Introduction to Nursing II, or Interpersonal Relationships in Nursing, is the first course with clinical contact required of all nursing students at the University of Miami. It is a three-credit course comprised of one hour of lecture, one hour of laboratory, and one hour of seminar each week.
Development of the Course
"Nursing 104," as it is most commonly known at the University, was conceived by the nursing faculty as they worked with students in their first clinical course and became aware of the common pressures that needed to be clarified and understood. The students had not had the time to assimilate the meaning of nursing nor to develop their own concepts of the profession. From the frustrations of this experience came the formulations of what the students needed to know about themselves, about human beings, and about nursing to be able to identify with the concept of themselves as nurses.
This was in the spring and summer of 1958. The curriculum changes that took place in the interval between the summer of 1958 and the fall of 1959 became an indication that the first major clinical experience would be in the combined area of certain basic fundamentals and obstetrics. In the fall of 1959, a committee of the faculty began to make plans for the development of an introductory course to precede the Maternal and Child Health course.
The committee established that the major component needed by the students was, first of all, an opportunity for contact with selected patients without having to use technical skills or procedures. This opportunity was to be followed by an unstructured seminar discussion in which the student was to be helped to identify the interactions and emotions involved. Additional components were to include the ethics of nursing, the role and expectations of students in clinical and academic settings, the relationship of nursing to the other disciplines, the function of the professional nurse, and self-identification, with an overall understanding of the hierarchy system of hospital settings.
It was anticipated that with this background the student could better evaluate her potential for adaptation to the nursing field. It was also expected that such a course would provide a real foundation for the work of each additional clinical experience, and that students could then be held responsible for an understanding and acceptance of the ethics and basic concepts of nursing as a profession. This course was an attempt to eliminate much of the frustrations and misdirected hours in early clinical areas usually experienced by the student.
The faculty committee reviewed numerous catalogues to learn how other nursing schools and colleges were providing students with an opportunity for developing skill and comfort in patient contact without having to use technical skills or procedures. At that time a good percentage of these schools offered courses for beginning students in such areas as psychology for nurses and selfunderstanding. Some courses required patient contact, but most did not. None of the courses seemed to focus upon the effect of the student on the patient and the identification of the patient's feelings and expressed needs to the extent to which we hoped to focus in Nursing 104.
In the spring of 1961 the first students were enrolled in Nursing 104. At this writing the course is in its fifth session.
Preplanning was an important part of the inception of this course, especially because it involved a somewhat new approach to clinical experience for nursing students. An initial conference was held with the nursing administrator and was followed by a conference with the nurses who would be involved. At this time the objective of the course was presented, and each nurse was given an opportunity to express her opinion and ask questions regarding the student's experience. It seemed advisable to have the selection of patients made with the approval of the charge nurses, as they would know the patients and which ones would likely have to remain in the hospital over an extended period.
A continued and informal communication regarding adjustments to be made is maintained with the nursing administrator. As a result of this communication and suggestions from nurses and other clinical instructors, the first laboratory experience of the semester was an introduction to the clinical setting by a "panel of experts" representing nursing administration, a charge nurse, an aide, the x-ray department, the pharmacy, and the laboratory. As do all courses, this one has undergone evolution. Its basic purpose and content have not been altered, but details have been perfected, and the learning experiences have become more clearly structured.
It may be of help to expose and identify some of the pitfalls experienced. The major area of concern was found to be communication in the clinical area used. The concept of nurses spending time with patients for the purpose of learning to identify and convey expressed needs without engaging in technical procedures is a new one to most nurses on active duty in the clinical setting. Nurses are not always comfortable having students engaged in this activity.
This may be evident by the following examples of attitude and concern:
1. A great deal of initial concern was demonstrated about the type of patient to whom the student might be assigned, i.e., one who is not too emotionally concerned or who is "happily adjusted" to his hospital experience, or one not "too ill" and who has a good disposition.
2. Special care was initially exerted by the charge nurse to assure that such student-patient contact was approved by the doctor. This is an interesting point, since students who give direct but complicated physical care to patients are given free access to the patients in all but exceptional cases.
3. Students felt that direct communication with both the charge nurse and an aide or a staff nurse giving direct care to the selected patients was difficult because of a demonstrated lack of appreciation on the part of the staff of the possible contribution of the student and a lack of student confidence.
