Parental acceptance of nursing participation in well-baby care

The growing demands of health care for all persons in the United States and the shortage of health workers have stimulated innovations and new approaches in the present health care system. Pediatric workers have experimented with plans requiring collaboration and realignment of roles between physicians and nurse in making health care available to more children. The present study attempted to evaluate parental acceptance of a health care plan which utilized examinations and counseling by a nurse as a regular par of well-baby care. The attitudes of 27 mothers concerning the health care of their children received from age 5 months to 12 months were evaluated. Fourteen of the children received traditional pediatric will0child care; 13 mothers voluntarily participated in the new plan in which the nurse conducted alternate well-baby visits. Each mother responded to a questionnaire dealing with her satisfaction and evaluation of well-child care. The responses were compared using factor analysis and t tests. No differences were found in the attitudes of mothers toward the care their children received, and the new plan seamed to be well accepted. This plan appears to be a favorable method of delivering health care to young children.

PARENTAL ACCEPTANCE OF NUHSING PARTICIPATION IN WELL-BABY CARE by Peggy Loi s Ch'j nn A thesis submitted to the faculty of the University of Uta h i n par t ~ a j f u : f) 1 1 me n t 0 f t he r ';:'11..1 j r emf: n t s for the degree of Master of Science College of Nursing University of Utah June 1970 This Thesis for the Master of Science Degre~ by Peggy Lois Chinn has been approved Apri 1 1970 UNlVtRSllY Of UI At! UBRI.RJB iii Acknowledgements This writer is grateful to many individuals who made contributions toward tile completion of this study. Particular appreciation is given to Or. Royal Murdock for his constructive guidance in developing the research design, to Miss Tomiye Ishimatsu, Or .. Miriam James" and Or. Ivan Lytle for their guidance and assistance during the writing of this study. Gratitude is expressed to Or. Gerald Snarr who so graciously gave his time and effort i11 the development of the study, to his assistant, LUCf 11'~ Hdc:<ing for her particular cooperation and assistance, and to the children and their mothers. iv TABLE OF CONTENTS Page LIST OF TABLES. v ABSTRACT # • ,. vi Chapter T I NTRODUC TI ON ... iI • ,. II. METHOD • • • 20 III. RESULTS . .. 24 IV. DISCUSSION • • • • • ,. 29 REFERENCES • • • • • • 31 Table 1 • 2. LIST OF TP.8LES Loadings on Items in the Factor Analysis. . . Means, t Values, and Significant Levels of the Graupi on Each Factor ••••••••••• v Page . . . . ~ . 27 • • • • • • 28 vi Abstract The grow~ng demands of ~eal~~ care for all persons in the United States and the shortage of health workers have stimulated innov~tions and new aoproachas in th~ present health care system. Pediatric work­ers have experimented with plans requiring collaboration and realign­ment of roles between physicians and nurses in rnaki~g health care avail­able to more children. The present study attempted to evaluate paren­tal acceptance of a health care plan which utilized examinations and counseling by a nurse as a regular part of well-baby care. The attitudes of 27 mothers concerning the health care their chi1- (ken received from age .5 months to 12 months \rJere evaluated. Fourteen of the chi idrcr'! received traditional pediatric we1l-chi ld care; 13 mo­thers vol~ntar~ly participated in the new plan in which the nurse con­ducted alternate well-baby visits. Each mother responded to a ques­tionnaire dealing with her satisfaction and evaluation of we11-child care. Th~ responses were compared using factor anaiysis and t tests. No differences were found in the attitudes of mothers toward the care their children received, and the new plan seemed to be well accepted. This plan ~pp~ar5 to be a favorable method of de!ivering health care to you~g children~ CH/\PTER I The role and function of nurses was one of the key problems in nursing identified in the February 1970 report by the National Commis­sion for the Study of Nursing and Nursing Education. There is much confusion in nursing and medicine, the two vitally concerned profes­sions, as to what roles nurses should be fulfilling. While there have been many suggestions for basic reorganization of the nursing role, there are 110 ready answers to questions regarding hO\~ best to organize or reorganize disciplines and roles to meet current and future hea1th care demands in the face of critical shortages of nursing and medical manpoltJer'. The first recommendation by the Commission \'Jas that funds be appropriated from various sources to investigate the impact of nurs­ing practice on the quality, effectiveness, and economy of health care. i\nothel~ recommendat ion i nvo lv~d the ~s tab 11 shment of nat i ana 1 and state Joint Practice Commissions between medicine and nursing to "discuss and make recommendations concerning the congruent rotes of the physician and the nurse in providing quality health care, with particular atten­tion to: the rise of the nurse clinician; the introduction of the phy­sician's assistant; the increased activity of other profe~sions and para-professions in areas long assumed to be the concern solely of the physician and/or the nursell (Natiot'lal Commission for the Study of NUf·S­ing and Nursing Educat'ion, 1970" p. 289). l~e key to action was identified in the report as being the dis­cussion and development of the role of the nurse in cooperation with other health care professionse Within the past few years, a number of promis'lng avenue5 for role change in nursing and medicine came to a 2 halt because of suspicion, fear of domination, or lack of understand-ing (1970 report). In pediatric practice, a great deal of interest and debate has been expressed regarding nursing Jlassistantll roles. The reports in the literature have been sporadic, with few methodical investigations as to the efficacy of these programs. The present study evolved as a result of an opportunity to collaborate with a pediatrician in the Salt Lake area in initiating an innovative nursing role. The purpose of the ex-periment was to try a new way to offer improved health care to more chi ldren. The approach chosen by the investigator and pediatrician for the present study was patterned after the plan of Alfred Skinner (1968). The. mothel~ was introduced to the nur se and offered the opt i on of re-ceivfng well-child care in a plan including the nurse conducting every other' visit.. The charge for nurse v'isits was 20 per cent less than the charge for the pediatrician visit, but the pediatrician was available for consult;:)tiofl during the nurse visits at no extra charge. The mo-thers who accepted the plan were asked to respond to a questionnaire regarci'i ng the it" sat i s fact ion \'Ji th the plan, and these responses were compar~d with a randomly selected group of mothers whose children re-ceived the traditional well-baby care offered in the pediatrician's office. Both groups responded in relation to the care of a child 5 months to 12 months of age who had received a minimum of four wel1- child visits. The experimental group had received a minimum of two nurse visits and two physician visits. Review of Related Literature Changes in pediatric practice have been evaluated and advocated in 3 recent years. The major impetus for change has come from the acute and grow; ng m;:.:npower sho!'" tage. I t has been es t -j mated that present 1 y there are 63 million children under 15 years of age in the United States, with 106,000 pediatricians and general practitioners to serve them. By 1980 the disparity will have increased to 75 million children and 68,000 child health physicians (Bergman, 1966). It has also been estimated that three to five times as many child health physicians are needed to meet adec!uate 1 y the hea 1 th care needs of chi 1 dren oj n thi s country (Crook, 1969) • In order to evaluate the nature of pediatric practice and some of the problems involved in the Seattle area, Bergman (1966) arbitrarily s61ected feur Board-certified pediatricians for detailed study. Their ages varied as did the setting of the practice. 