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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Differences in Technology Among Subspecialties in Community Health Nursing Mary J. Geis Published online: 07 Jun 2010.
To cite this article: Mary J. Geis (1991) Differences in Technology Among Subspecialties in Community Health Nursing, Journal of Community Health Nursing, 8:3, 163-170, DOI: 10.1207/s15327655jchn0803_6 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0803_6
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1991, 8(3), 163-170 Copyright O 1991, Lawrence Erlbaum Associates, Inc.
Differences in Technology Among Subspecialties in Community Health Nursing Mary J. Geis, RN, PhD Downloaded by [Temple University Libraries] at 20:23 22 November 2014
Governors State University
Interest in differentiating community health nursing from home health nursing has focused on theoretical models, concepts, and examinations of the historical origins and evolution of the roles. Although not usually included in the recent differentiation efforts, school and occupational health nursing traditionally have been considered important subspecialties of community health nursing. Utilizing an approach to technology developed by organizational researchers and focusing not on hardware and equipment, but on the characteristics of the raw materials and techniques employed, this study examined the differences among public health/community health, home health, school health, and occupational health on the three technological dimensions of uncertainty, instability, and variability. Survey data from nurses in the four areas (N = 40) were utilized. Results indicated that home health nursing differed significantly from the other groups on the dimensions of uncertainty and instability.
Efforts at identifying, defining, and differentiating community health nursing and its historic and emerging subspecialties have intensified in recent years. This study explored the differences on three dimensions of technology as experienced by nurses in home health, public health, school health, and occupational health. Whereas Freeman's (1957) early text included chapters on "Public Health Nursing in Clinics" and "Public Health Nursing in School and Occupational Health Programs," community health nursing texts of the 1980s display chapters on an increasing number of roles and settings for practice in the field. Fromer (1979, 1983) addressed "School Nursing" and "Health Needs and Nursing Care of the Labor Force" and Spradley (1981) discussed roles in such settings as homes, ambulatory care sites, schools, work sites, residential institutions, and the community at large. Archer and Fleshman (1979) examined community health nurses' (CHNs) roles as nurse practitioners and discharge planners and in such settings as schools, community organizations, and community mental health centers. Later, Archer and Fleshman (1985) addressed CHNs' roles in refugee, school and occupational health programs, home care, discharge planning, and correctional settings. Hall and Weaver (1985) described distributive nursing practice occurring in occuRequests for reprints should be sent to Mary J. Geis, RN, PhD, Governors State University, Route 54 and Stuenkel Road, University Park, IL 60466.
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
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pational health settings, home health agencies, and universities. Jarvis (1985) discussed the nursing role in ambulatory care, occupational health, school health, public health, home health, midwifery, developmental disabilities, gerontology, community mental health, continuing care, rural health, and hospice care. School and occupational health were addressed by Logan and Dawkins (1986). Stanhope and Lancaster (1988) dealt with the CHN as family nurse practitioner in primary/ambulatory care and in school, occupational, home health, and hospice settings. Bullough and Bullough (1990) discussed home health care nursing and specifically addressed high technology in home health care. Nursing practice with school children and adults in the working years was included as well. From this review of the treatment by selected sources of community health nursing roles and settings, school and occupational health emerge as historic and traditional inclusions in what might be termed the subspecialties of community health nursing. Home health-care nursing with its ancient roots and century old, proud tradition of visiting nurse associations and community nursing services in this country is hardly the new or emerging field that some would claim. This traditional and current prominence, however, supports the addition of home health-care nursing as a third major subspecialty. Garvey and Logue (1988, p. 806) described home health as "another aspect of community health nursing." In a conceptual approach to the problem of the relationship between community health nursing and home health nursing, Burbach and Brown (1988, p. 97) asserted that ". . . just because home health nursing takes place in the community does not make it the same as community health nursing." These authors, in noting the recent tremendous growth in home health services, lamented the confusion that some nurses have regarding what constitutes community health nursing and home health nursing. In fact, as