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My»: 1": {"315 . r- "I'm. n. 'a- .1; ,3' I; . u...‘ I” "ffp:ht ~ gang? — :fu‘; :5: 3;; 3;?” 'r.-‘ ‘ . vathng, v .-.- . 1 my J: 7.73%.] .1— ‘ £121 .. I 1:! L‘s-5c ‘4 75:54:13, 1,33,, ‘ kw _ I.\l’4 :Pfllll - }‘Ivln .H? ~ heir -! 2 V I I x} . £1. at ‘11? fix‘fib \ w tiu. A '- . 'w' " .uawa‘u 4.09;" . u'n'nun ”ll/WWW]! :1 a 87 18 H LIBRARY Michigan State University This is to certify that the dissertation entitled Therapeutic Touch: Promoting and Assessing Conceptual Change Among Health Care Professionals presented by Gwen Wyatt has been accepted towards fulfillment . — _ . of the requirements for PhD degree in Educational Psychology / Major professor Douglas Campbell, Ph.D. Date 8/8/88 MS U is an Affirmative Action/Equal Opportunity Institution 0-12771 )V1531_] RETURNING MAI§315L§; Place in book drop to LlBRARJES remove this checkout from w your record. ElfLE§ wi ll - , be charged if book is returned after the date stamped below. 43-74% 231%koqézyé5flE ‘ NOV 0 23333 THERAPEUTIC TOUCH: PROMOTING AND ASSESSING CONCEPTUAL CHANGE AMONG HEALTH CARE PROFESSIONALS by Gwen Karilyn Hamilton WYatt A DISSERTATION Submitted to Michigan State university in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Education Department of Counseling, Educational Psychology and Special Education 1988 ABSTRACT THERAPEUTIC TOUCH: PROMOTING AND ASSESSING CONCEPTUAL CHANGE AMONG HEALTH CARE PROFESSIONALS BY Gwen Karilyn Hamilton wyatt This study examined how health care educators can facilitate the conceptual change necessary for health care professionals to incorporate holistic interventions into their practice. The conceptual change model of Posner and Strike provided a framework for this study. The subjects were eleven registered nurses. The intervention was a two day advanced workshop on Therapeutic Tcuch. Data were obtained at four time intervals, using written surveys, case studies, audio tapes, and interviews. An inductive analysis resulted in twelve themes and revealed the additional variable of barriers to implementation in practice. The variable of orientation (holistic/dualistic) was also coded. The deductive analysis consisted of both process and outcome variables. The process variables were included in the workshop and were verified both by the subjects and a non-attending Therapeutic Tcuch instructor. These process variables were dissatisfaction with the existing concept, understanding, plausibility, and fruitfulness of the new concept. Gwen Karilyn Hamilton Hyatt The outcome variables derived from a stage theory including two levels of three variables: knowledge, application, and acceptance of the new concept. To evaluate all the data, an alternative rating system was developed for the stage evaluation, including two new variables (barriers and orientation). The results of the outcome analysis demonstrated that the majority of the subjects began at a stage one or two and rose to a stage three one week after the workshop, and then reverted back to stage one or two, two months after the workshop. The factor of barriers strongly contributed to this shift back to stages one and two. Another result was that acceptance of the new concept was found at all three stages rather than only stage three, as proposed by the conceptual change model. A final finding was that conceptual change concerning Therapeutic Touch was maintained better than for holistic interventions. Copyright by GWEN KARILYN HAMILTW WYATT 1988 DEDICATED TO the memory of my father, Baxter Laurel Hamilton (Jack) ACKNOWLEDGMENTS I wish to thank everyone who contributed to my dissertation and supported me through this process. First of all I thank my committee members: Dr. Douglas Campbell, Dr. Stephen Yelon, Dr. Don Hamachek, and Dr. Donald Melcer. For me, Dr. Melcer represented a kindred spirit in my pursuit of the new physics. I felt he truly understood that this study was my humble but deep felt contribution to the further exploration and application of the new physics concepts. This sense of purpose kept me moving through this adventure. Dr. Don Hamachek contributed his vision for the future. He was able to see the validity of a new research area in health care, and was willing to foster its development. During the process of this study, he continually provided me with new insights, not only related to Therapeutic Touch, but to a variety of emerging health interventions. Dr. Stephen Yelon kept me on target. He worked with me single-handedly through his sabbatical year in the development of my proposal. He helped me set goals and deadline which kept my study on course. He alerted me to all the dissertation landmarks along the way. Dr. Douglas Campbell guided the data analysis during the second year of my study. I came to realize, over the time I worked with him how fortunate I was to have such an outstanding scholar and mentor on my committee. I cannot imagine how different this study would have vi been without his guidance. I learned so much more than how to analyze qualitative data. I learned an entirely new style of teaching. He kept the context of our work environment open and non-threating, at all times. He was always supportive during the times of slow progress. He expressed a consistent level of sensitivity to everyone I saw him interact with during our meetings. In short, his style of teaching was exactly what was needed for my study, and I am grateful for this exceptional learning experience. Others who contributed to this study, who I wish to thank, are first of all, Maria Parisen. Maria served as my outside Therapeutic Touch rater for the the audio tapes. I know this took valuable time away from her other roles in life, but she most willing completed this evaluation. I also wish to thank my co-instructor in Therapeutic Touch and my friend, Sherry Dimmer. She was the person who believed in our ability to make a contribution to nursing, through providing Therapeutic Touch workshops. Further, I would like to thank the workshop participants who agreed to contribute their time and honest opinions to this study. It could not have happened without them. next, I wish to acknowledge the support I received personal through this project. I thank my mother, Emeline Hamilton, for instilling the goal of higher education, and for being an outstanding academic role model. I also thank my friends who have followed my progress step by step. My dear friend, Bernadette Pratt, has been my confidant through the peaks and valleys of this study. She helped me keep perspective through the difficult times and celebrated my successes. Another friend, Suzanne Budd, nurtured me through this process. She vii helped keep my life on schedule and reminded me to build in diversity. I also experienced a great deal of support from my colleagues in the College of Nursing. Their flexibility allowed me to meet my professional responsibilities while completing this degree. Last, but far from least, I wish to thank my son, Christopher, for his love and support. I have been a student for as long as he can remember. In retrospect, I hope that I have shared my time and energy wisely between my roles, and that my efforts encourage Chris in his own educational goals. He has truly been the spark that has keep my life kindled through this process. He provided me with a sense of "knowing“ that this project would come to a successful completion. For his faith in me, I am thankful. To all my professors, friends, and family members, who I have not mentioned individually, I also wish to extend a sincere thank you for your interest and support. Thank you everyone. viii TABLE OF CONTENTS Chapter Page I. II. ImmDMION.COOOOOOOOCOOOOOOOOOOOOO0.0.0.0....0.00.00.00.0000001 Selection of Prototype Intervention.............................l Need for the Study..............................................2 The Problem for HCEs.........................................4 Dissemination of New Interventions...........................5 Purpose of This Study...........................................5 Major Goals of This Study....................................6~ Conceptual Change Model.........................................6 A Model for Studying Conceptual Change.......................6 Conceptual Change Model Questions............................7 Model variables..............................................7 Stages of Conceptual Change..................................8 Assumptions of This Study.......................................9 - Statement of Research Questions................................10 Specific Questions Addressed in This Study..................lO “finition Of wrunt TemsOOOOOOOO.I...00.0.000000000000000012 Plan for “is stuGYOOOOOOOOOOOOOOOOO0.00...00.0.00000000000000012 lem MI“.O...OOOOOOOOOOOOOOOOOOOOOOO0.00.0000...0.0.0.14 Origins of the Conceptual Change Model.........................l4 Empiricist‘s Epistemology...................................lS Conceptual Change Epistemology..............................15 Distinction Between Normal and Revolutionary Science........16 Evolutionary Shift..........................................16 Distinction between Accommodation and Assimilation..........l7 Conditions of Learning......................................18 Teaching Methods............................................19 Conceptual Change Model Research...............................21 Therapeutic Touch as a Prototype...............................23 Description of Therapeutic Touch............................23 Steps of Therapeutic Touch..................................24 Link Between Therapeutic Teuch and Related Scientific Theories.......................26 Historical Studies..........................................31 Recent Studies..............................................33 smarYCOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOOOOOO0.00.00....36 ix III. PRWWOOOOOOOOOOOOO0.0...0.0.0.000...00.0.0000000000000000038 Introduction...................................................38 Research Design................................................38 Instrumentation................................................39 Before: Survey.............................................40 Before: Holistic Case Study................................40 Before: Therapeutic Touch Case Study.......................40 Demographic.................................................41 During: Audio Tapes........................................4l After: One‘week After Interview............................41 After: Survey..............................................42 After: Holistic Case Study.................................42 After: Therapeutic Touch Case Study........................42 workshop Description...........................................43 Origins of the workshop Content.............................43 workshop Cbmponents.........................................44 Setting for the workshop....................................51 Faculty for the werkshop....................................52 Subjects.......................................................53 Procedures for Data Collection.................................54 Phase One of Data Collection................................54 Phase Two of Data Collection................................55 Phase Three of Data Collection..............................57 Procedure for Data Analysis....................................58 Procedural Methods..........................................58 Inductive Themes and Meaning Uhits..........................59 Conditions of Learning......................................62 Overlap of Inductive and Deductive Analysis.................63 Stages of Conceptual Change.................................65 Determination of Stage Attainment...........................68 Added variables................................................70 Orientation.................................................70 Barriers....................................................7l Alternative staging...’0.0.0....0.0...OOOOOOOOOOOOOOOOCOOOO0.0072 smuYOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOCOOOOOOOOO0.0000000000000073 mum-PMS mmmsmWSOOOOOOOOOOO0.000000COCOCC74 Introduction...................................................74 Demographic Data...............................................74 All werkshop Participants...................................74 Study Participants..........................................75 Conditions of Learning.........................................76 Introduction................................................76 Instructor Perspective......................................78 Participant Perspective.....................................83 Outside TT Instructor's Perspective.........................88 Themes.........................................................88 Introduction............................................;...88 Sense of Self as a Professional.............................90 Potential Future, Feasibility or Research Promise of TT.....91 Aspects of the workshop Content.............................92 V. Aspects of the workshop Experience or Environment...........93 Attitudes/Opinions/Insights.................................94 Mention of Feelings or Change in Life Perspective...........95 Why Participants Attended TT II.............................96 Ability to Use TT At work...................................96 Mention of Specific Holistic Intervention or Approach.......97 Support of the New Holistic Conception......................98 smarYOOOOOOCOOOOOOO0.0.0.0....0.00.0.0.0....0................99 mm-STMImOCOOOOCOOOOOOOOOOOO000......00.0.000000000000101 Stages of Conceptual Change...................................lOl Introduction...............................................lOl Explanation of variables Found in Table 5.1................103 Explanation of variables Found in Table 5.2................106 Participant 7..............................................lll Participant l3.............................................116 Participant 14.............................................ll9 Participant 20.............................................123 Participant 33.............................................127 Summary of Data Sets with Three Time Intervals Represented...........................131 Participant l7.............................................133 Participant 27.............................................l37 Participant 32.............................................l41 Summary of Data Sets with Two Time Intervals Represented.............................l44 Participant l..............................................l46 Participant 28.............................................l48 Summary of Data Sets with One Time Interval Represented..............................150 Overall Conclusions........................................150 SW AND CMLUSIONS.O0.......0.I....0.0.0.0.00000000000000155 Summary.......................................................155 Research Questions and Instruments.........................155 Two Approaches to Analysis.................................156 First Results Chapter......................................157 Second Results Chapter.....................................158 Limitations...................................................159 Conclusions...................................................159 Research Question l........................................159 Research Question 2........................................160 Research Question 3........................................160 Implications and Recommendations..............................161 Theoretical Implications...................................161 Methodological Implications................................163 Practice Implications......................................165 Personal Reflections..........................................167 ”Beaten IssueSOIOOOOOOOOOOOOOOOOOOOIOO0.00.00.00.000000000167 ‘ Practice IssueBOOOOOOOOO0.0.0....O..0.0.0.0.000000000000000168 xi Experiences Associated with This Study.....................168 Learning Context for Analysis..............................169 Final Thoughts on the Health Care System...................l70 ”PmIGSOOOOOCOOO00.00.000.000...000......000......OOOOOOOOOOOOOOOOOO Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix QHNQNMUON’ Consent Form......................................l72 Holistic Case Study - Before......................l74 Therapeutic Touch Case Study - Before.............l75 Survey - Before...................................l76 Demographic Form..................................l79 Interview Questions...............................181 Cover Letter - After..............................183 Holistic Case Study - After.......................185 Therapeutic Touch Case Study - After..............186 Survey - After....................................187 BELImeCCCOOOOOO0.00.0...OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO Bibliwramy.00....00......OOOOOOOOOOOOOOOOOCC0.00000000000000190 “natal hferencea...OOOOOOOOOOOOOOOOO0.0.0....00.0.0000000000193 xii LIST OF TABLES TABLE Page 2.1 Interface of Conditions of Learning with Teaching Methods...............................................22 3.1 Interface of Data Collection Time Intervals with Data Collection Instruments...............................39 3.2 The Data Sources and the Number of Participants Who Were Requested to Participate, Who Completed Data Forms, and Who Completed Data Forms and Met Criteria...................................................54 Themes from the Data...........................................61 Interface of Conditions of Learning with Teaching Methods...............................................77 Number of Responses Illustrating Themes, by Subject...........100 Stages According to the Model.................................102 Staging Results Participant 25..............................105 Staging Results Participant 7...............................1l3 Staging Results Participant 13..........,...................1l7 Staging Results Participant 14..............................120 Staging Results Participant 20..............................124 Staging Results Participant 33..............................128 Summary of Subjects Who Completed All Three Data Collections..l32 Staging Results - Participant 17..............................135 0 Staging Results - Participant 27..............................138 l Staging Results - Participant 32..............................l42 2 Summary for Subjects Who Completed the Before and Two Months After Data.........................................l45 5.13 Staging Results - Participant 1...............................146 5.14 Staging Results - Participant 28..............................148 5.15 Summary for Subjects Who Completed Only the Before Data.......151 5.16 Summary Data for All Subjects.................................152 .0) e 0 H03 UIUIMWUIUIUUIUIUIUIUIh e PHH‘DO‘IGUIIDLQNHN xiii Chapter I INTRODUCTION New interventions are continually being introduced to the health care field, but how do health care professionals (HOP) sort out which modalities they will seriously consider? This question is often easily answered if HCPs understand how they will incorporate the new knowledge into their existing belief system. However, when an intervention is unique enough to potentially conflict with their existing belief structure, the answer may not be obvious. A new intervention must be very convincing to cause HCPs to re-evaluate their conceptual system. This study examines one such health care intervention - Therapeutic Touch (TT). Therapeutic Touch is a holistic intervention which many HCPs have been drawn to understand and practice in recent years. Once HCPs undertake the study of TT, they often become aware of a shifting in their underlying beliefs about health care. This study examines both the specific change in beliefs associated with learning TT and the change in foundational beliefs about health care in general. Selection of Prototype Intervention Therapeutic Touch was chosen as the prototype intervention for this study because it is of special interest to me, the researcher. I have taught a series of workshops on TT to HCPs over the past several years. After attending a TT workshop, HCPs often express changes in their thinking about their health care beliefs. This study focuses on the advanced TT workshop in the series. All participants had taken the basic Therapeutic Touch workshop (TT I) prior to attending the advanced Therapeutic Touch workshop (TT II). I was interested in better understanding the conceptual change that occurs as a result of the learning and practice of TT. This is why I was encouraged to study my workshop participants in light of a model for conceptual change. The model's variables appeared to be a good mode of entry into uncovering the factors that contribute to the philosophical changes experienced by TT workshop participants. TT is one of many holistic interventions which could have been used to assess HCP's conceptual change. This study is devoted to the conceptual change process with TT as its prototype holistic intervention. Need for the Study Today, there is an emergence of health care techniques which counter the present theoretical positions of many HCPs. For example, many non-invasive (holistic) health care modalities are being introduced in the health field such as mental imagery, biofeedback, hypnosis, and Therapeutic Touch. Such modalities integrate the aspects of mind and body in holistic care. The growing research base supports non-invasive modalities as an adjunct treatment to traditional invasive (dualistic) modalities such as surgery, medication, and radiation. Invasive (dualistic) modalities are short term in nature, must be frequently repeated by a health professional, and are often accompanied by undesirable side effects. Non-invasive (holistic) modalities include the clients and their families and can be continued independently after receiving proper instruction. However, HCPs often see the newer interventions as another task to add to an already busy schedule. Furthermore, many HCPs are more comfortable using the established dualistic modalities than trying to incorporate something new. However, HCPs and health care educators (HCEs) are becoming more aware of the potential usefulness of holistic modalities with the advent of increased support for them in the literature. Once a new intervention has received numerous citations, the next most appropriate method for dissemination of information and application of the newly publicized intervention is through workshops and seminars designed for HCPs. Because HCEs develop workshops on relatively innovative and often times conceptually new interventions for HCPs, they may choose to utilize a model for conceptual change. In this way, HCEs can help HCPs begin to make the conceptual change needed to understand the new intervention's contribution to health care. To evaluate the level of conceptual change following a workshop for HCPs, HCEs may turn to the emerging models of conceptual change. Strike and Posner (1985) outline one such model in the educational psychology literature. The conceptual change model suggests conditions necessary for conceptual change and specifies the methods of instruction needed in order to expect conceptual change to occur. This conceptual change model was chosen because the components involved are particularly relevant to innovative, holistic health care interventions. The conceptual change model includes ideas such as one's beliefs about the ultimate nature of the universe as well as other more conventional areas, i.e., drawing on past experiences, being economical and parsimonious. Other models commonly used in the health care literature such as Lewin's change theory (1942) or the Health Belief Model (Becker, 1974) emphasize compliance with prescribed health behaviors. This study of conceptual change focuses on changing well-established conceptions of HCPs. The interest of this project is not to obtain compliance with specific behaviors, but rather to influence HCP's conception of health care beliefs. The conceptual change model is the most useful in the sense that it contains both practical and philosophical conponents. The Problem for HCEs Health care educators (HCEs) are responsible for introducing new interventions to health care professionals (HCPs). However, HCPs frequently have difficulty accepting innovative interventions when the new ideas do not represent the established theoretical position. At present, most HCPs treat either the mind or the body based on a client's complaint. The established practice of treating the mind and body separately may hinder the HCPs capacity to seriously consider a new intervention such as one which assumes that the mind and body influence one another. For these reasons, HCPs frequently have difficulty making the conceptual change necessary to adopt innovative holistic health modalities which consider the mind and body simultaneously. Dissemination of New Interventions HCPs are continually exposed to opportunities for conceptual change, especially when considering the growing body of research and experiential literature available to nurture such change. Often something more than independent reading is required to truly trigger the first stage of conceptual change. Frequently, the literature will spur the HCPs' interest to the point that they actively search for educational experiences which will further validate or invalidate their personal questions. These educational opportunities usually are presented as a workshop or seminar given by an HCPs who can share their particular field of expertise. HCPs who serve as HCEs most commonly come from the academic community where theory and practice interface. Purpose of This Study The purpose of this study is to explore the change in conception experienced by workshop participants related to a holistic health care intervention. Major Goals of This Study The major goals of this study are: l. assessing the degree of conceptual change achieved two months after an advanced workshop on a holistic intervention (TT) which requires conceptual change for HCPs: 2. assessing the presence of methods and conditions of learning in the workshop: and 3. evaluating the theoretical contribution of themes derived inductively from the data. Conceptual Change Model A.Model for Studying:Conceptual Chapgg Strike and Posner (1985) view learning as conceptual change. They see learning as a rational process which involves the conditions under which a person is or should be willing to change his/her mind. This model presupposes the learner to be a processor of experience and information rather than a retainer of information. Strike and Posner (1985) state '...the task of learning is primarily one of relating what one has encountered to one's current ideas” (p.2). In order for the HOP to learn, he/she must understand new ideas, judge their truth value, and evaluate their consistency with currently held ideas. The model maintains that rational acceptance of a theory is based on whether the theory solves problems generated by a new conceptual context or by a previously held conception. Therefore, being rational involves how one solves outstanding problems generated by a current belief or by how one moves from one view to another. Conceptual Change Model Questions The conceptual change model of Strike and Posner addresses two main questions. 1. In what ways do learners incorporate new conceptions into current cognitive structures? (Assimilation) 2. In what ways do learners replace conceptions which have become dysfunctional with new ones? (Accommodation) This study focuses on the second question proposed by the conceptual change model, i.e., accommodation. Accommodation is necessary for HCPs to change their orientation from dualistic to holistic. Adopting TT is one source of evidence that this change is occurring. Model variables The conceptual change model is a stage theory containing a variety of variables. It proposes that a learner can be at one of three stages in the process of conceptual change. Within each stage are levels of change, and the levels focus on knowledge, application, and acceptance. Therefore, a learner is evaluated by level within a particular stage. The levels are basic and advanced for knowledge and application. Acceptance is either present or absent. The other major set of variables in the model are the conditions of learning. There are four conditions of learning which are integrated with specific teaching methods - plausibility of the new concept, understanding of the new concept, fruitfulness of the new concept, and dissatisfaction with the existing concept. In summary, the model variables consist of three stages, the four conditions of learning, and specific teaching methods. Stages of Conceptual Change There are three stages to conceptual change. Only when the learner has reached the third stage has he/she fully accommodated a new conception, i.e., made a conceptual change. Stage On . Stage one is minimal understanding. This is the minimal level of understanding required for a learner to begin to consider the possibility of the truth or reasonableness of a new conception (Strike & Posner, 1985). Following instruction, time must elapse before any given stage can be achieved. The amount of time needed to integrate a new conception will vary with the concept being accommodated. The learner at this level will be able to apply the conception to a simple or stereotype problem, but cannot see how the idea can be used in more complex situations (Strike & Posner, 1985). Stage two. Stage two is full understanding. The learner now has a level of understanding which resembles the expert. The learner sees a wide range of implications of the conceptions and can apply them to complex and novel situations. Again, after receiving instruction or knowledge, time must elapse before the new concept can be fully useful. Stage three. Stage three is accommodation. This level goes beyond stage two. Now the learner also has a degree of acceptance. Acceptance means that the learner believes the new concept is superior to the previously held concept and he/she is able to apply it regularly without slipping back to the old conception. Assumptions of This Study This study is based upon the following assumptions. 1. The current health care system is extensively dualistic. 2. Most HCPs accept the current health care system. 3. Conceptual change (accommodation) is necessary for the HCP's overall orientation toward health care to shift from dualistic to holistic. 4. The adoption by HCPs of TT as a viable intervention is one indication that conceptual change has occurred. In summary, accommodation rather than assimilation is necessary for the HCP's overall orientation to change from dualistic to holistic thinking in order to adopt TT. In other words, the person must change his/her established dualistic conceptions (accommodate) rather than simply add TT to his/her current belief system (assimilate) in order to achieve conceptual change. 10 Statement of Research Questions The broad theoretical question has three underlying aspects. In what ways do learners replace conceptions which have become dysfunctional with new ones? 1. 2. 3. To what degree do participants in a holistic health care workshop experience conceptual change? How do the methods of the workshop relate to the aspects of change noted? What additional factors account for the change noted? Specific Questions Addressed in This Study 1. What stage of conceptual change related to holistic interventions do registered nurses demonstrate before a (TT II) workshop when assessed by an open-ended written response to a general case study and gggggy? What stage of conceptual change related to 23 do registered nurses demonstrate before a TT II workshop when assessed by an open-ended written response to a 22 case study and 525231? What factors other than attending a TT I workshop influenced registered nurses attending TT II to incorporate holistic concepts into their nursing practice when questioned by an open-ended gggggy before attending a TT II workshop? What factors other than attending a TT I workshop influenced registered nurses to incorporate :2 concepts into their 6. 7. 11 nursing practice when questioned by an open-ended survey before attending a TT II workshop? Do registered nurses attending TT II believe that the four conditions of learning from the conceptual change model were presented in the TT II workshop when interviewed one week after the workshop? What stage of conceptual change related to holistic interventions did registered nurses demonstrate two months after attending a TT II workshop when assessed by an open-ended written response to the same general case study and survey used before TT II? What stage of conceptual change related to 2! did registered nurses demonstrate two months after attending a TT II workshop when assessed by an open-ended written response to the same gg_case study and gggygy used before TT II? What factors other than attending a TT II workshop influenced registered nurses to incorporate holistic concepts into their nursing practice when questioned by an open-ended survey two months after a TT II workshop? What factors other than attending a TT II workshop influenced registered nurses to incorporate 3! concepts into their nursing practice when questioned by an open-ended survey two months after a TT II workshop? 12 Definition of Impgrtant Terms The following definitions for key terms used in this study will provide a common basis for understanding. 1. 2. 3. 4. Health care professional (HCP). Registered nurses, medical doctors, osteopathic doctors, social workers, and psychologists are included in this definition. Health care educators (HOE). Health care professionals with a specific expertise, who offer educational programs for other health care professionals. Dualistic care. Care which gives primary emphasis to the physical aspects of a patient's symptoms. Holistic care. Care which emphasizes health and considers, in addition to the patient's symptoms, additional aspects of the patient's well-being, i.e., psychological, social, spiritual, and physical. Therapeutic Touch. A nursing intervention which balances the energy field surrounding a person. The nurse moves his/her hands through the patient's field in a head to toe direction, approximately three to five inches above the skin surface. Plan for This Study Chapter II presents a review of the literature in two areas. The literature related to the development of the conceptual change model and the literature on the research base of Therapeutic Touch. 