Study of factors involved in a five-week nursing intervention with emergency-room patients with emotional complaints

This present study investigated the factors involved in a five-week psychiatric nursing intervention with patients who came to a hospital emergency room for assistance with emotional problems. Sixteen patients were evaluated by psychiatric resident physicians and referred to the psychiatric nurse for a five-week treatment period. Following each patient's first appointment the referring physician and the psychiatric nurse jointly rated the patient's problems as to their severity and established treatment goals. Ten of the 16 referred patients continued contacts with the nurse throughout the five-week period. At the conclusion of the treatment period the patient's progress was evaluated by the nurse. The plan to have a separate evaluation by the referring physician at this time could not be carried out. Patients were contacted at six weeks and also at three months post treatment regarding their adjustment. There hospital records were reviews in ordered to determine if they had returned to that hospital for further psychiatric help. The data were examined in terms of the responses of the patients, the nurse, and the other hospital personnel, to the program. The number of visits was twice as great during the first week of treatment as during each subsequent week. The investigator believes that a flexible appointment schedule with provision for more than one appointment during the first week of treatment was an important consideration in meeting patient needs. There was no significant correlation between the improvement ratings and the number of contacts with the nurse, the amount of emotion expressed by patients, or the degree of nurses' involvement. However, the correlation between the amount of emotion expressed by patients and the involvement of the nurse were significant at the .01 level. The subjective ness of the ratings was considered. All of the patients had difficulties in interpersonal relationships with significant people in their lives, particularly with spouses. All of them appeared depressed and were unable to function according to their self expectations. Three families of patients involved themselves actively in contacts with the nurse. Further research is needed to determine the benefits of treating the type of patient seen in this study by individual appointments or in conjunction with other family members. The number of problems discussed decreased after the first week. The degree of emotion expressed decreased slightly and increased again during the fourth week which may have been related to the degree of rapport with the nurse and/or the discussion of termination at that time. Six of the ten patients expressed regret that their relationship with the psychiatric nurse must be terminated. One patient reacted by getting drunk and another patient, who had made a suicide attemp prior to coming to the emergency room, slashed her wrist. The investigator felt that an extension of the treatment period might have been beneficial. Due to the small sample, differences in response of patients according to sex and economic difference could not be generalized. Four of the nine psychiatric resident physicians referred patients to the nurse. Sixteen patients were referred during a period on nine weeks in which 3,115 adults were seen in the emergency room. The reason for the small number of referrals merits further investigation. The author believes that the data support the assumption that the type of service offered to patients was appropriate for a psychiatric nurse to give, and that patients did benefit in varying degrees. Further research is needed to determine the optimal period of treatment, the relative effectiveness of various treatment methods, such as including other members of the family, and the types of patients who might benefit most from this mode of treatment.

A STUDY OF FACTORS INVOLVED IN A FIVE-WEEK NURSING INTERVENTION WITH EMERGENCY ROOM PATIENTS WITH EMOTIONAL COMPLAINTS by Fern Pope Bettridge A thesis submitted to the faculty of the Univer sity of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nur sing Univer sHy of Utah June 1969 This Thesis for the Master of Science Degree by Fern Pope Bettridge has been approved May 1969 Chairman, I" . (, -:. ,( Supervisory Committee 1, ..) -/ / . ,1 (. : ( ..i" I , �.�.-: " Reader, Supervisory Committee Reader, Supervisbry Committee Head, :Major Depntmellt r ' . , ....• .1) / :.0, ACKNOWLEDGMENT I wish to express appreciation to Dr. John A. Wolfer, Dr. Royal P. Murdock, Dr. Robert Gray, Mrs. Bonnie Clayton and Miss Sumiko Fujiki for their guidance. Appreciation is given to the hospital staff, particularly to Dr. C. Hardin Branch and Dr. Leonard Schmidt of the Univer sity ci Utah Department of Psychiatry and to Mrs. Dorothy Lowman, Nursing Director, University Hospital. I wish to thank the patients who worked with me and also my husband and three children for their cooperation and encouragement. iii TABLE OF CONTENTS Page ABSTRACT· v .... viii LIST OF TABLES . Chapter I. II. III. 1 INTRODUCTION METHOD 10 RESULTS AND DISCUSSION 17 REFERENCES 43 APPENDIX A 44 APPENDIX B 51 . 57 VITA . . . . iv ABSTRACT The present study investigated the factors involved in a fiveweek p sychiatr ic nur sing inte rvention with patient s who caITle to a hospital eITlergency room for assistance with eITlotional problems. Sixteen patient s were evaluated by psychiatr ic re sident physicians and referred to the psychiatric nurse for a five-week treatment period. Follaving each patient's first appointITlent the referring physician and the psychiatric nurse jointly rated the patient's problems as to their severity and established treatment goals. Ten of the 16 referred patients continued contacts with the nurse throughout the five-week period. At the conclusion of the treatment period the patient's progress was evaluated by the nurse. The plan to have a separate evaluation by the referring physician at this tiITle could not be carried out. Patients were contacted at six weeks and also at three months post treatment regarding their adjustment. Their hospital records were reviewed in order to deterITline if they had returned to that hospital for further psychiatric help. The data were examined in terITlS of the responses of the patients, the nur se, and the ether ho spital per sonnel, to the program. v The number of visits was twice as great during the first week of treatment as during each subsequent week. The investi- gator believes that a flexible appointment schedule with provision for mor e than one appointment dur ing the fir s t week of t rea tment was an important consideration in meeting patient needs. There was no significant correlation between the improvement ratings and the number of contacts with the nurse, the amount of emotion expressed by patients, or the degree of nurses' involvement. However, the correlation between the amount of emotion expressed by patients and the involvement of the nurse were significant at the .01 level. The subjectiveness of the ratings was considered. All of the patients had difficulties in interper sonal relationships with significant people in their lives, particular ly with