f LLL.‘AL"§V\JL_I 7" v ‘ I ~‘ I > | J L, LIA va‘.llll. .-‘ ~ - 1 "‘ M " . . bolu La" -- - . .. I l . L ‘ l ‘4‘“ a! .- u I VJJ. . A 54 .deb ‘Alll V alto. JD" FEELINGS AND ATTITUDES 0F PULMONARY TUBERCULOUS PATIENTS SUBSEQUENT TO DIAGNOSIS AND DURING HDSPITALIZATION by Adeana. F. Peterson A PROJECT REPORT Submitted to the School of Social Work Michigan State University In Partial Fulfillment Of The hquiremente For The Degree 0! MASTER OF SOCIAL WORK JUNE 1956 Approved: 7711 2— Chairman, Research Cami ee 1.0 Z ML?- = MPAJYFLL . Director of School 1m Michigan Sim. Univers; m; LIBRARY 1 Immms Sincere appreciation is expressed to Mary Frances Hetsnecker. largery Ross and Manfred Lilliefores for the skillful editing of this study. i'he patience, encouragement and. inspirational philoso- plw of this committee served. immeasurably to aid in the final aocosplishment. 2o 0. J. Stringer. 11.12.. Administrator of Ingham Ohest Hospi- tal. A. 1.. Stanley. ll. 1).. Assistant Administrator. Valere Irapp. R. 1.. Directress of Nursing. and Idella Dukes. Chief Bocial Worker. I extend my thanks for the interest shown in this study. Vithout the combined philosophy of these key individuals in providing medical care and treatment for the 'total' individual. this study would not have been possible. Special thanks are also due the en- tire hospital staff for their support and readiness to help when needed. The assistance and time so willingly given by l‘aythe Eastman in typing and compiling factual material is gratefully appreciated. Io my son, Dean Roger. and to In family, I extend my deepest plaudits for their interest and patient understanding during the completion of this proJect. ii TABLE OF CONTHI‘I‘I'S Chapter Page I 0 INTRODUCT I ON 0 O O O O 0 O O O O 0 O O O O O O O O O O 1 II. HISTORY OF INGRAM CHEST HOSPITAL . . . . . . . . . . . 5 Description of the Setting Review of Literature I I I 0 METHODS AND PliOCEDI-JRES O I 0 0 O O O O O 0 O O O O O O 19 Selection of Patients Introductory Interview Controlled Interview Medical and Social Case Histories IV. PRESENTATION AND.ANALYSIS OF DATA . . . . . . . . . . . 25 Feelings and Attitudes as Revealed by Interviews Evaluation of Interviews Onset of symptoms Reaction to diagnosis Reaction to initial hospitalization Reaction to present services and facilities V. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . 47 APPL‘NDIX O O O O O O O O O O O O O O O O O O O O O O O O O O O 0 so BIBLIOW O O C C O O I O O O O O O O O O C I O O C O I O O 0 53 iii CHAPTER I Introduction Interest in understanding the "total“ person who comes for tuber- culosis treatment has been encouraged for many decades. The student entering the social work profession, whose field placement is in a tuberculosis hospital, is immediately confronted with the need for this understanding. Studentwsupervisory conferences inevitably center around efforts to develop this understanding in order to adequately prew pare the student to fulfill the enabling role. Knowledge of the patient's physical condition as related to his feelings and attitudes regarding the illness, and the resulting limitations, is considered to be the basis for this understanding. The reactions of the patient are the observable clues by which to better understand him, It was in realizing the need on the part of the social worker to learn about the total person that interest in this type of study originated. That tuberculosis is a disease affecting the entire social organism is recognized by even the most somatically oriented practitioner. The patient has innumerable problems, not the least of which is that he faces an illness which can be, at best, only arrested, never cured.l Treatment requires months and often years, during which the patient must be away from home and family for inestimable periods of time. 1 Edward Weiss, M.D.. and 0. Spurgion English, M.D., Ps chosom ti Medicing; (2nd ed: Philadelphia: H. B. Saunders Company, 1949) p. 615 -2- Even though the patient returns to a modicum of health the process may be most difficult. 'Uith present chemotherapy the patient general» 1y feels better much earlier in the treatment process, which fact often creates further emotional problems. The social worker considers the; factors contributing to these problems and attempts to help the patient in the process of adjustment . The problem is a study of patient attitudes and needs subsequent to diagnosis and during hospitalization. The basic reason for such a project is involved with the assumption that the tuberculous patient has attitudes and needs peculiar to, and resulting from, the illness and that there are services by which to meet these needs. If we accept the premise that the attitudes of an individual are usually defined by his previous experiences, individual reactions would be of assistance in the rehabilitation of the patient. The patients' attitudes and feelings are often indications of his understanding of tuberculosis as conditioned by his economic, social and intellectual perspective. To discover something about the patients' reactions to hospital services a questionnaire for a controlled inter- view was developed.1 within this structure the patient was given op- portunity for self-expression which would hopefully yield to evaluation and analysis. It was believed that the social work philosophy could V? 1 Rbring, Langfeld,‘ield, Fbgndatigns of Psychology, (New York: John Wiley and Sons, Inc., 1948) pp. 560 - 567 -3- be applied in three ways: (1) in the development of the structured interview, (2) in the actual interviewing process, and (3) in the evaluation of the reactions. The focus of the study was to determine the surface reactions as related to the following specific areas: 1. How does the patient feel concerning his illness and subsequent hospitalization? 2. what are the typical (general) reactions found among the patients? To understand the patient, one must grant him the opportunity to express how he feels about the illness and how his family feels. His reactions may indicate something as to whether or not services are adee quate to meet his needs. It is, in a sense, the study of inter-relation» ships. Present day medical practice is predicated on attention to the combination social, emotional, and pathological forces in treatment. If this be so, then the reactions of patients regarding available services and facilities would be useful indices of needs, either met or unmet. Knowledge of this type could conceivably provide an avenue to the inw tegration between the understanding of, and the needs of the patient. Further motivation to conduct this study was the realization that relatively few soc1al work students have the opportunity to work in a l tuberculosis hospital setting in Michigan. Worker's requirements are basically the same as one reviews social work skills and knowledge, 1Interview with Margery Ross, Assistant Professor of Social fibrk, Michigan State University. February, 1956. .4... but the added necessity to avail oneself of pertinent medical informa- tion is imperative. One must, at all times, be cognizant that the indie vidual and his "total" life situation is inevitably involved with tuber- culosis. The worker's focus is on the personal - social problems incident to the illness. The patient, family, worker - team approach is necessary 1 to help in solving these