N U R S I N G FORUM
265
HE effectiveness of the community health nurse is de-
T
pendent upon her ability to observe, interpret, and influence the behavior of the families with whom she works. Without these skills, the nurse is little more than a transmitter of information and the effect of her interventions is shortlived. The nurse who lacks behavioral orientation is often left pondering such questions as why, after five home visits and the review of all relevant health department pamphlets, the young mother with whom she is working is still propping her infant's bottle. Having exhausted all her knowledge of methods of intervention and having conveyed all information relevant to the problem, the nurse often comes away questioning not only the mother's motivation but her intelligence as well. She finds herself blaming the client for not learning and begins to develop negative attitudes toward working with the family - attitudes that are difficult to conceal on the next home visit. By the seventh home visit, then, it is not surprising that the young mother refuses to admit the nurse into her home, and the door is closed to future visits and any help the nurse might have been able to offer. Formal recognition has been given to the need for nurses to develop skill in influencing family health behavior so that situations as the one described do not occur. This recognition has taken the form of adoption of the Standards of Nursing
". ..
it is not surprisinl that the young mother refuses to admit the nurse intc her home.. .'
266
VOLUME X V
NO. 3
1976
Practice by the American Nurses’ Association Board of Directors and the endorsement of these Standards by the 1974 ANA House of Delegates. Specifically, Standard VI in the section referring to community health nursing states : “Nursing actions provide opportunities for consumer learning and participation,” and “Nursing actions influence consumer’s physiological, psychological, and social behaviors that maximize health potential.” (Congress for Nursing Practice, 1974) Although these Standards are intended to act as guides to practice, there exists a wide gap between the type of practice they propose and what is being taught in schools of nursing and carried out by the individual practitioner of nursing. ANA Standards of Nursing Practice require that the nurse focus energy on involving patients and families in planning
/
NURSING FORUM
267
ways to solve health problems. In addition, they emphasize that the role of the nurse includes helping families develop new behaviors that will then enable them to achieve the highest degree of health possible. However, in actuality, few nurses in education or practice are able to truly put the ANA Standards into operation. They continue to rely on traditional approaches such as “telling” patients what “they need to know” about “their problems.” Not only are the patient and family often not included in planning, but the nurse may not even understand the behavioral factors that have promoted the development of the identified problem. Why should such a gap exist between the recommended Standards of Practice and what is being done in actual practice? Why do nurses continue to be locked into traditional methods of carrying out the nursing process? The answer may be that nursing educators and practitioners have failed, thus far, to develop a framework for practice which is essentially derived from an understanding of human behavior and the factors that-influence it. Though behavior and behavior change is a relatively new focus for nursing, theoreticians in the fields of education and social psychology have done extensive research in this important area. One such theory, social learning, which focuses on behavior and the social context in which it occurs, has been used effectively in work with families and individuals and provides important clues to the nurse in developing a theoretical foundation for mderstanding and influencing behavior. (Becker, 1970) Since the community health nurse has the opportunity to observe behavior within the social environThe nurse observes and analyzes all behavior which occur during each home visit
268
VOLUME XV
NO. 3
1976
ment of the home, social learning theory is relevant to her task of formulating a sound framework and a nursing process derived from this framework. The nursing process begins with the nurse’s observation of all behaviors occurring during each home visit and her notation of the responses made by individuals present during the visit. Later, the nurse carefully analyzes these behaviors and begins to formulate hypotheses regarding the way in which the behavior of each family member influences the behavior of others. Data collection and analysis are based on the important principle that any behavior is, at least in part, controlled by the social responses made to it by persons in the immediate environment. (Patterson, 1971) A person’s past experiences constitute another force which influences behavior. Within the context of social learning theory, both the personal and vicarious experiences a person has had throughout his lifetime lead to the development of expectations as to what will happen if he or she acts a certain way. These expectations serve as controlling forces, influencing how the person will choose to behave in situations similar
N U R S I N G FORUM
269
