PSYCH STUDY GUIDE Chapter 1: The Concept of Stress Adaptation o Stress à Stress may be viewed as an individual’s reaction to any change that requires an adjustment or response, which can be physical, mental, or emotional. à NOT EVERYONES stress is the same à Physical stress- sweating, nausea, HAs, even vomit à Mental stress- forgetfulness, rumination (omg this is going to happen, same thing over n over in your mind) à Emotional stress- crying, yelling, screaming o Roy’s Adaptation Model à Roy (1976) defined adaptive response as behavior that maintains the integrity of the individual. à Adaptation (adaptive) is viewed as positive and is correlated with a healthy response. à When behavior disrupts the integrity of the individual, it is perceived as maladaptive. à Maladaptive responses by the individual are considered to be negative or unhealthy. -it can become pathological like the mass shootings. o Introduction à The word stress lacks a definitive definition. Bc for everyone it is different. à Adaptation is defined as restoration of homeostasis to the internal environmental system. à Adaptation includes responses directed at stabilizing internal biological processes and psychological preservation (like the rumination) of self-identity and self-esteem. à Maladaptive responses are perceived as negative or unhealthy and occur when the integrity of the individual is disrupted. o Stress as a Biological Response à Hans Selye defined stress as “the state manifested by a specific syndrome that consists of all the nonspecifically induced changes within a biologic system.” à “Fight-or-flight” syndrome. § Initial stress response § Sustained stress response o Stress as an Environmental Event à This concept defines stress as a “thing” or “event” that triggers the adaptive physiological and psychological responses in an individual. à The event is one that § Creates change in the life pattern of the individual § Requires significant adjustment in lifestyle § Taxes available personal resources à Stress is measured by the Miller and Rahe Recent Life Changes Questionnaire. à It is not certain whether stress overload merely predisposes a person to illness or actually precipitates it, but there does appear to be a clear causal link. à A weakness in the Miller and Rahe tool is that it does not consider § The individual’s personal perception of the event § His or her coping strategies and available support systems at the time of the life change o Stress as a Transaction Between the Individual and the Environment à This definition of stress emphasizes the relationship between the individual and the environment, which is appraised by the individual as taxing or exceeding his or her resources and endangering his or her well-being. à Precipitating event: a stimulus arising from the internal or external environment and perceived by the individual in a specific manner à Individual’s perception of the event § Primary appraisal: a judgment about the situation in one of the following ways • Irrelevant • Benign-positive • Stress appraisal § o o o o o o Secondary appraisal: an assessment of skills, resources, and knowledge that the person possesses to deal with the situation Individual’s perception à An event is judged irrelevant when the outcome holds no significance for the individual. à A benign-positive outcome is one that is perceived as producing pleasure for the individual. à Stress appraisals include harm/loss, threat, and challenge. à Harm/loss appraisals refer to damage or loss already experienced by the individual. à Appraisals of a threatening nature are perceived as anticipated harms or losses. à When an event is appraised as challenging, the individual focuses on potential for gain or growth, rather than on risks associated with the event. Stress as a Transaction Between the Individual and the Environment à Predisposing factors (Biopsychosocial) § Genetic influences § Past experiences § Existing conditions Genetic Influences (fam hx) à Those circumstances of an individual’s life that are acquired through heredity. à Examples include family history of physical and psychological conditions (strengths and weaknesses) and temperament (behavioral characteristics present at birth that evolve with development). Past experiences (ex-bank ruptcy the 3rd time, use to it so wont stress em out as much as first time) à Occurrences that result in learned patterns that can influence an individual’s adaptation response. à They include previous exposure to the stressor or other stressors, learned coping responses, and degree of adaptation to previous stressors. Existing Conditions à Incorporate vulnerabilities that influence the adequacy of the individual’s physical, psychological, and social resources for dealing with adaptive demands. à Examples include current health status, motivation, developmental maturity, severity and duration of the stressor, financial and educational resources, age, existing coping strategies, and a support system of caring others. Stress Management à Stress management is the use of coping strategies in the response to stressful situations. à Adaptive coping strategies protect the individual from harm and restore physical and psychological homeostasis. à Coping strategies are considered maladaptive when the conflict being experienced goes unresolved or intensifies à Some adaptive coping strategies include § Awareness § Relaxation § Meditation § Interpersonal communication with caring other § Problem-solving § Pets § Music Chapter 2: Mental Health/Mental Illness Historical and Theoretical Concepts o Introduction à The concepts of mental health and mental illness are culturally defined. à Individuals experience both physical and psychological responses to stress. o Historical Overview à Early beliefs centered on mental illness in terms of evil spirits or supernatural or magical powers that had entered the body. à The mentally ill were beaten, starved, and otherwise tortured to “purge” the body of these “evil spirits.” à Some correlated mental illness with