Journal of Nursing Education

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Social Problems Encountered by Public Health Nurses: Identification and Response Differences According to Education and Experience

Pauline Vincent, PhD, RN, FAAN; Joseph Davis, PhD

Abstract

ABSTRACT

Do nurses differ in relation to the identification of social problems and actions taken according to educational preparation? Using data from a larger field study, baccalaureate nurses (BSNs) were compared to Non-BSNs. The two groups did not differ in the number of problems that were identified, but BSNs did identify more problems related to non-immediate needs. The nurses took up to ten actions (x = 4.6) per problem, and the average number per BSN was less than the average per Non-BSN. The data lend some support to the position that BSNs are more likely to be selfassured and self-directed. Several questions are raised that are relevant to educators and administrators.

Abstract

ABSTRACT

Do nurses differ in relation to the identification of social problems and actions taken according to educational preparation? Using data from a larger field study, baccalaureate nurses (BSNs) were compared to Non-BSNs. The two groups did not differ in the number of problems that were identified, but BSNs did identify more problems related to non-immediate needs. The nurses took up to ten actions (x = 4.6) per problem, and the average number per BSN was less than the average per Non-BSN. The data lend some support to the position that BSNs are more likely to be selfassured and self-directed. Several questions are raised that are relevant to educators and administrators.

Introduction

Are the social problems identified by public health nurses who have graduated from baccalaureate programs accredited by the National League for Nursing (BS-Nurses) different from the social problems identified by nurses who have not graduated from these accredited programs (NonBS Nurses)? Once social problems are identified, do these two groups of nurses differ in the types of actions they take in relation to the problems? Are there differences in their responses to the problems according to the nurses' lengths of experience in public health nursing?

Reported studies, at best, permit only tentative answers to these questions. For example, several studies have indicated that nurses from "technical" nursing programs (Non-BS Nurses) tend to focus on the physiological and physical needs of patients, be concerned about meeting their patients' immediate health needs, and be careoriented (Gray, Murray, Roy & Sawyer 1977; Hover 1975). The BS-Nurses in the reported studies attended to these areas, but were concerned also about long-term, psychological and social needs that were not necessarily directly related to the patients' presenting problems, and they tended to be care oriented (Bullough & Sparks, 1980; Gray, Murray, Ray & Sawyer, 1977). These studies suggest that the two groups of nurses might differ in relation to their identification of certain types of problems. However, Reichow and Scott (1976) found that some employers of nurses believe that nurses achieve an equal level of competency within six months to two years of experience if there are differences in starting levels of ability among nurses from different types of educational programs.

Seniors in baccalaureate programs were found to have a greater degree of autonomy (Meléis & Farrell, 1974) and a significantly more professional ideal of nursing (Richards, 1972) than did Non-BS student nurses. These terms refer to independence of nursing practice, responsibility for adhering to nursing standards without "blind obethence" to physicians, etc. Waters, Charter, Vivier, Urrea and Wilson (1972) found that BS-Nurses were more likely than Non-BS Nurses to be self-directed, use special services to meet patients' needs, have more self-assurance, and make decisions more quickly. These findings suggest that the actions taken by BS-Nurses in response to identified social problems might differ from those taken by Non-BS-Nurses. This possibility is enhanced by the finding that BS-Nurses scored significantly higher than Non-BS-Nurses on a standardized test for critical thinking (Frederickson & Mayer, 1977). However, both groups used the four steps of the problem-solving process in random order, and often did not include the evaluation step, according to the Frederickson and Mayer study (1977).

Since there was limited information in the literature to derive answers to the above questions, data addressing these issues were obtained as part of a larger study conducted by the Visiting Nurse Association (VNA) of Cleveland in collaboration with the Federation for Community Planning (FCP). The VNA is a Medicare-certified home health agency and has been providing nursing care to people in their homes since 1902. Although most of the home visits are made by nurses, there are other professionals on the staff who contribute to the provision of comprehensive health care. The other professionals include occupational, physical and speech therapists; social workers; and a nutritionist. Approximately 70,000 home visits are made each year. The FCP is a community based research organization that is concerned with systematic planning to meet community needs. Part of the ongoing work of the FCP is the area of home health care systems improvement.

The larger field study was conducted to obtain data by which the VNA could make an informed decision in response to the continuing requests from the nurses for additional social worker assistance. Data were needed on what types of social problems the nurses were encountering, what they were doing about them, and how the social workers were responding to requests from the nurses.

