Investigation of the Schwartz, Parloff and Stephenson categorization of behavior of psychiatric nurses in nurse-patient interactions

A categorization of the behavior of psychiatric nurses formulated by Charlotte Schwartz, William Stephenson and Morris B. Parloff was investigated as to its adequateness for classifying a selected sample of incidents of psychiatric nurse behavior. The author proposed the hypothesis that additional categories would be needed in order to have a complete picture of the ongoing patterns of behavior in nurse-patient interactions. The Schwartz categorization included interventions by the nurse aimed at meeting a patient's physical needs and promoting his physical well being, meeting the emotional needs of a patient, upholding social standards, both cultural and ward and noninterventions reflecting respect for the patient's autonomy and integrity or due to the nurse's aversion to or intolerance of a patient's behavior. In the present study a category was provided for incidents not falling into the five Schwartz categories but no attempt was made to determine specifically what additional categories might be needed. A review of literature failed to reveal any other research into the categorization of the behavior of psychiatric nurses although articles have been written which suggest 37 additional categories such as meeting the patient's social needs, giving information to the patient, managing and supervising the patient's environment and gathering data about the patient. Some authors have cited examples of how the nurse may interact with a patient to meet her own needs, but no published study was found which indicated that categories of this particular nature have been used in classifying the actual behavior of nurses in nurse-patient interactions. In carrying out this investigation it was necessary to find some criteria for delineating a nurse-patient incident. Exploration of the literature did not reveal any tool that could be used for this purpose; therefore, a pilot study was conducted in order to develop a means for delineating incidents. To answer the question, Are categories other than the five set forth by Schwartz, Stephenson, and Parloff necessary in order to have a more complete categorization of the behavior of psychiatric nurses as they interact with patients?", 273 incidents of behavior were delineated from nurse-patient interaction recordings made by graduate psychiatric nurses. Five Judges were asked to use the Schwartz, et al., categories labeled A, B, C, D, and E, and an additional category, labeled F, to classify these incidents.

i\.N INVl:~STIGATION OF THE SCHi;JARTZ, PAHLOFF AND STEPI-iENSON Cj\'.TEGOI<IZATION OF BEHAVIorc OF PSYCI1IATRIC NUf{SES IN NURSE-PATIENT INTE1~ACTIONS by Parry 1',lurphy ~ thpsis submitted to the faculty o~ the University of Utah in tial £u Ilment of the requirements for the of MASTER OF SCIENCE Department of Nursing University o·r Utah June 1963 LIBRARY UNIVER3ITY O:F UTAH This Thes Reader, for the Master of Science Degree by laine Parry Murphy has been approved June 1963 ACKNO\'JLEDGEMENTS Sincere thanks are offered to the members of my com­mittee for the very fine help which they extended to me dur­ing the course of my investigation. Mrs. Macquin, as chairman of my committee, was especially helpful in editing early dra.fts to improve the readability of this thesis. Sue Fujiki, wi th questions such as, "LVhat are you trying to say here?," helped me considerably in clarifying my thoughts and ideas. Dr. McPhee quietly supported me in my endeavors and knew just vJhen words o:f encouragement would be especially useful. John holLer, while not a member of my committee, gave much assist­ance in relation to the technical aspects of research. To my husband, Do\v, and children Susan, Dan, Helen and Carl, I extend my thanks for letting me be a lazy wife and mother \"',rhile I have been a busy student. Special thanks to my mother :for taking care of Michael Shaun who attended school with me before he was born seven months ago. To Annetta Sharp, my one and only classmate, I say "There could never have been a better dozen." Thanks are offered to the psychiatric nurses whose recordings were used in this investigation, and to the judges for the time and effort expended on its behalf. To my typist, Doris Herrick, I give thanks for helping me to meet deadlines with patience and well done material. TABLE OF CONTENTS CHAPTER I. INTRODUCTION Statement of the Problem. . Purpose of the Study. Hypothesis .. Definition of Terms . Limitations . 110 REVIEW OF LITERATURE .. Broad Areas of Nurse-Patient Interaction. Nurse-Patient Relationship Process .. Summary III. METHOD OF RESEARCH. Pilot Study Preparation of Incidents .. Summary . . IV. PRESENTATION AND ANALYSIS OF DATA . . Results of Investigation. . . Data on Categorized Incidents . Discussion of Categories .... q •• A. Physical Care . . . . . . . . . . . B. Emotional Care. C. Permissiveness. D. Propriety. E. F. Not Classifiable. PAGE 1 1 4 5 5 7 10 10 13 16 18 20 23 24 25 25 25 28 28 29 30 31 32 34 CHAPTER v. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS .. Summary .. . . . Conclusions . Recommendations . BIBLIOGRAPHY 0 • APPENDIX A •• Directions for Judges . .".... Keysheet. . . . . . . . . . . . . . . . . . APPENDIX BOG • • • • • • • • • • • • • • • • • Illustration of Incidents . v PAGE 36 36 38 38 41 45 45 46 47 47 LIST OF TABLES TABLE PAGE I. Number of Incidents Delineated by First and Second Judges . 22 II. Results of Judges Categorization of Incidents . 26 III ~ r-:]"umber oL Incidents Placed in Each Category of Behavior by Each Judge . . 27 CHAPTER I " INTRODUCTION There has been much wri.tten about the nurse-patient relationship and the role of the psychiatric nurse; but little research has been done to identify or sUbstantiate specific aspects of the nurse-patient relationship. Among the many facets of nurse-patient interaction there still exists a need for research into the actual behavior or psy-chiatric nurses during their interactions with the patient. I" STATEMENT OF THE PROBLEM This study has been undertaken to investigate a cate-gorization of nurse's behavior made by Charlotte Schwartz, William Stephenson, and Morris B. Parlorr as to its adequate-ness in describing the usual behavior of psychiatric nurses in nurse-patient interactions. Schwartz and her co-authors have classified the behav-ior of psychiatric nurses into the following five categories: (1) Physical care. Interventions by the nurse aimed at meeting a patient's physical needs and promoting his physical well-being. (2) Emotional care. Interventions designed to meet the emotional needs of a patient. (3) Permissiveness. Nonintervention reflecting respect for the patient's autonomy and integrity. (4) Propriety. Interventions intended to uphold social standards--both cultural and ward. 2 (5) Withdrawal. Predominantly noninterventions due to the nurse's aversion to or intolerance of a patient's behavior. 1 It has become increasingly apparent that some of the behavior of psychiatric nurses does not fit into any of the Schwartz categories. The nurse responding as an individual to the patient has not been taken into account, although the quality of the intervention or nonintervention in each of their categories would certainly vary from nurse to nurse. "Psychiatric nursing will always be practiced at the personal psychological level of the nurse involved," states McGregor. 2 Bresseler has written that the depth of therapy depends upon the nurse's own needs and on her general psycho-pathology. 3 In discussing the source of the nurse's behavior, Brown and Fowler state that in spite of the importance of a positive motive in the nurse-patient relationship (which is a sincere interest in the patient and a genuine desire to help him) negative motives are common in nurse-patient inter-actions. A nurse may interact with a patient because she is curious about him, or she may be testing the strength of her own personality. The nurse may also be attempting to minimize lMorris B. Parloff, "The Impact of Ward Milieu Phil­osophies on Nursing Role Concepts," Psychiatry, 23, May 1960, p. 142. 