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Exploratory study to identify situations patients perceive as comfort or discomfort promoting, and the… Bredlow, Walter Axel 1976

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AIM EXPLORATORY STUDY TO IDENTIFY SITUATIONS PATIENTS PERCEIVE AS COMFORT OR DISCOMFORT PROMOTING, AND THE COPING RESPONSES THEY UTILIZE IN ADAPTING TO DISCOMFORT PROMOTING EXPERIENCES DURING THE DIAGNOSTIC REGIME by Walter Axel Bredlow A Thesis Submitted in Partial Fulfilment of the Requirements For the Master of Science in Nursing in the School of Nursing We accept this thesis as conforming to the required standard The University , of Br i t i s h Columbia October, 1975 In presenting th i s thesis in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make it f ree ly ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th is thes i s for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th i s thes is fo r f i nanc ia l gain sha l l not be allowed without my wr i t ten permission. Department of The Univers i ty of B r i t i s h Columbia 2075 Wesbrobk Place Vancouver, Canada V6T 1W5 Date Mr J>J i i i Abstract An exploratory study was conducted on 25 male and female patients who were admitted to a 29-bed surgical u n i t of a 450-bed general h o s p i t a l , f o r diagnostic testing. The purpose of the study was to;.answer the following questions: (1) What situations does the patient perceive as helping him f e e l comfortable while he i s experiencing the diagnostic regime? (2) What situations does the patient perceive as making him f e e l uncomfortable while he i s experiencing the diagnostic regime? (3) What coping responses does the patient u t i l i z e i n adapting to discomfort promoting situations during the diagnostic regime? The data f o r the study were collected through the u t i l i z a t i o n of a structured questionnaire f o r the i n i t i a l v i s i t and taped interviews with the selected patients. During the interviews, p a r t i c u l a r emphasis was placed upon exploring the patients' concerns by the use of Orlando's Open-Ended Interview Technique and a modified version of the C r i t i c a l Incident Technique. The results were then categorized into themes of patient responses, tabulated, and analyzed. The results of the study revealed that the situations the patient perceived as promoting comfort or discomfort were dependent upon two s i g n i f i c a n t variables: (1) The degree to which the patient's personal value system needs were met during the diagnostic regime; (2) The patient's a b i l i t y to mobilize adaptive coping responses to deal with the stresses created by the diagnostic regime. The coping responses u t i l i z e d by the patients i n adapting to discomfort promoting experiences i n hospital were numerous and highly i i i diversified. It was noted that the patients' ability to cope adaptively was primarily influenced by their evaluation of what was happening to them. In turn, this evaluation was affected by their past experience, their present biopsychosocial state, and the duration of the uncomfor-table experience. i v Acknowledgments The writer wishes to express his sincere appreciation to Professors Miss Rose Murakami, Miss A l i c e Baumgart, and Mrs. Helen E l f e r t whose guidance and encouragement helped sustain the writer during the long tedious course of t h i s study. Grateful acknowledgment i s also made of the cooperation and encouragement of the s t a f f of the general hospital and others who aided the writer i n undertaking t h i s study. The writer also wishes to thank Mrs. Shirley H i l l f o r her expert typing of the thesis . Dedication To the Lord, my wife Marianne, our children Walter J r . and J u l i e , and to the Patients who made the existence of t h i s Thesis a r e a l i t y TABLE OP CONTENTS Page A b s t r a c t • • • ^ Acknowledgements i v D e d i c a t i o n . . . . . . . . . . . . . . . v L i s t o f Tables v i i i L i s t of Figur e s Chapter I . INTRODUCTION TO THE STUDY * 1 S i g n i f i c a n c e of the Study 1 Purpose of the Study 2 Review of the L i t e r a t u r e . . 2 THEORETICAL FRAMEWORK UNDERLYING THE STUDY 7 D e f i n i t i o n o f Terms 11 U n d e r l y i n g Assumption . . . . 13 L i m i t a t i o n s • . 13 I I . METHODOLOGY 15 Sample . . . . ; 15 Data C o l l e c t i o n Tools 16 Data C o l l e c t i o n 18 A n a l y s i s of Data . J . . . . 19 I I I . FINDINGS . . . 21 Comfort Promoting S i t u a t i o n s . 21 Discomfort Promoting S i t u a t i o n s 26 F a c t o r s A f f e c t i n g the Degree of Comfort or Discomfort Experienced by the P a t i e n t During the D i a g n o s t i c Regime . . . . . . . . . . . . . . . . 34 v i v i i Chapter Page A. Personal Background F a c t o r s . 34 B. Expectations of Present H o s p i t a l i z a t i o n Experience 38 Coping Responses During the D i a g n o s t i c Regime 43 A. Adaptive Responses . . . . . . . . . . 44 B. Maladaptive Responses 48 IV. DISCUSSION OF THE FINDINGS 51 Comfort and Discomfort Promo-ting S i t u a t i o n s Discussed i n Terms of P a t i e n t s ' P e r s o n a l Value System Needs . . . 51 Comfort and Discomfort Promoting S i t u a t i o n s Discussed i n Terms of the P a t i e n t s ' A b i l i t y to M o b i l i z e Adaptive Coping Responses 54 V. IMPLICATIONS AND RECOMMENDATIONS ARISING FROM THE STUDY . 64 H o s p i t a l A d m i n i s t r a t i v e P o l i c i e s 64 Medical S t a f f 64 Research 65 Nursing . 66 V I . SUMMARY AND CONCLUSION 69 BIBLIOGRAPHY 73 APPENDICES 76 A. P a t i e n t Consent Form 78 B. Questionnaire U t i l i z e d i n the F i r s t I n t e r v i e w w i t h the P a t i e n t 80 C. P o l i c i e s and G u i d e l i n e s Regarding P a t i e n t Care. . . 84 D. P a t i e n t Data Sheet 90 LIST OF TABLES Table Page 1. Patient Responses During the Diagnostic Regime, Expressed i n Terms of Comfort Promoting S i t u a t i o n s 23 2. Responses of the Patient During the Diagnostic Regime Expressed i n Terms of Discomfort Promoting S i t u a t i o n s . . 30 3. Responses of the Patients During the Diagnostic Regime Expressed i n Terms of Personal Background Factors . . . . 35 4. Factors of the Patients' Personal Value System Needs . . . 36 5. Responses of the Patients During the Diagnostic Regime Expressed i n Terms of Expectations of Present Hospi-t a l i z a t i o n Experience 40 6. Categories of the Patients* Responses During the Diagnostic Regime 42 7. Responses of Patients During the Diagnostic Regime Expressed i n Terms of I n d i v i d u a l Coping Responses . . . . 43 8. Adaptive Coping Responses of Patients During the Diagnostic Regime Expressed i n Terms of Thinking A c t i v i t i e s 44 9. Adaptive Coping Responses of Patients During the Diagnostic Regime Expressed i n Terms of Ph y s i c a l A c t i v i t i e s 47 10. Maladaptive Coping Responses of Patients During the Diagnostic Regime Expressed i n Terms of Thinking A c t i v i t i e s 48 v i i i LIST OF FIGURES F i g u r e Page 1. F a c t o r s I n v o l v e d i n t h e D i a g n o s t i c Regime and i t s E f f e c t s Upon t h e P a t i e n t ' s P e r c e p t i o n o f C o m f o r t o r D i s c o m f o r t P r o m o t i n g S i t u a t i o n s and h i s R e s u l t a n t C o p i n g Responses 8 ix AN EXPLORATORY STUDY TO IDENTIFY SITUATIONS PATIENTS PERCEIVE AS COMFORT OR DISCOMFORT PROMOTING, AND THE COPING RESPONSES THEY UTILIZE IN ADAPTING TO DISCOMFORT PROMOTING EXPERIENCES DURING THE DIAGNOSTIC REGIME Chapter I INTRODUCTION TO THE STUDY The promotion of comfort f o r the p a t i e n t d u r i n g the d i a g n o s t i c process i s an e s s e n t i a l element of good n u r s i n g care. To s p e c i f y comfort as a goal i n n u r s i n g , however, does not imply t h a t the p a t i e n t must be, can be, or even d e s i r e s to be comfortable i n a l l ways at a l l times. The d i a g n o s t i c program i n both i t s medical and n u r s i n g phases may r e q u i r e t h a t the p a t i e n t ' s comfort assume a secondary p o s i t i o n on v a r i o u s occasions. Most p a t i e n t s are w i l l i n g t o undergo a degree of p h y s i c a l and p s y c h o l o g i c a l discomfort when i t i s perceived as b e i n g necessary t o f u r t h e r t h e i r d i a g n o s t i c program. I n a d d i t i o n to the promotion of comfort then, the nurse's r o l e i s to make the p a t i e n t ' s discomfort a t o l e r a b l e experience.^ SIGNIFICANCE OF THE STUDY I n t e r e s t i n conducting res e a r c h i n the area of p a t i e n t comfort was s t i m u l a t e d by the w r i t e r ' s past experience w i t h p a t i e n t s undergoing d i a g n o s t i c t e s t i n g , and by readings i n l i t e r a t u r e t h a t p e r t a i n to the p a t i e n t ' s emotional responses t o s t r e s s f u l s i t u a t i p n s . I t soon became 1 Margaret A. Kaufmann, "Comfort Measures: Sterotypes or, F l e x i -b l e Elements of Comprehensive P a t i e n t Care," American Nurses' Associa- t i o n - C l i n i c a l S e s sions. No. 11 (1962), p.19. 2 evident that i f nursing eare was to "be improved, then there was a need to f i r s t identify those situations that patients perceived as promoting comfort or discomfort. Equally important i s that nurses should become aware of how patients adapt to discomfort promoting experiences i n hos-p i t a l s . Knowledge of this factor could definitely aid the nurse i n helping patients strengthen existing adaptive behaviors and/or provide learning opportunities that w i l l enable the patient to learn healthier coping behaviors i n adapting to uncomfortable situations. Hence the need for conducting this study. PURPOSE OP THE STUDY This study w i l l focus on three questions: (1) What situations does the patient perceive as helping him feel comfortable while he i s experiencing the diagnostic regime? (2) What situations does the patient perceive as making him feel uncomfortable while he i s experiencing the diagnostic regime? (3) What coping responses do patients u t i l i z e in adapting to dis-comfort promoting experiences during the diagnostic regime? REVIEW OP THE LITERATURE Literature selected for review i n this study pertains to the concepts of waiting, uncertainty, worry-work, comfort and anxiety. There i s not a great deal of literature written on these concepts with the exception of anxiety. What i s available on the other concepts, has been based more upon informal opinions and theoretical speculation rather than actual research. Two authors have commented on factors contributing to comfort and discomfort while the patient i s experiencing the diagnostic regime. Ackerhalt stresses that because the time interval between the i n i t i a l recognition of the disease and the pursuing diagnosis cannot be predicted, the patient can only wait and speculate what i s wrong with him. This added element of uncertainty coupled with some patients' i n a b i l i t y to 2 wait comfortably, may intensify a patient's feelings of helplessness. On the other hand, Fox noted that information given be fellow patients regarding diagnostic procedures gave the patient a "sense of knowing and understanding", thus helping to counteract some of the stresses of uncer-3 tainty, unfamiliar procedures and equipment. The degree of anxiety experienced by the individual awaiting the results of his diagnostic tests and his way of coping with that anxiety has been implied by many writers. Results of the assessment of preoperative condition and post-operative welfare of surgical patients by Wolfer and Davis may have impli-cations for the patient experiencing the diagnostic regime. Their study revealed that at least 15 percent of the males and 30 percent of the females reported a high degree of fear and anxiety the night before surgery. They also noted that there was no substantial relationship between the patient's preoperative level of fear and anxiety and any 4 aspect of their postoperative recovery. As a result of the anxiety the patient i s experiencing, and of his need to adapt behaviors i n order to avoid, reduce, or relieve anxiety, Judith Ackerhalt, "The Concept of Waiting: Supporting the Patient Awaiting Diagnosis," A.N.A. Regional C l i n i c a l Conferences. No.2. (New York: American Nurses' Association, (1964), p. 78. '"3' " -Rene Fox, Experiment Peri1ous (Glencoe, I l l i n o i s : The Free Press, (19.59), PP. 114-90. ' ... -4Johh A. Wolfer and Carol E. Davis, "Assessment of Surgical Patients' Preoperative Emotional Condition and Postoperative Welfare," Nursing Research (September-October 1970), pp. 402-14. 4 he may u t i l i z e one of four major patterns of adaptive behavior. The patient may: (1) exhibit acting out behavior through anger or resentment to cope with his anxiety; (2) exhibit somatizing behavior such as head-aches, digestive disturbances, et cetera; (3) withdraw from others or go into a depression; or (4) use his anxiety i n the service of learning by enduring the anxiety while searching out causes and struggling with 5 the problem. Janis' work on the "worry-work" process has many important impli-cations for the patient experiencing the diagnostic regime, particularly i f the results prove to be unfavorable. Janis noted that the work of worrying enabled the patient to increase his level of tolerance and cope more adaptively i n the long run with a painful reality situation. As a result of his research, Janis contends that the more thorough the work of worrying, the more reality-tested the individual's self-delivered reassurances are l i k e l y to be, and hence the more emotional control he w i l l maintain under subsequent danger or deprivation.^ Orlando and Wiedenbach have proposed specific nursing guidelines to assess the patient's a b i l i t y to adapt to his hospitalization experi-ence and promote his comfort. In her book, The Dynamic Nurse-Patient Relationship. Orlando points to an efficient way of identifying and 7 dealing with the situational distress the patient i s experiencing. •Tlildegard Peplau, "A Working Definition of Anxiety," Some  Cl i n i c a l Approaches to Psychiatric Nursing, ed. Shirley F. Burd and Mar-garet A. Marshall (New York: The MacMillan Company, 1963), pp.324-55. ^Irving L. Janis, Psychological Stress, (New York: John Wiley and Sons, Inc., 1958), pp.401-11. "^Ida Jean Orlando, The Dynamic Nurse-Patient Relationship, (New York: G.P. Putman's Sons, 1961). 5 Wiedenbach takes Orlando's ideas one step f u r t h e r by emphasizing t h a t the nurse should not only i d e n t i f y and d e a l w i t h the p a t i e n t ' s d i s t r e s s , but he should a l s o seek v a l i d a t i o n from the p a t i e n t t o ensure t h a t the n u r s i n g i n t e r v e n t i o n s t h a t he u t i l i z e s do, i n f a c t , meet the p a t i e n t ' s needs.^ I n p r o v i d i n g comfort f o r the p a t i e n t , Kaufmarm contends t h a t the degree t o which the n u r s i n g s t a f f meet the p a t i e n t ' s expectations of how they should a c t i n t h e i r r e l a t i o n s w i t h him w i l l d e f i n i t e l y i n f l u e n c e h i s f e e l i n g s o f s a f e t y and comfort. She f u r t h e r emphasizes t h a t success-f u l n u r s i n g i n t e r v e n t i o n i s p a r t i c u l a r l y dependent upon the nurses understanding t h a t many p a t i e n t s hope to achieve a great d e a l o f comfort 9 through the i n t e r p e r s o n a l , i n t e r a c t i v e aspects o f t h e i r care. Recent n u r s i n g research has focused on the communication process and how i t can be used t o e l i c i t the p a t i e n t ' s f e e l i n g s and help them achieve a comfortable s t a t e . S e v e r a l authors d e f i n e n u r s i n g as the a r t and science o f pro-moting comfort. Anderson, et a l . s t a t e t h a t a primary f u n c t i o n of the nurse i s t o determine and he l p a l l e v i a t e the d i s t r e s s a p a t i e n t i s exp e r i e n c i n g i n h i s present s i t u a t i o n . ^ Smith contends t h a t the science of communication i s more p e r t i n e n t to n u r s i n g than the science of disease or pathology. She f u r t h e r s t a t e s , " the nurse's knowledge of the p a t i e n t must i n c l u d e an sunderstanding of h i s emotional r e a c t i o n and Er n e s t i n e Wiedenbach, C l i n i c a l N u r s i n g — A H e l p i n g A r t (New York: S p r i n g e r P u b l i s h i n g Company I n c . , 1967). 9 Kaufmann, op. c i t . , pp.20-2. 1 0 B a r b a r a J . Anderson, e t a l . , "Two Experimental Tests of P a t i e n t Centered Admission Procedures, "Nursing Research, XVI: 2(Spring 1965), 151-7. 6 helping him understand his feelings and reactions, and should become a standard part of any treatment regime."^ Authors discussing the means of dealing with the patient's dis-tress have a l l emphasized the importance of information i n helping meet the patient's comfort needs. Egbert writes, "patients benefit emotionally 12 from knowing what i s happening." Janis contends that providing infor-mation prior to experiencing a new situation helps one to mentally create, the anticipated experience, and thus adapt when one has to undergo the actual s i t u a t i o n . ^ The results of Skipper's study revealed that upon receiving information about their treatments, i l l n e s s , and social organi-zation of the hospital, patients were less anxious about their i l l n e s s and what was going to happen to them, their adaptation to the expectations 14 of the hospital staff was enhanced, and their need for safety was met. Myers noted that giving the patient pertinent information before and while carrying out procedures i n an unfamiliar situation was the most 15 successful i n relieving stress for the patient. The actual concerns that the patients have verbally expressed have been identified by two authors. Lineham noted that the actual concerns of patients covered a broad spectrum. Patients wanted to talk 1 1Dorothy M. Smith, "Myth and Method i n Nursing," American Journal of Nursing, LXVT 2 (February, 1964), pp.68-72. 12 Lawrence D. Egbert, "Psychological Support," International Psy- chiatry Clinics, ed. Harry S. Abram (Boston: L i t t l e Brown and Company, 1967), P.45. 13 'janis, op. c i t . , p.406. 14Jantes K. Skipper, "Communication and the Hospitalized Patient," Social Interaction and Patient Care, ed. James K. Skipper and Robert C. Leonard.(Philadelphia: Lippincott Co., 1965), pp.63-6. 1^Mary Myers, "The Effects of Three Types of Communication on Patient's Reaction to Stress," Nursing,Research, XIII: 2 (Spring, 1964), pp.126-31. 7 to t h e i r doctors, other than at doctors' rounds. They wanted privacy, especially when they had personal questions or when the doctor talked to them about t h e i r condition. They wanted a greater display of int e r e s t i n them as individuals from the doctors and nurses. They wanted better communication between doctors and fa m i l i e s ; explanations of what was being done to them and why; what to expect a f t e r an operation or treat-ment; more rapid reporting of t e s t s , and more explanation of nursing 16 procedures. Dloughly et a l . noted that patients do not want a s c i e n t i -f i c explanation of diagnostic test s , but rather an application of the 17 s c i e n t i f i c methods to t h e i r i n d i v i d u a l needs. THEORETICAL FRAMEWORK UNDERLYING THE STUDY On the basis of a review of the theoretical knowledge and research selected f o r t h i s study the writer postulates that the patient's admission to hospital and the diagnostic regime, can be vi s u a l i z e d i n terms of a systems theory approach (Refer to Figure 1, page 8). The conceptualiza-t i o n s t a r t s with kinds of s p e c i f i c inputs- jatient and medical care. The patient state i s defined as a function of personal background factors (information) and psychophysiological factors (energy). The medical care factors include the decision to ho s p i t a l i z e , when and how, plus the information given to the patient. The middle boxes, thinking about hos-p i t a l i z a t i o n and comparisons of actual events and expectations specify cognitive processes. The end boxes, feelings of comfort or discomfort expressed as concerns, and coping behaviors which are expressed i n terms 72 Dorothy T. Lineham, "What Patients Want to Know," American Journal of Nursing, LXII 5 (May, 1966), p.1068. 