This paper focuses on both the persona] and the professional responsibilities in health care, with a particular emphasis on examining the assumptions made about those patients who exhibit disorientation. What the health professional accepts as possible for the disoriented person in a hospital situation depends on three variables: personal experience; the theoretical framework used to explain the phenomenon of disorientation; and the ability to objectively observe that phenomenon.
My Pertinent personal experience was primarily with my grandparents. My grandfather live to be 70 and my grandmother 80. I would listen with interest to their history of the family and would join in many of their activities. I frequently spent part of my summer vacation with them. Since neither grandparent exhibited senility or disorientation at any time during their lives. I was conditioned to consider older people as individuals with many interests and activities.
In nursing school. I was taught that disorientation was a result of poor nursing care. So when I took care of patients I did not document how disoriented they were, but how "clear" they were. Fodo otherwise would have been to show my teacher the poor quality of my nursing care. With this expec tation I discovered it was possible to talk to patients clearly even when they were disoriented, and that there were meaningful thoughts behind their disorientation.
Later I was introduced to Bowen Family Systems Theory1 and his principal maxim: "Talk to the person behind the dysfunction." From exposure to Bowen Theory as well as personal experience with hospitalized patients, I came to disagree with the prevalent view of the nursing profession that disorientation was the result of biological causes that made interaction with the individual all but impossible.
The third variable that affects one's perspective on disorientation is the ability to objectively examine the phenomenon. In order toremain objective in observing disorientation, I told myself I was dealing with an individual who is, in part, responsible for his situation in life, and thus, in the condition he is exhibiting. The level of responsibilities he is willing to assume is a large determinant of how he will live his life. By following these maxims, I was able to resist being overly helpful or overly sympathetic with the patient. Later, as a nursing instructor in an acute care setting, I found that I could talk to a person exhibiting disorientation clearly and substantively.
All health professionals can learn that it is possible to reach the person behind the disorientation. Some nursing students understand this and put it into practice immediately. Others find it impossible to communicate with these patients. If students did not initially understand the principle, it seemed that they never became capable of comprehending it or of putting it into action. In part, thedifferenceamong these nurses seemed related to their own past family experience. This correlates to findings by Becker2 in using grandparent reminiscences to teach students to work successfully with the aging.
I initiated a project whereby I visited all persons exhibiting disorientation on any of the three units where my students worked. All the patients seen in the pilot study had been admitted to the hospital for a medical problem, and haddisplayed varying degrees of disorientation for the first time during this hospitalization. I found that with many of the patients, one interaction was enough to help them clear their disorientation and, for many, the disorientation did not reoccur, at least not during that hospitalization. As I continued to work, I learned more about myself and my approaches to patients who exhibited disorientation. I was enjoying this breakthrough until a student called me and said, "Come see this patient and perform your magic." I was concerned with this attitude because I knew that as long as it remained "my magic," the student would not have to assume the responsibility for learning what was possible for disoriented patients. At this point, I considered whether Bowen Theory could be used to increase my own effectiveness and as a framework to assist students in implementing a new perspective on disorientation.
Since the purposes of a theoretical framework are to provide ( 1 ) principles to guide actions, and (2) a new way to interpret data, I thought that exposure to this approach would eliminate the student's view that my success with disoriented patients was "magic."
From Bowen Theory, I began to define what is possible for a disoriented person in terms of "solid self." Solid self is that part of self that accepts responsibility for decisions about issues significant in one's life. It is not negotiable and does not disappear under stress. The more solid self, the less fluctuation in functioning is affected by either the degree of stress or the amount of support in the personal environment. The more dependent the individual is for support from his environment, particularly his important relationships, the more his functioning is dependent on factors outside self. Although dysfunction may seem severe, every individual has some solid self. This assumption is very important in determining the capabilities of all disoriented patients. In order to understand the factors contributing to disorientation, it is necessary to understand the disoriented person's relationship system; one evaluates the family and the health care system, and the amount of tension or anxiety in both those systems, and in what ways the health care system is contributing to the anxiety which exacerbates the disorientation.
One common characteristic of many family members and many health care professionals is their over-helpfulness; that is, their involvement in helping the patient without determining what the patient can do for himself. One interesting experiment reported in the literature demonstrates how functioning is impaired when organisms accept a passive role in their environment.
