nursing practice within the context of telehealth technology. She stated that autonomous nursing practice via telehealth might improve the quality and accessibility of nursing care. The study was a first attempt at 31

Work Satisfaction

Work satisfaction is an affective feeling that depends on the interaction of employees, their personal characteristics, values and expectations with the work environment and the organization (Cumbey & Alexander, 1998). Work satisfaction is also commonly termed job satisfaction. Much research has been accomplished in the area of work satisfaction both in and out of nursing. Large amounts of research were conducted on work satisfaction by social psychologists in the 1970's. Work satisfaction has been linked most often to turnover and loss of productivity, which have serious economic implications for organizations (Schwirian, 1998).

A summary of the nursing and related literature on work satisfaction appears in

Table 2 in Appendix G. This summary was limited to the last ten years of published literature. The bulk of research on the topic of work satisfaction is from the 1970' s, over

20 years ago. The main body of research in work satisfaction is dated, and was not even included in the summary provided. The need for new research in this area was evident, as the healthcare arena, market forces, technology, nursing shortages, and roles of women have all undergone major change in the last 20 years.

The findings from the work satisfaction literature summary provided the basis for selection of hypotheses and variables for this study, as well as the selection of instruments. The Index of Work Satisfaction tool was primarily selected because it measures the subscales most consistently reported as sources of satisfaction and dissatisfaction in the literature review: pay, autonomy, interactions with other nurses and physicians, and organizational policies. 34 reviewing the findings of this ~ummary, the determinants of stress appear to vary according to occupational group, and within nursing, vary somewhat by specialty. For example, critical care nurses cite coping with dying as a stre.ssor, whereas OB/GYN nurses do not. There is evidence that core determinant~ of stress, such as task overload, are relatively consistent for all nursing specialties,(Wheeler, 1998). However, there was enough conflicting data regarding stress to indicate that each specialty, as well as nursing as a whole, should be studied to determine its .own particular issues and results related to role stress.

Role conflict and role ambiguity

Role conflict is defined as lack of congruency or compatibility with a set of standards or conditions, which impinge upon role·performance (Rizzo, House, &

Lirtzman, 1970). Role ambiguity is defined as the existence or clarity of requirements that guide behavior and provide knowledge to a person in a role that their behavior is appropriate for the role (Rizzo, House & Lirtzman, 1970). Role conflict and role ambiguity are the primary components of role stress. Role conflict and role ambiguity are antecedent to role strain with its resultant turnover, which impacts negatively upon individuals and healthcare organizations (Hardy & Conway, 1988).

Within healthcare, social organizations such as hospitals may be considered a system of roles designed to achieve certain goals. Technology, increased organizational complexity, .new product demands, or a host of other factors may stimulate changes in the system of roles. Role expectations associated with changing positions and roles are initially unclear and ill-defined (Hardy & Conway, 1988). New and emerging roles typically are ambiguous until such roles become well established. The creation and 35 development of new roles in a rapidly changing society is likely to be an ongoing source of role ambiguity.

Large amounts ofresearch in the l 950's in hospital settings and in manufacturing settings resulted in the following findings regarding role conflict: multiple authority disrupts the individual's orientation to their profession or organization; persons oriented toward their profession are more critical of the organization and are more likely to ignore bureaucratic dictates; and professionals in organizations frequently experience stress as result of being caught in the middle (Rizzo, House, &_ Lirtzman, 1970). Rizzo, House and Lirtzman (1970) first measured role conflict and role ambiguity among factory workers, and developed what has become the standard instrument to measure role stress and its components: role conflict and role ambiguity. Among the types of conflict measured by the role instrument are: expected role behaviors which differ from the persons values; excessive role demands on the person's time, resources or capabilities; demands for incompatible role behaviors; and inconsistent policies and standards of evaluation. The types of ambiguity measured include unpredictable responses to the person's behavior; lack of role guidelines from the role set and lack of certainty about duties and authority. Schuler, Aldag, and Brief (1977) examined the Rizzo, House and

Lirtzman Role Questionnaire in six study populations, including nurses up to the head

nurse level, and found that ''role conflict and ambiguity are valid constructs in

organizational behavior research" (p. 126).

A summary of the last ten years' nursing and related literature related to role

conflict and role ambiguity appears in Table 4 at Appendix I. The bulk of the literature in \

36 this area was not included, since it was over 20 years old. Given the existence of emerging roles such as telenursing, a need existed for further research in this area.

Summary

Role conflict and role ambiguity, the majo'r components of rble stress, were chosen as dependent variables because they were empirical elements of role strain in the conceptual model of role theory. Role conflict and role ambiguity were extensively researched over 20 years ago, and can be measured empirically using a validated tool.

Role conflict and role ambiguity as components of role stress are important indicators of the status of a person's role. What has been de111onstrated is that the presence ofrole stress, evidenced by measured role ambiguity and role conflict, is an important precursor to potential detrimental organizational events. Role ambiguity and role conflict in the emerging role of telenursing needed investigation.

Executive Summarv of Review of Related Literature

The purpose of this chapter was to provide a summary of the current state of knowledge regarding professional role with a focus on telenursing, work satisfaction and its components, and role stress and its components. Through the previous review of related literature, the paucity of research in the emerging role of telenursing has become evident. Despite its existence for 25 years, the role of telenu_rsing has yet to undergo an in-depth examination. In addition, the bulk of the research related to work satisfaction, role stress and role strain was well over 20 years old. This necessitated a revisiting of these concepts, especially in relation to rapidly evolving technology in healthcare and the changing nature of the role of women in the workplace. These factors pointed to a 37 decided need for the current study to add to the body of knowledge of professional nursing and the evolution of new nursing roles. 38

Chapter 3

Method

In this chapter, methodological considerations are addressed. There are seven

areas of prime focus in this secti?n: research hypotheses, setting and sample, design,

measurement, proposed analysis, limitations and human subjects' protection. An

innovative procedure using the Internet for survey data collection is also described in

detail.

Research Hypotheses

The_previously presented research questions with each associated hypothesis are listed in Table 5. The model for testing variables of the telenursing role is depicted in

Figure 2. The hypotheses were derived from the testing model as well as the review of the literature. Conflicting literature existed on the relationship of variables such as pay, age, education level of nurses and experience to work satisfaction, role ambiguity and role conflict. Hypotheses were constructed to acknowledge that potential relationships existed. The purpose of this research and the hypotheses was to determine the direction and significance of these relationships in telenurses. Variables that predict role stress, role conflict and role ambiguity will be examined. 39

Table 5.

Research hypotheses

Research Question Research hypothesis

1. What are the individual and None. professional role characteristics, Descriptive data. work satisfaction and role stress, role ambiguity and role conflict of telenurses?

2. What are the relationships 2.a. There is a relationship among work satisfaction, among various aspects of role set education level, age, years of experience and role

(individual and professional role stress of telenurses. characteristics, work satisfaction) 2. b. There is a.relationship among number and type and role strain (role stress, role of professional role functions of telenurses and role ambiguity and role conflict) conflict. among telenurses? 2. c. There is a relationship among telenursing

experience and nursing experience and role stress

/ and role ambiguity.

3. Is there a difference in 3. a. There is a difference in role stress and role telenurses' role stress, role ambiguity of telenurses, depending on education ambiguity and role conflict, level. depending on various aspects of 3. b. There is a difference in role stress and role work satisfaction, individual and ambiguity of telenurses depending on experience in 40 professional role characteristics? nursing and experience in telenursing.

3. c. Role conflict and role stress differs among

telenurses with various combinations of role

functions.

4. What predicts role stress, role 4.a. Role stress of telenurses is predicted by work conflict and role ambiguity of satisfaction, individual characteristics (level of telenurses? education, age, years of nursing experience) and

number and type of professional role functions.

4. b. Role ambiguity of telenurses is predicted by

work satisfaction, individual characteristics (age,

level of education and years ·of nursing experience)

and number and type of professional role functions.

4. c. Role conflict of telenurses is predicted by work

satisfaction, individual characteristics (age, level of

education and years of nursing experience) number

and type of professional role functions and role

ambiguity.

5. What are the strategies by None. which telenurses adhere to the user Descriptive responses. competence and patient safety 11 th

Core Principle of the American

Nurses Association Core

Principles on Telehealth? ,---, . L ___ J = Independent Vanable 41

C=:> = Dependent Variable r···························································································································•························ ····································1 ,------, I · : Individual : l I Ch . . I I 1 aractenst1cs 1 1 I I I I :L ______XI I ,------, : Work Satisfaction : ·······•"!·•····· ►, : X2 l L------J ,------· l Professional l I I 1 Role l

lL ______X3 _,l 1...... ······································'

XI Xl ---..___.. XI------. ------. X2 Y2 X2 ~ X2 ► YI ► Y3 X3 _____. X3 ~ X3 ~ Y2 ~

Figure 2_._ Model for testing relationships of variables and predicting role stress of telenurses 42

Setting and Sample

The setting for this study was the 50 states. The population for this study was all telenurses currently practicing in the 50 states. Practicing telenurses were identified by two major strategies: 1) cataloguing/contacting all existing telehealth programs in the

United States to identify telenurses and 2) utilizing the snowball sampling technique.

Each strategy is described in further detail.

Cataloguing/contacting Telehealth Programs. All telenurses associated with telehealth programs in the United States were attempted to be identified using a three step approach. The first step was to use existing telehealth databases. The Federal

Telemedicine Gateway (1999), Department of Defense, Fort Detrick, Maryland; the

Office for the Advancement of Telehealth, Federal Telemedicine Directory (1998),

Rockville, MD; the Telemedicine Information Exchange (1999), Portland, Oregon, and the National Institutes of Health Telemedicine Grantees Database on the web

(www.nih.gov), Bethesda, MD were all downloaded. Recruiting letters were sent via email and regular mail to identify if nurses were working in the telehealth programs.

The second step was to contact all vendors of telehealth equipment in the United

States to formulate an additional list of organizations using telehealth technology. A complete list of telehealth vendors was obtained from the American Telemedicine

Association, which lists over 40 telehealth vendors. Recruiting letters· were also sent via email to identify telenurses in the vendor group. 43

The results of the step one and step two. approaches wei:e that a total of 497

recruiting letters were sent to telemedicine program~ and vendors in order to identify

specific telenurses. In addition, 45 phone calls were placed to programs and vendors who

did not have email contact information in their profiles.

Finally, the third step was to perform a literature search of t6lehealthjournals to

iden!ify the names of private companies and programs that have reported their

experiences with telehealth. The journals Telemedicine and TeleHealth Networks and

Telemedicine Journal were reviewed from the past 3 years. Through this strategy, 15 additional telehealth programs were identified that were not already identified in the first two steps. The author of the article was contacted with a recruiting letter via email, telephone or regular mail to ask for referral of te.lehealth nurses.

Within each telehealth program identified in the three-step process above, telenurses who were identified by,name were sent an individual invitation to participate in the study. For the organizations who were unable to be contacted, or if an organization refused to name their nurses, a letter of invitation to participate in the study was sent for dissemination through the program director to the nurses. A total of 167 individual nurses and 23 telehealth programs (with nurses not specifically named) were identified by this three-step strategy. Each nurse or program contact was then sent a letter or email (if made available to the researcher) and invited to participate in the study. Use of this three-pronged technique for identifying telenurses was responsible for identifying 21 %

of the sampling frame of telenurses for the study.

Snowball sampling technique. Also known as network sampling, snowball

sampling is a technique for building up a list or a sample of a special population by using 44

an initial set of its members as informants (Kish, 1965). This researcher had personal

knowledge of at least 50 telenurses in the United States. This pool of telenurses was

contacted and asked to refer other telenurses. Also, once known telenurses were

contacted via the cataloguing of telehealth programs strategy described previously, they

were asked to refer names of other known telenurses. Using this two-pronged snowball

sampling method, a potentially complete list of known telenurses in the United States was

developed.

Using the snowball sampling method, 621 telenurses were identified by name from other telenurse contacts:· Snowball sampli'ng was responsible for identifying 79% of the sample frame of telenurses for the study.

The sampling frame oftelenurses for the study was 811 (621 individuals from snowball sampling; 167 individuals from program/vendor/literature review and 23 potential individuals from program directors). Invitations were sent via email or regular mail to the 811 telenurses in the sampling frame. There were 341 regular mail invitations to participate sent and 4 70 email invitations to participate in the study sent to telenurses.

Twenty-three of the mailed invitations were returned as address unknown or unable to be delivered. One subject's secretary responded that she was unable to participate due to extended illness. Three subjects were not nurses and declined the invitation to participate. Taking into account the above, 784 of the initial 811 nurses comprise the

sampling denominator. From the 784, 3 71 (4 7%) provided no survey response to the

invitation which was a choice not to participate. From the 784, 206 (26%) provided a

response to the invitation but chose not to participate. Their choice could have been due

to failure to meet the screening criteria. Also, in fourteen cases, subjects responded via 45

email that they were far too bu~y to take the time to participate in the study. Ultimately,

207 (27%) of the telenurses in the sampling frame responded to the invitation and

completed the questionnaire. Of the 207, 196 had complete data. These 196 (25% of the

sample) represented the final sample used for data analysis.

The major sample bias that may result from snowball sampling is self-selection

(Sudman, 1976). Self-selection means that the person who is known to more people has a higher probability of being mentioned than does the isolated person, known to only a few others. A strategy for overcoming this sample bias was to continue snowball sampling until no new names were mentioned~ thereby eliminating the probability of missing elements of the selected population. For this study, snowball sampling continued until no new names were mentioned. If the strategy was successfully employed, in addition to removing self-selection sample bias, there was also no sampling variance, because the total universe was invited to participate in the survey.

Another self selection sampling bias that became evident in follow-up reminders and phone calls to nonrespondents was that the busiest and most stressed telenurses reported that they did not have time to respond to the survey. In several phone calls and email exchanges, telenurses reported being overwhelmed by their jobs and working 16-18 hours per day, causing them to feel unable to respond to the survey's 25 minute participation requirement. · Therefore, the findings of the study regarding· role stress may be underestimated since the telenurses who are experiencing the most role stress may not

have responded. 46

Power Analysis.

Since the total population of te~enurses was at first unknown, power analysis was conducted with three estimates of the size of the sample. All three estimates assumed an alpha level of .05 and a moderate effect size, and took into account the most complex analysis intended for this study (multiple regression analysis with 9 variables) (Cohen,

1988; Kraemer & Thiemann, 1987). For a sample size of 200 telenurses, power was .97.

The actual responses of 196 telenurses achieved a power of .97.

For a sample size of 150 telenurses, power was .90. For a sample size of 100 telenurses, power was .69. For a sample size of 70, power was .50. In her 1996 study of telenurses, Horton (1997) identified 130 telehealth nurses in the United States. Seventy four responded to her survey of roles, responsibilities and practices of telenurses. Given that there were over three times as many telehealth programs today as in 1996, it was anticipated that the sample of at·least 150 could be achieved via the two-pronged strategy described previously. This expectation was achieved and exceeded.

Design

Using the strategies of Dillman's (1978) Total Design Method to insure a quality survey process and maximize response rates, a descriptive, correlational study utilizing survey research methods was undertaken. The Telenursing Role Survey (Appendix E) was conducted, utilizing a combination of three modified, existing survey tools and three developed questions . The entire Telenursing Role Survey consisted of six sections. Four of the sections were survey tools, which are identified in Table 6. The remaining two sections were 1) an initial Introduction/Screening section of two questions to verify that subjects met t~e definition of telenurse and were actively involved in telehealth and 2) the Table 6.

Components of Telenursing Role Survey (Appendix E).

Variable Tool Comment INDEPENDENT

Individual Characteristics & National Sample Select (those underlined in attachment) questions from Division ofNursing, HRSA,

Professional Role Survey of Registered 1996 National Sample Survey of Registered Nurses. Modification of some questions

Nurses (Appendix B) I required.

11th ANA Core Principle on Three questions Three questions were developed and piloted: 1) current level of user competence_ on a

Telehealth (See Appendix A for Likert scale and 2) two open-ended question on strategies used to develop user ANA Core Principles) I competence and assure patient safety by telenurses. AnsWers were used for anecdotal

reporting.

Work Satisfaction Index of Work 59 Item Survey in two parts. Part A (15 items) was paired response. Part B (44 items)

Satisfaction was 7 point Likei-t scale response. Measures 6 subscales: pay, autonomy, task

(Appendix C) requirements, organizational policies, interaction and professional status. Total m~asure

for work satisfaction. Modified to change "hospital" terminology to "organization" ..

DEPENDENT 29 Item survey with 14 items that measure role ambiguity, 15 items that measure role Role stress Rizzo House Role conflict. Scores for each and a combined score for role stress. 7 point Likert scale Role ambiguity Questionnaire response. No modification of instrument required. Role conflict (Appendix D) 49

Conclusion, whereby subjects had the option to provide their contact information to

receive a copy of the results of the study. Each existing survey tool is described in

further detail in the Instrumentation Section.

Measurement

Measurement strategies consisted of two aspects. The first aspect encompassed

conducting a pilot of the Telenursing Role Survey (Appendix E) with the target a 39-

subject subsample of telenurses who were practicing or who had practiced in the telenursing role. Ten subjects were sent emails inviting them to participate telephonically in the Telenursing Role Survey. Twenty-four subjects were sent emails inviting them to participate via the web in the_ Telenursing Role Survey. Assigning a specific response method to subjects in the pilot study assured that each response method was tested during the pilot study. In all, 8 telephonic and 23 web subjects (for a total of 31 subjects) responded to the Invitation to Participate in the Pilot Study. Subsequently, Coefficient.

Alpha determinations were made for each survey tool. Also, pilot subjects were asked to provide feedback on the time to complete the survey, the construct and clarity of the three developed questions,· and the readability and facility of the internet-based survey. The pilot survey process.was conducted from April 13, 2000 until May 3, 2000. Results are further described under the Instrumentation section.

, The second aspect of measurement strategy focused on the Telenursing Role

Survey administration and data collection for the sampling frame utilizing an innovative

data collection technology. The use of an internet-based survey completed via the web

was intended to increase survey responses of telenurses in keeping with the concepts of

the Total Design Method (Anema & Brown, 1995; Dillman, 1978). The Total Design 50

Method is a survey approach strategy designed and tested to provide maximum response

to a survey. This researcher retained an Internet programmer to program and host the

Telenursing Role Survey. For those telenurses without access to the Internet, a toll-free number was provided for the nurse to call and conduct a telephone version of the survey.

This researcher was available from 8:30 AM to 11 PM Eastern Standard Time during the data collection period for administration of telephone surveys. All data from telephone and web based surveys was placed into an excel spreadsheet for importing into SPSS for data analysis. Telephone surveys were not audiotaped. for quality control purposes as initially planned, since survey data was not .entered directly into Excel at the time of each telephone survey. Initially it was projected that the researcher would enter telephonic responses directly to the Excel spreadsheet of survey data, necessitating a taped version of the survey to insure accurate data entry. Instead, what actually occurred was that during the telephonic survey, responses were recorded on a paper version of the survey.

At the end of the study, all paper-based data were entered by the investigator into the

Excel spreadsheet with the downloaded electronic data from the survey website. Data entry accuracy was verified by a third party individual who checked the accuracy of the paper survey data entry into Excel. Thirty data elements were identified as incorrectly entered, and were reentered accurately during this process. During the course of the data collection period, web data were placed on a server with a password code provided to subjects to enter the site (see Invitation Letter, Appendix K). Once the Internet survey was completed and the data were downloaded, all data were deleted from the web server. 51

Procedures

When the sampling frame of telenurses was identified as described in the Sample

Section, and the Telenursing Role Survey pilot was completed, an invitation to participate as a subject was mailed or emailed to each identified telenurse. The content of both mailed and emailed Invitations to Participate were the same. In keeping with the strategies of the Total Design Method, all regular-mail subjects received a personalized, original signed letter on official Medical College of Georgia School of Nursing letterhead, inviting them to participate in the survey data collection, and thanking them for their help. A total of 341 mailed Invitations to Participate in the study were sent.

For telenurses with email contact information, a personalized, electronic letter of

Invitation to Participate was emailed to the subject. For email subjects, 470 Invitations to

Participate were sent electronically.

When subjects w_ished to participate in the survey, they accessed the web site provided and followed instructions to complete the survey or called the toll free number provided to complete a telephone version of the Telenursing Role Survey. In keeping with the Total Design Method strategy, reminder letters, phone calls or a reminder email message were sent to those subjects who did not complete the survey (Anema & Brown,

1995). Reminders were sent June 16, 2000; July 12, 2000; August 3, 2000 and

September 8, 2000. A combination of mailed, telephonic and emailed reminders were

sent, based on availability of contact information for subjects. In all, 290 mailed

reminders were sent, 160 phone calls were made and 3 12 email reminder messages were

sent. The goal of the survey process was to attain an N of 200 per Power Analysis. It

was initially anticipated that the entire data collection phase would be approximately 45 52

days, targeted March through April 2000. The actual data collection phase was 4 months,

from May 28 to September 30, 2000. It was found that data collection during the summer

months took longer since individuals were away for vacation for extended periods,

university-based telenurses were not in session, and school telehealth nurses were not in

schools. Many email Invitations to Participate were sent repeatedly because of "out of

office" reply messages from vacationing individuals. It is anticipated that both the data

collection timeframe and response rate may have been improved if the data collection

period was during the "regular year", i.e. September through June.

Instrumentation

The Telenursing Role Survey was composed of six sections. They are delineated in

Table 7. Three existing survey instruments comprised three sections of the survey. A

fourth section identified strategies for adherence to the American Nurses Association

Table 7

Telenursirig Role Survey Sections and Content

Telenursing Role Survey Sections Section Content

1. Introduction Implied consent statement; Estimated time to complete_

survey; Two eligibility questions to determine whether

subject met definition of telenurse for study

2. Work Satisfaction Part 1 of the Index of Work Satisfaction

3. Attitude and Role Part 2 of the Index of Work Satisfaction;

Rizzo House & Lirtzman Role Questionnaire

l 4. Role Clarification Two open-ended questions to identify strategies for

adherence to ANA Core Principles on Telehealth 53

5. Individual Characteristics Selected questions from Division of Nursing, National

Sample Survey of Regist~red Nurses

6. Conclusion Thank you and voluntary provision of subjects' contact

information to receive copy of study findings in

exchange for their participation.

Core Principles on Telehealth. An Introduction section ~lso served as a screening section

for eligibility to complete the study. The Conclusion provided a thank you statement and

an area for subjects to voluntarily enter their contact information to receive copies of the

study results as appreciation for their participation.

The Pilot Study of the Telenursing Role Survey (Appendix E) was conducted

from April 13, 2000 until May 3, 2000. The target was a 30-subject subsample of

telenurses who were practicing or who had practiced in the telenursing role. A group of

34 telenurses who were known to the investigator was recruited to. participate in the pilot

study. The telenurses were from 11 different states. Since it was initially anticipated that

approximately 30% of the subjects would respond to the Telenursing Role Survey

telephonically, the pilot study was proportioned along the same lines. A total of 10 pilot

subjects were sent emails inviting them to participate telephonically in the Telenursing

Role Survey. A total of 24 subjects ~ere sent emails inviting them to participate via the

web in the Telenursing Role Survey. Assigning a specific response method to-subjects in

the pilot study a.ssured that each response method was tested during the pilot study: In

all, 8 telephonic and 23 web subjects (for a total of 31 subjects) responded to the

Invitation to Participate in the Pilot Study. 54

In addition to completing the Telenursing Role Survey, pilot participants were

also asked to provide feedback on the time to complete the survey, the construct and

clarity of the three developed questions, and the readability and facility of the internet

based survey. This feedback was requested via email separately, and upon completion of

the surv~y. The average time it took to complete the survey, (including both web and

telephone) was 27 minutes. Two comments pertained to the wording·of the existing

survey tools and suggested alternate wording. Because of the use of validated tools, the

wording was kept the same and not changed. One subject noted a minute or more delay

time for accessing each section of the survey on the web. A:~hough this subject persisted

in completing the survey, she suggested a better method for linking the survey sections to

avoid the delay and possible loss of interest of _a respondent. The web developer was

contacted and this problem was alleviated midway through the study when a new

technical version of the Telenursing Role Survey was posted to the web. Instead of

waiting in between sections, the survey was technically revised as one survey tool, and

going from section to section merely involved a click to immediately get to the next

section. The change was transparent to the subjects and did not affect the content or

structure of the survey itself. It did, however, affect and enable faster navigation through

the .sections of the survey by reducing waiting time in between sections.

As the telephonic surveys were administered, this investigator became more adept

at clearly enunciating the questions and streamlining the telephonic survey process. For r example, instead of reading each Likert scale response each time to the subject, the

subject was asked at the beginning of the section to jot down the 7 possible responses

which would be the same for each question in that section. In this way, the investigator 55

read the statement and the subject had the list of possible responses in front of them,

which streamlined the telephonic administration process.

One pilot participant noted that at the Conclusion section where the investigator's

email address was provided, that a participant could either click on the email address or

click the "done" button to save the survey answers. She suggested removing the email

ability from this section to insure the participant saved the data. This programming

-change was accomplished prior to conducting the larger study, and assured that data was

saved to the web server.

All data fields were completed in both the telephone and web surveys; there were

no missing data elements. Data from the web pilot surveys was downloaded upon

completion of the pilot study. Data was imported into Excel. Telephonic response data

was hand-entered into the Excel spreadsheet. A third-party individual fluent in data entry

verified accuracy of the data hand entered into the Excel spreadsheet by comparing the

telephonic paper survey responses to a printout of the Excel data. Three data entry errors

were corrected. Subsequently, the Excel data was imported into SPSS and a Coefficient

Alpha determination was calculated for each survey tool. Coefficient Alpha results are

reported in the next sections under each individual instrument's description.

Individual Characteristics and Professional Role questions were taken from the

Department of Health and Human Services, Division of Nursing (1996), National Sample

Survey of Registered Nurses (Appendix B), Rockville, Maryland. Items that were used

are underlined in Appendix B. The Division of Nursing conducts the National Sample

Survey of Registered Nurses every four years. In 1996, 29,950 registered nurses

responded to the survey, a representative sample of the 2.4 million nurses in the United 56

States. The 2000 National Sample Survey was being conducted at the same time as the data collection for the Telenursing Role Study. Standard error for each variable and for estimates of each state nurse population are provided on multiple tables in the Survey results manual.

The National Sample Survey of Registered Nurses is in the public domain

(Johnson, personal conversation, 1999). Several of the survey questions were modified slightly to accommodate the uniqueness of the role of telenursing. For example, one question asks what percent of the nurse's time is spent in direct patient care. This question was modified to ask what percent of the nurse's time is spent in face to face direct patient care and what percent of the nurse's time is spent in telehealth-delivered direct patient care.

