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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 i n P a r t i a l Fulfilment of the Requirements For the Master of Science i n Nursing  i n the School of Nursing  We accept t h i s thesis as conforming to the required standard  The University , of B r i t i s h Columbia October, 1975  In  presenting this  thesis  an advanced degree at the L i b r a r y s h a l l I  f u r t h e r agree  in p a r t i a l  fulfilment of  the requirements f o r  the U n i v e r s i t y of B r i t i s h Columbia,  make i t  freely available  that permission  for  I agree  r e f e r e n c e and  f o r e x t e n s i v e copying o f  this  that  study. thesis  f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s of  this  written  representatives. thesis  It  is understood that copying or p u b l i c a t i o n  f o r f i n a n c i a l gain s h a l l  permission.  Department of The U n i v e r s i t y of B r i t i s h  Columbia  2075 Wesbrobk P l a c e V a n c o u v e r , Canada V6T 1W5  Date  Mr  J>J  i  not be allowed without my  ii Abstract An exploratory study was conducted on 25 male and female p a t i e n t s who were admitted t o 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 , for diagnostic testing.  The purpose of the study was to;.answer the  f o l l o w i n g questions: (1)  What s i t u a t i o n s does the p a t i e n t perceive as h e l p i n g him f e e l comfortable while he i s experiencing the d i a g n o s t i c regime?  (2)  What s i t u a t i o n s does the p a t i e n t perceive as making him f e e l uncomfortable  (3)  while he i s experiencing the d i a g n o s t i c regime?  What coping responses does the p a t i e n t u t i l i z e i n adapting t o discomfort promoting s i t u a t i o n s during the d i a g n o s t i c regime? The data f o r the study were c o l l e c t e d through the u t i l i z a t i o n  of a s t r u c t u r e d questionnaire f o r the i n i t i a l v i s i t and taped interviews w i t h the s e l e c t e d p a t i e n t s . During the i n t e r v i e w s , p a r t i c u l a r emphasis was placed upon e x p l o r i n g the p a t i e n t s ' concerns by the use of Orlando's Open-Ended Interview Technique and a modified v e r s i o n of the C r i t i c a l Incident Technique.  The r e s u l t s were then categorized i n t o themes of  p a t i e n t responses, tabulated, and analyzed. The r e s u l t s of the study revealed that the s i t u a t i o n s the p a t i e n t perceived as promoting comfort o r discomfort were dependent upon two s i g n i f i c a n t v a r i a b l e s : (1)  The degree t o which the p a t i e n t ' s personal value system needs were met during the d i a g n o s t i c regime;  (2)  The p a t i e n t ' s a b i l i t y t o m o b i l i z e adaptive coping responses t o 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. The coping responses u t i l i z e d by the p a t i e n t s i n adapting t o  discomfort promoting experiences i n h o s p i t a l were numerous and h i g h l y  iii diversified.  I t 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 uncomfortable experience.  iv Acknowledgments The w r i t e r wishes t o express h i s 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 s u s t a i n the w r i t e r d u r i n g the long tedious course of t h i s study. G r a t e f u l acknowledgment i s also made of the cooperation and encouragement of the s t a f f of the general h o s p i t a l and others who aided the w r i t e r i n undertaking t h i s study. The w r i t e r also wishes to thank Mrs. S h i r l e y H i l l f o r her expert t y p i n g of the t h e s i s .  Dedication To the Lord, my wife Marianne, our c h i l d r e n Walter J r . and J u l i e , and to the P a t i e n t s who made the existence of t h i s Thesis a r e a l i t y  TABLE OP CONTENTS Page Abstract  •  • •  Acknowledgements Dedication  ^ iv  . . . . . . . . . . . . . . .  v  L i s t o f Tables  viii  L i s t of Figures Chapter I.  INTRODUCTION TO THE STUDY  *  1  S i g n i f i c a n c e o f t h e Study  1  Purpose o f t h e S t u d y  2  Review o f t h e L i t e r a t u r e  . .  THEORETICAL FRAMEWORK UNDERLYING THE STUDY  7 11  D e f i n i t i o n o f Terms U n d e r l y i n g Assumption  . . . .  Limitations II.  • .  13 13 15  METHODOLOGY 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 o f Data III.  2  FINDINGS  . J . . . .  19  . . .  21  Comfort P r o m o t i n g 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 t h e Degree o f Comfort o r D i s c o m f o r t E x p e r i e n c e d by t h e P a t i e n t D u r i n g t h e D i a g n o s t i c Regime . . . . . . . . . . . . . . . .  34  vi  vii Chapter  Page A. P e r s o n a l Background F a c t o r s  .  34  B. E x p e c t a t i o n s o f P r e s e n t H o s p i t a l i z a t i o n 38  Experience  43  C o p i n g Responses D u r i n g t h e D i a g n o s t i c Regime A. A d a p t i v e Responses  . . . . . . . . . .  48  B. M a l a d a p t i v e Responses IV.  44  DISCUSSION OF THE FINDINGS  51  Comfort and D i s c o m f o r t Promo-ting S i t u a t i o n s D i s c u s s e d i n Terms o f P a t i e n t s ' P e r s o n a l V a l u e System Needs . . . Comfort and 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 D i s c u s s e d i n Terms o f t h e P a t i e n t s ' A b i l i t y t o M o b i l i z e A d a p t i v e C o p i n g Responses V.  IMPLICATIONS AND RECOMMENDATIONS ARISING FROM THE STUDY .  54 64  Hospital Administrative Policies  64  Medical S t a f f  64  Research  65  Nursing VI.  51  .  66 69  SUMMARY AND CONCLUSION  BIBLIOGRAPHY  73  APPENDICES  76 78  A. P a t i e n t Consent Form B. Q u e s t i o n n a i r e U t i l i z e d i n t h e F i r s t Interview w i t h the P a t i e n t C. P o l i c i e s and G u i d e l i n e s R e g a r d i n g P a t i e n t Care. D. P a t i e n t D a t a S h e e t  80 . .  84 90  LIST OF TABLES Table 1.  Page P a t i e n t Responses D u r i n g the D i a g n o s t i c Regime, E x p r e s s e d 23  i n Terms o f Comfort Promoting S i t u a t i o n s 2.  Responses o f the P a t i e n t D u r i n g t h e D i a g n o s t i c Regime E x p r e s s e d i n Terms o f 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  3.  . .  30  Responses o f 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 . . . .  35  4.  F a c t o r s o f the P a t i e n t s ' P e r s o n a l V a l u e System Needs . . .  36  5.  Responses o f 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  E x p r e s s e d i n Terms o f P e r s o n a l Background F a c t o r s  E x p r e s s e d i n Terms o f E x p e c t a t i o n s o f P r e s e n t H o s p i 40  t a l i z a t i o n Experience  6.  C a t e g o r i e s o f t h e P a t i e n t s * Responses D u r i n g t h e 42  D i a g n o s t i c Regime  7.  Responses o f P a t i e n t s D u r i n g t h e D i a g n o s t i c Regime E x p r e s s e d i n Terms o f I n d i v i d u a l C o p i n g Responses  8.  . . . .  43  A d a p t i v e Coping Responses o f 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 E x p r e s s e d i n Terms o f T h i n k i n g 44  Activities  9.  A d a p t i v e Coping Responses o f 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 E x p r e s s e d i n Terms o f P h y s i c a l Activities  10.  47  M a l a d a p t i v e C o p i n g Responses o f 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 E x p r e s s e d i n Terms o f T h i n k i n g Activities  48 viii  L I S T OF F I G U R E S Figure 1.  Page 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 Promoting S i t u a t i o n s and h i s R e s u l t a n t Coping Responses  ix  8  AN EXPLORATORY STUDY TO IDENTIFY SITUATIONS PATIENTS PERCEIVE AS COMFORT OR DISCOMFORT PROMOTING, AND  THE  COPING RESPONSES  THEY UTILIZE I N ADAPTING TO DISCOMFORT PROMOTING EXPERIENCES DURING THE  DIAGNOSTIC REGIME  Chapter I INTRODUCTION TO THE  The  STUDY  p r o m o t i o n o f c o m f o r t f o r the p a t i e n t d u r i n g the  p r o c e s s i s an e s s e n t i a l element o f good n u r s i n g c a r e .  diagnostic  To s p e c i f y c o m f o r t  as a g o a l i n n u r s i n g , however, does not i m p l y t h a t the p a t i e n t must be, can be,  o r even d e s i r e s t o be c o m f o r t a b l e i n a l l ways a t a l l t i m e s . The  d i a g n o s t i c program i n b o t h i t s m e d i c a l and n u r s i n g phases  r e q u i r e t h a t the p a t i e n t ' s c o m f o r t assume a secondary p o s i t i o n on occasions.  various  Most p a t i e n t s are w i l l i n g t o undergo a degree o f p h y s i c a l  psychological discomfort t h e i r d i a g n o s t i c program.  when i t i s p e r c e i v e d  may  and  as b e i n g n e c e s s a r y t o f u r t h e r  I n a d d i t i o n t o the p r o m o t i o n o f c o m f o r t t h e n ,  t h e n u r s e ' s r o l e i s t o make t h e p a t i e n t ' s d i s c o m f o r t SIGNIFICANCE OF THE  a tolerable  experience.^  STUDY  I n t e r e s t i n c o n d u c t i n g r e s e a r c h i n the a r e a o f p a t i e n t c o m f o r t was  s t i m u l a t e d by the w r i t e r ' s p a s t e x p e r i e n c e w i t h p a t i e n t s u n d e r g o i n g  d i a g n o s t i c t e s t i n g , and by r e a d i n g s  i n l i t e r a t u r e that p e r t a i n to  the  p a t i e n t ' s e m o t i o n a l r e s p o n s e s 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  M a r g a r e t A. Kaufmann, "Comfort M e a s u r e s : S t e r o t y p e s or, F l e x i b l e Elements o f Comprehensive P a t i e n t Care," A m e r i c a n Nurses' A s s o c i a t i o n - C l i n i c a l S e s s i o n s . 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 i d e n t i f y 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 hospitals.  Knowledge of t h i s f a c t o r could d e f i n i t e l y a i d the nurse i n  helping patients strengthen e x i s t i n g adaptive behaviors and/or provide learning opportunities that w i l l enable the patient to learn h e a l t h i e r coping behaviors i n adapting to uncomfortable s i t u a t i o n s . for  Hence the need  conducting t h i s 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 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 do patients u t i l i z e i n adapting to d i s comfort promoting experiences during the diagnostic regime? REVIEW OP THE LITERATURE  Literature selected f o r review i n t h i s study pertains to the concepts of waiting, uncertainty, worry-work, comfort and anxiety. There i s not a great deal of l i t e r a t u r e 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 t h e o r e t i c a l speculation rather than actual research. Two authors have commented on factors c o n t r i b u t i n g to comfort and discomfort while the patient i s experiencing the diagnostic regime. Ackerhalt stresses that because the time i n t e r v a l 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 i n t e n s i f y a patient's feelings of helplessness. On the other hand, Fox noted that information given be fellow patients regarding diagnostic procedures understanding",  gave the patient a "sense of knowing and  thus helping to counteract some of the stresses of uncer-  3 t a i n t y , unfamiliar procedures and equipment. The degree of anxiety experienced by the i n d i v i d u a l awaiting the r e s u l t s of h i s diagnostic tests and his way of coping with that anxiety has been implied by many w r i t e r s . Results of the assessment of preoperative condition and postoperative welfare of s u r g i c a l patients by Wolfer and Davis may have i m p l i cations f o r the patient experiencing the diagnostic regime.  Their study  revealed that a t l e a s t 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 r e l a t i o n s h i p  between the patient's preoperative l e v e l of f e a r and anxiety and any  4 aspect of t h e i r postoperative recovery. As a r e s u l t of the anxiety the patient i s experiencing, and of his need to adapt behaviors i n order to avoid, reduce, or r e l i e v e anxiety, J u d i t h 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 :  Press, (19.59), PP. 114-90.  '  ...  The Free  -  J o h h A. Wolfer and Carol E. Davis, "Assessment of S u r g i c a l Patients' Preoperative Emotional Condition and Postoperative Welfare," Nursing Research (September-October 1970), pp. 402-14. 4  4 he may u t i l i z e one of four major patterns of adaptive behavior. (1)  patient may:  The  exhibit a c t i n g out behavior through anger or resentment  to cope with h i s 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 h i s 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 i m p l i cations f o r the patient experiencing the diagnostic regime, p a r t i c u l a r l y i f the r e s u l t s prove to be unfavorable.  Janis noted that the work of  worrying enabled the patient to increase h i s l e v e l of tolerance and cope more adaptively i n the long run with a p a i n f u l r e a l i t y s i t u a t i o n .  As a  r e s u l t of h i s research, Janis contends that the more thorough the work of worrying, the more r e a l i t y - t e s t e d the i n d i v i d u a l ' s s e l f - d e l i v e r e d 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 s p e c i f i c nursing guidelines to assess the patient's a b i l i t y to adapt to h i s h o s p i t a l i z a t i o n experience and promote h i s comfort.  In her book, The Dynamic Nurse-Patient  Relationship. Orlando points to an e f f i c i e n t way of i d e n t i f y i n g and  7 dealing with the s i t u a t i o n a l d i s t r e s s the patient i s experiencing.  •Tlildegard Peplau, "A Working D e f i n i t i o n of Anxiety," Some C l i n i c a l Approaches to P s y c h i a t r i c Nursing, ed. S h i r l e y F. Burd and Margaret A. Marshall (New York: The MacMillan Company, 1963), pp.324-55. ^ I r v i n g 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 t a k e s O r l a n d o ' s i d e a s one s t e p f u r t h e r b y e m p h a s i z i n g t h a t t h e n u r s e s h o u l d n o t o n l y i d e n t i f y and d e a l w i t h t h e p a t i e n t ' s d i s t r e s s , b u t he  s h o u l d a l s o seek v a l i d a t i o n from t h e p a t i e n t t o ensure t h a t t h e  nursing interventions that  he u t i l i z e s do, i n f a c t , meet t h e p a t i e n t ' s  needs.^ I n p r o v i d i n g c o m f o r t f o r t h e p a t i e n t , Kaufmarm contends t h a t t h e degree t o w h i c h t h e n u r s i n g s t a f f meet t h e p a t i e n t ' s e x p e c t a t i o n s o f 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 h i s f e e l i n g s o f s a f e t y and c o m f o r t .  influence  She f u r t h e r emphasizes t h a t s u c c e s s -  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 t h e n u r s e s u n d e r s t a n d i n g t h a t many p a t i e n t s hope t o a c h i e v e a g r e a t d e a l o f c o m f o r t  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 r e s e a r c h has f o c u s e d on t h e communication p r o c e s s and how i t c a n be u s e d t o e l i c i t t h e p a t i e n t ' s f e e l i n g s and h e l p them achieve a comfortable s t a t e . S e v e r a l a u t h o r s d e f i n e n u r s i n g as t h e a r t and s c i e n c e o f p r o moting comfort.  Anderson,  e t a l . s t a t e that a primary f u n c t i o n o f the  n u r s e i s t o determine and h e l p a l l e v i a t e t h e d i s t r e s s a p a t i e n t i s experiencing i n h i s present s i t u a t i o n . ^  S m i t h contends t h a t t h e s c i e n c e  o f communication i s more p e r t i n e n t t o n u r s i n g t h a n t h e s c i e n c e o f d i s e a s e o r p a t h o l o g y . She f u r t h e r s t a t e s , " t h e n u r s e ' s knowledge o f t h e p a t i e n t must i n c l u d e an s u n d e r s t a n d i n g o f h i s e m o t i o n a l r e a c t i o n and  York:  E r 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 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. B a r b a r a J . Anderson, e t a l . , "Two E x p e r i m e n t a l T e s t s o f P a t i e n t C e n t e r e d A d m i s s i o n P r o c e d u r e s , " N u r s i n g R e s e a r c h , XVI: 2 ( S p r i n g 1965), 1 0  151-7.  6 helping him understand h i s f e e l i n g s and reactions, and should become a standard part of any treatment regime."^ Authors discussing the means of dealing with the patient's d i s 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." mation p r i o r to experiencing a new  Janis contends that providing i n f o r s i t u a t i o n 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 r e s u l t s of Skipper's  study revealed that upon  r e c e i v i n g information about t h e i r treatments, i l l n e s s , and s o c i a l organization of the h o s p i t a l , patients were l e s s anxious about t h e i r i l l n e s s and what was  going to happen to them, t h e i r adaptation to the  expectations  14 of the h o s p i t a l s t a f f was  enhanced, and t h e i r need for safety was  Myers noted that g i v i n g the patient pertinent information before while carrying out procedures i n an unfamiliar s i t u a t i o n was 15  met. and  the most  successful i n r e l i e v i n g stress f o r the patient. The actual concerns that the patients have v e r b a l l y expressed have been i d e n t i f i e d by two authors. Lineham noted that the actual Dorothy M. Smith, "Myth and Method i n Nursing," American Journal of Nursing, LXVT 2 (February, 1964), pp.68-72. concerns of patients covered a broad spectrum. Patients wanted to t a l k 11  12  Lawrence D. Egbert, "Psychological Support," International Psyc h i a t r y C l i n i c s , 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.  Jantes K. Skipper, "Communication and the Hospitalized Patient," S o c i a l Interaction and Patient Care, ed. James K. Skipper and Robert C. 14  Leonard.(Philadelphia: Lippincott Co., 1965), pp.63-6.  ^Mary Myers, "The E f f e c t s of Three Types of Communication on Patient's Reaction to Stress," Nursing,Research, XIII: 2 (Spring, 1964), 1  pp.126-31.  7 to t h e i r doctors, other than a t doctors' rounds.  They wanted p r i v a c y ,  e s p e c i a l l y when they had personal questions o r when the doctor t a l k e d t o them about t h e i r c o n d i t i o n . They wanted a greater d i s p l a y o f i n t e r e s t i n them as i n d i v i d u a l s from the doctors and nurses.  They wanted b e t t e r  communication between doctors and f a m i l i e s ; explanations o f what was being done t o them and why; what t o expect a f t e r an operation o r t r e a t ment; more r a p i d r e p o r t i n g of t e s t s , and more explanation o f n u r s i n g  16 procedures.  Dloughly e t a l . noted that p a t i e n t s do not want a s c i e n t i -  f i c explanation of d i a g n o s t i c t e s t s , but r a t h e r an a p p l i c a t i o n o f the 17 s c i e n t i f i c methods t o t h e i r i n d i v i d u a l needs. THEORETICAL FRAMEWORK UNDERLYING THE STUDY On the b a s i s o f a review o f the t h e o r e t i c a l knowledge and research s e l e c t e d f o r t h i s study the w r i t e r postulates that the p a t i e n t ' s admission to h o s p i t a l and the d i a g n o s t i c regime, can be v i s u a l i z e d i n terms o f a systems theory approach (Refer t o Figure 1, page 8 ) .  