Dru's study on rats, "Influence of Interoperative Experience and Age on Recovery of Visual Functioning Following Two Stages of Lesions of the Striate Cortex,"4 describes three different postoperative treatments used on three groups of rats. In the first group, the rats were placed in a white environment after surgery and held passive. This group of rats had no ability to distinguish between stripes and bars and there was no return of this vision. In the second group, the rats were held passive and stripes and bars were rotated by them. The ability to discriminate between stripes and bars was partially regained but not significantly. In the third group, the rats were allowed to roam in an environment with stripes and bars. In this group, the amount of vision regained was significant. Apparently a way to recover abilities lost through brain damage (it is unknown whether disorientation includes lost abilities) is to encourage active participation by the individual in his environment.5'6
My examination of the data gained led me to the following hypothesis: The stress that contributes to the loss of functioning in disorientation is the stress of an unresolved decision. The individual has abdicated decision making for self on an issue of importance in his life and is dissatisfied with the outcome or the results of the decision made by others. I based my nursing interventions on data gathered in light of this hypothesis and the variables identified by the theory. I also established criteria for rating the interactions. The interaction was considered successful if a patient was able to assume responsibility for significant life decisions and to remain oriented to significant life events. It was considered partially successful if the individual needed more than one interaction to remain oriented. In these cases, the individual did not assume responsibility for the decision and the disorientation continued to return although the patient could exhibit some clear thinking.
The following characteristics are common of all the individuals and their family systems contacted in the pilot study.
1. Intense fusion with spouse (if living) or history of intense fusion with a significant other. In the limited and specific perspective of this study, I looked only at the nuclear family.
2. Absence of communication from the family and health care personnel of significant information about the state of health or plans for future care to the patient. The rationale often given by both family and health care personnel was that the information was too difficult or too hard for the patient to handle, or the disorientation itself was used as an excuse.
3. The patients did not ask questions about the important events in their life, thereby playing this part in the process. Each individual patient was not reaching out to the environment and the environment was isolating him.
4. "Doing for," was the mode of assistance of both the family and health care personnel and communication was aimed "at" the individual rather than "to" the individual. For example, if the spouse of the patient was in the room, he or she would answer for the patient. Frequently, the health care personnel only documented the state of disorientation and how bad it was, and were thereby relating only to the dysfunctional aspects of the person.
5. There was a focus on what was wrong with the patient.
6. There was an area of past success or responsible functioning by the patient outside the family identified for each individual, eg, a profession or business success. This responsibility and achievement was seen as an indication of solid self.
7. There were significant decisions involved in every case: (1) hospitalization, whether or not to be hospitalized; (2) future placement, whether to go home alone or to a nursing home; (3) the extent of medical care, whether or not to discontinue renal or peritoneal dialysis or chemotherapy; and (4) dying, which included the question of the quality of life and also the decision of where to die.
In summary, the disorientation was most characterized by: (1) abdication of decision-making on a significant issue and dissatisfaction with the outcome of that decision made by others; (2) disruption or deprivation of meaningful relationships; and (3) intense fusion in the marital relationship.
Certain concepts from Bowen Theory explain the relationship issues contributing to the dysfunction of the disoriented person. According to Bowen,3 when family tensions are high and available family triangles are exhausted, the. family system triangles in certain "outsiders" to absorb the tension. Family members triangle health care personnel in an attempt to cope with the stress that preceded and/or is generated by the illness. The overfunctioning of health care professionals contributes to and usually intensifies the underfunctioning of the patient. The triangle can be changed and the anxiety can be reduced in the presence of a significant person who remains objective about the issue and can maintain a one-to-one relationship with the disoriented individual, the health care team, and the members of the family. When the health professional relates to the person behind the disorientation, she becomes significant to the disoriented patients because they have usually been deprived of meaningful relationships in their families during the course of their illness. She becomes important because no one else is talking to disoriented patients about the issues and decisions important to them unless it is to coerce them into complying with the decision already made by others.
Mr. X was a 91-year-old man who was hospitalized exhibiting disorientation for the first time. When I went to talk with him, he did become clear. I did not know the significant issue and decision facing him so, although his disorientation would clear during our interaction, it would reoccur. As I became clearer about the hypotheses and assuming that it was necessary to communicate about the issue to achieve any substantial, long-lasting effects after his discharge, I questioned the staff and discovered that he had had a physical examination and his doctor had discovered a hernia. The tension must have been intense because his wife reacted to the news by insisting that he be hospitalized, despite his opposition. She requested hospitalization for a complete check-up to make sure that there was nothing else wrong. He was dissatisfied that he had abdicated responsibility for the decision and was dissatisfied with the outcome of her decision. These statements were validated by the staff.
Mrs. Y had metastatic cancer in advanced stages. When I first saw her, she was combative, abusive, and disoriented. It seemed that no one in the health care team was able to talk to her. In my first series of interactions, I did not know the significant issue facing her, but she did become clear on every interaction. At the time of one interaction she opposed having her intravenous continued. I said to her, "As part of the contract you have made with your doctor, this is the treatment that he has outlined and you have accepted. If you pull the IV out and wish to maintain that contract with him, it will be restarted. One thing you are fighting is the pain." She looked at me and said, "I don't want the IV. I don't want chemotherapy anymore." I said, "Ordinarily I would support an individual in such a decision, but this decision may be a product of your being upset. If you make the same decision tomorrow morning and you would like help in implementing it, I will support you. I would be glad to talk with you then."
