In December, 1964, the Psychiatric Nursing Coordinator at Medical College of Virginia and I received a request from three diploma schools of nursing to plan a two-day workshop on integrating psychological concepts in basic nursing programs. We were aware that Federal support for integration projects is concentrated in baccalaureate programs. We were also aware of the limited number of adequately prepared persons in psychiatric nursing on some diploma faculties. It seemed to us as if they were reaching for the stars, yet we felt we could not dampen genuine interest in improving their programs. The following material is extracted from content given at that workshop.
"In 1 953 ... training funds were first made available from the National Institute of Mental Health for integration of psychiatric concepts in basic professional nursing programs." ' Another milestone in improving psychiatric nursing content was the conference, National League for Nursing's Basic Psychiatric Nursing Education Project, held in Chicago in 1957. The general purpose of the conference was, "... to identify content and methods from the social sciences, psychiatry and psychiatric nursing that can be utilized throughout the baccalaureate curriculum so that students will be better qualified to care for all patients." 2 Hildegard E. Peplau, a psychiatric nurse educator, has said that projects to integrate psychiatric content in basic programs are to ". ..provide a nurse faculty who can assist in the inclusion of socio-psychiatric knowledge into medical-surgical, maternal-child, and public health nursing." 3 Schmahl and UlLm an, in a paper given at a National League for Nursing work conference in 1962, stated "(psychiatric integration )... implies both... a goal and a technique for getting there... "(The goal) is that of identifying, understanding, and changing irrational behavior in oneself and others but limited to such behavior as it emerges in the professional experience of the. .. (student, nurse or teacher)." 4 One begins to understand that whether there be formal projects or informal individual attempts, efforts to integrate psychological concepts in the nonpsychiatric nursing areas are directed first at improving faculty understanding. Faculty, in turn, do the integrating. This is opposed to some views that the integrator works primarily with the students.
Why this movement to have schools of nursing include so much psychological content? What was the impetus? It became apparent to nursing leaders on the national level that nursing students were being prepared much more adequately to care for man's physical being than for his emotional life. Students were being offered curricula composed of courses focusing almost exclusively on man's physical ills and their care. There was often only one course which focused on man's emotional life, and this was all too frequently just a study of frank psychiatric disease conditions. The vast area on the continuum between demonstrable physical illness and clearly defined mental disorders was still largely untouched by nurse educators. Historically, nursing did bypass the mentally ill and the emotional aspects associated with the care of general hospital patients. Awareness of this fact led to the movement to integrate psychological content throughout nursing curricula.
Most of us are aware of the National Association for Mental Health's wellpublicized facts that over half of the hospital beds in this country are occupied by the mentally ill,3 and that at least half of the millions of medical and surgical patients treated by physicians and in hospitals have a mental illness complication. The American Psychiatric Association lists approximately forty disorders that are felt to be physical expressions of emotion.6 From these few facts it is clear that in order to care adequately for threefourths of all the hospitalized patients in our country, a nurse needs not only psychological concepts but knowledge in depth of the dynamics of human behavior. Nothing has been said about the emotionally uncomplicated patient with so-called normal responses of anxiety to surgery and hospitalization. When we include them, patients who experience threats to their self-image, and patients who experience separation anxiety, for example, it seems evident that programs to integrate psychological concepts throughout an entire curriculum should emerge.
To look at it another way, nursing care often falls short of its noble goals even though the spirit is willing. If it is not the spirit that is weak, then it might be the scientific foundation. Man is a sociological, psychological, and physiological being, yet how often nursing focuses on his physiology to the near exclusion of his world of emotions. There are always courses in the anatomy and physiology of the body, and they frequently cover an entire year. Students often must wait until they are seniors before they can take a single course in the anatomy and physiology of man's psyche. Yet they are often expected to give total nursing care for three or four years prior to taking the course. What is expected compared with what is offered is, of course, impossible to achieve. In several diploma schools of nursing selected at random, the ratio of hours devoted to man's physiology as compared with man's psyche is 900 to 200; 1,200 to 200; and 1,800 to 350 hours.
The National League for Nursing Basic Psychiatric Nursing Education Project concluded that one of the basic assumptions on which such programs could rest is "...that the curriculum in any educational setting operates as a whole." 7 This does not prevail in all settings. Formal faculty communication, including joint review and planning, between departments or courses is often limited and sometimes nonexistant. This condition, if unchanged, precludes successful attempts of faculty to integrate meaningful psychological content.
The project group also identified the following four goals of an integrated curriculum: 8
1. Help the student develop a philosophy that:
a. Human conduct operates as a whole
b. The physiological, psychological, and social aspects of that conduct are interrelated and must be understood in relation to each other.
