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Frameworks and Basic Concepts for Providing Nursing Care to Clients and Families Experiencing Psychiatric Disorders
defined as successful performance of mental functions, resulting functions, in the ability to engage in productive activities, enjoy fulfilling , activities relationships, and change or cope with adversity” relationships, Mentally Healthy A person is mentally healthy when a person possesses knowledge of oneself; meets one’s basic needs; assumes responsibility for one’s behavior and for self-growth; has learned to integrate thoughts, feelings, and actions; and can resolve conflicts successfully. A mentally healthy person maintains relationships, communicates directly with others, and respects others. A mentally healthy person adapts to change in one’s environment.
“is considered a clinically significant behavioral or psychological syndrome experienced by a person and marked by distress, disability, distress, disability, or the risk of suffering disability or loss of freedom” freedom” Mentally Ill The mentally ill show deficits in functioning; it is usually these deficits that bring them to the facilities where you will encounter them. Mental illness occurs when an individual is not able to view oneself clearly or has a distorted view of self, is unable to maintain satisfying personal relationships, and is unable to adapt to one’s environment. The American Psychiatric Association defines mental disorder as “clinically significant behavior or psychological syndrome or pattern that occurs in an individual and is associated with present distress (i.e., negative response to stimuli that are perceived as threatening) or disability (i.e., impairment increased risk of suffering, death, pain, disability, or an important loss of freedom). Signs of Mental Health • Happiness Finds life enjoyable Can see objects, people, and activities their possibilities for meeting his or her needs • Control over behavior Can recognize and act on cues to existing limits
Mental Health versus Mental Illness
2 Can respond to the rules, routines, and customs of any group to which he or she belongs • Appraisal of Reality Accurate picture of what is happening around the individual Good sense of the consequences, both good and bad, that will follow his or her acts Can see the difference between the “as if” and the “for real” in situations • Effectiveness in Work Within limits set by abilities, can do well in tasks attempted When meeting mild failure, persists until determines whether or not he or she can do the job • A Healthy Self-Concept Sees self as approaching individual ideals, as capable of meeting demands Has reasonable degree of self-confidence that helps in being resourceful under stress • Satisfying relationships Experiences satisfaction and stability in relationships Socially integrated and can rely on social supports • Effective Coping Strategies Uses stress reduction strategies that address the problem, issue, threat (e.g., problems solving, cognitive restructuring) Uses coping strategies in a healthy way that does not cause harm to self or others Signs of Mental Illness Major Depressive Episode Loses interest or pleasure in all or almost all usual activities and pastimes Describes mood as depressed, sad, hopeless, discouraged, “down in the dumps” Control Disorder, Undersocialized, Aggressive Shows repetitive and persistent pattern of aggressive conduct in which the basic rights of others are violated Schizophrenic Disorder Shows bizarre delusions, such as delusions of being controlled Has auditory hallucinations Manifests delusions with persecutory or jealous content Adjustment Disorder with Work (or Academic) Inhibition Shows inhibition in work or academic functioning whereas previously there was adequate performance Dependent Personality Disorder Passively allows other to assume responsibility for major areas of life because of inability to function independently Lacks self-confidence (e.g. sees self as helpless, stupid) Borderline Personality Disorder Shows pattern of unstable and intense interpersonal relationships Has chronic feelings of emptiness Substance Dependent Repeatedly self-administers substances despite significant substance-related problems (e.g. threat to job, family, social relationships)
Prevalence of Psychiatric Disorders in the United States
The prevalence rate is the portion of the population with a mental disorder at a given time. According to NIMH (National Institute of Mental Health) 21.1% of Americans aged 18+ --about 1 in 5 adults suffer from a diagnosable mental disorder. o DSM-IV: Diagnostic and Statistical Manual – classification system for mental disorders. Multi-axial system. Axis I: Clinical Disorders, most V-Codes, and conditions that need Clinical attention. Diagnosis Flow Charts. Axis II: Personality Disorders and Mental Retardation. Axis III: General Medical Conditions. Axis IV: Psychosocial and Environmental Problems. Axis V: Global Assessment of Functioning Scale. o ICD-9: International Statistical Classification of Diseases and Related Health Problems - classification of medical disorders.