The purposes of this descriptive study were to determine if there are differences between BS-Nurses and Non-BSNurses in relation to: 1. the social problems that they identify, or 2. the actions that they take when social problems are identified. The findings would facilitate decisions regarding interventions.

Method

Two sources of data were used in this study. One source was data from the larger study which sought to determine what types of social problems nurses encountered and what were the nurses' responses to these problems. The second source was the personnel files of the nurses who were involved with the sample cases in the larger study. In particular, the job classification and the number of years of public health nursing experience of each nurse were obtained. The job classification indicates if the staff nurse has a degree from a collegiate program accredited by the National League for Nursing (BS-Nurse) or does not (NonBS-Nurse).

In the larger study, a stratified random sample of 280 cases was obtained from the five VNA branch offices. During three consecutive months, the first 20 new cases that were visited by the VNA nurses in each of four of the branch offices were selected for inclusion in this study. A smaller number was selected each month from the new cases in the fifth branch office because the caseload was smaller in that office than in the other offices.

The primary method of data collection was structured interviewing by interviewers who met with the primary nurse for each case in the sample. These interviews took place shortly after the initial home visit was made to each case, and then every two weeks thereafter until the VNA services were discontinued, or until 18 weeks of VNA services were provided, whichever came first. The nurses were asked what they had observed in the home at the time of each visit, and what they had done vis-a-vis the social problems. The interviewers then forwarded the completed interview instruments to the FCP staff who coded the responses according to the pre-selected and defined social problems and actions. One of the co-investigators then checked the coding that had been done.

Table

TABLE 1INCIDENCE OF SOCIAL PROBLEMS

TABLE 1

INCIDENCE OF SOCIAL PROBLEMS

In the design of the larger study, 23 categories of social problems had been selected by experienced public health nurses. Once the data collection phase was terminated, it became apparent that some of the selected problems had occurred relatively infrequently. In view of this and to facilitate the analysis of the data, some of the original social problems were combined. Combinations were made when the nature of the two original categories was deemed to be similar (e.g. Parent/Child Relationships and Parent/Adult Child Realtionships) or when the nature of the needed specialized services was deemed to be similar (e.g. Legal Problems and Housing Problems). The final categories and their incidence within the sample are listed in Table 1.

For purposes of this study, a broad definition of "social problem" was used: a problem of a personal or social nature facing a patient or family that might be resolved through the use of community health or social services. Problems were excluded if they were primarily related to medical regimens or prescriptions, e.g. non-compliance with taking medications, lack of understanding of prescribed diets.

Findings

The characteristics of the sample cases were compared with the characteristics of all of the cases that had received ongoing care from the VNA during the year prior to the study. Comparisons were made according to age, sex, race, place of residence, and primary diagnosis. No significant differences were identified in these comparisons. Sixtythree percent of the sample were over the age of 64, 68% were females, 42% were black, 30% lived alone, 31% lived with one other person, and about three out of every four received Social Security or S.S.I. Although the sample cases lived in various sections of the county, about half (55%) resided on the east side of the City of Cleveland in generally lower middle class and poor neighborhoods.

All but 18 (6%) of the 280 sample cases had at least one identified social problem. The total number of problems identified was 838. Each particular problem was counted only once per household, even if the incidence of the problem occurred more than once in a particular household. The number of problems ranged from one to nine, with an average of 3.2 per household with social problems (838 problems in 262 cases).

As indicated in Table 1, the problem encountered most frequently among the sample cases was Inability to Care for Oneself (49.6% of the cases). Less than 10% of the sample cases had problems identified in each of the following categories: Situational Stress, Alcohol/Drugs, Vocational/ Educational, Parent/Child Relationships, or Child Abuse/ Care.

There were 57 nurses who had cases that were included in the larger study. Of these nurses, 39 (68%) were classified as BS-Nurses. The remainder (18 or 32%) were classified as Non-BS-Nurses. Approximately half (56%) of the Non-BSNurses had taken some college courses. Two of them held baccalaureate degrees from programs that were not accredited by the NLN, and one had a public health nursing certificate.