7hey were followed by B fou,"th-yedr medical student from the first h05pital call in the morn­ing until leaving for home in the evening for a varied number of days. Though his sample was small} Bergmc.!1 reported that the data coincidp.d with simi 1ar stal~wide (Oregon) and nationwide surveys. I~ 8ergman's group, an average of 50 per cent of the pediatrician's tim€. was spent 0:1 \-JEd l-chi Jd care.. The other time spent with patients involved problems typica1 of the sUI'f'lmer time of the year, such as acci­dents, al1crgies J and respirator·y illness" The phY::3icians felt that during the winter, the ratio of well-child care to respiratory illness \'JOU i d be rever5ed (50%/20%). Each of th~ pedi atr i ci fins regret ted not taking subspecialty training which he felt would orovide more intellec­tual stimulation. The pcdi~tricians in the study wer6 not concerned with the fees drawn from their practice except for the fact that though their most valuable asset was time, they could not charge for it. Rather, they must charge for visits and procedures. Bergman pointed out that this must be a major consideration in any plan advocating a change in the structure of pediatric practice, for the pediatrician is financially penalized for spending time with patientso A steady stream of newborns into a practice insures its success; therefore, the well-baby care is of utmost importance. However, the pediatricians in Bergman's study felt their specialized talents were wasted by the drain on their time by well-baby care. When asked of the value of the well-child visits, there ~/as question as to whether all mothers need to see them so often. 4 One of the physicians in the study suggested that one answer to intellectual disenchantment would be more involvement with children who have birth defects, multiple handicaps, chronic illness, and other long-term conditions. These are presently handled by institutions which have an almost inherent difficulty in dealing with "whole child­ren. 1I He a 1 so fe 1 t tha t i ncreas i ng pub 1i c f inane i a 1 cover age of such conditions would make feasible this type of utilization of private pediatric practice. These factors have led the nurse, aide, and technician to assume some of the technical tasks formerly within the exclusive domain of the physician. Several different approaches have been advocated to expand even further the nurse's role in pediatric practice. Pellegrino (1965) observed that this trend serves to recapture the nurse's oppor­tunity fer close patient contact while the physician time with patients 5 is decreasing. The trained nurse can understand the diagnostic and therapeutic plan, make pertinent observations in the light of the total plan} and make suggestions to improve it. She can help in interpreting the plan to the patient and can detect and manage psychosocial aspects. Both medicine and nursing, Pellegrino pointed out, fear that change in established patterns of practice will threaten traditional values and ethical standards. But the threat will be greater, he stated, if the professions do not conscientiously reorganize their efforts with consideration of requirements in contemporary knowledge. Pellegrino, therefore, closely examined the ethical codes of nursing and medicine for implications of changing patterns in medical care. Nothing could be found '¥'1hi ch \-/OU 1 d countermand a rea t i gnment of ro 1 es such as those proposed for pediatric practice. Rather each code, devoted as it is to the good of the patient, impli~itly imposes on each profession the duty to explore all possible avenues which might improve the services rendared ~he patient (Pellegrino, 1964, 1965, 1966). Pellegrino further pointed out problems which occur when realign­ment of roles occurs. The usual initial procedure is to multiply tasks and procedures and find people to perform them. He proposed that the rnostfruitful approach would be to look at the tasks themselves in the light of the patient's real need without regard for who does them. Another difficu1ty involves the Iiteam ll approach. Cooperative ac­tivity of all health professionals has become a necessity in optimal care. I-!oh'ever." ethical problems and dangers involved are (a) the ten­dency to difFuse responsibi lity, (b) the threat to the person-to-person relationship, (e) the 1nsurance of group competence, and (d) the dele- 6 gation of task! to those most capable of performing them. Pellegrino pointeci out that the physician in a cooperative activity must remain as "caotain,1I but recognizing his limitations, he must appreciate and uti­lize the skills or others and be sensitive to the patients' needs for services other than his own (Peliegrino, 1965). n,e American Medical Association Law Division recently examined the legal risks of new kinds of paramedical personnel to assist the physician in new ways. While there are increased risks, these are min­imized by thoroughly trained assistants and careful supervision. Fur­ther protection may be obtained in some states by amending the Medical Practice Act (Connelly & Yankauer, 1969). The Nursing Practice Act in Utah allows for delegation to a nurse under physician supervision vir­tually any medical procedure that does not, on a scientifically deter­mined basis, require the personal knowledge, skill, and judgment of a physician (Law5 Affecting Nurse Practice Act, 1963). The 15?~R 1 of ~~~i ca 1 E ducat; on in 1965 pub 1 i shed two correspond­ing addre!.)c.es on the changing nurse-physician r-elationship as viewed by the nurse and by the physician. These offer a summary of some of th(;: problems invo1ved in change, and some trends and solutions which might be pursued. Pratt (196S) opened his address by quoting the tra­ditional physician's concept of the nurse as: She must feel like a girl, act like a lady, think like a man" and work like a dog. He pointed out that nurseS often assume new and greater responsibilities 7 through default because there is no one else available to assume them. The nurse has become a partner on whom he increasingly relies. In the field of direct patient care, the nurse-physician relationship has be­come one of mutual interdependence. Unfortunately, he observed, all too few physicians fully realize this. Pratt observed that because of scientific advances in medicine, the physician is able to give far superior care to patients without spending much time with them. Patients complain about this seeming aloofness ,\<\,;th no explanations and no reassurance. These have become nursing roles, and nursing education has provided a modern nurse with exponded knowledge in psychology and sociology to fill these needs. Schlotfeldt (196Sa) delivered the nurse's view of the changing nUf~se-physician re1ationship.. She identified the goals common to both professions as preserving optimal haalth for all, restoring patients to maximum productivity, helping them to adjust to disabilities and infirmities for which no cures exist, and preserving the dignity and rights of individuals in health, in illness, and in death. Physicians and nurses generally use different means to attain the overall goals they share. However, their collaboration in the process of arriving at a therapeutic program and the activities in which they engage, blur the distinctive features of each role. The issue now is whether t'lese two professions must stake out claims on particular tech­niques and procedures o~ whether they can work together to determine which of them can best ,dssume respons'ibility for a particular aspect of patient care. The ultimate criterion, indicated Schlotfeldt, must be thf".! welfc:lr(; of the patient. 