NURSING PRACTICE by Jane A . Schmahl, R.N., M.A.

I T H O U T routine life would be chaos. Some routine is essential for the effective organization of our every- W day living, as the eating of certain amounts of foods

at prescribed times, the establishment of certain hours for slcep and modes of preparation for it, and the use of a par- ticular route for traveling to work. Inherent in every routine is a plan, the purpose of which is to achieve a specific out- come. To realize a certain goal, we attempt to identify and

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utilize all conditions and situations that will facilitate its achievement and, simultaneously, to avoid those that may interfere with its attainment.

When we lose sight of the goal for which a routine has been established and are concerned instead with the form of the routine, we are involved in carrying out a ritual. A routine can be identified as a ritual when a particular form is being practiced in spite of changes in the situation that make the routine no longer necessary and when the form is used to avoid facing the demands of new goals and develop- ing increased awareness of new content and ways of dealing with it.

The development of a routine into a ritual is occasioned by the desire to alleviate anxiety. The individual or group wants to maintain security in a situation that has existed over a long period of time and to reinforce elements of this security through a continuation of actions that have pre- sumably been serviceable for this purpose in the past.

A case in point are religious dietary laws. Out of the stress to meet certain dangers and to preserve health, there was once a need to establish certain routines for the pre- paration of foods and to eat certain foods and avoid others. Authority for the enforcement of these rules was vested in a leader with the authority to mete out reward and punish- ment; consequently, they became incorporated in a paternal- istic social structure as well as in the religious system. Since perpetuation of the religious system as it was originally de- signed is dependent upon uncritical adherence to the laws, the rituals continue even after the dangers or other reasons that brought them into being cease to exist. Their observance, however, still alleviates or deals in a general way with the individual's anxiety, since he thereby avoids clashes with

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other members of the group or protects himself against the disapproval of the leader.

TYPES OF RITUALISM IN NURSING PRACTICE

Much nursing care consists of prescribed routines that have evolved out the need to budget time, effort, and money. I f the procedures associated with the serving of meals to patients, the measuring and giving of medications, and the supervision of patients’ bathing in the morning and the ar- rangements for their retiring at night are to be carried out, the patients must almost always conform to routines. Con- sequently, most of the decisions about a patient’s life during his hospitalization are made, though often unconsciously, on the basis of rules or routines.

As a result of this habituation to a routinized environment, the nurse may develop a series of automatic responses for dealing with patients and personnel. To a person who ob- serves a nurse giving medications, taking vital signs, giving treatments, and so on, it seems evident that she is busily engaged with people. However, it is possible that nothing particularly personal is taking place; the nurse’s responses may be stcrcotyped. These responses may become formalized into rituals which are then incorporated in the traditions of nursing.

Some of the more obvious rituals carried out by nurses arc those associated with cleanliness and order; with time (thc cmphasis being on speed and conformity to precise and rigid schedules) ; with communication (these rituals fre- quently involve the use of professional language, recourse to vague generalities, the utilization of talking as a means of postponing action or fleeing from emotionally charged

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situations, and the employment of various strategems for withholding information from patients) ; and with the main- tenance of a “professional attitude” (which often is seen as being synonymous with the preservation of interpersonal distance through avoiding involving one’s self in a situation or revealing one’s self, particularly to patients). Among the specific ritualistic practices that might be mentioned are the wearing of a uniform, the promotion of so-called indepen- dence in patients to the exclusion of attention to other goals, and, in psychiatric nursing, the approaches to patients that are based on the rule “Thou shalt not touch the patient.” These rituals are aimed at maintaining consistency, but they keep the nurse from learning what she should know about her patients and from correlating her own reactions.

One group of ritualistic maneuvers, which might be en- titled “Secrecy,” are so prevalent as to warrant special consideration.

SECRECY

The most classic examples of secrecy occur in the nurse’s responses to patients. All of us are familiar with the situation in which a patient asks, “What is this medicine?,” “What is my blood pressure?,” “When can I go home?,” or “Am I going to get better?” and the nurse responds with something like, “The medicine is what the doctor ordered for you,” “Now you know I’m not supposed to tell you your blood pressure,” or “You ought to ask your doctor,” or remains silent or changes the subject.

To trace the origin of this ritual of secrecy, one must go back to the days when all matters pertaining to diseases and medical practice were considered so arcane that only a phy-

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sician could understand them; when it was believed that the patient, in particular, must be kept in the dark about many of the aspects of his ailment and treatment and that only the physician was capable of determining and explaining the details that might be revealed to him and his family. For the nurse to deal with the patient’s questions evasively was consistent with this concept; in fact, adeptness in this respect may well have been regarded as a nursing skill.

