An automaton is a "living being acting in a mechanical or involuntary manner; especially, a person who follows a routine without active intelligence," according to Webster's New International Dictionary, second edition. "Following" implies dependence or reliance upon an object or person for guidance and direction. "Without active intelligence" implies that the individual behaves, acts, or conducts himself in the manner suggested without understanding why and without seeking a reason for the suggested act. Do nurse educators encourage this kind of behavior? Or do we discourage such behavior? Do we provide students with the opportunity to think, to engage in discourse? Or are we in fact producing automatons in nursing?
Let us observe three students who have been assigned to give patient care. The assignments have been carefully selected by the instructor to meet certain stated objectives of the course. Student X has been assigned to care for Mr. Jones. The Kardex states that Mr. Jones is given a bed bath daily. The student does not question the rationale for the bed bath; she follows without active intelligence. Unless she encounters a discrepancy between what was said by the team leader or instructor and what she observes on the Kardex, it does not occur to her to question the reason for the bed bath.
Student Y has been assigned to care for Danny who recently underwent surgery. The Kardex states that the child is to ambulate twice daily (b.Ld.). The team leader states that Danny usually goes to the playroom after his bath and stays until lunchtime. The student does not question her interpretation of the order; she follows without active intelligence.
Student Z has given a bed bath to Mrs. Smith and is now ready to make the bed. The Kardex states that Mrs. Smith is on bedrest with bathroom privileges (B. R. P.). Can Mrs. Smith sit in the chair while the student makes the bed? Who took care of her yesterday? Did she get up during bedmaking yesterday? The student consults a person who has cared for the patient. She learns from this person that the patient was allowed to sit by the bed during bedmaking yesterday, and so she follows without active intelligence. She does not question this person's interpretation of the order, but continues in like manner to make the bed exactly as she found it, without question. "The person who made the bed before me must have had a reason for putting this sheet here or that towel there," she reasons.
Are these three examples of automatic response the exception or the rule? For the author, they have been more often the rule. You may say, "But these examples are such pedestrian, lowlevel activities. Our students are engaged in much more difficult activities which require thinking." I submit that these pedestrian low-level activities performed by nurses every day are important and exert a direct influence on all other kinds of activities. If the student is not prodded to seek the reason for the simple acts described above, she will fail to question in other situations. She will fail to assume responsibility for her own acts and will place the blame or credit for the act on another person or thing.
The purpose of the questioning is not to test the merit of the other person's decision, but to evaluate whether the decision needs to be modified in light of the patient's changing condition. If the student knows the why of readymade decisions, she is in a better position to determine whether a modification is necessary. A decision made one day may be quite inappropriate on another day. Without questioning the rationale for her actions she may be perpetuating something which is not benefitting the patient and which, in fact, may be detrimental to him. As long as the student is not provided opportunities for experiencing achievement with decision-making based on her own reasoning, she will continue to rely on others for help. She will continue to rely on the Kardex, the instructor, the team leader, the registered nurse, and the doctor to guide and direct her in all matters concerning patient care. In the present hierarchical system of most hospitals the nursing student will encounter little difficulty in obtaining an answer from someone or something, be it rational or irrational. To what can we attribute this dependence upon persons and things?
Erich Fromm writes in Man for Himself l that although our whole culture, its ideas and its practices, emphasizes self-reliance and independence, the individual underneath it all has a great need to conform and to please. We look to an expert in every field to tell us "how things are, how they ought to be done, so that all we have to do is listen to him and swallow his ideas." The person who dares to question the "expert" is frowned upon and may even be ostracized by his group.
Do our educational institutions encourage this kind of behavior? Is the student the passive recipient of facts and principles, or is he taught how to think, how to inquire, and how to discover knowledge? Is the tendency to rely upon others a common characteristic of young female students? The dependence-independence conflict of the adolescent years may be a contributing factor. The young student may still be experiencing some of the insecurity of being independent, of "standing on her own feet." She may encounter periods in which she longs for the safety and protection afforded by a mother surrogate. Being a member of the female sex, at least in American culture, may also be a contributing factor. It is socially acceptable and expected that the female be more dependent than the male.
