I 4...“: 111. 22'. THESIS tad ‘ 'n. LIBRARY Michigan State University L 3.. - This is to certify that the F thesis entitled k The Selective Perceptions Resulting from Training for l 0 Vertical Division of Labor and the Effect on Organiza- 1 ition Cohesion. ‘ presented by Luther Parmolee Christmon has been accepted towards fulfillment of the requirements for Doctor of Philosoghx degree in Sociologx & Anthropology 77,2; 5 % / - \iz' /ZJ_4A': :f'. 1.45. 4.x Major professor Date February H, 1965 0-169 THE SELECTIVE PERCEPTIONS RESULTING FROM TRAINING FOR A VERTICAL DIVISION OF LABOR AND THE EFFECT ON ORGANIZATION COHESION By Luther Parmalee Christman A THESIS Submitted to _ Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Sociology I965 ABSTRACT THE SELECTIVE PERCEPTIONS RESULTING FROM TRAINING FOR A VERTICAL DIVISION OF LABOR AND THE EFFECT ON ORGANIZATION COHESION by Luther Parmalee Christman This study is concerned with an analysis of the consequences of differential training on the selective perceptions of the persons assigned to a department of nursing. The vertical division of labor, to which was attached specific types of training for each position in the hierarchical arrangement of positions, was exam- ined. The central hypothesis stated differences in training would result in marked differences in the selective perceptions of the members of each stratum of nursing role types. These differences in selective perceptions and orientations would then have consequences for the cohesiveness or lack of cohesiveness of the nurs- ing department. lndices for measuring the custodial-clinical orientations of each different role type were developed. A custodial-clinical continuum was employed because of the importance previous research had attached to the interplay of these two orientations and the implication this interplay had for therapeutic care of mental patients. It was expected that no "pure" types would be found but elements of Luther Parmalee Christman both orientations would be observed in all role types at all levels. The outcome in orientation for each role type would be largely dependent on the selective attention influenced by the type of training. The universe for the study was the entire nursing staff of a large state hospital. Five different role types were identified by type of training. These types ranged from the intense, highly formalized university training of professional nurses to extremely modest on-the-iob training of attendants. The various indices were administered in questionnaire form. The central hypotheses were supported. Significant differences in orienta- tions and in expectation systems were observed. Role types seemed poorly articu- lated. The significant differences in orientation suggest other disruptive conditions -- such as inadequate communication systems -- may be present. The findings are highly suggestive that the nursing department is low in cohesion. This set of conditions is brought about by (I) the vertical division of labor, (2) the creation of role types based on training, (3) the reduced ability to share the perspectives of other role types because of the position arrangement, and (4) the selective action of the perceptual screens created by the interaction of actor and position. As an organization, the nursing department appears unwieldy and vulnerable to having the goal of therapeutic nursing care easily displaced. ACKNOWLEDGMENTS The writer wishes to acknowledge the generous advice and assistance given. throughout this study. A maior contribution came from the writer's chairman, Walter Freeman, who not only during this study but over a period of years, did much to attempt to sharpen a disciplined approach to research. The guidance committee, composed of Jay Artis, Duane Gibson, Erwin Bettinghaus, and Robert Stewart were helpful at various stages of the study. Robert Stewart was particularly helpful during a crucial stage of the study. Frederick Waisanen and Hideya Kumata, originally on the committee but now on leave, greatly stimulated the formation of the original design and methodology of the study. Francis Sim advised on the statistical treatment of the data and greatly facilitated its progress through the Computer Labora- tory and Data Processing Services. The cooperation of this center is grate- fully acknowledged. A special note of gratitude goes to Philip Brown, M. D. , superintendent of the state hospital in which this study was done and Alfred Galli, R. N. , director of nursing at the same hospital who whole-heartedly cooperated in encouraging the nursing staff to participate as respondents. Vernon A. Stehman, M. D. , constantly encouraged the writer throughout his entire graduate program. Finally with warm gratitude, I thank Dorothy and Gary, Judith, and Lillian for being so greatly supportive during the stressful periods of this study. TABLE OF CONTE NTS ACKNOWLEDGMENTS ......... w ............. ii LIST OF TABLES ........................ VT,in LIST OF APPENDICES ..................... . vm Chapter I. THE NEED FOR THIS STUDY ....... . ....... I The stratification of Nursing The State of Unmet Expectations Historical Dimension of the Problem Statement of the Problem Importance of the Problem Theme of Custodial verses Therapeutic Orientations How Social Structure Reinforces Perceptions Stratification as an Impediment to the Sharing of Perceptions The Practical Nurse Perceived as a Stranger 2. THE DIVISION OF LABOR IN HOSPITALS ......... I4 Purpose and Aims of this Study The Influence of Selected Perceptions on the Role of the Nurse The Effect of Occupational Training on the Perceptual Process Differences in Perceptions and Expectations within Professional Nursing Attitude of Attendants to the Work Task The Influence of Social Structure on Interaction and Allil’Ude The Relation of Role Perceptions and Role Expectations to the Study Page Chapter 3. METHOD AND PROCEDURE ................ 23 The Population for the Study The Instruments Source of Items Data Needed to Test the Hypotheses Method of Collecting the Data Method of Administering the Questionnaire Method of Statistical Analysis Hypotheses for the Study 4. RESULTS OF DIFFERENCES IN CUSTODIAL-CLINICAL PERCEPTIONS AMONG NURSE ROLE TYPES ......... 36 The Pattern of Differences among Groups Hypothesis I: Perceptions vary with Training Differing Perceptions of Registered .Nurses Hypotheses 2 and 3: Congruence as to Goals, Means, and Work Tasks Hypotheses 4 and 5: Extrinsic-Intrinsic Job Orientations Hypotheses 6 and 7: Effect of Supervision on Orientation Hypothesis 8: Effect of Employment Tenure on Orientation 5. ROLE EXPECTATIONS .................. 59 Hypotheses 9 and I0: Congruence as to Role Expectations Role Type and Clinical Expectations Expectations for Work Organization The Affect Dimension of the Expectation System Review of the Findings Some Theoretical Reflections on the Findings 6. SALIENCY OF THE NURSING ROLE ............ 9O Hypotheses II and I2: Saliency of Nursing RoIe lnternaIization of the Role Clarity of Self-perceptions of the Nursing Role Relation of Saliency and Role Expectations )- A: Page Chapter 7. SUMMARY AND CONCLUSIONS ............. 99 The Social Utility of Role Articulation Manpower Waste Perceptions and Communication Difficulty Psychiatric Practice: An Uncertain Venture Dissonance Reduction Unmet Expectations Staffing Pattern and Social Structure Changes In-service and Continuing Education BIBLIOGRAPHY ........................ I08 APPENDIX A ......................... I23 APPENDIX B .......................... I38 APPENDIX C .......................... I42 APPENDIX D .......................... I65 APPENDIX E .......................... I76 APPENDIX F .......................... I77 Table I0. II. I2. I3. I4. I5. LIST OF TABLES Type of Role as Related to Custodial-cl inicaI Perceptions of Patient Care ................... Type of Role as Related to Custodial-clinical Perceptions of Ward Milieu ................... Type of Role as Related to Custodial-clinical Perceptions of Work Tasks .................... Technical-professional Perceptions of the Professional Nurse Role by Registered Nurses ............... Type of Role as Related to Extrinsic-intrinsic Perceptions of Nurse Role ..................... Rank of Means of Four Indices for all Groups ........ Custodial-clinical Perceptions of Patient Care by Attendants. . Custodial-clinical Perceptions of Ward Milieu by Attendants. . Custodial-clinical Perceptions of Work Tasks by Attendants. . . What Should an Attendant Nurse Do? (Clinical Statements). . . What Should a Licensed Practical Nurse Do? (Clinical Statements) ..................... What Should a Registered Nurse Do? (Clinical Statements). . . What Should an Attendant Nurse Do? (Organization Maintenance Statements) ............... What Should a Licensed Practical Nurse Do? (Organization Maintenance Statements) ............... What Should a Registered Nurse Do? (Organization Maintenance Statements) ............... vi Page 39,40 4I 45 48 50 .54 .55 .56 .65 66 .67 . .69 ..70 ..7I Table' Page I6. What Should an Attendant Nurse Do? ("Affect" Statements). . .. 74 I7. What Should a Licensed Practical Nurse Do? ("Affect" Statements) ....................... 75 I8. What Should a Registered Nurse Do? (”Affect" Statements). . . 76 I9. Type of Role as Related to SaI iency ............. 9I 20. Type of Role as Related to Nursing Role Statements ...... 95 2I . Type of Role as Related to Specific Nursing Role Statements. . . 96 22. Type of Role as Related to Length of Employment in the Hospital. .I24 23. Type of Role as Related to Previous Employment ........ I25 24. Type of Role as Related to Number of Jobs Held ........ I26 25. Type of Role as Related to Hospital Location .......... I27 26. Type of Role as Related to Work Shift ............. I28 27. Type of Role as Related to Position in the Hospital ....... I29 28. Type of Role as Related to Age ............... I30 29. Type of Role as Related to Sex ............... I3I 30. Type of Role as Related to Race ............... I32 3I . Type of Role as Related to Education ............. I33 32. Type of Role as Related to Marital Status ........... I34 33. Type of Role as Related to Religion .............. I35 34. Type of Role as Related to Political Preference ......... I36 35. Type of Role as Related to Organization Membership ...... I37 vii LIST OF APPENDICES Page Appendix A. Additional Tables Showing Social Variables .......... I23 B. Tentative Characteristics for the Building of a Custodial- CIinicaI Typology ................... I38 C. Questionnaire used in Obtaining the Data ........... I42 D. The Indices ........................ I65 I. Custodial-clinical Perceptions of Patient Care 2. Custodial-clinical Perceptions of the Work Task 3. Custodial-clinical Perceptions of Ward Milieu 4. Extrinsic-intrinsic Perceptions of the Nurse Role 5. Technical-professional Perceptions of the Professional Nurse Role E. Subiects not Available ................... I76 F. Subjects Questionnaires Not Used because of Incomplete Form. . I77 viii CHAPTER I THE NEED FOR THIS STUDY Mental hospitals presently are under great social pressure to become more therapeutic in operation. One of the impediments to this goal may be the inabil- ity of the various patient-care disciplines to come to consensus on the definition of patient care and the respective roles of each discipline.1 Consensus is a meas- urement of the degree to which the cultural orientations of various individuals or groups are congruent. Statements about consensus point out differences and similarities in the orientations of two or more groups. 2 The differences in training of the various disciplines produce varying, selective perceptions and act as imped- iments to viewing the situation from the standpoint of the generalized other. The same problem of different types of training is present within one of the disciplines, that of nursing. These differences in training have developed because IE. Chance and J. Arnold, "The Effect of Professional Training, Experience, and Preference for a Theoretical System upon Clinical Case Description," Human Relations I3 (I 960) 3:I95-2I3. The authors state clinicians are characterized in their assessment of the concerns of a patient by certain kinds of biases which result in selective observation. Factors in such selective observation include order of case presentation, length of experience, membership of a clinical discipline, and formal training in a given theory. The authors suggest that increased awareness of the operation of such biases may be an aid to effective communication in the clin- ical field. Cf. L. Schatzman and R. Bucker, "Negotiating a Division of Labor Among Professionals in the State Mental Hospital, " Psychiatr , 27 (I964) 3: 266- 277. The manner in which persons from different training and disciplines "nego- tiate" for their treatment roles in the inter-disciplinary setting is discussed in this paper. 2A. Etzioni, A Comparative Analysiso_f Complex Organization, New York, The Free Press of Glencoe, I96I, p. I28. 2 the division of labor within nursing has evolved as a vertical division of labor as opposed to a horizontal division such as other clinical departments in the hospital have tended to do. Nursing positions are stratified and specific tasks attached to them often in an exclusive fashion. This condition greatly reduces the possibility of sharing similar perceptions of appropriate patient care on the part of the various nursing groups. Instead of a stimulating interchange, a pathological cleavage may occur among the nursing groups. A vertical division of labor, for purposes of this study, is defined as the delegation of tasks and activities by a hierarchical position arrangement. Tasks are assigned to positions in order of their complexity. The lower down one goes in this position arrangement the fewer iudgmental abilities are required and the more motor skills are demanded. Conversely the higher the position, in this order of arrangement, the greater is the amount of iudgmental ability required. In this vertical division of labor the same phenomena of "blocked mobility" is present as is true of horizontal division of labor. That is, no one can move up to positions above without taking the formal education program demanded for that position. For instance, an attendant cannot become a licensed practical nurse, nor no licensed practical nurse can become a registered nurse, without taking the prescribed training. This is the case even between the professional nurse role types. However in the horizontal division of labor the persons working in close collaboration to serve the organizational goals of that particular depart- ment usually function at a peer level -- that is the personshave very similar education, class, status, and general style of life. For example, there is a S considerable difference in the type of collaboration and division of labor when 3 a physician specializing in internal medicine and a psychiatrist are cooperating on managing a psychosomatic condition in a patient than when a professional nurse and an attendant are collaborating on the nursing problem of that same patient. The commonalty of the shared perceptions has a greater likelihood of variance in the latter than in the former set of conditions. The Stratification of Nursing The various groups constituting the nursing staff are prepared for their assigned role by several different kinds of training. This suggests that they may have varying selective perceptions in the image they hold of patient care. However, previous training is only one of the chief means by which the percep- tual process is developed and reinforced. The position and role of the actor are equally important in influencing perceptions. This raises a difficult problem of control if one attempts to study any one of these variables. All three act as intervening variables which influence attitudes in the work situation. The inter- action between these variables is always present and one cannot be very certain about the nature of this interaction. Imagery is important in giving the cues which set up predispositions to act. The same nursing situation will have a dif- ferent prescription for nursing personnel according to their training, position, and role. Since each individual nursing person must interact with others of dif- ferent training, no matter who is the position encumbent, there is conflict potential. Therefore, with great variations in the preparation of the various groups which compose the nursing staff, there should be a marked discrepancy in their expectations as to what constitutes the nursing care of patients. 