problems. Thus, the study is devoted to an examination of attitudes and needs subsequent to diagnosis and during hospitalization. The writer will present a description of the hospital, a review of general literature on social work with tuberculous patients, and the findings from the questionnaire. .Any implications which may be drawn from the evaluation of the findings will be stated in the concluding chapter. l 'leiss and English, 92, cit.. p. 617 CHAPTER II History of Ingham Chest Hospital Since the hospital was opened in 1913 tremendous progress has been realized in the physical structure, scientific treatment and services of qualified personnel.1 Evolution stems from an originfll ten bed facility, manned by one nurse, a maid and a Janitor, all under the medical supervision of six Lansing physicians. By 1919 the bed capacity grew to thirtywsix and in that year the first medi- cal director was appointed. The entire forty-three year history of operation records the services of only three medical directors. The first was replaced after four years and the second appointee re- signed after thirteen years of service. The third and present direct- tor is completing his eighteenth year of service in May of this year. Hdministration of services and facilities for patient care is delegated by the Medical Director, C. J. Stringer, H.D.. to the following key personnel: A. L. Stanley, H. D., Assistant Director, who is completing twelve years of service in this hospital; valere Trapp, R. N.. Directress of Nurses since 1944; Olive Henderson, Directress of Food Service for sixteen years, and Kenneth Grouse, Business Manager for twelve years. One can readily see that the administration has been conducted by the same individuals during the past twelve years. 10. J. Stringer, M. D.. Director Ingham Chest Hospital. Col- lection of unpublished articles. =5- *- Rehabilitation services are of comparatively recent implementae tion in the hospital care program. None the less, in just ten years since the service was inaugurated, many changed have occurred. The department has the services of an Occupational Therapist, a Librarian, a School Teacher, and presently, a Social Worker. Direction has varied from that of a Psychologist, a Vocational Counsellor, and a Social Worker, to the present status of no coordinator, as such. Prior to the appointment of C. J. Stringer, M. D., surgical cases were transferred to the University Hospital in Ann Arbor, Michigan. Under his able direction, a surgical service was inaugurated in the institution in 1938. At the present time, Ingham Chest Hospital is the surgical center for senatoria located in Marquette, Houghton, Huskegon and Powers. The staff also conducts the surgical program at Ionia State Hospital and Traverse City State Hospital. In 1948 facilities were such that authorization was initiated to permit admission of non-tuberculous thoracic surgery cases. On January 1, 1955, the name was changed from Ingham County Tuberculosis Sanatorium to Ingham Chest Hospital, the reason being that the pro- gress and character of treatment services and facilities has been such as to make the previous designation incomplete. Since l9u8, and especially in the recent two or three years, much of the hos- pital's work has been concerned with the treatment of chest diseases other than tuberculosis. The hospital operates in three primary divisions: a7.” l. W: Responsible for the conduct of all hospital activities outside of the hospital, such as; case finding, follownup studies, operation of the mobile Xaray unit, and contact with other physicians. 2. ,flggpipgligapigg; Responsible for all activities conduct- ed within the hOSpital for the care and treatment of in- patients. 3. Re b t o 2 Includes program of occupational therapy, library facilites, education up to college age and medi- cal social service, involving counselling ofiindpatients prior to return to gainful occupations and adjustive living. The philosophy involves a faith in the fundamental value and in- tegrity of human life and a conviction that by positive action, services can be»employed which contribute to the maximum adjustment and usefulness of the patient. This is the structure within which the social worker functions. Often the tuberculosis patient enters the hospital with various con- cerns. He can be helped to work out his own problems and to resolve the confusion of feelings with satisfaction if the social worker's understanding approach is accepted. 9 Description of the Setting and Review of Literature Desggiptign 9f the Setting Ingham Chest Hospital is a relatively small, compact, modern institution with a capacity of one hundred forty one beds. Although it is designated as a general chest hospital, only about twenty per- cent of the cases are non-tuberculous. The age span of the tubercu- lous patient is wide. .At the present time, April 27, 1956, the =8= hospital population consists of the following age groups: #3: Years 0 through 9 13 10 through 19 8 20 through 29 14 30 through 39 13 40 through 49 8 50 thr oush 59 8 60 through 69 ll 70 through 79 6 80 and over 2 0f the total patient group, approximately ten are non-tubercua lous; fifteen are surgical (tuberculosis transfers and other chest cases). and the remainder are on bed rest and drug therapy. Bed rest implies graduated bath room privileges and occasional modified activia ty. Patients wear masks at all times when not at their bed side and are prohibited from kissing or holding hands with relatives or friends. They are placed in a single room with private bath or in three bed wards with community bathrooms. The hospital is constructed on the T plan, which provides for three wings; east, west and south. The physical plant has been im- proved throughout the years in various ways. Mainly, the improvements have provided more adequate facilities with which to serve a larger number of individuals in need of thoracic care and treatment. The four floor structure is laid out as follows: General Administrative offices are located on the first floor as are the Out Patiedt Department, Observation Hard, and the Pediatrics Ward. The patient is admitted through the Out Patient Department and adults are usually referred to the :9- second or third floors (male patients to second and female patients to third.) Both floors contain some single rooms and three bed wards. Surgery is located on the fourth floor, along with private rooms for care of surgical patients. 