The conceptualiza-  t i o n s t a r t s w i t h kinds o f s p e c i f i c inputs- jatient and medical care. The p a t i e n t s t a t e i s defined as a f u n c t i o n o f personal background f a c t o r s (information) and psychophysiological f a c t o r s (energy).  The medical  care f a c t o r s include the d e c i s i o n t o h o s p i t a l i z e , when and how, plus the information given t o the p a t i e n t . The middle boxes, t h i n k i n g about hosp i t a l i z a t i o n and comparisons o f a c t u a l events and expectations s p e c i f y c o g n i t i v e processes.  The end boxes, f e e l i n g s o f comfort o r discomfort  expressed as concerns, and coping behaviors which are expressed i n terms 72  Dorothy T. Lineham, "What P a t i e n t s Want t o Know," American J o u r n a l of Nursing, LXII 5 (May, 1966), p.1068. 17  'Alice Dloughly, e t a l . , "What P a t i e n t s Want t o Know About T h e i r Diagnostic Tests." Nursing Outlook, XI 4 ( A p r i l , 1963), pp.265-7.  8  •z  ,—2>  IX  ft  fc  <s ft -» ? o «  0 00 X  HE  Pi  5e  <  £ 0 P  §^ £  &  ft  9  o f adaptive or maladaptive behavior, s p e c i f y response outputs.  The  arrows represent information or energy flow routes and feedback loops which a f f e c t the nature of the patient!s c o g n i t i v e processes and  the  s p e c i f i c type and degree of h i s response output. The personal background f a c t o r s provide the i n d i v i d u a l w i t h i n f o r mation he can u t i l i z e i n s t r u c t u r i n g h i s h o s p i t a l i z a t i o n experience during the diagnostic regime.  He may  a l s o possess c e r t a i n kinds of  a b i l i t i e s which w i l l a i d him i n coping with the  experience.  The biopsychosocial f a c t o r s represent those f a c t o r s 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 d i a g n o s t i c regime has been very p a i n f u l and/or anxiety provoking, and has used up a great deal of the p a t i e n t ' s energy, obviously he i s going to have l e s s 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 h i s a b i l i t y to  adapt s u c c e s s f u l l y to h i s h o s p i t a l i z a t i o n experience. The medical care f a c t o r s as mentioned previously c o n s i s t information and plans.  of  The information i s the knowledge which i s given  to the p a t i e n t and which he u t i l i z e s i n t h i n k i n g about h i s h o s p i t a l i z a tion.  The plans are the decisions the p h y s i c i a n 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 p a t i e n t i s i n h o s p i t a l . The p a t i e n t ' s t h i n k i n g about h o s p i t a l i z a t i o n and the d i a g n o s t i c regime i s consistent with J a n i s ' s work of worrying or mental r e h e a r s a l . I t i s the c o g n i t i v e a c t i v i t i e s the p a t i e n t undergoes i n order to prepare himself f o r a s t r e s s f u l event. Some i n d i v i d u a l s 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 o f 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 r e g i m e , b u t 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 o f 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 acceptance of i t s presence.  the  F o r t h i s i n d i v i d u a l a c e r t a i n amount o f  d e n i a l a l l o w s h i s s i t u a t i o n t o 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 a b l e t o a r r i v e a t a compromise between a l m o s t t o t a l d e n i a l and the r e a l i t y o f the s i t u a t i o n . t o t a l d e n i a l i s maladaptive  On t h e o t h e r hand,  because i t does n o t a l l o w the i n d i v i d u a l t o  p r o c e e d t h r o u g h t h e normal worry-work p r o c e s s 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 o f  cancer.  The outcome o f t h i n k i n g i s e x p e c t a t i o n s and p l a n s .  That i s ,  i n d i v i d u a l c o g n i t i v e l y f o r m u l a t e s a s e t o f e x p e c t a t i o n s about how s h o u l d behave and how  the  he  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 o f t i m e , t e s t s , doctor v i s i t s , et cetera.  I n a l l p r o b a b i l i t y he a l s o does some  m e n t a l r e h e a r s i n g w h i c h a l l o w s him t o make p l a n s o f a k i n d . " i f p a i n occurs, t h e n I w i l l t r y and do thus and so."  F o r example,  This combination  e x p e c t a t i o n s and p l a n s t h e n a l l o w s him t o make c o m p a r i s i o n s  between the  a c t u a l e x p e r i e n c e s t h a t o c c u r t o him and what he expected and for.  of  rehearsed  Out o f t h e s e c o m p a r i s o n s , p e r 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  patient's cognitive a c t i v i t i e s .  These d i f f e r e n c e s t h e n produce f e e l i n g s  o f comfort and/or d i s c o m f o r t w h i c h can be e x p r e s s e d as p o s i t i v e o r negative concerns.  That i s , the c o n c e r n s a c t as a m e d i a t i n g v a r i a b l e o r  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  of coping responses.  The  concerns  and c o p i n g r e s p o n s e s a r e p e r c e i v e d by the n u r s e as b e i n g a d a p t i v e o r m a l a d a p t i v e and p r o v i d e s h e r w i t h cues as t o how needs a r e b e i n g  met.  w e l l the p a t i e n t ' s comfort  11 I t i s d e f i n i t e l y p o s s i b l e that the p a t i e n t can experience discomf o r t i n events which occur exactly as he expected, but the w r i t e r contends that the p a t i e n t w i l l be b e t t e r able to cope w i t h 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 p a t i e n t  w i l l experience f e e l i n g s of discomfort, the degree of discomfort expressed by the p a t i e n t should not be as great as i t would be i f the p a t i e n t 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 f o l l o w i n g d e f i n i t i o n s of the major terms were accepted: I. II. ni. IV. V.  VI.  S i t u a t i o n - A combination of circumstances and events o c c u r r i n g at a s p e c i f i c time. Perception - The process by which people s e l e c t , organize and i n t e r pret sensory i n p u t . Comfort - A s u b j e c t i v e f e e l i n g of well-being. Discomfort - A s u b j e c t i v e f e e l i n g of apprehension and d i s t r e s s . Personal Background Factors - Represents that combination of f a c t o r s which the p a t i e n t uses as a reference point f o r a s s o c i a t i n g and judging h i s current h o s p i t a l experience. This consists of: A.  Past Experience - Past knowledge and a b i l i t i e s acquired as an observer or r e c i p i e n t of the h e a l t h care d e l i v e r y system.  B.  Personal Value System Needs - Those f a c t o r s which the p a t i e n t perceives as being necessary to maintain h i s self-esteem.  Expectations of Present H o s p i t a l i z a t i o n Experience - The p a t i e n t ' s a n t i c i p a t i o n of what he i s l i k e l y to experience and what he hopes w i l l happen during h i s current admission to h o s p i t a l . This c o n s i s t s of: A.  Expected Information - The information the p a t i e n t would l i k e to receive concerning h i s i l l n e s s and o v e r a l l h o s p i t a l i z a t i o n experience.  18  J a n i s , op. c i t . , pp.401-11.  12  VII.  B.  Expected Events - The h o s p i t a l routines and diagnostic procedures the.patient expects to experience.  C.  People - Those responses the patient would l i k e to see demonstrated i n the i n d i v i d u a l s he cornea i n contact with. This consists of responses demonstrated by: 1.  Professionals  2.  Visitors  3.  Other Patients  Perception of Actual H o s p i t a l i z a t i o n Experience - The patient's cognitive and a f f e c t i v e responses to s i t u a t i o n s occurring during the diagnostic regime. A.  Comfort-Promoting Situations - Those s i t u a t i o n s that have a tendency to f a c i l i t a t e a subjective f e e l i n g of w e l l being. These consist o f : .1.  B.  Actual Information - The information given to the patient which he perceives as comfort promoting.  2.  Actual Events - The h o s p i t a l routines and diagnostic procedures the patient experiences and perceives as comfort promoting.  3.  People - The responses the patients see demonstrated i n the i n d i v i d u a l s 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  Discomfort-Promoting Situations - Those s i t u a t i o n s that have a tendency to increase the patient's subjective feel i n g s of apprehension and d i s t r e s s . These consist of: 1.  Actual Information - The information given to the patient which he perceives as promoting discomfort.  2.  Actual Events - The h o s p i t a l routines and diagnostic procedures the patient experiences and perceives as promoting discomfort.  3.  Actual People - The responses the patient sees demonstrated i n the i n d i v i d u a l s he comes i n contact with, and which he perceives as promoting discomfort. This consists of responses demonstrated by:  13  VIII.  a.  Professionals  b.  Visitors  c.  Other P a t i e n t s  C o p i n g Responses - The p a t i e n t ' s r e s p o n s e s t h a t f a c i l i t a t e o r h i n d e r h i s a b i l i t y t o meet h i s c o m f o r t needs. A.  B.  A d a p t i v e - The p a t i e n t ' s r e s p o n s e s w h i c h r e s u l t i n him f e e l i n g more c o m f o r t a b l e o r b e i n g a b l e t o 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 p r o c e s s e s o c c u r r i n g w i t h i n t h e 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 l o c o m o t o r r e s p o n s e s o r i n t e r a c t i o n with environmental s t i m u l i .  M a l a d a p t i v e - The p a t i e n t ' s r e s p o n s e s w h i c h r e s u l t i n him feeling distressed. 1.  Thinking  These c o n s i s t o f :  Activities  2. Physical Activities 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 w h i c h i n v o l v e a manual p e n e t r a t i o n o f two i n c h e s o r more i n l e n g t h o f a body o r g a n o r c a v i t y by a m e c h a n i c a l i n s t r u m e n t .  IX.  X.  E x 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 w h i c h i n v o l v e l e s s t h a n two i n c h e s o f manual p e n e t r a t i o n o f t h e body by a mechanic a l i n s t r u m e n t {eg. n e e d l e ) , o r e l e c t r o n i c p e n e t r a t i o n o f a body o r g a n o r c a v i t y w i t h a m e c h a n i c a l i n s t r u m e n t (,eg. x-rays). UNDERLYING ASSUMPTION The u n d e r l y i n g a s s u m p t i o n o f t h i s s t u d y was t h a t t h e p a t i e n t s  would e x p r e s s t h e i r t r u e f e e l i n g s about t h e s i t u a t i o n s they p e r c e i v e d as p r o m o t i n g c o m f o r t and/or d i s c o m f o r t ,  and t h e ways i n w h i c h t h e y a t t e m p t e d  t o cope w i t h u n c o m f o r t a b l e e x p e r i e n c e s d u r i n g t h e d i a g n o s t i c regime* LIMITATIONS T h i s s t u d y was s u b j e c t t o t h e 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 o n l y from one ward i n one g e n e r a l 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  4.  Only twenty-five  5.  Since the researcher was  can speak English.  patients were selected f o r the study. a p a r t i c i p a n t observer, i t was noted that  some patients were able to achieve an added degree of comfort when they were able to verbalize t h e i r concerns to someone who to l i s t e n .  I f the patients did not have t h i s opportunity,  was  the number  of s i t u a t i o n s that the patient perceived as uncomfortable may been higher than i s a c t u a l l y reported i n t h i s study. therefore be taken into consideration.  willing  have  This fact must  Chapter I I METHODOLOGY The exploratory approach was used t o conduct t h i s study.  This  approach was s e l e c t e d f o r the f o l l o w i n g reasons: (1)  I n order t o conduct a more i n t e n s i v e study i n the area o f p a t i e n t comfort, the exploratory approach can be used t o 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 f a c t o r s that a f f e c t p a t i e n t 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 i n t o one with a more precise meaning, frequent changes i n the research procedure are often necessary i n order t o provide f o r the gathering o f data relevant t o the emerging hypothesis. SAMPLE The sample s e l e c t e d 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 , l o c a ted i n the Vancouver area.  P a t i e n t s were admitted from the Vancouver area  and by r e f e r r a l s from o u t - l y i n g d i s t r i c t s . , The 25 men and women that were f i n a l l y s e l e c t e d ranged between the ages o f twenty and seventy-six year of age, and were chosen according to the f o l l o w i n g c r i t e r i a : (1)  Must be between eighteen and eighty years o f age.  (2)  Must be undergoing d i a g n o s t i c t e s t s and a w a i t i n g the t e s t r e s u l t s .  (3)  Must be w i l l i n g t o p a r t i c i p a t e i n the study and a l l o w the w r i t e r t o  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 a b l e t o speak E n g l i s h . DATA COLLECTION 'TOOLS Taped I n t e r v i e w s - A l l i n t e r v i e w s were taped t o ensure t h a t no  i n t e r v i e w d a t a were l o s t .  The taped i n t e r v i e w s a l s o e n a b l e d t h e 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 o r d e r to  :  check t h e v a l i d i t y o f t h e w r i t e r ' s a n a l y s i s o f t h e c o l l e c t e d d a t a . 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 c o m p i l e d based on  the w r i t e r ' s p a s t e x p e r i e n c e  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 g a i n e d from r e a d i n g s i n r e l a t e d l i t e r a t u r e . o f t h e q u e s t i o n s , was t e s t e d on t h r e e p a t i e n t s .  The c l a r i t y  As a r e s u l t , e i g h t ques-  t i o n s were m o d i f i e d b e f o r e t h e q u e s t i o n n a i r e was u s e d i n t h e main s t u d y ( s e e Appendix B ) . The  q u e s t i o n n a i r e was u s e d i n t h e main s t u d y f o r t h e f o l l o w i n g  reasons: (1)  I t gave t h e w r i t e r an o p p o r t u n i t y t o g a i n a r a p p o r t w i t h t h e p a t i e n t .  (2)  I t p r o v i d e d a d e f i n i t e s t r u c t u r e f o r t h e f i r s t i n t e r v i e w and h e l p e d s e t t h e tone f o r subsequent i n t e r v i e w s .  (3)  I t a l l o w e d t h e w r i t e r an o p p o r t u n i t y t o e l i c i t a wide v a r i e t y o f p a t i e n t ' s f e e l i n g s and c o n c e r n s about h i s h o s p i t a l i z a t i o n d u r i n g the d i a g n o s t i c regime.  experience  T h i s was p a r t i c u l a r l y i m p o r t a n t  for  i d e n t i f y i n g problems t h a t r e l a t e t o t h e p a t i e n t ' s c o m f o r t needs. O r l a n d o ' s 0pen-Ended I n t e r v i e w Technique - O r l a n d o a d v o c a t e s a n open-ended i n t e r v i e w t e c h n i q u e w i t h v i r t u a l l y u n l i m i t e d p r o b i n g f o r u s e by n u r s e s i n d i a g n o s i n g p a t i e n t ' s needs. techniques  She proposes t h a t t h e i n t e r v i e w  s h o u l d be c a r r i e d o u t i n t h e f o l l o w i n g manner;  (1) t h e n u r s e  17 observes the patient's v e r b a l and non-verbal a c t i v i t y f o r possible symptoms of d i s t r e s s ;  (2) the nurse makes a t e n t a t i v e i n t e r p r e t a t i o n of these  symptoms and then comments ( t o the p a t i e n t ) e i t h e r about the symptom or on h i s f e e l i n g s about the p a t i e n t ' s behavior; and (3) steps (1)  the nurse continues w i t h  and (2) u n t i l he and the patient are i n apparent agreement on  what the p a t i e n t n e e d s , ( i f anything), and there are no apparent discrepant symptoms.  Safety features to guard against bias are i n c l u d e d i n these  guidelines as the p a t i e n t w i l l , under the impact of repeated  probing,  eventually r e v e a l any o r i g i n a l bias that the nurse may have and  discount  it. 9 1  Modified C r i t i c a l Incident Technique - The c r i t i c a l i n c i d e n t technique asks the patient to describe a p a r t i c u l a r a c t i o n . It's biggest advantage i s due to the f a c t that the information which i s gathered about a p a r t i c u l a r i n c i d e n t or s i t u a t i o n i s based upon a report of what a c t u a l l y took place and how the p a r t i c i p a n t s behaved. technique i s high.  Thus the r e l i a b i l i t y of t h i s  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 . I n t h i s study the w r i t e r used a s l i g h t 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.  When o b t a i n i n g d e s c r i p t i o n s of s i t u a t i o n s which  the p a t i e n t perceived as promoting comfort or discomfort, the w r i t e r asked the p a t i e n t t o : (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 P r a c t i c e , and the Nursing P r o f e s s i o n (Cleveland: The Press of Case Western Reserve U n i v e r s i t y , 1968), pp.44-5. 20 C l a r a A. Hardin, " C r i t i c a l I n c i d e n t , What Does I t Mean to Research?" Nursing Research. I l l 3 (February, 1955)» pp.108-9.  18 (2)  D e s c r i b e what t h e o t h e r p e r s o n d i d i n t h e s i t u a t i o n .  (3)  D e s c r i b e what he d i d i n t h e s i t u a t i o n .  (4)  E x p l a i n why he p e r c e i v e d t h e s i t u a t i o n as c o m f o r t a b l e o r u n c o m f o r t a b l e .  (5)  I f t h e s i t u a t i o n was u n c o m f o r t a b l e , d e s c r i b e what he t r i e d t o do t o make h i m s e l f f e e l more c o m f o r t a b l e . O r l a n d o ' s open-ended i n t e r v i e w t e c h n i q u e and t h e m o d i f i e d c r i t i c a l  i n c i d e n t t e c h n i q u e were u t i l i z e d because t h e y a l l o w t h e w r i t e r t o o b t a i n a more a c c u r a t e , p r e c i s e , d e t a i l e d r e p o r t o f t h e p a t i e n t ' s p e r c e p t i o n o f his  experiences i n h o s p i t a l d u r i n g the diagnostic  regime.  DATA COLLECTION The d a t a f o r t h e s t u d y was c o l l e c t e d i n t h e 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 t o p a r t i c i p a t e i n the s t u d y was f i r s t o b t a i n e d from t h e p a t i e n t (Appendix A ) .  The w r i t e r t h e n  used the q u e s t i o n n a i r e t o 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 . S t e p I I - Subsequent V i s i t s - The w r i t e r conducted taped  inter-  v i e w s w i t h t h e p a t i e n t on each s u c c e s s i v e v i s i t u n t i l t h e p a t i e n t r e c e i v e d the r e s u l t s o f a l l h i s d i a g n o s t i c t e s t s . asked t h e f o l l o w i n g q u e s t i o n s : c e r n was t o d a y ? " comfortable?"  (2)  (3)  u n c o m f o r t a b l e ? , and  (1)  D u r i n g each i n t e r v i e w t h e w r i t e r  "What would y o u s a y y o u r b i g g e s t con-  "Were t h e r e any s i t u a t i o n s today t h a t made y o u f e e l  "Were t h e r e any s i t u a t i o n s today t h a t made y o u f e e l (4)  I f t h e 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 u n c o m f o r t a b l e t h e w r i t e r a s k e d , "What d i d y o u do t o make y o u r s e l f f e e l more c o m f o r t a b l e ? " w h i l e t h e 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 c o n c e r n s i n r e l a t i o n t o t h e above q u e s t i o n s , t h e 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 t e c h n i q u e s and a m o d i f i c a t i o n o f t h e c r i t i c a l  inci-  d e n t t e c h n i q u e t o e x p l o r e t h e p a t i e n t ' s f e e l i n g s and concerns i n d e p t h .  19 The r e s u l t s 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 f i v e broad categories of patient responses.  These categories were derived as a r e s u l t of the general  thematic responses that became evident during the analysis of the data and on the basis of the t h e o r e t i c a l knowledge and research selected f o r this study.  To provide further c l a r i f i c a t i o n , the f i v e  general categories were broken down into sub-categories.  These sub-  categories were derived by systematically grouping s p e c i f i c themes of patient responses that arose during the a n a l y s i s .  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 (3)  11).  Each transcribed interview was systematically analyzed f o r each s p e c i f i c theme of patient responses that could be grouped under the appropriate sub-category.  Each s p e c i f i c theme; was scored only once  i n each interview, but i f the same theme was noted i n another i n t e r view i t was once again scored.  For example, i f the patient stated  i n the f i r s t interview that he valued food, then t h i s s p e c i f i c theme was scored under the personal value system need sub-category.  Even  i f the patient brought up t h i s 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 t h e f o l l o w i n g r e a s o n s : (a)  Whenever t h e w r i t e r u s e d O r l a n d o ' 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 o f t h e c r i t i c a l i n c i d e n t t e c h n i q u e t o e x p l o r e the p a t i e n t ' s f e e l i n g s and c o n c e r n s i n d e p t h , t h e w r i t e r would q u i t e o f t e n e l i c i t t h e same theme two o r t h r e e t i m e s . (b)  The w r i t e r would o c c a s i o n a l l y summarize t h e s p e c i f i c theme t h e p a t i e n t had s t a t e d t o make c e r t a i n t h a t t h e theme t h e w r i t e r was a c t u a l l y t h e theme t h e p a t i e n t wanted t o communicate. each t i m e t h e p a t i e n t v a l i d a t e d t h e w r i t e r ' s p e r c e p t i o n again e l i c i t e d .  perceived  Therefore,  t h e theme was  I f t h e w r i t e r were t o s c o r e some themes u n d e r t h e s e  c i r o u m s t a n c e s t h e 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 .  Scoring  each s p e c i f i c theme o n l y once d u r i n g t h e i n t e r v i e w p r o v i d e d a c l e a r e r p i c t u r e o f t h e p a t i e n t ' s r e s p o n s e s as r e p r e s e n t e d by each s u b - c a t e g o r y . (c)  A f t e r t h e w r i t e r had completed t h e a n a l y s i s , a l l t h e s p e c i f i c themes i n each s u b - c a t e g o r y were t a b u l a t e d  and p r e s e n t e d u n d e r t h e g e n e r a l  category o f responses. The  v a l i d i t y o f t h e w r i t e r ' s a n a l y s i s was judged by two i n d e p e n -  d e n t judges n o t f a m i l i a r w i t h t h e r e s e a r c h d e s i g n .  Comparisons o f t h e  a n a l y s i s form, u s i n g f i v e r a n d o m l y - s e l e c t e d t r a n s c r i b e d i n t e r v i e w s  resulted  i n an 8 9 % concordance w i t h t h e one judge and an 8 5 % concordance w i t h t h e other judge.  Chapter I I I FINDINGS The f i n d i n g s a r i s i n g from the a n a l y s i s of data are presented i n this section.  Data are presented t o answer the questions of what s i t u a -  t i o n s the p a t i e n t perceives as promoting comfort o r discomfort and what coping behaviors are u t i l i z e d i n adapting t o discomfort promoting e x p e r i ences during the d i a g n o s t i c regime. COMFORT PROMOTING SITUATIONS A c t u a l 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 p a t i e n t s regarding information that helped them f e e l more comfortable. The responses ranged from 0-11 a mean of 3.88 responses per p a t i e n t .  with  There were two p a t i e n t s from whom  no responses were e l i c i t e d . The information the p a t i e n t s perceived as comfort promoting covered a very broad spectrum and e i t h e r focused around the d i a g n o s t i c regime o r s i t u a t i o n s that were perceived as being meaningful t o a p a r t i cular patient.  I t v a r i e d from g e t t i n g a typed information card about  the d i a g n o s t i c t e s t s , o b t a i n i n g information regarding what t o expect during the d i a g n o s t i c regime, g e t t i n g an o r i e n t a t i o n to the ward, r e c e i v i n g l e t t e r s from family and f r i e n d s , f i n d i n g out that one's roommate came out o f surgery and i s doing f i n e , t o 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 p a t i e n t perceived the i n f o r mation given as comfort promoting was w e l l demonstrated by a 73-year-old  21  22 lady whose admission diagnosis was g a s t r o - i n t e s t i n a l bleeding. Upon r e c e i v i n g her f i n a l diagnosis on the day of the f i f t h interview she stated: "...and then he t o l d me. He s a i d . Oh, I know what pleased me. He t o l d me that the r e s u l t s of the gastroscopy t e s t were benign. So whether they took a l i t t l e b i t of something I don't know. He s a i d maybe i t might be l i k e a small u l c e r - more l i k e a small erosion. And so I s a i d '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 s i t u a t i o n s 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 s p e c i f i c themes appeared to a r i s e 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 o r getting an i n j e c t i o n before c e r t a i n diagnostic tests (eg. gastroscopy t e s t ) .  The patients were pleased  that something was being done f o r them - the diagnostic regime was  progres-  s i n g and now they w i l l f i n a l l y f i n d out what i s wrong with them. Receiving good food and the kind of food they wanted proved to be a very event f o r many patients.  comforting  F i n a l l y , many patients commented on how nice i t  was that the h o s p i t a l p o l i c i e s and routines were much more f l e x i b l e and personalized than they were i n the past. An event that a patient perceived as comfort promoting was best i l l u s t r a t e d by a forty-two-year-old a f t e r waiting f o r a month.  lady who was admitted to the h o s p i t a l  During one interview she stated:  "I r e a l l y f e e l much better i n being i n the h o s p i t a l 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 f o r almost a month to get i n here and I would not have gotten i n i f i t wasn't f o r a c a n c e l l a t i o n . I would probably be waiting s t i l l . So I had a whole month to think about it."  23 Table I Patient Responses During the Diagnostic Regime, Expressed i n 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  156  42.08  6.24  1-23  Actual V i s i t o r s  31  8.66  1.24  0-4  Actual Other Patients  13  3.83  -  0-4  366  99.96  Actual Professionals  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, i n terms of comfort i n g s i t u a t i o n s , involved the behavior of the professional people came i n contact with them. a mean of 6.24  The responses e l i c i t e d ranged from 1-23  who with  responses per patient.  The situations the patients perceived as comfort promoting covered a wide spectrum but general themes arose throughout the i n t e r views.  I t meant a great deal to many patients to be seen by t h e i r doctor  at least every other day.  I t was  e s p e c i a l l y comforting  to know that the  doctor would come back to see them on weekends or a f t e r hours, take time to explain things at t h e i r own  l e v e l of understanding, and show extra  consideration by allowing them to have a pass from h o s p i t a l . This type of behavior demonstrated by the doctor reinforced the patient's feelings that the doctor cared about him as an i n d i v i d u a l who  was worthy of his  24 a t t e n t i o n and concern. One o f the most important themes that arose was i f the p a t i e n t f e l t that the p r o f e s s i o n a l s were aware of and understood h i s f e e l i n g s and needs.  This perception f a c i l i t a t e d the p a t i e n t ' s f e e l i n g s of comfort and  increased h i s t r u s t i n the p r o f e s s i o n a l s who came i n contact w i t h him. The comforting responses o f the nurses were s p e c i f i c a l l y mentioned by the p a t i e n t s .  I t meant a great deal t o the p a t i e n t when he would f i n d  the nurse easy t o t a l k t o , when she would do l i t t l e things f o r him, and when she would demonstrate concern f o r h i s w e l f a r e . A good example o f the behavior demonstrated by p r o f e s s i o n a l s which the p a t i e n t perceived as comfort promoting was w e l l v e r b a l i z e d by a 62year-old man admitted f o r severe coronary a r t e r y disease. Regarding the n u r s i n g care he received a f t e r h i s angiogram t e s t , he s t a t e d : "The nurse checked me every t e n 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 c e r t a i n l y reassured that they were keeping a check on me and I was very pleased w i t h the a t t e n t i o n I was r e c e i v i n g . " A c t u a l 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 o f 31 responses e l i c i t e d , regarding v i s i t o r s , that the p a t i e n t s perceived as promoting comfort. w i t h a mean o f 1.24 responses.  The responses ranged from 0-4  Ten p a t i e n t s d i d not v e r b a l i z e any r e s -  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 o f v i s i t o r s ' behavior t o the p a t i e n t ' s v a r i e d from p a t i e n t t o p a t i e n t .  I t meant a great deal t o the p a t i e n t t o  be v i s i t e d by those whom he cared about o r who were close t o him. I t was very comforting t o the p a t i e n t when v i s i t o r s were w i l l i n g t o take time out from t h e i r busy schedule t o come and v i s i t him. Many p a t i e n t s , 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 i n lessening the f e e l i n g s of loneliness and/or the boring time spent i n h o s p i t a l . F i n a l l y , a f a m i l i a r face was something that was very meaningful to the patient, e s p e c i a l l y i f he was waking up from a diagnostic test requiring a general anesthetic or a f t e r experiencing a diagnostic test of long duration. The importance of v i s i t o r s to the patients can probably be best summarized by a 49-year-old business man hypertension.  admitted f o r i n v e s t i g a t i o n of  While t a l k i n g about the importance of v i s i t o r s , he stated:  "We r e l y on our v i s i t o r s to l e t us know how important we are. I t ' s not the number of v i s i t o r s , as much as the consideration shown by them taking t h e i r time and trouble to v i s i t i n a h o s p i t a l . You know yourself how you had to go and put yourself out to see someone i n the h o s p i t a l simply because you thought enough of that person. I t can be a damn nuisance having to do i t , but, on the other hand, you have enough consideration f o r 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 e f f o r t . . . I t makes one f e e l wanted and gives you a f e e l i n g 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 f e e l more comfortable.  The range of responses varied from  0-4  with only seven patients expressing a response. The s i t u a t i o n s the patients perceived as promoting comfort were varied.  One  of the most s i g n i f i c a n t things the patients found  was the opportunity to compare notes on t h e i r diagnostic t e s t s .  comforting One  woman stated that she found t a l k i n g to the other patients about the  gas-  troscopy test comforting because she then knew what to expect when she experienced,the t e s t .  One man,  who had a heart attack, said i t was com-  f o r t i n g to know that i f he got i n t o any trouble, h i s roommate could r i n g f o r help.  S t i l l other patients s a i d i t was  comforting to see other pa-  t i e n t s getting good care and attention and getting w e l l .  In the l a t t e r  case, i t appeared that the patients were i d e n t i f y i n g with the other  26 patients - t h e i r well-being produced a comforting e f f e c t on the i n t e r viewed p a t i e n t s . DISCOMFORT PROMOTING SITUATIONS Actual Information - Table 2, page 30, shows the a c t u a l information to the p a t i e n t which he perceived as promoting discomfort.  given  The responses  represent 13.53% o f the t o t a l number o f discomforting s i t u a t i o n s and range from 0-10 w i t h a mean o f 2.64 responses per p a t i e n t . The information p e r t a i n i n g t o the a c t u a l diagnostic process ranked f i r s t i n promoting discomfort.  Receiving information that the t e s t r e s u l t s  r e f l e c t e d no pathology was quite u p s e t t i n g t o the p a t i e n t s who d e f i n i t e l y f e l t that something was wrong w i t h them. the patients who went home undiagnosed.  This was e s p e c i a l l y true f o r Some patients f e l t they were not  t o l d enough about the d i a g n o s t i c t e s t they were to have, while  others  were upset because they had made plans f o r discharge and then the t o l d them they needed another d i a g n o s t i c t e s t .  doctor  A few patients were upset  when they found out what k i n d o f t e s t they would have t o undergo. The one f a c t noted was that many p a t i e n t s were not worried about the o v e r a l l t e s t i t s e l f but only one aspect of i t .  F o r example, when one man was  t o l d that the gastroscopy tube had t o go down h i s t h r o a t , h i s response was,  " I was r e a l l y shaken by t h i s ! " Information regarding the patient's p h y s i c a l c o n d i t i o n and t r e a t -  ment, as a r e s u l t of the d i a g n o s t i c t e s t s , arose as another discomfort promoting f a c t o r . One woman was t o l d that i f her u l c e r d i d not c l e a r up she would need surgery.  A few interviews l a t e r she s a i d , "....today  the doctor t o l d me that i f I d i d 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 h o s p i t a l 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 promot i n g discomfort i n the p a t i e n t .  For example, one woman s t a t e d , "....Dr.  X happened t o see me today and he s a i d , *I thought you were home already.' Here I thought he was l o o k i n g a f t e r me." The l a s t k i n d o f information that upset some patients was r e c e i v i n g information which the patients perceived as an i n s u l t t o 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 b a s i s , not from a p h y s i o l o g i c a l b a s i s . one young woman s t a t e d , " to c o l l e c t welfare.  I n another s i t u a t i o n ,  the doctor implied that I was i n the h o s p i t a l  Who does he t h i n k he i s and who does he t h i n k I am?  I manage my own boutique and the l a s t place I want t o be r i g h t now i s i n the h o s p i t a l . " A c t u a l Events - An examination o f Table ;2, page 30, reveals that the a c t u a l events the patients perceived as promoting discomfort f o r 50% o f the t o t a l number o f responses.  The responses ranged from 0-  23 with a mean o f 9.76 responses per p a t i e n t .  There was only one p a t i e n t  who r e f r a i n e d from expressing a response i n t h i s  category.  There were 12 p a t i e n t s who expressed concern about pain.  accounted  experiencing  For those 12 patients the degree o f pain v a r i e d but i t was noted  that the more pain the p a t i e n t experienced the more t h e i r  conversation  and concerns centered around "pain", and the l e s s energy they had f o r s u c c e s s f u l l y coping with the diagnostic regime.  I t was also noted that  the patient's a b i l i t y t o s u c c e s s f u l l y cope was f u r t h e r hampered when the doctors were unable t o f i n d the cause of pain.  For example, two p a t i e n t s  had t o stay i n h o s p i t a l 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 u l c e r s 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 f u r t h e r complicated when the doctors were unable to f i n d the cause of the headache.  The w r i t e r observed that both patients s t a r t e d  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 a c t u a l t e s t procedures were often a source of discomfort f o r the p a t i e n t s .  However, i t appeared that the t e s t s were uncomfortable to  the degree that the patient perceived c e r t a i n aspects of the t e s t as being p a i n f u l , of long duration, embarassing, or  fear-provoking.  Nine patients expressed many v a r i e d concerns about food.  The con-  cerns ranged from the meals not being b i g enough to asking f o r coffee and r e c e i v i n g tea instead.  The more general concerns r e l a t e d to g e t t i n g t h e i r  dinner l a t e , food being c o l d , d i s l i k i n g the meal because i f was so " f l a t t a s t i n g " 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 c e r t a i n d i a g n o s t i c t e s t s . I t was noted that food was a very important f a c t o r i n making these p a t i e n t s ' h o s p i t a l i z a t i o n experience a comfortable one. I t appeared that the w a i t i n g period was most uncomfortable f o r the patient when he d i d not perceive anything as happening or i f he d i d not see the diagnostic regime as progressing. they f e l t very bored i n h o s p i t a l - "The nothing to do."  Seven patients stated that  days seem very long and you have  Two p a t i e n t s stated that they f e l t very confined i n the  h o s p i t a l while two others s a i d , " 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 p a t i e n t  underwent at l e a s t one form of d i a g n o s t i c t e s t per day i t helped r e l i e v e h i s boredom and p a r t i a l l y f u l f i l l e d h i s need to see  progress.  