Burbach and Brown observed, many nurses assume that the fields are synonymous. After citing definitions of the two fields, Burbach and Brown recounted the similarities. These include a shared setting, the independent nature of the practice, recognition of the importance of the family, and an ". . . overlap in terms of the organization and provision of services" (p. 98). Essential differences between home health nursing and community health nursing, according to Burbach and Brown, involve community health nursing's aggregate focus, the continuous nature of the care provided and the emphasis on wellness, health promotion, and primary prevention. Home health care remains fundamentally an illness-oriented service, episodic in nature and focused on persons who in some sense have sought care themselves. Differences between the two areas raise issues regarding the preparation of practitioners, design of continuing education offerings, and research efforts. In their plea for conceptual differentiation between community health nursing and home health nursing, Burbach and Brown (1988) concluded: If we do not distinguish the concepts of community health nursing from home health care nursing, the profession risks another identity crisis. The integrity of the definition
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of community health nursing practice will be compromised, and nursing will miss the chance to clearly define the scope of home health nursing. Most distressing is the thought that nursing may lose the gains it has made toward focusing on wellness and family-centered care and toward integrating the philosophy of community health into all aspects of nursing. (p. 100) Another approach to exploring the differences between the various aspects or subspecialties of community health nursing is empirical rather than purely theoretical or conceptual. Home health nursing has been described traditionally as "handson" and more recently as "high tech." High tech in this instance commonly refers to the utilization of central venous access devices, intravenous therapy and dialysis equipment, ventilators, and similar materials for client care. An alternative approach to technology allows a comparison of the various community health nursing practice domains. This approach employs Perrow's (1965) conception of technology and was employed by organizational researchers in Canada. The framework for the research reported here was based on the Canadian research. TECHNOLOGY AND NURSING SUBUNIT TECHNOLOGY Perrow (1965) viewed organizations as systems that utilize energy ". . . in a patterned, directed effort to alter the condition of basic materials in a predetermined manner" (p. 913). Organizations take raw materials, perform a series of acts upon those raw materials, and thus alter them in a desired manner. Manufacturing industries combine materials in various ways; schools transmit information and values; accounting firms recombine items of information; and hospitals change the living situations, personalities, or physical conditions of persons who are ill. Although health-care technology is often equated with sophisticated equipment, Perrow (1965) saw equipment as merely the "tool" of technology and in fact did not include it in his definition. Instead, Perrow viewed technology as ". . . techniques or complex of techniques employed to alter 'materials' (human or nonhuman, mental or physical) in an anticipated manner" (p. 915). Various devices or equipment are created simply to serve the technology that is, in essence, based on the nature of the raw material. Building on the work of Perrow and other organizational researchers, Hickson, Pugh, and Pheysey (1969), in their efforts to examine the relationship between organizational structure and technology, identified three facets of the latter concept: operations technology, materials technology, and knowledge technology. Operations technology was defined as ". . . the equipping and sequencing of activities in the workflow," and materials technology as concerning ". . . characteristics of the materials in the workplace." Knowledge technology referred to ". . . the characteristics of the knowledge used in the workflow" (p. 380). Overton, Schneck, and Hazlett (1977) utilized the conceptual approaches of Perrow and of Hickson et al. in their study that attempted to identify the dimensions
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of technology in various types of nursing subunits and to explore the degree to which those subunits could be differentiated on the basis of the tasks performed. Subunit in this instance was defined as
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
