INFLUENCE OF INITIAL NURSING EOUCATIONAL PREPARATION

ON PATIENT ASSESSMENT

BY

CAROLYN JEAN YOCOM B.S.N., University of Pennsylvania, 1970

M.S.N., Case Western Reserve University, 1975

THESIS

Submitted as partial fulfillment of the requirements for the degree of Doctor of Philosophy In Nursing Sciences

In the Graduate College of the University of Illinois at Chicago Health Sciences Center, 1985

Chicago, Illinois

HI. i.̂ r .mi.iwijw i n ni •• •• I rotnin»mmu.iJi'j.;e*mTagJe3V- j

UNIVERSITY OF ILLINOIS AT CHICAGO HEALTH SCIENCES CENTER GRADUATE COLLEGE

Certificate of Approval

April 29, 1985 Date

I HEREBY RECOMMEND THAT THE THESIS PREPARED UNDER MY

SUPERVISION BY CAROLYN JEAN YOCQM

ENTITLED INFLUENCE OF INITIAL NURSING EDUCATIONAL

PREPARATION ON PATIENT ASSESSMENT

BE ACCEPTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR

THE DEGREE OF Doctor of Philosophy

In Charge of Thesis

Recommendation concurred in

Head of Department

Committee on

Final Examination

80173

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Copyright by

Carolyn Jean Yocom

1985

ACKNOWLEDGMENTS

I wish to acknowledge the following Individuals for their

contributions to this dissertations

To my advisor and committee chair, Dr. Leona Peterson, for her

continued guidance, support, encouragement and understanding.

To the other members of my committee, Drs. Mary Bevls, Karyn

Holm, Margaret Grler, and Eta Berner, for their guidance.

To the panel members, Kathy Bronsteln, June Krawczak and Kathy

Czurylo, whose expert contributions were essential to the completion

of this dissertation.

To the Deans and Directors who facilitated access to their

students, and to the students who participated In the study. Without

them, the study could not have been completed.

Finally, to my family and friends. Their encouragement, support

and faith were essential and deeply appreciated.

This research was supported In part by a Research Support Award

from Alpha Lambda Chapter, Sigma Theta Tau, National Honor Society of

Nursing.

CJY

III

TABLE OF CONTENTS

chapter EASE

I INTRODUCTION 1 A. Background of the study 2

1. Definitions 3 2. Nursing process and nursing diagnosis 4 3. Cognitive processes..... 6 4. Characteristics of educational programs

and students that influence problem solving abilities..... 11

B. Conceptual framework....... 13 Cm Purpose of the study 15 D. Research Questions 15 E. Significance of the study 17

II LITERATURE REVIEW 21 A. The diagnostic process 21

1. The task environment. 22 a. Summary 25

2. Characteristics of the problem solver 26 a. Processing capabiI Itles 26 b. Short term memory 27 c. Long term memory 28

1) Organization of stored Information 29

2) Role of knowledge stored In LTM In problem solving... 31

d. Interaction of the processing system with the external environment 35

e. Summary 37 3. Diagnosis Identification 38

a. Concept attainment 38 b. Factors Influencing diagnostic

accuracy 40 4. Summary 44

B. Measurement of clinical problem solving ability.. 44 1. Observation-based methods 46 2. Record-based methods 46 3. Simulation methods..... 47

a. Oral format 48 b. Patient management problems 48

1) Psychometric properties 51 4. Summary 53

C. Nursing education 53

Iv

TABLE OF CONTENTS (continued)

CHAPTER BASSE

1. Historical overview 54 2. Differences In associate and

baccalaureate degree students and graduates 66 a. Demographic and pre-enrol Intent

educational characteristics 66 b. Characteristics related to nursing

program selection 70 1) Distance from home 70 2) Selection of type of

nursing program.. 70 3) Reason for selection of a

nursing career 71 c. Personal attributes of students... 71

1) Professional values 72 2) Leadership qualities 72 3) Other personality factors.. 72 4) Academic

aptitude/achievement 73 d. Clinical attributes of graduates.. 75

1) Competency ratings 75 a) Summary 84

2) Critical Incident reports.. 85 3) Problem solving ability.... 86 4) Summary 91

I I I METHOD 93 A. Research design 93 B. Population and sample selection 95

1. Rationale for sample selection 95 2. SamplIng procedure............. 96 3. Solicitation of Institutional agreement to

participate 97 4. Sample characteristics 98

a. Characteristics of participating programs..... 98

b. Characteristics of student participants 99

C. Operational IzatIon of the conceptual model 105 1. Independent variable 105 2. Covartates 105

a. Task setting 106 b. Task complexity 106 c. Critical thinking ability. 106 d. Post-high school education 107

v

TABLE OF CONTENTS (continued)

CHAPTER PAGE

e. Non-education related health care experience.. 107

f. Age and gender 107 g. Intellectual ability 107

3. Dependent variables 108 D. Instruments 108

1. Measurement of the covarlates 108 a. Background Inventory 108 b. Watson-Glaser Critical Thinking

Appraisal 109 1) Inference 110 2) Recognition of assumptions. 110 3) Deduction 110 4) Interpretation 110 5) Evaluation of arguments.... 111

2. Measurement of the dependent variable 112 a. Description 113 b. Content vaI IdIty 115 c. Construct va I Id Ity 116 d. Reliability 118

E. Procedure 119 1. Pilot testing 119 2. Data col lection 120

F. Protection of human subjects 121 G. Data reduction. 122

1. Covar I ates 122 2. Dependent variables 122

a. Patient Information 122 1) Scoring formulas...... 123

a) Efficiency score 123 b) Proficiency score.... 124 c) Psychosocial data

score 124 d) Percent psycho­

social data score.. 124 b. Nursing diagnoses 125

1) Expert panel composition.... 125 2) Analysis of diagnostic

statements 126 3) Reliability 126

vl

TABLE OF CONTENTS (continued)

CHAPTER EASE

a) Inter-rater re11ab11-?ty 127

b) Intra-rater re I lab 11-Ity 127

4) Training of panel members 127

5) Scoring formulas... 129 3. Summary 130

IV ANALYSIS AND RESULTS 135 A. Influence of program type on assessment ability.. 135

1. Analysis and results 135 2. Conclusions 152

B. Data collection efficiency 152 C. Data co 11 ect I on proficiency 153 D. Amount of psychosocial patient data selected..... 158 E. Percent of psychosocial patient data selected.... 160 F. Nursing diagnosis Identification 163 G. Amount of plausible psychosocial nursing

diagnoses Identified 169 H. Percent of plausible psychosocial nursing

diagnoses Identified 171 I. Additional data analyses 174

1. Differential performance on PMPs 174 2. Proportion of AD and BD participants

selecting Individual data Items 175 3. Frequency of diagnostic statement

Identification 178 4. Type referent Identified for the nursing

diagnosis of Anxiety.... 181 5. Differences In learning experiences 182

J. Summary 183

V DISCUSSION 188 A. Conclusions 188

1. Assessment ability 189 2. Diagnostic ability 194 3. Data collection ability 195 4. Differential performance on the two

simulations 198 B. Implications 198 C. Recommendations 201 D. Summary 205

vll

TABLE OF CONTENTS (continued)

CHAPTER PAGE

VI APPENDICES 207 Appendix A . 208 Appendix B 210 Appendix C 211 Appendix D 213 Appendix E 220 Appendix F . 222

VII CITED LITERATURE 223

VIII VITA 240

vl II

LIST OF TABLES

IABJLE EASE

I CHARACTERISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) STUDENTS AS CITED IN THE LITERATURE, BY AGE, MARITAL STATUS, FAMILY RESPONSIBILITIES AND PRE-MATRICULATION ACADEMIC ACHIEVEMENTS 67

II DISTRIBUTION OF PARTICIPATING ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PROGRAMS BY FINANCIAL SUPPORT AND NUMBER OF PARTICIPANTS 100

111 DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS 101

IV ACADEMIC CHARACTERISTICS OF STUDY PARTICIPANTS 103

V SUMMARY OF THE INDEPENDENT VARIABLE, COVARIATES, AND DEPENDENT VARIABLES USED FOR DATA ANALYSIS 132

VI RELATIONSHIP BETWEEN THE LATENT VARIABLES OF KNOWLEDGE BASE, EDUCATION RELATED CLINICAL LEARNING EXPERIENCES, TASK COMPLEXITY AND ASSESSMENT ABILITY AND THEIR INDICATORS FOR THE MODEL EXPLAINING PERFORMANCE ON PMP-BROWN 138

VII RELATIONSHIP BETWEEN THE LATENT VARIABLES OF KNOWLEDGE BASE, EDUCATION RELATED CLINICAL LEARNING EXPERIENCES, TASK COMPLEXITY AND ASSESSMENT ABILITY AND THEIR INDICATORS FOR THE MODEL EXPLAINING PERFORMANCE ON PMP-ELLIS 139

VIII CORRELATION MATRIX: EXOGENOUS AND ENDOGENOUS VARIABLES IN THE MODEL FOR PMP-BROWN 141

IX CORRELATION MATRIX: EXOGENOUS AND ENDOGENOUS VARIABLES IN THE MODEL FOR PMP-ELL IS 142

X DIRECT EFFECT, INDIRECT EFFECT AND EFFECT COEFFICIENTS REPRESENTING INFLUENCE OF EDUCATIONAL PREPARATION ON PMP-BROWN ASSESSMENT PERFORMANCE 147

XI DIRECT EFFECT, INDIRECT EFFECT AND EFFECT COEFFICIENTS REPRESENTING INFLUENCE OF EDUCATIONAL PREPARATION ON PMP-ELL IS ASSESSMENT PERFORMANCE 148

ix

LIST OF TABLES (continued)

TABLE PAGE

XII GOODNESS OF FIT AND LEVEL OF SIGNIFICANCE FOR MODELS REPRESENTING ASSESSMENT PERFORMANCE ON PMP-BROWN AND PMP-ELLIS 150

XIII GOODNESS OF FIT AND TESTS OF SIGNIFICANCE FOR EACH ENDOGENOUS VARIABLE WITHIN THE PMP-BROWN MODEL 151

XIV GOODNESS OF FIT AND TESTS OF SIGNIFICANCE FOR EACH ENDOGENOUS VARIABLE WITHIN THE PMP-ELLIS MODEL 151

XV DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS' PERFORMANCE ON DATA COLLECTION ACTIVITIES ON PMP-BROWN 154

XVI DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS* PERFORMANCE ON DATA COLLECTION ACTIVITIES ON PMP-ELL IS 155

XVII ANALYSIS OF VARIANCE OF THE DATA COLLECTION EFFICIENCY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 156

XVIII ANALYSIS OF VARIANCE OF THE DATA COLLECTION EFFICIENCY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELL IS 156

XIX ANALYSIS OF VARIANCE OF THE DATA COLLECTION PROFICIEN­CY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 157

XX ANALYSIS OF VARIANCE OF THE DATA COLLECTION PROFICIEN­CY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELL IS 158

XXI ANALYSIS OF VARIANCE OF THE AMOUNT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCA­LAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 159

XXII ANALYSIS OF VARIANCE OF THE AMOUNT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCA­LAUREATE DEGREE PARTICIPANTS ON PMP-ELL IS 160

x

LIST OF TABLES (continued)

TABLE PAGE

XXIII ANALYSIS OF VARIANCE OF THE PERCENT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCA­LAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 161

XXIV ANALYSIS OF VARIANCE OF THE PERCENT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCA­LAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS 162

XXV DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS' PERFORMANCE ON NURSING DIAGNOSIS IDENTIFICATION ACTIVITIES ON PMP-BROWN 164

XXVI DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS' PERFORMANCE ON NURSING DIAGNOSIS IDENTIFICATION ACTIVITIES ON PMP-ELLIS 165

XXVII ANALYSIS OF VARIANCE OF THE NUMBER OF PLAUSIBLE NURS­ING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BAC­CALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 166

XXVIII ANALYSIS OF VARIANCE OF THE NDXSCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 166

XXIX ANALYSIS OF VARIANCE OF THE NUMBER OF PLAUSIBLE NURS­ING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BAC­CALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS 167

XXX ANALYSIS OF VARIANCE OF THE NDXSCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS 168

XXXI ANALYSIS OF VARIANCE OF THE AMOUNT OF PLAUSIBLE PSY­CHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 170

XXXII ANALYSIS OF VARIANCE OF THE AMOUNT OF PLAUSIBLE PSY­CHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS 171

xl

LIST OF TABLES (continued)

TABLE EASE

XXXIII ANALYSIS OF VARIANCE OF THE PERCENT OF PLAUSIBLE PSY­CHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN 172

XXXIV ANALYSIS OF VARIANCE OF THE PERCENT OF PLAUSIBLE PSY­CHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS 173

XXXV SUMMARY OF REPEATED MEASURES ANALYSES OF VARIANCE RESULTS FOR WITHIN SUBJECTS DIFFERENCES IN PERFORM­ANCE ON PMP-BROWN AND PMP-ELLIS FOR DATA COLLECTION AND NURSING DIAGNOSIS IDENTIFICATION TASKS 176

XXXVI SUMMARY OF DATA ITEMS WHERE STATISTICALLY SIGNIFICANT DIFFERENCES IN PERCENT OF AD AND BD PARTICIPANTS SELECTING ITEMS WERE DEMONSTRATED, BY PMP 177

XXXVII FREQUENCY DISTRIBUTION OF NURSING DIAGNOSIS STATEMENTS IDENTIFIED MOST FREQUENTLY ON PMP-BROWN 179

XXXVIII FREQUENCY DISTRIBUTION OF NURSING DIAGNOSIS STATEMENTS IDENTIFIED MOST FREQUENTLY ON PMP-ELL IS 180

XXXIX DESCRIPTIVE STATISTICS AND RESULTS OF ANALYSES OF VARIANCE COMPARING THE CLINICAL LEARNING EXPERIENCES OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS, BY VARIABLE 184

XL CHARACTERISTICS OF INSTITUTIONS FROM WHICH THE STRATI­FIED RANDOM SAMPLE OF ASSOCIATE DEGREE AND BACCALAU­REATE DEGREE NURSING PROGRAMS WERE SELECTED 208

XL I RESULTS OF COCHRAN'S C TEST FOR HOMOGENEITY OF VARI­ANCE 222

xlf

LIST OF FIGURES

FIGURE EASE

1 Conceptual model 16

2 McClure's Model 1. 59

3 McClure's Model 2 59

4 McClure's Model 3 61

5 Spark's extension of McCture's Model 3 62

6 Path analysis results for PMP-Brown 144

7 Path analysis results for PMP-Ellls 144

xll I

SUMMARY

The purpose of this study was to examine the direct and Indirect

Influences of type of educational program attended on data collection

and nursing diagnosis Identification abilities of generic nursing

students within three months of graduation from associate degree and

baccalaureate degree nursing programs.

The primary research question qui ding this study was: Are the

patient assessment abilities of associate and baccalaureate degree

nursing students Influenced by the type of educational program

attended. Additional research questions addressed were differences

between the associate and baccalaureate degree students with regard to

data collection efficiency, data collection proficiency, amount and

percentage of psychosocial data collected, number of plausible nursing

diagnoses Identified, and amount and percentage of psychosocial nursing

diagnoses Identified.

A non-equivalent groups, post-test on Iy design was used. A

convenience sample of 91 associate degree and 86 baccalaureate degree

students was obtained from five randomly selected associate degree

programs and six randomly selected baccalareate degree programs within

a three state area In the mid-west. Participants completed the Watson-

Glaser Critical Thinking Appraisal (Form A), two latent Image,

branching type clinical simulations, and a background Inventory.

Analyses of variance, chl square and path analysis techniques were used

xlv

SUMMARY (CONTINUED)

to analyze the data. Performance on each simulation was analyzed

separately.

Analysis of performance on one simulation demonstrated

differences In the diagnostic abilities of the two groups <F (1,9) =

5.16; p<.05). No differences were found In data collection efficiency

or proficiency. In amounts or percent of psychosocial data collected,

or In amounts or percent of psychosocial nursing diagnoses Identified.

Path analyses revealed differential effects of the type of program

attended on the assessment abilities of the participants. On one

simulation, the effect coefficient was .411 while on the other It was

-.067.

On one simulation, baccalaureate degree participants Identified a

greater number of more complete nursing diagnosis statements than their

associate degree counterparts. Performance of all participants

differed across the two simulated patient encounters, demonstrating the

Influence of case specificity. Although not conclusive, findings

provide partial support for the claim that type of educational program

attended Influences diagnostic ablllltes of the participants. This has

Implications for differentiation of clinical practice of the two type

of graduates.

xv

I. INTRODUCTION

One question the nursing profession must address Is: What are the

differences. If any. In the nursing practice of graduates of associate

degree and baccalaureate degree nursing programs? Since the stated

goals and the course content Included In these two types of nursing

programs are different, the answer to this question has ramifications

for nurse educators, nursing service administrators, the profession as

a whole, and for the public the profession serves.

An example of the primacy of this concern Is the reluctance of

members of the New York State legislature to Introduce a bill revising

the state's nurse practice act to reflect the requirement of a

baccalaureate degree for the practice of professional nursing and the

associate degree for the practice of practical/technical nursing (New

York State Nurses' Association, 1983). The primary reason for this

reluctance Is the state nurses' association's Inability to demonstrate

that differences exist In the level of nursing care provided by

graduates of these two types of programs.

Previous research to distinguish between the nursing capabilities

of associate degree and baccalaureate degree graduates has been based,

primarily, on self-ratings, ratings of administrators and educators,

and on comparisons of self-ratings with the ratings of others (Chamlngs

and Teevan, 1979; Dlckerson, 1976; Hogstel, 1975; McKenna, 1971; Pitts,

1975; Schuyler, 1983; SchwIrian, 1979). A review of the results of

these studies has not demonstrated unequivocal evidence that

1

2

differences do exist. One threat to the validity of these studies Is

lack of control for the educational preparation of administrators who

rate staff members (McCloskey, 1981).

A different approach to demonstrating the existence of

differences In the level of nursing practice due to educational

preparation Is to focus on graduates' abilities to apply and use the

nursing process (Asplnall, 1976; Baumann and Bourbonnats, 1982; Davis,

1972; 1974; deTornyay, 1968; Gordon, 1980; Verhonlck et al., 1968. The

major focus of this research has been on decision making activities

associated with planning Interventions used for patients with specific

nursing problems or nursing diagnoses. Researchers have examined the

patient assessment abilities of the nurse In only a small proportion of

these studies. In addition, only 8 of these studies have compared,

directly or Indirectly, the capabilities of the associate degree

graduate or student with those of the baccalaureate degree graduate or

student CBassett, 1977; Frederlckson and Mayer, 1977; Gover, 1972; Gray

et al., 1977; Johnston, 1982; Retd, 1981; Sparks, 1979).

The remainder of this chapter Is focused on the background of the

present study, the conceptual framework, the purpose, the research

questions to be addressed, and the significance of the study.

Subsequent chapters Include a review of the literature, the methodology

used to conduct the study, the results, and a discussion of the results

and conclusions.

A. Background of the study

The provision of effective and efficient nursing care Is

3

dependent upon the nurse's cognitive ablIIty to define clearly a

patient's health problems and to select Interventions that have a high

probability of resolving those problems (Gordon, 1982). Such cognitive

activity Is an Integral part of nursing care and has been

conceptualized as the nursing process. The sections that follow

provide an overview of 1) the steps of the nursing process and the

Identification of a nursing diagnosis, 2) the cognitive processes

Involved In problem solving activity, and 3) the characteristics of

associate and baccalaureate degree students and programs that Influence

problem solving activity.

1 * Definitions

The terms used In this study are defined as follows:

1. Problem solving - A goal-dIrected sequence of

cognitive operations.

2. Problem solving process - The scientific method

utilized In problem solution which Includes encountering a problem,

collecting and analyzing the data In connection with a problem,

Identifying the exact nature of the problem, deciding on a plan of

action, carrying out the plan, and evaluation of the plan and the new

situation.

3. Nursing process - The problem solving process used by

nurses. An orderly systematic manner of determining the client's

problems, making plans to solve them, Implementing the plan or

assigning others to Implement ft, and evaluating the extent to which

the plan was effective In resolving the problems Identified. The four

4

phases of the process are: assessment, planning, Implementation, and

evaluation.

4. Assessment - A component of the nursing process that

encompasses Information gathering, a diagnostic Judgment, and the

labeling of a health problem.

5. Nursing diagnosis - A concise term representing a

cluster of signs and symptoms that describes responses to actual or

potential health problems or states-of-the-patlent which nurses by

virtue of their education and experience are able, licensed, and

legally responsible and accountable to treat.

6. Efficiency score - A measure of the degree to which a

participant's choices of data and procedural steps on a clinical

simulation are helpful In the resolution of a client's problem. A

ratio of the number of essential Items selected or steps taken to the

total number of Items and procedural steps selected (McGuIre et al.(

1976).

7. Proficiency score - A measure of the degree to which a

participant's selection of data and procedural steps corresponds with

those Judged optimal by experts In the field. A ratio of the number of

essential data and procedural steps taken minus the non-essential Items

selected to the optimal number of Items to be selected (McGuIre et at.,

1976).

2. Nursing, process, and. nursJng. diagnosis

The nursing process Is an application of scientific problem

solving to the management of patient care. This process consists of

5

the following steps: 1) assessment - which Includes data collection

and the Identification of nursing diagnoses; 2) formulation of a plan

of care; 3) Implementation of care; and 4) evaluation of outcomes

(Asplnall and Tanner, 1981; Carnevelli, 1983; Yura and Walsh, 1978).

The relevance of the plans for and the Implementation of specific

nursing care Is dependent upon the accuracy of the nursing diagnosis

statement. This statement must accurately reflect those problems

manifested by patients that can be dealt with and managed by nurses

working Independently or InterdependentIy with other health

professionals.

The diagnostic activity of the nurse was sanctioned by the

American Nurses' Association (ANA) when It published the Generic

Standard*; of Practice (1973). Additionally, the nurse practice acts In

all political Jurisdictions of the United States directly or Indirectly

address Incorporation of nursing diagnostic activity within the scope

of professional nursing practice (W. Young, persona! communication,

November 28, 1983).

The nursing diagnostic process has been described as being both

dynamic and cyclic In that diagnoses change with a patient's condition

(Mahomet, 1975). Abdellah and Beland (1965, p. 9) stated, "A nursing

diagnosis Is a determination of the nature and extent of the nursing

problems presented by Individual patients and families receiving

nursing care." Komortta (1963, p. 84) said: "A nursing diagnosis

should be a conclusion based on scientific determination of an

Individual's nursing needs, resulting from critical analysis of his

6

behaviour, the nature of his Illness, and numerous other factors which

affect his condition."

Other descriptions and definitions of nursing diagnoses and the

diagnostic process are very similar to that Identified by Komorlta

(1963) (Bonney and Rothberg, 19635 Carlson, 1972; Dodge, 1975b; Durand

and Prince, 1966; Gebble and Levlne, 1975; Kelly, 1966; Matheny et al.,

1972; McCain, 1965; Norrls, 1964; Roy, 1974a; 1974b). The common

element linking the various statements Is a conclusion that the

diagnostic process Is Inferential and culminates In a conclusive

statement of nursing Judgment; It recognizes patterns derived from the

nurse's Investigation of an individual's total condition.

3. Cognitive processes

The ability of Individuals to formulate nursing diagnoses is

limited by their Information processing abilities. Therefore, an

overview of the human Information processing system, and the use of

diagnostic hypotheses as a means of dealing with a problem solving task

within an open system will be discussed. In addition, characteristics

of the task environment and of the problem solver that Influence

problem solving ability also will be described.

Human problem solving behavior, which Includes problem

Identification (e.g., diagnosis), was described in terms of a theory of

human Information processing by Newell and others (Newell et al., 1958;

Simon and Newell, 1971; 1972). These Investigators described the

Information processing system as follows. Following the Initial

reception of Information via sense organs, subsequent processing occurs

7

in sensory memory where the Input either decays and Is lost from the

system or Is transferred to short term memory (STM). The STM Is a

working memory having rather limited capacity In terms of both the

quantity (Miller, 1956) and the length of time Information can be

retained (Simon and Newel 1, 1971; 1972). From the STM, Information to

be retafned Is transferred to long term memory (LTM) where It Is stored

along with the rules for Its processing (Simon and Newell, 1971; 1972).

The retrieval of Information from L7W entails Its transfer back to STM

(Bourne et a I., 1979).

Simon and Newell (1971; 1972) demonstrated that a problem solver,

when confronted with a task, defines It In terms of a problem space.

In searching memory for a solution to the problem, a promlnantly used

heuristic Is that of means-ends-analysis. This approach Is appropriate

when a specified goal or end-state Is present (Sweller and Levlne,

1982).

However, In clinical problem solving, an open, probabilistic

system prevails (Gordon, 1982; Grler, 1976; Hammond, 1966). A patient

presents with symptoms or a complex of symptoms representing the

presence of a problem of undefined nature. The clinician Is faced with

an Infinite number of possibilities from which to determine the cause

of the complaints and to prescribe a treatment plan. In order to limit

the problem space, the clinician formulates provisional hypotheses, or

diagnoses, and then tests these hypotheses (Elstein et al., 1978).

Research In medical problem solving has demonstrated that there

are four components of hypothesis generation (Elstein et al., 1978).

8

These components are: 1) attending to Initially available cues, 2)

Identifying problematic elements from among these cues, 3) associating

from problematic elements to LTM and back, generating hypotheses and

suggestions for further Inquiry, and 4) Informally rank ordering

hypotheses according to subjective estimation. The "problematic

element", referred to above, appears to serve as an Indexing key In an

associative process which links observations to prior knowledge.

Additional data are then collected In an attempt to confirm or reject

the set of provisional hypotheses (Elstein et aI., 1972).

At the current time, there Is no reason to reject this process as

the process by which nurses hypothesize and test out nursing diagnoses

(Gordon, 1982). This approach Is comparable to the sub-goal setting

strategies used to limit problem spaces, as described by Reed and

Abramson (1976), and sub-set sampling of hypotheses as described by

Levlne (1970).

The cognitive aspect of a diagnostic task Is one of concept

attainment (Bruner et al., 1956; Gordon, 1982). A diagnostic concept

consists of 1) observable facts or lower concepts; 2) an Idea or

pattern of the facts and their relationships which form a person's

recognlttonat capacity; and 3) a symbol or name which represents the

entire relationship (BIrcher, 1982).

A nursing diagnosis is a complex concept reflecting the actual or

potential health problems which nurses by vlrture of their education

are licensed, and legally responsible and accountable to treat

(BIrcher, 1982; Morltz, 1982). In relation to an Individual's

9

diagnostic ability, Gordon (1982, p. 46) Indicated that:

Diagnostic competence Includes the ability to collect, Interpret, and analyze clinical data and the ability to cluster data In the formulation of problems. These cognitive-perceptual abilities are basic to the diag­nostic phase of the nursing process.

Gordon (1982) stated that the formulation of a nursing diagnosis

requires theoretical knowledge of a set of categories and their

critical defining characteristics. The possession and use of a network

of concepts, such that one or more cues may generate a set of

diagnostic hypotheses, then can be subjected to testing via further

clinical observation. However, If one does not know that the Incidence

of a specific nursing diagnosis Is Increased In the presence of a

particular disease entity or Its treatment, one may not search for cues

or attend to cues that are present. The formulation of appropriate

nursing diagnoses Is dependent upon the ability to generate multiple

hypotheses, recognize cue clusters, and permit these to control the

search for confirming or dI sconfirming Information.

One of the cognitive processes Involved In the diagnostic task Is

the exercise of Judgment. Newell and others (Newell, 1968; Newell and

Simon, 1971; 1972) stated that Judgment Is a cognitive process that

takes place between the Input of Information and output. Judgment Is

more than a simple transfer of Information. Prior to output, the

Individual, via Judgment, adds fnformtlon to that already available In

the situation. Depending upon the nature of the domain being Judged,

the output takes the form of an estimation, assertion, evaluation or

classification as to class membership.

10

Problem solving ability has been Investigated In terms of 1)

characteristics of the task environment and 2) characteristics of the

problem solver. Some of the characteristics of the task environment

that Influence problem solving ability are task complexity and task

setting (Bashook, 1976; Elsteln et al., 1978; McGuIre and Page, 1973;

Norman and Felghtner, 1981; Norman et al., 1983; Simon and Newell,

1971; 1972).

Characteristics of the problems solver reported to be associated

with problem solving ability are cognitive style,

Intelligence/aptitude, gender, age, creative ability, critical thinking

ability, and knowledge base (Bourne and Domlnowskl, 1972; Burke, 1965;

Burke and Maler, 1965; Laughlln, 1967, 1968; Laughlln et al., 1968;

Mater and Casselman, 1970; Maler and Jenson, 1969; Mendelsohn et al.,

1966; Ptshktn and Rosenblum, 1966; Plshkln and Wolfgang, 1965; Plshkln

et at., 1967). Kissinger and Munjas (1981) noted that historical

knowledge Influences application of acquired knowledge to problem

solving situations.

CharacterIstlcs of the nurse problem solver associated with

the exercise of clinical Judgment are theoretical knowledge, years of

clinical experience, and level of education (Broderlck and Ammentorp,

1979; Baumann and Bourbonnals, 1982; Davis, 1972; 1974; Grler and

Schnltzler, 1979). These characteristics were corroborated In medical

studies conducted by Burkett and Knafl (1974), Klelnmuntz (1968), and

Knafl and Burkett (1975). The relationship between problem solving

ability and characteristics of personality type, critical thinking and

11

Intellectual ability also were examined and Inconclusive results

reported (Kissinger and Munjas, 1981; Koehne-KapIan and Tilden, 1976;

Tanner, 1977).

A number of researchers Investigated the general problem solving

abilities and/or strategies used by nurses (Asplnall, 1976; 1979;

Baumann and Bourbonnals, 1982; Broderlck and Ammentorp, 1979; Dlncher

and Stldger, 1976; Farrand et at., 1982; Grler, 1972; Grler and

Schnltzler, 1979; Hammond, 1964; 1966; Hammond et al., 1967; Holzemer

et al., 1981; Johnston, 1982; Kelly, 1964a; 1964b; 1966; McLaughlin et

al., 1978; 1979; Sparks, 1979; Tanner, 1977). Of these researchers,

only a few have compared, either directly or Indirectly, the data

gathering and diagnostic capabilities of associate degree graduates or

students with their baccalaureate counterparts. In addition, the

results of some of these studies are suspect due to methodological

problems which Include small sample size and questions regarding

Instrument validity and reliability.

4. Characteristics of educational programs and S.tudfiRtS

that Influence problem sol v Ing ah I Mty

The ability of the nurse to Identify, analyze, and cluster

data and to Identify nursing diagnoses accurately Is dependent upon

knowledge acquired through formal education and clinical practice

(Gordon, 1982; McCarthy, 1981). Within nursing, there currently exist

three different types of formal educational programs through which an

Individual can become eligible for licensure to practice as a

registered nurse. The three types of programs are hospital-based

12

diploma programs, associate degree programs offered, primarily, by

junior and community colleges, and baccalaureate degree programs

offered by senior colleges and universities.

Although diploma programs were most prevalent prior to 1950

(I.e., prepared the vast majority of nurses), support for their

existence has waned. The reports of Goldmark (1923), Brown (1948) and

the Committee on the Function of Nursing (1950) all advocated moving

nursing education Into Institutions of higher learning. In a 1965

paper on the scope and nature of nursing practice In relationship to

educational requirements, the ANA took a position that the preparation

of Individuals for practice as professional nurses should take place

within Institutions of higher learning. The assumption underlying this

position Is that a baccalaureate education better prepares the nurse to

deliver professional nursing care than does associate degree or diploma

preparation (ANA, 1965).

This position has been reaffirmed by Individual state nurses'

associations (e.g., Illinois, Indiana, New York). Several states are

now working towards the Introduction of legislation to make the

necessary changes In their respective nurse practice acts.

The two levels of educational preparation supported by the ANA

are the associate degree for the practice of technical nursing, and the

baccalaureate degree for the practice of professional nursing. The

goals and objectives, and the scope and depth of the formal educational

content and the clinical learning experiences of these two types of

programs differ In many respects (Dowe, 1974; Dustan, 1964; Hartley,

13

1975; Johnston, 1982; Kramer, 1981; McClure, 1976; Melels and Farrell,

1974; Montag, 1951; National League for Nursing, 1967; 1978; 1979;

Richards, 1972; RInes, 1977a; 1977b; Schlotfeldt, 1977; Sparks, 1979;

Waters et at., 1972; Wren, 1971). These differences will be addressed

In the literature review.

The characteristics of the students In the two types of programs

have been found to differ In age (Dowe, 1974; Dustan, 1964; Hartley,

1975; Sparks, 1979; Wren, 1971), years of education between high school

and enrollment In nursing school (Dustan, 1964; Sparks, 1979), and

years of work experience In a health related discipline prior to

enrollment (Melels and Farrell, 1974; Richards, 1972; Wren, 1971).

These differences will be addressed In the literature review.

RInes (1977a; 1977b) theorized that differences should be evident

in the assessment abilities of associate degree and baccalaureate

degree graduates. The associate degree graduate Is expected by nurse

educators to use the following processes: observation, directed

questioning, physical examination, and measurement of bodily function.

The outcome or product of data collection Is the provision of

Information to the professional nurse, doctor, or other member of the

health team.

In contrast, the baccalaureate graduate Is expected by nurse

educators to perform data collection based on the following:

Interviewing, obtaining a patient history, Identification of questions

to be answered. Identification of sources of data, categorization of

data, and Interpretation of data. The expected outcome Is the

14

statement of nursing diagnoses and a plan for nursing care (RInesf

1977a; 1977b).

It Is clear that the baccalaureate graduate Is expected by nurse

educators to function differently than Is the associate degree graduate

with respect to data collection and Identification of nursing

diagnoses. Therefore, the major differences In the knowledge base of

graduates of the two types of programs should be reflected In the types

of data that they collect and the nursing diagnoses that they Identify.