The unfamiliarity of the hospital setting may be another factor. When confronted with new situations and new responsibilities in unfamiliar surroundings, the individual tends to regress. In regression an increase in egocentrism and an increase in dependent responses may be observable. The main concern of the nursing student may be "How am I doing?" rather than "How is my patient doing?" Experts and authority figures represent power and strength. They are feared and admired and thereby evoke dependent responses. The hierarchical system in the hospital sets the stage. Everyone on the staff is an "expert" or represents authority to the uninitiated nursing student. The student is the newest and "greenest" member on the team. The instructor and the experience she brings to her teaching assignment may be another important factor. Were we, as nursing students, allowed to think or were we given facts and principles to learn and demonstrations of how to do things so that we would not have to think? We may not realize that how we were taught may exert a subtle influence on how we teach.
What about the student-teacher relationship? Is this a factor? Sears refers to a diadic relationship between parent and child in which the child comes to expect certain behavior from the parent in response to his own behavior. 2 Is the student-teacher relationship analogous? Does each have an expectation system whereby one expects certain behavior from the other? If the instructor expects adherence to rules and regulations, does not the student behave accordingly? Is there a relative difference in power between the student and instructor? Does the instructor, like the mother, control both the qualitative properties of the student's environment, i.e., the kinds of behavior she will learn, as well as the rewards or the punitive measures that reinforce or extinguish his actions? The instructor is guardian of the reward or punitive measure -the grade. She also controls to a degree the quality of the learning activity by selecting the teaching situation and providing the climate which could facilitate or impede learning. Whenever the agent controls both the source of gratification and frustration, the resulting relative power tends to provoke dependent responses.3
Many factors, both within the person and in the setting, encourage reliance upon persons and things and discourages self-reliance. What can we nurse educators do to ensure that we do not prepare persons who will function as automatons?
The task of nursing education is to establish and maintain a climate for questioning. This means that the perceived difference in relative power between student and teacher must be reduced and, if possible, obliterated. The student must feel free to question, to exchange ideas, and to challenge her instructor and peers without fear of penalty. If the student feels she is being evaluated each time she raises a question, she will stop asking questions of the instructor. Two things may happen: (1) she may follow the suggestions given by another person without "active intelligence," or (2) she may attempt to answer the question herself even though she knows she needs help. Students are afraid to ask questions when they have been made to "feel small" or when it has been somehow communicated to them that "you should know better." Many times through skillful questioning the student can be helped to arrive at her own answers. She is helped to bring forward knowledge she has stored away and which is not readily accessible for immediate use. These experiences are rewarding and encourage the student to continue to inquire in areas of doubt.
Some instructors maintain a permissive and non-authoritarian climate and yet the students do not question. Somewhere between early childhood and adulthood the art of questioning has been extinguished. The seemingly insatiable curiosity of the preschooler is no longer evident. Therefore, the student must be prodded to question. The instructor acts as a "catalyst" to start the "wheels rolling." She questions and questions until she feels that the student has incorporated the mode of inquiry into her total behavioral repertory. The instructor must phrase her questions carefully so that the student will not feel threatened. She must help the student realize the importance of raising questions. If the student has been allowed and, in fact, encouraged to ask the instructor questions and to challenge the validity or rationale of the instructor's comments, she will be less threatened by questions directed to her. She will think about the questions raised not in terms of, "What does the instructor want me to say?," but in terms of "Why am I doing this for (or with) my patient?" She must feel free of evaluation during these exercises and focus her efforts on the process itself. A spirit of camaradie is established as both student and instructor explore the reasons together.
The inquiring attitude is initiated early in the student's nursing education - from the first bathing of patients to more complex acts. The student is asked to give reasons for the kind of bath her patient is receiving. What are the contraindications for, say, a shower or tub bath? There are many reasons for insisting that a patient be bathed in bed, but all too often the only reason given is, "The team leader told me to bathe him in bed," or "That's what was written on the Kardex." The student is asked to explain why she chose to make the bed as she did. Why did she choose to place a sheet here and a towel there? Again the answer too often seems to be, "That's the way I found the bed made."