'The basement south wing houses social service, including Occupational Therapy, Library, Medical Social Service and School Room. A teacher, trained in special education, pro- vides instruction for patients under twenty-five years of age. This wing also contains an auditorium which augments patient services and provides space for class instruction for nurses" training. Food service is located in an adjoining building, connected by a tramway. Fbod is prepared and transmitted to the patients in steam carts. ‘A cafeteria for staff is located in this building. The above description of Ingham Chest Hospital indicates something of the physical aspects attending the tuberculosis patient. The entire facility would be useless unless manned by efficient, coordinated, well- trained professional and noneprofessional personnel. From the trained staff the patient learns about the disease, how it spreads and how to avoid infection to others. There is opportunity for Xurays and chemo- therapy as well as needed surgical treatment. The total function of the hospital is geared to the care and rehabilitation of the patient. Because the tuberculosis patient usually requires long hospitali- zation, it would be impossible for the average individual to bear the costs involved. Therefore, in the State of Michigan, the patient is eligible for care in a tax-supported institution within the county where residency is established. In addition to alleviating the drain on family finances, this factor provides in most instances for care near to family and friends. Previous Studies and ngzent Litezatgpe Many articles have been written which offer support and informa- tion helpful in this study. The writer has attempted to confine the review to the focus of the study, and in so doing finds that availa- ble literature reveals little which would indicate that previous studies are analogous to the nature and findings of this one. Inter- est in the patient as a I'total" organism is considered and reported on in various ways. Rachel Faude Woodl, formerly Directress of the Rehabilitation De- partment in this institution, completed a Masters project in 1952 re- garding.AMA2 discharges. Her study included interviews to obtain her data and.information gathered from medical and case records. Consider- ation was given to age groups, family pressures, length of hospitaliz- 1 Rachel Faude Hood, "Discharge Against Medical Advice,'_%§: seagch Project, nghgm SanatOEium, Michigan State College, (1952 2 Against Medical Advice ation and the extent of illness involved. Findings from that study indicated conclusively that discontent on the part of patients was relatively unimportant as a reason for leaving against medical advice. The largest percentage left because of family pressures. ,Another interesting conclusion which Wood made is that sixtyathree percent of the patients who left against medical advice did so within the first five months of hospitalization. Although the focus of that study was different from the writer's, it is con- ceivable that the feelings and attitudes of the sixtyathree percent leaving during the first five months were responsible for the inability to adjust to hospital requirements. The most valuable social work literary contribution to this study is considered by the writer to be that of Minna Field.1 She covers what the illness means to the patient plus his reactions to all phases of hospitalization and considers attitudes involving the adjustive problems of the patient. At the time she wrote this book, Field was Assistant to the Chief, Division of Social Medicine, Montefiore Hospital, New York. Her am- bition in writing this volume was to present the “evolution of a con- cept of integration of medical and social care of the sick which was influenced more deeply by increased understanding of human behavior l Minna Field, Patignts erg Peoplg, (New York: Columbia Univer- sity Press, 1953) Q12. and by broad social changes than by any single historical fact."1 She develops this by use of case material and her own concepts which were formulated by many years of service in a general hospital. The emphasis is on prolonged illness which is aptly described as 'an ex- tension of acute disease over a longer period of time."2 Uhen actual- ly confronted with diagnosis, the tuberculosis patient is faced with extreme adjustment. The diagnosis is a symbol to which everyone re- acts differently, but with basic common confusion. The social pro- blems resulting from a diagnosis of tuberculosis permeate every facet of the individual's life. The threat to the prognostic implications for the patient”s future is greatly involved with the relationship between the physical and emotional balance.3 The author considers what the illness meansrto the patient as it interrupts the ordinary pattern of living. She indicates the ”life factors“ as the determinants of individual differences in reacting to illness. In the discussion of treatment, she considers patient re- actions to the illness and to the meaning of hospitalization and past hospital adjustment. In the final chapter, Field states '....no mat- ter what aspect of prolonged illness we consider, we find that facili- ties for care are either completely lacking or are grossly inadequate 1 ADI-So. Po 3 21bid., pp. 78 a 79 3Ibid., p. 8 'to meet the needs.“1 Social work with the tuberculous patient is specifically dice czussed in a paper by Pauline Miller.2 She was serving as a special (consultant to the Medical Social Section, Division of Public Health £5ervice at the time it was written. The focus which Miller used was ‘that of the problems which patients present when faced with a diagnosis (of active tuberculosis. She discusses the way a patient accepts the illness as related to his adjustment to hospitalization. The recog- laition is indicated that the individual determines the movement to- *ward a goal of wellabeing. The paper was helpful to this present study as it indicated the efforts of the social worker to meet the individual where he is, in his feeling, and recognizes with him his capabilities and capacities to help himself. The necessity to approach the "patient as a whole" is never of greater importance than at the point of diagnosis of tuberculosis. That the emotional aspects of tuberculosis reveal themselves through physiological manifestations is never more obvious than just follow~ ing the diagnosis. Up to this point, unless the patient actually suspects tuberculosis, organic malfunctioning is of major import- ance. .At the point of diagnosis, however, the psychic aspects come 1 Ibid,, p. 184 2Pauline Miller, Mgdical Social Service in a Tuberculgsis Sanatorigm, (Hashingtonz U. 8. Public Health Service Publication No. 133, Government.Printing Office, 1951) p. 11 ' 1 jgnto the picture in often times greater proportion. A characteristic of the psychic aspect observable in chronic 1.11ness is regression and it varies according to the degree of need. tvkdch.the individual is facing. At the time of diagnosis, one could expeculate that the individual is suddenly at his greatest point of sdnock and subsequent dependency. Only as he progresses,do the depend- esncy needs lessen and the patient returns to some degree of adjustment. It is with this initial reaction that the medical social worker is con- <:erned. Understanding the inter=relationship of the organic disease ‘bo the individual personality is of obvious necessity to one interest- ed in helping the "patient as a whole." Any evaluation of needs and services, whether it be in the per- son or in the material facility used to help the person, is inevitably involved with complexities. The factors to consider are innumerable, creating an even greater necessity to attend to the understanding of interurelationships. The reaction of the patient to a diagnosis of tuberculosis places much demand upon treatment processes conducive to meet emotional needs. The patient must, of necessity, be helped to alleviate dependency behavior to a degree concomitant to his physical restrictions.2 1Harriet M. Bartlett, nge Aspects of Social Casewozk_1n a Medical Setting. (Chicago: Emerican Association of Medical Social Workers, 1940) pp. 115 ., 140 2Frances Upham, ”A.Dynamic Approach to Illness." Ehflill Servige Association