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Perseverance: The meaning of patient education in psychiatric nursing
Perseverance: The Meaning of Patient Education in Psychiatric Nursing Patricia E. Freed This phenomenological study was undertaken to discern the meaning psychiatric nurses attach to their patient education experiences. Although patient education crosses all nursing specialty areas, no studies have attempted to describe how it is unique to psychiatric nursing. Hermeneutic analysis of audiotaped, semistructured, in-depth interviews revealed three themes, The Teaching Way, Being In-Between, and Seeing Inside, which, when taken together, formed one constitutive pattern: perseverance. The results indicate that psychiatric nurses are very much involved in educating their patients and that the process differs from traditional expectations of learning readiness. There is also an apparent need to educate students about the realities of health care settings and how to deal with them. The researcher, herself a psychiatric nurse, came away from this study with a renewed respect for nurses' commitment to patient education, for their ability to use themselves as therapeutic tools, and for their ability to practice from within political settings which seldom encourage or reward nurses for patient education. Further studies are needed to explore how nurses deal with the political realities affecting their practices and how they maintain their commitment to patient care under such circumstances. Copyright © 1998 by W.B. Saunders Company
Y INTEREST IN THE phenomenon of patient education in psychiatric nursing arose from personal experience as a psychiatric nurse and clinical psychiatric nurse educator. Having faced and overcome challenging patient education experiences, it was easy to empathize with students who experienced similar difficulties in clinical settings. But it remained difficult to encourage students to engage in patient education with those who denied their illness, refused treatment, or otherwise showed behaviors that indicated they were disinterested, unable to concentrate, or generally unmotivated. Traditional textbook expectations about the process of patient education emphasize learner readiness, so it is no wonder that students wait to begin teaching until a compliant, motivated patient/ learner manifests. In acute care settings this is seldom the case. To instill the importance of the nurses' role as patient educator in view of contradictions inherent in the educational process was a matter of great concern. This study was undertaken to discover the meaning of patient education for
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psychiatric nurses in the hopes that such a discovery would provide "knowledge" that would guide practice and shape student nurses' understanding of this phenomenon as it exists in psychiatric nursing. PATIENT EDUCATION IN PSYCHIATRIC NURSING
Patient education has a long history in nursing and has been extensively investigated (Lindeman, 1988, 1989). But within the specialty area of psychiatric nursing much less is known. There is even some dispute about the extent of patient education performed by psychiatric nurses (Ferguson, 1991; Harmon & Tratnack, 1992; Williams, 1989). Redmon (1993) reviewed the educational
From the Barnes College of Nursing, University of Missouri, St. Louis, MO. Address reprint requests to Patrieia E. Freed, Barnes College of Nursing, University of Missouri, St. Louis, 8001 Natural Bridge Road, St. Louis, MO 63121. Copyright © 1998 by W.B. Saunders Company 0883-9417/98/1202-000753.00/0
Archives of Psychiatric Nursing, Vol. XII,No. 2 (April), 1998: pp 107-113
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content in psychiatric textbooks and found that they did not have any substantial information about patient teaching. In fundamental textbooks, a genetic, four-step educational process is presented that is assumed to guide practice in all specialty areas. But in actuality, the emphasis on learning readiness during the assessment phase of the process could be quite detrimental to educating psychiatric patients who are more likely to deny their illness and refuse to comply with treatment. A search of The Nursing and Allied Health (CINAHL) database for patient education in psychiatric nursing, covering the years 1982 through the present, resulted in only 36 articles. Most of these were informational, suggesting various approaches, techniques, or content areas which could be used or presented to meet psychiatric patients and/or their families needs. Only two of these articles were research based (Kuipers, Bell, Davidhizar, Cosgray, & Fawley, 1994; Youssef, 1987). Pothier, Stuart, Puskar, and Babich (1990) cautioned that psychiatric nursing as a specialty nursing area may be in danger of extinction, noting that few new graduates are interested in this area. To address the problem they propose that a research agenda for the 1990s, that will explore the discrete psychiatric nursing phenomenon which constitute the practice, is essential.
THE STUDY
The philosophical beliefs of Heidegger guided the search for meaning in this study. Hermeneutic analysis, concerned with meaning in the stories (audiotaped and transcribed texts) of psychiatric nurses, was the method of analysis. Reading and rereading the texts of the nurses' stories involved whole to part and part to whole analysis described by Munhall (1993) as a simultaneous process of discovery and reflective interpretation. Heidegger (1967/1927) proposes that knowledge originates in the subjective experience of individuals. It is the task of the investigator to reveal the common or shared meanings that lie in the lived experience of the stories the nurses tell. This was done by moving beyond the interview dialogue, reading and rereading texted stories to develop insights, interpretations, and impressions many times over, and confirming them between and among the texts. Ferguson (1996) has called this a "fusion of horizons."
Participants Benner's (1984) ideas about nursing expertise guided participant selection in this study to collect stories from nurses believed to have proficiency in their field. The clinical facility from which participants were drawn was in the process of designing a Benner-based merit system of evaluation. Nurse managers, familiar with Benner's ideas, were asked to recommend proficient psychiatric nurses for inclusion in this study. An eligible pool of 15 subjects was recommended by the nurse managers. All who were recommended volunteered to be interviewed, agreed that they had engaged in patient education, and had a story to articulate. Participants were aware that their participation was not confidential but that their anonymity was protected. From the pool of 15 informants, 12 semistructured, in-depth interviews were conducted and transcribed. Participants were asked to tell a story of their patient education experiences which they believed was exemplary of patient education in psychiatric nursing. The approach to interviewing and gathering stories was based on a qualitative study of psychiatric nurses performed by McElroy (1990). Interviews were concluded at 12 stories because the researcher believed that essential information and themes had been illuminated, pattems were repeating, and no new themes were emerging (Sandelowski, 1986); this has been referred to as a point of saturation in qualitative studies (Morse, 1997). Each of the participants was a registered nurse working full-time in an acute care psychiatric setting with at least 3 years experience in psychiatric nursing. Education and background varied; ages ranged from late 20s to mid 40s. Interviews were conducted at the convenience of the participant. Throughout the interview, active listening and clarification skills were used to understand the nurse's perception of the experience. FINDINGS
Analysis of the nurses' stories disclosed three themes: The Teaching Way, Being In-Between, and Seeing Inside, which describe the phenomena these nurses experienced, and a constitutive pattern, perseverance, which marked the meaning in the lived experience of patient education for these nurses. The findings of a qualitative study are shared with the community of interest through phenomenologic writing and rewriting of the discovery (Lauterbach, 1993). Because credibility of
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qualitative study lies in faithfulness to the subject's words (Sandelowski, 1986), transcriptions f r o m the nurses' stories are p r o v i d e d to support the researche r ' s interpretive c o m m e n t s .
