Nursing Student Journal Notes PDF

Foundations From the journal of Antonella Molinari, nursing student I still can’t get over the conversation I had with my client Nora today. Apparently, the orthopedic surgeon came by to discuss her surgery. What impressed her most was the amount of time that he spent with her. He perched...

Foundations From the journal of Antonella Molinari, nursing student I still can’t get over the conversation I had with my client Nora today. Apparently, the orthopedic surgeon came by to discuss her surgery. What impressed her most was the amount of time that he spent with her. He perched himself on the edge of her bed, asked her about her concerns, and then actually listened and responded to them! First, she shared her fears about anesthesia and that the surgery might make things worse.  But then he asked her about her home life, what her duties would be upon discharge, and how she planned to deal with the fact that she would have to remain on bedrest for several days after the surgery. She felt that he really cared about her answers. He also took the time to draw a picture for her so that she would clearly understand just what would happen in the operating room. He assured her that everyone who touched her would be as gentle as possible Once she was fully comfortable with the explanation, he continued to chat for a few minutes longer, even getting her to laugh at a joke or two. Only then did he ask her to sign a consent form. She felt like she was this doctor’s only patient. I wonder how he knew the best approach to dispel Nora’s fears. Client- Professional relationships Health care providers must remember that it is always the providers’ responsibility to establish and maintain effective relationships with their clients Boundaries good relationship between a client and a health care provider depends on effective communication, mutual respect, and shared trust. Clinicians must also be careful about disclosing personal information to clients. The health professional is responsible for establishing and maintaining financial, emotional, and physical boundaries Touch is another important element in the healing relationship Preservation of Dignity The threat to dignity may be the primary source of the client’s anxiety about the medical visit. This can be as simple as observing common courtesies, such as knocking before entering a treatment or examination room, introducing yourself appropriately, and demonstrating warmth and concern. Medical examinations involve taking a history, asking about personal and social circumstances, and inquiring about spiritual beliefs and values Trust, Respect, and Compassion No matter how sophisticated the technology of health care becomes, healing relies on three simple human elements: compassion, touch, and conversation trust involves risk and uncertainty, which can create anxiety There are many barriers to developing a trusting health care relationship. One that is all too common occurs when clients feel rushed during medical encounters The involvement of third-party payers is another barrier to developing trust. Trust between clients and health care professionals can be affected by clients’ knowledge that other people will view their medical records  Health care, as a commercial field, consider the clients as consumers, who are empowered by lawsuits when they believe they have not obtained the outcomes for which they have paid. This threatens the ability of health providers to trust clients Continuing education, caring for clients in a way that always seeks what is best for clients, respecting and keeping clients’ personal information confidential, and avoiding any behavior that takes advantage of the clients’ Health care ethics A dilemma: is a conflict that requires careful consideration of all possible solutions to identify the one that balances the interests of all involved Ethics: are a set of moral principles that serve as a guiding philosophy for behavior. They help to ensure that health providers make the best possible decisions that honor the rights of clients. four basic ethical principles: autonomy, beneficence, non-maleficence, and justice Autonomy Autonomy, or self-determination based on trust, respect, truthfulness, information sharing, and confidentiality The legal doctrine of informed consent written consent is required for legal protection today and must be kept with clients’ records. Several issues must be addressed in the process: 1) Clients must be informed in a language that they can understand (lay terms and in their primary language) (2) All risks and benefits must be outlined (3) Any and all reasonable alternatives must be discussed (4) Clients must sign a statement that indicates their understanding and acceptance of the treatment.  This right can be waived in certain situations. For example, consent can be assumed if a client is brought into an emergency department in an unconscious state. Treatment can also be administered without parental consent in some cases, particularly if a legal mandate supports the decision. One of the best illustrations of this occurs when a parent refuses lifesaving treatment for a minor child based on religious beliefs. A court can order a health care facility to provide the treatment necessary to save that child’s life.  Any ethical dilemmas in end-of-life care must be based on clients’ own beliefs and values Advance directives allow competent adults to express their wishes regarding life-sustaining treatment should they become unable to make such decisions later Euthanasia is an especially controversial topic. Whereas some people believe that it is simply a matter of clients exercising their right to autonomy by hastening death and “dying with dignity,” others consider it to be an act of suicide and believe it is morally and legally wrong. Beneficence and Non-maleficence The ethical principle of beneficence guides providers to “do good” or “provide benefit,” while non-maleficence means to “do no harm’’ Justice Justice: is the ethical obligation to be fair. Three types of justice are involved in health care: 1) Rights-based justice applies to the obligation providers have to respect client rights. 