13 In Chapter III, the procedures used in the study including subjects, research design, instrumentation, and data collection are discussed. Also, the procecedures for data analysis are described. The results of analysis of the process variables of the conceptual change model and the inductive themes will be presented in Chapter Iv. Chapter‘v reports the results of the analysis of the stages of conceptual change. Finally, Chapter VI presents a summary of the study, limitations, conclusions, implications, and recommendations for future research. Chapter II LITERATURE REVIEW Conceptual change is a relatively new concept in the educational psychology literature. During the early 1980s, Strike and Posner began exploring how learners change their established conceptions. Prior to this, most studies had been conducted on the initial teaching of concepts to children, but virtually nothing had been explored related to changing the conceptions of adult learners. In this void, these two researchers and their associates began to develop a framework for evaluating conceptual change. The evolving theory emerged from their background in cognitive psychology, and differs from empiricism. The framework then outlines the essential ingredients for conceptual change to occur. This study will look at the conceptual change of health care providers, related to their health care beliefs. Origins of the Conceppual Change Model Strike (1982) first began sharing the conceptual change model in his book Educational Policy and the Just Society, citing the various people who led his thinking towards the need for a new model. These names included Popper, Kuhn and Toulmin with their contrasting views on the scientific paradigm, and less recently, Plato and Kant's divergent 14 15 views on inquiry and knowing. From this background, Strike (1982) itemized the empiricist's stance and then his perception of the same issues. ggpiricist's Epistemolggy 1. All knowledge originates in experience. 2. Experience is the sole evidence of our beliefs. 3. Knowledge is additive and bottom up. 4. Experience is given to us in atoms referred to as sensations or sense data. Conceptual Changngpistemolggy 1. Problems are generated by current conceptions. 2. Solution to problems are judged by means of current conceptions. 3. Current conceptions are a product of a history of conceptual development. These statements of contrast with empiricism set the stage for the theory itself. It is clear that the conceptual change theory deals with established concepts rather than new learning. Strike (1982) goes beyond saying that the mind is not blank; he says that what is in the mind influences the perception of the addition of anything new or the revision of anything old. 16 Distinction between Normal and Revolutionary Science In explaining how conceptual change fits into scientific inquiry, Strike (1982) drew upon Kuhn's account of the distinction between normal and revolutionary science. Normal science is dominated by paradigms with puzzles to be solved. There is a central commitment to defining the problem, indicating strategies for solution, and specifying criteria for what counts as solutions. On the other hand, there is revolutionary science. This is when a paradigm is beset by anomalies and faced with a rival theory. It is possible for one paradigm to be overthrown and replaced by a competitor. A new paradigm becomes certified when it achieves sufficient dominance among the appropriate scientific groups to have its standards become the standards of rationality for the group. Any dissidents then are viewed as incompetent (Strike, 1982). Evolutionapy Shift Strike suggests a third possible mode of change -- an evolutionary shift. In the explanation, he borrows the term "conceptual ecology" from Toulmin (1972): '...conceptual variation occurs in a conceptual ecology. An adequate account of science must not just explain why claims are accepted or rejected, but how they are changed. Epistemology on this view is the theory of conceptual change" (p.145). What Strike states is that one concept can be examined while the remainder provide the intellectual ecology to make a rational 17 conceptual shift possible. Conceptual change would be a gradual change rather than an all-or-nothing revolutionary change. Strike and Posner (1985) have broken the evolutionary process of conceptual change down into three stages. The three stages of conceptual change are: 1. Minimal Understanding: The minimal level required for a person to begin to entertain a new conception, but an appreciation of the full range of applications is still lacking. This person is able to apply the new conception to simple or stereotyped problems, but not more complex situations. 2. Full understanding: This person's understanding resembles that of an expert. This person can see a wide range of implications and can apply the concept to complex and novel situations. 3. Accommodation: This person has full understanding and novel application plus a degree of acceptance. Distinction Between Accommodation and Assimilation The conceptual change model borrows the terms assimilation and accommodation from Piaget. In Posner, Strike, Hewson, and Gertzog's (1982) use of these terms, accommodation is the alteration of central commitments which occurs when assimilation of phenomena to current concepts is unsuccessful and new central concepts must be adopted. A person will usually try to assimilate new phenomena to old concepts in a way that requires minimal dislocation of central beliefs or basic 18 concepts which have two features: they are what other concepts assimilate to and what changes when accommodation is required. Therefore, the first task in instruction is to identify the basic concepts or basic conceptual units. The conceptual change model theorists link accommodation and assimilation to the three stages of change by pointing out that accommodation (conceptual change) is not a straight forward and linear process. Conceptual change is a gradual process, evolving through the three stages from assimilation to accommodation. Conditions of Learnipg Posner and Strike further specified conditions of conceptual change which served as the conditions of learning for this study. 1. Dissatisfaction with existing conceptions. This may occur when one or more of the following are experienced. a. A conception is incapable of interpreting experience presumed to be interpretable. b. A conception is seen to be no longer necessary in the interpretation of experiences previously considered significant. c. A conception is incapable of solving some problems that it presumably should be able to solve. d. A conception violates an epistemological or metaphysical standard. 19 e. The implications of a conception are unacceptable. f. A conception becomes inconsistent with knowledge in other areas. 2. Minimal understanding of a new conception. a. The new concept is necessary to construct or identify a framework in which to locate the new idea. b. The new concept is necessary to attach the framework to the world in at least prototypical ways. 3 Initial plausibility of a new conception. Initial plausibility can be thought of as the anticipated degree of fit of a new conception into an existing conceptual ecology. 4. Fruitfulness of a new conception. a. The new concept must help interpret experiences, solve problems, and in certain cases meet spiritual or emotional needs. b. The new concept must do more than the prior conception without sacrificing prior benefits (Strike & Posner, . 1985). Teaching Methods The conceptual change model refers to the teaching methods as the conceptual ecology. There are seven features to the conceptual ecology. l. Anomalies: Failure of a given idea to fit a current concept. 3. 5. 6. 7. 20 Analogies and Metaphors: These can serve to suggest new ideas and to make them intelligible. Exemplars and Images: Prototypical examples, thought experiments, imagined or artificially simulated objects. Past Experience: Conceptions must not appear to contradict one's past experience. Epistemological Commitments: a. Explanatory ideals. Most fields have subject matter and specific views concerning what counts as a successful explanation in the field. b. General views about the character of knowledge. Some standards for successful knowledge such as elegance, economy and parsimony. Metaphysical Beliefs and Concepts: a. Metaphysical beliefs about science. Beliefs concerning the extent of orderliness, symmetry, or nonrandomness of the universe. b. Metaphysical concepts of science. Particular scientific conceptions often have a metaphysical quality in that they are beliefs about the ultimate mature of the universe. Other Knowledge: a. Knowledge in other fields. New ideas must be compatible with other things people believe to be true. 21 b. Competing conceptions. The new conception should appear to have more promise than its competitors (Strike & Posner, 1985). These conditions of learning and methods are the process components of the conceptual change model. Table 2.1 shows how the conditions of learning interface with the teaching methods. Conceptual Chapgngodel Research Strike and Posner constructed the model from elements proven successful in completed research, adding their own ideas. The research consisted mainly of studies with elementary science and mathematics programs (Posner, et a1., 1982). Ortany (1975) used the model component of the metaphor in his discussion of science education. Nussbaum.and Novak (1976) assessed second grader's concept of the earth using a structured interview. Nussbaum (1979) repeated the study of children's conceptions of the earth as a cosmic body, examining the response of fourth and fifth graders. The results suggested the interview method to be useful in evaluating change over time. Stavy and Berkovitz (1980) used cognitive conflict to teach quantitative aspects of temperature to fourth graders. Posner and Gertzog (1980) utilized the clinical interview as an approach to measuring conceptual change. This study suggested the best methods of inquiry were 1) general open-ended questions, 2) problemesolving tasks, 3) garden-path tasks which lead the students to counterintuitive conclusions, and 4) comprehensive tasks. 22 Table 2.1 Interface of Conditions of Learning with Teaching Methods CONDITIONS OF LEARNING Dissatis- Minimal Plausi- Fruitful- TEACHING METHODS faction Uhderstandigg bility, ness Anomalies x x x Analogies & Metaphors x x Exemplars and Images x x Epistemological x x Commitments Metaphysical Beliefs x x and Concepts Past Experience x x x Other Knowledge x x x The X's indicate how the teaching methods operationalize the four conditions of learning. 23 From the limited research and literature utilizing the components of the conceptual change model, the time seems ripe for further development. Researchers have typically extracted key aspects of the model and branched off into their own direction of emphasis. This study incorporates the full complement of variables from the conceptual change model and applies them to a group of HCPs who were in the process of experiencing change in their basic health care beliefs. In order to establish the conceptual change model's credibility, research will have to be designed and conducted to test the predictability of the variables and the overall usefulness of the model. Therapeutic Touch as_g Prototype Therapeutic touch was chosen as a prototype to which to apply the conceptual change model because it is necessary for most learners to make a shift in basic concepts in order to understand and accept TT. This section will include a brief description of TT, the historical beginnings and the most current studies. Descpiption of Therapeutic Touch Therapeutic Touch is a holistic health care intervention, which is a supplement to traditional health care and not a replacement. Therapeutic Touch is performed on the human energy field which is approximately three to five centimeters beyond the skin surface at any given time. This intervention is an effort to balance the human energy field and make it more uniform and smooth. Therapeutic Touch is based 24 on the original research of Dr. Delores Krieger, a professor at New York university. The research in this area began in the late 19603 and has continued to be refined. The studies to date have focused on the effectiveness of TT, in such areas as decreasing stress, relieving pain, and calming restless newborns. Steps of Thergpeutic Touch 1. Centering. The first and most essential step is called centering. This may be thought of as entering a meditative or very relaxed state of mind. The practitioner's mind is alert but peaceful and calm. This could be thought of as the opposite of feeling fragmented or stressed. The practitioner must be able to let go of outside pressures of daily life in preparation for providing a treatment. This can be accomplished through a variety of ways, such as visual imagery of a peaceful scene, focusing on one's breathing, or using a one such as a work or sound to recall a previous calm. Assessment. The practitioner moves his/her hands through the patient's energy field three to five centimeters away from the skin surface in a head to toe direction to perceive variations in the field. When sensing such differences, the practitioner is asked to compare bilateral anatomical areas. A totally healthy field would lack such variations. However, most 4. 25 people are not perfectly balanced at any time. These variations are most commonly described by the practitioner as warm or cool areas. Other descriptors include tingling, pressure, or a vacuum. The practitioner makes a mental note of the location of the variations in the field in order to validate the finding with the patient. Activating the field. In this step the practitioner moves her/his hands briskly but smoothly through the field to activate the energy flow. This can but need not include a brief physical massage to tense areas of the body. The shoulders or neck area are the most common example. This step mobilizes the patient's static or congested energy in the field so it will be easier to balance. gpgggy transfer. The practitioner concentrates on drawing energy from the environment and directing it to the depleted area of the patient's field. The practitioner mentally images energy entering his/her body, usually through the head. This conscious intent of energy flow is then directed to the patient's field through the practitioner's hands. By acting as a channel, the practitioner does not tire during the treatment since there is no depletion of personal energy. In fact, the practitioner often feels revitalized after providing a treatment. 26 5. Balancing. After the depleted areas of the field have been energized, the practitioner's focus shifts to smoothing out the entire field. The goal of this step is to help the field feel as symmetrical as possible throughout. The practitioner adjusts areas of congestion by using his/her hands to gently shift energy to areas of deficit. For instance, if a patient has an excess of energy over the left arm, the practitioner tries to move the energy so that it felt more like the right arm. This process is conducted over the entire body, always comparing right and left sides in a head to toe direction. 6. Evaluation. This is a final check of the field to determine that as much balance as possible has been achieved. With many conditions it is not possible to balance the field entirely in one treatment: repeated treatments are required. NOrmally, the practitioner would limit a treatment to approximately fifteen minutes, but the treatment can be repeated on a daily basis for a severe imbalance or weekly to monthly depending upon the patient's condition. Link Between Therapeutic Touch and Related Scientific Theories Now that I have presented a brief description of TT, I will discuss how TT is linked to related sciences. Fedoruk (1984) has complied an excellent summary of this scientific link. I draw upon her work, including several of her direct quotes. 27 gpgerian Nursing Theory. Rogerian Nursing Theory is the most closely linked theory to TT and is in turn supported by broader scientific theories. The basic assumptions which apply to TT from Rogerian Theory and which are stated in Rogerian terminology are the following. 1. Man is an open-system in continual interaction with his/her environment. 2. Man has the capacity for conscious thought processes (Rogers, 1970). 3. Man is a unified whole that is more than the sum of his/her parts. 4. Man's life is negenthropic and patterned. gpgn gystem. The first two assumptions of Rogers' are supported by twentieth-century physics. We entered this century with a Cartesian and Newtonian world view, where humanity was seen as separate from his/her environment. In this sense humanity was an outside observer of his/her reality. But this conception changed dramatically with the introduction of Einstein's conception of space-time and the interchangeability of energy and matter. With Einstein's theory of relativity, humanity was suddenly placed inside his/her reality as a participant. Einstein explained that time, mass, speed, momentum and energy were relative to the perception of the observer (Fedoruk, 1984). The second theory to lend shift away form Newtonian Law was Quantum Physics. It found that at the subatomic level electrons would manifest 28 as either waves (fields) or particles, depending on the instrument used. Capra (1975) stated that the predictable laws of nature were replaced with 'wavelike patterns of probabilities - not probabilities of things but rather probabilities of interconnections" (p. 57). Einstein also summarized this conception: We may therefore regard matter as being constituted by the regions of space in which the field is extremely intense...There is no place in this kind of physics for both the field and matter, for the field lg the only reality (Capra, 1975, p. 197). Quinn (1982), in her research on TT, has also shown the link between Quantum Field Theory and current practical application of human field phenomena. Quinn points to the work of Burr at Yale university School of Medicine. Burr developed a sensitive vacuum voltmeter and demonstrated that all living things are surrounded by an electrodynamic field (Quinn, 1982). The Navy has also pursued this line of investigation by development of a Superconducting‘Quantum Interference Device (SQUID). This device can isolate individual magnetic fields from the background noise of the earth's magnetic field. It is predicted that such devices will be common place in health care within the near future for detecting the fields produced by major organs such as the brain and heart (Fedoruk, 1984). Conscious Thought. Bohm, a leading theoretical physicist and former associate of Einstein, has made a further contribution to linking the theories of physics to TT. For his study of subatomic movement, he developed the Theory of Implicate Order. He perceived an 29 implicate order to the universe which can be characterized as invisible to the naked eye out of which the explicate (visible) is manifested. '... physical matter has its root in the nonmanifest' (Bohm, 1982, p. 82). Be included thoughts, feelings, desires and will in this implicate order. '... consciousness is a material process, more subtle than the usual material processes that we look at with our senses, or with our scientific instruments“ (Bohm, 1982, p. 82). Bohm then built the connection between Einstein's work, Quantum Field Theory, and his Theory of Implicate Order and applied it to the explicate world. He drew upon the central component of TT, meditation, and stated that 'meditation is a way of connecting man's consciousness with the field or totality behind the Implicate Order so that.man's consciousness can act as a vehicle or an instrument for the operation of this totality - of intelligence, compassion, and truth' (1982, p. 98) in the explicit order of reality. In Lionberger's (1985) study of nurses' practice of TT, she found that while nurses carried out TT in unique ways, the one central stable variable was a meditative state during TT. Macrae (1985) states, "The Therapeutic Touch process evokes a certain quality of being that can best be described as meditative" (p. 272). 30 Unified Whole. Systems Theory clearly states that the whole is more than the sum of its parts (Wilbur, 1982). weiss (1971) states: A living system is no more adequately characterized by an inventory of its material constituents such as molecules, than the life of a city is described by the list of names and numbers in a telephone book. Only by virtue of their interactions do molecules become patterns in the living process; in other words, through their behavior Life is process, not substance (p.267). 'Nggenthropy and Pattern. Prigazine won his NObel Prize for his Theory of Dissipative Structures. He was able to find exceptions to the previously held law of entropy or a gradual running down of the universe (Second Law of Thermodynamics). Based on this theory, Weiss was able to prove that humanity and most biological systems functions like dissipative structures. In other works, they are exceptions to entropy because they continually reorganize themselves at higher and more complex level (weiss, 1971). we see that Rogerian Theory is again supported in terms of negentropy and the whole as being greater than the sum of its parts. Summary. In summary, I have shown that TT is consistent with the current scientific descriptions of the world - humanity is an open system interconnected to others and the whole. “In this description of the world a transfer of energy or matter, for E-MCZ, from one person to another is not a remarkable phenomena but an unavoidable event“ (Fedoruk, 1984, p. 48). This transfer of energy takes place through a process which is compatible with modern physics where consciousness is 31 viewed as a subtle material process which creates or defines our reality out of the universal field (Bohm, 1982). It may seem that great pains have been taken to establish the basis of TT. But in a world where holistic health care modalities are scrutinized, it is essential to be able to demonstrate the theoretical placement of TT in the larger scientific picture. Historical Studies Prior to the investigation of TT with the human energy field, a series of studies examined the energy fields of mice, plants, and enzymes. Grad (1961, 1967), a biochemist at McGill university, conducted a series of experiments that attempted to influence the energy fields of animals and plants. Grad used non-human subjects to remove the effects possibly due to suggestion. In one study, twenty-eight mice were divided into three groups - one control and two experimental. All mice were calmed for two weeks by holding and stroking by the laboratory assistants. Then each was anesthesized, and a skin flap of equal size was removed from each mouse's back. The control group received food and water and were housed in the same cage as the other two groups. Experimental group one received laying-on-of-hands to their cage for 15 minutes each day by a known healer. Experimental group two had their cage heated each day for 15 minutes to simulate the amount of heat created by the healer's hand. After 11 and 14 days, the experimental group one had significantly more healing than the control group or the second experimental group. 32 Grad (1961) repeated this study on 300 mice using a double blind design. The laboratory assistants doing the wounding and measuring did not know which group the mice were in. One group had this method. Group two received no treatment again. Group three had their cages held by the healer. The results were the same. On days 15 and 16, the experimental group had significantly smaller wounds than the other two groups. Grad (1965) next conducted a series of studies using plants as subjects. An equal number of barley seeds were planted in pots and were all watered with a saline solution to make them 'sick.‘ However, the saline solution for the experimental seeds were first held in a beaker by a known healer for fifteen minutes. After two weeks, the plants were compared for number of plants that sprouted per pot and the mean height of sprouted plants. The experimental seeds were significantly healthier than the control seeds, based on the measurements. Be conducted another plant study with several more control groups, but still found the same results. Smith (1972), a biochemist at Rosemary Hill College in Buffalo, New York, chose to investigate enzyme activity. Pour flasks of the enzyme trypsin were used in this double blind study. One flask received no treatment (control). A second flask was held by a known healer for 75 minutes. The third flask was exposed to destructive ultraviolet light until its activity was reduced by 68% to 80% and then held by the same known healer for 75 minutes. The fourth was exposed to a high magnetic field for three hours to increase enzyme activity. The two flasks which were 33 held by the healer, including the one exposed to ultraviolet light, reached the same level of activity as the flask that was placed in the high magnetic field. The control flask showed no change in activity. Smith (1973) repeated this study several times, using a variety of enzymes. The results indicated that several enzymes were very susceptible to the healer's influence, some enzymes were moderately influenced and some were unaffected, e.g., amylase. Recent Studies Following these studies with animals, plants, and enzymes, Krieger was the first person to use human subjects. Rrieger measured hemoglobin levels before and after treatments. Hemoglobin is the oxygen-carrying component of the red blood cell. The same known healer treated 43 experimental subjects for 30 minutes twice a day for two weeks. 'The control group of 33 subjects did not receive any treatment. The means of the treatment group post-test hemoglobin levels changed significantly while the control group has no change. This study was replicated in 1974 controlling for more variables among subjects, and the results were again very significant (.001) for the experimental group (Krieger, 1974). The known healer, Estebany, had been utilized in all studies described to this point. Krieger hypothesized that healing was not a divine gift, but a human potential. Later in 1974, Krieger instructed 32 nurses in TT and replicated the hemoglobin study. Half of the nurses administered routine nursing care to hospitalized patients for 34 two days. The other half (16) administered TT along with their routine care for two days. The post-test hemoglobin levels were significant (.001 for the TT subjects and unchanged for the control group (Krieger, 1975)). In 1979, Krieger conducted an exploratory study at the University of California with Ancoli and Peper. This study examined the physiological changes of Krieger during healing and changes in the subjects. Biofeedback equipment was used to measure electroencephalography (EEG), electromyography (mo) , electroculagraphy (EOG), and galvanic skin response (GSR). These findings demonstrated that Krieger, during healing, had an unusual amount of fast rhythmical beta EEG activity, and the EOG data indicated Rrieger was in a steady state of concentration (Nrieger, et al., 1979). The one outstanding result of the subjects was an abundance of large amplitude alpha activity, both with their eyes open and closed. The subjects reported being in a deep state of relaxation. Two doctoral dissertations done under the guidance of Krieger examined the effects of TT on anxiety levels of hospitalized cardiovascular patients. Both found significantly greater reduction in anxiety levels in the groups receiving TT than in the control group (Heidt, 1980; Quinn, 1982). Another study examined certain physiological parameters associated with response to stressful stimulus, a film entitled Subincision (Randolph, 1980, 1984). This film has been commonly used in other stress research. The experimental group received TT while watching the 35 film. The control group did not. No significant differences were found in skin conductance levels. Randolph speculated that her failure to find effects might be due to the subject's focusing their attention on the stressful film which prohibited their attending to the TT intervention. Another study of stress utilized transcutaneous oxygen pressure as the dependent variable. This study suggests that the patient's focus of attention may not be crucial since significant effects were found in newborn infants (Pedoruk, 1984). The next dissertation conducted at New York University was on acute pain postoperatively (Neehan, 1985), using a pre-test and post-test. The standard treatment group (receiving narcotics) reported significantly greater decreases in pain than the TT treatment group. However, this study could be redesigned to include a group who received standard treatment plus TT. Therapeutic Touch is advocated as an adjunct to standard treatment, not as a substitute. Peper and Beck (1981) conducted a qualitative study. Thirteen participating patients were questioned at the end of a two-week workshop on TT. The findings indicated the intentions conveyed by the practitioner's self confidence, ability to communicate with the clients, and/or empathy inferred were perceived by clients as the most important aspect of the intervention. Randolph (1980) conducted a survey of 70 TT practitioners. The central findings indicated that practitioners use medical care 36 (doctors) sparingly. Of the practitioners surveyed, 76% used no medication, 828 were non-smokers, 90% exercised at least once per week, and 30t were vegetarian. Krieger conducted a Federally funded study involving instructing Lamaze childbirth couples in TT so that the husbands then could perform TT on their wives during labor delivery. There were significantly fewer complications and discomfort with the TT group as compared to another Lamaze group who did not receive TT instruction (Krieger, 1983). SW! While this review of the literature attests to the new, yet growing, body of research on Therapeutic Touch, there are those who question some of the methods (Clark & Clark, 1984) and the feasibility of such pursuits (Jurgens, Meehan, E‘Wilson, 1987). This criticism from within the professional community has not dampened the research efforts or the practice of TT, but it does speak to the infancy of this new intervention, along with many other new holistic approaches. This literature review also points out that the bulk of the research has been directed toward testing for evidence of the human energy field or for testing TT's usefulness in alleviating symptoms. This study branches off in a different direction; it evaluates the learning process of HCPs who choose to learn TT. Therefore, this study adds to the research in two ways: 1) it includes the full complement of variables from the conceptual change model to examine something other 37 than elementary mathematics or science, i.e., HCP's change in beliefs about health care, using the prototype of TT, and 2) it examines an entirely new area in TT research, i.e., the teaching process and outcomes 0 Chapter III PROCEDURES Introduction The procedures chapter will be divided into three parts. First will be a description of the design and the intervention (the TT workshop). Next will be the procedures for data collection. The final section will cover the procedures used for the data analysis. Research Design The design for this study was mainly qualitative in nature, but many of the design features resemble those associated with quantitative research. The data were analyzed in terms of word units instead of numbers, contributing to the qualitative character of the project. Frequently, it was useful to summarize group data in a table. In some cases, the tables displayed the results in a numerical format. This combination of qualitative and quantitative reporting of results was the clearest expression of the results. Another typically quantitative feature was the use of a pre- and post-test before and after the intervention, which was a two day TT II workshop. As mentioned in Chapter I, this is the second workshop in a series on TT. I chose this workshop because all participants had previously attended a TT I workshop, and they would be more likely than total novices to be in the 38 39 process of change related to their health care beliefs. The data collected before the workshop were used as a base line to compare with the post-test data. There was also an inductive and a deductive aspect to the study. The data were first analyzed inductively for themes. Then the data were deductively analyzed using the variables of the conceptual change model. Instrumentation The data collection sources were developed specifically for this study. Their development was guided by the conceptual change model literature. The research questions addressed both the process and outcome components of the conceptual change model. A brief description of each research instrument is found in Table 3.1. Table 3.1 Interface of Data Collection Time Intervals with Data Collection Instruments Before Intervention 1 week after 2 months after Survey Audio Tapes Interviews Survey by telephone Case Study (Holistic) Case Study (Holistic) Case Study (TT) Case Study (TT) 40 Before: Survey The survey was a set of open-ended questions to help determine what factors other than attending a TT I workshop had influenced their TT practice and their use of holistic interventions. Research:guestions 3 a 4. What factors other than attending TT I workshop influenced registered nurses attending TT II to incorporate holistic concepts into their nursing practice when questioned by an openrended questionnaire before attending a TT II workshop? What factors other than attending a TT I workshop influenced registered nurses attending TT II to incorporate TT concepts into their nursing practice when questioned by an open-ended survey before attending a TT II workshop? Before: Holistic Case Study This case study posed a typical clinical situation in which every nurse has found her/himself at some time. It involved intervening with a patient in pain. This case study was used to determine how'holistic or dualistic the nurse's intervention would be. The responses were coded for the various stages of conceptual change and the nurse's overall dualistic-holistic orientation. Research Question 1. What stage of conceptual change related to holistic interventions do registered nurses demonstrate before a TT II workshop when assessed by an open-ended written response to a general case study? Before: Therapeutic Touch Case Study This case study dealt specifically with a client who was requesting a TT treatment. The nurse was asked to describe her intervention. Again the holistic and dualistic orientation was evaluated along with the stage of conceptual change. 