NURSING PROCESS AND THE PROBLEM OF

EVALUATING ITS EFFECTIVENESS

 

Ida O. Pelletier

Academic Conference

McLean Hospital

May 3, 1968

 

            Dr. Washburn has invited me to present my concept of nurse-patient interaction.  Before I mention interaction I must first describe what I consider as basic to the analysis of the nurse-patient contact.  I understand the contact as two individual processes of action not as an interaction process per se.  The patient has his process of action and the nurse’s hers.  Whatever happens during a nurse-patient contact these two processes remain distinct.  However, each process may function as a one or two-way street. 

            In the material before you I have tried to illustrate the nurse-patient contact as two separate one-way streets in Figure 1.

 

On the left the nurse acts.  The patient, on the right, may perceive her act and visa versa.  Once perception takes place the process of each begins.  They both think and feel, their reactions propel their actions and they continue to act through the end of the contact.  Neither has direct access to what the other actually perceived, thought, or felt.  Each uses his own perception of the other as a stimulus for his own process, each on a one-way street.  If neither makes available to the other the process of his action I do not believe their acts can interact.           

In Figure 2 I have illustrated the processes of each individual again but here each is a two-way street.

 

Everything is the same; but each process through the action itself in a verbal form makes available to the other the perceptions, thoughts and feelings and the stage is at least set for their acts to interact.  In both diagrams the process of the patient and the nurse evolves in the same way so we should keep in mind why nurses and patients are together in the first place.  While the patient is in treatment he requires the nurse’s care and pays for it; the nurse is paid to give it.  Unless the nurse and the patient reveal their reactions through their actions I do not believe it is possible for the nurse to give nor for the patient to receive that care.

            Since most of my work has focused on the process of the nurse’s action, that is, nursing process, I’ll first discuss my own formulation of the process and a specific discipline which I believe guides its effectiveness.

            I will then describe the training of nurses in this discipline and finally the method we are attempting to develop to evaluate the training and the discipline objectively.

            Nursing process is comprised of four items, all of which reside with the nurse.

1.      Her own immediate perceptions in any nursing situation

2.      The automatic thoughts stimulated by the same perceptions.

3.      The feelings which immediately result from the same thoughts.

4.      The immediate action, that is, what the nurse says and does, including her non-verbal behavior.

            These items occur in rapid sequence – so rapid that one can say the process is almost instantaneous.

            Perceptions, thoughts, and feelings taken together comprise the entire immediate reaction.  What is said and/or done is considered as the item of action.  I will use these terms, reaction and action, to refer to these parts of nursing process rather than repeating the separate items. 

            My discussion of nursing process assumes that it is directed toward one or both of two ends.

1.      Finding out and meeting the patient’s immediate needs for help.

2.      Developing and maintaining productive work relationships with others who affect nursing situations.

            Together, I think of these as effective results of nursing process.  When these results are absent I judge the process to be ineffective.

            The partial illustration of a nurse’s reconstruction of a process – culminating in two possible actions is shown in Figure 3.

 

 

The perception columns are identical in Process A and in Process B.  “Mr. G, walking back and forth, face red.”  The thought and feeling columns are also identical, “looks angry, something must have happened; afraid to ask, he might hit me.”

            In Process A nurse said “Good morning” and the one-way street sign went up.  She mentioned none of her reaction to Mr. G; the words “good morning” were inconsistent with the content of her reaction to him.  Inconsistent in the sense that none of the reaction was verbalized.

            Being afraid and deciding not to ask the patient was based on her own assumption that her thought was correct.  If she asked – the patient would hit her – an assumption no one could expect the patient with the red face walking back and forth to understand if all he heard was “Good morning.” 

            In Process B the reaction was verbally expressed and the two-way street sign went up.  What the nurse said matched at least some of the content of her immediate reaction.  “I’m afraid you will hit me if I ask you a question.  Should I be afraid?”  The nurse’s statement to Mr. G was consistent with the content of her reaction to him.  In first expressing a part of her reaction and then asking for verification or correction she invited the patient’s thoughts to be expressed in his action and set a stage for heir acts to interact.