4 In the hospital social system the various nursing groups are arranged in a stratified order. The professional nurse group is at the top of this stratification with the licensed practical nurses and attendant nurses in subordinate positions. Within the professional nurse group there is further stratification. Registered nurses with college degrees usually have the topmost positions, with the non- degree registered nurses in lesser hierarchical roles. Even though degree nurses may occupy the top stratum, they are a very pronounced minority in numbers. Degree nurses have high visibility but the opportunity to interact with other nursing groups is greatly hampered by their few members. As a result, their power as a " role model" is greatly attenuated. The intended consequences of training is to prepare nursing personnel for their occupational roles. The unintended consequences may be the development of several different sets of expectations and predispositions to act in the care of patients by the different groups of nursing personnel. Due to these differences in training, there may be conflict as to how the nursing care of patients is defined by these differing groups of nursing personnel. The State of Unmet Expectations Historical Dimension of the Problem Traditionally, because of the absence of professional nurses, care in mental hospitals has been performed primarily by attendants. The lack of professional nurses is in part the result of several social factors. Mental hospitals have usually been located in rural, isolated settings; state legislatures. have demonstrated a reluctance to appropriate budgets large enough to pay for professional staffs; and, 5 until recently, psychiatric nursing has had low prestige within professional nurs- ing. As a result of long tenure in a caring role, attendants developed their own expectation system. In the last decade, increasingly larger numbers of profes- sional and licensed practical nurses have been employed. Because of this action, new roles and positions were introduced into the nursing department. These differently trained nursing groups have brought their varying expectations of appropriate nursing care with them to the mental hospitals. Several new sets of nursing expectations have been introduced in a social system where formerly only one, chiefly that of attendant personneli‘, was held. This new set of condi- tions suggests there may be a lack of cohesion and integration of the nursing groups in the nursing department. Cohesion, for purposes of this study, is defined as a positive expressive relationship which permits and promotes instru- mental cooperation. In this study the degree of hierarchical cohesion is used as the principal index of organizational cohesion. Hierarchical cohesion is consid- ered present when there is consensus as to the perceptions and role expectations among the role types in the hierarchical arrangement. When dissensus exists in * Although in this study the perceptions as a result of training are being studied, other variables are contributing to the perceptual screens. Discord between the attendants and the two other groups exists because the introduction of these two better trained nurse groups has lowered the upward mobility of the attendant group. Positions in the hospital hierarchy which once were occupied by attendant supervisorS, are now almost all filled by professional nurses. In some mental hospitals, licensed practical nurses are used to fill the lower level supervisory positions when registered nurses are unavailable. Thus what was once the domain of the attendant has been usurped, in his perception, by the two other groups. Dahrendorf views this as a conflict emerging from the author- ity structure of the social organization. He states that conflict between in- terest groups varies in its intensity in direct relation to the degree of mobility from one group to another. See R. Dahrendorf, " Toward a Theory of Social Conflict," Journal -o_f_Conflict Resolution 2 (I958) 2:]70-83. 6 the perceptions and role expectations among these same role types, then a state of low cohesion will be assumed to exist. The presence of strong agreement about perceptions and expectations within role types accompanied by a lack of agree- ment among role types will be considered as suggestive of conflict within the organization. The probable disruption of the prevailing expectation system by the several sets of new nursing expectations creates interesting structural phenomena. Which, if any, of these nursing expectation systems will survive? Which, if any, will be the most powerful in modifying the expectations of the other nurse groups. A knowledge of the role perceptions of these competing and differentially prepared nurse groups would be of value in the planning of change to accomplish therapeu- tic ends. Statement of the Problem Nursing personnel have a common core of knowledge acquired through training. However, the training in the various role-types of nursing personnel show maior differences. These are mainly length of time, amount of theoretical and substantive content, and quality of supervision. One of the problems created by these differences in training is the difference in the nature of the interaction with position and role. As a result, it might be expected that each of the var- ious role types will hold different perceptions and role expectations for themselves and others in the process of giving nursing care. In this study, perception is The above definition of cohesion is adapted directly from Etzioni. See A. Etzioni, op. cit., p. I46. 7 defined as the abstracting process for coding information inputs into meaningful parts. It is a refining of sensory inputs into meaningful wholes. Role expecta- tions are the beliefs and attitudes held by the members of an actor's role set about what the actor should do or not do as part of his role.4 If this is the case, then a state of unmet expectations exist. It is posited that if this state of conditions is present the nursing department lacks cohesion. Therefore, the ability to ma- bilize nursing resources to cooperate in therapeutic patient care is probably greatly reduced . Importance of the Problem It is assumed that the different levels of achieved roles in the nursing staff are theoretically designed to be mutually supportive in the task of giving care to patients. It is also posited, that in order for staff members to be mutually supportive, a high degree of consensus about the perceptions of nursing care roles must exist. This would imply that the expectations of each group for the other are being met. If this state of conditions existed, there would be large areas of overlap of roles. Theme of Custodial verses Therapeutic Orientations The rapidly growing literature on mental hospitals contains many references 0 to the conflict over appropriate care and treatment of patients as a result of the different orientations of hoSpital personnel concerning the means of this process. 4R. L. Kahn, et al., Organizgti_onal Stress: Studiesi_n Role Conflict and Ambiguity, New York, Wiley, I964, pp. I4-I5. 8 A theme of custodial versus therapeutic orientationsi" appears to pervade the research findings and seems to be the base for much of this conflict. Orientation, as used here, is viewed as sets of attitudes comprising a Gestalt or "whole" form. The perceptual process of the actor is assumed to be greatly influenced by this organization of sets of attitudes. If orientations and value systems are partially due to training, then an examination of types of perceptions and expectations resulting from differing training should be fruitful. If this is the case, then a lack of cohesion will be evident due to wide variations in clinical and custodial orientations as well as dissensus regarding perceptions of the nursing role. There will be varying degrees of this cohesion and lack of cohesion. How Social Structure Reinforces Perceptions Although training is important in developing perceptions of the work task, the interaction patterns of the role sets of each of the various nursing groups is O O O O 0 Q 5 very Important In reInforcmg these perceptIons. SImmel , who suggested a concept One observer, comments on the close relationship of therapeutic and custodial functions. In coming to grips with this problem one of the difficulties lies in attempting to clarify the differences between both concepts. "The goal of the hospital is here purposely defined as 'coping' with the consequences of illness in order not to exclude what is usually called the custodial function. But custodial care is, in the light of the institutional definition of illness, a second best, to be accepted only insofar as the preferable goal, namely, recovery from the state of illness, is not technically possible or is excessively costly." See T. Parsons, "The Mental Hospital as a Type of Organization," in M. Greenblatt, D. J. Levinson, R. H. Williams (ed.), The Patient and the Mental Hospital, Glencoe, Illinois, The Free Press, I957, p. I09. — 5Simmel, G. , "The Persistance of Social Groups: I", The American Journal of Sociology; 3 (I898) 5:662-98. 9 of persistency in groups, offers enlightening clues to some of the variables influ - encing the possible lack of cohesion of these groups. He stressed that the indoc— trination of the normative values of a system is the continuing and reinforcing pattern which maintains the boundaries of the system; that the larger and more homogeneous the social system, the more easily it can resist invasion, assimilate others, control forces of change, and restore itself to its own normative pattern. Large numbers of attendants are available to initiate the neophyte. Because the change in numbers among attendants is relatively small at any one time, as compared with the number of those who remain constant, the normative values and attendant behavior patterns persist since there is always a preponderance of norm bearers ready to indoctrinate new members. This is especially true of norm bearers with status. The attendant supervisors -- norm bearers with status -- have comparatively little turnover and are in a strategic power position to en- force the norms; whereas, the total number of professional personnel, particularly that of professional nurse personnel, is comparatively small. The multiplication of the numbers of persons in interaction greatly reduces the possibility of mean- ingful contacts. As a'consequence, the nurse relationship and interaction pattern suggested by this theoretical notion would leave little opportunity for means of developing shared perceptions of nursing care. If we look at the numbers and the manner of arraying each stratum of nursing personnel, we see further evidences of possible dissensus and lack of cohesion. As stated above the attendants outnumber the registered nurses by a considerable ratio. The registered nurses are responsible for supervising attendants, as well as giving care to patients. The heavy work load of sheer IO numbers of persons places great demands on the time registered nurses have to attend to the needs of each task. The scarce supply of professional personnel plus the unlimited demands on the registered nurses' time and services make for built-in tension and encourages a propensity to fleeting contacts. This reduces perceptibly the impact of any change action on the persistant group pattern. Each attendant, therefore, of the large attendant group, can be more easily replaced by another without impairing self-maintenance of the group.* Each professional nurse, in the small professional group, can be easily replaced without increasing the change action. Stratification as an Impediment to the Sharing of Perceptions The hierarchical positions of the different nursing groups reveals another likely source of conflict if perceptions are not congruent. The attendants are in intimate direct action with patients. The registered nurses dominate middle and top nursing management positions. If one set of perceptions of patient care is functioning at the policy making and program planning level and another is functioning at the level at which these policies and programs are being opera- tionalized, then dissensus and lack of cohesion between the groups becomes *In this study for example, the 55 registered nurses are theoretically responsible for the supervision of 547 attendants and 2,250 patients, a total of 2,797 persons or almost a I:5I ratio of nurses to others results. Compare this with the attendants interacting with patients and a resulting ratio of I:5 emerges. The intensity of interaction is obviously different and in favor of the attendant being better able to enforce his perceptions and normative values in the carrying out of patient care. 6L. Christman, "The Attendant -- Helpmate or Hinderance," Perspectivesh Psychiatric Care, I (I963) 3:10—12. II highly probable. This likelihood becomes increased if the nurses in middle- management levels, who usually are nurses without collegiate education, have different perceptions than those with advanced training at top management levels. The nurses,with the training designed to prepare people to be most therapeutic, usually occupy role positions at the top of the nursing hierarchy but which do not permit very much specific interaction with patients or nursing personnel in lower positions. By their very remoteness, they are unable to act as a "clinical role model" by which perceptions could be re-enforced or changed. Unless the organization of the hospital carefully provides a means by which consensus can be openly achieved, a state of arbitrariness and covert disagreement can readily exist. The Practical Nurse Perceived as a Stranger Up to this point little has been said about the licensed practical nurse. This type of nursing personnel is a relative newcomer to psychiatric hospitals. At best, practical nurses appear to have a relatively insecure role. The attend- ant nurses are prone to look upon them as interlopers* and as offering a threat to the iob security of attendants. The registered nurses also do not seem overly willing to accept them. There: is a tendency among this group to look upon the licensed practical nurse as only being partially trained because of the short * An incident occurring during this research may illustrate the case in point. Two practical nurses attempted to teach a nursing technique to the attendants on the word with whom they worked. They were sharply rebuffed. The clinching statement came from an attendant supervisor who said, "You may have learned the right way while you were in school, but as long as you work here you will do it the Hospital way." I2 period of over-all training as well as the specific lack of psychiatric training in the practical nurse curriculum. Thus a person whose perceptions of psychiatric care are not formed by specific psychiatric training is injected into the psychi- atric patient core