In pursuing the idea of conceptualizing comfort as a proper aim of
psychiatric nursing I extracted 12 nurse behaviors from my clinical data
that were used repeatedly to increase patient comfort. I quantified
these behaviors for two months. The following are a list of these
behaviors with a representative example of all but the first. The first
was too general and continuous for example.
1. I focused on recognizing patients by name, being certain I
was correct about their names, and using their names often and
appropriately. I also introduced myself. Names were viewed as
supportive to the internalization of personal feelings of
dignity and worth.
2. I interpreted, taught, and gave as much honest information
as I could about patients' situations when it was sought or
when puzzlement was apparent. This was based on the belief that
it was their life, and choice was their prerogative since they
were their own projects.
_Examples_
(a) While drinking coffee with a few patients at the dining room table
suddenly we could hear Sidney, in his customary way, wailing, moaning,
and muttering in another room. It is a sad sound. I was about to get up
and go to him as I often do, when Arthur, who was sitting next to me,
face working, and tense posture-wise, aggravatedly said, "Sidney doesn't
have to do that, he should control himself, the rest of us control
ourselves." I said, "When others express how miserable they feel, it
sometimes arouses our own feelings about our misery." This was an
attempt to provoke 32-year-old Arthur to work on his own {114} feelings
of misery and to deter his projection of anger at himself out onto
Sidney. Arthur looked at me sharply, like he had gotten the message, and
agreed by relaxedly nodding his head.
(b) Alice, diagnosed as manic depressive, has been depressed. This
depression dates from her going out to a department store and asking for
a job. She was hired for a five-day-a-week job. This was done on her
own. Later her readiness for a five-day-a-week job and her participation
in the unit were questioned. Then Alice became depressed.
Alice was sitting in the dayroom. I sat down next to her. She looked
very sad, her eyelids as well as her mouth, drooped. Her mouth worked as
if she wanted to talk, but she was quiet. I asked her about her job
decision. She said that she had not taken it. I said, "You look so sad
that I feel like holding your hand." Her hands were in her coat pockets,
but she looked at me and smiled weakly. I said, "Sometimes a conflict of
wanting to do two things at once in the present and not being able to
can bring up the feelings of a past very much more important similar
experience." Alice just shook her head up and down and looked at me.
Alice is in her mid-forties. Later I was walking down the hall to leave
saying goodbyes to various people. Alice came out of a side room, put
both her hands out to me, and said, "goodbye and thank you." In a
previous contact Alice had discussed her suicidal thoughts with me.
3. I verbalized my acceptance of patients' expressions of
feelings with explanations of why I experienced these feelings
of acceptance when I could do this authentically and
appropriately.
_Example_
I met a new patient at coffee. Later she was the only patient in the
dayroom when I went in. She had not spoken at coffee. Now she sat very
stiffly in her chair. I sat down next to her and reintroduced myself.
She looked scared but told me her name. Her shifting eyes reminded me of
a cornered animal. She blurted out, "I don't believe I've met you." It
was like she had said, "go away." I smiled at her and said, "We were
introduced at coffee, but with so many new people it's hard to
remember." Conversation continued to be tense. At one point Marion
bolted from her chair toward the door. I thought she was going to leave.
I stayed in my chair. She went to the fish bowl in the corner. We
continued to talk about the fish. Marion came back and sat down a few
seats away from me. I said that I felt I'd been asking her an awful lot
of questions but that I was only trying to get to know her. Marion
seemed to relax in her chair and gave a great deal of information about
herself in a strange stiff sort of way often inserting a word that did
not have meaning for me. I encouraged, supported and showed my interest.
Finally she said that she {115} had been admitted to McLean in her
third year of nurses' training just before her psychiatric experience.
She had been in therapy there, one-to-one for a couple of years. I
teased her about knowing the ropes, yet giving me a difficult time. This
was an attempt to increase her feelings of adequacy by bringing out the
similarities of the old situation which she knew and this new situation.
For the first time she really grinned at me, almost laughed. Marion is
in her early thirties.
4. When verbalizations of acceptance were not appropriate, I
acted out this acceptance by my behavior of staying with or
doing for when appropriate.
_Example_
Mary is a middle-aged patient who, on her first days in the unit, was
liberally gobbling her food with alertness for only more to be had. Her
only rather loud, irrelevant, smiling expression was about her daughter
who was a go-go dancer, had three children, and whom she had visited
twice by bus in California. This day she approached me and asked if I
would file her nails. I said that I would but asked if she knew if there
was a file in the unit. Another patient offered his. We sat down and I
filed. The patient poured out a life story full of misery. This was a
side of this patient that I had not perceived. I listened, nodded, and
filed. The story started in the 1930s about her husband and
mother-in-law's behavior; their marital separation; his being killed in
World War II; their two children; their son, now thirty, was born with
cerebral palsy, is blind and mute, and has been institutionalized since
eleven months old; their daughter's husband left her with three children
after fourteen years of marriage. I silently wondered what old feeling
might have been aroused in her by her daughter's marital separation. Her
daughter is so busy that she is unable to write regularly. She has told
Mary not to worry if she doesn't hear from her. Mary then expressed
concern over not receiving her usual letter this week from her mother,
whom she visits. Mary had tried to reach her by phone and would again. I
inquired if her mother lived alone. Yes, but next to relatives. She then
related the drastic physical problems of a relative. I felt the sadness
of this woman as she talked and empathized with the tough time she had
had.
