Psychological Reports, 1975, 36, 255-266. @ Psychological Reports 1975
W H A T ARE THE RELATIONSHIPS OF QUALITY PATIENT CARE TO NURSES' PERFORMANCE, BIOGRAPHICAL AND PERSONALITY VARIABLES? ELAINE D. DYER, MARY A. MONSON, AND JENNIE B. VAN DRIMMELEN
veteran^ Admini~trationHorpital, Sal; Lake City Brigham Young University, P+ovo, Urah Summary.-Relationships among measures of quality patient care, nurse performance, biographical and personalicy data were smdied for 387 staff nurses from 60 wards of 7 VA hospitals. Patient-care ratings were obtained by outside observers and nurses' performance ratings were obrained from three supervisory levels, peers and subordinates. Correlations between patient-care scores and performance scores were surprisingly low. Coefficients in the high twenties were rare. Education was related positively with patient care and nursing performance measures, often significantly. Age was usually related negatively to patient care and performance measures, often significantly. Higher rated nurses generally described themselves in more positive terms and as more open, helpful, energetic and people-oriented. Personality patterns of nurses rated high by various raters reflect situational needs of raters. Second-level supervisors rated nurses high who were dominant, verbal, and ascendant but cooperative participators. Head nurses rated nurses high who were not dominant but were self-controlled, responsible and cooperative in interactions with others and felt things were going well. Education was positively related to Califo~nia Psychological Inventory scores except for Responsibility. Age was negatively related except for Responsibility, Self-control, and Good impression.
Personal hlstory and personality measures have been used to describe and sometimes pred~ctsuccessfd people in a variety of educational and work settings. Krall ( 1970) reported negative results in using Draw-a-Person to predict success in nursing. Adams and Klein (1970) found significant differences between nursing students and other college women using the Edwards Personal Preference Schedule. Wren ( 197 1 ) found significant biographical differences between freshmen student nurses in baccalaureate, diploma, and associate degree programs. Rawls and Rawls (1968) found significant differences on five of the 15 Edwards Personal Preference Schedule scales and 10 of the 18 California Psychological Inventory scales. Their biographical inventory questions corroborated findings from the personality measures and described the successful executive as more self-confident, ambitious, competitive, dominant, aggressive, manipulative and opportunistic in dealing with others. H e was also more impulsive and more prone to emphasize personal pleasure and self-gain. Query (1966) found successful seminary students significantly different from seminary students who dropped from the program on five of the 18 CPI scales. Successful students were higher on Capaciry for status, Tolerance and Flexibility and significantly lower on Sociability and Self-acceptance.
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The work of Dyer and colleagues (Dyer, 1967; Dyer, Monson, & Van Drimmelen, 1971, 1972) indicated that biographical and personality measures are consistently related at significant levels with nursing performance, administrative position, and education. The work of Cline, Richards, and Needham ( 1962 ) , Ellison, James, Fox, McDonald, and Taylor (1969), Taylor, Smith, Ghiselin, and Ellison ( 1961 ) also indicated the value of biographical information in predicting success on the job. The present study was completed to increase our understanding of relarionships of several measures of quality patient care with nurses' performance, biographical, and personality data.
METHOD Three hundred and eighty-seven staff nurses from 60 medical-surgical wards in seven V.A. hospitals completed a Biographical Inventory and the California Psycho!ogical Inventory. Hospitals were similar in bed capacity (400 to 600). medical and nursing school affiliation, bed occupancy rate and patient turnover rate. Two hospitals were located in the south, two in the midwest, and three on the west coast. The average age of nurses was 42 yr. with a standard deviation of 12. Educational preparation was 48% diploma, 14% associate degree, 30% bachelor's degree and 8 % had continued their education beyond the bachelor level. Performance ratings were obtained on staff nurses from three levels of nursing supervision, ward-nurse peers, and ward subordinates. Quality of patient care was described by trained observers from outside the hospital who monitored care using three patient-care measuring instruments: Wayne State Quality Patient Care Scales, Veterans Administration Nursing Care Quality Evaluation, and a one-page Patient Interview containing six questions plus occurrences the patient liked or disliked. Relationships among measures of quality care, performance-rating instruments, biographical, and personaliry variables were studied using intercorrelation matrices, item analyses and t tests. Relationships of Wayne State scales with measures of nursing performance were studied in an individual-item jntercorrelation matrix. Relationships of the Veterans Administration patient-care scale and Patient Interview with measures of performance were studied using data reduced to ward scores. This was necessary because the Veterans Administration care scale and Patient Interview scores were obtained only on a ward basis. Correlations from the individual variables matrix were interpreted for 387 staff nurses ( 7 2 .12, p = .OJ). Correlations from the ward matrix were interpreted .27, p = .05). When correlations of the Veterans Adminisaccording ro 50 wards (s tration care scales or Patient Interview with other variables are referred to in the results section, correlations are from the ward intercorrelation matrix. Relationships of biographical items to quality care measures and performance evaluation measures were studied using an item analysis program. For each quality care and performance measure and each biographical question an eta, standard error and N were computed and for each question alrernative a biserial, point biserial, standard error, N, and percentage. Biographical questions relating significantly in one direction on one end of the scale and significantly in the opposite direcrion on the other end of the scale were interpreted as discriminators of quality care or performance. In order to study personality differences between high- and low-scoring nurses on the patient-care and nurses' performance instruments, staff nurses were divided into upper and lower thirds and compared on scales of the California Psychological Inventory using independent r rests. Differences were interpreted at the .10 level to allow more instructive descriptions of characteristics.
QUALITY PATIENT CARE AND CHARACTERISTICS OF NURSES
257
Measuring lnstrunients Patient care.-Three instruments were used to assess quality level of patient care. The first was the Veterans Administration Nursing Care Quality Evaluation, developed by a VA task force of nurse clinicians, nurse administrators, management systems personnel, and consultants. Items in final form had been scrutinized by several hundred nurses and were considered to be important indicators of patient care. Items were built to be observable on a "yes." "no" or "not applicable" basis. Scores for subscales were determined by dividing total number of yes responses by total number of applicable responses. Seventy-one items define 14 areas considered to be imporcant in patient care. Six areas are applicable only with patients receiving various types of special care. Major areas of the instrument are named: Symptoms. Identification, Personal Hygiene, Welfare and Comfort, Immediate Environment, Restraints and Protective-Safety Measures, DressingsCompresses-Bandages-Binders, Inrubation-Infusion Therapy. Preventive-Supportive-Assistive Therapy. Special Precautions, Other Bedside Therapy, Physician's Orders, Nursing Notes, and Nursing Care Plan. For this smdy che first four areas ( 1 3 questions) were summed and called Comfort and Safety, the next seven questions defined the Environment scale, the next seven areas or 24 questions were summed and called Special Therapy. Physician's Orders area was not used. The Nursing Notes area has seven questions and Nursing Care Plan scale 14 questions. A total score was obtained by summing the five subscale scores. The second measure, Wayne State Quality Patient Care Scales, was adapted by Mabel Wandelt and Joel Ager from scales developed by Doris Slater. Five subscale scores and toral score were used in this study. The five scales used consisted of 7 to 15 items and were named: Psycho-social, Individual, Physical, General, Communication, and Professional Implications. The third measure. the Patient Interview, was comprised of eight questions which described nurse-patient relationships from the patient's point of view. Typical questions asked h e patient if nurses were kind to patients and visitors, answered lights promptly, listened to patients and explained procedures. Things most satisfying or annoying to patients also were sought. Performance measures.-There were G measures. ( 1 ) Nurse Performance Description Scales contains five scales of 10 items each. Items discriminating nursing performance ar the .05 level in a variety of seniogs were retained. Retest reliabilities were mosdy in che high eighties and correlations with other performance rating instruments from .4Os to .70s. ( 2 ) Descriptive Scales for Nursing Performance contains 1G scales named: Patient-care Competence, Use of Time, Quality of Work, Skill with People, Oral Communication, Receptiveness to Change, Creativity, Orientation Toward Independent Achievement, Breadth oE Knowledge, Stimulation Value, Tolerance, Group Leadership, Patientcare Expertise, Cleverness with New Ideas, Leadership Adroitness, and Over-all Work Description. Retest reliabilities for total score are in the high .70s and .80s and correlations with other measures of performance range from .40s to .70s. These first two performance scales correlate in the .50s. ( 3 ) An Official Performance Rating (Proficiency) was o b tained from hospital records for each staff nurse. ( 4 ) The Chief Nurse ranked nurses according to over-all effectiveness. Rankings were transformed to a scale with a mean of 50 and standard deviation of 10. ( 5 ) Ward registered nurses nominated their wardpeer registered nurses on sca!es to determine best in patient care, group leadership, interpersonal relationships, and over-all. Nominations were converted to a scale with a mean of 50 and standard deviation of 10. ( 6 ) Ward licensed practical nurses and nursing assistants nominated staff tegiscered nurses on the same scales as peers. Scores were converted to a scale with a mean of 5 0 and standard deviation of 10.