structure. It would seem reasonable to assume that practical nurses perceptions and expectations for the psychiatric nursing care of patients would not be congruent with the other nursing groups. If the above set of conditions holds for the nursing staff of the psychiatric hospital, then it has implications for the whole interdisciplinary cooperation of that hospital. It may be that highly specific types of training which differ sharply from each other, in conjunction with patterns in which the role positions for each are arrayed, may either impede or facilitate patient therapy. If it is the case for psychiatric hospitals, then it may probably be the case for general hospitals as well as other types of patient care facilities. This may also be the case for all institutions where highly cooperative role relationships are the chief means of bringing about a socially desirable end.7 This'study is limited to an exploratory examination of the perceptions and expectations that nursing personnel in each nursing group hold for themselves, for each other, and for patient care. It does not attempt to study how these i.e. The rehabilitation of prisoners is one example. Scott compares the twin goals of custody and resocialization of prisons and mental hospitals. She concludes the structure of both organizations has resulted in the most strenuous system requirements being placed upon those persons least able to deal with them -- the attendant and the guard. See F. G. Scott, "Action Theory and Research in Social Organization," American Journal _o_f Sociology, 64 (I 959), 4:386-95. I3 perceptions and expectations are expressed in empirical behavior. From previous studies there is enough evidence to suggest a high probability exists that this behavior will follow the stated predispositions of the different nursing role types.8 For example, see A. F. Behymer, " Interaction Patterns and Attitudes of Affiliate Students in a Psychiatric Hospital," Nursing Outlook, I (I953), 4:202-07; R. P. Bullock, "Position, Function, and Job Satisfaction of Nurses in the Social System of a Modern Hospital, " Nursing Research, 2 (I953), I:4-I4; H. Mauksch, The Nurse: A Study in Role Perception, unpublished doctoral dissertation, University of_Chi—ca—go7 I760;_F. R. Morimoto, "Favoritism in Personnel-patient Interaction,‘I Nursing Research, 3 (I955) 3:I09-I2; L. Narvon and J. C. Stauffacher, "A Comparative Analysis of the Personality Structure of Psychiatric and Non-Psychiatric Nurses," Nursing Research, 7 (I958) 2:64-67; C. G. Scwartz, " Problems for Psychiatric Nurses in Playing a New Role on a Mental Hospital Vlbr ," in M. Greenblatt, D. J. Levinson, and R. H. Williams (eds.), The Patient and the Mental Hospital, Glencoe, Illinois. The Free Press, I957, pp. 402-26. CHAPTER 2 THE DIVISION OF LABOR IN HOSPITALS The literature on the social structure of mental hospitals presents consid- erable evidence that hospital personnel seem to function in a social structure less flexible than most organizations.I Because of the highly complex nature of the work tasks in caring for patients, a sharp division of labor has evolved. Fixed positioning is inevitably the case. The division of labor has resulted in the articulation of a series of related but separate systems such as those of medicine, psychology, Social work and nursing. Much specialized training is required to enact, in an adequate fashion, the various subroles in a given professional work role. Professional education prepares for roles specific to that profession and for roles in no other profession except where there is overlap. 2 The hospital 1See I. Belkanp, Human Problems 9f gm Mental Hospital, McGraw- Hill, I956; Jules Henry, "The Formal Structure of a Psychiatric Hospital," Psychiatry, I7 (I955) 2: I39- 5I; M. Schwartz and E. L. Shockley, T__h__e N__u__rse a_n_d t__he Mental Patient Russell Sage Foundation, I956; H. W. Dunham— and S. —Weinberg, The Culture o_f the State Mental Hospital, Detroit, Wayne State University Press, I960; W. Caudhill, The Psychiatric Hospital a__s a_ S___mall Society, Boston, Harvard University Press, I958; A. Stanton and M. Schwartz, The Mental Hospital, Basic Books, I954; E. Goffman, Asylums, New York, Doubleday and Company, I96I; D. C. Gilbert and D. J. Levinson, "Role Performance, Ideology, and Personality in Mental Hospital Aides," in M. Greenblatt, D. J. Levinson, and R. H. Williams (eds. ), The Patient In t_h_e Mental Hospital, Glencoe, Illinois, The Free Press, I957,— pp. 197- 20—8. 2For an interesting insight into "Blocked Mobility" see H. L. Smith, "Two Lines of Authority are One Too Many," 'I_'_lr_I_e Modern Hospital, 84 I4 I5 stratification pattern, as well as the numbers of each group, influences to a great extent the interaction patterns of these respective groups with each other. The marked differences in training of the various groups in nursing may be preventing the cohesive articulation of the various nursing groups with each other. Historically3 the three-year hospital schools of nursing have been the chief means by which nurses received their education. Ninety percent of all nurses presently are being educated in hospital diploma programs. However, the nursing programs in junior colleges and the collegiate schools of nursing are educating increasingly larger numbers of students. Since all these programs produce a registered nurse, there is a wide range of training for roles by which the final product is brought forth. During the last decade, graduate education in nursing has become more prevalent. This development further broadens the range of training. Professional nurses are assisted in giving nursing care by licensed practical nurses and by attendants.4 The licensed practical nurse is the product of a one- year vocational education program usually in a high school or junior college. The attendant has varying amounts of on-the-job training.* Thus, in nursing itself, (I 955) 3:59-64. As described in this article blocked mobility exists when mem- bers of one occupational category cannot advance beyond the limit set by the next higher category. Smith states this is characteristic of hospital social structure. 3$ee Report of the Surgeon General's Consultant Group on Nursing, Toward Quality in Nursing, U. S. Department of Health, Education and Wel- fare, Public Health Service Publication No 992, I964. 4In the United States in I962 there were 550,000 professional nurses in practice, 225,000 practical nurses, and more than 400,000 aides, orderlies and attendants; Ibid. , pp. 6-9. *In the hospital under study the attendants received a one hundred and fifty hour on—the-job training program. I6 there is a system of overlapping, but separate roles, each with a different training program. However, the content of the training is not the only variable which contributes to the way the nursing role is perceived. The time it takes to obtain training would appear to be an equally crucial variable. The length of training itself allows or does not allow time for the reinforcement of role perceptions. Attitudes are inipart developed by substantive information; strengthened by the clinical supervision of nursing practice teachers; and in part internalized by the student from the covert communication of teachers and other nursing practitioners. Although a core of nursing knowledge may be common to all nursing personnel, the manner in which this core is utilized may differ sharply when modified by the . differential training. Extensions of this core acquired by training may act as an independent variable when in interaction with role and position. Purpose and Aims of this Study The Influence of Selected Perceptions on the Role of the Nurse This study is an exploratory examination of the role perceptions of various nursing groups. Much of the work role of nursing personnel has to do with the environmental management of the patient. It is assumed that there are at least two major task functions allocated to this role. These two functions embody activities which require clinical orientations and those relying primarily on custo- dial orientations. It is further assumed that the perceptions held by the nursing staff related to which tasks should receive primacy in patient care will greatly effect the character of role performance. It is conceded that elements of both orientations will be found in all roles at all levels. However, the outcome of I7 selective attention to one or the other will reveal the saliency of either orienta- tion for role performance. It is assumed that the greater the differentation in the kinds of perceptions as to role and role expectations in nursing, the greater will be the role conflict and the less the tendency to organization cohesion and role integration. The problem of this dissertation is to explore the areas of consensus and dis- sensus in role perception in the nursing staff of a mental hospital. The patterns by which role perceptions vary will be examined. It is expected that these patterns will reveal areas of agreement and lack of agreement. A knowledge of the ob- stacles preventing cohesion on the therapeutic end of the clinical-custodial continuum will be useful in planning improved patient care. The Effect of Occupational Training on the Perceptual Process The background of life experience orients the selective perceptions by which an individual defines each social situation. Expectations of what is appropriate work behavior are formulated by training and experience. Occupational training is a vital part of one's life experience. Such training tends to develop selective attention to the phenomena in a work situation. Individuals probably tend to define the work situation largely in terms of these social experience variables along with the social structure in which actors find themselves. Since meanings are products of past experience, people from different educa- tional and training backgrounds tend to perceive identical situations in somewhat different ways. Martin and Simpson5 in their study of psychiatric nursing found 5H. W. Martin and l. H. Simpson, Pattern53_f Psychiatric Nursing, Chapel Hill Institute for Research in Social Science of the University of North Carolina, I956. I8 that the meaning of patient needs for registered nurses was different from that of attendants. They also found a difference for both groups in the perception of the meaning of relating to patients. Scheffé found a very marked difference between attendants and professional staff in the expectations held for patient care. Differences in Perceptions and Expectations within Professional Nursing The research on the nursing profession shows considerable agreement that nursing is a profession in transition.7 One study8 suggests that nurses are currently being educated with conceptions of nursing which older generations find unaccept- able. A study comparing students in diploma (hospital) schools with those in collegiate schools of nursing found the latter had low identification with the hos- pital bureaucracy and high identification with the nursing profession. Students from diploma schools had a reverse pattern, being high with the hospital bureauc- racy and less intense identification with professional goals. As a result of this study, Corwin9 concludes The apparently inconsistent effects of role conception can be explained when the type of training program in which the conception was learned is known. That is, the nature of the association is 6T. J. Scheff, " Control Over Policy by Attendants in a Mental Hospital," Journal of Health and Human Behavior, 2 (I96l) 2:93-I05, , Differential Displacement of Treatment Goals in 0 Mental Hospital," Administrative Science Quarterly, 7 (I962) 2: 208-I7. 7For an interesting study, see G. R. Meyer, Tenderness and Technique: Nursing Values in Transition, Los Angeles, Institute of Industrial Relations, University of Clefornia, I960. 8H. L. Smith, "Contingencies of Professional Differentiation," American Journal_o_f_Sociology, 63 (I 958) 4:4I0-I4. 9R. G. Corwin, "Role Conception and Career As iration: A Study of Identity in Nursing," The Sociological Quarterly, 2 (I 6I) 2:69—86. I9 influenced by the type of training program in which personnel have originally learned about nursing. . . In the training program the student learns more than role conceptions; she learns to integrate role concep- tions into a total identity (p. 83). O O ‘0 O O O The fIndIngs of another study revealed that nursmg students In deloma schools of nursing preferred nurse-doctor situations rather than nurse-patient situations. For students in collegiate schools of nursing, preference was in the reverse order. These studies would seem to give additional evidence that dif- ferences in training produce tendencies toward differing selective perceptions. Attitudes of Attendants to the Work Task It has been observedll’ '2 that nurses delegate low level tasks downward as they take on more complex tasks. Nurse aides and attendants perceive that they are assigned the humblest jobs and conclude they are doing the "dirty work" in the name of healing the sick. BelknapI3 states that members of the attendant group frequently develop the general attitude that they are doing the real work and carrying the parasites of the upper levels. He found also this attitude dis- couraged upward communication and resulted in a manipulating of information to create embarrassment for those with high status. 10G. R. Meyer, "The Attitude of Student Nurses Toward Patient Contact and Their Images of the Perference for Four Nursing Specialties," Nursing Research, 7 (I958) 3:I26-30. HSmith, op. cit. 12E. C. Hughes, Men a_n_d Their Work, Glencoe, Illinois, The Free Press, I958, p. 76. ml. Belknap, Human Problemso_fg State Mental Hospital, New York, McGraw-Hill, I956. 20 The Influence of Social Structure on Interaction and Attitude Rowland”, in a pioneer study of the social structure of mental hospitals, observed that employees limit friendship ties to members of their own class group and that rigid class patterns carry over to leisure time interaction. Members of each class are strongly conscious of the class lines differentiating the attitude of each class toward other classes. Mischler and Tropp‘s report a higher rate of intro-group than inter-group interaction. They further elaborate on their find- ings by noting that this interaction is with significant others in the same subgroup. This limiting of non-work association to members of their respective groups greatly inhibits the formation of friendship patterns and mutual trust so necessary for free communication across groups. The degree of structuring is crucial in the formation of associational ties and the manner in which they influence role perception. The tighter the social structure, the more limited and more sharply defined will be the roles (and there- fore the role perceptions) and vice versa. 16 as mentioned earlier, research indicates that hospitals are relatively rigid bureaucracies and allow but little deviation and alternatives to behavior. However, partly because the various 4 I H. Rowland, "Interaction Processes In the State Mental Hospital, " Psychiatry, I (I 938) 4323- 37. 15E. Mischler and A. Troop, " Status and Interaction in a Psychiatric Hospital," Human Relations, 9 (I 956) 2:I87-203. 16E. Goffman, The Presentation of Self In Everyday Life, Garden City, N. Y., Doubleday AncF-r, I959. Throughout the monograph—the author attempts to show how the social structure tends to influence perceptions. He points out that the greater the degree of structuring the more likely will stereotypical eXpectations result. For example, see p. 27. 