Journal of Advanced Nursing, 1976,1,11-23
Nurses' attitudes towards a patient wiio iias a psychiatric iiistory Madeleine M. Brady R.N. M.S. Ed.D. candidate Instructor, Psychiatric Nursing, St. Vincent's Hospital School of Nursing, New York, N.Y., USA Acceptedfor publication 11 fuly
BRADY MADELHNE M . (1976) Journal of Advanced Nursiug i , 11-23
Nurses' attitudes towards a patient who has a psychiatric history This study was carried out in a large Metropolitan General Hospital in New York, USA. The aim of the study was to deterniine the differences in nurses' attitudes towards a general hospital patient who had, or had not, a previous psychiatric illness. One hundred and twenty-eight graduate (trained) nurses were asked to read the patient's case notes, to view videotapes and to answer questionnaires as part of the research method. Analysis of the data obtained demonstrates the statistically significant finding below the 0-02 level that the nurses' attitudes were generally more negative towards the former psychiatric patient. In several instances, the disturbed behaviour of the patient was more significant than the patient's previous hospitalization: the findings also suggest that the graduate nurses equate mental illness with organic causes. The study poses many questions for nurse educators, but particularly for those responsible for psychiatric nursing education.
INTRODUCTION The nurse's attitude towards a patient is generally considered to be one of the basic factors contributing to the administration of total therapeutic nursing care. These attitudes to a great extent are the result of environments and experiences to which the nurse has been exposed. Thus, the patient may be viewed in diverse ways for a variety of reasons. Often one of these reasons is related to the nurse's perceptions of the patient himself. These perceptions may be realistically based on an accurate appraisal of the patient as an individual. However, sometimes the patient is considered in a stereotyped manner, and judgements made on generalizations of a specific social group. Through the ages, societies have expressed differing attitudes towards the mentally ill. Generally, these have been positive expressions of feelings in approaches and treatment. However, within the last three centuries, both in America and Europe, the mentally ill have not only been harassed, segregated and persecuted, but even executed as witches (Deutsch 1949). These negative feelings II
12
M.M. Brady
have not entirely disappeared. Too often from childhood onwards, fear and avoidance are the reactions of many people to a person with an emotional illness. Statistics are rising in the number of people seeking psychiatric care. Current treatment is directed towards providing only the most chjonically ill patients with continued hospitalization. The majority of the acutely ill patients receive shortterm therapy, and return to the community from which they came as quickly as possible. Most of the time, no further follow-up care is needed. This results in increasing numbers of people each day having a history of some type of psychiatric hospitalization. They are soon absorbed into the general population. When medical problems arise, they, like the rest of the populace, seek appropriate facilities. This time, a general hospital provides the care if hospitalization is required. In the general hospital, nurses relate closely to all patients as care is provided. Their attitudes are especially important because of the intimate daily contact and the resultant potentially significant nurse-patient interactions. The patient whose history includes a past psychiatric hospitalization frequently finds that the staff become aware of this past history all too quickly. Exposure to hospital environments reveal that, despite lack of validation of published studies, the fact remains that too often staff communications centre on this point. Verbally and nonverbally, attitudes are imparted as a result of this history. Often these messages differ in type and quality from those transmitted about patients who have no such history. Whether negative or positive in value, they certainly influence the nursepatient relationship and thus the subsequent care. But more importantly, with more attempts at promoting positive attitudes and behaviour (Francis & Munjas 1968) towards all patients, it is to be hoped that negative attitudes and behaviour are not being perpetuated by the current nursing practitioners. DEFINITIONS 1 Attitude: 'A complex tendency of a person to respond consistently in a favourable or an unfavourable way to social objects in his environment' (Proshansky & Seidenberg 1965). a Elicited verbal attitude: 'A statement of the respondent's opinion' (Green 1954)b Action attitude: 'Verbal or non-verbal behaviour directed towards an object in the referent class' (Green 1954). 2 Nurses: Nurses having direct patient contact who are graduates of Hospital Diploma, Associate Degree or Baccalaureate programmes in nursing. 3 Former psychiatric patient: Patient currently being treated in a general hospital who has had a previous eight month hospitalization in a psychiatric hospital. THEORETICAL FRAMEWORK The problem under study is grounded on the theory of attribution as it relates to attitudes and behaviour. It may be defined as the process 'whereby people attribute
Nurses' attitudes to patient with psychiatric history characteristics, intentions, feelings and traits to the objects in their social world' (Kanouse & Hanson 1971). This theory is based on several assumptions, one of which is that 'The particular cause that he (subject) attributes for a given event has important consequences for his subsequent feelings and behaviour. T'he "meaning" of the event and his subsequent reactions to it are determined to an important degree by its assigned cause' (Jones et al. 1971). This theory then is being used to support the basic assumption of the study. That is, that nurses will demonstrate these specific 'consequences' when they make responses based on the information that a particular patient has had a psychiatric illness. The associations made may be positive or negative causing accepting or rejecting attitudes. PURPOSE In the past, studies have been conducted on attitudes of psychiatrists towards patients (Lawinger & Dobie 1968), volunteer workers' opinions about mental illness (Vernallis & St. Pierre 1964), nursing students' attitudes toward psychiatric treatment and hospitals (Toomey et al. 1961) and even attitudes of relatives of former patients toward mental illness (Freeman 1961). Attitude studies among nurses (MacGregor 1967, Blaylock 1970, Rickelman 1971) have proved helpful, but there seems to be a lack of specific studies about former psychiatric patients being cared for in general hospitals. Whether we like to admit it or not, psychiatric patients do get labelled (Petroni & Griffin 1969), arid stereotyping of patients occurs (Jourard 1959). This study then is designed to identify some of the attitudes found among current graduate nurses towards a patient who has been previously hospitalized for mental illness. To accomplish this, it is necessary to determine the differences in the nurses' attitudes toward a patient who has, or has not, had this psychiatric history. The present research project proposes to do this. HYPOTHESES 1 There will be differences in nurses' elicited verbal attitudes towards a patient who has a psychiatric history of hospitalization. 2 There will be differences in nurses' action attitudes towards a patient who has a psychiatric history of hospitalization. LIMITATIONS 1 This study deals only with the subject's own identification of attitudes and behaviour. The findings are conscious personal responses. No attempt is made to seek motivation. 2 The data identifies subjects' elicited verbal and action attitudes based on a specific constructed contrived situation. No attempts are made to generalize to a
13
14
M. M. Brady
larger population or even to forecast what might have been the subjects' actual attitudes or behaviours in the same or other real situations.
SAMPLE This study was conducted in a large Metropolitan city in a iooo bed general hospital employing over 300 registered nurses. One hundred and twenty-eight nurses from all departments (psychiatry excluded) volunteered to participate in the project. They were assigned by random sampling to the experimental groups. No personality testing was performed since it was assumed that participants obtained from such a large centrally located teaching medical facility would provide a representative population.