8 Schlotfeldt observed that the reason for evaluating the reassess-ing the nurse-physician relationship stems from the need for medical and nursing services to work together in solving the recognized and in-creasing problem of society's need for adequate health services. Un-less the roles of both the physician and the nurse are examined and the functions critically assessed in relation to modern concepts of profes-sional practice, neither profession is adequately fulfi 11ing its res-ponsibility to the patient, to society, or to the profession itself. Nursing education has persisted in efforts to provide professional nurse-cliniciarls who are well-qualified professionals and eager to con-tribute their particular knowledge and skills to a team of health pro-fessionals~ All too frequently, Schlotfeldt indicated, they are pre-vented from providing such care by an entrenched nursing organizational structure which relegates nursing to hospital management roles (Schlot-feldt, 1965a, 196,b). As a rr.ajor approach to solving the many problems in the transi-tions that are and must be made, Schlotfeldt proposes general experi-mentation. She stated: The long-range goal for any experimentation is the im­provement of patient care in its most inclu~ive meaning. Co~comitontly, the proposed experiment should aim to provide an ex~mplary learning climate for students of lth professions .. The -;mrr;ediate purpose of the ex­perilnent is to determine those changes in physician and ;'JtJr$E! roie functions and role re'latiol1ships that are mC5t prondsing for accomplishing long-I·ange goals (Schlotfeldt, p. 775, 1965a). Currently, one of the better known programs to train nurses as pediatric associates is one developed and directed by Henry K. Silver at Colorado General Hospital, He suggested that physicians and nurses can and should work together to determine who can best assume respon­sibility for a particular aspect of a patientls therapeutic regimen (Silver, Ford, & Stearly, 1967; Si1ver, 1967). 9 Silver recognized that this idea tends to aggravate the already acute nursing shortage, but he hoped that further realignment of ro1e relationships of all health workers would permit a more effective uti­lizution of personnel at all levels. 'rhe gaps in chi ld health supervision during the preschool years, the inadequacies in the quality and quantity of care received by many children from low-income families, and the need for more effective methods of case finding are al I factors which directed Silver's ef­forts toward developing the new approach in providing adequate health care. He stated that this will require experimentation to find the most effective use of physicians, public health nurses, and others. Programs need to be developed and supported which will test the effec­tiveness of different methods of identifying heaith problems and pro­viding the best possible management. Silver's program was developed under the combined auspices of the Department of Pediatrics of the School of Medicine and the School of Nursing at the University of Colorado~ It prepares the nurse for com­pretlensive well-child care to children of all ages. It trains her to identify and appraise acute and chronic conditions and refer them to other facilities as indicated, and to evaluate and manage temporarily emergency situations until medical assistance is available. The nurse increases her skills in assessing the physical and psychosocial devel­opment of children and studies variations in growth patterns. She also 10 l~arn~ counteling skills, immunization procedures, and teehniques of dev~10~menta1 tests and evaluative procedures, such as history taking l basic physical examinations, and a limited number of laboratory tests. These nurses have a four-month intensive training program in wel1- child care, components of a comprehensive physical examination, essen­tials of infant problems, immunization programs, preventative aspects of health care, management of common child illnesses (within the lim­its of the Nurse-Practice Act), and emergency care. This is followed by 20 months of supervised training in pediatric nursing stations which are located in low-income areas, where the nurse sees children and re­fers them to appropriate agencies and clinics. Initially, the nurses were required to have an M.S. in public health nursing. However l at present only a B.S. in nursing is required. In addition, training has been expanded to include qualifications for a nurse holding a position in the pediatrician's office. P~ysicians participating in the Colorado program deal with criti­cal decisions affecting the health of the child. By increased know­ledge and skill in child care, the nurse has been able to uti lize her 1etent potential for a more expanded and dynamic role in providing ex­cellent health care to chi ldren. With her assistance, the physician has found it possible to devote more attention to children who need his specialized skills and can focus on the aspects of patient care which require his intensive knowledge. The program is less concerned with the transfer of functions from one profession to another and more interested in establishing an effective, meaningful, and productive colleague relationship (Silver & Ford, 1967). 11 A group of two Denver pediatricians reported on their experience with a nurse practitioner from Silver's program. They indicated that this was an economically sound means of partially relieving the imme­diate manpower shortage and of improving health care to children. The activities of the nurse practitioner in their practice included (a) con­ducting routine checkups for boys to the age of nine years and girls through adolescence, with the physician participating at the end of each visit, (b) assisting in the evaluation of sick children, (c) coun­seling of mothers, particularly in the postpartum period and when new problems arise in the family, such as diabetes or allergy, (d) liaison with social workers and other paramedical personnel to facilitate pa­tient care, (e) taking selected telephone calls and giving advice or referring to the physician, and (f) performing and evaluating develop­mental screening tests and screening for abnormal hearing, vision, and speech. The parental acceptance of the nurse practitioner increased as parents became acquainted and realized that the nurse's examinations and advice consistently received the approval of the physician. The nurse's salary for the first year was $7,620. The number of patients seen in the office increased by 18.8 per cent; however, there was no increase in the amount of time spent in the office by either pediatrich~n. The additional income to the office by the nurse's ser­vices was $16,800, and the monthly amount exceeded the nurse's salary by the fifth month of the employment (Schiff, Fraser, .