The effect of a psychiatric nursing approach during hospital admission with Alaskan native patients

Much of the current nursing research is based upon the assumption that admission to a hospital is a distressing experience. These studies generally employ a clinical experimental method in which reduction of distress is achieved through a warm, personalized nursing approach. Measurements of systolic blood pressure, radial pulse, oral temperature and respiratory rate have been commonly used as an index of nursing effectiveness in reducing patient distress. The patient sample in this study consisted of 54 Eskimo, Aleut and Athapaskan patients who were admitted over a three month period for elective medical and surgical conditions. The purpose of the study was to measure the influence of a psychiatric nursing approach upon the reduction of emotional distress during hospital admission of Alaska native patients. The experimental group received a warm, personalized approach from the psychiatric nurse who attempted to identify and respond to patient feelings about hospitalization. The control group received the routine admission from the hospital staff with the assumption that admission procedures in a large hospital are often task-oriented, hurried and impersonal. Pre and post admission measures of systolic and diastolic blood pressure, radial pulse, oral temperature and respiratory rate were used as indices of emotional distress. A post admission interview was conducted by an independent observer to determine patient feelings about admission. It was hypothesized that Alaskan patients receiving a personalized nursing approach as part of the hospital admission procedure would experience greater reduction in their vital sign measures and greater relief from their emotional distress than patients receiving a less personal approach. It was further expected that the group difference in vital sign decrease would reflect a difference in the amount of emotional stress reduction. Results indicated no significant difference between the experimental and control groups in the five vital sign measures. This indicated that the experimental psychiatric nursing approach was no more effective in reducing patient distress than the routine admission administered by the hospital staff, at least from the vital sign measures. Post admission interview results concurred with the statistical findings.

THE EFFECT OF A PSYCHIATRIC NURSING APPROACH DURING HOSPITAL ADMISSION WITH ALASKAN NATIVE PATIENTS by Judith Lee Rollins A thesis submitted to the faculty of the University of Utah in partial fulfillment of the requirements for the degr ee of Master of Science College of Nursing University of Utah June, 1968 " , This Thesis for the Master of Science Degree by Judith Lee Rollins has been approved June, Chairman, nAsory Supe 1968 Committee Reader, Supervisory C9'rnmittee Reader, Supervis ory Committee '-/ ./ //' j(t J / ' ./ . //.A., /,-;.·L.-Lt ? >J Head, � (, )� .. _ Major Department f : � "��:t-,f� :U .! �I '.� i L� l�,,;. �" . ;� I . � I . :'\ � / t·.� .. J j t..J f? � -: � H.;... ACKNOW LEDGMENTS The author wishes to expr es s her deep gratitude and appreciation to her committee chairman Dr. John A. Wolfer and committee members Mrs. Bonnie Clayton and Dr. Charles Dibble for their guidance and encouragement during the preparation of this thesis. Sincere appreciation and recognition are given to the personnel and patients of the Alaska Native Medical Center for the us e of their facilities, their cooperation and as sistance extended in conducting the study. This investigation was supported, in part, by a research and demonstration grant (No. Sav-I04-266) from the Vocational Rehabilitation Administration, Department of Health, Education and Weliare, Washington, D. C. The writer wishes to extend an individual thanks to her parents, Dr. and Mrs. John P. Rollins for their unfailing support and encouragement. For the interest shown by friends and neighbors in Alaska and Utah and the many ways they assisted, the writer is deeply grateful. iii TABLE OF CONTENTS Page ABSTRACT ... vi LIST OF TABLES v Chapter I. II. INTRODUCTION. 1 METHOD 8 III. RESULTS. 15 IV. DISCUSSION. 25 33 REFERENCES VITA . . . . 37 . iv LIST OF TABLES Page TABLE 1 2 3 4 Distribution of Patient Sam.ple by Ethnic Group .... . . . . . 16 Distribution of Patient Sam.ple on Clinical Units . . . . . . . . . . 17 Pre and Post Adm.ission Mean Vital Sign Scores of Alaskan Native Patients in the Experim.ental and Control Groups. . . . . . . . 22 Experim.ental Patient Perceptions of Nurse Behavior during Adm.ission . . v . . . 