to those he has experienced. (Rotter, 1954) Behaviors which have resulted in positive consequences in the past are more likely to be performed again when similar situations arise. (Patterson, 1971) For example, a parent who has had the experience that hitting a child stops the child from misbehaving, even for a very short period of time, is likely to resort to this means of discipline again and again until a more successful way of dealing with the problem behavior is found. It follows, therefore, that one of the nurse’s important tasks is to collect data not only related to the behavior she observes in the family with which she’s working, but also related to the family’s past experiences. With data from the past she can begin to interpret her observations in the context of forces that have led to their development. Clues on how to help families learn new behaviors are found in information derived from such interpretation. Having reviewed all collected data related to both current and past behavior, and having analyzed these data from the perspective of possible forces which have led to the development of the behavior, the nurse is ready to state the specific problems which might be worked on with the family. These problems, described in behavioral terms, constitute the nursing diagnosis. The situation of the young mother who bottle-props her baby described earlier is a good example to use to describe how the process works in practice. The nurse begins implementing the process by reviewing the data she has collected regarding the identified problem. She might find, for example, that she has observed four feeding sessions in which the mother offered the baby the bottle while warmly cradling him. However, she has noted that although the mother begins by cradling the baby, she quickly withdraws the bottle after just
210
VOLUME X V
NO. 3
1976
a few minutes, not allowing the baby to satisfy either his hunger or sucking needs. Following each session, the nurse has observed that the baby cries loudly. When the crying becomes intense, the mother grabs the bottle and props it beside the baby. The baby’s sobbing stops, he resumes sucking, and falls asleep. After each episode, the mother expresses dissatisfaction with caring for the baby and anger about the time it takes to feed him. The nurse proceeds to analyze the data in an attempt to develop a better undcrstanding of the nursing problem that of the mother’s behavior toward the infant. In formulating a nursing diagnosis, the nurse concludes that the mother is unable to identify and appropriately respond to the behavioral cues exhibited by the infant. The nurse determines that the reason the mother persists with her approach to the infant is that she found bottle-propping an effective way of gctting the baby to stop crying. The baby’s response reinforced the mother to continue using her approach. Although the approach alleviated the baby’s crying, that the mother expressed dissatisfaction with feeding in general suggests to the nurse that perhaps the mother might be open to new approaches to the problem. The nurse identifies the mother’s dissatisfaction with her approach to the problem as a possible source of motivation to look for new ways of dealing with the baby’s crying. The next step is onc of formulating, together with the family, sonic short and long-term goals. The nurse shares her observations, encourages discussion by the family, and helps the members to begin to identify new approaches to the problems as they define them. Rarely will a family deny being disturbed by a problem, the existence of which is documented by behavioral observation. Rather, a common response on the
N U R S I N G FORUM
271
part of families is the expression of relief at finding someone who is willing to work with them in finding more effective solutions. Before trying out new approaches, the nurse encourages the family members to validate for themselves her observations. For example, the nurse might ask the mother who bottleprops to collect data about exactly what occurs immediately prior to, during, and following feeding episodes. (Patterson, 1971, p. 16) The period for collecting data should be manageable for the family, and the nurse should provide a calendar chart to make recording of observations easier. Families have expressed enthusiasm with this method of problem solving, commenting that not only did the approach facilitate more accurate identification of the problem, but helped clarify factors that had led to its existence in the first place. To follow through on the example of the young mother, it is likely that through her own recorded observations she would begin to see that it was not the cradling that provoked the baby’s crying but the removal of the bottle before the
Q
212
VOLUME XV
NO. 3
P
1976
baby’s hunger or sucking needs were met. At this point the mother might need direction by the nurse to analyze her behavior and re-evaluate its appropriateness in light of the infant’s behavioral responses. Though families initially require direction in studying behaviors that contribute to problems, their skill increases with each experience. Eventually families can become quite capable of using this type of approach in dealing with problems as they arise. They may develop quite sophisticated insight into behaviors that have led to the creation of problems, such as how each family member tends to respond in particular situations and how to anticipate and prevent problems from occurring. At this point, it is useful for the nurse to begin to plan and implement new approaches. The trial period for new behaviors should be short and the goals easily attainable. The goals should be based on suggestions made by the family to encourage the family’s continued commitment. For example, the nurse might suggest that for three consecutive days the mother try cradling her baby for at least 15 minutes each feeding session. She might instruct the mother to gauge the feeding time by using a watch or clock so as to insure accuracy in following through. Though other factors, such as the mother’s non-verbal communication during feeding and her general attitude toward the baby, might affect his response, several positive experiences most likely would occur during the trial period. As families begin to learn how to change their behavior and as they discover new workable approaches to problems, The baby’s crying is provoked by the removal of the bottle before his hunger or sucking needs are met.