B. Conceptual framework

Effective use of the nursing process for planning and delivering

nursing care Is highly dependent upon the cognitive Information

processing abilities of the nurse. The outcomes of the nursing process

are Influenced by task complexity, the environmental setting In which

the task occurs, and by the characteristics of the problem solver

(Gordon, 1980; Newell et a!., 1958; Simon and Newell, 1971; 1972).

Characteristics of the nurse problem solver that Influence

Information processing In a clinical setting, and that have been

Identified In the literature, are age , gender, theoretical knowledge

base, years of clinical experience, level of educational preparation.

Intellectual ability, creativity, critical thinking ability and

cognitive style. In addition, age (Knopf, 1975; Nash, 1975; Sparks,

1979), intellectual ability (Dustan, 1964; Schwirian, 1979; Sparks,

1979), the number of years of post-high school education prior to

enrollment (Sparks, 1979), and pre-nurslng experience In a clinical

environment (Sparks, 1979) have been found to differentiate between

15

students enrolled In associate degree and In baccalaureate degree

programs. Attributes which characterize the differences between

associate degree and baccalaureate degree education Include the scope

and depth of theoretical content and clinical practice, and the

specific goals and objectives of the programs.

A determination of the Influence of the type of education

program attended on ab11Ity to collect patient data and Identify

diagnoses Is dependent on controlling the task environment and the

Influences of age, gender, knowledge base, critical thinking ability,

post high school education, and pre-nurslng experience on educational

preparation. A graphic description of this model Is depicted In Figure

1.

c. Purposfi af. .the study

The purpose of this study was to examine the direct and Indirect

Influence of the type of educational preparation on the data collection

and nursing diagnosis Identification abilities of generic nursing

students within three months of graduating from associate degree and

baccalaureate degree nursing programs.

D. Research questions

The primary research question was: Are the patient assessment

abilities of associate and baccalaureate degree nursing students, when

measured within three months prior to graduation from a program of

study accredited by the National League for Nursing, Influenced by type

of educational program?

16

a ^ KNOW PREED SETTING

THINK

GENDER

SSESS

AGE PROGRAM

HSRANK EDCLIN

-> COMPLEX PRECLIN

Figure 1. Conceptual Model.

a PREED = Years of post high school education; HSRANK = high school quartlle rank; PRECLIN = years of pre-nurslng clinical experience; KNOW = nursing knowledge; EDCLIN = education related clinical learning experiences; COMPLEX = perceived complexity; ASSESS = assessment ability; SETTING = task setting.

17

Additional questions addressed were:

1. When graduating associate and baccalaureate degree nursing

students are compared. Is there a difference In data collection

efficiency?

2. When graduating associate and baccalaureate degree nursing

students are compared, Is there a difference In data collection

proficiency?

3. When graduating associate and baccalaureate degree nursing

students are compared. Is there a difference In the amount of

psychosocial history data selected?

4. When graduating associate and baccalaureate degree nursing

students are compared, Is there a difference In the percent of

psychosocial history data selected?

5. When graduating associate and baccalaureate degree nursing

students are compared. Is there a difference In the amount and

completeness of nursing diagnoses Identified?

6. When graduating associate and baccalaureate degree nursing

students are compared. Is there a difference In the amount of

psychosocial nursing diagnoses Identified?

7. When graduating associate and baccalaureate degree nursing

students are compared, Is there a dlffernce In the percent of

psychosocial nursing diagnoses Identified?

E. SJg.n.1 -f.Icanca. of, tha_ study

Although the depth and breadth of course work and the major

objectives and goals of baccalaureate and associate degree nursing

18

programs differ, the graduates of both types of programs are eligible

to take the same licensing examination to practice as a registered

nurse, and are hired to fill similar. If not Identical, clinical

positions. The current licensing practices and the use of associate

degree and baccalaureate degree prepared graduates to fulfill similar

roles and functions tn nursing service settings also have been

identified as factors contributing to the confusion experienced by the

public and other health professionals as to the roles and functions of

nurses with different educational backgrounds (Gray et al., 1977;

McClure, 1976; Sweeney, 1980).

Since the ability to Identify relevant nursing diagnoses Is a

prerequisite for planning and Implementing nursing Interventions, the

results of this study will contribute to a further delineation of the

roles and responsibilities of the technical nurse from those of the

professional nurse.

The profession, as reflected In the ANA position paper on

educational preparation for nursing, has stated that baccalaureate

graduates should perform differently from associate degree graduates tn

terms of the scope of their practice and the complexity of the care

they provide patients and the patient's significant others. The

additional education obtained In a program of study leading to a

baccalaureate degree should prepare the graduate for a different level

of practice.

If differences can be demonstrated between the practice of the

associate and baccalaureate degree nurses, these will provide nursing

19

service administrators, nurse educators, state licensing boards and

legislatures, and the professional organization with a basis for

further clarification of the roles and responsibilities of the

technical nurse and the professional nurse. If differences can be

demonstrated, these results would aid In the delineation of specific

educational program objectives, and the types of assignments that

should be given to graduates of the different types of programs. If

the capabilities of the professional nurse and the technical nurse can

be distinctly differentiated and this Information disseminated to the

public at large, the expectations of other professionals and of

Individuals seeking health care from the nursing community may become

less confused and more realistic.

The number of Individuals currently graduating from associate

degree programs In nursing Is far greater than the number graduating

from baccalaureate programs (Vaughn, 1983). It Is an accepted fact

that the cost of two years of education Is cheaper, both for the

Individual student and for the public as a whole, than Is the cost of

four or five years of education necessary for a baccalaureate degree.

If there are no differences In the abilities of the associate degree

nurse and the baccalaureate degree nurse, It would be foolish for

society to support the more expensive baccalaureate program.

The cost of health care also could be Influenced by the

educational preparation of nurses. If the differences between the

roles and functions of the two levels of nursing practice were

delineated, it would facilitate the use of nursing personnel

20

appropriate to the care needs of the patient. On the other hand,

differential pay scales, as provided by some health care Institutions,

which acknowledge the additional preparation and enhanced capabilities

of the baccalaureate graduate would not be necessary If differences can

not be demonstrated between graduates of the two types of programs.

Therefore, additional public and private monies could be saved.

The following chapter contains a review of literature pertaining

to the diagnostic process, the measurement of clinical problem solving

ability and differences In associate and baccalaureate degree programs

and their students and graduates.

II. LITERATURE REVIEW

This study was based on the premise that the ability to collect

significant patient data and to formulate nursing diagnoses Is, In

part, dependent upon an Individual's knowledge base. The major focus of

this chapter Is a review of the literature relevant to a description of

the diagnostic process and a description of differences In the goals,

objectives, and content of associate and baccalaureate degree nursing

programs and characteristics of their students and graduates. An

additional section contains a review of the literature concerning the

measurement of clinical problem solving ability.

A. The dI agnostic prnrass

The diagnostic process refers to the analytical and evaluative

process aimed at determining the cause or nature of a patlent*s

problems (Barrows and Tamblyn, 1980). In the preceding chapter, It was

stated that the diagnostic process Is a problem solving task that

occurs In a probabilistic environment (Gordon, 1982j Grler, 1976;

Hammond, 1966). In addition, the cognitive aspect of a diagnostic task

also has been described as one of concept attainment (Blrcher, 1982;

Bruner et al., 1956; Gordon, 1980; 1982).

Information processing theory was chosen as the theoretical

framework for this study since this theory describes the cognitive,

problem solving processes that are used for Identification of nursing

diagnoses. The major focus of research within this paradigm has been

21

22

on a description of processes by which Information Is processed and

factors Imposing limitations on Information processing.

The theory, as developed by Newell et at. (Newell et al., 1958;

Simon and Newell, 1971; 1972) describes problem solving behavior as an

Interaction between a problem solver (the Information processing

system) and a problem or task (the task environment). How well a

problem solver utilizes the processing system Is dependent upon how

well one can adapt to constraints Imposed by the processing system

(Internal factors) and constraints Imposed by the task environment

(external factors) (Newell et al., 1958). Characteristics of the task

environment and characteristics of the problem solver that Impact on

diagnostic ability will be described In terms of Information processing

theory and research findings reported In nursing and medical

IIterature.

1. Task, environment

The nature of the task environment determines to a large

extent the behavior of the problem solver. Independently of the

detailed structure of the Internal Information processing system (Simon

and Newell, 1971; 1972). This subsection addresses environmental

factors that Influence clinical problem solving: setting,

characteristics of patient cues, and context of care.

The setting In which a clinical diagnostic task occurs has been

described as an open, probabilistic system (Gordon, 1980; Grler, 1976;

Hammond, 1966). As a result, clinical diagnoses are arrived at under

conditions that are Indeterminate In nature (Elstetn et al., 1978).

23

This situation has been described best by Hammond (1964; 1966)

and Kelly (1966) In their studies of clinical inference In nursing.

Signs and symptoms (cues) of a patient's condition from which a

clinician derives a diagnosis are not completely dependable. They are

probabilistically related to a given state of affairs. A specific

condition may be manifested by one cue one time and by a different one

on another occasion. In addition, a single cue may be produced by

several different conditions. The great majority of data are

uncertain, fallible, and Inter-substltutable (Hammond, 1966). Hammond

also noted that a nurse is faced with an uncertainty-geared task when

attempting to Infer the state of a patient. He stated that "The

nurse's problem is to Infer correctly the Impalpable state of the

patient from the uncertain, palpable data presented by the patient"

(1966, p.29). This conclusion also was reached by Kelly (1966) who

noted that data available from patients are Incomplete, probabilistic

In nature, and may have high Information value or be Irrelevant or

Inconsequential.

Additional evidence of the less than optimal conditions under

whtch diagnostic conclusions are arrived at Is related to findings that

data obtained directly from patients are characterized as

unstandardlzed and poorly quantified (Koran, 1975a; 1975b). Laboratory

test results also have been found to vary widely In sensitivity,

specificity, reliability, and accuracy (McNeil, 1975).

The characteristics of patient data have been examined In

relationship to their Impact on the diagnostic process. Cianfranl

24

(1982) examined the Influence of the amount and relevance of data on

the ability of 180 critical care nurses and students In graduate

nursing programs to Identify patient health problems. He found that

the accuracy of problem Identification was significantly less In the

presence of low relevant data than when high relevant data were

present. He also found that as the amount of available data Increased,

there was an Increase In the number of problems Identified, the time

necessary to Identify these problems, and In the number of errors

committed.

Archer et al. (1955) found that as the amount of Irrelevant

Information Increased, performance on a concept Identification task

decreased. This was corroborated by the findings of Walker and Bourne

(1961) who also found a decrease In performance related to an Increase

In the amount of Irrelevant data. In addition. Walker and Bourne (1961)

also found that as the amount of relevant data Increased, performance

on the concept attainment task decreased.

Bourne and Haywood (1959) examined performance on a concept

Identification task In relationship to different amounts and levels of

redundancy In relevant and Irrelevant data. They found that when non-

redundant Irrelevant data were added to available relevant data,

performance on the task diminished. In the presence of relevant and

Irrelevant data, the addition of redundant relevant data resulted In

Improved performance. The addition of redundant Irrelevant data to

varying levels of relevant data also Interfered with performance but

not as much as when non-redundant, Irrelevant data were added.

25

The results of these studies Indicate that both quantity and

quality of available data Influence diagnostic performance by adding

both to the amount of Information that needs to be processed and to the

level of complexity that needs to be dealt with.

An additional environmental characteristic that influences

diagnostic accuracy Is the context of care. Bashook (1976) noted that

problem solving In an emergency situation should be different than that

In a non-emergency situation due to the time constraints imposed on the

decision maker* Equivocal evidence has been accumulated In regard to

the performance of clinicians exposed to patients with different

problems. Elsteln et al. (1978) concluded that diagnostic competence

may be case related since they found considerable variation In the

diagnostic effectiveness of physicians and medical students across

patient problems. In contrast. Barrows et al. (1982) reported finding

little variation In physlcan performance across a variety of simulated

patient problems. Norman et al. (1983) found no support for "case

specificity" as an explanation for differences In diagnostic ability,

a. Summary

A diagnostic task is accomplished In an open

probabilistic system using data that are Incomplete and unstandardlzed,

probabilistic In nature, poorly quantified, and varying In sensitivity,

specificity, and reliability. In addition, the amount and relevancy of

the data available to the diagnostician also Influence diagnostic

outcomes. Variations In diagnostic accuracy are associated with the

context of care and also may be related to care specificity.

26

2. Character istics, of. the prob.l em salver

The focus of this section Is to describe the characteristics

of the human processing system. Simon and Newell (1971; 1972) described

the human Information processing system In terms analogous to

Information flow through an artificial Intelligence system.

Information obtained from the external environment Initially Is

processed through sensory memory where the Input, represented

symbol leally, either decays and Is lost from the system or Is

transfered to short term memory (STM). The STM Is a working memory

which Is the central processing unit of the system. Information can be

stored temporarily In STM but that which Is to be retained Is

transfered to long term memory (LTM) where It Is stored along with the

rules for Its processing. Use of Information stored In LTM for problem

solving Involves Its transfer back to STM for processing, the outcome

of which subsequently results In output. This output may take the form

of a problem solution, a search of the problem space for additional

Information, or the storage or retrieval of Information from LTM. The

processing capabilities and the characteristics of the STM and the LTM

wilt be described In detail.

a. Process, I no flanahMltles

The processing capability of a human Information

processing system Is dependent upon the number of processes It can do

simultaneously, the time It takes to perform each process, and the

amount of work done by each Individual process (Simon and Newell, 1971;

1972). The system operates In a serial as opposed to a parallel

27

fashion. It executes one elementary Information process at a time. As

the problem solver searches sequentially, small successive additions

are made to the store of Information about a problem and Its solution

(Simon and Newell, 1971; 1972). The processing rate Is dependent

upon the type of process being executed and Its complexity. The

results of rote memory experiments provided evidence that 5 to 10

seconds are required to store a symbol In LTM. In contrast, when

subjects were required to search down lists of simple arithmetic

problems, only milliseconds were found to be needed for the transfer of

Information Into and out of STM (Simon and Newell, 1971; 1972).

b. Short, teria memory

The processing of Information In STM significantly

Influences problem solving ability (Lindsay and Norman, 1977; Simon and

Newell, 1971; 1972). The major limitations of STM are Its capacity and

the amount of time that Information can be retained. The STM has a very

small capacity. Miller (1956), In a review of rote memory

experiments, concluded that the capacity of the STM Is 2.6 bits (s.d. =

0.6) of Information. This translates to a capacity for 7, plus or

minus 2 categories of Information that can be retained at any one time.

Elsteln et al. (1972; 1978) In Investigations of the reasoning

processes used by expert physicians, found that the number of

diagnostic hypotheses entertained at any one time was four, plus or

minus one. Although these estimates differ from those of Miller

(1956), they do depict the limited capacity that Is available.

The capacity of STM can be Increased through a process refered to

28

as "chunking" (Miller, 1956). Chunking refers to the grouping of

meaningful Items Into one category. However, as the number of Items

chunked together Increases, the qual Ity of the Information decreases

(Miller, 1956).

Shanteau and Phelps (1977), In an Investigation of the judgmental

processes used by IIvestock Judges, found that experts were able to

process larger amounts of Information than were non-experts. This

ability was attributed to the chunking of data In STM. Chase and Simon

(1973) found that grand master chess players were able to recreate

chess positions differently than were novices. The grand masters

replaced chess pieces In groupings that represented their relationships

under actual game positions. In contrast, novices replaced the pieces

Individually. The actions of the grand masters were Interpreted as

being representatIve of the chunking of Information In STM.

Long term retention of Information Is not a characteristic of

STM. Information not rehearsed Is generally lost within 30 seconds.

Rehearsal enhances the processing, but not the capacity of Information

held In STM. Repeated rehearsal of an Item Increases the likelihood

that It will be transfered to LTM from which It can be recalled

(Klatzkey, 1975; Lindsay and Norman, 1980; Simon and Newell, 1972).

c. Long term memory

Information to be retained for future use Is stored In

LTM. The organization of Information In LTM and Its role In problem

solving are discussed In the following subsections.

29

1) Organ teat-ton of stored Informat Ion

Through learning, certain stimuli or patterns of

stimuli are designated by particular symbols that can be stored In LTM.

The LTM has unlimited storage capacity and Is organized assocIat IveIy

with Its content being composed of symbols and structures of symbols

(also called chunks or nodes) that represent recognizable

configurations (Simon and Newell* 1972). The stored symbols serve as

the Internal representation for the corresponding stimulus patterns or

chunks. As new symbol structures are stored In LTM, they can be

embedded as symbols In other symbol structures, thus forming an

associative network of concepts and relations between concepts

(Anderson, 1980; Anderson and Bower, 1972; Simon and Newell, 1972).

Mayer (1975) noted that the extent to which new nodes are added

and linked to other nodes In LTM can vary along three dimensions.

First, the degree to which new nodes are acquired by a learner Is

reflected quantitatively by the amount of learning that takes place.

The second dimension Is the degree to which new nodes are connected

with one another In a single, well defined structure. The third

dimension Is the degree to which new nodes are connected with concepts

already existing In the learner's cognitive structure, thus forming an

Integrated network.

Mayer (1975) subsequently conducted an Investigation Involving

the use of different Instructional methods for teaching probability

theory. The results demonstrated that when there was no difference In

the amount of Information learned, a teaching method promoting the

30

Integration of new Information within existing knowledge resulted In

more flexible problem solving abl IIty than did a method focusing on

teaching procedural steps.

The results of several Investigations have provided Insight Into

the organization of Information stored In LTM. Collins and Quill Ian

(1969) used subject reaction times for the retrieval of Informtlon from

LTM In order to Judge the truth of assertions about concept

organization. Results of their Investigation supported the assumption

that a network of concepts and their associated properties are arranged

hierarchically. This finding was supported by the results of

Investigations of medical problem solving conducted by Kletnmuntz

(1968) and Wortman (1972).

Klelnmuntz (1968) used a variation of a 20 questions game to

examine the diagnostic skills of 12 neurologists who possessed varying

levels of experience. As the neurologists progressed through a

diagnostic task, they were encouraged to think aloud. The sessions

were recorded and the transcribed reports were used for analysis.

Klelnmuntz (1968) found that more experienced physicians tended to

start with general questions about the state of a patient and converged

on a diagnosis using progressively more specific questions. This

finding supports the hierarchical organization of Information In

memory.

Wortman (1972) used verbal protocol analysis and subsequent

computer simulations of a neurologist engaged In several diagnostic

tasks to test the hypothesis that medical knowledge Is organized

31

hierarchically. Results of the study provided support, but not

conclusive evidence for this type of organization. However, the

findings did corroborate those of Klelnmuntz.

Schwartz and Simon (1976) and Rubin (1975, cited In Tanner, 1977)

developed memory models that view the organization of medical knowledge

as a network of elements Interconnected by various relationships.

Rubtn (1975) Identified two major types of relationships. One type of

network Is represented by a hierarchical memory organization In which a

lower level concept Is related to an upper level concept (I.e., "X" Is

a type of "Y"). The second type of network refers to the organization

of concepts at a specific level within the hierarchy (I.e., "X" causes

"Y" or "Xw Is a complication of "Y"). The amount and organization of

knowledge stored In LTM has an essential role In determining the

outcomes of problem solving tasks.

2 ) Role of knowledge •storflri tn LTM In problem solving)

The role of knowledge In problem solving has been

addressed by Greeno (1980), Larkln (1980), and Simon (1980). All three

emphasized that all problem solving Is based on knowledge and that

without extensive and accessible knowledge, there can be no development

of expertise In problem solving. Greeno (1980) emphasized that any

task aiming to attain some goal constitutes a problem and the solution

of any such problem requires appropriate knowledge. A person may not

have learned exactly what to do In a specific problem situation, but

whatever the person Is able to do requires some knowledge, even If that

32

knowledge may be In the form of general strategies for analyzing

situations and for attempting solutions to the problem.

In relation to clinical problem solving, Hammond (1964; 1966)

stated that the nurse needs to be competent In Information seeking and

must have a thorough background of theoretical knowledge to conduct a

search for cues and to evaluate evidence. El stein et al. (1978) noted

that the possession of relevant bodies of Information and a

sufficiently broad experience with related problems Impacts on the

determination of what Information In the clinical situation Is

pertinent, which findings are significant, and how these findings can

be Integrated Into appropriate diagnostic hypotheses and conclusions.

In their studies. El stein et al. (1978) concluded that the effective

clinician has knowledge of the relation of findings, the relative

frequencies of different possible patient conditions, and the

particular characteristics of those conditions.

The results of Investigations In clinical problem solving In

nursing have shown that differences In problem solving ability can be

attributed to differences In knowledge (Asplnall, 1976: Baumann and

Bourbonnals, 1982; Davis, 1972; 1974; Verhonlck et al., 1968).

Verhonlck et ai. (1968) used a filmed, simulated patient care situation

to determine what observations were made, what types of nursing actions

were planned and what rationales were used for planned actions. The

study sample consisted of a large, diverse group of nurses attending

two national conventions. Included In the study were 43 nurses with

doctorates, 559 with masters degrees, 495 with baccalaureate degrees,

33

and 479 who had no degree. Analysis of the data revealed that

educational level was related to performance regarding the frequency of

Identifying relevant observations. Irrelevant observations, and

Inappropriate observations. The frequency and percent of both relevant

and Irrelevant observations made by each educational group Increased

with each higher degree. Conversely, an Inverse relationship was found

between the highest degree and the frequency and percent of

Inappropriate data selection. Nurses with no degree selected more

Inappropriate data than those with successively higher degrees.

Davis (1972; 1974) conducted two studies examining the

relationship between level of education and clinical expertise. These

studies were based on the assumption that through advanced knowledge

the nurse can make more complete, complex, thorough assessments and

carry through the appropriate required and designated Interventions.

Davis replicated the methodology of Verhonlck et at. (1968) using the

same taped simulations and data collection procedures. in the first

study, the respondents were 20 clinical specialists and 20

baccalaureate prepared nurses who were matched for years of clinical

experience. Analysis of the results demonstrated that the clinical

specialists made significantly more relevant observations, suggested a

greater number of relevant actions based on their observations, and

gave more appropriate reasons for their actions than did the

baccalaureate prepared nurses.

In the 1974 extension of the study, data were collected from an

additional 20 clinical specialists and 27 diploma prepared nurses. As

34

In the first study, analysis of the results demonstrated that In all

three areas, the performance of the clinical specialists was superior

to that of the baccalaureate prepared nurses, whose performance was

superior to that of the diploma nurses. An additional finding In this

study was that education and not years of experience was found to be

the determining factor In both the quality and quantity of patient

care.

Asplnall (1976) used a written case study of a patient exhibiting

an Impairment In the ability to process thoughts In order to determine

the ability of nurses with varying levels of education and experience

to Identify the cause of the patient's problem. The respondents were

6 nurses with masters degrees, 43 with baccalaureate degrees, 87 with

diplomas, and 51 with associate degrees. Of the 12 possible problems

that could be Identified, masters prepared nurses Identified a mean of

4 problems; baccalaureate nurses, 3.93; diploma nurses, 3.23; and

associate degree nurses, 3.35. Analysis of the data revealed

statistically significant differences between the number of problems

Identified by the baccalaureate and associate degree nurses and between

the baccalaureate and diploma nurses„ When the mean number of problems

Identified by nurses with less than 10 years of experience was

compared with that for nurses with 10 or more years of experience, a

statistically significant difference was demonstrated; those with less

experience Identified more problems.

Baumann and Bourbonnals (1982) used a convenience sample of 50

nurses working In critical care settings to explore decision making In

35

crisis situations and to determine factors nurses considered relevant

In making rapid patient care decisions under crisis conditions. A

semi-structured Interview was used In conjunction with a critical care

case study for data collection.

Participants In the study were 49 females and 1 male who ranged

between 20 and 50 years of age. Forty-three participants were

graduates of diploma schools and 7 had baccalaureate degrees. Analysts

of responses revealed that, Irregardless of the differences In

educational preparation, the factors most frequently cited as having

the greatest Influence on rapid decision making were knowledge and

experience.

The amount and organization of knowledge In LTM plays an

Important role In a diagnostic concept attainment task and the

subsequent search for cues In the environment. The learning histories

of students enrolled In associate and baccalaureate degree programs Is

also relevant to the amount and structure of Information stored In LTM.

These relationships will be addressed in subsequent subsections.

d. Interaction, of the, process ing, system, w ith, tha. - external

envlronmant

When faced with a problem solving task, the problem

solver is goal directed In the search for a solution (Simon and Newell,

1972). Attainment of a solution Is achieved through the development

of an Interface between the Internal processing system and the task

environment. This Interface Is represented In STM by a problem space.

The problem space can be thought of as a state of knowledge to which

36

the problem solver can attain. A search Is conducted through the

Information available In the problem space until a knowledge state Is

attained that Includes the problem solution (Simon and Newell, 1971;

1972). The process an Individual uses to achieve the problem solution

Is dependent upon whether the problem exists In a closed or an open

system.

In a closed system, the problem solver has knowledge of the

specific goals to be attained and compares knowledge of this goal to

the current knowledge state. Following each successive comparison, an

additional piece of Information Is added or deleted depending upon a

decrease or Increase In the distance between the current and the

desired state. This process continues until the two states are

synonymous. This process Is refered to as means-ends analysis (Simon

and Newell, 1971; Sweller and Levlne, 1982).

In contrast, a clinical diagnostic problem represents an open

system In which there are an Infinite number of possible end states;

the desired end state Is the Identification of a specific diagnosis.

In order to deal with the vagaries of an open system, problem solvers

transform It Into a series of hypothetical closed systems which can be

tested either serially or simultaneously (Bartlett, 1958). Using

verbal protocol analyses, El stein et al. (1972; 1978), Gordon (1980),

and Klelnmuntz (1968) demonstrated that clinicians Involved In a

diagnostic process utilize this approach. Based on Initially available

Information, the LTM Is searched for diagnostic labels that may

explain the data. The hypothesized diagnoses, which may be at the

37

level of "ideas", "guesses", or "Impressions" are then tested using a

hypothetIco-deductlve approach (Elstetn et al., 1978). Etsteln et al.

(1978) characterized the diagnostic process as one which entails

repetitive stages of cue acquisition, hypothesis generation, cue

Interpretation, and hypothesis testing.

Gordon (1980), In an Investigation of the hypothesis testing

strategies used by 60 graduate nursing students, found that they used a

mixed hypothesis-testing strategy. Under unlimited and limited (I.e.,

12 trials to solution) Information conditions, the use of multiple

hypothesis testing diminished significantly as the diagnostic tasks

progressed. As the use of multiple-hypothesis testing decreased, there

was a concomitant Increase In the use of single hypothesis testing.

This finding Indicates that while a hypothetIco-deductlve process Is

utilized, the process changes from one of simultaneous hypothesis

testing to single hypothesis testing as the field of possible diagnoses

Is narrowed. The Initial use of multiple hypothesis testing helps to

limit the subsequent search much more efficiently than would the

Initial use of single hypothesis testing.

e. Summary

Short term memory has a significant Influence on

problem solving ability due to limited capacity and low retention time.

These limitations can be compensated for by using data chunking

techniques. In contrast, LTM has an unlimited storage capacity. It

contains the symbolic representations of stimulus patterns, organized

In hierarchical associations as networks of concepts and relations

38

between concepts. The development of expertise In problem solving Is

dependent upon the amount and organization of Information acquired

through learning, that Is stored In LTM.

To deal with the open probabilistic system representative of a

diagnostic task. Initially available data are used to search LTM for

diagnostic labels that may account for this data. The potential

diagnoses are then transferred to STW where they help limit the scope

of the environment to be searched. A hypothetlco-deductlve approach Is

then used to test out the diagnostic hypotheses. An application of the

Interaction between the Internal processing system and the external

environment, as represented by the problem space, to a diagnostic task

Is addressed In the next subsection.

3. Diagnosis triantIfIratIon

The process of determining which diagnostic label best

represents a given cluster of patient data and factors which Influence

the accuracy of the diagnostic process are discussed In the following

subsections.

a. Concept, attainment

Arrival at a Judgment concerning which diagnoses best

explain the pattern of patient cues ts a concept attainment task

(Bruner et at., 1956; Gordon, 1980; 1982; Klelnmuntz, 1968). Bruner et

al. (1956) stated that diagnoses are examples of disjunctive concepts.

The presence of one attribute or another attribute, or both. Is

sufficient to define the concept. This Is consistent with the

39

previously described relationships existing between patient cues and

the diagnoses which they define.

A nursing diagnosis Is a symbol or name of a complex concept that

Is composed of lower-level concepts (I.e., observable facts) and their

relationship with each other (Blrcher, 1982). As discussed previously,

learned symbolic representations of concepts are stored In LTM and are

transferred selectively to SIM during problem solving tasks. In a

diagnostic task, the Initially perceived patient characteristics In the

problem space are used as the basis for a search of LTM for concepts

that Include these characteristics. Those concepts in LTM that Include

one or more of the characteristics become the hypothesized diagnoses

that are transferred to STM and serve as the goal against which

Information obtained from the problem space Is compared (Barrows and

Tamblyn, 1980; Simon and Newell, 1972).

Since diagnostic categories are disjunctive concepts, a concept

formation theory needs to take this Into account. Rosch and Mervls

(1975) demonstrated support for using "family resemblances" as a

structural basis for making comparisons. Using this approach, the

diagnostic categories (concepts) retrieved from LTM are used as

prototypical models against which groupings of currently available

Information are compared. The more attributes an Information grouping

has In common with one diagnostic category, the less tt will have In

common with others. The diagnosis Is Identified based on a subjective

appraisal and Informal rank ordering of the hypothesized diagnoses

(Elstein et at., 1972; 1978).

40

The accuracy of a diagnosis Is Influenced by the constraints

Imposed by both the Internal processing system and cognitive biases.

These will be addressed In the next subsection.

b. Factors. InfI imnrTnp diagnostic accuracy

The formulation of early diagnostic hypotheses has been

used to transform an open system Into a series of hypothetical closed

systems In which the clinician operates. The formulation of multiple

early hypotheses provides Insurance against premature closure about a

patient's problem (Elsteln et al., 1972; 1978). This formulation

forces consideration of possible alternative explanations for the

aval lable data.

Barrows et al. C1978) noted that the efficiency, effectiveness,

and quality of a clinician's evaluation of a patient are dependent

largely upon the hypotheses generated. The results of Klelnmuntz's

(1968) study demonstrated that patient Information not directly related

to hypothesized diagnoses Is usually forgotten. When data do not seem

to fit any hypothesis, they need to be challanged In terms of

reliability and the hypotheses need to be challenged In terms of their

adequacy (Barrows and Tamblyn, 1980).

Tanner (1977), In an Investigation designed to evaluate the

effects of different teaching strategies on early hypothesis generation

and diagnostic accuracy, found significant, positive relationships

between the formulation of diagnostic hypotheses and both the quality

of an Information search and diagnostic accuracy. The qualtty of

Information search was related to the validity and dependabllty of cues

41

sought and the search strategy employed. The correlation coefftcents

between the number of early hypotheses generated and diagnostic

accuracy ranged between 0.57 and 0.75 (p<.001). However when this

relationship was re-examined while controlling for Information quality,

a much lower correlation was demonstrated between the two factors (r

=0.256, p < .05).

Another factor contributing to diagnostic accuracy problems Is

that of cognitive strain due to the capacity limitations of the STW.

The value of chunking data to deal with this problem was previously

discussed. Another approach that can Increase the amount of Information

available for processing at any one time Is the use of an external

memory (Simon and Newell, 1972).

Aspfnall (1979) evaluated the use of decision trees for Improving

the diagnostic abilities of nurses. Thirty triads of nurses matched

for basic education, length of experience, and performance In a

previous study (Asplnaii, 1976) were exposed to three levels of

treatment prior to measurement of diagnostic ability on a written case

study. One group, the control, received only the written case study;

the second group received the case study and a list of the 18 possible

diagnoses; the third group received the case study, the list of

diagnoses, and a decision tree for each diagnosis, it was hypothesized

that the decision trees would facilitate the systematic use of data to

rule In or out each diagnosis.

Analysis of the data demonstrated that those nurses who received

the decision tree Identified a significantly greater number of correct

42

diagnoses and were more accurate than either of the other two groups

of nurses. In addition, those who received the list of diagnoses

Identified a significantly greater number of correct diagnoses than did

those In the control group. Further analysis demonstrated that use of

th© decision tree was most effective In aldtng those nurses who had the

least amount of education (I.e., diplomas and associate degrees).

Early hypothesis generation and the use of data chunking and

decision trees have been found to Influence diagnostic accuracy

positively. This accuracy can be Influenced negatively by one or more

types of Inductive biases. Kahneman and Tversky (1972; 1973; Tversky,

1977; Tversky and Kahneman, 1973) proposed a theory that described

people's dependence on a limited number of heuristic principles to

simplify cognitive processing. However, the use of these principles,

as demonstrated In Asp Inail's (1979) study, can lead to errors and

bIases In Judgement.

Asplnall (1979) reported that one nurse, who had access to the

decision trees, diagnosed the presence of renal failure when the

patient In fact had none of the criteria for this problem. When

questioned, the nurse replied that based on her past experience,

patients with hepatic disease also had renal failure. This example

demonstrates one of the heuristics, availability, described by Tversky

and Kahneman (1973). This refers to a strategy by which people assess

the frequency of a class or the probability of an event by the ease

with which It Is brought to mind.

Use of the availability heuristic can be biased by a number of

43

factors besides frequency and probability. The retrlevablIIty of

Instances Is one such bias where the recall of similar Instances

Influenced current judgment (Tversky and Kahneman, 1973). Evidence of

the use of this heuristic In the retrieval of diagnostic hypotheses

also has been Identified In physicians (Elsteln et al., 1972).

A second heuristic Is that of representativeness (Tversky and

Kahneman, 1974). According to this heuristic, the probability of an

event Is determined by "the degree to which It: 1) Is similar In

essential characteristics to the parent population, and 2) reflects

the salient features of the process by which It Is generated" (p. 430).

Biases occur when base rates, IIkelIhood of occurrance, and degree of

similarity are not taken Into consideration (Tversky and Kahneman,

1972).

