ambulatory patient needs identified by the...
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Ambulatory patient needs identified by the nurseperforming in an expanded role in four settings
Item Type text; Thesis-Reproduction (electronic)
Authors Sterne, Jean Garnet, 1945-
Publisher The University of Arizona.
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Link to Item http://hdl.handle.net/10150/554601
AMBULATORY PATIENT NEEDS IDENTIFIED BY THE NURSE PERFORMING IN AN EXPANDED ROLE IN FOUR SETTINGS
by .Jean Garnet Sterne
A Thesis Submitted to the Faculty of theCOLLEGE OF NURSING
In Partial Fulfillment of the Requirements For the Degree ofMASTER OF SCIENCE
In the Graduate CollegeTHE UNIVERSITY OF ARIZONA
STATEMENT.BY AUTHOR
This thesis has been submitted in partial fulfillment of requirements for an advanced degree at The . ..University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Libraryo •
Brief quotations from this thesis are allowable without special permission 9 provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript, in whole or in part may be granted by the head of the major department of the Dean of the Graduate College when in his judgment the proposed use of the. material is in the interests of scholarship. In all other instances9 however, permission must be obtained from the author.
SIGNED:
APPROVAL BY THESIS DIRECTOR
This thesis has been approved on the date shown below:
ARLENE M „ PUTT . ~ ^DateProfessor of Nursing
ACKNOWLEDGMENTS
The researcher wishes to express her sincere gratitude to her thesis committee members: Arlene Putt 9 Ed o Do, Chairman; IXene Toten, Assistant Professor of Nursing, Louella Murphy, Assistant Professor of Nursing from the College of Nursing for their cooperation and assistance during this study»
A note of thanks must be given to the patients who graciously cooperated to assist the researcher in her studyo
Gratitude is also expressed to John MacGregor,MoD o ; David Ben-Asher , M »D <> ; Brendan Phibbs , M „D «, ; Samuel Goldfein, M „D „ ; John Wenham, M o D 0 ; Howard Lawrence, M * D „3 and Charles Harter, M «D o for their support and guidance during this study»
Lastly, the author would like to thank her husband, Robert Sterne, for his understanding, encouragement, and enduring support throughout all phases in the completion of this thesis <>
TABLE OF CONTENTS
\ ̂:Pase\ :LIST OF TABLES » o e c o o » • o o » » <, » . . . . viiABSTRACT . . „ .. . o . o . o « o o <> » , c o o • viiiCHAPTER
l o PRESENTATION OF THE PROBLEM o . o o o c o o . 1The Purpose of the Study » . o • o o o » o 2Statement of the Problem o o » » * o o o o 2Significance of the Study » o o » o o o ® 3Hypothesis to be Tested « o @ „ o o o » « 3Theoretical Framework o ® ® ® . » ® o 4Application of Theory to the Research
Situation © .« ® @ © ® .« © © © © © © © © 3Ass ump11ons ® © © © * © © © © o ■ ©■ © © © © 6Definitions © © ■© © © © © © © © © © © * ©. 6Limit a11ons © © © © © © © © © © © © © © © 7 -Organization of the Study © © © © © o » © 8
2© REVIEW OF THE LITERATURE © © © © © © © © © © © 9Indications for an Expanded Role of
the Nurse in the Care of Ambulatory Patients © © © © © ©© © © © ©@ @@ © © 9
Identification of Patient Needs andthe Expanded Role of the Nurse © © © © 10
Interviewing Skills and the ExpandedRole of the Ambulatory Care Nurse © © © 12
Physical Examination and the ExpandedRole of the Ambulatory Care Nurse © » © 13
Counseling and Therapeutic Listening and the Expanded Role of theAmbulatory Care Nurse © © © © © © © © © 15
Consultation , Coordination 9 andReferral Activities in the Expanded Role of the Ambulatory Care Nurse © © © 17
Research Activities and the ExpandedRole of the Ambulatory Care Nurse © © © 19
Summary © © © © © © © © © © © © © © © © © 20
i iv
V
TABLE OF CONTENTS— ContinuedPage
3. RESEARCH DESIGN „ „ . . . „ „ . . .... . . . 21Design of the Study . . . . . . . . . . 21Collection of Data . . . . . . . . . . . . 23Categorizing the Data .. . . . . . . . . . 24
4. PRESENTATION AND.ANALYSIS OF DATA . . . . . . 27Characteristics of the Sample . . . . . . 27Findings Related to the Hypothesis . . . . 29
5. DISCUSSION OF FINDINGS . . . . . . . . . . . .. 36Findings Related to the Theoretical
Framework and Hypothesis . . . . . . . . 36Recommendations. . . . . . . . . . . .... 38
6 . SUMMARY - o . 0 . . . 0 0 . . . . . . . . . . . . 40Methodology . . . . . . . . . . . . . . . . 4lF xndings . . . . . . . . . . . . . . . . . 41Conclusions . . . . . . . . . . . . . . . 42
APPENDIX A. IDENTIFICATION OF PHYSIOLOGICALNEEDS OF AMBULATORY PATIENTS —RAW DATA. SHEET . . . . . . . . . . 44
APPENDIX B. INTERVIEW SCHEDULE TO OBTAIN MEDICAL.HISTORY FROM THE AMBULATORYPATIENT TO IDENTIFY PHYSIOLOGICALNEEDS 0 0 0 0 4 . .. o o o . e e o o e ■ 46 .