2.2 million Affects men and women equally May appear earlier in men than women Any affective (mood) disorder (major depression, dysthymic disorder, bipolar disorder (9.5%) 18.8 million Women affected 2 x more than men Depressive disorders may be appearing earlier in life in those born in recent decades compared to the past Often co-occurs with anxiety and substance abuse Major Depressive Disorder (5%) 9.9 million Leading cause of disability in US and established economies worldwide
(1.1% prevalence over 12 months)
4 Nearly twice as many women as men Bipolar Affective Disorder (1.2%) 2.3 million Affects men and women equally Anxiety Disorders (panic disorder, OCD, posttraumatic stress, generalized anxiety and phobias (13.3%) 19.1 million Anxiety disorders frequently co-occur with depressive disorders, eating disorders, and/or substance abuse Panic Disorder (1.7%) 2.4 million Typically develops in adolescence or early adulthood About 1 in 3 people with panic disorder develops agoraphobia (Agoraphobia describes a condition where the sufferer becomes uneasy is environments that are unfamiliar or where he/she perceives that he or she has little control. Triggers may include crowds, wide open spaces or traveling alone even for short distances. The anxiety is often compounded by a fear of social embarrassment in case of panic attacks or appearing distraught in public) Obsessive–compulsive Disorder (OCD) (2.3%) 3.3 million First symptoms begin in childhood or adolescence Post-traumatic stress Disorder (PTSD) (3.6%) 5.2 million Can develop at any time About 30% of Vietnam veterans experienced PSTD after the war; percentage high among first responders of 9/11 terrorists attacks on the US Generalized anxiety Disorder (2.8%) 4.0 million Can begin across the life cycle; risk is highest between childhood and middle age Social phobia (3.7%) 5.3 million Typically begins in childhood or adolescence Agoraphobia (2.2%) 3.2 million Specific phobia (4.4%) 4.4 million Any substance abuse/Alcohol dependence (11.3%/7.2%)
Chapter 2: Psychiatric Nursing Evolution of a Specialty
of the Mentally Ill Early Civilization The insane were treated through magical rituals, prayer, and exorcism.
5 Greek and Roman cultures developed ideas of body “humors” – blood, black bile, yellow bile, and phlegm-which could influence emotional stability. Hippocrates believed that excesses of black bile caused melancholy and that bloodletting could remove this excess. Middle Ages and Renaissance The term “lunatic” emerged to refer to one controlled by the lunar body. Treatment of the mentally ill was influenced by beliefs that the mentally ill were evil, witches, or heretics. The mentally ill were excluded from community life or institutionalized. Care was custodial; they were poorly fed and clothed and were restrained. Eighteenth and Early Nineteenth Centuries The mentally ill were committed to asylums. They were place in prison if they committed a crime. Their care was performed by persons without training or interest in helping others and was often lacking in compassion. A few physicians in the U.S. and England began to view the insane as persons suffering disease and needing some kind of treatment. English physician William Battie’s word elevated mental services to something respectable physicians could do. He also believed that the care of the mentally ill should be done by carefully selected and trained. Insanity was viewed as a disease. Physicians began to classify mental disorders. They described moral and physical causes of mental illness. In 1846, the term psychiatry was introduced by physicians and they published their work in The Journal of Mental Science. Asylums were built for the treatment and cure of the insane. Nineteenth Century Conditions in the asylums became unbearable. There was a called for reform. Dorothea Lynde Dix became a leader for reform. She advocated for humane treatment as well as safe and comfortable environments for the patient. Through her efforts, care was improved in the U.S., Canada, and Scotland. Nursing Education Eighteenth and Nineteenth Centuries In 1882, the McLean Asylum in Somerville, Massachusetts, opened the first training school in the world for mental health nurses.
6 Cowles, the physician superintendent of McLean, believed that the presence of a “nurse” indicated not only that the patient was ill but also that there was a hope of recovery. Other schools were opened: Bellevue Training School in New York Connecticut Training School in New Haven These schools operated under the Nightingale model. The year 1893 marked the first meeting of organized nursing in the U. S. Important Nurse Leaders included: Isabel Hampton and Lavinia Dock. Dock. Mental health nurses continued to be trained at asylums and their training evolved to keep up with new approaches in psychiatric care. Twentieth Century The American Psychiatric Association established a committee on Training Schools for Nurses. Johns Hopkins Hospital School included psychiatric nursing in the training of general nurses. This was the first time a hospital program offered training in psychiatric care to all students. By 1920, the first psychiatric nursing textbook was publish, Nursing Mental Disease by Harriet Bailey. In the 1930s, somatic therapies emerged In 1946, the U.S. Congress passed the National Mental Health Act, which established the National Institutes of Mental Health.
was the first nurse to identify psychiatric nursing both as a essential element of general nursing and as a specialty area that embraces specific governing principles” (p. 24). She was the first nurse to describe the nurse-patient relationship as foundation of nursing practice (p. 24). She emphasizes the shifting the focus from what nurses do to patients to what nurses do with patients. She described that stages of the nurse-patient relationship (p. 24). The skills of the psychiatric nurse include: observation, interpretation, and intervention. She also applied Sullivan’s theory of anxiety to nursing practice.
Peplau and the Therapeutic Relationship
a general self-care deficit theory of nursing. Has three constitute theories –self-care, self-care deficit, and nursing systems which are based on six central and one peripheral concept. Self-care Self-care agency
self-care demand Self-care deficit Nursing agency Nursing system Focus: Goal of self-care as integral to the practice of nursing (p. 25) She emphasized the role of the nurse in promoting self-care activities of the client; this has relevance to the seriously and persistently mentally ill client (p. 25).
first differentiated between nursing and medicine by stating that curing is the domain of medicine, and caring is the domain of nursing. She proposed 10 carative factors that involved forming a humanistic, altruistic system of values: instilling faith-hope; cultivating sensitivity to one’s self and To others; developing helping-trust relationships; expressing positive and negative feelings’ using scientific problem-solving methods for decision making; promoting interpersonal teaching-learning; providing an environment that supports, protects, and corrects mental, physical, sociocultural, and spiritual aspects; Assisting with the gratification of human needs; and allowing for existential-phenomenological forces.
phenomena are somehow caused by an array of biochemical and neurophysiologic processes that take place from moment to moment.