29 There were many h o s p i t a l routines and procedures that the patients saw as promoting discomfort. The o v e r a l l f a c t noted, however, was that the s i t u a t i o n s 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 t h i s expectat i o n was  met. The situations the patients perceived as discomfort promoting were  many and v a r i e d . ted  Seven patients expressed annoyance at having to be admit-  to the h o s p i t a l on Friday afternoon although the diagnostic tests would  not begin u n t i l Monday morning. f o r so long.  Why  One man  stated, "We  can't we come i n Sunday night?  have to wait around  I t ' s just wasting tax-  payers' money, and, besides, what can you do i n a h o s p i t a l a l l weekend?" Seven patients stated they d i d not l i k e to be i n the hospital and a few f e l t the h o s p i t a l was only f o r s i c k people - these patients did not see themselves as being s i c k .  Two patients were upset when t h e i r diagnostic  tests were cancelled, others were annoyed at being transferred to other rooms within the ward, two patients commented upon coming to the h o s p i t a l and having to wait three to four hours u n t i l the patient i n t h e i r bed  was  discharged, and f i n a l l y , two patients f e l t that they should not need personal 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 o v e r a l l health care of patients. He stated: "...because of t h e i r complexity, the h o s p i t a l s tend to become bogged down i n t h e i r bureaucracy and they become great plants wherein the people who a c t u a l l y control them are more interested i n the f i n a n c i a l aspects of the h o s p i t a l , the s o c i a l implications, s o c i a l record and s o c i a l h i s t o r y . They're more concerned about the impression they make on the public at large, the importance of the i n s t i t u t i o n a l l e v e l . This i s the f i r s t l e v e l of functioning.  30 The second l e v e l o f f u n c t i o n i n g , t h e n u r s e - p a t i e n t d o c t o r r e l a t i o n s h i p s h o u l d be t h e most i m p o r t a n t l e v e l o f f u n c t i o n i n g . T h i s i s a l m o s t f o r g o t t e n by t h e o t h e r s i d e o f t h e h i e r a r c h i a l l e v e l . T h e r e f o r e , t h e two l e v e l s c o n t r a d i c t one a n o t h e r . The u p p e r 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 w h i l e t h e m e d i c a l 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 h u m a n i t a r i a n b a s i s . Emphasis s h o u l d go back t o t h e h u m a n i t a r i a n s i d e . The s o c i o - e c o n o m i c system i n o u r d e m o c r a t i c s o c i e t y has gone hay w i r e and i t ' s t h e 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 a n a l y z e d t h e f u n c t i o n i n g o f t h e h o s p i t a l and was a b i t u p s e t when he came t o t h e 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 , t h e p a t i e n t does n o t come f i r s t , r a t h e r , h i s c a r e r a n k s l o w e r i n p r i o r i t y i n relation to administrative  policies.  Table  2  Responses o f t h e P a t i e n t s D u r i n g t h e D i a g n o s t i c Regime E x p r e s s e d i n Terms o f 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  N-25 Number o f Responses  Percentage of T o t a l  Mean  Range  66  13.53  2.64  0-10  A c t u a l Events  244  50.00  9.76  0-23  Actual  Professionals  102  20.90  4.08  0-16  Actual  Visitors  20  4.09  -  0-5  2.24  0-12  Actual  Information  A c t u a l Other P a t i e n t s  56  11.47  488  99.99  A c t u a l P r o f e s s i o n a l s - T a b l e 2,  above, shows t h a t t h e r e were a t o t a l o f  102 r e s p o n s e s e l i c i t e d from t h e p a t i e n t s i n r e g a r d 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.  t o discomfort  promo-  The r e s p o n s e s ranged  f r o m 0-16 w i t h a mean o f 4.08 r e s p o n s e s p e r p a t i e n t .  There were n i n e  31 p a t i e n t s from whom no response was e l i c i t e d i n t h i s area. The s i t u a t i o n s the p a t i e n t s perceived as promoting discomfort arose as a r e s u l t of the p r o f e s s i o n a l person v i o l a t i n g the patient's personal value system.  This was e s p e c i a l l y true i n those s i t u a t i o n s where  the patient f e l t that the p r o f e s s i o n a l person v i o l a t e d h i s need t o 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 r i g h t s as an i n d i v i d u a l .  Twelve  patients f e l t t h a t they were being treated very impersonally by the prof e s s i o n a l s t a f f a t one p o i n t during t h e i r period of h o s p i t a l i z a t i o n .  In  coming t o t h i s conclusion i t appeared that the patients were responding more t o the p r o f e s s i o n a l person's a t t i t u d e s r a t h e r than t o any other factor.  This perception was f u r t h e r r e i n f o r c e d when the doctors and  nurses d i d not take time out t o t a l k w i t h them. The patients expressed other concerns about the p r o f e s s i o n a l people they came i n contact w i t h . Seven p a t i e n t s expressed disappointment i n t h e i r doctors when they could not f i n d out what was wrong with them o r how t o cure t h e i r problem.  S i x p a t i e n t s expressed f e e l i n g s of d i s a p p o i n t -  ment because they d i d not see t h e i r doctor as soon, o r as f a s t , as they expected they would.  Five patients expressed annoyance a t being t o l d one  t h i n g by one doctor and then being t o l d something e l s e by another doctor. A l l f i v e p a t i e n t s f e l t that the doctors should get together and decide what they were going t o t e l l the p a t i e n t .  Four patients f e l t that the  p r o f e s s i o n a l people d i d not r e a l l y understand them o r t h e i r needs. F o r example, one man f e l t that the nurses d i d not see him as being as i l l as the other patients and, t h e r e f o r e , d i d not give him the a t t e n t i o n he expected.  Three patients v e r b a l i z e d concerns about the doctors u s i n g  complex medical terminology instead of layman's terms and two p a t i e n t s 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 o f a discomfort promoting s i t u a t i o n was best expressed by a 29-year-old lady whose admission diagnosis was a b l e e d i n g u l c e r . When t a l k i n g about the doctors, she s t a t e d : "They a l l stand outside i n the h a l l and t a l k , which i s very poor, I t h i n k . . . 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 obvious 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 t h i n k they should have some other place t o t a l k about i t , o r discuss i t i n f r o n t o f the p a t i e n t , but not go outside and t a l k a blue streak." A c t u a l V i s i t o r s - Table 2, page 30, shows that there were only twenty r e s ponses e l i c i t e d from the p a t i e n t s i n regard t o v i s i t o r s (only eight expressed any concerns i n t h i s category). The w r i t e r was unable t o note any general themes as the responses e l i c i t e d were v a r i e d and h i g h l y i n d i v i d u a l i z e d . The responses ranged from, a p a t i e n t 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 , v o i c i n g concerns that one's parents d i d not lookktoo w e l l , and, f i n a l l y , expressing f e e l i n g s o f disappointment  that the expected  visi-  t o r s d i d not come t o v i s i t , nor d i d the v i s i t o r s stay as long as the p a t i e n t 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 p a t i e n t i s probably best exe m p l i f i e d by a p a t i e n t who was admitted f o r i n v e s t i g a t i o n of a hypertensive state.  This man was having q u i t e a few f i n a n c i a l worries a t the time and  he became quite upset when h i s 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 i n c i d e n t , the man s t a t e d :  "...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 R i c h 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 s a i d , 'I t h i n k you should read t h i s , ' and i t annoyed me because, I s a i d 'number one, I'm here t o 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 t o grow r i c h w i t h peace  33 of mind o r o t h e r w i s e . And f u r t h e r m o r e , I t h i n k t h e a u t h o r i s a C h a r l a t a n . Anyway, I was t h e n a l i t t l e c o n t r i t e because I thought she was...I suppose she was w e l l - m e a n i n g . B u t t h i s has been t h e b a s i s o f o u r r e l a t i o n s h i p . She wants t o make bucks and she wants me t o make them. And, she's more i n t e r e s t e d , I f e e l , i n t h e d o l l a r t h a n i n t h e r e l a t i o n s h i p between two human b e i n g s , w h i c h d o e s n ' 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 u p s e t me." 1  A c t u a l O t h e r P a t i e n t s - An e x a m i n a t i o n o f T a b l e 2, page 30, r e v e a l s t h a t the of  r e s p o n s e s o f o t h e r p a t i e n t s a c c o u n t e d f o r 11.47% o f t h e t o t a l number s i t u a t i o n s t h e p a t i e n t s p e r c e i v e d a s p r o m o t i n g 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 o f 2.24 r e s p o n s e s p e r 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 c o n c e r n s e x p r e s s e d by t h e 14 p a t i e n t s c o v e r e d a wide v a r i e t y of  situations.  The r e s p o n s e s ranged from s e e i n g a n o t h e r p a t i e n t  fall  o u t o f bed, b e i n g wakened up by a n o t h e r 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 d y i n g , h e a r i n g a n o t h e r p a t i e n t c o n s t a n t l y c o m p l a i n i n g , s e e i n g one's roommates g o i n g home, l i s t e n i n g t o a n o t h e r p a t i e n t c a l l i n g for  a n u r s e t h r o u g h o u t t h e 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  smell". P r o b a b l y one o f t h e most s i g n i f i c a n t t h i n g s t h a t made t h e p a t i e n t f e e l u n c o m f o r t a b l e was s e e i n g and i d e n t i f y i n g w i t h a n o t h e r s i c k i n d i v i d u a l . N i n e p a t i e n t s v e r b a l i z e d t h a t t h e y would i d e n t i f y w i t h t h e o t h e r 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 a s t o how t h e y c o u l d h e l p them. one 65-year-old  F o r example,  lady stated:  " I was t a l k i n g t o my roommate. She was v e r y u p s e t because she c o u l d n ' t go home. I found h e r v e r y dep r e s s i n g t o t a l k t o . I found m y s e l f l o o k i n g f o r words t o c o m f o r t h e r b u t t h e y were a l l h o l l o w b e 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 c o m f o r t a b l e . I would have l i k e d to h e l p h e r o u t b u t I f e l t so h e l p l e s s i n t h e situation."  34 FACTORS AFFECTING THE DEGREE OF COMFORT OR DISCOMFORT EXPERIENCED BY.THE PATIENT DURING THE DIAGNOSTIC REGIME There a r e two b a s i c f a c t o r s w h i c h must be c o n s i d e r e d as a f f e c t i n g the degree o f c o m f o r t o r d i s c o m f o r t t h e p a t i e n t e x p e r i e n c e s d u r i n g t h e d i a g n o s t i c regime.  These f a c t o r s a r e p e r s o n a l background f a c t o r s  and  e x p e c t a t i o n s of the present h o s p i t a l i z a t i o n experience.  PERSONAL BACKGROUND FACTORS P a s t E x p e r i e n c e - T a b l e 3» page 35,  shows the number o f p a t i e n t r e s p o n s e s  e x p r e s s e d i n terms o f p a s t e x p e r i e n c e . Three g e n e r a l 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  t a l k i n g about t h e i r p a s t e x p e r i e n c e s i n h o s p i t a l ; (2)  relatives  the i n f l u e n c e of  t h e 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 p e r s o n a l e x p e r i e n c e s , e s p e c i a l l y t h r o u g h p a s t 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 t a k e n from i n t e r v i e w s w i t h t h r e e d i f f e r e n t p a t i e n t s demonstrate t h e i n f l u e n c e o f t h e above themes. The i n f l u e n c e o f 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 p a s t e x p e r i e n c e i s b e s t 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 l a d y who 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 .  was  told  She s t a t e d :  "Dr. X.came i n and t o l d me t h i s m o r n i n g 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 t h e 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 t h e most h o r r i b l e t e s t e v e r . I'm n e r v o u s as i t i s , so t h e w a i t i n g w i l l be t h a t much worse. I am g o i n g 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 t h e t e s t . I know t h a t as t h e t i m e f o r t h e t e s t comes, I'm g o i n g t o f e e l h o r r i b l e . I keep t h i n k i n g , ' s h o u l d I go t h r o u g h w i t h t h e t e s t o r s h o u l d n ' t I ? ' , b u t s i n c e Dr. X s a i d I need i t t h e r e ' s no sense o f f r e t t i n g o r w o r r y i n g about i f . " The i n f l u e n c e o f t h e mass media i s b e s t e x e m p l i f i e d by a f i v e - y e a r - o l d m a r r i e d woman who  had a c h r o n i c stomach u l c e r .  twenty-  She s t a t e d :  35 " I came t o t h e h o s p i t a l t h i s time because I had r e a d and h e a r d on t e l e v i s i o n t h a t t h e y a r e making g r e a t advances i n t h e f i e l d o f m e d i c i n e . You know, you watch a l l t h o s e d o c t o r shows on t e l e v i s i o n and see a l l the new t r e a t m e n t s t h e y a r e u s i n g t o h e l p p a t i e n t s g e t b e t t e r . Then you r e a d a l l the advances t h e y ' r e making i n t h e m e d i c a l f i e l d , p a r t i c u l a r l y i n t h e l a s t few y e a r s . I t makes me t h i n j c t h a t maybe t h e y can f i n a l l y c u r e y o u r u l c e r . Otherwise I d o n ' t t h i n k I would come i n t o t h e h o s p i t a l . " The i n f l u e n c e o f t h e p a t i e n t ' s own p e r s o n a l e x p e r i e n c e s , e s p e c i a l l y t h r o u g h p a s t 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 p a s t 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 c a n ' t s t a n d i n e f f i c i e n c y . I had t h r e e e x p e r i e n c e s w i t h quackery. F o r example, one d o c t o r l a b l e d me as h a v i n g a dropped k i d n e y . He gave me an I.V.P. t e s t and I have n e v e r went t h r o u g h such a c r u e l procedure i n my whole l i f e . I passed out t h r e e t i m e s w i t h v i o l e n t p a i n . I t h e n f i n d out t h a t I n e v e r had a dropped k i d n e y . That d o c t o r s h o u l d have known. An e x p e r i e n c e l i k e t h i s makes you wonder how competent some d o c t o r s a r e . You know, a g r e a t d e a l o f how s a f e you f e e l i n h o s p i t a l depends upon how much c o n f i d e n c e you have i n y o u r d o c t o r . " Table 3 Responses o f t h e P a t i e n t s D u r i n g t h e D i a g n o s t i c Regime E x p r e s s e d i n Terms o f P e r s o n a l Background F a c t o r s  N-25 Number o f Responses  Mean  Range  Experience  195  7.80  1-18  P e r s o n a l V a l u e System Needs  162  6.48  1-22  P e r s o n a l Background Factors Past  Total,  357  P e r s o n a l V a l u e System Needs - T a b l e 3,  above, shows t h e p a t i e n t s ^ respon-  s e s i n terms o f p e r s o n a l v a l u e system needs. responses  e l i c i t e d , r a n g i n g from 1-22  There were a t o t a l o f  w i t h a mean o f 6.48  responses  162 per  36 patient.  Because o f the importance o f the p a t i e n t ' s p e r s o n a l v a l u e  needs upon h i s p e r c e p t i o n of comfort  and d i s c o m f o r t promoting s i t u a t i o n s ,  a more d e t a i l e d a n a l y s i s i s shown i n T a b l e 4,  Table  below.  4  F a c t o r s of the P a t i e n t ' s P e r s o n a l Value System Needs  N-25  P e r s o n a l Value  Number o f P a t i e n t s E x p r e s s i n g the Need  System Need  To know the r e s u l t s o f the d i a g n o s t i c t e s t s . Affiliation. To see a purpose i n h a v i n g the t e s t s ( f i n d what i s wrong). P r i v a c y , d i g n i t y , p r i d e and  or p a i n .  Health.  23 22  out  confidentiality.  R e l i e f from p h y s i c a l d i s c o m f o r t  14 11 11 10  To see p r o g r e s s b e i n g made.  9 9 8  Economic  8  Respect f o r i n d i v i d u a l i t y . Food.  security.  3 3  Honesty. To be  busy.  Cleanliness. Not  t o i n f r i n g e upon o t h e r s '  rights.  Religion. Intellectual stimulation. To have c o n t r o l of the To  achieve.  Happiness. Cognitive  clarity.  Competence by  others.  situation.  system  3 3 2 2 2 2 1 1 1  37 Table 4» page 36,  shows that there were only two p a t i e n t s who d i d  not want to know the r e s u l t s of t h e i r d i a g n o s t i c t e s t s .  One 42-year-old  woman expressed a f e a r of what the r e s u l t s might be so she wanted to hear the r e s u l t s from her own home town doctor.  She f e l t her own f a m i l y 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 e l d e r l y man who had p o s s i b l e heart problems  stated that he d i d not r e a l l y care about r e c e i v i n g the r e s u l t s of the t e s t s as long as the doctors were happy. Of the twenty-three p a t i e n t s who wanted to know the r e s u l t s of t h e i r d i a g n o s t i c t e s t s , fourteen (60.87%) c o n t i n u a l l y emphasized that they wanted to know what was wrong w i t h them. Twenty-two out,of the twenty-five p a t i e n t s stated that they wanted to be with another patient during the d i a g n o s t i c 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 p a t i e n t s wanted to be with j u s t one other person.  The  reason they gave was i f there was more than one other p a t i e n t , i t would be too n o i s y , there would be quite a few other p a t i e n t p e r s o n a l i t i e s to adjust t o , and there would be a decrease i n p r i v a c y . Only ten p a t i e n t s v e r b a l i z e d that t h e i r h e a l t h was a very important part of t h e i r personal value system. Many stated they had taken t h e i r h e a l t h 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 p h y s i c a l h e a l t h . Nine p a t i e n t s v e r b a l i z e d that they wanted respect f o r t h e i r individuality.  