2Esther lVL McGregor, "Is Psychiatric Nursing at the Crossroads?", Nursing World, April 1958, p. 29. 3Bernard Bresseler, "The Psychotherapeutic Nurse," American Journal of Nursing, 62, May 1962, ppo 87-90. 3 or justify the existence of her own conflict or to make some personal gain. Acting out her own conflicts may bring about other behavior from the nurse or she may care for the patient merely because someone in authority says that she should. 4 Psychiatric nurses interact with patien~in a variety of ways under a variety of conditions. Some of the ways of interacting are more therapeutic than others. Each nurse tends to develop her own pattern of behavior in nurse-patient relationships, and the nurses who are most likely to contrib-ute to the improvement of a psychiatric patient are those whose edominant behavior is successful in meeting the emo-tional needs of the patient and reflects her respect for him as an individual. A nurse responds to patients at any given time in the only way she capable of at that time. However, she may learn new ways of responding which will bring about more desirable behavior on the part of the patient. To improve behavior an individual must know in what direction the behav ior needs to be improved. In order to help nurses become aware of patterns of behavior which contribute toward patient improvement, it may be helpful to determine as nearly as pos-sible all of the ways in which a psychiatric nurse usually 4Martha M. Brown and Grace Fowler, Psychodynamic Nursing (Philadelphia: W. B. Saunders Co., 1961), pp. 107- 108. 4 interacts with a patient. It could then be predicted that the nurse's behavior at any given time during a nurse-patient interaction would probably be in one of these ways. Observa­tion of the nurse's behavior by herself or by others, inter­preted in relation to such a categorization, would provide for greater insight into the nurse-patient interaction and recognition of the nurse's behavior. From this recognition desired changes might be effected. The author believes that a useful categorization of the behavior of psychiatric nurses should include a category of behavior which is specific to what is happening in the situation to the nurse. II. PURPOSE OF THE STUDY The purpose of this study was to investigate the possi­bility that the categorization of the behavior of psychiatric nurses formulated by Schwartz, Stephenson, and Parloff is of value but not sufficiently comprehensive to be of use in categorizing all of the usual behavior of the nurse occurring in the process of a nurse-patient interaction. One or more additional categories are needed to determine ongoing patterns of behavior as a baseline for establishing more effective pat­terns of behavior in nurse-patient interactions. No attempt was made to determine specifically what other categories are needed. 5 III" HYPOTHESIS The Schwartz, Stephenson, and Parloff categories of the behavior of psychiatric nurses, which include physical care, emotional care, permissiveness, propriety and with­drawal, will not be adequate to classify all of the behavior noted in the nurse-patient interactions of this study. IVo DEFINITION OF TERMS Psychiatric Nurse. A nurse with a masters degree in psychiatric nursing. First -J-u-- :::..-- The group called "first judges" was made up of two psychiatric nurses, two graduate students in psychiatric nursing (one being the author~ and a psychologist. They served during the pilot project to determine criteria for delineating a nurse-patient incident 9 Second Judges. The group called "second judges" also served during the pilot project and was made up of four psy­chiatric nurses. Third Judges. Five psychiatric nurses, prepared in graduate programs in different locales of the country, com­prised the group called "third judges." As a part of the major project they classified nurse-patient incidents into categories. 6 ,Nu~~·~patient interaction recordings. Actions which occur between the nurse and the patient in each other's pres-enee, cr(~ating products for each other, communicating with each other or showing the possibility of affecting each other, which are recorded by the nurse soon after the interaction. Incidents of behavior. Specific motor and verbal acts some degree of sequential organization directed toward ~he ~ttainment of same immediate goal or end state. S Intervention. To act as an influencing force. Aut Ability to be responsible for one's own actions. Physical~. Intervention by the nurse aimed at meeting a pa~ient's physical needs and at promoting his physi­cal well-being. 6 These needs include basic physiological needs such as hunger, thirst, elimination, protection from external dangers, and measures of personal hygiene.' Emotional care. Interventions by the nurse designed to meet the emotional needs of a patient. 8 These include SJohn W. Thibaut and Harold H. Kelley, The Social Psycholo91 of Groups (New York:: John Wiley & Sons, Inc., 1959 ), p" 12. 6Parlo£f, ,~ cit...:.., p. 142. own, ~ cit., p. 19. 8parloff, ~ cito j p. 142. 7 needs for love, warmth and affection from others and to give love; need for self-respect and esteem from others; the need to be able to util one's potential ies to accomplish and aChieve. 9 Permissiveness. Non-intervention by the nurse reflect- .respect .for the patient's autonomy and integrity .10 This includes attitudes and actions which enable the patient to ch:termiue the (~xt'12nt and l.imits of' OV.r:1 behavior .11 Interventions by the nurse intended to uphold soci standards--both cultural and ward. 12 Predominant non-interventions due to the nurse's aversion to or intolerance of a patient's behav-ior, 13 V" LI1"1ITATIONS The nurse-patient interaction recordings utilized for this study represented a small sample of nurse-patient inter-own j ~ cit., po 19. lOParlo:f.f, ~ cit 0, p. 1420 llJacob Finsinger and Sheppard G. Kellam, npermissive­ness-- Its Definition, Usefulness and Application in Psycho­therapy," American Journal of Psychiatry, 115:993, May, 1959. 1 10:f£, ~ cit., po 142. 13Ibid. 8 actions and may not have included all of the possible inter­actions between a nurse and a patient. The incidents as delineated from the nurse-patient interaction recordings were not always clearly stated and may have forced the judges to make meaningless categorizations. The nurse-patient interaction recordings may not have been as accurate or complete as desirable. Some nurses may hav(~ rE·corc1ecJ incidents which they thought their supervisor expected them to and may not have recorded other incidents. Incidents may have been recorded which the nurse believed to indicate her progress in relating to the patient and she may have eliminated those \IJhich were embarrassing to her in some way. The nurse may not have seen the significance of a spec­ific interaction and have failed to record it. The inter­action may not have been recorded soon af'ter it had taken ace and some of the data may have been forgotten. These limitations were minimized, however, by the nature of the graduate program in psychiatric nursing pursued by the writers of the recordings. The program permits the nurse to relate and examine her own behavior in a nonthreatening atmosphere so that learning can take place. Interactions were recorded soon after they occurred. The recorders were helped to util­ize theoretical knowledge which influenced their ability to record incidents of significance. Another limitation was that some of the responses of the nurses in the incidents had the possibility of fitting 9 into more than one category" Wben physical 'ca're is given to a patient, his emotion.al needs are often also met. When meeting the emotional needs of a patient, the nurse may be og care of some of hel:' own needs, Out of the total 273 inC1dents 160 were placed in the same category by three or more the f judges a Aside from individual interpre-of the incidents, this may have been due to the diffi-ch several categories the response ld The judges were not given any specific definitions of the terms used in describing each of the categories and at least one judge felt that this handicapped her in deciding where to place the incidents, especially in re9ard to her interpretation o,f the term, Hintervention." The subjective feeling of each of the judges naturally influenced the decisions as to which category specific inci­dents were assigned to and mu.st be taken into aCCoLlnt when interpreting the data. CHAPTER II REVIEW OF LITERATURE In reviewing the literature, the writer found most oaches to reflect two broad areas concerning nurse-patient interaction. These approaches were: (1) surveys of descrip-t of broad areas of nurse-patient interactions, and (2) lorations of the process of nurse-patient relationship studies. The former raisec questions which provided the basis for this study. Broad areas of nurse-patient interaction. Reissman and Rohrer have edited a series of studies from which the observation was made that nurses are involved with work which is dependent upon a physiological level of knowledge, a psy-chological level of knowledge, and a social and cultural level of description. 