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E. D. DYER, ET AL.
Biographical Inventory has a total of 132 questions describing developmental, educational and professional history along with questions to assess attitudes and values. California Prychological Inventory contains 18 scales describing factors associated with social interaction, named Dominance ( D o ) , Capacity for status (Cs), Sociability (Sy ) , Social presence (Sp), Self-acceptance (Sa), Sense of well-being ( W b ) , Responsibility ( R e ) , Socialization (So), Self-control (Sc) , Tolerance ( T o ) , Good impression ( G i ) , Communalicy (Cm) , Achievement via conformance (Ac) , Achievement via independence ( A i ) , Intellectual efficiency ( I e ) , Psychological mindedness (Py) , Flexibility (Fx) and Femininity ( Fe) .
RESULTS~ The VA care subscale score intercorrelations varied from -.I6 to .40. Negative correlations mostly were with the Environment scale and highest positive correlations were between Nursing Notes and Nursing Care Plans. Highest subscale/total score correlation was .82 with Nursing Care Plans. Wayne State subscale intercorrelations varied from .38 to .73. Lowest correlations occurred between Psycho-social and Communication and highest between Psycho-social and Physical. Highest subscale with total score correlation was -88 and occurred with Professional Implications. Patient Interview questions intercorrelated from -.24 to .62. Negative correlations were with knowing the nurse's name and highest correlations were between answering the light promptly and the nurse being described as kind. Intercorrelations among patient-care instruments indicated a number of significant relationships. Environment was the most independent in the VA care scales and Professional Implications was the most independent in the Wayne State scales. Total scores of the VA care scale and Wayne State scales correlated .54. Knowing the nurse's name and the nurse explaining procedures before completing them seemed to be the most independent areas in Patient Interview. Correlations between quality of patient-care scores and nurse-performance scores were quite independent. They varied from no relationship to the high .20s but most fell between .07 and .18. There was evidence of source-variance in the performance measure, that is, scores obtained from a single rater had higher correlations with other items in the same instrument than with other rating instruments. Scores of raters closer together in administrative level had higher correlations than with those farther away, e.g., supervisors' and head nurses' ratings had higher correlations with each other's than with subordinates' ratings. Likewise, subordinate and peer ratings correlated more highly than ratings from subordinate and head nurse. Age
Age was negatively related at significant levels to VA care scales: Nursing Notes (-.45), Nursing Care Plans ( -.40) and Total score (-38). Age was 'Tables on file in Document NAPS-02511. Order from Microfiche Publications, 440 Park Ave S., New York, N. Y. 10016. Remit $1.50 for microfiche or $5.00 for photoCOPY.
TABLE 1 INTERCORRELATION OF WARD SCORES Measures
I
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 11 18
VA Patient Care Scales 1. G m f o n & Safety 2. Environment 39 3. Special Therapy 01 12 23 -08 18 4. Nursing Notes 5. Nursing Care Plan 25 -16 13 40 6. Total 63 26 34 45 82 Wayne State Care Scales 7. Psycho-social 05 23 16 07 -13 01 8. Physical 03 04 05 05 10 1 1 73 9. General 04 04 14 17 25 23 65 65 10. Communication 07 02 16 31 35 38 38 48 48 11. Professional Implicate 03 06 18 02 20 22 65 63 61 64 12. Total 06 09 18 16 21 38 81 84 82 75 88 Patient Interview -24 01 09 08 1 1 03 17 12 14 22 27 23 13. Name R.N. 14. R.N. Kind to You 02 14 12 05 12 16 -12 00-21 00 -04 -09 05 15. R.N. Kind to Visitors 13 23 -08 02 -05 01 05 04 -16 -09 -21 -10 -24 16. Answers Light Promptly 08 28 05 07 20 22 -10 -04 -16 -09 -22 -16 -03 17. R.N. Listens to You 00 21 00 07 18 18 -18 -14 -27 -23 -17 -24 21 18. R.N. Explains to You 31 23 -02 -25 26-24 -01 06-02 -13 06-01 20 Note.-Decimals omitted. N = 50 wards, r .27,fi = .05. '
2
?
B
4
5: 5 m
P
!zi (n
=!
G? 62 49 42 52 36 60 35 15 31 36
9
2w i!
E. D. DYER, ET AL.
260
negatively related to Wayne State scale scores, with the General scale at (-.23) and Communication scale at (-.36). In general, age was negatively related to performance. The two exceptions that reached significance were official rating proficiency (.13) and working without recognition for long periods of time (.15). In brief, older nurses received higher official ratings and could work for long periods without having their efforts recognized. Age was not systematically related to answers given on Patient Interview questions. TABLE 2
RELATIONSHIPSOF AGE AND Measure
Age
EDUCATION TO PATIENT
Educ.
V.A. Patient Care Scales Comfort & Safety -18 -05 09 -27 Environment 13 -12 Special Therapy -45 29 R.N. Notes 29 R.N. Plans -40 Total -38 18 Wayne State Care Scales -06 03 Psycho-social Physical 03 30 General -2 3 27 Communication -36 09 Professional Implications 07 19 Total -08 28 Note.-N = 387, r % .12, p = .05.
CAREAND PERFORMANCE
Measure
Age
Performance Measures Proficiency 13 Chief Nurse Rank -18 Supervisor rating -20 Head nurse rating -09 Peer over-all rating 04 Subordinate over-all rating 02 Patienr Interview Listen to patients 02 R.N. kind to patients 12
Educ. -13 11 02 -09 02 00 26 -25
Education was positively related at significant levels to VA care scale scores: Nursing Notes (.29), Nursing Care Plans (.29), and with Environment ( -.27). Education was generally related positiveIy to Wayne State scale scores, three significantly, Physical (.30), General (.27), and Total (.28). Education was positively related to performance measures with few exceptions. Two relationships were negative at significant levels, reacting promptly in emergencies ( -. 13 ) and Official Rating ( -. 13) . Better educated nurses as described by patients listen to patients more (.26) but are viewed as less kind (.25). Biographical Inventory This inventory was item-analyzed to determine high correlates of patient care and performance measures. Only quesrions which correlated at the .05 level in one direction for high scorers and the opposite direction for low scorers are interpreted. The N varies from 258 to 310. The number and percentage OF nurses choosing the alternative is given in parentheses at the end of each statement.