appendix c. In t e r v i e w questions to identify: PHYSIOLOGICAL NEEDS DURING A
COUNSELING SESSION WITH THEAMBULATORY PATIENT . . . . . . . . . 48
APPENDIX D. INTERVIEW SCHEDULE TO IDENTIFYSAFETY, LOVE, ESTEEM, AND SELF ACTUALIZATION NEEDS OF THE AMBULATORY PATIENT BY THE NURSE IN AN EXPANDED ROLE . . . . . . . . . 50
APPENDIX E
... .. vlTABLE OF CONTENTS--Continued
PageIDENTIFICATION OF PSYCHOLOGICAL
NEEDS OF AMBULATORY PATIENTS —RAW DATA SHEET . „ . „ „ . . „ . „ . 52
REFERENCES CITED „ . «, . . „ „ „ . « „ „ „ „ „ „ .„ 53
LIST OF TABLES
Table Page1 o Age of Patients in Four Ambulatory Health
Care Settings #. <> © o © © © © © © © © © © © 282© Ambulatory Patients ? Basic Needs
Identified by the Nurse Performing the.Expanded Role in Four Ambulatory HealthCare Settings @ ©■ © © © © © © © © © © © © © 30
3 e Chi Square Analysis of the Total Number ofNeeds identified for Ambulatory Patients © © 30
4 © Total Number of Needs Identified forAmbulatory Patients According to TheirS eX » o © © © © © © © © o . o © a o © ® © o o 31
5 © Chi Square Analysis of the Total Number ofNeeds Identified for Ambulatory Patients According to Their Sex © © © © © © © © © © © 32
6 © Frequencies of Role Components Delineatedby a Nurse in an Expanded Role in Identification of Ambulatory Patients*Needs in Four Settings © © © © © © © © © © © 33
7 ® Total Number of Ambulatory Patient NeedsIdentified According to AcademicEducation for Employment © © © © © © © © © © 3^
vii
ABSTRACT
The focus of this study was on the identification of ambulatory patients 1 basic health needs and the analysis of the role the nurse performed to identify these needs„ Maslow’s hierarchy of needs 9 as a theoretical framework 9 provided structure in determining the significance of identification of patients 1 basic health needs by the nurse performing the expanded role»
Thirty-five patients in four ambulatory care settings: a cardiac clinic of a university medical center 9private physicians ? offices , and an emergency room of a 300 bed general hospital were included in the study as they chose to visit the ambulatory health care facility*
Measures for this study were: (1) interviewschedules to identify basic physiological and psychological health needs, and (2) the tabulation of the number of patient health needs identified by the nurse performing the expanded role*
The findings of the study warranted the rejection of the null hypothesis: There is no significant differenceof basic physiological and psychological needs identified by the nurse in an expanded role caring for patients in the four ambulatory health care settings*
:
: ' ' - - 'The nurse in the expanded role significantly
identified basic health needs for female patients with gastroenterology disease and for non-professionally employed patientso
Additional research should be conducted using the team approach of professional nurses in comparing educational preparation to roles performed in identifying patients 1 basic health needs«
CHAPTER 1
PRESENTATION OF THE PROBLEM
Over the past two decades, the crisis in the delivery of health care has precipitated the development of assistant health careerists to help physicians and nurses meet the increased demands for health care of individuals and familieso The American Nurses' Association (1970) has made an official statement recognizing the need for technicians and new types of health careerists » The main concern of this professional organization was that the growing number of health assistants will increase fragmentation and lead to a decline in authority and accountability for patient care thus impairing the meeting of the total health needs of individuals and families« One alternative to retard such occurrences has been the expansion of the nurse's role = This expansion should relieve the professional nurse of non-nursing duties to provide for total patient care in a manner that promotes continuity and responsibility of the practitioner for services rendered (American Nurses' Association, 1970). !
1
The Purpose of the Study The purpose of the study was to identify ambulatory
patient needs by a nurse performing in an expanded role in four outpatient settings » More specifically 9 the investigation attempted to identify needs of ambulatory patients that will provide a broader data base from which to plan for meeting the patient's total health needs• The expanded role of the nurse as a primary health care agent in the outpatient setting will be described in terms of what activities she performed to identify both physiological and psychological needs of patients„
Statement of the Problem The controversy today regarding the expanded role
of the nurse is concerned with definition of the relationships of the patient to the nurseo The role requires a liberalized approach to meet the needs of the ambulatory patient o In this study , the expanded role of the nurse requires a direct comparison of what the needs are of patients in the outpatient facility of a university medical center, two private physicians’ offices, and an emergency room of a 300 bed general hospital» When needs of these patients have been identified, a role can be described and developed for the nurse giving comprehensive care in the proposed expanded role concept» The research attempted to answer the following question: What needs of ambulatory
. .3patients does the nurse in an expanded role identify in four settings: a clinic of a medical center, two privatephysicians? offices, and an emergency room of a 300 bed general hospital?
Significance of the Study The problem this research attempted to solve is
significant because the answer will contribute to the general definition of the expanded role of the nurse <> Patients will benefit because the nurse caring for them will have a clearer definition of her role as a practitioner e Presumably, the question the research sought to answer will identify specific needs of ambulatory patients, and the potential to provide continuity of care when the nurse assumes in a systematic manner, the role described„ x _
Hypothesis to be Tested The hypothesis tested in this study was: There is
no significant difference of basic physiological and psychological needs identified by the nurse in an expanded role caring for patients in four ambulatory health care settings of:
1 o A cardiac clinic of a university medical center®2 o A .gastroenterologist 9s private office ®
3 o A nephrologist f s private office <>4 o An emergency room of a 300 bed general hospital o
Theoretical Framework The general framework within which the research is
conducted is a theory of a hierarchy of needs based on the work of Maslow (1954)„ Maslow defined fundamental motivational tendencies as needs, and described man as possessing a hierarchial system of needs (Maslow, 1970) ».
Vernon (1969) in an attempt to describe this hierarchial system proposed a model shaped like a pyramid <> At the base of the pyramid were man's physiological needs o On the second level was safety; the third, love; the fourth self esteem and esteem for others; and at the summit, self actualizationo
Maslow (1970) defined his concept, self actualization , as the highest motivational organization of man« The prerequisite of self actualization is the satisfaction of the physiological, safety, love, and esteem needs„ Self actualization involves according to Vernon (1969)9 in addition to satisfaction of lower needs, a capacity to overcome frustration and conflict <> This requires integration of motivational related interests, personal achievements , and involvement of human relationships*
Some primary characteristics of the self actualizef (Maslow, 1970) are:
: ■ . ■ : :V -lo S elf acceptance o2 o Spontaneity of behavior and inner life'o'3 o Problem centered approach to life in fulfilling a
mission or task o4 e Capacity for creativity and appreciation for the
basic things in life o
5 o Identification of a feeling of affection for mankind o
Toffler?s (1970) suggestion of not merely helping people to survive9 but helping them to gain new mastery over their destinies, by designing new social and personal change regulators9 is a way to achieve self actualizationo
Application of Theory to the Research SituationThis study applied the theory of Maslow fs hierarchy
of needs to the ambulatory patient visiting the clinic, physician's office, or emergency room. The research proposed that the ambulatory patient's needs are arranged in a hierarchial system and that before attainment of self actualization, his basic needs must be identified o This identification of basic needs has to be conducted in a personal and social manner that aims basically to help ambulatory patients be motivated to actualize independence, self acceptance, and achieve a problem centered approach to coping with their dis ease o The research nurse, as a change regulator, attempted to identify physiological needs
of the ambulatory patient through the performance of certain activities of a prescribed role. Psychological needs were identified by interviewing the patient to obtain information about his desire, yearning, or lack of a basic need to be fulfilled.