Neuroscience as a Basis for Practice
treatment of mental disturbances is directed at the suspected transmitter receptor problem. Transmitters (p. 40) Dopamine Fine muscle movement Integration of emotions and thoughts Decision making Stimulates hypothalamus to release hormones (sex, thyroid, adrenal) Decreased in Parkinson’s, Depression Increased in Schizophrenia, Mania Norepinephrine
8 Affects mood Stimulates sympathetic branch of ANS for “fight or fright” in response to stress Decreased in Depression Increased in Mania, Anxiety, Schizophrenia Serotonin Sleep regulation, hunger, mood, stress, and pain perception Plays a role in aggression and sexual behavior Decreased in Depression Increased in Anxiety Histamine Alertness Inflammatory response Stimulates gastric secretions Decreased in Depression, Sedation, Weight gain GABA Plays a role in inhibition; reduces aggression, excitation, and anxiety May play a role in pain perception Has anticonvulsant and muscle-relaxing properties Decreased in Anxiety, Schizophrenia, Huntington’s chorea Increased in reduction of anxiety Acetylcholine Plays a role in learning, memory Regulates mood: mania, sexual aggression Affects sexual and aggressive behavior Stimulates PNS Decreased in Alzheimer’s, Huntington’s chorea, Parkinson’s Increased in Depression Substance P (SP) Centrally active SP antagonist has antidepressant and anti-anxiety effects in depression Promotes and reinforces memory Enhances sensitivity to pain receptors to activate Involved in regulation of mood and anxiety Role in pain management
(SRIF) Altered levels associated with cognitive disease Decreased Alzheimer’s Decreased levels of SRIF found in the spinal fluid of some depressed clients Increased in Huntington’s chorea Neurotensin Endogenous antipsychotic-like properties Decreased levels found in spinal fluids of schizophrenic clients
nursing is “the diagnosis and treatment of human responses to actual or potential mental health problems” (p. 64) Box 4-1: Psychiatric Mental Health Nursing Phenomena of Concern
What is Psychiatric Mental Health Nursing? (p. 64)
Actual or potential mental health problems of clients pertaining to the following: Maintenance of optimal health and well-being and prevention of psychobiological illness Self-care limitations or impaired functioning related to mental and emotional stress Deficits in the functioning of significant biological, emotional, and cognitive systems Emotional stress or crisis components of illness, pain, and disability Self-concept changes, developmental issues, and life process changes Problems related to emotions such as anxiety, anger, sadness, loneliness, and grief Physical symptoms that occur along with altered psychological functioning Alterations in thinking, perceiving, symbolizing, communicating, and decision making Difficulties relating to others Behaviors and mental states that indicate the client is a danger to self or others or has a severe disability Interpersonal, systematic, sociocultural, spiritual, or environmental circumstances or events that affect the mental and emotional well being of the individual, family, or community Symptom management, side effects and toxicities associated with psychopharmacological intervention and other aspects of the treatment regimen What do psychiatric Nurses Do? (p. 65) “to promote and maintain optimal mental functioning, to prevent mental illness (or further dysfunction), and to help clients regain or improve their coping abilities” (p. 65)
Basic Level Nursing Counseling Milieu therapy (homelike environment) Promotion of self-care activities Psychobiological interventions Health teaching Case management Health promotion and health maintenance Advanced Level Nursing All of the above plus Psychotherapy
Psychiatric Mental Health Nursing Interventions (p. 66)
prescription and treatment Consultation
Prevention (keep clients in a healthy state) Adult and youth recreational center Schools Day care centers Churches, temples, synagogues, mosques Ethnic cultural centers Secondary Prevention (screening, detection of early symptoms) Crisis Shelters (homeless, battered women, adolescents) Correctional community facilities Youth residential treatment centers Partial hospitalization programs Chemical dependency programs Nursing homes Industry/work sites Outreach treatment in public places Hospices and acquired immunodeficiency syndrome programs Assisted living facilities Tertiary Prevention (in need of treatment) Community health treatment centers Psychosocial rehabilitation programs
Where do psychiatric nurses work? (p. 87)
is a complex whole, including knowledge, belief, art, moral, law, custom, and any other capabilities and habits acquired by man as a member of society. It comprises every verbal or behavioral system that transmits meaning. It is learned, shared, and ever-changing It is learned through socialization, shared by all group members, and associated with adaptation to the environment. Cultural blindness is the attempt to treat all persons fairly by ignoring differences and acting as though the differences do not exist. Can be perceived as insensitivity just as readily as are stereotyping and ethnocentrism.
Cultural and Ethnic Considerations
is normal in one culture may not be normal in another.