What is the purpose in asking these questions of our students? After all, a sheet placed here or a towel placed there may have little or no effect on the patient's comfort or well-being. The primary purpose is to teach the process of inquiry. If we wait for "quality" questions or "thought-provoking" questions, the opportunities for developing the inquiring attitude will be too few and too infrequent. The inquiring attitude is not something that can be set aside to be used only on given occasions. It must permeate everything the student does. If the student is prodded to question activities which are performed daily, she will more quickly develop the habit of inquiry.
The questioning concerning nursing activities such as those described herein will provide multiple opportunities for reinforcement. Many an instructor has shared the sense of achievement experienced by young students when they find that a modification resulting from their inquiry brought forth an expression of gratitude and appreciation from their patients. Students need to experience satisfaction and achievement from these questioning exercises. If they do not receive this kind of reinforcement they will fail to develop the habit of inquiry. The instructor is responsible for ensuring that the student experiences maximum satisfaction and rninimum frustration in her efforts at independent thinking. If repeated enough successful experiences will be in and of themselves rewarding. Other kinds of material and verbal reinforcements, although important, are less effective.
The student's first questions then are concerned with seeking the reasons for carrying out prescribed medical and nursing measures. Although many medical and nursing orders are written in unequivocal terms, others leave a great deal of latitude for interpretation. And so the student must also be encouraged to question the interpretation of medical and nursing orders. If the patient is on bedrest with bathroom privileges, what does this mean? What are the limits? What factors must be considered in setting limits? Can the nurse make the decision to be permissive or to adhere to the letter? What factors will influence her decision? If the patient has been ordered to ambulate three times a day (t.Ld.), what does this mean? What is the rationale behind the order? Why was a limit set? What is the patient's tolerance in terms of activity? What factors cause fatigue? What are the risks of overfatigue? Too often the tendency is to accept another person's interpretation of the order rather than to systematically assess the situation and interpret it according to their findings.
A case in point is the student who was caring for a 3-1/2-year-old child who had undergone a unilateral nephrectomy and ureterectomy for removal of a Wilms' tumor. The surgery had been done approximately a week prior to the day the student was assigned to the patient. The team leader advised the student that the child could be ambulated three times a day (t.i.d.). She proceeded to explain that on the previous day the child was ambulated to the playroom after her morning bath and until lunchtime. The student interpreted the team leader's report as a suggestion and repeated the experience without questioning the rationale. She followed without "active intelligence." Questions subsequently raised were about the meaning of ambulation and the meaning of t.Ld. Did ambulation mean "to walk" or "to be up in a wheelchair?" What is the purpose of ambulation? Why are limits set? What is the condition of the patient? What about the stress on the body after an organ has been removed? How did the child tolerate ambulation the day before? What other factors might cause fatigue besides neuromuscular activity? What kind of environment does one usually encounter in the playroom? The student had not raised any of these questions. Her automaton - like activity of following without active intelligence- could have resulted in dire consequences to her patient.
The student must learn to ask the "why" of medical and nursing orders and the interpretation of these orders. To counter the tendency of students to behave as automatons, i.e., to fall into already established patterns of patient care without question, the instructor must deliberately teach two other kinds of questions. She must teach the student to question the consequences of her actions in terms of the patient's responses, and to raise those questions which are necessary for arriving at a solution of problems encountered.