1 A nurse is educated to help take care of the patients' physical, emotional, and social needs. How she does this depends upon the "culture" of the particular ward or area of her work. In nAn Approach to the Study of Nurse-Patient Inter-action in Psychiatric Nursing," the nurse is described as 1Leonard R sman and John R. Rohrer, Change and Dilemma in Nursing Profession (New York: G. P. Putnam's Sons, 1957), pp. 286-88. 11 behaving towards the patient in response to his physical needs, his social needs, his emotional needs, and his need for spec­ific information. 2 Carl elaborates upon this theme in her discussion of the components of psychiatric nursing: . the psychiatric nurse utilized her knowledge and understanding of sociology, principles of behavior, com­munication, and physical and natural science concepts in a very specific way. By utilizing many nursing approaches, each based upon high level perception of clues in the nurse-patient relationship and upon realistic nursing goals, the psychiatric nurse was better able to provide nursing care to the mentally ill which is characterized as having positive influence upon the patient. 3 Other authors have cited the behavior of psychiatric nurses in relation to nurse-patient interactions in a more specific way. Schmall stated that the psychiatric nurse is concerned with the management of the patient's manifestations of irrational motivation in daily experiences on the ward, and that her behavior is directed towards meeting the patient's needs appropriately, helping him to communicate and helping him to participate sociallYo 4 2Western Interstate Commission for Higher Education, An Approach to the Study of Nurse-Patient Interaction in PSychiatric NUrSIng. Report of the Psychiatric Nursing-Group on Defining Clinical Content Graduate Nursing Programs, July 25-September 2, 1960. (Colorado: Fleming Law Building, 1961), p. 15. 3Mary Kathryn Carl, "Components of Psychiatric Nursing," Nursing Research, 10, (Summer, 1961), p. 171. 4Jane A. Schmall, "The Psychiatric Nurse and Psycho­therapy," American Journal of Nursing, (July, 1962), pp 460- 465. -- 12 Vause, in "The Psychotherapeutic Nurse," stated that the primary ways of interacting with psychiatric patients, in addition to all the aspects of physical care, are to meet their dependencr needs, provide support and a proving ground for testing behavior. S The subroles of the workrole of nurses are given by Peplau as mother surrogate, technician, manager, socializing agent, health teacher, and counselor or psychotherapist. 6 J. Frank Whiting and co-authors classified the general aspects of the nurse-patient relationship into four general content areas. These areas were: (1) physical care, (2) sup-portive emotional care, (3) patient education, and (4) lia­sion between patient and others. 7 In characterizing nursing-role concepts held by psy-chiatric nurses and ward administrators, Schwartz, Stephenson and Parlo£f drew a large sample of statements characterizing activities of psychiatric nurses from the following sources: (1) a review of appropriate literature; (2) individual and group interviews with psychiatric nurses employed at several 5Mary Ella Vause, "The Psychotherapeutic Nurse," American Journal of Nursing, (May, 1962), pp. 88-89. 6Hildegard E. Peplau, "Interpersonal Techniques: The Crux of Psychiatric Nursing," American Journal of Nursing, (June, 1962), pp. 50-54. 7 J . Frank Whiting and others, "The Nurse-Patient Rela­tionship and the Healing Process," (New York: A Progress Report to the American Nurses Associations, Inc., 1958), p. 31. (Mimeographed.) 13 hospitals; (3) lengthy interviews with two psychiatrists directing experimental wards at the National Institute of Mental Health; and (4) direct observation of nursing beha-vior. From this initial sample of statements sixty items were selected as representing ideal nursing activities. These sixty items were then classified by seven judges into the fol-lowing five categories~ (1) Physical care, (2) Emotional care, (3) Permissiveness, (4) Propriety, (5) Withdrawal. 8 Nurse-patient relationship process. A review of the literature indicated a growing interest in the field of psy-chiatric nursing in regard to the therapeutic role of the psychiatric nurse. 9 Although there is still a tendency to view the psychiatric nurse in the traditional role of a "medicine nurse" or a "physical-care nurse," or an tladmini-strative nurse," there is a trend toward the study Of the nurse-patient interaction process. This body of knowledge is being developed to help the psychiatric nurse establish and maintain a relationship with psychiatric patients which will aid them in their fulfillment of their potential as human beings. lO 8parloff, ~ cit., p. 142. 9Dorothy E. Gregg, "The Therapeutic Roles of the Nurse," Perspectives in Psychiatric Care, 1, (January- February, 1963), pp. 18-24 -- 10Madeline Leininger, "Changes in Psychiatric Nursing," The Canadian Nurse, 57, (October, 1961), pp. 938-949. 14 "The sum total of what the patient is--the whole patient--seeks nursingo The nurse too, brings her entire self to the patient. nIl Schwartz and Shockley have stated: . there is continuing interaction--action and reac­tion, response and counter response--between the patient and the nurse. . In this chain of interaction the nurse affects the patient in many ways, and the patient also influences the nurse. 12 Kachelski states: The nurse-patient relationship is a bond between two people, one a nurse, the other a patiento Both bring something to that relationship; both need something from it. The patient brings his discomfort and needs some kind of caring from the nurse; the nurse brings her pro­fessional skills and the need for a measure of success and satisfaction in carrying out her role. 13 In discussing interpersonal techniques, Pep1au stated that, "In a carefully guided nurse-patient relationship the nurse learns the art and science of the counseling technique. f1 She argued that the art part of this technique is intu tively based and consists of clinical judgements made by the nurse minute by minute. In teaching counseling to students in this manner they get a full view of the difficulties of a psychiatric patient and of the variations in patterns of behavior. They learn the value of knowledge and proceedures llpamela Poole, "Comprehensive Nursing Care," The Canadian Nurse, 57, (February 1961), po 120. ; l2Morris S. Schwartz and Emmy L. Shockley, The Nurse and the Mental Patient (New York~ Russel Sage Foundation, 1956),po 196. 13Audrey Kachelski, "The Nurse-Patient Relationship," American Journal of Nursing, (May, 1961), po 76. 