. . . a geographic inpatient area of a hospital having an assigned number of beds, its own regular complement of nursing staff with shared goals, a formal hierarchical structure, and arrangements for nursing tasks; that is, it could be considered a bounded administrative and social unit. (Overton et al., 1977, p. 207) Examples used in the study included psychiatry, intensive care, rehabilitation, pediatrics, surgery, and obstetrics. The researchers projected that their study could increase understanding of the concept of technology, at least as observed in nursing subunits, and the measures obtained could provide the basis for future multivariate research that would include measures of structure and other organizational variables. Three elements composed the raw materials dimension explored by Overton et al. These three aspects were uncertainty, instability, and variability. Methodology used in the Overton et al. study included the development of a questionnaire that operationalized the three concepts. Questionnaire items addressing instability sought information regarding patients' needs for frequent nursing observation and the incidence of emergencies. Variability was explored in terms of the variety of health problems and age groups encountered in patients. Uncertainty, reflecting the complexity and multiplicity of health problems, was measured in part by items dealing with the length of the health history required and the unpredictability of the hospital stay. Other issues that addressed uncertainty included the need for analysis of complex problems in nursing care and the direction of nursing care efforts to sociopsychological needs. An important feature of a replication study by Leatt and Schneck (1981) was the identification of a quick, economical, and reliable method of calculating technological instability, uncertainty, and variability by summing selected item responses to form composite scores. Subunit responses to items with high loadings on a particular factor were summed to form the composite score for that factor. Responses to eight items were summed to obtain the composite score for instability, seven items for uncertainty, and three for variability. The expected utility of this measure was its potential for facilitation of future research examining the relationships among technology, organizational structure, and human behavior in hospital subunits. METHODS
Leatt and Schneck's 21-item questionnaire was utilized with minor modifications in wording and terminology to make the questions more appropriate for the community setting. One additional question was added regarding communication with other members of the health-care team. The questionnaire was distributed to convenience samples of generalized public health nurses (PHNs) employed by local health departments, and to home health,
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
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school, and occupational health nurses. Public health respondents and home health respondents were secured through personal contacts with agency directors of nursing known to the researcher. The nursing directors agreed to distribute, collect, and return the questionnaires from staff nurses who voluntarily consented to participate. School health and occupational health nursing respondents were obtained with the assistance of senior-level nursing students who make observation visits to schools and worksites as a part of their practicum experience in community health nursing. Nurses who agreed to participate either returned the completed questionnaires with the students or mailed the material to the researcher later. All respondents practiced in the Chicago metropolitan area, and sampling continued until 10 respondents were secured for each of the four areas. Respondents represented three small local health districts, two medium-sized hospital-based home health agencies, several public school districts, and a variety of industries. No additional demographic or other data were collected from respondents. Leatt and Schneck's method of summing subunit responses to high loading items in order to obtain composite scores for each factor was utilized. Each of the four areas of public health/community health, home health, school health, and occupational health was treated as a subunit in the manner described by Overton et al. and Leatt and Schneck. Composite scores were calculated based on the items found in the Leatt and Schneck study to have high loadings on the three factors labeled uncertainty, variability, and instability.
RESULTS Mean scores for the four groups on the three dimensions demonstrated that the highest levels of uncertainty, instability, and variability occurred in home health nursing practice. Patterns of scores on the three dimensions in the other clinical areas varied. Table 1 displays the mean scores, and Figure 1 provides a more graphic illustration of the mean scores' comparisons. Mean scores on uncertainty were 23.6 for home health and 20.6 for community health. Occupational health scores and school health scores on uncertainty were 14.7 and 14.1, respectively. A different pattern was observed with instability. Home health scores were highest with a mean of 19.2, followed by occupational health with a mean score of 16.0. Community health followed with a mean score of 14.4, and school health exhibited the lowest mean score, 13.3. TABLE 1 Mean Scores for Specialty Areas on Dimensions of Technology Dimensions Uncertainty Instability Variability
Community Health
Home Health
School Health
20.6
23.6 19.2 8.8
14.1
14.7
13.3
16.0
7.6
7.7
14.4
6.5
Occupational Health
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Geis Uncertainty
10
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Home Health
Conmuni ty Health
Occupational Health
School Health
Instability
10
Home Health
Occupational Health
Community Health
School Health
School Health Health
Community Health
4
Home Health
Occupational Health
Ordering
eas' mean scores on technology dimen-
sions.