The Teaching Way F o r the nurses in this study, teaching is a w a y of b e i n g that is u n q u e s t i o n a b l y an aspect of their nursing role. T h e i r patient-teaching actions f o l l o w f r o m expectations o f their b e h a v i o r that derive f r o m within the individual's v a l u e system o f responsibility, and m e s h through institutional expectations, legal-ethical obligations, and patient anticipation. O n e nurse described it this way: I believe teaching is what nurses can do and should do very well, as opposed to any of the other categories of health care providers. I mean, I think that particularly in health care reform, I think that is one niche that we can secure for ourselves more so than we've done in the past. Patients, uhm, research shows that patients tend to believe in us and trust in us, uhm, more so than other health care providers. We have the most access of any other health care providers to the patient and I think it's something that people need for one thing. (Informant #3) This nurse speaks o f the valuing of teaching as integral to practice and also foresees the importance o f this aspect o f the nursing role in the future of nursing. Expectations, obligations, and a strong sense that patients n e e d nurses and trust nurses derives f r o m the narrative. A n o t h e r nurse speaks o f patient education as a " m i n d - s e t " that requires b e i n g alert for " t e a c h i n g o p p o r t u n i t i e s " and taking advantage o f any e v e r y d a y aspect o f patient-nurse contact that can b e c o m e a teaching m o m e n t . The nurse states: I think you have to look for the opportunities because they can certainly pass right on by, if you don't notice. So I think you have to have an orientation to teaching that is something you think about as a part of your nursing role to the patient and family and that mind-set helps me anyway be more aware of some of the opportunities. (Informant #8) To the u n m o t i v a t e d or uninterested patient, the c o m m i t t e d nurse sees possibilities in the future saying: Talk to them anyway, because I feel it's my responsibiiity and I never know exactly what they're going to hem. Maybe they'll hear something that'll spark their interest, if not now, later. (Informant #4) T h e c o m m i t m e n t to patient education arises f r o m
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the b e l i e f that patient education is essential to the patient's survival. What's important you know, sometimes it just saves their very lives, you know, their medication, saved their lives, it keeps them off the street, or it keeps them from doing goofy things that makes them victims. Besides being just so uncomfortable with[in] their lives or so suicidal. I mean I think patient education saves any patient's life whether its heart problems or whatever, it also gives the family something to ground themselves with, you know if you can do [something], help your family member do, they may have a better life or you [the patient] may have a better life. (Informant #9) The T e a c h i n g W a y is chosen by these nurses as w a y of existing in the world. It is deeply ingrained in a nurse's ethical and m o r a l fiber and occupies the nurse's thoughts and actions during the e v e r y d a y e x p e r i e n c i n g of the world.
Being In-Between T h e t h e m e B e i n g I n - B e t w e e n reveals a positional stance w h i c h is similar to, yet different f r o m Bishop and S c u d d e r ' s (1991) description o f the " w e b of c o n n e c t i o n s " (p. 65) f r o m w h i c h nurses in bureaucratic health care settings practice. Others h a v e also described the nurse as an i n - b e t w e e n health care professional (Englehardt, 1985; M a c I n tyre, 1983). H e r e the nurse describes the precarious position f r o m w h i c h she practices. We do a lot of patient teaching here as you know and we do that with all our patients, we try to do that. We give the patients a list of medications that they're taking, uhm and uhm, we give them, well, uh, I don't talk about diagnoses with the patient until after the doctor has made the diagnosis and has told them, uh, I just feel the doctor should tell them, the patient, what the diagnosis is before I do. (Informant #6) F o r this nurse, being i n - b e t w e e n is a n o n p o w e r f u l position in w h i c h beliefs about the i m p o r t a n c e of the patient k n o w i n g about the illness can b e c o m e secondary to the nurse's e n m e s h m e n t into a context in w h i c h the physician is seen as h a v i n g authority o v e r nurses. Patients h a v e the right to k n o w their m e d i c a l diagnosis, but f r o m an i n - b e t w e e n position, e v e n that essential i n f o r m a t i o n m a y be problematic because s o m e t i m e s doctors tell t h e m and s o m e t i m e s they do not. T h e nurse treads carefully in this position. Yeah, they do that, (pause) if the patient asks. Before if I ask the patient what has the doctor discussed [with] you,
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[your] diagnosis, or what has this doctor diagnosed you with, what illness do you have, uhm, and when they say "I don't know," or "you know he didn't tell me" or "I asked him and he didn't say," mad then I will go on and approach the doctor and say, "do you want me to?" [and] "What is the problem?," "Why haven't you," or "what happened," or, what happened is, [that] some patient's really don't want to know or they don't want them to know, so I just go on and follow the doctor's lead. I ' m only the nurse. (Informant #7)
But being in-between the patient and the physician is not always perceived in such a passive manner. One nurse confronts a physician about an upset patient who wasn't informed by the physician of a change in medication. We got this one doctor that I did not think had the best bedside manner and who was somewhat of a god, you know, you do this cause I say it's b e s t . . , who increased her [the patient's] lithium right away. The next morning when I came in she had refused her medication during the night and he had increased it and didn't let her know. She met me at the door wanting to know "what the hell is going on here," so I approached him [the doctor] and I didn't get a good reception from him but I didn't care (pause) and he told me, and I knew what he was doing then. And I still had to approach him and then I asked him to talk to her and this kind of relieved her [the patient] a little bit. (Informant #12)
While being in-between, the nurse recognizes a responsibility to mediate between patient and doctor so that a patient gets the information needed. The context of health care is an inescapable part of providing patient-education and the nurses are well aware of it. Well first of all I was thinking about, this assignment, [the interview] this came to mind as I was thinking about teaching although it's a part of nursing's expectation and nursing practice in the area of psych [psychiatric nursing] that has not always been expected or even wanted by the milieu perhaps. The most difficult thing to deal with, is how to provide patient teaching that I see is needed and necessary in an environment that may not support that, and (pause) so that's been the biggest challenge for me. (Informant #3)