QUALITY PATIENT CARE AND CHARACTERlSTICS OF NURSES
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Nurses who received high Wayne State scale scores from outside observers described themselves on the biographical inventory differently from low scorers. High scorers liked clearly specified assignments about half the time (41, 2 0 % ) ; low scorers most of the time (87, 5 0 % ) . High scorers encouraged associates to continue their education most of the time (75, 4 3 % ) ; low scorers rarely (5, 3% ). High scorers felt classmates came to them for assistance only rarely (27, 1 4 % ) ; low scorers felt classmates came for assistance less than half the time (55, 27%). High scorers felt they express themselves orally to a great extent (21, 10% ) ; low scorers express themselves to a considerable extent (79, 39%). When ranking words, high scorers felt people were most important (142-162, 77-82 % ) ; low scorers felt learning was most important ( 15, 8% ) . High scorers enjoyed filling out the questionnaire-wanted to talk about it (65, 3 2 % ) ; low scorers found it neither interesting nor too distasteful (25, 1 2 % ) . Nurses who received high performance scores from their second level supervisors described themselves differently from low scorers. High scorers enjoyed what they do on the job most of the time (214, 6 9 % ) ; low scorers less than half the time ( 16, 5 '0). High scorers said they possess a teaching ability to a great extent (45, 1 5 % ) ; low scorers to a moderate extent (118, 38%). High scorers felt they expressed themselves in writing to a limited extent (125, 4 0 % ) ; low scorers to a considerable extent (112, 36%) High scorers felt they have considerable ability ro organize (129, 4 2 % ) ; low scorers have limited ability (16, 5 % ) . High scorers felt proud of their work to a great extent (139, 45 %) ; low scorers to a moderate extent ( 33, 11% ) . High scorers felt responsible for work assignment deadlines to a great extent (206, 6 6 % ) ; low scorers to a considerable extent (96, 31 % ). High scorers worked as supervisors from 3 to 6 yr. (32, 1 0 % ) ; low scorers had never supervised others (192, 6 2 % ) . High scorers said they surpassed 70% of their classmates in high school (91, 2 9 % ) ; low scorers surpassed 80% (90, 2 9 % ) . High scorers were 41 to 50 yr. of age (67, 2 2 % ) ; low scorers were 51 to 60 (65, 2 1 % ) . High scorers actively lead the discussion in a group (105, 3 4 % ) ; low scorers lead the discussion an average amount ( 140, 45 % ) . High scorers felt somewhat comfortable talking with patients who complain about care (70, 2 9 % ) ; low scorers felt very comfortable (45, 1 5 % ) . High scorers derive greatest satisfaction from working with and through others ( 1 18, 38% ) , low scorers from personally doing things for patients (163, 53%). H ~ g hscorers during high school wanted to be all around American Girls ( 125, 40% ) ; low scorers wanted to be humorous and witty (18, 6 % ) . Nurses who received high performance scores from their head nurse described themselves differently than low scorers. High scorers have not participated in community organizations ( 157, 5 1% ) ; low scorers have participated for 7 to 10 yr. (27, 9%). High scorers have a diploma in nursing (143, 4 6 % ) ; low scorers have an associate degree (47, 15% ) . When ranking five words, high
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E. D. DYER, ET AL.
scorers felt people are most important (239, 7 7 % ) ; low scorers felt learning most important (31, 1 0 % ) . Nurses who received high official ratings described themselves differently from low scorers. High scorers enjoy what they do on the job most of the time (177, 69% ) ; low scorers less than half the time (13, 5% . High scorers felt they express themselves in writing to a limited extent (31, 1 2 % ) ; low scorers to a considerable extent (88, 34%). High scorers felt people misunderstand them little if at all (94, 3 7 % ) ; low scorers felt misunderstood to a moderate extent (37, 14%). High scorers worked as a staff nurse 11 or more yr. (103, 4 0 % ) ; low scorers 2 yr. or less (59, 23%). High scorers have had 11 yr. or more experience as a surgical staff nurse (49, 1 9 % ) ; low scorers have no experience as a surgical staff nurse (51, 20%). High scorers have had 3 to 6 yr. experience as an operating room staff nurse (6, 2 % ) ; low scorers have had 2 yr. or less (41, 1 6 % ) . High scorers have had 19 yr. or more experience (74, 2 9 % ) ; low scorers have had less than 2 yr. (55, 2 1 % ) . High scorers wanted to be all around American Girls in high school (104,40%) ; low scorers wanted to be humorous and witty ( 14, 5% ) . Nurses who received high patient-care scores from their peers described themselves differently from low scorers. High scorers have had 2 yr. or less experience as a head nurse (68, 2 3 % ) ; low scorers 7 to 10 yr. (10, 3 % ) . High scorers entered nursing on the advice of parents, relatives or counselors (213, 71 %); low scorers made plans on their own (35, 12% ) . High scorers said education was very important, practically imperative in their childhood home ( 1G2, 54% ) ; low scorers said education was important but not imperative (110, 36%) High scorers have had 2 yr. or less professional experience (74, 25% ) ; low scorers have had 19 yr. or more (75, 25% ) . Nurses who received high patient-care scores from subordinates described themselves differently from low scorers. High scorers felt responsible for deadlines to a considerable extent (88, 3 2 % ) ; low scorers to a great extent (178, 6 5 % ) . High scorers enjoy directing the work of others ro a moderate extent ( 100, 36% ) ; low scorers to a considerable extent ( 103, 38% ) . High scorers entered nursing on the advice of parents and counselors ( 196, 7 2 % ) ; low scorers made plans on their own (21, 8 % ) . Nurses who received high scores on the Composite (derived by averaging scores from the various raters) describe themselves differently from low scorers. High scorers like to pursue thoughts less than half the time (102, 33%); low scorers half the time (130,42% ) . High scorers encourage associates to continue their education about half the time ( 2 7 , 9 % ) ; low scorers encourage them all the time ( 131,42% ). High scorers evaluate their thoughts most of the time ( 192, 62%) ; low scorers all of the time (41, 1 3 % ) . High scorers feel they can express themselves in writing to a limited extent ( 35, 11% ) ; low scorers to a considerable extent ( 112, 36%). High scorers enjoy directing work of others to
QUALITY PATIENT CARE A N D CHARACTERISTICS OF NURSES
263
a considerable extent ( 117, 38% ) ; low scorers to a moderate extent ( 107, 35 % ) . High scorers liked to work alone to a limited extent ( 119, 38% ) ; low scorers prefer to work alone to a moderate extent (84, 27%). High scorers said they received advice from parents or other relatives in choosing a nursing career (37, 1 2 % ) ; low scorers made plans on their own (219, 7 1 % ) . High scorers felt somewhat comfortable listening to patients complain about care (90, 2 9 % ) ; low scorers felt very comfortable (45, 15% ). High scorers derived most satisfaction from working through and with others (118, 3 8 % ) ; low scorers derived most satisfaction from doing things personally for patients ( 163, 53 % ) . When ranking five words, high scorers felt people were most important (239, 77%); low scorers felt learning was most important (32, 10%).
