UBC Theses and Dissertations

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UBC Theses and Dissertations

A phenomenological approach to understanding nurses' experiences working with patients in inpatient psychiatric… Barratt, Linda Ann 1991

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A PHENOMENOLOGICAL APPROACH TO UNDERSTANDING NURSES' EXPERIENCES WORKING WITH PATIENTS IN INPATIENT PSYCHIATRIC CARE SETTINGS by LINDA ANN BARRATT B.A., Simon Fraser University, 1984 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Counselling Psychology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA 1991 OCTOBER 1991 © LINDA ANN BARRATT 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada Date dd. DE-6 (2/88) A B S T R A C T T h e p u r p o s e o f t h i s p h e n o m e n o l o g i c a l s t u d y was t o e x p l o r e a n d d e s c r i b e n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s , w i t h t h e a i m o f u n c o v e r i n g k n o w l e d g e a n d u n d e r s t a n d i n g o f t h i s p h e n o m e n o n . D a t a were c o l l e c t e d t h r o u g h 16 i n d e p t h i n t e r v i e w s w i t h e i g h t f e m a l e r e g i s t e r e d n u r s e s c u r r e n t l y e m p l o y e d i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . D a t a a n a l y s i s o f t h e v e r b a t i m t r a n s c r i p t s b e g a n c o n c u r r e n t l y w i t h d a t a c o l l e c t i o n a n d c o n t i n u e d d u r i n g t h e f o r m a l a n a l y t i c p h a s e w i t h m e a n i n g u n i t s e m e r g i n g f r o m t h e d a t a . I n t h e f i n a l a n a l y s i s s i x m a j o r themes a n d one s u b t h e m e were e x p l i c a t e d t o f o r m t h e e s s e n t i a l f e a t u r e s o f t h e n u r s e s ' e x p e r i e n c e s o f w o r k i n g w i t h p a t i e n t s i n i n p a t i e n t c a r e s e t t i n g s . T h e s i x m a j o r themes a n d one s u b t h e m e a r e : o n e , t h e e x p e r i e n c e o f f e a r o f b e i n g p h y s i c a l l y h a r m e d ; t w o , t h e e x p e r i e n c e o f c o n f l i c t ; t h r e e , t h e e x p e r i e n c e o f a m b i v a l e n c e i n r e l a t i o n s h i p s w i t h p h y s i c i a n s ; f o u r , t h e e x p e r i e n c e o f s a d n e s s , d i s a p p o i n t m e n t a n d f r u s t r a t i o n ; f i v e , t h e e x p e r i e n c e o f s a t i s f a c t i o n ; s i x , t h e e x p e r i e n c e o f g r o w t h . A s u b t h e m e o f a l a c k o f a d m i n i s t r a t i v e s u p p o r t e m e r g e d i n c o n j u n c t i o n w i t h t h e theme o f f e a r o f b e i n g p h y s i c a l l y h a r m e d . T h e s i x themes a n d one s u b t h e m e r e p r e s e n t t h e r a n g e o f t h e n u r s e s ' e x p e r i e n c e i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . I m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , a d m i n i s t r a t i o n , e d u c a t i o n a n d r e s e a r c h a r e s u g g e s t e d . G e n e r a l i m p l i c a t i o n s f o r n u r s i n g r e s e a r c h a r e i n t h e r e a l m o f s t u d i e s w h i c h w i l l f u r t h e r n u r s e s ' u n d e r s t a n d i n g o f p a r t i c u l a r a s p e c t s o f t h e i r e x p e r i e n c e s w i t h p a t i e n t s i n i n p a t i e n t c a r e s e t t i n g s s u c h as f e a r o f b e i n g p h y s i c a l l y h a r m e d . i v T A B L E OF CONTENTS A B S T R A C T i i T A B L E OF CONTENTS i v L I S T OF T A B L E S v i ACKNOWLEDGEMENTS v i i CHAPTER O N E : INTRODUCTION 1 C o n c e p t u a l i z a t i o n o f t h e P r o b l e m 1 P u r p o s e o f t h e S t u d y 3 R e s e a r c h Q u e s t i o n 4 B a c k g r o u n d t o t h e P r o b l e m 4 T h e o r e t i c a l F r a m e w o r k 16 M e t h o d o l o g i c a l A p p r o a c h 20 A s s u m p t i o n s 23 L i m i t a t i o n s 24 CHAPTER TWO: REVIEW OF R E L A T E D L I T E R A T U R E . . . . 26 T h e T h e r a p e u t i c N u r s e - P a t i e n t R e l a t i o n s h i p : T h e o r e t i c a l W o r k s 26 T h e C o m m u n i c a t i v e A c t i o n o f t h e N u r s e i n t h e C o n s t i t u t i o n o f t h e N u r s e - p a t i e n t R e l a t i o n s h i p 30 N u r s e - p a t i e n t C h a r a c t e r i s t i c s i n t h e C o n s t i t u t i o n o f t h e N u r s e - p a t i e n t R e l a t i o n s h i p 38 T h e S o c i a l O r g a n i z a t i o n i n t h e C o n s t i t u t i o n o f t h e N u r s e - p a t i e n t R e l a t i o n s h i p . . . . 47 E v e n t s i n t h e W i d e r S o c i a l C o n t e x t a n d C h a n g e s i n N u r s i n g I d e o l o g i e s i n t h e C o n s t i t u t i o n o f t h e N u r s e - p a t i e n t R e l a t i o n s h i p 51 Summary 54 CHAPTER T H R E E : METHODOLOGY 56 I n t r o d u c t i o n 56 S e t t i n g f o r t h e S t u d y 56 S e l e c t i o n o f P a r t i c i p a n t s 57 P o p u l a t i o n 57 S e l e c t i o n P r o c e d u r e s 57 C r i t e r i a f o r S e l e c t i o n o f P a r t i c i p a n t s . 58 C h a r a c t e r i s t i c s o f t h e P a r t i c i p a n t s 61 E t h i c a l C o n s i d e r a t i o n s 62 D a t a C o l l e c t i o n 62 D a t a A n a l y s i s 65 R e l i a b i l i t y , V a l i d i t y , a n d B i a s 67 V Summary 70 CHAPTER FOUR: P R E S E N T A T I O N OF THE ACCOUNTS . . . . 71 D e s c r i p t i o n s o f t h e Themes o f E x p e r i e n c e . . . 73 THE P A R T I C I P A N T S ' ACCOUNTS 7 8 T h e E x p e r i e n c e o f F e a r o f B e i n g P h y s i c a l l y H a r m e d 78 S u b t h e m e : T h e E x p e r i e n c e o f a L a c k o f A d m i n i s t r a t i v e S u p p o r t 88 T h e E x p e r i e n c e o f C o n f l i c t 101 T h e E x p e r i e n c e o f A m b i v a l e n c e i n R e l a t i o n s h i p s w i t h P h y s i c i a n s . . . 113 T h e E x p e r i e n c e o f S a d n e s s , D i s a p p o i n t m e n t , a n d F r u s t r a t i o n . . 126 T h e E x p e r i e n c e o f S a t i s f a c t i o n 134 T h e E x p e r i e n c e o f P e r s o n a l a n d P r o f e s s i o n a l G r o w t h 157 CHAPTER F I V E : D I S C U S S I O N OF F I N D I N G S , I M P L I C A T I O N S AND CONCLUSION OF THE STUDY . . . 173 D i s c u s s i o n o f F i n d i n g s 173 I m p l i c a t i o n s o f t h e S t u d y 184 N u r s i n g P r a c t i c e 184 N u r s i n g A d m i n i s t r a t i o n 186 N u r s i n g E d u c a t i o n 188 N u r s i n g R e s e a r c h 190 C o n c l u s i o n 191 R e f e r e n c e s 193 A p p e n d i x A 213 A p p e n d i x B 216 A p p e n d i x C 218 A p p e n d i x D 220 A p p e n d i x E 223 A p p e n d i x F 226 A p p e n d i x G 228 v i L I S T OF T A B L E S T a b l e Page 1. P a r t i c i p a n t C h a r a c t e r i s t i c I n f o r m a t i o n 61 v i i ACKNOWLEDGEMENTS I w o u l d l i k e t o a c k n o w l e d g e a n d t h a n k t h e n u r s e s who p a r t i c i p a t e d i n t h i s s t u d y by s h a r i n g t h e i r e x p e r i e n c e s w i t h me. I w o u l d a l s o l i k e t o e x p r e s s my a p p r e c i a t i o n t o t h e members o f my c o m m i t t e e : D r . R . Y o u n g , t h e s i s s u p e r v i s o r , D r . B . L o n g a n d D r . H . C l a r k e f o r t h e i r c o n s t r u c t i v e f e e d b a c k , i n t e r e s t a n d s u p p o r t . T h a n k y o u t o my m o t h e r f o r t e a c h i n g me t h e v a l u e o f l e a r n i n g a n d o f e d u c a t i o n . T h a n k y o u t o my s i s t e r J o a n C h r i s t i e a n d f r i e n d s K a t h y D o y l e a n d B a r b a r a G r e e n l a w f o r t h e i r e n c o u r a g e m e n t a n d c a r i n g . A s p e c i a l t h a n k y o u t o my h u s b a n d , R o b e r t a n d s i s t e r - i n - l a w , A n d r e a B a r r a t t , f o r t h e i r m o t i v a t i o n , s u s t e n a n c e a n d c o n f i d e n c e i n me. CHAPTER ONE: INTRODUCTION Conceptualization of the Problem T h e p h i l o s o p h i c a l themes a n d i n t e r p r e t a t i o n s o f t h e n u r s e ' s e x p e r i e n c e a r e p a r t o f t h e k e y t o u n d e r s t a n d i n g t h e n u r s e ' s w o r l d , i t s t r u e m e a n i n g a n d r e a l i t y f o r t h e n u r s e . I n o r d e r t o u n d e r s t a n d n u r s i n g as i t i s e x p e r i e n c e d we must d e s c r i b e a n d e x p l i c a t e t h o s e m e a n i n g s ( W a t s o n , 1 9 8 5 ) . T h i s s t u d y i s a n e x p l o r a t i o n o f n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s w o r k i n g w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . B e c a u s e p s y c h i a t r i c n u r s i n g i s p r a c t i s e d w i t h i n t h e c o n t e x t o f a n u r s e - p a t i e n t r e l a t i o n s h i p , t h e s t u d y s p e c i f i c a l l y e x p l o r e s n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s a d m i t t e d t o a n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g b e c a u s e o f a s e v e r e m e n t a l h e a l t h p r o b l e m . T h e i m p e t u s f o r t h i s s t u d y grew o u t o f my own c l i n i c a l e x p e r i e n c e , b o t h as a n u r s e a n d n u r s i n g i n s t r u c t o r , i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . F r o m my work w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s , I h a v e g a i n e d c o n s i d e r a b l e u n d e r s t a n d i n g o f what i t means t o become a c o - p a r t i c i p a n t i n t h e s u b j e c t i v e w o r l d o f a p e r s o n who s u f f e r s f r o m a s e v e r e m e n t a l h e a l t h p r o b l e m . 2 I h a v e j o u r n e y e d t h r o u g h a r e a l m o f s t r o n g e m o t i o n a l t o n e s b o t h , my p a t i e n t s ' a n d my own, w h i c h h a v e s h a p e d a n d moved me. I h a v e w o r k e d w i t h p a t i e n t s whose w o r l d s I f e l t a f r a i d t o e n t e r a n d o t h e r s whose w o r l d s I e n t e r e d w i t h o u t f e a r o r d i f f i c u l t y . I h a v e s u c c e s s f u l l y e n g a g e d t r o u b l e d p e o p l e t h r o u g h e m p a t h i c m e a n s ; e n t e r i n g t h e i r w o r l d , s e e i n g t h r o u g h t h e i r e y e s . I h a v e s h a r e d t h e i r f e a r s a n d t h e i r j o y s . I h a v e b e e n t r u s t e d by p a t i e n t s t o a s s i s t them i n t h e i r u n d e r s t a n d i n g o f t h e i r p e r c e p t i o n s o f t h e w o r l d . I h a v e a l s o f e l t t h e h e l p l e s s n e s s o f b e i n g u n a b l e t o e f f e c t c h a n g e i n p a t i e n t s e i t h e r as a r e s u l t o f t h e a l i e n n a t u r e o f t h e p a t i e n t ' s w o r l d o r my own i n a b i l i t y t o d e a l w i t h what t h e p a t i e n t ' s b e h a v i o u r e v o k e d w i t h i n me. I n a l l t h e s e e n c o u n t e r s w i t h p a t i e n t s I h a v e e x p e r i e n c e d t h e r e l a t i o n s h i p as a l e a r n i n g e x p e r i e n c e w h e r e e i t h e r m y s e l f o r t h e p a t i e n t o r b o t h o f us h a v e g a i n e d new k n o w l e d g e a n d s k i l l s , e a c h b e c o m i n g more c o m p e t e n t ; t h e p a t i e n t i n c o p i n g w i t h i l l n e s s a n d me i n h e l p i n g p a t i e n t s . I n s p i t e o f what I a n d o t h e r n u r s e s know a n d u n d e r s t a n d o f o u r e x p e r i e n c e s i n t h e s e r e l a t i o n s h i p s w i t h p a t i e n t s , p s y c h i a t r i c n u r s i n g r e m a i n s a c o m p l e x phenomenon t h a t i s p o o r l y u n d e r s t o o d by n u r s e s t h e m s e l v e s a n d o t h e r members o f t h e h e a l t h c a r e t e a m . 3 One o f t h e m a i n r e a s o n s f o r t h i s l a c k o f u n d e r s t a n d i n g i s due t o t h e l a c k o f k n o w l e d g e a b o u t t h a t i n t e r s u b j e c t i v e e x p e r i e n c e o f b o t h t h e n u r s e a n d t h e p a t i e n t i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p . S p e c i f i c a l l y , t h e r e i s l i t t l e known a b o u t n u r s e s ' e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n p s y c h i a t r i c c a r e s e t t i n g s t h a t h e l p s us u n d e r s t a n d t h e m e a n i n g s a n d i n t e r p r e t a t i o n s o f t h e i r e x p e r i e n c e s . T h e r e h a s b e e n a l a c k o f s y s t e m a t i c i n v e s t i g a t i o n o f t h e l i v e d e x p e r i e n c e o f t h e n u r s e i n t h i s r e l a t i o n s h i p . P u r p o s e o f t h e S t u d y G i v e n t h e l a c k o f s y s t e m a t i c i n v e s t i g a t i o n d e t a i l i n g n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s , t h e p u r p o s e o f t h i s s t u d y was t o e x p l o r e a n d d e s c r i b e n u r s e s ' p e r c e p t i o n s o f t h o s e e x p e r i e n c e s , w i t h t h e a i m o f u n c o v e r i n g k n o w l e d g e a n d u n d e r s t a n d i n g o f t h i s p h e n o m e n o n . S p e c i f i c a l l y , t h e s t u d y a i m e d t o u n c o v e r a n d d e s c r i b e common themes e x p r e s s e d by n u r s e s t h r o u g h t h e i r p e r c e p t i o n s o f a n d t h e i r r e s p o n s e s t o e v e n t s t h a t h a p p e n b e t w e e n them a n d t h e p a t i e n t s t h e y n u r s e i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . As a n u r s e c o m m i t t e d t o t h e a d v a n c e m e n t o f p s y c h i a t r i c n u r s i n g p r a c t i c e a n d t h e o r y , I b e l i e v e t h a t 4 a s t u d y o f n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n w o r k i n g w i t h p a t i e n t s who s u f f e r f r o m s e v e r e m e n t a l h e a l t h p r o b l e m s w i l l g e n e r a t e v a l u a b l e i n s i g h t s a b o u t t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s a n d t h e m e a n i n g t h e s e r e l a t i o n s h i p s h a v e f o r t h e m . T h i s k n o w l e d g e w i l l a l s o c o n t r i b u t e t o a b e t t e r u n d e r s t a n d i n g o f t h e p r a c t i c e o f p s y c h i a t r i c n u r s i n g i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . S u c h k n o w l e d g e c o u l d a l s o c o n t r i b u t e t o t h e c o n t i n u e d f o r m u l a t i o n o f t h e o r i e s o f p s y c h i a t r i c n u r s i n g p r a c t i c e t h a t a r e b a s e d on a n d a r e f a i t h f u l t o r e a l i t i e s o f p r a c t i c e . R e s e a r c h Q u e s t i o n T h e r e s e a r c h q u e s t i o n f o r t h e s t u d y was : "What a r e n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s w o r k i n g w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s ? " B e c a u s e p s y c h i a t r i c n u r s i n g i s p r a c t i s e d w i t h i n t h e c o n t e x t o f a n u r s e - p a t i e n t r e l a t i o n s h i p , t h e s t u d y s p e c i f i c a l l y a s k e d : "What a r e n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s t h a t a r e a d m i t t e d t o a n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g b e c a u s e o f a s e v e r e m e n t a l h e a l t h p r o b l e m ? " B a c k g r o u n d t o t h e P r o b l e m  P s y c h i a t r i c n u r s i n g P s y c h i a t r i c n u r s i n g i s b o t h a p a r t o f a l l n u r s i n g a n d a s p e c i a l i z e d a r e a o f n u r s i n g . T h i s s t u d y f o c u s e s 5 on p s y c h i a t r i c n u r s i n g as a s p e c i a l t y . A s a n u r s i n g s p e c i a l t y , i t i s d e s c r i b e d as a n a r e a o f n u r s i n g p r a c t i c e e m p l o y i n g t h e o r i e s o f human b e h a v i o u r as i t s s c i e n c e a n d t h e p u r p o s e f u l u s e o f s e l f as i t s a r t . I t i s d i r e c t e d t o w a r d b o t h p r e v e n t a t i v e a n d c o r r e c t i v e i m p a c t s u p o n m e n t a l d i s o r d e r s a n d t h e i r s e q u e l a e a n d i s c o n c e r n e d w i t h t h e p r o m o t i o n o f o p t i m a l m e n t a l h e a l t h f o r s o c i e t y , t h e c o m m u n i t y , a n d t h o s e who l i v e w i t h i n i t ( A N A , 1 9 7 6 ) . A s s p e c i a l i s t s , p s y c h i a t r i c n u r s e s f o c u s t h e i r p r a c t i c e on p e r s o n s e x p e r i e n c i n g m e n t a l h e a l t h p r o b l e m s t h a t a r e t y p i c a l l y a s s o c i a t e d w i t h e i t h e r s e v e r e e m o t i o n a l d i s t r e s s o r i m p a i r m e n t i n one o r more i m p o r t a n t a r e a s o f f u n c t i o n i n g o r w i t h a s i g n i f i c a n t i n c r e a s e d r i s k o f s u f f e r i n g d e a t h , p a i n , d i s a b i l i t y , o r a n i m p o r t a n t l o s s o f f r e e d o m (DSM 1 1 1 - R , 1 9 8 7 ) . W i t h i n t h e c o n t e x t o f p s y c h i a t r i c n u r s i n g , e m p h a s i s i s p l a c e d on t h e r e l a t i o n s h i p b e t w e e n t h e n u r s e a n d t h e p a t i e n t w h i c h i s a i m e d a t p r o m o t i n g p a t i e n t g r o w t h , c h a n g e , c o p i n g a n d a d a p t i o n ( O r l a n d o , 1 9 6 1 ; P e p l a u , 1 9 5 2 , 1 9 6 4 , 1 9 8 9 ; T r a v e l b e e , 1 9 7 1 ; U j h e l y , 1 9 6 8 , 1 9 8 5 ) . C h a r a c t e r i s t i c a l l y , " p s y c h i a t r i c n u r s i n g i s s i m i l a r t o a l l n u r s i n g i n t h a t i t u s e s a n i n t e r p e r s o n a l p r o c e s s t o a c h i e v e t h e p u r p o s e o f n u r s i n g " ( D o o n a , 1 9 7 9 , p . 9 3 ) . T h e n u r s e - p a t i e n t r e l a t i o n s h i p , 6 c o n s c i o u s l y a n d d e l i b e r a t e l y e s t a b l i s h e d a n d m a i n t a i n e d by t h e n u r s e , i s t h e medium t h r o u g h w h i c h t h e n u r s i n g p r o c e s s i s i m p l e m e n t e d a n d t h e means by w h i c h a p a t i e n t i s h e l p e d t o grow a n d c o p e t h r o u g h an e x p e r i e n c e o f i 1 l n e s s . I n p s y c h i a t r i c n u r s i n g h o w e v e r , t h e p a t i e n t a n d t h e n u r s e make s p e c i a l u s e o f t h i s i n t e r p e r s o n a l p r o c e s s . T h i s p r o c e s s i s r e f e r r e d t o a s t h e t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p a n d i s u s e d f o r t h e p u r p o s e o f i n t e n s i v e s h o r t t e r m i n t e r v e n t i o n s u c h as a s s i s t i n g p a t i e n t s t o s o l v e i m m e d i a t e p r o b l e m s , a n d when a p p r o p r i a t e , f o r s u p p o r t i v e p s y c h o t h e r a p y ( L e g o , 1 9 8 0 ) . T h e r e l a t i o n s h i p a l s o s e r v e s as a c o r r e c t i v e e m o t i o n a l e x p e r i e n c e f o r p a t i e n t s , a n e x p e r i e n c e t h a t f a c i l i t a t e s t h e h e a l i n g o f wounds i n f l i c t e d by p r e v i o u s l y d a m a g i n g r e l a t i o n s h i p s w i t h s i g n i f i c a n t o t h e r s a n d a m o d e l f o r f u t u r e r e l a t i o n s h i p s . T h e r e l a t i o n s h i p p r o v i d e s a way f o r p a t i e n t s t o l e a r n t h r o u g h e x p e r i e n c e t o s o l v e p r o b l e m s a n d t o d e v e l o p i n t e r p e r s o n a l c o m p e t e n c i e s t h a t h a v e b e e n l o s t o r n e v e r l e a r n e d ( P e p l a u , 1 9 5 2 ) . I n g u i d i n g p a t i e n t s t h r o u g h t h i s i n t e r p e r s o n a l p r o c e s s , p s y c h i a t r i c n u r s e s make u s e o f a d v a n c e d k n o w l e d g e o f t h e p s y c h o s o c i a l a n d b i o p h y s i c a l s c i e n c e s , t h e o r i e s o f p e r s o n a l i t y , human b e h a v i o u r , 7 p s y c h o p a t h o l o g y a n d p h a r m a c o l o g y . P s y c h i a t r i c n u r s i n g a l s o demands i n d e p e n d e n t t h i n k i n g , c r e a t i v i t y , k e e n o b s e r v a t i o n s k i l l s , i n t e r a c t i v e s k i l l s , d e c i s i o n - m a k i n g s k i l l s a n d s k i l l i n t h e t h e r a p e u t i c u s e o f s e l f . T h e c o n c e p t o f t h e r a p e u t i c u s e o f s e l f i m p l i e s t h a t n u r s e s , n o t o n l y p r o c e d u r e s o r t e c h n i q u e s , f a c i l i t a t e h e a l i n g a n d c o n s t r u c t i v e p e r s o n a l g r o w t h i n p a t i e n t s . I t i m p l i e s t h a t n u r s e s u s e t h e m s e l v e s as t h e i n s t r u m e n t s o f c h a n g e ; t h a t t h e y b r i n g t h e m s e l v e s as r e a l p e o p l e t o t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n f l u e n c i n g them i n p o s i t i v e d i r e c t i o n s ( T r a v e l b e e , 1 9 7 1 ) . T h i s i n v o l v e s t h e p u l l i n g t o g e t h e r o f s e v e r a l i m p o r t a n t p e r s o n a l e l e m e n t s i n c o m b i n a t i o n w i t h t h e k n o w l e d g e a n d t h e s k i l l s l i s t e d a b o v e t o c r e a t e c o n d i t i o n s o f t r u s t a n d s a f e t y w h e r e b y p a t i e n t s c a n r e s p o n d i n a t r u s t i n g manner a n d h e l p t h e m s e l v e s . I t i n v o l v e s s e l f a w a r e n e s s a n d t h e a b i l i t y t o i n t e r p r e t a n d m o n i t o r o n e ' s own b e h a v i o u r ; k n o w l e d g e a b o u t o n e ' s b e l i e f s , v a l u e s , a t t i t u d e s a n d d o m i n a n t e m o t i o n a l themes t h a t may p r e v e n t t h e g r o w t h o f b o t h o r e i t h e r t h e p a t i e n t a n d t h e n u r s e i n t h e r e l a t i o n s h i p . I t i n v o l v e s t h e e x p r e s s i o n o f t h e human q u a l i t i e s o f c o m p a s s i o n , c a r i n g , empathy u n d e r s t a n d i n g a n d a c c e p t a n c e o f t h e p a t i e n t as w o r t h y o f r e s p e c t a n d d i g n i t y ( S t u a r t & S u n d e e n , 1 9 8 7 ) . 8 W i t h i n t h e c o n t e x t o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p , p s y c h i a t r i c n u r s e s p e r f o r m a v a r i e t y o f r o l e s i n c a r i n g f o r p a t i e n t s . T h e t h e r a p e u t i c u s e o f s e l f i s o p e r a t i v e i n a l l o f t h e s e r o l e s . E a c h o f t h e s e r o l e s a r i s e s o u t o f t h e m u l t i p l i c i t y o f p a t i e n t ' s n e e d s ( B e n f e r , 1 9 8 0 ; P e p l a u , 1 9 5 2 , 1 9 6 4 , 1 9 8 9 ) . T h e s e r o l e s i n c l u d e : N u r t u r e r , c o u n s e l l o r , t e a c h e r , t e c h n i c i a n , a n d a d v o c a t e . A s n u r t u r e r , t h e n u r s e f u n c t i o n s a s p h y s i c a l c a r e g i v e r a n d p r o t e c t o r f r o m i n j u r y . T h e n u r s e a s s i s t s p a t i e n t s t o meet b a s i c p h y s i o l o g i c a l n e e d s s u c h as s a f e t y a n d n u t r i t i o n . The n u r s e i s warm a n d c a r i n g a n d i s a s o u r c e o f u n c o n d i t i o n a l a c c e p t a n c e as p a t i e n t s move t o w a r d more a u t o n o m o u s a n d a d a p t i v e b e h a v i o u r . A s c o u n s e l l o r , t h e n u r s e a s s i s t s p a t i e n t s t o e x a m i n e c u r r e n t r e s p o n s e s t o p a i n f u l a n d f r i g h t e n i n g s t r e s s o r s , p a t t e r n s o f p r o b l e m s o l v i n g a n d i n t e r p e r s o n a l d i f f i c u l t i e s a n d t o d e v e l o p a p p r o p r i a t e c o p i n g s t r a t e g i e s . As t e a c h e r , t h e n u r s e h e l p s p a t i e n t s l e a r n b e h a v i o u r s t h a t p r o m o t e m e n t a l a n d p h y s i c a l h e a l t h a n d i m p r o v e d i n t e r p e r s o n a l s k i l l s l e a d i n g t o s u c c e s s i n l i v i n g w i t h o t h e r p e o p l e . T h i s may i n c l u d e b a s i c a s p e c t s o f s e l f c a r e , how t o r e l a t e t o o t h e r s , how t o d e t e r m i n e a p p r o p r i a t e s o c i a l b e h a v i o u r , how t o s o l v e p r o b l e m s a n d how t o u s e t i m e p r o d u c t i v e l y . A s t e a c h e r t h e n u r s e i s a l s o a r o l e m o d e l f o r p a t i e n t s . As t e c h n i c i a n , t h e n u r s e a d m i n i s t e r s m e d i c a t i o n s , m o n i t o r s t h e i r d e s i r e d e f f e c t s a n d a s s e s s e s f o r s i d e e f f e c t s . T h i s r e q u i r e s k n o w l e d g e a b o u t s e v e r a l d i m e n s i o n s o f p s y c h o t r o p i c d r u g u s e , s u c h as d r u g i n t e r a c t i o n s , t h e r a p e u t i c v e r s u s t o x i c d o s a g e l e v e l s , d e s i r e d e f f e c t s a n d s i d e e f f e c t s a n d c l i n i c a l judgemen a b o u t p a t i e n t b e h a v i o u r a n d t h e n e e d f o r a n d t i m i n g o f m e d i c a t i o n s . A s t e c h n i c i a n , t h e n u r s e may a l s o be i n v o l v e d i n c a r r y i n g o u t m e d i c a l a n d s u r g i c a l p r o c e d u r e s . A s a d v o c a t e , t h e n u r s e e d u c a t e s p a t i e n t s a n d f a m i l i e s a b o u t t h e i r r i g h t s a n d p r o t e c t s p a t i e n t s f r o m h e a l t h c a r e s y s t e m a b u s e s o r n e g l e c t ( H a b e r e t a l . , 1987) . I n p s y c h i a t r i c n u r s i n g , a s i n n u r s i n g i n g e n e r a l , " n u r s e s a r e a c c o u n t a b l e f o r g a t h e r i n g c o m p l e t e a n d a c c u r a t e d a t a a b o u t p a t i e n t ' s n e e d s , m a k i n g s o u n d j u d g e m e n t s a b o u t t h e d a t a , p l a n n i n g a n d i m p l e m e n t i n g a p p r o p r i a t e n u r s i n g c a r e , a n d e v a l u a t i n g t h e e f f e c t s o c a r e i n a n o n g o i n g , d y n a m i c m a n n e r " ( H a g e r t y , 1 9 8 4 , p . 4 ) . T h i s i s a c c o m p l i s h e d by u s i n g t h e n u r s i n g p r o c e s s a d e l i b e r a t e , p r o b l e m s o l v i n g a c t i v i t y c o n s i s t i n g o f f i v e m a j o r c o m p o n e n t s . T h e f i v e c o m p o n e n t s a r e 10 a s s e s s m e n t , d i a g n o s i s , p l a n n i n g , i n t e r v e n t i o n a n d e v a l u a t i o n w i t h i n w h i c h e x i s t s a s e r i e s o f o n g o i n g , s y s t e m a t i c a c t i o n s , i n t e r a c t i o n s , a n d t r a n s a c t i o n s b e t w e e n t h e n u r s e a n d t h e p a t i e n t . T h e u s e o f t h e n u r s i n g p r o c e s s i s c e n t r a l t o t h e n u r s e ' s p r a c t i c e a n d t o t h e r o l e o f t h e n u r s e . P s y c h i a t r i c n u r s i n g as a p r o c e s s o r i e n t a t e d p r a c t i c e w i t h a s c i e n t i f i c k n o w l e d g e b a s e i s g u i d e d by t h e A m e r i c a n N u r s e s ' A s s o c i a t i o n S t a n d a r d s o f P s y c h i a t r i c M e n t a l H e a l t h N u r s i n g P r a c t i c e ( 1 9 8 2 ) . T h e s t a n d a r d s p r e s c r i b e t h e s k i l l s a n d b e h a v i o u r s i n i t i a t e d a n d c a r r i e d o u t i n d e p e n d e n t l y by t h e n u r s e . T h e s e s t a n d a r d s a r e a p p l i e d t o t h e p r a c t i c e o f p s y c h i a t r i c n u r s i n g i n C a n a d a a n d t h e U . S . ( s e e A p p e n d i x A ) . The C a n a d i a n F e d e r a t i o n o f M e n t a l H e a l t h N u r s e s i s p r e s e n t l y d e v e l o p i n g C a n a d i a n s t a n d a r d s f o r m e n t a l h e a l t h a n d p s y c h i a t r i c n u r s i n g p r a c t i c e . P s y c h i a t r i c n u r s i n g i s p r a c t i s e d i n a v a r i e t y o f s e t t i n g s . T h e s e t t i n g f u r t h e r d e f i n e s t h e n a t u r e o f t h e n u r s e ' s p r a c t i c e by d e t e r m i n i n g t h e k i n d s o f e x p e r i e n c e s p s y c h i a t r i c n u r s e s h a v e i n w o r k i n g w i t h p a t i e n t s w i t h m e n t a l h e a l t h p r o b l e m s . T h e n u r s e who w o r k s an 8 t o 12 h o u r s h i f t w i t h p a t i e n t s i n an i n p a t i e n t s e t t i n g h a s d i f f e r e n t k i n d s o f e x p e r i e n c e s t h a n , f o r e x a m p l e , t h e n u r s e who s e e s p a t i e n t s f o r one 11 h o u r o n c e a week i n a c o m m u n i t y s e t t i n g . F o r t h e p u r p o s e s o f t h i s s t u d y , t h e i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g i s d e s c r i b e d . T h e I n p a t i e n t P s y c h i a t r i c C a r e S e t t i n g T h e i n p a t i e n t s e t t i n g i s one o f t h e c o n t e x t s i n w h i c h p s y c h i a t r i c n u r s i n g i s p r a c t i s e d . W i t h i n t h e i n p a t i e n t s e t t i n g n u r s e s f o r m p a r t o f a n i n t e r d i s c i p l i n a r y t e a m u s u a l l y c o n s i s t i n g o f m e d i c a l d o c t o r s o f whom t h e m a j o r i t y a r e p s y c h i a t r i s t s , o t h e r p h y s i c i a n s , p h a r m a c i s t s , s o c i a l w o r k e r s , c l i n i c a l p s y c h o l o g i s t s , o c c u p a t i o n a l a n d r e c r e a t i o n a l t h e r a p i s t s . T h e t e a m ' s o v e r a l l p u r p o s e i s t o p r o v i d e t r e a t m e n t f o r p a t i e n t s who a r e u n a b l e t o r e m a i n a t home o r i n t h e c o m m u n i t y b e c a u s e o f t h e s e v e r i t y o f t h e i r m e n t a l h e a l t h p r o b l e m s . T h e s e m e n t a l h e a l t h p r o b l e m s g e n e r a l l y i n c l u d e b e h a v i o u r s t h a t t h r e a t e n t h e p a t i e n t ' s own s a f e t y a n d t h e s a f e t y o f o t h e r s , o r t h a t i n t e r f e r e w i t h t h e p e r s o n ' s a b i l i t y t o i n d e p e n d e n t l y meet h i s / h e r b a s i c human n e e d s s u c h as n u t r i t i o n , a c t i v i t y , a n d r e s t . T h e n u r s i n g d i a g n o s e s mos t commonly a s s o c i a t e d w i t h s u c h p r o b l e m s a r e p o t e n t i a l f o r v i o l e n c e , s e l f - d i r e c t e d o r d i r e c t e d a t o t h e r s ; s e l f - c a r e d e f i c i t due t o s e v e r e w i t h d r a w a l i n t o t h e s e l f , r e g r e s s i o n t o a n e a r l i e r l e v e l o f d e v e l o p m e n t o r a l t e r a t i o n s i n t h o u g h t a n d p e r c e p t u a l p r o c e s s e s ( T o w n s e n d , 1 9 8 8 ) . T h e t e a m a l s o a s s i s t s p a t i e n t s i n c r i s i s . S p e c i f i c a l l y , p s y c h i a t r i c t r e a t m e n t i n an i n p a t i e n t s e t t i n g i s f o r t h e f o l l o w i n g p u r p o s e s : 1 . To p r o t e c t t h e p a t i e n t a n d o t h e r s f r o m t h e p a t i e n t ' s s u i c i d a l o r h o m i c i d a l b e h a v i o u r . 2 . To s a f e g u a r d t h e p a t i e n t ' s r e p u t a t i o n i n t h e c o m m u n i t y (when b e h a v i o u r i s b i z a r r e ) . 3 . To remove t h e p a t i e n t f r o m a n i n t o l e r a b l e e n v i r o n m e n t o r s i t u a t i o n . 4 . T o p r o v i d e c l o s e o b s e r v a t i o n a n d m o n i t o r i n g o f p a t i e n t ' s m e n t a l s t a t u s i n o r d e r t o f o r m u l a t e a d i f f e r e n t i a l d i a g n o s i s . 5 . To e x p l o r e a n d i m p r o v e c r i t i c a l r e l a t i o n s h i p s a n d c o n f l i c t s i t u a t i o n s . 6. T o p r o v i d e p s y c h o t h e r a p i e s a n d s o c i o t h e r a p i e s t h a t p r o m o t e o p t i m a l f u n c t i o n i n g i n d a i l y l i v i n g . 7 . To p r o v i d e r a p i d a d m i n i s t r a t i o n a n d p r o f e s s i o n a l m o n i t o r i n g o f p s y c h o t r o p i c m e d i c a t i o n s c h e d u l e s t o o c o m p l e x f o r home u s e ( P a r i o s , 1 9 8 4 , p . 9 0 ) . T h e m a j o r a p p r o a c h u s e d by t h e m e n t a l h e a l t h t e a m t o a c h i e v e t h e s e o b j e c t i v e s i s t h e u s e o f m i l i e u t h e r a p y . M i l i e u t h e r a p y i s d e f i n e d as " t h e p u r p o s e f u l u s e o f p e o p l e , r e s o u r c e s , a n d e v e n t s i n t h e p a t i e n t ' s e n v i r o n m e n t t o p r o m o t e o p t i m a l f u n c t i o n i n g i n a c t i v i t i e s o f d a i l y l i v i n g , d e v e l o p m e n t / i m p r o v e m e n t o f 13 i n t e r p e r s o n a l s k i l l s , a n d c a p a c i t y t o manage o u t s i d e t h e i n s t i t u t i o n a l s e t t i n g " ( W i l s o n & K n e i s l , 1 9 8 9 , p . 1 1 7 0 ) . I n m i l i e u t h e r a p y t h e e n v i r o n m e n t i s d e l i b e r a t e l y s t r u c t u r e d t o be t h e r a p e u t i c ; t o p r o v i d e human r e l a t i o n s h i p s t h a t s a t i s f y e m o t i o n a l n e e d s , r e d u c e p s y c h o l o g i c a l c o n f l i c t s a n d d e p r i v a t i o n a n d s t r e n g t h e n i m p a i r e d ego f u n c t i o n s ( H a b e r e t a l . , 1 9 8 7 ) . T h i s c o n c e p t i s b a s e d on t h e a s s u m p t i o n t h a t t h e s o c i a l m i l i e u i t s e l f c a n be a n i n s t r u m e n t o f c h a n g e ; t h a t p e o p l e c h a n g e , l e a r n a n d m a t u r e as a r e s u l t o f t h e i r i n t e r p e r s o n a l a n d s o c i a l r e l a t i o n s h i p s a n d e x p e r i e n c e s . J o n e s ( 1 9 5 3 ) , t h e o r i g i n a t o r o f t h e c o n c e p t o f t h e t h e r a p e u t i c c o m m u n i t y i n w h i c h t h e t o t a l e n v i r o n m e n t i s u s e d t o p r o m o t e b e h a v i o u r a l c h a n g e s u g g e s t s t h a t i n some , b u t n o t a l l , p s y c h i a t r i c c o n d i t i o n s , t h e r e i s much t o be l e a r n e d f r o m o b s e r v i n g p a t i e n t s i n a f a m i l i a r s o c i a l e n v i r o n m e n t s o t h a t t h e i r u s u a l ways o f r e l a t i n g t o o t h e r p e o p l e a n d t h e i r r e a c t i o n s t o s t r e s s c a n be o b s e r v e d . T h e s i t u a t i o n i s p o t e n t i a l l y t h e r a p e u t i c when p a t i e n t s a r e made aware o f t h e e f f e c t o f t h e i r b e h a v i o u r on o t h e r p e o p l e , a n d h e l p e d t o u n d e r s t a n d some o f t h e m o t i v a t i o n u n d e r l y i n g t h e i r a c t i o n s . A l t h o u g h t h e r o l e s o f e a c h member o f t h e i n t e r d i s c i p l i n a r y t e a m a r e s i m i l a r a n d o f t e n o v e r l a p , 14 e a c h d i s c i p l i n e p e r f o r m s d i f f e r e n t f u n c t i o n s r e l a t e d t o t h e i r a r e a o f e x p e r t i s e . W i t h i n t h e i n p a t i e n t s e t t i n g n u r s e s h a v e t h e u n i q u e n e s s o f b e i n g i n t h e e n v i r o n m e n t 24 h o u r s a day a n d s o , i n a d d i t i o n t o f u n c t i o n i n g as t h e p r i m a r y c a r e g i v e r s , n u r s e s a r e a l s o r e s p o n s i b l e f o r t h e management o f t h e p a t i e n t ' s e n v i r o n m e n t a n d f o r t h e c o o r d i n a t i o n o f t h e m e n t a l h e a l t h t e a m ' s a c t i v i t i e s ( B e n f e r , 1 9 8 0 ) . A s t h e p r i m a r y c a r e g i v e r s , n u r s e s a r e r e s p o n s i b l e f o r e n t e r i n g i n t o t h e r a p e u t i c r e l a t i o n s h i p s w i t h p a t i e n t s f o r t h e p u r p o s e s o f p r o v i d i n g s h o r t t e r m i n t e r v e n t i o n s , p r o v i d i n g p h y s i c a l c a r e t o p a t i e n t s , a d m i n i s t e r i n g a n d m o n i t o r i n g o f p s y c h o p h a r m a c o l o g i c a l t r e a t m e n t s , d o i n g h e a l t h t e a c h i n g a n d p a r t i c i p a t i n g i n t h e r a p y g r o u p s a n d a c t i v i t i e s . B e c a u s e o f t h e s e v e r i t y o f p a t i e n t ' s p r o b l e m s e n c o u n t e r e d i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s , n u r s e s a r e a l s o r e s p o n s i b l e f o r i n t e r v e n i n g i n s i t u a t i o n s t h a t r e q u i r e i m m e d i a t e , i n t e n s i v e i n t e r v e n t i o n s t o r e l i e v e t h e p a t i e n t ' s s e v e r e e m o t i o n a l d i s t r e s s a n d t o p r e v e n t b e h a v i o u r s t h a t a r e a p o t e n t i a l d a n g e r t o s e l f a n d o t h e r s . A s m a n a g e r s o f t h e p a t i e n t ' s e n v i r o n m e n t , n u r s e s a r e r e s p o n s i b l e f o r t h e m a i n t e n a n c e o f a t h e r a p e u t i c e n v i r o n m e n t a n d a w a r e n e s s o f t h e o n g o i n g a n d e v e r -c h a n g i n g p r o c e s s e s o c c u r r i n g i n i t . T h e y a r e 15 r e s p o n s i b l e f o r p r o v i d i n g a p h y s i c a l e n v i r o n m e n t t h a t i s s a f e a n d s e c u r e f o r p a t i e n t s . T h e y must c r e a t e a n a t m o s p h e r e o r " t o n e " i n t h e e n v i r o n m e n t w h i c h i s s e n s e d by p a t i e n t s as h e a l i n g a n d n u r t u r i n g . T h e y must be m i n d f u l o f s e n s o r y a n d s o c i a l s t i m u l i t h a t may c o n t r i b u t e t o i n c r e a s e d d i s t u r b e d b e h a v i o u r i n p a t i e n t s . T h e y must p r e p a r e s t r u c t u r e d s c h e d u l e s ; t i m e f o r t h e r a p y , f o r m e a l s , f o r a c t i v i t i e s o f d a i l y l i v i n g , f o r t h e r a p y g r o u p s a n d a c t i v i t i e s on a n d o f f t h e u n i t . N u r s e s must u s e c l i n i c a l j u d g e m e n t i n e n f o r c i n g t h e u n i t ' s norms a n d r u l e s a n d r e g u l a t i o n s ( J o h n s o n , 1 9 8 6 ) . As c o o r d i n a t o r o f t h e m e n t a l h e a l t h t e a m ' s a c t i v i t i e s , n u r s e s o r g a n i z e a l l a s p e c t s o f p a t i e n t c a r e , c o n t i n u a l l y a s s e s s i n g p a t i e n t s ' l e v e l o f f u n c t i o n i n g , c o m m u n i c a t i n g t h e i r f i n d i n g s t o o t h e r t eam members a n d c o l l a b o r a t i n g i n t h e p l a n n i n g a n d i m p l e m e n t a t i o n o f i n t e r v e n t i o n s . P s y c h i a t r i c n u r s i n g a n d t h e i n p a t i e n t c o n t e x t o f c a r e h a v e b e e n d e s c r i b e d . I t s h o u l d be n o t e d , h o w e v e r , t h a t p s y c h i a t r i c n u r s i n g a n d t h e many c o n t e x t s o f p s y c h i a t r i c n u r s i n g c a r e do n o t l e n d t h e m s e l v e s e a s i l y t o c o n c r e t e , one d i m e n s i o n a l d e s c r i p t i o n s . T h e y a r e b o t h p r o c e s s e s a n d p a r t s o f l a r g e r s y s t e m s ; p s y c h i a t r i c n u r s i n g i s p a r t o f n u r s i n g a n d i n p a t i e n t p s y c h i a t r i c 16 c a r e s e t t i n g s a r e p a r t o f t h e t o t a l m e n t a l h e a l t h s y s t e m a n d t h e h o s p i t a l o r g a n i z a t i o n . T h e o r e t i c a l F r a m e w o r k A h u m a n i s t i c i n t e r p e r s o n a l n u r s i n g m o d e l p r o v i d e s t h e t h e o r e t i c a l f r a m e w o r k f o r t h i s s t u d y . T h i s n u r s i n g m o d e l s y n t h e s i z e s t h e t h e o r e t i c a l f r a m e w o r k s o f P a t e r s o n a n d Z d e r a d ' s h u m a n i s t i c m o d e l ( 1 9 8 8 ) , P e p l a u ' s d e v e l o p m e n t a l i n t e r p e r s o n a l m o d e l (1952) a n d T r a v e l b e e ' s i n t e r p e r s o n a l p r o c e s s m o d e l ( 1 9 7 1 ) . I n t h i s p s y c h i a t r i c n u r s i n g m o d e l , e m p h a s i s i s p l a c e d on t h e r e l a t i o n s h i p b e t w e e n t h e n u r s e a n d p a t i e n t w h i c h i s d e s c r i b e d as "an e x i s t e n t i a l e x p e r i e n c e l i v e d b e t w e e n t h e n u r s e a n d p a t i e n t w h e r e b y e a c h n u r s i n g s i t u a t i o n r e c i p r o c a l l y e v o k e s a n d a f f e c t s t h e e x p r e s s i o n a n d m a n i f e s t a t i o n s o f t h e s e human b e i n g s ' c a p a c i t y f o r a n d c o n d i t i o n o f e x i s t e n c e " ( P a t e r s o n & Z d e r a d , 1 9 8 8 , p . 3 ) . N u r s i n g i s v i e w e d as a l i v i n g , i n t e r s u b j e c t i v e , t r a n s a c t i o n a l a c t o r phenomenon w h i c h comes i n t o e x i s t e n c e when one p e r s o n n e e d s a s p e c i a l i z e d f o r m o f h e l p ; i t i n v o l v e s a mode o f b e i n g a n d a mode o f d o i n g s o m e t h i n g ( P a t e r s o n & Z d e r a d , 1 9 8 8 ) . N u r s i n g i s m o r e t h a n t h e a p p l i c a t i o n o f k n o w l e d g e a n d s k i l l s , a l t h o u g h n e c e s s a r y t o a n a c t o f n u r s i n g , i t i s a s e n s e o f b e i n g w i t h o r a c o - p a r t i c i p a n t i n t h e s u b j e c t i v e - i n t e r n a l w o r l d o f t h e e x p e r i e n c i n g p e r s o n ( W a t s o n , 1 9 8 5 ) . I t i s 17 a r e l a t i o n s h i p o f I a n d T h o u "no m a t t e r w h e t h e r s p o k e n o r s i l e n t - w h e r e e a c h o f t h e p a r t i c i p a n t s r e a l l y h a s i n m i n d t h e o t h e r o r o t h e r s i n t h e i r p r e s e n t a n d p a r t i c u l a r b e i n g a n d t u r n s t o them w i t h t h e i n t e n t i o n o f e s t a b l i s h i n g a l i v i n g m u t u a l r e l a t i o n " ( B u b e r , 1 9 6 5 , P . 1 9 ) . W i t h i n t h i s c o n c e p t u a l f r a m e w o r k e a c h p e r s o n i s v i e w e d as a c o m p l e x l i v i n g o r g a n i s m w i t h t h e c a p a c i t y t o l e a r n a n d grow i n s p i t e o f l i m i t a t i o n s i m p o s e d by b i o l o g i c a l a n d e n v i r o n m e n t a l f a c t o r s . R e c o g n i t i o n i s g i v e n t o t h e u n i q u e n e s s o f e a c h p e r s o n ' s s u b j e c t i v e e x p e r i e n c e , o f d i s c o v e r i n g a n d r e s p e c t i n g t h o s e e x p e r i e n c e s a n d t h e m e a n i n g s a t t a c h e d t o t h e m . E m p h a s i s i s p l a c e d on t h e p r e s e r v a t i o n o f t h e i r i n t e g r i t y a n d f r e e d o m o f t h e p e r s o n t o p a r t i c i p a t e i n d e c i s i o n s t h a t d i r e c t l y a f f e c t t h e m . T h e n u r s e - p a t i e n t r e l a t i o n s h i p s e r v e s as a c o r r e c t i v e e m o t i o n a l e x p e r i e n c e f o r p a t i e n t s ; an e x p e r i e n c e w h i c h p r o v i d e s f o r t h e h e a l i n g o f wounds i n f l i c t e d by p r e v i o u s l y d a m a g i n g r e l a t i o n s h i p s w i t h s i g n i f i c a n t o t h e r s a n d as a m o d e l f o r f u t u r e r e l a t i o n s h i p s . I t i s i n t h e r e l a t i o n s h i p where p a t i e n t s l e a r n t o d e v e l o p ways t o c o n v e r t t e n s i o n a n d a n x i e t y a s s o c i a t e d w i t h i n t r a p s y c h i c a n d r e l a t i o n s h i p c o n f l i c t s i n t o more p u r p o s e f u l a c t i v i t y . 18 C o m m u n i c a t i o n i s v i e w e d as a means i n h e l p i n g p a t i e n t s e s t a b l i s h r e l a t e d n e s s , s u s t a i n t h e i r movement t o w a r d h e a l t h , a n d a c h i e v e i n t e r p e r s o n a l c o m p e t e n c y . N u r s e s u n d e r s t a n d t h e e l e m e n t s o f t h e c o m m u n i c a t i o n p r o c e s s a n d u s e s p e c i f i c s k i l l s a n d t e c h n i q u e s t o a c h i e v e t h e g o a l s o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p . P u r p o s e f u l c o m m u n i c a t i o n w i t h i n t h e r e l a t i o n s h i p i s a c h i e v e d when t h e n u r s e u s e s t h e c o m m u n i c a t i o n s k i l l s o f e m p a t h y , r e f l e c t i n g a n d p a r a p h r a s i n g , s e l f -d i s c l o s u r e , c o n f r o n t i n g a n d i n t e r p r e t i n g , a n d i m m e d i a c y . S e l f - a w a r e n e s s , r e s p e c t , c o m p a s s i o n , e m p a t h i c u n d e r s t a n d i n g b l e n d e d w i t h a s t r o n g b e l i e f i n t h e s e l f - a c t u a l i z i n g p o t e n t i a l o f t h e p a t i e n t a r e a l l e s s e n t i a l p e r s o n a l q u a l i t i e s o f t h e n u r s e i n t h e n u r s e -p a t i e n t r e l a t i o n s h i p . A l t h o u g h e a c h n u r s e - p a t i e n t e n c o u n t e r i s u n i q u e a n d o r i g i n a l , a l l n u r s e - p a t i e n t i n t e r a c t i o n s p r o c e e d t h r o u g h f o u r d i s t i n c t b u t i n t e r r e l a t e d p h a s e s ; o r i e n t a t i o n p h a s e , i d e n t i f i c a t i o n p h a s e , w o r k i n g p h a s e , a n d t e r m i n a t i o n p h a s e . I n t h e o r y , e a c h p h a s e b u i l d s u p o n t h e p r e c e d i n g p h a s e a n d d e f i n e s r o l e s a n d t a s k s r e q u i r e d o f t h e n u r s e ; h o w e v e r i n r e a l i t y , i s s u e s a n d t a s k s b e l o n g i n g i n one p h a s e may s u r f a c e i n a n o t h e r . T h e o r i e n t a t i o n p h a s e b e g i n s when p a t i e n t a n d n u r s e meet a n d become known t o e a c h o t h e r a n d b e g i n 19 e s t a b l i s h i n g a w o r k i n g p a r t n e r s h i p . R o l e s a n d r e s p o n s i b i l i t i e s o f b o t h p a r t i c i p a n t s a r e d i s c u s s e d . P a t i e n t p r o b l e m s a r e i d e n t i f i e d a n d t h e n u r s e l i s t e n s f o r themes t h a t may h e l p b o t h p a t i e n t a n d n u r s e d e f i n e t h e s e p r o b l e m s more c l e a r l y . T h e n u r s e c o l l e c t s d a t a a b o u t t h e p a t i e n t a n d b e g i n s t o make t e n t a t i v e h y p o t h e s e s w h i l e t h e p a t i e n t g a t h e r s d a t a a n d makes i n f e r e n c e s a b o u t t h e n u r s e . T h e g r a d u a l t r a n s i t i o n i n t o t h e i d e n t i f i c a t i o n p h a s e i s a c c o m p a n i e d by d e e p e r e x p l o r a t i o n o f t h e p a t i e n t ' s f e e l i n g s , n e e d s a n d g o a l s . T h e n u r s e ' s r e s p o n s i v e n e s s a n d empathy i s c r u c i a l f o r t h e d e v e l o p m e n t o f t r u s t a n d e m o t i o n a l s e c u r i t y i n t h e r e l a t i o n s h i p . O n c e a p a t i e n t h a s i d e n t i f i e d w i t h a n u r s e , t h e y e n t e r t h e w o r k i n g p h a s e i n w h i c h p a t i e n t s b e g i n a n i n t e n s i v e p r o c e s s o f u n d e r s t a n d i n g t h e m s e l v e s a n d t h e ways t h e y n e e d t o c h a n g e . I n c r e a s e d i n s i g h t i s g a i n e d ; t h e m e a n i n g o f i l l n e s s a n d t h e d y n a m i c s o f o n e ' s b e h a v i o u r a r e b e t t e r u n d e r s t o o d . New ways o f b e h a v i n g a r e i d e n t i f i e d a n d a r e t e s t e d w i t h i n t h e r e l a t i o n s h i p . I d e a l l y t e r m i n a t i o n o f t h e r e l a t i o n s h i p o c c u r s when b o t h p a t i e n t a n d n u r s e b e l i e v e i t i s a p p r o p r i a t e . T e r m i n a t i o n o c c u r s when t h e p a t i e n t h a s a t t a i n e d s u f f i c i e n t i n t e l l e c t u a l a n d i n t e r p e r s o n a l c o m p e t e n c y t o 20 m a i n t a i n an o p t i m a l l e v e l o f w e l l b e i n g . I s s u e s s u c h as l o s s , a b a n d o n m e n t a n d a n g e r a r e f r e q u e n t p a t i e n t r e a c t i o n s t o t e r m i n a t i o n a n d must be a d d r e s s e d . T e r m i n a t i o n p r o v i d e s a p u r p o s e f u l c l o s u r e t o m e a n i n g f u l r e l a t i o n s h i p s by p r o v i d i n g a m o d e l l i n g e x p e r i e n c e f o r t h e t e r m i n a t i o n o f f u t u r e r e l a t i o n s h i p s . T h e h u m a n i s t i c - i n t e r p e r s o n a l m o d e l o f p s y c h i a t r i c n u r s i n g e m p h a s i z e s t h e r e l a t i o n s h i p b e t w e e n t h e n u r s e a n d p a t i e n t as t h e i n t e r p e r s o n a l s t r u c t u r e w i t h i n w h i c h t h e n u r s e p r o v i d e s n u r s i n g c a r e t o t h e p a t i e n t . Methodological Approach T h e p h e n o m e n o l o g i c a l a p p r o a c h o f q u a l i t a t i v e r e s e a r c h was u s e d t o i n v e s t i g a t e t h i s s t u d y ' s r e s e a r c h q u e s t i o n . S i n c e p h e n o m e n o l o g i c a l r e s e a r c h e x i s t s f o r t h e p u r p o s e o f e x p l o r i n g i n d i v i d u a l s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s , i t i s a n a p p r o p r i a t e m e t h o d o l o g y f o r e x p l o r i n g t h e e x p e r i e n c e o f n u r s e s w o r k i n g w i t h p a t i e n t s i n p s y c h i a t r i c c a r e s e t t i n g s ( G i o r g i , 1 9 7 5 ; P o l k i n g h o r n e , 1 9 8 9 ) . P h e n o m e n o l o g y , t h e s t u d y o f human e x p e r i e n c e a s i t i s l i v e d ( M e r l e a u - P o n t y , 1 9 6 4 ) , i s a m e t h o d i n p h i l o s o p h y t h a t h a s grown i n r e a c t i o n t o " t h e d e n i g r a t i o n o f p h i l o s o p h i c a l k n o w l e d g e a n d t h e o b j e c t i f i c a t i o n o f humans" (Ornery, 1 9 8 3 , p . 