AssumptionsIn application of the above theoretical framework
to this research, the following general assumptions were made:
1, Patients in the clinic or office have a hierarchial system of needs that are not completely fulfilled.
2. Patients can express themselves in English in answering questions of the interview schedules designed to elicit data about their basic needs.
D e f initjons1. A multidirectional approach to fill a perceived
gap, and a projection of new components (activities) into health care is the performance of activitiesto identify physiological needs of the patient (Murphy, 1970).
2. A traditional office nurse role is defined by Yankauer (1969) as a technical, clerical positioninterspersed with laboratory duties delegated by the physician.
. \ W .....................; ; .■... : ; ; 73= In the expanded role, the nurse as a primary care
agent is one who makes initial and continuing assessments of a person's health status in collaboration with or independently from others ("The Nurse as a Primary Care Agent," 1971)°
4. A basic unfulfilled need as defined by Jourard(1967) is a prevalent state of being of a feeling of yearning, lack, or desire.
5« A professional is defined as one who has academic education for employment such as law, medicine, nursing, etc.
LimitationsV ------------------ -------------
In answering the question posed in this research, the study is restricted by the following factors:
1. The study sample is composed of 35 patients: 9 cardiac patients seen in the cardiology clinic of a university hospital, 9 gastroenterology patients seen in a private physician's office, 9 patients seen in a general hospital emergency room, and 8 nephrology patients seen in a nephrologist's officeo
2. The patients were under the care of a physician chosen on the basis of his use of the ambulatory health care setting delineated above.
3 ° The patients received care by one nurse researcher9 performing the expanded role in a clinic setting, private physicians* offices, or the emergency room of a 300 bed general hospital <>
Organization of the Study This chapter has described the background concepts
of the expanded role of the nurse in the ambulatory care setting, and the theoretical framework within which the research was conducted o
The following chapter reviews the literature related to identifying the needs of ambulatory patients and the role of the nurse in a clinic or physician *s office»Chapter 3 discusses the research design, measurement instruments selected for use, and the study sampleo
Chapter 4 presents the analysis of data, the characteristics of the sample, and the findings related to the hypothesis using Chi Square method of statistical analysis «>
Chapter 5 is a discussion of the findings related to the theoretical framework and the hypothesis with recommendations for further study *
Chapter 6 is a summary of the research study including the purpose, methodology, findings, and conclusions of the data obtained from 35 patients encountered in four ambulatory care settings.
CHAPTER 2
REVIEW OF THE LITERATURE
Chapter 2 contains a brief review of the literature pertaining to the expanded role of the nurse and the needs of ambulatory patients.
Indications for an Expanded Role of the Nurse in the Care of Ambulatory Patients
The crisis in American health care as reported by the "Report of the National Advisory Commission on Health Manpower" (1966) emphasizes the inadequate health care delivery system where providing better health care requires greater utilization of the existing manpower resources.The approach to meeting the needs of patients requires a role change of health professionals to provide more services. The nurse in an expanded role is one proposed solution to bridging the gaps of the current health care delivery system.
From 1959 t° 1968, cost of living rose 20 percent as compared to medical costs that rose 45 percent, while hospital costs rose 122 percent ("Plight of the U.S. Patient, " 1968). Improved general living conditions, better diets, and housing facilities contributed to increased life expectancy according to Lysaught (1970).
9 . . - " '
■ : ' 10The result of increased life expectancy requires
that the health professional provide mor'e service than ever before for a longer period of time to meet the rising health needs of the very young and the very old populations (Lysaught, 1970).
Identification of Patient Needs and the Expanded Role of the Nurse
Identifying needs of patients involves a nurse- patient relationship that has often been termed a caring interaction. The physician’s role has been one of curing involved with diagnostic and treatment procedures in the delivery of health care to patients.
In 1958, Schulman reported that care functions of the nurse were diminishing and one decade later, Duff and Hollingshead (1968) identified a primary role of the nurse as a personal assistant to the physician. The nurse: helped directly by giving medication, collecting specimens, and assisting with treatments; but spent little time learning the medical, social, and personal problems of the patient. The conclusion was drawn that the nurse-patient relationship was administrative, task oriented, and technical. Yankauer (19.69) emphasized the need for further study of the working duties of the nurse in giving ambulatory care because there was little available data in the literature about such a role.
.. .• ; V ..V V'_ ; ■ . ■ • 11Speaking before the United States Senate Ways and
Means committee on national health insurance, Traux (1971) said that because nurses have continual and intensive contact with patients and families, they are more aware of the consumers’ desires and needs than any other health professional group.
Millis (1970) stated that the difference in the care-cure model was the relationship of the professional to his patiento • The physician pays periodic visits to the patient whereas, the nurse is involved in a continual interaction process with the patient.
The nurse, as a primary health care agent involved in a continual interaction process with 33 clinic patients, was studied by Lewis and Resnik (1967). These authors related that patients in the experimental clinic complained less of the care given by a nurse as opposed to the patients who were treated in the usual manner in the control clinic.
Leonard and Tyron (1965) theorized that if a patient is approached as possessing the ultimate decisioii to accept or reject care, then the effectiveness of that care is increased and is satisfactory to both patient andstaff. .
In the outpatient setting as compared with in- patient settings, the consumer has more control in the nurse-patient relationship. The manner in which the nurse
.. ; ;- 12functions can determine, to an extent, the benefits derived by the patient in the clinic visit.
Interviewing Skills and the Expanded Role of the Ambulatory Care Nurse
Expansion of the nurse's role by greater use of interpersonal skills, such as interviewing to identify health needs is one activity that can influence the benefit a patient derives from a visit to the clinic = The nurse usually thinks of herself as one who relates to people who are sick. Shanks (1970) emphasized that the nurse must use her scientific, observational, and objective skills with personal qualitative judgments in relating to patients. Added to this, Mouchel (1970) stated that standards of care will improve when nurses learn how to question patients to obtain information.