The questioning student assigned to care for the 3-1/2-year-old child described above would ask herself what were the consequences of my interpretation of the "ambulate three times daily" order to my patient? Did she become cranky and fussy in the playroom? Were there other indications that her body was being overtaxed? In light of these consequences, what can I do differently next time? The student is in a learning role. She does not have all the answers. Neither does the nurse practitioner. If she forms the habit of continually evaluating her acts in light of their consequences to her patient, she will ultimately hold in her hands a repertory of acts which she has found to be successful. Understanding the reasons for the success of these acts will help her to transfer them to other similar situations. The student may evaluate the consequences of her acts in terms of patient comfort, satisfaction, or distress. Does he seem to be more comfortable now? What did I do that might have contributed to his comfort? She attempts to identify the acts that might have contributed to his state of comfort. If the student feels that the patient is uncomfortable or in distress, she will ask herself, "What did I do or not do that might have contributed to his state of discomfort?" Sometimes it is helpful to ask students to set a goal as part of their plan of care. The goal is derived from the assessment of the patient's behavior and may be stated in general terms. What kinds of things would I like to achieve with and for my patient today? Many times the goal cannot be achieved during the student's short period of interaction, but she can work toward achieving it. The acts that contribute to the achievement of the goal are specific, concrete, and tangible. The successful application of the inquiring attitude is evident from the following report prepared by a nursing student.
Establishing a goal
When I first met the patient he was not very responsive. He agreed with a vague "OK" or a mumble to any procedures as though he really did not have a choice. He didn't seem to care what happened to him or what went on. He just closed his eyes and ignored everyone. I got the feeling he was just letting himself be handled. I could well understand this attitude. Because of the intestinal obstruction which had hospitalized him and the ensuing operation, he could neither walk nor eat. The IV feeding kept him nourished, and the tender abdominal muscles which had been cut during the operation made it difficult for him to get up and put on his prosthetic leg. Having lost control of ingestion and a good deal of activity, he must have felt very helpless. So I wanted to try to give him some control, to show him that he was considered a thinking person with preferences and opinions.
Activities to achieve the goal
I tried to show consideration for him by asking his opinion. When I gave him his bath, he would wince now and then. I asked if I was rubbing too hard. I told him to be sure and tell me if I hurt him. Also, I told him he should tell me if I missed drying a part. And I asked him which side he thought it would be easier to roll over on. He had mentioned having a backache, so when he rolled over for me to wash his back I asked if a back rub might help. He said "Maybe," so I gave him a back rub which he said felt "pretty good."
My calling on him to express his opinions forced him to become a little more alert, I think. But he really came alive when it was time for his walk. He suddenly took control. This apparently was the high point of his day (perhaps because it was something he could do almost all for himself, and the better he could do it, the sooner he could have complete control again). He was quite determined. The team leader had said that he had walked down the corridor the day before and had done well just using the wall rail, so I knew what the patient had in mind. When one of my instructors asked if he were going to get up to sit in the chair, he said with determination, "No, I'm going to walk - down to the nurse's station." At the questioner's look of doubt, I quickly reassured him, "Oh, Mr. L did it yesterday too. He can do it!"
Although Mr. L could walk well, he still needed help in getting up. I asked what he was going to do. He said he didn't exactly know. I told him, "Well, I can help you if you will tell me what to do," and I stood waiting. I thought that I should let him decide when he wanted help. As I said before, he took control. He told us to get the chair out of the way, where to put his prosthesis, and when to just let him "relax" for a moment. When he had his leg on he said, "O.K., I'm all right now." He literally tore down the corridor and back, hanging onto the rail with one hand and pushing his IV stand with the other. We helped him get back into bed and he seemed in much better spirits. He kept his eyes open and watched what was going on and talked more.
After a doctor's visit, he told me he was going to try to cough. "I hate to do it but they want me to." When he finished, "That's enough," he said (announcing his control over the matter). I said, "I think that's pretty good. Keep up the good work!" I hoped that my words would encourage him to keep trying even though it hurt. I also meant to imply that he, the patient, had done the "work" and was quite capable. He said, "I will!," and smiled just a little.
In evaluation, it is hard to tell how much good I did because the patient himself did a lot for himself quite suddenly. It really was quite a change in behavior. Perhaps, though, I encouraged his enthusiasm. I mentioned before that my calling on him to express his opinion about what was to be done next forced him to pay more attention to the environment. He watched what I was doing and he gave some thought to it when he answered me. I think, perhaps, my quick reassurance to my instructor about Mr. L's being able to walk to the nurse's station also reassured Mr. L. At least someone had confidence in him.