5 1 ) . P h e n o m e n o l o g i c a l r e s e a r c h e r s do n o t r e f u s e t o e x a m i n e t h e sum o f t h e p a r t s o f a phenomenon b u t r e c o g n i s e t h a t a w h o l e may be d i f f e r e n t f r o m t h e sum o f i t s p a r t s . Ornery (1983) s t a t e s " p h e n o m e n o l o g y a c c e p t s t h e e x p e r i e n c e as i t e x i s t s i n t h e c o n s c i o u s n e s s o f t h e s u b j e c t ( p . 60) . . . [ a n d ] i t d o e s n o t r e d u c e t h e human b e i n g u n d e r s t u d y t o an o b j e c t w i t h many s m a l l q u a n t i t a t i v e u n i t s " ( p . 4 9 ) . "Human phenomena [ s u c h as n u r s i n g ] a r e n o t o b j e c t l i k e ; t h e y c a n n o t be i n s p e c t e d a n d s t u d i e d i n t h e manner o f o b j e c t s . . . . t h e y a r e n o t n e u t r a l i t e m s t h a t c a l l f o r a n e u t r a l a n d d e t a c h e d i n d e p e n d e n t d e s c r i p t i o n . T h e y h a v e t o do w i t h modes o f e x i s t i n g a n d t h e m e a n i n g o f b e i n g " ( W a t s o n , 1 9 8 5 , p . 8 1 ) . P s y c h i a t r i c n u r s i n g , a n d n u r s i n g i n g e n e r a l , w h i c h d e s c r i b e t h e i r p r a c t i c e i n t e r m s o f t h e i n t e r a c t i v e n a t u r e o f human o r g a n i s m s a n d w h i c h p r o n o u n c e s n u r s i n g ' s h u m a n i s t i c a n d m u l t i d i m e n s i o n a l a p p r o a c h e s t o p a t i e n t c a r e , n e e d t o be s t u d i e d u s i n g a r e s e a r c h m e t h o d t h a t e m b r a c e s a h o l i s t i c p e r s p e c t i v e . P h e n o m e n o l o g y i s a r e s e a r c h m e t h o d t h a t p r o v i d e s n u r s i n g w i t h new ways o f k n o w i n g , p a r t i c u l a r l y ways o f g r a s p i n g w h o l e s a n d c o m p l e x m e a n i n g s o f b o t h n u r s e s ' a n d p a t i e n t s ' e x p e r i e n c e s as t h e y e x i s t . P h e n o m e n o l o g y r e v e a l s t h a t w h i c h i s n o t s e e n o r o b s e r v e d by o t h e r s b u t w h i c h i s e x p e r i e n c e d a n d i s " i n e x t r i c a b l y b o u n d 22 w i t h o b j e c t i v e r e a l i t y " ( M u n h a l l & O i l e r , 1 9 8 6 , p . x i v ) . P h e n o m e n o l o g y s e e k s t o u n d e r s t a n d t h e s u b j e c t i v e m e a n i n g o f human e x p e r i e n c e . O p e r a t i o n a l D e f i n i t i o n s T h e f o l l o w i n g i s a l i s t o f o p e r a t i o n a l d e f i n i t i o n s f o r t h e t e r m s u s e d i n t h e r e s e a r c h q u e s t i o n : P a t i e n t : A n i n d i v i d u a l who i s e x p e r i e n c i n g a m e n t a l h e a l t h p r o b l e m a n d who i s h o s p i t a l i z e d i n a p s y c h i a t r i c c a r e s e t t i n g , s p e c i f i c a l l y a n i n p a t i e n t p s y c h i a t r i c u n i t . N u r s e : A r e g i s t e r e d n u r s e who i s p r e p a r e d a t t h e d i p l o m a , b a c c a l a u r e a t e , o r m a s t e r s l e v e l a n d who i s c u r r e n t l y w o r k i n g i n a n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g . P s y c h i a t r i c N u r s i n g : A s p e c i a l i z e d a r e a o f n u r s i n g p r a c t i c e e m p l o y i n g t h e o r i e s o f human b e h a v i o u r as i t s s c i e n c e a n d p u r p o s e f u l u s e o f s e l f as i t s a r t . I t i s d i r e c t e d t o w a r d b o t h p r e v e n t a t i v e a n d c o r r e c t i v e i m p a c t s u p o n m e n t a l d i s o r d e r s a n d t h e i r s e q u e l a e a n d i s c o n c e r n e d w i t h t h e p r o m o t i o n o f o p t i m a l m e n t a l h e a l t h f o r s o c i e t y , t h e c o m m u n i t y , a n d t h o s e i n d i v i d u a l s who l i v e w i t h i n i t ( A N A , 1 9 7 6 ) . P s y c h i a t r i c C a r e S e t t i n g : P s y c h i a t r i c c a r e s e t t i n g s i n c l u d e t h o s e s p e c i a l i z e d p r o g r a m s w i t h i n h o s p i t a l s t h a t a r e s t r u c t u r e d t o p r o v i d e f o r i n d i v i d u a l s who a r e 23 e x p e r i e n c i n g m e n t a l h e a l t h p r o b l e m s . T h e s e u n i t s a n d / o r p r o g r a m s i n c l u d e i n p a t i e n t p s y c h i a t r i c u n i t s , day o r e v e n i n g h o s p i t a l p r o g r a m s , a n d o u t p a t i e n t t h e r a p y p r o g r a m s . Assumptions T h e p h e n o m e n o l o g i c a l m e t h o d r e q u i r e s t h a t r e s e a r c h e r s r e v e a l t h e i r a s s u m p t i o n s a b o u t t h e phenomena u n d e r i n v e s t i g a t i o n a n d t h e n s u s p e n d t h e s e i n o r d e r t o f u l l y u n d e r s t a n d t h e e x p e r i e n c e o f t h e p a r t i c i p a n t a n d n o t i m p o s e a p r i o r e x p l a n a t i o n on t h e s e e x p e r i e n c e s . T h e t e c h n i q u e u s e d t o c o n t r o l p r e c o n c e i v e d e x p e c t a t i o n s a n d e x p l a n a t i o n s i s c a l l e d b r a c k e t i n g . I n b r a c k e t i n g r e s e a r c h e r s h o l d t h e i r b e l i e f s a n d n o t i o n s a b o u t t h e phenomena " i n a b e y a n c e w h i l e w a t c h i n g t h e m e s , e s s e n c e s , a n d m e a n i n g s s u r f a c e f r o m t h e d a t a d u r i n g t h e p r o c e s s o f a n a l y z i n g , i n t u i t i n g , a n d d e s c r i b i n g " ( S m i t h , 1 9 8 9 , p . 1 5 ) . T h e p e r s o n a l a s s u m p t i o n s b r o u g h t t o t h i s s t u d y by t h e r e s e a r c h e r a r e d e s c r i b e d i n A p p e n d i x B . F i v e a d d i t i o n a l a s s u m p t i o n s made by t h i s r e s e a r c h e r w e r e : o n e , t h a t p s y c h i a t r i c n u r s i n g p r a c t i c e i s b a s e d on a t h e r a p e u t i c r e l a t i o n s h i p b e t w e e n t h e n u r s e a n d t h e p a t i e n t ; t w o , t h e n u r s e i n i t i a t e s t h e n u r s e - p a t i e n t r e l a t i o n s h i p f o r t h e p u r p o s e o f i m p l e m e n t i n g t h e n u r s i n g p r o c e s s a n d t o b r i n g a b o u t 24 p a t i e n t g r o w t h , c h a n g e , c o p i n g , a n d a d a p t a t i o n ; t h r e e , t h e n u r s e - p a t i e n t r e l a t i o n s h i p i s a f f e c t e d by t h e n u r s e ' s e x p e r i e n c e s w i t h s p e c i f i c p a t i e n t b e h a v i o u r a n d s i t u a t i o n s , n u r s i n g c o l l e a g u e s a n d s u p e r i o r s , p h y s i c i a n s , h o s p i t a l p o l i c i e s a n d p r o c e d u r e s a n d by c h a n g e s i n t h e h e a l t h c a r e s y s t e m ; f o u r , n u r s e s who h a v e t h e h i g h e s t d e g r e e o f c o n t a c t w i t h p a t i e n t s i n p s y c h i a t r i c c a r e s e t t i n g s h a v e u n i q u e a n d d i f f e r e n t e x p e r i e n c e s w o r k i n g w i t h p a t i e n t s t h a n do o t h e r p r o f e s s i o n a l s , s u c h as o c c u p a t i o n a l t h e r a p i s t s a n d s o c i a l w o r k e r s , who a l s o work w i t h p a t i e n t s i n p s y c h i a t r i c c a r e s e t t i n g s ; f i v e , n u r s e s who work w i t h p a t i e n t s i n p s y c h i a t r i c c a r e s e t t i n g s h a v e s i m i l a r a n d d i f f e r e n t e x p e r i e n c e s o f n u r s i n g as t h e i r c o u n t e r p a r t s i n o t h e r a r e a s o f n u r s i n g . L i m i t a t i o n s L i m i t s t o t h e g e n e r a l a p p l i c a t i o n o f t h i s s t u d y were s e t by t h e c h o s e n m e t h o d o f i n q u i r y n a m e l y , t h e p h e n o m e n o l o g i c a l m e t h o d . T h e g o a l o f t h e p h e n o m e n o l o g i c a l m e t h o d i s t o " u n c o v e r t h e m e a n i n g o f h u m a n l y e x p e r i e n c e d phenomenon" t h r o u g h t h e a n a l y s i s o f p a r t i c i p a n t s ' c o n c r e t e d e s c r i p t i o n s . B e c a u s e t h e r e s e a r c h e r was i n t e r e s t e d i n a l l o w i n g a phenomenon t o "show i t s e l f " w i t h o u t t h e u s e o f " p r e d i c t i v e p r e s c r i p t i o n s o f t h e q u a n t i t a t i v e m e t h o d s " , t h e r e s e a r c h e r s e l e c t e d t h e s t u d y ' s p a r t i c i p a n t s a c c o r d i n g t o t h e i r k n o w l e d g e b a s e a n d r e c e p t i v i t y a n d n o t t o a c h i e v e s t a t i s t i c a l g e n e r a l i z a t i o n ( P a r s e e t a l . , 1 9 8 5 , p . 1 5 ) . T h e r e s e a r c h e r t h e r e f o r e , u s e d n o n - p r o b a b i l i t y s a m p l i n g t e c h n i q u e s a n d k e p t t h e s a m p l e s i z e s m a l l b e c a u s e o f t h e amount o f t i m e i t t a k e s t o t r a n s c r i b e a n d a n a l y z e t h e v e r b a t i m n o t e s f o r e a c h p a r t i c i p a n t . A p r i m a r y l i m i t a t i o n o f n o n - p r o b a b i l i t y s a m p l i n g t e c h n i q u e s a n d a s m a l l s a m p l e s i z e i s t h a t t h e r e s e a r c h e r c a n n o t g e n e r a l i z e t h e f i n d i n g s o f a s t u d y t o t h e p o p u l a t i o n b e i n g s t u d i e d . T h e r e f o r e , t h e f i n d i n g s o f t h i s s t u d y c a n n o t be g e n e r a l i z e d o r a p p l i e d t o o t h e r p o p u l a t i o n s o f n u r s e s w o r k i n g i n o t h e r a r e a s o f p s y c h i a t r i c n u r s i n g p r a c t i c e o r t o t h e p r a c t i c e o f n u r s i n g i n g e n e r a l . G e n e r a l i z a t i o n , a t e r m r o o t e d i n q u a n t i t a t i v e m e t h o d s o f i n q u i r y , d o e s n o t r e l a t e t o p h e n o m e n o l o g i c a l r e s e a r c h a n d t h e r e f o r e t o t h i s s t u d y ( S m i t h , 1 9 8 9 ) . 26 CHAPTER TWO: REVIEW OF R E L A T E D L I T E R A T U R E T h e p u r p o s e o f t h i s c h a p t e r i s t o p r o v i d e a r e v i e w o f l i t e r a t u r e r e l a t e d t o t h e c o n c e p t u a l i z a t i o n o f t h e p r o b l e m s t a t e m e n t i n C h a p t e r O n e . R e l e v a n t r e s e a r c h a n d t h e o r y w i l l be e x p l o r e d t o f u r t h e r s u b s t a n t i a t e t h e c o n c e p t u a l i z a t i o n o f t h e p r o b l e m . T h i s c h a p t e r w i l l t h e r e f o r e c e n t r e a r o u n d t h e o r e t i c a l a n d r e s e a r c h w o r k s r e l a t e d t o t h e t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p . T h e d i s c u s s i o n o f r e l e v a n t r e s e a r c h on t h e t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p i s d i v i d e d i n t o f o u r s e c t i o n s : o n e , t h e c o m m u n i c a t i v e a c t i o n o f t h e n u r s e i n t h e c o n s t i t u t i o n o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p ; t w o , p a t i e n t a n d n u r s e c h a r a c t e r i s t i c s i n t h e c o n s t i t u t i o n o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p ; t h r e e , t h e s o c i a l o r g a n i z a t i o n i n t h e c o n s t i t u t i o n o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p ; f o u r , e v e n t s i n t h e w i d e r s o c i a l c o n t e x t a n d c h a n g e s i n n u r s i n g i d e o l o g i e s . T h e T h e r a p e u t i c N u r s e - P a t i e n t R e l a t i o n s h i p :  T h e o r e t i c a l W o r k s T h e n u r s e - p a t i e n t r e l a t i o n s h i p h a s a v e r y s p e c i a l p l a c e i n p s y c h i a t r i c n u r s i n g d i s c o u r s e . T h e t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p , f i r m l y e s t a b l i s h e d as t h e c o r n e r s t o n e o f p s y c h i a t r i c n u r s i n g , i s a phenomenon w e l l d e f i n e d a n d d e s c r i b e d i n b o t h t h e g e n e r a l a n d p s y c h i a t r i c n u r s i n g l i t e r a t u r e . 27 P e p l a u , i n h e r c l a s s i c w o r k , I n t e r p e r s o n a l R e l a t i o n s i n N u r s i n g ( 1 9 5 2 ) , h e r a l d e d t h e i n t r o d u c t i o n o f t h e f i r s t s y s t e m a t i c t h e o r e t i c a l f r a m e w o r k f o r p s y c h i a t r i c n u r s i n g a n d f o c u s e d on t h e t h e r a p e u t i c r o l e o f t h e n u r s e i n a o n e - t o - o n e r e l a t i o n s h i p w i t h p a t i e n t s . P e p l a u ' s t h e o r y w h i c h draws f r o m S u l l i v a n ' s I n t e r p e r s o n a l t h e o r y a n d , i n p a r t f r o m l e a r n i n g t h e o r y , p r o v i d e s a f r a m e w o r k w i t h i n w h i c h n u r s e s h e l p p a t i e n t s t o e x p l o r e t h e i r c u r r e n t i n t e r p e r s o n a l e x p e r i e n c e s i n o r d e r t o i m p r o v e them t h r o u g h t h e d e v e l o p m e n t o f i n t e r p e r s o n a l c o m p e t e n c i e s ( L e g o , 1 9 8 0 ) . P e p l a u (1952) d e f i n e d n u r s i n g a s , "a s i g n i f i c a n t , t h e r a p e u t i c , i n t e r p e r s o n a l p r o c e s s t h a t a i m s t o p r o m o t e a p a t i e n t ' s h e a l t h i n t h e d i r e c t i o n o f c r e a t i v e , c o n s t r u c t i v e , p r o d u c t i v e , p e r s o n a l a n d c o m m u n i t y l i v i n g " ( p . 1 6 ) . M e l l o w ( 1968 ) i n t r o d u c e d a s e c o n d t h e o r e t i c a l f r a m e w o r k f o r p s y c h i a t r i c n u r s i n g p r a c t i c e w h i c h a l s o c e n t r e d on t h e d e v e l o p m e n t o f a n u r s e - p a t i e n t r e l a t i o n s h i p b u t drew f r o m p s y c h o a n a l y t i c t h e o r y r a t h e r t h a n f r o m S u l l i v a n ' s i n t e r p e r s o n a l t h e o r y . M e l l o w b e l i e v e d t h a t t h e n u r s e - p a t i e n t r e l a t i o n s h i p s e r v e d as a c o r r e c t i v e e x p e r i e n c e f o r t h e p a t i e n t . T h e p r e m i s e was t h a t t h e p a t i e n t w o u l d l e a r n t o h a v e more s a t i s f y i n g i n t e r p e r s o n a l r e l a t i o n s h i p s i n g e n e r a l . O r l a n d o ( 1 9 6 1 ) , d r a w i n g f r o m S u l l i v a n ' s 28 i n t e r p e r s o n a l t h e o r y a n d s y m b o l i c i n t e r a c t i o n i s m , p r e s e n t e d a t h i r d c o n c e p t u a l f r a m e w o r k f o r a l l n u r s e -p a t i e n t r e l a t i o n s h i p s , n o t j u s t p s y c h i a t r i c s i t u a t i o n s . O r l a n d o ' s f r a m e w o r k f o c u s e d on t h e n u r s e r e s p o n d i n g t o p a t i e n t s ' unmet n e e d s t h r o u g h a d y n a m i c n u r s e - p a t i e n t r e l a t i o n s h i p ; d y n a m i c , m e a n i n g t h e n u r s e i s a c t i v e l y i n v o l v e d w i t h p a t i e n t s c o n t i n u a l l y a s s e s s i n g a n d r e s p o n d i n g t o t h e i r unmet n e e d s . O r l a n d o e m p h a s i z e d d e l i b e r a t e a c t i o n s by n u r s e s w i t h i n t h e i n t e r p e r s o n a l p r o c e s s : f i r s t , t h e n u r s e o b s e r v e s t h e p a t i e n t s ' d i s t r e s s a n d h e l p s t h e p a t i e n t t o e x p r e s s t h e m e a n i n g o f h i s / h e r b e h a v i o u r , a n d s e c o n d l y , t h e n u r s e a s s i s t s t h e p a t i e n t i n i d e n t i f y i n g ways t o r e l i e v e h i s / h e r d i s t r e s s . O r l a n d o ' s t h e o r y i s s i g n i f i c a n t b e c a u s e i t p r o v i d e d a f r a m e w o r k f o r t h e d e v e l o p m e n t o f t h e c o m p o n e n t s o f t h e n u r s i n g p r o c e s s w h i c h i s n u r s i n g ' s m o d e l f o r p r o b l e m s o l v i n g i n t h e c l i n i c a l p r a c t i c e . A l t h o u g h P e p l a u ' s , M e l l o w ' s a n d O r l a n d o ' s t h e o r i e s h a v e f o r m e d t h e b a s i s f o r most p s y c h i a t r i c n u r s i n g p r a c t i c e t h e o r y , t h e r e h a s b e e n i n t h e l a s t 20 y e a r s , a g r e a t d e a l o f p s y c h i a t r i c n u r s i n g p r a c t i c e t h e o r y b a s e d on c o n c e p t s f r o m e x i s t e n t i a l a n d h u m a n i s t i c p s y c h o l o g y ( P a t e r s o n & Z d e r a d , 1978; P e p l a u , 1 9 5 2 , 1 9 6 4 , 1 9 8 7 , 1 9 8 9 ; T r a v e l b e e , 1 9 7 1 ; U j h e l y , 1 9 6 8 , 29 1 9 8 5 ) . T h e s y n t h e s i s o f e x i s t e n t i a l a n d h u m a n i s t i c c o n c e p t s i n t o a n u r s i n g p r a c t i c e t h e o r y h a s r e s u l t e d i n an e m p h a s i s i n t h e l i t e r a t u r e on t h e s e l f - a w a r e n e s s o f t h e n u r s e ; t h e r a p e u t i c u s e o f s e l f i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p ; f a c i l i t a t i v e c o n d i t i o n s f o r c o n s t r u c t i v e p e r s o n a l i t y c h a n g e , a n d t h e d e v e l o p m e n t o f t h e r a p e u t i c c o m m u n i c a t i o n s k i l l s . M o s t p s y c h i a t r i c n u r s i n g t h e o r i s t s t o d a y c o n c e p t u a l i z e p s y c h i a t r i c n u r s i n g p r a c t i c e f r o m e x i s t e n t i a l a n d h u m a n i s t i c t h i n k e r s s u c h as M a y , B u b e r , M a s l o w a n d R o g e r s . T h e o r y d e v e l o p m e n t i s d e v o t e d t o t h e o r i e s o f h e l p i n g w i t h e m p h a s i s on t h e n u r s e - p a t i e n t r e l a t i o n s h i p d e f i n i n g t h e r e l a t i o n s h i p as an " I - T h o u " r e l a t i o n s h i p : d o i n g a n d b e i n g w i t h p a t i e n t s . R o g e r s ' f a c i l i t a t i v e c o n d i t i o n s , a i m e d a t h e l p i n g p a t i e n t s t o become more f u l l y f u n c t i o n i n g , a r e c o n s i s t e n t l y i n c l u d e d i n d i s c u s s i o n s o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p . T h e r e i s a l s o a n e m p h a s i s t o w a r d t h e t r a i n i n g o f n u r s e s i n h e l p i n g s k i l l s t o d e v e l o p t h e r a p e u t i c r e l a t i o n s h i p s . I n s p i t e o f a l o n g a n d a c o n t i n u e d e m p h a s i s on t h e n u r s e - p a t i e n t r e l a t i o n s h i p b o t h i n g e n e r a l n u r s i n g a n d i n p s y c h i a t r i c n u r s i n g t h e o r y , t h e l i t e r a t u r e r e v e a l s a l e s s t h a n c o m p r e h e n s i v e r e s e a r c h t r a d i t i o n on t h e n u r s e - p a t i e n t r e l a t i o n s h i p . 30 T h e l i t e r a t u r e a l s o r e v e a l s t h a t i n v e s t i g a t i o n s o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p g e n e r a l l y f a l l i n t o themes a n d a r e c o n s t i t u t e d on " a s s u m p t i o n s a n d i d e a s d e r i v e d f r o m a r a n g e o f t h e o r e t i c a l a n d i d e o l o g i c a l f r a m e w o r k s w h i c h h a v e a c t e d t o f r a m e r e s e a r c h q u e s t i o n s , a n d t o d e t e r m i n e t h e p e r s p e c t i v e f r o m w h i c h r e s e a r c h h a s b e e n d i r e c t e d " ( M a y , 1 9 9 0 , p . 3 0 7 ) . I n p s y c h i a t r i c n u r s i n g , r e s e a r c h on t h e n u r s e -p a t i e n t r e l a t i o n s h i p c a n be d i v i d e d i n t o f o u r t y p e s : o n e , t h e c o m m u n i c a t i v e a c t i o n o f t h e n u r s e i n t h e c o n s t i t u t i o n o f t h e r e l a t i o n s h i p ; t w o , p a t i e n t a n d n u r s e c h a r a c t e r i s t i c s i n t h e c o n s t i t u t i o n o f t h e n u r s e -p a t i e n t r e l a t i o n s h i p ; t h r e e , t h e s o c i a l o r g a n i z a t i o n i n t h e c o n s t i t u t i o n o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p . M o r e r e c e n t l y , n u r s e t h e o r i s t s h a v e p r o p o s e d t h a t t h e n u r s e - p a t i e n t r e l a t i o n s h i p may a l s o be c o n s t i t u t e d by e v e n t s i n t h e w i d e r s o c i a l c o n t e x t a n d c h a n g e s i n n u r s i n g i d e o l o g i e s . A l t h o u g h no r e s e a r c h c o u l d be f o u n d t o s u p p o r t t h i s v i e w , a b r i e f d i s c u s s i o n o f i t i s i n c l u d e d b e c a u s e o f i t s r e l e v a n c e t o t h i s s t u d y . T h e C o m m u n i c a t i v e A c t i o n o f t h e N u r s e i n t h e  C o n s t i t u t i o n o f t h e N u r s e - p a t i e n t R e l a t i o n s h i p . May ( 1 9 9 0 ) d e s c r i b e d t h e c o m m u n i c a t i v e a c t i o n o f t h e n u r s e a s " t h o s e a s p e c t s o f i n t e r p e r s o n a l e n c o u n t e r s b e t w e e n n u r s e s a n d p a t i e n t s w h i c h a r e i n some way 31 q u a n t i f i a b l e " a n d " f r o m w h i c h i n f e r e n c e s may be d r a w n a b o u t t h e n a t u r e o f t h e s o c i a l r e l a t i o n s h i p b e t w e e n them" ( p . 3 0 8 ) . T h i s t y p e o f r e s e a r c h f o c u s e s on t h e d i r e c t o b s e r v a t i o n a n d m e a s u r e m e n t o f n u r s e - p a t i e n t i n t e r a c t i o n s a n d i t a s s u m e s t h a t t h e r e i s a c o n n e c t i o n b e t w e e n t h e f r e q u e n c y , d u r a t i o n , a n d q u a l i t y o f n u r s e -p a t i e n t i n t e r a c t i o n s a n d t h e f o r m a t i o n o f a t h e r a p e u t i c r e l a t i o n s h i p . M e a s u r e m e n t o f d u r a t i o n a n d f r e q u e n c y o f v e r b a l  i n t e r a c t i o n . S t u d i e s w h i c h m e a s u r e t h e d u r a t i o n a n d f r e q u e n c y o f v e r b a l i n t e r a c t i o n h a v e c o n s i s t e n t l y shown t h a t n u r s e - p a t i e n t i n t e r a c t i o n i s t y p i c a l l y o f s h o r t d u r a t i o n , i n f r e q u e n t a n d t h e c o n t e n t o f t h e i n t e r a c t i o n d e l i m i t e d a n d c o n t r o l l e d by n u r s e s (Adams & M a c l l w r a i t h , 1 9 6 3 ; K e c k & W a l t h e r , 1 9 7 7 ; M c L e o d C l a r k , 1982 ; S t o c k w e l l , 1 9 7 2 ) . I n t e r e s t i n g l y , v e r y l i t t l e o f t h i s t y p e o f r e s e a r c h h a s b e e n c o n d u c t e d w i t h n u r s e s i n p s y c h i a t r i c c a r e s e t t i n g s . I t h a s t a k e n p l a c e m o s t l y i n m e d i c a l a n d s u r g i c a l c a r e s e t t i n g s w h e r e p a t i e n t s a r e h o s p i t a l i z e d f o r a p h y s i c a l i l l n e s s . T h e r e i s some e v i d e n c e , h o w e v e r , t o s u g g e s t t h a t n u r s e - p a t i e n t i n t e r a c t i o n i n p s y c h i a t r i c c a r e s e t t i n g s i s a l s o o f s h o r t d u r a t i o n , i n f r e q u e n t a n d f o c u s e d on n u r s i n g t a s k s a n d a d m i n i s t r a t i v e a c t i v i t i e s . A l t s c h u l ( 1972 ) r e p o r t e d o b s e r v a t i o n a l d a t a c o n c e r n i n g n u r s e -32 p a t i e n t i n t e r a c t i o n r a t e s a n d t i m e s on f o u r p s y c h i a t r i c w a r d s . A l t h o u g h i n t e r e s t i n g , t h e l a c k o f h o m o g e n e i t y among t h e p a t i e n t s a m p l e a n d t h e w a r d s u s e d t o c a r r y o u t t h e s e o b s e r v a t i o n s r a i s e s q u e s t i o n s a b o u t t h e a c c u r a c y o f t h e s e f i n d i n g s . T h e s t u d y a l s o e x c l u d e d o t h e r v e r b a l i n t e r c h a n g e s b e t w e e n t h e n u r s e s a n d p a t i e n t s t h a t may c o n t r i b u t e t o t h e n u r s e - p a t i e n t r e l a t i o n s h i p o r be p e r c e i v e d by b o t h n u r s e s a n d p a t i e n t s a s h e l p f u l e n c o u n t e r s . F o r e x a m p l e , i n t e r c h a n g e s t h a t o c c u r r e d d u r i n g r o u n d s , mea l t i m e s , a t t h e t i m e o f d r u g a d m i n i s t r a t i o n , d u r i n g r e c r e a t i o n a l a c t i v i t i e s a n d f o l l o w i n g o f f - w a r d a c t i v i t i e s s u c h as o c c u p a t i o n a l t h e r a p y . A l t s c h u l d i d n o t d e s c r i b e what t h e n u r s e s w e r e d o i n g when t h e y were n o t i n c o n t a c t w i t h p a t i e n t s . B u n c h ( 1982 ) i n a q u a l i t a t i v e c o m p a r a t i v e f i e l d s t u d y t h a t e x a m i n e d t h e e f f e c t o f a b n o r m a l s c h i z o p h r e n i c c o m m u n i c a t i o n on t h e n u r s e - p a t i e n t i n t e r a c t i o n s on a p s y c h i a t r i c w a r d r e p o r t e d , t h a t , i n s p i t e o f t h e i r p r o f e s s i o n a l m a n d a t e t o e n g a g e i n t h e r a p e u t i c r e l a t i o n s h i p s w i t h p a t i e n t s , t h e n u r s e s s p e n t m o r e t i m e i n t a l k i n g b u s i n e s s w i t h e a c h o t h e r , m e d i c a t i n g a n d s e c l u d i n g p a t i e n t s t h a n i n t e r a c t i n g w i t h t h e m , e v e n when w a r d s were q u i e t . T h e i n s t i t u t i o n a l r e q u i r e m e n t s seemed t o t a k e p r e c e d e n c e o v e r p r o f e s s i o n a l a n d c l i n i c a l r e q u i r e m e n t s . B u n c h (1982) s u g g e s t e d t h a t n u r s e s h a v e " g r e a t d i f f i c u l t y o p e r a t i o n a l i z i n g t h e i r p r o f e s s i o n a l m a n d a t e s , k n o w l e d g e , a n d u n d e r s t a n d i n g o f p s y c h o p a t h o l o g y a n d b a l a n c i n g t h e s e s a t i s f a c t o r i l y w i t h t h e i n s t i t u t i o n a l demands" ( p . 1 0 7 ) . T h e d e a r t h o f r e s e a r c h on t h e c o m m u n i c a t i v e a c t i o n o f t h e p s y c h i a t r i c n u r s e w i t h p a t i e n t s i s s u r p r i s i n g g i v e n t h e h i g h p r i o r i t y t h a t q u a l i t y n u r s e - p a t i e n t i n t e r a c t i o n a n d t h e n u r s e - p a t i e n t r e l a t i o n s h i p r e c e i v e i n p s y c h i a t r i c n u r s i n g l i t e r a t u r e ( F i e l d , P i e r c e - J o n e s , 1 9 6 7 ; M e l l o w , 1968; O r l a n d o , 1 9 6 1 ; P e p l a u , 1 9 5 2 , 1 9 6 4 , 1 9 8 7 , 1 9 8 9 ; T r a v e l b e e , 1 9 7 1 ) . T h r e e r e a s o n s may a c c o u n t f o r t h i s , o n e , t h e r e may e x i s t an a s s u m p t i o n amongs t n u r s e r e s e a r c h e r s t h a t b e c a u s e p s y c h i a t r i c n u r s i n g i s f o c u s e d on t h e u s e o f s e l f i n a r e l a t i o n s h i p w i t h p a t i e n t s , t h e r e i s no n e e d f o r t h i s t y p e o f r e s e a r c h . T h e a s s u m p t i o n i s t h a t , b e c a u s e p s y c h i a t r i c n u r s e s a r e n o t b o u n d by n u m e r o u s t a s k s a n d p r o c e d u r e s , t h e f r e q u e n c y a n d d u r a t i o n o f t h e i r i n t e r a c t i o n s w i t h p a t i e n t s must be s u p e r i o r t o t h o s e o f t h e i r g e n e r a l n u r s i n g c o u n t e r p a r t s . A s e c o n d r e a s o n , w h i c h may a c c o u n t f o r t h e p a u c i t y o f r e s e a r c h on t h e c o m m u n i c a t i v e a c t i o n o f t h e n u r s e i n p s y c h i a t r i c s e t t i n g s , may h a v e t o do w i t h t h e f a c t t h a t 34 t h e f o c u s on i n t e r p e r s o n a l r e l a t i o n s h i p s i n p s y c h i a t r i c n u r s i n g e m e r g e d i n c o n c e r t w i t h m i l i e u t h e r a p y . T h e s t u d y o f n u r s e - p a t i e n t i n t e r a c t i o n r a t e s a n d f r e q u e n c y o f t i m e as m e a s u r e s o f t h e q u a l i t y o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p i s h a m p e r e d by t h e n u m e r o u s o t h e r t h e r a p e u t i c a c t i v i t i e s s t r u c t u r e d i n t o t h e m i l i e u . I t may be t h a t many o f t h e n u r s e s ' t h e r a p e u t i c i n t e r a c t i o n s , a s s e s s m e n t s , a n d i n t e r v e n t i o n s a r e c a r r i e d o u t i n t h e c o n t e x t o f t h e g r o u p s a n d a c t i v i t i e s a n d n o t s o l e l y d u r i n g o n e - t o - o n e t i m e w i t h t h e p a t i e n t . L e g o ( 1 9 8 0 ) , i n a r e v i e w o f l i t e r a t u r e on t h e n u r s e -p a t i e n t r e l a t i o n s h i p , s t a t e d t h a t " i t was d i f f i c u l t t o s e p a r a t e s t u d i e s i n m i l i e u t h e r a p y f r o m s t u d i e s i n o n e -t o - o n e r e l a t i o n s h i p s b e c a u s e t h e two h a v e s o o f t e n b e e n s t u d i e d t o g e t h e r " ( p . 7 9 ) . A t h i r d e x p l a n a t i o n f o r t h e l a c k o f r e s e a r c h on t h e c o m m u n i c a t i v e a c t i o n o f t h e n u r s e may h a v e t o do w i t h t h e f a c t t h a t p s y c h i a t r i c n u r s i n g c o n c e p t s were d e v e l o p e d u s i n g c o n c e p t s b o r r o w e d f r o m p s y c h o a n a l y t i c t h e o r y a n d i n t e r p e r s o n a l t h e o r y . I t i s o n l y n a t u r a l t h e r e f o r e t h a t r e s e a r c h i n t o t h e n u r s e - p a t i e n t r e l a t i o n s h i p w o u l d f o c u s on t h e l a r g e r r e l a t i o n s h i p d y n a m i c s o c c u r r i n g b e t w e e n t h e n u r s e a n d t h e p a t i e n t t h a n on t h e c o m m u n i c a t i v e a c t i o n s o f t h e n u r s e . M e a s u r e m e n t o f g e n e r a l a s p e c t s o f n u r s e - p a t i e n t 35 r e l a t i o n s h i p s . W h i l e p s y c h i a t r i c n u r s i n g h a s p r o d u c e d i n s t r u m e n t s t h a t p u r p o r t t o m e a s u r e a s p e c t s o f n u r s e -p a t i e n t i n t e r a c t i o n s i t h a s n o t p r o d u c e d s i g n i f i c a n t r e s e a r c h m e a s u r i n g t h e d u r a t i o n a n d f r e q u e n c y o f n u r s e -p a t i e n t i n t e r a c t i o n s . T h r e e s c a l e s h a v e e m e r g e d f r o m t h e f i e l d o f p s y c h i a t r i c n u r s i n g . M e t h v e n a n d S c h l o f e l d t (1962) d e v e l o p e d t h e " S o c i a l I n t e r a c t i o n I n v e n t o r y " t o s t u d y t h e n a t u r e o f v e r b a l r e s p o n s e s n u r s e s g i v e i n e m o t i o n a l - l a d e n s i t u a t i o n s . Mathews (1962 ) c o n s t r u c t e d t h e " R e s p o n s e t o P a t i e n t " i n s t r u m e n t t o m e a s u r e p e r s o n - c e n t r e d q u a l i t i e s o f n u r s e s ' r e s p o n s e s t o p a t i e n t s . A i k e n a n d A i k e n (1973 ) d e s i g n e d a s c a l e b a s e d on C a r l R o g e r s ' ( 1968) a n d C a r k h u f f a n d B e r e n s o n ' s ( 1967 ) work t o m e a s u r e t h e f a c i l i t a t i v e l e v e l o f t h e r a p e u t i c r e l a t i o n s h i p . T h e a p p l i c a b i l i t y o f t h e s e s c a l e s i s q u e s t i o n a b l e i n t e r m s o f v a l i d i t y a n d r e l i a b i l i t y as no a d d i t i o n a l i n d i c a t i o n o f t h e i r u s e i n c l i n i c a l s e t t i n g s c o u l d be f o u n d i n t h e l i t e r a t u r e . I t a l s o a p p e a r s t h a t t h e s e s c a l e s were d e v e l o p e d f o r e d u c a t i o n a l p u r p o s e s ; t o be u s e d as t e s t i n g m e t h o d s i n t h e t e a c h i n g o r t r a i n i n g o f h e l p i n g s k i l l s t o n u r s i n g s t u d e n t s a n d p r a c t i s i n g n u r s e s . M o r e r e c e n t l y , F o r c h u k a n d Brown (1989) d e v e l o p e d an i n s t r u m e n t t o m e a s u r e t h e p h a s e s o f t h e n u r s e -p a t i e n t r e l a t i o n s h i p as d e s c r i b e d by P e p l a u ( 1 9 5 2 ) . T h e s c a l e i n c l u d e s n u r s e a n d p a t i e n t b e h a v i o u r s i n e a c p h a s e . P r e l i m i n a r y r e s u l t s h a v e e s t a b l i s h e d i n i t i a l r e l i a b i l i t y a n d v a l i d i t y o f t h e i n s t r u m e n t . F o r c h u k a n d Brown a l s o r e p o r t e d on t h e u s e f u l n e s s o f t h e s c a l e i n p r a c t i c e . R e p o r t s f r o m n u r s e s r e v e a l e d t h a t t h e i n s t r u m e n t p r o v i d e s a n a c c u r a t e a s s e s s m e n t o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p . N u r s e s r e p o r t e d t h a t when t h e y c a n a c c u r a t e l y a s s e s s t h e p h a s e o f t h e r e l a t i o n s h i p , a p p r o p r i a t e i n t e r v e n t i o n s a r e more l i k e l t o be s e l e c t e d . M e a s u r e m e n t o f t h e e f f e c t o f s p e c i f i c c o m m u n i c a t i v e  b e h a v i o u r s . A s m a l l number o f p s y c h i a t r i c n u r s i n g s t u d i e s h a v e a l s o f o c u s e d on t h e e f f e c t s o f a p a r t i c u l a r p a t t e r n o f c o m m u n i c a t i o n on t h e n u r s e -p a t i e n t r e l a t i o n s h i p . T h e s e s t u d i e s e x a m i n e d t h e e f f e c t s o f t o u c h , s i l e n c e , a n d t h e u s e o f e m p a t h y . De A u g u s t i n i s e t a l ' s ( 1963 ) s t u d y o f t h e u s e o f t o u c h i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p f o u n d t h a t t o u c h was o f t e n i n t e r p r e t e d i n many d i f f e r e n t ways by p s y c h i a t r i c p a t i e n t s , m a i n l y i n c r e a s i n g t h e i r a n x i e t y . F o r some p a t i e n t s , i t was e x p e r i e n c e d as a b r i n g i n g b a c k t o r e a l i t y ; b a c k f r o m i n n e r t h o u g h t s a n d f a n t a s i e s . A g u i l e r a (1965) r e p o r t e d t h a t t o u c h i n g by t h e n u r s e i n c r e a s e d v e r b a l c o m m u n i c a t i o n s , r a p p o r t , 37 a p p r o a c h b e h a v i o u r a n d p o s i t i v e a t t i t u d e s o f p a t i e n t s t o w a r d n u r s e s ( L e g o , 1 9 8 0 ) . A r e c e n t s t u d y by S m i t h a n d C a n t r e l l ( 1988) u s i n g m e a s u r e s o f a n x i e t y ( p h y s i o l o g i c a l a n d s e l f - r e p o r t ) s u g g e s t s t h a t c o n t r a r y t o p r e v i o u s r e s e a r c h f i n d i n g s t h a t g e n e r a l m e d i c a l a n d s u r g i c a l p a t i e n t s e x p e r i e n c e b o t h v e r b a l a n d p h y s i c a l i n t r u s i v e n e s s , s u c h as t o u c h , as c o m f o r t i n g , p a t i e n t s w i t h s c h i z o p h r e n i c d i s o r d e r s e x p e r i e n c e d i n c r e a s e d a n x i e t y by b o t h v e r b a l a n d p h y s i c a l a n d i n t r u s i v e n e s s ( O l a n d , 1 9 7 8 ) . S m i t h a n d C a n t r e l l a c k n o w l e d g e d t h a t t h e a p p l i c a b i l i t y o f t h e s e f i n d i n g s t o p s y c h i a t r i c p a t i e n t s may be q u e s t i o n a b l e as t h e s e p a t i e n t s may n e e d i n c r e a s e d p e r s o n a l s p a c e b e c a u s e o f t h e i r d i s o r d e r s . S e l f - r e p o r t m e a s u r e s o f p a t i e n t a n x i e t y may a l s o l e a d t o i n a c c u r a t e c o n c l u s i o n s . M a n s f i e l d ( 1973 ) c o n d u c t e d a n i n v e s t i g a t i o n t o i d e n t i f y v e r b a l a n d n o n - v e r b a l b e h a v i o u r s t h a t f a c i l i t a t e d e m p a t h i c c o m m u n i c a t i o n on i n i t i a l i n t e r a c t i o n s b e t w e e n a n e x p e r i e n c e d p s y c h i a t r i c n u r s e a n d a p s y c h i a t r i c p a t i e n t . S e v e n b e h a v i o u r s t h a t c o n v e y e d h i g h l e v e l s o f empathy t o t h e p a t i e n t s w e r e i d e n t i f i e d . T h e s e b e h a v i o u r c a t e g o r i e s w e r e : i n t r o d u c t i o n t o t h e p a t i e n t , h e a d a n d b o d y p o s i t i o n s , v e r b a l b e h a v i o u r , r e s p o n s e t o n o n - v e r b a l c u e s , f a c i a l 38 e x p r e s s i o n s , v o i c e t o n e s , a n d m i r r o r i m a g e s . T h e g e n e r a l i z a b i 1 i t y o f t h e s t u d y i s m i n i m a l b e c a u s e i t was l i m i t e d t o one n u r s e i n t e r a c t i n g w i t h s i x p a t i e n t s ( D o y l e , 1 9 8 9 ) . A l t h o u g h t h e s e s t u d i e s a r e u s e f u l i n g u i d i n g p s y c h i a t r i c n u r s i n g p r a c t i c e , t h e l i t e r a t u r e r e v e a l s t h a t t h e s e t y p e o f s t u d i e s were r a r e l y r e p l i c a t e d a n d when t h e y w e r e , t h e f i n d i n g s were i n c o n s i s t e n t . L e g o ( 1 9 8 0 ) , i n a r e v i e w o f t h e l i t e r a t u r e , n o t e d t h a t p s y c h i a t r i c n u r s i n g r e s e a r c h e r s t e n d e d t o work i n i s o l a t i o n f r o m one a n o t h e r a n d r a r e l y b u i l t on one a n o t h e r ' s work w h i c h " g i v e s t h e l i t e r a t u r e a p i e c e mea l l o o k " ( p . 8 1 ) . Summary: T h e r e s e a r c h on t h e c o m m u n i c a t i v e a c t i o n s o f t h e n u r s e i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p c o n t r i b u t e s l i t t l e t o t h e r e s e a r c h q u e s t i o n i n t h i s s t u d y . B e c a u s e t h e s t u d i e s c o n c e n t r a t e d on t h e m e c h a n i c s o f i n d i v i d u a l e n c o u n t e r s , t h e m e a n i n g s a n d u n d e r s t a n d i n g s a t t r i b u t e d t o t h e s e e n c o u n t e r s by t h e a c t o r s were n e g l e c t e d . N u r s e - p a t i e n t C h a r a c t e r i s t i c s i n t h e C o n s t i t u t i o n o f  t h e N u r s e - p a t i e n t R e l a t i o n s h i p S i n c e t h e n u r s e - p a t i e n t r e l a t i o n s h i p i n v o l v e s t w o -way c o m m u n i c a t i o n b e t w e e n n u r s e a n d p a t i e n t , i t i s i m p o r t a n t t o e x a m i n e t h e i n f l u e n c e o f p a t i e n t b e h a v i o u r on t h e n u r s e a n d v i c e v e r s a . R e s e a r c h i n v o l v i n g t h e s t u d y o f n u r s e a n d p a t i e n t c h a r a c t e r i s t i c s a n d t h e i n t e r a c t i o n o f t h e s e c h a r a c t e r i s t i c s i n t h e c o n s t i t u t i o n o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p h a s b e e n p o p u l a r i n p s y c h i a t r i c n u r s i n g . H o w e v e r , t h i s t y p e o f r e s e a r c h f r e q u e n t l y f o c u s e s on i d e n t i f y i n g a n d d e s c r i b i n g c l i n i c a l c o n d i t i o n s , d i a g n o s t i c c a t e g o r i e s o f p a t i e n t s a n d p a t i e n t b e h a v i o u r s , t h a t a r e b e l i e v e d t o i n c r e a s e o r d e c r e a s e s o c i a l d i s t a n c e o r s i m p l y c r e a t e p r o b l e m s i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p . I n o t h e r w o r d s , t h e p a t i e n t i s v i e w e d as t h e p r o b l e m . T h e i n f e r e n c e s d r a w n a b o u t t h e n u r s e - p a t i e n t r e l a t i o n s h i p i n t h i s t y p e o f r e s e a r c h h a v e a l s o f r e q u e n t l y b e e n f o r m u l a t e d f r o m p s y c h o a n a l y t i c a n d S u l l i v a n ' s i n t e r p e r s o n a l t h e o r y . M u t u a l w i t h d r a w a l . Gwen T u d o r ' s ( 1952 ) b e n c h m a r k s t u d y , A S o c i o p s y c h i a t r i c N u r s i n g A p p r o a c h t o I n t e r v e n t i o n i n a P r o b l e m o f M u t u a l W i t h d r a w a l on a M e n t a l H o s p i t a l Ward s i g n a l l e d a s h i f t i n t h e c o n c e p t u a l i z a t i o n o f p s y c h i a t r i c n u r s i n g t h e o r y a n d r e s e a r c h f r o m a n i n t r a p e r s o n a l f o c u s ( p o p u l a r p r i o r t o t h e 1 9 5 0 ' s ) t o a n i n t e r p e r s o n a l f o c u s a n d , t o some e x t e n t t o a f o c u s on t h e s o c i a l m i l i e u o f a w a r d . T h e e a r l y 1 9 5 0 ' s was a l s o when m i l i e u t h e r a p y was f i r s t b e i n g i m p l e m e n t e d i n p s y c h i a t r i c c a r e s e t t i n g s . T h r o u g h t h e p r e s e n t a t i o n o f two c a s e s t u d i e s , T u d o r 40 d e m o n s t r a t e d a r e l a t i o n s h i p b e t w e e n n u r s i n g s t a f f ' s w i t h d r a w a l f r o m p a t i e n t s a n d p a t i e n t s ' w i t h d r a w a l f r o m r e a l i t y . She d i s c o v e r e d t h a t when p a t i e n t s w e r e l a b e l l e d as h o p e l e s s , a s s a u l t i v e , u n r e s p o n s i v e , a n d u n a b l e t o t o l e r a t e c l o s e n e s s , t h e y were i g n o r e d by n u r s i n g s t a f f who t h e n e n g a g e d i n f u r t h e r l a b e l l i n g o f p a t i e n t s a s u n a b l e t o h a n d l e i n t e r a c t i o n s a n d a v o i d e d c o n t a c t s w i t h them e v e n more a n d i n d o i n g s o , t h e p a t i e n t s w i t h d r e w e v e n more a n d became u n a p p r o a c h a b l e . She l a b e l l e d t h i s p r o c e s s " m u t u a l w i t h d r a w a l " a n d r e a s o n e d t h a t t h i s p a t t e r n o f s t a f f a v o i d a n c e a n d p a t i e n t w i t h d r a w a l c o n t r i b u t e d t o i l l n e s s m a i n t a i n i n g b e h a v i o u r . T u d o r t e s t e d h e r f o r m u l a t i o n by d e v i s i n g a n d i m p l e m e n t i n g i n t e r p e r s o n a l n u r s i n g i n t e r v e n t i o n s on t h i s p a t t e r n o f n u r s e - p a t i e n t i n t e r a c t i o n . She f o u n d t h a t p a t i e n t s who e x p e r i e n c e d t h e n u r s i n g i n t e r v e n t i o n s became l e s s w i t h d r a w n . T e s c h e r ( 1964 ) a n d C l o u d ( 1 9 7 2 ) , u s i n g a c a s e e x a m p l e a p p r o a c h , d e s c r i b e d t h e phenomenon o f r e s i s t a n c e i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p . T e s c h e r s u g g e s t e d t h a t when a n i n t e r p e r s o n a l r e l a t i o n s h i p i s p e r c e i v e d as t h r e a t e n i n g by e i t h e r t h e p a t i e n t o r t h e n u r s e , d i s t a n c e m a n e u v e r s w i l l be u s e d t o p u s h t h e o t h e r p e r s o n away . F o r m s o f r e s i s t a n c e were a l s o d e s c r i b e d a n d e f f e c t i v e n u r s i n g i n t e r v e n t i o n s were 41 i d e n t i f i e d a n d d e m o n s t r a t e d t h r o u g h t h e c a s e e x a m p l e s . H a l l ( 1 9 7 2 ) r e p o r t i n g r e s u l t s f r o m a f i e l d s t u d y i n a p s y c h i a t r i c s h o r t s t a y s e t t i n g a l s o i d e n t i f i e d t h e phenomenon o f m u t u a l w i t h d r a w a l . W h i l e o b s e r v i n g g r o u p s s h e n o t i c e d t h a t n u r s e s i g n o r e d p a t i e n t s who d i d n o t d i s c u s s t h e i r f e e l i n g s , p r o b l e m s o r l i f e e x p e r i e n c e s a n d t h a t t h i s c a r r i e d o v e r t o o u t s i d e t h e g r o u p s b o t h i n t h e number o f s t a f f c o n t a c t s a n d f r e q u e n c y o f m e n t i o n i n r e p o r t s . P a t i e n t s who d i d l i t t l e t o draw a t t e n t i o n t o t h e m s e l v e s were u n c o n s c i o u s l y i g n o r e d by s t a f f . H a l l ( 1977 ) s u g g e s t e d t h a t v a r i a b l e s o t h e r t h a n b i z a r r e b e h a v i o u r s t i m u l a t e m u t u a l w i t h d r a w a l i n t o d a y ' s t h e r a p e u t i c s i t u a t i o n s a n d p r o p o s e d i n t e r p e r s o n a l a t t r a c t i o n as a n a r e a f o r r e s e a r c h . R e s e a r c h r e l a t e d t o i n t e r p e r s o n a l a t t r a c t i o n i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p i s d i s c u s s e d l a t e r i n t h i s s e c t i o n o f t h e l i t e r a t u r e r e v i e w . T h e c h r o n i c p a t i e n t . S l a v i n s k y a n d K r a u s s (1980) r e p o r t t h a t t h e phenomenon o f m u t u a l w i t h d r a w a l i s e v i d e n t i n t o d a y ' s p s y c h i a t r i c c a r e s e t t i n g s i n w h i c h t h e p a t i e n t p o p u l a t i o n i s l a b e l l e d as c h r o n i c a l l y m e n t a l 1y i l l . D e i n s t i t u t i o n a l i z a t i o n w h i c h was b e l i e v e d w o u l d b r i n g a b o u t t r e m e n d o u s hope f o r t h e q u a l i t y o f l i f e f o r t h e c h r o n i c a l l y m e n t a l l y i l l seems t o h a v e done n o t h i n g 42 more t h a n c h a n g e t h e s e t t i n g o f c a r e f o r t h e m . E l i m i n a t i n g i n s t i t u t i o n a l c a r e h a s n o t e l i m i n a t e d c h r o n i c i l l n e s s . R a r e l y a r e t h o s e a s p e c t s o f i n s t i t u t i o n a l l i f e s u c h as t o l e r a n c e o f d e p e n d e n c e , t h a t were a b e n e f i t t o c h r o n i c p a t i e n t s t r a n s f e r r e d t o t h e c o m m u n i t y a n d t o c o n t e m p o r a r y i n p a t i e n t p s y c h i a t r i c s e t t i n g s i n g e n e r a l h o s p i t a l s where t h e s e p a t i e n t s a r e t r e a t e d d u r i n g a c u t e p h a s e s o f t h e i r i l l n e s s . T h e r e f o r e , what h a s r e s u l t e d i s a l a r g e g r o u p o f p a t i e n t s b e i n g f r e q u e n t l y a d m i t t e d t o i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s o f g e n e r a l h o s p i t a l s a n d l a b e l l e d as ' d i f f i c u l t ' b e c a u s e o f t h e i r c h r o n i c i t y . S h e e t s , P r o v o s t , a n d R e i h m a n (1982 ) a n d G l i c k , K l a r , a n d B r a f f ( 1984 ) r e p o r t e d t h a t n u r s e s l a b e l l e d c h r o n i c p a t i e n t p o p u l a t i o n s as ' d i f f i c u l t ' , t o c a r e f o r b e c a u s e t h e y a l t e r n a t e b e t w e e n h e l p s e e k i n g b e h a v i o u r a n d h e l p r e j e c t i n g b e h a v i o u r a n d t h e r e f o r e p r e c i p i t a t e c o u n t e r t r a n s f e r e n c e r e s p o n s e s o f f r u s t r a t i o n a n d a n g e r i n t h e n u r s e . T h e d i f f i c u l t p a t i e n t . G a l l o p a n d Wynn ( 1 9 8 7 ) , i n a s t u d y o f t h e p h e n o m e n o l o g y o f t h e ' d i f f i c u l t ' p a t i e n t , r e p o r t e d t h a t n u r s e s i d e n t i f i e d t h e c h r o n i c a l l y i l l as ' d i f f i c u l t ' t o e s t a b l i s h r e l a t i o n s h i p s w i t h b e c a u s e t h e y e x p e r i e n c e d a l a c k o f c o n t r o l a n d f e l t t o t a l l y i n c o m p e t e n t i n c a r i n g f o r t h e m . T h e two d o m i n a n t s e t s 43 o f p a t i e n t c h a r a c t e r i s t i c s n u r s e s p e r c e i v e d as ' d i f f i c u l t ' w e r e h i g h a f f e c t / h i g h i n t e n s i t y / c h r o n i c / a t t r a c t i v e a n d h i g h a f f e c t / h i g h i n t e n s i t y / c h r o n i c a n d u n a t t r a c t i v e . T h e s e c h a r a c t e r i s t i c s w e r e l i n k e d w i t h t h e d i a g n o s t i c c a t e g o r y o f p e r s o n a l i t y d i s o r d e r , s p e c i f i c a l l y b o r d e r l i n e p e r s o n a l i t y d i s o r d e r . N u r s e s r e p o r t e d f e e l i n g i n t e n s e l y o v e r w h e l m e d , g u i l t y , h e l p l e s s , e n g u l f e d a n d t e a r f u l when n u r s i n g t h e s e p a t i e n t s . G a l l o p a n d Wynn s t a t e t h a t " t h e c u r r e n t p a t t e r n o f c r i s i s a d m i s s i o n s f o r c h r o n i c p a t i e n t s means t h a t n u r s e s a r e u n l i k e l y t o s e e c h a n g e o r g r o w t h . I n s t e a d , n u r s e s c a r e f o r c h r o n i c a l l y i l l p a t i e n t s , who d u r i n g t h e i r a d m i s s i o n s , e x p r e s s i n t e n s e f e e l i n g s o f r a g e , h o p e l e s s n e s s , a n d who do n o t r e s p o n d t o t r e a t m e n t i n t e r v e n t i o n s " ( p . 