2. Help the student become more sensitive to and understanding of the dynamics of human behavior.
3. Help the student develop her skills as a therapeutic agent.
4. Help the student to realize her full potential as an individual and member of her profession.
To explore the far-reaching implications of these benign sounding goals would be a scholarly work in itself. Let us just ask a few questions, in order to focus on one of the above goals. Do we really want students to become therapeutic agents for example? Do we approach all patients in this manner, as we expose our thinking to students? Therapeutic implies treatment. Do we believe nurses can or should be responsible for acts of therapy? An agent must make decisions and judgments. Will we give students the authority to do it and then act on her judgments? What if in a student's judgment she decides it would be therapeutic to take a suspicious patient to the kitchen to see food being prepared; or perhaps sit on the bed of a distraught patient?
In order to help us decide further whether or not we can integrate a curriculum, some aspects of a setting that would be essential for a successful project are enumerated below:9
1. Philosophy and objectives that are in harmony with current trends and new knowledge in the areas of psychiatry and mental health.
Question: Do we strengthen a student's ego by insisting that she make decisions about herself, or are we still making her decisions for her?
2. An administration that will support and assist the faculty.
Question: Do we really believe such a project would enhance the student's nursing ability or look good in the catalogue?
3. A faculty and an administration that can reorient their thinking and evaluating in accordance with the prevailing psychiatric and mental health concepts.
Question: Are we evaluating at the end of the learning period and only in relation to course objectives, or do we attempt to give grades while the learning is still going on; and do we still evaluate aspects such as good grooming which, let us assume, are not course objectives?
4. An institution that emphasizes qualitative rather than quantitative care. Question: When a staff is merely a skeletal suggestion of a staff, are units closed, or is existing staff forced to cope with quantity and not quality as the goal?
5. A faculty which can develop behavior patterns that permit them to wait for satisfactions, recognizing that most teaching is present-oriented, and that the satisfactions which stem from teaching are intangible and future-oriented.
Question: Are you a teacher who needs to say "she learned that from me in my class"?
If the order of the day is to integrate psychological concepts, then exactly what are psychological concepts? One must really break it down further and ask, "What is a concept"? and "What does psychological mean"?
A concept is something conceived in the mind, i.e., a thought or a notion; it is an abstract idea which has been generalized from particular instances. For example, sufficient numbers of patients, who have complained excessively and have been constantly dissatisfied, have been studied in depth. With such data put through the process of inductive reasoning, we come out with the abstract idea, generalization, or concept that excessive complaints or dissatisfaction in a hospital situation may be an indication of underlying anxiety. It is derived from the major concept that all behavior has meaning and can be understood. There are also operational definitions. The operational definition is the steps or operations of the idea. Take the concept or idea of problem-solving. The operational definition would be the operations or steps in the method.
What makes a concept psychological, and is that the term we really want? The University of North Carolina School of Nursing referred to them as social science and psychiatric concepts; the University of Colorado School of Nursing called them mental hygiene concepts; and the Catholic University of America School of Nursing called them psychiatric-mental health nursing concepts. 10'12 On the one hand it does not matter what label you give concepts as long as faculty and students within a school have a common definition. On the other hand we should use the term with the definition intended if there is to be a common understanding between schools. Social science deals with the institutions and functioning of human society. One might not want such an all-encompassing term. Psychiatric refers to emotional disorders. One might not want the connotation of pathology. Mental hygiene refers to measures for reducing the incidence of mental illness. Mental health means "soundness of mind," but psychological refers to man's behavior. We usually mean we want to integrate ideas about man's behavior, thus avoiding the biased emphasis on man's physiological functioning.
According to some of the foregoing statements, any idea about man's behavior could be a concept. However, there are some more or less universally accepted ideas. But even before accepting certain psychological concepts, one must believe, as a basic assumption, that to help people, one must know them, and to know them, one must be able to understand why they behave as they do.
A basic tenet among psychiatrists and psychologists is the previously mentioned belief that all behavior has meaning and can be understood. This idea has come to be the conceptual framework for most integration projects. It includes the word "behavior" which, in psychological language, means thought processes, mood, and motor activity. Another way of saying all behavior has meaning is to say all behavior is a result of specific antecedant events. The nurse armed with skill in problem-solving and knowledge of psychological concepts could identify the antecedent events and discover the meaning.
Some behaviors are common human reactions inherent in man's repertoire of responses and are therefore predictable. For instance, we always respond physiologically to an emotionally disturbing situation. If one observes an exaggerated psysiological response such as agitation, in a patient on bedrest, one could look for the emotional antecedent and provide relief. This would be comprehensive nursing care as opposed to calling the resident for a sedative order. We also know the converse is true, i.e., we respond to physiologically disturbing experiences. It is also generally true that persistent lack of satisfaction of psychological needs seems to be directly related to physiological reactions. Some of the vital psychological needs are the need to communicate, the need to be liked, and the need for security. I am certain we can think of patients for whom these needs were not met and which could have accounted for physiological reactions.