They wanted the p r o f e s s i o n a l s 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 p a t i e n t s . The one way many p a t i e n t s evaluated whether or not the p r o f e s s i o n a l person, e s p e c i a l l y the  38 d o c t o r , r e s p e c t e d t h e i r i n d i v i d u a l i t y was by t h e degree o f a t t e n t i o n and c o n c e r n t h e p r o f e s s i o n a l p e r s o n gave them. An example o f a p e r s o n a l v a l u e system need i s w e l l demonstrated a 25-year-old l a d y who ted.  by  e x p r e s s e d a w i s h t o have h e r i n d i v i d u a l i t y r e s p e c -  D u r i n g t h e 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 n o t a c t l i k e y o u a r e j u s t a n o t h e r bed number. I ' d l i k e them t o t r e a t me l i k e a p e r s o n , n o t 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 i n t e r e s t e d , and h e l p you any time t h e y can and e x p l a i n a n y t h i n g you want and can t a l k t o y o u about p e r s o n a l t h i n g s . " I n summary t h e n , t h e w r i t e r n o t e d t h a t t h e i n d i v i d u a l ' s p e r s o n a l  v a l u e system needs were e l i c i t e d whenever t h e i r needs were met o r v i o l a t e d t h r o u g h r e c e n t e x p e r i e n c e s i n t h e h o s p i t a l o r on a p r e v i o u s a d m i s s i o n t o a hospital. EXPECTATIONS OP PRESENT HOSPITALIZATION EXPERIENCE E x p e c t e d I n f o r m a t i o n - An e x a m i n a t i o n o f T a b l e 5» P&ge 40, 40.6%  reveals that  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 e x p e r i e n c e f o c u s e d around e x p e c t e d i n f o r m a t i o n . There was o n l y one p a t i e n t who  d i d n o t e x p r e s s a need f o r any k i n d o f i n f o r m a t i o n .  The e x p e c t e d i n f o r m a t i o n u s u a l l y c e n t e r e d around t h e 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 t o know what was g o i n g t o happen  d u r i n g t h e d i a g n o s t i c regime, what t h e r e s u l t s o f t h e t e s t s would r e v e a l , and whether t h e t e s t would h u r t them i n any way.  The p a t i e n t s wanted  r e a s s u r a n c e t h a t t h e y would be i n competent hands and t h a t t h e s t a f f would t r y t h e i r b e s t t o make the d i a g n o s t i c t e s t e x p e r i e n c e as c o m f o r t a ble  as p o s s i b l e ,  A few p a t i e n t s wanted r e a s s u r a n c e t h a t t h e 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 t h e y d i d n o t want any  m a t i o n about the t e s t s because i t might cause them t o worry more.  inforThe  39 other expected information ranged from expecting the nurse t o t e l l them where the bathroom was t o expecting the doctor t o t e l l them when they could go home. An example of the p a t i e n t ' s expectation i n terms of r e c e i v i n g information was w e l l expressed by a 55-y ar-old man whose admission d i a g e  n o s i s was cancer of the stomach.  He s t a t e d :  "....This i s where I was g e t t i n g back t o what I discussed l a s t F r i d a y n i g h t , how r e a l l y impor-i tant i t i s that people are advised o f what i s going t o happen t o them while they are i n hosp 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. ranged from 0-11  The responses  with a mean of 4'«16' responses per p a t i e n t .  Twenty-three of the twenty-five p a t i e n t s expressed d e f i n i t e ideas of what they thought would happen t o them d u r i n g the d i a g n o s t i c regime. Many p a t i e n t s s a i d they were t o l d what t o expect by t h e i r doctors or from knowledge gained from past experiences. Most patients knew what diagnost i c t e s t s they would undergo unless the doctors suddenly decided they required another t e s t .  Many p a t i e n t s had a good idea of when they could  expect the r e s u l t s of t h e i r t e s t s and when they could probably go home. In most cases the p a t i e n t s appreciated knowing what t o expect d u r i n g the d i a g n o s t i c 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 d i d not apply t o those p a t i e n t s who were admitted from outside the Vancouver area. Many of the r e f e r r i n g general p r a c t i t i o n e r s d i d not appear t o know what d i a g n o s t i c t e s t s the p a t i e n t could expect or, i f they d i d , they never t o l d t h e i r p a t i e n t s .  P a t i e n t s who d i d not know  40 what to expect during the d i a g n o s t i c 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 f e e l i n g s of discomfort due to d i s t o r t e d expectations. On tb&other hand, i f the p r o f e s s i o n a l 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 p a t i e n t ' s h o s p i t a l i z a t i o n p e r i o d become a more comfortab l e one. An example of a p a t i e n t ' s expectations of the d i a g n o s t i c regime was w e l l i l l u s t r a t e d by a 56-year-old lady who was admitted with abdominal p a i n . During the t h i r d i n t e r v i e w she s t a t e d : "When I came to the h o s p i t a l I expected to get r e s u l t s by having a l l the necessary t e s t s and being t o l d what's wrong with me and get t h i s t h i n g a l l done I...I expect them to give me a g a l l bladder t e s t-because I have never had one before. Tomorrow's t e s t should t e l l me what's wrong with me." Table 5 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 Expectations of Present H o s p i t a l i z a t i o n Experience  N-25  Expectations  Number of Responses E l i c i t e d  Percentage of T o t a l  Mean  Range  40.6  7.08  0-14  Expected Events  177 104  23.85  4.16  0-11  Expectations of Professionals  134  30.73  5.36  0-10  6  1.38  mm  15  3.67  436  100.23  Expected Information  Expectations of Visitors Expectations of Other Patients  0-2 0-2  Expectations of P r o f e s s i o n a l s - Table 5, above, shows that 30.73% of the p a t i e n t s ' expectations focused upon how they f e l t they should be treated by p r o f e s s i o n a l s , p a r t i c u l a r l y the doctors and nurses.  Of the twenty-  41 t h r e e p a t i e n t s e x p r e s s i n g a t l e a s t one e x p e c t a t i o n , one o f tbemost s i g n i f i c a n t 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 t h e d o c t o r s and n u r s e s to  r e s p e c t them as i n d i v i d u a l s .  They wanted r e s p e c t f o r t h e i r f e e l i n g s o f  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 e x p e c t e d honesty from t h e p r o f e s s i o n a l people who came i n c o n t a c t w i t h them. A g r e a t number o f p a t i e n t s e x p e c t e d t h e d o c t o r t o f i n d o u t what was wrong w i t h them and cure i t i f n e c e s s a r y .  I t was n o t e d t h a t t h e p a t i e n t  was more a c c e p t i n g o f the d o c t o r ' s i n a b i l i t y t o diagnose  the problem p r o -  v i d i n g t h e d o c t o r i n f o r m e d him ahead o f time t h a t s u c h a s i t u a t i o n c o u l d arise.  Many o f t h e p a t i e n t s expected t h e d o c t o r 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 d o c t o r s t o  g e t t o g e t h e r and d e c i d e what they were g o i n g t o do i n s t e a d o f one d o c t o r o r d e r i n g one t h i n g and a n o t h e r d o c t o r o r d e r i n g s o m e t h i n g e l s e . An example o f t h i s was e x p r e s s e d by a 25-year-old l a d 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 d o c t o r s come around t o see y o u , b u t b e f o r e they s a y a n y t h i n g t o you, I t h i n k t h e y s h o u l d g e t t o g e t h e r a t t h e desk, o r whenever they a r e g o i n g t o g e t t o g e t h e r , and make one s e t o f r u l e s , and l e t you know t h a t , i n s t e a d o f each d o c t o r t e l l i n g y o u a l l s o r t s o f t h i n g s . " E x p e c t a t i o n s o f V i s i t o r s and O t h e r P a t i e n t s - T a b l e 5, page 40, shows t h a t the responses  e l i c i t e d from t h e p a t i e n t s i n terms o f e x p e c t a t i o n s o f v i s i -  t o r s and o t h e r p a t i e n t s , were v e r y l o w i n r e s p e c t t o t h e o t h e r f a c t o r s . O n l y 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 e x p e c t a t i o n s o f v i s i t o r s w h i l e t w e l v e p a t i e n t s s t a t e d d e f i n i t e e x p e c t a t i o n s o f o t h e r p a t i e n t s . The range o f responses  e l i c i t e d v a r i e d from 0 t o 2 r e s p o n s e s .  The o n l y g e n e r a l i z a -  t i o n t h a t c o u l d be made was t h a t t h e p a t i e n t s expected t h e v i s i t o r s and o t h e r p a t i e n t s t o behave i n a c e r t a i n manner.  F o r example, one p a t i e n t  s t a t e d t h a t she expected t h e v i s i t o r s t o 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 t h e o t h e r p a t i e n t s s h o u l d 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 t h e p r o f e s s i o n a l s t a f f get them w e l l .  T h i s man  f e l t t h a t too  many p a t i e n t s e x p e c t 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. R e g a r d i n g t h i s he s t a t e d , " t h i s i s n o t r i g h t , t h e p a t i e n t has t o t a k e some responsibility i n getting well". I t i s i m p o r t a n t t o remember t h a t when a n a l y z i n g t h e s i t u a t i o n s t h e p a t i e n t p e r c e i v e s as p r o m o t i n g c o m f o r t o r d i s c o m f o r t , i t must be  viewed  w i t h i n t h e c o n t e x t o f the p e r s o n a l background f a c t o r s and t h e e x p e c t a t i o n s o f 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 t h e degree  o f c o m f o r t o r d i s c o m f o r t e x p e r i e n c e d by t h e p a t i e n t cannot be  underestimated.  T h e r e f o r e , t h e s e c a t e g o r i e s o f p a t i e n t r e s p o n s e s have been p r e s e n t e d i n t h e f i n d i n g s of the study. COPING RESPONSES DURING THE DIAGNOSTIC REGIME T a b l e 6,  below, shows t h a t t h e c a t e g o r y o f i n d i v i d u a l c o p i n g r e s -  ponses r e p r e s e n t e d 28.82% o f t h e t o t a l number o f r e s p o n s e s e x p r e s s e d by t h e p a t i e n t s d u r i n g t h e d i a g n o s t i c regime. t h a t t h e p a t i e n t s may  T h i s s u r p r i s i n g f i n d i n g suggests  be a b l e t o cope much b e t t e r w i t h u n c o m f o r t a b l e  i e n c e s d u r i n g t h e d i a g n o s t i c regime t h a n p r e v i o u s l y a n t i c i p a t e d by  exper-  the  researcher. Table 6 C a t e g o r i e s o f P a t i e n t s ' Responses D u r i n g t h e D i a g n o s t i c Regime  N-25 . Number o f Responses  Percentage  of Total  P e r s o n a l Background F a 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 P r o m o t i n g 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 C o p i n g Responses  667  28.82  2314  99.90  Total . . . . . . . . . . .  43 T a b l e 7,  below, shows t h a t the p a t i e n t s v e r b a l i z e d 569  r e s p o n s e s as opposed t o 101  maladaptive responses.  The f i n d i n g s r e v e a l e d  t h a t the h i g h a d a p t i v e responses were p r i m a r i l y due p a t i e n t s attempted ble  adaptive  t o the f a c t  t o l o g i c a l l y r e a s o n out the r e a l i t y o f the  t h a t most  uncomforta-  e x p e r i e n c e , had f e e l i n g s o f hope and had t r u s t i n the p r o f e s s i o n a l  people c a r i n g f o r them.  (See T a b l e 8,  page 44).  When one o r more o f  these a b i l i t i e s and/or f e e l i n g s were absent, the p a t i e n t s had the to  express a h i g h e r r a t e of maladaptive  responses.  Table 7  Responses o f 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 E x p r e s s e d i n Terms o f I n d i v i d u a l Coping Responses  N-25  Number o f Responses  Responses Thinking  Activities  Percentage of T o t a l  309  42.12  Mean  12.36  Range  1--32  A d a p t i v e Responses Physical  Activities  260  38.81  10.40  1--25  Thinking  Activities  93  13.88  3.72  0--15  8  1.19  -  0--2  M a l a d a p t i v e Responses Physical  Activities  670  100  tendency  44 Table 8 Adaptive Coping Responses of P a t i e n t s During the Diagnostic Regime Expressed i n Terms of Thinking A c t i v i t i e s  N-25 Number of P a t i e n t s Expressing the Theme  S p e c i f i c Themes Expressed 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  20  Expressing f e e l i n g s of hope  19  Expressing f e e l i n g s of t r u s t i n the p r o f e s s i o n a l people c a r i n g f o r them  18  Expressing f e e l i n g of optimism  10  Expressing f e e l i n g s that they are undergoing the d i a g n o s t i c regime f o r a purpose - to f i n d out what i s wrong with them  9  P e r c e i v i n g themselves as not s i c k i n comparison to other p a t i e n t s  8  Expressing f e e l i n g s that they must accept the r e s u l t s of the d i a g n o s t i c t e s t s even i f they are not as they hoped them to be Expressing f e e l i n g s that they attempt to put worries r e l a t i n g to the d i a g n o s t i c regime out of t h e i r mind  7  Searching f o r and planning a l t e r n a t e s o l u t i o n s 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  6  Deciding to cope with the d i a g n o s t i c regime one step at a time  4  Expressing f e e l i n g s of i n t e r e s t and c u r i o s i t y about the d i a g n o s t i c regime Expressing f e e l i n g s of humor about t h e i r s i t u a t i o n  3 3  Expressing f e e l i n g s of f a i t h i n God  2  Seeing the d i a g n o s t i c 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 one's own outlook i n l i f e ADAPTIVE RESPONSES Thinking A c t i v i t i e s - Table 7, page 43, reveals that t h i n k i n g a c t i v i t i e s represent almost h a 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  t o cope w i t h uncomfortable  experien-  ces d u r i n g the d i a g n o s t i c regime. The p a t i e n t s had a tendency a c t i v i t i e s i n t h e i r attempts  t o u t i l i z e t h r e e primary t h i n k i n g  t o cope w i t h uncomfortable  Twenty p a t i e n t s s t a t e d t h a t they attempted  experiences.  t o l o g i c a l l y reason t h i n g s out  and see the r e a l i t y of t h e i r p r e s e n t s i t u a t i o n , n i n e t e e n p a t i e n t s e x p r e s sed f e e l i n g s of hope about the d i a g n o s t i c regime and e i g h t e e n p a t i e n t s expressed f e e l i n g s of t r u s t i n t h e i r d o c t o r s , nurses and o t h e r 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  w r i t e r noted t h r e e o t h e r i n t e r e s t i n g f a c t s d u r i n g the a n a l y -  s i s o f T a b l e 8,  page 44.  The f a c t t h a t o n l y s i x p a t i e n t s expressed  f e e l i n g s o f s e a r c h i n g f o r and p l a n n i n g a l t e r n a t e s o l u t i o n s t o problems r e l a t i n g t o t h e i r p r e s e n t s i t u a t i o n r a i s e s an important q u e s t i o n as t o how  people s o l v e problems d u r i n g c r i s i s p e r i o d s i n t h e i r l i v e s .  were o n l y two  people who  q u e s t i o n s as t o how of c r i s i s .  expressed f e e l i n g s of f a i t h i n God.  There  This raises  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 d u r i n g p e r i o d s  F i n a l l y , o n l y two  p a t i e n t s t a l k e d about s e e i n g the d i a g n o s t i c  regime as a l e a r n i n g e x p e r i e n c e , p a r t i c u l a r l y i n terms o f c h a n g i n g own  o u t l o o k on The  life.  p a t i e n t ' s attempt  t o a d a p t i v e l y cope w i t h the d i a g n o s t i c  regime, i n terms o f t h i n k i n g a c t i v i t i e s , i s w e l l e x e m p l i f i e d by a o l d man  their  43-year  admitted f o r i n v e s t i g a t i o n o f c a r d i a c and c i r c u l a t o r y problems.  D u r i n g the f i r s t  i n t e r v i e w he s t a t e d :  "...but I d i d n ' t t h i n k about myself because I ' d a l r e a d y woken up, so I knew t h a t whatever they d i d , they've done i t , and they went i n because they weren't sure whether I had c a n c e r . But i t was a p o l y p . But w o r r y i n g about c a n c e r . What's the sense of w o r r y i n g about c a n c e r because what's the p o i n t o f w o r r y i n g about something t h a t may not be - i t ' s a waste o f t i m e . I  t h o u g h t , '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 t h e r e i s . You have t o hope t h a t t h e s u n comes up tomorrow, o r 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 - T a b l e 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%  o f t h e t o t a l number o f c o p i n g r e s p o n s e s .  The r e s p o n s e s  ranged from 1-25 w i t h a mean o f 10.40 r e s p o n s e s p e r p a t i e n t . An e x a m i n a t i o n o f T a b l e 9, page 47, r e v e a l s that the t h r e e 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 c o p i n g w i t h t h e h o s p i t a l i z a t i o n e x p e r i e n c e has been r e a d i n g , w a l k i n g and t a l k i n g . was  I f the patient  u n a b l e t o c a r r y o u t a t l e a s t one o f t h e s e a c t i v i t i e s he would s t a t e  t h a t t h e w a i t i n g p e r i o d was v e r y 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 t h e d i a g n o s t i c regime b y 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 n o t l i k e h i s roommate.  I f any problems  a r o s e he would p r e t e n d he c o u l d n o t h e a r because he was l i s t e n i n g t o his radio.  He a l s o s t a t e d p a s s i n g t h e time by k e e p i n g a d i a r y o f h i s  h o s p i t a l experience. up"  the doctors  A n o t h e r woman p a s s e d t h e time b y t r y i n g t o "show  and n u r s e s who she f e l t were n o t b e i n g h o n e s t w i t h  her.  Two men had a game o f f o o t b a l l on t h e 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 o f whiskey i n t o t h e h o s p i t a l d u r i n g a n o t h e r e v e n i n g . The  f i n d i n g s suggest t h a t p a t i e n t s c o u l d 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 o f t h e d i a g n o s t i c regime, p r o v i d i n g t h e y u t i l i z e d t h e i r imagination  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 o f P a t i e n t s During the Diagnostic Regime Expressed i n Terms o f P h y s i c a l A c t i v i t i e s  N-25 Number of Patients Expressing the Theme  Activities Reading  20  Walking  17  T a l k i n g with Others  14  Phoning Friends and R e l a t i v e s  12  L i s t e n i n g t o the Radio  8  Asking Questions  8  R e p o s i t i o n i n g o f Body•< Alignment  8  Helping Others  7  Watching T e l e v i s i o n  6  K n i t t i n g , P l a y i n g Cards, Jig-Saw Puzzles, E t c .  