29 ABSTRACT Much of the current nursing research is based upon the assumption that admission to a hospital is a distressing experienc e. Thes e studies generally employ a clinical experimental method in which reduction of distres s is achieved through a warm, personalized nurs ing approach. Measurements of systolic blood pressure, radial pulse, oral temperature and respiratory rate have been commonly used as an index of nursing effectiveness in reducing patient distress. The patient sample in this study consisted of 54 Eskimo, Aleut and Athapaskan patients who were admitted over a three month period for elective medical and surgical conditions. The purpose of the study was to measure the influence of a psychiatric nursing approach upon the reduction of emotional distress during hospital admission of Alaska native patients. The experimental group received a warm, personalized approach from the psychiatric nurse who attempted to identify and respond to patient feelings about hospitalization. The control group received the routine admission from the hospital staff with the assumption that admission procedures vi in a large hospital are often task-oriented, hurried and im.personal. Pre and post adm.ission m.easures of systolic and diastolic blood pressure, radial pulse, oral tem.perature and respiratory rate were used as indices of em.otional dis tres s. A post adm.is sion interview was conducted by an independent observer to determ.ine patient feelings about adm.ission. It was hypothesized that Alaskan patients receiving a personalized nursing approach as part of the hospital admission procedure would experience greater reduction in their vital sign m.easures and greater relief from. their em.otional distress than patients receiving a less personal approach. It was further expected that the group difference in vital sign decrease would reflect a difference in the am.ount of em.otional stres s reduction. Results indicated no significant difference between the experim.ental and control groups in the five vital sign m.easures. This indicated that the experim.ental psychiatric nursing approach was no m.ore effective in reducing patient distres s than the routine adm.ission adm.inistered by the hospital staff, at least from. the vital sign m.easures. Post adm.ission interview results concurred with the statistical findings. vii CHAPTER I INTRODUCTION Today more than ever, nursing research is examining nursing procedures and routine techniques in order to determine their effectiveness in improving patient welfare. One general nursing procedure currently under scrutiny is hospital admission. That admission into a hospital creates distress has been reported by a number of authors (Dichter, 1954; Fortin, 1960; Lederer, 1958; Taylor, 1962; Trundeau, 1920; Wolff, 1953). "Becoming a patient requires not only leaving the familiar and the loved, but submitting to the strange, the embarrassing and the uncomfortable": (Elms, 1964, p. 266). Wolff has emphasized that the degree of distress in a situation depends a great deal upon the patient's perception of that situation. His perceptions are affected by previous contact with illness, medicine and medical personnel, by the unique system of elements that constitute the institution of medicine in his culture (Saunders, 1954, p. 7), by what his friends and neighbors tell him as well as by his individual needs and values. The degree of distress will vary individually, 2 but it is the nurse, as the professional person most closely associated with the patient, who must be concerned with the patient r s interpretation of his hospitalization so that she can plan his nursing care accordingly. The nurse has an opportunity during the admission procedure, not only to evaluate the patient's physical and emotional response, but also to establish a rapport with him that may help to reduce his distress. A number of recent studies have investigated the distressreducing effectiveness of varying nursing approaches (Anderson, 1962, 1956; Anderson & Leonard, 1964; 1963, 1964; Elms & Leonard, 1966; Elms, Mertz, 1961, 1962; Meyers, 1964~Moran, 1963). The present study is based on a study by Elms and Leonard (1966) of women being admitted to a general hospital for elective gynecological surgery. Patients were ambulatory at the time of admission and all faced similar surgical prospects. approach. Patients received three different kinds of nursing The experimental approach was an individualized method of ca re focus ing on the patient r s pr es enting needs in an attempt to meet them most appropriately for the individual. A second approach was less personal and focused on completion of the admis sion proc edure according to the hospital manual. 3 Although the nurse was friendly, no attempt was made to identify or explore the patient's feelings about hospitalization. Inclusion of this approach gave some opportunity to take the nurse's personal qualities into account. Differences between the experimental and control approach could more reasonably be attributed to the elements of the approach itself rather than to the nurse's education, personality or other personal traits. Patients receiving the control approach were admitted by the hospital staff in the routine manner. Pre and post admission measures of systolic blood pressure, oral temperature, radial pulse and respiratory rate were used as indices of emotional reaction. A post admis sion interview was conducted to determine patient reactions to the admission proceduree Results of the post admission interview supported the statistical findings; the experimental group demonstrated greater reduction in measures of systolic blood pressure, radial pulse, oral temperature and respiratory rate than the control group did. None of the studies cited have taken into account differences in cultural background as a factor potentially affecting individual patient response to hospital admission. 