Psychiatric aides' perceptions of the nurse-patient relationship

This thesis reports a study in which the Whiting Q-sort methodology of assessing values and perceptions in relation to patient care has been applied to psychiatric aids in a state mental hospital which conducts a pre-service training program. The aim has been to assess those aspects of nursing care-physical care, supportive emotional care, liaison, and patient education-considered of greater and of lesser importance by a group of psychiatric aids (1) before a pre-service education program, (2) at the end of the pre-service education program, and (3) after the trainees have spent one month caring for mental ill patients.

PSYCHIATRIC AIDES' PERCEPTIONS OF THE NURSE-PATIENT RELATIONSHIP by Lottie P. Felkner A thesis submitted to the faculty of the University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Nursing University of Utah Ju~e, 1961 This Thesis for the Master of-Science Degree by Lottie P. Felkner has been approved May, 1961 L:h -t :;L. Reader, supervrs~li&mmrttee tee ACKNOWLEDGMENTS Grateful acknowledgments are expressed for the splendid cooperation on ~he part of the utah state Mental Hospital Nursing Service Department, the Chairman of the Research Committee at the hospital, a.nd the psychiatric aides who participated in this study. Specifically, I wish to thank Miss Cynthia Curtis, R.N. and Edward H. Beaghler, M.D. for making the study possible. Sincere appreciation is due Nr. Leo Ericksen and Mrs. Kathryn Sums ion , psychiatric aide instructors, for their close cooperation and interest in the project. Recognition is given to the American Nurses' Founda­tion and to Dr. J. Frank Whiting, for their permission to use the Q-sort instrument in this research project, with special thanks extended to Dr. Whiting for additional material and helpful suggestions. To my committee, especially to my chairman, I wish to express my thanks for their gUidance, constructive cri,ticisms, and encouragements. Special thanks are extended to my t'ypist for her helpful assistance and cooperation. To Gary, Marilyn, and Bill my most humble thanks for making it possible for me to devote uninterrupted time to this project. TABLE OF CONTENTS CHAPTER . 1. II. INTRODUCTION • . .~ . . . . . · . . . · . . . statement of the Problem • Importance of the Problem · . . . . . . . . . · . . . . . . . Hyp othes es • . • • • • • • • • Definition of Terms ••••••• Delimi ta tiona • • • • • • • • • • REVIEW OF THE LITERATURE • • . • • • · . . . . . · . . . . . • • • • • • · . . . . . PAGE 1 4 5 7 8 11 13 Psychiatric Aide Training •• • • • • • • •• 13 III. IV. V. Application of the Whiting Q-Sort Methodology to the Nurse-Patient Relationship . . . . . Summary of Review of Literature • • . . . DESIGN • • • • • • • • • • • • • • · . . • • • • THE FINDINGS • . . • • • • • • • • • • • • • Pre-Service Instruction The Work Experience •• . . · . . . . . . · . . . . . . Discussion of the Aides' Point of View on the Nurse-Patient Relationship • • • • • • • •• SUMMARY, CONCLUSIONS, AND RECOM:MENDATIONS • • • 'Summary . . . . . . . . . . . . · . . . . . . Conclusions and Recommendations • • • • • BIBLIOGRAPHY • • • • · . . . . · . . · . . . . • • APPENDIX A. Letters • • · . . . . · . . · . . . . • • 19 23 26 34 49 64· 81 92 92 95 99 104 CHAPTER APPENDIX B. ,APPENDIX C. APPENDIX D. Q-Sort Items . . . . . . . . . . . . Instructions for the Q~Sort and Forms • • Comparison of the Rank Assigned to the Q-Sort Items in All Three Sorts; Tabulation or Raw Data . . . . . ~ . . APPENDIX E. Basic Training Course for Psychiatric v PAGE 106 114- 120 Aides • • . • • • • • • • • • • • ., •• 132 APPENDIX F. Job Description of Psychiatric Aide • •. 135 LIST OF TABLES TABLE I. Nurse-Patient lationship Q-Sort .. . . . . .. . II. III. IV .. V. Background Variables of the Fourteen Aide- Students .. • .. • • • <» .. • • • • .. • .. .. • · .. category and Item Means for Sort I • • . . . . .. category and Item Means for Sorts I and II . Items for Which a Statistically Significant Difference Was Found in Sort II As Compared · . PAGE 22 35 49 58 With Sort I ... .. . .. . • • • . .. . • .. ... 60 VI. Summary of Category and Item Means for All Three Sorts . . . .. .. . .. . .. . .. . . . .. VII. Items for Which aSta~istically Significant Difference Was Found in Sort III As VIII. IX. X. XI. XII. XIII. Compared Wi th Sort I . • • • • .. ..... Items for Which a Statistically Significant Difference Was Found in Sort III As Compared With Sort II ••• . • .. .. .. Corr~lation Coef.ficients for Sorts I and II, I and III, and II and III .. • • . .. • . .. Comparison of the Rank Assigned to the Q-Sort .. . · .. Items in All Three Sorts .. • .. • .. .. .. Tabulation of Raw Data--Sort I • Tabulation of Raw Data--Sort II Tabulation of Raw Data--Sort III . . . . . .. . . . . . . .. .. . .. .. .. 73 74 78 120 123 126 129 CHAPTER I INTRODUCTION Mental illness is a major social problem. The number of mental patients, who are identified and diagnosed is increasing. Some familiar statements are: Out of every twenty-two persons living today, one will spend part of his life in a mental hospital. Recent studies indicate that one out of every ten persons in the United States is emotionally or mentally maladjusted and needs treatment for some personality disorder. More than half the patients who visit their family doctor for some physical ailment are really suffering from some type .of emotional disorder. Nervous and mental diseases take a larger toll than do lancer, infantile paralysis, and tuberculosis combined. Providing adequate care for the mentally ill is a complex task involving many major problems. One of the gravest problems is that of supplying sufficient numbers of personnel to care for the patients. In the nursing field alone, the problem is very acute. One authority states that the committee on nursing in psychiatrlc hospitals of the National Health Assembly pointed out that half of the nationts hospital beds are occupied by mentally ill patients and are serviced by less than two per cent of all the registered nurses. 2 IGeorge Thorman, Toward Mental Health, Public Affairs Pamphlet, No. 120, 1948, ,po 22. , 2Paul V. Lenikau, "Toward Mental Health, If Mental Hygiene, 36':203, April, 1952. 2 The American Hospital Association states that on the average day in 1957 there were about 675,000 patients in psychiatric institutions. This figure represents only those hospitals that participated in the 1957 American Hospital survey. The reporting hospitals, not all of which gave complete data, listed the following ratio of nursing per­sonnel: 3 14,000 registered professional nurses 8,000 practical nurses 100,000 psychiatric aides These statistics point to the fact that most of the twenty-four-hour-a-day nursing care of mentally ill patients is given by psychiatric aides and attendants. This type of personnel constitutes over 80 per cent of the nursing staff in psychiatric institutions.4 Of all people concerned with the treatment and care of the psychiatric patient, the psychiatric aide has the most continuous and intimate association with him. The aide has the opportunity to develop close relationships with patients and to observe patient behavior in a variety of situations. Professional nursing education is emphasizing a change in the nurse-patient relationship from one which stressed physical care to a broader relationship which considers the 3Hospitals, Guide Issue, August 1, 1958 (Part 2). 4Suggestions for Experimentation in ~ Education of Psychiatric Aides, National League for Nursing, 1959. (Monograph) 3 psychological and social aspects of the patient. As a nurse educator specializing in the area of psychiatric nursing the writer of this thesis has been inter­ested in finding out to what extent the newer philosophy of nurse-patient relationship is be}ng transmitted to groups of psychiatric aides, what methods have been used, and how the outcomes have been measured. Some pioneer work has already been done in this area and promising tools developed. In an attempt to promote greater understanding about the nurse-patient relationship, the American Nurses' Founda-tion awarded a grant-in-aid to the Veterans Administration Hospital, Rutland Heights, Massachusetts, for a one-year methodological study.5 The purpose of the study was to develop techniques which would provide data in relation to the nurse-patient relationship. A Q-sort technique developed by Dr. J. F. Whiting made possible the gathering of data concerning the registered nurses' and patients' values and perceptions related to specific functions performed in the course of daily patient care. 6 5 J. Frank Whi ting and others, "The llurse-Pa tient Rela­tionship and the He~ling Process, JJ A Progress Report t·o the American Nurses' Foundation (New York: The American Nurses' Foundation, Inc., 1958), p. v. 6Ibid ., po vii. 4 In contrast to the registered nurse, the psychiatric aide has usually had no preparation in nursing at the begin­ning of his or her employment. Some hospitals offer a pre­service education program. One advantage of pre-service instruction is its potentiality for being patient-centered instruction rather than traditional procedure-centered instruction. This thesis reports a study in which the Whiting Q-sort methodology of asseSSing values and perceptions in relation to patient care has been applied to psychiatric aides in a state mental hospital which conducts a pre-service training program. The aim has been to assess those aspects of nursing care--physical care, supportive emotional care, liaison, and patient education--considered of greater and of lesser import­ance by a group of psychiatric aides (1) before a pre-service education program, (2) at the end of the pre-service education program, and (3) after the trainees have spent one month caring for mentally ill patients. I. STATEMENT OF THE PROBLEM It is being increasingly recognized that the persons working most closely with the psychiatric patient are the ones who can most readily change or influence behavior of the patient. The fact that this close interpersonal relationship can have either a healing or a harmful effect is important and points up the need for the nurse and psychiatric aide to understanct not only what the patient is doing and why, but also what the nurse or aide is doing and how it is affecting the patient. Nursing personnel as in~,ividuals and as groups have been shown to vary in the importance they assign to the various nursing funotions they perform, and this difference in valuation is likely to influence the emphasis given to oertain types of nursing oare. 7,B, 9 The study reported here has been an attempt to ,disoover what elements of patient oare are oonsidered of greater and of lesser importanoe by a group of psyohiatric aides before a pre-servioe training program, ,at the end of the training program, and after the trainees have spent one month oaring for psyohiatric patients. II. IMPORTANCE OF THE PROBLEM It is believed that each person who enters the patient's life has an influence on him, and this influence 7 J. Frank Whiting, "Q-Sort: A Technique for Evalua ting Perception of Interpersonal Relationships," Nursing Research, 4:73, October, 1955. BErnest Dichter, "A Psyohological Study of the Hospital patient Relationship; What the Patient Really Wants from the Hospital," Modern Hospital, B3:51-54, September, 1954. 9Francoise Morimoto, "Favoritism in Personnel-Patient Interaction," Nursing Research, 3:109-11, February, 1955. 6 may be either of a harmful or helpful nature. The hospital­ized mentally ill patient has continuous contact usually with only one group of personnel, psychiatric aides. One of the biggest problems with which state mental hospitals deal is the problem of recruiting suitable employees to give care to the patients. One state hospital superin­tendent wrote sixty-six years ago that ••• the welfare and comfort of the inmates, and their recovery as well, depends la.rgely upon the personal character of the attendants. The duties of those directly engaged in the care of patients are varied, and for their most successful performance require talent of no mean order. The attendant needs to control and direct those under his care, and at the same time be a companion and an entertainer. It often happens that he who enter­tains and pleases best, fails in housekeeping, while the good housekeeper, who polishes the door knobs to the brightness of mirr,or, rasps the patients's feelings with equal vigor. Hence the complaint is rife allover the country that the attendants are continually changing and so often are unsatisfactory.lO In the past the attendant was concerned chiefly with the realm of activities having to do with the physical care of the patient. Attention to the patients' basic needs: eating, bathing, dressing, sleeping, and elimination, com-prised the daily routines which filled the greater portion of the attendant's day. He watched the depressed, the hyperactive, the suspicious, and the withdrawn, with limited understanding and insight as to the meanings of these kinds lOBernard Hall and others, PS)Chiatric Aide Education (New York: Grune and Stratton, 1952 , p. 4. 7 of behaviors. In giving nursing care to patients, the psychiatric aide or attendant operates, consciously or unconsciously, Qn the basis of his concepts, particularly his concepts about people and the way they feel and act. In directing a study toward assessing those elements of patient care considered of greater and of lesser importance by a group of psychiatric aides, it was thought that some general inferences as to attitudes might be confirmed. III. HYPOTHESES After reviewing the literature in the general area of psychiatric aide training, the researcher of this study concluded that no significant differences could be found in the trainees' perceptions of the nurse-patient relationship with respect to the mean scores assigned to the four categor­ies: (1) physical care, (2) supportive emotional care, (3) liaison, and (4) patient education, before and after a four-week training sessione It was assumed that the trainees would perceive the physical aspect of the nurse-patient relationship as rela­tively more important after having spent a period of time working in direct contact with patients. The reasons for this assumption were: (1) the trainees would take on atti­tudes from other aides in the ward setting, which had been 8 observed and in which emphasis appeared to be on physical care; (2) the fact that in this particular hospital setting there were no professional nurses working at the ward level; (3) the popular public image of the nurse as a person who gives physical care to those unable to care for themselves. In view of the literature reviewed and the first-hand knowledge gained from observing the teaching methods and student activities during the training program, two major hypotheses were formulated: Hypothesis #1. There will be no statistically signifi­cant differences in how the aides perceive the nurse-patient relationship before and after the pre-service training program as measured by the mean score assigned to the four areas being evaluated in this study. The trainees will perceive the categories in the nurse-patient relationship Q-sort in the following order of importance: (1) liaison, (2) physical care, (3) supportive emotional eare, and (4) patient educa­tion. HypotheSis #2. After working for a period of one month on the wards, the aides will rank the categories of nurse-patient relationship in order of importance as follows: (1) physical care, (2) liaison, (3) supportive emotional care, and (4) patient education. IV. DEFINITION OF TERMS Psychiatric~ aide or attendant. These terms are used 9 interchangeably. This is a person who assists with the care of the mentally ill. The title "psychiatric aide" usually means the person has had some form of instruction. In some hospital settings, due to the shortage of professional nursing personnel, the psychiatric aide may work in charge of a ward or of a group of other aides. Remotivation. When psychiatrically ill patients have lost the will to survive, the remotivation technique is an attempt to appeal to the unwounded portion of the personality to assist the patient to become active and interested in his surroundings. Ward level. This is a term which implies giving direct patient care in the ward setting. Nursing ~ functions. Any function which is per­formed directly for or in behalf of the patient, and which contributes to his well being, is designated as a nursing care function. The specific functions used in the investi­gative research reported in this thesis were the one hundred items contained in the Q-sort, the instrument utilized in this study. A complete list of these functions may be found in the Appendix of this thesis. Categories of nursing functions.llIn order to llWhi ting and others, "The Nurse-Patient Relationship 10 understand the varying emphases which are put upon different general aspects of the nurse-patient relationship the one hundred items in the Q-sort were classified as follows: 1. Liaison--This category refers to those activities that are carried out between the nurse and the doctor, or the nurse and other staff members or depa~tments, concerned with the care and the treatment of the patient. 