Another idea is that psychotic behavior is usually beyond the conscious control of the individual. How many postoperative, obstetric, pneumonia, rheumatic fever, arteriosclerotic, uremic, diabetic, and hyperthyroid patients have we labeled as uncooperative when in fact they probably had acute brain syndromes? They are far more common in general hospitals than in psychiatric hospitals. Knowing about that concept and the care of those patients could lead the nurse to avoid sedation, for example, which will only increase the confusion and uncooperaüveness.
Another idea is that patterns of behavior are learned. An individual may come to depend upon hostility, dependence, or withdrawal as a method for handling difficult situations. An angry difficult patient, one who cries and will not eat, or one who is sullen and uncommunicative, is not behaving in a fashion consciously designed to aggravate the staff. He is responding to some unmet need or fear in the only way he knows how. Symptomatic intervention such as avoidance, restricting a visitor, giving tranquilizers, or tube feedings serve only to prolong the unmet condition and intensify the behavior. Knowing about learned patterns of responses, in this instance, could lead to much more comprehensive care. It is also true that patients are likely to respond in a manner similar to the one by which they are approached. This implies the need for self-understanding on the part of student and teacher. This is a vast area to which lip service and course outline space is often given as compared with genuine experiences in which the student is helped to explore the self.
Another concept is the idea that some forms of behavior are specific indications of psychological disequilibrium. For example, withdrawal from social interaction is frequently a behavior employed to avoid greater psychological discomfort. One could ascertain with some degree of validity what the discomfort is about An individual in a state of disequilibrium (a sick person is always in such a state) will almost always respond in exaggerated ways emotionally to minor environmental disturbances. Another behavior we often encounter is regression. If it is known that regression is an expected stage of illness, a nurse should meet dependency needs such as feeding a patient who might otherwise feed himself. A patient will not move toward greater independence until some of his dependent needs are met. So often a nurse fears the patient will become more dependent if she meets his dependency needs. Another concept is the one which states that man has an inherent potential for growth and change. A patient will move toward health and independent functioning as his dependent needs are met. Suspicion, doubt, and mistrust are other forms of specific behavior which are usually indicative of insecurity. A patient who refuses medication will often respond favorably when measures are taken to increase his security and trust, such as giving him some facts. Some of us still cling to the idea that we must evade reality when a patient asks direct questions. Many of us rationalize and point to the physician as the barrier.
Some behaviors are nonspecific indications of disequilibrium. They need to be investigated further. Examples are: attempts to manipulate the environment, illogical behavior, excessive demands for attention, and excessive complaints of dissatisfaction. Such behaviors almost always indicate unmet needs. But what the needs are can be determined only on an individual basis.
Most of the foregoing ideas have been derived from the major concept that all behavior has meaning and can be understood. Other vital concepts have to do with anxiety, body-image, guilt and atonement, levels of awareness, ego-adaptive mechanisms, ambivalence, personality development tasks, and unconscious motivation. Some of these ideas are more or less aligned with psychiatry, but in essence they have to do with understanding people. They are concepts nonpsychiatric nursing instructors should have working acquaintance with if they are to help students learn to give total care. Greater understanding of these ideas is essential if a psychologically integrated curriculum is to get off the ground.
In summary, although unstated up to this point, the thesis is that effective psychologically integrated curriculums are difficult to achieve and, in some settings, particularly in diploma programs, impossible to achieve. Impossible, that is, without attitudinal changes on the part of administrators or faculties, or both. Nevertheless, many faculties do work constantly to attain higher levels of thinking and teaching, and to develop individuals who believe in reaching for the stars. This paper is an attempt to encourage such groups and to lay the groundwork for additional interest and research in this area.
- 1. Bureau of Nursing Research and Studies: Report of The University of Colorado School of Nursing Experience in the Integration of Mental Hygiene Concepts in the Basic Collegiate Program, University of Colorado, Denver, 1960, p. 3.
- 2. National League for Nursing: Integration of Psychiatric Nursing Concepts in Baccalaureate Basic Programs, New York, 1963, p. 55.
- 3. Peplau, H. E.: Trends in Psychiatric Mental Health Nursing, a paper presented at the Southern Regional Education Board Workshop, Atlanta, 1964.
- 4. National League for Nursing, op cit., p. 4.
- 5. National Association for Mental Illness: Twelve Facts About Mental Illness, New York, 1965, pamphlet 508.
- 6. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Washington, D. C, 1952, pp. 29-31.
- 7. National League for Nursing, op cit., p. 55.
- 8. Ibid., p. 56.
- 9. Ibid., p. 60.
- 10. Gifford, A. J.: Unity of Nursing Care, University of North Carolina, Chapel Hill, 1960, p. 5.
- 11. Bureau of Nursing Research and Studies, op cit., title page.
- 12. Kupka, M. E.: The Teaching of Psychiatric-Mental Health Nursing in the Basic Professional Nursing Program, Washington, D. C, 1964, p. iii.