4 The individual needs of a particular patient have been of paramount concern to nurses in their striving to assist the patient towards achievement and m.aintenance of health. Only recently, however, has there been emphasis on the patient as an individual whose unique background influences his behavior. Psychiatric nurses have particular interest and training in understanding the motivating forces underlying human behavior (Brown & Fowler, 1966, p. 44). Some of the motivational forces commonly recognized are needs for air, food, water, shelter, rest and recreation. Not so obvious but nontheless basic are needs to com.m.unicate with others and to be understood, to know the unspoken rules of group membership in order to feel accepted as having position and status. To be understood by others and to fulfill the requirements of group membership in an unfamiliar situation such as hospitalization requires information in order to determine what is expected of oneself and what to expect from others. As basic as these needs are, the influence of an individual's experiences within the context of his culture may determine to a great extent how these needs will be manifested, perceived by others, and resolved (Barnouw, 1963, p. 72; LaBarre, 1947; Wallace, 1958). Hall, 1959; 5 While working with the Alaska natives as a staff nurse in a public health hospital during the summer of 1965, the researcher observed that many adults admitted to a medical service appeared quiet, passive and rather docile. Although Alaska native women generally have been described in these terms, such a picture of the men is somewhat incongruent with ethnographic studies, (Chance, 1966, p. 97; 1966, p. 68). Edm.onds, Eskimo m.en and women have been described as " ... light hearted, and cheerful. .. generally peaceable and not easily discouraged ... [and possessing] a keen sense of humor (Roberts, 1954, p. 41). Aleut people have been characterized by many as tough, hardy and " ... to the utmost good natured, pleasant, friendly and honorable" (Elliott, 1886, p. 235; Shade, 1949, p. 11; Hrdlicka, 1945, p. 206). While the women are more shy, less given to talkati venes sand dir ectnes s in their eye contact with strangers, the men are more outspoken and do not hes ita te to look directly at people to whom they are speaking (Shade, 1949, p. 11 - 1 2) . It was evident that during the brief orientation to the ward facilities patients had had varying experiences with presumably unfamiliar standard hospital equipment including 6 elevators, bedpans, toilets, call-lights and numerous other items. These patients demonstrated few of the usual signs of distress observed among patients of other cultural groups under similar circumstances, such as talkativeness, incessant demands upon the staff, irritability and loudlyvoiced complaints (Dichter, 1954, p. 52). Yet since hospital- ization has been presumed to be a distressing situation, it was assumed that the Alaska native patients were manifesting distress in quietness, passivity, docility or in some other behavior that a nurse with psychiatric training could observe and respond to in such a way as to reduce the patient1s distress. It was the purpose of this study to measure the effectivenes s of two different nursing approaches with Alaska native patients during hospital admis sion. One approach, given by the psychiatric nurse researcher was individualized, supportive and was designed to recognize and respond to patient distress. The second approach was a routine admission given by members of the hospital staff. A reduction in the systolic blood pressure, radial pulse, oral temperature and respiratory rate readings from before to after admission was used as an index of patient distress. 