In/. J. Nun. Stud. Vol. IS, pp. 153.157. Pergamon Press Ltd., 1978. Printed in Great Britain.

00204878/78/0801-0153

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The student nurse as therapeutic consultant CORNELIUS J. HOLLAND,*

RAYMOND M. DALY University of Windsor, Ontario, Canada. and

and CHARLES T. CAPANZANO New York School of Psychiatry, New York, U.S.A.

Introduction

During the past decade parents have been taught to act as the primary agents of change for the problem behaviours of their children, which formerly often necessitated treatment by the professional (Brown, 1971; Berkowitz and Graziano, 1972; O’Dell, 1974; Tavomina, 1974). Although this extension of therapeutic services is still in its earlier stages of development and is awaiting much needed research, it promises to become one of the most significant developments in applied mental health in the latter part of the 20th century. Concurrent with this development is an attempt to train para-pscyhotherapeutic specialists to assume the role of primary consultants for the home-based programs of the parent-therapist. This article describes one such program, Directive Parental Counseling (DPC) (Holland, 1976) and its implementation by student nurses. Student consultants

The student consultants selected for the research+ were randomly drawn from a pool of 41 student nurses who volunteered to participate in the study as partial fulfillment of the requirements for either the psychiatric or pediatric nursing courses offered during the third year of the undergraduate curriculum in nursing at the university where the study was undertaken. The students were advised that the project would require of them a commitment of 20 hr of training and at least 10 hr of consulting with parents. From the pool of 41 volunteers, 24 were randomly selected. It was established before commencing that any student whom the nursing faculty research directors felt to be a risk to participating families or themselves would be asked to withdraw. This negative selection criterion was not invoked. *Requests for reprints should be addressed to Cornelius J. Holland, Ph.D., Department of Psychology, University of Windsor, Windsor, Ontario N9B 3P4. *The research project was supported by a grant from the Ontario Psychological Association. 153

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CORNELIUS J. HOLLAND, RA YMOND M. DAL YAND CHARLES T. CAPANZANO

Of the 24 selected consultants, 23 were female and one male. The mean age was 21.79 yr; the median 23.78; the range was 20-42. At the time of the study, the students in the nursing program had taken one course in introductory and one in educational psychology. While they had experience in family interviewing as part of a course requirement in community health nursing, they had no formal experience in psychotherapy or counseling. Training procedures

The nursing students were taught the principles of behavioural counseling in 12, 2 hr sessions. The major written instrument of instruction was Directive Parental Counseling: The Parents’ Manual (Holland, 1976), the same instrument that the parents would use during counseling. This is a 92 page book which serves as an interview guide for the therapist, reducing the central principles of operant psychology to a non-technical 30 step procedure (see Appendix A). * The first 1 ‘/z hr of each weekly training session was conducted by the two project codirectors, faculty members of the Psychology Department who maintained overall supervision of the program. The Parents’ Manual was presented in a typical didactic lecture format supplemented at times by material from Directive Parental Counseling: The Counselor’s Guide (Holland, 1977).+ During the remaining half hour of the training session the student nurses met in their randomly assigned supervision group. Each of the six groups of four were led by a doctoral student in clinical psychology. The graduate students had experience in conducting at least one DPC program in a professional clinical setting under the supervision of one of the project directors. Two members of the nursing faculty rotated among the small groups to offer additional professional consultation. Questions generated by the lectures were elaborated and clarified during the group discussion period. Appropriate interviewing techniques were demonstrated through roleplaying procedures. Fear of failure and other anxieties due to anticipated difficulties were discussed in a supportive manner. The training program was conducted within the pre-established time schedule. Seldom did any of the twelve sessions last beyond the 2-hr limit. Subjects Twenty-four families having a child with active behaviour problems in the home participated in this study. The children were referred by mental health specialists, family physicians and social services personnel. Cases were accepted and assigned to the counselors randomly without regard to the presenting problems. This procedure conforms closely with actual clinical practices where treatment is usually determined by need for help rather than any other selection criterion. A wide range of typical problems was treated (Eyberg and Johnson, 1974) with some form of disobedience being the most common. Other problems included temper tantrums, whining, talking-back or defiance, fighting, inappropriate eating habits, refusal to go to bed at agreed.upon times and inappropriate attention getting. *Appreciation is expressed toward Anna Gupta, Janet Rosenbaum, Sharon Gurlicky and Lila Cominsky of the Faculty of Nursing, University of Windsor. *Directive Parental Counseling: The Counselor’s Guide and Directive Parental Counseling: The Parents’ Manual are available from the University of Windosr Bookstore, University of Windsor, Windsor, Ontario N9B 3P4, Canada.

