- Email: [email protected]
Mental health nursing consultation in the General Hospital
85
MENTAL HEALTH NURSING CONSULTATION IN THE GENERAL HOSPITAL NANCY L. IIEDLUND, R.N., Ph.D.
Associate Pro/essor and Chairnlan, Program hz Nursing Research, School o[ Nursing, Yale University, New Haven, Connecticut
ABSTRACT Mental health consultation was provided to the nurses and patients of a general hospital over a three-year period. The purpose of the consultation was to help create a "therapeutic community" within individual nursing units. Through individual consultation and group discussions nurses increased their skills in caring for patients and in handling tile psychosocial aspects of patient care. INTRODUCTION The general-hospital environment can be characterized as a highly stressful "extreme environment" for both patients and staff. ~ One way to conceptualize the stress of this environment is to think of it as a situation that presents loss or continuous threat of loss. Accordingly, the stress of this environment is the ongoing demand for grief and resolution of loss. For patients and staff, this demand can seem overwhelming, -~and it comes for patients at a time when their adaptive capacities are already severely challenged. Loss presents more than stress, however, since it creates an opportunity also for personal growth. ~ Because the crisis of responding to loss permanently affects a person, successful resolution can create the opportunity for achieving an enduring and greater capacity for coping. On the other hand, maladaptive response can leave a person with a reduced overall capacity for coping with loss. This paper describes my development of a program to create a "therapeutic community" milieu for patients and staff in the general-hospital environment of a large urban medical center, a milieu designed to promote effective coping with the stresses of responding to real and threatened losses. The social/psychological perspective that guided my work as a consultant to this program comprised four tenets: 1) participants in
FALL / 1978
social interaction are influenced by perceptions, cognitions, and expectations of self and others; 2) behavior is both determined (by past events and present learning) and determining (of the course of subsequent interaction); 3) social interaction takes place in a social environment that influences interactions; and 4) individuals are both systems and parts of units within larger systems. My role in this program involved consultation with nursing and medical staffs and some clinical nursing with patients and families. The role was unique, in that I could use my double background as a psychiatric nurse and a social psychologist. In this paper I describe my role, the communication problems I found in practice, and the results of consultation that reflect the development of a therapeutic community. INTRODUCING THE CONSULTANT R O L E The broad purpose of my role was to assist staff and patients in coping with the losses inherent in illness and health care in the hospital setting. At the nursing unit level, this purpose was described as assisting the staff to create a therapeutic community in which the interactions of patients and staff could promote effective coping and adaptation to loss. Nurses at this level were under great pressure to perform well, since few patients were routine or uncomplicated in their illness or treatment. Nursing units existed within departments, which ranged up to several hundred beds in size; nursing department heads were responsible to a director of nursing. I too was directly responsible to the director of nursing, who provided me with the necessary freedom for moving about within departments. Introducing my role required some strategies to confront two sources of potential resistance: the administrative staff and the professionals who practice patient care, such as nurses, physicians, and social workers. Resistance from the administrative staff was anticipated because patient counselling can introduce changes into the organization of a hospital that have consequences beyond their anticipated effects on a patient's well-being. These consequences can run counter to the conveniences of the organization, as Goffman (1961) has noted? For example, patients
86 can become more assertive, refusing to tolerate delays, inefficiency, and lack of explanations. Resistance from the professional staff was anticipated because the need for a mental health consultant might imply deficiencies in existing patient care. Moreover, professionals might react to the freedom of movement I had within the organization. I sought acceptance and respect within the hospital at the levels of both the nursing unit and higher administration. That is, as I worked directly with the units in a consulting role to demonstrate and effect the usefulness of a mental health nurse consultant, I also became involved in patient-care committees, assumed a leadership role in organizing nursing grand-rounds, and maintained formal and informal communication with other hospital staff. I began my role as a mental health nursing consultant by being on call for discussion about patient problems. My initial task was to create, through informal visits to nursing units, opportunities for dialogue with individual nurses. General interest in patient counselling soon led to occasional group discussions with the nurses to discuss patient-care problems. At first the emphasis in these group discussions was the ventilation of the nurses' feelings. When my acceptance and lack of criticism of their responses became apparent, subsequent discussions became more productive in planning nursing actions to increase the patients' efforts to cope. I was then able to help the nursing staff to identify their needs for further information. The nurses had fairly clear ideas about what might be helpful in a problematic situation, but they usually felt their ability inadequate to talk with the patient. Our discussions would thus include practice in communicating effectively. Follow-up discussions would be scheduled for later to review the nurses' progress. Eventually regular weekly discussions with nursing units were established to expedite problem solving before problems reached extreme proportions. COMMUNICATION PROBLEMS OR BARRIERS I found three major categories of communication problems among nurses in the course of these discussions: I) over-identification with patients or families, 2) resistance, and 3) transference/countertransference. These problems were usually manifestations of some form of intense emotional reaction to patients, family, other staff, or me. Over-identification with patients or their families was a frequent cause of intense and distressing reactions. Nurses would sometimes fear how incapacitated they would feel if they were in the patient's predicament. The nurse's anxiety, helplessness, and depression would then prevent her from helping the patient.