Normal vs. Abnormal Behavior
health nurse need to practice culturally relevant nursing if they are to meet the need of their culturally diverse clients. clients
A Global Perspective
- connected more to economic and social standing in society than to cultural identity. However, many cultural, racial ant ethnic minority groups are also economically and socially disadvantaged. Culture - shared beliefs, values, and practices that guide a group’s members in patterned ways of thinking and acting. The cultural norms help members of the group make sense of the world around them and make decisions about appropriate ways to relate and behave. Ethnicity - ethnic groups of common heritage and history. These groups share a worldview. From this worldview, they develop beliefs, values, and practices that guide members of the group in how they should think and act in different situations. Worldview - a system for thinking about how the world works and how people should behave in the world and in relationship to one another Enculturation – the process through which members of a group are introduced to the culture’s worldview, beliefs, values, and practices.
7-3: Selected Nonverbal Communication Patterns Nonverbal Predominate Patterns Seen Communication American in Other Cultures Pattern Patterns Eye contact Eye contact is associated with Eye contact is avoided as a attentive-ness, politeness, respect, sign of rudeness, arrogance, honesty, self-confidence. challenge, or sexual interest. Personal space Intimate space: 0-1 1/2 ft Personal space significantly Personal space: 1 ½-3 ft closer or more distant than in In personal conversation, if a person American culture. enters into the intimate space of the Closer- Middle Eastern, other, the person is perceived as Southern European, and aggressive, overbearing, and offensive. Latin American If a person stays more than expected, Farther- Asian the person is perceived as aloof. When closer than the norm, standing very close frequently indicates acceptance of the other.
Understanding Culture in the Context of Mental Illness
Moderate touch indicates personal warmth and conveys caring.
A nod means “yes.” Smiling and nodding means “I agree.” Thumbs up means “good job.” Rolling one’s eyes while another is talking is an insult.
Touch norms vary. Low-touch cultures – touch may be considered an overt sexual gesture capable of “stealing the spirit” of another or taboo between women and men. High-touch cultures – People touch one another as frequently as possible Raising eyebrows or rolling the head from side to side means “yes.” Smiling and nodding means “I respect you.” Thumbs up is an obscene gesture. Pointing one’s foot at another is an insult.
from cultural expectations is considered by others within the culture to be a problem and frequently is defined by the cultural group as “illness” (p. 103)
Legal and Ethical Guidelines
- major branch of philosophy, is the study of values and customs of a person or group. It covers the analysis and employment of concepts such as right and wrong, good and evil, and responsibility. Bioethics – ethical dilemmas surrounding client care.
- the act of doing good; helping others. Autonomy - right to make one’s own decision. (concept of informed consent). Justice - treating others fairly and equally. Fidelity (nonmaleficence) - maintaining loyalty and commitment to the client and doing no wrong. Veracity - one’s duty to tell the truth.
Five Principles of Bioethics
8-1: Code of Ethics for Nurses (p. 117) – guides the nurse in tough ethical decisions. Civil Rights - persons with mental illness are guaranteed the same rights under federal and state laws as any other citizen. Specific Client Rights Client Consent - proper order for specific therapies and treatment are required and must be documented in the client’s chart. Communication - right to communicate fully and privately with those outside the facility; right to visitors; phone/mail access; etc. Freedom from Harm - freedom from unnecessary or excessive physical restraint, isolation, and medication, as well as freedom from abuse and neglect. Dignity and Respect - right to be treated with dignity and respect; free from discrimination on the basis of ethnic origin, gender, age, disability, or religion. Confidentiality - records must be kept private; no photographs without written consent; maintain privacy according to HIPPA. Participation in Plan of Care - involve the client in decision making in all aspects of care.
Mental status assessment Psychosocial assessment Physical exam History taking Interviews Standardized rating scale Verification of all data Diagnosis Identify problem and etiology Construct nursing diagnoses and problem list Prioritize nursing diagnoses Outcomes Identify outcomes Planning Identify safe, pertinent, evidence-based actions Strive to use interventions that are culturally relevant and compatible with health beliefs and practices Implementation Basic level: counseling, milieu therapy, self-care activities, psychobiological interventions, health teaching, case management, health promotion and maintenance Advanced level: psychotherapy, prescription meds, consultation
14 If outcomes have not been achieved at desired level: additional data gathering, reassessment, revision Documentation Documentation is the responsibility of the entire mental health team.
A therapeutic nurse-client relationship has specific goals and functions. Goals in a therapeutic relationship include the following: Facilitating communication of distressing thoughts and feelings Assisting clients with problem solving to help facilitate activities of daily living Helping clients examine self-defeating behaviors and test alternatives Promoting self-care and independence
Goals of a Therapeutic Relationship
– self awareness of one’s feelings as they arise within the relationship and the ability to communicate them when appropriate. Empathy – one understands the ideas expressed, as well as the feelings that are present in the other person. Positive Regard – implies respect; It is the ability to view another person as being worthy of caring about and as someone who has strengths and achievement potential.