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Implementing the DPCprogram Parents were seen individually in their own homes for 10 weeks by the student consultants in 1 hr sessions. All parents were given copies of the DPC Parents’Manual to read and use throughout the program. During the 10 weeks, the parents learned the concepts, language, and observation and data collection skills necessary to plan and implement a behaviour change program. They were also taught to identify and modify one specific target behaviour. During the intervention phase, the nursing students met weekly in a small group with their psychology graduate student supervisors. General concerns regarding counseling and consultation and specific topics related to the DPC system were discussed. Professional personnel from the participating referral agencies maintained nominal supervisory responsibility for those parents who were originally referred to them. Two nursing faculty members were also available for consultation as were the two psychology professors who co-directed the project. Although this back-up support was available if needed, the nursing students relied almost exclusively on their weekly group supervision sessions. Thus while there was ample opportunity for extensive formal supervision, the nursing students were encouraged to take responsibility for the clinical judgments and decisions which are required during therapeutic encounter. The student nurses learned to value their personal resources, their past educational achievements and the new skills they learned in their formal training program. Results

Of the 24 families who began the DPC program, only one failed to complete the 10 week sequence due to marital difficulties which seriously interfered with the mother’s ability to implement the program consistently. Although provisions were made to ensure that counseling could continue beyond the 10 week period if necessary, this provision was not required. Due to illness, one student nurse was unable to complete the program, and the training sessions were carried out by the graduate student supervisor. Table 1 presents a summary of mothers’ observations of the outcome of the training Table 1. Summary of the reduction in the number of episodes of unacceptable behaviour Behaviour

070Decrement

Ngn-compliance (N = 7)

65.8

Fighting with sibs (N = 4)

75.5

Whining/nagging

77.6

(N = 3)

Temper tantrums (N = 2)

16.0

Bedtime problems (N = 2)

52.0 VoDecrement

Talking back (N = 1) Dinner time eating problems (N = 1)

98 50*

Stealing (N = 1)

70

Inappropriate attention seeking (N = 1)

95

*A negative score implies that the problem behaviour increased in severity. A negative score was also recorded in one of the temper tantrum problems.

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J. HOLLAND,

RA YMOND A4. DAL Y AND CHARLES

T. CAPANZANO

program for the 22 children from which data was gathered. Of the families who completed the program with their original student consultant, 13 of the 22 were judged to be successful using a 60% reduction in frequency of targeted behaviour in the desired direction as the success criterion. The overall percentage decrement of target behaviour was 61%. A

typical experience

Although this project was a formal study of the characteristics of therapists, parents and children which are predictive of successful application of the DPC system, it may be useful to report a typical student’s reaction, selected at random, to the counselling experience, “The problem behaviour of Dorothy, a 7 yr old girl, was one of inappropriate attention-getting. If her mother was sitting on a chair or couch Dorothy would often sit very close and touch her mother’s arm, leg, play with hair and nails, or as her mother put it “maul me”. The behaviour dropped from 10 to 0 per week during the program. The mother feels that her daughter is a much improved little girl. She also feels that she is more relaxed and comfortable with her daughter and now encourages her to help her in the kitchen. She can also sit with Dorothy for longer periods and enjoy it and enjoy doing things with her that she was unable to do in the beginning. My experience with the parents was a mixture of acceptance and rejection. Our meetings progressed slowly because there was constant conflict between them. The father added only a minimal amount of effort and so changed very little. The mother worked with the DPC in a positive manner and changed from her uncomfortable, distant feelings towards Dorothy, to offering social rewards and freely including her daughter more in her activities. She discovered that Dorothy had many positives she hadn’t realized before. I have enjoyed working with this family and 1 feel that the program has been of benefit to them. They have frequently mentioned their confidence in the program and its effectiveness. I shall contact them in a month’s time to note further progress or difficulty. I feel that this is one of the best experiences that 1 have had in my three years of nursing. It was encouraging to note thatpublic health nurses could do much in this program to assist a family in the home. Being accepted by the parents and being able to present myself and the program in an acceptable manner will give me encouragement and confidence in my future publich health work.”