At other times, a nurse would feel angry over the wa~ a patient or relative was being treated by physicians 0"r other professionals and would even take sides in con. filets, thus preventing herself from assuming a mort objective and helpful role. With guidance, the nurses learned to d!stinguish patients' predicaments from their own, which allowed them to accept their own reac. tions and to implement ways of caring for their patients. Resistance interfered in many ways with the poten. tial success of the program. It seemed in general It derive from the nurses' wish for success and from their simultaneous fear of inadequacy. As one example 0f resistance, a nurse might say, "Perhaps this is really psychiatric problem and the patient should see a psy. chiatrist." This statement shows concern for the pa. tient, yet desire that someone else solve the problem. It is also an obvious expression of anger toward the patient, since it labels his behavior as "crazy" and offers a solution few patients would like. I encouraged psychiatric consultation only if it really seemed needed. Otherwise, I preferred the nurses to consider themselves capable of being helpful and effective with anxious, depressed, and even psychotic patients. A second example of resistance was the frequent expression, "If only y o u would talk to thepatient; we know that would help." I usually refused to see a patient at a nurse's request unless there was real con. fusion about his problem. I would choose instead tc reinforce the nurse's responsibility for dealing with problems, emphasizing that the nurse already had relationship with the patient and was seen by him a.~ responsible for his care. Thus the patient's sense ol security would be enhanced by interpersonal nursing care.
A third example of resistance was found in the nurses' stereotypes of mental health professionals Many nurses had had previous experience with psychiatrists who seemed more eager and comfortable witt analyzing their "problems" than the patient's prob. lems. Although the intense emotional reactions oJ nurses to patients did demand further understanding the nurses' need for help in managing the immediate situation was usually more urgent. Introspection and perhaps discussion of personal reactions to patient: would come later, and would be usually more produc. tive if the nurse had experienced a sense of competence in managing the patient. Transference/countertransference involved reactions to the patients that were affected by the nurses' earlier experiences in life? For example, a nurse migh: respond to a patient as she had earlier responded to parent or sibling. Patients also had reactions of thi~ type towards the staff, as when they saw nurses a~
PATIENT COUNSELLING AND HEALTH EDUCATIO~
87 threatening parents. At first, the transference reactions of patients were easier for nurses to understand than their own. But as they became more self-aware and more involved in understanding their interaction with patients, their own reactions and their patients' reactions and behaviors became clearer. THE RESULTS O F CONSULTATION The purpose of my role as a consultant was to help create a therapeutic milieu within individual nursing units, a milieu consistent with the meaning of therapeutic community in psychiatric settings. 6 In this type of milieu, the system of interaction of the individuals in a unit--patients, family, and staff--creates the process by which psychological healing takes place9 That is, through interaction within the unit, patients can gain greater awareness, learn new behaviors, and achieve resolution of unresolved problems. At the same time, because feedback and communication are facilitated, staff members can learn more about how their practice affects others, understand more fully patients and colleagues, and support better the people with whom they work. We found that the creation of a therapeutic milieu within individual nursing units usually took six to twelve months and would be characterized by the progressive achievement of the nurses in coping with their own and patients' distresses. Their improvement was always reflected in a shift to a more specific focus and purpose in their discussions with me and in their motivation to be involved in these discussions,r I list and briefly describe below the areas that were discussed and in which the nurses improved. 1) The collection of data was constantly emphasized in our discussions, in order to establish the habit of fully describing and assessing the patient's problem. I stressed collecting data specifically about the patient's communication and behavior, expectations about his illness and care, perceptions of the situation, relationships with others, and past experiences including losses. 2) Finding possible reasons for patients' behaviors was also emphasized; I encouraged the nurses to consider what painful feelings in response to loss and what certain behaviors might be accomplishing.8-1z I would include in these discussions relevant theoretical perspectives.2, 13-15 Gradually, as potential explanations such as fear or sadness became clear, the staff's perspective on patients' behavior became less emotional. When nurses realized that they could effectively formulate problems and explanations, motivation to more actively analyze problems cognitively or theoretically replaced their prior tendencies to simply react emotionally to difficult patients. 3) As the nurses became more confident in their
FALL/ ] 978