2. Physical Care--This category refers to those nursing fUnctions directed toward meeting the biological needs of the patient. 3. Supportive Emotional Care--This includes those nursing care functions that offer support to the individual patient by meeting his psychological needs. 4- Patient Education--This category includes all activities concerned with helping the patient gain knowledge ~nd understanding about his illness and about health matters in general. Therapeutic~. .Includes aspects of patient care, the principles of which are based on the science or art of healing. Professional nurse. A nurse who has graduated from a state accredited school for nurses and is licensed to and the Healing Process," .2.E.- cit., p. 31. 11 practice as a registered nurse. Interpersonal approach. The act of using onevs per­sonality as a communication tool. v. DELIMITATIONS This study is limited to one class of psychiatric aides participating in a pre-service education program at a state mental hospital. All class sessions were observed by the researcher of this study for the purpose of gaining knowledge about the course, the varlous methods of teaching, and the frequency and extent of use of these methods, even though teaching methods were not an issue in this research. The course was conducted as planned. No changes were made in terms of course content and methods of instruction. No attempt was made to study the aide-patient relation­ship. It was not within the purposes of this study to analyze nursing care given by the aide. The purpose of this study was to assess the changes that take place within the group as to perception of the nurse-patient relationship after: (1) having been exposed to a pre-service education program designed to introduce the trainees to the various elements of nursing care significant to the psychiatric patient, and (2) having spent a period of one month working on the ward. The discussions and analysis of the findings were based upon the assumptions and observations of only one person, the researcher of this project, and have not been subjected to further examination. 12 CHAPTER II REVIEW OF THE LITERATURE The review of literature was limited to two general areas: (1) psychiatric aide instruction and (2) application of the Whiting Q-sort to the nurse-patient relationship. The review is organized into two sections corresponding to these areas. There were many sources relating to psychiatric aide instruction and" except for a very brief historical review, only those sources emphasizing instruction in relation to the changing role of the psychiatric aide in response to the newer concepts of psychiatric care are incladed in this report. Although no other research e4 actly paralleled the approach taken in this study, the literature did reveal three .studies in the psychiatric setting in which the Q-sort methodology developed by Dr. J. Frank Whiting was used and several in non-psychiatric settings. I.. PSYCHIATRI C AIDE TRAINING Historically, the development of instructional pro­grams for psychiatric aides has been related to the develop­ment of nursing education programs. l ,2 When the early IBernard Hall and others, Ps)chiatric Aide Eduoation (New York: Grune and Stratton, 1952 , p. 18. ---- 2Alice M. Robinson, The Psychiatric Aide (Philadelphia: J. B. Lippincott Co.), pp. 3::tr. 14 training schools established for nurses in mental hospitals were forced to close because they could no longer meet the high standards required for nursing education, in most i instances no provision was made for the education of attend-ants. These untrained attendants had to assume the vital role of caring for the mentally ill patients. 3 About the only preparation the attendants received was of an in-service nature, and in many state hospitals even this type of educa­tion was not attempted.4 For a long time conditions in public mental hospitals were not good for several reasons: poor pay, poor working conditions, failure of the public to recognize the social problem of mental illness, and the absence of adequately trained professional personnel.5 Shortly after World War II, with a better supply of manpower available, Dr. Karl A. Menninger, in cooperation with the Veterans Administration and the Menninger Foundation, started The Menninger School for Psychiatric Aides. 6 Because of the continued shortage of professional nurses in the public mental hospitals, other hospitals began to develop similar programs. In 1947, New Jersey established educational pro­grams for psychiatric aides in four of its state hospitals. 3Hall and others, £E. cit., p. 8. 4Robinson, ~. ci t., p. 4. 6Hall and others, £E. cit., p. 13. 15 Since World War II, the Veterans Administration Nursing Service has constructed a curriculum for the nursing assist-ants in the Veterans Administration's hospitals throughout the country.? In 1948, the American Psychiatric Association survey indicated that ninety-rive attendant training programs existed in one hundred ninety-two hospitals. 8 These programs stressed the importance of physical care, learning of diag­nostic terminology, and the management of the hyperactive patient chiefly by mechanical means. With the development or newer concepts in psychiatry, the role of the psychiatric aide is beginning to change. 9 ,lO,11,12,13 One or the most important psychiatric developments of the past few years has been the introduction of the so-called tranquilizing drugs. In many instances such '. major disorders as psychotic behavior have disappeared follow-ing administration of tranquilizing agents. As a direct 7Ibid., p. 111 .. 9IOid .. , pp. 114-115. 8I bid .. , p.. 1 6 .. lORobinson, £E. cit., p. 14 .. ~lHenry Brill and Lillian Salsman, "Mental Hygiene and the Tranquilizing Drugs ," Nursing World, CXXX, No.6, (June, 1956), 8. 12Robert N. Rapoport and Rhona S., Belmont Hospital, Surrey, England, "Democra tiza tion and Authori ty in a Thera­peutic Community," Behavioral Science II, No.2 (April, 1957), 128. 13Maxwell Jones, The Therapeutic Community (New York: Basic Books, 1953). 16 result of drug therapy, nurses and other ward personnel have recognized the improvement which has taken place in morale of patients and employees and the increased opportunities for constructive work with patients. 14 However, one nurse warns: An attendant in one state hospital commenting on these differences said: "In the good old days we used to have two or three battles a dayl" When the major portion of a day was concerned with activities commonly lumped under the heading of custodial or semi-custodial care, there was little opportunity to heed preSSing personal problems of patients. Now many more patients are bathing, feeding, and dressing themselves. This leaves a kind of vacuum which will most assuredly produce anxiety on the part of personnel. Anxiety is uncomfortable, so they will move to relieve discomfort. They may move in pro­ductive ways that will be helpful to patients. Or they may be nonproductive, devising novel schemes to keep them busy, andlthe old pattern will proceed under a new coat of paint. ;, The direction in which the personnel move will depend to a.great extent on the kind of leadership and guidance available to them. Most state hospitals do not have pro-fessional nurses to care for patients. In these hospitals the aide is expected to do complicated tasks, such as give medications, including narcotics. Both the American Psychi-atric Association and the American Nurses' Association recognize the need for more formal education for the 14Brill and Salsman, loco £!1. 15Elizabeth M. Maloney and Lucile Johannesen, "How the Tranquilizers Affect Nursing Practice," The American Journal of Nursin8, LVII, No.9 (September, 1957), 1144. 17 psychiatric aide. 16 However, this area of nursing has not been defined well enough to establish standards and minimum qualifications for licensing the psychiatric aide. Some hospitals offer an in-service education program to meet the needs of the aide as they relate to a specific hospital ward or unit. Other hospitals 'offer the aides experience in group work with patients. The "remotivation" technique used almost exclusively by the psychiatric aide is a very valuable tool in helping the aide to know, understand, and to better communicate with his patient. 17 ,18,19 With better communications with patients, there is less need for physical restraints, seclusion, or even sedatives. Several nursing studies reviewed were aimed at increas­ing understanding of the nursing care of the mentally ill.2~21,22 16"The Preparation and Licensing of Psychiatric Aides," ~ American Journal of Nursing, LVI, No.2, (Feb., 1956), 197. 17Walter F. Pullinger, Jr., "Remotivation," The Ameri­can Journal of Nursing, LX, No.5 (May, 1960), 682.--- 18Robinson, £E. cit. 19Helena Willis Render and Olga M. Weiss, Nurse­Patient Relationships in psychiatri (second edition; New York: McGraw-HIll Book-Co., Inc., 959), pp. 275-282. 20Gwen E. Tudor, ffA Socio-psychiatric Approach to Interaction in a Problem of Mutual Withdrawal on a Mental Hospital Ward," Psychiatry, 15:193, 1952. 21June Mellow, "Research in Psychiatric NUrsing: Part a, Nursing Therapy with Individual Patients," The American Journal of Nursing, 55:572, 1955. ' 22Harriet Kandler and others, "A Study of Nurse-Patient Interaction in a Mental Hospital," The American Journal of Nursing, 52:110-1103, 1952. 18 It was generally agreed by these authors that improved communication skills among patients and personnel could help the patient in his movement toward health. Also, these studies tended to support the theory that knowledge of human behavior is a prerequisite to establishing effective nurse­patient relationships. One experimental study by Bernstein and others con-cluded that nurses' skills and attitudes in interpersonal relationships can be modified when nurses understand the techniques they are using and how these techniques affect behavior of the patient. 23 A somewhat similar experiment was conducted by Morris M. Pauleen, Ph.D., at the New Jersey Neuro-psychiatric Institute for psychiatric aides. This study had as one of its main objectives the development of understanding of human behavior in the trainees and the impr0vement of their perception and understanding of patients' behavior as human behavior similar to their own. 24 While it was concluded that this objective was reasonably well attained in six months, it was recommended that the course be extended to one year in length to allow 23Lewin Bernstein and others, "Teaching Nurse-Patient Relationships," Nursing Research, I, II, and III, 1952, 1953, 19.54. 24Morris M. Pauleen, "A Training Experience in Inter­personal Relations for Paychia tric Technicians, If Mental Hygiene, XLII, No.1, January, 19.58. 19 the trainees opportunity to develop a greater depth of understanding of human behavior. This recommendation to extend the program to one year is in agreement with man~ other programs outlined for the psychiatric aide. One such program--A Modified Practical Nurse Program for Psychiatric Aides in Minnesota25_-is nine months in length. However, since this program is relatively young, no evaluation of it is available. At the present time there are several types of pro­grams for the psychiatric aide: (1) the short pre-service programs ranging in length from two weeks to twelve weeks; (2) courses ranging in length from six months to twenty-four months; (3) in-service training only; and (4) ·a combination of a pre-service program and an in-service training program. II. APPLICATION OF THE WHITING Q-SORT METHODOLOGY TO THE NURSE-PATIENT RELATIONSHIP The Whiting Q-sort was developed to answer such questions as: What attitudes and expectations concerning the relative importance of nursing functions as socialization, 25 Annie Laurie Crawford, Ruth G. Hahn, 'a nd Sister Mary Dorothy, ttA Modified Practical Nurse Program for Psychiatric Aides in Minnesota," Nursing World, CXXXI, No.6, June, 1957. 20 satisfaction of emotional needs, education, and physical care are held by different groups within the nursing profession and by various groups which come into contact with nurses?26 What the-person feels is important in terms of the nurse-patient relationship is of paramount importance since all the functions nurses are called upon to carry out with patients are important to someone. 27 ••• man thinks, feels, imagines, muses, dreams, and all else. All such is behavior, every bit as certainly as is his purposeful walking from one place to another or his toying with a ball. In so far as this subjective behavior can be made amenable to reliable. operations, scientific method is at issue and, in that sense, objec­tive procedures. This is precisely our position in Q­methodology. Along Q-lines all subjective behavior, regarded as arbitrary and unscientific, is capable of study with full scientific sanction, satiafying every rule and procedure of scientific method.2~ The Whiting Q-sort is designed to solve two major problems: (1) the problem of correlation, or degree of similari ty, between differen1t indi viduals' or different groups' attitudes, expectations, or opinions at a given time; and (2) the degree of change in individuals' or groups' 26J • Frank Whiting and others, rtThe Nurse-Patient Relationship and the Healing Process," A Progress RetOrt to the American Nurses' Foundation (New York: The Amer can 'Nii'rses ' Foundation, Inc., 1958), p .. 16. 27-Ibid. 28William Stephenson, The Study of Behavior: Q­technique and Its Methodology-rIThicago:--University of ChIcago Press, 1953), p. 25. 21 attitudes or opinions from one time to another. 29 The first problem, in terms of the subject matter of nursing research, can be rephrased thus: How does Nurse A compare with Patient B in terms of attitudes and expectations concerning the importance of salient features of the nurse-patient relationship? These same kinds of comparisons can be made between responses by any two relevant individuals! or groups' Q-sorts. 