41 Research Qgestion 2. What stage of conceptual change related to Therapeutic Touch do registered nurses demonstrate before a TT II workshop when evaluated by an open-ended written response to a Therapeutic Touch case study? Degggraphic This was the standard form used for all programs offered by the Life Long Education Department of the College of Nursing at Michigan State University. It was a forced-choice questionnaire. There were a few opportunities for short open-ended choices if a response did not fit any of the forced choices. The form included questions such as age, sex, and employment features. During: Audio Tapgg The facilitator recorded the entire workshop so that an outside reviewer could validate the conditions of learning and teaching methods of the conceptual change model at a later date. This data source was obtained to lend support for research question five, which addressed the process elements of the study. After: One Week After Interview This interview consisted of a prepared list of questions designed to validate the conditions of learning and teaching methods drawn from the conceptual change model and found in the workshop. They were all open-ended responses. I developed these questions based on the guidelines in the conceptual change model literature. 42 Research_guestion 5. Do participants believe that the four conditions of learning and teaching methods from the conceptual change model were presented in the TT II workshop when interviewed within a week after the workshop? After: Survey This survey was the same as the one used before the workshop. Only the tense of the questions was changed to reflect an AFTER.workshop response to TT and other holistic interventions. Research Questions 8 a 9. What factors other than attending a TT II workshop influenced registered nurses to incorporate holistic concepts into their nursing practice when questioned by an open-ended survey two months after a TT II workshop? What factors other than attending a TT II workshop influenced registered nurses to incorporate TT concepts into their nursing practice when questioned by an open-ended survey two months after a TT II workshop? After: Holistic Case Study This case study was identical to the "before holistic case study,“ and with which it was compared. Researchpguestion 6. What stage of conceptual change related to holistic interventions do registered nurses demonstrate two months after attending a TT II workshop when evaluated by an open-ended written response to the same general case study used before TT 11? After: Therapeutic Touch Case Study This case study was identical to the “before TT case study.“ Research Question 7. What stage of conceptual change related to TT do TT II registered nurses demonstrate two months after attending a TT II workshop when evaluated by an open-ended written response to the same Therapeutic Touch case study used before TT II? 43 Workshop Description This workshop was very similar to others which are held for HCPs. The format was a two-day presentation away from the HCP's site of practice. All participants attend by their own choice. Employers did not require this workshop for continued practice. The workshop was held at a retreat-type conference center. Publicity flyers for the workshop were distributed through an established mailing list of HCPs, professional organizations, and agencies where HCPs were in practice. Registrations were accepted by mail through the Life Long Education office on campus. The day of the workshop each participant was provided with a folder containing program objectives, professional articles on the topic, an outline of the content, and evaluation forms. The speakers were university professors who had extensive instruction and practice in the topic to be presented. I was one of the two presenters. The workshop consisted of typical components: lecture, small group interaction, media, discussion, breaks and lunch for informal networking. In all these ways the workshop was very predictable for any HCP participant. Origins of the workshop Content The content contained an explanation and demonstration of an innovative non-invasive holistic health care intervention, TT. Therapeutic Touch was derived from the nursing theory of Dr. Martha Rogers and developed for nursing practice by Dr. Delores Krieger. 44 Therapeutic Touch is an intervention based on the assumption that humans are surrounded by an energy field. Therapeutic Touch consists of steps to balance the human energy fields in order to place the body in the best possible condition for natural healing to occur. In this sense the mind and body are working on the same goal holistically. Workshop CW The workshop had 20 components during the two day presentation. Each component will be described, followed by examples of the seven methods from the conceptual change model which interface with the model's four conditions of learning (plausibility, understanding, fruitfulness and dissatisfaction). The methods will be underlined. l. The workshop began with introductions of the speakers and then introductions of the participants. These introductions began the interaction process. As participants introduced themselves, they mentioned exggples of TT from their practice, they drew on their p255 egperiences of holistic interventions, and they shared some of their beliefs about the ultimate nature of the universe (metaphysical beliefs). 2. Next, a mini-lecture was given by one the presenters on the historical background of TT research and its placement in the broader health care delivery system. This raised many questions which were handled as briefly as possible at the time but very openly so participants felt involved. The lecture focused on areas such as how TT was compatible with other knowledge the HCPs were familiar with. 45 This included a discussion of the ultimate nature of the universe, including ideas about the orderliness of the universe and the relation between science and commonplace experiences (megaphysical beliefs). 3. The presenters demonstrated the TT process. A volunteer from the audience was asked to serve as the client for the demonstration. The steps were reviewed as the demonstration was conducted. Again, questions were raised and answered. This was an opportunity to demonstrate how economical TT is in terms of their time and parsimonious in clear, easy to learn steps (epistemological commitments). The demonstration also created a visual igggg_that the participants could recall as they began their practice session later. In addition the demonstration drew upon past knowledge they had learned in TT I. 4. The question and answer period immediately following the demonstration included many of the methods. One of the most common types of questions related to coping with anomalies in practice. They raised unique patient situations into which they had not been able to intervene with using dualistic/traditional approaches. we then discussed how TT might be used in such cases. Often other participants answered the questions by drawing upon their experience with similar patients and the presenters either affirmed this application or suggested alternatives. This interactive process helped the questioner realize that others in their profession were accepting and applying TT 46 successfully. This peer support related to the methods of helping the learner see how the concept was becoming useful to others in their profession (epistemological commitments). 5. Following the discussion a video tape on TT was shown. The video elaborated upon the research and practice applications of TT. The video showed the originator of TT explaining its usefulness and research base. All the participants were familiar with Dr. Krieger, the originator, and have accepted her as the authority in this field (epistemological commitment). The video also drew upon other scientific disciplines to explain the theoretical base for TT (ggpgp knowledge). 6. Then there was a snack break. After break, any further questions were entertained. 7. Next a meditation or guided imagery was conducted by one of the presenters. This was to elicit the relaxation response and help the person feel very calm and peaceful within ('centered' is the TT word for this state of mind). The participants then discussed their experience during the meditation. This portion of the workshop help the participants create mental iggggg which are useful when preforming TT. It also drew upon their metaphysical beliefs to help them see the relationship between a commonplace relaxation exercise and a way to create orderliness in their own emotional state. 8. A supervised practice session followed. The participants reviewed the techniques they had learned in TT I. Feedback was given on a one-to-one basis. Participants worked in groups of three and 47 served as each other‘s patients. They were able to practice TT as they had learned it in TT I (epistemological commitments). Then a general discussion was held with responses from.participants who acted as the practitioner and the "patient.“ During the discussion they were able to talk about how they used TT for the variety of conditions they experienced during practice. Many of the symptoms they alleviated for participants during the practice session were new to them.(gghg£ knowledge and anomaly). 9. Next was dinner. The presenters ate and interacted with the participants. 10. Following dinner, the first activity consisted of a series of energy field exercises. The experience provided tangible exagples of the energy field described in the practice of TT. It also seemed satisfying to their metephysical beliefs since it demonstrated the relationship between science and the new concept of holistic interventions. They already understood fields such as the magnetic field, and these exercises branched off into related but less common examples of fields. 11. A discussion was led on the application of TT to unique clinical situations. The participants drew upon their past experiences with clients. They asked questions about application to their specific client symptoms. The presenters responded by referring to the research and to Dr. Krieger‘s comments from her annual retreat (epistemological commitments). 48 12. The formal instruction was adjourned for the night. There were informal discussions which continued around the camp fire by the lake. Many continued to practice on each other informally and others discussed related topics. Some significant networking could occur during this informal time. 13. The following morning began with breakfast. Again, many individualized questions arose for the presenters during breakfast. 14. The instruction began with a discussion of the uses of imagery and color with TT. Suggestions were given as to how to work these techniques into their practice. This provided igggeg_for the participants to incorporate with their practice of TT. 15. Next, the group was broken up into discussion groups of about five. They were asked to discuss an article from their syllabus and responsed to a set of questions. The article had to do with the human energy field and how to better perceive the field. During the discussion the symmetry and orderliness of the universe in general was illuminated, including the specific example of humanity as part of the universe (metaphysical beliefs). The small groups also gave participants an opportunity to evaluate how the holistic concepts fit their view of what counts as a successful explanation in their profession (epistemological commitments). 16. A general discussion with the large group followed. Each small group reported on their discussion and the presenters collected the ideas in a summary fashion at the end of the discussion. During the discussion, both presenters and participants used a variety of 49 analogies and metephors to make their points from their discussion groups. A commenly used analggy was attempting to study salt by analyzing sodium and chloride separately. They all realized that this would only provide information on the two separate substances and nothing at all about salt as a compound. The analggy to humanity is that if they only study the biological symptom, they will only know more about that symptom. It is necessary to assess the person holistically to find the most useful information. For instance if a person complained of back problems and the nurse addressed only the back, she/he may entirely miss the heavy psychological or emotional burden the person is carrying. 17. Following the break there was another practice session in groups of three. Participants were encouraged to incorporate the color and igggery techniques as they practiced TT. During the practice, the presenters circulated among each group to provide guidance and answer questions individually. After the practice the group was reconvened for a general discussion. The discussion focused on their experiences during practice and also on the application potential to practice. Some additional research was shared by the presenters as it applied to the questions raised from the HCPs who practice in various settings. In this discussion there was a strong emphasis on drawing upon anomalies in their practice. The presenters provided suggestions of how to apply TT to difficult and unique situations. The presenters also indirectly touched on the participants' epistemological commitment since this discussion allowed the presenters to share their expertise 50 in an open manner that seemed logical and practical. The presenters drew upon the content they learned directly from Dr. Krieger or the published research. 18. Lunch with the presenters was next. 19. After lunch, the activities included energy center balancing, music and art therapy. During a mini-lecture, the one instructor explained how such techniques could be used with patients or as methods for centering oneself. This section provided more tools/ideas for the participants to take home. They usually had heard of the use of music and art as patient interventions, but may not have known how to apply them. Here they were given techniques which were easy to incorporate for their patients or themselves (other knowledge). Egggplgg were provided for all the techniques and they were all linked back to TT. It was stressed that centering was the most important step in TT. This gave participants permission to take care of their interior state as well as caring for their patients. This became a useful analggy since participants realized they deliver better care when they feel calm and composed themselves. 20. The workshop then concluded by the HCPs being asked to fill out the workshop evaluation. Participants were invited to remain for informal questions with the presenters and to enjoy the retreat setting. This has been a brief overview of the workshop and its components. The examples of methods are only a sample of what was included, but 51 they are representative of the events and dialogue that occurred. An outline summary of the workshop is as follows: Therapeutic Touch II Day One 1:00 - 1:30 Registration 1:30 - 2:30 Introductions and Pretest Materials 2:30 - 3:00 Mini-lecture, History, Research, Health Care Context 3:00 - 3:30 Video on Touch 3:30 - 3:45 Break 3:45 - 4:30 Energy Field Exercises 4:30 - 5:30 Practice Session and Discussion 5:30 - 7:00 Dinner with Presenters 7:00 - 9:00 Practice with Energy Dynamics, Discussion of Research Day Two 7:30 - 8:30 8:30 - 9:00 9:00 -10:00 10:00-10:15 10:15-10:45 10:45-12:00 12:00- 1:00 1:00 - 2:00 2:00 - 3:00 3:00 - 3:15 Breakfast Imagery and Colors Discussion of Article - Fields and Clinical Application Break Centering Practice Session with Color and Imagery Lunch Energy Centers and Practice Music and Art Therapy as Centering Summary/Evaluation Setting for the Workshop The workshop was held at a rustic, heavily wooded retreat setting adjacent to a large lake in northern Michigan. The classroom was a spacious open area with windows across the back of the room and a door on either side of the room. The participants had padded arm chairs but no desktops to write on. They wrote on their laps, using the folders given out at the workshop registration as a hard surface. 52 Faculty for the workshop There were two co-instructors for the workshop and one facilitator. The facilitator was a nurse employed by the College of Nursing at Michigan State University. Her role was to introduce the presenters and to handle all the managerial aspects of the program. The two presenters were both tenured assistant professors with the College of Nursing at Michigan State University. TT is of special interest to both of them so they have developed a series of workshops on this topic and present them throughout the year in addition to their regular teaching load. One of the presenter's speciality area is psychiatric nursing and the other's is medical-surgical nursing. This combination has been very useful in teaching holistic intervention where mind and body are considered as a unit. These two faculty were able to lend their expertise to each of the two aspects. Both presenters have studied TT with the originator, Dr. Delores Krieger, for the past six years. Each summer they have attended the annual invitational retreat Dr. Krieger holds in New York or washington. This has been an opportunity to keep abreast of their skills and the latest research and application. They have offered workshops through Michigan State university for the past five years. They have served as speakers on this topic for organizations through out Michigan. In September of 1987 they presented a paper at the International Primary Health Care Conference and provided a TT workshop at the Florence Nightingale School of Nursing in London, England. The 53 medical-surgical instructor introduced above is also the researcher of this project. Due to this fact, I frequently refer to myself in first person throughout this report. Sub ects The potential subjects for this study were HCP participants who self-selected to attend this health care workshop. No one was required to attend by their employer. The group was comprised of a variety of HCPs, but most were registered nurses. Most were actively practicing their profession. Others were retired. For participants to be included in the study, they had to be registered nurses who were currently working in some aspect of nursing, to be between the ages of 20 and 70, and to have attended a Therapeutic Touch I workshop given by the same instructor. There were 33 people in attendance at the TT II workshop. All participants were invited to take part in the study. I intended to sort out the subjects after the workshop according to the criteria. I was aware from the registration list that not all participants would fit the criteria. All the participants were interested in the study and in seeing the forms, whether they intended to participate or not. Of the 33, 21 completed the forms prior to the workshop. Of the 21, 11 fit the criteria for the study. Six of the eleven were interviewed by telephone one week later. Nine of the eleven returned the data forms two months later. The Table 3.2 depicts the steps in meeting the criteria for inclusion in the study. 54 Table 3.2 The Data Sources and the Number of Participants Who were Requested to Participate, Who Completed Data Forms, and Who Completed Data Forms and Met Criteria PARTICIPANTS I 33 Requested Cogpleted Met Criteria Survey (before) 33 21 11 Case Study (general before) 33 21 11 Case Study (TT before) 33 21 11 Interview (after) 8 6 6 Survey (after) 11 9 9 Case Study (general after) 11 9 9 Case Study (TT after) 11 9 9 Procedures for Data Collection Phase One of Data Collection - July 10L_1987, 2 P.M. Copies of the data collection forms are in the appendix. All data forms were coded with a number, i.e., each participant had a number. The instructors were introduced by the facilitator to the participants assembled in the class room. At this point, the participants were informed of the study and asked if they would like to participate. The consent form was discussed first: it had been placed in the workshop folders which were handed out as participants checked in for the workshop. The consent form was explained while the participants read it. If they were interested in participating, they 55 signed the consent forms and were given the first research form - the survey. Once they had completed the survey, they were given the general case study with their research code number on it. After they completed the first case study, they were given the TT case study, again with their code number on it. The participants were aware of their number and were asked to double check that they were consistently receiving their code number as the three forms were distributed. At the end of the workshop, participants were asked to submit their demographic data sheets and workshop evaluation forms, which was standard workshop procedure. The demographic data forms were not coded with the participant's number. Subjects were asked at a later time to identify their demographic sheet by their social security number. Phase Two of Data Collection - July 13-18, 1987 As part of the consent fonm completed prior to the workshop, participants were asked if they would take part in a telephone interview one week after the workshop (July 13-18, 1987). They included the date and time they wished to be called. Eight participants agreed to be interviewed but only six were available at the time they had indicated. The seventh potential participant interview did not answer the telephone. The eighth call was answered by a family member who indicated the participant was not available at the time she had suggested. The six interviews lasted approximately 60 minutes each. One person was contacted at her work setting while the others had asked to be called at home in the evening. 56 Interview Questions. The interview questions were based on the four conditions of learning from the conceptual change model (Appendix F). The conceptual change model suggested a series of questions for each condition. These questions were designed by the researcher to fit the content of the workshop. The model stated the suggested questions in a very general way, and I added the specific focus and reviewed them with my advisors. Another researcher may have worded the questions somewhat differently. This was one of the decisions that had to be made in order to proceed with the study. Here is one example to demonstrate how the general statements from the model were adapted to this study. For the condition of learning titled ”minimal understanding,“ one of the model aspects was stated this way, 'It is necessary to construct or identify a framework in which to locate the new idea.“ The actual question used in the interview was, “To what extent did the TT workshop help you begin to see a holistic framework in which to locate this new intervention of TT?w All six participants were asked all questions. If a subject gave a brief or unclear response, she was asked to elaborate. This often led to actual examples with their patients or family members. The questions could be answered as abstractly or concretely as the subject wished; the nurses frequently chose to respond in a very concrete fashion by giving very specific examples. During the interviews, I took notes of our conversation. The notes consisted of the actual quotes from the conversations, as closely as I could record them. I 57 then converted the notes into a typed version within a few days after the calls. This made it possible for me to recall most of the details of the conversations and to convert the notes into full statements. Phase Three of Data Collection - September 10, 1987. On September 10, 1987, the follow up data forms were mailed to all participants who agreed to participant in the data collected before the workshop and who fit the criteria for the subjects. This included eleven people. In the packet that was mailed to each person were the following items: 1. The survey in an envelope numbered 1. 2. The holistic case study in an envelope numbered 2. 3. The TT case study in an envelope numbered 3. 4. The blank demographic data sheet with their identification number on it. 5. A letter of instruction. 6. A return envelope addressed to myself with postage affixed. The survey form was modified to change the tense from present to past for the logical reading of the post survey. The letter of instruction asked that the forms be opened and answered as they were sequentially numbered. They were also asked if their demographic data could be used for the study. If they consented, they filled in their social security numbers on the blank copy of the demographic form. In this way the numbers could be matched with their demographic form from the workshop which also had their social security numbers. The 58 enclosed demographic form was clearly coded with their identification number for the study. Nine of the participants mailed back their packet of data collection forms and demographic information. Procedure for Data Analysis This section will describe how the data were analyzed. First, the basic unit of analysis will be described - the meaning unit. Second, the emergence of the inductive themes will be explained. Following will be a discussion of how the data for the conditions of learning and the stages of conceptual change were analyzed. Finally, the variables of overall orientation and barriers to practice will be discussed. Orientation and barriers are variables I chose to add to this study. I added the orientation variable prior to the study to assess the nurses' underlying conceptual beliefs as being dualistic or holistic. The barrier variable emerged from the inductive analysis of the data. ‘With the discussion of each variable, I will quote examples from the data to enliven the explanation. Procedural Methods The data were first treated inductively. It was analyzed for patterns that naturally emerged. As a second step, the aspects of the conceptual change model were analyzed deductively. This sequence of inductive then deductive steps was to allow two types of analysis. This approach to the data let me first observe their responses independently before being influenced by the model. I realized that 59 this initial analysis could only be semi-independent since the conceptual change model had already influenced the development of the data collection instruments. But, within this limitation, the data were inductively analyzed first. This more independent analysis will be described first. Inductive Themes and Meaning Units The data were reviewed as a whole initially to get an overall sense of themes. During this scanning process, it became apparent that I was using some unit of analysis to identify the themes. As I proceeded with this process, I realized that what I was doing was dividing the data into units of meaningful comments. The units were not always an entire response to one question. Generally, a meaning unit involved two to three sentences. Since I analyzed the data myself, this procedure was not validated by another analyst. I will provide an example to demonstrate how I determined where a unit ended and the next began. Here is a quote from the data, 'There are too many ultra sounds on babies when there really isn't a problem.“ This is where the unit ended. The remainder of the cement went on to another example. The rest of the quote was treated as a separate meaning gnig. 'I shared TT with a friend and she was able to do it too." In this case I divided the data where the participant switched topics from using ultra sounds to sharing TT with a friend. Most responses were brief, being confined to a few sentences. The most in-depth responses were obtained during the interviews. These comments 60 were still only a few sentences in length. From the assessment of the data in this manner, the unit of analysis became this type of meaning unit. As I worked through the data in this way, I met frequently with my advisor to review my progress. I first brought data from just one subject. I shared my impression of the themes with my advisor and he often added others or helped me more clearly state the themes I had identified. we worked primarily from the one subject's data set to derive the majority of themes. Then I decided to move on to other subjects to see if the themes were appropriate across data sets. I found that they were useful for much of the data. I did add a few new themes and merged several of the original themes to encompass a broader interpretation. This process occurred over a two to three month period so there was time to put the data down and reflect on the themes and then come back to it later with a fresh outlook. This process of theme sorting could have gone on indefinitely, but at a certain point, I decided that a wide cross-section of themes was in place and I would proceed with other aspects of analysis. From this overall analysis of the data, the meaning units became clearer and the themes were determined. Approximately 10 themes were outlined initially. Once this was done, each meaning unit from all data sources was categorized by theme. During the process of categorizing the units, there were two additional themes which emerged. Therefore, the themes and the meaning 61 units emerged simultaneously. It was a back and forth process (refer to Table 3.3). Table 3.3 Themes from the Data 1. Dissatisfaction with the dualistic system 2. Application of an intervention to a specific illness or with a specific person 3. A sense of self as a professional 4. The potential future, feasibility or research promise 5. Aspects of the workshop content 6. Aspects of the workshop experience or environment 7. Attitude, opinion or insight 8. Expression of feelings or change in life perspective 9. Why a person attended TT II 10. Ability to use TT at work 11. Mention of specific holistic intervention or approach 12. Support of new holistic conception The first example will serve as an introduction to the themes and involves theme number two, i.e., 'application of TT or a holistic interventions to a specific condition or with a specific person.” This theme was used to categorize meaning units that mentioned a specific intervention. In some cases this was TT and in others it was a related holistic intervention, such as imagery, biofeedback, or relaxation. These types of meaning units often included a specific type of patient or a family member. 62 Meaning Unit: 'A Greek lady was unable to sleep. The doctor put her on sleeping pills. I used a relaxation tape with her. She took the tape home. It was a metamorphosis. She is sleeping well and no more pills. It was my last ditch effort that worked.‘ This unit clearly fits this theme. It mentions a specific intervention which is a relaxation tape and a specific patient situation, a sleeping problem. Many of these inductive themes were quite independent of the conceptual change model while other themes clearly overlapped with the model. The first example was a more independent theme. Later we will look at a theme that is much more dependent on the conceptual change model. But, now let us turn to the further coding of the thought units by applying the aspects of the conceptual change model. Conditions of Learning It is helpful to recall that the interviews were the primary source of information about the conditions. The questions for the interviews were derived from the conceptual change model. There were a variety of questions used to address each condition. Therefore, as the data were analyzed, the conditions came predominately from the interviews. The reason for making this point is because the post surveys also contained some content related to the conditions, even though it was not asked for directly. This may mean that the post surveys were influenced by the interviews, but perhaps the participants would have made the same responses regardless. This possibility is mentioned since it exists as a potential influence on the data responses. 63 Each meaning unit was further analyzed to see if it contained content related to any of the four conditions of learning. A sample meaning unit demonstrating the condition of plausibility is next. Meaning Unit: ”Yesterday I put my hand on a man's stomach with an exam - not a real formal TT treatment. His stomach was rumbling and very bloated. Today the abdomen is down and his pants nearly fall off. I can't say for sure how much the TT helped. But, I believe it did help. Having attended the workshop so recently, made me think to do this during the exam.‘ This unit was coded as an example of plausibility. It fit this coding for plausibility since a portion of the definition for plausibility is that the new conception needs to be capable of solving a problem which would otherwise be an anomaly. Ordinarily, the nurse would be helpless to solve such a problem. The nurse could only assess the problem, but would have no intervention available. This clearly was an anomaly in practice which now has a plausible solution. In this case, the nurse reflected upon the workshop experience and used a skill she would not have had otherwise. An additional aspect of plausibility is that the learner can draw from her experience and find the new concept consistent and useful. This subject easily recalled a clinical experience where TT had been useful. Overlap of Inductive and Deductive Analysis NOw that we have seen an example of both an inductive theme and a deductive condition of learning from the model, it is important to look at a less clear aspect of the data analysis. There was one instance where the inductive theme overlapped with a deductive condition of 64 learning. This combination of theme and condition was “dissatisfaction with the existing dualistic system.