2 1 4 ) . D r a w i n g f r o m p s y c h o a n a l y t i c t h e o r y , G a l l o p & Wynn p r o p o s e d t h a t t h e p a t i e n t s ' a n g r y f e e l i n g s become p r o j e c t e d o n t o s t a f f who t h e n e x p e r i e n c e t h e m as t h e i r own h e l p l e s s n e s s ( p . 2 1 4 ) . G a l l o p f u r t h e r s u g g e s t e d t h a t i n n u r s i n g " p a t i e n t s a r e a c r i t i c a l s o u r c e o f c o n f i r m a t i o n o f t h e c a r i n g , c u r i n g a n d c o m p a s s i o n a t e q u a l i t i e s o f h e a l t h c a r e p r o f e s s i o n a l s " a n d t h a t t h e " d i f f i c u l t p a t i e n t may f a i l i n t h i s t a s k o f c o n f i r m a t i o n o r i n f a c t may b e , l a b e l l e d ' d i f f i c u l t ' b e c a u s e t h e y f a i l t o c o n f i r m t h e s e 44 q u a l i t i e s " ( p . 2 1 4 ) . A number o f o t h e r s t u d i e s h a v e d e m o n s t r a t e d l i n k s b e t w e e n p s y c h i a t r i c p a t i e n t c h a r a c t e r i s t i c s a n d p s y c h i a t r i c n u r s e s ' r e s p o n s e s . C h a r a c t e r i s t i c s t h a t a r e t y p i c a l l y c o n s i d e r e d ' d i f f i c u l t ' by n u r s e s a n d as c r e a t i n g p r o b l e m s o f a v o i d a n c e , a n g e r a n d f r u s t r a t i o n i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p a r e : m a n i p u l a t i v e , d e m a n d i n g , n o n - c o m p 1 i a n t , o v e r - d e p e n d a n t , d a n g e r o u s t o s e l f a n d o t h e r s a n d w i t h d r a w n p s y c h o s i s ( C o l s o n e t a l , 1 9 8 5 ; H i g h l y & N o r r i s , 1 9 5 7 ; Newsom e t a l . 1963 ; N e i l l , 1 9 7 9 ; R o s e n t h a l e t a l , 1980; S t o c k w e l l , 1972; U j h e l y , 1 9 6 3 ) . T h e a b u n d a n t l i t e r a t u r e on t r a n s f e r e n c e a n d c o u n t e r t r a n s f e r e n c e phenomenon i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p ( G a l l o p , 1 9 8 5 ; H a y , D r a k e , & L i n d y , 1985 ; J o h n s o n , 1967 ; S c h r o d e r , 1 9 8 5 ; W i t h e r s p o o n , 1985) s t a n d s as e v i d e n c e t h a t t h e i n t e r a c t i o n o f n u r s e a n d p a t i e n t c h a r a c t e r i s t i c s p l a y a n i m p o r t a n t p a r t i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p . I n t e r p e r s o n a l a t t r a c t i o n . I n t e r p e r s o n a l a t t r a c t i o n h a s a l s o b e e n s t u d i e d as a v a r i a b l e t h a t i n f l u e n c e s t h e n u r s e - p a t i e n t r e l a t i o n s h i p i n p s y c h i a t r i c c a r e s e t t i n g s . N o n - n u r s i n g s t u d i e s r e p e a t e d l y r e v e a l t h a t a t t r a c t i o n , b a s e d on s i m i l a r i t y , s o c i a l d e s i r a b i l i t y , r e c i p r o c i t y o f l i k i n g a n d p r o x i m i t y , i s a f a c t o r i n t h e e s t a b l i s h m e n t a n d m a i n t e n a n c e o f t h e r a p e u t i c 45 r e l a t i o n s h i p s ( H a l l , 1 9 7 7 ) . N u r s i n g s t u d i e s i n d i c a t e t h a t i n i t i a l l i k i n g o f t h e p a t i e n t i s r e l a t e d t o f a v o u r a b l e o u t c o m e s ( S h a d e r , K e l l m a n , & D u r r e l l , 1967) a n d t h a t t h e p a t i e n t c h a r a c t e r i s t i c s l i k e d by n u r s e s i n p a t i e n t s were c o n f o r m i t y , c o m p l i a n c e , a p p r e c i a t i v e n e s s , a n d r e s p e c t ( B l a y l o c k , 1972 ; L e v i n e , 1 9 7 0 ; R i c k l e m a n , 1 9 7 2 ) . G a l l o p (1985) r e p o r t i n g r e s u l t s o f a s t u d y o f i n t e r p e r s o n a l a t t r a c t i o n a n d n u r s i n g n e e d s i n d i c a t e d t h a t n u r s e s show i n c r e a s e d l i k i n g f o r p a t i e n t s who t h e y p e r c e i v e d as s h a r i n g s i m i l a r b e l i e f s a b o u t t h e i r n u r s i n g n e e d s . I n a l a t e r s t u d y on t h e phenomenon o f t h e ' d i f f i c u l t ' p a t i e n t , G a l l o p a n d Wynn (1987 ) p r o p o s e d t h a t i n t e r p e r s o n a l a t t r a c t i o n i s a f a c t o r i n l a b e l l i n g p a t i e n t s a s ' d i f f i c u l t ' . S u i c i d a l p a t i e n t s . A n o t h e r c a t e g o r y o f p a t i e n t s c o n s i d e r e d d i f f i c u l t a r e s u i c i d a l p a t i e n t s . S t u d i e s o f n u r s e s ' r e s p o n s e s w o r k i n g w i t h s u i c i d a l p a t i e n t s r e v e a l t h a t t h e i r e x p e r i e n c e s a r e h i g h l y c o n f l i c t u a l a n d e m o t i o n a l b e c a u s e t h e y a r e o f t e n i n c o n f l i c t b e t w e e n t h e i r c o d e o f e t h i c s a n d t h e p a t i e n t s ' c h o i c e s . A l t h o u g h t h e y b e l i e v e t h a t l i v e s c a n be p r e s e r v e d t h r o u g h c a r e f u l l i s t e n i n g , t a l k i n g , c o m p a s s i o n , a n d w o r k i n g w i t h p a t i e n t s t o i d e n t i f y a l t e r n a t e o p t i o n s , t h e y a l s o e x p r e s s a p p r e h e n s i o n , a n g e r a n d h e l p l e s s n e s s i n t h e i r r e l a t i o n s h i p s w i t h s u i c i d a l p a t i e n t s b e c a u s e 46 t h e r e i s no s t a t i s t i c a l l y p r o v e n e f f e c t i v e a p p r o a c h t o d e a l i n g w i t h s u i c i d a l p a t i e n t s . ( H a m e l - B i s s e l 1 , 1985 ; L a n d e e n , 1 9 8 7 ; R e g u e r o , 197 9; S e n c i c l e , 1978 ; S u m n e r , 1 9 7 6 ) . A l t h o u g h r e s e a r c h w h i c h s e e k s t o e x p l a i n p r o b l e m s o f a v o i d a n c e , a n g e r a n d h e l p l e s s n e s s i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p h a s b e e n u s e f u l i n a d d i n g t o n u r s i n g p r a c t i c e t h e o r y , i t h a s , o f l a t e l y , come u n d e r some c r i t i c i s m i n t h e l i t e r a t u r e . May ( 1 9 9 0 ) , i n a s e l e c t e d r e v i e w o f t h e l i t e r a t u r e on t h e n u r s e - p a t i e n t r e l a t i o n s h i p , s u g g e s t s t h a t t h i s t y p e o f r e s e a r c h may a d d t o t h e b o d y o f k n o w l e d g e a b o u t t h e d i f f i c u l t o r b a d p a t i e n t b u t i t g e n e r a l l y n e g l e c t s t h e l a r g e n u m b e r s o f p a t i e n t s w i t h whom n u r s e s e a s i l y a n d s u c c e s s f u l l y e s t a b l i s h a n d m a i n t a i n r e l a t i o n s h i p s w i t h d u r i n g t h e i r h o s p i t a l i z a t i o n . B e c a u s e t h i s t y p e o f r e s e a r c h f r e q u e n t l y l i e s h e a v i l y on t h e s i d e o f t h e p a t i e n t ' s c h a r a c t e r i s t i c s as p r o b l e m a t i c i t p r o m o t e s a v i e w t h a t n u r s e s ' r e s p o n s e s a n d c o n s e q u e n t p r o b l e m s i n t h e r e l a t i o n s h i p a r e r e l a t e d d i r e c t l y a n d s o l e l y t o t h e a n x i e t y p a t i e n t s c r e a t e i n t h e n u r s e . I t a l s o i m p l i e s t h a t n u r s e s ' r e s p o n s e s a r e c o n s i s t e n t i n a l l s i t u a t i o n s w i t h c e r t a i n t y p e s o f p a t i e n t s a n d t h a t t h e n u r s e -p a t i e n t r e l a t i o n s h i p i s a u n i d i r e c t i o n a l p r o c e s s : t h e r e c i p r o c a l n a t u r e o f t h e r e l a t i o n s h i p i s o v e r l o o k e d . 47 May (1990 ) r e f e r r e d t o t h i s t y p e o f r e s e a r c h as " p a t i e n t s t e r e o t y p i n g a n d d e f e n s i v e n u r s i n g " ( p . 3 0 8 ) . K e l l y a n d May ( 1982 ) s u g g e s t e d t h a t much o f t h e l i t e r a t u r e on g o o d a n d b a d p a t i e n t s i s a p p a r e n t l y a b o u t p a t i e n t s b u t most o f i t f o c u s e s on n u r s e s ' o p i n i o n s a b o u t p a t i e n t s b e c a u s e o f t h e m e t h o d o l o g i e s u s e d i n c o l l e c t i n g d a t a , n a m e l y q u e s t i o n n a i r e s a n d i n t e r v i e w s . K e l l y a n d May a l s o v i e w e d t h i s t y p e o f r e s e a r c h as p r o b l e m a t i c b e c a u s e r a r e l y a r e c o n c e p t s s u c h as m a n i p u l a t i v e , u n c o o p e r a t i v e e t c . , a d e q u a t e l y d e f i n e d . I t i s a s s u m e d t h a t t h e r e a d e r a n d r e s e a r c h e r s h a r e a s i m i l a r u n d e r s t a n d i n g o f t h e c o n c e p t s . A f i n a l c r i t i c i s m o f t h i s t y p e o f r e s e a r c h i s t h a t t h e n u r s e - p a t i e n t r e l a t i o n s h i p i s n o t v i e w e d as p a r t o f a w i d e r s o c i a l c o n t e x t w h i c h i s a l s o s i g n i f i c a n t i n c o n s t i t u t i n g t h e n u r s e - p a t i e n t r e l a t i o n s h i p . T h e S o c i a l O r g a n i z a t i o n i n t h e C o n s t i t u t i o n o f t h e  N u r s e - p a t i e n t R e l a t i o n s h i p T h e l i t e r a t u r e makes i t a b u n d a n t l y c l e a r t h a t t h e d y a d i c e n c o u n t e r b e t w e e n t h e n u r s e a n d p a t i e n t g i v e s r i s e t o e m o t i o n a l r e s p o n s e s i n b o t h t h e n u r s e a n d t h e p a t i e n t a n d t h e r e f o r e c o n s t i t u t e s t h e n u r s e - p a t i e n t r e l a t i o n s h i p . O n l y r e c e n t l y , h o w e v e r , h a s t h e l i t e r a t u r e a d d r e s s e d t h e s o c i a l o r g a n i z a t i o n as a c r e a t o r o f c o n d i t i o n s i n w h i c h d i f f e r e n t f o r m s o f 48 n u r s e - p a t i e n t r e l a t i o n s h i p s a r e p r o m o t e d o r i n h i b i t e d . D a w k i n s , Depp a n d S e l z e r ( 1985 ) u s i n g a 7 8 - i t e m s c a l e m e a s u r e d p s y c h i a t r i c n u r s e s ' p e r c e p t i o n s o f o c c u p a t i o n a l s t r e s s . T h e y r e p o r t e d p s y c h i a t r i c n u r s i n g j o b s t r e s s as m u l t i f a c e t e d a n d t h e i s s u e s i n v o l v e d were a d m i n i s t r a t i v e / o r g a n i z a t i o n a l , s t a f f c o n f l i c t , l i m i t e d r e s o u r c e s , s c h e d u l i n g i s s u e s , n e g a t i v e p a t i e n t c h a r a c t e r i s t i c s a n d s t a f f p e r f o r m a n c e . F i f t y p e r c e n t o f t h e h i g h s t r e s s o r i t e m s w e r e p r o d u c e d by a d m i n i s t r a t i v e / o r g a n i z a t i o n a l i s s u e s , w i t h t h e s i n g l e mos t s t r e s s f u l i t e m b e i n g " n o t b e i n g n o t i f i e d o f c h a n g e s b e f o r e t h e y o c c u r " ( p . 1 2 ) . T h e r e m a i n i n g h i g h s t r e s s o r i t e m s c e n t r e d on themes r e l a t e d t o w o r k i n g i n a n u n r e s p o n s i v e , u n a p p r e c i a t e d , u n c o m m u n i c a t i v e work e n v i r o n m e n t t h a t made c h a n g e s f o r t h e s a k e o f c h a n g e a n d t h a t made t o o many w i d e l y d i v e r g e n t demands on n u r s e s . N e g a t i v e p a t i e n t c h a r a c t e r i s t i c s were v i e w e d as m o d e r a t e l y t o h i g h l y s t r e s s f u l w i t h p a t i e n t c h a r a c t e r i s t i c s r e l a t e d t o v i o l e n c e as most s t r e s s f u l . T h e d e g r e e o f s t r e s s a s s o c i a t e d w i t h t h e s e c h a r a c t e r i s t i c s was a l s o r e l a t e d t o t h e amount a n d n a t u r e o f r e s o u r c e s a v a i l a b l e t o t h e n u r s e s i n d e a l i n g w i t h t h e s e c h a r a c t e r i s t i c s . F o r e x a m p l e , w o r k i n g w i t h h o s t i l e p a t i e n t s on an i n a d e q u a t e l y s t a f f e d w a r d was r a t e d as a h i g h s t r e s s i t e m . 49 Trygstad (1986), using semi-structured i n t e r v i e w s , conducted an ex p l o r a t o r y study on s t r e s s and coping i n p s y c h i a t r i c nursing. She i d e n t i f i e d that the most important determinants of work s t r e s s were d i f f i c u l t i e s i n the nurse-nurse or s t a f f nurse-head nurse r e l a t i o n s h i p and t h e i r a b i l i t y to work together. This determinant accounted f o r 50% of a l l s t r e s s reported by nurses. Thematically, the s t r e s s o r s converged on r e l a t i o n s h i p problems r e l a t e d to inadequate or i n e f f e c t i v e communication, performance problems, and s t a f f coping problems. Head nurses were viewed as p i v o t a l i n r e s o l v i n g these problems. They were i d e n t i f i e d as e i t h e r c o n t r i b u t i n g to s t a f f - s t a f f f r i c t i o n or h e l p f u l i n r e s o l v i n g problems. Head nurses' and s u p e r v i s o r s ' a t t i t u d e s and p r a c t i c e s which c o n t r i b u t e d to s t r e s s i n c l u d e d scheduling, u n i l a t e r a l d e c i s i o n making, i n s u f f i c i e n t p o s i t i v e reinforcement or support, i n s u f f i c i e n t i n f o r m a t i o n to s t a f f , lack of c l i n i c a l or a d m i n i s t r a t i v e e x p e r t i s e and lack of responsiveness to s t a f f . While a source of s t r e s s , p o s i t i v e r e l a t i o n s h i p s with other co-workers and head nurses were a l s o reported as a major source of s a t i s f a c t i o n , w i t h being l i s t e n e d t o , as the most h e l p f u l response. Problems with p a t i e n t s accounted f o r only 13% of s t r e s s o r s and 50 t h e s e c e n t r e d a r o u n d p a t i e n t c h r o n i c i t y , r e c i d i v i s m a n d t h e p o t e n t i a l f o r v i o l e n c e . D o i n g o n e ' s b e s t f o r p a t i e n t s , w o r k i n g c o o p e r a t i v e l y w i t h o t h e r s t a f f i n t h e c a r e o f p a t i e n t s a n d r e v i s i n g o n e ' s e x p e c t a t i o n s o f d e s i r e d p a t i e n t o u t c o m e were d e s c r i b e d as e f f e c t i v e c o p i n g s t r a t e g i e s . T r y g s t a d ' s ( 1986 ) s t u d y i s s i g n i f i c a n t f o r two r e a s o n s : f i r s t , i t p r o v i d e s "one l i n k s p e c i f i c t o p s y c h i a t r i c s t a f f n u r s e s i n t h e s t u d y o f s t r e s s a n d c o p i n g as a c o m p l e x p r o c e s s " ( p . 27) a n d s e c o n d l y , b e c a u s e o f i t s c h o s e n m e t h o d o l o g y , p r o v i d e s i n s i g h t a n d t h e r e f o r e g r e a t e r u n d e r s t a n d i n g o f p s y c h i a t r i c n u r s i n g p r a c t i c e as i t i s e x p e r i e n c e d by n u r s e s t h e m s e l v e s . C r o n i n - S t u b b s a n d B r o p h y (1985 ) i n a s t u d y w h i c h i n v e s t i g a t e d t h e r e l a t i o n s h i p o f s o c i a l s u p p o r t , o c c u p a t i o n a l s t r e s s a n d work s e t t i n g (4 s p e c i a l t y a r e a s ) t o t h e b u r n o u t o f s t a f f n u r s e s f o u n d t h a t p s y c h i a t r i c n u r s e s e x p e r i e n c e d s i g n i f i c a n t l y l e s s a f f i r m a t i o n , on a n d o f f t h e i r j o b , t h a n i n t e n s i v e c a r e n u r s e s a n d s i g n i f i c a n t l y l e s s a s s i s t a n c e t h a n o p e r a t i n g room n u r s e s . T h e y s u g g e s t t h a t what may a c c o u n t f o r t h e s e d i f f e r e n c e s i s t h a t mos t o f t h e c a r e g i v e n by p s y c h i a t r i c n u r s e s o c c u r s as i n t e r a c t i o n s w i t h t h e n u r s e - p a t i e n t r e l a t i o n s h i p ; h e n c e t h e i r n u r s i n g i n t e r v e n t i o n s a r e l e s s o b s e r v a b l e t h a n a r e t h o s e o f 51 i n t e n s i v e c a r e n u r s e s . O u t c o m e s a r e a l s o l e s s c o n c r e t e . Events in the Wider Social Context and Changes in Nursing Ideologies in the Constitution of the Nurse- patient Relationship A f i n a l e x a m p l e o f t h e i m p a c t o f w i d e r s o c i a l c o n t e x t on i n t e r p e r s o n a l r e l a t i o n s h i p s i s W i l l i a m ' s ( 1974 ) s e n s i t i v e a c c o u n t o f c h a n g i n g i d e o l o g i e s o f n u r s i n g on n u r s e - p a t i e n t r e l a t i o n s h i p s . T h e c o n c e p t o f v o c a t i o n , s h e a r g u e s , l e g i t i m i z e s n i n e t e e n t h - c e n t u r y v i e w s o f t h e r o l e o f w o r k i n g - c l a s s f e m a l e s a s o b e d i e n t s e r v a n t s . B u t , as a s i d e a f f e c t , i t s a n c t i f i e d t h e u n p l e a s a n t a n d m e n i a l t a s k s w h i c h t h e n u r s e h a d t o p e r f o r m f o r t h e p a t i e n t , t r a n s f o r m i n g t h e s t a t u s o f b o t h . C u r r e n t ' p r o f e s s i o n a l ' c o n c e p t s o f n u r s i n g r e f l e c t p r e s s u r e s t o w a r d s g r e a t e r e q u a l i t y b e t w e e n t h e s o c i a l c l a s s e s a n d t h e s e x e s . B u t a n u n i n t e n d e d c o n s e q u e n c e o f s u c h a r e -d e f i n i t i o n i s t h a t e v e r y d a y c a r e f o r t h e p a t i e n t may be s e e n as o u t s i d e t h e ' p r o f e s s i o n a l ' n u r s e ' s r o l e . A s a r e s u l t , t h e h e l p l e s s p a t i e n t may no l o n g e r be o f f e r e d d e f i n i t i o n s o f h i s h e l p l e s s n e s s , w h i c h a l l o w h i m t o f e e l a p e r s o n o f w o r t h , a n d i n s t e a d may be t r e a t e d c u s t o d i a l l y a s a r e g r e s s e d 52 c h i l d . (Heyman & Shaw, 1 9 8 4 , p . 40) I n s p i t e o f t h e c o n t i n u e d e m p h a s i s on t h e t h e r a p e u t i c r o l e o f t h e n u r s e i n p s y c h i a t r i c n u r s i n g l i t e r a t u r e , n u r s i n g l e a d e r s ( C a r t e r , 1986 ; O r l a n d o , 1 9 8 7 ; P e p l a u , 1989) a r e e x p r e s s i n g c o n c e r n t h a t t h e n u r s e ' s t h e r a p e u t i c r o l e may s l o w l y d i s a p p e a r i n p s y c h i a t r i c c a r e s e t t i n g s . C a r t e r ( 1986 ) a n d W e s t w e l l a n d M c C a y ( 1988 ) s u g g e s t t h a t t h e r e m e d i c a l i z a t i o n o f p s y c h i a t r y a n d d e i n s t i t u t i o n a l i z a t i o n o f p s y c h i a t r i c p a t i e n t s a r e f a c t o r s c o n t r i b u t i n g t o t h e d e m i s e o f t h e t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p as t h e m a j o r f o c u s o f p s y c h i a t r i c n u r s i n g . T h e s h i f t t o w a r d d e f i n i n g m e n t a l i l l n e s s as a d y s f u n c t i o n t h a t h a s b i o c h e m i c a l , g e n e t i c , o r s o m a t i c e t i o l o g y seems t o be l e a d i n g n u r s e s away f r o m t h e r a p e u t i c work w i t h p a t i e n t s . W e s t w e l l a n d M c C a y (1 988 ) s t a t e d " i t t a k e s l e s s t i m e t o a d m i n i s t e r a p i l l a n d w a i t f o r t h e a n t i c i p a t e d r e s u l t s t h a t i t [ d o e s ] t o s t a r t t h e p r o c e s s o f e s t a b l i s h i n g a r e l a t i o n s h i p w i t h a p a t i e n t a n d b e g i n t o do some t h e r a p e u t i c w o r k " ( p . 1 4 8 ) . W e s t w e l l a n d M c C a y c h a l l e n g e d p s y c h i a t r i c n u r s e s t o t a k e c h a r g e o f t h i s s i t u a t i o n a n d u s e i t as a n o p p o r t u n i t y t o c a r v e o u t a p r o f e s s i o n a l r o l e f o r t h e m s e l v e s . T h e y s t r e s s e d t h e n e e d t o i d e n t i f y , d e s c r i b e a n d p r o m o t e t h e c l i n i c a l s k i l l s a n d k n o w l e d g e 53 t h a t a r e u n i q u e t o p s y c h i a t r i c n u r s i n g . T h e y a d v i s e d p s y c h i a t r i c n u r s e s t o r e c o g n i z e a n d r e v i v e t h e o n e - t o -one n u r s e - p a t i e n t r e l a t i o n s h i p as t h e c e n t r a l f o c u s o f p s y c h i a t r i c n u r s i n g p r a c t i c e a n d t h a t t o f u r t h e r a b a n d o n t h i s f o c u s w i l l l e a d t o " i m p e r s o n a l a n d d e h u m a n i z e d n u r s i n g c a r e " ( p . 1 5 7 ) . W e s t w e l l a n d M c C a y ( 1 9 8 8 ) , c i t i n g L e g o , s u g g e s t e d t h a t s o c i e t y ' s movement t o w a r d s t e c h n o l o g y i s c o n t r i b u t i n g t o t h e e r o s i o n o f t h e human a s p e c t s o f n u r s i n g c a r e p r o v i d e d i n b o t h p s y c h i a t r i c a n d m e d i c a l c a r e s e t t i n g s . L e g o b e l i e v e s t h a t n u r s e s h a v e l e a p t on t o t h e t e c h n o l o g i c a l b a n d wagon a n d a r e a b a n d o n i n g t h e more h u m a n i s t i c i n t e r p e r s o n a l a s p e c t s o f n u r s i n g p r a c t i c e . She b e l i e v e s t h i s h a s l e d t o a d e v a l u a t i o n o f t h e n u r s e - p a t i e n t r e l a t i o n s h i p i n a l l a r e a s o f n u r s i n g p r a c t i c e . W e s t w e l l a n d M c C a y (1988 ) s t a t e " t h a t w i t h o u t a s t r o n g b e l i e f i n t h e v a l u e o f t h e t h e r a p e u t i c r e l a t i o n s h i p , n u r s e s c a r i n g f o r p s y c h i a t r i c p a t i e n t s h a v e b e g u n t o f e e l d e v a l u e d a n d d e m o r a l i z e d " ( p . 1 5 1 ) . B e n n e r ( 1 9 8 4 a ) a r g u e s t h a t t h e power o f n u r s i n g p r a c t i c e l i e s i n c a r i n g a n d t h a t t h e e a r l y r o o t s p s y c h i a t r i c n u r s i n g w h i c h l i e i n t h e r e l a t i o n s h i p a s p e c t s o f c a r e , h a v e b e e n i n s t r u m e n t a l i n f o s t e r i n g e x p e r t p s y c h i a t r i c n u r s i n g c a r e . She a d v i s e s 54 p s y c h i a t r i c n u r s e s t o u n c o v e r , name, a n d d e s c r i b e t h e c o m p o n e n t s o f e x p e r t n u r s i n g a n d c a r i n g a n d t o do s o u s i n g i n t e r p r e t a t i v e r e s e a r c h m e t h o d s . B e n n e r s t a t e s t h a t w i t h a n i n t e r p r e t a t i v e a p p r o a c h , t h e m e a n i n g o f t h e n u r s i n g e x p e r i e n c e i s m a i n t a i n e d r a t h e r t h a n s t r i p p e d away t o o b j e c t i f i e d , c o n t e x t - f r e e t r a i t s o r b e h a v i o u r s , t h u s p r o v i d i n g n u r s e s w i t h a f u l l e r a n d c l e a r e r u n d e r s t a n d i n g o f n u r s i n g . T h i s v a l u a b l e k n o w l e d g e c a n s e r v e as a s c i e n t i f i c b a s i s f o r p r a c t i c e r a t h e r t h a n i m p o s i n g t h e o r y on p r a c t i c e . Summary I t i s c l e a r f r o m t h e l i t e r a t u r e t h a t t h e n u r s e -p a t i e n t r e l a t i o n s h i p i s a c o m p l e x p h e n o m e n o n . T h e c o m p l e x i t y o f t h i s r e l a t i o n s h i p i s n o t a l w a y s g i v e n a d e q u a t e r e c o g n i t i o n i n b o t h t h e o r y a n d r e s e a r c h . R a r e l y a r e t h e i n t e n t i o n s a n d u n d e r s t a n d i n g s o f t h e a c t o r s t a k e n i n t o c o n s i d e r a t i o n n o r i s t h e i r e x p e r i e n c e , a s t h e y l i v e i t , m a i n t a i n e d . ( B e n n e r , 1984a) T h e way p a t i e n t s a n d n u r s e s t a l k a b o u t t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h e a c h o t h e r i s s i g n i f i c a n t , " t h e l a n g u a g e t h e y u s e a n d t h e c o n n e c t i o n s t h e y make r e v e a l t h e w o r l d t h a t t h e y s e e a n d i n w h i c h t h e y a c t " ( K r a u s s , 1 9 8 7 , p . 1 4 ) . N u r s e s who a r e c o - p a r t i c i p a n t s i n t h e s e r e l a t i o n s h i p s e x p e r i e n c e t h e i r own r e a l i t y o f t h e s e 55 r e l a t i o n s h i p s . T h i s r e a l i t y a r i s e s f r o m a c o n t i n u i t y o f c o n s c i o u s n e s s ( a w a r e n e s s ) " a l o n g w i t h t h e i r p e r c e p t i o n s o f s e l f a n d o t h e r s ; f e e l i n g s , t h o u g h t s , b o d i l y s e n s a t i o n s , s p i r i t u a l b e l i e f s , d e s i r e s , g o a l s , e x p e c t a t i o n s [ a n d ] e n v i r o n m e n t a l c o n s i d e r a t i o n s . . . " ( W a t s o n , 1 9 8 5 , p . 5 6 ) . I n o r d e r t o g a i n a b e t t e r u n d e r s t a n d i n g o f t h e n u r s e s ' e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s , we n e e d t o a s k q u e s t i o n s t h a t w i l l u n c o v e r t h e i r e x p e r i e n c e s i n t h e i r t o t a l i t y . T h e p u r p o s e o f t h i s s t u d y i s t o e x p l o r e n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s a d m i t t e d t o i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s b e c a u s e o f a s e v e r e m e n t a l h e a l t h p r o b l e m w i t h t h e a i m o f u n c o v e r i n g k n o w l e d g e a n d u n d e r s t a n d i n g o f t h e s e r e l a t i o n s h i p s . C h a p t e r T h r e e d e s c r i b e s t h e r e s e a r c h m e t h o d o l o g y . I t i n c l u d e s a d e s c r i p t i o n o f t h e r e s e a r c h a p p r o a c h , p r o c e d u r e s f o r c o l l e c t i o n a n d t r e a t m e n t o f d a t a , a n d d a t a a n a l y s i s . CHAPTER T H R E E : METHODOLOGY I n t r o d u c t i o n T h e p h e n o m e n o l o g i c a l a p p r o a c h o f q u a l i t a t i v e r e s e a r c h t h e o r y was c h o s e n as t h e m e t h o d o l o g i c a l a p p r o a c h t o t h i s s t u d y . G i v e n t h e e m p h a s i s o f p h e n o m e n o l o g y on t h e m e a n i n g s a n d i n t e r p r e t a t i o n s o f human e x p e r i e n c e , i t was b e l i e v e d t h a t a p h e n o m e n o l o g i c a l m e t h o d w o u l d b e s t d e s c r i b e a n d e x p l i c a t e t h e m e a n i n g o f n u r s e s ' e x p e r i e n c e s w o r k i n g w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . A p i l o t i n t e r v i e w w i t h one p a r t i c i p a n t p r o v i d e d a d d i t i o n a l s u p p o r t f o r u s i n g t h e p h e n o m e n o l o g i c a l m e t h o d t o s t u d y n u r s e s ' e x p e r i e n c e s . T h e i n t e r v i e w r e v e a l e d a r i c h s o u r c e o f d a t a f r o m w h i c h themes o f e x p e r i e n c e c o u l d be e x p l i c a t e d . T h e i n t e r v i e w a l s o h e l p e d t h e r e s e a r c h e r t o b e g i n t o e x p l i c a t e a n d b r a c k e t o u t h e r own p r e s u p p o s i t i o n s a n d e x p l a n a t i o n s o f t h e s e e x p e r i e n c e s , a n i m p o r t a n t p r o c e s s when s t u d y i n g a f a m i l i a r p h e n o m e n o n . T h i s c h a p t e r w i l l d e s c r i b e t h e a p p l i c a t i o n o f p h e n o m e n o l o g y as a m e t h o d i n t h e s e l e c t i o n o f p a r t i c i p a n t s , a n d i n t h e p r o c e s s o f d a t a c o l l e c t i o n a n d d a t a a n a l y s i s . S e t t i n g f o r t h e S t u d y T h e s e t t i n g f o r t h e s t u d y was t h e L o w e r M a i n l a n d 57 o f t h e P r o v i n c e o f B r i t i s h C o l u m b i a , C a n a d a . S e l e c t i o n of P a r t i c i p a n t s P o p u l ation T h e p o p u l a t i o n f o r t h i s s t u d y was R e g i s t e r e d N u r s e s e m p l o y e d i n f o u r i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s o f G e n e r a l H o s p i t a l s l o c a t e d i n t h e L o w e r M a i n l a n d o f t h e P r o v i n c e o f B . C . S e l e c t i o n Procedures T h e p h e n o m e n o l o g i c a l r e s e a r c h m e t h o d d i r e c t e d t h e r e s e a r c h e r t o u s e n o n - p r o b a b i l i t y s a m p l i n g f o r t h e s t u d y . B e c a u s e p h e n o m e n o l o g i c a l r e s e a r c h e r s s e e k r i c h a n d v a r i e d d e s c r i p t i o n s f r o m i n f o r m a n t s , p a r t i c i p a n t s w e r e s e l e c t e d a c c o r d i n g t o t h e i r k n o w l e d g e b a s e a n d n o t t o a c h i e v e s t a t i s t i c a l g e n e r a l i z a t i o n ( M o r s e , 1986 ; P o l k i n g h o r n e , 1 9 8 9 ) . P a r t i c i p a n t s were c h o s e n a c c o r d i n g t o t h e c r i t e r i a o f a p p r o p r i a t e n e s s a n d a d e q u a c y : a p p r o p r i a t e n e s s r e f e r s " t o t h e d e g r e e i n w h i c h t h e m e t h o d o f s a m p l i n g f i t s t h e p u r p o s e o f t h e s t u d y as d e t e r m i n e d by t h e q u e s t i o n [ a n d ] a d e q u a c y r e f e r s t o t h e q u a l i t y , c o m p l e t e n e s s , a n d amount o f i n f o r m a t i o n c o n t r i b u t e d by i n f o r m a n t s . . . " ( M o r s e , 1 9 8 6 , p . 1 8 5 ) . F o r t h i s s t u d y , t h e c r i t e r i o n o f a p p r o p r i a t e n e s s o f p a r t i c i p a n t was met by n u r s e s who were a b l e t o f u n c t i o n as i n f o r m a n t s by d e s c r i b i n g t h e i r e x p e r i e n c e s o f w o r k i n g w i t h p a t i e n t s i n i n p a t i e n t 58 p s y c h i a t r i c c a r e s e t t i n g s . A d e q u a c y o f s a m p l e was d e t e r m i n e d by t h e q u a l i t y , c o m p l e t e n e s s , a n d amount o f i n f o r m a t i o n c o n t r i b u t e d by t h e i n f o r m a n t s . A d e q u a c y was a c h i e v e d by i n t e r v i e w i n g i n f o r m a n t s u n t i l t h e r e s e a r c h e r h a d g a i n e d a f u l l a n d c o h e r e n t u n d e r s t a n d i n g o f t h e s i t u a t i o n a n d e x p e r i e n c e d " r e d u n d a n c y i n i n f o r m a n t s ' d e s c r i p t i o n s " ( P a r s e , C o y n e , & S m i t h , 1 9 8 5 , p . 1 7 ) . F o r t h i s s t u d y , a d e q u a c y was a c h i e v e d by i n t e r v i e w i n g a l l e i g h t p a r t i c i p a n t s t w i c e . C r i t e r i a f o r S e l e c t i o n o f P a r t i c i p a n t s T h e s a m p l e f o r t h e s t u d y c o n s i s t e d o f e i g h t n u r s e s who met t h e f o l l o w i n g s e t o f c r i t e r i a : 1 . F e m a l e R e g i s t e r e d N u r s e s . 2 . C u r r e n t l y e m p l o y e d as R e g i s t e r e d N u r s e s on a f u l l t i m e b a s i s i n a n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g o f a g e n e r a l h o s p i t a l . 3 . A min imum o f f i v e y e a r s n u r s i n g e x p e r i e n c e i n a n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g o f a g e n e r a l h o s p i t a l as a R e g i s t e r e d N u r s e . T h i s s t u d y e x c l u d e d r e g i s t e r e d n u r s e s s u c h as h e a d n u r s e s , n u r s e m a n a g e r s , c o o r d i n a t o r s a n d c l i n i c a l n u r s e s p e c i a l i s t s as e a c h o f t h e s e c a t e g o r i e s o f n u r s i n g p e r s o n n e l assume d i f f e r e n t r o l e s a n d f u n c t i o n s t h a n t h e s t a f f n u r s e . T h e s e i n d i v i d u a l s a r e a l s o r a r e l y t h e p r i m a r y c a r e g i v e r s i n i n p a t i e n t p s y c h i a t r i c c a r e u n i t s . T h e s t u d y s a m p l e was r e s t r i c t e d t o a s m a l l homogeneous g r o u p i n o r d e r t o d e c r e a s e t h e p o t e n t i a l d e g r e e o f v a r i a t i o n i n t h e p a r t i c i p a n t s ' d e s c r i p t i o n s o f t h e i r e x p e r i e n c e s a n d b e c a u s e o f t h e s m a l l s a m p l e s i z e u s e d f o r t h i s s t u d y . I n p a t i e n t u n i t s were s p e c i f i e d f r o m w h i c h t h e s a m p l e was d r a w n b e c a u s e t h e r e s e a r c h e r w a n t e d t o f o c u s s p e c i f i c a l l y on n u r s e s ' e x p e r i e n c e s w o r k i n g w i t h p a t i e n t s whose m e n t a l h e a l t h p r o b l e m s were v a r i e d i n n a t u r e a n d g e n e r a l l y c o n s i d e r e d s e v e r e e n o u g h t o w a r r a n t an i n p a t i e n t a d m i s s i o n t o h o s p i t a l . T h e r e s e a r c h e r ' s r o l e as a n u r s i n g i n s t r u c t o r i n some o f t h e h o s p i t a l s on t h e L o w e r M a i n l a n d o f B . C . a d d e d a n o t h e r c r i t e r i a f o r p a r t i c i p a t i o n i n t h e s t u d y . I n o r d e r t o m i n i m i z e p r e - c o n c e i v e d e x p e c t a t i o n s b e t w e e n t h e i n v e s t i g a t o r a n d p a r t i c i p a n t s , t h e i n v e s t i g a t o r i n t e r v i e w e d o n l y p a r t i c i p a n t s w i t h whom s h e h a d no o n g o i n g r e l a t i o n s h i p . G i v e n t h a t t h e i n v e s t i g a t o r ' s r o l e i s o n l y t o t e a c h n u r s i n g s t u d e n t s i n t h e s e s e t t i n g s a n d i s e m p l o y e d by a n a g e n c y o u t s i d e t h e h o s p i t a l s , t h e i n v e s t i g a t o r d i d n o t e n c o u n t e r p r o b l e m s w i t h b i a s o r e x p e c t a t i o n d u r i n g t h e i n t e r v i e w s . P r o c e d u r e f o r P a r t i c i p a n t R e c r u i t m e n t I n i t i a l r e c r u i t m e n t o f p a r t i c i p a n t s was a c c o m p l i s h e d by p l a c i n g a d v e r t i s e m e n t s i n i n p a t i e n t 60 p s y c h i a t r i c c a r e s e t t i n g s o f G e n e r a l H o s p i t a l s i n t h e L o w e r M a i n l a n d o f B . C . L e t t e r s w e r e s e n t t o t h e a p p r o p r i a t e n u r s i n g a d m i n i s t r a t o r s o f h o s p i t a l s i n t h e L o w e r M a i n l a n d o f B . C . known t o h a v e i n p a t i e n t p s y c h i a t r i c c a r e u n i t s ( s e e A p p e n d i x C ) . T h e a d m i n i s t r a t o r s w e r e a s k e d t o p l a c e a n e n c l o s e d a d v e r t i s e m e n t on t h e p s y c h i a t r i c u n i t ( s ) o f t h e h o s p i t a l ( s e e A p p e n d i x D ) . T h o s e n u r s e s i n t e r e s t e d i n p a r t i c i p a t i n g were a s k e d t o c o n t a c t t h e r e s e a r c h e r by t e l e p h o n e . A l e t t e r o f e x p l a n a t i o n was s e n t t o t h e p r o s p e c t i v e p a r t i c i p a n t s by t h e i n v e s t i g a t o r f u r t h e r o u t l i n i n g t h e n a t u r e o f t h e r e s e a r c h ( s e e a p p e n d i x D ) . T h e l e t t e r was f o l l o w e d up by a p h o n e c a l l a p p r o x i m a t e l y t e n d a y s l a t e r t o a s k p a r t i c i p a n t s t o c o n f i r m t h e i r p a r t i c i p a t i o n a n d t o s e t up a d a t e f o r t h e f i r s t i n t e r v i e w . A t t h e b e g i n n i n g o f t h e f i r s t i n t e r v i e w f u r t h e r e x p l a n a t i o n o f t h e s t u d y was g i v e n a b o u t t h e s t u d y when r e q u e s t e d . A w r i t t e n c o n s e n t was o b t a i n e d a n d a c o p y was g i v e n t o e a c h p a r t i c i p a n t ( s e e A p p e n d i x F ) . A d d i t i o n a l r e c r u i t m e n t i n v o l v e d t h e u s e o f a s n o w b a l l s a m p l i n g t e c h n i q u e ( M o r s e , 1 9 8 6 ) . Once i n i t i a l s e l e c t e d i n f o r m a n t s were c o n t a c t e d a n d t h e s t u d y d i s c u s s e d w i t h t h e m , t h e y w e r e a s k e d t o i n t r o d u c e t h e r e s e a r c h e r t o o t h e r k n o w l e d g e a b l e i n f o r m a n t s . 61 M o r s e ( 1 986 ) s t a t e s t h a t i n t h e s n o w b a l l s a m p l i n g t e c h n i q u e " r e c e p t i v i t y p r o b l e m s a r e p a r t i a l l y o v e r c o m e , as some t r u s t i s e s t a b l i s h e d t h r o u g h i n t r o d u c t i o n s by a m u t u a l a c q u a i n t a n c e , a n d t h e r e s e a r c h e r i s u s i n g t h e f i r s t i n f o r m a n t ' s j u d g e m e n t t h a t t h e n e x t i n f o r m a n t h a s some k n o w l e d g e o f t h e t o p i c " ( p . 1 8 4 ) . Two p a r t i c i p a n t s were r e c r u i t e d u s i n g t h e s n o w b a l l s a m p l i n g t e c h n i q u e . C h a r a c t e r i s t i c s o f t h e P a r t i c i p a n t s T h e c h a r a c t e r i s t i c s o f a l l e i g h t p a r t i c i p a n t s a r e p r e s e n t e d i n T a b l e 1. T a b l e 1 P a r t i c i p a n t C h a r a c t e r i s t i c I n f o r m a t i o n A g e N o . o f Y e a r s P s y c h N u r s i n g L e v e l s o f E d u c a t i o n * S a r a h 61 24 D i p l o m a R . N . * L e a h 36 10 D i p l o m a R . N . & R . P . N . ; B . A . * R a c h e l 39 18 D i p l o m a R . N . * D i a n a 27 5 D i p l o m a R . N . p l u s u n i v e r s i t y c o u r s e s * R o s e 37 6 D i p l o m a R . N . * R e b e c c a 43 17 D i p l o m a R . N p l u s u n i v e r s i t y c o u r s e s * L i l y 35 5 D i p l o m a R . N . * B r i g i t 41 10 D i p l o m a R . N . * p s e u d o n y m 62 E t h i c a l C o n s i d e r a t i o n s B e f o r e i n i t i a t i n g t h i s s t u d y t h e i n v e s t i g a t o r o b t a i n e d a p p r o v a l f r o m t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a ' s b e h a v i o r a l s c i e n c e s s c r e e n i n g c o m m i t t e e f o r r e s e a r c h i n v o l v i n g human s u b j e c t s . T h e r i g h t s o f t h e p a r t i c i p a n t s i n t h e s t u d y were s a f e g u a r d e d by p r o v i d i n g them w i t h i n f o r m a t i o n r e g a r d i n g t h e r e s e a r c h q u e s t i o n , t h e p u r p o s e o f t h e s t u d y , a n d c o n f i d e n t i a l i t y . P a r t i c i p a n t s were a l s o i n f o r m e d t h a t t h e y may be q u o t e d v e r b a t i m i n t h e r e s u l t s o f t h e s t u d y . T h i s i n f o r m a t i o n was d i s c u s s e d v e r b a l l y w i t h p a r t i c i p a n t s a n d e a c h was p r o v i d e d w i t h a l e t t e r o f i n f o r m a t i o n ( s e e A p p e n d i x E ) a n d a c o n s e n t ( s e e A p p e n d i x F ) . T h o s e a g r e e i n g t o p a r t i c i p a t e were a s k e d t o s i g n t h e c o n s e n t f o r m . B o t h t h e l e t t e r o f i n f o r m a t i o n a n d t h e w r i t t e n c o n s e n t g a v e c l e a r i n f o r m a t i o n a b o u t t h e p a r t i c i p a n t s r i g h t s t o r e f u s e t o p a r t i c i p a t e , a n s w e r any q u e s t i o n s , r e q u e s t e r a s u r e o f any t a p e o r p o r t i o n o f a t a p e , a n d t h e r i g h t t o w i t h d r a w f r o m t h e s t u d y a t any t i m e . D a t a C o l l e c t i o n T h e p h e n o m e n o l o g i c a l m e t h o d i s b a s e d on t h e a s s u m p t i o n t h a t t h e r e a l i t y o f a phenomenon c a n be r e v e a l e d t h r o u g h t h e p a r t i c i p a n t s ' c o n c r e t e d e s c r i p t i o n s o f t h e i r e x p e r i e n c e s ( S m i t h , 1 9 8 9 ) . S m i t h 63 (1989) s t a t e s "by a l l o w i n g u n b r i d l e d d e s c r i p t i o n s of the l i v e d experiences, the r e s e a r c h e r has data r e f l e c t i n g the personal r e a l i t i e s of the l i v e d experiences f o r a l l s u b j e c t s " (p. 14). The data f o r t h i s study were c o l l e c t e d i n a s e r i e s of i n t e n s i v e u n s t r u c t u r e d i n t e r v i e w s conducted over a p e r i o d of three months. The i n i t i a l i n t e r v i e w s explored the p a r t i c i p a n t s ' experiences i n a broad general sense. Each p a r t i c i p a n t was asked to d e s c r i b e i n t h e i r words t h e i r p e r c e p t i o n s of t h e i r experiences of working with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . P a r t i c i p a n t s were encouraged to e l a b o r a t e on and i n c l u d e d e t a i l e d d e s c r i p t i o n s of personal encounters with s p e c i f i c p a t i e n t s . P a r t i c i p a n t s were encouraged to d e s c r i b e t h e i r r e l a t i o n s h i p s with p a t i e n t s and what meaning these had f o r them. Second i n t e r v i e w s were used f o r c l a r i f i c a t i o n and v a l i d a t i o n of the data. T h i s process was accomplished by p r e s e n t i n g the p r e l i m i n a r y thematic a n a l y s i s to each of the p a r t i c i p a n t s . Each p a r t i c i p a n t was asked to c l a r i f y and v a l i d a t e whether the themes i n f e r r e d from t h e i r accounts were an ac c u r a t e r e p r e s e n t a t i o n of t h e i r e xperiences. Because the phenomenological r e s e a r c h e r sought to g a i n a deeper and c l e a r e r understanding of what i t i s 64 l i k e f o r someone t o e x p e r i e n c e s o m e t h i n g , t h e r e s e a r c h e r a s k e d o p e n - e n d e d q u e s t i o n s t h a t f o c u s e d t h e p a r t i c i p a n t on t h e i r e x p e r i e n c e . A s a m p l e o f t r i g g e r q u e s t i o n s u s e d a r e l i s t e d i n a p p e n d i x G . I n a d d i t i o n t o t h e u s e o f q u e s t i o n s , t h e r e s e a r c h e r o c c a s i o n a l l y n e e d e d t o u s e p r o b e s t o k e e p a p a r t i c i p a n t ' s l i n e o f t h o u g h t f o c u s e d on t h e i r e x p e r i e n c e . A n e x a m p l e o f a p r o b e u s e d i n t h i s s t u d y i s : " Y o u t a l k e d a b o u t a . . . a n d y o u s a i d " i t r e a l l y i m p a c t e d me", . . . c o u l d y o u t e l l me more a b o u t what t h a t meant f o r y o u " . A l l e i g h t p a r t i c i p a n t s h a d i n i t i a l i n t e r v i e w s t h a t l a s t e d f r o m 60 t o 90 m i n u t e s . D a t a c o l l e c t i o n c e a s e d f o l l o w i n g t h e s e c o n d i n t e r v i e w f o r a l l e i g h t o f t h e p a r t i c i p a n t s . T h e s e c o n d i n t e r v i e w a l s o l a s t e d f o r 60 t o 90 m i n u t e s . D a t a c o l l e c t i o n c e a s e d when t h e r e s e a r c h e r h a d g a i n e d f u l l a n d c o h e r e n t d e s c r i p t i o n s o f t h e p a r t i c i p a n t s ' e x p e r i e n c e s o r when p a r t i c i p a n t s h a d e x h a u s t e d t h e t o p i c . T h e s e t t i n g f o r t h e i n t e r v i e w s was w h e r e i t was most c o m f o r t a b l e , c o n v e n i e n t a n d a p p r o p r i a t e f o r t h e p a r t i c i p a n t a n d t h e r e s e a r c h e r . F o r a l l e i g h t o f t h e p a r t i c i p a n t s , t h e s e t t i n g f o r t h e i n t e r v i e w s was t h e p a r t i c i p a n t ' s home. F o r e a c h o f t h e i n t e r v i e w s t h e r e s e a r c h e r e n s u r e d t h a t o p t i m a l c o n d i t i o n s were c r e a t e d 65 f o r the i n t e r v i e w s ; c o n d i t i o n s that f a c i l i t a t e d s e r i o u s , p u r p o s e f u l i n t e r a c t i o n . The i n t e r v i e w room was q u i e t and f r e e of d i s t r a c t i o n s and measures were implemented to prevent i n t e r r u p t i o n s and i n t e r f e r e n c e s . Data Analysis The aim of phenomenological r e s e a r c h i s to d i s c l o s e l i v e d experiences; to draw t h i n k i n g c l o s e r to the r e a l i t y of experience i t s e l f through d e s c r i p t i o n s of concrete experiences ( O i l e r Boyd, 1989, p. 17). Data a n a l y s i s t h e r e f o r e , was geared toward c o n s t r u c t i n g an a b s t r a c t d e s c r i p t i o n of each p a r t i c i p a n t ' s e xperiences, how she i n t e r p r e t e d them and how she gave meaning to her s i t u a t i o n s w i t h i n an i n t e r s u b j e c t i v e r e a l i t y (Benner, 1985; O i l e r , 1982, 1989; Ornery, 1983; Rodney, 1988). F o l l o w i n g each i n t e r v i e w the audio tapes were t r a n s c r i b e d verbatim and a formal process of i d e n t i f y i n g the c a t e g o r i e s or themes that appeared i n the d e s c r i p t i o n s of the p a r t i c i p a n t s ' experience began. The u n r a v e l l i n g of these c a t e g o r i e s or themes r e q u i r e d a process of s e q u e n t i a l steps ( C o l a i z z i , 1978; G i o r g i , 1975; Polkinghorne, 1989; Van Kaam, 1966). Because t h i s study sought to understand the s t r u c t u r e of a c o n t e x t - r e l a t e d phenomenon, the nurses' experience with p a t i e n t s , G i o r g i ' s (1975a) steps were an a p p r o p r i a t e 6 6 framework f o r data a n a l y s i s . The steps of G i o r g i o ' s framework are as f o l l o w s : 1. The re s e a r c h e r reads the e n t i r e d e s c r i p t i o n s t r a i g h t through t o get some sense of the whole.... 2. The re s e a r c h e r reads the same d e s c r i p t i o n more slow l y and d e l i n e a t e s each time that a t r a n s i t i o n i n meaning i s p e r c e i v e d . . . [and] obtains a s e r i e s of meaning u n i t s or c o n s t i t u e n t s .... 3. The re s e a r c h e r then e l i m i n a t e s redundancies, but otherwise keeps a l l u n i t s . He then c l a r i f i e s or e l a b o r a t e s the meaning of the c o n s t i t u e n t s by r e l a t i n g them to each other and to the sense of the whole .... 4. The re s e a r c h e r r e f l e c t s on the giv e n c o n s t i t u e n t s , s t i l l expressed i n the concrete language of the s u b j e c t , and transforms the meaning of each u n i t from the everyday n a i v e language of the s u b j e c t i n t o the language of p s y c h o l o g i c a l s c i e n c e .... 