2)Legal justice requires providers to honor morally acceptable laws. 3)Distributive justice refers to the distribution of scarce resources. Recognizing Attitudes, Beliefs, and Values  From the journal of Donald Spencer, occupational therapy student I was sitting in the conference room today, waiting for our team meeting to begin. I couldn’t believe the discussion that was going on. Mrs. Nadia had been admitted last night with a left hip fracture, due to falling out of bed. Apparently, she was well-known to the staff, with a long history of obesity, diabetes, coronary artery disease, and arthritis. She was now scheduled to undergo surgery. I couldn’t believe what the staff members were saying. One of them actually said it was her own fault, and she deserved what she got. Angie, the nutritionist, stated, “I’ve worked with her over and over again. I’ve explained the importance of a balanced diet to her, but she just doesn’t listen. She always loses weight while she’s in the hospital, but as soon as she’s home, she’s back to her old habits of eating candy, ice cream, and cookies, the pounds go right back on. Pam, the physical therapist, said, “I’m glad I’m rotating to the outpatient department tomorrow. I would hate to be the one to have to get her out of bed and walking. She’s so big! She only fits into one of the wheelchairs in the hospital. Every time she’s admitted, I end up wasting time trying to find it.” At that point, the charge nurse arrived, and the conference began. All day long, I kept thinking about poor Mrs. Nadia. Imagine how she would feel if she knew what the staff thought about her. I’ve always been a few pounds overweight myself, but I’ve never thought too much of it. Now, I’m wondering if others talk about me behind my back. Health care professionals are presumed to treat all individuals with respect and dignity. Codes of ethics provide a list of professional values and describe ethical responsibilities. It is important to recognize, however, that as one enters into therapeutic relationships, providers and clients do so having developed distinct personalities, temperaments, natural abilities, talents, values, and beliefs. Lessons learned in life shape the way individuals view the world. Developing self-awareness and an understanding of one’s strengths and limitations is an important personal and professional lesson. Individuals begin to develop personal values at a very early age. Parents, extended families, society, schools, and culture all serve to mold and shape personal values. People tend to be more comfortable when they are with individuals who are similar to themselves. Although hesitant to admit it, everyone has personal biases. Individuals may be aware of some biases, but others may exist in the subconscious mind. Both overt and covert prejudices can affect interactions with clients and colleagues. When individuals become aware of their biases, they are less likely to make inappropriate or incorrect judgments about others. This chapter discusses the importance of recognizing our own attitudes, beliefs, and values and identifying how they shape what we think and feel and how we behave. Developing awareness helps avoid stereotyping and discrimination. The significance of valuing interdisciplinary viewpoints and working together in teams is emphasized. UNDERSTANDING VALUES To develop a sense of self, every individual needs to develop both intra-personal and inter-personal intelligence. Intrapersonal intelligence: involves developing an understanding of one’s own feelings and emotions, so that you can discriminate among them and be able to purposefully use them to guide your behaviors Interpersonal intelligence: involves understanding the feelings, behaviors, and motivations of those around you. It is the ability to recognize changes in other’s moods, intentions, or motivations Values are strong beliefs and attitudes about the worth of a thought, idea, object, or course of action Values may include religious beliefs, honesty, the importance of a good education, a strong work ethic, and/or taking care of family. Socioeconomic status and culture influence value systems However, to be effective, health care practitioners need to examine, understand, and reflect on their own values and beliefs, and appreciate and respect those of their clients and colleagues At times, the values of a health professional are in conflict with those of clients or colleagues. It is the provider’s responsibility to respect clients’ and colleagues’ values while main training personal values Moral Reasoning, Self-Assessment, and Reflection To be successful, providers must first develop moral sensitivity Then, they must develop moral reasoning, the ability to analyze a situation and come to a moral decision. Finally they must develop the skills to act on the decisions they made Effective health care professionals recognize how their actions affect the lives of their clients. The most successful providers understand the importance of the client–provider relationship, identify their own personal beliefs and values, examine differences between their beliefs and values and those of their clients, and promote awareness of ethical issues found in practice. Practitioners develop moral reasoning skills by practicing self-assessment. Through ongoing self-assessment, they identify strengths and weaknesses related to their knowledge, skills, experiences, and values; improve critical thinking skills; and develop a plan for continuing competence. The use of reflection and reflective writing has been shown to be a useful tool in developing these skills ATTITUDES, STIGMA, AND PREJUDICE IN HEALTH CARE DELIVERY Research shows that when asked to attribute positive or negative qualities, distribute resources, or indicate liking for several different groups, individuals, in general, favor those who are similar to themselves. Favoritism for like individuals is so embedded in people’s value systems that pronouns such as “us” are more favorably valued than those such as “them.” Social behavior often operates in an unconscious manner, and people may not realize that past experiences affect future judgments. This supports the findings that people who deny prejudice have been shown to discriminate against others. The ethnocentrism of health care providers may lead to stigma and prejudice in health care delivery, impair one’s ability to provide culturally appropriate care, and contribute to inadequate treatment and even misdiagnosis. ATTITUDES, STIGMA, AND PREJUDICE IN HEALTH CARE DELIVERY -Ethnocentrism was first defined as the tendency to favor in-groups and disparage members of the out-groups - Prejudice is defined as having a poor attitude toward an individual simply because he or she belongs to a group to which negative qualities have been assigned, resulting in erroneous assumptions. -Risk factors for many illnesses and conditions Some are within a person’s control, such as cigarette smoking, substance abuse, obesity, sedentary lifestyle, multiple sex partners, and failure to wear seat belts. -Some health care providers “blame” clients for their illnesses The role of health care professionals is not to blame but to assist clients with their illnesses or disabilities. Although it is appropriate to inform clients as to how their habits may be affecting their health. Discrimination in Health Care Segregation, dissimilar treatment, and racism continued to be factors in the epidemiological gap between the majority (White) and minority groups. Ethnic bias result in lower satisfaction with care, higher rates of depression postponing of medical tests and treatments Another form of bias is gender bias. Another type of bias is ageism. Other Common Biases and Their Effects on Health Care Delivery HIV/AIDS MENTAL ILLNESS OBESITY DRUG AND ALCOHOL ADDICTIONS DISABILITY Multicultural Perspective Race, Ethnicity and Culture Although race and ethnicity make a significant contribution to culture, they are not the only determinants. Race is generally perceived to be determined by genetically inherited traits that are identifiable by physical characteristics, such as skin color, facial features, and hair color or texture. Race is