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The nurses’ interpretation of the interaction between themselves and elderly, confused patients Blais, Dawn Evelyn 1985

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THE NURSES' INTERPRETATION OF THE INTERACTION BETWEEN THEMSELVES AND ELDERLY, CONFUSED PATIENTS by DAWN EVELYN BLAIS B . S . N . U n i v e r s i t y of B r i t i s h C o l u m b i a , 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES The School of Nur s ing We accep t t h i s t h e s i s as conforming to the r e q u i r e d s t andard THE UNIVERSITY OF BRITISH COLUMBIA August 1985 Dawn B l a i s , 1985 <^  In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date i i A b s t r a c t The Nurses ' I n t e r p r e t a t i o n of the I n t e r a c t i o n Between  Themselves and E l d e r l y , Confused P a t i e n t s Using symbol ic i n t e r a c t i o n as a t h e o r e t i c a l framework, the r e s e a r c h e r e x p l o r e d the nur se s ' i n t e r p r e t a t i o n of t h e i r i n t e r a c t i o n s with e l d e r l y , confused p a t i e n t s for the purposes of under s t and ing nur se s ' behav ior and of implementing more e f f e c t i v e n u r s e - p a t i e n t i n t e r a c t i o n s . Q u a l i t a t i v e data were c o l l e c t e d d u r i n g i n t e r v i e w s with 18 r e g i s t e r e d nurses c u r r e n t l y working e i t h e r f u l l - t i m e or p a r t - t i m e in one of three extended care u n i t s . F i n d i n g s i n d i c a t e d tha t the nurses p e r c e i v e d s p e c i f i c p a t i e n t b e h a v i o r s , nurse b e h a v i o r s , and e x t e r n a l f a c t o r s as i n f l u e n c i n g a l l phases of t h i s i n t e r a c t i o n . S ix c a t e g o r i e s of p a t i e n t behav ior s emerged from the d a t a . These c a t e g o r i e s a r e : (a) d i s r u p t i v e b e h a v i o r s , (b) c o n t e x t u a l l y i n a p p r o p r i a t e b e h a v i o r s , (c) u n i n t e l l i g i b l e b e h a v i o r s , (d) memory-impaired b e h a v i o r s , (e) u n p r o d u c t i v e r e p e t i t i o n s , and ( f ) u n p r e d i c t a b l e f l u c t u a t i o n s . These behav ior s i n f l u e n c e d the n u r s e - p a t i e n t i n t e r a c t i o n by reduc ing the f requency wi th which nurses a t t ached unders tandab le meaning to p a t i e n t s ' b e h a v i o r , thereby r e d u c i n g the e f f e c t i v e n e s s of and t h e i r s a t i s f a c t i o n with the i n t e r a c t i o n . The nur se s ' p e r c e i v e d tha t t h e i r behav ior i n f l u e n c e d the t y p e , f r e q u e n c y , and d u r a t i o n of n u r s e - p a t i e n t i i i communicat ion , the degree to which the i n t e r a c t i o n was i n d i v i d u a l i z e d and p a t i e n t f o c u s e d , and the extent of p a t i e n t c o n t r o l d u r i n g the i n t e r a c t i o n . When p a t i e n t s i n f l u e n c e d n u r s i n g behav io r s in ways that reduced the frequency and p e r s o n - o r i e n t e d nature of the i n t e r a c t i o n , the nurses e x p e r i e n c e d the i n t e r a c t i o n as s t r e s s f u l and d i s s a t i s f y i n g and subsequent ly withdrew to some degree . E x t e r n a l f a c t o r s d e s c r i b e d as p e r s o n a l , i n t e r p e r s o n a l , and impersonal e i t h e r f a c i l i t a t e d or impeded the nur se s ' a b i l i t y to a s s i gn unders tandab le meaning to p a t i e n t s ' b e h a v i o r . The amount of under s t and ing t h a t o c c u r r e d i n f l u e n c e d the q u a l i t y of care and communication and the amount of s t r e s s exper i enced by the nur se . The f i n d i n g s suggest tha t g e r i a t r i c nurses should focus t h e i r behav ior on p a t i e n t s ' p s y c h o s o c i a l and emotional needs i n a d d i t i o n to t h e i r p h y s i c a l needs . Nurses must be aware of the impact of behav ior i d e n t i f i e d as c o n f u s i o n on the i n t e r a c t i o n . In response they must d i r e c t t h e i r c a r e g i v i n g and communication behav ior s toward m i n i m i z i n g the impact of the reduced under s t and ing t h a t occurs d u r i n g the i n t e r a c t i on . i v Tab le of Contents ABSTRACT i l TABLE OF CONTENTS iv ACKNOWLEDGMENTS vi CHAPTER 1 INTRODUCTION 1 Background to the Problem 1 Statement of the problem 5 D e f i n i t i o n of Terms. 6 T h e o r e t i c a l P e r s p e c t i v e 8 Purpose of the Study 12 Assumptions 13 L i m i t a t i o n s 13 Summary 14 CHAPTER 2 LITERATURE REVIEW 15 I n t r o d u c t i o n 15 Confus ion 16 Nurses ' A t t i t u d e s Toward E l d e r l y P a t i e n t s 23 N u r s e - P a t i e n t I n t e r a c t i o n 30 Summary 39 CHAPTER 3 METHODOLOGY 42 The In f luence of Symbol ic I n t e r a c t i o n i n Choosing a Research D e s i g n . . . . . 42 S e l e c t i o n of the Study Group 44 C r i t e r i a f o r p a r t i c i p a t i o n .• 44 Process fo r e l i c i t i n g s u b j e c t p a r t i c i p a t i o n 44 Data C o l l e c t i o n 46 E t h i c a l c o n s i d e r a t i o n s 46 Data c o l l e c t i o n procedure 47 Data A n a l y s i s 48 Summary 48 CHAPTER 4 PRESENTATION OF THE FINDINGS 50 ' P a t i e n t Behav ior s I n f l u e n c i n g the I n t e r a c t i o n 50 D i s r u p t i v e behav io r s 51 C o n t e x t u a l l y i n a p p r o p r i a t e behav ior s 52 U n i n t e l l i g i b l e behav io r s 53 Memory-impai red behav io r s 54 Unproduc t ive r e p e t i t i o n s 54 U n p r e d i c t a b l e f l u c t u a t i o n s 55 E f f e c t of P a t i e n t Behav ior s on Nurse Behav ior s 56 P a t i e n t behav ior s caus ing nurses to approach the i n t e r a c t i o n 57 P a t i e n t behav io r s caus ing nurses to avo id the i n t e r a c t i o n 59 Nurse Behav ior s and T h e i r In f luence on the I n t e r a c t i o n 62 The p r e i n t e r a c t i on phase 63 The i n t r o d u c t o r y phase 64 V The working phase 65 Nurses ' communication behav io r s 67 Nurses ' responses to nega t ive p a t i e n t behav ior 73 Nurses ' behav ior s tha t humanize the i n t e r a c t i o n 77 Nurses ' behav io r s tha t i n f l u e n c e p a t i e n t c o n t r o l 80 E x t e r n a l F a c t o r s I n f l u e n c i n g the I n t e r a c t i o n 81 Personal f a c t o r s 82 I n t e r p e r s o n a l f a c t o r s ; 86 Impersonal f a c t o r s 90 Summary 93 CHAPTER 5 DISCUSSION OF THE FINDINGS 95 The I n t e r a c t i o n as a Means of Communication 99 The I n t e r a c t i o n as a V e h i c l e For C a r i n g 107 The I n t e r a c t i o n as a Source of S t r e s s . . . 120 Summary 126 CHAPTER 6 SUMMARY, CONCLUSIONS, AND IMPLICATIONS 129 Summary 129 C o n c l u s i o n s 133 I m p l i c a t i o n s fo r Nurs ing 135 Nurs ing p r a c t i c e 135 Nurs ing e d u c a t i o n . 136 Nurs ing re search 137 Footnotes 139 References . 140 Appendi xes Appendix A 150 Appendix B 152 Appendix C 153 Appendix D 154 Appendix E 156 Appendix F 159 Appendix G 161 Acknowledgments I would l i k e to thank the members of my committee , D r . Margaret Campbell and Bet ty Johnson, fo r t h e i r p e r s e v e r e n c e , s u p p o r t , and good humour. T h e i r knowledge and wisdom has impacted g r e a t l y on t h i s study and w i l l c o n t i n u e to i n f l u e n c e my work i n the f u t u r e . I am indebted to my p a r e n t s , Norman and Joan B l a i s , and to Peter Hor s l ey fo r t h e i r c o n t i n u e d support and f i n a n c i a l a s s i s t a n c e d u r i n g t h i s l engthy p r o c e s s . I would a l s o l i k e to thank my c o l l e a g u e s , S h a r i l y n L indsey and Man Yeow Low, and my f r i e n d , J anet Morgan, f o r so generous ly s h a r i n g t h e i r time and e x p e r t i s e . L a s t l y , but most i m p o r t a n t l y , I would l i k e to thank those nurses who shared t h e i r thoughts and f e e l i n g s so t h a t o ther nurses working with e l d e r l y p a t i e n t s might b e n e f i t . 1 CHAPTER ONE I n t r o d u c t i o n Background to the Problem In 1921, 5% of Canadians were aged 65 and o v e r . T h i s percentage of aged Canadians i n c r e a s e d u n t i l the post war baby boom (1947-1960) , then resumed again i n the 1970's (Stone & F l e t c h e r , 1980) . In 1981, approx imate ly 9.7% of Canadians were 65 and over ( S t a t i s t i c s Canada, 1981). Unless the b i r t h r a te i n c r e a s e s , the percentage of e l d e r l y w i l l i n c r e a s e u n t i l approx imate ly the year 2006 at the ra te of one percentage p o i n t per decade. I t i s p r o j e c t e d t h a t by the year 2006 the e l d e r l y w i l l comprise about 11.5% of the p o p u l a t i o n . At t h i s time the baby boom g e n e r a t i o n w i l l begin to reach age 65 and Canada's e l d e r l y p o p u l a t i o n w i l l e s c a l a t e d r a m a t i c a l l y fo r 25 y e a r s . By the year 2031 approx imate ly 18% of the p o p u l a t i o n w i l l be 65 and over (Stone & F l e t c h e r , 1980) . Some sources e s t imate we i n s t i t u t i o n a l i z e 8% to 10% of our e l d e r l y ( S t a t i s t i c s Canada, 1982; Schwenger & G r o s s , 1980) w h i l e o ther s e s t imate as few as 5% (Stone & F l e t c h e r , 1980) . Disagreement r e g a r d i n g the percentage of our e l d e r l y r e c e i v i n g i n s t i t u t i o n a l care a r i s e s due to a l ack of consensus about what c o n s t i t u t e s an i n s t i t u t i o n and a l so about what l e n g t h of stay i n a general h o s p i t a l c l a s s i f i e s the e l d e r l y person as a long term care p a t i e n t ( S t a t i s t i c s 2 Canada, 1982). Al though the percentage of i n s t i t u t i o n a l i z e d e l d e r l y seems s m a l l , a document p u b l i s h e d by S t a t i s t i c s Canada (1984) s t a t e s tha t i n 1981, 158,000 Canadians aged 65 and over were l i v i n g i n n u r s i n g homes and i n s t i t u t i o n s f o r the e l d e r l y and c h r o n i c a l l y i l l . The p r o p o r t i o n of i n s t i t u t i o n a l i z e d versus n o n - i n s t i t u t i o n a l i z e d e l d e r l y may not i n c r e a s e over t i m e . However, as the percentage of e l d e r l y i n c r e a s e s , i t i s l o g i c a l to conc lude tha t the number of e l d e r l y i n i n s t i t u t i o n s w i l l i n c r e a s e c o n c u r r e n t l y . Wolanin and P h i l l i p s (1981) e s t imate that 50% of e l d e r l y p a t i e n t s in long term care u n i t s are admit ted due to con fus ion or w i l l develop c o n f u s i o n d u r i n g t h e i r s t a y . "The confused e l d e r l y w i l l be more l i k e l y than o ther e l d e r l y persons to become i n v o l v e d with . . . i n s t i t u t i o n s [due to] t h e i r g r e a t e r dependency needs and the i n a b i l i t y of the immediate f a m i l y to supply the e x t e n s i v e and complex persona l care they r e q u i r e " (p . 353) . Al though t h i s s tatement r e f e r s to e l d e r l y Amer icans , t h i s r e s e a r c h e r ' s e x p e r i e n c e , p lus the exper i ence of c o l l e a g u e s , suggests tha t t h i s s i t u a t i o n a l so e x i s t s in Canada. Hence, we see a phenomenon which c o n f r o n t s nurses i n the p r a c t i c e s e t t i n g : the e l d e r l y p e r s o n , w i t h i n an i n s t i t u t i o n , who i s i d e n t i f i e d as c o n f u s e d . As the number of these e l d e r l y p a t i e n t s in i n s t i t u t i o n s i n c r e a s e s , the number of nurses f a c i n g t h i s phenomenon w i l l i n c r e a s e a l s o . 3 Numerous s t u d i e s have i n d i c a t e d tha t nurses p r e f e r to work with young and middle aged p a t i e n t s and tend to s t e r e o t y p e o l d e r p a t i e n t s as dependent , i n a c t i v e , and withdrawn ( C a m p b e l l , 1971; Coe, 1967; S t o c k w e l l , 1972) . T h i s seems to be the predominant theme among a t t i t u d e s t u d i e s a l though o c c a s i o n a l s t u d i e s i n d i c a t e tha t nur se s ' a t t i t u d e s toward e l d e r l y p a t i e n t s are n e u t r a l or p o s i t i v e ( F u t r e l l & Jones , 1977; T a y l o r & Harned, 1978). One might assume tha t the e l d e r l y p a t i e n t who has been l a b e l l e d as confused would be more l i k e l y to be s t i g m a t i z e d and avo ided by n u r s e s . The nega t ive va lues and a t t i t u d e s and r e s u l t a n t s t e r e o t y p i n g by nurses may l e a d to a l o s s of the e l d e r l y p e r s o n ' s i n d i v i d u a l i t y and a d u l t s t a tu s f o l l o w e d by inadequate and i n a p p r o p r i a t e care (Solomon & V i c k e r s , 1979) . In f a c t , the l i t e r a t u r e i n d i c a t e s t h a t many e l d e r l y p a t i e n t s r e c e i v e d e p e r s o n a l i z e d , c u s t o d i a l , and abus ive care (Anderson & S tone , 1969; Buckelew, 1982; L o r e , 1979; P o d n e i k s , 1983; S e e l i g , 1982) . An i n a b i l i t y to i n t e r a c t e f f e c t i v e l y and m e a n i n g f u l l y i s o f ten c i t e d by nurses as the pr imary d i f f i c u l t y when working with e l d e r l y p a t i e n t s . Wolanin and P h i l l i p s (1981) i d e n t i f y many of the behav ior s d e s c r i b e d by n u r s e s , such as " c o n c e n t r a t i o n poor" and "not aware of s u r r o u n d i n g s , " as p r e v e n t i n g the p a t i e n t from i n t e r a c t i n g with h i s environment a c c o r d i n g to the c a r e g i v e r ' s e x p e c t a t i o n s . C o n s e q u e n t l y , nurses tend to avo id i n t e r a c t i n g with these p a t i e n t s ( C o h l e r 4 & S h a p i r o , 1964; S t o c k w e l l , 1972; Tudor , 1953), or to i n t e r a c t with them us ing t a s k - o r i e n t e d , r a t h e r than p a t i e n t - o r i e n t e d , i n t e r a c t i o n s ( W e l l s , 1981) . Wolanin (1977) i n d i c a t e s that a d i r e c t r e l a t i o n s h i p e x i s t s between communication problems and l a b e l s of c o n f u s i o n i n the e l d e r l y p a t i e n t . These i n t e r a c t i o n a l d i f f i c u l t i e s i n h i b i t development of the n u r s e - p a t i e n t r e l a t i o n s h i p e s s e n t i a l f o r the p r o v i s i o n of care which i s a t tuned to the p a t i e n t ' s needs. S o l u t i o n s to t h i s problem cannot be e f f e c t i v e wi thout an under s t and ing of the i n t e r a c t i o n between the nurse and the e l d e r l y p a t i e n t i d e n t i f i e d as c o n f u s e d . 1 "The care of the confused e l d e r l y i s a human s e r v i c e t h a t cannot be mechanized or c o m p u t e r i z e d ; i t i s . . . [an e s s e n t i a l l y ] human i n t e r a c t i o n " (Wolanin & P h i l l i p s , 1981 p. 374) . T h i s study w i l l focus on one aspect of tha t i n t e r a c t i o n : the meaning which the nurse a t t aches to the i n t e r a c t i o n between h e r s e l f and the p a t i e n t i d e n t i f i e d as confused . Wolanin and P h i l l i p s (1981) conc lude t h e i r book on the p r e v e n t i o n and care of c o n f u s i o n i n the e l d e r l y person with the f o l l o w i n g s ta tement : We are only beg inn ing to turn our r e s e a r c h i n t e r e s t to the . . . confused e l d e r l y p e r s o n . I t i s a f r o n t i e r that must be pene t ra ted by p r o v i d e r s of d i r e c t care who have re search s k i l l s . There has been a great deal of r e search by those who do not have d i r e c t c o n t a c t with 5 the confused e l d e r l y . Now we need to l e a r n from the c a r e g i v e r s who have worked c l o s e l y with them and who have i n s i g h t s tha t can l e a d to r e s e a r c h a b l e s o l u t i o n s to the problems s t i l l f a c i n g a l l of us . (p . 375) Statement of the Problem Nurses are c o n s t a n t l y i n t e r a c t i n g with p a t i e n t s who are e l d e r l y , i n s t i t u t i o n a l i z e d , and i d e n t i f i e d as c o n f u s e d . Most of the l i t e r a t u r e which r e l a t e s to t h i s i n t e r a c t i o n dea l s with n u r s e s ' a t t i t u d e s toward the e l d e r l y and wi th t a s k - o r i e n t e d n u r s i n g i n t e r v e n t i o n s to c o n t r o l the i n c o n s i s t e n t l y d e f i n e d causes and e f f e c t s of c o n f u s i o n . There i s consensus tha t t h i s i n t e r a c t i o n with the p a t i e n t pre sent s a problem f o r n u r s e s , y e t few s t u d i e s have been done which exp lo re t h i s a r e a . Nurses i n t e r a c t i n g d a i l y with these p a t i e n t s have l i t t l e under s t and ing of ways to i n t e r a c t which w i l l help them meet p a t i e n t s ' needs and d e r i v e a sense of s a t i s f a c t i o n from t h e i r work. T h e r e f o r e a study which e xp lo re s t h i s i n t e r a c t i o n may prov ide nurses with some i n s i g h t which w i l l enhance the e f f e c t i v e n e s s of the i n t e r a c t i o n . For t h a t r e a s o n , t h i s study w i l l exp lo re the nur se s ' i n t e r p r e t a t i o n s of the i n t e r a c t i o n between themselves and p a t i e n t s i d e n t i f i e d as c o n f u s e d . The f o l l o w i n g ques t ions w i l l be used to guide the s tudy : 1. What e f f e c t do nurses p e r c e i v e t h a t p a t i e n t behav io r s have upon the n u r s e - p a t i e n t i n t e r a c t i o n ? 6 1.1 What p a t i e n t behav ior s i n f l u e n c e the i n t e r a c t i o n ? 1.2 What are n u r s e s ' f e e l i n g s in response to these behavi ors? 1.3 What e f f e c t do these p a t i e n t behav ior s have upon t h e i r behav ior w i t h i n the i n t e r a c t i o n ? 2. What e f f e c t do nurses p e r c e i v e t h e i r behav ior has upon the n u r s e - p a t i e n t i n t e r a c t i o n ? 2.1 What nurse behav ior s do they i d e n t i f y as i n f l u e n c i n g the i n t e r a c t i o n ? 2.2 What e f f e c t do nurses i d e n t i f y t h e i r behav ior has upon p a t i e n t s ' behav ior w i t h i n the i n t e r a c t i o n ? 3. What f a c t o r s o u t s i d e of the n u r s e - p a t i e n t i n t e r a c t i o n do nurses p e r c e i v e as i n f l u e n c i n g both t h e i r behav ior and p a t i e n t s ' behav ior w i t h i n the i n t e r a c t i o n ? D e f i n i t i o n of Terms 1. Nurse : a male or female p e r s o n , r e g i s t e r e d as a nurse (under the Nurses [ R e g i s t e r e d ] Act ) w i t h i n the p r o v i n c e of B r i t i s h C o l u m b i a , who has worked i n an extended care u n i t f o r at l e a s t one year i n e i t h e r a f u l l - t i m e or permanent p a r t - t i m e c a p a c i t y . 2. P a t i e n t : an e l d e r l y male or female p e r s o n , i n s t i t u t i o n a l i z e d w i t h i n an extended care u n i t and i d e n t i f i e d as confused by the nur se . 7 3. Extended Care U n i t : a u n i t with the human and m a t e r i a l r e sources a p p r o p r i a t e to p rov ide care fo r i n d i v i d u a l s who are f u n c t i o n i n g at an extended care l e v e l a c c o r d i n g to the c r i t e r i a o u t l i n e d by the government of B r i t i s h Co lumbia . 4. I n t e r a c t i o n : r e c i p r o c a l l y i n f l u e n c e d behav ior s on the par t of two people w i t h i n p h y s i c a l p re sence ; a l l behav ior s c o n s i s t of verba l symbols and/or nonverbal ges tures and have meaning fo r at l e a s t one of the i n d i v i d u a l s (Charon , 1979; Lauer & H a n d e l , 1977). 5. O b j e c t : any th ing tha t can be p o i n t e d to or r e f e r r e d t o ; o b j e c t s are c a t e g o r i z e d as p h y s i c a l , s o c i a l ( p e o p l e ) , and a b s t r a c t ( i d e a s , p r i n c i p l e s , and p r o c e s s e s ) ; the nature of every o b j e c t c o n s i s t s of the meaning tha t i t has fo r the person fo r whom i t i s an o b j e c t (Blumer, 1969). 6. I n t e r p r e t a t i o n : an i n t e r n a l process whereby the nurse i d e n t i f i e s o b j e c t s w i t h i n the s i t u a t i o n which have meaning fo r her and then ma in ta ins or m o d i f i e s those meanings based on past exper i ence and the present s i t u a t i o n (Blumer , 1969) . 7. Meaning: something which i s a s s i gned to an o b j e c t through an i n t e r p r e t i v e process and r e s u l t s in the ac tua l response or r ead ine s s to respond to an o b j e c t i n a p a r t i c u l a r way (Blumer , 1969; Lauer & H a n d e l , 1977). 8 T h e o r e t i c a l P e r s p e c t i v e T h i s study e x p l o r e s the i n t e r a c t i o n between nurses and e l d e r l y p a t i e n t s i d e n t i f i e d as c o n f u s e d . T h e r e f o r e i t i s necessary to have a framework fo r t h i s study which c o n c e p t u a l i z e s the i n t e r a c t i o n r a t h e r than f o c u s i n g on i n d i v i d u a l p a r t i c i p a n t s w i t h i n the i n t e r a c t i o n . Symbol ic i n t e r a c t i o n , as a t h e o r e t i c a l p e r s p e c t i v e , " focuses on the nature of the i n t e r a c t i o n " (Charon , 1979, p. 3) thereby p r o v i d i n g a s u i t a b l e framework fo r t h i s s tudy . The f o l l o w i n g s e c t i o n o u t l i n e s the ba s i c assumptions of t h i s theory and d e s c r i b e s the symbol ic i n t e r a c t i o n i s t ' s c o n c e p t i o n of the i n t e r a c t i o n . Symbolic i n t e r a c t i o n c o n s i d e r s the i n t e r a c t i o n process a s u b s t a n t i v e t o p i c i n i t s own r i g h t (Lauer & H a n d e l , 1977), a process tha t forms human b e h a v i o r r a t h e r than a means or a s e t t i n g fo r the e x p r e s s i o n of human b e h a v i o r . I t a l so c o n s i d e r s i n t e r a c t i o n e s s e n t i a l to the p h y s i c a l and emotional w e l l - b e i n g of the i n d i v i d u a l . Symbolic i n t e r a c t i o n attempts to e x p l a i n behav ior by d e t e r m i n i n g the meaning t h a t the i n d i v i d u a l a t t aches to s p e c i f i c exper i ences w i t h i n the i n t e r a c t i o n ( S c h r o e d e r , 1981). Blumer (1969) has i d e n t i f i e d three p h i l o s o p h i c a l premises which form the core of t h i s approach : (a) humans ac t toward o b j e c t s ( p h y s i c a l , s o c i a l , and a b s t r a c t ) based on the meaning tha t these o b j e c t s have fo r them, (b) the 9 meaning of o b j e c t s i n l i f e i s d e r i v e d from the p e r s o n ' s i n t e r a c t i o n s , and (c) meanings are handled i n and m o d i f i e d through an i n t e r p r e t i v e process used by people to deal with o b j e c t s tha t they e n c o u n t e r . Symbolic i n t e r a c t i o n i s t s assume the p o s i t i o n t h a t the meanings which o b j e c t s have f o r human beings are c e n t r a l i n t h e i r own r i g h t (Blumer , 1969) . Blumer (1969) and Charon (1979) i n d i c a t e t h a t , i n c o n t r a s t to symbol ic i n t e r a c t i o n i s t s , many o ther s o c i a l s c i e n t i s t s see meaning as forming a n e u t r a l l i n k between the f a c t o r s r e s p o n s i b l e f o r human behav ior (eg . p e r s o n a l i t y and s o c i a l s t r u c t u r e ) and the behav ior s as the product s of these f a c t o r s . The premise , tha t humans ac t toward a l l o b j e c t s tha t they p e r c e i v e i n t h e i r wor ld on the ba s i s of the meaning tha t these o b j e c t s have fo r them, p laces a d i r e c t l i n k between the r o l e of meaning and the format ion of b e h a v i o r . The meaning determines the way i n which the i n d i v i d u a l p e r c e i v e s the o b j e c t , i s prepared to ac t toward i t , and i s ready to t a l k about i t (Blumer , 1969) . The second premise r e f e r s to the source of meaning i n s t a t i n g tha t the meanings of o b j e c t s a r i s e through i n t e r a c t i o n s with o t h e r s . T h i s i n t e r a c t i o n c o n s i s t s of communicating with symbols which can be p h y s i c a l o b j e c t s , human a c t s , or meaningful words (Kneisl- & W i l s o n , 1979; Lauer & H a n d e l , 1977) . I m p l i c i t w i t h i n t h i s premise i s the idea tha t meaning i s not i n t r i n s i c to e i t h e r the makeup of 10 the o b j e c t or the p e r s o n a l i t y of the i n d i v i d u a l (Blumer , 1969; K n e i s l & W i l s o n , 1979). Examined from a symbol ic i n t e r a c t i o n i s t p e r s p e c t i v e , the meaning o f con fu s ion i s not determined by i n t r i n s i c f a c t o r s t h a t c h a r a c t e r i z e p e o p l e , nor i s i t e s t a b l i s h e d by the nature of c e r t a i n a c t s . Ra ther , the meaning o f c o n f u s i o n i s a s o c i a l p r o d u c t , c r e a t e d through the d e f i n i n g a c t i v i t i e s o f people as they i n t e r a c t . The meaning of an o b j e c t f o r a person grows out o f the way i n which o ther people ac t toward the person wi th regard to the o b j e c t (Blumer , 1969). T h e i r a c t i o n s operate to de f ine the o b j e c t fo r the p e r s o n . Al though symbol ic i n t e r a c t i o n views meanings as s o c i a l p r o d u c t s , formed through the d e f i n i n g a c t i v i t i e s o f people as they i n t e r a c t (Blumer, 1969; K n e i s l & W i l s o n , 1979), these meanings as such are not e f f e c t i v e fo r g u i d i n g a c t i o n s (Blumer , 1969) . The use o f meanings i n a c t i o n s must f i r s t i n v o l v e an i n t e r p r e t i v e process which takes p lace w i t h i n the i n d i v i d u a l (Blumer , 1969) . A c c o r d i n g to B lumer ' s (1969) t h i r d premise , the use o f meanings by the person to d i r e c t a c t i o n s must occur through an i n t e r n a l proces s of i n t e r p r e t a t i o n . Dur ing the i n t e r p r e t i v e process the person f i r s t c o n s i d e r s what i s i m p o r t a n t , t h a t i s , which o b j e c t s w i t h i n the s i t u a t i o n have meaning f o r the p e r s o n . The meanings are then e i t h e r 11 m o d i f i e d or ma inta ined i n l i g h t of the c u r r e n t s i t u a t i o n and the i n d i v i d u a l ' s p r e v i o u s exper ience (Blumer , 1969). While both i n t e r n a l ( p s y c h o l o g i c a l ) and e x t e r n a l ( s o c i o l o g i c a l ) f a c t o r s o c c u r r i n g w i t h i n the s i t u a t i o n are c o n s i d e r e d , they are c o n s i d e r e d only i n the c o n t e x t of how they are handled w i t h i n the i n t e r p r e t i v e process (Blumer , 1969; L i n d e s m i t h , S t raus s & D e n z i n , 1975). T h i s i n t e r n a l process of i n t e r p r e t a t i o n i s necessary to enable the person to unders tand r e a l i t y and o r g a n i z e a c t i o n s (Lauer & H a n d e l , 1977) . People i n t e r p r e t s p e c i f i c s i t u a t i o n s i n t h e i r own way and then ac t based on t h e i r i n t e r p r e t a t i o n of the s i t u a t i o n . T h e r e f o r e , under s t and ing an i n d i v i d u a l ' s i n t e r p r e t a t i o n of a s i t u a t i o n g ives us b e t t e r i n s i g h t i n t o the meanings a s s i gned to o b j e c t s w i t h i n t h a t s i t u a t i o n and a g r e a t e r under s t and ing of t h e i r a c t i o n s w i t h i n t h a t s i t u a t i o n (Ashworth , 1979; Blumer, 1969; Lauer & H a n d e l , 1977). Dur ing i n t e r a c t i o n s with the p a t i e n t , the nurse responds c r e a t i v e l y through an i n t e r p r e t i v e p r o c e s s . She does not respond m e c h a n i c a l l y to i n t r i n s i c q u a l i t i e s w i t h i n 2 the p a t i e n t . Ra ther , she a s s igns meanings to p a t i e n t behav io r s w i t h i n the s p e c i f i c s i t u a t i o n based on what she has l e a r n e d from p r e v i o u s i n t e r a c t i o n s and on her p e r c e p t i o n s of the c u r r e n t s i t u a t i o n , and then responds i n terms of those meanings . T h i s i n t e r n a l process through which she i n t e r p r e t s the s i t u a t i o n a l lows the nurse to 12 respond to the p a t i e n t and the s i t u a t i o n i n terms of the meaning they have fo r h e r . In t h e i r a s s o c i a t i o n s , p e o p l e s ' c h a r a c t e r i s t i c mode o f i n t e r a c t i o n i s on the symbol ic l e v e l , t h a t i s , they seek to unders tand the meaning of each o t h e r ' s a c t i o n s (Blumer, 1969) . The meaning o f an a c t i o n s i g n i f i e s three t h i n g s : what the i n i t i a t o r p lans to do, what the r e c i p i e n t i s to do, and the j o i n t a c t i o n t h a t occur s as a r e s u l t of both a c t i o n s . I f there i s mi sunder s t and ing i n any one o f these areas of meaning, the i n t e r a c t i o n i s i n e f f e c t i v e and the j o i n t a c t i o n i s impeded (Blumer , 1969). When a c t i o n s have the same meaning fo r two i n d i v i d u a l s i n an i n t e r a c t i o n , they are s a i d to understand each o ther (Blumer , 1969) . Thus , the nurse p re sent s i n s t r u c t i o n s , r e q u e s t s , or s tatements as an i n d i c a t i o n o f what she i s p l a n n i n g to do as wel l as what she wants the p a t i e n t to do. Her r e q u e s t s , i n s t r u c t i o n s , or s tatements are symbols tha t convey to the p a t i e n t who r e c o g n i z e s them, the i n t e n t i o n and the plan o f the for thcoming a c t i o n s o f the n u r s e . The p a t i e n t who responds o r g a n i z e s h i s response on the ba s i s of what the symbols mean to him. Purpose o f the Study The nur se s ' behav ior i s based upon t h e i r i n t e r p r e t a t i o n o f t h e i r i n t e r a c t i o n s with the e l d e r l y , confused p a t i e n t s . By c l a r i f y i n g the nur se s ' i n t e r p r e t a t i o n o f the s i t u a t i o n , 13 i t i s p o s s i b l e to b e t t e r unders tand t h e i r behav ior with these p a t i e n t s . T h e r e f o r e , the purpose of t h i s study i s to e x p l o r e the nur se s ' i n t e r p r e t a t i o n s of these n u r s e - p a t i e n t i n t e r a c t i o n s us ing symbol ic i n t e r a c t i o n as a t h e o r e t i c a l framework. An improved under s t and ing of t h i s area has i m p l i c a t i o n s fo r more e f f e c t i v e n u r s e - p a t i e n t i n t e r a c t i o n s fo r nurses working with e l d e r l y , confused p a t i e n t s . I t might a l so prov ide i n p u t to a d m i n i s t r a t o r s to e s t a b l i s h more meaningful supports f o r nurses working i n t h i s area and to educators to p r o v i d e more meaningful and r e a l i s t i c c l a s s room and c l i n i c a l e x p e r i e n c e s . Assumptions I t i s assumed tha t a l l behav io r s d i r e c t e d toward an o b j e c t w i t h i n the i n t e r a c t i o n are a product of how people i n t e r p r e t t h a t , and o t h e r , i n t e r a c t i o n s (Bogdan & T a y l o r , 1975). I t i s f u r t h e r assumed t h a t , w i t h i n t h e i r i n t e r a c t i o n s with p a t i e n t s , nurses w i l l i d e n t i f y c e r t a i n p a t i e n t s as c o n f u s e d . The d e c i s i o n to s e l e c t nurses as p a r t i c i p a n t s in t h i s study was guided by the assumption t h a t nurses are able to d e s c r i b e and are w i l l i n g to t a l k about t h e i r i n t e r a c t i o n s with p a t i e n t s i d e n t i f i e d as c o n f u s e d . L i m i t a t i o n s There are l i m i t a t i o n s to the g e n e r a l i z a b i l i t y of the study c o n c l u s i o n s from groups of r e g i s t e r e d nurses working in extended care u n i t s to nurses working i n o ther a r e a s . 14 Without f u r t h e r study i t would not be p o s s i b l e to s t a t e the d i f f e r e n c e s and s i m i l a r i t i e s between t h i s group and o ther groups of n u r s e s . In a d d i t i o n , i t i s p o s s i b l e tha t the nur se s ' accounts c o u l d have been i n f l u e n c e d i n some way by the ph i lo sophy and p h y s i c a l c h a r a c t e r i s t i c s of t h e i r r e s p e c t i v e i n s t i t u t i o n s . Summary As our p o p u l a t i o n ages , the problems which occur now w i l l become more f requent and consequent ly more u r g e n t . The l i t e r a t u r e and t h i s r e s e a r c h e r ' s exper i ence i n d i c a t e t h a t i n t e r a c t i o n s between nurses and e l d e r l y p a t i e n t s i d e n t i f i e d as confused are o f ten seen as problems by nurses and can r e s u l t in s t e r e o t y p i n g and inadequate care fo r the e l d e r l y . T h i s study has been des igned to c o n t r i b u t e to the under s tand ing of t h i s i n t e r a c t i o n . Through f u r t h e r u n d e r s t a n d i n g , nurses w i l l come c l o s e r to p r o v i d i n g the q u a l i t y of care which w i l l he lp to meet the needs of the el d e r l y . 