“ While most of the themes were independent of the model, dissatisfaction was frequently commented upon in a similar manner to the condition. Dissatisfaction became a theme as well as a condition. All meaning units that were categorized under the dissatisfaction theme were also coded with this condition. The converse was not the case. Many meaning units were categorized under one of the other 11 themes but were coded with the condition of dissatisfaction. The meaning unit was first matched to a theme in terms of its most obvious or overriding tone. After the meaning units and themes were matched up during the inductive analysis, the deductive variables of the model were matched with each meaning unit. Therefore, for a meaning unit to be located with the theme of dissatisfaction, dissatisfaction had to be the most obvious aspect of the comment. In the deductive process, the dissatisfaction element was only part of the meaning unit or embedded in another more dominate comment. Therefore, it was coded with dissatisfaction as a condition of learning but not with the dissatisfaction theme. To help explain this overlap of theme and condition an example is used from the data. Meaning;Unit: “Traditional medicine dominates because this is the way health care has always been done. I have begun to realize that the traditional is not the only way. The holistic can be as or more helpful. The holistic approach gives the patient more input into their health care. They stay calmer without tranquilizers in the surgical area.“ 65 This meaning unit emphasizes the advantages of a holistic approach. The dissatisfaction is stated in terms of the perpetuation of a traditional system without reevaluation. It also shows a comparison between the dualistic and holistic system with evidence of the holistic having more advantages. There is the implication that this subject is in the process of constructing a new holistic framework when she states she is beginning to realize that the holistic approach may have more merit than the dualistic. This has been an explanation of how the conditions of learning were treated. The first example, plausibility, was applied as a separate and distinct coding process. The second, dissatisfaction, was a duplication of the theme by the same name. The other two conditions of learning were coded like the first example (plausibility) and will be treated in more depth in the results section. Speges of Conceptual Change The data were further coded for other aspects of the model. The next coding was in relation to the stage of conceptual change. There are three stages to the model. Each stage involves three variables. The three potential variables are knowledge, application, and acceptance. Both knowledge and application have a basic and advanced level. Acceptance is either present or absent. For subjects to achieve stage 3 they need to demonstrate advanced knowledge and 66 application, as well as the presence of acceptance. Stage 2 includes advanced knowledge and application but not acceptance. Stage 1 requires only basic knowledge and application. Prior to the study, I intended to rely entirely upon the case studies to determine the stage of change, but these data were much scantier than I had hoped for, so as a result all data sources were coded for their stage of conceptual change. This allowed for a broader picture in chapter V’of a participant's stage of development before and after the intervention. For descriptive purposes, an example of stage 3 features will be shown. Stage 3 requires advanced knowledge, advanced application and acceptance. I will first describe the two levels of knowledge to show the distinction. Then, I will describe the advanced level of application and give an example of acceptance. Meaning Unit: “You can realign the patient's field with TT to decrease the pain medication.“ This example shows basic knowledge regarding the balancing of the patient's field, but there is no advanced description to indicate a sophisticated level of knowledge. Here is an example of advanced knowledge for comparison. Meaninngnit: “I'd try to unruffle the energy around the head (for a head ache) and then try to smooth it out. I d also check out the whole body and look for other areas of imbalance and do the same thing. I assume that the head imbalance may not be occurring only in the head. Everything is connected.“ 67 This is considered an advanced level of knowledg_. The key features are the detail of the description, the consideration of the entire field, and the understanding that a headache may or may not originate in the head. This is an example of how knowledge was coded. Application was coded in a similar manner for the basic and advanced levels. I will include an example of advanced application next. Meaning Unit: “I have taught my mom to use imagery with her arthritis. I used green with her when I did a TT treatment after TT II. The next time I went over she had a green dress on. She said it helped. She requested more TT when I went over again.“ This is an example of advanced application since she is using color with TT and is able to apply TT to unique situations that were not specifically covered in the workshop. The other supporting aspect is instructing her mom about imagery so her mom could cope more holistically on her own. Now instead of only having medication to rely upon, she can also use her consciousness to help her control her arthritis symptoms. These factors all contribute to this statement being coded as advanced application of TT. Basic application would have included beginning level skills with the energy field on standard examples covered in the workshop. Acceptance was coded as present or absent in a meaning unit. Meaninngnit: “I would attempt to use TT under most any condition if I felt it would help.“ This statement is supportive of TT as a valid intervention. Some statements were more direct but many were embedded within situational 68 examples. Any meaning unit that spoke of the usefulness or value of TT was coded as acceptance of TT. Many statements did not deal with acceptance specifically. But, the ones that did were most frequently supportive of TT. There were very few statements of non-acceptance. These three levels are what are necessary for stage 3 attainment within the conceptual change model. In summary, stage 3 consists of advanced knowledge, advanced application and acceptance of TT as a valid intervention. Determination of Stege Attainment As the data were analyzed, subjects were evaluated for all three aspects of the stage theory of conceptual change. A subject could have any combination of the three stage theory variables. For example, one meaning unit might indicate basic knowledge and another statement advanced knowledge. The same was true for application. ‘With acceptance, it was either present or absent. Not all statements dealt with these three elements of the stages, but any that did were coded accordingly. A staging for each subject at each of the three time intervals was compiled. The stage was determined for both TT and holistic interventions at all three time intervals (before, one week after, and two months after). Further, a parallel system of staging was used to that of the model. One staging system relied entirely upon the variables of the conceptual change model. The second, my revised staging system, added the variables of barriers and orientation to the three model variables, by taking into acount the results of the 69 thematic analysis. Many data sets did not have an adequate complement of model variables to determine a stage rating. In these cases, a question mark was used in place of a stage rating. The revised rating system considered whatever model variables were available along with the variables of barriers and orientation. I conducted the revised staging and allowed the non-model variables to substitute for missing model variable. This substitution was supported by frequent quotes from the data. By instituting the revised rating system, I was able to give a stage rating to all data sets at each time interval. Stage 1. For stage 1, I looked for basic knowledge and application statements. The one issue that came up several times was that stage 1 subjects often also expressed acceptance of the intervention: according to the model, acceptance is only a feature of stage 3. Stage 2. To evaluate stage 2, I looked for statements of advanced knowledge and application. The concern with this group was that often it was a very close call between basic and advanced if the numbers of each were similar. In these cases the data were considered to be at the advanced stage. Stage 2 did not have the problem with acceptance that stage 1 experienced, because if they expressed acceptance, they automatically went to a stage 3. This process left few stage 2 people since they often had acceptance at stage 1 and once they advanced their knowledge and application, they became stage 3. 70 Stage 3. Stage 3 included anyone who indeed had advanced knowledge and application along with acceptance. There were no difficulties with this determination other than the one mentioned for stage 2, that is, that subjects began to overlap into stage 3. Another problem worth mentioning was the occasional lack of evidence for attaining a stage 1 at all. Some subjects made very brief comments on the written forms and it was difficult to decide if they had even expressed a stage 1. In these cases, I created a stage 0 to account for these situations. The case studies did not hold as much data about stage achievement as had been anticipated. Fortunately the lack of data on the surveys and case studies were often balanced out by the dense data found in the interviews. Added variables Orientation Following the coding derived from the model, I receded using the two variables I added. The overall orientation was the first variable added. Each meaning unit was coded for its overall tone as to whether it was holistic or dualistic in nature. This variable seemed to be a necessary addition. While the model is useful, it is also generic. By adding this variable, I was able to tailor the model to my specific area of interest, i.e., holistic versus dualistic orientation. This coding was to provide evidence as to whether the subject had made a broad conceptual change from dualistic to holistic or a specific change in terms of acceptance of TT as a sound intervention. It does seem 71 that any application of this model would need its own discipline-specific variable to test the underlying concept. One example of a dualistic orientation will be depicted here to show the operational meaning of orientation. Meaning Unit: "The nurse is able to administer a drug to the patient based on a doctor's order that she knows will block pain at the physical level.“ This meaning unit is coded as dualistic since it speaks only of a physical dimension. There is no suggestion of a contribution from a psycho-social-spiritual aspect of the patient or the nursing care. This is a typical example of a dualistic thought unit where only the physical level of the patient is addressed. Barriers The final coding was for barriers. Barriers are not considered in the conceptual change model, but they were referred to in the nurse's responses. The barriers were either related to ability to practice TT or ability to learn TT. This variable of barriers was first uncovered during the inductive analysis of the data. There were very few barriers noted overall, but they were found across data sources. In a typical participant's data set, there were usually only one or two examples. They could easily have been overlooked due to their low number but they brcughtout interesting aspects of the change process that might not have been considered otherwise. Many other models of change have a barrier component. The dissatisfaction condition is 72 probably intended to deal with this area, but I found these barriers really were not dissatisfaction with the existing conception. A typical example follows next. Meaning Unit: “I found it hard to focus during the workshop. I thought there was too much for the time frame we had.‘ This example shows a barrier to the learning process of TT. She believed there was too much content covered in the workshop. The other type of barrier had to do with the ability to practice, such as not having anyone else in their geographical area with whom to practice. Alternative Stagigg. Finally, I have taken the liberty to apply a second type of stage rating to the data to help account for some of the problems associated with applying the conceptual change model to holistic health care conceptual change. I alluded to this alternative system earlier and will now describe it more specifically. I found there were more types of data that contributed to the rating decision than the model contained. In addition to information on orientation and barriers, I had had a subjective experience with these subjects through the workshop and interviews that could be drawn upon when a person appeared to be on the cusp of a stage. Therefore, I conducted a second rating where these additional factors were considered. In this process I decided that anyone who was able to express both basic and advanced knowledge or application would be credited with the advanced level rather than the basic. If a person was able to demonstrate knowledge 73 or application within a set of data obtained during the same time period, this would constitute adequate evidence for that feature. The results section will indicate the nurses' stage of conceptual change according to the model variables and to the revised assessment, including the additional variables of orientation and barriers. Summary This description of the analysis process has been presented in the chronological order in which the analysis was conducted. The analysis began with the inductive process of identifying themes and meaning units in the data. Then the features of the conceptual change model were used to deductively code each meaning unit. The process variables of teaching methods and conditions of learning were discussed. The outcome variables for the three stages of conceptual change along with their internal levels were described. I also added two variables - overall orientation and barriers. Brief examples were used to help explain each type of coding. The results of this complex coding system will be dealt with in the next two chapters. Chapter IV RESULTS - PROCESS VARIABLES AND THEMES Introduction The purpose of this chapter is to illuminate the theory, process and experience of conceptual change by portraying the workshop participants as individuals and as a group. To do this, the data were analysed through the process variables of the conceptual change model and the inductive themes. The process variables included the conditions of learning (plausibility, fruitfulness, understanding, and dissatisfaction) and the seven teaching methods. There were 12 ‘ inductive themes. The outcome variables will be discussed in the next chapter, which is devoted to the stages of conceptual change. Degggrapgic Data All WOrkshongarticipants There were a total of 33 people who attended the workshop. The 21 people who provided the demographic data at the workshop ranged in age from 28 to 67 years. The overall group was largely composed of females with only 2 males in attendance. All 21 were registered nurses. There are three educational paths to becoming a registered nurse that were represented by this group. Two participants had a non-degree diploma in nursing, 4 others had a two—year degree in nursing, 7 had a 74 75 bachelors degree, and the remaining 8 registered nurses had a master's degree. The majority of these nurses (17) started practice with a more basic nursing education and then returned to college to obtain their current educational status during the last 10 to 15 years. The participants at the time of the workshop practiced nursing in direct patient care settings (10), taught in a school of nursing (7), or worked as a clinical administrator (4). Study Particiggnts Eleven subjects were the core respondents in the study. Six of these 11 took part in all data collection activities. Three completed the surveys and case studies, both before and after the workshop, and 2 completed these forms before the workshop only. I was unable to identify the demographic data sheets of these latter subjects, since the social security identification number was requested for the data collected after the workshop. All 9 were women and ranged in age from 28 to 67 years, with no specific clustering at a particular age. One received her registered nurses' training in a non-degree diploma program: three earned their registered nurses' education in a two-year degree program at a community college: three had a bachelor's degree and two had master's degrees. Over half the group had begun their nursing practice with more basic nursing education and then returned to college predominately during the 1980's to attain their current educational level. Four subjects worked part- or full-time in direct nursing care at a hospital, one was a hospital nursing administrator, 76 and 3 were employed in nursing faculty positions or as public school nurses. Their actual clinical sites varied greatly, including intensive care, maternal-child, medical-surgical, and general practice. Half the group had their workshop tuition paid by their employer and the other half covered their own expenses. Most subjects drove over 106 miles to attend. All 9 subjects had previously attended a TT I workshop. From this demographic summary, it is clear that these 9 subjects were representative of the overall group. Conditions of Learnigg Introduction In the procedures chapter, I discussed the workshop's 19 components and indicated how the seven teaching methods were used with each component. In this section I will again call upon the seven methods to show how they were utilized with the four conditions of learning. A table depicting the interface of the conditions with the methods (see table 4.1) will serve as a reference point for keeping the multiple variables clearly in mind. According to the model, conceptual change is achieved by establishing four basic conditions of learning through the instructional methods used to teach a new conception. we will first look at the instructors' intended incorporation of the four conditions of learning via the teaching methods suggested by the conceptual change model. The conditions are plausibility, fruitfulness, understanding, and dissatisfaction with the established conception. Each condition of 77 learning has several teaching methods associated with it. The model very clearly incorporates the methods into the operational definitions for two of the conditions. With the other two conditions, the workshop instructors integrated the conditions and methods as outlined by the model. Secondly, I describe the participants' view of the conditions of learning. The third section depicts an outside TT instructor's perception; she was not present at the workshop but listened to audio tapes of the workshop and provided a validity check of the presence of the conditions of learning and teaching methods. Table 4.1 Interface of Conditions of Learning with Teaching Methods CONDITIONS OF LEARNING Dissatis- Minimal Plausi- Fruitful- TEACBING METHODS faction understanding, bility ness Anomalies x x x Analogies & Metaphors x x Exemplars and Images X x Epistemological x x Commitments Metaphysical Beliefs x x and Concepts Past Experience x x x Other Knowledge X x x 78 Instructor Perspective Plausibility. For the plausibility condition of learning, the methods were described in terms of the defining statements from the model. This made it very easy to plan the instruction. Below is a list of statements for how plausibility is operationalized in the conceptual change model. Each teaching method is underlined. 1. 2. 3. 5. 7. One finds it consistent with one's current metaphysical beliefs, i.e., orderliness of the universe or a particular scientific conception. One finds it consistent with one's epistemologiggl commitments, i.e., explanatory ideals or general views about the characteristics of knowledge. One finds the conception to be consistent with other theories or knowledge about which one is aware. One finds the conception to be consistent with 2222 expgriences. One is presented with exggples or is able to create iggggg_for the conception, which match one's sense of what the world is or could be like. One finds the new conception capable of solving problems of which one is aware, i.e., resolving anomalies. One finds the conception to be analggous to or metaphorical with some other conception with which he/she is already familiar. 79 Included next are a few key examples of instructional methods that were used to teach the condition of plausibility. The workshop was built upon nursing theory (epistemological commitments, explanatory $93215) that was familiar to the participants. A specific example was the work of Dr. Martha Rogers, a leading nurse theorist, who all the nurses had been exposed to during nursing school or through the TT literature. Therapeutic Touch is an intervention based on this theorist's work. They were also aware of the research base for TT through the studies of Dr. Delores Krieger (epistemological commitments, explanatory ideals). In the workshop, a video was used which included Dr. Krieger expounding on TT. Another concept covered in the workshop was holistic care (metaphysical beliefs), which is the basis of nursing. An overhead was used which depicted where related holistic interventions fit into the overall model for health care (gxggples and images). The nurses already utilized many of the other holistic interventions, such as biofeedback, massage, accupressure, and the relaxation response. A final example used in the workshop was a mini-lecture which drew upon the field theory concepts of Einstein and Burr (other knowledge) as they relate to nursing and TT. Pruitfulness. The condition of fruitfulness has three descriptors and the methods are listed separately. This condition left it to the instructors (myself and colleague) to utilize the three suggested methods to establish the condition of fruitfulness. The instructional 80 methods suggested were a) showing how anomalies can be resolved, b) drawing on past experience, and c) pointing out other knowledge of which the participants were aware. 1. One becomes committed to a conception because it helps interpret experiences, solve problems, and in certain cases, meet spiritual or emotional needs. 2. The new conception must be able to lead to new insights and discoveries. 3. One must be able to generate or understand novel practical applications or experiments which the new conception suggests. The instructors blended the above definitions with the methods. Through the workshop, the instructors provided an expanded view of the world and therefore of patient care. Participants learned that it was not necessary to touch a patient in order to have a significant interaction. Such intangible spiritual aspects of patient care were explained within the context of TT. The nurses were able to understand a new way to care for patients which added to their current practice. Participants were able to see direct application to patient situations which could be treated with TT. For example, there is often little to be done for the comatose patient. These patients are an anomaly of sorts since the nurse often feels helpless to intervene. At the workshop nurses were taught how TT could be used with both the family and patient in such cases. 81 Understanding. This condition specifies that minimal understanding must be taught. Understanding actually means, in this case, creating a cognitive framework in which to situate the new idea. The methods for achieving understanding are the use of analogies and metaphors and the incorporation of examples and images. 1. It is necessary to construct or identify a framework in which to locate the new idea. 2. It is necessary to attach the framework to the world in at least prototypical ways. This condition was met during the workshop when the instructors drew an analogy between the current model of health care and the newer holistic model being presented. In this sense, the condition of understanding was closely linked to the condition of plausibility. They both require connecting the new conception to an existing framework for the learner. Through the use of overheads, participants were shown images of the new framework and given specific examples so they could cognitively construct their own framework as they listened, discussed and questioned throughout the two days. Dissatisfaction. The condition of dissatisfaction involves ways of bringing into question the exiting conception. The definitions from the model integrate the methods. 1. A conception is incapable of interpreting experiences assumed to be interpretable, resulting in an anomaly. 82 2. A conception is seen to be no longer necessary in the interpretation of experiences previously considered significant (past experiences). This may be a consequence of another conception's greater success in interpreting the experiences or another conception's reducing the significance of the experiences. 3. A conception is incapable of solving some problems that it presumably should be able to solve. 4. A conception violates an epistemological or metaphysical standard. 5. The implications of a conception are unacceptable. 6. A conception becomes inconsistent with knowledge in other 2522!- The instructors were able to meet this condition by offering a new way of looking at health care delivery. The instruction of TT involves many examples of anomalies from nursing practice that can now be addressed. One common example is dealing with pre-operative anxiety. The nurses had felt very inadequate in this situation in the past. During the workshop the nurses became aware of how to use TT to help relax the patient and convey a sense of caring. The workshop also drew upon metaphysical beliefs. The nurses had often been aware of the intangible aspects of their care, but TT offered them a way to understand the energy exchange between patient and nurse. The examples from practice arose from the participants themselves as they drew from their past experiences. The workshop 83 allowed a forum for openness about the less concrete aspects of care. Common examples included why a dying patient is able to hold on to life until a distant family member arrives at the bedside; and how a statistically terminal diagnosis can be reversed without medical intervention. Participents Perepective In this section the four conditions of learning are viewed from the participants' perspective. Six participants were asked a series of questions about each condition during telephone interviews. A sample response from these interviews will follow each question. Plausibiliey. 1. Q. To what extent was the workshop content consistent or inconsistent with your basic belief system, personally and professionally? A. IThe concepts fit well with my personal understanding of the world. The workshop helped draw things together. Now, even if someone were a Buddist or Christian, I could still show them how to do TT or do it to them if they wanted.“ 2. Q. Did the workshop content seem consistent with your current knowledge base in any way? A. "The workshop built on old information from TT I and Dr. Krieger's book and discussions with friends at work - two other R.N.s.' 3. Q. How do the concepts of the workshop seem consistent with your past experiences? A. 4. Q. A. 5. Q. A. 84 'Yes, I have had personal experiences. I have seen patients who heal themselves. If we consider both the mind and body, we can understand and support the patient. One patient had a fractured hip that wouldn't heal. The x-ray showed no healing. But, then the patient had a change in mental outlook. She became more positive because she really wanted to go home. Healing began to occur. The x-ray showed the change. The doctor said, the patient did that one herself." Could you give an example of how TT or another holistic intervention could be used in some situation where the traditional dualistic health care system has not been helpful? 'TT can be used where traditional methods are not available. I was called upon for leg cramps on a bike tour. TT was so successful, I was asked to go next year again to help the riders. It helped the riders physically so their legs could go on, but it also helped mentally. They felt more relaxed and peaceful and calm.‘ Do the concepts from the workshop seem similar to other concepts you are already familiar with? Could you describe another belief or intervention which is holistic in nature besides TT? "Before the workshop, I looked into reflexology and modeling and role modeling at U of M with Helen Erickson. Modeling and role modeling is based on the fact that people know deep inside what made them sick and what will make them better. The method brings out into the open the causes. They wrote the book Modeling and Role Modeling. It's by Evelyn Tomlin, Mariannne Swaine, and Helen Erickson at U of Michigan. It was real interesting." Fruitfulness. 10 Q. A. In what ways do the concepts from the workshop help you think of or understand novel but practical applications or experimentation in this area in the sphere of holistic health care? “Same as intercranial pressure I already mentioned. I have monitors all over in the intensive care unit. Blood pressure, heart rate could be used as measures in research. I can see TT with post open heart patients to lower their blood pressure rather than using medications." 2. Q. A. 3. Q. A. 85 Can you visualize a new situation where you would feel comfortable applying TT in the full belief that it would meet the needs of that situation? If so, why would this be possible for you at this time? "Yes, I can visualize a situation, both personally and professionally. I work in the emergency room. I can use TT with migraine headaches. The emergency room doctor is good about trying new things. I could use TT with the Thorazine to help the migraine. They would need less of the medication if I added TT.“ To what extent did the workshop help you see the research potential of TT for nurses in a way that it would further validate TT and bring it into main stream health care? 'me way to mainstream TT is for more nurses to come out of the closet. Nursing research will make it more accepted. Research will take TT into clinical situations. It will become more acceptable. It is non-invasive - not a threat to the patient or MD. They may be willing to go along with TT. It is important to get more people involved in TT like staff nurses and administrators. Administrators need to be more aware of TT and open to it as a resource.‘ Uhderstandipg. 1. Q. A. To what extent did the TT workshop help you begin to see a holistic framework in which to locate this new intervention of TT? I'I think a person has to put together their own framework. But in the workshop, by presenting theory, research and academic information, this helps to put the framework together. I think I need more insdepth academic aspects to help build my framework. I have the new information now and I'm putting it all together on my own." Describe how the workshop made it possible for you to see a workable connection between your ideas of a holistic framework and the setting in which you carry on your nursing practice. A. 3. Q. A. 86 "My practice setting is very practical. There are more options than I had thought of. I can try whatever I think the patient needs. Yesterday, I put my hands on a man's stomach with an exam - not a real formal TT treatment. Bis stomach was rumbling and very bloated. Today, the abdomen is down and his pants nearly fell off. I can't say for sure how much the TT helped. But, I believe it did help. Having attended the workshop so recently, made me think to do this during the exam." was the workshop taught in a manner that allowed you to understand the basic concepts? 'The concepts were presented well. There was a lot to experience. There was more than information. This was an experience in my own body. It was shocking to feel the energy with my hands.“ Dissatisfaction. 1. Q. A. A. Since attending the TT workshop, can you think of a client situation that cannot be understood by using the traditional dualistic model of mind and body as separate? 'I can't separate the mind and body, ever. Now I can't look at one without the other. The elderly are a good example. They have to be treated holistically.“ As a result of the TT workshop, in what ways are you able to look beyond the traditional dualistic model of health care and visualize new holistic possibilities? ”Before the workshop, it was hard for me to connect my beliefs and my actions with comatose patients. I wasn't sure how they felt and thought about their condition. Now it is easier to believe I can help them.‘ Since attending the TT workshop, are you aware of client situations that cannot be solved by using the traditional dualistic health care model? I'I work in the recovery room. we do D a C s with spontaneous abortions. These women need emotional support and spiritual support too. This is what they ask for. I could easily just shuffle them through as a physical surgery but they are real people and have these needs too.“ 87 4. Q. In what ways do you believe that the TT workshop has encouraged you to look at the difference between the traditional dualistic model of health care and your spiritual or metaphysical views of such issues? A. 'Yes, traditionally, the physical diagnosis is the objective. The holistic considers the whole person which includes an opportunity for the spirit to be acknowledged too. 'With traditional health care there is no growth. It is all physical - the spirit doesn't grow.“ 5. Q. In what ways has the TT workshop led you to question the side effects resulting from the traditional dualistic model of health care? A. “Yes, with many invasive procedures things get worse. They are often worse after surgery. For instance, in maternal/child health. If the heart beat lowers below the accepted normal, they do a C section now. All babies' heartbeats lower before birth. The C sections are often unnecessary. The natural process is turned mechanical. There are too many ultrasounds on babies when there really isn't a problem." 