s primary health care providers, nurses are regularly confronted with patient problems that could be handled most effectively through the understanding and application of learning principles. Examples are numerous. Jimmy is scheduled for surgery tomorrow. He is afraid. The nurse will be the only person to prepare him psychologically. Sally, a paraplegic girl on a rehabilitation unit, spends her days

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whining in a loud, high-pitched, aversive manner. The reaction of her nurse to this behavior will determine whether Sally continues her constant whining or whether she learns more adaptive and satisfying behaviors. Patient X talks “crazy” and refuses to eat. His nurse is the only professional person who will have significant interactions with him. Problems such as these are faced daily by professional nurses. Few realize that the principles of learning provide tools to help. Often nurses fail to use these tools either because they hesitate to wade through the usual pedantic discourses on learning, or because the connection between these principles and nursing practice has never been made clear to them. In this article I review the principles of the two basic types of learning - classical and operant conditioning - thought to be most useful to the practicing nurse.

CLASSICAL CONDITIONING Classical or Pavlovian conditioning occurs when a neutral stimulus comes to elicit a new response through being associated in time with another stimulus which reflexively elicits that response. For example, a pain stimulus such as the prick of a hypodermic needle reflexively elicits responses such as fear and withdrawal. Originally neutral stimuli, which immediately precede the painful stimuli, such as the sight of a nurse or the smell of medicine, will come to elicit the responses of fear and withdrawal.

Pain from shot

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elicits ---....

Because pain is involved with many hospital experiences, fear is the most troublesome and omnipresent conditioned (i.e. learned) response in the medical setting. Needles, knives, drills, white coats, medicinal smells, and the hospital itself are all originally neutral stimuli which, through association in time with pain, become conditioned stimuli eliciting the conditioned response of fear. Once such learning takes place, the fear may generalize to other similar stimuli. Thus, the fear acquired when the nurse gives Johnny a shot will appear, albeit at slightly reduced intensity, when another nurse attempts to give Johnny a shot next month, or next year. In fact, the fear response may generalize at a still lower level to all women similar in appearance to nurses. However, if Johnny is repeatedly exposed to other females with no pain resulting, this generalized fear will undergo extinction and Johnny will have formed a stimulus discrimination. That is, he will react with conditioned fear only to some females, i.e., those who wear white uniforms and carry the label of nurse. Now you may say, that’s all well and good, but what of those patients who react to a medical procedure with fear even though they have never had a direct painful experience with that or a similar medical procedure. First, let me point out that the fear may have generalized from an aversive experience in a nonmedical setting. Thus, Mr. G’s fear of an upper endoscopy may be generalized fear of something in his throat originally conditioned when he got meat stuck in his

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throat followed by the (very aversive) feeling that he could not get his breath. Similarly, Johnny’s fear of needles may have generalized from fear originally conditioned when he was stuck by a pin. There are cases of fear reaction, however, where there is no history of direct painful experience with similar stimuli. In some persons this fear can be explained as a reflexive reaction to novel stimuli. This type of unconditioned fear reaction to novelty drops out rapidly as the person becomes accustomed or habituated to the new stimuli. More enduring fear reactions, in the absence of prior personal experience with the eliciting stimuli, often stem from vicarious or observational learning. The patient has observed the affective reactions of others (directly or pictorially) as they underwent painful experiences. Johnny may be classically conditioned to fear nurses and needles through observation of his brother screaming in painful reaction to a shot or through observation of a similar scene on TV. In fact, all learning which occurs through direct experience can occur vicariously through observation of another person’s behavior and its consequences for them. (Bandura, 1969) Regardless of how it has been acquired, fear, like other classically conditioned responses, can be reduced or extinguished through repeated or extended exposure to the eliciting conditioned stimulus in the absence of any painful event. (Shipley, 1974) Johnny’s fear of the nurse could be extinguished if he spent appreciable time with her and experienced no pain. The fear which had generalized to the other nurse would also undergo some extinction. This is called generalization of extinction. Fear can also be extinguished vicariously through modeling, just as it can be acquired in this manner. Inasmuch as Johnny observes his brother being examined by