& Walters, 1969). William G3 Crook (1968, 1969) suggested that the Colorado nurse practitioner program imposes the danger of settiflg a trend in child health care which may not be in the best interest of child health or 12 of pediatricians. His concern was for the nurse practitioner \'Jorking in a~ outlying health station with pediatric consultation available only on a long-distance basis. In such a situation, the nurse might be called upon to make decisions which exceeded her level of competence. Crook emphasized that such health care is superior to no health care at all, but urged that alternative and supporting solutions be consid­ered (Crook, 1969). He presented certain major areas of consideration to the American Pediatric Society in 1968: (a) changes in pediatric medical education which would prepare physicians for the duties and challenges facing them in practice, (b) better facilities, organiza­tion, financing, and supporting personnel in office practice, (c) use of several levels of personnel on the health care team, with the pedia­trician remaining a personal physician to a larger number of families. These can include administrative assistants, Jlretii-ed mothers,1I recep­tionists, clerical workers, and the highly trained nursing assistant (Crook, 1968). Because of the acute manpower shortage in the area of pediatrics, the American Academy of Pediatrics established a Subcommittee on Pedia­tri~ Manpov/er as one of the major divisions of the Counci 1 on Pediatric Practice. This committee, a1though aware that there were many alterna­tives for solution of the basic problems, chose to pursue in depth the concept of interprofessional care of the ambulatory patient and the Iiexpanded role" of the nurse in patient car-e. The committee knew of a number of relatively small-scale demonstrations of a nurse function­ing successfully in such a role but had no information about practices and opinions of the Academy membership on these matters. Furthermore, 13 it found virtually no data concerning the actual allocation of tasks to allied health workers in offices and of the roles which such workers play in ambulatory care. These factors prompted a study supported by the Children's Bureau and the Academy and conducted by Yankauer, Con­nelly, and Feldman. A pretest was given in the State of Massachusetts and to a tV'JO per cent random sample of fellows in all other states (1968). The major study was nationwide (1969). All practitioners in the pretest indicated that they presently delegate many technical tasks but few patient-care tasks. A majority favored delegation of specific patient-care tasks related to informa­tion seeking, information giving, and counseling. Of the respondents, 80 per cent felt that increased delegation in general would result in improved and/or more efficient child care (Yankauer, Connelly, & Feld­man, 1968). The major study included all Regular Fellows of the American Aca­demy of Pediatrics. The response rate was 88 per cent, and the results confirmed the indications of the pretest. There was great variation in nursing roles and task delegation by geographic region and urbani­zation. Though pediatric opinion in general clearly favors the utili­zation of a1 lied health workers and professional nurses in pediatric care, plans to expedite it will necessarily have to consider these differences. There is a need for flexible planning and careful eval­uat'ion of the many different manpower solutions which are av'ailable to meet the srun~ basic demand (Yankauer, Connelly, & Feldman, 1969)~ Most of the patient-care tasks which the respondents of the major study indicated they would delegate are tasks that have been carried 14 out for many years by public health nurses. Yankauer, Connelly, and Feldman (1969) indicated that the nurse is the preferred person for task delegation, but that present postgraduate nursing programs in maternal and child health cannot meet the demands for personnel. Pub­lic health nurses, they stated, have a special stake in the changes occurring in pediatric practice. With a new orientation to caretaking needs rather than institutional and program needs, and a new personal liaison between nurse and physician, the public health nurse can move relatively easily into a nurse-practitioner role. Skinner (1968) reported a study conducted in his own practice on the parental acceptance of a plan which permitted a nurse assistant to execute a portion of well-baby care in his office. In 1966, he initi­ated the plan primarily to serve large families and to improve their compliance with health supervision standards. To selected mothers, Skinner offered the option of alternate visits with the nurse after his three-week and six-week checks. Nurse visits were available at a charge of 0.6 units, compared to 1.5 units for the physician visits. The nurse!s service included interval history, inspection of the un­dressed baby, measurements, diet counsel, and anticipatory guidance. The ~lan was readi ly accepted by the majority of the mothers, and the infants' care was clearly kept more current. Upon occasion, the nurse found i1 lness or problems requiring the physician's attention, and the chi ld \>-Jas. seen by the physician. TitfiJ questionnaires were used in Skinner's study. The first .was sent to parents of all newborns during the year of 1966. From a total of 71, 50 questionnaires were returned. The second questionnaire was 15 sent to the same parents and also to 174 parents of 1966 newborns in the practices of three cooperating colleagues. The latter question­naire contained a brief description of the plan and questions concern­int its appropriateness for the first, second, or later babies. There were 94 replies from this portion. Among 24 patients who had been offered the plan in Skinner's practice, 22 accepted and 2 rejected the option to participate. All who participated indicated satisfaction with the plan. The majority of mcthers whose children were patients of Skinnerls colleagues indi­cated that the plan would be appropriate for second and later babies but not for the first (Skinner, 1968). The questionnaire also invited comments. Among those who accep­Led the plan there was an emphasis .on their satisfaction with the care received. The comments also reflected a need for competence on the part of the nurse, the need to avoid changeovers in the nursing person~ nel, and pleasure with the savings in cost. Among those who disapproved the plan the feeling was reflected that the first year was so crucial that repeated physician visits were mandatory, especially with the first baby_ There was a clear contrast between the acceptance by Skinnerls selected patients and by those who had no prior knowledge or contact with the program. Skinner concluded that in a community of professional and executive persons of middle class, such a plan for health care would be accepted by a majority of the families (Skinner, 1968) Pat.tel"SOn, Bergman, and Wedgwood (1969) conducted a study in the Seattle area to determine parental attitudes toward de1egation of tasks usually performed by pediatricians. The aim was to examine how such factor~ as type of pediatric facility used, socioeconomic level, age 16 of parents l number of children, and experience with nurse visits would affect approval or disapproval of task delegation. Structured inter­views were conducted in the homes of 145 mothers du~ing January through March 1968. Each mother had at least one child age five years or under who had a well-child appointment during January, FebruarYI or March 1968. In addition, her child or children had visited the same pedia­trician or clinic for at least three well-child visits. Three groups of patients were selected; a group under the care of one of four pri­vate pediatricians, a sample from a prepaid group health plan, and a sample from two public well-baby clinics. Two of the private physi­cians utilized a pediatric assistant; the other two did not. The re­sults indicated that there were no significant differences in accep­tance between groups. Three-fourths of all mothers approved the con­cept, and 94 per cent indicated willingness to try it. Prior experi­ence with nurse office visits appeared to make a striking difference in acceptance. While this group represented a selection bias (these mo­thers had previously been presented the option to participate in such an experience and had accepted) such experience had not apparently ad­versely affected acceptance of the concept. The mothers were asked to indicate the level of training which