Mean scores on variability for the four clinical areas exhibited the least amount of range. The home health score was 8.8, occupational health was 7.7, school health was 7.6, and community health was 6.5. A one-way analysis of variance (ANOVA) performed on the data indicated that the differences in mean scores were significant at p < .05 level for uncertainty and instability but not for variability. Table 2 includes the specific results of the analysis. TABLE 2 ANWA for Specialty Areas' Scores on Technology Dimensions
Dimension Uncertainty Factor Error Instability Factor Error Variability Factor Error
df 3 36 3 36 3 36
Sum of Squares
M Score
F Ratio
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DISCUSSION Among the four areas studied, home health-care nursing consistently ranked highest on the three dimensions of technology. Home health-care nurses indicated that in their view the raw materials, in this case the human beings that they cared for, were unstable in condition and variable in their characteristics. Techniques employed in processing materials or providing care were not only varied, but uncertain in terms of the likelihood of achieving desired outcomes. In the Overton et al. and Leatt and Schneck studies, intensive care units ranked highest on instability and second following psychiatric units on uncertainty. The high rankings of home health nursing on these dimensions may reflect the increasing acuity of home-care clients as well as the more holistic approach to care both necessary and possible in the home setting where intermittent nursing visits may take place over several weeks or longer. School health nursing ranked lowest on both uncertainty and instability and third on variability. These results may reflect the age and usual health status of the client population served. Thus, these clients have similar characteristics and the condition of their health is generally stable. Techniques utilized in delivering health programs to school-age children apparently are viewed as more established and assured of predictable outcomes than are techniques utilized in the other specialties. Occupational health ranked only slightly higher than school health on both uncertainty and variability, perhaps reflecting the generally healthy, comparatively young work force population and the application of such established techniques as screening and referral programs and selected health education efforts. Ranking second after home health on instability may in some cases reflect the potential for serious injury that may exist in many occupational health settings. Generalized CHNs apparently experience less uncertainty than home health nurses but more than both school health nurses and occupational health nurses. Community health clients are viewed as more stable than home health clients and occupational health clients, but somewhat more unstable than the school age population. Community health ranked last in variability of clients and techniques. Diminishing funds, the need to target particular populations for service, and the results of other cost conscious efforts to limit services may have contributed to this finding. As in the Overton et al. and Leatt and Schneck studies, variability was the least useful of the three dimensions in differentiating among the subunits or clinical areas. Analyzing theoretical models and concepts and exploring the historical roots and evolution of community health nursing and its related specialties are useful ways of examining similarities and differences and increasing understanding of the phenomena in these areas. Utilizing other variables such as technology can contribute to these efforts by providing an alternative approach that explores the largely cognitive dimensions of an area that is more than mere hardware. Future research should include an application of the technology approach with a larger, more representative sample. Just as with general organizational research,
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subsequent studies of community health nursing specialty areas might address the impact of additional variables such as organizational structure, systems of values and beliefs, and organizational cultures. Understanding the nature of these features of organizational life in the various practice areas will assist managers and educators in identifying and promoting the development of relevant and appropriate values and behaviors among students and practitioners.
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REFERENCES Archer, S. E., & Fleshman, R. P. (1979). Community health nursing: Patterns andpmctice (2nd ed.). North Scituate, MA: Duxbury. Archer, S. E., & Fleshman, R. P. (1985). Community health nursing (3rd ed.). Monterey, CA: Wadsworth Health Sciences. Bullough, B., & Bullough, V. (1990). Nursing in the community. St. Louis: Mosby. Burbach, C. A., & Brown, B. E. (1988, February). Community health and home health nursing: Keeping the concepts clear. Nursing and Health Care, 9, 97-100. Freeman, R. B. (1957). Public health nursingpmctice. Philadelphia: Saunders. Fromer, M. J. (1979). Community health and the nursingprocess. St. Louis: Mosby. Fromer, M. J. (1983). Community health and the nursingprocess (2nd ed.). St. Louis: Mosby. Garvey, E., & Logue, J. H. (1988). The community health nurse in home health and hospice care. In M. Stanhope & J. Lancaster (Eds.), Community health nursing: Process andpractice for promoting health (2nd ed., pp. 805-825). St. Louis: Mosby. Hall, J. E., & Weaver, B. R. (1985). Distributive nursing practice: A systems approach to community health (2nd ed.). Philadelphia: Lippincott. Hickson, C. J., Pugh, D. S., & Pheysey, D. C. (1969, September). Operations technology and organizational structure: An empirical reappraisal. Administmtive Science Quarterly, 14, 378-397. Jarvis, L. L. (1985). Community health nursing: Keeping the public healthy (2nd ed.). Philadelphia: Davis. Leatt, P., & Schneck, R. (1981, June). Nursing subunit technology: A replication. Administrative Science Quarterly, 26, 225-236. Logan, B. R., & Dawkins, C. (1986). Family-centered nursing in the community. Menlo Park, CA: Addison-Wesley. Overton, P., Schneck, R., & Hazlett, C. B. (1977, June). An empirical study of the technology of nursing subunits. Administrative Science Quarterly, 22, 203-21 9. Perrow, C. (1965). Hospitals: Technology, structure, and goals. In J. G. March (Ed.), Handbook of organizations (pp. 910-971). Chicago: Rand McNally. Spradley, B. W. (1981). Community health nursing concepts andpractice. Boston: Little, Brown. Stanhope, M., & Lancaster, J. (1988). Community health nursing: Process andpractice for promoting health (2nd ed.). St. Louis: Mosby.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Differences in Technology Among Subspecialties in Community Health Nursing Mary J. Geis Published online: 07 Jun 2010.