difficult to determine and can be even harder to identify Ethnicity describe people of similar backgrounds, who identify with one another and choose to live or socialize together. Characteristics that may be considered when defining ethnicity include geographic origin or residence; migration history, race, language or dialect spoken, religion or spiritual beliefs, shared traditions, values, or symbols, occupation, socioeconomic status. Culture: Is a pattern of learned beliefs, shared values, and behavior; it includes language, styles of communication, practices, customs, and views on roles and relationships A critical distinction between the concept of culture and race or ethnicity is that it is learned, not inherited. This learning occurs during the socialization process, beginning at birth. Culture produces material, or observable artifacts, with which we are all familiar, such as art, music, style of dress, and food preference. Culture also has nonmaterial aspects such as values, beliefs, attitudes, and feelings. Religious beliefs or spiritual practices, morals, ethics, and views about the roles of family members are examples of nonmaterial culture.  Acculturation Acculturation is the process through which people in subcultures adopt traits of the larger, or normative, culture Acculturation occurs across a spectrum of levels as norms and beliefs Transition from the culture of origin to the new majority culture. The rate of acculturation can fluctuate and is affected by many factors such as: - Age: younger individuals acculturating more quickly than older people - length of time - Place of residence living with people from the native culture or the majority culture, language spoken at home, and amount of contact with the country of origin. Assimilation Assimilation is different than acculturation in that the arriving group is totally absorbed into the dominant society. Their original culture is overridden by the dominant group In other words, the culture of origin has disappeared. Ethnocentrism Ethnocentrism is a belief in the superiority of one’s culture or ethnic group. It creates a barrier to establishing relationships with those from other cultures whose beliefs or actions are perceived as odd or unacceptable  Worldview The aspects of culture that involve values, beliefs, and the way members of a group understand the world around them can be summarized under the concept of worldview. Worldview consists of several dimensions: (1) social organization and relationships (2) time orientation (3) activity orientation and levels of environmental control (4) use of space (5) communication between people Social Organization and Relationships The majority culture in the United States and other Western cultures is individualistic and places importance on the values of autonomy, that is, self-determination. Each person has the primary responsibility for his or her actions. Personal autonomy is highly valued and rewarded Time Orientation People from various cultures may have different orientations to time. Some are present oriented, whereas others focus primarily on the past or future People of cultures that focus on the past tend to value elders and honor traditions Changes in traditional practices, beliefs, and behaviors are strongly discouraged. In Asian cultures, for example, people often have a past-orientation and rely on traditional healing practices, such as herbal treatments, and the use of traditional healers The advice of elders is precious; they are considered to have gained great wisdom. Activity Orientation/Environmental Control Culture influences the level of control people believe they have over their environment and how much they can affect their destinies. Use of space Cultural space refers to the ways different cultures use the body and regard visual, and interpersonal distance to others Personal space refers to the space immediately surrounding the body. What is comfortable for one person may be unacceptable for another. Communication Unfortunately, many health care providers in the United States speak only English, while clients from other cultures may have limited English skills. language is a significant component of communication Language and communication differences present significant barriers language problems were the greatest barrier to obtaining health care for their children Communication High or low context. Context refers to the level of environmental or social cues that are available to help frame the exchange of information Low-context communication also assumes that words must be used to explain everything because little is implicitly understood High-context communication It is dependent on nonverbal interactions, strong group identification, and understanding of the rules of interaction. It relies on shared group experiences, history, and customs to express ideas, rather than verbal communication Health beliefs and practices It determines how people define health and illness, explains the causes of illness, and describes how to maintain health and how to restore health when illness occurs The ways people be Have when they are ill are also culturally determined, as are the expected behaviors of health care providers. Clients may appear in the medical setting complaining of “evil eye,” or “soul loss.” Asian Cultures believe that health results from a harmony between the body and the spirit. harmony is the foundation for good health and well-being, and a disruption will lead to illness Latino/Hispanic Cultures Latinos as a group tend to have strong religious beliefs. Good health is regarded as good luck or a gift from God. Poor health is the result of fate and is not under the active control of the client or family. Disease or disability may also be perceived as punishment for sins or as a result of negative spiritual forces, such as the “evil eye.” African American Cultures The first Black people who were brought to America from Africa were sold as slaves. Families were disrupted, native cultures destroyed, and human rights ignored. Other Black Americans are people who are descended from slaves but have lived in the Caribbean and came to the United States voluntarily. It is believed that God is responsible for all spiritual and physical health. Further, only God has the power to make decisions about who shall live or when someone shall die. Prayer is used as a healing technique The culture of medicine Therefore, every medical encounter has three potential cross-cultural components: (1) the native culture of the health care provider (2) the native culture of the client (3) the culture of the majority health care system Cultural competency is more than just attaining knowledge about cultural groups. It also involves being able to communicate with individual clients to understand their specific beliefs. These may vary according to the ethnic groups with which the clients identify, as well as their age, gender, social background, level of education. Making connections Communication “Communication: is the interpretation of meaning from interpersonal interactions and extends far beyond verbal information to include elements of body movement, expressions, and subconscious