15 for their application to explain observations. The student is able to work over information with the patient so that he can understand and benefit from his previous experiences in living. Peplau further stated that in teaching counseling in the nurse-pa~ient relationship the nurse learns how not to usurp the time with the patient to meet her own needs. The student learns about herself--her needs for approval, the paintes at which she is vulr:lerable, her strengths and weak-nesses in developing therapeutic relationships. Peplau stated that "students invariably report that learning about counsel-ing of one pa~ient helps them to use to better advantage the two to three minute contacts they have with patients in the ward settingo",14 Studies have been made to evaluate different types of interactions between the patient and the nurse. Methven and Schlolfeldt constructed a social interaction inventory which reveal types of verbal responses nurses tend to make in situa-tions in which the people involved experience considerable stress which produces anxiety. They stated that: One criterion for judging the effectiveness of the nurse-patient relationship would appear to be the extent to which the nurse creates an atmosphere in which the patient is able to progress toward solution of his own problems having direct bearing on his state of health. Verbal exchanges between nurse and patient are one means of creating such an atmosphere. 15 14Peplau, ~ cit., pp. 50-54. lSDolores Methven and Rozella M. Schlol£eldt, "The Social Interaction Inventory," Nursing Research, 11, (Spring, 1962), pp. 83-88. 16 The inventory which they constructed contains thirty situations known to present problems to nurses during their interactions with patients and their families. Five types of responses typically given by nurses were found to be use­ful as a diagnostic and evaluation tool to assess verbal com­munication skills of student nurses and nursing practi­tioners. 16 SUM~~RY Most literature surveyed generally agreed that the broad areas of psychiatric nurse-patient interaction include physical care and emotional care and that hopefully these components of care will be skillfully blended. It is also evident that although all nurses deal with emotions and feel­ings to some extent, this is the primary focus of the psychi­atric nurse, for she is working with patients whose difficulty stems from unhealthy emotions and feelings which interfere with their relationships with people. Other categories of behavior of the psychiatric nurse which have been reported include meeting the patient's social needs, giving informa­tion to the patient, managing and supervising the patient's environment and gathering data about the patient. There is a striking absence, however, of categories of behavior which take into account what is happening to the nurse in the l6I bid. 17 situation except for the category of withdrawal described by Schwartz, et al. 17 It is the belief of the author that with-out such categories limitations exist in analyzing psychi­atric nurse interactions with psychiatric patients. Brown,18 Peplau,19 and others have cited examples of how the nurse may interact with a patient to meet her own needs, but the author has found no published studies which indicate that categories of this particular nature have been used in classifying the actual behavior of nurses in nurse-patient interactions. l7Parlof£, ~ cita, p. 142. l8Brown, ~ cit. 19Peplau, ~ cit., pp. 50-54Q CHAPTEH III METHOD OF HESEAHCH In at:tempting to determine the adequacy o.f the Schwartz, et al , classification of the behavior of psychiatric nurses, it was decided to test it, using recordings o~f actual behavior 0:( sji(hi,)tric nurses ng with psychiatric patients. The tlNO initial ~)roblems considered were (1) to obtain nurse'- pat lent data and (2) to delineate incidents from this data. Recordings made by graduate s~udents in psychiatric nursing, written primarily to scribe w~at had taken place in nursE:--patient interactions with 'no i\catPgoriz2,tions fT in mind, 1JH:;>re availablE' arg1 s(:>l (:cted as the da~ta G be used this investigation. A lot study was conduc ee! t.O establish some criteria for delineating incidents from the recordings of nurse-patient interactions, since ad0quate tools were not available for this. As Arnoult l has stated, one of the major problems lies in escribing behavior in ways which allow for statements to show quantitative relations between stimulus and response. Several investigators had rec erl this problem and offered useful suggestions as ed in the following statements: lI'vlalcolm D. i\rnoul t, nThe i ion o.f a Social Stimulus, T! (For presentation at Symposium of Dimensions o:f Stimulus ituations which Account for Behavior Variance, Texas Christian University, 1961). 19 Arnoult, in his paper, mentioned, A genuine science of behavior consists in determining the relations between stimuli described in the language of physical measurement, and responses described in the same language .... The intervening processes which we adopt should be securely anchored to external, observable events which can be described independently of the behavior which is being explained.. . The elimination of intro­spective data imposed great difficulties on psychologists interested in studying such complex phenomena as emotion, motivation and thinking, but the necessity for limiting ourselves to observed behavior has been accepted, and great strides have been made in discovering ingenious methods for measuring these phenomena. 2 Cattell recognized this problem when he wrote: . any quantitative designation of the psychological meaning of a situation must always be referred to a defined population, as to species and culture. Granted the reference group, by designation of a set of para­meters, then the situational index defines a situation in terms of the meaning of the behavior for the group, which takes place in that situation. 3 Ruesch and Bateson state: A social situation is established when people have entered into communication; the state of communication is determined by the fact that a person perceives that his perception has been noted by others. As soon as this fact has been established, a system of communica­tion can be said to exist. 4 From conclusions reached by the author through con-sideration of these research studies, the following criteria were considered in delineating incidents from the nurse- 2Ibid. 3Raymond B. Cattell, "Formulating the Environmental Situation." (For presentation at Symposium on Dimensions of Stimulus Situations which Account for Behavior Variance, Texas Christian University, 1961). 4Jurgen Ruesch and Gregory Bateson, Communication (New York: W. W. Norton & Co., 1951), p. 28. 20 patient interaction recordings. These were: (l) The group studied is the nurse and the patient, (2) descriptions are of overt behavior, (3) introspective data is excluded, and (4) any observable system of communication between the patient and the nurse is included. Pilot-study to develop means of delineating a nurse-patient incident. Three nurse-patient interaction recordings written by three psychiatric nurse graduate students were selected at random from several hundred done by them and used :for the pilot project. These recordings consisted of a detailed description of what the nurse said, felt, and did, what the patient said and did, and the nurses's interpreta-tion of the interaction. Each interaction had taken place over a period of a few minutes to an hour. The recordings were duplicated, using one column for the communications of the nurse and the opposite column for those of the patient. The nurse's sUbjective feelings and interpretations were deleted from the recordings. Five judges, hereinafter called the "first judges," delineated incidents from these record-ings on two separate occasions, using the following defini-tion for incidents of behavior: Incidents of behavior are specific motor and verbal acts which exhibit some degree of sequential organiza­tion directed toward the attainment of some immediate goal or end state. 5 5Thibaut, ~ cit., p. 12. 