Did the nurses differ in their identification of social problems according to their educational preparation? As indicated in Table 2, there were 834 problems in the larger study that had been identified by staff nurses. Of these, 584 (70%) were identified by BS-Nurses. That is, 68% of the nurses identified 70% of the social problems. Thus, overall there was no significant difference between the nurses in relation to the identification of social problems, according to their educational preparation. However, it is interesting to note that there are five social problems that have a ratio of approximately 3-to-l in comparisons between the BSNurses and the Non- BS-Nurses, although the ratio of these two groups of nurses is approximately two BS-Nurses to one Non-BS-Nurse. For example, of the 24 Vocational/ Educational problems identified, 19 were identified by BSNurses, compared to five who were identified by Non-BSNurses. The four other social problems that have a ratio of approximately 3-to-l are: Inability to Care for Oneself, Legal/Housing, Situational Stress, and Alcohol/Drugs. That is, the BS-Nurses were more likely to identify these five social problems than were the Non-BS-Nurses, taking into account the fact that there were more BS-Nurses than Non-BS-Nurses in this study.

Table

TABLE 2SOCIAL PROBLEMS IDENTIFIED BY EDUCATION OF NURSES

TABLE 2

SOCIAL PROBLEMS IDENTIFIED BY EDUCATION OF NURSES

As indicated in the above literature review, some investigators (Bullough & Sparks, 1980; Hover, 1975) have found that Non-BS-Nurses tend to focus on the physiological and physical needs of patients. In addition, BS-Nurses attend to these areas, but are concerned also about long-term psychological and social needs. Given this, the following hypothesis was tested: BS-Nurses will have a higher average number of instances than will the Non-BS-Nurses of reporting each of the social problems that imply psychological or interpersonal needs or the need for comprehensive care (i.e., care that is beyond the immediate physiological and physical needs of the patient). A panel of experienced public health nurses identified ten of the 16 problems as meeting one or more of these criteria.

In all but one of the ten categories, the average number of instances that the BS-Nurses reported each of these problems was higher than the average number reported by NonBS-Nurses (Table 3). The one exception is the Social Isolation category, in which the average is equal for both groups of nurses. The difference between the two groups of nurses was statistically significant using the test for binomial distribution and a .05 level of signiñcance.

Table

TABLE 3AVERAGE NUMBER OF CASES WITH SOCIAL PROBLEM BY EDUCATION OF NURSES

TABLE 3

AVERAGE NUMBER OF CASES WITH SOCIAL PROBLEM BY EDUCATION OF NURSES

Table

TABLE 4AVERAGE NUMBER OF CASES WITH SOCIAL PROBLEM BY EDUCATION OF NURSES WITH MORE THAN TWO YEARS OF PUBLIC HEALTH NURSING EXPERIENCE

TABLE 4

AVERAGE NUMBER OF CASES WITH SOCIAL PROBLEM BY EDUCATION OF NURSES WITH MORE THAN TWO YEARS OF PUBLIC HEALTH NURSING EXPERIENCE

According to Reichow and Scott (1976), some employers believe differences in starting levels are not maintained after six months to two years of nursing experience. Given the nurse population included in this study, it was not possible to do statistical tests on the data for nurses with less than two years of experience. There was only one NonBS-Nurse with less than one year of public health nursing experience compared to 16 BS-Nurses with this amount of experience. In addition, there were only five Non-BSNurses compared to 27 BS-Nurses who had two years or less of experience in public health nursing. To determine if length of public health nursing experience affected the differences between BS-Nurses and Non-BS-Nurses in relation to the identification of social problems, comparisons were made of the nurses with more than two years of experience. It was hypothesized that BS-Nurses and NonBS-Nurses with more than two years of public health nursing experience would be similar in their reporting of the problems included in Table 3.

The comparisons between the subgroups of BS-Nurses and Non-BS-Nurses who had had more than two years of public health nursing experience indicate that in all but three categories, the averages are higher for the BS-Nurses (Table 4). The two subgroups of nurses had equal averages for three problem categories: Legal/Housing, Situational Stress, and Alcohol/Drugs. Although the two larger groups of nurses had equal averages in the category of Social Isolation (Table 3), this similarity was not maintained in the comparison of the subgroups with more experience. The BS-Nurses with more than two years of public health nursing experience had a higher average in this category than did the Non-BS-Nurses with a similar amount of public health nursing experience. However, the differences in identification of the ten social problems were not found to be statistically significant using a one-tailed test for binomial distribution. Therefore, the hypothesis derived from the literature review was supported.

The second major purpose of this descriptive study was to determine if BS-Nurses differ from Non-BS-Nurses in relation to the actions that they take when they identify social problems. As indicated above in the Method section, the nurses were asked at the time of each interview what they had done in relation to the social problems that had been identified. On occasion, the nurses responded that they had taken no action regarding the identified social problem because another service provider was attending to the problem, another problem was getting priority attention, the patient was unwilling to accept services related to the problem, or the problem had been resolved. Responses of this nature were categorized as "no action." The remaining actions were categorized as "positive actions" so as to differentiate the two categories. Only the "positive actions" were used to determine if the two groups of nurses were different in what actions they took.