mechanisms “ Although clients consider a provider’s demonstration of caring and empathy to be extremely important to them, such demonstrations are often lacking in many medical encounter Empathy is the ability to identify with and understand someone’s situation, feelings, and emotions and recognize that the client is someone’s mother, daughter, wife, or sibling. “be in the clients’ shoes,” to actually see things through their eyes “You never really appreciate what it’s like being a patient until you are a patient” The first step in developing empathy is to practice effective communication skills Good communication skills allow health care providers to focus on the person, not the disease; to build a therapeutic alliance that improves both the client’s and provider’s perspectives must possess effective communication skills to motivate clients, promote adherence with treatment protocols, and ensure appropriate, cost efficient outcomes poor communication often results in negative consequences It could lead to inaccurate diagnoses Elements of effective communication Communication begins when the sender expresses an idea, either verbally or nonverbally Verbal messages are influenced by paralanguage cues, such as tone of voice, pitch, volume, and speed Nonverbal messages may be sent intentionally or unintentionally. They include facial expression, touch, proxemics, and behavior DEVELOPING CLIENT–PRACTITIONER RELATIONSHIP Studies confirm that practitioners who adopt a friendly and reassuring manner are more effective than those who do not. “How are you feeling?” Clients have a right, and often a need, to express their emotions regarding their illness or disability. As health care professionals, we need to develop an awareness and ability to reflect on our own attitudes, styles, and approaches to clients. Rather than assuming that a client is “difficult,” it is important to question our own attitudes and develop more effective strategies. Taking the time to view clients as the “experts” ” in their individual situations and allowing time for them to express their desires, values, and emotions may improve therapeutic relationships and lead to better client outcomes Client-Sensitive Language “language shapes thought” Focusing on the individual enables us to see his or her abilities, needs, desires, and goals rather than the impairments. For example, the common expression of “confined to a wheelchair” promotes a negative concept of being limited, even imprisoned. MINDFULNESS: BEING PRESENT IN THE MOMENT While running from client to client, it is easy to forget that each person is a unique human being. To avoid this, providers should practice mindfulness. This requires that we fully attend to each task mindful practitioners develop self-awareness, clearing their minds of mental clutter, so that they are able to focus on the present moment Mindfulness involves self-assessment, the ability to be aware of one’s own opinions, prejudices (bias), and expectations VERBAL COMMUNICATION Vocabulary Paralanguage (tone of voice, pitch, volume, and speed ) Active Listening Active listening involves being alert and receptive to both verbal and nonverbal communication cues Whenever possible, eliminate the physical and mental distractions that may hinder communication. Active listening shows clients that you are fully present in the moment, grasping the meaning of what they are saying can clarify miscommunication and de-escalate conflict Keep in mind that clients sometimes just need to talk to express their fear, anger, or frustration with their illness, injury, or disability. NONVERBAL COMMUNICATION Facial Expressions Touch Touch is another form of nonverbal communication, There are several forms of touch, procedural or instrumental touch occurs when our hands come in contact with clients such as moving a client into bed, performing range-of-motion exercises, or drawing blood Expressive or caring touch involves contact that is meant to convey emotional support. This may include resting a hand on a client’s arm or shoulder Hands may be placed directly on the skin, over clothing, or several inches above the client’s body Health professionals’ touching style is influenced by their cultural backgrounds, previous experience, and education. Although many studies show that touch has a calming and comforting effect on clients, individual responses to touch vary, depending on age, gender, parts of the body being touched, physical environment, cultural heritage, prior experience, and personal interpretation of the meaning of the touch It is important to inform clients about what you are going to do and the reason for it. Touch should be firm enough to let the client feel safe and secure Spatial Distances/Proxemics The concept of proxemics represents another aspect of spatial distances. Proxemics: identifies the distances we maintain while communicating with other Distracting Behaviors Constantly checking your watch, answering telephone calls, responding to pagers, or talking with others while you are with clients conveys a message that you are really too busy to be with them BARRIERS TO EFFECTIVE COMMUNICATION Role uncertainty Sensory Overload Voice and Word Choice Physical Appearance Gender Differences Cultural Barriers CONFLICT  Levels of Conflict PERSONAL CONFLICT At the personal level, conflict occurs within an individual He or she may receive pressure from colleagues to do something that is not in accordance with his or her personal value system For example, a supervisor may suggest that an occupational therapist delegate portions of a client’s treatment to an occupational therapy assistant in order to increase productivity. The occupational therapist may believe that the client requires the attention and skills of a therapist and that it is inappropriate to delegate this part of the care. INTERPERSONAL CONFLICT Conflict develops at the interpersonal level when two or more individuals exhibit conflicting values or beliefs. For example, interpersonal conflicts frequently occur between nursing home staff members and residents’ family members INTRAGROUP CONFLICT Intragroup conflict exists when members within a group disagree with each other as to what course of action should be taken INTERGROUP CONFLICT Intergroup conflict arises between two or more groups of people, departments, or organizations that have conflicting beliefs or needs Sources of Conflict Conflicts include content, psychological, and procedural components.Content issues are related to specific factors, such as time and money. Procedural components of conflict involve policies, the chain of command, and decision making responsibility Lack of communication and unclear expectations are also sources of conflict. E-mail communication may also be a source of conflict. Strategies to Manage Conflict - AVOIDANCE Avoidance is an unassertive and uncooperative conflict management strategy in which individuals simply ignore or evade the fact that a conflict exists -ACCOMMODATION Accommodation is an unassertive but cooperative approach to conflict management. In the accommodation, the person neglects his or her own needs to meet the needs of others. COMPETITION is an aggressive, uncompromising