Since only an excerpt of the National Sample Survey of Registered Nurses was utilized (Demographic questions only) for the Telenursing Role Survey, no reliability analysis was conducted for this survey tool in the Pilot Study or the main study.

The Index of Work Satisfaction (Appendix C) is a validated survey that measures

I six key components or aspects of work and work role satisfaction: pay, professional status, organizational policies, task requirements, interaction and autonomy (Stamps,

1997). The impacts of these elements upon work satisfaction were previously discussed in the review of literature. The strength of the Index of Work Satisfaction (IWS) was its ability to measure these elements and their potential effect upon telenurses.

The Index of Work Satisfaction is a two-part questionnaire. Part A contains 15 paired comparisons which, when scored, provides an overall group score for the importance of each component of work satisfaction. Part B contains 44 items with a 7 57 point Likert scale response. An individual score and group scores for each component of work satisfaction are calculated in Part B. Group results of Part A can be utilized to weight the score received in group scores of Part B. Use of this weighting component is supported by Maslow' s theory, which suggests that different components of work satisfaction produce different amounts of work satisfaction.

The IWS was constructed and validated· from 1972 to 1980 in seven large-scale, separate studies. From work accomplished in the 1960' s and early 1970' s, 5 to 13 components of job satisfaction were identified by various researchers·(Vroom, 1964;

Maslow, 1964; Heinrichs, 1968; Smith, Kendall & Hulin, 1969), and consistently the six items of the IWS were found to be the main indicators of job satisfaction. The IWS has been administered to physicians, nurses and other direct health care professionals in an ambulatory setting, EMT' s, long-term care aides, and community health workers. The

IWS has been used in at least 88·studies listed in the IWS text, spanning 1975 to 1995.

The majority were hospital-based nursing studies; two were conducted in nursing homes and six studies involved regional surveys of nurses. Written permission from the publisher for use of the IWS was obtained (see Appendix J).

Scoring of the IWS was conducted by personal computer. Instructions for scoring were provided with the survey manual.

Throughout the course of the IWS development, four factor analytic studies used varimax factor analytic technique to assess the validity of the scale items. In t_he final study, a varimax rotation produced 12 factors that accounted for 62 percent of the variance. All factor loadings were above the .4 level, except two items, which were revised as a result of the analysis. 58

The internal validity of the IWS scale Part Bis measured by Cronbach's Alpha coefficient. In the multiple studies described in the IWS manual, Cronbach's Alpha ranged from .52 to .81. In the Pilot Study of the Telenursing Role Survey, the

Cronbach's Alpha coefficient of Part B of the IWS was .93. In the Telenursing Role

Study, Cronbach's Alpha for the total Part B of the IWS was .92. Cronbach's Alpha's for the subscales of the IWS were the following: a) pay .87 b) interaction .83 c) organizational policies .83 d) autonomy .82 and e) task requirement .68 and f) professional status .45. The low reliability for professional status may be due to difficulty or confusion interpreting the questions to telenursir.6 versus nursing in general, i.e. several statements in this section asked "Nursing is not widely recognized as being an important profession" and "Most people appreciate the importance of nursing care to patients".

The Rizzo, House, and Lirtzman Role Ouestionnai~e {Appendix D) is a 29 item survey with a 7 point Likert scale response that measures role conflict and role ambiguity

(Rizzo, House & Lirtzman, 1970). Fifteen items address role conflict and fourteen items address role ambiguity. Approximately 85% of the published research on role conflict and role ambiguity has used the Role Questionnaire (Jackson and Schuler, 1985).

Higher scores were indicative of higher levels of role conflict and role ambiguity. A composite role stress score is obtained by summing the scores of the two scales.

Coefficient alpha reports range from .81 to .86 for both scales (Schuler, Aldag & Grief,

1977; Johnson, 1986). Use of the Role Questionnaire with 285 nurse educators by Fain

(1987) resulted ·in Coefficient alpha of .79 for role conflict and .73 for role ambiguity. In a study of 871 nurse educators, Lambert & Lambert, (1993) found coefficient alphas for 59

role conflict, role ambiguity and role stress as .61, .16 and .58, respectively. They

suggest that the role ambiguity subscale may not be sensitive·enough for use with nurse

educators who were employed on a full time basis. A Cronbach's Alpha was calculated

for the Pilot study of Telenursing Role Survey, which was .90. The Cronbach's Alpha

for the Telenursing Role Study was .92. The Role Ambiguity subscale Cronbach's Alpha

was .87 and the Role Conflict subscale Cronbach's Alpha was .85. Written permission to

use the Rizzo, House and Lirtzmann Role Questionnaire has been obtained (See

Appendix J).

The American Nurses Association Core Principles on Telehealth (Appendix A)

are a set of 12 broad guidelines for those healthcare providers that practice using telehealth technology. The Core Principles were endorsed by a multitude of professional organizations including the ANA. Since the twelve principles are so broad, the utility of the principles to the individual practitioner will need to be developed over time by each professional group. In order to begin to operationalize the use of the principles and understand how the principles apply to telenursing practice, a review of the principles was made to select one principle to focus an initial effort in this study.

This study focused on the 11 th Core Principle of Telehealth, which dealt most

directly with telenurses' role. The 11 th Core Principle states "The safety of clients and

practitioners must be ensured. Safe hardware· and software, combined with demonstrated

user competency, are essential components of safe telehealth practice" (ANA, p. x,

1998). Thus, one Likert-scale item to measure level of user competence was developed

·using the principles obtained in the Joint Program on Survey Management, September

1999 course on Question Design. User competence was defined as the amount of 60 technical competence perceived by the telenurse, and was assessed by the item "I feel comfortable with my level of technical competence in using telemedicine technology".

Two additional open-ended questions were included for subjects to list the strategies employed to attain user competence and to assure patient safety in the use of telehealth technology. The two open-ended questions were "What strategies does your organization utilize to assure user competence in operating telemedicine technology?

Please describe" and "What strategies does your organization utilize to assure patient safety in the use of telemedicine technology? Please describe." The listed strategies will be analyzed using a content analysis procedure at a later date and will be described anecdotally apart from the formal analysis of this study. Beginning to catalogue the strategies used by telenurses sets the stage for further examination of the telenursing role· in a subsequent study.

Analysis

Data was analyzed using SPSS, a commercially available statistical software package. The level of significance for accepting all hypotheses was established at p <

.05. Tables and illustrative graphs were prepared to depict the results of data• analysis and are included in the Findings Chapter. Missing data were analyzed and handled according to the process describe_d by Polit and Hungler (1995). Procedures to address missing data included the following: a) deleting the case if a large amount of the data for that case is missing, and b) substituting the mean value of the data if the missing data is not extensive

(Polit & Hungler, 1995). As mentioned under Sample Section, 207 nurses completed the

Telenursing Role Survey. Eleven of the nurses completed less than 75% of the questionnaire. These cases were delet~d from the analysis. Of the remaining 196 cases, 61

202 data elements were missing out of 28,224 data points (.7%). These data were replaced by substituting the mean value of the data.

Methods

Descriptive statistics were conducted for the sample of telenurses' responses.

Descriptive statistics focused on such data as the number of telenurses, educational preparation of nurses, nursing experience, and type of facility of employment in telenursing. Frequency distributions for each variable were presented, to include the lowest and highest values and number of values reported. Scores for each instrument were reported. Scores were computed from raw item responses via computer calculations. Coefficient alphas were calculated for each tool that has a summative score

(Index of Work Satisfaction and Rizzo, House and Lirtzman Role Questionnaire) . For

Hypothesis 2., means, standard deviations and correlations for the variables included in the study were calculated. A correlation rriatrix was prepared for all variables. As a check for multicollinearity of variables, correlations were examined and insured that co.rrelations between independent variables were < .65. Any correlation between variables > .65 may indicate multicollinearity, i.e. that the variables were so highly correlated that they may be the same variable (Burns & Grove, 1993). For hypothesis 2. a., correlations between the indep~nde._nt ·variables of work satisfaction, age, education level, years of experience and the dependent variable, role stress were examined and reported. For hypothesis 2. b. the correlation between the independent variables, number of role functions and types of role functions, and the dependent variable of role conflict was examined and reported. For hypothesis 2. c., the correlation coefficient between the 62 independent variables telenursing experience and years of nursing experience and the dependent variables of role stress and role ambiguity was examined and reported.

Hypothesis 3. a. was tested utilizing one-way analysis of variance. Education levels were coded as 1 through 4 (1 =diploma nurse; 2 = associate degree nurse; 3= bachelor's degreed nurse; 4 = graduate degreed nurse (MS,Phd)) based on

the distribution of the sample. The analysis of variance was conducted between the independent variable of education level and the dependent yariables of role stress and role ambiguity.

The type of analysis for Hypothesis 3. b. depended. l'JOn the distribution of scores for the independent variables (experience in nursing and experience in telenursing). If these values fall into logical categories, one-way analysis of variance was used. If they were distributed on a continuum, correlational statistics were used and the direction of the relationship was interpreted.

For Hypothesis 3. c., i!1 order to identify clusters of types of role functions, data was examined in detail to assess if combinations occur in the data. Certain combinations of professional roles may become evident; for example, administrator, supervisor and consultant for those nurses involved in non-patient care roles in telehealth programs.

Common clusters of role functions were identified and assigned a number. One-way analysis of variance was con1ucted between the cluster types (independent variable) and the dependent variables of role conflict and role stress. The results of this one-way analysis of variance determined if there was a difference in the cluster types' in relation to role conflict and role stress. 63

For Hypothesis 4. a., the total work satisfaction score was used in the regression

model. Level of education ( coded 1-4 or 1-3 as previously described), years nursing

experience, telenursing experience, age, type of professional role, and number of

professional role functions were entered into the regression equation. Role stress was regressed on these variables.

For Hypothesis 4. b., the work satisfaction total score was correlated with role ambiguity. The work satisfaction score, Level of education (coded 1-4 or 1-3 as previously described), age, years nursing experience, telenursing experience, type of professional role, and number of professional role functions were entered into the regression equation. Role ambiguity was regressed on these variables.

For Hypothesis 4. c., again the total work satisfaction score was correlated with role conflict. Role conflict was regressed on the .three work satisfaction variables, level of education (coded 1-4 or 1-3 as previously described), age, years of nursing experience, telenursing experience, type of professional role, number of professional rol.e functions as the first step of the hierarchical regression. In the second step, role ambiguity was added to the equation. The addition of role ambiguity 'into the hierarchical regression allowed examination of the impact of role ambiguity upon the equation at the point that it was entered.

Limitations

Generalizability of findings may be limited because this was a descriptive versus

experimental design. Response rate to the survey may also limit generalizability of the

findings, due to potential inability of obtaining a representative sample of the population 64 of telenurses. The multilevel reminder process and multiple response options (web-based or telephone interview) for subjects was designed to overcome this limitation.

Self-selection sampling bias may also be a limitation, as previously described. As mentioned, the findings regarding role stress may be underestimated due to selection bias.

Snowball sampling continued until no new names were mentioned to minimize self selection sampling bias and_ to reduce sample variance.

Selection of the particular variables in this study may fail to ascertain attributes of the telenursing population that choosing other variables may have identified. In order to compensate for this limitation, a thorough review of the literature regarding previous emerging roles in nursing, as well as characteristics of the general nurse population has been accomplished, and the current variables carefully selected according to previous significant findings.

Findings related to role stress may be understated as described in the Procedures

Section. Several subjects who were contacted via telephone and via email for reminders to respond to the survey indicated they were too busy and overstressed to take the time to complete the survey.

Human Subjects Protection

This research proposal was submitted in February 2000 for approval to the

. Human Assurance Committee/Institutional Review Board of the Medical College of

Georgia. Human Assurance approval was obtained on April 11, 2000. Written consent

to participate was not required for subjects. A subject's consent to participate was

evidenced by their active participation in picking up the phone, calling the toll-free phone

number and completing the survey or going online to complete the survey via the 65

Internet. Permission for telephonic surveys to be audiotaped was not requested at the beginning of each telephone survey since no surveys were audiotaped, as initially · envisioned for quality control of data entry. The risks of this research were minimal to none. The only anticipated risk was irritation regarding using the Internet as a new modality for data collection, as opposed to a more traditional approach such as the paper based survey. Provision of an alternate method, telephone survey, was made to minimize the irritation.

Disclosure of potential participant names by vendors, other nurse contacts and telemedicine organizations was made with the consent of the participant. For example, vendors-who were contacted indicated they would check with their network of nurses ·to see who would agree to participate, and only then were the names and email addresses of the potential participants provided to the researcher.

Data was maintained on disc in a locked filing cabinet and was confidential.

Codes were provided for participants to track their participation. Names or other identifying information were not utilized in any of the responses or on the web server. At the conclusion of the survey, if subjects indicated an interest in receiving the results of the survey and were willing to provide contact informatfon, the final survey section was provided for them to list their email or regular mail contact information. A summary copy of the findings will be provided to them, per their stated preference. 66

Chapter 4

. Findings

The primary purpose of this study was to examine the professional role and individual characteristics, work safo;faction, role stress, role ambiguity and role conflict of telenurses practicing in the United States. The focus was on examination of the telenursing role. Creating a model from a portion of Role Theory as the theoretical framework depicted in Figure 1, a descriptive study utilizing survey research methodology was undertaken. The model also serves as a framework for the presentation of findings of the research. As related to the Ro~~ Set, demographic data representing individual characteristics of telenurses are described first. Telenurses' professional experience, age and education are described. The roles, titles and functions of telenurses are described in detail. The work satisfaction of telenurses both as a group and individually are presented. A presentation of the subscales of work satisfaction for telenurses is also made. These subscales, or components of work satisfaction, include autonomy, pay, task requirements, organizational policies, interaction and professional status ..

As related to role strain, the measurements of role stress, role ambiguity and role conflict of telenurses are described. Then, significant relationships and predictions of role stress are presented in detail. Correlations, analysis of variance, and regression analyses for the hypothesized relationships are presented in accordance with the corresponding hypotheses numbers 2,3, and 4 as delineated in 1:able 5.

Finally, Hypothesis 5 is addressed along with the issue of self-reported competency of telenurses. A brief description of the subjective data related to strategies 67

for user competence and strategies for patient safety is reported. Further in-depth content

analysis of open-ended questions on nurse competence preparation and strategies for

patient safety will be conducted and reported -separately at a later date.

Individual Characteristics

The population of telenurses in the United States, totaling 796, was identified

using _the three-pronged strategy described in detail under the Methods Section in

Chapter 3. Of the population, 196 (27%) of respondents had completed data that was

used to conduct the analysis. The 196 telenurses represented 40 of the 50 states. Figure

3 depicts the representation of the respondents via geographic area. As depicted,

telenurses from Alaska and Hawaii also participated in the study.

119,, ¢. 1 6 0~ 1_,.b6-0

No Telenurse Respondents ·::>,:{

~ Telenurse Respondents Present

Figure 3. Geographic Representation of Telenursi11g Role Study Respdndents 68

Ninety one percent of the telenurses ru = 179) were female and 9% were male ill

= 17). The mean age oftelenurses was 46.37 (SD= 7.70). The minimum age was 28.

The maximum age was 74. Table 8 depicts the ages of telenurses in the study.

Table 8

Ages of Telenurses

Age Frequency Percent

<30 yrs 3 1.5

<40 yrs 33 16.8

<50 yrs 97 49.5

<60 yrs 56 28.6

>60 yrs 7 3.6

Total 196 100.0

Nine percent of telenurses were from minority backgrounds, to include 2%

American Indian or Alaskan Native ru = 4), 4 % Asian or Pacific Islander ru = 8), and

3% Black, not of Hispanic origin Q:! = 6). The majority oftelenurses, 69%, were married ill= 135). Tvventy percent Q:! = 40) were widowed, divorced or separated and

11 % ill = 21) were never married. Fifty-one percent of telenurses ~ = 100) had children.

Highest education level of telenurs·es varied greatly within the sample. Twelve telenurses (6%) had diplomas in nursing. Thirty-one nurses (16%) had Associates

Degrees. Sixty-one nurses (31 % ) held Baccalaureate degrees. The largest percentage of telenurses, 46% Q:! = 91), held Graduate Degrees at either the Master's (N = 73) or 69

Doctoral (N = 18) level. Twenty-seven percent of telenurses held advanced practice certification, as depicted in Table 9.

Table 9

Telenurses with Advanced Practice Preparation

Advanced Practice Frequepcy Percent

Area

Clin Nurse Spec. 30 15.3

Nurse Anesthetist .5

Nurse Midwife 2 1.0

Nurse Practitioner 19 9.7

None 144 73.5

Total 196 100.0

The range of professional experience of telenurses spanned a min.imum of 6 months to a maximum of 41 years in nursing. The mean ·for years of experience in nursing for telenurses was 21.16 years (SD= 9.26). Thirty-four telenurses (17%) were new to their telenursing role, having worked less than six months in their telenursing positions. Eighty three percent (N = 162) of telenurses had heen in their telenursing role for greater than six months.

Table 10 depicts the employment status of telenurses. Mean salaries for each category (full time in telenursing, part time in telenursing and self employed in telenursing) are also provided. 70

Table 10

Emgloyment Status and Salary ofTelenurses

Employment N Percent Mean Salary SD

Status

Full Time 13 67.8 $49,989 $17,88

Part Time 5 28.6 $30,867 $23,03

Self Emp ·3.6 $33,750 $15,45

Total 19 100.0 $45,050 $20, 11

Professional Role

Tele~urses worked in at least 29 different practice settings, as depicted in Table

11. There were 49 possible setting responses in the Telenursing Role Survey, including an "other" category. Forty-three telenurses who selected ··other" specified their practice setting. Their responses were then recoded to add nine categories to the existing survey

Table 11

Work Settings of Telenurses

Frequency Percent

Acute Care/Community Hospital, Nonfederal 28 14.3

Home Care 12.8

Disease Management Company 15 7.7

Federal Government Hospital 10 5.2 71

University 10 5.2

Multispecialty Group Physician Practice 9 4.6

Nonprofit Hospital 7 3.6

Private Company 7 3.6

Military Telemetj.icine Organization 6 3.1

Visiting Nu~se Service 5 2.6

Physician Group Practice 4 2.0

Prison or Jail 4 2.0

Telemedicine Company/Vendor 4 2.0 .., Consultant ., 1.4

Nursing Group Practice 2 1.0

Community Mental Health Facility 2 1.0

Federal Agency 2 1.0

Call Center 2 1.0

Rehab/Disability Agency 2 1.0.

Web Portal 2 1.0

Neighborhood Health Center, Rural Health_ 1 each 0.5 each

Center, School Nurse, Freestanding Physician

Clinic, Freestanding Nurse Clinic, Ambulatory

Surgical Center, Health Planning, Insurance

Company, Legal/Policy Organization

Other, not specified 38 19.4

Total 196 100 72

categories. The total reported practice settings for telenurses ·are_.identified in

Table 11 . Thirty-eight subjects (19.4%) did not specify "other" as requested.

As part of the Telenursing Role Study, nurses were asked to describe their role functions as administrative, coordination with other agencies/pe.rsonnel, in-person direct patient care, telemedicine-delivered patient care, research, supervision, teaching and other (checking all that applied to each telenurse and indicating the percent of time spent in each role function in a usual work week). Of the eight possible role functions, 52% of telenurses (N = 102) fulfilled 4 role functions. Forty-eight telenurses (24%) had 3 or fewer roles. Forty- six nurses (24 %) fulfilled 5 or more functions. One telenurse encompassed all 8 role functions. Table 12 depicts the various roles reported by telenurses, and the frequencies that the roles were reported. It should be remembered that the telenurses reported a combination of role functions, therefore there are far more than

196 total reported functions. Those functions listed under "other" included: business development, strategic planning, speaking engagements, designing and installing telemedicine equipment in hospitals, managing/developing web and clinical information systems, new project management and evaluation, writing (newsletters, proposals, grants, administrative reports and articles), conducting telemedicine demonstrations, attending trade shows, travel and networking. 73

Table 12

Role Functions of Telenurses and Percentage of Time Spent in each Role Function

N Minimum% Maximum% Mean% of SD

of time spent of time spent time spent

Administrative 82 0 90 28.9 21.9

Consultation with agencies 90 2 70 20.4 15.3 or other professionals

In-person direct patient care 44 2 75 22.4 22.3

Telemedicine-deli vered 75 2 100 31.1 30.0 direct patient care

Research 47 2 45 12.4 10.3 .., Supervision 52 .) 50 17.7 14.4 .., Teaching · 43 .) 80 15.7 17.0

Other 19 ·5 75 27.4 21.5

Once the role functions data were examined in detail across all subjects, several

patterns of combinations of role functions emerged from the data. These combinations

were recoded into four "types" of telenursing functions. Table 13 reports the frequencies

of nurses in each identified type of telenursing role. They were categorized as:

1. Multiple role telenurse - encompassed nurses with 5, 6, 7 or 8 reported role

functions. These telenurses all had administrative functions, and in addition, fulfilled

any combination of other additional functions 74

2. Admini.strator telenurse - encompassed nurses with 4 reported role functions. The~e

functions were all administrative with some clinical, research or supervision added.

3. Clinical telenurse with one other role - encompassed nurses with 2 or 3 reported role

functions. These telenurses fulfilled clinical functions with one additional

supervisory, research or administrative role.

4. Clinical telenurse - encompassed telenurses with one reported role function, 100%

telemedicine-delivered direct patient care.

Table 13

Types of Telenursing Role Functions

Frequency Percent

Multiple role telenurse 46 23.5

Administrator telenurse 102 52

Clinical with one additional role 36 18.4

Clinical 12 6.1

Total 196 100

Telenurses reported 24 different titles for their telenursing positions. A large number of telenurses (N = 42) did not select one of the 32 options provided for role title in the

Telenursing Role Study. They indicated their position title was "other" but did not specify what it was. Table 14 indicates the various telenursing position titles that were reported. 75 \ Table 14

Telenursing Position Titles

Frequency Percent

Coordinator* 28 14.4

Administrator of organization/department 26 13.3

Nurse clinician 18 9.3

Case manager 12 6.1

Consultant 10 5.1

Clinical nurse specialist 9 4.6

Nurse manager 7 3.6

Supervisor or assistant supervisor 7 3.6

Researcher 5 2.5

Staff nurse 5 2.5

Director** 5 2.5

Other - specified*** 4 2.0

Nurse practitioner 4 2.0

'"I Administrator of nursing .) 1.5

'"I Owner/shareholder .) 1.5

No position title 2 1.0

Head nurse 0.5

In-service education direct.or 1 0.5

Instructor 0.5

Professor or assistant/associate professor 0.5 76 \- ·,.

School nurse 1 0.5

Team leader 1 0.5

Other - not specified 42 21.5

Total 196 100

* Titles included: Technical Telemedicine Coordinator, Care Coordinator, Clinical

Consult Coordinator, Clinical Coordinator, Coordinator of the TeleHealth Program,

Research Coordinator, Mental Health Coordinator, Telemedicine Coordinator, Program

Development Coordinator, Project Coordinator, Research/Telemedicine Coordinator,

Telehome Health Project Coordinator

**Titles included: Clinical Products Director, Patient Service Center Director, Telehealth

Project Director, Telemedicine Program Director

*** Titles included: Biomedical Engineering Clinical Nurse Specialist, Consumer

Information Nurse, Diabetes Educator, and Intake Nurse. 77

Telenurses reported the type of patients who are primarily treated in the telemedicine area in which they work. Results are reported in Table 15

Table 15

Types ofTelemedicine Patients seen by Telenurses

Frequency Percent

Pediatric 57 41.9

Various patients, not specifically specialized 41 17.2

Obstetrics/gynecologic 30 12.6

Chronic care 27 17.6

Basic medical/s:urgical or specialty areas not specified 19 7.9

Coronary care 10 4.2

Psychiatric 5 2.1

Rehabilitation 3 1.3

Neurological 2 .8

Orthopedic 2 .8

Total 196 100

Work Satisfaction

Part A of the Ind.ex of Work Satisfaction (IWS) measured the components of work satisfaction t_hat are most important to telenurses as a group. The value provided by scoring Part A is the Component Weighting Coefficient (CWC). The CWC is a scale value for each component of work satisfaction (autonomy, pay, professional status, 78 interaction, organizational policies and task requirements) as related to its deviation from the mean of all the scale values. Thus, the ewe value is a comparison of one factor with all the other factors for telenurses as a group.

As an overall group, and as a measure of Part A of the Index of Work Satisfaction

(IWS), telenurses felt that autonomy (eWS = 3.87) was the most important factor related to their work satisfaction. Autonomy was defined in the IWS as the amount of job related independence, initiative and freedom either permitted or required in daily work activities (Stamps, 1997). The second most important factor that contributed to telenurses' job satisfaction as a group was Interaction (eWS = 3.44). Interaction was defined in the IWS as the opportunities presented for both formal and informal social and professional contact during working hours (Stamps, 1997).

The third most important factor for telenurses' work satisfaction overall was

Professional Status (eWS = 3.12). Professional Status was defined in the IWS as the overall importance or significant the telenurses felt about their job, both in their own view and in the view of others (Stamps, 1997). The fourth most important factor for telenurses' work satisfaction was task requirements (eWS = 2.89). Task requirements were defined as the things that must be accomplished as part of a role (Stamps, 1997).

The next to least important factor for telenurses' work satisfaction was pay (eWS

= 2. 77). Pay was defined in the IWS as the dollar remuneration and fringe benefits received for work done (Stamps, 1997). The final and least important factor for telenurses' work satisfaction was Organizational Policies (eWS = 2.43). Organizational

Policies were defined in the IWS as the management policies and procedures put forward 79 in the telenurses' work area and by the administration of their organization (Stamps,

1997).

Part B of the IWS provided both individual and group measures of the components of work satisfaction and total work satisfaction for telenurses. Table 16 provides the data for the five work satisfaction components and total work satisfactjon of individual telenurses.

Table 16

Individual Work Satisfaction Scores of Telenurses

N Possible Minimum Maximum Mean= Standard

Range of Component Deviation

Scores Scale Score

Autonomy 196 8-56 20 56 43.30 8.27

Interaction 196 10-70 19 69 50.85 9.77

Professional 196 7-49 27 49 39.28 4.82

Status

Task 196 6-42 9 41 24.41 5.78

Requirements

Pay 196 6-42 6 39 22.64 8.07

Organizational 196 7-49 7 48 30.08 8.91

Policies

Total Work 196 44-308 100 285 210.56 34.15

Satisfaction 80

Telenurses' individual, total work satisfaction scores from Part B of the IWS can also be categorized into four quartiles, based on the possible range of scores of work satisfaction. The Quartiles divides the possible scores into four equal categories, in order · to see where the groupings of responses lie in relation to all possible scores. Table 17 provides a description of the grouping of telenurses' total work satisfaction scores.