Additional errors In diagnoses can occur as a result of the

misuse or tack of use of available Information. Bruner et al. (1956)

demonstrated that hypotheses are formed on the basis of positive

Information even though negative Information may have greater

diagnostic value. Information confirming hypotheses also are used more

effectively than Information which disproves them (Bruner et a!., 1956;

Kozleleckl, 1972). Diagnostic biases also can occur as a result of

overestimating the diagnostic value of the earliest obtained

Information (Kozleleckl, 1972) and of falling to revise diagnoses on

receipt of additional Information. In their clinical Inference

studies, Hammond et al. (1967) found evidence of the failure of nurses

.pa

44

to revise appropriately their Judgments of a patient's condition as

new Information was obtained.

4. Summary

Arrival at a Judgment regarding which diagnoses best explain

patient cues Is a concept attainment task made difficult by the fact

that diagnostic categories are examples of disjunctive concepts. The

Initially perceived Information, defined by the problem space. Is used

as a basis for searching LTW for concepts that include this

Information. Use of a "family resemblance" approach, as described by

Rosch and Mervls (1975) has received support as a structural basis for

making comparisons between available cue patterns and the attributes of

a diagnostic category, as stored In LTM.

Diagnostic accuracy is Influenced by the number of hypothesized

diagnostic categories Initially generated, the validity and reliability

of the available data, and cognitive strain related to STM limitations.

To cope with these limitations, data chunking, early hypothesis

formulation, external memory devises, and heuristics have been used.

An examination of the cognitive aspects of a diagnostic task

demonstrates that the characteristics of the environment, as

represented by the problem space In Internal memory, the limitations of

the STM and the processing system, the amount and organization of

Information stored In LTM, and the subjective analysis of patient cues

all influence diagnostic accuracy.

B. Measurement, of. cl inical. probJem soJvlng. ab i l ity

Boshuizen and Claessen (1982) stressed the Importance of

45

differentiating between the task of problem solving and the ability to

problem solve. They suggested that the term "problem solving" be used

to signify the activity and that "problem solving ability" be used to

signify the trait or ability to problem solve. Subsequently, In

discussing research In medical problem solving, they stated that

"Medical problem solving refers to the thinking processes that take

place In the course of finding an answer to the question: 'What Is

wrong with this patient and what should be done with him/her?1" Cp.

82). Within a nursing context, the measurement of problem solving

ability then becomes one of assessing " how well" a nurse Is able to

define and propose solutions to those patient problems that are

amenable to nursing Intervention.

Selection of an Instrument to measure clinical problem solving

ability and, specifically, assessment ability, must be based on

evaluations of appropriateness of an Instrument's format and mode of

administration; Its validity and reliability; Its cost; and the degree

of difficulty associated with Its preparation and administration In

relation to the explicit purpose of a study (McGuIre, 1980a; Vu, 1979).

Several different approaches have been used to assess problem solving

ability. These approaches have been characterized as observation-based

methods, record-based methods, and simulation methods (Vu, 1979). A

brief overview of the characteristics of the observation- and record-

based methods and a more comprehensive examination of one form of the

simulation method are Included In the following sections.

46

1. Ohserva-Hrin-hasftri rntH-hnHg

Observation of Individuals engaged In the performance of

various aspects of clinical problem solving Incorporates the use of

rating scales* written reports, and observer Impressions. These

observations may occur In actual clinical settings utilizing real

patients or Involve the use of trained actors.

Use of actual clinical settings and patients for the purpose of

making comparisons of problem solving abilities across Individuals has

several disadvantages. Difficulty Is encountered due to Inability of

the observer to control patient cooperation and environmental activity

In a testing situation. An additional potential problem, If the

problem solver Is a student, Is the occurrence of events to occur that

might endanger the patient and/or the student (McGuIre, 1980by McGuIre

et al., 1976).

Observer related variables also Influence the quality of the

data obtained. Factors that may Influence reliability and validity of

data are associated with problems in delineating the specific versus

the global activity to be evaluated, observer definition of "good"

versus "bad" performance, and weighting assigned to various performance

categories (Barro, 1973; Vu, 1979). McGuIre (1980b) advised that

considering time and cost associated with use of observation methods.

It should be reserved for assessment of Interpersonal and psychomotor

techniques.

2. Recorri-haseri methods

A retrospective, Indirect approach to the assessment of

47

problem solving ability Involves examination and evaluation of written

patient records. Factors contributing to questionable validity of

conclusions based on this method Include qualifications of the

reviewer. Inability of the measurement process to determine the problem

solving process utilized, and Influence of potential review on the

performance of the Individual being evaluated (Barro, 1973; Vu, 1979).

Evidence also has accumulated that Indicates clinicians do not always

completely record history and physical examination data that they have

collected (Barro, 1973; Norman and Felghtner, 1981; Norman and

Wakefield, 1978; Page and Fielding, 1980; Vu, 1979).

3. Simulation methods

Clinical problem solving tasks can be simulated through the

use of several different methods. One method already mentioned Is the

use of trained actors to portray a patient. As an alternative, several

other methods have been developed to assess how, or how well.

Individuals perform In a given clInlcal problem solving situation.

These Include the use of paper and pencil exercises, computer-managed

exercises, and/or an oral format (McGuIre, 1980b).

The common element Itnklng these formats Is use of a

predetermined description of a patient situation. The extent of this

description depends upon the purpose of the assessment and may be a

written, verbal, or audio-visual account. The problem solver Is

directed through the simulated experience according to the specific

method adopted for use.

48

a. OraJ, format

In the oral format, an examiner Is provided with all of

the data about a case and supplies this to the examinee upon specific

Inquiry or In response to a management decision (McGuIre, 1980b).

During the exercise, each Inquiry and management decision made by the

examinee Is recorded on a checklist (McGuIre, 1980b) or recorded on

tape (Tanner, 1977).

Use of this format permits ongoing extraction, by the examiner,

of the examinee's explanations of the reason for requesting specific

data, the meaning of those data regarding diagnosis and management

decisions, and why specific actions were Implemented (Tanner, 1977). A

major advantage of this format Is the examinee Is not prompted In the

selection of data, diagnoses, or management selections by the presence

of lists of written options (McGuIre, 1980b). However, this method Is

not useful for group testing and, therefore, Is a time consuming

enterprise when the object of a study Is to determine how well an

Individual performs or when a large number of participants are to be

evaluated. In addition, the use of another Individual to supply the

responses and to query the examinee Imposes a high degree of

artificial IIty on the testing situation.

b. Patient management problems

A number of variations of the paper-and-pencl1 format

have been developed for use In the evaluation of problem solving skills

(McGuIre, 1980b; Vu, 1979). One variation, the Patient Management

Problem (PMP) pioneered at the University of Illinois at Chicago, uses

49

a branching technique which requires the use of sequential analysis and

decision making (McGufre and Babbott, 1967). The branched format

permits alternative approaches and a variety of pathways through which

a solution can be reached. The technique also Involves the use of a

special answer sheet on which the examinee reveals sequentially the

results of decisions by erasing an opaque overlay or by developing

Invisible printing, thus, permitting access to only that Information

which has been requested (McGuIre, 1968).

The content of a PMP simulation Is presented In a series of

sections that permit the examinee freedom to select an Individual

course In resolving the problem presented. The simulation begins with

an opening scene which describes the problem to be solved, but contains

no more Information than that which Is usually evident during an

Initial encounter with a patient. A series of sections, corresponding

to different stages In the evaluation and resolution of the problem

follow the opening scene. Each section may contain an option segment,

which Includes a list of specific Inquiries or options available, and a

bridging segment that directs the examinee to the next appropriate

section or to a list of strategic alternatives. The beginning of each

segment contains Instructions regarding the type of response that Is

required (McGuIre, 1980b; McGuIre et al., 1976).

Quantitative measurement of performance on a PMP Is achieved

through the assignment of a weighted score to each Item. The weighting

system used and the summary performance scores to be reported are based

on the purpose of the study and the number of Items that can be grouped

50

together to obtain a summary score. The summary scores suggested by

M c G u I r e a n d o t h e r s ( M c G u I r e a n d B a b b o t t , 1 9 6 7 ; M c G u I r e e t a 1 9 7 6 )

Include measures of proficiency, efficiency, errors of ommlston and

commission, and overall competence.

Several characteristics of this type of written simulation make

It suitable for assessing problem solving skills. These

characteristics are freedom to select an Individual approach to

problem resolution, provision of Immediate feedback regarding the

Information desired or the outcomes of actions, and Inability to

retract a selection that proves to be unwarranted or unwise (McGuIre et

al., 1976).

Additional advantages Include ability to predetermine and

standardize the task to be performed while eliminating Irrelevant

complexities that would affect the evaluation process and/or the level

of difficulty. The PMP format also enables the sampling of a broad,

representative sample of problems and provides for the pre­

determination of criteria to be used for performance (McGuIre et a I.,

1976).

One criticism of the PMP format Is based on the presence of lists

of decision options. Neuble and others (1982), Martin (McGuIre, 1980b)

and McCarthy (1966) reported that the cueing effects of these lists

result In artificial Inflation of patient history and physical

examination proficiency scores. When performance on cued and non-cued

tests was compared, substantial Increases were seen, on the cued test.

51

In both the total number of Items selected and In the number of correct

Items selected (McCarthy, 1966).

A concern related to the use of complex scoring systems and the

use of Item weighting, as proposed by McGuIre, Is related to the

masking of qualitative differences that may exist between decisions.

The selection of an action that results In patient death Is weighted no

differently than one causing discomfort or financial difficulty (Vu,

t979). Reliance on only the summary scores suggested by McGuIre also

masks differences In the type of patient Information selected and/or In

the areas of data selection concentration.

(1). Psychometric, properties

The psychometric properties of various PMPs have

been reported and although It is generally concluded that the content

validity of well constructed PMPs Is supported (Page and Fielding,

1980), the results of construct vaI Id Ity, criterion validity and

reliability estimations are highly test dependent. Various methods

have been used to estimate the validity of various PMPs. These Include

factor analysis (Juul et al., 1979), analysis of variance techniques

(Farrand et al., 1982; Norman et al., 1983; Norman and Felghtner,

1981), and correlational analyses. Including multi-trait, multi-method

procedures using Pearson product moment correlation coefficients

(Donnelly and Galagher, 1978; Farrand et al., 1982; Holzemer et al.,

1981; Norman et al., 1983; Page and Fielding, 1980; Sedlack and

Nattress, 1972; Sherman et a I., 1979; Wolf et a I., 1983), Spearman's

52

rank order correlation coefficients (DIncher and Stldger, 1976;

Holzemer et al., 1981), and cannonlcal correlation (Reld, 1981).

The stability of measures over time and the Internal stability

have been estimated using test-retest procedures (deTornyay, 1968;

Farrand et al.f personal communication, January, 1984) and Cronbach's

coefficient alpha (McGuIre and Babbott, 1967; Norlclnl, 1983).

Modifications In the use of Cronbach's coefficient alpha are

necessitated by the branching nature of PMPs and the ability to reach

an end-point In the exercise via different pathways and different

numbers of Items. Therefore, use of this statistic has been extended to

a comparison of composite scores measuring the same concepts within

tests or across multiple tests.

Problems that have been Identified with estimating the

reliability of PMPs are related to the use of a branching technique, as

discussed above, the Interdependence of Items (McGuIre and Babbott,

1967) the content and case specificity of each PMP (Norman et al.,

1983, Norlclnl et al., 1983), and knowledge of outcomes which can

Influence Item selection when a test-retest approach Is used (McGuIre

et al., 1976). An example of problems that can occur with test-retest

procedures was described by deTornyay (1968). She reported that the

unfamiliar content matter of one PMP so piqued the Interest of a group

of study participants, that they Investigated the area between the time

of the original testing and post-testing. This resulted In a

significant Increase In scores on the retest.

53

4. Summary

Three different approaches have been used to assess problem

solving ability. Observational approaches utilizing rating scales,

written reports and observer Impressions have been used In both actual

and simulated clinical settings. Comparisons of Individual performances

are made difficult due to uncontrollable events In the setting and

observer biases. Record review provides a retrospective and Indirect

approach to the assessment of clinical problem solving ability. The

validity of conclusions based on this approach are questionable

secondary to the Influence of potential review on the performance of

the Individual to be rated. In addition, evidence exists Indicating

clinicians do not always completely record all Information collected

and used for diagnostic and management purposes.

One type of paper and pencil simulation that Is appropriate for

testing large groups of Individuals In the patient management

problem (PMP). It provides for a standardized task environment,

permits alternative approaches and a variety of pathways through which

a solution can be achieved, and uses a pre-determlned, objective

scoring system. This method has received some criticism because It

provides the examinee with lists of available data which, through a

cueing effect, can lead to score Inflation. The validity and

reliability of PMPs can be estimated via a number of statistical and

review procedures.

'This section contains an overview of the historical evolution of

54

associate degree (AD) and baccalaureate degree (BD) programs In the

United States, the differences In the currlcular content of the two

programs, and differences In characteristics of AD and BD students and

graduates.

1. Historical overview

The 1965 American Nurses' Association (ANA) postlon

statement calling for the baccalaureate degree as the minimum

requirement for entry Into the practice of professional nursing was a

culmination of five years of formal deliberations within the

professional organization (ANA, 1965). However, If one goes back to

the beginning of formal nursing education, Florence Nightingale

envisioned nursing education being conducted In schools of nursing that

were Independent of service agencies (ANA, 1965). Within the United

States, the earliest nursing schools were Independent and adhered to

the Nightingale pattern. However, by the end of the 19th Century, the

number of hospital sponsored and controlled schools mushroomed In

response to desperate staffing problems (ANA, 1965; Brown, 1948);

Goldmark, 1923).

For over 100 years, nursing leaders In the United States have

been campaigning for the placement of nursing education In degree

granting Institutions. Wooley, In A Century of Nursing written In

1876, stressed the desirability of elevating nursing to an educated and

honorable profession and expressed the opinion that nursing education

should be located In Institutions of higher education (ANA Commission

on Nursing Education, 1979).

55

In 1923, the Committee for the Study of Nursing Education (1923)

(commonly referred to as the Wins low - Goldmark Report) noted that

nursing was one of the few fields of professional life that still used

an apprentice type of training. The report called for the movement of

nursing education Into "Independent Institutions organized and endowed

for a specifically educational purpose" (p.17). Additionally, It was

noted that the "development and strengthening of university based

programs for the training of nursing leaders was of fundamental

Importance for the furtherance of nursing education" (p.26).

These sentiments have been echoed by others. The most prominent

voices were the Report of the Committee on the Grading of Nursing

Schools (1934), Brown's (1948) report to the National Nursing Council,

and the report of the Committee on the Functioning of Nursing (1950).

The first collegiate nursing programs In the United States were

offered at Teachers College, Columbia University, and at the University

of Minnesota. Teachers College first admitted "properly qualified

graduate nurses" In 1899. These students were admitted Into the Junior

class; thus, they were automatically awarded two years of college

credit for their hospital training (Committee for the Study of Nursing

Education, 1923). It was, however, the University of Minnesota that

pioneered university education for nurses when. In 1910, It established

a school of nursing as part of the general university system. Upon

completion of the program of study. Its graduates were granted a

special professional degree (Commtttee for the Study of Nursing

Education, 1923). Although this program did not lead to a college

56

degree, Jt represented the first basic nursing program In the country

to be completely under the control of an educational Institution. The

first nursing programs leading to a college degree as well as a nursing

diploma were established between 1916 and 1920 and Included the

programs at Teachers College and at the University of Cincinnati

(PI Ileplch, 1962).

A movement developing parallel to the one calling for the

placement of nursing education within educational Institutions was one

concerned with the development of two levels of nursing practice.

Goldmark (1923), In her report to the Committee for the Study of

Nursing Education, called for formal training and licensure of a

subsidiary grade of nursing service worker who would practice under the

direction of a physician or a trained nurse. She envisioned this group

of Individuals working with the mild or chronically III or with

convalescents, and, thereby, freeing the trained nurse to care for the

more acutely III. Goldmark referred to these Individuals as practical

or household nurses or as attendants.

Brown (1948) Indicated that two types of nursing functions

existed: technical and professional, and that It would require less

time to prepare a person to perform the technical aspects of care than

to perform the professional aspects. She noted that practical nurses,

orderlies, and aides represented a large core of the system of

assistant nursing service and that they performed an Important role In

releasing nurses to give medication, treatments, and other "more true Iy

nursing care" (p.59).

57

Brown's (1948) recommendation that the services provided by non­

professional workers be formalized Into a functional system was

Instrumental to Montag's development of a program to prepare nurses who

would perform predominantly technical functions (Montag, 1956). Montag

(1956) proposed the preparation of technically prepared nurses In two-

year colleges. She envisioned this type of practitioner functioning on

a level between that of the nursing assistant and that of the

professional nurse.

The two premises upon which the AD program was developed were

that 1) the function of nursing can and should be differentiated and

2) that these functions lie along a continuum differentiated at three

different levels with professional nursing at one end, the assisting

personnel at the other end, and the technical, or semi-professional,

personnel between the two. At that point on the continuum where the

functions of the professional and technical nurse meet, the roles of

the two become similar. However, Montag (1980) never saw the technical

and professional roles as replacements for each other. Nor did she

see the AD program as a stepping stone Into or preparation for a BD

program. The AD nursing program was seen as a terminal program.

Montag (Montag and GotkIn,1959) proposed and developed a two year

sample curriculum that Incorporated both general education and nursing

education courses that could be offered In Junior and community

colleges. A pilot project was Implemented In 1952 and extended through

1957 (Montag and Gotkln, 1959). The curriculum Implemented In these

programs was to be different from that offered In diploma and

58

baccalaureate programs and was to be based on "a clear picture of the

product to be produced by the educational program and the functions

this product should perform" (Montag and Gotkln, 1959, pp 342-343).

In the final report of the cooperative five year project that

Implemented and evaluated the Initial AD programs, Montag (Montag and

Gotkln, 1959) stated that the objectives of both associate degree and

baccalaureate degree programs needed to be stated clearly. Programs

claiming to prepare practitioners of the same competency should not

differ In length, content, and method since there can be little

Justification for a program requiring four years for Its completion

unless It prepares a practitioner who Is different In competence from a

graduate of the Junior college program. How the graduates of BD and AD

programs differ Is a question that has led to confusion and conflict

(Johnson, 1966; Tschudln, 1964; Waters et al., 1972).

McClure (1976) pointed out that the difficulty experienced In

differentiating the practice competencies of AD and BD programs may be

due to misconceptions In Interpretation of Montag*s model. Using Venn

diagrams, she proposed that a literal transformation of Montag's work,

as Illustrated In Model 1 (Figure 2), views professional and technical

nursing as adjoining one another although carrying out separate,

discrete, and easily Identifiable function. Educational components of

the two programs would, therefore, be equally separate, discrete, and

easily Identifiable. An alternative conceptualization, as represented

by Model 2 (Figure 3), depicts an overlap In the functioning of the two

levels of nursing practice. This model depicts some patient needs

59

Professional Nursing

Technical Nursing

Figure 2. McClure's Model 1 (McClure, 1976).

Technical Nursing

Professional Nursing

Figure 3. McCLure's Model 2 (McClure, 1976).

60

falling within the purely professional realm, some within the purely

technical realm, and some within an area that can be met by either

level of practitioner. Since large portions of practice are still

conceived of as separate, discrete, and easily Identifiable, the

curricula should reflect these differences.

However, McClure (1976) found little support for either Model t

or Model 2 and concluded that a large number of the problems

encountered In differentiating the two levels of practice were due to

trying to Impose a Model 1 or Model 2 concept on a Model 3 world.

Model 3 (Figure 4) Illustrates the technical aspects of care as being

part of the professional nurse's realm but which also can be delegated

to the technical nurse. The curriculum patterns consistent with Model

3 would result In the AD program preparing Individuals to assist In

carrying out selected aspects of care that also could be performed by

graduates of BD programs.

Sparks (1979) extended McClure's Model 3 to Incorporate

differences In "knowledge base and intellectual skills gained.

Including problem solving, critical thinking, and/or decision making'

(p.42). Her conceptualization of McClure's model (Figure 5)

illustrates that the differences between technical and professional

nursing are knowledge base, responsibility, and role. This model Is

consistent with the ANA's position (1965) that theory base and depth of

knowledge differentiate technical from professional nursing practice.

From Inception, the goals of AD and BD programs have

differed. The objective of the BD program Is to prepare liberally

61

Professional Nursing

Technical Nursing

Figure 4. McClure*s M^del 3 (McClure, 1976).

62

Nursing Process

Role

Professional Nursing BSN

Responsibility Knowledge Base

Nursing Process

Role

echnical Nursing

Knowledge Base

Responsibility

Figure 5. Spark's extension of McClure's Model 3 (Sparks, 1979).

63

educated IndFvtduals capable of functioning as professional nurses In a

variety of roles and settings. In contrast, the objective of the AD

program Is to prepare technical nurses capable of functioning In a

caregiver role within a structured, hospital setting (Bensman, 1977;

DeChow, 1967; Kramer, 1981; Montag, 1956; 1980; Montag and Gotkln,

1959; Schlotfeldt, 1967). Accomplishment of these objectives, via

currlcular content was addressed by DeChow (1967), Johnson (1966),

Kramer (1981), Schlotfeldt (1967; 1977) and the NLN Task Force on

Competencies of Graduates of Nursing Programs (1982).

In addition to the obvious difference In program length

(generally two years for the AD and four years for the BD) differences

exist In the proportion of total course work alloted to nursing courses

and liberal arts and science courses, and In the focus of course work.

Johnson (1966) examined differences In the level of knowledge to which

students In the two types of programs were exposed. She found that the

AD student's background In the physical and social sciences and In the

humanities was generally limited to Introductory survey courses which

provide for the acqulslslon of practical, but limited knowledge.

Since the content offered Is often from the perspective of practicality

or applicability to the solution of everyday affairs. Its usefulness

regarding the practice of knowledge may be limited since the depth of

knowledge of underlying principles Is limited.

In contrast, the BD student's background Included Introductory

level and upper division courses that provided for the understanding of

major concepts and principles and the ability to see relationships

64

between facts and among facts, concepts and theories. Acquisition of

theoretical knowledge at this level provides the student with the

ability to manipulate acquired knowledge, to seek new relationships,

and to move between empirical findings and abstract conceptualizations.

In nursing courses, Johnson (1966) noted that the content In AD

programs focused on the knowledge required to Identify and take

appropriate action In common, concrete, and specific problems

experienced by patients. Content was characterized as largely

empirical In nature and directly related to the anticipated actions and

activities associated with care delivery. Focus of theoretical

explanations was on specific bases for recognition of problems and on

the rationale for action In particular situations.

Nursing courses for BD students differed from the AD courses In

relation to organization and treatment of content. Focus In BD

programs was on theoretical explanations for responses to Illness or

factors leading to Illness. In addition, principles, concepts, and

theories of basic sciences were examined In the BD programs with

relation to ability to explain or predict patient responses or modes of

nursing Intervention.

Schlotfeldt (1977) contrasted the foci of baccalaureate and

associate degree education. She noted that while technical study

focuses on the development of particular skills and mastery of selected

essential concepts, programs of professional study focus Initially on

the behavioral sciences through which students gain mastery of concepts

about man. Subsequently, In the nursing program, professional

65

study focuses on the study of man In various states of health and

functional levels, and on development of Judgment and decision making.

Other dichotomies between technical and professional education

noted by Schlotfeldt (1977) were, for the technical program student,

related to a focus on accepted ways of performing. For the student In a

professional program, the focus was on the use of knowledge In the face

of uncertainty. Other dichotomies mentioned were a cumulative

repertoire of skills versus a holistic approach to the study of persons

who are served In a variety of ways; the mastery of skills and of

relevant existing knowledge versus the mastery of existing knowledge

and skills, the ability to Identify gaps In knowledge, and the value of

systematic Inquiry; and a focus on accountability to others within the

field versus the estab11shment and maintenance of Interprofessional

relationships.

These aforementioned findings were corroborated by a task force

of the the National League for Nursing (NLN). Following a review of NLN

documents and a review of the literature, the NLN Task Force on

Competencies of Graduates of Nursing Programs (1982) concluded thai-

differences do exist In the knowledge base among the different types of

nursing education programs. They also estimated the distribution of

course work within programs. In AD programs. It was estimated that

approximately 5Q% of course work was In the basic physical and social

sciences and 50% was In the nursing program. In addition, content

relative to legal Issues, ethics, nutrition, and pharmacology usually

was Integrated In the nursing courses. Within the four year BD

66

programs, It was estimated that 35J6 to 4056 of course work was In the

physical and social sciences, 30$ to 55% was In nursing courses, and an

additional 25JS to 35j8 met degree area distributive requirements.

2. Differences, in associate, and, baccalaureate degree students

and graduates

The characteristics of AD and BD students and graduates have

been reported by a number of Investigators. Their findings will be

reported In terms of demographic and pre-enrolIment educational

characteristics, factors related to nursing program selection,

personality attributes of students, and clinical performance attributes

of graduates.

a. Demographic and pre-enrolJ ment. educational

characteristics

The characteristics of AD and BD students regarding

their ages, marital status, family responsibilities, high school

performance, and educational experiences between high school and

nursing program matriculation were reported In a number of studies

(Dustan, 1964; Gray et at., 1977; Knopf, 1975; Melels and Farrell,

1974; Nash, 1975; Richards, 1972; Schwerlan, 1979; Sparks, 1979; Wren,

1971). Their findings are summarized In Table I

In general, all Investigators reported that the AD student was

older than the BD student, was married as opposed to single, and had

more family responsibilities than did the BD student. Three out of four

investigators found that the BD student had a higher high school rank

than did the AD students. While one study (Wren, 1971) found no

67

TABLE I

CHARACTERISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) STUDENTS AS CITED IN THE LITERATURE, BY AGE, MARITAL STATUS, FAMILY RESPONSIBILITIES AND PRE-MATRICULATION ACADEMIC ACHIEVEMENTS.

Variable and Source

Study population (n)

Findings

AGE; Range:

1. Gray et al. (1977)

2. Knopf (1975)

3. Nash (1975)

4. Richards (1972)

5. Sparks (1979)

Mean: 1. Gray et a I.

(1977)

2. Dustan (1964)

3. Melels and Farrell (1974)

4. Sparks 1979)

5. Wren (1971)

AD = 22 BD = 22

not reported

not reported

AD = 134 BD = 120

AD = 22 BD » 22

AD = 54 BD = 193

AD BD

AD BD

AD BD

38 97

108 128

224 58

AD: 20 to 29} BD: 21 to 24

ADs had a wider age range than BDs

More AD students over the age of 25 than BD students

AD: 20 to over 50; BD: 20 to 40

AD = 108 AD: less than 20 to 55; BD: 21 BD = 128 to 30

AD = 21; BD = 22 (p not reported)

AD students had a higher mean age than BD students

AD =30.1; BD = 23.8 (p not reported)

AD = 26.09; BD = 23.46 (p < .01)

AD = 24.4; BD = 19.9 (p < .05)

68

TABLE I (continued)

CHARACTERISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) STUDENTS AS CITED IN THE LITERATURE, BY AGE, MARITAL STATUS, FAMILY RESPONSIBILITIES AND PRE-MATRICULATION ACADEMIC ACHIEVEMENTS.

Variable and Source

Study population (n)

Findings

MARITAL STATUS % married: 1. Gray et a I.

(1977) AD = 22 BD = 22

2. Melels and AD = 38 Farrell (1974 BD = 97

AD = 1456; BD = 23%

AD = 5656; BD= 28j6

3. Nash (1975)

4. Richards (1972)

5. Schwerlan (1979)

6. Sparks (1979)

7. Wren (1971)

not reported

AD = 134 BD = 120

AD = 342 BD = 240

AD = 108 BD = 128

AD = 224 BD = 58

Greater percentage of AD than BD students married

AD = 60%} BD = 4156

AD = 57%; BD = 3 856

AD = 36/6; BD - 16J6

AD = 3856; BD = 3.556

FAMILY RESPONSIBILITIES; 0 of chIIdren: 1. Melels and AD = 38

FarrelI (1974) BD = 97 AD = 38 students had 15 children; BD = 97 students had 9 children

2. Nash (1975)

not reported

J6 of students with children: 1. Schwerlan AD = 342

(1979) BD = 240

More AD than BD students had children under 6 years of age

AD = 5556; BD = 15J6

69

TABLE I (continued)

CHARACTERISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) STUDENTS AS CITED IN THE LITERATURE, BY AGE, MARITAL STATUS, FAMILY RESPONSIBILITIES AND PRE-MATRICULATI ON ACADEMIC ACHIEVEMENTS.

Variable and Study Source population Findings

(n)

HIGH SCHOOL PERFORMANCE Mean class rank: 1. Dustan AD = 54

(1964) BD = 193 No differences (no statistics

reported)

2. Wren (1971)

AD = 224 BD = 58

Upper quartlle ranking: 1. Schwerlan AD = 342

(1979) BD = 240

2. Sparks (1979)

AD = 108 BD = 128

AD = 28.8; BD = 19.6 (p slglf. but level not reported)

AD = 70j8; BD = 88J6

AD = 5056 BD = 7556 (p < .05)

POST HIGH SCHOOL EDUCATION; # years before nsg. enrolIment: 1. Knopf

(1975)

2. Sparks (1979)

Degrees earned: 1. Melels and

Farre11 (1974)

not reported

AD = 108 BD = 128

AD = 38 BD = 97

AD students had more years of education than did BD students

AD = 1.49 years; (p < .01)

BD = 0.55

AD: 63J6 had 4 years of col lege, 5{6 had a BS degree, and 8J6 had > 4 years of college.

BD: 19j6 had an AD degree; 7% had BS degrees In other fields.

70

difference In the number of years of post high school education before

entering a nursing program. Investigations by Knopf (1972) and Sparks

(1979) revealed that AD students had more years of post-high school,

pre-nurslng education than did the BD students. Melets and Farrell

(1974) found that more BD students had prior degrees than did AD

students.

b. Characteristics, related to nursing, program selection

Differences In characteristics that Influence the

selection of a nursing program by a prospective student have been

reported by several Investigators. These factors Include the distance

between home and the school, factors Influencing the selection of a

nursing program, and reasons for selecting nursing as a career.

1) Dlstence. from home

Dustan (1964) discovered that AD students attended

"more locally based" schools than did BD students. Wren (1971) found a

statistically significant difference In the mean number of miles

between home and school (AD = 39.5; Bd = 91.4), but concluded that this

was a function of school location within the state In which her study

was conducted.

2) Se.lect.lQfi. of. type, of. nursing, program

Differences have been reported In the factors

students Identified as Influencing their selection of a nursing

program. Dustan (1964) found that AD students cited cost, program

length, opportunity to live at home, and maintenance of family

responsibilities as having major Influences on program selection. The

71

BD students cited opportunities for personal and professional

development as most Influencing their decisions. Proximity to home

and/or economic considerations were found to be the most frequently

cited factor by AD students participating In studies conducted by

Sparks (1979), Wren (1971), Schwlrtan (1979), Nash (1975), Bui lough

and Sparks (1975), and Knopf (1975). Program length was cited by AD

students participating In studies conducted by Knopf (1975), Wren

(1971), Bui lough and Sparks (1975) and Schwertan (1979).

The most frequently cited reasons for the selection of a BD

program were program quality and location (Sparks, 1979), program

quality and career advancement (Schwerlan, 1979), and a desire for a

collegiate degree and a nursing program (Knopf, 1975).

3) Reason..for sblent,ton of, a, nurslnc. career

Dustan (1964) found no differences between AD and

BD students tn the reasons they cited for entering nursing. The reasons

cited most frequently were: Interest In and liking people, Interest In

caring for the sick, and Interest In the medical field. Sparks (1979)

also reported no differences In cited reasons. Those most frequently

cited were wanting to help people, past health related work experience,

and Job security. Wren (1971) reported that helping people was cited

most frequently by both AD and BD students, followed by "always wanted

to be a nurse" for AD students and "self Improvement" for BD students,

c. PsrsofiaJ_ attrJbutcs. of. students

The personal attributes of students enrolled In AD and

72

BD programs that have been studied are their professional values, their

leadership qualities, and various personality factors.

1) Professional, values

Attributes regarding professional orientation have

been examined by Eller (1976), Simons (1982), Archer (1976), Blaney

(1974), Watson (1983), and Davis (1973). All except Blaney and Archer

found BD students achieved significantly higher professionalism scores

than did AD students. Archer reported statistically significant

differences on subscale scores on an unidentified Instrument, but

concluded that no specific pattern could be Identified. Blaney

concluded there was no "great" difference In the professional values

held by AD and BD students.

2) Leader skip, tmn 1.1 .ties

The leadership opinion questionnaire used by

Melels and Farrell (1974) and Carrel I (1977) demonstrated no

statistically significant differences between AD and BD students on the

consideration subscale. However, AD students In both studies had

statistically significant higher scores on the structure subscale than

did the BD students. Richards reported no differences In the leadership

abilities of AD and BD students.

3) Other persona 1,1 ty. factors

Dowe (1974) found that analysis of reponses on the

Omnibus Personality Inventory (OPI) demonstrated statistically

significant higher scores for AD students than for BD students for

thinking Introversion and esthetlcism. Richards (1972) found no

73

statistically significant differences regarding social ability*

responsibility, or emotional stability for students In the two types

of programs. Ventura (1975) stated that AD and BD students differed on

some measures of social behavior but that all groups were similarly

high In some areas and low In others. She did not Identify what these

specific areas were. Melels and Farrell (1974) determined that AD and

BD students were similar In their levels of self esteem but that BD

students had slgnlflcanly higher scores for communication when tested

with the Satisfactory Achievement Scale.

4) Academic aptitude/achievement

In addition to comparing ratings of high school

performance, a number of other measures have been used to compare the

Intellectual abilities of AD and BD students. These measures Include

the Scholastic Aptitude Test (SAT) (Dustan, 1964; Gray et al., 1977;

Wren, 1971), Quick Word Test (Sparks, 1979), State Board Test Pool

Examination (SBE) results (Archer, 1976; Counts, 1975; McQuald and

Kane, 1979), OPI (Melels and Farrell, 1974), and IPAT test of general

Intelligence (Richards, 1972).