Such secretiveness is, of course, wholly contradictory to modern concepts of health care, according to which the patient and the members of his family are looked upon as partners in the planning and implementation of his regimen. Moreover, the possible ill-effects of evading the patient’s questions are now recognized. All illness is accompanied by some degree of anxiety; there is always some concern about its outcome. Moving from the world of the well to that of the sick involves a series of contacts with strange people and exposure to odd equipment and a foreign language. Hence, the nature of illness and the condition of being a patient provide fertile soil for the distortion of any communi. cation from others. The patient whose questions are by- passed in one manner or another by the nurse is left to ruminate about his current status and what he can or cannot expect in the future. Generally, he feels caught in a circle of mystcry which for him signifies an unhappy outcome.

Recognition of these facts has changed the role of the nurse. She is no longer the guardian of secrets, the mute purveyor of physical care only. As the person who is most available to the patient and the one whom he is likely to rcgard as most approachable, she is recognized as being in the best position to deal with his questions in a positive way. This is not to say that she should necessarily respond to

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a patient’s question on the same level at which he asked it, that is, to tell him his blood pressure reading, his diagnosis, his prognosis, and so on. It is important, however, that she take heed of his questions and attempt to clarify their mean- ing. In asking for his blood pressure reading, a patient may merely be seeking knowledge and reacting in an automatic way. However, such a question often arises from some anxiety and is aimed at getting reassurance that all is going well. To tell the patient his blood pressure reading may help to assuage the anxiety temporarily but also close the door to a clarification of deeper concerns which have been dis- placed onto the reading.

Unfortunately, many nurses have not accepted this com- munications responsibility. They do not see that because of this function and others that are unique to nursing the nurse has a place on the health team in her own right and not merely as an adjunct to the physician. Instead of recognizing that equality is derived from such differences in functions and responsibilities, they tend to confuse equality with same- ness and to become involved in the frustrating struggle of emulating the physician instead of developing their nursing abilities. However, although they feel that their own role is not worthwhile and that they should be more like the phy- sician, they are afraid to put this desire into action.

The nurse who denies the fundamental equality of the nursing role is likely to feel aggressive, hostile, jealous, and demoralized. For her, the ritual of secrecy continues to be useful. When she says to the patient, “You ought to ask the doctor,” she may be communicating, “I am as helpless as you are. The doctor is the source of all power. I’m sworn to secrecy. 1 would like to be friends with you, but the big brother, higher up, forbids it,” or, “If I were dealing with

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you, I could do a much better job, but I have to defer to him.”

Through such responses, the nurse gains the feeling that she is enforcing a law, and in this policeman’s role, she feels less helpless and powerless.

The rituals of secrecy, then, although originally developed in the patient’s behalf, owe their perpetuation to the needs of the nurses who continue to practice them. These needs - the need to overcome feelings of helplessness and to com- pensate for lack of self-esteem - must therefore be given primary attention in any efforts to eliminate this set of rituals from modern nursing practice.

NURSES’ NOTES

Few rituals in nursing are more exasperating and frustrat- ing to every member of the health team than are stereotyped nurses’ notes. Such notations as “slept well,” “bath given,” “comfortable a.m.,” and “no complaints” are of little use in promoting the patient’s welfare. Moreover, except for the fact that she is performing a procedure that is expected of her, the nurse who prepares such records does not experi- ence any satisfaction. On the contrary, it is demoralizing to prepare a record that may be read by no one.

Why, then, is this ritual continued? Unlike the secrecy ritual, the goal of the routine from which the ritual evolved is still a valid one. For the maintenance of continuity of care and treatment, it is important that the person who has the most intimate contact with the patient over the longest period of time - the nurse - make and record observations that will be of import to the other participants in his care. Too often, however, instead of recording actual data

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about the patient that will have meaning to others, the nurse gives a generalized account, based on a value judg- ment, of what may or may not have been happening to him. The physician, finding that these notations contribute little of significance about the patient’s actual behavior or con- dition, ceases to refer to them. The nurse then feels hurt and, although she may admit that her record is useless, counters by insisting that it would be pointless to take the pains to prepare a meaningful report “because no one would read it anyway.” Nonetheless, because the leaders recognize the validity of the original goal, they continue to require this daily stint, and the form of the routine is maintained although its purpose is not achieved.