ability to develop sound interventions based on their understanding of patient-care problems, they assumed active responsibility from myself for the development of treatment or nursing-care plans. 4) Nurses' Communication skills showed important progress. A great deal of time was spent talking about ways of saying things to patients to facilitate their coping efforts. Based on Berne's (1961) 1~ formulations of ego states, we developed alternative responses to problem situations and showed through simulation and discussion how certain responses were more helpful than others. The nurses usually had not realized how frequently their responses were either defensive or critical (like those of a child or of a parent), nor had they realized how threatening these responses can be for patients and families. After these realizations, more neutral and sensitive responses could be made. 5) The nurses showed increasing ability to recognize and then understand their own extreme reactions to patients. In initial discussions, such reactions as over-identification, resistance, and transference were discussed in a theoretical or hypothetical context, so these ideas could be introduced in the manner of anticipatory guidance. 3 Later discussions about intense emotional reactions to patients were thus substantially less threatening, because these ideas were known by the nurses to be normal and usual pitfalls for people in helping professions. 6) As the program progressed, the nurses showed an increasing ability to separate patients' reactions from their own. When a patient or family member would express either anger or criticism, the nurses would no longer react personally, since they had learned that they did not have to feel angry simply because the patient or family member was angry. Thus the nurses were increasingly able to become emotionally available to patients and family members and to focus on experiences, losses, and grief. The increased sense of competence generated by this ability seemed to further motivate nurses to become more deeply involved in the psychological experiences of their patients as well as in the program's consultation process. 7) As a consequence of developing the foregoing skills, nurses became increasingly able to assist patients in solving their problems without attempting to solve them for the patients. The depressed patient could then speak of feelings of hopelessness and futility and find understanding rather than cheery encouragement. "I can see how you feel," a nurse might say, "and that doesn't mean life is not worthwhile, it means you feel very sad and discouraged right now there's a difference." By accepting the validity of the patient's emotional pain, yet by not accepting that the patient's drastic conclusions about hopelessness 9
.
.
88 and futility are inevitable, the nurse could minimize depression and reduce the possibility of the patient's choosing drastic alternatives (including suicide); yet she could still accept the reality of the patient's emotional pain. xr 8) As the program progressed, I received increasing support from head nurses and department heads. The head nurse was clearly the key person in a unit. When she was interested in our work, the staff nurses would be significantly more committed to the therapeutic community concept, families would be more involved in daily care as well as discharge planning, and nurses and family members would rarely engage in the competition and conflict that often characterize hospital settings. CONCLUSIONS In summary, I think that this three-year program showed these three results: 1) more effective patientcounselling practices; 2) increased respect for the psychosocial aspects of patient care and increased staff interest in developing competencies in this aspect of care; and 3) increased awareness of the independent aspects of nursing practice; that is, the counselling and teaching activities for which nurses are responsible without physician direction or permission. Empirical studies of the effects of this program were not undertaken, owing to the constraints of administrative dictates and the lack of funds. The effects of
the program on patient care were relatively clear, as I have shown. Consequences of the program at higher levels of administration, however, were less tangible and more difficult to assess. Major changes in the ad. ministration of the nursing department ultimately led to the termination of all mental health nursing con. sultation in the adult and pediatric units of the hos. pital, for the work was seen as a "luxury" and as a threat to administrative power. Accordingly, the long. term or higher-order benefits of the program remain to be demonstrated empirically. The nursing orientation of the program did not preclude interdisciplinary collaboration, especially between nurses and physicians. Indeed, one overall effect of the program was better collaboration among nurses, staff, and physicians in achieving patient-care goals. Just recently a surgeon told a head nurse who was involved in the program, "I really like having my patients on your unit; you have a good crew, and it's truly a therapeutic community here." Other types of professionals were welcome to the discussions, but few came. The final measure of the success of the program was the observable increase in satisfaction and well-being of patients and their families, a direct result of better patient-counselling practices. I hope that the program described in this paper can generate substantive research to document the ultimate value of the therapeutic community in the general hospital.