they considered acceptable for assistants. levels considered accept­able by 80 per cent or more of all groups were (a) R.N. with on~the­job training by the physician-employer, (b) medical corpsman or prac­tical nurse with training in a one-to-two-year university course with 17 practical experience, and (c) R.N, with training similar to trat indi­cated for the medical corpsman or practical nurse_ In all groups 70 per cent or more indicated disapproval of an assistant with no health ex~rfence who received training on the job. Delegated tasks which received consistent acceptance from a major­itYof all groups included obtaining blood specimens, giving infant care information, interpreting a prepared instruction sheet, providing normal growth and development information, taking histories, and pro­viding telephone advice. The authors commented that if such experiments in child health care are first instit~ted in affluent suburban areas, their chances for acceptance throughout other areas will be considerably enhanced. Innovations instituted in poverty areas might shed the label of second­class care (Patterson, Bergman, & Wedgwood, 1969). Connelly and Yankauer (1969) indicated 13 current programs which train nurse associates or other assistants for pediatric practice. rhes~ are located in the ~-?astern portion of the Uni ted States and the western coastal st6tes. The program at the University of Colorado and one in Detroit, Michigan~ are the on'y two listed for the remaining 3reas.. The !:!.;"l..!..1 .. itr~~ ~2urn~..! repor ted on use by pedi a tr i ci ans of nurses with additional training. It was reported that only 42 per cent of doctors surveyed said that they themselves would utilize a nurse as­sistant, and that some opposition had come from nurses. Nevertheless, grcw'j ng parenta 1 acceptance, as we 11 as favorab 1 e experi ence wi th phy­s; cif;.ns who uti lize such a service, has given the practice impetus for 18 expansion. An estimated 200 nurse practitioners were known to be work-lng in pediatrics at the time of the report (Hollie, 1969). Statement of the Problem The literature indicated that while there is a need and a great deal of interest in utilizing assistants in pediatric care, there has been very little empirical evidence of the success of such innovations. Schiff, Fraser, and Walters (1969) reported an impressive degree of success and acceptance of a nurse practitioner in the Denver area. Preliminary reports of two extensive surveys of this patient popula-tion which were not yet completed indicated that services provided by the nurse practitioner were highly satisfactory to the parents. The competence of the nurse was indicated by a joint assessment of a large group of children who were seen initially by the pediatric nurse prac- I titioner and shortly thereafter by a pediatrician (Schiff, Fraser, and Wa 1 ter, 1969). Patterson, Bargman, and Wedgwood (1960) examined mothers' reac-tions to the concept of task delegation in child care of various socio-economic groups. They concluded that the use of allied health workers "is a marketable commodity for patient fami lies of all groups and com-mented on the advantage of initiating such plans in affluent suburban areas where there may be some reluctance to accept the plan as compared to other socioeconomic areas. Skinner (1968) reported that 22 out of 24 mothers accepted a nurse associate plan in his office, all of whom expressed satisfaction with the service. There has been no report of a comparison between attitudes toward health care received in a plan utilizing task delegation to an assis- 19 tant and attitudes toward traditional pediatric health care. There has also been no report of such an innovation in child health care in the Utah area. However, there has been interest and opinion expressed regarding various approaches which might be used in this area to reach child health needs of both the rural areas and the large child popula­tion in the greater Salt Lake City area. The present study, therefore, was designed to institute a colla­borative nurse-physician plan of child health care services in a pedia­tric office serving the Salt Lake City area and to compare the atti­tudes of mothers toward the health care received in the plan with those of mothers whose children received health care in the usual manner. The hypotheses tested were: Null t!l:eothesis There will be no difference between the attitudes toward well-baby care of mothers whose children received well-baby care in the collabor­ative nurse-physician plan and mothers whose children received well­baby c~re in the traditional manner. A 1 t~,£ Hypothesi s There will be a difference between the attitudes toward well-baby care of mothers whose children received well-baby care in the collabor­ative nurse-physician plan and mothers whose children received well­baby care in the traditional manner. CHAPTER I I The present study was conducted in the office of Gerald V. Snarr, M.D., and at Cottonwood Hospital in Murray, Utah, from June 15, 1969, through February 1970. The subjects were mothers of term infants who had experienced no major complications of pregnancy and whose infants were evaluated by Dr. Snarr as being within normal limits of health and clevelopment. Before the study was initiated, in-service training was conducted in the office one day a week and daily at Cottonwood Hospital during rounds. This period of training continued for three \o/eeks. Items specifically included during this period were physical examination of the newborn, including use of the stethoscope and otoscope; routine instructions to be given to mothers during hospitalization; routine advice and instructions given during office well-baby visits; immuni­zation procedures and instructions for carea Evaluation of progress and problems encountered was made by the nurse and pediatrician at reg­u1ar -intervals. The philosophies, policies, and routines used by Dr. Snarr were those used by the nurse in her management and guidance, The responsi­bilities dnd functions of the nurse included taking interval history, inspection of the undressed baby using stethoscope and otoscope, meas­l( rements, diet counsel, anticipatory guidance, administering immuniza­tions and obtaining laboratory specimens. Notat1cns were made by the nurse on the patient records regarding observations, advice given, consl!Jtation with Dr. Snarr, immunizations given, laboratory examina-t i ons perfo:~med, and independent judgments made... The tota 1 time spent 21 by the nurse included daily visits to the hospitai from June 15 through August 1969 and one-half day in the office weekly from June 15, 1969, through February 1970. The preliminary portion of the study involved hospital evaluation of newborn infants and introduction of the new plan of we1l-baby care to the mothers. The physician examined the infant on the first day and made a judgment as to whether the baby and mother met the criteria for the new plan of well-baby care. He then explained the plan to the mo­ther and introduced the nurse associate, offering the mother the op­tion of participating. The following facts were presented consistently to each mother: 1. The nurse will examine the baby each day for the remainder of the hospital stay and discuss findings, problems, and instructions with the mother. 2. The pediatrician will examine the baby thoroughly at one month of age to determine the state of health and development at that point. If this examination is satisfactory, the nurse will then be available for alternate visits throughout the first year. 3. The pediatrician will be directly responsible for any illness. L~. The nurse visits will be at the option of the mother, and the physician will be available for consultation and/or visits at any time. 5~ The purpose of the plan is to allow mothers to become acquainted ~ith the services of the nurse~ who is ~pecifically trained to help fam­ilies with child-rearing and child-health problems. This type of plan is being initiated in several areas of the country to provide better health care for more children. 