approach to managing conflict. For example: a student proposes an alternative evidence-based treatment approach rather than one an experienced practitioner has been using for many years. The supervisor refuses to consider the students’ proposal or listen to the rationale, insisting that it be done her way. This style may result in quick, short-term agreements. However, the results are based upon an “I win, you lose” strategy, which may be counterproductive over time and negatively affect client outcomes. COMPROMISE is a strategy midway between competition and accommodation. Consider Melissa, a 15-year-old girl with juvenile rheumatoid arthritis. Her medication made her drowsy and impaired her ability to think clearly, affecting her school work. Her physician compromised and prescribed another medication that was not as effective but had fewer side effects. COLLABORATION involves both assertiveness and cooperation. It is a problem solving approach in which all parties want to fully address the concerns of everyone. “win–win” solution For example, Imagine a situation in which a manager enlists input from the entire staff to address how they might change the hours and staffing patterns of their operation. Although most authors agree that this is the preferred approach to managing conflict, it is the most difficult and often the most time consuming to achieve and, therefore, may not be appropriate in all situations. MEDIATION Sometimes, individuals or groups may be unable to resolve conflict, and it escalates. Members of each side may try to convert otherwise neutral parties to their points of view. A neutral third party is invited to facilitate the process. Types of Interviews THE BIOMEDICAL MODEL INTERVIEW The biomedical model of health care is founded on the premise that anatomy, physiology, pathology and other biological forces are responsible for health and illness, function and dysfunction. Therefore, the biomedical client interview was designed to identify disease or dysfunction and to determine an appropriate medical intervention or, to phrase it more casually, it was concerned only with the “two Fs”—to find it and fix it. Using the traditional biomedical model, health professionals have been taught to start the client interview by taking a history. THE CLIENT-CENTERED INTERVIEW True patient-centered care places increased emphasis on the therapeutic encounter between the patient and the provider” Each client is viewed as the expert on his or her health and is given the opportunity to be heard and respected client-centered care is hearing clients’ stories and learning what their symptoms and discomforts mean to them Allow storytelling! INVITE, LISTEN, SUMMARIZE It is a simple system that guides practitioners in performing a client-centered interview. They call this strategy invite, listen, and summarize -invite the client to provide important information include “Tell me a little about yourself” or “Tell me what brings you here today -Professionals actively listen to the client’s story -clinicians summarize what they have heard, using statements such as “You have been having chest pain for several weeks that does not seem related to exercise “ Asking and Listening It permits us to hear each client’s story, while gathering information about both the diagnosis and the type of care that will be acceptable to him or her.  Motivation, Adherence and collaborative treatment planning The more motivated and willing clients are to be actively involved in their therapeutic intervention, the more adherent they will be and the better their outcomes.  Many factors affect therapeutic adherence Adherence: The degree to which clients follow a treatment regimen The treatment program could be in a clinic or at home and might include activities such as a diet, exercise plan Five dimensions of adherence ❑ Patient-related factors ❑ Social/economic factors ❑ Therapy-related factors ❑ Condition-related factors ❑ Health system-related factors Difficult patients! “difficult patient” was defined as one who is not open to therapy… - Sometimes, therapists blame their clients Factors affecting motivation and adherence - Locus of Control (Can we influence our future??!!) - Self-Efficacy (Related to how successful people believe they can be in accomplishing a task) - Self-Esteem (self worth, person with strong self-esteem is more likely to feel in control of his or her life and be more motivated to be an active participant in health care than person with low self-esteem) Many factors affect self-esteem, such as: - Anxiety. - Difficulty with social relationships. - Changes in body image, and depression are seen in clients with craniofacial conditions, facial injuries, facial cancer, and conditions to surgically correct face and jaw. Strategies to enhance motivation and adherence Modifying Health Behaviors Trans-theoretical model for health behavior change Five A’s behavioral interventional protocol Motivational interviewing Modifying Health Behaviors Multiple factors need to be addressed to improve adherence, such as those associated with the individualized behavioral, cognitive, emotional, and technical needs of the client The health belief model is associated with people’s perceptions of their health status. If clients believe that health is given by a higher power, then they will also believe that they have no ability to make a change in their status. Trans-theoretical model for health behavior change Change in health behavior is a process that takes time. The trans-theoretical model for health behavior change, also called the stages of change mode clients are likely to pass through six nonlinear stages on their way to change, including the following: Trans-theoretical model for health behavior change - Pre-contemplation (contemplation means the action of looking thoughtfully for something) clients are in this stage when we first encounter them and have no plans to begin to make a change. clients are not expecting to make any changes within the next 6 months. - Contemplation are considering doing so within the next 6 months. - Preparation Plan to take action in the near future to achieve their goal - Action clients in the action stage as highly motivated. -Maintenance Once people achieve their goals, they progress to the maintenance stage and can remain there for 6 months to 5 years. -Termination : positive lifestyle change Five A’s behavioral interventional protocol The five steps are easy to follow, take little time to complete, and have been shown to be more successful in promoting client motivation and adherence than information and advice alone. This model is also closely aligned with the trans-theoretical model and motivational interviewing First, Address the issue Second, we Assess the clients Third, we Advise the clients. Fourth, we Assist the clients to make change Finally, we Arrange for follow-up Motivational interviewing Predicated on the belief that clients are responsible for their own actions and health motivational interviewing can be a valuable strategy to enhance motivation and adherence. It is now used in medical, public health, and other health promotion arenas  Motivational interviewing