2] subgroups in nursing have different training, each subgroup is prone to define the situation differently. The rigidity of the hospital system reduces the opportu- nity of any one group taking the roles of others and thus displaces the opportunity to share the perspectives of others. It follows then that the opportunity of view- ing oneself from the standpoint of the other nursing groups, in this setting, also becomes limited. Since the nursing subgroups have such a restricted opportunity of defining their respective group behavior in terms of the expectations of other nurse role types, consensus as to appropriate behavior with patients should tend also to be reduced. If a person holds a particular value system as a result of his training, he will be in conflict with those who hold a different value system. If conflict occurs it probably will be over the clash of differing expectations as persons with different value systems define the situation in different ways. Blau and Scott found that the individual commitment of caseworkers was not nearly as important an indicator of behavior with clients as was the value system of the group to which they were assigned. Value systems, in part, can result also from training as well as the norms of the social system in which the actor finds himself. With the many opportunities for a non-congruency of role expectafions to occur, as a result of interaction occurring with differently trained nursing groups, a predict- able result would be a lack of cohesion and integration of the nursing system. 17P. N. Blau and R. W. Scott, Formal Organizations, San Francisco, Chandler Publishing Company, I962. 22 The Relation of Role Perception and Role Expectation to the Study Role perception and role expectations are central to this study. Gross, Mason, and McEachern state‘s, " . . .three basic ideas which appear in most conceptualizations considered, if not in the definitions of role themselves are that individuals: (I) - in social locations, (2) - behave, (3) - with reference to expectations." In their study they raise the question of the impact of differential consensus on the functioning of social systems, on group effective- ness, group equilibrium, and on the gratification of the members of the social system. Olmstedl9 has a useful description of the function of role: to maintain consistency among sets of behavioral expectations, so that people know what behavior to expect of certain persons, and how to react to them. This facilitates everyday predictability of behavior and reinforces our belief that we are interpreting situations properly. This study suggests that differences in training tend to make it difficult to main- tain consistency among sets of behavioral expectations between the various strata of nursing personnel. It assumes the lack of agreement as to these expectations is disruptive to the socially desirable goal of therapeutic patient care. 18N. Gross, W. Mason, and A. McEachern, Explorationsi_n Role Analysis, New York, John Wiley & Sons, I958, p. l7. I9D. W. Olmsted, Social Groups, Roles, and Leadership: An Introductiontgthe Concepts, East Lansing, Institute for Community-D-evelop- ment and Services, Michigan State University, I96I , p. 26. CHAPTER 3 METHOD AND PROCEDURE The Population for the Study The universe selected for this study was the entire nursing staff of a state mental hospital. This state hospital is of new, modern construction located on the suburban fringe of a large city. It first opened its doors in I952 and has gradually expanded in size as new constructionwas completed. At the time of this study, it had a patient capacity of 2,250. The nursing staff had members in each of the role types deemed necessary to the study. In some ways the hospital is not representative. Since it was in operation only a relatively short time, it does not have a long history. The various interactions of personnel with patients may not be settled in any fixed pattern. Many of the norms and attitudes about patient care among nursing personnel can be assumed to be partly the result of five existing conditions. These are: (I) the recruiting process by which persons are attracted to the hospital; (2) the amount of funds allocated to employ the numbers of each of the different groups of nursing personnel; (3) the positions of the different role types; (4) the various rules, written and unwritten, which prescribe the action of personnel; and (5) the different types of training programs which prepare each group of nursing personnel to function in patient care. It is the last of these conditions which is the central concern of this study. 23 24 This set of conditions was chosen because it seemed to be the set most amendable to an exploratory study under the non-funded means by which this study was done. Over the period of time this study was being contemplated, the writer became increasingly aware that differences in training seemed to be producing differing behavior with patients. This observation piqued the curios- ity enough to stimulate the present level of investigation. A further influence for choosing training differential arouse from the present movement in the field of mental health to develop new types of care facilities. With this development is a growing dilemma as to how to staff these new facilities -- by whom and with what kind of training. In addition, there currently is a great deal of discussion and indecision at state and federal levels as to what type or types of training programs are useful in improving nursing care of patients in all psychiatric care facilities. The final decision as to this training will influence the allocation of large sums of public tax funds. A very modest study, such as this, will prob- ably go unnoticed in such a major decision. The findings, however, may suggest that further investigation in this direction may be warranted. The Instruments Since the study required the gathering of data measuring perceptions and expectations, the following indices were used: I. The Ten Statements Test (Who Am I?) 2. The "What Should (a registered nurse, on attendant-nurse, and a licensed practical nurse) Do ?" Index. 3. A Custodial-Clinical Perceptions of Patient Care Index. 4. A Custodial-Clinical Perceptions of the Work Task Index. 25 5. A Custodial-Clinical Perceptions of Ward Milieu Index. 6. An Intrinsic-Extrinsic Perceptions of Nurse Role Index. 7. A Technical-Professional Perceptions of Professional Nurse Role Index. 8. A Semantic Differential Index of Attitudes Toward Patients. 9. A Semantic Differential Index of Attitudes of Registered Nurses Toward Professional Relationships. For form and organization of the questionnaire was directly adopted, and was very similar to, a questionnaire being developed by Professor Frederick Weisanen for the so-called Six Nation Study being conducted by the Department of Sociology at Michigan State University. Source of Items The suggestion for many of the items used on the various indices came from the studies of mental hospitals already cited. An attempt was made to construct index items that seemed to represent common themes and findings across several studies. However, many of the items come from observations from this writer's experience in state mental hospitals over a period of ten years preceeding this study. This experience was as a director of nursingland nursing consultant. His total experience in nursing extends over a much longer time. It is probable, therefore, that his experience has greatly colored the selection of themes from the literature and the wording of items. The findings may reflect the results of this bias. The Ten Statements Test and the "What Should a ----- Do ?" Index are taken from the work of Kuhn and MacPartland1 and their students. These ¥ 1M. H. Kuhn and T. S. MacPartland, "An Em irical Investigation of Self-Attitudes," American Sociological Review, I9 I954) 1:68-76. See 26 instruments, especially the Ten Statements Test, have received attention in the sociological literature. These two indices were used in an attempt to explore a relationship between role perception 'and role expectation. The instruments were pre-tested on a very limited stratified sample (35 persons) of another state hospital. The sample included all role types. As each person completed the questionnaire the writer questioned each respondant con- cerning the clarity of items and instructions. No one expressed having any difficulty except with the semantic differential items. As a result of this informa- tion, additional instruction was given to the research population concerning these items in an attempt to assist the respondants to complete these indices. Data Needed to Test the Hypotheses Method of Collecting the Data The data were collected by questionnaire. Five hundred and thirty-six questionnaires were administered. This represented the total nursing staff except also the Manual for the Twenty - Statements Problem. Research Department. The Greater Kansas City Mental Health Foundation, Kansas City, Mo. (Ditto) Rev. January, I959. 2For example, see C. J. Couch, "Family Role-Specialization and Self- Attitudes in Children," The Sociological Quarterly 3 (I962) 2:II5-2I and F. B. Waisanen, " Some Correlates of Student Role," Paper read at the Ohio Valley Sociological Meetings at Michigan State University, March, I96I . Cf. J.F.T. Bugental and S. L. Zelen, "Investigation into the"self concept": The W-A-Y Technique," Journal of Personality, I8 (I950) 4:483-98. 27 for eleven persons. Of this group, eight attendants and two licensed practical nurses were on leaves of absence for long term illness and similar reasons. There was only one refusal. Of the questionnaires administered a total of four hundred and seventy-nine were considered usable. An examination of the non-usable* revealed that this sub-population so closely resembled the total population that for purposes of this study the universe can be considered to be complete (see Appendix F). Method of Administering the Questionnaire In administering the questionnaire, the following introductory remarks were used: This is a study to gather information in an attempt to improve patient care by improving nursing care. It was designed at Michigan State University and all the information will be kept confidential by the sociology department of that university. In attempting to improve patient care there are several approaches that might be used. One of these would be to ask experts in the field how best to do this. Another means is to go to the peOple who are doing the work and gather and pool the vast amount of knowledge they have so as to make it useful to everyone. This is what the study you are participating in is trying to do. Everyone who answers the questionnaire is very important to the study. This is not a test -- but a questionnaire designed to gather information. Every answer is a correct one; therefore, in this instance everyone has 0 "I00%" . This questionnaire and the means of handling the data has been so designed as to conceal the identity and preserve the anonymity of each person filling in the questionnaire. The anonymity of each person participating in the study is absolutely guaranteed. *The decision for rejecting the use of a questionnaire was based on whether maior gaps in responses occurred in the indices or in social information. Most of e gaps occurred in faulty completion of the semantic differential section or in fuilure to complete the social information section. 28 The questionnaire was administered in groups ranging from two to twenty persons. The average group was 8 to I0 persons. It was administered during their working hours. All the questionnaires were administered by the investigator, except for a very small number (I I) which were administered Ly two registered nurses who had been trained by the investigator. During the administration of the questionnaire, the investigator remained with each group through the time nec- essary to respond to the instrument. During this time, he was available to any respondent who desired clarification of any of the items on the instrument. In the process of administration, three minutes were allowed for the "Who Am I?" question and two minutes a piece were allowed for each "What Should A ------- Do?" question. These questions were preceded by a brief explan- atory statement about the question. The remainder of the questionnaire was untimed but respondents were encouraged to answer as rapidly as possible. The respondents were divided into three major classifications -- registered nurses, licensed practical nurses, and attendant nurses. The registered nurses were further divided into nurses with college degrees* and nurses without a col- lege degree. The attendant nurses were divided by type of supervision. Those supervised closely by registered nurses were placed in one category and those supervised by an attendant nurse supervisor were placed in another. Closeness is here defined as having a registered nurse as the head nurse_on the ward unit and not a general, loose type of supervision. Likewise, closeness of supervision *In this group of twelve nurses, four held a baccalaureate degree and eight held a Master's degree. Of the nurses without degrees, thirty-six came from diploma programs (hospital schools of nursing) and seven came from associate degree (junior college) programs (see Tables 27 and 3] , Appendix A). 29 by attendant supervisors is defined as having an attendant as the charge attendant on the ward or unit. This type of division enabled a comparison of attendants who could observe the behavior of a professional "role model" as a supervisor against those attendants who did not have this behavioral model. Thus it was possible to compare some effect of the social structure upon the perceptions of the attendant as well as the effect of the training. In order to make the text less cumbersome, the different role types of nursing personnel under study will have the following designations: I. Registered nurses with college degrees will be called Type I Nurses. 2. Registered nurses without college degrees will be called Type II Nurses. 3. Attendants closely supervised by registered nurses will be called Type I Attendants. 4. Attendants closely supervised by other attendants will he called Type II Attendants. Except for race, the entire attendant population had characteristics similar to a national composite of attendants revealed by a recent study. 3 The popula- tion, for attendants in general, approaches a 2:I ratio of Negroes over whites. In the Type II attendant group, the ratio increases to almost 3:I . In the national sample, only I8.6% of attendants were classified as Negro. In contrasting this ratio with the professional nurse group, one finds a ratio of roughly I3:I of white over Negro . a__Highlights from Survey_o_f Psychiatric Aides, Manpower Studies Unit, Training and Manpower Resources Branch, National Institute of Mental Health, U. S. Department of Health, Education and Welfare, Public Health Service Publication No. II5I, April, I964. 