30 The second major problem the Q-sort technique is designed to handle is the assessment of degree of change in attitudes, expectations, and opinions about a given subject from one time to another. Here the question, framed in terms of nursing research, is: How does Nurse A agree with her own previous response to the Q-sort when it is administered a second time? For example, the Q-sort can be used to assess the efficacy of in-service and other educational programs for staff nurses or other nursing personnel. 3l The Whiting Q-sort consists of a group of one hundred cards, each with a true statement about the nurse's behavior in relating to patients. These one hundred statements are divided into four categories of twenty-five statements to each category. Table I illustrates the Q-sort for the nurse­patient relationship.32 29Whiting and others, £E. cit., p. 17. 30Ibid. 31~. 22 TABLE I NURSE-PATIENT RELATIONSHIP Q-SORT* Aspects Liaison Physical Care Supportive Emptional Care patient Education Number of cards 1-25 26-50 51-75 76-100 Example of­typical statement The nurse explains to the patient what his doctor's instructions mean. The nurse gives the patient pre-operative physical treatment. The nurse makes the patient feel welcome and wanted in the hospital. The nurse teaches the patient about his illness in ;terms that he can under­stand. *See Appendix C for instructions for the Q-sort. With the number of individuals who have already parti­cipated in data collection and feedback of information based on the Whiting Q-sort technique approaching three thousand, some interesting results can be interpreted from various hospital settings. The findings from three acute general medical a'nd surgical settings, one tuberculosis setting, and one medical-neurological service demonstrate one point of view which emphasizes bedside nursing, with strong stress on physical~. Two ambulatory psychiatry settings, taken together, demonstrate a second point of view, stressing supportive emotional ~.33 23 Results indicate that there are wide areas of agree­ment between nurses as to what is relatively more important and relatively less important to them in giving day-to-day patient care, particul'arly in those settings which emphasize physical aspect of the patient's illness and in those settings in which the objective is to alleviate emotional illnesses. 34 The findings reported" in a recent thesis (1960) at the University of utah, conducted in a psychiatric unit in a general hospital, showed that supportive emotional care and the physical care categories of nursing functions were con­sidered in that order by the nursing personnel to be the most important functions in terms of patient comfort. The patients ranked physical care as most important. 35 III. SUMMARY OF REVIEW OF LITERATURE Psychiatric Aide Education The literature contained few studies which were 33J • Frank Whi ting, IlNeeds, Values, Perceptions and , the Nurse-Patient Relationship," Journal of Clinical Psychol­ESZ, 15:146-50, April, 1959. 34Ibid • . 350ra Loy N. Robison, ft Study of Nursing Personnel and Patients' Perceptions of Nursing Functions Contributing to patient Comfort," (unpublished Master's thesis, University of Utah, Salt Lake Ci ty, 1960) to 24 experimental. However, the review of literature did reveal sources which described the many problems in this area and the existing need for more research to determine the length of programs, as well as the content of programs: It appears that the least qualified member of the hospital team, the psychiatric aide, is confronted with the problem of caring for the patient at the ward level in settings which do not offer adequate guidance and leadership. His problem is twofold in that he not only must care for the patient, but must find some way of meeting his own needs for recognition and status in situations that are changing very rapidly and that require quick adjustments to meet patient needs. With increasing emphasis being placed on the dynamics of communication, both verbal and nonverbal, the influence of the tranquilizing drugs, the need for better understanding of the mentally ill, the use of industrial therapy, the implica-tions of "open wards" and rehabilitation, and the new tech­nique of "remotivation," it is concluded that more research is needed in the area of psychiatric aide education to deter­mine what skills, understandings, abilities, and attitudes are necessary for competent work performance. AP¥lication of the Whiting Q-sort Methodology to the Nurse­Fa lent RelatIonship The changing philosophy of nursing education and of 25 patient care makes it necessary to assess those behaviors involved in the nurse-patient interaction to determine if there is common agreement as to what is of greater and of lesser importance in caring for patients in various hospital settings. The development of the Whiting Q-sort methodology was in response to the need to develop a method which would help to answer some of the pressing practical problems facing the nursing profession. , This methodology is considered in greater detail in the following chapter. CHAPTER III DESIGN The fact that in large state mental hospitals a large amount of the nursing care is carried out by semi-skilled aides who work very closely with the patients in their activities of daily living made it desirable to look for a tool that would assess the elements of nursing care as they are perceived by this group on a day-to-day basis .. Method The Whiting Q-sort Methodology developed by Dr. J. Frank Whiting and published by the American Nurses' Founda­tion, Incorporated in 1958 was the instrument chosen. Both of these sources were contacted and permission obtained to use the instrument in this study. The major goal of Dr. Whiting'S research was to develop a method for measurement of groups and individual perceptions of the nurse-patient relationship. Those persons living in close contact with patients (nurses, physicians, and others) were asked to define the relationship as they perceived it. It was felt that this type of defining process would make for naturalness and validity of definition. l IJ .. Frank Whiting and others, "The Nurse-Patient Rela­tionship and the Healing Process," A .Progress Report to ~ American Nurses' Foundation (New York: The American Nurses' Foundation, Inc.), p. 23. 27 From interviews with these professional people, it was necessary to convert the raw material into a manageable form. The ultimate goal was to derive a series of concepts as they exist today in our hospitals. It was important that the series of concepts have two general characteristics. First, the series should adequately sample the multitude of' important behaviors the nurse carries out in giving nursing care. Second, it was necessary f'or the series to be concise enough to allow the individual patient, nurse, physician, or other person to be able to make a general response ,to the total series, e.g., to evaluate the relative importance of each of the behaviors within the series.2 Finally, four categories of nursing care were defined. Each category consisted of twenty-five items which specifi­cally f'it into that category. As mentioned earlier the specific categories were: 1. Physical Care 2. Supportive Emotional Care 3. Patient Education 4. Liaison See Appendix C for instructions for the Q-sort. A.dvantages and Disadvantages of the Q-sort Thel Q-:-sort is considered by its author to be superior 28 to the interview, the questionnaire, the attitude scale, or the rating scale in its flexibility of use for gaining significant data. Another advantage claimed for the tech­nique, when compared to the interview, is that it is infinitely more amenable to experimental control than is the interview by itself. The interviewing situation always has the problem of interviewer bias. Since the experimental control of the Q-sort is better, the validity and reliability are greatly increased •. Moreover, the Q-sort method of assess­ment of attitudes and opinions is much more likely to reveal true reactions than the questionnaire, where persons may say "yes" to all favorable statements and "no" to all unfavorable ones. The method is free from the peculiarities of response which lead some individuals to respond "I don't know" twice as often as others and hence make their scores non-comparable. Finally, once developed and standardized, the use of the Q­sort is much less time-consuming than is the interview; and, therefore, experimentation based on it becomes more admini­stratively feasible. 3 Some disadvantages of the Q-sort method are: First, careless item writing will confront the subject with logically meaningless choices. The major portion of time on any Q-sort development needs to be used for making sure that one has carefully constructed and standardized the items. Second, 3Ibid., pp. 20-21. 29 there is sometimes criticism of the difficulty of sorting one hundred cards into nine piles with varying numbers of cards in each pile. To overcome this difficulty, the four­step method of sorting has been introduced.4 Selecting the population !£ be studied. A state mental hospital with a patient population of about one thousand which conducts a pre-service instructional program for psychiatric aides was chosen for the study. The hospital, like most state hospitals, was overcrowded and understaffed. About half of the twenty-seven wards had only two psychiatric aides on duty at a time. These aides had as many as fifty patients for whose care they were responsible, in addition to all the details involved in ward management. Pre-service instruction. The pre-service education used has evolved from one that formerly stressed physical care of patients, and the learning of psychiatric terminology­schizophrenia, mania, depressions, traumatic injuries--to one that emphasizes the interpersonal approach between the aide and the patient, as well as stressing the importance of patient behavior as related to an on-going evaluative process of patient progress. Permission to study the pre-service education group was secured through the Director of Nursing Service and the 30 Chairman of the Research Committee of the hospital. The class knew they were participating in an experimental study and oooperated completely. The course was taught by two psychiatric aide instruc­tors, two professional nurses, three psychiatrists, and one social worker, with guest lecturers from the department of psychology, the volunteer service, the dietary department, and the hospital pharmaoy. The program was four weeks in length. The first three weeks were spent in concentrated c~ass work. The last week was spent in the clinical setting allowing the newly employed aide opportunity for work in the clinical area with follow-up supervision by the class instructors. Patient contact was stressed from the very first day of class, and each of the students was assigned to interact with just one patient throughout the entire course. They were taught from the very beginning that the patient can often get emotional relief from sharing his troubles, and also that the patient may develop a new perspective that points to a different solution to his problems through experience and contact with a warm and friendly human being. Minimum requirements for admission to the pre-service education program were: 1. The candidate shall have passed the employment office screening tests (a battery of tests given by the 31 state employment office). 2. The candidate must be between the ages of eighteen and approximately fifty years. (However, some candidates who are over fifty are employed if they are in good physical and mental health.) 3. The candidate must present evidence of satisfactory social and emotional adjustment as determined by work or school history and pass a psychological evaluation. (The Minnesota Multiphasic Personality Inventory was given to each prospective aide and scored through the hospital psychology department.) 4. ,The candidate was required to have a personal interview with both the director of nursing service and the personnel director. There were fourteen candidates in the class chosen for study. During the pre-service education period, the aides were considered students only and were not assigned to any aide coverage on the wards. Emphasis was on education and not service rendered to the institution. Those aides failing to satisfactorily complete the program were not retained by the hospital nursing service. The regular aide salary was paid throughout the pre-service session. See Appendix E for course objectives and course out-li~ e. Background variables. A study of the personal 32 characteristics of the individuals in the training program-- age, sex, previous work experience, amount of formal schooling, any courses or special instruction relating to hospital work--was made in an effort to determine whether these demographic variables might be relevant to degree and typ e of change. Collecting ~ analyzing ~~. Each aide partici­pating in the training program sorted the one hundred items according to the specific instructions for the nurse-patient relationship Q-sort before the pre-service training was begun, at the end of the training program, and again after having spent a period of one month caring for psychiatric patients. Each individual sort was tabulated and later trans­ferred to a tabulating' sheet for the entire group. (See Appendix D for tabulating form.) The data were analyzed in the following manner: The mean score for each category was calculated by adding the values aSSigned to each item in the category and dividing by the number of items in the category. Ranking of the individual items as to the degree of importance was done by a comparison of the means for each item. Significant differences between the categories and between the items of the nurse-patient relationship Q-sort ,,' 33 were developed by calculating the t values for each category and for each item for any two sorts, and comparing them with a standard t table for levels ot significant difference. The correlation coefficient for the sorts was calcu-lated by using the following formula: d2 r = I - 2N s.d. 2 In this formula, N refers to the one hundred items in the sample, d refers to a composite of the squared differences between the individual items for any two sorts, and s.d. refers to the standard deviation for this sort. The s.d. will be the same for all sorts using this particular distri­bution. CHAPTER IV THE FINDINGS This chapter reports the responses made by the selected group of psychiatric aides concerning the relative importance of such nursing functions as physical care, supportive emotional care, patient education, and liaison. Testing was at three designated times, and the tool used was the nurse-patient relationship Q~sort developed by Dr. J. F. Whiting for the American Nurses t Foundation. l The findings and the analysis of the findings are presented and discus~ed in four sections. The first section consists of an outline of the first sort showing th.e rank aSSigned to all one hundred items, followed by a brief summary. The second section consists of a brief description of the pre-service instruction, an outline of the second sort, and a summary. The third section contains comments on the work experience, an outline of the third sort, and a summary. The fourth section is a discussion of the aides t point of view on the nurse-patient relationship. The aide group studied consisted of people from both rural and urban backgrounds. Table II shows some background lJ. Frank Whiting and others, tiThe Nurse-Patient Rela­ti on ship and the Healing Proc es s, tt A pro~res s ,Re! ort to the American Nurses t Foundation (New York: ~e Amer can Nursest Foundation, Inc., 1958). 