NURSING FORUM
273
their confidence grows. Certainly these are outcomes that persist long after the last nursing visit is made. Should the mother described come to feel more capable as a mother through her experience with the feeding problem, she would probably transfer this learning to other situations. She might become more able to interpret her infant’s general behaviors, therefore respond more appropriately to his needs and develop more positive feelings about hersef as a mother. Two techniques I have found to be helpful in assisting families to learn new behaviors are modeling and role-playing. (Rotter, 1953, p. 340) In modeling, the nurse demonstrates, within the context of the home environment, a new behavior that the family has been considering as an approach to an identified problem. In using this technique, the nurse allows the family to actually see the behavior before trying it. To return to the bottle-propping example, the nurse might plan to visit at feeding time and actually demonstrate how to hold, burp, and comfort the infant. She would involve the mother in the demonstration session by encouraging her to discuss her thoughts about the new approach. Family members must never be regarded as passive recipients of information or their motivation will most certainly be affected. Rather, they should be encouraged to express their opinions and ideas. The technique of modeling is based on the theory that behavior is learned not only through direct experience but also vicariously through observing the behavior of others. The second technique, role-playing, involves re-creating a problem situation to allow family members to try new ap-
“This way baby swallows less air
and feels more comfortable afterwards.”
274
VOLUME XV
NO. 3
1976
proaches and become more comfortable with new behaviors. It is particularly useful when the problem involves interaction between two adults. The role-playing technique might, for example, bc uscd in working with a depressed woman whose husband is being treated for alcoholism. To help the woman deal with the husband’s behaviors, such as manipulation a n d accusation, the nurse would structure the setting so that a typical husband/wife situation would be acted out between nurse and wife. The wife might try playing the part of her husband to derive increased sensitivity to his feelings. She would also play-act herself, trying new ways of countering his manipulative pleas or accusations. Ultimately, the goal would be that the wife select the behaviors she felt most comfortable with and use these to promote changes in her husband’s behavior. Role playing by entire families is useful in helping all involved to become more sensitive to the feelings of others and less frightened of change. A valuable outcome of carrying out the nursing process, according to the guides described, and making use of the techniques presented is that both the nurse and the consumer
N U R S I N G FORUM
275
of the nurse’s services are provided with ways of measuring effectiveness in an objective manner. The records of behaviors observed provide on-going accounts of the changes which have occurred in response to nurse interventions. In addition, changes in the ability of families to problem solve independently are measured by noting the degree to which they demonstrate, in actual situations, their ability: (1) to take initiative in carrying out the process of observing, and ( 2 ) to interpret their own behavior and identify accurately problems and possible solutions. The more independent families become in carrying out the problem-solving process, the more lasting the influence of the nurse’s interventions. A family’s growth will continue long after the last home visit has been made. This framework provides the nurse with a basis for practice which enables her to truly fulfill the goal stated in the ANA Standard of Practice by equipping her with the necessary tools “to maximize the health potential of families.” REFERENCES
Becker, Wesley C., Parents Are Teachers: A Child Management Program, Champaign, Ill., Research Press, 1970, p. 6. Congress for Nursing Practice, “Standards of Nursing Practice,” American Nurse, 6: I3 (July), 1974. Milio, Nang, “A Framework for Prevention : Changing HealthDamaging to Health-Generating Life Patterns,” American Journal of Public Health, Vol. 66, No. 5 (May), 1976, pp. 435-439.
Patterson, Gerald R., Families: Application of Social Learning 10 Family Life, Champaign, Ill.: Research Press, 1971, p. 16. Rotter, Julian B., Social Learning and Clinical Psychology, New York: Prentice Hall, 1954, p. 342. Rottkamp, Barbara C., “A Behavior Modification Approach to Nursing Therapeutics in Body Positioning of Spinal Cord-Injured Patients,” Nursing Research, Vol. 25, No. 3 (May-June), 1976, pp. 181-185.