17 'Alice Dloughly, et a l . , "What Patients Want to Know About Their Diagnostic Tests." Nursing Outlook, XI 4 ( A p r i l , 1963), pp.265-7. 8 HE •z ,—2> IX <s -» fc ft ? o « 0 0 0 £ 0 P Pi e < § ^  £ 5 ft X & ft 9 of adaptive or maladaptive behavior, specify response outputs. The arrows represent information or energy flow routes and feedback loops which affect the nature of the patient!s cognitive processes and the s p e c i f i c type and degree of his response output. The personal background factors provide the individual with i n f o r -mation he can u t i l i z e i n structuring his h o s p i t a l i z a t i o n experience during the diagnostic regime. He may also possess certain kinds of a b i l i t i e s which w i l l aid him i n coping with the experience. The biopsychosocial factors represent those factors which are operative i n the patient's present s i t u a t i o n . For example, regarding the concept of energy, one w i l l note that i f the diagnostic regime has been very painful and/or anxiety provoking, and has used up a great deal of the patient's energy, obviously he i s going to have less energy a v a i l a -ble f o r thinking. This may have a d e f i n i t e impact on his a b i l i t y to adapt successfully to h i s h o s p i t a l i z a t i o n experience. The medical care factors as mentioned previously consist of information and plans. The information i s the knowledge which i s given to the patient and which he u t i l i z e s i n thinking about his h o s p i t a l i z a -t i o n . The plans are the decisions the physician makes regarding the nature of the patient's h o s p i t a l i z a t i o n , the time, and the diagnostic regime while the patient i s i n h o s p i t a l . The patient's thinking about h o s p i t a l i z a t i o n and the diagnostic regime i s consistent with Janis's work of worrying or mental rehearsal. I t i s the cognitive a c t i v i t i e s the patient undergoes i n order to prepare himself f o r a s t r e s s f u l event. Some individuals may f e e l that the only way they can cope with a threatening s i t u a t i o n i s to t o t a l l y deny i t s existence. The w r i t e r 10 contends t h a t even a "normal i n d i v i d u a l " u t i l i z e s a c e r t a i n amount of d e n i a l w h i l e he i s e x p e r i e n c i n g the d i a g n o s t i c regime, but he u s u a l l y a l t e r n a t e s between the d e n i a l of a p o s s i b l e s t r e s s f u l s i t u a t i o n and the acceptance of i t s presence. For t h i s i n d i v i d u a l a c e r t a i n amount of d e n i a l allows h i s s i t u a t i o n to become more t o l e r a b l e , and, when i n t e g r a t e d w i t h worry-^work the i n d i v i d u a l i s able to a r r i v e a t a compromise between almost t o t a l d e n i a l and the r e a l i t y of the s i t u a t i o n . On the other hand, t o t a l d e n i a l i s maladaptive because i t does not a l l o w the i n d i v i d u a l t o proceed through the normal worry-work process and b u i l d up h i s t o l e r a n c e to a l a t e r c r i s i s , as i n r e c e i v i n g a p o s i t i v e d i a g n o s i s of cancer. The outcome o f t h i n k i n g i s expectations and p l a n s . That i s , the i n d i v i d u a l c o g n i t i v e l y formulates a s e t of expectations about how he should behave and how s i g n i f i c a n t others, ( d o c t o r s , nurses, e t c . ) , i n the environment w i l l behave, about what w i l l happen t o him i n terms of time, t e s t s , doctor v i s i t s , e t c e t e r a . I n a l l p r o b a b i l i t y he a l s o does some mental r e h e a r s i n g which a l l o w s him to make plans of a k i n d . For example, " i f p a i n occurs, then I w i l l t r y and do thus and so." This combination of expectations and plans then a l l o w s him to make comparisions between the a c t u a l experiences t h a t occur t o him and what he expected and rehearsed f o r . Out of these comparisons, per c e i v e d d i f f e r e n c e s a r i s e i n the p a t i e n t ' s c o g n i t i v e a c t i v i t i e s . These d i f f e r e n c e s then produce f e e l i n g s of comfort and/or discomfort which can be expressed as p o s i t i v e or negative concerns. That i s , the concerns a c t as a mediating v a r i a b l e or o r g a n i z i n g f a c t o r i n the i n i t i a t i o n o f coping responses. The concerns and coping responses are perceived by the nurse as b e i n g adaptive o r mal-adaptive and provides her w i t h cues as t o how w e l l the p a t i e n t ' s comfort needs are b e i n g met. 11 I t i s d e f i n i t e l y possible that the patient can experience discom-f o r t i n events which occur exactly as he expected, but the writer contends that the patient w i l l be better able to cope with the s i t u a t i o n because 18 i t w i l l not come as a shock to him. Therefore, although the patient w i l l experience feelings of discomfort, the degree of discomfort expressed by the patient should not be as great as i t would be i f the patient had not expected the s t r e s s f u l event to a r i s e . DEFINITION OF TERMS For the purpose of t h i s study the following d e f i n i t i o n s of the major terms were accepted: I . S i tuation - A combination of circumstances and events occurring at a s p e c i f i c time. I I . Perception - The process by which people select, organize and i n t e r -pret sensory input. n i . Comfort - A subjective f e e l i n g of well-being. IV. Discomfort - A subjective f e e l i n g of apprehension and d i s t r e s s . V. Personal Background Factors - Represents that combination of factors which the patient uses as a reference point f o r associa-t i n g and judging his current hospital experience. This consists of: A. Past Experience - Past knowledge and a b i l i t i e s acquired as an observer or recipient of the health care delivery system. B. Personal Value System Needs - Those factors which the patient perceives as being necessary to maintain his self-esteem. VI. Expectations of Present Ho s p i t a l i z a t i o n Experience - The patient's anticipation of what he i s l i k e l y to experience and what he hopes w i l l happen during his current admission to ho s p i t a l . This consists of: A. Expected Information - The information the patient would l i k e to receive concerning his i l l n e s s and o v e r a l l h o s p i t a l i -zation experience. 18 Janis, op. c i t . , pp.401-11. 12 B. Expected Events - The hospital routines and diagnostic proce-dures the.patient expects to experience. C. People - Those responses the patient would like to see demon-strated i n the individuals he cornea i n contact with. This consists of responses demonstrated by: 1. Professionals 2. Visitors 3. Other Patients VII. Perception of Actual Hospitalization Experience - The patient's cognitive and affective responses to situations occurring during the diagnostic regime. A. Comfort-Promoting Situations - Those situations that have a tendency to f a c i l i t a t e a subjective feeling of well-being. These consist of: Actual Information - The information given to the patient which he perceives as comfort promoting. Actual Events - The hospital routines and diagnostic procedures the patient experiences and perceives as comfort promoting. People - The responses the patients see demonstrated i n the individuals he comes i n contact with and which he perceives as promoting comfort. These consist of responses demonstrated by: a. Professionals b. Visitors c. Other Patients B. Discomfort-Promoting Situations - Those situations that have a tendency to increase the patient's subjective fee-lings of apprehension and distress. These consist of: 1. Actual Information - The information given to the patient which he perceives as promoting discomfort. 2. Actual Events - The hospital routines and diagnostic pro-cedures the patient experiences and perceives as pro-moting discomfort. 3. Actual People - The responses the patient sees demonstrated i n the individuals he comes i n contact with, and which he perceives as promoting discomfort. This consists of responses demonstrated by: .1. 2. 3. 13 a. P r o f e s s i o n a l s b. V i s i t o r s c. Other P a t i e n t s V I I I . Coping Responses - The p a t i e n t ' s responses t h a t f a c i l i t a t e or hinder h i s a b i l i t y t o meet h i s comfort needs. A. Adaptive - The p a t i e n t ' s responses which r e s u l t i n him f e e l i n g more comfortable or bein g able to t o l e r a t e d i s c o m f o r t . These-consist o f : 1. T h i n k i n g A c t i v i t i e s - Those c o g n i t i v e processes o c c u r r i n g w i t h i n the p a t i e n t ' s mind. 2. P h y s i c a l A c t i v i t i e s - The p a t i e n t ' s locomotor responses o r i n t e r a c t i o n w i t h environmental s t i m u l i . B. Maladaptive - The p a t i e n t ' s responses which r e s u l t i n him f e e l i n g d i s t r e s s e d . These c o n s i s t o f : 1. Th i n k i n g A c t i v i t i e s 2. P h y s i c a l A c t i v i t i e s IX. I n t r u s i v e , T e s t s - Those d i a g n o s t i c t e s t s which i n v o l v e a manual p e n e t r a t i o n o f two inches o r more i n l e n g t h o f a body organ or c a v i t y by a mechanical instrument. X. E x t r u s i v e Tests - Those d i a g n o s t i c t e s t s which i n v o l v e l e s s than two inches of manual p e n e t r a t i o n o f the body by a mechani-c a l instrument {eg. needle), o r e l e c t r o n i c p e n e t r a t i o n of a body organ or c a v i t y w i t h a mechanical instrument (,eg. x - r a y s ) . UNDERLYING ASSUMPTION The u n d e r l y i n g assumption of t h i s study was th a t the p a t i e n t s would express t h e i r true f e e l i n g s about the s i t u a t i o n s they perceived as promoting comfort and/or d i s c o m f o r t , and the ways i n which they attempted t o cope w i t h uncomfortable experiences d u r i n g the d i a g n o s t i c regime* LIMITATIONS This study was subject t o the f o l l o w i n g l i m i t a t i o n s : 1. P a t i e n t s were s e l e c t e d only from one ward i n one general h o s p i t a l i n the Vancouver area. 2. Patients were selected only over a one month's period of time. 3. The findings can be generalized only to those patients between twenty and seventy-six years of age and who can speak English. 4. Only twenty-five patients were selected for the study. 5. Since the researcher was a participant observer, i t was noted that some patients were able to achieve an added degree of comfort when they were able to verbalize their concerns to someone who was willing to l i s t e n . I f the patients did not have this opportunity, the number of situations that the patient perceived as uncomfortable may have been higher than i s actually reported i n this study. This fact must therefore be taken into consideration. Chapter I I METHODOLOGY The exploratory approach was used to conduct t h i s study. This approach was selected f o r the following reasons: (1) In order to conduct a more intensive study i n the area of patient comfort, the exploratory approach can be used to c l e a r l y i d e n t i f y the problems and generate s p e c i f i c hypotheses about the factors that af f e c t patient comfort. (2) An exploratory approach allows more f l e x i b i l i t y i n the research design. This method i s advantageous because, as the i n i t i a l l y vaguely defined problem i s transformed into one with a more precise meaning, frequent changes i n the research procedure are often neces-sary i n order to provide f o r the gathering of data relevant to the emerging hypothesis. SAMPLE The sample selected f o r t h i s study was chosen from a twenty-nine bed s u r g i c a l u n i t i n a four hundred and f i f t y bed general h o s p i t a l , loca-ted i n the Vancouver area. Patients were admitted from the Vancouver area and by r e f e r r a l s from out-lying d i s t r i c t s . , The 25 men and women that were f i n a l l y selected ranged between the ages of twenty and seventy-six year of age, and were chosen according to the following c r i t e r i a : (1) Must be between eighteen and eighty years of age. (2) Must be undergoing diagnostic tests and awaiting the test r e s u l t s . (3) Must be w i l l i n g to participate i n the study and allow the writer to 15 16 have taped i n t e r v i e w s w i t h them d a i l y d u r i n g t h e i r h o s p i t a l s t a y . (4) Must "be able t o speak E n g l i s h . DATA COLLECTION 'TOOLS Taped Inte r v i e w s - A l l i n t e r v i e w s were taped to ensure t h a t no i n t e r v i e w data were l o s t . The taped i n t e r v i e w s a l s o enabled the w r i t e r to have two independent judges compare t h e i r r e s u l t s w i t h h i s i n order : to check the v a l i d i t y o f the w r i t e r ' s a n a l y s i s o f the c o l l e c t e d data. Questionnaire - A s t r u c t u r e d q u e s t i o n n a i r e was compiled based on the w r i t e r ' s past experience w i t h p a t i e n t s undergoing d i a g n o s t i c t e s t i n g and on i n s i g h t s gained from readings i n r e l a t e d l i t e r a t u r e . The c l a r i t y of the questions, was t e s t e d on three p a t i e n t s . As a r e s u l t , e i g h t ques-t i o n s were mo d i f i e d before the qu e s t i o n n a i r e was used i n the main study (see Appendix B ) . The q u e s t i o n n a i r e was used i n the main study f o r the f o l l o w i n g reasons: (1) I t gave the w r i t e r an opportunity to ga i n a rapport w i t h the p a t i e n t . (2) I t provided a d e f i n i t e s t r u c t u r e f o r the f i r s t i n t e r v i e w and helped s e t the tone f o r subsequent i n t e r v i e w s . (3) I t allowed the w r i t e r an opportunity to e l i c i t a wide v a r i e t y of p a t i e n t ' s f e e l i n g s and concerns about h i s h o s p i t a l i z a t i o n experience d u r i n g the d i a g n o s t i c regime. This was p a r t i c u l a r l y important f o r i d e n t i f y i n g problems t h a t r e l a t e t o the p a t i e n t ' s comfort needs. Orlando's 0pen-Ended I n t e r v i e w Technique - Orlando advocates an open-ended i n t e r v i e w technique w i t h v i r t u a l l y u n l i m i t e d probing f o r use by nurses i n diagnosing p a t i e n t ' s needs. She proposes t h a t the i n t e r v i e w techniques should be c a r r i e d out i n the f o l l o w i n g manner; (1) the nurse 17 observes the patient's verbal and non-verbal a c t i v i t y f o r possible symp-toms of d i s t r e s s ; (2) the nurse makes a tentative interpretation of these symptoms and then comments (to the patient) either about the symptom or on h i s feelings about the patient's behavior; and (3) the nurse continues with steps (1) and (2) u n t i l he and the patient are i n apparent agreement on what the patient needs,(if anything), and there are no apparent discrepant symptoms. Safety features to guard against bias are included i n these guidelines as the patient w i l l , under the impact of repeated probing, eventually reveal any o r i g i n a l bias that the nurse may have and discount i t . 1 9 Modified C r i t i c a l Incident Technique - The c r i t i c a l incident technique asks the patient to describe a p a r t i c u l a r action. It's biggest advantage i s due to the fact that the information which i s gathered about a p a r t i c u l a r incident or s i t u a t i o n i s based upon a report of what actually took place and how the participants behaved. Thus the r e l i a b i l i t y of t h i s technique i s high. Another advantage i s that i t appears to be adaptable 20 to many kinds of s i t u a t i o n s . In t h i s study the writer used a s l i g h t modification of the c r i t i -c a l incident technique. When obtaining descriptions of situations which the patient perceived as promoting comfort or discomfort, the writer asked the patient to: (1) Describe the s i t u a t i o n and b r i e f l y describe relevant aspects of the background of the s i t u a t i o n . 19 Powhatan J . Woolridge, James K. Skipper J r . , and Robert C. Leonard, Behavioral Science, S o c i a l Practice, and the Nursing Profession (Cleveland: The Press of Case Western Reserve University, 1968), pp.44-5. 20 Clara A. Hardin, " C r i t i c a l Incident, What Does I t Mean to Research?" Nursing Research. I l l 3 (February, 1955)» pp.108-9. 18 (2) Describe what the other person d i d i n the s i t u a t i o n . (3) Describe what he d i d i n the s i t u a t i o n . (4) E x p l a i n why he perceived the s i t u a t i o n as comfortable o r uncomfortable. (5) I f the s i t u a t i o n was uncomfortable, d e s c r i b e what he t r i e d t o do to make h i m s e l f f e e l more comfortable. Orlando's open-ended i n t e r v i e w technique and the modified c r i t i c a l i n c i d e n t technique were u t i l i z e d because they a l l o w the w r i t e r t o o b t a i n a more accurate, p r e c i s e , d e t a i l e d r e p o r t o f the p a t i e n t ' s p e r c e p t i o n o f h i s experiences i n h o s p i t a l d u r i n g the d i a g n o s t i c regime. DATA COLLECTION The data f o r the study was c o l l e c t e d i n the f o l l o w i n g manner: Step I - I n i t i a l V i s i t - A w r i t t e n consent to p a r t i c i p a t e i n the study was f i r s t obtained from the p a t i e n t (Appendix A). The w r i t e r then used the q u e s t i o n n a i r e to s t r u c t u r e the f i r s t taped i n t e r v i e w . Step I I - Subsequent V i s i t s - The w r i t e r conducted taped i n t e r -views w i t h the p a t i e n t on each successive v i s i t u n t i l the p a t i e n t r e c e i v e d the r e s u l t s of a l l h i s d i a g n o s t i c t e s t s . During each i n t e r v i e w the w r i t e r asked the f o l l o w i n g questions: (1) "What would you say your b i g g e s t con-cern was today?" (2) "Were there any s i t u a t i o n s today t h a t made you f e e l comfortable?" (3) "Were there any s i t u a t i o n s today t h a t made you f e e l uncomfortable?, and (4) I f the p a t i e n t d e s c r i b e d a s i t u a t i o n t h a t made him f e e l uncomfortable the w r i t e r asked, "What d i d you do t o make y o u r s e l f f e e l more comfortable?" while the p a t i e n t was d e s c r i b i n g h i s f e e l i n g s and concerns i n r e l a t i o n to the above questions,the w r i t e r u t i l i z e d Orlando's open-ended i n t e r v i e w techniques and a m o d i f i c a t i o n of the c r i t i c a l i n c i -dent technique t o explore the p a t i e n t ' s f e e l i n g s and concerns i n depth. 