35 TABLE II BACKGROUND VARIABLES OF THE FOURTEEN AIDE-STUDENT~ Last school Student Age Sex Work experience g:r;ade completed A 26 F Sales clerk 4 years, 12 Volunteer worker in general hospital 1 year B 26 M Army 2 years, College 2 years Missionary 2 years C 27 F Clerk 2 months, 12 Machine operator 6 months D 24 F Clerk 4 years, College 2 years state Hospital attendant 1 year, 8 months, Missionary 2 years E 35 M Trucking business 12 12 years F 19 M Truck driver 3 months, College 1 year Assistant plumber and electrician 8 months, Farm laborer 15 months G 27 M Orchard work 3 months, College 2 years Salesman 3 years, MiSSionary 2-1/2 years, Clerk 3 months, Carpenter 3 months H 25 M Powder worker 5 years, Dairyman 10 months, College 2 years Laborer 10 months I 39 F Housewife 12 J 44 F Beauty operator and 12 manager 1 year, Carpenter 1 year, Clerk 1 year Red Cross course 36 TABLE II (continued) Last school -Student Age Sex Work experience grade completed K 35 F Housewife 12 L 22 M Missionary 2 years, 12 Railroad 1 year M 27 F Waitress 3 years 9 N 26 M store manager 2 months, College 2 years Credit manager 2 years, Salesman 1 year, Missionary 2-1/2 years variables of the fourteen aide-students who participated in this study. (The personal information form may be found in Appendix C.) The class was equally divided as to sex. The mean age of the group was 28.71 years. All of the class members lived in or near the city in which the mental hospital is located. All students were of the same religious faith, Latter-day Saints, and five of the aides had fulfilled church missions. Although information relative to church missions was not requested on the personal information form, the aide-students volunteered this additional information. Casual conversations of aides usually centered around religion and church activities. A wide range of work experience was evident within the group.. According to Robinson, aides fall into four main categories: ••• (1) the person who has tried many jobs, perhaps 37 has rais ed a family, and feels. that a job as an aide caring for the mentally ill will offer security and interest and also will be a contribution to the community; (2) the student, who needs to work while going to school or desires experience which will offer better prepara­tion for his chosen field of work; (3) the "drifter," who knows that the mental hospital is a "soft touch" for a while, or feels protected in an environment of sick people, or is domineering enough to want to work where he can assert himself with people who, for the most part, cannot or will not fight back; (4) the person who wishes to make a career of being a mental hospital aide, who starts out with this in mind and takes pains to prepare himself for the job. 2 Schooling ranged from completion of ninth grade to completion of two years of college. At the present time, five of the seven male students are enrolled in a university. The Director of Nursing Service stated that this group was a "typical class of aid~s for this hospital." The Whiting Q-sort was administered to the aides at three designated times: (1) before the pre-service instruc­tion period; (2) at the end of the pre-service instruction period; (3) after the aides had spent a period of one month working on the wards, The Q-sort administered before the pre­service instruction .period will subsequently be referred to in this report as Sort I. The second administration of the Q-sort at the end of the pre-service instruction period will 2Alice M. Robinson, The PSIChiatric Aide (Philadelphia: J. B. Lippincott Co"' 1954·)-;--P. 1-. 38 be referred to as Sort II, and the third Q-sort administered following the one-month work period will be referred to as Sort III. Testing of the aides' perceptions of the nurse-patient relationship was carried out in two groups with seven aides in each group_ The average time per individual for completing the Q-sort was forty minutes with a range of thirty minutes to one hour fifteen minutes. Before the Q-sort was administered to the aides, the specific instructions for the Q-sort were read aloud, and the aides were encouraged to ask,q~estipns about any part of the instruc~ions. The four-step method of Q-sorting was carried out as outlined in Appendix C. Because the trainees had had no preparation in nursing, it was thought necessary to read through the items to determine ,if everyone understood the wording and the meaning of all the words. One word, aseptic, in Item 32 was defined for the group. Following these pre­liminary instru~tions, the aides were each given the one hundred statements to sort into three piles. They were instructed to place the statements about the nurse-patient relationship which were felt to be most important in the extreme left-hand pile, No.1; the statements Which were felt to be of least importance in the extreme right-hand pile, No.3. The remaining statements were to be placed in pile No.2. Subsequently, each of these three piles was further 39 divided into three piles representing most important, medium, and least important. The final outcome was nine piles. The end result for each person responding to the Q-sort in this manner is that each of the one hundred items is ranked from one to nine according to the importance assigned by the sorter to each item. The lower mean values indicate a high degree of relative importance, the higher mean values indicate a low degree of relative importance. The behavior perceived as being of most relative importance by the total; group was assigned a rank of one, that of least relative importance a rank of one hundred. Ranking of the individual items as to the degree of importance was done by a comparison of the means for each item. Whenever two or more items had equal mean values a composite of the ranks displaced was calculated and the items were assigned to the average of the ranks displaced. The fractions appearing in the rank orders of the sorts ,indicate that a number of items received the same rank, in some instances making the rank number a value ending in five-tenths. The 90e hundred items were further divided into three , levels on the basis of placement of items as sorted. Section A, items one through thirty-three were assigned a HIGH level of importance; Section B, items thirty-four through sixty­seven were assigned a MEDIUM level of importance; Section 0, items sixty-eight through one hundred were assigned a LOW 40 level of imp ortanc e. Each sort was analyzed by determining the order of importance which the aides, as a total group, assigned to the behaviors stated in the Q-sort items. Comparisons between categories and items of any two sorts are based upon a statistical analysis of the means computed from the responses made to each item by the total group_ If the difference between categories and items was statistically significant, the probability level of the significant difference appears in parentheses, for example, (.05). Each sort was outlined separat.ely to show the import­ance assigned to the nursing care functions at the three different times. Following each major section of the sort, a percentage breakdown of the various items into their , '. respective categories is shown. Sort I was made by the aide-students on the first day of the training course before any course content was presented. Sections A, B, and C, presented below, show the breakdown of items considered as of high, medium, and low importance at this time. Rank Item 1. Sort I Section. A. High Relative Importance The nurse m~kes sure the doctor's orders about the patient's 'care are carried out. Rank 3. 3. 3. 5. 6.5 6.5 9. 9. 9. 11. 11. 11. 16. 16. -Item 1. 11. 33. 27. 31. 51. 4. 56. 72. 12. 29. 66. 49. 50. 57. The nurse observes the patient's physical condition and reports new symptoms to the doctor. 41 The nurse observes changes in the patient's emotional condition and reports them to the doc tor~. The nurse watches the patient for any toxic symptoms following the administration of medication. The nurse. promptly detects changes in the patient's' physical condition. The nurse stays with the patient until he has taken his medication. The nurse makes the patient feel welcome and wanted in the hospital. The nurse encourages the patient to have coofidence in his physician. The nurse reassures the patient by handling an emergency without showing excitement. The nurse helps establish the patient's confidence in her by keeping her promises. The nurse refers to the doctor the patient who will not take his medicine. The nurse checks the patient's physical condition before leaving him. The nurse helps the patient to feel more comfortable by calling him by his name. - The nurse gives the patient in pain prescribed medication. The nurse protects the patient from extremes of heat an~ cold. The nurse calms down the upset patient. Rank, 16. 18. 19.5 19.5 21.5 21.5 24.5 27.5 27.5 31.5 31.5 31.5 31.5 31.5 Item 82. 24. 38. 41. 28. 39. 37. 55. 73. 36. 48. 17. 30. 46. 60. 65. The nurse teaches the patient how to help in his "recovery. The nurse oarries out the hospital rules concerning the patient impartially. The nurse helps the bedridden patient care for his bodily needs. The nurse helps prevent bedsores on her patients. 42 The nurse safeguards the patient from injury by' using equipment properly. The nurse is gentle when feeding a patient. The nurse spends suffioient time with each patient to make sure his physical needs have been attended to. The nurse observes any difficulty the patient 'has eating his meals. The nurse reassures the patient who is alarmed over changes in his treatment pro­cedures. The nurse expresses interest in the patient.s confidence in her by keeping her promises. The nurse helps the patient to carry out prescribed physical treatment. The nurse changes the patient. s dressings. The nurse aids the patient who has diffi­culties at home to get in touch with the social worker. The nurse conserves the patient's strength by relieving pain. The nurse gives prescribed medication when the patient is unable to sleep. The nurse tries to understand why a patient is being uncooperative. The nurse introduces herself to the new patient. 43 Of the items selected as having a high level of importance, 52 per cent fell into the category of physical care; 24 per cent were in the category of supportive emotional care; 21 per cent were in the category of liaison; and 3 per cent were in the category of patient education. Section B. Medium Relative Importance Rank Item 31.5 75. 36.5 32. 36.5 47 · 36.5 58. 36.5 64. 41.5 20. 41.5 53. 41.5 74. 77. 41.5 79. 41.5 91. The nurse expresses to the patient her con­fidence that unpleasant or painful treatments will be helpful. The nurse aids the patient.s recovery by practicing aseptic techniques. The, nurse is ca'reful not to jar the pa tient when giving treatments. The nurse is understanding when a patient refuses his medication. The nurse spends as much time as she can with a new patient to make him feel at home. The nurse reports a patient's complaints to the appropriate authority. The nurse tries to understand how the patient feels about his illness. The nurse assures the patient who is apolo­getic about calling her that she is glad to come. The nurse teaches the patient about his ill­ness in terms that he can understand. The nurse teaches the patient with a communic­able disease how to avoid spreading infection. The nurse teaches the patient how to carry out pre~cribed physical treatment. Rank Item 46. 46. 61. 46. 84. 48. 40. .51 • .5 2. 16. .52. .54. 67. .51 • .5 80. .56 • .5 8. .56 • .5 78. .56 • .5 86. .56 • .5 89. 10. The nurse shows sympathy toward an aggra­vating patient. 44 The nurse listens to the patient as he airs his feelings about environmental distur­bances in his d~ily hospital life. The nurse explains to the patient the need for unpleasant or painful treatments. The nurse notices when the patient is tired and arranges for his rest. The nurse suggests that the patient discuss his troubles with the doctor. The nurse discusses with the patient how a referral to the occupational or educational therapist could help him • The nurse helps the patient express his fears about his illness • The nurse is considerate with the patient so that something new is not embarrassing. The nurse stops to talk to the patient while on routine visits • The nurse teaches the patient good health habi ts • The nurse refers the patient's questions about his illness to the doctor • The nurse teaches the patient how to prevent a relapse of his illness • The nurse explains to the patient why he must be isolated • The nurse encourages the patient on a special diet to share responsibility for carrying it out. The nurse asks the patient for information about himself which the doctor needs. Rank Item 59.5 69. 62. 34. 62. 42. 62. 85. 65. 15. 65. 18. 65. 94. 26. 45 The nurse expresses interest in the patient and his fa.mily. The nurse reoognizes and plans for the patient's physical needs. The nurse arranges the patient comfortably after trea.tment. The nurse answers the patient's questions about his treatment. The nurse tells the patient of the avail­ability of a spiritual counselor. The nurse explains to the patient how other professional workers can help him. The nurse explains to the patient before he leaves the hospital how to take his medicines at home. The nurse gives the patient pre-operative phy,sical treatment. Of the items selected as having a medium level of importance, 33 per cent were in the category of supportive emotional care; 29 per cent were in the category of patient education; 21 per cent were in the category of liaison; and 17 per cent were in the category of physical care .. Rank Section c. LoW Relative Importance -Item 90. 7. The nurse explains to the pat.ient why changes in his treatment are nec essary. The nurse accompanies the physician when he sees the patient. Rank Ite'm 81. 72.5 5. 72.5 35. 72.5 43. 72.5 45. 72.5 62. 72.5 76. 78. 68. 78. 83. 78. 88.. 80. 71. 82. 22. 82. 98. 82. 100. 85. 13. 46 The nurse teaches the patient how to protect hilUsel:f~ from disease. The nurse explains to the patient what his doctor's instructions mean. The nurse carries out diagnostic tests con­cerning the patient's physical condition. The nurse makes the patient comfortable by giving him back rubs. :, The nurse makes sure the patient has correct foods to eat. The nurse asks the patient what his inter­ests are. The nurse teaches the patient the value of recreation during his recovery. The nurse helps the patient pass the time by talking to him when he is alone. The nurse corrects the patient's mistaken ideas about his illness. The nurse explains to the patient why he needs a special diet. The nurse discusses the patient's progress with him when he requests this. The nurse explains to the patient what the hospital arrangements are for safeguarding his valuables. The nurse explains to the patient the steps involved in preparing for an operation. The nurse explains to the patient the reason for diagnostic tests. The nurse interprets the patient's problems to co-workers to seek their cooperation in planning for the patient. Rank Item 85. 96. 85. 99. 88. 19. 88. 93. 88. 97. 91. 70. 91. 87. 91. 95. 93.5 3. 93.5 23. 21. 95.5 63. 97. 98. 