Table 17

Telenursing Total Work Satisfaction Scores by Quartile

Range of scores Frequency Percent

First Quartile 44-112 · 1 .5

(Low Work

Satisfaction)

Second Quartile 113-180 37 18.9

(Slight Work

Satisfaction)

1,,,, Third Quartile 181-248 .) .) 67.9

(Moderate Work

Satisfaction)

Fourth Quartile 249-308 r_) 12.8

(High Work

Satisfaction)

Total 44-308 196 100 81

" The telenursing group Index of Work Satisfaction is calculated in Table 18. The

Index of Work Satisfaction for telenurses as a group is 14. 77.

Table 18

Overall Index of Work Satisfaction for Telenurses as a Grou:g

Component I. Component II. Component III. Component IV. Component

Weighting Scale Score Mean Score Col Adjusted

Coefficient (Part B IWS) II/# items for Scores (Col I X

(Part A IWS) each component Col III)/6

components

Autonomy 3.87 43.30 5.41 3.49

Interaction 3.44 50.85 5.09 2.92

Professional 3.12 39.28 5.61 2.92

Status

Task 2.89 24.41 4.07 1.96

Requirements

Pay 2.77 22.64 3.77 1.74

Organizational 2.43 30.08 4.29 1.74

Policies

Group Work. 210.56 (range 4. 71 (range 1-7) · 14. 77 (Index of

Satisfaction 44-308) Work Satisf. -

Range 0.9-37.1) 82

Role strain/Role stress

Results of the Telenursing Role Study as related to the measurement of role

strain/role stress are provided. Table 19 lists descriptive data for telenurses' role

ambiguity, role conflict and role stress as measured by the Rizzo, House and Lirtzmann

Role Questionnaire component of the Telenursing Role Study.

Table 19

Role Stress, Role Ambiguity and Role Conflict Scores of Telenurses

Variable N· Minimu Maximum Total SD Mean SD

Mean Component

Score Score*

Role Ambiguity 196 17 87 40.87 13.84 2.92 .99

Role Conflict 196 20 92 49.42 13.92 3.29 .93

Role Stress 196 39 179 90.30 24.77 3.11 .89

* Note: Range= 1 to 7, with 1 indicating lowest and 7 indicating highest role conflict,

. role ambiguity or role stress

Significant correlations of study variables are depicted in Table 20 .

Multicollinearity exists in several variables, most notably Number of role functions and

Type of role functions. Since the Type of role function was derived from the Number of

role functions as described under the Individual Characteristics Findings, this is expected.

As a result, the variable number of role functions was only used in hypothesis testing due

to the multicollinearity between these variables.

Muticollinearity may also be evident between Role ambigui~y and Role conflict

and between Role ambiguity and Role stress. Similarly, multicollinearity exists Table 20

Pearson Correlations of Study Variables

I. 2. _,."'I 4. 5. 6. 7. 8. 9. 10.

1. Work Satisfaction 1.000 -.663** -.748** -.760** .074 .098 -.071 .122 -.123 -.142*

2. Role Ambiguity -.663 1.000 .724** .928** .161 * -.008 .032 -.129 .126 .115

3. Role Conflict -.748** .724** 1.000 .929** .110 -.060 .057 -.038 .032 .092

~- Role Stress -.760** .928** .929** 1.000 .146* -.037 .048 -.090 .085 .111

5. Highest education level .074 .161* .110 .146* 1.000 .172* .072 -.035 .010 .013

6. Years nursing experience .098 -.008 -.060 -.037 .172* 1.000 -.092 -.044 .029 .251 **

7. Telenursing experience -.071 .032 .057 .048 .072 -.092 1.000 .011 -.057 .036

8. Number of role functions .122 -.129 -.038 -.090 -.035 -.044 .011 1.000 -.938** -.187**

9. Type of role function -.123 .126 .032 .085 .010 .029 -.057 -.938** 1.000 .216**

10. Age -.142* .115 · .092 .1 11 .013 .251 ** .036 -.187** .216** 1.000

** Correlat10n IS sigmficant at the 0.01 level (2-tailed). * Correlat1011 IS sigmficant at the 0.05 level (2-tailed). 84

between Role conflict and Role stress. Multicollinearity is explained in this case of role

stress, since role stress is derived from the combined measures of Role ambiguity and

role conflict. Thus, multicollinearity between role ambiguity and role stress, and between

role conflict and role stress, is expected.

In the case of role ambiguity and role conflict, the correlation was . 72. Most

researchers consider multicollinearity to exist if the bivariate correlation is greater than

.65 (Bums & Grove, 1993). However, some researchers use a correlation of .80 or greater as an indicator of multicollinearity (Schroeder, 1990). The correlation value for role ambiguity and role conflict falls directly in between the two suggested parameters.

In order to test further for multicollinearity, the Variance Inflation Factor (VIF) for these variables was calculated using SPSS. A large VIF value is an indicator of multicollinearity (SPSS, 1999). The VIF has a range from 1 to infinity, with a larger VIF indicating multicollinearity (Wulder, 2000). The VIF for role ambiguity and role conflict was calculated as 1.9. Thus, multicollinearity between role ambiguity and role conflict was estimated as not present, and the variables were utilized as planned in the analysis.

Hvpothesis Testing

Hypothesis 2.a. stated;, There is a relationship among work satisfaction, education level. age, years of experience and role stress of telenurses.'' The hypothesis was tested using the Pearson Correlation coefficient for the variables of work satisfaction, role stress, years of nursing experience and age. These variables were interval level variables, appropriate for correlation analysis. A significant inverse relationship (r = -

.760, p <.01) was found between role stress and work satisfaction, such that low work

satisfaction is correlated with high role stress. In addition, a significant inverse 85 relationship (r = -.141, p <.05) was found between age and work satisfaction, such that lower work satisfaction is correlated with greater age of telenurses. An expected positive

. correlation (r = .251, p <.01) existed between age and years of nursing experience such that greater age is correlated with more years of experience in nursing.

Highest level of education was a categorical variable. To check for differences in variables based on highest level of education and to complete Hypothesis 2.a. testing, four Analyses of Variance were conducted utilizing the categorical variable Highest level of education as the independent variable. Dependent variables in the ANOV A were work satisfaction, role stress, age and years of experience in nursing. There was no significant relationship between Highest level of education and work satisfaction or role stress.

There was a significant relationship between Highest level of education and age F (3,191)

= 3 .24, p < .05 and Highest level of education and years of experience in nursing F

(3,191) = 8.75, p < .05.

Hypothesis 2 b stated ·'There is a relationship among number and type of professional role functions of telenurses and role conflict." This hypothesis was tested using the Pearson Correlation coefficient with the variables Number of professional role functions and role conflict. Type of role functions was not utilized in the hypothesis testing, since multicollinearity of this variable with Number of rol~ functions was previously established. No significant correlation between these variables was found.

Hypothesis 2 c stated "There is a relationship among telenursing experience and

nursing experience and role stress and role ambiguity. This hypothesis was tested using

the Pearson correlation coefficient with the variables telenursing experience, years 86 nursing experience, role stress and role ambiguity. No siguificant relationship among these variables was found.

Hypothesis 3 a stated "There is a difference in role stress and role ambiguity of telenurses, depending on education level." This hypothesis was tested using one way

ANOVA with Highest education level as the independent variable and role stress and role ambiguity as the dependent variables. No significant difference in role stress and role ambiguity of telenurses, depending on highest education level was found.

Hypothesis 3 b stated "There is a difference in role stress and role ambiguity of telenurses depending on experience in nursing and experienc~ in nursing." This hypothesis was testing using two one way ANOVA's with 1) Years of nursing experience as the independent variable and role stress and role ambiguity as the dependent variables and 2) Telenursing experience as the independent variable and role stress and role ambiguity as the dependent variables. No significant difference in role stress and role ambiguity of telenurses depending on either years of nursing experience or telenursing experience was found. In order to test for the impact of years of nursing experience upon role stress and role ambiguity, while controlling for highest education level, hierarchical regression analysis was conducted. Highest level of education was entered into the equation first. Years nursing experience was entered next. The dependent variable was role ambiguity. Table 21 and Table 22 provide a summary of the results of the hierarchical regression. Highest education level is a significant predictor of role

ambiguity and role stress. When controlling for highest education level, years of nursing

experience is not a significant predictor of either role ambiguity or role stress. 87

Table 21

Summary of Hierarchical Regression Analysis for Variables Predicting Role Ambiguity

· Variable B SE B fl

Step 1

Highest education level 2.43 1.07 .16*

Step 2

Years nursing experience -5.69 .108 -.04

Note. * Significant R2 = .03 for Step 1 (p < .05)

Change R2 = .001 for Step 2 (not significant)

Table 22

Summary of Hierarchical Regression Analvsis for Variables Predicting Role Stress

Variable H SE_H fl

Step 1

Highest education level 4.10 2.01 . I-*)

Step 2

Years nursing experience -.18 .20 -.07

Note. * Significant R- = .02 for Step I (p < .05).

2 Change R = .004 for Step 2 (not significant)

Hypothesis 3c stated '"Role conflict and role stress differs among telenurses with

various combinations of role functions." This hypothesis was tested using one way

ANOV A with the categorical variable of role functions (multiple role telenurse, 88 administrative, clinical with one other function, clinical) as the independent variable and with role stress and role conflict as the dependent variables. No significant relationship was found, indicating that role conflict and role stress do not differ among telenurses with the identified combinations of role functions.

Hypothesis 4 a stated "Role stress of telenurses is predicted by work satisfaction, individual characteristics (level of education, age, years of nursing experience) and number and type of professional role functions. This hypothesis was tested using multiple linear regression. The model was statistically significant F ( 5, 189) = 31.12, p <

.001. The combination of work satisfaction, age, highest education level, years nursing experience and number of role functions explained 62% of the variance in role stress.

Work satisfaction (B = -. 78, t = -16) and highest education level (B = .20, t = 4) are statistically significant independent predictors of role stress. Higher work satisfaction is associated with lower role stress. Higher education level is associated with higher role _ stress.

Hypothesis 4 b stated ··Role ambiguity of telenurses is predicted by work satisfaction, individual characteristics ( age, level of education and years of nursing experience) and number and type of professional role functions. This hypothesis was tested using multiple linear regression. The model was statistically significant F (5, 189)

= 35.76, p < .001. The combination ~f work satisfaction, age, highest education level, years nursing experience and number of role functions explained 49% of the variance in role ambiguity. Work satisfaction (B = -. 68, t = -12) and highest education level (B =

.20, t = 3.8) are statistically significant independent predictors of role ambiguity. Higher 89 work satisfaction is associated with lower role ambiguity. Higher education level is associated with higher role ambiguity.

Hypothesis 4 c stated "Role conflict of telenurses is predicted by work satisfaction, individual characteristics (age, level of education, and years of nursing experience) number and type of professional role functions and role ambiguity. This hypothesis was tested using hierarchical regression analysis. Type of professional role function was eliminated from the analysis due to previous documentation of multicollinearity. Controlling for the independent variables of work satisfaction, highest education level, years ·nursing experience, and age, the impact of role ambiguity upon role conflict was assessed. Table 23 identifies results of the hierarchical regression analysis. In the final model, three variables were statistically significant independent predictors of role conflict. Work satisfaction (B = - .52, t = - 8.8), highest education level

(B = .09, t = 2.1) and role ambiguity (B = .3 8, t = 6.4) are statistically significant independent predictors of role conflict. Higher work satisfaction is associated with lower role conflict. Higher education level is associated with higher role conflict. Higher role ambiguity is associated with higher role conflict. 90

Table 23

Summary of Hierarchical Regression Analysis for Variables Predicting Role Conflict

Variable fl SE B .i

Step 1

Work satisfaction - 2.11 .02 - .52*

Age - 1.59 .08 - .01

Highest education level 1.41 .68 .09*

Years nursing experience - 2.22 .07 - .02

Number of role functions .76 .44 .08

Step 2

Role ambiguity .38 .06 .38*

2 Note. *Significant R ·= .60 for St~p 1 (p < .001)

2 * Significant change R = .07 for Step 2 (p < .001) 91

Hypothesis 5 was analyzed by examining the frequencies in answer to the one item question "I feel comfortable with my level of technical competence in using telemedicine technology". Table 24 lists responses to this statement.

Table 24

Res12onses to Comfort with Level of Technical Com:getence for Telenurses

Response Frequency Percent

Totally agree 70 29.3

Mostly agree 98 41.0

Slightly agree 8 3.3

Neither agree nor disagree 4 1.7

Slightly disagree 9 3.8

Mostly disagree 6 2.5

Totally disagree .4

Total 196 100

Telenurses \Vere also asked to respond to two open-ended questions related to 1) the strategies used in their organization for achieving nurse user competence with telemedicine technology and 2) the strategies used in their organization to assure patient safety in the use of telemedicine technology. Answers to the nurse user competence question ranged from "no strategies - was left on my own to figure it out" to "6 month complete orientation with a mentor and a final checklist for competency completion".

Subjective data of responses ranged between these two endpoints. 92

Answers to the strategies for patient safety ranged from assuring the patient

informed consent process occurred, educating patients and their families about

equipment, assessing electrical and equipment safety in patients' homes, privacy and

security of patient data, development of policies for patient safety and inf~ction control of

equipment, to "none". All responses by telenurses to the two open-ended questions will

be analyzed usirig content analysis at a future date and will be reported separately from

this dissertation.

Summary of Findings

Findings from the Telenursing Role Study were rich with data regarding the emerging roles, titles and functions of telenurses as well as their individual characteristics. Factors of importance and their order of importance for the work satisfaction of telenurses have been identified. The Index of Work Satisfaction for telenurses as a group was calculated and provides a baseline for future research with the growing population of telenurses. In addition, measures of role conflict, role ambiguity and role·stress for telenurses have been identified as a benchmark for telenurses' future research. Relationships between and among selected variables upon role stress, role ambiguity and role conflict have resulted in informing the profession about some significant findings. The Discussion Section in Chapter 5 will provide interpretation of the findings, comparison of current findings to past literature and research, as well as

recommendations for future investigation. 93

Chapter 5

Discussion and Recommendations -

The intent of this study was to examine the professional role and _individual characteristics, work satisfaction, role stress, role ambiguity and role conflict of telenurses practicing iii the United States. This research arose from the investigator's interest in understanding issues and variables related to the rapidly emerging role of telenurses as telehealth technologies proliferate. Using a portion of Role Theory as the theoretical framework, a descriptive study utilizing survey research methods was undertaken. The focus was on examination of the telenursing role, using a portion of Role

Theory (Figure 1) as the framework. The purposes of this research were to:

l.· Describe a) telenurses' professional role(s) and individual characteristics and b)

strategies for adherence to the user competence and patient safety portion of one of

the American Nurses Association (ANA) Core Principles on Telehealth

2. Measure a) telenurses' work satisfaction and its components and b) telenurses'

role stress, role ambiguity and role conflict

3. Predict the relationship between the components of work satisfaction, individual

and professional role characteristics, and role stress, role ambiguity and role conflict.

From the identified population of 796 telenurses in 40 states, 196 (27% response rate) telenurses provided complete and us.able responses. Data analysis was based on the

196 responses. The discussion and recommendations will be presented based on the responses of the 196 participants, and within the theoretical framework and stated research purpose of the study. Prior to further discussion of the findings and recommendations, the limitations of the study will be presented. 94

Limitations of the Study

The limitations of the study are as follows:

I) A review of the available literature regarding telenursing roles revealed that there

was limited information in this area. Horton's study (1996) of 74 telenurses was the

single, pioneering work in this area to date. This lack of foundational literature

hindered the linking of the current study findings with previous study findings.

2) The high coefficient alpha scores attained indicated that there was internal"

consistency within the survey instruments utilized. However, replication of this

study using these instruments is necessary to fully establish reliability within the

population of telenurses.

3) Although survey participants were from 40 of the 5 0 states, and represented a

variety of healthcare organizational structures and entities, generalizability of the

study' s findings is limited since the entire population of telenurses is not truly

known. The 10 rural states where telenurses were not represented may provide a

different perspective than the responses provided.

4) Use of the web-based, online survey as a relatively new data collection

methodology may have been either a limitation or an enhancement of the study.

During the course of the data collection, several America Online (AOL) users

indicated that they were "'kicked off' of the survey midway through. Because of the

use of an incompatible w~b browser by AOL customers, responses may have been

lost. Nurses always had'the option of calling the toll-free telephone number to

conduct the telephonic version of the study. Except for less than a dozen email

messages related to browser difficulties as mentioned above, the extent of users' 95

difficulty with accessing or completing the survey online is not known. The

response rate may have been impacted by the use of the online survey data collection

method.

5) Due to the stress and demands of the new telenursing role, the very subjects that

might have provided the highest role stress scores may not have had time to take the

survey. In response to reminder notes and emails, 14 telenurses indicated that they

were so busy and overwhelmed by their jobs that they had no time to respond to the

Telenursing Role Survey. Thus, the reports of work satisfaction and its components

may be overstated and the reports of role stress and its components may be

understated for the population of telenurses.

6) Response rate of27% was a limi_tation of the study. Horton attained a 58%

response rate in her mai'led survey of telenurses in 1996. Although response rate was

lower, there was a very high completion rate of data for the respondents who did

complete the survey. Low response rate could be due to nurses calling themselves

telenurses who are working in telephone triage or help lines, however they could not

meet the definition of telenurse for this study. This is indicated by the 26% response

rate of nurses who accessed the study, but could not pass the screening criteria for

the definition of telenursing for this study, and thus could not complete the study.

Theoretical Framework Discussion

In congruence with the theoretical framework:. depicted in Figure 1 for the

Telenursing Role Study, the elements of the Role Set will be discussed first. These elements included Individual Characteristics of telenurses, the Professional Role of telenurses and Work Satisfaction of telenurses. Next the relationship of the Role Set 96 findings to Role Strain and its components will be discussed. Finally, theoretical implications of the overall find_ings will be presented.

Individual Characteristics

The Individual Characteristics of telenurses will be compared with available data from the Horton 1996 telenursing ro'Ie study and the 1996 Division of Nursing National

Nursing Survey, which is conducted every four years. Data from the 2000 National

Nursing Survey is currently being collected and is· not yet available for comparison. The

Division of Nursing National Nursing Survey, as noted previously, provides data that is representative of all the RN's in the United States.

The mean age oftelenurses in this study was 46.37 years (SD= 7.70). Horton

(1996) reported a mean of 41 years. The 1996' Division of Nursing National Nurse

Survey reported the average age of nurses as 44.3 years. It appears that the mean age of telenurses is reflective of the general population of nurses in general, when factoring the four-year difference in study dates.

The average number of y_e_ars of experience in nursing in the Horton ( 1996) study was 16.4, with a range of 3 to 30 years. In the Telenursing Role Study, the mean for years of experience in nursing was 21.16 years (SD = 9 .26), with a range of 6 months to

41 years. Considering the time that has elapsed since the Horton study, the years of experience in telenursing are, on average, equal, although the range of experience is greater in the current study.

In the Telenursing Role Study, 17% of telenurses were new to their nursing role

(6 months ·or less in the position). In the Horton (1996) study, 26% of telemedicine

programs in which the telenurses worked were active < 1 year, although specific time 97 spent in the telenursing role by telenurses was not reported. This difference is expected since four years ago, telenursing was very new, as were many telemedicine programs.

The 1996 the National Nursing Survey found 8.9 % of nurses were male.

Similarly, findings of the Telenursing Role Study were also that 9% of telenurses were male. Interestingly, Horton ( 1996) found that 16 % of telenurses were male. She attributed this to the large number of nurse respondents from military and prison settings.

In the Telenursing Role Study, 9 % of telenurses came from racial/ethnic minority backgrounds, similar to the 10 % reported in the 1996 National Nursing Survey. Sixty nine percent (N = 135) oftelenurses were married, as compared to 72 % ofregular nurses. Fifty-one percent of telenurses (N = 100) had children, as compared with 55% of· regular nurses.

In the Telenursing; Role Study, 68% of nurses worked full time in telehealth, as opposed to 27% in Horton's 1996 study. The average full-time salary of telenurses is now $49,980, as opposed to the Division of Nursing 1996 rate for all RN's of $42,071.

Even with a projected 11 % increase since 1996 (reflecting the same increase as occurred from 1992 to 1996 in the National Nursing Survey), to $46,699 in the average nursing salary, telenurses earn approximately $3000/year more.

Education level of telerrurse,s was different from the overall population of nurses and previous study of telenurses. Table 25 represents a comparison of the highest levels of nursing education for the Horton (1996), Division of Nursing (1996) National Nursing

Study and Telenursing Role Study. As portrayed, the percents of telenurses with

Diploma and Associates Degrees in the current study are far fewer than the 1996 studies. 98

The percents of telenurses with Graduate Degrees in the Tele,nursing Role Study are more than double the previous studies. It appears that teleimrses as a group are highly

Table 25

Comparison of Studies of Percents of Nurses with Highest Education Levels*

Study Source Diploma Associates Baccalaureate Graduate

National Nursing Survey (1996) 27% 32% 31% 15%

Telenurses - Horton (1996) 12% 23% 36% 19%

Telenursing Role Study (2000) 6% 16% 31% 46%

*Note: Totals may equal> 100% due to roundmg. In the Horton study, LPN's were also included, thus the total is <100%. educated. This could also reflect sampling bias of snowball sampling, whereby nurses with Graduate Degrees referred other nurses of the same type to the study.

An area of great disparity between telenurses and the registered nurse population is concentration of advanced practice nurses. The Division of Nursing (1996) survey respondents reported that 6.3 % of nurses had advanced practice preparation, with the largest number as Nurse Practitioners (43%). In the Telenursing Role Study, 27% of telenurses held advanced practice certification, with the largest number Clinical Nurse

Specialists (57%).

Summarv of Individual Characteristics

The typical Y2K (Year 2000) Telenurse is 46 years old, has worked 21 years in nursing and more than 6 months in her telenursing position. She has a 27% chance of being an advanced practice nurse, and has at least a baccalaureate degree, and likely a 99 graduate degree as well. The typical telenurse is white, female, married, and has children.· She works full-time in ·telenursing and m~kes just over $49,000 per year.

' ; Professional Role

Telenurses worked in at least 29 different practice settings, nine of which were not categorized in the National Nursing Survey-. These nine were Legal/Policy

Organization, Consultant, Rehabilitation/Developmental Disability Agency, Disease

Management Company, Private Company, Telemedicine Vendor, Web Portal, Military

Telemedicine Organization and Call Center. The addition of new categories to the already existing 49 practice setting choices listed in the National Nursing Survey indicates that telenursing is opening new opportunities and practice areas for nurses.

In 1996, 60 % of all U.S. nurses worked in hospitals as their primary practice setting. In the Telenursing Role Study, 23% (N = 45) of telenurses worked in. hospitals, with the next largest setting Home Care, representing 12.8% of telenurses (N = 25).

Role functions of telenurses vary by study. Table 26 Depicts the various role functions reported by nurses and telenurses. 100

Table 26

Role Functions Comparison of Telenurses and Nurses

Role Function Telenurses - Horton National Nursing Telenursing Role

(1996) Survey (1996) Study (2000)

Administrative 15% 14.7% 28.9%

Consultation with -- 8.5% 20.4% agencies or other professionals

Direct patient care 51% 59.8% 53 .5% (22.4% in-

person + 3 1.1 %

telemedicine-

delivered)

Research 5% 1.9% 12.4%

Supervision -- 9.7% 17.7%

Teaching 7% 4.9% 15.7%

Other 21% .5% 27.4%

The "'other" category of role functions from both Horton's 1996 and the current study included consultants, technicians and evaluators. Other role functions defined in the current study include business development, strategic planning, speaking engagements, designing and installing telemedicine systems, new project management, writing (newsletters, proposals, grants, administrative reports, and articles), conducting 101 telemedicine demonstrations, attending trade shows, travel and networking. The large

category of "other" functions identified in the Telenursing Role Study showed a

definitive business and technical slant for telenurses. Such functions are not a typical

part of the current nursing education curriculum, which may need to either be expanded to meet the demands of such emerging roles as telenursing or perhaps a new telenursing specific curriculum should be initiated.

This concept is reinforced when one examines the types of telenursing role function as identified in the _patterns reported in Table 13: multiple role telenurse, administrator telenurse, clinical telenurse with one additional role and clinical telenurse.

Except for clinical-only telenurses, (representing 6.1 % of respondents), the majority of telenurses (93. 9%) provide varied role functions beyond the patient care function. As noted, 23 .5% of telenurses have 5 or more role functions. The need for multitasking abilities, priority setting, decision-making and other critical thinking and business functions is evident in the analysis of the telenursing professional role. While current nursing preparation includes most of these abilities, there is a need for business practice education such as negotiating skills, business teaming/partnering process knowledge, contract basics, and other associated business skills. Also, correlation of study variables as depicted in Table 20 indicates that age is positively correlated with type of role function (r - .22, p <.O 1). This means that older nurses are more likely to be in the clinical plus one function or clinical only telenurse type categories. Thus, younger nurses are more likely to have multiple role functions, which would reinforce the need for providing young telenurses additional business and technical skills. 102

Analysis of the position titles reported in the Telenursing Role Study indicates a.

host of new nursing titles, in parallel with the new practice sites reported by respondents.

Coordinator titles included: Technical Telemedicine Coordinator, Care Coordinator,

Clinical Consult Coordinator, Clinical Coordinator, Coordinator of the TeleHealth

Program, Research Coordinator, Mental Health Coordinator, Telemedicine Coordinator,

Program Development Coordinator, Project Coordinator, Research/Telemedicine

Coordinator, Telehome-Health Project Coordinator. Other, new telenursing titles included: Clinical Products Director, Patient Se_rvice Center Director, Telehealth Project

Director, Telemedicine Program Director, Biomedical Engineering Clinical Nurse

Specialist, Consumer Information Nurse, Diabetes Educator, and Intake Nurse. The variety of-titles serves as another indicator of the newness and lack of standardization of

-nomenclature for telemedicine/telehealth/telenursing. As noted in the Definitions

Section~ the terminology in the telehealth arena i~ not yet standardized or unified.

The Division of Nursing National Nursing Survey respondents reporte~

Medical/Surgical (39%) and Coronary Care (20%) as the two largest groups of patients treated by nurses. The Telenursing Role Study respondents surprisingly reported

pediatrics (42%) and various patients, not specifically specialized (17%) as the two types

of patients most treated by telenurses. Based on typical teleconsultation in hospital-based

telemedicine centers, various types of consultations usually occur on an as-needed basis,

so the report of various patients is a logical result. Somewhat of a surprise is that

pediatrics is the largest group of patients treated by telenurses. 103

Summary of Professional Role

It is clear from past study of the roles and functions of U.S. nurses and telenurses, that the telenursing role has some unique aspects and is emerging rapidly from the time of the Horton study in 1996. Horton identified 130 telenurses in 1996 in the U.S. In

2000, there were 796 telenurses identified, a 600% increase from 1996. This does not take into account the additional population of telenurses who we~e not identified by the three-phase process utilized for this study and described in the Methods Section in

Chapter 3.