19 The results of the taped interviews were then transcribed, tabulated and analyzed. ANALYSIS OP DATA The data collected i n the study were tabulated and analyzed i n the following manner: (1) The taped interviews were transcribed. (2) The analyzed, data were grouped into five broad categories of patient responses. These categories were derived as a result of the general thematic responses that became evident during the analysis of the data and on the basis of the theoretical knowledge and research selected for this study. To provide further c l a r i f i c a t i o n , the five general categories were broken down into sub-categories. These sub-categories were derived by systematically grouping specific themes of patient responses that arose during the analysis. For example, during the analysis the general category of."personal background factors" gradually emerged. This general category was comprised of the two sub-categories of "past-experience" and personal value system needs" (see page 11). (3) Each transcribed interview was systematically analyzed for each specific theme of patient responses that could be grouped under the appropriate sub-category. Each specific theme; was scored only once in each interview, but i f the same theme was noted in another inter-view i t was once again scored. For example, i f the patient stated in the f i r s t interview that he valued food, then this specific theme was scored under the personal value system need sub-category. Even i f the patient brought up this same theme three|times during the interview i t was scored only once but i f the patient mentioned the i same theme i n each successive interview i t was once again scored. T h i s method o f s c o r i n g was s e l e c t e d f o r the f o l l o w i n g reasons: (a) Whenever the w r i t e r used Orlando's open-ended i n t e r v i e w technique and/or a m o d i f i c a t i o n of the c r i t i c a l i n c i d e n t technique to explore the p a t i e n t ' s f e e l i n g s and concerns i n depth, the w r i t e r would q u i t e o f t e n e l i c i t the same theme two o r three times. (b) The w r i t e r would o c c a s i o n a l l y summarize the s p e c i f i c theme the p a t i e n t had s t a t e d to make c e r t a i n t h a t the theme the w r i t e r perceived was a c t u a l l y the theme the p a t i e n t wanted t o communicate. Therefore, each time the p a t i e n t v a l i d a t e d the w r i t e r ' s p e r c e p t i o n the theme was again e l i c i t e d . I f the w r i t e r were t o score some themes under these ciroumstances the r e s u l t a n t t a b u l a t i o n would he d i s t o r t e d . S c o r i n g each s p e c i f i c theme only once d u r i n g the i n t e r v i e w provided a c l e a r e r p i c t u r e of the p a t i e n t ' s responses as represented by each sub-category. ( c ) A f t e r the w r i t e r had completed the a n a l y s i s , a l l the s p e c i f i c themes i n each sub-category were t a b u l a t e d and presented under the general category of responses. The v a l i d i t y of the w r i t e r ' s a n a l y s i s was judged by two indepen-dent judges not f a m i l i a r w i t h the resea r c h design. Comparisons of the a n a l y s i s form, u s i n g f i v e randomly-selected t r a n s c r i b e d i n t e r v i e w s r e s u l t e d i n an 89% concordance w i t h the one judge and an 85% concordance w i t h the other judge. Chapter I I I FINDINGS The findings a r i s i n g from the analysis of data are presented i n th i s section. Data are presented to answer the questions of what s i t u a -tions the patient perceives as promoting comfort or discomfort and what coping behaviors are u t i l i z e d i n adapting to discomfort promoting experi-ences during the diagnostic regime. COMFORT PROMOTING SITUATIONS Actual Information - Table 1, page 23, reveals that there were a t o t a l of 99 responses e l i c i t e d from the patients regarding information that helped them f e e l more comfortable. The responses ranged from 0-11 with a mean of 3.88 responses per patient. There were two patients from whom no responses were e l i c i t e d . The information the patients perceived as comfort promoting covered a very broad spectrum and either focused around the diagnostic regime or situations that were perceived as being meaningful to a p a r t i -cular patient. I t varied from getting a typed information card about the diagnostic t e s t s , obtaining information regarding what to expect during the diagnostic regime, getting an orientation to the ward, r e c e i -ving l e t t e r s from family and friends, f i n d i n g out that one's roommate came out of surgery and i s doing f i n e , to being t o l d that he does not have cancer of the stomach and could go home tomorrow. An example of a s i t u a t i o n where the patient perceived the i n f o r -mation given as comfort promoting was well demonstrated by a 73-year-old 21 22 lady whose admission diagnosis was gastro-intestinal bleeding. Upon recei-ving her f i n a l diagnosis on the day of the f i f t h interview she stated: "...and then he told me. He said. Oh, I know what pleased me. He told me that the results of the gastroscopy test were benign. So whether they took a l i t t l e b i t of something I don't know. He said maybe i t might be like a small ulcer - more like a small erosion. And so I said 'Oh* and he said 'but i t was benign.'...That's good news...!" Actual Events - Table 1, page 23, shows that 18.34% of the situations the patients perceived as comfort promoting were actual events. The responses ranged from 0-10 with a mean of 2.68 responses per patient. There were four patients from whom no responses were e l i c i t e d . Four specific themes appeared to arise from the patients' e l i c i t e d responses. Many patients commented on how good i t was to receive some-thing i f they were experiencing any pain or getting an injection before certain diagnostic tests (eg. gastroscopy test). The patients were pleased that something was being done for them - the diagnostic regime was progres-sing and now they w i l l f i n a l l y find out what i s wrong with them. Receiving good food and the kind of food they wanted proved to be a very comforting event for many patients. Finally, many patients commented on how nice i t was that the hospital policies and routines were much more flexible and personalized than they were i n the past. An event that a patient perceived as comfort promoting was best il l u s t r a t e d by a forty-two-year-old lady who was admitted to the hospital after waiting for a month. During one interview she stated: "I really feel much better i n being i n the hospital now .because I now know that I am i n here and things are f i n a l l y getting under way. I had to wait for almost a month to get i n here and I would not have gotten in i f i t wasn't for a cancellation. I would probably be waiting s t i l l . So I had a whole month to think about i t . " 23 Table I Patient Responses During the Diagnostic Regime, Expressed in Terms of Comfort Promoting Situations N-25 Number of Responses Percentage of Total Mean Range Actual Information 99 27.05 3.88 0-11 Actual Events 67 18.34 2.68 0-10 Actual Professionals 156 42.08 6.24 1-23 Actual Visitors 31 8.66 1.24 0-4 Actual Other Patients 13 3.83 - 0-4 366 99.96 Actual Professionals - An examination of Table 1, above, reveals that 42.08% of the responses e l i c i t e d from the patients, in terms of comfor-ting situations, involved the behavior of the professional people who came in contact with them. The responses el i c i t e d ranged from 1-23 with a mean of 6.24 responses per patient. The situations the patients perceived as comfort promoting covered a wide spectrum but general themes arose throughout the inter-views. I t meant a great deal to many patients to be seen by their doctor at least every other day. It was especially comforting to know that the doctor would come back to see them on weekends or after hours, take time to explain things at their own level of understanding, and show extra consideration by allowing them to have a pass from hospital. This type of behavior demonstrated by the doctor reinforced the patient's feelings that the doctor cared about him as an individual who was worthy of his 24 attention and concern. One of the most important themes that arose was i f the patient f e l t that the professionals were aware of and understood his feelings and needs. This perception f a c i l i t a t e d the patient's feelings of comfort and increased h is t r u s t i n the professionals who came i n contact with him. The comforting responses of the nurses were s p e c i f i c a l l y mentioned by the patients. I t meant a great deal to the patient when he would f i n d the nurse easy to t a l k to, when she would do l i t t l e things f o r him, and when she would demonstrate concern f o r his welfare. A good example of the behavior demonstrated by professionals which the patient perceived as comfort promoting was well verbalized by a 62-year-old man admitted f o r severe coronary artery disease. Regarding the nursing care he received a f t e r his angiogram t e s t , he stated: "The nurse checked me every ten minutes a f t e r I came from the operating room, f o r the f i r s t hour and then every hour. I was cer t a i n l y reassured that they were keeping a check on me and I was very pleased with the attention I was receiving." Actual V i s i t o r s - An examination of Table 1, page 23, reveals that there were a t o t a l of 31 responses e l i c i t e d , regarding v i s i t o r s , that the patients perceived as promoting comfort. The responses ranged from 0-4 with a mean of 1.24 responses. Ten patients did not verbalize any res-ponses about v i s i t o r s ' behavior as promoting comforting experience. The s p e c i f i c meaning of v i s i t o r s ' behavior to the patient's varied from patient to patient. I t meant a great deal to the patient to be v i s i t e d by those whom he cared about or who were close to him. I t was very comforting to the patient when v i s i t o r s were w i l l i n g to take time out from t h e i r busy schedule to come and v i s i t him. Many patients, p a r t i c u l a r l y those from outside the Vancouver area, f e l t that v i s i t o r s 25 were of a great benefit in lessening the feelings of loneliness and/or the boring time spent i n hospital. Finally, a familiar face was something that was very meaningful to the patient, especially i f he was waking up from a diagnostic test requiring a general anesthetic or after experiencing a diag-nostic test of long duration. The importance of visitors to the patients can probably be best summarized by a 49-year-old business man admitted for investigation of hypertension. While talking about the importance of v i s i t o r s , he stated: "We rely on our v i s i t o r s to l e t us know how important we are. It's not the number of v i s i t o r s , as much as the con-sideration shown by them taking their time and trouble to v i s i t i n a hospital. You know yourself how you had to go and put yourself out to see someone in the hospital simply because you thought enough of that person. It can be a damn nuisance having to do i t , but, on the other hand, you have enough consideration for that person's feelings to l e t him know that you care, so you go. The point i s that you've indicated that effort...It makes one feel wanted and gives you a feeling of self-worth." Actual Other Patients - Table 1, page 23, shows that there were only 13 responses e l i c i t e d i n respect to other patients' behavior that made the patient feel more comfortable. The range of responses varied from 0-4 with only seven patients expressing a response. The situations the patients perceived as promoting comfort were varied. One of the most significant things the patients found comforting was the opportunity to compare notes on their diagnostic tests. One woman stated that she found talking to the other patients about the gas-troscopy test comforting because she then knew what to expect when she experienced,the test. One man, who had a heart attack, said i t was com-forting to know that i f he got into any trouble, his roommate could ring for help. S t i l l other patients said i t was comforting to see other pa-tients getting good care and attention and getting well. In the lat t e r case, i t appeared that the patients were identifying with the other 26 patients - t h e i r well-being produced a comforting effect on the i n t e r -viewed patients. DISCOMFORT PROMOTING SITUATIONS Actual Information - Table 2, page 30, shows the actual information given to the patient which he perceived as promoting discomfort. The responses represent 13.53% of the t o t a l number of discomforting situations and range from 0-10 with a mean of 2.64 responses per patient. The information pertaining to the actual diagnostic process ranked f i r s t i n promoting discomfort. Receiving information that the test r e s u l t s re f l e c t e d no pathology was quite upsetting to the patients who d e f i n i t e l y f e l t that something was wrong with them. This was especially true f o r the patients who went home undiagnosed. Some patients f e l t they were not to l d enough about the diagnostic test they were to have, while others were upset because they had made plans f o r discharge and then the doctor t o l d them they needed another diagnostic t e s t . A few patients were upset when they found out what kind of test they would have to undergo. The one fact noted was that many patients were not worried about the o v e r a l l test i t s e l f but only one aspect of i t . For example, when one man was t o l d that the gastroscopy tube had to go down his throat, his response was, "I was r e a l l y shaken by t h i s ! " Information regarding the patient's physical condition and trea t -ment, as a re s u l t of the diagnostic t e s t s , arose as another discomfort promoting factor. One woman was t o l d that i f her u l c e r did not c l e a r up she would need surgery. A few interviews l a t e r she said, "....today the doctor t o l d me that i f I did have an operation I'd be a poor s u r g i -c a l r i s k because I'd probably get a stomach u l c e r again." 27 Information r e l a t i n g to the hospital routines and communication d i f f i c u l t i e s between the members of treatment team ranked high i n promo-t i n g discomfort i n the patient. For example, one woman stated, "....Dr. X happened to see me today and he said, *I thought you were home already.' Here I thought he was looking a f t e r me." The l a s t kind of information that upset some patients was r e c e i -ving information which the patients perceived as an i n s u l t to t h e i r s e l f -esteem. Three patients were t o l d that t h e i r problem stemmed from a psychological basis, not from a physiological basis. In another s i t u a t i o n , one young woman stated, " the doctor implied that I was i n the hospital to c o l l e c t welfare. Who does he think he i s and who does he think I am? I manage my own boutique and the l a s t place I want to be right now i s i n the hospital." Actual Events - An examination of Table ;2, page 30, reveals that the actual events the patients perceived as promoting discomfort accounted f o r 50% of the t o t a l number of responses. The responses ranged from 0-23 with a mean of 9.76 responses per patient. There was only one patient who refrained from expressing a response i n t h i s category. There were 12 patients who expressed concern about experiencing pain. For those 12 patients the degree of pain varied but i t was noted that the more pain the patient experienced the more t h e i r conversation and concerns centered around "pain", and the less energy they had f o r successfully coping with the diagnostic regime. I t was also noted that the patient's a b i l i t y to successfully cope was further hampered when the doctors were unable to f i n d the cause of pain. For example, two patients had to stay i n hospital f o r a longer period of time than they had a n t i c i -pated because they developed severe headaches during the diagnostic 28 regime. Both patients were diagnosed as having stomach ulcers and f o r t h i s reason they could not he given an analgesic containing a s p i r i n . The s i t u a t i o n was further complicated when the doctors were unable to f i n d the cause of the headache. The writer observed that both patients started becoming depressed and remained quite depressed throughout the duration of t h e i r h o s p i t a l i z a t i o n . The actual test procedures were often a source of discomfort f o r the patients. However, i t appeared that the tests were uncomfortable to the degree that the patient perceived certain aspects of the test as being p a i n f u l , of long duration, embarassing, or fear-provoking. Nine patients expressed many varied concerns about food. The con-cerns ranged from the meals not being b i g enough to asking f o r coffee and receiving tea instead. The more general concerns related to getting t h e i r dinner l a t e , food being cold, d i s l i k i n g the meal because i f was so " f l a t t a s t ing" or the meals not being a t t r a c t i v e , and not being able to eat because of having to undergo certain diagnostic t e s t s . I t was noted that food was a very important factor i n making these patients' h o s p i t a l i z a t i o n experience a comfortable one. I t appeared that the waiting period was most uncomfortable f o r the patient when he did not perceive anything as happening or i f he did not see the diagnostic regime as progressing. Seven patients stated that they f e l t very bored i n hospital - "The days seem very long and you have nothing to do." Two patients stated that they f e l t very confined i n the hospital while two others said, " I t i s r e a l l y hard on you when a l l you can;do i s to s i t here and wonder." I t was observed that i f the patient underwent at least one form of diagnostic test per day i t helped re l i e v e hi s boredom and p a r t i a l l y f u l f i l l e d h is need to see progress. 29 There were many hospital routines and procedures that the patients saw as promoting discomfort. The overall fact noted, however, was that the situations the patient perceived as uncomfortable depended upon the i n d i v i -dual's expectations of what should happen and whether or not this expecta-tion was met. The situations the patients perceived as discomfort promoting were many and varied. Seven patients expressed annoyance at having to be admit-ted to the hospital on Friday afternoon although the diagnostic tests would not begin u n t i l Monday morning. One man stated, "We have to wait around for so long. Why can't we come i n Sunday night? It's just wasting tax-payers' money, and, besides, what can you do i n a hospital a l l weekend?" Seven patients stated they did not like to be i n the hospital and a few f e l t the hospital was only for sick people - these patients did not see themselves as being sick. Two patients were upset when their diagnostic tests were cancelled, others were annoyed at being transferred to other rooms within the ward, two patients commented upon coming to the hospital and having to wait three to four hours u n t i l the patient i n their bed was discharged, and f i n a l l y , two patients f e l t that they should not need per-sonal references to be admitted. One of the best examples of an actual event the patient perceived as promoting discomfort was expressed by a business man who was commenting upon the overall health care of patients. He stated: "...because of their complexity, the hospitals tend to become bogged down i n their bureaucracy and they become great plants wherein the people who actually control them are more interested i n the financial aspects of the hospital, the social implications, social record and social history. They're more concerned about the impression they make on the public at large, the impor-tance of the institutional level. This i s the f i r s t level of functioning. 