She remained clear that night and the next morning, and she was taken off chemotherapy. As an individual who had not functioned independently for a long period of time, she had difficulty assuming responsibility for herself. Since we never worked through the basic issue facing her at that time, disorientation would reoccur late at night, be present in the morning, and would be manifest with other health personnel. It would not occur with me because I would talk about the activities and issues important to her in the here and now.
She was discharged and was later readmitted, having been beaten by her alcoholic husband. She was in a state of malnutrition and the cancer had advanced to near-end stages. She was again combative, abusive, and was described as disoriented. She did not remember my name but did recognize me. She said, "I want to go home. They want to send me to an institution but I want to go home." I could hear my previous training prompting me to say, "But you can't do that. Who would take care of you?" Instead I said, "How do want to implement that decision?" She said, "I want to sign myself out against medical advice."
I told her, "In order to do that and have the system hear you, you will have to remain clear and refrain from your confused and combative behavior. If you can show that you are making a clear decision, I will support you in that decision if you want."
Individuals can almost always handle reality if they seek out or are given the facts of reality without their being laden with intensely emotional overtones. I asked her if she wanted suggestions about ways to help her remain clear. She said "yes" and I informed her about actions she could take, such as keeping the door to her room open, the lights on, and not letting herself become isolated, since these factors often seem to correlate with disoriented behavior. She could keep herself involved with people and sit in the hall when she thought it was needed. She asked me to return that evening to see her.
When 1 returned she was in bed with all but the night light out and the door closed. She was not disoriented. One of the things I had said to her was, "I know at times life situations seem overwhelming but I do believe that individuals have the strength to handle them with dignity." That dignity was there that night. She had faced the fact that she could not go home and had decided she would go to a home for incurables. She went quietly and with the dignity she wanted for herself.
Correlations with the Literature
A brief correlation of these findings with the pilot study research and the state of knowledge available in the literature will be reviewed brieflv.
My goal in working with these patients was to clear the disorientation so that the health professional would see what was possible for disoriented patients and thereby begin to work more easily with their functional aspects. I wanted to clear people with the minimum amount of time, the minimum amount of interactions.
I divided factors and intervention on disorientation reported in the literature into three categories: (1) the core area, (2) the intermediate area, and (3) the peripheral area. Those interactions that required the least amount of time and energy to clear the individual were considered a core methodology. Those taking the most time and the most repeated visits with disorientation reoccurring were considered peripheral. The peripheral approaches to disorientation include: (1) reality orientation, which is based on the concept of sensory deprivation, and (2) certain aspects of attitudinal therapy.7
Additudinal therapy, in part, deals with how the health professional relates to the patient, and how tone of voice reflects underlying assumptions about disorientation. The tone of voice as well as the speed and volume of speech reflect attitude and the underlying process in the relationship between the health care professional and the patient. It is possible to work with the manifestations of the process or with the force motivating it. It takes longer to achieve results by working on the speech rather than the process underlying the verbal communication.
Research from animal behavior shows that auditory and visual perceptions are important to orientation. Sensory deprivation is especially important if the health care professional and the family member cannot learn about and communicate with the patient about the significant issue facing him. To the extent that the patient is functioning from solid self, he is able to control his environment. For example, despite hospital regulations, the patient still has latitude to decide whether he wants lights on, whether he would like to leave his room, and so forth. He need not be a helpless victim.
The content of communications between health care professionals and patients can also be classified into the same areas: (1) core, (2) intermediate, and (3) peripheral. Peripheral communications reflect the "super helper role," whereby the professional decides what the individual should be oriented to: what day it is, what time it is, who the president is, and so forth. An individual who is struggling with an issue important and stressful in his life does not have the energy to remember these things. Since these facts are not connected with immediate concerns or activities, they are essentially superfluous and only clutter their minds. One program of reality orientation, for example, met five days a week for six weeks. While there was some behavior change, there was a significant decrease in oriented behavior one week after the class had ended. This would indicate a peripheral approach, since a good deal of time and frequency of contact were needed to maintain orientation.7-9
In the intermediate area are the treatments based on the organic causes of disorientation. Nothing in the literature on physiology can provide a direct correlation between physiological and organic changes in the elderly that are in proportion to the symptoms of disorientation and senility. One person I worked with had a high blood chemistry, which is frequently associated with disorientation. The staff became upset when I said I could talk to him. They kept showing me his BUN report to explain the disorientation they were reporting. The higher the BUN, closer he came to making his decision to discontinue renal dialysis. During this time he was able to talk to me about his death, his readiness for it, and his concern about getting the living, particularly his wife, ready for his dying. Thus, although there does seem to be a correlation to the organic factors, the research in the literature has not explained what this correlation is.