spouses. All of them appeared depressed and were unable to function according to their self expectations. Three familie s ci patients involved themselves actively in contacts with the nurse. Further research is needed to determine the benefits of treating the type of patient seen in this study by individual appointment s or in conjunction with other family members. The number of problems discussed decrea sed after the first week. The degree of emotion expressed decreased slightly and increased again during the fourth week which may have been vi related to the degree of rapport with the nurse and/or the discussion of termination at that time. Six of the ten patients expressed regret that their relationship with the psychiatric nur se must be terminated. One patient reacted by getting drunk and another patient, who had made a suicide attempt prior to coming to the emergency room, slashed her wrist. The investigator felt that an extension of the tr eatment per iod might have been beneficia 1. Due to the small sample, differences in response of patients according to sex and economic differences cruld not be generalized. Four d. the nine psychiatric resident physicians referred patients to the nurse. Sixteen patients were referred during a period of nine weeks in which 3,115 adults were seen in the emergency room. The reasons for the small number of referrals mer it s further inve stigation. The author believes that the data support the assumption that the type of service offered to patients was appropriate for a psychiatric nurse to give, and that patients did benefit in varying degrees. Further research is needed to determine the optimal period of treatment, the relative effectiveness of various treatment methods, such as including other member s of the fan"lily, and the types of patients who might benefit most from this mode d. tr ea tment. vii LIST OF TABLES Table 1 Page Frequency of Therapeutic Cmtacts for the Ten Patients Who Completed the Treatment Period. . , . . , . . . . . . . . . 19 2 Broken Appointments 21 3 Cancelled Appointments 22 4 Problems Most Frequently Mentioned by Patient s. , . . . . 24 Problems Receiving the Three Highest Intensity Ratings . . . . . . . 25 Number of Problems per Week and Number of Patient Visits . . . . . . . . . 27 7 Ratings of the Intensity ci Patient Emotion 28 8 Emotional Expression of Patients and Emotional Involvement d Nur se . 30 Patient Improvement Rating s by Psychiatric Nurse 35 5 6 9 0 10 11 • • " • • • • Sex and Welfare Differences for the Total 16 Patients Referred . . . . . . . 39 Sex and Welfare Differences for the Ten Patients Who Ccntinued . . . . . 40 viii CHAPTER I INTRODUCTION At the present time the need for psychiatric services is so great that existing facilities and personnel cannot provide assistance to everyone who requests such help. Although increased numbers of professional workers have become prepared to provide psychiatric services, more people are requesting these services than ever before. It is imperative that psychiatric nur se s, as well as other mental health workers, explore ways in which their skills may be utilized more effectively for the promotion of mental health. The role of the psychiatric nur se has expanded rapidly in recent years to include many activities beyond the walls of hospital units, particularly in community mental health centers and in outpatient clinics. The educational preparation of nurses has also extended to meet the requirements of expanded roles. Stokes (1969) states that: Mo st graduate curriculums in psychiatr ic - menta 1 hea lth nursing have helped their nursing students develop a broad theoretical base in: (1) normal growth and development; (2) dynamics of human behavior; (3) family dynamics; (4) psychopathology; (5) epidemiology of 2 mental illness; (0) group dynamics; and (7) the social sciences, particularly sociology, including role theory, and social psychology. Few, if any, of the other disciplines in the (mental health) center have had such a broadly based graduate program (p. 55). However, Stokes (1969) further states that: . . . . the general trend in departments of psychiatry had been to provide . . . such auxillary per sonnel as psychologists and social workers but little or no provisions had been made to include psychiatric nurses in the absence of in-patient unit. Reasons for this derive historically from the traditional ties of the psychiatr ic nur se to the psychiatr ic hospital setting and currently from the relative unclar ity concerning the role of the psychiatric nurse in a general hospital and community program (p. 20). It becomes clear that more research is needed to identify further those situations in which the nurse can work productively. One of these situations might be in the treatment of emer gency room psychiatric patients. The purpose of this study was to determine what the results would be of a five-week psychiatric nursing intervention with patients who came to a hospital emergency room for assistance with emotional complaints. It was developed to see if a psychiatric nurse would be of benefit to patients who were seeking help with their emctional problems, who did not require hospitalization, and who were unable to pay for private psychiatric help. 3 It was assumed that patients who were motivated to seek help would be experiencing some degree of emotional distress. It was further assumed that many patients referred to the nurse would be experiencing some degree of depression although depression was not one of the criteria for patient selection. A short intervention period was considered appropriate for this group of people since depressed patients were reported by Bellak and Small (1965) as being particularly responsive to brief psychotherapy. Also, Wolberg (1965) and Wayne and Koegler (1966) indicated that depression is the most frequent presenting symptom d. patients who are able to profit from short term psychotherapy. The length of therapy referred to in the literature as "brief" or "short term" varied from one visit (Frohman, 1948) to twentyfive or more visits (Wayne and Koegler, 1966). For this study, the treatment period was limited to five weeks for the following reasons: 1. Patients will show favorable results in five weeks as indicated by Bellak and Small (1965) who reported favorable results during five weeks of therapy for depressed patients. 4 2. Description of a five week treatment program would help to define those situations in which a nurse may work productively. 3. Economy of finances and personnel are important considerations in providing a structure for program planning that might be of interest to administrator s of hospitals and other agencies. 4. Time was limited in which to conduct the study. In order to establish appropriate goals for this five-week treatment period, a survey wa s made of the literature concerning short term therapy. Wolberg (1965) indicated that further research is needed in short term psychotherapy to define appropriate objectives and techniques more clearly as well as the circumstances in which these are most effective. Some of the goals which Wolberg (1965) indicated as being appropriate for short term therapy also seemed to be appropriate goals for the nurse-patient interaction type of treatment carried out in this study. These were: 1. Relief of symptoms. 