30 The second l e v e l o f f u n c t i o n i n g , the n u r s e - p a t i e n t -d octor r e l a t i o n s h i p should be the most important l e v e l o f f u n c t i o n i n g . This i s almost f o r g o t t e n by the other s i d e of the h i e r a r c h i a l l e v e l . Therefore, the two l e v e l s con-t r a d i c t one another. The upper a d m i n i s t r a t i v e l e v e l i s more concerned about p u b l i c image wh i l e the medical l e v e l i s t r y i n g t o e s t a b l i s h f u n c t i o n i n g on a humanitarian b a s i s . Emphasis should go back to the humanitarian s i d e . The socio-economic system i n our democratic s o c i e t y has gone hay wire and i t ' s the p a t i e n t t h a t s u f f e r s . " T h i s p a t i e n t had analyzed the f u n c t i o n i n g of the h o s p i t a l and was a b i t upset when he came to the r e a l i z a t i o n t h a t , i n many s i t u a t i o n s , the p a t i e n t does not come f i r s t , r a t h e r , h i s care ranks lower i n p r i o r i t y i n r e l a t i o n t o a d m i n i s t r a t i v e p o l i c i e s . Table 2 Responses of the P a t i e n t s During the D i a g n o s t i c Regime Expressed i n Terms of Discomfort Promoting S i t u a t i o n s N-25 Number of Responses Percentage of T o t a l Mean Range A c t u a l Information 66 13.53 2.64 0-10 A c t u a l Events 244 50.00 9.76 0-23 A c t u a l P r o f e s s i o n a l s 102 20.90 4.08 0-16 A c t u a l V i s i t o r s 20 4.09 - 0-5 A c t u a l Other P a t i e n t s 56 11.47 2.24 0-12 488 99.99 A c t u a l P r o f e s s i o n a l s - Table 2, above, shows th a t there were a t o t a l o f 102 responses e l i c i t e d from the p a t i e n t s i n regard t o discomfort promo-t i n g s i t u a t i o n s i n v o l v i n g p r o f e s s i o n a l people. The responses ranged from 0-16 w i t h a mean of 4.08 responses per p a t i e n t . There were nine 31 patients from whom no response was e l i c i t e d i n t h i s area. The situations the patients perceived as promoting discomfort arose as a re s u l t of the professional person v i o l a t i n g the patient's personal value system. This was especially true i n those situations where the patient f e l t that the professional person violated his need to be treated l i k e a d i s t i n c t i n d i v i d u a l with rights as an i n d i v i d u a l . Twelve patients f e l t that they were being treated very impersonally by the pro-fessional s t a f f at one point during t h e i r period of h o s p i t a l i z a t i o n . I n coming to t h i s conclusion i t appeared that the patients were responding more to the professional person's attitudes rather than to any other factor. This perception was further reinforced when the doctors and nurses did not take time out to t a l k with them. The patients expressed other concerns about the professional people they came i n contact with. Seven patients expressed disappointment i n t h e i r doctors when they could not f i n d out what was wrong with them or how to cure t h e i r problem. Six patients expressed feelings of disappoint-ment because they did not see t h e i r doctor as soon, or as f a s t , as they expected they would. Five patients expressed annoyance at being t o l d one thing by one doctor and then being t o l d something else by another doctor. A l l f i v e patients f e l t that the doctors should get together and decide what they were going to t e l l the patient. Four patients f e l t that the professional people did not r e a l l y understand them or t h e i r needs. For example, one man f e l t that the nurses did not see him as being as i l l as the other patients and, therefore, did not give him the attention he expected. Three patients verbalized concerns about the doctors using complex medical terminology instead of layman's terms and two patients got upset when they heard the doctors t a l k i n g about them outside t h e i r room. 32 A good example of a discomfort promoting s i t u a t i o n was best expres-sed by a 29-year-old lady whose admission diagnosis was a bleeding u l c e r . When t a l k i n g about the doctors, she stated: "They a l l stand outside i n the h a l l and t a l k , which i s very poor, I think...I haven't heard anything that i s a l l that personal, i t ' s mostly what's the matter. One p a r t i c u l a r case was about Mrs. X., and about her problem; i t wasn't a l l that personal, but she heard i t , and i t was quite ob-vious who they were t a l k i n g about. So, I don't f e e l i t i s very good. I think they should have some other place to ta l k about i t , or discuss i t i n front of the patient, but not go outside and t a l k a blue streak." Actual V i s i t o r s - Table 2, page 30, shows that there were only twenty res-ponses e l i c i t e d from the patients i n regard to v i s i t o r s (only eight expres-sed any concerns i n t h i s category). The writer was unable to note any general themes as the responses e l i c i t e d were varied and highly i n d i v i d u a l i z e d . The responses ranged from, a patient complaining that the v i s i t o r s were too loud, that there were too many v i s i t o r s , voicing concerns that one's parents did not lookktoo w e l l , and, f i n a l l y , expressing feelings of disappointment that the expected v i s i -tors did not come to v i s i t , nor did the v i s i t o r s stay as long as the patient hoped they would when they f i n a l l y v i s i t e d her. A s i t u a t i o n where a v i s i t o r upset the patient i s probably best ex-emplified by a patient who was admitted f o r investigation of a hypertensive state. This man was having quite a few f i n a n c i a l worries at the time and he became quite upset when his wife brought him a book c a l l e d "Grow Rich With Peace of Mind." When r e c a l l i n g the incident, the man stated: "...My wife v i s i t e d me today unexpectedly, and she brought me t h i s book c a l l e d , "Grow Rich With Peace of Mind." And, at t h i s time, under these circumstances when I have enough on my mind and I'm coping with a problem, my wife brought me t h i s book and said , 'I think you should read t h i s , ' and i t annoyed me because, I said 'number one, I'm here to get over a problem caused by overpressure. Number two, I haven't the s l i g h t e s t i n c l i n a t i o n to grow r i c h with peace 33 of mind o r otherwise. And furthermore, I t h i n k the author i s a C h a r l a t a n . 1 Anyway, I was then a l i t t l e c o n t r i t e because I thought she was...I suppose she was well-meaning. But t h i s has been the b a s i s o f our r e l a t i o n s h i p . She wants to make bucks and she wants me to make them. And, she's more i n t e r e s t e d , I f e e l , i n the d o l l a r than i n the r e l a t i o n s h i p between two human beings, which doesn't r e v o l v e around money a t a l l , b a s i c a l l y . So t h i s s o r t o f upset me." A c t u a l Other P a t i e n t s - An examination o f Table 2, page 30, r e v e a l s t h a t the responses o f other p a t i e n t s accounted f o r 11.47% of the t o t a l number of s i t u a t i o n s the p a t i e n t s perceived as promoting d i s c o m f o r t . The r e s -ponses ranged from 0-12 w i t h a mean of 2.24 responses per p a t i e n t . The concerns were e l i c i t e d from 14 p a t i e n t s . The concerns expressed by the 14 p a t i e n t s covered a wide v a r i e t y of s i t u a t i o n s . The responses ranged from s e e i n g another p a t i e n t f a l l out o f bed, b e i n g wakened up by another p a t i e n t ' s s n o r i n g , h e a r i n g a p a t i e n t t a l k about dying, h e a r i n g another p a t i e n t c o n s t a n t l y complaining, s e e i n g one's roommates going home, l i s t e n i n g to another p a t i e n t c a l l i n g f o r a nurse throughout the n i g h t , t o a s i c k l a d y " g i v i n g o f f a bad s m e l l " . Probably one o f the most s i g n i f i c a n t t h i n g s t h a t made the p a t i e n t f e e l uncomfortable was s e e i n g and i d e n t i f y i n g w i t h another s i c k i n d i v i d u a l . Nine p a t i e n t s v e r b a l i z e d t h a t they would i d e n t i f y w i t h the other p a t i e n t ' s c o n d i t i o n s and f e l t h e l p l e s s as to how they could h e l p them. For example, one 65-year-old lady s t a t e d : " I was t a l k i n g t o my roommate. She was very upset because she couldn't go home. I found her very de-p r e s s i n g t o t a l k t o . I found myself l o o k i n g f o r words to comfort her but they were a l l h o llow be-cause she was s u f f e r i n g and unhappy w h i l e I was f e e l i n g f a i r l y comfortable. I would have l i k e d to h e l p her out but I f e l t so h e l p l e s s i n the s i t u a t i o n . " 34 FACTORS AFFECTING THE DEGREE OF COMFORT OR DISCOMFORT EXPERIENCED BY.THE PATIENT DURING THE DIAGNOSTIC REGIME There are two b a s i c f a c t o r s which must be considered as a f f e c t i n g the degree of comfort or discomfort the p a t i e n t experiences d u r i n g the d i a g n o s t i c regime. These f a c t o r s are personal background f a c t o r s and expectations of the present h o s p i t a l i z a t i o n experience. PERSONAL BACKGROUND FACTORS Past Experience - Table 3» page 35, shows the number of p a t i e n t responses expressed i n terms of past experience. Three general themes were i d e n t i f i e d as i n f l u e n c i n g f a c t o r s i n r e -gard t o past experience. These themes were: (1) f r i e n d s and r e l a t i v e s t a l k i n g about t h e i r past experiences i n h o s p i t a l ; (2) the i n f l u e n c e of the mass media, p a r t i c u l a r l y r a d i o and t e l e v i s i o n ; and (3) the p a t i e n t s ' own personal experiences, e s p e c i a l l y through past h o s p i t a l i z a t i o n . The f o l l o w i n g examples taken from i n t e r v i e w s w i t h three d i f f e r e n t p a t i e n t s demonstrate the i n f l u e n c e of the above themes. The i n f l u e n c e of f r i e n d s and r e l a t i v e s t a l k i n g about t h e i r past experience i s best i l l u s t r a t e d by a f o r t y - t w o - y e a r - o l d lady who was t o l d t h a t she needed a g a s t r i c a n a l y s i s t e s t . She s t a t e d : "Dr. X.came i n and t o l d me t h i s morning t h a t I needed a tube down my t h r o a t . My g i r l f r i e n d had the same t e s t done and the way she d e s c r i b e d i t t o me, i t had t o be the most h o r r i b l e t e s t ever. I'm nervous as i t i s , so the w a i t i n g w i l l be t h a t much worse. I am going t o have t r o u b l e s l e e p i n g t o n i g h t because I w i l l be t h i n k i n g about the t e s t . I know t h a t as the time f o r the t e s t comes, I'm going t o f e e l h o r r i b l e . I keep t h i n k i n g , 'should I go through w i t h the t e s t o r shouldn't I ? ' , but s i n c e Dr. X s a i d I need i t there's no sense of f r e t t i n g o r worrying about i f . " The i n f l u e n c e of the mass media i s best e x e m p l i f i e d by a twenty-f i v e - y e a r - o l d married woman who had a c h r o n i c stomach u l c e r . She s t a t e d : 35 " I came to the h o s p i t a l t h i s time because I had read and heard on t e l e v i s i o n t h a t they are making great advances i n the f i e l d of medicine. You know, you watch a l l those doctor shows on t e l e v i s i o n and see a l l the new treatments they are u s i n g to h e l p p a t i e n t s get b e t t e r . Then you read a l l the advances they're making i n the medical f i e l d , p a r t i c u l a r l y i n the l a s t few y e a r s . I t makes me thinjc t h a t maybe they can f i n a l l y cure your u l c e r . Otherwise I don't t h i n k I would come i n t o the h o s p i t a l . " The i n f l u e n c e of the p a t i e n t ' s own personal experiences, e s p e c i a l l y through past h o s p i t a l i z a t i o n , i s w e l l demonstrated by a f i f t y - f i v e - y e a r - o l d man whose a d m i t t i n g d i a g n o s i s was cancer. I n t a l k i n g about h i s past e x p e r i -ences i n h o s p i t a l , he s t a t e d : " I can't stand i n e f f i c i e n c y . I had three experiences w i t h quackery. For example, one d o c t o r l a b l e d me as having a dropped kidney. He gave me an I.V.P. t e s t and I have never went through such a c r u e l procedure i n my whole l i f e . I passed out three times w i t h v i o l e n t p a i n . I then f i n d out t h a t I never had a dropped kidney. That doctor should have known. An experience l i k e t h i s makes you wonder how competent some doctors a r e . You know, a great d e a l of how s a f e you f e e l i n h o s p i t a l depends upon how much con-f i d e n c e you have i n your doctor." Table 3 Responses of the P a t i e n t s During the D i a g n o s t i c Regime Expressed i n Terms of Personal Background F a c t o r s N-25 Personal Background Fact o r s Number of Responses Mean Range Past Experience P e r s o n a l Value System Needs T o t a l , 195 162 357 7.80 6.48 1-18 1-22 P e r s o n a l Value System Needs - Table 3, above, shows the p a t i e n t s ^ respon-ses i n terms of personal value system needs. There were a t o t a l of 162 responses e l i c i t e d , r anging from 1-22 w i t h a mean of 6.48 responses per 36 p a t i e n t . Because of the importance of the patient's personal value system needs upon h i s perception of comfort and discomfort promoting s i t u a t i o n s , a more d e t a i l e d analysis i s shown i n Table 4, below. Table 4 Factors of the Patient's Personal Value System Needs N-25 Personal Value System Need Number of Patients Expressing the Need To know the r e s u l t s of the diagnostic t e s t s . 23 A f f i l i a t i o n . 22 To see a purpose i n having the t e s t s ( f i n d out what i s wrong). 14 Privacy, d i g n i t y , pride and c o n f i d e n t i a l i t y . 11 R e l i e f from ph y s i c a l discomfort or pain. 11 Health. 10 Respect f o r i n d i v i d u a l i t y . 9 Food. 9 To see progress being made. 8 Economic s e c u r i t y . 8 Honesty. 3 To be busy. 3 C l e a n l i n e s s . 3 Not to i n f r i n g e upon others' r i g h t s . 3 R e l i g i o n . 2 I n t e l l e c t u a l s t imulation. 2 To have c o n t r o l of the s i t u a t i o n . 2 To achieve. 2 Happiness. 1 Cognitive c l a r i t y . 1 Competence by others. 1 37 Table 4» page 36, shows that there were only two patients who did not want to know the results of t h e i r diagnostic tests. One 42-year-old woman expressed a fear of what the results might be so she wanted to hear the results from her own home town doctor. She f e l t her own family doctor could give her the "bad news" i n a more acceptable manner than the doctor i n the h o s p i t a l . Another elderly man who had possible heart problems stated that he did not r e a l l y care about receiving the results of the tests as long as the doctors were happy. Of the twenty-three patients who wanted to know the results of t h e i r diagnostic t e s t s , fourteen (60.87%) continually emphasized that they wanted to know what was wrong with them. Twenty-two out,of the twenty-five patients stated that they wanted to be with another patient during the diagnostic regime. An i n t e r e s t i n g f a c t noted about t h i s high a f f i l i a t i o n need was that twenty-one out of the twenty-two patients wanted to be with just one other person. The reason they gave was i f there was more than one other patient, i t would be too noisy, there would be quite a few other patient personalities to adjust to, and there would be a decrease i n privacy. Only ten patients verbalized that t h e i r health was a very impor-tant part of t h e i r personal value system. Many stated they had taken t h e i r health f o r granted u n t i l they were suddenly faced with an i l l n e s s . Experiencing i l l n e s s motivated them to re-evaluate t h e i r present l i f e s t y l e i n r e l a t i o n to t h e i r physical health. Nine patients verbalized that they wanted respect f o r t h e i r i n d i v i d u a l i t y . They wanted the professionals to see them as a worthwhile i n d i v i d u a l who had r i g h t s , even i f they were patients. The one way many patients evaluated whether or not the professional person, especially the 38 d o c t o r , respected t h e i r i n d i v i d u a l i t y was by the degree of a t t e n t i o n and concern the p r o f e s s i o n a l person gave them. An example of a personal value system need i s w e l l demonstrated by a 25-year-old la d y who expressed a wish t o have her i n d i v i d u a l i t y respec-t e d . During the t h i r d i n t e r v i e w , she s t a t e d : " . . . i t i s n i c e r i f they can j u s t t a l k t o you f o r a few minutes and not act l i k e you are j u s t another bed number. I'd l i k e them t o t r e a t me l i k e a person, not j u s t a bed, and someone l y i n g i n i t . I'd l i k e them t o be interested, and help you any time they can and e x p l a i n anything you want and can t a l k t o you about personal t h i n g s . " I n summary then, the w r i t e r noted t h a t the i n d i v i d u a l ' s personal value system needs were e l i c i t e d whenever t h e i r needs were met or v i o l a t e d through recent experiences i n the h o s p i t a l or on a previous admission t o a h o s p i t a l . EXPECTATIONS OP PRESENT HOSPITALIZATION EXPERIENCE Expected I n f o r m a t i o n - An examination of Table 5» P&ge 40, r e v e a l s t h a t 40.6% of the p a t i e n t s ' expectations r e g a r d i n g t h e i r present h o s p i t a l i z a -t i o n experience focused around expected i n f o r m a t i o n . There was only one p a t i e n t who d i d not express a need f o r any k i n d of i n f o r m a t i o n . The expected i n f o r m a t i o n u s u a l l y centered around the d i a g n o s t i c regime i t s e l f . The p a t i e n t s wanted to know what was going t o happen d u r i n g the d i a g n o s t i c regime, what the r e s u l t s o f the t e s t s would r e v e a l , and whether the t e s t would h u r t them i n any way. The p a t i e n t s wanted reassurance t h a t they would be i n competent hands and t h a t the s t a f f would t r y t h e i r best to make the d i a g n o s t i c t e s t experience as comforta-b l e as p o s s i b l e , A few p a t i e n t s wanted reassurance t h a t the t e s t s were d e f i n i t e l y necessary. Two p a t i e n t s s t a t e d they d i d not want any i n f o r -mation about the t e s t s because i t might cause them to worry more. The 39 other expected information ranged from expecting the nurse to t e l l them where the bathroom was to expecting the doctor to t e l l them when they could go home. An example of the patient's expectation i n terms of receiving information was well expressed by a 55-y ear-old man whose admission diag-nosis was cancer of the stomach. He stated: "....This i s where I was getting back to what I discussed l a s t Friday night, how r e a l l y impor-i tant i t i s that people are advised of what i s going to happen to them while they are i n hos-p i t a l . Now t h i s i s our whole l i f e nowadays i . . . communication, and i f you don't have any i n f o r -mation you're nothing!" Expected Events - Table 5, Page 40, shows that 23.85% of the responses e l i c i t e d from the patients involved expected events. The responses ranged from 0-11 with a mean of 4'«16' responses per patient. Twenty-three of the twenty-five patients expressed d e f i n i t e ideas of what they thought would happen to them during the diagnostic regime. Many patients said they were t o l d what to expect by t h e i r doctors or from knowledge gained from past experiences. Most patients knew what diagnos-t i c tests they would undergo unless the doctors suddenly decided they required another t e s t . Many patients had a good idea of when they could expect the resu l t s of t h e i r tests and when they could probably go home. In most cases the patients appreciated knowing what to expect during the diagnostic regime and the period of h o s p i t a l i z a t i o n was therefore a more comfortable one f o r them. This did not apply to those patients who were admitted from out-side the Vancouver area. Many of the r e f e r r i n g general practitioners did not appear to know what diagnostic tests the patient could expect or, i f they did, they never t o l d t h e i r patients. Patients who did not know 40 what to expect during the diagnostic regime were quite often those who had no past h o s p i t a l i z a t i o n experience. Many experienced feelings of discomfort due to distorted expectations. On tb&other hand, i f the professional s t a f f e l i c i t e d and explored some of t h e i r concerns and expectations at the time of admission, the patient's h o s p i t a l i z a t i o n period become a more comforta-ble one. An example of a patient's expectations of the diagnostic regime was well i l l u s t r a t e d by a 56-year-old lady who was admitted with abdominal pain. During the t h i r d interview she stated: "When I came to the hospital I expected to get results by having a l l the necessary tests and being t o