6. Q. In what ways has the TT workshop caused you to become aware of inconsistencies between the traditional dualistic health care model and the holistic knowledge you have gained in the workshop? A. “This is related to the previous question for me. Traditional medicine is done because this is the way health care has always been done. It was accepted. I've been a nurse for 20 years. That's just the way it was. In the last 2 years, I have begun to realize that the traditional is not the only way. The holistic can be as or more helpful. The holistic approach gives the patient more input into their health care. They stay calmer without tranquilizers in the surgical area. I can use color, imagery, and music in the recovery room. You explained that to me at break - how to start. It doesn't have to be a big deal, just a little start. So I think holistic more." From this sample of participants comments, they clearly supported the presence of the four conditions in the workshop. This sampling cut across all six subjects. Each subject made statements referring to all four conditions, so only the clearest examples were used here. Outside TT Instructor's Perspective The third evaluation for the conditions of learning was done by another instructor of TT who was not present at the workshop. She listened to audio tapes of the workshop to make her determinations of the conditions present in the workshop. This person is similar to the workshop presenters in that she holds a Master's Degree in nursing, and she received her TT instruction from the same teacher, Dr. Delores Krieger. Ber analysis was of the four conditions and the teaching methods. She sampled 36 segments of the audio tapes. Many excerpts contained more than one example. She found 46 examples of plausibility, 9 of fruitfulness, 22 of understanding, and 12 of dissatisfaction, with their accompanying methods. This step of the ’analysis was necessary to validate from an outside perspective that the conditions and methods were indeed in place during the workshop. By adding this outside perspective, I was able to establish the presence of these parts of the model by triangulation with the instructors' and participants. It was critical to be certain that the methods and conditions were actually in the workshop if I hoped to be able to apply the outcome portion of the model, i.e., the stage theory. Themes Introduction This section will describe the themes in more depth. The themes were introduced in chapter three as part of the description of the analysis process. Two of the themes were defined there. They were 89 1) application of an intervention to a specific person or illness, and 2) dissatisfaction with the dualistic system. The former was used as a clear example of a theme that was identified independent of the conceptual change model. The latter example was used to show how one inductive theme and a condition of learning from the mode] overlapped in the analysis. In this section the remaining themes will be presented with examples from the data. This discussion will begin with the third theme. I will list the themes next as a reference point for the discussion. Themes in the Data 1. Dissatisfaction with the dualistic system 2. Application of an intervention to a specific person or illness 3. A sense of self as a professional 4. The potential future, feasibility, or research promise 5. Aspects of the workshop content 6. Aspects of the workshop experience or environment 7. Attitude, opinion, or insight 8. Expression of feelings or change in life perspective 9. Why they attended TT II 10. Ability to use TT at work 11. Mention of specific holistic intervention or approach 12. Support of new holistic conception 90 Sense of Self as a Professional This theme did not occur as commonly as some of the other themes. This theme generally referred to the level of professional confidence the person had with TT and how she was received by her peers and supervisors. Here is one example which refers to the peer response. “There have been many factors that have influenced my self concept since April (TT I). Specifically, related to TT, I like the feeling and enjoy the reputation of being a 'good witch' at work.“ This examples shows that the subject believed her peers saw her as making a very unique contribution in a favorable manner. The next example came after a brief comment about living in an area where there are no other TT practitioners. She was trying to problem solve within her professional role. “My director of nursing is very modern in her thinking. I'm going to talk to her. She won't laugh at me. She may have heard about it. She may know others in our hospital who have gone to workshops on TT.“ This person seemed to feel that TT was different enough within her profession that some people may ridicule her. But, she thought of an administrative person within her setting who would be able to offer support. She is faced with a common problem of introducing a new intervention into a system that is unfamiliar with TT and may even resist change of this type. The final example illustrates one nurse's lack of confidence in her ability to begin using TT in her professional setting. “I want to use TT on some of the patients here but fear I'm not skilled enough.“ This is a usual response to any new intervention whether it be giving the 91 . first few injections or beginning TT. The difference is that TT can easily be postponed without ramifications. This example addresses ability only; there are many other reasons professionals do not inmediately incorporate TT into their practice. Potential Future, Feasibilitygor Research Promise of TT This theme was tapped most often during the telephone interviews. During the interviews, subjects elaborated more extensively than on the written forms. Also, some of the interview questions touched on this theme more directly than other data sources. From the name of the theme, it is clear that a variety of responses were given about the future of TT. Some subjects dwelled on the research potential while others talked more about the application to future practice. In general, the comments for this theme consisted of speculative looks into the future. “One way to mainsteam TT is for more nurses to come out of the closet. Nursing research will make it more accepted. Research will take TT into clinical situations. It will become more acceptable. It is non-invasive - not a threat to the patient or MD. They may be willing to go along with TT.“ This futuristic look included both research and acceptance by the general health care team. The next example is from a person who mentioned a specific use for TT in the future. “I think TT will be used with sleep problems for the elderly. I wrote a grant for TT in a nursing home. I was hoping to 92 drop down the medications and not have the effects of all the drugs caused with the elderly. I didn't get funded but I was sure it would have helped.“ A final example is about teaching other nurses in her agency so they too can use TT. “I can see using TT as an inservice to teach staff nurses in cardiac care unit and emergency room at our hospital. In the recovery room, the nurse could do TT to the arm of a patient as she touches them.“ In summary this series of responses in the data all look ahead to the future of TT. ‘Agpects of the workshngContent This theme was identified whenever a person mentioned some planned part of the workshop content. This theme contrasts with the next theme I will mention, which deals with the unplanned portions of the workshop. Here are a few samples of content themes. “The workshop was well presented. It took one step at a time.“ This comment addressed the sequence and quality of the content. Another person commented, “What helped most was the talk about energy fields and inclusion of imagery with TT.“ This person spoke more specifically about two of the mini-lectures of the workshop - fields and imagery. A third person mentioned the development of a cognitive framework for inclusion of TT in a broader understanding. “In the workshop, by presenting theory, 93 research, and academic information, this helps to put the overall framework together.“ This content theme was one of the most frequently commented upon, as can be seen by looking at table 4.2 (p. 100). Aspects of the workshop Experience or Environment This is the second theme that contains comments specifically about the workshop. These comments were more subjective in nature than the content comments. They mentioned features of the workshop that could not be found in the written plans, but which naturally occurred as a feature of the setting and the interactive style of the program. “The workshop was enhanced by the fact that everyone was so enthusiastic.“ This person talked of the overall tone she experienced at the workshop. “It helped to share with knowledgeable others.“ Here the exchange with others was seen as useful. “The support of the workshop helped me allow'myself to be more open with holistic modalities. I had many of the same questions and doubts as other participants. I feel ready to take the risk.“ This person mentioned the peer support experienced at the workshop. She mentioned feeling confident enough to try TT in her practice. A final example expresses a commonly mentioned aspect of the workshop. “Being close to nature enhanced my learning.“ The natural setting was frequently mentioned as a positive part to the overall experience. Many participants embedded this type of comment within their comments about interactions with others at the workshop. 94 Attitudes/Opinions/Insights This theme involves changes in the way the person looked at various situations. Sometimes the responses sounded like an attitude; other responses seemed to be more opinionated; still other comments sounded more like the nurse had an insight which broke new cognitive ground. These distinctions were very subtle and I had trouble at times interpreting the differences. I realize that another rater may have treated this grouping of comments somewhat differently, but this seemed the most sensible to me. One person said it this way, “I think I am more open to new ideas: I think I look at people differently.“ She seemed to be aware of some change, but was still unable to make a strong statement. She articulated, as best she could, her own self understanding. “TT helped me realize how I can influence my perspective and feelings about situations. I keep reminding myself that action follows thought.“ Here there seemed to be a change in attitude that had led to a greater sense of control in some situations. “I have an increased awareness since TT.“ I would like to have asked this person to elaborate more on her brief comment, but this came from the written survey. She did note a change in her outlook, perhaps in terms of greater insight. Not everyone had responses that fit this theme. The comments tended to be more general than some of the comments representing other themes. 95 Mention of Peelipgs or Change in Life Perspective This theme covers statements about specific feelings or changes in life perspective. Frequently there was mention of their religious values. This first example came from a critical care nurse who had begun to question the high-tech environment she worked in. “When I tell them that I hate machines, they ask me why I'm there.“ Ber change in thinking had created dissatisfaction at work. This showed that the changes that occur from pursuing TT were not always positive. She was confronted with how to reconcile her new thinking with her old workplace. She used a strong word (hate) to express her feeling. The difficulty represented by this example caused me to realize there may need to be supportive follow-up for nurses who attend our workshops. The next examples from two different nurses deal with spiritual changes. “I believe my spiritual plane is being directed to help people. I feel I'm able to do something more. I have a desire to be helpful.“ “During the workshop, I was wondering how to fit my Christianity in with TT. I didn't feel it went against those beliefs. I was doing a lot of comparing with my religion during the weekend. These values seem to be shifting.“ This was a significant comment since spiritual values are generally deeply held aspects of one's life perspective. The final example mentioned changes in practice. “Between TT I and TT II a lot of questions came up for me: I use a more holistic approach now. I know other modalities too. I have eliminated some of the dualistic modalities. But, I use some of both. I now would use 96 less pain medication, some TT and imagery. The last two years I have really changed my thinking. I see it with my family and friends too. Everyone is more open to TT. It feels right inside for me. I have more questions to be answered on the level I am on now with my more open beliefs.“ This comment began with changes in her nursing practice and then she went on to talk about how the change had also entered her personal life. She further mentioned an awareness of being in the process of change when she referred to her current “level.“ Whprarticipents Attended TT II Most participants made one comment on this point. The survey administered before the workshop asked this question specifically. Here is a variety of different responses. “The nurse who was the TT advocate on the unit had to move to another state.“ “I've been able to see that it can work.“ “I feel I can use TT with practice but don't really know how and the excellence of the first workshop.“ “1 need some reaffirmation on TT.“ “I feel this is a useful tool and will be helpful in professional and personal life.“ These responses varied from a very practical need to replace a skill on a nursing unit to general interest and usefulness in both their personal and professional lives. Ability to Use TT at work This theme addressed the acceptance people felt in their practice settings. It did not include specific types of treatment. The 97 comments are based on peer and supervisor acceptance in the work place. “My co-workers ask about and want the information I learn. People are getting more curious so it is easier and more open.“ Another person said, “I will, in the future, give a program on TT to my colleagues.“ A.more frustrated person said, “My work setting is receptive to TT if we have time - in other words - non-technological, holistic interventions have low priority on our unit. The setting is very hectic and stressful - I gave up trying to use it at work for now.“ The next nurse spoke of her supervisor's response. “My nursing director thought I had lost it when I first explained it to her. Seven months later she was ready to come with me to TT II.“ One person mentioned a specific barrier, “I can't take it into practice, I really need a partner.“ A final comment was, “As long as it doesn't need an M.D. order we could try anything.“ These comments were all made by different people. Some were unable to practice at all due to their current circumstances. Others were having more favorable responses from peers and administrators. Mention of Specific Holistic Interventions orvApproaches For this theme, people mentioned related holistic interventions. “I frequently use accupressure and massage for my students, family, and friends for relief from pain, stress, and tension.“ Another person said, “I've tried imagery and centering to help myself.“ A third person mentioned reflexology. “I bought a book on reflexology which I've been experimenting with.“ Some people used situational examples. 98 “I work with my suicidal friend. I can help her develop a shield from her husband's negative energy. He is suicidal too and she gets pulled into it by him. She is such a good friend. She can learn to keep some distance from his field to protect herself from his feelings.“ This has been a cross section of the types of responses mentioned. Some focused on more definite interventions while, as in the last example, others referred to an approach to a problem. Sgpport of the New Holistic Conception This theme includes comments that definitely support a holistic approach to health care. They are different from the comments that criticized the dualistic system. These comments were supportive and in some instances gave rationales for the effectiveness of a holistic approach. For example, “What we need are clinics with doctors and other HCPs to works together as a team. This could include accupressure, counseling - every one could work together to meet the patient's needs. In Hawaii they accept holistic health - it is the norm. A nurse was running the clinic. A patient might get accupuncture, shishu, chiropractory or see a DO doctor. I went there with a migraine after three days of pain. It was wonderful.“ Another person said it this way, “I can't separate the mind and body ever. Now I can't look at one without the other. The elderly are a good example. They have to be treated holistically.“ A third person said, “Before the workshop I believed that mind and body were related - after the workshop, I can't think of any exceptions.“ These examples ranged 99 from how to operationalize a holistic health care team to perceptions of what holistic meant to them. Summary This concludes the discussion of inductive themes. In Table 4.2 the themes are itemized by their number of occurrences in the data. Each subject is identified by her code number only. The table points out the frequency of each theme, making clear the most dominate trends. The themes have provided a natural assessment of the data. They demonstrate the primary areas of emphasis from the participant's view-point. It is clear that an entire study could be conducted utilizing only the inductive process, but the focus of this study is change, based on a specific model - the conceptual change model. The most striking contribution to this study from identifying the themes was evidence found about barriers to practice. This discovery during the inductive analysis significantly influenced the deductive analysis of the nurses' stages of conceptual change. As we will see in chapter V, two systems to determining stages of conceptual change were used. One system is based solely upon the variables of the conceptual change model. The other is a revised rating system which takes into account the variables of barriers to change and holistic/dualistic orientation. Without the revised rating system, as a result of the inductive analysis, only a few nurses could have been rated for their stage of conceoptual change. The data sets often were missing variables essential to the model, but also contained one or both of the 100 two added variables. All data sets could be rated following the revised staging system. Table 4.2 Number of Responses Illustrating Themes, by Subject susasc'rs sumac-rs (code 3) 1 $3 1_4 _11 39 g; g _3_g 3; TOTALS ms DIssarrsrac'rIow 1 1 5 2 4 7 2 27 spscrnc APPLICATION 2 3 3 1 4 5 4 2 5 30 3er as pnomssxom 4 5 4 7 2 1 25 mung poms-rm. 2 3 5 s 4 5 25 mansnop com 6 6 1o 9 4 1 s 41 wonxsaor EX/ENVIR 1 2 1 3 2 1 2 2 14 mums/mergers 1 3 2 2 2 1 1 2 14 muucsmmpscrm 2 3 2 4 4 4 4 2 s 30 m TT 11 1 1 2 1 1 1 1 1 1 10 use AT wow: 4 7 a s 9 a 3 3 7 54 HOLISTIC INTERNENTION 3 3 2 1 5 6 2 3 4 29 summer nousnc _3 _3 _1 _ __1_ _e _ _1_ _ 1_3, mars 30 3o 51 21 55 45 16 18 40 312 CEAPTER'V RESULES-STAGING Stages of Conceptual Change Introduction This chapter will deal with the outcomes of the intervention, i.e., the stages of conceptual change. There is a summary table of the data for each subject to help in conveying the results. Each table is followed by a description of the most significant aspects of the results for that subject. First, I will present a sample table (5.1) that demonstrates how to interpret the individual tables. The rows for the BEFORE data show an example of an ideal stage 1, according to the model of conceptual change that guided this study. The AFTER ONE WEEK data rows show an ideal stage 2 example. The APTER.TWO MONTH data rows show an ideal stage 3 example. The elements of each stage are displayed here for easy reference to table 5.1. Stage 1 : Basic knowledge, basic application Stage 2 a Advanced knowledge, advanced application Stage 3 Advanced knowledge, advanced application, and acceptance 101 102 Table 5.1 Stages According to the Model DATA SOURCES K APP ACC MOD MOD REV REV 10f ORT DEC SUM SUM DEC BAR BEFORE TT Survey Bas1 Bas No l4 1 Case Bas Bas No 1 HOLISTIC Survey Bas Has No l 1 Case Bas Bas No l AFTER 1 week TT Interview Adv Adv No 2 26 HOLISTIC Interview Adv Adv2 No 2 26 AFTER 2 months TT Survey Adv Adv Yes 3 35 Case Adv Adv Yes 3 HOLISTIC Survey Adv Adv Yes 3 3 Case Adv Adv Yes3 3 PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, {of BAR I number of barriers, Ort I orientation, Mod Dec I model decision,Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, 501 I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, -- I missing data 103 §§planation of variables Found in Table 5.1 Look first at the superscript 1 next to Bas (for BASIC). It is found under the vertical column labeled K (for KNOWLEDGE) and in the horizontal row labeled BEFORE /TT/ SURVEY. Superscript 1 indicates that on the TT SURVEY, before the workshop began, the subject demonstrated BASIC KNOWLEDGE. Look next at the Adv (for ADVANCED) with the superscript 2. This is found under the column titled APP (for APPLICATION). It is also located in the row called AFTER ONE WEEK /HOLISTIC/ INTERVIEW. Combining the horizontal and vertical axis, this means that the subject demonstrated ADVANCED APPLICATION on the holistic aspects of the INTERVIEW, one week after the workshop. Superscript 3 is found next to the YES. This YES is found under the column for ACCEPTANCE and in the row labeled AF'I'ER TWO MONTH /HOLISTIC/ CASE. This combination means that on the HOLISTIC CASE, completed two months after the workshop, this subject demonstrated ACCEPTANCE of holistic interventions. Superscript 4 is located next to the number 1 and is found in the column for MODEL DECISION and in the row for BEFORE /TT/ SURVEY. This means that on the TT SURVEY administered before the workshop, the subject had a stage 1 rating according to the model. Superscript 5 is found next to the 3 that is located under the heading for MODEL SUMMARY and in the row for AFTER TWO MONTHS /TT SURVEY data. It is the summary of the two data sources for the AFTER /TT data, according to the model. Each individual TT source (AFTER 104 /SURVEY and AFTER /CASE) has a rating of 3; therefore, the summary also averages out to a stage 3. Such summative ratings are for all three time intervals for both the holistic and TT concepts. Also note that for the AFTER ONE WEEK data, the summary is identical to the individual rating since there is only one source for each of the TT and HOLISTIC ratings (see superscripts 6). The next four headings on the chart represent the revised rating system I developed during the study and its accompanying variables. I will briefly describe the revised system and then apply it to an example once I begin the actual data presentation. The heading titled REV SUM is for the REVISED SUMMARY based on my alternative rating system. The heading REV DEC is for the REVISED DECISION on an individual data source using the new rating system. This format keeps the summary data in the center of the tables for easy comparative reference, for both the model and revised decisions. The final two columns are for the two additional variables I coded in the data. iof BAR is for NUMBER OF BARRIERS. This column lists the number of barriers to the practice of TT, or other holistic interventions, that were mentioned for each data source. The last heading is ORT (for ORIENTATION), as I assessed it, for a given data source. Net all data sources revealed either barriers or orientation, but where subjects did mention them, they were included in the tables. 105 Participgnt 25 Table 5.2 Staging Results - Participant 25 Components K APP ACC MOD MOD REV REV #Of ORT DEC SUM SUM DEC BAR BEFORE TT Survey Bas Bas Yes 1 1 1+ 1+3 1 H01 Case Bas Bas Yes 1 1+ 1 HOLISTIC Survey Bas Bas Yes 1 ? 1- 1+ 1 Hal Case -- -- No ? 0 Dul AFTER 1 week TT Interview Adv Adv Yes 3 3 3 3 HOLISTIC Interview -- Adv Yes 2 2 3- 3- H011 AFTER 2 months TT Survey Bas Bas Yes 1 1 2+4 1+ 42 Case Adv Bas Yes 1 3- 2 HOLISTIC Survey Bas Adv Yes 1 ? 2 3- 2 H01 Case —-- --- No ? 0 Dul PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, {of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data, 0 I less than stage one 106 gyplenation of Variables Found in Table 5.2 The best way to understand the alternative rating process is to begin with one of the subjects. Table 5.2 has the identical format as that of the sample table (5.1) but it also includes the new revised ratings and variables as well. The description of the added variables and ratings begins at the right margin and moves toward the center of the chart. The heading at the far right side of the table is ORT (for ORIENTATION). Superscript 1 appears next to the HOL (for HOLISTIC). The HOL is also in the row for the AFTER ONE WEEK /HOLISTIC/ INTERVIEW data. This axis means that on the HOLISTIC items of the interview, the subject revealed a HOLISTIC ORIENTATION. The second column from the right is #of BAR (for NUMBER.OF BARRIERS). Superscript 2 is next to the 4. This example appears in the row for the AFTER.TWO MONTHS /TT/SURVEY. This subject mentioned four barriers to the practice of TT when she responded to the SURVEY questions, two months after the workshop. The third column from the right is REV DEC (for REVISED DECISION). Superscript 3 is next to the 1+. This superscript is also in the row for the BEFORE /TT SURVEY data. The 1+ means that after I considered all possible data, both the model elements and the added variables, this was my REVISED DECISION on the stage rating for this data source. The plus sign next to any rating indicates that it was a strong rating at that stage, but not strong enough to constitute the next higher stage. 107 Finally, superscript 4 next to the 2+ comes under the column headed REV SUM.and in the row for the AFTER TWO MONTHS [TT/ SURVEY data. This means that the REVISED SUMMARY is a 2+ rating. The 2+ rating results from averaging the two data sources for the AFTER.TWO MONTH/TI period, which are 1+ (SURVEY) and 3- (CASE). The minus following any rating indicates that the data only weakly met the stage criteria, but that it is stronger than the next lower stage. By looking at the decision columns in the center of the table, we see that the model results are different than those from my revised rating system, in most instances. The model involves the three key features KNOWLEDGE, APPLICATION, and ACCEPTANCE. In the revised rating, I also consider the subject's ORIENTATION and any perceived BARRIERS. There are several instances where the model does not lead to a rating for the subject, due to missing data. To compensate for the occasional lack of adequate variables in the model, I drew upon the two added variables to determine the revised ratings. Within each time segment, I comment on the stages for both the TT and the HOLISTIC data sources. My point of reference is the SUMMARY rating columns found in the center of the tables. Before Data Summaries for Participant 25. The TT data results in a revised 1+ rating as opposed to a stage 1 rating according to the model. The model does not account for evidence of ACCEPTANCE at stage 1. The revised rating includes ACCEPTANCE and the HOLISTIC ORIENTATION 108 the total formula. According to the revised rating, the TT data suggests a strong stage 1, or as I code it, a 1+. The HOLISTIC portion of the data is rated a revised stage 1- while the model does not allow for a summary rating due to missing data. For the revised rating, I considered the subject's solid stage 1 on the SURVEY and the mention of a HOLISTIC ORIENTATION in the presence of a BARRIER. I weighed these factors against the missing data and the indicators of a DUALISTIC ORIENTATION on the CASE STUDY. I also took into account that the SURVEY tapped her actual practice while the CASE was a hypothetical situation. It may have been more difficult to transfer her knowledge to an abstract situation rather than to something she had actually experienced. Here is an example of the strength of her HOLISTIC ORIENTATION. “I have a strong desire to become proficient and self confident to use the holistic knowledge to relieve my clients pain and anxiety and fears.“ When presented with the CASE, this subject responded only to the data given. The CASE required her to describe how to medicate a pain patient; it did not directly suggest the possibility of any holistic interventions. Any holistic additions were included by the subject on her own. Some subjects did draw in holistic interventions without any cues to do so, but this subject happened to respond to the situation just as it was presented. She said, “Identify patient's pain - verify medication order - time of last dose - sign out medication and administer - document treatment completed - signify relief or 109 non-relief.“ It appears that the subject's TT conceptual commitment is stronger than her HOLISTIC ORIENTATION for this time segment, considering both rating systems. After One Week Data Summaries for Participant 25. The TT aspects of the data demonstrates a sound stage 3 across both rating systems. The MODEL DECISION does not allow a HOLISTIC rating due to missing KNOWLEDGE data. The REVISED DECISION is a 3-. Even though the HOLISTIC portion of the interview lacks evidence of KNOWLEDGE, it does reveal a HOLISTIC ORIENTATION and two key features of stage 3. Here is a sample of her holistic position. “I think I concentrate more on the holistic now. Doctors treat organs or conditions and don't look at the rest. If a person is admitted with a heart problem the diabetes takes a back seat. They forget teaching and diet control. The psycho-social aspects are the last thing for MDs to deal with. It's all left to the social worker and the nurses.“ Another researcher might have credited her with holistic knowledge for this statement since it alludes to her understanding. While she does not demonstrate her knowledge of exactly how to perform some of these holistic interventions, she does speak of the importance of them in her perception of patient care. In conclusion, while the REVISED and MODEL DECISIONS agree with a stage 3 for the TT data, the model does not lead to a decision on the HOLISTIC data, while the REVISED DECISION is 3-. 110 After Two Months Data Summaries for Participant 25. The TT portion of the data is a stage 1 according to the model. The REVISED DECISION is stage 2+ since there ARE one or two features of stage 3 present in each TT source. This is in the presence of a total of six barriers. She supplied an example of ADVANCED APPLICATION where she was able to move beyond specific examples taught in the workshop. “I can apply it by sending energy to my staff. It can help validate that TT really works.“ The HOLISTIC data is a stage 2 by my REVISED DECISION. Less weight is given to the CASE, where there is inadequate data, and I included the presence of a HOLISTIC ORIENTATION. When this subject was questioned directly in the SURVEY about her use of holistic interventions, she was able to explain how she used such interventions in her practice. But, when given a hypothetical case where holistic interventions were not mentioned, she did not add them spontaneously. I place more emphasis on what she is actually doing in her practice than on how she responded to a hypothetical case. To summarize this time segment, the TT data reveals a stage 1 on the model variables, while the REVISED DECISION is a 2+. The HOLISTIC data is undetermined by the MODEL DECISION and a stage 2 by the REVISED DECISION. Overall, with my revised ratings this subject went from a TT stage 1+ prior to the workshop, then to a stage 3 one week after the workshop and dropped back to a stage 2+ two months after the workshop in the face of a significant increase in barriers. The MODEL DECISIONS see 111 these TT results as indicating a stage 1 prior to the workshop, a stage 3 one week after and a stage 1 two months after. Therefore, from the revised ratings of TT, it appears that the conceptual change peaked one week after the workshop and fell back to stage 2 two months after. The MODEL DECISIONS show a similar pattern with a more dramatic decline two months after,i.e., to stage 1. The HOLISTIC REVISED DECISION is a 1- before the workshop. For one week after, the HOLISTIC data suggested a 3-, and a stage 2 for two months after. The model led to an undetermined rating from the HOLISTIC data for all three time frames. In summary, applying the model does not result in a pattern over the time segments due to lack of data. The REVISED HOLISTIC DECISION was similar to the revised TT pattern over time, but does not provide as strong a picture. In general, this data suggests that the conceptual change related to TT was more complete than for the holistic conception. It also raises the question of the long term stability of the TT conception in the midst of numerous barriers, since the underlying concept of holism seems quite tenuous. Participant 7 Before Workshop Data Summaries for Participent 7. On the TT portion of the BEFORE data the MODEL DECISION does not yield a SUMMARY rating due to missing APPLICATION data. The REVISED SUMMARY includes the presence of ACCEPTANCE at a stage 1 and acknowledges the BARRIER. This results in a 1+ REVISED SUMMARY rating. 112 The HOLISTIC data results in a 1 SUMMARY rating from the model. The REVISED SUMMARY results in a 1+ due to the abundance of support on additional variables. This person showed evidence of ACCEPTANCE and HOLISTIC ORIENTATION in both data sources. Here is a quote about her HOLISTIC ORIENTATION: “I'm excited about any tool other than narcotics.“ ACCEPTANCE was shown both in her work setting and in her own personal experience. “They are holistic minded at work.“ “TT I made me more aware of the usefulness of holistic interventions.