witchcraft, and mentally ill individuals were burned at the stake. à Hippocrates associated mental illness with an irregularity in the interaction among the four humors: blood, black bile, yellow bile, and phlegm. à During the Middle Ages, the mentally ill were sent out to sea on sailing boats with little guidance in search of their lost rationality. This practice originated the term ship of fools. à During this same period, the Middle Eastern Islamic countries began to establish special units in general hospitals for the mentally ill, creating what were likely the first asylums for the mentally ill. à In colonial America, mental illness was equated with witchcraft. Many were burned at the stake or put away in places where they could do no harm to others. à The first hospital in America to admit mentally ill clients was established in Philadelphia in the mid18th century. à Benjamin Rush, often called the father of American psychiatry, was a physician at the hospital and initiated the first humane treatment for mentally ill individuals in the United States. à à à à à à In the 19th century, Dorothea Dix was successful in her lobbying for the establishment of state hospitals for the mentally ill. § Her goal was to ensure humane treatment for these patients, but the population grew faster than the system of hospitals, and the institutions became overcrowded and understaffed. Linda Richards is considered to be the first American psychiatric nurse. § She graduated from the New England Hospital for Women and Children in Boston. § She helped establish the first school of psychiatric nursing at the McLean Asylum in Waverly, Massachusetts, in 1882. Psychiatric nursing was not included in the curricula of schools of nursing until 1955. The National Mental Health Act was passed by the federal government in 1946, which provided funds for the education of psychiatrists, psychologists, social workers, and psychiatric nurses. à Graduate-level psychiatric nursing was also established during this period. à Deinstitutionalization and the community health movement began in the 1960s. o Mental Health à Defined as “the successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms” o Mental Illness à Defined as “maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual’s social, occupational, or physical functioning” à Horwitz describes cultural influences that affect how individuals view mental illness, including § Incomprehensibility: the inability of the general population to understand the motivation behind the behavior § Cultural relativity: the “normality” of behavior is determined by the culture o Psychological Adaptation to Stress à Anxiety and grief have been described as two major, primary psychological response patterns to stress. à A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. à Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual’s functioning. à à à à à Anxiety à A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. à Anxiety is extremely common in our society. à Mild anxiety is adaptive and can provide motivation for survival. à Can lead to depression Peplau’s four levels of Anxiety MUST KNOW!!! à Mild: seldom a problem. Sharpens senses. à Moderate: perceptual field, attention span and concentration decreases à Severe: perceptual field is so diminished that concentration centers on one detail only or on many extraneous details. Person has difficulty completing a simple task (headaches, palpitations, insomnia) à Panic: the most intense state; unable to focus on even one detail. Misperceptions are common. Behaviors may be wild. May hallucinate; feelings of terror (like they’re going crazy, or losing control) Behavioral adaptation responses to anxiety § At the mild level, individuals employ various coping mechanisms to deal with stress. § A few of these include eating, drinking (DT- delirium tremors), sleeping, physical exercise, smoking, crying, laughing, and talking to persons with whom they feel comfortable. At the mild to moderate level, the ego calls on defense mechanisms for protection, such as § Compensation § Denial § Displacement § Identification § Intellectualization § Introjection § Isolation § Projection § Rationalization § Reaction formation § Regression § Repression § Sublimation § Suppression § Undoing § à à à Grief § The subjective state of emotional, physical, and social responses to the loss of a valued entity; the loss may be real or perceived § Elisabeth Kübler-Ross (5 Stages of Grief) • Denial • Anger • Bargaining • Depression • Acceptance Anticipatory grief: the experiencing of the grief process before the actual loss occurs. Mourning process is completed prematurely. Family may disengage emotionally (e.x.-from dying person) Resolution: length of the grief process is entirely individual § It can last from a few weeks to years § It is influenced by a number of factors à à à à à Resolution is hindered or delayed by § The experience of guilt for having had a “love-hate” relationship with the lost entity § Having experienced a number of recent losses and being unable to complete one grieving process before another one begins Resolution is facilitated by § Anticipatory grieving: being able to experience feelings associated with grief before the actual loss occurs. Resolution of the grief response is thought to occur when an individual can look back on the relationship with the lost entity and accept both the pleasures and the disappointments of the association. Maladaptive grief response § Prolonged response § Delayed/inhibited response § Distorted response § o DSM-IV-TR Multiaxial Evaluation System à Axis I: Clinical disorders and other conditions that may be a focus of clinical attention à Axis II: Personality disorders and mental retardation à Axis III: General medical conditions à Axis IV: Psychosocial and environmental problems à Axis V: Global assessment of functioning rated on the Global Assessment of Functioning (GAF) Scale, which measures an individual’s psychological, social, and occupational functioning o Example