7 It was hypothesized that Alaskan patients receiving a personalized nursing approach, as part of the hospital admission procedure would experience a greater reduction in their vital sign measures and greater relief from their emotional distress than patients receiving a less personal approach. It was further expected that the group difference in vital sign decrease would refelct a difference in the amount of emotional stres s reduction. CHAPTER II METHOD Nursing approaches. The nursing approach to the experimental group was conducted by a professional nurse with one year of graduate preparation as a psychiatric nurse clinician. This approach followed the experimental approach described by Elms and Leonard (1966) which focused on the individual patient with his unique needs and emotions in an attempt to reduce his distres s during hospital admission. This approach was based upon and utilized some of the special skills that the training of a psychiatric nurs e clinician provided. According to Brown and Fowler, "As an observer the nurse has three functions: the spectator, the participant and the introspectionist" (1966, p. 77). As a spectator the nurse may "look on" or she may act as catalyst to stimulate interaction between herself and the patient. She may provide a stabilizing influence just by her physical presence. Though the term "catalyst" may imply distance or reserve in the nurse, she functions quite to the contrary; for the nurse as a participant-observer is actively engaged in the interaction with her patient as she obs erves and 9 responds to him. As introspectionist the nurse clinician observes herself; that is, she attempts to recognize and understand her responses to others and their responses to her. All of these skills mayor may not be operating simultaneously, depending upon the situation (Brown & Fowler, p. 78). Another set of clos ely as s ociated skills are thos e relating to communication. The need for reciprocal communication has been previously noted. Communication may be verbal, involving the use of words to convey and clarify the individual's thoughts, feelings and concerns and fears to others, or it may not be verbal. Non-verbal communication, rarely separate from the verbal form, conveys attitudes, feelings, and thoughts to others intentionally or unintentionally through posture, gestures, facial expressions and vocal inflections. Unless the message is understood by both parties, communication is to some extent unsatisfactory (Brown & Fowler, p. 88). In the course of observation, the psychiatric nurse is aware of these aspects of interaction both in herself and the patient. She attempts to determine whether the patient is in distress, identify, if possible the cause of distress and respond to the patient in such a way to alleviate his distress. 10 While attempting to recognize feelings of distr es s in Alaska native patients the nurse used four questions developed by Elms and Leonard (1966, p. 40), as gUides to common sources of patient distress: the reason for hospital admission, the meaning of hospitalization, the preparations made before hospitalization and the effect of these preparations on patient feelings during admission and the patient feelings about adaptation to the situation. The approach to the control group of patients was conducted by regular hospital personnel with the as sumption that admission procedure in a large hospital is often taskoriented, hurried and impersonal. Elms and Leonard's criterion measures of patient distress were modified slightly with the addition of diastolic blood pressure readings. Other tneasures used were: systolic blood pressure, radial pulse, oral temperature and respiratory rate. Nutnerous reports have indicated an elevation of blood pressure and pulse readings in response to the stress engendered by new situations (Cannon, 1953; Elliott, 1966; Malmo & Shagass, 1952; May, 1950; McGinn, Harburg, Julius, McLeod, 1964; Schachter, 1957). Althoughfewer studies of changes in respiratory rates in respons e to stres s 11 have been reported (Jost, Ruilmann, Hill & Gulo, 1952; May, 1950), Elms and Leonard found a significant reduction in respiratory rates in their experimental patients. Few researchers have reported the use of oral temperature as an index of emotionality, but DuBois (1951, p. 88) and Elms and Leonard (1966, p. 44) noted that oral temperatures increased in distressing situations and decreased significantly after the distress was relieved. Setting and patient sample. Data were collected between July 13 and August 29, 1966 in a 400 bed general hospital established in 1953 for the Alaska native population. patients meeting the study criteria were included. All Originally the sample was to cons is t only of Eskimo patients but so few were admitted during a two-week period that Aleut and Athapaskan patients were also included. Only English- speaking patients of either sex who were at least 12 years of age were included. Study patients were those who had elective rather than emergency conditions. Patients with known circulatory conditions and obstetric patients in labor were excluded from the study. Procedure. All patients in the study were conducted by wheelchair or stretcher to the admission office where 12 preliminary social and medical data w'ere recorded. Pa tients then were given a brief examination in the outpatient department and as signed to a clinical unit. Clinical unit per sonnel and the researcher were notified of the patientls arrival. When patients reached the clinical unit the researcher recorded all vital signs, including height and weight. Control patients were then admitted in the routine fashion by non-native staff