            The immediate reaction of the nurse in any given situation must be viewed as her only immediately available resource with which to fulfill the nursing task.  Whether this reaction is right or wrong; appropriate or inappropriate at the outset, it has potential value in accomplishing the task, provided the nurse impose a specific discipline on her process.

            The discipline I speak of has three distinct characteristics.

1.      The nurse must verbally express part or all of her own immediate reaction to the person or persons she is reacting to.

2.      She must in her verbal statement designate the immediate reaction as belonging to herself.

3.      She must ask the person to verify or correct that immediate reaction.

            In Process B the nurse did impose this discipline on her process.  She expressed her own immediate feeling and the thought provoking it.  She designated the thought and feeling to herself and asked the patient about the feeling.  My experience has taught me that the use of this discipline by one enables the other to respond more readily with his perceptions, thoughts, and feelings.  The more each tells the other about the genesis of his immediate reaction the more they understand one another and the more mutually satisfying the outcomes.  Failure to impose the entire discipline on the nurse’s own process at least some of the time with any one person may result in misinterpretations of actions on both sides.  I need not emphasize here how misinterpretations decrease productivity and satisfaction and how they may form an unreliable and sometimes disastrous basis for decision making.

            Next, I would like to discuss the complicated process of teaching this simple discipline.  By virtue of its complexity I can do so only in a very general way.  The discussion of teaching will assume that the teacher is skilled in imposing the same discipline on her own activities.

            The first step is to help the nurse identify her own process as distinct from anyone else’s.  She is asked to reconstruct as fully as possible a five to ten minute contact which she selects on the basis of some vague or specific dissatisfaction with it.  She used a process record form like the one on page 3 of the material that was distributed.

            In the beginning the nurse finds it difficult to write the record.  This difficulty stems from her initial inability to distinguish perception from thought and feeling.  For example, (You can follow me with the process record form on page 3) the say and do column of a process record will read:  “Mr. Jones, do you know what time it is?”  The perception column will read:  “He said ‘no’ because he doesn’t want to go to school.”  The thought and feeling column rarely, at least in the beginning, has any entries.  Continuing in the say and do column the nurse’s next response might read “Well, you have ten minutes to get ready.”

            These entries supply the teacher with the nurse’s own record of the experience and only as much as the nurse is initially able to write on her own.  The next task for the teacher is to help the nurse put the record straight.  Continuing with the same example, the nurse is instructed to move the thought, “Because he doesn’t want to go to school,” originally entered in the perception column to the thought column.  Since the nurse mentioned no feeling in her record the teacher attempts to elicit any feeling the nurse might have had during that brief contact.  The teacher generally succeeds in eliciting some feeling that was present if she offers some possible feelings as a way of stimulating the nurse to verbalize whatever feeling she is able to express.  For example, the teacher might ask if the nurse felt angry or happy when the patient said “no.”  The nurse might respond “Well, frankly, I don’t particularly care if he ever goes to school.”

            The teacher has now helped the nurse collect all of the items that proceeded her saying, “Well, you have ten minutes to get ready.”  Collecting and distinguishing perception from thought and feeling helps the nurse identify her own individual process of action.

            The process record now appears in the sequence that the nurse remembers and the second step in learning the discipline begins: to analyze that particular process of action.  This analysis is focused on whether or not the thoughts and feelings and actions were new to that immediate perception or came from somewhere else.  Were the thoughts and feelings that the nurse said she had a direct new result of having heard the patient say “no” when she asked him if he knew what time it was.  In other words, the teacher has to help the nurse identify the source of the thought and feeling.  To continue, using the same example, did the nurse think the patient didn’t want to go to school just because she heard him say “no.”  The teacher does not as yet understand the connection the nurse made – “no” meaning “don’t want to go to school.”  Questioned about this the nurse may say, “Well, of course not, the word “no” doesn’t mean “doesn’t want to go to school.”  And the next question is where did the connection come from?  The nurse then tells about the thoughts and feelings relevant to her previous contacts with the patient where no attempt was made to interact.  It is here that we learn about the many mornings when the nurse had contact with the same patient because the nurse is now saying “He does it every day, it’s almost as if he were deliberately trying to be late.  No matter how often I tell him how little time he as to get ready, he doesn’t seem to care.  If he doesn’t care whether he’s late or not why should I care if he goes to school.”