And how has this nurse dealt with it? The nurse replied, "I manage, I can usually get them [patients] to ask me questions and then I have to answer them, don't I?" (Informant #3) Being in-between clearly reveals the contextual nature of the patient education experience occurring within the health care setting. This theme discloses the moral predicament nurses must face as they strive to respect the individual and family's
rights and simultaneously operationalize their understandings of nursing care within a model of health care that is often in conflict with their own. It is a tightrope walked across a dilemma as this nurse states: Well, you teach very selectively, knowing who the physician is, knowing how much they want the patient to know, and you try to gauge it so that then the patient doesn't generate a list of questions to go back to the physicians, about the medication and question, you know, "I shouldn't really be taking this, or what about the risk?" (Informant
#4) It is through this theme that the nurses expressed the most frustration and insecurity about their own worth and had the greatest need to find a means to support their ethical commitment to the patient. Larson (1979) writes that each person finds his or her own "little metaphors," which are the maxims of truth by which he or she may sustain himself. Nurses in this study used the words "he has a right to know," to find solace for themselves and to justify their actions in less than supportive environments. These nurses recognized the limitations associated with the Being-in-Between experiences they have had, and sought direct and indirect ways to overcome them.
Seeing Inside Seeing Inside is a preliminary way of being toward patient education which requires self awareness, self reflection, and a precursory acceptance of the other as a being in the world. According to Heidegger (1927/1962) our concernful dealings (intention) in the world allow us to "encounter" other human beings who are experiencing the world in similar ways. Patient education is a conscious act representing the focus of a psychiatric nurse's intention, or concernful dealings in the world, which are directed towards the other, who happens to be an individual experiencing mental illness. Seeing Inside encompasses those efforts the nurse engages in to know the details of the other person's life and troubles, understand reasons for the patient's behavior, identify what the patient needs to know, and to find an approach that will "fit" the particular patient. Oh, I was talking to her all the time, I guess setting [forming] our relationship because she would listen to me and I could get her to calm down a little bit. I was always trying to tell about her medicines and such, it was just that it took a little while before she'd trust me enough to listen. I
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think the first time I said something she cursed me and then said, "The hell I do!" Initially I'd just say something like "you seem to be calm today, the medication must be helping," little things like that. (Informant #2) The nurse expects that the attempts to approach the patient will e v e n t u a l l y be successful and accepts the patient's behavior as it is. The nurse comes to k n o w the patient's possibilities and motivations and keeps them in m i n d to help m o v e the patient through difficult situations. When she had this episode she went totally bananas, that's when she left the children, and so I kept using that [the episode] you know, that if you want to raise your children you'll have to take your medication. (Informant #2) O n e nurse reflects in her story all that she k n o w s about her patient and describes a relationship which has b e e n o n g o i n g for years, e v e n through the patient's wellness. She's been out of the hospital for a year, she's on clozaril. She got her children back, she got her GED and she got a job. She also got a boyfriend and she got pregnant. So she has been calling us and telling us how well she was doing and I was elated. In fact she came in to see us one day and I didn't even recognize her, I thought she was a visitor. Her baby is not quite 2 weeks old and she's been here almost a week [readmitted]. She called me when she got pregnant because the doctor took her off Clozaril and she knew she was gonna [going to] get sick again and she did. The first few days she was here she didn't want any "damn Clozaril" and wouldn't let anybody draw her blood. (Informant #12) The nurse describes r e m i n d i n g this patient about how well she was able to care for her b a b y w h e n she was taking her medication. The nurse's k n o w l edge of the patient's past and present enables her to see inside to t h e patient's distorted sense of time and enables an e n c o u n t e r with the patient which m a y restore it. As a time of waiting, looking and reflecting, Seeing Inside allows the nurse to free herself from previous assumptions about the patient. I think it's important you put down your value system and your agenda and see who your patient is and not make assumptions that just because they are old, [that] they are senile and forgetful and demented, and could not process the information. And so there's no point in giving it. (Informant #10) She adds: I think people should know that it takes a long time, it takes lots of patience to teach a patient say psychiatric medica-
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tions, or anything, because we're not really sure if they're grasping it. You just keep trying, it never ceases. You just do what you have to do. (Informant #9) Seeing Inside requires looking deeper than the exterior things that a patient says or things that a patient does. It is n o t only a matter of looking into the patient, it is also a matter of looking into the n u r s e ' s ability to care. I always feel that I do not want any heroic efforts to keep me alive, but it's remarkable you have these geriatric patients up in their 80s or 90s and they want, they want everything. Absolutely everything for life saving measures and, (pause) and have made that decision. Either people choose not to think about it or they decide they want to live no matter what, not knowing exactly, how or what kind of turmoil they might go through while medicine tries to save their life. (Informant #8) The nurse moves outside of the self by reflecting on personal values about life, considering where the patient's values lie, and then b r i n g i n g back a personal u n d e r s t a n d i n g into the m e a n i n g of the patient's experience. F r o m this self-interpretive orientation which makes seeing inside possible, the nurse engages in patient education.