15 CHAPTER TWO L i t e r a t u r e Review As our p o p u l a t i o n of aging i n d i v i d u a l s grows and our h o s p i t a l beds are occup ied by a p r o g r e s s i v e l y l a r g e r percentage of p a t i e n t s over 65 y e a r s , we see a c o n c u r r e n t i n c r e a s e in a g e - r e l a t e d s t u d i e s w i t h i n the h e a l t h care p r o f e s s i o n s . Nurs ing l i t e r a t u r e r e f l e c t s t h i s s h i f t (Brimmer, 1971) . T h i s study focuses on an i d e n t i f i e d problem i n h e a l t h c a r e : the i n t e r a c t i o n between the nurse and the e l d e r l y , i n s t i t u t i o n a l i z e d p a t i e n t i d e n t i f i e d as confused . There i s a l ack of l i t e r a t u r e r e l a t i n g d i r e c t l y to t h i s problem statement but there i s much l i t e r a t u r e which p e r t a i n s to r e l a t e d areas of the problem. T h i s l i t e r a t u r e review i s o r g a n i z e d i n t o three r e l a t e d a rea s : the concept of c o n f u s i o n , nur se s ' a t t i t u d e s toward aging p a t i e n t s , and n u r s e - p a t i e n t i n t e r a c t i o n s . The f i r s t s e c t i o n present s l i t e r a t u r e r e l a t e d to the concept of c o n f u s i o n . Al though much of t h i s l i t e r a t u r e i s not e m p i r i c a l l y based, i t w i l l be i n c l u d e d here because i t i d e n t i f i e s the c u r r e n t focus of n u r s i n g wi th r e s p e c t to the concept of c o n f u s i o n . The second area i d e n t i f i e d r e l a t e s to nur se s ' a t t i t u d e s toward the e l d e r l y and t h e i r impact on p a t i e n t c a r e . The t h i r d area of t h i s l i t e r a t u r e review 16 concerns n u r s e - p a t i e n t i n t e r a c t i o n s which are r e l a t e d to the problem s ta tement . Confus i on C o n f u s i o n , as a c o n c e p t , has not been c l a r i f i e d by h e a l t h care workers g e n e r a l l y or by nurses s p e c i f i c a l l y . W i t h i n the n u r s i n g l i t e r a t u r e con fus ion has been i d e n t i f i e d as a c h a r a c t e r i s t i c , a d i a g n o s i s , and a symptom. When con fus ion i s d e s c r i b e d as a b e h a v i o r a l d i s t u r b a n c e , there i s no c o n s i s t e n t b e h a v i o r or group of behav ior s which are i d e n t i f i e d as r e p r e s e n t i n g t h i s c o n c e p t . Among most r e l e v a n t n u r s i n g a r t i c l e s there are as many c a t e g o r i e s and d e f i n i t i o n s r e l a t e d to c o n f u s i o n as there are a r t i c l e s . T h i s has f a r - r e a c h i n g i m p l i c a t i o n s fo r a l l f a c e t s of n u r s i n g c a r e . There are numerous a r t i c l e s w r i t t e n by doc tor s which focus on the e l d e r l y p a t i e n t who has been diagnosed as confused (Bayne, 1978, 1979; G f e l l e r , 1978; G i l l i s , E l k , L e f e v r e & J o f f e , 1981; L i p t z i n , 1981; M o r r a n t , 1983). W i t h i n the medical model , c o n f u s i o n i s c a t e g o r i z e d i n t o acute and c h r o n i c c o n f u s i o n a l s t a t e s (known r e s p e c t i v e l y as d e l i r i u m and dementia) depending upon e t i o l o g y and r e v e r s i b i l i t y of s igns and symptoms. Many n u r s i n g authors view c o n f u s i o n in terms of e t i o l o g y and d i a g n o s i s . T h i s view of c o n f u s i o n r e f l e c t s the f requent use of the medical model as a framework (Gerdes , 1968; L a P o r t e , 1982; Mackey, 17 1983; Wahl , 1976; Whitehead, 1980). T h i s approach assumes tha t the pr imary causa l agent l i e s w i t h i n the i n d i v i d u a l . M o r r i s and Rhodes (1972) d e s c r i b e o r g a n i c c o n f u s i o n as a mental d i s o r d e r r e l a t e d to p h y s i c a l causes such as e l e c t r o l y t e d i s t u r b a n c e s , i n f e c t i o u s p r o c e s s e s , c e r e b r a l d i s o r d e r s , drug t o x i c i t y , or r e s p i r a t o r y d i sea se s with the predominant f e a t u r e s be ing impairment of r ecent memory and d i s o r i e n t a t i o n . Bos s ' s (1982) a r t i c l e on acute c o n f u s i o n a l s t a t e s i d e n t i f i e s them as r e v e r s i b l e i n nature and r e s u l t i n g from c e r e b r a l d y s f u n c t i o n secondary to sys temic or CNS i n f e c t i o n , i n t o x i c a t i o n , trauma, CVA, s e i z u r e , tumour, or m e t a b o l i c d i s o r d e r s such as h y p o x i a , d e h y d r a t i o n , or hypog lycemia . She a s s o c i a t e s r e s u l t i n g b e h a v i o r a l d i s t u r b a n c e s with d i s r u p t i o n of c o r t i c a l f u n c t i o n . Many n u r s i n g a r t i c l e s focus on t r e a t m e n t s , o u t l i n i n g a set of s k i l l s or t a s k s , such as r e o r i e n t i n g t e c h n i q u e s , which are des igned as n u r s i n g i n t e r v e n t i o n s . The assumption i s tha t these measures w i l l reduce the behav ior s i d e n t i f i e d as c o n f u s i o n and the problem w i l l be c o n t r o l l e d or r e s o l v e d (Gerdes , 1968; P a t r i c k , 1967; K r o n e r , 1979). S ince i t s development by Taulbee and Folsom (1966) , r e a l i t y o r i e n t a t i o n has been advocated as a major n u r s i n g i n t e r v e n t i o n for confused and d i s o r i e n t e d i n s t i t u t i o n a l i z e d p a t i e n t s . R e a l i t y o r i e n t a t i o n (RO) d i r e c t s the nurse to modify her i n t e r a c t i o n s so t h a t she s y s t e m a t i c a l l y r e o r i e n t s 18 the p a t i e n t to h i s su r round ing environment with emphasis on t i m e , p l a c e , and p e r s o n . Al though some e v a l u a t i v e r e sea rch has i n d i c a t e d t h a t e l d e r l y p a t i e n t s ' o r i e n t a t i o n to t h e i r environment improves as a r e s u l t of RO ( H o g s t e l , 1979; Ho lden , 1979; Mulcahy & Rosa, 1981; S e t t l e , 1975), much of the l i t e r a t u r e conc ludes tha t RO produces few, i f any, b e h a v i o r a l changes ( B u r t o n , 1982; MacDonald & S e t t i n , 1978; Powel1-Proc tor & M i l l e r , 1982; V o e l k e l , 1978) . Burton (1982) ques t ions whether RO i s age and c u l t u r e a p p r o p r i a t e to the people and the s e t t i n g s fo r which i t i s used . T h i s author f u r t h e r s t a t e s t h a t by " a p p l y i n g a package l i k e RO, c l i n i c i a n s do not appear to be us ing s k i l l s i n behav ior a n a l y s i s " (p . 431) , nor do they appear to be us ing these s k i l l s to unders tand the b e h a v i o r - e n v i r o n m e n t r e l a t i o n s h i p . As a t h e r a p y , RO e x e m p l i f i e s the d e s i r e to f i n d an easy answer to a d i f f i c u l t prob lem. In t h e i r haste to so lve t h i s prob lem, nurses have s i d e - s t e p p e d the person and focused on the c o n f u s i o n and d i s o r i e n t a t i o n , a focus which permeates much of the n u r s i n g l i t e r a t u r e . In an attempt to a l l e v i a t e the problem b e h a v i o r and to move the i n d i v i d u a l toward r e a l i t y , nurses i n t e r v e n e to change the behav ior r a t h e r than to know and adapt t h e i r care to the i n d i v i d u a l . V a l i d a t i o n t h e r a p y , proposed by F e i l (1967, 1982) as an a l t e r n a t i v e way of i n t e r a c t i n g with p a t i e n t s , focuses on h e l p i n g d i s o r i e n t e d p a t i e n t s to reach t h e i r goa l s and not 19 the goa l s of the n u r s i n g s t a f f . I t advocates i n t e r a c t i o n s which support and v a l i d a t e the p a t i e n t s ' f e e l i n g s i n o rder to e s t a b l i s h a r e l a t i o n s h i p of t r u s t . F e i l (1982) , a f t e r 5 year s of s tudy , found tha t v a l i d a t i o n therapy not only produced s i g n i f i c a n t changes i n b e h a v i o r , but t h a t i t a l so r e l i e v e d some of the a n x i e t y and t e n s i o n so o f ten e v i d e n t i n e l d e r l y p a t i e n t s i d e n t i f i e d as c o n f u s e d . A small number of a r t i c l e s pre sent a p a t i e n t - c e n t e r e d approach to i n t e r a c t i n g with e l d e r l y , confused p a t i e n t s . Jahraus (1974) focused on p a t i e n t needs i n an attempt to understand and i n t e r v e n e with p a t i e n t s d i s p l a y i n g confused b e h a v i o r . The i n t e r v e n t i o n s emphasize the maintenance of meaningful a d u l t l e v e l r e l a t i o n s h i p s . Each p a t i e n t f i n d s meaning in d i f f e r e n t t h i n g s , t h e r e f o r e " r e c o g n i t i o n of each person as unique i s a f i r s t e s s e n t i a l " (p . 19) . Wolanin and P h i l l i p s (1980) c o n s i s t e n t l y r e i t e r a t e the idea tha t nurses e v a l u a t e and a s s i gn meaning to confused behav ior based upon t h e i r norms and v a l u e s . To be e f f e c t i v e i n working wi th e l d e r l y p a t i e n t s , nurses must look at the meaning of the behav ior fo r the p a t i e n t . As e a r l y as 1961, Orlando s t a t e d tha t "when the nurse p e r c e i v e s the p a t i e n t , the thoughts which a u t o m a t i c a l l y occur to her r e f l e c t the meaning or i n t e r p r e t a t i o n tha t she a t t aches to her p e r c e p t i o n . These meanings may or may not be c o r r e c t from the p a t i e n t ' s p o i n t of view" (p . 4 0 ) . 20 I t seems e v i d e n t tha t the concept of c o n f u s i o n i s not wel l r e searched and t h e r e f o r e not wel l unders tood by n u r s e s . T h i s s i t u a t i o n r e s u l t s i n an i n c o n s i s t e n t , ambiguous, and s u b j e c t i v e i n t e r p r e t a t i o n of a concept f r e q u e n t l y used i n nur s i ng. Two s t u d i e s were found which attempted to c l a r i f y f o r nurses some aspects of the concept of c o n f u s i o n . C h i s h o l m , D e n i s t o n , I g r i s a n , and Barbus (1982) , concerned about the impact of the f r e q u e n t l y observed l a b e l l i n g process on the c o n f u s e d , e l d e r l y p e r s o n , s t u d i e d the i n c i d e n c e , p r e v a l e n c e , and s e v e r i t y of c o n f u s i o n among 99 e l d e r l y p a t i e n t s i n a general h o s p i t a l . T h i s study a l so e x p l o r e d f a c t o r s which had the p o t e n t i a l to c o n t r i b u t e to c o n f u s i o n and were s u b j e c t to n u r s i n g i n t e r v e n t i o n . T h e i r study i n d i c a t e s t h a t n e i t h e r a h igh i n c i d e n c e of m i s l a b e l l i n g nor a high p reva l ence of c o n f u s i o n e x i s t e d on the wards which were s t u d i e d . They summarize by say ing tha t "perhaps the p e r c e p t i o n of a high i n c i d e n c e of c o n f u s i o n i s r e l a t e d to the impact of c o n f u s i o n on the s t a f f and t h e i r workload r a t h e r than the a c t u a l i n c i d e n c e of c o n f u s i o n " (p . 9 4 ) . In c o n c l u d i n g , they suggest t h a t the " s t a f f ' s p e r c e p t i o n of the magnitude of the problem would then i n f l u e n c e the n u r s i n g i n t e r v e n t i o n s tha t they implemented" (p . 94-95) . Wolanin (1977) , ba s ing a study on the premise t h a t c o n f u s i o n i s most r e a l i s t i c a l l y d e f i n e d by the p e r c e p t i o n s of the c a r e g i v e r s , attempted to de f ine c o n f u s i o n w i t h i n the 21 contex t tha t c a r e g i v e r s used to d e s c r i b e the behav ior s of t h e i r p a t i e n t s . Al though t h i s study emphasizes the p e r c e p t i o n of p a t i e n t behav ior s by both the doctor and the nur se , data c o l l e c t i o n focused p r i m a r i l y on nur se s ' w r i t t e n records and verba l a c c o u n t s . F o l l o w i n g a n a l y s i s of these r e c o r d i n g s , Wolanin r e p o r t e d tha t nurses tend to i d e n t i f y con fus ion as behav ior s which are s o c i a l l y d i s r u p t i v e and a l i e n a t i n g , such as combat ivenes s , wander ing , and s u s p i c i o u s n e s s w h i l e doc tor s tend to i d e n t i f y behav ior s which i n d i c a t e problems with i n t e l l e c t u a l f u n c t i o n i n g , such as impa i red idea a s s o c i a t i o n , thought q u a l i t y , and memory. The author a l s o notes a r e l a t i o n s h i p between communication problems and the behav ior noted in confused p a t i e n t s . Behavior problems seem dependent upon the p a t i e n t ' s a b i l i t y to understand those who work with him as wel l as h i s a b i l i t y to express h i m s e l f . Another study conducted i n B r i t a i n by Meacher (1972) compared the exper i ence s of e l d e r l y , confused p a t i e n t s when they were segregated from or i n t e g r a t e d with l u c i d p a t i e n t s . Meacher conc luded tha t c o n f u s i o n , r e g a r d l e s s of i n t e g r a t i o n or s e g r e g a t i o n , i s an attempted a d a p t a t i o n by the e l d e r l y person to an environment tha t i gnores h i s needs. "Rather than r e p r e s e n t i n g a p u r e l y a d v e n t i t i o u s outf low of meaningless g i b b e r i s h and i n e x p l i c a b l e b e h a v i o r , s o - c a l l e d c o n f u s i o n a l symptoms . . . c o n s t i t u t e d a s e r i e s of s k i l l f u l adjustments compensating fo r the p a i n f u l exper i ences of 22 i s o l a t i o n , impotence and hope le s snes s " (p . 338) . Solomon (1982) and S l a t e r and Lipman (1977) a l so view c o n f u s i o n as an adap t ive mechanism fo r p a t i e n t s u r v i v a l w i t h i n c e r t a i n s o c i a l systems. Two elements of the concept of c o n f u s i o n occur c o n s i s t e n t l y throughout the l i t e r a t u r e . F i r s t , c o n f u s i o n i s most o f ten i d e n t i f i e d w i t h i n a s o c i a l contex t by someone o ther than the e l d e r l y person e x h i b i t i n g the b e h a v i o r s . Confus ion i s most o f ten i d e n t i f i e d by nurses based upon t h e i r p e r c e p t i o n s of the p a t i e n t ' s b e h a v i o r . Barnes (1974) d e s c r i b e s c o n f u s i o n as those behav ior s tha t appear i l l o g i c a l to n u r s i n g s t a f f whi le Chisholm et a l . (1982) s t a t e tha t " e l d e r l y p a t i e n t s are f r e q u e n t l y l a b e l l e d confused as a r e s u l t of behav ior s tha t are d i s t u r b i n g to n u r s i n g s t a f f " (p . 8 7 ) . Wolanin (1977) conc ludes tha t the d i a g n o s i s of con fus ion i s based as much on the s u b j e c t i v e f e e l i n g s as i t i s on the o b j e c t i v e o b s e r v a t i o n s of those c a r e g i v e r s i n t e r a c t i n g wi th e l d e r l y p a t i e n t s . Second, many of the behav ior s and c h a r a c t e r i s t i c s which nurses use to d e s c r i b e c o n f u s i o n , such as memory l o s s , p r o b l e m a t i c e x p r e s s i v e and r e c e p t i v e f u n c t i o n i n g , d i s r u p t i v e b e h a v i o r , and d i m i n i s h e d consc iousnes s are a l so i d e n t i f i e d as b a r r i e r s to communicat ion . Wolanin (1977) c a t e g o r i z e s a l l b e h a v i o r i d e n t i f i e d as con fus i on as i n t e r f e r i n g e i t h e r with n u r s e - p a t i e n t i n t e r a c t i o n or with the nurses h e l p i n g or l i k i n g the p a t i e n t . 23 B a r r i e r s to under s t and ing the message of another person i n c l u d e severa l d i f f e r e n t f a c t o r s . Communication t h e o r i s t s i n d i c a t e t h a t m a l f u n c t i o n s of the organs of communicat ion, t h a t i s , the r e c e i v e r ' s a b i l i t y to see, hear , and comprehend a l l e x t e r n a l s t i m u l i , a f f e c t the p e r c e p t i o n , e v a l u a t i o n , and e x p r e s s i o n of the p a t i e n t ( P a r r y , 1968; Reusch, 1961). An i n a b i l i t y to speak or speech which i s i n c o h e r e n t or t a n g e n t i a l a l so produces b a r r i e r s to a p p r o p r i a t e i n t e r a c t i o n (Meacher, 1972; P a r r y , 1968). Sundeen, S t u a r t , R a n k i n , and Cohen (1976) i d e n t i f y " i n t e r n a l n o i s e , " such as a n x i e t y or low s e l f - e s t e e m , as a l so i n t e r f e r i n g with e f f e c t i v e i n t e r a c t i o n . A l l of the above c h a r a c t e r i s t i c s or behav ior s have been a s s o c i a t e d i n the l i t e r a t u r e with the concept of c o n f u s i o n . T h i s study assumes t h a t c o n f u s i o n i s i n t e r a c t i o n a l i n nature and tha t the meanings a s s o c i a t e d with con fus ion come from the i d e n t i f i c a t i o n of c e r t a i n behav io r s by c e r t a i n audiences r a t h e r than from something tha t a r i s e s from w i t h i n the i n d i v i d u a l . Wolanin (1977) i d e n t i f i e s " the r e l a t i o n s h i p of communication to the behav ior noted i n the confused p a t i e n t " (p . 74) as an important area fo r f u r t h e r s tudy . Nurses ' A t t i t u d e s Toward E l d e r l y P a t i e n t s In our s o c i e t y , ag ing i s awarded l i t t l e s t a tus or r e s p e c t and aging i n d i v i d u a l s are o f ten i g n o r e d , r i d i c u l e d , or p i t i e d (Green , 1981). Nurses , as a pa r t of the l a r g e r 24 s o c i e t y , accept the common s t e reo type tha t con fus ion and i l l n e s s i n the e l d e r l y are an i n e v i t a b l e and i r r e v e r s i b l e p a r t of the aging process ( C i l i b e r t o , L e v i n & A r l u k e , 1981; Rodi n & Langer , 1980) . Rodin and Langer (1980) c a r r i e d out a number of s t u d i e s , one of which was des igned to i n v e s t i g a t e how p r e v a l e n t s t e r e o t y p e s might a f f e c t ac tua l i n t e r a c t i o n s i n v o l v i n g o l d e r p e o p l e . They c o n s i d e r e d not only the ex tent to which p r o f e s s i o n a l s who deal with the e l d e r l y use age as a cue fo r i n t e r p r e t i n g b e h a v i o r , but a l so whether the l a b e l s they a s s i gn a f f e c t t h e i r b e h a v i o r . The study r e s u l t s i n d i c a t e tha t age p red i spose s to a d i a g n o s i s which i s o r g a n i c a l l y based and tha t t reatment i s more drug r e l a t e d and more demanding of i n s t i t u t i o n a l i z a t i o n . They a l s o found tha t there are l e s s demands fo r i n t e l l e c t u a l f u n c t i o n i n g made on e l d e r l y p e o p l e . C i l i b e r t o et a l . (1981) s t u d i e d the e f f e c t of c h r o n o l o g i c a l age on the c l i n i c a l judgment of nurses with r e s p e c t to cases p r e s e n t i n g symptoms of mental c o n f u s i o n and a n x i e t y . T h e i r r e s u l t s support those of Rodin and Langer . They found tha t nurses are more l i k e l y to g ive a d i a g n o s i s of o r g a n i c b r a i n syndrome when the p a t i e n t i s d e p i c t e d as e l d e r l y r a t h e r than young . E l d e r l y p a t i e n t s are a l s o more l i k e l y to be seen as a p p r o p r i a t e cand ida te s fo r i n s t i t u t i o n a l i z a t i o n and are more o f ten g iven negat ive prognoses than younger p a t i e n t s e x h i b i t i n g s i m i l a r symptoms. 25 Brown ( c i t e d i n C a m p b e l l , 1971) s t u d i e d the f a v o r a b l e and unfavorab le a t t i t u d e s of nurses toward the e l d e r l y and conc luded tha t a l a r g e percentage of nurses a s s o c i a t e the idea of age with the concept of a person with some degree of i l l n e s s r e q u i r i n g n u r s i n g c a r e . A c c o r d i n g to Campbell (1971) , r e g i s t e r e d nur se s , a l though they are the l e a s t w i l l i n g of a l l n u r s i n g c a r e g i v e r s (RN/LPN/Aide) to accept a g e - r e l a t e d s t e r e o t y p e d s ta tements , spend the l e a s t time c a r i n g for o l d people and p r e f e r not to work with them. The r e s u l t s of Coe ' s study (1967) i n d i c a t e t h a t nurses b e l i e v e e l d e r l y p a t i e n t s to be slow and d i f f i c u l t to communicate w i t h . The study nurses expressed annoyance with t r e a t i n g the e l d e r l y because they were i n c o n t i n e n t , compla ined f r e q u e n t l y , and were unable to feed themse lves . Glads tone and McKegney (1980) e x p l o r e d the r e l a t i o n s h i p between p a t i e n t behav ior s and n u r s i n g a t t i t u d e s . They conc luded from t h e i r data tha t a small number of s p e c i f i c p a t i e n t behav ior s p e r c e i v e d by n u r s i n g s t a f f are h i g h l y c o r r e l a t e d with the f e e l i n g and a t t i t u d e responses of those same s t a f f . S p e c i f i c a l l y , those p a t i e n t s who are i n p a i n , c r y , or seem depressed cause s t a f f to f ee l d r a i n e d and to want to a v o i d the p a t i e n t . Al though numerous s t u d i e s conclude t h a t nur se s ' a g e - r e l a t e d a t t i t u d e s are n e g a t i v e , some s t u d i e s f i n d t h e i r a t t i t u d e s to be n e u t r a l or p o s i t i v e ( F u t r e l l & Jones , 1977; 26 T a y l o r & Harried, 1978). H a t t o n ' s study ( 1977 ) , a l though i t showed a r e l a t i o n s h i p between f a v o r a b l e d i s p o s i t i o n and p o s i t i v e i n t e r a c t i o n , was unable to show a r e l a t i o n s h i p between unfavorab le d i s p o s i t i o n (acceptance of the c u l t u r a l l y de f ined s t e r e o t y p e ) and negat ive i n t e r a c t i o n s . These negat ive and r e s t r i c t i v e s o c i e t a l v a l u e s , a t t i t u d e s , and s t e r e o t y p e s he ld by many nurses have important i m p l i c a t i o n s f o r t h e i r p a t i e n t care (Green , 1981; LaMonica , 1979; M i l l e r , 1976). They form the ba s i s of the n u r s e ' s ph i lo sophy which i n f l u e n c e s her d e c i s i o n s r e g a r d i n g the q u a l i t y and q u a n t i t y of care she p r o v i d e s fo r each p a t i e n t ( J e n n i n g s , Nordstrom & Shumake, 1972). Al though i t i s d i f f i c u l t to t e s t the assumption t h a t s t e r e o t y p i n g and a t t i t u d e s are t r a n s l a t e d i n t o b e h a v i o r , S tockwel l (1972) c a r r i e d out a study i n 12 London h o s p i t a l s which attempted to d i s c o v e r whether n u r s i n g care d i f f e r e d between "most l i k e d " and " l e a s t l i k e d " p a t i e n t s . S tockwel l found t h a t the p a t i e n t s most l i k e d by nurses are those t h a t (a) remember the n u r s e ' s name, (b) communicate r e a d i l y with the nur se , (c) joke and laugh with the nur se , and (d) express a d e t e r m i n a t i o n to get wel l and cooperate i n be ing helped to do so. I t i s e v i d e n t tha t aged p a t i e n t s are the most l i k e l y to e x h i b i t behav ior s which nurses l i k e l e a s t . They are a l so the most l i k e l y to r e c e i v e negat ive responses from n u r s e s . The study i n d i c a t e d tha t n u r s e ' s nega t ive responses are r e f l e c t e d by (a) the amount of time taken to 27 answer the c a l l b e l l , (b) the number of hypodermic i n j e c t i o n s g iven fo r p a i n , and (c) the amount of time the nurse spent in verba l communication wi th the p a t i e n t . Wi l son and Simon (1978) s t u d i e d the reward and punishment responses of nurses toward d e v i a n t and c o n v e n t i o n a l p a t i e n t behav ior i n a p s y c h i a t r i c f a c i l i t y . Dev iant behav io r s are i d e n t i f i e d as a g i t a t e d , a g g r e s s i v e , d e l u s i o n a l , or r e g r e s s i v e behav ior s as wel l as speech d i s t u r b a n c e s , memory d i f f i c u l t i e s , poor h y g i e n e , and somatic c o m p l a i n t s . They found t h a t nurses r e i n f o r c e the dependent and d e v i a n t behav io r s i n t h e i r p a t i e n t s , e s p e c i a l l y i f they are o l d e r (> 65 ) , w h i l e they i g n o r e , and t h e r e f o r e n e g a t i v e l y r e i n f o r c e t h e i r more s o c i a l l y a p p r o p r i a t e b e h a v i o r s . These r e s u l t s are s u b s t a n t i a t e d by L e s t e r and B a l t e s (1978) , Lowenthal (1958) , and M i k u l i c (1971) . They conclude t h a t b e h a v i o r s , such as b a t h i n g and c o n t i n e n c e , which the e l d e r l y person i s ab le to complete i n d e p e n d e n t l y on a d m i s s i o n , are o f ten l o s t to the p a t i e n t because they are not r e i n f o r c e d by n u r s e s . Hatton s t u d i e d the e f f e c t of nur se s ' a t t i t u d e s on t h e i r response to p a t i e n t s ' needs. The r e s u l t s support the assumption t h a t nurses with a more f a v o r a b l e d i s p o s i t i o n toward e l d e r l y p a t i e n t s e x h i b i t a h igher percentage of p o s i t i v e i n t e r a c t i o n s wi th them. Some of H a t t o n ' s f i n d i n g s , a l though not r e l a t e d to the purpose of t h a t s tudy , are i n t e r e s t i n g and r e l e v a n t fo r t h i s s tudy . For example, 28 a l though nurses d i f f e r i n the l e n g t h of t h e i r i n t e r a c t i o n s with p a t i e n t s , each nurse i s c o n s i s t e n t i n her p a t t e r n of l e n g t h , t h a t i s , nurses c o n s i s t e n t l y have e i t h e r l onger or s h o r t e r i n t e r a c t i o n s . Nurses with s h o r t e r i n t e r a c t i o n s tend to spend more time at the n u r s e ' s s t a t i o n or i n v o l v e d i n n o n - n u r s i n g f u n c t i o n s . Some nurses avo id i n t e r a c t i n g with confused p a t i e n t s whi le o ther s c o n s i s t e n t l y spend more time i n t e r a c t i n g with confused p a t i e n t s i n a c a r i n g and c o m f o r t i n g way. Once the l a b e l of c o n f u s i o n i s p l aced on an e l d e r l y p e r s o n , r e g a r d l e s s of the behav ior t h a t he e x h i b i t s , i t i n f l u e n c e s a l l f a c e t s of care t h a t the e l d e r l y person r e c e i v e s (Meacher, 1972; Wolanin & P h i l l i p s , 1981). T h i s h i g h l y s u b j e c t i v e i n t e r p r e t a t i o n of p a t i e n t behav ior i s based upon a combinat ion of knowledge, a t t i t u d e s , b e l i e f s , and exper i ence s unique to each nurse and not upon a c l e a r under s t and ing of the concept of c o n f u s i o n . The a t t i t u d e s and r e s u l t i n g behav ior of nurses are a v i t a l f a c t o r i n f l u e n c i n g the s a t i s f a c t i o n of p a t i e n t s ' needs ( O r l a n d o , 1961). I f nurses possess negat ive a t t i t u d e s toward the e l d e r l y , s u b t l e s igns of r e j e c t i o n , d i s r e s p e c t , and i n d i f f e r e n c e w i l l be communicated d u r i n g i n t e r a c t i o n ( M i l l e r , 1976; Solomon, 1982). The t reatment from h e a l t h p r a c t i t i o n e r s and the demands of s o c i e t y l ead to lowered s e l f - e s t e e m i n the e l d e r l y person ( J ahraus , 1974; Rodin & Langer , 1980). Subsequent to f e e l i n g s of low s e l f - e s t e e m , 29 the e l d e r l y person f e e l s l e s s adequate and independent r e s u l t i n g in i n c r e a s e d s e l f - c a r e needs and withdrawal ( F i e l d i n g , 1979). Rosendahl and Ross (1982) , s tudy ing the r e l a t i o n s h i p between nurse behav ior and p a t i e n t re sponse , found t h a t e l d e r l y p a t i e n t s respond more a c c u r a t e l y on a mental s t a tus q u e s t i o n n a i r e when the nurse comple t ing the q u e s t i o n n a i r e u t i l i z e s a t t e n d i n g behav io r s which communicate a t t e n t i v e n e s s , r e s p e c t , and i n t e r e s t to the p a t i e n t d u r i n g the i n t e r v i e w . A review of the l i t e r a t u r e i n d i c a t e s tha t many nurses have va lues and a t t i t u d e s toward the e l d e r l y which n e g a t i v e l y i n f l u e n c e the n u r s e - p a t i e n t i n t e r a c t i o n . No s t u d i e s have been found which have e x p l o r e d nur se s ' a t t i t u d e s toward e l d e r l y p a t i e n t s i d e n t i f i e d as confused . However, i t can be assumed tha t c o n f u s i o n would r e i n f o r c e or exaggerate a l r e a d y e x i s t i n g a t t i t u d e s . Al though r e s e a r c h e r s have s t u d i e d nur se s ' a t t i t u d e s and i d e n t i f i e d the a c t u a l or p o t e n t i a l impact they have upon the q u a l i t y and q u a n t i t y of p a t i e n t c a r e , no s t u d i e s have been found which exp lo re the exper i ence of nurses as they i n t e r a c t with e l d e r l y , confused p a t i e n t s . Without the nur se s ' p e r s p e c t i v e i t i s d i f f i c u l t to unders tand the r e a l i t y of t h i s p a r t i c u l a r n u r s e - p a t i e n t i n t e r a c t i o n and to p lan and e f f e c t change i n t h i s a r e a . T h i s study w i l l not d i r e c t l y i n v e s t i g a t e nur se s ' a t t i t u d e s but through a review of a t t i t u d e - r e l a t e d l i t e r a t u r e the par t tha t va lues and a t t i t u d e s , and 30 consequent ly b e h a v i o r , p lay i n the i n t e r a c t i o n between the nurse and the p a t i e n t i s acknowledged. N u r s e - P a t i e n t I n t e r a c t i o n C a r l s o n (1972) ma in ta ins tha t communication and s o c i a l i n t e r a c t i o n are the b a s i c foundat ions fo r a meaningful e x i s t e n c e . I t i s the communication o c c u r r i n g d u r i n g the i n t e r a c t i o n between the nurse and p a t i e n t t h a t f a c i l i t a t e s the format ion of the n u r s e - p a t i e n t r e l a t i o n s h i p . The n u r s e - p a t i e n t r e l a t i o n s h i p p r o v i d e s the framework w i t h i n which a l l of the needs of the p a t i e n t are met ( T r a v e l b e e , 1969). The s a t i s f i e d need f o r meaningful communication and f requent i n t e r a c t i o n i s e s s e n t i a l to ma in ta in mental h e a l t h fo r i n s t i t u t i o n a l i z e d e l d e r s (Evans , 1979; J a h r a u s , 1974) . A c c o r d i n g to Schutz (1960) , n o n f u l f i l l m e n t of " i n t e r p e r s o n a l needs " such as i n c l u s i o n , c o n t r o l , and a f f e c t i o n l ead to d i f f i c u l t i e s a s s o c i a t e d with emotional i l l n e s s and, i f p r o l o n g e d , r e s u l t i n a general l o s s of m o t i v a t i o n fo r l i f e . In o rder to be a n x i e t y f ree a person must f i n d a comfor tab le b e h a v i o r a l r e l a t i o n with o ther s with regard to the exchange of i n t e r a c t i o n , power and l o v e . The need i s not whol ly s a t i s f i e d by a c t i n g towards o ther s i n a p a r t i c u l a r f a s h i o n . A s a t i s f a c t o r y balance must be e s t a b l i s h e d and m a i n t a i n e d , (p . 20) The l i t e r a t u r e i n d i c a t e s tha t the concept of con fus ion i s i n t e r a c t i o n a l i n n a t u r e . I t a l so i n d i c a t e s tha t i n t e r a c t i o n s between nurses and e l d e r l y p a t i e n t s are o f ten 31 seen as problems by nurses and can r e s u l t i n s t e r e o t y p i n g and inadequate c a r e . T h e r e f o r e , i t i s important to focus on the n u r s e - p a t i e n t i n t e r a c t i o n to gain a c l e a r e r under s t and ing of the degree of need s a t i s f a c t i o n exper i enced by both p a t i e n t s and nurses d u r i n g the i n t e r a c t i o n . Al though no s t u d i e s were found which are d i r e c t l y r e l a t e d to t h i s one, s evera l s t u d i e s were found which examine r e l e v a n t aspects of the n u r s e - p a t i e n t i n t e r a c t i o n . Many of the s t u d i e s are based i n p s y c h i a t r y , p o s s i b l y due to the emphasis on i n t e r a c t i o n as be ing more n a t u r a l l y a par t of the c a r i n g p r o c e s s . Tudor (1952) s t u d i e d the i n t e r a c t i o n between the nurse and the withdrawn p a t i e n t wi th a d i a g n o s i s of c h r o n i c s c h i z o p h r e n i a . Many of the p a t i e n t c h a r a c t e r i s t i c s and behav ior s presented by the r e s e a r c h e r are s i m i l a r to those pre sented by Wolanin (1977) as i d e n t i f y i n g the confused p a t i e n t . Tudor assumed f i r s t tha t mental i l l n e s s i s the p a t i e n t ' s way of p a r t i c i p a t i n g i n the s o c i a l process and second, tha t s t a f f ' s a t t i t u d e s and a c t i v i t i e s are an i n t e g r a l pa r t of the p a t i e n t ' s d a i l y l i f e and move the p a t i e n t e i t h e r toward or away from h e a l t h . T h i s author d e s c r i b e d the e f f e c t of mutual withdrawal between the nurse and the p a t i e n t , sugges t ing t h a t those p a t i e n t s who do not respond d e s p i t e repeated attempts from s t a f f and those p a t i e n t s who engage i n unacceptab le or a n x i e t y - p r o v o k i n g behav ior most o f ten r e c e i v e the l e a s t s o c i a l i n t e r a c t i o n . 32 In response to these p a t i e n t b e h a v i o r s , the s t a f f withdraw, m a i n t a i n minimal communication when making demands on the p a t i e n t , i n d i c a t e l i t t l e r e s p e c t fo r the p a t i e n t as an i n d i v i d u a l , and show ev idence of a n x i e t y when i n t e r a c t i n g with the p a t i e n t . C o h l e r and Shapiro (1964) a l so s t u d i e d the i n t e r a c t i o n between the nurse and the p a t i e n t wi th c h r o n i c s c h i z o p h r e n i a . They h y p o t h e s i z e d t h a t a g r e a t e r number of s t a f f members would r e p o r t be ing t r o u b l e d by communication problems than would r e p o r t be ing t r o u b l e d by problems a r i s i n g from other f a c e t s of t h e i r c o n t a c t wi th p a t i e n t s . T h e i r r e s u l t s s t a t i s t i c a l l y conf i rmed t h i s h y p o t h e s i s . They a l so found tha t when s t a f f t a l k to p a t i e n t s t h e i r communication i s more i n s t r u m e n t a l , t h a t i s , i s necessary to the f u n c t i o n i n g of the ward or to the c o n t i n u a t i o n of ongoing a c t i v i t y , than i t i s s u p p o r t i v e , t e n s i o n r e d u c i n g , or r e l a t e d to p a t i e n t s ' f e e l i n g s and w e l l - b e i n g . S t a f f who have h igher ra te s of soc ioemot iona l communication spend more time t a l k i n g to p a t i e n t s , as opposed to not t a l k i n g or t a l k i n g to o ther s t a f f , than s t a f f who use p r i m a r i l y i n s t r u m e n t a l communicat ion . T h i s f i n d i n g i s conf i rmed by B u r c h e t t (1967) who found , through n o n - p a r t i c i p a n t o b s e r v a t i o n of 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 n a g e r i a t r i c s e t t i n g , t h a t i n t e r a c t i o n s with the t o t a l l y dependent p a t i e n t are b r i e f e r and more d i r e c t i v e i n nature than those with l e s s dependent p a t i e n t s . 33 Withdrawal and decreased communication are e s t a b l i s h e d and ma inta ined by the a c t i o n s of both the nurse and the p a t i e n t . C o n v e r s e l y , p a t i e n t s who i n t e r a c t more f r e q u e n t l y with s t a f f r e c e i v e more t h e r a p e u t i c e f f o r t , are more l i k e d , and are viewed more o p t i m i s t i c a l l y than o ther p a t i e n t s ( A l t s c h u l , 1972; Coe, 1967; Coh le r & S h a p i r o , 1964; S t o c k w e l l , 1972; Whi te , 1977). Moores and Grant (1977) conclude that m e n t a l l y handicapped p a t i e n t s e x h i b i t i n g maladapt ive behav ior r e c e i v e more a t t e n t i o n from s t a f f but i t i s not a t t e n t i o n which i s l i k e l y to improve t h e i r b e h a v i o r . C o n v e r s e l y , p a t i e n t s with h igher l e v e l s of independent f u n c t i o n i n g and adap t ive behav ior are i n v o l v e d i n p a t t e r n s of i n t e r a c t i o n s , a g r e a t e r p r o p o r t i o n of which are p o s i t i v e and verba l i n n a t u r e . A l t s c h u l (1972) h y p o t h e s i z e d t h a t i n the format ion of a r e l a t i o n s h i p , both the nurse and p a t i e n t p e r c e i v e themselves as having a r e l a t i o n s h i p with each o t h e r . Among the sample, those nurses seen to i n t e r a c t most o f ten wi th p a t i e n t s were mentioned by the p a t i e n t s most f r e q u e n t l y as be ing a v a i l a b l e , as having t i m e , and as be ing i n t e r e s t e d and k i n d . White (1977) , us ing the n u r s e - p a t i e n t i n t e r a c t i o n as a framework for e x p l o r i n g the impact of nur se s ' a t t i t u d e s on e l d e r l y p a t i e n t s , a l so i d e n t i f i e d the r e c i p r o c a l nature of the i n t e r a c t i o n . The behav ior of p a t i e n t s i n f l u e n c e s nur se s ' a t t i t u d e s and behav io r s which i n turn i n f l u e n c e p a t i e n t s ' s e l f - e s t e e m . 