2. Restoration of the level of functioning prior to illness. 3. Under standing of the problem initiating the upset. 4. Recognition of some pervasive personality problems. that prevent better life adjustment. 5 5. Partial cognizance of the origin of present problems in past exper ience. 6. Recognition of the relationship of prevailing per sonality problems and the current illness. 7. Identification d. remediable measures for environmental di£ficultie s. It was assumed that all of these goals might not be appropriate for every patient seen in this study; however goals would be restricted strictly to those enumerated above. The purpose of the nursing intervention in this study was to build upon existing strengths and to help the individual to utilize his own and other resources more effectively. In order to accom- plish these objectives the therapeutic process was adapted from Wolberg (1965) to include the following activities when appropriate: 1. Establishing a rapid working relationship through listening, communicating understanding, communicating confidence and reassuring the patient that he is not hopeless. 2. Enabling the patient to become aware of his feelings and to express them. 3. Assisting the patient in observing himself by connecting feelings with events and his self concept. 6 4. Helping the patient to examine alternative s of behavior. 5. Encouraging the patient to evolve a constructive philosophy of life which involves a) Separating the past from the present. b) Tolerating a certain amount of tension, anxiety, ho stility, fru str ation and depr iva tion. c) Correcting what can be improved in one1s life situation and accep:ing what cannot be improved. d) Stopping unreasonable demands on oneself. e) Establishing a reasonable level of self esteem. f) Accepting one's role in regard to sex, parenthood, being an authority and relationship to other authorities, etc. 6. Helping the patient to anticipate future problems and to formulate a tentative plan of action. It was anticipated that aU of the psychiatric patients seen In the emergency room would be experiencing some kind of crisis. All patients who seek help, or for whom help is sought, have an identifiable precipitating event in their history, but this event may not be as recent or as clearly defined as for individuals coming to an emergency room. identified by Caplan. Paul (1956) refers to four phases of crisis These are: first, the rise of tension 7 following the impact of the situation and an attempt to cope with it in a familiar manner; and increased tension; second, the lack of successful resolution third, the mobilization of additional internal and external resources through which the problem is solved, or it is defined in a new way or certain goals are given up; and fourth, if these are not successful, there is major disorganization. It was as sumed that most of the patient s in thi s study would be in the third of these four phases and that patients described in the fourth pha se would require hospitalization. Robischon (l967) identified adaptive responses to crises as ability to under stand the situation, expres s feeling s and release tension appropriately, use the resources available and work actively at problem solving. She stated that maladaptive responses to crises may include denial, magical thinking, excessive fantasy, reg re s sion, suppre s sion of anxiety with c linica 1 manife stations, projection of blame and/or guilt feelings and depression and withdrawal from reality. For this study an assessment of the patient I s reaction and the severity of maladaptive responses were to be assessed by the psychiatrist prior to referral to the psychiatric nurse. 8 In order to assess the results of the nursing intervention and the factors involved in this study several subquestions were posed: 1. Would there be a difference in the frequency with which the patients would see the nur se dur ing the weekly intervals? 2. Would broken appointments occur frequently, thereby interfering with communication? 3. Wruld there be certain kinds of problems these patients would bring to the attention of a nur se at different weekly intervals? 4. Would there be any observable pattern of intensity of emotional expr ession within the weekly intervals? 5. Would there be a relationship between the degree of emoticnal involvement felt by the nurse with a particular patient and the amount of emotion expressed by the patient? 6. What kinds of reactions might there be frcnl members of patients' families? 7. Would there be any observable reactions to termination of the patients' relationship s with the nur se? 9 8. Would patients improve sufficiently during the fiveweek period that further psychiatric help would not be required within a six-week or three-month period? 9. Would there be any relationship between the rating of improved behavior and the degree of nurse! s involvement or the emotional expre s sion of patient s ? 10. Would there be any differences in the behavior of male and female patients or of patients who were welfare recipients and those who were not in regard to appointments kep:, emotion expressed by the patient, nurse! s involvement, or re sults of treatment? 11. How would doctors and other hospital personnel respond to a nurse who was conducting this type of study? 12. What implications do these data have for providing nursing service to the type of patients selected for this study? CHAPTER II METHOD The study was conducted in the Emergency Room of the University Hospital in Salt Lake City, Utah, which serves all patients who apply for service whether the co st of the medical care is to be paid for from private funds or from agency resources. The patients included in the study would ordinarily have been referred to the psychiatric out-patient clinic of University Hospital which was staffed by the Department of Psychiatry staff and psychiatric resident physicians, or to other community facilities. Some of these patients might not have been referred for further help because of lack of funds or limited facilities. During the period fronl October 15 to December 15, 1968, when patients were being selected for this study 3,ll5 adult patients carne into the emergency room for treatment. No record was kept of the number of patients referred to psychiatric residents for con sultation. The investigator in this study was a psychiatric nurse who had completed the fir st year of a two-year graduate program designed to prepare psychiatric nurse clinicians. In preparation, 11 the investigator conferred with the chief psychiatric resident of psychiatric services in the emergency room about details of the study and incorporated recommendations suggested by him. The chief resident then discus sed the study with the head of the Department of Psychiatry, and cleared the way for it. The chief resident also discussed the project with eight other psychiatric residents who rotated on call to the emergency room. Each resident was provided with a written copy of the procedure (Appendix A) which was also posted in the emergency room. Four of the eight residents agreed to participate in the study. Approval to conduct the study wa s obtained also from the director of Nursing