5. The re s e a r c h e r then s y n t h e s i z e s and i n t e g r a t e s the i n s i g h t s achieved i n t o a d e s c r i p t i o n ... (pp. 74-75). The end r e s u l t of the a p p l i c a t i o n of t h i s procedure was a number of d e s c r i p t i v e statements that captured the p a r t i c i p a n t s ' naive d e s c r i p t i o n s i n a c l e a r and p s y c h o l o g i c a l l y r e l e v a n t way ( G i o r g i , 1975). Through the i d e n t i f i c a t i o n and i n t e g r a t i o n of c a t e g o r i e s or themes, the e s s e n t i a l f e a t u r e s or 67 s t r u c t u r e o f t h e n u r s e s ' e x p e r i e n c e o f w o r k i n g w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s were e x p l i c a t e d . I n o t h e r w o r d s , i m p l i c i t a w a r e n e s s o f t h i s c o m p l e x phenomenon became e x p l i c i t f o r m u l a t e d k n o w l e d g e ( V a n Kaam, 1 9 6 9 ) . T h e a n a l y s i s o f d a t a was f a c i l i t a t e d t h r o u g h t h e u s e o f t h e E t h n o g r a p h c o m p u t e r p r o g r a m f o r q u a l i t a t i v e r e s e a r c h . T h e e n t i r e d a t a f i l e was e n t e r e d o n t o t h e p r o g r a m , e a c h i n t e r v i e w r e c o r d c o d e d a n d c a t e g o r i z e d , a n d t h e n , p o r t i o n s o f t h e t e x t c o r r e s p o n d i n g t o s p e c i f i e d c o d e s r e t r i e v e d a n d p r i n t e d f o r a n a l y s i s . R e l i a b i l i t y , V a l i d i t y , a n d B i a s T r u s t w o r t h y r e s e a r c h d a t a must be r e l i a b l e , v a l i d a n d b i a s f r e e . T h e s t a b i l i t y a n d c o n s i s t e n c y o f a m e a s u r e c o n t r i b u t e s t o r e l i a b i l i t y o f r e s e a r c h d a t a . T o e n s u r e e x t e r n a l r e l i a b i l i t y i n t h i s s t u d y , a l l d a t a were c o l l e c t e d i n p r e c i s e l y t h e same way t h r o u g h t h e u s e o f u n s t r u c t u r e d i n t e r v i e w s . E a c h p a r t i c i p a n t was a s k e d t h e same o p e n - e n d e d q u e s t i o n a n d a n o n d i r e c t i v e i n t e r v i e w s t y l e was u s e d . I n t e r n a l r e l i a b i l i t y was e n s u r e d by t r e a t i n g a l l d a t a c o l l e c t e d i n e x a c t l y t h e same way . A l l i n t e r v i e w s were a u d i o - t a p e d a n d t r a n s c r i b e d v e r b a t i m . A k e y c o n c e r n i n u s i n g u n s t r u c t u r e d i n t e r v i e w s i s v a l i d i t y , t h e d e g r e e t o w h i c h t h e q u e s t i o n s e l i c i t t h e 68 i n f o r m a t i o n t h a t was i n t e n d e d . I n o t h e r w o r d s , were t h e r e s p o n s e s t o my q u e s t i o n s t r u t h f u l o n e s o r w e r e t h e y a l t e r e d by t h e r e s p o n d e n t ' s d e s i r e t o p l e a s e me; t e l l me what I w a n t e d t o h e a r t o e n s u r e t h e s u c c e s s o f my r e s e a r c h o r were t h e y a l t e r e d f o r f e a r o f r e p r i s a l f r o m t h e i r e m p l o y e r . T h e r e a r e a number o f ways i n w h i c h I a t t e m p t e d t o c o n t r o l f o r t h e s e p r o b l e m s . A l l p a r t i c i p a n t s w e r e i n f o r m e d t h a t f u l l c o n f i d e n t i a l i t y w o u l d be m a i n t a i n e d t h r o u g h o u t t h e s t u d y a n d i n a n y p u b l i s h e d a n d u n p u b l i s h e d m a t e r i a l r e s u l t i n g f r o m t h e s t u d y . T h e s t u d y was n o t a f f i l i a t e d w i t h any h e a l t h c a r e a g e n c y n o r was a n y h e a l t h c a r e a g e n c y o r p e r s o n s ( i n c l u d i n g t h e p a r t i c i p a n t s ) i n a n a g e n c y i d e n t i f i e d . P a r t i c i p a n t s were a l s o made a w a r e i n my r e c r u i t m e n t a d v e r t i s e m e n t , i n f o r m a t i o n l e t t e r , a n d t h e w r i t t e n c o n s e n t t h a t a l l i n t e r v i e w s w o u l d be a u d i o t a p e d , t r a n s c r i b e d v e r b a t i m a n d t h a t t h e y may be q u o t e d v e r b a t i m i n t h e r e s u l t s o f t h e s t u d y . P a r t i c i p a n t s were a l s o i n f o r m e d t h a t t h e y c o u l d t e r m i n a t e a n i n t e r v i e w o r t h e i r p a r t i c i p a t i o n i n t h e s t u d y s h o u l d t h e y w i s h t o do s o . O p t i m a l c o n d i t i o n s were a l s o c r e a t e d f o r t h e i n t e r v i e w s o t h a t p a r t i c i p a n t s r e m a i n f o c u s e d on t h e i n t e r v i e w a n d f e l t s a f e e n o u g h t o d i s c l o s e p e r s o n a l a s p e c t s o f t h e m s e l v e s a n d t h e i r e x p e r i e n c e s . T h e i n t e r v i e w s e t t i n g was p r i v a t e , 69 c o m f o r t a b l e , f r e e o f d i s t r a c t i o n s a n d n o i s e a n d m e a s u r e s were t a k e n t o p r e v e n t i n t e r r u p t i o n s a n d i n t e r f e r e n c e s . A c t i v e l i s t e n i n g s k i l l s a n d p r o b i n g t e c h n i q u e s were u s e d t o a s s i s t p a r t i c i p a n t s i n t a l k i n g a b o u t t h e i r e x p e r i e n c e s . S e c o n d i n t e r v i e w s were u s e d w i t h e a c h p a r t i c i p a n t f o r t h e p u r p o s e s o f c l a r i f i c a t i o n , e x p a n s i o n o f d e s c r i p t i o n s , a n d v a l i d a t i o n o f d a t a . T h e s e i n t e r v i e w s w e r e a l s o u s e d t o c h a l l e n g e p a r t i c i p a n t ' s d a t a t o e n s u r e t h a t t h e y h a d n o t b i a s e d t h e i r r e s p o n s e s t o meet t h e a p p r o v a l o f t h e r e s e a r c h o r t o e n s u r e t h e s u c c e s s o f t h e s t u d y . T h e r e w e r e d i f f e r e n t a s p e c t s t o t h e p r o b l e m o f b i a s i n t h i s s t u d y . As s t a t e d i n t h e i n t r o d u c t i o n my own e x p e r i e n c e o f n u r s i n g p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s i s what f i r e d t h e i n c e p t i o n o f my s t u d y . B e c a u s e my p e r s o n a l i n v e s t m e n t i n t h i s s t u d y was h i g h a n d I was s t u d y i n g a phenomenon f a m i l i a r t o me, I k e p t a j o u r n a l o f t h e r e s e a r c h p r o c e s s , s p e c i f i c a l l y t h e d a t a c o l l e c t i o n p r o c e s s , t o augment my a w a r e n e s s o f any b i a s t a k i n g p l a c e . I a l s o u s e d a b r a c k e t i n g t e c h n i q u e . P r i o r t o i n t e r v i e w i n g t h e p a r t i c i p a n t s I g e n e r a t e d a l i s t o f p o s s i b l e themes t h a t I t h o u g h t w o u l d emerge f r o m t h e n u r s e s ' a c c o u n t s . T h i s l i s t i n c l u d e d themes I h o p e d w o u l d be r e v e a l e d a n d t h o s e I expected would be r e v e a l e d . T h i s l i s t forms p a r t of my personal assumptions d e s c r i b e d i n Appendix B. T h i s process of i d e n t i f y i n g my preconceived n o t i o n s p r o v i d e d some p r o t e c t i o n a g a i n s t the u n w i t t i n g i m p o s i t i o n of my ex p e c t a t i o n s on the study. Summary T h i s study through a phenomenological approach aims to uncover the r e a l experience of the nurse working i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . By st u d y i n g the nurses' p e r c e p t i o n s of t h e i r experience, a c l e a r e r , deeper and more accurate d e s c r i p t i o n of what i t means f o r nurses to work with p a t i e n t s i n p s y c h i a t r i c care s e t t i n g s w i l l be obtained. From these d e s c r i p t i o n s , n u r s i n g concepts that are f a i t h f u l to the r e a l world of the nurse's experience w i l l p r o v i d e an acc u r a t e b a s i s f o r theory development and f u r t h e r r e s e a r c h . 71 CHAPTER FOUR: PRESENTATION OF THE ACCOUNTS T h e r e s u l t s o f t h e s t u d y a r e p r e s e n t e d i n t h i s c h a p t e r . T h e a c c o u n t s g i v e n by t h e p a r t i c i p a n t s d e s c r i b e t h e i r p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . A l t h o u g h common themes e m e r g e d a c r o s s a l l o f t h e a c c o u n t s , r e c o g n i t i o n i s g i v e n t o t h e u n i q u e n e s s o f e a c h p a r t i c i p a n t ' s s u b j e c t i v e e x p e r i e n c e a n d t h e m e a n i n g s t h e y a t t a c h t o t h e m . T h e c o n s t r u c t i o n o f t h e s e a c c o u n t s i s t h e r e s u l t o f two p a r a l l e l p r o c e s s e s : t h e i n t e r v i e w i n g p r o c e s s a n d t h e d a t a a n a l y s i s p r o c e s s . T h e i n t e r v i e w i n g p r o c e s s r e f l e c t e d a n e v o l v i n g d i a l o g u e b e t w e e n t h e r e s e a r c h e r a n d t h e p a r t i c i p a n t s . E a c h p a r t i c i p a n t was i n i t i a l l y a p p r o a c h e d w i t h b r o a d o p e n - e n d e d q u e s t i o n s t o f o c u s them on d e s c r i b i n g t h e i r e x p e r i e n c e s w i t h p a t i e n t s . P a r t i c i p a n t s were a s k e d t o t e l l t h e r e s e a r c h e r a b o u t t h e i r e x p e r i e n c e s by r e c o u n t i n g a s p e c i f i c e n c o u n t e r o r a r e l a t i o n s h i p t h e y h a d h a d w i t h a p a t i e n t . F o l l o w i n g e a c h i n i t i a l i n t e r v i e w , t h e f o r m a l p r o c e s s o f a n a l y s i s b e g a n w i t h t h e r e a d i n g a n d r e r e a d i n g o f t h e e n t i r e d e s c r i p t i o n s . T h i s was d o n e t o g e t a s e n s e o f t h e n u r s e s ' e x p e r i e n c e s as a w h o l e . T h e n e x t s t e p o f t h e a n a l y s i s i n v o l v e d t h e i d e n t i f i c a t i o n o f m e a n i n g u n i t s ( G i o r g i , 1 9 7 5 ) . T h e s e m e a n i n g u n i t s were a t t a i n e d by r e r e a d i n g t h e t r a n s c r i p t a n d d e l i n e a t i n g e a c h t i m e a t r a n s i t i o n i n m e a n i n g was p e r c e i v e d . E a c h u n i t o r c o n s t i t u e n t was t h e n r e f l e c t e d u p o n u n t i l t h e m e a n i n g w i t h i n e a c h u n i t was f u l l y a p p r e h e n d e d . T h e u n i t s were t h e n t r a n s f o r m e d i n t o t h e r e s e a r c h e r s w o r d s . T h e s e a g g r e g a t e s o f f o r m u l a t e d m e a n i n g u n i t s were t h e n o r g a n i z e d i n t o t e n t a t i v e c a t e g o r i e s o r themes o f e x p e r i e n c e . F i n a l l y , t h e r e s e a r c h e r s e a r c h e d f o r a n d i d e n t i f i e d common themes t h a t h a d e m e r g e d a c r o s s a l l o f t h e p a r t i c i p a n t s ' a c c o u n t s . T h e s e themes were t h e n o r g a n i z e d i n t o a t e n t a t i v e f r a m e w o r k a n d u s e d by t h e r e s e a r c h e r i n t h e s e c o n d i n t e r v i e w s t o f u r t h e r c l a r i f y a n d v a l i d a t e p a r t i c i p a n t s ' d e s c r i p t i o n s o f t h e i r e x p e r i e n c e s . E a c h p a r t i c i p a n t was p r e s e n t e d w i t h t h e p r e l i m i n a r y t h e m a t i c a n a l y s i s a n d a s k e d t o c l a r i f y a n d v a l i d a t e w h e t h e r t h e themes e x p l i c a t e d f r o m t h e i r a c c o u n t s were a n a c c u r a t e r e p r e s e n t a t i o n o f t h e i r e x p e r i e n c e s . T h i s p r o c e s s r e s u l t e d i n t h e r e f i n e m e n t o f some themes a n d i n t h e theme o f t eam s u p p o r t b e i n g d r o p p e d b e c a u s e t h e n u r s e s d i d n o t p r o v i d e s u f f i c i e n t e x p e r i e n t i a l d a t a f o r t h e t h e m e . I n t h e f i n a l s t a g e o f a n a l y s i s , t h e r e s e a r c h e r a t t e m p t e d t o weave t h e t h e m a t i c p i e c e s i n t o a n i n t e g r a t e d w h o l e t h a t i s t r u e t o t h e p a r t i c i p a n t s ' experiences and rep r e s e n t s the e s s e n t i a l f e a t u r e s of nurses' experiences working with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . The themes of experience w i l l now be presented. D e s c r i p t i o n s of the Themes of Experience: The f i n d i n g s of t h i s study i n d i c a t e t h a t the nurses' experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s are a complex and m u l t i f a c e t e d phenomenon which r e s i s t s being f i x e d or r e i f i e d . Each one of the themes moves, flows, and meshes to represent the nurses' t o t a l experience even when they appear c o n t r a d i c t o r y . No one, p a i r or group of themes of the nurses' experience can be i s o l a t e d from the others and set apart as most s i g n i f i c a n t or important. Opposites are e q u a l l y meaningful. C o n f l i c t i s as much pa r t of the nurses' experiences as i s s a t i s f a c t i o n . Although the p r e s e n t a t i o n of the themes w i l l be i n a l i n e a r order i t must be remembered that "Each c o n s t i t u e n t (theme) p a r t i c i p a t e s i n the others i n a n o n - l i n e a r f a s h i o n , b r i n g i n g the experience i n t o f u l l n e s s . . . " ( C l a s p e l l , 1983, p. 88). The p r e s e n t a t i o n of the themes i s t h e r e f o r e not i n order of p r i o r i t y or p r o g r e s s i o n but connotes a flow, a continuous process. Six major themes and one subtheme have been e x p l i c a t e d from the nurses' accounts of t h e i r l i v e d experience. 1. The experience of f e a r of being p h y s i c a l l y harmed. Subtheme: The experience of a l a c k of a d m i n i s t r a t i v e support. 2 . The experience of c o n f l i c t . 3 . The experience of ambivalence i n r e l a t i o n s h i p s with p h y s i c i a n s . 4. The experience of sadness, disappointment and f r u s t r a t i o n . 5. The experience of s a t i s f a c t i o n . 6. The experience of growth. The next s e c t i o n of t h i s chapter i s an e x p l a n a t i o n of each of these themes of experience f o l l o w e d by a p r e s e n t a t i o n of the accounts from which the themes were e x p l i c a t e d . Each p a r t i c i p a n t has been g i v e n a pseudonym to enhance the r e a d a b i l i t y of the accounts without compromising her anonymity. The Experience of Fear of Being P h y s i c a l l y Harmed The r i s k of p h y s i c a l a s s a u l t i n c a r i n g f o r p a t i e n t s with mental h e a l t h problems i s always i n the background. Dangerous, u n p r e d i c t a b l e p a t i e n t behaviour engenders a n x i e t y and f e a r sometimes i n t e r f e r i n g with r e l a t i o n s h i p b u i l d i n g . A c t u a l s i t u a t i o n s of v i o l e n c e produce a d d i t i o n a l f e e l i n g s of inadequacy, s e l f - b l a m e 75 a n d a n g e r . I n a d e q u a c y a t p o s s i b l y n o t h a v i n g r e c o g n i z e d t h e s i g n s a n d i n d e a l i n g e f f e c t i v e l y w i t h t h e v i o l e n t s i t u a t i o n a n d s e l f - b l a m e , i n t h e n o t i o n t h a t one h a d somehow p r o v o k e d t h e s i t u a t i o n o r w i l l be f o u n d o u t a s h a v i n g p r o v o k e d t h e s i t u a t i o n . A n g e r r e s u l t i n g f r o m b e i n g p l a c e d o r p l a c i n g o n e s e l f i n p o t e n t i a l l y o r a c t u a l v i o l e n t s i t u a t i o n s a n d a n g e r r e s u l t i n g f r o m i n a d e q u a t e e m o t i o n a l a n d r e s o u r c e s u p p o r t d u r i n g a n d a f t e r i n c i d e n t s o f v i o l e n c e . S u b t h e m e : T h e E x p e r i e n c e o f a L a c k o f A d m i n i s t r a t i v e  S u p p o r t . T h e r e i s a p e r c e i v e d l a c k o f a d m i n i s t r a t i v e s u p p o r t by n u r s e s i n c a r i n g f o r p a t i e n t s w i t h m e n t a l h e a l t h p r o b l e m s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . E m o t i o n a l a n d r e s o u r c e s u p p o r t i n t i m e s o f c r i s i s i s p a r t i c u l a r l y d i f f i c u l t t o a c t u a l i z e . T h e E x p e r i e n c e o f C o n f l i c t T h e n u r s e s ' d e s c r i p t i o n s r e v e a l e s t a b l i s h i n g m e a n i n g f u l c o n t a c t w i t h p a t i e n t s t h e y p e r c e i v e d as m a n i p u l a t i v e , d e p e n d e n t , n o n - c o m p l i a n t , d e m a n d i n g a n d d a n g e r o u s i s e x t r e m e l y c h a l l e n g i n g f o r n u r s e s . T h e i r e n c o u n t e r s w i t h t h e s e p a t i e n t s a n d t h e i r c o l l e a g u e s become f r a u g h t w i t h f e e l i n g s o f a n g e r , f r u s t r a t i o n , f e a r a n d d i s g u s t . P r o t e c t i v e d e f e n s e s t r a t e g i e s s u c h as d i s t a n c i n g , s t e r e o t y p i n g , a n d r i g i d t r e a t m e n t r e g i m e s a r e e m p l o y e d t o d e a l w i t h t h e i n t e n s e l y f e l t 7 6 c o n f l i c t s a n d f e e l i n g o f h e l p l e s s n e s s . T h e E x p e r i e n c e o f A m b i v a l e n c e i n R e l a t i o n s h i p s w i t h P h y s i c i a n s T h e p h y s i c i a n ' s p r e s e n c e i n t h e n u r s e - p a t i e n t r e l a t i o n s h i p i s a s o u r c e o f p l e a s u r e a n d s a t i s f a c t i o n a n d a s o u r c e o f c o n f l i c t . S u p e r f i c i a l l y a n d c o m p a r e d t o o t h e r c l i n i c a l s e t t i n g s g r e a t e r e q u a l i t y b e t w e e n n u r s e a n d p h y s i c i a n i s p e r c e i v e d a n d e n j o y e d i n p s y c h i a t r i c c a r e s e t t i n g s . T h e o p p o s i t e f o r m s a n e q u a l p a r t o f t h e i r p e r c e p t i o n . P h y s i c i a n s ' p e r c e i v e d o p p o s i t i o n t o n u r s e s ' n e e d s , g o a l s , p h i l o s o p h i e s a n d p e r c e p t i o n s o f p a t i e n t s i t u a t i o n s i s a l s o e x p e r i e n c e d a n d p r o d u c e s c o n f l i c t . T e n s i o n a n d r e s e n t m e n t s a r e f e l t a n d b u i l d up w i t h p a t i e n t c a r e u l t i m a t e l y a f f e c t e d . T h e E x p e r i e n c e o f S a d n e s s , D i s a p p o i n t m e n t , a n d  F r u s t r a t i o n T h e e x p e r i e n c e o f b e i n g i n r e l a t i o n s h i p s w i t h p a t i e n t s o f t e n c r e a t e s f e e l i n g s o f l o s s f o r t h e n u r s e when t h e p a t i e n t ' s l i f e p l a n s o r p o t e n t i a l i s d e s t r o y e d by a m e n t a l i l l n e s s . T h e r e i s s a d n e s s a n d d i s a p p o i n t m e n t . F r u s t r a t i o n i s e x p e r i e n c e d when p a t i e n t s make c h o i c e s p e r c e i v e d as k e e p i n g them s i c k o r when one c a n n o t e f f e c t c h a n g e i n a p a t i e n t who h a s t h e c a p a b i l i t i e s t o c h a n g e a n d a l t e r t h e c o u r s e o f h i s / h e r l i f e . T h e l o w e r i n g o f o n e ' s e x p e c t a t i o n s a n d d o i n g t h e b e s t one c a n f o r t h e p a t i e n t i n t h e s e c i r c u m s t a n c e s i s a c o p i n g s t r a t e g y . I t s e r v e s t o r a t i o n a l i z e t h e f e e l i n g s o f h e l p l e s s n e s s a n d h o p e l e s s n e s s a n d p r o v i d e s f o r some m e a s u r e o f s u c c e s s f o r b o t h p a t i e n t a n d n u r s e . The Experience of S a t i s f a c t i o n E x p e r i e n c e s o f s a t i s f a c t i o n a r e r e v e a l e d i n t h e n u r s e s ' d e s c r i p t i o n s o f t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . T h e s e a r e r e v e a l e d as h a v i n g a c h i e v e d t r u s t , i n t i m a c y , c l o s e n e s s , c o n n e c t e d n e s s , a n d r a p p o r t . T h e y a r e d e s c r i b e d as a r e c i p r o c a l way o f r e l a t i n g w h e r e m u t u a l c a r i n g a n d s h a r i n g o c c u r . T h e y a r e e x p e r i e n c e s o f b e i n g i n t h e r e l a t i o n s h i p w i t h p a t i e n t s : a u t h e n t i c a n d e m p a t h i c . The Experience of Growth B e i n g i n r e l a t i o n s h i p s w i t h p a t i e n t s a n d n u r s i n g c o l l e a g u e s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s i s d e s c r i b e d as c o n t r i b u t i n g t o b o t h p e r s o n a l a n d p r o f e s s i o n a l g r o w t h . A w a r e n e s s o f s e l f i s g a i n e d a n d p e r s o n a l c h a n g e s a r e e x p e r i e n c e d . O n e ' s n u r s i n g p r a c t i c e i s r e f i n e d a n d p e r s o n a l s t y l e s o f h e l p i n g a r e d e v e l o p e d a n d e x t e n d e d . 78 T H E P A R T I C I P A N T S ' ACCOUNTS  T h e E x p e r i e n c e o f F e a r o f B e i n g P h y s i c a l l y H a r m e d F e a r o f b e c o m i n g p h y s i c a l l y h a r m e d by p a t i e n t s was e x p e r i e n c e d as a common s t r e s s o r . T h e r i s k o f a s s a u l t a s s o c i a t e d w i t h c a r i n g f o r p a t i e n t s w i t h m e n t a l h e a l t h p r o b l e m s on i n p a t i e n t u n i t s was s t a t e d r e p e a t e d l y . A l t h o u g h p a r t i c i p a n t s a c c e p t e d t h e p o t e n t i a l f o r a s s a u l t a s p a r t o f t h e i r j o b a n d f e l t v a r y i n g d e g r e e s o f c o m p e t e n c y i n d e a l i n g w i t h v i o l e n t s i t u a t i o n s , t h e i r f e a r o f b e i n g p h y s i c a l l y h a r m e d was a l w a y s i n t h e b a c k g r o u n d . I t seems no m a t t e r how l o n g n u r s e s h a v e w o r k e d i n a p s y c h i a t r i c c a r e s e t t i n g , t h e y s t i l l e x p e r i e n c e f e a r when t h e y a r e f a c e d w i t h a g g r e s s i v e p a t i e n t s . One p a r t i c i p a n t h a d w o r k e d i n p s y c h i a t r y f o r o v e r 24 y e a r s . T h e f o l l o w i n g e x c e r p t s i l l u s t r a t e t h i s t h e m e . S a r a h : . . . I am a l w a y s f r i g h t e n e d when we h a v e a n a g g r e s s i v e p a t i e n t . . . I t c a n be t e r r i b l y f e a r f u l . F o r i n s t a n c e , i n t h e p a r t i c u l a r p l a c e I ' m w o r k i n g i n now, i f i t ' s r e a l l y a s a f e t y t h i n g a n d i f y o u h a v e n o b o d y a r o u n d t o h e l p y o u c a l l t h e RCMP t o h e l p y o u . A n d i t ' s a n o k a y f e e l i n g t h a t y o u ' v e g o t someone t o h e l p y o u b u t i t ' s n o t a n o k a y f e e l i n g t o h a v e s u c h f e a r . A n d I d o n ' t c a r e f o r t h e k i n d o f t e n s e n e s s t h a t i t e v o k e s . Umm I ' m n o t s u r e t h a t t h e r e i s a n e a s y a n s w e r t o i t , c e r t a i n l y t h e r i s k o f b e i n g h u r t i s j u s t a n a w f u l f e e l i n g a n d t h a t n e v e r d i m i n i s h e s . L i l y : . . . I t i s s c a r y a t t i m e s , w e ' v e h a d o u r v i o l e n t s i t u a t i o n s w h e r e I ' v e s e e n a s e c u r i t y g u a r d w i t h h i s h a i r r i p p e d o u t , I ' v e h a d m e t a l t r a y s t h r o w n a t me, umm I h a v e , s h a k e e v e r y t i m e I t h i n k o f t h a t p a r t i c u l a r s i t u a t i o n w h e r e t h o s e t r a y s w e r e f l y i n g a t me, we h a d no c o n t r o l o v e r t h i s m a n . I g o t t h i s h o t sweat a n d i t ' s a v e r y s c a r y f e e l i n g t o h a v e t h e s e t h i n g s t h a t I o n l y t h o u g h t were i n p u b s o r s o m e t h i n g l i k e t h a t , y o u know, a n d t h e y were h a p p e n i n g on my u n i t . Umm b u t a g a i n , t h a t ' s t h e e x c i t e m e n t a n d t h e c h a l l e n g e o f d e a l i n g w i t h p e o p l e l i k e t h a t . R o s e : I remember we h a d one l a d y who was v e r y v e r y s i c k , v e r y p s y c h o t i c s h e was q u i t e v i o l e n t a n d s h e w o u l d j u s t f r e a k o u t , t a k e a l l h e r c l o t h e s o f f a n d r u n down t h e w a r d . She was v e r y f r i g h t e n i n g s h e w o u l d come a t p e o p l e w i t h h i g h k i c k s a n d s h e was a b r u p t a n d h a l l u c i n a t i n g v e r y b a d l y . . . 80 T h e f o l l o w i n g p a r t i c i p a n t ' s e x c e r p t f u r t h e r i l l u s t r a t e s t h i s t h e m e . T h e p a r t i c i p a n t ' s a f f e c t a n d c h o i c e o f w o r d s i n d e s c r i b i n g t h e p a t i e n t a r e e v i d e n c e o f t h e e x t r e m e f e e l i n g s o f f e a r s h e e x p e r i e n c e d n u r s i n g a p a t i e n t who was a l s o known t o h a v e a h i s t o r y o f v i o l e n c e . T h e e l e m e n t o f i n t e n t i o n a l i t y t o t h e p a t i e n t ' s v i o l e n t b e h a v i o u r a l s o seemed t o i n t e n s i f y t h e n u r s e s f e a r a n d a l s o e n g e n d e r f e e l i n g s o f a n g e r . B r i g i t : . . . a b o u t a m o n t h a g o . We h a d t h i s , h e ' s s c h i z o p h r e n i c a l s o known h i s t o r y o f v i o l e n c e a n d j a i l a n d q u i t e s a d i s t i c , a r e a l w i n n e r . T h i s guy was a r e a l h o r r o r show b u t u n f o r t u n a t e l y he was a l s o v e r y p s y c h o t i c a t t h e t i m e a n d p a r a n o i d a n d r e a l l y some r e a l l y s t r a n g e t w i s t e d b i z a r r e s t u f f , y o u know d e l u s i o n s t o do w i t h h u r t i n g p e o p l e a n d o h i t was j u s t g r o s s . Anyway he s t a r t e d t o l o s e i t one a f t e r n o o n , t h i s f e m a l e p a t i e n t went t o t a l k t o h i m a n d he j u s t y e l l e d o u t " f u c k o f f " a n d I t h o u g h t oh G o d , I know w h a t ' s g o i n g t o h a p p e n s o I went o u t a n d I t o l d t h e f e m a l e p a t i e n t j u s t t o l e a v e a n d I s a i d w h a t ' s t h e p r o b l e m a n d he s a i d "she was c o m i n g a t me . . . " a n d now he was r e a l l y p a r a n o i d a b o u t a l l o f t h i s s o I t o l d h i m I w a n t e d h i m t o t a k e some m e d i c a t i o n s s o I p o u r e d h i m a w a l l o p i n g d o s e o f h a l d o l a n d a t i v a n a n d he t o o k i t 81 a n d s a i d " y o u c a n g i v e me a l l t h e m e d i c a t i o n y o u want b u t i t ' s p r o b a b l y n o t g o i n g t o do any g o o d , t h i s t i m e I j u s t y e l l e d , n e x t t i m e I ' m c o m i n g o u t b i t i n g , p u n c h i n g , A n d I s a i d , " w e l l " , a n d I r e a l l y h o p e d t h i s m e d i c a t i o n w o u l d t a k e e f f e c t s o o n . A n d w i t h i n 15 m i n u t e s he was a t t h e d e s k a g a i n a n d he was s a y i n g " . . . I want my c l o t h e s a n d i f I c a n ' t h a v e t h a t " , t h e guy was u n f o r t u n a t e l y c e r t i f i e d as w e l l , " a n d i f I c a n ' t h a v e t h a t t h e n I ' m g o i n g t o k i c k A n d s o he m a r c h e d away a n d s o I t h o u g h t t h i s i s i t , a n d I j u s t c a l l e d t h e C o d e a n d I t h o u g h t I ' m n o t e v e n g o i n g t o f o o l a r o u n d w i t h t h i s o n e . I j u s t , u s u a l l y I j u s t p h o n e t h e s u p e r v i s o r a n d s a y c o u l d y o u s e n d f o r 5 g u y s b u t I t h o u g h t t h i s i s a C o d e a l l o v e r t h e h o s p i t a l s o t h e g u y s s t a r t e d c o m i n g a n d when he saw them he r a n i n t o t h e d i n i n g room a n d p i c k e d up a c h a i r a n d he s a i d " a n y o n e comes n e a r me y o u ' r e g o n n a g e t i t . " So I s a i d t o t h e u n i t c l e r k , p h o n e t h e p o l i c e , t h i s i s a C o d e l i k e f o r t h e p o l i c e a n d j u s t as s h e was r e a c h i n g f o r t h e p h o n e one o f t h e g u y s j u s t , I mean t h e y d o n ' t p a y me e n o u g h t o do any o f t h i s , he j u s t went up a n d g r a b b e d t h e c h a i r a n d p u t i t down. W h i c h , a n d t h e p a t i e n t seemed t o r e a l i z e y e a h t h e r e ' s o t h e r p e o p l e t a k i n g c o n t r o l 82 o f t h e s i t u a t i o n a n d s o I h a d t h e m e d i c a t i o n a l l d r a w n up t o g i v e h i m IM as w e l l a s , t h e r e s t r a i n t s r e a d y . A n d he d i d n ' t f i g h t a t a l l , he s a y s " y o u g u y s c a n do t h i s i t ' s b e e n d o n e t o me b e f o r e , when I g e t o u t o f t h e s e t h i n g s I ' m g o i n g t o b r e a k y o u r f u c k i n g f a c e s a n d y o u ' r e d e a d , y o u ' r e a l l d e a d . " W h i c h I t h o u g h t , t h e y s a y t h a t , b u t when e v e r y o n e l e f t , a n d h e , a n d y o u know t h o s e r e s t r a i n t s a r e u s e l e s s L i n d a , p e o p l e g e t o u t o f t h e m . So he s t a r t e d g e t t i n g o u t o f t h e m , s o I c a l l e d e v e r y o n e b a c k a n d s o I s a i d " t h i s guy i s g o i n g t o n e e d a c o n s t a n t " , j u s t t o make s u r e t h a t i f h e ' s g o i n g t o g e t o u t h e ' s n o t g o i n g t o come up a t us f r o m b e h i n d a n d b r a i n us w i t h a c h a i r o r s o m e t h i n g . So we g o t a c o n s t a n t , I h a d t o c a l l t h e p e o p l e b a c k t o p u t h i m b a c k i n r e s t r a i n t s a n d t h e n f i n a l l y when p e o p l e l e f t he was l o o k i n g r i g h t a t me a n d s a y i n g t h a t e s p e c i a l l y me, b e c a u s e I g a v e t h e m e d i c a t i o n a n d o r c h e s t r a t e d t h e w h o l e t h i n g , t h a t I w a s , he s a i d "when", i t w a s n ' t i f , "I g e t o u t o f t h e s e y o u a r e d e a d " a n d he c a l l e d me n a m e s , y o u know y o u c a n i m a g i n e t h e u s u a l 4 l e t t e r . A n d t h e n t a l k i n g a b o u t , he s a y s " I ' m n o t e v e n g o i n g t o come a t y o u f r o m i n f r o n t , I ' m g o i n g t o come a t y o u f r o m b e h i n d a n d y o u w o n ' t know what h i t y o u . A n d i f I d o n ' t do i t h e r e , I ' l l do i t some n i g h t on t h e s t r e e t . " A n d t h e n I s a i d , " y e a h r i g h t . " B u t s t i l l t h a t k i n d o f t h i n g , y o u know y o u ' r e l i s t e n i n g t o , t h a t k i n d o f v e r b a l a b u s e a n d i t k i n d o f g e t s t o y o u , y o u know. B u t anyway s i t u a t i o n s l i k e t h a t a r e v e r y a n x i e t y p r o d u c i n g a n d I am, i n f a c t , when I was g i v i n g t h e IM m e d i c a t i o n my h a n d s , t h e y a l w a y s , I h a t e t h a t , b u t i t h a p p e n s , e s p e c i a l l y when p e o p l e a r e a r o u n d h o l d i n g down t h e p a t i e n t a n d y o u r s t a n d i n g t h e r e g i v i n g t h i s m e d i c a t i o n w i t h t r e m b l i n g h a n d s . B r i g i t g o e s on t o s a y how s h e f e e l s when s h e h a s t i m e t o r e f l e c t on t h e s e s i t u a t i o n s . She f e e l s a n g r y a t h e r c o m p l e t e v u l n e r a b i l i t y . B r i g i t : . . . A n d t h o s e k i n d s o f t h i n g s c a n be b a s i c a l l y o r p o t e n t i a l l y s o u l d e s t r o y i n g b e c a u s e y o u go home a n d y o u t h i n k o f t h e a n g e r o f h a v i n g someone c l u t c h y o u a r o u n d y o u r c l o t h i n g a n d how d a r e t h e y do t h a t a n d how d i d y o u g e t y o u r s e l f i n t o t h a t s i t u a t i o n w h e r e t h e y d i d t h a t . . . . y o u ' r e s u d d e n l y v u l n e r a b l e , t h a t t h e way he h a d me he c o u l d h a v e p u t h i s f i s t up i n my f a c e a n d I d o n ' t know what I c o u l d h a v e d o n e a b o u t i t . . . . s o m e t i m e s , i t ' s , i t makes y o u a n g r y . W e l l i t makes me a n g r y t h a t I ' v e p u t m y s e l f i n a p o s i t i o n where I ' m v u l n e r a b l e t o s o m e o n e ' s p h y s i c a l a t t a c k s a n d i t ' s somehow, w e l l y o u ' r e t h e n u r s e , y o u ' r e t h e f r o n t l i n e . T h e n e x t p a r t i c i p a n t ' s a c c o u n t d e s c r i b e d t h e f e a r s h e e x p e r i e n c e d when s h e became i n c o r p o r a t e d i n t o a p a t i e n t ' s d e l u s i o n a l s y s t e m t h a t c o n t a i n e d themes o f v i o l e n c e a n d s a t a n i s m . R a c h e l : . . . O n e c a s e t h a t I c a n t h i n k o f was a man who i n c o r p o r a t e d me i n t o h i s d e l u s i o n a l s y s t e m , w h i c h was f u l l o f demons a n d s y m b o l s a n d s a t a n i c k i n d s o f m e s s a g e s a n d I became a s a t a n i c s p y o r s o m e t h i n g a n d t h a t was when I r e a l i z e d t h a t t h e r e was no way I c o u l d h a v e a t h e r a p e u t i c r e l a t i o n s h i p w i t h h i m . A c h a n g e h a d t o be m a d e . . . . T h e man d e c i d e d t h a t I was s a t a n i c , h a d a p p a r e n t l y a l s o s p o k e n t o h i s d o c t o r a b o u t i t . I t was a c t u a l l y d u r i n g a m e e t i n g t h a t he t o l d , e x p r e s s e d h i s f e a r a n d a n g e r , v e r y a n g r y . . . he a n n o u n c e s t o t h e w h o l e c o m m u n i t y t h a t I w a s n ' t r e a l l y a n u r s e , t h a t I was p a r t o f a s a t a n i c c u l t t h a t was g i v i n g h i m h i s p o i s o n f o u r t i m e s a day o r w h a t e v e r . A n d c e r t a i n l y I was e x t r e m e l y a f r a i d when I h a d t h a t i n f o r m a t i o n . . . t h e r e was no way I c o u l d c o n t i n u e n u r s i n g t h i s p a t i e n t . I t was c e r t a i n l y n o t h e l p f u l f o r h i m o r h e l p f u l f o r me b e c a u s e I was 85 t o o a n x i o u s , t h a t he h a d a h i s t o r y o f v i o l e n c e as we l 1. E v e n t h o u g h n u r s e s e x p e r i e n c e f e a r n u r s i n g p a t i e n t s who become a g g r e s s i v e b e c a u s e o f a p s y c h o t i c i l l n e s s , t h e n u r s e s ' a c c o u n t s r e v e a l a more c o m p a s s i o n a t e a t t i t u d e t o w a r d p s y c h o t i c p a t i e n t s who became a g g r e s s i v e . T h e y f e e l more p r o t e c t i v e t o w a r d t h e p a t i e n t a n d a r e b e t t e r a b l e t o r a t i o n a l i z e t h e p a t i e n t ' s b e h a v i o u r . T h e y a l s o e x p r e s s l e s s a n g e r when d e s c r i b i n g s i t u a t i o n s w i t h t h e s e p a t i e n t s . T h i s i s r e f l e c t e d i n L e a h ' s d e s c r i p t i o n o f a n a c t u a l s i t u a t i o n w i t h a p a t i e n t whom s h e b e l i e v e d was d e l i b e r a t e l y v i o l e n t t o w a r d s a n o t h e r p a t i e n t . L e a h : . . . I remember w o r k i n g a n d w i t n e s s i n g one o f t h e p a t i e n t s who w a s . . . t h e r e b e i n g a s s e s s e d b e c a u s e he was a p p a r e n t l y i n s a n e . . . t h e p a t i e n t p i c k e d up a [ h a r d o b j e c t ] a n d t h r e w i t f u l l f a c e a t a n o t h e r p a t i e n t a c r o s s t h e room h i t t i n g h i m r i g h t i n t h e h e a d . . . . I remember f e e l i n g n o t o n l y a n g e r b u t t o t a l r a g e . . . I j u s t f e l t j u s t t o t a l l y d i s g u s t e d by t h e w h o l e i n c i d e n t . I f o u n d t h a t I c o u l d n ' t e v e n r a t i o n a l i z e h i s b e h a v i o u r o f somebody who was i n s a n e o r v e r y m e n t a l l y i l l b e c a u s e o f t h e f e e l i n g s o f a n g e r t h a t I h a d . A n o t h e r p a r t i c i p a n t , D i a n a , r e v e a l s s i m i l a r 86 e m o t i o n a l r e a c t i o n s . She s t a t e s : D i a n a : F o r p e o p l e t h a t a r e s u f f e r i n g f r o m some k i n d o f p s y c h o t i c i l l n e s s a n d a r e o u t o f c o n t r o l I g u e s s . . . I f i n d i t h a r d e r t o u n d e r s t a n d i n t e l l e c t u a l l y what t h e y a r e g o i n g t h r o u g h , t h e r e ' s no q u e s t i o n s a b o u t t h a t . I d o n ' t s o much u n d e r s t a n d what t h e i r e x p e r i e n c e c o u l d be l i k e e x c e p t t h a t i t must be v e r y t e r r i f y i n g . A n d s o , when I ' m f a c e d w i t h somebody t h a t i s v e r y i l l , l i k e t h a t , I g u e s s I f e e l p r o t e c t i v e o f t h e m , I f e e l s y m p a t h y f o r t h e m . . . . I n a d d i t i o n t o e v o k i n g f e e l i n g s o f f e a r a n d a n g e r , v i o l e n t s i t u a t i o n s seem t o e v o k e f e e l i n g s o f i n a d e q u a c y a n d r a i s e d o u b t i n n u r s e s i n t e r m s o f t h e i r c o m p e t e n c y . N u r s e s q u e s t i o n t h e i r a c t i o n s a n d r e v i e w v i o l e n t i n c i d e n t s o v e r a n d o v e r a g a i n t o d e t e r m i n e i f t h e y m i s s e d any c u e s o r i f t h e y a c t e d i n t h e b e s t way p o s s i b l e . B r i g i t : . . . . h a v i n g a p a t i e n t o u t o f c o n t r o l a n d a n g r y i s v e r y f r i g h t e n i n g a n d y o u r p h y s i c a l s a f e t y t h r e a t e n e d b u t I ' m a l s o t h i n k i n g my p h y s i c a l s a f e t y b u t a l s o my a c c o u n t a b i l i t y what c a n I do h e r e , b e c a u s e i f someone g e t s h u r t o r i t e n d s up b e i n g an i n v e s t i g a t i o n o f some k i n d a n d I ' m l o o k e d a t as t h e one who s c r e w e d u p . Y o u know a l l t h e s e 87 t h i n g s a r e r a c i n g t h r o u g h y o u r m i n d . How i s t h i s g o i n g t o l o o k on p a p e r when I c h a r t i t , d i d I do t h e r i g h t t h i n g s d i d I c o v e r a l l t h e p o s s i b i l i t i e s . . . . y o u g e t home, a n d y o u g e t o f f work a n d i t t a k e s a l o n g t i m e t o u n w i n d . T h i n g s j u s t k e e p g o i n g r o u n d a n d r o u n d y o u r h e a d . E v e n a f t e r 10 y e a r s a n d t h e s e t h i n g s h a p p e n f a i r l y f r e q u e n t l y b u t t h e r e i s a l w a y s t h a t m a j o r a n x i e t y o f d i d I do e v e r y t h i n g r i g h t , y o u know. C o u l d I h a v e d o n e i t b e t t e r ? . . . D i d I c a t c h i t s o o n , b e c a u s e I ' m c o n s t a n t l y a s s e s s i n g t h e p a t i e n t t o s e e , now i s t h i s one e s c a l a t i n g o r w h a t e v e r , b e c a u s e t h e s o o n e r y o u c a t c h i t t h e l e s s c h a n c e t h e r e i s o f a m a j o r f u l l b l o w n a c t i n g o u t v i o l e n t e p i s o d e . L i l y : . . . I remember one t i m e t h i s g i r l h a d gone a b i t p s y c h o t i c on h e r meds a t 8 :30 i n t h e m o r n i n g . . . b o t h t h i s m a l e n u r s e a n d m y s e l f were p l a n t e d on t o p o f t h i s g i r l a n d s h e was j u s t g o i n g w i l d . . . . t h i s d o c t o r comes w a l k i n g i n t h e w a r d . . . " w e l l I ' m g l a d y o u ' r e h e r e " a n d I ' m j u s t s h a k i n g . . . . I s a i d , "I w o u l d l i k e t o come a n d s i t down w i t h y o u [ a n d p a t i e n t ] a n d t h a t moment t e a r s j u s t c a m e . . . i t was q u i t e o v e r w h e l m i n g - I j u s t went 88 i n t o t h e b a t h r o o m a n d c r i e d my e y e s o u t a n d I t h i n k i t was b e c a u s e I was s o u n s u r e t h a t what I was d o i n g was r i g h t . I ' d h a d t h e CPZ t h r o w n a l l o v e r me, s h e j u s t a b o u t t h r e w a t a b l e t h r o u g h t h e t v , a n o t h e r p a t i e n t j u s t a b o u t g o t i n v o l v e d w i t h t h e f i g h t , we h a d a b o u t f o u r p a t i e n t s on a t t h a t t i m e t h a t were q u i t e v o l a t i l e a n d t h a t w o u l d i f s h e h a d s w o r n a t them o r c a l l e d them a y o u know what s h e w o u l d h a v e maybe s e t them a l l o f f . A n d I was u n d e r s o much t e n s i o n . . . . d i d I m i s s s o m e t h i n g ? was I s u p p o s e d t o do t h i s ? I n summary , t h e a c c o u n t s r e v e a l t h a t b e c o m i n g t h e t a r g e t o f i n p a t i e n t p s y c h i a t r i c c a r e , v i o l e n c e i s a l w a y s i n t h e b a c k g r o u n d a n d e n g e n d e r s f e e l i n g s o f f e a r , a n g e r , i n a d e q u a c y a n d s e l f d o u b t . A p e r c e i v e d l a c k o f a d m i n i s t r a t i v e s u p p o r t c o n t r i b u t e s t o t h i s f e a r a n d p r o d u c e s l o n g t e r m p e r s o n a l a n d p r o f e s s i o n a l r a m i f i c a t i o n s . S u b t h e m e : T h e E x p e r i e n c e o f a L a c k o f A d m i n i s t r a t i v e  S u p p o r t N u r s e s who work i n d i f f i c u l t a n d d e m a n d i n g s i t u a t i o n s e x p e c t t o be g u i d e d , a f f i r m e d a n d s u p p o r t e d by t h e i r n u r s i n g l e a d e r s . T h e y n e e d t o h a v e a s e n s e o f r e l i a b l e a l l i a n c e a n d s u p p o r t i n w h i c h t h e y c a n e x p e c t c o n t i n u i n g a s s i s t a n c e a n d s u p p o r t f r o m t r u s t w o r t h y a n d 89 a u t h o r i t a t i v e p e r s o n s i n t h e h o s p i t a l o r g a n i z a t i o n . The n u r s e s ' d e s c r i p t i o n s r e v e a l a p e r c e i v e d l a c k o f a d m i n i s t r a t i v e u n d e r s t a n d i n g a n d s u p p o r t i n c a r i n g f o r p a t i e n t s i n p s y c h i a t r i c c a r e s e t t i n g s . T h e r e i s a p e r c e i v e d u n w i l l i n g n e s s o f a d m i n i s t r a t o r s t o l e a r n a b o u t t h e "work" o f p s y c h i a t r i c n u r s e s a n d a l a c k o f g e n u i n e i n t e r e s t a n d c o n c e r n f o r t h e e m o t i o n a l n e e d s o f t h e n u r s e who c h o o s e s t o work i n p s y c h i a t r y . T h i s l a c k o f e m o t i o n a l s u p p o r t was f e l t more a c u t e l y i n c r i s i s s i t u a t i o n s p a r t i c u l a r l y s i t u a t i o n s i n v o l v i n g t h e management o f a n a g g r e s s i v e p a t i e n t . D i a n a : I t h i n k p s y c h i a t r y r e a l l y l a c k s s u p p o r t . . . I t h i n k we l a c k a l o t o f s u p p o r t t h a t o t h e r n u r s i n g u n i t s g e t . . . how do y o u e x p l a i n t o p e o p l e who a r e c o m i n g a r o u n d f o r two m i n u t e s what y o u ' r e d o i n g . A n d a l o t o f t i m e s t h a t makes me f e e l v e r y c o n f l i c t e d b e c a u s e I s e n s e t h a t t h e r e ' s t h i s b i a s t o w a r d s p s y c h i a t r y t h a t w e ' r e n o t d o i n g a n y t h i n g a n d I r e a l l y h a t e t h a t - I r e a l l y h a t e i t . T h e amount o f work we do i s i n c r e d i b l e a n d y o u c a n ' t e x p l a i n i t t o someone who i s t r a i n e d i n m e d i c a l s u r g i c a l n u r s i n g a n d t h a t ' s what t h e y ' v e b e e n d o i n g f o r 25 y e a r s t h a t ' s w h e r e I f e e l t h e r e i s a b i g p r o b l e m . I f t h e r e i s g o i n g t o be s u p e r v i s o r t h e r e s h o u l d be some p e o p l e w i t h p s y c h i a t r i c 90 e x p e r i e n c e t h a t know what y o u ' r e t a l k i n g a b o u t . . . . Y o u r e a l l y h a v e t o g i v e e a c h o t h e r s u p p o r t i n p s y c h b e c a u s e i t r e a l l y d o e s n ' t come f r o m t h e r e s t o f t h e h o s p i t a l a n d i t ' s v e r y o b v i o u s . I mean mos t p s y c h i a t r i c u n i t s a r e i n some b a c k w i n g o f t h e h o s p i t a l o r t h e y ' r e i n a t o t a l l y s e p a r a t e b u i l d i n g a n d t h a t s a y s s o m e t h i n g . I n a d d i t i o n t o a p e r c e i v e d l a c k o f w i l l i n g n e s s f r o m o t h e r h o s p i t a l p e r s o n n e l t o t r y a n d u n d e r s t a n d t h e "work" o f p s y c h i a t r i c n u r s e s , D i a n a ' s a c c o u n t a l s o r e v e a l s a l a c k o f a t t a c h m e n t a n d s e n s e o f p l a c e i n t h e h o s p i t a l o r g a n i z a t i o n . T h e "two m i n u t e " v i s i t f r o m t h e n u r s i n g s u p e r v i s o r i s s i g n i f i c a n t i n r e i n f o r c i n g p s y c h i a t r i c n u r s e s ' f e e l i n g s o f s e p a r a t e n e s s a n d d i f f e r e n c e f r o m o t h e r n u r s e s i n t h e h o s p i t a l o r g a n i z a t i o n . I n t h e n e x t e x c e r p t t h e p a r t i c i p a n t d e s c r i b e s a n i n c i d e n t , w i t h a n u r s i n g s u p e r v i s o r , i n v o l v i n g t h e p o t e n t i a l f o r v i o l e n c e , where s h e e x p e r i e n c e d a d i s r e g a r d f o r h e r own a n d h e r p a t i e n t ' s w e l f a r e a n d s a f e t y . N o t o n l y d i d t h e s u p e r v i s o r c o m m u n i c a t e h e r d i s p l e a s u r e a t h a v i n g t o come t o t h e p s y c h i a t r i c u n i t t o a s s i s t h e r , R a c h e l a l s o f e l t t h a t p o l i c y a n d p r o c e d u r e t o o k p r e c e d e n c e o v e r t h e p e o p l e i n v o l v e d i n t h e s i t u a t i o n . 91 R a c h e l : I h a v e a n e x a m p l e o f t h a t . A few weeks ago when I was w o r k i n g n i g h t s a p a t i e n t who h a s a h i s t o r y o f v i o l e n c e a n d h a d b e e n r a t h e r h i g h w o u l d g e t up d u r i n g t h e n i g h t , a n d . . . h e w o u l d g e t up a c o u p l e o f t i m e s d u r i n g t h e n i g h t a n d he w o u l d n e e d a l o t o f r e d i r e c t i o n t o g e t b a c k t o h i s r o o m . . . We w o u l d c a l l t h e s e c u r i t y t o come o v e r a n d g i v e us a h a n d . A n d a t a b o u t 5:00 i n t h e m o r n i n g we were w o r k i n g i n t h e o f f i c e a n d we h e a r d [ a n o i s e ] . . . he was q u i t e t h r e a t e n i n g i n h i s v o i c e t o n e . . . . We h a d c o n c e r n s t h a t he w o u l d t h e n maybe r u n o f f down t h e s t r e e t . . . I r a n t o t h e p h o n e a n d d i a l l e d [ n u m b e r ] , i t r a n g t h r e e t i m e s w i t h no r e s p o n s e s o I h u n g up a n d d i a l l e d [ c o d e n u m b e r ] , what I n e e d e d was a q u i c k r e s p o n s e f r o m t h e s e c u r i t y . . . t o come a n d h e l p us r e d i r e c t h i m . T h e [ c o d e ] number i s one t h a t i s i m m e d i a t e l y r e s p o n d e d t o a t t h e s w i t c h b o a r d f o r e m e r g e n c y f i r e , e m e r g e n c y m e d i c a l c o n d i t i o n s i f someone h a s a c a r d i a c a r r e s t . . . . A n d I s a i d " p l e a s e p a g e t h e s e c u r i t y t o come s t a t t o -- - " . . . . I a s s u m e d t h a t s h e [ s w i t c h b o a r d ] w o u l d go t h r o u g h t h e i r p a g i n g s y s t e m s h e h o w e v e r , d i d n o t . . . t h e s u p e r v i s o r came r u n n i n g . . . . A n d s o a f t e r we g o t h i m [ p a t i e n t ] b a c k i n t o h i s r o o m . . . t h e s u p e r v i s o r s a i d t o me "why d i d y o u d i a l [ c o d e 92 n u m b e r ] " a n d I s a i d w e l l , " b e c a u s e I d i a l l e d [ a n u m b e r ] a n d i t r a n g a b o u t t h r e e t i m e s a n d I d i d n ' t h a v e t h e t i m e a n d i t was a n u r g e n t s i t u a t i o n . A n d s h e s a i d t o me, " w e l l t h a t ' s t h e c o d e p h o n e , t h a t ' s o n l y f o r c o d e [ X ] , w h i c h i s a c a r d i a c a r r e s t " . . . I h e a r d t h e n e x t n i g h t , t h e day s u p e r v i s o r a l s o h a d q u e s t i o n e d why we u s e d t h a t p h o n e a n d t h a t i r r i t a t e d me. T h a t became more t h e i s s u e t h a n t h e u r g e n c y o f t h e s i t u a t i o n . T h e s a f e t y , o u r s a f e t y , t h e s a f e t y o f t h e p a t i e n t . . . T h o s e k i n d o f t h i n g s i r r i t a t e me. What becomes t h e i s s u e . A n d I f i n d t h e s u p e r v i s o r s maybe more i n c l i n e d t o n o t u n d e r s t a n d c o m p l e t e l y t h e s i t u a t i o n i n p s y c h i a t r y . R a c h e l t o l d t h e r e s e a r c h e r o f a n o t h e r s i t u a t i o n w i t h a n u r s i n g s u p e r v i s o r w h e r e s h e e x p e r i e n c e d a l a c k o f u n d e r s t a n d i n g . T h i s s i t u a t i o n seemed t o make R a c h e l p a r t i c u l a r l y a n g r y b e c a u s e t h e s u p e r v i s o r ' s b e h a v i o u r d i s p l a y e d a f u n d a m e n t a l l a c k o f c o m p a s s i o n f o r t h e p a t i e n t i n h i s p r e d i c a m e n t as w e l l a s a d i s r e g a r d f o r t h e f a c t t h a t R a c h e l ' s work w i t h t h i s p a t i e n t d o e s n o t b e g i n a n d e n d w i t h t h i s p a r t i c u l a r s i t u a t i o n . T h e r e was no r e c o g n i t i o n t h a t R a c h e l m i g h t h a v e a t h e r a p e u t i c r e l a t i o n s h i p w i t h t h e p a t i e n t t h a t was w o r t h p r e s e r v i n g . 