34 A l t s c h u l (1972) , in a f r e q u e n t l y c i t e d s tudy , focused on the i n t e r a c t i o n p a t t e r n s between nurses and p a t i e n t s on acute p s y c h i a t r i c wards i n an attempt to e s t a b l i s h whether the format ion of a n u r s e - p a t i e n t r e l a t i o n s h i p depends upon the p a t t e r n of i n t e r a c t i o n between the nurse and p a t i e n t . P a t i e n t age, d i a g n o s i s , and behav ior were f a c t o r s t h a t , to some e x t e n t , i n f l u e n c e d the frequency and d u r a t i o n of i n t e r a c t i o n s . Nurses i n t h i s study responded to p a t i e n t behav ior s r a t h e r than d i a g n o s t i c l a b e l s when i n i t i a t i n g i n t e r a c t i o n s , a l though p a t i e n t s with a p h y s i c a l i l l n e s s i n c o n j u n c t i o n with p s y c h i a t r i c symptoms r e c e i v e d the g r e a t e s t amount of i n t e r a c t i o n t ime . Few nurses mentioned age as a d e t e r m i n i n g f a c t o r i n t h e i r d e c i s i o n s r e g a r d i n g who should r e c e i v e a t t e n t i o n , a l though A l t s c h u l observed t h a t the number and d u r a t i o n of i n t e r a c t i o n s wi th p a t i e n t s under 25 years and over 50 year s were s i g n i f i c a n t l y g r e a t e r , e s p e c i a l l y i f they had a p h y s i c a l i l l n e s s . A l t s c h u l (1972) s t a t e s tha t nurses were unable to i n d i c a t e any framework or purpose which p r o v i d e d guidance fo r i n i t i a t i n g or d i r e c t i n g t h e i r i n t e r a c t i o n s with p a t i e n t s . Ins tead they r e l i e d upon chance , common sense , or i n t u i t i o n to g ive them d i r e c t i o n . The nurses d i d not c o n s i s t e n t l y i d e n t i f y s p e c i f i c p a t i e n t behav io r s which i n f l u e n c e d t h e i r i n t e r a c t i o n s , a l though A l t s c h u l observed tha t p a t i e n t s who d i d not i n i t i a t e any form of i n t e r a c t i o n and those who i n d i c a t e d v e r b a l l y or through behav ior tha t 35 they were f i n e , were approached l e a s t o f t e n . I t i s i n t e r e s t i n g to note t h a t a c o n s i s t e n t theme throughout the i n t e r v i e w s was the n u r s e ' s concern about whether a t t e n t i o n should be g iven to those p a t i e n t s who (a) reques ted a t t e n t i o n , (b) d i d not approach the n u r s e , or (c) s t a t e d they were f i n e . The nurses i n A l t s c h u l ' s study were c o n s i s t e n t l y t r o u b l e d by t h e i r i n a b i l i t y to dec ide which p a t i e n t needed t h e i r a t t e n t i o n most. Wel l s (1980) , as p a r t of a l a r g e r r e s e a r c h p r o j e c t i n E n g l a n d , e x p l o r e d verba l n u r s e - p a t i e n t communication i n a g e r i a t r i c r e h a b i l i t a t i o n s e t t i n g . T h i s study focused on v a r i o u s f a c t o r s which Wel l s i d e n t i f i e d as r e l e v a n t i n de te rmin ing the q u a l i t y of communication on the ward. These f a c t o r s i n c l u d e frequency and d u r a t i o n of communicat ion, the i n i t i a t o r of and p a r t i c i p a n t s in the communicat ion, the l o c a t i o n and conten t of the communicat ion , and the p r i n c i p a l a c t i v i t y of the nurse d u r i n g the communicat ion . N u r s e - p a t i e n t c o n v e r s a t i o n s were tape r e c o r d e d , t r a n s c r i b e d , and then a n a l y z e d . P r i o r to t a p i n g , each p a t i e n t was i n t e r v i e w e d to assess mental f u n c t i o n i n g and each nurse was asked to score p a t i e n t s " a c c o r d i n g to the presence and/or degree of ' con fu s ion 1 " ( p . 105) as Wel l s thought tha t "a p a t i e n t ' s mental a b i l i t y would a f f e c t verba l communicat ion" (p . 105) . The r e s u l t s i n d i c a t e d t h a t , on average , each nurse had four verba l exchanges per hour , the average exchange being 36 one minute and 28 seconds . S e v e n t y - f i v e percent of these exchanges took p lace whi le the nurse was c a r r y i n g out p h y s i c a l care tasks at the b e d s i d e . The remaining 25% took p l ace d u r i n g o r i e n t i n g , s o c i a l i z i n g , c o m f o r t i n g , or i n s t r u c t i n g a c t i v i t i e s away from the p a t i e n t ' s room. N u r s e - i n i t i a t e d c o n v e r s a t i o n s comprised 72.5% of a l l c o n v e r s a t i o n s ; however a l l but 18% of p a t i e n t s i n i t i a t e d at l e a s t one c o n v e r s a t i o n . The taped c o n v e r s a t i o n s were ana lyzed fo r content and c l a s s i f i e d as be ing e i t h e r p rocedura l ( task o r i e n t e d ) , personal ( p a t i e n t o r i e n t e d ) , or mixed . Wel l s found t h a t the m a j o r i t y (54.1%) of n u r s e - p a t i e n t verba l communication focused on a procedure or task w h i l e a s i g n i f i c a n t l y s m a l l e r number (20.8%) were concerned with the p a t i e n t and were of a s o c i a l n a t u r e . T h i s f i n d i n g c o r r o b o r a t e s those of C o h l e r and Shap i ro (1964) and Paton and S t i r l i n g (1974) . S t o c k w e l l ' s study (1972) found tha t nurses are s a t i s f i e d with t a s k - o r i e n t e d i n t e r a c t i o n p a t t e r n s and t h i n k they prov ide adequate o p p o r t u n i t y fo r communicat ion . Wel l s comments t h a t , a l though these c o n v e r s a t i o n s c o n t a i n persona l i n f o r m a t i o n about the p a t i e n t , they do not seem to be p a t i e n t c e n t e r e d , tha t i s , there i s no apparent p a t i e n t - o r i e n t e d purpose to the c o n v e r s a t i o n . The nature of the exchange i s s u p e r f i c i a l and the i n t e n t of the nurse unknown. Al though Wel l s does not e x p l o r e nur se s ' p e r c e p t i o n s of t h e i r i n t e r a c t i o n s , i t seems p o s s i b l e tha t 37 these o b s e r v a t i o n s s u b s t a n t i a t e A l t s c h u l ' s f i n d i n g s tha t nurses do not e x h i b i t a framework or purpose to guide t h e i r c o n v e r s a t i o n s with p a t i e n t s . More r e c e n t l y , nurses have e x p l o r e d the i n t e r a c t i o n a l dynamics of f ami ly c a r e g i v e r s with t h e i r e l d e r l y , confused f a m i l y members and found t h a t the anger and f r u s t r a t i o n f e l t by c a r e g i v e r s leads to l e s s meaningful communicat ion , f requent p s y c h o l o g i c a l and s o c i a l n e g l e c t , and o c c a s i o n a l abuse (Beck & Ferguson , 1981; Beck & P h i l l i p s , 1983; Johnson , 1979). High s t r e s s l e v e l s are seen as i n h e r e n t when an e l d e r l y , dependent person i s p l aced w i t h i n a f a m i l y system ( Johnson, 1979). The s t r e s s on the c a r e g i v e r i s compounded when tha t e l d e r l y person i s seen as confused (Beck & P h i l l i p s , 1983). Abuse r e p o r t s from e l d e r s and p r o f e s s i o n a l s combined i n d i c a t e t h a t at l e a s t 62% of abused e l d e r s have some degree of mental impairment (Block & S i n n o t , 1979). Beck and P h i l l i p s s t a t e t h a t c e r t a i n b e h a v i o r s , i n d i c a t i v e of mental impairment and o f ten l a b e l l e d as c o n f u s i o n , are e s p e c i a l l y p r o b l e m a t i c to f a m i l y c a r e g i v e r s and when e v i d e n t , are l i k e l y to l e a d to abuse. These behav io r s r e f l e c t decreased c o n t a c t with the s u r r o u n d i n g s , decreased memory f u n c t i o n , decreased under s t and ing and judgment, and decreased verba l communicat ion . While the i n t e n t i o n of these s t u d i e s i s not to r e l a t e f ami ly i n t e r a c t i o n p a t t e r n s to the p a t t e r n s of 38 n u r s e - p a t i e n t i n t e r a c t i o n s , the emotional and i n t e r a c t i o n a l responses of f a m i l i e s d e s c r i b e d by the authors resemble the responses of nurses r e p o r t e d i n v a r i o u s s t u d i e s . Tudor (1952) and White (1977) both i n d i c a t e t h a t withdrawal and o ther n e g a t i v e l y va lued p a t i e n t behav io r s can be a l t e r e d by the purpose fu l i n t e r a c t i o n of the n u r s e . Rosendahl and Ross (1982) c o n f i r m these p o s i t i v e e f f e c t s . Other s t u d i e s a l so i n d i c a t e tha t i n d i v i d u a l i z e d n u r s i n g c a r e , focused on development of a n u r s e - p a t i e n t r e l a t i o n s h i p , f a c i l i t a t e s f u l f i l l m e n t of p a t i e n t s ' needs and t h e r e f o r e has a p o s i t i v e impact on p a t i e n t b e h a v i o r (Thomas, 1967; Wei s s , 1968). Wel l s (1980) conc ludes her l eng thy study of g e r i a t r i c n u r s i n g problems by s t a t i n g " a f t e r three year s of r e s e a r c h , and e i g h t i n t e r r e l a t e d and p r o g r e s s i v e s u b s t u d i e s , the most l o g i c a l c o n c l u s i o n i s t h a t e f f e c t i v e and meaningful n u r s i n g care of the e l d e r l y r e s t s on e f f e c t i v e and meaningful n u r s e - p a t i e n t r e l a t i o n s h i p s " (p . 123) . P o s i t i v e and purpose fu l i n t e r a c t i o n s between nurses and p a t i e n t s are e s s e n t i a l in d e v e l o p i n g t h i s r e l a t i o n s h i p ( T r a v e l b e e , 1969) . T h e r e f o r e , there i s an " urgent need f o r r e sea rch . . . i n t o a spect s of i n t e r a c t i o n on g e r i a t r i c wards" ( W e l l s , 1980, p. 124) . T h i s study w i l l not focus d i r e c t l y on the i n t e r a c t i o n , but on the nur se s ' i n t e r p r e t a t i o n s of the i n t e r a c t i o n . The i n f l u e n c e of n u r s i n g d e c i s i o n s and a c t i o n s on the n u r s e - p a t i e n t i n t e r a c t i o n and consequent ly on the q u a l i t y of 39 p a t i e n t care i s g r e a t . For the e l d e r l y , i n s t i t u t i o n a l i z e d p a t i e n t , the n u r s e , as r e spondent , p l ay s a c r u c i a l r o l e i n meeting p a t i e n t needs ( C i l i b e r t o et a l . , 1981; D a v i s , 1968; F i e l d i n g , 1979). Summary The l i t e r a t u r e review emphasizes the m u l t i f a c e t e d nature of the study problem. Three areas of l i t e r a t u r e r e l a t e d to the study problem have been rev iewed . These areas i n c l u d e the concept of c o n f u s i o n , n u r s e s ' a t t i t u d e s toward e l d e r l y p a t i e n t s , and the i n t e r a c t i o n between the nurse and the e l d e r l y p a t i e n t i d e n t i f i e d as c o n f u s e d . Each of these areas impacts on the n u r s e ' s i n t e r p r e t a t i o n of the i n t e r a c t i o n between h e r s e l f and the e l d e r l y , confused p a t i e n t . The study of the concept of c o n f u s i o n w i t h i n n u r s i n g l i t e r a t u r e i s s p a r s e . The few s t u d i e s t h a t have been implemented have shown tha t i t i s d i f f i c u l t to c o n s i s t e n t l y de f ine or d e s c r i b e c o n f u s i o n . I t seems e v i d e n t t h a t much of the impact i s r e l a t e d to problems of communicat ion . The m a j o r i t y of n u r s i n g l i t e r a t u r e d e a l i n g with con fus ion i s e i t h e r presented i n a case study format and i s t h e r e f o r e d i f f i c u l t to g e n e r a l i z e to a l a r g e r p o p u l a t i o n or i s p redominant ly i n f l u e n c e d by the medical model . L i t e r a t u r e w r i t t e n w i t h i n the framework of the medical model focuses on c o n f u s i o n i n r e l a t i o n to e t i o l o g y and d i a g n o s i s . 40 T h i s r e f l e c t s a t reatment and cure o r i e n t a t i o n and t h e r e f o r e i s on ly m i n i m a l l y h e l p f u l in g u i d i n g nurses who are p r o v i d i n g care fo r e l d e r l y , confused p a t i e n t s . Nurses ' va lues and a t t i t u d e s toward the aged have long been i d e n t i f i e d as a problem by nurse r e s e a r c h e r s , hence the l a r g e p r o p o r t i o n of a t t i t u d e s t u d i e s i n r e l a t i o n to a l l n u r s i n g s t u d i e s of the aged (Gunter & M i l l e r , 1977). T h i s l i t e r a t u r e review has focused p r i m a r i l y on s t u d i e s t h a t have exp lo red the e f f e c t of nur se s ' a t t i t u d e s upon t h e i r i n t e r a c t i o n s with the e l d e r l y . They i n d i c a t e t h a t nur se s ' i n t e r a c t i o n s are o f t e n , a l though not a lways , n e g a t i v e l y i n f l u e n c e d by t h e i r a t t i t u d e s about e l d e r l y p a t i e n t s . The impact of these nega t ive i n t e r a c t i o n s on the p a t i e n t was a l so d i s c u s s e d . Because no r e s e a r c h d i r e c t l y r e l a t e d to the study problem was found i n the l i t e r a t u r e , n u r s e - p a t i e n t i n t e r a c t i o n s s i m i l a r i n nature to the i n t e r a c t i o n be ing e x p l o r e d i n t h i s study were rev iewed . The r e c i p r o c a l nature of the n u r s e - p a t i e n t i n t e r a c t i o n i s a r e c u r r e n t theme throughout the l i t e r a t u r e . Communication (verba l and n o n - v e r b a l ) i s an i n t e g r a l pa r t of the i n t e r a c t i o n and problems i n t h i s area impact g r e a t l y on both the nurse and the p a t i e n t . I n t e r a c t i o n s t u d i e s i n d i c a t e tha t communication i s more task o r i e n t e d than p a t i e n t o r i e n t e d and tha t when i t i s p a t i e n t o r i e n t e d i t does not appear to be t h e r a p e u t i c . 41 CHAPTER THREE Methodology The purpose of t h i s study i s to exp lo re the nur se s ' i n t e r p r e t a t i o n s of t h e i r i n t e r a c t i o n s wi th e l d e r l y p a t i e n t s they have i d e n t i f i e d as c o n f u s e d . Symbol ic i n t e r a c t i o n p r o v i d e s a t h e o r e t i c a l framework fo r v iewing the study problem. A d e s c r i p t i v e r e s e a r c h des ign p r o v i d e s an o p p o r t u n i t y to examine a l l r e l e v a n t a spects of the problem and a l lows fo r the f l e x i b i l i t y to focus more c l o s e l y on c e r t a i n a spects as they a r i s e (Br ink & Wood, 1978). T h i s chapter d e s c r i b e s the i n f l u e n c e of symbol ic i n t e r a c t i o n i n choos ing a r e sea rch des ign in a d d i t i o n to the s e l e c t i o n of p a r t i c i p a n t s , the process of data c o l l e c t i o n , the e t h i c a l c o n s i d e r a t i o n s , and the data a n a l y s i s r e l a t e d to t h i s s tudy . The In f luence of Symbol ic I n t e r a c t i o n i n Choice of Design The symbol ic i n t e r a c t i o n i s t approach i s d e r i v e d from the view t h a t the i n d i v i d u a l a c t i v e l y a s s i gns meaning to r e a l i t y and then responds based on those meanings . I t i s d i f f i c u l t to assume t h a t the meaning an observer a t t aches to an i n t e r a c t i o n w i l l be the same meaning he ld by p a r t i c i p a n t s w i t h i n the i n t e r a c t i o n . T h e r e f o r e , the r e s e a r c h e r who wants to f u l l y unders tand an i n d i v i d u a l ' s s o c i a l a c t i o n s must attempt to f i n d out how the p a r t i c i p a n t s i n t e r p r e t t h e i r s i t u a t i o n i n order to see the a c t i o n s as the i n d i v i d u a l sees 42 them (Blumer, 1969; L i n d e s m i t h et a l . , 1975). In o rder to unders tand the b e h a v i o r , the r e s e a r c h e r must capture the process of i n t e r p r e t a t i o n from the p e r s o n ' s p o i n t of view (Bogdan & T a y l o r , 1975). To do t h i s the r e s e a r c h e r c o l l e c t s d e s c r i p t i v e accounts d e t a i l i n g the o b j e c t s tha t the i n d i v i d u a l takes i n t o a c c o u n t , h i s i n t e r p r e t a t i o n of these o b j e c t s , and h i s a c t i o n s toward the o b j e c t s i n a v a r i e t y of s i t u a t i o n s (Blumer, 1969). An e x p l o r a t o r y d e s c r i p t i v e des ign a l lows the r e s e a r c h e r to gather these d e t a i l e d q u a l i t a t i v e data (Br ink & Wood, 1978). The r e s e a r c h e r must a l s o note the a l t e r n a t i v e k inds of ac t s which the i n d i v i d u a l maps out and the i n t e r p r e t a t i o n t h a t leads to the s e l e c t i o n and e x e c u t i o n of h i s s p e c i f i c a c t i o n (Blumer, 1969). The r e s e a r c h e r must determine what form of i n t e r a c t i o n i s o c c u r r i n g r a t h e r than impose a p r e c o n c e i v e d s t r u c t u r e on the i n t e r a c t i o n p r i o r to study (Blumer , 1969) . The e x p l o r a t o r y d e s c r i p t i v e approach u t i l i z e d i n t h i s study d i r e c t s the r e s e a r c h e r to use the i n d i v i d u a l ' s p e r s p e c t i v e of the i n t e r a c t i o n , r a t h e r than the r e s e a r c h e r ' s p r e c o n c e i v e d i d e a s . o p e r a t i o n a l i z e d by r i g i d r e s e a r c h t e c h n i q u e s , to gain more under s t and ing of the study problem ( F i l s t e a d , 1970). An e x p l o r a t o r y d e s c r i p t i v e d e s i g n , coup led wi th a s t r a t e g y such as i n - d e p t h i n t e r v i e w i n g , i s an a p p r o p r i a t e method when the purpose of the study i s to i n c r e a s e under s t and ing of human b e h a v i o r . L i n d e s m i t h et a l . (1975) 43 s t a te t h a t an open-ended i n t e r v i e w i n g s t r a t e g y i s a p p r o p r i a t e fo r use with a symbol ic i n t e r a c t i o n i s t framework. " Q u a l i t a t i v e methodology a l lows the r e s e a r c h e r to ' ge t c l o s e to the d a t a ' thereby d e v e l o p i n g the a n a l y t i c a l , c o n c e p t u a l , and c a t e g o r i c a l components of e x p l a n a t i o n from the data i t s e l f " ( F i l s t e a d , 1970, p. 6 ) . S e l e c t i o n of the Study Group  C r i t e r i a f o r P a r t i c i p a t i o n The study p a r t i c i p a n t s were drawn from E n g l i s h - s p e a k i n g R e g i s t e r e d Nurses working e i t h e r f u l l - t i m e or permanent p a r t - t i m e i n one of three extended care u n i t s i n the Grea te r Vancouver a r e a . In comparison to nurses working i n acute care h o s p i t a l s and i n community a g e n c i e s , nurses working i n extended care u n i t s , by v i r t u e of the p a t i e n t c r i t e r i a f o r a d m i s s i o n , have e x p e r i e n c e d a l a r g e r number of i n t e r a c t i o n s with p a t i e n t s i d e n t i f i e d as confused . I t was thought t h a t these nurses were best able to address the t o p i c of the s t u d y . Nurses having worked l e s s than one year i n extended care were exc luded from the study as i t was thought t h a t i t takes t h i s amount of time fo r the nurse to i n t e g r a t e the concept of the " e l d e r l y , confused p a t i e n t " i n t o her i n t e r a c t i o n s . Process fo r E l i c i t i n g Sub jec t P a r t i c i p a t i o n F o l l o w i n g approval from n u r s i n g a d m i n i s t r a t i o n and c o l l a b o r a t i o n with the head nurses on the extended care 44 wards, the r e s e a r c h e r made i n i t i a l c o n t a c t with the R e g i s t e r e d Nurses on each ward. T h i s c o n t a c t o c c u r r e d at weekly s t a f f meetings or at change of s h i f t . Group s i z e ranged from one to s i x n u r s e s . Al though the m a j o r i t y of nurses were c o n t a c t e d , those on h o l i d a y s or working at t imes tha t made c o n t a c t d i f f i c u l t were not seen d u r i n g the r e c r u i t i n g p e r i o d . A t o t a l of 53 nurses were c o n t a c t e d . Dur ing the i n i t i a l meetings the r e s e a r c h e r pre sented the nurses with a l e t t e r of i n f o r m a t i o n and a consent form (see Appendixes A and B ) . The nurses read the i n f o r m a t i o n l e t t e r wi th the r e s e a r c h e r present and the d i s c u s s i o n f o l l o w i n g enabled the r e s e a r c h e r to answer ques t ions and c l a r i f y p o i n t s . The nurses were then i n s t r u c t e d to c o n t a c t the r e s e a r c h e r e i t h e r by te lephone or by mail ( r e t u r n i n g a s igned consent form) i f they wished to p a r t i c i p a t e i n the s tudy . A l l nurses i n d i c a t i n g a d e s i r e to p a r t i c i p a t e ma i l ed t h e i r consent forms to the r e s e a r c h e r who then c o n t a c t e d them by te lephone to arrange a mutua l ly agreeable time f o r an i n t e r v i e w . A p i l o t study was c a r r i e d out p r i o r to comple t ion of the study proposa l to eva lua te the e f f e c t i v e n e s s of (a) the study q u e s t i o n s , (b) the i n t e r v i e w g u i d e , and (c) the r e s e a r c h e r ' s i n t e r v i e w t e c h n i q u e s . A f o u r t h extended care u n i t , not i n c l u d e d w i t h i n the a c t u a l s tudy , was u t i l i z e d for the p i l o t s tudy . F o l l o w i n g approval from n u r s i n g a d m i n i s t r a t i o n and the head n u r s e s , the r e s e a r c h e r met with 45 a group of R e g i s t e r e d Nurses , three of whom p a r t i c i p a t e d i n the p i l o t s tudy . Based on these three taped i n t e r v i e w s , the i n t e r v i e w guide was r e v i s e d to more c l e a r l y r e f l e c t the study ques t ions and to p rov ide more guidance fo r the r e s e a r c h e r . A member of the r e s e a r c h e r ' s a d v i s o r y committee l i s t e n e d to one of the tapes and p rov ided feedback on the r e s e a r c h e r ' s i n t e r v i e w i n g s k i l l s . Data C o l l e c t i o n E t h i c a l C o n s i d e r a t i o n s The r i g h t s of the nurses p a r t i c i p a t i n g i n t h i s study were ensured through the use of informed consent and the maintenance of anonymity and c o n f i d e n t i a l i t y . In keeping with the d i r e c t i v e s of the U n i v e r s i t y of B r i t i s h C o l u m b i a , a w r i t t e n consent was o b t a i n e d from a l l study p a r t i c i p a n t s . In a d d i t i o n , a l l p a r t i c i p a n t s were made aware ( through a l e t t e r of i n f o r m a t i o n ) of the study purpose , the nature of t h e i r reques ted i n v o l v e m e n t , the means for e n s u r i n g anonymity and c o n f i d e n t i a l i t y , the approximate amount of time r e q u i r e d , and t h e i r r i g h t to withdraw or re fuse to p a r t i c i p a t e at any t ime . To ma in ta in anonymity and c o n f i d e n t i a l i t y , taped r e c o r d i n g s and subsequent t r a n s c r i p t s d i d not i d e n t i f y the p a r t i c i p a n t s . Access to t r a n s c r i p t s and tapes was l i m i t e d to the r e s e a r c h e r and her a d v i s o r y committee and, throughout c o n s u l t a t i o n with committee members, the p a r t i c i p a n t s were 46 not r e f e r r e d to by name. A l l consents were ma i l ed to the r e s e a r c h e r and head nurses were not informed of the nur se s ' p a r t i c i p a t i o n to ensure tha t n e i t h e r co-workers nor a d m i n i s t r a t o r s were aware of the i d e n t i t y of study p a r t i c i p a n t s . Data C o l l e c t i o n Procedure E ighteen nurses composed the convenience sample used i n t h i s s tudy . Each nurse was i n t e r v i e w e d once with i n t e r v i e w times rang ing from 45 to 90 m i n u t e s . Except fo r one i n t e r v i e w , which took p l ace i n a p r i v a t e room at the School of N u r s i n g , a l l the nurses were i n t e r v i e w e d i n t h e i r homes. The i n t e r v i e w s were tape recorded and subsequent ly t r a n s c r i b e d fo r a n a l y s i s . The r e s e a r c h e r / i n t e r v i e w e r used the sample of i n t e r v i e w q u e s t i o n s (see Appendix C) as an o u t l i n e of conten t areas for data c o l l e c t i o n d u r i n g the i n t e r v i e w . Al though the i n t e r v i e w focused on areas determined by these open-ended q u e s t i o n s , the i n t e r v i e w e r encouraged the nurses to determine the content and d i r e c t i o n of the areas e x p l o r e d . T h i s unscheduled i n t e r v i e w s t y l e a l lowed the r e s e a r c h e r to focus on s p e c i f i c content a r e a s , w h i l e at the same time prob ing fo r u n d e r l y i n g f a c t o r s or r e l a t i o n s h i p s too complex or e l u s i v e to be e x p l o r e d by more s t r a i g h t f o r w a r d q u e s t i o n s . I t a l s o a l lowed fo r a s h i f t i n sequence or t o p i c s i n keeping wi th the needs of the nurses ( I s aac , 1971) . The r e s e a r c h e r approached the i n t e r v i e w i n an i n f o r m a l , s u p p o r t i v e manner. 47 The n u r s e s were e n c o u r a g e d t o o p e n l y d i s c u s s t h e i r t h o u g h t s and f e e l i n g s , w i t h t h e a s s u r a n c e t h a t t h e r e was no r i g h t o r wrong a n s w e r . D a t a A n a l y s i s The q u a l i t a t i v e d a t a f r o m t h e t a p e d i n t e r v i e w s were t r a n s c r i b e d and c o d e d i n t o 3 g r o u p s : e x t e r n a l f a c t o r s , p a t i e n t b e h a v i o r s , and n u r s e b e h a v i o r s . Once c o d e d , t h e d a t a w i t h i n e a c h g r o u p were t h e n c a t e g o r i z e d . The c a t e g o r i e s were d e v e l o p e d by t h e r e s e a r c h e r f o l l o w i n g r e p e a t e d e x a m i n a t i o n o f t h e d a t a . Once t h e c a t e g o r i e s were d e v e l o p e d , t h e d a t a were c l a s s i f i e d a c c o r d i n g t o t h e c a t e g o r i e s and t h e c a t e g o r i e s were r e v i s e d and r e f i n e d u n t i l t h e y a c c u r a t e l y r e f l e c t e d t h e d a t a . Summary The m e t h o d o l o g y u s e d t o l o o k a t t h e s t u d y p r o b l e m i s b a s e d on an e x p l o r a t o r y d e s c r i p t i v e r e s e a r c h d e s i g n . S y m b o l i c i n t e r a c t i o n , as t h e t h e o r e t i c a l f r a m e w o r k , p r o v i d e s d i r e c t i o n f o r c h o o s i n g t h i s r e s e a r c h d e s i g n . T h i s d e s i g n i s a p p r o p r i a t e i n t h a t i t p r o v i d e s t h e n e c e s s a r y f l e x i b i l i t y f o r l o o k i n g a t a p r o b l e m a b o u t w h i c h v e r y l i t t l e i s w r i t t e n . The method p r o v i d e s d i r e c t i o n f o r t h e s e l e c t i o n o f p a r t i c i p a n t s , t h e p r o c e s s o f d a t a c o l l e c t i o n , and t h e d a t a a n a l y s i s . S e l e c t i o n c r i t e r i a r e s u l t e d i n a c o n v e n i e n c e s a m p l e o f n u r s e s most s u i t e d t o p r o v i d e t h e d e s c r i p t i o n s n e c e s s a r y t o 48 address the study problem. U n s t r u c t u r e d i n t e r v i e w s focused on areas r e l a t e d to the nur se s ' exper ience with a s p e c i f i c type of n u r s e - p a t i e n t i n t e r a c t i o n . Al though the i n t e r v i e w s focused on c e r t a i n a r e a s , they were d i r e c t e d by i n f o r m a t i o n tha t the nurses p e r c e i v e d as important to share . The data were ana lyzed us ing content a n a l y s i s . 49 CHAPTER FOUR P r e s e n t a t i o n of F i n d i n g s Based on the methodology d e s c r i b e d i n Chapter 3, data were o b t a i n e d from 18 nurses working i n extended care u n i t s . The i n t e r v i e w e r asked these nurses to d e s c r i b e t h e i r i n t e r a c t i o n s with e l d e r l y p a t i e n t s i d e n t i f i e d as c o n f u s e d . The i n t e r v i e w focused on the content areas o u t l i n e d i n the study q u e s t i o n s . P r e s e n t a t i o n of the f i n d i n g s i s o r g a n i z e d , a c c o r d i n g to these q u e s t i o n s , i n t o the f o l l o w i n g s e c t i o n s : (a) p a t i e n t behav io r s i n f l u e n c i n g the i n t e r a c t i o n , (b) the e f f e c t of p a t i e n t b e h a v i o r s on nurse b e h a v i o r s , (c) nurse behav io r s and t h e i r i n f l u e n c e on the i n t e r a c t i o n , and (d) e x t e r n a l f a c t o r s i n f l u e n c i n g the i n t e r a c t i o n . P a t i e n t Behav ior s I n f l u e n c i n g the I n t e r a c t i o n As i n d i v i d u a l s " encounter each o ther they are r e q u i r e d to take account of the a c t i o n s of one another as they form t h e i r own a c t i o n " (Blumer , 1969, p. 10) . An i n d i v i d u a l takes account of a n o t h e r ' s a c t i o n s , i n p a r t , by i n t e r p r e t i n g the i n d i c a t i o n s of o ther s (Blumer , 1969) . T h e r e f o r e , as nurses i n t e r a c t wi th e l d e r l y p a t i e n t s whom they i d e n t i f y as c o n f u s e d , they are d e t e r m i n i n g which behav io r s have meaning fo r them based on the pre sent s i t u a t i o n and on t h e i r past e x p e r i e n c e . T h i s s e c t i o n pre sent s the n u r s e s ' d e s c r i p t i o n s of p a t i e n t behav io r s which they p e r c e i v e d i n f l u e n c e d the n u r s e - p a t i e n t i n t e r a c t i o n . 50 F o l l o w i n g c a r e f u l examinat ion of the i n t e r v i e w d a t a , 6 c a t e g o r i e s of p a t i e n t behav ior s were developed by the r e s e a r c h e r . A l l p a t i e n t behav io r s i d e n t i f i e d by the nurses as i n f l u e n c i n g the i n t e r a c t i o n were then c l a s s i f i e d w i t h i n these c a t e g o r i e s . These c a t e g o r i e s are as f o l l o w s : (a) d i s r u p t i v e b e h a v i o r s , (b) c o n t e x t u a l l y i n a p p r o p r i a t e b e h a v i o r s , (c) u n i n t e l l i g i b l e b e h a v i o r s , (d) memory-impaired b e h a v i o r s , (e) u n p r o d u c t i v e r e p e t i t i o n s , and (f ) u n p r e d i c t a b l e f l u c t u a t i o n s . I n d i c a t o r s of these behav ior s and the f requency of t h e i r occur rence are i l l u s t r a t e d i n Appendix D. D i s r u p t i v e Behav ior s D i s r u p t i v e behav io r s are d e f i n e d as p a t i e n t b e h a v i o r s which are u p s e t t i n g to o t h e r s . The nurses r e p o r t e d these behav io r s as n e g a t i v e l y i n f l u e n c i n g the i n t e r a c t i o n . P h y s i c a l a c t i o n s i d e n t i f i e d by the nurses as d i s r u p t i v e i n c l u d e d p h y s i c a l l y abus ive a c t i o n s such as h i t t i n g , and verba l a c t i o n s such as y e l l i n g . They a l so c o n s i s t e n t l y i d e n t i f i e d c e r t a i n t r a i t s such as " a g i t a t e d , " " u n c o o p e r a t i v e , " " a n x i o u s , " "demanding , " and " i m p a t i e n t , " which c h a r a c t e r i z e d p a t i e n t s ' i n t e r a c t i o n s . When d e s c r i b i n g b e h a v i o r s in the o ther f i v e c a t e g o r i e s , on ly o c c a s i o n a l l y d i d the nurses s p e c i f y t h e i r emotional r e a c t i o n s to the p a t i e n t b e h a v i o r s , whereas when d e s c r i b i n g d i s r u p t i v e behav io r s the nurses f r e q u e n t l y r e p o r t e d f e e l i n g s 51 of anger , f r u s t r a t i o n , and emotional exhaus t ion d u r i n g and f o l l o w i n g the i n t e r a c t i o n s . C o n t e x t u a l l y I n a p p r o p r i a t e Behav ior s C o n t e x t u a l l y i n a p p r o p r i a t e behav ior s are those p a t i e n t b e h a v i o r s w h i c h , a l though meaningful w i t h i n themse lve s , are p e r c e i v e d by the nurses as out of c o n t e x t w i t h i n the pre sent s i t u a t i o n . The nurses f r e q u e n t l y d e s c r i b e d p a t i e n t s e x h i b i t i n g these behav io r s as a c t i n g "out of c o n t e x t " or as " l i v i n g i n another r e a l i t y . " The meaning which the nurses a t t ached to t h e i r p e r c e p t i o n s of c o n t e x t u a l l y i n a p p r o p r i a t e p a t i e n t behav io r s may or may not have been c o r r e c t a c c o r d i n g to the p a t i e n t . When d e s c r i b i n g c o n t e x t u a l l y i n a p p r o p r i a t e b e h a v i o r s , the nurses d e s c r i b e d verba l behav io r s where the c h o i c e and use of words were a p p r o p r i a t e and the ideas were b r o a d l y i n t e l l i g i b l e but the t o t a l s tatement was i n a p p r o p r i a t e when r e l a t e d to the pre sent s i t u a t i o n . Other s tatements were c o n s i d e r e d i n a p p r o p r i a t e because the p a t i e n t was u t i l i z i n g a past time frame, r e f e r r i n g p r i m a r i l y to past r o l e s and former f a m i l y members, w h i l e the nurses were a c t i n g w i t h i n the present time frame. The c o n t e x t u a l l y i n a p p r o p r i a t e behav io r s of p a t i e n t s u s ing a p re sent time frame were d e s c r i b e d by some nurses as r e f l e c t i n g mistaken or f a l s e p e r c e p t i o n s ( d e l u s i o n s , i l l u s i o n s , or h a l l u c i n a t i o n s ) , impa i red judgment of a b i l i t i e s , and i n a c c u r a t e e x p e c t a t i o n s of o ther s w i t h i n the pre sent s i t u a t i o n . Other nurses 52 s p e c i f i e d c e r t a i n p h y s i c a l behav io r s r e l a t e d to c o o r d i n a t i o n , f a c i a l e x p r e s s i o n , and body movements as behav ior s w h i c h , i n some s i t u a t i o n s , would be a p p r o p r i a t e but which they p e r c e i v e d were i n a p p r o p r i a t e w i t h i n the c o n t e x t of the c u r r e n t s i t u a t i o n . Al though many nurses i n t h i s study d e s c r i b e d the c o n t e x t u a l l y i n a p p r o p r i a t e behav io r s as having meaning fo r p a t i e n t s based on t h e i r past exper i ence or c u r r e n t p e r c e p t i o n s , they conc luded tha t the behav ior s d i d not have a s i m i l a r meaning fo r them and consequent ly l a b e l l e d the p a t i e n t s ' behav ior as c o n f u s i o n . U n i n t e l l i g i b l e Behav ior s U n i n t e l l i g i b l e b e h a v i o r s encompass those verba l and p h y s i c a l p a t i e n t b e h a v i o r s which were not unders tood by the nurses and were p e r c e i v e d as i n a p p r o p r i a t e r e g a r d l e s s of the s i t u a t i o n . As noted p r e v i o u s l y , the meaning which the nurses a t t ached to t h e i r p e r c e p t i o n s of p a t i e n t s ' b e h a v i o r may or may not have been c o r r e c t a c c o r d i n g to the p a t i e n t . The behav ior s d e s c r i b e d were: (a) decreased response to p h y s i c a l s t i m u l i , such as pa in and hunger , and to the a c t i o n s of o t h e r s ; (b) purpose l e s s a c t i v i t i e s , such as wandering and head bang ing ; and (c) g a r b l e d or u n i n t e l l i g i b l e speech . These p a t i e n t behav ior s d i d not g ive the nurses any i n d i c a t i o n of how they were to respond or what the p a t i e n t was i n t e n d i n g to do. These p a t i e n t s were d e s c r i b e d as " i n c o h e r e n t , " "not r e s p o n s i v e , " or "not aware 53 of s u r r o u n d i n g s " and as having " l i t t l e or no d i r e c t or i n d i r e c t c o m m u n i c a t i o n . " Memory-Impaired Behav ior s Behav ior s sugges t ive of memory impairment were d e s c r i b e d as i n f l u e n c i n g the i n t e r a c t i o n . The nur se s ' d e s c r i p t i o n s focused on p a t i e n t s ' i n a b i l i t y (a) to r e c o g n i z e t h e i r n u r s e , f a m i l y , and/or f r i e n d s ; (b) to i d e n t i f y time and/or p l a c e ; (c) to remember r ecent e v e n t s ; and (d) to i d e n t i f y s e l f . Some nurses r e f e r r e d to memory problems wi thout s p e c i f y i n g b e h a v i o r s . "I th ink t h a t confused people are f o r g e t f u l . " Others s p e c i f i e d t h a t shor t term, r a t h e r than long term memory, was p r i m a r i l y a f f e c t e d . Unproduc t ive R e p e t i t i o n s P a t t e r n s of u n p r o d u c t i v e , r e p e t i t i o u s a c t i v i t y were d e s c r i b e d by the nurses as b e h a v i o r s , e v i d e n t i n p a t i e n t s i d e n t i f i e d as c o n f u s e d , t h a t i n f l u e n c e d the i n t e r a c t i o n . P a t i e n t s were d e s c r i b e d as a sk ing the same q u e s t i o n s over and over again r e g a r d l e s s of the n u r s e s ' r e sponses . In a d d i t i o n , the nurses d e s c r i b e d s i t u a t i o n s where c o n s t a n t r e p e t i t i o n of the same word or p h y s i c a l a c t i v i t y o c c u r r e d wi thout a break . The nurses were unable to i d e n t i f y anyth ing w i t h i n the s i t u a t i o n t h a t p r e c i p i t a t e d the p a t i e n t s ' r e p e t i t i o u s a c t i o n s . They s t a t e d tha t they had exhausted a l l a p p r o p r i a t e responses to these p a t i e n t s with l i t t l e or no c e s s a t i o n of the r e p e t i t i o u s b e h a v i o r . Most a c t i v i t i e s were p e r c e i v e d by the nurses as having some 54 meaning fo r p a t i e n t s , s p e c i f i c a l l y i n r e l a t i o n to t h e i r p r e v i o u s l i f e e x p e r i e n c e . U n p r e d i c t a b l e F l u c t u a t i o n s F l u c t u a t i o n s i n e i t h e r mood or a c t i o n were r e p o r t e d as i n t e r f e r i n g with the n u r s e - p a t i e n t i n t e r a c t i o n . These f l u c t u a t i o n s proceeded from behav io r s of a p o s i t i v e nature to behav io r s of a nega t ive nature or v i c e versa and were p e r c e i v e d by the nurses as extreme and u n a n t i c i p a t e d . I t was the phenomenon of change tha t was i d e n t i f i e d as i n t e r f e r i n g with the i n t e r a c t i o n and not the behav io r s themse lve s . The nurses s p e c i f i e d t h a t p a t i e n t s ' changes i n behav ior c o u l d not be p r e d i c t e d by any observab le changes w i t h i n the s i t u a t i o n , t h e r e f o r e these changes were d i f f i c u l t f o r them to u n d e r s t a n d . When d e s c r i b i n g the numerous behav io r s which they i d e n t i f i e d as i n f l u e n c i n g the i n t e r a c t i o n , the nurses a l s o shared some c h a r a c t e r i s t i c s r e l a t e d to these b e h a v i o r s . They d e s c r i b e d v a r i o u s l e v e l s of behav io r s i d e n t i f i e d as c o n f u s i o n . These l e v e l s of c o n f u s i o n were d i f f e r e n t i a t e d a c c o r d i n g to one or more of the f o l l o w i n g c r i t e r i a : (a) the p a t i e n t ' s degree of awareness , (b) the p a t i e n t ' s a b i l i t y to communicate, (c) the s e v e r i t y of the p a t i e n t ' s d i s r u p t i v e b e h a v i o r s , and (d) the f requency and d u r a t i o n of the p a t i e n t ' s l u c i d and confused p e r i o d s . The nurses most o f ten i l l u s t r a t e d p a t i e n t s ' l u c i d moments by d e s c r i b i n g some i n c r e a s e i n the f requency of 55 unders tandable communicat ion . For example, one nurse s t a t e d "Somebody . . . can c a r r y on a normal c o n v e r s a t i o n with you today , [but ] tomorrow they are t a l k i n g nonsense . " When d e s c r i b i n g these l u c i d moments, the nurses noted tha t p a t i e n t s ' awareness of t h e i r p e r i o d i c c o n f u s i o n was a n x i e t y p rovok ing fo r them and consequent ly uncomfortab le fo r the n u r s e . "To know t h a t somebody knows they are confused . . . i s very d i s t r e s s i n g f o r them and fo r y o u . " The nurses i d e n t i f i e d these p a t i e n t s as more d i f f i c u l t to care fo r as i n d i c a t e d by the f o l l o w i n g a c c o u n t s : "Those people who are r a t i o n a l at t imes and confused [a t t imes] are the hardes t people to deal with but they need the most time and e n e r g y . " "The p a t i e n t was very confused but was i n some ways o r i e n t e d . That was the hardes t . . . . I f someone i s p a r t l y confused you r e a l l y have to honor t h e i r r e a l i t y . " E f f e c t of P a t i e n t Behav ior s on Nurse Behav ior s Human be ings i n i n t e r a c t i n g with one another have to take account of what each o ther i s doing or i s about to do; they are f o r c e d to d i r e c t t h e i r own conduct or handle t h e i r s i t u a t i o n i n terms of what they take i n t o a c c o u n t . (Blumer, 1969, p . 