California Psychological Inventory Personality differences were analyzed between nurses receiving high and low scores on patient care and performance measures. Scores on the various meas-
pS
FOR
TABLE 3 DIFFERENCES ON CALIFORNIA PSYCHOLOGICAL INVENTORY FOR STAFF NURSES RATED HIGH ON PATIENT CARE BY VARIOUSRATERS
Age Educ.
1
2 3 4
5 6 7 8
9 10 11 12 13 14 15 16 17
18
.10 .01 3 .10 .O1 .01 .OJ .01 -
Outside Observers
2nd Level Supervisor Head Nurse Peer S u b r d i - ComScale Check- Scale Official nate posite Rating list Rating Proficiency
.o1 .10
.o1
.10
.01 .Ol
.I0 .10
.01 .10
.I 0 -
.10 .I0 .10 .I0
.I0
.01 .10
.10
.01 .I0
.01 .10 .10 .O1 .10 .10
.01 .01
.10 .01 .10 .10
.I0
.10 .I0 -
2 .01
.10
.10
.10 .10 .10
.01
.10 .10 .10
.10
.I0 -
Code.-Scales of the California Psychological Inventory: 1. Dominance ( D o ) , 2. Capacity for status (Cs), 3. Socialibiy (Sy), 4. Social presence (Sp), 5. Self-acceptance (Sa), 6. Sense of well-being ( W b ) , 7. Responsibility ( R e ) , 8. Socialization (So), 9. Self-control (Sc), 10. Tolerance ( T o ) , 11. Good impression ( G i ) , 12. Cornmuaality (Cm),13. Achievement via conformance ( A c ) , 14.Achievement via independence ( A i ) . 15.Intellectual efficiency (Ie). 16. Psychological-mindedness (Py), 17. Flexibility ( F x ) , and 18. Femininity ( F e ) . Italic enuies indicate negative relationship. ' p determined by r test for independent measures.
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E. D. DYER, ET AL.
ures were divided into upper and lower thirds and compared using independent t tests. Differences are shown in Table 3 and were interpreted at the .10 level to include scales which permitted instructive descriptions. Both .01 and .10 levels were included to suggest the magnitude of differences. Staff nurses who received high Wayne State quality patient-care scores from outside observers had higher scores on Capacity for status and Tolerance describing high performers as more ascendant, active, enterprising, resourceful, accepting and non-judgmental. Their breadth of interest was greater and more varied. Staff nurses who received high performance scores from their second level supervisor had higher scores on Dominance, Sense of well-being and cooperative achievement indicating they were more ascendant, socially outgoing and verbally fluent. They followed policies and were cooperatively achievement oriented preferring to achieve on a group basis. Staff nurses who received high performance scores from their head nurse had high scores on Socialization, Self-control and Sense of well-being indicating they exercised self-control, followed policies and procedures and felt things were going well for them. Scaff nurses who received high scores on the official hospital-rating instrument from their head nurse had high scores on eight of the 18 scales of the California Psychological Inventory indicating they were not dominant and exercised self-control. They were responsible, intelligent, tolerant people who followed hospital policy and procedures. They preferred to work and achieve on a group basis. Staff nurses nominated by their peers as best in providing patient care wanted to move up in nursing, felt things were going well for them and were responsible, self-controlled rule followers. They were also efficient intellectually and wanted to achieve independently. Subordinates most often gave high patient-care ratings to staff nurses who were self-controlled and followed policies and rules. Staff nurses who received high scores on a composite of the performance instrument scales felt that things were going well, observed the policies of the institution, wanted to achieve cooperatively and were intellectually efficient. Education differentiated at the .01 level of significance on 7 of the 18 scales of this inventory. Nurses wich more education were more poised, ascendant and self-assured in social situations. They were also more impulsive, tolerant and flexible. In addition, the better educated staff nurses were more efficient intellectually, independent in their achievement desires and more aware of the needs of others. They questioned rules and policies more. Older staff nurses had lower scores on the inventory scales. They were less sociable and outgoing and tended to be more quiet, patient, unassuming and self-
QUALITY PATIENT CARE A N D CHARACTERISTICS OF NURSES
265
restrained. They also had a reduced sense of self-worth and less ability for independent thinking and action. The older nurses were honest, responsible, conscientious, dependable and exercised self-control. They were self-denying, strict and thorough in their work. They wanted to make a favorable impression on others. They were not as intellectually efficient, flexible or independently achievement oriented as their younger staff nurse associates.
DISCUSSION Correlations of patient-care scores and nurse performance scores were surprisingly low. Less than 9% of the variance in care could be accounted for by any one performance score. This seems unusual since performance scales were designed to measure aspects of patient care and health team interaction. Source bias was evidenced by higher correlations within scales of the same instrument and lower correlations between instruments. Age was negatively related to patient-care scores assigned by outside observers and most often negatively related to nurse performance scores from chree levels of supervision, peers, and subordinates. The noteworthy exception was the official performance rating instrument of the insticution. Older staff nurses received higher scores from their head nurses on this form requiring staff nurse signature indicating strong and weak points had been reviewed. Staff nurse performance measures completed by the head nurse not requiring review with the staff nurse demonstrated negative relationships with age. It is probably difficult for younger, better educated head nurses to confront older staff nuzses and document poor performance. The results of such confrontations can resulc in deteriorated relationships. Forward looking counseling programs focusing upon objectives to be accomplished on the unit should result in better working relationships and a concerted effort toward accomplishing objectives. Education was positively related to patient care and performance scores often significantly. Both outside observers who were unaware of the staff nurses education and performance raters in the hospital assigned higher scores to better educated nurses. Raters seemed to give high scores to staff nurses who helped them accomplish their objectives. Supervisors gave high ratings to nurses who were active participants in group work Head nurses rate high those who cheerfully and cooperatively accomplished the day's work.. Generally, nurses who received high patient care and performance scores describe themselves in more positive cerms and as outgoing, participating people who enjoy their work, encourage their CO-workersand like to work with and through others. Positive forward looking educational programs seem indicated to improve the interpersonal effectiveness and self image of staff nurses. Improvements in patient care and nurse satisfaction should result.