To cite this article: Mary J. Geis (1991) Differences in Technology Among Subspecialties in Community Health Nursing, Journal of Community Health Nursing, 8:3, 163-170, DOI: 10.1207/s15327655jchn0803_6 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0803_6
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1991, 8(3), 163-170 Copyright O 1991, Lawrence Erlbaum Associates, Inc.
Differences in Technology Among Subspecialties in Community Health Nursing Mary J. Geis, RN, PhD Downloaded by [Temple University Libraries] at 20:23 22 November 2014
Governors State University
Interest in differentiating community health nursing from home health nursing has focused on theoretical models, concepts, and examinations of the historical origins and evolution of the roles. Although not usually included in the recent differentiation efforts, school and occupational health nursing traditionally have been considered important subspecialties of community health nursing. Utilizing an approach to technology developed by organizational researchers and focusing not on hardware and equipment, but on the characteristics of the raw materials and techniques employed, this study examined the differences among public health/community health, home health, school health, and occupational health on the three technological dimensions of uncertainty, instability, and variability. Survey data from nurses in the four areas (N = 40) were utilized. Results indicated that home health nursing differed significantly from the other groups on the dimensions of uncertainty and instability.
Efforts at identifying, defining, and differentiating community health nursing and its historic and emerging subspecialties have intensified in recent years. This study explored the differences on three dimensions of technology as experienced by nurses in home health, public health, school health, and occupational health. Whereas Freeman's (1957) early text included chapters on "Public Health Nursing in Clinics" and "Public Health Nursing in School and Occupational Health Programs," community health nursing texts of the 1980s display chapters on an increasing number of roles and settings for practice in the field. Fromer (1979, 1983) addressed "School Nursing" and "Health Needs and Nursing Care of the Labor Force" and Spradley (1981) discussed roles in such settings as homes, ambulatory care sites, schools, work sites, residential institutions, and the community at large. Archer and Fleshman (1979) examined community health nurses' (CHNs) roles as nurse practitioners and discharge planners and in such settings as schools, community organizations, and community mental health centers. Later, Archer and Fleshman (1985) addressed CHNs' roles in refugee, school and occupational health programs, home care, discharge planning, and correctional settings. Hall and Weaver (1985) described distributive nursing practice occurring in occuRequests for reprints should be sent to Mary J. Geis, RN, PhD, Governors State University, Route 54 and Stuenkel Road, University Park, IL 60466.
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
164
Geis
pational health settings, home health agencies, and universities. Jarvis (1985) discussed the nursing role in ambulatory care, occupational health, school health, public health, home health, midwifery, developmental disabilities, gerontology, community mental health, continuing care, rural health, and hospice care. School and occupational health were addressed by Logan and Dawkins (1986). Stanhope and Lancaster (1988) dealt with the CHN as family nurse practitioner in primary/ambulatory care and in school, occupational, home health, and hospice settings. Bullough and Bullough (1990) discussed home health care nursing and specifically addressed high technology in home health care. Nursing practice with school children and adults in the working years was included as well. From this review of the treatment by selected sources of community health nursing roles and settings, school and occupational health emerge as historic and traditional inclusions in what might be termed the subspecialties of community health nursing. Home health-care nursing with its ancient roots and century old, proud tradition of visiting nurse associations and community nursing services in this country is hardly the new or emerging field that some would claim. This traditional and current prominence, however, supports the addition of home health-care nursing as a third major subspecialty. Garvey and Logue (1988, p. 806) described home health as "another aspect of community health nursing." In a conceptual approach to the problem of the relationship between community health nursing and home health nursing, Burbach and Brown (1988, p. 97) asserted that ". . . just because home health nursing takes place in the community does not make it the same as community health nursing." These authors, in noting the recent tremendous growth in home health services, lamented the confusion that some nurses have regarding what constitutes community health nursing and home health nursing. In fact, as Burbach and Brown observed, many nurses assume that the fields are synonymous. After citing definitions of the two fields, Burbach and Brown recounted the similarities. These include