members. Since the researcher was non-native, non- native staff members were used throughout the admission procedure. Experimental patients remained with the researcher in the treatment room. Using Elms and LeonardIs questions as a guide, the nurseresearcher talked individually with patients about the circumstances and pr eparations leading up to their hospitalization. The researcher responded to patient feelings about the pre-adlllission period in an explanatory, supporting manner and instituted appropriate nursing actions to relieve patient distress. If for any reason patients were unable or unwilling to talk, the nurse took special care to give them time and opportunity to expres s thems elves. In addition, the researcher discussed general procedures on the clinical unit with the patients. Such procedur es included mealtimes, 13 visiting hours, admission examination, and recreational facilities. On the way to the patients I rooms the nurs e pointed out the location of supplies, TV, lavatories and bathIng facilIties. Patients were introduced to their room- mates, shown the mechanics of operating the bed and calllight and made as comfortable as possible. The researcher spent approximately 50 minutes with each of the experimental patients; in two instances she spent three hours with patients. Staff nurs es spent from 20 to 30 minutes with control patients. An hour and forty minutes after the patients I arrival on the clinical unit the res earcher returned to take post admission vital signs on all patients. Use of an oral thermometer helped keep conversation to a minimum so that the approach to both groups was as uniform as possible. The same stethescope and sphygmomanometer were u....;ed throughout the study. A structured post admission interview with specific open- ended questions was conducted by an independent observer with all patients 48 hours after admission. The purpose of the interview was to determine patient feelings about the kind of admission procedure received. Patients wer e not told of the connection between the interview and 14 admission. Other topics regarding the purpose for hospital- ization, the number of previous hospitalizations and current patient feelings about the hospital were discussed. The observer had been raised on the Seward Peninsula and spoke English and several Eskimo dialects fluently. The interviewer and patients had not met before and the interviewer was not told which approach the patient had received in order to minimize a possible measurement bias towards either group. The interviewer recorded after each interview the group to which she thought each patient belong~d, in order to determine the degree of the obs erver I s objectivity during the interview. CHAPTER III RESULTS From a total of 410 patients admitted between July 13 and August 29 , 1966 , 54 Aleut, Eskimo and Athapaskan patients were included in the study. Four of the 54 patients, two from each group were dropped from the study. Three of these had incomplete vital sign measurements and one patient belonged to a different ethnic group. Patients ranged in age from 14 to 70 year s. The median age for the experimental group was 37 and for the control group 35 years. The number of patient admissions ranged from one to nine in the experimental group and one to ten in the control group with an average of two admissions per patient in both groups. Patients in both groups were admitted to various clinical units in the hospital for a variety of ailments. The distribution of patients by ethnic group is shown in Table 1 and the distribution of patients on clincial units is shown in Table 2. There are several factors that influenced the volume of patient admission, the number of patients in each 16 Table 1 Distribution of Patient Sam.ple by Ethnic Group Group II Group I Eskim.o 7 3 Female 7 6 Male Aleut 4 3 Female 5 6 Male Athapaskan 1 5 Female 1 2 25 25 Male Total 17 Table 2 Distribution of Patient Sample on Clinical Units Group I Group II Eye 3 1 Orthopedics 3 6 General surgery 6 3 Gynecologic surgery 2 5 Tuberculosis 2 2 Obstetrics 1 0 Dental 1 0 General medicine 7 8 25 25 Clinical Unit TOTAL 18 of the three ethnic groups and the variety of clinical problem.s. In the Alaska native population sum.m.er is devoted to the gathering of m.ajor food supplies or to earning m.oney to buy them.. Every person available m.ust contribute tim.e and energy toward this goal to insure adequate stores for survival. As a rule, only persons requiring im.m.ediate m.edical attention can afford to be hospitalized during this period. Another factor influencing adm.is sion at the tim.e of this study was that patients with elective disorders were placed on a priority list for adm.ission to the m.ain treatm.ent center in Anchorage. They m.ay have had to wait several weeks for adm.ission because of lack of space at the hospital or lack of governm.ent funds for transportation at the end of the fiscal year in July. These factors resulted in a som.e- what