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the nurse without any adverse consequences to the brother, Johnny’s fear of examination would undergo some extinction effect. Another example of the use of stimulus exposure to extinguish conditioned fear is found in the psychologic preparation of patients for surgery. Most methods of preparation utilize actual or pictorial exposure to the operating room, recovery room, IVs, catheters, and so on. With each such exposure, the fear-eliciting properties of the stimuli should be further extinguished. (Shipley, et al., 1976) Often the nurse hesitates to expose her patient to these stimuli since they are frightening to him. However, it is only with sufficient exposure that the fear is reduced. The extinction procedure is best done before the operation since following the operation the patient is forced to experience these frightening stimuli, in addition to pain and weakness. Of course, other more cognitive mechanisms may be involved in the fear-reducing effects of preparation for surgery such as material aimed at providing the patient with accurate information about the timing and intensity of painful events to come. Repeated exposure to hospital stimuli can also be used prior to aversive conditioning experiences to reduce the amount of fear that will be attached to these stimuli as a result of their inevitable pairing with pain. The decrement in learning which results from nonreinforced pre-exposure of the to-be-conditioned stimulus is known as latent inhibition. Latent inhibition will occur if a child’s first few visits to the doctor or dentist involve exposure to various stimuli, such as nurses and white coats, without his experiencing pain. The amount of fear subsequently conditioned to these stimuli when they are, of necessity, paired with pain will then be less than had the preexposure not been provided.

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OPERANT CONDITIONING In the 1930s, B. F. Skinner (1938), noting that every response produces some consequence, experimentally manipulated the consequences produced by a hungry rat pressing a lever. Every time the rat pressed the lever he got a food pellet (this is called a continuous reinforcement schedule). Under this schedule, the rate of the bar-pressing response increased from 1 or 2 per day to 100 per minute. This relationship has been found to hold true for all living organisms and provides a means of increasing specific behaviors in people. This type of learning is called operant or instrumental conditioning. It occurs when a specific response is instrumental in obtaining a rewarding stimulus or in removing an aversive stimulus. The principles of operant learning provide powerful treatment for many disorders. For example, a mute patient may be taught to speak through the provision of positive reinforcement following talking behaviors. If no rudimentary speech is present to reinforce, talking may be shaped by rewarding successive approximations to the talking behavior desired. The patient might first be reinforced for any lip movements, then only if a vocalization is made, then only for vocalizations that approximate words, then for words, and so forth. These same basic techniques may be used to increase the social skills of a shy, withdrawn patient, to teach a quadriplegic patient to manipulate objects using his teeth, or to increase self-care and social behaviors in mentally retarded patients. In fact, it has just recently been discovered that even the visceral responses controlled by the autonomic nervous system such as responses of the glands, cardiac muscle, and smooth muscle of the alimentary canal may be modified by

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using the principles of operant conditioning. A person may learn to raise or lower his blood pressure, heart rate, or frequency of alpha brain waves. In the typical procedure, the bodily function of interest is monitored and information on rate or occurrence is provided as feedback to the patient. The patient receives reinforcement for responses of specified magnitude or direction. However, the success in changing the bodily function in the desired direction is frequently the only reinforcement needed. The fact that visceral responses respond to operant learning suggests that learning may be involved in the etiology of psychosomatic symptoms and that learning can be utilized in their treatment. For example, Engel at the Gerontology Research Center in Baltimore has had notable success in the operant treatment of cardiac arrhythmias. Randt at the New York University School of Medicine has reported successful operant modification of abnormal paroxysmal spikes in epileptic patients. Many other visceral responses such as intestinal and gastric function have been successfully modified in animals and will no doubt be extended to humans in the near future. Operantly learned responses, like classically conditioned responses, can be extinguished. Skinner discovered that if the food following the bar-press response was consistently withheld, the response rate rapidly declined to its original low level. From a practical standpoint, this finding means that if we have a person who is emitting an undesirable response at a high rate, we have a mechanism to get rid of that response. Let’s take the child who cries an hour or two at bedtime as an example. We carefully observe the situation and note that father or mother goes into the child’s bedroom within 10 minutes every time the child cries. We hypothesize