Telenursing is causing change in titles and work locations of nurses. In addition, the telenursing role demands multitasking abilities, business and technical skills. The business skills demanded of telenurses are beyond the typical administrative skills in a head nurse or nurse manager position. Business skills require proposal preparation, budgetary preparation and justification, knowledge of business structure, joint ventures and partnerships, marketing and public relations and a host of other business-specific skills.

While telenurses are still based predominantly in hospitals, the percentage of telenurses (23 .5%) working in all types of hospitals compared to regular nurses ( 60%) working in all types of hospitals is less than half. Therefore, a conclusion is that the numbers and varieties of practice settings of telenurses are expanding from the traditional hospital setting. Entrepreneurial aspects of the role are evident as nurses are working as owners and shareholders, for web portals and telemedicine equipment vendors. The emerging professional role of telenurses may demand a new or enhanced curriculum at the graduate or post-baccalaureate level to prepare nurses for this new role. 104

Work Satisfaction

Part A of the Index of Work Satisfaction (IWS) identified the components of work satisfaction that are most important to telenurses as a group. They are, in order of most to least importance: autonomy, interaction, professional status, task requirements, pay, and organizational policies. Taking into account that almost one-third of telenurses are advanced practice nurses, the issue of autonomy being in the forefront is logical.

Typically, telenurses are the only person, or one of only a few, in their organization in the telenursing role, therefore autonomy is inherent in the positinn. A worthy future research topic is whether autonomy is the main cause or incentive for nurses to -seek a telenursing position. Results of autonomy as the highest factor in telenurses' work satisfaction are in agreement with previously published work satisfaction studies, which list autonomy as highly correlated with job satisfaction (Blegen, 1993; Irvine & Evans, 1995; Pierce,

Hazel & Mion, 1996; Seymour & Bischerhof, 1991 ).

The importance of interaction as the second highest component of work satisfaction is of interest. It has been the investigator's experience that many nurses _are resistant to the concept of telenursing because the)' view use of computer and telecommunications technologies as cold, impersonal, or ;'not nursing". Findings of this study indicate that interaction is of great importance to telenurses~ and, indeed it has been this investigator's experience that telemedicine technology facilitates communication and interaction between nurses and patients, as well as patients and physicians.

The finding that professional status is the third most important factor in telenurses' work satisfaction is logical considering the generally high education level of 105 telenurses and their resultant professional achievements. Telenu'tsing may provide a role that is perceived as unique, leading edge and of professional challenge; Also, the telenursing role poses opportunity for multiple functions, allowing nurses to be involved in research, publishing, speaking, etc. as well as telenursing.

Task requirements are the fourth most important factor relating to telenurses' work satisfaction. It is reported in the work satisfaction literature that monotony, task routinization, task significance and task identity all contribute to lack of or increase in work satisfaction (Wheeler, 1998; Irvine &'Evans, 1995; Blegen, 1993; Roedel &

Nystrom, 1988). Findings regarding task requirements agree with. the reported literature, and also indicate the importance of the tasks that telenurses are asked to do as a part of their job. The implication for employers aµd telemedicine programs are to wisely and appropriately generate the scope of work for telenurses, and frequently reevaluate and monitor the work requirements with the telenurses.

Also interesting to note is that even though telenurses are paid higher as compared to regular nurses, pay is the next to least important component of their work satisfaction.

This finding suggests that it is other aspects of the role, rather than increased pay, that is the source of their work satisfaction. The findings regarding pay for telenurses appears similar to findings for other groups of m\rses. DeGroot, Burke and George ( 1998) found that even though a significant increase in pay (p < .001) was given to nurses in a Midwest tertiary care hospital, there was no difference in staff work sati_sfaction as a result of the increase. Further data indicates that pay is a source of dissatisfaction for nurses if it is not adequate (DeGroot, Burke & George, 1998; Irvine & Evans, 1995; Seymour &

Buscherhof, 1991 ), but once a level of pay appropriate to the nurse is reached, it may no 106 longer impact work satisfaction. This is a fine, but important distinction, especially for those Human Resources personnel, administrators, vendor organizations, and others who are oriented to the "bottom-line" and believe that pay holds the same importance for nurses as it does for business persons in general. It does not appear to be the case.

Organizational policies are the least important factor related to work satisfaction of telenurses. It is ironic that in many organizations policies and procedures are deemed highly important by adminisJrators and nurses. Findings indicate there may be a discrepancy between the perception of importance by the organization as opposed to perception of importance by the telenurse in relation to organizational policies.

The relationship of work satisfaction to other study variables was identified in

Table 20. Work satisfaction is negatively correlated with role ambiguity (r = - .66, p <

.01), role conflict (r = - .75, p < .01) and role stress (r = - .76, p < .01). Thus, correlations indicate that higher work satisfaction is associated with decreased role stress, role ambiguity and role conflict in telenurses.

The results of Part B of the IWS, when calculated along with Part A, provided the actual Index of Work Satisfaction. Telenurses IWS was 14.77, (range=. 9- 37.1).

Table 27 lists findings from previous studies using the IWS. Nurses who used the IWS in their organizations are listed. The table is a representative sample of the multitude of studies, where typical results for IWS are in the 12-13 range. As is noted, telenurses'

IWS is within the range of other nurses' IWS. The overall IWS for telenurses is in the mid-range of work satisfaction, and, although slightly higher than most studies, by no means indicates that telenurses are more satisfied than other nurses. 107

Table 27

IWS Scores of Selected Studies of Nurses

N Year of Study IWS Score

Telenursing Role Study 196 2000 · 14.77

211-bed Texas Hospital* 62 1992 13.7

55-bed Nebraska hospital* 68 1993 12.4

378-bed New York hospital* 254 1994 12.96

600-bed Ohio hospital* 134 '1992 12.3

40-bed long term care unit* 118 1994 12.75

Denver community hospital* 83 -- 13.3

Arizona hospital* 145 -- 12.66

Northern Michigan rural hospitals* 126 -- 15.94 .. *Note. From Nurses and Work Sat1sfact1on. An Index for Measurement, 2 na Ed1t10n.,_ by

P. L. Stamps, 1997, Chicago: Health Administration Press.

The findings of telenurses as being mostly satisfied, but not highly satisfied, with telenursing is also validated by the Quartile scores of Part B of the IWS. As depicted in

Table 17, 67.9 % of telenurses (N = 133), had scores in the Third Quartile of the IWS.

This translates into the majority of nurses being moderately satisfied with their telenursing positions, but not highly satisfied. These findings provide a caution for those nurses who b~lieve that they will achieve high work satisfaction from a new nursing role such as telenursing. The findings suggest that telenursing may be fraught with the same 108

issues and challenges as other nursing positions in relation to work satisfaction, since

telenurses are not more satisfied with their work as a group. Findings of the current study

are in concert with Mottaz (1988), who found that nurses have a fairly low level of work

satisfaction relative to other professional occupations. University faculty, administrative

personnel, elementary school teachers, and clerical workers all had higher work

satisfaction than nurses. Mottaz (1988) found that only policemen and factory workers

had lower levels of job satisfaction than nurses. It appears that the nursing profession

leaders, as con:~irmed by th~ findings of this study, may need to do a "re-look" at the

factors that impact work satisfaction in order to support emerging roles for nurses and to

compete for quality personnel in the job market. Data from previous studies are also

quite dated, therefore there is a need for further research to reassess nursing's work

satisfaction compared to other professional occupations.

Summary of Work Satisfaction

From the current study, it has been suggested that telenurses have moderate work

satisfaction, aligned with other populations of nurses .. Work satisfaction of telenurses is

. negatively associated with role stress, role ambiguity and role conflict, such that lower

work satisfaction is associated with higher role stress, role ambiguity and role conflict.

The factors most important to telenurses' work satisfaction are respectively, autonomy,

interaction, professional status, task requirements, pay and organizational policies. An

important point is that a baseline for work satisfaction for telenurses has been identified.

Future research can monitor the emerging role of telenurses in relation to this variable. 109

Role Strain/Role Stress

Findings of the Telenursing Role Study included measures of role stress, role ambiguity and role conflict for telenurses. The mean component role ambiguity score for telenurses was 2.92 (SD= .99). The mean component role conflict score for telenurses was 3.29 (SD= .93). The mean component role stress score•for telenurses was 3.11 (SD

= .89). The range for the mean components scores was 1 to 7, with 4 as the midpoint.

The lower the role stress, ambiguity or conflict, the closer the score was to 1. The higher the role stress, ambiguity or conflict, the closer the score was to 7. Telenurses have less than midpoint measures of role ambiguity, role conflict and role stress. Table 28 depicts the findings of telenurses' scores as compared to past reported values ofrole ambiguity and role conflict from studies that used of the Rizzo, House and Lirtzmann Role

Questionnaire. As can be seen from Table 28, telenurses have lower reported role conflict than respiratory care directors, hospital nurse executives, U.S. hospital CEO's, and New England nursing faculty. Telenurses have higher reported role ambiguity than respiratory care directors, hospital nurse executives, U.S. hospital CEO's's and clinical nurse specialists from California, Oregon and Washington. The· only known group with higher reported role ambiguity is New England nursing faculty. The overall measure of role stress, reflec~ing the measured roles strain of telenurses, is less for telenurses than for respiratory care directors, hospital nurse executives and New England nursing faculty.

Telenurses do have more reported role stress/role strain than U.S. hospital CEO's.

Findings for telenurses are unexpectedly low regarding role ambiguity and role conflict.

One would expect role ambiguity and role conflict to be higher for nurses in a relatively new role. However, since 83% of telenurses reported being in their telenursing role for 110

Table 28

Comparisons of Studies Measuring Role Stress, Role Ambiguity and Role Conflict of Various Healthcare Groups

Study Type of Sample Scale Role conflict Role ambiguity Role stress (RS)

(RC) mean (RA)mean mean component

component score . component score score

Telenursing Role N = 196; telenurses 7 pt Likert; Higher 3.29 2.92 3.11

Study (2000) in U.S. score=Higher RC,RA,RS SD= .93 SD= .99 SD= .89

Burke, N = 175; Respiratory 7 pt Likert; Higher 3.86 2.64 --

· Tompkins & Care Directors score=Higher RC,RA,RS SD= .97 SD= .93 3.25***

Davis (1991)

Burke & Scalzi N = 74; hospital 7 pt Likert; Higher 4.0 2.7 -- - ( 1988) nurse executives SGOre=Higher RC,RA,RS SEM = .14* SEM = .11* 3.35***

Burke & Scalzi N = 119; hospital 7 pt Likert; Higher 3.4 2.4 --

(1988) CEO's in U.S. score=Higher RC,RA,RS SEM = .077* SEM = .08* 2.9*** 111

Study Type of Sample Scale Role conflict Role ambiguity Role stress (RS)

(RC) mean (RA) mean mean component

Gomponent score component score score

Johnson (1986) N = 138; Clinical 7 pt Likert; Lower -- 5.31 --

Nurse Specialists score=Higher RC,RA,RS 2.69**

from CA, OR & WA

states

Fain (1987) N = 285; nursing 7 pt Likert; Higher 4.07 5.67 --

faculty in New score=Higher RC,RA,RS SD= 1.06 SD= .80 4.87***

England

Note: Dashes md1cate data not reported.

* Standard error of the mean

** Value reversed for purposes of comparison to other studies

* * * Value calculated based on reported RA and RC 112

> 6 months, perhaps their issues related to role conflict and ambiguity had resolved.

Also, since telenurses reported internction as the second highest factor related to their work satisfaction, it is possible th~t favorable interaction in their work setting contributes to low role conflict and role ambiguity. Interaction as related to good communication of expectations, feedback and favorable work environment could contribute ·to lower role stress. Data for comparison of telenurses to other nurses is limited due to the age of reported studies and limited use of the Rizzo, House and Lirtzmann Role Questionnaire to measure role stress and its components in nurse samples. An important point is that a baseline for role stress, role ambiguity and role Gonflict for t~lenurses has been identified.

Future research can monitor the emerging role of telenurses in relation to these variables.

Relationship between Role Set and Role Strain/Role Stress

The hypotheses tested in the Telenursing Role Study provided illumination regarding the relationships between and among the variables association with the role set

(age, highest level of education, number of telenursing functions, work satisfaction, years nursing experience, telenursing experience) and between role strain/role stress and its components (role ambiguity and role conflict). The finding that work satisfaction is inversely correlated with role stress, role conflict and role ambiguity for telenurses is also consistent with reported findings in the literature (Tuck, 1997; Burke, Tompkins &

Davis, 1991 ~ Burke & Scalzi~ 1988; Brief, Aldag, VanSell & Malone, 1970). In all of the cited studies, work satisfaction and role stress are significantly and negatively associated.

Repetition of results from studies over a 30-year period marrying work satisfaction and role stress in nursing suggested that interventional studies, rather than descriptive studies, should be undertaken. The basis of the rel~tionship between work satisfaction, and its 113

. resultant role stress and subsequent turnover, burnout and somatic symptoms have been

documented ( Decker & Borgen, 1993; Tyler, Carroll & Cunningham, 1991; Hardy &

Conway, 1988). Studies that monitor the results of strategies specifically geared toward

improving work satisfaction should be undertaken in order to improve the work

satisfaction of nurses.

An interesting finding of the study was that there was no relationship between

years of nursing experience, and role stress or role ambiguity nor telenursing experience

and role stress or role ambiguity. There was also no relationship between number of

telenursing roles and role stress, role ambiguity or role conflict. Hierarchical regression

was conducted to determine if, when controlling for education level, years of nursing

experience and telenursing experience predicted role stress or role ambiguity. When

controlling for education level using hierarchical regression, it was found the highest

level of education in nurses significantly predicted role ambiguity and role stress. Years

nursing experience and telenursing experience did not predict role stress or role

ambiguity. Since education level predicts role stress in telenurses, it may be difficult to

promote higher education in nursing to nurses who are interested in telehealth and

telemedicine. Nutse with higher education could also experience more in~ernally or

externally-induced performance pressure or expectations, resulting in higher role stress.

A future research study could identify the specifics of the causes of role stress in

telenurses with higher education levels.

The results of multiple linear regression identified that work satisfaction and

education level are statistically significant independent predictors of role stress and role

ambiguity. Higher work satisfaction is associated with lower role stress and role 114

ambiguity. Higher education level is associated with higher role stress and higher role

ambiguity. Perhaps nurses with higher education have the expectation ( either internally

or externally influenced) of needing to meet more and various requirements due to their

higher education level. Hierarchical regression revealed that work satisfaction,

education level and role ambiguity are statistically significant independent predictors of

role conflict. Higher role ambiguity is associated with higher role conflict. These

findings, as discussed previously, are consistent with the literature that work satisfaction

and role stress are negatively associated.

_Policy Issues related to Telenursing

In the Telenursing Role Study, the majority of telenurses (73.6%) reported that

they were comfortable with their level of technical co~petence related to use of telemedicine technology, as depicted in Table 24 in Chapter 4. As was also reported,

83% of telenurses had been in their telenursing roles for> 6 months. Logically, level of

competence is expected sine~ even those who are in a new role should have a level of

comfort by the time they have been in the role for more than 6 months. What is of

concern is that when the responses to the two open-ended questions regarding preparation

of telenurses for their telenursing role, and strategies for patient safety in the use of

telemedicine technologies are examined, there is a wide range in the reported strategies.

A brief review of the descriptive responses to the open-ended questions reveals that there

is a lack of standardization in the telenursing role preparation process, as well as the -

patient care process for telehealth-delivered care. Preparation for the role of telenursing

was reported as ranging from "none" to "6 months of precepting with a mentor and

competency checklist", with a variety of strategies in between such as vendor training, 115

on-site visits for training, technical training, and structured orientation programs ranging

from one day to 3 weeks. Most recently, the American Association of Amb_ulatory Care

Nurses informed the nursing community that they would be establishing "Standards of

Care for Telehealth Nurses" (Sharp, Communication, Oct 2000). While a worthy goal, it

appears inappropriate for one subspecialty organization in nursing to unilaterally develop

standards for nurses who practice in over 29 different settings, many of which are not ambulatory care. It is apparent that in the range of answers provided, there is a large disparity in strategies for preparation for the telenursing role and a resultant need for agreement upon a common strategy for all nurses involved in the telenursing role, regardless of subspecialty.

In pa;allel, the need for patient safety strategies related to informed consent, telemedicine equipment safety, infection control, electrical safety standards, and thorough knowledge and training in use of telehealth devices.and equipment are key .. Again, there

are no set standards as of yet. It would be unfortunate for the first malpractice case to be

brought against a telenurse in the current practice arena without such standards in place.

The role of telenursing is rapidly e~erging, as has _been documented by the

current study. A minimum of a 600 % increase since 1996 in the population of telenurses

has been revealed by the current study. Telenurses cross all boundaries of specialties,

with particular emphasis on advanced practice nurses. Telenurses practice in nine new

identified practice settings, and have a host of new titles. With the rapid evolution of

digital technologies, digital Internet service via cable TV companies, wireless email via

cell phone, and other leading edge, advanced technologies, the role oftelenursing is.only

expected to grow more rapidly. A recommendation is for nursing leaders of professional 116 nursing organizations to collaborate in response to the challenge of emerging technologies. Leaders should join forces to proactively promote, support and guide the emerging telenursing role.

Leaders should include nursing education .leaders, since educational preparation of nurses for the technical and business aspects of the telenursing role is needed. A post baccalaureate or graduate level preparation in the skills, issues, functions and role of telenurses should be considered. It is quit~ logical that telenursing could be offered as a track or area within existing or planned nursing informatics programs. As Richard (1997) poses "Who is going to prepare the nurses of tomorrow to live in the futuristic setting?

The answer is: the faculty of today" (p. 43 7). Telenursing skills and content could be integrated into the nursing education curriculum. Including telenursing content in such nursing faculty-based programs as The Cure for Technophobia described by Richard

(1997), where common technologies such as distance learning, email, and web development are taught to nursing faculty, and then used by the faculty as part of the education process.

Directions for future research

Action recommendations and several recommendations for further.research have been proposed in the body of the preceding discussion. The paucity of research on the roles of telenur"ses indicates virtually unlimited opportunities for future research. ·The findings of this study have raised questions that warrant further research in a number of specific areas, most notably: 117

1) What are the generalizability of findings of the present study to the entire

population of telenurses in the United States and the population of telenurses

internationally?

2) How cari nursing realign nursing roles to create incentives for achievement of

higher education for nurses, when an increase in role stress is the result of this

achievement?

3) What policy guidelines and standards are useful to the practice and preparation of

telenurses?

4) Do telenurses require a formalized educational program to provide professional

credibility and credentialing in this role?

5) What are the public policy implications of the identified telenursing roles·?

6) What are the patient privacy, healthcare process reengineering and ethical

' implications of the identified roles of telenurses?

7) What databases or tracking mechanisms (i.e. addition to the Division of Nursing

National Nursing Survey) should be added or created to monitor changes in

demographics and roles of telenurses?

Conclusion

The theoretical framework of a selected portion of Role Theory relating to role set and its impact on role strain has been tested with a sample of telenurses from 40 states.

Findings have upheld the theoretical underpinnings of Role Theory, in that elements of role set do describe, impact and predict role strain/role stress of telenurses. The dotted line in the relationship between Role Set and Role Strain was validated. Telenurses do not always experience Role Strain, and in fact, demonstrated a less than moderate Role 118

Stress/strain. The factors that do influence Role Strain in telenurses are present in the

model, specifically highest education level and work satisfaction. This researcher would

not consider modifying the model as initially presented, and considers that the portion of

Role Theory that was tested in this study was indeed validated and upheld.

The Telenursing Role Study served to identify the professional role of telenurses

in the Year 2000, to describe the individual characteristics of those telenurses, to measure

the work satisfaction, the components of work satisfaction, the role stress, role ambiguity

and role conflict of telenurses. Mostly importantly, predictive power of certain role set

characteristics, namely work satisfaction and education level, to predict role stress and role ambiguity has been identified, as well as power of role ambiguity to predict role conflict. Variability in preparation of telenurses for their telenursing role has been documented. Variability in patient safety aspects of telenursing practice has been noted.

The Telenursing Role Study serves as a baseline for nursing practice for the emerging role of telenursing. The role of telenurses has been benchmarked by this study.

Future growth and maturity of the telenursing role can be measured against the findings

of this study. The growth of the role of telenursing is inevitable in the technological

society in which we live. The challenge, posed at the beginning of this study by Porter

O-Grady ( 1999) remains, :: A script for a preferred future for health care is unfolding.

The key question is whether nurses are at the table proactively writing the script or at the . door lamenting the need to write it" (p. 34 ). It is the recommendation and desire of this

investigator that nurses lead the direction of the use of telehealth technology in their own

profession, and that this particular research will provide a small step to do so. 119

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in a health care information system is essential

9. Documentation requirements for telehealth services must be developed that ensure

documentation of each client encounter with recommendations and treatments,

communication with other health care providers as appropriate and adequate

protections for client confidentiality.

10. All clients directly involved in a telehealth encounter must be informed about the

process, the attendant risks and benefits, and their rights and responsibilities. Clients

must provide adequate informed consent.

11. The safety of clients and practitioners must be ensured. Safe hardware and software,

combined with demonstrated user competency, are essential components of safe

telehealth practice.

12. A systematic and comprehensive research agenda must be developed and supported

by government agencies and health care professions for the ongoing assessment of

telehealth services.

Note: from Core Principles on Telehealth~ by the American Nurses Association, 1998, pp. ii-iii, Washington DC: American Nurses Publishing. Appendix B NATIONAL SAMPLE SURVEY OF REGISTERED NURSES

Instructions Everyone receiving this questionnaire is requested to complete it. This includes persons who are: - Retired - Not presently working - Employed but not as an RN - Employed as an RN

If you receive more than one questionnaire, please complete only one copy and return it and all extra copies of tbe questionnaire to the Research Triangle Institute. Do not give extra questionnaires to another nurse to complete. Please read and carefully follow all instructions and answer all questions unless otherwise instructed. Many questions request you to .. Circle only one number." Please circle the number in front of the correct response and not the response. EXAMPLE: The correct way to answer a question is to (Circle only one number): @circle the number in front of the response. 2. Circle the response. Please return your completed questionr:,aire in the enclosed postage-paid envelope at your earliest convenience.

PUBLIC BURDEN STATEMENT Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or ·any other aspect of this collection of information, including suggestions for reducing this burden, to DHHS R.eports Clearance Officer; Paperwork Reduction Project (0915-0192); Room 531-H; Hubert H. Humphrey Bldg., 200 Independence Ave., SW; Washington, DC 20201.

102 l;vl IUN A: EOUCATIUN ------ IRCLE THE APPROPRIATE NUMBER CORRESPONDING TO YOUR ANSWER IN EACH QUESTION OR SUPPLY EQUESTED INFORMATION .

l. In what type of~ nursing education program .. · . 3a. BEFORE STARTING THE BASIC NURSING EDUCA were you prepared to become a registered nurs;:? TION PROGRAM described in Question 1, were (Circle only one number) you ever licensed to practice as a licensed practi cal or vocational nurse? 1. Diploma 2. Associate Degree 1. Yes 3. Baccalaureate Degree 2. No 4. Master's Degree 5. Doctorate (N.D.) 3b. BEFORE STARTING THE BASIC NURSING EDUCA TION PROGRAM described in Question 1, did you receive a degree from any other formal post tJ. In what month and year did you graduate from this secondary education program? pmgram? · 1. Yes 2. No ---+ (Skip to 4a) Month Year f c. In which State or foreign country was this basic 3c. What was the highest degree you received before nursing education program located? starting your basic nursing education program? (Circle only one number) r 1. Associate Degree !; For office use 2. Baccalaureate Degree .'• 3. Master's Degree 4. Doctorate Degree

a. IMMEDIATELY PRIOR TO STARTING THE BASIC 3d. Was this degree in·a health-related field? NURSING EDUCATION PROGRAM described in Question 1, were you employed in a health occu 1. Yes ~(Skip to 4a) pation?

-1. Yes 2. No--. (Skip to 3a) 3e. What was your major field of study? (Circle only one number) b. Were you employed as a (Circle only one number) 1. Biological .or Physical Science 1. Nursing Aide 2. Business or Management 2. Licensed PracticalNocational Nurse 3. Education 3. Other (Specify)._,---______4. Liberal Arts 5. Social Science 6. Other (Specify)______

----llllli~· .. ,.._ 103 4a. SINCE GRADUATING FROM THE BASIC NURSING EDUCATION PROGRAM YOU DESCRIBED IN QUESTION 1, have you earned any additional degrees?

1. Yes f 2. No --.(Skip to 6) 4b. For each academic degree you have received since graduation from your basic nursing education program, please indicate (i) the type of degree; (ii) whether or not the degree is related to your nursing career; and (iii) the year the degree was received.

(i) (ii) (iii) ------+------1------1Received Related to Year degree nursing career in which (CHECK ALL (CIRCLE you received Type of Degree THAT APPLY) YES OR NO) your degree

Associate degree in nursing 19

Baccalaureate in nursing

...... ~ ...... ~--· .. ··.···-··~: .... =-·--.,.,..,...--._-:*~~~ .... ·.. ·~-•,--· Baccalaureate in another fie.Id · _' · 19_·._ . . ' .. .,. ... ~ . . ••• r ,. ... ., .,.,,•-... - .... '••--~•-- :,,.,• •••• ...__.. ,_,, ••••••--

Master's in nursing

Masters in another field 19

Doctorate in nursing 19 . ,. .. ,,. ,.. ,.. _, ... .,. ·-•-·6--- --...... Doctorate in another field 19 __

IF YOU HA VE LISTED A MASTER'S OR DOCTORATE DEGREE IN QUESTION 4b, CONTINUE WITH QUESTION 5, OTHERWISE SKIP TO QUESTION 5.