REFERENCES 1. Pierce, C. M. (1975): The mundane extreme environment and its effect on learning. In: Learning Disabilities: Issues and Recommendations ]or Research. Editor: S. G. Brainard. National Institute of Education, Department of Health, Education, and Welfare, Washington, D.C. 2. Brown, E. L. (1963) Newer Dimensions o] Patient Care. Russell Sage, New York. 3. Caplan, G. (1963). Principles o] Preventive Psychiatry. Basic Books, New York. 4. Goffman, E. (1961): Asyhtms. Anchor, New York. 5. Freud, S. (1922): Transference. In: General b,troduction to Psychoanalysis. Allen and Unwin, London. 6. Jones, M. (1953): The Therapeutic Community. Basic Books, New York. 7. White, R. (1959): Motivation reconsidered: The concept of competence, Psychol. Rev. 66, 297. 8. Bowlby, J. (1960): Separation anxiety, lnt. J. Psychoanal. 41, 89-113. 9. Bowlby, J. (1973): Attachmet;t and loss. Voi. II. Separation. Basic Books, New York.
10. Freud, S. (1948): Mourning and melancholia (1925). In: Collected Papers. Vol. II. Hogarth Press, London. 11. Lindemann, E. (1944): Symptomatology and management of acute grief. Am. J. Psychiatry 101, 141. 12. Rochlin, G. (1965) : GrieIs and Discontents: The Forces o] Change. Little, Brown, and Company, Boston. 13. Caplan, G. (1964): Emotional crises. In: The Encyclopedia o] Mental Health. pp. 521-532. Editors: A. Deutsch and H. Fishbein. Franklin and Watts, New York. 14. Deutsch, M. (1973): The Resolution o] Conltict. Yale University Press, New ttaven. 15. Erikson, E. H. (1963): ChiMhood and Society. W. W. Norton, New York. 16. Berne, E. (1961): Transactional Analysis in Psycho9 therapy. Grove Press, New York. 17. Ujhely, G. (1966): Grief and depression--implications for preventive and therapeutic nursing care. Nuts. Forum 5, 23.
PATIENT COUNSELLING A N D HEALTH EDUCATION
MENTAL HEALTH NURSING CONSULTATION IN THE GENERAL HOSPITAL NANCY L. IIEDLUND, R.N., Ph.D.
Associate Pro/essor and Chairnlan, Program hz Nursing Research, School o[ Nursing, Yale University, New Haven, Connecticut
ABSTRACT Mental health consultation was provided to the nurses and patients of a general hospital over a three-year period. The purpose of the consultation was to help create a "therapeutic community" within individual nursing units. Through individual consultation and group discussions nurses increased their skills in caring for patients and in handling tile psychosocial aspects of patient care. INTRODUCTION The general-hospital environment can be characterized as a highly stressful "extreme environment" for both patients and staff. ~ One way to conceptualize the stress of this environment is to think of it as a situation that presents loss or continuous threat of loss. Accordingly, the stress of this environment is the ongoing demand for grief and resolution of loss. For patients and staff, this demand can seem overwhelming, -~and it comes for patients at a time when their adaptive capacities are already severely challenged. Loss presents more than stress, however, since it creates an opportunity also for personal growth. ~ Because the crisis of responding to loss permanently affects a person, successful resolution can create the opportunity for achieving an enduring and greater capacity for coping. On the other hand, maladaptive response can leave a person with a reduced overall capacity for coping with loss. This paper describes my development of a program to create a "therapeutic community" milieu for patients and staff in the general-hospital environment of a large urban medical center, a milieu designed to promote effective coping with the stresses of responding to real and threatened losses. The social/psychological perspective that guided my work as a consultant to this program comprised four tenets: 1) participants in
FALL / 1978
social interaction are influenced by perceptions, cognitions, and expectations of self and others; 2) behavior is both determined (by past events and present learning) and determining (of the course of subsequent interaction); 3) social interaction takes place in a social environment that influences interactions; and 4) individuals are both systems and parts of units within larger systems. My role in this program involved consultation with nursing and medical staffs and some clinical nursing with patients and families. The role was unique, in that I could use my double background as a psychiatric nurse and a social psychologist. In this paper I describe my role, the communication problems I found in practice, and the results of consultation that reflect the development of a therapeutic community. INTRODUCING THE CONSULTANT R O L E The broad purpose of my role was to assist staff and patients in coping with the losses inherent in illness and health care in the hospital setting. At the nursing unit level, this purpose was described as assisting the staff to create a therapeutic community in which the interactions of patients and staff could promote effective coping and adaptation to loss. Nurses at this level were under great pressure to perform well, since few patients were routine or uncomplicated in their illness or treatment. Nursing units existed within departments, which ranged up to several hundred beds in size; nursing department heads were responsible to a director of nursing. I too was directly responsible to the director of nursing, who provided me with the necessary freedom for moving about within departments. Introducing my role required some strategies to confront two sources of potential resistance: the administrative staff and the professionals who practice patient care, such as nurses, physicians, and social workers. Resistance from the administrative staff was anticipated because patient counselling can introduce changes into the organization of a hospital that have consequences beyond their anticipated effects on a patient's well-being. These consequences can run counter to the conveniences of the organization, as Goffman (1961) has noted? For example, patients