30 The entire attendant population is relatively young with only twenty-five percent of the universe being over forty years of age. The sex characteristic is almost identical with the findings of the national survey. Forty-two percent of the population is male. Seven of the fifty-five registered nurses are male. This departs somewhat from the usual complete femaleness of this group. A pre- ponderance (65%) of the attendant respondents were married. In education this universe again tends to resemble the national pattern. Sixty-seven percent of the attendants had completed high school* or had attained some high school education. Like the findings at the national level, most attendants had a work history of semi-skilled jobs in various occupations previous to their employment by the hospital. The religious preference of the population was eighty percent Protestant . * * In order to assess the effects of work shift and of race4 on the respondents, both of these variables were run against the data. No significant differences 1"48% completed high school, I9% attained some high school. ** Descriptive data, in a more complete form, are contained in the tables in Appendix A. 4Although no significant differences because of race were found in this data, it would be unwise to rule out race as a variable. It is more likely that the instruments were not sensitive to the effect of the attitudes produced by racial differences. The whole notion of socioeconomic class, community expe- rience, access to resources, and other social factors influencing life style have an effect on attitudes. The entire area of non-work activity of the various nursing role-types might be explored with fruitfulness. Etzioni suggest aspirations and outside linkages are not deposited at the doors of mental hospitals as each actor assumes his work role. He states: 3I differences in the data were demonstrated for either of these variables. Therefore, no further references will be made to either. Method of Statistical Analysis The data were treated by using the Kruskal -Wallis one-way analysis of variance by ranks Sigel5 states: The Kruskal-Wallis technique tests the null hypothesis that the k samples come from the same population or from identical popula- tions with respect to averages. The test assumes that the variable under study has an underlying continuous distribution. It requires at least ordinal measurement of that variable.* Tate and Clleland6 in commenting on the usefulness and power of the test make the following observation: It is the best nonparametric test available for detecting significant differences among sample averages. It appears to be about equal It seems now that other primary groups -- such as families, neighbors, and so forth -- have much influence on the aspirations and attitudes of the actors in organizational contexts. A fuller understanding of aspirations and attitudes will be achieved only when the communities are taken into account. Reference groups constitute a strong orientation to behavior. If some of the con- flict in nursing has its roots in reference group linkages, then an examination of this area may yield greater insight into its causes. For a fuller account of this notion, see Etzioni,"lnterpersonal and Structural Factors in the Study of Mental Hospitals." Psychiatty 23 (I960) I:I3-2I. 55. Sigel, Nonparametric Statistics, New York, McGraw-Hill, I956, pp. I84-85. * In the tables to follow, the Kruskal-Wallis H statistic has been used for the test of significance under the assumption of ordinality in Likert-type measures. 6M. E. Tate and R. C. Clleland, Nonparametric and Shortcut Statistics, Danville, Illinois, Interstate Printers and Publisher, (I957), p. I09. 32 in power to the normalized-rank mdhod proposed by Fisher and Yates and at least 90 percent as powerful as the F test for differences among means of samples for normal, equally variable populations. Hypotheses for this Study It is assumed that specific occupational training has a major influence on the selective attention given to perceptual cues occurring in the work environ- ment. It is posited that differences in training will result in the occurrence of significantly different perceptual processes in the same work milieu. It is further posited that there will be a lack of congruence of perceptions between role types with the most training and those with the least training. Therefore, it is hypoth- esized: I. Perceptions of nursing care of patients will vary with training. In order to provide therapeutic nursing care of patients, it is assumed there should be general consensus about goals, means, and work tasks as these pertain to nursing care. It is further assumed there may be at least two broad, general areas of agreement regarding work performance -- those expectations embracing custodial and those embracing clinical activities. It is assumed further that the type and amount of training has a major influence on how custodial or how clin- ical the actors in the various role types perceive the task for which they have been trained. It is posited the custodial-clinical orientations will vary directly with the amount of formal training of the actor. It is posited further that these variations in clinical-custodial orientations by role types will result in a lack of 33 consensus about the goals. means, and work tasks in nursing. Therefore, it is hypothesized: 2. There will tend to be agreement about goals, means, and work tasks within role types according to training. 3. There will tend to be disagreement about goals, means, and work tasks between role types according to training. It is assumed that all strata of nursing groups are concerned with the finan- cial satisfactions obtained through employment in nursing. However, it is posited that a direct correlation exists between clinical orientation and professional satisfaction from the nursing job. It is further posited that nursing personnel who have a custodial orientation to nursing care will perceive, as primary, the finan- cial and tenure satisfactions of the job. Therefore, it is hypothesized: 4. Custodially oriented persons will tend to have extrinsic job orientations. 5. Clinically oriented persons will tend to have intrinsic job orientations. It is assumed that the empirical meaning of therapeutic nursing care is transmitted by the behavior of immediate superordinates in giving nursing care. These superordinates are highly visible "role models" ,* and tend to define nursing care by their actions. It is posited that the "role model" provided will be crucial to the development of the set of expectations for the roles involved in nursing care. As an extension of this assumption, it is posited further that attendants working under the "role model" provided by the close supervision of professional * " Role model" is defined as the behavior exhibited by persons having direct and continuous power in the work setting of the actor by the supervision and 34 nurses will have different expectations of nursing care than will attendants work- ing under the "role model" provided by attendant supervisors. Therefore, it is hypothesized: 6. Subordinates supervised by registered nurses will tend to have orienta- tions that registered nurses in general hold. 7. Subordinates supervised by attendants will tend to have orientations that attendant supervisors in general hold. It is Posited the longer an actor remains in an organization the more likely he is to conform to the rules and regulations governing the hospital and the less likely he will be to identify with professional goals. Therefore, it is hypoth- esized: 8. The longer the employment the greater the tendency towards custodial orientations about goals, means, and work tasks. Basic to the theory of symbolic interaction is the notion of the ability to share the perspectives of the generalized other. It is assumed if there is to be integration of role expectations with relevant others, there must be a common orientation to these role expectations. It is Posited that differences in training will lead to dissensus concerning role definitions in the work milieu. It is posited further that the lack of consensus as to roles will also create a state of dissensus in role expectations and these role expectations will vary with training. There- \ fore, it is hypothesized: leadership they provide. ' It is assumed that imagery is important in giving orientation to behavior. 35 9. There will tend to be agreement about role expectations within role types according to training. I0. There will tend to be disagreement about role expectations between role types according to training. It is posited that actors having high identification with the nursing role will demonstrate this saliency by showing an awareness of the clinical possibil- ities of giving patient care. It is posited further that actors with low identifica- tion will have little motivation to therapeutic care and will tend to ignore the clinical possibilities of care. Therefore, it is hypothesized: II. Nursing personnel who write salient nursing role statements in "Who Am I?" also will write primarily clinical nursing statements for their own role type in "What does a ------ do ?" . I2. Nursing personnel who do not write salient nursing role statements in "Who Am I?" also will not write primarily clinical nursing statements for their own role type in "What does a ------ do ?" . W“, l‘—'—‘ f—fi" v L..f~_.__ -n ._—.— ( fi—wfi .1 \I , CHAPTER 4 RESULTS OF DIFFERENCES IN CUSTODIAL-CLINICAL PERCEPTIONS AMONG NURSE ROLE TYPES The Pattern of Differences among Groups The three indices designed to measure perceptions of goals and means of patient care all showed a similar order of direction. It was expected that no "pure" types would be found, but elements of both orientations would be observed in all role types. The outcome in orientation for each role type will be largely dependent on the selective attention influenced by the type of training. * Nurses with college degrees had the most clinical orientation. Attendants, who had no professional role model, were the most custodial in their orientation. The order from clinical to custodial perceptions of patient care was arrayed in this fashion: (I) registered nurses with college degrees; (2) registered nurses without college degrees; (3) licensed practical nurses; (4) attendants supervised by registered nurses; (5) attendants supervised by other attendants. The indices had minor exceptions to this order. The most prominent of these exceptions to the order of the pattern is that of the Work Tasks Index. On this index the nurses without degrees scored higher on the clinical end than nurses with degrees, and attendants supervised by * For a suggested custodial-clinical typology, see Appendix B 36 37 nurses scored higher than practical nurses. However, the few exceptions to the straight order appear to be anomalies rather than a disruption of the pattern. HYPOTHESIS I: PERCEPTIONS OF NURSING CARE WILL VARY WITH TRAINING. Findings and Discussion It is posited that if various kinds of training and work experience with that training develop different selective perceptions of the work world applicable to that training, then nursing personnel with different types of training will perceive the nursing care of patients differently. Specifically, it is hypothesized that the more varied the preparation of the various role types on the nursing staff, the greater will be the discrepancy in the perceptions of the nursing care of patients. In order to test this hypothesis, the observed scores of each of the different role types were examined to ascertain where the greatest percentage of observed scores clustered on the continuum. The continuum runs I to I0, with I represent- ing the custodial end of the continuum and I0 representing the clinical end. The percentages of the observed scores were categorized as to whether they feel into a high, medium, or low range of clinical orientation. In this way, the tendency of each group to have orientations in either direction was examined. The degree to which observed scores were spread gives a strong suggestion of the perceptions of the various groups. For the most part, Type I nurses cluster in a narrow range on the clinical end of the continuum. All others, especially the attendants, have much more diffuse orientations ranging from the highly custodial to the highly v "' \c" ‘,/._._-————- -I‘Hr"; 'MF .- w]— 38 clinical. The utilization of this analytic tactic reveals a suggestive pattern. For example, on the Custodial-clinical Perceptions of Patient Care Index the observed scores show a graded shift by groups from the clinical to the custodial end of the index (see Table I, p. 39). This index was designed to explore the perceptions of the process of giving nursing care and the organization of that process. More than any other, this index demonstrated the most pronounced difference between Type I nurses and the entire remainder of the nursing staff. Fifty-seven percent of the observed scores of this group of nurses (Type I) falls on the highest clinical end of the index. Type II attendants composed the group with the lowest clinical orientation. Seventeen percent of the observed scores of this group were on the clinical end. Polarization between the two groups occurred to a greater degree than on any other index. In fact, for twenty-nine percent of the Type II attendants, the index did not discriminate how custodially oriented they actually may be. * They received the most extreme score on the index and some presumably could have attained a more custodial score. The Perceptions of Ward Milieu Index attempted to explore the perceptions for the hospital ward environment and its effect on patient care. There is a tend- ency to perceptions of increased restriction and of less permissiveness as the ob- served scores of the role types are examined in the previously noted order (see Table 2, p. 4I). The role types which are the largest numerically in the popula- tion demonstrate a greater propensity to lack of permissiveness. This means that *As with most indices these instruments polarize but do not discriminate finally at the extremes. Where nursing groups cluster at the extremes, there is no way of knowing how much more clinical or how much more custodial that particular group might be if a more discriminating instrument had been devised. en :. $34" _z :s as E; 8. X: x: S. «2 EN .23 Sc 39 ES 8 2 _ 2 _ an E .N 3 .N 0.20222. __ 25 9 :3 83 $9 3 E R 8 S om .N mm .N meagre. _ 85 3e :3 a: m 0— .V 5 cod and mamSZ _autuoi panama: ac as as D D 6 mg NNN 36. NRSZ __ max... A5 8i 3 n: . . mung: m N m m..o N. S N «N... m e z _ .F 2-0 :9: we .32 v N; 33 IL $8 .3 :82 coto._ca_..O .._oo_c:U.. h_o 00.600 aaNh 0—0”. m sonaU Eaton— mo meow—dogma. _oumc__UI_o_pot:U o._. p.233. ad. £01 *0 09:. . — 036.— \I .333 :o ..o: 203:3: no 1332306 up :3, no. m . _— .9_:o: U_o mocoto> co mix—6:0 xaBIo:o a___o>>r_0v_m2v_ 9: 3.35:” 0* 33 on :3, I .0 5:33:33 353 .3 3.: >391. rcopceto So 3:33:23. : max... .0 .333: “3333.. .3 pofltooom 3:26:33 Bo ficopcmt< _ max... .m .3293 emu—_ou Soft; 33:: “333mm: 90 3mSZ __ 39¢ . N .momcmop emu—_Ou its 3.9.5: 33339.2 90 3mSZ _ was; .0 3.03:5: 3.0;; 3.93: of 2 to popcooc :03 no... Emucom .om:o: has. 25 05:0..— eab 20.. of mo £:o_u:0n_3: or: *0 E33: 9.: 23:35 933—0 :25 A v :_ 33:3: 0;... .m ..33 33o> o_ou... co 39:0: of whoflpfi 933—0 :3, mm :_ 33:3: 9:. .v 6:02:33: 9: 3.6 35236 90:: of amco: of 326. of .3233ch of So _ou_::u 90:: of 390: 9: 359; mi .m .m:otaou3a 9+— 08 35230 9.0.: of :35 9: mo a:_o> 9: 3:06» of 8:02.383 of Ba _ou_:__o 90.: 9.: :35. of co 033 or: 390— 9: .N .336... .6595 of 50¢ :32 0.6 :o:a_>mp .2352... 9.: pco :35 9:. .— .332 :o Soc—moot: szcotca be»: 3 E? 33.2 of :_ 3:930 comb o>as 3E3 >6..— ahaumpcm oh mcotcm>cou EatoU k. 32:86 I. _ s33 _o.Vn_ vu:n m2 .2 u I A5 89 Ave 8. 8. of K... a; on .m iv 89 39 E 3. 8. 9% mm; 2.6 aa 39 39 M 2 3. E. S _m.~ 36 as 63. as o 2 N _m 8; 8.... as A3 A: D cm 0 a. B; 8.0 :3 any 3 w v o S 8. 8.0 07m :9: W06»: 2 33 ..m 58 ..2m :82 :o:2:otO .._oo_::U.. mo 00..me .96... ficovcotd. = 09¢ 2:03:22. _oaxh 3232 30209.. .3330: 3952 : max.— 3332 _ max» max... £3. 33:2 «:03 *0 335003; _oum:__U|_o_vot.DU o.— va—om n< 0.0m “_0 09¢. .N 033. 