Services. The nursing supervisor of the out- patient department and emergency room services was helpful in having the nursing staff become involved and making arrangements for a room to be used by the investigator for the purpo ses of the study. The sample included sixteen patients, ages 19 to 60 years of age, who were first seen and evaluated by a psychiatric resident physician in the emergency room of the hospital. They were neither hospitalized nor referred to other community psychiatric facilities for treatment. The number was determined by the amount of time available to be devoted to the study and further 12 limited to adults with problerns which were not incident to either adolescence or old age. No patients who had required hospitaliza- tion for psychiatric problems within the previous six months were included in order to limit the sample to patients whose problems apparently were of an acute rather than a chronic nature. Only residents of the Salt Lake City area were included in the sample since patients were asked to return to the University Hospital for appointments with the psychiatric nurse. These appointments with the psychiatric nurse were scheduled by the referring psychiatrist. The patient! s name, address, telephone number and ho spital number were placed on an appointment schedule sheet of the emergency room. The appointment was made in writing to the patient for the following day whenever possible or within a maximum of two days from the initial visit to the emer gency room. The referring psychiatrist explained that the psychiatric nurse would be available to discuss their problems with them during a limited period of five weeks and that there would be no extra fee for this service. The psychiatric nurse checked for new referrals each morning. After seeing the patient, subsequent appointments were 13 made by the nurse on the basis of the patient's individual needs. All appointments were from fifty to sixty minute s in length. During the first a{pointment, the patients were informed that the psychiatric nurse would be available to discuss their problems with them as often as they wished for one hour periods during the next five weeks. It was explained that another appoint- ment would be arranged with the referring physician at that time and if further help were needed they would be referred for further assistance. After the fir st appointment, the psychiatr ic nur se conferred with the referring psychiatrist and completed the progress rating form (Appendix A) indicating an evaluation of the patient I s presenting problem or problems and the therapeutic goals. The content of each subsequent appointment varied according to the needs of each patient but were in accordance with the goals and activities described in Chapter I as appropriate for short term therapy. The psychiatric nurse attempted to be as helpful as possible to the patients through interested listening, encouraging them to discuss their current problems, and to express their feelings about their difficulties. Efforts were directed toward helping the patient to arrive at some conclusions regarding appropriate action for coping with their life situations. 14 Following each appointment, the session and an estimate of the patient I s emotional state were recorded by the nur se on the patient's medical record. Any undesirable reactions to medication, marked increase in depression, suicide threats, or bizarre behavior were called to the attention of the referring re sident by telephone or by per sonal contact. The records of each visit were used by the nurse to plan for future appointments and for evaluation. For each appointment period data recorded included the kinds of problems presented and a rating ci. the severity of each problem (to the patient) on the basis of the following criteria: 1. Problems mentioned only casually without signs of emotion in the course of discussing something else. 2. Problems of a secondary nature which were discussed briefly and did not seem to be associated with other major problems. 3. Problems of a secondary nature which were discussed briefly and which seemed to be associated in some way with another problem discussed with more intensity. 4. Problems discussed at some length but ln a calm manner. 15 5. Problems discussed at some length accompanied by signs of tension such as smoking, fidgeting, swinging foot, tapping fingers) etc., or with facial expression and po stur e indicating depre s sion. 6. Problems discussed coherently but with weeping or outbur sts of anger. 7. Problems only discussed with great difficulty accompanied by outbur sts of anger, crying, blocking ci speech, facial distortion, hiding of the face, tense posture, or other signs of intense emotion. The overall amount of emotion expressed by the patient and the emotional involvement of the nurse during each appointment period were also rated on a scale of one to seven. If any appointments were missed a telephone call was made whenever po s sible or a letter wa s sent encouraging the patient to return and another appointment time was suggested. Telephone calls were accepted from patients or members of patients' families in addition to scheduled appointments. Upon completion of the five-week period an appointment was made for the referring resident psychiatrist to re-evaluate the patient in ternlS of established therapeutic goals and to complete 1.6 a second prcgress rating form without reviewing the first rating form. A separate rating form was completed also by the psychiat- ric nurse at the end of the five-week period. As an evaluation of the effects of therapeutic endeavor the patients were contacted by telephone six weeks later and again three months later to determine if they had sought further psychiatric treatment and how they felt they were adjusting to their life situations. Their hospital records were also reviewed to determine whether or not they had been seen again in the emergency roonl of University Hospital for psychiatric reasons. CHAPTER III RESULTS AND DISCUSSION Sixteen patients, 5 men and 11 women, were referred to the psychiatric nurse during a period of nine weeks. patients were not included in the study. Of these, six Three women, two of them welfare recipients, failed to keep the first appointment. When contacted by telephone they stated that they preferred not to make any further appointments. Three other patients did not return after the fir st appointment. Two of these, both women, gave as their reasons for not continuing either lack of transportation or unwillingness to corne to the hospital for appointments. The third patient could not be contacted by telephone or letter. The ten patients who continued the scheduled contacts with the psychiatric nurse included four men and six women. At the completion of work with these ten patients the investigator analyzed the data. These will be discussed in relation to the questions that were posed. Question 1. Would there be a difference in the frequency with which the patients would see the nurse during the weekly intervals? The number of appointments kept totaled 60. There were 37 telephone calls made, of which 11 were considered to be therapeutic. 