86 can become more assertive, refusing to tolerate delays, inefficiency, and lack of explanations. Resistance from the professional staff was anticipated because the need for a mental health consultant might imply deficiencies in existing patient care. Moreover, professionals might react to the freedom of movement I had within the organization. I sought acceptance and respect within the hospital at the levels of both the nursing unit and higher administration. That is, as I worked directly with the units in a consulting role to demonstrate and effect the usefulness of a mental health nurse consultant, I also became involved in patient-care committees, assumed a leadership role in organizing nursing grand-rounds, and maintained formal and informal communication with other hospital staff. I began my role as a mental health nursing consultant by being on call for discussion about patient problems. My initial task was to create, through informal visits to nursing units, opportunities for dialogue with individual nurses. General interest in patient counselling soon led to occasional group discussions with the nurses to discuss patient-care problems. At first the emphasis in these group discussions was the ventilation of the nurses' feelings. When my acceptance and lack of criticism of their responses became apparent, subsequent discussions became more productive in planning nursing actions to increase the patients' efforts to cope. I was then able to help the nursing staff to identify their needs for further information. The nurses had fairly clear ideas about what might be helpful in a problematic situation, but they usually felt their ability inadequate to talk with the patient. Our discussions would thus include practice in communicating effectively. Follow-up discussions would be scheduled for later to review the nurses' progress. Eventually regular weekly discussions with nursing units were established to expedite problem solving before problems reached extreme proportions. COMMUNICATION PROBLEMS OR BARRIERS I found three major categories of communication problems among nurses in the course of these discussions: I) over-identification with patients or families, 2) resistance, and 3) transference/countertransference. These problems were usually manifestations of some form of intense emotional reaction to patients, family, other staff, or me. Over-identification with patients or their families was a frequent cause of intense and distressing reactions. Nurses would sometimes fear how incapacitated they would feel if they were in the patient's predicament. The nurse's anxiety, helplessness, and depression would then prevent her from helping the patient.
At other times, a nurse would feel angry over the wa~ a patient or relative was being treated by physicians 0"r other professionals and would even take sides in con. filets, thus preventing herself from assuming a mort objective and helpful role. With guidance, the nurses learned to d!stinguish patients' predicaments from their own, which allowed them to accept their own reac. tions and to implement ways of caring for their patients. Resistance interfered in many ways with the poten. tial success of the program. It seemed in general It derive from the nurses' wish for success and from their simultaneous fear of inadequacy. As one example 0f resistance, a nurse might say, "Perhaps this is really psychiatric problem and the patient should see a psy. chiatrist." This statement shows concern for the pa. tient, yet desire that someone else solve the problem. It is also an obvious expression of anger toward the patient, since it labels his behavior as "crazy" and offers a solution few patients would like. I encouraged psychiatric consultation only if it really seemed needed. Otherwise, I preferred the nurses to consider themselves capable of being helpful and effective with anxious, depressed, and even psychotic patients. A second example of resistance was the frequent expression, "If only y o u would talk to thepatient; we know that would help." I usually refused to see a patient at a nurse's request unless there was real con. fusion about his problem. I would choose instead tc reinforce the nurse's responsibility for dealing with problems, emphasizing that the nurse already had relationship with the patient and was seen by him a.~ responsible for his care. Thus the patient's sense ol security would be enhanced by interpersonal nursing care.