276
VOLUME XV
NO. 3
1976
265
HE effectiveness of the community health nurse is de-
T
pendent upon her ability to observe, interpret, and influence the behavior of the families with whom she works. Without these skills, the nurse is little more than a transmitter of information and the effect of her interventions is shortlived. The nurse who lacks behavioral orientation is often left pondering such questions as why, after five home visits and the review of all relevant health department pamphlets, the young mother with whom she is working is still propping her infant's bottle. Having exhausted all her knowledge of methods of intervention and having conveyed all information relevant to the problem, the nurse often comes away questioning not only the mother's motivation but her intelligence as well. She finds herself blaming the client for not learning and begins to develop negative attitudes toward working with the family - attitudes that are difficult to conceal on the next home visit. By the seventh home visit, then, it is not surprising that the young mother refuses to admit the nurse into her home, and the door is closed to future visits and any help the nurse might have been able to offer. Formal recognition has been given to the need for nurses to develop skill in influencing family health behavior so that situations as the one described do not occur. This recognition has taken the form of adoption of the Standards of Nursing
". ..
it is not surprisinl that the young mother refuses to admit the nurse intc her home.. .'
266
VOLUME X V
NO. 3
1976
Practice by the American Nurses’ Association Board of Directors and the endorsement of these Standards by the 1974 ANA House of Delegates. Specifically, Standard VI in the section referring to community health nursing states : “Nursing actions provide opportunities for consumer learning and participation,” and “Nursing actions influence consumer’s physiological, psychological, and social behaviors that maximize health potential.” (Congress for Nursing Practice, 1974) Although these Standards are intended to act as guides to practice, there exists a wide gap between the type of practice they propose and what is being taught in schools of nursing and carried out by the individual practitioner of nursing. ANA Standards of Nursing Practice require that the nurse focus energy on involving patients and families in planning
/
NURSING FORUM
267
ways to solve health problems. In addition, they emphasize that the role of the nurse includes helping families develop new behaviors that will then enable them to achieve the highest degree of health possible. However, in actuality, few nurses in education or practice are able to truly put the ANA Standards into operation. They continue to rely on traditional approaches such as “telling” patients what “they need to know” about “their problems.” Not only are the patient and family often not included in planning, but the nurse may not even understand the behavioral factors that have promoted the development of the identified problem. Why should such a gap exist between the recommended Standards of Practice and what is being done in actual practice? Why do nurses continue to be locked into traditional methods of carrying out the nursing process? The answer may be that nursing educators and practitioners have failed, thus far, to develop a framework for practice which is essentially derived from an understanding of human behavior and the factors that-influence it. Though behavior and behavior change is a relatively new focus for nursing, theoreticians in the fields of education and social psychology have done extensive research in this important area. One such theory, social learning, which focuses on behavior and the social context in which it occurs, has been used effectively in work with families and individuals and provides important clues to the nurse in developing a theoretical foundation for mderstanding and influencing behavior. (Becker, 1970) Since the community health nurse has the opportunity to observe behavior within the social environThe nurse observes and analyzes all behavior which occur during each home visit
268
VOLUME XV
NO. 3
1976
ment of the home, social learning theory is relevant to her task of formulating a sound framework and a nursing process derived from this framework. The nursing process begins with the nurse’s observation of all behaviors occurring during each home visit and her notation of the responses made by individuals present during the visit. Later, the nurse carefully analyzes these behaviors and begins to formulate hypotheses regarding the way in which the behavior of each family member influences the behavior of others. Data collection and analysis are based on the important principle that any behavior is, at least in part, controlled by the social responses made to it by persons in the immediate environment. (Patterson, 1971) A person’s past experiences constitute another force which influences behavior. Within the context of social learning theory, both the personal and vicarious experiences a person has had throughout his lifetime lead to the development of expectations as to what will happen if he or she acts a certain way. These expectations serve as controlling forces, influencing how the person will choose to behave in situations similar
N U R S I N G FORUM
269