a shared setting, the independent nature of the practice, recognition of the importance of the family, and an ". . . overlap in terms of the organization and provision of services" (p. 98). Essential differences between home health nursing and community health nursing, according to Burbach and Brown, involve community health nursing's aggregate focus, the continuous nature of the care provided and the emphasis on wellness, health promotion, and primary prevention. Home health care remains fundamentally an illness-oriented service, episodic in nature and focused on persons who in some sense have sought care themselves. Differences between the two areas raise issues regarding the preparation of practitioners, design of continuing education offerings, and research efforts. In their plea for conceptual differentiation between community health nursing and home health nursing, Burbach and Brown (1988) concluded: If we do not distinguish the concepts of community health nursing from home health care nursing, the profession risks another identity crisis. The integrity of the definition
Differences in Technology
165
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
of community health nursing practice will be compromised, and nursing will miss the chance to clearly define the scope of home health nursing. Most distressing is the thought that nursing may lose the gains it has made toward focusing on wellness and family-centered care and toward integrating the philosophy of community health into all aspects of nursing. (p. 100) Another approach to exploring the differences between the various aspects or subspecialties of community health nursing is empirical rather than purely theoretical or conceptual. Home health nursing has been described traditionally as "handson" and more recently as "high tech." High tech in this instance commonly refers to the utilization of central venous access devices, intravenous therapy and dialysis equipment, ventilators, and similar materials for client care. An alternative approach to technology allows a comparison of the various community health nursing practice domains. This approach employs Perrow's (1965) conception of technology and was employed by organizational researchers in Canada. The framework for the research reported here was based on the Canadian research. TECHNOLOGY AND NURSING SUBUNIT TECHNOLOGY Perrow (1965) viewed organizations as systems that utilize energy ". . . in a patterned, directed effort to alter the condition of basic materials in a predetermined manner" (p. 913). Organizations take raw materials, perform a series of acts upon those raw materials, and thus alter them in a desired manner. Manufacturing industries combine materials in various ways; schools transmit information and values; accounting firms recombine items of information; and hospitals change the living situations, personalities, or physical conditions of persons who are ill. Although health-care technology is often equated with sophisticated equipment, Perrow (1965) saw equipment as merely the "tool" of technology and in fact did not include it in his definition. Instead, Perrow viewed technology as ". . . techniques or complex of techniques employed to alter 'materials' (human or nonhuman, mental or physical) in an anticipated manner" (p. 915). Various devices or equipment are created simply to serve the technology that is, in essence, based on the nature of the raw material. Building on the work of Perrow and other organizational researchers, Hickson, Pugh, and Pheysey (1969), in their efforts to examine the relationship between organizational structure and technology, identified three facets of the latter concept: operations technology, materials technology, and knowledge technology. Operations technology was defined as ". . . the equipping and sequencing of activities in the workflow," and materials technology as concerning ". . . characteristics of the materials in the workplace." Knowledge technology referred to ". . . the characteristics of the knowledge used in the workflow" (p. 380). Overton, Schneck, and Hazlett (1977) utilized the conceptual approaches of Perrow and of Hickson et al. in their study that attempted to identify the dimensions
166
Geis
of technology in various types of nursing subunits and to explore the degree to which those subunits could be differentiated on the basis of the tasks performed. Subunit in this instance was defined as
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