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ADAMS, J., & KLEIN, L. R. Studen& in nursing school: consideration in assessing personality characteristics. Nursing Research, 1970, 19, 362-366. CLINE, V. B., RICHARDS,J. M., JR., & NEEDHAM,W. Life history background of students who achieve in science. Science Education, 1962, 46, 258-261. DYER, E. D. Nurse Performance Descripiion: criteria, predictors and correlates. Salt Lake City: Univer. of Utah Press, 1967. DYER, E. D., COPE, M. J., MONSON, M. A,, & VAN DRIMMELEN, J. B. Can job performance be predicted from biographical, personality and administrative climate inventories? Nursing Research, 1972, 21, 294-304. D Y ~ E., D., MONSON, M. A,, & VAN DRIMMELEN,J. B. Are administrative level, age, and educational preparation reflected in California Psychological Inventory scores? Psychological Reports, 197 1, 29, 1111-1120. DYER, E. D., MONSON, M. A,, VAN DRIMMELEN,J. B. Male registered nurses' differences on the California Psychological Inventory. Psychological Reports, 1972, 30, 956. ELLISON,R. L.. JAMES, L. R., FOX, D. G., MCDONALD,B. W., & TAYLOR,C. W. Development and validation of a biographical inventory for the identification of high level nursing talent. Final Report, Contract No. P H 108-66-02, Washington, D. C., U. S. Public Health Service, 1969. KRALL, V. Personality factors in nursing school success and failure. Nursing Research, 1970, 19, 265-268. QUERY,W. T. CPI facrors and success of seminary students. Psychological Reports, 1966, 18, 665-666. RAWLS, D. J., & RAWLS, J. R. Personality characteristics and personal history data of successful and less successful executives. Psychological Reports, 1968, 23, 10321034. TAYLOR,C. W., SMITH. W. R., GHISELIN.B.. & ELLISON,R. L. Explorations i n the measuremeni and prediction of cont~ibutionso f one sample o f scientists. Ladrland AFB: U. S. A. F., AFSC, Personnel Laboratory, 1961. (ASD-TR-62-96) WREN, G. R. Some characteristics of freshmen students in baccalaureate, diploma and associate degree nursing programs. Nursing Research, 1971, 20, 167-172. Accepted hrovember 20, 1974.
W H A T ARE THE RELATIONSHIPS OF QUALITY PATIENT CARE TO NURSES' PERFORMANCE, BIOGRAPHICAL AND PERSONALITY VARIABLES? ELAINE D. DYER, MARY A. MONSON, AND JENNIE B. VAN DRIMMELEN
veteran^ Admini~trationHorpital, Sal; Lake City Brigham Young University, P+ovo, Urah Summary.-Relationships among measures of quality patient care, nurse performance, biographical and personalicy data were smdied for 387 staff nurses from 60 wards of 7 VA hospitals. Patient-care ratings were obtained by outside observers and nurses' performance ratings were obrained from three supervisory levels, peers and subordinates. Correlations between patient-care scores and performance scores were surprisingly low. Coefficients in the high twenties were rare. Education was related positively with patient care and nursing performance measures, often significantly. Age was usually related negatively to patient care and performance measures, often significantly. Higher rated nurses generally described themselves in more positive terms and as more open, helpful, energetic and people-oriented. Personality patterns of nurses rated high by various raters reflect situational needs of raters. Second-level supervisors rated nurses high who were dominant, verbal, and ascendant but cooperative participators. Head nurses rated nurses high who were not dominant but were self-controlled, responsible and cooperative in interactions with others and felt things were going well. Education was positively related to Califo~nia Psychological Inventory scores except for Responsibility. Age was negatively related except for Responsibility, Self-control, and Good impression.
Personal hlstory and personality measures have been used to describe and sometimes pred~ctsuccessfd people in a variety of educational and work settings. Krall ( 1970) reported negative results in using Draw-a-Person to predict success in nursing. Adams and Klein (1970) found significant differences between nursing students and other college women using the Edwards Personal Preference Schedule. Wren ( 197 1 ) found significant biographical differences between freshmen student nurses in baccalaureate, diploma, and associate degree programs. Rawls and Rawls (1968) found significant differences on five of the 15 Edwards Personal Preference Schedule scales and 10 of the 18 California Psychological Inventory scales. Their biographical inventory questions corroborated findings from the personality measures and described the successful executive as more self-confident, ambitious, competitive, dominant, aggressive, manipulative and opportunistic in dealing with others. H e was also more impulsive and more prone to emphasize personal pleasure and self-gain. Query (1966) found successful seminary students significantly different from seminary students who dropped from the program on five of the 18 CPI scales. Successful students were higher on Capaciry for status, Tolerance and Flexibility and significantly lower on Sociability and Self-acceptance.
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The work of Dyer and colleagues (Dyer, 1967; Dyer, Monson, & Van Drimmelen, 1971, 1972) indicated that biographical and personality measures are consistently related at significant levels with nursing performance, administrative position, and education. The work of Cline, Richards, and Needham ( 1962 ) , Ellison, James, Fox, McDonald, and Taylor (1969), Taylor, Smith, Ghiselin, and Ellison ( 1961 ) also indicated the value of biographical information in predicting success on the job. The present study was completed to increase our understanding of relarionships of several measures of quality patient care with nurses' performance, biographical, and personality data.
METHOD Three hundred and eighty-seven staff nurses from 60 medical-surgical wards in seven V.A. hospitals completed a Biographical Inventory and the California Psycho!ogical Inventory. Hospitals were similar in bed capacity (400 to 600). medical and nursing school affiliation, bed occupancy rate and patient turnover rate. Two hospitals were located in the south, two in the midwest, and three on the west coast. The average age of nurses was 42 yr. with a standard deviation of 12. Educational preparation was 48% diploma, 14% associate degree, 30% bachelor's degree and 8 % had continued their education beyond the bachelor level. Performance ratings were obtained on staff nurses from three levels of nursing supervision, ward-nurse peers, and ward subordinates. Quality of patient care was described by trained observers from outside the hospital who monitored care using three patient-care measuring instruments: Wayne State Quality Patient Care Scales, Veterans Administration Nursing Care Quality Evaluation, and a one-page Patient Interview containing six questions plus occurrences the patient liked or disliked. Relationships among measures of quality care, performance-rating instruments, biographical, and personaliry variables were studied using intercorrelation matrices, item analyses and t tests. Relationships of Wayne State scales with measures of nursing performance were studied in an individual-item jntercorrelation matrix. Relationships of the Veterans Administration patient-care scale and Patient Interview with measures of performance were studied using data reduced to ward scores. This was necessary because the Veterans Administration care scale and Patient Interview scores were obtained only on a ward basis. Correlations from the individual variables matrix were interpreted for 387 staff nurses ( 7 2 .12, p = .OJ). Correlations from the ward matrix were interpreted .27, p = .05). When correlations of the Veterans Adminisaccording ro 50 wards (s tration care scales or Patient Interview with other variables are referred to in the results section, correlations are from the ward intercorrelation matrix. Relationships of biographical items to quality care measures and performance evaluation measures were studied using an item analysis program. For each quality care and performance measure and each biographical question an eta, standard error and N were computed and for each question alrernative a biserial, point biserial, standard error, N, and percentage. Biographical questions relating significantly in one direction on one end of the scale and significantly in the opposite direcrion on the other end of the scale were interpreted as discriminators of quality care or performance. In order to study personality differences between high- and low-scoring nurses on the patient-care and nurses' performance instruments, staff nurses were divided into upper and lower thirds and compared on scales of the California Psychological Inventory using independent r rests. Differences were interpreted at the .10 level to allow more instructive descriptions of characteristics.