Perseverance: The Constitutive Pattern The constitutive pattern, wherein lies the m e a n ing of the patient education experience, is perseverance. Perseverance is built on the nurses' c o m m i t m e n t (Teaching Way), ability to see inside (Seeing Inside), and to stand i n - b e t w e e n ( B e i n g InBetween) in the health care setting. It is c o m p o s e d of elements of trust, patience, acceptance, caring, and hope which are integral to the nurse's investm e n t in what it m e a n s to teach people who have mental illnesses. These elements have b e e n described as the " q u i n t e s s e n c e of n u r s i n g " b y Paterson (1978, p. 65) and represent essential n u r s i n g qualities. A m a x i m or an adage tells a great truth. These nurse express the constitutive pattern of perseverance in patient education through m a x i m s such as: "You just have to keep trying," " y o u just never k n o w , " "I like to think of it as planting little seeds," "You just have to keep plugging, doing your best." T h e y express the great truth of perseverance which contains a hope for the future but not a guarantee. The nurses in this study sustain their teaching endeavors because the present is alive with possibilities. Listen for perseverance as a nurse speaks of
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a patient that the nurse is not sure " h e a r s " the i n f o r m a t i o n intended: I think that nurses need to offer it, and offer it, and offer it, because you really do not know. And like if they are in an agitated or depressed state, they may look like there is nobody home and there never will be, but once the depression is lifted (pause) there really is someone in there. (Informant #9) P e r s e v e r e a n c e is held out in h o p e for the future. While it's sad you know we really get a lot of returns. You know, for a lot of reasons and sometimes its because they're not taking their medications and lot of times that's with the younger set, that's hard because no one wants to take medicines and it's a thing that goes on. In most of the cases forever (pause) and sometimes when they get older they're not able to care for themselves as well as they think they should be able to care for themselves, as well as they did before, and they can't. Some of them start getting depressed about it or they, and some of them don't even realize it maybe, you know, you find them that way (pause) still denying it (pause) and sometimes you can do something about it and sometimes you can't. (Informant #2) But p e r s e v e r a n c e helps one carry on. I think, my love for psych patients, I think, if you don't feel really dedicated to psych patients your beating your head against a brick wall cause it is tiring, yet it is rewarding. Seeing patients get better and to feel that you had some part in their getting better, being able to talk to them and being able to support the family, you know. You know, I think its really hard, I don't mean really, but not so much to take care of but just to teach him on his own if he [the patient] has no support. No support other than just the hospital, you're gonna [going to] take care of him here and throw him back to the wolves, so to speak, so you have to expect some recidivism. (Informant #8) T h e nurse, accepting that the patient is functioning as best as he or she can at the present m o m e n t , p e r s e v e r e s in c o m m i t m e n t to continue patient education, perseveres in establishing trust, perseveres in s h o w i n g acceptance, and p e r s e v e r e s personally through a b e l i e f that patients will g r o w in their o w n t i m e and in their o w n w a y s (Mayeroff, 1972). SUMMARY
T h e values and concerns describing the p h e n o m e n o n o f patient education in psychiatric nursing are e m b e d d e d in nursing practice and actualized in each e n c o u n t e r f r o m an i n - b e t w e e n position. T h e s e understandings o f the inherent nature o f the patient e d u c a t i o n e x p e r i e n c e in psychiatric nursing refute s o m e earlier findings about patient education and
suggest that nurses v i e w their teaching role as integral to practice and engage in patient teaching with psychiatric patients whether or not they are m o t i v a t e d to learn. T h e nature o f the teaching act in the stories o f these nurses is closely tied to the practice setting, reflecting e m p h a s i s on traditional teaching that is acute care and disease related rather than addressing health p r o m o t i o n or self-care activities. N o t unexpectedly, these nurses face the political realities o f functioning within a large bureaucracy and pressures f r o m extraneous groups that attempt to limit their a u t o n o m y and threaten their confidence. CONCLUSION
It is clear f r o m this study that psychiatric nurses are v e r y m u c h i n v o l v e d in educating their patients. Students w h o read this study should c o m e a w a y with an appreciation of the challenges i n v o l v e d in educating psychiatric patients and the strength o f c o m m i t m e n t required. Psychiatric nurses w h o read this study m a y c o m e a w a y with a r e n e w e d and clarified understanding o f their o w n practice and sense o f pride in the c o m m i t m e n t r e v e a l e d here. The n e e d to p r o v i d e students with the skills to negotiate within the reality o f politically charged settings is apparent. The qualities w h i c h sustain these nurses to continue their teaching e n d e a v o r s within an unsupportive, often e v e n a hostile environment, w o u l d also be a worthy research consideration. REFERENCES
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, California: Addison-Wesley Publishing Company. Bishop, A.H. & Scudder, J.R. (1991). Nursing: The practice of caring. New York: National League for Nursing Press, Pub. No. 14-2422. Englehardt, H.T. (1985). Physicians, patients, health care institutions-and the people in between: nurses. In A. Bishop & J. Scudder (Eds.), Caring, curing and coping (pp. 62-79). Tuscaloosa, AL: University of Alabama Press. Ferguson, D.S. (1996). The lived experience of clinical educators. Journal of Advanced Nursing, 23, 835-841. Ferguson, K. (1991). Health education in psychiatry, part 1. Nursing Standard, 5(42), 33-35. Harmon, R.B. & Tratnack, S.A. (1992). Teaching hospitalized patients with serious, persistent mental illness. Journal of Psychosocial Nursing & Mental Health Services, 30(7), 33-38. Heidegger, M. (1927/1962) Being and time. J. MacQuarrie & E. Robinson (Trans). New York: Harper and Row.
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Kuipers, J.C., Bell, C., Davidhizar, R., Cosgray, R. Fawley, R. (1994). Knowledge and attitudes of chronic mentally ill patients before and after medication education. Journal of Advanced Nursing, 20(3), 450-456. Larson, M. (1979). Robert Frost as teacher. Journal of Higher Education, 50(4), 445-451. Lanterbach, S. (1993). In another world: A phenomenological perspective and discovery of meaning in mothers' experience with death of a wished~for baby. Doing phenomenology. In R Munhall and C. Oiler Boyd (Eds.), Nursing research: A qualitative perspective (pp. 133179). New York: National League for Nursing Press. Lindeman, C.A. (1988). Patient education. Annual Review of Nursing Research, 6, 29-60. Lindeman, C.A. (1989). Patient education--part 2. Annual review of Nursing research, 7, 199-212. MacIntyre, A. (1983). To whom is the nurse responsible. In C. Murphy & G. Hunter (Eds.), Ethical problems in the nurse-patient relationship (pp. 78-83). Newton, MA: Allyn & Bacon. Mayeroff, M. (1972). On Caring. USA: Harper Collins. MeElroy, E. (1990). Uncovering clinical knowledge in expert psychiatric nursing practice (Doctoral dissertation, University of Alabama at Birmingham). Dissertation Abstracts International, 52(03), 1355B.