l d what's wrong with me and get t h i s thing a l l done I...I expect them to give me a g a l l bladder test -because I have never had one before. Tomorrow's test should t e l l me what's wrong with me." Table 5 Responses of the Patients During the Diagnostic Regime Expressed i n Terms of Expectations of Present Hospitalization Experience N-25 Number of Res- Percentage Expectations ponses E l i c i t e d of Total Mean Range Expected Information 177 40.6 7.08 0-14 Expected Events 104 23.85 4.16 0-11 Expectations of Pro-30.73 5.36 0-10 fessionals 134 Expectations of 1.38 0-2 V i s i t o r s 6 mm Expectations of Other 3.67 0-2 Patients 15 436 100.23 Expectations of Professionals - Table 5, above, shows that 30.73% of the patients' expectations focused upon how they f e l t they should be treated by professionals, p a r t i c u l a r l y the doctors and nurses. Of the twenty-41 three p a t i e n t s expressing at l e a s t one e x p e c t a t i o n , one of tbemost s i g n i f i -cant f a c t o r s t h a t arose was t h a t the p a t i e n t s wanted the doctors and nurses to respect them as i n d i v i d u a l s . They wanted respect f o r t h e i r f e e l i n g s of p r i d e and d i g n i t y , c o n f i d e n t i a l i t y , p r i v a c y and expected honesty from the p r o f e s s i o n a l people who came i n contact w i t h them. A great number of p a t i e n t s expected the do c t o r t o f i n d out what was wrong w i t h them and cure i t i f necessary. I t was noted that the p a t i e n t was more a c c e p t i n g of the doctor's i n a b i l i t y to diagnose the problem pro-v i d i n g the doctor informed him ahead of time t h a t such a s i t u a t i o n could a r i s e . Many of the p a t i e n t s expected the doctor t o t e l l them what were h i s plans f o r the d i a g n o s t i c regime. Other p a t i e n t s expected the doctors to get together and decide what they were going to do i n s t e a d of one doctor o r d e r i n g one t h i n g and another doctor o r d e r i n g something e l s e . An example of t h i s was expressed by a 25-year-old lad y who s t a t e d : "W e l l , I t h i n k i t i s f i n e t h a t a l l the doctors come around t o see you, but before they say anything t o you, I t h i n k they should get together a t the desk, or whenever they are going t o get together, and make one set of r u l e s , and l e t you know t h a t , i n s t e a d of each doctor t e l l i n g you a l l s o r t s of t h i n g s . " Expectations of V i s i t o r s and Other P a t i e n t s - Table 5, page 40, shows t h a t the responses e l i c i t e d from the p a t i e n t s i n terms of expectations of v i s i -t o r s and other p a t i e n t s , were very low i n respect to the other f a c t o r s . Only f o u r p a t i e n t s s t a t e d any d e f i n i t e expectations o f v i s i t o r s w h i l e twelve p a t i e n t s s t a t e d d e f i n i t e expectations of other p a t i e n t s . The range of responses e l i c i t e d v a r i e d from 0 t o 2 responses. The only g e n e r a l i z a -t i o n t h a t could be made was t h a t the p a t i e n t s expected the v i s i t o r s and other p a t i e n t s to behave i n a c e r t a i n manner. For example, one p a t i e n t s t a t e d t h a t she expected the v i s i t o r s to be q u i e t when they were v i s i t i n g and one man f e l t t h a t the other p a t i e n t s should assume some r e s p o n s i b i l i t y 42 i n h e l p i n g the p r o f e s s i o n a l s t a f f get them w e l l . This man f e l t t h a t too many p a t i e n t s expect the p r o f e s s i o n a l s t a f f t o do e v e r y t h i n g f o r them. Regarding t h i s he s t a t e d , " t h i s i s not r i g h t , the p a t i e n t has t o take some r e s p o n s i b i l i t y i n g e t t i n g w e l l " . I t i s important t o remember th a t when a n a l y z i n g the s i t u a t i o n s the p a t i e n t perceives as promoting comfort or d i s c o m f o r t , i t must be viewed w i t h i n the context of the personal background f a c t o r s and the expectations of the present h o s p i t a l i z a t i o n experience. T h e i r e f f e c t s upon the degree o f comfort or discomfort experienced by the p a t i e n t cannot be underestimated. Therefore, these c a t e g o r i e s of p a t i e n t responses have been presented i n the f i n d i n g s of the study. COPING RESPONSES DURING THE DIAGNOSTIC REGIME Table 6, below, shows t h a t the category of i n d i v i d u a l coping r e s -ponses represented 28.82% of the t o t a l number of responses expressed by the p a t i e n t s d u r i n g the d i a g n o s t i c regime. T h i s s u r p r i s i n g f i n d i n g suggests t h a t the p a t i e n t s may be able to cope much b e t t e r w i t h uncomfortable exper-iences d u r i n g the d i a g n o s t i c regime than p r e v i o u s l y a n t i c i p a t e d by the r e s e a r c h e r . Table 6 Categories of P a t i e n t s ' Responses During the D i a g n o s t i c Regime N-25 . Number of Responses Percentage of T o t a l Personal Background Fa c t o r s 357 15.39 Expectations of Present H o s p i t a l i -z a t i o n Experience 436 18.85 Comfort Promoting S i t u a t i o n s 366 15.85 Discomfort Promoting S i t u a t i o n s 488 21.01 I n d i v i d u a l Coping Responses 667 28.82  T o t a l . . . . . . . . . . . 2314 99.90 43 Table 7, below, shows that the patients v e r b a l i z e d 569 adaptive responses as opposed to 101 maladaptive responses. The findings revealed that the high adaptive responses were p r i m a r i l y due to the f a c t that most patients attempted to l o g i c a l l y reason out the r e a l i t y of the uncomforta-ble experience, had f e e l i n g s of hope and had t r u s t i n the professional people c a r i n g f o r them. (See Table 8, page 44). When one or more of these a b i l i t i e s and/or f e e l i n g s were absent, the patients had the tendency to express a higher rate of maladaptive responses. Table 7 Responses of Patients During the Diagnostic Regime Expressed i n Terms of I n d i v i d u a l Coping Responses N-25 Number of Responses Responses Percentage of T o t a l Mean Range Thinking A c t i v i t i e s 309 42.12 12.36 1--32 Adaptive Responses Ph y s i c a l A c t i v i t i e s 260 38.81 10.40 1--25 Thinking A c t i v i t i e s 93 13.88 3.72 0--15 Maladaptive Responses Physical A c t i v i t i e s 8 1.19 - 0--2 670 100 Table 8 44 Adaptive Coping Responses of Patients During the Diagnostic Regime Expressed i n Terms of Thinking A c t i v i t i e s N-25 S p e c i f i c Themes Expressed Number of Patients Expressing the Theme Attempting to l o g i c a l l y reason out the r e a l i t y of the s i t u a t i o n Expressing feelings of hope Expressing feelings of trust i n the professional people caring f o r them Expressing f e e l i n g of optimism Expressing feelings that they are undergoing the diagnostic regime f o r a purpose - to f i n d out what i s wrong with them Perceiving themselves as not sic k i n comparison to other patients Expressing feelings that they must accept the results of the diagnostic tests even i f they are not as they hoped them to be Expressing feelings that they attempt to put worries r e l a t i n g to the diagnostic regime out of t h e i r mind Searching f o r and planning alternate solutions to problems r e l a t i n g to t h e i r present s i t u a t i o n Deciding to cope with the diagnostic regime one step at a time Expressing feelings of interest and c u r i o s i t y about the diagnostic regime Expressing feelings of humor about t h e i r s i t u a t i o n Expressing feelings of f a i t h i n God Seeing the diagnostic regime as a learning experience, p a r t i c u l a r l y i n terms of changing one's own outlook i n l i f e 20 19 18 10 9 8 7 6 4 3 3 2 ADAPTIVE RESPONSES Thinking A c t i v i t i e s - Table 7, page 43, reveals that thinking a c t i v i t i e s represent almost ha l f (42.12%) of the t o t a l number of responses the 45 patients u t i l i z e d i n t h e i r attempts to cope with uncomfortable experien-ces during the diagnostic regime. The patients had a tendency to u t i l i z e three primary t h i n k i n g a c t i v i t i e s i n t h e i r attempts to cope with uncomfortable experiences. Twenty patients stated that they attempted to l o g i c a l l y reason things out and see the r e a l i t y of t h e i r present s i t u a t i o n , nineteen patients expres-sed f e e l i n g s of hope about the diagnostic regime and eighteen patients expressed f e e l i n g s of t r u s t i n t h e i r doctors, nurses and other p r o f e s s i o -n a l s t a f f c a r i n g f o r them. The wr i t e r noted three other i n t e r e s t i n g f a c t s during the analy-s i s of Table 8, page 44. The f a c t that only s i x patients expressed f e e l i n g s of searching f o r and planning alternate solutions to problems r e l a t i n g to t h e i r present s i t u a t i o n r a i s e s an important question as to how people solve problems during c r i s i s periods i n t h e i r l i v e s . There were only two people who expressed f e e l i n g s of f a i t h i n God. This r a i s e s questions as to how people u t i l i z e r e l i g i o u s p r a c t i c e s during periods of c r i s i s . F i n a l l y , only two patients talked about seeing the diagnostic regime as a l e a r n i n g experience, p a r t i c u l a r l y i n terms of changing t h e i r own outlook on l i f e . The patient's attempt to adaptively cope with the diagnostic regime, i n terms of t h i n k i n g a c t i v i t i e s , i s well exemplified by a 43-year old man admitted f o r i n v e s t i g a t i o n of cardiac and c i r c u l a t o r y problems. During the f i r s t interview he stated: "...but I didn't think about myself because I'd already woken up, so I knew that whatever they d i d , they've done i t , and they went i n because they weren't sure whether I had cancer. But i t was a polyp. But worrying about cancer. What's the sense of worrying about cancer because what's the point of worrying about something that may not be - i t ' s a waste of time. I thought, 'no, I d i d n ' t have i t because I always t h i n k p o s i t i v e . ' You have t o hope, t h a t ' s a l l there i s . You have to hope th a t the sun comes up tomorrow, or i f i t doesn't we're a l l i n t r o u b l e and w e ' l l a l l be dead..." P h y s i c a l A c t i v i t i e s - Table 7, page 43, shows t h a t p h y s i c a l a c t i v i t i e s represent 38.81% of the t o t a l number o f coping responses. The responses ranged from 1-25 w i t h a mean of 10.40 responses per p a t i e n t . An examination of Table 9, page 47, r e v e a l s that the three most common p h y s i c a l a c t i v i t i e s p a t i e n t s u t i l i z e i n coping w i t h the h o s p i t a l i -z a t i o n experience has been reading, w a l k i n g and t a l k i n g . I f the p a t i e n t was unable t o c a r r y out at l e a s t one of these a c t i v i t i e s he would s t a t e t h a t the w a i t i n g p e r i o d was very l o n g and b o r i n g . Twelve p a t i e n t s attempted t o cope w i t h the d i a g n o s t i c regime by u t i l i z i n g unique a c t i v i t i e s . F o r example, one man t a l k e d about b r i n g i n g an earphone r a d i o i n case he d i d not l i k e h i s roommate. I f any problems arose he would pretend he could not hear because he was l i s t e n i n g t o h i s r a d i o . He a l s o s t a t e d p a s s i n g the time by keeping a d i a r y of h i s h o s p i t a l experience. Another woman passed the time by t r y i n g to "show up" the doctors and nurses who she f e l t were not being honest w i t h her. Two men had a game of f o o t b a l l on the h o s p i t a l s t a i r s one day and smuggled a b o t t l e of whiskey i n t o the h o s p i t a l d u r i n g another evening. The f i n d i n g s suggest t h a t p a t i e n t s could cope w i t h t h e i r boredom d u r i n g the w a i t i n g p e r i o d of the d i a g n o s t i c regime, p r o v i d i n g they u t i l i z e d t h e i r i m a g i n a t i o n i n c r e a t i n g i n t e r e s t i n g comfort promoting s i t u a t i o n s . 47 Table 9 Adaptive Coping Responses of Patients During the Diagnostic Regime Expressed i n Terms of Physical A c t i v i t i e s N-25 Number of Patients A c t i v i t i e s Expressing the Theme Reading 20 Walking 17 Talking with Others 14 Phoning Friends and Relatives 12 Listening to the Radio 8 Asking Questions 8 Repositioning of Body•< Alignment 8 Helping Others 7 Watching Television 6 K n i t t i n g , Playing Cards, Jig-Saw Puzzles, Etc. 5 Writing 3 Keeping Outside of One's Room 3 An excellent example of a man u t i l i z i n g adaptive coping behaviors, i n terms of physical a c t i v i t i e s , i s demonstrated by a 43-year-old man who had many repeated admissions to hospital f o r diagnosis and treatment. During the f i r s t interview,with the writer he stated: "The nurses have been very considerate here i o me; of course I work at i t . On a l l the s h i f t s , I work on the g i r l s . I t ' s a game I play with people, and I work on and get them,all to l i k e me as much as they can l i k e a patient. I f you go into the hospital with a superior attitude you've l o s t h a l f the people already. This applies to being anywhere. I f you continue with that superior attitude you've-lost two-thirds, then before the evening i s over you're alone -you're the only one not saying good-bye to someone. So no matter where I am, especially i n the ho s p i t a l , I t r y to make a l l the nurses l i k e me i n a general way. I don't get smart and I don't get 'smutty' or 48 dirty with the nurses. I try to be pleasant and say cute things. Maybe, i f I find out what their interests are I ' l l ask them about i t . I ' l l work u n t i l the g i r l finds me pleasant, and i f you work them a l l that way, well then, they're more pleasant to you, your service i s better, and they're enjoying their job more. You don't go too far though, you try to find a happy medium with each nurse. This way you end up with more service." MALADAPTIVE RESPONSES Thinking.Activities - Table tf, page 4-3, shows that there were 93 responses or 13.88% of the total number of individual coping responses that were expressed as maladaptive thinking a c t i v i t i e s . The responses ranged from 0-15 with a mean of 3.72 responses per patient. There were 19 patients who expressed concerns i n this area. Table 10 Maladaptive Coping Responses of Patients During the Diagnostic Regime Expressed i n Terms of Thinking Activities N-25 Number of Patients Themes Expressed Expressing the Theme Expressing feelings of helplessness 9 Expressing fear of the unknown 8 Expressing disappointment with one's own emotional reaction to stress 7 Expressing feelings that they see no improvement i n their condition 5 Expressing feelings of being rejected by the doctors and/or nurses 4 Expressing feelings of depression 4 Deciding not to t e l l the doctor about any pain they are experiencing because they f e l t i t would not do any good 4 Expressing thoughts of committing suicide 2 Expressing feelings that his physical condition was worse than he had thought i t was 1 49 Table 10, page 48, shows that the highest frequency of the patients* maladaptive thinking activities focus upon experiencing feelings of helplessness in regard to their present situation while fear of the unknown ranks a close second. Interesting also, is the fact that seven patients expressed disappointment with their own emotional reaction to the stress caused by the diagnostic regime. The four patients who decided not to t e l l their doctors they were experiencing pain did so because they felt that, since the doctor was unable to help relieve the pain during the diagnostic regime, the best thing to do was to keep quiet about the pain - that way the doctor would discharge them. An example of a patient who verbalized maladaptive behavior in terms of thinking activities was well demonstrated by a 43-year-old man admitted for investigation of a gastric ulcer. During the fi f t h interview he stated: "I think when the doctor told me that I had these highs and lows - there's something there. That has something to do with i t . One day you're just on the clouds, the next day you're down where nothing matters. You don't care anymore. You know I have a fear that something could touch me off...and believe i t or not I live in a high rise and that isn't good for a person who's in that mood - it's too easy. You look down there, fourteen floors down, and...I don't know why, I've always got i t in my head. I don't want to do i t by no means, you know, but I always think, 'isn't that an easy way to go. I could just be a splash down at the bottom.' It seems like... almost in a way, it's a t h r i l l falling there I And I keep thinking, 'what would i t be like going down that far?' Those thoughts shouldn't be there. That's an awful thing to have on your mind because i t could happen , I should live in a low rise in case something ;should upset me enough that I'm not going to get clear enough to realize that it's stupid and, up and do i t before it's too late to stop. I never told my wife this. She doesn't know that I'm thinking of such things. Oh, I ' l l never jump out of a window but I'm scared that something's going to click there...that I'm not going to be able to control. That's only a worry." 5 0 P h y s i c a l A c t i v i t i e s - Table 7, page 43• r e v e a l s t h a t there were only e i g h t maladaptive responses, i n terms of p h y s i c a l a c t i v i t i e s , expressed by a s m a l l m a j o r i t y of the p a t i e n t s . I n a l l instances the responses were a l l h i g h l y i n d i v i d u a l i z e d and s p e c i f i c t o th a t p a r t i c u l a r p a t i e n t e x p r e s s i n g the responses. F or example, one lady phoned her husband and i n s t e a d of f e e l i n g b e t t e r she s t a t e d she f e l t even l o n e l i e r . Another lady denied t h a t she was upset but t e a r s were coming i n t o h er eyes while she was t a l k i n g t o the w r i t e r . One lady would not consent t o having a l i v e r biopsy u n t i l a l l the doctors got together and decided i f she r e a l l y needed one. She was angry because they could not decide what was wrong w i t h her or what d i a g n o s t i c t e s t s they should run. This same lady had gotten very upset d u r i n g her l a s t admission to h o s p i t a l and had signed h e r s e l f out aga i n s t the doctor's consent. She s a i d she knew i t was wrong but she f e l t i t was her only s o l u t i o n t o her problem a t the time. Chapter IV DISCUSSION OF THE FINDINGS The results of this study revealed that the situations the patients perceived as promoting comfort or discomfort were dependent upon two si g n i -ficant variables: (1) The degree to which the patient's personal value system needs were being met during the diagnostic regime. (2) The patient's a b i l i t y to mobilize adaptive coping responses to deal with the stresses caused by the diagnostic regime. COMFORT AND DISCOMFORT PROMOTING SITUATIONS DISCUSSED IN TERMS OF THE PATIENT'S PERSONAL VALUE SYSTEM NEEDS A careful analysis of the situations the patient perceived as pro-moting comfort revealed that the patient's personal value system needs were being met to some degree, either through his own efforts or through the efforts of others. Conversely, the patient's perception of a discom-forting situation was due to his needs not being met or being violated by other people. The importance of understanding and meeting the individual's per-sonal value system needs i s well illustrated by Syngg and Combs. In their book, Individual Behavior, they point out that a person's values are of great importance i n the understanding of the behavior of others. When a person's values are known i t often becomes possible to predict with great accuracy how he may behave in given situations. The individual's values and needs have profound effects on his perceptions and has important im-plications i n a l l types of social interaction. I t has been shown for example, that persons whose values favor a certain event or outcome tend 51 52 21 to expect such a desired outcome. Syngg and Combs writings support the writer's conclusions that the patient comes to h o s p i t a l with some d e f i n i t e expectations of what should happen to him and how others should respond to him during the diagnostic regime. The patient's past experience, h i s current biophyscho-s o c i a l condition, and the information given to him by h i s doctor p r i o r to h i s admission to h o s p i t a l influences h i s expectations. However, the w r i t e r contends that these f a c t o r s play a minor r o l e i n comparison to the influence of the i n d i v i d u a l ' s personal value system needs i n determining h i s expectations. I t then follows that the degree of comfort or discom-f o r t experienced by the patient would depend upon the extent to which h i s expectations were being met. To substantiate the writer's conclusions, the two f o l l o w i n g nurse-patient i n t e r a c t i o n s i l l u s t r a t e the importance of the nurse recognizing how the patient's personal value system needs greatly determines; h i s expectations as to how he should be treated during the diagnostic regime. The f i r s t example shows the ^ patient's f e e l i n g s of discomfort when her need to he, treated with respect as an i n d i v i d u a l with r i g h t s , i s v i o l a t e d . The second example demonstrates another patient's f e e l i n g s of comfort when t h i s same need and resultant expectation i s met. Patient #1: Patient: Dr. S. i s making me f e e l that I shouldn't even be i n t h i s h o s p i t a l . The impression.I'm g e t t i n g from him i s that I am not s i c k enough to be here. Yet i t was through h i s suggestion that I am here i n the f i r s t place; I didn't ask to come i n . Arthur W. Combs and Donald Svngg. I n d i v i d u a l Behavior, ed. Gardner Murphy (Revised ed.; New York: Harper and Row,. Publishers, (1959), PP.37-121. 