of Americap, New York, (1949) pp. 16 - 1? -15- In considering all reactions, attention is drawn to the person sand histehavier as modified by his background. What the individual lurings to the initial experience of hospitalization for tuberculosis dietermines to a great extent, his reaction. Our society has tradi- ‘hionally popularized the concept of hospitalization as a fearful ex- ]perience which demonstrates the seriousness of illness. Fhrthermore, 'the American concept of survival and responsibility is inconsistent trith the husky, strong individual succumbing to long hospitalization, which is so often necessary in tuberculosis. Thus, many individuals still regard hospitalization as an indication of weakness and ex- ‘treme incapacity.1 These fears and apprehensions traditionally perpetuated in our society are further accentuated by the forced separation from family, friends and the normal patterns of activity. The demands upon the individual up to this point have been of much magnitude.. First. he experiences either consciously or unconsciously, the physical symp- toms of abnormal organic functioning. ‘Secondly, the traumatic ex- perience of the diagnosis of tuberculosis which inevitably leads him into this phase of initial hospitalization.2 , Another tendency noted is that of rejection. Patients often re- act-to the initial hospitalization by completely rejecting the diag- 1Miller, 92. 915,. pp. 1 - 3 2 1.12.11” pp. 8-9 also zaostic reason. They feel they are hospitalized "Just for a check up" sand indicate resignation to the necessity of the check up only so that "Then I'd know.” This aspect might well be an escape for many from the recognition of reality. However, one is thoughtful of our modern (education to appreciate the benefits of hospitalization as a means of ssecuring these tests and routine check up. Therefore, many are emotion- sally incapable of accepting even the possibility of their being tuber- <3ulous and look upon the hospitaliztion as a welcome rest while tests tare being run. These patients invariably experience much the same 'emotion when the initial diagnosis is confirmed by tests as do patients ‘who accepted the diagnosis originally.1 To the writer, behavior is not something which can be tabulated, coded and placed into convenient slots to be reviewed for future pre- diction. It can, however, be indicative of clues to which the social worker tunes the pace of service. It was with this thought in mind that consideration was given to pursue this type of study. Initially, the hospital is built for the specific purpose of serving the physically ill individual by helping to restore his health. The objective is to offer to the patient the opportunity to combine his own strengths and resources with medical care to attain maximum health. The initiation of medical care implies the use of services, skills, and facilities of many disciplines. The hospital can only offer services 1Field, pp, 013., pp. 81 = 84 if these disciplines are coordinated and synchronized. The various services involved are many and the internrelationship complex. The medical staff, combined with the nursing staff, offer treatment in accordance with physical needs. The clerical and technical (laboratory workers, Xoray technicians) staff supply the facilitating services. The food service staff serves in still another capacity as does the maintenance staff. All are coordinated to serve the patient under the direction of administration. All of the afore mentioned personnel combine to attend the patients“ needs. A noticeable omission, however, is that of social services which contribute to the needs of the patient by understand- ing him as a person, and how he feels about this particular illness. This differs from, and yet compliments, the physician's treatment, in that medical treatment is administered without particular attenw tion to the individual"s background or social history. The physician treats the individual and the organic anomaly, and the social worker compliments this by considering the individual as the whole person. What he brings by way of background, plus his responsibilities, aims and goals, are considered along with the illness. The physical equipment, organization of the hospital, and the specialization necessary to an efficient, successful hospital, often result in frightened, confused, dependent, or antagonistic 1Bartlett, op, cit,, pp. 11 = 29 :18; :patients. The social worker attempts to help the patient relate more ‘positively to the complexities of hospital life. To adequately meet the patients“ needs the worker must, therefore, be aware of the needs and know of skills by which to meet these needs. The major areas of jpatient concern involve the need to adjust to hospital living; under- standing hospital procedures; fear of treatment; fear of surgery and the fear of postwhOSpital adjustment. The services offered in the institution will be accepted as op- jportunities toward getting better or resented as authoritative restrict- ions. The patient inevitably goes through this experience with a jpositive, healthy growth, or with a negative, resentful, arbitrary approach. The way he uses the experience is important, not only to himself, but later to the community he represents. The movement of any individual hinges upon his or her determination. The goal is elusive, the time required unknown, and even the most healthy, mature, . , 1 individuals battling tuberculosis may lose sight of their goal. It is with this individual, the longmterm tuberculosis patient, that the study is concerned. The social worker's role is to under- stand, and help the patient establish himself within the physical and emotional limits he represents. There are ways to help in this ad- Justment and to be effective, the social worker must first understand what the illness means to the patient. lHarold Nitzberg. "Rehabilitation of the Tuberculous a A Casework Process.” Sogial Casework, XXXI, (Feb. 1950) pp. 61 - 64 CHAEER III Methods and Procedures The findings of this study evolved from the use of the follow- ing tools, techniques and procedures: 1. The selection of patients 2. The introductory interview 3. The controlled interview 4. Use of the medical and social case histories. JIach of these items will be considered separately and in the order ‘used in the study. Jittention will be given to the development and ‘use of each. The Selection of Patients On December 21, 1955, a study of the hospital population was made by Idella Dukes, Chief Medical Social Worker and the writer. From eighty-one pulmonary tuberculosis patients, forty-two were se- lected for the study. Selection was based on the following criteria: 1. 4111 under nineteen years of age were excluded.~ 2. Patients nineteen through seventy-five years of age were evaluated by Idella Dukes. She had previous contact with all and the selections were based on her knowledge of the patients' condition. Excluded were: patients physical- ly handicapped through deafness, blindness, too 111 or mentally incompetent. Of the forty-two patients selected for the study, nine were discharged or left AMI} before being interviewed and three refused to participate. 