42 most patients are under the immediate supervision of persons who perceive the most restriction to the daily living activities of patients. The first deviation in the pattern of perceptions occurs in the data associated with the Custodial-clinical Perceptions of Work Tasks Index. Here the findings show that the Type II nurses hold a more clinical perception, as measured by this index, than do the nurses of Type I (see Table 3, p. 43). This index tries to ex- plore the social-psychological appraisal of the work tasks, work activity, and the immediate decision-making process about that activity. One possible explana- tion for the Type ll nurses receiving more clinical scores on this index comes out of the literature of the. studies on the nursing profession. This literature stresses the taskorientation of diploma nurses. If the findings of these studies are valid, it may be the case that due to their concern over work tasks, the non-degree nurses may have more insight into the effect of these activities on the patients them- selves. Since it is usually Type II nurses who closely supervise the Type I attend- ants, there may be some "spill-over" of this concern on this group of attendants also. Differing Perceptions of Registered Nurses The index designed to measure technical versus professional perspectives of nursing was administered to the registered nurse group only. The attempt here is to try to explore whether the nursing process is perceived as a technical, hand- skill, stereotyped activity or if nursing is seen as a process based on scientific knowledge in which professional education has a high value. Or to put it another way, it endeavors to ascertain whether nursing is seen as hands rather than head, and a generalized worker not trained for anything specific as opposed to a worker mo.Vn_ 0n.0 «00.0. n I as .00. .8. mm. Q0. 00. $0. 3 .N a. .0 .22 .5 .00. 83 3 B. «0. 0mm 00 .N 00 .0 38000.2 _. a: an. .8. .0... 0. mm 8 .0 on .N E .0 2:00:22 _ 25 .09 an. a... 0 o. m. .m Ea 2.0 32:2 .8209... 0028: .3 .00. .8. 0. 0. o. 0.0 gm 8.0 .0.52 ._ a: .00. a... .3 v 0 0 N. 0.: 3.0 32:2 _ 85 SA. 00.: 0-0 .002 0-. :3 IL in. .05 :82 max.— 33. 9...: v15......0 20.3.8.0. 30.56.302.06 2 020.3. 2. 0.00. .o 8.: .m 0.02 44 using knowledge in a scientific fashion. On this index the observed scores of Type | nurses all fall on the professional end of the scale(see Table 4, p. 45). The index does not adquately discriminate at the professional end for fifty percent of this group. The professional perceptions of the degree nurses may greatly exceed the dimensions tapped by this index. When compared with Type I nurses, those in Type II show a much more diffuse and generalized orientation. Almost half (48%) of the observed scores of Type II nurses fall on the technical end. The statistics support a highly significant difference between the two groups. Based on the findings, there is some evidence to suggest the hypothesis predicting that perceptions will vary with training has some support. Not only is some support present, but it is in an order that was predicted. The more in- tense, prolonged and professional-like the training, the greater is the clinical orientation. It also is suggestive that limited training, without a "role model" to give meaning and direction to that training, appears to result in lesser clinical orientation and predisposition to act. HYPOTHESIS 2: THERE WILL TEND TO BE AGREEMENT ABOUT GOALS, MEANS, AND WORK TASKS WITHIN CLASSES ACCORDING TO TRAINING. HYPOTHESIS 3: THERE WILL TEND TO BE DISAGREEMENT ABOUT GOALS, MEANS, AND WORK TASKS BETWEEN CLASSES ACCORDING TO TRAINING. 45 .3 xoczs>>rcco<< of .6» Boom N of 03m 53 0.80... I «50349.30. of mo .09 90:9. 9:. .o_noomco.._o.3c_ So 338 D xoc:,._>>ucco<< or: tea I m:_o>>u_ov.ma._v_ 9:. i. .38... 2.: ”.0 tea 355303 9.: E9659. 39.0.. a_mE 6—03 of “.0 “Eu _ouEsuE 2.: E0359. mamcac Bo.— k. .8. v. .. wu.u :6. u I .3. AB .3 an m. a. _N no a: 26 .23 $5 Eu .3 o 0— 8 av oc.~ 3% 33:2 __ on: .3 as a m o N. am; 8K 3.52 . 2.: 24. .9: To .32 m; :3 z .25 .E :82 «corp—cato .._oco_3£o.n_= mo 9290 max.— 9.52 3232 8.0333. 3 0—0”. 932 35939; 2.; *0 302380.. 3:39.39... .. _ouEgooH— .w 030.— Findings and Discussion The findings are only mildly suggestive that the hypothesis predicting agree— ment within classes is supported. The variance within each group is quite high. The opportunity for interaction between groups may be one explanation of this variance. Turnover in staff may be another. There is some evidence that agree- ment exists within the Type I nurses more than within any of the other role types. However, in comparing the observed scores. by role types for all the indices, there is a definite pattern of agreement on all indices for each role type. It seems reasonable to assume that the pattern suggests a tendency towards agreement. The data for support of the hypothesis predicting disagreement between classes about goals, means, and work tasks is on much firmer ground. The means of the observed scores for all scales are arrayed in a consistent pattern which tends to document persistent disagreement about these objectives of patient care. The data suggests that each group is acting on different selective perceptions. As a result, there is a likelihood that low cohesion exists between groups in giving nursing care to patients. However, since the variance in most cases is quite high, the findings cannot be considered conclusive. HYPOTHESIS 4: CUSTODIALLY ORIENTED PERSONS WILL TEND TO HAVE EXTRINSIC JOB ORIENTATIONS. HYPOTHESIS 5: CLINICALLY ORIENTED PERSONS WILL TEND TO HAVE INTRINSIC JOB ORIENTATIONS. 47 Findings and Discussion It is assumed that almost everyone needs to feel iob security and to feel adequately remunerated as well. However. in the case of clinically oriented persons it is posited that satisfaction will be enhanced by a feeling of professional satisfaction in addition to monetary values. On the other hand, it is posited that custodically oriented persons will obtain their primary satisfaction in job security, iob income, and personal goals other than professional satisfaction. The value the different nursing groups place on the professional (intrinsic) satisfactions of the job as compared to the salary and job tenure (extrinsic) satisfa- tions closely follows the pattern unfolded by the observed scores of the previous indices (see Table 5, p. 48). As might be expected, the highly career-oriented nurses -- the Type I nurses -- exhibited a heavy grouping of observed scores (56%) on the most intrinsic end of the scale. The licensed practical nurses evinced a tapering off of this high intrinsic value and displayed an equal compilation of observed scores in the middle range of the scale as at the intrinsic end. The ob- served scores of the attendants are the obverse of those found for the nurses. Both attendant role types gravitate toward the extrinsic end. Type | attendants show a slightly higher tendency to extrinsic perceptions than do Type II attendants, but this difference is minimal. The correlation between high clinical and high intrinsic and between high extrinsic and low clinical scores seems to fit too closely into the regularity of the pattern already observed to have occurred by chance. The nursing groups with the highest clinical scores would also seem to have the most professional satisfa- tion. Conversely the close relationship between low clinical and high extrinsic .0_OUm Gr: n—O UGO Ummcmhthm of £399.... 39.9 :9; 6.8... or: “_o 3.6 33238 of 20359 39.0.. 33 .. .8. V .. vu.w show u z 8. 3.. 3. a... 3d 2. .8. SN. .3. we 3 9.. am a. .N a... as am. .3. K. a. .m 3 and R... an. an. as a. N. N .m mg E6 .8. an. a: E I m a. 5... mm... .8. ..va a. K .. . N. 8.. 0.. o.-. .9: E .32 m.-. 30.. fl 5.5 .2” 822 scota.cotO ..u_mc_.;c_= go @0500 _o.o.P flcapcotd‘ : max... m.co_uco.._< _ mg: 3332 _outuoi panama... 82:2 __ max... 3232 _ 09¢ 09:. 0—0”. 0—0”. 9.52 ..O acotaouam 2335 I o_mEtxm 0.— p220”— m< 33. ..O max.— .m min... 49 suggests that role types with this combination of scores would not place as much emphasis on professional satisfactions. These findings might be the reflection of a "life style'I of broader general characteristics- When persons occupying posi- tions in a work organization have intense training for that position the role expectations probably vary greatly from those of persons occupying similar posi- tions who are prepared in a much less intense fashion. The notion of reference groups as well as that of selective attention would seem to reinforce the tendency to have differing role expectations. In this case nurses may tend to take their cues about professional satisfactions from their professional organization, while attendants may be heavily influenced in this area by union membership. The different focus of these reference organizations give further coloration to the perceptual process. The data on attendants are not startling and should be expected. If it is at all revealing, it may reflect the same orientation that semi-skilled workers probably have to any iob or occupation in which semi-skilled workers are found. Since attendants are recruited primarily from semi-skilled occupations, they may carry this value orientation with them to the mental hospital (see Table 23 in Appendix A). Further support to the notion that these three main groups of nursing personnel represent different occupations is supplied by these data. Rather Than a single generalized occupation of nursing, these three main groups are highly distinct and separate occupations concerned with the care of patients (See Table 6, p. 50). 50 Nos“~ N_é mN.m mu; mN.— m.m— m o— m.— N n v m m N — m m v _ N n .v m .V m N — n v m N _ “€09.22. 3.89.2.4. 32:2 _outuoi 33:2 __ 09¢. $952 _ cab. __ 09A.— _ max.— pounce: .020 xcom coo<< mxcox .0 Sam o_om 9.52 .0 3338.0“. ummcvchutcExM 97.0.— pco>> .o mcotaoucum _oo_c__ur_o:uot.au 32:2 20>) *0 30:30.0; _ou_c_ _ur _o_potau ocoU Eaton. mo «cotooumi _ou_c__ur _o_potau mob. xopE 339.0 :< .0“. mou_pc_ .50". c0 «:32 .0 xcom .0 033 51 From the findings gathered by the administration of this index, it seems appropriate to assume that both hypothesis predicting the direction of extrinsic i: and intrinsic perceptions of the nurse role are supported. HYPOTHESIS 6: SUBORDINATES SUPERVISED BY REGISTERED NURSES WILL TEND TO HAVE ORIENTATIONS THAT REGISTERED NURSES IN GENERAL HOLD. HYPOTHESIS 7: SUBORDINATES SUPERVISED BY ATTENDANTS WILL TEND TO HAVE ORIENTATIONS THAT ATTENDANT SUPERVISORS IN GENERAL HOLD. findinggnd Discussion: The Nurse as a "Role Model" On all the indices the observed scores of Type I attendants tended to be closer to the observed scores of Type II attendants than to those of registered nurses. Therefore, it is apparent that this hypothesis is not supported by the 1lThe Extrinsic-intrinsic Index was found to be significant when run against other variables such as age and race. The attendants in the older age groups demonstrate a strong tendency to emphasize iob tenure leanings. Attendants in the younger age groups are more interested in the job itself. Whites tend to look upon the attendant iob with the "extrinsic" values accentuated -- that is, iob tenure and steady salary. Negroes on the other hand, tend to place a heavier emphasis on the "intrinsic" components of the attendant. position. For Negroes the position of attendant probably rates higher on the scale of iob aspirations while for whites this job may rate well down on this same scale. Because data related to these variables was unobtainable, no further analysis was made. n. . -“ __.__. ..q..__ -. 52 data. Although on most indices Type I were slightly more clinical in their orienta- tion than the Type II attendants the difference does not appear to be sufficient to warrant any other decision. The slight modification of perceptions does seem suggestive. Would this modification have been greater if more than one registered nurse had been on the ward interacting with patients and attendants? When only one nurse is assigned to a word, it means that for at least two days a week there is no professional nurse supervision. When the days off for the attendant staff are prorated, it means that an attendant may have as few as three days a week when he is supervised by a professional nurse. This would greatly reduce the interaction time. Such limited interaction may not be sufficiently conducive to the develop- ment of perceptions which would stimulate attention on therapeutic activities. Further reduced effect of this kind of "role-model" activity may occur because of normative values of peers in the attendant group. The clinical activities of the nurse may not be producing corresponding clinical perceptions in the attendant with enough cumulative force to modify the "frozen" expectations resulting from the position and training of the attendant. When peer expectations are coupled with the demands of the bureaucratic structure, clinical practice may have a very ephemeral value . The Attendant Supervisor as a " Role Model . " In order to provide data to test the hypothesis predicting that subordinates supervised by attendants will tend to have the orientations that attendant super- visors in general hold, that block of attendants was separated into two divisions. ]This tendency among professional nurses also has been noted by Mauksch. He states bureaucratic pressures usually always win out over the clinical pressures raised by patients. See Mauksch, op. cit. 53 One section contained all the attendant supervisors, the other that of all the supervisees. Both sections were then run against the three indices measuring custodial versus clinical perceptions. The findings, although not completely definitive, are in the predicted direction. For two out of the three indices the Kruskal-Wallis test fails to reiect the null hypothesis that both groups are from the same population (see Tables 7, 8, and 9, pp. 54-56). The data obtained from the index tapping the clin- ical and custodial perceptions of patient care turns out to be significant at p <.Ol level. A possible explanation for this index demonstrating a significant difference can be obtained by examining the role of the attendant supervisor. The attendant supervisors have considerable opportunity to interact with the professional staff of the hospital. This includes professionals from other dis- ciplines as well as professional nurses. All must contact the attendant supervisor when discussing patient care activities on words supervised by attendants. The attendant supervisors have a greater opportunity than other attendants to be ex- posed to the clinical discussions of the professional staff. The attendant super- visors usually attend more of the clinical conferences where patients are diagnosed . and their therapy program outlined. It may be the case that this interaction pattern acts as a form of "in-service education" for the supervisors and may account for the . O O O O * Increase In observations on the CllnlCOl end of the scale. * A somewhat harsher interpretation might be that attendant supervisors have acquired the appropriate clinical vocabulary but not the clinical meaning the words are used to portray. Therefore, they are not able to demonstrate a form of clinical leadership that would modify the attitudes of the attendants they supervise. 54 _o.Vm _o.o._. .1.u .85. u I E. a... 89. ..m ..m. 8 ..m Ra Rd .8. a... .3 m... E. K 8N k. .N m: .5 .3 .E .m 9. .1 3 ..S . N: o.-n .2: .1 8.2 . 33 H .35 .3 282 cotohcotO _._oo_:__U.. u_o mocmoo reoccotd. : our. 9.9; Zoos... 2.09.32. max... Eoccotxx reoccotd‘ xm Sou Eaton *0 302.339. 15.36 i _o_potou K 053 55 :91: om. V m .u ..o «8.. u I #3 an. .5 2 8. 2. ..m 3.. an .20. .8. 8m. 39 on 8 .m 0% 5.. mm .m .2. a... 2... o. ..m mm 3 8.. .o.m 2-.. ..m... We .32 T. .53 IL in. .2m :82 cozoEotO 1007.29. .0 00.90 3:09.23. __ 09$. Sofliooom Eo—ocot< 09$. 201:2}. Q 35232 3 33...... .22... .o 20.38.... .82.... - 3.8.3 .m 0...... .m.: on. Va. 56 vu.v 8n. n I am. as .5 so; 8. 8 2. ..m 2. .N as .v :20. em. .3. a... R on 8 cum 85 oo ... N 35.82.... __ 8;. an. an. .8. an R 8 mm .2 «N .m . 29.33% 20.522 l l l l [Pl l 2-.. r_m... Wm .32 .7. 25. z 5.5 .3 53.2 .220 .cog cotoEotO _._oo_c:U.. No @0500 9.9.0 3:03:23. xm 870... 