5. I expressed purposely, to burst asunder negative self
concepts, my authentic human tender feelings for patients when
appropriate and acceptable.
_Example_
I was sitting in a rather large group of patients in the dayroom. A
casual conversation ensued about Thanksgiving as it had been and
Christmas as it might be. There was talk of having been at home and
plans for being at home. I supported and encouraged the discussion
because of the meaningfulness of holidays, past and present. Snow was
initiated as a {116} topic. I said, "It would be nice to have a white
Christmas, but not too white." Vincent, a stiff, exact, ritualistic
person who avoids stepping in an obvious fashion on thresholds, does
little jiggle-like dance steps before sitting down, and again before
settling in his chair, suddenly spoke. "Josephine, I beg your pardon,
but I must take issue with you." I encouraged his unusual behavioral
expression. He went on and on about the importance of a white Christmas.
I let my mind flow with his jumbled discourse trying to decipher what he
was getting at rather than each specific rapidly mentioned issue. He
went from white to black, day to night, goodness to badness, love to
hate, this side of the world to the other side of the world (Vietnam). I
expressed that he seemed to keep mentioning two sides of things and that
for some reason I could not help thinking of boys and girls. I said that
he was over on that side of the world (room) and that I was over on this
side of the world. I asked why he did not come over to my side, paused a
minute, felt this was asking too much of this patient, and said, "Well
I'll come over to your side then." When I sat down next to Vincent, he
giggled as he does. Arthur, a younger patient, made a critical jealous
type comment about Vincent's age (50ish). Arthur has done this before
when I give attention to Vincent. Has Arthur a stereotype of father
images and perhaps mother images? I said to Vincent "you have beautiful
white hair, and big, brown, smiling Italian eyes." Vincent sat back
smiling shyly but comfortably and the discussion of the group continued.
6. I supported patients' rights to loving relationships with
others: families, other staff, and other patients.
_Example_
Alice M. said that she was sad to be back at the hospital after her
weekend at home. Alice is a quiet, bland, soft-spoken person about
fifty. She wears a worried expression even when she smiles and strikes
me like she is "turned inside" herself. I encouraged her to talk about
her time at home. She told me about how they had painted the living room
with what for her was a show of real excitement. I said that her wish to
be at home was very understandable. I did this because this patient
almost whispers her wish to be at home and, generally, no one responds
to it. Alice talked on with encouragement about the single sister whom
she visits and the pleasure it gives her to be with this sister.
[I have other examples of this nurse behavior that indicate supporting
of relationships between patients and between patients and other
personnel.]
7. I showed respect for patients as persons with the rights to
make as many choices for themselves as their current
capabilities allowed.
_Example_
Discussion of group at coffee revolved around Carolyn's needing a new
pair of shoes. The issues were where these might be gotten (Carolyn has
{117} money), what kind she should get, and who and when someone would
take her for them. It struck me as if Carolyn might not have been
present. I asked Carolyn what kind of shoes she would like. Carolyn
responded that she did not know whether she should buy regular shoes, or
sneakers, or canvas shoes like Marilyn had gotten. She beamed. Since,
she has come up to me several times and discussed the two pairs of
different kinds of shoes she bought and why. Carolyn is a sweet, simple,
retarded, deaf sixty year old whose behavior resembles an eight year
old.
8. I attempted to help patients consider their currently
expressed feelings and behaviors in light of past life
experiences and patterns, like and unlike their current ones.
_Example_
On my arrival after Christmas, Irene expressed anger at me in a laughing
way for having been away. Then she moved from a seat in the corner of
the room to a chair behind me at the coffee table. I moved to allow her
to move up to the table, but she did not. After coffee Irene nonverbally
with eyes and body movements told me to follow her. She led me into a
small beauty parlor room and we both sat down. She closed her eyes. I
said, "You seem to have some feelings about us all having been away."
First she blurted, "I missed you," then in a quieter voice denied this,
"It wasn't important that you weren't here." I said, "It could be
helpful to you to talk about your present missing feelings as you had
some very important losses of people when you were younger." Her eyes
literally popped open and she again blurted, "You mean my parents?" I
said, "Yes and your therapist could help you with this." I then asked if
she ever had the opportunity to talk with anyone about such things. She
replied, "No, well I had a social worker when I was a little girl." I
tried at this point to transfer feelings of the past to the present.