18 Eight of the telephone calls involved family members other than the patient. Letters were written to three patients who did not have telephones. The number of therapeutic contacts per patient varied from one visit and three telephone calls to twelve visits and one telephone call. The average number of therapeutic contacts was 5.8 visits and I. 1 telephone calls per patient. The Spearman rank order correlation between the number of contacts of patients with the psychiatric nurse and the improvement ratings was -.42 which was not significant. The number of visits was twice as great during the first week of treatment than dur ing each sub sequent week. Thi s figure did not include the three patients who kept only the first appointment. The investigator believes that a flexible appointment schedule with provisions for more than one appointment dur ing the fir st week of treatment was an important consideration in meeting patient needs. Additional appointments probably would have been scheduled for seven of the ten patients if a five-week limit had not been established. Question 2. Would broken appointments occur frequently, thereby interfering with communication? 19 Table 1 Frequency of Therapeutic Contacts for the Ten Patients Who Completed the Treatment Period Weeks of Treatment Contacts Number of visits Therapeutic phone calls First Second Third Fourth Fifth Total 20 9 10 10 9 58 3 1 1 2 2 9 20 Cancelled appointments or failure to appear without notice did cause some loss of time in treatment. One fourth of the fail- ures to appear were cancelled appointments. None of the patients who continued with treatment failed to keep appointment s dur ing the first week. Less time was lost through broken or cancelled appointments during the third week than during any other week. Two patients who were welfare recipients were out of contact with the nurse for two week periods but returned and became actively involved in treatment after having been contacted by the nurse and encouraged to return. The author believes that these patients might not have continued treatment without encouragement. The reasons for failure to keep appointments and the weeks at which they occurred are listed on Tables 2 and 3. Question 3. Would there be certain kinds of problems these patients would bring to the attention of a nurse at different weekly intervals? The problem mentioned most frequently by the ten patients who continued treatment was that of conflict with his or her spouse. Nine of the ten patients were concerned about this and the other patient was not married. More intense emotion was also expressed concerning this problem than any other with the exception of 21 Table 2 Broken Appointments Weeks of Treatment Reasons Given First Second Third Fourth Fifth Total Work 4 4 1 2 Lack of transportation 1 Moved 1 Forgot 1 1 2 Confused about time 1 1 2 Not interested in further appointments 6 Total 6 1 6 4 2 0 5 17 22 Table 3 Cancelled Appointments - Weeks of Treatment Reasons Given Fir st Second Third Fourth Fifth Total Lack of transportation o 1 o 2 1 4 III health o o o 2 o 2 Total o 1 o 4 1 6 23 alcoholism. Conflicts with family members other than spouses were also mentioned by over half of the patients. Insufficient funds and indebtedness were frequent complaints and a good deal of emotion was expressed concerning unemployment when this occurred. Seven of the ten patients voluntarily said they felt depressed and the other three appeared depressed by their posture, expression, and the content of their conversation. Four patients complained of anxiety. All of the patients seen in this study had difficulties in interpersonal relationships with significant people in their lives. None of them were able to perform according to their self-expectations. See Table 4. The nurse rated the emotional intensity of the problems discussed using a seven point scale. Problems receiving the highest intensity ratings are reported in Table 5. The conflicts in relationships with people continued throughout the five week period, diminishing from the highest intensity rating of 7 dur ing the fir st week to the highe st rating of 4 during the fifth week. The number and intensity of physical complaints decreased from 13 during the first week to 2 during the fifth week. The total number of problems decreased from 103 during 20 visits the first week, or approximately 5.0 problems per patient, to 22 24 Table 4 Problems Most Frequently Mentioned by Patients Problems No. of Patients Conflicts with spouse 9 Insufficient funds 8 Depression 7 Indebtedne s s 7 Conflicts with mother 5 Conflicts with father 5 Anxiety 4 Overdependence on other s 4 Lack of transportation 4 25 Table 5 Problems Receiving the Three Highest Intensity Ratings Intensity Rating Problem Conflicts with spouse- 7 Excessive consumption of alcohol 7 Anxiety. . 6 Tenseness 6 Overdependence . 6 Unemployment 6 " Conflicts with children, siblings, hospital personnel and law enforcement per sonnel . 5 5 Lack of social contacts - 5 Insufficient funds 5 Loss of appetite 5 Indigestion . . . Depression. . . . . . . . . . Inability to make decisions . - . . .. 5 5 5 26 problems during 9 visits of the fifth week, or 2.4 problems per patient. The number of problems and patient visits are indicated in Table 6. Two explanations for the decrea se in the number of problems were considered. One was that the patients were bothered by fewer problems after the first week and the other was that they were able to focus more upon specific problems. Since the intensity of emotion expressed by patients did not decrease during this period, it was as sumed that the latter explanation wa s more valid. Question 4. Wwld there be any observable pattern of intensity of emotional expression within the weekly intervals? The judged intensity of emotion expressed decreased in the second week and remained at that level during the third week. A noticeable increase occurred in the fourth week and declined about to the original level during the final week. The increase in emotional expression during the fourth week may have been related to the degree of rapport which had developed between the patients and the nur se or to the discus sion cf. termination at that time. On Table 7 ratings are shown for the emotional intensity of each visit or therapeutic phone call (indicated by "ph") for each individual patient. 27 Table 6 Number of Problems per Week and Number of Patients' Visits Weeks of Treatment First Second Third Fourth Fifth Patient visits Mean of problems per visit 20 5.0 9 3.2 10 2.2 10 9 2.7 2.4 Table 7 Ratings of the Intensity of Patient Emotion Patient No. First Week Second Week Third Week Fourth Week Fifth Week Average 1 5, 4 2 1, 4 2 2 5, 4, 3 3 5, 5 3 4 lph 4 6, 4 3 5 5, 2ph 3ph 6 4, 5 5, 3 7 5, 6ph, 5ph, 4, 5 8 2, 3 9 4 10 Average .5 3 3.0 3 4.0 2. 5 5ph 4 4.4 3ph 3.2 3, 5 4, 5 5, 4, 5, 5ph, 6 4.5 4, 6 5 5 4.6 3 3, 4, 5 4 3.3 4 3ph 3.6 5, 5, 6 5, 5 4, 6 6 4 5. 1 4.4 3.7 3.7 5.2 4.5 4. 