of a Psychiatric Diagnosis à Axis I: 300.4 Dysthymic Disorder à Axis II: 301.6 Dependent Personality Disorder à Axis III: 244.9 Hypothyroidism à Axis IV: Unemployed à Axis V: GAF = 65 (current) Week 2 Chapter 5: Ethical and Legal Issues in Psychiatric/Mental Health Nursing o Introduction à Nurses are constantly faced with the challenge of making difficult decisions regarding good and evil or life and death. à Legislation determines what is “right” or “good” within a society. o Core Concepts à Ethics: a branch of philosophy that deals with distinguishing right from wrong à Bioethics: term applied to ethics when they refer to concepts within the scope of medicine, nursing, and allied health à Moral behavior: conduct that results from serious critical thinking about how individuals ought to treat others à Values: personal beliefs about what is important and desirable à Values clarification: a process of self-exploration by which people identify and rank their own personal values à Right: a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and entitlement to a benefit or service à Absolute right: when there is no restriction whatsoever on the individual’s entitlement à Legal right: a right on which the society has agreed and formalized into law o Ethical Considerations Theoretical perspectives à Utilitarianism: an ethical theory that promotes action based on the end result that produces the most good (happiness) for the most people à Kantianism: suggests that decisions and actions are bound by a sense of duty à Christian ethics: do unto others as you would have them do unto you à Natural law theories: do good and avoid evil. Human knowledge of the difference between good and evil directs decision making. à Ethical egoism: decisions are based on what is best for the individual making the decision o Question à An operating room nurse asks a psychiatric nurse, “How can you work with the mentally ill day in and day out?” The psychiatric nurse replies, “It's just the right thing to do.” The psychiatric nurse is operating from which ethical framework? o Kantianism o Christian ethics o Ethical egoism o Utilitarianism à Correct Answer à Correct answer: A o Kantianism focuses on the morality of actions. Actions are judged as right or wrong based on ethical principles. The nurse’s response indicates a Kantian perspective. o Ethical Dilemmas à Ethical dilemmas occur when moral appeals can be made for taking either of two opposing courses of action. à Taking no action is considered an action taken. o Ethical Principles à Autonomy: emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected à Beneficence: refers to one’s duty to benefit or promote the good of others à Nonmaleficence: abstaining from negative acts toward another; includes acting carefully to avoid harm à Justice: based on the notion of a hypothetical social contract between free, equal, and rational persons. The concept of justice reflects a duty to treat all individuals equally and fairly à Veracity: refers to one’s duty to always be truthful o A Model for Making Ethical Decisions à Assessment à Problem identification à Plan à Implementation à Evaluation o Ethical Issues in Psychiatric/Mental Health Nursing à The right to refuse medication à The right to the least restrictive treatment alternative o Legal Considerations à Nurse Practice Act defines the legal parameters of professional and practical nursing. à Types of laws § Statutory law: enacted by legislative body (US Congress) § Common law: derived from decisions made in previous cases (may differ state to state) o Classifications Within Statutory and Common Law à Civil law: protects the private and property rights of individuals and businesses o Torts: an individual has been wronged (intentional/unintentional) o Contracts: one party has failed to fulfill an obligation (breach) à Criminal law: provides protection from conduct deemed injurious to the public welfare o Legal Issues in Psychiatric/Mental Health Nursing à Confidentiality and Right to Privacy o HIPAA o Doctrine of privileged communication o Exception: a duty to warn à Informed consent à Restraints and seclusion -not a form of punishment. o False imprisonment o Legal Issues in Psychiatric/Mental Health Nursing à Commitment issues docs can only ADMIT, commit=only court can do. o Voluntary admissions o Involuntary commitments= happens when pt refuses § Emergency commitments § The mentally ill person in need of treatment § Involuntary outpatient commitment § The gravely disabled client o Legal Issues in Psychiatric/Mental Health Nursing à Nursing liability o Malpractice and negligence o Types of lawsuits that occur in psychiatric nursing § Breach of confidentiality § Defamation of character • Libel • Slander o Legal Issues in Psychiatric/Mental Health Nursing à Nursing liability o Invasion of privacy o Assault and battery o False imprisonment o Avoiding Liability à Respond to the client à Educate the client à Comply with the standard of care à Supervise care à Adhere to the nursing process à Document carefully à Follow-up as required à Develop and maintain a good interpersonal relationship with client and family Week 3 Chapter 6- Relationship Development Introduction o The nurse-client relationship is the foundation on which psychiatric nursing is established. o A therapeutic relationship is an interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and illness prevention. Role of the Psychiatric Nurse o Nursing has evolved through various roles from custodial caregiver and physician’s handmaiden to recognition as a unique, independent member of the professional health-care team. o Peplau identified six sub-roles within the role of the nurse § The stranger: in the beginning, nurse and client are strangers to each other § The resource person: the nurse provides information related to the client’s health care § The teacher: the nurse identifies learning needs and provides information required by the client or family to improve the health situation § The leader: democratic leadership