No significant differences In measures of Intellectual ability

were Identified by Counts (1975), Melels and Farrell (1974), Richards

(1972) or Sparks (1979). Differences In performance on the SAT varied.

In Dustan's study (1964), AD students had statistically higher mean

scores than did the BD students. The opposite was demonstrated by Wren

(1971). Gray et a|. (1977) found that more BD students than AD

students were In the upper decile and the upper quartlle of their high

74

school classes and had SAT scores greater than 1000, and that more AO

students than BD students were In the upper quartlle but had SAT scores

of less than 1000.

Comparisons of performance on the SBE also produced equivocal

results. Counts (1975) found no differences In the mean scores of AD

and BD graduates for both the medical and surgical nursing sections of

the exam* McQuald and Kane (1979) reported that AD graduates had

higher mean scores on the medical and surgical nursing sections than

did the BD graduates. Graduates of BD programs had higher mean scores

for the psychiatric, obstetric, and pediatric nursing sections. Further

analyses by McQuId and Kane (1979) revealed that BD graduates had

higher subscores than did AD graduates for the categories of

"understanding of mental health", "human relations; and "causes of

disease". No clear pattern of performance could be Identified for AD

students but the pattern was closer to that for diploma (DP) graduates

than to that for the BD graduates. They also found that, for all

programs, within school differences In performance were greater than

between school differences. Archer (1976) reported that AD graduates'

scores for obstetric and psychiatric nursing examinations were

significantly different from those of BD students. However, multiple

regression analysts demonstrated that age, ethnicity, and

Intelligence, rather than type of education, explained these

differences.

75

d. Ql ln lcaL attrthii+p^ nf grafhiatfis

An examination of differences In clinical competencies

of AD and BD graduates has been approached from several different

perspectives. Included are ratings by nursing educators and

administrators, comparisons of ratings regarding what the competencies

should be versus actual differences, and comparisons of self-ratings by

staff nurses with those of nursing educators, nursing service

administrators, and others. Analyses of critical Incident reports and

problem solving performance as measured on clinical simulations have

also been used to differentiate between the graduates of the AD and BD

programs.

1) Competency, rat ings

Chamlngs and Teevan (1979) examined differences In

AD and BD nurse educators' perceptions regarding differences In

conceptual, human, and functional competencies of graduates of AD and

BD programs. An 80 Item Instrument, based on a taxonomy of

competencies developed by the Southern Regional Education Board (Haase,

1976) was distributed to 222 randomly selected nurse educators

representing programs In a wide geographic area of the United States.

Data analysis was based on questionnaires returned by 57^ (n=63) of the

BD educators and by 50% (n-56) of the AD educators. Chi square and t-

test results Indicated that expectations for BD graduates were higher

but not clearly different In kind from those held for AD graduates.

Analysis of subscale scores demonstrated higher expectations for BD

graduate on the conceptual and human scales than for AD graduates.

76

Therefore, Ft was concluded that BD graduates were expected to

demonstrate greater competence In the ability to reason, to know and

use theoretical content, to recognize, analyze, synthesize, and

evaluate situations (conceptual competencies), and In the conduct of

Interpersonal and Intrapersonal Interactions (human competencies).

Differences In nursing educators' and admlnstrators' expectations

of the clinical competencies of beginning practitioners were examined

by Dlckerson (1976). She distributed an Investigator designed

scale composed of 36 competency statements to 127 nursing service

administrators and 165 nursing education administrators. Data analysts

was based on the 178 (60S?) returned questionnaires. Significant

differences were found between the ratings of nursing educators and

nursing service administrators of expected competencies for a beginning

nurse practitioner. Nursing service administrators rated Interpersonal

relationships and effective group functioning as more Important than

did the educational administrators. Educational administrators

considered patient safety, evaluation of patient care, continuity of

care, need for establishing priorities In planning care, alteration In

care necessitated by a patient's changing condition, and problem

solving more Important than did the nursing service administrators.

Although not elaborated on by the Investigator, significant differences

also were demonstrated between the ratings of some competencies when

the ratings of educational administrators were analyzed by type of

program (I.e., AD or BD). These Indicate different competency

expectations for graduates of AD and BD programs.

77

Pttts (1975) examined differences In actual versus Ideal

differences In the outcome goals of AD and BD programs. A mall survey

was conducted using a sample selected from physicians, hospital nursing

service administrators, nursing educators, and practicing nurses In the

state of Washington. Analysis of differential responses to a 37 Item

questionnaire revealed differences In perceptions of different

occupational groups regarding both Ideal and actual program goals.

Further analysis demonstrated that nursing educators perceived little

difference did exist but that they believed It should exist between the

outcome goals of AO and BD programs; nursing service administrators

perceived that a small difference did exist but that none should.

Practicing nurses perceived some differences existed and some should

exist. The responses of physicians Indicated that they perceived little

difference In the outcome goals and believed little should exist.

Schuyler (1983) examined perceived Importance of specific

critical requirements expected of beginning practloners for AD, diploma

(DP), and BD programs, and performance capab11 Itles of these new

graduates as perceived by nursing educators, nursing service

supervisors, and recent graduates. Methodology was not described.

Findings Indicated general agreement existed among groups regarding

perceived Importance of the areas under study to a common core of

knowledge and skills possessed by all beginning practitioners. Rank

order comparisons of Item ratings of perceived Importance demonstrated

agreement among nursing educators, nursing supervisors, and graduates

78

of DP and BD programs, but not among the AD students, educators, and

nursing service supervisors.

Comparisons of mean ability ratings Indicated that supervisors

perceived AD graduates as less than adequately prepared to function In

9 of 10 areas; DP graduates In 6 of 10 areas; and BD graduates, In 2 of

10 areas. In contrast, comparisons of graduates' self-ratings revealed

that they perceived themselves as adequately prepared In all areas.

Educators rated their students as adequately prepared In 8 of 10 areas.

Hogstel (1975) used an Investigator designed Instrument for an

analysis of differences between AD and BD graduates In relation to the

functions they were performing. Questionnaires were mailed to 109 AD

graduates, 236 BD graduates, and 100 employers. A A0% response rate

was attained In each group. Analysis of variance and t-test were used

to determine the existence of differences In function In 5 areas:

physical care and technical skills. Interpersonal relationships,

leadership, decision making, and community health care.

Based on self-ratings, the only function In which the BD

graduates were performing to a significantly greater extent than the AD

graduates was In community health. In terms of preparation, AD

graduates perceived themselves significantly better prepared than BD

graduates In the area of physical care and technical skills. Employers

rated BD graduates as significantly better than AD graduates In 4 of

the 5 functional areas, but reported that they did not discriminate

between the two types of graduates on orientation, position, promotion,

79

or assignment to nursing activities. A small majority of the employers

differentiated between AD and GD graduates In salary.

McKenna (1971) used 4 BD and a total of 6 AD and DP graduates,

from one clinical unit, who had been working according to job

descriptions delineating professional and technical nursing activities,

to examine components of tasks, knowledge, basic skills, and sources of

decisions. Over a period of seven consecutive work periods, staff

recorded the tasks they performed. Judgments concerning the type of

worker who should perform each task, the decision source, and the basic

skill and knowledge source for each task.

Analysis of 2801 tasks revealed the performance of 334 different

tasks. Of the total tasks, 73J6 were performed by either AD/DP or BD

graduates. In addition, BD graduates performed more of their tasks

with people while the AD/DP graduates performed more of their tasks

with things. It was concluded that 1) even though the BD graduates

performed tasks appropriate for their group, they did not do so with

the consistency of the AD/DP groups; 2) there were differences In

function, knowledge sources, and basic skills reported by the two

groups; and 3) the two groups perceived no differences In the sources

of their decisions.

Stanton (1982) Investigated differences In clinical competency of

AD and BD graduates within their Initial 3 to 12 months of employment

after licensure. Head nurses used the Slater Nursing Competencies

Rating Scale to evaluate retrospectively the performance of 90 AD and

143 BD graduates working In 35 Colorado hospitals. Analysis of the

80

results Indicated that new BD graduates displayed greater clinical

competence than did AD graduates.

tn a national study designed to operational Ize and measure

nursing performance, Schwerlan (1979) used an Investigator designed

Instrument (the Schwertan 6-D[mensIon Scale of Nursing Performance) (6-

D Scale) to obtain self-ratings and supervisor ratings of 3004

graduates of AD, DP, and BD programs. The respondent group of graduates

consisted of 342 AD, 332 DP, and 240 BD graduates; the overall

response rate was 30Jf. Supervisors returned questionnaires for 687

graduates. The six areas that were rated were: Interpersonal

relationships and communications, leadership, critical care, planning

and evaluation of care, teaching and collaboration, and professional

development. Results Indicated that AD graduates rated themselves

lower than DP and BD graduates on all six scales; BD graduates rated

themselves higher than AD and DP graduates on the

teaching/collaboration and planning of care scales.

The 6-D Scale also was used by two additional Investigators.

Chance (1982) used a modified version to compare self and supervisor

perceptions of the nursing performance of 34 AD, 35 DP, and 36 BD

graduates employed as staff nurses tn seven hospitals In a Southeastern

metropolitan area. No significant differences were demonstrated between

the self-perceptions of graduates from the three types of programs.

Supervisors rated BD graduates significantly higher than other

graduates In critical care performance. Additional analyses revealed

that hospital, type of unit, and shift were significant predictors of

81

components of nursing performance and that s e l f a n d supervisor ratings

were significantly correlated on over half of the Items.

McCloskey (1981) conducted a study to determine whether nurses

with different educational preparation differed In their Job

effectiveness. She hypothesized that Job effectiveness was a function

of formal education, continuing education. Job skills. Job

responsibility, and aptitude. A random sample of 402 nurses stratified

by type of education (practical, AD, DP, BD), size of hospital employed

In, and type of unit, was drawn from 12 general hospitals In the

Chicago area. A total of 53 practical nurses, 63 AD, 134 DP, and 49 BD

graduates participated In the study (75$ return rate). Self and head

nurse ratings on the 6-D Scale and Indicators of continuing education,

formal education, and Job responsibility were used to predict Job

effectiveness. Analysis of the results led to the conclusion that years

of nursing education had a significant but small effect on Job

performance, accounting for only 1 -2$ of the variance. It also was

found that the effects of nursing education on Job performance were

Indirect rather than direct.

Waters et al. (1972) explored and described evidence of

differences In nursing practice of graduates of AD and BD programs In

the San Francisco area. Data collection methods consisted of Interviews

with 12 nursing service directors, observations of and Interviews with

each of 22 AD and 22 BD graduates, and an Interview with the 22 head

nurses who were the subjects'Immediate supervisors. Observations were

designed to provide data regarding varieties of nursing actions

82

Implemented by the subjects. Follow-up Interviews were used to

substantiate observed nursing actions and to elicit examples of

critical or highly significant nursing problems worth remembering.

Ten of the 12 directors Interviewed reported specific differences

between the practice of BO graduates and of AD graduates. Analysis of

staff nurse activities and attitudes revealed that AD graduates*

performances appeared to be consistent with technical nursing practice

as described In the literature. In most cases nursing problems AD

graduates dealt with were concrete and specific, and nursing actions

had fairly predictable outcomes. Problems and Interventions were more

often physiological and physical than psychological or social In

nature.

The practice of BD graduates was found to be more technical than

professional In nature when Judged according to criteria cited In the

literature. Only 6 of 24 BD graduates were Judged to be practicing

professional nursing more consistently than the others. The practice

of these 6 Individuals was described as being wider In scope, less

common, having more alternatives to solutions, and often psychological

In nature.

All of the head nurses, with one exception. Indicated that

differences did exist between the practice of the two groups. The AD

graduates were characterized as working with more basic problems of

patient care; their practice was based on sound principles of nursing

care. In contrast, BD graduates were seen to have more depth for

83

solving problems, were more aggressive In trying to reason why, and

examined the psychological aspects of patient care.

Bui lough and Sparks (1975) conducted a survey of 201 AD students

and 192 BD students who were graduating from 3 AD and 4 BD programs In

the Los Angeles area. They used a questionnaire designed to ascertain

one of two basic orientations of the nursing role: one focused on

curing a patient's Illness and the other focused on caring for

patients. Based on the results of responses to both single Items and

parallel Items, the Investigators concluded that although the dominant

response of all respondents was one of a caring orientation, a

significant difference In orientation was found between the AD students

and the BD students. The AD students were more cure oriented while the

BD students were more care oriented.

Nelson (1978) conducted a study to determine If graduates of AD,

DP, and BD programs differed In perceptions of their competencies, If

supervisors differed In their perceptions of competencies of graduates

of the three programs, and If there were differences between the

perceptions of graduates and supervisors.

The Nurse Competency Inventory (NCI), an Investigator designed

Instrument containing 35 competency statements, was used to collect

data within three broad areas: technical skills, communication skills,

and administrative skills. The NCI was mailed to 429 graduates of 2 AD,

3 DP , and 4 BD programs. A 75^ return rate was achieved. Analysis of

the results Indicated that significant differences existed between the

competency perceptions of AD, DP, and BD graduates In each competency

84

area and across all areas combined. In overall competence and In

communication skills, BD graduates rated themselves higher than AD

graduates. There were no significant differences between AD and BD

self-ratings for technical skills and administrative skills.

Supervisors also rated the three groups significantly different with

regard to overall competence and competence In each of the three areas.

Supervisors of BD graduates rated BD nurses as more competent than AD

nurses In all three areas. Significant differences also were found

between perceptions of graduates and supervisors of overalI competency.

Ratings of BD graduates and their supervisors were significantly less

different than those of AD and DP graduates and their supervisors In

the areas of administrative skill and overall competence.

a) Summary

Thirteen Investigators have compared and

contrasted the clinical competencies of AD and BD graduates. A wide

variety of Instruments and data sources were used to obtain

measurements of expected and/or actual competencies. The majority of

ratings were based on retrospective analyses of a graduate's

performance or from the perspective of the actual and/or Ideal

competencies of all AD graduates, considered as a whole, and all BD

graduates considered as a whole. Data analyses led to varied

conclusions; although a majority of the Investigators stated there were

differences In the competencies of the two groups, others concluded no

differences existed. Although the results of these studies provide

Insight Into the various aspect of the roles and functions assumed by

85

the AD and BD graduates, the results do not provide direct Information

as to the assessment abilities of graduates.

2) Critical Incident reports

Jacobs (1980), as part of a larger study,

performed a content analysis of 9884 critical Incidents provided by

over 2000 nurses In a nationwide sample to determine the relationship

between educational preparation and number of effective and Ineffective

critical Incidents reported. Both self-reports and reports of observed

nursing performance were utilized.

Significant differences Mere found both between and within

behavioral areas In types of behaviors reported by and/or about AD, DP,

and BD graduates. Nurses from BD programs were most often Involved In

Incidents concerning leadership and professional responsibility;

patient teaching and the promotion of psychological well-being;

exchanging and recording Information about patients; and planning

nursing care. Significant differences also were demonstrated among the

three types of graduates In overall amount of effective and Ineffective

Incidents reported. More effective Incidents were reported about BD

graduates than about the AD and DP graduates. The greatest percentage

of Ineffective Incidents Involved AD graduates. Content analysts

failed to reveal consistent patterns of differences among the three

types of graduates In the following areas: degree of self-determination

by the nurse; degree of Judgment versus rote behavior; reasons for

Ineffective behaviors or close calls; and factors contributing to

success or lack of success of a reported Intervention.

86

3) Problem. goJyJng. abl i,lt.y

Studies designed to differentiate between how AD

and BD students problem solve In specific clinical situations have been

conducted by Bassett (1973), Fredertckson and Mayer (1977), Gover

(1972), Gray et al. (1977), Johnston (1982), and Sparks (1979). Gray

et at. (1977) used open-ended short essay questions based on cl(nlca)

situations to determine If there were differences In the performance of

techntcal skills, teaching, leadership, the provision of support to

patients and their families. In Interviewing for assessment purposes,

actions In structured situations, and actions following observations.

Participants In this study were a random sample of 27 AD and 22 BD

students graduating from the University of Vermont. Student responses

to questionnaire Items were coded by panel members acting In concert,

to reflect whether the performance of stated activities was to be

expected of technical level, professional level, or of all nurses.

Responses subsequently were assigned a point value. Significant

differences were demonstrated between mean technical skill,

professional, and total scores. BD students had higher mean total and

professional scores; AD students had higher technical skill scores.

Individual Item analyses revealed differences In scope of

functioning In the areas of teaching, provision of anticipatory

guidance, leadership, emotionally supportive actions, nursing process,

use of knowledge, use of extra time, and relationships with co-workers.

In the areas of nursing process and use of knowledge, BD students

provided responses representing the following actlvlltes: actively

87

seeks Information, evaluation of the adequacy of a plan of care, health

promotion and maintenance, prevention of health problems, and use of

knowledge as a base for assessment and planning.

The Investigators also noted that a comparison of nursing actions

that all nurses would take with those taken only by BD nurses helped to

explain why the general public and nursing have difficulty describing

differences In professionally and technically prepared nurses. Those

actions specific to the BD nurse are not readily visible because they

Involve use of knowledge In assessment prior to action and In planning

for and Implementing of preventive nursing actions. In contrast,

actions of AD nurses were readily vtslble and could be performed by

all nurses.

The generalIzablIIty of the findings of this study Is limited

due to the small sample size and the fact that all participants were

obtained from one Institution. In addition, the Instruments used to

collect data did not provide direct measures of students' abilities to

collect data and to formulate nursing diagnoses. Therefore, the study's

results provide no direct Information regarding any differences that

might exist In the assessment abilities of these two types of students.

Johnston (1982) conducted a study to delineate strategy

differences In the use of the nursing process by AD, DP, and BD

graduates. Using a theoretical model developed by Rtnes (1977a),

Johnston (1982) developed a questionnaire In which each Item

exemplified one of the theorized process strategies used by either

technical (AD, DP) or professional graduates. The final form of the

88

questionnaire was distributed to 60 staff nurses working full time In

one of 7 units within a hospital. A 10$ return rate was attained and

Included 8 AD, 5 DP, and 29 BD graduates. The AD and DP graduates were

treated as one group.

Results Indicated partial support for the hypothests that

different strategies were used by the two groups of nurses. In the

assessment phase, BD graduates preferred the use of analytical

questioning techniques more so than did the AD/DP graduates who

preferred the measurement of bodily functioning. Both groups equally

preferred the use of direct questlonnlng and the Identification of

alternative sources of data. As a product of the assessment phase, BD

graduates were found to prefer Identification of nursing diagnoses as

opposed to production of Information for other health team members, as

was preferred by the AD/DP graduates. There were no Identifiable

differences In strategies used In the planning and Intervention phases.

Different strategies again were demonstrated In the evaluation phase.

BD graduates preferred the strategy of Interpreting outcome of care

while AD/DP graduates preferred the strategy of reporting outcome of

care to others.

Johnston's (1982) study demonstrated that AD and BD graduates

used different strategies In their use of the nursing process by having

subjects Indicate which of several alternatives they wouJd take given a

specific situation. Although this methodology provides Insight Into

projected differences In behavior, It does not provide any Information

89

regarding what patient Information was considered relevant and what

problems were Identified as a result of having access to those data.

Frederlckson and Mayer U977) utilized a filmed clinical sequence

developed by Verhonlck et al. (1968) to Investigate the processes used

by graduates of AD and BD programs. Responses to the filmed situation

were categorized as follows: problem definition, data collection,

postulatton of solutions, and evaluation of solutions. Results

Indicated that both groups used primarily the first three steps

enumerated above. No significant differences were found between the

problem solving process used by AD and BD students.

The methodology used In this study provided the participants with

an opportunity to Identify relevant data. However, It did not provide

for the Initiation of data collection activity In those Instances when

the participant might have desired more Information. The participant

was.a passive observer. Therefore, although the results of this study

provide Insight Into the assessment capabilities of participants. It

does not provide a picture of what they would do If they had some

control over data collection activities.

Gover (1972) designed and used the Nursing Performance

Simulation Instrument (NPSI) to measure the problem solving abilities

of technical and professional nurses. The NPSI consists of four

clinical simulations In which specific patient care situations are

described. The respondent then chooses among a number of forced-choice

alternative actions that could be Implemented. Results Indicated no

90

significant differences In problem solving ability. Further

Information was not available about this study.

Bassett (1977) also used the NPSI to determine the existence of

differences In problem solving abilities of last term AD and BD

students. No significant differences were demonstrated between

performances of the two groups of students. Further Information was not

available about this study.

Sparks (1979) used the NPSI and an Investigator designed

Instrument, the Nursing Process Utilization Inventory (NPUI), to

evaluate problem solving abilities of AO and BD students. The NPUI

consists of two client situations In which a narrative description of a

client, Including relevant data, Is provided. Using an open ended Item

format, the student Is directed to Indicate each client's nursing

problem, the substantiating data, and, for the three priority problems

Identified by each participant, to Indicate objectives for care and

outcome evaluation criteria, nursing actions to be taken, and rationale

for each stated action.

Participants In the study were 128 AD and 108 BD senior level

students In programs located In three mid-western states. Analysis of

the NPSI scores demonstrated no significant differences In problem

solving abilities of the two groups of students. Analysis of the NPUI

revealed that BD students had significantly higher scores than did AD

students for the composite scores on each of the two simulations and

for problem Identification and care planning scores. Sparks suggested

that an explanation for the difference In outcomes, as measured by the

91

NPUI and the NPSI possibly could be related to the NPSI not measuring

nursing process ability.

Re Id (1981) designed a study to examine the psychometric

properties of the NPSI and the Clinical Nursing Simulation Instrument

(CNSI), a branching type simulation developed by the nursing faculty at

the University of St. Thomas. These Instruments were administered to

96 AD and 45 BD students from three AD and three BD programs In

Tennessee. The results of analyses lent support to Spark's conclusion

that the NPSI did not measure problem solving ability. Rather, Reld

(1981) concluded. It tests nursing knowledge. Analysis of student

performance on the two tests resulted In the demonstration of no

significant difference In performances of AD and BD students.

The NPSI used by Gover (1972), Bassett (1973), Sparks (1979) and

Reld (1981) and the NPUI used by Sparks (1979) do not provide an

opportunity for the participant to select patient data. As In several

of the previously described studies, data are presented and the

participant Is expected to react. The use of this type of Instrument

yields artificial Information regarding the overall assessment

abilities of the participant. A second concern regarding the

conclusions of Gover (1972), Bassett (1973), and Sparks (1979) Is

related to Sparks' (1979) question and Reld's (1981) conclusion that

the NPSI tests knowledge rather than problem solving ability.

4) Summary

Differences In the problem solving ability of AD

and BD graduates or students have been addressed directly by seven

92

Investigators. They have used a variety of Instruments designed to

address the question: What would you do In this situation? Although

the work of Frederlckson and Mayer (1977) best exemplifies the need to

look at what data are used to formulate nursing diagnoses or problems,

none of the studies addresses the need to examine the entire range of

activities encompassed In the assessment phase. Included should be

determinations of what data are Identified as relevant to collect,

what conclusions are drawn as a result of having access to specific

data, and are correct Judgments arrived at based on the data collected.

The methodology necessary to obtain Information regarding data

collection and nursing diagnosis Identification abilities of

graduating AD and BD students will be addressed In the next chapter.

III. METHOD

The primary research question to be addressed by this study wast

Are the patient assessment abilities of associate and baccalaureate

degree nursing students, when measured within three months prior to

graduation from a program of study accredited by the National League

for Nursing, Influenced by type of educational program? The secondary

questions addressed were: When graduating associate and baccalaureate

degree nursing students are compared. Is there a difference In 1) data

collection efficiency and proficiency?; 2) amount and percent of

psychosocial history data selected?; 3) number and completeness of

nursing diagnoses Identified?; and 4) amount and percent of

psychosocial nursing diagnoses Identified?

This chapter is focused on the methodological processes used In

conducting the study. The following sections Include descriptions of

the design of the study, population of Interest and sample selection

procedure, operational IzatIon and measurement of the conceptual model,

and data collection procedures.

A. Research design

Influence of type of nursing education program attended on

graduating students' abilities to collect patient data and Identify

nursing diagnoses was examined using a non-equivalent groups, post-test

only design (Cook and Campbell, 1979), This design was selected since

potential participants could not be assigned to treatment groups (I.e.,

93

94

either an associate or a baccalaureate degree program) and naturally

occurring groupings thus were studied.

A major weakness of this design Is lack of pre-test Information.

Therefore, It was Impossible to compare pre-nurslng education problem

solving abilities of participants, attribute any post-test differences

to type of educational program attended, or rule out selection bias

(Cook and Campbell, 1979). For these reasons, Cook and Campbell (1979)

classified the non-equivalent groups, post-test only design as a non-

experimental design.

To arrive at plausible causal Inferences regarding the total

Influence of type of nursing education program attended on data

collection and nursing diagnosis Identification abilities of the study

participants, several procedures were used to overcome the lack of

pretest measures. These Included measurement of additional variables

(covarlates) that are associated with performance on outcome measures

and selection of a nursing program, and use of selected statistical

analysis procedures. These covarlates and stattslttcal analysis

procedures will be discussed subsequently.

To prevent hypothesis guessing by the participants, a threat to

the Internal validity of the study (Cook and Campell, 1979), the Deans

and Directors of schools solicited for participation In the study and

potential participants were Informed only that the purpose of the study

was to explore the Influence of various educational factors and

Individual characteristics on clinical decisionmaking abllltes of

graduating students.

95

B. Population and sample selection

The target population was all National League for Nursing (NLN)

accredited associate and generic baccalaureate degree nursing programs.

Stratified random sampling, with replacement, was used to select 6

Institutions offering AD programs and 6 Institutions offering BD

programs located In three mtdwestern states and within a 150 mile

driving distance of a large mldwestern city. The population of

Institutions offering BDs was stratified so that two programs from

public supported Institutions and four programs from private

Institutions would be Included In the sample In proportion to their

representation In the population. A convenience sample of students

enrolled In their first nursing education program then was obtained.

It was anticipated that a minimum of 100 AD and 100 BD students who

were within 3 months of graduation would agree to participate In the

study.

1. Rationale for sample selection

The rationale for the sampling frame was as follows.

Limitation of the sample to only those Institutions which have attained

NLN accreditation was a quality control factor. The attainment of NLN

accreditation Indicates that a program has met standards of quality

that have been established for a specific level of educational

preparation for nursing.

A three state area was selected to provided a broader

representation of programs than would be provided by confinement of the

sample to one state. Confinement of the sample to within one hundred

96

fifty miles was Imposed due to travel time and financial considerations

associated with data collection.

Only students enrolled In AD and BD programs were Included In the

study since these two levels of programs were endorsed by the ANA

(1965) as appropriate for the preparation of technical and professional

nurses. To prevent confounding the study results due to the completion

of other nursing programs, only generic nursing students enrolled In

their first nursing education program were Included In the study.

Students with a degree In another area of study but enrolled In their

first nursing program also were eligible for Inclusion. Additionally,

only students within 3 months of graduation were Included to allow

students to gain maximum benefit from their educational program while

still providing for flexibility In the scheduling of data collection.

2. Sampling procedure

The State Approved Schools of Nursing - RN (NLN, 1983) was

used to Identify alt NLN accredited AD and BD degree nursing programs

In the designated geographic area. The Identified Institutions were

stratified Into three groups depending upon type of program offered and

the source of funding (private, public) for those Institutions offering

baccalaureate programs In nursing. Within each group, each Institution

was assigned a number.

A table of random numbers was used to compile lists of randomly

ordered associate degree granting Institutions, private baccalaureate

degree granting Institutions, and public baccalaureate degree granting

Institutions. The characteristics of the 19 AD and the 6 public BD and

97

15 private BD nursing programs from which the stratified random sample

was drawn are summarized In Table XL (Appendix A).

The convenience sample of participants was to be acquired from

the first six AD programs, the first two public BD programs, and the

first four private BD programs, on the respective lists, whose

Dean or Director was willing to participate In the study and who would

allow the Investigator access to the student population.

3. Solicitation of Institutional agreement to participate

A letter (Appendix B) was sent to the Dean or Director of

the first 6 AD, the first 2 public BD and the first 4 private BD

programs on the randomly ordered lists of programs. The letter

explained the purpose of the study, described the level of

participation required, and requested participation In the study. A

follow-up phone call, approximately one week after the anticipated

receipt of the letter, was made to ascertain willingness to participate

In the study.

If there were agreement to participate, arrangements subsequently

were made for a mutually agreeable time and place for student testing.

In addition, at the Dean's or Director's discretion, a liaison person

from the program was Identified to facilitate communication and

arrangements.

After all preliminary arrangements were made for testing,

sufficient copies of a letter (Appendix C) addressed to graduating

students was disseminated to all those generic students within 3

months of graduating. This letter described the general purpose of the

98

study, the extent of participation required and requested participation

In the study. In addition, the arrangements for testing were announced

and those students who desired to participate were requested to sign up

for a testing session. These lists were returned by program personnel

to the Investigator. Several days prior to the Investigator's visit to

the campus, those students Indicating a desire to participate received

a memo reminding them of the study and the arrangements that had been

made.

If a school declined to participate In the study, the next school

on the appropriate randomly ordered list was contacted using the same

procedure as described above. This procedure was repeated until the

Deans or Directors of 6 AD and 6 BD (2 public and 4 private) programs

agreed to participate.

The Director of 1 AD program, who Initially Indicated a desire to

permit the program's students to participate, eventually withdrew this

permission. Notification arrived at a point In time when the academic

calenders of the programs remaining on the random list of schools made

It Impossible to obtain a replacement. For this reason, the AD

students who participated In the study were obtained from 5 different

schools rather than the Initially planned 6 schools.

4. Sample characteristics

The following sections Include descriptions of the programs

and the students that participated In the study.

a. Characteristics of participating programs

Selected characteristics of the 11 schools from which

99

student participants were obtained and number of participants from each

school are summarized In Table II. All BD programs were located In

4-year colleges or In universities. Each required 4 academic years for

completion of course work. The modal curriculum pattern was one of 1

1/2 years of liberal arts and science (LAS) courses and 2 1/2 years of

nursing courses with at least one LAS course within each academic

semester or quarter. Four nursing programs reported that they had an

"Integrated" nursing curriculum pattern; the other two had a

"traditional" curricula. The required and elective LAS coursework

Included both Introductory and upper level (I.e., advanced) courses. A

review of the required courses for each program revealed that

approximately 30% to 45JS of the total credits required for graduation

were nursing courses.

The AO programs were located In community colleges or technical

Institutes. Three programs required 2 academic years for program

completion; 2 required an additional summer term In addition to the two

academic years. The modal curriculum pattern was a mix of nursing and

LAS courses throughout the program. The LAS courses can be described

best as single, Introductory level courses (I.e., Introduction to

sociology, anatomy and physiology, etc.) Nursing course work accounted

for 40J6 to 50J6 of the total number of courses required for graduation,

b. Characteristics of student participants

Of the 177 participants In the study, 86 were from BD

programs and 91 were from AD programs. The demographic characteristics

of the participants are summarized In Table III. Academic performance

100

TABLE II

DISTRIBUTION OF PARTICIPATING ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PROGRAMS BY FINANCIAL SUPPORT AND NUMBER OF PARTICIPANTS

a Program Financial Support Number of

Public Private Participants

AD-1 X AD-2 X AD-3 X AD-4 X AD-5 X

BD-1 BD-2 BD-3 BD-4 BD-5 X BD-6 X

21 40 21 5 4

SubtotaI 91

X 12 X 6 X 36 X 11

6 15

SubtotaI 86

TOTAL 177

a AD = Associate degree program; BD s Baccalaureate degree program.

t o t

TABLE 111

DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS

Characteristic Group

a b AJI AD BD

(n = 177) <n = 91) <n = 86)

c AGE mean standard deviation range

d GENDER femaIe male

e MARITAL STATUS single married separated/dIvorced

f NUMBER OF CHILDREN mean standard deviation range

a AD = Associate Degree.

b BD = Baccalaureate Degree.

c F(1,9) = 23.674, p<.00t.

d 2 X (1) = 0.41, p>.05.

e 2 X (2) = 45.39, p<.001.

f F(1,9) = 27.49, p<.001.

27.12 29.70 24.38 6.67 6.83 5.30

20 - 53 20 - 53 21 - 47

169 86 83 8 5 3

90 24 66 73 55 18 14 12 2

0.76 1.27 0.21 1.16 1.27 0.71 0 - 4 0 - 4 0 - 4

102

characteristics of the participants are summarized In Table IV.

Analyses of Variance (ANOVA), with schools nested within program type,

and Chi square were used to determine the presence of any

statistically significant differences between the two groups. These

analyses demonstrated that the AD participants were significantly older

than the BD participants. Also, a significantly greater percentage of

the AD participants were married and had greater family

responsibilities than did BD participants. These findings demonstrate

that the sample was demographlcally similar to those used in other

studies contrasting AD and BD students (Dustan, 1964; Gray et al.,

1977; Knopf, 1975; Melets and Farrell, 1974; Nash, 1975; Richards,

1972; Schwerlan, 1979; Sparks, 1979; Wren, 1971).

Analysis of the academic characteristics demonstrated only one

statistically significant difference. A greater percentage of the BD

participants reported graduation from high school In the highest

quart!le, while the greater proportion of AD participants reported they

were In the second quart 11e. This finding Is consistent with those

reported by Schwerlan (1979) and Sparks (1979). Although no

statistically significant difference was demonstrated, the AD

participants reported having experienced more years of post-high school

education than had the BD participants. This difference Is In the same

direction as that reported by Knopf (1975) and Sparks (1979).

Although not statistically different, AD participants achieved a

higher score on the NCLEX-RN examination than did the BD participants.