            The teacher now has some understanding and the nurse some justification for the thought – “He doesn’t want to go to school” and for the feeling “not caring if he goes or not.”  Both the teacher and the nurse now find the content of the statement “You have ten minutes to get ready” inconsistent with the content of the reaction.  The teacher then appeals to the nurse’s capacity to reason.  If, by the nurse’s own judgement, reminding the patient about the time does not help the patient get to school on time then why does she continue to remind the patient of the time.  It is at this point that the reason why the nurse is unable to behave consistently in the immediate situation comes to light.  Generally, she is inconsistent because of her own or someone else’s expectation of what her performance should be – these expectations can be real or imagined. 

            When the nurse is forced to examine her own inconsistent behavior we uncover these previously acquired expectations.  The nurse will explain the illogical act of our example by saying: “Dr. Jones will be furious with me; the school will criticize us for not getting patients there on time.  It was my assignment to get him to school on time.  I’m supposed to accept the patient’s behavior.  Everybody agrees that we have to be firm about his getting to school on time” and so on.

            At this point the teacher arrives at the third step which is to help the nurse experience freedom from expectations which cause her to act in a manner which is inconsistent with her true reaction.  When the teacher understandingly rejects the inconsistency of the nurse’s action she in effect validates the nurse’s completely subjective perception, thought and feeling.  It is this validation which frees the nurse from expectations other than the one she is professionally obligated to – the fullest utilization of her perceptions, thoughts and feelings as the rational basis of her activities with patients and staff personnel.

            By exploring for the validity of her reactions she is better able to fulfill the expectations of her role, in this case, to help the patient get to school on time or to find out that the patient needs help with a different problem.  When she understands the process by which she can help the patient she finds her own identity as a professional nurse.

            Now to return to her while she still thinks the patient is deliberately late.  Again an appeal is made to the nurse’s reasoning capacity.  If the patient is deliberately late then he must know what time it is – so why remind him?

            The fourth step is literally but lovingly to coerce the nurse to be herself with the specified discipline, for now she must acquire additional data to confirm or correct her reaction.

            So the nurse goes back to the patient – she expresses and explores with him her perception, thought and feeling and finds out what the patient’s perception, thoughts, and feelings were which explain his action.

            For example, the patient may say to her “No I want to go but I felt staff pushing me off the hall every morning but no one pushed me, Right? They just told me what time it was.”

            Or: “I thought I was crazy – I was sure I was being pushed but no one really pushed, I just couldn’t make sense of it.”

            Or: “You’re damn right I don’t want to go to school because I’ll sock Johnny there and then I’ll lose my privileges.”

            Or: “I don’t want to go to school because I’ll see Johnny there and he wants me to escape with him and I’m afraid to tell him I don’t want to go.”

            Or: “I’m not in the hospital to learn English; I’m here to fix what’s wrong with me.”

            The teacher has now overcome the fourth hurdle, helping the nurse acquire additional data to confirm or correct her previous thoughts and feelings.

            The entire teaching process has been directed toward helping the nurse become aware of her own initial inability to state clearly to the person to whom she is responding the perception, thought, and/or feeling which explain her action.  This awareness helps her understand in a very real sense the same initial inability of others with whom she has difficulty.  Understanding her own process of action releases her responsive capacity to focus on the exploration of her reaction and thereby understand another’s process of action.  Her training or course is not complete until she independently is able to initiate the exploration of and correct or validate her thoughts and feelings.