5. What was the one primary focus of your master's and/or doctorate degree(s)? (Circle only one number for each relevant degree)

Sa. Master's Sb. Doctorate

1. Clinical Practice 1. Clinical Practice 2. Education 2. Education 3. Supervision/Administration 3. Supervision/ Administration 4. Other (Specify) 4. Research 5. Other (Specify)

104 , . . 6a. SINCE GRADUATING FROM THE BASIC NURSING EDUCATION PROGRAM YOU DESCRIBED IN QUESTION 1, have you completed a formal educational program preparing you for advanced practice as a clinical nurse . specialist, nurse anesthetist, nurse-midwife, or nurse practitioner? ' ~- r1. Yes 2. No ---+ (Skip to la) A B C D Clinical Nurse Nurse Nurse- Nurse Specialist Anesthetist Midwife Practitioner &b. Please check the advanced practice nurse category(ies) .□· for which you have been prepared. □ □ □ _For items 6c-6h, the first column on the left contains the description of the response items for each question. In .the column for the advanced practice category(ies) which you checked, please circle the number corresponding to the number of the appropriate response item. 6c. Length of Program (Please circle appropriate response) 1. Less than 3 months 1 1 1 1 2. 3 through 8 months 2 2 2 2 3. 9 months or more .3 3 3 3 6d. Award Received (Please circl~.appropriate response) 1. Certificate 1 1 1 1 2. Master's Degree 2 2 2 2 I 3. Post-Master's Certificate 3 3 3 3 4. Other Degree 4 4 4 4 (Specify) (Specify) (Specify) (Specify) (Specify in appropriate column) Se. Specialty Studied (Please circle appropriate response} 1. Adult health/medical surgical 1 1 1 1 2. Anesthesia 2 2 2 2 3. Community health/public health 3 3 3 3 4. Critical care 4 4 4 4 5. Family 5 5 5 5 6. Geriatric/gerontology 6 6 6 6 7. Maternal-child health 7 7 7 7 8. Neonatal 8 8 8 8 9. Nurse-midwifery 9 9 9 9 10. Obstetric/gynecology 10 10 10 10 11. Occupational health 11 11 11 11 12. Oncology 12 12 12 12 13. Pediatric 13 13 13 13 14. Psychiatric/mental health 14 14 14 14 15. Rehabilitation 15 15 15 15 16. School health 16 16 16 16 17. Women's health 17 17 17 17 18. Other 18 18 18 18 (Specify) (Specify) (Specify) I (Specify) (Specify in appropriate column) l I !

(continued) 105 (question 6 continued from page 3)

A B C D Clinical Nurse Nurse Nurse• Nurse Specialist Anesthetist Midwife Practitioner Sf. Currently Certified by a National Certifying Body (Please circle appropriate response) 1. Yes 1 1 1 1 2. No 2 2 2 2 (If you do not have~ certifications, go ta la) 6g. National Certifying Body (Please circle appropriate response) 1. American Academy of Nurse Practitioners 1 1 , 1 2. American Association of Nurse Anesthetists 2· 2 2 2 3. American College of Nurse-Midwives 3 3 3 3 4. American Nurses Credentialing Center (ANCC) 4 4 4 4 5. National Certification Board of Pediat~ic Nurse Practitioners and ·Nurses (NCPNP7N) 5 ·5 5 5 6. National Certification Corporation for thei Obstetric, Gynecologic, and Neonat~I Nursing Specialties (NCC) 6 6 6 6 7. Other 7 7 7 7 I (Specify) -(~pec,ify) (Specify) (Specify) (Specify in appropriate column) I 6h. Type of Certification. (Please circle appropriate response) CS - clinical specialist NP - nurse practitioner 1. Adult NP 1 1 1 1 2. Certified registered nurse anesthetist (CANA) 2 2 2 2 3. Certified nurse-midwife (CNM) 3 3 3 3

4. Community Health CS 4 4 ; 4 4 5. F~mily NP 5 5 5 5 6. Gerontological CS 6 6 6 6 7. Gerontological NP 7 . 7 7 7 8. Medical-surgical CS 8 8 8 8 9. Neonatal NP 9 9 9 9 10. Pediatric NP 10 10 10 10 11. Psychiatric & mental health CS - Adult 11 11 11 11 12. Psychiatric & mental health CS - Child

& Adolescent t 12 12 12 12 ! ! \ 13. School NP 13 13 13 13 14. Women'~ Health Care NP (Ob-Gyn NP) 14 14 14 14 ! 15. Other ! 15 I 15 15 15 (Specify) (Specify) (Specify) (Specify) (Specify in appropriate column)

106 7a. Are you currently enrolled In a formal education SECTION B: EMPLOYMENT STATUS program leading to an academic degree with a nursing or nursing-related maJor? 8. Were you employed in nursing as of March 20, 1. Yes 1996? (SEE NOTE BELOW) 2. No ---.(Skip to 8) NOTE: Employment also includes: being on a temporary leave of absence from your f nursing position; on vacation; on sick leave; 7b. Are you considered a full-time or part-time stu or a nurse doing private duty or working dent? through a temporary employment service and not on a case at the moment. 1. Full-time student 2. Part-time student 1. Yes _ 2. No ___. (Skip to 20) 7c. What degree are you currently working toward in this program? r (Circle only one number) Questions 9 through 18 refer to your principal employ 1. Associate Degree ment setting and nursing position as of March 20, 1996. If you held more than one position in nursing, provide 2. Baccalaureate your answers in terms of what you consider your 3. Master's principal nursing position during your regular work year. 4. Doctorate For example, if you hold more than one nursing position 5. Other (Specify) (e.g., day/night or winter/summer), consider the princi pal nursing position as the one at which you spend the greater amount of tjme.

7d. How are your tuition and fees being financed? 9. What was the location of employment on March (Circle all that apply) - 20, 1996? (SEE NOTE BELOW) NOTE: If you were not employed in a fixed location 1. Personal and family resources (e.g., you were a private duty nurse or 2. Employer tuition reimbursement plan (including worked through a temporary employment Veterans Administration employer·tuition plan) service), consider the area where you~ 3. Federal traineeship, scholarship;. or grant most of your working time as your location of employment. · · 4. Federally assisted loan 5. State or local government loan or scholarship City: ______6. Non-government scholarship, loan, or grant 7. University teaching or research fellowship C~unty: ______8. Other resources (Specify) State (or country if not U.S.A.): ·

ZIP Code:

10. In your principal nursing position are you: (Circle only one number) 1 . An employee of the facility for which you are working? 2. Employed through a temporary employment service agency? 3. Self employed?

107 11. Which one of the following settings best describes the TYPE OF SETTING in which you were working on ,.. March 20, 1996 in your principal nursing position? (If your employment is that of a private duty nurse or you work through a temporary employment service, CIRCLE THE ONE SETTING in which you spend most of your working time.) CIRCLE ONLY ONE NUMBER ON PAGE

Hospital (Exclude nursing home units and all off-site School Health Service units of hospitals but include all on-site clinics and other services of the hospitals) 51 O Public school system 520 Private or parochial elementary or secondary 11 0 Non-Federal, short-term hospital, except psychiatric school (for example, acute care hospital) 530 College or university 120 Non-Federal, long-term hospital, except psychiatric 540 Other (Specify) ______130 Non-Federal psychiatric hospital 140 Federal Government hospifal Occupational Health Board of Nursing 420 Visiting nurse service (VNS/NA) 930 Nursing or health professional membership 425 Other home health agency (non-hospital based) association 430 Community mental health facility (including 940 Health planning agency freestanding psychiatric outpatient clinics) 950 Prison or jail 435 Community/neighborhood health center 960 Insurance company (review claims) 440 Planned Parenthood/family planning center 970 Other (Specify/------·- 445 Day care·center 450 Rural health care center 455 Retirement community center 460 Hospice 465 Other (Specify) ______

108 12. Which one of the following titles best corresponds 13b. Does your prlnclpal nursing position Involve to the position title for your principal nursing direct patient care In a hospital setting during a position? usual work week? (Circle only one numbe~) 1. Yes 1. Administrator of facility/agency or assistant 2. No---. (Skip to 15) 2. Administrator of nursing or assistant (e.g., vice president for n·ursing, diredor/assistant director of r nursing service) 3. Case manager 14a. In what type of unit do you work more than half 4. Certified nurse anesthetist (CANA) of your patient care time during a usual work 5. Charge nurse week? (Circle only one number) 6. Clinical nurse specialist 7. Consultant 1. Intensive care bed unit 8. Dean, director, or assistant/associate director of 2. Step-down, transitional nursing education bed unit 9. Discharge planner 3. General/specialty (Go to 14b) 10. Head nurse or assistant head nurse ( other than intensive care 11. ·Infection control nurse or step-down) bed unit 12. In-service education director 4. Outpatient department 13. Instructor 14. Insurance reviewer 5. Operating room 15. Nurse clinician 16. Nurse coordinator 6. Post anesthesia 17. Nurse manager recovery unit 18. Nurse-midwife 7. Labor/deli•,gry room 19. Nurse practitioner 8. Emergency department 20. Outcomes'manager 21. Patient care coordinator 9. Home health care -. (Skip to 15) 22. Private duty nurse 10. Hospice unit 23. Professor or assistant/associate professor 11. Other specific area (Specify) 24. Public health nurse 25. Quality assurance nurse 26. Researcher 12. No specific assigned 27. School nurse type of area 2B. Staff nurse 29. Supervisor or assistant supervisor 30. Team leader 14b. What type of patients are primarily treated in the 31. No position title hospital unit in which you work? 32. Other (Specify) (Circle only one number) 1 . Chronic care 2. Coronary care 13a. For your principal nursing position, approxi 3. Neurological ...., mately what percentage of your time is spent in the following areas during a usual work week? 4.Newbom Please make sure the total equals 100%. 5. Obstetrics/gynecologic 6. Orthopedic Percent 7. ··pediatric . A. Administration ...... ___% 8. Psychiatric B. Consultation with agencies and/or professionals ...... · % 9. Rehabilitation 10. Basic medical/surgi1::al (or specialty areas Direct patient care, not including C. not specified above) staff supervision ...... % 11. Work in multiple units not specifically specialized D. Research ...... %

E. Supervision ...... % I F. Teaching nursing or other students in health care occupations (include all class preparation time) ...... _. .. %

G. Other (Specify) ...... %

TOTAL MUST EQUAL ...... -1.Q.Q_ % 109 15. If you were EMPLOYED BY AN INSTITUTION OR 19a. Do you hold more than one position in AGENCY and were scheduled to work for the _nursing for pay? normal "full" work week throughout the normal work year, as defined by the agency, circle cat 1. Yes egory "1 ". If you worked less than the normal 2. No__. (Skip to 23a) "full" work week and/or less than the normal work r year, circle either "2" or "3", whichever is appli cable. 19b. In your other nursing position(s) for pay, do you: - (Circle all that apply) · If you were SELF-EMPLOYED and are·generally available for work throughout the year during what 1. Work as an employee of the facility? would constitute a normal "full" work week, circle 2. Work through a temporary employment service category "1 ". If you restrict yourself to work only agency? a segment of the work week and/or year, circle either "2" or "3", whichever is applicable. 3. Work in a self-employed capacity? Do you: 19c. What type of work do you do in your other 1. Work an entire calendar year or school or academic - nursing position(s) for pay? (Circle all that apply) year on a full-time basis? 1. Home health 2. Work an entire calendar year or school or academic year on a part-time basis? 2. Hospital staff 3. Nursing home st~ff 3. Work only part of the normal work year on either a 4. Private duty nursing full- or part-time basis? 5. Teaching 6. Patient consultation ~ Approxima,tely how many hours are you usually 7. Consultation scheduled to work during a normal work week 8. Research (as defined by the agency} at your principal nursing position? If you do not work on a routine 9. Other (Specify) schedule, how many hours do you usually work during a week at your principal nursing position? _____ hours 19d. What is the average number of hours per week 16b. How many hours did you actually work during - you spend in your other nursing position(s)? the week beginning on March 18, 1996? (Include Please also provide an estimate of the total overtime but exclude holidays, sick leave, number of weeks in 1996 that you will spend in vacation time not worked.) this other nursing position(s). Note: If you are self-employed or do not work a routine schedule, _____hours report the estimated number of weeks you expect to work in 1996. 17. Approximately how many weeks are there in your Average hours per week ______normal work year for your principal nursing position (include in your work year paid vacation, Weeks in 1996 etc.) Note: If you are self-employed or do not work a routine schedule, report the estimated number of weeks you expect to work in 1996. , 19e. How many hours did you actually work in your _____ weeks other nursing position during the week beginning on March 18, 1996? If you did not work in your 18. PLEASE SPECIFY THE ANNUAL EARNINGS FOR other nursing position(s) during that week, .... YOUR PRINCIPAL POSITION ONLY. please enter "O" . What is your gross annual salary before deduc ____hours tions for taxes, social security, etc.? If you do not have a set annual salary (for example, you are part-time, private duty, or self-employed), provide an estimate of your annual earnings for 1996. 19f. For your other nursing position(s), please provide an estimate of the total annual earnings for 1996. Note: If you are self-employed or do not Annual earnings: S_____ / year work a routine schedule, report the estimated amount you expect .o earn in 1996.

Estimated annual earnings $ ______/ year

SKIP TO QUESTION 23a

110 SECTION C: EMPLOYMENT STATUS OF 22b. How many weeks have you been actively seeking ANS NOT EMPLOYED IN NURSING a nursing position? 1 . Less than a week 20. How long has it been since you last worked for 2. One week or more pay as a registered nurse? . Indicate number of weeks ____ 1. Never worked as a registered nurse 2. Less than a year 22c. Are. you looking for a full-time or part-time 3. One year or more _nursing position? Indicate number of years _____ 1. Full-time 2. Part-time 21 a. Are you employed in an occupation other than 3. Either nursing?

1. Yes SECTION D: PRIOR NURSING 2. No (Skip to 22a) EMPLOYMENT STATUS

23a. Were you employed in nursing one year ago on [ Are yo=sidered a full-time or part-time March 20, 1995? employee? 1. Yes_. 1. Full-time 2. No (Skip to 24) 2. Part-time r 23b. In your principal nursing position at that time, if 21 c. Are you employed in a health-related agency or you were EMPLOYED BY AN INSTITUTION OR position? AGENCY and were scheduled to work for the normal "full" work week throughout the normal 1. Yes work year, as defined by the agency, circle 2. No category "1 ''.. If you worked less than the normal "work year, circle either "2" or "3", whichever is 21 d. What is the reason(s) you are not working in a applicable. nursing position? .. If you were SELF-EMPLPYED and were generally (Circle all that apply) available for work throughout the year during what would constitute a normal "full'' work week, circle 1. Difficult to find a nursing position category "1 ". If you restricted yourself to work only 2. Hours more convenient in other position a segment of the work week and/or year, circle 3. Better salaries available in current type of either ·"2" or "3", whichever is applicable. position In your nursing position of one year ago did you: 4. Concern about safety in health care environment 1. Work an entire calendar year or school or 5. Inability to practice nursing on a professional academic year on a full-time basis? level 2. Work an entire calendar year or school or 6. Find current position more rewarding academic year on a part-time basis? professionally 3. Work only part of the normal work year on either 7. My nursing skills are out-of-date a full- or part-time basis? 8. Other (Specify)

23c. What was the location of your principal position on March 20, 1995? If you were not employed in a 22a. Are you actively seeking employment as a fixed location (e.g., you were a private duty nurse), registered nurse (e.g., making inquiries as to consider the area where you spent most of your availability of employment, answering advertise working time as your location of employment. ments, having interviews)? City: (Skip to 23a) County: ______

State (or country if not U.S.A.):

ZIP Code:

111 23d. · Which one of the following settings best describes the type of employment setting of your principal position in which you worked a year ago on March 20, 1995? CIRCLE ONLY ONE NUMBER ON PAGE

Hospital (Exclude nursing home uni~s an~ _all off-site School Health Service units of hospitals but include all on-site clinics and other 51 O Public school system services of the hospitals) 520 Private or parochial elementary or secondary 11 O Non-Federal, short-term hospital, except school psychiatric (for example, acute care hospital) 530 College or university 120 Non-Federal, long-term hospital, except 540 Other (Specify) psychiatric 130 Non-Federal psychiatric hospital _ 140 Federal Government hospital Occupational Health (Employee Health Service) 150 Other type of hospital (Specify) 61 O Private Industry 620 Governm~nt

Nursing Home/Extended Care Facility 630 Other (Specify) 21 O Nursing home unit in hospital 220 Other nursing home Ambulatory Care Setting 230 Facility for mentally retarded 710 Solo practice (physician) 240 Other ty·pe of extended care facility (Specify) 715 s'olo practice (nurse) 720 Partnership (physicians)

Nursing Education Program 725 Partnership (nurses) 310 LPN/L VN program 730 Group practice (physicians) 320 Diploma program (RN) 735 Group practice (nurses) 330 Associate degree program (RN)' 740 Partnership or group practice (mixed group of professionals) 340 Baccalaureate and/or higher degree nursing program 750 Freestanding clinic (physicians) 350 Other program (Specify) 755 Freestanding clinic (nurses) 760 Ambulatory surgical center (non-hospital based)

Public Health/Community Health Setting 770 Dental practice 400 Official State Health Department 780 Health Maintenance Organization (HMO) 405 Official State Mental Health Agency 790 Other (Specify) 41 o Official City or County Health Department 415 Combination (official/voluntary) nursing service Other 420 Visiting nurse service (VNS/NA) 91 O Central or regional Federal agency 425 Other home health agency (non-hospital based} 920 State Board of Nursing 430 Community mental health facility (including freestanding psychiatric outpatient clinics} 930 Nursing or health professional membership association 435 Community/neighborhood health center 940 Health planning agency 440 Planned Parenthood/family planning center 950 Prison or jail 445 Day care center 960 Insurance c~mpany (review claims) 450 Rural health care center 970 Other (Specify) 455 Retirement community center 460 Hospice 465 Other (Specify) ______

112 23e. One year ago, on March 20, 1995, were you 28. How old are the children who live at home with employed by your current employer? - you? (include all children who live with you 6 months of the year or more) 1. Yes, in same position as current one (Skip to 24) (Circle only one number) 2. Yes, in different position 1. No children at home 3. No f 2. All less than 6 years old

231. If answer to above question is 2 or 3, provide the 3. All 6 years old or older principal reason for the change 4. Some less than 6 and some 6 or over (Circle only one number)

1. Received a promotion 29. Which category best describes how much income 2. Was laid off -you or, if you are currently married, you and your 3. Employer shifted positions due to reorganization spouse together anticipate earning during 1996? (Include your annual employment earnings before 4. Was more interested in another position{job deductions, your spouse's annual employment 5. Offered better pay/benefits earnings before deductions, if married; and all 6. Reiocated to a different geographic area other income, including alimony, child support, dividends, royalties, interest, social security, 7. Employer reduced the number of registered retirement, etc.) nurses on staff · 8. Better opportunity to do the kind of nursing that 1. $15,000 or less I like 2. 15,001 to 25,000 9. Employer planned to reduce salaries/benefits 3. 25,001 to 35,000 10. Changes in organization/unit made work more 4. 35,001 to 50,000 stressful 5. 50,001 to 75,000 11. Other (Specify) 6. 75,001 to 100,000 7. 100,001 to 150,000 8. More than $150,000

SECTION E: GENERAL INFORMATION~ 30. Where were you living on March 20, 1996? We would like you to answer some additional questions for. use in the statistical interpretation of your responses. City: 24. What is your sex? County: ______

1. Female State (or country, if not U.S.A.) 2. Male

25. What is your year of birth? - ZIP Code:

31 a. Did you reside in the same city on March 20, 26. What is your racial/ethnic background? 1996 and on March 20 1995? - (Circle only one number) 1 1 1. Yes~ (Skip to 32) 1. Hispanic 2. American Indian or Alaskan Native 12. No 3. Asian or Pacific Islander .., 4. Black, not of Hispanic origin 31 b. Where were you living on March 20, 1995? 5. White, not of Hispanic origin City: 27. What is your current marital status? County: ______- 1. Now married State (or country, if ncit U.S.A.) 2. Widowed, divorced, separated 3. Never married

ZiP Code: 32. Please indicate below when and where you were issued your first U.S. license (by one of the 50 States or the District of Columbia) to practice as a registered nurse.

32a. In what year did you receive your first U.S. 32b. What State issued you your first. license? license? (Circle appropriate year) 1996 1993 1990 1987 1984 1981 For office use 1995 1992 1989 1986 1983 1980 OJ 1994 1991 1988 1985 1982 Prior to 1980 Please note that the following question (Q.33) is very important in order to determine how many nurses in the country your answers may represent. As soon as this determination is calculated and the proper statistical code assigned, your name(s) and registration number(s) will no longer be associated with the other information in this questionnaire.

33. In the space provided below, please provide the following information:

Column A - List all states in which you are now actively licensed.

Column B - List the permanent number of your certificate of registiation or license for each state you listed.

Column C - List your complete name as it appears on each license, or circle "s~me" if it is the same as on questionnaire label.

Permanent ( A. number on C. State certificate of Name as it appears on the registratio_n FOR OFFICE USE of registration or license, or circle "same" at right of Licensure or license name line if same as o.n address label on back cover 0. E.

Last First Ml

1. same

2. same

3. same

4. same

5. same

6. same

7. same

8. same

9. same

10. same

114 .-· ~ .. :> ~,J:~1fi!~\1·:~ :, -~.· >··; :· . : AS SOON AS YOUR. ANSWERS HAVE BEEN 36. Are your name and address, as they appear on the PRocesseo, THIS INFORMATION WILL NO .,....label of this questionnaire, correct? LONGER BE ASSOCIATED WITH ANY OTH.ER (Circle only one number) INFORMATION ON THIS QUESTIONNAIRE. 1. Yes 2. No (Please indicate co"ect name and address) 34. If we should need to contact you regarding the - questionnaire, what Is the best time to call? Last First Ml

Box number or street address ______35. What Is your telephone number? .______..__.I-I-- ,.....__.._

Area Code Number City ______

State ____ ZIP Code ______

37. Use this space for any special comments you wish to make about any of your responses to the questions or any additional remarks you may have. ·

THANK YOU VERY MUCH FOR YOUR HELP. PLEASE RETURN THE QUESTIONNAIRE IN THE ENCLOSED SELF-ADDRESSED ENVELOPE.

IF YOU HA VE RECEIVED MORE THAN ONE COPY OF THE QUESTIONNAIRE, PLEASE RETURN THE EXTRA COPY(IES) ALONG WITH THE COl\iIPLETED QUESTIONNAIRE. I

Research Triangle Institute ATTN: Ilona Johnson P.O. Box 12194 Research Triangle Park, NC 27709-2194 115 Appendix C . [NDEX OF WORK SATISFACTION

Part A (Paired Comparisons)

Listed and briefly defined on this sheet of paper are six terms or factors that are in volved in how people feel about their work situation. Each factor has something to do with "work satisfaction." We are interested in determining which of these is most important to you in relation to the others. Please carefully read the definitions for each factor as given below: 1. Pay-dollar remuneration and fringe be~efits received for work done 2. Autonomy-amount of job-rela~d independence, initiative, and freedom, either permitted or required in daily work activities 3. Task Requirements-tasks or activities that must be done as a regular part of the job 4. Organizational Policie~-management policies and procedures put forward by the hospital and nursing administration of this hospital 5. Interaction-opportunities presented for both formal and informal social and professional contact during working hours 6. Professional Status-overall importance or significance felt about your job, both in your view and in the view of others Scoring. These factors are presented in pairs ori the questionnaire that you have been given. Only 15 pairs are presented: this is every set of combinations. No pair is repeated or reversed. For each pair of terms, decide which one is more important for your job satisfaction or morale. Please indicate your choice by a check on the line in front of it. For example: If you felt that Pay (as defined above) is more important than Autonomy (as defined above), check the line before Pay. __ Pay or __ Autonomy We realize it will be difficult to make choices in some cases. However, please· do try to select the factor which is more important to you. Please make an effort to answer every item; do not change any of your answers.

1. __ Professional Status or __ Organizational Policies 2._Pay or __ Task Requirements 3. __ Organizational Policies or __ Interaction 4. __ Task Requirements or __ Organizational Policies 5. __ Professional Status or __ Task Requirements 6._Pay or __ Autonomy 7. __ Professional Status or __ Interaction 8. __ Professional Status or __ Autonomy 9. __ Interaction or __ Task.Requirements 10. __ Interaction or _Pay 11. _ Autonomy or __ Task Requirements 12. __ Organizational Policies or __ Autonomy 13._Pay or __ Professional Status ;14. __ Interaction or __ Autonomy 115. __ Organizational Policies or __ Pay Usage 61

Part B (Attitude Questionnaire)

,The following items represent statements about satisfaction with your occupation. Please respond to each item. It may be very .difficult to fit your responses into the seven cate gories; in that case, select the category that comes closest to your response to the state ment. It is very important that you give your honest opinion. Please do not go back and change any of your answers. Instructions for Scoring Please circle the .number that most closely indicates how you feel about each statement. The left set of numbers indicates degrees of disagreement. The right set of numbers indicates degrees of agreement. The center number means "unde cided." Please use it· as little as possible. For example, if you strongly disagree with the first item, circle 1; if you moderately agree with the first statement, you would circle 6. Remember: The more strongly you feel about the statement, the further from the cen ter you should circle, with disagreement to the left and agreement to the right.