Bermosk (1964) pointed out that the relative structure found in the interview for health need identification is based upon the nurse's understanding of human behavior and her skills in using the principles of interviewing. The nurse researcher takes her cues from the patient as he presents his problem through verbal arid nonverbal communications.
According to Salnit (1966) , the interview should serve as a basic instrument for diagnosis and treatment.It should be flexible enough to allow for expression of the
• . . ‘ ■ 1 ̂ patient's fears, anticipations, and questions about hissymptoms.
Interviewing then is a function by which the nurse can clarify the patient's reasoning for coming to the clinic or office. The nurse's performance affects the structure and outcome of the interview to identify the health needs of the patient.
Physical Examination and the Expanded Role of the Ambulatory Care Nurse
Siegal and Bryson (1963, p. 1015) almost a decade ago, cited that "clinics" have a responsibility for determining physical and emotional handicaps of patients as well as a responsibility toward preventive aspects of combating nutritional and communicable diseases. One way to screen patients for physical handicaps or disease is to perform a physical examination.
Private practitioners responded positively to nurses performing physical examinations in a survey conducted by McCormack (19?1) provided the physicians had . been associated with highly competent nurses. These physicians were willing to delegate to the nurse this responsibility.
From a study of 1000 apparently well persons, examined by a nurse, then a doctor, Kaku, Gilbert, and Sachs (1970) concluded that there were few serious differ- - ences in the recorded findings.
: ■ 14A questionnaire administered to nurses 9 residents9
and medical students on acceptability of role expansion strongly advocated that it was "all right" for nurses to perform screening physical examinations„ Younger personnel unexposed to rigid role expectations 9 tended to be more receptive to role changes (Reed and Roghmann, 19719 p » 372)
The older the clinician as reported in "Why the Routine Physical--Is Anything But" (1972), the more likely he was to feel that physical examinations should be done alone by the doctor 9 whereas residents and hospital based physicians favored a doctor-nurse team approach during the examination.
Among others, Swedish diabetic nurse specialists (Donaldson, 1971) , pediatric nurse practitioners (Silver, 1971)9 and student health service nurses (Hofheims, 1972) all practicing in the expanded role, have been reported as performing physical examinations for evaluation of presence and severity of disease, and routine health screening purposes -
Patients surveyed as to acceptance of nurses in the expanded role responded according to socioeconomic class„ Upper middle class professionals accepted the nurse performing physical examinations while lower working class patients preferred the physician to do the examination (Conant, 1971)•
Morgan (1971) answers the question 9 "Should nurses do physical examinations ? ,! with the comment that compet ence is not the major problem-- Rather 9 nurses and physicians must collaborate as a team to identify a wider spectrum of needs.
In addition to performing physical examinations
for evaluation or screening purposes 5 Schiff (1969) 3 Yankauer (196 9 ) 9 and Donaldson (1971) reported that the
nurse in an expanded role did a complete blood count,
histological tests, urinalysis, clinitest-acetest9 stool
guiac, and stool cultures as routine laboratory tests -
Yankauer (1969) also reported that pediatric nurse practitioners as primary care nurses performed hearing, vision, and developmental screening tests as well«
Counseling and Therapeutic Listening and the Expanded Role of the Ambulatory Care Nurse
Cartwright and Scott (1961) studied the work of a nurse employed in a general practice in England. Among those traditional duties which included direct physical care, she reported that the nurse functioned as a counselor with patients» During home visits the nurse discussed the nature of the patient's illness, how it was likely to develop, and what signs and symptoms were usual, She also cleared up misconceptions of disease or illness a patient might have expressedo
■ : ■ 16 Farissey (1967 ̂ and McCormack (1971) recognised
that patients have problems related to psychosocial care. Therapeutic listening was the approach necessary to meet these problems and this was often a neglected need of outpatients.
According to Donaldson (1971) Swedish nurse specialists counseled diabetic patients regarding mechanisms and treatment of their disease as it applied to their life situation. Schiff (1969) reported that nurses in the expanded role in a pediatrician's office counseled mothers at particular times during postpartal care and also during visits to the patient in the hospital. During these counseling sessions, Schiff (1969), a physician, noted that the mothers discussed facts and feelings which they felt were hot relevant to discuss with the physician. Such discussions led to earlier recognition of patient needs and initiation of treatment before major complications.
Suchman (1965) listed four factors influencing psychosocial care that should be considered during counseling sessions by the nurse. These include adaptations that a patient makes to illness according to:
1. Symptom experience. I2 . Assumption of the sick role. i3« Medical care contact.4. Recovery phase. "
- -17Certain assumptions have been made«, according to
Redman (1968) 9 by nurses that take for granted a patient gs health needs that may require identification during counseling sessions. These include the abilities to:
I. Describe symptoms»2o Carry out treatments„3 - Keep appointments <,4. Follow up referralso
Consultation, Coordination, and Referral Activities in the Expanded,Role of
the Ambulatory Care Nurse
DeYoung and Towers (1968) indicated that defining the role of nursing was viewed as an interdisciplinary approach that allows for a greater base of data collection to accept or reject the role change. An interdisciplinary approach advocated by Bates (1970) and Morgan (1971) to role definition is the cardiologist-coronary care nurse team working together to identify a wider spectrum of needs of the patient.
In consultation9 the interdisciplinary approach of identifying needsv provides the opportunity to select or reject a greater number of alternatives in the coordination of health services for the patient. Wang (1970) after studying the ambulatory nursing service provided for chronically ill patients9 concluded that these services varied with the needs of the patient, Coordination of care
■ ■ ■ ■■ : , V- ■' : .
involved the nurse acting at times as the patient's advocate when accompanying him to other services*
Wang and Brayton (1970) in a later report of the Health Maintenance Service Project of chronically ill patients clarified further the role of the nurse. As a primary care agent consulting with various physicians of specialty clinics, the nurse established a consensus regarding the primary service goals for the patient»Reality oriented discussions regarding the purpose of the clinic patient's visit enabled the nurse to make plans for . long term care* Frequently identified needs were housing and medication scheduling that the patient was unable to provide for himself, The nurse referred the housing problem to social services, and contacted the public healthnursing service for supervision of medication routines *
Another method for providing consultation services is to have the nurse available for telephone conversations as patients call the clinic or office to ask a question about a particular health problem ( "Six "Easy Ways' to Save Time on the Telephone, " 1971) » The nurse can interview thepatient by phone to determine what health needs must be metimmediately and then advise the patient accordingly regarding appointments, referral or other agency visits*
Cartwright and Scott (1961) , studying the work of the nurse in a general practice, identified a consultant role to the physician, Wang (1970) clarified that the type
of physician making the most referrals to the nurse in a
collaborative manner had the longest experience in a team
relationship with the nurse. Physicians with the least
amount of experience in a team relationship with the nurse
usually referred the patient in a one way direction with no
mutual plans of agreement evidenced.