METHOD The project was designed to study nurses' attitudes under a controlled situation. A brief patient history was composed after researching the literature, studying patients' charts, and interviewing physicians and nurses. To determine whether the patient's psychiatric history contributed to the nurses' attitudes, half of the histories made reference to an eight month psychiatric hospitalization four years previously; the other half made no such reference. In addition, since organic causes and/or symptomatology is often considered in a different manner when purely psychological components are involved, the histories were further altered. Symptoms described and treatments ordered by the doctor were lnore physically oriented in one half of the histories. The histories of the other half appeared more psychological in origin and physicians' orders were more psychotherapeutically oriented. An original five minute videotape presentation of a typical nurse-patient interaction was produced. Actors simulated a situation in which interpersonal reactions were greatly taxed. Since patient behaviour often influences the nurse's responses, two tapes were made that depicted differing levels of disturbed patient behaviour. One tape demonstrated more overt patient upset activity and negativistic responses than the other. Each subject viewed one of the tapes after reading the history. Thus, an experimental design was set up that provided eight groups of subjects, each reading some variation of a basic patient history and viewing one videotape presentation (Table i). Following this presentation, a questionnaire was given to each subject. This questionnaire was a result of a review of the literature, open-ended questions administered to nursing students, observation of actual patient situations and discussions with graduate nurses. A preliminary form was constructed and its usability tested. After a series of pilot studies, during which time the form was refined, a final draft of the questionnaire, with 13 questions containing 98 items, was produced.
Nurses' attitudes to patient with psychiatric history TABLE I Jlist oj eight experimental ^ iroups with distinguish11/1^ independent variables
Group I II III IV V VI VII VIII
Behaviour
Less disturbed Less disturbed Less disturbed Less disturbed More disturbed More disturbed More disturbed More disturbed
Illness
Psychiatric history
Organic Organic Psychological Psychological Organic Organic Psychological Psychological
With Without With Without With Without With Without
DATA COLLECTION Small groups of nurses viewed the tapes on a portable monitor brought to the various hospital conference rooms. This necessitated numerous testing times. Subjects were told that the project was to study nurse-patient relationships. They were urged to maintain secrecy about the study to promote the reliability of the findings. After reading the history, which had been previously assigned to each subject by random selection, and viewing the tape, they received a questionnaire. They were instructed to read the questions carefully and to answer them with their first response. At no time was any reference made to the actual point of the study. ANALYSIS OF D A T A Raw data from the questionnaires was transferred to IBM cards which were separated into the eight experimental groups. Each of the 98 dependent variables from the test was treated separately. A three-way analysis of variance was performed on each of them. This data has been analysed and reported at the 0*02 level of statistical significance. In testing the two hypotheses, the differences of means of the groups reading the psychiatric history were then compared with those not reading the history. These findings were the significant statistics. However, in computing and analysing the data, findings at the significant level resulted when the other group mean differences were treated. This paper reports a summary of the major findings. P R E S E N T A T I O N OF THE D A T A First hypothesis 'There will be differences in nurses' elicited verbal attitudes towards a patient who has a psychiatric history of hospitalization' is supported at the significant level by two items. Several additional items are statistically significant when organicity and behaviour are considered. The subjects were asked to indicate the strength of their feelings about twelve
M. M. Brady
i6
statements the nurse niight make about the patient. A seven-point scale was checked. Terms ranged from 'Extremely strong' (7 points), through a midpoint 'Moderate' (4 points) to 'Not at all' (i point). Table 2 contains the list of statements with the group means for each.
TABLE 2
Group meaiis of independent variables for nurses' 'thoughts' about the patient
No Nurses' thoughts
I couldn't handle patient effectively I wouldn't let patient make a fool of me My behaviour might 'set patient off' This patient may become assaultive Patient needs more time than I can spend She really only needs a good 'talking to' I wish she'd act like this to the doctor This patient needs help only I can give This patient shouldn't be in the hospital Others could work better with this patient I wish this patient would 'snap out of it' I would never like to work with a patient like this
Psychiatric history
No history
No Organic
organic
Disturbed disturbed behaviour behaviour
(X)
(X)
(X)
(X)
(X)
(X)
3-406
2-938
3-406
2-938
3-344
3-000
1-938
1-844
1-906
1-875
1-672
2-109
3-063
3-107
3-063
3-107
3-219
2-951
3-129
2-502
2-849
2-782
3-145
2-486
4-332
3-736
3-928
4-141
4-158
3-910
1-844
2-020
1-864
2-000
1-785
2-078
3-590*
2-722*
3-171
3-141
3-300
3-011
1-547
1-328
1-359
1-484
1-516
1-391
2-949
2-469
2-672
2-746
2-828
2-590
2-625
2-156
2-328
2-453
2-328
2-453
2-136
2-297
2-156
2-277
2-297
2-136
2-203
2-094
2-036
2-234
2-234
2-063
* Less than 0-02 level of significance
One statement: 'I wish she'd act like this to the doctor,' showed a significant difference when the psychiatric history was considered. The subjects who perceived the patient with a previous psychiatric history felt slightly stronger about the statement than the subjects who viewed the patient without the history. Note the low rating on the scale, that is, from 'Slightly' to 'Somewhat strong'. Another question presented a series of fourteen descriptive words, which subjects checked on a similar seven-point scale. This measured the strength of their feelings about the patient. Items with their means are presented in Table 3. The feeling 'frustrated' showed a significant difference between the groups when the psychiatric history was considered. The groups viewing the patient with
Nurses' attitudes to patient with psychiatric history TABLE 3 Group means of independent variablesfor nursed feelings' about the patient
Nurses'feelings
No Psychiatric history history (X)
Ambivalent Angry Accepting Annoyed Concerned Distrustful Discouraged
Challenged Frustrated Impatient Rejecting Patient Sympathetic Trusting
3-104 2-359 3-198 2-780 5-324 2-553 3-146 5-381 4-094* 3-283 1-780
3-737 4-328 2-587
Organic
(X) 2-777
(X) 3-058
2-203 3-762 2-619 5-050 2-361
2-406
2-453
4-967 3-234'* 2-847 1-844 3-969 4-135 2-734
No organic
No Disturbed disturbed behaviour behaviour
(X)
(X)
2-823 2-156
3-214 2-422
3-344
3-631 2-656
3-329 2-743
5-274 2-486 2-586 5-203 3-510 3-174 I-671
5-441 2-254 3-200*
4-933
5-404
4-944
3-906 3-206
3-422 2-924 1-890
3-846
4-385
3-766 4-078
2-750
2-572
2-734
3-617 2-916 5-100 2-428 3-012 5-145 3-818 2-956 1-953 3-940
2-483
1-734 4-641
(X) 2-667 2-141
2-660 2,399*
3-859 3-823 2-587
' Less than 0-02 level of significance
the previous psychiatric history felt more 'frustrated' than the groups viewing the patient without the history. The level of the patient's behaviour contributed significant findings. Subjects who viewed the more disturbed patient were more 'discouraged' than the subjects who viewed the less disturbed patient. Another question was designed to discover how discerning the subjects were of the 'patient's appraisal of her own physical illness'. Again the subjects checked a seven-point scale. Choices ranged from a high 'Extremely exaggerated' (7 points), through a midpoint 'accurate reflection' (4 points), to a low 'extremely understated' (i point). When the previous psychiatric history and level of disturbed behaviour interacted, there was a significant finding. The means of the responses tended to cluster around 'somewhat exaggerated' (5) to 'rather exaggerated (6) as may be seen in Table 4.