Disagree Agree

1. My present salary is satisfactory. 1 2 3 4 5 6 7 2. Most people do not sufficiently appreciate the 1 2 3 4 5 6 7 importance of nursing care to hospital patients. 3. The nursing personnel oil my service do not hesitate to 2 3 4 5 6 7 pitch ·in and help one another out when things get in a rush. 4. There is too much clerical and "paperwork" required of 2 3 4 5 6 7 nursing personnel in this hospital. 5. The nursing staff has sufficient control over scheduling 2 3 4 5 6 7 their own w_ork shifts in my hospital. 6. Physicians in general cooperate with nursing staff on 2 3 4 5 6 7 my unit. _ 7. I feel that I am supervised more closely than is 2 3 4 5 6 7 necessary. 8. Excluding myself, it is my impression that a lot of 2 3 4 5 6 7 nursing personnel at this hospital are dissatisfied with their pay. 9. Nursing is a long way from being recognized as a 2 3 4 5 6 7 profession. 10. New employees are not quickl,y made to "feel at home" 2 3 4 5 6 7 on my unit. 11. I think I could do a better job if I did not have so much 2 3 4 5 6 to do all the time. ' 12. There is a great gap between 'the administration of this 2 3 4 5 6 7 hospital and the daily problems of the nursing service. 13. I feel I have sufficient input into the program of care 2 3 4 5 6 7 for each of my patients. 14. Considering what is expected of nursing service 2 3 4 5 6 7 personnel at this hospital, the pay we get is reasonable. 15. There is no doubt whatever in my mind that what I do 2 3 4 5 6 7 on my job is really important. 16. There is a good deal of teamwork and cooperation 2 3 4 5 6 7 between various levels of nursing personnel on my service. 62 Nurses and Work Satisfaction

Disagree Agree

17. I have too much responsibility and not enough 1 2 3 4 5 6 7 authority. 18. There are not enough opportunities for advancement of 1 2 3 4 5 6 7 nursing personnel at this hospital. 19. There is a lot of teamwork between nurses and doctors 1 2 3 4 5 6 7 on my own unit. 20. On my service, my supervisors make all the decisions. I 1 2 3 4 5 6 7 have little direct control over my own work. 21. The present rate of increase in pay for nursing service 1 2 3 4 5 6 7 personnel at this hospital is not satisfactory. 22. I am satisfied with the types o,f activities that I do on 1 2 3 4 5 6 7 my job. 23. The nursing personnel on my service are not as friendly 1 2 3 4 5 6 7 and outgoing as I would like. 24. I have plenty of time and opportunity to discuss 1 2 3 4 5_ 6 7 patient care problems with other nursing service personnel. 25. There is ample opportunity for nursing staff to 1 2 3 4 5 6 7 participate in the administrative decision-making process. 26. A great deal of independence is permitted, if not 1 2 3 4 5 6 7 required, of me. 27. What I do on my job does not add up to anything really 1 2 3 4 5 6 7 significant. 28. There is a lot of "rank consciousness" on my unit. 1 2 3 4 5 6 7 Nursing personnel seldom mingle with others of lower ranks. 29. I have sufficient time for direct patient care. 1 2 3 4 5 6 7 30. I am sometimes frustrated because all of my activities 1 2 3 4 5 6 7 seem programmed for me. 31. I am sometimes required to do things on my job that 1 2 3 4 5 6 7 are against my better professional nursing judgment. 32. From what I hear from and about nursing service 1 2 3 4 5 6 7 personnel at other hospitals, we at this hospital are being fairly paid. 33. Administrative decisions at this hospital interfere too 2 3 4 5 6 7 much with patient care. 34. It makes me proud to talk to other people about what I 1 2 3 4 5 6 7 do on my job. 35. I wish the physicians here would show more respect for 1 2 3 4 5 6 7 the skill and knowledge of the nursing staff. 36. I could deliver much better care if I had more time with 1 2 3 4 5 6 7 each patient. 37. Physicians at this hospital generally understand and 1 2 3 4 5 6 7 appreciate what the nursing staff does. 38. If I had the decision to make all over again, I would 1 2 3 4 5 6 7 still go into nursing. 39. The physicians at this hospital look down too much on 1 2 3 4 5 6 7 the nursing staff. 40. I have all the voice in planning policies and procedures 1 2 3 4 5 6 7 .for this hospit~l and my unit that I want. I 41. My particular job really doesn't require much skill or 1 2 3 4 5 6 7 "know-how.'' 42. The nursing administrators generally consult with the 1 2 3 4 5 6 7 staff on daily problems and procedures. Usage 63

Disagree Agree

43. I have the freedom in my work to make important 1 2 3 4 5 6 7 decisions as I see fit, and can count on my supervisors to back me up. 44. An upgrading of pay schedules for nursing personnel is 1 2 3 4 5 6 7 needed at this hospital.

Notes

1Stamps, P.L., et al. "Measurement of W~rk Satisfac tion Among Health Professionals." Medical Care 16: 337-52, April 1978. 2Slavitt, D.B., et al. "Nurses' Satisfaction with Their Work Situation." Nursing Research 22:114-20, March/ April 1978. :i ___ "Measwing the Levels of Satisfaction of Hospi- tal Nurses." Hospital and Health Services Administra tion 24:62-77, Summer 1979.

J Appendix D RIZZO, HOUSE AND LIRTZMANN ROLE QUESTIONNAIRE

QuEsnoNNAJRE ITEMS A..~ FACftlll LOADINGS

Factor loadings .30 Ima Ro~ Role number Statement oooJlict ambiguity 1. I have enough time ID camplete my work. 2. I feel certain about~ much authority I have.. .51 3. I perform tasks that. are too easy or boring. 4. ~. planned goals and objectives for my job. .42 -s~ I ha~ to-do ihiDp that should be done dif(~- .60 6. Lack of· policies ad pidelines to help me. .43 7. I am able to ad the smM regardless of the grouJ? I am ,.-itf»... .31 8. I am col'ft!Cted or ~ when I really doo"t es:pect it. 9. I work under ib<>+hl:-Nhle policies and guiddim!s. .60 10. I know that I have ~ my time properly. .62 11. I receive an ~~-e •wilhout the manpower .. C101Dplete iL .56 12. I bow wt.at mI ~ arc. · .En 13. I 1-ve to bock a nie • policy in order to carry 011111 an assign:mr:at. .54 u. I ~ ID ~ m, --,• iD performing my dutil!s. .38 -.35 15. I RJCeiYe MligmnelllS tbat are within my training amd capability. 16. I lee! certain how I will be evaluated for a raiR ar promotimlL .34 17. I laave just the right amount of work to do. .32 18. I bow that I have clmded my time properly~ .59 19. I work with two or mare groups who operate ~.diHeren~. .43 !O. I bow aacdy what ii expected of me. · ·_: . .61 21. I n,ceive iocompatihir requests &om two or mmir people. .56 22.. I am uncertain as ID _,., my job is linked. 23. I do ~ that are • tD be accepted by one peuoo and mmt accepted by others. .41 . 24. I am told hov-· weD I am doing my job. 25. I receive an ass;gnrn:,-nt without adequate ~ and ~ It uecute it. .52 26. Ezplanation is clear ai what has to be done. .35 27. I work on nrnecesszr:r things. .52 28. I i.ve ID worlc UJJCis- "-P diftletives or ordets.. .59 29. I perform wotk that ants my values. · .39 30. I do not know if my ....t will be ~table _to ~ boa. .30 Items 10 ad 18 on tins .«Jrn~tion were identical. owi:mg to a de - I error. Appendix E ======~===:===·---=------Preview Mode Press "Done" after you are finished previewing the survey. Your answer will not be recorded.

Telenursing Role Questionnaire - Introduction

This telenursing role questionnaire has six sections, some o'f which are very short ( 1 question) and some longer.

The entire survey will take approximately 25 minutes to complete. Your willingness to complete the survey is considered your consent to participate. You will not be identified in any way. All data will be reported anonymously. Thank you for contributing to this new body of research in telenursing. For any questions regarding this survey~ please contact Loretta Schlachta at (301) 371-84 78 or email lorettasch@com_2!.!serve.com.

This is section 1 of 6. PollCat Surveys http~LLwww.12ollcat.com

1.1 Please enier your-code n..umber from t.. he top-ofyour-inv-itatio-n---fo-participate~ ------~cco,_,-_c,~-"'--, ____- __-~=~'""-= Answer Required Code Number: -=----~-=-==...:-::.:... =..:_-______- . ___ .•:: .. ·- -- -- __ 1.2 Before continuing, please select any of the following statements that applies to you:

I am a registered nurse who takes care of patients using telemedicine (voice and video) technology. c· Yes c No -=---==--==-~-----··.:.:.:..:-=._ ------· -- .. ------··---· .. : --- -· ------1.3 I am a registered nurse working in a telemedicine program or company. Answer Required r Yes C No Ifyouhave--'not---'regisie'red ·,{Ye:~,-,,-·to- ·eHher· stateine-iit ¥f.Tor stateme1it #1 J, the11-y'ot1-ire'i1of ellg1bleto°' - complete this survey. Thank you very much for your time and interest in participating.

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Telenursing Role Questionnaire - Work Satisfaction

This is section.2 of 6. Listed and briefly defined here are six terms or factors that are involved in how people feel about their work situation. Each factor has something to do with work satisfaction. This research is interested in determining which of these is most important to you in relation to the others in regard to your telenursing role.

Please carefully read the definitions for each factor as given here:

1. Pay - dollar remuneration and fringe benefits received for work done: 2. Autonomy - amount of job-related independence, initiative, and freedom, either permitted or required in daily work activities. 3. Task Requirements - tasks or activites that must be done as a regular part of the job. 4. Organizational Policies - management policies and procedures put forward by your work area and the administration of your organization. 5. Interaction - opportunities presented for both formal and informal social and professional contact during working hours. 6. Professional Status - overall importance or significance felt about your job, both in your view and in the view of others.

These factors are presented in pairs in this questionnaire. Only 15 pairs are presented; this is every set of combinations. No pair is repeated or reversed. For each pair of terms, decide which one is more important for your job satisfaction or morale as related to your telenursing position. Please select the item that more important to you. I realize it may be difficult to make choices in some cases, but please answer all questions as best your can. Please do not go back and change your answers. Poll Cat Surveys http;/ /www .pollcat.com i.f~=Pfease ·enter your cotle number from the-·to·p ofyoi.ir invifafion In·o-.~-d-er "fo pirtfdp"afo-fiitlifs -" section of the questionnaire. Answer Required Code Number: 2.2 Professional Status· or Organizational Policies r Professional Status r Organizational Policies 2.3 Pay or Task Requirements o Pay c Task Requirements 2.4 Organizational Policie~ or Interaction c Organizational Policies c Interaction 2.5 Task Requirements or Organizational Policies c Task Requirements c Organizational Policies

-- ---·------·------·--· - --·---- ·------·------.. ------·- -- - - 2.6 Professional Status or Task Requirements c Professional Status c Task Requirements - . ------2. 7 Pay or Autonomy c Pay c Autonomy ff p~~fessional-Status or- inte~~ction r Professional Status r Interaction -=------=-~.-::~'.:-~·-:.:·=------_- -- 2.9 Professional Status or Autonomy r Professional Status r Autonomy - - 2.10 Interaction or Task Requirem·ents r Interaction r Task Requirements

------· ------2.11 Interaction or Pay r. Interaction r Pay 2.12 Autonomy or Task Requirements O Autonomy c Task Requirements

------·------· ·- - --···- - --.·.------.. ··------.· ..... ----=---:.-:::. .=:.:-:=::.=-=:::.:::..·_.:..-:::.·.=....:=.. ·::::=.:...:·...: --=..-: • .=....: - • _•.. :..:~=---·:. ~ .--:..:.. . ---=.:. - • .:·....:. .. ·:.·..:: ••.-··. 2.13 Organizational Policies or Autonomy c Organizational Policies c Autonomy =====c..· ------_.. _. _____ .______._ ----· ___ .______, _____ - 2.14 Pay or Professional Status c- Pay r Professional Status ------2.15 Interaction or Autonomy c- Interaction r Autonomy 2.16 Organizational Policies or Pay r Organization Policies C Pay Than1ty·ou for· completinfthis section ofthe ques-tf<)nn~afre.

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Telenursing Role Questionnaire - Attitude and Role

This is section 3 of 6. It is the longest section of the survey. After this, the rest of the survey goes very quickly. It is very important for you to complete the survey in its entirety.

The following items represent statements about how satisfied you are with your current telenursing role. Please respond to each item. It may be diffictilt to fit your responses into the seven categories; in that case, select the category that comes closest to your response to the statement. It is very important that you give your honest opinion. Please do not go back and change any of yot~r answers. Please select the response that most closely indicates how you feel about each statement. PollCat Surveys http://...www.pollcat.com :trPiease°e11°forYour c-octe·u·u·mbe"r"fro"ritthe "tori "of four fo,;tfation:.in._o.rde-r--to- pirticip~i'teiitthis· - section of the questionnaire. · Answer Required Code Number: 3.2 My present salary ·•s satisfactory. c Totally agree r Mostly agree )., C Slightly agree r Neither agree nor disagree r Slightly disagree C Mostly disagree r Totally disagree 3.3 Nursing is not widely recognized as being an important profession .. r Totally agree r Mostly agree c Slightly agree r Neither agree nor disagree r. Slightly disagree , c Mostly disagree c Totally disagree --···------···· -----·- -·----- ···------·- -- ..... - 3.4 Most people do not sufficiently appreciate the importance of nursing care to patients. C- Totally agree c Mostly agree o Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c- Totally disagree

-=·=-=-=-=--=-~:=.--=-..::::..:::::..:7"· .: ....·-:______··_..:. :·-... :.:_____ 7-_·.:.:..·--·--=·.. -_;_.-:-::~·-·.=-..:..·-.• - - .• ------. - _._. 3.5 The personnel in my work area do not hesitate to pitch in and help one another out when things get in a rush. c Totally agree r Mostly agree (' Slightly agree r- Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.6 There is to_o much clerical a:nd 'fpaperwork" required of nurses in this organization. r Totally agree r .Mostly agree c Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree ·3. 7 The nurses have sufficient control over their own schedule in this organization. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree - . - 3.8 Physicians, in general, cooperate with nurses in my work area. c Totally agree r Mostly agree r Slightly agree C Neither agree nor disagree (" Sligqtly disagree C Mostly disagree r. Totally disagree . - 3.9 I feel that I am supen'ised more closely than is necessary. r. Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree C Slightly disagree r Mostly disagree C Totally disagree

. ·- . --· ·- ·::.- ...:: - . - - . - - 3.10 It is my impression that a lot of nurses in this organization are dissatisfied with their pay. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree c Slightly disagree /

Slightly disagree c Mostly disagree c Totally disagree ---·------· ··------·-·------·-·-·---. ·-- -=~~------·------·---·------·. --- -·------· .______------·---··---·· ------·---- ·. -·· -- 3.11 Most people appreciate the importance of nursing care to patients. c Totally agree c Mostly agree c- Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree r Totally disagree 3.12 It is hard for ne,v employees to feel "at home" in my work area. r Totally agree r. Mostly agree r. Slightly agree r Neither agree nor disagree r Slightly disagree . r Mostly disagree r Totally disagree

~ - - . 3.13 There is no doubt whatever in my mind that what I do on my job is really important. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.14 There is a great gap between the administration of this organization and the daily problems of us nurses. o Totally agree c Mostly agree c Slightly agree o Neither agree nor disagree o Slightly disagree c Mostly disagree r Totally disagree

------·-··-.·.------.·· .. -··------,·- ·------·-··------. _.: __ :,_· ____ -- _. ____ ------3.15 I feel I have sufficient input in the program of care for the patients in my area of responsibility. c Totally agree C Mostly agree C Slightly agree r Neither agree nor disagree C Slightly disagree C Mostly disagree (' Totally disagree 3.16 Considering what is expected of me, the pay we get is reasonable. · r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree "'- J c._..; r Slightly disagree r Mostly disagree c Totally disagree 3.17 I think I could do a better job if I did not have so much to do all the time. o Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree

-=-===----:..:-=·-=-----=-=..:..·:.·__ -_-:.=:_-:..:.:-•• ·.. --.-_-_~------===------=-,;:;-·_-:·:..::::_ --·- .. -----~--~.:.:-:... --· _- - - - -::..:-=---=--=---=---=·=-- ;;_ .._ ··: ___:_~:-·:.:.:.::-:.::..--:-.:·_..::_,.:_=.-:..:- .• ·•.::·.-- ..• ------•. 3.18 There is a good deal of teamwork and cooperation between various levels of personnel in my work area. r Totally agree r Mostly agree C Slightly agree r Neither agree nor disagree C Slightly disagree r Mostly disagree r Totally disagree 3.19 I have too much responsibility and not enough authority. r Totally agree r Mostly agree r. Slightly agree r Neither agree nor disagree r Slightly disagree C Mostly disagree r Totally disagree ------.--···:·- ----· _ •• ·• - - - - ·. ::.: •• - - - . 11 - : _•. : 3.20 There are not enough opportunities for ad:vancement of us nurses in this organization. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree ------=-~=-:.:.....--=----·..:. ·....:..::.:.::....--:::--:::::.:::-_·.:.::-::::~::=.::::.=:.-=--==-=--=..:=-= ------·-- ·------. ------· • -- ·•.. -- --·· . ______------3.21 There is a lot of teamwork between nurses and doctors in my work area. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree r Slightly disagree c Mostly disagree c Totally disagree

__:. . - - ·: - . . - •• - - . - . ------· .. . :._____ ... - 3.22 In my work area, my supervisors make all the decisions. I have little direct control over my own work. r. Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree - . - 3.23 The present rate of increase in pay for nurses in this organization_ is not satisfactory. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.24 I am satisfied with the types of activities that I do on my job. c Totally agree o Mostly agree c S}ightly agree C· Neither agree nor disagree c Slightly disagree c Most Iy disagree c Totally disagree

--·------·- - -·- -- - -· ·..:. ..: ------· ------·-. - . - 3.25 The nurses in this organization are not as friendly and outgoing as I would like. c Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r· Mostly disagree r Totally disagree -·- -·------·· .. -- - . 3.26 I have plenty of time and opportunity to discuss work problems with other personnel in my work area.

r Totallv., ac0 ree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree ··.:::-·.---;.:. .:·;: :.:...· _. .. . .· .: . - - --·---- -· -- ·-----···----- ···-...... :·-·.-.-:-":-:·.·-· _-_-:,·..:.::_ 3.27 There is ample opportunity for nurses to participate in the administrative decision-making process. r Totally agree r Mostly agree r Slightly agree c Neither agree nor disagree o Slightly disagree c Mostly disagree o Totally disagree 3.28 A great deal of independence is permitted, if not required, of me. C Totally agree c Mostly agree C Slightly agree c Neither agree nor disagree c Slightly disagree r Mostly disagree r. Totally disagree

- ·---· -· -- . . - . - 3.29 What I do on my job does not add up to anything really significant. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree

. - 3.30 There is a lot of "rank consciousness" in my work area: nurses seldom mingle with those with less experience or different types of educational preparation. r. Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.31 I have sufficient time for working .with patients. C Totally agree c Mostly agree C . Slightly agree c Neither agree.nor disagree r· Slightly disagree c Mostly disagree r Totally disagree - .. 3.32 I am sometimes frustrated because all of my activities seem programmed for me. r- Totally agree r Mostly agree r Sometimes agree r Neither agree nor disagree r Slightly disagree r Mostly disagree Totally disagree r r -- . . -•·- . -- . 3.33 I am sometimes required to do things on my job that are against my better professional nursing judgement. r Totally agree r Mostly agree r Slightly agree r Neither agree no·r disagree r Slightly disagree r Mostly disagree r Totally disagree

... - . . . -- 3.34 From what I hear from and about nurses in other organizations, we in this organization are being fairly paid. (' Totally agree r Mostly agree r Slightly agree 2

Table of Contents

ACKNOWLEDGEMENTS ...... ii

ABSTRACT ...... iii-iv

LIST OF TABLES ...... v-vi

LIST OF FIGURES ...... vii

CHAPTER 1: INTRODUCTION ...... p. 4

I. Background ...... ·...... ::p. 4 . )

II. Purpose ...... p. 9

III. Significance ...... p. 9

IV. Theoretical Framework: Role Theory ...... p. 11

a. Conceptual Model of Role Theory ...... p. 16

V. Research Questions ...... p. 17

VI. Definition of Terms ...... p. 17

CHAPTER 2: REVIEW OF RELATED LITERATURE ...... p. 22

I.Professional Role ...... p. 22

a. Nursing ...... p. 23

b. Telenursing ...... p. 26

II. Work Satisfaction ...... p. 30

III. Role Strain ...... ; ...... p. 31

a. Role Stress ...... p. 32

b. Role Conflict and Role Ambiguity ...... p. 33 c Neither agree nor disagree o Slightly disagree o Mostly disagree c Totally disagree ijs==i

-• •-• -••- -•• - • ••• •• H • • 3.39 Physicians in this organization generally understand and appreciate what the nurses do. r Totally agree r Mostly agree c Slightly agree c Neither agree nor disagree r Slight disagree r Mostly disagree r Totally disagree 3.40 If I had the decision to make all oyer again, I ,vould still go into nursing. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree C Mostly disagree r Totally disagree 3.41 The physicians in this organization look down too much on the nurses. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree c Slightly disagree Slightly disagree c Mostly disagree o Totally disagree

-.•-••--•-----• ..••--.•-- -._•••.•••••••••:• •••• •••- 04 ••- 0•••--=--=--•-:. .:_•::::::::::-.::..:.::..:.:•• ••-••-•••••-••-••••·•••H ••---••- -•-•-••••• -•-• :... -~=:... 3.42 I have all the voice in planning policies and procedures for this organization and in my work area that I want. C Totally agree n Mostly agree C Slightly agree C Neither agree n9r disagree r Slightly disagree C Mostly disagree r Totally disagree 3.43 My particular job doesn't require much skill or "know-how." c Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.44 The administrators generally consult ·with the staff on daily problems and issues. -r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.45 I have the freedom in my work to make important decisions as I see fit, and can count on my supervisors to back me up. o Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree ·.. .:. ___ ._-_: ___-.-::.:.·. ______.__ - -· - --- 3.46 An upgrading of pay schedules for nurses is needed in this organization. c Totally agree c Mostly agree r, Slightly agree r Neither agree nor disagree c Slightly disagree c Mostly disagree r Totally disagree

- . . 3.47 I have enough time to complete my work. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree - . . . . --~ . - - - - . .. - 3.48 I feel certain about ho,v much authority I have. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree 3.49 I perform tasks that are too easy or boring. c Totally agree c- Mostly agree c Slightly agree c Neither agree nor disagree r- Slightly disagree r Mostly disagree c Totally disagree 3.50 There are clear, planned goals and objectives for my job. r Totally agree c Mostly agree r Slightly agree c Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.51 I have to do things that should be done differently. r Totally agree

(' Mostly agree

(' Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.52 There is a lack of policies and guidelines to help me. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree ------··- - - ·- ._ . .:..·:..·:.. ---=-=· .. - . . ------· ... -- ·-· - 3.53 I am able to act the same regardless of the group I am with. r Totally agree r Mostly agree (' Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree -- - - 3.54 I am corrected or rewarded when I really don't expect it. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.55 I work under incompatible policies and guidelines. r Totally agree c Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree Slightly disagree r_, Mostly disagree r: Totally disagree

·------·- ·------··-----··------. ----··------3.56 I receive an assignment without the manpower to complete it. C- Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Sllghtly disagree c Mostly disagree c Totally disagree -- 3.57 I know what my responsibilities are. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.58 I have to buck a rule or policy in order to carry out an assignment. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree ·- '· ·, r Slightly disagree r Mostly disagree r. Totally disagree 3.59 I have to "fe~I my way" in performing my duties. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree -----·•·· --· ------. --- - ·- - 3.60 I receive assignments that are within my training and capability. r. Totally agree

C Mostly agree C Slightly agree C Neither agree nor disagree r Slightly disagree r Mostly disagree (' Totally disagree

3.61 I feel certain how I will be evaluated for a raise or promotion. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree - - 3.62 I have just the right amount of work to do. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree Slightly disagree c Mostly disagree c Totally disagree 3.63 I know that I have divided my time properly. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree r Slightly disagree r Mostly disagree c Totally disagree

-: . .: ~ -- . - - 3.64 I work with two or more groups who operate quite differently. r Totally agree C Mostly agree r Slightly agree (' Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.65 I know exactly ·what is expected of me.

(' Totally agree

(' Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree ·r Totally disagree 3.66 I receive incompatible requests from two or more people. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree r- Slightly disagree · c Mostly disagree c Totally disagree 3.67 I am uncertain as to how my job is linked. r Totally agree c Mostly agree r Slightly agree r Neither agree nor disagree r. Slightly disagree r Mostly disagree r Totally disagree _.... ·.·. ---:_ - --- . _._.. - - .:.. - - 3.68 I do things that are apt to be accepted by one person and not accepted by ·?thers. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.69 I am told how well I am doing my job. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree Slightly disagree c Mostly disagree C· Totally disagree 3. 70 I receive an assignment without adequate resources and materials to execute it. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly d_i_sagree r Totally disagree . - . - . 3. 71 Explanation is clear of what has to be done. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3. 72 I work on unnecessary things. r Totally agree r Mostly agree r Slightly agree c ·Neither agree nor disagree r Slightly disagree r Mostly disagree r. Totally disagree 3. 73 I have to work _under vague directives or orders. c Totally agree c Mostly agree c Slightly agree c Neither agree nor disagree c Slight disagree c Mostly disagree c Totally disagree

------. -- .... -- 3. 74 I perform work that suits my values .. c Totally agree r Mostly agree c Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.75 I do not know if my work will be acceptable to my boss. r Totally agree r Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree r Mostly disagree r Totally disagree 3.76 I feel comfortable with my level of technical competence in using telemedicine technology. r Totally agree c Mostly agree r Slightly agree r Neither agree nor disagree r Slightly disagree Slightly disagree o Mostly disagree o Totally disagree 3. 7_7 Bef~re I took my current telenursing position, I was computer literate. o Totally agree o Mostly agree o Slightly agree c Neither agree nor disagree c Slightly disagree c Mostly disagree c Totally disagree T-liaiik yoU:lor completing this section of the questionnaire.

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Telenursing Role Questionnaire - Role Clarification

This is section 4 of 6. PollCat Surveys !lttp~/lw.ww_.po.!lccit._~_QDl

4.1 Pleas·e- e-1ifor°y-(i°ur-'-co-Je·iiu-mbe0r from--tlie· fop -of yourTnvfratfon fri orderfo--parficipate "in this - section of the questionnaire. Answer Required Code Number: ...... , ... . ---=-=--======-=-=-·:~:: ;-_· .. -·--=-- __ - __ -_-. ----- .. ---- ·-·- -· _------·-·.------. _.::-_:::.~ ..:: ·.-:-.. -.: .. _ ------=-----=---.:...... --:-.:.::-·:-:--:-- --· -- -- ··::::::::.:.:-:::-.=-:·::-==.:-: -_:-:..· .:.-. --·· . 4.2 What strategies does your organization utilize to assure user competence in operating telemedicine technology? Please describe.· ~:~~~::on I I Periodic Training:!--_------1-: i:~~:~~~~~~ing I ·· ---~_2,:: Program: ±J Other: I 3

Additional -i------3]__,,;_~~ Comments: l

------. -··.·--- __. ------.------4.-3 What strategies does your organization utilize to assure patient safety in use of telemedicine technology?

Please describe:

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Telenursing Role Questionnaire - Individual Characteristics

This is section 5 of 6. This section provides information about you and your professional nursing background. Results will be combined with other subjects' responses. No individual data will be reported. PollCat Surveys http://www.pollcat.com s]°'"-PTe-as-eenter=fo-iir code- n-1iin6er from the top of your invitafion 111 orcfor fo--p~irfidpate in this - section of the questionnaire. Answer Required Code Number:

------•··- ~--·--·----·------·--··-- -····- -- ·- ____ . __ •.•• --· - ·- - - • -- -;-_-_-_._- ___ -_: :- =------_ -- _,:-::-~.:-.·==--:.--= .:.::· -..- .•.:.=:-:·_:::...:.------5.2 In what type of basic nursing education program were you prepared to become a registered nurse? C Diploma r Associate Degree c Baccalaureate Degree c Masters Degree r Doctorate 5.JTri-,vliat morith an

Month: Year: s-:l~tn· ,vhich s-tate oi·- foreign coun-try was th-is basic nursin-g prograin focate-d?-

State: Country: 5.5 What additional academic degrees do you have in addition to your basic nursing education program? Select all that apply. [J Associate degree in nursing (J Associate degree in another field r Baccalaureate in nursing C Baccalaureate in another field r Masters in nursing C Masters in another field C Doctorate in nursing C Doctorate in another field

..... ·:.-::..- . ....::. _·::____ :· ____--_-:::· ______···---- - . . ._ --·- - ·-. ------._ ... -- 5.6 Since graduating from your basic nursing education program, have you completed a formal educational program preparing your for advance practice? c Yes - Clinical nurse specialist c Yes - Nurse anesthetist (' Yes - Nurse midwife c Yes - Nurse practitioner c No --- 5.7 Were you employed in a telemedicine position as of March 20, 2000? c Yes - Continue to the next question r No - Skip to Question# 19 5~8- vVhahvas the location of employment on l\,farch 20, 2000'?