Research Activities and the Expanded Role of the Ambulatory Care Nurse
Direct responsibility of nurses participating in
medical research conducted by Beloff5 Korper5 and Weinerman
(1970) at Yale was to study medical students as they pro
vided comprehensive patient care in a clinic setting. In
contrast in a twelve year experience at Rochester
University, the nurse supervisor gave direct patient care
supporting the patient in the physicianfs absence in a
study of Combined Staff Clinic Program (Reed, 1970). The
differences in function of the above reported situations
involving nurses was the type of participation in medical
research. The nurse in the project conducted by Beloff
et al. (1 9 7 0 ) evaluated the capabilities of the medical
students providing comprehensive care. Nurses 9 roles
varied from being participators whose activity was measured
to being evaluators of the performance of medical students
and house officers.
20
SummaryThe above review of the literature related to the
expanded role of the nurse as a primary care agent for patients in the ambulatory health care setting. The nurse by increasing her skills to offer a broader range of services;
1. Learned to take a comprehensive health history that served as a data base for planning individual health care plans ®
2 o Increased her technical physical assessment skillsto detect the presence or severity of disease*
3« Learned interview techniques to facilitate thegathering of pert inent facts about the patient 9 s health needs5 and expectations of health care during counseling and therapeutic listening sessions»
4* Acted at times as the patient's advocate in th6home, hospital9 or community to coordinate thedelivery of health services to the patient.
. ' •>
From the review of the literature then 9 an outline of the role of the nurse in an attempt to reduce fragmentation and increase accountability for the quality of patient care has been developed to identify patients 9 basic health needs - These activities , mentioned above 9 are the expanded role of the nurse.
CHAPTER 3
RESEARCH DESIGN
The focus of this descriptive study was on the identification of ambulatory patients' basic health needs and the analysis of the role the nurse performed to identify these needs. In addition, demographic variables of age, sex, and occupation were also included in the study to indicate any trends in the sample population that the nurse researcher encountered in the ambulatory care setting.
Design of the StudyThis study Categorizes the psychological and
physiological needs of 35 ambulatory patients in four outpatient settings identified by a nurse in an expanded role using an interview schedule adapted from questionnaire by Modell and Schwartz (1962). This tool was pretested in the following manner. The above questionnaire by Modell and Schwartz (1962) was submitted to 8 patients in a medical clinic. From the responses obtained and consultation with a cardiologist, the interview schedules were derived for use in this study (see Appendix A).
The patient population consisted of 35 patients: nine cardiac, nine gastroenterology, nine emergency room,
’ 22and eight nephrology patients who met the following criteria:
lo Had medical diagnoses characteristic of the clinic or specialty office or hospital department in which they chose to seek health care assistance.
2 o Were between the ages of 20 and 80 years of ageand were able to speak, read, and write the English language <, <
3 o Were under the care of a physician who consented tohave their patients included in the study,
4o Voluntarily indicated their willingness toparticipate in the study knowing they would remain anonymous and could withdraw anytime they wanted without effect to their medical care® The subjects of this study were selected randomly as they made appointments or chose to visit the ambulatory care facility. On each appointment day sampled, the first and third patient who met the study criteria were included in the study in each of the four ambulatory care situations®
5 ® Were selected from diverse geographical communitylocations that included a cross section of Anglo 9 Mexican, and Indian residents ®
6® Who chose to use the following ambulatory cafe facilities:
a o A cardiac clinic in a university student neighborhoodo
bo A gastroenterologist and nephrologist's office located in middle income urban neighborhoods o
Co An emergency room of a 300 bed general hospital situated in a predominantly mixed English and Spanish speaking neighborhoodo
Collection of Data Data were collected over a ninety-day period from
August to October, 1972oPart of the expanded role of the nurse in this
study included the interviewing of patients to identify basic health care needs » The interview schedules used to measure physiological needs of the ambulatory patients were designed by the nurse researcher and a cardiologist with twenty-five years' experience in outpatient medicine. In addition 9 adaptation from Modell and Schwartz's (1962) questionnaire to identify nursing needs such as food, :fluid9 oxygen5 etc• was also incorporated into the tools„ The tools utilized to identify physiological needs are in Appendices A 9 B , and C o
A tabulation was made on the raw data sheet form of the physiological needs identified by the nurse performing the prescribed role. The tool utilized is in Appendices
24The measurement of psychological needs by the nurse
was by interview. Jourard (1967) stated that a basic need was not fulfilled if a desire, yearning, or lack was prevalent. Four questions were asked to determine if the patient had the needs (Yura, 196?):
1. Love o2. Esteem»3. Security.4. S elf-actualization.
If the patient indicated a lacking or desiring of a basic need, it was recorded as an identification of an unmet need on the raw data sheet. The tools utilized in identification of psychological needs are in Appendices D and ® «
Categorizing the Data The needs of the patients identified in the
ambulatory setting by the nurse performing the expanded role were categorized according to Maslow's hierarchy of needs into basic physiological and psychological health needs . ■ :
It was important to the study to:1. Know the frequency of patient health needs
identified by the nUrse performing the expanded ■ role. ' ■
2. Evaluate the most frequently identified health care needs of each group of patients encountered in the ambulatory health care setting.
The Chi Square method of statistical analysis with a .05 level of significance was used to determine any significant difference in the health needs identified by the nurse.
In addition to the examination of patients * health needs identified, the system of need identification utilized by the nurse researcher was studied.
The role components for the expanced role were obtained from a review of the literature pertinent to research studies done about the expanded role of the nurse in the ambulatory care setting. These are
A. Performs physical screening examinations and records assessments.
B. Interviews to obtain health history.C. Performs routine laboratory examinations or makes
requisition for them.D . Counsels patient to identify specific health needs.E. Coordinates patient care to identify specific
health needs. .F . Works collaboratively with physician and other
health team members to plan patient care and identify specific health needs.