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that parental attention is a reinforcer for the child and that the parents are maintaining the crying behavior on a continuous reinforcement schedule. After wise counsel from a knowledgeable nurse, the parents ignore the crying behavior and it extinguishes rapidly. This illustrates a law of behavior: Behavior maintained on a continuous reinforcement schedule will extinguish quickly when the reinforcing stimulus is withheld. Generally, however, in the real world a response is not reinforced 100 percent of the time. As the story goes, Skinner one day had trouble with his apparatus such that when the bar was pressed, the rat received food only occasionally. The rat was then on a schedule of occasional or partial reinforcement. When Skinner discontinued reinforcement altogether, he found that the rat kept responding for a long time before the response rate gradually diminished. Here a second and very important law of behavior had been established: Extinction is slow for behaviors maintained by partial reinforcement. In the example of the child who cried at night, if this behavior was on a partial reinforcement schedule, that is, if the parents occasionally gave the child attention contingent on crying (rather than every time he cried), the crying would take a long time to extinguish. The Las Vegas-type slot machine is often cited as an example of a partial reinforcement schedule and the highly resistant-to-extinction behavior it elicits. A vending machine, on the other hand, provides an example of a continuous reinforcement schedule. Every time you put your dime in the machine you get a pack of gum or whatever - a continuous reinforcement schedule. If your dime does not produce the gum, you would only try one or two more times before you stop responding, i.e., extinguish.

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Unfortunately, most human behavior is on a partial reinforcement schedule and, consequently, relatively difficult to extinguish. Behavior most likely to be on such an intermittent schedule of reinforcement is behavior which is very deviant, “crazy,” or which produces aversive consequences for others. When faced with such unwanted behavior, people attempt to stop the behavior and, in the process, often unwittingly reinforce and maintain the behavior they are trying to eliminate. Because it is generally aversive or because of the willingness of those of us in the helping professions to tolerate and even encourage “crazy” or deviant behavior, it readily creates the conditions that are most likely to perpetuate it. True, many “crazy” behaviors are frequently punished, but a schedule of reinforcement combining intermittent reward with occasional punishment generally results in behavior that is resistant to change. Also, because of the attention they provide, many interventions intended to punish actually serve as positive reinforcers. For example, verbal reprimands in the classroom have been shown to function as positive reinforcers capable of sustaining the disruptive behavior which they follow. (Madsen, et al., 1968) In one classroom, when children left their desks they were consistently told, “Sit down.” These reprimands increased the number of children out of their desks. Out-of-desk behavior was finally reduced to a low level by having the teacher ignore that behavior while simultaneously praising those children working at their desks. This latter example illustrates a very powerful and commonly used strategy in the elimination of undesirable behavior which has been maintained by positive reinforcement - the combination of extinction procedures aimed at the undesirable behavior and positive reinforcement of incompatible

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behavior. Another example of this technique occurred when the staff of a hospital physical rehabilitation unit.was about to send Sally, the paraplegic girl, to the state mental hospital because she spent most of her waking hours whining in a loud, high-pitched, aversive manner. Observation revealed that the ward personnel reacted to the whining behavior with anything from scolding and threats to loving care and attention. Occasionally the girl stopped whining to ask a question of the staff. This response category was generally ignored by the staff. Treatment, of course, involved simply switching the reinforcement contingencies. Whining was ignored and other verbal behaviors were reinforced with staff attention. Since whining and talking are physically incompatible responses, as talking increased, whining decreased. Schaefer and Martin (1969) cite another example of the use of these principles. After prolonged bed rest, geriatric patients in a large general hospital were routinely sent to physical therapy for exercises to regain their strength. The problem was that the elderly gentlemen sat around smoking cigars rather than doing exercises. The psychologist who was called in rapidly noted, as would any male, that the physical therapists were young attractive women. He also noticed that a pretty therapist would sweetly light a patient’s cigar and then try to cajole him into exercising. With another who was sitting in the sun and already smoking a lighted cigar, she would engage in banter designed to get him on his feet. As soon as a man complied with her suggestion that he exercise, the therapist abandoned him and would go to another patient who apparently, needed similar urging to do what he was supposed to do. The psychologist saw that as a consequence of sitting and smoking a cigar, an old man would instantly attract the attention of a pretty young woman who would now fuss over him, but as a consequence of taking his