Certain aspects of the attitudinal approach may be classified as intermediate. Although modifying the characteristics of verbal speech may be considered peripheral, activities recommended by attitudinal therapy, such as having the patient involved in all activities concerning him rather than having these activities done to or for him, would be intermediate. For example, a severely incapacitated individual can be drawn into the activity of bed bath simply by asking him which arm he prefers to have washed first. The health professional would begin by encouraging simple decisions and then move on to decisions of greater consequence. Again, this approach takes time and frequency of contact, but it does work to a certain extent.
Similarly, the content of communication in the intermediate category revolves around activities in the here and now. As in the case with Mrs. Y described earlier, the health professional discusses issues of immediate concern and consequences of decisions made about those issues.
The core category includes a consideration of the process between the health care professional and the patient. Most prevalent in the process of this kind of relationship is the professional as the doer and knower for the patient. If the patient is the doer, if he is capable of handling what is happening in his life, he does not need professional assistance. If he is not able to do this, he may make the decision of whether to accept or refuse assistance. In order to maintain a responsible position in the balance, the health professional should ask himself the following questions: (1) Whose life is it? (2) Who has to live with the consequences of this decision? and (3) Whose decision is it? In using these questions, it is possible to develop a realistic balance between the professional as knower and doer for the patient and the individual as knower and doer for himself.
The subject of communication using the core approach is the significant issues requiring decisions on the part of the patient. When the health professional can raise the issue and the patient is able to assume responsibility for dealing with the issue and makinga decision for self, the disorientation did not reoccur during that hospitalization.
There are two basic limitations to this approach. Since it does not attempt work on long-range goals, it has all the limitations inherent in short-term crisis intervention. I did not work for change in solid self except for that change that might occur when the individual assumed responsibility for the decision currently facing him.
One advantage of this approach is the calming effect on the family system. Both the health care professionals and the family members were better able to relate to the functional aspects of the patient. It also increased the understanding of the phenomenon of disorientation and appropriate approaches.
Areas for continued work include: (1) more indepth understanding of the important variables that lead to dysfunction before disorientation occurs so that one could do a predictive study that might then help to avert disorientation; (2) work with the overfunctioning members of the family since, according to Bowen Theory, it is easier for the overfunctioning one to change (to date, I have not found individuals in the family or in the health care profession motivated to change); (3) to develop approaches to achieve more basic change in the disoriented individuals themselves; and (4) to do a long-term follow-up study on recidivism.
When disorientation can be seen as a signal of anxiety in the family system and in the health care system rather than as a diagnosis of an individual patient, new possibilities for the disoriented person can emerge.
- 1. Bowen M: Principles and techniques of multiple family therapy.in Bradt J. Moynihan C (eds): Systems Theory. Washington. DC. Georgetown t'niversity. 1971.
- 2. Becker DG: Grandparents rediscovered. J Jewish Communal Serv 52(3):240-248, 1976.
- 3. Bowen M: Theory in the practice of psychotherapy, in Guerin Ρ(ed): Family Therapy. New York, Gardner Press, 1976.
- 4. Dru D: Influences of interoperative experience and age on recovery of visual function following two-stage lesions of the striate cortex, (unpublished dissertation. lf.SC, 1974). Quoted by Herr H, Psychology of Aging: An Overview, in Nursing and the Aged. New York, McGraw-Hill Book Company, 1976, pp 40-41.
- 5. Finch CB: Biological Theories of Aging, in Nursing and the Aged. New York, McGraw-Hill Book Company, 1976, pp 92-98.
- 6. Gribbon K: Cognitive processes in aging, in Nursing and the Aged. New York, McGraw-Hill Book Company, 1976, ρ 51.
- 7. Barnes J: Effects of reality orientation classroom in memory loss, confusion, and disorientation in geriatric patients. Gerontologist 14:138-142, April 1974.
- 8. Phillips DF: Reality Orientation. Hospitals J AH A 47:47-49, 101, July 1973.
- 9. Taulbee L: Reality orientation in the aged, in Nursing and the Aged. NewYork, McGraw-Hill Book Company, 1976, pp 245-254.
- Epstein LJ: Depression in the elderly. J Gerontol 31(3):278-282. May 1976.
- Payne R: Meeting the many health and social needs of the elderly, Geriatrics. April: 123. 125, 130. 1977.
- Picard M: States of disorientation or regression. Rev Gerontol Expression 3:9-14, 1973.