93 R a c h e l : . . . S o m e t h i n g h a p p e n e d one n i g h t . . . h e [ a p a t i e n t R a c h e l h a d b e e n l o o k i n g a f t e r ] became more d e c o m p e n s a t e d , i n t e r m s o f d e l u s i o n s a n d h e a r i n g v o i c e s a n d was g e t t i n g v e r y a g i t a t e d . . . he l u n g e d a t m e . . . he w a s . . . h a v i n g t r o u b l e w i t h h i s c o n t r o l . . . So I h a d t o c a l l i n some a s s i s t a n c e t o m e d i c a t e h i m . I h a d n u r s e s a n d t h e s u p e r v i s o r a n d s e c u r i t y . We h a d t o a s k h i m t o g e t i n t o h i s p y j a m a s a n d I w o u l d be g i v i n g h i m i n t r a m u s c u l a r m e d i c a t i o n . . . anyway when I went i n w i t h t h e g a n g a n d t o l d h i m I w o u l d be g i v i n g h i m some m e d i c a t i o n b e c a u s e he a p p e a r e d a n d p r e s e n t e d a g i t a t e d . . . he w a n t e d t o t a l k a b o u t i t f o r a s h o r t t i m e , I f e l t a r e a s o n a b l e l e n g t h o f t i m e . A n d I a l l o w e d t h a t t o h a p p e n . A n d I h e a r d t h e s u p e r v i s o r b e h i n d me w h i s p e r , " l e t ' s g e t on w i t h i t " . I t d i s t r e s s e d me t e r r i b l y , b e c a u s e I f e l t i t was o k a y f o r h e r t o come t h i s one t i m e a n d a s s i s t a n d maybe i t was u s i n g up h e r some v a l u a b l e t i m e o f h e r s . H o w e v e r , what I t h i n k s h e f a i l e d t o s e e i s t h a t my r e l a t i o n s h i p w i t h h i m went b e y o n d t h i s one n i g h t a n d t h a t , t h a t ' s j u s t n o t t h e way I o p e r a t e . I h a v e t o c o n s i d e r t h e on g o i n g r a p p o r t . . . . I was i r r i t a t e d . . . I f e l t i t was a b i t , w e l l c e r t a i n l y u n c a l l e d f o r a n d v e r y u n c o m p a s s i o n a t e . A n o t h e r p a r t i c i p a n t f e l t t h a t t h e r e seemed t o be a p r e v a i l i n g a t t i t u d e among n u r s i n g s u p e r v i s o r s , t h a t 94 "they [meaning p s y c h i a t r i c nurses] could cope w i t h aggressive s i t u a t i o n s on t h e i r own because they were psych nurses," and that because of t h i s a t t i t u d e nurses lacked support w i t h these s i t u a t i o n s . This perceived lack of concern engenders f e e l i n g s of anger. Rose: ...they think oh you can cope, you can manage t h i s because you're psych nurses and you have more s k i l l s to deal w i t h a v i o l e n t or aggressive p a t i e n t but i f they h i t you haven't got any more armour than anybody e l s e has. So you know they expect you to be able to deal w i t h i t but I t h i n k as a psych nurse I get j u s t as fr i g h t e n e d and worried as anyone e l s e would i f somebody i s threatening me. I f e e l f r i g h t e n e d and I f e e l nervous and I want to be supported by my su p e r v i s o r s . I want them to take i t s e r i o u s l y and I want them to provide me wi t h a safe work environment and I don't get paid to get h i t and pushed around and v e r b a l l y abused and I don't consider $20 an hour i s enough to get a l l that rough treatment. And they don't take i t s e r i o u s l y and the only reason they don't i s because they're not d e a l i n g w i t h i t d i r e c t l y . If they were de a l i n g w i t h i t d i r e c t l y a l l day they would take i t s e r i o u s l y . . . . B e i n g t o l d one " c a n c o p e " d o e s n o t e n c o u r a g e n u r s e s t o a s k f o r h e l p a n d s u p p o r t d u r i n g a n d a f t e r v i o l e n t s i t u a t i o n s . I t c o u l d a l s o c o n t r i b u t e t o n u r s e s n o t r e p o r t i n g a s s a u l t s i t u a t i o n s a s d o i n g so w o u l d i n d i c a t e t h a t t h e y were n o t c o p i n g . T h e p a r t i c i p a n t s p e r c e i v e d a l a c k o f s u p p o r t i n t h e f o r m o f e d u c a t i o n a n d a d e q u a t e human a n d o t h e r r e s o u r c e s . I n p a r t i c u l a r , p a r t i c i p a n t s f e l t a l a c k o f e d u c a t i o n a n d t r a i n i n g i n t h e management o f a g g r e s s i v e p a t i e n t s . T h e y e x p r e s s e d t h e n e e d f o r more i n f o r m a t i o n a b o u t a g g r e s s i o n a n d on g o i n g s k i l l t r a i n i n g i n t h e u s e o f t e c h n i q u e s f o r m a n a g i n g a g g r e s s i v e s i t u a t i o n s . P a r t i c i p a n t s s t a t e d , t h a t e v e n t h o u g h t h e y f e l t c o m p e t e n t i n m a n a g i n g a g g r e s s i v e s i t u a t i o n s , t h e y were c o n c e r n e d a b o u t b e g i n n i n g n u r s e s who l a c k e d e d u c a t i o n a n d s k i l l s i n m a n a g i n g a g g r e s s i o n a n d t h a t t h i s was c r u c i a l t o t h e i r own s a f e t y . When t eam members a r e i n c o m p e t e n t i n d e a l i n g w i t h a g g r e s s i v e s i t u a t i o n s e v e r y o n e was a t r i s k o f h a r m , p a t i e n t s a n d n u r s e s . N u r s e s a l s o w a n t e d a s a f e work e n v i r o n m e n t , a l o c k e d room a n d more m a l e n u r s i n g s t a f f . T h e y a l s o w a n t e d t h e h e l p o f a c r i s i s r e s p o n s e t e a m t o a s s i s t them i n a g g r e s s i v e s i t u a t i o n s . T h e r e was a l s o a f e l t n e e d f o r e m o t i o n a l s u p p o r t f r o m t h e i r n u r s i n g l e a d e r s a n d d o c t o r s f o l l o w i n g a g g r e s s i v e s i t u a t i o n s . R o s e : I ' d l i k e them t o p r o v i d e u s w i t h a s a f e r o o m , a room we c o u l d l o c k b e c a u s e I d o n ' t l i k e t o s e e t h e s e p e o p l e a l l c h e m i c a l l y r e s t r a i n e d a n d g e t t i n g h o r r i b l e s i d e a f f e c t s and g e t t i n g t o x i c a n d g e t t i n g w o r s e t h a n t h e y were i n t h e f i r s t p l a c e . . . . A n d I ' d l i k e more i n s e r v i c e s a n d I ' d l i k e more men w o r k i n g t h e r e . . . more e d u c a t i o n i n v i o l e n c e , how t o d e f u s e i t a n d how t o n o t j u s t d i f f u s e b u t how t o r e c o g n i z e t h a t y o u ' v e g o t a p o t e n t i a l l y v i o l e n t s i t u a t i o n , how t o d e a l w i t h i t when y o u c a n ' t d i f f u s e i t , y o u know a n d f e e l s a f e a n d f e e l i n c o n t r o l and we d o n ' t g e t e n o u g h o f t h a t . . . . Y e a h more s u p p o r t a n d more e d u c a t i o n . E d u c a t i o n on t h e u n i t a s a w h o l e . . . J u s t s o t h a t y o u knew y o u ' r e w o r k i n g w i t h p e o p l e who a l s o know what t h e y were d o i n g b e c a u s e i f y o u know what y o u ' r e d o i n g a n d no one e l s e d o e s o r n o t e v e r y b o d y e l s e d o e s t h e n what h a p p e n s i s y o u h a v e t o e d u c a t e them i n a c r i s i s a n d t h e n y o u g e t i n a r e a l m u d d l e b e c a u s e t h e y ' r e f r i g h t e n e d , t h e y d o n ' t know what t h e y ' r e d o i n g a n d t h e y c o u l d mess i t u p . T h e d e b r i e f i n g o f t r a u m a t i c s i t u a t i o n s , p a r t i c u l a r l y v i o l e n t s i t u a t i o n s t h r o u g h f o r m a l a n d i n f o r m a l p r o g r a m s by n u r s i n g l e a d e r s was a s s o c i a t e d w i t h s u p p o r t and when i t was n o t i n i t i a t e d by n u r s i n g 97 l e a d e r s n u r s e s f e l t u n s u p p o r t e d . T h e y w a n t e d e m o t i o n a l s u p p o r t a n d r e c o g n i t i o n t h a t t h e y h a d b e e n t h r o u g h a d i f f i c u l t s i t u a t i o n , no m a t t e r how s k i l l f u l l y t h e y h a d d e a l t w i t h t h e e v e n t . When s u c h s u p p o r t i s a b s e n t t h e n u r s e s e x p e r i e n c e d d o u b t s a b o u t t h e i r c o m p e t e n c y a n d t h e i r v a l u e as a p r o f e s s i o n a l . D i a n a : . . . I t h i n k t h e v a l u e i n d e b r i e f i n g s i t u a t i o n s l i k e t h i s i s t h a t f o r one t h i n g y o u g e t t h e s u p p o r t t h a t p e o p l e n e e d . T h e s u p p o r t t h e n g i v e s p e o p l e t h e f e e l i n g t h a t t h e y ' v e d o n e a n o k a y j o b . I t h i n k i f y o u d o n ' t g e t s u p p o r t , y o u f e e l a l m o s t l i k e , d i d I do s o m e t h i n g w r o n g ? a n d y o u s t a r t t o f e e l r e s e n t m e n t s a n d a l s o y o u ' v e b e e n p u t t h r o u g h a s t r e s s f u l s i t u a t i o n a n d a n y b o d y who g o e s t h r o u g h a s t r e s s f u l s i t u a t i o n s h o u l d be g i v e n t h e o p p o r t u n i t y t o t a l k a b o u t t h a t e x p e r i e n c e a n d g e t some f e e d b a c k I mean t h a t ' s j u s t b a s i c . . . i t ' s a t r a u m a a n d i f y o u ' r e n o t g i v i n g t h a t i n y o u r p l a c e o f e m p l o y m e n t o r y o u ' r e n o t p a r t i c i p a t i n g i n t h a t p r o c e s s t h e n I t h i n k y o u a r e t r a u m a t i z i n g b e c a u s e a n y t h i n g t h a t e v o k e s s u c h s t r o n g f e e l i n g s i n a n o t h e r human b e i n g n e e d s t o h a v e t i m e t o be w o r k e d t h r o u g h . Any i n s t i t u t i o n t h a t d o e s n ' t g i v e t h a t t i m e I d o n ' t t h i n k t h e y ' r e g o i n g t o k e e p t h e i r n u r s e s b e c a u s e I mean who on e a r t h w a n t s t o 98 go through those experiences and not have any p l a c e to deal with the f e e l i n g s . . . [otherwise] I t h i n k you're going to be a mess i n no time because those f e e l i n g have to go some p l a c e . And I t h i n k what they can end up doing i s r e a l l y p o i s o n i n g people, they can become very c y n i c a l , very angry. The nurses' accounts r e v e a l e d that when a s s a u l t s i t u a t i o n s are not d e b r i e f e d nurses, p a t i e n t s and the whole m i l i e u are a f f e c t e d f o r a long time. The long term e f f e c t s of an a s s a u l t s i t u a t i o n to i n d i v i d u a l s and to the ward m i l i e u were a r t i c u l a t e d by two p a r t i c i p a n t s who were adamant about the need to d e b r i e f v i o l e n t s i t u a t i o n s that occur on the wards. Blaming the v i c t i m , d i v i s i o n s among s t a f f , and absenteeism were common responses to a s s a u l t . One p a r t i c i p a n t even c i t e d an i n c i d e n t where a nurse a c t u a l l y r e s i g n e d . Rose: You need to d e b r i e f people, they... go through a c r i s i s i f something t e r r i b l e happens, l i k e i t has done a couple of times where I've worked, someone was a t t a c k e d and threatened, you need somebody has to be able to d e b r i e f everyone... because what o f t e n happens a f t e r t h a t k i n d of t h i n g , i f you're not c a r e f u l , i s people get c r i t i c i z e d f o r what they d i d and what they d i d n ' t do and they f e e l even worse then, they f e e l f r i g h t e n e d a n d a n g r y t o b e g i n w i t h , t h e y ' v e b e e n a t t a c k e d a n d a l l y o u n e e d i s some s m a r t p e r s o n s a y i n g " w e l l i f y o u ' d o n l y d o n e t h i s i t w o u l d n ' t h a v e h a p p e n e d " . . . i f y o u d o n ' t d e a l w i t h t h a t y o u ' r e g o i n g t o g e t s t a f f who r e f u s e one t o o n e s , who go o f f s i c k when t h e y ' v e g o t a v i o l e n t p a t i e n t on a one t o one t h e y w o n ' t come t o w o r k . . . So more s u p p o r t , n o t j u s t f r o m t h e s u p e r v i s o r s , b u t more s u p p o r t w i t h i n t h e u n i t y o u know t h e h e a d n u r s e o r t h e a s s i s t a n t h e a d n u r s e o r e v e n t h e d i r e c t o r . . . I t ' s n o t t h e k i n d o f s t u f f y o u c a n i g n o r e , i t h a p p e n s on p s y c h w a r d a g a i n a n d a g a i n a n d u n l e s s y o u ' v e g o t a g o o d v e h i c l e t o d e a l w i t h t h e n p e o p l e a r e n ' t g o i n g t o want t o s t a y t h e r e . S a r a h : . . . o n e y e a r ago a n u r s e was b a d l y h u r t a n d l e f t q u i c k l y . T h e w a r d r e m a i n e d d i v i d e d a l o n g t i m e , i t was n e v e r r e s o l v e d , p e o p l e were b l a m i n g e a c h o t h e r i t r e a l l y s e t o f f a s e t o f c i r c u m s t a n c e s t h a t , I d o n ' t know i f i t w i l l e v e r h e a l . I t s t i l l comes up t o d a y , a man was t r a n s f e r r e d t o us a week a g o , he d i d n ' t want t o come t o us he w a n t e d t o go t o a l o c k e d w a r d , he was 6 f t . 2 i n . w e i g h e d 198 o r 200 l b s . , d e f i n i t e l y m e a n i n g t o h u r t someone a n d he d i d n ' t want t o be 100 t h e r e , he was s t r o n g , k i c k e d o v e r c h a i r s , t h r e a t e n e d y o u w i t h h i s f i s t , a n d t h e s i z e o f h i m was i n t i m i d a t i n g e n o u g h and urn. I e x p l a i n e d t o h i m t h a t he was f r i g h t e n i n g u s , he s a i d "I know" he w a s n ' t p s y c h o t i c and he s a i d " y o u c a n ' t commit me, b e c a u s e I 'm a b e h a v i o u r p r o b l e m I 'm n o t p s y c h o t i c " . When I g o t b a c k t o t h e n u r s i n g s t a t i o n t h e o t h e r n u r s e s s a i d " i t was j u s t l i k e t h a t , j u s t l i k e t h a t o t h e r i n c i d e n t when t h e n u r s e r e s i g n e d " a n d I t h o u g h t t h a t ' s how c l o s e i t i s t o t h e s u r f a c e i t j u s t b r i n g s i t up a l l t h o s e f e e l i n g s , o f y o u a r e f r i g h t e n e d , y o u d o n ' t know what t o d o , y o u d o n ' t where y o u r s u p p o r t i s g o i n g t o come f r o m " . . . T h i s i n c i d e n t was n o t d i f f u s e d a n d t h a t ' s n o t b e i n g d o n e any m o r e , i t u s e d t o be d o n e r i g h t away . We t a l k e d a b o u t o u r f e e l i n g s a n d w e ' v e s t o p p e d d o i n g t h i s . I g u e s s I 'm a n g r y a t t h e 1 e a d e r s h i p . D e b r i e f i n g was c o n s i d e r e d i m p o r t a n t t o m a i n t a i n i n g p o s i t i v e r e l a t i o n s h i p s w i t h p a t i e n t s . D i a n a : W e l l t h e l o n g t e r m e f f e c t i s u s u a l l y p o s i t i v e b e c a u s e p e o p l e w i l l p r o b a b l y h a v e a n g e r t o w a r d s t h a t p a t i e n t , f e a r o r f e a r t h a t h a s t u r n e d i n t o a n g e r a l l d i f f e r e n t c o m b i n a t i o n s . So i f y o u ' r e g i v e n t h e o p p o r t u n i t y t o t a l k a b o u t t h o s e 101 f e e l i n g s then you're not going to pass them out to your p a t i e n t , a ct them out on your p a t i e n t so the r e l a t i o n s h i p i s d e f i n i t e l y going to be b e t t e r . In summary, the f i n d i n g s of t h i s study suggest that nurses p e r c e i v e a lack of a d m i n i s t r a t i v e support i n c a r i n g f o r p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . They do not t h i n k that they r e c e i v e adequate emotional, e d u c a t i o n a l and resource support p a r t i c u l a r l y d u r i n g and f o l l o w i n g s i t u a t i o n s i n v o l v i n g v i o l e n c e . They b e l i e v e that t r a i n i n g i n d e a l i n g with a g g r e s s i v e s i t u a t i o n s and the d e b r i e f i n g of a g g r e s s i v e s i t u a t i o n s should be i n i t i a t e d at the i n s t i t u t i o n a l l e v e l by t h e i r l e a d e r s . The Experience of C o n f l i c t Intense c o n f l i c t u a l f e e l i n g s are r e v e a l e d i n nurses' accounts of t h e i r encounters with p a t i e n t s they p e r c e i v e as m a n i p u l a t i v e , non-compliant, dependent, d i s r e s p e c t f u l , and dangerous. These p a t i e n t s are re p o r t e d as having been diagnosed as p e r s o n a l i t y d i s o r d e r s , such as b o r d e r l i n e p e r s o n a l i t y d i s o r d e r or a n t i - s o c i a l p e r s o n a l i t y d i s o r d e r . These p a t i e n t s were experienced by the nurse with i n t e n s e emotional responses. Extreme f e e l i n g s of anger, f r u s t r a t i o n , f e a r and d i s g u s t were evident i n the nurses' a f f e c t and choice of language when d e s c r i b i n g such p a t i e n t s . "You 102 j u s t want t o s h a k e h e r b e c a u s e i t i s j u s t l i k e y o u a r e w a s t i n g my t i m e , y o u ' r e w a s t i n g my money a n d y o u ' r e w a s t i n g t h e g o v e r n m e n t s t i m e , y o u s h o u l d be b a c k i n [ a n o t h e r c i t y ] . " P a r t i c i p a n t s r e p e a t e d l y u s e d s i m i l a r t e r m s t o e m p h a s i z e t h e i r r e s p o n s e s . T h e y s a i d t h e s e p a t i e n t s " s e t y o u u p " , " s u c k y o u i n " , " p u s h y o u r b u t t o n s " a n d " s p l i t " n u r s i n g s t a f f . A s e n s e o f h e l p l e s s n e s s a n d p o w e r 1 e s s n e s s was a l s o e v i d e n t i n t h e n u r s e s ' d e s c r i p t i o n s . T h e s e f e e l i n g s were a s s o c i a t e d w i t h a l o s s o f power a n d c o n t r o l a n d an i n a b i l i t y t o make a d i f f e r e n c e i n t h e s e s i t u a t i o n s . T h e n u r s e s f e l t t h e y h a d t o k e e p a l i d on t h e i r f e e l i n g s and k e e p some d i s t a n c e b e t w e e n them a n d t h e p a t i e n t s o t h a t t h e i r own f e e l i n g s d i d n o t i n t e r f e r e w i t h t h e c a r e o f t h e p a t i e n t . A n o t h e r phenomenon o b s e r v e d by t h e i n v e s t i g a t o r i s t h e f r e q u e n t u s e o f d i a g n o s e s when d i s c u s s i n g t h e s e p a t i e n t s . T h e s t e r e o t y p i n g o f p a t i e n t s a p p e a r s t o be a way o f c o p i n g ; a way o f d i s t a n c i n g o n e ' s s e l f f r o m t h e p a t i e n t a n d t h e i n t e n s e e m o t i o n a l r e s p o n s e s t h e y c r e a t e i n t h e n u r s e . L e a h : . . . I ' v e h a d e x t r e m e f e e l i n g s o f a n g e r i n w o r k i n g w i t h some p a t i e n t s who were p e r h a p s h o s t i l e t o o t h e r p a t i e n t s o r who I knew were d e l i b e r a t e l y m a n i p u l a t i n g o r d o i n g t h i n g s . A n d I w o u l d become v e r y a n g r y a n d l e a r n i n g how t o 103 m a i n t a i n t h a t r e l a t i o n s h i p w i t h o u t j u s t s h u t t i n g o f f i s a r e a l c h a l l e n g e f o r me e v e n n o w . . . w o r k i n g w i t h p a t i e n t s who e v o k e t h a t k i n d o f r e s p o n s e I h a v e f o u n d t h a t t o be a r e a l c h a l l e n g e . . . . One n u r s e d e s c r i b e d m a n i p u l a t i v e b e h a v i o u r i n t e r m s o f d i s r e s p e c t f u l b e h a v i o u r t o w a r d h e r w h i c h made i t d i f f i c u l t f o r h e r t o become t o t a l l y a c c e p t i n g o f t h e p a t i e n t . R a c h e l : W e l l t h e r e i s a l w a y s g o i n g t o be p a t i e n t s t h a t a r e g o i n g t o m a n i p u l a t e o r a t t e m p t t o m a n i p u l a t e . T h a t ' s u n p l e a s a n t b e c a u s e I g u e s s i t a u t o m a t i c a l l y c o n v e y s a d i s r e s p e c t a n d s o maybe a s much a s I want t o r e s p e c t p a t i e n t s I want them t o r e s p e c t me b a c k . A n d g e n e r a l l y s p e a k i n g I t h i n k t h a t h a p p e n s . Y o u g e t someone who i s p r e t t y s l i c k a n d i s g o i n g t o s t a r t p l a y i n g games t h e n a h . . . . t h e y ' r e n o t s a y i n g "I r e s p e c t y o u " a n d I d o n ' t l i k e t h a t . I d o n ' t l i k e t h a t a n y w h e r e . . . . R a c h e l a d d s t h a t s h e f i n d s n u r s i n g t h e s e p a t i e n t s more d i f f i c u l t t h a n n u r s i n g p a t i e n t s who a r e o u t o f c o n t r o l a n d p s y c h o t i c . She e x p e c t s them t o know b e t t e r b e c a u s e t h e y a r e n o t c r a z y . T h e y a r e p a t i e n t s who " p r e s s my b u t t o n s . " When a s k e d t o r e l a t e an e x a m p l e o f a p a t i e n t who h a d " p r e s s e d h e r b u t t o n s " R a c h e l r e v e a l s h e r p r o t e c t i v e m e c h a n i s m s i n d e a l i n g w i t h s u c h 104 p a t i e n t s . R a c h e l : Who h a s p r e s s e d my b u t t o n s . Mmm I h a v e t o t h i n k f o r a l i t t l e b i t . P a r t o f t h e d i f f i c u l t y o f r e m e m b e r i n g who p u s h e s my b u t t o n s i s t h a t I d o n ' t want t o r e m e m b e r . I t h i n k t h a t ' s maybe i m p o r t a n t . B e c a u s e I 'm s u r e t h e r e h a s b e e n a number b u t I c a n ' t t h i n k o f a s p e c i f i c i n c i d e n t . ( 1 o n g p a u s e ) I c a n ' t , i s n ' t t h a t s o m e t h i n g . I t ' s my o l d p r o t e c t i v e d e v i c e . I t a l l o w s me t o k e e p g o i n g b a c k t h e r e d a y a f t e r d a y . . . . I was t r y i n g t o t h i n k i f t h e r e maybe t h e r e was someone e v e n b a c k e a s t t e n y e a r s ago b u t I c a n ' t , I c a n ' t r e m e m b e r . In t h e n e x t e x c e r p t R a c h e l d i s c l o s e s t h e n e e d t o d i s t a n c e h e r s e l f a n d be c a u t i o u s w i t h p a t i e n t s s h e p e r c e i v e s a s m a n i p u l a t i v e . T h e y e n g e n d e r a n g e r i n h e r a n d f e a r t h a t s h e w i l l be p l a c e d i n s i t u a t i o n s s h e c a n n o t h a n d l e . R a c h e l : I c a n t h i n k o f p i c k i n g p e o p l e up i n t h e e m e r g e n c y room and g o i n g f r o m t h e e m e r g e n c y room t o t h e w a r d a n d a l r e a d y g e t t i n g a s e n s e t h a t a h t h e r e may be some p e r s o n a l i t y d i s o r d e r s t u f f a b o u t t h i s p e r s o n . T h e e n e r g y t h a t I p u t i n t o d e v e l o p i n g some k i n d o f r a p p o r t w i t h them w o u l d c e r t a i n l y be d i f f e r e n t t h a n t h e c h r o n i c p a t i e n t 105 who h a s d e c o m p e n s a t e d a n d who i s p s y c h o t i c a n d y e a h t h e r e w o u l d be more d i s t a n c e I g u e s s . T h e r e w o u l d be y e a h I w o u l d f e e l a l i t t l e more c a u t i o u s I g u e s s . R a c h e l g o e s on t o e x p l a i n what s h e w o u l d be g u a r d i n g a g a i n s t by d i s t a n c i n g h e r s e l f f r o m s u c h p a t i e n t s . R a c h e l : W e l l I g u e s s maybe p u t t i n g m y s e l f i n t o a s i t u a t i o n t h a t maybe I d o n ' t f e e l t h a t c a p a b l e o f h a n d l i n g , f o r e x a m p l e t h e m a n i p u l a t i o n . Or g e t t i n g a n g r y t h a t t h e y w o u l d come t o t h e h o s p i t a l u n d e r t h e d e m i s e o f w a n t i n g h e l p a n d t h e n t a k i n g a d v a n t a g e o f t h e p e o p l e t h a t a r e t h e r e t o p r o v i d e i t . T h a t i s , t h a t makes me m a d . When t h e r e s e a r c h e r r e v e a l e d t o R a c h e l t h a t o t h e r n u r s e s s t a t e d t h e y w e r e g u a r d i n g a g a i n s t g e t t i n g h u r t , a n d d i d t h a t h a v e any s i g n i f i c a n c e f o r h e r s h e i n i t i a l l y d e n i e d any s i g n i f i c a n c e . R a c h e l : Umm no i t d o e s n ' t a c t u a l l y . G e t t i n g h u r t on a p e r s o n a l l e v e l , no I c a n ' t a c t u a l l y s a y t h a t i t ' s a c o n c e r n t h a t I h a v e . I d o n ' t know a c t u a l l y . . . W e l l I g u e s s y e a h , oh y e a h . I w o u l d f e e l h u r t a s w e l l . H u r t a n d a n g r y . I g u e s s maybe I was d e n y i n g t h a t o n e . B e c a u s e y e a h I h a v e f e l t h u r t i n some r e l a t i o n s h i p s w i t h p a t i e n t s . Umm 106 h u r t t h a t some w o u l d s e e m i n g l y c h o o s e t o be m a n i p u l a t i v e o r a b u s i v e , v e r b a l l y . Or m i s u n d e r s t a n d I g u e s s m i s u n d e r s t a n d me, y e a h . P a t i e n t s p e r c e i v e d a s m a n i p u l a t i v e were f r e q u e n t l y d e s c r i b e d a s e n g a g i n g i n b e h a v i o u r s t h a t were h u r t f u l and s o m e t i m e s h u m i l i a t i n g t o n u r s e s . B e h a v i o u r s s u c h a s r e j e c t i n g t h e n u r s e s e f f o r t s t o h e l p and d r a w i n g t h i s t o t h e a t t e n t i o n o f o t h e r s t a f f . T h e n e x t p a r t i c i p a n t d e s c r i b e s how s h e p r o t e c t s h e r s e l f f r o m b e i n g h u r t when n u r s i n g p a t i e n t s s h e p e r c e i v e s a s m a n i p u l a t i v e , a n d a s i n s t i g a t i n g p r o b l e m s i n t h e i r r e l a t i o n s h i p s . L i l y : . . . I l i s t e n a l o t w i t h t h e s e p e o p l e , I d o n ' t t r y t o g i v e s o l u t i o n s . . . . t h e n y o u j u s t r e a l i z e t h a t n o , t h e s e p e o p l e a r e s k i l l e d , t h e y h a v e l e a r n e d how t o s u r v i v e w i t h t h e i r m a n i p u l a t i o n s , t h e y ' r e v e r y g o o d a t i t . So j u s t b e c a u s e y o u ' r e t h e n u r s e d o n ' t t h i n k y o u ' r e n o t g o i n g t o g e t s u c k e d i n t o i t t o o . . . . B u t I g u e s s i n i t i a l l y y o u c o u l d g e t h u r t , s u c k e d i n . When a s k e d t o e x p l a i n what s h e meant by g e t t i n g " s u c k e d i n " L i l y d e s c r i b e s t h i s a s h a v i n g " l o s t t h e g a m e " , b e i n g " b e a t o u t " , and l o s i n g p r i d e . She s t a t e s s h e must r e m a i n " n e u t r a l " w i t h t h e s e p a t i e n t s , r e v e a l i n g l i t t l e o f h e r s e l f , a n d n e v e r l e t t i n g them 107 become a f r i e n d . She bel ieves that her "caring" behaviours and s e l f - d i s c l o s u r e s would be used against her by the patient to gain control or to p i t her against other s t a f f . L i l y : . . . y o u never t e l l people about your own personal s e l f . . . w i t h a manipulative personal i ty disorder type pat ient , you are more neutral -n e u t r a l . Because they use some of those personal , you're g i v i n g , you're car ing , to manipulate you. They use that against you, "oh well so and so she used to rub my back every night when I complained about a back ache you don't do that ." . . . S o that nurse thought that warm touch and a l l that f ee l ing she was g iv ing that patient was great but what ended up happening she, the pat ient , used that against you and s p l i t s ta f f a l l up manipulating people. So I think that ' s the d i f f erence . No, not to a l l people do you show that level of warmth to . There i s a sense that nurses work hard to discover manipulative patterns early i n a pat i ent ' s h o s p i t a l i z a t i o n so that they can gather up the i r defenses i n order to deal with these patients with the least amount of personal discomfort poss ib le . Rose: . . . I think you have to be able to spot 108 somebody l i k e t h a t f a i r l y e a r l y on as t o w h e t h e r t h e y a r e g o i n g t o be v e r y v e r y d e m a n d i n g a n d v e r y m a n i p u l a t i v e a n d I t h i n k y o u h a v e t o be a b l e t o r e a l i z e when t h e y a r e g o i n g t o do t h a t . A n d i t ' s v e r y h a r d t o b e g i n w i t h . . . . I n a s e c o n d i n t e r v i e w R o s e was a s k e d t o e l a b o r a t e on what i t means t o h e r t o n u r s e a p a t i e n t whom s h e p e r c e i v e s as m a n i p u l a t i v e . R o s e : Umm i t ' s v e r y d i f f i c u l t t o work w i t h a m a n i p u l a t i v e p a t i e n t . I f i n d i t v e r y f r u s t r a t i n g , i f s o m e b o d y ' s g o t a p e r s o n a l i t y d i s o r d e r i f t h e i r b o r d e r l i n e o r h i s t r i o n i c . . . t h e y w i l l s p l i t , t h a t ' s what t h e y d o . . . A s s o o n as y o u f i n d y o u r s e l f a t a n o t h e r s t a f f m e m b e r ' s t h r o a t a b o u t t h a t p a t i e n t t h e n y o u ' v e s p l i t . A n d I f i n d them v e r y f r u s t r a t i n g p e o p l e t o work w i t h -m a n i p u l a t o r s - b e c a u s e I ' m n o t v e r y s y m p a t h e t i c t o t h e m , I ' m f a i r l y m a t t e r o f f a c t a n d v e r y b l a c k a n d w h i t e a n d I d o n ' t g i v e an i n c h . I c o n t r a c t w i t h t h e m , I s e t l i m i t s . . . I g i v e them v e r y s t r o n g s t r u c t u r e . I ' m n o t s u r e w h e t h e r I o v e r d u e i t a b i t . I may be d o i n g i t t o p r o t e c t m y s e l f r a t h e r t h a n f o r t h e i r b e n e f i t , b u t I d o n ' t r e a l l y h a v e much t r o u b l e w i t h t h e m , w i t h t h e m a n i p u l a t o r s . . . . I f i n d them f r u s t r a t i n g a n d d i f f i c u l t t o work w i t h b e c a u s e t h e y t e n d t o d e s t r o y t h e w h o l e w a r d a t m o s p h e r e I mean t h e y g e t e v e r y b o d y g o i n g . P e o p l e a r e up i n arms a n d c r y i n g a n d c o m p l a i n i n g a n d e v e r y t h i n g a n d i t j u s t t a k e s two p e r s o n a l i t y d i s o r d e r s i n a w a r d o f 24 p a t i e n t s a n d y o u ' v e g o t c h a o s . A n d I t h i n k t h a t ' s p r o b a b l y why t h e y i r r i t a t e me. R o s e t h e n d e s c r i b e s what i t w o u l d be l i k e f o r h e r i f s h e d i d n o t s e t up t h e s e p r o t e c t i v e m e a s u r e s . R o s e : Oh i t w o u l d be t e r r i b l e i t w o u l d make y o u f e e l e n g u l f e d a n d a c t u a l l y , t h e way I d e s c r i b e them t o c o - w o r k e r s . . . i s I d e s c r i b e them as b l a c k h o l e s b e c a u s e t h e y ' r e a b s o l u t e l y b o t t o m l e s s a n d t h e y ' r e l i k e a b i g n e g a t i v e f o r c e a n d l i k e i t d o e s n ' t m a t t e r how much y o u p u t i n t h e r e i t w i l l g e t l o s t a n d i t w o n ' t make any d i f f e r e n c e . B e c a u s e what w i l l h a p p e n i s y o u ' l l g e t s u c k e d i n t o o a n d y o u ' l l d i s a p p e a r down t h e b l a c k h o l e a n d t h a t ' s I g u e s s how I f e e l a b o u t some o f t h o s e p e o p l e . P a r t i c i p a n t s i n t h e c u r r e n t s t u d y r e p e a t e d l y e x p r e s s e d c o n c e r n a b o u t m a n i p u l a t i v e a n d d e m a n d i n g p a t i e n t s " s p l i t t i n g " them o r t h e y d e s c r i b e d a c t u a l s i t u a t i o n s w h e r e t h e phenomenon o f " s p l i t t i n g " was e x p e r i e n c e d by t h e m . T h e n e x t p a r t i c i p a n t ' s 110 d e s c r i p t i o n o f h e r e x p e r i e n c e n u r s i n g a p a t i e n t who s t a f f p e r c e i v e d as d e p e n d e n t a n d m a n i p u l a t i v e i l l u s t r a t e s t h e d i v i s i v e n e s s t h a t r e s u l t e d f r o m s t a f f p e r c e p t i o n s o f t h i s p a t i e n t . L i l y : O k a y , I ' l l t a l k t o y o u a b o u t one l i t t l e l a d y t h a t came i n a n d s h e h a d h a d a m i l d s t r o k e . A n d s h e was s e v e r e l y d e p r e s s e d . . . . A n d h e r e ' s t h i s l i t t l e l a d y , s h e l o o k e d l i k e e v e r y o n e ' s l i t t l e g r a n n y a n d s p o k e t h a t way t o o , v e r y s o f t s p o k e n a n d v e r y k i n d . . . I was h e r p r i m a r y a n d i t was a m a j o r c h a l l e n g e b e c a u s e t h i s l a d y o n l y s p o k e i n t e r m s o f s o m a t i c c o m p l a i n t s . . . . I w o u l d s p e n d a l o t o f t i m e t a l k i n g w i t h h e r w h i c h c a u s e d a l o t o f p r o b l e m s on t h e w a r d b e c a u s e some p e o p l e t h o u g h t I was b e i n g s u c k e d i n t o t h i s l a d y . . . . So umm a t t i m e s I was r e a l l y u p s e t b e c a u s e d i f f e r e n t s t a f f w o u l d come t o me a n d g i v e me i d e a s . . . s o i t was a c o n s t a n t r e - e v a l u a t i n g , i s t h i s t h e r i g h t c a r e p l a n t h a t I was d o i n g . . . s o I p i c k e d up on a l o t o f f r u s t r a t i o n f r o m t h e s t a f f o v e r t h a t p a r t i c u l a r s i t u a t i o n . T h e y w a n t e d me t o be q u i t e b l u n t w i t h h e r a n d t e l l h e r t o g e t h e r a c t t o g e t h e r a n d some p e o p l e j u s t c o u l d n ' t s e e t h a t t h i s l a d y saw h e r s e l f as p a r a l y s e d f r o m t h e n e c k down r e g a r d l e s s . She n e e d e d , i n a way , t h a t s i c k n e s s I l l b e c a u s e i t g o t h e r a l o t o f a t t e n t i o n f r o m h e r f a m i l y w h i c h s h e w o u l d h a v e n e v e r g o t u n l e s s s h e was p h y s i c a l l y i l l b e c a u s e t h e y d i d n ' t u n d e r s t a n d d e p r e s s i o n , s a d n e s s , d e e p s a d n e s s . . . . p e r s o n a l i t y d i s o r d e r , c a n c a u s e a l o t o f m i x e d f e e l i n g s w i t h t h e s t a f f . One p a r t i c i p a n t d e s c r i b e s t h e p r o b l e m s i n d i a g n o s i n g a p a t i e n t as p e r s o n a l i t y d i s o r d e r e d . T h e s e p r o b l e m s o f t e n b e g i n p r i o r t o t h e p a t i e n t ' s a d m i s s i o n when s t a f f d i s a g r e e a b o u t w h e t h e r t h e p a t i e n t s h o u l d be a d m i t t e d t o a n i n p a t i e n t u n i t a n d a b o u t t r e a t m e n t m e t h o d s . C o n f l i c t a l s o a r i s e s w i t h r e g a r d s t o t h e a c c u r a c y o f t h e d i a g n o s i s . T h e f o l l o w i n g p a r t i c i p a n t b e l i e v e s t h a t t h e d i a g n o s i s i t s e l f i s p r o b l e m a t i c , t h a t o n c e a p a t i e n t i s l a b e l l e d as a p e r s o n a l i t y d i s o r d e r t h e s t a f f a u t o m a t i c a l l y assume t h a t t h e p a t i e n t w i l l b e h a v e i n c e r t a i n ways o r t h a t c e r t a i n b e h a v i o u r s a r e q u i c k l y a t t r i b u t e d t o a p e r s o n a l i t y d i s o r d e r a n d f u r t h e r a s s e s s m e n t s o f t h e p a t i e n t a p p e a r s t o c e a s e . R e b e c c a : I h a t e t h e d i a g n o s i s p e r s o n a l i t y d i s o r d e r . . . i t ' s k i n d o f a w r i t e o f f d i a g n o s i s t h a t I f i n d v e r y f r u s t r a t i n g . P e o p l e c a n a c t i n ways t h a t make them p o s s i b l y make them a p p e a r t o be p e r s o n a l i t y d i s o r d e r s b u t f o r a w h o l e d i f f e r e n t s e t o f r e a s o n s . A n d I r e a l l y s o m e t i m e s f e e l t h a t s o l i t t l e g o e s i n t o d i s c o v e r i n g who t h e s e p e o p l e a r e a b o u t o r why. Why t h e y a r e l i k e t h i s . A n d y o u g i v e somebody some o f t h e s e d i a g n o s i s a n d t h a t ' s i t , i f t h e y want h e l p i n t h e f u t u r e somebody j u s t l o o k s a t t h a t a n d t h e y ' r e s c u r r i e d o f f t o somebody e l s e a n d i t g o e s on a n d o n . So t h a t ' s a f r u s t r a t i n g o n e , t h a t d i a g n o s i s . . . . t h e t h e r a p y t a k e s a l o n g l o n g t i m e . . . . o n an i n p a t i e n t u n i t we d o n ' t h a v e t h a t l u x u r y o f d o i n g l o n g t e r m t h e r a p y . T h e d o c t o r s w i l l work v e r y h a r d a t n o t a d m i t t i n g somebody w i t h t h a t d i a g n o s i s . . . O n c e i t ' s t h e r e on s o m e b o d y ' s r e c o r d s i t ' s l i k e a b r a n d a n d t h e a s s u m p t i o n i s t h a t t h e y a r e g o i n g t o come i n t o h o s p i t a l , t h e y ' r e g o i n g t o c a u s e p r o b l e m s , t h e y ' r e g o i n g t o s e l f - m u t i 1 a t e . . . I n s u m m a r y , t h e e x p e r i e n c e o f c o n f l i c t i n n u r s e -p a t i e n t e n c o u n t e r s was d e s c r i b e d by n u r s e s i n t h e c u r r e n t s t u d y . P a t i e n t v a r i a b l e s w e r e c i t e d as t h e m a j o r r e a s o n f o r t h e c o n f l i c t . B e h a v i o u r s t h a t were v i e w e d as p a r t i c u l a r l y t r o u b l e s o m e t o t h e n u r s e s w e r e : m a n i p u l a t i v e , n o n - c o m p l i a n t , d e p e n d e n t , d e m a n d i n g , d i s r e s p e c t f u l a n d d a n g e r o u s t o o t h e r s . T h e s e " d i f f i c u l t " b e h a v i o u r s were p e r c e i v e d as i n t e r f e r i n g w i t h r e l a t i o n s h i p b u i l d i n g a n d o f t e n i n t r a c t a b l e , no m a t t e r what t h e n u r s e s a i d o r d i d . 113 The Experience of Ambivalence in Relationships with  Physicians T h e n u r s e s ' a c c o u n t s r e v e a l t h a t t h e p h y s i c i a n ' s power t o d e f i n e s i t u a t i o n s i n v o l v i n g n u r s e s a n d p a t i e n t s , b o t h t o g e t h e r a n d s e p a r a t e l y , d i r e c t l y a n d i n d i r e c t l y , i s e n o r m o u s . S u p e r f i c i a l l y t h e n u r s e s i n t h e c u r r e n t s t u d y d e s c r i b e d s a t i s f a c t o r y r e l a t i o n s h i p s w i t h p h y s i c i a n s i n t h e p s y c h i a t r i c c a r e s e t t i n g p a r t i c u l a r l y when t h e y a r e c o m p a r e d t o r e l a t i o n s h i p s w i t h p h y s i c i a n s i n o t h e r c l i n i c a l s e t t i n g s . H o w e v e r , when t h e p a r t i c i p a n t s d e s c r i b e d a c t u a l s i t u a t i o n s w i t h d o c t o r s a d i f f e r e n t p i c t u r e e m e r g e d . N u r s e s d i d n o t f e e l l i s t e n e d t o , c o n s u l t e d o r g i v e n c r e d i t f o r t h e i r k n o w l e d g e a n d s k i l l s . T h e y f e l t d o c t o r s c a l l e d a l l t h e s h o t s a n d t h a t many t i m e s t h e y h a d l i t t l e c h o i c e b u t t o c o m p l y w h i c h l e f t them f e e l i n g a n g r y . T h i s i s i l l u s t r a t e d i n t h e f o l l o w i n g a c c o u n t . R a c h e l : . . . I do f i n d t h a t g e n e r a l l y s p e a k i n g p r o b a b l y 80% o f t h e p h y s i c i a n s w i l l want t o h e a r what y o u h a v e t o s a y a n d r e s p e c t what y o u h a v e t o s a y . T h e same p a r t i c i p a n t l a t e r d e s c r i b e d a s i t u a t i o n w h e r e s h e was t o t a l l y l e f t o u t o f a t r e a t m e n t d e c i s i o n by a d o c t o r . A s a r e s u l t t h e p a t i e n t e n d e d up 114 r e c e i v i n g m e d i c a t i o n he d i d n o t n e e d . I t l e f t h e r f e e l i n g a n g r y , u n d e r m i n e d a n d i n v a l i d a t e d e s p e c i a l l y s i n c e s h e h a d n u r s e d on t h a t u n i t f o r t e n y e a r s a n d t a k e s h e r work v e r y s e r i o u s l y . R a c h e l : . . . When y o u do r o u n d s a n d y o u ' v e g o t , a p a r t i c u l a r p a t i e n t s l e e p i n g s o u n d l y , s n o r i n g , g r i n d i n g t h e i r t e e t h a n d t h e y c o m p l a i n a l l day t h a t t h e y d o n ' t s l e e p a n d t h e d o c t o r comes i n a n d k e e p s c h a n g i n g t h e i r H . S . s e d a t i o n b e c a u s e t h e y ' r e n o t s l e e p i n g b u t i n f a c t t h e y a r e s l e e p i n g . P e r h a p s t h e y d o n ' t f e e l r e s t e d when t h e y wake up o r t h e y , y o u know, want more m e d i c a t i o n . I t d o e s n ' t seem t o m a t t e r , my p a r t n e r a n d I make a p o i n t o f s a y i n g , "I u n d e r s t a n d y o u f e e l l i k e y o u ' r e n o t s l e e p i n g t h a t w e l l a t n i g h t s o i f y o u s e e t h e f l a s h l i g h t y o u g i v e us a s i g n , we may n o t be a b l e t o do a n y t h i n g e x c e p t a c k n o w l e d g e t h a t y o u ' r e awake b u t t h e n we c a n d o c u m e n t i t a n d y o u r d o c t o r w i l l k n o w . " So we e v e n d o c u m e n t t h a t . . . t h e y s l e e p a l l n i g h t , s n o r e a n d g r i n d t h e i r t e e t h a n d t h e n e x t day t h e m e d i c a t i o n i s d o u b l e d o r t r i p l e d . So t h a t ' s a l i t t l e b i t i r r i t a t i n g . . . I f e e l a n g r y a b o u t t h a t a n d i n v a l i d a t e d . Y o u know, I t a k e my work v e r y s e r i o u s l y a n d I d o n ' t f e e l t h a t I t h a t I d o c u m e n t s o m e t h i n g t h a t i s n o t s o 115 a n d I w o u l d l i k e t o t h i n k t h a t a f t e r b e i n g i n t h e same p l a c e f o r a l m o s t t e n y e a r s t h a t , I g u e s s t h a t ' s p a r t o f i t t o o , t h e y know I ' m n o t g o i n g t o w r i t e s o m e t h i n g down t h a t i s n ' t s o . A n d s o i f i t ' s r e f l e c t e d i n what t h e y o r d e r t h e n I r e a l i z e t h a t i t d o e s n ' t m a t t e r what I s a y , i t ' s i r r i t a t i n g a n d i t makes me mad . T h e n u r s e s ' a c c o u n t s r e v e a l e d t h a t i t i s d i f f i c u l t f o r n u r s e s t o a p p l y t h e i r k n o w l e d g e w i t h p h y s i c i a n s . E i t h e r t h e y a r e n o t c o n s u l t e d by p h y s i c i a n s o r t h e i r r e c o m m e n d a t i o n s a r e n o t a c c e p t e d . T h i s i s c l e a r l y i n d i c a t e d i n t h e f o l l o w i n g a c c o u n t . T h e n u r s e ' s k n o w l e d g e o f m e d i c a t i o n s a n d h e r a s s e s s m e n t o f t h e e f f e c t s o f t h e m e d i c a t i o n on t h e p a t i e n t a r e c o m p l e t e l y n e g a t e d by t h e p h y s i c i a n . R o s e : . . . W e ' v e g o t t h i s guy r i g h t now h e ' s on d e s i p r a m i n e a n d h e ' s h a v i n g i t a l l a t n i g h t a n d i t s p e e d s y o u up I mean i t ' s a n e n e r g i z i n g a n t i -d e p r e s s a n t , he c a n ' t s l e e p . A n d I t r i e d t o p o i n t t h a t o u t t o t h e d o c t o r a n d s a y " w e l l d o n ' t y o u t h i n k i f he h a d i t i n t h e m o r n i n g i t w o u l d h e l p . " "Oh n o , i t w o n ' t make any d i f f e r e n c e . " W e l l t h a t k i n d o f t h i n g f r u s t r a t e s me b e c a u s e I know damn w e l l t h a t i t w o u l d make a d i f f e r e n c e . . . . A n d somehow w e ' r e p l a y i n g s e c o n d f i d d l e t o t h e m e d i c a l 116 p r o f e s s i o n a n d we s h o u l d n ' t we s h o u l d be a p r o f e s s i o n i n o u r own r i g h t b u t i t d o e s n ' t seem l i k e we a r e y e t . So I g u e s s I g e t s t e a m e d up a b o u t t h a t . R o s e a l s o p o i n t s o u t t h a t s h e n o t o n l y ends up h a v i n g t o l i v e w i t h t h e d o c t o r ' s d e c i s i o n by h a v i n g t o manage t h e p a t i e n t ' s u n n e c e s s a r y d i s t r e s s b u t s h e a l s o h a s t h e a d d e d t a s k o f e x p l a i n i n g t h e d o c t o r ' s a c t i o n s t o t h e p a t i e n t . R o s e : . . . I t ' s s o s t u p i d i t r e a l l y i s . A n d l i k e I mean y o u d o n ' t work i n p s y c h i a t r y f o r y e a r s a n d y e a r s n o t t o know what k i n d o f a n t i - d e p r e s s a n t t h a t p e r s o n s h o u l d p r o b a b l y be o n , what k i n d o f s i d e e f f e c t s t h e y ' r e g o i n g t o g e t w h i l e t h e y ' r e on i t a n d what d o s a g e t h e y n e e d . A n d t h e d o c t o r s k i n d o f p r e t e n d t h a t we d o n ' t know t h a t s t u f f a n d we d o . B u t t h e y ' r e n o t t h e r e a l l d a y a n d t h e y d o n ' t s e e , t h e y s e e t h e p a t i e n t f o r t e n m i n u t e s a d a y a n d w e ' r e t h e r e f o r e i g h t h o u r s s o w e ' r e a b e t t e r j u d g e o f what t h a t p a t i e n t i s d o i n g . A n d i t ' s s u c h a shame b e c a u s e y o u j u s t s e e them m a k i n g s u c h i n c r e d i b l y , I mean t h e y ' r e n o t b a d m i s t a k e s t h e y ' r e j u s t n o t d o i n g t h e p a t i e n t any g o o d . . . l i k e t h i s p a t i e n t t h a t ' s on d e s i p r a m i n e a n d c o u l d n ' t s l e e p he s a i d "I c a n ' t s l e e p I f e e l t e r r i b l e . " I 117 s a i d " w e l l s o m e t i m e s t h e s e m e d i c a t i o n s g i v e y o u s i d e a f f e c t s f o r a c o u p l e o f weeks a n d y o u j u s t f e e l l o u s y a n d what h a p p e n s i s y o u r e n e r g y l e v e l comes up b e f o r e y o u r mood d o e s s o y o u a c t u a l l y f e e l w o r s e . " A n d I s a i d "some o f them a r e e n e r g i z i n g s o y o u d o n ' t s l e e p v e r y w e l l a n d he s a i d " w e l l w o u l d n ' t i t be b e t t e r i f I t o o k i t i n t h e m o r n i n g " e v e n he f i g u r e d t h a t o u t . A n d I s a i d " w e l l y o u h a v e t o t a l k t o y o u r d o c t o r a b o u t i t . . . " A n o t h e r p a r t i c i p a n t t a l k e d a b o u t t h e c o n t r o l o v e r t r e a t m e n t p l a n s t h a t d o c t o r s h a v e a n d how f r u s t r a t i n g t h a t was f o r h e r p a r t i c u l a r l y when s h e c o u l d s e e t h a t t h e p a t i e n t was r e a d y t o work on i m p o r t a n t i s s u e s b u t t h e d o c t o r w o u l d d i r e c t them n o t t o . She d e s c r i b e s h e r f r u s t r a t i o n as i t r e l a t e s t o w o r k i n g w i t h p a t i e n t s w i t h e a t i n g d i s o r d e r s . R e b e c c a : Y e s , w o r k i n g w i t h e a t i n g d i s o r d e r p a t i e n t s umm w i t h o u t b e i n g a b l e t o work on what i s s u e s p u t them - - g a v e them t h a t d i a g n o s i s i n t h e f i r s t p l a c e . Umm I f i n d t h a t j u s t v e r y f r u s t r a t i n g . I f e e l l i k e w e ' r e f i x i n g up a s y m p t o m , w e ' r e t a k i n g c a r e o f s o m e o n e ' s t e m p e r a t u r e a n d s e n d i n g them o u t w i t h t h e r e s t o f w h a t e v e r t h e i r i n f e c t i o n i s . Umm a g a i n i t seems 118 l i k e s e x u a l a b u s e comes up o f t e n w i t h e a t i n g d i s o r d e r s a n d i n t h e p a s t w e ' v e h a d v e r y c l e a r d i r e c t i o n s f r o m m e d i c a l s t a f f n o t t o d e a l w i t h t h o s e i s s u e s . A n d t h a t f e e l s l i k e w e ' r e n o t e v e n d o i n g h a l f j o b , w