6. The nurse explains to the patient how his nursing care is related to his illness. 47 The nurse explains to the patient the nurs­ing procedures she. is carrying out. The nurse refers the patient to other hos­pital services for help with post­hospitalization plans. The nurse explains to the patient why he needs a certain amount of rest. The nurse instructs the patient how to main­tain an adequate state of nutri tion. The nurse discusses with the patient the affairs at home which are worrying him. The nurse explains why the patient cannot do all the things he would like to. The nurse explains to the patient why he needs to take his medicine. The nurse answers the patient's questions about his progress by telling him what his doctor has said~ The nurse explains the hospital routines to the patient. The nurse tells the patient what schedule of treatment the hospital staff have worked out for him. The nurse talks to the patient about his hobbies. The nurse adjusts some of the hospital routines to meet the individual needs of patients. The nurse tells the patient when his physi­cian will be giving hi.m a physioal examination. Rank -Item 99. 92. 100. The nurse explains to the patient how she will care for his physical needs. 48 The nurse tells the patient the function and purpose of the various hospital departments. Of the items selected as having a low level of import­ance, 40 per cent were in the category of patient education; 33 per cent were-in the category of liaison; 17 per cent were·:,tn the category of supportive emotional care; and 10 per cent were in the category of physical care. Summary, Sort I The core of the healing process in hospitals seems to evolve around the doctor-nurse-patient relationship, part of which the beginning aide could recognize. The aides who had had no previous nursing experience selected five items out of the first eleven items, which, according to Whiting, comprise part of the core of the healing process in hospitals. 3 Three of the five items were placed in first, second, and third places. The following table pictures the category and item means for Sort I. The numbers in parentheses following each of the category averages indicate the order of importance attributed to that category. Prior to any instruction or 3Whiting and others, E.E,. cit., p. 64. 49 experience the aides perceived physical care as most import­ant and patient education as least important. See Appendix D for the mean rank of each item in Sort I. TABLE III CATEGORY AND ITEM MEANS FOR SORT I Physical care category Mean 114.33 (1) Item Mean 4.57 Supportive emotional care 120.55 (2) 4.82 Liaison 128.44 (3) 5.12 I. PRE-SERVICE INSTRUCTION Patient Education 136.68 (4) 5.46 Briefly, the pre-service training course can be characterized as follows: 1. The course was taught by two psychiatric aide instructors, two professional nurses, three psychiatrists, and one social worker, with guest lecturers from the depart­ment of psychology, the volunteer service, the dietary depart­ment, and the hospital pharmacy. 2. Th~ length of the course was one hundred sixty hours distributed over a four-week period. 3. The core of the course centered around broad areas: 50 a. Planned experience with a specific patient. b. Demonstrations of nursing procedures with planned ward experience for return demonstrations. c. Tours to hospital f~cilities, departments, and wards. d. Group discussions relating to all phases of the course. 4. Instruction focused on helping the aide student recognize principles which are consonant with adequate ~ nursing care. Special attention was placed upon the under-standing of the patients' needs and the relationships between employees and patients, and between members of each group. 5. The writer of this study did not participate in the teaching of the course. She did, however, observe all class sessions, as well as observe the aide-patient inter-action on the wards, which is a usual student learning activity. See Appendix E for course outline and objectives. Sort II was given at the end of the instructional period. Sections A, B, and C, below, show the rank assigned to the one hundred items in Sort II. -Rank Item 1. 9. Sort II Section A. High Rela~ive Importance The nurse makes sure the doctor's orders about the patient's care are carried out. Rank Item 2. 33. 4. 1. 4. 11. 4. 27. 6. 31. 7. 49. 8. 28. 9. 41. 10. 50. 11.5 4. 11.5 44. 72. 32. , 51. 14.5 56. 51 The nurse watches the patient for any toxic symptoms following the administration of medi­cation. The nurse observes the patient's physical condi ti on and report.s new symptoms to the doctor. The nurse observes changes in the patient's emotional condition and reports them to the doctor. The nurse promptly detects changes in the patient's physical condition. The nurse stays with the patient until he has taken his medication. The nurse gives the patient in pain prescribed medication. The nurse safeguards the patient from injury by using equipment properly. The nurse helps prevent bedsores on her patients. The nurse protects the patient from extremes of heat and cold. The nurs·e encourgaes the patient to have confidence in his phy·sician. The nurse observes any difficulty the patient has eating his meals. The nurse helps establish the patientsf confidence in her by keeping her promises. The nurse aids the patient's recovery by practicing sound aseptic techniques. The nurse makes the patient feel welcome and wanted in the hospital. The nurse reassures the patient by handling an emergency without showing excitemen~. Rank 17.5 17.5 19. 20. 21.5 21.5 23. 24.5 ·24.5 27. 27. 27. 30.5 30.5 30.5 30.5 34.5 Item 29. 66. 60. 36. 12. 73. 38. 48. 57. 8. 20. 30. 45. 46. 55. 64. 37. The nurse checks the patient's physical condition before leaving him. The nurse helps the patient to feel more comfortable by calling him by his name. The nurse tries to understand why a patient is being uncooperative. The nurse helps the patient to carry out prescribed physical treatment. The nurse refers to the doctor the patient who will not take his medicine. 52 The nurse expresses interest in the patient's progress. The nurse helps the bedridden patient care for his bodily needs. The nurse changes the patient's dressings. The nurse calms down the upset patient. The nurse refers the patient's questions about his illness to the doctor. The nurse reports a patient's complaints to the appropriate authority. The nurse conserves the patient's strength by relieving pain. The nurse makes sure the patient has correct foods to eat. The nurse gives prescribed medication when the patient is unable to sleep. The nurse reassures the patient who is alarmed over changes in his treatment pro­cedures. The nurse spends as much time as she can with a new patient to make him feel at home. The nurse spends sufficient time with each patient to make sure his physical needs have been attended to. 53 Of the items selected in Sort II as having a high level of importance, 52 per cent were in the category of physical care; 27 per cent were in the category of supportive emotional care; 21 per cent were in the category of liaison. There were no items placed in the category of patient educa­tion. Rank 37. 39.5 39.5 39.5 39.5 43. 43. 43. Section B. Medium Relative Importance .I..t..e...m.... 39. 53. 74. 34. 35. 40. 43. 67. 26. 80. 91. The nurse is gentle when feeding a patient. The nurse tries to understand how the patient feels about his illness. The nurse assures the patient who is apologetic about calling her that she is glad to come. The nurse recognizes and plans for the patient's physical needs. The nurse carries out diagnostic tests con­cerning the patient's physical condition. The nurse notices when the patient is tired and arrapges for his rest. The nurse makes the patient comfortable by giving him back rubs. The nurse stops to talk to the patient while on routine v~Bits. The nurse gives the patient pre-operative pq-Fsical treatment. ~ The nurse teaches the patient good health habits. The nurse teaches the patient how to carry out prescribed physical treatment. Rank Item 46.5 46.5 46.5 46.5 51.5 51.5 51.5 51.5 51.5 51.5 56. 56. 56. 60. 60. 42. 54. 58. 77. 15. 16. 47. 65. 81. 61. 75. 82. 2. 10. The nurse arranges the patient comfortably afteritreatment. 54 The nurse is oonsiderate with the patient so that something new is not embarrassing. The nurse is understanding when a patient refuses his medication. The nurse teaches the patient about his ill­ness in terms that he can understand. The nurse tells the patien~ of the availability of a spiritual counselor. The nurse discusses with the patient how a referral to the ocoupational or educational therapist could help him. The nurse carries out the hospital rules concerning the patient impartially. The nurse is careful not to jar the patient when giving treatments. The nurse introduces herself to the new patient. The nurse teaches the patient how to p~otect himself from disease. The nurse listens to the patient as he airs his feelings about environmental disturbances in his daily hospital life. The nurse expresses to the patient her con­fidence that unpleasant or painful treatments will be helpful. The nurse teaches the patient how to help in his recovery. The nurse sugg~sts that the patient discuss his troubles with the doctor. The nurse asks the patient for information about himself which the doctor needs. Rank Item 60. 18. 60. 60. 95. 22. 64. 79. 74. 84. 67. 17. 67. 52. The nurse explains to the patient how other professional workers can help him. 55 The nurse encourages the patient on a special diet to share responsibility for carrying it out. The nurse explains to the patient why he needs to take his medicine. The nurse explains to the patient what the hospital arrangements are for safeguarding his valuables. The nurse teaches the patient with a oommunic­able disease how to avoid spreading infection. The nurse explains to the patient the need for unpleasant or painful treatments. The nurse aids the patient who has diffi­culties at home to get in touch with the social worker. The nurse helps the patient express his fears about his illness. Of the items selected as having a medium level of importance, 27 per cent were in the category of supportive emotional care; 27 per cent were in the category of patient education; 23 per cent were in the oategory of physical care; and 23 per cent were in the category of liaison. Rank Item 67. Section C. Low Relative Importance The nurse shows sympathy toward an aggravating patient. Rank -Item 70. 13. 70. 76. 70. 86. 74. 68. 74. 69. 74. 78. 74. 90. 74. 97. 77.5 71. 77.5 87. 80. 25. 80. 62. 80. 63. 83. 85. 83. 88. The nurse interprets the patient's problems to co-workers to seek their cooperation in planning for the patient. The nurse teaches the patient the value of recreation during his recovery. 56 The nurse explains to the patient why he must be isolated. The nurse helps the patient pass the time by talking to him when he is alone. The nurse expresses interest in the patient and his family. The nurse teaches the patient how to prevent a relapse of his illness. The nurse explains to the pati,ent why changes in his treatment are necessary. The nurse instructs the patient how to main­tain an adequate state of nutrition. The nurse discusses the patient's progress with him when .:.he requests this. I The nurse explains why the patient cannot do all the things he would like to. The nurse adjusts some of the hospital routines to meet the individual needs of patients. The nurse asks the patient what his interests are. The nurse talks to the patient about his !:lobbies •. The nurse answers the patient's questions aboht hid treatments. The nurse explains to the patient why he needs a special diet. -Rank Item 83. 94. 85.5 93. 85.5 99. 87. 23. 88.5 7. 88.5 82. 91. 5. 91. 91. 92. 93. 6. 70. 98. 3. 19. 98. 100. 57 The nurse explains to the patient before he leaves the hospital how to take his medicine.s at home. The nurse explains to the patient why he needs a certain amount of rest. The nurse explains to the patient the nursing procedures she is carrying out. The nurse explains the hospital routines to the patient. The nurse accompanies the physician when he sees the patient. The nurse teaches the patient how to help in his recovery. The nurse explains to the patient what his doctor's instructions mean. The nurse tells the patient the function and purpose of the various hospital departments. The nurse explains to the patient how she will care for his physical needs. The nurse tells the patient when his physician will be giving him a physical examination. The nurse discusses with the patient .the affairs at home which are worrying him. The nurse explains to the patient the steps involved in preparing for an operation. The nurse answers the patient's questions about his progress by telling him what his doctor has said. The nurse refers the patient to other hospital services for help with post-hospitalization plans. The nurse explains to the patient the reason for diagnostic tests. Rank Item 99. 96. 100. 21. The nurse explains to the patient how his nursing care is related, to his illness. 58 The nurse tells the patient what schedule of treatment the hospital staff have worked out for him. Of the items selected as having a low level of importance, 4.9 per cent were in the category of patient educat'ionj 30 per cent were in the category of liaison; 21 per cent were in the category of supportive emotional care. There were no items placed in the category of physical care. Summary, Sort II Table IV presents the means for categories of nursing functions and the item means for Sorts I and II. TABLE IV CATEGORY AND ITEM MEANS FOR SORTS I AND II Supportive Patient Physical Emotional Liaison Education Care Care Category Mean (SI)* 114·.33 120.55 128.44 136.68 (SII )~t-* 106.75 123.56 128.67 140.61 Item Mean (SI) 4.57 4,.82 5.12 5 .. 46 (SII) 4.27 4.94 5.14 5.62 ~~SI :::: Sor't I. *~~SII == Sort II. Table V shows those items in which a statistically significant change occurred. 59 Comments on Differences Found between Sort I and Sort II Specific reasons as to why the items shown in Table V emerged with statistically significant differences is diffi­cult to determine since chance occurrence cannot be ruled out. Of those items perceived as more important in Sort II, one is a liaison item which deals with the "nurse-doctor­patient relationship," and specifically with the doctor's authority role. Two items are physical care items, one touching on safeguarding the patient by using equipment properly; the other relating to correct foods for the patfent. The physical care category of nursing functions was selected as the most important category in both Sorts I and II. In the pre-service training period, both of these items were stressed in the course of instruction by the registered nurses and the dietitian. The other item (95) is in the patient education category; however, it focuses attention on the importance of the patient taking his medicine. All items dealing with the giving, administering, or explaining about medicines were ranked highly important. Of those items viewed as less important in Sort II, three were liaison items and three were patient education items. These two categories were ranked in third and fourth TABLE V ITEMS FOR WHICH A STATISTICALLY SIGNIFICANT DIFFERENCE WAS FOUND IN SORT II AS COMPARED WITH SORT I Item Item Item Mean Mean Sort I Sort II Items perceived as more import-ant In Sort II tnan In Sort I: 9. The nurse makes sure the doc-tor's orders about the patient's care are carried out. 2.28 1.57 28. The nurse safeguards the patient from injury by using equipment properly. 