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Morse, J.M. (1997) The pertinence of pilot studies. Qualitative Health Research, 7(3), 323. Munhall, R (1993). Model of existential investigation. In R Munhall & C. Oiler Boyd (Eds.), Nursing research: A qualitative perspective (2nd ed.). New York: National League for Nursing Press. Paterson, J. (1978). The tortuous way toward nursing theory. In National League for Nursing, Theory Development: What, why and how. New York: National League for N-ursing. Pothier, R, Stuart, G., Puskar, K., & Babich, K. (1990). Dilemmas and directions for psychiatric nursing in the 1990's. Archives of Psychiatric Nursing, 4(5), 284-291. Redmon, B. (1993). Patient education at 25 years: where we have been and where we are going. Journal of Advanced Nursing, 18, 725-730. Sandelowski, M. (1986). The problem of rigor in qualitative reesearch. Advances in Nursing Science, 8(3), 27-37. Youssef, F.A. (1987). Discharge planning for psychiatric patients; the effects of a family-patient teaching program. Journal of Advanced Nursing, 12(5), 611-616. Williams, C.A. (1989). Patient education for people with schizophrenia. The context of the nurse-patient relationship. Perspectives in Psychiatric Care, 25(2), 14-21.
Y INTEREST IN THE phenomenon of patient education in psychiatric nursing arose from personal experience as a psychiatric nurse and clinical psychiatric nurse educator. Having faced and overcome challenging patient education experiences, it was easy to empathize with students who experienced similar difficulties in clinical settings. But it remained difficult to encourage students to engage in patient education with those who denied their illness, refused treatment, or otherwise showed behaviors that indicated they were disinterested, unable to concentrate, or generally unmotivated. Traditional textbook expectations about the process of patient education emphasize learner readiness, so it is no wonder that students wait to begin teaching until a compliant, motivated patient/ learner manifests. In acute care settings this is seldom the case. To instill the importance of the nurses' role as patient educator in view of contradictions inherent in the educational process was a matter of great concern. This study was undertaken to discover the meaning of patient education for
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psychiatric nurses in the hopes that such a discovery would provide "knowledge" that would guide practice and shape student nurses' understanding of this phenomenon as it exists in psychiatric nursing. PATIENT EDUCATION IN PSYCHIATRIC NURSING
Patient education has a long history in nursing and has been extensively investigated (Lindeman, 1988, 1989). But within the specialty area of psychiatric nursing much less is known. There is even some dispute about the extent of patient education performed by psychiatric nurses (Ferguson, 1991; Harmon & Tratnack, 1992; Williams, 1989). Redmon (1993) reviewed the educational
From the Barnes College of Nursing, University of Missouri, St. Louis, MO. Address reprint requests to Patrieia E. Freed, Barnes College of Nursing, University of Missouri, St. Louis, 8001 Natural Bridge Road, St. Louis, MO 63121. Copyright © 1998 by W.B. Saunders Company 0883-9417/98/1202-000753.00/0
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content in psychiatric textbooks and found that they did not have any substantial information about patient teaching. In fundamental textbooks, a genetic, four-step educational process is presented that is assumed to guide practice in all specialty areas. But in actuality, the emphasis on learning readiness during the assessment phase of the process could be quite detrimental to educating psychiatric patients who are more likely to deny their illness and refuse to comply with treatment. A search of The Nursing and Allied Health (CINAHL) database for patient education in psychiatric nursing, covering the years 1982 through the present, resulted in only 36 articles. Most of these were informational, suggesting various approaches, techniques, or content areas which could be used or presented to meet psychiatric patients and/or their families needs. Only two of these articles were research based (Kuipers, Bell, Davidhizar, Cosgray, & Fawley, 1994; Youssef, 1987). Pothier, Stuart, Puskar, and Babich (1990) cautioned that psychiatric nursing as a specialty nursing area may be in danger of extinction, noting that few new graduates are interested in this area. To address the problem they propose that a research agenda for the 1990s, that will explore the discrete psychiatric nursing phenomenon which constitute the practice, is essential.
THE STUDY
The philosophical beliefs of Heidegger guided the search for meaning in this study. Hermeneutic analysis, concerned with meaning in the stories (audiotaped and transcribed texts) of psychiatric nurses, was the method of analysis. Reading and rereading the texts of the nurses' stories involved whole to part and part to whole analysis described by Munhall (1993) as a simultaneous process of discovery and reflective interpretation. Heidegger (1967/1927) proposes that knowledge originates in the subjective experience of individuals. It is the task of the investigator to reveal the common or shared meanings that lie in the lived experience of the stories the nurses tell. This was done by moving beyond the interview dialogue, reading and rereading texted stories to develop insights, interpretations, and impressions many times over, and confirming them between and among the texts. Ferguson (1996) has called this a "fusion of horizons."