0f the three patients refusing to take part in the study. two were xlgainst Medical Advice -19- :20: 'women and one man. The man. aged sixty, was interned on the Obser= vation floor in a locked room as a result of legal commitment. Inic tially, he was receptive to the idea of the study and invited the workw or to sit down, while comfortably situating himself. As the first question was asked. he sat up and stated9 “On second thought, I want no part of this." He went on to relate his extreme anger at being housed in a locked "cell" and showed hostility over his inability to obtain a medical discharge. Aware of his emotional state, the worker indicated understanding and reminded him that it was his privilege to decline. However. should he reconsider. he could feel free to have the nurse call for a later interview. The two women patients who refused. did so rather subtly, by con» stantly indicating suspicion. When appointments were made, they re: peatedly excused themselves as unable to participate. One of these women made four appointments and on each occasion refused for physi- cal reasons. The other patient could never bring herself to openly refuse, but her apprehension was so obvious as to cause her name to be withdrawn from the study. From the remaining thirtymthree patients selected for the study, the following facts were compiled: 1. The age range is from nineteen to seventyufive years. . There are twelve females. ages twenty~three to seventy-five years. N There are twentymone males, ages nineteen to sixtyoeight years. Of the total groupD eighteen are married. Of the eighteen married. fourteen have from one to sixteen children. Kath.) 0. 0 9219 Each patient was contacted on two occasions. The first during the introductory interview, which lasted about five minutes. The second contact was during the controlled interview which lasted no less than oneuhalf hour and no more than one hour, the average lasting about fortyufive minutes. Although it was discovered that questions per- mitted the patient opportunity for catharsis, no therapeutic aim, per so, was intended in the research interview. The Introductory Interview A brief bedside contact with each of the patients selected for the study gave opportunity to introduce the worker and invite their participation in the study. About five minutes were spent explaining that they would be given the opportunity to express their feelings re- garding specific questions. In each instance it was indicated that they were not obligated in any way to participate if they preferred not to do so. .mfter relatively few patient contacts, however, the liospital I'grapevine" portrayed a rather complete summary of the pro- (zess involved, which resulted in a veritable eagerness on the part (of the other patients to participate. The Controlled Interview Any consideration of attitudes implies interest in what an indi- 'vidual perceives and how he behaves. Much literature has indicated that behavior is directed by acquired attitudes. These attitudes, whether widely socially accepted or unique to one individual, are considered to lee the result of experience.1 Therefore, to discover attitudes, one [must know something of the individual's life history and personality. (The most direct way to explore this area seemed to be to create open (questions, which, when used in an interview situation, would allow the Ipatient to project his attitudes and feelings into the answer. In so (icing, the writer might expect the reactions to be spontaneous and re= 'vealing. Discussion with Idella Dukes, Chief Medical Social Worker, and other members of the hospital staff served to narrow the focus. It ‘was decided to devise questions which would indicate pertinent data in.the patients' history, while specifically structuring them to bring out the patient feelings and attitudes. Attention was given to the order and type of questions. Efforts were made to avoid vague or ob» scure questions and to eliminate the use of technical or unfamiliar twords. Considering that many individuals like to talk about themselves, Iit was decided to begin with the patient and discover what he thinks about most. As the controlled interview was the major tool employed, it is "£311 to consider how and where it was conducted. Following the intro- Ctuctory interview, the worker made plans to schedule appointments with time patients. At the appointed time the worker accompanied the patient to a private interviewing room. Every effort was made to create 1Boring, Langfeld, Held, op, 91 ., pp. 560 - 567 923° can atmosphere of acceptance and rapport. At the beginning of each interview the patient was reassured that the information given would lee held in confidence. on some occasions opportunity was given for the patient to reduce observable tension by general discussion or (questions in which he might indicate interest in order to prepare for Imaximum participation in the interview, The procedure of the controlled interview was not a question and .answer technique, but a structured interview. To illustrate this pro» cess, consider the responses of a mother of five children, whose diag= :nosis is far advanced pulmonary tuberculosis, when asked, ”what do you feel caused your illness?" “Overwork, I guess. I had four children to take care of by myself as my husband was in the service. We had moved out on a farm in the country. There was a pump, but it didn't work because soon after we moved there the kids threw sand in it, so I had to lug water from a neighbor's house about oneuhalf mile away. The kids were all pretty young and couldn't help much. I was tired all the time and so run down. It must have been that because the only person I ever knew who had tuber- culosis was a neighbor. She lived next door to us about ten years before I ever got sick. I took care of both her and her little girl and didn't know they had tuberculosis until after they died; she never told me.“ Another response to the same question was that of a man who indie (Basted his feelings as to how he became infected as follows: "Oh, Just exposure, I guess, and a swift life. I've been the kind of fellow with questionable habits on the outside. I have no family and so no responsibility. Life for me wasn't involved. I drank heavily and was partying all the time. It‘s unbecoming to think of that life now; it doesn't even oc- cur to me when I'm not with others of the same crowd. Say, Mrs. P., mind if I ask you; could you get tuberculosis by neglect or exposure?" I told him this was an interesting question and asked if we might consider it at another time and he was agreeable. These excerpts of interviews illustrate the writer's belief that this type of structured interview offers material of an evalu- ative nature different from that obtained by use of a questionnaire. .All of the interviews were conducted and evaluated by the writer and the findings are discussed in the following pages. Medical and Social Case Histories These records were used mainly to obtain factual material such as date of admission, diagnosis, age, sex, marital status, family, occupation and schooling. CHAPTER IV Presentation and Analysis of Data In order to adequately present the findings of this study, each question of the controlled interview was broken down into general re- sponses. The questions were evaluated individually and the major re- sponses tabulated. The limitations of such a procedure are recognized as those involving the elements of personal equation and subjective judgement, wherever one person does the evaluation, as did the writer. Conscious effort was made to avoid analytic interpretation of the inter- views with the patients, which were, as far as possible, recorded ver- batim and the evaluations made in accordance with the reactions as stated by the patient. The first part of this chapter will be devoted to discussing data obtained from specific questions.1 The question will be stated and the general classification indicated. Not every question will be used in this manner, as some elicited answers which did not yield to clas- ‘sification, as will be noted. In some instances sample responses will 130 included to illustrate feelings and attitudes, as well as to show the writer's efforts at affecting an objective evaluation. As the data were evaluated it became obvious that the patients‘ reactions to the controlled interview fell into four major responses, these being: l See.mppendix 925a ”26:. 