QUALITY PATIENT CARE AND CHARACTERISTICS OF NURSES
257
Measuring lnstrunients Patient care.-Three instruments were used to assess quality level of patient care. The first was the Veterans Administration Nursing Care Quality Evaluation, developed by a VA task force of nurse clinicians, nurse administrators, management systems personnel, and consultants. Items in final form had been scrutinized by several hundred nurses and were considered to be important indicators of patient care. Items were built to be observable on a "yes." "no" or "not applicable" basis. Scores for subscales were determined by dividing total number of yes responses by total number of applicable responses. Seventy-one items define 14 areas considered to be imporcant in patient care. Six areas are applicable only with patients receiving various types of special care. Major areas of the instrument are named: Symptoms. Identification, Personal Hygiene, Welfare and Comfort, Immediate Environment, Restraints and Protective-Safety Measures, DressingsCompresses-Bandages-Binders, Inrubation-Infusion Therapy. Preventive-Supportive-Assistive Therapy. Special Precautions, Other Bedside Therapy, Physician's Orders, Nursing Notes, and Nursing Care Plan. For this smdy che first four areas ( 1 3 questions) were summed and called Comfort and Safety, the next seven questions defined the Environment scale, the next seven areas or 24 questions were summed and called Special Therapy. Physician's Orders area was not used. The Nursing Notes area has seven questions and Nursing Care Plan scale 14 questions. A total score was obtained by summing the five subscale scores. The second measure, Wayne State Quality Patient Care Scales, was adapted by Mabel Wandelt and Joel Ager from scales developed by Doris Slater. Five subscale scores and toral score were used in this study. The five scales used consisted of 7 to 15 items and were named: Psycho-social, Individual, Physical, General, Communication, and Professional Implications. The third measure. the Patient Interview, was comprised of eight questions which described nurse-patient relationships from the patient's point of view. Typical questions asked h e patient if nurses were kind to patients and visitors, answered lights promptly, listened to patients and explained procedures. Things most satisfying or annoying to patients also were sought. Performance measures.-There were G measures. ( 1 ) Nurse Performance Description Scales contains five scales of 10 items each. Items discriminating nursing performance ar the .05 level in a variety of seniogs were retained. Retest reliabilities were mosdy in che high eighties and correlations with other performance rating instruments from .4Os to .70s. ( 2 ) Descriptive Scales for Nursing Performance contains 1G scales named: Patient-care Competence, Use of Time, Quality of Work, Skill with People, Oral Communication, Receptiveness to Change, Creativity, Orientation Toward Independent Achievement, Breadth oE Knowledge, Stimulation Value, Tolerance, Group Leadership, Patientcare Expertise, Cleverness with New Ideas, Leadership Adroitness, and Over-all Work Description. Retest reliabilities for total score are in the high .70s and .80s and correlations with other measures of performance range from .40s to .70s. These first two performance scales correlate in the .50s. ( 3 ) An Official Performance Rating (Proficiency) was o b tained from hospital records for each staff nurse. ( 4 ) The Chief Nurse ranked nurses according to over-all effectiveness. Rankings were transformed to a scale with a mean of 50 and standard deviation of 10. ( 5 ) Ward registered nurses nominated their wardpeer registered nurses on sca!es to determine best in patient care, group leadership, interpersonal relationships, and over-all. Nominations were converted to a scale with a mean of 50 and standard deviation of 10. ( 6 ) Ward licensed practical nurses and nursing assistants nominated staff tegiscered nurses on the same scales as peers. Scores were converted to a scale with a mean of 5 0 and standard deviation of 10.
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E. D. DYER, ET AL.
Biographical Inventory has a total of 132 questions describing developmental, educational and professional history along with questions to assess attitudes and values. California Prychological Inventory contains 18 scales describing factors associated with social interaction, named Dominance ( D o ) , Capacity for status (Cs), Sociability (Sy ) , Social presence (Sp), Self-acceptance (Sa), Sense of well-being ( W b ) , Responsibility ( R e ) , Socialization (So), Self-control (Sc) , Tolerance ( T o ) , Good impression ( G i ) , Communalicy (Cm) , Achievement via conformance (Ac) , Achievement via independence ( A i ) , Intellectual efficiency ( I e ) , Psychological mindedness (Py) , Flexibility (Fx) and Femininity ( Fe) .
RESULTS~ The VA care subscale score intercorrelations varied from -.I6 to .40. Negative correlations mostly were with the Environment scale and highest positive correlations were between Nursing Notes and Nursing Care Plans. Highest subscale/total score correlation was .82 with Nursing Care Plans. Wayne State subscale intercorrelations varied from .38 to .73. Lowest correlations occurred between Psycho-social and Communication and highest between Psycho-social and Physical. Highest subscale with total score correlation was -88 and occurred with Professional Implications. Patient Interview questions intercorrelated from -.24 to .62. Negative correlations were with knowing the nurse's name and highest correlations were between answering the light promptly and the nurse being described as kind. Intercorrelations among patient-care instruments indicated a number of significant relationships. Environment was the most independent in the VA care scales and Professional Implications was the most independent in the Wayne State scales. Total scores of the VA care scale and Wayne State scales correlated .54. Knowing the nurse's name and the nurse explaining procedures before completing them seemed to be the most independent areas in Patient Interview. Correlations between quality of patient-care scores and nurse-performance scores were quite independent. They varied from no relationship to the high .20s but most fell between .07 and .18. There was evidence of source-variance in the performance measure, that is, scores obtained from a single rater had higher correlations with other items in the same instrument than with other rating instruments. Scores of raters closer together in administrative level had higher correlations than with those farther away, e.g., supervisors' and head nurses' ratings had higher correlations with each other's than with subordinates' ratings. Likewise, subordinate and peer ratings correlated more highly than ratings from subordinate and head nurse. Age
Age was negatively related at significant levels to VA care scales: Nursing Notes (-.45), Nursing Care Plans ( -.40) and Total score (-38). Age was 'Tables on file in Document NAPS-02511. Order from Microfiche Publications, 440 Park Ave S., New York, N. Y. 10016. Remit $1.50 for microfiche or $5.00 for photoCOPY.
TABLE 1 INTERCORRELATION OF WARD SCORES Measures
I
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 11 18
VA Patient Care Scales 1. G m f o n & Safety 2. Environment 39 3. Special Therapy 01 12 23 -08 18 4. Nursing Notes 5. Nursing Care Plan 25 -16 13 40 6. Total 63 26 34 45 82 Wayne State Care Scales 7. Psycho-social 05 23 16 07 -13 01 8. Physical 03 04 05 05 10 1 1 73 9. General 04 04 14 17 25 23 65 65 10. Communication 07 02 16 31 35 38 38 48 48 11. Professional Implicate 03 06 18 02 20 22 65 63 61 64 12. Total 06 09 18 16 21 38 81 84 82 75 88 Patient Interview -24 01 09 08 1 1 03 17 12 14 22 27 23 13. Name R.N. 14. R.N. Kind to You 02 14 12 05 12 16 -12 00-21 00 -04 -09 05 15. R.N. Kind to Visitors 13 23 -08 02 -05 01 05 04 -16 -09 -21 -10 -24 16. Answers Light Promptly 08 28 05 07 20 22 -10 -04 -16 -09 -22 -16 -03 17. R.N. Listens to You 00 21 00 07 18 18 -18 -14 -27 -23 -17 -24 21 18. R.N. Explains to You 31 23 -02 -25 26-24 -01 06-02 -13 06-01 20 Note.-Decimals omitted. N = 50 wards, r .27,fi = .05. '
2
?
B
4
5: 5 m
P
!zi (n
=!
G? 62 49 42 52 36 60 35 15 31 36
9
2w i!
E. D. DYER, ET AL.
260
negatively related to Wayne State scale scores, with the General scale at (-.23) and Communication scale at (-.36). In general, age was negatively related to performance. The two exceptions that reached significance were official rating proficiency (.13) and working without recognition for long periods of time (.15). In brief, older nurses received higher official ratings and could work for long periods without having their efforts recognized. Age was not systematically related to answers given on Patient Interview questions. TABLE 2
RELATIONSHIPSOF AGE AND Measure
Age
EDUCATION TO PATIENT
Educ.