3 N (X) 29 Question 5. Would there be a relationship between the degree of emotional involvement felt by the nurse with a particular patient and the amount of emotion expressed by the patient? A rank order correlation revealed that the relationship of the ratings for these two factors was. 903, which was significant at the. 01 level. Both of these ratings were made by the nur se and the subjective nature of the material is recognized. Emotional responses of psychiatric nurses to emotion expressed by patients may vary greatly. However, there has been little research to provide information concerning this. See Table 8 for ratings of patient emotion and nur se' s involvement. Question 6. What kinds of reactions might there be from members of patients' families? Three of the families of patients completing the five week period involved themselves actively in contacts with the nurse. The mother of Patient 1 accompanied him to the first two appointments. At the second awointment the nur se indicated tha t she would prefer to see the patient alone. S'ubsequently the patient's father called three times to express his opinions about his son's problems and to ask for guidance in dealing with his son. The husband of Patient 6 accompanied his wife to six of her twelve appointments and joined actively in the discussion of their 30 Table 8 Emotional Expression of Patients and Emotional Involvement of Nurse Patient No. Average Emotional Rating of Patients Average Involvement Rating of Nur se 1 3.0 3.0 2 4.0 4. 1 3 2.5 2. 5 4 4.4 3.8 5 3.2 3.7 6 4.5 4.5 7 4.6 5. 2 8 3.3 3.9 9 3.6 3.3 10 5. 1 5. 1 31 problems. One telephone call was also received from him regarding his wife's reaction to termination. One telephone call wa s made by the nur se to the mother of Patient 7 to promote her understanding and interest in him during the crisis with his wife. The wife of Patient lO accompanied him to six of his nine appointments. She became suspicious of what was happening in her absence and requested via a telephone call that she also see the nur se alone. Both the patient and his wife attempted to influence the nurse to favor their side of the marital argument, whereupon the nurse requested that they attend appointments together. At the time of termination another telephone call was received from this patient's wife requesting advice. Six of the patients were living with their spouses and one was very dependent upon his parents. It was felt that the contacts with other family members in this study aided the patients in for mulating practical solutions to their problems. Further research is needed to determine the benefits of treating the type of patient seen in this study by individual appointments or in conjunction with other family members. Question 7. Would there by any observable reactions to termination of the patients' relationships with the nurse? 32 Termination was discussed during the fourth week and thereafter. Six of the ten patients verbally expressed regret that their relationship with the psychiatric nur se must be terminated. Three of the four welfare patients did not seem to understand that there was a five week limit to their relationship with the nurse even though this was carefully explained during the fir st appointment. Patient 1 reacted during the fourth week when termination was mentioned by buying three bottles of wine on the way home and proceeding to drink them. All further appointments were broken with the excuse of working late although appointments were made as late as 8 p. m. Patient 6, who had ingested a toxic drug prior to her initial visit to the emergency room, slashed her wrist following termination. The laceration was superficial and did not require suturing. However, her husband called the nur se and another appointment was made and kept to further discuss her feelings about termination. The investigator questioned if termination may have been less disturbing to patients had there been greater continuity of services available to them following termination. An extension of the treatment period might have been beneficial for several patients. 33 Question 8. Would patients im.prove sufficiently during the five-week period that further psychiatric help would not be required within a six-week or a three-month period? The severity of patients I problems was rated jointly by the referring psychiatric resident and the psychiatric nurse following the patient ' s fir st appointm.ent with the nurse. initial ratings was 4.25. The mean of these The mean of the severity of these problems as rated by the nurse at the end of the five-week period was 2.75. The mean of the decrease in the severity rating of each patient's problems plus the ratings of progress toward goals was used as an overall improvement rating. The method of the study included a re-evaluation by the referring resident physician; however, only two of the ten patients actually received such a rating. Several factors were involved in this. 1. Appointments with the physician were broken for reasons including transportation problems, forgetting, and the statement by one patient tha t the doctor did not understand her problems and could do nothing for her so that the r e- evaluation wa s pointle ss in her opinion. 2. Hospital procedures required a $9.00 fee for nonwelfare patient s seeing a doctor in the emergency room; 34 therefore, they were referred to a psychiatric outpatient clinic where one appointment could be made without charge. One patient kept her clinic appoint- ment but was requested to complete a series of forms since she had not been seen in the clinic before. She left without seeing the doctor. 3. The residency period for some of the resident physicians terminated before the last two patients had completed the five week period and they were, therefore, not available for re-evaluation. Because of the se difficulties only the improvement rating of the psychiatric nurse was considered. A summary of the major presenting problems, the treatment goals, and the basis of the improvement rating for each patient is explained in Appendix B. The ratings given are presented in Table 9. In addition to the improvement ratings patients were contacted and their hospital charts were reviewed to indicate further treatment needs. During the six weeks per iod following termination, Patient 4 returned to the emergency room for emotional reasons one week after termination and did not return after that time. 35 Table 9 Patient Improvement Ratings by Psychiatr ic Nur se Patient Number Improvement Rating 1 2 2 3 3 1 4 2 5 3 6 4 7 5 8 2 9 2 10 2 36 During the period between six weeks and three months following termination two patients called the p sychiatr ic nur se requesting further help. They were referred to the Emergency Room of University Hospital where both were seen by psychiatric residents for one interview. Two of the patients applied for further service at the Salt Lake County Community Mental Health Center but had not been accepted for treatment during the period of this study. Three mmths following termination none of the patients felt that all of their problems had been solved. Patients 1 and 10 felt that they were having serious difficulty in coping with their problems. Question 9. Would there be any relationship between the rating of improved behavior and the degree of nurser s involvement or the emotional expression of patients? There were several reasons why this question was posed. One assumption was the possibility that patients who expressed their emotions more freely might derive more benefit from treatment than those who did not. However, it was also possible that those who expressed more emotion might have been having more difficulty than others. Another assumption was that the degree of the nurse's emotional involvement might influence the 37 effectiveness of treatment. However, none of the assumptions were supported by the data. The rank order correlation between the degree of emotion expressed by patients and their improvement ratings was -4.6. The rank order correlation between the degree of nursers involvement and improvement ratings was -1. 