to those he has experienced. (Rotter, 1954) Behaviors which have resulted in positive consequences in the past are more likely to be performed again when similar situations arise. (Patterson, 1971) For example, a parent who has had the experience that hitting a child stops the child from misbehaving, even for a very short period of time, is likely to resort to this means of discipline again and again until a more successful way of dealing with the problem behavior is found. It follows, therefore, that one of the nurse’s important tasks is to collect data not only related to the behavior she observes in the family with which she’s working, but also related to the family’s past experiences. With data from the past she can begin to interpret her observations in the context of forces that have led to their development. Clues on how to help families learn new behaviors are found in information derived from such interpretation. Having reviewed all collected data related to both current and past behavior, and having analyzed these data from the perspective of possible forces which have led to the development of the behavior, the nurse is ready to state the specific problems which might be worked on with the family. These problems, described in behavioral terms, constitute the nursing diagnosis. The situation of the young mother who bottle-props her baby described earlier is a good example to use to describe how the process works in practice. The nurse begins implementing the process by reviewing the data she has collected regarding the identified problem. She might find, for example, that she has observed four feeding sessions in which the mother offered the baby the bottle while warmly cradling him. However, she has noted that although the mother begins by cradling the baby, she quickly withdraws the bottle after just
210
VOLUME X V
NO. 3
1976
a few minutes, not allowing the baby to satisfy either his hunger or sucking needs. Following each session, the nurse has observed that the baby cries loudly. When the crying becomes intense, the mother grabs the bottle and props it beside the baby. The baby’s sobbing stops, he resumes sucking, and falls asleep. After each episode, the mother expresses dissatisfaction with caring for the baby and anger about the time it takes to feed him. The nurse proceeds to analyze the data in an attempt to develop a better undcrstanding of the nursing problem that of the mother’s behavior toward the infant. In formulating a nursing diagnosis, the nurse concludes that the mother is unable to identify and appropriately respond to the behavioral cues exhibited by the infant. The nurse determines that the reason the mother persists with her approach to the infant is that she found bottle-propping an effective way of gctting the baby to stop crying. The baby’s response reinforced the mother to continue using her approach. Although the approach alleviated the baby’s crying, that the mother expressed dissatisfaction with feeding in general suggests to the nurse that perhaps the mother might be open to new approaches to the problem. The nurse identifies the mother’s dissatisfaction with her approach to the problem as a possible source of motivation to look for new ways of dealing with the baby’s crying. The next step is onc of formulating, together with the family, sonic short and long-term goals. The nurse shares her observations, encourages discussion by the family, and helps the members to begin to identify new approaches to the problems as they define them. Rarely will a family deny being disturbed by a problem, the existence of which is documented by behavioral observation. Rather, a common response on the
N U R S I N G FORUM
271
part of families is the expression of relief at finding someone who is willing to work with them in finding more effective solutions. Before trying out new approaches, the nurse encourages the family members to validate for themselves her observations. For example, the nurse might ask the mother who bottleprops to collect data about exactly what occurs immediately prior to, during, and following feeding episodes. (Patterson, 1971, p. 16) The period for collecting data should be manageable for the family, and the nurse should provide a calendar chart to make recording of observations easier. Families have expressed enthusiasm with this method of problem solving, commenting that not only did the approach facilitate more accurate identification of the problem, but helped clarify factors that had led to its existence in the first place. To follow through on the example of the young mother, it is likely that through her own recorded observations she would begin to see that it was not the cradling that provoked the baby’s crying but the removal of the bottle before the
Q
212
VOLUME XV
NO. 3
P
1976
baby’s hunger or sucking needs were met. At this point the mother might need direction by the nurse to analyze her behavior and re-evaluate its appropriateness in light of the infant’s behavioral responses. Though families initially require direction in studying behaviors that contribute to problems, their skill increases with each experience. Eventually families can become quite capable of using this type of approach in dealing with problems as they arise. They may develop quite sophisticated insight into behaviors that have led to the creation of problems, such as how each family member tends to respond in particular situations and how to anticipate and prevent problems from occurring. At this point, it is useful for the nurse to begin to plan and implement new approaches. The trial period for new behaviors should be short and the goals easily attainable. The goals should be based on suggestions made by the family to encourage the family’s continued commitment. For example, the nurse might suggest that for three consecutive days the mother try cradling her baby for at least 15 minutes each feeding session. She might instruct the mother to gauge the feeding time by using a watch or clock so as to insure accuracy in following through. Though other factors, such as the mother’s non-verbal communication during feeding and her general attitude toward the baby, might affect his response, several positive experiences most likely would occur during the trial period. As families begin to learn how to change their behavior and as they discover new workable approaches to problems, The baby’s crying is provoked by the removal of the bottle before his hunger or sucking needs are met.