8) In response to the a c t i o n s of p a t i e n t s , nurses i n t e r p r e t p a t i e n t s ' i n d i c a t i o n s and e i t h e r modify or m a i n t a i n t h e i r p lans i n l i g h t of t h e i r i n t e r p r e t a t i o n of the c u r r e n t s i t u a t i o n . T h i s s e c t i o n present s the e f f e c t of 5-6 p a t i e n t s ' behav ior upon the nur se s ' behav ior w i t h i n the i n t e r a c t i on . The i n t e r v i e w data i n d i c a t e d t h a t p a t i e n t s ' behav ior s had a d e f i n i t e impact on the nur se s ' b e h a v i o r s . The nurses d e s c r i b e d v a r i o u s responses to p a t i e n t s ' behav ior b u t , f o l l o w i n g repeated e x p l o r a t i o n of the d a t a , i t became e v i d e n t to the r e s e a r c h e r t h a t p a t i e n t b e h a v i o r s g e n e r a l l y a f f e c t e d the n u r s e s ' behav ior i n one of two ways. P a t i e n t behav ior s a f f e c t e d the degree to which the nurses e i t h e r withdrew from or p a r t i c i p a t e d i n the i n t e r a c t i o n . T h e r e f o r e , f i n d i n g s i n d i c a t i n g the e f f e c t of p a t i e n t behav io r s on the n u r s e s ' b e h a v i o r are pre sented i n the f o l l o w i n g c a t e g o r i e s : (a) p a t i e n t b e h a v i o r s c aus ing nurses to approach the i n t e r a c t i o n , and (b) p a t i e n t behav io r s c aus ing nurses to a v o i d or withdraw from the i n t e r a c t i o n . P a t i e n t Behav ior s Caus ing Nurses to Approach the  I n t e r a c t i on P a t i e n t behav ior s tha t e l i c i t e d p o s i t i v e responses from the nurses were both nonverbal and verba l . Nonverbal responses c o n s i s t e d p r i m a r i l y of eye c o n t a c t and s m i l i n g , whereas verba l responses c o n s i s t e d of p a t i e n t s ' s tatements tha t they l i k e d the n u r s e , a p p r e c i a t e d her e f f o r t s , or would coopera te with events t a k i n g p l a c e . The nurses d e s c r i b e d f e e l i n g " r e w a r d e d , " " w o r t h w h i l e , " and " s a t i s f i e d " i n response to these p a t i e n t behav io r s which they p e r c e i v e d i n d i c a t e d t h a t p a t i e n t s were aware of t h e i r p r e s e n c e , were 57 happy and c o m f o r t a b l e , and were w i l l i n g to cooperate with t r e a t m e n t s . These b e h a v i o r s enhanced the nur se s ' m o t i v a t i o n to s t i m u l a t e v e r b a l l y , to have p h y s i c a l c o n t a c t w i t h , and to spend time wi th p a t i e n t s . The nurses i n d i c a t e d t h a t p a t i e n t s only o c c a s i o n a l l y thanked them or s t a t e d tha t they a p p r e c i a t e d t h e i r e f f o r t s . Al though t h i s l ack of a p p r e c i a t i v e p a t i e n t behav ior r e s u l t e d in f e e l i n g s of f r u s t r a t i o n and low morale fo r some n u r s e s , i t was not a concern f o r o t h e r s . Those nurses who were not concerned seemed to need r e l a t i v e l y l i t t l e o v e r t l y a p p r e c i a t i v e p a t i e n t b e h a v i o r to f ee l encouraged . " I t ' s not so much t h a t they a p p r e c i a t e what you do, i t ' s j u s t the response you ge t , a smi le or a hug, from someone who i s u s u a l l y a g g r e s s i v e . That makes you f ee l i t ' s a l l w o r t h w h i1e . " . P a t i e n t s ' responses seemed to have more impact i f they o c c u r r e d unexpected ly or f o r the f i r s t t i m e . " I t ' s such a major advance to have somebody say 'Good morning ' tha t h a s n ' t s a i d a n y t h i n g f o r 6 months . " I n t e r a c t i o n s evok ing more p o s i t i v e p a t i e n t r e sponse s , and hence a more p o s i t i v e f e e l i n g response from the n u r s e s , were g e n e r a l l y p a t i e n t focused and c e n t e r e d on p a t i e n t s ' s o c i a l and emotional needs . " I t i s i n t e r a c t i n g wi th those people t h a t g ive s you s a t i s f a c t i o n and makes the job d e l i g h t f u l . . . . I f i t was a l l c l i n i c a l and o b j e c t i v e i t w o u l d n ' t feed you very much. " 58 Al though the nurses shared many emotions which d i d not r e f l e c t opt imism and h a p p i n e s s , when asked to summarize t h e i r f e e l i n g s about working wi th e l d e r l y p a t i e n t s i d e n t i f i e d as c o n f u s e d , 17 of the 18 nurses s t a t e d t h a t they g e n e r a l l y f e l t good about t h e i r work and would not choose to work e l s e w h e r e . They b e l i e v e d they were ab le to b r i n g happiness and comfort i n t o p a t i e n t s ' l i v e s and t h a t the p a t i e n t s l i k e d and t r u s t e d them. One nurse s t a t e d the f o l l o w i n g : "I can f e e l p o s i t i v e even when i t i s n e g a t i v e , when they are not b e t t e r . I d o n ' t expect our confused p a t i e n t s to become l u c i d , but I can f ee l t h a t they are e x p r e s s i n g happiness . . . and t h a t i s s a t i s f y i n g fo r me." P a t i e n t Behav ior s Caus ing Nurses to A v o i d or Withdraw From  the I n t e r a c t i o n P a t i e n t b e h a v i o r s i d e n t i f i e d as d i s r u p t i v e , u n r e s p o n s i v e , f l u c t u a t i n g , and r e p e t i t i o u s most f r e q u e n t l y p r e c i p i t a t e d nega t ive nurse r e sponse s , and s u b s e q u e n t l y , some degree of avoidance or withdrawal on the par t of the n u r s e s . The frequency and s e v e r i t y of p a t i e n t s ' b e h a v i o r s i n f l u e n c e d the degree to which the nurses avoided or withdrew from the i n t e r a c t i o n . The nurses f r e q u e n t l y mentioned p a t i e n t s ' l e v e l of c o n f u s i o n as i n f l u e n c i n g t h e i r p a r t i c i p a t i o n i n the i n t e r a c t i o n . Those p a t i e n t s having fewer i n t e l l i g i b l e s t a tement s , l e s s apparent awareness of the env i ronment , and more u n i n t e l l i g i b l e p a t t e r n s of b e h a v i o r were p e r c e i v e d as 59 more s e v e r e l y confused and t h e r e f o r e as having a g r e a t e r nega t ive impact on the i n t e r a c t i o n . The nurses s t a t e d t h a t i t was d i f f i c u l t to spend time with these p a t i e n t s and some r e p o r t e d t h a t they a c t u a l l y spent l e s s time with them, e s p e c i a l l y i f they were " r u s h e d " or at the "end of [ t h e i r ] s h i f t . " P a t i e n t s e x p e r i e n c i n g l u c i d p e r i o d s d u r i n g which time they were aware of t h e i r c o n f u s i o n were d e s c r i b e d as be ing l e s s s e v e r e l y confused and as be ing a g i t a t e d or depressed as a r e s u l t of t h e i r awareness . The nurses i d e n t i f i e d f e e l i n g s of a n x i e t y and sadness o c c u r r i n g i n response to these p a t i e n t s . As noted e a r l i e r , the nurses found i t d i f f i c u l t to i n t e r a c t with them. Anger and f r u s t r a t i o n were the two nega t ive f e e l i n g responses most f r e q u e n t l y exper i enced by the nurses i n response to p a t i e n t s ' b e h a v i o r s . The nurses a l s o d e s c r i b e d f e e l i n g " i m p a t i e n t , " " i r r i t a t e d , " " m e n t a l l y t i r e d , " and " g u i l t y . " A s s o c i a t e d with t h e i r f e e l i n g s of g u i l t was an i m p l i e d sense of f a i l u r e . These nega t ive f e e l i n g responses were a s s o c i a t e d with the n u r s e s ' i n a b i l i t y to e s t a b l i s h c o n t a c t , to e l i c i t c o o p e r a t i o n , to ensure comfor t , and, l e s s f r e q u e n t l y , to understand the p a t i e n t . The nurses a l s o i d e n t i f i e d the absence of p a t i e n t a p p r e c i a t i o n or feedback as r e s u l t i n g i n f e e l i n g s of low morale and f r u s t r a t i o n . These f e e l i n g s d e t r a c t e d from the n u r s e s ' m o t i v a t i o n to i n i t i a t e or c o n t i n u e the i n t e r a c t i o n . 60 The nurses e x p e r i e n c e d f r u s t r a t i o n s p e c i f i c a l l y when they were not able to get the p a t i e n t to stop the b e h a v i o r . "There i s no rea son ing [wi th them], no changing t h e i r d i r e c t i o n . You c a n ' t put them o f f no matter what you t r y . You get very angry , very f r u s t r a t e d ! " The idea t h a t the nur se s ' f e e l i n g s r e s u l t e d from t h e i r i n a b i l i t y to " reason w i t h " or "get through t o " the p a t i e n t i s c o n s i s t e n t -throughout t h e i r s t a tement s . T a s k - r e l a t e d i n t e r a c t i o n s , more f r e q u e n t l y than p a t i e n t - r e l a t e d i n t e r a c t i o n s , r e s u l t e d i n r e s i s t a n t or d i s r u p t i v e p a t i e n t r e sponse s . These l e d to nega t ive f e e l i n g responses on the par t of the n u r s e s . In a d d i t i o n to d e s c r i b i n g p a t i e n t behav io r s t h a t p r e c i p i t a t e d nega t ive nurse r e sponse s , the nurses d e s c r i b e d t h e i r p e r c e p t i o n s of a broader a spect of b e h a v i o r , t h a t i s , the p a t i e n t s ' e x i s t e n c e or c i r c u m s t a n c e s l i v i n g as d i s a b l e d , e l d e r l y people w i t h i n an i n s t i t u t i o n . The nurses e x p e r i e n c e d f e e l i n g s of f r u s t r a t i o n and sadness i n response to p a t i e n t s ' dependency on o ther s to meet t h e i r v a r i o u s needs. They d e s c r i b e d them as be ing " l o c k e d i n t o " t h i s dependent e x i s t e n c e . The nur se s ' f r u s t r a t i o n a l so stemmed from t h e i r p e r c e i v e d i n a b i l i t y to meet the p a t i e n t s ' needs , e s p e c i a l l y t h e i r s o c i a l and emotional needs. "A l o t of f r u s t r a t i o n comes from not be ing able to do more [ to f i l l ] t h e i r need f o r someone to be c l o s e to them and to care for them. " 61 The nurses a l s o r e p o r t e d f e e l i n g s of f r u s t r a t i o n , sadness , and compassion toward p a t i e n t s they p e r c e i v e d as l o n e l y and wi thout adequate f a m i l y support and as unaware of l i f e o u t s i d e of the i n s t i t u t i o n . "I f ee l compassion f o r some of them because . . . you know they w i l l never r e c o g n i z e the rea l wor ld as such a g a i n . " Nurse Behav ior s and T h e i r I n f luence on the I n t e r a c t i o n The i n t e r a c t i o n process occurs whenever two people communicate. Impl i c i t w i t h i n t h i s s tatement i s the idea t h a t each i n d i v i d u a l w i t h i n the i n t e r a c t i o n i n f l u e n c e s the behav ior of the o ther i n d i v i d u a l . The p r e v i o u s s e c t i o n s presented the n u r s e s ' p e r s p e c t i v e of p a t i e n t b e h a v i o r s and t h e i r e f f e c t on nurse b e h a v i o r s w i t h i n the i n t e r a c t i o n . T h i s s e c t i o n c o n t i n u e s the sequence of i n t e r a c t i o n by p r e s e n t i n g , again from the nur se s ' p e r s p e c t i v e , those nurse behav ior s t h a t i n f l u e n c e the i n t e r a c t i o n . N u r s e - p a t i e n t i n t e r a c t i o n s progres s through a s e r i e s of phases , each phase i n c o r p o r a t i n g c e r t a i n unique aspects of the i n t e r a c t i o n but a l so o v e r l a p p i n g wi th o ther phases . These phases have been i d e n t i f i e d as the p r e i n t e r a c t i o n phase , the i n t r o d u c t o r y phase , the working phase, and the t e r m i n a t i o n phase (Sundeen et a l . , 1976; T r a v e l b e e , 1969). The f o u r t h phase, t h a t " o f t e r m i n a t i o n , w i l l not be used as par t of the framework fo r t h i s s e c t i o n as t h i s study focuses on the ongoing i n t e r a c t i o n and because the nurses d i d not d i s c u s s t h e i r behav ior i n r e l a t i o n to the t e r m i n a t i o n of the 62 i n t e r a c t i o n . The nurse behav io r s t h a t i n f l u e n c e d the i n t e r a c t i o n w i l l be presented w i t h i n the framework of the f i r s t 3 phases . The nur se s ' tendency was to focus t h e i r accounts on behav io r s which they p e r c e i v e d , based on t h e i r e x p e r i e n c e , e f f e c t i v e l y i n f l u e n c e d the i n t e r a c t i o n . On o c c a s i o n they d e s c r i b e d i n e f f e c t i v e behav io r s to i l l u s t r a t e t h e i r nega t ive impact on p a t i e n t s . T h i s s e c t i o n w i l l focus on e f f e c t i v e nurse behav ior s and the r e s u l t i n g impact on p a t i e n t behav ior and u l t i m a t e l y on the n u r s e - p a t i e n t i n t e r a c t i o n . When a v a i l a b l e , b e h a v i o r s i l l u s t r a t i n g i n e f f e c t i v e aspects of the i n t e r a c t i o n w i l l be p r e s e n t e d . The P r e i n t e r a c t i o n Phase T h i s phase occur s be fore the nurse i n i t i a l l y i n t e r a c t s with the p a t i e n t or before every i n t e r a c t i o n . Dur ing t h i s phase the nurse r e l i e s on i n f o r m a t i o n from secondary s o u r c e s . T h i s i n f o r m a t i o n i n f l u e n c e s the n u r s e ' s thoughts and f e e l i n g s about the p a t i e n t p r i o r to the i n t e r a c t i o n and subsequent ly i n f l u e n c e s t h e i r b e h a v i o r d u r i n g the i n t e r a c t i o n (Sundeen et al . , 1976; T r a v e l b e e , 1969). Of the 15 nurses who thought i t was impor tant to be knowledgeable about t h e i r p a t i e n t s , 3 nurses expressed concern t h a t the p a t i e n t ' s past h i s t o r y , o b t a i n e d from any s o u r c e , " p r e j u d i c e d " the c a r e g i v e r wi th r e s p e c t to t h a t p a t i e n t . They p r e f e r r e d a c t u a l n u r s e - p a t i e n t i n t e r a c t i o n s as the pr imary means of knowing p a t i e n t s ' p re fe rence s and 63 l i f e p a t t e r n s . A l l o ther nurses i n d i c a t e d tha t i n f o r m a t i o n o b t a i n e d from any source and r e l a t e d to the p a t i e n t s ' past or p re sent l i f e was v a l u a b l e . The I n t r o d u c t o r y Phase The i n t r o d u c t o r y phase extends from the i n i t i a l meeting to the time when the nurse i s able to view the p a t i e n t as a unique human b e i n g . Dur ing the i n t r o d u c t o r y phase the nurse begins to e s t a b l i s h a sense of t r u s t between h e r s e l f and the p a t i e n t (Sundeen et a l . , 1976). T h i s phase v a r i e s i n l e n g t h a c c o r d i n g to the n u r s e - p a t i e n t i n t e r a c t i o n . The nurses i d e n t i f i e d t h i s as a d i f f i c u l t t i m e , l a s t i n g anywhere from "2 to 3 months" to " y e a r s . " Dur ing t h i s t i m e , they ga ined knowledge about the p a t i e n t s ' p r e f e r e n c e s and needs , past h i s t o r y , b a s e l i n e b e h a v i o r s , and f a m i l y and f r i e n d s . Without e x c e p t i o n , the nurses s t a t e d t h a t knowing t h e i r p a t i e n t s was important because i t enhanced t h e i r under s t and ing of p a t i e n t b e h a v i o r s , a l lowed them to d e c i p h e r u n c l e a r communicat ion , and i n c r e a s e d the a p p r o p r i a t e n e s s and a c c e p t a b i l i t y of t h e i r approaches to p a t i e n t s . The nurses f e l t more p o s i t i v e about t h e i r i n t e r a c t i o n s when they knew p a t i e n t s . That i s the hardes t t h i n g , g e t t i n g to know them. I t takes you a couple of months but once you have c r o s s e d tha t hurd le i t i s r e a l l y home f ree because then you know what they want, how they l i k e t h e i r m e d i c a t i o n , how to approach them f o r t h e i r t r e a t m e n t s . 64 Knowledge of t h e i r p a t i e n t s was an important f a c t o r i n f l u e n c i n g the nur se s ' a b i l i t y to i n d i v i d u a l i z e the i n t e r a c t i o n . " I t takes time to f i n d o u t . I n i t i a l l y I approach everyone i n the same manner u n t i l I get to know them, then I t a i l o r the care to t h e i r l i k e s . " A l l nurses d e s c r i b e d t h e i r i n i t i a l approach to p a t i e n t s as i n d i v i d u a l i z e d . They s t r e s s e d t h a t i t was impor tant to assess p a t i e n t s ' mood before i n t e r a c t i n g because t h e i r "approach [had] to be changeable as . . . p a t i e n t s ' mood c h a n g e [ d ] . " They a l s o m o d i f i e d t h e i r b e h a v i o r to complement the p a t i e n t s ' p e r s o n a l i t y or c h a r a c t e r i s t i c way of i n t e r a c t i n g . For example, wi th q u i e t e r , l e s s b o i s t e r o u s p a t i e n t s the n u r s e s ' approaches were q u i e t e r and more gen t l e but wi th p a t i e n t s e x h i b i t i n g a g g r e s s i v e and loud b e h a v i o r , t h e i r approach was b o l d e r and more a s s e r t i v e . When p a t i e n t s c o n s i s t e n t l y r e f e r r e d to events i n a past time frame, the nurses adapted t h e i r c o n v e r s a t i o n to i n c o r p o r a t e the people or events i n p a t i e n t s ' past o r i e n t a t i o n . As the i n t r o d u c t o r y phase ends , t r u s t i s d e v e l o p i n g and the nurse i s i n c r e a s i n g l y able to p e r c e i v e the p a t i e n t as a unique human b e i n g . T h i s i n d i c a t e s t h a t the i n t e r a c t i o n i s e n t e r i n g the working phase (Sundeen et a l . , 1976) . The Working Phase I t i s d u r i n g the working phase t h a t the nurse attempts to m a i n t a i n the f e e l i n g of mutual t r u s t tha t has been e s t a b l i s h e d d u r i n g the i n t r o d u c t o r y phase 65 (Sundeen et al . , 1976) . T r a v e l b e e (1969) i d e n t i f i e s r e l a t e d n e s s as the c u l m i n a t i o n of t h i s phase. I f r e l a t e d n e s s i s e s t a b l i s h e d , the p a t i e n t has the o p p o r t u n i t y to engage i n meaningful i n t e r a c t i o n with a s e n s i t i v e , c a r i n g person who r e f l e c t s u n c o n d i t i o n a l acceptance and hones ty . The goa l s of the nurse d u r i n g t h i s phase are to help the p a t i e n t cope with pre sent problems , communicate and s o c i a l i z e with o t h e r s , t e s t new p a t t e r n s of b e h a v i o r , and f i n d meaning i n i l l n e s s ( T r a v e l b e e , 1969). The 3 goa l s i d e n t i f i e d by the nurses in t h i s study were to (a) e s t a b l i s h c o n t a c t with the p a t i e n t based upon some degree of mutual awareness , (b) e l i c i t p a t i e n t c o o p e r a t i o n , and (c) reach some degree of mental and p h y s i c a l p a t i e n t c o m f o r t . Al though the goa l s are not i d e n t i c a l , they appear compat ib le with the goa l s i d e n t i f i e d i n the l i t e r a t u r e . I t i s i n t e r e s t i n g to note t h a t most nurses d i d not express goals tha t were d i r e c t l y r e l a t e d to c o n f u s i o n , r a t h e r , t h e i r goals were r e l a t e d to p a t i e n t c o n t a c t , c o o p e r a t i o n , and c o m f o r t . The nurses d e s c r i b e d many d i f f e r e n t b e h a v i o r s t h a t i n f l u e n c e d the i n t e r a c t i o n . For the purpose of c l a r i t y , the b e h a v i o r s are o r g a n i z e d a c c o r d i n g to the f o l l o w i n g head ings : (a) n u r s e s ' communication b e h a v i o r s , (b) nur se s ' responses to nega t ive p a t i e n t b e h a v i o r s , (c) n u r s e s ' behav io r s tha t humanize the i n t e r a c t i o n , and (d) n u r s e s ' behav io r s t h a t i n f l u e n c e p a t i e n t c o n t r o l . 6 6 Nurses' communication b e h a v i o r s . The nurses i n d i c a t e d t h a t t h e i r communication b e h a v i o r was an i m p o r t a n t i n f l u e n c e on the n u r s e - p a t i e n t i n t e r a c t i o n . The n u r s e s ' d e s c r i p t i o n s of t h e i r communication b e h a v i o r s are p r e s e n t e d w i t h i n the f o l l o w i n g 4 a r e a s : (a) nonverbal communication, (b) t a s k - o r i e n t e d v e r s u s p a t i e n t - o r i e n t e d communication, (c) r e a l i t y o r i e n t a t i o n , and (d) the i n f l u e n c e of c o n f u s i o n on communication. The nurses i d e n t i f i e d nonverbal communication b e h a v i o r s which they p e r c e i v e d were e f f e c t i v e to v a r y i n g degrees i n meeting the g o a l s of the n u r s e - p a t i e n t i n t e r a c t i o n . These g o a l s were r e l a t e d p r i m a r i l y to p a t i e n t c o n t a c t , c o o p e r a t i o n , and c o m f o r t and, l e s s f r e q u e n t l y , to p a t i e n t u n d e r s t a n d i n g . Eye c o n t a c t and t o u c h i n g were d e s c r i b e d by a m a j o r i t y of the nurses as e f f e c t i v e nonverbal communication b e h a v i o r s . Eye c o n t a c t was c o n s i d e r e d a p p r o p r i a t e i n a l l s i t u a t i o n s , r e g a r d l e s s of p a t i e n t b e h a v i o r or r e s p o n s i v e n e s s . I t was e f f e c t i v e i n c a p t u r i n g p a t i e n t s ' a t t e n t i o n and k e e p i n g them f o c u s e d as much as p o s s i b l e on the i n t e r a c t i o n . Some nurses i n d i c a t e d t h a t eye c o n t a c t was e f f e c t i v e i n m a i n t a i n i n g n u r s e - p a t i e n t c o n t a c t because i t was c o m f o r t i n g and f u l f i l l e d p a t i e n t s ' need f o r r e c o g n i t i o n . Touching b e h a v i o r s decreased p a t i e n t s ' w i t h d r a w a l and i n c r e a s e d t h e i r awareness of o t h e r s i n the environment. These b e h a v i o r s were a l s o d e s c r i b e d as e f f e c t i v e i n 67 e l i c i t i n g p a t i e n t s ' c o o p e r a t i o n and d e c r e a s i n g t h e i r d i s r u p t i v e b e h a v i o r . P a t i e n t s responded to touch by s m i l i n g , e s t a b l i s h i n g eye c o n t a c t , re sponding v e r b a l l y , and r e t u r n i n g t o u c h i n g b e h a v i o r s . Touching behav io r s took v a r i o u s forms, f o r example, backrubs , h a n d - h o l d i n g , and hugs. The n u r s e s ' d e s c r i p t i o n s of t o u c h i n g i m p l i e d t h a t they i s o l a t e d t o u c h i n g as a t h e r a p e u t i c n u r s i n g i n t e r v e n t i o n and regarded the t o u c h i n g a s s o c i a t e d wi th p a t i e n t s ' p h y s i c a l care as d i f f e r e n t . Touching behav io r s a s s o c i a t e d with p h y s i c a l care were not i d e n t i f i e d as enhancing c o n t a c t or communication wi th the p a t i e n t or as i n c r e a s i n g emot ional comfort or c o o p e r a t i o n . The nurses p e r c e i v e d t h a t , i n c o n j u n c t i o n with t o u c h i n g and eye c o n t a c t , nonverbal b e h a v i o r s , such as s m i l i n g , l i s t e n i n g , w a i t i n g , and g e s t u r i n g , communicated warmth and reas surance and s i g n i f i e d t h a t they were focused on the p a t i e n t . These b e h a v i o r s e s t a b l i s h e d n u r s e - p a t i e n t c o n t a c t and e l i c i t e d p a t i e n t c o o p e r a t i o n . The nurses u s e d , g e s t u r e s when they and the p a t i e n t l a c k e d a common language , when p a t i e n t s were unable to communicate v e r b a l l y , and when they p e r c e i v e d the p a t i e n t was unable to unders tand verba l s t a tement s . Ges tures were used p r i m a r i l y to communicate i n s t r u c t i o n s , e x p l a n a t i o n s , or que s t ions r a t h e r than fo r s o c i a l purpose s . Tone of v o i c e was i d e n t i f i e d by the nurses as be ing an important a spect of n u r s e - p a t i e n t communicat ion . The n o t i o n 68 t h a t tone of v o i c e was more important than the content of the c o n v e r s a t i o n was e v i d e n t in most of the nur se s ' s t a tements . " S o o t h i n g , " " q u i e t , " and " c a l m " v o i c e s were d e s c r i b e d as most e f f e c t i v e i n c o m f o r t i n g p a t i e n t s e s p e c i a l l y i f they were a g i t a t e d . " C l e a r , " " s l o w , " and " a u t h o r i t a t i v e " v o i c e s were e f f e c t i v e i n e s t a b l i s h i n g p a t i e n t c o n t a c t . The nurses d e s c r i b e d t h e i r verba l communication as being p r i m a r i l y task o r i e n t e d and of an e x p l a n a t o r y n a t u r e . They p e r c e i v e d t h a t t h e i r communication was task o r i e n t e d because most of t h e i r n u r s e - p a t i e n t i n t e r a c t i o n s were focused on tasks such as f e e d i n g , t r a n s f e r r i n g , and d i s p e n s i n g m e d i c a t i o n s . The nurses i d e n t i f i e d the need to e x p l a i n t h e i r a c t i o n s p r i o r to implementing them i n order to decrease p a t i e n t s ' f ea r and a n x i e t y but not n e c e s s a r i l y to i n c r e a s e t h e i r u n d e r s t a n d i n g . In response to these e x p l a n a t i o n s , the nurses d e s c r i b e d p a t i e n t s as " l e s s anx ious " and more " c o o p e r a t i v e . " The nurses a l so d e s c r i b e d c o n v e r s a t i o n s which focused on p a t i e n t - r e l a t e d t o p i c s r a t h e r than n u r s i n g t a s k s . These c o n v e r s a t i o n s c e n t e r e d on p a t i e n t s ' p re sent s i t u a t i o n and past l i f e and were d e s c r i b e d as having a dual purpose : to p r o v i d e i n f o r m a t i o n f o r the nurse and enjoyment fo r the p a t i e n t . Some nurses encouraged p a t i e n t s to v e r b a l i z e about t h e i r needs or problems w h i l e o ther nurses s t a t e d they i n v o l v e d the p a t i e n t i n " s o c i a l c h i t - c h a t " to norma l i ze 69 t h e i r t a s k - o r i e n t e d i n t e r a c t i o n s . C o n v e r s a t i o n s f o c u s i n g on t o p i c s f a m i l i a r to p a t i e n t s were i d e n t i f i e d as l i k e l y to e l i c i t p a t i e n t r e sponse s , e i t h e r verba l or n o n v e r b a l . The nurses i n d i c a t e d t h a t p a t i e n t s were more r e s p o n s i v e to and f e l t more p o s i t i v e about i n t e r a c t i o n s tha t were focused on them r a t h e r than on a t a s k . The nurses d e s c r i b e d r e a l i t y o r i e n t a t i o n (RO) as an i n a p p r o p r i a t e approach to i n t e r a c t i n g because i t focused on t e l l i n g p a t i e n t s t h a t t h e i r concept of r e a l i t y was i n c o r r e c t and removed p a t i e n t s ' o p p o r t u n i t y to choose the r e a l i t y tha t was most comfor tab le f o r them. The nurses found t h a t RO, when f o r c e d upon u n r e c e p t i v e p a t i e n t s , p r e d i c t a b l y r e s u l t e d i n i n c r e a s e d anger and aggre s s ion or w i t h d r a w a l . The nurses p e r c e i v e d c o n f u s i o n as something t h a t was p o s i t i v e f o r p a t i e n t s because i t made them fee l good to be l i v i n g i n a r e a l i t y t h a t was happ ier and more rewarding than t h e i r pre sent r e a l i t y . They s t a t e d t h a t d i s t u r b i n g t h i s r e a l i t y was "ve ry d i s t r e s s i n g " f o r p a t i e n t s because t h e i r p e r c e p t i o n s of r e a l i t y were " something they depend[ed] o n . " Some nurses no longer c o n s i d e r e d RO a v i a b l e approach , w h i l e o ther s used i t s e l e c t i v e l y when p a t i e n t s reques ted o r i e n t i n g i n f o r m a t i o n or e x h i b i t e d a g i t a t i o n w i t h i n a past time frame. When the nurses p r o v i d e d RO, the ex tent of r e o r i e n t i n g was determined by the degree of comfort and acceptance e x h i b i t e d by the p a t i e n t . 