37. Neither of these cor relations wa s significant. Question 10. Would there be any differences in the behavior of male and female patients or of patients who were welfare recipients and those who were not in regard to appointments kept, emotion expressed, nurse's involvement, or results of treatm.ent? Due to the small sample, differences in responses of patients according to sex and welfare differences cannot be generalized. However, in this study a greater proportion of males and non welfare patients continued with treatment and kept appointments. Both patient expression ci. emotion and nurses' involvement were higher with men and welfare patients. This improvement rating was some- what higher with females and nonwelfare patients. The patient who returned to the emergency room one week following termination was a woman, receiving welfare assistance. The two patients who returned later in the three month period were both men, one 38 receiving welfare and one not receiving welfare assistance. See Tables 10 and 11. Que stion 11. How would doct or s and other ho spital per sonnel respond to a nurse who was conducting this type of study? Nine resident physicians were scheduled on call for psychiatric consultation to the emergency room. The 16 patients included in this study were referred by four of these residents. No information was obtained regarding the reasons for lack of referrals from other psychiatric residents. It was assumed that there would have been a fairly large number of patients who would have met the sample criteria since there were 3,115 adults who came to the emergency room during the period of referral to the psychiatric nurse. No record was kept of how many of these were referred to resident physicians for psychiatric consultation or how many of them would have met the sample criteria. No limitations were made upon the number of new patients who could be referred per week. the criteria were accepted. eligible; All referrals of patients who met None were referred who were not however, a nine week period was required to obtain sixteen referrals. 39 Table 10 Sex and Welfare Differences for the Total 16 Patients Referred Male FeITlale Welfare Nonwelfare NUITlber referred 5 11 9 7 NUITlber who continued treatITlent 4 6 4 6 NUITlber of appointITlents kept 25 33 28 30 NUITlber of appointITlents broken 8 10 10 8 NUITlber of appaintITlents cancelled 2 4 5 1 18 19 14 23 NUITlber of telephone calls 40 Table 11 Sex and Welfare Differences for the 10 Patients Who Continued Male Female Welfare Average rating of emotional expression Nonwelfare 4. 1 3.6 4. 2 3.6 Average rating of nurses's 4. 1 involvement 3.6 4.2 3.6 Average improvement rating 2.5 2.2 2.8 2.2 41 Some of the factors which may have been involved were: 1. Patients may have chosen not to accept the proposed plan of tr eatment. 2. Resident physicians may have been reluctant to refer patients to a psychiatric nurse. 3. Resident physicians may have been unwilling or unable to spend the necessary time conferring with the nurse and re- evaluating the patient s. 4. Resident physicians may have made an overly cautious selection of patients among those who might have been referred. There was some expression by the participat- ing resident physicians of a rather protective attitude toward the nurse and a tendency to refer only patients with whom they thought she would enjoy working. All of the participating residents were supportive of the nur se, and wer e encouraging and noncr itical in their communications. Other hospital personnel were consistently cooperative. The reasons for the small number of referrals to the psychiatric nurse merits further investigation. The author also suggests further investigation of attitudes of other disciplines in the mental health field toward psychiatric nurses, particularly 42 in regard to nurse's participation in the type of treatment given in this study. Question 12. What implications do these data have for providing nursing service to the type of patients selected for this study? Due to the limited sample involved in this study, generalizations ci the results may not be valid for larger populations. However, the author believes that the data support the as sumption that the type of service offered to patients was appropriate for a psychiatric nurse to give, and that patients did benefit in varying degrees. Further research is needed to determine the optimal period of treatment; the relative effectiveness of various treatment methods, such as including other members of the family; and the types of patients who might benefit from this mode of treatment. 43 REFERENCES Bellak, L., & Small, F. ~mergency l?~~Eot!!~£~ ~ndl>.!iet psychotherapy. New York: Grune and Stratton, 1965. Frohman, B. S. Brief psychotherapy. Febiger, 1948. Paul, L. Crisis intervention. Philadelphia: Lee and Mental Hygiene, 1956, 50, 141-145. Robischon, Paulette. The challenge of cri sis theory for nur sing. Nursing Outlook, 1967, 15, 28-32. Stokes, Gertrude A. The role of psychiatric nurses in community mental health practice. New York: Faculty Press, 1969. Wayne, G. J., & Koegler, P. R. Emergency psychiatry and brief therapy. Boston: Little, Brown and Co., 1966. Wolberg, L. R. Short-term psychotherapy. and Stratton, 1965. New York: Grune APPENDIX A 44 PROCEDURE FOR EMERGENCY ROOM REFERRAL TO A PSYCHIATRIC NURSE (Fern Bettridge) 1. Eligible Patients a) Males or females, with problems of a psychiatric nature. b) Between 19 and 60 years of age (with the idea of eliminating the problems of adolescence or senility). c) Residents of the Salt Lake area who can come to the University Hospital for appointments. d) Who do not require hospitalization now and have not been hospitalized for psychiatric care in the past six months. e) Who are asking for help or at lea st are willing to keep the first appointment. f) Who are not referred elsewhere for help. 2. The patient will be evaluated in the Emergency Room by the resident on call who will determine whether or not a referral to the nur se should be made. The patient I s name, hospital number, and, if possible, a phone where she can be reached, will be recorded on an appointment sheet posted on the wall in the Emergency Room Nurses l Station and the appointment date and time given to the patient in writing. Patients should come to the Emergency Room desk when they arrive for the appointment. 3. The nurse will check each morning before any appointment times to see what appointments may have been scheduled. Subsequent appointments will be made by her on the basis of need but for a limited period of five weeks. 