This finding Is consistent with national results reported by the

103

TABLE IV

ACADEMIC CHARACTERISTICS OF STUDY PARTICIPANTS

Characteristic Group

All (n = 177)

a AD

(n = 91)

b BD

<n = 86)

H.S. QUARTILE RANKING

highest 2nd highest 3rd highest lowest

94 68 10 5

37 44 6 4

57 24 4 1

YRS. POST H.S. EDUCATION

mean 1.27 standard deviation 1.68 range 0-10

1.48 1.54

0 - 1 0

1.05 1.80 0 - 9

PRIOR DEGREE

none AD/AS Bac Masters Post-Masters

151 10 12 3 1

78 4 8 1 0

73 6 4 2 1

CUMULATIVE GPA

mean 3.27 standard deviation 0.40 range 2-4

3.33 0.43 2 - 4

3.21 0.37 2.37 - 4

104

TABLE IV (continued)

ACADEMIC CHARACTERISTICS OF STUDY PARTICIPANTS

Characteristic Group

All (n=177)

AD (n=91)

BD (n=86)

NURSING GPA

mean st.dev. range

3.19 0.47 2 - 4

3.25 0.51 2 - 4

3.12 0.37 2 - 4

NCLEX-RN SCORES

mean st.dev. range

2036.67 294.95

1317 - 2928

a AD = Associate Degree.

b BD = Baccalaureate Degree,

c 2 X (3) = 12.21, p <.01.

d F< 119) = 1.431, p>.05.

e 2 X (4) = 3.09, p>.05.

f F(1,9) = 1.194, p>.05.

9 F(1,9) = 0.607, p>.05.

h F(1,9) = 3.918, p>.05.

2090.85 265.77

1528 - 2793

1979.34 314.45

1317 - 2928

105

National Council of State Boards of Nursing (Personal communication,

January, 1985) for the July, 1984 examination. The AD participants also

reported higher nursing and cumulative GPAs than did BD participants.

It Is difficult to arrive at any conclusions regarding the meaning of

this finding due to the Influence of the grading policies and practices

of Individual programs.

C. OperationalFzatlon of the conceptual model

The conceptual model, as previously described, stated that when

confronted with a nursing problem, Information processing capabilities

of the nurse, as reflected by the Implementation of the assessment

phase of the nursing process, Is dependent upon task setting and

complexity, type of educational program attended, and Individual

characteristics that affect cognitive, Information processing abilities

and/or the selection of a specific type of nursing education program.

Subsequent sections contain descriptions of the variables Included In

the model.

1. Independent variable

The Independent variable was the type of educational program

attended: an AD nursing program or a BD program.

2. Covarlates

The covarlates were those factors which Influence

cognitive, Information processing capability and/or the selection of a

nursing education program. The factors Influencing Information

processing were: task setting and complexity, and critical thinking

ability and gender of the problem solver. Those factors related to the

106

selection of a nursing education program were: number of years of pre-

nurslng work experience In health care settings, and number of years of

post-htgh school education prior to entering a nursing program. Factors

associated with both program selection and cognitive Information

processing were: age and Intellectual ability. Indicators selected to

represent each of these are described below.

a. Task setting

Two paper and pencil latent Image clinical simulations

(PMP-Brown and PMP-Ellls) were used to standardize and, therefore,

control the setting In which the clinical nursing problem was

experienced. Performance on the two simulations was analyzed

separately.

b. Task complexity

Task complexity was assessed from two different

perspectives. Each participant was requested to rate the level of

difficulty encountered In completing each simulated clinical problem

and to Indicate the degree of preparation that the nursing education

program provided for dealing with the simulated situation.

c. Critical thinking abtlIty

Critical thinking ability of a participant as reflected

by the general reasoning processes and problem solving processes used

to deal with problems encounterd In everyday life, was Indicated by the

total score on the Watson-Glaser Critical Thinking Appraisal (CTA)

(1980).

107

d. Post-high school education

Each participant was requested to Indicate the total

number of years of higher education completed prior to entering the

current nursing program. For descriptive purposes, the degree or

certificate earned, If any, was also to be Indicated.

e. Nnn—wdiiratton related health care experience

Each participant was requested to Indicate the number

of years worked In a clinical setting prior to entry Into a nursing

program and for descriptive purposes, the job title. The same

Information was obtained regarding work experience (non-education

related) In a clinical setting during program matriculation.

f. Age and gender

Each participant was requested to Indicate the current

age. In years, and sex.

g. Intellectual ability

Academic achievement was used as an Indirect measure of

Intellectual ability. An Indicant of pre-matIculatton achievement was

a participant's self-report of the high school quartlle ranking at the

time of graduation. Indicants of post-mat IcuIat Ion academic achlevment

were self-reports of the current cumulative GPA for all course work and

the cumulative GPA for all nursing course work. An additional measure

of academic achievement was a participant's score on the NCLEX-RN.

This score was obtained from the board of nursing In the political

Jurisdiction where the participant took the NCLEX-RN In July, 1984.

108

3. Dependent variables

The assessment phase of the nursing process Involves the

collection and analysis of patient Information and culminates In the

Identification of relevant nursing diagnoses. For the purposes of this

study, dependent variables were: efficiency of data collection,

proficiency of data collection, types of data collected (psychosocial

data and physiological data), total number of plausible nursing

diagnoses Identified, completeness of nursing diagnostic statements,

and types of plausible nursing diagnoses Identified (psychosocial

nursing diagnoses and physiological nursing diagnoses).

D. Instruments

The four Instruments used to gather data were: 1) the Background

Inventory (Bt), 2) the Watson-GIaser Crlttcal Thinking Appraisal, Form

A (CTA), and 3) two latent Image clinical simulations. The Bl and CTA

provided data relevant to the covarlates selected. The simulations were

selected to provide data pertaining to a participant's data gathering

and nursing diagnosis skill, the dependent variables. Each of these

Instruments Is described In subsequent sections.

1. Measurement of the covarlates

a. Background Inventory

The Background Inventory (Bl) (Appendix D) Is a

modification of one used by Sparks (1979) to collect demographic

Information and assess those characteristics Identified In the

literature as factors contributing to the selection of a nursing

education program and/or cognitive problem solving ability.

109

Mod If feat Ions Included changes In the structure of several Items In

order to Increase thetr clarity, expansion of the number and/or type of

response options available within several Items, and addition of Items

to assess a participant's famlllartty with nursing diagnosis

terminology, classroom and clinical learning experiences related to the

types of situations depicted In the simulations, and perceptions

regarding the difficulty of the simulations.

Prior to use, the Bl was reviewed by 3 nurse educators for Item

clarity and ease of completion. In addition, It was administered to

students who participated In the pilot testing of the procedural steps

of data collection. Information obtained from the review and use of

the Bl was used to make minor modifications In the layout of the

Instrument and In wording of the directions.

b. Watson-GIaser Critical Thinking Appraisal

The Watson-GIaser Critical Thinking Appraisal (CTA) Is

an 80 Item Instrument composed of five, sixteen Item subtests (Watson

and GIaser, 1980). This unttmed Instrument requires approximately 40

minutes for completion and can be handscored. The Instrument measures

general reasoning processes used on a dally basis. As conceptualized

by Watson and Glaser (1980), critical thinking ability Is one aspect of

general reasoning and problem solving processes necessary for the

Interpretation of Information, formation of Judgments, and decision

making In everyday life.

The authors viewed critical thinking ability as a composite of

attitudes, knowledge and skills, each of which Is estimated by measures

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of the five subtests. A high level of competency In critical thinking,

as measured by the CTA, was operationally defined by Watson and Glaser

(1980) as the' ab11Ity to perform correctly the universe of tasks

represented by the 5 subtests. This Instrument was selected to provide

a measure of critical thinking ability based on the assumption that

activities represented In this Instrument are similar to those used In

a diagnostic task. The five subtests are as follows:

1) Inference

The Inference subtest samples ability to

discriminate among degrees of truth or falsity or probability of

certain Inferences drawn from given facts or data.

2 ) Recognition of assumptions

This subtest samples ability to recognize unstated

assumptions from given facts or data.

3) Deduction

The deduction subtest samples ability to reason

deductively from given premises; recognize the relation of Implication

between propositions and delineate whether what seems to be an

Implication or necessary Inference between one proposition and another

Is Indeed so.

4) Interpretation

The Interpretation subtest samples ability to

weigh evidence and distinguish between unwarranted generalizations and

probable Inferences which, although not conclusive or necessary, are

warranted beyond a reasonable doubt.

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5) Evaluation of arguments

The evaluation subtest samples ability to

distinguish between arguments which are strong and Important to the

question at Issue and those which are weak and unimportant or

Irrelevant.

The authors reported that content va11dIty of the Instrument was

supported by the Judgments of qualified persons and the results of

research studies that supported the authors* beliefs that the Items In

the CTA represented an adequate sample of the five abllltes, as

represented by Items In the different subtests. Additionally, the total

score yielded by the test represents a valid estimate of the

proficiency of Individuals with respect to these aspects of critical

thinking.

Watson and Glaser (1980) reported that claims for construct

validity of the Instrument were supported by research results that

demonstrated that students who had participated In programs aimed at

developing critical thinking ability showed greater change In CTA

scores than did those exposed to course content delivered by

traditional lecture methods. The CTA also has been shown to relate to

various measures of academic achlevemnt and traditional measures of

general Intelligence. Although the CTA was found to correlate with

general Intelligence, factor analyses of the CTA subtests with other

measures of Intelligence were reported to demonstrate that the CTA

measured a dimension of ability that was distinct from overall

Intellectual ability.

112

The authors measured degree of Internal consistency In the CTA by

calculating split-half reliability coefficients for 10 different norm

groups. Samples chosen for reliability studies Included at least one

representative from each of the kinds of groups used for normlng the

responses. Reliability coefficients for Form A (used In this study)

ranged between .69 and ,85; for Form B, between .70 and .82

The stab 11Ity of responses over time was assessed using a group

of college students (n = 96) via test-re-test procedures with a 3 month

Interval between testing periods. The .73 correlation between

responses at the two times Indicated reasonable stability over time

(Watson and Glaser, 1980).

Alternate form ret fab!IIty was calculated by correlating the

responses of 228 high school seniors who took both Forms A and B of the

CTA. The correlation coefficient was .75. These results were reported

to be consistent with those observed on previous forms of the test

(Watson and Glaser, 1980).

2. Measurement of the dependent variable

Portions of two patient management problems (PMPs) developed

by Schleutermann and others (1979) and Farrand and others (1979) were

used to measure data collection and nursing diagnosis Identification

abilities of participants. These Instruments are latent Image,

branched simulations In which the participant Is presented with a brief

patient description and asked to demonstrate an approach to data

collection and nursing diagnosis Identification.

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a. Description

The PMPs, "Mr. Ellis, a 48 year old man complaining of

chest pain and difficulty breathing" (PMP-Ellls) (Schleuterman et a I.,

1979) and "Mr. Brown, an adult male with frequent episodes of

eplstaxls" (PMP-Brown) (Farrand et a I., 1979), are 2 of 3 PMPs

developed for use In the education and evaluation of graduate students

enrolled In a nurse practlttoner program (Holzemer et al., 1981). For

this study, only the patient assessment sections, which Included a

brief opening statement (patient description) and lists of potentially

available history data, physical findings, and Iaboratory/dlagnostic

test results, and the patient problem Identification sections were

utilized. Patient problem sections were located at the conclusion of

the opening statement, at the conclusion of the three data collection

components, and In the management section. This last sect ton served as

a logical conclusion to the simulation since It directed the

participant to Identify the three highest priority nursing diagnoses to

which nursing care would be directed.

The medical management and follow-up sections of these PMPs were

not used because they were deemed Inappropriate for use with

undergraduate students (e.g., they required decisions regarding the

selection and dosage of medications to be used In treatment). Of the

276 total Items In PMP-Ellls, 148 Items were distributed across the

three assessment sections as follows: history = 68 Items, physical

findings = 38 Items, and laboratory/diagnostic test results = 42 Items.

Distribution of 140 assessment Items, out of 276 total Items, In PMP-

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Brown was as follows: history = 63 Items, physical findings = 37 Itmes,

and laboratory/diagnostic test results = 40 Items.

In order to adapt the settings In which the patient encounters

occurred Into ones more familiar to AD and BD students, statements In

the opening scenes that read "You are a nurse practitioner...." were

modified to state: "You are a nurse...,". The opening scene for PMP-

EMIs was modified further to reflect a more likely setting - I.e., one

In which both AD and BD students would likely find themselves employed

In the near future. Therefore, the statements nurse

(practitioner) employed In a walk-In clinic of a city health

department..." and "...arrives In your office complaining..." were

changed to: "...nurse employed on a general medical-surgical unit of a

community hospital..." and "...Is admitted to your unit

complaining...".

Additional modifications were made In each PMP on the pages where

a participant was directed to select one of several actions that could

be Initiated. One of these options was "Consult with a physician"; the

response to which was "Physician feels you can work up this patient.

Make another selection In this section." For PMP-Ellls, this response

was changed to: "Physician on call does not answer his page. Make

another selection In this section." On PHP-Brown, the original

response was modified to read: "Physician has been called to the

emergency room. Make another selection In this section."

The final modification on both PMPs Involved the statements

directing a participant to record the problems and/or possible

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diagnoses being considered at that time. These statements were changed

so that the participant was directed to Indicate the nursing diagnoses

that were being considered. A discussion with the primary author of

PMP-Brown, and co-author of PMP-EMIs concerning these modifications

led to the conclusion that the modtflcatons would not alter outcomes of

the assessment sections (Farrand, personal communication, January,

1983).

b. Content valIdlty

In support of the content validity of the PMPs, Farrand

et al. (1982) cited construction by several nurse practitioners and an

educator. Included In the development phase were delineation of

learning objectives, a blueprint, the opening scene, and section

options. Content for each section was developed according to nursing,

medical and educational principles. Branching techniques were

constructed to allow for variation In management styles and emphasis

was placed on patient safety and quality care with a focus on both

effectiveness and efficiency In the delivery of care. Following their

Initial construction, the PMPs were examined for content omissions,

clarity, structural flaws, Implausible alternatives, redundancy,

allowance for variation In managment styles, format and directional

clarity.

A panel of experts, which Included an educational evaluator with

experience In the construction of latent-Image simulations, a master's

prepared adult nurse practitioner, a doctorally prepared nurse-

physlolog 1st, and two physicians with specialties In preventive

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medicine and family practice, critiqued the format and content, and

scored each Item for appropriateness for Inclusion In the PMP. Each

Item was reviewed for Its applicability to the problem, fidelity to a

real patient encounter, and possible variations In management. The

panel also critiqued the PMPs for Item clarity and construction,

c. Construct valIdlty

The construct validity of the PMPs as a measure of

clinical problem solving was explored using several different

approaches. Following the development of PMP-Ellls, a multi-method,

multi-trait correlation matrix, a multivariate analysis of covarlance,

and stepwise multiple regression analysis were used to assess constract

validity (Holzemer et al«, 1981). The multiple methods utilized were

self-chart audit, colleague evaluation, self-evaluation, and a

cognitive examination. The traits were: cognitive knowledge, problem

solving skill, and perception of clinical practice. It was

hypothesized that the validity of the PMP would be supported If:

"Significant correlations were observed between the PMP scores and the

self-audit, self-evaluation, and colleague evaluation; moderate

correlations were observed between the PMP scores and the cognitive

examination; and significant differences were demonstrated between

certificate and masters-prepared nurse practitioners" (p.140).

A total of 79 nurse practltoners completed the PMP and self

evaluation, 68 supplied colleague evaluation data, 60 completed the

cognitive examination, and 33 completed the self chart audit. Of the

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60 practitioners completing the cognitive examination, 26 were master's

prepared and 34 were certificate prepared.

Holzemer et al. (1981) concluded that the results of the

Investigation provided "moderate evidence" (p. 139) supporting the

claim that the PMP simulation was a valid measue of the construct:

clinical problem solving. Findings supporting this conclusion were: a

Pearson product moment correlation of .54 (Spearman's rho = .56)

between performance on the cognitive examination and overall

proficiency score on the PMP, and significant correlations between PMP

proficiency score and self evaluation scores (r =.23, rho = .19). In

addition, step-wise multiple regression analysis, with PMP proficiency

score as the dependent variable, demonstrated that after the Influence

of performance on the cognitive examination was removed (31.89!? of the

variance), only 5.65f of the variance In PMP proficiency could be

explained by the Inclusion of four additional variables (self-

evaluation of management skill, col league evaIuatIon of management

skill, master's preparation, and self-evaluation of data-gathering

skill). No difference was demonstrated between the performance of

certificate and master's prepared Individuals on the PMP.

Additional work to Investigate the construct validity of PMP-Ellls

and PMP-Brown and an additional PMP was reported by Farrand and others

(1982). It was hypothesized that a claim for the construct validity of

the simulations would be warranted If significant differences were

found between the performance of nurse practitioners and nurses (I.e.

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not nurse-practIt loners) on simulations designed for use with nurse

practitioners.

A sample of 34 nurses and 53 nurse practitioners completed the

three PMPs, a demographic survey, and a cognitive examination

constructed to test knowledge that paralleled the content of the three

PMPs. Data analysis procedures utilized multivariate analyses of

variance and co-variance, and Pearson product moment correlations.

The analysis of variance demonstrated that significant differences

in performance on the PMPs existed for the type of preparation

(p=.0001). The pooled test of the covarlate was not significant.

However, further examination of the correlations between examination

subscores and the respective PMPs demonstrated that significant,

moderate correlations were present for PMP-EII Is (r - .49) and for PMP-

Brown (r = .32)j for the third PMP, the correlation was .12.

Therefore, overall, the covarlate was not of sufficient magnitude to be

significant.

Based on the demonstration that meaningful differences were found

In the performance of nurses and nurse practitioners, Farrand et al.

(1982) concluded that support for the construct validity of the

clinical simulations was warranted.

d. Reliability

Overall reliability of each PMP and reliability of the

sections to be used for this study were supported based on results of

test-re-test procedures (Farrand, personal communication, January,

1983). Estimations of Internal consistency of various sections of the

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PMPs could not be assessed due to the dependent nature of Items and

absence of additional similar sections within each PMP.

E. procedure

1. PMot testing

Prior to Initiation of formal data collection, the Bl and

and PMPs were administered to a convenience sample of 6 undergraduate.

Junior students enrolled In the nursing program of a large mid-western

university. All students had completed a course In the care of adults

with acute medical-surgical nursing problems. The purpose of the pilot

testing was to determine the clarity of Instructions regarding

completion of the Bl and the PMPs and the amount of time necessary to

complete the Instruments.

Following completion of these instruments, the pilot subjects

were requested to Indicate those areas where they were unsure of the

Intent of an Item or directions for Its completion. When pilot subjects

returned the completed Instruments to the Investigator, the Instruments

were reviewed to determine If the correct procedures had been followed.

All participants completed the Bl and the PMP according to the written

and verbal directions that were provided. In addition, pilot subjects

were questioned Individually to determine If anything was unclear to

them during test completion.

All pilot subjects were able to complete the 2 PMPs and the Bl

within 75 minutes; this Included the time required to distribute the

Instruments and review the directions for their completion. Therefore,

It was concluded that the entire set of Instruments (the Bl, CTA, and

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the two PMPs) could be completed within a 2-hour period. Based on the

pilot subjects' comments, the content of the written Instructions was

expanded to Include Information regarding the order In which the

Instruments were to be completed.

2. Data col lection

Procedures used for formal data collection were as follows.

At the agreed upon times and locations, the Investigator met with those

students Indicating an Interest In participating In the study.

Following an explanation of the study, those desiring to participate

were requested to sign a consent form (Appendix E) Indicating that they

were participating voluntarily In the study, that confidentiality would

be maintained, and that the Investigator could have access to their

Individual scores on the NCLEX-RN examination following Its

administration In July, 1984. Those Interested In receiving a written

report of their performance on the PMPs and the CTA were requested to

provide mallIng Instructions.

Each participant received an envelope containing a complete set of

pre-coded Instruments, developing pens for use with the PMPs, a pencil,

and written Instructions for completing all Instruments. Order of the

Instruments In the envelope was as follows: 1) one of the PMPs, 2)

the CTA, 3) the second PMP, and 4) the Bl. The order In which the

PMPs were Included In the set was alternated In order to control for a

possible fatigue factor. The PMP-Ellls was the first Instrument I n

the evenly numbered sets and PMP-Brown was the first Instrument In the

odd numbered sets.

12!

To provide for Instruction and practice In using the latent Image

simulations, the first page of the first slmulatton In each set of

Instruments was Identical to those In all other sets. Following a

practice session, answering of questions from partlciants, and a review

of the written Instruction page, the participants were Instructed to

beg In.

Although no strict time limit was Imposed on completion of any

one Instrument, suggestions for self-timing were provided. It was

anticipated that completion of the entire set of Instruments would

require approxlmatley 2 hoars. All participants completed the task

within the alloted time period.

Upon completion of all Instruments, participants were Instructed

to return all Instruments to the envelope and to give the envelope to

the Investigator. Participants were thanked Individually for their

participation and provided with a written summary of expected outcomes

for each PMP. Following scoring of the CTA and the PMPs, all

participants who provided a mailing address received a written report

of their performance and, for the purpose of comparison, the means

scores for all participants, the AD participants, and the BD

participants.

F. Protection of human subjects

This study was approved by the Institutional Research Review

Board, Health Sciences Center, University of Illinois at Chicago

(exempt status) and by the Research Committee of the College of

Nursing, University of Illinois at Chicago.

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The Deans and Directors of all programs permitting access to

students were assured that the school would not be Identified. In

addition, all participants were assured that their responses and the

degree of their participation In the study would remain confidential.

All participants In the study were requested to sign a consent to

participate form (Appendix E) and Informed of their right to withdraw

from the study, without penalty, at any time during the testing period.

G. Data rerinrtlnn

All Instruments were precoded with an Identification number to

Insure proper matching of responses on various Instruments. Following

completion, each participant's Instruments were coded to Indicate the

specific program attended and whether It was an AD or BD program.

1. Covarlates

All responses on the B| were coded and entered Into a

computer file for further analysis. Responses on the CTA were hand

scored according to the directions provided In the manual (Watson and

Glaser, 1980) and subscores, total score, and percentile score were

entered Into the computer file. Percentile score for BD participants

was based on a normative sample of 182 nursing students In mldwestern

university baccalaureate nursing programs; that for AD participants, on

a normative sample of 388 students In Junior and community colleges

(Watson and Glaser, 1980).

2. Dependent variables

a. Patient Information

Each Item within the history, physical, and

123

diagnostic/laboratory test result sections on each PMP was scored to

Indicate If a participant had or had not selected It. This Information

was entered Into the computer file. Furthermore, each Item within each

of these sections was weighted to reflect Its contribution to the

Identification of the simulated patients' nursing diagnoses. The three

point scale, developed by a panel of experts (Holzemer et al., 1981),

ranges from a +1 to a -1s +1 Indicated patient Information or a data

collection step that was essential to data collection and/or diagnosis,

0 Indicated Information or a step that was contributory but not

essential, and -1 Indicated Information or a step that was

Inappropriate, unsafe, of low quality, unreasonably costly, or delayed

proper treatment.

In addition to the weighting system described above, an expert

panel of 3 nurses (to be described In a subsequent section) classified

alt patient Information options In the history sections as having

primary relevance to either a physiological or a psychosocial nursing

diagnosis. Each panel member Independently Judged the Items; the focus

of each Item was then designated according to the majority opinion.

1) Scoring formulas

Following the computer Input of Individual

responses to each Item and the coding system to be used for score

computation, the following scores were generated for each participant

for each PMP.

a) Efficiency score

The Efficiency Score (E) was a measure of the

124

degree to which a partlclpantts choices of data and procedural steps

are helpful In the resolution of a cllent*s problems. It was computed

as a ratio of the number of essential (+1) Items selected to the total

number of Items selected.

Number of +1 Items selected E = X 100

Total number of Items selected

b) Proficiency score

The Proficiency Score (P) was a measure of

the degree to which a participant's selection of data and procedural

steps corresponds with those Judged optimal by experts In the fteld. It

was computed as a ratio of the number of essential (+1) items selected

minus the npn-essentlal (-1) Items selected to the total number of

essential (+1> Items available.

Number of +1 Items - number of -1 Items selected

P = X 100

Total number +1 Items available

c) Psychosocial data score

The Psychosocial Data Score was a measure of

the total number of psychosocial history data selected by each

participant.

d) Percent psychosocial data ££££&

The Percent Psychosocial Data Score (J&PSDS)

was a measure of the percentage of all data selected that had a

psychosocial focus. It was computed as a ratio of the number of

125

psychosocial history data Items (PSI) selected to the total number of

history data Items selected.

Total number PSI selected *PSDS = X 100

Total number of history Items selected

b. Nursing diagnoses

All diagnostic statements generated by each participant

at the completion of each phase of each PMP (I.e., following reading

the opening scene, the selection of history data, etc.) were compiled

and submitted to an expert panel for review. The majority opinion of

the panel was used to determine If a participant generated diagnostic

statement was a nursing diagnosis, whether the focus of a nursing

diagnosis statement was physiological or psychosocial, and the

plausibility of each nursing diagnosis statement. A nursing diagnosis

was plausible If a majority of panel members agreed that given the

patient data available to the participant, the nursing diagnosis could

exist.

These Judgments were used as a basis for determining the

diagnostic ability of the participants. The following sections

describe panel composition, the analysis procedure used by panel

members, reliability estimates, and procedures used to train panel

members. An additional section Includes a description of the procedure

used for scoring the diagnostic statements.

1) Expert panel composition

The panel of experts was composed of 3 master's

prepared nurses who were recognized by their peers as "experts In the

126

use of nursing diagnoses". All currently were using nursing diagnoses

In their nursing practice.

One member of the panel was a nurse educator with clinical

expertise In the nursing care of Individuals with respiratory problems.

A second member was a clinical specialist In cardiovascular nursing at

a large mid-western hospital. The third was a clinical specialist In

neurology at a large mldwestern medical center. AM panel members

received remuneration for their services.

2) Ana?ysIs of diagnostic statements

Each panel member independently reviewed and

classified each diagnostic statement to determine whether It was a

nursing diagnosis. If It were not, the panel member went on to the

next statement. If the statement was a nursing diagnosis, the panel

member Indicated Its focus: physiological, psychosocial, or mixed.

Each nursing diagnostic statement then was divided Into a maximum of

three components: stem (I.e., alteration In comfort), modifier (I.e.,

acute, chronic, potential, mild, severe, etc.) and referent or

etiology (I.e., related to tissue trauma). Each of the nursing

diagnosis statement components then was Judged as falling within one of

three categories: 1) incomplete or non-ex Istant statement; 2) complete

and plausible statement; or 3) complete, but Implausible statement.

3) Reliability

Inter-rater and Intra-rater reliability

coefficients were calculated upon completion of the Independent

evaluation, by each panel member, of the 3151 participant generated

127

diagnostic statements. The reliability coefficients were calculated

as the percent of agreement among panel members and were based on a

minimum of 1 or a maximum of 5 judgments per diagnostic statement

(I.e., 1) a nursing diagnosis?, 2) focus, and presence and plausibility

of the 3) modifier, 4) stem, and 5) referent).

a) Inter-rater reliability

A!I three panel members agreed on the

classification of 84.32£ of the statement components. At least two

panel members agreed on the rating of 97.55% of the statement

components.

b) Intra-rater reI lability

Prior to distributing the participant

generated statements to the panel members, 50 of the statements were

reproduced and coded with a bogus Identification code; these duplicate

statements were Included In the entire set of statements distributed to

each panel member. Percent of agreement for the classification of the

original and duplicate statement components was calculated for each

panel member. The Intra-rater reliability for one panel member was

94%f for a second member, 96and for the third member, 98?.

4) Training of panel members

Prior to analyzing the entire set of diagnostic

statements generated by the study participants, each panel member

received a list of essential and contributory patient Information that

participants could select. Based on this Information, each panel member

was Instructed to generate a list of nursing diagnoses that could be

128

present given the Information available following each phase of data

collection (I.e., following the opening scene, the history data, the

physical data, the laboratory/diagnostic data, and the final priority

listing). The panel generated lists of nursing diagnoses then were

compiled Into one master list and reviewed Jointly by the panel

members. At this time, redundancies were eliminated, diagnostic

statements refined and consensus reached regarding the plausibility of

each diagnostic statement. This master list served as a guide In

evaluation of participant generated diagnostic statements.

Panel members were Introduced to the diagnostic statement

evaluation task during a 2-hour training session. Diagnostic

statements representative of all those generated by study participants

were used to describe the evaluation process and to provide the panel

members with practice In using the rating form. Following the Joint

review of several diagnostic statements and discussions regarding areas

of actual or potential disagreement, the members were given 25

statements to evaluate Independently. At the completion of this task,

the ratings of each panel member, for each statement, were discussed.

When the panel members and the Investigator concluded that the

panel had reached consensus on decision rules to be used to Judge each

diagnostic statement, a final I 1st of 50 diagnostic statements was

distributed to each panel member. Following Independent, written

evaluations of these statements by panel members, the extent of Inter-

rater reliability for the training session, calculated as the percent

of agreement, was determined. All three members agreed 69.6% of the

129

time regarding the various levels of analysis of a diagnostic

statement. At least two panel members agreed 97.6% of the time. These

results were considered sufficiently high to discontinue training.

5) Scoring formulas

Following analysis of the diagnostic statements by

each panel member, the results were collated and the majority opinion

of the classification of each component of a statement was coded and

entered Into the computer file. To deal with those statements where

the panel could not agree on a classification, or were Inconsistent In

their classifications, the panel was reconvened as a group to discuss

the statements In question and arrive at a consensus. Following

discussion, all areas of disagreement or Inconsistency were resolved.

The Joint decision of the panel regarding the classlflcatlon(s) In

question then were used to code these statements.

Diagnostic statement stems were coded to reflect If they were a

non-nursing diagnosis, a plausible nursing diagnosis, or an Implausible

nursing diagnosis. The referent component for each nursing diagnosis

was coded to reflect If It were plausible or not, given the nursing

diagnosis stem's level of plausibility: If the nursing diagnosis stem

were plausible, the referent was coded as either plausible or

Implausible; If the stem were Implausible, the referent was also

Implausible. This coding system also was used to code the nursing

diagnosis stem's modifiers.

A NursIng Diagnosis Score (NDXSCORE), for each PMP, was computed

based on the following weighting system:

130

A non-nursing diagnosis statement = 0 points

An Implausible nursing diagnosis stem = 0 points

A plausible nursing diagnosis stem without a plausible referent = 1 point

A plausible nursing diagnosis stem and referent = 2 points

NDXSCORE = Sum of all points accrued for each diagnostic statement Identified within a PMP

All nursing diagnosis statements also were coded to reflect their

focus: physiological, psychosocial or mixed. The total number of

psychosocial nursing diagnoses (PSDX) Identified was computed as the

sum of the psychosocial and mixed nursing diagnoses Identified within a

PMP.

PSDX = Total number of psychosocial and mixed nursing diagnoses Identified

The percent of psychosocial nursing diagnoses (jfPSDX) Identified

was based on the following formula:

PSDX JSPSDX =

Total number of all diagnostic statements identIf led

3. Summary

A non-equivalent groups, post-test only design was used to

examine the data collection and diagnostic abilities of a convenience

sample of 91 AD and 86 BD students graduating from 5 randomly selcted

AD programs and 6 randomly selected BD programs. Instruments used for

data collection were Watson and Glaser's (1980) Critical Thinking

Appraisal (Form A), 2 PMPs (Farrand et al., 1979; Schleutermann et al.,

131

1979) and a background Inventory. The specific variables used for data

analysis, their Indicators and source are summarized In Table V. Data

analysis procedures and results of the study are described In the next

chapter.

132

TABLE V

SUMMARY OF THE INDEPENDENT VARIABLE, COVARIATES, VARIABLES USED FOR DATA ANALYSIS

AND DEPENDENT

Variable name Indicators Source

Independent variable

Program

Covar1ates

Critical thinking ability

Age

Associate or Baccalaureate degree program

Total score

Age In years

Critical Think­ing Appraisal

Background Inventory

Prior academic achievement

Prior health care experience

High School quart 11e rank

Years worked In health care

Background Inventory

Background Inventory

Prior education

Nursing knowledge base

Nursing education related clIn lea I learning experiences

Years of post-high school education

Nursing CPA

Cumulative GPA

NCLEX-RN Score

No. of Pts. with the simulated probI em

Background I nventory

Background Inventory

Background Inventory

State Boards of Nursing

Background Inventory

133

TABLE V (continued)

SUMMARY OF THE INDEPENDENT VARIABLE, COVARIATES, AND DEPENDENT VARIABLES USED FOR DATA ANALYSfS

Variable name Indicators Source

CovarIates (continued)

Nursing education related clinical learnng experiences (continued)

Task complexity

Dependent Variables

Assessment Ablltty

Efficiency of data col lection

Proficiency of data col lection

Amount of psychosocial data collected

Educational emph­asis on problem solving

Frequency wrote nursing care plans

FamlIlarlty with nursing diagnosis terminology

a Difficulty completing PMP

Degree of educational preparation for completing PMP

Background Inventory

Background Inventory

Background Inventory

Background Inventory

Background Inventory

DXSCORE Each PMP

Efficiency Score Each PMP

Proficiency Score Each PMP

Efficiency Score Each PMP

Proficiency Score Each PMP

Psychosocial Data Each PMP Score

134

TABLE V {continued)

SUMMARY OF THE INDEPENDENT VARIABLE, COVARIATES, AND DEPENDENT VARIABLES USED FOR DATA ANALYSIS

Variable name Indicators Source

Dependent Variables (continued)

Percent of psychosocial data collected

Amount of psychosocial NDXes Identified

Percent of psychosocial NDXes Identified

% Psychosocial Data Each PMP

Psychosocial Nursing Each PMP Diagnosis Score

% Psychosocial Nurs- Each PMP Ing Diagnosis score

PMP = Patient management problem.

NDXSCORE = composite score representing number and completeness of nursing diagnoses Identified.

IV. ANALYSIS AND RESULTS

The purpose of this chapter fs to report the procedures used for

data analysis and the results. The research questions which guided the

study will be used as an organizational framework for reporting these

results. Although the data collected regarding performance on each PMP

were analyzed separately, findings will be presented Jointly within

the parameters represented by each research question. An additional

section Includes results of secondary data analyses.

A. Influence of program type on assessment ability

The primary research question to be answered by this study was:

Are the patient assessment abilities of associate degree (AD) and

baccalaureate degree (BD) nursing students, when measured within three

months prior to graduation from a program of study accredited by the

National League for Nursing, Influenced by type of educational program

attended?

t. Analysis and results

A path analytic approach was used to address this question.