22 6. The visits by the nurse are given at a slight fee reduction. An attempt was made to evaluate the factors which promoted a mo­ther's dec1sion to accept or reject the optional plan. The question­naire Form A (see Appendix A) was given to mothers who accepted the plan; Form R (see Appendix B) was given to those who rejected the plan. During hospitalization, a total of 17 mothers were offered the option to participate in the new plan of well-baby care. Fifteen ad­ditional mothers were offered the plan at the time of the first well­baby visits. Tnese were mothers whose infants were born after the com­pletion of the ho~pital portion of the study or at another hospital in the city. They were given the same information presented to mothers in the hospital ~xc~pt for the item pertaining to ho~pital Qare. Well-baby visits proceeded on an alternate basis unless illness or surgery intervened, in which case the pediatrician had sole respon­sibility for care, continuing the well-baby visits until the problem was completel ccleared. Six months after the inception of the plan those mothers whose children had received a minimum of two nurse visits and two pediatri­cian visits (Group I) were asked to complete a questionnaire (see Ap­pendix C). The same questionnaire was presented to a randomly selected number of mothers whose children had seen the pediatrician for a mini­mum of four well-baby visits. The children in both groups were 5 to 12 months of age. The mothers in Group II had not been introduced to the new plan, and the children had received well-baby care in the tradi­tional manner offered in the office. The questionnaire (Appendix C) was designed to evaluate mothers' 23 attitudes relating to six goals of well-baby care which were identified by the pediatrician and nurse as guidelines for all well-baby care in this office. These were: 1. To give the mother a feeling of rapport, satisfaction, and im­port3nce in carrying out well-baby care (Items 1, 6, & 8). 2~ fo give the mother guidance and help with individual problems and concerns (Items 5, 11, & 17). 3. To give anticipatory guidance for developmental, physical, nu­tritional, and emotional needs of the child (Items 4, 10, & 15). 4. To carry out the immunization program (Items 3, 9, & 14). 5~ To examine and assess the child's present state of development and state of health (Items 2, 8, & 13). 6. To maintain reasonable expense for the fami ly while meeting operational expenses (Items 7, 12, & 16). The responses were given along a five-point scale from relatively positive to relatively negative attitudes. The instructions were iden­tical for each group. The only variation was for those mothers in Group I who wished to distinguish between the nurse and the physician on a. ~dng'le scale. They were instructed to place a 0 for doctor and 3n N for nurse in the appropriate places on the scale in place of cir-cli~ g a single response. The qu~stjonnaire responses were evaluated using the t test to de­term; TIC differences between gr·oups. The ques t i onna ire was factor ana- 1yzed to determine homogeneity of items. CHAPTER III The initial questionnaires used in this study (Appendixes A & B) provided an estimate of the degree of acceptability which might be ex­pected of a new plan of well-baby care, and indicated some of the mo­ther1s reactions. A total of 17 term babies were born in Cottonwood Hospital to mothers who indicated Dr. Gerald Snarr as their pediatri­cian. These infants were all judged by Dr. Snarr within 24 hours of birth as meeting the criteria for the new plan of well-baby care. The plan was described to all the mothers and the nurse was introduced. Of the 17 mothers, 15 chose to participate in the plan. Of these 15 mothers, seven were in the 20-25 year age group, seven in the ?~830 year age group, and one in the 35-40 year age group. The monthly fam­ily income was $250-500 for six of the families, five families had an income of $500-750 monthly, and three families had an income of over $'750 month1y. Six of the fathers were professional or white-collar workers, and nine were laborers or blue-collar workers. All 15 of the famil1~s had one or more children at home. Twelve of the mothers indicated that this plan would be appropriate for the first baby. Of the statements which reflected their feelings about the plan, the state­ment regarding the competence of the nurse was most often checked. In ad{.lTtion, four mothers made their own comment to the effect that this plan mus~ be a good one because they trusted Dr. Snarr1s judgment. As one mother said, flHe must have faith in the ability of the nurse con­cerned or he wouldn't suggest such a plan. 11 More than half of the mo­thers indicated that they would like working with a nurse, that they felt they did not need to see Or. Snarr every visit and that they 1iked 25 the fee savings involved. Less than half of the mothers indicated that they wou 1 d 1i ke worki ng wi th another woman or that they were re­luctant about trying the plan, but were reassured by the fact that Dr. Snarr would be available at any time. The two mothers who rejected the plan were both in higher-income levels (over $750 monthly) and the fathers were professionals or white­collar workers. Both fami lies had relatives living close to the area, both had more than one child, and both indicated the plan was not ap­propriate for the first baby. One of the mothers had four other chi ld­ren at home and indicated that she did not need any kind of well-baby care for her child. The other mother rejected the plan because this was her first pediatrician. She therefore preferred to see him every v'i5it; oth~;rwise she stated she had no objection to the plan. These responses were mainly for initial survey purposes and were not subjected to further evaluation. The findings from the responses to the questionnaire (Appendix C) given to two groups of mothers at the conclusion of the study, were first evaluated using factor analysis. Each of the 27 mothers rated each of th2 19 statements from 1 to 5; the scores indicated relatively positve attitudes (1) and relatively negative attitudes (5). The score of 3 was defined as a neutral response. The intercorrelations between statements were factor analyzed to produce six factors. The questionnaire had been designed with three items relating to each of six goals of well-child care (see p. 22). The factors isolated, how­ever, did not relate to the goals as outlined initially. The items were identified by their loadings in each factor, and labeled as indi- cated on Table 1. Factor I was labeled IISatisfaction with the evaluation of the child. 1I The items which appeared in this factor dealt with the de­gree of satisfaction with ttle well-baby visits, the accuracy, thor­oughness, and reporting of the physical examination, the helpfulness of the information received, and the adequacy of the visits in terms of money charged. 