5  Writing  3  Keeping Outside of One's Room  3  An e x c e l l e n t example of a man u t i l i z i n g adaptive coping behaviors, i n terms of p h y s i c a l a c t i v i t i e s , i s demonstrated by a 43-year-old man who had many repeated admissions t o h o s p i t a l f o r diagnosis and treatment. During the f i r s t interview,with the w r i t e r he s t a t e d : "The nurses have been very considerate here i o me; of course I work a t 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 w i t h people, and I work on and get them,all t o l i k e me as much as they can l i k e a p a t i e n t . I f you go i n t o the h o s p i t a l with a s u p e r i o r a t t i t u d e you've l o s t h a l f the people already. This a p p l i e s t o being anywhere. I f you continue with that s u p e r i o r a t t i t u d e you've-lost two-thirds, then before the evening i s over you're alone you're the only one not saying good-bye t o someone. So no matter where I am, e s p e c i a l l y i n the h o s p i t a l , I t r y t o 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' o r  48 d i r t y with the nurses. I t r y to be pleasant and say cute things. Maybe, i f I f i n d out what t h e i r 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 t h e i r job more. You don't go too f a r though, you try to f i n d a happy medium with each nurse. This way you end up with more service."  MALADAPTIVE RESPONSES T h i n k i n g . A c t i v i t i e s - Table tf, page 4-3, shows that there were 93 responses or  13.88% of the t o t a l number of i n d i v i d u a l coping responses that were  expressed as maladaptive thinking a c t i v i t i e s . 0-15  with a mean of 3.72  The responses ranged from  responses per patient.  There were 19 patients  who expressed concerns i n t h i s area. Table 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  N-25  Themes Expressed  Number of Patients 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 f e e l i n g s that they see no improvement i n t h e i r 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 h i s 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, i s 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 f e l t 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 i n terms of thinking activities was well demonstrated by a 43-year-old man admitted for investigation of a gastric ulcer. During the f i 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 i n that mood - i t ' s too easy. You look down there, fourteen floors down, and...I don't know why, I've always got i t i n 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 i n a way, i t ' s a t h r i l l f a l l i n g 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 i n case something ;should upset me enough that I'm not going to get clear enough to realize that i t ' s stupid and, up and do i t before i t ' 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."  50  P h y s i c a l A c t i v i t i e s - T a b l e 7, page 4 3 • r e v e a l s t h a t t h e r e were o n l y e i g h t maladaptive  responses,  i n terms o f p h y s i c a l a c t i v i t i e s , e x p r e s s e d  small m a j o r i t y of the p a t i e n t s .  by a  I n a l l i n s t a n c e s t h e r e s p o n s e s 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 t h 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 r e s p o n s e s .  F o r example, one l a d y phoned h e r husband and i n s t e a d o f  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 u p s e t b u t t e a r s were coming i n t o h e r eyes w h i l e she was t a l k i n g t o the w r i t e r .  One l a d y would n o t consent t o h a v i n g a l i v e r  b i o p s y u n t i l a l l t h e d o c t o r s got t o g e t h e r and d e c i d e d i f she r e a l l y needed one. She was angry because t h e y c o u l d n o t d e c i d e what was wrong w i t h h e r o r what d i a g n o s t i c t e s t s t h e y s h o u l d r u n . gotten very upset d u r i n g h e r l a s t admission h e r s e l f out against the doctor's consent.  T h i s same l a d y had  t o h o s p i t a l and had s i g n e d She s a i d she knew i t was wrong  but she f e l t i t was h e r o n l y s o l u t i o n t o h e r problem a t t h e t i m e .  Chapter IV DISCUSSION OF THE FINDINGS The r e s u l t s of t h i s study revealed that the situations the patients perceived as promoting comfort or discomfort were dependent upon two s i 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 c a r e f u l 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, e i t h e r through h i s own e f f o r t s or through the e f f o r t s of others.  Conversely, the patient's perception of a discom-  f o r t i n g s i t u a t i o n was due to h i s needs not being met or being v i o l a t e d by other people. The importance of understanding and meeting the i n d i v i d u a l ' s personal value system needs i s well i l l u s t r a t e d by Syngg and Combs.  In t h e i r  book, I n d i v i d u a l 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 i n given s i t u a t i o n s .  The individual's values  and needs have profound e f f e c t s on h i s perceptions and has important p l i c a t i o n s i n a l l types of s o c i a l i n t e r a c t i o n .  I t has been  im-  shown f o r  example, that persons whose values favor a c e r t a i n event or outcome tend  51  52 to  expect  21  s u c h a d e s i r e d outcome.  Syngg and Combs w r i t i n g s support  the w r i t e r ' s c o n c l u s i o n s t h a t  the p a t i e n t comes t o h o s p i t a l w i t h some d e f i n i t e e x p e c t a t i o n s o f what s h o u l d happen t o him and how o t h e r s s h o u l d respond t o him d u r i n g t h e d i a g n o s t i c regime.  The p a t i e n t ' s p a s t e x p e r i e n c e ,  h i s current biophyscho-  s o c i a l c o n d i t i o n , and t h e i n f o r m a t i o n g i v e n t o him by h i s d o c t o r to  h i s admission  to hospital influences h i s expectations.  prior  However, t h e  w r i t e r contends t h a t t h e s e f a c t o r s p l a y a minor r o l e i n comparison t o t h e i n f l u e n c e o f t h e i n d i v i d u a l ' s p e r s o n a l v a l u e system needs i n d e t e r m i n i n g his  expectations.  f o r t experienced  I t then f o l l o w s t h a t t h e degree o f comfort  o r discom-  by the p a t i e n t would depend upon the e x t e n t t o which h i s  e x p e c t a t i o n s were b e i n g met. To s u b s t a n t i a t e the w r i t e r ' s c o n c l u s i o n s , t h e two f o l l o w i n g n u r s e p a t i e n t i n t e r a c t i o n s i l l u s t r a t e t h e importance o f the n u r s e r e c o g n i z i n g how the p a t i e n t ' s p e r s o n a l v a l u e system needs g r e a t l y determines; h i s as t o how he s h o u l d be t r e a t e d d u r i n g the d i a g n o s t i c regime.  expectations  The f i r s t  example shows t h e ^patient's f e e l i n g s o f d i s c o m f o r t when h e r need t o he, t r e a t e d w i t h r e s p e c t as an i n d i v i d u a l w i t h r i g h t s , i s v i o l a t e d . example demonstrates a n o t h e r  p a t i e n t ' s f e e l i n g s o f comfort  The second  when t h i s same  need and r e s u l t a n t e x p e c t a t i o n i s met. Patient Patient:  #1: D r . S. i s making me f e e l t h a t I s h o u l d n ' 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 t h a t I am n o t s i c k enough t o be h e r e . Y e t i t was t h r o u g h h i s s u g g e s t i o n t h a t I am here i n t h e f i r s t p l a c e ; I d i d n ' t ask t o come i n .  A r t h u r W. Combs and Donald Svngg. I n d i v i d u a l B e h a v i o r , e d . Gardner Murphy ( R e v i s e d ed.; New Y o r k :  (1959), PP.37-121.  H a r p e r and Row,. P u b l i s h e r s ,  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 s a i d , ' t i r e d ' , and he s a i d , ' w e l l , i f that's your only complaint.'  Nurse:  So how d i d that make you f e e l ?  Patient:  Well, I f e l t r a t h e r s t u p i d because i t wasn't a complaint r e a l l y . But, I f e l t that the important part o f my treatment was the r e s t and that wasn't what I was g e t t i n g ; so he should r e a l l y know about i t . He didn't seem t o think i t was too important. He then asked me, 'how i s your stomach?' And I t o l d him about the d i f f e r e n t times I have had pain and what not; and he s a i d , 'okay, see you tomorrow,* o r something t o .that e f f e c t . I j u s t get the f e e l i n g now that he thinks I shouldn't be here. W e l l , that's f i n e , i f he wants t o send me home I would l i k e t o go home, but i t was on h i s suggestion, as w e l l as my doctor's, that I came here.  Nurse:  You say, you perceived that he doesn't want you here?  Patient:  I j u s t - i t ' s j u s t a f e e l i n g that he i s passing on t o me. J u s t by the way he says c e r t a i n t h i n g s .  Nurse:  How d i d you reach t h i s  Patient:  W e l l , j u s t 1>he way - when I s a i d I was t i r e d and j u s t the way he s a i d , 'well i f that i s your only complaint.' - And, j u s t the look he gave me. But I don't q u i t e understand what he means that I should be walking up and down the h a l l f o r , one thing.,  Nurse:  D i d you ask him?  Patient:  No,,_I didn't ask him because quite f r a n k l y I was annoyed and didn't f e e l l i k e t a l k i n g t o him anymore.  conclusion?  P a t i e n t #2: Nurse:  Could you t e l l me why you l i k e your f a m i l y doctor?  Patient:  You can s i t down and v i s i t w i t h her l i k e a - w e 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 meansjal o t more t o me than i f you found somebody - w e l l - 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 e l s e , or some other, s t u p i d t h i n g l i k e t h a t . She doesn't do t h i s .  NurseJ  You mean she takes time out w i t h you t o 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 s h e ' l l s i t there and l i s t e n . And, i f she f e e l s that there i s something that you are holding back, s h e ' l l 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 t o , she's the f i r s t one that I went to that gave me, uh - I mean, that looked a t 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 d i f f e r e n t doctor and he didn't even do t h i s . I t just made me f e e l uneasy, because how could he know what, where and when, or anything about my pregnancy unless he d i d some t e s t s . He j u s t didn't give a damn about me. '  Nurse:  Do you mean then, that your doctor treats you l i k e an important person?  Patient:  Yes, she c e r t a i n l y does!  COMPORT AND DISCOMFORT PROMOTING SITUATIONS DISCUSSED IN TERMS OP THE PATIENT'S ABILITY TO MOBILIZE ADAPTIVE COPING RESPONSES The r e s u l t s 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 diagnostic 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 h i s past experiences, h i s present biopsychosocial s t a t e , and the duration o f the perceived s t r e s s . The r e s u l t s indicated that whether or not a p a r t i c u l a r s i t u a t i o n causes stress depended a great deal on the way the patient evaluated the stress s i t u a t i o n , e s p e c i a l l y i n r e l a t i o n to h i s f e e l i n g s about h i s a b i l i t y to cope with i t .  Further, h i s evaluation and adaptive responses were i n -  fluenced by h i s past experiences which conditioned him to react i n s p e c i f i c patterns of learned behaviors.  He therefore not only reacted to the a c t u a l  existence o f danger, but to perceive threats and symbols of danger experienced i n h i s past.  Stress s i t u a t i o n s 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. I f 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 i s constantly experiencing threat.  The patient who i s worried about finding a job so that he can pay  off his b i l l s w i l l find each additional day in hospital a great burden. Finally, the illness i t s e l f draws a certain amount of the patient's attention and emotional energy. I f he i s experiencing pain of long duration and i s unable to anticipate when i t w i l l end, or i f the underlying reason for his pain i s unclear, he w i l l have a more d i f f i c u l t time i n coping with the pain.  As a result, his hope i s lowered and he w i l l 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 f a i r l y 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 demonstrate the influence of the patients' past experience, present physical, psychological, and social state, and duration of stress, upon their evaluation 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 t o a d a p t i v e l y cope w i t h the s t r e s s e s o f the diagnostic regime and hence t h e i r r e s u l t a n t f e e l i n g s o f comfort o r discomfort. , The f i r s t i n t e r view shows how the patient's past experience r e s u l t e d i n him e v a l u a t i n g the s t r e s s e s of the d i a g n o s t i c regime as l i f e threatening. H i s r e a l i t y based fears r e s u l t e d i n him experiencing a great deal of discomfort and he had many problems i n coping a d a p t i v e l y throughout the diagnostic regime. Patient:  Now .you're here f o r a purpose. I n my case, I have t o go through some t e s t s . Now, what are the t e s t s ? O r i g i n a l l y t h i s s t a r t e d out as-^a bleeding u l c e r but, only today i t came f o r t h that i t ' s p o s s i b l y 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 r a t h e r 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 t a b l e , the surgeon w i l l open you up and sew you up, and i n s i x months you're b u r i e d . This I don't want, because l i k e I say; I worked f o r 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 i d e a l time t o r e a l l y start living.  Nurse:  When d i d you t h i n k i t might be cancer?  Patient:  Today when Dr. B. r e f e r r e d t o i t as a tumor. A l s o , Dr. B. r e f e r r e d to i t as malignant. Now when Dr. S. came i n he s a i d that Monday's t e s t s w i l l be a gastroscopy t e s t , and he would take a biopsy t o check f o r cancer c e l l s . But, then, those b r i n g f o r t h l i t t l e reminders i n the past; i n 1965 my brother-in-law passed on with cancer. About two years ago a f e l l o w I worked w i t h , 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 t o the day. - R e a l l y , you only have t o see one person dying of cancer and you'd be a f o o l not t o take a page out of the book and j u s t s a y ^ ' w e l l , I hope that t h i s w i l l ,neyer happen t o me.' I'm f i n d i n g out very f a s t that as the years r o l l along, these things,do happen t o 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 h i s i n i t i a l stages but he was a well-proportioned man o f 185 pounds, and about three weeks before he passed on I saw him and he was around 100-110 pounds. * This patient's f e e l i n g s of discomfort, due t o h i s past experience  can be contrasted t o another patient whose past experience helped him t o be able t o cope a d a p t i v e l y with the stresses created by the diagnostic regime. Nurse:  A f t e r your past f i v e admissions t o h o s p i t a l , you,appear t o know  57 the h o s p i t a l routines and understand the diagnostic tests* Patient:  Yes. You get to know the way a h o s p i t a l works and runs. You gain confidence, and a f t e r 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 H o s p i t a l ; so you p r e t t y well get to know what t o expect. So,, that's c e r t a i n l y a comforting thing. The next two excerpts of interviews demonstrates the influence of  the patient's present psychological state upon h i s evaluation of what he's experiencing and h i s subsequent a b i l i t y to cope adaptively with the s t r e s 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:  Edgar, are you saying that you are a f r a i d that you may also become- mentally i l l y o u r s e l f and possibly commit suicide?  Patient:  (nods h i s head i n agreement)  Nurse:  That's the way I'm reading you r i g h t now. Edgar.  Patient:  No, but you don't get a second chance i f you do i t .  Nurse:  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 r u l e your present l i f e . We can't change the past, Edgar.  Patient:  ( c r i e s f o r a period of time) - I'm g e t t i n g upset.  Nurse:  Edgar, what's upsetting o r hurting you r i g h t now?  Patient:  These things you didn't know about, but I didn't r e a l l y expect to t e l l you about them.  Nurse:  Edgar, I was aware that you seemed quite depressed. know that?  Patient:  But you haven't,  Bid you  Yeah, I know, (pause) I think when the doctor t o l d me that I have these highs and lows, that has something to do with i t . One day you're j u s t 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 a f r a i d of.  Patient:  Yes. And I know another t h i n g that hurts. I f e e l sorry f o r 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 i t ? Because they didn't l i k e me. I wet the bed too much. I remember that f o r instance. Things l i k 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 t h i s up while I'm here i n hospital.  Patient #2: Nurse:  What i f the r e s u l t s of your t e s t s 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 s i x months to l i v e , that's okay with me. I have l e d a good l i f e . I have nothing to complain about. Too many people s t a r t worryi n g i f they are t o l d they are going to die i n s i x 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 i n d i v i d u a l may t a l k himself i n t o i t , and he dies within a year. No, I couldn't be bothered to worry. I'm not concerned about the t e s t s . 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 r e t i r e 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 l i k e l i v i n g alone so I don't f e e l 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, f r u s t r a t i o n s and disappointments as very threatening. His many expressed feelings of discomf o r t r e f l e c t e d h i s i n a b i l i t y to adaptively cope with such s i t u a t i o n s . The second patient, on the other hand, coped very well throughout the diagnostic regime.  His inner strength and t r u s t i n others enabled him  to adaptively cope with a l l the s t r e s s f u l s i t u a t i o n s that arose, despite the f a c t that he was i n hospital f o r cardiac i n v e s t i g a t i o n . The influence of the patient's present s o c i a l circumstances upon  59 his  evaluation of what i s happening to him and h i s resultant a b i l i t y to  adaptively cope with the diagnostic regime stresses i s i l l u s t r a t e d by excerpts from the following two nurse-patient interviews. ple  The f i r s t exam-  shows the patient expressing f e e l i n g s o f comfort because he had job  security, despite the f a c t that he had to come to hospital f o r diagnostic tests.  The second example demonstrates how the patient's lack of job  security hindered h i s 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 f i n e here, and even i f I have to get a new man i n , ' 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 . If I knew I was s i t t i n g here wasting my time, I'd f e e l 'well, I could be working those days and not - and just come i n when they need me f o r the operation so something l i k e that, because you're l o s i n g money, or they need you a t work, o r your job might be jeopardized, you know.' But now I know i t i s n ' t ; my job i s secured, and that's a wonderful f e e l i n g there. I've never had a job l i k e that before. That other job I worked f o r the l a s t 15 years, p r i o r to t h i s one, wasn't that way a t a l l . I f I'd have done t h i s , through no f a u l t of my own o f course, they would have just cut my pay then and there as of the day I l e f t . This company makes you r e a l i z e that you have a good company to work f o r , you know. You f e e l 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 f e e l I'm taking a holiday almost, you know. - I am w i l l i n g to go ahead andstay i n here and get the tests over with .  