allows the client to be an active participant in planning his or her care § The surrogate: for the client, the nurse fulfills basic needs, which is associated with mothering § The counselor: the nurse uses “interpersonal techniques” to help clients learn to adapt to difficulties or changes in life experiences o Peplau believed that the emphasis in psychiatric nursing should be on the counseling sub-role. o Peplau and Sullivan, both interpersonal therapists, emphasized the importance of relationship development in the provision of emotional care. Dynamics of a Therapeutic Nurse-Client Relationship o Therapeutic nurse-client relationships can occur only when each views the other as a unique human being; when this occurs, both participants have needs met by the relationship. o Therapeutic relationships are goal-oriented and directed at learning and growth promotion. o Goals are often achieved through use of the problem-solving model § Identify the client’s problem § Promote discussion of desired changes § Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively § Discuss alternative strategies for creating changes the client desires to make o Weigh benefits and consequences of each alternative o Help client select an alternative o Encourage client to implement the change o Provide positive feedback for client’s attempts to create change o Help client evaluate outcomes of the change and make modifications as required Question 1. Which is the primary nursing goal when establishing a therapeutic relationship with a client? A) To promote client growth B) To develop the nurse’s personal identity C) To establish a purposeful social interaction D) To develop communication skills o Correct Answer… Correct answer: A § The goal of a therapeutic nursing interaction is to promote client insight and behavioral change directed toward client growth. Therapeutic Use of Self o Definition: ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions o Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition. Gaining Self-Awareness o Values clarification is one process by which an individual may gain self-awareness. o Beliefs: ideas that one holds to be true. May be § Rational § Irrational § Held on faith § Stereotypical o Attitudes: frames of reference around which an individual organizes knowledge about his or her world § Attitudes have an emotional component § They may be judgmental, selective, and biased § Attitudes may be positive or negative o Values: abstract standards, positive or negative, that represent an individual’s ideal mode of conduct and ideal goals. § Values differ from attitudes and beliefs in that they are action oriented or action producing. § Attitudes and beliefs become values only when they have been acted on. § Attitudes and beliefs flow out of one’s set of values. Conditions Essential to Development of a Therapeutic Relationship o Rapport o Trust o Respect o Genuineness o Empathy Phases of a Therapeutic Nurse-Client Relationship o Preinteraction phase § Obtain information about the client from chart, significant others, or other health-team members § Examine one’s own feelings, fears, and anxieties about working with a particular client o Orientation (introductory) phase § Create an environment for trust and rapport § Establish contract for intervention § Gather assessment data § Identify client’s strengths and weaknesses o Orientation phase § Formulate nursing diagnoses § Set mutually agreeable goals § Develop a realistic plan of action § Explore feelings of both client and nurse o Working phase § Maintain trust and rapport § Promote client’s insight and perception of reality § Use problem-solving model to work toward achievement of established goals § Overcome resistance behaviors § Continuously evaluate progress toward goal attainment § Transference § Occurs when the client unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from the past § Phases of a Therapeutic Nurse-Client Relationship Phases of a Therapeutic Nurse-Client Relationship o Working phase (cont) § Countertransference § Refers to the nurse’s behavioral and emotional response to the client o Termination phase § Therapeutic conclusion of relationship occurs when § Progress has been made toward attainment of the goals § A plan of action for more adaptive coping with future stressful situations has been established § Feelings about termination of the relationship are recognized and explored Question 2. A client threatens to kill himself, his wife, and their children if the wife follows through with divorce proceedings. During the preinteraction phase of the nurse/patient relationship, which interaction should the nurse employ? A) Acknowledging the client's actions and encouraging alternative behaviors B) Establishing rapport and developing treatment goals C) Providing community resources on aggression management D) Exploring personal thoughts and feelings that may adversely impact the provision of care Correct answer: D § In the pre-interaction phase, the nurse must clarify personal attitudes, values, and beliefs to become aware of how these might affect the nurse’s ability to care for various clients. This occurs before the nurse meets the client. Boundaries in the Nurse-Client Relationship o Professional boundaries limit and outline expectations for appropriate professional relationships with clients. o Professional boundary concerns commonly include issues such as § Self-disclosure § Gift-giving § Touch § Friendship or romantic association o Warning signs that indicate that professional boundaries of the nurse-client relationship may be in jeopardy § Favoring a client’s care over another’s § Keeping secrets with a client § Changing dress style for working with a particular client o Warning Signs § Swapping client assignments to care for a particular client § Giving special attention or treatment to one client over others § Spending free time with a client § Frequently thinking about the client when away from work § Sharing personal information or work concerns with the