Within the fields of sociology, economics, and political science, this

approach has gained acceptance as a technique useful for drawing

Inferences regarding causal relationships In non-experimental studies

(Cook and Campbell, 1979; Hanushek and Jackson, 1977; Pedhazur,1982).

The model used to explain assessment ability (Figure 1) was constructed

so It consisted of a series of hypotheses about how endogenous

135

136

variables are related to one or more exogenous variables and additional

endogenous variables (Hanushek and Jackson, 1977). The exogenous

variables, those which have their values determined outside the model

and are taken as given, were Critical Thinking Ability, Age, Gender,

Prior Academic Achievement, Prior Education, and Prior Health Care

Experience. The endogenous variables, representing events explained by

the model, were Type Program Attended, Nursing Knowledge Base, Nursing

Education Related Clinical Learning Experiences, Task Complexity and

Assessment AblIIty.

Prior to testing the model and determining the Influence of

educational preparation on assessment ability, correlation coefficients

were estimated between and among the latent variables (Nursing

Knowledge Base, Education Related Clinical Learning Experiences,

Assessment Ability) and the directly observed variables (Type Program

Attended, Age, Gender, Prior Academic Achievement, Prior Clinical

Experience, Critical Thinking Ability, and Prior Education) In the

model. As a preliminary step to determining these coefficients,

Pearsonlan correlation coefficients were computed between all possible

combinations of all Indicator variables, with program type treated as a

dummy variable (0 = ADj 1 = BD). In addition, an observed variable,

gender was dropped from Inclusion In the model since only 8 of the 177

participants were male. A visual Inspection of the respective scatter

plots revealed the existence of linear relationships or non-

relattonshlps between the various pairs of variables; no non-lInear

relationships were Identified.

137

The measurement model of LISREL VI (Joreskog and Sorbom, 1984)

was used to specify the relationships between the unobserved, latent

variables and their respective observed. Indicator variables and

between and among the exogenous and endogenous variables In the model.

The parameters representing the relationships between a latent variable

and Its Indicator variables (lambda) were estimated using maximum

likelihood estimates. The maximum tlkllhood estimates were obtained by

an Iterative procedure which minimizes a definite fitting function by

successively Improving the parameter estimates beginning with the

Initial estimates which the program computes using Instrumental

variables methods and least squares methods. The maximum 11k11 hood

estimates of the lambda values between the latent variables and their

respective Indicators for PMP-Brown are reported In Table VI. Those

for PMP-EIMs are reported In Table VII. Also Included In these

Tables are the standard errors and the t-values for each of the

lambdas.

A review of these Intermediate results for the PMP-Brown model

revealed that all t-values except three (familiarity with nursing

diagnosis terminology with Education Related Clinical Learning

Experiences; perceived difficulty of the simulation with Task

Complexity; and Data Proficiency Score with Assessment Ability) were

above 2.0. A t-value above 2.0 Indicates that a specific observed

variable is a significant predictor of the latent variable (Joreskog

and Sorbom, 1984). The modification Indices provided by the LISREL VI

program revealed the non-existence of any theoretically significant

138

TABLE VI

RELATIONSHIP BETWEEN THE LATENT VARIABLES OF KNOWLEDGE BASE, EDUCATION RELATED CLINICAL LEARNING EXPERIENCES, TASK COMPLEXITY AND ASSESSMENT ABILITY AND THEIR INDICATORS FOR THE MODEL EXPLAINING PERFORMANCE ON

PMP-BROWN

Latent Indicator Lambda Standard t-value variables variables coefficients error

Knowledge NCLEX .671 .070 9.577 Base Nsg. GPA .835 .065 12.844

Cum. GPA .877 .064 13.772

Education # of pts. .406 .089 4.571 Re1ated Emph. prob. .301 .086 3.485 CI In leal solving Learning NCP freq. .166 .092 1.80 Experience NDX faml1. .481 .085 1.960

Task Difficulty - .568 .101 - 5.617 Comp1 ex Ity Prepared .642 .107 5.989

Assessment DXSCORE .928 .159 1.115 AbllIty ProfIclency .276 .086 3.190

Efficiency .091 .081 5.851

139

TABLE VII

RELATIONSHIP BETWEEN THE LATENT VARIABLES OF KNOWLEDGE BASE, EDUCATION RELATED CLINICAL LEARNING EXPERIENCE, COMPLEXITY AND ASSESSMENT ABILITY AND THEIR INDICATORS FOR MODEL EXPLAINING PERFORMANCE ON PMP-ELLIS

Latent variables

Indicator variables

Lambda coefficients

Standard error

t-va1ue

Knowledge NCLEX .671 .070 9.577 Base Nsg. GPA .835 .065 12.844

Cum. GPA .877 .064 13.772

Education # of pts. .594 .116 5.111 Re 1ated Emph. prob. .618 .122 5.047 CI In leal solving LearnIng NCP freq. - .033 .036 - .908 Experience NDX famll. - .152 .042 - 3.620

Task Difficulty - .246 .089 - 2.775 Comp1 exIty Prepared .660 .147 4.536

Assessment DXSCORE .269 .072 3.721 AbllIty Proficiency .749 .046 16.380 (ASSESS) Efficiency .943 a a

a Both values at t.

are 0 due to setting the starting value for this variable

140

relationships between any one observed variable and the remaining

latent variables. Therefore, the originally conceived models

representing the relationship of the Indicator variables to the latent

variables were retained for the next step of the analysis.

The Intermediate results for the PMP-EIIIs model revealed only

one t-value below the 2.0 level (frequency that care plans were written

with Education Related Clinical Learning Experiences). A review of the

modification Indices revealed the non-extstence of any theoretically

significant relationship between any one observed variable and the

remaining latent variables. Therefore, the originally conceived models

representing the relationship of the Indicator variables to the latent

variables were retained for the next step of the analysis.

Using the LISREL VI program, first-order correlation coefficients

were computed between and among all exogenous and endogenous variables

In the models for PMP-Brown and PMP-EIIIs. These are reported In Tables

VIII and IX, respectively. These coefficients were used to determine

the parameters for each hypothesized path In each of the two models.

The following regressions were run, using SPSS-X (SPSS, Inc., 1983)

regression procedure, to obtain the pertinent path coefficients:

1. Type Program Attended was regressed on Prior Academic

Achievement and Age.

2. Nursing Knowledge Base was regressed on Critical Thinking

Ability, Age, Prior Academic Achievement, Prior Education and Type

Program Attended.

TABLE VIM

CORRELATION MATRIX: EXOGENOUS AND ENDOGENOUS VARIABLES IN THE MODEL FOR PMP-BROWN

Knowl- Educ. Complex- Assess- Program Crlt. Prior Prior Age Non-ed. Variables edge Rel. I+y ment Think. Educ. Yrs. Clinical

Base CI. Exp. Skill Ability Achlev. Educ. Exp.

Know ledge Base

Educ. rel. CI. Exp.

Complexity

Assessment Ski 11

Program

Critical Thinking

Prior Ed. Achlev.

Prior yrs. Education

Age

Non-Ed. rel, Cltn. Exp

1.000

-.121 1.000

.087 .240 1.000

.205 .224 -.058 1.000

-.167 -.362 -.158 .380 1.000

.411 -.443 .123 .167 .164 1.000

.335

.182

-.169 -.196

.078

.158

.208

.210 -.164 .211

.009 .139 -.122

.235

.127 -.127

.224 1.000

.085 -.062

.104 -.400 .044 -.103

.106 -.274 .112 .171

1.000

.369 1.000

.312 .386 1.000

TABLE IX

CORRELATION MATRIX: EXOGENOUS AND ENDOGENOUS VARIABLES IN THE MODEL FOR PW-ELLIS

Variables Knowl- Educ, Complex- Assess- Program Crlt. Prior Prior edge Rel. Ity ment Think. Educ. Yrs. Base CI. Exp. Skill Ability Achlev. Educ.

Age Non-ed. CI Inlcol Exp.

Know I edge Base

Educ. rel. CI. Exp.

Complexity

Assessment Ski 11

Program

Critical Thinking

Prior Ed. Achlev.

Prior yrs. Education

Age

Non-Ed. rel. Clin. Exp

1.000

-.217

-.141

'.090

-.187

.411

.335

.182

.210

.009

1.000

.669 1.000

-.154 .015 1.000

-.148 -.117 -.076 1.000

-.286 -.194 -.036 .164 1.000

-.235

-.008

-.200 .026

.055

.235

.092 -.127

.224 1.000

.085 -.062

.060 .017 .014 -.400 .044 -.103

.120 -.089 .076 -.274 .112 .171

1.000

.369 1.000

.312 .386 1.000

143

3. Education Related Clinical Learning Experiences was

regressed on Type Program Attended.

4. Task Complexity was regressed on Education Related Clinical

Learning Experiences and Prior Clinical Experience.

5. Assessment Ability was regressed on Critical Thinking

Ability, Nursing Knowledge Base, Type Program Attended, Education

Related Clinical Learning Experiences, Task Complexity and Age.

All Independent variables within each of the above regression

models, for each PMP, were entered as a block. With forced entry, all

variables that satisfied the tolerance criterion (0.01) were entered

one at a time In order of decreasing tolerance. However, they were

treated as a single block for computing the requested statistics. The

tolerance of a variable Is the proportion of Its variance not accounted

for by other Independent variables In the equation. All Independent

variables met the criterion for Inclusion.

Figures 6 and 7 report the results of the regression equations In

terms of path coefficients and residuals (u) for the models

explaining performance on PMP-Brown and PMP-Ellls, respectively.

Examination of path coefficients for the PMP-Brown model revealed that

all were greater than 0.05, a generally accepted level Indicating the

existence of a meaningful causal relationship (Pedhauser, 1982). The

path coefficient between Type Program Attended and Assessment Ability

(.7397) Indicates that the type of program attended had a large direct

Influence on assessment ability, as measured by performance on PMP-

Brown, The residual associated with the endogenous variable

144

> KNOW {— .1071

PREED

CO cv

THINK

ASSESS AGE

PROGRAM

HSRANK

..8690 ^EDCLIN

.9580 1584 ^ COMPLEX PRECLIN

4

Figure 6. Path analysts results for PHP-Brown

a PREED = Years of post high school education; THINK = critical thinking ability; HSRANK = high school quartlte rank; PRECLIN = years of pre-nursing clinical experience; KNOW = nursing knowledge; EDCLIN = education related clinical learning experiences; COMPLEX = perceived complexity; ASSESS = assessment ability; u - residuals.

145

.1070 KNOW £ PREED

r~'i oi col <V/

THINK

vo CTl cn

-.,0112 ASSESS AGE

PROGRAM

HSRANK

.7234 .1717 >COMPLEXf PRECLIN

Figure 7. Path analysis results for PMP-Ellls

a PREED a Years of post high school education; THINK - critical thinking ability; HSRANK = high school quartlle rank; PRECLIN = years of pre-nurslng clinical experience; KNOW = nursing knowledge; EDCLIN = education related clinical learning experiences; COMPLEX = perceived complexity; ASSESS = assessment ability; u = residuals.

146

Assessment Ability (.6791) Is large. Indicating that variables not In

the model exerted major Influence on the assessment ability of AD and

BD graduates. It should be noted that residuals for other endogenous

variables In the PMP-Brown model also were large and, therefore,

Indicate that these attributes were explained by variables not In the

modeI.

Examination of path coefficients and residuals In the PMP-EII Is

model revealed that the explanatory capacity of program attended on

assessment ablliity was small and also has a negative effect

(-.0689). In addition, the residual (u = .9651) associated with

Assessment ability Is of great magnitude, thus Indicating that

assessment ability Is best explained by variables not In the model.

The amount of Influence exerted by type of program attended on

overall assessment skill for each model was determined. These effects

are expressed In terms of direct effects, Indirect effects and an

effect coefficient, representing the total direct and Indirect effects.

Results for the Influence of program attended on PMP-Brown assessment

performance are reported In Table X and those for PMP-EII Is assessment

performance. In Table XI. 2

A goodness of fit test with a X distribution (Sprecht, 1975)

was used to determine If the models fit the data. The statistical

evidence for rejection of the null hypothesis Indicated that the model

did not fit. However, a conclusion as to acceptability of a model

also must be based on a review of theoretical and experiential

evidence. To test the multi-stage, over I dent I fled model, goodness of

147

TABLE X

DIRECT EFFECT, INFLUENCE OF

INDIRECT EFFECT AND EFFECT COEFFICIENTS REPRESENTING EDUCATIONAL PREPARATION ON PMP-BROWN ASSESSMENT

PERFORMANCE

Effect Path Coefficient

DIrect Effect

Type Program Attended —> Assessment Ability 0.7397

Indirect Type Program Attended —> Nursing Knowledge Effect Base —> Assessment Ability - 0.0775

Indirect Type Program Attended —> Education Related Effect Clinical Learning Experiences —>

Assessment Ability - 0.2748

Indirect Type Program Attended —> Education Related Effect Clinical Learning Experiences —> Task

Complexity —> Assessment Ability 0.0232

Effect Coefficient

0.4106

148

TABLE XI

DIRECT EFFECT, INDIRECT EFFECT AND EFFECT COEFFICIENTS REPRESENTING INFLUENCE OF EDUCATIONAL PREPARATION ON PMP-ELLIS ASSESSMENT

PERFORMANCE

Effect Path Coefficient

DIrect Effect

Indirect Effect

Indirect Effect

Indirect Effect

Effect Coeff tclent

Type Program Attended —> Assessment Ability - 0.0689

Type Program Attended —> Nursing Knowledge Base —> Assessment Ability

Type Program Attended —> Education Related Clinical Learning Experiences —> Assessment AblIIty

Type Program Attended —> Education Related Clinical Learning Experiences —> Task Complexity —> Assessment Ability

- 0.0238

0.0468

-0.0214

- 0.0673

149

fit was determined by application of the following formula (Sprecht,

1975): 2

1 - R m Q =

1 - M

2 2 2 2 where R = 1 — (1 — R )(1-R )...(! —R ) for the fully recursive

1 2 p

model and where for the over Ident IfIed model to be compared with the

2 2 2 fully recursive model, M = 1 - (1 - R H1-R )...(1 - R ).

1 2 p

The measure of goodness of fit, 0, was tested for significance as

follows:

W = -(N-d) log Q e

where N = sample size; d = number of overIdentifying restrictions (the

number of paths hypothesized to be zero); log = natural logarithm. e 2

The level of significance, W, has an approximate X distribution with

the degrees of freedom = d. The goodness of fit and the test of

significance for the models representing performance on PMP-Brown and

PMP-Ellls are reported In Table XII.

These results Indicated that the PMP-Brown model did not fit the

data while that for PMP-Ellls does. Examination of the squared

residual paths Indicated that the greatest discrepancies between

values for the fully recursive PMP-Brown model and those for the

hypothesized over I dent I fled PMP-Brown model were associated with the

endogenous variables of Education Related Clinical Learning Experiences

150

TABLE XII

GOODNESS OF FIT AND LEVEL OF SIGNIFICANCE FOR MODELS REPRESENTING ASSESSMENT PERFORMANCE ON PMP-BROWN AND PMP-ELLIS

Model 2 R m

2 M Q W

PMP: Brown

PMP: El 1 Is

.9199

.8800

.8065

.7492

.4137

.7995

a 60.195

b 15.258

a df=20; p < .05.

b df=20; p > .05.

and Task Complexity. In order to explore these relationships further,

the fit of the model for each endogenous variable was examined

separately using the formulas described previously. Results of these

calculations are reported In Table XIII and XIV for the models

explaining performance on PMP-Brown and PMP-Ellls, respectively.

These results Indicated that, within the overall PMP-Brown model,

the models for the Individual endogenous variables of Education Related

Clinical Learning Experiences, Task Complexity, and Assessment Ability

did not, statistically, fit the data. Within the overall PMP-Ellls

model, the Individual models for all endogenous variables fit the data.

A review of the theoretfcal framework on which the complete models were

based and the hypothesized relationships among the variables In the

151

TABLE XIII

GOODNESS OF FIT AND TESTS OF SIGNIFICANCE FOR EACH ENDOGENOUS VARIABLE WITHIN THE PHP-BROWN MODEL

Variable 0 W df P

Type Program Attended 0.953 3.627 3 > 0.05

Nursing Knowledge Base 0.998 0.160 3 > 0.05

Education Related Clinical Learning Experiences 0.682 28.606 5 < 0.05

Task Complexity 0.737 2.641 6 > 0.05

Assessment Ability 0.865 10.949 3 < 0.05

TABLE XIV

GOODNESS OF FIT AND TESTS OF WITHIN

SIGNIFICANCE THE PMP-ELLIS

FOR EACH MODEL

ENDOGENOUS VARIABLE

Variable 0 W df P

Type Program Attended 0.953 3.627 3 > 0.05

Nursing Knowledge Base 0.998 0.160 3 > 0.05

Education Related Clinical Learning Experiences 0.890 8.701 5 > 0.05

Task Complexity 0.959 3.130 6 > 0.05

Assessment AblIIty 0.979 1.636 3 > 0.05

152

models led to the conclusion that the models for PMP-Brown and PMP-

Ellts were acceptable as originally conceived In spite of the lack of

statistical fit for the PMP-Brown model.

2. Conclusions

Based on the magnitudes of the effect coefficients, the

following conclusions about the theoretical acceptability of the 2

models and the statistical fit of the PMP-Ellis model were drawn. On

PMP-Brown, which simulates the clinic visit of a patient with

hypertenion and complaints of eplstaxls, the type of program attended

by participants had a strong causal effect on assessment ability. This

causal relationship was demonstrated by both the direct effect

coefficient (.74) and the total effect coefficient (.41).

In contrast, on PMP-Ellls, which simulates the admission of a

patient with chronic obstructive pulmonary disease and pneumonia and

complaining of chest pain, the type of program attended by the

participants had a neglIglble causal effect on assessment ability.

This was demonstrated by both the direct effect coefficient (-.07) and

the total effect coefficient (-.07).

Specific differences In the performance of the AD and BD

participants with regard to the data collection and nursing diagnosis

Identification abilities are addressed In the following sections.

B. Data col I artIon efficiency

The second research question to be answered was: When graduating

associate and baccalaureate degree nursing students are compared. Is

there a difference In data collection efficiency? A one way analysis

153

of variance (ANOVA), with schools nested within program, was used to

answer this question and the remaining research questions. The

statistical null hypotheses tested were that: mean = mean . An AD BD

alpha of 0.05 was set as the level of statistical significance for all

tests. Cochran's C was used to test the assumption that the variance

In scores for the two groups was equal. This assumption was met except

where noted otherwise. Table XL I (Appendix F) summarizes the Cochran's

C results for each set of score variances tested.

Data collection efficiency scores of AD and BD participants and

for all participants combined are summarized In Tables XV and XVI for

PMP-Brown and PMP-Ellls, respectively.

For PMP-Brown, ANOVA results (Table XVII) demonstrated no

statistically significant differences in data collection efficiency of

the two groups (F (1,9) = 1.94; p>.05). Therefore, the null hypothesis

was not rejected.

The ANOVA results (Table XVIII) for data collection efficiency

on PMP-Ellls demonstrated no statistically significant differences In

the performance of the two groups (F (1,9) = .77; p>.05). Therefore

the null hypothesis could not be rejected.

These results demonstrate that AD and BD participants selected

the same ratio of essential data to total data selected In both PMP-

Brown and In PMP-Ellls.

C. Data collection proficiency

The third research question to be answered was: When graduating

associate and baccalaureate degree nursing students are compared. Is

154

TABLE XV

DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS' PERFORMANCE ON DATA COLLECTION ACTIVITIES ON

PMP-BROWN

Variable Group

AD (n = 91)

BD (n = 86)

ALL (n = 177)

Eff tctency Mean 61.17 Standard deviation 12.75 Range 0 - 88.2

Proficiency Mean Standard deviation Range

Number Psychosocial Data Selected Mean Standard deviation Range

28.4 11.75 -3.12 - 60.9

3.51 1.85 0 - 7

Percent Psychosocial Data Selected Mean 12.9 Standard deviation 7.3 Range 0 - 33.3

60.91 11.68 0 - 80.4

30.94 11.49 -3.13 - 56.3

3.69 1.74 0 - 8

12.6 5.6 0 - 25.0

61.040 12.20 0 - 88.2

29.71 11.66 -3.13 - 60.9

3.59 1.79 0 - 8

12.7 6.5 0 - 33.3

155

TABLE XVI

DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS' PERFORMANCE ON DATA COLLECTION ACTIVITIES ON

PMP-ELLIS

Variable Group

AD (n = 91)

BD (n = 86)

ALL (n = 177)

Efficiency

Mean 44.79 Standard deviation 23.73 Range 0 - 86.4

Proficiency

Mean Standard deviation Range

25.46 19.59 -5.56 - 63.0

Number Psychosocial Data Selected

Mean 1.48 Standard deviation 1.57 R a n g e 0 - 5

Percent Psychosocial

Dfl±a Selected Mean 5.1 Standard devlatton 5.3 Range 0-25

40.92 24.58 0 - 78.0

23.43 22.02 -13.0 - 74.1

1.39 1.66 0 - 6

4.2 4.4 0 - 14.7

42.91 24.16 0 - 86.4

24.47 20.77 -13.0 - 74.1

1.44 1.61 0 - 6

4.7 4.9 0-25

156

TABLE XVII

ANALYSIS OF VARIANCE OF THE DATA COLLECTION EFFICIENCY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN

Source SS df MS

Within 25420.22 166 153.13 Constant 659450.24 1 659458.24 4306.42 .001 School within 790.73 9 87.86 .57 .82 Type (Error 1)

Error 1 790.73 9 87.86 Type 2.97 1 2.97 .03 .86

TABLE XVIII

ANALYSIS OF VARIANCE OF THE DATA COLLECTION EFFICIENCY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS

Source SS df MS

Within 94347.24 166 418.79 Constant 325863.09 1 325863.09 573.34 .001 School within 7686.08 9 854.01 1.50 .151 Type (Error 1)

Error 1 7686.08 9 854.01 Type 663.22 1 663.22 .77 .401

157

there a difference In data col lection proficiency? Data collection

proficiency scores of AD and BD participants and for all participants

are summarized In Tables XIV and XV for PMP-Brown and PMP-EUIs,

respectively. The ANOVA results for performance on PMP-Brown (Table

XIX) demonstrated no statistically significant differences In

performance of AD and BD participants £F £1,9) = 1.94; p>.05).

Therefore, the null hypothesis could not be rejected.

TABLE XIX

ANALYSIS OF VARIANCE OF THE DATA COLLECTION PROFICIENCY OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN

Source SS df MS F P

Within 22471.76 166 135.37 Constant 156184.00 1 156184.00 1153.74 .001 School within 1183.77 9 131.53 .97 .47 Type fError 1)

Error 1 1183.77 9 131.53 Type 255.54 1 255.54 1.94

o

IN •

The ANOVA results for PMP-Ellls £Table XX) also demonstrated no

statistically significant differences In data collection proficiency

156

TABLE XX

ANALYSIS OF VARIANCE OF THE DATA COLLECTION PROFICIENCY SCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS

Source SS df MS F P

Within 69518.33 166 418.79 Constant 105998.45 1 105998.45 253.11 .001 School within 6224.87 9 691.65 1.65 .105 Type (Error 1)

Error 1 6224.87 9 691.65 Type 182.17 1 182.17 .26 .620

F (1,9) = .26; p>.05). Therefore, the null hypothesis could not be

rejected.

These results demonstrate that AD and BD participants were

equally proficient In their selection of patient data on both PMP-

Brown and on PMP-EIIIs.

D. Amount of psychosocial patient data selected

The fourth research question to be answered was: When graduating

associate and baccalaureate degree nursing students are compared, Is

there a difference In the amount of psychosocial history data selected?

Tables XV and XVI summarize the amounts of psychosocial data collected

by AD and BD participants and by all participants. The ANOVA results

for PMP-Brown (Table XXI) demonstrated no statistically significant

159

differences In the amount of psychosocial history data selected by the

AD and BD participants (F (1,9) = .48; p>.05). Therefore, the null

hypothesis could not be rejected.

TABLE XXI

ANALYSIS OF VARIANCE OF THE AMOUNT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON

PMP-BROWN

Source SS df MS F P

Within 538, .49 166 3, .24 Constant 2285, .29 1 2285, .29 704.49 .001 School within 26. .79 9 2, ,98 .92 .51 Type (Error 1)

Error 1 26, ,79 9 2, ,91 Type 1. ,44 1 1. ,44 .48 .50

Cochran's C demonstrated that total score variances of the

two groups on PMP-Brown were not homogeneous. However, since the

largest group (AD) had the smallest variance In scores and the p value

for the F was greater than ,05, Jack of homogeneity would result In an

even greater p value. Therefore, It Is unnecessary to be concerned

about decreasing the probability of a Type 1 error since the null

hypothesis has not been rejected (Glass and Hopkins, 1984).

160

The ANOVA results for PMP-Etlts (Table XXII) also demonstrated no

statistically significant differences In amount of psychosocial

history data selected by the two groups of participants (F (1,9) = .15;

p>.05). Therefore the null hypothesis could not be rejected.

TABLE XXII

ANALYSIS OF VARIANCE OF THE AMOUNT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON

PMP-ELLIS

Source SS df MS F P

Within 434.72 166 2.62 Constant 367.37 1 367.37 140.28 .001 School within 20.56 9 2.28 .87 .55 Type (Error 1)

Error 1 20.56 9 2.28 Type .34 1 .34 .15 .71

These findings demonstrate that AD and BD participants did not

differ In amount of psychosocial data selected In the history sections

of either PMP: Brown or PMP: Ellis.

E. Percent of psychosocial patient data selected

The fifth research question to be answered was: When graduating

associate and baccalaureate degree nursing students are compared. Is

161

there a difference In the percent of psychosocial history data

selected? Tables XV and XVI summarize percentage of psychosocial

history data selected by AD and BD participants and by all

participants, for PMP- Brown and PMP-Ellls, respectively. On PMP-

Brown, ANOVA results (Table XXIII) demonstrated no statistically

significant differences In percentage of total history data selected

that was psychosocial In focus (F (1,9) = .13; p>.05). Therefore, the

null hypothesis could not be rejected.

TABLE XXIII

ANALYSIS OF VARIANCE OF THE PERCENT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON

PMP-BROWN

Source SS df MS F P

Within .72 166 .004 Constant 2.87 1 2.87 659.91 .001 School within .02 9 .003 .60 .78 Type (Error 1)

Error 1 .02 9 .003 Type .00 1 .00 .13 .73

On PMP-EII Is, ANOVA results (Table XXIV) also demonstrated no

statistically significant differences In the performance of the two

162

groups CF (1,9) = 1.85; p>.05). Therefore, the null hypothesis could

not be rejected.

TABLE XXIV

ANALYSIS OF VARIANCE OF THE PERCENT OF PSYCHOSOCIAL HISTORY DATA SELECTED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON

PMP-ELLIS

Source SS df MS F

Within .406 166 .002 Constant .387 1 .387 158.20 .001 School within .017 9 .002 .75 .66 Type (Error 1)

Error 1 .017 9 .002 Type .003 1 .003 1.85 .21

Cochran's C demonstrated that total score variance of the two

groups on PMP-Ellls was not homogeneous. The probability of a Type 1

error may be lower than that which was observed because the larger

group of participants (AD) had the greatest variance In scores (Glass

and Hopkins, 1984).

These findings demonstrate that AD and BD participants selected

an equal percentage of psychosocial history data as was measured by

PMP-Brown and by PMP-Ellls.

163

F. Nursing diagnosis Identification

The sixth research question to be answered was: When graduating

associate and baccalaureate degree nursing students are compared. Is

there a difference In the number of plausible nursing diagnoses

Identified? This question was answered based on results of two

different scores: number of plausible nursing diagnoses Identified and

NDXSCORE - a composite score reflecting the type of each diagnostic

statement Identified (a symptom, medical diagnosis or a nursing

diagnosis) and completeness of the Identified nursing diagnosis

statements. Performances of AD and BD participants In the diagnostic

tasks are summarized In Tables XXV and XXVI for PMP-Brown and PMP-

ElI Is, respectively.

Statistically significant differences In number of plausible

nursing diagnosis statements Identified on PMP-Brown were not

demonstrated by ANOVA results (Table XXVII) (F (1,9) = 4.27j p>.05).

Cochran's C demonstrated that total score variance of the two

groups on PMP-Brown was not homogeneous. Probability of a Type 1

error may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

In contrast, ANOVA results (Table XXVIII) did demonstrate a

significant difference In NDXSCOREs (F (1,9) - 5.16); p<.05). The BD

participants Identified a greater number of plausible nursing diagnoses

that were stated more completely than those Identified by AD

participants on PMP-Brown.

164

TABLE XXV

DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS' PERFORMANCE ON NURSING DIAGNOSIS

IDENTIFICATION ACTIVITIES ON PMP-BROWN

Variable Group

AD (n = 91)

BD (n = 86)

ALL (n = 177)

Number oi Plausible Nursing Diagnoses I dent IfIed

Mean 3.35 Standard deviation 2.88 R a n g e 0 - 1 0

5.76 3.91

0 - 2 2

4.52 3.61

0 - 2 2

NDXSCORE

Mean 5.40 Standard deviation 4.73 Range 0-16

10.02 7.38 0 - 4 1

7.64 6.57 0 - 4 1

Amount q± Plausfale Psychosocial Nursing Diagnoses Identified

Mean Standard Range

devIatIon 2.01 2.17 0 - 9

3.44 2.40

0 - 1 0

2.71 2.39

0 - 1 0

Percent Plausible Psychosocial Nursing D1agnoses I dent 1f1ed

Mean Standard Range

deviation 28.3 29.3 0 - 100

36.9 25.0 0 - 100

32.5 27.6 0 - 100

165

TABLE XXV!

DESCRIPTIVE STATISTICS OF ASSOCIATE DEGREE (AD) AND BACCALAUREATE DEGREE (BD) PARTICIPANTS* PERFORMANCE ON NURSING DIAGNOSIS

IDENTIFICATION ACTIVITIES ON PMP-ELLIS

Variable Group

AD BD ALL (n = 91) (n - 86) (n = 177)

Numher Q± Plausible Nursing Diagnoses Identified

Mean 4.99 7.57 6.24 Standard deviation 4.94 4.97 5.11 Range 0-17 0-19 0-19

NDXSCQRE

Mean 7.48 12.12 9.69 Standard deviation 7.85 9.01 8.71 Range 0-32 0-37 0-37

Amount Plausible Psychosocla I Nurs1ng

D. lag noses Identified

Mean 1.30 2.03 1.65 Standard deviation 1.66 1.80 1.77 Range 0-6 0-7 0-7

Percent Plausible Psychosocial Nursing Diagnoses Identified

Mean 13.2 19.3 16.0 Standard deviation 15.5 16.2 16.0 Range 0 - 50.0 0 - 66.7 0 - 66.7

166.

TABLE XXVII

ANALYSIS OF VARIANCE OF THE NUMBER OF PLAUSIBLE NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS

ON PMP-BROWN

Source SS df MS

Within Constant School within Type (Error 1)

1503.56 3615.82 539.06

166 1 9

9.06 3615.82 59.90

399.20 6.61

.001

.001

Error 1 Type

539.06 255.56

9 1

59.90 255.56 4.27 .07

TABLE XXVIII

ANALYSIS OF VARIANCE OF THE NDXSCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-BROWN

Source SS df MS

Within 4996.37 166 30.05 Constant 10342.42 1 10342.42 343.62 .001 School within 1651.34 9 183.48 6.10 .001 Type (Error 1)

Error 1 1651.34 9 183.48 Type 946.87 1 946.87 5.16 .05

167

Cochran's C demonstrated that total score variance of the two

groups on PMP: Brown was not homogeneous. The probability of a Type 1

error may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

On PMP-EII Is, the ANOVA results did not demonstrate any

statistically significant difference In the number of plausible nursing

diagnoses Identified (Table XXIX) (F (1,9) = 1.91j p>.05).

TABLE XXIX

ANALYSIS OF VARIANCE OF THE NUMBER OF PLAUSIBLE NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS

ON PMP-ELLIS

Source SS df MS F P

Within 2907.76 166 17.52 Constant 6898.45 1 6898.45 311.63 .001 School within 1386.31 9 154.03 7.49 .001 Type (Error 1)

Error 1 1386.31 9 154.03 Type 294.48 1 294.48 1.91 .20

Cochran's C demonstrated that total score variance of the two

groups on PMP-Ellfs was not homogeneous. The probability of a Type 1

168

error may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

The ANOVA results (Table XXX) for the differences In the

NDXSCOREs on PMP-EII Is also demonstrated the presence of no

statistically significant difference In the performances of the two

groups (F (1,9) = 2.28; p>.05). Therefore, the null hypothesis, with

regard to performance on PMP-EII Is, could not be rejected.

TABLE XXX

ANALYSIS OF VARIANCE OF THE NDXSCORES OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE PARTICIPANTS ON PMP-ELLIS

Source SS df MS F P

Within 8851.65 166 53.32 Constant 16617.09 1 16617.89 311.63 .001 School within 3597.02 9 399.67 7.49 .001 Type (Error 1)

Error 1 3597.02 9 399.67 Type 911.23 1 911.23 2.28 .165

Cochranfs C demonstrated that total score variance of the two

groups on PMP-EII Is was not homogeneous. The probability of a Type 1

169

error may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopktnsf

1984).

Comparisons of the diagnostic ablliitles of the AD and BD

participants yielded contradictory findings. Both groups Identified

simtlar numbers of plausible nursing dtagnosls statements on both PMP-

Brown and on PMP-EII Is. However, on PMP-Brown, the BD participants

achieved a higher NDXSCORE than did the AD participants. This

Indicated that the BD participants Identified a significantly higher

number of more complete nursing diagnosis statements than the AD

participants. Therefore, for PMP-Brown, there was evidence supporting

rejection of the null hypothesis that there Is no difference In the

number and completeness of nursing diagnosis statements Identified by

the two groups. In contradiction to this finding, no statistically

significant difference was demonstrated between the performance of the

AD and BD participants on PMP-Ellls. Therefore, for performance on this

PMP, the null hypothesis could not be rejected.