“ The only thing that keeps this subject at only a stage 1 is the BASIC KNOWLEDGE and BASIC APPLICATION. If there had been evidence of an ADVANCED level on either of these variables, the stage would have been elevated. In summary, for TT the model variables do not lead to a SUMMARY rating, while the revised rating is a 1+ stage. ‘With the HOLISTIC data, the MODEL results were a l and the REVISED a 1+. For both the TT and HOLISTIC data, the REVISED DECISION produced higher ratings. After One week Data Summaries For Participant 7. As always, there is only one data source, the interviews, for both TT and HOLISTIC information. According to the model, the TT portion of the data is a stage 3. The revised rating yields a 3+ rating since the stage is complete, even in the presence of two BARRIERS. For the HOLISTIC portion, the model variables alone do not yield a decision due to missing data. This same set of data is a 3- according to the REVISED DECISION, since there is an overall HOLISTIC 113 Table 5.3 Staging Results - Participant 7 DATA SOURCES K APP ACC MOD MOD REV REV #of ORT DEC SUM SUM DEC BAR BEFORE TT Survey Bas -—— Yes ? ? 1+ 1+ 1 Case Bas Bas Yes 1 1+ HOLISTIC Survey Bas Bas Yes 1 1+ Hol Case Bas Bas Yes 1 1 1+ 1+ Hol AFTER 1 week TT Interview Adv Adv Yes 3 3 3+ 3+ 2 HOLISTIC Interview Adv --- Yes ? ? 3- 3- Hol AFTER 2 months TT Survey --- --- -- ? ? l- 0 4 Case Bas Bas Yes 1 1+ HOLISTIC Survey --- Bas Yes ? l Hol Case -- -- Yes ? ? l l- Hol PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, 40f BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Ho1 I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data, 0 I less than stage one 114 ORIENTATION to help compensate for the missing APPLICATION data. Next is an example of her HOLISTIC ORIENTATION. “The pain workshop I attended used ice, music and diversion therapy. TT fits in well with all the holistic approaches. “I am more aware of the whole person. I have to think of the person as a whole.“ In summary, the set of revised variables continue to result in rating this subject higher than the model system, and has alternative variables to make up for the lack of model variables. After Two Months Data Summaries for Participgnt . The TI SURVEY is nearly void of variables for this person, who only mentioned four BARRIERS. Her BARRIERS focus on not having anyone to practice with. “I really need someone to match up with here for support. I went to the workshop alone and no one in my particular hospital in Grand Rapids knows about TT. This makes it hard for me.“ Fortunately, the CASE reveals more. KNOWLEDGE and APPLICATION are briefly stated, but are accurate at a BASIC level. This results in an unratable situation for the model rating system and a 1- from the REVISED DECISION. The HOLISTIC data also has many gaps. This makes it impossible to rate the data according to the model variables alone. The subject mentioned her HOLISTIC ORIENTATION on both sources. This fact allows the revised rating of a 1. This was her comment on the CASE, “There is a place for narcotics in the emergency room perhaps or just post-op. Other comfort measures such as positioning, ice application, diversionary measures - such as music, imagery, etc. Also the new 115 patient controlled analgesic pumps are much better, than an IM large dose. This could be very effective with TT, imagery, etc.“ In this quote she clearly combines biological measures with the psychosocial approaches to make a holistic statement. In conclusion, using only the model variables, I had a difficult time rating the TT data over time. The MODEL SUMMARY ratings went from a questionable rating on the BEFORE data, to a 3 on the AFTER ONE WEEK data and a questionable rating again for the AFTER TWO MONTHS decision. The REVISED TT SUMMARY began with a 1+ for the BEFORE data, then a 3+ one week after, and back to a 1- two months after. For the HOLISTIC data, the model results began with a 1 and then an undetermined rating for the two AFTER data decisions. Conversely, the REVISED DECISION was similar but weaker for the IT decision. This REVISED HOLISTIC DECISION started with a 1+, then peaked to a 3- one week after and went back to a 1 two months AFTER. By depending upon only the MODEL DECISION for this data set, there would not have been any useful pattern. ‘With the additional variables, we have a better idea of where this person was conceptually. On both the TT and holistic concept, this subject went from basically a 1 rating to a 3 one-week after and back to a 1 two months after the workshop. Each concept had different variables of strength, but both turned out to be fairly equal ratings over all. The change that was apparent one week after had disappeared by two months after. It also seems important to 116 realize that the strongest data source was the personal interview. It raises the issue of what the data would have looked like had an interview been used at the other two data collection times. Participgpt 13 Before Data Summaries for Participant 13. By looking at the SUMMARY data derived from the model, we see no rating is determined. For the REVISED DECISIONS on the TT SURVEY, I rely upon the fact that ACCEPTANCE is mentioned as well as one BARRIER. Here is her ACCEPTANCE statement, “I accept II the same as I accept the use of medication, ice, heat, accupressure, accupunture, etc. If it works, use. Since I work mainly with the elderly I like the idea of IT because it doesn't introduce foreign material (drugs, needles) etc which can cause confusion.“ Her BARRIER is related to a lack of peer support. She said, “I wish I knew others in my area that were interested in IT and other holistic healing methods.“ These two variables lead to a stage 1 decision. The CASE data is all present plus a HOLISTIC ORIENTATION which results in a 3+ rating. Therefore, the REVISED SUMMARY is a 2+ for TT. The HOLISTIC data receives a 3+ from.my REVISED DECISION. There are ample supporting variables even though evidence of KNOWLEDGE from the SURVEY is missing. After One week Summaries for Participant 13. My REVISED DECISION and the decision according to the model are similar. Both systems give the data a rating of 3 on the TT and holistic components. Using the 117 Table 5.4 Staging Results - Participant 13 DATA.SOURCES K APP ACC MOD MOD REV REV {Of ORT DEC SUM SUM DEC BAR BEFORE TT Survey -- Bas Yes ? ? 2+ 1 1 Case Adv Adv Yes 3 3+ Hol HOLISTIC Survey --- Adv Yes ? ? 3+ 3 1 H01 Case Adv Adv Yes 3 3+ Hol AFTER 1 week TT Interview Adv Adv Yes 3 3 3 3 HOLISTIC Interview Adv Adv Yes 3 3 3+ 3+ Hol AFTER 2 months TT Survey Bas Bas Yes 1 2 2+ 1+ 2 Case Adv Adv Yes 3 3 HOLISTIC Survey Adv Adv Yes 3 2 2+ 3 H01 Case Bas Bas Yes 1 2- H01 PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, #of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summer , Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data 118 revised system, I also elevated the 3 to a 3+ stage on the HOLISTIC data due to the presence of a HOLISTIC ORIENTATION. Here is a clear example of her experience: “I'm a clinical specialist with the elderly. The other day I was walking to the chapel with a man in his 70's. I suggested using imagery with him for his sleep problem instead of so much medicine. He said he was using biofeedback to help him sleep too. Since the workshop, I feel more sensitive to the possibilities of what to discuss with a patient. I never would have brought any thing up with a patient before - now I find he is already using a holistic approach - he may never have mentioned biofeedback either. If he believes it will work, I think it will work for him.“ After Two Months Data Summaries for Participant 13. Again both ratings are very similar: they are stage 2 for both the TT and HOLISTIC data. I have added a plus to my REVISED DECISIONS by utilizing the additional variables. Here are a few examples of her HOLISTIC ORIENTATION: “I use holistic approaches when people ask for help or ideas. As long as it doesn't need an M.D.'s order we can try anything at work. I have used accupressure points to treat headaches with friends and colleagues.“ In summary, the TT decisions according to the model started out undetermined, then led to a 3 rating one week after, and finally a 2 rating two months after. My REVISED DECISION began with a 2, then a 3 one week after, and ended with a 2+ two months after. The HOLISTIC data has nearly the same pattern. According to the model, there is an undetermined rating for BEFORE data, followed by a 3 one week after and concluding with a 2 two months after the workshop. 119 My REVISED DECISION began as a 3+ before the workshop, continued with a 3+ one week after and dropped back to a 2+ two months after. For this subject, the REVISED DECISION made it possible to rate the data on all three time intervals. Without the REVISED DECISION, there would not have been a rating for data collected before the workshop. It was also possible to accentuate the strengths of the data with the plus rating which was present in all the HOLISTIC data, and in the TT data collected after two months. Participant 14 Before Data Summaries for Participant 14. According to the model, the TT summary rating is a stage 1. The revised rating is a 1+ due to the addition of the ACCEPTANCE variable and the HOLISTIC ORIENTATION. The model does account for ACCEPTANCE unless there is ADVANCED KNOWLEDGE and ADVANCED APPLICATION. By using the revised rating, ACCEPTANCE can be included in the decision. The HOLISTIC data created a difficult rating decision. There are two missing sources of data on the SURVEY and there is DUALISTIC data in the CASE. According to the model this data is unrateable. I made a REVISED DECISION of a stage 1-. I based the 1- rating on the two variables present, BASIC APPLICATION and HOLISTIC ORIENTATION. Here is an example of her HOLISTIC ORIENTATION: “I think I am more open to new ideas since the first workshop on TT. I find myself doing a lot of informal counselling and assisting people to get the medical help they need.“ This rating may be too generous in light of the scant data. 120 Table 5.5 Staging Results - Participant 14 DATA SOURCES K APP ACC MOD MOD REV REV #Of ORT DEC SUM SUM DEC BAR BEFORE TT Survey Bas Bas Yes 1 1 1+ 1+ Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey -- Bas -- ? ? l- 1 801 Case Dul Dul No ? 0 Dul AFTER 1 week TT Interview Adv Bas Yes 1 l 3- 3- l HOLISTIC Interview Adv Adv Yes 3 3 3+ 3+ Hol AFTER 2 months TT Survey Bas Bas Yes 1 1 1+ 1+ 1 Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey Bas -- Yes ? ? l- l 1 H01 Case Dul Dul No ? 0 Dul PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, #of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data, 0 I less than stage one 121 The other option is to use a 0+ rating, but this seems to lack meaning. ‘With the absence of supporting data and the presence of DUALISTIC data, I acknowledge the weakness of this particular rating. After One Week Data Summaries for Participant 14. The TT data is rated dramatically different by the two rating methods. The decision according to the model is confined by the presence of BASIC APPLICATION. Even though all the other variables of a stage 3 are evident, the BASIC APPLICATION keeps the MODEL DECISION at a stage 1. In making the REVISED DECISION, I took into account the BARRIER.which may have inhibited the subject's application. I gave the TT data a revised rating of 3-. I realize that this person is not a strong stage 3 but that the additional variable (BARRIER) is able to contribute support to the decision. In the following quote, the subject first stated how she was able to use TT at work and then she mentioned her barrier to more advanced application. “I can use TT at work with the staff members. They have symptoms - like headaches, backaches, tension, muscles spasms: they are wound up too tight.“ Next she mentioned her reservation, which I coded as a BARRIER: “Since this is new knowledge, it is easy for others to be critical. I want to be ready to present this content to other HCPs. I understand it, but it will be very new to other HCPs.“ The HOLISTIC data is clearly a stage 3. I increased the revised rating to a 3+ due to the presence of a HOLISTIC ORIENTATION. 122 After Two Months Data Summaries for Participant 14. The IT data is a stage 1. I added a + to the revised rating to make it a 1+. There is a HOLISTIC ORIENTATION and a BARRIER mentioned to make this data set a very strong stage 1. If there had been ADVANCED KNOWLEDGE or ADVANCED APPLICATION I would have easily considered elevating the stage number. The HOLISTIC data is again a problem to rate, as in the BEFORE sources. There is one additional data source in this AFTER.data to draw upon since the subject indicated ACCEPTANCE. The following quote demonstrates her sense of acceptance of holistic interventions. “Through the use of holistic methods, I feel more in control of my own wellness and can help other people feel that too.“ The necessary model variables are not available for making a decision. I rated this data as a stage l-. I acknowledge this is a weak rating. Hewever, this 1- rating is somewhat stronger than on the same BEFORE data set due the addition of the ACCEPTANCE variable. In conclusion both rating systems resulted in stage ratings from the TT data. According to the model, I rated the TT data as a l on all three time intervals. For the revised rating, I gave the data a 1+ before the workshop, a-3- one week after, and a 1+ again two months after the workshop. Turning next to the HOLISTIC data, I am only able to determine a rating according to the model's variables for the AFTER ONE WEEK source, which is a solid 3. My revised ratings are 1- before the workshop, 3+ one week after, and 1- again at the two month after interval. The clearest data for both decisions came from the interview one week after the workshop. 123 This finding again points to the strength of the interview. Many subjects expressed themselves best verbally. Also, I was able to ask subjects during the interview to elaborate if a response was incomplete. The written sources did not allow for any type of followbup for incomplete responses. Participant 20 Before Data Summaries for Participant 20. Both TT decisions are based on only the SURVEY data. The CASE was not filled out. I do not know if she overlooked the CASE or chose not to respond. While the TT data is a stage 1 according to the model, I raised this to a 1+ for the revised rating. This increase in rating was based on her mentioning four BARRIERS and indicating ACCEPTANCE. The HOLISTIC data is rated a 1 according to the model. I revised this decision to a 1+ since there is a HOLISTIC ORIENTATION evident in both data sources, as well as the mention of a BARRIER. Next is an example of her HOLISTIC ORIENTATION, “I find it helpful to use TT techniques in assessment because it opens one to more possibilities than the obvious (ex: post-op open heart patient with TI I may find his discomfort is in his leg or hand).“ This subject referred to her barriers in terms of her work setting. “My work setting is receptive to TT if we have time - in other words - non-technical, holistic interventions have low priority on our unit. The noise level on the unit is also a hindrance and too many interruptions.“ 124 Table 5.6 Staging Results - Participant 20 DATA SOURCES K APP ACC MOD MOD REV REV {of ORT DEC SUM SUM DEC BAR BEFORE TT Survey Bas Bas Yes 1 1 1+ 1+ 4 Case -- -- --- ? ? HOLISTIC Survey Bas Bas --- 1 1 1+ 1+ 1 Hol Case Bas Bas -- 1 1+ Hol AFTER 1 week TT Interview Adv --- Yes ? ? 3- 3- 4 HOLISTIC Interview Adv Bas Yes 1 1 3- 3- H01 AFTER 2 months TT Survey --- Bas Yes ? ? 1- l- 3 Case --- Bas Yes ? l- HOLISTIC Survey Adv Adv Yes 3 2 2+ 3+ 2 H01 Case Bas Bas Yes 1 1 Dul PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, {of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data 125 After One Week Data Summaries for Participant 20. Because of the missing APPLICATION data on the TT interview, I am unable to determine a rating from the model. For the REVISED DECISION, this same data leads to a 3- rating. I based this REVISED DECISION on the presence of two of the three necessary model variables and the mention of four BARRIERS. This is a substantial number of barriers to overcome and still demonstrate ADVANCED KNOWLEDGE and ACCEPTANCE. Here is one example of her acceptance: “I can see how TT would be helpful with kids - they are anxious during hospital stays or even non-hospital settings. For instance, my husband teaches emotionally impaired kids - it may be useful to calm them down so they can work better.“ This subject mentioned professional resistance as a barrier: “Nursing has the potential to change and influence the health care system, including TT and holistic care. Overall nursing has a confidence problem. This may be a long far off goal. we nurses don't present ourselves well on documentation we already have.“ For the HOLISTIC data, I derived a stage 1 rating according to the model. The REVISED DECISION was a 3- because of the addition of the HOLISTIC ORIENTATION and ACCEPTANCE. I used the additive effect of these two variables to offset the fact that the subject showed only BASIC APPLICATION. After Two Months Data Summaries for Participant 20. The TT data is unrateable according to the model due to missing one of the model variables, KNOWLEDGE. To determine the REVISED DECISION, I took into 126 account that the data does shows ACCEPTANCE and also three BARRIERS. Her barriers continue to be related to her work setting. “Things are very hectic and stressful at work - I gave up trying to use TT at work for now.“ She mentioned ACCEPTANCE as a useful tool for herself. “I've been very selfish and trying to utilize TT and other holistic interventions to keep myself energized.“ With these two additional categories of variables, I revised the rating to a 1-. The HOLISTIC data reveals interesting results. It demonstrates how differently this subject responded to the SURVEY, which had to do with application to her practice, and to the CASE, which was a hypothetical situation. She was clearly a stage 3 on the SURVEY but only a stage 1 on the CASE. These two sources averaged out to a stage 2 according to the model. For the REVISED DECISION, I considered the additional variables. In this case I found that the two ORIENTATION statements negated each other, since one was HOLISTIC and the other DUALISTIC. Here is evidence of the subject's DUALISTIC ORIENTATION: “Giving narcotics to decrease pain stimulation in the central nervous system. Morphine, I think act the same way as the endomorphins that the body naturally produces.“ It seems clear that the subject was not opposed to a HOLISTIC ORIENTATION but rather was responding directly to the CASE presented. This subject was also able to maintain a stage 3 on the SURVEY in the presence of two BARRIERS. Even though the CASE contained ACCEPTANCE data which could have elevated the rating, I felt it was again neutralized by the DUALISTIC ORIENTATION. Therefore, the REVISED SUMMARY decision of 2+ is based on a combination of a stage 3+ on the SURVEY and a l on the CASE. 127 In summary, according to the model, this subject was a stage 1 for TT concepts before the workshop, and an undetermined rating at the two AFTER time intervals. Looking next at the revised rating system, this subject began as a stage 1+ TT before the workshop, then a 3- one week after and back to a 1- two months after. The revised ratings demonstrate the commonly seen peak to stage 3 one week after with the decline back to the original stage two months later. The pattern for the HOLISTIC summaries was somewhat different than for the TT. According to the model, the subject began at a stage 1, continued at a stage 1 one week after and elevated to a stage 2 two months after. This is a rather unusual sequence, i.e., to see an increase two months after rather than at the one week after interval. Next, the REVISED DECISIONS were a stage 1+ before the workshop, a stage 3- one week after, and a stage 2+ two months after. This subject was able to partially maintain her change in conception two months after, by demonstrating a stage 2 for both holistic ratings. we have often seen a decline back to a stage 1 at this third time interval. Participant 33 Before Data Summaries for Participant 33. Beginning with the TT data, I was unable to determine a SUMMARY decision from the model variables. This decision was based on an interesting combination of data: the CASE data suggests a strong stage 3 but the SURVEY is missing data on KNOWLEDGE. The decision according to the model would have been rateable 128 Table 5.7 Staging Results - Participant 33 DATA SOURCES K APP ACC MOD MOD REV REV #Of ORT DEC SUM SUM DEC BAR BEFORE IT Survey --- Bas Yes ? ? 2+ 1+ 2 Case Adv Adv Yes 3 3 HOLISTIC -Survey --- --- --- ? ? 2- 1- H01 Case Adv -- Yes ? 3- Hol AFTER 1 week TT Interview Adv Adv Yes 3 3 3 3 HOLISTIC Interview Adv Adv Yes 3 3 3+ 3+ Hol AFTER 2 months TT Survey Adv Adv Yes 3 3 3+ 3 Case Adv Adv Yes 3 3+ Hol HOLISTIC Survey Adv Adv Yes 3 ? 1+ 3+ Hol Case -- -- No ? 0 Dul PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, {of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data, 0 I less than stage one 129 and perhaps a high stage if evidence of KNOWLEDGE had been present. For the REVISED DECISION, I took into account the presence of ACCEPTANCE and two BARRIERS, which enabled me to provide a rating for the SURVEY. Therefore, the REVISED SUMMARY is a 2+. The HOLISTIC data are sketchy. There actually is no data on the SURVEY which relates to the model variables. Fortunately, in the comments on one of the added variables, she did make a clear HOLISTIC ORIENTATION statement: “The workshop helped me be more aware of certain areas of my life and others. I have felt that there is more to healing than medications and traditional treatments.“ She was also able to carry this orientation over to the more abstract CASE STUDY. She said, “The reaction of the patient could come from the combination of physiological relief from the drug as well as the psychological effect from receiving the drug.“ Here she acknowledged more than the physical response to encompass the holistic perspective. Based on the circumstances presented about this data, I am unable to make a decision according to the model. My REVISED DECISION is a 2—. After One Week Data Summaries for Participant 33. This data is very easy to code. All the necessary model variables are present, allowing for a stage 3 rating. I elevated the revised rating to 3+ because of additional evidence of HOLISTIC ORIENTATION: “To reduce post-op medication we could use color, TT and imagery. This could help people get off pain meds quicker.“ 130 After Two Months Data Summaries for Participant 33. The TT data contains all the model variables needed for a stage 3 rating. I raised the REVISED DECISION to a 3+ since there was also mention of a HOLISTIC ORIENTATION. On the SURVEY, this subject was at stage 3 plus has a HOLISTIC ORIENTATION. The CASE study was an entirely different picture. She responded very knowledgeably to the situation given but it was strictly from a biological view point. Here is her comment: “The action of morphine is by increasing the threshold for pain, produces mood elevation and can cause drowsiness or sleep. It is also believed that morphine effects the brain receptors, the endorphines which produce analgesic effect. However, it can also cause decreased respirations, carbon dioxide retention, urinary retention, constipation, decreased gastric motility, depresses cough reflex and can cause nausea and vomiting.“ This shows that in her practice she is able to maintain a holistic perspective but when faced with a theoretical situation she reverts back to a dualistic explanation. Using only the model variables, I am unable to rate this data. For the revised rating, I gave this data set a 1+ based on the strength of the SURVEY and offset by the weakness in the CASE STUDY. In conclusion, the TT data received a stage 3 at both one week after and two months after, according to the model. The revised TT rating is a 2+ before the workshop, a 3 after one week, and a 3+ after two months. ‘We see again that the additional variables allow a REVISED DECISION at each time interval. This subject was able to remain at 131 stage 3 according to both rating systems for both AFTER.workshop time intervals. This is rather unique since we have often seen a decrease after two months. The HOLISTIC data is rated according to the model only on the AFTER ONE WEEK data, receiving a stage 3. In the other two time intervals the ratings are questionable due to lack of data. The revised rating is a 2- before the workshop, a 3+ after one week and a 1+ after two months. Here we see the peak in the rating from the interview data, one week after the workshop. Summary;of Data Sets with Three Time Intervals Represented At this point I will provide an interim summary for the six subjects who participated in all three data collections. There are several patterns emerging that will not be seen in the rest of the subjects who participated in only one or two of the data collections. I will begin with a chart of the data found in the center two columns of the individual subjects' charts just presented. The two center columns of the individual charts are summary ratings according to the model and to my REVISED DECISIONS. The summary data is rearranged on this chart and divided into the two main subdivision of TT data and HOLISTIC data. The data have been rearranged to highlight the group patterns. Look first at the four columns of AFT-1 data, which are from the interviews. The clearest pattern is the dominance of stage 3 ratings obtained during the interview one week after the workshop. 132 Table 5.8 Summary Chart of Participants Who Completed All Three Data Colletions THERAPEUTIC TOUCH DATA HOLISTIC DATA SUBJECTS MODEL REVISED MODEL REVISED BEE AFT-1 APT-2 BEE APT-1 APT-2 BEE AFT-1 APT-2 BEE AFT-1 APT-2 25 1 3 1 1+ 3 2+ ? ? ? 1- 3— 2- 07 ? 3 ? 1+ 3+ 1— 1 ? ? 1+ 3- l 13 ? 3 2 2+ 3 2+ ? 3 2 3+ 3+ 2+ 14 1 1 1 1+ 3- 1+ ? 3 ? 1- 3+ 1- 20 l ? ? 1+ 3- l- l 1 2 1+ 3- 2+ 33 ? 3 3 2+ 3 3+ ? 3 ? 2- 3+ 1+ BEF I BEFORE data, AFTIl I AFTER ONE WEEK data, AFTI2 I AFTER.TWO MONTHS data The timing of the interview'may have been a key factor. All interviews were conducted the week immediately following the workshop. All but two of the stage 3 ratings occur in the INTERVIEW data one week after the workshop. There are also only three interviews that were not rated as indicated by question marks. The three were all found in the MODEL DECISIONS. This fact provides a weaker pattern, to the peak after one week, for the model data due to the three undecided situations. The interviews yielded the greatest quantity of data to draw upon for analysis. It was very natural for me to ask a subject to elaborate on 133 a comment when any response seemed incomplete. This attests to the richness of the interview as a data source. By contrast, the SURVEYS often elicited very brief written responses. Look next at the frequency of question marks throughout the chart. Of the 72 possible decisions, 16 were undecided, as indicated by question marks. All 16 undecided results were due to a lack of necessary data according to the model. As mentioned in the interview discussion, only three of these undetermined ratings occurred in the AFTER.ONE WEEK data. The remaining 13 undetermined ratings were divided nearly evenly between the two SURVEYS (before and after). A decision was made for each possible REVISED DECISION. In short, the REVISED DECISIONS allowed for a more complete picture of the data to emerge since it contained no undetermined decisions. The three patterns presented here are the most striking at this point in the analysis. The next section will look at the subjects who participated in only two data collections, i.e., before and two months after the workshop. I will again comment on the patterns for this group of subjects before going on to the last group who contributed only to the BEFORE data. Participant 17 Before Data Summaries for Participant 17. The IT summary data is held to a stage 2 according to the model's criteria. I upgraded this rating to a stage 3 for the REVISED DECISION since there are mainly ADVANCED variables involved and ACCEPTANCE is present in both the 134 SURVEY and CASE. In addition, there is mention of a HOLISTIC ORIENTATION and one BARRIER to overcome. Next is the subject's statement of ACCEPTANCE from the CASE study. “TT works because of the interaction with and between fields - resonancy - the slinky concept of Roger's to attain change.“ If ACCEPTANCE had an advanced stage this comment would surely qualify. She incorportates the TT theory with the Rogerian nursing theory in expressing her acceptance. This is a knowledgeable person who was able to demonstrate application to an abstract CASE study. She used some very good examples of application in the the SURVEY as well, but did not specific her actions. “I use IT with the elderly and intensive care patients - with my husband who has Chron's Disease and is anxious at times.“ This quote could easily have been ADVANCED APPLICATION if she had described her actions. In summary, I had no difficulty raising the REVISED DECISION to a 3. The HOLISTIC data is unrateable according to the model variables. The SURVEY is missing indicators of both knowledge and application. The REVISED DECISION I determined to be a 2-. In the light of missing model variables, I had HOLISTIC ORIENTATION on both data sources and one BARRIER to contribute to the REVISED DECISION. She mentioned that it is natural for her to be holistic due to her work setting and educational background, which stresses a holistic approach. “My work setting is very receptive to holistic care. we all have Master's of Science in Nursing, mostly from‘Wayne State University, so holism is an assumption.“ This subject knew that I was also a wayne State University graduate and that I would be able to relate to her 135 Table 5.9 Staging Results - Participant 1? DATA SOURCES K APP ACC MOD MOD REV REV #of ORT DEC SUM. SUM DEC BAR BEFORE IT Survey Adv Bas Yes 1 2 3 3- 1 Case Adv Adv Yes 3 3 H01 HOLISTIC Survey --- -- Yes ? ? 2- 1- l Hol Case Adv Bas Yes 1 3- H01 AFTER 2 months TT Survey -- Bas Yes ? ? 1+ 1+ 2 Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey -- Bas Yes ? ? 1- 1+ 2 Hal Case Dul Dul No ? 0 Dul PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, {of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data, 0 I less than stage one 136 statements about her educational preparation. While her comments do not neatly fit the model variables, she surely expresses a HOLISTIC ORIENTATION. After Two months Summaries for Participant 17. I am unable to rate this data according to the model since the variable of KNOWLEDGE is not mentioned on the SURVEY. I decided on a 1+ revised rating. The REVISED DECISION is based on the presence of ACCEPTANCE which is not required at a stage 1 at all, plus the HOLISTIC ORIENTATION and two BARRIERS. This subject states her ACCEPTANCE with simplicity and understanding. “Touch is a mode of healing and balancing of the individual to heal themselves.“ She mentions her barriers in terms of her own blocks to the method. “My hinderance to practicing TT is my own unbalance.“ Her orientation remained as strong as before the workshop. “My work setting is already very receptive. I will: in the future, give a program on TT to my colleagues.“ The HOLISTIC data is quite surprising. Again the KNOWLEDGE data is missing, but also the CASE response is entirely DUALIST. I was unable to give a MODEL rating for this data. For the REVISED DECISION, I rated this person a l-. The CASE STUDY did not show her earlier ability to apply holistic interventions to an abstract situation. She responded in a completely biological manner. The 1- REVISED SUMMARY rating is held up by the strength of the SURVEY rating which is a 1+. In conclusion, on the TT BEFORE data, I gave a model rating of 2 versus the revised rating of 3. I could not determine a rating for the 137 HOLISTIC data according to the model variables. I gave a revised holistic rating of 2-. For the AFTER.TT data the model decision was undetermined; where as the REVISED DECISION was a 1+. The HOLISTIC data was again unrated according to the model variables. I gave this data a revised rating of 1-. Both rating systems show a decline in change at the AFTER.TWO MONTHS collection date. I was unable to give a model rating from the variables presented on the AFTER data at all. The revised ratings both decreased to the 1 range, with the TT data beginning with a 3 on the BEFORE data and the HOLISTIC data having been a 2- on the BEFORE data. Any progress toward change noted on the BEFORE data was associated with choosing attending the workshop, having attended the TT I workshop at an earlier data, and any experiences in the intervening time. However, her change was not sustained after the workshop as demonstrated by the AFTER data. Participgnt 27 Before Data Summaries for Participant 27. The IT data was easily rated. All the model variables were present for both the SURVEY and CASE. The SURVEY had complete ADVANCED level data. The CASE has indicated BASIC KNOWLEDGE and APPLICATION. Therefore, the summary according to the model is a stage 2. For the REVISED DECISION, I included the HOLISTIC ORIENTATION plus the ACCEPTANCE expressed on the CASE STUDY. The REVISED SUMMARY 18 2+. 138 Table 5.10 Staging Results - Participant 27 DATA SOURCES K APP ACC MOD MOD REV REV 50f ORT DEC SUM SUM DEC BAR BEFORE TT Survey Adv Adv Yes 3 2 2+ 3 Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey Bas Bas Yes 1 1 1+ 1+ Hol Case Bas Bas Yes 1 1+ Hol AFTER 2 months TT Survey Adv Bas Yes 1 1 2+ 3 1 Case Bas Bas Yes 1 1+ HOLISTIC Survey --- Bas Yes ? ? 1+ 1+ Hol Case -- -- -- ? ? PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, #of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, -- I missing data 139 The HOLISTIC data has all the MODEL variables at the BASIC level. This resulted in a stage 1 rating according to the model. For the REVISED rating, I also considered the HOLISTIC ORIENTATION and ACCEPTANCE, which was present in both data sources. The addition of these variables above the requirements for a stage I contributed to a the REVISED DECISION of stage 1+. Next is a typical statement of this subject's HOLISTIC ORIENTATION, which was present in three of the four BEFORE data sources. "When a pain medication is given, a nurse is providing comfort psychologically, physically and emotionally. The drug itself has components to relax the patient but a placebo could help the patient just the same in many circumstances. I think the patient receives support not only from the drug but from contact with the care giver.