53 Nurse: Go on. Patient: But he i s making me f e e l - w e l l , yesterday, he asked me how I was f e e l i n g and I said, ' t i r e d ' , and he sai d , 'well, i f that's your only complaint.' Nurse: So how did that make you feel? Patient: Well, I f e l t rather stupid because i t wasn't a complaint r e a l l y . But, I f e l t that the important part of my treatment was the rest and that wasn't what I was getting; so he should r e a l l y know about i t . He didn't seem to think i t was too important. He then asked me, 'how i s your stomach?' And I to l d him about the d i f f e r e n t times I have had pain and what not; and he said, 'okay, see you tomorrow,* or something to .that e f f e c t . I just get the f e e l i n g now that he thinks I shouldn't be here. Well, that's f i n e , i f he wants to send me home I would l i k e to go home, but i t was on hi s suggestion, as well as my doctor's, that I came here. Nurse: You say, you perceived that he doesn't want you here? Patient: I just - i t ' s just a f e e l i n g that he i s passing on to me. Just by the way he says certain things. Nurse: How did you reach t h i s conclusion? Patient: Well, just 1>he way - when I said I was t i r e d and just the way he said, 'well i f that i s your only complaint.' - And, just the look he gave me. But I don't quite understand what he means that I should be walking up and down the h a l l f o r , one thing., Nurse: Did you ask him? Patient: No,,_I didn't ask him because quite frankly I was annoyed and didn't f e e l l i k e t a l k i n g to him anymore. Patient #2: Nurse: Could you t e l l me why you l i k e your family doctor? Patient: You can s i t down and v i s i t with her l i k e a - we l l , l i k e two women - or - uh - you can s i t and v i s i t with her; not l i k e a doctor but l i k e another human being. And, t h i s meansja-l o t more to me than i f you found somebody - well - uh -'here I ' l l t r y and give you some p i l l s , and i f they don't work come back again and I ' l l give you, something else, or some other, stupid thing l i k e that. She doesn't do t h i s . NurseJ You mean she takes time out with you to f i n d out what i s r e a l l y wrong? 54 Patient: She takes the time out; she's got the time of Jot, and she'll s i t there and l i s t e n . And, i f she feels that there i s something that you are holding back, she'll go about i t i n such a way that you're going to t e l l her before you leave that door. - Like, I was t e l l i n g Dr. S. the other day, 'in a l l the doctors I've ever gone to, she's the f i r s t one that I went to that gave me, uh - I mean, that looked at me and got the needle out and took my blood. And she's the f i r s t one that I have ever seen do that. - When I f i r s t got pregnant I went to a different doctor and he didn't even do this. I t just made me feel uneasy, because how could he know what, where and when, or anything about my pregnancy unless he did some tests. He just didn't give a damn about me. ' Nurse: Do you mean then, that your doctor treats you like an important person? Patient: Yes, she certainly does! COMPORT AND DISCOMFORT PROMOTING SITUATIONS DISCUSSED IN TERMS OP THE PATIENT'S ABILITY TO MOBILIZE ADAPTIVE COPING RESPONSES The results of the study indicated that the degree of comfort or discomfort was highly dependent upon the patient's a b i l i t y to mobilize adaptive coping responses to deal with the,stresses caused by the diag-nostic regime. This a b i l i t y i n turn was greatly influenced by the patient's evaluation of what was happening to him. Further, the patient's evaluation was affected by his past experiences, his present biopsychosocial state, and the duration of the perceived stress. The results indicated that whether or not a particular situation causes stress depended a great deal on the way the patient evaluated the stress situation, especially i n relation to his feelings about his a b i l i t y to cope with i t . Further, his evaluation and adaptive responses were i n -fluenced by his past experiences which conditioned him to react i n specific patterns of learned behaviors. He therefore not only reacted to the actual existence of danger, but to perceive threats and symbols of danger exper-ienced i n his past. Stress situations which the patient evaluates as 55 physically damaging or threatening to his survival, such as being given a positive diagnosis of cancer, carry a high degree of threat. Similarly, stress situations which threaten the adequacy and worth of the patient involves a strong element of threat. If the patient's resources for coping adaptively with stress are limited due to marginal psychological adjustment, continued social pressure or physical stress (eg. pain), the slightest frustration or perceived pressure of the diagnostic regime may place him under severe stress. The patient who deeply doubts his adequacy and worth is constantly experiencing threat. The patient who is worried about finding a job so that he can pay off his b i l l s will find each additional day in hospital a great burden. Finally, the illness itself draws a certain amount of the patient's atten-tion and emotional energy. If he is experiencing pain of long duration and is unable to anticipate when i t will end, or i f the underlying reason for his pain is unclear, he will have a more difficult time in coping with the pain. As a result, his hope is lowered and he will have less resources for adaptively coping with the stresses. The antithesis was also true. The results of the study indicated that i f the patient was fairly well adjusted and was not experiencing a great deal of continued social or physical stress, his evaluation of what was happening to him was more reality oriented and he had more resources to cope adaptively with the stresses caused by the diagnostic regime. The following excerpts from interviews with selected patients demon-strate the influence of the patients' past experience, present physical, psychological, and social state, and duration of stress, upon their evalua-tion of what was happening to them. These examples further illustrate how the patients' evaluation of what was happening to them affected their 56 a b i l i t y to adaptively cope with the stresses of the diagnostic regime and hence t h e i r resultant feelings of comfort or discomfort. , The f i r s t i n t e r -view shows how the patient's past experience resulted i n him evaluating the stresses of the diagnostic regime as l i f e threatening. His r e a l i t y based fears resulted i n him experiencing a great deal of discomfort and he had many problems i n coping adaptively throughout the diagnostic regime. Patient: Now .you're here f o r a purpose. In my case, I have to go through some te s t s . Now, what are the tests? O r i g i n a l l y t h i s started out as-^a bleeding u l c e r but, only today i t came fo r t h that i t ' s possibly a tumor. And then there was t a l k l a t e r on of cancerous c e l l s . Now the word 'cancer' i s a rather f i l t h y word,land you immediately take a 'nose-dive''down. - 'What i f I have cancer?' I've heard of cases you know; everybody's heard of cases whereby you get on the operating table, the surgeon w i l l open you up and sew you up, and i n s i x months you're buried. This I don't want, because l i k e I say; I worked for t h i r t y years. I plan on r e t i r i n g next year. I ' l l be 57 and I think t h i s i s an idea l time to r e a l l y s t a r t l i v i n g . Nurse: When did you think i t might be cancer? Patient: Today when Dr. B. referred to i t as a tumor. Also, Dr. B. referred to i t as malignant. Now when Dr. S. came i n he said that Monday's tests w i l l be a gastroscopy t e s t , and he would take a biopsy to check f o r cancer c e l l s . But, then, those bring f o r t h l i t t l e remin-ders i n the past; i n 1965 my brother-in-law passed on with cancer. About two years ago a fellow I worked with, he had cancer. So these things s t a r t f l a s h i n g through your mind; and both men had s i x months to the day. - Really, you only have to see one person dying of cancer and you'd be a f o o l not to take a page out of the book and just s a y ^ ' w e l l , I hope that t h i s w i l l ,neyer happen to me.' I'm fi n d i n g out very fast that as the years r o l l along, these things,do happen to youl - Now, as f a r as the cancer b i t i s concerned, I don't know too much about i t but I know when i t h i t my brother-in-law, now - I never saw him i n his i n i t i a l stages but he was a well-proportioned man of 185 pounds, and about three weeks before he passed on I saw him and he was around 100-110 pounds. * This patient's feelings of discomfort, due to his past experience can be contrasted to another patient whose past experience helped him to be able to cope adaptively with the stresses created by the diagnostic regime. Nurse: After your past f i v e admissions to ho s p i t a l , you,appear to know 57 the hospital routines and understand the diagnostic tests* Patient: Yes. You get to know the way a hospital works and runs. You gain confidence, and after the f i r s t session i n there, I - i t was eleven months. I got to know everything pretty well i n the General Hospital; so you pretty well get to know what to expect. So,, that's certainly a comforting thing. The next two excerpts of interviews demonstrates the influence of the patient's present psychological state upon his evaluation of what he's experiencing and his subsequent a b i l i t y to cope adaptively with the stres-ses caused by the diagnostic regime. The f i r s t example concerns a man who was considered to be poorly adjusted while the second man interviewed was considered to be well adjusted. Patient #1: Burse: Patient: Nurse: Patient: Nurse: Patient: Nurse: Patient: Nurse: Patient: Edgar, are you saying that you are afraid that you may also be-come- mentally i l l yourself and possibly commit suicide? But you haven't, (nods his head i n agreement) That's the way I'm reading you right now. Edgar. No, but you don't get a second chance i f you do i t . That's true. I would hope that you would get help f i r s t . The thing I'm worried about i s that you are l i v i n g i n the past and you're allowing the past to rule your present l i f e . We can't change the past, Edgar. (cries for a period of time) - I'm getting upset. Edgar, what's upsetting or hurting you right now? These things you didn't know about, but I didn't really expect to t e l l you about them. Edgar, I was aware that you seemed quite depressed. Bid you know that? Yeah, I know, (pause) I think when the doctor told me that I have these highs and lows, that has something to do with i t . One day you're just on the clouds, the other day you're down where nothing matters. You don't care. 58 Nurse: And the disappointment of knowing that you may have to have an operation - the one thing you're afraid of. Patient: Yes. And I know another thing that hurts. I feel sorry for kids that are pushed around because I was pushed around. I was pushed from home to home then back to the orphanage where I f i r s t started, you know. What was it? Because they didn't like me. I wet the bed too much. I remember that for instance. Things lik e that. They didn't l i k e me, you see. Well then where do I go? Back to that stupid l i t t l e orphanage again. And I can see I've been connecting this up while I'm here i n hospital. Patient #2: Nurse: What i f the results of your tests aren't what you hoped them to be? Patient: I f the doctor comes i n and t e l l s me that I have six months to l i v e , that's okay with me. I have led a good l i f e . I have nothing to complain about. Too many people start worry-ing i f they are told they are going to die i n six months. For example, i f the doctor t e l l s a person that he's only got a year to l i v e , then that individual may talk himself into i t , and he dies within a year. No, I couldn't be bothered to worry. I'm not concerned about the tests. The doctors know what they are doing. I can accept whatever they t e l l me. I was working i n a logging camp but i f they t e l l me I can't work then I ' l l retire and take l i f e easy. I don't have much money but I can manage. I used to f i s h . I could do that or I can take up reading again. I lik e l i v i n g alone so I don't feel I ' l l have too many problems. Does that answer -your question? The f i r s t patient's intense feelings of inadequacy and low s e l f -worth resulted i n him evaluating minor stresses, frustrations and disap-pointments as very threatening. His many expressed feelings of discom-fort reflected his i n a b i l i t y to adaptively cope with such situations. The second patient, on the other hand, coped very well throughout the diagnostic regime. His inner strength and trust i n others enabled him to adaptively cope with a l l the stressful situations that arose, despite the fact that he was i n hospital for cardiac investigation. The influence of the patient's present social circumstances upon 59 his evaluation of what i s happening to him and his resultant a b i l i t y to adaptively cope with the diagnostic regime stresses i s illustrated by excerpts from the following two nurse-patient interviews. The f i r s t exam-ple shows the patient expressing feelings of comfort because he had job security, despite the fact that he had to come to hospital for diagnostic tests. The second example demonstrates how the patient's lack of job security hindered his a b i l i t y to adaptively cope during the diagnostic regime. Patient #1t. Nurse: Who, would you say, has helped you the most so far? Patient: My superior at work, not only today - a couple of days ago he has given me - I think he has helped me more than anyone, else and he hasn't said hardly anything. The only thing he said, 'don't worry, everything w i l l be fine here, and even i f I have to get a new man in,' and a l l t h i s . So he has taken i t upon himself to t e l l me not to worry about i t -'Just don't think about your job or nothing, everything i s taken care of.' And, they are paying me while I'm away. So you know those l i t t l e things mean an awful l o t . I f I knew I was s i t t i n g here wasting my time, I'd feel 'well, I could be working those days and not - and just come i n when they need me for the operation so something lik e that, because you're losing money, or they need you at work, or your job might be jeopardized, you know.' But now I know i t isn't; my job i s secured, and that's a wonderful feeling there. I've never had a job like that before. That other job I worked for the last 15 years, prior to this one, wasn't that way at a l l . I f I'd have done this, through no fault of my own of course, they would have just cut my pay then and there as of the day I l e f t . This company makes you realize that you have a good company to work for, you know. You feel pretty good with them. And, when he said, 'don't worry, don't worry,' you think, 'well, that's pretty nice, I won't even have to think about my job.' I feel I'm taking a holiday almost, you know. - I am willin g to go ahead andstay i n here and get the tests over with . Patient #2: Nurse: With the other two roommates going home, did you sort of wish you were going home too, and getting out of hospital? Patient: No, not really - well - uh - i n a sense yes, and i n a sense, Nurse: Patient: Nurse: Patient: Nurse: 60 no. I've.got no r e a l home to go to. You know - I have an apartment, and - hut I've only "been there a short while and i t ' s not yet a home r e a l l y . I t ' s just a place to be. So I'm not r e a l l y looking forward to that. And, of course, another unfortunate thing i s that I went out, I think yester-day, and I have my car parked at the garage down here by my o f f i c e building. And f o r some damn reason the s t a r t e r quit on me, and they don't know why. I've asked them to t r y and f i n d out. So there's another problem I have to look at. Not only that, i f I'm not out at the end of the month, then I have no licence f o r the car so I can't drive i t anyway. So I have a few things to figure out as to how I'm going to go about doing those things. When your roommates were here, you could help booster one another up, but now you're going to have to face up to a few of your concerns? Yeah - w e l l , I think perhaps I tended to shove those worries to the back of my mind, you know, and thought, 'well, you know, I ' l l take care of them l a t e r . ' Now suddenly they're pushed to the front of my mind, partly because of my mood, partly because there i s n ' t a relationship to occupy my mind. Actually then, you have /a l o t of things on your mind? Yeah, I have quite a few things that I'm going jto have to square away. I, have to f i n d out just how long I'm going to be i n here. I'm c e r t a i n l y not earning very much money i n here. I think I might have enough finances to l a s t one month. I hope that man from Eaton's comes up to see me because I want to f i n d out just how long i t ' s going to be a f t e r I pass t h e i r exam before I can get i n there and get into a salaried, area, then I ' l l be okay. I ' l l be able to swing i t . Isn't i t kind of funny? You're i n here to f i n d out the reason f o r your high blood pressure and then a l l t h i s happens. That's not doing much f o r your blood pressure. Patient: No, that's perfectly true, though i t proves one thing. The medication I'm presently on must be working because my blood pressure hasn't gone any higher. In any event, I'm t i r e d ; when I'm t i r e d my mood tends to become depressed. I'm depressed. I'm worried about the future because at the moment I can't see a future, and i t c e r t a i n l y troubles me quite deeply. This patient had expressed many feelings of discomfort and he gra-dually became more depressed throughout the l a t t e r part of his h o s p i t a l i z a -t i o n . An analysis of these feelings