TABLE 4 Mean table of two-way variables for nurses' attitudes toward patient's appraisal of her own physical illness Disturbed/no organic Disturbed/organic Less disturbed/no organic Less disturbed/organic Psycliiatric history/no organic Psychiatric liistory/organic
5-250 5-625 5-281 5-813 5-313 5-719
' Less than 0-02 level of significance
No psychiatric history/no organic No psychiatric history/organic Psychiatric history/disturbed Psychiatric history/less disturbed No psychiatric history/disturbed No psychiatric history/less disturbed
5-219 5-719 5-188* 5-844* 5-688* 5-250*
M. M. Brady
i8
Subjects viewed the patient with more disturbed behaviour and no previous psychiatric history as 'exaggerating her appraisal' more than the patient with a psychiatric history. However, the patient with the less disturbed behaviour who had a previous psychiatric history was considered to 'exaggerate more' than the patient without the history (Figure i). Mean scale 60 5-8 5-6 5-4 5-2 50
Without psychiatric history
With psychiatric history
With psychiatric history
Without psychiatric history
FiGtJRE I A visualization of the relationship between the means of groups related to psychiatric history and level ofbehavioiirfor patient's exaggeration of her own physical illness
A related question 'How accurate do you consider the patient's appraisal of her psychological problems?' yielded no significant data. As in the previous question, possible responses ranged from 'extremely exaggerated' (7), downwards to 'extremely understated' (i). This time the means of the groups clustered around the lower end of the scale. Responses ranged in the 2 7-3-3 range on the scale (2='rather understated'; 3 ='somewhat understated'; 4='accurate reflection'). This question and its relationship to the previous one is discussed later. Still another question listed 21 phrases or words, and their opposites, that the nurse might use to characterize the patient. Subjects checked on a nine-point scale the point closest to the best description of the patient. These phrases are listed in Table 5. There are no significant findings that relate to the hypothesis. However, there are three responses at the significant level which relate to the disturbed behaviour. TABLE 5
List of words and their opposites for use by subjects to describe the patient
Difficult—easy to work with Anxious—not anxious Complaining—uncomplaining Manipulative—not manipulative Offensive—not offensive Unselfish—selfish Domineering—passive Demanding—undeman ding Fearful—not fearful* Witty—dull Happy—unhappy
Appreciative—unappreciative of nursing care Accepting—denying of illness* Loud^quiet Cooperative—uncooperative Difficult—easy to talk with Disrespectful—respectful to staff Well-adjusted—not well-adjusted Polite—impolite Comfortable—uncomfortable * Quarrelsome—amiable
' Less than 0-02 level of significance
Nurses' attitudes to patient with psychiatric history The more disturbed patient was considered to be more 'fearful' (x= 8-727), 'uncomfortable' (3c=2-o63) and 'denying of her illness' (:v=2-i88). It is noteworthy that these means were some of the highest in the study. In characterizing the patient's behaviour in general, there were no significant differences between groups. The subjects checked one descriptive term from a list of seven. Possible descriptions ranged from 'extremely inappropriate' (7), through 'moderately inappropriate' (4), to 'appropriate' (i). Means of the groups peaked at the 4-5 range on the scale; that is 'moderately' to 'rather inappropriate' respectively. Thus, the subjects viewed the patient's behaviour as neither 'extreme' nor 'appropriate'.
Second hypothesis 'There will be differences in nurses' elicited action attitudes towards a patient who has a psychiatric history of hospitalization' is proven tenable by three items. In addition, when organicity and behaviour are considered, several additional items are statistically significant. From a list of thirteen suggestions and their opposites, that the subjects would give to other nurses to ensure the best nursing care for the patient, two items were significant. Items and group ineans are found in Table 6. The high group means indicated patients' needs would be greatly 'anticipated', but the needs of the patient without the history would be 'anticipated' somewhat more than those of the patient with the history. In the item relating to 'probing' reasons for patient's behaviour, the patient without the psychiatric history would be 'probed' more than the patient with the history. There were two responses statistically significant when behaviour was considered. All buzzers were to be answered promptly; but the more disturbed patient's 'buzzers were to be answered' a little more promptly than the less disturbed patient's. The less disturbed patient was to be 'corrected' a little more than the disturbed patient 'about her psychological problems'. A further question contained a list of eight suggestions for additional nursing care directives to be included in the subject's communications to other staff members. On a nine-point scale, ranging from 'very strongly' to 'doesn't apply', the subjects checked the strength of their feelings. Group means were high on the scale for these responses (Table 7). The subjects felt strongly that the staff should repeat 'patient's statements about family and other persons in her life'. They felt even more strongly that the patient with the psychiatric history was to have this material repeated more than the patient without the history. The final series of questions sought to determine the necessity of knowing the various medical and psychological symptoms, history and diagnoses for the planning of nursing care. There were no significant findings related to the hypothesis. However, at the significant level, the subjects viewing the patient with obvious organicity considered 'medical', and 'psychiatric diagnoses' and a 'neurological
19
20
M.M.
Brady
TABLE 6 Group means of independent variablesfor nurses' directions for patient care to be given by others
No Directions for care Encourage—discourage patient talk about symptoms Anticipate needs—only approach patient on call Probe—don't find patient reason for behaviour Limit contact—watch patient closely Listen—don't listen to patient's complaints Give attention—stay away from patient Help patient see staff knows best—^permit patient to make all decisions Encourage patient help self get better—irrelevant Let patient wait—answer all buzzers promptly Correct—don't correct patient's view of psychological problems Accept without question— put limits on behaviour On doctor's orders get patient out of bed—^permit patient to remain in bed Discuss with patient bath time—nurse plan time
No organic
Disturbed behaviour
disturbed behaviour
(X)
(X)
(X)
7-609
7-781
8-016
7-357
8-313*
7-828
8-016
8-078
7-766
6-611*
7-609*
7-016
7-205
7-016
7-205
2-375
2-379
2-313
2-442
2-051
2-703
7-797
8-078
8-125
7-750
8-219
7-656
6-750
7-374
7-297
6-827
7-328
6-796
6-172
6-578
6-313
6-838
6-203
6-547
6-453
6-594
6-844
6-203
6-188
6-859
2-817
2-969
2-836
2-949
2-336*
3-449*
4-571
5-172
4-898
4-844
4-305*
5-438*
3-766
4-094
3-953
3-906
3-859
4-000
5-188
5-344
5-469
5-063
5-141
5-391
5-797
6-219
6-281 .