‘ After Two Months Summaries for Participant 27. On the TT data there is a decrease from a stage 2 on the BEFORE data to a stage 1 on the AFTER data according to the model variables. This decrease occurred because the APPLICATION on the SURVEY went from ADVANCED, before the workshop, to BASIC afterwards. The model is very sensitive to these types of changes due to a limited number of variables to rely upon for a decision. The REVISED DECISION remained at a 2+ stage, as it was for the BEFORE data. I made this decision because the ACCEPTANCE was still present in both the SURVEY and the CASE and there was the mention of one BARRIER to overcome. This subject mentioned barriers as personal situations which had arisen since the workshop and 140 inhibited her ability to practice. “My practice of TT has been hindered by personal problems, I don't have the needed energy.“ This is an example of how seemingly unrelated circumstances could have affected the subjects' ability to incorporate TT into their practice. The HOLISTIC data has many gaps. This subject began a sentence for the CASE STUDY but stopped before completing her thought. It appears she may have been interrupted and then forgot to complete it before mailing the data back to me. Fbr this reason, the result will be based on the SURVEY alone. I was unable to make a MODEL DECISION because there is not a KNOWLEDGE statement. This leaves the MODEL DECISION as a question mark. For the REVISED decision I gave the data a 1+ rating. This again was based on the supporting data provided by the HOLISTIC ORIENTATION and the indicators of ACCEPTANCE expressed on the SURVEY. The next quote refers to her personal struggle at this data collection time, but it still has the HOLISTIC ORIENTATION I could easily code. 'I'm working on centering to help me through personal situations both physically and emotionally.” In conclusion, the TT data, according to the model, began at a stage 2 before the workshop and dropped to a stage 1 two months after the workshop. The revised rating maintained a 2+ rating over the time interval from before to two months after the workshop. The HOLISTIC data was a stage 1 before the workshop and undecided two months after the workshop according to the MODEL. The quantity of missing variables in the AFTER data made it impossible to determine a 141 staging according to the MODEL. The REVISED data drew upon the additional variables and remained a 1+ rating over the two time intervals. The most obvious disadvantage in this data set was the lack of information immediately after the workshop which the interview had provided for the first six subjects discussed. The added variables of BARRIERS and ORIENTATION were very useful in being able to rate this data. Overall the BEFORE data was much more complete and made a stronger statement as to the appropriate stage, but the AFTER.data still had enough to determine a revised stage. The greatest weakness was the lack of data for the HOLISTIC CASE two months after the workshop. The REVISED HOLISTIC DECISION had to made based on only the SURVEY, which was not ideal. Participant 32 Before Data Summaries for Participant 32. The TT data is very straight forward. All the necessary model variables are available for a stage 1 rating. Fbr the REVISED rating, I elevated the stage to a 1+ due to the HOLISTIC ORIENTATION and one BARRIER. The HOLISTIC data has one significant gap. There was no mention of APPLICATION on the CASE study. The absence of this variable created an undecided situation for the rating according to the model. As I considered the revised rating, I was able to take into account the richness of the remaining variables. There was ACCEPTANCE, which is not expected at a stage 1, and a HOLISTIC ORIENTATION on both the 142 Table 5.11 Staging Results - Participant 32 DATA SOURCES K APP ACC MOD MOD REV REV {of ORT DEC SUM SUM DEC BAR BEFORE IT Survey Bas Bas Yes 1 1+ 1+ 1 Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey Bas Bas Yes 1 1+ 1+ Ho1 Case Bas -- Yes 7 l Hbl AFTER 2 months TT Survey Bas Bas Yes 1 2+ 1+ Case Adv Adv Yes 3 3+ Bel HOLISTIC Survey Bas Bas Yes 1 1+ 1+ Case -- -- -- 7 ? PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, #of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, -- I missing data 143 SURVEY and CASE STUDY. It is reasonable to give this data a revised rating of 1+. Next is this subjects' HOLISTIC ORIENTATION from her CASE STUDY. 'It (giving medication) is a nursing intervention, I hope an assessment of the severity of the pain has been made and any other available methods of alleviating pain have been used." After Two Months Data Summaries for Participant 32. The TT data was all present plus a sampling of the variables I added. The SURVEY contained all the necessary elements of a stage 1 rating. The CASE contained all the elements of a stage 3 rating. These results summarised to a stage 2 rating for both the MODEL and the REVISED DECISIONS. I did make the REVISED DECISION a 2+, due to the extra variable, ie, ACCEPTANCE with BASIC KNOWLEDGE and APPLICATION, and the HOLISTIC ORIENTATION. ‘ This subject, as with the previous subject (27), did not complete the HOLISTIC CASE. The rating is based on the SURVEY alone. The SURVEY is clearly a stage 1 according to the model. I elevated the rating to a 1+ rating since there is also ACCEPTANCE in the data. Next is a quote which combines her HOLISTIC ACCEPTANCE with her HOLISTIC ORIENTATION. 'I personally use meditation with visualization -also- do accupressure on family and friends and self. The general public is more aware of and more receptive of holistic interventions like massage and accupressure." 144 In conclusion, the TT responses became stronger on the AFTER data for the MODEL and REVISED DECISIONS. Both began, on the BEFORE data, with a stage 1 or 1+ respectively and became a 2 or 2+ on the AFTER data. The HOLISTIC data went from an undecided rating for the BEFORE data, according to model, to a l on the AFTER data. The REVISED DECISION remained a 1+ for both the BEFORE and AFTER data. This overall data set shows an increase in stage or at least a maintenance of the BEFORE stage in the AFTER data. There was not as much data at the AFTER interval since the subject did not complete the HOLISTIC CASE and there was only one mention of a HOLISTIC ORIENTATION among the possible extra variables. Summary of Data Sets with Two Time Intervals Represented At this point I will provide an interim summary for the three subjects who participated in only two data collections, BEFORE and AFTER.TWO MONTHS. I will again, as in the summary for the six subjects who completed all three data collections, present a rearranged chart of only the summary columns from the individual charts. The rearrangement divides the data into the two main divisions of TT and HOLISTIC. For this composite there were a possible 24 staging decisions. However, due to a lack of variables on some data forms, I was unable to determine five of the ratings according to the model's criteria. The majority of the undetermined ratings occurred from applying the model 145 Table 5.12 Summary for Subjects Who Completed the Before and Two Months After Data THERAPEUTIC TOUCH HOLISTIC SUBJECT MODEL REVISED MODEL REVISED BEF AFT-1 AFT-2 BEF AFT-1 AFTI2 BEF AFT-1 AFT-2 BEF AFT-l AFT-2 17 1 2 1+ 2+ ? 1 1+ 1+ 27 2 ? 3 1+ ? ? 2- 1- 32 2 1 2+ 2+ 1 7 1+ 1+ BEF I before data, AFT-2 I two months after data to the HOLISTIC data, i.e., four of the five. The one other undetermined rating was for the MODEL DECISION on the TT data for one subject. The TT data does not show a clear pattern for either the MODEL or REVISED DECISIONS. Each subject responded differently when comparing the BEFORE and AFTER data. One subject increased, one subject decreased and the third remained at the same rating. For the MODEL DECISION on the HOLISTIC data, no pattern can be noted due to the lack of decisions. As mentioned in the general statement, the bulk of the undetermined ratings occurred in applying the model to the HOLISTIC data. For the REVISED DECISION, we see that 146 two subjects remained the same at the BEFORE and AFTER time intervals, and the third showed a decreased rating on the AFTER data. Overall, these three data sets point out the disadvantage of not having the interview data immediately after the workshop as I had for the first six subjects. With the data available, it is difficult to make a strong case for any particular pattern in this interim summary. Participant 1 Table 5.13 Staging Results - Participant 1 DATA SOURCES K APP ACC MOD MOD REV REV #Of ORT DEC SUM SUM DEC BAR BEFORE TT Survey Adv Adv Yes 3 2 2+ 3 Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey --- Adv Yes ? ? 3 3- l Hol Case Adv »Adv Yes 3 3+ Hol PARAMETERS OF THE CHART R I knowledge, App I application, Acc I acceptance, #of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, Hol I holistic, Dul I dualistic, + I a strong rating for the stage, — I a weak rating for the stage, --- I missing data 147 Before Data Summaries for Participant 1. The TT data allows a clear rating. The SURVEY led to a stage 3 and the CASE a stage 1, according to the model criteria. These two ratings summarized to a stage 2 for the MODEL DECISION. I raised the REVISED DECISION to a 2+ due to the additional variables not required by the model. There is both a HOLISTIC ORIENTATION and ACCEPTANCE with the stage 1 data. Next is a quote stating the subject‘s HOLISTIC ORIENTATION. 'I'm excited to learn more about holism and thrilled to possibly find or create a practice setting where as a nurse I'll be able to practice holistic wellness care instead of following the traditional medical illness model.“ This subject's HOLISTIC data is missing a KNOWLEDGE statement on the SURVEY so I am unable to determine a rating according to the model. By using the additional variables, I give a revised 3 rating to the HOLISTIC data. The data is missing a KNOWLEDGE statement but contains three additional variables to support the decision. This nurse definitely incorporated a HOLISTIC ORIENTATION into her response to the CASE study. 'The morphine is designed to relieve the pain and anxiety. The nurse's presence with the patient and talking with him or her is to provide support, listening and empathy for him which will also serve to relieve the anxiety and pain. Some of this can be done by the laying on of hands to clear the skin and give the injection. The nurse's intention to help the patient is what matters most.“ This subject would have been an interesting participant to follow since she demonstrated such strong ratings on this BEFORE data. I am 148 some what surprised that she chose not to participate in the follow up data collection. It is impossible to determine what other factors in her life may have contributed to her decision to not participant further, but she showed an ADVANCED level on the BEFORE data that is available. Participant 28 Table 5.14 Staging Results - Participant 28 DATA SOURCES K APP ACC MOD MOD REV REV #Of ORT DEC SUM SUM DEC BAR BEFORE TT Survey -- -- Yes ? ? l 1- 1 Case Bas Bas Yes 1 1+ Hol HOLISTIC Survey --- --— III ? ? 1 1- 1 H01 Case Bas Bas Yes 1 1+ Hol PARAMETERS OF THE CHART K I knowledge, App I application, Acc I acceptance, #of BAR I number of barriers, Ort I orientation, Mod Dec I model decision, Mod Sum I model summary, Rev Sum I revised summary, Rev Dec I revised decision CODING'WITHIN THE CHART Bas I basic, Adv I advanced, Yes I present, No I absent, ? I unable to determine from data presented, H01 I holistic, Dul I dualistic, + I a strong rating for the stage, - I a weak rating for the stage, --- I missing data 149 Before Data Summaries for Participant 28. This subject did not indicate KNOWLEDGE and APPLICATION in her TT data: therefore, I was unable to determine a rating according to the model. I decided upon a revised rating of a stage 1. The subject did have two of the added variables, one BARRIER and a HOLISTIC ORIENTATION. Also she mentioned ACCEPTANCE on both the SURVEY and CASE STUDY. Here is her ACCEPTANCE statement from the TT CASE. “Therapeutic Touch as an intervention can decrease the need for some medication there by controlling the adding of foreign substances to the body.‘ The HOLISTIC data again was missing a number of the model variables on the SURVEY. This absence resulted in an undetermined rating according to the model. I gave a revised rating of 1 based on the HOLISTIC ORIENTATION and the mention of BARRIERS along with ACCEPTANCE on the CASE STUDY. Her HOLISTIC ORIENTATION is not especially strong. 'I have become more receptive to newly presented and unorthodox treatment methods. I am interested in non-traditional healing methods.“ Her BARRIERS statement is in terms of lack of knowledge. 'I have very little background knowledge in wholistic medicine or methods.“ It appears that she was new to the exploration of holistic methods. In conclusion, I was unable to rate this data according to the model. It was missing too many of the essential model variables. My REVISED DECISION was only a stage 1 for both the TT and HOLISTIC data. This participant seemed receptive to holistic interventions but also may have been just beginning to introduce herself to such 150 possibilities. Her verbal comments express her newness to the holistic field most clearly. She had more specific knowledge about TT than holism in general. Summary of Data Sets with One Time Interval Represented At this point I will provide an interim summary for the two subjects who participated in only the BEFORE data collection. Table 5.15 represents the two center summary columns from the individual tables. They are now divided by TT and HOLISTIC data. For these two data sets we see that there was only one decision based solely on the model criteria. That MODEL DECISION was a stage 2 for the TT data. The remainder of the decisions are the revised ratings which drew also from the added variables of ORIENTATION and BARRIERS. I did not see any pattern in these two data sets. The first subject was very advanced for the BEFORE data and the second subject was a weak stage 1. Overall Conclusions I will first present a chart of the combined summary charts. In this way, we view together the three groups which have to this point been discussed separately. The first section of the chart represents the six subjects who participated in all three data collections. The second section is a display of the summary data for the three subjects who produced the BEFORE and the AFTER TWO MONTH data. The last section 151 Table 5.15 Summary for Subjects Who Completed Only the Before Data THERAPEUTIC TOUCH IDLISTIC SUBJECT NOEL REVISED MDEL REVIS- BEF AFT-1 APT-2 BE? APT-1 AFT-2 BEE AFT-1 AFT-2 BEEI AFT-1 APT-2 01 2 2+ ? 3 28 ? 1 ? 1 SUB I subject by number, BEE I BEFORE data, AFT-1 I AFTER ONE WEEK data, APP-2 I ASTER TWO MONTHS data represents the two subjects who took part in only the BEFORE data collection. Netice that the data becomes more sparse in proceeding down the chart. Looking first at the overall picture of these results, we see first that all the undecided ratings occur under the potential MODEL DECISIONS. There were total of 104 possible combined MODEL and REVISED DECISIONS. Of this 104, 24 were undecided due to a lack of model variables. If the REVISED DECISIONS had not been included in this study there would have been a total of 52 possible decisions. Of these 52, the same 24 decisions would also have been undetermined. Without using the REVISED DECISIONS, nearly half of the results would have been 152 Table 5.16 Summary Data for All Subjects THERAPEUTIC TOUCH HOLISTIC SUBJECT MODEL REVISED MODEL REVISED BEF AFT-1 AFT-2 BEF APT-1 AFT-2 BEF AFT-1 AFT-2 BEE APT-1 AFT-2 25 1 3 1 1+ 3 2+ 2 ? ? 1- 3- 2- 07 7 3 7 1+ 3+ 1- 1 ? ? 1+ 3- 1 13 ? 3 2 2+ 3 2+ ? 3 2 3+ 3+ 2+ 14 1 1 1 1+ 3- 1+ ? 3 ? 1- 3+ 1- 20 1 ? ? 1+ 3- 1- 1 1 2 1+ 3- 2+ 33 ? 3 3 2+ 3 3+ ? 3 ? 2- 3+ 1+ 7 1 2 1+ 2+ ? 1 1+ 1+ 27 2 ? 3 1+ ? ? 2- 1- 32 2 1 2+ 2+ ? 1+ 1+ 01 2 2+ ? 3 28 2 1 ? 1 SUB I subject by number, BEF I BEFORE data, AFTIl I AFTER ONE WEEK data, APT-2 I AFTER.TWO.MONTHS data 153 lost. By using the REVISED DECISIONS, only one fourth of the results were undecided, due to incorporating the two added variables and to acknowledging that ACCEPTANCE can occur prior to stage 3. Looking next at the HOLISTIC data, it is clear that most of the missing data occurred on this portion of the SURVEY and CASE STUDY. The chart section titled HOLISTIC and subtitled MODEL shows this large frequency of undecided ratings, which indicate missing variables. As noted earlier in the interim summary for the six complete data sets, the interviews obtained during the week after the workshop showed the greatest peak in change, i.e., the greatest frequency of stage 3. The interview data was the most detailed as well as showing the greatest change. Unfortunately, this change does not appear to have been sustained over time, i.e., two months later. The interview findings are especially interesting since the interviews were conducted primarily to validate the presence of the conditions of learning in the workshop. It was only later that I realized how rich this data was in terms of the rating decisions. The subjects who participated in only one or two data collections did not seem to be significantly different from the other six who participated in all three collections. It would of course have been very beneficial to have had the complete data sets on all 11 subjects. In conclusion, it appears that subjects made a significant conceptual change (majority of stage 3) immediately after the workshop but that they reverted back to their pre-workshop state (stage 1 to 2) 154 by the time of the follow up, two months later. The conceptual change related to TT was only slight more stable over time than the conceptual change for holistic interventions. Chapter‘VI SUMMARY AND CONCLUSIONS Sumar ! This study was designed to evaluate the conceptual change of registered nurses who attended an advanced workshop on a holistic intervention known as Therapeutic Touch. The study utilized the conceptual change model proposed by Posner and Strike (1985). The literature reviewed for the conceptual change model was predominately research on elementary school science and mathematics. No studies were found that applied the model to a health care intervention as this study has done. The other literature reviewed was on Therapeutic Touch research. There was an abundance of research on the effects of Therapeutic Touch but again nothing on the teaching process and outcomes that this study addressed. Research Questions and Instruments The research questions were formulated to assess two areas for potential change - holistic and Therapeutic Touch conceptions. Both concepts were tapped by use of a survey and two case studies. The survey was divided into an equal number of questions on holism and Therapeutic Touch. The first case study provided an opportunity for subjects to demonstrate their application and knowledge of holistic 155 156 interventions. The second case study focused on Therapeutic Touch application and knowledge. These three instruments (survey and two case studies) were administered just prior to the workshop and two months after the workshop. This pre— and post-test design provided comparative outcome data. A telephone interview was used one week after the workshop as another data source. The telephone interview was designed to elicit subjects' assessments of the process components specified by the conceptual change model, i.e., four conditions of learning and seven teaching methods. The interviews were useful in determining the presence of the conditions and methods in the workshop, and proved to be an additional source of outcome data. By applying the outcome criteria to the interview data, a second post-test was available in addition to the written outcome data of the survey and case studies. This also added a third time interval to the data. Two Appgoaches to Analysis A combination of qualitative and quantitative results were obtained from the data collected. All data sources asked for open-ended responses which created qualitative data. However, the results were often more conveniently displayed in table formats, with some tables being quantitative in nature. In the process of analysis, the data was first analyzed using an inductive approach. The model was initially put aside and the data was examined for naturally emerging themes. As I searched for themes, I became aware that I was dividing the data into manageable units. The 157 units were soon named meaning units. The inductive analysis of the meaning units yielded 12 themes and one additional variable. The meaning units then continued to serve as the unit of analysis for the deductive analysis. The second analysis was deductive and used the outcome variables of the conceptual change model for coding the meaning units. During this deductive analysis, I also coded the meaning units with two additional variables, one of which was found to be significant during the inductive process, i.e., barriers to practice, and the other which I added prior to the study, orientation (holistic/dualistic). First Results Chapter The results were presented in two separate chapters. The first results chapter presented the demographic characteristics of the participants and the process portion of the study. The interview data confirmed that the conditions of learning and the teaching methods (process components) that were to be incorporated were percieved by the subjects to be present in the workshop. The process components were further validated by a TT instructor who was not in attendance at the workshop, but who reviewed audio tapes of the workshop. This person also found examples of the conditions of learning and the teaching methods presented in the workshop. This chapter concluded with a description of the inductive themes and their influence upon the staging process. 158 Second Results Chapter The second results chapter was devoted to the outcome variables. Two types of outcome results were reported. One set of results was derived from the variables associated solely with the conceptual change model. The other set of results included the model variables plus the two variables added to the analysis. Using only the model variables, there were many undetermined stage ratings for both holistic and Therapeutic Touch conceptual change. Using the revised rating method, i.e., by adding the two new variables, a stage of conceptual change for all the holistic and Therapeutic Touch data sets could be determined. Therefore, there was a complete set of results for the revised rating methods which allowed for more conclusive reporting of the findings. The most striking outcome from the revised staging method was the notable peak to stage 3 one week after the workshop for the majority of subjects. The stage 3 peak was also found, but with less support, in the conceptual change model ratings. The data demonstrated that subjects generally were at stage 1 or 2 before the workshop and reverted back to a stage 1 or 2 two months after the workshop. Another feature of the data reported in the second results chapter was the value of the interview method over the written data forms, i.e., the survey and case studies. The interview produced an abundance of significant data. The strength of the study relied to a great extent, for both process and outcome results, upon the rich interview data. 159 Limitations There were a number of limitations to this study: 1. The development of data instruments and the analysis of the data was guided by the conceptual change model and verified by my committee, but the instruments were all original and lacked established reliability. 2. The paper and pencil data collection instruments failed to elicit the completeness of responses anticipated. 3. There was possible bias towards acceptance since one of the instructors was also the interviewer and researcher. 4. Subjects were predisposed to acceptance since they had already attended a TT I workshop. Conclusions The conclusions are organized around the three broad research questions. Within the limitations of these data, the following conclusions can be drawn: Research Question 1 To what degree do participants in a holistic health care workshop experience conceptual change? 1. The majority of subjects arrived at the TT II workshop at stage 1 or 2 of conceptual change related to both TT and holistic conceptions. 3. 4. 5. 160 The majority of subjects moved to stage 3 of conceptual change one week after the TT II workshop for both TT and holistic conceptions. The majority of subjects reverted back to stage 1 or 2 of conceptual change two months after the TT II workshop. Subjects generally maintained TT conceptual change better than holistic conceptual change over time. The variable of acceptance (from the conceptual change model) was found at all three stages rather than only at stage 3. Research Question 2 How do the methods of the workshop relate to the aspects of change noted? 6. The conditions of learning and teaching methods of the conceptual change model were confirmed, by subjects and a non-attending TT instructor, as having been part of the workshop. Research Question 3 What additional factors account for the change noted? 7. Barriers to both the practice of IT and the use of holistic interventions were identified through the inductive analysis. Overall orientation was found to a large extent to be holistic. This may be due to participants having attended TT I and thus being predisposed to holistic interventions. 161 Igplications and Recommendations Theoretical Implications A number of theoretical issues were raised in this study. The use of the inductive method led to discoveries that would otherwise have been overlooked. For instance, barriers may never have been addressed without using both the inductive and deductive methods. The model was not equipped to make sense of barriers. From this study it is clear that the entire area of barriers needs to be looked at much more closely. Due to the numerous types of barriers mentioned, it is possible that the decrease from stage 3 two months after the workshop could at least partially be accounted for by the barriers. There may be major subdivisions within the barriers that could be managed in different ways if they were fully understood. Perhaps other related bodies of literature could be explored also to further account for the role barriers play in this type of study, such as transfer of learning and diffussion of innovations. An inconsistency found in this study involved the model's variable of acceptance. Acceptance was not expected to be involved until stage 3 of conceptual change: however, it was found at all stages. Subjects demonstrated acceptance of TT even when they were beginners in terms of knowledge and application. There may have been an underlying belief system at work. Acceptance can be, in part, explained by looking at some of the potential hardships subjects overcame to attend. In many cases, the workshop was a personal expense if an employer did not cover the costs. There was a time expenditure to drive, in most case, over 162 130 miles and devote two days. Subjects could have experienced cognitive dissonance if they had not stated and believed their acceptance comments. Another factor associated with acceptance at all stages is that each subject had previously attended TT I, and therefore may have been predisposed to acceptance. A further point, not included in this study, is a spontaneous statement I often encounter as the presenter. People express to me a recognition of their attraction to IT at almost a preconscious level. While this may sound very mystical, it is a comment I have heard in various words. The originator of TT, Dr. Krieger, is often quoted as saying, 'TT seems to have a life of its own.‘ In other words, teaching and practice are made easier since the people who are attracted to TT do have an initial level of acceptance. This is a less than clear area that warrants further study. The unexpected presence of acceptance at stages 1 and 2 may be unique to TT, but additional data needs to be gathered (e.g., participants'informal comments). It is further possible that the conceptual change model is not a direct analogy to the subjects and content of this study. Features of the conceptual change model have been used primarily with the misconceptions of elementary science and mathematics students. It is also possible that I did not treat the variables exactly as Posner and Strike had intended. I may have coded comments as acceptance that they would have been considered low-level acceptance. It is possible that Posner and Strike had in mind a more stable and deeply held belief of acceptance. Finally, acceptance may have been biased by the fact that 163 I was both the interviewer and the workshop instructor. Subjects may have wanted to please me by over stating their acceptance. For these various reasons, I am not surprised to find acceptance at all three stages. Methodolpgical Igplications The research method found to be most valuable was the interview. In a future study of this nature, subjects could be interviewed prior to the workshop as they check in and again two months after the workshop. Perhaps the later interview also could actually be conducted in the clinical setting. The interviews could utilize the same questions that were used on the survey. I believe the survey questions were appropriate but the pencil and paper method was the cause of the weak and scant data. The questions used in the interview one week after the workshop could be revised to include the survey questions along with the process questions. This interview focused exclusively upon the conditions of learning and the methods (process components) of the workshop. These process questions could be scaled down, to keep the interview at a reasonable length and still provide time for the survey questions. This would give a balance to the process and outcome portions for this interview. In this study, the interviews averaged 60 minutes. To be practical, an interview should not exceed an hour. I further recommend a third interview after the workshop, one year later. It could be insightful to interview subjects who chose to 164 attend TT II two years in a row. They could provide a great deal of information on their motives for repeating TT II. It would also be useful to talk with those who did not re-attend, to determine if barriers or any other factors affected their practice or overall orientation. I would like to explore specifically what barriers persist on a long term basis. A final implication for future studies is the use of the inductive methodology which produced the twelve themes. This approach could be the basis of analysis rather than peripheral to the deductive variables. In fact, it could be useful to concentrate on only those variables from the conceptual change model which proved most useful and valid. This would allow'much more comprehensive exploration of the themes. This methodology could incorporate the variables of orientation and barriers found in this study, and could utilize a similar revised stage rating system. In this study the revised rating system was superimposed upon the data because the conceptual change model was unable to account for all the variables. It would add a great deal of freedom and creativity to proceed in a more inductive manner using the exploration of themes as the framework for the analysis. To summarize my theoretical and methodological comments, the model lacks a full complement of variables needed for a study of conceptual change related to holistic health care. Further, acceptance proved to be a feature of all three stages. I would suggest a model that includes knowledge, application, acceptance, barrier, and orientation 165 for future research on TT as a prototypical holistic health intervention. I also recommend the maintaining of a combined inductive and deductive approach. I believe it is possible that additional variables affect the integration of new concepts and skills into the existing health care system which have not been discovered in this study. I strongly recommend an inductive qualitative approach to this teaching-learning research while we are still trying to uncover the predominate variables. Practice Implications In the future I recommend that Therapeutic Touch workshops be offered in the health care agency with administrative support. By taking participants away from.the work setting, an artificial environment is created. This atmosphere is a very relaxed setting compared to the usual work environment. In fact, many participants seem to take on a semi-vacation disposition. While this mental attitude may have many personal benefits, the HCPs often leave unable to translate their learning back into the clinical environment. Another of the subjects' main concerns after the workshop was the lack of support in their work site. WOrkshop participants often attend alone and travel from various locations around the state. One recommendation would be for participants to attend in teams from their agencies. They could support each other after returning to their home agencies and perhaps offer an inservice for their agency. As the 166 workshop presenter, I have given thought to this frequently mentioned barrier of 'aloneness' after they leave the workshop. In light of this concern, I have developed a new workshop designed specifically to teach participants how to prepare a teaching unit. The participants in this workshop will have taken TT I and TT II so they have a thorough exposure to the concepts. This new workshop is aimed at providing the extra support needed to take the ideas back to their clinical sites so that the participants will have a way to introduce their peers and supervisors to their TT knowledge. I would also like to do a follow-up study on the group who attends the new instructional workshop to see if I have begun to address the implementation barriers disclosed in this study. I have thought of additional ways to meet the practice needs expressed in this study. I recommend mini-refresher courses be offered throughout the year for past participants. I could offer a one-day practice course at the university. If funds were available, I would also consider going to their work sites, providing feedback on specific cases, meeting with their supervisors, and simply increasing my visible support. Another possibility would be to create a 'hotline' so past participants could call to ask about difficult cases, literature references, or ideas on how to present an inservice to a particular group. I have also considered publishing a monthly newsletter on current events in holistic areas with special emphasis on TT, to be sent to all past participants. 