1. Reactions to Symptoms 2. Reactions to Diagnosis 3. Reactions to Initial Hospitalization 4. Reactions to services and Facilities For purposes of analysis the data will be discussed in relation to these four classifications of responses. Feelings and.Attitudes as Revealed by Interviews Adjustment to hospital living requires much effort on the part of all patients. The bewilderment of quietude and rest periods in a tuberculosis hospital is undoubtedly conducive to feelings of strange- ness and loneliness. Furthermore, the presence of technical machinery manned by skilled, whitemclad technicians, undoubtedly holds some fear for all on the first admittance. Schedules for meals, rest, visit- ing, personal care and housekeeping services leave little opportunity for personal attention by staff. One of the patients interviewed mentioned having relatives and friends come from a distance of more than one hundred miles only to be told they could not see him because ‘there were no scheduled visiting hours at that time. Another told of “the necessity for eating within an allotted time when throughout his Ilifetime he had always eaten at a later hour and spent a considerable ammount of time eating. The first question was intentionally placed at the beginning of the interview to encourage the patient to talk about himself. It was felt that in this manner the focus would immediately be patient-center- ed, while at the same time, a yes or no answer was not warranted. ”27.= The answers in most instances were rather terse and contained little elaboration. Predominantly, the patients seemed preoccupied with their plans for the future. What Do You Think About Most? Women .1193 Going Home 1 10 Getting Better 9 5 Future Plans 2 6 At first glance one is impressed with the fact that there is a difference in the focus between the men and the women patients inter— viewed. Of the total group of twentywone men, nearly half were anxi- ous about "going home," while only onewfourth indicated much thought about 'getting better." Whereas, of the twelve women patients partio cipating in the study, threeofourths were concerned about "getting better” and only one mentioned specific thoughts about “going home." Some typical responses will illustrate this point more clearly: 1. One man said, "Nothing'bothers me; just want to go home.” 2. Another man said, 'I'm anxious about getting out.‘' 3. .A father of two children said, "Oddly enough, not about getting out; it's about the future, what kind of work can I do?” ETypical responses from women patients were: 1. ”I think too much of tuberculosis all the time. Don't worry though. I'll get better.” 2. "I think first of tuberculosis and then about God and death.” 3. "Honder what will happen when I'm released.“ 4, "Getting well and being able to live again.“ Considering that tuberculosis often strikes individuals in the saga productive years of their life, it would seem understandable that the male individual would be faced with somewhat different thoughts. He is the wage earner, and as such, is faced with the problem of adequate- ly providing for his family. Therefore, the plans for his future and going home are conceivably realistic. In the case of the female patient the reverse seems to occur, which is fortified by the cultural pattern, that the woman is entitled to care.1 This incapacity is a veritable preservation of status. The attention which they demand is involved with their ability to be possessive, even in a hospital bed. Although the first question was answered quite quickly, the second encouraged elaborate replies. In the majority of cases it revealed answers involving other questions. The implications of prolonged ill- ness often present a fearful experience. How the patient reacts to symptoms is determined largely by his personality and his expectations of life which involve his goals and ambitions. Regardless of whether he accepts or rejects recognizable symptoms, he inevitably must alter his way of life. When asked how they discovered their illness, they Ilsually elaborated on whether or not they had symptoms, how they react-_ ed to them, and what they did about them. In their answers, one can laegin to understand something of their personality characteristics, a 'bit about their background, and often their acceptance or rejection of the implications of symptoms, by their reference to duties, responsi- bilities and ambitions. The question seemed indicative of the following lField, 02, cit,, p. 79 ago: factors: How Did You Find Out You Had Tuberculosis? Romanian; Routine eray 4 14 Symptoms a Tuberculosis not suspected 6 lb Symptoms a Tuberculosis suspected 6 7 The patients who had routine erays are those who had health examinations to meet employment requirements, who voluntarily used the services of the mobile Xaray unit of the hospital. The remain8 ing fifteen patients interviewed were discovered to have tuberculosis as a result of various routine X=rays, such as general surgical cases *who, under the present system of hospital treatment, are routinely gfiven chest X=raysg prenatal examinations; school examinations or in» duction examinations for United States service, However, the writer did observe that those individuals whose illness is not discovered routinely, usually do not seek help until the symptoms become rather severe. The tuberculosis patient interviewed in this study who may ccupational and familial demands upon the individual. The patient who lied a large family dependent upon him or her for support and care showed £1 greater degree of emotional reaction to symptoms, regardless ofirejec- ilion or concern for their meaning. The reactions showed little tendency towards a realistic approach on the part of the individual to the initial Symptoms, even though they suspected tuberculosis. Flanders Dunbar. Mind and Body, (New York: Random House, Inc., 1955) pp. 231 = 239 :41: Another observation was that the greater the degree of emotional concern, the more intense were the symptoms. The patients interviewed ‘who had been diagnosed as far advanced cases were seventeen in number, and of these, fourteen indicated much emotional concern of the symp- toms. Again, the study seems to confirm social work philosophy: that the individual”s ability to cope with a situation hinges upon the emotional reaction to a given aspect, all of which is modified by the jpatient's life experiences. Reactions to Diagnosiso Regardless of the number of symptoms, the way the