City: State: Zip code: 5.9 In your telemedicine position, are you: r An employee of the organization for which you.are \Vorking? c Employed through a temporary employment service agency? r Self employed? 5.10 Which of the following settings best describes the TYPE OF SETTING in which you were working on March 20, 2000 in telemedicine? o Hospital - Nonfederal, acute care or community hospital o Hospital - Nonfederal, long term care hospital o Hospital - Nonfederal, psychiatric hospital o Hospital - Federal government hospital c Hospital ..: Other c, Nursing Home/Extended Care Facility - Nursing home unit in hospital c Nursing Home/Extended Care Facility - Other nursing home c Nursing Home/Extended Care Facility - Facility for mentally retarded c Nursing Home/Extended Care Facility~ Other c Public Health/Community Health Setting - Official state health department r Public Health/Community Health Setting - Official state mental health agency c Public Health/Community Health Setting - Official city or county health department r. Public Health/Community Health Setting - Visiting nurse service c Public Health/Community Health Setting - Home health agency Public H~alth/Community Health Setting - Community mental health facility (inc. psych outpt C clinic) c Public Health/Community Health Setting - Community/neighborhood health center r Public H_ealth/Community Health Setting - Planned parenthood/family planning center r Public Health/Community Health Setting - Rural health care center r Public Health/Community Health Setting - Day care center r Public Health/Community Health Setting - Retirement community center r Public Health/Community Health Setting - Hospice r Public Health/Community Health Setting - Other r School Health Service - Public school system c School Health Service - Private or parochial elementary or secondary school r School Health Service - College or university r. School Health Service - Other r Occupational Health (Employee Health Service) - Private industr:., (' Occupational Health (Employee Health Service) - Government o Occupational Health (Employee Health Service) -. Other c Ambulatory Care Setting - Solo practice (physician) c Ambulatory Care Setting - Solo practice (nurse) o Ambulatory Care Setting - Partnership (physician) c Ambulatory Care Setting - Partnership (nurses) c Ambulatory Care Setting - Group practice (physicians) c Ambulatory Care Setting - Group practice (nurses) c Ambulatory Care Setting - Partnership or group practice (mixed group of professionals) c Ambulatory Care Setting - Freestanding clinic (physicians) c Ambulatory Care Setting - Freestanding clinic (nurses) c Ambulatory Care 'Setting - Ambulatory surgical center (non-hospital based) c Ambulatory Care Setting - pental practice r. Ambulatory Care Setting - Health Maintenance Organization (HMO) c Ambulatory Care Setting - Other c Other - Central or regional Federal agency r Other - State Board of Nursing r Other - Nursing or health professional membership association c Other - Health planning agency r Other - Prison or jail r Other - Insurance company (review claims) c Other 5.1l .If you selected "Other" as a response in Quesfion #10, please specify other.

Specify other: ------· ···------· - . - - -· . -- . - . . 5.12 Which of the following titles best corresponds to the position title for your telemedicine position? Select only one. r Administrator of organization/department r Adi11inistrator of nursing r Case n'tanager r Certified nurse anesthetist c Charge nurse c Clinical nurse specialist c Consultant c Dean, directo_r or assistant/associate director of nursing education o Discharge planner o Head nurse or assistant head nurse c Infection control nurse c In-service education director C Instructor r. Insurance reviewer r Nurse clinician r Nurse coordinator c Nurse manager r Nurse midwife r Nurse practitioner r Outcomes manager r Patient care coordinator r Private duty nurse r Professor or assistant/associate professor r Public health nurse r Quality assurance nurse r Researcher c School nurse c Staff nurse r Supervisor or assistant supen:isor r Team leader r No position title r Other 5.13 If you _selected "Other" as a response for Question #12, please specify other.

-~pe~!~-~-t~~-~: ------_J.,_·,~.:-.:::•m·.:::::.:'. ______:.:c:..: :.·='.:::::...::::·: _··::...-·:::::::·."':'.'.:'.··::. -~.::.,:·.:·:c .. ,_._'._=:::::.:,·::·::::::...--c:·· .:::.-:·:··--:----: ...... - . . 5.14 For your telemedicine position, approximately what percentage of your time is spent in the following areas during a usual work week? Please m·ake sure the total equals 100%. Administration: L..... Consultation with agencies and/ or professionals: In-person, face to face, direct patient care (not including staff supervision): Telemedicine delivered direct patient care (not including staff supervision): Research: Supervision: Teaching nursing or other students in health care occupations: Other: 5J·s·-tr you selected "Other" ~•s your respo_nse for

Specify othe_r:

·- - - . - 5.16 What type of patients are primarily treated in the telemedicine area in which you work? r Chronic care r Coronary care r Neurological r Newborn r Obstetrics/gynecologic r Orthopedic r Pediatric r Psychiatric c Rehabilitation o Basic medical/surgical ( or specialty areas not specified above) c Various patients, not specifically specialized 5.17 Do you: c work in telemedicine on a full-time basis? c work in telemedicine on a part-time basis?.· c work only part of the year on either a full or part-time basis? 5.18 Please specify the annual earnings.for your telemedicine position only. What is your gross annual salary before deductions for taxes, social security, etc.? If you do not have a set annual salary (for example, you are part time or self employed), provide an estimate of your annual earnings for 1999.

Annual earnings: __ /year 5.19 Do you hold more than one position in nursing for pay? c Yes - Continue to the next question c No - Skip to Question #24

- - 4" --- 5.20 What type of work do you do in your other nursing position(s) for pay? Select all that apply. r Home health 1 Hospital staff 1 Nursing home staff 1 Private duty nursing [" Teaching r Patient consultation ["" Consultation 1 Research r Other :{!1 -ffyou· selected

Specify other: 5.22 What is the average number of hours per week you spend in other nursing position(s)?

Average hours·per I week: ·...... -- ...... ·--··· ...... - ·-- ...... , s:23 -Fo·r-yo"i1r .. otheriursTiii position(s), p·Iease'provicfe an-·es"iimateof tiieiitafearnings-for 1§~i9: (If you are self-employed or do not work a routine schedule, report the estimate amount you expect to earn in 2000). y~~;~l earnings per [. __ .•.

-----·---·---·- - ·--. - - - - -__ --_ - -_ - - -- .. ------. 5.24 What is your sex? c Male C Female 5~15--Wlia·t is your year of6irth? ,_

Year of birth: - ---·· . -·. -- - . - ··- - 5.26 What is your racial/ethnic background'? r Hispanic r American Indian or Alaskan Native r Asian or Pacific Islander . r Black, not of Hispanic origin r White, not of Hispanic origin 5.27 What is your current marital status? r Now married r Widowed, divorced, separated r Never married ·

··.. ·.--:-_· :.·:·-.:: - - - 5.28 How old are the children who live at home with you? r No children at home r All less than 6 years old r All 6 years old or older r Some less than 6 and some 6 or over 5.29 Which category best describes how much income you or, if you are currently married you and your spouse together anticipate earning during 2000? (Include your annual employment earnings.before deductions, your spouse's annual employment earnings before deductions, if married; and all other income, including alimony, child support, dividends, royalties, interest, social security, retirement, etc.) c $15,000 or less C $15,001 to $25,000 C $25~001 to $35,000 C $35,001 to $50,000 r. $50,001 to $75,000 C $75,001 to $100,000 r $100,001 to $150,000 r. More than $150,000 5.30 Where were you living on March 20, 2000?

City: County: State (or country if -~~------~-~...... ______not USA): Zip code: ·--. 5.31 In what year did you receive your first US registered nursing license? r 2000 r 1999 r 1998 r 1997 r 1996 r 1995 r 1994 r 1993 C 1992 r 1991 r 1990 r 1989 0 1988 C 1987 C 1986 r 1985 C 1984 C 1983 C 1982 C 1981 C 1980 r 1979 r 1978 C 1977 r 1976 r 1975 r Before 1975 5.32 Which state issued, you your first registered nursing license?

State: Thank you for completing this section of the questionnaire.

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Telenursing Role Questionnaire - Conclusion

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Email Address: i;-j-iuT1 N-ame ··

Full Name: ... " ...... ---- ··-·--- ·· ... _··_·:·. --·-- -.... ____ · '. .. _. __ .. ---- . ·, -- . --- .. - - ·-- ______04 _____ ------··------••------···· --- -- 6.3 Address

Address: 6.4 City

City: 6.-5 State

State: 6.6 Zipcode

Zipcode: tliant"yo'i\-:fo~r .. yot1i- ffn1e -in --compie11't1-~ttfi1s·1mpo1:tarifrese-arcfr: Fot"t~/ci.i.1estYo~~\~egarrfm=r111rs-·stirvey~-' please contact Loretta Schlachta at (301) 3 71-84 78 or email [email protected].

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Summary of Literature Related to Telenursing

Author Purpose Variables Tools/ Number & type Findings Strengths/ weaknesses

measured Instruments of subjects

Nakamura, To evaluate Functional Katz Index of 16 paired 1) The ADL independence scores of the Strength: Well-

Takehito, the · independence, ADL subjects with videophone group (mean 62.9, SD 26.9) designed comparison of - Akao effectiveness family Independence similar age, sex, improved significantly, compared to home telemedicine

(1999) of 3- month structure, ADL; one with without videophone group (mean 60.4 SD capability.

home length of visits. videophones, 27.3) (p< .05) Weakness:

telemedicine Anecdotal data one without. 13 2) Time required to contact patient was 3 Generalizability to US

use for home on experience home health minutes for videophone, 18 minutes patients/providers.

care of home health nurses without videophone (travel time to patient

nurses. participated. home).

3) Communications with videophones 2

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects

enabled the following capabilities:

assessment of weight loss and prompt

corrective advice; evaluation of nutritional

balance of meals; assessment of everyday

schedule and change in physical

condition; supervision of physical

exercise; advice on health to family

caregivers; speech exercise; encouraging

physical activity.

Jerant, To describe a None- Case studies 12 chronically 1)Patients and providers liked care and Weakness: Was a proof

Schlachta, home Description of ill, elderly . home telemedicine technology qf concept for use of

Epperly, telemedicine project patients with 4) Case study data showed decrease in the technology. Focus

Barnes- monitoring multiple ER and ER visits and hospital admissions for was not on evaluation 3

Author Purpose Variables Tools/ Number & type Findings Strengths/ weaknesses

measured Instruments of subjects

Camp intervention hospital visits reported patients. of outcomes.

(1998) for care of Intervention period was

high cost, short ( 10 months) to

chronically see changes in chronic

ill patients illness utilization

trajectory.

Strength: Reported

patient and provider

satisfaction with home

telemedicine

technology 4

Author Pu.rpose Variables Tools/ Number & type Findings Strengths I weaknesses

measured Instruments of subjects

Wright, To describe None None None 1) Telecommunication has the potential Strength: Nurse use of

Bennet, & components, to overcome some of the barriers to CIT described and

Gramling advantages, providing therapy,help, healthcare and/or protocol ·guidelines are

(1998) disadvantage counseling for caregivers of patients with presented.

sand future dementia.

directions of 2) Risks of CIT include questionable

Caregiver effectiveness because of lack of personal

Interventions contact; safety in crisis situations, risk of

via loss of privacy, and accurate

Telecommun documentation of outcome.

ications 3) Authors allude to current nurse-

(CIT) caregiver care being provided using both

telephone and video technologies, 5

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects

however no details are provided in this

article.

4) A CIT protocol is provided for use.

Horton To identify Education, Self- 7 4 telemedicine 1)Discussed in detail in proposal Strength: Landmark

(1997) the roles, roles, developed nurses in the US study identifying issues

responsibiliti responsibilities questionnaire in new nursing role.·

es and , practices, Weakness: Sample

practice of program variance not addressed;

nurses m influences total population

telehealth/ unknown.

telemedicine

programs 6

Author Purpose Variables Tools/ Number & type Findings Strengths/ weaknesses ... measured Instruments of subjects

Johnston, To evaluate Cost, length of Self- 200 (100 1) Video visits took 18 minutes vs. 1.75 Strengths: First

Wheeler, the costs and visit, return on developed control group) hours for traditional in-home visits. controlled trial

& Deuser effectiveness investment measures for elderly home 5) Patient satisfaction with home care comparison of

(1997). of home cost, length of care service services improved telemedicine vs.

telemedicine visit, return patients 6) · 200 hospital days were saved during traditional home care.

care for on investment requiring 2 or the study Weakness: No

home health more home care 7) $200,000 patient related health care values/significance

care use visits (skilled, expenses were saved on an $80,000 reported to support

RN only) per investment. conclusions. Nurses

week 8) Nurses displayed resistance to use of were able to self-select

technology. patients as control vs.

intervention, leading to

some bias. 7

Author Purpose Variables Tools/ Number & type Findings Strengths I weaknesses

measured Instruments of subjects

Warner To describe None- None None 1) Nurse, using a two-way voice/video Strength: Raises issues

(1996) the system of description. system, can provide meaningful and describes

telehealth interaction with the patients, assess, teach, experience with

home care monitor and implement many of the Telehealth home care.

functions normally rendered in a physical Weakness: No data

visit to the home. provided.

2) Documentation of encounter in an - electronic patient record gives opportunity

for access to other authorized healthcare

team providers.

3) Home telehealth decreases

"windshield time", allowing home health

nurses to care for more patients in the 8

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects

same day.

4) Elements of appropriateness of home

telehealth identified: patients must have a

touch tone phone; patients or caregivers

must be able to hear, see and use the

telemedicine system; physical care may be

required to support ADL in addition to

telehealth care.

· 5) Cites personal experience with

benefits of telehealth home care: increased

knowledge, autonomy for the

patient/caregiver; greater level of control

and satisfaction for the home health nurse. 9

Author Purpose Variables Tools/ Number & type Findings Strengths I weaknesses

measured Instruments of subjects

Nelson & To describe None- None None 1) Description of current roles in Weakness: Not a study.

Schlachta the role of descriptive telenursing: head nurse of telemedicine Strength: Description

(1995) telenursing article clinic, nursing consultant to developing of existing roles in

telemedicine programs, home telenursing.

telemedicine monitoring, presenting

telemedicine patients to specialty

physicians, nurse practitioners using

telemedicine as physician supervision in a

nurse-run clinic.

6) Enabling characteristics of telenursing

identified: strong clinical expertise,

1 leadership, reengineering expertise, .• informatics capability. IO

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects . 7) Future telenursing roles identified:

moderating support groups via internet,

home workstations for patient monitoring,

, authoring decision support applications

· for providers/patients deciding about

treatment, online literature searches.

TT.111ggms, . To describe a Providers Self-designed 34 nurses and 4 1) During the 3-year test period, 961 1) Strength:

Conrath, test of attitudes questionnaire physicians in 3 telemedicine sessions were conducted in Comparison before and

Dunn telemedicine toward to measure com1nunities in three main categories: medical after implementation of

(1984) in remote telemedicine prov_ider northwest consultations for patients, education (RN a telemedicine system.

areas of attitudes Ontario & MD), social and therapeutic contacts Description of

Canada toward (patients in hospital communicated with experience of

telemedicine families back home). telenurses. 11

Author Purpose Variables Tools/ Number & type Findings Strengths I weaknesses

measured Instruments of subjects

2) 2) 73. 7 % of providers held positive or 2) Weakness:

; strongly positive attitudes about the Unvalidated tool us~d.

telemedicine system (p, > 01 ). The· nurses Values not reported.

were more positive than the physicians .. were.

3) All four MD' s became more favorable

toward the system over time; 2 of the

RN' s became more negative, 13 remained

the same_ and 19 became more positive.

4) RN' s felt the system prevented some

transfers to city hospitals; MD's did not. l.L.

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects

Roberge, To evaluate Accuracy, None 15 rural 1) Using real-time, bi-directional TV Strength: Reports .. Page, the use of usefulness of hospitals linked quality communications, radiologists experience of nurses

. Sylvestre, satellite telemedicine by satellite with achieved 93 % accuracy compared to with telemedicine for

Chahlaoui communicati system a tertiary care direct viewing of same films. education.

· (1982) ons for center in 2) System was used for teleradiology 38 Weakness:Focusis

telemedicine Montreal % of time; tele-education to include primarily on radiology

in Canada nursing education 11 % of time; testing use of system; little

an~ maintenance 39% of time and other, detail on nursing

12 % of time. Total hours used were 596 · activities.

hours of slow-scan transmission and 193

hours of real-time TV in 6-month trial -~ period.

3) Slow-scan transmission was not fj

Author Purpose Variables Tools/ Number & type Findings Strengths/ weaknesses

measured Instruments of subjects

deemed acceptable for radiology

interpretation or interaction.

Dunn, To report the None- None Nurses, 1) Slow-scan syst_em was used more than Strength: Account of

Conrath, experience of description physicians in 600 times in 2 years. Most common use early telenursing roles.

Acton, using a slow- rural areas of was transmission of radiology images Weakness: No data

Higgins, scan Toronto from a nurse in a rural clinic to the provided to back up

Bain telemedicine hospital. Other us_es were medical reported experience.

(1980) . system ~n consultation and diagnoses, where the --

Canada nurse presented the patient to the MD via

telemedicine, contit:ming education and

social/therapeutic (patients in hospital

- contacting family members back-home).

2) Telemedicine made some patient 14

Author Purpose Variables Tools/ Number & type Findings Strengths/ weaknesses

measured Instruments of subjects

transfers unnecessary and also made

appropriate transfer of other patients

faster.

Jones, To compare Infant transfer Self- 1,268 neonates 1) Transfer rate for infants assesse_d by

Hones, & the results of rates, developed evaluated over television was higher than for telephone

2 Halliday neonatal infant medical 12 months; half (X _= 7.46, df= 1, p < .01).

(1980) telemedicine mortality and record survey with telephone, 2) Presence of a nurse at the community

consultations morbidity, tool and half with hospital was essential to position the baby

with prenatal risk demographic telemedicine in front of the camera, describe symptoms

telephone tool and aid the neonatologist in observations.

consultations 3) Telemedicine was inconvenient; took ·•

almost 25 minutes to establish the

connection for the consultation. D

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects

Fuchs To identify Independent Self-designed Total of 89 1) Prior experience with telemedicine Weakness: Results

(1979) provider variables: structured interviews resulted in less apprehension. reported did not include

attitudes training of questionnaire conducted five 2) Of 65 consults, 15 were reported not . nurses' responses and

toward providers, prior to accompany times over a 2 adequately conducted using telemedicine. experience, primarily

telemedicine experience interviews. year period with Reasons were skin problems could not be MD.

use ma with 4 7 different diagnosed, TV is not a substitute for good

remote telemedicine, health medical history, and just don't know why.

Indian general professionals 3) Need to see motion versus still

reservation attitudes about ( some repeated pictures was agreed to be a requirement

telemedicine. several by all. -- Dependent interview): 21 4) Negat_ive effects reported by MD's

variables: MD's,4 were not patients related, but MD' s losing

estimates of administrators, time setting up equipment for consults. 10

Author Purpose- Variables Tools/ Number & type Findings · Strengths I weaknesses

measured Instruments of subjects

major benefit, 6 nurses, 5 PA's

problems from

telemedicine,

attitudes

toward

telemedicine.

Straker, To describe Characteristics Self-designed Pediatric Nurse I) 58 staff-conferences discussing 138 Strength: Role of

Mostyn, use of a cable of consults, report Practitioners problem cases· with psychiatrist occurred nurses described in

Marshall TV link experience (no # rep_orted) in 2-year period. more detail.

(1976) between a with usmg 2) 30 patient consults, with nurse Weakness:Nurses - health clinic telemedicine telemedicine presenting patient from the clinic, were perceptions not

in New York over 2 years to conducted. Outcomes were N= 4 problem reported.

City and a consult with resolution; N~ 7 further diagnostic study 17

Author Purpose Variables Tools/ Number & type Findings Strengths / weaknesses

measured Instruments of subjects

medical - MD's required; N= 21 recommendation for

school treatment; N= 6 referral to other agencies.

3) Acceptance of therapy for children

. was 66% higher after telemedicine

consults. Prior to telemedicine, parents

refused most referrals to the medical MD.

4) Author reports that "television

contacts were intimate and

· effective ... (Patients) also seem to gain a

sense of heightened self-esteem that is not

as noticeable after an in-person

consultation. The feeling of being on

television and the possible identification Appendix G Table 2.

Summary of Nursing Literature Related to Work Satisfaction

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

Tovey & To compare None- Open· 265 ward I) Sources of dissatisfaction Strength:

Adams major sources Qualitative comments nurses across a)High frequency > 19 Validates current . , (1999) of satisfaction analysis . page added to England Changes in healthcare system, elements measured

and a larger piece Availability of staff, Standards of care, in job satisfaction

dissatisfaction of research to Personal support, Job security survey tools.

in the l 990's develop scales b )Moder~te frequency 12-18 Identifies new

with previous to measure Role conflict, Workload, Staff elements to be

research ward development opportunity, Morale, added to job

findings organizational Stress satisfaction survey

features c)Low frequency <11 tools.

Ward leaders management style, Weakness: Ability 2

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses ' Resources/equipment, Introduction of to generalize to US

computers, Pay, Pressure of additional population of

rol~s, Paperwork, ·Ability to voice nurses.

opinions

2) Sources of satisfaction

Aspects of teamwork

Enjoyment/love of nursing

Ct.mbey & To examine Organizational Structure 800 RN's, 31 I) Nursing experience in health

Alexander the structure, Instrument, LPN'·s public department significantly correlated with

.(1998) relationships technology, Technology· : health nurses job satisfaction (r = .56, p< .01).

among environment, Instrument, ma 2) Three dimensions of structure,

variables job satisfaction Environmental southeastern vertical participation, horizontal

Uncertainty state participation and formalization were

Scale, correlated s1gnificantly to job 3

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

McCloskey/ satisfaction ( r = .55, .48 and -.40

Mueller respectively; p<.001)

Satisfaction

Scale.

DeGroot, To evaluate Unit costs, pay, Self designed 68 RN's in a 1) All staff were paid significantly Weakness:

Burke & the impact of job satisfaction, demograp~ic. Midwest more under the new salary model Measures taken

GE'orge a new salary organizational questionnaire, tertiary care (p=.0001) after six months

(1998) model commitment, Job description hospital 2) No difference in staff satisfaction, may be too soon to

anticipated Index, supervision, promotion and coworkers reflect changes;

turnover Organizational as result of the new salary model. many glitches in

Commitment 3) Age (r -.18, r - .21) and years as an the

Questionnaire, RN (r -.17, r - .23) had a negative implementation of

Professional relationship to coworker relations and the new salary

Commitment care quality (p<.05) model were noted 4

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

Questionnaire, in the article and r

Anticipated may have biased

Turnover the results.

Scale, Multiple survey

Professional completion may

Practice '\ have caused less

Climate Scale, accurate answers

Perception of because of length

Staffing of surveys.

Adequacy

\ Questionnaire,

Life

Orientation

Test j

Author Purpose Variables - Tools/ _# and type of Findings Strengths/

measured instruments subjects weaknesses

Fung-kam To identify Job satisfaction Index of work 190 RN's in 1)Autonomy, professional status and Strengths: well-

(1998) the sources of Satisfaction acute and pay were ranked as most reported,

job (IWS) chronic important(Weight coefficients 3 .4 2, descriptjve study

satisfaction hospitals in 3.40, 3.40 respectively, Range .9-5.3) of Hong Kong

Hong Kong 2) Age & years RN experience nurses using the

positively correlated with satisfaction- IWS

with pay at r=. 15 and r=. 1·6 Weakness:

respectively, with p<. 04, alpha.OS. Generalizability to

4) Nurses in the acute hospital were other Hong Kong

more satisfied with professional status and US nurses.

than chronic (x-acute = 4.29, SD=.80; x-

chronic=3:87, SD=.85; F=l0.19,

p<.0003) 6

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

·ounkin, To understand Job satisfaction, Index of work 3514 rural 1) The most important path to retention

Stratton & the job recruitment & Satisfaction, nurses from was job satisfaction (.175, p<. 001).

Juhl satisfaction of retention unknown other six states The second most important path •

(1997) rural nurses strategies, level tools affecting retention was the perceived

of vacancies in quality of the community in which the ,•~• .>

rural heal th care nurses live (.133, p<. 001).

agencies 2) Rural nurses who reported no

employment options also reported ·

higher levels of job satisfaction (-

.215, P<.05)

Lynn& Tq examine Perceived Nurses 73 nurses in a I) One year post case management

Kelley the effects of quality of care Perceptioi1 of community initiation,

(1997) case delivered, work Quality Scale, hospital; 4 a). pay and reward decreased

management satisfaction, Index of Work case managers significantly (t test-3.07, p<.001) 7

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

on nursmg control over Satisfaction, and 69 staff b) Developing a relationship ·with

practice nursing practice Nurse's nurses patients increased (t test 2.78, p<

Opinion about .001)

Nursing Scale, c) Collegial respect increased (t test

Control over 3.39, p<.001

Nursing

Practice Scale

Tuck To identify Social support, Norbeck Social 127 nurse 1) Job related stress and nurse manager Weakness: No

(1997) areas of work Job Stress; Job Support managers age was negatively related to job values for

related stress satisfaction Questionnaire, from 14 acute - satisfaction. significance

for nurse Caplan Social hospitals in · 2) Job experience and management provided.

managers and Support the experience had a significant positive

its impact on Questionnaire, Philadelphia relationship with _work satisfaction.

satisfaction Job-Related area 3) Lack of support from supervisors 8

Author Purpose Variables Tools/ # and type of Findings Strengths/ .•

measured instruments subjects weaknesses

Tension Index, and coworkers was related significantly

Index of Work to lower satisfaction levels.

Satisfaction

Pierce, To determine Autonomy, job I )Investigator- 69 employed 1) 36% of variance in job satisfaction Weakness:

Hazel, & impact of a satisfaction, job designed rehabilitation was predicted by 4 variables: Finding #2, no

Mion, newly turnover Personal RN's in Ohio (F=6.12; df=4,54; p=.0004) significance of

(1996) instituted Information Perceived autonomy -1.97 impact of PPM is

professional Tool Hours worked -0.20 reported, just raw

practice 2)Qual.ity of Age -1.49 scores.

model (PPM) Employment Time in. p·osition -1.27

Survey 2) 1 year after implementation of the

3)Work PPM, perceived autonomy and job

Satisfaction satisfaction increased and job turnover

./ Scale rate decreased. 9

Author Purpose Variables Tools/ # and type of Findings Strengths/ " measured instruments subjects weaknesses

Irvine & l)Meta- Job satisfaction, Meta-analytic 21 published 1) Mean correlates of job satisfaction: Weakness:

Evans analysis of · behavioral techniques; job (%variance due to sampling error 4.79% Potential upward

(1995) each variable intentions, aver,age · satisfaction to 66.01 %) bias since meta-

2) Meta- nurse turnover weighted studies; 19 . Routinization -.52 analysis based on

analytic study correlations with nursing Supervisor relations .51 published studies

., investigating from multiple personnel. Leadership .51 only, with

causal studies 9,64~ subjects Autonomy .46 tendency to favor

relationships Stress -.39 publishing

among Feedback.38 significant results

variables Promotion Opportunity .3 8 only.