4.42 3.57 45. The nurse makes sure the patient has correct foods to eat. 5.57 4.64 95. The nurse explains to the patient why he needs to take his medicine. 6.05 5.28 Items Eerceived as less i,ort-ana In Sort II ~nan in Sor I: 5. The nurse explains to the patient what his doctor's instructions mean. 5.57 5.78 17. The nurse aids the patient who has difficulties at home to get in touch with the social worker. 4.64 5.42 24. The nurse carries out the hos-pital rules concerning the patient impartially. 4.21 5.07 79. The nurse teaches the patient with a communicable disease how to avoid spreading in-fection. 4.78 5.35 60 P. .05 .05 .05 .05 .05 .05 .05 .05 61 TABLE V (continued) Item Item Item Mean Mean Sort I Sort II P. 82. The nurse teaches the patient how to help in his recovery. 4·.07 5.21 .05 96. The nurse explains to the patient how his nursing care is related to his illness. 5.92 6.71 .01 positions in both sorts, but as w~th relatively less import­ance in Sort II. The liaison items having to do with "orientation to the hospital organization" were not ranked as highly as those liaison items dealing with the "nurse­doctor- patient relationship." Patient education items were ranked as least important in both sorts. During the course of the pre--service instructional program the following hypothesis was formulated: Hypothesis #1. There will be no statistically sig­nificant differences in how the aides perceive the nurse­patien: t relationship before and after the pre-service training program as measured by the mean score assigned to the four areas being evaluated in this study. The trainees will preoeive the categories in the nurse-patient relation­ship Q-sort in, the following order of importance: (1) liaison, (2) physical care, (3) supportive emotiollal care, and (4) patient education. 62 When Sort II was analyzed and compared with Sort I it was found that although the categories were perceived in the same order of importance as in Sort I, the physical care category in Sort II wa$ perceived as of greater importance at a statistically significant level (.01). The patient education category was perceived as of less importance in ~ort II than in Sort I, but not at a statistically significant level. This means that the aides assigned greater value to the physi'cal care category of nursing functions after the pre-servic e course. As a res'ul t of this greater emphasis on physical care, the patient education category, was viewed as less important. These findings led to the rejection of the first hypothesis. Careful examination of parts of the pre-service instructional course may offer plausible answers as to the reasons for the above trend. Three factors observed in the pre-service educational program ~ere outstanding in relation to physical care. One, a statement made by one of the doctors, was: "I allow you to make one mistake on my ward." The doctor was no.t asked for clarification of the statement. However, in group discussion, later, the statement was I interpreted as meaning such mistakes as giving the wrong medication or burning a patient with a hot water bottle. The second factor of signif.icance was the lecture and demonstration on preparing and giving medications. The students, in return demonstrations, had to give one another intramuscular injections. This procedure provoked many comments, such as: nI'm scared to death." "Gee, that hurt.tt "How will I ever give an uncooperative patient a shot?" The third factor arousing concern in the aides was the giving of narcotics. Many questions were asked abo'ut this procedure. One' question of particular interest was: "How come I can even handle narcotics? I thought that was against the law." Counting and tabulating of narcotics were stressed, and examples of the narcotics sheets were shown to the students. The above examples show that the instructional program stressed physical care and particularly the giving of medication. Although many liaison activities were talked about and a tour of the hospital conducted, this category remained practically the same in Sort II as in Sort I. However, those liaison items (1, 4, 9, 11, and 12) dealing with the activities the nurse carries out in relation to the doctor 1 s orders were ranked high among those items perceived as of high relative importance. Patient education was not pointed up in the lectures. Supporti·ve emotional care was discussed in conjunotion with the aide-patient interactions (each aide was assigned to 64 interact with one patient throughout the course). The stu­dents talked freely about patient behavior. Some typical student statements were: "My patient says very silly things." ttl donrt know whether to agree with my patient or not; she thinks she is the mother of God." "My patient thinks the world is coming to an end, and the only people saved will be the ones who go to the moon in a rocket ship." The psychiatrist talked with each student individually about his or her patient. He discussed the patient's illusions, delusions, and hallucinations in simple language. The doctor also gave the aides suggestions about how to answer the patientsl questions as well as how to respond to irrational and irrelevant thought content expressed by the patients. To the writer of this paper, the aide stud"ents seemed to be more concerned during the discussions with the giving and charting of medications than with any other single aspect of the pre-service instruction course. II. THE WORK EXPERIENCE T~e purpose of administering the Q-sort for the third time was to determine how the aides would perceive those aspects of nursing care--liaison, physical care, supportive emotional care, and patient education--after having worked for a period of one month in the ward setting. After taking into consideration the nature of the ward 65 assignments, the presenting patient needs on the various wards, and the newly employed aides 1 jobs, the writer formed a second hypothesis: Hypothesis #2. After working for a period of one month on the wards the aides will rank the categories of nurse-patient relationship in order of importance as follows: (1) physical care, (2) liaison, (3) supportive emotional care, and (4) patient education. Rank 1. 2. 3. 5. 5. 5. The actual findings of Sort III follow: Item 9. 31. 33. 1. 11. 27. Sort III Section A. High Relative Importance The nurse makes sure the doctor's orders. about the patient.s care are carried out. The nurse stays with the patient until he has taken his medication. The nurse watches the patient for any toxic symptoms following the administration of medication. The nurse observes the patient.s physical condition and reports new symptoms to the doctor. The nurse observes changes in the patient's emotional condition, and reports them to the doctor. The nurse promptly detects changes in the patient·s physical condition. Rank 7.5 7.5 9.5 12. 12. 12. 17.5 17.5 17.5 17.5 20. 21. 22.5 22.5 Item 4. 49. 29. 75. 28. 38. 41. 46. 36. 12. 48. 50. 57. 32. 44. 47. 56. The nurse encourages the patient to have confidence in his physician. 66 The nurse gives the patient in pain prescribed medicatioll. The nurse checks the patient's physical condition before leaving him. The nurse.helps establish the patient's confidence in her by keeping her promises. The nurse safeguards the patient from injury by using equfpment properly. The nurse helps the bedridden patient care for his bodily needs. The nurse helps prevent bedsores on her patients. The nurse gives prescribed medication when the patient is unable to sleep. The nurse helps the patient to carry out prescribed physical treatment. The nurse refers to the doctor the patient who will not take his medicine. The nurse changes the patient's dressings. The nurse protects the patient from extremes of heat or cold. The nurse calms down the upset patient. The nurse aids the patient's recovery by prac­ticing sound aseptic te'chniques. The nurse observes any difficulty the patient has eating his meals. The nurse is careful not to jar the patient when giving treatments. The nurse reassures the patient by handling an emergency without showing excitement. Rank 26.5 26.5 28.5 28.5 30.5 30.5 Item 39. 73. 2. 66. 51. 60. 54. 79. 30. 67 The nurse is gentle when feeding a patient. The nurse expresses interest in the patient's progress. The nurse suggests that the patient discuss his troubles with the doctor. The nurse helps the patient to feel more comfortable by calling him by his name. The nurse makes the patient feel welcome and wanted in the hospital. The nurse tries to understand why a patient isbeirlg uncooperative. The nurse is considerate with the patient so that something new is not embarrassing. The nurse teaches the patient with a communic­able disease how to avoid spreading infecti0n. The nurse carries out the hospital rules concerning the patient impartially. The nurse conserves the patientfs strength by relieving pain. Of the items selected in Sort III as having a high level of importance, 4.8 per cent were in the category of physical care; 28 per cent were in the category of supportive emotional care; 21 per cent were in the category of liaison; and 3 per cent were in the category of patient education. Section B. Medium Relative Importance Rank Item 34.5 37. The nurse spends sufficient time with each patient to make sure his physical needs have been attended to. Rank Item 43. 34.5 74. 34.5 95. 38.5 58. 38.5 40.5 40. 40.5 44. 8. 44. 20. 44. 26. 44. 34. 44. 42. 47.5 15. 47.5 53. 10. The nurse makes the patient comfortable by giving him back rubs. 68 The nurse assures the patient who is apolo­getic about calling her that she is glad to come. The nurse explains to the patient why he needs to take his medicine. The nurse is understanding when a patient refuses his medication. The nurse spends as much time as she can with a new patient to make him feel at home. The nurse notices when the patient is tired and arranges for his rest. The nurse shows sympathy toward an aggravating patient. The nurse refers the patient 1 s questions about his illness to the doctor. The nurse reports a patient's complaints to the appropriate authority. The nurse gives the patient pre-operative physical treatments. The nurse recognizes and plans for the patient" s physical needs,. The nurse arranges the patient comfortably after treatment. The nurse tells the patient of the availabil­ity of a spiritual counselor. The ~urse tries to understand how the patient feels about his illness. The nurse asks the patient for information about himself which the doctor needs. The nurse stops to talk to the patient while on routine visits. Rank Item 52.5 55. 52.5 76. 52.5 84. 94. 58.5 58.5 13. 58.5 16. 58.5 18. 58.5 61. 58.5 65. 58.5 91. 63.5 63.5 35. 63.5 68. 69 The nurse reassures the patient who is alarmed over changes in his treatment procedures. The nurse teaches the patient the value of recreation during his recovery_ The nurse explains to the patient the need for unpleasant or painful treatments. The nurse explains to the patien~ before he leaves the hospital how to take his medicines at home. The nurse expresses interest in the patient and his family. The nurse interprets the patient's problems to co-workers to seek their cooperation in planning for the patient. The nurse discusses with the patient how a referral to the occupational or educational therapist could help him. The nurse explains to the patient how other professional workers can help him. The nurse listens to the patient as he airs his feelings about environmental disturbances in his daily hospital life. The nurse introduces herself to the new patient. The nurse teaches the patient how to carry out prescribed physical treatment. The nurse aids the patient who has diffi­culties at home to get in touch with the social worker. The nurse carries out diagnostic tests con­cerning the patient's physical condition. The nurse helps the patient pass the time by talking to him when he is alone. Rank Item 63.5 75. 66.5 81. 66.5 90. 70 The nurse expresses to the patient her con­fidence that unpleasant or painful treatments will be helpful. The nurse teaches the patient how to protect himself from disease. The nurse explains to the patient why changes in his treatment are necessary. Of the items selected as having a medium level ot importance, 35 per cent were in the category of supportive emotional care; 23 per cent were in the category of liaison; 21 per cent were in the category of physical care; and 21 per cent were in the category of patient education. Rank Item 7. 82. 69. 72. 45. 72. 52. 72. 86. 75.5 25. Section C. Low Relative Importance The nurse accompanies the physician when he sees the patient. The nurse teaches the patient how to help in his recovery. The nurse enoourages the patient on a speci~l diet to share responsibility for carrying it out. The nurse makes sure the patient has correct foods to eat. The nurse helps the patient express his fears about his illness. The nurse explains to the patient why he must be isolated. ,The nurse adjusts some of the hospi tal routines -to meet the individual needs of patients, Rank Item 75.5 62. 75.5 71. 75.5 78. 80. 79.5 5. 79.5 93. 81.5 22. 81.5 100. 84. 19. 84. 78. 84. 85. 86.5 92. 86.5 96. 88. 99. 14. 71 The nurse asks the patient what his interests are. The nurse discusses the patient.s progress with him when he requests this. The nurse explains why the patient cannot do all the things he would like to. The nurse teaches the patient good health habi ts. The nurse explains to the patient what his doctor's instructions mean. The nurse explains to the patient why he needs a certain amount of rest. The nurse explains to the patient what the hospital arrangements are for safeguarding his valuables. The nurse explains to the patient the reason for diagnostic tests. The nurse refers the patient to other hos­pital services for help with post­hospitalization plans. The nurse teaches the patient how to prevent a relapse of his illness. The nurse answers the patient's questions about his treatment. The nurse explains to the patient how she will care for his physical needs. The nurse explains to the patient how his nursing care is related to his illness. The nurse explains to the patient the nur.sing procedures she is carrying out. The nurse tells the patient the function and purpose of the various hospital departments. Rank Item 89.5 70. 91.5 88. 91.5 98. 94. 6. 94. 77. 94. 97,. 97. 23. 97. 63. 97. 83. 99. 21. 100. 3. The nurse discusses with the patient the affairs at home which are worrying him. 72 The nurse explains to the patient why he needs a special diet. The nurse explains to the patient the steps involved in preparing for an operation~ The nurse tells the patient when his physician will be giving him a physical examination,. The nurse teaches the patient about his ill­ness in terms that he can understand. The nurse instructs the patient how to maintain an adequate state of nutrition. The nurse explains the hospital routines ;to the patient. The nurse talks to the patient about his' hobbies. .The nUrse corrects the patient's mistaken ideas about his 111ness. . The nurse tells the patient what schedule of treatment the hospital staff have worked out for him. The nurse answers the patient's questions about his progress by telling him what his doctor has said. Of the items selected as having a low level of import- , ance, 51 per cent were in the category of patient education; 32 per cent were in the category of liaison; 14 per cent were in the category of supportive emotional care; and 3 per cent were in the category of patient education. 