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exercise, the same old man would just as instantly lose the attention of this young woman. His recommendation therefore, was simple: Instruct the physical therapists to disregard the elderly gentlemen completely while they are sitting and smoking. But let the slightest attempt on their part to get up and do some exercising be a signal for a nurse to fuss over them, exercise with them, joke with them, and in short, reward their “good” behavior. The results were spectacular. Within two days the attending physician had to advise the physical therapy department to slow down lest one of these patients succumb to a heart attack from overexertion! (Shaefer and Martin, p. 190) As these examples illustrate, health professionals often react to maladaptive behaviors, “crazy” talk, or physical complaints with rapt attention. Unfortunately, our interest reinforces the very pathologic behavior we seek to reduce. Alternatively, patient behaviors are often so aversive to staff members that they react with verbal reprimands much like the teacher who kept telling her students, “Sit down.” Thus, patients who talk incessantly are repeatedly told to be quiet, and when quiet, they are ignored. These patient behaviors are difficult to change, not only because they are maintained on a partial reinforcement schedule, but to change the patient’s behavior the behavior of all the ward personnel who come in contact with the patient must be consistently altered. If a patient’s “crazy” talk is ignored by nurses on the day and night shifts but attended to by a nurse on the evening shift, the crazy talk will persist. Specifying the target behavior and ensuring a consistent reaction to it by all the staff is critical to the success of any behavior-change program. Another factor to be aware of is the temporal course of extinction. When reinforcement is discontinued, the patient is likely to exhibit a temporary acceleration or intensification

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of the behavior, particularly if the behavior was maintained on a continuous reinforcement schedule. Thus, the institution of an extinction schedule to the child who cries at bedtime will typically result in longer and more intense crying followed by rapid decline in the crying behavior. Similarly, the whining girl increased the intensity of that behavior when first placed on an extinction schedule. Many novice, would-be behavior modifiers take this initial exacerbation as evidence that extinction doesn’t work and discontinue the manipulation prematurely. These principles of learning are frequently not understood by other members of the treatment team, and the nurse is in a good position to provide this expertise. Certainly the nurse who understands learning mechanisms possesses a useful tool to help her reduce a patient’s fear, increase a patient’s adaptive behavior, or decrease undesirable patient behaviors.

REFERENCES Bandura, A., Principles of Behavior Modification, New York: Holt, Rinehart, &Winston, 1969. Madsen, C. H., W. C. Becker, and D. R. Thomas, “Rules, Praise, and Ignoring : Elements of Elementary Classroom Control,” Journal of Applied Behavior Analysis, 1968, 1, pp. 139-150. Schaefer, H. H., and P. L. Martin, Behavioral Therapy, New York: McGraw-Hill, 1969. Shipley, R. H., “Extinction of Conditioned Fear in Rats as a Function of Several Parameters of CS Exposure,” Journal of Comparative and Physiological Psychology, 1974, 87, pp. 699-707. Shipley, R. H., J. H. Butt, J. E. Farbry, and B. Horowitz, “Effects of Preparation for Endoscopy: Psychological and Physiological Changes,” Clinical Research, 1976, 24, p. 301a. Skinner, B. F., The Behavior of Organisms: A n Experimental A p proach, New York: Appleton - Century, 1938. 94

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Applying learning theory to nursing practice.

s primary health care providers, nurses are regularly confronted with patient problems that could be handled most effectively through the understandin...
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