by Dolores E . Little, R.N. , M.N.

THE prevailing practices in hospital nursing guarantee to a patient that he will be securely wrapped in a protective cocoon from which no information regarding his condition will emanate to relatives or friends. This intriguing concept of nursing care, despite its pervasiveness, has not been de- fined in present-day nursing curriculums and has received scant, if any, attention in nursing literature. On the contrary, numerous articles have been written on the importance of enlisting family support as an adjunct in patient therapy. In view of this paradox, it seems appropriate to examine the current practices relating to nurse-family communica- tions and the mechanisms that tend to perpetuate these practices .

Although there have been few changes in the way in which a patient’s family seeks information, nurses, over the years have improved their techniques for dealing with questions

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about the patient. A common question the relatives of a pa- tient ask of nurses is, “How is he doing today?” For years, nurses had one answer to this question: “He is doing as well as could be expected.” This reply gave the patient’s family a tremendous opportunity to examine the ramifications of all its possible meanings. The interpretation of the response did not seem to be a concern of nurses. The double-talk quality of the reply did, however, evoke the interest of cartoonists and comedians, who illustrated and mimicked the remark until nurses were forced to develop a broader repertoire of responses.

The result of this expansion is a battery of answers which achieve the same purpose: say something and tell nothing. The increase in the number of possible answers, of course, demands that nurses be more knowledgeable about which one is most appropriate to a particular situation. Instead of relying upon one stock answer, a nurse must choose from several that are equally ambiguous.

1. There is no change in his condition. 2. He is about the same today. 3. His condition is still satisfactory. 4. He is still listed as critical. (This answer is a particu-

larly good one when the patient is dying, because it implies that someone else put him on the list and relieves the nurse of the responsibility for explaining its meaning.)

5 . He seems pretty good. 6. He had a better night. 7. He had a comfortable day. 8. He seems to be resting now.

The manner of delivering these pearls of information has

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also been standardized. Regardless of whether the patient is getting better or is dying, nurses utter these phrases with the matter-of-factness of a telephone recording that reports the time of day.

If nurses think about this behavior, they may assume that automaton-like answers in some way reassure the family. Perhaps they believe the content and the tone of the response will assure the patient’s family that everything is under con- trol and that they are protecting the patient from outside environmental factors that would affect his recovery.

When the members of a family are not satisfied with these answers, they attempt to find out more specific information about the patient. Since in our culture, to be permitted to eat everything, to have a daily bowel movement, to sleep eight hours, and to have no fever are taken as signs of re- covery from an illness, the most frequent inquiries concern the patient’s eating, bowel-functioning, sleeping, and tem- perature. Nurses have developed a standard method for handling the specific as well as the general questions. The family is usually referred to the patient’s physician as the only person who is qualified to release these secrets about the patient. Nurses simply say to the patient’s family, “You’ll have to ask his doctor about that,” or, “His doctor can give you that information.” This kind of referral is doubly effec- tive, since it not only answers the current question but even- tually stops the family from bothering the staff with any more questions.

The methodology of the nurse-developed responses to the patient’s family has been so clearly defined that this activity can now be delegated to other personnel in the hos- pital. A ward clerk can use these answers for from twenty- five to forty patients, consequently relieving the nurses of

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this task. An even higher level of efficiency can be reached by delegating this responsibility to the switchboard operator. This method is used primarily when the fami!y telephones the hospital for information about the patient. The switch- board operator has bcen so well trained in how to use the standardized answers that she can handle information about 200 or 400 patients! It is conceivablc that the efficiency level may achieve new heights when recording devices handle these calls, thus relieving even the switchboard operator of this task.

The skill that nurses and other personnel have developed in performing these evasive maneuvers is reinforced by tra- ditional routines and by the socio-organizational structure of our present-day hospitals, In the “good old days,” all ques- tions about a patient were referred to his physician, and nurses were trained not to give out any information, with the caution that to do so was a cardinal sin. Today, many nurses still follow this traditional practice and conscientiously teach it to young nurses. Physicians, too, strengthen this posi- tion by informing nurses that they will personally handle the dissemination of all information about the patient.