Factors that Enhance Growth in Others
Problem Areas Overhelping – doing for clients what they are able to do themselves or goes beyond the wishes and needs of the client. Controlling – asserting authority and assuming control of clients “for their own good.” Narcissism – having to find weakness, helplessness, and/or disease in clients to feel helpful, at the expense of recognizing and supporting clients’ healthier, stronger, and more competent features
Phase - During the orientation phase, the nurse assessed the client, identified problems, and discussed plans for the visit. Working Phase - In the working phase, the client identified their problems, asked questions, and recognized the nurse was beneficial. Termination Phase - In the termination phase, problems were solved, the client became independent and established goals, and the relationship ended.
Peplau’s Phases of Nurse-Client Relationship
Tools of Psychiatric Mental Health Nursing
nursing. Psychiatric mental health nurses use tools of self and tools of knowledge in their work Therapeutic communication is the purposeful use of dialog to bring about the client’s insight, control of symptoms, and/or healing. To accomplish therapeutic communication, the nurse needs to understanding communication theory and how to build a positive nurse-client relationship.
is the key to successful psychiatric – mental healthy
a sense of relationship between two people Has meaning in communication. Public space = approximately 12 feet Social space = 9 to 12 feet Personal space = 18 inches to about 4 feet Intimate space = closer than 18 inches
to movements, expressions, question, and posture that accompany interactions and influence communications. NOTE: They are almost always culture-bound.
Actions or Kinetics
the context in which the words are delivered, and they influence meaning directly. Include tone, pitch, emotions expressed verbally (such as anxiety or anger or fear), and sounds of hesitation, nervous laughter, and nervous coughing. Must be interpreted within the context of the client’s cultural and social/familial norms.
a form of communication used almost daily by nurses providing direct physical care and support to clients. Can convey warmth, positive regard, and support during silence, and reassurance that the nurse is fully present and caring. Have many meanings (appropriate and inappropriate touching).
the use of words, written and spoken, to send messages to another.
communication to be most therapeutic, it must convey a respectful attitude, one that supports the individuality and self-esteem of both the client and the nurse.
to all of the messages sent by others than verbal or written. behaviors, cues, and presence (such as proximity) that send a message.
Silence - absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking. Silence often encourages the client to verbalize, provided that it is interested and expectant. Silence gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most important. Much nonverbal behavior takes place during silence, and the nurse needs to be aware of the client and his or her own nonverbal behavior. Accepting – indicates that the person has been understood. An accepting response indicates the nurse has heard and followed the train of thought. It does not indicate agreement but is nonjudgmental. Facial expression, tone of voice, and so forth also must convey acceptance or the words lose their meaning. Giving Recognition - acknowledging, indicating awareness. Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a person, as an individual. Such recognition does not carry the notion of value, that is, of being “good” or “bad.” Sometimes clients cannot verbalize or make themselves. Offering Self - making oneself available; offers presence, interest, and desire to understand. The nurse can offer his or her presence, interest, and desire to understand. It is important that this offer is unconditional, that is, the client does not have to respond verbally to get the nurse’s attention. Offering General Leads - giving encouragement to continue. General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction. They also encourage the client to continue if he or she is hesitant or uncomfortable about the topic. Giving Broad Openings - allowing the client to take the initiative in introducing the topic. Broad openings make explicit that the client has the lead for the interaction. For the client who has trouble talking, broad openings may stimulate him or her into taking the initiative. Placing the Events in Time or Sequence - clarifying the relationship of events in time. Putting events in proper sequence helps both the nurse and client to see them in perspective. The client may gain insight into cause-and-effect behavior and
Techniques To Enhance Communication (p. 187-188)
17 consequences, or the client may be able to see that perhaps some things are not related. The nurse may gain information about recurrent patterns or themes in the client’s behavior or relationships. Making Observations - verbalizing what the nurse perceives; calls attention to behavior Sometimes clients cannot verbalize or make themselves understood. Or the client may not be ready to talk. Encouraging Description of Perception - asking the client to verbalize what he or she perceives. To understand the client, the nurse must see things from his or her perspective. Encouraging the client to describe ideas fully may relieve the tension the client is feeling and he or she might be less likely to take action on ideas that are harmful or frightening. Encouraging Comparison - asking that similarities and differences be noted. Comparing ideas, experiences, or relationships brings out many recurring themes. The client benefits from making these comparisons because he or she might recall past coping strategies that were effective or remember that he or she has survived a similar situation. Restating - repeating the main idea expressed. The nurse repeats what the client has said in approximately or nearly the same words the client has used. This restatement lets the client know that he or she communicated the idea effectively. This encourages the client to continue. Or if the client has been misunderstood, he or she can clarify his or her thoughts. Reflecting - directing client actions, thoughts, and feelings back to client. Reflection encourages the client to recognize and accept his or her own feelings. The nurse indicates that the client’s point of view has value, and that the client has the right to have opinions, make decisions, and think independently. Focusing - concentrating on a single point. The nurse encourages the client to concentrate his or her energies on a single point, which may prevent a multitude of factors or problems from overwhelming the client. It is also a useful technique when a client jumps from one topic to another. Exploring - delving further into a subject or idea. When clients deal with topics superficially, exploring can help them examine the issue more fully. Any problem or concern can be better understood if explored in depth. If the client expresses an unwillingness to explore a subject, however, the nurse must respect his or her wishes. Giving Information - making available the facts that the client needs. Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. The nurse is functioning as a resource person. Giving information also builds trust with the client. Seeking Clarification – helps clients clarify their own thoughts and maximize mutual understanding between nurse and client.