client § Receiving of gifts or continued contact/communication with the client after discharge Chapter 7- Therapeutic Communication Introduction o The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client—they are the “tools” of psychosocial intervention. § Tool, we use is therapeutic communication. What Is Communication? o Interpersonal communication is a transaction between the sender and the receiver; both persons participate simultaneously. o In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship. The Impact of Preexisting Conditions o Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted. § Values, attitudes, and beliefs: attitudes of prejudice are expressed through negative stereotyping § Culture or religion: cultural mores, norms, ideas, and customs provide the basis for ways of thinking § Social status: high-status persons often convey their high-power position with gestures of hands-on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status § Gender: masculine and feminine gestures influence messages conveyed in communication with others § Age or developmental level: the influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome,” “dude,” and others § The environment in which the transaction takes place: territoriality, density, and distance are aspects of environment that communicate messages § Territoriality: the innate tendency to own space § Density: the number of people within a given environmental space § Distance: the means by which various cultures use space to communicate § Four kinds of distance in interpersonal interactions § Intimate distance: the closest distance that individuals allow between themselves and others § Personal distance: the distance for interactions that are personal in nature, such as close conversation with friends § Social distance: the distance for conversation with strangers or acquaintances § Public distance: the distance for speaking in public or yelling to someone some distance away Question 1. The unit manager needs to meet with a client who is exhibiting escalating hostility. Which would be the most appropriate location for the nurse to meet with this client? A) The client’s room with the door shut B) A quiet corner of the day room C) The nurse’s station D) The unit’s treatment room ´ Correct answer… Correct answer: B § A quiet corner of the day room provides for some privacy in a neutral space while not limiting access to help if safety issues arise. Nonverbal Communication o Components of nonverbal communication § Physical appearance and dress § Body movement and posture § Touch § Facial expressions § Eye behavior § Vocal cues or paralanguage Therapeutic Communication Techniques o Using silence: allows client to take control of the discussion, if he or she so desires o Accepting: conveys positive regard o Giving recognition: acknowledging, indicating awareness o Offering self: making oneself available o Giving broad openings: allows client to select the topic o Offering general leads: encourages client to continue o Placing the event in time or sequence: clarifies the relationship of events in time o Making observations: verbalizing what is observed or perceived o Encouraging description of perceptions: asking client to verbalize what is being perceived o Encouraging comparison: asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships o Restating: lets client know whether an expressed statement has or has not been understood o Reflecting: directs questions or feelings back to client so that they may be recognized and accepted o Focusing: taking notice of a single idea or even a single word o Exploring: delving further into a subject, idea, experience, or relationship o Seeking clarification and validation: striving to explain what is vague and searching for mutual understanding o Presenting reality: clarifying misconceptions that client may be expressing o Voicing doubt: expressing uncertainty as to the reality of client’s perception o Verbalizing the implied: putting into words what client has only implied o Attempting to translate words into feelings: putting into words the feelings the client has expressed only indirectly o Formulating a plan of action: striving to prevent anger or anxiety from escalating to an unmanageable level the next time the stressor occurs Question 2. As the move-out date to leave the shelter gets closer, a battered wife states, “I'm afraid to leave here. I'm afraid for my safety and the safety of my children.” Which nursing statement is most supportive? A) “This is a difficult transition. Let's formulate a plan to keep you all safe in the community.” B) “It’s the policy that clients can only live here 30 days. Maybe we can ask for more time.” C) “You've had a month to come up with a plan for keeping you and your family safe.” D) “Hopefully, your husband has been in counseling. I’m sure this will work out fine.” o Correct answer… Correct answer: A § The nurse is using the therapeutic techniques of “reflection” and “formulating a plan of action.” The use of these communication facilitators indicates that the nurse is supportive of the client’s feelings and appreciates the need for a safety plan. Nontherapeutic Communication Techniques o Giving reassurance: may discourage client from further expression of feelings if client believes the feelings will only be belittled o Rejecting: refusing to consider client’s ideas or behavior o Giving approval or disapproval: implies that the nurse has the right to pass judgment on the “goodness” or “badness” of client’s behavior o Agreeing/disagreeing: implies that the nurse has the right to pass judgment on whether client’s ideas or opinions are “right” or “wrong” o Giving advice: implies that the nurse knows what is best for client and that client is incapable of any self-direction o Probing: pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse o Defending: to defend what the client has criticized implies that client has no right to express ideas, opinions, or feelings o Requesting an explanation: asking “why” implies that the client must defend his or her behavior or feelings o Indicating the existence of an external source of power: encourages the client to project blame for his or her thoughts or behaviors on others o Belittling feelings expressed: causes the client to feel insignificant or unimportant o Making stereotyped comments, clichés, and trite expressions: these are meaningless in a nurseclient relationship o Using denial: blocks discussion with then client and avoids helping him or her identify and explore areas of difficulty o Interpreting: results in the therapist telling the client the meaning of his or her experience o Introducing an unrelated topic: causes the nurse to take over the direction of the discussion Question 3. The nurse is performing an initial assessment on a newly admitted client who is oriented times four. Which of the following communication techniques would best facilitate obtaining accurate and complete client data? A) Closed-ended questions B) Requesting an explanation C) Open-ended questions D) Interpreting o Correct answer… Correct answer: C § Open-ended questions are phrased in a way that gathers as much information as possible. By the use of phrases such as “Tell me about…” or “Describe to me…” a varied and rich body of information can be assessed. Active Listening o To listen actively is to be attentive to what the client is saying, both verbally and nonverbally. o Several nonverbal behaviors have been designed as facilitative skills for attentive listening. o S – Sit squarely facing the client o O – Observe an open posture o L – Lean forward toward the client o E – Establish eye contact o R – Relax Process Recordings o Process recordings are written reports of verbal interactions with clients. o They are written by the nurse or student as a tool for improving communication techniques. Feedback is useful when it o Is descriptive rather than evaluative and focused on the behavior rather than on the client o Is specific rather than general o Is directed toward behavior that the client has the capacity to modify o Imparts information rather than offers advice o Is well-timed Chapter - Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health Nursing NOT BE TESTED MUCH Cultural Concepts o Culture describes a particular society’s entire way of living, encompassing shared patterns of beliefs, feelings, and knowledge that guide people’s conduct and are passed from generation to generation. o Ethnicity relates to people who identify with each other because of a shared heritage. o Nurses must understand these cultural concepts because cultural influences affect human behavior, the interpretation of human behavior, and the response to human behavior. o Caution must be taken not to assume that all individuals who share a culture or ethnic group are the same. o This constitutes stereotyping and must be avoided. o All individuals must be appreciated for their uniqueness. How Do Cultures Differ? o Communication § Has its roots in culture? § Is expressed through language, paralanguage, and gestures o Space (the place where communication occurs) § Territoriality: individual control of a space § Density: number of people in a space can influence § Distance: various cultures use space to communicate o Social organization § Social organizations are the groups within which individuals are acculturated, acquiring knowledge and internalizing values. § Examples of social organizations are families, religious groups, and ethnic groups. o Time § Some cultures place great importance on values that are measured by time, whereas others are actually scornful of clock time. § Whether individuals perceive time in the present orientation or future orientation influences many aspects of their lives. Present/Future o Present orientation: § Often do not consider the future implications of present-day plans and struggle to see the point of preventive care, opting instead to seek treatment for health problems as the symptoms arise. o Future orientation: § Patients are more apt to delay gratification and engage in present inconveniences to ensure comfortable futures. § Patients with future time orientations generally keep medical appointments, comply with the plan of care, and set up advance directives and living wills to prepare for future events. How Do Cultures Differ? o Environmental control o Environmental control has to do with the extent to which individuals perceive they have control over their environment. o Cultural beliefs and practices influence how individuals respond to their environment during periods of wellness or illness. o Biological variations § Differences among people in various racial groups include body structure, skin color, physiological responses to medication, electrocardiographic patterns, susceptibility to disease, and nutritional preferences and deficiencies. Application of the Nursing Process – Background Assessment Data o Northern European Americans § Language has roots in the first English settlers. § Descendants of these immigrants comprise what is considered the dominant cultural group in the United States. § They value territory; personal space is about 18 inches to 3 feet. § Less value is placed on marriage and religion than once was. § Punctuality and efficiency are valued highly. § They are future oriented. § Most value a healthy lifestyle but still enjoy fast food. Question 1. Which value of the Northern European American culture should a nursing instructor include when teaching about cultural diversity? A) Northern European Americans are present oriented. B) Northern European Americans are highly religious, and church attendance is critical. C) Northern European Americans value punctuality and efficiency. D) Northern European Americans emphasize family cohesiveness due to increased technology. o Correct Answer… Correct answer: C § Punctuality and efficiency are highly valued in Northern European American culture. Application of the Nursing Process – Background Assessment Data o African Americans § Language dialect thought to be a combination of various African languages and the languages of other cultural groups present in the United States at the time of its settlement. § Some African Americans are completely assimilated into the dominant culture; others find it too difficult and prefer to remain in their own social organization. § Forty-five percent of African American households are headed by women. § There are large support groups of families and friends. § Some African Americans (particularly from the rural South) practice folk medicine and receive their care from a “granny”, “old lady,” or “spiritualist.” § Hypertension and sickle cell anemia have genetic tendencies within the African American community. o Native Americans § Less than half of Native Americans live on reservations. § Touch is not highly regarded by Native Americans, and a handshake may be viewed as aggressive. § They sometimes appear silent and reserved. § They are uncomfortable expressing emotions. § Primary social organizations are the family and tribe. § Children are taught to respect tradition. § Native Americans are present-time oriented. § Medicine man is called a shaman and uses a variety of methods in practice; may work closely with conventional medicine to heal the sick. § Health problems include tuberculosis, alcoholism, and nutritional deficiencies. Question 2. Which psychiatric diagnosis is common within the Native American culture? A) Schizophrenia B) Alcohol abuse and dependence C) Posttraumatic stress disorder D) Impulse control disorder § Correct Answer… Correct answer: B § A variety of physical, sociocultural, and environmental causes have been linked to the high rate of alcoholism among Native Americans. Application of the Nursing Process –Background Assessment Data o Asian/Pacific Islander Americans § Large group in the United States today, comprising about 4 percent of the U.S. population § Includes immigrants (and their descendants) from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands § Although they are viewed as one (Asian) culture, they constitute a multiplicity of differences regarding attitudes, beliefs, values, religious practices, and language § Many younger generations Asian Americans have become almost totally acculturated into the U.S. culture. § Asian Americans are soft-spoken; to raise the voice indicates a loss of control. § Touching is not considered totally appropriate by some Asian Americans. § The family is the ultimate social organization, and loyalty to family is emphasized above all else. § Education is highly valued, although many remain undereducated. § Religious practices and beliefs are diverse and exhibit influences of Taoism, Confucianism, Hinduism, Buddhism, Islam, and Christianity § Time orientation is both past and present. § Restoring the balance of yin and yang is the fundamental concept of Asian health practices. § Rice, vegetables, and fish are main staple foods. § Psychiatric illness is viewed as behavior that is out of control and brings great shame to the family. § Incidence of alcohol dependence is low, perhaps because of a possible genetic intolerance of the substance. Application of the Nursing Process – Background Assessment Data o Latino Americans § Ancestry is traced to Mexico, Spain, Puerto Rico, Cuba, and other countries of Central and South America. § The common language is Spanish. § Touch is a common form of communication. § Latinos are very group oriented, and the primary social organization is a large extended family. § Latinos tend to be present oriented. § Roman Catholicism is the predominant religion. § Folk medicine combines elements of Roman Catholicism and Indian and Spanish ancestries. § The folk healer is called a curandero (male) or curandera (female). § Many still subscribe to the “hot and cold” theory of disease (a concept similar to the yin and yang beliefs of Asian Americans). § The prevalence for psychiatric illness is higher among U.S.-born Latinos than it is for immigrants from the same cultural group. Application of the Nursing Process – Background Assessment Data o Western European Americans § Origin is France, Italy, or Greece § Each has a unique language, with unique dialects within each language § Warm and affectionate, very physically expressive; use a lot of body language, including hugging and kissing § Very family oriented; interact in large groups § A strong allegiance to the cultural heritage is common. § Father is head of the household. § Traditional Western European women view their roles as mother and homemaker. § Children are prized and cherished, and elderly are respected for their age and wisdom. § Roman Catholicism is the predominant religion for the French and Italians, Greek Orthodox for the Greeks. § Western European Americans are present-oriented and view whatever happens in the future as God’s will. § Most follow health beliefs and practices of the dominant American culture, but some folk beliefs and superstitions endure. § Wine is the beverage of choice, but the alcoholism rate is low. Application of the Nursing Process – Background Assessment Data o Arab Americans § Ancestry and traditions are traced to the nomadic desert tribes of the Arabian Peninsula. § Arabic is the official language of the Arab world. § Conversants stand close together, maintain steady eye contact, and touch (only between members of the same gender) the other’s hand or shoulder. § Speech is loud and expressive, with lots of gesturing. § Time is present-oriented, and punctuality is not taken seriously except in case of business or professional meetings. § The man is the head of the household, and women are subordinate to men. § The family is the primary social organization, and children are loved and indulged. § Women value modesty and many observe the custom of hijab—covering the body except for one’s face and hands. § Cardiovascular disease is a common health concern. § Sickle cell anemia and thalassemia’s are prevalent in the eastern Mediterranean. § Many spices and herbs are