individual felt sibout them was directly influenced by the background which determined tunese feelings. ”It has not been sufficiently stressed that there are annotional patterns which are related to eating habits, appetite and runtrition, and that these may be responsible for the underweight with which many cases of pulmonary tuberculosis begin. Furthermore, the Binallow respiratory excursion seen in certain neuroses may play some rusle in this disease. These, and probably other emotional factors, Slnould be considered in the etiology of pulmonary tuberculosis.”1 The questions answered regarding the patients' feeling subsequent tag and following diagnosis revealed more feelings and attitudes than flaund any place else in the interview. The ability of the individual ”to inhibit and sublimate physical limitations seemed lost, or so 1 » Weiss and English, op, citgg p. 615 =J+2«= seriously affected as to create a veritable regression to complete deo pendency. The patients indicated apprehension, anxiety, doubt, anger, and a gamut of emotional reactions, all of which can be termed to a certain degree, regressive and childulike. Hgaction to Initial Hospitalization After many attempts to evaluate this area, the writer recognized that we were actually not solely concerned with the reaction to initial hospitalization. The reactions, as such, mean very little, except as they are related to the individual. .m.glance through the evaluative summaries brings out such words as depressed, resigned, worried, heart- 'broken, lonely, and others. These by themselves, mean very little. Iiowever, when one considers that a twenty year old male of recent mi- egration from Mexico, married, with two children, reporting a third égrade education, reports he felt I'Strange and lonely" upon his initial abdmission, the words assume specific significance. Fbr all patients hospitalization necessitates the commending of <>neself into complete dependency. The change to unfamiliar surroundings, ziew routines and fear of the unknown, all tend to place the patient in at new world a that of a tuberculosis patient. A statement by one patient interviewed in this study, portrays very well the initial feelings of (change when he said, "Vhen my daughter left, it felt like the door closed on the best friend I had in the world." 1 I} A. White, The Meaning:of Disegsg, (Baltimore: The Williams and Wilkins Company, 1926) p. 179 :43: Here is one individual summing up in one sentence the complete feeling of being shut off from the world. Even by the use of the word I'had" in the last phrase, he expressed much emotional connotation. Regction to Present Services and Facilities In the attempt to discover the needs and attitudes of the patients. we have explored something of their background and reactions to the total illness. Now it seems conceivable to expect that in the indi- vidual approach we may learn something further about the patients' needs by exploring how he either accepts or rejects hospital services. EPhe effective administration of a busy hospital demands routine to ‘best serve the patient population. The pressures which routine im- Ialies often affect the individual patient by encouraging dependence. .It sets up a schedule which is easy to follow and not infrequently, liard to break. This situation is rather clearly portrayed by Henry 13. Richardson, M.D. when he says: "Entering a hospital does two things; ‘the patient goes into a protective environment and he leaves the re- aponsibility and stimulation of the home...At the hospital his clothes zare in a bag, his pajamas belong to the hospital, food is brought to Iiim regularly, and the only thing he has to do is to carry out orders Elnd this with an entirely passive attitude...The patient starts from ‘the environmental age of a young child in terms of responsibility.'1 1Henry B. Richardson, M.D. Psychosomatic Factors in Convales- cence. (New York: Academy of Medicine, 1940) p. Ink outta. Many interviews portrayed vivid feelings of frustration at the un- availability of the out doors. The sudden restriction to one room wherein three people are housed, is to some, analogous to their con» ception of prison. Many of the patients worked on the outside as laborers and farmers, and the restricitons to them are further indi- cations of the already serious illness. The lack of understanding of hospital procedures was evidenced in almost every patient interviewed. At time of admittance, most had pleasant memories of staff treatment and then, as one patient related, “It starts.” They are taken through the Out Patient Department, sit inhile X=rays are developed and often hear their names repeated in the eudjoining room, while not able to hear what is said about themselves. {Eben a doctor advises, ”You.better stay a while.” They are taken upo sstairs, handed a mask, a pair of pajamas, and told to go to bed. Tests and examinations often do not start until the following day, (luring which interim the patient is cautioned not to do many things, Irut seldom is told why he is restricted. The "patient grapevine" Starts along about this point in time, and he may learn he is to be llere for 'Six months to a year,‘ and is considered a positive tubercu- ILosis patient until his tests return and prove him negative, about esight to ten weeks hence. Very probably he has been told little of ‘hhe meaning of tests, positive=negative, or why he must rest from twelve=thirty to tw0mthirty in the afternoon. After the patient has been hospitalized several days, he knows :45- when meals arrive, and accepts rest period as imperative,wears his mask, and now comes a Friday morning, better known as IRounds Day." During the early part of Friday, the Medical Staff, comprised of the Administrator, his Assistant, the Resident Physician, the Supervisor of Nurses, and the Chief Social ibrker, together make complete rounds of the hospital, seeing every patient. This is immediately threaten- ing to the majority of patients. The attention which he may experi- ence may well be considered with importance when he views the Adminis- trator and his staff. He is invited to participate in the discussion occurring across his bed, but the apprehension he feels by the total situation often causes questions to elude him. The team approach is for the most part of great importance to the patientsn well being, but the experience of rounds to many patients is very frightening. The scientific contribution which this group on rounds can make to the patients' welfare is of minor significance to the individual as compared to the frightening picture which the team makes at a given moment. Nor are these regular services the only ones to which the patient must adjust. During this period he is continuously conscious of the length of hospitalization as defined by the illness. Little time is spent explaining to him what to expect in treatment. Monday comes and is better known as I'Shot Day." The new patient may not be ready for shots, and no one explains; he waits, sometimes many days, until the medical recommendation is written for medication. The unknowns in- volved are, for the patient, ususally very threatening. «46¢ By considering the degree of threat which patients experienced and shared during the interviews we have viewed some of the depths of attitudes and feelings involved. Reactions noted in the interviews