Patient #2: Nurse:  With the other two roommates going home, d i d you s o r t of wish you were going home too, and getting out o f hospital?  Patient:  No, not r e a l l y - well - uh - i n a sense yes, and i n a sense,  60 no. I've.got no r e a l home to go t o . 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 j u s t a place to be. So I'm not r e a l l y l o o k i n g forward to t h a t . And, of course, another unfortunate t h i n g i s t h a t I went out, I t h i n k y e s t e r day, and I have my car parked at the garage down here by my o f f i c e b u i l d i n g . And f o r some damn reason the s t a r t e r q u i t 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 a t . Not only t h a t , i f I'm not out at the end of the month, then I have no l i c e n c e f o r the car so I can't d r i v e i t anyway. So I have a few things to f i g u r e out as to how I'm going to go about doing those t h i n g s . Nurse:  When your roommates were here, you could help booster one another up, but now you're going to have to face up t o a few of your concerns?  Patient:  Yeah - w e l l , I t h i n k perhaps I tended to shove those worries to the back of my mind, you know, and thought, ' w e l l , you know, I ' l l take care of them l a t e r . ' Now suddenly they're pushed to the f r o n t of my mind, p a r t l y because of my mood, p a r t l y because there i s n ' t a r e l a t i o n s h i p to occupy my mind.  Nurse:  A c t u a l l y then, you have /a l o t of things on your mind?  Patient:  Yeah, I have q u i t e a few things that I'm going jto have to square away. I, have to f i n d out j u s t 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 t h i n k 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 j u s t 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 i n t o a s a l a r i e d , area, then I ' l l be okay. I ' l l be able to swing i t .  Nurse:  I s n ' 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 p e r f e c t l y t r u e , though i t proves one t h i n g . The medication I'm presently on must be working because my blood pressure hasn't gone any higher. I n 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 f u t u r e , and i t c e r t a i n l y troubles me q u i t e deeply. This p a t i e n t had expressed many f e e l i n g s of discomfort and he gra-  d u a l l y became more depressed throughout the l a t t e r part of h i s h o s p i t a l i z a tion.  An a n a l y s i s of these f e e l i n g s revealed that he had evaluated each  a d d i t i o n a l day i n h o s p i t a l as a great burden.  This evaluation i n t u r n was  61  based upon h i s present s o c i a l circumstances which hindered h i s a b i l i t y t o cope a d a p t i v e l y , hence h i s increased f e e l i n g s of depression. !  The f i r s t pa-  t i e n t had no discomforting f e e l i n g s i n t h i s area and therefore had more energy t o cope a d a p t i v e l y w i t h the s t r e s s e s caused by the d i a g n o s t i c regime. The e f f e c t s of the p a t i e n t ' s p h y s i c a l c o n d i t i o n and duration o f s t r e s s upon h i s a b i l i t y t o cope a d a p t i v e l y with the d i a g n o s t i c regime i s best exemplified by a 29-year-old lady who developed a severe headache d u r i n g the d i a g n o s t i c regime.  Her f i r s t problem was diagnosed as a stomach u l c e r  but the doctors were unable t o diagnose the cause of her headaches.  During  the tenth i n t e r v i e w the f o l l o w i n g d i s c u s s i o n took p l a c e : 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 g e t t i n g t o me. r I don't know, i t ' s seven days now and i t ' s g e t t i n g me down. The f a c t that i t ' s been there f o r so long was g e t t i n g me down and I was a l s o worried about - there might be something wrong with my head, or, you know, could I have a b r a i n 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 ' v e j i a d 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 p a i n , whereas my stomach u l c e r pain was l e s s 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 t o 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 t h a t ' s done i s t o constipate me, but i t doesn't r e a l l y r e l i e v e the headache.  Nurse:  So how does the future JLook t o you r i g h t  Patient:  W e l l , I'm beginning t o wonder i f and when I'm ever going t o get out of here. You know, I'm a l i t t l e depressed due to the f a c t 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 t a k i n g i t f r e q u e n t l y . So I am s o r t of discouraged because maybe I was expecting too much. I had thought that once I saw my doctor he would give me something t o r e l i e v e me of. the pain and a l l o w me to s t a r t e a t i n g again; Now he's t o l d me that i t might take a day, two days, three days before t h i s ) i s going t o do anything because the headache has taken a hold of i t s e l f . So now I'm t h i n k i n g , 'Well, here I've  now?  62 got another three days of not being able to eat p r o p e r l y , and you know i t ' s s o r t o f 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 t o two weeks while they run t e s t s . I wish my headache would j u s t go because I think that i t ' s h a l f the problem o f 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 o r noise on T.V. I t j u s t about d r i v e s 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. 1  The t w e l f t h i n t e r v i e w f u r t h e r demonstrates the demoralizing e f f e c t s of long term s t r e s s (pain) upon the p a t i e n t ' s a b i l i t y t o adaptively cope w i t h the stresses of the d i a g n o s t i c regime. Nurse:  You s a i d you have many f e e l i n g s today?  Patient:  A t 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 r e s t o f the days that I've had i t - i t ' s worrying me and i t ' s had me depressed; and I've s o r t of been down i n the dumps, a l i t t l e b i t blue maybe. I can't f i g u r e out why i t ' s l a s t i n g so long; - and - I don't know whether i t ' s nerves o r whether i t i s an e f f e c t of my c a r accident, o r what i t i s , you know. Because I can't understand a headache - I mean, I've had them before, up to f o u r days, but I've never had them going t h i s l o n g - and - I never touched my dinner t o n i g h t .  Nurse:  You didn't?  Patient:  Uh - mainly because I didn't f e e l l i k e e a t i n g . My headache was so bad and my stomach was so upset, I think due t o the headache more than anything e l s e . And i t i s s o r t o f g e t t i n g me down because I t h i n k , 'I can't understand why i t ' s there continuously f o r that many days.' So - uh - I didn't say anyt h i n g t o my doctor t h i s morning. He asked me i f I s t i l l had the headache, and I s a i d 'yes' and he s a i d , 'did the medicat i o n help?' I s a i d , 'they ease i t a b i t . ' But a t 4:30 PM they gave me some p i l l s but i t hasn't done a t h i n g f o r my headache. She gave me some p i l l s again about an hour-and-ah a l f ago and i t hasn't helped. They're not very strong due to the f a c t that I have an u l c e r . But that's s o r t o f p l a y i n g on my nerves a l i t t l e b i t . I can't, q u i t e understandawhy i t would l a s t that long, I'm k i n d 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 p l a y i n g on my nerves because I've had i t f o r so many days now, you know, I b e l i e v e that t h i s i s the f i f t h o r s i x t h day that I've had i t now and i t i s g e t t i n g t o the point where i t i s u p s e t t i n g me because I f e e l that i s n ' t normal that somebody has a headache f o r t h a t . l e n g t h o f time. And, i f i t ' s a f f e c t i n g my - you know 4  so that I can't eat, then i t ' s not helping my n i c e r neither. Nurse:  And you're s t a r t i n g to f i n d yourself spending more time worrying about i t ?  Patient:  Yeah, I am. I haven't f e l t that way u n t i l today. I f i n d i t hard to talk to people and I f i n d i t hard to be p o l i t e . And y e t I've had v i s i t o r s and I don't want to upset them. My mom and dad were i n and I didn't want them t o be aware of the f a c t that I had i t . They know I had a headache but they don't know how severe i t r e a l l y i s , . ;  The major source of t h i s patient's discomfort was due to the f a c t that her doctor was unable to r e l i e v e her prolonged headache.  This patient's  evaluation of her present s i t u a t i o n was one of discouragement.  Her response  to her evaluation was depression.  During the l a t t e r h a l f of her h o s p i t a l i -  zation she was spending so much energy i n attempting t o 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-  p a i r and her depression deepened.  She f i n a l l y l e f t h o s p i t a l without a c t u a l l y  knowing what had caused her headache.  CHAPTER V IMPLICATIONS AND RECOMMENDATIONS ARISING FROM THE STUDY H o s p i t a l Administrative P o l i c i e s The f a c t that 22 of the 25 patients interviewed wanted to be i n a room with at l e a s t one other patient supports Schachter's f i n d i n g s t h a t , under anxiety-provoking s i t u a t i o n s 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 e x p e r i -  22 ence.  I t i s therefore recommended t h a t , unless otherwise requested by  the p a t i e n t , 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 h o s p i t a l f o r d i a g n o s t i c t e s t i n g demonstrated some apparent degree of f e a r .  This f e a r motivated  them t o e x h i b i t v a r y i n g degrees of v i g i l a n c e responses.  A persistently  high l e v e l of a n t i c i p a t o r y f e a r , such as a f e a r 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 c a p a c i t i e s and a greater tendency t o 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 h i g h l y s e n s i t i v e t o the doctor's verbal and non-verbal communications and, i n many cases, misinterpreted them.  The doctor was the  most s i g n i f i c a n t person t o the p a t i e n t during the diagnostic regime and the more t r u s t the patient had i n h i s doctor, the greater was the iprobab i l i t y that the p a t i e n t would experience f e e l i n g s of comfort.  It is  therefore important that the doctor understand that h i s own a t t i t u d e s toward the p a t i e n t , as w e l l as h i s 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 U n i v e r s i t y Press, 1959), pp.12-24.  64  65 the patient, both a f f e c t the patient's t r u s t i n him.  I t i s therefore  recommended that the doctor should make c e r t a i n that the patient's i n t e r pretation of the doctor's communication i s the same as what the doctor intended to convey to him. up any misunderstandings unnecessary  The doctor then has the opportunity to c l e a r  that a r i s e and hence to reduce the l i k e l i h o o d of  discomfort and anxiety f o r the patient.  Research Many patients had d i f f i c u l t y v e r b a l i z i n g t h e i r s p e c i f i c tions of the diagnostic regime.  expecta-  Most had a vague idea of what they expec-  ted but could not e a s i l y put i t i n t o 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 h i s admission to h o s p i t a l , h i s lack of knowledge of h o s p i t a l procedures, h i s misunderstanding of the doctor's reports, and so on.  However, the findings of the  study also revealed that the patient's expectations arose as a r e s u l t of h i s underlying personal value system needs.  Therefore, an i d e n t i f i c a t i o n  of these needs could provide the helping person with clues as to the patient's expectations as well as to i d e n t i f y p o t e n t i a l problems that may a r i s e during the diagnostic regime.  For example, i f the patient had unrea-  l i s t i c expectations of how h i s 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 h i s expectations and to b r i n g the patient's expectations i n l i n e with the actual behavior of the doctor.  I t i s therefore recommended that f u r t h e r research be con-  ducted to devise a t o o l that would e l i c i t and i d e n t i f y the patient's personal value system needs. The r e s u l t s of t h i s study revealed that patients can cope more  66 a d a p t i v e l y t h a n 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 p o s s e s 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  t h a t c a n 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 t h e d i a g n o s t i c r e g i m e . s k i l l s and a b i l i t i e s  However, t h e s e  v a r i e d with 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 t h e d u r a t i o n o f t h e p e r c e i v e d s t r e s s .  It is  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 f o r m u l a t e  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 t h e 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 a t t h e same t i m e t o r e l a t e them t o t h e f a c t o r s mentioned above. Further experimental  r e s e a r c h needs t o be conducted t o d e t e r m i n e  whether o r n o t p a t i e n t c o m f o r t 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 b y t h e degree t o w h i c h t h e p a t i e n t ' s p e r s o n a l v a l u e system needs a r e b e i n g met, and t h e patient's a b i l i t y  t o mobilize adaptive  coping responses t o deal w i t h the  s t r e s s e s c r e a t e d by t h e d i a g n o s t i c r e g i m e .  Such r e s e a r c h c o u l d t e s t t h e 1  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 c o m f o r t e x p e r i e n c e when t h e p a t i e n t ' s p e r s o n a l v a l u e system needs a r e 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 p a t i e n t , c o m f o r t e x p e r i e n c e when t h e p a t i e n t i s a b l e t o m o b i l i z e a d a p t i v e  coping responses t o  d e a l w i t h t h e s t r e s s e s c r e a t e d by t h e d i a g n o s t i c regime. Nursing The  i m p l i c a t i o n s o f 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 t h e p a t i e n t ' s p e r s o n a l  system needs and t h e 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 p o s s e s s e s .  value Nursing  has / t r a d i t i o n a l l y .followed t h e m e d i c a l model and hence, t h e i d e n t i f i c a t i o n o f t h e s e f a c t o r s has been dependent on t h e n u r s e ' s own s e n s i t i v i t y t o t h e 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 s h o u l d be  67 u t i l i z e d at the time of the patient's admission to h o s p i t a l and i  provide clues as to the p a t i e n t ' s expectations.  should  As w e l l , i t should  iden-  t i f y p o t e n t i a l problems that could a r i s e during the diagnostic regime.  The  problems could then be a n t i c i p a t e d 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 p a t i e n t . The w r i t e r 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 f a c t o r s , 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 p a t i e n t ' s needs or her own ingenuity i n enabling the p a t i e n t to u t i l i z e h i s own resources i n coping with the stresses of the d i a g n o s t i c regime. The i m p l i c a t i o n s of t h i s study s t r e s s the importance of the nurse's r o l e i n f a c i l i t a t i n g congruence between the patient's expectations and h i s a c t u a l experiences during the diagnostic regime.  The nurse accomplishes  t h i s congruence by i n t e r v e n i n g 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 c a r i n g 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 f o r a c e r t a i n diagnostic t e s t , i t i s imperative that the nurse provide the p a t i e n t with the c o r r e c t informat i o n at the appropriate time.  The p a t i e n t 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 u a l l y happen to him.  I n those s i t u a t i o n s where the nurse a n t i c i p a t e s that the p a t i e n t  may  s t i l l experience a moderate degree of discomfort, the nurse can help the p a t i e n t u t i l i z e h i s 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 d i a g n o s t i c u n i t have a good t h e o r e t i c a l back-  ground i n the biopsychosocial needs of the p a t i e n t .  68  This knowledge can be  acquired through an i n s e r v i c e educational program or through a d d i t i o n a l education a t a c o l l e g e 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 f a m i l y i n h i s nursing care during the d i a g n o s t i c regime. patient may  The involvement of the  e l i m i n a t e , or at l e a s t reduce, h i s f e a r of the unknown because  i t gives him more c o n t r o l i n being able to p r e d i c t what i s going to happen to him;during the d i a g n o s t i c regime. perience l e s s f e e l i n g of helplessness.  With l e s s f e a r he w i l l , i n t u r n , exThe involvement of the family i s  important becuase the p a t i e n t looks to h i s f a m i l y f o r emotional support. Therefore, the nurse can guide the f a m i l y members i n g i v i n g the kind of psychological b o l s t e r i n g that w i l l promote f e e l i n g s of comfort. the family members could provide the nurse w i t h v i t a l , information  In turn, that  would be pertinent to the p a t i e n t ' s f e e l i n g s of comfort during the diagn o s t i c regime.  CHAPTER VI  SUMMARY AND CONCLUSION An exploratory study was conducted on 25 male and female p a t i e n t s who were admitted t o a 29-bed s u r g i c a l u n i t o f a 450-bed general h o s p i t a l for diagnostic testing. The study was conducted t o answer the f o l l o w i n g questions: (1)  What s i t u a t i o n s does the p a t i e n t perceive as h e l p i n g him f e e l comfortable while he i s experiencing the d i a g n o s t i c regime?  (2)  What s i t u a t i o n s does the p a t i e n t perceive as making him f e e l uncomfortable while he i s experiencing the diagnostic regime?  (3)  What coping responses does the p a t i e n t u t i l i z e i n adapting t o discomfort-promoting s i t u a t i o n s during the d i a g n o s t i c regime? The data f o r the study were c o l l e c t e d through the u t i l i z a t i o n o f  a s t r u c t u r e d questionnaire f o r the i n i t i a l i n t e r v i e w and taped interviews w i t h the selected p a t i e n t s .  