70 Some nurses i n d i c a t e d t h a t p a t i e n t s ' l e v e l of c o n f u s i o n i n f l u e n c e d n u r s e - p a t i e n t communication whi le o ther nurses c l e a r l y i n d i c a t e d t h a t i t was not a f a c t o r i n f l u e n c i n g t h e i r communicat ion . Those nurses who i n d i c a t e d t h a t p a t i e n t s ' l e v e l of c o n f u s i o n was i n f l u e n t i a l , r e p o r t e d t h a t i t a l t e r e d the f requency of t h e i r verba l i n t e r a c t i o n and t h e i r e x p e c t a t i o n s r e g a r d i n g p a t i e n t s ' r e sponse . The nurses were l e s s i n c l i n e d to communicate v e r b a l l y or to spend time t a l k i n g with p a t i e n t s d e s c r i b e d as more s e v e r e l y c o n f u s e d . These nurses i n d i c a t e d t h a t they were more i n c l i n e d to communicate v e r b a l l y , to have p h y s i c a l c o n t a c t , and to spend time wi th p a t i e n t s i d e n t i f i e d as l e s s c o n f u s e d . "I f ee l more p o s i t i v e t h a t by t a l k i n g to [ the l e s s confused] p a t i e n t s or e x p l a i n i n g t h i n g s you are g e t t i n g through whereas wi th the ones t h a t are t o t a l l y confused you are not so sure you are r e a c h i n g them. " The nurses f r e q u e n t l y e x p l a i n e d tha t the p a t i e n t s ' responses were u n i q u e , were o f ten d i f f i c u l t to d e c i p h e r , and sometimes f l u c t u a t e d over time i n response to c o n s i s t e n t nurse b e h a v i o r . T h i s made i t d i f f i c u l t to c o n s i s t e n t l y and r e l i a b l y assess the e f f e c t i v e n e s s of t h e i r a c t i o n s . Based on p a t i e n t s ' r e sponse s , p a r t i c u l a r l y t h e i r nonverbal r e sponse s , the nurses i n d i c a t e d they were more comfor tab le a s s e s s i n g the degree of p a t i e n t s ' acceptance of t h e i r a c t i o n s r a t h e r than the degree of p a t i e n t s ' u n d e r s t a n d i n g . The nurses s t a t e d t h a t i t was more d i f f i c u l t to determine 71 c o n c l u s i v e l y the ex tent of p a t i e n t s ' under s t and ing when they were s e v e r e l y c o n f u s e d . "A smi le i s p r e t t y b a s i c and t h a t d o e s n ' t n e c e s s a r i l y mean t h a t someone has unders tood s o m e t h i n g . " P a t i e n t s d e s c r i b e d as l e s s confused were a l s o d e s c r i b e d as more l i k e l y to i n d i c a t e v e r b a l l y t h a t they u n d e r s t o o d . The e f f e c t i v e n e s s of nonverbal communication b e h a v i o r , such as t o u c h i n g , g e s t u r i n g , and eye c o n t a c t , was d e s c r i b e d by the nurses as v a r y i n g a c c o r d i n g to p a t i e n t s ' l e v e l of c o n f u s i o n . The use of touch and eye c o n t a c t was e f f e c t i v e wi th p a t i e n t s i d e n t i f i e d as s e v e r e l y confused w h i l e g e s t u r i n g was e f f e c t i v e with those p a t i e n t s d e s c r i b e d as l e s s c o n f u s e d . The nurses c l e a r l y i d e n t i f i e d the importance of and the problems i n h e r e n t i n meaningful communication wi th p a t i e n t s who were i n s t i t u t i o n a l i z e d and i d e n t i f i e d as c o n f u s e d . "I t h i n k a l o t of the e l d e r l y are cheated out of a n y t h i n g but s u p e r f i c i a l t a l k . A l o t of them have probab ly never had a rea l c o n v e r s a t i o n f o r as long as they have been i n extended c a r e . " Nurses ' responses to nega t ive p a t i e n t b e h a v i o r . In response to those p a t i e n t behav io r s they i d e n t i f i e d as n e g a t i v e l y i n f l u e n c i n g the i n t e r a c t i o n , the nurses d i d one of the f o l l o w i n g : (a) l e f t the s i t u a t i o n and r e t u r n e d l a t e r to c o n t i n u e the i n t e r a c t i o n or asked another nurse to r e p l a c e them, (b) c o n t i n u e d the i n t e r a c t i o n r e g a r d l e s s of 72 p a t i e n t response u n t i l the purpose of the i n t e r a c t i o n had been comple ted , (c) m o d i f i e d t h e i r b e h a v i o r as f r e q u e n t l y as was necessary u n t i l the p a t i e n t responded p o s i t i v e l y , or (d) removed the p a t i e n t from the s i t u a t i o n . The predominant b e h a v i o r i d e n t i f i e d by 9 n u r s e s , i n response to p a t i e n t s ' d i s r u p t i v e or abus ive a c t i o n s , was to l eave the s i t u a t i o n . Some nurses l e f t because they d i d not f ee l comfor tab le " f o r c i n g [ t h e i r ] w i l l " on the p a t i e n t w h i l e o ther s l e f t i n an attempt to reduce t h e i r " f r u s t r a t i o n . " Most nurses l e a v i n g the s i t u a t i o n i n d i c a t e d t h a t they resumed the i n t e r a c t i o n l a t e r u s ing a s i m i l a r or d i f f e r e n t approach to e l i c i t p a t i e n t c o o p e r a t i o n . I t i s i n t e r e s t i n g to note t h a t the same nurse would l eave some i n t e r a c t i o n s but would remain and c o n t i n u e wi th o t h e r s . There was no s p e c i f i e d c r i t e r i o n to determine when the nurses l e f t or remained . I t seemed to depend on a combinat ion of f a c t o r s , such as the ex tent of p a t i e n t s ' r e s i s t a n c e , the amount of a v a i l a b l e time to r e t u r n , and the n u r s e s ' f e e l i n g s i n response to p a t i e n t s ' b e h a v i o r s . Some nurses c o n t i n u e d t h e i r i n t e r a c t i o n s but implemented an a l t e r n a t e approach . They i n d i c a t e d t h a t , by c o n t i n u i n g the i n t e r a c t i o n and m o d i f y i n g t h e i r approach , they were o f ten able to e l i c i t p a t i e n t c o o p e r a t i o n . The nurses d e s c r i b e d v a r i o u s approaches such as d i s t r a c t i o n t e c h n i q u e s . Many of the nurses noted tha t a s l o w e r , more p e r s o n a l i z e d approach was f r e q u e n t l y s u c c e s s f u l i n e l i c i t i n g 73 c o o p e r a t i v e p a t i e n t r e sponse s . They r e p o r t e d tha t as t h e i r knowledge of p a t i e n t s i n c r e a s e d , t h e i r r e p e r t o i r e of e f f e c t i v e , a l t e r n a t e responses a l s o i n c r e a s e d . When the nurses d i d not know p a t i e n t s , they r e p o r t e d us ing a t r i a l - a n d - e r r o r approach to determine v a r i a t i o n s t h a t would e l i c i t p o s i t i v e p a t i e n t r e sponse s . M o d i f y i n g i n t e r a c t i o n s to i n c o r p o r a t e p a t i e n t s ' needs, a l though i d e n t i f i e d as more s a t i s f y i n g , was a l s o i d e n t i f i e d as c r e a t i n g a c o n f l i c t f o r the n u r s e s , g iven time and s t a f f c o n s t r a i n t s . " [ I ] t r y and deal wi th t h i n g s on an i n d i v i d u a l b a s i s , but i f I am doing something e l s e I d o n ' t always have time to stop and check t h i n g s out the way I would l i k e t o . " Some nurses p e r c e i v e d t h a t they d i d not adequate ly meet p a t i e n t s ' needs f o r m o b i l i t y , a f f e c t i o n , s e c u r i t y , and c o n t r o l through t h e i r i n t e r a c t i o n s . Other n u r s e s , a l though p e r c e i v i n g t h a t they were unable to meet p a t i e n t s ' needs to the degree t h a t they would l i k e , i n d i c a t e d t h a t they m o d i f i e d t h e i r care to the g r e a t e s t ex tent p o s s i b l e to i n c o r p o r a t e the i n d i v i d u a l needs of p a t i e n t s . O c c a s i o n a l l y , the nurses c o n t i n u e d the i n t e r a c t i o n d e s p i t e p a t i e n t r e s i s t a n c e , i n d i c a t i n g t h a t l e a v i n g and r e t u r n i n g l a t e r was not a v i a b l e o p t i o n fo r them. The nurses d e s c r i b e d these i n t e r a c t i o n s as mainly t a s k - r e l a t e d , the purpose be ing e i t h e r to change s o i l e d or wet c l o t h i n g or to implement a t r e a t m e n t . They i d e n t i f i e d being " c l e a n and d r y " as a p r e f e r a b l e s i t u a t i o n . The nurses p e r c e i v e d 74 p a t i e n t s as not under s t and ing the i n t e n t of t h e i r a c t i o n s when they r e s i s t e d the nur se s ' attempts to change or t r e a t them. When the nurses were unable to e l i c i t p a t i e n t c o o p e r a t i o n through e x p l a n a t i o n , they f e l t compel led to c o n t i n u e with the i n t e r a c t i o n d e s p i t e p a t i e n t r e s i s t a n c e . The nurses d i d not p e r c e i v e p a t i e n t s ' b e h a v i o r o c c u r r i n g as the r e s u l t of a c o n s c i o u s d e c i s i o n to remain unchanged or u n t r e a t e d . Instead they f e l t t h a t p a t i e n t s d i d not unders tand the meaning of the n u r s e s ' a c t i o n s and t h e r e f o r e p e r c e i v e d them as a g g r e s s i v e . A l l of the nurses i n d i c a t e d t h a t these i n t e r a c t i o n s presented a c o n f l i c t between the e x p e c t a t i o n s of t h e i r job and t h e i r a b i l i t y to respond to p a t i e n t s ' wishes or r e q u e s t s . I m p l i c i t w i t h i n t h e i r s tatements about p a t i e n t s ' r eques t s was the idea t h a t p a t i e n t s should have some c h o i c e s about t h e i r care and t h a t these c h o i c e s should be r e s p e c t e d by the n u r s e . Some nurses i n d i c a t e d that they removed p a t i e n t s from s i t u a t i o n s where t h e i r " a g g r e s s i v e , " " l o u d , " or " a g i t a t e d " a c t i o n s were d i s t u r b i n g to o t h e r s . These p a t i e n t s were then i s o l a t e d from the r e s t of the ward. The nurses d e s c r i b e d t h i s as e f f e c t i v e i n r e d u c i n g the no i se and d i s r u p t i v e b e h a v i o r f o r the m a j o r i t y of people on the ward but as i n e f f e c t i v e i n changing the p a t i e n t s ' d i s r u p t i v e b e h a v i o r . I t seems e v i d e n t from the n u r s e s ' accounts tha t p a t i e n t s d e s c r i b e d as " n o i s y " and " l o u d " r e c e i v e d more n u r s i n g time 75 than o ther p a t i e n t s . T h i s t i m e , however, was focused on d e c r e a s i n g the no i se l e v e l and/or removing the p a t i e n t from the s i t u a t i o n ' . P a t i e n t behav ior d e s c r i b e d as unrespons ive posed a d i f f e r e n t problem for some n u r s e s . The l a ck of p a t i e n t response n e c e s s i t a t e d u n i l a t e r a l d e c i s i o n making by the nurses d u r i n g the i n t e r a c t i o n . They used v a r i o u s c r i t e r i a to a s s i s t them i n d e c i d i n g on the most a p p r o p r i a t e nurse b e h a v i o r s . The nurses s t a t e d tha t they used "common sense" and the g u i d e l i n e s . f o r care developed by t h e i r nurse managers. The nurses a l s o observed p a t i e n t s ' behav io r s to assess fo r changes i n these behav ior s or to determine i f they o c c u r r e d i n r e l a t i o n to e x t e r n a l f a c t o r s . One nurse i n d i c a t e d t h a t a t r u s t i n g , p o s i t i v e approach to p a t i e n t s ' r e s i s t i v e behav io r s i n c o r p o r a t e d the e x p e c t a t i o n t h a t the p a t i e n t would c o o p e r a t e . She b e l i e v e d t h a t nurses who expected p a t i e n t s to be u n c o o p e r a t i v e tended to ac t i n ways t h a t removed the p a t i e n t s ' c h o i c e to c o o p e r a t e . She i n d i c a t e d t h a t t h i s b e h a v i o r was r e s p o n s i b l e , to some e x t e n t , f o r p r e c i p i t a t i n g p a t i e n t s ' r e s i s t a n t b e h a v i o r . Nurses ' behav ior s tha t humanize the i n t e r a c t i o n . The nurses i d e n t i f i e d behav io r s which i n f l u e n c e d the degree to which the i n t e r a c t i o n focused on i n d i v i d u a l s as people r a t h e r than as p a t i e n t s . These nurse behav io r s i m p l i e d v a r i o u s degrees of under s t and ing of the p a t i e n t s ' s i t u a t i o n 7 6 as i n s t i t u t i o n a l i z e d i n d i v i d u a l s e x p e r i e n c i n g some i n a b i l i t y to communicate e a s i l y and to ac t i n d e p e n d e n t l y . Most nurses c l e a r l y i n d i c a t e d t h a t they i n d i v i d u a l i z e d the i n t e r a c t i o n whenever p o s s i b l e . They i n c o r p o r a t e d p a t i e n t s ' p r e f e r e n c e s and needs and attempted to m a i n t a i n p a t i e n t s ' p r e v i o u s l i f e i n t e r e s t s . For example, they arranged b a t h i n g schedules and r i s i n g times a c c o r d i n g to p a t i e n t s ' p r e f e r e n c e s . The nurses emphasized the importance of be ing adaptable i n o rder to accommodate p a t i e n t s ' p r e f e r e n c e s . They a l s o i n d i v i d u a l i z e d t h e i r i n t e r a c t i o n s by r e c o g n i z i n g t h a t c e r t a i n t h i n g s , such as the use of mus i c , humor, or touch were not a p p r o p r i a t e f o r a l l p a t i e n t s . In order to m a i n t a i n p r e v i o u s l i f e i n t e r e s t s as much as p o s s i b l e the nurses encouraged p a t i e n t s to p a r t i c i p a t e i n ward a c t i v i t i e s a s s o c i a t e d wi th t h e i r p r e v i o u s i n t e r e s t s or o c c u p a t i o n . The nurses d e s c r i b e d a more p e r s o n - o r i e n t e d focus r e f l e c t i n g d i g n i t y , warmth, and honesty as be ing important when working with e l d e r l y p a t i e n t s i d e n t i f i e d as c o n f u s e d . They i l l u s t r a t e d d i g n i f i e d i n t e r a c t i o n s as i n t e r a c t i o n s tha t were t o t a l l y focused on the p a t i e n t , were a p p r o p r i a t e l y paced , and were a d u l t o r i e n t e d . Genuine p a t i e n t a c c e p t a n c e , w i thout judgment, was seen by the nurses as an impor tant f o u n d a t i o n fo r m a i n t a i n i n g a t r u s t i n g r e l a t i o n s h i p . The nurses i n d i c a t e d t h a t knowing and a c t i n g i n accordance with p a t i e n t s ' p e r c e p t i o n s of r e a l i t y was another p r e r e q u i s i t e of 77 a t r u s t i n g r e l a t i o n s h i p . They s t a t e d t h a t i t was important to respond to p a t i e n t s based on t h e i r r e a l i t y and not on the n u r s e s ' p e r c e p t i o n s of r e a l i t y . The f o l l o w i n g statement c l e a r l y i l l u s t r a t e s the empathet ic approach advocated by many of the nur se s : As soon as she sees a person . . . she w i l l say "Help me, he lp me, I am s i c k " . . . . I used to say "No, you are not s i c k , you are okay" because she was b e t t e r than most of our p a t i e n t s but i t d i d n ' t do any good. Yes terday I s t a r t e d s ay ing "I know you are s i c k , I know" and she seemed to be a lmost r e l i e v e d t h a t somebody e l s e b e l i e v e d h e r . The use of humor and a c h e e r f u l , p o s i t i v e approach were i d e n t i f i e d as nurse behav io r s e f f e c t i v e i n c r e a t i n g a happ ie r atmosphere and i n n o r m a l i z 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 . P a t i e n t s were i d e n t i f i e d as r e f l e c t i n g the n u r s e s ' c h e e r f u l , s m i l i n g demeanor. P a t i e n t s a l so responded to more o v e r t forms of humor and were d e s c r i b e d as re sponding to l a u g h t e r r e g a r d l e s s of t h e i r under s t and ing of the j o k e . The nurses i d e n t i f i e d l a b e l l i n g as a nurse behav ior which was easy to do and which o c c u r r e d f r e q u e n t l y but which p r e c l u d e d a p e r s o n - o r i e n t e d approach to p a t i e n t s . L a b e l l i n g a l t e r e d the n u r s e s ' e x p e c t a t i o n s of p a t i e n t s , r e s u l t i n g i n e x p e c t a t i o n s t h a t the p a t i e n t would always be d i s r u p t i v e , 78 uncommunicat ive , or i n a p p r o p r i a t e . One nurse d e s c r i b e d the impact of l a b e l l i n g as f o l l o w s : People have s o r t of c a t e g o r i z e d them i n t h i s l i t t l e box and almost put the l i d on and s a i d " W e l l , t h i s l ady i s t h i s way" but they s t i l l have t h e i r l u c i d moments. They can s t i l l be a p p r o p r i a t e wi th t h e i r l o v e d ones even though they have a l o t of b r a i n damage and may not be a p p r o p r i a t e i n a l o t of i n s t a n c e s . . . . T h e i r words come out r i g h t even though , most of the t i m e , they are what most people would l a b e l as c o n f u s e d . The nurses i n d i c a t e d t h a t p h y s i c a l c a r e , a l though i t was i m p o r t a n t , tended to r e i n f o r c e p a t i e n t s ' dependence. They i m p l i e d t h a t t a s k - o r i e n t e d i n t e r a c t i o n s were more t e c h n i c a l than human and t h e r e f o r e were not c o n s i d e r e d as en joyab le f o r p a t i e n t s or n u r s e s . Al though the nurses p e r c e i v e d t h a t p h y s i c a l care was e s s e n t i a l , they c o n s i d e r e d tha t meeting p a t i e n t s ' s o c i a l and emot ional needs had a h igh p r i o r i t y fo r both nurses and p a t i e n t s . "Even though I know t h e i r p h y s i c a l needs are r e q u i r e d to be looked a f t e r and i f they w e r e n ' t l ooked a f t e r they would be most u n c o m f o r t a b l e , i t i s more s u c c e s s f u l and b e t t e r f o r the p a t i e n t to do n i c e t h i n g s and to [ l e t them] know t h a t someone c a r e s . " Al though some nurses were unable to d e s c r i b e s p e c i f i c responses t h a t would c h a r a c t e r i z e a p a t i e n t whose needs had 79 been s a t i s f i e d , o ther nurses who were able d e s c r i b e d these p a t i e n t s as " t r u s t i n g , " " r e s p o n s i v e , " and " h a p p y . " Nurses ' behav io r s t h a t i n f l u e n c e p a t i e n t c o n t r o l . The nurses d e s c r i b e d a v a r i e t y of behav io r s which were u n i f i e d by a common e l e m e n t - - t h e i r i n f l u e n c e on p a t i e n t s ' d e c i s i o n making and u l t i m a t e l y on p a t i e n t s ' c o n t r o l and independence . The nurses p r o v i d e d p a t i e n t s with o p p o r t u n i t i e s to determine how they would behave w i t h i n c e r t a i n s i t u a t i o n s by encourag ing them to be as p h y s i c a l l y independent as p o s s i b l e , a sk ing them for i n p u t i n t o d e c i s i o n s c o n c e r n i n g t h e i r c a r e , and comply ing wi th t h e i r r e q u e s t s . The nurses m o d i f i e d the p a t i e n t s ' o p p o r t u n i t y to e x e r c i s e c o n t r o l i n accordance with p a t i e n t s ' p h y s i c a l and c o g n i t i v e a b i l i t i e s . They i n d i c a t e d t h a t , i n response to t h i s i n c r e a s e d c o n t r o l , p a t i e n t b e h a v i o r was p o s i t i v e and more c o o p e r a t i v e . Most nurses p r o v i d e d p a t i e n t s with e x p l a n a t i o n s i n an attempt to e l i c i t t h e i r c o o p e r a t i o n and, l e s s o f t e n , to i n c r e a s e t h e i r u n d e r s t a n d i n g . They p e r c e i v e d t h a t p r o v i d i n g i n f o r m a t i o n , t h a t i s , t e l l i n g the p a t i e n t what they were going to do and what they expected the p a t i e n t to do, i n c r e a s e d the p o s s i b i l i t y tha t the p a t i e n t would dec ide to c o o p e r a t e . Some nurses i n d i c a t e d t h a t p a t i e n t s were l e s s anxious when nurses d e s c r i b e d t h e i r a c t i o n s p r i o r to implementing them. 80 E x t e r n a l F a c t o r s I n f l u e n c i n g the I n t e r a c t i o n " In order to unders tand the a c t i o n of people i t i s necessary to i d e n t i f y t h e i r world of o b j e c t s " (Blumer, 1969, p. 11) . The meaning of o b j e c t s a r i s e s out of the process of d e f i n i t i o n and i n t e r p r e t a t i o n t a k i n g p l ace d u r i n g i n t e r a c t i o n (Blumer , 1969). I t i s impor tant to unders tand the nur se s ' p e r c e p t i o n s of t h e i r w o r l d , tha t i s , which o b j e c t s they i d e n t i f y as important and the meaning they a t t ach to the i d e n t i f i e d o b j e c t s , as t h e i r p e r c e p t i o n of these o b j e c t s i n f l u e n c e s t h e i r a c t i o n s w i t h i n the i n t e r a c t i o n . T h i s s e c t i o n present s the nur se s ' d e s c r i p t i o n s of f a c t o r s ( o b j e c t s ) , o c c u r r i n g o u t s i d e of t h e i r i n t e r a c t i o n s with p a t i e n t s , which they i d e n t i f i e d as i n f l u e n c i n g both nurse and p a t i e n t b e h a v i o r s w i t h i n the i n t e r a c t i o n . The term f a c t o r or e x t e r n a l f a c t o r w i l l be used when r e f e r r i n g to these i d e n t i f i e d o b j e c t s . F o l l o w i n g repeated examinat ion of the d a t a , the r e s e a r c h e r developed 3 c a t e g o r i e s of f a c t o r s . These c a t e g o r i e s are r e l a t e d to the source of the f a c t o r . They a r e : (a) personal f a c t o r s , (b) i n t e r p e r s o n a l f a c t o r s , and (c) impersonal f a c t o r s . Personal f a c t o r s are d e f i n e d as those f a c t o r s t h a t o r i g i n a t e w i t h i n the i n d i v i d u a l nurse or p a t i e n t and do not occur as a r e s u l t of the i n t e r a c t i o n or f a c t o r s t h a t occur due to events w i t h i n the i n d i v i d u a l ' s per sona l l i f e . The ca tegory of i n t e r p e r s o n a l f a c t o r s i n c l u d e s a l l r e l e v a n t i n t e r a c t i o n s of 81 the nurses and p a t i e n t s e x c l u d i n g i n t e r a c t i o n s o c c u r r i n g between them. T h e r e f o r e , t h i s ca tegory i n c l u d e s those i n t e r a c t i o n s , d e s c r i b e d by the nurses i n the s t u d y , which o c c u r r e d between o ther nurses and the p a t i e n t . The t h i r d c a t e g o r y , named impersonal f a c t o r s , r e f e r s to those f a c t o r s , e x t e r n a l to the n u r s e - p a t i e n t i n t e r a c t i o n , t h a t are not human o b j e c t s , such as the p h y s i c a l env i ronment . Personal F a c t o r s T h i s s e c t i o n begins wi th the p r e s e n t a t i o n of personal f a c t o r s r e l e v a n t to the study p o p u l a t i o n . The f a c t o r s i d e n t i f i e d by the nurses a r e : (a) n u r s e s ' b e l i e f s , (b) p a t i e n t s ' c u l t u r e , (c) the nur se s ' f a t i g u e and persona l prob lems , (d) nur se s ' i d e n t i f i c a t i o n with the aging p r o c e s s , (e) p a t i e n t s ' p h y s i c a l / p h y s i o l o g i c a l problems , ( f ) c a r e g i v e r s ' n a t i o n a l i t y , and (g) c a r e g i v e r s ' gender . 1 The frequency of occur rence and an i n d i c a t o r of each f a c t o r are presented i n Appendix E . The nurses d e s c r i b e d t h e i r b e l i e f s about p a t i e n t s , 3 c o n f u s i o n , c a r e g i v i n g , and c a r e g i v e r s . From these d e s c r i p t i o n s , i t seems e v i d e n t tha t t h e i r b e l i e f s i n f l u e n c e d the care t h a t they p r o v i d e d d u r i n g t h e i r i n t e r a c t i o n s wi th p a t i e n t s . The nur se s ' b e l i e f s about p a t i e n t s encompassed the ideas t h a t they were human, had f e e l i n g s , and deserved worthwhi le and purpose fu l l i v e s . They expressed the b e l i e f tha t p a t i e n t s ' p e r s o n a l i t y and past h i s t o r y c o n t r i b u t e d to 82 t h e i r i n d i v i d u a l i t y and i n f l u e n c e d t h e i r b e h a v i o r . Some nurses a l s o s t a t ed t h a t a l l p a t i e n t s , r e g a r d l e s s of the s e v e r i t y of t h e i r c o n f u s i o n , c o u l d respond i n some way to the i n t e r a c t i o n . These nurses i n d i c a t e d tha t p a t i e n t s ' comprehension exceeded t h a t p e r c e i v e d by the nurses and that p a t i e n t s ' d i f f i c u l t y l ay i n communicating t h i s idea to c a r e g i v e r s . They expressed the b e l i e f tha t p a t i e n t s , a l though not able to i d e n t i f y a s p e c i f i c nurse by name, c o u l d determine i f she was a c a r i n g p e r s o n . The nurses a l so expressed the b e l i e f t h a t a l l p a t i e n t b e h a v i o r had meaning and o c c u r r e d f o r a r ea son . V a r i o u s b e l i e f s about the concept of c o n f u s i o n were d e s c r i b e d by the n u r s e s . They r e l a t e d behav io r s i d e n t i f i e d as c o n f u s i o n to exper i ence s which had o c c u r r e d e a r l i e r i n p a t i e n t s ' l i v e s . Some nurses i n t e r p r e t e d these behav io r s as p o s i t i v e i n t h a t they enabled p a t i e n t s to m e n t a l l y r e l i v e t h e i r p r e v i o u s l i f e exper i ence s thereby p r o t e c t i n g themselves from t h e i r p re sent r e a l i t y . Two nurses b e l i e v e d t h a t c o n f u s i o n was more a p t l y d e s c r i b e d as the " i n a b i l i t y to communi c a t e . " Based on t h e i r b e l i e f t h a t the extended care u n i t was the p a t i e n t s ' home, the nurses i n d i c a t e d tha t c a r e g i v i n g should be i n d i v i d u a l i z e d , f a c i l i t a t e reasonable p a t i e n t c o n t r o l , focus on q u a l i t y of l i f e , and r e f l e c t empathy, t r u s t , k i n d n e s s , and d i g n i t y . They a l s o expressed the b e l i e f t h a t g e r i a t r i c n u r s i n g n e c e s s i t a t e d a g r e a t e r 83 emotional and s o c i a l commitment to p a t i e n t s than o ther types of n u r s i n g . The n u r s e s , d e s c r i b i n g t h e i r b e l i e f s about c a r e g i v e r s , focused on the q u a l i t i e s t h a t they deemed e s s e n t i a l , such as p a t i e n c e , empathy, warmth, and compass ion . Two nurses s t a t e d tha t these q u a l i t i e s were inborn r a t h e r than a c q u i r e d . The nurses d e s c r i b e d e f f e c t i v e c a r e g i v e r s as those who were " c r e a t i v e , " "people o r i e n t e d , " " c a r i n g , " and " a b l e to cope wi th s t r e s s . " They b e l i e v e d tha t c a r e g i v e r s should "know the b a s i c s " but not n e c e s s a r i l y possess a d d i t i o n a l s k i l l s and knowledge about g e r i a t r i c n u r s i n g and t h a t they should have a c e r t a i n amount of " l i f e exper i e n c e . " Aspect s of p a t i e n t s ' c u l t u r e , such as t h e i r i n a b i l i t y to communicate i n E n g l i s h and the presence of customs unknown to the n u r s e s , were i d e n t i f i e d as personal f a c t o r s tha t r e s u l t e d i n the n u r s e s ' i n a b i l i t y to unders tand the s i g n i f i c a n c e of p a t i e n t a c t i o n s , to o b t a i n i n f o r m a t i o n r e g a r d i n g p a t i e n t s ' needs, and to a l l a y p a t i e n t s ' s u f f e r i n g . The nurses r e p o r t e d t h a t f e e l i n g f a t i g u e d and l a c k i n g energy or e x p e r i e n c i n g personal problems decreased t h e i r t o l e r a n c e and a l t e r e d t h e i r mood or "mental o u t l o o k " toward p a t i e n t s i d e n t i f i e d as confused . The nurses f r e q u e n t l y d e s c r i b e d t h e i r f a t i g u e as o c c u r r i n g due to j o b - r e l a t e d causes . Some nurses expressed concern about t h e i r i n c r e a s i n g i d e n t i f i c a t i o n with the aging process and consequent ly with 84 the p a t i e n t s i n the extended care u n i t . T h i s i d e n t i f i c a t i o n i n t e r f e r e d wi th the nur se s ' a b i l i t y to " s h a r e " themselves wi th p a t i e n t s . A l l nurses e x p e r i e n c i n g these f e e l i n g s were c l o s e to r e t i r e m e n t and one had r e c e n t l y recovered from a s e r i o u s i l l n e s s . P a t i e n t s ' hunger , p a i n , d e h y d r a t i o n , and impa i red bowel f u n c t i o n were i d e n t i f i e d as personal f a c t o r s i n f l u e n c i n g the p a t i e n t s ' b e h a v i o r . These f a c t o r s were d e s c r i b e d as p r e c i p i t a t i n g some change i n the p a t i e n t s ' b a s e l i n e behav ior s r e s u l t i n g i n wake fu lnes s , w i t h d r a w a l , r e s t l e s s n e s s , and decreased r e c e p t i v e n e s s to nurse b e h a v i o r s . P a t i e n t s ' mood, d e s c r i b e d as f l u c t u a t i n g from "good days" to "bad d a y s , " was a l so i d e n t i f i e d as i n f l u e n c i n g t h e i r b e h a v i o r . C a r e g i v e r s ' gender was d e s c r i b e d as i n f l u e n c i n g the behav ior of some female p a t i e n t s . The nurses i d e n t i f i e d the presence of male c a r e g i v e r s as prompting a g g r e s s i v e behav ior i n these p a t i e n t s . The nurses a l so i n d i c a t e d t h a t some p a t i e n t s responded a g g r e s s i v e l y to non-Caucas ian c a r e g i v e r s . I n t e r p e r s o n a l F a c t o r s The ca tegory of i n t e r p e r s o n a l f a c t o r s i n c l u d e s a l l the r e l e v a n t i n t e r a c t i o n s of the nurses and the p a t i e n t s e x c l u d i n g i n t e r a c t i o n s o c c u r r i n g between them. The i n t e r p e r s o n a l f a c t o r s i d e n t i f i e d by the nurses are (a) n u r s e s ' i n t e r a c t i o n s wi th m a n a g e r s / a d m i n i s t r a t o r s , (b) nur se s ' i n t e r a c t i o n s with o ther c a r e g i v e r s , (c) nur se s ' 85 i n t e r a c t i o n s wi th p a t i e n t s ' f a m i l y / f r i e n d s , (d) nur se s ' r e l a t i o n s h i p with d o c t o r s , (e) nur se s ' r e l a t i o n s h i p with n o n g e r i a t r i c nurses and the p u b l i c , ( f ) p a t i e n t s ' i n t e r a c t i o n s with f a m i l y / f r i e n d s , (g) p a t i e n t s ' i n t e r a c t i o n s wi th o ther c a r e g i v e r s , (h) p a t i e n t s ' i n t e r a c t i o n s with o ther p a t i e n t s , and ( i ) p a t i e n t s ' p a r t i c i p a t i o n i n ward a c t i v i t i e s . The frequency of occur rence and an i n d i c a t o r of each f a c t o r are shown i n Appendix F . Al though the nurses were s p l i t i n t h e i r p e r c e p t i o n s of nurse managers (head nurses and s u p e r v i s o r s ) and a d m i n i s t r a t o r s , t h e i r i n t e r a c t i o n s wi th these people c l e a r l y had an impact on the nur se s ' s a t i s f a c t i o n and enthus i a sm. The nurses who p e r c e i v e d t h e i r managers and a d m i n i s t r a t o r s as a p o s i t i v e i n f l u e n c e c h a r a c t e r i z e d them as s u p p o r t i v e , openly communicat ive , and as e f f e c t i v e r o l e models , w h i l e the nurses i n d i c a t i n g they were a nega t ive i n f l u e n c e , d e s c r i b e d them as unaware and u n i n t e r e s t e d i n events on the ward. Those nurses d e s c r i b i n g a nega t ive r e l a t i o n s h i p a l s o s t a t e d they were seldom asked fo r i n p u t r e g a r d i n g ward d e c i s i o n s or g iven p o s i t i v e feedback about t h e i r work. T h e i r i n t e r a c t i o n s wi th o ther c a r e g i v e r s (RNs and n u r s i n g a ide s ) p r o f o u n d l y i n f l u e n c e d the nur se s ' comfort at work. They d e s c r i b e d s t a f f cohes ivenes s as be ing an impor tant pa r t of job s a t i s f a c t i o n , i n d i c a t i n g tha t " t e n s i o n between the s t a f f " r e s u l t e d i n i n c r e a s e d s t r e s s and 86 decreased s a t i s f a c t i o n which u l t i m a t e l y i n f l u e n c e d the n u r s e - p a t i e n t i n t e r a c t i o n . The nur se s ' i n t e r a c t i o n s with p a t i e n t s ' f a m i l i e s and f r i e n d s i n f l u e n c e d t h e i r a b i l i t y to i n d i v i d u a l i z e p a t i e n t s ' care and to enjoy t h e i r work. Some nurses saw the r e l a t i o n s h i p as s t r e s s f u l and as i n t e r f e r i n g wi th c a r e g i v i n g when f a m i l i e s attempted to " d i c t a t e the agenda" f o r p a t i e n t c a r e . Others viewed t h e i r i n t e r a c t i o n s wi th p a t i e n t s ' f a m i l i e s and f r i e n d s as p o s i t i v e , i d e n t i f y i n g them as a source of support on the ward. A l l nurses d e s c r i b e d the n u r s e - d o c t o r r e l a t i o n s h i p as a nega t ive i n f l u e n c e . The nurses f e l t f r u s t r a t e d and o f ten i n e f f e c t i v e d u r i n g t h e i r i n t e r a c t i o n s with d o c t o r s . They s t a t ed t h a t doc tor s v i s i t e d l e s s f r e q u e n t l y than necessary and were g e n e r a l l y a p a t h e t i c and uncommunicat ive . They a l so i n d i c a t e d tha t doc tor s tended to devalue and l a b e l p a t i e n t s i n ways t h a t decreased p a t i e n t s ' i n d i v i d u a l i t y . The nurses i d e n t i f i e d a common c o n c e r n , tha t i s , tha t n o n g e r i a t r i c nurses thought g e r i a t r i c nurses were " t i r e d and o l d and d i d n ' t want to work anymore" and tha t they were unable to "dea l wi th the s t r e s s on s u r g i c a l w a r d s . " Accompanying these statements were f e e l i n g s of resentment and anger . The nurses a l s o d e s c r i b e d the p u b l i c as be ing i g n o r a n t about g e r i a t r i c n u r s i n g and as m i n i m i z i n g i t s va lue and importance w i t h i n s o c i e t y . 87 Support systems comprised of f a m i l y , f r i e n d s , and c l e r g y were i d e n t i f i e d as an important i n t e r p e r s o n a l f a c t o r impac t ing on p a t i e n t s ' p e r c e p t i o n s of e v e n t s . The nurses d e s c r i b e d the p a t i e n t s r e c e i v i n g r e g u l a r v i s i t o r s as "more aware of human c o n t a c t " and as having more f requent communication w h i l e they d e s c r i b e d those p a t i e n t s having l e s s f r e q u e n t v i s i t o r s as " w i t h d r a w n , " " a g i t a t e d , " and as " r a m b l i n g or c a l l i n g o u t . " Some nurses i n d i c a t e d tha t the presence of f a m i l i e s had a somewhat nega t ive impact on p a t i e n t s due to the f a m i l i e s ' i n a b i l i t y to r e l a t e wel l wi th confused p a t i e n t s and a l s o to t h e i r need to c o n t r o l p a t i e n t s ' a c t i v i t i e s . A m a j o r i t y of the nurses i n d i c a t e d t h a t c a r e g i v e r s ' i n t e r a c t i o n s with p a t i e n t s had a profound e f f e c t on p a t i e n t s ' b e h a v i o r . The e f f e c t was most o f ten d e s c r i b e d as n e g a t i v e . The nurses c h a r a c t e r i z e d these nega t ive n u r s e - p a t i e n t i n t e r a c t i o n s by t h e i r absence of n u r s i n g assessment , p a t i e n t d e c i s i o n making, and p a t i e n t - c e n t e r e d communicat ion . These o ther c a r e g i v e r s were d e s c r i b e d as r i g i d l y adher ing to r o u t i n e s developed f o r t h e i r convenience and as u t i l i z i n g r a p i d , rough a c t i o n s . Negat ive a t t i t u d e s which dehumanized p a t i e n t s and r e s u l t e d i n l a b e l l i n g and n e g l e c t were a l s o d e s c r i b e d . In re sponse , p a t i e n t behav ior was d e s c r i b e d as r e s i s t a n t , a g g r e s s i v e , or wi thdrawn. Other nurses r e f l e c t e d a more n e u t r a l view of c a r e g i v e r s ' approaches , d e s c r i b i n g them as d i f f e r e n t but e f f i c i e n t and 88 as r e l y i n g on m e d i c a t i o n s and r e s t r a i n t s d u r i n g t h e i r i n t e r a c t i o n s . These c a r e g i v e r s were d e s c r i b e d as l e s s c a r i n g and as p r e f e r r i n g book work and s u p e r v i s o r y d u t i e s . Fewer nurses d e s c r i b e d t h e i r c a r e g i v i n g c o l l e a g u e s as "empathet ic and c a r i n g , " as having a " f e e l f o r the j o b , " and as " l o v i n g o l d p e o p l e . " The nurses noted t h a t care was i n c o n s i s t e n t when c a r e g i v e r s changed f r e q u e n t l y . These c a r e g i v e r s were not aware of p a t i e n t s ' i n d i v i d u a l needs and p r e f e r e n c e s and c o n s e q u e n t l y , t h e i r i n t e r a c t i o n s with p a t i e n t s o f ten p r e c i p i t a t e d a g g r e s s i v e re sponse s . The nurses were c o n s c i o u s of the need to r e e s t a b l i s h r a p p o r t when they had not worked wi th a p a t i e n t f o r some t i m e . The i n t e g r a t i o n of more confused p a t i e n t s wi th l u c i d or l e s s confused p a t i e n t s was d e s c r i b e d as a f a c t o r having a nega t ive impact on p a t i e n t s ' b e h a v i o r . The nurses d e s c r i b e d the problems of i n t e g r a t i o n as stemming from the i n c r e a s e d " n o i s e l e v e l " and " c o n f u s i o n " of the more confused p a t i e n t s and the angry and demora l i zed responses of the l u c i d and l e s s confused p a t i e n t s . Without e x c e p t i o n , the nurses f e l t tha t confused and l u c i d p a t i e n t s should be s e p a r a t e d . Some nurses r e p o r t e d t h a t a c t i v i t i e s were b e n e f i c i a l f o r p a t i e n t s because the s o c i a l s t i m u l a t i o n i n h e r e n t i n these a c t i v i t i e s i n c r e a s e d p a t i e n t s ' awareness , whi le o ther s s t a t e d t h a t group a c t i v i t i e s were d e t r i m e n t a l because they i n c r e a s e d p a t i e n t s ' a g i t a t i o n . 