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Expertise of Community Health Nurses, Thesis of Community Health

A thesis submitted to the Faculty of the Graduate College of the Oklahoma State University in 1988. It explores the expertise of community health nurses and includes a literature review, methodology, and analysis and discussion of the research findings. The author expresses gratitude to her mentors, nursing supervisors, health departments, and community health nurses who participated in the study. The document also acknowledges the author's family for their support.

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EXPERTISE
OF
COMMUNITY
HEALTH
NURSES
By
DONNA
JOHNSON
ECKHART
II
Bachelor
of
Science
in
NUxsing
University
of
Michigan
Ann Arbor, Michigan
1953
Master
of
Science
in
NUrsing
State
University
of
New
York
at
Buffalo
Buffalo,
New
York
1976
Submitted
to
the
Faculty
of
the
Graduate College
of
the
Oklahoma
State
University
in
partial
fulfillment
of
the
requirements
for
the
Degree
of
DCC'rOR
OF
EDUCATION
December,
1988
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EXPERTISE OF COMMUNITY HEALTH NURSES

By

DONNA JOHNSON ECKHART

II

Bachelor of Science in NUxsing

University of Michigan

Ann Arbor, Michigan

Master of Science in NUrsing

State University of New York at Buffalo

Buffalo, New York

Submitted to the Faculty of the

Graduate College of the

Oklahoma State University

in partial fulfillment of

the requirements for

the Degree of

DCC'rOR OF EDUCATION

December, 1988

Th~'5^ ;g ,qgg.o 6 ,q€.. Cop.^ 'L

PREFACE

This study was concerned with the expertise of conununity health nurses as evident in self-reported, personal examples of care which were rated by three expert judges. The study partially replicated research conducted among hospital nurses which identified expertise as the highest level of performance and also identified domains of nursing practice in that practice setting. One objective of the study was to determine whether expertise was identifiable in the narrative examples submitted by the community health nurses. A second objective was to determine whether all the domains of practice identifiable in the institutional setting could also be identified in community health nursing practice. A third objective was to examine potential relationships between the expert level of community health nursing practice, as identified by the judges in this study, and various demographic variables. In addition, the results of the two studies were compared. I wish to express my sincere appreciation to my doctoral committee: to Dr. Thomas Karman, chairman of the committee, for hie scholarly advisement and patience with my compulsive attention to detail; to Dr. Robert Kamm, for his willing assistance making evident his philosophy that students are nwnber one; to Dr. Craig Robison for his help and special friendship; to Dr. Russell Dobson for his interest and encouragement with the study methodology; and to Dr.

iii

Shirley Steele for her nursing expertise and generosity as a mentor

who challenged me to rise to my potential. Thanks are also extended

to Dr. Jim Duke for his help with the statistical treatment of the study. Gratitude is expressed to the health departments who permitted their staff nurses to participate in the study. Also, appreciation is extended to the nursing supervisors who distributed the research instruments and encouraged staff participation. Special gratitude is expressed to the community health nurses who submitted personal examples of expertise. Without them the study would not have been possible. Finally, a special appreciation is appropriate for my husband, Frank, who supported me in all my educational endeavors and commanded

the computer which enabled me to produce this piece of work. Also, my

five children provided immeasurable support as they saw my metamorphosis from an unemployed homemaker to a professional woman.