e ' r e s i m p l y d e a l i n g w i t h s y m p t o m s . I t ' s e s p e c i a l l y f r u s t r a t i n g when y o u c a n s e e t h a t t h e p a t i e n t t h e m s e l v e s a r e r e a d y . So y e a h I mean t h a t ' s f r u s t r a t i n g . . . T h e n u r s e s i n t h e s t u d y were adamant t h a t t h e y n e e d e d t o f e e l s a f e w h i l e a t w o r k ; t h a t u n d e r no c i r c u m s t a n c e s s h o u l d t h e y become v i c t i m s o f v i o l e n c e . B e c a u s e t h e d o c t o r o f t e n h a s t h e f i n a l s a y when i t comes t o t r e a t m e n t d e c i s i o n s s u c h as m e d i c a t i n g , r e s t r a i n i n g o r s e c l u d i n g p a t i e n t s some p a r t i c i p a n t s f e l t t h a t t h e i r s a f e t y w i t h p a t i e n t s was s o m e t i m e s i n j e o p a r d y . R a c h e l : . . . s o m e t i m e s y o u f e e l l i k e , I f e e l l i k e i t d o e s n ' t m a t t e r what my o p i n i o n o r c o n c e r n s may b e , I d o n ' t a l w a y s g e t t h e s u p p o r t f r o m t h e d o c t o r s . . . i n t h e management [ o f a p a t i e n t ] , f o r e x a m p l e , t h e n u r s e s f e e l t h a t t h e s e c l u s i o n r o o m , f o r e x a m p l e , t h a t w e ' r e u s i n g f o r now, s h o u l d c o n t i n u e . A n d t h e d o c t o r may s a y t h a t he d o e s n ' t a g r e e w i t h t h a t , l e t ' s t r y h i m o u t a n d s e e how he d o e s . T h a t s o r t o f t h i n g . . . . i n t h e l a s t week o r so we've had a case l i k e t h i s . And i t d i d t u r n out that although the doctor d i d n ' t agree, the head nurse i n t e r v e n e d and supported the s t a f f and there was a s t a f f d e c i s i o n that was upheld. I t ' s not always l i k e that though. It seems that what the d o c t o r s says goes. And yet he's not the one t h a t ' s there through the n i g h t , you know, i n the middle of the n i g h t when there's only two of you there and t h i n g s can be p r e t t y s c a r y . . . you f e e l anxious and v u l n e r a b l e . . . . Another p a r t i c i p a n t expressed anger at doctors who disappear or do not p a r t i c i p a t e i n a s s i s t i n g n u r s i n g s t a f f when p a t i e n t s become v i o l e n t . She r e v e a l s f e e l i n g dehumanized by what she p e r c e i v e s as t h e i r l a c k of c a r i n g towards nurses. B r i g i t : ...you're the nurse, you're the f r o n t l i n e . I ' l l t e l l you I've worked at another p l a c e t h a t i f p a t i e n t s got v i o l e n t the r e s i d e n t s , and I'm t a l k i n g about the d o c t o r s , the r e s i d e n t s d i d not even deal with i t they back r i g h t o f f and i t was our job to deal with the v i o l e n t p a t i e n t and once they were subdued then they would step i n . L i k e women and these guys would suddenly walk q u i c k l y away from a v e r b a l or a p h y s i c a l t h r e a t . . . at times t h i n k well what am I - the handmaiden, 120 the body guard, the watch dog, the punching bag -you know, what i s t h i s ? Sometimes I do get q u i t e angry about t h i s p r o f e s s i o n that I've chosen and I'm sure that I don't know, sometimes I wonder what the i n t e r n s and the doctors say "don't worry the nurses w i l l take care of i t , they're t r a i n e d t o . " T r a i n e d l i k e dogs I mean what i s t h i s . L i k e i t r e a l l y i s . Another p a r t i c i p a n t t a l k e d about her and other nurses' r e a c t i o n s f o l l o w i n g a s e r i e s of v i o l e n t s i t u a t i o n s with p a t i e n t s on t h e i r ward where they f e l t unsupported by the d o c t o r s . The c o n f r o n t a t i o n that e v e n t u a l l y o c c u r r e d between the nurses and doc t o r s r e v e a l s the lack of empathy that the nurses p e r c e i v e d they r e c e i v e d from the d o c t o r s . They seemed to t h i n k that o f f e r i n g a b i t of reassurance would be s u f f i c i e n t . T h i s s i t u a t i o n r e v e a l s how a s s e r t i v e the nurses had to become with the doc t o r s to ensure t h e i r own and ot h e r s ' s a f e t y . L i l y : ... i t got to the p o i n t the s t a f f were r e f u s i n g to care f o r these people, do one to one care and f o r v i o l e n t s i t u a t i o n s . So I mentioned i t to my c l i n i c i a n , I s a i d "something's got to be done, they have v a l i d reason f o r r e f u s i n g even though they're not supposed to r e f u s e n u r s i n g care 121 b e c a u s e v i o l e n c e i s p a r t o f a p s y c h i a t r y u n i t b u t I c a n s e e why t h e y ' r e r e f u s i n g , we c a n ' t j u s t t e l l them t o go o u t t h e r e a n d c a r e f o r t h a t p a t i e n t r e g a r d l e s s o f how y o u f e e l . We s h o u l d g e t down t o t h e f e e l i n g l e v e l a n d I ' l l t e l l y o u what i t i s , t h e y d o n ' t f e e l s u p p o r t e d by t h e d o c t o r s . " We h a d a c o u p l e o f s i t u a t i o n s w h e r e t h e d o c t o r s were , t h e m a i n d o c t o r s w e r e away , a n d t h e y w o u l d l e a v e t h e i r r e s i d e n t s on c a l l . A n d t h e r e s i d e n t s d i d n ' t know t h e p a t i e n t s a n d t h e y w e r e n ' t f a m i l i a r w i t h t h e d r u g s , i t was a r e a l z o o . A n d s o I s a i d "I t h i n k i t ' s t i m e t h a t t h i s comes t o a s u r f a c e . . . I t h i n k i t ' s t i m e t h a t y o u p l a n an o p e n a g e n d a s t a f f m e e t i n g w h e r e a l l t h i s s t u f f c a n be v e n t e d o p e n l y a n d a l l t h i s b i t t e r n e s s s p e c i f i c a l l y . " So anyway i t t u r n e d o u t t h a t umm we d i d a n d a h I was s o p l e a s e d b e c a u s e t h a t p a r t i c u l a r s t a f f member who was s t r a n g l e d , f o r t h e f i r s t t i m e , b l a s t e d t h a t d o c t o r . . . t h a t he d i d n o t f e e l t h e d o c t o r h a d m e d i c a t e d t h a t p a t i e n t e n o u g h . A n d r e a l l y p u t t h e d o c t o r on t h e s p o t . T h e d o c t o r s s a i d " y o u know we u n d e r s t a n d i t ' s v e r y d i f f i c u l t t o d e a l w i t h v i o l e n t p a t i e n t s " a n d t h e n I s a i d "we a r e n o t s u p p o s e d t o r e f u s e t o c a r e f o r v i o l e n t p e o p l e , we a r e n o t a l l o w e d t o r e f u s e o u r a s s i g n m e n t s b e c a u s e 122 we a r e s u p p o s e d t o know what t o do w i t h t h e s e p e o p l e . B u t t h a t means y o u c a n ' t e i t h e r . So t h a t means on t h e weekends y o u h a v e someone on c a l l , no more o f t h i s m i x i n g up t h e c a l l b u t t o n s s o no one i s on c a l l on t h e o t h e r e n d . No more p u t t i n g a f a m i l y p r a c t i c e r e s i d e n t t o be f i r s t on c a l l on a l o n g w e e k e n d . I f we h a v e a v i o l e n t p a t i e n t on b o a r d I want t o h a v e someone who knows what t h e y a r e d o i n g . A n d y o u c a n ' t r e f u s e t h a t , i t ' s a two s i d e d t h i n g . We c a n o n l y g i v e t h e meds t h a t a r e o r d e r e d , we c a n o n l y g i v e t h e c a r e i n t h a t r e s p e c t t h a t y o u s a y i s o k a y . We c a n ' t do i t on o u r own". So t h e y k i n d o f went b l a n k a t t h a t o n e . . . B u t t h e r e s t i l l i s a t e n s i o n a r o u n d a v i o l e n t p a t i e n t . T h e p a r t i c i p a n t s a c c o u n t s r e v e a l t h a t t h e y p e r c e i v e t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s a s d i f f e r e n t t h a n t h o s e o f d o c t o r s w i t h p a t i e n t s . T h e y do n o t s e e t h e m s e l v e s as e x t e n s i o n s o f d o c t o r s b u t a s a s e p a r a t e h e l p i n g d i s c i p l i n e w i t h i t s own ways o f c a r i n g f o r p a t i e n t s . T h e n e x t p a r t i c i p a n t d e s c r i b e d f e e l i n g c h a l l e n g e d by a p s y c h i a t r i s t who d u r i n g a s t a f f e d u c a t i o n s e s s i o n ( i n s e r v i c e ) on t r a n s f e r e n c e a n d c o u n t e r t r a n s f e r e n c e t o l d them t h a t t h e r a p i s t s s h o u l d n o t u s e a n y s e l f - d i s c l o s u r e w i t h p a t i e n t s . She d e s c r i b e s h e r r e a c t i o n t o t h i s " s t r o n g s t a t e m e n t " a n d 123 why s h e h a d d i f f i c u l t y a c c e p t i n g t h i s f o r h e r , a s a n u r s e , who h a s s p e n t many y e a r s d e v e l o p i n g a s t y l e o f h e l p i n g t h a t w o r k s f o r h e r . T h e n u r s e f e l t t h a t t h e d o c t o r s ' s t a t e m e n t r e f l e c t e d a l a c k o f a w a r e n e s s o f t h e d i f f e r e n c e s b e t w e e n n u r s e s ' r e l a t i o n s h i p s a n d d o c t o r s ' r e l a t i o n s h i p s w i t h p a t i e n t s ; t h a t t h e d o c t o r s i m p l y a s s u m e d t h a t n u r s e s d i d t h e r a p y o r w o r k e d w i t h p a t i e n t s i n e x a c t l y t h e same way as d o c t o r s . R e b e c c a : . . . w e h a d a n i n s e r v i c e a t work a few weeks ago on t r a n s f e r e n c e a n d c o u n t e r t r a n s f e r e n c e i s s u e s a n d one o f t h e t h i n g s t h a t came up d u r i n g t h a t was t h e p s y c h i a t r i s t who was p r e s e n t i n g made . . . a v e r y s t r o n g s t a t e m e n t i n t e r m s o f t h e r a p i s t s u s i n g no s e l f - d i s c i o s u r e a t a l l . A n d t h a t d i d n ' t s i t r i g h t w i t h me a t t h e t i m e a n d I ' v e b e e n d o i n g a l o t o f t h i n k i n g a b o u t why t h a t d i d n ' t s i t r i g h t w i t h me. A n d I t h i n k i t h a s t o do w i t h t h i s - I e n d up u s i n g a l o t o f my own l i f e e x p e r i e n c e s i n how I do t h e r a p y . E v e n r e l a t i n g what t h o s e e x p e r i e n c e s a r e . . . . A n d I g u e s s I f o u n d t h a t , f o r me i t ' s a n e f f e c t i v e way t o d e a l w i t h a l o t o f p e o p l e u s i n g t h a t . Umm I d o n ' t f a b r i c a t e s t o r i e s b u t I w i l l s m o o t h o u t l i f e d e t a i l s s o t h a t t h e y make a b e t t e r s t o r y f o r m a k i n g t h e p o i n t . . . I t a l k a b o u t my g a r d e n a n d my c a t s , t h e t r o u b l e I h a v e 124 p i c k i n g t h i n g s out when I go shopping because sometimes with a p a t i e n t you can work t h i n g s out together and to me i t ' s such a v a l u a b l e t h i n g , and to suddenly be you know t o l d t h i s i s not a l l o w a b l e . I go back to t h i n k i n g yeah, as a p s y c h i a t r i s t who sees a p a t i e n t f o r a l i m i t e d amount of time to ma i n t a i n that d i s t a n c e , e v e r y t h i n g w i t h i n that time that the p s y c h i a t r i s t sees the p a t i e n t i s therapy u n d e r l i n e d with a c a p i t a l T, i t ' s therapy. With us we're with the p a t i e n t so much i t would be good i f a l l of our conta c t s were t h e r a p e u t i c but they're not therapy a l l the time... I've thought about t h i s a l o t s i n c e she gave the i n s e r v i c e and I don't know how to e l i m i n a t e the s e l f - d i s c i o s u r e without redoing e v e r y t h i n g and I don't t h i n k I'd be w i l l i n g to do th a t . The f o l l o w i n g excerpt f u r t h e r r e v e a l s the nurses' p e r c e p t i o n s of t h e i r r e l a t i o n s h i p with p a t i e n t s as compared to t h e i r p e r c e p t i o n s of p h y s i c i a n s ' r e l a t i o n s h i p s with p a t i e n t s . Diana: ... I b e l i e v e , compared to the medical model i n which we're working with - that n u r s i n g has s o r t of a d i f f e r e n t approach even though i t ' s somewhat based on the medical model i t ' s 125 d i f f e r e n t . . . I t ' s b a s e d on more o f a r e l a t i o n s h i p , a more p e r s o n a l r e l a t i o n s h i p , more h o l i s t i c r e l a t i o n s h i p t h a n umm t h a t I s e e w i t h p a t i e n t s v e r s u s d o c t o r s o r o t h e r w o r k e r s i n t h e h o s p i t a l . . . t h e r e l a t i o n s h i p w i t h n u r s i n g s t a f f i s d i f f e r e n t . . . I t ' s l e s s f o r m a l a n d i t ' s more e n j o y a b l e I t h i n k . Y o u g e t t o e x p e r i e n c e p e o p l e a s t h e m s e l v e s a n d a l o t o f t h i n g s come o u t i n t h a t p r o c e s s . . . h a v i n g t h i s o p p o r t u n i t y t o s e e p e o p l e t h r o u g h a w i d e r a n g e o f e x p e r i e n c e s . . . y o u g e t t o make a f i n e r a s s e s s m e n t . . . no one e l s e i n t h e t e a m h a s t h a t o p p o r t u n i t y a n d s o a g a i n t h e v a l u e o f n u r s i n g i s v e r y i m p o r t a n t t h e r e . I t ' s e n j o y a b l e . . . i t I b e l i e v e i s more r e a l i t y b a s e d . I n summary , t h e n u r s e s ' d e s c r i p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n e v i t a b l y i n v o l v e d some d i s c u s s i o n a b o u t t h e i r r e l a t i o n s h i p s w i t h d o c t o r s . A l t h o u g h t h e y g e n e r a l l y f e l t s u p p o r t e d by d o c t o r s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s w i t h r e g a r d s t o p a t i e n t c a r e t h e y a l s o f r e q u e n t l y d e s c r i b e s i t u a t i o n s w h e r e t h e y d i d n o t f e e l c o n s u l t e d , s u p p o r t e d , l i s t e n e d t o a n d g i v e n c r e d i t f o r t h e i r s k i l l s . T h e r e were f r e q u e n t c o m p l a i n t s t h a t d o c t o r s a l w a y s h a v e t h e f i n a l s a y , no m a t t e r w h a t . T h e p e r c e i v e d d i f f e r e n c e s i n n u r s e s r e l a t i o n s h i p s w i t h 126 p a t i e n t s a n d d o c t o r ' s r e l a t i o n s h i p s w i t h p a t i e n t s i s a l s o r e v e a l e d by t h e n u r s e s i n t h e s t u d y . T h e E x p e r i e n c e o f S a d n e s s , D i s a p p o i n t m e n t , a n d F r u s t r a t i o n T h e r e a l i t i e s o f w o r k i n g i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s means t h a t n u r s e s c a r e f o r p a t i e n t s who s u f f e r f r o m m e n t a l h e a l t h p r o b l e m s t h a t c a r r y a h i g h p o t e n t i a l f o r p r o g r e s s i v e a n d p e r v a s i v e i m p a i r m e n t i n m u l t i p l e a r e a s o f f u n c t i o n i n g . T h e a c c o u n t s r e v e a l t h a t t h e i n a b i l i t y o f t h e n u r s e t o e f f e c t c h a n g e , a l t e r t h e c o u r s e o f a m e n t a l i l l n e s s o r make a d i f f e r e n c e i n t h e l i v e s o f some p a t i e n t s r e s u l t s i n f e e l i n g s o f s a d n e s s , d i s a p p o i n t m e n t , a n d f r u s t r a t i o n . R o s e : I t ' s v e r y v e r y t r a g i c e s p e c i a l l y w i t h s c h i z o p h r e n i a b e c a u s e mos t o f t h e p e o p l e g e t i t when t h e y ' r e s o y o u n g , t h e y g e t i t when t h e y ' r e 18 o r 19 t h e i r w h o l e l i v e s a r e d e s t r o y e d . T h e i r f u n c t i o n i n g g o e s d o w n h i l l r a p i d l y , t h e y c a n ' t f o r m r e l a t i o n s h i p s , t h e y c a n ' t h o l d j o b s , t h e y c a n ' t g e t a g o o d i n c o m e , t h e y j u s t e n d up on t h e s t r e e t . I t ' s s o s a d , a n d p e o p l e w i t h m a n i c d e p r e s s i o n t h e y ' r e a l r i g h t f o r a w h i l e a n d t h e n t h e y s p e n d a l l t h e i r money o r k i l l t h e m s e l v e s b e c a u s e t h e y g e t s o d e p r e s s e d . Some o f t h e o t h e r , y o u know t h e u n i p o l a r d e p r e s s i o n s a n d a n x i e t y d i s o r d e r s t h e y ' r e 127 much more t r e a t a b l e a n d t h e y c a n go away f o r g o o d b u t t h e umm p s y c h o s i s i s s o d a m a g i n g t o p e o p l e ' s 1 i v e s . S a r a h : . . . I ' m l o o k i n g a f t e r a l a d y who was j u s t d i s c h a r g e d . . . who h a s d e c o m p e n s a t e d s o b a d l y , s h e i s t o t a l l y c h r o n i c c a r e , s h e h a s no i n s i g h t , v e r y b r i g h t a l l t h r o u g h u n i v e r s i t y , c a r e e r i n [ a p r o f e s s i o n ] a n d a r o u n d age 28 became u n m a n a g e a b l e a n d went t o T a n d s p e n t $ 1 5 , 0 0 0 i n one d a y . . . . A n d I s e e h e r now a n d s h e ' s n e v e r c o m p l i e d w i t h m e d i c a t i o n , s h e comes i n now a n d s h e ' s age [ a n u m b e r ] a n d I , w h a t ' s g o i n g t o h a p p e n t o h e r a n d t h a t i s r e a l l y s a d . A n d I ' m c l o s e t o h e r b u t t h e r e ' s n o , I v e r y c l o s e t o h e r a n d s h e d e p e n d s on me when s h e comes t o t h e w a r d b e c a u s e t h e r e i s l o t s o f new n u r s e s now t h a t s h e h a s no r e l a t i o n s h i p w i t h a n d i t ' s h a r d f o r h e r . . . we s e e h e r now s h e ' s p o o r l y g r o o m e d , a n d h e r g o a l s a r e e x p a n s i v e . . . a l o t o f a n g e r , s h e ' s t r o u b l e s o m e i n t h e c o m m u n i t y I s e e n t h e d e t e r i o r a t i o n a n d I wonder w h e r e i s t h i s l a d y g o i n g t o e n d u p . . . y e s I f e e l a t r e m e n d o u s s a d n e s s . . . e s p e c i a l l y when y o u s e e them f r o m maybe t h e f i r s t o r s e c o n d a d m i s s i o n a n d t h e n t e n a d m i s s i o n s l a t e r o r t e n y e a r s l a t e r 128 o r w h a t e v e r . A n d s e e t h e d e c o m p e n s a t i o n a n d t h e l a c k o f c o p i n g s k i l l s . Oh y e s t h a t ' s v e r y s a d , v e r y s a d . F o r a n o t h e r p a r t i c i p a n t , R a c h e l , t h e p a t i e n t s h e d e s c r i b e d was t h e f i r s t p a t i e n t t h a t came t o h e r m i n d when a s k e d t o d e s c r i b e h e r e x p e r i e n c e i n h e r r e l a t i o n s h i p s w i t h p a t i e n t s . T h e p a t i e n t was a y o u n g man whose p o t e n t i a l t o become a s u c c e s s f u l a t h l e t e was h a l t e d by a m e n t a l i l l n e s s . R a c h e l : So a p a t i e n t t h a t s t i c k s o u t i n my m i n d ? T h e r e a r e a c t u a l l y a number o f t h e m . I g u e s s t h e f i r s t one t h a t came t o m i n d i s a m a l e i n h i s m i d d l e 2 0 s , who h a d b e e n i n c r e d i b l y s u c c e s s f u l i n h i s t e e n y e a r s a n d h a d h i s f i r s t b r e a k when he was 18 o r 19 a n d a h ( p a u s e ) i t i m p a c t e d me, I t h i n k , how s a d i t was t h a t he h a d s u c h p o t e n t i a l a n d t h a t he i s r e a l l y b a r e l y f u n c t i o n i n g i n a one b e d r o o m s u i t e h a v i n g g o n e t h r o u g h t h e u s u a l b o a r d i n g home s y s t e m . So t h a t i s p r o g r e s s , I g u e s s i n a s e n s e . I t s o m e t i m e s make me f e e l v e r y s a d t h a t , t h e r e c a n be s o much p o t e n t i a l a n d t h e n s o m e t h i n g l i k e m e n t a l i l l n e s s w i l l j u s t c h a n g e t h e i r w h o l e l i f e p l a n . . . I t ' s v e r y s a d . I t ' s r e a l l y s a d . I t f e e l s l i k e i t ' s n o t f a i r . A n d I t h i n k t h a t ' s what k e e p s me r e a l l y m o t i v a t e d t o r e a l l y b e n d o v e r b a c k w a r d s f o r p e o p l e b e c a u s e i t ' s r e a l l y n o t f a i r t h a t t h e y e n d up p s y c h o t i c . I t ' s a d e v a s t a t i n g l i f e l o n g a f f l i c t i o n t h a t g e t s v e r y l i t t l e r e s p e c t a n d u n d e r s t a n d i n g i n s o c i e t y . So I g u e s s y e a h t h a t ' s p a r t o f i t t o o , y o u want t o make up f o r a l l t h e p e o p l e t h a t a r e who a r e , I was g o i n g t o s a y s t u p i d , b u t a h who a r e n o t c o m p a s s i o n a t e a n d d o n ' t r e a l l y know, d o n ' t u n d e r s t a n d o r s t i g m a t i z e p e o p l e w i t h m e n t a l i l l n e s s . One p a r t i c i p a n t t a l k e d a b o u t h e r f e e l i n g s o f s a d n e s s a n d d i s a p p o i n t m e n t when f a m i l i e s a r e u n a b l e t o a c c e p t a m e n t a l h e a l t h p r o b l e m o r t h e p a r t i c u l a r t r e a t m e n t p l a n s f o r a p a t i e n t . L i l y : . . . My l a s t s i t u a t i o n w a s n ' t s o h a p p y . He was a n o l d g e n t a n d t h e y w a n t e d t o do E C T . . . . a n d t h e f a m i l y w o u l d n ' t a l l o w E C T a n d s o he w o u l d c r y a l l t h e t i m e a n d i f he w a s n ' t c r y i n g he w o u l d c r y o u t l o u d . . . y o u do e v e r y t h i n g f o r h i m , y o u make s u r e h e ' s c l e a n y o u t a l k t o h i m , y o u t a k e h i m f o r r i d e s , I ' d t a k e h i m , I e v e n b r o u g h t f l o w e r s i n t o h i m . . . . A n y t h i n g t o make h i s e n v i r o n m e n t a b i t b e t t e r , I ' d o r i e n t h i m t o t h e t i m e , d a t e a n d p l a c e , I ' d t e l l h i m a b o u t t h e w e a t h e r , e v e r y t h i n g b e f o r e he was c r y i n g o r m o a n i n g o u t l o u d . T h e p a r t i c i p a n t s ' a c c o u n t s r e v e a l t h a t t h e y 130 f r e q u e n t l y f e l t f r u s t r a t e d i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s . F r u s t r a t i o n was p r i m a r i l y a s s o c i a t e d w i t h p a t i e n t s who r e j e c t e d t h e i r h e l p o r who made c h o i c e s t h a t n u r s e s p e r c e i v e d k e p t them s i c k . R a c h e l : . . . T h e r e i s o f c o u r s e t i m e s when y o u d o n ' t a l w a y s meet w i t h s u c c e s s a n d t h a t ' s . . . c a n be f o r a v a r i e t y o f r e a s o n s . Y o u j u s t c a n ' t g e t r a p p o r t a n d u h , I a c t u a l l y h a v e a man r i g h t now t h a t I c a n t h i n k a b o u t who i s r e a l l y d i f f i c u l t t o g e t r a p p o r t w i t h . He r e m a i n s s u p e r f i c i a l a n d n o n -d i s c l o s i n g a n d d o e s n ' t g i v e o u t a l o t . . . h e w i l l c e r t a i n l y be a m e n a b l e t o g e t t i n g t o g e t h e r d a i l y t o s i t a n d h a v e a c h a t b u t I d o n ' t a l w a y s g e t a n y t h i n g b a c k , s e l d o m a c t u a l l y . . . e x c e p t t h a t " I ' m f i n e , oh y e a h , oh y e a h , I s e e what y o u mean" b u t he j u s t d o e s n ' t g i v e a n y t h i n g . W h i c h may be j u s t t h e way he a l w a y s i s , i t may be t o o t h a t he j u s t , I d o n ' t know, h e ' s g u a r d e d . . . i t ' s a l i t t l e b i t f r u s t r a t i n g a n d I n e e d t o r e m i n d m y s e l f t h a t i t i s n ' t a l w a y s p o s s i b l e w i t h e v e r y b o d y . B e c a u s e I c a n f e e l some s e n s e o f f a i l u r e . I do f o r me. A n d t h a t t h e r e a l i t y i s he d o e s n ' t , h e ' s n o t f o r t h c o m i n g w i t h a n y b o d y , i n c l u d i n g h i s d o c t o r . So i t i s n ' t l i k e a p e r s o n a l a f f r o n t . B u t i t c a n be v e r y d i s a p p o i n t i n g b e c a u s e I l i k e t o t h i n k by 131 t h e e n d o f t h e d a y t h a t s o m e t h i n g h a s h a p p e n e d f o r e v e r y o n e t h a t I h a v e w o r k e d w i t h , e v e n m i n o r , c e r t a i n l y e v e r y d a y t h e r e i s n ' t some m a j o r s h i f t b u t t h a t t h e r e be s o m e t h i n g . B u t w i t h t h i s p a r t i c u l a r man t h e r e a r e many d a y s when t h e r e i s n ' t a n y t h i n g . I t s o r t o f s t a y s t h e same . B r i g i t : T h i s w o u l d h a v e b e e n q u i t e a few y e a r s ago I ' d b e e n a n u r s e f o r maybe 3 t o 4 y e a r s a n d t h i s p a t i e n t , he was i n h i s 8 0 ' s b u t he l o o k e d a n d p r e s e n t e d much y o u n g e r a n d he h a d a l l h i s f a c u l t i e s , a n d he was a g i t a t e d d e p r e s s i o n a n d he was one o f t h o s e , l i t e r a l l y , w r i n g i n g h i s h a n d s a n d he was d e l u s i o n a l . . . . b u t u n d e r n e a t h a l l t h a t he seemed l i k e a r e a l l y n i c e m a n . He was t h e f i r s t p a t i e n t , I f e l t , I r e a l l y f e l t a r e a l l i k i n g f o r a n d I r e a l l y w o u l d l o o k f o r w a r d t o w o r k i n g w i t h h i m a l t h o u g h he was e x t r e m e l y d i f f i c u l t i n t h a t he j u s t w o u l d h a v e t h e s e , t h e y seemed a t t h e t i m e , f i x e d d e l u s i o n s t h a t he w o u l d n o t g e t e n o u g h f o o d , t h a t he w o u l d c o n t i n u a l l y moan o v e r a n d o v e r "Oh my g o d , Oh my g o d " a n d i t was j u s t r e a l l y , a n d he w o u l d n ' t go o u t . He was t o t a l l y i n d e c i s i v e . . . we e n d e d up w i t h E C T as t h e c h o i c e a n d . . . i t d i d h a v e g o o d r e s u l t s , he s t o p p e d a l l t h i s a n d he was 132 a b l e t o r e l a x m o r e . B u t t h e n what he w o u l d do i s . . . m i n i m i z e any p r o b l e m s o r n o t , o r d e n y t h a t he h a d any p r o b l e m s . . . he w o u l d n o t want t o d i s c u s s any p r o b l e m s t h a t he h a d i n h i s l i f e . Y o u know he w a n t e d t o k e e p t h i n g s v e r y s u p e r f i c i a l . A n d I r e a l l y w a n t e d h i m t o , I j u s t w a n t e d s o much t o h e l p h i m , b e c a u s e a s I s a i d , I r e a l l y l i k e d h i m . B u t he j u s t w o u l d n ' t go a l o n g w i t h t h a t . L e a h : . . . I g e t f r u s t r a t e d , p a r t i c u l a r l y i f i t ' s somebody who h a s b e e n on a r o u n d r o b i n a d m i s s i o n a n d t h e y ' r e m a k i n g p o o r c h o i c e s a g a i n a n d a g a i n o r v e r y d y s f u n c t i o n a l c h o i c e s . . . T h e n u r s e s ' a c c o u n t s r e v e a l t h a t s p e c i f i c s t r a t e g i e s a r e u s e d t o d e a l w i t h t h e s e e x p e r i e n c e s . I t a p p e a r s t h a t n u r s e s a t t e m p t t o c r e a t e some common g r o u n d , a m u t u a l l y u n d e r s t o o d n e g o t i a t e d r e a l i t y w i t h p a t i e n t s . F i r s t , t h e r e i s a r e c o g n i t i o n a n d a c c e p t a n c e o f t h e p a t i e n t a n d t h e l i m i t a t i o n s r e s u l t i n g f r o m t h e i r m e n t a l h e a l t h p r o b l e m s a n d o r a n a c c e p t a n c e o f p a t i e n t s d e c i s i o n s e v e n when t h e y do n o t a g r e e w i t h t h e m . S e c o n d l y , t h e r e i s a l o w e r i n g o f o n e ' s e x p e c t a t i o n s s o t h a t b o t h p a t i e n t a n d n u r s e c a n a c h i e v e some m e a s u r e o f s u c c e s s . T h e f o l l o w i n g e x c e r p t i l l u s t r a t e s t h e u s e o f t h i s s t r a t e g y . R o s e : Y e a h , i t ' s a r e v o l v i n g d o o r . Y o u do s e e t h e same p a t i e n t s o v e r a n d o v e r a g a i n a n d i t ' s q u i t e n i c e a c t u a l l y b e c a u s e y o u g e t somebody y o u know "oh M r s . s o a n d s o i s c o m i n g b a c k - o h f i n e g r e a t no p r o b l e m , d o n ' t n e e d t o show h e r a r o u n d s h e ' s b e e n h e r e b e f o r e " y o u know b u t on t h e o t h e r h a n d y o u f e e l a b i t s a d t h a t t h e y h a d t o come b a c k . B u t t h e n y o u t h i n k w e l l y o u k e p t them o u t f o r a w h i l e , y o u g o t them b a c k on t h e i r f e e t f o r a w h i l e s o t h e y s t a y e d o u t a n d t h e y ' r e c o m i n g b a c k y o u know f o r a r e c h a r g e ( l a u g h i n g ) b u t i t ' s s a d c a u s e y o u d o n ' t r e a l l y want them t o h a v e t o come b a c k a t a l l b u t t h e n y o u know t h e y a l w a y s w i l l . . . I t h i n k y o u j u s t h a v e t o be i n t h e f i e l d f o r a w h i l e . . . y o u r p e r s p e c t i v e c h a n g e s , f o r a w h i l e i t ' s t h e f i r s t b i t , o h d e a r t h a t p o o r p e r s o n h a d t o come b a c k a g a i n , a n d t h e n i t c h a n g e s t o , w e l l t h e y ' v e b e e n o u t f o r e i g h t m o n t h s , t h e y ' v e b e e n f u n c t i o n i n g , t h e y ' v e b e e n l i v i n g w i t h t h e i r f a m i l i e s , t h e y ' v e b e e n d o i n g t h i s a n d t h a t , t h e y h a d a j o b o r w h a t e v e r t h e y were d o i n g , g o i n g t o s c h o o l , t h e y ' v e b e e n y o u know a n d t h e y ' r e j u s t h a v i n g a r e l a p s e a n d t h e y ' l l be h e r e f o r two m o n t h s l i k e t h e y w e r e l a s t t i m e a n d w e ' l l g e t them b a c k on t h e i r f e e t a n d t h e y ' l l go o u t a g a i n f o r a n o t h e r e i g h t m o n t h s s o y o u r p e r s p e c t i v e c h a n g e s . . . . I t c e r t a i n l y i s n ' t i d e a l by any means b u t a t l e a s t i f y o u r e x p e c t a t i o n s a r e l o w e r e d o r c h a n g e d t h e n y o u d o n ' t d r i v e y o u r s e l f c r a z y t r y i n g t o g e t e v e r y b o d y b e t t e r b e c a u s e i t d o e s n ' t w o r k . . . i f y o u r e x p e c t a t i o n s a r e l o w e r e d a n d y o u r a n x i e t i e s a r e l e s s , y o u ' l l r e l a t e t o them much b e t t e r b e c a u s e y o u w o n ' t be p u t t i n g s o much p r e s s u r e on them t o c h a n g e when t h e y c a n ' t . Y o u know t h e y c a n ' t a n d i f t h e y h a v e a l l t h i s p r e s s u r e p u t on them by h e a l t h p r o f e s s i o n a l s t o do t h i s a n d do t h a t t h e y j u s t f e e l more h o p e l e s s t h a n t h e y d i d i n t h e f i r s t p l a c e . . . . I n summary , t h e a c c o u n t s r e v e a l t h a t b e i n g i n r e l a t i o n s h i p s w i t h p a t i e n t s e v o k e s f e e l i n g s o f s a d n e s s , d i s a p p o i n t m e n t a n d f r u s t r a t i o n i n t h e n u r s e . N u r s e s f e e l p a r t i c u l a r l y s a d by p a t i e n t ' s e x p e r i e n c e s w i t h i n t r a c t a b l e m e n t a l h e a l t h p r o b l e m s . D i s a p p o i n t m e n t a n d f r u s t r a t i o n i s more o f t e n a s s o c i a t e d w i t h c a r i n g f o r p a t i e n t s who t h e n u r s e s p e r c e i v e a s m a k i n g c h o i c e s t h a t k e e p them s i c k . T h e E x p e r i e n c e o f S a t i s f a c t i o n T h e s e l f - d i s c l o s u r e s o f t h e n u r s e s r e v e a l e x p e r i e n c e s o f d e e p s a t i s f a c t i o n i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . 135 They r e v e a l these as experiences of t r u s t , intimacy, r e c i p r o c i t y , and as having achieved r a p p o r t . They d e s c r i b e these as moments or r e l a t i o n s h i p s where they f e l t connected with p a t i e n t s and experienced t h e i r own presence as v a l u a b l e and worthwhile to the p a t i e n t . They are a l s o moments of r e a l i z a t i o n and v a l i d a t i o n of the nurses' h e l d p r o f e s s i o n a l values of r e s p e c t , honesty, c o n s i s t e n c y , empathy and c a r i n g . In other words, the a c t u a l i z a t i o n of one's values and b e l i e f s about n u r s i n g . The f o l l o w i n g excerpts of a c t u a l nurse-p a t i e n t s i t u a t i o n s r e v e a l s moments when nurses experienced s a t i s f a c t i o n . Diana: ... One of the t h i n g s about n u r s i n g i s there are so many l i t t l e i n c i d e n t s t h at happen, you know, day to day kinds of t h i n g s t h a t nobody r e a l l y pays much a t t e n t i o n to or t a l k s a l o t about i n rounds or anything l i k e that but there's these l i t t l e encounters that you have with p a t i e n t s that r e a l l y make n u r s i n g enjoyable and worthwhile. I'm t h i n k i n g about a few years back when I was s t i l l i n W. a p a r t i c u l a r l y a g i t a t e d f e l l o w had come i n from emergency. There were ten o r d e r l i e s on him, w i t h i n seconds, he was f e a r f u l . . . I r e a l l y f e l t f o r the guy. I mean he was t o t a l l y out of c o n t r o l ... I see as my r o l e i s connecting with that 136 p e r s o n i n no m a t t e r what s t a t e t h e y ' r e i n . I drew an i n j e c t i o n a n d went i n t o t h e s e c l u s i o n room a n d m e a n w h i l e he was b e i n g h e l d down by t e n o r d e r l i e s a n d he made e y e c o n t a c t w i t h me a n d f o r t h a t moment I c o u l d r e a l l y a p p r e c i a t e how s c a r e d t h i s guy was a n d s t o p p e d t h e p r o c e d u r e a n d a c t u a l l y t o o k t h e t i m e o u t t o j u s t c o m f o r t h i m a n d t a l k t o h i m a b o u t h i s e x p e r i e n c e , e m p a t h i z e how s c a r y i t must be a t t h i s t i m e a n d t h a t I ' m g o i n g t o h e l p h i m g e t some c o n t r o l b a c k b e c a u s e h e ' s f e e l i n g so o u t o f c o n t r o l t h a t makes i t e v e n more s c a r y . So j u s t t a k i n g t h a t t i m e o u t I c o u l d j u s t s e e h i m r e l a x a n d he t o o k t h e i n j e c t i o n a n d s e t t l e d b u t i t ' s t h o s e k i n d o f e x p e r i e n c e s t h a t , y o u know, o r a l s o w a t c h i n g one o f my c l i e n t s a b r e a c t , l i k e a c h i l d a b r e a c t i n g a b u s e a n d b e i n g t h e r e w i t h t h a t c h i l d who i s i n a n a d u l t b o d y b u t r e l i v i n g t h i s t e r r i b l e e x p e r i e n c e a n d h e l p i n g them g e t t h r o u g h i t . T h e y make e y e c o n t a c t w i t h y o u a n d , y o u know, i t c o u l d be a 32 y e a r o l d woman b u t i t ' s a 4 y e a r o l d c h i l d i n t h a t s t a t e l o o k i n g a t y o u t o be t h e r e a n d t o c o m f o r t them a n d b e i n g a b l e t o do s o t h a t i s r e a l l y s o m e t h i n g e l s e . I mean t h o s e a r e t h e l i t t l e e x p e r i e n c e s t h a t no one r e a l l y h e a r s a b o u t b e c a u s e some o f t h a t s t u f f i s r e a l l y h o r r i b l e a n d 137 i t ' s e n o u g h t o make y o u r e a l l y s i c k b u t h e l p i n g p e o p l e g e t t h r o u g h t h o s e e x p e r i e n c e s i s s o m e t h i n g t h a t I f i n d q u i t e r e w a r d i n g . I n t h e n e x t e x c e r p t L e a h r e v e a l s a moment o f r e c i p r o c i t y - d e e p f e l t a p p r e c i a t i o n f r o m t h e p a t i e n t f o r c a r i n g . T h e a c c o u n t r e v e a l s t h a t " b e i n g w i t h " a p a t i e n t i n v o l v e s t o u c h i n g t h a t g o e s b e y o n d what i s n e c e s s a r y t o a t t e n d t o p h y s i c a l a n d p s y c h o l o g i c a l n e e d s . I t i s more t h a n d o i n g f o r t h e p a t i e n t , i t i s a " p r e s e n c i n g " t h a t c o n v e y s c a r i n g a n d t h a t t r a n s c e n d s b a r r i e r s s u c h as t h a t i n a b i l i t y t o e n g a g e i n v e r b a l c o m m u n i c a t i o n . L e a h : . . . what I h a v e f o u n d t o be v e r y g r a t i f y i n g w i t h p a t i e n t s t h a t I h a v e w o r k e d w i t h i s when t h e y h a v e , a c h i e v e d t h e l e v e l o f t r u s t a n d t h e n b e e n a b l e t o l e t me i n t o some o f t h e i r i n n e r mos t a r e a s w h i c h p e r h a p s t h e y h a v e n ' t b e e n a b l e t o s h a r e w i t h somebody o r i t ' s an a r e a t h a t h a s b e e n v e r y p a i n f u l . A n d t h e s e a r e t h e r e w a r d i n g t i m e s . I ' v e w o r k e d w i t h one p a t i e n t i n p a r t i c u l a r who s t a n d s o u t who d i d n ' t s p e a k f o r s i x m o n t h s a n d was h o s p i t a l i z e d a n d I was w o r k i n g w i t h t h i s p a t i e n t q u i t e c l o s e l y , I was h e r p r i m a r y n u r s e . A n d e v e n t h o u g h s h e n e v e r s p o k e a w o r d t o me f o r t h e f i r s t s i x m o n t h s o f t h e r e l a t i o n s h i p I w o u l d go i n a n d 138 c o n t i n u e w o r k i n g w i t h h e r a s i f s h e was s p e a k i n g . A n d t h e r e were n o n - v e r b a l c u e s a n d I knew s h e was q u i t e aware o f what was h a p p e n i n g w i t h m e . . . . B u t on t h a t d a y I remember s a y i n g t o h e r " I ' m g o i n g on h o l i d a y s a n d I ' m g o i n g t o be away f o r t h r e e weeks a n d we w o n ' t be w o r k i n g t o g e t h e r ( s h e h a d n ' t u t t e r e d a w o r d b e f o r e t h a t ) a n d I ' m n o t g o i n g t o be b a c k u n t i l t h e n b u t I w i l l be b a c k a f t e r t h r e e w e e k s " . She s a t a n d s h e d i d n ' t s a y a n y t h i n g a n d I s t a r t e d t o w a l k o u t o f t h e room a n d s h e s a i d , " t h a n k y o u v e r y m u c h " . A n d I t u r n e d a r o u n d a n d I was a b s o l u t e l y f l o o r e d a n d I s a i d , " p a r d o n me". A n d s h e s a i d , " t h a n k y o u v e r y much f o r h a v i n g b e e n w i t h me f o r t h e s e l a s t s i x m o n t h s " . A n d f o r me t h a t was i n c r e d i b l e b e c a u s e i t showed t h a t s h e t r u s t e d e n o u g h t o h a v e b e e n a b l e t o s h a r e t h a t e v e n t h o u g h s h e h a d p e r h a p s w a n t e d t o s p e a k b e f o r e , a n d t h i s l a t e r d e v e l o p e d i n t o a d e e p e r r e l a t i o n s h i p w i t h u s , s h e was a b l e t o t a k e t h a t f i r s t s t a n c e . So t h a t was r e a l l y g r a t i f y i n g . A n d when I came b a c k s h e c o n t i n u e d t o s p e a k , i t was v e r y s e l e c t i v e who s h e s p o k e w i t h b u t s h e c o n t i n u e d t o do t h a t . So I t h i n k a l o t o f t h a t was b e c a u s e o f t h e t y p e o f r e l a t i o n s h i p we h a d a n d t h e way i t was e s t a b l i s h e d a n d t h e f a c t t h a t I 139 wasn't w i l l i n g to j u s t give up on her or ju s t say oh w e l l she's not t a l k i n g and whatever her problem i s . S a t i s f a c t i o n was derived from being able to develop r e l a t i o n s h i p s with p a t i e n t s who are extremely d i f f i c u l t to connect w i t h because of a mental h e a l t h problems such as extreme withdrawal from r e a l i t y and suspiciousness which i n t e r f e r e with the p a t i e n t ' s a b i l i t y to t r u s t others. Rachel: ... That's probably who I l i k e to work with the best. Is the schizophrenic who needs a l o t of support and follow-up i n the community... I f i n d i t very g r a t i f y i n g and s a t i s f y i n g . I f e e l that I'm p l a y i n g a v i t a l part i n t h e i r f u t u r e , r e a l l y . And that i f I can become t h e i r resource and support and get some rapport. When you get some rapport w i t h someone l i k e t h a t , you f e e l l i k e you can move mountains. There i s n ' t anything, I don't t h i n k , that's more g r a t i f y i n g . (pause) In a c r i s i s to have 6 people i n a room, because a pa t i e n t i s going to act out or i s very paranoid you have to c a l l the troops to come and give some a s s i s t a n c e , and they turn and look s t r a i g h t at you, and w i l l look to you to help them because they're r e a l l y so scared. That, i t ' s a l l worth 140 i t . . . to t h i n k that I co u l d connect with someone as d i s t u r b e d as an a c u t e l y paranoid s c h i z o p h r e n i c because they are so umm i n v o l v e d i n t h e i r own world, that ah, to th i n k that you co u l d connect at some l e v e l , i t ' s a c h a l l e n g e and then when you can, when you achieve that i t ' s very rewarding, i t ' s very rewarding f o r me... I would be the primary nurse, but I might be the only person that they can do that with. So even that i s k i n d of I f e e l a b i t p r i v i l e g e d almost maybe... there i s something that f e e l s good about the f a c t that t h i s person w i l l d i s c l o s e with me and t r u s t me...I guess i t ' s t r u s t , and i t i s very, i t ' s i n c r e d i b l y s a t i s f y i n g . The f o l l o w i n g excerpts r e v e a l how nurses l e a r n from f i r s t hand experience the t h e r a p e u t i c p o s s i b i l i t i e s that g i v i n g of the s e l f and "being i n " a r e l a t i o n s h i p with a p a t i e n t b r i n g s . The encounters with t h e i r p a t i e n t s r e v e a l the consequences of t r u s t . T h i s i s evidence to the nurses that they have cared i n a way that allows p a t i e n t s to d i s c l o s e t h e i r emotional p a i n . Diana: ... the r e l a t i o n s h i p that I h o l d with one p a t i e n t i n p a r t i c u l a r - i s i t ' s umm a v a l i d a t i o n of a l l my b e l i e f s around t h i s area because I've 141 gotten to know every aspect of her l i f e and have c h a l l e n g e d her to change t h i n g s that are a problem, and to develop t h i n g s that are not a problem l i k e s t rengthen those p a r t s of h e r s e l f that are not i n t u r m o i l . And we haven't had to use any drugs, we've had to - I mean she's d e f i e d a l l the odds about p e r s o n a l i t y d i s o r d e r s i n i n p a t i e n t s e t t i n g s . So something i s working th e r e , I'm not t r y i n g to be s e l f - r i g h t e o u s i n my statement there but i t ' s l i k e something i s o b v i o u s l y working f o r t h i s person and i t i s I t h i n k , a d i r e c t , r e s u l t of the r e l a t i o n s h i p t h at she's been able to develop with not j u s t myself but other s t a f f as w e l l . That to me i s rewarding cause I'm g i v i n g something of myself, I'm not g i v i n g a drug, I'm not g i v i n g whatever i t i s I'm g i v i n g myself to t h i s person. I'm g i v i n g her my time, my energy, whatever and i t ' s working. Leah: ...And I have found that probably to be one of the most f u l f i l l i n g times i s when I see somebody who has a l o t of b o t t l e d up emotions and f i n a l l y has enough t r u s t to l e t i t go. And I remember once s i t t i n g with a p a t i e n t who c r i e d f o r 2 hours s t r a i g h t and I sat and d i d nothing but s i t 142 with t h i s p a t i e n t and a f t e r she c r i e d f o r 2 hours umm she stopped and she looked at me and she s a i d "you know t h i s i s r e a l l y one of the f i r s t times i n my l i f e s i n c e being a c h i l d that I remember being allowed to do t h i s " . The p a t i e n t had had a horrendous h i s t o r y of p h y s i c a l and sexual abuse and had been extremely e m o t i o n a l l y abused as well and had always been t o l d not to share, not to t a l k . . . I r e a l l y f e l t a sense of achievement f o r her because she had c r o s s e d one m i l e s t o n e and I knew that t h i s was a r e a l l y good s i g n f o r her. My being comfortable with that s i t u a t i o n umm i n d i c a t e d to me that I was d e v e l o p i n g as a c l i n i c i a n and i n the r e l a t i o n s h i p . . . and was at a l e v e l that I f e l t comfortable i t and she d i d too. And I f e l t t h a t I was doing a good job and I was proud of where she was a t . P a r t i c i p a n t s d e s c r i b e d s a t i s f y i n g encounters with p a t i e n t s i n v a r i o u s ways which suggest a connectedness, an intimacy, and fondness f o r p a t i e n t s . One t a l k e d about "a f e e l i n g between them". One used the term "we." Others t a l k e d about "being w i t h " p a t i e n t s . One p a r t i c i p a n t , B r i g i t , d e s c r i b e d i t as "a c e r t a i n look" that passed between the p a t i e n t and the nurse. When asked to d e s c r i b e what she meant by t h i s " c e r t a i n look" 143 she e x p l a i n e d i t as the look that t e l l s you, you have made " c o n t a c t " with another human being. She a l s o s t a t e s t hat when she makes t h i s contact with a p a t i e n t she sees them more as a person r a t h e r than a d i a g n o s i s . She a l s o f e e l s more competent. B r i g i t : ... when, you know, that ah, he or she has been acknowledged as a human being and i t ' s almost l i k e ( s i g h ) umm what can I say, i t ' s l i k e a nod... you get a p a t i e n t I t h i n k that maybe t h i s way --o f t e n you get a p a t i e n t who i s r e a l l y not very a p p r o p r i a t e s o c i a l l y and has never been and i s you know j u s t not ever going t o , the prognosis i s r e a l l y t e r r i b l e but you get that p a t i e n t and at the end of the c o n v e r s a t i o n w i l l grab your hand and e i t h e r shake i t or t r y to k i s s i t but i t ' s they're s a y i n g "I j u s t . " T h i s has happened so many times i n my career i t ' s r e a l l y hard to d e s c r i b e i t because i t sounds l i k e hand shaking or k i s s i n g i s r e a l l y i n a p p r o p r i a t e but with c e r t a i n p a t i e n t s i t ' s l i k e i t ' s done i m p u l s i v e l y at the end of a c o n v e r s a t i o n i t ' s l i k e as they're h o l d i n g your hand e i t h e r wanting to shake i t or k i s s i t they look at you and acknowledge that you, they take my hand and i t ' s l i k e a c l u t c h and i t ' s d i r e c t eye co n t a c t , no matter how crazy they've 144 been or how d i f f i c u l t or unusual the c o n v e r s a t i o n . . . has been for them, I am ta lk ing about something real i n the i r l i v e s , something concrete that they are able to respond to appropr ia te ly . I t ' s l i k e they acknowledge that you've touched the part of me that I know exis ts but no one else can see, not that I'm any major Houdini i n f e r r e t i n g out but i t ' s jus t , take a few minutes to ta lk about, yeah sure i t ' s hard to get up th i s morning and yeah I had a hard time gett ing up myself th i s morning but we want you i n group your input i s welcome and i t ' s your chance to see that l i k e . Just treat them with some d ign i ty or having the conversation with them when they s tar t out r e a l l y crazy but you say something r e a l l y c o n c r e t e . . . i t ' s just th i s eye contact and i t ' s a l i ghtn ing of the f a c i a l expression i t ' s l i k e that person at that moment could be your next door neighbour you're ta lk ing to over the fence. I t ' s acknowledging two human beings and your f a c i a l expressions equal to equal. They look at you they smile and you look back and you smile and that ' s not to say that ten minutes la ter they're not gonna be gesturing at t h e i r shadow i n the window but i t ' s that you've made that contact and they 145 know y o u h a v e a n d t h a t i t g i v e s t h e m , i t ' s a p l u s f o r t h e m , t h a t y e s I c a n be a p p r o p r i a t e . What i t means t o me i s I s t i l l h a v e t h e a b i l i t