5-734
5-984
6-031
Psychiatric history
No history
Organic
(X)
(X)
(X)
7-516
7-875
7-531*
' Less than 0-02 level of significance
consultation' as more important than did the subjects viewing the nonorganic patient. DISCUSSION From a list of 98 items that were equally weighted with positive and negative concepts, it is noteworthy that at the significant level the items related to the presence of a psychiatric history tended to be more negative in quality. Subjects were more 'frustrated', 'discouraged', 'would anticipate patient's needs less' when the patient had previously been hospitalized for a mental illness. The response 'repeat patient's statements about family, etc' to other staff may be considered
Nurses' attitudes to patient with psychiatric history
21
TABLE 7 Croup means of iiidepetideiit variables for nursed communications to other staff
Communication Describe patient's feelings about nurse staff Quote patient's exact physical complaints Warn nursing staff of patient's behaviour Differentiate real and imagined sypmtoms Describe patient's emotional complaints Repeat patient's statements re family etc. Describe patient's physical resistance to care Pass information about patient-mother relationship
Psychiatric No history history
Organic
No organic
No Disturbed disturbed behaviour behaviour
(X)
(X)
(X)
(X)
(X)
(X)
7-688
7-344
7-375
7-656
7-766
7-266
7-750
7-000
7-422
7-328
7-516
7-234
7-323
7-231
7-194
7-360
7-594
6-960
6-702
6-884
6-765
6-781
6-640
6-906
8-328
8-125
8-375
8-078
8-266
8-188
8-313*
7-456*
7-906
7-862
7-984
7-784
7-594
6-938
7-172
7-359
7-469
7-063
8-313
7-688
7-891
8-000
8-109
8-000
' Less than 0-02 level of significance
positive. But even here, one would have to ascertain further whether morbid curiosity or zeal for the psychotherapeutic approach prompted this response. 'I wish she'd act like this to the doctor' also raises a question. The researcher meant the statement to be positive, so that the doctor could properly evaluate the patient's condition. However, there remains a question as to interpretation. Did some respondents view this as a hostile response to a very difficult patient? As an angry attack, might not the nurse wish the physician to share her problems? This statement is open to further study. Another rather negative attitude is found when the nurse would 'probe patient a little less for reasons for her behaviour' when the patient had the psychiatric history. Here, the opposite choice was 'Don't try to fmd reasons'. It seems unfortunate in this day of dynamic psychiatry that nurses would deliberately plan not to seek reasons for patient behaviour. The item which showed interaction between psychiatric history and level of behaviour is informative in itself, but may also be helpful in understanding some of the other data. Note that the more disturbed patient with no psychiatric history was considered to 'exaggerate her physical illness' more and that the less disttirbed patient with a history was considered to 'exaggerate' more. In this item, it seems as if the disturbed behaviour stimulated more negative responses, despite the presence of a psychiatric history, while when the behaviour was less disturbed, the psychiatric history seems to take precedence. Other responses that related to disturbed behaviour seem to support this statement.
22
M. M. Brady
When there was disturbed behaviour, the subjects would 'answer (patients') buzzers' more promptly and would not correct the patient's views 'about her psychological problems'. They also judged this patient as being more 'fearful', 'uncomfortable' and 'denying of her illness'—all rather valid and sensitive perceptions, but apparently based on the overt behaviour they had viewed. It is also revealing that subjects judged the disturbed patient to 'exaggerate her physical illness', but greatly 'understate' her psychological problems. These ratings seem to be the result of the subjects' feelings. The physical manifestations are overt and observable. Their expressions are often disruptive to nursing care and so may be viewed more negatively. Psychological problems involve more hidden feelings and emotions and so more mystery surrounds them. The subjects then judge the patient as having little insight. Finally, there seems to be a relationship between organicity and psychiatric illness in the minds of the subjects. It is logical to expect a medical diagnosis and neurological consultation to be important for the organically ill patient. But it is a surprise to fmd the psychiatric diagnosis of equal importance for the organic patient. These subjects had been exposed to the concepts of modern psychiatry at some place in their nursing education. Apparently they still hold the belief that mental illness is equated with physical causes. This study raises many questions for nurse educators, but for psychiatric nurse educators in particular. To improve nurse-patient relationships and subsequently, nursing care, further research is urgently needed. The literature demonstrates a lack of information about former psychiatric patients who are being treated in general hospitals for medical reasons. Their numbers increase every day. Nursing service and education cannot lose sight of these patients if the profession is to meet its obligations in serving the sick.
References BLAYLOCKJ. (1970) Characteristics of Nurses and Medical-Surgical Patients to Whom They React Positively and Negatively. (Unpublished Doctoral dissertation) Teachers College, Columbia University, New York. DEUTSCH A. (1949) The Mentally III in America, p. 36. University Press, New York. FRANCIS G. & MUNJAS B . (1968) Promoting Psychological Comfort, p. 5. Wm. C. Brown Company, Dubuque, Iowa. FREEMAN H . (1961) Attitudes toward mental illness among relatives of former patients. American Sociological Review 26, 59-66." GREEN B . (1954) Attitude measurement. Handbook of Social Psychology, p. 340. Ed. Lindzey G. Wesley Publishing Company, Cambridge, Massachusetts. JONES E. et al. (1971) Introduction. Attribution: Perceiving the Causes of Behavior. General Learning Press, Morristown. JouRARD S. (1959) How well do you know your patients? American fournal of Nursing 59,1568-71. KANOUSE D . & HANSON L.R. Jr. (1971) Negativity in evaluations. Attribution: Perceiving the Causes of Behavior. (Jones, Ed.) General Learning Press, Morristown. LAWINGER P . & DoBiE S. (1968) The attitude of the psychiatrist about his patient. Comprehensive Psychiatry 9, 627-632.
Nurses' attitudes to patient with psychiatric history
23
MACGREGOR F. (1967) Uncooperative patients: some cultural interpretations. American Journal of Nursing 88-91. PETRONI F. & GRHTIN C . (1969) Labelling and psychiatry. Perspectives in need of data. Social Science and Medicine 3, 239-247. PROSHANSKY H . & SHDENBERG B . (1965) Basic Studies in Social Psychology, p. 97. Holt, Rinehart and Winston, New York. RiCKELMAN B . (1971) Nurses and Psychiatric Patients to Whom they react Positively and Negatively.
(Unpublished Doctoral dissertation) Teachers College, Columbia University, New York. ToOMEY L. et al. (1961) Attitudes of nursing students toward psychiatric treatment and hospitals. Mental Hygiene 45, 589-602. VERNALLIS F . & ST. PIERRE R. (1964) Volunteer workers' opinions about mental illness. Journal of Clinical Psychology XX, 140-143.