iv

Chapter Page

 - Biographical Vari~es Potential Relationship Between Skill Level and - Comparing Sunttna.ry. the• • • • Expert• • • • • • • Nurse• • I • • • in• I • Two• • • I Settings.• • • • • I • • • .• • • • • • • • • I • 
  • V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS................... - SummaryFindings, of Implications,the Study.................................. and Conclusions - ReconttnendatiOilSt I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I - Research. I I I I I I I I I I I I I t I I I I I I I I I I I I I I I I I I I I I I I I I I - Nursing Ed.ucation.
  • A SELEC~D BIBI..IOORAPHY•••••••• I •••• I ••••••••• I •••••••••••••••••• I
  • APPENDilCES •••••• I ••••••••••••••••••••• I ••• I •••••••••••••• I • • • • • • • • - APPENDIX A- LETTER TO PARTICIPANTS •••••••••••••••••••••••• - APPEND[X B- BIOORAPHICAL QUESTI~RE .•.••..••..••••••••• - APPENDIX C- INSTRUCTIONS TO SUBJECTS•....••••••.•.••••••.• - APPENDIX D- FOLLOW-Ul? LE~R TO SUPERVISORS .....•.•••••••• - APPENDIX E - EXAMPLES OF EXl?ERT COMMUNITY HEALTH NURSING. • • - HEALTH NURSING.•••••..•••••• I •••••••••••••••• I APPENDIX F - SELEC~D EXAMPLES OF NON-EXl?ERT COMMUNITY

LIST OF TABLES Table Page I. Expertise by CUrrent Level of Education................... 72 II. Domains Identified in Examples ............................ 77 III. Experts' Rating of All ~es .....................•....• 79 IV. Scores of Expert and Non-Expert Groups .................... 80 v. Ages of Sl.Jl::)j ects......... •................................ 82 VI. Expertise by Age Groups ................................... 82 VII. Subjects by Basic Professional Program.................... 83 VIII. Expertise by Basic Nursing Education...................... 84 IX. Expertise by Additional College Credits Earned............ 85

X Expertise by Higher Degree ................................ 87

XI. Expertise by Certificatio~ ............................... 88

XII. Expertise by Marital Status ............................... 89

XIII. Summary of T-Test Comparisons Between Expert and Non-Expert Nursing Groups ............................... 90 XIV. Summary of the Logistic Model Predicting Public Health

Nursing Expertise....................................... 93

vii

2 expertise or a breakdownin performance. She contended that as expert clinicians document their performance, new areas of clinical knowledge are made available for furtherstudy and development. While pursuing documented examples of expert community health nursing, responses were sought to the following research questions:

  1. Are the seven domains of nursing practice identified by Benner ( 1984) inthe acute-care setting alsoidentifiable from clinical practice examples reported by community health nurses?
  2. canself-reportedincidents of expert nursing care be usedto discern anexpert level of community health nuxsing practice?
  3. Is there a relationship betweenthe level of skill performance reported by community health nurses and nurses' ages, educational backgrounds, national certification statuses, marltal statuses, lengths of experience in nursing, lengths of experiencein communityhealth nursing practice, agencysizes, or sizes of the populationserved?
  4. How do the results of this study of nurses inthe community setting compare with Benner's study whichincluded the expert nurse in the hospital setting? Background and Significance Excellencein nursingpractice is anelusive quality. Yet the need to defineand measure expert nursing practiceis an inescapable task. Many previous studies of nursing practice have attempted a description from the sociological perspective. others have used approaches such as task analysis, competency lists, and the application of abstract scientific concepts to describe nursing

practice. However 1 there has been a paucity of descriptive studies which permit identification of the knowledge embedded in clinical practice and permit identifying the behaviors of the expert nurse.

3

Clinical knowledge is gained over time. Because nursing is an applied discipline 1 it has been described as both an art and a science. Nurses who are in the front line of practice know intuitively which problems are important (Dick 1 19831 p. 44). What nurse clinicians learn from clinical practice enables them to make clinical judgments which vary according to the level of in-depth skill acquired. Benner ( 1984) has described what expert nurses do in specific patient care situations and has identified how beginners perform differently from experts. She also proposed that as nurses develop their careers 1 they change their intellectual orientation and refocus their decision-making on a different basis than the process-oriented one they were taught. Benner used the Dreyfus Model of Skill Acquisition as a tool for examining and understanding the differences between the experienced nurse and the novice. The model was inductively derived by two University of california 1 Berkeley 1 professors who brought together their expertise as mathematician/systems analyst and philosopher (as cited in Benner 1 1982a 1 p. 402). Although the model was developed from studies of chess players and pilots 1 Benner found that 1 when it was generalized to nursing 1 it took into account increments in skilled performance based upon experience as well as educatio~ Benner ( 1982al p. 402) used interviews and participant observations to confirm the generalizabili ty of the Dreyfus Model of Skill Acquisition to nursing. The model asserted that in the