"Oh, for how long? What was she like?" "I don't remember," and Irene
closed her eyes. In a few minutes Irene requested that I set her hair.
She is capable of doing this herself. I set her hair, but discussed the
question of what she was really asking for. I believe she was asking for
concrete attention to test my ability to care for her. I was trying to
say, concretely, by setting her hair, that people could care about her.
9. I encouraged patients' expression to come to understand
better their behavioral messages to enable me to respond
overtly as appropriately and therapeutically as possible.
_Example_
The previous time I was at the hospital Alice had not come to the unit.
I was told that she felt too depressed to come down. I went to see her.
She had looked surprised and impressed by my visit. She talked on at
some length about her suicidal thoughts. I supported this on the basis
that {118} verbal expression might make active expression unnecessary
if she experienced empathy regarding how dreadful she felt. Then with
little encouragement she had come down to the unit with me. Today, Alice
was always near me, but nonverbal except for concise responses to
questions that were offered with effort. I verbalized my reflections on
her behavior and said that I was wondering about it. She said, "I like
having you around; it takes me away from my thoughts." "How are your
thoughts?" "The same, I wonder if I'll ever get better?" "You've gotten
better before. I wonder if you're not more concerned about whether you
can stay well." Alice, eyes watery, agreed with a nod. Irene, another
patient, interrupted, "Don't expect too much from me, I've been here
twelve years." I responded to them both, "But, I do expect a lot of you;
things don't always have to be the same."
10. I verified my intuitive grasp of how patients were
experiencing events by questions and comments, and being alert
to their responses.
_Example_
Vincent's ritualistic behavior is associated in my mind with his
exaggerated conscious expression of only the true, the good, and the
beautiful. On this occasion we had just had a long talk about his
weekend at home, his concerns about his family, and his food likes and
dislikes. As we left a room he took his usual long step over the
threshold. I noted this aloud and asked him if he knew why he did this.
His expression became wide-eyed and smiling which indicates to me he
consciously or unconsciously is selecting what he is going to say. We
came to the next threshold. He stopped me by touching my arm and said,
"Josephine, I almost grabbed you to prevent your bumping into that
patient." In relation to my last question I focused on the "grabbed you"
and said, "Vincent, to think about grabbing me is a pretty natural
thought, and no reason to take a wide step over a threshold." He put his
foot very deliberately if rather testily, right in the middle of this
threshold. He stopped, looked at me with his hands together and giggled.
Then he had to go to the bathroom.
11. I attempted to encourage hope realistically through
discussing individual therapeutic gains that could be derived
from patients' investment in therapeutic opportunities
available to them.
_Example_
My impression of Arthur, a thirty-two year old, is that he works at
responding to me agreeably as he thinks I want him to, he frequently
goes out of his way to make cutting comments to me about middle-aged men
patients, and he responds with anger or teasing to a female patient his
age. Arthur has a mother, father, and two older sisters. He obviously
let me win at Ping-pong several times. I discussed this with him and
asked if {119} he had ever talked with anyone about his responses to
older women, people in general, or if he understood them. He said, "No,
I have not been able to exactly figure this out yet." I repeated the
talking it over. He said, "I haven't had much chance for that." Then
staring at me he asked seriously, "Do you think talking it over would
help?" I said, "I think that it would take a great deal of effort on
your part, but I believe that it could help."
12. I supported appropriate patient self-images with as many
concrete "hard to denies" as possible.
_Example_
Alice, a middle-aged woman, in the midst of a discussion of the
difficulties of living outside the hospital, past relationships with
nursing personnel, and her past practical nurse jobs suddenly said, "I
worry about being sexually OK." This was kind of blurted out and she
observed me closely. I said, "I thought that you had some concerns about
this in relation to how you responded to my cutting the hairs on your
face. I guess everyone worries at times about their adequacy in this
area." She said, "I've never been able to have intercourse; I can just
go as far as heavy petting. People say you can get a lot expressed if
you have intercourse." I said, "Some people can, but if you have other
standards that you've grown up with, (I suspect a rather religious,
rigid Jewish background) it might cause difficulties to go against those
standards." (Alice first became ill at sixteen, left school, and had
some treatment in the community.) "It's pretty responsible not to be
willing to bring a fatherless baby into the world, and I'm sure you'd
have feelings about how your family might have responded to this sort of
thing." Alice nodded and said "It's just that I don't know how womanly I
am." I said with gestures and emphatically, "Well, Alice, if you have
two things up here and no thing down here, then the fact is that you are
a woman." Discussion pursued about her further talking about this topic
with her therapist and the value of her working through her feelings in
this area. This was a lengthy discussion and the first talking I had
experienced Alice doing since her depression. {120} {121}