G. Amount of plausible psychosocial nursing diagnoses Identified

The seventh research question to be answered was: When

graduating associate and baccalaureate degree nursing students are

compared. Is there a difference In the amount of psychosocial nursing

diagnoses Identified? Tables XXV and XXVI summarize the amount of

psychosocial nursing diagnoses Identified by AD and BD participants and

by all participants. On PMP-Brown, ANOVA results (Table XXXI)

demonstrated no statistically significant differences In amount of

170

plausible psychosocial nursing diagnoses Identified by AD and BD

participants (F=2.28; df=1,9; p>.05). Therefore, the null hypothesis

could not be rejected.

TABLE XXXI

ANALYSIS OF VARIANCE OF THE AMOUNT OF PLAUSIBLE PSYCHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSXIATE DEGREE AND BACCALAUREATE DEGREE

PARTICIPANTS ON PMP-BROWN

Source SS df MS F P

Within 629.22 166 3.79 Constant 1296.28 1 1296.28 341.98 .001 School within 282.98 - 9, 31.44 8.29 .001 Type (Error 1)

Error 1 282.98 9 31.44 Type 90.53 1 90.53 2.88 .124

Cochran's C demonstrated that tota1 score variance of the two

groups on PMP-Brown was not homogeneous. Probability of a Type 1

error may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

On PMP-ElI Is, ANOVA results (Table XXXII) demonstrated no

statistically significant differences In amount of plauslblle

171

TABLE XXXII

ANALYSIS OF VARIANCE OF THE AMOUNT OF PLAUSIBLE PSYCHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE

PARTICIPANTS ON PMP-ELLIS

Source SS df MS F P

Within Constant School within Type (Error 1)

435.13 485.02 90.75

166 1 9

2.62 485.02 10.08

185.03 .001

Error 1 Type

90.85 24.09

9 1

10.08 24.097 2.39 .157

psychosocial nursing diagnoses Identified by the two groups (F=1.75;

df=l,9; p>.05). Therefore, the null hypothesis could not be rejected.

Cochran's C demonstrated that total score variance of the two

groups on PMP-EII Is was not homogeneous. Probability of a Type 1 error

may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

These results demonstrate that AD and BD participants Identified

simitar numbers of plausible psychosocial nursing diagnoses on both

PMP-Brown and on PMP-EII Is.

H. Percent of plausible psychosoctal nursing diagnoses Identified

The eighth research question to be answered was: When graduating

172

associate and baccalaureate degree nursing students are compared. Is

there any difference In the percent of psychosocial nursing diagnoses

Identified? Tables XXV and XXVI summarize the percentage of plausible

psychosocial nursing diagnoses Identified by AD and BD participants and

by all participants. On PMP-Brown, the ANOVA results (Table XXXIII)

demonstrate no statistically significant difference In percentage of

plausible psychosocial nursing diagnoses Identfled by the AD and BD

participants. Therefore, the null hypothesis could not be rejected.

TABLE XXXII I

ANALYSIS OF VARIANCE OF THE PERCENT OF PLAUSIBLE PSYCHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE

PARTICIPANTS ON PMP-BROWN

Source SS df MS F P

Within 7.46 166 .045 Constant 18.67 1 18.67 415.45 .001 School within 5.57 9 .62 13.77 .001 Type (Error 1)

Error 1 5.57 9 .62 Type .33 1 .33 .53 .48

173

Cochran's C demonstrated that total score variance of the two

groups on PMP-Brown was not homogeneous. Prrbablllty of a Type 1 error

may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

On PMP-Ellls, ANOVA results (Table XXXIV) demonstrated no

statistically significant differences In percentage of psychosocial

nursing diagnoses Identified by the two groups. Therefore, the null

hypothesis could not be rejected.

TABLE XXXIV

ANALYSIS OF VARIANCE OF THE PERCENT OF PLAUSIBLE PSYCHOSOCIAL NURSING DIAGNOSES IDENTIFIED BY ASSOCIATE DEGREE AND BACCALAUREATE DEGREE

PARTICIPANTS ON PMP-ELLIS

Source SS df MS F P

Within 3.54 166 .02 Constant 4.61 1 4.61 216.03 .001 School within .86 9 .09 4.45 .001 Type (Error t)

Error 1 .86 9 .09 Type .17 1 .17 1.75 .218

174

Cochran's C demonstrated that total score variance of the two

groups on PMP-EII Is was not homogeneous. Probability of a Type 1

error may be greater than what was observed because the larger group of

participants (AD) had the least variance In scores (Glass and Hopkins,

1984).

These results demonstrated that AD and BD participants Identified

similar percentages of plausible psychosocial nursing diagnoses on PMP-

Brown as we 11 as on PMP-EII Is.

I. Additional data analyses

The data were examined further and submitted to additional

analyses to determine 1) differences In participant performance on the

2 PMPs; 2) differences In the proportions of AD and BD participants

selecting Individual patient data Items; 3) frequencies of diagnostic

statement identification on each PMP; 4) differences In the proportions

of AD and BD participants citing Job or family stress as an etiology

for anxiety; and 5) differences In the types of learning experiences

engaged In by AD and BD patlclpants. The following subsections contain

the results of these analyses.

1. Differential performance on PMPs

A visual Inspection of the 8 Individual data collection and

nursing diagnosis Identification scores for PMP-Brown and PMP-EII Is

(Tables XV, XVI, XXV, and XXVI) revealed that In all but 1 Instance

(Number of psychosocial nursing diagnoses Identified) the differences

between the PMP-Brown and PMP-EII Is scores appeared to be disparate. To

175

explore this further, the data were submitted to a series of repeated

measures, one-way ANOVAs.

The within subjects results of these ANOVAs are reported In Table

XXXV. Statistically significant differences were observed across all 8

scores. The scores for data collection efficiency and proficiency,

amount and percent of psychosocial data selected, and amount and

percent of psychosocial nursing diagnoses Identified were higher on

PMP-Brown than on PMP-Ellls. Scores for number of plausible nursing

diagnoses Identified and NDXSCORE were higher on PMP-EIHs than on PMP-

Brown. These results Indicate that the participants performed

differently on the two PMPs.

2. Proportion of AD and BP participants selecting Individual

data Items

The efficiency and proficiency scores only provide an

Indication of the quantities of essential, contributory, and non­

essential data that were selected by participants. To determine If

AD and BD participants differed In their selection of Individual data

Items, the proportions of AO and BD participants selecting each Item 2

was subjected to X analysis.

Statistically significant differences were demonstrted for 9 of

the 140 Items In PMP-Brown and for 4 of the 147 Items In PMP-Ellls. 2

The proportions of participants selecting these Items and the X

statistics are reported In Tables XXXVI. Of the 9 Items In PMP-Brown,

1 Item Is from the history section (family history of similar symptoms;

2 from the physical examination section (observation and palpation of

176

TABLE XXXV

SUMMARY OF REPEATED MEASURES ANALYSES OF VARIANCE RESULTS FOR WITHIN SUBJECTS DIFFERENCES IN PERFORMANCE ON PMP-BROWN AND PMP-ELLIS FOR DATA

COLLECTION AND NURSING DIAGNOSIS IDENTIFICATION TASKS

Source SS df MS

EffIclency SCSFB Within celts 49423.26 166 297.73 PMP 29095.03 1 29095.03 97.73 <.001

ProfIclency Score Within cells 36529.20 166 220.05 PMP 2423.97 1 2423.97 11.02 .001

Amount Psychosocial Data Selected Within cells 396.39 166 PMP 410.06 1

2.39 410.06 171.73 <.001

Percent Psychosocrai Data Selected Within cells .59 166 PMP .57 1

.004

.57 161.39 <.001

Number Plausible Nursing Diagnoses .l.dmt.liJsd Within cells 1181.44 166 7.12 PMP 262.78 1 262.78 36.92 <.001

NDXSCORE Within eel Is PMP

3812.82 370.18

166 1

22.97 370.18 16.12 <.001

Number PsychesocI a I Nursing Diagnoses Identified Within cells 321.89 166 1.94 PMP 97.73 1 97.73 50.40 <.001

Percent Plausible Nursing Diagnoses Identified Within cells 3.52 166 .02 PMP 2.36 1 2.36 111.55 <.001

177

TABLE XXXVI

SUMMARY OF DATA ITEMS WHERE STATISTICALLY SIGNIFICANT DIFFERENCES IN PERCENT OF AD AND BD PARTICIPANTS SELECTING ITEMS WERE DEMONSTRATED,

BY PMP

Item Percent of participants selecting

2 a X

AD BD

PMP-Brown Similar symptoms In family 63.7 80.2 5.15

Observation of precordtum 9.9 23.3 4.83

Palpation of precordfum 6.6 20.9 6.58

Hematocrit 54.9 70.9 4.17

Mean corpuscular volume 4.2 23.3 11.86

Mean corpscular hemoglobin 7.7 24.4 8.08

Mean corpuscular hemo­globin concentration

4.2 15.1 4.68

Platelet count 39.6 53.3 6.12

Red blood ceil count 42.9 59.3 4.14

PMP-E11 Is Loss of consciousness 19.8 37.2 5.79

Thrombophlebitis 12.1 25.6 4.45

Observation/palpation of precordlum

14.3 32.6 7.30

Percussion of heart 16.5 33.7 6.14

a (df = 1; p < .05).

178

the precordlum); and 6 from the laboratory section (hematocrit, mean

corpuscular volume, mean corpuscular hemoglobin, mean corpuscular

hemoglobin concentration, platelet count, and red blood cell count).

In all Instances, a greater proportion of BD than AD participants

selected these Items. With the exception of the history Item, all data

had been classified previously, by a panel of experts, as essential

data.

Of the 4 Items In PMP-EII Is, 2 Items were In the history section

(loss of consciousness and thrombophlebitis) and 2 were In the physical

examination section (observation and palpation of the precordlum and

percussion of the heart). However, only one of these (observation and

palpation of the precordlum) was classified as essential data.

Overall, these results Indicate there was very little dlffernce In the

proportions of AD and BD participants selecting each Item on either

PMP-Brown or on PMP-EII Is.

3. Frfiquftnry of diagnostic statement 1denttflcatTon

The participants Identified a total of 23 different nursing

diagnoses on PMP-Brown and 26 different nursing diagnoses on PMP-EII Is.

Frequency distributions of the 10 most frequently Identified nursing

diagnoses on PMP-Brown and PMP-EII Is, by all participants and by AD and

BD participants, are reported In Tables XXXVII and XXXVIII,

respectively. On PMP-Brown, the most frequently Identified nursing

diagnosis was Anxiety (n = 339). The most frequently Identified

nursing diagnosis with a physiological focus was Alteration In

Circulation (n = 98). On PMP-EII Is, the most frequently Identified

179

TABLE XXXVI I

FREQUENCY DISTRIBUTION OF NURSING DIAGNOSIS STATEMENTS IDENTIFIED MOST FREQUENTLY ON PMP-BROWN

Diagnosis Group

AD BD All

Anx1ety 145 194 339

Alteration In Circulation 68 30 98

Alteration In Cardiac Output: Decreased

29 51 80

Alteration In Individual Cop Ing

11 51 62

Fluid Volume Deficit 6 43 49

Knowledge Deficit 17 30 47

Alteration In Tissue Perfusion

9 29 38

Alteration In Comfort 2 35 37

Alteration In Nutrition: More than required

5 11 16

180

TABLE XXXVIII

FREQUENCY DISTRIBUTION OF NURSING DIAGNOSIS STATEMENTS IDENTIFIED MOST FREQUENTLY ON PMP-ELLIS

Diagnosis Group

A D B D A l l

Alteration In Comfort 109 144 253

Anxiety 97 145 242

Alteration In Breathing 177 47 224 Patterns

Alteration In Respiratory 34 84 118 Status

Alteration In Gas Exchange 33 78 111

Alteration In Cardiac 21 55 76 Output: Decreased

Alteration In Circulation 26 10 36

Alteration In Tissue 5 32 37 Perfusion

Alteration In Airway 20 5 25 Clearance

Alteration In Self Concept 10 0 10

181

nursing diagnosis was Alteration In Comfort (n = 252). The most

frequently Identified nursing diagnosis with a psychosocial focus was

Anxiety (n = 242).

A total of 112 different non-nursing diagnosis statements were

Identified on PMP-Brown and 124 on PMP-EIIIs. The most frequently

Identified non-nursing diagnosis on PMP-Brown was Hypertension or

descriptors Indicating this problem (I.e., elevated blood pressure,

etc) (n=185). Statements Indicating this problem were Identified a

total of 126 times by 22 AD participants (24?) and 59 times by 11

BD participants (13j0. Chi square analysis demonstrated no

statistically significant difference In the proportions of AD and BD

participants Identifying these statements.

On PMP-EIIIs, the most frequently Identified non-nursing

diagnosis statement was pneumonia or descriptors Indicating this

problem (I.e., resptratoy Infection, etc.) (n = 97). These statements

were Identified 76 times by 23 AD participants {25%) and 21 times by 3

BD participants (35?). Chi square analysis demonstrated a statistically

significant difference In the proportions of AD and BD participants 2

who Identified diagnostic statements representing pneumonia (X (1) =

16.63; p < .05).

4. Type referent Identified for the nursing diagnosis—Q±

Anxiety

On PMP-Brown, the nursing diagnosis, Anxiety was Identified

145 times by 45 AD participants <4956) and 194 times by 59 BD

participants (69JC). Chi square analysis demonstrated a statistically

182

significant difference in the proportions of AD and BD participants 2

Identifying this nursing diagnosis (X (1) = 7.39; p < .05). Further 2

analyses with X demonstrated that a greater proportion of the

diagnostic statements Identified by BD participants (26$) had a

referent indicting that anxiety was related to stress In the home or at 2

work than those Identified by AD participants (15j6) (X (1) = 3.99; p <

.05).

5. Differences in learning experiences

Differences In classroom and clinical learning experiences

of the AD and BD participants were examined. Two questions on the

Backgrond Inventory (Bl) requested participants to Indicate the number

of contact hours spent In various types of learning experiences where

the nursing care of patients similar to those represented by PMP-Brown

and PMP-Ellls were discussed. The types of learning experiences listed

on the Bl were: lecture, lecture-discussion, discussion, seminar, and

conference.

An examination of the descriptive statistics and the frequency

distributions demonstrated the unreliability of the data that were

collected. In 8 of the 11 programs, participants' time estimates

varied greatly (I.e., estimates ranged between 1 and 20 hours of

lecture within a single program). Therefore, additional analyses were

not undertaken.

Nine additional questions on the Bl requested participants to

Indicate the number of patients they had cared for with medical

diagnoses similar to the simulated patients, the level of difficulty

183

experienced completing each simulation, how well they felt their

educational program prepared them to deal with the simulated situations,

their familiarity with nursing diagnosis terminology, the frequency

that nursing care plans were Initiated or updated, and the degree of

emphasis on problem solving within their curriculum. The descriptive

statistics and the ANOVA results are reported In Table XXXIX. No

differences were found when the experiences of the AD and BD

participants were compared.

An examination of program catalogs and other available printed

materials from each program did not provide any additional Information

regarding the types and amounts of time spent In learning activities

related to the content of the 2 PMPs.

J. Summary

Influence of type of nursing educational preparation on the

assessment abilities of graduating AD and BD students was examined

using a path analytic procedure. Direct and indirect effects of type

program attended on assessment ability, on the hypothesized causal

model for PMP: Brown performance. Indicated a strong direct effect

(.74) and a moderate overall effect (.41). Although the fit of this

model was not supported statistically. It was accepted on theoretical

grounds.

In contrast, direct and Indirect effects of type program attended

on assessment ability, on the hypothesized causal model for PMP: Ellis

performance, indicated a negative and negligible Influence. Direct and

184

TABLE XXXIX

DESCRIPTIVE STATISTICS AND RESULTS OF ANALYSES OF VARIANCE COMPARING THE CLINICAL LEARNING EXPERIENCES OF ASSOCIATE DEGREE (AD) AND

BACCALAUREATE DEGREE (BD) PARTICIPANTS, BY VARIABLE

a Variable Group F

AD BD

Preparation ,f.or PMPrBrown Mean Standard deviation Range

Preparation ion PMP-EII Is Mean Standard deviation Range

Difficulty q± PMP-Brown Mean Standard deviation Range

Difficulty q± PMP-EII Is Mean Standard deviation Range

Number £f patients with hypertension Mean Standard deviation Range

Number M patients with COED

Mean Standard deviation Range

1.96 .63

0 - 3

2.04 .58

0 - 3

1.79 .80

1 - 4

1.97 .72

1 - 4

7.76 6.10 0 - 2 8

3.67 2.56 0 -10

1.78 .76

0 - 3

1.97 .54

1 - 3

1.88 .85

1 - 42

2.06 .77

1 - 4

6.15 5.27 0 - 3 0

2.76 3.23 0 - 2 0

2.039

.398

.390

.774

1.033

1.198

t85

TABLE XXXIX (continued)

DESCRIPTIVE STATISTICS AND RESULTS OF ANALYSES OF VARIANCE COMPARING THE CLINICAL LEARNING EXPERIENCES OF ASSOCIATE DEGREE (AD) AND

BACCALAUREATE DEGREE (BD) PARTICIPANTS, BY VARIABLE

Variable Group

AD BD

Famt I larity y.fth nursing diagnosis terminology Mean 3.11 3.36 1.787 Standard deviation .75 .59 Range 1-4 2-4

Frequency slid nursing care plans Mean 1.49 1.93 4.364 Standard deviation .58 .65 Range 0-4 0-4

Emphasis £& problem solving Mean 2.30 2.40 .005 Standard deviation .73 .67 Range 0-3 1-3

a F (1,9) .05 = 5.12.

186

effect coefflcents were both -.06. Fit of this model was supported on

statistical grounds In addition to theoretical grounds.

Differences In data collection and nursing diagnosis

Identification activities of AD and BD participants were examined using

a series of one-way, nested ANOVAs. The purpose of these analyses was

to determine If there were any differences between the two groups with

regard to data collection efficiency, data collection proficiency,

number and percent of psychosocial history data selected, number and

completeness of plausible nursing diagnosis statements Identified, and

number and percent of plausible psychosocial nursing diagnoses

Identified. Performance on each PMP was analyzed separately.

The only statistically significant (p<.05) difference

demonstrated was in the NDXSCORE for PHP: Brown. The BD participants

identified a significantly greater number of more complete nursing

diagnosis statements than did AD participants.

Additional analyses demonstrated that the 1) proportion of AD and

BD participants selecting individual data Items differed significantly

in only 9 Items on PMP-Brown and In 4 Items on PMP-Ellls; and 2) a

significantly greater proportion of BD participants Identified

stressors at home or at work as the etiology for Anxiety In PMP-Brown.

In addition, the most frequently Identified nursing diagnosis

statements on PMP-Brown were Anxiety and Alteration In Circulation;

those on PMP-Ellls were Alteration In Comfort and Anxiety. Repeated

measures ANOVAs demonstrated that participants performed differently on

187

PMP-Brown than on PMP-Ellls. Due to unreliable data, differences In

learning experiences of the two groups could not be Identified.

The following chapter Includes a discussion of the conclusions

that can be drawn from these findings, their Implications, and

recommendatIons for further study.

V. DISCUSSION

The purpose of this study was to examine the Influence of type of

educational preparation on data collection and nursing diagnosis

Identification abilities of generic nursing students within 3 months of

graduating from associate degree (AD) and baccalaureate degree (BD)

nursing programs. To achieve this goal, the performance of AD and BD

students on two simulated clinical situations was examined. The

primary research question addressed by this study was: Are the patient

assessment abilities of AD and BD nursing students, when measured

within 3 months prior to graduation from a program of study accredited

by the National League for Nursing, Influenced by type of educational

program? The seven, secondary questions addressed were: When

graduating AD and BD nursing students are compared. Is there a

difference In 1) data collection efficiency, 2) data collection

proficiency, 3) number of psychosocial data Items selected, 4) percent

of psychosocial data Items selected, 5) number and completeness of

plausible nursing diagnoses Identified, 6) number of psychosocial

nursing diagnoses Identified, and 7) percent of psychosocial nursing

diagnoses Identified.

A. Conclusions

The findings did not provide conclusive evidence that the type of

educational program attended influenced assessment ability.

Performance on one clinical simulation (PMP-Ellis) demonstrated that

type of program attended had a small and negative effect on assessment

188

189

ability and resulted In demonstration of no differences In performance

on data collection and diagnostic tasks. However, on a second

simulation (PMP-Brown), type of program attended had a strong, positive

Influence on overall assessment abllty. In addition, statistically

significant difference was demonstrated for one measure of diagnostic

ability. The BD participants Identified a greater number of more

complete nursing diagnosis statements than did AD participants. This

finding provided partial support for claiming a difference In the

diagnostic abilities of the two groups. This claim was further

supported by findings on PMP-Ellls; although not statistically

significant, the scores of the AD and BD participants were In the same

direction as those on PMP-Brown.

It also was demonstrated that the participants performed

differently on the two clinical simulations. They were less efficient

and proficient In data collection, but Identified a greater number of

plausible nursing diagnosis statement on PMP-Ellls than on PMP-Brown.

The purpose of this chapter Is to discuss the findings and their

Implications for nursing education and practice. Recommendations

for further study will also be discussed.

1. Assessment ability

Assessment ability was defined as a composite of three

variables: data collection efficiency score, data collection

proficiency score, and the NDXSCORE - an Indicator of the number and

completeness of plausible nursing diagnoses Identified. The

conceptual framework for the study stated that assessment ability was

190

Influenced by the level of educational preparation In nursing, age,

gender, theoretical knowledge base, critical thinking ability, post-

high school education, task complexity and task setting. The

conceptualized relationships among these factors was diagramed In

Figure 1. Due to the small number of men participating, the Influence

of gender was not considered during data analysis. Task setting was

controlled through use of 2 different clinical simulations.

Path analyses of models representing factors Influencing

assessment performance on PMP-Brown and PMP-ElI Is demonstrated

contradictory outcomes. On PMP-Brown, the magnitude of direct effect

(.74) and total effect (.41) coefficients Indicated that, when other

factors In the conceptual model were controlled, type of program

attended had a very strong, positive causal Influence on assessment

ability. The positive direction of these coefficients Indicated that

participants from BD programs performed at a higher level on the

outcome variable than did those from AD programs.

In contrast to these findings, the magnitude of direct effect (-

.06) and total effect (-.06) coefficients for the PMP-Ellls model

Indicated that type of program attended had a small, negative Influence

on assessment ability. The negative direction of these coefficients

Indicated that participants from AD programs performed at a higher

level on the outcome variable than did those from BD programs.

A factor contributing to differences In influence of program

attended on measures of assessment ability may be attributed to

learning histories of the participants. The goals, scope and depth of

191

format educational content and the clinical learning experiences of AD

and BD programs differ In many respects. Johnson (1966) noted that

content In AO programs focused on knowledge required to Identify and

take appropriate action In common, concrete and specific problems

experienced by patients. In BD programs, the focus was on theoretical

explanations for responses to Illness or factors leading to Illness.

In addition, principles, concepts and theories of basic sciences are

examined with relation to their ability to explain or predict patient

responses or modes of Intervention.

Information regarding the learning experience activities In

classroom and clinical settings was obtained. However, that related to

types and amounts of classroom activities was unreliable and could not

be used. Examination of reported clinical learning experiences (Table

XXXIX) revealed no statistically significant differences between the

two groups for: number of patients cared for with medical diagnoses

similar to those simulated; perceived difficulty of the simulated

experiences; level of perceived educational preparation for dealing

with the simulated patients* problems; frequency nursing care plans

were developed; familiarity with nursing diagnosis terminology; or

emphasis on problem solving behavior within the program of study.

It Is possible that the problems represented by the two

simulations may have some bearing on the differential performance of

the two groups when considered In relation to the focus of course

content In AD and BD programs. The opening scene for PMP-Brown

provides very little Information about the patient's problems. All

192

that Is known Is that a middle-aged black male comes to the clinic with

a history of eplstaxts and displaying minor symptoms of anxiety. There

Is no Information provided as to the possible cause of his problem.

Only through data collection Is It revealed that he has an elevated

blood pressure and Is under stress due to changes In Job and home

responslblIitles.

As demonstrated by the various data collection scores and the

number of plausible nursing diagnoses Identified (Tables, XV, XVII,

XIX, XXI, XXIII, XXV, XXVII, XXXI, AND XXXIII), AD and BD participants

collected similar amounts and types of data and Identified similar

numbers and types of nursing diagnosis statements. However, the

NDXSCOREs were significantly different (Table XXVIII). Further

examination of the referents for the nursing diagnosis, Anxiety (the

most frequently Identified nursing diagnosis) revealed that a greater

proportion of BD than AD participants were able to Identify that the

anxiety was related to occupational and domestic stressors.

When these findings are considered In relation to the academic

backgrounds of the two groups. It Is the BD program that contains a

greater concentration of course work In the behavioral sciences and an

emphasis on using this Information to determine the specific bases for

the recognition of problems (Johnson, 1966; National League for

Nursing, 1982).

In contrast, PMP-EIIIs represents a patient experiencing an acute

physiological problem (pneumonia supertmposed on chronic bronchitis)

manifested by complaints of chest pain and difficulty breathing. The

193

situation occurs In an acute medical-surgical unit. Examination of all

data collection and nursing diagnosis scores (Tables XVI, XVIII, XX

XXII, XXIV, XXVI, XXVII, XXVIII, XXX AND XXXII) demonstrated no

differences In the performance of the 2 groups. The similarity In

performance can be attributed to the type of patient situation

encountered and the focus of the learning activities In the 2 types of

educational programs.

The nature and severity of the patient's complaints. In addition

to the wife's plea to help her husband because "he Is having a heart

attack" Indicates the existence of a situation that needs to be dealt

with Immediately. The situation also represents the possible ex Istance

of 2 commonly occurring problems (acute respiratory and cardiac

diseases) (Luckman and Sorensen, 1980). The combination of 1) an

emergency situation, 2) a basic phystologcal problem, 3) a commonly

occurIng problem, and 4) the structured setting In which the situation

takes place may be responsible for the similarity In performance of the

AD and BD graduates. The objectives and content of BD programs are

directed towards preparing the graduate to perform In a variety of

settings, while those for AD programs are directed towards preparing an

Individual who Is capable of functioning In a care giver role within a

structured, hospital setting (DeChow, 1967} Kramer, 1981} SchlotfeJdt,

1967). Although no documentation could be found, It Is also highly

possible that both types of programs would Include similar content

regarding basic data to be collected and the nursing problems

experienced when a patient manifests respiratory and/or cardiac

194

distress. Whether this Is responsible for the lack of significant

differences In the data collection and nursing diagnosis scores, or for

the AD students demonstration of a slightly greater assessment ability

Is open to speculation.

2. Diagnostic ablIIty

One component of patient assessment Is the ability to

Identify nursing diagnoses. The statistically significant, higher

NDXSCORE of BD participants on PMP-Brown Indicated they were able

to Identify more complete diagnostic statements than AD participants.

Since there was no statlstlcaly significant difference In the number of

nursing diagnoses Identified, this finding reflects the ability to

determine plaslble referents (or etiologies) for the Identified nursing

diagnosis stems. Although not statistically significant, the findings

on PMP-EII Is were In the same direction.

The lack of differences In the numbers of nursing diagnoses

Identified, on both PMPs, can be related to the learning experiences

provided In both types of programs. Both groups of participants

reported similar levels of "familiarity" with nursing diagnosis

terminology.

Another factor contributing to Identification of similar numbers

of nursing diagnoses Is the frequency with which "Anxiety" was

Identified on both PMPs (Tables XXXVII and XXXVI11). The use of

"Anxiety" as both a medical diagnosis and a nursing diagnosis may be

responsible for the Inability to demonstrate any statistically

significant differences In either the number of plausible nursing

195

diagnoses Identified or In the number and percent of psychosocial

nursing diagnoses Identified. On PMP-Brown, Anxiety was the most

frequently Identified nursing diagnoses by all participants (n = 339)

and by AO (n = 145) and BD (n = 194) participants. This Is In

comparison to the second most frequently Identified nursing diagnosis,

Alteration In Circulation (all = 98; AO = 68; BD = 30). Similarly, on

PMP-EIils, Anxiety was Identified 242 times by all participants (AD =

97; BD = 145). The frequency with which this diagnosis was Identified

was exceeded only by Alteration In Comfort (All = 253; AD = 109; BD =

253).

The diagnostic statements were Identified on each PMP following

the selection of patient Information from the history, physical and/or

laboratory data sections. Data collection abilities of the AD and BD

participants will be addressed In the next section.

3. Data col lection ability

Performance on data collection activities will be discussed

In terms of differences In the efficiency and proficiency of the

partlcpants and differences In the proportions of participants

selecting Individual data Items. influence of a cueing effect on the

magnitude of all efficiency and proficiency scores also will be

Included.

Data collection efficiency and proficiency scores reflect the

amounts of essential, contributory, and non-essenttat data selected and

the order In which the history, physical and laboratory data were

selected. The findings demonstrated that the two groups used similar

196

ratios of essential data to total data selected (efficiency) and

similar ratios of essential and non-essential data to the total amount

of essential data available (proficiency).

Both groups were much more efficient than proficient.

Approximately 61$ of all PMP-Brown data and 43J6 of all PMP-EII Is data

that they selected previously had been determined, by a panel of

experts, as essential for the Identification of the patients' problems.

Proficiency scores of 30$ and 24$, for PMP-Brown, and PMP-EIIIs,

respectively, Indicated that participants selected relatively few

essential and even fewer non-essential Items In comparison to the

total number of essential Items available, or they selected a

relatively large number of non-essential Items In relation to the

number of essential Items selected and total number of essential Items

available. In view of the magnitude of the efficiency score for PMP-

Brown, the low proficiency score Is probably a reflection of selection

of relatively little data, overall In relation to the total amount of

essential data available. For PMP-EIIIs, the low proficiency score Is

problably related to the low efficiency score (I.e., < 50$) which Is a

reflection of the selection of a large ratio of non-essential data to

essential data. In addition. If relatively little data was collected,

this would also lower the proficiency score.

Lack of a difference In data collection efficiency and

proficiency scores Indicates that the two groups collected similar

ratios of essential data to total data selected and were not very

proficient In their data collection. They collected Inordinate amounts

197

of non-esentlal data (as demonstrated on PMP-Ellls); additionally, they

did not Identify what data were essential to collect.

Efficiency and proficiency scores only Indicate the quantities of

different types of data that were selected. An examination of

proportions of AD and BD participants selecting each data Item, on each

PMP, revealed the presence of some differences (Table XXXVI). On PMP-

Brown, a greater proportion of BD participants selected 8 essential

Items and 1 contributory Item. On PMP-Ellls, a greater proportion of

BD participants selected 1 essential Item and 3 contributory Items.

Six of the 8 essential Items selected by the BD partlcpants on PMP-

Brown reflected the status of the patients hematopoetlc status. That a

greater proportion of the BD participants Identified the need to

examine these Indicators, In light of the patient complaints of

frequent nosebleeds, probably Is Indicative of differences In content

of AD and BD programs.

One factor that may be obscuring actual data collection and

proficiency abilities of both groups of participants Is the cueing

effect provided by lists of available data. Neuble et al. (1982),

Martin (McGuIre, 1980b) and McCarthy (1966) reported that cueing

effects of such lists result In artificial Inflation of patient history

and physical examination scores. When performance on cued and non-cued

tests was compared, substantial Increases were seen on the cued test In

both the total number of Items selected and In the numer of correct

Items selcted (McCarthy, 1966). Therefore, the performances of the AD

198

and BD par+Icpants on PMP-Brown and on PMP-Ellls may be artificially

Inflated.

4. Differential performance on the two simulations

An additional finding of this study was a demonstration of

a differential performance on the two PMPs. Statistically significant

differences were demonstrated between all data collection and nursing

diagnosis Identification scores on PMP-Brown and those of PMP-Ellls

(Table XXXV). Elsteln et al. (1978) concluded that case specificity

may be responsible for differences In performances across patients.

Case specificity refers to those factors that differentiate one type

of patient diagnostic and management problem from others (I.e.,

validity and reliability of patient data, types of data available, and

areas of expertise of the problem solver (physician)). In addition,

Bashook (1976) noted that data collection and diagnostic performance In

an emergency situation should be different from performance In a non­

emergency situation due to time constraints tmposed on the decision

maker. Therefore, the differences In the task environment (I.e., a non­

emergency clinic setting vs. a potential emergency setting) and content

of the two PMPs were probably responsible for the observed differences

In performance.

The Implications of these findings for nursing education and

nursing practice are discussed In the next section.

B. Imp IIcatIons

The need to distinguish between the nursing practice of AD and BD

graduates Is of primary concern to nurse educators, nursing service

199

administrators, the nursing profession as a whole, state licensing

boards and legislatures, and the public served by the profession. If

differences can be demonstrated In the assessment abilities of

graduates from AD and BD educational programs, these differences can

serve as the basis for further clarification of the roles and

responsibilities of the technical and professional nurse. If

differences can not be demonstrated, the educational practices within

the two types of programs need to be re-examined and defined In terms

of expected outcomes.

Although path analyses of the models constructed to explain the

Influence of type educational program attended on overall assessment

abilities provided conflicting results, the demonstration of

statistically significant differences In the diagnostic ability of AD

and BD participants (on one PMP) does contribute to the differentiation

of the abilities of AD and BD graduates. Although no difference was

demonstrated In diagnostic ability on the second PMP, scores were In

the same direction; this finding adds support to a claim that BD

graduates Identify more complete nursing diagnosis statements than do

AD graduates.

If additional research findings can substantiate that BD

graduates are able to Identify more complete diagnostic statements

(I.e., Include a plausible etiological statement), this should have an

Impact on nursing practice. Such an etiological statement helps to

focus plans for Implementing nursing care that meets the specific needs

of Individual patients. Therefore, If the greater ability of BD

200

graduates to Identify complete, patient specific, nursing diagnoses can

be confirmed, this should result In nursing care that Is more specific

to the Individual needs of patients than that based on less complete

nursing diagnosis statements.