Why, in their exasperation, do nurses not attempt to reverse this process and de-ritualize this routine? In some instances, the nurse may question whether the preparation of meaning- ful nurses’ notes can be de-routinized. As one nurse stated, “Having to write nurses’ notes every day on an orthopedic patient who has been in the hospital for months on end and whose condition varies little from one day to the next is foolish and a complete waste of time.”

In other instances, it is possible that the nurse does not wish to accept the responsibility of preparing a really descrip- tive statement. We nurses tend to derogate our self-worth and thus are inclined to evaluate whatever we do in terms of good or bad, right or wrong, and to expect either approval or ridi- cule for our actions. The nurse who commits herself in writing lays herself open to possible criticism. She also risks having to answer further questions and requests for vali- dation. This threat of subsequent involvement is enhanced by the fact that nurses’ notes become a permanent part of a legal document.

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Perhaps, if the nurse were to perceive her observations of each patient as a single but important aspect of a complex series of events that have implications for the total manage- ment of the patient she might be able to prepare notes that she considers worthwhile rather than a “waste of time.” She might also be less concerned about saving face through avoiding the risks inherent in the acceptance of responsibility. The de-ritualization of nurses’ notes would constitute a con- crete demonstration of the nurses’ professional status and therapeutic effectiveness.

THE TABOO AGAINST TOUCHING

In addition to the rituals that are observed throughout the entire field of nursing, each specialty has developed its own ritualistic practices. One example of such a specialized ritualistic observance is the “rule” - though not explicitly stated as such - in psychiatric nursing which prohibits touching between patients and nurses.

It is possible that the do-not-touch taboo derives from two sources. In the past, the psychiatric nurse often used her hands to restrain, threaten, punish, or otherwise control or subdue patients. Therefore, the prohibition against touching patients may have originally represented an effort on the part of the profession to shake itself loose from the jailkeeper image. If this is in fact a source of this ritual, the ritual is no longer justifiable; the physical control of patients is no longer thought of as a major activity of psychiatric nurses.

Responsibility for the perpetuation of this ritual is more likely due to the second possible reason for its origin. This reason is related to the fact that the psychiatrist, because of the transference phenomenon that operates in the patient-

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psychiatrist relationship, avoids touching his patients. Thus, the observance of the no-touch rule by psychiatric nurses may be associated with their desire to emulate the physician - in this case, the psychiatrist.

This ritual deprives the nurse of one of the most important vehicles in nursing - one that is particularly useful in the nurse’s role as mother-surrogate. Through touching the patient, the nurse can convey to him her gentleness, her feeling of caring for him, and her understanding of his feel- ings. This is not to suggest that the nurse should use touching indiscriminately as a way of relating with the psychiatric patient. Meaningful touching is a matter of appropriate tim- ing. However, the nurse misses out on the timing when she makes “not touching” a ritual.

To illustrate this point: The nurses staffing a particular psychiatric unit were made extremely uncomfortable by the behavior of a nine-year old schizophrenic boy who had been hospitalized for over two years. He would throw his arms around them, kiss them, and tug at their skirts. As a con- sequence of his behavior and their discomfort, a rule was made that no patient was to touch any nurse.

A few days after the rule was in force, the boy asked one of the nurses if she would “let me wear your watch and I’ll let you wear my ring, and then we can be married to each other.” The nurse responded by putting on his ring in a condescending manner, but telling him while she did it that they could not be married, that they could only be good friends. The boy responded by crying, “Oh no!”

What was the nurse reacting to? The young patient was hardly referring to the concrete, social institution of marriage with its complex relationship, but rather to his desire and longing for a close, meaningful relationship, for the experi-

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ence of belonging to someone, and having someone special that he could call his own. But this bid, as were his others, was obviously lost, for the boy’s symbolic request for close- ness automatically evoked in the nurse a host of distance- making, limit-setting rules. The effects of a ritual are peculiar in that once the ritual is established it tends to spread to all situations that may only remotely resemble or approximate the original.

As in the case of the secrecy rituals, the elimination of the no-touch taboo will come about when psychiatric nurses fully recognize the worthwhileness of their contributions as nurses, Then they will realize the value of the fact that they can touch patients without interfering with nurse-patient relation- ships, and the meaningless no-touch ritual will disappear from psychiatric nursing.

In conclusion, if the nurse is clear about her own role and the different aspects of the role she is asked to take with the patient and the doctor, she is more likely to recognize and respond to the true meaning of behavior, and not be trapped by routines that turn into non-therapeutic rituals and automatic interpersonal responses. The truly professional nurse achieves recognition and status by affirming her pro- fessional rights, not by affecting a system of prescribed, routinized rites.

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