21 Another group of judges, who will be referred to in this study as "second judges," delineated incidents from the same recordings used by the first judges during their second attempt at delineating incidents. The second set of record­ings differed from the first set in that interactions with a third party were eliminated. The following table shows the number of incidents delineated by the first judges in their two trial runs and by th2 sE:c'C.Yn(~ juc'hJ~'s "pt,> :r s 1 e effort. The first judges either delineated approximately ~he same number of incidE:nts i 7rcm the recordings both t:imes or else they delineated a fewer number of incidents with the exception of one judge. The fewer number of incidents could be accounted for by the elimination of interactions which included a third party from the second set of recordings. The second judges delineated approximately the same number of incidents as did the first judges in the second trial. To determine if there was a significant difference between the total number of incidents delineated in samples one and two by the first judges the! value was calculated for the means of the two samples and compared with a stand­ard t table .for levels of significance. In the sample the t = 2.34. In the t table with four degrees of freedom at the .05 level of confidence, ! ~ 2.78. This would indicate that the di.fference between the mea.ns of the two samples was not significant and could be accounted for by chance factors. 22 TABLE I PILOT PROJECT DELINEATING INCIDENTS Number of Incidents Delineated by First Judges First Try Second Try Judge V W X Y Z V W X Y Z Interaction #1 5 6 8 10 16 5 '7 5 4 6 #2 4 5 6 7 9 5 9 5 5 6 #3 3 7 5 10 14 4 10 5 5 7 Number of Incidents Delineated by Second Judges Judge M N 0 P Interaction #1 6 7 5 6 #2 4 4 6 7 #3 5 4 5 6 23 The judges stated that their criteria for delineating incidents from the recordings were: (1) changes in activity, (2) changes in position, (3) changes in topic of conversation and (4) pauses. Upon the basis of the results of the pilot project the author decided to use the above criteria for the delineation of incidents for this research. No other suitable criteria for delineating a nurse-patient incident could be located. Preparation of incidents for investigation. Recordings of nurse-patient interactions were obtained from six gradu­ate nurses. The recordings were madeduring graduate work in the Masters Program for Psychiatric Nurses at the University of Utah. Each recording described interactions between the nurse and an acutely ill patient diagnosed as schizophrenic. Approximately forty-five incidents were delineated from each source making a total of 273 incidents. All persons referred to in the incidents were given coded symbols. Each incident was written on a separate paper, num­bered, and placed at random in an envelope containing a key­sheet and instructions for the third judges. (Samples of the keysheet and the instructions are in Appendix A.) The judges were asked to classify each incident into one of the five categories of psychiatric nurse's behavior developed by Schwartz, et al., or into a separate category provided for incidents which the judges believed were not classifiable under the categories developed by Schwartz, et al. 24 SUrvIMARY A pilot study was conducted to determine criteria for delineating nurse-patient incidents. Two hundred and seventy­three incidents were then delineated from nurse-patient inter­action recordings made by six graduate students in psychiatric nursing. Five judges were asked to place each incident into one of six categories: (A) Interventions by the nurse aimed at meeting a patient's physical needs and promoting his physical well-being, (B) Interventions designed to meet the emotional needs of a patient, (C) Nonintervention reflecting respect for the patient's autonomy and integrity, (D) Inter­ventions intended to uphold social standards--both cultural and ward, (E) Predominantly noninterventions due to the nurse's aversion to or intolerance of a patient's behavior, and (F) Interventions or noninterventions not classifiable in categories A, B, C, D, or E. CHAPTER IV PRESENTATION AND ANALYSIS OF FINDINGS Results of investigation. The results of the experi­ment supported the author's hypothesis that the Schwartz, Stephenson and Parloff categories of the behavior of psychi­atric nurses which includes physical care, emotional care, permissiveness, propriety and withdrawal, would not be ade­quate for describing all of the behavior noted in nurse­patient interactions utilized in this study. A large number of incidents were placed by the judges in Category F. Twenty­eight percent of all of the incidents were classified in this category. This number was surpassed only by Category B which rated 36 percent of all the incidents. The rank order of categories according to percentage of incidents classified in each category by the judges is shown in Table II. The number of incidents placed in each category by each judge is shown in Table III. Data ~ the categorized incidents. Examination of the incidents classified in the various categories by the judges gave evidence both to support and question certain assump­tions related to psychiatric nursing behavior. Samples of incidents which were placed in the same category by three or more judges are illustrated in Appendix B. TABLE II RESULTS OF JUDGES CATEGORIZATION OF INCIDENTS Rank Order of Categories B. Emotional care. Interventions designed to meet the emotional needs of the patient. F. Interventions or noninterventions not classifiable in other cate­gories C. Permissiveness. Noninterventions reflecting respect for patient's autonomy and integrity. E. Withdrawal. Naninterventions due to nurse's aversion to or intol­erance of a patient's behavior. A. Physical Care. Interventions by the nurse aimed at meeting a patient's physical needs and well­being. D. Propriety. Interventions intended to uphold social standards--both cultural and ward. Percentage of Incidents 36 percent 28 percent 15 percent 8 percent 8 percent 4 percent 26 27 TABLE III NUMBER OF INCIDENTS PLACED IN EACH CATEGORY OF BEHAVIOR BY EACH JUDGE Category A B C D E F Judge #1 26 113 15 17 41 62 Judge #2 23 96 39 13 2 100 Judge #3 31 161 6 5 1 69 Judge #4 14 44 130 18 3 63 Judge #5 14 74 13 8 71 93 Total 108 488 203 61 118 387 28 Discussion of Categories Category ~ Physical~. This category included interventions by the nurse aimed at meeting a patient's physical needs and promoting his physical well-being. Eight ent of the total number of incidents were placed in this category, and it ranked fifth among the categories. Nurses in various psychiatric settings show a wide ya.tl:]e in activities designed to meet the physical needs of patients. Some nurses in psychiatric settings are engaged almost exclusively in physical care activities while others spend little or no time with the physical aspects of nursing care. In re.ferring to this Schmall stated, HBecause psychi-atric nursing is apt to involve little or no physical care, it bec0mes more difficult to define the qualitative differ­ences between a one-to-one nurse-patient relationship and the patient-therapist relationship in individual psychotherapy.Ifl The findings of this investigation support the assumption that psychiatric nurses do interact with patients to meet their physical needs but that other activities take place HJ.or oJ::ten. A psychiatric nurse spends time with the patient doing whatever seems indicated, based on an understanrling of the needs being expressed by the patient and knowledge of thera- 1 S c h rna 11, 0 p. cit., p. 462, 29 peutic means of meeting such needs. This often means bathing the patient, helping him with his grooming, nourishment, and taking precautions for his safety. The psychiatric nurse assists the patient with needs which are paramount at the time so that more mature needs may emerge. Regression of some patients to an earlier, dependent phase of development necessitates the nurse taking care of physical needs. In additi to this, since psychiatric patients are human beings subject to physical ailments, their care includes medical and surgical procedures. New medications, such as the tranquil­izers, necessitate awareness of untoward effects by the nurse. The physical care of the patient is still a part of psychi­atric nursing. Category ~ Emotional~. This category includes interventions designed to meet the emotional needs of a patient. Thirty-six percent of the incidents were placed in this category, and it ranked first among the six categories. It