The use of non-nursing diagnosis statements by BD participants

does not comply with the Standards for Practice (ANA, 1973) or with the

Nurse Practice Acts In many polItlcal Jurisdictions (I.e., Illinois).

This finding has Implications for educators and administrators. If

nursing care Is to be based on the Identification of problems that

nurses are legally responsible and accountable to treat, terminology

used to describe these problems must reflect those problems and not

medical diagnoses. Students and graduates need to be Introduced to the

diagnostic task, and use of nursing diagnoses needs to be strongly

encouraged. In addition, all practicing nurses need to be Involved In

the ongoing processes of refining the diagnostic labels and validating

the defining characteristics that are essential for Identification of a

specific nursing diagnosis.

Although both groups of participants were equally proficient In

their data collection, the low magnitude of their scores Is cause for

concern. Mean proficiency scores ranged between 23.43 and 30.94.

Since the proficiency score was calculated as a ratio of essential data

Items minus the non-essential Items selected to the total number of

essential Items available, these low values Indicate that even though

the participants selected some essential data, they also were selecting

201

inordinate amounts of non-essential data, very few essential data In

relation to what were available, or both.

Given the unreliable and probabilistic nature of patient data

(Hammond, 1966; Koran, 1975a; 1975b; McNeil, 1975); collection of non-

esenttal data can contribute to diagnostic errors. Given the small

capacity of the short term memory (Miller, 1956), the collection of

non-essential data can lead to cognitive strain which In turn also can

contribute to diagnostic errors.

These findings have Implications for nurse educators, nursing

service administrators, and Inservlce educators. Efforts need to be

Initiated and/or continued to assist students and graduates In the

Identification of what data are essential to collect In a given

situation. Cognitive strain, also could be decreased by the use of

external memory aids such as decision trees. Such aids would reduce

the amount of information that needs to be retained and processed In

short term memory.

C. Recommendations

On the basis of this study, the following recommendations are

made for replication of the study and for additional study. The

recommendations pertaining to a replication of the study include

methodological Issues of sample selection. Instrumentation, and data

analysis.

Because participants in this study were a convenience sample

obtained from within randomly selected AD and BD programs, a selection

bias may have operated. Therefore, the findings can be generalized

202

only to comparable graduating students from AD and BD programs In the

three state region. It Is recommended that a random sample of

Individuals be used In future studies and that geographic boundaries be

enlarged.

The use of patient management problems that Incorporate a

branching type format should be continued In studies whose major

purpose Is to determine problem solving abilities. This format

provides a means whereby the study participant fs able to select an

approach to patient management while still providing the Investigator

with a means for controlling the study environment. In addition, as

reported In the literature review. It Is generally concluded that the

content validity of well constructed PMPs Is supported (Page and

Fielding, 1980.) The content, construct and criterion validity of the

PMPs used In this study were supported (Farrand et al., 1979; Holzemer

et al., 1981) as was the reliability (Farrand, personal communication,

1983).

In this study, performance on the clinical simulations was

analyzed using quantitative methods. Although this provided an

Indication of the performance abllftes of the two groups, additional

study also needs to be focused on the type of data collected by AD and

BD graduates. Data analysis In this study focused on the amounts of

essential, contributory, and non-essential data that were selected.

Although there were no statistically significant differences

demonstrated In the amounts of the data selected, this tells us nothing

about what data were specifically collected, what area(s) the data

203

collector focused on, or what data was used to support the Judgments

that specific nursing diagnoses were In fact present. Such measures

would provide greater Insight Into the data collection and nursing

diagnosis Identification abillltes of AD and BD graduates.

This study focused on only the assessment phase of the nursing

process. It Is recommended that future simulation studies be expanded

to Include goal setting. Identification of nursing Interventions and

evaluation of patient outcomes. Such an expansion would provide

Insight Into the abilities of AD and BD participants to apply these

processes. Because simulated clinical situations contain elements of

artificiality, consideration also needs to be given toward development

of reliable and valid methods of assessing performance in actual

clinical situations.

In this study, It Is possible that the long lists of available

data about each patient had a cueing effect on the participants and

resulted In score Inflation. As computerized technology becomes more

available It would appear that the next appropriate step would be to

move away from a latent Image format to a fully Interactive and

computerized simulation. If this type of format were used for testing,

the study participant would have to be provided with only the Initial

patient Information and would then be asked what type of Information

about the patient was desired. The participant then would have to

generate the categories of Information desired. In addition, the

computer could be programed to record each participant's progress thus

204

elImfna+lng the need for Inputlng this Information from hard-copy

formats.

The method of obtaining Information about participants' learning

histories and academic characteristics needs to be Improved. It was

found that self reports about previous experiences with situations

similar to those simulated were not a reliable source of estimated time

spent In related learning activities. It Is recommended that faculty

sources be used to obtain this type of data.

Depending upon the time available for testing, consideration

also should be given to administration of an Instrument designed to

test knowledge specific to the simulated situations. The cumulative

and nursing grade point averages and NCLEX - RN scores are general

Indicators of academic performance, and, with respect to GPAs, can not

be compared across Institutions.

The findings of this study also suggest several areas where

additional Investigation Is needed. The simulations used examined

performance only In relation to 2 different situations. Additional

study should be directed towards examining the performance of AD and BD

graduates on several different types of patient situations and In

several different settings. These replications would provide

additional Information relative to a differentiation of assessment

abilities of the two types of graduates.

Finally, this study examined performance only at one point In

time. The development and Implementation of longitudinal studies would

be beneficial In providing Information about whether performance

205

changes over time, what factors Influence any changes that occur, and

what direction do performance changes take.

C. Summary

The purpose of this study was to examine the direct and Indirect

Influences of type of educational program attended on data collection

and nursing diagnosis Identification abilities of generic nursing

students within three months of graduation from associate degree and

baccalaureate degree nursing programs.

The primary research question quldlng this study was: Are the

patient assessment abilities of associate and baccalaureate degree

nursing students Influenced by the type of educational program

attended. Additional research questions addressed were differences

between the associate and baccalaureate degree students with regard to

data collection efficiency, data collection proficiency, amount and

percentage of psychosocial data collected, number of plausible nursing

diagnoses Identified, and amount and percentage of psychosocial nursing

diagnoses Identified.

A non-equivalent groups, post-test only design was used. A

convenience sample of 91 associate degree and 86 baccalaureate degree

students was obtained from five randomly selected associate degree

programs and six randomly selected baccalareate degree programs within

a three state area In the mid-west. Participants completed the Watson-

Glaser Critical Thinking Appraisal (Form A), two latent Image,

branching type clinical simulations, and a background Inventory.

Analyses of variance, chl square and path analysis techniques were used

206

to analyze the data. Performance on each simulation was analyzed

separately.

Analysis of performance on one simulation demonstrated

differences In the diagnostic abilities of the two groups (F (1,9) e

5.16; p<.05). No differences were found In data collection efficiency

or proficiency, In amounts or percent of psychosocial data collected,

or In amounts or percent of psychosocial nursing diagnoses Identified.

Path analyses revealed differential effects of the type of program

attended on the assessment abilities of the participants. On one

simulation, the effect coefficient was .411 while on the other It was

-.067.

On one simulation, baccalaureate degree participants Identified a

greater number of more complete nursing diagnosis statements than their * t

associate degree counterparts. Performance of all participants

differed across the two simulated patient encounters, demonstrating the

Influence of case specificity. Although not conclusive, findings

provide partial support for the claim that type of educational program

attended Influences diagnostic ablllttes of the participants. This has

Implications for differentiation of clinical practice of the two type

of graduates.

APPENDICES

208

Appendix A

TABLE XL

CHARACTERISTICS OF INSTITUTIONS FROM WHICH THE STRATIFIED RANDOM SAMPLE OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE NURSING PROGRAMS WERE

SELECTED

Type State Financial Total program support enroltment

(10/15/82)

Assoc t ate degree

1111no Is Pub Ic 214 111Inots Pub Ic 179 1111noIs Pub Ic 225 1111 riots Pub Ic 264 111Inots Pub Ic 221 1111noIs Pub Ic 201 111Inots Pub Ic 167 1111noIs Pub Ic 229 1111no Is Pub ic 157 111tnols Pub Ic 542 111Inots Pub ic 223 Indiana Pub ic 174 Indiana Pub Ic 198 Indiana Pub ic 265 Indiana Pub Ic 254 W1 scons In Pub Ic 169 WIscons In Pub Ic 172 Wisconsin Pub Ic 197 Wisconsin Pub Ic 120

Baccalureate degree

Illinois Private 180 Illinois Public 155 Illinois PrIvate 196 Illinois Private 602 Illinois Private 91 Illinois PrIvate 107 Illinois Private 253 Illinois Private 461

209

Appendix A (continued)

TABLE XXXIX (continued)

CHARACTERISTICS OF INSTITUTIONS FROM WHICH THE STRATIFIED RANDOM SAMPLE OF ASSOCIATE DEGREE AND BACCALAUREATE DEGREE NURSING PROGRAMS WERE

SELECTED

Type State Financial Total program support enrolIment

(10/15/82)

Baccalaureate Degree (cont.)

111 Inols Pub 1 Ic 385 111Inols PrIvate 120 111Inols Private 119 111Inols PrIvate 216 111Inols PublIc 415 Indiana PrIvate 183 Indiana PrIvate 338 Indiana PublIc 134 WIscons In Public 1295 Wisconsin PrIvate 549 Wisconsin Pr1vate 199 Wisconsin PublIc 823 W1scons 1n Private 288

210

Append Fx B

LETTER TO DEANS AND DIRECTORS

Dear :

I seek your cooperation and that of your faculty to permit/encourage your senior students to participate In a study on clinical decision making. Student participation entails completion of two clinical sfmualatlons and related Instruments, a task that requires two hours of their time. It Is an educational experience since students will receive a copy of the optimal solutions to the simulations and an opportunity to receive feedback on personal performance In relation to group norms.

The use of decision making strategies within a nursing process framework Is an Important part of nursing today and Is receiving Increased emphasis as a means through which nursing can further establish Itself as an Independent profession. As part of my doctoral work In the College of Nursing at the University of Illinois at Chicago, I am conducting this Investigation of decision making strategies utilized by generic nursing students who are within three months of graduating from an NLN accredited nursing program. The findings from this Investigation will be useful to nurse educators and nursing service administrators who need Information to plan better utilization of new graduates.

To obtain a representative sample of Individuals entering the nursing profession, I have selected a stratified random sample of nursing programs from Illinois, Indiana, and Wisconsin and your program was Included In the sample. If you consent to participate, you will be asked to supply: a description of the parent Institution, the philosophy and conceptual framework of the nursing program and Its outcome objectives, a sample curriculum plan, the clock hour to credit hour ratio for classroom courses, and the average number of clock hours spent per week In clinical practice experiences for each term of the nursing program. I will need two hours with senior students either as a group or as a few groups at times, dates, and places of your choice during April through June, 1984. The experience Is such that It could be used as a clinical post-conference.

All Information Identifying students and nursing programs will be coded and kept confidential. If you desire, I shall supply your program with data summarizing the performance of your students.

In order to determine your Interest In helping with this study, I shall contact your office next week In order to make an appointment to speak with you.

Sincerely,

Carolyn J. Yocom R.N., M.S.N.

211

Appendix C

LETTER TO GRADUATING STUDENTS

Dear Graduating Student:

My name Is Carolyn Yocom and I am a doctoral candidate In the College of Nursing at the University of Illinois at Chicago. In conjunction with my dissertation, I am exploring the Influence of various educational factors and Individual characteristics on the clinical decision making abilities of new graduates. The results of this study should be useful to nurse educators In evaluating their curricula and to nursing service personnel In develop!Ing Inservlce programs.

As you approach graduation from your nursing program, I seek your participation In this study. Participation would Involve the completion of several questionnaires. Included are: (a) simulations of two different patient care situations In which you will be asked to select from IIsts of options, what approaches you would use to manage the patients' problems; (b) a questionnaire that assesses your critical thinking ability; and (c) a questionnaire that requests demographic and background Information. The amount of time required to complete these Is, approximately, two hours. A convenient time, between now and graduation, will be arranged for administration of these questionnaires.

All Information regarding Individual student participation and nursing programs will remain confidential and will be reported only In summary form without Identifying you or your Institution. Your participation or non-partIclpatlon will not affect your status within your own program since faculty will not have access to your responses.

I encourage you to participate In this research study. It provides you with a means of assessing your clinical decision making ability. The simulations permit you to work Independently through two different patient problems that occur In different clinical situations. They allow a means of assessing what you would do In a similar clinical situation without any risk associated with the outcomes, especially If you should take a less than beneficial approach to managing the patients' problems. Upon completion of the questionnaires, I will provide you with a summary of the optimal solutions to the patient management problems. In addition, following their scoring, I will provide you with your score and, for comparison, the group norms.

212

Appendix C (continued)

Your participation will make the results of this study more representative of all graduating nursing students and will permit broader conclusions and recommendations to be made. Participation would also fulfill a professional responsibility regarding your making a contribution to the Improvement of educational programs In schools of nursing and In the agencies and Institutions hiring new graduates.

If you are Interested In participating In this study, would you please sign your name on the sign-up sheet that Is available and indicate what day of the week and the times that you would have a two hour block of time available for me to administer the questionnaires. After I have looked at the responses, arrangements will be made for testing at one or two times that are convenient for the majority of those Indicating a desire to participate.

Thank you,

Carolyn J. Yocom R. N., M.S.N.

213

Appendix D

BACKGROUND INVENTORY

Directions!

The following Information about you Is requested to aid In summarizing and Interpreting your responses on the previous Instruments. Please provide as complete and accurate responses as possible. Study findings will be published only In summary form and no attempt will be made to Identify Individuals or specific schools.

Please respond by placing a check mark ( ) to the left of the appropriate response or by providing the requested Information.

A. Personal background:

1. Age:

2. Sex: (1) Female (2) Male

3. Current marital status:

(1) single (3) married (2) divorced (4) spouse deceased

4. Number of chtldren:

B. Educational Background

5. Check your approximate rank In your high school graduating class:

low / / / / / high BOTTOM 1/4 MID POINT TOP 1/4

6. What Is your current cumulative grade point average: .

7. What Is your current nursing grade point average: .

8. What scale Is your GPA calculated on:

(1) on a 4 point scale with nAM = 4 (2) on a 5 point scale with "A" = 5 (3) other (Specify)

214

Appendix D (continued)

9. Did you pursue any education beyond high school, but prior to entering your present educational program:

(0) No. Skip to question 12.

(1) Yes. If yes, number of years:

10. If answer above Is yes, what type of post high school Institution did you attend prior to your present program (excluding any pre-nurslng program): (check all that apply)

.(1) vocational or trade (5) military

.(2) hospital nursing program (6) business

.(3) Junior col lege (7) other (Specify).

.(4) senior college or university

11. If answer to question 9 was yes, what degree or certificate did you earn, If any: (check all that apply)

(0) none (4) BS or BA (1) LPN (5) MS or MA (2) RN (diploma) (6) Doctorate (3) AD, AAS, AA (7) Other (Specify)

12. What are your future educational plans:

(0) none (5) MS In other field (1) unsure (6) Doctorate in nursing (2) BS In nursing (7) Doctorate in other (3) BS In other field field (4) MS In nursing (8) Other (Specify)

13-15. Check highest level of educational attainment of:

13. Father I J J J J J J J J UJJJ tJJJJ UJJJ

14. Mother UJJJJJJJ UJJJ UJJJ UJJJ

15. Spouse UJJJJJJJ UJJJ UJJJ UJJJ

(years) 12345678 1234 1234 1234 elem. school h. sch. col. adv. ed.

215

Appendix D (continued)

C. Employment background and plans;

16. Years of health-care related work experience prior ±e present nursing education:

(If none, mark here: and skip to question 18)

17. This work was as a: (check all that apply)

(1) practical nurse (6) ward secretary (2) registered nurse (5) other (Specify) (3) nurses' aide

18. Years of non-education related health-care work experience during period of education: .

(If none, mark here and skip to question 20)

19* This work was as a: (check all that apply)

(1) practical nurse (6) ward secretary (2) registered nurse (5) other (Specify) (3) nurses' aide

20. After graduation do you plan (or hope) to be employed In a:

(1) hospital (5) nursing school (2) nursing home (6) physician's office (3) public/private (7) Industry

health agency (8) other (Specify) (4) public or private

school system

21. Five years from now, do you expect to be employed:

(1) full time In nursing (2) part time In nursing (3) outside of nursing (4) undecided (5) not at a 11

216

22.

Appendix D (continued)

Five years from now, what do you expect your position to be:

„(1) staff nurse .(2) head nurse or asst. .(3) supervisor or asst. .(4) adminIstrtor or asst. _(5) clinical nurse specialist

.(6) nurse faculty _(7) researcher .(8) Independent practice .(9) back In school .(10) other (specify)

23-25. Please check the occupational grouping that Is most characteristic of your: Father Mother Spouse

(1) Professional/technical (2) proprleter/manager (3) clerical/sales (4) skilled worker (5) semi-skilled worker (6) farmer/farm manager (7) service (8) unskilled worker (9) other (specify)

D. ExperIence w.I.th nursing process .and testing situations

26, Were you taught the nursing process In your present nursing program:

(0) No. Skip to Question 28. (1) Yes

27. If yes, were you Initially taught the nursing process during: first year of nursing studies second year of nursing studies third year of nursing studies fourth year of nursing studies

28. How familiar are you with nursing diagnosis terminology:

(1) not at all familiar (3) familiar (2) somewhat familiar (4) very familiar

29. During your educational clinical experiences did you usually write/update nursing care plans every:

(0) not at all (3) month (1) day (4) quarter/semester (2) week

217

Appendix D (continued)

30. Within your nursing program how much emphasis was placed on the [earning of problem solving/decision making strategies:

(0) none (1) little (2) some (3) much

31-40. In your nursing program, approximately how many hours were devoted to the nursing care of patients with hypertension and COPD (Chronic Obstructive Pulmonary Disease) In each of the following:

Hypertension CQPD hrs. hrs. lecture hrs. hrs. Iecture-d1scuss1on hrs. hrs. discussion hrs hrs. seminar hrs. hrs. conferences

41-42. During your nursing program, approximately how many patients have you cared for with:

Hypertension: COPD:

43-44. How difficult did you find the simulated clinical experience:

HypertenIon CQED (1) not difficult (2) somewhat difficult (3) difficult (4) very difficult

•45. Which simulation was the most complex:

(0) no difference In complexity (1) Mr. Ellis with chest pain and difficulty breathing (2) Mr. Brown with eplstaxts

46. How well did your educational program prepare you for dealing with health problems such as those manifestd by Mr. Ellis (chest pain):

(0) not at a 11 (1) minimally (2) fairly welI (3) very welI

218

Appendix D (continued)

47. How well did your educational program prepare you for dealing with health problems such as those manlfestd by Mr. Brown (eplstaxls)

(0) not at all (1) minimally (2) fairly welI (3) very welI

48. Which simulation did' you complete first:

(1) Mr. Ellis with chest pain and difficulty breathing (2) Mr. Brown with eplstaxls

E. Reasons icc enter Ino nursing/nursing program

49. Why did you choose nursing as a career: (Indicate all that apply)

(1) family Influence (2) to help people (3) Job security (4) financial security (5) past health related work (6) Influence of high school counselor (7) association with nurses (8) personal or family Illness (9) unable to find Job In another field (10) other (specify)

50. Why did you enter the nursing program you selected; (check all that apply)

(1) financial reasons (2) family Influence (3) proximity to home (4) academic requirements (5) quality of program (6) Influence of high school counselor (7) role model provided by graduates of program (8) to prepare for a specific Job In nursing (9) other (specify)

51. Do you expect to graduate at the completion of this term:

(0) No (1) Yes

219

Appendix D (continued)

Is there any other Information that would help me In Interpreting your responses on any of the Instruments?

Thank you for your participation In this study

220

Appendix E

CONSENT FORM

CLINICAL DECISION MAKING INVESTIGATION

The use of decision making strategies within a nursing process framework Is an Important part of nursing today and Is receiving emphasis as a means through which nursing can further establish Itself as an Independent profession.

The purpose of this study Is to explore the Influence of various educational factors and Individual characteristics on the clinical decision making abilities of graduating students enrolled In entry level educational programs. The results of this study should be of benefit to nurse educators as they review their curricula and to nursing service personnel as they plan and review orientation programs for new graduates.

Participation Involves the completion of two clinical simulations, a questionnaire that assesses critical thinking ability, and a questionnaire that requests demographic and background Information about you. The amount of time necessary to complete these Instruments ts approximately two hours.

Participation also entails your granting me permission to have access to your score on the professional nursing licensure examination to be administered In July, 1984.

All Information regarding Individual student participation and their nursing programs will remain confidential and will be reported only In summary form without Identifying you or your school. Your participation or non-partIclaptIon will not affect your status within your own program since faculty will not have access to your responses.

Your participation will make the results of this study more representative of all graduating nursing students and will permit broader conclusions and recommendations to be made. Participation would also fulfill a professional responsibility regarding your making a contribution to the improvement of educational programs In schools of nursing and In the agencies and Institutions hiring new graduates.

If you are willing to participate In this study, please complete the following section and then place the consent form In the man I la envelope. If you do not wish to participate, replace all materials In the man!la envelope and return them to the test administrator.

221

Appendix E (continued)

I AGREE TO PARTICIPATE IN THIS RESEARCH STUDY ON CLINICAL

DECISION MAKING. I UNDERSTAND THAT MY PARTICIPATION IS VOLUNTARY AND

THAT I MAY WITHDRAW AT ANY TIME. MY DECISION TO PARTICIPATE OR NOT

WILL HAVE NO BEARING ON MY STATUS IN THIS EDUCATIONAL PROGRAM. FOR THE

PURPOSE OF THIS STUDY, I GRANT PERMISSION TO CAROLYN YOCOM TO OBTAIN

THE RESULTS OF MY PERFORMANCE ON THE PROFESSIONAL NURSING LICENSURE

EXAMINATION (NCLEX-RN) TO BE ADMINISTERED IN JULY, 1984.

Name (print) Soc. Sec. §

Name (signature)

State where plan to take licensing exam:

Permanent mailing address (complete only If you want your clinical

simulation and critical thinking appraisal scores reported to you):

Number & Street

City, State, Zip

222

Appendix F

TABLE XL I

RESULTS OF COCHRAN'S C TEST FOR HOMOGENEITY OF VARIANCE

Patient Management Problem

VarIabIe PMP-Brown PMP-EIlls a C C

Efficiency Score .1515 .1419

Proficiency Score .1412 .1485 b

Number Psychosocial Data .2150 .1681 Selected

b Percent Psychosocial Data .1671 .2308 SeIected

b b Number Nursing Diagnoses .2777 .2138 Identified

b b NDXSCORE .2860 .2131

b b Number Psychosocial Nursing .2093 .2504 Diagnoses Identified

b b Percent Psychosocial Nursing .3274 .4944 Diagnoses Identified

a C = Cochran's C; df = 15,11,

b p < .05.

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VIII. VITA

NAME:

BIRTH DATE:

BIRTH PLACE:

EDUCATION:

1964

1970

1975

1985

PROFESSIONAL EXPERIENCE:

1964 - 1966

1966 - 1967

1967 - 1973

Carolyn Jean Yocom

Diploma In Nursing Ablngton Memorial Hospital School of Nursing Ablngton, Pennsylvania

B.S., Nursing University of Pennsylvania Philadelphia, Pennsylvania

M.S., Nursing Frances Payne Bolton School of Nursing Case Westrn Reserve University Cleveland, Ohio

Ph.D., Nursing Sciences University of Illinois at Chicago Health Sciences Center Chicago, MIT no I s

Staff Nurse Ablngton Memorial Hospital Ablngton, Pennsylvania

Inservice Education Instructor Ablngton Memorial Hospital Abngton, Pennsylvania

Instructor Ablngton Memorial Hospital School of Nursing Ablngton, Pennsylvania

240

241

VITA (continued)

1973 - 1974

1974 - 1975

1975 1977 1982

1977 1982 1985

1984 - 1985

PROFESSIONAL MEMBERSHIPS:

AWARDS AND HONORS:

Staff Nurse University Hospitals of Cleveland Cleveland, Ohio

Research Assistant Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio

Instructor Assistant Professor Research Assistant Col lege of NursIng University of Illinois at Chicago Health Sciences Center Chicago, Illinois

Assistant Professorial Lecturer Department of Nursing St. Xavler College Chicago, Illinois

American Association for the Advancement of Science

American Nurses Association Midwest Nursing Research Society National League for Nursing Sigma Theta Tau, Alpha Lambda Chapter Society for Research In Nursing Education

Professional Nurse Tralneeshlp Department of Health, Education, and Welfare Public Health Service, 1969 - 1970

Professional Nurse Tralneeshlp Department of Health, Education, and Welfare Public Health Service, 1974 - 1975

Sigma Theta Tau Frances Payne Bolton School of Nursing Case Western Reserve University, 1975

Graduate College Fellowship University of Illinois at Chicago, 1982 - 1983

242

VITA (continued)

Professional Nurse Traineeshlp Department of Health, Education, and Welfare Public Health Service, 1983 - 1984

Research Support Award Alpha Lambda Chapter Sigma Theta Tau, 1985

Student Recognition Award - Honorable Mention Alpha Lambda Chapter Sigma Theta Tau, 1985

Kim, M. J., Amoroso, R., Gulantck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical use of nursing diagnoses (preliminary results). Regional Conference on Nursing Diagnoses, Milwaukee, Wisconsin, November 2, 1979.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical Identification and usefulness of nursing diagnoses for cardiovascular patients. Chicago Heart Association, Chicago, Illinois, March 4, 1980.

Kim, M. J., Amoroso, R., Gulanick, M., Moyer, Ku, Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Agreement between clinical specialists and staff nurses on nursing diagnoses Identification. Fourth Midwest Nursing Research Conference, Kansas City, Kansas, April 14 - 15, 1980.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical testing of nursing diagnoses In cardiovascular nursing practice. Veterans Administration District § 17 Nursing Research Conference, North Chicago, Illinois, November 19, 1980.

243

VITA (continued)

Kim, M. J., Amoroso, R., Guianick, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical validation of nursing diagnoses In acute cardiovascular nursing. American Nurses Association Council of Nurse Researchers. Minneapolis, Minnesota, September 23, 1983.

Scherubel, J. C. and Yocom, C. J.: Academic performance as predictors of success on nursing licensure examinations. Graduate Student Exchange, Midwest Nursing Research Conference, Iowa City, Iowa, April 10 - 12, 1983.

Scherubel, J. C., Ellison, D. and Yocom, C. J.: Predictive validity of a tool used to evaluate baccalaureate nuring program applicants. Third Annual Scientific Meettng of the Society for Research In Nursing Education, San Francisco, California, January 9-11, 1985.

Yocom, C. J.: Nursing staff involvement In clinical research. Sixth Annual Research Conference. V. A. Medical District #17 Nursing Services and University of Illinois Nursing, Chicago, Illinois, October 21, 1983.

Yocom, C. J.: Nursing staff involvement In clinical research. Sigma Theta Tau, Beta Eta Chapter and University of Wisconsin -Madison, School of Nursing Research Day. Madison, Wisconsin, November 3, 1984.

Yocom, C. J.: Influence of Initial nursing educational preparation on patient assessment. Sigma XI Graduate Student Research Forum, University of Illinois at Chicago, Chicago, Illinois, April 1, 1985.

Yocom, C. J. and Scherubel, J. C.: Academic performance as predictors of success on nursing IIcensure examinations. 1983 Post Graduate Conference, Marquette University, Milwaukee, Wisconsin, June 10, 1983.

244

VITA (continued)

Yocom, C. J. and Scherubel, J. C.: Predictors of success on the NCLEX and SBE licensing examinations. Second Annual Scientific Meeting of the Society for Research In Nursing Education. San Francisco, California, January 18-20, 1984.

Yocom, C. J. and Scherubel, J. C.: Predictors of success on the NCLEX and SBE licensing examinations. Sigma Theta Tau, Beta Eta Chapter and University of Wisconsin Madison, School of Nursing Research Day, Madison, Wisconsin, November 3, 1984.

PUBLICATIONS: Ellison, D., Scherubel, J. C. and Yocom, C. J.: Evaluation of a process to evaluate baccalaureate nursing program applicants. Journal of Professional Nursing (In press).

Klm, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R. and Yocom, C.: Clinical use of nursing diagnoses. In Classification of Nursing Diagnoses - Proceedings of the Third and Fourth National Conferences,, eds. M. J. Kim and A. M. McClaln, pp 184-190. St. Louis, Mosby, 1982.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel. J., Stafford, M., Suhayda, R. and Yocom, C.: Clinical use of nursing diagnoses related to cardlovasuclar nursing. In Classification of Nursing Diagnoses - Proceedings of the Fifth National

Conferencef eds. M. J. Klm and A. M. McClaln, pp 128-138. St. Louts, Mosby, 1984.

Klm, M. J., Suhayda, R., Waters, L. and Yocom, C.: The effect of using nursing diagnoses In nursing care planning. In Classification of Nursing Diagnoses - Proceedings of the Third and Fourth National Conferences,, eds. M. J. Klm and A. M. McClaln, pp 158-165. St. Louis, Mosby, 1982.

245

VITA (continued)

Yocom, C. J.: Pre- and post-operative nursing. In Manual of Med lea I-Surg lea I Nursing, eds. E. HIncker and L. Malasanos, pp. 143-169, Boston, Little Brown, 1983.

Yocom, C. J.: Care of patients with peripheral vascular disease. In Manual of Med lea I-Surgical Nursing, eds. E. HIncker and L. Malasanos, pp. 505-520. Boston, Little, Brown, 1983.

Yocom, C. J.: Differentiation of fear and anxiety. In Classlf Icatlon af Nursing Diagnoses - Proceedings of the Fifth National

Conference,, eds. M. J. Kim and A. M. McClaln, pp 352-355. St. Louis, Mosby, 1984.

Yocom, C. J. and Scherubel, J. C.: Selected preadmission and academic correlates of success on state board examinations. Journal of Nursing Education (In press).

Kim, M. J., Amoroso, R., Gutanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical use of nursing diagnoses (preliminary results). Regional Conference on Nursing Diagnoses, Milwaukee, Wisconsin, November 2, 1979.

Kim, M. J., Amoroso, R., Gulantck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical Identification and usefulness of nursing diagnoses for cardiovascular patients. Chicago Heart Association, Chicago, Illinois, March 4, 1980.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical use of nursing diagnoses. Fourth National Conference on Classification of Nursing Diagnoses, St. Louis, Missouri, April 8 - 13, 1980.

PRESENTATIONS AND POSTERS:

246

VITA (continued)

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Agreement between clinical specialists and staff nurses on nursing diagnoses Identification, (poster) Fourth Midwest Nursing Research Conference, Kansas City, Kansas, April 14 - 15, 1980.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical testing of nursing diagnoses In cardiovascular nursing practice. Veterans Administration District #17 Nursing Research Conference, North Chicago, Illinois, November 19, 1980.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical use of nursing diagnoses In cardiovascular nursing. Fifth National Conference on Classification of Nursing Diagnoses, St. Louis, Missouri, April 14 - 17, 1982.

Kim, M. J., Amoroso, R., Gulanlck, M., Moyer, K., Parsons, E., Scherubel, J., Stafford, M., Suhayda, R., and Yocom, C.: Clinical validation of nursing diagnoses In acute cardiovascular nursing. American Nurses Association Council of Nurse Researchers. Minneapolis, Minnesota, September 23, 1983.

Kim, M. J., Suhayda, R., Waters, L. and Yocom, C.: The effect of using nursing diagnoses In nursing care planning. Third National Conference on Classification of Nursing Diagnoses. St. Louis, April 7 - 10, 1978.

Scherubel, J. C. and Yocom, C. J.: Academic performance as predictors of success on nursing licensure examinations. Graduate Student Exchange, Midwest Nursing Research Conference, Iowa City, Iowa, April 10 - 12, 1983.

247

VITA (continued)

Scherubel, J. C. Ellison, D., and Yocom, C. J.: Predictive validity of a tool used to evaluate baccalaureate nursing program applicants. Third Annual Scientific Meeting of the Society for Research In Nursing Education, San Francisco, California, January 9-11, 1985.

Yocom, C. J.s Differentiation of Fear and Anxiety. Fifth National Conference on Classification of Nursing Diagnoses, St. Louis, Missouri, April 14-17, 1982.

Yocom, C. J.: Nursing staff Involvement In clinical research. Sixth Annual Research Conference. V. A. Medical District #17 Nursing Services and University of Illinois Nursing, Chicago, Illinois, October 21, 1983.

Yocom, C. J.; Nursing staff Involvement In clinical research, (poster) Sigma Theta Tau, Beta Eta Chapter and University of Wisconsin - Madison, School of Nursing Research Day. Madison, Wisconsin, November 3, 1984.

Yocom, C. J.: Influence of Initial nursing educational preparation on patient assessment. Sigma XI Graduate Student Research Forum, University of Illinois at Chicago, Chicago, Illinois, April 1, 1985.

Yocom, C. J.: Influence of Initial nursing educational preparation on patient assessment. College of Nursing, University of Illinois at Chicago, April 29, 1985.

Yocom, C. J. and Scherubel, J. C.: Academic performance as predictors of success on nursing I(censure examinations.(poster) 1983 Post Graduate Conference, Marquette University, Milwaukee, Wisconsin, June 10, 1983.

248

VITA (continued)

Yocom, C. J. and Scherubel, J. C.: Academic performance as predictors of success on nursing licensure examinations. (poster) Illinois Nurses Assoclaton Biennial Convention, Chicago, Illinois, November 9, 1983.

Yocom, C. J. and Scherubel, J. C.: Predictors of success on the NCLEX and SBE licensing examinations. (poster) Second Annual Scientific Meeting of the Society for Research In Nursing Education. San Francisco, California, January 18-20, 1984,

Yocom, C. J. and Scherubel, J. C.: Predictors of success on the NCLEX and SBE licensing examinations, (poster) Sigma Theta Tau, Beta Eta Chapter and University of Wisconsin -Madison, School of Nursing Research Day, Madison, Wisconsin, November 3, 1984.