/

5

  1. Monitoring and ensuring the quality of health care practices
  2. Organizational and work-role competencies In the Dreyfus Model of Skill Acquisitionthe expert's

performance was consideredto be holistic. Therefore, in Benner' s

(1982a, p. 406) work, the expert nurse's performancewas also

consideredto be holistic ratherthan fractionated, procedural, and based uponincremental steps. Byviewing performancein this way, it

was possible for Bennerto capturethe intentions, expectations,

meanings, and outcomes of expert nursingpractice in acute care settings ( 1984, p. 4). While Benner viewed the expert nurse's performance as holistic,

the notionof holismwas not newinthe nursingliterature. Current

nursing literaturehad numerous examples of holis~ The holistic approach to nursing carehas included the physical, mental, and spiritual aspects of care. Holism was the unity (^) of mind and body wherein the individual is viewed as a unified biopsychosocial being. Alterations inone part affected the whole (Krauss, 1984, p. 372). Whitmore and Utz (1985, p. 147) stated that the doctrine of holism is inopposition to mechanism, reductionism, and dualism which have pervaded twentieth-century western medicine. Therefore, the doctrine of holismpertained bothto aspects of patient care as well as to the process used to view nursing performance. Martin (1986, p. 133) has stated that holistic nursing practice is a term deeply rooted innursing's past. She made reference to the holistic approach in the professional origins of nursing stating that Florence Nightingale might be called the first holistic nurse because she stressed the importance of primary prevention and health

6

maintenance. Martin also stated that the community health nurse has the opportunity to practice more holistically than his/her counterpart in the hospital. Therefore, it is assumed that the expert level of skill acquisition may be identified among nurses in the community

health nursing setting just as it was in the acute care setting.

Community health nursing practice has not received the attention for study that hospital nursing has received. Historically the term

11 public heal th 11 was used more often than the term 11 community heal th 11

to describe this subspecialty of nursing practice. In early accounts of home visiting, health teaching, and drawing on epidemiological concepts to determine the focus of actions, nurses were considered public health nurses (Stanhope & Lancaster, 1984, p. 123). While attempting to distinguish between community health nursing and public health nuxsing, Smith (1984, p. 179) stated that the practice of public health nursing is to some extent subsumed under the broad classification of community health nursing. However, she stated that the practice of public health nursing has traditionally focused on the health of populations by using programmatic planning techniques. Nevertheless, she stated that the goal of both those nurses considering themselves community health nurses and those who consider themselves public health nurses is the promotion of the health of populations. Gulino and LaMonica's (1986, p. 80) findings regarding the role of the public health nurse were consistent with Smith's statement that health promotion is the goal of those nurses who work in the community. They reported that seventy-nine percent of the nursing interventions in their sample of public health nursing home visits

8 Basic Assumptions The following assumptions weremade indesigning this study:

  1. Descriptive informationabout expert community health nursing practice can be gathered by requesting that nurses relate, in WTiting, theirpersonal experiences which made a difference for the client.
  2. Community health nurses who respond to the request for examples will be able to identifythose examples which are expert and report themwith honesty, objectivity, and fluency.
  3. Anonymity of respondents will increase the potential for obtainingvalid responses.
  4. Communityhealthnurses inlocal health departments which operate outside metropolitan areas inthe statewill have similar experiences and similarranges of educational backgrounds and other demographic characteristics.