And I think he responded to my statement that I would help if he would tell me what to do. He knew that it was up to him, then, to figure out how to get up and when to ask for help. And he took over. I'm sure his determination to walk and regain control was the biggest motivation, but at least, I didn't stand in his way.
Overall, I think I contributed a little to making him feel that he was still a person who could think and do and choose. When I left, he had just finished saying "I will" (in response to my comment to keep up the good work) and was alert. He responded quickly and brightly with an "OK!" when I said I would check on the medication he was waiting for.
The student expressed satisfaction with the care she had given. In retrospect she was able to identify certain things she had said or done that contributed to the goal she had set for her patient; she was evaluating her acts in light of their consequences to her patient.
Another opportunity to encourage independent thinking and action arises when the student encounters an obstacle to goal achievement. The instructor capitalizes on any opportunities that arise in the setting to encourage the inquiring attitude. What do I do when the patient refuses to take his bath or refuses to eat? How do I make it possible for a patient with multiple tubes to ambulate? Does the student automatically run for help or does she assess the situation to the best of her ability, devise a tentative solution, and then seek guidance and/ or concurrence from her instructor?
Problem solving can be introduced in various ways. The student can be asked to identify a problem and then to apply the process, or she can experience a problem and then be assisted in devising a solution through the problem-solving approach.
A nursing problem as defined by Abdellah4 and others is "a condition faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions." "A condition faced by the patient ..." provides the perspective for assessment. The only criterion for calling the condition a problem is if help is needed. The student must be able to determine whether the patient needs help or whether he can take care of the condition himself. A nursing problem, according to Chambers, 5 is a "specific need of the patient that requires nursing action to meet the need." The student must have knowledge of the needs and the behavioral manifestations which communicate these needs.
Until the student acquires the base of knowledge necessary to properly assess the patient's needs, the student is not asked to identify a "nursing problem." The problem-solving technique is introduced as soon as the student encounters a problem. What is an encountered problem? It is a condition or situation in which a person encounters an obstacle which does not have an obvious solution and which interferes with goal achievement. Students encounter all kinds of obstacles in patient care, and the frequency of the problems encountered is not predictable. The problem encountered is as "urgent" as the problems of daily living and usually demands an immediate solution. The student is expected to apply the problem-solving process to the solution of the problem. She is not expected to evaluate whether the individual needed assistance, or to classify her problem as patient centered, student centered, or task centered, or to identify the need inherent in the problem. Most problems encountered by beginning students are of a mechanical nature - involving the completion of certain tasks. If the student understands the problem-solving process as applied to encountered problems, she will be better able to move on to higher levels of problem solving, including the identification of nursing problems as defined by Abdellah and Chambers. The process for arriving at a solution is essentially the same. The knowledge brought to bear will, of course, differ in depth and scope.
An example of applying the problemsolving process to problems encountered is illustrated in the following case study:
The patient was a 5-1/2-year-old male with the diagnosis of intramedullary glioma with complete displacement of the third ventricle. The student was assigned to take care of this child during her morning laboratory experience. Among other things, she was to give the child his medications. The problem raised by the student was, "How do I get a child who has difficulty swallowing both liquids and solids to swallow two small pills?"
Having pinpointed the problem, she then began to gather data which she felt might help her to solve the problem.
The student wanted to know how the glioma affected the swallowing ability. She consulted the patient's chart and a textbook on neurology, and discovered the following:
The glioma was exerting pressure on cranial nerves VII, IX, X, and XII especially, impairing motor function of the muscles supplied by those nerves. Specifically, she discovered that:
1. Cranial nerve VII arises at the junction of the pons and medulla oblongata, with the main distribution to the facial muscles of expression. The patient showed definite right facial weakness, more marked in the lower face.
2. Cranial nerves DC and X arise from the medulla oblongata and supply the mucus membranes of the pharynx and larynx, salivary glands, and the posterior third of the tongue. Patient showed "poor palate movement."