4. Appointments should be made for the following day unless it is Sunday or the appointment times for the next day are 45 filled. In either case an appointm.ent may be made for two days later or the nurse may be contacted and special arrangements made. If necessary she may be reached at horne by calling Park City, 649-9520. (Please do not give thi s number to patient s. ) 5. The nurse will contact the referring physician following her fir st interview in order to discuss br iefly with him the patient's major problems and the therapeutic goals. At this time the patient f s problems will be rated according to their severity on a scale of 1 to 7, one being minimal and 7 being the most severe without requiring hospitalization. 6. Undesirable reactions to medication, marked increase in depression, suicide threats or bizarre behavior will be called to the attention of the physician at any time they are observed. The nurse will write a brief notation in the staff notes of each patient's chart following every interview in order to keep information current. 7. The doctor will be asked to see the patient approximately six weeks following the initial E. R. evaluation in order to re-evaluate the severity of the patient's problems and the degree of progress or deterioration in regard to the therapeutic goals. The nurse will make an appointment for the patient with the referring physician and provide and collect the rating forms. 46 SAMPLE APPOINTMENT SCHEDULE Hospital Patient's Name Number Mon. Oct. 21 J 1: 00 pm_ _ _ _ _ __ 2: 00 pm_ _ _._ _ __ Tues. J Oct. 22 10:00 am ------- 11 :00 am ------- Wed., Oct 23 1 :00 pm_ _ _ _ _ __ 2:00 pm_ _ _ _ _ __ Thurs., Oct. 24 9:00 am ------- 10:00 am ------- Fri., Oct. 25 3 :00 pm_ _ _ _ _ __ 4:00 pm_ _ _ _ _. Sat., Oc t. 26 9:30 am ------- 10:30 am ------- Telephone 47 PROGRESS RATING FORM Rating No. Name _, _________ Date. _____ ---------------Please Circle Severity Problem 1 1 2 3 4 5 6 7 Problem 2 1 2 3 4 5 0 I 7 Problem 3 1 2 3 4 5 6 7 Please circle to indicate progress toward goals or deterioration. Goals: 1 -3 -2 -1 0 1 2 3 4 5 2 -3 -2 -1 0 1 2 3 4 5 6 7 3 -3 -2 -1 0 1 2 3 4 5 6 7 6 7 Overall improvement rating __ Di spo sition of pa tien t: no further follow - up __ refer red to _ _ _ __ Comments: Signature -------------------- TABULATION OF PROBLEMS DISCUSSED 1 week 2 weeks I. 3 weeks 4 weeks 5 weeks Per sonal Problems A. Physical I. 2. 3. 4. 5. 6. 7. 8. 9. 10. II. 12. 13. 14. 15. B. eating, excessive los s of appetite indige stion sleeping, excessive insomnia e limina tion fatigue ave ractivity pain headaches tenseness inability to do work drinking alcohol poor sexual adjustment other Mental 1. 2. 3. 4. 5. anxiety depression suicidal thoughts suicidal actions euphor ia ~ 00 Menta l (continued) b. 7. 8. 9. 10 11. 12. 13. II. 1 week 2 weeks 3 weeks 4 weeks 5 weeks hallucinations delusions confusion incoherence excessive talking inability to talk over-dependence on other s inability to make deci sions Interpersonal Problems A. Family relationships 1. 2. 3. 4. 5. b. 7. 8. 9. B. spouse mother father children siblings in-law s grandparents girl friends other Social-Community 1. 2. neighbor s agency personnel ~ -..0 Social- Community (continued) 3. 4. 5. 6. 7. 8. 9. 1 week 2 weeks 3 weeks 4 weeks 5 weeks (a) school (b) ho spita 1 (c) welfare (d) law enforcement lack of social contacts employer co-worker friends public contacts feeling s about religious institutions other C. 1. 2. 3. 4. 5. 6. unemployment indebtedness inadequate housing inadequate supplies insufficient funds transportation U1 o APPENDIX B 51 Patient 1. Male Presenting problems: Dependency- -first rating 7, second rating 5 Depression--first rating 5, second rating 3 Goals: Decrease depression--progress rating 2 Increase independent behavior--progress rating 2 Improvement rating: Basis for rating: 2 Returned to work, made more independent decisions Further help requested: 2 ----- yes, within three months Female, Welfare Presenting problem: Depressicn--first rating 4, second rating 2 Goals: Help her accept situation- -progress rating 3 Strengthen self esteem--progress rating 3 Improvement rating: Basis for rating: 3 Able to get out of bed in the morning, assumed additicnal responsibilities, marked improvement in appearanc e Further help requested: No S2 Patient 3. Female Presenting problems: Depression--first rating 4, second rating 3 Dependence- -first rating 2, second rating 1 Goals: Strengthen self esteem- -progres s rating 1 Improve marital relationship--progress rating 2 Encourage independence- -progress rating 1 Improvement rating: Basis for rating: 1 stated she felt better, stated communica tion with husband improved, was able to work regularly, little change of affect Further help requested: Patient 4. No Female, Welfare Presenting problem: Depre s sion- -fir st rating S, second rating 4 Goals: Help her to make decisions- -progre ss rating 2 Improve self esteem- -progress rating 2 Improvement rating: 2 53 Basis for rating: Decided to stay with husband, marital situation improved somewhat, physical symptoms were less troublesome Further help requested: Yes, one week following termina- tion with no further treatment Patient 5. Female Pre senting problem: Depre s sian- -fir st rating 2, second rating 1 Goals: Improvement of communication- -progress rating 3 Encourage independence- -progress rating 3 Improvement rating: Basis for rating: 3 Talking with family about feelings, physical complaints disappeared Further help requested: Patient 6. No Female Presenting problems: Depression--first rating 6, second rating 3 Low self esteem- -first rating 6, second rating 3 Goals: Improve communication--progress rating 6 Raise self esteem--progress rating 3 54 Improvement rating: Basis for rating: 4 Hmsekeeping and child care improved, seemed to gain some under standing of her reactions Further help requested: Patient 7. No, although it was recommended Male Presenting problems: Depre s sion- -fir st rating 6, second rating 2 Ho stility--fir st rating 6, second rating 2 Goals: Express anger and accept reality--progress rating 6 Increase self esteem- -progress rating 4 Encourage more realistic philosophy of life--progre ss rating 6 Improvement rating: Basis for rating: 6 Marked improvement in depression, realistic expression of hostility, ceasing to make unreasonable demands on himself, positive action toward improving life situation Further help requested: Patient 8. No Female, Welfare Presenting problem: Depression--first rating 3, second rating 2 55 Goals: Promote decision making--progress rating 2 Improve family relationships- -progress rating 2 Improvement rating: Basis for rating: 2 Evaluated situation verbally but action on decisions was not observed, seemed less depressed Further help requested: Yes, through Community Mental Health Center Patient 9. Male Presenting problem: Depression--first rating 2, second rating 1 Goals: Consider alternatives of action- -progress rating 2 Establish realistic goals--progress rating 2 Improvement rating: Basis for rating: 2 Verbally evaluated alternatives and established goals but action on decisions was not observed Further help requested: No 56 Patient lO. Male, Welfare Presenting problem: Depression--first rating 6, second rating 4 Goals: Improve communication with wife--progress rating 2 Improve self esteem--progress rating 2 Improvement rating: Basis for rating: 2 Improved ccrnmunication and more independent action Further help requested: Yes, three months later