was anticipated that the largest number of inci­dents would be placed in this category because emotional needs constitute the basis for psychiatric care. As Kackelski has said, "All nurses deal with emotions and feelings to some extent, but .for the psychiatric nurse this area is primary because it is the area of the patients greatest difficulty and discomfort--and his primary reason for being in the 30 hospital.n2 The focus of psychiatric nursing is upon identi­fying, understanding and meeting the emotional needs of the patient. Category ~ Permissiveness. This category was planned to cover nonintervention reflecting respect for the patient's autonomy and integrity. Fifteen percent of the incidents were placed in this category and numerically it ranked third among the categories. The widest range of incidents appear in this category with six incidents categorized as permissive by one judge and 130 by another judge. When one considers the importance of actions which allow the patient to work with others in devel­oping his ability to be responsible for his own behavior, to feel the satisfaction of making decisions which increase his concept of self as a worthwhile individual, to know with cer­tainty that he has a vital role in his own therapy, it becomes evident that the category of permissiveness is closely related to emotional care. In many instances it would be difficult to separate permissiveness from emotional care and this may have resulted in the large number of incidents placed in category C by Judge #4. The definition of this category is ~intervention reflecting respect for the patients autonomy and integrity. Judge #4 indicated that her interpretation of intervention was limited and meant only to ?Kackelski ,·~.ci t. " p. 78. 31 come between as in the case of an altercation, thus she placed incidents in this category which other judges classi­fied as interventions of one kind or another. This variation in definition clouds the picture somewhat. Traditionally, nurses are taught to do things for patients. It is difficult for many nurses to do things with a patient or to let him do things for himself. In psychi­atric settings, this may be especially difficult in that the patient is not supposed to be able to take care of himself, and for him to do so may put an insecure nurse in a precari­ous position. To allow the patient to determine the extent and limits of his own behavior requires the nurse to have confidence in the patient and the degree of confidence she has in the patient is a reflection of the confidence she has in herself. On the other hand, a nurse may not intervene in what the patient is doing, not because she respects his autonomy and integrity, but because she is afraid of the dis­pleasure her intervention might produce in the patient. She also might not intervene due to lack of interest or under­standing of the patient's behavior. Category ~ Propriety. This category provided for interventions intended to uphold social standards--both cul­tural and ward. Four percent of the incidents were placed in this category and it ranked sixth among the categories. The fact that the fewest number of incidents were placed in this category raises many questions. When one 32 considers the traditional role of nurses where much attention is focused upon routines and schedules and other limit set­ting activities, the question arises as to why so few inci­dents were placed in this category. Do psychiatric nurses become less concerned in upholding ward standards? Do they become more concerned for the patient as an individual and how his needs can be best met? Do psychiatric nurses 1 more comfortable than other nurses in situations which would call forth behaviors to uphold social and moral standards? Do psychiatric nurses have a deeper and broader understanding of the dynamics of behavior which permits them to view cer­tain actions without alarm and need :for control, such as behavior with sexual connotations? Does the psychiatric nurse hope to break up pathological patterns of conformity by not being overly concerned with the "do's and donfts" of the ward? The author believes these questions can be ans­wered in the affirmitive. On the other hand, certain standards are necessary for people to get along in any group, and the nurse should be aware of these, understand her feelings in regards to them, and help the patient respond to them in a rational manner. The example of the nurse perhaps the best way to help a patient adopt more acceptable ways of behaving. Category E . Withdrawal. This category provided ~for predominantly noninterventions due to the nurse's aversion to 33 or intolerance of a patient's behavior. Eight and a half percent of the incidents were placed in this category and it ranked fourth among the categories. Withdrawal from or avoidance of a patient has received much attention from Gwen Tudor Wills and Morris Schwartz. They listed the following seven reasons why nurses minimize their contacts with patients (A) to avoid .failure, (B) to avoid a source of guilt, (C) because the patient is chronic and hopeless, (D) because the patient is indifferent, (E) when they focus on negativE behaviors, F) when they with­draw affective interest:; and (G) when they .feel helpless. 3 In the investigation reportEi~d here the number of inci-dents placed in this category slight placed in the category of meet:; needs. The reasons given for withdrawal on the part of the nurse by Wills and Schwartz points Gut the i Ity ;!~he nurse has in being itwith" a patient. The nurse's negative feelings about the patient interfere with her concept of him as a person whom she can help. The fact that such incidents were recorded by the psychiatric nurses may be an indication that they were aware of the significance of these feelings and wanted help in overcoming them. Psychiatric patients in general are very sensitive to how people feel about them. 3Morris Schwartz and Gwen Tudor~'vill, "Low Ivlorale and withdrawal on a Mental Hospital Ward," Psychiatry, XVI (November, 1953), po 337. 34 They are usually aware of attempts made to "cover up" unwanted feelings. It is better for the nurse under these circum­stances to withdraw temporarily until she is able to under­stand and hahdle these feelings frankly with the patient so that the patient can handle them alsoo Category ~ This sixth category was provided for by the author of the study to include interventions or noninter­ventions not classifiable in Categories A, B, C, D, or E. Twenty-eight percent of the incidents were placed in this category and it ranked second among the categories. The large number of incidents placed in this category indicated to the author that much of the time a nurse is interacting with a patient she exhibits behavior which has not been classified by Schwartz, Stephenson and Parloff. No attempt was made in this particular investigation to label the incidents placed in Category F. but many of the incidents reflected concern of the nurse for herself rather than for the patient. This finding indicates a need for additional categorizations of behavior of psychiatric nurses in nurse­patient interactions and that these categories should include behavior which shows needs of the nurse. The range of the number of incidents placed in each category by the different judges, especially in Categories C and E was revealing. This probably indicated individual dif­ferences of opinion of the judges based upon their previous experiences. The investigation did not provide a means for 35 testing this assumption, but it appears that the categoriza­tion of incidents is as much a reflection of the usual beha­vior of the judges of the recorded nurse-patient interactions as it is of the behavior of the nurse whose recordings sup­plied the data for this investigationo The question is also raised as to how much the quality and kind of training of the psychiatric nurse influences her ability to perceive differ-ences in psychiatr nurses behavior. CHAPTER V SUMMARY, CONCLUSIONS AND RECOMMENDATIONS I. S UlVilVJAR Y A categorization of the behavior of psychiatric nurses formulated by Charlotte