4.03 .0 acotooocom _ouwczu .. _o_potau .9 £30.— . _ -.._,.__._.- .-—. . 57 Therapeutic ward milieu is a very subtle notion. To develop this form of milieu requires considerable skill. A knowledge of behavioral science and an ability to perceptively apply that knowledge is essential in creating a therapeutic milieu . This demands an ability to conceptualize and to translate the concepts into action. This skill may not be obtained easily through the process of inter- acting with staff. If this is the case, it may explain why the attendant supervisors closely reflect the attitude towards milieu that their attendant colleagues share. Without a constant professional staff on the wards, the milieu would have to be deveIOped according to the perceptions of the attendants staffing the unit. Through their daily interaction with each other, they have developed a consensus about the work environment. It also may be the case that attendant supervisors interpret control and the ability to manipulate as a form of professionalism. If ”‘35 then is the case, they may be reluctant to accept an orientation that would “Use them to surrender much of this manipulative control. That attendants are alike on two indices tends to give some further limited support to the basic theoretical notions of this design. Since they are trained Similarly, there should exist a high degree of congruity in how they perceive the World of work. HYPOTHESIS 8: THE LONGER THE EMPLOYMENT, THE GREATER THE TENDENCY TOWARDS CUSTODIAL ORIENTATIONS ABOUT GOALS, MEANS, AND WORK. TASKS. I r 58 The Influence of Time on Perception The testing of this hypothesis proved to be very difficult from the data available: It is reasonable to assume that the findings partly reflect difficulties in measurement rather than the truth of the null hypothesis. Type II attendants constituted the largest numberically of the role types. The length of service of the respondents in this group were run against the various scales. No significant differences were obtainable. The same procedure was repeated but with all respondents included. No control was established against the interplay of the various role types. The results showed no significant differences for length of serVice except to suggest a trend. Entering nursing personnel show a higher clil’fical direction to their perceptions than do employees of longer service. The long term career employees show the next highest clinical orientation. The respondents with six to eight years of employment represent the largest (I76) bleak of employees. The data is somewhat suggestive that this time-group has the least clinical orientation. If the actors in this large group tend to remain In the employ of the hospital they eventually may become the prime norm bearers dUe to both size and length of service. If it is desirable to reduce conflict in the orientations to patient care, then an analysis in greater depth of the causes for the d”ference between this group and the entering and career groups will have to be Undertaken to obtain greater insight into the causes of the conflict. Either train- ”‘9 or social structure or both may need maior revisions. CHAPTER 5 ROLE EXPECTATIONS In order to obtain an increased amount of data about the selective percep- tual processes of each role type, measurements of the expectations for others as well as for self were included in the design. It was assumed that data of this kind would give additional insight into the nature of the perceptual screens of each of the role types. The perceptual and cognitive processes by which the actor defines the social situation are highly indicative of his predisposition to act in that situa- tion. If, however, the several sets of actors are defining the situation such that the expectations held for each other are not being met, then social integration and cooperation occur only in a haphazard fashion. For agreement and social cooperation to be maintained, a method of obtain- ing consensus must be built into the social structure. The human individual is born into society characterized by symbolic interactionI and in which consensus is built through symbolic interaction. Consensus refers to the sharing of a common definition of the situation by persons of diverse backgrounds. Since they face a common situation together, they are able to anticipate things together. Con- sensus is rarely complete, even for relatively simple exchanges. Invariably there 1B. N. Meltzer, The Social Psychology of George Herbert Mead, Kalamazoo, Division of Field Services, Western —Michigan University, I959, p.25. 59 60 is uncertainty, and much interchange occurs around this partial consensus. Through role-taking (in Mead‘s sense) one learns to share the perspective of others as well as the capacity to act toward self. Viewing oneself from the perspective of the generalized other implies defining one's behavior in. terms of the expectations of others. For the role under study a barrier is raised to the role-taking process. Positions are tightly stratified according to type of training. Blocked mobility and a tendency to prevent any intrusion into a perceived work area by other groups leads to the development: of a tight status hierarchy that reinforces the stratification system. With these structural impediments present, the opportunity to develop consensus through role-taking is greatly reduced. Instead different selective perceptions are operating for each role type. This set of conditions suggests there would tend to be agree- ment about role expectations within each group of this tightly stratified system.* However the Iikel ihood of agreement about these same role expectations between groups is not very high. HYPOTHESIS 9: THERE WILL TEND TO BE AGREEMENT ABOUT ROLE EXPECTATIONS WITHIN ROLE TYPES ACCORDING TO TRAINING. * Labor unions are becoming increasingly active in hospitals. In their own way, they give added impetus to this boundary maintenance phenomena. By their insistance on rigid iob descriptions and other such actions, there is a tend- ency to split the professional and the non-professional further apart. In addition, the tendency of civil service commissions to write tight and restricting job descriptions appears to foster bureaucratic rigidity. The actions of both groups seem to reinforce stratification patterns and to act as barriers to innovation and effective use of personnel. 6T HYPOTHESIS IO; THERE WILL TEND TO BE DISAGREE- MENT ABOUT ROLE EXPECTATIONS BETWEEN ROLE TYPES ACCORDING TO TRAINING. Role TyLe and Clinical Expectations An analysis of the What Should a ----- -- Do? Index gives further credence to the order of the pattern created by the data from the scales already discussed. Type I nurses perceive both themselves and the other nursing role types as being clinically’l oriented and expected to behave in a clinical fashion with patients. Patient centered care would be a central concern of this group. This clinical expectation has a different pattern from that of Type II nurses. The non-degree nurses attribute a (I) clinical expectation primarily to registered nurses with (2) less clinical expectations to the licensed practical nurse and (3) still less to attendants. The data shows that Type II nurses have a lesser clinical perception of attendants than do the attendants whom they supervise. Both Type II nurses and Type II attendants share a minimal clinical expectation for attendants (see Tables I0, II, and I2, pp. 62-64). The licensed practical nurses have higher clinical expectations for the other role types than do Type II nurses. Since practical nursing is a new and *In coding this section, a clinical response was any response that indicated an activity involving care of the patient. These statements of activity ranked from simple through more complex statements. i.e. (I) An attendant bathes patients, (2) Attendants give medications, (3) An attendant has good interper- sonal relations with patients, (4) An attendant helps disturbed patients. Usually the more complex therapeutic tasks were attributed to registered nurses. v \'~H '— -—‘_. - ”'— 62 eager vocation, it may account for the coloring of perceptions in this fashion. They may be inclined to wish to see all nursing personnel as "therapeutic" . It may be the case that the increasing awareness, among professional nurses’: of the inadequacy of diploma nursing programs causes some anxiety in the Type II nurses. 2 Hence they may have a desire to tighten control over their domain. H It also may be the case that non-degree nurses may be more defensive of their role because of their more cloistered form of education as compared to nurses with degrees who have had a more liberal education. On a broader dimension, the difference in clinical expectations between Type I and Type II nurses may represent a maior difference in life styles. It may be another form of the localit - cosmopolite notion advanced by Merton. Diploma nurses probably have a more parochial form. of life inthe hospital * , The American Nurses' Association is attempting to establish baccalaureate education as the basic educational preparation for professional nursing. 2Dustan attempted to assess the "goodness of fit" for persons in the three types of registered nurse training programs. She found that many had not chosen the program most appropriate to their career goals. See L. C. Dustan, . "Characteristics of Students in Three Types of Nursing Education Programs," Nursing Research I3 (I964) 2:159-66. ** The steady pressure which licensed practical nurses are exerting in their effort to upgrade themselves may be causing some of the defensiveness in the Type II nurses. In nursing there appears to be much more conflict between diploma nurses and practical nurses than between degree nurses and practical nurses. Frequently one hears diploma nurses make this type of statement, "The practical nurses are trying to take our jobs. " 3 . . R. K. Merton, Sacral Theory and SOCIOI Structure, Glencoe, Illinois, The Free Press, I957: PP! 387-420‘ \uol '- ' 63 based schools than do degree nurses who have experienced campus life. In addition, many more degree nurses appear to be active in the professional associa- tion and to occupy leadership positions in the profession. They also tend to belong to honorary societies and other associations which would permit the development of a more cosmopolitan view. The differences in training not only prepares these two role types differently for the actual practice of nursing but apparently gives im- petus to entirely different life styles. The difference in clinical expectations suggests that Type I nurses may be able to function more effectively on nursing teams than the Type II nurses, since they appear more predisposed to attribute clinical functions to others as well as themselves and thus are less possessive of clinical activities. One hunch might be that nurses without degrees may be more likely to assert their prerogatives in patient care by ascribing high status to themselves and lesser status to others. On the other hand, nurses with degrees may be more willing to assert their pre- rogatives through the application of scientific principles to patient care. An interesting contrast exists between role types within the attendant group- Type I attendants perceive higher clinical expectations for themselves than do those of Type II. They exactly reverse themselves as to the clinical expectations they hold for registered nurses. Why this pattern should exist is difficult to explain. In line with the theoretical notions of this study, Type I attendants should hold higher clinical expectations for nurses as well as attendants. Even though Type I attendants may possess a slightly more clinical orientation. because of the "role model" provided by registered nurses, they may not perceive this as an advantage. 64 Instead they may perceive themselves, in the manner suggested by Hughes4, as the persons doing the work and carrying the parasites on top. Type II attend- ants have about the same sporadic interaction with registered nurses as they do with the rest of the professional staff. They may attribute a degree of the same professional aura to nurses as they do to all professionals. This may result in some of the same clinical qualities being ascribed to nurses. Attendants working closely with nurses may be confusing quantitative with qualitative care of patients. That is, they may be aware that each day they seem to be just as busy and over-worked in caring for patients as are the registered nurses. What they may be missing, in this set of observations, is the qualitative difference in their respective interactions w ith patients. Since they may believe they are doing very similar activities with very dissimilar rewards, there may be much resentment over the reward system. Hence the tendency to de-emphasize the clinical expectations for nurses. Type II attendants, on the other hand, usually only observe the nurse in patient crisis of some sort. Nurses usually interact with this role type when they are called to the ward to assist with an unusual patient symptom of either a physical or emotional nature. One can speculate that in limited and specific interaction like this, a sort of "crises intervention" , may tend to promote a more clinical quality to the perceptions that Type II attendants'hold'for registered nurses (see Tables I0, II, ,and l2, pp. 65-67). 4 p. 52. E. C. Hughes, Men and Their Work, Glencoe, Illinois, The Free Press, 65 no. at... wu.n 8 ... u z .8.. .2. .2. .2. .2. .2. .. .. 0.. 8.. 8 8 8 8 n. 8 8 . . a. .N z 3.2 .8 .. .2. .8. .2. .2. .2. .2. 0.. 28822 88 8 3 2. 8 No 8 a. . 8 .N z __ 8... .8.. .8. .2. .8. .8. .8. .3. 0.. 3622.... S 2 n 2 m. o a 5.8 88 z .2... .8 .. .8. .8. .8 .. .m .. .o .. .o .. .8 8.52 .m m n o .. m m 8.. 8... 2 32.8... .328... .8.. .8. .3. .2. ..N. .2 .2. 0.. m... o. o n a v n m... 8.... z 8.52 _. 2... .8_. .8. .m. .8. .8. - - 0.. 2 m . m m o o .2. 8... z .352 _ 2... .20. o.-m |..I Im IN: I_- N $8 .5 So... comb—ocm rcmEosfi _oo_c:U .o 53:52 .22. mob. o_om mcmcomucm 25 352 .8222 ..< 28% .2; .o. ..3... 66 .8. VA— . u ... ..2 .8 ... 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N . c 8.. m... z 8202.0... .20. o.-n ....u M .NI |.- d .08 ....m 2.02 vocovcm £580.95 _ou_c__U ..o .3832 :28. 0...»... 20¢ 9:20ch ...... 0.52 00.2280”. < 20...... .2.... .2 0...... 68 Expectations for Work Organization The responses to "What Should a ------ do ?" Index were separated into three major categories for analysis. The clinical category mentioned above and an organization maintenance and affect orientation categories complete the three divisions. The organization maintenance categories consists of responses which have to do with the operation of the hospital bureaucracy. The statements made observations about the nature of the work organization and work environments. '1: Many of the observed responses mentioned routine bureaucratic tasks. Type II nurses, more than all other respondents, visualize more involvement for both attendants and licensed practical nurses in this area than do these groups themselves. Relatively speaking they do not perceive as deep an involvement in this area for registered nurses. Type I nurses are more disposed to seeing profes- sional nurses as having a primary responsibility in this area but attribute to other role types a nearly similar involvement. It may be the case the degree nurses perceive more clearly the manner by which bureaucracy can be used to effectively organize patient care (see Tables l3, l4, and 15, pp. 69-71). The licensed practical nurses, while holding some expectations that attend- ants and themselves have some obligation in this area, appear inclined to surrender the maior responsibility for this area to registered nurses. This expectation may be a by-product of their education. Practical nurses are carefully indoctrinated by * Responses in this category have characteristics similar to the following: (i) A nurse sees that the word is kept clean, (2) A nurse gives work assignments, (3) A nurse writes reports, (4) A nurse keeps top administration informed. 