. . . a geographic inpatient area of a hospital having an assigned number of beds, its own regular complement of nursing staff with shared goals, a formal hierarchical structure, and arrangements for nursing tasks; that is, it could be considered a bounded administrative and social unit. (Overton et al., 1977, p. 207) Examples used in the study included psychiatry, intensive care, rehabilitation, pediatrics, surgery, and obstetrics. The researchers projected that their study could increase understanding of the concept of technology, at least as observed in nursing subunits, and the measures obtained could provide the basis for future multivariate research that would include measures of structure and other organizational variables. Three elements composed the raw materials dimension explored by Overton et al. These three aspects were uncertainty, instability, and variability. Methodology used in the Overton et al. study included the development of a questionnaire that operationalized the three concepts. Questionnaire items addressing instability sought information regarding patients' needs for frequent nursing observation and the incidence of emergencies. Variability was explored in terms of the variety of health problems and age groups encountered in patients. Uncertainty, reflecting the complexity and multiplicity of health problems, was measured in part by items dealing with the length of the health history required and the unpredictability of the hospital stay. Other issues that addressed uncertainty included the need for analysis of complex problems in nursing care and the direction of nursing care efforts to sociopsychological needs. An important feature of a replication study by Leatt and Schneck (1981) was the identification of a quick, economical, and reliable method of calculating technological instability, uncertainty, and variability by summing selected item responses to form composite scores. Subunit responses to items with high loadings on a particular factor were summed to form the composite score for that factor. Responses to eight items were summed to obtain the composite score for instability, seven items for uncertainty, and three for variability. The expected utility of this measure was its potential for facilitation of future research examining the relationships among technology, organizational structure, and human behavior in hospital subunits. METHODS
Leatt and Schneck's 21-item questionnaire was utilized with minor modifications in wording and terminology to make the questions more appropriate for the community setting. One additional question was added regarding communication with other members of the health-care team. The questionnaire was distributed to convenience samples of generalized public health nurses (PHNs) employed by local health departments, and to home health,
Downloaded by [Temple University Libraries] at 20:23 22 November 2014
Differences in Technology
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school, and occupational health nurses. Public health respondents and home health respondents were secured through personal contacts with agency directors of nursing known to the researcher. The nursing directors agreed to distribute, collect, and return the questionnaires from staff nurses who voluntarily consented to participate. School health and occupational health nursing respondents were obtained with the assistance of senior-level nursing students who make observation visits to schools and worksites as a part of their practicum experience in community health nursing. Nurses who agreed to participate either returned the completed questionnaires with the students or mailed the material to the researcher later. All respondents practiced in the Chicago metropolitan area, and sampling continued until 10 respondents were secured for each of the four areas. Respondents represented three small local health districts, two medium-sized hospital-based home health agencies, several public school districts, and a variety of industries. No additional demographic or other data were collected from respondents. Leatt and Schneck's method of summing subunit responses to high loading items in order to obtain composite scores for each factor was utilized. Each of the four areas of public health/community health, home health, school health, and occupational health was treated as a subunit in the manner described by Overton et al. and Leatt and Schneck. Composite scores were calculated based on the items found in the Leatt and Schneck study to have high loadings on the three factors labeled uncertainty, variability, and instability.
RESULTS Mean scores for the four groups on the three dimensions demonstrated that the highest levels of uncertainty, instability, and variability occurred in home health nursing practice. Patterns of scores on the three dimensions in the other clinical areas varied. Table 1 displays the mean scores, and Figure 1 provides a more graphic illustration of the mean scores' comparisons. Mean scores on uncertainty were 23.6 for home health and 20.6 for community health. Occupational health scores and school health scores on uncertainty were 14.7 and 14.1, respectively. A different pattern was observed with instability. Home health scores were highest with a mean of 19.2, followed by occupational health with a mean score of 16.0. Community health followed with a mean score of 14.4, and school health exhibited the lowest mean score, 13.3. TABLE 1 Mean Scores for Specialty Areas on Dimensions of Technology Dimensions Uncertainty Instability Variability
Community Health
Home Health
School Health
20.6
23.6 19.2 8.8
14.1
14.7
13.3
16.0
7.6
7.7
14.4
6.5
Occupational Health
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10
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Home Health
Conmuni ty Health
Occupational Health
School Health
Instability
10
Home Health
Occupational Health
Community Health
School Health
School Health Health
Community Health
4
Home Health
Occupational Health
Ordering
eas' mean scores on technology dimen-
sions.