26Go Makes home visits to identify health needs of
ambulatory patients* *Ho Identification of psychological needs *
It was important to this study to:1 e Know the frequency of the role components performed
by the nurse in the expanded role *2 o Identify the most frequently performed role
components * 1 -3 o Determine if there was a significant difference in
the role the nurse performed in the ambulatoryhealth care setting.
The Chi Square method of statistical analysis with.05 level was used to measure any significant differences
, . '
in the role the nurse performed in the ambulatory health care setting*
CHAPTER 4
PRESENTATION AND ANALYSIS OF DATA
The analyses of data in this study are presented in this chapter„
Characteristics of the Sample Thirty-five patients, 13 professionally and 22 non-
prof ess ionally employed patients in four ambulatory cafe settings were studied by a nurse performing an expanded role to identify health care needs. The patients were treated by private physicians in a university cardiac clinic, private physicians' offices, and an emergency room of a 300 bed non-profit community hospital located in the southwest part of the country. The age range of the l4 male and 21 female subjects reported in Table 1 was from 20 to 80 years with a mean age of 40.0 for the emergency room patients, 53*5 for the nephrology pat Tents, 55•5 for the cardiac patients, and 59°2 for the gastroenterology patients. The average age for the patients as a total group was 52.0 years. In Table 1 the age ranges of the subjects in this study are presented.
27i
28Table 1. Age of Patients in Four Ambulatory Health Care
Settings
Setting Subject Age Mean AgeCardiac Clinic 1 50 55.5
. * 2 473 674 605 286 6o7 598 579 72-
Gastroenterologist's Office '/ x 36 59.22 433 624 775 636 657 698 729 ■ 46
Nephrologist's Office l 57 53 -52 653 554 675 566 607 388 8d
Emergency Room 1 20 40o02 223 24 04 205 396 677 338 749 6i
29Findings Related to the Hypothesis
The hypothesis of the study stated: There is no
significant difference in the basic physiological and
psychological health needs identified by the nurse in an
expanded role while caring for patients in four ambulatory
health care settings of:
1 o A cardiac clinic of a university medical center.
2 d A gastroenterologist 's office.
3 o A nephrologist's office
ko An emergency room of a 300 bed general hospital.- s ■Ambulatory patients' basic needs identified by the
■ - 1 nurse performing the expanded role are categorized in
Table 2 * The results of this study in regard to the
hypothesis are presented in Tables 2 and 3«
As seen in Table 2 9 the differences in the total
number of needs identified per patient group was:
gastroenterology, 55 ; cardiac 9 kO; nephrology 9 3 1 ; and
emergency room 3^ ® The Chi Square method of analysis was
used to detect any significant differences in the needs
identified by the nurse per ambulatory patient group.
In Table 3 are reported the Chi Square analyses of
these needs identified per group of patients by the nurse
in the ambulatory care setting. For Chi Square analysis
the expected frequency was based on the assumption that the
30Table 2» Ambulatory Patients 1 Basic Needs Identified by
the Nurse Performing the Expanded Role in Four Ambulatory Health Care Settings
Ambulatory Health Care Setting
Basic Need
Gastro- enterolo-
Cardiac gist's Clinic Office
Nephrologist 1 s Office
EmergencyRoom
Fluid 3 4 1 1Oxygen 8 4 5 8Rest 4 8 8 : 6Food 7 8 4 6Physical Activity 8 9 7 5Sexual Activity Elimination of
0 l 0 0Wastes 6 8 6 6
Love 0 0 0 0Esteem 1 4 0 iSafety 2 5 - 0 0Self Actualization 1 4 0 1Totals 4o 55 31 34
Table 3° Chi Square Analysis of the Total Number of NeedsIdentified for Ambulatory Patients
Observed ExpectedPatient Group Frequency Frequency P ValueGastroent ero1o gy 55 40 > .05Cardiac 40 4oNephrology 31 40Emergency Room 34 4oTotal Frequency 160
X2 = 8 e 54 with 3 df o
' \ - 31nurse would identify the same number of needs in each group; namely 40 per group»
Of the 35 patients sampled, statistical analysis revealed a significant difference at the «05 level in the identification of health needs of ambulatory patients encountered by the nurse in the expanded role» The null hypothesis was rejected at the „05 level of significanceo
In Table 4 are reported the total number of needs identified for ambulatory patients according to their sexo
Table 4 <> Total Number of Needs Identified for Ambulatory Patients According to Their Sex
S exCardiacClinic
Gastro- ent erolo gist's Office
Nephrologist 1 s Office
Emer - gency Room
Total Number of Needs
Identified
Males N = Ik
58 17 11 28 114
F ernales N = 21
21 80 38 32 l6l
In Table 5 the Chi Square analysis is recorded forthe total number of needs identified for ambulatory patients by>the nurse in the expanded role according to sexo Equal distribution of the frequency of needs identified was expected to occur in each group which was 137*50
32Table 5° Chi Square Analysis of the Total Number of Needs
Identified for Ambulatory Patients According to Their Sex _ . __
PatientGroup
FrequencyObserved
FrequencyExpected Total P Value
Males 114 137-50 275Females 161 137.50 > .01
< .001
x2 = 8.02 with 1 " r- '
needs identified for both female and male patients by thenurse,
The total number of needs identified was greaterfor female patients. To determine if the difference in thenumber of needs identified according to the sex of the
• 2patient was significant, the % test was performed. Statistical analysis revealed a significant difference in the number of needs identified for ambulatory patients according to sex at a significance greater than .01 and less than .001.
All role components were performed for all patients« Table 6 is a summary of needs identified in each role component.
The activities which elicited the most information performed by the nurse were:
1 . Taking health history.
33Table 6„ Frequencies of Role Componentsa Delineated by a
Nurse in an Expanded Role in Identification of Ambulatory Patients 1 Needs in Four Settings
Ambulatory Health Care Setting
Frequency of Role Components which Provided Data of
Patient NeedsTotals
Gastroenterologist's Office A 2 36N = 9 B 9C - ' 3 .D . 7E 2F 3G 2 '. ’ * H _8_
Cardiac Clinic A 3 28N = 9 b : 8c 2D 6
E .2 • vF 1G 0H 6
Nephrologist 1s Office A 0 22N = 8 B 8
C 0D 6E 0F 0G 2H 6
Emergency Room A 2 21N — 9 B 9C 0
D . 2E 0
. F 0G 0H 8
aThe Role Components are listed on page 25®
2. Interviewing to identify basic physiological needs and psychological needs.
3• Counseling to identify specific physiological .needs.