167 This project has helped me to think of many creative ways to assist the practice needs of my participants. I am currently considering another new workshop which focuses on advanced practice for participants who have attended the current complement of workshops. One of the originators of TT, who has a full time practice, could be invited to participate as a co-presenter at a practice focused workshop. In summary, the participants need a source of renewal and connection with TT practice which is not currently available in their clinical settings. They often mentioned being considered somewhat strange but harmless by their peers when they practice TT. They need a source of acceptance and reassurance on a regular basis to help integrate TT into their practice. It is not clear from this study if all holistic interventions would have the same barriers. Personal Reflections Research Issues Theoretically, researchers need to be more aware of studies and methods being conducted on TT around the country. A national research conference on TT could be helpful. I sense a need to share and compare research approaches and determine the most needed areas for future research. Joint projects or contrasting projects by different researchers could also be considered. Another basic need is funding for research. There are a few private foundations beginning to fund holistic health research. 168 Holistic HCEs can become more aware of these foundations and follow their funding activity. I believe that the educational component of any new area will always be a respected and essential aspect of any fundable project. Practice Issues Turning next to the practice setting, I plan to resume a more active TT practice myself. I had many reasons for limiting my practice during the last year but I plan to increase it again. My study has brought the issue of barriers to my attention and I would like to be able to relate to them first hand. I plan to start seeing private clients again and looking for additional ways to incorporate TT into my teaching role. I have also become a member of a local practice group of health care professionals who practice holistic health modalities. Egperiences Associated with This Study First and foremost, I realized the completely consuming and demanding nature of qualitative research. I had not understood the extent to which I would need to live with the data. Throughout the project, I continually expected more progress sooner. I did not like the suggestion that I put aside a section that seemed nearly done so I could 'get some distance and perspective." In fact, there were times I was sure this “putting aside" was a sign of failure and that this study would never come together as an intelligible whole. 169 All my past research had been quantitative. For my Master's thesis, I only had to tell the computer exactly what to do with the numbers I gave it and assume it would spew out the truth of my efforts. With this study the truth was up to me. I had to make several decisions about the data that seemed consistent, such as how to revise the assessment of stages of conceptual change. I was fully aware at these times that another researcher might have made different decisions. It was difficult to make such decisions, but making them was a necessary part of proceeding. Even with all the difficulty I experienced, I cannot imagine ever doing solely quantitative research in my professional career. The benefits of the qualitative method, in the end, outweigh the many frustrations of the process. Learnipg_Context for Analysis There is one other aspect of this study's process which has made a lasting impression upon me - the learning environment. I believe that the learning environment in many ways dictates what is possible. The context of my analysis was open and non-authoritarian. By analogy, it was interesting to me that my subjects often mentioned situational barriers. By contrast, while analyzing this study, my learning environment was virtually barrier free. This leads me to believe that my study is more creative and unique than it could have been in a more confining (less holistic) environment. As an educator myself, creating a holistic learning environment remains a personal value and I have 170 gained new insights through the role modeling I have experienced during the analysis of this study. Final Thogght on the Health Care System The problem of this study was stated in Chapter I as the difficulty of HCPs in accepting and incorporating holistic interventions into their practice. To help facilitate this addition in practice, the HCE needs to look to models for change. This study has utilized the conceptual change model of Posner and Strike, but looking beyond the model, there may also be other system factors at work. There continues to be resistance within the health care system for holistic interventions. This workshop content appears to be somewhat ahead of its time. The health care system is struggling to remain lucrative and is compelled more than ever to perform services that reap third party reimbursement. This means high-tech approaches to care. The financial base of the health care system is related to technology with its associated equipment, medications, and physical adjustments such as physical rehabilitation. There is currently little financial reward for holistic interventions. They simply are not recognized as essential. The nurse is often welcome to perform holistic measures as long as all the biological care is given priority. These factors leave the nurse yearning for change in a system that is still dualistic, offering mainly biological care. There must be a bridge found to link the dualistic and holistic approaches to care in order to bring greater integration. This need 171 was the focus of my study. I do see this change beginning to occur. I am more recently being asked to speak to health care agencies for their inservice programs. Previously, only academic settings would ask for programs since historically it is an acceptable setting to explore new ideas. I am encouraged to see these changes but I also realize it is only a beginning. We are still a long way from third party reimbursement for holistic health care which is a key element. This study has attempted to promote and assess the conceptual change necessary for individuals to make changes in their practice, but as pointed out by the barriers in this study, the larger health care system continues to present resistance. I believe this study has been a small step toward a larger conceptual change. I see this larger view as the planetary conceptual shift in beliefs from Newtonian to Quantum theory. I have only dealt with one small aspect of the planetary evolution in consciousness. But, in the future I hope researchers will be better equipped to assess this changing pattern in world view. I would very much like to be part of such a research effort. APPENDICES Appendix A Consent Fbrm Appendix A Consent FOrm Therapeutic Touch II July 10, 1987 As many of you may know, Therapeutic Touch is my primary area of interest in the nursing field. In order to advance the knowledge in this area, I have chosen to write my doctoral dissertation on Therapeutic Touch. To this end, I am seeking your assistance. I would like to ask you to provide some information for my study which I believe is central to the advancement of the teaching component of Therapeutic Touch. I am interested in looking at the conceptual change people experience after having attended a workshop on Therapeutic Touch and also to what extent the holistic concepts presented have been useful in your nursing practice. There is no right or wrong way to answer any of the questions. In fact, it is important that you be as realistic as possible. The information I would ask you to share would be the following: 1. I would like you to respond in writing to two brief case studies before this workshop begins. This will take about 10 minutes. 2. I would like you to respond to a questionnaire before the workshop begins. This will take about 10 minutes. 3. I would like about 5 participants to agree to a telephone interview within a week after this workshop. This would take about 30 minutes. 4. I would like you to respond in writing to two brief case studies which I will mail to you in about two months. This will take about 10 minutes. 5. I would like you to respond in writing to a questionnaire in about two months after you have returned the case studies. This will take about 10 minutes. Your participation in this study is voluntary. Even if you decide to participate in the study today, you can withdraw at any time without any consequences. Also, if you choose not to participate today this will not affect your workshop participation in any way. All information you provide will be treated confidentially. You will only be identified by a number so I can match your address up to mail you the case studies and questionnaire in two months. I would also like to tape record the workshop so I can evaluate the content covered. Once I 172 173 have completed my dissertation, I will be happy to provide any of you with a copy of the abstract (summary). None of your names will appear in any written report or the dissertation itself. The advantage of participation in this study is to be directly involved in the research process of Therapeutic Touch. For those who are interested, I will be glad to discuss this study further on breaks or after the workshop. Also if any of you are interested in conducting research in this area, I will be available to discuss your projects. I have read this consent form and understand the project. I agree to participate in the following way/s: The case studies and questionnaire before and two months after the workshop. The telephone interview within a week after the workshop. ppphone, best day, best time (please omit T 8 Th evenings) Signature Date Appendix B Holistic Case Study - Before Appendix B Therapeutic Touch II Case Study One July 10, 1987 Please respond to the following case study in the way which seems best to you. There are no right or wrong responses. This case study is optional. If you are willing to participate, please complete the following. Imagine the following situation. You as the nurse are delivering a typical dosage of morphine to a hospitalized patient for his/her severe leg pain. Please describe the mechanism of action of this nursing intervention. In what ways are you able to accept the mechanism of action which you described in this case study as being a realistic nursing intervention? 174 Appendix C Therapeutic Touch Case Study - Before Appendix C Therapeutic Touch II Case Study Two July 10, 1987 Please respond to the following case study in the way that seems best to you. There are no right or wrong answers. This case study is optional. Imagine a person has come to you for a Therapeutic Touch treatment. You feel an imbalance around the head area. What steps would you go through? What would your treatment for this person consist of? In what ways are you able to accept Therapeutic Touch as a realistic nursing intervention, if any? 175 Appendix D Survey - Before Appendix D Before Therapeutic Touch II Survey July 10, 1987 I am interested in your experiences since taking the beginning level Therapeutic Touch class (TT I). As you go through the questions, you will notice that they refer to both Therapeutic Touch and holistic interventions in general. Your opinion on both of these areas is of interest to me. Your responses will not be graded or affect your participation in the workshop in any way. Feel free to be as honest and open with your responses as possible. I will not be looking at any of your responses until after this workshop is finished. If you would be willing to participate in this survey, please answer the following questions in the way which seems best to you. O 1. Did you attend a Therapeutic Touch I (one) workshop given by today's presenters? yes, month, year no 2. What is your profession? R.N. L.P.N. Other, please specify 3. In what ways have you been able to practice Therapeutic Touch since attending TT I, if any? 4. In what ways have you been able to practice other holistic interventions since IT I, if any? 5. In what ways has your work setting become more receptive to Therapeutic Touch since TT I, if any? 176 6. 7. 10. 11. 177 In what ways has your work setting become more receptive to holistic interventions in general since IT I, if any? What factors or conditions have enhanced your use of Therapeutic Touch since TT I, if any? What factors or conditions have enhanced your use of other holistic interventions since TT I, if any? What factors or conditions have hindered your use of Therapeutic Tbuch since TT I, if any? What factors or conditions have hindered your use of other holistic interventions since TT I, if any? Looking back at changes in your life situation since IT I, has your knowledge of Therapeutic Touch influenced your perspective on life situations? Please be as specific as possible. 178 12. Looking back at changes in your life situation since TT I, has your knowledge of holistic health care influenced your perspective on life situations? Please be as specific as possible. 13. What influenced your decision to further pursue Therapeutic Touch by attending this workshop (TT II)? Appendix E Demographic Ferm Appendix E PARTICIPANT PROFILE 1. This form is designed for electronic reading, great care must be taken to complete it. 2. Use only a No. 2 pencil. Do not use a pen. 3. Erase errors completely and cleanly. 4. Select one response for each item. 5. Flntnesppropristo circlowithshssvyblack mark. Acceptable mark: 0 O O O Nonaccaptable marks: '3 Q 63 O 6. Do _ngg make anystray marksonthisform. \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ Program Title 883888888 000000000 000000000 om 888888888 Participant'sSocial SocurityNumber _... _‘—— —".— — — — 888888888 000000000 000000000 PARTICIPANTS... 1. Year of Birth Dacron 1919 0190-49 a Employ-mm 8mm 01920-29 0 1m 0 Full Time (Nursing) 01m 01m 0 MM (Nursincl Q fill TimslNon-Nursingl z IssloEduosdonaanpcadon Q MWlNon-Nunhcl OPrscdcalNuns 0 "Iain O om 0 Student lspscily school of nursing) QAooocioio Degree 0 Baccalaussts in Nursing 0 Other lspscllyl 7. Current Employment Setting a YoerasloEducstlonalPrspsratlonComlstsd 0 Hospital 0 Salon 193 0 1900-0 0 Nursing Horns/Medical Care Facility 0180-48 0 1970-79 0 Community Health 0180-50 01m 0 Clinic/Ambulatory Cara/HMO ‘ Q School System 4. lllgnootuvoloruoootioncoinolouo 0 11mm 0 Practical Nurss 0 Office 0 Diploma 0 School of Nursing 0 Associats Dogrss morning) 0 01m lspocifvi Q Baccalaureate Osgrss (Nursing) 0 Baccalaureate Dogrss lNon-Nursingl 0 Masters Degree (Nominal 8. Current Position Hold 0 Masters Degree (Non-Nursing) O 51.11 Nurse 0 Doctorate (Nisslngl 0 Doctorate (Non-Nursing) O Other lopocllyi 5. You High.“ Level of Education Completed 0 Nurse Practitioner (F.N.P.. P.N.P.l 0 Clinical Specialist 11mm Degree) 0 Hood Nurse 0 Supervisor 0 Instructor/Faculty 0 More 1s- 0 191mm 0 Director/Administrator 0 1940-49 0 1970-79 0 Consultant 0 1950-59 0 moo-as 0 0th.! (specify) 179 180 O" l IVS i I Additionslltanmmsyhsinssrtsdlnthisspacs. O ccuncumlcu 0 came 0 WW 0 scum 0 WWW 0 WW 0 Shawl/WW OOtlnrlIooclM 10. MolorltyolWorltTlmsDirsctsdToward O OlroctNminoc-n O Supervision O Adminhtrstlon O PatismlCIsm/CmEducstlon O ShldsntEducatlon O Othsrlspscllyl ll. HoglatrstlonFssIsPsldby 0 Soil OSslludEmploysr 0 am OOthsr 12. TlmsSpsntlorthlsEducstlonaledwlty O Poroonol O Pmudfinployar‘s O Employer's O Othsr l3. ThoMllssTrawslodOnoWaytoAtssndProoram O lSorlsss 0 75-113 0 1845 O lmormors 0 48-75 14. ThlsEduoatlonlepportunltstmstoMyAttsndon By 0 Brochusilscsivsdatl'loms O BrodiursSsustEmploymsntSstting O Colo-sue O NewsMsds O Othsrlspscllyl 16. lhswsatssndsdprewlomoflsrlngstromthlscontlnulng odooatlonprovldsr. 0 Yes 0 No 0 Don't Know ThlsformdavdopsdbyWSMUMWdWWNMMEdehWMmMWW. Fanmhmcdlflflm (tantalum. 0.1m ...“:‘.”-:“‘ I .1 1 a" :LI-I woos-m1 magma..." Appendix F Interview Questions Change. Appendix F Interview to be Conducted after Therapeutic Touch II Between July 12 and 19, 1987 This interview is based on the four conditions for Conceptual The major categories will be listed by number and the specific questions drawn from the model by a lower case letter. The subjects will not see these questions. They will be used as a guideline to help standardize the interviews and cover the necessary aspects of the conceptual change model. The researcher will write down the subject's responses as the interview is conducted. 1. Dissatisfaction with Existing Conceptions Since attending the TT workshop, can you think of a client situation that cannot be understood by using the traditional dualistic model of mind and body as separate? As a result of the TT workshop, in what ways are you able to look beyond the traditional dualistic model of health care and visualize new holistic possibilities? Since attending the TT workshop, are you aware of client situations that cannot be solved by using the traditional dualistic health care model? In what ways do you believe that the TT workshop has encouraged you to look at the difference between the traditional dualistic model of health care and your spiritual or metaphysical views of such issues? In what ways has the TT workshop led you to question the side effects resulting from the traditional dualistic model of health care? In what ways has the TT workshop caused you to become aware of inconsistencies between the traditional dualistic health care model and the holistic knowledge you have gained in the workshop? Minimal Understanding of a New Conception b. C. To what extent did the TT workshop help you begin to see a holistic framework in which to locate this new intervention of TT? Describe how the workshop made it possible for you to see a workable connection between your ideas of a holistic framework and the setting in which you carry on your nursing practice? was the workshop taught in a manner that allowed you to understand the basic concepts? 181 3. 182 Initial Plausibility of a New Conception To what extent was the workshop content consistent or inconsistent with your basic belief system, personally and professionally? Did the workshop content seem consistent with your current knowledge base in any way? How do the concepts of the workshop seem consistent with your past experiences? Could you give an example of how TT or another holistic intervention could be used in some situation where the traditional dualistic health care system has not been helpful? Do the concepts from the workshop seem similar to other concepts you are already familiar with? Could you describe another belief or intervention which is holistic in nature besides TT? Pruitfulness of a new Conception In what ways do the concepts form the workshop help you think of or understand novel but practical applications or experimentation in this area in the sphere of holistic health care? Can you visualize a new situation where you would feel comfortable applying TT in the full belief that it would meet the needs of that situation? If so, why would this be possible for you at this time? To what extent did the workshop help you see the research potential of TT for nurses in a way that it would further validate TT and bring it into main stream health care? Appendix G Cover Letter - After Appendix G Cover Letter - After MICHIGAN STATE UNIVERSITY EAST LANSING 0 MICHIGAN 0 4.8261317 COLLEGE 0! WC September 10, 1987 Dear I hope your summer has been pleasant since I saw you at our Therapeutic Tbuch workshop in July. I have been busy working on your wonderful data. Your responses are making a fasinating study for me. I enjoyed talking with a number of you during the telephone interviews after the workshop. I believe this study will.make a significant contribution to understanding the learning process which occurs with Therapeutic Touch. I'm now looking forward to your last contribution. This is what I have enclosed for your completion. You‘ll notice that the envelopes are numbered. Please complete them in the order suggested. This will keep the data consisent with the order in which you answered them just prior to the workshop. Please recall, you can answer these in anyway that seems appropriate to you. There are no right or wrong responses. What ever you write will add to my understanding of the learning process. I have also enclosed the participant profile sheet. I forgot to number these when you filled them out at the workshop. My goof! If you filled one out then, you could just put your social security number on this one so I could match it to the one you filled out at the workshop. If you are not sure if you filled one out at the workshop, please complete this one. In either case, please return the profile sheet with the other forms. I have enclosed an envelope for you to return the forms in. Please try to return them by the end of September. If you have any questions, call me collect in the evening at 517-349-1020. I will be in England until September 26th presenting a paper on Therapeutic Tbuch at an International Health Conference and providing a workshop at the Nightingale School of Nursing. I'm really looking forward to these 183 184 experiences. But, at any rate, I will be home by September 26th. You can also leave a message on my answering machine and I will call you when I get home. Thank you so much for your help. Your contributions have made this study possible for me. Best wishes in your practice! Sincerely, Gwen wyatt Appendix 8 Holistic Case Study - After Appendix B After Therapeutic Touch II First Case Study Two Months After Please respond to the following case study in the way which seems best to you. There are no right or wrong responses. As you may recall, this case study is optional. If you are willing to participate, please complete this case study. Imagine the following situation. You as the nurse are delivering a typical dosage of morphine to a hospitalized patient for his/her severe leg pain. Please describe the mechanism of action of this nursing intervention. In what ways are you able to accept the mechanism of action which you described in this case study as being a realistic nursing intervention, if any? Thank you very much for your information. Please return this case study at your earliest convenience in the envelope provided. 185 Appendix I Therapeutic Touch Case Study - After Appendix I After Therapeutic Touch II Second Case Study Two Months After Please respond to the following case study in the way which seems best to you. There are no right or wrong answers. As you may recall, this case study is optional. Imagine a person has come to you for a Therapeutic Touch treatment. You feel an imbalance around the head area with your hands. What steps would you go through? What would your treatment consist of? In what ways are you able to accept Therapeutic Tbuch as a realistic nursing intervention? Thank you very much for your information. Please return this case study, at your earliest convenience, in the envelope provided. 186 Appendix J Survey - After Appendix J After Therapeutic Touch II Survey Two Months After by Mail I am interested in your experiences since taking the Therapeutic Touch II workshop at Higgins Lake on July 10 a 11, 1987. Please answer the questions in terms of what has occurred since the dates of the workshop. Feel free to be as honest and open with your responses as possible. As you may recall, this is an optional questionnaire. If you are willing to participate in this survey, please answer the following questions in the way which seems best to you. 1. In what ways have you been able to practice Therapeutic Touch since the TT II workshop, if any? 2. In what ways have you been able to practice other holistic interventions since the TT II workshop, if any? 3. In what ways has your work setting become more receptive to Therapeutic Touch, if any? 4. In what ways has your work setting become more receptive to other holistic interventions, if any? 187 188 5. What factors or conditions enhanced your use of Therapeutic Touch during the workshop, if any? since the workshop, if any? 6. What factors or conditions have enhanced your use of other holistic health interventions since the workshop, if any? during the workshop, if any? 7. What factors or conditions have hindered your use of Therapeutic Touch since the workshop, if any? during the workshop, if any? 8. What factors or conditions have hindered your use of other holistic health interventions since the workshop, if any? during the workshop, if any? 189 9. Looking back at changes in your life situation since Therapeutic Touch II, has your knowledge of Therapeutic Touch influenced your perspective on life situations? Please be as specific as possible. 10. Looking back at changes in your life situation since Therapeutic Touch II, has your knowledge of holistic health care influenced your perspective on life situations? Please be as specific as possible. Thank you very much for your information. Please return this questionnaire at your earliest convenience in the envelope provided. Would you like a summary of the results of this study mailed to you? yes, no BIBLIOGRAPHY BIBLIOGRAPHY Bohm, D. (1982). Wholeness and the implicate order. London: Routledge and Regan Paul. Pedoruk, R.B. (1984). Transfer of the relaxation response: Therapeutic touch as a method for reduction of stress in premature Doctoral dissertation, university of Maryland. Grad, D., Cadoret, R.J., & Paul, G.I. (1961). An unorthodox method of wound healing in mice. International Journal of Parapsychology, ;, 5-24. neonates o Grad, B.A. (1963). A telekinetic effect on plant growth. International Journal of Parapsychology, g, 117-113. Grad, B.A. (1964). Telekinetic effect on plant growth II. International Journal of Parapgyghglggy, g, 473-485. An investigation of the effects of therapeutic Doctoral dissertation, Heidt, P.R. (1980a). touch on anxiety of hospitalized patients. New York University, 1979. Effect of therapeutic touch on anxiety levels in Heidt, P.R. (1980b). Nursingghesearch,‘gg, 32-37. hospitalized patients. (1974). Healing by the laying-on—of-hands as a The response of in-vivo human Krieger, D. facilitation of bioenergetic change: hemoglobin. Psychoenergetic Systems, 1, 121-129. Krieger, D. (1979). Englewood Cliffs, NJ: Prentice-Hall. The therapeutic touch. Krieger presents childbirth study at Krieger, D. (1983, Fall). cooperative Connection Newsletter Therapeutic Touch research day. of the Nurse Heralers, Professional Associates, Inc., 1(2), l-2. Krieger, D., Peper, 3., & Ancoli, S. (1979). Therapeutic touch: Searching for evidence of physiological change. American Journal of Nursing, 12, 660-662. Lionberger, H. (1985). An interpretive study of nurses' practice of therapeutic touch. Doctoral dissertation, university of California, San Francisco. 190 191 Macrae, J. (1985). Therapeutic touch as meditation. In D. Runz (Ed.), Spiritual aspects of the healing arts. Wheaton, IL: Theosophical Publishing House. Meehan, T.C. (1985). An abstract of the effect of therapeutic touch on the experience of acute pain in post-operative patients. Doctoral dissertation, New York university. Nussbaum, J. (1979). Children's conceptions of the earth as a cosmic body: A cross-age study. Science Education, 61(1), 83-93. Nussbaum, J., a Novak, J. (1976). An assessment of children's concepts of the earth utilizing structured interviews. Science Education, 62(4), 535-550. Ortany, A. (1975). Why metaphors are necessary and not just nice. Educational Theory, 25, 45-53. Peper, E., & Ancoli, S. (1977). The two endpoints of an EEG continuum of meditation. Paper presented at the Biofeedback Society of America Conference at Orlando, Florida. Posner, G., & Gertzog, W. (1982). The clinical interview and the measurement of conceptual change. Science Education, 66(2), 195-209. Posner, G., Strike, K., Hewson, P., & Gertzog, W. (1982). Accommodation of a scientific conception: Toward a theory of conceptual change. Science Education, 66(2), 211-227. Quinn, J.P. (1982). An investigation of the effects of therapeutic touch done without physical contact on state anxiety of hospitalized cardiovascular patients. Doctoral dissertation, New York university. Randolph, G. (1980a). The difference in physiological response of female college students exposed to stressful stimulus, when simultaneously treated by either therapeutic touch or causal touch. Doctoral dissertation, New York university, 1980. Dissertation Abstracts International, 11, 523B. University Microfilms No. 8017552. Randolph, G.L. (1984). Therapeutic and physical touch: Physiological response to stressful stimuli. Nursing Research, 3;, 33-36. Rogers, M.E. (1970). An introduction to the theoretical basis of nursing. Philadelphia: E.A. Davis. Rogers, M.E. (1970). The theoretical basis of nursing. Philadelphia: F.A. Davis Co. 192 Smith, J. (1972). Paranormal effects of anzyme activity. Human Smith, M.J. (1973). Enzymes are activated by the laying-on-of-hands. Human Dimensions, 3, 46-48. Stavy, R., & Berkovitz, B. (1980). Cognitive conflict as a basis for teaching quantitative aspects of the concept of temperature. Science Education, 61(5), 679-692. Strike, R. (1982). Educational policy and the just socie_y. Chicago: University of Illinois Press. Strike, R., & Posner, G. (1985). A conceptual change view of learning and understanding. In L. West a A. Pines (Eds.), Cognitive structure and conceptual change (pp. 211-230). New York: Academic Press. Toulmin, S. (1972). Homan understanding. In R. Strike, Educational policy and the just society. Chicago: university of Illinois Press. Weiss, P.A. (1971). Within theygates of science and beyond. New York: Hafner Publishing Co. ‘Wilber, K. (Ed.). (1974). The holographicqparadigg, Boulder, Colorado: Shambhala. GENERAL REFERENCES Bohm, D. (1982). The enfolding-unfolding universe: A conversation with David Bohm. In Ken Wilber (Ed.), The holographic paradigm. London: Shambhala. Borelli, M.D., & Heidt, P. (Eds.). (1981). Therapeutic touch. New York: Springer Publishing Co. Burr, H.S. (1973). The fields of life. New York: Ballantine Books. Burr, 3.8., & Northrop, P.S.C. (1935). The electro-dynamic theory of life. The Quarterly Review of Biology,‘lg, 322-333. Capra, P. (1975). The Tao of physics. New York: Bantam. Dossey, L. (1982). Space, time and medicine. Boulder, Colorado: Shambhala. Panslow, C. (1983). Therapeutic touch: A healing modality throughout life. Topics in Clinical Nursing, 72-79. Gallagher, J. a Reid, D.K. (1981). The learning theory of Piaget & Inhelder. Monterey, California: Brooks/Cole Publishing. Grad, B.A. (1965). Some biological effects of the "laying-on-of-hands': A review of experiments with animals and plants. Journal of the American Society of Psychological Research, 52, 95-127. Grad, B.A. (1967). Laying-on-of-hands: Implications for psychotherapy, gentling and placebo effect. Journal of the American Society of Psycholggical Research, 61, 286-305. Grad, B.A., Cadoret, R.J., & Paul, 6.1. (1961). An unorthodox method of wound healing in mice. International Journal of Parapsychology, 3' 5-24. Krieger, D. (1973). The relationship of touch, with intent to help or health to subjects in-vivo hemoglobin values: A study in personalized interaction. Proceedings of the Ninth Nursing Research Conference, (pp. 39-58). San Antonio, Texas: American Nurses' Association. Krieger, D. (1972). The response of in-vivo human hemoglobin to an active healing therapy by direct laying-on-of-hands. Human Dimensions, I, 12-15. 193 194 Krieger, D. (1975). Therapeutic touch: The importance of nursing. The American Journal of Nursing, 15, 784-787. Krieger, D. (1981). Foundation for holistic health nursing practices: The renaissance nurse. Philadelphia: Lippincott. Krieger, D., Peper, E., & Ancoli, S. (1979). Physiological indices of therapeutic touch. American JOurnal of Nursing, 4, 660-662. Kuhn, T. (1970). Structure of scientific revolutions. Chicago: University of Chicago Press. Macrae, J. (1979). Therapeutic touch in practice. American Journal of Nursing, 12, 664-665. Modgil, S. & Modgil, C. (1982). Jean Piaget: Consensus and controversy. New York: Praeger. Pelletier, R.R. (1978). Toward a science of consciousness. New York: Dell Publishing Co. Quinn, J.P. (1979). One nurse's evolution as a healer. American Journal of Nursing, 12, 662-664. Quinn, J.P. (1984). Therapeutic touch as energy exchange: Testing the theory. Advances in Nursing Science, 6(2), 42-49. Smith, J. (1972). Paranormal effects of enzyme activity. Human BONE ADDRESS: HOME TELEPHONE: BUSINESS ADDRESS: BUSINESS TELEPHONE: PRESENT POSITION: CURRICULUM VITA Gwen Wyatt 2388 Seville Drive Okemos, Michigan 48864 (517) 349-1020 College of Nursing A9108 Life Sciences Building Michigan State University East Lansing, Michigan 48824 (517) 353-6672 or 355-6523 Assistant Professor EDUCATION 1969 B.A. Michigan State university, East Lansing, Michigan 1973 M.A. Michigan State university, East Lansing, Michigan 1975 R.N. Henry Ford Hospital School of Nursing, Detroit, Michigan 1980 M.S.N. Wayne State university, Detroit, Michigan 1988 Ph.D. Michigan State University, East Lansing, Michigan PROFESSIONAL WORK EXPERIENCE Title Assistant Professor Practitioner Instructor Med/Surg. Instructor Cardiac Instructor Med/Surg. Staff Nurse 5 Charge Nurse Place College of Nursing Michigan State University East Lansing, Michigan Dr. Clifford Hale Lansing , Michigan Lansing Community College Lansing , Michigan School of Nursing Hurley Medical Center Flint, Michigan Lansing Community College Lansing , Michigan E.W; Sparrow Hospital Lansing, Michigan 195 Date 9/80 to present 10/80 to 1/83 3/80 to 8/80 9/77 to 6/78 9/75 to 6/77 9/75 to 5/77