            The last topic of this discussion is to describe our attempt to develop an objective method of evaluating nursing process and training in the specified discipline.  This is the aim of our current mental health project grant.

            The initial problem we faced was obvious.  We cannot observe what the nurse’s reaction was before she acted unless she tells us what it was.  But whether or not she chooses to tell us what her reaction is we can still observe her action.  In either case, it’s only the action that is available to the perception of the one with whom she is in contact.  Furthermore, since verbal expression is the principle mode of out understanding and misunderstanding one another I believed that if objective evidence of a one-way or two-way street were present it could be found in the verbal exchanges that take place in nursing situation.

            Thus, in our present project we first had to define the items of verbal expression.  These items are defined as used in the study on the material before you.

            Items of Verbal Expression

            Perception:       A physical stimulation of any of the subject’s five senses

Thought:          An idea, which occurs in the mind of the subject

Feeling:             A state of mind inclining the subject toward or away from, for or against a            perception, thought, or act.

Action:                          An act that was, is being, or will be carried out by the subject.

 

We designed the coding of these items on the basis of the characteristic form they take in conversation.  Three characteristics of the items verbally expressed are before you on page 4:

            If the subject verbally stated the item to the object it was designated as having the characteristic X.

            If the subject asked the object about the item it was designated as having the characteristic Y.

            If in the expression of an item the subject designated the item as belonging to the self it was assigned the characteristic Z.  Z was isolated on the basis of the hunch that if some one was expressing his own reaction he would in the verbal expression designate the item to the self.

            As for the characteristics and their combinations, they may be illustrated as follows: In each case the same item of thought is being expressed.

X                     the subject states the item.  “You don’t have privileges.”

Y                     The subject asks about the item.  “Why don’t you have privileges?”

X+Y                The item is stated and then asked about.  “You don’t have privileges.  Do you know why?”

X+Z                 the same as X except that it is designated to the self.  “I don’t think you have privileges.”

X+Y+Z            Same as X+Z but followed by Y.  “I don’t think you have privileges.  Do you think you do?”

We believed at the time the coding scheme was designed that X+Y+Z best described for objective purposes the process discipline.  The variable X+Z represented only a part of that discipline.

            In order to relate these variables to some concept of effectiveness and to test our hypothesis about their relative value we operationalized “effectiveness” as the presence of helpful outcomes.  Outcome was defined as expressions by the object of relief from distress or symptoms or expressions of solution to a work or living problem.

            The data were obtained by taping conversations of nurses while on duty, at predetermined time intervals.  Subjects included six nurses before and after training in the discipline and six nurses who had already been trained.  Their objects were patients and staff members in work situations.  One hundred forty-four taped 10 minute interval transcripts were coded for verbal expression and outcome variables.

            Statistical analysis of the data has focused on answering essentially three questions.

1.      How do the variables of verbal expression relate to the presence of helpful outcomes?

2.      What is the relationship between the subject’s verbal expression variables and those of the object?

3.      Can we successfully train nurses to use the discipline?

            It is not as yet possible for me to discuss in detail the statistical analysis of all the data in answer to the three questions.  I can, however, in a general way mention some results we have found thus far.

            As to the first questions: How do the expression variables relate to the presence of helpful outcomes.  We analyzed both the subject’s and the object’s use of the expression variables.

            The nurse-subject’s use of the discipline variable (X+Y+Z) was significantly related to helpful outcomes.  That is, when the nurse said things like “I’m afraid to ask you a question.  Should I be afraid?" then the person to whom she spoke had a helpful outcome.  Also significantly related to outcome was the nurse’s partial use of the discipline variable (X+Z), the expression of items designated to the self – like “I think you don’t want to go to school.”  None of the other variables related to helpful outcomes.

            In analyzing the object’s use of the expression variables only the discipline variable (X+Y+Z) was significantly related to helpful outcome.  For example, a patient saying “I felt staff pushing me off the hall every morning but no one really pushed me – Right?”

            As to the second question: How does what the nurse say relate to what the object of her conversation says?