V.A. Patient Care Scales Comfort & Safety -18 -05 09 -27 Environment 13 -12 Special Therapy -45 29 R.N. Notes 29 R.N. Plans -40 Total -38 18 Wayne State Care Scales -06 03 Psycho-social Physical 03 30 General -2 3 27 Communication -36 09 Professional Implications 07 19 Total -08 28 Note.-N = 387, r % .12, p = .05.
CAREAND PERFORMANCE
Measure
Age
Performance Measures Proficiency 13 Chief Nurse Rank -18 Supervisor rating -20 Head nurse rating -09 Peer over-all rating 04 Subordinate over-all rating 02 Patienr Interview Listen to patients 02 R.N. kind to patients 12
Educ. -13 11 02 -09 02 00 26 -25
Education was positively related at significant levels to VA care scale scores: Nursing Notes (.29), Nursing Care Plans (.29), and with Environment ( -.27). Education was generally related positiveIy to Wayne State scale scores, three significantly, Physical (.30), General (.27), and Total (.28). Education was positively related to performance measures with few exceptions. Two relationships were negative at significant levels, reacting promptly in emergencies ( -. 13 ) and Official Rating ( -. 13) . Better educated nurses as described by patients listen to patients more (.26) but are viewed as less kind (.25). Biographical Inventory This inventory was item-analyzed to determine high correlates of patient care and performance measures. Only quesrions which correlated at the .05 level in one direction for high scorers and the opposite direction for low scorers are interpreted. The N varies from 258 to 310. The number and percentage OF nurses choosing the alternative is given in parentheses at the end of each statement.
QUALITY PATIENT CARE AND CHARACTERlSTICS OF NURSES
261
Nurses who received high Wayne State scale scores from outside observers described themselves on the biographical inventory differently from low scorers. High scorers liked clearly specified assignments about half the time (41, 2 0 % ) ; low scorers most of the time (87, 5 0 % ) . High scorers encouraged associates to continue their education most of the time (75, 4 3 % ) ; low scorers rarely (5, 3% ). High scorers felt classmates came to them for assistance only rarely (27, 1 4 % ) ; low scorers felt classmates came for assistance less than half the time (55, 27%). High scorers felt they express themselves orally to a great extent (21, 10% ) ; low scorers express themselves to a considerable extent (79, 39%). When ranking words, high scorers felt people were most important (142-162, 77-82 % ) ; low scorers felt learning was most important ( 15, 8% ) . High scorers enjoyed filling out the questionnaire-wanted to talk about it (65, 3 2 % ) ; low scorers found it neither interesting nor too distasteful (25, 1 2 % ) . Nurses who received high performance scores from their second level supervisors described themselves differently from low scorers. High scorers enjoyed what they do on the job most of the time (214, 6 9 % ) ; low scorers less than half the time ( 16, 5 '0). High scorers said they possess a teaching ability to a great extent (45, 1 5 % ) ; low scorers to a moderate extent (118, 38%). High scorers felt they expressed themselves in writing to a limited extent (125, 4 0 % ) ; low scorers to a considerable extent (112, 36%) High scorers felt they have considerable ability ro organize (129, 4 2 % ) ; low scorers have limited ability (16, 5 % ) . High scorers felt proud of their work to a great extent (139, 45 %) ; low scorers to a moderate extent ( 33, 11% ) . High scorers felt responsible for work assignment deadlines to a great extent (206, 6 6 % ) ; low scorers to a considerable extent (96, 31 % ). High scorers worked as supervisors from 3 to 6 yr. (32, 1 0 % ) ; low scorers had never supervised others (192, 6 2 % ) . High scorers said they surpassed 70% of their classmates in high school (91, 2 9 % ) ; low scorers surpassed 80% (90, 2 9 % ) . High scorers were 41 to 50 yr. of age (67, 2 2 % ) ; low scorers were 51 to 60 (65, 2 1 % ) . High scorers actively lead the discussion in a group (105, 3 4 % ) ; low scorers lead the discussion an average amount ( 140, 45 % ) . High scorers felt somewhat comfortable talking with patients who complain about care (70, 2 9 % ) ; low scorers felt very comfortable (45, 1 5 % ) . High scorers derive greatest satisfaction from working with and through others ( 1 18, 38% ) , low scorers from personally doing things for patients (163, 53%). H ~ g hscorers during high school wanted to be all around American Girls ( 125, 40% ) ; low scorers wanted to be humorous and witty (18, 6 % ) . Nurses who received high performance scores from their head nurse described themselves differently than low scorers. High scorers have not participated in community organizations ( 157, 5 1% ) ; low scorers have participated for 7 to 10 yr. (27, 9%). High scorers have a diploma in nursing (143, 4 6 % ) ; low scorers have an associate degree (47, 15% ) . When ranking five words, high
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E. D. DYER, ET AL.
scorers felt people are most important (239, 7 7 % ) ; low scorers felt learning most important (31, 1 0 % ) . Nurses who received high official ratings described themselves differently from low scorers. High scorers enjoy what they do on the job most of the time (177, 69% ) ; low scorers less than half the time (13, 5% . High scorers felt they express themselves in writing to a limited extent (31, 1 2 % ) ; low scorers to a considerable extent (88, 34%). High scorers felt people misunderstand them little if at all (94, 3 7 % ) ; low scorers felt misunderstood to a moderate extent (37, 14%). High scorers worked as a staff nurse 11 or more yr. (103, 4 0 % ) ; low scorers 2 yr. or less (59, 23%). High scorers have had 11 yr. or more experience as a surgical staff nurse (49, 1 9 % ) ; low scorers have no experience as a surgical staff nurse (51, 20%). High scorers have had 3 to 6 yr. experience as an operating room staff nurse (6, 2 % ) ; low scorers have had 2 yr. or less (41, 1 6 % ) . High scorers have had 19 yr. or more experience (74, 2 9 % ) ; low scorers have had less than 2 yr. (55, 2 1 % ) . High scorers wanted to be all around American Girls in high school (104,40%) ; low scorers wanted to be humorous and witty ( 14, 5% ) . Nurses who received high patient-care scores from their peers described themselves differently from low scorers. High scorers have had 2 yr. or less experience as a head nurse (68, 2 3 % ) ; low scorers 7 to 10 yr. (10, 3 % ) . High scorers entered nursing on the advice of parents, relatives or counselors (213, 71 %); low scorers made plans on their own (35, 12% ) . High scorers said education was very important, practically imperative in their childhood home ( 1G2, 54% ) ; low scorers said education was important but not imperative (110, 36%) High scorers have had 2 yr. or less professional experience (74, 25% ) ; low scorers have had 19 yr. or more (75, 25% ) . Nurses who received high patient-care scores from subordinates described themselves differently from low scorers. High scorers felt responsible for deadlines to a considerable extent (88, 3 2 % ) ; low scorers to a great extent (178, 6 5 % ) . High scorers enjoy directing the work of others ro a moderate extent ( 100, 36% ) ; low scorers to a considerable extent ( 103, 38% ) . High scorers entered nursing on the advice of parents and counselors ( 196, 7 2 % ) ; low scorers made plans on their own (21, 8 % ) . Nurses who received high scores on the Composite (derived by averaging scores from the various raters) describe themselves differently from low scorers. High scorers like to pursue thoughts less than half the time (102, 33%); low scorers half the time (130,42% ) . High scorers encourage associates to continue their education about half the time ( 2 7 , 9 % ) ; low scorers encourage them all the time ( 131,42% ). High scorers evaluate their thoughts most of the time ( 192, 62%) ; low scorers all of the time (41, 1 3 % ) . High scorers feel they can express themselves in writing to a limited extent ( 35, 11% ) ; low scorers to a considerable extent ( 112, 36%). High scorers enjoy directing work of others to
QUALITY PATIENT CARE A N D CHARACTERISTICS OF NURSES
263
a considerable extent ( 117, 38% ) ; low scorers to a moderate extent ( 107, 35 % ) . High scorers liked to work alone to a limited extent ( 119, 38% ) ; low scorers prefer to work alone to a moderate extent (84, 27%). High scorers said they received advice from parents or other relatives in choosing a nursing career (37, 1 2 % ) ; low scorers made plans on their own (219, 7 1 % ) . High scorers felt somewhat comfortable listening to patients complain about care (90, 2 9 % ) ; low scorers felt very comfortable (45, 15% ). High scorers derived most satisfaction from working through and with others (118, 3 8 % ) ; low scorers derived most satisfaction from doing things personally for patients ( 163, 53 % ) . When ranking five words, high scorers felt people were most important (239, 77%); low scorers felt learning was most important (32, 10%).