revealed that he had evaluated each additional day i n hospital as a great burden. This evaluation i n turn was 61 based upon his present s o c i a l circumstances which hindered his a b i l i t y to cope adaptively, hence his increased feelings !of depression. The f i r s t pa-t i e n t had no discomforting feelings i n t h i s area and therefore had more ener-gy to cope adaptively with the stresses caused by the diagnostic regime. The effects of the patient's physical condition and duration of stress upon h i s a b i l i t y to cope adaptively with the diagnostic regime i s best exemplified by a 29-year-old lady who developed a severe headache during the diagnostic regime. Her f i r s t problem was diagnosed as a stomach u l c e r but the doctors were unable to diagnose the cause of her headaches. During the tenth interview the following discussion took place: Patient: I was annoyed because my headache i s s t i l l there. Nurse: Go on. Patient: You know - I guess i t ' s getting to me. r I don't know, i t ' s seven days now and i t ' s getting me down. The fact that i t ' s been there f o r so long was getting me down and I was also worried about - there might be something wrong with my head, or, you know, could I have a brain tumor? or things l i k e that were going throughrmy mind. I t gets you down a b i t because, I f e e l now I'vejiad t h i s headache a week; i t ' s set me back a whole week. I f e l t I was improving and now I've been having a l o t of pain, whereas my stomach u l c e r pain was less frequent up u n t i l the time I got t h i s headache. I t ' s a l i t t l e discouraging to me that they, can't do. something to get r i d of i t so that I can eat; but I guess they can't, otherwise they would have done i t . I mean - they put me on these Codeine 60 and a l l that's done i s t o constipate me, but i t doesn't r e a l l y relieve the headache. Nurse: So how does the future JLook to you right now? Patient: Well, I'm beginning to wonder i f and when I'm ever going to get out of here. You know, I'm a l i t t l e depressed due to the fact that I know that t h i s business has set me back - and I have a temperature too, and i t ' s going up and down. They are taking i t frequently. So I am sort of discouraged because maybe I was expecting too much. I had thought that once I saw my doctor he would give me something to reli e v e me of. the pain and allow me to s t a r t eating again; Now he's to l d me that i t might take a day, two days, three days before t h i s ) i s going to do anything because the headache has taken a hold of i t s e l f . So now I'm thinking, 'Well, here I've 62 got another three days of not being able to eat properly, 1 and you know i t ' s sort of gotten me down that way. Because when I came i n , I was t o l d that I'd be i n 10 days to two weeks while they run t e s t s . I wish my headache would just go because I think that i t ' s h a l f the problem of my stomach r i g h t now. I t ' s probably bothering me more since I_'ve got t h i s headache because I can't read, and I can't stand l i g h t s or noise on T.V. I t just about drives me nuts. And I haven't read a book because I can't concentrate on my reading, and I haven't been doing anything. So the day i s long and i t ' s discouraging. The twelfth interview further demonstrates the demoralizing effects of long term stress (pain) upon the patient's a b i l i t y to adaptively cope with the stresses of the diagnostic regime. Nurse: You said you have many feelings today? Patient: At one point today I was very depressed because I s t i l l have t h i s headache, and i t ' s worse today, t h i s afternoon, than a l l the rest of the days that I've had i t - i t ' s worrying me and i t ' s had me depressed; and I've sort of been down i n the dumps, a l i t t l e b i t blue maybe. I can't figure out why i t ' s l a s t i n g so long; - and - I don't know whether i t ' s nerves or whether i t i s an effect of my car accident, or what i t i s , you know. Be-cause I can't understand a headache - I mean, I've had them before, up to four days, but I've never had them going t h i s long - and - I never touched my dinner tonight. Nurse: You didn't? Patient: Uh - mainly because I didn't f e e l l i k e eating. My headache was so bad and my stomach was so upset, I think due to the headache more than 4 anything else. And i t i s sort of getting me down because I think, 'I can't understand why i t ' s there continuously f o r that many days.' So - uh - I didn't say any-thing to my doctor t h i s morning. He asked me i f I s t i l l had the headache, and I said 'yes' and he said, 'did the medica-t i o n help?' I sai d , 'they ease i t a b i t . ' But at 4:30 PM they gave me some p i l l s but i t hasn't done a thing f o r my headache. She gave me some p i l l s again about an hour-and-a-h a l f ago and i t hasn't helped. They're not very strong due to the fact that I have an ulcer . But that's sort of playing on my nerves a l i t t l e b i t . I can't, quite understandawhy i t would l a s t that long, I'm kind of worrying that when I h i t my head and something's happened there. But - so that's why I've been a l i t t l e blue and depressed. I t ' s playing on my nerves because I've had i t f o r so many days now, you know, I believe that t h i s i s the f i f t h or s i x t h day that I've had i t now and i t i s getting to the point where i t i s upsetting me because I f e e l that i s n ' t normal that somebody has a headache f o r that.length of time. And, i f i t ' s a f f e c t i n g my - you know so that I can't eat, then i t ' s not helping my nicer neither. Nurse: And you're starting to find yourself spending more time worry-ing about i t ? Patient: Yeah, I am. I haven't f e l t that way u n t i l today. I find i t hard to talk to people and I find it hard to be polite. And yet I've had visitors and I don't want to upset them. My mom and dad were i n and I didn't want them to be aware of the fact that I had i t . They know I had a headache but they don't know how severe i t really i s ,;. The major source of this patient's discomfort was due to the fact that her doctor was unable to relieve her prolonged headache. This patient's evaluation of her present situation was one of discouragement. Her response to her evaluation was depression. During the latte r half of her hospitali-zation she was spending so much energy i n attempting to cope with the pain, that she was unable to adaptively cope with minor stresses that arose during the diagnostic regime. The ensuing days were f i l l e d with feelings of des-pair and her depression deepened. She f i n a l l y l e f t hospital without actually knowing what had caused her headache. CHAPTER V IMPLICATIONS AND RECOMMENDATIONS ARISING FROM THE STUDY Hospital Administrative P o l i c i e s The fact that 22 of the 25 patients interviewed wanted to be i n a room with at least one other patient supports Schachter's findings that, under anxiety-provoking situations such as undergoing diagnostic t e s t s , people prefer to be with other people who are undergoing a s i m i l a r experi-22 ence. I t i s therefore recommended that, unless otherwise requested by the patient, the patient should be admitted to a semi-private room while he i s undergoing diagnostic t e s t s . Medical S t a f f Many of the patients who came to the hospital f o r diagnostic t e s t i n g demonstrated some apparent degree of fear. This fear motivated them to exhibit varying degrees of vigilance responses. A per s i s t e n t l y high l e v e l of anticipatory fear, such as a fear of having cancer, produced i n these patients a lowering of r e a l i t y - t e s t i n g capacities and a greater tendency to cope maladaptively with s t r e s s f u l s i t u a t i o n s . Often these patients were highly sensitive to the doctor's verbal and non-verbal com-munications and, i n many cases, misinterpreted them. The doctor was the most s i g n i f i c a n t person to the patient during the diagnostic regime and the more tru s t the patient had i n his doctor, the greater was the iproba-b i l i t y that the patient would experience feelings of comfort. I t i s therefore important that the doctor understand that his own attitudes toward the patient, as well as his manner of presenting information to 22 Stanley Schachtery The Psychology>of A f f i l i a t i o n (Stanford, C a l i f o r n i a : Stanford University Press, 1959), pp.12-24. 64 65 the patient, both affect the patient's trust i n him. I t i s therefore recommended that the doctor should make certain that the patient's inter-pretation of the doctor's communication i s the same as what the doctor intended to convey to him. The doctor then has the opportunity to clear up any misunderstandings that arise and hence to reduce the likelihood of unnecessary discomfort and anxiety for the patient. Research Many patients had d i f f i c u l t y verbalizing their specific expecta-tions of the diagnostic regime. Most had a vague idea of what they expec-ted but could not easily put i t into words. This d i f f i c u l t y was, no doubt, compounded by such factors as the patient's anxiety due to his admission to hospital, his lack of knowledge of hospital procedures, his misunder-standing of the doctor's reports, and so on. However, the findings of the study also revealed that the patient's expectations arose as a result of his underlying personal value system needs. Therefore, an identification of these needs could provide the helping person with clues as to the patient's expectations as well as to identify potential problems that may arise during the diagnostic regime. For example, i f the patient had unrea-l i s t i c expectations of how his doctor should behave towards him, a problem could develop very quickly since the doctor would not be able to meet the patient's expectations of him. Medical or nursing intervention would then be required to help the patient become more r e a l i s t i c i n his expectations and to bring the patient's expectations i n lin e with the actual behavior of the doctor. I t i s therefore recommended that further research be con-ducted to devise a tool that would e l i c i t and identify the patient's personal value system needs. The results of this study revealed that patients can cope more 66 a d a p t i v e l y than was o r i g i n a l l y a n t i c i p a t e d . The f i n d i n g s showed t h a t p a t i e n t s possess s p e c i f i c s k i l l s and a b i l i t i e s t h a t can be u t i l i z e d i n h e l p i n g them cope a d a p t i v e l y d u r i n g the d i a g n o s t i c regime. However, these s k i l l s and a b i l i t i e s v a r i e d w i t h the p a t i e n t ' s past experience, h i s present b i o p s y c h o s o c i a l s t a t e , and the d u r a t i o n of the perceived s t r e s s . I t i s t h e r e f o r e recommended t h a t f u r t h e r r e s e a r c h be conducted t o formulate a t o o l t h a t would e l i c i t and i d e n t i f y the p a t i e n t ' s s p e c i f i c s k i l l s and a b i l i -t i e s and at the same time to r e l a t e them to the f a c t o r s mentioned above. Fu r t h e r experimental research needs to be conducted to determine whether or not p a t i e n t comfort i s s i g n i f i c a n t l y i n f l u e n c e d by the degree t o which the p a t i e n t ' s personal value system needs are bein g met, and the p a t i e n t ' s a b i l i t y to m o b i l i z e adaptive coping responses to deal w i t h the s t r e s s e s created by the d i a g n o s t i c regime. Such 1 research could t e s t the f o l l o w i n g n u l l hypotheses: (1) There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n p a t i e n t comfort experience when the p a t i e n t ' s personal value system needs are met; (2) There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n patient, comfort experience when the p a t i e n t i s able t o m o b i l i z e adaptive coping responses t o de a l w i t h the s t r e s s e s created by the d i a g n o s t i c regime. Nur s i n g The i m p l i c a t i o n s of the study f o r n u r s i n g r e v e a l the importance of the nurse i n e l i c i t i n g and i d e n t i f y i n g the p a t i e n t ' s personal value system needs and the s p e c i f i c s k i l l s and a b i l i t i e s he possesses. Nursing has / t r a d i t i o n a l l y .followed the medical model and hence, the i d e n t i f i c a t i o n o f these f a c t o r s has been dependent on the nurse's own s e n s i t i v i t y to the p a t i e n t ' s needs. I t i s t h e r e f o r e recommended t h a t a t o o l be a v a i l a b l e t o a s s i s t the nurse i n i d e n t i f y i n g these f a c t o r s . Such a t o o l should be 67 u t i l i z e d at the time of the patient's admission to hospital and should i provide clues as to the patient's expectations. As w e l l , i t should iden-t i f y potential problems that could arise during the diagnostic regime. The problems could then be anticipated and a l l e v i a t e d by the nurse before they have an opportunity to create discomfort f o r the patient. The writer must caution the reader that while such a t o o l would a s s i s t the nurse i n i d e n t i f y i n g the, above factors, i f the data gained i s not u t i l i z e d properly t h i s t o o l would simply become another meaningless procedure. Further, such a t o o l could never replace the nurse's s e n s i t i -v i t y to the patient's needs or her own ingenuity i n enabling the patient to u t i l i z e h i s own resources i n coping with the stresses of the diagnostic regime. The implications of t h i s study stress the importance of the nurse's role i n f a c i l i t a t i n g congruence between the patient's expectations and h i s actual experiences during the diagnostic regime. The nurse accomplishes t h i s congruence by intervening i n those spheres of the patient's l i f e that may be the source of the patient's u n r e a l i s t i c expectations of those caring f o r him. For example, i f the patient i s very anxious and f e a r f u l , of what i s going to happen to him when he goes for a certain diagnostic t e s t , i t i s imperative that the nurse provide the patient with the correct informa-t i o n at the appropriate time. The patient w i l l then know what to expect ; and h i s expectations can be congruent with what w i l l a c t ually happen to him. In those situations where the nurse anticipates that the patient may s t i l l experience a moderate degree of discomfort, the nurse can help the patient u t i l i z e h is e x i s t i n g s k i l l s and a b i l i t i e s to cope as adaptively as possible when the s i t u a t i o n does a r i s e . Therefore, i t i s recommended that a l l nurses who work i n a diagnostic unit have a good theoretical back-68 ground i n the biopsychosocial needs of the patient. This knowledge can be acquired through an inservice educational program or through additional education at a college or u n i v e r s i t y . I t i s imperative that the nurse involve the patient and h i s family i n h i s nursing care during the diagnostic regime. The involvement of the patient may eliminate, or at least reduce, his fear of the unknown because i t gives him more control i n being able to predict what i s going to happen to him;during the diagnostic regime. With less fear he w i l l , i n turn, ex-perience less f e e l i n g of helplessness. The involvement of the family i s important becuase the patient looks to his family f o r emotional support. Therefore, the nurse can guide the family members i n giving the kind of psychological bolstering that w i l l promote feelings of comfort. In turn, the family members could provide the nurse with v i t a l , information that would be pertinent to the patient's feelings of comfort during the diag-nostic regime. CHAPTER VI SUMMARY AND CONCLUSION An exploratory study was conducted on 25 male and female patients who were admitted to a 29-bed s u r g i c a l u n i t of a 450-bed general h o s p i t a l f o r diagnostic testing. The study was conducted to answer the following questions: (1) What situations does the patient perceive as helping him f e e l comfortable while he i s experiencing the diagnostic regime? (2) What situations does the patient perceive as making him f e e l uncomfortable while he i s experiencing the diagnostic regime? (3) What coping responses does the patient u t i l i z e i n adapting to discomfort-promoting situations during the diagnostic regime? The data f o r the study were collected through the u t i l i z a t i o n of a structured questionnaire f o r the i n i t i a l interview and taped interviews with the selected patients. The patients' concerns were e l i c i t e d and ex-plored i n depth by applying Orlando's Open-Ended Interview Technique and a modified version of the C r i t i c a l Incident Technique. The res u l t s were then categorized into themes of patient responses, tabulated and analyzed. The results of the study revealed that the patient's perception of situations as promoting comfort or discomfort was dependent upon two s i g -n i f i c a n t variables: (1) the degree to which the patient's personal value system needs were being met during the diagnostic regime; (2) the patient's a b i l i t y to mobilize adaptive coping responses to deal with the stresses caused by the diagnostic regime. The findings of the study support the model i n Figure 1, page 8. The patient's past experience, h i s present biopsychosocial state, and medical care factors a l l influence h is thinking and his expectations of 69 70 the h o s p i t a l i z a t i o n experience d u r i n g the d i a g n o s t i c regime. However, i t i s the p a t i e n t ' s personal value system needs t h a t appear to be the funda-mental f a c t o r governing h i s a t t i t u d e s towards h o s p i t a l i z a t i o n and p a r t i c u -l a r l y h i s expectations as t o what i n f o r m a t i o n he should r e c e i v e , how s i g n i -f i c a n t others should behave toward him, and what should,happen to him i n terms o f time and events. During the d i a g n o s t i c regime the p a t i e n t made a comparison between the a c t u a l s i t u a t i o n s he experienced and the s i t u a t i o n s he expected and r e -hearsed f o r . I t was noted t h a t the p a t i e n t reported e x p e r i e n c i n g f e e l i n g s of comfort whenever the a c t u a l i n f o r m a t i o n he r e c e i v e d , . o r the sequence o f events, o r the behavior of s i g n i f i c a n t others toward him was congruent w i t h h i s e x p e c t a t i o n s . On the other hand, the p a t i e n t experienced f e e l i n g s o f discomfort whenever the a c t u a l behavior of s i g n i f i c a n t others toward him, or the i n f o r m a t i o n he r e c e i v e d , o r the sequence of events were incongruent w i t h h i s e x p e c t a t i o n s . The f i n d i n g s of the study a l s o revealed t h a t the coping responses the p a t i e n t u t i l i z e d i n adapting to discomfort-prompting s i t u a t i o n s were p r i m a r i l y dependent upon the way the p a t i e n t evaluated the s t r e s s s i t u a t i o n and e s p e c i a l l y upon h i s e v a l u a t i o n of h i s own a b i l i t i e s t o cope w i t h i t . However, t h i s e v a l u a t i o n and the subsequent adaptive o r maladaptive r e s -ponses were d e c i s i v e l y i n f l u e n c e d by the p a t i e n t ' s past experiences, h i s present b i o p s y c h o s o c i a l s t a t e , and the d u r a t i o n of the perceived s t r e s s . I f the p a t i e n t was m a n i f e s t i n g an extensive degree of d y s f u n c t i o n a l be-h a v i o r i n one or more of these areas, then he would evaluate many normal s t r e s s e s of the d i a g n o s t i c regime as extremely t h r e a t e n i n g . I t appeared t h a t such a p a t i e n t would d i s p l a y g r e a t e r f e e l i n g s of discomfort and a reduced a b i l i t y t o cope a d a p t i v e l y w i t h s t r e s s f u l s i t u a t i o n s tha+. the w e l l - f u n c t i o n i n g p a t i e n t . The reverse was tru e f o r the p a t i e n t who d i d 71 not appear to have any severe d i f f i c u l t i e s i n these areas. Therefore, as shown i n Figure 1, page 8, the level of adaptive or maladaptive coping res-ponses exhibited by the patient reflected the degree of comfort or discom-fort he was experiencing. The results of the study also revealed that the patient's feelings of comfort were increased whenever he was able to mobilize adaptive coping responses to deal with the stresses created by the diagnostic regime. On the other hand, i t was noted that the patient experienced a greater degree of discomfort whenever he had d i f f i c u l t y i n mobilizing adaptive coping res-ponses . The implications of the study demonstrate the importance of the helping professional recognizing that the patient's feelings of comfort are best promoted when the helping person fosters situations that are con-gruent with the patient's expectations. I t i s therefore imperative that the helping person be able to create situations that w i l l e l i c i t the pa-tient's personal value system needs, as these needs determine the patient's expectations of the kind and amount of information he wants to receive during the diagnostic regime, and of how he thinks others should behave toward him. Since feelings of comfort are also promoted when the patient i s able to mobilize adaptive coping responses to deal with the stresses caused by the diagnostic regime, i t i s important that the helping person be able to e l i c i t and identify the specific s k i l l s and a b i l i t i e s the pa-tient possesses. These specific s k i l l s and a b i l i t i e s must also be iden-t i f i e d and considered i n relation to the patient's past experience, his present biopsychosocial state, and the duration of the stress he i s ex-periencing. 