Mean scores on variability for the four clinical areas exhibited the least amount of range. The home health score was 8.8, occupational health was 7.7, school health was 7.6, and community health was 6.5. A one-way analysis of variance (ANOVA) performed on the data indicated that the differences in mean scores were significant at p < .05 level for uncertainty and instability but not for variability. Table 2 includes the specific results of the analysis. TABLE 2 ANWA for Specialty Areas' Scores on Technology Dimensions
Dimension Uncertainty Factor Error Instability Factor Error Variability Factor Error
df 3 36 3 36 3 36
Sum of Squares
M Score
F Ratio
Differences in Technology
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DISCUSSION Among the four areas studied, home health-care nursing consistently ranked highest on the three dimensions of technology. Home health-care nurses indicated that in their view the raw materials, in this case the human beings that they cared for, were unstable in condition and variable in their characteristics. Techniques employed in processing materials or providing care were not only varied, but uncertain in terms of the likelihood of achieving desired outcomes. In the Overton et al. and Leatt and Schneck studies, intensive care units ranked highest on instability and second following psychiatric units on uncertainty. The high rankings of home health nursing on these dimensions may reflect the increasing acuity of home-care clients as well as the more holistic approach to care both necessary and possible in the home setting where intermittent nursing visits may take place over several weeks or longer. School health nursing ranked lowest on both uncertainty and instability and third on variability. These results may reflect the age and usual health status of the client population served. Thus, these clients have similar characteristics and the condition of their health is generally stable. Techniques utilized in delivering health programs to school-age children apparently are viewed as more established and assured of predictable outcomes than are techniques utilized in the other specialties. Occupational health ranked only slightly higher than school health on both uncertainty and variability, perhaps reflecting the generally healthy, comparatively young work force population and the application of such established techniques as screening and referral programs and selected health education efforts. Ranking second after home health on instability may in some cases reflect the potential for serious injury that may exist in many occupational health settings. Generalized CHNs apparently experience less uncertainty than home health nurses but more than both school health nurses and occupational health nurses. Community health clients are viewed as more stable than home health clients and occupational health clients, but somewhat more unstable than the school age population. Community health ranked last in variability of clients and techniques. Diminishing funds, the need to target particular populations for service, and the results of other cost conscious efforts to limit services may have contributed to this finding. As in the Overton et al. and Leatt and Schneck studies, variability was the least useful of the three dimensions in differentiating among the subunits or clinical areas. Analyzing theoretical models and concepts and exploring the historical roots and evolution of community health nursing and its related specialties are useful ways of examining similarities and differences and increasing understanding of the phenomena in these areas. Utilizing other variables such as technology can contribute to these efforts by providing an alternative approach that explores the largely cognitive dimensions of an area that is more than mere hardware. Future research should include an application of the technology approach with a larger, more representative sample. Just as with general organizational research,
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subsequent studies of community health nursing specialty areas might address the impact of additional variables such as organizational structure, systems of values and beliefs, and organizational cultures. Understanding the nature of these features of organizational life in the various practice areas will assist managers and educators in identifying and promoting the development of relevant and appropriate values and behaviors among students and practitioners.
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REFERENCES Archer, S. E., & Fleshman, R. P. (1979). Community health nursing: Patterns andpmctice (2nd ed.). North Scituate, MA: Duxbury. Archer, S. E., & Fleshman, R. P. (1985). Community health nursing (3rd ed.). Monterey, CA: Wadsworth Health Sciences. Bullough, B., & Bullough, V. (1990). Nursing in the community. St. Louis: Mosby. Burbach, C. A., & Brown, B. E. (1988, February). Community health and home health nursing: Keeping the concepts clear. Nursing and Health Care, 9, 97-100. Freeman, R. B. (1957). Public health nursingpmctice. Philadelphia: Saunders. Fromer, M. J. (1979). Community health and the nursingprocess. St. Louis: Mosby. Fromer, M. J. (1983). Community health and the nursingprocess (2nd ed.). St. Louis: Mosby. Garvey, E., & Logue, J. H. (1988). The community health nurse in home health and hospice care. In M. Stanhope & J. Lancaster (Eds.), Community health nursing: Process andpractice for promoting health (2nd ed., pp. 805-825). St. Louis: Mosby. Hall, J. E., & Weaver, B. R. (1985). Distributive nursing practice: A systems approach to community health (2nd ed.). Philadelphia: Lippincott. Hickson, C. J., Pugh, D. S., & Pheysey, D. C. (1969, September). Operations technology and organizational structure: An empirical reappraisal. Administmtive Science Quarterly, 14, 378-397. Jarvis, L. L. (1985). Community health nursing: Keeping the public healthy (2nd ed.). Philadelphia: Davis. Leatt, P., & Schneck, R. (1981, June). Nursing subunit technology: A replication. Administrative Science Quarterly, 26, 225-236. Logan, B. R., & Dawkins, C. (1986). Family-centered nursing in the community. Menlo Park, CA: Addison-Wesley. Overton, P., Schneck, R., & Hazlett, C. B. (1977, June). An empirical study of the technology of nursing subunits. Administrative Science Quarterly, 22, 203-21 9. Perrow, C. (1965). Hospitals: Technology, structure, and goals. In J. G. March (Ed.), Handbook of organizations (pp. 910-971). Chicago: Rand McNally. Spradley, B. W. (1981). Community health nursing concepts andpractice. Boston: Little, Brown. Stanhope, M., & Lancaster, J. (1988). Community health nursing: Process andpractice for promoting health (2nd ed.). St. Louis: Mosby.