heterogeneous sam.ple in which the clinical problem.s of the patients tended to be of an acute rather than a chronic nature. At the tim.e of adm.ission, patients were seen briefly in the outpatient departm.ent to e:valuate the presenting sym.ptom.s, determ.ine assignm.ent to a clinical unit and to record a short medical history. In some instances hyper- tensive patients and form.er hospital employees were 19 admitted to the study before these factors we re discovered from the medical records. The hypertensive patients balanced out in both study groups. Two patients in the experimental group had been previously employed in a hospital and therefore may have been less distressed. Experimental interview. Verbal and non-verbal r espons es were recorded immediately after the interview. of verbal responses categorized were: The six kinds talkativeness, moaning, verbalized fear, irritability, nervous laughter and high-pitched vocal tones. In some instances one type of verbal behavior predominated but in most instances patients responded with more than one kind of verbal behavior. Fourteen of the 25 patients in the experimental group initiated conversation and continued to talk as if they could not expres s their thoughts rapidly enough. Ten patients, some of whom were very talkative, voiced actual fears concerning the process and course of hospitalization. For example, one girl feared she would die in the hospital becaus e so many television patients did not leave the hospital alive. Nine patients had high-pitched voices accompanying their free-flowing verbalization and six of the total 25 laughed nervously. One patient moaned with 20 discomfort during part of the interview and one patient expressed irritably her displeasure over the necessity for repeated surgery. Six nonverbal behaviors, assumed to be indicative of distress were observed. These were: tense physical appearance, withdrawal from conversation, evident perspiration, frequent change of sitting position, frequent rapid glances about the room and clasping hand gestures. Patients tended to display one or more of these behaviors. Observation of these nonverbal behaviors seemed to concur with the verbal reports of distress expressed by patients. Process recordings with 23 experimental patients were made hnmediately following the specialized interview. Two interviews were not recorded because they followed each other immediately and the two accounts became confused. Statistical results. The purpose of this study was to discover if a specialized psychiatric nursing approach with Alaska native patients would significantly reduce patient distress during hospital admission. Pre and post admission vital sign measurements were used as indices of distress. 21 An evaluation of the significance of mean differences in both groups was made using a.! test. ~tolic and diastolic blood pressure. The expected larger decreases between the pre and post admission measures for the experimental group were not obtained. Table 3 contains pre and post admission measures, mean difference scores, standard deviations and.! test results for the experimental and control groups. A.£of 1. 17 indicated that the mean decrease in systolic blood pressure 5.92 mm Hg in the experimental group was not significantly different from the mean decrease of .96 mm Hg in the control group. Other investigators (Elms, 1964; Schachter, 1957) found a significant reduction in vital sign measurements. The expected larger decrease between the pre and Fost admission diastolic blood pressure measures for the experimental group was not obtained. A t of 1. 11 indicated the mean difference between the groups was not significant. Although Elms and Leonard (1966) did not record the diastolic blood pressure, Schachter (1957) reported a significant increase during periods of anger, fear and pain. Pulse and respiratory rate. The mean pulse rate in the experimental group decreased more than in the control 22 Table 3 Pre and Post Adm.ission Mean Vital Sign Scores of Alaskan Native Patients in Experilllental and Control Groups Pre-Adlllission Post-Adlllis sion S. D. Mean S.D. Mean i Test Systolic BP Experilllental 141. 12 29.45 135.20 22.27 Control 143.84 27.65 142.88 27.32 1. 17 Dia s tolic BP Exper illlental 98.32 17.59 96,08 16.44 Control 96.16 22.46 98.40 25.22 Exper illlental 87.28 13.97 81.48 14.50 Control 85.60 14.08 82.64 12.01 Experilllental 20.96 4.63 20.88 4.12 Control 21. 18 3.63 22.64 2.23 Exper illlental 98.76 1.05 98.48 1. 93 Control 98.76 1.74 98.40 1.74 1. 