18 Helps to ensure that what the client said or needs is clearly identified and not misunderstood. Presenting reality – indicates what is real. When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real. The nurse does this by calmly and quietly expressing the nurse’s perceptions or the facts, not by way of arguing with the client or belittling his or her experience. The intent is to indicate an alternative line of thought for the client to consider, not to “convince” the client that he or she is wrong. Voicing Doubt – expressing uncertainty about the reality of the client’s perceptions. Another means of responding to distortions of reality is to express doubt. Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusions. This does not mean the client will alter his or her point of view, but at least the nurse will encourage the client to reconsider or re-evaluate what has happened. The nurse neither agreed nor disagreed; however, he or she has not let the misperceptions and distortions pass without comment. Seeking Consensual Validation - searching for mutual understanding, for accord in the meaning of the words. For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants. Sometimes, words, phrases, or slang terms have different meanings and can be easily misunderstood. Verbalizing the Implied - voicing what the client has hinted at or suggested. Putting into words what the client has implied or said indirectly tends to make the discussion less obscure. The nurse should be as direct as possible without being unfeelingly blunt or obtuse. The client may have difficulty communicating directly. The nurse should take care to express only what is fairly obvious; otherwise, the nurse may be jumping to conclusions or interpreting the client’s communication. Encouraging Evaluation – asking client to appraise quality of their experiences. Encourage clients to develop the habit of continual self-assessment. Helps client to establish a sense of self. Attempting to Translate into Feelings - seeking to verbalize client’s feelings that he or she expresses only indirectly. Often what the client says, when taken literally, seems meaningless or far removed from reality. To understand, the nurse must concentrate on what the client might be feeling to express himself or herself this way. Suggesting Collaboration - offering to share, to strive, to work with the client for his or her benefit. The nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and improve the ability to form satisfactory relationships. The nurse offers to do things with, rather than for, the client.
– organizing and summing up that which has gone
19 Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants. It omits the irrelevant and organizes the pertinent aspects of the interaction. It allows both client and nurse to depart with the same ideas and provides a sense of closure at the completion of each discussion. Encouraging Formulation of a Plan of Action - asking the client to consider kinds of behavior likely to be appropriate in future situations. It may be helpful for the client to plan in advance what he or she might do in future similar situations. Making definite plans increases the likelihood that the client will cope more effectively in similar situation.
Premature Advice – assumes the nurse knows what is best and the client can think for self. Inhibits problem-solving and fosters dependency. Premature advice may interfere with enabling the patient to be the agent of change. Minimizing Feelings - misjudging the degree of the client’s discomfort. When the nurse tries to equate the intense and overwhelming feelings the client has expressed to “everybody” or to the nurse’s own feelings, the nurse implies that the discomfort is temporary, mild, self limiting, or not very important. The client is focused on his or her own worries and feelings; hearing the problems or feelings of others is not helpful. Falsely Reassuring – underrates a person’s feelings and belittles a person’s concern. May cause the client to stop sharing feelings if he or she thinks they will not be taking seriously. Attempts to dispel the client’s anxiety by implying that there is not sufficient reason for concern completely devalue the client’s feelings. Vague reassurances without accompanying facts are meaningless to the client. Showing Nonverbal Signs of Boredom or Resentment - tells the client that you are not interested or distracted and that she or she is not important. Most of us often give way our inner feelings non-verbally. (Non verbal self portrait). Such communications more often than not, are consistent with our emotions and attitudes and in a subtle manner portray our emotional spectrum. Where words fail, a subtle gesture speaks volumes. It can reflect and unfold the intriguing art of negotiations. Non verbal clues can reveal whether the person you are talking to is lying, friendly, bored, defensive, eager or anxious. Gestures are often like words in a language. Be always confident, sincere, open hearted, truthful and have positive expressions Making Value Judgments – believing your own values and beliefs are superior are more important than the client’s.