A third example of resistance was found in the nurses' stereotypes of mental health professionals Many nurses had had previous experience with psychiatrists who seemed more eager and comfortable witt analyzing their "problems" than the patient's prob. lems. Although the intense emotional reactions oJ nurses to patients did demand further understanding the nurses' need for help in managing the immediate situation was usually more urgent. Introspection and perhaps discussion of personal reactions to patient: would come later, and would be usually more produc. tive if the nurse had experienced a sense of competence in managing the patient. Transference/countertransference involved reactions to the patients that were affected by the nurses' earlier experiences in life? For example, a nurse migh: respond to a patient as she had earlier responded to parent or sibling. Patients also had reactions of thi~ type towards the staff, as when they saw nurses a~
PATIENT COUNSELLING AND HEALTH EDUCATIO~
87 threatening parents. At first, the transference reactions of patients were easier for nurses to understand than their own. But as they became more self-aware and more involved in understanding their interaction with patients, their own reactions and their patients' reactions and behaviors became clearer. THE RESULTS O F CONSULTATION The purpose of my role as a consultant was to help create a therapeutic milieu within individual nursing units, a milieu consistent with the meaning of therapeutic community in psychiatric settings. 6 In this type of milieu, the system of interaction of the individuals in a unit--patients, family, and staff--creates the process by which psychological healing takes place9 That is, through interaction within the unit, patients can gain greater awareness, learn new behaviors, and achieve resolution of unresolved problems. At the same time, because feedback and communication are facilitated, staff members can learn more about how their practice affects others, understand more fully patients and colleagues, and support better the people with whom they work. We found that the creation of a therapeutic milieu within individual nursing units usually took six to twelve months and would be characterized by the progressive achievement of the nurses in coping with their own and patients' distresses. Their improvement was always reflected in a shift to a more specific focus and purpose in their discussions with me and in their motivation to be involved in these discussions,r I list and briefly describe below the areas that were discussed and in which the nurses improved. 1) The collection of data was constantly emphasized in our discussions, in order to establish the habit of fully describing and assessing the patient's problem. I stressed collecting data specifically about the patient's communication and behavior, expectations about his illness and care, perceptions of the situation, relationships with others, and past experiences including losses. 2) Finding possible reasons for patients' behaviors was also emphasized; I encouraged the nurses to consider what painful feelings in response to loss and what certain behaviors might be accomplishing.8-1z I would include in these discussions relevant theoretical perspectives.2, 13-15 Gradually, as potential explanations such as fear or sadness became clear, the staff's perspective on patients' behavior became less emotional. When nurses realized that they could effectively formulate problems and explanations, motivation to more actively analyze problems cognitively or theoretically replaced their prior tendencies to simply react emotionally to difficult patients. 3) As the nurses became more confident in their
FALL/ ] 978
ability to develop sound interventions based on their understanding of patient-care problems, they assumed active responsibility from myself for the development of treatment or nursing-care plans. 4) Nurses' Communication skills showed important progress. A great deal of time was spent talking about ways of saying things to patients to facilitate their coping efforts. Based on Berne's (1961) 1~ formulations of ego states, we developed alternative responses to problem situations and showed through simulation and discussion how certain responses were more helpful than others. The nurses usually had not realized how frequently their responses were either defensive or critical (like those of a child or of a parent), nor had they realized how threatening these responses can be for patients and families. After these realizations, more neutral and sensitive responses could be made. 5) The nurses showed increasing ability to recognize and then understand their own extreme reactions to patients. In initial discussions, such reactions as over-identification, resistance, and transference were discussed in a theoretical or hypothetical context, so these ideas could be introduced in the manner of anticipatory guidance. 3 Later discussions about intense emotional reactions to patients were thus substantially less threatening, because these ideas were known by the nurses to be normal and usual pitfalls for people in helping professions. 6) As the program progressed, the nurses showed an increasing ability to separate patients' reactions from their own. When a patient or family member would express either anger or criticism, the nurses would no longer react personally, since they had learned that they did not have to feel angry simply because the patient or family member was angry. Thus the nurses were increasingly able to become emotionally available to patients and family members and to focus on experiences, losses, and grief. The increased sense of competence generated by this ability seemed to further motivate nurses to become more deeply involved in the psychological experiences of their patients as well as in the program's consultation process. 7) As a consequence of developing the foregoing skills, nurses became increasingly able to assist patients in solving their problems without attempting to solve them for the patients. The depressed patient could then speak of feelings of hopelessness and futility and find understanding rather than cheery encouragement. "I can see how you feel," a nurse might say, "and that doesn't mean life is not worthwhile, it means you feel very sad and discouraged right now there's a difference." By accepting the validity of the patient's emotional pain, yet by not accepting that the patient's drastic conclusions about hopelessness 9
.