11 Radial puls e .82 Respiratory rate 1.58 Oral telllperature .84 23 group as hypothesized but the mean difference was not significant. These results were inconsistent with those in other studies (Elms & Leonard, 1966; Rogers, 1966; Schachter, 1957). The measurement of respiratory rate by obs erving movement of the chest wall is commonly employed clinically along with the pulse rate as an index of physical well-being. Respiratory rates demonstrated no appreciable change in the experimental group means with a very slight increase in respiratory rate for the control group. Again the 1 test results indicated that the mean difference was not significant. Temperature. It was predicted that as distres s was reduced, patients I temperatures would decrease toward the commonly accepted norm of 98.6 degrees Fahrenheit. Patients' temperatures in both groups were not assumed to be associated particularly with their clinical diagnoses. Pre admission means of 98.76 in both groups were slightly higher than the accepted norm (Table 3) of 98.6 degrees F. but did not change in the expected direction. The mean difference between the groups was not significant. Elms and Leonard (1966, p. 44) reported a reduction in all group means with the experimental group achieving the 98.6 24 degree F. norm, nevertheless their mean differences were not significant. Responses of body temperature to distressful elements in the environment have not been as adequately studied as other physiological manifestations. Temperature elevation as a response to stress has been studied mainly in children (Moran, 1963). It is pos sible that adult respons es are less pronounced and therefore more difficult to measure. Also children ' s temperatures are frequently taken rectally while adult temperatures are usually taken orally. It is commonly accepted that temperatures taken rectally are more accurate than those taken orally (DuBois, 1951; Elms & Leonard, 1966). Oral thermometers were used in this study. CHAPTER IV DISCUSSION There are several possibilities for the lack of expected differences between groups in this study. All but three patients had been hospitalized one or mor e times previously since the establishment of the Alsaka public health ,service units throughout the state in 1953. Therefore the hospital setting may be more familiar to patients than assumed and patients may not have been as distressed during hospital admission as hypothesized. Elms and Leonard did not specify first admis sion patients in their sample group since any hospitalization was thought to be distres sing. However, a comparative study with first and multiple admissions might indicate whether first admis sion is the more distressing. A second possibility is that patients may have been ups et, but the experimental nursing approach did not reduce patient distres s satisfactorily. Clinical obs ervation, however, indicated that patients receiving the more specialized nursing approach appeared more relaxed and more receptive to the post admission course of treatment. 26 A third possibility is that patients admitted for nonemergency conditions were distressed but they were not as distres sed about the fact of hospitalization as were the elllergency rOOlll (Mertz, 1961) or mentaL hospital adlllis sions (Anderson, 1962; Anderson & Leonard, 1964) of other studies. Results of the studies cited lllay indicate a greater reduction of distress after hospital adlllission because of the stressful circulllstances that precipitated hospitalization. Moreover, investigators (Anderson, 1962; Anderson & Leonard, 1964; Mertz, 1961) lllay have found the expected changes in the vital signs because they did not employ an independent observer to record patient vital signs. Hence, the investigators may have found a significant decrease in experimental group vital signs because llleasurelllent errors lllay have been made in the hypothesized direction. It is possible that the initial adlllission period, which was assumed to be the most distressing, was not the period of greatest distress. It may be that Alaska native patients were lllore distressed after they were first exposed to hospital equipment, first encountered explanations that were beyond their understanding of English, or when they were first inforllled of illlpending, unexpected forllls of treatment. 27 A four day workshop held at the study hospital for nursing personnel in early August, 1966, may have affected the present results. The focus of the conference was upon improving and individualizing patient care from admis sion until discharge. Following the conference there appeared to be more individual consideration and emotional support given by staff nurses to control patients than had occurred prior to the conference. This kind of attention to the control group may have decreased the difference between the two treatmerts. Another possibility is that the vital sign changes did not explicitly reflect changes of emotional distress. Still, however, observers of others studies (Elms, 1964; Schachter, 1957) found differences in the expected direction. It may be that the author's awareness of the importance of independent obs ervation and the pos sible bias that could develop resulted in more objective results. Several variables in the patient sample, res earch design, and research environment which may have affected the results have been mentioned in the foregoing discussion. It seems necessary here to suggest only that the patient sample in future studies be more homogeneous in age, diagnosis, sex and ethnic group. 