As the profession of nursing matures, new developments occur. To keep up with new and continuing developments in their profession, nurses gather at meetings to share ideas, establish networks, and expand their knowledge and skill base. When the meeting is organized around a particular aspect of professional nursing, "the attendees, organizers, and speakers form a rich sample of experts from which valuable data can be collected. The purpose of this paper is to describe how the participants of a national conference were utilized as a sample from which data were collected to gain consensus on a concept of relevance to nursing. The concept analyzed in this paper is the development, implementation, and evaluation of nursing centers.
Historically, nursing centers, sometimes referred to as nurse managed centers or nursing clinics, have been defined as a setting which is owned, operated, and/or governed by professional nurses and which provides direct access to nursing services for patients or clients (Riesch, Felder & Stauder, 1980). At the first national meeting organized around the theme of nursing centers in 1982, the definition of nursing centers was "a setting in which care was nurse managed and which had potential for student learning, faculty practice, and nursing research" (Lang, 1983). This definition was the object of considerable controversy. Thus, the National Planning Committee for the Second Biennial Conference on Nurse Managed Centers employed the Delphi Method to gain consensus on the definition of a nursing center.
THE DELPHI METHOD
Through the use of a paper-and-pencil questionnaire, the Delphi method enables respondents to express opinions anonymously and without face-to-face confrontation. Those responding to the questionnaire are considered a panel of experts. The technique enables investigators to gather large amounts of objective and subjective data from a group of experts expeditiously.
As summarized by Fink, Kosecoff, Chassin, and Brook (1984), the method consists of multiple rounds of data collection. During the first round, respondents are asked to supply items to construct the questionnaire. After analyses and summarization of these suggested items, the questionnaire is constructed and distributed to the sample constituting the second round. At this time, the panel simply responds to the items and may suggest further items to be included on the instrument. During the third round, the analyses from the second round are distributed with the questionnaire to the respondents so that they can identify how their answers compared with those of the entire group. Respondents have the opportunity, during this round, to explain their responses to the items in an attempt to influence others toward their point of view.
Data from the third round, that is the numerical and written responses for each item, are distributed with the questionnaire for the fourth round. After respondents have had the opportunity to analyze the groups collective responses, they again complete the questionnaire. Numerical responses only are considered during this final round. The data then are analyzed for significance relative to sample subgroups or demographic characteristics and summarized for reporting purposes. Previous applications of the method have involved mailed questionnaires at intervals of several days, weeks and months. The authors have not found a recorded instance of the method applied during such an intensive timeframe such as a twoday conference.
The theme of the conference, held May 30 through June 1 , 1984, was Nurse Managed Centers: Impact Upon Health Care Delivery. The six-member national planning committee issued a call for abstracts in Fall 1983 pertaining to any aspect of planning, developing, implementing, and evaluating a nurse managed center. Twenty-eight abstracts were accepted for poster or paper presentation. Invited speakers addressed the participants on the topics of control of nursing practice, defining impact, governmental and philanthropic support of nursing centers, marketing, and legislative activities. The conference was advertised through professional journal and newsletter announcements, mailings, and brochures. Also utilized for conference planning purposes was a database of existing and planned nursing centers developed and maintained by the first author. The conference attracted a national sample of persons involved in the concept of nurse managed centers.
Sample: Of the 178 registrants to the conference, 148 participated at Round One, 147 at Round Two, and 143 at Round Three. Fifty-three percent of the sample were educators, 21% were administrators, and 11% were clinicians. More than 80% of the sample were masters prepared. The greatest number of participants were in the 30- to 39-yearold age group and most had practiced as a professional nurse from six to ten years. Forty-eight percent of the sample reported they had practiced in a nurse managed center while 44% reported having directed or managed such a center. The average self-perceived degree of expertise with nurse managed centers was 4.73 (SD= 1.50) on a scale for which 1 indicated low expertise and 7 high expertise. The participants were considered a legitimate sample of experts.