.
88 and futility are inevitable, the nurse could minimize depression and reduce the possibility of the patient's choosing drastic alternatives (including suicide); yet she could still accept the reality of the patient's emotional pain. xr 8) As the program progressed, I received increasing support from head nurses and department heads. The head nurse was clearly the key person in a unit. When she was interested in our work, the staff nurses would be significantly more committed to the therapeutic community concept, families would be more involved in daily care as well as discharge planning, and nurses and family members would rarely engage in the competition and conflict that often characterize hospital settings. CONCLUSIONS In summary, I think that this three-year program showed these three results: 1) more effective patientcounselling practices; 2) increased respect for the psychosocial aspects of patient care and increased staff interest in developing competencies in this aspect of care; and 3) increased awareness of the independent aspects of nursing practice; that is, the counselling and teaching activities for which nurses are responsible without physician direction or permission. Empirical studies of the effects of this program were not undertaken, owing to the constraints of administrative dictates and the lack of funds. The effects of
the program on patient care were relatively clear, as I have shown. Consequences of the program at higher levels of administration, however, were less tangible and more difficult to assess. Major changes in the ad. ministration of the nursing department ultimately led to the termination of all mental health nursing con. sultation in the adult and pediatric units of the hos. pital, for the work was seen as a "luxury" and as a threat to administrative power. Accordingly, the long. term or higher-order benefits of the program remain to be demonstrated empirically. The nursing orientation of the program did not preclude interdisciplinary collaboration, especially between nurses and physicians. Indeed, one overall effect of the program was better collaboration among nurses, staff, and physicians in achieving patient-care goals. Just recently a surgeon told a head nurse who was involved in the program, "I really like having my patients on your unit; you have a good crew, and it's truly a therapeutic community here." Other types of professionals were welcome to the discussions, but few came. The final measure of the success of the program was the observable increase in satisfaction and well-being of patients and their families, a direct result of better patient-counselling practices. I hope that the program described in this paper can generate substantive research to document the ultimate value of the therapeutic community in the general hospital.
REFERENCES 1. Pierce, C. M. (1975): The mundane extreme environment and its effect on learning. In: Learning Disabilities: Issues and Recommendations ]or Research. Editor: S. G. Brainard. National Institute of Education, Department of Health, Education, and Welfare, Washington, D.C. 2. Brown, E. L. (1963) Newer Dimensions o] Patient Care. Russell Sage, New York. 3. Caplan, G. (1963). Principles o] Preventive Psychiatry. Basic Books, New York. 4. Goffman, E. (1961): Asyhtms. Anchor, New York. 5. Freud, S. (1922): Transference. In: General b,troduction to Psychoanalysis. Allen and Unwin, London. 6. Jones, M. (1953): The Therapeutic Community. Basic Books, New York. 7. White, R. (1959): Motivation reconsidered: The concept of competence, Psychol. Rev. 66, 297. 8. Bowlby, J. (1960): Separation anxiety, lnt. J. Psychoanal. 41, 89-113. 9. Bowlby, J. (1973): Attachmet;t and loss. Voi. II. Separation. Basic Books, New York.
10. Freud, S. (1948): Mourning and melancholia (1925). In: Collected Papers. Vol. II. Hogarth Press, London. 11. Lindemann, E. (1944): Symptomatology and management of acute grief. Am. J. Psychiatry 101, 141. 12. Rochlin, G. (1965) : GrieIs and Discontents: The Forces o] Change. Little, Brown, and Company, Boston. 13. Caplan, G. (1964): Emotional crises. In: The Encyclopedia o] Mental Health. pp. 521-532. Editors: A. Deutsch and H. Fishbein. Franklin and Watts, New York. 14. Deutsch, M. (1973): The Resolution o] Conltict. Yale University Press, New ttaven. 15. Erikson, E. H. (1963): ChiMhood and Society. W. W. Norton, New York. 16. Berne, E. (1961): Transactional Analysis in Psycho9 therapy. Grove Press, New York. 17. Ujhely, G. (1966): Grief and depression--implications for preventive and therapeutic nursing care. Nuts. Forum 5, 23.
PATIENT COUNSELLING A N D HEALTH EDUCATION