Obstructive Communication (pp. 191 – 192)
20 Listening to, understanding and respecting the client’s values, opinions, needs and ethnocultural beliefs and integrating these elements into the care plan with the client’s help. Asking “why” question – asking the client to explain why he or she believes, feels, or has acted in a certain way. Clients frequently interpret “why” questions as accusations or think the nurse knows the reason and is simply testing them. Regardless of client’s perception of the nurse’s motivation, “why” questions can cause resentment, insecurity, and mistrust. Asking Excessive Questions - probing. Probing tends to make the client feel used or invaded. Clients have the right not to talk about issues or concerns if they choose. Pushing and probing by the nurse will not encourage the client to talk. Giving Approval, Agreeing - indicating accord with the client. Approval indicates the client is “right” rather than “wrong.” This gives the client the impression that he or she is “right” because of agreement with the nurse. Opinions and conclusions should be exclusively the client’s. When the nurse agrees with the client, there is no opportunity for the client to change his or her mind without being “wrong.” Disapproving – denouncing the client’s behavior or ideas. Disapproval implies that the nurse has the right to pass judgment on the client’s thoughts or actions. It further implies that the client is expected to please the nurse. Disagreeing - opposing the client’s ideas. Disagreeing implies the client is “wrong.” Consequently, the client feels defensive about his or her point of view or ideas. Changing the Subject - Introducing an unrelated topic. The nurse takes the initiative for the interaction away from the client. This usually happens because the nurse is uncomfortable, doesn’t know how to respond, or has a topic he or she would rather discuss
Levels of Psychiatric Mental Health Clinical Nursing Practice (p. 65)
Level - registered nurse; manages the inpatient or outpatient nursing care of clients; administers medications; completes assessments on clients, establishes outcomes, writes nursing diagnoses, and implements plan of care, including client/family teaching. Advanced Level – RN with psychiatric mental health specialty; has passed a certification exam. Advanced practice RN – psychiatric mental health (APRN-PMH); MSN with psychiatric nursing specialty; provides psychotherapy; prescribes psychotropic medications (in most states); manages and coordinates client care.
Levels of Anxiety
Anxiety - common in all of us. An example of mild anxiety is if you have a big presentation or test coming up. You may feel nervous to the point you perform better. This is an optimal level of anxiety. Mild anxiety comes and goes. It gives us energy to get the job done and move on. Moderate Anxiety - a level of anxiety in which problem solving is impaired, but can be accomplished with assistance. Physiological changes occur with moderate anxiety; examples of this include increased respirations and heart rate. Psychologically, a person experiencing this level of anxiety will have a difficult time concentrating and staying on task. Severe Anxiety - a level of anxiety in which problem solving is not possible. The ability to attend to details is lost. This person will need treatment to avoid going into panic. Physiologically, body systems speed up. This is an uncomfortable state to be in. Panic Level of Anxiety - the highest level of anxiety. Behavior can be bizarre and contact with reality is lost. Tending to the safety of this individual is paramount. Anxiety results when an actual or perceived threat is directed toward
all (except suppression) operate on an unconscious level, so that we are not aware of their operations” (p. 17). “They deny, falsify, or distort reality to make it less threatening” (p. 17).
Two Common Features of Defense Mechanisms
Healthy Defenses (pp. 217-218) - The individual deals with emotional conflict or internal or external stressors by dedication to meeting the needs of others. Unlike the self-sacrifice sometimes characteristic of reaction formation, the individual receives gratification either vicariously or from the response of others. others Sublimation - Attenuating the force of an instinctual drive by using the energy in other, usually constructive activities. This definition implies acceptance of the Libido Theory; the examples do not require it. Sublimation is often combined with other mechanisms, among them aim inhibition, displacement, and symbolization. Examples: (1) a man who is dissatisfied with his sex life but who has not stepped out on his wife becomes very busy repairing his house while his wife is out of town. Thus, he has no time for social activities. (2) a woman is forced to undertake a restrictive diet; she becomes interested in painting and does a number of still life pictures, most of which include fruit. The conscious use of work or hobbies to divert one’s thoughts from a problem or from a rejected wish is an analog of this. Sublimation is often a desirable mechanism.
Common Defense Mechanisms
22 However, the consequences may, in addition to preventing instinctual satisfaction, interfere with the person's life in other ways if disproportionate time, money, or effort is used in the activity. activity. Humor - The individual deals with emotional conflict or external stressors by emphasizing the amusing or ironic aspects of the conflict or stressors. Suppression - Usually fisted as an ego defense mechanism but actually the conscious analog of repression; intentional exclusion of material from consciousness. At times, suppression may lead to subsequent repression. Examples: (1) a young man at work finds that he is letting thoughts about a date that evening interfere with his duties; he decides not to think about plans for the evening until he leaves work. (2) a student goes on vacation worried that she may be failing; she decides not to spoil her holiday by thinking of school. (3) a woman makes an embarrassing faux pas at a party; she makes an effort to forget all about it. In the first example, suppression was probably a desirable mechanism since it permitted concentration on work and deferred dealing with plans for the evening until a more appropriate time. In the second instance, suppression would have been undesirable if failing work could have been corrected during vacation or if a realistic appraisal of probable consequences of the school situation would have permitted battery planning. Intermediate Defenses (p. 218) Repression - The involuntary exclusion of a painful or conflictual thought, impulse, or memory from awareness. This is the primary ego defense mechanism; others reinforce it. Displacement - One way to avoid the risk associated with feeling unpleasant emotions is to displace them, or put them somewhere other than where they belong. A common example is being angry at your boss. Displaying that anger could cost you your job. You might be afraid that you can not contain it, but also afraid of what will happen if you express it toward your boss. You might instead express it, but redirect it toward some other, safer source, such as your partner or best friend. You yell at them and pick a fight. They will forgive you or ignore it, and then you are able to express your anger but without risking your job. Reaction Formation - Going to the opposite extreme; overcompensation for unacceptable impulses. Examples: (1) a man violently dislikes an employee; without being aware of doing so, he "bends over backwards" to not criticize the employee and gives him special privileges and advances. (2) a person with strong antisocial impulses leads a crusade against vice. (3) a married woman who is disturbed by feeling attracted to one of her husband's friends treats him rudely. Intentional efforts to compensate for conscious dislikes and prejudices are sometimes analogous to this mechanism.