89 Impersonal F a c t o r s Impersonal f a c t o r s , tha t i s , non-human o b j e c t s tha t were i d e n t i f i e d by the nurses as i n f l u e n c i n g the i n t e r a c t i o n , are presented i n the f o l l o w i n g s e c t i o n . These f a c t o r s a r e : (a) pr imary n u r s i n g , (b) the s u p e r v i s o r y versus the c a r e g i v e r r o l e , (c) s t a f f i n g p a t t e r n s , (d) time c o n s t r a i n t s , (e) n o i s e , ( f ) i n s t i t u t i o n a l i z a t i o n , (g) p h y s i c a l env i ronment , and (h) m e d i c a t i o n s . The frequency of occur rence and an i n d i c a t o r of each f a c t o r are presented i n Appendix G. The use of pr imary n u r s i n g was d e s c r i b e d by the nurses as enhancing the q u a l i t y of t h e i r p a t i e n t c a r e . They b e l i e v e d t h a t , when compared to team n u r s i n g , pr imary n u r s i n g enhanced t h e i r attempts to know t h e i r p a t i e n t s and t h e r e f o r e a l lowed f o r g r e a t e r c o n s i s t e n c y and i n d i v i d u a l i z e d care d u r i n g t h e i r i n t e r a c t i o n s . I t i s i n t e r e s t i n g to note t h a t a l l nurses i d e n t i f y i n g pr imary n u r s i n g as an e x t e r n a l f a c t o r worked i n an extended care u n i t t h a t a c t i v e l y implemented primary n u r s i n g . The nurses i d e n t i f i e d the s u p e r v i s o r y versus the c a r e g i v e r r o l e of the RN as a f a c t o r i n f l u e n c i n g the n u r s e - p a t i e n t i n t e r a c t i o n . Some nurses p e r c e i v e d the s u p e r v i s o r y r o l e , a r o l e i n which the nurse spent l e s s time p r o v i d i n g p h y s i c a l c a r e , as a more e f f e c t i v e r o l e because they were ab le to focus to a g r e a t e r ex tent on t a l k i n g with p a t i e n t s . In t h i s r o l e , these nurses i n d i c a t e d they had a 90 broader view of ward events which enabled them to more e f f e c t i v e l y i d e n t i f y the problems r e q u i r i n g t h e i r a t t e n t i o n . They p e r c e i v e d themselves as more r e s p o n s i b l e fo r d e c i s i o n making on the ward when they were assuming a s u p e r v i s o r y r o l e . Other nurses i d e n t i f i e d the s u p e r v i s o r y r o l e as l e s s e f f e c t i v e and l e s s s a t i s f y i n g due to the decreased amount of time a c t u a l l y spent wi th the p a t i e n t s and to the need to r e l y on i n f o r m a t i o n from the n u r s i n g a ides f o r much of t h e i r p a t i e n t assessment. S t a f f / p a t i e n t r a t i o s and s h i f t r o t a t i o n s were two f ace t s of s t a f f i n g p a t t e r n s , i d e n t i f i e d by the n u r s e s , which r e s u l t e d i n what they p e r c e i v e d as an u n s a t i s f a c t o r y q u a l i t y of p a t i e n t care and i n f e e l i n g s of f r u s t r a t i o n , g u i l t , and d e p r e s s i o n . The r a t i o of c a r e g i v e r s to p a t i e n t s was i d e n t i f i e d by a l l nurses as be ing low, r e s u l t i n g i n l e s s time fo r p a t i e n t s and subsequent shor t cut s i n c a r e . Concerns with s h i f t r o t a t i o n s focused p r i m a r i l y on the number of hours worked i n a day (12) and the number of c o n s e c u t i v e s h i f t s worked at one time ( 6 ) . A l l nurses s t a t e d t h a t at the end of the s h i f t or s t r e t c h of s h i f t s they were t i r e d and consequent ly l e s s t o l e r a n t and t h a t they tended to withdraw or i n t e r a c t more a b r u p t l y wi th o t h e r s . Time c o n s t r a i n t s were i d e n t i f i e d by a m a j o r i t y of the nurses as d e c r e a s i n g t h e i r a b i l i t y to p r o v i d e care i n a manner t h a t was s a t i s f y i n g f o r them. They s a i d tha t they were "never f i n i s h e d " and t h a t t h e i r i n t e r a c t i o n s were shor t 91 and f r e q u e n t l y ru shed . They d e s c r i b e d s i t u a t i o n s where they d i d not have "enough time to do any th ing except the e s s e n t i a l s , " thus p r e c l u d i n g the "one to one t ime" t h a t they seemed to r e l a t e to a h igher q u a l i t y of c a r e . I t i s important to note tha t many nurses i d e n t i f i e d a c l o s e r e l a t i o n s h i p between s t a f f i n g p a t t e r n s and time c o n s t r a i n t s . A l l nurses i d e n t i f y i n g no i se as a f a c t o r d e s c r i b e d i t as o r i g i n a t i n g from the p o p u l a t i o n of p a t i e n t s i d e n t i f i e d as confused . The nurses s t a t e d tha t the no i se was " f r u s t r a t i n g " and "hard on the nerves " and d e s c r i b e d t h e i r r e a c t i o n s as more nega t ive because of the n o i s e . P a t i e n t s ' l o s s of p o s s e s s i o n s , l o s s of p r i v a c y , and l o s s of c o n t r o l over themselves and t h e i r remain ing pos se s s ions were d e s c r i b e d as a spect s of i n s t i t u t i o n a l i z a t i o n which n e g a t i v e l y impacted on p a t i e n t s ' b e h a v i o r . Increased p a t i e n t withdrawal or aggre s s ion were p e r c e i v e d by the nurses as changes r e s u l t i n g from i n s t i t u t i o n a l i z a t i o n . The nurses s p e c i f i e d c e r t a i n a spects of the p h y s i c a l env i ronment , such as l i g h t i n g , d e c o r a t i o n s , and c o l o r , i n a d d i t i o n to p a t i e n t s ' f a m i l i a r i t y with t h i s env i ronment , as i n f l u e n c i n g p a t i e n t s ' b e h a v i o r . The nurses i d e n t i f i e d r e l o c a t i o n , e i t h e r from home to f a c i l i t y or from one room to a n o t h e r , as d e c r e a s i n g p a t i e n t s ' f a m i l i a r i t y with the environment and as be ing " t r a u m a t i c " f o r p a t i e n t s . They 92 d e s c r i b e d p a t i e n t s as i n c o n t i n e n t , more confused , d i s o r i e n t e d , and r e s t l e s s as a r e s u l t of r e l o c a t i o n . M e d i c a t i o n s were i d e n t i f i e d as i n f l u e n c i n g the p a t i e n t s e i t h e r by i n c r e a s i n g s e d a t i o n and consequent ly i n c r e a s i n g c o n f u s i o n or by d e c r e a s i n g c o n f u s i o n and thereby making the p a t i e n t s more r e s p o n s i v e to the nur se s ' use of t o u c h , c o n v e r s a t i o n , and eye c o n t a c t . Summary The f i n d i n g s pre sented i n t h i s chapter were the nur se s ' p e r c e p t i o n s of t h e i r i n t e r a c t i o n s wi th p a t i e n t s i d e n t i f i e d as confused . These f i n d i n g s d e s c r i b e d p a t i e n t s ' behav io r s which i n f l u e n c e d the i n t e r a c t i o n , the e f f e c t of these behav ior s on nurse b e h a v i o r s , nurse behav io r s that i n f l u e n c e d the i n t e r a c t i o n , and the e x t e r n a l f a c t o r s t h a t i n f l u e n c e d the i n t e r a c t i o n . The nurses p e r c e i v e d tha t s p e c i f i c b e h a v i o r s , e v i d e n t in p a t i e n t s i d e n t i f i e d as con fused , i n f l u e n c e d the i n t e r a c t i o n . These p a t i e n t behav ior s p r o v i d e d b a r r i e r s to mutua l ly unders tandab le communication and i n f l u e n c e d the degree to which the nurses p a r t i c i p a t e d w i t h i n the n u r s e - p a t i e n t i n t e r a c t i o n . The nurses were able to d e s c r i b e behav io r s t h a t i n c r e a s e d t h e i r p a r t i c i p a t i o n and behav ior s that prompted t h e i r withdrawal from the i n t e r a c t i o n . The f i n d i n g s i n d i c a t e t h a t the nur se s ' behav ior s i n f l u e n c e d a l l phases of the n u r s e - p a t i e n t i n t e r a c t i o n . 93 They i n f l u e n c e d the t y p e , f r e q u e n c y , and d u r a t i o n of n u r s e - p a t i e n t communicat ion , the degree to which the i n t e r a c t i o n was i n d i v i d u a l i z e d and p a t i e n t - f o c u s e d , and the ex tent of p a t i e n t c o n t r o l d u r i n g the i n t e r a c t i o n . P e r s o n a l , i n t e r p e r s o n a l , and impersonal f a c t o r s i n f l u e n c i n g the i n t e r a c t i o n emerged from the d a t a . Personal f a c t o r s , such as the nur se s ' b e l i e f s and the p a t i e n t s ' p h y s i o l o g i c a l c o n d i t i o n ; i n t e r p e r s o n a l f a c t o r s , such as the n u r s e - d o c t o r r e l a t i o n s h i p and the p a t i e n t - f a m i l y i n t e r a c t i o n ; and impersonal f a c t o r s , such as time c o n s t r a i n t s and the p h y s i c a l env i ronment , i n f l u e n c e d the nur se s ' and the p a t i e n t s ' a c t i o n s and f e e l i n g responses d u r i n g the n u r s e - p a t i e n t i n t e r a c t i o n . 94 CHAPTER FIVE D i s c u s s i o n T h i s study ex p lo red the nur se s ' i n t e r p r e t a t i o n s of t h e i r i n t e r a c t i o n s with p a t i e n t s i d e n t i f i e d as confused . The f i n d i n g s i n d i c a t e d t h a t the nur se s ' and p a t i e n t s ' behav ior s were r e c i p r o c a l l y i n f l u e n c e d and tha t both were i n f l u e n c e d by e x t e r n a l f a c t o r s . Chapter 4 p re sented the nur se s ' d e s c r i p t i o n s of nurse and p a t i e n t behav ior s which o c c u r r e d d u r i n g the i n t e r a c t i o n and e x t e r n a l f a c t o r s which i n f l u e n c e d the i n t e r a c t i o n . The purpose of t h i s chapter i s to ana lyze the nur se s ' d e s c r i p t i o n s of the i n t e r a c t i o n and to compare them to the r e l a t e d l i t e r a t u r e . F o l l o w i n g c a r e f u l c o n s i d e r a t i o n of the f i n d i n g s , three r e c u r r i n g themes became e v i d e n t . Each theme a l l u d e s to a meaning which the nurses a t t a c h e d to the i n t e r a c t i o n . They a r e : (a) the i n t e r a c t i o n as a means of communicat ion , (b) the i n t e r a c t i o n as a v e h i c l e f o r c a r i n g , and (c) the i n t e r a c t i o n as a source of s t r e s s fo r the nur se . A l l nurses i n d i c a t e d t h a t t h e i r i n t e r a c t i o n s wi th p a t i e n t s had more than one meaning. Chapter 5 begins with a general d i s c u s s i o n of the n u r s e - p a t i e n t i n t e r a c t i o n . The remaining s e c t i o n s of t h i s chapter are o r g a n i z e d a c c o r d i n g to the a forement ioned themes. 95 Due to the nature of the i n t e r a c t i o n , communicat ion , c a r i n g , and s t r e s s are i n t r i c a t e l y i n t e r r e l a t e d . Obvious i n t e r r e l a t i o n s h i p s w i l l be noted but , f o r the purposes of c l a r i t y , f i n d i n g s w i l l be d i s c u s s e d w i t h i n the area most i n d i c a t e d by the d a t a . The r e c i p r o c a l nature of the i n t e r a c t i o n i s e v i d e n t throughout the nur se s ' a c c o u n t s . Those i n t e r a c t i o n s e x p e r i e n c e d as most s a t i s f y i n g fo r the nurses were a l s o p e r c e i v e d as most s a t i s f y i n g fo r the p a t i e n t s , based on t h e i r p o s i t i v e re sponse s . The nur se s ' i n t e r a c t i o n s o c c u r r e d more f r e q u e n t l y and were e x p e r i e n c e d as more s a t i s f y i n g when p a t i e n t s ' responses were of a p o s i t i v e r a t h e r than a nega t ive n a t u r e . White (1977) noted the r e c i p r o c a l nature of the i n t e r a c t i o n and i n d i c a t e d tha t p a t i e n t s ' b e h a v i o r s i n f l u e n c e nur se s ' behav io r s which i n tu rn i n f l u e n c e p a t i e n t s ' s e l f esteem. The nurse behav io r s i d e n t i f i e d as p r e c i p i t a t i n g the most s a t i s f y i n g i n t e r a c t i o n s i n t h i s study have been i d e n t i f i e d i n the l i t e r a t u r e as enhancing p a t i e n t s ' s e l f esteem ( H i r s t & M e t c a l f , 1984; J a h r a u s , 1974). The nurses d e s c r i b e d many problems which were p a r t of the n u r s e - p a t i e n t i n t e r a c t i o n . These problems , which formed b a r r i e r s to e f f e c t i v e communication and c a r i n g and c r e a t e d s t r e s s w i t h i n the i n t e r a c t i o n , stemmed from the n u r s e s ' l ack of under s t and ing of the meaning of p a t i e n t s ' behav ior and 96 the apparent l ack of under s t and ing of the nur se s ' behav ior by the p a t i e n t s . The theory of symbol ic i n t e r a c t i o n attempts to e x p l a i n b e h a v i o r by d e t e r m i n i n g the meaning t h a t the i n d i v i d u a l a t t aches to s p e c i f i c exper i ence s w i t h i n the i n t e r a c t i o n ( S c h r o e d e r , 1981). The meaning of the a c t i o n s i g n i f i e s what the i n i t i a t o r p lans to do, what the r e c i p i e n t i s to do, and the j o i n t a c t i o n t h a t r e s u l t s from both a c t i o n s . I f there i s mi sunder s t and ing i n any one of these areas of meaning then the i n t e r a c t i o n i s i n e f f e c t i v e (Blumer, 1969; Lauer & H a n d e l , 1977) . When the meaning of p a t i e n t s ' a c t i o n s was u n c l e a r , the nurses were not sure why. these a c t i o n s o c c u r r e d and how they were to respond to them. Consequent ly the j o i n t a c t i o n s of the nurses and p a t i e n t s were not always harmonious or p r e d i c t a b l e and o f ten d i d not r e s u l t i n the outcome d e s i r e d by the n u r s e s . Symbol ic i n t e r a c t i o n f u r t h e r i n d i c a t e s that i n d i v i d u a l s a s s i gn meaning to o t h e r s ' b e h a v i o r w i t h i n a s p e c i f i c i n t e r a c t i o n based on what they have l e a r n e d from p r e v i o u s i n t e r a c t i o n s and on t h e i r p e r c e p t i o n s of the c u r r e n t s i t u a t i o n , and then respond i n terms of those meanings (Blumer, 1969; Lauer & H a n d e l , 1977). Because the meanings a s s i gned by the nurses to the p a t i e n t ' s behav ior w i t h i n a s p e c i f i c i n t e r a c t i o n p r o v i d e d l i t t l e d i r e c t i o n , the nurses o f ten based t h e i r a c t i o n s on i n f o r m a t i o n they had gleaned 97 d u r i n g p r e v i o u s i n t e r a c t i o n s with t h a t p a t i e n t and on t h e i r knowledge of the p a t i e n t ' s background. A m a j o r i t y of the nurses i n d i c a t e d tha t knowing about p a t i e n t s ' needs, p r e f e r e n c e s , b a s e l i n e b e h a v i o r s , and background was e s s e n t i a l to e f f e c t i v e communication and c a r e . T h i s i n f o r m a t i o n helped the nurses to unders tand the p o s s i b l e meanings which p a t i e n t s a t t ached to t h e i r b e h a v i o r , thus p r o v i d i n g some d i r e c t i o n fo r t h e i r a c t i o n s . I n t e r a c t i o n s t h a t i n c o r p o r a t e d p a t i e n t s ' needs and p r e f e r e n c e s and r e f l e c t e d p a t i e n t s ' p e r s p e c t i v e s were s a t i s f y i n g fo r the nurses and p a t i e n t s . In order to a s s i gn meaning to pre sent b e h a v i o r based on i n f o r m a t i o n accumulated from p r e v i o u s i n t e r a c t i o n s , i t was important tha t p a t i e n t s ' b e h a v i o r s were c o n s i s t e n t wi th t h e i r behav io r s d u r i n g p r e v i o u s i n t e r a c t i o n s . When p a t i e n t behav ior f l u c t u a t e d , t h i s i n t e r f e r e d with the nur se s ' a b i l i t y to r e l y on a c t i o n s which had been s u c c e s s f u l d u r i n g p r e v i o u s i n t e r a c t i o n s with these p a t i e n t s . T h i s r e s u l t e d i n a c t i o n s tha t were l e s s meaningful and consequent ly l e s s s a t i s f y i n g . C o n t r a r y to the f i n d i n g s of A l t s c h u l (1972) and Wel l s (1980) , the nurses i n t h i s study r e p o r t e d a framework or goal o r i e n t a t i o n fo r t h e i r n u r s e - p a t i e n t i n t e r a c t i o n s . They i n d i c a t e d tha t p a t i e n t c o n t a c t , comfor t , and c o o p e r a t i o n were general goa l s of t h e i r i n t e r a c t i o n s . Some nurses d e s c r i b e d t h e i r i n t e r a c t i o n s as be ing b u i l t on t r u s t . 98 Increased p a t i e n t comprehension or under s t and ing was not f r e q u e n t l y mentioned as a r e a l i s t i c goal of the i n t e r a c t i o n . The l ack of a t t e n t i o n to p a t i e n t s ' comprehension or under s t and ing as an i n t e r a c t i o n a l goal i s i n t e r e s t i n g i n l i g h t of the nur se s ' focus on l ack of under s t and ing as a b a r r i e r to the i n t e r a c t i o n and as the b a s i s f o r the nur se s ' m o d i f i c a t i o n s of t h e i r b e h a v i o r . The nurses i n d i c a t e d tha t p a t i e n t s ' degree of comprehension was d i f f i c u l t to a s se s s . T h e r e f o r e , changes i n comprehension would be d i f f i c u l t to e v a l u a t e . T h i s p o s s i b l y e x p l a i n s the l ack of n u r s i n g goals r e l a t e d to p a t i e n t s ' comprehens ion . I t i s a l s o p o s s i b l e t h a t the nurses d i d not f ee l competent or have the knowledge and s k i l l s necessary to deal with the goal of i n c r e a s i n g p a t i e n t s ' comprehens ion . Palmateer and McCartney (1985) found t h a t the m a j o r i t y of nurses i n t h e i r study d i d not, have the knowledge and s k i l l s needed to adequate ly d e f i n e and assess p a t i e n t s ' c o g n i t i v e f u n c t i o n i n g . The I n t e r a c t i o n as a Means of Communication The nurses spent much of t h e i r i n t e r v i e w time d e s c r i b i n g n u r s e - p a t i e n t communicat ion . While they d e s c r i b e d i t as be ing f raught with problems and f r u s t r a t i o n s , they a l s o d e s c r i b e d i t as be ing one of the most important and o f ten most s a t i s f y i n g par t s of the n u r s e - p a t i e n t i n t e r a c t i o n . T h i s s e c t i o n w i l l ana lyze those p a t i e n t b e h a v i o r s , nurse b e h a v i o r s , and e x t e r n a l f a c t o r s 99 r e l a t e d to communication tha t e i t h e r f a c i l i t a t e d or impeded achievement of the goals of c o n t a c t , comfor t , and c o o p e r a t i o n . The nurses d e s c r i b e d numerous p a t i e n t b e h a v i o r s , e s p e c i a l l y those i n d i c a t i v e of c o n f u s i o n , as p r e s e n t i n g b a r r i e r s to meaningful communication and t h e r e f o r e to e f f e c t i v e and s a t i s f y i n g i n t e r a c t i o n s . Those p a t i e n t behav io r s t h a t were d e s c r i b e d as f l u c t u a t i n g , out of c o n t e x t , u n i n t e l l i g i b l e , memory-impaired, r e p e t i t i o u s , and d i s r u p t i v e p r e c l u d e d e f f e c t i v e communication because the p a t i e n t s were unable to i n t e r a c t i n a way t h a t had meaning fo r the nur se . T h i s a f f e c t e d communication by d e c r e a s i n g the degree of mutual u n d e r s t a n d i n g . P a t i e n t s e x h i b i t i n g the a forement ioned behav io r s were d e s c r i b e d as having d i f f i c u l t i e s communicating v e r b a l l y , tha t i s , both the conten t of the c o n v e r s a t i o n and the way i t was communicated made i t d i f f i c u l t f o r the nurse to u n d e r s t a n d . Authors have i d e n t i f i e d e x p r e s s i v e d i f f i c u l t i e s as c h a r a c t e r i z i n g the i n t e r a c t i o n s of p a t i e n t s i d e n t i f i e d as confused (Beck & P h i l l i p s , 1983; H a y t e r , 1981; Meacher, 1972; Palmateer & McCar tney , 1984). The r e l a t i o n s h i p between e x p r e s s i v e d i f f i c u l t i e s and i n e f f e c t i v e communication has been noted by communication t h e o r i s t s ( P a r r y , 1968; Ruesch, 1961) and o ther s (Meacher, 1972). In a d d i t i o n to p a t i e n t s ' e x p r e s s i v e problems , the nurses p e r c e i v e d p a t i e n t s ' l ack of apparent comprehension as 100 n e g a t i v e l y i n f l u e n c i n g a l l f a c e t s of communicat ion . Comprehension has been i d e n t i f i e d as an e s s e n t i a l component of e f f e c t i v e communication ( B e r l o , 1969; P a r r y , 1968; Ruesch, 1961) . P a t i e n t behav io r s which l e d the nurses to b e l i e v e t h a t the p a t i e n t was unable to comprehend have been i d e n t i f i e d as p r e v e n t i n g the e l d e r l y , confused person from i n t e r a c t i n g a c c o r d i n g to the c a r e g i v e r s ' e x p e c t a t i o n s and as r e s u l t i n g i n i n e f f e c t i v e communication (Beck & P h i l l i p s , 1983; Wolanin & P h i l l i p s , 1981). W o l a n i n ' s f i n d i n g s (1977) i n d i c a t e d t h a t " the behav io r s of p a t i e n t s seemed dependent on t h e i r a b i l i t y to unders tand those who work with them" ( p . 7 4 ) . The p a t i e n t s ' l e v e l of c o n f u s i o n was determined by the nurses based, i n p a r t , on the p a t i e n t s ' a b i l i t y to communicate a p p r o p r i a t e l y and unders tandab ly at both the content and process (way of communicating) l e v e l . T h i s f i n d i n g i n d i c a t e s the c l o s e a s s o c i a t i o n i n the n u r s e s ' minds between p a t i e n t s ' communication a b i l i t y and the l a b e l c o n f u s i o n . Wolanin (1977) acknowledges tha t many p a t i e n t s diagnosed as confused may have d i f f i c u l t y communicating but she a l s o c a u t i o n s nurses t h a t "communicat ion problems . . . can l e a d to the impre s s ion t h a t the c l i e n t i s confused when he i s not " ( 1980, p. 124) . P a t i e n t s having more severe e x p r e s s i v e problems and decreased comprehension were i d e n t i f i e d by the nurses as more s e v e r e l y confused . The nurses m o d i f i e d the frequency 101 and type of communication used d u r i n g the i n t e r a c t i o n a c c o r d i n g to the p a t i e n t s ' p e r c e i v e d l e v e l of c o n f u s i o n . S i m i l a r nurse responses have been documented i n s t u d i e s conducted by A l t s c h u l (1972) , S tockwel l (1972) , and Tudor (1952) . The nurses p e r c e i v e d t h a t the m a j o r i t y of t h e i r communication d u r 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 was task o r i e n t e d and of an e x p l a n a t o r y n a t u r e . Al though t a s k - o r i e n t e d communication was more f r e q u e n t , p a t i e n t - c e n t e r e d communication was i d e n t i f i e d as more s a t i s f y i n g and meaningful f o r p a t i e n t s and the n u r s e s . Numerous s t u d i e s , u s ing o b s e r v a t i o n a l t e c h n i q u e s , c o n f i r m t h a t n u r s e - p a t i e n t communication i s o f ten more task o r i e n t e d than i t i s p a t i e n t c e n t e r e d ( B u r c h e t t , 1967; C o h l e r & S h a p i r o , 1964; W e l l s , 1980). S t o c k w e l l ' s study (1972) , which s t a t e d tha t nurses were s a t i s f i e d with t a s k - o r i e n t e d i n t e r a c t i o n s , does not support the f i n d i n g s i n t h i s s tudy . The nurses r e j e c t e d r e a l i t y o r i e n t a t i o n (RO) as an e f f e c t i v e means of communicat ion . Authors i n d i c a t i n g t h a t RO i s not e f f e c t i v e have done so based on the l ack of improvement i n c o g n i t i v e f u n c t i o n i n g and p h y s i c a l a b i l i t y f o l l o w i n g p a t i e n t s ' exposure to t h i s communication s t r a t e g y (MacDonald & S e t t i n , 1978; V o e l k e l , 1978). The study nurses focused on the l ack of improvement i n n u r s e - p a t i e n t c o n t a c t and p a t i e n t comfort r a t h e r than on changes i n comprehension when d i s c u s s i n g the e f f e c t s of RO. They r e j e c t e d RO because 102 of the l ack of c h o i c e i t l e f t p a t i e n t s to choose a r e a l i t y t h a t was comfor tab le f o r them. Many p a t i e n t s , when exposed to RO, i n c r e a s i n g l y e x h i b i t e d d i s r u p t i v e or withdrawn b e h a v i o r s . T h i s f i n d i n g i s conf i rmed by Campos (1984) , Hogste l (1979) , and Teasda le (1983) . The nurses i d e n t i f i e d nonverbal communication as the most e f f e c t i v e means of e s t a b l i s h i n g n u r s e - p a t i e n t c o n t a c t and i n c r e a s i n g p a t i e n t comfort with a l l p a t i e n t s but e s p e c i a l l y with those p a t i e n t s i d e n t i f i e d as s e v e r e l y c o n f u s e d . Pres ton (1973) found tha t p a t i e n t s were " ab le to respond to nonverbal communication when they [were] no longer able to unders tand or communicate v e r b a l l y " (p . 2064) . Nonverbal communication behav io r s are wel l documented as e f f e c t i v e i n t e r v e n t i o n s with e l d e r l y , confused p a t i e n t s ( B a r t o l , 1983; B u r n s i d e , 1973; H i r s t & M e t c a l f , 1984; Wolanin & P h i l l i p s , 1981). I t seems probable t h a t p a t i e n t s who were no longer able to comprehend or a s s i g n meaning to the nur se s ' verba l communication were s t i l l ab le to unders tand the meaning of nonverbal communication i n d i c a t i n g tha t the nurses c a r e d . B a r t o l (1983) d e s c r i b e d the most e f f e c t i v e type of touch as " f r e q u e n t , gen t l e touch tha t i s not task o r i e n t e d " (p . 235) . T h i s s tatement concurs with the statements of the study n u r s e s . Rosendahl and Ross (1982) i d e n t i f i e d eye c o n t a c t as an important " a t t e n d i n g b e h a v i o r " (p . 572) a v a i l a b l e to c a r e g i v e r s to i n d i c a t e to the p a t i e n t t h a t the 103 c a r e g i v e r i s c a r i n g and i n t e r e s t e d . The nurses i n the c u r r e n t study i n d i c a t e d tha t the e f f e c t i v e n e s s of eye c o n t a c t and t o u c h i n g stemmed from the p a t i e n t s ' p e r c e p t i o n s of these behav io r s as i n d i c a t i n g tha t they c a r e d . The nurses s t a t e d tha t c o n v e r s a t i o n conducted at a s lower pace was more e f f e c t i v e in e s t a b l i s h i n g c o n t a c t and e l i c i t i n g c o o p e r a t i o n . A study by P a n i c u c c i , P a u l , Symonds, and T a m b e l l i n i (1968) s u b s t a n t i a t e s t h i s as an e f f e c t i v e i n t e r v e n t i o n with' w e l l , e l d e r l y i n d i v i d u a l s . R ichardson (1982) i d e n t i f i e s expanded or slowed speech and a slowed pace as e f f e c t i v e communication i n t e r v e n t i o n s with confused , e l d e r l y p a t i e n t s . The nurses i n d i c a t e d t h a t the nature and the f requency of communication were i n f l u e n c e d by f a c t o r s e x t e r n a l to the a c t u a l n u r s e - p a t i e n t i n t e r a c t i o n . E x t e r n a l f a c t o r s , a c c o r d i n g to Blumer (1969) , are a pa r t of the s i t u a t i o n which must be d e f i n e d and i n t e r p r e t e d by the i n d i v i d u a l p r i o r to a c t i o n but do not predetermine or c o n t r o l the responses of the i n d i v i d u a l . Those f a c t o r s tha t tended to i n c r e a s e the s e v e r i t y of p a t i e n t s ' c o n f u s i o n were p e r c e i v e d by the nurses as d e c r e a s i n g the e f f e c t i v e n e s s of t h e i r communication wi th p a t i e n t s . C u l t u r a l f a c t o r s were p e r c e i v e d by the nurses as b a r r i e r s to e f f e c t i v e communicat ion . Parry (1968) and Ruesch (1961) i d e n t i f y a l ack of common language and u n f a m i l i a r customs as b a r r i e r s to mutual under s t and ing 104 d u r i n g communicat ion . Wolanin and P h i l l i p s (1981) i n d i c a t e t h a t communication problems with e l d e r l y , confused p a t i e n t s are o f ten compounded by c u l t u r a l d i f f e r e n c e s . P a t i e n t s having f requent v i s i t o r s and a more s t i u l a t i n g environment were i d e n t i f i e d as communicating more f r e q u e n t l y i n ways t h a t were unders tandable to o t h e r s . C a r l s o n (1968) noted i n her study tha t i n c r e a s e d v i s u a l and a u d i t o r y s t i m u l a t i o n not only enhanced e l d e r l y p a t i e n t s ' awareness and communication but a l s o i n c r e a s e d t h e i r general l i f e s a t i s f a c t i o n . Not ing the p r e v i o u s l y mentioned r e l a t i o n s h i p between p a t i e n t s ' communication a b i l i t i e s and the nur se s ' r e sponses , i t seems p o s s i b l e t h a t f a m i l i e s and f r i e n d s a l s o responded more f r e q u e n t l y and with more verba l communication to those p a t i e n t s who were able to communicate more e f f e c t i v e l y . T h i s i s another example of the r e c i p r o c a l nature of the i n t e r a c t i o n . An i n t e r e s t i n g omis s ion was noted i n the study f i n d i n g s . The nurses d i d not i d e n t i f y p a t i e n t s ' a b i l i t y to see or hear as imping ing on n u r s e - p a t i e n t communicat ion . Communication t h e o r i s t s , i n a d d i t i o n to those authors d i s c u s s i n g c o n f u s i o n , f r e q u e n t l y note t h a t d i s a b i l i t i e s r e l a t e d to v i s i o n and h e a r i n g present s e r i o u s b a r r i e r s to p a t i e n t s ' p e r c e p t i o n and e x p r e s s i o n and consequent ly to t h e i r communication ( B u r c h e t t , 1967; Oyer , Kapur , & D e a l , 1976; P a r r y , 1968; Ruesch, 1961; W o l a n i n , 1977). I t i s p o s s i b l e t h a t a u d i t o r y and v i s u a l d i s a b i l i t i e s were so 105 p r e v a l e n t t h a t the nurses accepted them as the norm among t h i s p a t i e n t p o p u l a t i o n . Snyder , Pyrek , and Smith (1979) s t a t e tha t among the 295 extended care r e s i d e n t s i n t h e i r s t u d y , 59% were e i t h e r l e g a l l y b l i n d or had low v i s u a l a c u i t y even wi th c o r r e c t i v e l e n s e s . Oyer et a l . (1976) i n d i c a t e t h a t the r a t i o of people with h e a r i n g l o s s i n c r e a s e s from 3.5 per 1000 people under 17 year s to 133 per 1000 people over 65 y e a r s . These f a c t s s u b s t a n t i a t e the p e r c e i v e d p reva lence of a u d i t o r y and v i s u a l d i s a b i l i t i e s among t h i s p a t i e n t p o p u l a t i o n . I t i s e v i d e n t t h a t the nurses a s s o c i a t e d e f f e c t i v e communication with a high q u a l i t y of n u r s i n g c a r e . They noted tha t nega t ive n u r s i n g approaches were c h a r a c t e r i z e d by a l ack of n u r s e - i n i t i a t e d and p a t i e n t - o r i e n t e d communication and i d e n t i f i e d n u r s i n g r o l e s as more e f f e c t i v e when they f a c i l i t a t e d n u r s e - p a t i e n t communicat ion . The nurses focused t h e i r i n t e r v e n t i o n s on m a n i p u l a t i n g e x t e r n a l f a c t o r s to decrease t h e i r nega t ive impact or f a c i l i t a t e t h e i r p o s i t i v e impact on communication and f e l t g u i l t y when they were unable to e s t a b l i s h or m a i n t a i n n u r s e - p a t i e n t c o n t a c t . The a s s o c i a t i o n of q u a l i t y care wi th e f f e c t i v e communication i s wel l documented i n the n u r s i n g l i t e r a t u r e ( B u r n s i d e , 1973; O r l a n d o , 1961; T r a v e l b e e , 1969; Watson, 1979). Al though communication w i l l not be addressed e x p l i c i t l y i n the next s e c t i o n , i t i s important to remember t h a t c a r i n g depends upon the q u a l i t y , of the communication d u r i n g the 106 n u r s e - p a t i e n t i n t e r a c t i o n ( B u r c h e t t , 1967) . Open, hones t , p a t i e n t - c e n t e r e d communication r e f l e c t s e m p a t h e t i c , o p t i m i s t i c , and humani s t i c c a r i n g and enhances p a t i e n t s ' sense of i d e n t i t y and s e l f - e s t e e m . T h i s , i n t u r n , r e s u l t s i n improved p a t i e n t communicat ion , g r e a t e r m o t i v a t i o n to be independent , and a sense of wel l be ing ( B a r t o l , 1983; J a h r a u s , 1974) . The I n t e r a c t i o n as a V e h i c l e For C a r i n g The c a r i n g process i s a process u t i l i z e d by nurses to a s s i s t p a t i e n t s to a t t a i n or ma in ta in an opt imal l e v e l of h e a l t h fo r t h a t p a t i e n t at tha t t i m e . The nurses i n t h i s study i n d i c a t e d t h a t the i n t e r a c t i o n was a means of p r o v i d i n g care fo r p a t i e n t s they had i d e n t i f i e d as c o n f u s e d . The goa l s of the c a r i n g p r o c e s s , as i d e n t i f i e d by the n u r s e s , were to help p a t i e n t s to exper ience mental and p h y s i c a l c o m f o r t , to have c o n t a c t with o t h e r s , and p o s s i b l y to e s t a b l i s h some degree of t r u s t i n the n u r s e . The nurses d i d not i n d i c a t e tha t they expected p a t i e n t s to reach an opt imal l e v e l of h e a l t h , r a t h e r t h e i r goa l s seemed to be an improved l e v e l of p a t i e n t comfort and c o n t a c t . Gaut (1984) s t a t e s t h a t " c a r i n g i s accompl i shed through many o ther a c t i v i t i e s " (p . 