69 89V.— vu.0 .88... I .8.. ... .8. .... .3. .8. .2.. .... 8.. m 2 8 .0 .2 38 3.. 2... z .8.. ... ... .... .2. .8. ...... 0.. 08 m m 2 8 .2 8. 8.. 2... z .8.. .8. ...... .m. .2. .2.. .8. ... ... . . V m .8 8 2.. 8.. z .8 .. .... .... .-. .8. .8. .8. ... .m . . o . 2 2 a... 2.. z .8.. .-. .2. .3. .8. .2. .8. ... 8 o m 0 2 . 2 8.. 3.. z .8.. .-. .... .-. .8... .... .8. 0.0 2 o . o n N v 8.. 8.. z .2... 2A .... In. M |.. .8: $0.. .2. 5002 pogomocm 8:09.305 00:05:50.2 :0_.0N_:om.0 .0 .mmEDZ _0.0._. _20. 2:00:22. __0axh 2:00:22. .00.. 32:2 _00_ .005 00300..— mmmSz __ 00.... 82:2 _ 00x.— 09... 0.0M. 9.20.05 WOO Owl—DZ hCOmvcmt< C< U-DOr—m #0:; .m. 030» 70 50. 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IN- |.- d 500...; 2.0.2 pocopcm £520.06 00:20.52). :020N_:090 ..0 53:52 _o.0h 09¢. 33. @520?“ 25 0.52 32.2.... 00200.. < 20...... .2.... .3 0...... 71 .oo.V8_ ..u... .828 u I .82. .... .0. .8.. .88. .08. .8. ... .... 2 08 80 02 00. 80 08.. 80.. z .2... .8 .. .8. .0. .... .88. ..8. .08. ... 25.0022 088 0 2 08 0. 88. 8. 2.. 08.. z :0... .88.. .8. ... .88. .08. .08. .... 0.. 2.5.82... .0 . 0 2 2 88 . 2.. .8.. z .00... .82. .2. ... .2. .88. .8.. .2. 0.. .0202 .8 0 8 0 . 0 0 8.. 838 z .0250... 00200... .82. ... .8.. ...8. .3. .88. .2. ... 8.. 0 0 0 0 8. . 82. 2.8 2 .0202 __ 0.... .8.. .8. .8. .08. ...8. .08. .-. ... 8. . . 8 v 8 8 0.... 80.8 2 .0202 _ 0.... .2... 2.... fl .8”. .8; fl :8. $08 .28 2.0.2 002005 820.53% 00:23:32 :o..o~.:om.0 .0 .3832 .20.. 08.x.— 0_0~_ 97.50:... 808 02.2 020280.. 0. 0.8.8 .9... .2 0....0. 72 training to expect that all planning for nursing care will be done by registered nurses. * Attendants in general, and Type II in particular, attribute a much more reduced expectation of involvement in organization maintenance activities both to themselves and to the other role types. An analysis of the attendants' expecta- tion system, for both clinical and bureaucratic functions, suggests that attendants in general see the nursing role as a very restricted one on both of these dimensions. It probably means that they see the role with few if any alternatives to behavior. Type II attendants, isolated as they are from professional contact, appear to see the role for themselves in even more constricted components. If the role prescrip- tion is defined in such a narrow fashion, then the attendants may be perceiving attendant-patient interaction as controlled by these limited dimensions. This suggests the interaction may tend to be of a "stereotyped" nature such as that suggested by Goffman5 in his study of total institutions. Many observers have pointed out the cruciality of the attendant role in the care of patients. Each patient has prolonged daily contact with attendants. If the perceptions and expec- tations (noted by data of this study) constitute the predispositions to act of these same attendants, then patients are probably caught in an interaction net of dubious therapeutic value. * Legal overtones are present also. The nursing practice act states licensed practical nurses must always be supervised by registered nurses. The law holds professional nurses responsible for decisions about practice. 5Goffman, Asylums, op. cit. 73 The Affect Dimension of the Expectation System The third category of the scale is concerned with responses that reflect a type of generalized affect. This generalized affectlr is not necessarily specific to nursing but could apply to any daily life activity. However, for some respond- ents it may take on a high specificity for the nursing role.M The number of responses in this category for all groups is greatly reduced when compared with the number of responses in the other two categories. The statistics do not have the same degree of significance seen in the other dimensions of the expectation system. Therefore, no conclusions of any certainty can be stated (see Tables 16, 17, and 18, pp. 74-76). The licensed practical nurses, who made observations in this category, perceived a more affective state both for themselves and the other nursing role *** types. In contrast, Type I nurses have little or no expectations for either * Responses in this character were of this pattern: (I) A nurse is kind, (2) Be courteous, (3) A nurse works with others, (4) A nurse respects others. ** The findings from the semantic differential scales, although not usable in this study because they did not clearly discriminate, are highly suggestive of the concern about the expectations held for each other. The findings do suggest that the various groups are more concerned about their relationship with each other than with their relationships with patients. It may be the case that the state of unmet expectations, as suggested by the findings of the indices used in this study, focuses concern on the relationships between groups. *** It often has been noted that physicians frequently write orders for "Ten- der Loving Care'' for their patients; that faculty frequently request nursing students and nurse supervisors frequently suggest to staff that "T. L. C." be give to patients. However, this usually is done without anyone defining iust what is means by T. L. C. Everyone appears to be decoding it to mean whatever the 74 .8.: mm. V n. .6... 888.8" I .88.. S .8. E .8.. .8.. .88. .8 88.. .88 8. 88 88 ..8 888 8... 8... z .88.. .8. .8. .8. .8.. .8.. .88. .8. 888 88 8. 88 8.. 8.8 3. 88.. 88.. z .88.. .8. .8. S .8.. .8.. .88. 88 88 8 . 8 8. 8 8 88.. 88.8 2 .8.. .8.. .-. .... .... 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Type II attendants rated this generalized affect characteristic almost as high for themselves as did the practical nurses for themselves. Why some Type II attendants who, for the most part, have a highly circumscribed perception of the nursing role, emerge with as much comparative emphasis on this set of expectations is another interesting question. Perhaps this group also equates 9: " being nice to people" as having the equivalency of formal training. decoder wants it to mean. Thus there are as many idiosyncratic versions of T. L.C. as there are persons ordered to give it to patients. Licensed practical nurses usually receive only a very limited amount of training in inter-personal relations based on knowledge coming from the behavioral sciences. Because of this superficial ity of training, they may construe high affect as professional behavior. It may be they use this high affect because they do not have enough training to enable them to use scientific principles in planning patient care. In role performance, with the affect overlay, they may actually be setting up a screen that blots out perceptions of patients that could be more useful in their care. If the above is the case, it may account for the presence of many of the generalized "affect" statements, especially those of partially trained per- sons. Taylor Caldwell has given a biting account of this characteristic of nursing personnel in "T.L.C. -- Keep Your Paws Off Me," National Review, 15 (I963) 6:]03-04. * It may be that this attitude of politeness and reduction of interpersonal conflict may be representative of a broader adaptation pattern. The respondents making these kinds of observations may be representative of those persons who in general use this type of adaptive pattern in interpersonal situations. Further discriminatory study would have to be made to ascertain whether this form of attitude has any significance for the characteristics this study is attempting to explore. 78 Review of Findings An analysis of the differing expectations measured by the index, What Should a ------ Do? reveals what appears to be a state of "unmet expectations'I . An examination of the observations, on the clinical expectation section of the scale, showed that Type I nurses held a high expectation for other role types as well as for nurses. These same clinical expectations are not reciprocated by the attendants. Type I attendants add further stress to the articulation of the various sets of expectations. These attendants work most closely with registered nurses but hold only a constricted clinical role for nurses. The dichotomy existing in the registered nurse group suggests other possibilities to the disruption of mutual sets of expectations. Type II nurses tend to hold lower clinical expectations for other groups than these groups hold for themselves. It may be the case that this role type does not perceive other groups as having much clinical competence. Type I, on the other hand, expects an involvement of all role types with patients. Since both groups of professional nurses must work and plan together, the likeli- hood of at least covert clash over the programming of nursing care seems highly probable. It would appear also that attendants would not be inclined to meet the clinical expectations at the level that the degree nurses hold these expecta- tions. It would appear that clinical practice might have some utility in caring for patients. However, there appears to be considerable lack of clarity of this nation. It might well be of crucial importance to the management of therapeutic patient care to have agreement on the expectations for the clinical componentof the nursing role. From the findings, there does not appear to be any maior congru- ency among the various sets of expectations of the different role types for this essential characteristic. 79 A similar condition of unmet expectations can be observed to exist in the area of bureaucratic functions. The definite difference of expectations between Type I nurses and Type ll attendants is probably the extreme example. The posi- tions Type I nurses usually hold are concerned with the entire design of nursing care which entails the mobilization of the bureaucratic resources available to nursing for this purpose. Included in this process are such functions as writing iob descriptions and establishing the standards of nursing care. Attendants, being in intimate contact with patients, are in a position to either respond to these expectations or to impose their own. Mutual agreement about expectations will facilitate harmonious articulation of the different role types. Lack of agree- ment, on the contrary, will result in a tendency to social cleavage. From the findings it appears this part of the index represents another area of non-congruent sets of expectations. The part of the index not considered very important by most of the respond- ents -- that of affect -- continues to bear out this tendency to non-congruence of expectations. As noted earlier even though there is no significance in the statistics the observations of role types on this part of the index are slightly sugges- tive that various sets of expectations fail to articulate with each other. The buffeting of patients caught in the backwash of all these non-congruent sets of expectations may place patients in a condition of therapeutic ieopardy. An assessment of the findings from the foregoing data would tend to support the hypothesis predicting disagreement about role expectations between role types according to training. Although there is a prevailing pattern of consistency of 80 expectations within role types, on the various parts of the scale, these findings are only suggestive that the hypothesis stating agreement within each role type according to training is supported. Some Theoretical Reflections on the Findings Cohesion or lack of cohesion in organizations may be greatly effected by the manner in which the division of labor within organizations is allocated. The position arrangement and role prescriptions for those positions may greatly influ- ence the manner in which roles articulate, complement and supplement the inter— dependence between roles, and provide for the effective mobilization of human effort in social productiveness and goal attainment. The foregoing seem to be important variables effecting the state of cohesion of an organization and there- . fore its organizational effectiveness. ln task and specialty allocation, there are at least two means by which specialization can be ordered. The two following examples are used to help clarify this notion. Medicine, faced with a great expansion of the scope of activities to be accomplished by that discipline in health care, dropped from the work role of the physician many of these task areas. New work groups were created to serve these areas. The occupations of physical therapy and medical technology are examples of emerging professions coming from such horizontal division of labor. Nursing, on the other hand, when faced with this expansion of effort, tended to cling to most of its traditional activities as well as to accept many new ones. The new task activities were the consequence of developing new 8i knowledge; were passed on by physicians who wished to give up low-level tasks to concentrate on higher level activities; and were the result of action by hospital administrators who were faced with the proliferation of new tasks and the need to assign responsibility for them to some department. The nursing profession seems to have attempted to meet this problem by forming various strata of nursing, each with particular functions. These sub-groups or sub-collectivities were formed in an effort to cope with the expanding expectations of nursing tasks. Levels of activities of decreasing complexity of nursing skill were developed -- each with different patterns of training . In the process of doing this many of the so-called low level or custodial tasks. -- those needing the least training -- were identified and assigned to personnel who did not have any formal training. However, much time must be invested in carrying on these custodial activities because they are basic to the _f Health and Human Behavior, 2 (I 96]) 2293-105. "Differential Displacement of Treatment, Goals in a Mental Hospital," Administrative Science Quarterly, 7 (I962) 2:208-l7. Schatzman, L., and Bucker, R. , "Negotiating a Division of Labor Among ' Professionals in the State Mental Hospital," Psychiatry, 27 (I 964) 3:266-77. Schwartz, C. G. , " Problems for Nurses in Playing a New Role on a Mental Hospital Ward," in M. Greenblatt, D. J. Levinson, and R. H. Williams (eds.), The Patient and the Mental Hospital, Glencoe, Illinois, The Free Press,—I957, pp. 402-26. Schwartz, N., and Shockley, E. L. , The Nurse and the Mental Patient, New York, Russell Sage Foundation, I956. I22 Scott, F. G., "Action Theory and Research in Social Organization," American Journal _o_f Sociology, 64 (I959) 4:386-95. Seeman, M., Evans, J. W., and Rodgers, E. L., "The Measurement of Stratifica- tion in Formal Organizations," Human Organization, I9 (I960) 2:90-96. Sigel, S., Nonparametric Statistics, New York, McGraw-Hill, I956. Simmel, G. , "The Persistance of Social Groups: I," The American Journal_o_f Sociology, 5:662-98. Smith, H. L., "Contingencies of Professional Differentiation," American Journal if Sociology, 63 (I958) 4:4I0-l4. . "Two Lines of Authority are One Too Many," The Modern Hospital, 84 I I 955) 3: 59-64. Stanton, A., and Schwartz, M., The Mental Hospital, New York, Basic Books, I954. _ Tate, M. W., and Clleland, R. C., Nonparametric and Shortgul Statistics, Danville, Illinois, Interstate Printers and Publisher, I957. Waisanen, F. B. , "Some Correlates of Student Role," paper read at the Ohio Valley Sociological Meetings at Michigan State University, Mar ch, I961 . 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