Nurses' attitudes towards a patient wiio iias a psychiatric iiistory Madeleine M. Brady R.N. M.S. Ed.D. candidate Instructor, Psychiatric Nursing, St. Vincent's Hospital School of Nursing, New York, N.Y., USA Acceptedfor publication 11 fuly
BRADY MADELHNE M . (1976) Journal of Advanced Nursiug i , 11-23
Nurses' attitudes towards a patient who has a psychiatric history This study was carried out in a large Metropolitan General Hospital in New York, USA. The aim of the study was to deterniine the differences in nurses' attitudes towards a general hospital patient who had, or had not, a previous psychiatric illness. One hundred and twenty-eight graduate (trained) nurses were asked to read the patient's case notes, to view videotapes and to answer questionnaires as part of the research method. Analysis of the data obtained demonstrates the statistically significant finding below the 0-02 level that the nurses' attitudes were generally more negative towards the former psychiatric patient. In several instances, the disturbed behaviour of the patient was more significant than the patient's previous hospitalization: the findings also suggest that the graduate nurses equate mental illness with organic causes. The study poses many questions for nurse educators, but particularly for those responsible for psychiatric nursing education.
INTRODUCTION The nurse's attitude towards a patient is generally considered to be one of the basic factors contributing to the administration of total therapeutic nursing care. These attitudes to a great extent are the result of environments and experiences to which the nurse has been exposed. Thus, the patient may be viewed in diverse ways for a variety of reasons. Often one of these reasons is related to the nurse's perceptions of the patient himself. These perceptions may be realistically based on an accurate appraisal of the patient as an individual. However, sometimes the patient is considered in a stereotyped manner, and judgements made on generalizations of a specific social group. Through the ages, societies have expressed differing attitudes towards the mentally ill. Generally, these have been positive expressions of feelings in approaches and treatment. However, within the last three centuries, both in America and Europe, the mentally ill have not only been harassed, segregated and persecuted, but even executed as witches (Deutsch 1949). These negative feelings II
12
M.M. Brady
have not entirely disappeared. Too often from childhood onwards, fear and avoidance are the reactions of many people to a person with an emotional illness. Statistics are rising in the number of people seeking psychiatric care. Current treatment is directed towards providing only the most chjonically ill patients with continued hospitalization. The majority of the acutely ill patients receive shortterm therapy, and return to the community from which they came as quickly as possible. Most of the time, no further follow-up care is needed. This results in increasing numbers of people each day having a history of some type of psychiatric hospitalization. They are soon absorbed into the general population. When medical problems arise, they, like the rest of the populace, seek appropriate facilities. This time, a general hospital provides the care if hospitalization is required. In the general hospital, nurses relate closely to all patients as care is provided. Their attitudes are especially important because of the intimate daily contact and the resultant potentially significant nurse-patient interactions. The patient whose history includes a past psychiatric hospitalization frequently finds that the staff become aware of this past history all too quickly. Exposure to hospital environments reveal that, despite lack of validation of published studies, the fact remains that too often staff communications centre on this point. Verbally and nonverbally, attitudes are imparted as a result of this history. Often these messages differ in type and quality from those transmitted about patients who have no such history. Whether negative or positive in value, they certainly influence the nursepatient relationship and thus the subsequent care. But more importantly, with more attempts at promoting positive attitudes and behaviour (Francis & Munjas 1968) towards all patients, it is to be hoped that negative attitudes and behaviour are not being perpetuated by the current nursing practitioners. DEFINITIONS 1 Attitude: 'A complex tendency of a person to respond consistently in a favourable or an unfavourable way to social objects in his environment' (Proshansky & Seidenberg 1965). a Elicited verbal attitude: 'A statement of the respondent's opinion' (Green 1954)b Action attitude: 'Verbal or non-verbal behaviour directed towards an object in the referent class' (Green 1954). 2 Nurses: Nurses having direct patient contact who are graduates of Hospital Diploma, Associate Degree or Baccalaureate programmes in nursing. 3 Former psychiatric patient: Patient currently being treated in a general hospital who has had a previous eight month hospitalization in a psychiatric hospital. THEORETICAL FRAMEWORK The problem under study is grounded on the theory of attribution as it relates to attitudes and behaviour. It may be defined as the process 'whereby people attribute
Nurses' attitudes to patient with psychiatric history characteristics, intentions, feelings and traits to the objects in their social world' (Kanouse & Hanson 1971). This theory is based on several assumptions, one of which is that 'The particular cause that he (subject) attributes for a given event has important consequences for his subsequent feelings and behaviour. T'he "meaning" of the event and his subsequent reactions to it are determined to an important degree by its assigned cause' (Jones et al. 1971). This theory then is being used to support the basic assumption of the study. That is, that nurses will demonstrate these specific 'consequences' when they make responses based on the information that a particular patient has had a psychiatric illness. The associations made may be positive or negative causing accepting or rejecting attitudes. PURPOSE In the past, studies have been conducted on attitudes of psychiatrists towards patients (Lawinger & Dobie 1968), volunteer workers' opinions about mental illness (Vernallis & St. Pierre 1964), nursing students' attitudes toward psychiatric treatment and hospitals (Toomey et al. 1961) and even attitudes of relatives of former patients toward mental illness (Freeman 1961). Attitude studies among nurses (MacGregor 1967, Blaylock 1970, Rickelman 1971) have proved helpful, but there seems to be a lack of specific studies about former psychiatric patients being cared for in general hospitals. Whether we like to admit it or not, psychiatric patients do get labelled (Petroni & Griffin 1969), arid stereotyping of patients occurs (Jourard 1959). This study then is designed to identify some of the attitudes found among current graduate nurses towards a patient who has been previously hospitalized for mental illness. To accomplish this, it is necessary to determine the differences in the nurses' attitudes toward a patient who has, or has not, had this psychiatric history. The present research project proposes to do this. HYPOTHESES 1 There will be differences in nurses' elicited verbal attitudes towards a patient who has a psychiatric history of hospitalization. 2 There will be differences in nurses' action attitudes towards a patient who has a psychiatric history of hospitalization. LIMITATIONS 1 This study deals only with the subject's own identification of attitudes and behaviour. The findings are conscious personal responses. No attempt is made to seek motivation. 2 The data identifies subjects' elicited verbal and action attitudes based on a specific constructed contrived situation. No attempts are made to generalize to a
13
14
M. M. Brady
larger population or even to forecast what might have been the subjects' actual attitudes or behaviours in the same or other real situations.
SAMPLE This study was conducted in a large Metropolitan city in a iooo bed general hospital employing over 300 registered nurses. One hundred and twenty-eight nurses from all departments (psychiatry excluded) volunteered to participate in the project. They were assigned by random sampling to the experimental groups. No personality testing was performed since it was assumed that participants obtained from such a large centrally located teaching medical facility would provide a representative population.