36 ) . The nurses d e s c r i b e d i n d e t a i l the a c t i v i t i e s or c a r i n g behav io r s t h a t they implemented d u r i n g the i n t e r a c t i o n . They were concerned about the q u a l i t y of care t h a t they p r o v i d e d fo r t h e i r 107 p a t i e n t s . When d e s c r i b i n g behav ior s t h a t they b e l i e v e d r e f l e c t e d e i t h e r a high or a low q u a l i t y of c a r e , the nurses a l s o d e s c r i b e d p a t i e n t behav io r s and e x t e r n a l f a c t o r s tha t i n f l u e n c e d the i n t e r a c t i o n and a l t e r e d the q u a l i t y of t h e i r c a r e . T h i s s e c t i o n w i l l d i s c u s s the n u r s e s ' b e h a v i o r s , p a t i e n t s ' b e h a v i o r s , and e x t e r n a l f a c t o r s tha t i n f l u e n c e d the q u a l i t y of care d u r i n g the i n t e r a c t i o n . The nurses d e s c r i b e d those p a t i e n t behav io r s tha t i n t e r f e r e d with the p r o v i s i o n of care i n much g r e a t e r d e t a i l than they d i d those behav io r s t h a t f a c i l i t a t e d t h e i r c a r e g i v i n g . T h e r e f o r e , the nurse and p a t i e n t b e h a v i o r s tha t the nurses p e r c e i v e d decreased the q u a l i t y of care w i l l be d i s c u s s e d f i r s t . They w i l l be f o l l o w e d by a d i s c u s s i o n of nurse and p a t i e n t behav io r s t h a t enhanced the q u a l i t y of c a r e . Those e x t e r n a l f a c t o r s i n f l u e n c i n g the q u a l i t y of c a r e g i v i n g w i t h i n the i n t e r a c t i o n w i l l be d i s c u s s e d at the end of t h i s s e c t i o n . Lack of knowledge about p a t i e n t s was d e s c r i b e d as a b a r r i e r compromising the q u a l i t y of care t h a t the nurses were ab le to p r o v i d e . They r e p o r t e d t h a t the ex tent to which they knew the p a t i e n t s ' b e h a v i o r , background, needs , and p r e f e r e n c e s impacted on t h e i r a b i l i t y to p r o v i d e i n d i v i d u a l i z e d and p e r s o n a l i z e d care t h a t was a c c e p t a b l e to p a t i e n t s . Yet the nurses d i d not i d e n t i f y any sy s temat i c method fo r data g a t h e r i n g t h a t would develop a base of knowledge over t i m e . They observed p a t i e n t s ' b e h a v i o r , both 108 o u t s i d e of and d u r i n g the i n t e r a c t i o n , and u t i l i z e d a t r i a l - a n d - e r r o r method to determine a p p r o p r i a t e approaches to p a t i e n t s . T h i s data g a t h e r i n g o c c u r r e d most o f ten when p a t i e n t s were newly admit ted and seldom i n response to problems i d e n t i f i e d l a t e r as p a t i e n t s became known to the s t a f f . A l though care was goal d i r e c t e d , these goa l s were general i n nature and not r e l a t e d to i n d i v i d u a l p a t i e n t problems . At no time d i d the nurses mention the e x i s t e n c e of care p l a n s . T h i s suggests t h a t , i f they d i d e x i s t , p o s s i b l y t h e i r impact on the i n t e r a c t i o n was m i n i m a l . I t seems e v i d e n t t h a t these nurses were not u s ing a sy s t emat i c method of problem s o l v i n g as a pa r t of t h e i r c a r i n g . Nurses ' attempts to p r o v i d e c o n s i s t e n t , i n d i v i d u a l i z e d care fo r e l d e r l y p a t i e n t s i s g r e a t l y compromised wi thout the use of the n u r s i n g process (Watson, 1979; Wolanin & P h i l l i p s , 1981; Y u r i c k , Robb, S p i e r , & E b e r t , 1980). Lauer and Handel (1977) i n d i c a t e t h a t one ' s d e f i n i t i o n of the s i t u a t i o n i s dependent upon o n e ' s goals or p lan of a c t i o n . When these goa l s are not compat ib le with the goals of the o ther person i n the i n t e r a c t i o n , j o i n t a c t i o n i s o f ten impeded. The nurses i n d i c a t e d t h a t p a t i e n t behav ior s i d e n t i f i e d as f l u c t u a t i n g , d i s r u p t i v e and/or r e s i s t a n t , u n i n t e l l i g i b l e , or r e p e t i t i o u s i n t e r f e r e d with t h e i r a b i l i t y to p r o v i d e care because they i n t e r f e r e d with t h e i r a b i l i t y to reach t h e i r g o a l s . I t seems p o s s i b l e t h a t the nur se s ' c a r e g i v i n g goa l s of c o m f o r t , c o o p e r a t i o n , and c o n t a c t at 109 t imes were not compat ib le with the p a t i e n t s ' g o a l s . I t i s a l so p o s s i b l e tha t the p a t i e n t s were not aware t h a t the i n t e r a c t i o n was d i r e c t e d toward these g o a l s . When p a t i e n t s ' behav ior was d i s r u p t i v e and/or r e s i s t a n t , r e p e t i t i o u s , u n i n t e l l i g i b l e , or u n r e s p o n s i v e , the nurses r eac ted i n one of three ways: They c o n t i n u e d the i n t e r a c t i o n d e s p i t e p a t i e n t b e h a v i o r , withdrew from the i n t e r a c t i o n by p h y s i c a l l y removing themselves or the p a t i e n t , or i n t e r a c t e d i n ways tha t d e p e r s o n a l i z e d the i n t e r a c t i o n . Lauer and Handel (1977) s t a t e t h a t , when the i n d i v i d u a l ' s d e f i n i t i o n of the s i t u a t i o n and p lan of a c t i o n are not compat ib le with those of the o ther person i n the i n t e r a c t i o n , t h i s i n d i v i d u a l has l i m i t e d o p t i o n s . One may e i t h e r t e rmina te the i n t e r a c t i o n , accept the o ther p e r s o n ' s d e f i n i t i o n of the s i t u a t i o n , or impose one ' s own d e f i n i t i o n of the s i t u a t i o n on the o ther p e r s o n . These o p t i o n s are c o n s i s t e n t wi th those used by the nurses i n t h i s s t u d y . I t seems t h a t many nurses chose to remain i n the i n t e r a c t i o n when they were able to implement an a l t e r n a t e approach t h a t was a c c e p t a b l e to the p a t i e n t . The nurses a l s o s tayed more o f ten when t h e i r a c t i o n s were task o r i e n t e d and the goal of the i n t e r a c t i o n was r e l a t e d to p a t i e n t s ' p h y s i c a l c o m f o r t . Other r a t i o n a l e s fo r d e c i d i n g when to leave or stay were not used c o n s i s t e n t l y . These d e c i s i o n s were made based on the unique i n t e r p l a y of the nur se s ' a f f e c t i v e b e h a v i o r s , p a t i e n t s ' b e h a v i o r s , and e x t e r n a l 110 f a c t o r s d u r i n g each i n t e r a c t i o n . Lauer and Handel (1977) r e p o r t tha t one t e rmina te s or c o n t i n u e s the i n t e r a c t i o n based on the importance of one ' s goa l s to o n e s e l f and the a v a i l a b i l i t y of a l t e r n a t e ways to ach ieve them. When the nurses chose to c o n t i n u e the i n t e r a c t i o n d e s p i t e p a t i e n t r e s i s t a n c e , c o n t r o l was removed from the p a t i e n t s . The n u r s e s ' behav io r s tha t rushed p a t i e n t s , o f f e r e d l i t t l e or no e x p l a n a t i o n of the i n t e r a c t i o n , and p h y s i c a l l y removed p a t i e n t s from the s i t u a t i o n decreased the p a t i e n t s ' a b i l i t y to ac t independent ly and t h e r e f o r e decreased p a t i e n t s ' c o n t r o l . When c o n t r o l was removed p a t i e n t s were d e s c r i b e d as more a g g r e s s i v e or wi thdrawn. T h i s sequence of a c t i o n s i s wel l documented by those who have s t u d i e d 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 n i n s t i t u t i o n a l s e t t i n g s (Meacher, 1972; W e l l s , 1980). White (1977) s t a t e s tha t these n u r s i n g behav io r s r e f l e c t a l ack of " r e s p e c t , esteem, and l o v e " (p . 17) and are i n t e r p r e t e d as such by p a t i e n t s . T h i s i n t e r p r e t a t i o n r e s u l t s i n decreased s e l f esteem which i s o f ten e x h i b i t e d by i n c r e a s e d dependence or d i s r u p t i v e b e h a v i o r ( J a h r a u s , 1974) . H i r s t and M e t c a l f (1984) s t a t e t h a t the independence encouraged i n e l d e r l y people a l lows fo r g r e a t e r c o n t r o l w i t h i n t h e i r environment and thereby enhances t h e i r s e l f - e s t e e m . These p a t i e n t s e x h i b i t an i n c r e a s e d awareness and m o t i v a t i o n to i n t e r a c t and be independent . I l l The nurses i n d i c a t e d tha t care which focused on p a t i e n t s ' p h y s i c a l needs , a l though nece s s a ry , was not e m o t i o n a l l y or s o c i a l l y s a t i s f y i n g f o r p a t i e n t s or the nurses because i t r e i n f o r c e d p a t i e n t s ' dependence and d i s a b i l i t y . I t i s wel l documented t h a t d i s a b i l i t y i n the e l d e r l y l e a d i n g to dependence and p o s s i b l e i n s t i t u t i o n a l i z a t i o n i s c l o s e l y l i n k e d with low s e l f esteem ( H i r s t & M e t c a l f , 1984; J a h r a u s , 1974). P a t i e n t s e x h i b i t i n g behav ior d e s c r i b e d as loud and d i s r u p t i v e r e c e i v e d more n u r s i n g time than o ther p a t i e n t s but i t was time focused on the b e h a v i o r r a t h e r than on the p e r s o n . T h e r e f o r e , a l though they r e c e i v e d more t i m e , the q u a l i t y of the a t t e n t i o n at these times i s s u s p e c t . T h i s f i n d i n g corresponds wi th t h a t of Moores and Grant (1977) . Orlando (1961) d e s c r i b e s r e s i s t a n t , u n c o o p e r a t i v e , and withdrawn p a t i e n t b e h a v i o r as " i n e f f e c t i v e p a t i e n t b e h a v i o r " (p . 78) which prevent s the nurse " from c a r r y i n g out her concerns fo r the p a t i e n t ' s c a r e " (p . 78 ) . Orlando f u r t h e r d e s c r i b e s these p a t i e n t behav io r s as a s i g n a l of d i s t r e s s or a m a n i f e s t a t i o n of an unmet need o c c u r r i n g because n u r s i n g a c t i o n s , a l though in tended fo r the p a t i e n t ' s b e n e f i t , are c a r r i e d out a u t o m a t i c a l l y and do not i n f a c t meet the p a t i e n t ' s needs . The nurses i n t h i s study d i d not c o n s i d e r the p a t i e n t ' s r e s i s t a n t or withdrawn behav ior or any change i n behav ior as a cue t h a t the p a t i e n t ' s needs were unmet. "As long as the nurse a l lows the p a t i e n t to behave 112 i n e f f e c t i v e l y the problem remains" ( O r l a n d o , 1061, p . 8 0 ) . T h e r e f o r e , the onus l i e s on the nurse to assess the p a t i e n t ' s needs and, i f p o s s i b l e , h i s p e r c e p t i o n s of the s i t u a t i o n . The nurses i n t h i s study i n d i c a t e d t h a t , due to communication d i f f i c u l t i e s , i t was f r e q u e n t l y i m p o s s i b l e to assess p a t i e n t s ' p e r c e p t i o n s of the i n t e r a c t i o n . In a d d i t i o n , the nurses seldom mentioned t h a t they asked the p a t i e n t to d e s c r i b e h i s needs or v a l i d a t e t h e i r p e r c e p t i o n s of h i s needs. The c o n s c i o u s use of the n u r s i n g process would focus the nur se s ' a t t e n t i o n on the p a t i e n t ' s needs thereby i n c r e a s i n g the n u r s e s ' e f f e c t i v e n e s s and d e c r e a s i n g the p a t i e n t ' s r e s i s t a n t and d i s r u p t i v e b e h a v i o r . Wel l s (1980) c o n c l u d e d , f o l l o w i n g e x p l o r a t i o n of g e r i a t r i c n u r s e s ' ward work, tha t care focused p r i m a r i l y on r o u t i n e s t h a t might or might not have been a p p r o p r i a t e f o r each p a t i e n t r a t h e r than on p a t i e n t ' s needs . R ichardson (1982) p r o v i d e s a d i f f e r e n t p e r s p e c t i v e on r o u t i n e s by s t a t i n g tha t they can enhance the c o n t i n u i t y of care and minimize u p s e t t i n g changes , thereby b e n e f i t i n g e l d e r l y p a t i e n t s . The nurses i n t h i s study i n d i c a t e d t h a t r o u t i n e s , a l though necessary f o r the o r d e r l y and e f f i c i e n t comple t ion of p h y s i c a l c a r e , needed to be f l e x i b l e and f a c i l i t a t e p e r s o n - o r i e n t e d i n t e r a c t i o n s i n order to p r o v i d e a high q u a l i t y of c a r e . The p r e v a l e n c e of s t e r e o t y p i n g and subsequent l a b e l l i n g among nurses i s wel l e s t a b l i s h e d ( C i l i b e r t o et a l . , 1980; 113 Rodin & Langer , 1980). The e f f e c t s of l a b e l l i n g , such as predetermined e x p e c t a t i o n s , are a l s o wel l documented (Brown, 1967; Coe, 1967) . Throughout the nur se s ' accounts i t i s e v i d e n t t h a t c e r t a i n p a t i e n t s l a b e l l e d as s e v e r e l y confused were not expected to i n t e r a c t i n a p p r o p r i a t e or unders tandab le ways. The nurses m o d i f i e d t h e i r b e h a v i o r s , such as time spent and amount and type of verba l communicat ion , a c c o r d i n g to the p a t i e n t s ' l a b e l s . Al though nurses d i d i d e n t i f y the e x i s t e n c e and the impact of l a b e l l i n g , they d i d not i d e n t i f y t h e i r l a b e l s and subsequent a c t i o n s as pa r t of the same p r o c e s s . The nurses p e r c e i v e d t h a t behav io r s which focused on the p s y c h o s o c i a l a spects of care d u r i n g the n u r s e - p a t i e n t i n t e r a c t i o n r e s u l t e d i n a h i g h e r q u a l i t y of care and consequent ly were more s a t i s f y i n g fo r both the nurses and p a t i e n t s . T h i s o b s e r v a t i o n suggests t h a t p a t i e n t s set a h igher p r i o r i t y on t h e i r needs f o r p s y c h o l o g i c a l comfort and a f f i l i a t i o n with o t h e r s than they p l aced on t h e i r needs fo r p h y s i c a l c o m f o r t . The nur se s ' behav ior s t h a t i n d i v i d u a l i z e d the i n t e r a c t i o n , were person c e n t e r e d r a t h e r than task o r i e n t e d , and i n c r e a s e d p a t i e n t c o n t r o l were p e r c e i v e d as more e f f e c t i v e because they e l i c i t e d p o s i t i v e p a t i e n t r e sponse s . H i r s t and M e t c a l f (1984) s t a t e t h a t " s e l f - e s t e e m i s the f o u n d a t i o n of p s y c h o s o c i a l h e a l t h " (p . 72) . T h e r e f o r e , those n u r s i n g i n t e r v e n t i o n s des igned to meet e l d e r l y p a t i e n t s ' p s y c h o s o c i a l needs w i l l f o s t e r t h e i r s e l f 114 esteem. Because t h e i r s e l f esteem i s t r aumat i zed to such a grea t ex tent through a g i n g , i n s t i t u t i o n a l i z a t i o n , and the l a b e l of c o n f u s i o n a p p l i e d by c a r e g i v e r s , i t seems p o s s i b l e t h a t p a t i e n t s would have many unmet p s y c h o s o c i a l needs . F e i l (1982) s t a t e s t h a t very o l d p a t i e n t s who are d i s o r i e n t e d or confused respond a c c o r d i n g to t h e i r f e e l i n g s r a t h e r than t h e i r t h o u g h t s . I f t h i s i s the ca se , then g r a t i f i c a t i o n of t h e i r p s y c h o s o c i a l needs c o u l d c o n c e i v a b l y be p e r c e i v e d by e l d e r l y , confused p a t i e n t s as more important than a t t e n t i o n to t h e i r p h y s i c a l needs . The l i t e r a t u r e i n d i c a t e s t h a t the decreased persona l c h o i c e a v a i l a b l e to many i n s t i t u t i o n a l ! * z e d e l d e r l y has a nega t ive impact on t h e i r p s y c h o l o g i c a l w e l l - b e i n g ( H u l i c k a , C a t a l d o , M o r g a n t i , & Nehrke, 1983; Langer & R o d i n , 1976) . Watson (1979) i d e n t i f i e s the need f o r c o n t r o l as an important p s y c h o s o c i a l need fo r p a t i e n t s and suggests tha t one way to promote a d a p t i v e responses to p a t i e n t s ' l ack of c o n t r o l i s to p r o v i d e a c c u r a t e i n f o r m a t i o n p lus a v a i l a b l e a l t e r n a t e r e sponse s . Numerous s t u d i e s have r e p o r t e d i n c r e a s e s i n the p h y s i c a l and p s y c h o l o g i c a l wel l be ing of e l d e r l y people g iven r e s p o n s i b i l i t y f o r some aspect s of t h e i r d a i l y l i f e (Langer & R o d i n , 1976; Rodin & Langer , 1977) . Many nurses i n t h i s study r e p o r t e d t h a t they were c o n s c i o u s of p a t i e n t s ' need fo r c o n t r o l and i n re sponse , p r o v i d e d p a t i e n t s with o p p o r t u n i t i e s to choose when, how, and where they would i n t e r a c t . 115 Al though the nurses r e c o g n i z e d the need fo r p a t i e n t c o n t r o l , the degree of p h y s i c a l independence and the number of d e c i s i o n - m a k i n g o p p o r t u n i t i e s made a v a i l a b l e to p a t i e n t s were i n f l u e n c e d by the p a t i e n t s ' behav ior and by c e r t a i n e x t e r n a l f a c t o r s . When p a t i e n t s ' behav ior was d i s r u p t i v e or when e x t e r n a l f a c t o r s , such as time c o n s t r a i n t s , a d v e r s e l y a f f e c t e d the i n t e r a c t i o n , p a t i e n t s ' o p p o r t u n i t i e s to e x e r c i s e some c o n t r o l w i t h i n the i n t e r a c t i o n d e c r e a s e d . I t seems p o s s i b l e tha t nurse behav io r s t h a t i n c r e a s e d p a t i e n t s ' c o n t r o l were not seen by these nurses as an i n t e g r a l pa r t of c a r i n g but r a t h e r were i n t e r v e n t i o n s implemented only i n c e r t a i n c i r c u m s t a n c e s . The nurses were mot iva ted to withdraw from i n t e r a c t i o n s tha t they c o n s i d e r e d were not p r o g r e s s i n g toward achievement of the goa l s of c o m f o r t , c o o p e r a t i o n , and c o n t a c t and were u p s e t t i n g fo r both the nurses and p a t i e n t s . The nurses p e r c e i v e d t h a t l e a v i n g the s i t u a t i o n or removing p a t i e n t s from the s i t u a t i o n enhanced p a t i e n t s ' c o n t r o l to some ex tent because by ending the i n t e r a c t i o n they d i s c o n t i n u e d t h e i r attempts to c o n t r o l p a t i e n t s ' a c t i o n s . A l t h o u g h , t h e l i t e r a t u r e g ive s l i t t l e d i r e c t i o n f o r nurses i n v o l v e d i n these u p s e t t 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 , wi thdrawing from the i n t e r a c t i o n i s not c o n s i d e r e d an e f f e c t i v e way of i n c r e a s i n g p a t i e n t c o n t r o l ( C o h l e r & S h a p i r o , 1964; T u d o r , 1952) . Other a u t h o r s , w h i l e not i n d i c a t i n g t h a t i t i s b e n e f i c i a l to p a t i e n t s , do s t a t e t h a t at t imes i t i s best to 116 leave the s i t u a t i o n and a v o i d a rgu ing with the p a t i e n t ( R i c h a r d s o n , 1982). The nurses who removed p a t i e n t s from the s i t u a t i o n i n d i c a t e d t h a t t h i s nurse behav ior was not h e l p f u l in changing p a t i e n t b e h a v i o r . The l i t e r a t u r e i n d i c a t e s tha t moving p a t i e n t s from a source of p o t e n t i a l i n t e r a c t i o n by i s o l a t i n g them from o ther s i s a means of n u r s i n g c o n t r o l t h a t i s d e t r i m e n t a l to them (Meacher , 1972; Watson, 1979) . R ichardson (1982) , i n an a r t i c l e on o r g a n i c b r a i n syndrome, suggests t h a t d i v e r t i n g p a t i e n t s ' a t t e n t i o n d u r i n g u p s e t t i n g i n t e r a c t i o n s may decrease the s t r e s s of the i n t e r a c t i o n . T h i s i n t e r v e n t i o n i s o f ten e f f e c t i v e because of p a t i e n t s ' d i m i n i s h e d shor t term memory. The nurses i n t h i s study i d e n t i f i e d the use of d i v e r s i o n t echniques as e f f e c t i v e with some p a t i e n t s d u r i n g u p s e t t i n g i n t e r a c t i o n s . In a d d i t i o n to nurse and p a t i e n t behav io r s t h a t i n f l u e n c e d the q u a l i t y of p a t i e n t c a r e , the nurses i d e n t i f i e d some e x t e r n a l f a c t o r s t h a t c o n s i s t e n t l y i n f l u e n c e d the n u r s e - p a t i e n t i n t e r a c t i o n and consequent ly the n u r s e s ' a b i l i t y to p r o v i d e a high q u a l i t y of c a r e . I n s t i t u t i o n a l i z a t i o n , r e l o c a t i o n , and the d e p e r s o n a l i z i n g approaches of o ther c a r e g i v e r s were i d e n t i f i e d as f a c t o r s which reduced p a t i e n t s ' independence and c o n t r o l over t h e i r sur roundings and d a i l y a c t i v i t i e s . P a t i e n t s ' responses to t h i s r e d u c t i o n i n c o n t r o l were d e s c r i b e d as a g g r e s s i v e or wi thdrawn. The l o s s of mastery (or c o n t r o l ) ' o v e r v a r i o u s persona l f u n c t i o n s and over one ' s 117 s i t u a t i o n can r e s u l t i n a poor sense of s e l f esteem and mani fe s t s i t s e l f as i n s e c u r i t y and withdrawal or r e s i s t a n t , d i s r u p t i v e behav ior ( H i r s t & M e t c a l f , 1984; J a h r a u s , 1979). Low s t a f f - p a t i e n t r a t i o s and consequent time c o n s t r a i n t s were i d e n t i f i e d as e x t e r n a l f a c t o r s t h a t reduced the q u a l i t y of p a t i e n t care t h a t the nurses were able to p r o v i d e and consequent ly decreased t h e i r sense of job s a t i s f a c t i o n . These f a c t o r s , e s p e c i a l l y time c o n s t r a i n t s , were a r e c u r r e n t theme throughout the nur se s ' a c c o u n t s . Godfrey (1978) s t u d i e d job s a t i s f a c t i o n among nurses i n general and found widespread d i s s a t i s f a c t i o n c o n c e r n i n g u n d e r s t a f f i n g . Wel l s (1980) a l so found u n d e r s t a f f i n g a concern among g e r i a t r i c n u r s e s . W e l l s , w h i l e acknowledging the i n s u f f i c i e n t s t a f f - p a t i e n t r a t i o , i n d i c a t e d t h a t nurses focused on s t a f f shortages to the e x c l u s i o n of o ther e v i d e n t prob lems . The n u r s e s ' i n t e r a c t i o n s with o ther members of the h e a l t h care team a l so impacted on job s a t i s f a c t i o n and c a r e g i v i n g . B r a i t o and Caston (1983) conc lude from t h e i r study of f a c t o r s i n f l u e n c i n g nur se s ' job s a t i s f a c t i o n , t h a t cohes ion among c a r e g i v e r s was one of the s t r o n g e s t c o n t r i b u t o r s to job s a t i s f a c t i o n . The nurses i n t h i s study i n d i c a t e d tha t i n t e r a c t i o n s with o ther c a r e g i v e r s p r o f o u n d l y a f f e c t e d t h e i r c a r e g i v i n g . Godfrey (1978) found tha t 57% of her sample found n u r s i n g a d m i n i s t r a t o r s s u p p o r t i v e of c a r e g i v e r s whi le 70% of nurses r e p o r t e d p o s i t i v e feedback 118 from f a m i l i e s . The nurses in t h i s study were s p l i t i n t h e i r p e r c e p t i o n s of a d m i n i s t r a t o r s and managers as e i t h e r e f f e c t i v e or i n e f f e c t i v e but d i d i n d i c a t e tha t they were very i n f l u e n t i a l with r e s p e c t to c a r e g i v i n g and job s a t i s f a c t i o n . The nurses i d e n t i f i e d t h a t pr imary n u r s i n g enhanced t h e i r knowledge of p a t i e n t s and i n c r e a s e d t h e i r a c c o u n t a b i l i t y fo r i n d i v i d u a l p a t i e n t s r a t h e r than f o r p a t i e n t s as a group. T h i s he lped the nurses to i n d i v i d u a l i z e and humanize t h e i r p a t i e n t c a r e . Mezey (1983) concurs t h a t a pr imary nurse ass ignment i s important e s p e c i a l l y i n long term care as the nurse i s able to p lan care based on data tha t she has c o l l e c t e d over time and can more e a s i l y r e c o g n i z e s i g n i f i c a n t changes i n the p a t i e n t s ' r e sponse s . Only those nurses c u r r e n t l y working as primary nurses i d e n t i f i e d t h i s system of c a r e g i v i n g as advantageous . T h i s s e c t i o n has d i s c u s s e d the n u r s e s ' i n t e r p r e t a t i o n of the c a r i n g process which o c c u r r e d d u r i n g the i n t e r a c t i o n . I t i s e v i d e n t that many of the n u r s e s ' and p a t i e n t s ' behav ior s and e x t e r n a l f a c t o r s i n h e r e n t i n t h i s i n t e r a c t i o n acted as b a r r i e r s to e f f e c t i v e c a r i n g . T h i s , i n t u r n , r e s u l t e d i n an i n t e r a c t i o n t h a t was p o t e n t i a l l y s t r e s s f u l fo r both the nurse and the p a t i e n t . The next s e c t i o n d i s c u s s e s the nur se s ' p e r c e p t i o n s of the s t r e s s f u l s i t u a t i o n s t h a t o c c u r r e d d u r i n g the i n t e r a c t i o n . 119 I n t e r a c t i o n as a Source of S t r e s s fo r the Nurse The r e a l i t y of c a r i n g fo r and communicating with p a t i e n t s who i n t e r a c t i n ways tha t are u n p r e d i c t a b l e and d i f f i c u l t to unders tand i s s t r e s s f u l f o r the n u r s e . The nurses i n t h i s study c l e a r l y i d e n t i f i e d numerous sources of s t r e s s o r i g i n a t i n g both w i t h i n the i n t e r a c t i o n and from f a c t o r s o u t s i d e of the i n t e r a c t i o n . T h i s s e c t i o n w i l l d i s c u s s the nur se s ' accounts of s t r e s s f u l a spect s of the i n t e r a c t i o n and r e l a t e them to the l i t e r a t u r e . I t i s i n t e r e s t i n g to note t h a t , d e s p i t e the i n c r e a s e i n the amount of r e sea rch and the number of p u b l i c a t i o n s c o n c e r n i n g g e r o n t o l o g i c a l n u r s i n g , there i s a p a u c i t y of l i t e r a t u r e a d d r e s s i n g the problem of s t r e s s r e l a t e d to i n t e r a c t i n g with e l d e r l y , confused p a t i e n t s . T h i s c l o s e l y p a r a l l e l s the l a ck of r e l e v a n t l i t e r a t u r e r e l a t e d to the concept of c o n f u s i o n . Beck and P h i l l i p s (1983) s t a t e t h a t high s t r e s s l e v e l s are a s s o c i a t e d with c a r i n g fo r c o n f u s e d , e l d e r l y p e o p l e . Al though . they are w r i t i n g about f a m i l y c a r e g i v e r s , the c o g n i t i v e and s o c i a l p a t i e n t behav ior s t h a t they pre sent as s t r e s s f u l f o r c a r e g i v e r s are s i m i l a r to those i d e n t i f i e d by the nurses in t h i s s t u d y . Wolanin and P h i l l i p s (1981) i n d i c a t e t h a t much of the s t r e s s d e s c r i b e d by nurses o r i g i n a t e s from c a r i n g f o r p a t i e n t s who do not " r e a c t or communicate i n p r e d i c t a b l e p a t t e r n s " (p . 372) . The nurses i n d i c a t e d tha t those i n t e r a c t i o n s where p a t i e n t s e x h i b i t e d behav io r s d e s c r i b e d as d i s r u p t i v e , u n r e s p o n s i v e , and 120 u n p r e d i c t a b l e were p r o b l e m a t i c fo r them. They d e s c r i b e d these p a t i e n t behav ior s as problems because they made i t d i f f i c u l t f o r the nurses to complete t a s k s , e l i c i t responses t h a t i n d i c a t e d tha t the p a t i e n t s were aware, v a l i d a t e t h e i r a c t i o n s , and p r e d i c t what p a t i e n t s would do d u r i n g the i n t e r a c t i o n . Lauer and Handel (1977) s t a t e tha t the t h i n g s one encounters w i t h i n the i n t e r a c t i o n are d e f i n e d i n terms of t h e i r r e l e v a n c e fo r one ' s p lan of a c t i o n . T h e r e f o r e , behav ior s tha t i n t e r f e r e d with the nur se s ' p lan of a c t i o n c o u l d be i n t e r p r e t e d by them as problems and consequent ly be p e r c e i v e d as s t r e s s f u l . Watson (1979) s t a t e s t h a t s t r e s s w i t h i n any n u r s e - p a t i e n t i n t e r a c t i o n occurs when something i n t e r r u p t s the i n d i v i d u a l ' s planned a c t i v i t i e s . These statements concur wi th the statements made by the nurses r e g a r d i n g the impact of p a t i e n t s ' b e h a v i o r s . The nurses r e p o r t e d t h a t p a t i e n t behav io r s which c l e a r l y i n d i c a t e d t h e i r a p p r e c i a t i o n o c c u r r e d i n f r e q u e n t l y . Other authors have i d e n t i f i e d t h i s l ack of a p p r e c i a t i v e behav ior as both s t r e s s f u l and as o c c u r r i n g f r e q u e n t l y d u r i n g i n t e r a c t i o n s wi th p a t i e n t s i d e n t i f i e d as confused ( H a y t e r , 1981) . Those nurses needing more obvious e x t e r n a l rewards f e l t f r u s t r a t e d and l e s s s a t i s f i e d than those nurses who were able to f ee l a p p r e c i a t e d and rewarded i n response to more s u b t l e p a t i e n t b e h a v i o r s . B r a i t o and Caston (1983) found tha t the s i n g l e l a r g e s t c o n t r i b u t o r to job 121 s a t i s f a c t i o n among nurses was the i n t r i n s i c rewards of t h e i r work ( i . e . , the degree to which they found the work s e l f - f u l f i l l i n g ) . Perhaps those nurses who d i d not f e e l t h a t working with e l d e r l y , confused p a t i e n t s was s e l f - f u l f i l l i n g needed to exper i ence more e x t e r n a l rewards than o ther nurses and when they were not f o r t h c o m i n g , e x p e r i e n c e d a g r e a t e r degree of s t r e s s . D i s c r e p a n c i e s i n each n u r s e ' s a b i l i t y to cope wi th the s t r e s s w i t h i n the i n t e r a c t i o n , t h a t i s , to remain with the p a t i e n t and a v o i d wi thdrawing e i t h e r p h y s i c a l l y or p s y c h o l o g i c a l l y , were e v i d e n t throughout the s tudy . Al though s e v e r a l s t u d i e s noted s t a b l e , i n d i v i d u a l d i f f e r e n c e s i n i n t e r a c t i o n among n u r s e s , they were unable to e x p l a i n these v a r i a t i o n s ( C o h l e r & S h a p i r o , 1964; Hargreaves , 1968; H a t t o n , 1977). Al though t h i s s e c t i o n d i s c u s s e s the i n t e r a c t i o n as a source of s t r e s s , the nurses i n d i c a t e d tha t i t was made more s t r e s s f u l by f a c t o r s tha t o c c u r r e d o u t s i d e of the n u r s e - p a t i e n t i n t e r a c t i o n . The i n f l u e n c e of e x t e r n a l f a c t o r s on p a t i e n t behav ior and nurse behav ior w i t h i n the i n t e r a c t i o n i s wel l documented (Whi te , 1977; Wolanin & P h i l l i p s , 1981; Y u r i c k et a l . , 1982). As noted at the b e g i n n i n g of t h i s c h a p t e r , these f a c t o r s do not determine the n u r s e s ' a c t i o n s but are o b j e c t s w i t h i n the s i t u a t i o n which have meaning fo r the n u r s e . T h e r e f o r e , they must be 122 d e f i n e d and i n t e r p r e t e d by the nurses as pa r t of the s i t u a t i o n p r i o r to t h e i r a c t i o n s w i t h i n the i n t e r a c t i o n . The nurses p e r c e i v e d t h a t f a t i g u e and time c o n s t r a i n t s c r e a t e d s t r e s s w i t h i n the n u r s e - p a t i e n t i n t e r a c t i o n because they decreased the p e r s o n - o r i e n t e d nature and the frequency of i n t e r a c t i o n s . Because the nurses b e l i e v e d these aspects of the i n t e r a c t i o n to be i m p o r t a n t , a c o n f l i c t was c r e a t e d between what the nurses d e s i r e d to do and what they p e r c e i v e d was f e a s i b l e g iven the s i t u a t i o n . Wolanin and P h i l l i p s (1980) acknowledge t h a t " c o n f l i c t may a r i s e because of a need to care fo r the e l d e r l y i n a way [ the nurse] would l i k e to be cared fo r and the l ack of time . . . to do i t " (p . 372) , but i n d i c a t e tha t there are no r e a l i s t i c s o l u t i o n s to the prob lem. Other authors do not i n d i c a t e t h a t t h i s c o n f l i c t e x i s t e d fo r the nurses i n t h e i r s t u d i e s (Meacher, 1972 ;. W e l l s , 1980), a l though they do i n d i c a t e t h a t nurses e x p e r i e n c e d s t r e s s when they were unable to complete a l l the r e q u i r e d tasks because of time c o n s t r a i n t s and l a ck of p a t i e n t c o o p e r a t i o n . The nurses d e s c r i b e d , i n d e t a i l , the poor q u a l i t y of care g iven by some o ther c a r e g i v e r s . Menzies (1960) a l so found t h a t nurses h a b i t u a l l y compla ined about the poor q u a l i t y of care g iven by o ther n u r s e s . Menzies a t t r i b u t e s t h i s behav ior to nur se s ' system of d e n i a l which prompts them to i s o l a t e unacceptab le a spects of t h e i r c a r e g i v i n g and p r o j e c t them onto o ther n u r s e s . Al though the c o n f l i c t tha t 123 a r i s e s among s t a f f when they p e r c e i v e o ther s to be g i v i n g poor care i s s t r e s s f u l , Menzies says i t i s l e s s s t r e s s f u l than acknowledging the unacceptab le a spects of one ' s own c a r e g i v i n g p r a c t i c e s . Some nurses p e r c e i v e d p a t i e n t s as unable to meet t h e i r needs and consequent ly as dependent on the nurses fo r a s s i s t a n c e to meet them. The nur se s ' f r u s t r a t i o n and sadness stemmed from t h e i r p e r c e i v e d i n a b i l i t y to meet these needs p lus t h e i r p e r c e p t i o n of p a t i e n t s as never becoming any l e s s dependent . The nurses d i d not l a b e l these f e e l i n g s as hope les snes s and h e l p l e s s n e s s but i t seems tha t some nurses were f e e l i n g h e l p l e s s to meet p a t i e n t s ' needs and hopeless about p a t i e n t s ' p o t e n t i a l f o r improvement. These are not uncommon a f f e c t i v e responses when nurses are working with p a t i e n t s e x p e r i e n c i n g permanent d i s a b i l i t i e s or t e rmina l i l l n e s s . A number of authors i d e n t i f y t h a t , w i t h i n a c u r e - o r i e n t e d h e a l t h care system, nurses c a r i n g fo r p a t i e n t s who cannot be r e s t o r e d to a p r e v i o u s l e v e l of h e a l t h are s u b j e c t to s t r e s s brought on by t h r e a t s to t h e i r p r o f e s s i o n a l s e l f ( B u r c h e t t , 1967; H o l s c l a w , 1965). I t seems p o s s i b l e t h a t another a s s a u l t on the g e r i a t r i c nur se s ' p r o f e s s i o n a l s e l f comes from those nurses who, because o f t h e i r c u r e - o r i e n t e d framework, p e r c e i v e g e r i a t r i c nurses as l e s s able and l e s s v a l u a b l e . The study nurses i n d i c a t e d tha t o ther nurses d i d not va lue and unders tand t h e i r work. T h i s f i n d i n g i s c o n s i s t e n t with those of Wel l s 124 (1980) who found " u n e x p e c t e d l y " tha t the g e r i a t r i c nurses i n her study d i s l i k e d the d i s p a r a g i n g comments and a c t i o n s of o ther nurses and h e a l t h p r o f e s s i o n s toward g e r i a t r i c nur se s . Wel l s s t a t e s tha t there was a sense of genuine anger e v i d e n t in the statements of the g e r i a t r i c n u r s e s . Other authors a l so i d e n t i f y the low s t a tu s p o s i t i o n of g e r i a t r i c nurses as being s t r e s s f u l ( B u r c h e t t , 1967; Y u r i c k et al . , 1982) . One means of d e a l i n g wi th these s i t u a t i o n s tha t are p e r s o n a l l y and p r o f e s s i o n a l l y t h r e a t e n i n g i s to wi thdraw, e i t h e r p h y s i c a l l y or p s y c h o l o g i c a l l y , by f o c u s i n g on the t a s k - o r i e n t e d aspects of the i n t e r a c t i o n and on the i l l n e s s r a t h e r than on the person ( H o l s c l a w , 1965; M e n z i e s , 1960). Ward s i t u a t i o n s tha t r e i n f o r c e the s p l i t t i n g of 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 n t o f u n c t i o n a l ta sks and r i t u a l i z e d procedures r e i n f o r c e the nur se s ' p s y c h o l o g i c a l withdrawal ( M e n z i e s , 1960) . The nurses i n t h i s study i n d i c a t e d t h a t they withdrew both p h y s i c a l l y and p s y c h o l o g i c a l l y when they were no longer ab le to deal wi th the s t r e s s apparent w i t h i n the i n t e r a c t i o n . I m p l i c i t w i t h i n the concept of c a r i n g i s the humani s t i c approach and t h e r a p e u t i c involvement of the nur se , tha t i s , her commitment to the person r a t h e r than to the h e a l t h problem tha t brought him i n t o c o n t a c t with h e r . T h i s n u r s i n g involvement p l ace s the nurse i n a p o s i t i o n of g r e a t e r v u l n e r a b i l i t y and h igher emotional r i s k ( H o l s c l a w , 1965; R o b e r t s , 1976) . The emotional r e a c t i o n of the study 125 nurses to the n u r s e - p a t i e n t i n t e r a c t i o n i n d i c a t e s the ex tent of the nur se s ' commitment to c a r i n g fo r t h e i r p a t i e n t s i n the best way they c o u l d . The nurses responded to the i n t e r a c t i o n with s t rong p o s i t i v e and nega t ive f e e l i n g s . When the i n t e r a c t i o n was s t r e s s f u l , the nurses r e a c t e d with f e e l i n g s of anger , f r u s t r a t i o n , and g u i l t . F e e l i n g s of g u i l t were i d e n t i f i e d by Wolanin and P h i l l i p s (1981) as being p e r v a s i v e when nurses f ee l they have "not g iven good or even adequate c a r e " (p . 