28 Post-adtnission interview. The post adtnission interview was designed to suppletnent patients I physiological responses to hospitalization by reporting their subjective perceptions of the experience. Using a modification of the fortn Elms and Leonard followed, patients were asked eleven questions concerning nursing attention they received during adtnission. Table 4 lists nine of the questions, and patient responses categorized into "yes, instance "satisfactory J /I " "no, " "don't know" and in one "unsatisfactory J " and "don't know. II The two retnaining questions dealt with reasons for hospitalization and length of titne patients had to prepare prior to adtnission. Four patients, two from each group were not interviewed; three were discharged before the interview could be given and one was related to the independent obs erver. Interviews with four patients, two frotn each group exceeded the 48 hour limit for the interview by five days because the interviewer was ill. The independent interviewer indicated which patients she thought belonged to the experitnental and control group to see if she knew which patients received the experitnental nursing approach. The obs erver correctly identified 15 of the Table 4 Experimental Patient Perceptions of Nurse Behavior During Admission A) Did the nurse seem to be interested in the reason you came to the hospital? B) Did the nurse seem to know you had come? C) Did the nurse seem to be interested in how you felt about coming to the hospital? D) Did the nurse seem to be concerned about you as a person? E) Did the nurse seem to be more interested in the things she had to do than in how you were feeling? F) Did the nurse tell you what you needed to know about the hospital routines? G) Are these questions or the ones the nurse asked you too personal? H) Have you ever been to the hospital before? I) How do ym feel about the hospital now? TOTAL Answer Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Sat. Unsat. DK Experimental 22 1 0 20 3 0 20 2 1 21 0 2 7 9 7 17 6 0 0 22 1 23 0 0 17 4 2 23 Control 20 0 3 23 0 0 18 0 5 20 0 3 4 12 7 7 15 1 3 16 4 20 2 1 11 10 2 23 N ...0 30 experimental group and 7 of the control group. chi square of 5.72 (p A significant < .02) indicated the observer correctly identified more patients in the experimental than in the control group. Such accuracy is not surprising since the information necessary for identifying the nursing approach the patient received became available to the interviewer during the cours e of the interview. The experimental and control groups were significantly different in their response to three items. A nonsignificant chi square of 1.04 indicated that the two groups were not significantly different in their responses to the item (Item E, Table 4). A significant chi square of 8.50, (p < .01) indicated that more experimental patients learned what they needed to know about hospital routines than control patients (Item F). Although this could not be demonstrated in a significant reduction of vital sign measures, possibly more experimental patients were relieved of their distres s than control patients who indicated that they had not learned what they needed to know. A significant chi square of 3.85 (p < .05) indicated that proportionately more experimental than control patients expressed satisfaction with the hospital setting. 31 A factor which may have affected the results of the interview was the phrasing of the questions. Both the independent observer and the nurse observed that patient r espons es to questions a bout their "feelings" wer e difficult and sometimes impossible to obtain. The observer said that explaining and grasping the concept of "feelings about something'l was difficult for some patients to understand even when the question was translated into the patient's own dialect. Interview questions, shown in Table 4, could h,·,\:,e been stated more clearly. For example, language and cultural differences might have made question B, concerning the nurse's awareness of the patient's arrival on the clinical unit rather odd. The questions required some abstractions and subj ective analysis of a situation that patients indicated, at least verbally, they could not handle. Question E regarding the nurse's awareness of the patient's feelings during admission (Table 4) may be confusing because it follows a questions nearly all patients answered affirmatively. Unles s patients listened attentively to all the interview questions, it is possible they might not have clearly understood question E and answered "yes" automatically. It is also possible patients were responding with the answer they thought the interviewer expected. 32 A final possibility is that patients may have been reticent to report their feelings, fearing to appear critical of the care they receive from the government. 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