METHOD The project was designed to study nurses' attitudes under a controlled situation. A brief patient history was composed after researching the literature, studying patients' charts, and interviewing physicians and nurses. To determine whether the patient's psychiatric history contributed to the nurses' attitudes, half of the histories made reference to an eight month psychiatric hospitalization four years previously; the other half made no such reference. In addition, since organic causes and/or symptomatology is often considered in a different manner when purely psychological components are involved, the histories were further altered. Symptoms described and treatments ordered by the doctor were lnore physically oriented in one half of the histories. The histories of the other half appeared more psychological in origin and physicians' orders were more psychotherapeutically oriented. An original five minute videotape presentation of a typical nurse-patient interaction was produced. Actors simulated a situation in which interpersonal reactions were greatly taxed. Since patient behaviour often influences the nurse's responses, two tapes were made that depicted differing levels of disturbed patient behaviour. One tape demonstrated more overt patient upset activity and negativistic responses than the other. Each subject viewed one of the tapes after reading the history. Thus, an experimental design was set up that provided eight groups of subjects, each reading some variation of a basic patient history and viewing one videotape presentation (Table i). Following this presentation, a questionnaire was given to each subject. This questionnaire was a result of a review of the literature, open-ended questions administered to nursing students, observation of actual patient situations and discussions with graduate nurses. A preliminary form was constructed and its usability tested. After a series of pilot studies, during which time the form was refined, a final draft of the questionnaire, with 13 questions containing 98 items, was produced.
Nurses' attitudes to patient with psychiatric history TABLE I Jlist oj eight experimental ^ iroups with distinguish11/1^ independent variables
Group I II III IV V VI VII VIII
Behaviour
Less disturbed Less disturbed Less disturbed Less disturbed More disturbed More disturbed More disturbed More disturbed
Illness
Psychiatric history
Organic Organic Psychological Psychological Organic Organic Psychological Psychological
With Without With Without With Without With Without
DATA COLLECTION Small groups of nurses viewed the tapes on a portable monitor brought to the various hospital conference rooms. This necessitated numerous testing times. Subjects were told that the project was to study nurse-patient relationships. They were urged to maintain secrecy about the study to promote the reliability of the findings. After reading the history, which had been previously assigned to each subject by random selection, and viewing the tape, they received a questionnaire. They were instructed to read the questions carefully and to answer them with their first response. At no time was any reference made to the actual point of the study. ANALYSIS OF D A T A Raw data from the questionnaires was transferred to IBM cards which were separated into the eight experimental groups. Each of the 98 dependent variables from the test was treated separately. A three-way analysis of variance was performed on each of them. This data has been analysed and reported at the 0*02 level of statistical significance. In testing the two hypotheses, the differences of means of the groups reading the psychiatric history were then compared with those not reading the history. These findings were the significant statistics. However, in computing and analysing the data, findings at the significant level resulted when the other group mean differences were treated. This paper reports a summary of the major findings. P R E S E N T A T I O N OF THE D A T A First hypothesis 'There will be differences in nurses' elicited verbal attitudes towards a patient who has a psychiatric history of hospitalization' is supported at the significant level by two items. Several additional items are statistically significant when organicity and behaviour are considered. The subjects were asked to indicate the strength of their feelings about twelve
M. M. Brady
i6
statements the nurse niight make about the patient. A seven-point scale was checked. Terms ranged from 'Extremely strong' (7 points), through a midpoint 'Moderate' (4 points) to 'Not at all' (i point). Table 2 contains the list of statements with the group means for each.
TABLE 2
Group meaiis of independent variables for nurses' 'thoughts' about the patient
No Nurses' thoughts
I couldn't handle patient effectively I wouldn't let patient make a fool of me My behaviour might 'set patient off' This patient may become assaultive Patient needs more time than I can spend She really only needs a good 'talking to' I wish she'd act like this to the doctor This patient needs help only I can give This patient shouldn't be in the hospital Others could work better with this patient I wish this patient would 'snap out of it' I would never like to work with a patient like this
Psychiatric history
No history
No Organic
organic
Disturbed disturbed behaviour behaviour
(X)
(X)
(X)
(X)
(X)
(X)
3-406
2-938
3-406
2-938
3-344
3-000
1-938
1-844
1-906
1-875
1-672
2-109
3-063
3-107
3-063
3-107
3-219
2-951
3-129
2-502
2-849
2-782
3-145
2-486
4-332
3-736
3-928
4-141
4-158
3-910
1-844
2-020
1-864
2-000
1-785
2-078
3-590*
2-722*
3-171
3-141
3-300
3-011
1-547
1-328
1-359
1-484
1-516
1-391
2-949
2-469
2-672
2-746
2-828
2-590
2-625
2-156
2-328
2-453
2-328
2-453
2-136
2-297
2-156
2-277
2-297
2-136
2-203
2-094
2-036
2-234
2-234
2-063
* Less than 0-02 level of significance
One statement: 'I wish she'd act like this to the doctor,' showed a significant difference when the psychiatric history was considered. The subjects who perceived the patient with a previous psychiatric history felt slightly stronger about the statement than the subjects who viewed the patient without the history. Note the low rating on the scale, that is, from 'Slightly' to 'Somewhat strong'. Another question presented a series of fourteen descriptive words, which subjects checked on a similar seven-point scale. This measured the strength of their feelings about the patient. Items with their means are presented in Table 3. The feeling 'frustrated' showed a significant difference between the groups when the psychiatric history was considered. The groups viewing the patient with
Nurses' attitudes to patient with psychiatric history TABLE 3 Group means of independent variablesfor nursed feelings' about the patient
Nurses'feelings
No Psychiatric history history (X)
Ambivalent Angry Accepting Annoyed Concerned Distrustful Discouraged
Challenged Frustrated Impatient Rejecting Patient Sympathetic Trusting
3-104 2-359 3-198 2-780 5-324 2-553 3-146 5-381 4-094* 3-283 1-780
3-737 4-328 2-587
Organic
(X) 2-777
(X) 3-058
2-203 3-762 2-619 5-050 2-361
2-406
2-453
4-967 3-234'* 2-847 1-844 3-969 4-135 2-734
No organic
No Disturbed disturbed behaviour behaviour
(X)
(X)
2-823 2-156
3-214 2-422
3-344
3-631 2-656
3-329 2-743
5-274 2-486 2-586 5-203 3-510 3-174 I-671
5-441 2-254 3-200*
4-933
5-404
4-944
3-906 3-206
3-422 2-924 1-890
3-846
4-385
3-766 4-078
2-750
2-572
2-734
3-617 2-916 5-100 2-428 3-012 5-145 3-818 2-956 1-953 3-940
2-483
1-734 4-641
(X) 2-667 2-141
2-660 2,399*
3-859 3-823 2-587
' Less than 0-02 level of significance
the previous psychiatric history felt more 'frustrated' than the groups viewing the patient without the history. The level of the patient's behaviour contributed significant findings. Subjects who viewed the more disturbed patient were more 'discouraged' than the subjects who viewed the less disturbed patient. Another question was designed to discover how discerning the subjects were of the 'patient's appraisal of her own physical illness'. Again the subjects checked a seven-point scale. Choices ranged from a high 'Extremely exaggerated' (7 points), through a midpoint 'accurate reflection' (4 points), to a low 'extremely understated' (i point). When the previous psychiatric history and level of disturbed behaviour interacted, there was a significant finding. The means of the responses tended to cluster around 'somewhat exaggerated' (5) to 'rather exaggerated (6) as may be seen in Table 4.