Participants Benner's (1984) ideas about nursing expertise guided participant selection in this study to collect stories from nurses believed to have proficiency in their field. The clinical facility from which participants were drawn was in the process of designing a Benner-based merit system of evaluation. Nurse managers, familiar with Benner's ideas, were asked to recommend proficient psychiatric nurses for inclusion in this study. An eligible pool of 15 subjects was recommended by the nurse managers. All who were recommended volunteered to be interviewed, agreed that they had engaged in patient education, and had a story to articulate. Participants were aware that their participation was not confidential but that their anonymity was protected. From the pool of 15 informants, 12 semistructured, in-depth interviews were conducted and transcribed. Participants were asked to tell a story of their patient education experiences which they believed was exemplary of patient education in psychiatric nursing. The approach to interviewing and gathering stories was based on a qualitative study of psychiatric nurses performed by McElroy (1990). Interviews were concluded at 12 stories because the researcher believed that essential information and themes had been illuminated, pattems were repeating, and no new themes were emerging (Sandelowski, 1986); this has been referred to as a point of saturation in qualitative studies (Morse, 1997). Each of the participants was a registered nurse working full-time in an acute care psychiatric setting with at least 3 years experience in psychiatric nursing. Education and background varied; ages ranged from late 20s to mid 40s. Interviews were conducted at the convenience of the participant. Throughout the interview, active listening and clarification skills were used to understand the nurse's perception of the experience. FINDINGS
Analysis of the nurses' stories disclosed three themes: The Teaching Way, Being In-Between, and Seeing Inside, which describe the phenomena these nurses experienced, and a constitutive pattern, perseverance, which marked the meaning in the lived experience of patient education for these nurses. The findings of a qualitative study are shared with the community of interest through phenomenologic writing and rewriting of the discovery (Lauterbach, 1993). Because credibility of
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qualitative study lies in faithfulness to the subject's words (Sandelowski, 1986), transcriptions f r o m the nurses' stories are p r o v i d e d to support the researche r ' s interpretive c o m m e n t s .
The Teaching Way F o r the nurses in this study, teaching is a w a y of b e i n g that is u n q u e s t i o n a b l y an aspect of their nursing role. T h e i r patient-teaching actions f o l l o w f r o m expectations o f their b e h a v i o r that derive f r o m within the individual's v a l u e system o f responsibility, and m e s h through institutional expectations, legal-ethical obligations, and patient anticipation. O n e nurse described it this way: I believe teaching is what nurses can do and should do very well, as opposed to any of the other categories of health care providers. I mean, I think that particularly in health care reform, I think that is one niche that we can secure for ourselves more so than we've done in the past. Patients, uhm, research shows that patients tend to believe in us and trust in us, uhm, more so than other health care providers. We have the most access of any other health care providers to the patient and I think it's something that people need for one thing. (Informant #3) This nurse speaks o f the valuing of teaching as integral to practice and also foresees the importance o f this aspect o f the nursing role in the future of nursing. Expectations, obligations, and a strong sense that patients n e e d nurses and trust nurses derives f r o m the narrative. A n o t h e r nurse speaks o f patient education as a " m i n d - s e t " that requires b e i n g alert for " t e a c h i n g o p p o r t u n i t i e s " and taking advantage o f any e v e r y d a y aspect o f patient-nurse contact that can b e c o m e a teaching m o m e n t . The nurse states: I think you have to look for the opportunities because they can certainly pass right on by, if you don't notice. So I think you have to have an orientation to teaching that is something you think about as a part of your nursing role to the patient and family and that mind-set helps me anyway be more aware of some of the opportunities. (Informant #8) To the u n m o t i v a t e d or uninterested patient, the c o m m i t t e d nurse sees possibilities in the future saying: Talk to them anyway, because I feel it's my responsibiiity and I never know exactly what they're going to hem. Maybe they'll hear something that'll spark their interest, if not now, later. (Informant #4) T h e c o m m i t m e n t to patient education arises f r o m
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the b e l i e f that patient education is essential to the patient's survival. What's important you know, sometimes it just saves their very lives, you know, their medication, saved their lives, it keeps them off the street, or it keeps them from doing goofy things that makes them victims. Besides being just so uncomfortable with[in] their lives or so suicidal. I mean I think patient education saves any patient's life whether its heart problems or whatever, it also gives the family something to ground themselves with, you know if you can do [something], help your family member do, they may have a better life or you [the patient] may have a better life. (Informant #9) The T e a c h i n g W a y is chosen by these nurses as w a y of existing in the world. It is deeply ingrained in a nurse's ethical and m o r a l fiber and occupies the nurse's thoughts and actions during the e v e r y d a y e x p e r i e n c i n g of the world.
Being In-Between T h e t h e m e B e i n g I n - B e t w e e n reveals a positional stance w h i c h is similar to, yet different f r o m Bishop and S c u d d e r ' s (1991) description o f the " w e b of c o n n e c t i o n s " (p. 65) f r o m w h i c h nurses in bureaucratic health care settings practice. Others h a v e also described the nurse as an i n - b e t w e e n health care professional (Englehardt, 1985; M a c I n tyre, 1983). H e r e the nurse describes the precarious position f r o m w h i c h she practices. We do a lot of patient teaching here as you know and we do that with all our patients, we try to do that. We give the patients a list of medications that they're taking, uhm and uhm, we give them, well, uh, I don't talk about diagnoses with the patient until after the doctor has made the diagnosis and has told them, uh, I just feel the doctor should tell them, the patient, what the diagnosis is before I do. (Informant #6) F o r this nurse, being i n - b e t w e e n is a n o n p o w e r f u l position in w h i c h beliefs about the i m p o r t a n c e of the patient k n o w i n g about the illness can b e c o m e secondary to the nurse's e n m e s h m e n t into a context in w h i c h the physician is seen as h a v i n g authority o v e r nurses. Patients h a v e the right to k n o w their m e d i c a l diagnosis, but f r o m an i n - b e t w e e n position, e v e n that essential i n f o r m a t i o n m a y be problematic because s o m e t i m e s doctors tell t h e m and s o m e t i m e s they do not. T h e nurse treads carefully in this position. Yeah, they do that, (pause) if the patient asks. Before if I ask the patient what has the doctor discussed [with] you,
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[your] diagnosis, or what has this doctor diagnosed you with, what illness do you have, uhm, and when they say "I don't know," or "you know he didn't tell me" or "I asked him and he didn't say," mad then I will go on and approach the doctor and say, "do you want me to?" [and] "What is the problem?," "Why haven't you," or "what happened," or, what happened is, [that] some patient's really don't want to know or they don't want them to know, so I just go on and follow the doctor's lead. I ' m only the nurse. (Informant #7)