Instrument: The instrument utilized for the first round of the survey was a 22-item paper and pencil questionnaire. Developed by the National Planning Committee, items were taken from ideas published in the literature (Alton & Miereort, 1980; Culang, Josephson, Marcus, & Vezina, 1980; Damen, 1980; Häuf, 1977; Henry, 1978; Herman & Krall, 1984; Lewis & Resnick, 1962; Mezey & Chiamulera, 1980; Ossler & Goodwin, 1982), papers from the 1982 conference (Mezey, 1982; Hawkins, 1982), and from the planning committees personal experience and practice. The instrument was reviewed by research colleagues for clarity, by a statistician for analysis purposes, and by selected staff from three nurse managed centers for content.
Respondents were instructed to indicate whether they agreed or disagreed with each of the statements using a 7point Likert-type scale. In an effort to evoke a strong response, the items were constructed so that the stern of each statement contained the word "should," for instance, "Nurse managed centers should be based upon nursing models of care." Items were constructed around the issue of the philosophy, organization, staffing, activities and functions, and delivery of care in such centers.
After the first round, six items were added to the questionnaire as suggested by the panel (sample). These items were worded similarly to the original 22 items. The second round of the questionnaire contained space for opinions and rationale from the subjects as well as the median, inter-quart i Ie range, and range for each item from the first round.
Procedure: The Delphi method was modified by the investigators to include only three rounds. As explained above, the planning committee constructed the instrument before the conference so that it could be distributed to conference registrants. At on-site check-in for the conference, each participant received, with the packet of conference materials, the Round One questionnaire, a computer scan sheet, and instructions for its completion. During the orientation and introductory remarks of the conference, these instructions were reiterated. Conferees were oriented to all the survey procedures which would occur over the duration of the conference. They were reminded particularly to code their response sheets with their conference number so that analysis of the demographic data could be accomplished after the conference ended. The schedule for data collection is depicted in Table 1.
Participants were given time to complete the questionnaire, placing their responses on a nine-column computer scan sheet. This constituted Round One. The questionnaires and the scan sheets were collected immediately by three research assistants who hand carried the forms to the University of Wisconsin-Milwaukee (UWM) testing center. Within two hours, the data from the scan sheets were entered into the Sperry Univac 1100 mainframe and accessed for analysis by the data analyst for the UWM School of Nursing's Center for Nursing Research and Evaluation. The data analyst used the Biomedical Data Processing (BMDP) program to compute the median, interquartile range, and range for each item. These data were placed on a transparency so they could be reported to the conference audience.
SCHEDULE FOR DATA COLLECTION AND TABUUTION
While the data analyst was preparing the numerical data, the research assistants perused each questionnaire for additional items suggested by the panel. These additional items were typed and placed on a transparency for reporting purposes.
After the first afternoon paper presentation. Round Two of the procedure occurred. The median, interquartile range, and range for each item from Round One were reported using an overhead transparency and each participant was asked to record these data on their Round Two questionnaire. At this time the additional six items were added to the questionnaire also through the use of an overhead transparency. Participants were given time to complete the numerical aspects oí the questionnaire on the scan sheet and to provide rationale if their response to any of the items was outside the interquartile range. Upon completion of these tasks, respondents were asked to deposit both the scan sheet and questionnaire in a box so designated on their way to a refreshment break. The research assistants returned the scan sheets to the University testing center a second time where the data were entered into the mainframe computer system. The data analyst again computed the median, interquartile range, and range for each item.
The research assistants recorded and summarized the written rationales provided for each item and entered them into a word processing program on a personal computer. These data were printed and then copied at a commercial copy center for expedited feedback to the panel.
The second morning of the conference, prior to the first paper presentation, Round Three occurred. The numerical data were reported using overhead transparencies. Participants were requested to record these data on their Round Three questionnaire. Each participant received a copy of the written feedback for their use in responding to the questions. As with the earlier rounds, time was allotted for questionnaire completion and the research assistants collected the scan sheets. Objective data only were obtained in Round Three. These data were entered into the mainframe system at the University and each item was analyzed for its mean, standard deviation, and ranking among all 28 items.