26 Factor II was labeled IIEmpathy with the doctor." The items which appeared in this factor dealt with the amount of concern and interest exhibited by the doctor or nurse, the amount of help available between regular visits, and the feeling of freedom to discuss financia' con-cerns. Factor III \\las labeled liThe va'lue of well-baby care. 1I The items dealt with the information and records received through well-baby care, how helpful and \tJorthwhi le the visits were to the mother, the ava; la­bility of help between visits, the adequacy of well-baby visits in re­lation to cost, and the nature of answers to specific questions or problems. The statements which showed loadings on Factors IV, V, and VI did not appf:-3.r to sho\v any common aspects that could be subject'ively iden­tified or named. Factor VI seemed to deal with pragmatic aspects, but none cf the factots wel-e 1abeied due to the lack of obvious general­ity across statements~ While these three factors did account for an ide0tifiable magnitude of loading, the percentage (22%) of the total variance was relatively insignificant. The items which appeared in Factors IV, V, and VI are indicated on Table 1. Table 1 Loadings on Items in the Factor Analysis Factor I. Satisfaction with the evaluation of the child. Item 1 Item 2 Item 8 I tern 13 Item 17 Item 7 Factor II. Empathy with the doctor. Item 11 Item 14 Item 18 Item 5 I tern T 2 Factor III. The value of well-baby care. Item 3 Item 5 Item 6 Item 7 Item 17 F actor I V. Item '10 Item 19 Facto,- V. Item 9 Item 5 • Item 13 Item 18 Factor VI. Item 7 Item 15 Item 16 Loadings .6505 .8406 .7811 .7858 .5251 .5431 -.8787 -.8243 -.7619 -.4963 -.4957 .7046 .5611 .6854 .4754 ~7081 .6956 .8142 .8620 .l~413 .4646 .4496 -.5288 -.6401 -.7660 27 28 Th~ differences between the experimental group (those who parti-cipated in the new plan of well-baby care) and the control group (those who received traditional well-baby care) were evaluated by! tests. A total score of all items was calculated for each subject by add-ing the ratings given on each item. The mean score for the experimen-tal group was 32.65, and the mean score for the control group was 32.21. The t value for the two groups was .228, which was not significant (p..> .05, df = 25). Differences bet\veen the two groups were then ana 1 yzed on each of the six factors. Scores for each subject on each factor were obtained by adding the ratings given for the items identified in each factor. l~ere were no significant differences found between the two groups on any of the six factors. The values are indicated "in Table 2. Table 2 Means, t Values, and Significance Levels of the Groups on Each Factor Means Factor Experimental Control t .e. df I 7. 15 6.50 87750 > .05 25 II 7.23 8.07 .7357 :> .05 25 III 7.31 8. 14 .7845 > .05 25 IV 4.23 3. 14 1" 9480 > .05 25 V 5.08 5.57 • 75l~2 > .05 25 VI 7.77 7.29 ~5877 > .05 25 CHAPTER IV The survey of the reactions of mothers to the new plan indicated that an adequate percentage of mothers in this area would initially accept such a plan and would be favorable toward actually participat­ing v.d t.h their own chi ldren. The mothers sampled were generally equi ... valent as to socioeconomic status, and the reactions to the plan seemed to be similar from one mother to another. These results indicated the feasibility of continuing with the study on the basis of an adequate number of mothers who would participate. While the resu1ts of the factor analysis of the concluding ques­tionnaire did not coincide with the proposed goal identification, there were at least three major dimensions which appeared in this sample. They were: satisfaction with the evaluation of the child (Factor I), empathy with the doctor (Factor II), and the value of well-baby care (Factor III). While the responses did seem to reflect general and overall satisfaction with the doctor and the care received in either manner, both groups of mothers seemed to respond with some distinction bet\'/een at 1 cast these three factors. No s i gni fi cant di fferences were found between the responses of the two groups to all items, and the :~ck of differences prevailed when these were evaluated by factors. Therefore,the null hypothesis was accepted. Because there were no differences between the groups in this sample and with this plan as it v:as performed in thi s study, there ~/as no detectable change in the mothers' satisfaction with well-child care in the new plan as co~pared to the mothers' satisfaction with traditional care. E ieven lTtoth;-;;rs ildded cornments to the questionnaire form. Most of 30 these expressed overall satisfaction with the care their children had received. The request for more information predominated in the com­ments. Five mothers in the control group indicated a desire for more information on developmental processes, medications, and child-rearing problems. One mother in the experimental group reinforced her desire for more anticipatory guidance, while two mothers in this group indi­cated that more information was given to them by the nurse than by the doctor. One mother in the experiment complained that telephone contact with the doctor was difficult to obtain; another expressed the desire for a separate waiting room for children who are ill. There were several limitations involved in this study. First, the number of patients who responded to the questionnaire was small. This was due to the fact that the percentage of patients who had participated in the new plan and were eligible to respond was small. Several child­ren who participated had surgical or medical problems which required that their care be handled by the physician alone, and some children moved awi3.Y before the criteria were fulfilled. In addition, the nurse was available in the office only once a week, which limited her contact with and availability to the patients. Wh~le the persons involved in this study were satisfied and in­spired with the seeming effectiveness and feasibility of such a plan fer this area, more empirical evidence needs to be gathered to further identify the strengths and weaknesses, as well as the effect on the health of children. The validity of the evaluati~n questionnaire can­not be judged at this point; further use of this tool could assess its value in identifying the attitudes of mothers toward well-baby careo 31 References Bergman, A. B., et ale Time-motion study of practicing pediatricians. Pediatrics, 1966, 38, 254-263. Connelly, J. P., & Yankauer, A. Al lied health personnel in child health care. Pediatric Clinics of North America, 1969, 16, 921-927. Crook, W. G. The private pediatrician's future. American Journal of Diseases of Chiidren, 1968, 116,479-485. Crook, W. G. A practicing pediatrician looks at associates, assistants, and aides. Pediatric Clinics £! ~orth America, 1969, 16, 929-938. Hollie, Pam. Nurses with training in diagnosing ills help ease MOs' workloads: I'Nurse practitionerslJ examine patients, advise mothers. Jennifer's mom is satisfied. Wall street Journal, Aug. 4, 1969, p. 1. Lalt-/s Affecting Nurse Practice Act. The Utah Code Annotated 1953 as Amem­ded to and including Session Laws 1963. State of Utah, Department of Registration, 1963. National Commission for the Study of Nursing and Nursing Education. Sum­m~ ry ,*eport and recommendations. American Journal of Nursing, 1970, 70, 279-294. Patterson, Patricia, Bergman, A. B., & Wedgwood, R. J. Parent reaction to the concept of pediatric assistants. Pediatrics, 1969, 44, 69- 75. Pellegrino, E. D. ing practice. Nursing and medicine. Ethical implications for chang­American Journal of Nursing, 1964, 64, 110-112. Pellegrino, E. D. The ethical implications of changing patterns of med­ical care. North Carolina Medical Journal, 1965, 26, 73. Pellegrino, E. D. The physician and the nurse. Annals of Internal Med­icine:- 1966, 16lt, 11l+0-1145. Principlcsaof medical ethics. ~~~~.~ 1967, 161+, 148L~. -J-o-u-r-n-a-l -o-f -th-e- American Medical Associa- ------~ -------- ------- Pratt, H. The doctor's view of the changing nurse-physician relation­ship.. Jouinai of ~9i.cal Education, 1965, 40, 767. S chi f f, D. ~l .. , F r as e r, o. J., & Wa 1 t e r s, H. L. The p e d i at ric n u r ~ e p r a c - titioner in the office of pediatricians in private practice. Pedia­trics, 1969, 44, 62-68. 