3. Cranial nerve XII arises from the medulla oblongata and supplies the muscles of the tongue. Patient's tongue is without atrophy, but moves very slowly.
She also assessed the patient's swallowing behavior and observed the following:
1. When swallowing liquids, patient choked and usually coughed back the liquid.
2. Patient choked even when drinking small amounts of liquid from a cup, sucking from a straw, or when small amounts of liquid were pipetted into the front of his mouth.
3. Patient was coughing up mucus and sounded congested. He had a standing order for oral-pharyngeal suctioning as necessary. Suctioning the patient before asking him to swallow did not help.
4. Patient could swallow semisolids such as ice cream or mashed potatoes without difficulty; it took him a longer time to swallow solids such as small pieces of bread, meat, or canned fruit, but he could swallow.
Having gathered this data, the student then summarized her findings thusly:
The patient was having difficulty swallowing liquids, perhaps because liquids do not exert enough pressure as a mass against the sensory nerves of the mouth to stimulate a massive motor response - massive enough to swallow without difficulty. Solids involve chewing and working the food mass into a bolus, which requires more controlled movements of the tongue and palate. Semisolids are a compromise. They provide enough motor stimulation but do not require chewing.
The student decided not to mix his pills (crushed) with a favorite semisolid, such as chocolate ice cream, since mixing a disliked medication with a liked food could, if done frequently enough, result in the development of a negative association with the previously liked food and therefore be rejected at a later date. Also, crushing the pills into a solution involved a greater amount of fluid to be swallowed than placing the pills whole in the child's mouth and having him "wash it down" with a smaller amount of fluid. He had to use the muscles of his tongue and palate when drinking from a cup or sucking with a straw. Knowing that he had such poor control of his tongue and palate, she decided she could avoid requiring him to use those muscles to swallow by placing the pills far back on his tongue and pipetting water into the back of his mouth.
Having eliminated the least plausible solution, she elected to place the pills at the back of the child's tongue and pipetted water in the back of his mouth. Result: "Success. The child swallowed pills and water without choking!"
The student had encountered an obstacle to goal achievement. She recognized the child's need for the medication but she did not have a ready solution. She brought all that she knew to bear on her solution. We did not explore the nature oí the problem, or classify the problem, or determine whether it was student or patient centered.
These are the methods, processes, or techniques which must be introduced early in the nursing student's education. She must learn or relearn to question, to ask "Why?" She must learn to evaluate her acts in terms of their consequences to her patient. She must learn to solve problems encountered in a systematic way. Measures must be instituted to guard against the production of automatons. All nurse educators, whether teaching in a diploma, associate degree, or baccalaureate program of nursing, share this responsibility.
Koffka states that "the best we learn at school is not the sum of positive knowledge acquired but that we learn how to think, so that we can assume an independence which rests upon our ability to supplement the situation that confronts us with appropriate intervening phenomena."6 The student of nursing must learn the mode of inquiry if she is to assume an independence required for the practice of her profession.
- 1. Fromm, Erich: Man For Himself, New York, Holt, Rinehart & Winston, 1947, pp. 79-87.
- 2. Sears, R. R., J. M. Whiting, V. Nowlis, and P. S. Sears: "Some ChildRearing Antecédante of Aggression and Dependency in Young Children," Genetic Psychology Monographs, 47:47, 177, 1953.
- 3. Parsons, Talcott: Family, Socialization and Interaction Process, Glencoe, Ill., The Free Press of Glencoe, 1955, p. 61.
- 4. Abdellah, Faye G., I. Beland, A. Martin, and R. Matheney: PatientCentered Approaches to Nursing, New York, The Macmillan Company, 1960, p. 80.
- 5. Chambers, Wilda: "Nursing Diagnosis," American Journal of Nursing, 62: 102-104, 1962.
- 6. Koffka, K.: The Growth of the Mind, Paterson, N. J., Littlefield, Adams & Co., 1959, p. 166.