According to their reports, the nurses took 3,799 positive actions in relation to the 834 social problems that had been identified. This is an average of 4.6 actions per problem. The range was from one to ten actions per problem. There was one instance in which the nurse reported taking ten actions in relation to one social problem. The identified social problem in this situation was Inability to Care for Oneself. There were 65 cases which had at least one social problem for which five or more actions were taken. There were six cases that had a total of nine social problems each. The nurses indicated taking nine different actions for each of the problems.

It was hypothesized that the average number of actions taken by BS-Nurses would be lower than the average taken by the Non-BS-Nurses. This was based on the inference of Waters and others (L972) that BS-Nurses make decisions more quickly than Non-BS-Nurses do. As indicated in Table 5, the average number of actions taken per nurse in the BS-Nurse category was lower (64.5) than the average number taken per nurse in the Non-BS-Nurse category (71.4). That is, the data are in the expected direction.

Table

TABLE 5AVERAGE NUMBER OF ACTIONS BY EDUCATION OF NURSES

TABLE 5

AVERAGE NUMBER OF ACTIONS BY EDUCATION OF NURSES

It is important to note that for the seven categories of actions, the BS-Nurses have higher averages for three of the categories, and the Non-BS-Nurses have higher averages for four of the categories. The averages for the BSNurses are higher for the following categories: Coordinated Services, Contacted Administrative Staff, and Tried to Resolve Problem Alone. The Non-BS-Nurses had higher averages for the remaining categories: Discussed Problem with Patient, Contacted Other VNA Personnel, Arranged for Service Provision, and Explored for Possible Service Provider.

Discussion

The finding that 838 social problems were identified in 262 of the 280 (94%) cases in this study endorses the position of many regarding the need for public health nurses to have a broad educational background. This position is augmented by other findings in this study. For example, the number of problems per household with social problems ranged from one to nine, with an average of 3.2 per household. Each of two categories of problems occurred in approximately half of the sample cases. Five of the 16 social problems included in this study were each identified in less than 10% of the sample cases, and all of the 16 social problems were identified among the sample cases.

Does educational background make a difference in the identification of social problems? Comparisons of the BSNurses and the Non-BS-Nurses suggest that it does. The BS-Nurses identified a larger number of social problems, had a higher average number identified per nurse for most problems, and had a higher number of instances of identifying social problems that imply psychological or interpersonal needs or the need for comprehensive care than did the Non-BS-Nurses. It is important to note that VNA nurses are assigned to districts, and each nurse is responsible for all of the cases in a particular district. Assignments are not made according to the nurses educational preparation.

Before generalizations can be made to all public health nurses, further study is needed. This field study was done in only one agency, and has some limitations in relation to the validity and reliability of the data collection method. To assure consistency in the categorizing of the social problems, the coding was done by FCP staff, and checked by one of the co-investigators. However, the data used were descriptions of the situations reported by the nurses. No independent evaluations of the situations were made to determine whether other social problems existed in the households of the cases included in this study. We have no basis for questioning the information given by the nurses. However, it is possible that other social problems existed in the households of the cases included in this study. It is also possible that some nurses did not report on social problems that they observed because they believed that they could not or would not do anything about them. They were aware of the study design which included asking the nurses what they had done regarding identified social problems. One might speculate about a kind of "realism" that might occur over time when certain problems are identified but limited opportunities to be of assistance to the families are perceived. Might the nurses be less likely to report the existence of these problems? If their efforts in the past have not been productive, would more experienced nurses choose to not report the signs of these problems more frequently than less experienced nurses who had not encountered these problems as often? These problems might include unsafe housing that the family refuses to move from because it is located in a familiar area and has been their home for many years; and alcoholism that is not recognized as a "problem" by the patient or members of the household, or that they are not willing to take any action toward resolving. A re-design of this study might include a home visit by a member of the research team to ascertain what social problems exist in each household.

The finding that BS-Nurses and Non-BS-Nurses with two or more years of public health nursing experience were not significantly different in problem identification needs to be viewed with caution. The categorization of the nurses (i.e., BS-N or Non-BS-N) was based on whether they had a baccalaureate degree from a National League for Nursing accredited program. Of the 13 Non-BS-Nurses included in these comparisons, 54% had some collegiate education. Two held baccalaureate degrees, one had a public health nursing certificate, and four had completed some college course work. According to McCloskey (1983), in her study of nursing education and job effectiveness, "the significant variable is not the nursing degree (one program versus another) but years of nursing education" (p.57). Longitudinal studies are needed to determine if changes in social problem identification occur over time, and should include a large enough sample of nurses so that types and years of nursing education can be examined in comparisons regarding problem identification.