Motivational interviewing follows three key counseling principles o Express empathy provider communicates an understanding of what clients are experiencing. o Develop a discrepancy the provider helps clients become aware of the discrepancies between their present unhealthy behaviors and the goals and values that they would be striving to achieve. oSupport self-efficacy supports and communicates the belief that clients are able to effect change. Important skills for motivational interviewing include reflective listening, asking open ended questions, affirming, and summarizing Goal Setting Ideally, the client not only sets short-term and long-term goals but also enters into a contract to reach these goals by adhering to healthy behaviors If a goal is set too high, clients will be unable to achieve success. If a goal is too low, clients may achieve success but will lack a sense of accomplishment. -Discuss prognosis and anticipated time frames for recovery. -Educating clients about the importance of short-term goals and their relationship to long-term goals is critical Education and Empowerment Ask clients if they will be able to adhere to the program that you have both agreed on. Various educational approaches have been found useful, including treatment booklets with clear graphics; videotapes, DVDs, iPods®, iPhones®, and YouTube The more information clients are given at one time, the more likely they are to forget. Our teaching approach may not match the client’s learning style. Some individuals prefer to hear only the facts, whereas others prefer a more personable approach Clients need to be educated on how to evaluate all sources of information because some are unreliable As health care professionals, we need to be well informed so that we can answer questions appropriately and ensure that clients receive accurate information. Feedback and Follow-Up Positive feedback has been shown to improve self-esteem, enhance individuals’ perceptions of their own competency, and improve motivation and adherence to give feedback in a timely manner. Positive feedback may be provided whenever clients follow through with program guidelines or make progress toward their goals. Clients can give themselves positive self-feedback. For example, they may track their own progress in journals or calendars. - Telephone calls, e-mails, group attendance, and personal counseling. - Health care practitioners need to encourage, support, educate, communicate, and build sustaining therapeutic alliances with clients. - Having information, and being able to use it, and being involved in partnerships increases the clients’ self-efficacy Peer Support Groups Help people clarify values, improve self-esteem, increase knowledge, develop coping strategies, maintain healthy lifestyle habits, and reduce or eliminate addictions In fact, groups are so beneficial and popular, it seems as though they exist for almost any problem, condition, or diagnosis Support Groups also benefit family members who are learning to live with an individual who has been diagnosed with an illness Primary and Secondary Control-Enhancing Strategies Some clients start out motivated but lose their motivation over time. This is especially true for clients dealing with a chronic impairment or terminal illness. Maintaining motivation can also be difficult for elderly people Two-step approach, involving primary and secondary control-enhancing strategies, can be very effect Primary and Secondary Control-Enhancing Strategies Primary control-enhancing strategies allow people to accomplish desired goals in new ways by modifying the environment primary control-enhancing strategies no longer achieve the goals, secondary strategies can be utilized to retain a form of personal control Clients who use secondary control-enhancing strategies modify their internal environment by altering their expectations and reframing what is important. Loss/ Grief, coping and family  —From the journal of Linda Whitehead, nursing student My client Nora had a miscarriage, and it was an early miscarriage at that. I don’t want to seem insensitive, but it’s not like she lost an actual baby. You should have seen her. She was hysterical! On her follow-up appointment today, she was in the throes of grief. If anyone has a reason to grieve like that, it would be my other client Lina. I can’t even imagine carrying a baby to term and then discovering that the umbilical cord had become wrapped around a foot. I still don’t understand why the doctor kept her in the hospital for 12 hours, with a dead baby inside of her, before finally delivering it. Perinatal loss results in the loss of dreams, self-esteem, the parental role, and the confidence in the ability to create and deliver a healthy baby. It explores loss and grieving from the perspective of the “three D’s” —disease, disability, and death— and recognizes loss, grieving, and coping as a process rather than stages. Understanding loss Health professionals need to adjust their sights and goals accordingly to deal with individuals’ losses.  Types of Loss ▪ Loss of health (one loss often leads to additional losses, Clients with diabetes, for instance, may face the loss of extremities) ▪Memory, cognitive, and intellectual losses (They may experience confusion and deteriorating memory. Activities of daily living, such as washing, bathing, and dressing, may pose additional problems) loss of these social roles is also a reflection of a loss of autonomy , which negatively influences personal decision making and control of one’s life Losses may be sudden, gradual, anticipated or total. A person can lose (external objects), such as one’s home. Primary internal losses can result in secondary external losses, For example, a person who is diagnosed with (AIDS) may experience physical and/or mental deterioration, which necessitates assistance from others.  Understanding grief Where there is loss, there is the universal human phenomenon of grief, a neuro-psychobiological process that occurs in response to loss in every age group and culture. Grief can affect all dimensions of a person— physical, emotional, cognitive, behavioral, and spiritual.  Types of Grief The purpose of cultural traditions and rituals associated with death, such as wakes and funerals, is to help mourners (people who are going through grief) face their losses. Psychological signs include an initial shock and disbelief, followed by sorrow and often regret. Grief-related emotions, such as anger, guilt, despair, sadness, depression, denial, and fear, tend to be powerful, confusing, and overwhelming Physical signs associated with a grief reaction include fatigue, sighing, hyperventilation, feelings of physical emptiness in the abdomen and chest, and a sense of a lump in the throat. Anorexia, insomnia, and disorientation may also be present, Cognitive signs are often present as well, including anxiety, confusion, and difficulty making decisions.  