Schwartz, William Stephenson and Morris B. Parloff was investigated as to its adequateness for classifying a selected sample of incidents of psychiatric nurse behavior. The author proposed the hypothesis that addi­tional categories would be needed in order to have a complete picture of the ongoing patterns of behavior in nurse-patient interactions. The Schwartz categorization included interven­tions by the nurse aimed at meeting a patient's physical needs and promoting his physical well being, meeting the emotional needs of a patient, upholding social standards, both cultural and ward and noninterventions reflecting respect for the patient's autonomy and integrity or due to the nurse's aver­sion to or intolerance of a patient's behavior. In the pre­sent study a category was provided for incidents not falling into the five Schwartz categories but no attempt was made to determine specifically what additional categories might be needed. A review of literature failed to reveal any other research into the categorization of the behavior of psychi­atric nurses although articles have been written which suggest 37 additional categor such as meeting the patient's social needs, giving information to the patient, managing and super­vising the patient's environment and gathering data about the patient. Some authors have cited examples of how the nurse may interact with a patient to meet her own needs, but no published study was found which indicated that categories of this particular nature have been used in classifying the actual behavior of nurses in nurse-patient interactions. In carrying out this investigation it was necessary to find some criteria for delineating a nurse-patient incident. Exploration of the literature did not reveal any tool that could be used for this purpose; therefore, a pilot study was conducted in order to develop a means for delineating inci­dents. To answer the question, HAre categories other than the five set forth by Schwartz, Stephenson, and Parloft necessary in order to have a more complete categorization of the beha­vior of psychiatric nurses as they interact with patients?", 273 incidents of behavior were delineated from nurse-patient interaction recordings made by graduate psychiatric nurses. Five ju were asked to use the Schwartz, et al., categor-ies labeled A, B, C, D, and E, and an additional category, labeled F, to classify these incidents. 38 II.. CONCLUSIONS Twenty-eight percent of the total number of 273 inci­dents were placed by the judges in Category Fo This finding supported the authorrs hypothesis that the Schwartz, Stephenson and ParI off categorization of the behavior of psychiatric nurses would not be complete enough for describ­ing all of the behavior noted in the nurse-patient inter­actions of this study and that additions to this categoriza­tion are desirable. While attempt was not made to determine the nature of the additional categories needed, there were indications that one of the additional categories should pro­vide for nurse behavior stemming from the nurse's own needs. III.. RECO~~ENDATIONS As a result of this investigation the author makes the following recommendations~ 1. Further research should be done to develop cri­teria for delineating specific nurse-patient incidents. 2. Further research should be done to determine the influence of personal experiences of individuals serving as judges when they are classifying similar experiences of other people. 3. A study aimed at identifying and defining addi­tional categores of behavior of the psychiatric nurse in nurse-patient interactions should be conducted. 39 4. Further research into the nature of the concern the nurse has for herself during a nurse-patient interaction should be done. There has been a great deal of emphasis in the field of psychiatric nursing upon the kind of behavior desirable for the nurse while interacting with the patient, but little attention has been paid to the kinds of behavior which actu­ally take place. The patient is expected to take an honest look at himself in order to make a better adjustment to liv­ing and it is on this same emise that the author suggests that the psychiatric nurse look at more than the "ideal" nurse in order to make a better adjustment to nursing. A more complete categorization of the behavior of the psychi­atric nurse in nurse-patient interactions is essential in establishing a solid :foundation for the further development of therapeutic psychiatric nursing. BIBLIOGRAPHY BIBLIOGRAPHY Ao BOOKS Brown, Martha, and Grace Fowler. Psychodynamic Nursing. Philadelphia: W. B. Saunders Co., 1961. Garrett, Henry E. Statistics in Psychology and Education. Nc::w York: Longman, Green a.nd Co., 1958.-- Reissman, Leonard and John C. er. in Nursing Profession4 New 'York~ 1957. Change and Dilemma GQ P. Putnam's Sons, Schwartz, Morris S. and Emmy C. Schockley. the Mental Patient. New York: Russel 1956. The Nurse and Foundation, Thibaut, John W. and Harold H. Kelley. The Social Psychology of Groups. New York: John Wiley & Sons, Inc., 1959. Ruesch, Jurgen and Gregory Bateson, Communication. New York: W. W. Norton & Co., 1951. B. OTHER PUBLICATIONS Arnoult, Malcolm D.. "The Specification of a Social Stimulus. 1f For presentation at Symposium of Dimensions of Stimulus Situations which account for Behavior Variance, Texas Christian University, 1961. Cattell, Raymond B. "Formulating the Environmental Situation." For presentation at Symposium of Dimensions of Stimulus Situations which account for Behavior Variance, Texas Christian University, 1961. Western Interstate Commission for Higher Education. An Approach to the Study of Nurse-Patient Interaction-in PsychiatrIC N'iirsing. Report of the Psychiatric Nursing Group on defining Clinical Content Graduate Nursing Programs, Colorado, 1961. Whiting, J. Frank and others. "The Nurse-Patient Relationship and the Healing Process." A progress report to the American Nurses Associations, New York, 1958. (Mimeo­graphed.) 42 C. PERIODICALS Bresseler, Bernard. "The Psychotherapeutic Nurse," American Journal of Nursing, 62, May 1962, pp. 87-90. Carl, Mary Kathryn. "Components of Psychiatric Nursing,fT Nursing Research, 10, Summer 1961, p. 171. Croley, M. Jay_ "What Does a Psychiatric Nursing Specialist Do?, fT American Journal o~f Nursing, 62, February 1962, pp_ 72-74. Finsinger, Jacob and Sheppard G. Kellam. "Permissiveness­Its Definition, Usefulness and Application in Psycho­therapy," American Journal of Psychiatry, 175:993, May 1959. Fries, Olive H. and M. L. McLellan. "Helping Patients Get Well," Nursing Outlook, 7~654-55, November 1959. Gregg, Dorothy E.. "The Therapc>utic Roles o.f the Nurse," Perspectives in Psychiatric Care, 1, January-February 1963, pp. 18-24. Hayes, Joyce Samhammer. "The Psychiatric Nurse as Socio­therapist, rr American Journal o:f Nursing, 62, June, 1962, pp. 64-67. Kachelski, Audrey. "The Nurse-Patient Relationship," American Journal of Nursing, May, 1961, p. 76. Leininger, Madeline. "Changes in Psychiatric Nursing," The Canadian Nurse, 57, October, 1961, pp. 938-949. McGregor, Esther M. "Is Psychiatric Nursing at the Cross­roads?," Nursing World, April 1958, p. 29. Methvea, Dolores and Rozella M. Schlolfeldt. "The Social Interaction Inventory," Nursing Research, 11, Spring, 1962, pp. 83-88. Parloff, Morris B. "The Impact of Ward Milieu Philosophies on Nursing Role Concepts," Psychiatry, 23, May 1960. Peplau, Hildegard E. "Interpersonal Techniques: The Crux of Psychiatric Nursing," American Journal of Nursing, June 1962, pp. 50-54. Poole, Pamela. "Comprehensive Nursing Care," The Canadian Nurse, 57, February, 1961, po 120. 