4. Although students were assigned to the same ward on the same day of each week, frequently it was found that charge nurses, in their busy schedule, "forgot" that students would be in the area and were thus unprepared and had to select patients hastily.
5. In the first session of the course students were assigned to the ward during the morning hours. Frequently during these hours students were not able to see their assigned patient because the patient was being given morning care. This was felt to be a result of at least two factors: (a) the lack of early assignment and communication with those directly responsible for the patient's care, (b) the concept that the student was a "visitor," and could not therefore observe the care being given.
The several adjustments made appear to have eliminated most of the above breaks in communication. These previously stated reactions would seem to be expressions of some lack of acceptance by nurses of this approach to nursing education. Let me hasten to add, however, that the major response to date has been a favorable one, and as our own communication and adjustment have improved in the setting, so also has the response to this program.
Adjustments that have been found useful and expethent include the following;
1. Following several visits in the clinical setting, each student was instructed to begin charting pertinent data on the patient's chart, with the assurance of the safeguard of having notes checked by the instructor and the charge nurse before entering the data on the chart. An almost immediate increase in interest by the staff was noted. Students found it easier to communicate directly with the staff concerning their patients. Doctors felt that some patients benefited and reported this to head nurses.
2. As the staff became more comfortable with what the students were doing and communication increased, they were less inhibited in assigning students to patients who presented more difficult adjustments, and they even made suggestions as to the goals for the student's visit. They shared more information with the students initially and recommended that students who demonstrated specific skills be assigned to particular patients.
3. Students thus gained more recognition and the feeling that they were becoming a member of a team.
Another noted pitfall in the original structure of the course was the large number of students in the seminar which was held immediately following class and not closely related to the patient experience. It was then decided to hold the seminars immediately following patient contact and to limit the group to small numbers of 6 to 12 students. The seminars were then held in the clinical setting.
Better student participation was noted following this alteration in the course. It was found that it was still difficult to have each student contribute a meaningful discussion of the day's experiences in the time allotted. The seminars thus became more structured, were centered about selected nurse-patient problem areas, and were regarded as more productive. During this experience, students were to ask nurses to identify problem areas in nursepatient relationships.
Having exposed the major pitfalls and adjustments of this course, we now turn to the challenges and productive experiences. First of all, students have an opportunity to learn to become acutely aware of interactions between themselves and patients, since they have only such interactions to focus upon, rather than the myriad tasks of nursing. They are given the unique opportunity of listening to a patient for approximately 45 minutes, uninterrupted by demands upon their attention and time.
Students are helped to become acute observers of needs as expressed by patients in both verbal and nonverbal ways. A form for recording each patient contact experience has been developed to enable the student to pinpoint her observations.
The form includes an example of the verbal and nonverbal communication between the student and the patient, and identification of the patient's needs as learned during the contact, the emotions of the student about the visit, an evaluation of how the patient accepts or does not accept his illness, and to whom and what the student reported about the contact.
Students are responsible for reporting to the personnel directly responsible for the care of the selected patient, and also to the charge nurse. Students are helped to identify pertinent data and some of the basic principles of communication. Most helpful in this process has been the early experience of charting under supervision. Through this experience students learn what material is meaningful and acceptable on a legal chart, and how to express what they wish to report.
Students share in the seminar their contacts with patients of varied backgrounds and diagnoses. Repeated contacts are made with the same patient over a period of time, in order to gain a depth in awareness of the patient's needs as the relationship develops.
Some excerpts from the student-patient contacts may be of interest, if we keep in mind that this course constitutes the student's first experience within a hospital setting.
Mr. K. appeared to be in need of a lot of attention, and he knew how to utilize bis anxiety. He flattered his nurse continuously while she was in the room, and with such a technique he received attention to his satisfaction.
I think the patient has a need to discuss these fears about oxygen and uric acid with his doctor. It would relieve his apprehension and even help his progress, or help him to relax more.
The patient mentioned several times about going home. He doesn't like to be in a position wherein he cannot control his own freedom. I think the reason this is uppermost in his mind is he isn't occupied during the day he has a need to be active.
The patient has many physical needs. She is completely dependent on the nurse for everything. I'm not sure, but I think that she responds most to family topics and topics about her garden at home because she has a need for some contact with these things.
From the patient's statement, "I just have to face the facts," one has the impression that the patient has accepted his condition. But his acts prove differently. I think he wants to accept it, but finds it very hard to do so.