2Statistical analysis, using the % method, revealed no significant differences in the role components performed by the nurse in the expanded role in identifying ambulatory patients • basic physiological and psychological needs in four ambulatory cafe settings.
Table 7 presents the total number of patient needs identified by the nurse in an expanded role according to the occupation of the patient in four ambulatory care settings.
Table 7• Total Number of Ambulatory Patient Needs .Identified According to Academic Education for Employment
Patient GroupTotal Number of Patient
Needs Identified
ProfessionallyEmployed PatientsN = 13 112
Non-Professionally iEmployed Patients
163N = 22
X2 = 10.78 with 1 df.
The total number of needs identified was greaterfor non-prof ess ionaily employed patients <> To determine ifthe difference in the number of needs identified according - -: : ; - ■ ■ ' ' ' ■■■■ ■ 2 to occupation of the patient was significant, the x test
was performed. Statistical analysis revealed a significantdifference in the needs identified for ambulatory patientsaccording to occupation at a significance greater than .01and less than .001V
In the following chapter the findings of this studywill be discussed in relation to the theoretical frameworkdescribed in Chapter 1.
CHAPTER 5
DISCUSSION OF FINDINGS
This chapter discusses the :findings pertinent to the theoretical framework and the results of this study»
Findings Related to the Theoretical Frameworkand Hypothesis
The null hypothesis that there is no difference inthe identification of basic physiological and psychologicalhealth needs by the nurse in an expanded role caring forpatients in the ambulatory care setting has been rejectedat the .05 level of significance by testing the data
2obtained in this study with the x method«The findings generated by this study indicate that:
1 . The nurse in the expanded role significantly identified more basic health needs in women with gastroenterology disease seen in the gastroenterologist's office = See Tables 2 and 4,
2. The nurse in the expanded role significantly identified basic health needs among non-professionally employed ambulatory patients seen in four settings of a cardiac clinic of a medical center, a nephrologist's office, a
36}
. . v : - ;■ 3?gastroenterologistfs office3 and an emergency room of a 300 bed general hospital„
3 ® The components of the nursing role performed most frequently in this study were interviewing and counseling techniques o These findings are in agreement with the activities performed by Swedish nurse specialists reported by Donaldson (1971) and with nurses performing in the expanded role reported by Schiff (1969)0
The interaction between nurse and patient was asocial process of the nurse asking a question that wouldidentify a need of Maslow?s hierarchial system ofphysiological and psychological needs„ The patients*anticipated response was an answer that would identify a
'' v ' • .desire or lack of satisfaction of a basic physiological orpsychological needo
The nurse in the expanded role 3 as a changeregulator 3 can assist the patient to identify basichealth needs and to plan his health care. A nursing careplan can be developed that would center around thesatisfaction of the basic needs that may have been unful?filled due to the patient's illness. Identification ofbasic needs assists the patient in satisfying lower needsand pursuing higher levels of need satisfaction. A goalfor the expanded role of the nurse in helping to identify
V: : ^ ' : V/ , ;'V:: 38basic health needs would be to aid in motivating the ambulatory patient to actualize independence, self acceptance, and achievement of a problem centered approach to coping with his health problems. With gastroenterology, women patients, the nurse in the study in the expanded role attempted to achieve this goal. Helping the patients in identifying basic health needs enables them to gain new mastery over their destinies » In this study, the nurse performing in the expanded role was able to significantly identify basic health needs of women gastroenterology patients seen in a private physician's office*
In summary then, the nurse performing in the expanded role as a hew social and personal change regulator could facilitate patients to achieve the goal of self actualization*
Recommendations Recommendations derived from this study are:
1* A study of the socioeconomic levels with a widerrange in age, and diagnoses should be performed for a more heterogeneous sample of the population*
2 * A study using the team approach of professionalnursing personnel comparing educational preparation to the roles performed in identifying patients * health needs should be conducted*
A (descriptive study of the existing staff fs roles in the ambulatory care setting and the system used to identify basic health needs should be examined to identify the role components used by the various health team members»Finally additional research should be done to determine if the findings of this study were typical or atypical of the relationship of the nurse to the patients encountered in the ambulatory health care facility in identifying needs®
CHAPTER 6
SUMMARY
For the last ten years 9 professional nurses have been delegating direct patient care services to lesser trained nursing assistantso Many nurses today are expressing concern about this fragmentation and decrease in accountability for patient care such as the opinions expressed by the official statement of the American Nurses' Association (1970)o
Much of the role defined in this study does not contain any new or controversial components => Rather the role emphasizes that the nurse perform direct patient care activities in attempting to identify basic health needs of ambulatory patients *
The study described in the preceding chapters was an attempt to apply Maslow’s hierarchial system of.needs to nursing practice through identification of ambulatory patients' basic health needs by the nurse in an expanded role o
Also included in the investigation were the variables of age9 sex, and occupation of patients encountered in the ambulatory health care settingo
' 40
- 41Methodology
This descriptive study was designed to focus on the identification of ambulatory patients? basic health needs and analysis of the role the nurse performed to identify these needs * Maslow Vs hierarchy of needs was analyzed to determine the significance of health needs identified by the nurse performing the expanded role to help facilitate the patient's attainment of self actualization„ The nurse's role was structured to identify needs that would facilitate the patient's pursuit of need satisfaction both at the basic level and higher levels to aid the patient in coping with his illness.