Further study is also indicated in relation to the actions taken by public health nurses once they have identified a social problem. The range of actions taken per problem was from one to ten. There were 65 cases which had at least one social problem for which five or more different actions were taken. In six cases, each with nine social problems, the nurses reported taking nine different actions for each of the problems. How do the nurses decide on which action to take? On what basis do they decide to try to resolve the problem alone? At which point do they discuss the identified social problem with their Master's-prepared supervisors or the agency social workers or the available psychiatric nurse clinicians? Do they approach these resource people when the problem is identified or when the nurses' efforts "fail"? Frederickson and Mayer (1977) found that BS-Nurses and Non-BS-Nurses used the four steps of the problem-solving process, but did this in a random order and often did not include the evaluation step of the process. If this random ordering is found to be related to the number of actions taken per problem, the nurses may need continuing assistance in the appropriate use of the problem-solving process, particularly in identifying possible resources that can be used in their interventions.

Summary

Based on hypotheses derived from a review of the literature, BS-Nurses were compared to Non-BS-Nurses in a visiting nurse agency according to their identification of social problems and the actions that they took in response to these problems. Of the 280 cases included in this study, 94% had at least one social problem, and some had as many as nine. The mean was 3.2 social problems per case among those with social problems.

No significant difference was identified in the two groups of nurses according to the total number of social problems identified. However, the BS-Nurses were more likely than Non-BS-Nurses to identify problems that imply psychological or interpersonal needs or the need for comprehensive care. This difference is significant at a probability level of .05. However, this difference was not maintained when comparisons were made among those who had had more than two years of experience in public health nursing.

The findings support the position that preparation for public health nursing should include a broad educational background. However, the findings on the actions taken suggest some questions about how decisions are made regarding which actions are taken when a social problem is identified. Replication of this study by others is needed to determine if similar findings are demonstrated. In addition, longitudinal studies are needed to determine if changes occur over time in relation to problem identification and actions taken in response to them. An unanswered question is whether the significant variable is nursing education or nursing experience, or a combination of the two. The answers to these questions are needed if we are to assist public health nurses in responding efficiently when social problems are identified in the households of cases that are referred to them.

References

  • Bullough, B. & Sparks, C. (1980). Baccalaureate vs. associate degree nurses: the care-cure dichotomy. Nursing Outlook 23(11), 688-692.
  • Frederickson, R. & Mayer, G. (1977). Problem-solving skills: what effect does education have? American Journal of Nursing, 77(1) 1167-1169.
  • Gray, J., Murray, B., Roy, J. & Sawyer, J. (1977). Do graduates of technical and professional nursing programs differ in practice? Nursing Research 26(5), 368-373.
  • Hover, J. (1975). Diploma vs. degree nurses: are they alike? Nursing Outlook, 23(11), 684-687.
  • McCloskey, J. (1983). Nursing education and job effectiveness. Nursing Research, 32(1), 53-58.
  • Meléis, A. & Farrell, K. (1974). Operation concern: a study of senior nursing students in three nursing programs. Nursing Research 23(6) 461-468.
  • Reichow, R. & Scott, R. (1976). Study compares graduates of two-, three-, and four-year programs. Hospitals 50(14) 95-97.
  • Richards, M. (1972). A study of differences in psychological characteristics of students graduating from three types of basic nursing programs. Nursing Research 21(3) 258-261.
  • Waters, V., Chater, S., Vivier, M., Urrea, J., & Wilson, H. (1972). Technical and professional nursing: an exploratory study. Nursing Research 21(2), 124-131.

TABLE 1

INCIDENCE OF SOCIAL PROBLEMS

TABLE 2

SOCIAL PROBLEMS IDENTIFIED BY EDUCATION OF NURSES

TABLE 3

AVERAGE NUMBER OF CASES WITH SOCIAL PROBLEM BY EDUCATION OF NURSES

TABLE 4

AVERAGE NUMBER OF CASES WITH SOCIAL PROBLEM BY EDUCATION OF NURSES WITH MORE THAN TWO YEARS OF PUBLIC HEALTH NURSING EXPERIENCE

TABLE 5

AVERAGE NUMBER OF ACTIONS BY EDUCATION OF NURSES

10.3928/0148-4834-19870401-05

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