Hospital policies constitute another factor which has strengthened this concept of nursing care. Concern about the increasing number of law suits has led hospital authorities to spell out the who, when, and what of the information released about a patient. These policies affect the nurses’ be- havior with patients’ families.

Because of the tight bond of secrecy on the part of nurses, patients’ families have been forced to find other resources for providing answers to their questions. Some families do exactly as they are told to do and call the patient’s physician. Other families may be timid or reluctant to call the busy physician,

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or may be so anxious to get the information immediately that they use any available source.

One means of obtaining information about their family member is to solicit such information from other patients on the unit. It is surprising how many facts other patients know about the patient of the inquiring family. After all, they are around for twenty-four hours; they have both time and opportunity to gather and disseminate this information. That they do not have the perspective to know whether the infor- mation they give the families is reliable seemingly has little bearing on the acceptance of this information; at least, the family gets some news.

Another consistent supplier of information to patients’ families is the janitor or cleaning maid on the ward unit. It is astounding how much these workers know about all of the patients and their therapy. They create the impression of having time to talk and seem to be more available than are members of the nursing staff.

If none of these resources is used, the members of the patient’s family find that information procured over the back fence is satisfying and specific. Neighbors and friends seem to be able to provide the family with answers to any ques- tion. After all, the abundance of medical articles in lay litera- ture and the advent of Ben Casey have developed a very sophisticated public. Another significant aspect of these an- swers is that the relatives and friends can always relate ex- periences about themselves or others who have had exactly the same kind of condition or problem as the patient.

These four methods used by patients’ families to obtain information do not threaten the perpetuation of the say- something-and-tell-nothing concept of nursing care; they really strengthen its use. Because families have found other

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resources from which to obtain information, they do not pro- test their exclusion from access to sound, scientific knowledge.

Regardless of all the forces that strengthen the say-nothing practices, however, the survival of the concept is being threat- ened. One threat is the flow of contributions to the field of nursing from the cultural anthropologists. They are making nurses more aware of the distinct difference between our culture and other cultures with respect to the inclusion of the patient’s family in his care. In hospitals where many of the patients are from cultural backgrounds that include the family in the patient’s care, nurses are being forced to be more explicit in their answers to questions by family mem- bers.

Another trend that may threaten the concept is the exten- sion of hospital visiting hours. When visits from patients’ families were restricted to a few designated hours, nurses had to deal with the families’ questions for a limited time only. Now, in many hospitals, families can visit at any time during a period ranging from eight to fifteen hours. In these hospitals, nurses come in contact with the patients’ families at various times and must handle the families’ questions more directly.

Another threat to the operational definition of the say- something-and-tell-nothing concept is the active participa- tion of expectant fathers in the care of their wives on obstet- ric services. The policy of no information is disappearing on these services because the husband cannot be included in the care of his wife unless he has information about her condi- tion. Similarly, this practice is fast disappearing on those pediatric services where parents participate in the care of their children. Like the expectant father on the obstetric service, the parents must have their questions answered

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if they are to assist knowledgeably in the child’s plan of care. Will the standardization and the mechanization of the

answering service, traditional practice, and prevailing hos- pital policies continue to control this aspect of nursing care? Or, will the trend toward family involvement that is invading obstetric and pediatric nursing services with seeming success extend to other services in the hospital and break down the informational barrier?

It is obvious that a confiict is brewing on the battleground of hospital nursing, The Nightingale soldiers of the say- something-and-tell-nothing front will be opposed by the Nightingale soldiers who say something and give meaningful answers to questions asked by the patients’ families. As the battle rages in departmental sections of the hospital, the families of some patients will hear all of the news, while the families of other patients will be subjected to bland evasions. When the families observe this conflict in nursing care, they will have to choose sides, and it will be interesting to see which camp they will join. Who will win this battle will be determined by which side the patients’ families will support. It is on the degree to which these families recognize and express the need for their intelligent participation in the patient’s therapy that the outcome of this “battle of no information” depends.

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