NURSING FORUM
273
their confidence grows. Certainly these are outcomes that persist long after the last nursing visit is made. Should the mother described come to feel more capable as a mother through her experience with the feeding problem, she would probably transfer this learning to other situations. She might become more able to interpret her infant’s general behaviors, therefore respond more appropriately to his needs and develop more positive feelings about hersef as a mother. Two techniques I have found to be helpful in assisting families to learn new behaviors are modeling and role-playing. (Rotter, 1953, p. 340) In modeling, the nurse demonstrates, within the context of the home environment, a new behavior that the family has been considering as an approach to an identified problem. In using this technique, the nurse allows the family to actually see the behavior before trying it. To return to the bottle-propping example, the nurse might plan to visit at feeding time and actually demonstrate how to hold, burp, and comfort the infant. She would involve the mother in the demonstration session by encouraging her to discuss her thoughts about the new approach. Family members must never be regarded as passive recipients of information or their motivation will most certainly be affected. Rather, they should be encouraged to express their opinions and ideas. The technique of modeling is based on the theory that behavior is learned not only through direct experience but also vicariously through observing the behavior of others. The second technique, role-playing, involves re-creating a problem situation to allow family members to try new ap-
“This way baby swallows less air
and feels more comfortable afterwards.”
274
VOLUME XV
NO. 3
1976
proaches and become more comfortable with new behaviors. It is particularly useful when the problem involves interaction between two adults. The role-playing technique might, for example, bc uscd in working with a depressed woman whose husband is being treated for alcoholism. To help the woman deal with the husband’s behaviors, such as manipulation a n d accusation, the nurse would structure the setting so that a typical husband/wife situation would be acted out between nurse and wife. The wife might try playing the part of her husband to derive increased sensitivity to his feelings. She would also play-act herself, trying new ways of countering his manipulative pleas or accusations. Ultimately, the goal would be that the wife select the behaviors she felt most comfortable with and use these to promote changes in her husband’s behavior. Role playing by entire families is useful in helping all involved to become more sensitive to the feelings of others and less frightened of change. A valuable outcome of carrying out the nursing process, according to the guides described, and making use of the techniques presented is that both the nurse and the consumer
N U R S I N G FORUM
275
of the nurse’s services are provided with ways of measuring effectiveness in an objective manner. The records of behaviors observed provide on-going accounts of the changes which have occurred in response to nurse interventions. In addition, changes in the ability of families to problem solve independently are measured by noting the degree to which they demonstrate, in actual situations, their ability: (1) to take initiative in carrying out the process of observing, and ( 2 ) to interpret their own behavior and identify accurately problems and possible solutions. The more independent families become in carrying out the problem-solving process, the more lasting the influence of the nurse’s interventions. A family’s growth will continue long after the last home visit has been made. This framework provides the nurse with a basis for practice which enables her to truly fulfill the goal stated in the ANA Standard of Practice by equipping her with the necessary tools “to maximize the health potential of families.” REFERENCES
Becker, Wesley C., Parents Are Teachers: A Child Management Program, Champaign, Ill., Research Press, 1970, p. 6. Congress for Nursing Practice, “Standards of Nursing Practice,” American Nurse, 6: I3 (July), 1974. Milio, Nang, “A Framework for Prevention : Changing HealthDamaging to Health-Generating Life Patterns,” American Journal of Public Health, Vol. 66, No. 5 (May), 1976, pp. 435-439.
Patterson, Gerald R., Families: Application of Social Learning 10 Family Life, Champaign, Ill.: Research Press, 1971, p. 16. Rotter, Julian B., Social Learning and Clinical Psychology, New York: Prentice Hall, 1954, p. 342. Rottkamp, Barbara C., “A Behavior Modification Approach to Nursing Therapeutics in Body Positioning of Spinal Cord-Injured Patients,” Nursing Research, Vol. 25, No. 3 (May-June), 1976, pp. 181-185.
276
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NO. 3
1976