Different types and responses to grief… Just as there are different types and reactions to loss, there are different types and responses : anticipatory, acute, chronic, delayed and suppressed grief Grief has typically been considered to have two temporal phases: anticipatory grief: is experienced prior to the actual loss ,conventional grief occurs following a loss Anticipatory grief includes preparing for losses that will occur as a result of surgery and disease progression, as well as death five major processes of expected loss in palliative care, “realization,” “caretaking,” “presence,” “finding meaning,” and “transitioning’’ Anticipatory grief in clients with advanced cancer involves facing many losses and, ultimately, death and being concerned with their role and relationship within the family The person who is acutely grieving may experience profound sadness, anxiety, denial, anger, and depression - He or she may feel overwhelmed, confused, numb, helpless, and hopeless Grief can also become chronic. With chronic grief, a person enters a state of perpetual mourning. In some cultures, following the death of their husbands, widows dress completely in black for the rest of their lives Grief may also be delayed or absent. Some people suppress their grief; however, it can be triggered at a later date This may occur when the individual perceives that the time and environment are safe for grieving or when the grief can no longer be inhibited. GRIEVING BEHAVIOR There are typically primary and secondary mourners Primary mourners are people who perceive that they have lost the most—the client, family, and close friends Secondary mourners also despair, but there is less of a void in their lives. They are likely to be coworkers and less close friends. Grief or sorrow (emotional suffering) caused by bereavement (having something taken away) have bereavement behaviors as a response to loss are influenced by religious beliefs, age, cultural and community aspects, the personality of the grieving person, and the relationship between who is grieving and what is lost. These include practices such as: Photographic collections at memorial services Candle lighting Charitable funds Condolence visits Specific prayers Stuffed animals and flowers left at the scene of accidents  Stages of Grieving and Dying Table 7–2 Comparative Models of Grieving Stages of Grieving and Dying (Kübler-Ross, 1969) Integrative Theory of Bereavement (Sanders, 1989) Denial Shock Anger Awareness of loss Bargaining Conservation and withdrawal Depression Healing Acceptance Renewal  Integrative Theory of Bereavement This model also has five phases, which are correlated with emotional, biological, and social factors First phase, person experiences shock: The person numbly moves through this initial phase, often unable to complete the simplest tasks or make any decisions During the second phase, the person develops an awareness of the loss: Reality is beginning to “set in,” and the person is starting to understand the meaning of the loss In the third phase of conservation and withdrawal, the individual may feel fatigued, even listless: “I feel like a rag doll” or “I can barely get through the day. I don’t have energy to spare.” Fourth phase of healing begins. It is a time of adjusting to a new reality Finally, there can be renewal: during this fifth phase, the person is reaching resolution of his or her grief and emerging at the other end, engaged in life, often enthusiastically. Tasks of Mourning Worden believes that grief is a process that involves learning to master four tasks of mourning. First: the person needs to accept the reality of the loss, to accomplish this task, the person comes out of denial The second, Once the person accepts the loss as real, the grieving person needs to experience the pain associated with grief Third task of mourning is adjusting to circumstances created by the loss. Fourth task, emotionally relocating the deceased and progressing with life Common Themes Across the Models DENIAL: Denial of the situation, fears, and thoughts can be present even when the circumstances are visible and difficult for others to deny. Denial is not necessarily a one-time response. It can reappear whenever there are new challenges to face. ANGER: When dealing with loss and grief, anxiety and depression Anger can appear when a person no longer fits society’s picture of “normal.” It may fester when a client can no longer do the same activities in the previous way. BARGAINING: negotiate SADNESS AND DEPRESSION ACCEPTANCE: A client who no longer denies the reality, has come to terms with anger GUILT: Anger and guilt are natural parts of the grieving process. ANXIETY DIMINISHED PROBLEM SOLVING Any type of loss can result in a period of distress. A person can feel confused and defeated people who are grieving often have difficulty acquiring, storing, and processing information Depression can also affect cognitive functioning Grief outcomes Following a loss, three inter-dependent elements influence outcome: 1 -The pain of the loss of attachment and suffering of dealing with the situation 2- The ‘’handicapping” deprivation of not having what you once had before the loss 3- The deterioration of cognitive capabilities, including problem solving Chronic sorrow Sadness is a response to loss and is a natural part of the grieving process. There is sadness around chronic conditions. There is also sadness that is lifelong, episodic in nature, or progressive. It may be a response to a chronic or terminal illness. It can affect both the individual with a chronic illness or disability, as well as the family members. Chapter 8 I coping From the journal of Paul Rodriguez, physical therapist student When I first looked at Diane sitting in her wheelchair by the edge of the pool, I only saw a woman “crippled” by her condition. Scleroderma had stretched her skin so taut that I thought it would tear. It pulled with such force that her facial features were distorted into a permanent smile, and her hands and feet were deformed. She was a 20-year-old woman, though she looked at least 40, and was frozen in place. There was nothing she could functionally do for herself. On Saturday mornings, she was transformed as she “swam” in the community pool. As her volunteer pool buddy this week, I carefully lifted her tight body off the chair and lowered her into the water. Almost inaudibly, she said, “This is what heaven feels like. It’s the one time all week that I feel like a human being.” It seemed like being in the pool gave her a small sense of control and an important way for her to cope with her life. Coping is “defined as the thoughts and behaviors used to manage the internal and external demands of situations that are appraised as stressful’’. To cope optimally with change, the person first needs to accept the loss, grieve the loss, and then learn to adapt to the changes. Coping strategies can differ with regard to success. Some may be inadequate, such as “giving up”. Blaming others, blaming oneself, using defense mechanisms. Adaptive coping is healthier and more successful, and includes dealing with problems, being realistic in the assessment of stress and coping, identifying and confronting unhealthy emotional responses to stress.  