72 Further research i s required to formulate a nursing t o o l that w i l l i d e n t i f y the patient's personal value system needs and the s p e c i f i c s k i l l s and a b i l i t i e s he would be able to u t i l i z e i n coping adaptively with s t r e s s f u l experiences during the diagnostic regime. Such a t o o l could then provide the nurse with information that w i l l enable her to anticipate and prevent potential problems that could occur during the diagnostic regime. The nurse would then be able to fost e r situations more congruent with the patient's expectations and/or help modify the patient's expecta-tions to make them more congruent with the actual situations the patient would experience. Consequently, the patient would be able to experience more comfort and be able to cope more adaptively with the stresses created by the diagnostic regime. BIBLIOGRAPHY A. BOOKS Abrams, Harry D. (ed.). International Psychiatry C l i n i c s . Boston: L i t t l e Brown and Company, 1967. American Nurses' Association. A.N.A. Convention C l i n i c a l Sessions,-Vol. X New York: American Nurses' Association, 1964. . A.N.A. C l i n i c a l Sessions. Vol XI. New York: American Nurses' Association, 1962. , A.N.A. C l i n i c a l Sessions. New York: American Nurses' Associa-t i o n , 1963. . A.N.A. C l i n i c a l Sessions - American Nurses' Association. 1966. San Francisco. New York: Appleton-Century-Crafts, 1967. , A.N.A. Regional C l i n i c a l Conferences. No. 2. New York: American Nurses' Association, 1964. Beland, Irene L. C l i n i c a l Nursing:, Pathological and Psychosocial Approaches. New York: MacMillan Co., 1965. Burd, Shirley F., and Marshall, Margaret, A. (eds.). Some C l i n i c a l Approaches to Psychiatric Nursing. New York: The MacMillan Company, 196% Carlson, Carolyn, E. Behavioral Concepts and Nursing Intervention. Philadalphia: J.B. Lippincott Company, 1970. Fox, Rene. Experiment Perilous. Glencoe, I l l i n o i s : The Free Press, 1959. Grinker, Roy L. Mid-Century Psychiatry. S p r i n g f i e l d I l l i n o i s : Charles C. Thomas Publisher, 1953. J a n i s , I . Psychological Stress. New York: John Wiley and Son's, 1958. Jourard, Sidney. Personal Adjustments. Td. ed. New York: C o l l i e r -MacMillan Ltd., 1968. , The Transparent S e l f . Princeton, New Jersey: D. Van Nostrand Company, Inc., 1964. Leonard, Robert C., and Skipper, James K. (eds.). S o c i a l Interaction and  Patient Care. Philadelphia: Lippincott Co., 1965. Skipper, James K., and Woolridge, Powhatan J . Behavioral Science. S o c i a l Practice, and the Nursing Profession. Cleveland, Ohio: The Press of Case Western Reserve University, 1968. 73 Maslow, Abraham H., Toward a Psychology of Being. Td. ed. New York: Van Nostrand Reinhold Company, 1968. May, Rollo. The Meaning of Anxiety. New York: The Ronald Press Company, 1950. Murphy, Gardner, (ed.) Individual Behavior. Rev. Ed. New York: Harper and Row, Publishers, 1959. Orlando, Ida Jean. The Dynamic Nurse-Patient Relationship. New York: G.P. Putman's Sons, 1961. Peplau, Hildegard E. Basic P r i n c i p l e s of Patient Counselling. Philadelphia: Smith, Kline and French Laboratories, 1964. Perry, Helen Swick, and Gavel, Mary Ladd. (eds.) The Psychiatric Interview. New York: W.W. Norton Company, 1954. Rogers, CarL R. Client-Centered Therapy. New York: Houghton M i f f l i n Company, 1961. , On Becoming a Person. Boston: Houghton Publishing Company, 1961. Sargent, S. Sta n f i e l d , and Williamson, Robert C. So c i a l Psychology. 3d. ed. New York: The Ronald Press Company, 1968. Schachter, Stanley. The Psychology of Affiliation-Experimented Studies  of the Sources of Gregariousness. Stanford C a l i f o r n i a : Stanford University Press, 1968. Wiedenbach, Ernestine. C l i n i c a l Nursing - A Helping A r t . New York: G.P. Putman's Sons, 1961. Woolberg, L.B. The Techniques of Psychotherapy. New York: Grune and Straton, 1954. B. PERIODICAL Anderson, Helen C , and Hay, S t e l l a A., "Are Nurses Meeting Patients' Needs?" American Journal of Nursing. LXIII 12 (December, 1968), 96-9. Anderson, Barbara J . , et a l . , "Two Experimental Tests of Patient Centered Admission Procedure," Nursing Research, XVI 2 (Spring, 1965), 151-7. Cleland, V i r g i n i a S., "Effects of Stress on Performance," Nursing Research, LXVII 1 (January, 1967), 108-11. Davis, Carol Ed., and Wolfer, John A., "Assessment of Surgical Patients' Preoperative Emotional Condition and Postoperative Welfare," Nursing  Research (September-October, 1970), 402-14. 74 Dloughly, A l i c e , et a l . , "What Patients Want to Know About Their Diagnostic Tests," Nursing Outlook. XI 4 ( A p r i l , 1963), 265-7. Dumas, R.G., and Leonard, R.D., "Effects of Nursing on the Incidence of Postoperative Vomiting," Nursing Research. XIV (Spring, 1965), 151-7. Elder, Ruth G., "What i s the Patient Saying?" Nursing Forum. 11 1 (1963), Hardin, Clara A., " C r i t i c a l Incident, What Does i t Mean to Research?" Nursing Research. I l l 3 (February, 1955), 105-9. Hart, Betty L., and Rohweder, Anna W., "Support i n Nursing," American  Journal of Nursing. LIX9 (October, 1959), 1398-1401. Hayes, Dorothea R., "Waiting, A Concept i n Nursing," Nursing World. CXXII 5 (June, 1958), 67-72. Hecht, Alan, "Questions Relatives Ask," G e r i a t r i c Nursing. IV 2 (February, 1968), 23-5. Jourard, S.M., "To Whom a Nurse Can Give Personalized Care," American  Journal of Nursing, LXI 3 (March, 1961), 86-8. Larsen, V i r g i n i a , "What Hosp i t a l i z a t i p h Means to Patients," American  Journal of Nursing, LXI 5 (May, 1961), 42-7. Lederer, H.D., "How the Sick;;¥iew Their World," Journal of Soc i a l Issues. VIII 4 (1952), 4-15. Lineham, Dorothy T., "What Patients Want to Know," American Journal of Nursing. LXII 5 (May, 1966), 1066-70. Martin, Harry W., and Pronge, Arthur J . , "The States of I l l n e s s , Psycholo-g i c a l Approach," Nursing Outlook. X (March, 1962), 168-71. Myers, Mary E., "The Effects of Three Types of Communication on Patients 1 Reaction to Stress," Nursing R e s e a r c h . XIII 2 (Spring, 1964), 126-31. Rogers, C a r l , "The Necessary and S u f f i c i e n t Conditions of Therapeutic Per-sonality Change," Journal of Consulting Psychology. XXI 2 (1957), 95-101. Smith, Dorothy M., "Myth and Method i n Nursing," American Journal of Nursing. LXIV 2 (February, 1964), 68-72. Tryon, P h y l l i s A., "Patient P a r t i c i p a t i o n Vs. Patient Pa s s i v i t y , " Nursing  Forum. I I 2 (1963), 48-§6. C. UNPUBLISHED WORKS V i g l i o l e t t i , Ann Flo r a , "Effects of Two Nursing Admission Approaches of Patients' Distress and Ward Adjustment, A C l i n i c a l Experiment." Unpublished Masters Thesis, Yale University, New Haven, 1964. 75 APPENDIX 76 APPENDIX A P a t i e n t Consent Form 77 Patient Consent Form My name i s Walter Bredlow and I am a male nurse from the Univer-sity of Br i t i s h Columbia. I am studying how we can help people feel more comfortable while they are waiting for the results of their tests. I would l i k e to know i f you would allow me to come and see you for a short period of time u n t i l you have received the result of your tests. To help me be as accurate as possible, I would lik e to tape record our talks. To ensure confidentiality, the tape w i l l not be identified as yours nor w i l l your name appear anywhere on the transcript of our talks. I f you decide to allow me to come and v i s i t you now, but change your mind at a later time, that w i l l be fine. I w i l l keep a copy of this consent form for my records and have one put on your chart. I understand the above form and give my consent to have Mr. Walter Bredlqw v i s i t me with the understanding that I can terminate his v i s i t s at any time, i f I so desire. Signature of the Patient . Late 78 APPENDIX B Questionnaires U t i l i z e d i n the F i r s t Interview with the Patient 79 QUESTIONNAIRES UTILIZED IN THE FIRST INTERVIEW WITH THE PATIENT Patient's General Knowledge of the Hospital 1. Did you know what to expect when you cane to the hospital f o r tests? 2. Did you f e e l that you received enough information to help you get to know the hospital routine? 3. What kinds of information would you l i k e to know? 4. Whom would you l i k e to t e l l you t h i s information? 5. Gould you give me the reson f o r your choice? 6., Do you know the doctor who i s looking a f t e r you while you are i n the hospital? Diagnostic Tests 1. Were you aware of the tests that you might be getting while you were i n the hospital? 2. Did you f e e l that you received enough information about the tests you would be having? 3. What information would you have l i k e d to receive about the tests? 4. Whom would you l i k e to receive t h i s information from? 5. Were there any tests that made you f e e l uncomfortable? 6. What was there about the tests that made you f e e l uncomfortable? 7. What did you do to t r y and make yourself f e e l more comfortable? 8. Was there anything that could have been done to make you f e e l more comfortable while you were undergoing your tests? Waiting Period Duration 1. How long have you been waiting f o r the results of your tests? 2. Did you expect to be waiting t h i s long? 3 . Do you have any idea of how much longer you w i l l be waiting? 80 Comforts 1. What do you do to pass the time while you are waiting? 2. What do you do to f e e l more comfortable while you are waiting? 3. Have you talked to anyone else? 4 . Did you f i n d that you f e l t much better a f t e r t a l k i n g to someone else? 5. Would you l i k e to be with others while you are waiting? 6. Was there anything done to help you f e e l more comfortable while you were waiting? 7. Can you describe the s i t u a t i o n f o r me and t e l l me exactly what happened? 8. What did the other i n d i v i d u a l do i n the situation? 9. What did you do i n t h i s situation? 10. Were you pleased with the outcome? Discomforts 1. Was there any s i t u a t i o n that made you f e e l uncomfortable? 2. Could you describe what happened? 3. What did the other i n d i v i d u a l do i n the situation? 4 . What did you do? 5. Do you f e e l that the other i n d i v i d u a l understood your discomfort and how you attempted to deal with i t ? 6. Was there anything done to make you f e e l more comfortable i n the s i t u a -tion? 7. ' I f you were i n the same s i t u a t i o n next time, would you t r y to deal with i t i n the same way? Feelings and Views on the Waiting Period 1. Do you want to know a l l the results of your tests? 2. Do you f i n d that you get tense or up-tight as the time f o r your tests draws near? 3. Do you f i n d that you get tense or up-tight as the resul t of your tests draws near? 81 4» Can you describe what you thought about while you were waiting for the result of your tests? 5. Is there anything that could be done to make you more comfortable during this waiting period? 6. How did you handle the situation? 7. Did i t help you feel more comfortable? 8. What does a positive diagnosis mean to you? 9. What do you plan to do i f the results of the tests are not what you hoped them to be? 82 APPENDIX C Policies and Guidelines Regarding Patient Care 83 EACH PATIENT WILL HAVE A WRITTEN PROFILE IN THE KAHDEX WITHIN 24 HOURS OF  ADMISSION . PROCEDURE: Dated. Include only pertinent data related to: 1) "behavioral characteristics 2) s o c i a l data - family, l i v i n g arrangements, f i n a n c i a l status while i n h o s p i t a l , hobbies, i n t e r e s t s , employment 3) understanding of i l l n e s s ( f i r s t admission?) 4) v i s i t o r s expected (who, when and how often?) EACH PATIENT AND/OR FAMILY MEMBER WILL RECEIVE AN ORIENTATION TO THE WARD  WITHIN 24 HOURS OF ADMISSION PROCEDURE: A) On admission: 1) V i t a l s t a t i s t i c s - weight, height, v i t a l signs 2) Information re a l l e r g i e s , meds, die t 3) Information re signs and symptoms, i v e . - what brought the patient to hospital? 4) Physical orientations: - bedside equipment, reading l i g h t - c a l l l i g h t - washrooms, telephone 5) Introductions - to nurse and to other patients i n the room 6) Give patients SPH admitting pamphlet and printed ward information B) Following days (7:30 - 3:30) 1) Discuss with patient SPH pamphlet 2) Review with patient a l l items included i n the printed ward information 3) Obtain information and write up patient p r o f i l e i n Kardex 84 ORIENTATION CHECK LIST VITAL STATISTICS: Weight Height BP,P,R Temp. INFORMATION: PHYSICAL ORIENTATION; Al l e r g i e s Meds Bedside equip. Reading l i g h t Diet S&S C a l l Washrooms l i g h t Telephone INTRODUCTIONS: Nurse Other patients READING MATERIAL GIVEN; SPH Pamphlet Ward information DISCUSSION: PATIENT PROFILE: SPH Pamphlet Ward information Information obtained Written i n Kardex EACH PATIENT'S GOALS AND APPROACHES WILL BE DISCUSSED WITH HIM/HER IMMEDIATELY AFTER WRITING MONITORING: Dated Write i n nurse's notes, i . e . , - Goals and approaches discussed (or not discussed) with patient. EACH PATIENT'S HOSPITALIZATION WILL BE DISCUSSED WITH AT LEAST ONE  MEMBER OF HIS/HER FAMILY OR OTHER SIGNIFICANT PERSON WITHIN 48 HOURS OF ADMISSION MONITORING: Write i n nurse's notes, i . e . , - Hospitalization discussed with patient's wife, son, frie n d . . . . . . . OR - No v i s i t o r s i n to discuss patient's h o s p i t a l i z a t i o n . 1) How do you think your wife (son, etc.) i s doing i n hospital? 2) Could anything he done d i f f e r e n t l y ? 3) How i s the family coping? 85 EACH PATIENT WILL RECEIVE FRE-TEST EXPLANATION (TEACHING) FOR EACH TEST AND PROCEDURE PROCEDURE; D Between 2:00-3:00 P.! 7:30-3:50 S t a f f a. Inform patients of tests scheduled f o r next day b. Give patient a teaching card c. T e l l patient that evening s t a f f w i l l explain tests and answer questions. ( I f patient does not ask questions or indicate concern, day s t a f f w i l l explain tests to patient's s a t i s f a c t i o n ; reminding patient that evening s t a f f w i l l follow through. I f day s t a f f does teach, t h i s must be charted i n the nurse's notes. 2) Between 6:00-7:00 P.M. 5:30-11:50 S t a f f a. Explain to each patient the tests scheduled f o r the following day b. Between 8:50-10:00 P.M., review with patient what has been taught re his t e s t , and answer any questions c. Chart teaching and feedback results i n nurse's notes d. .. Leave teaching card with patient u n t i l comple-t i o n of t e s t . EACH PATIENT WILL RECEIVE MEALS AND SNACKS AS INDICATED ON HIS/HER DIET MENU . .. PROCEDURE; 1) At 2:00 P.M. - Collect a l l completed menus f o r your patients and place them with the Dietary Census i n the Ward Aid's basket. 2) At mean times - Check each of your patient's meal trays against t h e i r menus. 5) At 11:00 A.M., 5:00 P.M., and 8:50 P.M. - Check that your patients have received snacks as ordered. 86 4) Omissions, a d d i t i o n s and changes: a) Write on the back of p a t i e n t ' s menu and take t o desk. The N u r s i n g U n i t C l e r k w i l l phone changes, t o k i t c h e n . b) Check w i t h your p a t i e n t s i n 1 5 minutes t o note i f requested food has a r r i v e d . 87 MENU CHECK LIST PATIENT'S NAME DATE Menu completed Yes No TRAY/MENU OK INCORRECT CHANGE RECEIVED BREAKFAST SNACK LUNCH SNACK SUPPER SNACK 88 APPENDIX D P a t i e n t Data Sheet 89 Diagnostic Regime Data N-25 Total Mean Range Number of Interviews 99 3.96 1-10 Number of Interviews i n Minutes 3367 34.00 13-83 Age 1832 47.33 20-76 Number of Previous Admissions 140 5.60 0-20 Doctor's V i s i t s 109 4.36 1-16 Family V i s i t s 104 4.16 1-16 Intrusive Tests 30 1.20 0-3 Extrusive Tests 76 3.04 1-9 Waiting Period i n Days 137 5.48 1-16 S o c i a l Data of Patients N-25 M a r i t a l Status Education Place of Residence Marr. Div. Sep. Widowed Formal Secon. Univ. Vancouver Area Out of Vancouver 15 2 5 3 6 14 5 14 11 Admitting and F i n a l Diagnosis i n Terms of General Diagnostic Categories N-25 Diagnostic Category Admitting Diagnosis F i n a l Diagnosis Endrocrinology 3 1 Cardiology 8 6 Gastrointerology 12 11 Hypertensive State 2 2 Undiagnosed 0 5 90 91 PATIENTS RESPONSES DURING THE DIAGNOSTIC REGIME P A T I E N T N U M B E R i 2 3J4 . 5 j 6 17 3J9J!0JllJL2J16JlAjl5J<6ll7J!BJB MJzi|?2Ja; .4J25 T O T A L 1 P 1 1 SON I AL 1 i B A I 1 GRC i •1 WD F 1 | ACTC i s' ' PAST EXPERIENCE ' li 1 5 i U 6 7 0 J |8 (6 2 j ^ Ui 5 9 2 4 !lO 8 ? 8 4 l i i j e 2 9 5 PERSONAL W.UE SYSTEM .\'£.£DS 4 i 1 • 5 5 5 6 S 4 & 22 5|2 J 6 7 2 a 6 j e 4 9 6 jl!jfi 162 i EXf >EC TA TIC )N, I 5 1 a 1 r r OS ! 1 1 Pfl rAL 1 IZ/ VT!( 3N 1 1 :XF 1 >Ef ?IE >IC E i INFORMATION tc ) l 0 10 2 1 7 ID 6 10 14 7 2 5 11 .1,0 l 5 u M l i 9 177 EVENTS 5 2 0 4 7 J' 5 5 6 2 s 0 5 J J 5 i l 5 4 l e! .y 7 104 PROFESSIONALS 3 J rc 6 J 5 0 4 ;o 10 4 0 9 10 (0 2 2 7 * 9 5 9 i 34-VISITORS c o 0 ,0 1 0 1 2 0 0 0 0 0 0 0 o ic 0 0 0 0 0 0 2 0 S OTHER PATIENTS 0 0 0 o i 2 I j / 0 0 1 0 o 0 O 1 1 / ; 2 0 0 1 i 5 1 COME 1 OP I T Pf & TI 1 NC 51" 1 ru AT 10 N{ INFORMATION j ' i l 4 5 0 4 10 4 HI J 2 5 5 5 2 1 7| 7 J 0 6 4-U- 2 3 9 EVENTS I 0 4 5 t \ 1 |s a J -> 4 2 10 5 0 1 J | 2 2 0 4 • ' i i i 2 6 7 " PROFESSIONALS. £ .2 /z e i 12 5 6 7 2.- .J M 4 fl 2 14 3 4 1 : | 2 156 VISITORS 1 0 J i i lU 0 o J i 0 J • 3 |C 0 2 o\i — i — 0 0 2 0 31 OTHER PATIENTS < -1 1 1 0 1 0 2 o i+ 0 0 0 1 o 0 0 1 1 It i 0 0 J 0 o| 0 O to DI. £ ot-?F( DR r f 3 P 01-10 T! MG c >!T s I INFORMATION 5 4- 0 6 i i 4 i u. 7 J 0 4 I 9 o w 2 I J *5 s\r 4 66 EVENTS ' 2 4- 0 (4 9 Jo 15 21 5 IS s i W n I.' i 13 li ! 8 10 15 19 10 2 4 4 PROFESSIOl-WLS J 8 0 16 5 o 0 4 a n c 0 I 0 0 0 7 z 0 I a 6J4. 10 J 0 2 VISITORS 0 0 0 4 2 0 4 0 2 i | 5 0 0 0 0 0 0 i 0 1 0 0 0 |0 2 0 OTHER PATIENTS 0 J 0 12 0 0 S' 1 4 9 / 0 0 0 J 0 7 1 0 0 j J|O 2 5 5 ADAPTIVE R E S P O N S E S IN )l\ 'IC >u \L c DP 1 >IN & Rl .Sf 1 £ THINKIfC ACTIVITIES <2 f a .'4 20 6 i /5 X IS lo -S2 4 1 12 to to 6 II 6 9 17 u !£ 7 PHYSICAL ACTIVITIES 5 J -V 14 17 3 18 t— 13 7 25 5 / a 6 » 11 7 6 20 rt 24 8 NA1APTIVE RESPONSES THINKING ACTIVITIES 5 0 4 7 I 6 i 7 2 4 0 1 & 0 S 0 J t 2 15 1 6 9 93 PHYSICAL ACTIVITIES o o D z 0 o l 0 / 1 0 c u 0 l 0 : 0 0 0 0 1? 0 i 8 

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