            The results of this analysis were particularly interesting.  We found highly significant relationships between the following: The more the nurse used X, that is, simple expressions like “You have ten minutes to get ready”, then the more her object used the same variable.

            The more the nurse used the discipline variable (X+Y+Z) like “I think you’re trying to be late.  Is that what you are doing?” then the more her object used the same variable, like “No one pushed me off the hall – Right?”

            The nurse’s use of the above who variables were the only two that were significantly related to her object’s use of the same variables.

            As to the other variables we found some interesting relationships which are in line with the established methods of interviewing and exploration which enable objects to talk about themselves.  The more the nurse explored items or expressed items and then explore them then the more her object designated statements to the self.  However, the use of these variables was not significantly related to outcome.

            Since we found that the more the nurse used the discipline variable the more her object did and since the use of this variable for the nurse and her object was significantly related to helpful outcome we decided to pursue this relationship further.  We took those cases in which both object and subject used the discipline variable and compared them with those cases in which one or the other or both did not use the variable.  We found a higher significance with helpful outcome when both were using the discipline variable rather than when one, the other, or neither were using it.

            Still, we cannot as yet be certain that the discipline variable represents the verbal expression of one’s own immediate reaction with what is verbally expressed.  We are planning to do other analysis with additional data to test this hypothesis further.

            This brings us to the third question: Can we successfully train nurses in the specified discipline.

            We had a total of twelve nurses as subjects.  Six of them, who were untrained in the specified discipline and then trained, will be referred to as Novices.  The other six nurses who were already trained by observed along with the novices will be referred to as veterans.

            In testing for what difference training made among the total novice group, we compared their observations before and after training.  Immediately after training they increased their use of the discipline variable by 25%.  This increase was statistically significant.

            We also were interested in seeing if novices before training differed from veterans who had already been trained.  Perhaps this was not a fair comparison because individual differences are wide enough without training them to express their individuality.  In spite of this, veterans used the discipline variable 20% more than novices did.  Although not statistically significant this result did indicate a measurable difference.

            When we compared novices with veterans again after the novices were trained the novices were 6% higher in their use of the discipline variable.  This result indicated that training did reduce the difference between the two groups.

            One might wonder why novices as a group used the discipline variable slightly more immediately after training than did the veterans who had been trained sometime before.  It is not surprising to me as least that when a nurse is no longer under the constant stimulation that was available in the training program – she may have less time and availability to deliberate on her process of action.

            I do not believe, however, that she ever completely loses interest – once she experiences the gratification of resolving difficulties by her own effort and on her own initiative.  It’s just that sometimes she is faced with a higher level of difficulty and can only just begin to explore her process and not be able to continue alone.  Just beginning it is sometimes enough to stimulate the other person to make his process known.

For Example:

            A white psychiatric patient once said to a Negro student of mine who was in training at the time – “I don’t want you for a nurse – you’re black and I’m white.”  The nurse explained that what he said hurt her because she thought she was capable, and asked him to help her understand how her black skin made him not want her as his nurse.  He said, “Black is black and I don’t want you here.”  This was as far as she could go in exploring that reaction with him.  She then decided on a course of action but before carrying it out asked the patient about it.  “Since this is a special experience for me, I think I can make arrangements with my teacher to change my assignment but I’m not sure another student will be assigned to care for you.  Is it alright if that’s what I do?”

            “No, You stay; there’s no difference; we’re all human under the skin and anyway you’re not scared of me.  Everybody else is.”

            On the day this patient was discharged he told the student that he couldn’t put his finger on exactly what he wanted to thank her for but that it had something to do with her not hating him for what he said to her when he was so sick.

            Results like this are what remind me of what it means to be human under the skin.  We all have our own individual processes of action that people are willing to respect and understand if we are able and willing to communicate at least a part of our process to them.  In certain situations we are unable to, that is, we are unable to interact unless someone by virtue of his ability to make his process known to us stimulates our making our process available to him.

            I hope now that we can talk about what is under the skin.