32 Schlotfe1dt, Rozella M. cian relationship. The nurseis view of the changing nurse-physi­Journal 2i ,t1edical Edudation, 1965a, 40, 772. Schlotfeldt, Rozella M. A mandate for nurses and physicians. can Journal of Nursing, 1965b, 65, 102-105. -Ameri- Si lver, H. K. Pediatric nurse practitioner. ing, 1967, 67, 2083-2087. American Journal of Nurs- Sf lver, H. K., & Ford, Loretta C. Pediatric nurse practitioner at Colo­r ado. ,l\mer i can Jou rna 1 £f. ~iD..9.' 1967, 67, 1 L!·43 -1444. Silver, H. K., Ford, Loretta e., & Stearly, Susan C. A program to in­crease health care for children: the pediatric nurse practitioner program. Pediatrics, 1967, 39, i56-760. Skinnel"J A. S.. Parental acceptance of delegated pediatric services. E~ll~~~ic~, 1968, 41, 1003-1004~ Ynnkauer, A~, Connelly, J. P., & Feldman, J. S. A survey of allied hec::lth v.Jorker obiigation in pediatric practice in t~assachusetts and in the United States. Pediatrics, 1968, 42, 733-741. Yankd~er A., Ccnne11y, J. P., & Feldman, J. S. Task performance and task legation in pediatric office practice. American Journal of E~,b1ic H'3~lth, 1969, 59, 1104-1117. Appendix A Questionnaire Form A Age group (please ceeck): under 20 20 - 25 25 - 30 30 - 35 35 - 40 over 40 Approximate family income per month: under $250 _ $1000 - 1250 $250 - 500 $1250 - 1500 $500 - 750 $1500 - 2000 $750 - 1000 over $2000 Please indicate the type of employment which provides your family income: Do you have relatives living within a two-hour drive of your home? No Yes Please indicate which applies! My parents My husband's parents Brothers or sisters Aunts, uncles, or grandparents How many children do you have at home? 33 34 Please check one: I feel this plan is appropriate for the first baby_ I feel this plan is not appropriate for the first baby_ Please check the following statements which reflect your feelings: I would like to take advantage of the plan that Dr. Snarr has offered me because I like the fee savings involved. I would like working with a nurse. I would like working with another woman. I feel the nurse is competent enough to give my child adequate care as outlined in the plan. I feel reluctant about accepting the plan at all but am willing to try it. I am only accepting it because I know Or. Snarr will be available to me anytime I need him, I know I can handle my baby well, provided no special problems arise, and I don't feel I need to see Dr. Snarr every visit. Other reasons (please specify): Appendix B Questionnuire Form R Age group (please check): under 20 20 - 25 25 - 30 30 - 35 35 - 40 over 40 Approximate family income per month: under $250 $1000 - 1250 $250 - 500 $1250 - 1500 $500 - 750 $1500 - 2000 $750 - 1000 over $2000 Please indicate the type of employment which provides your family income: Do you have relatives living within a two-hour drive of your home? No Yes Please indicate which applies: My parents My husbandts parents Brothers or sisters Aunts, uncles, or grandparents How many children do you have at home? 35 Please check one: I feel this plan is appropriate for the first baby. I feel this plan is not appropriate for the first baby. Please check the following statements which reflect your feelings: I prefer not to take advantage of the plan that Dr. Snarr has offered me because the fee savings doesn't matter to me. I would not like working with a nurse. I would not like working with another woman. I do not feel that the nurse is competent enough to give my chi 1 d adequate care as outlined in the plan. I feel reluctant about accepting the plan and am not will-ing to try it. I prefer not to accept it because I am afraid Dr. Snarr will not be readily available if I need him. I am not sure if I can handle my baby well, and I feel I need to see Dr. Snarr every visit. Other reasons (please specify): Appendix C Dear Mother: Because we are interested in planning improved health care for babies, we would like to ask you to rate certain features of your child's care over the past several months. We are anxious to have your candid opinions and reactions, plus any ideas or suggestions you care to add. We feel you will be our most valuable source to determine areas of needed improvement. In response to each item, please circle the appropriate number along the eorresponding scale. Example: Each time I visit the doctor's office, I am placed in the same ex­amining room. Always Never (2) 3 4 5 This response would indicate that you seem to be in the same room on most visits, but you have been in other rooms on occasion. 1 • My child's well-baby visits have generally 1 eft me with a feel-ing of the fo 11 owi ng degree of satisfaction: Very satisfied Dissatisfied 2 4 4 5 2~ The assessment of my child's development and state of health has seemed Accurate Inaccurate 2 3 4 5 3. I have been given an up-to-date record of immunizations given my child. Always Never ____________2 _ _______~ 3_ _________4_ __________2 __ 37 4. I was given information about baby care and my baby's needs of which I have not given prior thought or of which I was not aware. Frequently Never 2 3 4 5 5. When I have needed help with some problem between office visits, I was able to receive help to the following extent: Readi fy available 2 3 6. I feel that the well-baby visits are Very helpful and worthwhile --------2- ------3- ---- 4 4 Not available 5 Not helpful and not worthwhi Ie 5 7. I feel that my well-child visit expenses have been Reasonable, \-11 t h adequa te returns in hea1th care 2 3 4 Unreasonable, with inadequate returne in health care 5 8, When my child was examined, I was informed of findings and these were explained to me. Always Never -.. 2 3 4 5 .......-~- - 9 .. I fee1 that the \-Iay shots are given to my child is usually Sat i ~lfactory Unsatisfactory 2 3 4 5 38 10. I was sat1sfied with my child's feeding schedule as outlined in the office visits to the following extent: Very satisfied 2 3 4 Not satisfied 5 11. When I have come to the office with specific concerns and ques­tions, the following attention and concern is given to them by the doctor: Adequate Inadequate 2 3 4 5 12. I have felt free to discuss financial concerns with someone in the office. Always Never 2 3 4 5 13. The physical examination of my child has seemed Thorough Inadequate 2 3 4 5 14. Vlhen my chi 1d received an immunization, I was given informa­tion regarding the nature of the vaccine and any possible reactions. Never 2 3 4 5 15. My well-child visits included information regarding what type of activity and progress to expect from my baby during the vl/eeks to come. Adequate information 11 2 3 ----------------------~~------- 4 No information 5 39 16. The expense of my well-baby visits was More than expected 2 3 4 Less than expected 5 40 17. When I have a specific question regarding my baby's care at home, I have generally received the following types of answers: Very helpful 2 3 4 Not helpful 5 18. I feel as if the doctor is truly interested in my child and my problems. Always Never 2 3 4 5 19. I would prefer for the fol lowing individual to give shots and take my child's blood samples (please check one): Doctor Nurse No preference 20. Please give any further comments or suggestions which might help us in planning an improved program of well-baby care. Name Birthplace Birthdate Elementary School High School Co llege Un i ve r s -j t y D8:Jree Professional Organizations Professional Positions VITA Peggy Lois Chinn Columbia, South Carolina 25 February 1941 Riverside School Hila, Hawaii Hawaii Baptist Academy Honolu1u, Hawaii t,1 a r s H i 1 1 Colle 9 e Mars Hill, North Carolina 1958-1960 University of Hawaii Honclulu, Hawaii 1960-1964 B.S. in Nursing, University of Hawaii Honolulu, Hawaii, 1961t r'1.mer i can Nurses I A~~soci at ion Ut~h State Nurses' Association Staff Nu~se, Castle Memorial Hospital, Kai lua, Ha\vai i, S~mmer, 1964 Staff Nurse, Weld County Memorial Hospit@l, Greeley, Colorado, Autumn, 1964 P~diatric Nurse, Greeley Medical Group, Greeley, Colorado, 1965-1967