But being in-between the patient and the physician is not always perceived in such a passive manner. One nurse confronts a physician about an upset patient who wasn't informed by the physician of a change in medication. We got this one doctor that I did not think had the best bedside manner and who was somewhat of a god, you know, you do this cause I say it's b e s t . . , who increased her [the patient's] lithium right away. The next morning when I came in she had refused her medication during the night and he had increased it and didn't let her know. She met me at the door wanting to know "what the hell is going on here," so I approached him [the doctor] and I didn't get a good reception from him but I didn't care (pause) and he told me, and I knew what he was doing then. And I still had to approach him and then I asked him to talk to her and this kind of relieved her [the patient] a little bit. (Informant #12)
While being in-between, the nurse recognizes a responsibility to mediate between patient and doctor so that a patient gets the information needed. The context of health care is an inescapable part of providing patient-education and the nurses are well aware of it. Well first of all I was thinking about, this assignment, [the interview] this came to mind as I was thinking about teaching although it's a part of nursing's expectation and nursing practice in the area of psych [psychiatric nursing] that has not always been expected or even wanted by the milieu perhaps. The most difficult thing to deal with, is how to provide patient teaching that I see is needed and necessary in an environment that may not support that, and (pause) so that's been the biggest challenge for me. (Informant #3)
And how has this nurse dealt with it? The nurse replied, "I manage, I can usually get them [patients] to ask me questions and then I have to answer them, don't I?" (Informant #3) Being in-between clearly reveals the contextual nature of the patient education experience occurring within the health care setting. This theme discloses the moral predicament nurses must face as they strive to respect the individual and family's
rights and simultaneously operationalize their understandings of nursing care within a model of health care that is often in conflict with their own. It is a tightrope walked across a dilemma as this nurse states: Well, you teach very selectively, knowing who the physician is, knowing how much they want the patient to know, and you try to gauge it so that then the patient doesn't generate a list of questions to go back to the physicians, about the medication and question, you know, "I shouldn't really be taking this, or what about the risk?" (Informant
#4) It is through this theme that the nurses expressed the most frustration and insecurity about their own worth and had the greatest need to find a means to support their ethical commitment to the patient. Larson (1979) writes that each person finds his or her own "little metaphors," which are the maxims of truth by which he or she may sustain himself. Nurses in this study used the words "he has a right to know," to find solace for themselves and to justify their actions in less than supportive environments. These nurses recognized the limitations associated with the Being-in-Between experiences they have had, and sought direct and indirect ways to overcome them.
Seeing Inside Seeing Inside is a preliminary way of being toward patient education which requires self awareness, self reflection, and a precursory acceptance of the other as a being in the world. According to Heidegger (1927/1962) our concernful dealings (intention) in the world allow us to "encounter" other human beings who are experiencing the world in similar ways. Patient education is a conscious act representing the focus of a psychiatric nurse's intention, or concernful dealings in the world, which are directed towards the other, who happens to be an individual experiencing mental illness. Seeing Inside encompasses those efforts the nurse engages in to know the details of the other person's life and troubles, understand reasons for the patient's behavior, identify what the patient needs to know, and to find an approach that will "fit" the particular patient. Oh, I was talking to her all the time, I guess setting [forming] our relationship because she would listen to me and I could get her to calm down a little bit. I was always trying to tell about her medicines and such, it was just that it took a little while before she'd trust me enough to listen. I
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think the first time I said something she cursed me and then said, "The hell I do!" Initially I'd just say something like "you seem to be calm today, the medication must be helping," little things like that. (Informant #2) The nurse expects that the attempts to approach the patient will e v e n t u a l l y be successful and accepts the patient's behavior as it is. The nurse comes to k n o w the patient's possibilities and motivations and keeps them in m i n d to help m o v e the patient through difficult situations. When she had this episode she went totally bananas, that's when she left the children, and so I kept using that [the episode] you know, that if you want to raise your children you'll have to take your medication. (Informant #2) O n e nurse reflects in her story all that she k n o w s about her patient and describes a relationship which has b e e n o n g o i n g for years, e v e n through the patient's wellness. She's been out of the hospital for a year, she's on clozaril. She got her children back, she got her GED and she got a job. She also got a boyfriend and she got pregnant. So she has been calling us and telling us how well she was doing and I was elated. In fact she came in to see us one day and I didn't even recognize her, I thought she was a visitor. Her baby is not quite 2 weeks old and she's been here almost a week [readmitted]. She called me when she got pregnant because the doctor took her off Clozaril and she knew she was gonna [going to] get sick again and she did. The first few days she was here she didn't want any "damn Clozaril" and wouldn't let anybody draw her blood. (Informant #12) The nurse describes r e m i n d i n g this patient about how well she was able to care for her b a b y w h e n she was taking her medication. The nurse's k n o w l edge of the patient's past and present enables her to see inside to t h e patient's distorted sense of time and enables an e n c o u n t e r with the patient which m a y restore it. As a time of waiting, looking and reflecting, Seeing Inside allows the nurse to free herself from previous assumptions about the patient. I think it's important you put down your value system and your agenda and see who your patient is and not make assumptions that just because they are old, [that] they are senile and forgetful and demented, and could not process the information. And so there's no point in giving it. (Informant #10) She adds: I think people should know that it takes a long time, it takes lots of patience to teach a patient say psychiatric medica-
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tions, or anything, because we're not really sure if they're grasping it. You just keep trying, it never ceases. You just do what you have to do. (Informant #9) Seeing Inside requires looking deeper than the exterior things that a patient says or things that a patient does. It is n o t only a matter of looking into the patient, it is also a matter of looking into the n u r s e ' s ability to care. I always feel that I do not want any heroic efforts to keep me alive, but it's remarkable you have these geriatric patients up in their 80s or 90s and they want, they want everything. Absolutely everything for life saving measures and, (pause) and have made that decision. Either people choose not to think about it or they decide they want to live no matter what, not knowing exactly, how or what kind of turmoil they might go through while medicine tries to save their life. (Informant #8) The nurse moves outside of the self by reflecting on personal values about life, considering where the patient's values lie, and then b r i n g i n g back a personal u n d e r s t a n d i n g into the m e a n i n g of the patient's experience. F r o m this self-interpretive orientation which makes seeing inside possible, the nurse engages in patient education.