Scope and Limitations Inthe study of expert nursingpractice of community health nurses, the sample was self-selected from thepopulation of community health nurses whowere employed by three governmental agencies. Therefore, the sample was a limitation of the study as it did not include community health nurses employed inother settings. Because the studywas limited to a relatively rural, south-central state, the findings are not (^) generalizable to any otherstate or to a more urban population. Another limitation of the study was the lack of a structured instrument which might have guided the subjects in theirresponses and encouraged more detail and completeness of the examples. The

9

inability of the investigator to talk with the subjects to clarify and

amplify examples was also a limitatio~

The influence of unconscious processes and selective recall of

experience when producing examples cannot be estimated and was

therefore a limi tatio~ Also, because the study data consisted of

self-reported data, it was possible that deliberate distortion may

have occurred.

Another limitation was that individuals with associate degree or

diploma preparation in nursing participated in the study. This made it impossible to generalize these results to those areas where only nurses with baccalaureate or higher degree preparation are employed as community health nurses.

The scope of the study was limited to perceptions of a limited

number of nurses and to certain specific roles performed by those

nurses who chose to participate. This was not representative of all

nurses and all roles of community health nurses. The subjects were limited to those nurses who provide direct care to clients. The influence of some uncontrolled variables may be minimized in this way.

Definition of Tenns For the pw:pose of the study, the following defini tiona were used: Basic Professional Education - The education which prepares the nurse to take the licensure examination to become a registered nurse. This education may be the baccalaureate program in higher education, the associate degree program at a community college, or the diploma program at a hospital school of nursing.

11

Expertise - A special skill which develope when the clinician tests and refines theoretical and practical knowledge by challenging expectations in actual clinical situations. Experience is a requisite which promotes perception of the clinical situation as a whole. Health Promotion - The prevention of illness by educating, counseling, and motivating the client toward the highest level of wellness that is achievable for the individual and his/her family. Holistic Health - The unity of mind and body in a biopsychosocial being in which alterations in one part will affect the whole. Holism - A doctrine which opposes mechanism, reductionism, and

dualism. The assumption is that it is not possible to understand an

individual by looking at the component physical or chemical units that make up the body. The focus is on the individual' s culture, environment, and physical, spiritual, and mental health. Organization of the Study

This research study is presented in five chapters. Chapter I introduces the study, explains the problem, discusses the significance of the study, assumptions, limitations, and defines terms. Chapter II presents a review of the literature related to excellence in nursing, commitment and creativity in nursing, expertise and the expert nurse, and expertise in community health nursing practice. Chapter III presents the methodology of the study including subjects, instrumentation, and collection and treatment of the data. Chapter IV describes the findings of the study. Chapter V includes a summary, conclusions, and recommendations for further research and for nursing education.

CHAPTER II

REVIEW OF SELECTED LITERATURE Introduction The movement of higher education away from the classical curriculum heralded offerings in the applied areas of study. Although the Yale Report of 1828 attempted to perpetuate the old course of

study, the curriculum was reshaped, and the concept of the mind was

also altered (Rudolph, 1962, p. 132-3). The mind was no longer viewed

as a receptacle and a muscle with various potentialities waiting to be trained. Lindsley, an academic reformer of the nineteenth century, recognized the need for a broadly practical education, yet he was also conunitted to intellectual excellence (p. 116). Lindsley s ideas for a great educational institution made it possible for John Dewey, a later reformer, to expand the potential for excellence using a method of education based on the principles of problem solving (Levine, 1979, p. 258). The wholeness of experience, rather than compartmentalization of knowledge, represented the epitome of Dewey s vision (p. 260). By ascribing the virtue chiefly to the process rather than to the sutaect itself, experience-based education came into being. Dewey also focused on the continuity of the educational process, according to Ratner {1939, p. 627), by stating, (^11) Education is a constant reorganizing and reconstructing of

experience. 11 This concept of education was compatible with the