California Psychological Inventory Personality differences were analyzed between nurses receiving high and low scores on patient care and performance measures. Scores on the various meas-
pS
FOR
TABLE 3 DIFFERENCES ON CALIFORNIA PSYCHOLOGICAL INVENTORY FOR STAFF NURSES RATED HIGH ON PATIENT CARE BY VARIOUSRATERS
Age Educ.
1
2 3 4
5 6 7 8
9 10 11 12 13 14 15 16 17
18
.10 .01 3 .10 .O1 .01 .OJ .01 -
Outside Observers
2nd Level Supervisor Head Nurse Peer S u b r d i - ComScale Check- Scale Official nate posite Rating list Rating Proficiency
.o1 .10
.o1
.10
.01 .Ol
.I0 .10
.01 .10
.I 0 -
.10 .I0 .10 .I0
.I0
.01 .10
.10
.01 .I0
.01 .10 .10 .O1 .10 .10
.01 .01
.10 .01 .10 .10
.I0
.10 .I0 -
2 .01
.10
.10
.10 .10 .10
.01
.10 .10 .10
.10
.I0 -
Code.-Scales of the California Psychological Inventory: 1. Dominance ( D o ) , 2. Capacity for status (Cs), 3. Socialibiy (Sy), 4. Social presence (Sp), 5. Self-acceptance (Sa), 6. Sense of well-being ( W b ) , 7. Responsibility ( R e ) , 8. Socialization (So), 9. Self-control (Sc), 10. Tolerance ( T o ) , 11. Good impression ( G i ) , 12. Cornmuaality (Cm),13. Achievement via conformance ( A c ) , 14.Achievement via independence ( A i ) . 15.Intellectual efficiency (Ie). 16. Psychological-mindedness (Py), 17. Flexibility ( F x ) , and 18. Femininity ( F e ) . Italic enuies indicate negative relationship. ' p determined by r test for independent measures.
264
E. D. DYER, ET AL.
ures were divided into upper and lower thirds and compared using independent t tests. Differences are shown in Table 3 and were interpreted at the .10 level to include scales which permitted instructive descriptions. Both .01 and .10 levels were included to suggest the magnitude of differences. Staff nurses who received high Wayne State quality patient-care scores from outside observers had higher scores on Capacity for status and Tolerance describing high performers as more ascendant, active, enterprising, resourceful, accepting and non-judgmental. Their breadth of interest was greater and more varied. Staff nurses who received high performance scores from their second level supervisor had higher scores on Dominance, Sense of well-being and cooperative achievement indicating they were more ascendant, socially outgoing and verbally fluent. They followed policies and were cooperatively achievement oriented preferring to achieve on a group basis. Staff nurses who received high performance scores from their head nurse had high scores on Socialization, Self-control and Sense of well-being indicating they exercised self-control, followed policies and procedures and felt things were going well for them. Scaff nurses who received high scores on the official hospital-rating instrument from their head nurse had high scores on eight of the 18 scales of the California Psychological Inventory indicating they were not dominant and exercised self-control. They were responsible, intelligent, tolerant people who followed hospital policy and procedures. They preferred to work and achieve on a group basis. Staff nurses nominated by their peers as best in providing patient care wanted to move up in nursing, felt things were going well for them and were responsible, self-controlled rule followers. They were also efficient intellectually and wanted to achieve independently. Subordinates most often gave high patient-care ratings to staff nurses who were self-controlled and followed policies and rules. Staff nurses who received high scores on a composite of the performance instrument scales felt that things were going well, observed the policies of the institution, wanted to achieve cooperatively and were intellectually efficient. Education differentiated at the .01 level of significance on 7 of the 18 scales of this inventory. Nurses wich more education were more poised, ascendant and self-assured in social situations. They were also more impulsive, tolerant and flexible. In addition, the better educated staff nurses were more efficient intellectually, independent in their achievement desires and more aware of the needs of others. They questioned rules and policies more. Older staff nurses had lower scores on the inventory scales. They were less sociable and outgoing and tended to be more quiet, patient, unassuming and self-
QUALITY PATIENT CARE A N D CHARACTERISTICS OF NURSES
265
restrained. They also had a reduced sense of self-worth and less ability for independent thinking and action. The older nurses were honest, responsible, conscientious, dependable and exercised self-control. They were self-denying, strict and thorough in their work. They wanted to make a favorable impression on others. They were not as intellectually efficient, flexible or independently achievement oriented as their younger staff nurse associates.
DISCUSSION Correlations of patient-care scores and nurse performance scores were surprisingly low. Less than 9% of the variance in care could be accounted for by any one performance score. This seems unusual since performance scales were designed to measure aspects of patient care and health team interaction. Source bias was evidenced by higher correlations within scales of the same instrument and lower correlations between instruments. Age was negatively related to patient-care scores assigned by outside observers and most often negatively related to nurse performance scores from chree levels of supervision, peers, and subordinates. The noteworthy exception was the official performance rating instrument of the insticution. Older staff nurses received higher scores from their head nurses on this form requiring staff nurse signature indicating strong and weak points had been reviewed. Staff nurse performance measures completed by the head nurse not requiring review with the staff nurse demonstrated negative relationships with age. It is probably difficult for younger, better educated head nurses to confront older staff nuzses and document poor performance. The results of such confrontations can resulc in deteriorated relationships. Forward looking counseling programs focusing upon objectives to be accomplished on the unit should result in better working relationships and a concerted effort toward accomplishing objectives. Education was positively related to patient care and performance scores often significantly. Both outside observers who were unaware of the staff nurses education and performance raters in the hospital assigned higher scores to better educated nurses. Raters seemed to give high scores to staff nurses who helped them accomplish their objectives. Supervisors gave high ratings to nurses who were active participants in group work Head nurses rate high those who cheerfully and cooperatively accomplished the day's work.. Generally, nurses who received high patient care and performance scores describe themselves in more positive cerms and as outgoing, participating people who enjoy their work, encourage their CO-workersand like to work with and through others. Positive forward looking educational programs seem indicated to improve the interpersonal effectiveness and self image of staff nurses. Improvements in patient care and nurse satisfaction should result.
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E. D. DYER, ET AL. REFERENCES
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