Discussion

What has been described is a research project in which student nurses through a series of home visits carried out a currently popular and useful type of mental health intervention called parental counseling. Of the research done thus far on DPC, the 59% criterion success and 61% overall decrement across the 22 children obtained by the student nurses is slightly below the level achieved by more clinically experienced counselors. In one study using as counselors doctoral level students in psychology, a 60% criterion success (using the same 60% reduction criterion) and 70.7% overall decrement was obtained across 10 children (Hyde, 1975). Another study in progress, using professional counselors from community agencies yielded 80% criterion success with an overall decrement percentage of 85.4% across 13 children (Fulgenzi, 1978). Both of these studies used training procedures and focusses on target behaviours very similar to those of the present study. In view of the differences in clinical experience of the three groups the gains achieved by the student nurses is impressive. Another impressive statistic for the present study is the attrition of only one family starting the program and failing to finish. This is undoubtedly due in part to the counseling being done in the house, reducing considerably the difficulties parents often face in arranging transportation for themselves and babysitting arrangements for other children in the family. The low attrition however, also reflects the value which the student nurses were able to communicate to the parents and to which the parents were able to respond in turn.

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Although, some success, using the method described above, can be claimed it must be remembered that the sample was small and that any generalisations based on these data must be made with appropriate caution.

References Berkowitz, B. P. and Graziano, A. M. (1972). Training parents as behavior therapists: a review. Behav. Res. & Therapy 10,297-3 17. Brown, D. Cl. (1971). Behavior modification in child and school mental health: an annotated bibliography on applications with parents and teachers. DHEW Publication No. (HSM) 719043, National Institute of Mental Health, Rockville, MD. Eyberg, S. M. and Johnson, S. M. (1974). Multiple assessment of behavior modification with families. J. Consult. clin. Psychol. 42,594-m. Fulgenzi, J. (1978). Stimulus%nd response generalization effects of directive parental counseling. Doctoral dissertation in progress, University of Windsor. Holland, C. J. (1976). Directive parental counseling: the parents’ manual. Behav. Therapy 7, 123-127. Holland, C. J. (1977). Directive parental counseling: the counselor’s guide. Unpublished manuscript. Hyde, N. (1975). Directive parental counseling: an empirical study. Unpublished doctoral dissertation, University of Windsor. O’Dell, S. (1974). Training parents in behavior modification: a review. Psychol. Bull. 81.418433. Tavomina, J. B. (1974). Basic models of parent counseling: a review. Psychol. Bull. 81,827-835.

(Received 20 December 1977; acceptedforpublication

Appendix A DPC: The 30 steps Step 1: List the problems and select one Step 2: The two aspects or parts to the problem Step 3: Estimate how often Step 4: Set reasonable goals for both aspects Step 5: A-B-C or the core of the program Step 6: Discovering the positives Step 7: Discovering the negatives Step 8: Making words matter Step 9: Making rules Step 10: Decreasing aspect No 1: where or when? Step 11: Decreasing aspect No 1: what happens now? Step 12: Decreasing aspect No. 1: three possible consequences Step 13: Decreasing aspect No. 1: the punishement consequence Step 14: Decreasing aspect No. 1: the loss consequence Step 15: Decreasing aspect No. 1: the neutral consequence Step 16: The neutral consequence: who else gives positives? Step 17: The neutral consequence: sometimes vs never Step 18: Rehearsing for decreasing aspect No. 1 Step 19: Increasing aspect No. 2: where or when? Step 20: Increasing aspect No. 2: what happens now? Step 21: Increasing aspect No. 2: two possible consequences Step 22: Increasing aspect No. 2: deprive if necessary Step 23: Increasing aspect No. 2: step-by-step Step 24: Increasing aspect No. 2: structuring behaviour to occur Step 25: Increasing aspect No. 2: immediacy of reward Step 26: Increasing aspect No. 2: vary types of reward Step 27: Increasing aspect No. 2: vary amounts of reward Step 28: Increasing aspect No. 2: not all the time Step 29: Increasing aspect No. 2: what is your child doing that’s right? Step 30: Rehearsing for increasing and decreasing.

1 March 1978)

The student nurse as therapeutic consultant.

In/. J. Nun. Stud. Vol. IS, pp. 153.157. Pergamon Press Ltd., 1978. Printed in Great Britain. 00204878/78/0801-0153 $ct2.Gu/o The student nurse as...
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