372) . Beck and P h i l l i p s (1983) i d e n t i f y f e e l i n g s of anger and f r u s t r a t i o n as be ing a common response of f a m i l y c a r e g i v e r s to the s t r e s s of c o n t i n u a l i n t e r a c t i o n wi th e l d e r l y , confused p e o p l e . The nurses in t h i s study i n d i c a t e d tha t t h e i r i n t e r a c t i o n s with p a t i e n t s i d e n t i f i e d as confused were plagued by problems t h a t p r e c l u d e d e f f e c t i v e communication and c a r i n g . Because of these problems , the i n t e r a c t i o n s were s t r e s s f u l . Summary T h i s chapter began with a general d i s c u s s i o n of the f i n d i n g s i n r e l a t i o n to the n u r s e - p a t i e n t i n t e r a c t i o n . The remaining s e c t i o n s presented a d i s c u s s i o n of the f i n d i n g s as they r e l a t e d to communicat ion , c a r e g i v i n g , and s t r e s s w i t h i n the i n t e r a c t i o n . The n u r s e - p a t i e n t i n t e r a c t i o n was r e c i p r o c a l i n nature and goal d i r e c t e d . Problems arose when the nurses and 126 p a t i e n t s were unable to a s s i gn m u t u a l l y unders tandable meanings to behav ior d u r i n g the i n t e r a c t i o n . Communicat ion, c a r e g i v i n g , and s t r e s s w i t h i n the i n t e r a c t i o n were i n f l u e n c e d by f a c t o r s o u t s i d e of the i n t e r a c t i o n . N u r s e - p a t i e n t communication was a d v e r s e l y a f f e c t e d by p a t i e n t s ' e x p r e s s i v e and r e c e p t i v e d i f f i c u l t i e s and the nur se s ' i n a b i l i t y to unders tand p a t i e n t s ' communication b e h a v i o r . Communication s t r a t e g i e s were more e f f e c t i v e when they were p e r s o n a l i z e d , f a c i l i t a t e d p a t i e n t c h o i c e , and were n o n v e r b a l . The nurses a s s o c i a t e d communication a b i l i t i e s with the p a t i e n t s ' l e v e l of c o n f u s i o n . P a t i e n t behav io r s n e g a t i v e l y i n f l u e n c e d c a r e g i v i n g because they were u p s e t t i n g fo r nurses and gave nurses l i t t l e d i r e c t i o n f o r p l a n n i n g t h e i r c a r e . The g r e a t e r the extent to which the nur se s ' behav ior s focused on p a t i e n t s ' p s y c h o s o c i a l needs , t h a t i s , p a t i e n t s ' needs fo r c o n t r o l and persona l c o n t a c t , the more s a t i s f y i n g the i n t e r a c t i o n was fo r both the nurses and p a t i e n t s . The nurses p e r c e i v e d tha t t h e i r i n t e r a c t i o n s with e l d e r l y , confused p a t i e n t s were f r e q u e n t l y s t r e s s f u l . Nurses p e r c e i v e d these i n t e r a c t i o n s as s t r e s s f u l because they were u n p r e d i c t a b l e , u p s e t t i n g , and d i f f i c u l t to u n d e r s t a n d . The nurses a l s o e x p e r i e n c e d s t r e s s because they focused on c a r i n g r a t h e r than c u r i n g i n a r e l a t i v e l y c u r e - o r i e n t e d h e a l t h care system. The nurses responded to 127 the s t r e s s w i t h i n the i n t e r a c t i o n by wi thdrawing p h y s i c a l l y and/or p s y c h o l o g i c a l l y . 128 CHAPTER SIX Summary, C o n c l u s i o n s , and I m p l i c a t i o n s The study was des igned to p rov ide i n s i g h t i n t o under s t and ing the nur se s ' p e r c e p t i o n s of t h e i r i n t e r a c t i o n s wi th e l d e r l y p a t i e n t s i d e n t i f i e d as c o n f u s e d . T h i s chapter begins wi th a summary of the s tudy , f o l l o w e d by the c o n c l u s i o n s , and the i m p l i c a t i o n s fo r n u r s i n g p r a c t i c e , e d u c a t i o n , and r e s e a r c h . Summary T h i s study e x p l o r e d the nur se s ' i n t e r p r e t a t i o n s of t h e i r i n t e r a c t i o n s with e l d e r l y , confused p a t i e n t s . T h i s i n t e r a c t i o n has been d e s c r i b e d as f r aught wi th problems tha t p r e c l u d e the p r o v i s i o n of care which i s a t tuned to p a t i e n t s ' needs. S ince the nurses are the pr imary c a r e g i v e r s , an under s t and ing of t h e i r p e r s p e c t i v e would p rov ide v a l u a b l e i n s i g h t i n t o these problems . The i n f o r m a t i o n from t h i s study should p r o v i d e d i r e c t i o n fo r e d u c a t o r s , a d m i n i s t r a t o r s , c l i n i c i a n s , and s t a f f nurses to beg in f o c u s i n g on ways to i n c r e a s e the e f f e c t i v e n e s s of t h i s i n t e r a c t i on . T h i s e x p l o r a t o r y study examined the n u r s e - p a t i e n t i n t e r a c t i o n w i t h i n the framework of symbol ic i n t e r a c t i o n . T h i s t h e o r e t i c a l p e r s p e c t i v e c o n c e p t u a l i z e s the i n t e r a c t i o n as a process tha t determines human behav ior r a t h e r than a v e h i c l e fo r the e x p r e s s i o n of human b e h a v i o r . Human 129 behav ior depends upon the meaning a t t r i b u t e d to a l l t h i n g s , human and o t h e r w i s e , i n d i c a t i n g t h a t the meaning of an o b j e c t i s not i n h e r e n t but a r i s e s out of the i n t e r a c t i o n . The meaning which a person a t t aches to something determines the way tha t the i n d i v i d u a l p e r c e i v e s the t h i n g , i s ready to ac t toward i t , and i s ready to t a l k about i t (Blumer , 1969) . The theory of symbol ic i n t e r a c t i o n p r o v i d e d d i r e c t i o n fo r the problem s ta tement , study q u e s t i o n s , and the cod ing and a n a l y s i s of d a t a . A l i t e r a t u r e review was conducted to e x p l o r e (a) the concept of c o n f u s i o n as i t r e l a t e d to e l d e r l y p a t i e n t s , (b) n u r s e s ' a t t i t u d e s toward e l d e r l y p a t i e n t s , and (c) n u r s e - p a t i e n t i n t e r a c t i o n s with e l d e r l y p a t i e n t s . The review r e v e a l e d the p a u c i t y of n u r s i n g l i t e r a t u r e r e l a t e d to e l d e r l y , confused p a t i e n t s . The r e l e v a n t l i t e r a t u r e i n d i c a t e d t h a t the concept of c o n f u s i o n was i n c o n s i s t e n t l y d e f i n e d and p r o v i d e d l i t t l e d i r e c t i o n fo r n u r s e s . I t a l so showed t h a t the concept was i n t e r a c t i o n a l i n nature and was r e l a t e d to communication problems . As no r e l e v a n t s t u d i e s e x p l o r i n g n u r s e s ' a t t i t u d e s toward e l d e r l y , confused p a t i e n t s were found , i t was assumed t h a t behav ior i d e n t i f i e d as c o n f u s i o n would exaggerate a l r eady e x i s t i n g a t t i t u d e s . The a t t i t u d e s t u d i e s , e x p l o r e d i n the l i t e r a t u r e r e v i e w , i n d i c a t e d t h a t nur se s ' i n t e r a c t i o n s were o f t e n , a l though not a lways , n e g a t i v e l y i n f l u e n c e d by t h e i r a t t i t u d e s c o n c e r n i n g e l d e r l y p a t i e n t s . The l i t e r a t u r e which 130 addressed these 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 n d i c a t e d t h a t they presented numerous problems which compromised communication and c a r e g i v i n g . T h i s was a d e s c r i p t i v e study which e x p l o r e d the nur se s ' i n t e r p r e t a t i o n of t h e i r b e h a v i o r , p a t i e n t s ' b e h a v i o r , and the e x t e r n a l f a c t o r s i n f l u e n c i n g the i n t e r a c t i o n . The study was conducted with a convenience sample of 18 R e g i s t e r e d Nurses working i n one of three extended care u n i t s . The r e s e a r c h e r , u s ing an u n s t r u c t u r e d i n t e r v i e w , c o l l e c t e d q u a l i t a t i v e data from the n u r s e s . Each nurse was i n t e r v i e w e d once with i n t e r v i e w times rang ing from 45 to 90 mi nu te s . The q u a l i t a t i v e data were t r a n s c r i b e d verba t im and coded as e i t h e r p a t i e n t b e h a v i o r s , nurse b e h a v i o r s , or e x t e r n a l f a c t o r s . Each group of coded data was c a t e g o r i z e d fo r the purposes of answering the study q u e s t i o n s . The frequency of responses and the data i n each ca tegory were then d e s c r i b e d . S ix c a t e g o r i e s of behav io r s emerged from the data coded as p a t i e n t b e h a v i o r s . P a t i e n t s ' behav ior s impacted on the nur se s ' b e h a v i o r s by i n f l u e n c i n g the f requency and type of communication and c a r e g i v i n g behav io r s which o c c u r r e d dur ing the i n t e r a c t i o n . The data coded as nurse behav ior s were d i s c u s s e d w i t h i n the framework of the n u r s e - p a t i e n t i n t e r a c t i o n . The nur se s ' behav io r s w i t h i n the p r e i n t e r a c t i o n and i n t r o d u c t o r y phases 131 of the i n t e r a c t i o n were concerned with g e t t i n g to know the p a t i e n t . In format ion gathered d u r i n g these phases i n c r e a s e d the nur se s ' under s t and ing of p a t i e n t s ' behav ior and the e f f e c t i v e n e s s of t h e i r c a r e . The nur se s ' behav ior s w i t h i n the working phase focused on humanizing the i n t e r a c t i o n , communicating with p a t i e n t s , i n f l u e n c i n g p a t i e n t s ' c o n t r o l , and re sponding to u p s e t t i n g p a t i e n t b e h a v i o r s . The data coded as e x t e r n a l f a c t o r s were c a t e g o r i z e d a c c o r d i n g to the source of the f a c t o r s and named a c c o r d i n g l y as p e r s o n a l , i n t e r p e r s o n a l , and impersonal f a c t o r s . W i t h i n each c a t e g o r y , the nurses i d e n t i f i e d some f a c t o r s tha t p o s i t i v e l y i n f l u e n c e d the i n t e r a c t i o n but the m a j o r i t y of a l l f a c t o r s were p e r c e i v e d by the nurses as b a r r i e r s to e f f e c t i v e i n t e r a c t i o n s . The f a c t o r s i n each ca tegory i n f l u e n c e d the p a t i e n t s ' b e h a v i o r a l s t a b i l i t y , the n u r s e s ' morale and enthus i a sm, and/or the p e r s o n - o r i e n t e d focus of the i n t e r a c t i o n . Three themes, a l l u d i n g to the meanings which the nurses a t t a c h e d to the i n t e r a c t i o n , were e v i d e n t across the 3 groups of coded d a t a . The nurses i n t e r p r e t e d the i n t e r a c t i o n as (a) a means of communicat ion , (b) a v e h i c l e fo r c a r i n g , and (c) a source of s t r e s s . P a t i e n t behav io r s were i d e n t i f i e d as b a r r i e r s to communication because they d i d not have a s i m i l a r meaning f o r the nurses and p a t i e n t s and t h e r e f o r e p r e c l u d e d mutual u n d e r s t a n d i n g . Some of the nur se s ' communication behav io r s 132 focused on overcoming the e f f e c t s of p a t i e n t behav ior but some r e s u l t e d i n d e p e r s o n a l i z a t i o n of the i n t e r a c t i o n e s p e c i a l l y when the i n t e r a c t i o n was task o r i e n t e d . P a t i e n t s ' behav io r s were d e s c r i b e d as i n f l u e n c i n g the nur se s ' c a r e g i v i n g b e h a v i o r s . Care tha t focused on p a t i e n t s ' u p s e t t i n g behav io r s and p h y s i c a l needs was l e s s s a t i s f y i n g fo r the nurses and p a t i e n t s than care tha t humanized the i n t e r a c t i o n s and encouraged p a t i e n t c o n t r o l . These behav io r s were p e r c e i v e d as r e p r e s e n t i n g a h i g h e r q u a l i t y of care and were more s a t i s f y i n g fo r both the nurses and p a t i e n t s . Those p a t i e n t behav io r s and e x t e r n a l f a c t o r s t h a t produced a c o n f l i c t between the nur se s ' a c tua l and d e s i r e d behav ior s and t h a t i n c r e a s e d the u n p r e d i c t a b i l i t y and l ack of under s t and ing between the nurses and p a t i e n t s c r e a t e d s t r e s s and decreased job s a t i s f a c t i o n f o r the n u r s e s . C o n c l u s i o n s 1. P a t i e n t behav io r s c h a r a c t e r i s t i c of c o n f u s i o n i n f l u e n c e the n u r s e - p a t i e n t i n t e r a c t i o n by r e d u c i n g the f requency wi th which nurses a t t a c h unders tandable meaning to p a t i e n t s ' b e h a v i o r . T h i s l ack of under s t and ing impedes the e f f e c t i v e n e s s of and s a t i s f a c t i o n with the i n t e r a c t i o n . 2. There are d i f f e r i n g degrees of c o n f u s i o n both among p a t i e n t s and w i t h i n one p a t i e n t at v a r i o u s t i m e s . Those p a t i e n t s p e r c e i v e d as having fewer unders tandable or 133 a p p r o p r i a t e behav io r s are i d e n t i f i e d as more s e v e r e l y confused and are at r i s k to r e c e i v e l e s s f requent i n t e r a c t i o n s tha t are more task o r i e n t e d than person o r i e n t e d . 3. When nur se s ' c a r i n g and communication behav io r s occur l e s s f r e q u e n t l y and are more task o r i e n t e d than person o r i e n t e d , the nurses exper ience the i n t e r a c t i o n as s t r e s s f u l and d i s s a t i s f y i n g and subsequent ly withdraw from the i n t e r a c t i on . 4. Based on p a t i e n t s ' r e sponse s , the nurses p e r c e i v e d t h a t t h e i r c a r i n g and communication behav io r s have more meaning to p a t i e n t s when they are focused on p a t i e n t s ' p s y c h o s o c i a l needs as wel l as t h e i r p h y s i c a l needs . 5. E x t e r n a l f a c t o r s i n f l u e n c e the nur se s ' and p a t i e n t s ' behav io r s by e i t h e r f a c i l i t a t i n g or impeding t h e i r a b i l i t y to a s s i gn a m u t u a l l y unders tandable meaning to each o t h e r ' s behav ior d u r i n g the i n t e r a c t i o n . The amount of under s t and ing between the nurses and p a t i e n t s d u r i n g the i n t e r a c t i o n i n f l u e n c e s the q u a l i t y of care and communi c a t i o n . 134 I m p l i c a t i o n s fo r Nurs ing Nurs ing P r a c t i c e Nurses i n t e r a c t i n g wi th e l d e r l y p a t i e n t s i d e n t i f i e d as confused should focus on under s t and ing the meaning t h a t p a t i e n t s a s s i gn to t h e i r own and o t h e r s ' b e h a v i o r . Us ing the n u r s i n g process would enhance the nur se s ' knowledge of p a t i e n t s ' i n d i v i d u a l needs , unique p e r s o n a l i t y , and background, thereby i n c r e a s i n g t h e i r awareness of p a t i e n t s ' p e r c e p t i o n s and the meaning of p a t i e n t s ' b e h a v i o r . An i n c r e a s e d awareness and under s t and ing of p a t i e n t s ' p e r s p e c t i v e s would h o p e f u l l y decrease the i n c i d e n c e of l a b e l l i n g and would focus care on i n d i v i d u a l p a t i e n t problems , thereby i n c r e a s i n g the e f f e c t i v e n e s s and meaning of care and communicat ion . Nurses must focus on d e v e l o p i n g e f f e c t i v e and meaningful r e l a t i o n s h i p s with p a t i e n t s through the use of t h e r a p e u t i c communicat ion . I n t e r a c t i o n s which focus on p a t i e n t s ' s o c i a l and emotional needs as wel l as t h e i r p h y s i c a l and p h y s i o l o g i c a l needs are i m p e r a t i v e . Nurses must possess the knowledge and s k i l l s to communicate t h e r a p e u t i c a l l y with e l d e r l y , confused p a t i e n t s . Nurse managers and a d m i n i s t r a t o r s need to be aware of those f a c t o r s tha t enhance the e f f e c t i v e n e s s and c o n s i s t e n c y of c a r e , such as c o n s i s t e n t c a r e g i v e r s and primary n u r s i n g , and ensure t h a t these are a v a i l a b l e to n u r s e s . They must be aware of the s t r e s s e s i n h e r e n t i n the i n t e r a c t i o n s with 135 e l d e r l y , confused p a t i e n t s and prov ide the nurses with o p p o r t u n i t i e s to d i s c u s s t h e i r f e e l i n g s and thoughts r e g a r d i n g these i n t e r a c t i o n s . Nurse managers and a d m i n i s t r a t o r s have a r e s p o n s i b i l i t y to be aware of events on the ward and to p r o v i d e a p p r o p r i a t e rewards when nurses perform w e l l . Nurse managers must have the knowledge and s k i l l s necessary to enable them to ac t as e f f e c t i v e r o l e models i n the c l i n i c a l s e t t i n g . Nurses must be knowledgeable about those e x t e r n a l f a c t o r s t h a t impact on p a t i e n t s , the type of p a t i e n t responses t h a t are l i k e l y to o c c u r , and the impact t h a t these might have upon the n u r s e - p a t i e n t i n t e r a c t i o n and i n c o r p o r a t e t h a t knowledge i n t o c l i n i c a l p r a c t i c e . Nurs ing E d u c a t i o n Nurse educator s must address the unique concerns of nurses working with e l d e r l y , confused p a t i e n t s . They must make a v a i l a b l e to these nurses the knowledge and s k i l l s needed to s y s t e m a t i c a l l y and a c c u r a t e l y assess p a t i e n t behav ior and p lan a p p r o p r i a t e i n t e r v e n t i o n s fo r these p a t i e n t s . A l l l e v e l s of n u r s i n g e d u c a t i o n must i n c l u d e a p p r o p r i a t e knowledge and s k i l l s i n areas such as t h e r a p e u t i c communicat ion , t h e r a p e u t i c t o u c h , and aging r e a c t i o n s to l o s s and g r i e f . Nurses must a l so be knowledgeable about the p h y s i c a l , s o c i a l , e m o t i o n a l , and p h y s i o l o g i c a l problems which may i n i t i a l l y pre sent as confused b e h a v i o r s . Knowledge and s k i l l s i n these areas 136 would p r o v i d e nurses with a l a r g e r number of o p t i o n s fo r communicating and g i v i n g care d u r i n g the i n t e r a c t i o n , thereby i n c r e a s i n g the i n c i d e n c e of p o s i t i v e outcomes and r e d u c i n g n u r s e s ' f r u s t r a t i o n and s t r e s s . A h o l i s t i c approach , f o c u s i n g more on c a r i n g than c u r i n g , would p rov ide a more r e a l i s t i c and h e l p f u l framework fo r g e r i a t r i c n u r s e s . Nurs ing Research T h i s d e s c r i p t i v e study i n v o l v e d a small study p o p u l a t i o n of R e g i s t e r e d Nurses working i n extended care u n i t s . In order to g e n e r a l i z e f i n d i n g s to a l a r g e r p o p u l a t i o n of c a r e g i v e r s , i t i s necessary to r e p l i c a t e t h i s study with nurses working with s i m i l a r p a t i e n t s i n genera l h o s p i t a l s and care f a c i l i t i e s . F u r t h e r study i s a l so r e q u i r e d to i d e n t i f y the i n t e r p r e t a t i o n s of n u r s i n g a ides as c a r e g i v e r s working with e l d e r l y , confused p a t i e n t s . F u r t h e r s t u d i e s i n c o r p o r a t i n g a methodology of p a r t i c i p a n t or n o n p a r t i c i p a n t o b s e r v a t i o n would a l l ow e x p l o r a t i o n of the r e l a t i o n s h i p between nur se s ' p e r c e p t i o n s or i n t e r p r e t a t i o n s of the i n t e r a c t i o n and t h e i r a c t u a l behav io r s w i t h i n the i n t e r a c t i o n . I n d i v i d u a l n u r s e ' s a c t i o n s v a r i e d at d i f f e r e n t t i m e s . The f i n d i n g s a l so i m p l i e d t h a t there were d i f f e r e n c e s between d i f f e r e n t nurses i n s i m i l a r s i t u a t i o n s . Al though p a t i e n t s ' behav io r s i n f l u e n c e d these d i s c r e p a n t a c t i o n s , f a c t o r s o ther than p a t i e n t behav ior s i n f l u e n c e d the nur se s ' a c t i o n s . D e s c r i p t i o n s of these f a c t o r s remain vague. There 137 i s a need to e x p l o r e f u r t h e r these f a c t o r s to i d e n t i f y more c l e a r l y what they are and to e x p l o r e t h e i r impact on nur se s ' a c t i o n s w i t h i n the i n t e r a c t i o n . F i n d i n g s t h a t demonstrate the s t r e s s exper i enced by the nurses d u r i n g the i n t e r a c t i o n i n d i c a t e the need f o r f u r t h e r e x p l o r a t i o n i n t h i s a r e a . Future s t u d i e s should e x p l o r e those aspects of the i n t e r a c t i o n t h a t are s t r e s s f u l , i n a d d i t i o n to those nurse behav io r s t h a t are e f f e c t i v e and i n e f f e c t i v e in r e d u c i n g t h i s s t r e s s . Such s t u d i e s would p r o v i d e a f o u n d a t i o n fo r t e a c h i n g nurses to i n t e r a c t i n ways t h a t would maximize t h e i r e f f e c t i v e n e s s d u r i n g s t r e s s f u l i n t e r a c t i ons . 138 Footnotes H e n c e f o r t h , the e l d e r l y , i n s t i t u t i o n a l i z e d p a t i e n t i d e n t i f i e d as confused w i l l be r e f e r r e d to as " the p a t i e n t " un le s s o therwise i n d i c a t e d . For the purposes of c l a r i t y , the nurse w i l l be i d e n t i f i e d as female and the p a t i e n t as male . 3 The term c a r e g i v e r w i l l be used when the r e s e a r c h e r i s r e f e r r i n g to R e g i s t e r e d Nurses and n u r s i n g a i d e s . The term nurses w i l l r e f e r to R e g i s t e r e d Nurses o n l y . 139 References A l t s c h u l , A . T . (1972) . N u r s e - p a t i e n t i n t e r a c t i o n p a t t e r n s  i n acute p s y c h i a t r i c wards. 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N u r s i n g : The p h i l o s o p h y and s c i e n c e of  c a r i n g . Bos ton : L i t t l e , Brown & Co. Wei s s , T . J . (1980) . Nurse s , p a t i e n t s and s o c i a l systems  The e f f e c t s of s k i l l e d n u r s i n g i n t e r v e n t i o n upon  i n s t i t u t i o n a l i z e d o l d e r p a t i e n t s . Co lumbia : U n i v e r s i t y of M i s s o u r i . W e l l s , T . J . (1980) . Problems i n g e r i a t r i c n u r s i n g . E d i n b u r g h : C h u r c h i l l L i v i n g s t o n e . W h i t e , C. M. (1977) . The n u r s e - p a t i e n t e n c o u n t e r : A t t i t u d e s and behav io r s i n a c t i o n . Journa l of G e r o n t o l o g i c a l  Nurs i ng , 3(3) , 16-20. Whitehead , T . (1980) . D e l i r i u m i n o l d age: Confus ing the causes of c o n f u s i o n . Nurs ing M i r r o r , 151(3) , 38-39. W i l l i a m s , M . , Ho l loway , J . R . , Winn, M. C , W o l a n i n , M. 0 . , L a w l e r , M . , Westwick, C , & C h i n , M. (1979) . Nurs ing a c t i v i t i e s and acute c o n f u s i o n a l s t a t e s . Nurs i ng  Research , 28, 25-35. W o l a n i n , M. 0. (1977) . Confus ion s tudy : Use of grounded theory as methodology. Communicating Nur s ing Research , 8, 68-75. W o l a n i n , M. 0 . , & P h i l l i p s , L . F . (1980) . Who's confused here? G e r i a t r i c N u r s i n g , 1_, 122-126. W o l a n i n , M. 0 . , & P h i l l i p s , L . F . (1981) . Confus ion  P r e v e n t i o n and c a r e . S t . L o u i s : C . V . Mosby. Y u r i c k , A . G . , Robb, S. S . , S p i e r , B. E . , & E b e r t , N. J . (1980) . The aged person and the n u r s i n g p r o c e s s . New York : Appl e t o n - C e n t u r y - C r o f t's. 149 Appendix A Informat ion L e t t e r My name i s Dawn B l a i s . I am a R e g i s t e r e d Nurse and a graduate s tudent i n the School of Nurs ing at U . B . C . S ince 1977 I have been working as a nurse wi th e l d e r l y p a t i e n t s , many of whom are i d e n t i f i e d as confused . My personal e x p e r i e n c e , p lus the exper ience of my c o l l e a g u e s , has l e d to an i n t e r e s t in t h i s a r e a . I am p a r t i c u l a r l y i n t e r e s t e d in l e a r n i n g more about the n u r s e ' s thoughts and f e e l i n g s i n r e l a t i o n to her i n t e r a c t i o n s with e l d e r l y , confused p a t i e n t s . I am c o n d u c t i n g a study which w i l l become par t of my t h e s i s . I t w i l l e x p l o r e the nur se s ' i n t e r p r e t a t i o n of the i n t e r a c t i o n between h e r s e l f and the e l d e r l y , confused p a t i e n t . The i n f o r m a t i o n from t h i s study w i l l h o p e f u l l y help to b e t t e r educate and to c r e a t e a more r e a l i s t i c support system for nurses working i n t h i s a r e a . I f you wish to p a r t i c i p a t e I w i l l arrange a mutua l ly agreeable time and l o c a t i o n fo r an i n t e r v i e w . The i n t e r v i e w w i l l be conducted in a l o c a t i o n o ther than the ward, e i t h e r at the School of Nurs ing or i n your home i f t h a t i s p r e f e r a b l e . The i n t e r v i e w w i l l be tape recorded and w i l l l a s t approx imate ly one to one and a h a l f hour s . No names or i d e n t i f y i n g i n f o r m a t i o n w i l l be i n c l u d e d on the t a p e s . The tapes w i l l be t r a n s c r i b e d by a s e c r e t a r y and erased 150 f o l l o w i n g comple t ion of the t h e s i s . The t r a n s c r i b e d i n f o r m a t i o n w i l l be acce s sab le only to myse l f and my a d v i s o r s and w i l l be de s t royed when the tapes are e r a s e d . The r e s u l t s of the study w i l l be made a v a i l a b l e to you i n a summarized form once the t h e s i s i s comple ted . Dur ing the i n t e r v i e w I w i l l be a sk ing general que s t ions c o n c e r n i n g your i n t e r a c t i o n s with e l d e r l y , confused p a t i e n t s . You w i l l be f ree to re fuse to answer any ques t ions d u r i n g the i n t e r v i e w . I f you agree to be par t of t h i s s t u d y , then l a t e r change your mind, you w i l l be able to withdraw your consent at any t i m e . N o n p a r t i c i p a t i o n or withdrawal w i l l have no e f f e c t on present or fu ture employment or r e l a t i o n s h i p s i n the work s e t t i n g . I t i s important fo r the v a l i d i t y of my study tha t you do not share the content of your i n t e r v i e w with o ther s who have not y e t p a r t i c i p a t e d i n t h e i r i n t e r v i e w . I f you would be i n t e r e s t e d in be ing a pa r t of t h i s s t u d y , p lease c o n t a c t me by te lephone or s i gn and r e t u r n the a t t ached consent form i n the stamped envelope p r o v i d e d and I wi11 c o n t a c t y o u . I hope you w i l l dec ide to be par t of t h i s s t u d y . Thank y o u . Dawn B l a i s (731-0817) 151 Appendix B Consent fo r P a r t i c i p a t i o n i n the Study: "The Nurses '  I n t e r p r e t a t i o n of the I n t e r a c t i o n Between Themselves and the E L d e r l y , Confused P a t i e n t " I have read the i n f o r m a t i o n l e t t e r presented by the r e s e a r c h e r and I agree to p a r t i c i p a t e i n t h i s s tudy . SIGNATURE: DATE: TELEPHONE NUMBER: 152 Appendix C Sample of In terv iew Questions 1. When you are with confused p a t i e n t s , what p a t i e n t b e h a v i o r s do you n o t i c e t h a t i n f l u e n c e the i n t e r a c t i o n ? 2. Why do you n o t i c e these p a r t i c u l a r behav ior s ? 3. What do you do when the p a t i e n t behaves t h i s way? 4. What are your f e e l i n g s when the p a t i e n t behaves t h i s way? 5. What t h i n g s do you do tha t i n f l u e n c e your i n t e r a c t i o n s wi th the p a t i e n t ? 6. In what way do your r e a c t i o n s i n f l u e n c e the p a t i e n t ? 7. Do you change your a c t i o n s i n any way when you are faced with these p a t i e n t behav ior s ? 8. Is there any th ing t h a t happens o u t s i d e of your i n t e r a c t i o n with the p a t i e n t tha t i n f l u e n c e s your b e h a v i o r wi th the p a t i e n t ? 9. Is there a n y t h i n g t h a t happens o u t s i d e of your i n t e r a c t i o n with the p a t i e n t t h a t i n f l u e n c e s the p a t i e n t s ' behav ior? 153 Appendix D Frequency and Indicators of Patient behaviors A. Disruptive Behaviors (17 nurses; 94%) Upsetting physical actions " . . . real belligerant behavior where they are hitt ing out, scratching, clawing, and bi t ing . We feel they are confused at that time". Upsetting manner of interacting " . . . very whiny voice, very demanding, very impatient." B. Contextually Inappropriate Behaviors (16 nurses; 89%) Action based on events or people in earl ier l i f e "They are back in time, back in their childhood, seeing people who have been gone for years." Faulty perceptions or beliefs of present events "A lot of them hallucinate. They talk about things that aren't there l ike 'The cats are upstairs, I can hear them' Inappropriate physical action "No coordination a lo t of the time, especially in their hands." c. Unintel l ig ible Behaviors (13 nurses; 72%) Decreased response to the surroundings "She just s its there, never resists anything, never does anything." Purposeless act ivity "Somebody is eating breakfast and they are trying to eat a milk carton." Garbled or unintel l ig ible speech "The words just don't come out. They are jumbled and make no sense whatsoever." 154 Memory-impaired Behaviors (12 nurses; 67%) Unable to recognize familiar "The next day you go there"and they others don't even recognize your name." Spatial and/or temporal disorientation 'Lack of orientation to where they are ....Complete lack of being aware of the time s lo t . " Unable to remember recent events "[He] can't even remember what [he] has been talking about or what we have been doing to him." Unable to identify self "Sometimes they can't even t e l l you their name." Unproductive Repetitions (7 nurses; 39%) Repetitious verbal actions "They ask the same questions over and over." Repetitious physical actions "When somebody claps their hands, some body else points their finger; i t i s the repetitious movements." Unpredictable Fluctuations (5 nurses; 28%) Fluctuating mood "One moment they are very aggressive and the next they are very loving. " Fluctuating physical actions "One day you bend down to put their slipper back on and they hug you and the next time you do i t they hi t you." 155 Appendix E Frequency and Indicators of Personal Factors A. Nurses' beliefs about patients (13 nurses; 72%) "They don't know the [nurse] and they don't know the name, but they can te l l i f that nurse cares about them." "They comprehend more than you think but they just can't respond appropriately in language." "Even the ones that just lay there . . . they have a completely different set of things that goes on with each of them--the way they react, the way they cry out." Nurses' beliefs about caregivers (10 nurses; 56%) "You have to be a very special person. [You need] compassion, empathy, and be able to cope with the mental stress and be a nice person at the same time." "If I was classifying myself I am people oriented, not the type that needs to get a l l the meds and treatments done. That's very important working with extended care patients." Nurses' beliefs about caregiving (8 nurses; 44%) "You address them or treat them in a manner that is not babying them, as an adult." "It has to be an honest approach. You can't go in . . . saying nice things but not really believing i t . " "In geriatrics you have to care for them individual ly . " 156 Nurses' fatigue and personal problems (10 nurses; 56%) "Some days i f you haven't had a good sleep . . . your tolerance i sn ' t what i t should be." "If there are problems at home, some-one is i l l or there are problems in the family, within 4 or 5 days you wil l be i l l . " Patients' culture 39%) (7 nurses; "You find the resident upset and probably confused but because of the language barrier you are not sure what you are dealing with." " . . . you really need to know because a response in one culture that is perfectly normal in another is not." Nurses' beliefs about confusion (6 nurses; 33%) " . . . [confusion] is a very complex picture with a lot of contributing factors from their past." "Their confusion l ie s in their inabi l i ty to speak back." "Confusion is not a problem, i t ' s their only survival technique." Patients' physical/physiological problems (5 nurses; 28%) "One of the things is hunger at night time . . . . They show that in their confusion sometimes." "They become withdrawn or aggressive to nursing care and that is how they react to having pain or discomfort." 157 H. Nurses associating self with "I am finding i t harder to share the aging process (3 nurses; 17%) more of myself because I think I can see myself as one of them." I. Caregivers' nationality and/ or gender (3 nurses; 17%) "These women who are confused, you can almost read their expression, 'What is this guy doing in my bedroom?'" 158 Appendix F Frequency and Indicators of Interpersonal Factors A. Patients' interactions with "Some patients are more responsive to caregivers (14 nurses; 78%) some nurses than they are to others. Maybe that [nurse's] manner is too aggressive for the patient to deal with so they withdraw even more with that person." B. Nurses' interactions with "I think the whole team interaction caregivers (13 nurses; 72%) plays a part in your job satisfaction. . When I am with aides I have confidence i n , I can go home and feel that things have gone we l l . " "Working with people that are rough and uncaring is the sort of thing that makes you exhausted." Patients' interactions with "Confused patients that have not got family/friends (10 nurses; family support withdraw." 56%) "We have seen them come back . . . the ones who have v i s i tors . They start communicating." D. Patients' interactions with "The quiet withdrawn are very distressed other patients having varied by the overt confusion. I think there is degrees of confusion a definite fear of the noise. (10 nurses; 56%) "These people that are mentally okay get upset and confused because there are so many confused people." 159 Nurses' relationship with managers/administrators (9 nurses; 50%) "The decisions are made by the higher ups. We find that the team leaders aren't asked for input, the head nurse and director make the decisions." Nurses' interactions with doctors (6 nurses; 33%) " . . . a lot of apathy from the doctors too. They make their monthly or 6 monthly cal l i f you really bug them." Interactions with others through ward act iv i t ies (5 nurses; 28%) "We have a lot of act iv i t ies available on the ward . . . . Some of the confused patients respond really well to music appreciation sessions." Perceptions of non-geriatric nurses and the public (5 nurses; 28%) "People think you have physical d i sab i l i t ie s you are hiding in ger iatr ics . " I. Nurses' interactions with patients' family/friends (5 nurses; 28%) "Families are supportive when they come and say you are doing a good job." 160 Appendix G Frequency and Indicators of Impersonal Factors A. Time constraints (13 nurses; 72%) "You just don't have time to do the touching and talking that you want to. I always need another hour." B. Staffing patterns (12 nurses; 67%) "We feel guilty because we don't have the time to give the confused people because we haven't got the staff." "Nurses should not be working 6 days in a row . . . i t makes i t too hard to stay posit ive." Nurses' supervisory versus caregiver role (7 nurses; 39%) "When you are in a supervisory capacity in one way you loose because you don't physically see that much of them but on the other hand you are gaining because you are getting to know them better because you are talking to them rather than doing actual nursing care." Patients' familiarity with environment (6 nurses; 33%) "They may be perfectly fine at the f a c i l i t y they are in but you move them to a new one and they become total ly incontinent, confused, and disoriented. E. Ward noise (5nurses; 28%) "When you are fresh and not t ired and the day is early the noise dosen't bother you, but as the day goes on the noise increases and you find that you react a lot more negatively." 161 F. Medication (5 nurses; 28%) "Medications are a biggy. I think i f they are properly monitored they might be okay but we have a tendency to over-medicate so they fa l l asleep in the chair . " Institutional ization (4 nurses; 22%) "One of the things that makes me so sad about inst i tut ional izat ion is that they give up so much-objects around them that i t must be devastating to give up and to share a room with three strangers takes away their privacy." Physical environment (4 nurses; 22%) "In our unit we try to decorate i t l ike home with lots of pictures in the corridors. Some of them really l ike to s i t in front of them and really enjoy them." I. Primary nursing vs team "I am more aware of everything...about nursing (3 nurses; 17%) my primary care patients. Although at nights we work with a l l 75 patients, I know my primary cases a lo t better." 

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