The p a t i e n t s ' 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 v e r s i o n o f the C r i t i c a l Incident Technique.  The r e s u l t s were  then categorized i n t o themes o f p a t i e n t responses, tabulated and analyzed. The r e s u l t s of the study revealed that the p a t i e n t ' s perception o f s i t u a t i o n s as promoting comfort o r discomfort was dependent upon two s i g nificant variables: (1)  the degree t o which the p a t i e n t ' s personal value system needs were being met during the d i a g n o s t i c regime;  (2)  the p a t i e n t ' s a b i l i t y t o m o b i l i z e adaptive coping responses t o deal w i t h the s t r e s s e s caused by the d i a g n o s t i c regime. The f i n d i n g s o f the study support the model i n Figure 1, page 8.  The p a t i e n t ' s past experience, h i s present biopsychosocial s t a t e , and medical care f a c t o r s a l l i n f l u e n c e h i s t h i n k i n g and h i s expectations o f  69  70 the h o s p i t a l i z a t i o n e x p e r i e n c e d u r i n g t h e d i a g n o s t i c r e g i m e .  However, i t  i s t h e p a t i e n t ' s p e r s o n a l v a l u e system needs t h a t appear t o be t h e f u n d a m e n t a l f a c t o r g o v e r n i n g 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 e x p e c t a t i o n s as t o what i n f o r m a t i o n he s h o u l d r e c e i v e , how s i g n i f i c a n t o t h e r s s h o u l d behave toward him, and what should,happen t o him i n terms o f t i m e and e v e n t s . D u r i n g t h e d i a g n o s t i c regime t h e 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 e x p e r i e n c e d hearsed f o r .  and t h e s i t u a t i o n s he e x p e c t e d and r e -  I t was n o t e d t h a t t h e p a t i e n t r e p o r t e d e x p e r i e n c i n g f e e l i n g s  o f c o m f o r t whenever t h e 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 t h e sequence o f e v e n t s , o r t h e b e h a v i o r o f s i g n i f i c a n t o t h e r s toward him was c o n g r u e n t w i t h his expectations.  On t h e o t h e r hand, t h e p a t i e n t e x p e r i e n c e d  feelings of  d i s c o m f o r t whenever t h e a c t u a l b e h a v i o r o f s i g n i f i c a n t o t h e r s toward h i m , o r t h e i n f o r m a t i o n he r e c e i v e d , o r t h e sequence o f e v e n t s were  incongruent  with his expectations. The  f i n d i n g s o f t h e 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 a d a p t i n g t o d i s c o m f o r t - p r o m p t i n g  s i t u a t i o n s were  p r i m a r i l y dependent upon t h e way t h e p a t i e n t e v a l u a t e d t h e 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 o f h i s own a b i l i t i e s t o cope w i t h However, t h i s e v a l u a t i o n and t h e subsequent a d a p t i v e o r m a l a d a p t i v e  it. res-  ponses were d e c i s i v e l y i n f l u e n c e d by t h e p a t i e n t ' s p a s t e x p e r i e n c e s , h i s p r e s e n t b i o p s y c h o s o c i a l s t a t e , and t h e d u r a t i o n o f t h e p e r c e i v e d s t r e s s . I f t h e p a t i e n t was m a n i f e s t i n g a n e x t e n s i v e degree o f d y s f u n c t i o n a l beh a v i o r i n one o r more o f these a r e a s , t h e n he would e v a l u a t e many normal s t r e s s e s o f t h e d i a g n o s t i c regime a s e x t r e m e l y  threatening.  I t appeared  t h a t s u c h 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 o f d i s c o m f o r t and a r e d u c e d 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+. t h e well-functioning patient.  The r e v e r s e was t r u e f o r t h e 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 l e v e l o f adaptive or maladaptive coping r e s ponses exhibited by the patient r e f l e c t e d the degree o f comfort o r discomf o r t he  was experiencing. The r e s u l t s of the study also revealed that the patient's f e e l i n g s  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 m o b i l i z i n g adaptive coping r e s ponses . The implications of the study demonstrate the importance of the helping professional recognizing that the patient's f e e l i n g s o f comfort are best promoted when the helping person f o s t e r s s i t u a t i o n s that are congruent with the patient's expectations.  I t i s therefore imperative that  the helping person be able to create s i t u a t i o n s that w i l l e l i c i t the pat i e n t ' 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 f e e l i n g s 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 i d e n t i f y 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 the pat i e n t possesses.  These s p e c i f i c 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 r e l a t i o n to the patient's past experience, h i s present biopsychosocial state, and the duration of the s t r e s s he i s experiencing.  72  Further research i s required t o formulate a n u r s i n g t o o l that w i l l i d e n t i f y 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 would be able t o u t i l i z e i n coping a d a p t i v e l y w i t h  s t r e s s f u l experiences during the d i a g n o s t i c regime.  Such a t o o l could  then provide the nurse w i t h information that w i l l enable her to a n t i c i p a t e and prevent p o t e n t i a l problems that could occur during the d i a g n o s t i c regime.  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Dumas, R.G., and Leonard, R.D., " E f f e c t s o f Nursing on the Incidence o f Postoperative Vomiting," Nursing Research. XIV (Spring, 1965), 151-7. E l d e r , Ruth G., "What i s the P a t i e n t Saying?" Nursing Forum. 11 1 (1963), Hardin, C l a r a A., " C r i t i c a l I n c i d e n t , What Does i t Mean t o Research?" Nursing Research. I l l 3 (February, 1955), 105-9. Hart, Betty L., and Rohweder, Anna W., "Support i n Nursing," American Journal o f Nursing. L I X 9 (October, 1959), 1398-1401. Hayes, Dorothea R., "Waiting, A Concept i n Nursing," Nursing World. CXXII 5 (June, 1958), 67-72. Hecht, A l a n , "Questions R e l a t i v e s 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 J o u r n a l o f Nursing, LXI 3 (March, 1961), 86-8. Larsen, V i r g i n i a , "What H o s p i t a l i z a t i p h Means t o P a t i e n t s , " American J o u r n a l o f Nursing, LXI 5 (May, 1961), 42-7. Lederer, H.D., "How the Sick;;¥iew T h e i r World," J o u r n a l o f S o c i a l Issues. V I I I 4 (1952), 4-15. Lineham, Dorothy T., "What P a t i e n t s Want t o Know," American J o u r n a l o f Nursing. LXII 5 (May, 1966), 1066-70. M a r t i n , Harry W., and Pronge, Arthur J . , "The States of I l l n e s s , Psycholog i c a l Approach," Nursing Outlook. X (March, 1962), 168-71. Myers, Mary E., "The E f f e c t s o f Three Types o f Communication on P a t i e n t s Reaction t o S t r e s s , " Nursing R e s e a r c h . X I I I 2 (Spring, 1964), 126-31. 1  Rogers, C a r l , "The Necessary and S u f f i c i e n t Conditions o f Therapeutic Pers o n a l i t y Change," J o u r n a l o f Consulting Psychology. XXI 2 (1957),  95-101.  Smith, Dorothy M., "Myth and Method i n Nursing," American J o u r n a l o f Nursing. LXIV 2 (February, 1964), 68-72. Tryon, P h y l l i s A., " P a t i e n t P a r t i c i p a t i o n Vs. P a t i e n t P a 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 F l o r a , " E f f e c t s o f Two Nursing Admission Approaches o f P a t i e n t s ' D i s t r e s s and Ward Adjustment, A C l i n i c a l Experiment." Unpublished Masters Thesis, Y a l e U n i v e r s i t y , 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 Univers i t y of B r i t i s h Columbia.  I am studying how we can help people f e e l more  comfortable while they are waiting f o r the r e s u l t s of t h e i r t e s t s .  I  would l i k e to know i f you would allow me to come and see you f o r a short period of time u n t i l you have received the r e s u l t o f your t e s t s .  To help me be as accurate as possible, I would l i k e to tape record our t a l k s .  To ensure c o n f i d e n t i a l i t y , the tape w i l l not be i d e n t i f i e d as  yours nor w i l l your name appear anywhere on the t r a n s c r i p t of our t a l k s . I f you decide to allow me to come and v i s i t you now, but change your mind at a l a t e r time, that w i l l be f i n e .  I w i l l keep a copy of t h i s  consent form f o r 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 h i s v i s i t s a t any time, i f I so d e s i r e .  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 w i t h the P a t i e n t  79  QUESTIONNAIRES UTILIZED IN THE FIRST INTERVIEW WITH THE PATIENT P a t i e n t ' s General Knowledge o f the H o s p i t a l 1.  D i d you know what t o expect when you cane t o the h o s p i t a l f o r t e s t s ?  2. D i d you f e e l that you received enough information to help you get t o know the h o s p i t a l routine? 3.  What kinds of information would you l i k e t o know?  4.  Whom would you l i k e to t e l l you t h i s  5.  Gould you give me the reson f o r your choice?  information?  6., Do you know the doctor who i s l o o k i n g a f t e r you while you are i n the hospital? Diagnostic Tests 1.  Were you aware o f the t e s t s that you might be g e t t i n g while you were i n the h o s p i t a l ?  2. D i d you f e e l that you received enough information about the t e s t s you would be having? 3.  What information would you have l i k e d t o receive about the t e s t s ?  4.  Whom would you l i k e t o receive t h i s information from?  5.  Were there any t e s t s that made you f e e l uncomfortable?  6.  What was there about the t e s t s that made you f e e l uncomfortable?  7.  What d i d you do to t r y and make y o u r s e l f f e e l more comfortable?  8.  Was there anything that could have been done t o make you f e e l more comfortable while you were undergoing your t e s t s ?  Waiting Period Duration 1.  How long have you been w a i t i n g f o r the r e s u l t s of your t e s t s ?  2. D i d you expect t o be w a i t i n g t h i s long? 3 . Do you have any idea o f how much longer you w i l l be waiting?  80  Comforts 1.  What do you do t o pass the time while you are waiting?  2.  What do you do t o f e e l more comfortable while you are waiting?  3.  Have you t a l k e d t o anyone else?  4.  D i d you f i n d that you f e l t much b e t t e r a f t e r t a l k i n g t o someone else?  5.  Would you l i k e t o be w i t h others while you are waiting?  6.  Was there anything done t o 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 e x a c t l y what happened?  8.  What d i d the other i n d i v i d u a l do i n the s i t u a t i o n ?  9.  What d i d you do i n t h i s s i t u a t i o n ?  10.  Were you pleased w i t h 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 d i d the other i n d i v i d u a l do i n the s i t u a t i o n ?  4.  What d i d 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 t o deal w i t h i t ?  6.  Was there anything done t o 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 t o deal w i t h i t i n the same way? Feelings and Views on the Waiting Period 1.  Do you want t o know a l l the r e s u l t s o f your t e s t s ?  2.  Do you f i n d that you get tense o r u p - t i g h t as the time f o r your t e s t s draws near?  3.  Do you f i n d that you get tense o r up-tight as the r e s u l t draws near? 81  o f your t e s t s  4»  Can you describe what you thought about while you were waiting f o r the r e s u l t of your tests?  5.  I s there anything that could be done to make you more during t h i s waiting period?  6.  How d i d you handle the situation?  7.  Did i t help you f e e l more  8.  What does a p o s i t i v e diagnosis mean to you?  9.  What do you plan to do i f the r e s u l t s of the tests are not what you hoped them to be?  comfortable  comfortable?  82  APPENDIX C  P o l i c i e s 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 p e r t i n e n t data r e l a t e d t o : 1)  "behavioral c h a r a c t e r i s t i c s  2)  s o c i a l data - f a m i l y , 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 o f 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)  B)  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 r e a l l e r g i e s , meds, d i e t  3)  Information r e signs and symptoms, i v e . - what brought the p a t i e n t t o h o s p i t a l ?  4)  Physical orientations: - bedside equipment, reading l i g h t - call light - washrooms, telephone  5)  Introductions - t o nurse and t o other p a t i e n t s i n the room  6)  Give p a t i e n t s SPH admitting pamphlet and p r i n t e d ward information  F o l l o w i n g days (7:30 - 3:30) 1)  Discuss w i t h p a t i e n t SPH pamphlet  2)  Review w i t h p a t i e n t a l l items included i n the p r i n t e d ward information  3)  Obtain information and w r i t e up p a t i e n t p r o f i l e i n Kardex  84  ORIENTATION CHECK LIST VITAL STATISTICS:  Weight  Height  BP,P,R  Temp.  INFORMATION:  Allergies  Meds  Diet  S&S  PHYSICAL ORIENTATION;  Bedside equip.  Reading light  Call light  Washrooms Telephone  INTRODUCTIONS:  Nurse  Other patients  READING MATERIAL GIVEN;  SPH Pamphlet  Ward information  DISCUSSION:  SPH Pamphlet  Ward information  PATIENT PROFILE:  Information obtained  Written i n Kardex  EACH PATIENT'S GOALS AND APPROACHES WILL BE DISCUSSED WITH HIM/HER IMMEDIATELY AFTER WRITING Dated  MONITORING:  Write i n nurse's notes, i . e . , - Goals and approaches discussed ( o r not discussed) w i t h p a t i e n t .  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 . , - H o s p i t a l i z a t i o n discussed w i t h p a t i e n t ' s w i f e , son, f r i e n d . . . . . . . OR  - No v i s i t o r s i n t o discuss p a t i e n t ' s h o s p i t a l i z a t i o n .  1) How do you t h i n k your wife (son, etc.) i s doing i n h o s p i t a l ? 2)  Could anything he done d i f f e r e n t l y ?  3)  How i s the f a m i l y coping?  85  EACH PATIENT WILL RECEIVE FRE-TEST EXPLANATION (TEACHING) FOR EACH TEST AND PROCEDURE PROCEDURE;  D  7:30-3:50 S t a f f  Between 2:00-3:00 P.! a.  Inform p a t i e n t s of t e s t s scheduled f o r next day  b.  Give p a t i e n t a teaching card  c.  T e l l p a t i e n t that evening s t a f f w i l l e x p l a i n t e s t s and answer questions. ( I f p a t i e n t does not ask questions or i n d i c a t e 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 p a t i e n t that evening s t a f f w i l l f o l l o w 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)  5:30-11:50 S t a f f  Between 6:00-7:00 P.M. a.  E x p l a i n t o each p a t i e n t the t e s t s scheduled f o r the f o l l o w i n g day  b.  Between 8:50-10:00 P.M., review w i t h p a t i e n t what has been taught re h i s t e s t , and answer any questions  c.  Chart teaching and feedback r e s u l t s i n nurse's notes  d. .. Leave teaching card w i t h p a t i e n t u n t i l complet 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. - C o l l e c t a l l completed menus f o r your p a t i e n t s and place them with the Dietary Census i n the Ward Aid's basket.  2)  At mean times - Check each o f your p a t i e n t ' 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 p a t i e n t s have received snacks as ordered.  86  4)  O m i s s i o n s , a d d i t i o n s and changes: a)  W r i t e on t h e back o f p a t i e n t ' s menu and t a k e 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 y o u r p a t i e n t s i n 1 5 m i n u t e s t o n o t e i f r e q u e s t e d f o o d has a r r i v e d .  87  MENU CHECK LIST  PATIENT'S NAME  DATE  Menu completed  Yes  No  TRAY/MENU OK  INCORRECT  BREAKFAST  SNACK  LUNCH  SNACK  SUPPER  SNACK  88  CHANGE RECEIVED  APPENDIX D  P a t i e n t D a t a Sheet  89  Diagnostic Regime Data  N-25 Mean  Total  Range  99  3.96  1-10  Number o f Interviews i n Minutes  3367  34.00  13-83  Age  1832  47.33  20-76  Number o f Previous Admissions  140  5.60  0-20  Doctor's  109  4.36  1-16  104  4.16  1-16  I n t r u s i v e Tests  30  1.20  0-3  E x t r u s i v e Tests  76  3.04  1-9  137  5.48  1-16  Number o f Interviews  Visits  Family V i s i t s  Waiting P e r i o d i n Days  S o c i a l Data of P a t i e n t s  N-25 Education  M a r i t a l Status Marr.  15  D i v . Sep. Widowed  2  5  3  Place o f Residence  Formal Secon. Univ.  6  14  5  Vancouver Area  Out of Vancouver  14  11  Admitting and F i n a l Diagnosis i n Terms o f General Diagnostic Categories  N-25 Diagnostic Category  Admitting Diagnosis  Endrocrinology Cardiology  F i n a l Diagnosis  3 8  1 6  12  Hypertensive State  2  11 2  Undiagnosed  0  5  Gastrointerology  90  91  PATIENTS  RESPONSES  PATIENT  NUMBER  i  DURING  PERSONAL W.UE SYSTEM  ' .\'£.£DS  1 1 S O N AL  1  1G R C  I  i  i BA  I  •  4  6 S 4  1 5 5 5  i  EXf>ECTATIC)N,  tc) l 0 10 2 1 7  rc 6 J 5  3 J  VISITORS  c o 0 ,0 1  PATIENTS  0 0  ar  1  14 7 2 5 0  5 6 2 s  0 o  EVENTS  i l  I  0  j  £  VISITORS  1 0  OTHER  PATIENTS  <-1 1  1  010  Pf  &  /  \  4 5 t  1  2 i o i+  i  i  EVENTS  ' 2 4- 0 (4  PROFESSIOl-WLS  J 8 0 16 5 o  4  PATIENTS  |s a J  00  4 2 10 5 0 J | 2  fl 2  .J M 4  i 0 J • 3|C 0  0 1 o 0 0  i u.7 J  0  Jo 15 21 5 IS s  i 34-  2 0  S i5  4-U-  39  1  9  :|2 2 0  31  O  to  4  66  s  >!T  0 0  0 0 0 J  c DP>IN &  Rl.Sf  0  s\r  13 li ! 8 10 15 19 10 7  0 0 0 0 0 0 i /  67"  156  2 o\i 0 0  c  0  2  I  i W n I.' i  1  4 •'iii  — i — 0 0 J 0 o| 0  1 It  i  2 0  2  14 3 4 1  4 I 9 o w 2 I J *5  0 4 a n c 0 I  244  z 0 I a 6J4. 10  J02  1 0 0 0 |0  20  0  7 1 0 0 j J|O 2  55  £  1  RESPONSES i a .'4 20 6 /5 X IS lo -S2 4 1 12 to to 6  THINKIfC  ACTIVITIES  <2 f  PHYSICAL  ACTIVITIES  5 J -V 14 17 3 18 13  t—  NA1APTIVE  ->  1  3  IN )l\ 'IC>u\ L ADAPTIVE  104  9 5 9  2 0 0 1  1  f P 01-10 T! MG  0 J 0 12 0 0 S' 1 4  /;  177  e! .y 7  1  1  0 0 0 4 2 0 4 0 2 i|5  VISITORS OTHER  9  *  HI J 2 5 5 5 2 7| 7 J 0 6  0 o J  J i lU  5 4- 0 6  7  l  51" ruAT 10N{  TI NC  4 5 0 4 10 4  DI.£ ot-?F(DR r INFORMATION  i  u M li 9  5  J J 5 il 5 4  0 0 1 0 o 0 O 1 1  .2 /z e i 12 5 6 7 2.-  PROFESSIONALS.  .1,0 l  11 5  0 4 ;o 10 4 0 9 10 (0 2 2  i 2 I  295  162  6 jl!jfi  1 1 :XF>Ef?IE >ICE 1  1 2 0 0 0 0 0 0 0 oic 0 0 0 0 0 0  0  COMEOP T 1 I  j'  s'  J 6 7 2 a 6 je 4 9  r OS Pfl AL IZ/VT!(3N ! 1  10  TOTAL  i  9 2 4 !lO 8 ? 8 4 l i i j e  5  1 INFORMATION  MJzi|?2Ja; .4J25  FACTC  r  ID 6  5 2 0 4 7 J' 5  PROFESSIONALS  OTHER  5  REGIME  1 |  22 5 | 2 1  &  1  I 1  EVENTS  •1 WD  li 1 5 i U 6 7 0 J | 8 (6 2 j ^ Ui  i  INFORMATION  DIAGNOSTIC  2 3 J 4 .5 j 6 17 3J9J!0JllJL2J16JlAjl5J<6ll7J!BJB  1 P ' PAST EXPERIENCE  THE  7 25 5  »  a 6  /  II  6 9 17 u !£ 7  11 7 6 20  24 rt  8  RESPONSES 4 7 I 6 i 7 2 4 0 1 & 0 S 0  THINKING  ACTIVITIES  5 0  PHYSICAL  ACTIVITIES  o o D z 0 o l  0 /  1 0 c  u  0  l  0  :  J t 2 15 1 6 9  93  1? 0 i  8  0  0  0 0  

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