73 Summary, Sort III Table VI shows the category and item means for all three sorts. Tables VII and VIII, pages 74 and 78, respect­ively, show those items Which emerged with statistically significant differences between Sorts I and III, and between Sorts II and III. TABLE VI SUMMARY OF CATEGORY AND ITEM MEANS FOR ALL THREE SORTS Supporti-ve Physical Emotional Patient Care Care Liaison Education Category Mean: Sort I 114.33 120.55 128.44 136.68 Sort II 106.75 123.56 128.67 140.61 Sort III 106.30 124.68 127.34 141.68 Item Mean: Sort I 4.57 4.82 5.12 5.46 Sort II 4.27 4·.94 5.14 5.62 Sort III 4.25 4.98 5.09 5.66 The aides regarded the physical care and supportive emotional care categories of nursi~g functions as relatively more important and the liaison and patient education 74 TABLE VII ITEMS FOR WHICH A STATISTICALLY SIGNIFICANT DIFFERENCE WAS FOUND IN· SORT III AS COMPARED WITH SORT I Item Items perceived as more i~ort­ant in Sort III than In Sort II: 2. The nurse suggests that the patient discuss his troubles with the doctor. 13. The nurse interprets the patient.s problems to co­workers to seek their coopera­tion in planning for the patient. 14. The nurse tells the patient the function and purpose of the various hospital depart­ments. 25. The nurse adjusts some of the hospital routines to meet the individual needs of patients. 31. The nurse stays with the patient until he has taken his medication. 43. The nurse makes the patient comfortable by giving him ba.ck rubs. 46. The nurse gives prescribed medication when the patient is unable to sleep. 92. The nurse explains to the patient how she will care for his physical needs. Item Mean Sort I 5.07 5.92 6.78 6.28 3.64 5.57 6.57 Item Mean Sort II 4.42 5.28 6.14 2.78 4·. 00 6.00 P. .05 .05 .05 .05 .05 .05 .05 .05 75 TABLE VII (continued) Item Item Item Mean Mean Sort I Sort II P. 95. The nurse explains to the patient why he needs to take his medication. 6.07 4.71 .01 Items Eerceivedas less and In Sort III ~nanrn imEort- Sort I: 17. The nurse aids the patient who has difficulties at horne to get in touch with the social worker. 4.64 5.35 .05 51. The nurse makes the patient feel welcome and wanted in the hospital. 3.64 4.50 .05 55. The nurse reassures the patient who is alarmed over changes in his treatment procedures. 4.50 5.14 .05 65. The nurse introduces herself to the new patient. 4.64 5.28 .05 75. The nurse expresses to the patient her confidence that unpleasant or painful treat-ments will be helpful. 4.64 5.35 .05 77. The nurse teaches the patient about his illness in terms that he can understand. 4.78 5 .. 92 .05 78. The nurse teaches the patient how to prevent a relapse of his illness. 5.14 5.92 ..05 80 .. The nurse teaches the patient good health habits. 5 .. 07 5.71 .05 76 TABLE VII (continued) Item Item Item Mean Mean Sort I Sort II P. 82. The nurse teaches the patient how to help in his recovery. 4.07 5.50 .05 83. The nurse corrects the patient's mistaken ideas about his illness. 5.71 6.35 .05 85. The nurse answers the patientts questions about his treatment. 5.28 5.92 .05 categories of nursing functions as relatively less important. There were no statistically significant changes at the category level between Sorts II and III; there was, however, one statistically significant change at the category level between Sorts I and III. The physical care category of nursing functions was viewed as slightly more important in Sort III than in Sort II, and statistically more important than in Sort I (.01). The supportive emotional care category of nursing functions was viewed as less important in Sort III than in Sorts I and II. The, patient education category of nursing functions was seen as less important in Sort III than in Sorts I and II. The mean scores attached to the categories in Sort III 77 differed only slightly from the mean scores in Sort II. In Sort III there was a slight shift of emphasis to the liaison category with items in this category viewed as more important, and some items in the supportive emotional care and patient education categories being chosen as less important. Tables VII and VIII show those items which emerged with differences of statistical significance between Sorts I and III, and between Sorts II and III. Four of the items regarded as more important in Sort III were liaison items which had to do with the nurse acting as a liaison between the patient and co-workers or other hospital departments. The other itetns deal with . rnedications and comfort measures from a physical point of view. Of the items regarded as of less importance, one is a liaison 'item which states that the nurse aids the patient who has difficulties at home to get in touch with the social worker. The other items viewed as of less importance are supportive emotional care and patient education items. Three of the supportive emotional care items (51, 55, and 65) seemed rather important to the writer, but apparently did not have the same importance to the aides. One deals with the nurse making the patient feel welcome and wanted in the hospital; another states that the nurse reassures the patient who is alarmed over changes in his treatment procedures; and the other is concerned with the nurse introducing herself to the new patient. 78 TABLE VIII ITEMS FOR WHICH A STATISTICALLY SIGNIFICANT DIFFERENCE WAS FOUND IN SORT III AS COMPARED WITH SORT II Item Item Item Mean Mean Sort I Sort II Items Eerceived as more an~ In Sort III than In iInEort- Sort II: 2. The nurse suggests that the patient discuss his troubles with the doctor. 5.28 4.42 31. The nurse stays with the patient until he has taken his medication. 3.42 2.78 46. The nurse gives prescribed medication when the patient is unable to sleep. 4.64 4.00 47. The nurse is careful not to jar the patient when giving treatments. 5.07 4.28 79. The nurse teaches the patient with a communicable disease how to avoid spreading infection. 5.35 4.64 94. The nurse explains to the patient before he leaves the hospital how to take his medicines at home. 5.78 5.14 95. The nurse explains to the patient why he needs to take his medicine. 5.28 4.71 96. The nurse explains to the patient how his nursing care is related to his illness. 6 .. 71 6.00 P. .05 .05 .05 .05 .05 .05 .05 .. 05 79 TABLE VIII (continued) Item Item Item Mean Mean Sort I Sort II P. 100 .. The nurse explains to the patient the reason for diag-nostic tests. 6.57 5.85 .05 Items Eerceived as less import-an: C In Sor:C III than In Sor:C II: 45. The nurse makes sure the patient has correct foods to eat. 4.64 5.57 .05 63. The nurse talks to the patient about his hobbies. 5.71 6.35 .05 77. The nurse teaches the patient about his illness in terms that he can under-stand. 5.00 6.28 .05 80. The nurse teaches the patient good health habits. 4.92 5.71 .05 97. The nurse instructs the patient how to maintain an adequate state of nutrition. 5.57 6.28 .05 Of the items viewed as more important in Sort III than in Sort II, one was a liaison item; three were physical care items, two of these having to do with medications. The others were patient education items relating specifically to the physical care functions which the nurse performs. Of those items viewed as less important in Sort III than 80 in Sort II, one had emerged as of greater. importance in Sort II, than in Sort I. The item was "The nurse makes sure the patient has correct foods to eat." This item may have been viewed as an aide responsibility immediately after the training course; but after the work experience, the aides may have realized that the dietitian is responsible for making sure that the patient has correct foods to eat, and that the aides' responsibility is in the feeding of the patient. Of the remaining four items regarded as less important in Sort III than in Sort II, one is a supportive emotional care item and the others are patient education items. The second hypothesis was also rejected since the aides' perceptions as to the order of importance assigned to the categories remained constant for all three sorts. Comments ~ work Experience I Eight of the aides were assigned to wards on which the patients were all ambulatory, five were assigned to the Geriatrics Division, and one was assigned to work as relief person and rotated a~ong the wards as needed. On the ambulatory wards the patients were responsible for house­keeping details and were also responsible for their personal hygiene under the supervision of the aide. The aide's job on these wards consisted of carrying out routines, keeping 81 the ward atmosphere on an even keel, and encouraging patient activity. On the Geriatrics Division the aide; was required to give more physical care, such as feeding the patient, bathing, and keeping the patient tidy. No measurable differ­ences in th~ responses of aides according to work assignment were identified. See Appendix F for job description of the psychiatric aide. III. DISCUSSION OF THE AIDES'POINT OF VIEW ON THE NURSE-PATIENT RELATIONSHIP The aides 1 perceptions of the nurse-patient relation­ship remained unchanged as to the order of importance assigned to the various categories of nursing functions in all three sorts. There was a shift to assigning greater importance to the physical care items and some liaison items after the pre­service instruction period and the work experience. The patient education and supportive emotional care items were viewed as of less importance. However, despite this shift in emphasis in Sorts II and III, there was over-all agree­ment in all three sorts as to which items from each category were important. (See Appendix D for a comparison of the rank assigned to the Q-sort items in all three sorts.) For example, all of the liaison items ranked as highly important were identical for ,all three sorts wi th the exception of two items. The aides as a group consistently 82 ranked as highly important those liaison items dealing with the core of the nurse-doctor-patient relationship. Items 9, 1, 11, 4, and 12 were selected as the five most important liaison items in all three sorts. Items 9, 1, and 11 deal with those behaviors pertinent to carrying out doctor's orders and reporting either physical or emotional changes in the patient's condition to the doctor. Item 4 involves the nurse's role as a support to an effective doctor-patient relationship. Item 12 deals with the doctor's authority role. In this instance, the specific issue is medication. The five items, ranked among the most important items in all three sorts, correspond to Dr. Whiting's findings in a tuberculosis hospital setting. Dr. Whiting's subjects identified these items as the five most important items of the entire sort.4 In the present study the five items were included among the first eleven in Sort I; in the first twenty-one in Sort II; and in the first sixteen in Sort III. Those liaison items viewed as of medium importance involved behaviors dealing with referring patients! problems to th~ doctor, telling the patient about the availability of spiritual help, informing the patient of occupational and educational therapists who could help him, and explaining how other professional workers could assist with the patient's 4Whiting and others, ~. cit., p. 64. 83 progress toward health. The liaison items ranked as of low relative importance included such items as the nurse answeriqg the patient's question about his progress by telling him what his doctor has said, the nurse telling the patient the function and pur­pose of the various hospital departments, and the nurse telling the patient what schedule of treatment the hospital staff members have worked out for him. An inspection of the above items shows that those behaviors involving action on the part of the nurse that enhances the nurse-doctor-patient relationship were perceived as of greater imp?rtance, while those items dealing with routines and rules were viewed as of less importance. The liaison category of nursing functions was ranked in third place in all three sorts. As stated before, the aides viewed the physical care category of nursing functions as the most important cat-.egory in all three ~ortso Those items dealing with the technical aspects of physical care and with the immediate physical experience of the patient were ranked as of high relative importance in all three sorts. The physical care items viewed as of medium relative importance had to do with giving th~ patient pre-operative care, recognizing and planning for the patient's physical needs, and providing for the patient's rest when he tires. 84 These three items did not seem too pertinent to the setting since the patients are encouraged to care for their own physical needs and great emphasis is placed on activity_ The other items ranked as of medium importance stressed the importance of treatments and caring for the patients after treatments. Some physical care items viewed as of low relative importance in Sort I were viewed as of medium relative importance in Sort II. Only one physical care item was viewed as of low relative importance in Sort III. This particular item (45) has already been discussed in this paper. In recapitulation of data, the aides viewed the physi­cal care category of nursing functions of the nurse-patient relationship as the most important aspect. Of the supportive emotional care items ranked as of high relative importance, eight were common to all three sorts. These items stressed making the patient feel welcome and wanted in the hospital, calming the disturbed patient, understanding why a patient is being uncooperative, and calling the patient by his name. In the pre-service instruc­tional course the necessity of the aide being a warm, friendly, and accepting person was emphasized. However, the various ranks assigned to two of these items in the three different sorts should be noted. Item 51, "The nurse makes 85 the patient feel welcome and wanted in the hospi tal, It was ranked 6.5 in Sort I, 14.5 in Sort II, and 28.5 in Sort III. Despite the emphasis in the instructional course on friendli­ness, this item was viewed as of progressively less importance in Sorts II and III. The rank assigned to Item 51 is also of interest. "The nurse calms down the upset patient." This item was ranked 16 in Sort I, 24.5 in Sort II, and 17.5 in Sort III. The importance attached to this item was relatively high before the pre-service education, declined after the instructional period, and again went up after the work experience. No satisfactory explanation of the fluctuation of this item was found by the writer. The items in the supportive emotional care category ranked as of medium importance deal with the nurse trying to understand how the patient feels about his illness, helping the patient to express his fears about his illness, and being considerate with the patient so that something new is not embarrassing. Items 58 and 59 state that the nurse is understanding when a patient refuses his medication and that the nurse shows sympathy toward an aggravating patient. Both of these items touch upon the patient's negative feelings. Of the supportive emotional care items perceived as of low relative importance, three deal with the nurse-patient interaction in which the nurse asks the patient what his interests are, about his hobbies, and helps him to pass the time by talking to him when he is alone. The other items ranked at this level involve the patient's family and his home. A review of the supportive emotional care category shows that a large percentage of the items were perceived 86 as of medium relative importance. The review of literature revealed that in the psychiatric settings in which the nurse­patient relationship Q-sort had been used as a research tool, with such personnel as registered nurses, social workers, psychologists, and psychiatrists, a common point of view had emerged stressing supportive emotional care as the most important aspect of the nurse-patient relationship.5,6 Two authors state that an interest in the patient's fears, anxieties, uncertainties, and hatreds take precedence over an interest in his temperature, pulse, and respiration. The unpleasant, perverse, unreasonable behavior exhibited by the mentally disturbed patient is all a part of the illness and corresponds to the fever, vomitus, and fetid breath of the patient on the medical or surgical ward of a general 5 ..