The three steps in a coping process. The initial step or primary appraisal (evaluation) is when a person evaluates the stress. For example: (“Am I in trouble?”). The next step or secondary appraisal is when a person thinks about ways of coping. (i.e., "What, if anything, can I do about it?”). The third step, tertiary appraisal, is when coping options are put into action. These actions do not necessarily lead to immediate success; more commonly, they have to be tried, evaluated, and modified. Coping Skills -APPRAISAL-FOCUSED COPING: Appraisal-focused coping helps an individual seek out the meaning in a situation that might be threatening or negative and look for the positive. -PROBLEM-FOCUSED COPING: is directed at solving the problem at hand and altering situations. -EMOTION-FOCUSED COPING: managing the emotions associated with a critical situation. Our role as health care professionals is to facilitate the use of adaptive coping strategies, helping to line up necessary resources and make referrals as needed. Defense Mechanisms Defense mechanisms have been described as the common elements of all are that they: (1) Protect the individual from tension, hurt, anxiety, pain, and psychic dis-organization. (2) Tend to be unconscious. Defense Mechanisms - Denial of (or minimizing) reality. - Fantasy: total escape from reality, where an imaginary world that is less threatening is an alternate to the real one. - Repression/suppression: A person who is raped can have selective amnesia of the events. Defense Mechanisms -Projection: In projection, individuals see positive or negative traits of themselves and put them outside of the self, onto other people. -Reaction formation: If a reaction is too painful, negative, or threatening, a person can reform the reaction, accepting attitudes, feelings, impulses, and thoughts that are the opposite of his or her true feelings.  Psychological adaptation strategy Cognitive Reframing Reframing helps put meaning to the loss and makes it not only bearable but perhaps even positive. Emotional and Practical Support: Support from families and friends has been shown to contribute to survival in aging adults and has an important impact on adaptation. Health providers can be very effective in supporting coping. Counseling: The purpose of counseling is to enable people to recognize and use their own coping resources. Support Groups: Sharing practical information and “success” stories with others are additional rehabilitation and psychosocial strategies. Hope: “Hope is the ability to invest our energy and vision in a reality beyond our sight in the present moment, Hope plays a central role in healing. Disability  Age related disability —From the journal of Nicole Jackson, occupational therapy student I’m really concerned about one of my favorite clients. My instructor has been treating her on and off for many years. She has diabetes, visual impairment, polyneuropathies, and a fairly recent amputation of her left lower extremity. It seems that every time she’s admitted, there’s a little more wrong with her and a little less that we can do to help her remain independent. It’s very frustrating for us, and it must be even more so for her. What troubled me the most today was her mental status. She seemed very confused and asked for clarification of the same information over and over. Perhaps she’s just overwhelmed by this hospitalization, but I called her primary physician, just in case. People with disabilities represent the largest minority group in the United States, with the latest estimate standing at 54.4 million. This number is equivalent to 1 in every 19 U.S. citizens. The onset of disability can occur at any point throughout the life span, but the incidence increases with age, when chronic health conditions become common and natural changes associated with death occur. THE SOCIAL CONTEXT OF DISABILITY Disability arises not just from impairments, but by society’s refusal to accept these impairments and to make accommodations for them.  Birth to Age Three Developmental disability is defined as a severe, chronic disability that originated at birth or during childhood and is expected to continue. It substantially restricts an individual’s functioning in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, capacity for independent living. Examples of developmental disabilities include autism, behavior disorders, brain injury, cerebral palsy, Down syndrome, fetal alcohol syndrome, intellectual disability, and spina bifida. Clients are children between the ages of birth and 3 and their families. Practitioners focus on facilitating positive relationships between children and their parents. Some studies have found that children who have disabilities are at risk for developing unhealthy relationships with their parents. Developmental disabilities may be negatively impacted by the stress associated with caregiving. Siblings of children who have disabilities are at risk for developing a range of problems. These include lower social competence. low self-esteem. Shyness. Somatic complaints. Poor peer relations. Delinquency (negligence). loneliness and isolation. Anxiety and depression. Anger, excessive worry and poor or failing grades in school. School age children School-age children with disabilities spend a significant amount of their time outside of the home interacting with issues related to their education. Once they reach age 3, they are entitled to receive services through the public school system. Children who have developmental disabilities often have very different life experiences than those who do not. They may be routinely excluded from many social events, such as clubs, sports, and birthday parties, because of mobility impairments. Adults with Developmental Disabilities The most common fall into three broad categories: physical, cognitive, and psychosocial. PHYSICAL PROBLEMS: Physical problems can be due to a specific diagnosis, for example, spastic (convulsive) paraparesis related to brain injury in cerebral palsy. COGNITION/COMMUNICATION: such as intellectual disability associated with Down syndrome. PSYCHOSOCIAL CONCERN: required to develop a sense of trust and security. Health definition Health is defined as the absence of illness, injury, and disability. Sudden onset disability Trauma, such as spinal cord injury, stroke, or amputation, can be devastating from both physical and psychosocial perspectives. Return-to-Work Issues Significant social, emotional, physical, and financial barriers face those trying to enter or reenter the workforce after an acute-onset disability. A key feature of the law provides that the employee must be able to perform essential functions of the job with reasonable accommodations. An accommodation: is any modification to the work site or job responsibilities. This may include physical adaptations to the work place, retraining the employee for a new job, changing the work location, or allowing flexible hours.  Unemployment following a disability is a significant financial stressor for the client and his or her family Many factors affect this return rate to work after disability: 1. level of lesion and residual motor function. 2. Race. 3. Age. 4. Marital status. 5. The type of work they do. 6. Education. Powerful predictors of overall health include The availability of social support. The ability to cope. Mental health. Positive attitude.