Perseverance: The Constitutive Pattern The constitutive pattern, wherein lies the m e a n ing of the patient education experience, is perseverance. Perseverance is built on the nurses' c o m m i t m e n t (Teaching Way), ability to see inside (Seeing Inside), and to stand i n - b e t w e e n ( B e i n g InBetween) in the health care setting. It is c o m p o s e d of elements of trust, patience, acceptance, caring, and hope which are integral to the nurse's investm e n t in what it m e a n s to teach people who have mental illnesses. These elements have b e e n described as the " q u i n t e s s e n c e of n u r s i n g " b y Paterson (1978, p. 65) and represent essential n u r s i n g qualities. A m a x i m or an adage tells a great truth. These nurse express the constitutive pattern of perseverance in patient education through m a x i m s such as: "You just have to keep trying," " y o u just never k n o w , " "I like to think of it as planting little seeds," "You just have to keep plugging, doing your best." T h e y express the great truth of perseverance which contains a hope for the future but not a guarantee. The nurses in this study sustain their teaching endeavors because the present is alive with possibilities. Listen for perseverance as a nurse speaks of
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a patient that the nurse is not sure " h e a r s " the i n f o r m a t i o n intended: I think that nurses need to offer it, and offer it, and offer it, because you really do not know. And like if they are in an agitated or depressed state, they may look like there is nobody home and there never will be, but once the depression is lifted (pause) there really is someone in there. (Informant #9) P e r s e v e r e a n c e is held out in h o p e for the future. While it's sad you know we really get a lot of returns. You know, for a lot of reasons and sometimes its because they're not taking their medications and lot of times that's with the younger set, that's hard because no one wants to take medicines and it's a thing that goes on. In most of the cases forever (pause) and sometimes when they get older they're not able to care for themselves as well as they think they should be able to care for themselves, as well as they did before, and they can't. Some of them start getting depressed about it or they, and some of them don't even realize it maybe, you know, you find them that way (pause) still denying it (pause) and sometimes you can do something about it and sometimes you can't. (Informant #2) But p e r s e v e r a n c e helps one carry on. I think, my love for psych patients, I think, if you don't feel really dedicated to psych patients your beating your head against a brick wall cause it is tiring, yet it is rewarding. Seeing patients get better and to feel that you had some part in their getting better, being able to talk to them and being able to support the family, you know. You know, I think its really hard, I don't mean really, but not so much to take care of but just to teach him on his own if he [the patient] has no support. No support other than just the hospital, you're gonna [going to] take care of him here and throw him back to the wolves, so to speak, so you have to expect some recidivism. (Informant #8) T h e nurse, accepting that the patient is functioning as best as he or she can at the present m o m e n t , p e r s e v e r e s in c o m m i t m e n t to continue patient education, perseveres in establishing trust, perseveres in s h o w i n g acceptance, and p e r s e v e r e s personally through a b e l i e f that patients will g r o w in their o w n t i m e and in their o w n w a y s (Mayeroff, 1972). SUMMARY
T h e values and concerns describing the p h e n o m e n o n o f patient education in psychiatric nursing are e m b e d d e d in nursing practice and actualized in each e n c o u n t e r f r o m an i n - b e t w e e n position. T h e s e understandings o f the inherent nature o f the patient e d u c a t i o n e x p e r i e n c e in psychiatric nursing refute s o m e earlier findings about patient education and
suggest that nurses v i e w their teaching role as integral to practice and engage in patient teaching with psychiatric patients whether or not they are m o t i v a t e d to learn. T h e nature o f the teaching act in the stories o f these nurses is closely tied to the practice setting, reflecting e m p h a s i s on traditional teaching that is acute care and disease related rather than addressing health p r o m o t i o n or self-care activities. N o t unexpectedly, these nurses face the political realities o f functioning within a large bureaucracy and pressures f r o m extraneous groups that attempt to limit their a u t o n o m y and threaten their confidence. CONCLUSION
It is clear f r o m this study that psychiatric nurses are v e r y m u c h i n v o l v e d in educating their patients. Students w h o read this study should c o m e a w a y with an appreciation of the challenges i n v o l v e d in educating psychiatric patients and the strength o f c o m m i t m e n t required. Psychiatric nurses w h o read this study m a y c o m e a w a y with a r e n e w e d and clarified understanding o f their o w n practice and sense o f pride in the c o m m i t m e n t r e v e a l e d here. The n e e d to p r o v i d e students with the skills to negotiate within the reality o f politically charged settings is apparent. The qualities w h i c h sustain these nurses to continue their teaching e n d e a v o r s within an unsupportive, often e v e n a hostile environment, w o u l d also be a worthy research consideration. REFERENCES
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Kuipers, J.C., Bell, C., Davidhizar, R., Cosgray, R. Fawley, R. (1994). Knowledge and attitudes of chronic mentally ill patients before and after medication education. Journal of Advanced Nursing, 20(3), 450-456. Larson, M. (1979). Robert Frost as teacher. Journal of Higher Education, 50(4), 445-451. Lanterbach, S. (1993). In another world: A phenomenological perspective and discovery of meaning in mothers' experience with death of a wished~for baby. Doing phenomenology. In R Munhall and C. Oiler Boyd (Eds.), Nursing research: A qualitative perspective (pp. 133179). New York: National League for Nursing Press. Lindeman, C.A. (1988). Patient education. Annual Review of Nursing Research, 6, 29-60. Lindeman, C.A. (1989). Patient education--part 2. Annual review of Nursing research, 7, 199-212. MacIntyre, A. (1983). To whom is the nurse responsible. In C. Murphy & G. Hunter (Eds.), Ethical problems in the nurse-patient relationship (pp. 78-83). Newton, MA: Allyn & Bacon. Mayeroff, M. (1972). On Caring. USA: Harper Collins. MeElroy, E. (1990). Uncovering clinical knowledge in expert psychiatric nursing practice (Doctoral dissertation, University of Alabama at Birmingham). Dissertation Abstracts International, 52(03), 1355B.
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