• Frank Whiting and others, t1The Nurse-Patient Relationship and the Healing Process," A Progress Re10rt to the American Nurses' Foundation (New York: The Amer can Nurses' Foundation, Inc., 1958), Appendix VI. 60ra Loy N. Robison, "Study of Nursing Personnel and Patients' Perceptions of Nursing Functions Contributing to Patient Comfort," unpublished Master's thesis, University of Utah, 1960. 87 hospital. 7 Current trends in psychiatry are directed toward a concept of patient care which emphasizes the importance of providing the psychiatric patient with a therapeutic milieu that plans for his total needs. In the review of literature mentioned above, the more sophisticated workers in the psychi­atric setting chose the supportive emotional care category as the most important aspect of the nurse-patient relationship. In this study, the fact that the psychiatric aides chose the physical care category of nursing functions as the most important aspect of the nurse-patient relationship may be based on the differences between a professional point of view as opposed to that of a beginning aide. The patient education category had one item ranked as of high relative importance in Sorts I and III; six items ranked as of medium relative importanc~ and thirteen items ranked as of low relative importance in all three sorts. These items deal with general health teaching and specific instructions to the patient regarding his care. This category was perceived as least important in all three sorts. Although the aides' perceptions as a group tended to be similar, the correlation coefficients between sorts for 7Helena Willia Render and Olga M. Weiss, Nurse-Patient Relationships in PSlchiatry (second edition; New York: McGraw­HIlI Book Co. ), --r 9 59, p. 3 • 88 some of the aides were below the range of correlations established for another group o'r heal th workers (.56- .. 88). Tabl~ IX depicts the correlation coefficients for Sorts I and II, I and III, and II and III. The data collected from the aide-students were examined carefully in an attempt to discover what personal character­istics, if any, had a bearing on the degree and type of change in any individual sort. The sorts of the three students whose correlation coefficients were quite low are selected for further discussion but no conclusions have been reached as to why these particular students emphasized these particular items. student K, whose correlation coefficient for Sorts I and II was .10, was a housewife with a high school education, married, and the mother of three children. In Sort I, this student chose supportive emotional care items as the most important items of the entire sort. After the pre~service instruction course, she chose mostly those liaison items dealing with the core of the nurse-doctor-patient relationship and supportive emotional care items, as well as some physical care items, as the' most important. After the work experience, she chose those liaison items making up the core of the nurse-doctor-patient relationship, as well as physical care items, as the most important items. Student B, whose correlation coefficient for Sorts I TABLE IX CORRELATION COEFFICIENTS FOR SORTS I AND II, I AND III, AND II AND III r for Sorts r for Sorts r for Sorts Aide-Student I and II I and III II and III A .51 .38 .39 B .39 .21 .55 C .68 .70 .72 D .68 .66 .60 E .36 .39 .49 F .45 .30 .14 G .52 .53 .72 H .60 .48 .43 ' .. I . 47 .27 .38 J .36 .. 21 .54 K .10 .31 .13 L .. 70 .69 .81 M .31 .41 .46 N .75 .72 .86 89 90 and III was .21, chose in Sort I those items dealing with supportive emotional care and physical care as the most important. After the work experience, Student B chose those liaison items which make up the core of the nurse-doctor­patient relationship and physical care items as the most important. This student was a twenty-six-year-old male, married, and the father of one child; had two years of college; and was, at the time of the study, enrolled in a university. Student F, whose correlation coefficient for Sorts II and III was .14, was a married, nineteen-year-old male who had had one year of college and was, at the time the study was made, enrolled in a university. This student assigned greater emphasis to the physical car~r' items following the pre-service instructional course but stressed liaison, supportive emotional care, and patient education items following the work experience. In summary, th~re was marked similarity in the aides! perceptions as a total group.. However, a careful examination of the individual sorts revealed wide differences in percep­tions among the aides. The writer of this paper was unable to determine if any personal characteristics such as age, sex, previous work experience, and amount of schooling were related to the degree and type of change between any two sorts or between the sorts of different individuals. A much 91 larger sample would probably be required in order to identify differences in sorts related to personal characteristics. CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS I. SUMMARY With the objective.of learning what attitudes toward nurse-patient relationships a group of newly employed psychi­atric aides brought to their new occupation and how these attitudes changed after a pre-service education program and again after one month of working on the wards with psychiatric patients, the Q-sort developed by Dr. J. F. Whiting wa~ given to fourteen psychiatric aide students in the fall of 1961. The age of the aide-students ranged from nineteen to forty-four years. All of them lived in or near the city in which the mental hospital is located. Twelve of the f.ourteen were married. School experience ranged from ninth grade to completion of two years of college. Five were continuing as college students. Work experience was varied. Two of the older students, both women, had not worked since high sohool days. Each of the other students had held at least one job and some had held as many as four. ~he pre-service instruction focused on helping the aide-students recognize principles of nursing care necessary in the psychiatric' setting.. Only a brief introdu.ction to many of the phases of nursing care was given. The course was 93 160 hours in length and was distributed over a period of four weeks with the time fairly equally distributed among the broad areas of individual work with one patient, demon­strations of nursing procedures with planned ward experience for return demonstrations, tours to hospital departments and wards, and group discussions. Two hypotheses were formulated, one in null form, to be tested by statistical measures. Hypothesis #1. There will be no statistically sig­nificant differences in how the aides perceive the nurse­patient relationship before and after the pre-service training program as measured by the mean score assigned to the four areas being evaluated in this study. The trainees will perceive the categories in the nurse-patient relationship Q-sort in the following order of importance: (1) liaison, (2) physical care, (3) supportive emotional care, (4) patient education. Hypothesis #2. After working for a period of one month on the wards the aides will rank the categories of nurse-patient r~lationship in order of importance as follows: (1) physical care, (2) liaison, (3 ) supportive emotional care, (4) patient education. Both of these hypotheses were refuted. The physical care category in Sort II emerged with a statistically signifi­cant difference when compared to Sort I (P. = .01). The 94 rank order of importance of the categories of nursing func­tions in all three sorts was: (1) physical care, (2) support­ive emotional care, (3) liaison, and (4) patient education. Although the aides' perceptions of the nurse-patient relationship remained unchanged as to the order of importance assigned to the various categories of nursing functions in all three sorts, greater importance was assigned to the physical care items and some liaison items after the pre­service instruction period and after the work experience. Despite this shift in emphasis in Sorts II and III, there was over-all agreement in the three sorts as to which items from each category were important. The correlation coefficients between sorts for several of the aides were considerably below the expected range of correlations established in a previous study of this kind, indicating in these instances considerable change in attitudes over the period being studied. The data collected from the aide-students were examined carefully in an attempt to discover what personal characteristics might have had a bearing on the degree and type of change in any two sorts. The writer of this paper was unable to determine if any personal characteristics such as age, sex, previous work experience, or amount of schooling were related to the degree and type of change between any two sorts or between the sorts of different individuals. A much 95 larger sample would probably be required in order to identify differences in sorts related to personal characteristics. II. CONCLUSIONS AND RECOMMENDATIONS On the basis of the findings of this study the writer presents· the following conclusions and recommendations: 1. The findings of this study have significance for those concerned with pre-service and in-service education of psychiatric aides. However, larger numbers of new and experienced aides should be tested with the Q-sort in this institution to determine typical and deviant psychiatric aide attitudes and, if possible, to identify personal character­istics of individuals which influence the importance they assign to items in the Q-sort. Significant findings in the latter area could be useful in aide selection and training. 2. The pre-service instructional course was of a type believed to be common in psychiatric institutions. It placed its main emphasis on physical care of patients and particularly on nursing duties directed toward giving and charting medications. The influence of the instructional program was demonstrated in Sort II. Recent psychiatric literature and teaching have emphasized the importance of supportive emotional care and patient teaching. The objec­tives and content of the pre-service course should be carefully evaluated in relation to the philosophy of psychiatric 96 nursing care subscribed to by the institutional staff and changes made if indicated. The writer would like to see the same Q-sort given before and after a course emphasizing a developmental approach, self-understanding, supportive emotional care and patient teaching to see what, if any, changes such an approach might induce. 3. In the course of the study the writer observed evidences of aide culture patterns which might well exert influences on the attitudes of aides. A study of the aide culture pattern in the institution is recommended. 4. On the whole the measured attitude changes were small during the two-month period included in the study. This study reaffirms the difficulty of bringing about attitude changes in a short period of time. If attitude change is desired, a longer term in-service program is recommended to promote progress toward the goals selected. 5. Although net change in attitudes was small, some individual changes were considerable. Further study of such changes would be desirable. These may have a positive or negative relationship to "the authoritarian personality." 6. If one goal of the mental hospital is to estab­lish a therapeutic community in which both the patients and the personnel progress toward more effective interpersonal relationships, more study is needed of the attendant because he is the person in longest and most continuous personal 97 relationship with patients and he has had the least prepara­tion for this important and potentially challenging and rewarding work. BIBLIOGRAPHY BIBLIOGRAPHY BOOKS Greenblatt, M., R. H. York, and E. L. Brown. From Custodial to Therap.,eutic Care in Mental Hospitals. New York: Russell 'Sage FoundatlOn, 1955. Hall, Bernard, and others. Psychiatric Aide Education. New York: Grune and stratton, 1952. - Jones, ,Maxwell. The Therapeutic Community. New York: Basic Books, Inc., Publishers, 1953. Render, Helena'Willia, and M. Olga Weiss. Nurse Patient Relationships in Psychiatry_ Second edition.' New York: McGraw-Hi!t BoOK Company, Inc., 1959. Rodeman, Charlotte R. A Guide for Psychiatric Aides. New York: Macmillan Co:, 1956.--- Robinson, Alice M. The PS!Chiatric Aide. Philadelphia: J. B. Lippincottuo., 954.· -- stephenson, William. The Study of Behavior: Q-techniques and Its MethodologY:- Chicago: University-of Chicago Press, 1953. OTHER SOURCES Lambertson, Eleanor C. Nursing Team'- or~anization and Functioning. New York: Teachers Go1 ege, ColumOTa University, Bureau of Publications, 1953. National League for Nursing. Concepts of Behavioral Science in NqrSin~ Education. New York: National League for Nursing, 958. National League for Nursing. .sug~estions for Ex~erimentation in the Education of Psych~atr c Aides. New ork: National League for Nursing, 1959. . Robison, Ora Loy N. "Study of Nursing Personnel and Patients; Perceptions of Nursing Functions Contributing to patient Comfort." Unpublished Master's thesis, University of Utah, 1960. 100 Whiting, J. Frank, and others. "The Nurse-Patient Relation­ship and The Healing Process," A Progress Report to the American Nurses' Foundation, Inc. New York: The-Xmerican Nurses' Foundation, Inc., I9~ PERIODICALS ttAmerican Hospital Association Report on the 1957 Survey,tt Hospitals, Gui~e Issue" Part 2, August, 1958. Astryke, Mildred, and Peter A. Peffer.' "Women as Aides to Care for Male Psychiatric Patients," The American Journal of Nursins, 52: 996, August, 1952. - Bateman, J. Fremont, and Warren H. Dunham. "The state Mental Hospital as a Specialized Community Experience," American Journal of Psychiatry, 105:445-448, December, 1948. -- Bernstein, Lewin, and others. "Teaching Nurse-Patient Relationships," Nur~ing Research, 3:80-4, October, 1954,. Black, Kathleen, and Mary Shields. TtPr,oficiency of Psychi­atric Nursing Personnel," Nursing Outlook, 3:37-41, January, 1955. Bonner, C. A. "Mental Hospital, Employees, Their Importance in Future Mental Hospital Betterment," American Journal of Psychiatry, 105:669-672, March, 1949. Brill, Henry, and Lillian Salsman. "Mental Hygiene and the Tranquilizing Drugs," Nursing World, 130:8, June, 1956. Crawford, Annie Laurie, Ruth G. Hahn, and Sister Mary Dorothy. "A Modified Practical Nurse Program for Psychiatric Aides in Minnesota,""Nursing World, 6:25, June, 1957. Day, Max, and Alice M. Robinson. "Training Aides Through Group Techniques," Nursing Outlook, 2:308-10, June, 1954. Dichter, Ernest. "The Hospital Patient Relationship: What the Patient Really Wants from the Hospital,tt The Modern Hospital,