43 Schmall, Jane A. "The Psychiatric Nurse and Psychotherapy," American Journal of Nursing, July 1962, pp. 460-465. Schwartz, Morris and Gwen Tudor ~vill.. "Low Morale and Wi th­. prawal on a Mental Hospital Ward," Psychiatry, XVI, November 1953, p. 337. Vause, Mary Ella. "The Psychotherapeutic Nurse," American Journal of Nursing, May 1962, pp. 88-89. APPENDIX APPENDIX A DIRECTIONS FOR JUDGES The purpose of this study is to investigate the possi-bility that the categorization of the behavior of the psychi-atric nurse as formulated by Charlotte Schwartz, William Stephenson, and Morris B. Parloff, is not sufficiently com-prehensive in categorizing all of the behavior of nurses involved in nurse-patient interactions. Incidents (275) have been delineated from recordings made by six graduate nurse students. You are to classify each of these incidents into one of the five categories developed by Schwartz, et al., or into a separate category for those incidents which are not classifiable in the categories developed by Schwartz, et al. It will take approximately two hours to classify these incidents and it should be done in one sitting. 1. Familiarize yourself with the six categories listed under Psychiatric Nurse's Behavior on the keysheet. 2. On the accompanying keysheet place the number of each incident in the square representing the category which best describes the behavior of the nurse. 3. You may change the placement of the incidents at any time. 4. Return the incidents along with the keysheet to me at the earliest possible date. Thank you. KEYSHEET PSYCHIATRIC NURSE'S BEHAVIOR A. Interventions by the nurse aimed at meeting a patient's physical needs and promoting his physical well-being. B. Inte~ventions designed to meet the emotional needs of a patient. C. Nonintervention reflecting respect for the patient's autonomy and integrity. D. Interventions intended to uphold social standards-­both cultural and ward. E. Predominantly noninter­ventions due to-the nurse's aversion to or intolerance of a patient's behavior. F. Interventions or non­interventions not-cIassi­fiable in categories A, B, C, D, or E. 46 JUDGE'S CLASSIFICATION OF INCIDENTS APPENDIX B ILLUSTRATION OF INCIDENTS Category A: Physical care. Interventions by the nurse aimed at meeting a patient's physical needs and promoting his physical well-beingo Incident #2~ Mrs. B. sat on couch, puffing, rubbing her brow. Occasionally she moaned. Nurse said, "Mrs. B. 's tired?" Mrs. B. looked at nurse, chuckled, "I'm real tired. IT Nurse said, Heome, Mrs. B., and I will fix your bed so you can nap." Incident #12: Mrs. B. was not eating. Nurse said, "Do you need more sugar on your cereal ?" Mrs. B. did not look up but said, "Yes." Nurse poured sugar and handed her a spoon. Mrs. B. ate cereal. Incident #42: Mrs. B. smoked cigarette until just small end left, held on to it. Nurse took cigarette from hand and put it outo Incident #5: Nurse found Mrs. B. lying on bed in night­clothes. After greeting her she said, "May I help you get dressed?" Mrs. B. said, "Yes." They went to clothes room together and nurse assisted her with dressing. Incident #103: Nurse helped Mrs. B. with her bra, plac­ing the sanitary pad in them to soak up the milk from her breasts. Category B: Emotional Care. Interventions designed to meet the emotional needs of the patient. Incident #11: Mrs. B. said, "I'm afraid. I wish I could sleep .. " She took of:f her shoes, lay down on her bed, reached for nurse's hand. Nurse covered her and held her hands. Incident #23: Mrs. B. began to cry. Nurse put her arm around her shoulder. Mrs. B. put her head on the nurse's bosom. Nurse put her other arm around her. Mrs. B. lay still .. 48 Incident #90: Mrs. B. looked at Mrs. A. Her eyes widened, she pulled the nurse into her room. Nurse said, "Does Mrs. A. frighten you?" Mrs. B. said, "Yes," and began walking around the nurse, holding on to her hand. Nurse stayed close to Mrs. B. Incident #20~ Mrs. B. lay watching the nurse. Soon she began to shake the bed with her feet and continued to look at the nurse. Nurse began to rock the bed gently as she watched Mrs. Bo Category c~ Permissiveness. Nonintervention reflecting t for the patient's autonomy and integrity. Incident #248: Mrs. B. walked down hall, looking straight ahead. She paused at top of stairs, then began to des­cent them. Nurse followed her silently. Mrs. B. stopped suddenly, squinted her eyes. Nurse took her arm. Mrs. B. shook nurse's hand off and started walking up the stairs saying, "Don't take me down there. I don't want to go . and don't lead me around, I don't want you to lead me around, I'm a sane girl." Nurse said, "I'll wait here for you." Mrs. B. walked up to the first landing, paused and returned, saying, "You can come now you want to . it's okay,," Nurse joined patient. Incident #25: For ten to £teen minutes Mrs. B. was almost constantly moving about, getting people to sign her notebook with their names and addresses •.. trying to give her fruit away ... talking to Dr. A ... going to the bathroom. Nurse remained on chair where both Mrs. B. and she had been sitting. Mrs. B. came to nurse every few minutes for a second or two. Soon she sat down and began talking with the nurse. Incident #137: During the ride Mrs. B. asked nurse if they could stop, saying, "I need to get some milk for mother." Nurse parked the car, waited while Mrs. B. went into the store. Incident #102: Nurse said, "Mrs. B. would you like to sit down?" lVlrs. B. said, "Wai t a minute." She stood watching and listening. Nurse sat and waited. Mrs. B. slowly backed toward the chair and sat down. Category D~ Propriety 0 Interventions intended to uphold social standards--both cultural and ward. Incident #21: Mrs. B. and the nurse were sitting together. Mrs. B. said, "Do you mind if I smoke?" Nurse said, "Not at all, go right ahead." Incident #36 Mrs. B moved in chair so that bottom of her robe came open midway above her knees. She got up, pulled the sides of the robe together. 49 Incident #186: Mrs. B. started to leave the room without putting her cosmetic box awayQ Nurse said, "Let's put your box awaYort Mrso B. turned, took box and put it a\vay" Category E~ Withdrawal. Predominantly noninterventions due to the nurse's aversion to or intolerance of a patient's behavior~ Incident #272~ Mrs. B. sat down between two women. Nurse sat in chair opposite her, watching her. Mrs. B. caught the nurse1s eye and stared for a long time, smiled and began to laugh. The nurse left. Incident #34 ~ Mrs. B. said, "Guess who's coming today?'" Nurse said, "Who?" Mrs. B. said, "Mr. Santa Claus. He's going to bring us some bubble gum and we're going to see who can blow the biggest bubbles. ff Nurse remained silent. Incident #97~ Mrs. B. held up her underpants and said, "I don't want to lose these. "they're the only ones my husband bit a hole in." She looked at the nurse and said, "That shocked you, didn't it?" Nurse said, "Oh, I don't know--did I seem to be shocked?" Mrs. B. said, "Sure you did. 1t She stood up, "I'm more human than you are." Incident #114~ Mrs. B. said, "I was angry with you because I thought you called me a Jew." Nurse said, "Did you really think I called you a Jew?" Mrs. B. paused, covered her :face, rubbed her eyes, and said, "Yes, n looking intently at the nurse. Nurse did not reply. Category F: Interventions or noninterventions not classi­fiable in categories A, B, C, D, and E. 50 Incident #72: Nurse noticed how nice Mrs. B. looked after she helped her get dressed up. "Mrs. B., shall we go to the lounge and sit down?" Mrs. B. started to follow the nurse, then turned, saying, "Wait a minute." She then pulled her hair down over her face and smeared lipstick on her chin. Incident #105: Mrs. B. said, 711 saw Mrs. Y. at the hospital. She is sweet to me. I like her. Of course, I always liked you too,," Nurse said, "We really didn't see a lot of each other while I was at the hospital." Mrs. B. said, "No, but I saw you take C. for walks." Incident #75: Mrs. B. said, "Are you sure you couldn't get me on with the pink 1adiE.~s?1T Nurse replied, "I really don't know anything at all about the volunteers." Mrs. B. said, "Dr. S. told me to ask you about it." Nurse replied, "No, I don't know anything about it." Incident #117: Mrs. B. said, "Miss R .. is getting married. Are you invited to the wedding?" Nurse said, "Yes, I think I will take care of the guest book or something." Incident #239: Nurse said, "I"f you had the chance, Miss B., would you go out with F. again?" fvliss B. replied, fiNo, I don't think so." Nurse asked, "But you're not sure?U l'vliss B. said, nYes, I'm sure. I wouldn't go out with him.n