y n o t t o s e e p e o p l e a s a d i a g n o s i s , s t e r e o t y p e p e o p l e , umm be c y n i c a l a n d f e d up w i t h t h e j o b w h i c h o f t e n I am umm b u t i f I c a n remember t o do t h i s k i n d o f c o n t a c t , i t j u s t r e m i n d s me t h a t i t i t ' s p a r t o f t h e human c o n d i t i o n and a s I s a i d t h e s e i l l n e s s e s a r e . . . r e a l l y c h r o n i c a n d d e b i l i t a t i n g a s w e l l . I t a l s o g i v e s me t h e s a t i s f a c t i o n o f k n o w i n g t h a t I t h i n k I 'm s k i l l e d a t my j o b , t h a t I h a v e t h e a b i l i t y t o work a r o u n d t h a t s e a o f c r a z i n e s s a n d b r i n g o u t a n d I t h i n k a f t e r t e n y e a r s i f I c a n ' t do t h a t t o u c h t h a t human p a r t o f t h a t p e r s o n o r t h a t a p p r o p r i a t e p a r t a n d be t h e r a p e u t i c w i t h o u t b e i n g s o r t o f t e x t b o o k c o n d e s c e n d i n g i t shows t h a t t h e r e i s a r e a s o n why y o u c h o s e y o u r c a r e e r a n d y o u do h a v e s o m e t h i n g t o o f f e r i t e v e n i f i t ' s o n l y t e m p o r a r y t h a t g i v e s t h a t p e r s o n maybe f o r a c o u p l e o f d a y s a g o o d f e e l i n g a b o u t t h e m s e l v e s . I t ' s n o t g o i n g t o c u r e them o r make them want t o go on t o y o u know b e i n g c o m p l i a n t w i t h t h e i r m e d i c a t i o n o r w h a t e v e r b u t i t ' s a l i t t l e d r o p i n t h e b u c k e t , a b r i c k i n t h e w a l l t h a t s a y s o k a y t h e r e a r e s o m e t i m e s t h a t i t ' s s o I 146 g u e s s i t k i n d o f r e a f f i r m s t h a t . F o n d s e n t i m e n t s were f r e q u e n t l y e x p r e s s e d by t h e n u r s e s t o w a r d p a t i e n t s . T h i s f o n d n e s s was e v i d e n t i n t h e way p a r t i c i p a n t s t a l k e d a b o u t p a r t i c u l a r p a t i e n t s t h e y h a d n u r s e d o r were p r e s e n t l y n u r s i n g . T h e s e e x p e r i e n c e s a r e " r e m e m b e r e d " w i t h t h e same f o n d n e s s by n u r s e s e v e n many y e a r s l a t e r a n d c o n t r i b u t e t o t h e i r s a t i s f a c t i o n w i t h p a t i e n t s . R o s e : . . . I w o r k e d i n E n g l a n d i n a v e r y l a r g e p s y c h i a t r i c h o s p i t a l w i t h some v e r y v e r y c h r o n i c , v e r y v e r y s i c k p e o p l e . . . A n d umm some o f t h o s e p e o p l e were r e a l c h a r a c t e r s and I mean i t was a l o n g t i m e ago b u t I remember some o f them c l e a r l y , r e a l l y c l e a r l y a n d some o f them w e r e . . . s t a n d o u t . . . T h e r e was t h i s w o n d e r f u l woman c a l l e d I. She was j u s t a w o n d e r f u l woman, s h e was a m a n i c -d e p r e s s i v e a n d s h e h a d h a d 25 a d m i s s i o n s i n 25 y e a r s a n d s h e u s e d t o come i n r e a l l y r e a l l y h i g h and r e a l l y r e a l l y low and we n e a r l y l o s t h e r o n c e b e c a u s e s h e was s o e m a c i a t e d a n d s h e w o u l d n ' t e a t a n d we h a d t o g i v e h e r E C T . . . E v e r y b o d y l o v e d h e r s h e w o u l d t e l l t h e most h i l a r i o u s j o k e s when s h e was h i g h a n d i t was v e r y h a r d n o t t o l a u g h i n f a c t we a l w a y s d i d a n y w a y , a n d umm t h e o t h e r p e r s o n I remember a n d t h i s i s a r e a l l y f u n n y s t o r y . T h i s 147 p a t i e n t who when he was h i g h he was v e r y , w e l l he was v e r y n a u g h t y , he w o u l d go a f t e r a l l t h e y o u n g g i r l s a n d I t h i n k he f r i g h t e n e d t h e l i f e o u t o f a c o u p l e , a n y w a y , one day he came up t o me a n d he was r e a l l y h i g h a s u s u a l and he s a i d t o me " I ' v e g o t a f i s h b o n e s t u c k i n t h e r o o f o f my m o u t h " , a n d h e ' d t r y a l l s o r t s o f p l o y s t o t r y and g e t c l o s e t o y o u n g l a d i e s . A n d I s a i d "I d o n ' t b e l i e v e y o u " . A n d he s a i d "I h a v e , I ' v e g o t a f i s h b o n e s t u c k i n my m o u t h . A n d I s a i d " a l r i g h t y o u k e e p y o u ' r e h a n d s t o y o u r s e l f and I ' l l h a v e a l o o k i n " . A n d I h a d a l o o k i n a n d s u r e e n o u g h t h e r e i t was s o I went a n d g o t a p a i r t w e e z e r s and I j u s t p u l l e d i t o u t a n d he was s o g r a t e f u l t h a t , what he d i d w a s , he w e n t , he s a i d " I ' v e g o t t o g e t y o u s o m e t h i n g , a l i t t l e p r e s e n t . " I s a i d " Y o u d o n ' t h a v e t o " . "No I d o " he s a i d . So he went rummag ing a r o u n d a l l t h e o l d c l o t h e s we u s e d t o s a v e f o r p a t i e n t s f o r t h e j u m b l e s a l e s a n d t h i n g s , rummage s a l e s . A n d he came b a c k w i t h t h i s b r a a n d he s a i d " h e r e y o u a r e d e a r " a n d he was s o g r a t e f u l , he r e a l l y , y o u know a n d t h e g e s t u r e was r e a l l y n i c e and he r e a l l y meant i t , w i t h , i t ' s j u s t s o f u n n y . I remember h i m a n d l o t s o f o t h e r p a t i e n t s . We h a d a l o v e l y p a t i e n t c a l l e d D who 148 was a s c h i z o p h r e n i c , f o r oh I d o n ' t know, p o o r l a d y , s h e was a b o u t 65 a n d s h e ' d b e e n a s c h i z o p h r e n i c s i n c e s h e was a b o u t 18 and s h e ' d p r o b a b l y b e e n i n h o s p i t a l t h a t l o n g . A n d s h e was s i t t i n g n e x t t o one o f t h e o t h e r p a t i e n t s and s h e s a i d t o h i m " A " s h e s a i d "I know y o u ' v e g o t my s t o m a c h g i v e i t b a c k " a n d I h a d n ' t b e e n i n p s y c h i a t r y v e r y l o n g a n d I j u s t c o u l d n ' t b e l i e v e my e a r s . T h a t was t y p i c a l , t h a t was a s a m p l e . . . F o n d n e s s was a l s o e x p e r i e n c e d a s f o c u s i n g on what r e a l l y m a t t e r s a n d what t h e p a t i e n t r e a l l y n e e d s . L i l y : . . . I h a d a n o t h e r o l d g u y . T h a t ' s my s p e c i a l t y , i t seems l i k e i t ' s t h e o l d p e o p l e . A n d he came i n a n d he was l i k e 90 p o u n d s , t i n y l i t t l e man a b o u t 5 f o o t n o t h i n g . . . W e l l I ' l l t e l l y o u t h a t m a n , I g o t r e a l l y , t h e y a l l s a i d " y o u s h o u l d t a k e h i m h o m e " . . . . W e ' d go f o r w a l k s , he w o u l d n ' t go w i t h a n y o n e e l s e , he r e a l l y g o t c o n n e c t e d t o me a n d I h a v e n ' t s e e n h i m b a c k e i t h e r . And he went f r o m , he w o u l d n ' t e v e n f e e d h i m s e l f , when we g o t h i m we h a d t o f e e d h i m a n d t h e n by t h e t i m e he l e f t he was t a l k i n g , w o u l d n ' t g e t o u t o f h i s room t o o m u c h . . . B u t he h a s n ' t b e e n b a c k s o I g u e s s h e ' s d o i n g o k a y . . . So t h a t was a h a p p y e n d i n g . M e e t i n g p a t i e n t s b a s i c n e e d s s u c h a s n u t r i t i o n , r e s t , 149 a c t i v i t y and s a f e t y was v i e w e d a s s o u r c e o f m u t u a l s a t i s f a c t i o n a n d s i g n i f i c a n t i n e s t a b l i s h i n g r a p p o r t . I t was v i e w e d a s t h e r i g h t t h i n g t o do w i t h p a t i e n t s who w e r e v e r y s i c k a n d u n a b l e t o meet t h o s e b a s i c n e e d s t h e m s e l v e s . R o s e : I t h i n k t h a t h a n d s o n , l i t e r a l l y h a n d s on a p p r o a c h w i t h some p a t i e n t s who a r e p s y c h o t i c . . . o f t e n t h e y d o n ' t e a t p r o p e r l y e i t h e r t h e y d o n ' t d r i n k p r o p e r l y t h e y h a v e t o be e n c o u r a g e d o f a l l t h o s e t h i n g s . . . i t ' s a way o f c o n n e c t i n g them t o t h e o u t s i d e w o r l d b e c a u s e t h e y ' r e n o t c o n n e c t e d i n v e r y many ways when t h e y ' r e p s y c h o t i c a n d t h a t c a n make them f e e l c a r e d f o r a n d r e a l . I h a v e e x a m p l e o f t h a t , r e c e n t l y a l a d y , v e r y p s y c h o t i c , q u i t e a g g r e s s i v e . . . h e r h a i r was f i l t h y , a w f u l and n o b o d y h a d b o t h e r e d t o wash i t , e i t h e r t h a t o r t h e y c o u l d n ' t g e t n e a r h e r s o I o f f e r e d t o wash h e r h a i r . She d i d n ' t r e a l l y want me t o s o I a s k e d h e r o n c e a g a i n " c a n I wash y o u r h a i r , I ' l l wash y o u r h a i r f o r y o u " . She e v e n t u a l l y a g r e e d s o we f i l l e d t h e b a t h t u b up a n d s h e g o t i n i t a n d I p u t l o t s o f b u b b l e s i n i t a n d I w a s h e d h e r h a i r a b o u t 3 o r 4 t i m e s I h a d t o i t was s o g r e a s y . A n d t h e n s h e a c c e p t e d i t r e a l l y w e l l s h e was g r e a t , s h e was s i t t i n g i n t h e b a t h t u b and I was p o u r i n g w a t e r a l l 150 o v e r h e r a n d s h e r e a l l y l i k e d t h a t and i t c a l m e d h e r down q u i t e a b i t a c t u a l l y . A n d t h e n t h e n e x t week I was t h e r e s h e r e m e m b e r e d i t . . . s h e s a i d " c o u l d y o u wash my h a i r a g a i n , c a n y o u h e l p me wash my h a i r " a n d I s a i d s u r e s u r e I w i l l . A n d s o we d i d i t a g a i n a n d I t h i n k e v e r y week f o r a b o u t 4 weeks I w a s h e d h e r h a i r f o r h e r b e c a u s e s h e h a d t e r r i b l e t a r d i v e d y s k i n e s i a . . . s h e c o u l d n ' t a c t u a l l y wash h e r h a i r h e r s e l f . A n d when s h e was w e l l e v e r y t i m e s h e saw me s h e ' d s a y , " d o y o u know t h a t r e a l l y meant s o much t o me t o h a v e somebody do t h a t y o u know I c o u l d n ' t do i t m y s e l f a n d i t r e a l l y made me f e e l g o o d " . . . I e n j o y c a r i n g . . . i t r e a l l y g i v e s me a l o t o f s a t i s f a c t i o n . . . A n o t h e r p a r t i c i p a n t , R a c h e l , b e l i e v e s t h a t m e e t i n g p a t i e n t s ' b a s i c n e e d s c o n t r i b u t e s t o b o t h t h e p a t i e n t s a n d h e r own s e n s e o f w o r t h . R a c h e l : . . . I t h i n k t h a t i f a p a t i e n t b e l i e v e s t h a t y o u t h i n k t h a t t h e y a r e i m p o r t a n t e n o u g h t h a t y o u s e e t o t h e i r n e e d s t h e n y o u c o n v e y t h a t y o u h a v e some r e s p e c t f o r who t h e y a r e . A n d i t d o e s n ' t m a t t e r how c r a z y t h e y a r e , t h e y s t i l l h a v e n e e d s a n d a h t h e y h a v e a r i g h t t o ah h a v i n g t h e i r n e e d s m e t . . . t h e s e a r e p e o p l e who f o r w h a t e v e r r e a s o n a r e n o t a b l e t o do t h a t f o r t h e m s e l v e s I 151 e n d e d up b e i n g a n u r s e b e c a u s e I l i k e t o h e l p p e o p l e . . . i t makes me f e e l umm g o o d a b o u t m y s e l f i t h e l p s my own s e n s e o f who I am o r my s e n s e o f p r o d u c t i v e n e s s a n d w o r t h a s w e l l t h a t I 'm d o i n g s o m e t h i n g t h a t h e l p s someone e l s e . B r i g i t whose e x p e r i e n c e i s t h a t s a t i s f y i n g r e l a t i o n s h i p s w i t h p a t i e n t s a r e r a r e i n p s y c h i a t r i c c a r e s e t t i n g s r e v e a l s t h e p o s i t i v e v a l u e o f r e l a t i o n s h i p s f o r h e r . T h e r e i s a s e n s e o f r e n e w e d b e l i e f t h a t one c a n s t i l l do a g o o d j o b a n d e n j o y m e n t b e i n g w i t h t h e p a t i e n t . S a t i s f y i n g r e l a t i o n s h i p s w i t h p a t i e n t s s u s t a i n s h e r t h r o u g h d i f f i c u l t t i m e s a n d h e l p s h e r a c c e p t some o f t h e h a r s h r e a l i t i e s o f work i n a p s y c h i a t r i c c a r e s e t t i n g . B r i g i t : . . . i t h a p p e n s one o u t o f t e n and i t ' s I t h i n k j u s t a l i t t l e d r o p i n t h e b u c k e t t h a t i t h e l p s , i t h e l p s me when I s t a r t f e e l i n g c y n i c a l y o u know a b o u t how e v e r y o n e i s s o s i c k and s o u n m o t i v a t e d a n d I 'm g e t t i n g c y n i c a l , I ' v e b e e n i n t h e b u s i n e s s f o r t e n y e a r s a n d y o u k e e p s e e i n g t h e same p e o p l e b a c k . B u t e v e r y p o s i t i v e t h i n g h e l p s i f I c a n make them f e e l g o o d and t h e y c a n make me f e e l g o o d by w a n t i n g t o h e l p them t h e n w e ' r e b o t h h e l p i n g e a c h o t h e r . . . i t g i v e s me c o n f i r m a t i o n t h a t I 'm n o t a n u r s e R a t c h e t o r s e e i n g p e o p l e a s 152 c i p h e r s o r d i a g n o s i s t h a t I 'm r e a l l y n o t . S o m e t i m e s I g e t r e a l l y c o n c e r n e d t h a t I 'm on t h e way t o b u r n - o u t a n d t h e n o c c a s i o n a l l y a p a t i e n t w i l l come a l o n g t h a t j u s t c o n f i r m s t h a t I 'm n o t b u r n t o u t a n d I r e a l l y do c a r e a b o u t p e o p l e . . . A c o u p l e o f weeks ago on o u r u n i t we a d m i t t e d a o l d man who i s c h r o n i c a l l y s c h i z o p h r e n i c . . . H e ' s b e e n t h a t way f o r a t l e a s t f o r t y y e a r s b u t he somehow managed t o l i v e i n t h e c o m m u n i t y b u t e v e r y o n c e i n a w h i l e he h a s a b r e a k down . A n d t h e r e ' s no h o p e f o r h i m a n d h e ' s g o t t h i s c h r o n i c d e l u s i o n t h a t he h a s an i n v i s i b l e g i r l f r i e n d . A n d t h e r e i s no v a l i d a t i o n o f t h i s and i t ' s a w h o l e i n t r i c a t e d e l u s i o n a n d f i x e d . . . T h i s h a s b e e n g o i n g on f o r y e a r s a n d y e a r s a n d no one c a n b r e a k h i m o f t h i s . U s u a l l y he c a n work a r o u n d i t b u t s o m e t i m e s he j u s t d e l a m i n a t e s o r d i s e n c a p s u l a t e s and t h e r e we a r e . H e ' s y o u know r e a l l y f u l l b l o w n q u i t e a g i t a t e d l y c r a z y . A n d y e t t h e r e i s j u s t s o m e t h i n g s o e n d e a r i n g a n d e n g a g i n g a b o u t t h i s m a n , I mean h e ' s a s c r a z y a s a h o o t o w l . . . I w o u l d e n g a g e h i m i n c o n v e r s a t i o n t h a t was n o t t o do w i t h h i s c r a z y p a r t and a s k h i m " w h e r e w e r e y o u b o r n " and "how were y o u b r o u g h t u p " . . . r e a l i t y b a s e d s t u f f . . . A n d he waxed e l o q u e n t . . . I t o t a l l y s t a y e d away f r o m 153 a l l h i s c r a z i n e s s a n d y o u know t h e r e was k i n d o f b o n d t h e r e b e t w e e n us t h a t he knew t h a t I r e c o g n i z e d h i m a s a human b e i n g t h a t h a d a p a s t a n d h a d f a m i l y a n d f r i e n d s a n d h a d d o n e o t h e r t h i n g s b e s i d e s be c r a z y o u t on t h e s t r e e t . In a s e c o n d i n t e r v i e w B r i g i t t a l k e d a g a i n a b o u t h e r e x p e r i e n c e n u r s i n g t h i s same p a t i e n t . She r e v e a l s t h a t h e r r e l a t i o n s h i p w i t h t h e p a t i e n t a s what " r e a l l y m a t t e r s " t o h e r a s a n u r s e . I t i s n o t t h e t h a n k s , t h e p r a i s e o r t h e g r e a t s t r i d e s made by p a t i e n t s . B r i g i t : W o r k i n g i n p s y c h i a t r y i f y o u ' r e l o o k i n g f o r s u c c e s s , g r e a t s t r i d e s , t h a n k s a n d p r a i s e f o r g e t i t . Y o u ' r e i n t h e w r o n g p r o f e s s i o n a b s o l u t e l y . I t ' s j u s t t o me and I c a n ' t b e l i e v e I 'm s a y i n g t h i s b e c a u s e I am q u i t e c y n i c a l a n d h a r d e n e d b u t when t h a t d o e s h a p p e n w i t h a p a t i e n t , t h a t a c k n o w l e d g e m e n t o f human t o human a n d t h a t I c a r e e n o u g h a n d I 'm s a y i n g t o t h e p a t i e n t t h a t I c a r e e n o u g h a b o u t y o u t h a t I 'm w i l l i n g t o l o o k b e y o n d y o u r c r a z i n e s s t o s e e t h e human b i t a n d t h a t y o u h a v e t h e g u m p t i o n t o r i s e a b o v e y o u r c r a z i n e s s t o a c k n o w l e d g e t h a t , e v e n t h o u g h i t ' s o n l y t e m p o r a r y . . . i t ' s s o m e t h i n g t h a t i s i n s t i l l e d i n my m i n d a s w e l l a s t h e p a t i e n t ' s . . . t o be a b l e t o r e l a t e on an a d u l t t o a d u l t b a s i s e v e n i f i t ' s 154 o n l y f o r a few m i n u t e s i t g i v e s me a p o s i t i v e f e e l i n g , i t ' s l i k e money i n t h e bank i n a way . B e c a u s e when t h i n g s g e t r e a l l y a w f u l and we seem t o g e t n o t h i n g b u t m a j o r s o c i o p a t h s t h a t a r e a n d y o u t h i n k "why am I i n t h i s b u s i n e s s " and y o u l o o k b a c k a n d o k a y t h e r e a r e t h e s e t i m e s a n d i t means s o m e t h i n g . A n d y o u know w i t h t h a t p a t i e n t i t h a s a l s o meant s o m e t h i n g . T h e e x i s t e n t i a l v a l u e s o f r e s p e c t , h o n e s t y , c a r i n g , b e i n g n o n - j u d g e m e n t a l , c o n s i s t e n c y , commi tment a n d empathy were r e p e a t e d l y s t a t e d a s t h e means o r c o n d i t i o n s t h e n u r s e s u s e d f o r c r e a t i n g t r u s t a n d r a p p o r t . T h e a c t u a l i z a t i o n o f t h e s e v a l u e s was s a t i s f y i n g t o n u r s e s . R a c h e l : . . . T h a t ' s t h e b i g g e s t t h i n g we h a v e t o do i n p s y c h i a t r y i s , w e l l what I d o , t h e s e c r e t , what I do i s , I c a n ' t r e a l l y . . . p u t m y s e l f i n t h e i r s h o e s b u t I t r y t o i m a g i n e what i t w o u l d be l i k e i f i t was one o f my c h i l d r e n o r b r o t h e r o r f a t h e r . T h a t ' s how I t h i n k a l o t a n d i t r e a l l y h e l p s when I f e e l f r u s t r a t e d a n d i m p a t i e n t a n d a l l t h o s e t h i n g s t h a t y o u a r e n a t u r a l l y g o i n g t o f e e l f r o m t i m e t o t i m e . . . I j u s t i m a g i n e what i t w o u l d be l i k e i f i t was my s o n o r b r o t h e r . A n d d e p e n d i n g on t h e p a t i e n t , we h a d a , n o t an e l d e r l y m a n , a 155 man i n h i s 60s who was c o n f u s e d and d i s o r i e n t e d a n d p r o b a b l y a l z h e i m e r and became v e r y a b u s i v e and a s s a u l t i v e w i t h u s . And i t ' s v e r y h a r d t o d e a l w i t h t h a t k i n d o f a b u s e . I t t u r n e d o u t a c t u a l l y t h e man was n o t a l z h e i m e r , i t was d r u g r e l a t e d . B u t t o d e a l w i t h t h a t I t h o u g h t - oh g e e h e ' s a b o u t t h e same age a s my f a t h e r . Y o u know s o t h a t h e l p s y o u t o k e e p some c o m p a s s i o n a n d e m p a t h y , I g u e s s . B r i g i t : . . . i f y o u t r e a t them w i t h r e s p e c t t h a t i s a p l u s f o r them a n d a p l u s f o r y o u a s w e l l . B e c a u s e I know a l o t o f c o - w o r k e r s o v e r a l l t h e y e a r s I ' v e w o r k e d i n p s y c h , y o u know t h e y a r e s o c o n t e m p t u o u s o f t h e p a t i e n t s . Y o u know i f y o u g i v e t h a t p e r s o n t h e b a s i c r e s p e c t and p o l i t e n e s s , a n d an a c k n o w l e d g m e n t t h a t t h e y a r e a human b e i n g t h a t w e ' r e a l l i n t h i s t o g e t h e r , k i n d o f , t h a t y o u u s u a l l y do g e t some k i n d o f r e s p e c t b a c k f r o m t h e p a t i e n t o r t h e y seem t o be a p p r e c i a t i v e o f b e i n g t r e a t e d l i k e a human b e i n g . . . I t ' s a l o o k on t h e i r f a c e o r how t h e y w i l l j u s t l o o k a t y o u . Y o u know t h e r e i s a c e r t a i n l o o k t h a t t h e y g e t w h e r e t h e r e i s d i r e c t e y e c o n t a c t o r t h e y w i l l s o m e t i m e s e n d a r e q u e s t w i t h an "I a p p r e c i a t e t h a t " I t ' s j u s t a 156 f e e l i n g t h a t i t ' s p a s s e d b e t w e e n y o u and t h e p a t i e n t . I ' v e r e a l l y s e e n t h a t h a p p e n q u i t e a b i t . Or e v e n an a c k n o w l e d g m e n t t h a t y o u know o f how t h e y ' r e f e e l i n g , l i k e a d e p r e s s e d p a t i e n t where y o u ' l l s a y " w e l l , y o u l o o k a b i t b e t t e r t o d a y " a n d o f t e n y o u ' l l h e a r a p a t i e n t s a y " w e l l l o o k s c a n be d e c e i v i n g " and I ' l l s a y , a n d , y o u know, I ' v e s a i d t h i s t o a few d e p r e s s e d p a t i e n t s , and i t ' s a m a z i n g how t h e r e s p o n s e y o u g e t . I ' l l s a y " I g u e s s i t ' s k i n d o f s c a r y b e c a u s e p e o p l e s a y y o u ' r e l o o k i n g b e t t e r a n d t h e y e x p e c t y o u t o s t a r t d o i n g a l o t o f t h i n g s t h a t maybe y o u r n o t q u i t e r e a d y b u t y o u know" y e a h y e a h t h a t h a p p e n s . A n d i t ' s j u s t t h e f a c t t h a t y o u a c k n o w l e d g e t h a t a n d c a r e e n o u g h t o know t h a t . T h a t t h e y a p p r e c i a t e t h a t . I f o u n d t h a t w i t h p a t i e n t s i f y o u a c k n o w l e d g e t h e i r f e e l i n g s t h e y a p p r e c i a t e t h a t o r t h e r e a c t i o n y o u g e t i s s u r p r i s e . . . B e c a u s e someone c a r e s t o n o t i c e o r t o e v e n m e n t i o n i t . T h e n e x t p a r t i c i p a n t t a l k e d a b o u t how s h e u s e s r e c r e a t i o n a l a c t i v i t i e s t o h e l p h e r c o n n e c t w i t h p a t i e n t s . By d o i n g s o s h e c o n v e y s t o t h e p a t i e n t s h e h a s some u n d e r s t a n d i n g o f t h e i r e x p e r i e n c e i n a way t h a t i s l e s s t h r e a t e n i n g f o r t h e m . 157 L i l y : ...I t a k e p e o p l e o u t f o r w a l k s a s much a s I c a n . . . p e o p l e w i l l o p e n up more i n t h e o u t d o o r s . We go p l a y f r i s b e e i n t h e p a r k a n d t h i n g s l i k e t h a t . . . F o r some r e a l l y w i t h d r a w n p e o p l e t h a t d o n ' t s p e a k a l o t t h a t ' s q u i t e a f e a t f o r them e v e n t o h a v e a s u p e r f i c i a l c o n v e r s a t i o n . So a w a l k i s v e r y t h e r a p e u t i c . . . In s u m m a r y , t h e e x p e r i e n c e o f s a t i s f a c t i o n i n r e l a t i o n s h i p s w i t h p a t i e n t s i s r e v e a l e d i n t h e n u r s e s ' a c c o u n t s . S a t i s f a c t i o n i s d e s c r i b e d a s h a v i n g a c h i e v e d t r u s t a n d r a p p o r t a n d i s m a r k e d by i n t i m a c y b e t w e e n n u r s e and p a t i e n t , r e c i p r o c i t y a n d a s e n s e o f h a v i n g a c t u a l i z e d o n e ' s v a l u e s and b e l i e f s . I t i s d e s c r i b e d a s i n s t a n c e s when t h e n u r s e s knew by t h e p a t i e n t ' s r e s p o n s e t h a t t h e i r p r e s e n c e was s i g n i f i c a n t t o t h e p a t i e n t a n d t h a t t h e p a t i e n t t r u s t e d t h e m . T h e E x p e r i e n c e o f P e r s o n a l a n d P r o f e s s i o n a l G r o w t h T h e n u r s e s ' d e s c r i p t i o n s o f t h e i r e x p e r i e n c e s w i t h p a t i e n t s r e v e a l e d t h a t t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s a n d c o l l e a g u e s i n t h e p s y c h i a t r i c c a r e s e t t i n g c o n t r i b u t e d t o t h e i r p e r s o n a l a n d p r o f e s s i o n a l g r o w t h . T h e y a l s o e x p e r i e n c e d t h e i r g r o w t h i n t h e i r e n c o u n t e r s w i t h p a t i e n t s . F o r some p a r t i c i p a n t s , i t was a s p e c i f i c p a t i e n t e x p e r i e n c e w h i l e f o r o t h e r s , i t was t h e c u l m i n a t i o n o f many e x p e r i e n c e s w i t h p a t i e n t s . Some 158 p a r t i c i p a n t s r e f e r r e d t o t h e s e e x p e r i e n c e s a s l e a r n i n g l e s s o n s w h i l e o t h e r s r e f e r r e d t o them a s g a i n i n g i n s i g h t s a b o u t t h e s e l f . C h a n g e s i n n u r s i n g p r a c t i c e were a t t r i b u t e d t o more e x p e r i e n c e a n d t o i n c r e a s e d k n o w l e d g e . T h e f o l l o w i n g p a r t i c i p a n t ' s d e s c r i p t i o n o f a r e c e n t p a t i e n t s i t u a t i o n i l l u s t r a t e s b o t h t h e p e r s o n a l a n d p r o f e s s i o n a l c h a n g e s f r e q u e n t l y r e v e a l e d by t h e p a r t i c i p a n t s . She d e s c r i b e s b e i n g more t h o u g h t f u l , r e f l e c t i v e , a n d a n a l y t i c a l a b o u t t h e p a t i e n t ' s b e h a v i o u r r a t h e r t h a n r e s p o n d i n g t o t h e b e h a v i o u r a l o n e . She a l s o d e s c r i b e s b e i n g more c o n f i d e n t w i t h h e r own a s s e s s m e n t s and i n t e r v e n t i o n s . On a p e r s o n a l l e v e l , s h e d e s c r i b e s b e i n g b e t t e r a b l e t o s e p a r a t e h e r s e l f f r o m t h e p a t i e n t ' s b e h a v i o u r a n d e x a m i n e i t more o b j e c t i v e l y a n d n o t a s a r e s p o n s e t o s o m e t h i n g s h e h a d s a i d o r d o n e . L e a h : One v e r y i n t e r e s t i n g e x a m p l e t h a t w o u l d i n d i c a t e a l o t o f t h e c h a n g e s t h a t h a v e o c c u r r e d i n my y e a r s o f p r a c t i c e was s o m e t h i n g t h a t h a p p e n e d on t h e weekend i n w o r k i n g w i t h a p a t i e n t . . . t h a t was q u i t e d i s t u r b e d and i t was v e r y i n t e r e s t i n g b e c a u s e o f t h e e m o t i o n a l r e s p o n s e t h a t I h a d t o t h e e x p e r i e n c e , t h a t was v e r y d i f f e r e n t now t h a n i t w o u l d h a v e b e e n e i g h t y e a r s a g o . T h e p a t i e n t came i n a n d f o r two o r t h r e e 159 d a y s was e x t r e m e l y a n g r y on a d m i s s i o n and my t e c h n i q u e was g i v i n g h e r s p a c e and j u s t o b s e r v i n g h e r b e h a v i o u r a n d when I a p p r o a c h e d h e r a n d s h e d i d n ' t want t o t a l k , I d i d n ' t f e e l o f f e n d e d , I d i d n ' t t a k e i t p e r s o n a l l y . R a t h e r I u s e d t h e w h o l e e x p e r i e n c e a s b e i n g an a s s e s s m e n t p u z z l e r a t h e r t h a n t a k i n g i t a s a r u d e b e h a v i o u r . Why was s h e r e a l l y d o i n g t h i s ? What was h a p p e n i n g ? T h e s t a f f a l l s a i d " o h b o y h e r e ' s a n o t h e r PD and s h e ' s a n g r y a n d m a n i p u l a t i n g " . A n d I s a i d " n o I d o n ' t t h i n k s o , my i n t e r p r e t a t i o n i s t h a t s h e ' s u s i n g i t a s a d e f e n s e m e c h a n i s m n o t o n l y t o w a r d s h e r own f e e l i n g s b u t t o w a r d s us a n d l e t ' s j u s t g i v e h e r t h e s p a c e and s e e what h a p p e n s ' . A n d t h a t c h a n g e i n t h i n k i n g i s v e r y d i f f e r e n t f r o m what i t w o u l d h a v e b e e n y e a r s ago f o r me. I t h i n k y e a r s ago I w o u l d h a v e r e a c t e d more t o t h e b e h a v i o u r r a t h e r t h a n b e i n g a b l e t o a n a l y z e why t h i s was h a p p e n i n g and f e e l i n g o k a y w i t h i t . . . d a y s i n t o t h e weekend t h e p a t i e n t b e g a n t o be q u i t e s e l f a b u s i v e . . . I f e l t t o t a l l y i n c o n t r o l o f t h e s i t u a t i o n . . . I knew what was g o i n g o n , t h e o t h e r n u r s e w a n t e d t o c a l l a c o d e , a n o t h e r one s a i d " I ' l l c a l l t h e d o c t o r f o r m e d i c a t i o n " a n d my i n i t i a l r e s p o n s e was a v e r y q u i c k a s s e s s m e n t o f 160 what was h a p p e n i n g w i t h t h i s p a t i e n t and b e c a u s e I h a d t h e f a c t s o f w h e r e s h e was c o m i n g f r o m i n h e r t h e r a p y I was a b l e t o i n t e r v e n e a n d I was a b l e t o be v e r y c a l m i n g f o r h e r , v e r y t h e r a p e u t i c i n s t e a d o f y e l l i n g a t h e r t o s t o p t h e b e h a v i o u r o r r e s t r a i n i n g o r d o i n g a n y t h i n g l i k e t h a t . . . i t was a v e r y s u p p o r t i v e r o l e a n d . . . I t h i n k t h a t s h i f t f o r me i n r o l e i s v e r y i n t e r e s t i n g b e c a u s e y e a r s ago I t h i n k I w o u l d h a v e r e a c t e d more t o t h e b e h a v i o u r a n d n o t . . . . I w o u l d h a v e p r o b a b l y d o n e t h e same t h i n g t h a t h a p p e n e d w i t h some o f t h e c o -n u r s e s . . . who were n o v i c e s and new g r a d s . . . . I w o u l d n o t h a v e h a d t h a t c o n f i d e n c e a n d p e r h a p s t h e a b i l i t y t o be o b j e c t i v e a n d make my own t r e a t m e n t a s s e s s m e n t s and p l a n s a s t o how I w a n t e d t o p r o g r e s s w i t h t h i s p a t i e n t . . . n o . P a r t i c i p a n t s t a l k e d a b o u t c h a n g e i n t h e i r p r a c t i c e i n t e r m s o f l e s s o n s t h e y h a d l e a r n e d . T h e s e l e s s o n s were m o s t f r e q u e n t l y g a i n e d d u r i n g e v e n t s o r s i t u a t i o n s t h a t s t a n d o u t a s s i g n i f i c a n t m a r k e r s i n t h e n u r s e s p r o f e s s i o n a l d e v e l o p m e n t . T h e y were o f t e n s i t u a t i o n s w h e r e t h e y were n o t s a t i s f i e d w i t h t h e i r p e r f o r m a n c e , h a d u s e d p o o r j u d g e m e n t o r h a d a c t e d i n ways t h a t were u n h e l p f u l t o p a t i e n t s . S a r a h : ...I remember o n c e l e a r n i n g , we h a d a l a d y 161 v e r y much l i k e t h e one I 'm d e s c r i b i n g , v e r y , v e r y p s y c h o t i c a n d s h e was i n s e c l u s i o n , we went i n t o m e d i c a t e h e r a n d s h e l o o k e d up a t me and s a i d t o me " o h S a r a h [ a c c e s s o r i e s ] a r e s o b e a u t i f u l " a n d b e f o r e I r e a l i z e d i t I 'm d i s c u s s i n g t h o s e damn [ a c c e s s o r i e s ] w i t h h e r , y o u know i t was t o t a l l y , t h a t w a s n ' t why we were t h e r e a n d I came o u t a f t e r w a r d s and somebody s a i d "why w o u l d y o u h a v e d o n e t h a t S a r a h , why w o u l d y o u s t a r t t a l k i n g a b o u t [ a c c e s s o r i e s ] when s h e h a d t o t a l l y d e s t r o y e d a room a n d was s t i l l r e a l l y s o v e r y d e s t r u c t i v e ? " A n d I s a i d "I d o n ' t know I d i d n ' t h e l p much b e c a u s e s h e k e p t g e t t i n g h i g h e r and h i g h e r t a l k i n g a b o u t t h e s e e a r r i n g s . I g u e s s I j u s t f e l t t h r e a t e n e d t h a t s h e was g o i n g t o do s o m e t h i n g i f I d i d n ' t r e s p o n d . " A n o t h e r p a r t i c i p a n t d i s c l o s e d t h a t a c r i t i c a l e v e n t i n h e r p r o f e s s i o n a l d e v e l o p m e n t was b e i n g a s k e d t o l e a v e a j o b b e c a u s e o f h e r l a c k o f m a t u r i t y w h i c h c o n t r i b u t e d t o p r o b l e m s i n h e r p e r f o r m a n c e . R e b e c c a : ...I h a v e n ' t a l w a y s l i k e d p s y c h i a t r y , I was a f r a i d o f i t t o b e g i n w i t h . I was y o u n g , I was o u t o f a s m a l l town i n O n t a r i o a n d grew up w i t h v a l u e s t h a t were v e r y n a r r o w , v e r y c l o s e d l i n e s a b o u t what was r i g h t a n d what was w r o n g , 162 most t h i n g s were w r o n g . . . I s t a r t e d w o r k i n g i n p s y c h i a t r y a n d d i s c o v e r e d t h a t t h e s e v a l u e s I h a d b r o u g h t i n t o t h e s i t u a t i o n j u s t w e r e n ' t s e r v i n g me a t a l l , t h e y d i d n ' t make s e n s e . . . I was a s k e d t o l e a v e t h a t j o b f o r t h e r e a s o n s I j u s t m e n t i o n e d . T h e h e a d n u r s e t o l d me I was n a i v e , I was t o o s e x u a l , t o o y o u n g . A n d a l t h o u g h I was q u i t e t i c k e d o f f a n d a n g r y , h u r t a t t h e t i m e , l o o k i n g b a c k s h e was r i g h t . I h a d a l o t o f g r o w i n g up t o d o . T h e i n t e r n a l j u d g e m e n t s I was m a k i n g a b o u t p a t i e n t s were n o t v a l i d umm t h e y were b a s e d on t h i s n a r r o w u p b r i n g i n g , t h e r e w a s n ' t , I n e e d e d t i m e t o grow up m y s e l f . . . I h a d t o go b a c k and r e a d d r e s s a l o t o f o l d v a l u e s . . . A n d i n a l o t o f c a s e s t h e y d i d n ' t make s e n s e . A n d g o i n g t h r o u g h a l l o f t h a t was r e a l l y h e l p f u l . When I s t a r t e d b a c k w o r k i n g i n p s y c h i a t r y t h i n g s h a d c h a n g e d i n s i d e me c o n s i d e r a b l y , a n d h a v e o n l y g o t t e n b e t t e r s i n c e . A l o t o f i s s u e s I w o u l d h a v e f o c u s e d a l l my a t t e n t i o n on 20 y e a r s ago I d o n ' t t h i n k a b o u t any m o r e . T h e y ' r e n o t i s s u e s , t h e y were n e v e r i s s u e s f o r t h e p a t i e n t s , t h e y s h o u l d n e v e r h a v e b e e n i s s u e s f o r me. F o r some p a r t i c i p a n t s c h a n g e i n t h e i r p r a c t i c e o c c u r r e d a s a r e s u l t o f i n s i g h t s g a i n e d when w o r k i n g w i t h 1 6 3 c e r t a i n p a t i e n t s . F o r e x a m p l e , S a r a h r e v e a l s h e r s t r u g g l e n u r s i n g a d o l e s c e n t p a t i e n t s a n d t h e i n s i g h t s s h e h a s g a i n e d a b o u t h e r s e l f i n t h e p r o c e s s . She a l s o r e v e a l s how d i f f i c u l t t h i s a d m i s s i o n was f o r h e r and how s h e h a s c h o s e n t o d e a l w i t h t h i s p r o b l e m . S a r a h : ...I do h a v e t r o u b l e w o r k i n g w i t h a d o l e s c e n t s a n d i n t h e a r e a I 'm w o r k i n g i n t h a t seems t o be a l r i g h t . T h e r e a r e t h e t i m e s I h a v e t o be a p r i m a r y t o an a d o l e s c e n t b u t n o t v e r y o f t e n . O v e r t h e y e a r s t h e p e o p l e I work w i t h a r e q u i t e w i l l i n g t o n e g o t i a t e . I t h i n k I go f r o m one e x t r e m e t o t h e o t h e r I am a l o v e l y k i n d , s w e e t l a d y t h e n I 'm a d i s c i p l i n a r i a n a n d t h e k i d s r e a l l y d o n ' t l i k e i t a t a l l . . . . I n t e r e s t i n g l y e n o u g h t h e same t h i n g h a p p e n e d when I was i n n u r s i n g s c h o o l I h a t e d w o r k i n g i n p a e d i a t r i c s , I ' v e n e v e r f e l t g o o d a b o u t p e d s , t h e c h i l d r e n u s e d t o g e t s o s i c k , oh g o d , I j u s t h a d d i f f i c u l t y w i t h i t a n d I ' v e h a d f i v e k i d s o f my own a n d n o n e o f my c h i l d r e n h a v e b e e n s i c k e x c e p t one and s h e w a s n ' t v e r y s i c k and i t was a v e r y s h o r t t i m e . I ' v e n e v e r d e a l t w i t h w h a t e v e r i t i s t h a t s c a r e s me a b o u t i t . I t ' s a l w a y s a c r i s i s , I h a v e r e a l d i f f i c u l t y s i t t i n g down a n d a l l o w i n g a l o t o f a d o l e s c e n t b e h a v i o u r , t h a t ' s n a t u r a l b e h a v i o u r . I want them t o c o n f o r m , 164 I h a v e t r o u b l e w i t h i t , and I go f r o m one e x t r e m e t o a n o t h e r . . . . I r e a l l y c a n ' t s t a n d t h a t c o n s t a n t c o n f l i c t , o r u n c e r t a i n t y , w h e t h e r t h e y a r e g o i n g t o b e a t y o u up o r g i v e y o u a b i g h u g . I h a v e b e e n a s s a u l t e d t h r e e t i m e s by a d o l e s c e n t s and I r e a l l y h a v e d i f f i c u l t y . I t t o o k me a l o n g t i m e i n my n u r s i n g c a r e e r t o s a y t h a t ' s n o t my f o r t e . . . . T h e n e x t p a r t i c i p a n t a l s o d e s c r i b e s a s p e c t s o f h e r s e l f s h e h a s become aware o f i n h e r r e l a t i o n s h i p s w i t h p a t i e n t s . R e b e c c a : . . . S o m e t h i n g I h a v e t o w a t c h o u t f o r i s an o v e r i n v o l v e m e n t c a u s e I know t h a t I c a n , I c a n d e v e l o p a l m o s t a m o t h e r r e l a t i o n s h i p i f I 'm n o t c a r e f u l , i f I 'm n o t w a t c h i n g . A n d t h e p a t i e n t e n d s up e x p e c t i n g , b e c a u s e I ' v e l e d them t o b e l i e v e , I was g o i n g t o be t h e r e f o r t h e m . So a g a i n , t h a t ' s s o m e t h i n g o v e r t h e l a s t f i v e o r s i x y e a r s t h a t I ' v e b e e n more a n d more aware o f . . . I ' v e h a d a c o u p l e o f r e l a t i o n s h i p s w i t h p a t i e n t s where I knew t h a t p a r t way t h r o u g h t h e demand on me was s o e x t r e m e and I ' d s e t i t up t h a t way m y s e l f . . . I r e s c u e t o o much . . . I 'm n o t a c o n f r o n t i v e k i n d o f t h e r a p i s t . I d o n ' t do i t w e l l and I d o n ' t do i t w i t h any c o n v i c t i o n and I u s u a l l y do i t w i t h a l o t o f g u i l t u n l e s s i t ' s v e r y 165 s p e c i f i c , c i r c u m s t a n c e s t h a t make c o m p l e t e s e n s e t o me. So y e a h , I go a t t h i n g s a s g e n e r a l l y v e r y s u p p o r t i v e s o i t ' s e a s y t o g e t s u c k e d i n t o b e i n g mum, r e a l l y f a s t . Some p a r t i c i p a n t s r e v e a l e d c h a n g e s i n s e l f a n d t h e i r p r a c t i c e by t e l l i n g t h e i n t e r v i e w e r a b o u t a s p e c t s o f t h e i r p r a c t i c e t h e y w o u l d n o t h a v e t a l k e d a b o u t e v e n j u s t a few y e a r s a g o . T h e s e d i s c l o s u r e s c e n t e r e d m a i n l y on t h e i s s u e o f v i o l e n c e a g a i n s t t h e n u r s e . T h e f o l l o w i n g p a r t i c i p a n t t e l l s t h e r e s e a r c h e r t h a t v i o l e n c e h a s a l w a y s e x i s t e d on p s y c h i a t r i c w a r d s b u t i t i s o n l y r e c e n t l y t h a t n u r s e s h a v e b e g u n t o t a l k a b o u t i t . She a t t r i b u t e s t h i s c h a n g e t o t h e c h a n g i n g r o l e o f t h e n u r s e . A n o t h e r p a r t i c i p a n t a t t r i b u t e s t h i s p a r t i c u l a r c h a n g e t o t h e " f e m i n i s t movement" w h i c h h a s b e g u n t o i n f l u e n c e t h e p r o f e s s i o n o f n u r s i n g , a p r o f e s s i o n s t i l l d o m i n a t e d by women. S a r a h : I t ' s a l w a y s b e e n t h e r e , i t ' s a l w a y s b e e n t h e r e , L i n d a . I t h i n k i t ' s j u s t r e c e n t l y t h a t w e ' v e b e e n a b l e t o t a l k a b o u t i t o r b r i n g i t o u t i n t h e o p e n t o a n y b o d y a n d e v e r y b o d y t h a t w a n t s t o l i s t e n . . . t h e r o l e o f t h e n u r s e i s c h a n g i n g a b i t and i t ' s c h a n g i n g t h a t y o u want t o be h e a r d . A n d maybe y o u ' v e come t o t h e s a t u r a t i o n p o i n t t h a t y o u c a n ' t t a k e any m o r e . T h a t i t ' s umm t h a t ' s n o t 166 r e a l l y why I 'm h e r e t o be h u r t . I h a v e some r i g h t s , I 'm h e r e t o h e l p and I 'm n o t h e r e t o h a v e my h e a d b e a t e n i n o r some o t h e r t h i n g s . Where a s b e f o r e I t h i n k t h a t was a s u b t l e m e s s a g e t h a t n u r s e s g o t t h a t t h a t was p a r t o f t h e i r j o b . And we b e l i e v e d i t ( l a u g h i n g ) . . . M o r e a n d more I l i s t e n t o what my b o d y s a y s t h e r e ' s a l l s o r t s o f s i g n s a n d s y m p t o m s , y o u come on a n d t h e w a r d ' s i n c h a o s , b e d s a r e n ' t m a d e , t h e n u r s i n g s t a t i o n i s a m e s s , y o u l o o k i n t h e k i t c h e n and t h e p e o p l e a r e s m o k i n g w h e r e e v e r t h e y want t o . . . a n d i f y o u i g n o r e t h o s e i t ' s e v e n more u n s a f e . T h e r e ' s no d o u b t i n my m i n d t h a t y o u ' v e g o t t o l i s t e n t o what y o u r b o d y i s s a y i n g a n d t h e t e n s e n e s s y o u know. I do more s a f e t y f a c t o r s now t h a n I ' v e e v e r d o n e i n my l i f e . W i t h l o c k i n g d o o r s and p u t t i n g on e x t r a l i g h t s , t h i s i s a t n i g h t . Y o u know a l l s o r t s o f t h i n g s j u s t t o p r o t e c t m y s e l f . . . . P a r t i c i p a n t s r e v e a l e d t h a t t h e y h a d t o become more r e a l i s t i c i n t h e i r e x p e c t a t i o n s o f s e l f a n d t h e d e g r e e t o w h i c h t h e y w o u l d be a b l e t o c h a n g e a n o t h e r p e r s o n . L e a h : ...I t h i n k when I f i r s t s t a r t e d t h e t y p e s o f r e l a t i o n s h i p s I h a d w i t h p a t i e n t s were a l m o s t f a l l i n g i n t o t h e c a t e g o r y o f c o - d e p e n d a n t . In t h e s e n s e t h a t I was v e r y i d e a l i s t i c and I g o t v e r y 167 c a u g h t up i n many o f my p a t i e n t s p r o b l e m s . I f o u n d i t v e r y h a r d t o d i s t i n g u i s h what my r o l e was a s a c l i n i c i a n a n d what I c o u l d do a s a h e l p e r and what I c o u l d do a s a f a c i l i t a t o r . A n d u l t i m a t e l y what h a s e v o l v e d i s my r o l e a s a f a c i l i t a t o r now. B u t i t h a s t a k e n 10 y e a r s f o r t h a t t o h a p p e n . . . my r e l a t i o n s h i p w i t h p a t i e n t s , i n t h e b e g i n n i n g , g o t t o a p o i n t w h e r e I w o u l d f e e l I was n o t d o i n g my j o b b e c a u s e o f my own u n r e a l e x p e c t a t i o n s t h a t I w o u l d h a v e . . . p a t i e n t p r o g r e s s was b a s e d on my v a l u e s y s t e m a n d n o t r e a l l y u n d e r s t a n d i n g what t h e p a t i e n t was s a y i n g o r w h e r e t h e y w e r e c o m i n g f r o m . R o s e : When I d i d o u t p a t i e n t p s y c h i a t r y f o r a w h i l e I h a d t h e s e p a t i e n t s who I f o l l o w e d p a t i e n t s f o r a l o n g t i m e umm f o r y e a r s p r o b a b l y and I d i d n ' t s e e v e r y many c h a n g e s i n them a t a l l . . . e v e n t u a l l y t h e y c h a n g e d b u t i t was t h e i r a g e n d a t h a t I was w o r k i n g w i t h i t w a s n ' t m i n e . A n d a s much a s I w o u l d t r y , t o b e g i n w i t h , t o f o r c e my g o a l s a n d my e x p e c t a t i o n s on t h e s e p e o p l e - - w e l l I d i d n ' t f o r c e them b u t , I r e a l i z e d t h a t I was c o m i n g o u t a g a i n s t b r i c k w a l l s a l l t h e t i m e a n d i t w a s n ' t r e a l i s t i c t o e x p e c t them t o do what I w a n t e d them t o d o . I t was more r e a l i s t i c t o 168 e x p e c t them t o do what t h e y w a n t e d t o do and h e l p them do i t . . . a l s o when I w o r k e d i n E n g l a n d i n a v e r y l a r g e p s y c h i a t r i c h o s p i t a l w i t h some v e r y v e r y c h r o n i c , v e r y v e r y s i c k p e o p l e . . . . S a r a h : . . . T h e e n d r e s u l t i s t h e y h a v e t o do i t t h e m s e l v e s b u t n o t l i k e y o u ' r e g o i n g t o j u s t go o u t a n d s a v e t h a t p e r s o n and t h e y ' r e n e v e r g o i n g t o come i n t o h o s p i t a l a g a i n b e c a u s e t h i s i s a l l what y o u d i d o r I d i d . Y o u know I ' v e n e v e r f e l t t h a t way , n e v e r f e l t t h a t way . On t h e o t h e r h a n d I know I ' v e h a d some p r e t t y b i g i m p a c t on some o f t h e p e o p l e I h a v e n u r s e d . . . b u t y o u d o n ' t g e t t h a t w i t h a l l y o u r p a t i e n t t h o u g h . . . my e x p e c t a t i o n s a r e a c e r t a i n q u a l i t y o f l i f e r a t h e r t h a n t o t a l q u a l i t y w h i c h i s u t o p i a a n d s o r t o f t h e " s a v i n g " . Y o u know i f t h a t ' s what y o u ' r e g o i n g t o do t h a t ' s u n r e a l i s t i c . What y o u ' d l i k e them t o h a v e a n d what t h e y c a n a c t u a l l y a c h i e v e a r e o f t e n f a r a p a r t . Some p a r t i c i p a n t s t a l k e d a b o u t b e c o m i n g " l e s s s e n s i t i v e " , h a r d e n e d t o t h e r e a l i t i e s o f p s y c h i a t r i c n u r s i n g . T h i s was r e v e a l e d a s b e i n g a b l e t o c o n d u c t a b i t o f a b a l a n c i n g a c t f o r t h e n u r s e s . On one h a n d t h e y c o p e d b e t t e r by b e c o m i n g l e s s s e n s i t i v e b u t on t h e 169 o t h e r h a n d some w o r r i e d t h a t t h e y w o u l d become o v e r l y h a r d a n d t h i s w o u l d i n t e r f e r e w i t h c a r i n g . B r i g i t : . . . A n o t h e r t h i n g a b o u t w o r k i n g i n p s y c h i a t r y t h a t y o u a l s o c a n ' t be t o o s e n s i t i v e o r e x p e c t p l e a s e s a n d t h a n k y o u s b e c a u s e , o r a t C h r i s t m a s y o u go t o o t h e r w a r d s a n d t h e r e ' s t o n s o f c h o c o l a t e s and g i f t s f r o m t h e p a t i e n t s and i n p s y c h i a t r y t h e s e p e o p l e b a s i c a l l y y o u c o u l d be h a e m o r r h a g i n g i n f r o n t o f them a n d " O h c o u l d I h a v e my c i g a r e t t e s p l e a s e ? " Y o u know, t h e y a r e v e r y c a u g h t up i n t h e m s e l v e s and t h a t ' s p s y c h i a t r y . A n d t o e x p e c t a l o t o f g r a t i t u d e o r r e c o g n i t i o n y o u ' r e n o t g o i n g t o g e t i t . T h a t d o e s n ' t b o t h e r me t o o m u c h . O c c a s i o n a l l y i f a p a t i e n t s a y s p l e a s e o r t h a n k y o u I go oh b o y t h a t was n i c e . . . I t d i d n ' t t a k e me t o o l o n g t o s e e t h e r e a l s i d e o f i t . T h e f o l l o w i n g e x c e r p t d e s c r i b e s t h e i n t r a p e r s o n a l s t r u g g l e n u r s e s c a n e x p e r i e n c e i n t r y i n g t o r e m a i n s e n s i t i v e t o p a t i e n t ' s e x p e r i e n c e w h i l e m a i n t a i n i n g t h e i r s e n s e o f i n t e g r a t i o n . B r i g i t d i s c l o s e s h e r c o n c e r n a b o u t b e c o m i n g l e s s s e n s i t i v e i n h e r r e a c t i o n s t o a p a t i e n t who c o m m i t t e d s u i c i d e w h i l e s h e was on d u t y . T h e s e r e a c t i o n s made h e r q u e s t i o n w h e t h e r s h e h a d become t o o h a r d e n e d . 