The instruments used were: -I, Structured interview questionnaires devised by the
nurse researcher and a cardiologist with twenty- five years' experience in outpatient medicine to elicit information about physiological and psychological health needs,
2 o Performance of a structured role based on a review of the literature pertinent to the research about the expanded role of the nurse in the ambulatory care setting, ;
■ / / iFindings
The hypothesis tested in the study was: There is no difference in the identification of basic physiological
v ' ■. ■■■. ' > 2and psychological health needs by the nurse in ah expanded role caring for patients in the ambulatory health care setting e
The difference in the total number of needs identified among ambulatory patients in four settings and therole components the nurse performed to identify these needs
2were analyzed by the use of the % method oThe total number of needs identified by the nurse
in an expanded role were statistically significant among gastroenterology women patients seen in the private physician's office» There was a significant difference revealed in identification of patient health needs and the role the nurse performed according to the occupation of the patients 5 seen in the ambulatory health care settings <>
ConclusionsThe findings of the research indicated a basis in
fact for the premise that the expanded role of the nurse is an important factor relating to the identification of ambulatory patients? basic health needs » This conclusion is predicted on the results of a descriptive study from data collected on thirty-five patients who utilized the services of a cardiac clinic, private physicians' offices 9 and an emergency room of a 300 bed non-profit community hospital«
Since performance of the expanded role of the nurse was found to have an effect on the identification of basic health needs of ambulatory patients, these findings should be of importance to nurses in defining their role as a practitioner in the care of ambulatory patients« Finally, this study is valuable to nurses in helping them to determine their relationship to patients in assisting the patient to meet his health needs and thus help bridge the gap in fragmentation of health services by providing more comprehensive health care as a primary health care agent in the expanded role of the nurse»
APPENDIX A
IDENTIFICATION OF PHYSIOLOGICAL NEEDS OF . AMBULATORY PATIENTS— RAW DATA SHEET
Case #___ Age___ICV_ IOVMarital Status: S M W D Sep.Occupation .______■ Retired: Yes No__Diagnosis ; ' ■ ' -
INSTRUCTIONS: Place a check mark (V) beside the need identified in the corresponding activity column.
Coded Activities of the Expanded Nurse Role to Identify Needs
A B C D E F G Total Number of Physiological Needs Needs Identified
1 . Fluid2. Oxygen3. Food k . Rest5• Physical Activity6 . Elimination of Wastes7. Sexual Activity
44
: ' . ' ■ : : ' : v ::<: V;>:f :W ' :V : 45Letter Coding: of Activities of the Expanded Nurse Role to be Used in Recording Data Above
A o Performs physical screening examinations and records assessments o
Bo Interviews to obtain medical historyoCo Performs routine laboratory examinations or makes
requisitions for them»Do Counsels patients to identify specific health needs *Eo Coordinates patient care to identify specific health
needs«Fo Works collaboratively with physician and other health
team members to plan patient care and identify specific health needso
Go Makes home visits to identify health needs of ambulatory patients <>
Ho Identification of psychological needs:1 o Love needo2 o S ecurity need o3 o Self actualization need.4 o Esteem need,
APPENDIX B
INTERVIEW SCHEDULE TO OBTAIN MEDICAL HISTORY FROM THE AMBULATORY PATIENT TO IDENTIFY PHYSIOLOGICAL NEEDS
1 . Do you understand what your sickness is?2. Do you understand what caused your sickness?3• Would you like me to tell you about it?4. Do you understand what you are taking your medicines
for?5• Do you know exactly how to take them?6 . Do you understand what the precautions are associated
with the medicine you are taking?7« Has your doctor told you exactly how much it is safe
for you to do?8 . How much are you actually doing every day?9• How do you feel when you do it?
10. Are you supposed to be on a special diet?11. Do you understand how to follow the diet as your
doctor ordered?12. Do you need more information about your diet?13« Is it possible for you to stay on this kind of diet?l4. Is it too expensive?15• Do you have any symptoms you haven't told your doctor
about?16 . Is your breathing difficult?17. What time of the day is your breathing likely to be
difficult ?\ \ 46 ■ ■■' - ■
18.19.20. 21. 22.
■■■ . . \ ■ ; \ . ....: 4?Do you ever have indigestion or discomfort in your chest?When do you notice this discomfort?What has been happening to your weight?Do you have trouble passing water?Describe if you can any problems that you may have in passing water?
1.
2 .
3 • 4.
5 •6 o7.
8 .
9-
10.
11 .
12.13.14.
APPENDIX C
INTERVIEW QUESTIONS TO IDENTIFY PHYSIOLOGICAL NEEDS DURING A COUNSELING SESSION WITH
THE AMBULATORY PATIENT
Do you have any problems that you have been unable to talk to your doctor about ?Are you worried about anything that you haven's been able to discuss with your doctor?How does your illness affect your daily life?What do you think you could do to improve the situation?Do you have any trouble getting to sleep?Do you often wake up in the night ?Can you describe what it is that wakes you from your sleep?Has your illness affected your sleeping in any other way that you'd like to tell me about?Do you have any problems with your bowels? Describe if you can what seems to be the problem?Is it any problem for you to travel to the clinic or office?Describe if you can the problem that you have in getting to the clinic or office.Where do you usually eat your meals?Who prepares your food when you eat?Do you have the energy to do the things you want to in your daily activity?
48
49
15° Describe if you can the problems that you have that prevent you from doing the things you want to do.
l6 . Of all the things that we have discussed about yourdaily life patterns and your general health, is there anything else that you think I should know about you or your illness?
/
APPENDIX D
INTERVIEW SCHEDULE TO IDENTIFY SAFETY* LOVE* ESTEEM*a n d s e l f Ac t u a l i z a t i o n n e e d s of t h e a m b u l a t o r y
PATIENT BY THE NURSE IN AN EXPANDED ROLE
1 o What brought you to the clinic or office today?2 o Describe if you can * how you see yourself in your life
situation?3 e Has your illness affected your life? In what way(s)?4 o Are there any tensions or stresses that you think are
affecting your overall health?'5 o What would you say they are?6 e How does this affect you?7 o Does your family know about your condition?8« Do you feel that there is any one person that under
stands how you feel about your condition?9 o Generally * would you describe your relationship with
your family or friends as (indicate what word[s] apply):a. lackingb . possessing_____affection and kindness? (love need)
10. Would you say that you (indicate what word[s] apply)sa. l a c k ___b . possessorder in your daily life. (safety or security need)
50
11.
12.
Would you say that you generally (indicate what word[s] apply):a. lackb. possessself direction in your daily life. (self actualization need)Would you say that a favorable reputation is (indicate what word[s] apply):a. desirableb . lackingc. present_____in your daily life? (esteem need)
APPENDIX E
IDENTIFICATION OF PSYCHOLOGICAL NEEDS OF AMBULATORY PATIENTS— RAW DATA SHEET
Case***** Age ICV IOVMarital Status: S M W D Sep.Occupation Retired : Yes_ NoDiagnosis _____ '_______' -
INSTRUCTIONS: Place a check mark (V) beside the need identified in the corresponding column.
Psychological Needs Interviews to Identify Identified Psychological Needs1 . love2 . safety 3 - esteem4. self actualization
52
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