Feedback.38

Participation .35

Role conflict -.35

Role ambiguity -.33 IO

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

Pay.23

Age .16

Work overload -.16

Experience .12

Organizational tenure .10

2) Mean correlates of turnover behavior:

Job satisfaction -.12 (100% of variance ·

due to sampling error

Behavioral intentions .34 (2.62% of

variance due to sampling error)

Knoop To identify Job Organizational 171 nurse l)Job involvement was related to Weakness: One-

(1995) the involvement, Commitment educators and satisfaction with the work itself item, unvalidated

relationships job satisfaction, Questionnaire, RN's in 11 r=.33,p<.001 measure of overall 11

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

among a organizational Job hospitals and 2) Job involvement was related to job satisfaction

cluster of commitment Descriptive 3 community opportunities for promotion, r=. 33, p<. was utilized to

attitudes Index, colleges in 001. . draw conclusions

toward work One-item job - southern 3) Commitment was related to overall about

satisfaction Ontario job satisfaction r=. 64, p<. 001. relationships.

measure

Mitchell To determine Work roles, Minnesota 258 RN's 1) No significance was found between a Weakness: The

(1994) if job Work role ,Satisfaction from four nurse's job satisfaction and the work role

satisfaction is values, Job Questionnaire, metropolitan correlation between work role values questionnaire was

I related to the satisfaction Work Role hospitals in and actual work roles. not tested for

congruence questionnaires Colorado reliability and

between a validity. All

nurse's nurses reported a

personal work high overall level l2

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

role value of satisfaction;

system and self-selection of ·- that of the respondents may

unit where the have occurred.

nurse works

Blegen Meta-analysis Job satisfaction Meta-analytic 48 published Weighted mean correlates of job Strenth:

(1993) of variables techniques and satisfaction: Correlations

related to job unpublished (95% Credibility Intervals range from produced by meta-

satisfaction studies with -.39-.65) analysis can be

15,048 RN's Stress -.609 regarded as more

engaged in Commitment .527 accurate estimates

I patient care Supervisor communication .44 7 of the population

Autonomy .419 than those '

Recognition .415 determined by 13

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

Routinization -.412 individual studies,

Peer Communication .358 to the extent the

Fairness .295 combined sample

LoctJs of control -.283 represents the

Age .133 population.

Years Experience .086 Weakness: Pay

Education -.070 was eliminated as

Professionalism .060 a variable in the

meta-analysis on

the basis that

nurses' pay varies

so little that no

effect on job

satisfaction can be 14

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

shown. The-

reference for this

statement was r

1980; the nursing

job market has

changed _since.

Seymoui· & To identify None- 22-page 252 randomly I )Areas of dissatisfaction with nursing: Strength:

B L,scherhof sources and qualitative questionnaire: chosen Institutional problems of work setting Qualitative

(1991) consequences study Careers in members of ( shifts, overload, hours, staff shortages, approach validates

of satisfaction Nursing: A the American supervisor inflexibility) N=124 findings of

and Survey of Nurses Pay does not match skills N=68 quantitative survey

dissatisfaction Attitudes, Association Gender role issues, sexism N=67 approaches of job

in nursing Choices and Problems with nursing colleagues N=66 satisfaction

Achievements Lack of autonomy, lack of flexibility, 15

Author Purpose Variables Tools, # and type of Findings Strengths/

measured instruments subjects weaknesses

lack of teamwork

2)Areas of satisfaction with nursing:

Clinical competence and interest in

nursing N=65

•, Hands-on work with patients N=30

Vehicle for learning, personal growth

N=30 '· 3 )N=27 left or were considering leaving

nursing as a result of dissatisfactions

Mottaz To investigate Overall work Self developed 1,615 1) Nurses have a fairly low level of Weakness: Did

(1988)· the nature and satisfaction, questionnaire employees in work satisfaction rel_ative to other not use a

sources of pe!ceptiohs of_ 8 occupations professional occupations (Mean, 2.87, standardized

work work rewards, in a large SD .480, range 1-4, F=29.34, p=. 000). survey.

satisfaction work values Midwest Only police officers (mean 2.81 ), Strength: 16

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

among metropolitan factory foremen (2.85) and factory Compared nurses

registered area, workers (2.57) had lower work to other employee

nurses, and to including 3 12 satisfaction. University faculty (J 17), groups usmg same

compare nonsuperv1sor administrative personnel (3 .10) survey.

nurses to y RN's from elementary school teachers (3 .18),

other four large clerical workers (3.03) had higher work

occupations hospitals satisfaction.

2) The major determinants of work

satisfaction for nurses are supervisory

assistance, task significance, task

involvement, task autonomy .and salary

(ANOVA 6.37, 7.68, 7'.16, 7.02, 6.07; F

= 9.42, 18.62, 15.22, 16.03, 12.50;

p<.05) 17

Author Purpose Variables Tools/ # and type of Findings Strengths/

measured instruments subjects weaknesses

Roedel & To identify Job l)Job 135 RN's 1) Task ide,ntity, autonomy and Strength:

Nystrom nurses' characteristics, Descriptive from a 200 feedback from the job significantly Information from

(1988) feelings of job satisfaction Index bed Midwest relate to job satisfaction (r= .22, .24 & study was used to

satisfaction 2)Jobs in community .30, p<.01) redesign jobs in

with different General hospital 2) Med-surg nurses (mean 37.06 +/- various work

nursing jobs 8.81) exhibit lowest job satisfaction areas. Study can

scores. OB nurses exhibit lowest scores be replicated by

overall: Skill variety 5.75 +/- 1.1; Task other organizations

identity 4.04 +/- 1.41; Pay 25.18 +/- Weakness:

9.72; Supervision 41.35 +/- 11.65. Generalizability to

other setting is

limited. Appendix H Table 3.

Summary of Literature Related to Role stress

Author Purpose Variables Tools/ Number/ type Findings Strengths I

measured Instruments of subjects weaknesses

Wheeler To identify Determinants · Review of 11 studies 1) Common to all studies are reported Weakness:

(1998) the major of stress published re~iewed; 60 determinants of nurse stress: work Description of

sources and literature ICU nurses & overload, interpersonal relationship studies is

determinants 60 general problems~ death and dying; difficulty erratic;

of stress nurses m with staff; difficulty over treatments conclusions are

England. 60% prescribed by doctors; difficult and made without

of nursing helpless patients; task routinization, giving full data

faculty in political-violence, lack of involyement from studies - Ireland (no #); with patients, staff shortages, role discussed.

300 hospital ambiguity, lack of support from senior Strength: 2

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

nurses m management; conflict with Findings

Northern establishment. support other

Ireland; 296 2) Successive pieces of research studies on

· general nurses continually highlight the same determinants of

in England fundamental nurse stress determinants. stress. Author

and US; 229 Why is nothing done to change this OR poses a valid

nurses m are interventions failing to make a question in

England; I 00 positive impa~t? finding #2.

critical care

nurses in US. :J

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects· weaknesses

Lambert & To examine Role stress, Self- 871 nurse 1) Significant negative correlations

Lambert the psychological developed educators were found between role stress (r -

(1993) relationships hardiness demographic from NLN- .23, -.27, -.12 ), role cop.flict (r -.30,

of variables data approved -.28, -.08) and each component of

ahd questionnaire, schools of psychological hardiness

predictors of Rizzo, House nursing in the ( commitment, control, challenge)

role stress and Lirtzman us p<.05

Role Conflict 2) Significant negative correlations

and Role were found between role stress (r -.

Ambiguity 21 ), role conflict (r -. 26) and the

Scale, overall measure of psychological

Personal hardiness. P< .001

Views Survey 3) Role ambiguity showed a ""I'

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

significant negative correlation with

the challenge component of the

overall measure of psychological

.; hardiness (r - .12, p < .001)

4) Coefficient alpha for the role

ambiguity subscale was very low (r

= .16)

5) The best predictor of role stress for

nurse educators overall was the

~_,-- belief that there was a lack of

control in their lives (R2 .047, F -

24.70, Beta - .230, p< .001) )

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

Tyler, To compare Occupational Nursing 156 RN's 1) Stress from excessive workload is Weakness:

Carroll & nurses in the stress, self- Stress Scale, from 4 public the primary cause of ill health and Generalizability

Cunningham public and reported General and 3 private psychological disorder in nurses, to US nurses.

(1991) private health, well- Health hospitals in regardless of whether they work in the

sectors being Questionnaire England public or private sector. Workload

predicted somatic symptoms (r2 .11, B

2 = .34, p<. 001 ), anxiety (r .10, B =

.32, p< .001 ), and social dysfunction (r2

.07, B = .27, p < .001).

2) For both public and private sector

nurses, death and dying and workload

were reported as the most frequent

sources of stress. 6

Author Purpose Variables Tools/ Number/ type · Findings Strengths/

measured Instruments of subjects weaknesses

Lees & Ellis· To identify Self esteem, Open-ended 20 RN's, 20 1) U nderstaffing was the most Weakness: No

(1990) the stressors assertion, interviews, 16 nursmg frequently cited stressor of all groups, values reported

and coping ways of PF students, 13 followed by dealing with death and for findings.

strategies of coping, Personality ex-student dying, conflict with nurses, overwork, Generalizability

nursing staff personality, Questionnaire nurses m conflict with doctors. to us nurses is

perceived , Gambrill & Wales 2) Conflict with nurses caused the questionable.

stressors and Richey most overall dissatisfaction, followed

perceived Assertion by understaffing, and doing

satisfactions Inventory, menial/monotonous tasks.

Ways of

copmg

Questionnaire 7

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

Dewe, To Work Self- 180 I nurses in I) 5 3 events were identified as work Strength:

(1989) investigate stressors, developed 9- general and stressors via interviews. These were Although a

the Coping item obstetric condensed into five components: work differept

relationship strategies, demographic hospital overload, difficulties relating to other sample,

between social- questionnaire, throughout 29 staff, difficulties involved in nursing findings are

stressor biographical interviews districts in . the critically ill ( dying patients), consistent with

frequency variables, New Zealand concerns over the treatment of patients ·other studies of

and response nursmg ( conflict with MD' s, quality of care nurses m

specialty issues), dealing with difficult or i.dentifying

helplessly ill patients. components of

2) 71 coping strategies were identified stress.

via interviews. They were condensed - to six components: problem-orientated 8

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

behavior, try to put things in

~ perspective, e~press feelings of

frustration, keep the problem to

yourself, accept the job as it is and try

not to let it get to you, Passive

strategies for handling the situation

(smoking, drinki~g, taking day off).

3) Staff nurses were more li~ely than

charge nurses to experience difficulties

relating to others

4) Charge nurses more frequently

dealt with difficult or helplessly ill

patients than staff nurses 9

Author Purpose Variables Tools/ Number/ type Findings Strengths I

measured Instruments of subjects weaknesses

Burke & To identify Role Rizzo, House 119 senior 1) Hospital executives experienced Strength: Uses

Scalzi role stress ambiguity, & Lirtzman hospital lower role conflict and role ambiguity same tool to

(1988) components role conflict Role executives in than nurse executives, however the compare two

of hospital · Questionnaire 2 cities in difference was not significant. different types

executives , Porter and Texas; none 2) Correlation between role conflict of samples.

and compare Lawler were nurses. and job satisfaction in nurse executives Weakness:

them to nurse Managerial was - .4, p< .01. Role

executives Attitudes and 3) Correlation between role ambig~ity questionnaire

Performance and job satisfactlon in nurse executives may not be

Questionnaire was - .3, p<. 01. sensitive to the

4) Correlation between role conflict type 9frole

and job dissatisfaction of hospital stress in

executives was .36, p < .001. hospital IO

Author Purpose Variables Tools/ Number/ type Findings Strengths/

t measured Instruments of subjects weaknesses

5) Correlation between role ambiguity executives.

and job dissatisfaction of hospital

executives was .39, p < .001.

6) Cited conclusions from 1970' s

research that role stress leads to

adverse consequences such as job

dissatisfaction, poor performance, job

turnover, increase ~n depressive - symptoms and psychosomatic

complaints. 11

Author Purpose Variables Tools/ Number/ type Findings Strengths I

measured Instruments of subjects weaknesses

Scalzi To better Role stress, Rizzo, House 75 top level 1) The most pervasive source of job Weakness: No

(1988) understand depression & Lirtzman nurse stress was overload. values reported.

role stress Role · executives in 2) Four major role stress related Strength:

and to assess Questionnaire general factors were overload, concerns Qualitative data

·coping , Center for hospitals _in regarding quality of care, role conflict provided insight

strategies Epidemiologi Los Angeles and role ambiguity. to strategies

c Studies County, CA 3) Coping strategies reported were used by nurse

Depression Time outside work, Personal support executives.

(CES-D) network, Space at work, Identifies

Scale, problem-solving resources,

•, individual somatization, changes activity, security

.' interviews within corporation, considers resigning,

psychologically drops out, 12

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

dysfunctional competition.

4) Role conflict consisted of working

with multiple groups "role overload" ,,--

and time management/workload

problems.

Brief, Aldag, To identify Level of Self- 157 practicing I) Baccalaureate nurses experience Weakness: No

VanSell, & the impact of nursmg · developed RN's from greater role ambiguity and role conflict . coefficient

Melone level of education, biographical Iowa than diploma or associate degree nurses alpha reported

(1970) nursmg role stress, questionnaire, ((F ~ 6.66, 3.06, p<.05) for role

education on role Activities · 2) Role stress is negatively correlated questionnaire.

role stress ambiguity, Performed by with job satisfaction. (no values Survey is 20

role conflict Nurses reported). years old and

Instrument, results may no 13

Author Purpose Variables Tools/ Number/ type Findi_ngs Strengths/

measured Instruments of subjects weaknesses

Rizzo, House longer be

& Lirtzman applicable.

Role

Questionnaire

, Job

Descriptive

Index Appendix I Table 4.

Summary of Literature Related to Role conflict, Role ambiguity

Author Purpose Variables Tools/ Number/ type Findings Strengths I

measured Instruments of subjects weaknesses

Bousfield To investigate Lived None- 7 CNS's 1) 8 elements emerged from the data as Strengths:

(1997) how a group of expenence phenomen- essential structures of the role of the CNS: Testimonial to

clinical nurse in the CNS ological enthusiasm for leadership, knowledge, the struggles

specialists role approach lack of organizational support, job of the role

(CNS) think isolation, poor time management, definition of

and experience inter/intra-role conflict with medical CNS ' their role. nursing. multidiscipl~nary staff and lack of

role definition, disempowerment,

burnout/stress.

Pranulis, To identify Role Pranulis 124 RN's, 25 · 1) Professional satisfaction was lowest for Weakness:

Renwanz-. influences on conflict, Influences on LPN's, 3 staff nurses and head nurses. No values

Boyle, & professionalism professional Professionalism student nurse 2) Emotional exhaustion was greater for provided. 2

Author Purpose Variables Tools/· Number/ type Findings Strengths t

measured Instruments of subjects weaknesses

Hodson satisfaction, Survey, Dyer technicians, 7 respondents under 50 years of age, those Strength:

(1995) burnout Personal nursing who had been in nursing for 6-10 years Qualitative

Satisfaction assistants at a and those employed at the VA 1-5 years. data identified

Inventory, western US 3) Respondents with baccalaureate examples of

Maslach Human Veterans degrees reported greater emotional role conflict

Services Medical Ctr exhaustion than those with technical or and role'

Survey, The vocational education in nursing. overload.

Change-Seeker 4) _Head nurses had the highest emotional

Index exhaustion scores.

5) Examples of role conflict and role

overload were frequently cited as

influences on professionalism. 3

Author Purpose Variables Tools/ Number/ type Findings Strengths/

-t. ~ measured Instruments ·of subjects weaknesses

Crossley To investigate Chief Self-developed 367 chief 1) A decrease in role ambiguity was

< (1993). relationships nursmg demographic nursmg found with increasing proximity to the

among variables officer survey, Rizzo, officers in a governing board (F=5.60, p<. 01).

governmg House and national 2) Role conflict score was mean 30.44

body Lirtzman Role sample of (SD 8.77). Chronbach alpha was .79.

proximity, Questionnaire, acute care 3) Role ambiguity score was mean 16.62

level of Hall hospitals (SD 6.13). Chtonbach alpha was .77.

reporting Professionalism

relationship, Scale

professional

ism, role

conflict and .. ' role

ambiguity 4

Author Purpose Variables Tools/ Number/ type Findings· Strengths/

measured Instruments of subjects weaknesses

Jamal& To examine the Behavior, Lodahl & 1148 nurses in 1) Coefficient alpha for role ambiguity Weakness:

-Baba prevalence and age, job Kejn~r Job eight hospitals scale is .88. Five variables ~- (1991) consequences of stress, role Involvement ma 4) Job stress is correlated with role were assessed

Type A ambiguity, measure, Rizzo, metropolitan overload (r .57, p< .001),"role conflict (r with one-item

behavior among role House and Canadian city .38,.p< .001), and role ambiguity (r .30, measures.

nurses . conflict, Lirtzman Role p< .001) .

overload, Questionnaire, 5) Type A nurses experienced

turnover, Michigan significantly greater job stress (ANOV A

job Overload Scale, 29.25, F=60.41, p<. 01), role ambiguity

involvement Parker & (ANOVA 10.01, F=5.34, p<. 01), role

, effort at Decotiis Job conflict (ANOVA 20.72, F=18.06, p<.

job, Stress scale, 01), and role overload (ANOVA 16.71, , . attendance Porter Scale of F=l 1.76, p<. 0l}than Type B nurses.

Organizational 5

Author Purpose Variables Tools/ Number/ type Findi_ngs Strengths/

measured Instruments of subjects weaknesses

. Commitment,

One-item

scales for:

global job

satisfaction, job

effort, turnover

cognition,

promotion

expectation.

Bortner Scale of

Behavior Type 6

Author Purpose Variables Tools/ Number/ type Findings Strengths I

measured Instruments of subjects weaknesses

Burke, To analyze Role Rizzo, House & I 7 5 directors I) Directors of respiratory care Weakness:

Tompkins & relationships conflict, Lirtzman Role of respiratory departments demonstrated relatively low Used one-

Davis among variables role Questionnaire, care in Texas · role-conflict scores (mean 3.86, SD .97) item measure

(1991) ambiguity, self designed hospitals with with even lower role ambiguity scores ofjob

job demographic >75 beds (mean 2.64, SD .93) satisfaction. - satisfaction survey, one- 2) Directors exhibited high role overload

item job - scores, (mean 4.35, SD 1.65).

satisfaction ·3) As role conflict and role ambiguity

question increase, job satisfaction decreases ((r - ' .310, -.429, p< .01)

Fain (1987) To compare Role Rizzo, House & 25 Deans or !)Faculty over 46 years of age Weakness:

nurse educators conflict, Lirtzman Role Chairpersons experienced greater satisfaction with {heir Small sample

perceptions of role Questionnaire, ofNLN pay (F=5.98, df=2/271, p< .05) size.

variables ambiguity, Job Descriptive schools of 2) Satisfaction with pay was significant 7

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

job Index nursing in for faculty holding a doctorate (F=3.95,

satisfaction .. New England df=2/282, p< .05)

3) F acuity teaching 1-5 years had a higher .. role ambiguity score than faculty teaching

16 years or more (F=3.50, df=3/227, p<

.05)

4) Faculty with a master's degree

exhibited higher role ambiguity than those

with doctorates (F = 3.95, df=2/282, p<

.05)

5) Role conflict (r -. 47, p< .01) and role

ambiguity (r - .40, p< .01) were

significantly associated with low job

satisfaction 8

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

Johnson To examine the Role Role ambiguity 13 8 Clinical 1) Cronbach' s alpha for role ambiguity Weakness:

(1986) role of CNS and ambiguity, . · portion of the Nurse scale was .90. Few data

problems job Rizzo, House Specialists 2) Mean role ambiguity score was 31.9 values

encount~red by satisfaction and Lirtzman (CNS) from (range 6-42), suggesting the CNS sample provided

CNS's Role Washington perceived a low degree of role ambiguity. regarding

Questionnaire, state, Oregon 3) Mean job satisfaction score was 41.79 research.

Job Descriptive and California (range 0-54), indicating a high degree of

Index satisfaction.

4) Role ambiguity was moderately and

inversely correlated with job satisfaction

(r -. 5246, p< .05).

5) Length of time in CNS position and

role ambiguity was moderately inversely

correlated. Nor value provided, p< .05. 9

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

Rizzo, To report on Satisfaction, Rizzo, House & 264 1) Two factors were extracted which Strength:

House & development of leadership, Lirtzman Role managerial account for 56% of the common variance: Development

Lirtzman a questionnaire organization Questionnaire and technical role ambiguity and role conflict. of a tool to

(1970) , anxiety employees of 6) Overall negative correlations indicate measure role

a large lowered degrees of need fulfillment with conflict and

manufacturing increased role conflict and role ambiguity: role

plant (all p < .05) ambiguity.

Autonomy r -.54 with role ambiguity Weakness: - Pay r - .40 with role ambiguity Generalizabi Ii

Persona~ recognition r -.56 with role ty to nurse

ambig population.

.. Advancement oppty r - .22 with role

conflict

Formalization r - .57 with role ambiguity 10

Author Purpose Variables Tools/ Number/ type Findings Strengths/

measured Instruments of subjects weaknesses

Goal consensus and clarity r - .48 with

role ambiguity )

Teamwork facilitation of supervisor r -

.45 with role conflict

. Tolerance of error by supervisor r - .27

with role conflict - Job induced anxiety r .22 with role

ambiguity Appendix J January 11, 2000 Dr. Sidney I. Lirtzman Office of the President Baruch College 17 Lexington Ave. ~~R_U.(H. __COl_t~q New York, NY 10010 JAN J 9 200C ,' L______- _j Dear Dr. Lirtzman: OFF/CE Of fht t-'h~SiUENT I am a doctoral student at the Medical College of Georgia, School of Graduate Nursing, Augusta, Georgia. My dissertation research is concerned with predicting role stress, role conflict and role ambiguity in telenurses, nurses who use telemedicine technology in their practice. For purposes of my dissertation research, I would like to request permission to utilize the Rizzo, House and Lirtzman Role Questionnaire.

Thank you in advance for your consideration of this request.

Loretta Schlachta, RN, MSHP, CHE

~11 ~~ . ';,l1c ~

~ ½,.-, ~"s ~'-""' _(., LW

Loretta Schlachta, RN, MSHP, CHE I ~ 6935 North Clifton Road (' . J --1'1 / Frederick, MD 21702 ~'- · Voice 301-371-8478 ♦ Facsimile 301-371-8538 Email [email protected] January 11, 2000 Ruth Degeorge Nursing Department F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Dear Ms. Degeorge:

I am a doctoral student at the Medical College of Georgia, School of Graduate Nursing, Augusta, Georgia. My dissertation research is in the area of telenursing/telemedicine. For purposes of my dissertation research, I would like to request permission to adapt the model depicted in the following reference:

Jacqueline Fawcett, 1999. The Relationship of Theory and Research. Page 64.

I plan to adapt the model to incorporate my own concepts and empirical elements that pertain to my dissertation. Thank you in advance for your consideration of this request.

Loretta Schlachta, RN, MSHP, CHE

)· -' -1 ,, :/A.,,.l....f~ '/ P'--<- -~~~ c!_'';LJ:A__,,_;_ "'-·L cc~~x

Loretta Schlachta, RN, MSHP, CHE 6935 North Clifton Road Frederick, MD 21702 . Voice 301-371-8478 ♦ Facsimile 301-371-8538 Email [email protected] DIRECTIOS FOR DECISIOSS

February 15, 20.00

Loretta Schlachta

Dear Ms. Schlachta:

This letter gives you ·permission to utilize and modify the Index of Work Satisfaction Questionnaire. If you have any questions, please do not hesitate to call.

Office Manager

395 Pleasant Street Northa~pton MA 01060 voice.413.584.0465 fax 413.582.1206 www.:i:;rinfo.com [email protected] Appendix K School of Nursing July 7, 2000 Mental Health:Psychiatric Nursing

Dear (Code# ):

. You are invited to participate in a research study that will describe the telenursing role in relation · to work satisfaction, role stress and characteristics of the work of telenurses. Your participation is very important to the study and to the as-yet undefined body.of knowledge regarding this new nursing role. This research is in support ofmy dissertation and also my continued interest in the role(s) of nurses in telemedicine-delivered care. I hope that you will agree to participate by either:

_1) accessing and completing a web-based questionnaire at http://www.pollcat.com/ty9j0fi5di~a or 2) calling 1-877-230-2420 (toll free number) and completing a telephonic questionnaire \ Directions for completing the Telenursing Role Questionnaire are found on the website or will be given telephonically. Yomresponse will be confidential. I ask that you provide the code number above so that I may track responses for followup reminders to those who did not complete the survey. Only the investigator cart access your response. In the event of any publication or report regarding this study, your identity will not be disclosed. All information will be removed from the web server at the completion of this study. ·

No potential risks are anticipated due to participation in this study. Some irritation related to interaction with the web site may occur. In that case, you can participate by using a toll-free phone number available to you from 8 AM till 11 PM Eastern Standard Time as an alternative.

Your participation in this research is entirely voluntary. You may decide to decline from completing a specific part of the survey or the whole survey without any penalty. Your completion and submission of the questionnaire by web or by telephone constitutes your consent to participate. If completing the survey by telephone, you may be asked for permission to audiotape your responses in order to provide quality assurance for the qata entry. If you decline to have your survey audiotaped, you can still participate in the telephone survey without audi~taping. ·

If you have any questions about the research, yo_u tnay contact the researcher Loretta Schiachta, RN, PhD(c) at...... ,r email at [email protected] or you may contact the faculty advisor, Dr. Su~rotteau at 706-721-4602. Any questions about the rights of human subjects may be directed to Dr. Schuster, Chair of the Medical College of Georgia Human Assurance· Committee at 706-721-3110.

Thank you for your participation. Your response is very important for the study and for our profession. Sincerely yours,

Loretta Schlachta, RN, PhD(c), CHE

Augusta, Georgia 30912-4220 (706) 721-4602 An Affirmative Action/Eoual O □□ ortunilv Erlur.~tion~l lnstit11tion