170 B r i g i t : . . . I k e p t a n a l y z i n g why am I n o t r e a l l y u p s e t . A n d I w a s n ' t y o u know. I mean I f e l t r e a l l y b a d l y f o r t h e p o o r woman b u t t h i s woman h a d made up h e r m i n d t h a t t h i s i s what s h e was g o i n g t o d o . . . . B u t I k e p t t h i n k i n g , why a r e n ' t I u p s e t , why a r e n ' t I r e a l l y u p s e t l i k e T a n d V . A n d I s t i l l I d o n ' t know why I w a s n ' t e m o t i o n a l l y o v e r w r o u g h t . I mean a l l I was t h i n k i n g , t h e f i r s t t h i n g t h a t came t h r o u g h my h e a d w a s , Oh boy I hope I d o n ' t do a n y t h i n g i l l e g a l h e r e , y o u know l i k e make a m i s t a k e . L i k e was t h i s g o i n g t o l e a d t o an i n q u e s t w a s . . . a n d I j u s t t h o u g h t t h e c h a r t i n g a n d e v e r y t h i n g h a s t o be j u s t r i g h t on a n d I h a v e t o make s u r e I c o n t a c t a l l t h e r i g h t p e o p l e . Oh my g o d a n d y o u know t h a t was my f i r s t , a n d , I f e l t l i k e "am I a c o l d a n d c a l l o u s p e r s o n ? " b e c a u s e I w a s n ' t r e a l l y u p s e t b u t I d o n ' t t h i n k I am. I know I ' m n o t a c o l d a n d c a l l o u s p e r s o n . I t h i n k t h i s woman was i n h o r r i b l e d i s t r e s s t h a t t h e s e v o i c e s were j u s t t o r m e n t i n g h e r . . . . So I ' m j u s t , s o I t h o u g h t t o h a v e l i v e d s u c h a t o r m e n t e d l i f e was v e r y s a d b u t t h i s i s what s h e c h o s e t o d o . A n d i t ' s s o m e t h i n g s h e w a n t e d t o do a n d s o m e t h i n g s h e s u c c e e d e d a t d o i n g . A n d I j u s t s o r t o f h o p e d t h a t i t w a s n ' t p a i n f u l , I t h i n k i t was v e r y 171 i n s t a n t . . . I f e l t very s o r r y f o r her but I wasn't emotional I wasn't overwrought I wasn't c r y i n g and c a r r y i n g on you know. And i n f a c t , my f i r s t thought was the paperwork and I know that sounds c a l l o u s but t h a t ' s r e a l l y , I j u s t thought t h i s i s something I have to deal with and the woman i s dead and she wanted to be dead.... In summary, the nurses' d e s c r i p t i o n s r e v e a l that being i n r e l a t i o n s h i p s with p a t i e n t s p l a y s a s i g n i f i c a n t p a r t to both t h e i r personal and p r o f e s s i o n a l growth. P a r t i c i p a n t s ' d e s c r i b e d p r o f e s s i o n a l growth i n terms of being more r e f l e c t i v e , a n a l y t i c a l and r e a l i s t i c i n t h e i r p r a c t i c e s . Personal growth i n c l u d e d i n s i g h t s about the s e l f , one's s t r e n g t h s and l i m i t a t i o n s . Summary The nurses' l i v e d experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s are complex and many-sided. The s i x major themes of experience d e r i v e d from the nurses' accounts are: f e a r of being p h y s i c a l l y harmed; c o n f l i c t ; ambivalence i n r e l a t i o n s h i p s with p h y s i c i a n s ; sadness, disappointment, and f r u s t r a t i o n ; s a t i s f a c t i o n and personal and p r o f e s s i o n a l growth. A subtheme of a lack of a d m i n i s t r a t i v e support emerged i n c o n j u n c t i o n 172 with the theme of fear of being p h y s i c a l l y harmed. The s i x themes and subtheme of experience form part of the nurses' t o t a l experience with t h e i r r e l a t i o n s h i p s with p a t i e n t s . The deep s a t i s f a c t i o n they experience i s as much part of t h e i r experience as the int e n s e , negative c o n f l i c t s that are experienced c a r i n g f o r p a t i e n t s perceived as manipulative or demanding. In t h i s study, i t i s evident that the nurse-patient dyad i s not the so l e c r e a t o r of the nurses experiences i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s . The presence of nursing a d m i n i s t r a t o r s and p h y s i c i a n s i s a l s o p e r c e p t i b l e and cannot be separated out of the nurses' experiences with p a t i e n t s . The nurses a l s o experienced personal and p r o f e s s i o n a l growth i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s . This process of growth i s c o n t i n u a l l y being transformed and shapes a l l subsequent nurse-patient encounters. Six major themes and one subtheme were revealed i n the nurses' accounts of t h e i r experiences i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t care s e t t i n g s . The f i n d i n g s and i m p l i c a t i o n s of the study w i l l be discussed i n Chapter F i v e . 173 CHAPTER FIVE: DISCUSSION OF FINDINGS, IMPLICATIONS AND CONCLUSION OF THE STUDY D i s c u s s i o n o f F i n d i n g s T h i s s t u d y h a s e x p l o r e d n u r s e s ' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . T h e p h e n o m e n o l o g i c a l a p p r o a c h t o u n d e r s t a n d i n g t h e n u r s e s ' e x p e r i e n c e r e v e a l e d s i x m a j o r themes a n d one s u b t h e m e t h a t were common t o a l l e i g h t p a r t i c i p a n t s . T h e f i n d i n g s i n d i c a t e t h a t n u r s e s ' e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s a r e c o m p l e x a n d m u l t i f a c e t e d . T h i s f a c t i s s u p p o r t e d i n t h e l i t e r a t u r e r e v i e w i n t h i s s t u d y . W h i l e n u r s e s r e v e a l t h a t t h e i r e x p e r i e n c e s i n t h e s e r e l a t i o n s h i p s a r e s a t i s f y i n g a n d g r o w t h -e n h a n c i n g , t h e e x p e r i e n c e s o f f e a r o f b e i n g p h y s i c a l l y h a r m e d a n d o f c o n f l i c t a r e a l s o e s s e n t i a l c h a r a c t e r i s t i c s o f t h e i r e n c o u n t e r s a n d r e l a t i o n s h i p s w i t h p a t i e n t s . T h e n u r s e s ' a c c o u n t s a l s o r e v e a l t h a t p h y s i c i a n s and n u r s i n g a d m i n i s t r a t o r s , who a r e p a r t o f t h e s o c i a l o r g a n i z a t i o n o f i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s , a f f e c t and d e t e r m i n e t h e i r e x p e r i e n c e s w i t h p a t i e n t s . T h e r e l a t i o n s h i p b e t w e e n t h e n u r s e a n d t h e p a t i e n t i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s i s n o t s i m p l y a 174 t w o - p a r t y t r a n s a c t i o n . W h i l e c e r t a i n a s p e c t s o f t h e n u r s e s ' d e s c r i p t i o n s o f t h e i r e x p e r i e n c e s a r e c o n g r u e n t w i t h t h e t h e o r e t i c a l w o r k s and r e s e a r c h s t u d i e s d i s c u s s e d i n C h a p t e r 2 , t h e themes f o r m i n g t h e o v e r a l l d e s c r i p t i o n o f n u r s e s ' e x p e r i e n c e s a r e u n i q u e t o t h i s s t u d y . No one r e s e a r c h s t u d y d i s c u s s e d i n C h a p t e r 2 g a t h e r e d d a t a t h a t r e v e a l e d t h e r a n g e o f n u r s e s ' e x p e r i e n c e s i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . In t h e c u r r e n t s t u d y , n u r s e s r e p o r t e d t h a t f e a r o f b e i n g p h y s i c a l l y h a r m e d by p a t i e n t s was a l w a y s i n t h e b a c k g r o u n d . D a n g e r o u s , u n p r e d i c t a b l e b e h a v i o u r i s a r e a l i t y o f n u r s i n g i n i n p a t i e n t p s y c h i a t r i c c a r e s e t t i n g s . I n a d e q u a t e r e s o u r c e s a n d i n f o r m a t i o n and a l a c k o f a d m i n i s t r a t i v e s u p p o r t , p a r t i c u l a r l y d u r i n g and f o l l o w i n g v i o l e n t s i t u a t i o n s , f u r t h e r c o n t r i b u t e d t o t h e n u r s e s ' f e a r , a n g e r a n d s e l f - d o u b t . T h e s e d e s c r i p t i o n s a r e c o n g r u e n t w i t h some o f t h e d a t a g a t h e r e d i n s t u d i e s on o c c u p a t i o n a l s t r e s s i n p s y c h i a t r i c n u r s i n g d i s c u s s e d i n C h a p t e r 2 o f t h i s s t u d y (Dawki n s , D e p p , & S e l z e r , 1 9 8 5 ; T r y g s t a d , 1 9 8 6 ) . T h e r e s e a r c h l i t e r a t u r e on p a t i e n t p h y s i c a l a s s a u l t i n n u r s i n g d e s c r i b e s s i m i l a r a f f e c t i v e r e s p o n s e s t o p o t e n t i a l a n d a c t u a l p a t i e n t v i o l e n c e ( C o n n & L i o n , 1 9 8 3 ; D a w s o n , K e h i a y a n , K y a n k o , M a r t i n e z , 1 9 8 8 ; H o l d e n , 175 1985; Lanza, 1983, 1984, 1985, 1987; Morrison, 1987/88; Poster & Ryan, 1989; Roberts, 1991; Ryan & Poster, 1989). In the c u r r e n t study, p a t i e n t c h a r a c t e r i s t i c s of man i p u l a t i o n , non-compliance, dependency, demanding behaviour, d i s r e s p e c t , and a danger to others were c i t e d as c o n t r i b u t i n g to experiences of c o n f l i c t i n n u r s e - p a t i e n t encounters and sometimes f e a r of being p h y s i c a l l y harmed. A number of re s e a r c h e r s (Colson et a l . , 1985; G a l l o p , 1985; G a l l o p & Wynn, 1987; G l i c k , K l a r , & B r a f f , 1984; H a l l , 1972, 1977; Hig h l e y & N o r r i s , 1957; N e i l l , 1979; Newsom et a l , 1963; Rosenthal et a l , 1980; Sheets, Provost, Reihman, 1982; Sl a v i n s k y & Krass, 1980; S t o c k w e l l , 1972; Tudor, 1952; Uj h e l y , 1963) have a l l r e p o r t e d s i m i l a r p a t i e n t c h a r a c t e r i s t i c s as " d i f f i c u l t " f o r nurses and as c r e a t i n g problems i n the n u r s e - p a t i e n t r e l a t i o n s h i p . The d i a g n o s t i c l a b e l of p e r s o n a l i t y d i s o r d e r , s p e c i f i c a l l y b o r d e r l i n e p e r s o n a l i t y d i s o r d e r , which i s most commonly a s s o c i a t e d with these c h a r a c t e r i s t i c s was a l s o f r e q u e n t l y a s s i g n e d by the nurse to p a t i e n t s who cre a t e d c o n f l i c t s i n the n u r s e - p a t i e n t r e l a t i o n s h i p both i n t h i s study and i n the s t u d i e s c i t e d above. The nurses' accounts r e v e a l that the presence of p h y s i c i a n s ' i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s 176 o f t e n n e g a t i v e l y a f f e c t s t h e i r experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s and u l t i m a t e l y the p a t i e n t ' s care. P h y s i c i a n s were i d e n t i f i e d as s t r e s s o r s f o r nurses p a r t i c u l a r l y when they ignored the nurses i n p u t , made u n i l a t e r a l d e c i s i o n s , and provided i n s u f f i c i e n t or i n a p p r o p r i a t e medical care. T h i s phenomenon has been i d e n t i f i e d and d i s c u s s e d i n both the l i t e r a t u r e on o c c u p a t i o n a l s t r e s s and q u a l i t y work environments i n n u r s i n g ( A t t r i d g e & C a l l a h a n , 1987; Dawkins, Depp & S e l z e r , 1985; T r y g s t a d , 1986) and i n t h e o r e t i c a l works on the dynamics of the nurse-doctor r e l a t i o n s h i p (Englehardt, 1985; K a l i s c h & K a l i s c h , 1977; S t e i n , 1967; Zaslove, U n g e r l e i d e r & F u l l e r , 1968). The experience of s a t i s f a c t i o n has been e x p l i c a t e d from the nurses' accounts of t h e i r l i v e d experiences i n t h e i r r e l a t i o n s h i p with p a t i e n t s . Research f o c u s i n g on the experience of s a t i s f a c t i o n of nurses i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i s v i r t u a l l y n o n - e x i s t e n t i n both general and p s y c h i a t r i c n u r s i n g . In p s y c h i a t r i c n u r s i n g there have been v i r t u a l l y no s t u d i e s to which the f i n d i n g s of t h i s study c o u l d be compared. Research on nurses' work s a t i s f a c t i o n does e x i s t but c e n t r e s mainly on working c o n d i t i o n s , o c c u p a t i o n a l s t r e s s of nurses, shortage of nurses, and 177 inadequate compensation. The f i n d i n g s of the c u r r e n t study are however, r e f l e c t e d i n both the i n t e r p e r s o n a l and humanistic t h e o r i e s of n u r s i n g (Peplau, 1952, 1964, 1987, 1989; Orlando, 1971; Travelbee, 1971; and Paterson & Zderad, 1988). These t h e o r e t i c a l works are d e s c r i b e d i n Chapter 2 of t h i s study and form the conceptual framework f o r the study. The nurses' accounts r e v e a l that nurses, as co-p a r t i c i p a n t s i n t h e i r r e l a t i o n s h i p s with p a t i e n t s , experience the r e l a t i o n s h i p as s a t i s f y i n g and as a l e a r n i n g experience as i s d e s c r i b e d i n both e a r l y and cu r r e n t n u r s i n g theory. For example, Travelbee (1971), drawing from e x i s t e n t i a l p hilosophy, d e s c r i b e d n u r s i n g as an i n t e r p e r s o n a l process "an experience or happening, or s e r i e s of happenings between a nurse, an i n d i v i d u a l or group of i n d i v i d u a l s i n need of the a s s i s t a n c e the nurse can o f f e r " (p. 8). C h a r a c t e r i s t i c a l l y the r e l a t i o n s h i p i s a mutually s i g n i f i c a n t meaningful experience and through i t the n u r s i n g needs of p a t i e n t and/or f a m i l y are met. She l a b e l l e d these r e l a t i o n s h i p s human-to-human r e l a t i o n s h i p s b e l i e v i n g t h a t i n order to e s t a b l i s h r e l a t e d n e s s and respond e f f e c t i v e l y to the humanness of the other both "nurse and p a t i e n t " need to transcend t h e i r r o l e s . Nursing a c t i v i t i e s are the means to 178 e s t a b l i s h i n g r e l a t e d n e s s and the nurses' values and b e l i e f s determine the q u a l i t y of n u r s i n g care p r o v i d e d and the extent to which nurses are able to a s s i s t p a t i e n t s to f i n d meaning i n t h e i r s i t u a t i o n . Rapport i s d e f i n e d as a l l those experiences, thoughts, f e e l i n g s and a t t i t u d e s t h at both nurse and p a t i e n t l i v e through and are ab l e to p e r c e i v e , share and communicate. I t i s the a b i l i t y to a p p r e c i a t e the "human-ness" of the other, the c a p a c i t y to be, as opposed to doing. It i s an openness to experience. Travelbee (1971) d e s c r i b e s rapport as moments of r e l a t e d n e s s "permeated by a type of ambient, enveloping, a l l p e r v a s i v e q u i e t n e s s and understanding of each to the oth e r " (p. 153). The nurses' accounts r e v e a l e d that the achievement of t r u s t and rapport with p a t i e n t s i s what r e a l l y matters to them and i s t h e i r major source of s a t i s f a c t i o n . They r e v e a l e d that even though i t would be n i c e to see p a t i e n t s cured of t h e i r mental h e a l t h problems, t h i s was not always r e a l i s t i c and that i f , at l e a s t , a r e l a t i o n s h i p can be e s t a b l i s h e d or they are "with" a p a t i e n t through an experience of i l l n e s s or r e l a p s e they have been h e l p f u l . S a t i s f a c t i o n i s d e s c r i b e d as i n s t a n c e s when the nurse knew by the p a t i e n t ' s response that she had made a d i f f e r e n c e and that the p a t i e n t t r u s t e d her. What remains u n c l e a r 179 however, i s whether these r e l a t i o n s h i p s are experienced as e x i s t e n t i a l r e l a t i o n s h i p s of I and Thou as d e s c r i b e d by T r a v e l b e e (1971) and Paterson and Zderad (1988). The nurses d e s c r i b e d a k i n d of being, a being "with" p a t i e n t s and a being " t h e r e " f o r p a t i e n t s which i n v o l v e s the nurse's a c t i v e presence i n the r e l a t i o n s h i p but d e s c r i p t i o n s of an I and Thou r e l a t i o n s h i p where there i s an exchange of two persons t r a n s c e n d i n g themselves and p a r t i c i p a t i n g i n the other's being; "a mutual common union i n b e i n g " (Paterson & Zderad, 1988, p.121) are r a r e l y r e v e a l e d . More o f t e n , the nurses' accounts r e v e a l e d a l a c k of r e c o g n i t i o n , thanks, p r a i s e , or a p p r e c i a t i o n of t h e i r presence i n t h e i r r e l a t i o n s h i p s with p a t i e n t s . Another c h a r a c t e r i s t i c of the n u r s e - p a t i e n t r e l a t i o n s h i p , d i s c u s s e d i n Chapter 2 of t h i s study, i s the a b i l i t y of the nurse to use h i m / h e r s e l f t h e r a p e u t i c a l l y i n the h e l p i n g process (Peplau, 1952; T r a v e l b e e , 1971). In t h i s study the nurses p e r c e i v e d themselves as instruments of change. They s t a t e d that they used themselves as well as t h e i r n u r s i n g s k i l l s and knowledge i n h e l p i n g p a t i e n t s deal with t h e i r mental h e a l t h problems. The nurses b e l i e v e d that p a t i e n t improvement, however small i t was, was d i r e c t l y r e l a t e d to t h e i r , or o t h e r s ' involvement with the 180 p a t i e n t . They re p e a t e d l y expressed the importance of being r e s p e c t f u l , honest, empathic, c a r i n g and c o n s i s t e n t i n the performance of a l l n u r s i n g a c t s even though t h i s was extremely c h a l l e n g i n g at times. They viewed these as the means they used to achieve t r u s t and r a p p o r t . The nurses a l s o c o n s i d e r e d the t e c h n i c a l and n u r t u r i n g aspects of t h e i r r o l e , such as h e l p i n g p a t i e n t s meet t h e i r b a s i c needs f o r n u t r i t i o n , r e s t , a c t i v i t y and s a f e t y as s i g n i f i c a n t and necessary to the establishment of r e l a t e d n e s s . I t would seem t h e r e f o r e that the t h e r a p e u t i c use of s e l f i s not always a c t u a l i z e d under the category of therapy or i n the c o u n s e l l i n g of p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . The t h e r a p e u t i c use of s e l f i s a l s o used i n the s t r u c t u r i n g of s p e c i f i c n u r s i n g i n t e r v e n t i o n s which c a l l f o r the nurse to use both h e r s e l f and her s p e c i a l i z e d n u r s i n g s k i l l s and knowledge. Some n u r s i n g t h e o r i s t s (Benner, 1986; C a r t e r , 1986; Lego, 1986; Westwell & McCay, 1988 & W i l l i a m s , 1974) suggest that c e r t a i n events i n the wider s o c i a l context and changes i n n u r s i n g i d e o l o g i e s are eroding the t h e r a p e u t i c r o l e of the nurse. They suggest t h a t the h i s t o r i c a l n u r s i n g values rooted i n human care are threatened by d e i n s t i t u t i o n a l i z t i o n , the r e m e d i c a l i z a t i o n of p s y c h i a t r y and technology. The 181 f i n d i n g s of the c u r r e n t study do not r e f l e c t such a t r e n d i n p s y c h i a t r i c n u r s i n g p r a c t i c e . The nurses' accounts r e v e a l e d that they valued t h e i r t h e r a p e u t i c r o l e , s p e c i f i c a l l y the t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p . They acknowledged that t h e r a p e u t i c r e l a t i o n s h i p s are sometimes d i f f i c u l t to a c t u a l i z e i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s but that they approach each p a t i e n t w i t h the goal of e s t a b l i s h i n g a t h e r a p e u t i c r e l a t i o n s h i p . Events such as d e i n s t i t u t i o n a l i z a t i o n and the r e m e d i c a l i z a t i o n of p s y c h i a t r y were r a r e l y mentioned by the p a r t i c i p a n t s as events or f a c t o r s i n h i b i t i n g or l i m i t i n g the formation of t h e r a p e u t i c r e l a t i o n s h i p s . P a t i e n t c h a r a c t e r i s t i c s were c i t e d more f r e q u e n t l y as i n h i b i t i n g the formation of t h e r a p e u t i c r e l a t i o n s h i p s . Only one p a r t i c i p a n t made a connection between p a t i e n t c h a r a c t e r i s t i c s and the d e i n s t i t u t i o n a l i z a t i o n of p s y c h i a t r i c p a t i e n t s . She s t a t e d that p a t i e n t s admitted to i n p a t i e n t p s y c h i a t r i c care s e t t i n g s of general h o s p i t a l s were " s i c k e r " than b e f o r e because there were i n s u f f i c i e n t community resources to c a t c h them at e a r l i e r stages of t h e i r i l l n e s s e s . For a c l e a r e r understanding of the p e r c e i v e d e f f e c t s of these phenomenon on the t h e r a p e u t i c r o l e of the nurse i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s f u r t h e r study i s r e q u i r e d . 182 Personal Meanings of the Study At the beginning of the study I revealed that my own personal experiences as a nurse and nurse educator i n inpat ient p s y c h i a t r i c care set t ings was what f i r e d th i s study. In addi t ion to generating valuable ins ights about nurses' experiences i n t h e i r re la t ionsh ips with pat ients i n inpat ient p s y c h i a t r i c care set t ings I hoped that such a study would also va l ida te my own experiences. As I re f l ec ted on the expl icated themes of experience I was both surpr ised at the di f ferences and re l i eved by the s i m i l a r i t i e s of the nurses' experiences to my own. I was p a r t i c u l a r l y re l i eved to hear that nurses feared being phys i ca l l y harmed and that th i s fear i s always i n the background and that I was nei ther strange or alone i n th i s experience. I was however, surpr ised at how open the nurses were regarding t h e i r fee l ings surrounding actual and potent ia l acts of v io lence i n inpat ient un i t s . I have always f e l t that admitting to fee l ings of v u l n e r a b i l i t y , such as fear , anger, inadequacy and se l f -doubt , about actual and potent ia l acts of v iolence was a taboo subject i n p s y c h i a t r i c nurs ing . That to do so would be equated to being incompetent or as someone that could not be r e l i e d on during such times of c r i s i s . That somehow 183 t h i s was p a r t of the job and that i f one could not handle i t one should not work i n p s y c h i a t r i c n u r s i n g . I was ple a s e d to l e a r n that the nurses i n t h i s study d i d not share my p e r c e p t i o n and that i n f a c t were demanding more o p p o r t u n i t i e s to t a l k about t h e i r f e e l i n g s surroundings i n c i d e n t s of v i o l e n c e . I a l s o had a profound experience d u r i n g the a n a l y s i s process i n the d i s c o v e r y that I was r e s i s t i n g the i n c l u s i o n of one of the themes, s p e c i f i c a l l y the theme of c o n f l i c t . I r e a l i z e d that I wanted to di s c o u n t t h i s i n f o r m a t i o n because I thought i t made nurses r e l a t i o n s h i p s with p a t i e n t s look bad. For me, i t r e v e a l e d what I p e r c e i v e d were d e f i c i e n c i e s i n t h e i r i n t e r p e r s o n a l s k i l l s . I a l s o f e l t t h a t the s t r a t e g i e s they d e s c r i b e d u s i n g to deal with " d i f f i c u l t p a t i e n t s " were mainly s e l f - p r o t e c t i v e r a t h e r than t h e r a p e u t i c . T h i s awareness and my acceptance of c o n f l i c t as a theme of experience helped me r e a l i z e t h at I was unc o n s c i o u s l y attempting to present the nurses i n the best l i g h t p o s s i b l e and that somehow to do otherwise was a l s o a r e f l e c t i o n on me as a nurse. It i s my b e l i e f t h at the eventual i n c l u s i o n of the theme of c o n f l i c t i n t o my f i n a l d e s c r i p t i o n of the nurses' experiences c o n t r i b u t e s to a more ac c u r a t e , r i c h e r and v i b r a n t d e s c r i p t i o n of the nurses' experiences i n t h e i r 184 r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . Implications of the Study The purpose of t h i s phenomenological study was to explore and d e s c r i b e nurses' p e r c e p t i o n s of t h e i r experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c are s e t t i n g s , w i t h the aim of uncovering knowledge and understanding of t h i s phenomenon. The f i n d i n g s of the study suggest some i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , a d m i n i s t r a t i o n , education and re s e a r c h . Nursing P r a c t i c e The themes of f e a r of being p h y s i c a l l y harmed and of c o n f l i c t r e v e a l that c a r i n g f o r p a t i e n t s with mental h e a l t h problems presents nurses with many c h a l l e n g e s . R e l a t i n g to p a t i e n t s whose behaviour i s experienced as f r i g h t e n i n g , c o n f l i c t u a l , annoying, and a n x i e t y -provoking o f t e n make i t d i f f i c u l t f o r nurses to f u l f i l t h e i r p r o f e s s i o n a l r o l e that i s , to r e l a t e f u l l y to p a t i e n t s and s t i l l m a i n t a in t h e i r own personal i n t e g r a t i o n . The b u i l d i n g of a personal support system and development of coping s k i l l s are e s s e n t i a l . Although the use of peers can be i n v a l u a b l e i n p r o v i d i n g emotional support and feedback a d d i t i o n a l recommendations are suggested. These are: 185 1. The implementation of i n f o r m a l v o l u n t a r y peer support groups or support networks to help nurses to cope with d i f f i c u l t p a t i e n t s . 2. The implementation of team b u i l d i n g s t r a t e g i e s , such as d a i l y team conferences, buddy systems, and p e r c e p t o r s h i p s f o r new s t a f f to p r o v i d e f o r the s h a r i n g of i n f o r m a t i o n and the g i v i n g and r e c e i v i n g of a f f i r m i n g feedback and support. 3. The use of s u p e r v i s i o n , the "process by which a nurse of l e s s e r experience i s a s s i s t e d by a nurse c l i n i c i a n of g r e a t e r experience to develop s e l f -awareness and t h e r a p e u t i c s k i l l s " (Beck, Rawlins, & W i l l i a m s , 1988, p. 1464), to help nurses grow i n p r o f e s s i o n a l competence, confidence and s a t i s f a c t i o n . 4. The implementation of master's l e v e l mental h e a l t h / p s y c h i a t r i c c l i n i c a l nurse s p e c i a l i s t s i n p s y c h i a t r i c care s e t t i n g s . As experts i n c l i n i c a l p r a c t i c e and p o s s e s s i n g of i n depth knowledge of p s y c h i a t r i c n u r s i n g c l i n i c a l s p e c i a l i s t s c o u l d p r o v i d e s u p e r v i s i o n , education, and c o n s u l t a t i o n to nurses who have been prepared at the g e n e r a l i s t l e v e l , which g e n e r a l l y means they have r e c e i v e d minimal p s y c h i a t r i c n u r s i n g experience and t h e o r e t i c a l content i n t h e i r e d u c a t i o n a l programs. 5. The undertaking of personal c o u n s e l l i n g by nurses 186 to a s s i s t them to develop h e a l t h y coping s t r a t e g i e s and as a method f o r improving t h e i r i n t e r p e r s o n a l e f f e c t i v e n e s s by e x p l o r i n g b l i n d s p o t s , b e l i e f s , v a l u e s , world views and v u l n e r a b i l i t i e s t h a t may c o n t r i b u t e to the d i f f i c u l t i e s t h a t they experience i n t h e i r r e l a t i o n s h i p s with p a t i e n t s . Nursing A d m i n i s t r a t i o n The n u r s i n g a d m i n i s t r a t o r ' s r o l e i n c r e a t i n g or enhancing a s u p p o r t i v e c l i m a t e i n h o s p i t a l s has been r e p e a t e d l y r e p o r t e d i n n u r s i n g l i t e r a t u r e (Brenner et a l , 1982; M a l l i s o n , 1988; McClure et a l , 1983). The c u r r e n t study's f i n d i n g s are important f o r n u r s i n g a d m i n i s t r a t i o n because they p r o v i d e n u r s i n g a d m i n i s t r a t o r s with the nurses' p e r s p e c t i v e of t h e i r experiences with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care u n i t s . The nurses' accounts r e v e a l that they p e r c e i v e a l a c k of a d m i n i s t r a t i v e support i n c a r i n g f o r p a t i e n t s with mental h e a l t h problems. The importance of s o c i a l support f o r nurses has been acknowledged f o r some time, " s i n c e nurses are o f t e n so i n need of support themselves they are unable to g i v e support to t h e i r p a t i e n t s " (Michaels, 1971, p. 1932). The l i t e r a t u r e on s o c i a l support (Cobb, 1976; Kahn, 1979; Weiss, 1974) d e f i n e s s o c i a l support as the p r o v i s i o n of s o c i a l r e l a t i o n s h i p that i n c l u d e s 187 components such as a sense of s e c u r i t y and p l a c e ; the ex p r e s s i o n of p o s i t i v e a f f e c t of one person toward another ( c a r i n g , r e s p e c t , l o v e ) ; the a f f i r m a t i o n or endorsement of another's behaviours, p e r c e p t i o n s or expressed views; and the g i v i n g of m a t e r i a l and symbolic a i d to another and guidance from a trustworthy and a u t h o r i t a t i v e person i n s t r e s s f u l s i t u a t i o n s . The nurses' accounts r e v e a l the need f o r g r e a t e r s o c i a l support from head nurses and n u r s i n g s u p e r v i s o r s i n the form of i n f o r m a t i o n and m a t e r i a l a i d s ; emotional support and help p a r t i c u l a r l y d u r i n g and a f t e r c r i s i s s i t u a t i o n s ; and reassurance and c o n f i r m a t i o n of t h e i r worth as nurses. A t t r i d g e and C a l l a h a n (1987) s t a t e : support p r o v i d e s reward, valu e , r e s p e c t and c a r i n g to p r o f e s s i o n a l s who [work] i n d i f f i c u l t and demanding... s i t u a t i o n s . . . . Nurses who f e e l supported can handle many d i s t r e s s i n g circumstances.... Nurses who do not p e r c e i v e support i n t h e i r work are o f t e n harassed, i n c o n f l i c t and experience l a c k of reward, value and r e s p e c t , a s i t u a t i o n which u l t i m a t e l y a f f e c t s view of s e l f as a worthwhile human being l e t alone as a des e r v i n g p r o f e s s i o n a l , (p. 36) The r e g u l a r p r o v i s i o n of h o s p i t a l i n s e r v i c e 188 programs f o c u s i n g on p s y c h i a t r i c n u r s i n g content i s recommended, p a r t i c u l a r l y ongoing s t a f f t r a i n i n g and education i n the management of a g g r e s s i v e p a t i e n t s . T r a i n e d emergency response teams f o r s i t u a t i o n s i n v o l v i n g p a t i e n t v i o l e n c e i s recommended. D e b r i e f i n g s e s s i o n s l e d by s k i l l e d group f a c i l i t a t o r s or c o u n s e l l o r s f o r s t a f f i n v o l v e d i n a s s a u l t s i t u a t i o n s i s a l s o recommended. Nursing Education The nurses' accounts r e v e a l e d t h a t developing t h e r a p e u t i c r e l a t i o n s h i p s with p a t i e n t s p e r c e i v e d as m a n i p u l a t i v e , non-comp1iant, dependent, demanding, d i s r e s p e c t f u l and dangerous to others was d i f f i c u l t . T h e r e f o r e the major i m p l i c a t i o n of t h i s f i n d i n g i s to i n c r e a s e the emphasis i n n u r s i n g c u r r i c u l a on the i n t e r p e r s o n a l dynamics and management of these behaviours, the s e l f awareness of the nurse, t r a n s f e r e n c e and c o u n t e r t r a n s f e r e n c e r e a c t i o n s and r e l a t i o n s h i p b u i l d i n g s k i l l s . The use of t e a c h i n g s t r a t e g i e s that promote i n t r o s p e c t i o n , c r i t i c a l t h i n k i n g and i n t e r a c t i v e s k i l l s development are a l s o recommended. Bevis (1989) suggests the i n c r e a s e d use of process education as a t e a c h i n g s t r a t e g y i n n u r s i n g , education to a s s i s t student i n the t r a n s f e r of knowledge and s k i l l s to the c l i n i c a l s i t u a t i o n . 189 G u l i n o (1982) proposes the e x p l o r a t i o n and use of e x i s t e n t i a l thought i n n u r s i n g education to help n u r s i n g students "grapple with those aspects of experience that are uniquely human and s u b j e c t i v e and that o f t e n become l o s t to her conscious awareness" (p. 357). G u l i n o suggests a move beyond the o b j e c t i v e the problem-oriented method, so widely taught i n n u r s i n g education programs to methods which encourage and prepare students to become more r e f l e c t i v e and c r i t i c a l i n t h e i r n u r s i n g p r a c t i c e . G u l i n o (1982) adds that " e x i s t e n t i a l i s m poses questions the nurse should c o n s i d e r when she i s immersed i n the c l i n i c a l s i t u a t i o n ; i t can generate q u e s t i o n s that w i l l move her to examine her c h o i c e s , and prepare her, at l e a s t i n some t e n t a t i v e sense, f o r the d i f f i c u l t r e a l i t y " (p. 259). Nursing p a t i e n t with complex mental h e a l t h problems r e q u i r e s more than a s e t of p r e s c r i b e d i n t e r v e n t i o n t a c t i c s . It r e q u i r e s a use of the s e l f b eginning with the c a p a c i t y to step o u t s i d e the s e l f to grasp the experience of the other. Nursing education programs at both the b a c c a l a u r e a t e and masters degree l e v e l have been slow to develop and o f f e r n u r s i n g degrees with a c l i n i c a l f o cus. The f i n d i n g s of t h i s study, p a r t i c u l a r l y those f i n d i n g s which r e l a t e to the theme of c o n f l i c t , suggest 190 that indepth study and c l i n i c a l l y s u p e r v i s e d p r a c t i s e i n d e a l i n g with p a t i e n t s with complex mental h e a l t h problems i s r e q u i r e d by nurses working i n p s y c h i a t r i c care s e t t i n g s . Nursing Research T h i s study has p r o v i d e d i n s i g h t s about nurses' experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . In view of these f i n d i n g s , areas f o r f u r t h e r study are suggested: 1. Study p a r t i c u l a r aspects of nurses' experience with p a t i e n t s i n i n p a t i e n t care s e t t i n g s i n more depth, f o r example, f e a r of being p h y s i c a l l y harmed. 2. Study nurses' experiences i n a p a r t i c u l a r phase of the n u r s e - p a t i e n t r e l a t i o n s h i p , as d e s c r i b e d by Peplau (1952), as i t e x i s t s i n i n p a t i e n t p s y c h i a t r i c are s e t t i n g s . 3. Study nurses' p e r c e p t i o n s of a d m i n i s t r a t i v e support i n n u r s i n g p a t i e n t s with mental h e a l t h problems i n i n p a t i e n t u n i t s . 4. Do a phenomenological study e x p l o r i n g p a t i e n t s ' p e r c e p t i o n s of t h e i r experiences with p s y c h i a t r i c urses on i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . C o n c l u s i o n The purpose of t h i s phenomenological study was to 191 e x p l o r e and understand nurses' p e r c e p t i o n s of t h e i r experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . E i g h t female r e g i s t e r e d nurses c u r r e n t l y employed i n p s y c h i a t r i c care s e t t i n g s were i n t e r v i e w e d . Data c o l l e c t i o n and data a n a l y s i s proceeded c o n c u r r e n t l y u n t i l a l l p a r t i c i p a n t s had been i n t e r v i e w e d twice. T e n t a t i v e themes i d e n t i f i e d from the f i r s t s e t of i n t e r v i e w s were v e r i f i e d and e l a b o r a t e d on i n the second set of i n t e r v i e w s . The f i n a l a n a l y s i s produced s i x major themes and one subtheme that were common to a l l e i g h t p a r t i c i p a n t s and which represent the e s s e n t i a l f e a t u r e s of the nurses' experiences i n t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c are s e t t i n g s . A d e s c r i p t i o n of these experiences p r o v i d e s i n s i g h t i n t o nurses' r e l a t i o n s h i p s with p a t i e n t s and the meaning these have f o r them. T h i s knowledge a l s o sheds l i g h t on the p r a c t i c e of p s y c h i a t r i c n u r s i n g i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . The study does not assume that t h i s d e s c r i p t i o n of the nurses' experiences encompasses the experiences of a l l nurses' r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . The study does not represent a s i n g u l a r , d e f i n i t i v e understanding and i n t e r p r e t a t i o n of the nurses' experience. I t p r o v i d e s a beginning 192 understanding of t h i s complex phenomenon and a s t a r t i n g p o i n t f o r more i n depth study. References 193 Adams, G. & M a c l l w r a i t h , P. (1983). G e r i a t r i c n u r s i n g . 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American  Journal of P s y c h i a t r y , 125 (73), 482-486. 213 Appendix A American Nursing Association Standards of Psychiatric  and Mental Health Nursing Practice 214 American Nursing A s s o c i a t i o n Standards of P s y c h i a t r i c  and Mental H e a l t h Nursing P r a c t i c e P r o f e s s i o n a l P r a c t i c e Standards Standard 1 Theory The nurse a p p l i e s a p p r o p r i a t e theory that i s s c i e n t i f i c a l l y sound as a b a s i s f o r d e c i s i o n s r e g a r d i n g n u r s i n g p r a c t i c e Standard 2 Data c o l l e c t i o n The nurse c o n t i n u o u s l y c o l l e c t s data that are comprehensive, a c c u r a t e , and s y s t e m a t i c . Standard 3 Diagnosis The nurse u t i l i z e s n u r s i n g d i a g n o s i s and/or standard c l a s s i f i c a t i o n of mental d i s o r d e r s to express c o n c l u s i o n s supported by recorded assessment data and c u r r e n t s c i e n t i f i c premises. Standard 4 Planning The nurse develops a n u r s i n g care p l a n with s p e c i f i c g o a l s and i n t e r v e n t i o n s d e l i n e a t i n g n u r s i n g a c t i o n s unique to each c l i e n t ' s needs. Standard 5 I n t e r v e n t i o n The nurse i n t e r v e n e s as guided by the n u r s i n g care p l a n to implement n u r s i n g a c t i o n s that promote, ma i n t a i n , o r r e s t o r e p h y s i c a l and mental h e a l t h , prevent i l l n e s s , a n d e f f e c t r e h a b i l i t a t i o n . Standard 5A Psychotherapeutic I n t e r v e n t i o n s The nurse uses p s y c h o t h e r a p e u t i c i n t e r v e n t i o n s to a s s i s t c l i e n t s i n r e g a i n i n g or improving t h e i r p r evious coping a b i l i t i e s and to prevent f u r t h e r d i s a b i l i t y Standard 5B H e a l t h Teaching The nurse a s s i s t s c l i e n t s , f a m i l i e s , and groups to achieve s a t i s f y i n g and p r o d u c t i v e p a t t e r n s of l i v i n g through h e a l t h t e a c h i n g . Standard 5C A c t i v i t i e s of D a i l y L i v i n g The nurse uses the a c t i v i t i e s of d a i l y l i v i n g i n a g o a l - d i r e c t e d way to f o s t e r adequate s e l f - c a r e and p h y s i c a l and mental well being of c l i e n t s . Standard 5D Somatic Therapies The nurse uses knowledge of somatic t h e r a p i e s and a p p l i e s r e l a t e d c l i n i c a l s k i l l s i n working with c l i e n t s . 215 Standard 5E T h e r a p e u t i c Environment The nurse p r o v i d e s , s t r u c t u r e s , and maintains a t h e r a p e u t i c environment i n c o l l a b o r a t i o n with the c l i e n t and other h e a l t h care p r o v i d e r s . Standard 5F Psychotherapy The nurse u t i l i z e s advanced c l i n i c a l e x p e r t i s e i n i n d i v i d u a l , group, and f a m i l y psychotherapy, c h i l d psychotherapy, and other treatment m o d a l i t i e s to f u n c t i o n as a p s y c h o t h e r a p i s t , and recognizes p r o f e s s i o n a l a c c o u n t a b i l i t y f o r n u r s i n g p r a c t i c e . Standard 6 E v a l u a t i o n The nurse evaluates c l i e n t responses to n u r s i n g a c t i o n i n order to r e v i s e the data base, n u r s i n g d i a g n o s i s , and n u r s i n g care plan.(American Nurses' A s s o c i a t i o n , 1982) 2 1 6 Appendix B Personal Assumptions 217 Personal Assumptions Nurses' P e r c e p t i o n s of t h e i r Experiences Working with Patents i n I n p a t i e n t P s y c h i a t r i c Care S e t t i n g s . The f o l l o w i n g i s a l i s t of the personal assumptions I brought to the study. These i n c l u d e the themes of experience I expected would be r e v e a l e d or hoped would r e v e a l e d i n the nurses' accounts. 1. That nurses would experience t h e i r r e l a t i o n s h i p s with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s as rewarding and g r a t i f y i n g . 2. That nurses would d e s c r i b e t h e i r experiences with p a t i e n t s as c h a l l e n g i n g and e x c i t i n g . 3. That nurses would r e v e a l experiences of burn out, of low involvement with p a t i e n t s and a l a c k of enthusiasm. 4. That nurses would r e v e a l experiences of f e e l i n g inadequate and incompetent. 5. That nurses would r e v e a l f e e l i n g s of anger at the lack of f i n a n c i a l rewards and r e c o g n i t i o n f o r doing such a d i f f i c u l t job. 6. That nurses would r e v e a l experiences of exhaustion and d e f e a t i n t r y i n g to help p a t i e n t s who choose not to change or who l a c k the c a p a b i l i t i e s to change. 7. That nurses would r e v e a l experiences surrounding the d e i n s t i t u t i o n a l i z a t i o n of p s y c h i a t r i c p a t i e n t s from the P r o v i n c i a l I n s t i t u t i o n . a) anger at having to nurse i n c r e a s i n g numbers of more d i f f i c u l t p a t i e n t s with the same amount of resources and s k i l l s . b) f r u s t r a t i o n at the l a c k of resources i n the community thus l e a d i n g to q u i c k e r decompensation of p a t i e n t s once d i s c h a r g e d and more frequent and c l o s e r readmissions. c) a sense of u s e l e s s n e s s at working hard to e f f e c t any long term change i n c h r o n i c p a t i e n t s . d) a sense of power1essness i n being a b l e to e f f e c t change i n the mental h e a l t h care system. 218 Appendix C H o s p i t a l L e t t e r : Research Study Appendix D Advertisement: Research Study other questions you may have about the study. If you decide to p a r t i c i p a t e i n the study, I w i l l ask you to s i g n a form consenting to your p a r t i c i p a t i o n and g i v i n g me p e r m i s s i o n to audiotape the i n t e r v i e w s . Thank you. Linda B a r r a t t RN, BA UBC C o u n s e l l i n g Psychology (MA) Student Appendix E Information: Research Study 224 Information : Research Study Nurses' P e r c e p t i o n s of t h e i r Experiences Working with P a t i e n t s i n I n p a t i e n t P s y c h i a t r i c Care S e t t i n g s I am a r e g i s t e r e d nurse working toward a master's degree i n c o u n s e l l i n g psychology at the U n i v e r s i t y of B.C. I am conducting a study to g a i n a b e t t e r understanding of the nurses' p e r c e p t i o n s of t h e i r experiences of working with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . I hope that by e x p l o r i n g and d e s c r i b i n g the experiences of nurses i n t h e i r r e l a t i o n s h i p s with p a t i e n t s , the d i s c i p l i n e of p s y c h i a t r i c n u r s i n g w i l l be p r o v i d e d with c l e a r e r and more accurate d e s c r i p t i o n s of the n u r s e - p a t i e n t r e l a t i o n s h i p as i t e x i s t s and what i t means to nurse p a t i e n t s i n p s y c h i a t r i c care s e t t i n g s . I hope that from these d e s c r i p t i o n s n u r s i n g concepts that are f a i t h f u l to the r e a l world of the nurse's experience w i l l p r o v i d e an accurate b a s i s f o r theory development and f u r t h e r r e s e a r c h . The procedure of the study w i l l i n v o l v e at l e a s t two, 90 minute i n t e r v i e w s scheduled at our mutual convenience. The i n t e r v i e w s w i l l take p l a c e at my home or yours a c c o r d i n g to your wish and the a p p r o p r i a t e n e s s of the s e t t i n g . I would p r e f e r not to i n t e r v i e w i n the h o s p i t a l s e t t i n g because I would p r e f e r not to be 225 a f f i l i a t e d w ith any agency. During the i n t e r v i e w s you w i l l be f r e e to comment as you wish about your experience working with p a t i e n t s i n i n p a t i e n t p s y c h i a t r i c care s e t t i n g s . I w i l l tape the i n t e r v i e w s f o r convenience, but complete c o n f i d e n t i a l i t y with regards to your name and pl a c e of employment w i l l be ensured throughout the study by coding names of p a r t i c i p a n t s . I w i l l t r a n s c r i b e a l l i n t e r v i e w s verbatim and w i l l look f o r common themes f r e q u e n t l y mentioned i n the i n t e r v i e w s . Should you choose to p a r t i c i p a t e i n my study, I w i l l i n f o r m you of the r e s u l t s of my study. Your i d e n t i t y w i l l remain c o n f i d e n t i a l i n p u b l i s h e d or unpublished m a t e r i a l . You may be quoted verbatim i n the r e s u l t s of the study. You are under no o b l i g a t i o n to p a r t i c i p a t e i n t h i s study and are f r e e to withdraw at any time. You a l s o have the r i g h t to request erasure of any tape or p o r t i o n of a tape at any time d u r i n g the study. P a r t i c i p a n t s i n the study w i l l be asked not to mention any names d u r i n g the i n t e r v i e w s and any names a c c i d e n t a l l y mentioned w i l l be erased. Linda B a r r a t t RN;BA UBC C o u n s e l l i n g Psychology (MA) Student Appendix F Consent Form: Research Study 228 Appendix G Sample Questions: Research Study Sample Questions: Research Study 229 Nurses' P e r c e p t i o n s of t h e i r Experiences Working with P a t i e n t s i n I n p a t i e n t P s y c h i a t r i c Care S e t t i n g s The f o l l o w i n g i s a sample of t r i g g e r q u e s t i o n s that w i l l be used i n the i n t e r v i e w s . The ph r a s i n g of these q u e s t i o n s may vary s l i g h t l y d u r i n g the i n t e r v i e w s but the goal of the q u e s t i o n w i l l remain the same. 1. Could you t e l l me about your experiences i n your r e l a t i o n s h i p s with p a t i e n t s on i n p a t i e n t p s y c h i a t r i c care s e t t i n g s ? 2. Could you t e l l me about an encounter or a r e l a t i o n s h i p you've had with a p a t i e n t ? 3. Could you t e l l me about a p a t i e n t that o f t e n comes to your mind; that stands out f o r you i n some way? 

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