TABLE 4 Mean table of two-way variables for nurses' attitudes toward patient's appraisal of her own physical illness Disturbed/no organic Disturbed/organic Less disturbed/no organic Less disturbed/organic Psycliiatric history/no organic Psychiatric liistory/organic
5-250 5-625 5-281 5-813 5-313 5-719
' Less than 0-02 level of significance
No psychiatric history/no organic No psychiatric history/organic Psychiatric history/disturbed Psychiatric history/less disturbed No psychiatric history/disturbed No psychiatric history/less disturbed
5-219 5-719 5-188* 5-844* 5-688* 5-250*
M. M. Brady
i8
Subjects viewed the patient with more disturbed behaviour and no previous psychiatric history as 'exaggerating her appraisal' more than the patient with a psychiatric history. However, the patient with the less disturbed behaviour who had a previous psychiatric history was considered to 'exaggerate more' than the patient without the history (Figure i). Mean scale 60 5-8 5-6 5-4 5-2 50
Without psychiatric history
With psychiatric history
With psychiatric history
Without psychiatric history
FiGtJRE I A visualization of the relationship between the means of groups related to psychiatric history and level ofbehavioiirfor patient's exaggeration of her own physical illness
A related question 'How accurate do you consider the patient's appraisal of her psychological problems?' yielded no significant data. As in the previous question, possible responses ranged from 'extremely exaggerated' (7), downwards to 'extremely understated' (i). This time the means of the groups clustered around the lower end of the scale. Responses ranged in the 2 7-3-3 range on the scale (2='rather understated'; 3 ='somewhat understated'; 4='accurate reflection'). This question and its relationship to the previous one is discussed later. Still another question listed 21 phrases or words, and their opposites, that the nurse might use to characterize the patient. Subjects checked on a nine-point scale the point closest to the best description of the patient. These phrases are listed in Table 5. There are no significant findings that relate to the hypothesis. However, there are three responses at the significant level which relate to the disturbed behaviour. TABLE 5
List of words and their opposites for use by subjects to describe the patient
Difficult—easy to work with Anxious—not anxious Complaining—uncomplaining Manipulative—not manipulative Offensive—not offensive Unselfish—selfish Domineering—passive Demanding—undeman ding Fearful—not fearful* Witty—dull Happy—unhappy
Appreciative—unappreciative of nursing care Accepting—denying of illness* Loud^quiet Cooperative—uncooperative Difficult—easy to talk with Disrespectful—respectful to staff Well-adjusted—not well-adjusted Polite—impolite Comfortable—uncomfortable * Quarrelsome—amiable
' Less than 0-02 level of significance
Nurses' attitudes to patient with psychiatric history The more disturbed patient was considered to be more 'fearful' (x= 8-727), 'uncomfortable' (3c=2-o63) and 'denying of her illness' (:v=2-i88). It is noteworthy that these means were some of the highest in the study. In characterizing the patient's behaviour in general, there were no significant differences between groups. The subjects checked one descriptive term from a list of seven. Possible descriptions ranged from 'extremely inappropriate' (7), through 'moderately inappropriate' (4), to 'appropriate' (i). Means of the groups peaked at the 4-5 range on the scale; that is 'moderately' to 'rather inappropriate' respectively. Thus, the subjects viewed the patient's behaviour as neither 'extreme' nor 'appropriate'.
Second hypothesis 'There will be differences in nurses' elicited action attitudes towards a patient who has a psychiatric history of hospitalization' is proven tenable by three items. In addition, when organicity and behaviour are considered, several additional items are statistically significant. From a list of thirteen suggestions and their opposites, that the subjects would give to other nurses to ensure the best nursing care for the patient, two items were significant. Items and group ineans are found in Table 6. The high group means indicated patients' needs would be greatly 'anticipated', but the needs of the patient without the history would be 'anticipated' somewhat more than those of the patient with the history. In the item relating to 'probing' reasons for patient's behaviour, the patient without the psychiatric history would be 'probed' more than the patient with the history. There were two responses statistically significant when behaviour was considered. All buzzers were to be answered promptly; but the more disturbed patient's 'buzzers were to be answered' a little more promptly than the less disturbed patient's. The less disturbed patient was to be 'corrected' a little more than the disturbed patient 'about her psychological problems'. A further question contained a list of eight suggestions for additional nursing care directives to be included in the subject's communications to other staff members. On a nine-point scale, ranging from 'very strongly' to 'doesn't apply', the subjects checked the strength of their feelings. Group means were high on the scale for these responses (Table 7). The subjects felt strongly that the staff should repeat 'patient's statements about family and other persons in her life'. They felt even more strongly that the patient with the psychiatric history was to have this material repeated more than the patient without the history. The final series of questions sought to determine the necessity of knowing the various medical and psychological symptoms, history and diagnoses for the planning of nursing care. There were no significant findings related to the hypothesis. However, at the significant level, the subjects viewing the patient with obvious organicity considered 'medical', and 'psychiatric diagnoses' and a 'neurological
19
20
M.M.
Brady
TABLE 6 Group means of independent variablesfor nurses' directions for patient care to be given by others
No Directions for care Encourage—discourage patient talk about symptoms Anticipate needs—only approach patient on call Probe—don't find patient reason for behaviour Limit contact—watch patient closely Listen—don't listen to patient's complaints Give attention—stay away from patient Help patient see staff knows best—^permit patient to make all decisions Encourage patient help self get better—irrelevant Let patient wait—answer all buzzers promptly Correct—don't correct patient's view of psychological problems Accept without question— put limits on behaviour On doctor's orders get patient out of bed—^permit patient to remain in bed Discuss with patient bath time—nurse plan time
No organic
Disturbed behaviour
disturbed behaviour
(X)
(X)
(X)
7-609
7-781
8-016
7-357
8-313*
7-828
8-016
8-078
7-766
6-611*
7-609*
7-016
7-205
7-016
7-205
2-375
2-379
2-313
2-442
2-051
2-703
7-797
8-078
8-125
7-750
8-219
7-656
6-750
7-374
7-297
6-827
7-328
6-796
6-172
6-578
6-313
6-838
6-203
6-547
6-453
6-594
6-844
6-203
6-188
6-859
2-817
2-969
2-836
2-949
2-336*
3-449*
4-571
5-172
4-898
4-844
4-305*
5-438*
3-766
4-094
3-953
3-906
3-859
4-000
5-188
5-344
5-469
5-063
5-141
5-391
5-797
6-219
6-281 .