The final report to the conference participants occurred as the last agenda item on the second and final day of the conference. The report included the data analyzed for Round Three, a summarization of sociodemographic characteristics of the panel, and a consensus definition of a nurse managed center.
Displayed in Table 2 are the rankings of all 28 items according to mean score. It is noteworthy that two of the top three ranked items were those suggested by the panel at Round One.
The consensus definition resulting from the survey was: Nurse Managed Centers are organizations that provide direct access to professional nurses who offer holistic client-centered health services for reimbursement. With the use of nursing models of health, professional nurses in Nurse Managed Centers diagnose and treat human responses to potential and actual health problems. Examples of professional nursing services include health education, health promotion, and health related research. Services are targeted to individuals and groups whose health needs are not being met (e.g., poor, women, elderly, minorities). An effective referral system and collaboration with other health care professionals are an integral part of Nurse Managed Centers. As models of professional nursing practice and research, Nurse Managed Centers are sites for faculty and student practice. They are administered by a professional nurse.
The opinions offered for each item by the respondents were, for the most part, pleas not to limit the philosophical underpinnings, definition, and activities of nursing clinics. Caution that some factions of the profession were moving too quickly to resolve issues without adequate data, or limiting activities too exclusively to nursing or wellness were examples of such pleas. Other statements included opinions that the focus of clinics should be upon the needs of consumers not those of the profession, that diagnoses and treatments nursing can "own" should be examined and documented, and entry to "independent practice" should be restricted to certain educationally qualified groups.
This first attempt to define the concept of a nurse managed center constitutes a significant beginning. With the continued interest in this area of nursing practice and the pending legislation at the levels of states and federal governments (Gephardt, 1987) regarding reimbursement and scope of practice issues, it is time nursing develop a cohesive stand on nursing clinics. The first step toward such a stand is a definition.
Defining a concept using a panel of experts assembled for a national meeting was a novel if not tedious and time consuming effort. Each step was planned meticulously. Alternative plans were developed if technologies such as the computer or the copy center failed. Dummy data were fed into the computer program prior to the authentic data to determine loopholes. A plan for data analysis without the aid of the computer was developed. Questionnaires were tested,, printed, and color coded for ease of data collection. Research assistants were trained on the procedures and the close timing of the entire operation.
The most difficult and challenging aspect of the procedure was obtaining the cooperation of the conference participants.lt was explained that their participation was voluntary. Most had not participated in the Delphi Method previously and some had difficulty grasping the intent. Time was at a premium since there was an over abundance of content in the papers, participants placed a high priority on face-to-face networking, and the conference planners underestimated the time it would take to complete each phase of data collection . If this method is to be attempted again, the rounds of data collection need to be scheduled directly into the agenda. Participants should be notified, in advance, that this method will be occurring, in fact, with adequate planning, the first round could indeed be instrument generation if participants, as they register, reply with suggestions for items. A firm date for item suggestions would need to be adhered to if the questionnaire was to be constructed in time for the conference.
RANKED CHARACTERISTICS OF NURSE MANAGED CENTERS DEVELOPED AT SECOND BIENNIAL CONFERENCE ON NURSE MANAGED CENTERS, 1984
Though the technique was successful and did generate a definition which elicited strong audience approval, considerable advanced planning is necessary to accomplish the tasks. Computer facilities and knowledgeable analysts must be available. An efficient and effective method of data collection, entry, access, and analysis is imperative. Staff who are willing to stay with the job until it is finished, who will do menial tasks, and who are accurate and dependable must be available. Finally, without dedicated and trailblazing participants, the method cannot be accomplished. Due to the tediousness, repetition, and the time commitment of the method, the authors suggest this method be reserved for a highly motivated audience with respect to a highly relevant issue.
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SCHEDULE FOR DATA COLLECTION AND TABUUTION
RANKED CHARACTERISTICS OF NURSE MANAGED CENTERS DEVELOPED AT SECOND BIENNIAL CONFERENCE ON NURSE MANAGED CENTERS, 1984