indicated consternation and despair subsequent to diagnosis and during the initial hospitalization. There was a positive change observable in the answer to those questions involving the patients' feelings at the time of the intervieW. CHAPTER V Summary and Conclusions This is a study of patient attitudes and needs subsequent to diago nosis and during hospitalization in Ingham Chest Hospital. The problem was selected as a result of the realization that to adequately ful- fill the enabling role one must attempt to understand the individual. It was believed that feelings and attitudes regarding the illness would be a basis for better understanding the patients. It was as- sumed in this study that pulmonary tuberculosis patients have attitudes and needs peculiar to, and resulting from the illness and that there are services by which to meet these needs. Thirty=three individuals were selected for the study out of a total of eightyuone pulmonary tuberculosis patients hospitalized on December 21, 1955. The criteria for selection was that the patients had pulmonary tuberculosis and there were no handicaps such as deaf- ness, blindness, illness or mental incompetency. The ultimate age range was nineteen to seventymfive years. The major tool used was a controlled interview, structured to in- clude Open end questions which would elicit the feelings and attitudes of the patients subsequent to diagnosis and during hospitalization. In so far as possible, responses were recorded verbatim. The interviews were evaluated by the writer and grouped into four major areas; reactions to symptoms, reactions to diagnosis, reactions to initial hospitalization and reactions to services and facilities. .47- .l.l_l .43., The questions asked early in the interviews resulted in eliciting negative feelings regarding preodiagnostic symptoms, diagnosis and plans for hospitalization. Reactions included such feelings as de~ pression, rejection and hostility to the discovery of the illness and necessary hospitalization. Questions asked later were focused to re- veal feelings which the patient had at the time of the interview, and a noticeable change occurred in responses. Reactions were more positive as indicated by confidence towards getting well, and less depression on the part of those interviewed. Also, the patients showed motivation to make plans for the future which might conceivably indicate more healthy attitudes. It would be only fair to reiterate at this point the understanding on the part of the writer, that reactions to interviews may possibly be distortions of basic feelings. However, during each evaluation, active effort was made to avoid interpretation on any level except the surface reactions. The assumptions of this study seem to have been supported, because if patients' needs had not been met in some degree by the services and facilities of the hospital, a change in attitudes could not have been observed. The writer believes the most significant finding of this study to be the indication that a positive change in attitude of the patients interviewed occurred during hospitalization. There are conceivably many factors involved in this change of attitudes which this study was not designed to discover. However, the following findings may have contributed to the positive change observed: .49- The present admittance procedure seems to have a positive reaction on the patient. Staff contacts are pleasantly recognised by the patients; such as the personalized attention by the dietician. The regular medical care received by the patient is ac- cepted positively as necessary to their regaining of health. In general, the patients in this group believe the craft and Vocational Rehabilitation program to be most helpful and should be continued. The findings further suggest the following considerations: 1. 2. 3. 5. Social casework services would be helpful to the patient at the time of diagnosis and initial hospitalization. Orientation procedures might be reviewed and reorganized to more fully meet the patient needs. The practice of hospital rounds might be reconsidered to discover whether or not the process could be restructured to alleviate patient anxiety. IPatient services and program may be reviews to consider the inclusion of limited "Outdoor activity' if the patient's physical condition warrants such a program. A.review of doctorepatient contacts might be made to de- termine whether thg patients' requests for 'Mbre individual time with doctors'' is necessary. 1 See page 37, Chapter IV APPENDIX 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Q51- QUESTIONS USED AS BASIS FOR CONTROLLED INTERVIEW TO DISCOVER ATTITUDES AND FEELINGS OF PULMONARY TUBERCULOSIS PATIENTS What do you think about most? How did you find out you had tuberculosis? What do you feel caused your disease? What symptoms have you had? What kind of symptoms have you had? How did you feel about your symptoms? Did you think your symptoms might mean tuberculosis? Who first told you you had tuberculosis? How did you feel when you first learned you had tuberculosis? How did you feel the night following your diagnosis? How do you feel now about your illness? How does your hospitalization help in getting well? Uhat do you enjoy about hospital life? Who made the plans for you to come to the hospital? What was your first impression of hospital staff? Uhat did you think of during your first day in the hospital? How many friends have you made here in the hospital? Do you make friends more easily now than before? How do you spend your time in the hospital? Do you participate in allowable hospital activities? Do you know much about tuberculosis? 22. 23. 24. 25. 26. 27. .52.: How did you learn about tuberculosis? Do you think you would like to learn more? How would more knowledge help you? How do you feel about entertainment brought into the hospital? What changes in hospital routine would you suggest to help you recover faster? What do you miss most by being in the hospital? BIBLIOGRAPHY BOOKS .Alexander, Franz: Psychosomatic Medicine. New York, I. W. Norton and Company, 1950. Bartlett, Harriett: Some Aspects of Casework in a Medical Setting. Chicago, American.Association of Medical Social Workers, 1940. Boring, Langeld, Weld: Foundations of Psychology. 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"Casework Service Today in a Hospital Setting.” Se- lected Paperg in Casework, National Conference of Social Workers, Raleigh Health Publication Institute, (1951) 655.: Miller, Pauline. "Medical Social Service in a Tuberculosis Sanator- ium.” U, S, Pqu;‘ M, Government Printu ing Office (1951) Wittkower. Edward, Durost, H. B. and Laing, U. A. R. 'A.Psychosomatic Study of the Course of Pulmonary Tuberculosis." U, SI Department of Health, Education and7Welfare (1955) REPORTS Coleman, Jules, M.. D. "Attitudes of Professional Personnel in the Treatment of Tuberculosis." ' and Welfare, CM 739 (1954) PumpianaMindlin, Eugene and Futterman, Samuel. 'The Role of Emotion- al Problems in Tuberculosis." A.paper presented at Institute for Social Werkers on Medical and Social Aspects of Tuberculosis, U, S, Department of Health, Egucation and Welfare (May 1950) UNPUBLISHED Ross, Margery. Assistant Professor of Social Work, Michigan State University. Stringer, C. J., M. D. Collection of articles. 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