5-734
5-984
6-031
Psychiatric history
No history
Organic
(X)
(X)
(X)
7-516
7-875
7-531*
' Less than 0-02 level of significance
consultation' as more important than did the subjects viewing the nonorganic patient. DISCUSSION From a list of 98 items that were equally weighted with positive and negative concepts, it is noteworthy that at the significant level the items related to the presence of a psychiatric history tended to be more negative in quality. Subjects were more 'frustrated', 'discouraged', 'would anticipate patient's needs less' when the patient had previously been hospitalized for a mental illness. The response 'repeat patient's statements about family, etc' to other staff may be considered
Nurses' attitudes to patient with psychiatric history
21
TABLE 7 Croup means of iiidepetideiit variables for nursed communications to other staff
Communication Describe patient's feelings about nurse staff Quote patient's exact physical complaints Warn nursing staff of patient's behaviour Differentiate real and imagined sypmtoms Describe patient's emotional complaints Repeat patient's statements re family etc. Describe patient's physical resistance to care Pass information about patient-mother relationship
Psychiatric No history history
Organic
No organic
No Disturbed disturbed behaviour behaviour
(X)
(X)
(X)
(X)
(X)
(X)
7-688
7-344
7-375
7-656
7-766
7-266
7-750
7-000
7-422
7-328
7-516
7-234
7-323
7-231
7-194
7-360
7-594
6-960
6-702
6-884
6-765
6-781
6-640
6-906
8-328
8-125
8-375
8-078
8-266
8-188
8-313*
7-456*
7-906
7-862
7-984
7-784
7-594
6-938
7-172
7-359
7-469
7-063
8-313
7-688
7-891
8-000
8-109
8-000
' Less than 0-02 level of significance
positive. But even here, one would have to ascertain further whether morbid curiosity or zeal for the psychotherapeutic approach prompted this response. 'I wish she'd act like this to the doctor' also raises a question. The researcher meant the statement to be positive, so that the doctor could properly evaluate the patient's condition. However, there remains a question as to interpretation. Did some respondents view this as a hostile response to a very difficult patient? As an angry attack, might not the nurse wish the physician to share her problems? This statement is open to further study. Another rather negative attitude is found when the nurse would 'probe patient a little less for reasons for her behaviour' when the patient had the psychiatric history. Here, the opposite choice was 'Don't try to fmd reasons'. It seems unfortunate in this day of dynamic psychiatry that nurses would deliberately plan not to seek reasons for patient behaviour. The item which showed interaction between psychiatric history and level of behaviour is informative in itself, but may also be helpful in understanding some of the other data. Note that the more disturbed patient with no psychiatric history was considered to 'exaggerate her physical illness' more and that the less disttirbed patient with a history was considered to 'exaggerate' more. In this item, it seems as if the disturbed behaviour stimulated more negative responses, despite the presence of a psychiatric history, while when the behaviour was less disturbed, the psychiatric history seems to take precedence. Other responses that related to disturbed behaviour seem to support this statement.
22
M. M. Brady
When there was disturbed behaviour, the subjects would 'answer (patients') buzzers' more promptly and would not correct the patient's views 'about her psychological problems'. They also judged this patient as being more 'fearful', 'uncomfortable' and 'denying of her illness'—all rather valid and sensitive perceptions, but apparently based on the overt behaviour they had viewed. It is also revealing that subjects judged the disturbed patient to 'exaggerate her physical illness', but greatly 'understate' her psychological problems. These ratings seem to be the result of the subjects' feelings. The physical manifestations are overt and observable. Their expressions are often disruptive to nursing care and so may be viewed more negatively. Psychological problems involve more hidden feelings and emotions and so more mystery surrounds them. The subjects then judge the patient as having little insight. Finally, there seems to be a relationship between organicity and psychiatric illness in the minds of the subjects. It is logical to expect a medical diagnosis and neurological consultation to be important for the organically ill patient. But it is a surprise to fmd the psychiatric diagnosis of equal importance for the organic patient. These subjects had been exposed to the concepts of modern psychiatry at some place in their nursing education. Apparently they still hold the belief that mental illness is equated with physical causes. This study raises many questions for nurse educators, but for psychiatric nurse educators in particular. To improve nurse-patient relationships and subsequently, nursing care, further research is urgently needed. The literature demonstrates a lack of information about former psychiatric patients who are being treated in general hospitals for medical reasons. Their numbers increase every day. Nursing service and education cannot lose sight of these patients if the profession is to meet its obligations in serving the sick.
References BLAYLOCKJ. (1970) Characteristics of Nurses and Medical-Surgical Patients to Whom They React Positively and Negatively. (Unpublished Doctoral dissertation) Teachers College, Columbia University, New York. DEUTSCH A. (1949) The Mentally III in America, p. 36. University Press, New York. FRANCIS G. & MUNJAS B . (1968) Promoting Psychological Comfort, p. 5. Wm. C. Brown Company, Dubuque, Iowa. FREEMAN H . (1961) Attitudes toward mental illness among relatives of former patients. American Sociological Review 26, 59-66." GREEN B . (1954) Attitude measurement. Handbook of Social Psychology, p. 340. Ed. Lindzey G. Wesley Publishing Company, Cambridge, Massachusetts. JONES E. et al. (1971) Introduction. Attribution: Perceiving the Causes of Behavior. General Learning Press, Morristown. JouRARD S. (1959) How well do you know your patients? American fournal of Nursing 59,1568-71. KANOUSE D . & HANSON L.R. Jr. (1971) Negativity in evaluations. Attribution: Perceiving the Causes of Behavior. (Jones, Ed.) General Learning Press, Morristown. LAWINGER P . & DoBiE S. (1968) The attitude of the psychiatrist about his patient. Comprehensive Psychiatry 9, 627-632.
Nurses' attitudes to patient with psychiatric history
23
MACGREGOR F. (1967) Uncooperative patients: some cultural interpretations. American Journal of Nursing 88-91. PETRONI F. & GRHTIN C . (1969) Labelling and psychiatry. Perspectives in need of data. Social Science and Medicine 3, 239-247. PROSHANSKY H . & SHDENBERG B . (1965) Basic Studies in Social Psychology, p. 97. Holt, Rinehart and Winston, New York. RiCKELMAN B . (1971) Nurses and Psychiatric Patients to Whom they react Positively and Negatively.
(Unpublished Doctoral dissertation) Teachers College, Columbia University, New York. ToOMEY L. et al. (1961) Attitudes of nursing students toward psychiatric treatment and hospitals. Mental Hygiene 45, 589-602. VERNALLIS F . & ST. PIERRE R. (1964) Volunteer workers' opinions about mental illness. Journal of Clinical Psychology XX, 140-143.