- Conflicts are represented by physical symptoms involving parts of the body innervated by the sympathetic and parasympathetic system. Example: a highly competitive and aggressive person, whose life situation requires that such behavior be restricted, develops hypertension. Undoing – makes up for an act or communication. A common behavioral example is compulsive hand washing. This can be viewed as cleansing oneself of an act or thought perceived as unacceptable. Cheating husband giving gifts. Rationalization – justifying illogical and unreasonable ideas, actions, or feelings by developing accepting explanations that satisfy the teller as well as the listener. Everybody cheats, so why shouldn’t I. Immature Defenses (pp. 218-220) Passive aggression - The individual deals with emotional conflict or internal or external stressors by indirectly and unassertively expressing aggression toward others. There is a facade of overt compliance masking covert resistance, resentment, or hostility. Passive aggression often occurs in response to demands for independent action or performance or the lack of gratification of dependent wishes but may be adaptive for individuals in subordinate positions who have no other way to express assertiveness more overtly. Acting-Out Behaviors - The individual deals with emotional conflict or internal or external stressors by actions rather than reflections or feelings. This definition is broader than the original concept of the acting out of transference feelings or wishes during psychotherapy and is intended to include behavior arising both within and outside the transference relationship. Defensive acting out is not synonymous with "bad behavior" because it requires evidence that the behavior is related to emotional conflicts. Dissociation - Splitting-off a group of thoughts or activities from the main portion of consciousness; compartmentalization. Example: a politician works vigorously for integrity in government, but at the same time engages in a business venture involving a conflict of interest without being consciously hypocritical and seeing no connection between the two activities. Some dissociation is helpful in keeping one portion of one's life from interfering with another (e.g., not bringing problems home from the office). However, dissociation is responsible for some symptoms of mental illness; it occurs in "hysteria" (certain somatoform and dissociative disorders) and schizophrenia. The dissociation of hysteria involves a large segment of the consciousness while that in schizophrenia is of numerous small portions. The apparent splitting of affect from content often noted in schizophrenia is usually spoken of as dissociation of affect, though isolation might be a better term.
- The individual deals with emotional conflict or internal or external stressors by attributing exaggerated negative qualities to self or others. Idealization - Overestimation of the desirable qualities and underestimation of the limitations of a desired object. Examples: (1) a lover speaks in glowing terms of the beauty and intelligence of an average-looking woman who is not very bright. (2) a purchaser, having finally decided between two items, expounds upon the advantages of the one chosen. Splitting - This term is widely used today to explain the coexistence within the ego of contradictory states, representative of self and others, as well as attitudes to self and others; other individuals or the self is perceived as "All good or all bad. Projection - Projection is something we all do. It is the act of taking something of ourselves and placing it outside of us, onto others; sometimes we project positive and sometimes negative aspects of ourselves. Sometimes we project things we don't want to acknowledge about ourselves, and so we turn it around and put it on others (i.e., "It's not that I made a stupid mistake, it's that you are critical of everything I do!"). Sometimes it is simply our experiences (i.e., "My father was a reasonable man when we disagreed, so if I use reason with my boss we can work out our disagreement"). The problem with projecting negative aspects of ourselves is that we still suffer under them. In the above example, instead of feeling inadequate (our true feeling) we suffer with the feeling that everyone is critical of us. While we escape feelings of inadequacy and vulnerability, we nonetheless still suffer and feel uneasy. The more energy you put into avoiding the realization that you have weaknesses, the more difficult it eventually is to face them. This is the main defense mechanism of paranoid and anti-social personalities. Denial - the simplest defense to understand. It is simply the refusal to acknowledge what has, is, or will happen. "My partner didn't have an affair, but was simply traveling for work a lot." A related defense is Minimizing. When you minimize you technically accept what happened, but only in a "watered down" form. "Sure, I have been drinking a bit too much lately, but it's only due to stresses at work; I don't really have a drinking problem since this is situational and not an inner weakness or something." Regression - Repression is often thought of as the parent of all defenses. Repression involves putting painful thoughts and memories out of our minds and forgetting them. All defenses do this to some extent. Traditionally, repression is unconsciously "forgetting," that is, forgetting and not even realizing that you are doing it. You have no conscious memory or knowledge of that which is repressed. The problem with repression is that the memory, feeling, or insight repressed doesn't go away. It continues to effect us because our unconscious gives it a life of its own. It
25 becomes all the more powerful because we repress it, and it can effect our decisions, reactions, etc... in ways that we don't see but others may. may.
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