used in cooking. § Bread is served at every meal and is viewed as a gift from God. § Lamb and chicken are the most popular meats. § Muslims are prohibited from eating pork and pork products. § Islam is the religion of most Arab countries, and there is no separation of church and state. § Spiritual medicine is combined with conventional medical treatment. § Mental illness is a major social stigma and symptoms are likely to be presented as physical complaints. Application of the Nursing Process –Background Assessment Data o Jewish Americans § The Jewish people came to the United States predominantly from Spain, Portugal, Germany, and Eastern Europe. § There are more than 5 million Jewish Americans living in the United States, and most are located in the larger urban areas. § Four main Jewish religious groups exist today § Orthodox § Reform § Conservative § Reconstructionists § Jewish Americans the primary language is English. § Hebrew is used for prayers and is taught in Jewish religious education. § Formal education is a highly respected value among the Jewish people; many holds advanced degrees and are employed as professionals. § Time orientation is simultaneously to the past, present, and future. § Children are highly valued and are expected to be forever grateful to their parents for giving them the gift of life. § Jewish Americans are very health conscious and maintenance of mental health is as important as physical health. § Genetic diseases common in the Jewish population include Tay-Sachs disease, Gaucher’s disease, and familial dysautonomia. § Alcohol, especially wine, is an essential part of religious holidays and festive occasions; it is viewed as appropriate and acceptable as long as it is used in moderation § Religious laws dictate how food is prepared, served, and consumed Culture-Bound Syndromes o Symptoms associated with specific cultures that may be expressed differently from the American culture o Most are considered to be “illnesses”, and most have local names Application of the Nursing Process –Diagnosis/Outcome Identification o Nursing diagnoses for individuals with varied cultural influences may include § Impaired verbal communication § Anxiety (moderate to severe) § Imbalanced nutrition, less than body requirements § Spiritual distress o Outcome criteria are identified for measuring effectiveness of nursing care Application of the Nursing Process –Planning/Implementation o Nursing intervention with clients whose beliefs are culturally influenced is aimed at ensuring that those beliefs are not misunderstood, and that nursing care includes elements that are important to the individual within his or her own culture. o Emphasis is also placed on developing a trusting relationship with the client and family and eliminating barriers to communication. Application of the Nursing Process –Evaluation o Evaluation is based on accomplishment of established outcome criteria. Spiritual Concepts o Spirituality § Refers to the human quality that gives meaning and sense of purpose to an individual’s existence § Exists within each individual regardless of belief system and serves as a force for interconnectedness between the self and others, the environment, and a higher power o Spiritual Needs § Meaning and purpose in life § Having a purpose in life gives one a sense of control and the feeling that life is worth living. § Faith § The acceptance of a belief in the absence of physical or empirical evidence. § Studies show that faith, combined with conventional treatment and an optimistic attitude, can be a very powerful element in the healing process. § Hope § A special kind of positive expectation—an energizing force. § Hope may promote healing, facilitate coping, and enhance quality of life. § Love § May be life’s most powerful force and the greatest spiritual need § May be an important key in the healing process by having a positive effect on the immune system § Studies have shown that individuals can overcome the effects of a deleterious lifestyle if they have the benefit of a strong, loving relationship § Forgiveness § The ability to release from the mind all the past hurts and failures, all sense of guilt and loss. § Long-held feelings of bitterness and resentment can have a detrimental effect on an individual’s health. § Forgiveness offers freedom and peace of mind and enables a person to begin the pathway to healing. o Religion § The practices are usually grounded in the teachings of a spiritual leader. § There are more than 6,500 religions in the world. § Affiliation with a religious group has been shown to be a health-enhancing endeavor. Spiritual Concepts o Religion (cont) § Studies indicate that individuals who have a religious faith or attend church regularly experience § Increased chance of survival following serious illness § Less depression and other mental illness § Longer life § Overall better physical and mental health § A religious commitment has been correlated with § Lower suicide rates § Lower drug use and abuse § Less juvenile delinquency § Lower divorce rates § Improved mental illness outcomes § May be correlated with strong support network found in religious organizations o Assessment of spiritual and religious needs § Nurses must consider spiritual and religious needs when planning care for their clients. § A spiritual assessment tool may be used to gather needed information. o Diagnoses/Outcome Identification § Nursing diagnoses that may be used when addressing spiritual and religious needs of clients include § Risk for Spiritual Distress § Spiritual Distress § Readiness for Enhanced Spiritual Well-Being § Risk for Impaired Religiosity § Impaired Religiosity § Readiness for Enhanced Religiosity o Planning/Implementation § Nursing intervention for clients who have spiritual and religious needs is aimed at helping the client achieve meaning and purpose in life that reinforce hope, peace, contentment, and self-satisfaction. o Evaluation § Evaluation is based on accomplishment of previously established outcome criteria.