This woman is not a "nut" or a "character." I liked her. She has life and spirit. She also has a desperate need to have her fear that death is at her door put aside. To my observation she has faulty eyesight and hearing, yet the nurse says just the opposite. I think the patient has been unjustly pegged as a "character." She needs help.
Of this last patient contact, the student reported the following responses:
I'm afraid to take sleeping pills.
I was scared to death when they took me for x-rays.
When I was coming out of anesthesia [I'm fifty] the nurse said, "She pulled through, and a woman Aer age."
Flowers- I don't want any. G? have enough soon - when I'm dead.
. . . this visit seemed to re-enforce my feelings about the needs of the patient. I believe the patient has accepted her illness, but expresses anxiety when she talks about going home and having her activities restricted. She states that she is fretful about being able to "keep busy" and that she is not able to do what she wants to. There seems to be a cry for help here.
Upon completing this course, the students of one session identified the following concepts and values which they became aware of and which they felt would help them in other areas of their nursing careers:
To gain the patient's confidence
To interpret verbal and nonverbal expressions
To select significant material
To recognize the needs of patients
To relate to various types of patients
To observe relationships between nurses and patients
To identify clues to patient's needs by such methods as reflection
The value of listening
The significance of appropriate responses
The importance of making appropriate responses
The significance of charting
The recognition of patients' needs
The responsibility to both the patient and the hospital
The student's relationship to the total hospital matrix
The multiple roles of the nurse.
The individuality of patients
Security within the hospital
An interesting refinement and further development in the course content has been the inclusion of common problem.
To identify clues to patients' needs by areas in nurse-patient relationships. Some of this material was derived from an opportunity which the fundamentals instructor and the psychiatric nursing instructor had to meet with students across the board in all class levels. It was soon evident to these instructors that certain common problem areas occur at every level and to the graduate nurse as well. We concluded that although these problems were common, we had not adequately faced them or given students an adequate opportunity to explore them.
The most frequently repeated and outstanding areas of concern were the following:
1. When patients are not expected to get well
2. When patients do not want to get well
3. When patients have different value systems
4. When recognized needs remain unmet
5. When students or nurses do not communicate what they observe
Throughout the course an intensive effort is made to deal with areas 4 and 5. Special lectures and seminars are focused on areas 1, 2, and 3, to which we also added areas that deal with situations when patients are fearful and anxious and when patients are dependent. Students are given an opportunity to ask registered nurses to identify areas they regard as significant problem areas.
The purpose of including this content is to expose the student to a recognition of problem areas and some exploration of the possible feelings involved, not to provide final solutions.
Evaluation of the Courte
One major method of evaluating the learning acquired in this course experience is the development of a standard tool. This is a situation-response test being developed by two psychiatric nursing instructors and the fundamentals instructor. The situations are developed to test the objectives of the course.
Test situations were administered to graduate nurses who had not been exposed to this course as well as to basic nursing students in the course. The results appear to indicate a possible correlation between the types of responses given and the student's or the nurse's concept of nursing, and seem to indicate that the knowledge being tested is not necessarily gathered through experience or general programs in nursing education. Upon completion of this tool, it is expected that such a test may be given prior to the course and again at its conclusion for determining the amount and quality of learning.
Additional, and perhaps the most meaningful, evaluation comes from the performance of these students in the subsequent clinical courses. Instructors in the first major clinical course, which involves fundamentals and obstetrics, state :
initially the students exhibited greater facility in identifying and meeting the physical and psychological needs of the patients. We feel that they perfected their technical skills. Another result of Nursing 104 is that the students have a better understanding of the role of the staff and, thus, relationships with them appear to be more productive. In this course we have adapted the patient contact unit to illustrate the student's identification of the patient's psychological and physical needs, how they have met them, and documentation for their actions. Perhaps the most rewarding aspect to us is that the student is motivated to seek learning experiences, develop beginning skills for teaching patients, and attain a higher degree of observation.
If a student emerges from this experience with a clearer concept of herself as a person and potential member of the nursing profession with a certain degree of skill and comfort in being with patients and a developing skill in observation and communication with team members, we will feel confident she has the foundation on which to build her chosen career. We will feel we have allowed for the continued development of the skills and interests with which the new student arrives, rather than stagnating or suppressing them.
Perhaps this is what we hope to do by approaching nursing education in this manner, in which we allow the student to recognize herself as a tool in the care of a total person.