Part 1 NCM 117 First Week PDF

CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF ACUTE AND CHRONIC BEHAVIOUR NCM 117 Lecture SESSION 1: FIRST WEEK 4 hours BSN III STUDENTS  Learning Objectives: By the end of this session, the students should be able to understand the following topics such as:...

CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF ACUTE AND CHRONIC BEHAVIOUR NCM 117 Lecture SESSION 1: FIRST WEEK 4 hours BSN III STUDENTS  Learning Objectives: By the end of this session, the students should be able to understand the following topics such as: Introduction to Psychiatric Nursing Evolution of mental-health-psychiatric nursing practice The Mental Health Nurse: Her Role and essential qualities Interdisciplinary Mental Health Team Mental Health- Illness Continuum  INTRODUCTION TO PSYCHIATRIC NURSING Psychiatric Nursing was recognized in the late 1800s although it was not required in nursing education programs until 1950.Psychiatric nursing practice has been profoundly influenced by Hildegard Peplau and June Mellow who wrote about the nurse-client relationship, anxiety, nurse therapy and interpersonal nursing theory. Historically, mental illness was viewed as demonic possession, sin or weakness and people were punished accordingly. Today, mental illness is seen as a medical problem with symptoms causing dissatisfaction with ones’s characteristics,abilities and accopmlishments,ineffective coping with life events and lack of personal growth.  Evolution of mental-health-psychiatric nursing practice ( Insert Images/Pictures)  MENTAL DISORDERS:ANCIENT TIMES People of ancient times believed that any sickness indicated displeasure of the Gods, in fact was a punishment for sins and wrongdoing. It might be either divine ( worshipped and adored) or demonic (ostrasized, punished and burned at stake). Aristotle (382 -322 BC): developed a theory that the amount of blood,water, yellow and black bile in the body controlled the emotions corresponded with happiness,calmness,anger and sadness.Imbalances of the four caused mental disorders and treatment by starving, bloodletting and purging in the 19th century. Early Christian Times (1-1000 AD) Strong superstitions and primitive beliefs that mentally ill are possessed by evil spirits and all diseases were blamed on demons. Treatment done by the priests who performed exorcisms and if failed, they used brutal measures such as incarceration in dungeons,flogging and starving. Renaissance (1300-1600)period in England considered mental illness as criminals; thrown in prison,chained and starved them; In 1775, they were viewing them as animals less than in human in the hospital for insane called St Mary of Bethlehem (built on 1547). Witch hunting were conducted and offenders were burned during this same period in the colonies later the United States.  1790s: PERIOD OF ENLIGHTENEMENT & CREATION OF MENTAL INSTITUTIONS Philippe Pinel in France and William Tuke in England (1790s) formulated the concept of asylum as a safe refuge or protection but they were being beaten,whipped and starved just because they were mentally ill. Dorothea Dix ( 1802-1887 United States) initiated a crusade( 32 state hospitals are opened as asylum) to reform the treatment of mental illness after a visit to Tuke’s institution in England. She advocated adequate shelter, nutritious food and warm clothing. After 100 years, the asylum hospitals taken a negative connotation of abusing the residents and isolating them from their homes and families.  Sigmund Freud (1856-1939) Emil Kraepelin(1856-1926)Eugen Bleuler (1857-1939): these men studied the diagnosis and treatment of mental illness. 1950s Development of Psychopharmacology to reduce agitation, psychotic thinking and depression. 1963 Enactment of Community Mental Health Centers Construction Act: a deliberate shift of institutional care in state hospitals to community facilities to provide emergency care, screening services,education,partial hospitalization and in and out-patient services. Federal legislation also provided Social Security Income as well as Disability income to severe and pertinent mental illness, not to rely to their family but the commitment laws changed in the early 1970s resulting to deinstitutionalization (1980s) as the revolving door of repetitive hospital admission without adequate community follow up. MENTAL ILLNESS in the 21st Century Healthy People 2020 objectives for mental health, originally Healthy People 2000 revised in January 2000 and again in 2010 to increase the number of people who are identified, diagnosed, treated, and helped to live healthier lives. The objectives strive to decrease the rate of suicide and homelessness, to increase employment among those with serious mental illness and to provide more services both for juveniles and for adults who are incarcerated and have mental health problems. (Box 1.1 pg 5 Videbeck) PSYCHIATRIC NURSING PRACTICE Two early nursing theorists shaped psychiatric nursing practice: Hildegard Peplau: published Interpersonal relations in Nursing (1952) and Interpersonal Techniques: The Crux of Psychiatric Nursing (1962). She described the therapeutic nurse-client relationship with its phases and tasks and wrote extensively about anxiety. The interpersonal dimension that was crucial to her beliefs forms the foundations of practice today.  June Mellow: (1968): Nursing Therapy, described her approach of focusing on client’s psychosocial needs and strengths. Mellow (1986) contended that the nurse as therapist is particularly suited to working with those with severe mental illness in the context of daily activities focusing on the here and now to meet each person’s psychosocial needs. Summary of specific areas of practice with intervention for both basic and advanced nursing practice Page 8 Videbeck Box 1.2 and Box 1.3  SELF- AWARENESS and THERAPEUTIC USE OF SELF  Before the student begin to understand clients, they must first know himself/herself SELF-AWARENESS is a process of developing an understanding of one’s own values, beliefs and attitudes. 1. VALUES- abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. To gain insight into oneself and personal values, the value clarification is helpful.  3 steps of Value Clarification a. Choosing- when the person considers a range of possibilities and chooses what is right. b. Prizing- when the person considers the value, cherishes it and publicly attaches it to himself. c. Acting- when the person puts value into action. CASE SCENARIO: Relate these 3 values to a student whose always clean and orderly suddenly found himself sharing a room with another student whose untidy, lazy and disorganized in his things. 2. BELIEFS- are ideas that one holds to be true, other beliefs might be irrational without empirical evidence. 3. ATTITUDES - general feelings or a frame of reference around which a person organizes knowledge about the world. CULTURAL AWARENESS QUESTION: When you were growing up, what did your parents and significant others say about people who are different from your family? Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs and attitudes in nursing, being aware of one’s feelings , thoughts and values as a primary focus. Points to consider when working on Self-Awareness: 1. Keep a Diary or Journal that focuses on experiences and related feelings. Review periodically to look for patterns or changes. 2. Talk with someone you trust about your experiences and feelings. 3. Engage in formal clinical supervision in order to gain insight and new approaches. 4. Seek alternative points of view. Put yourself in the client’s situation and think about his or her feelings, thoughts and actions. 5. Do not be critical of yourself and others for having certain values or beliefs.  THERAPEUTIC USE OF SELF By developing self-awareness and beginning to understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions in order to establish relationships with clients. This is called Therapeutic Use of Self. Peplau (1952) described it and believe that nurses must clearly understand themselves first. One tool that is useful in self-learning which creates a word portrait is the Johari window. Another way to expect others to behave or speak as a roadblock to the formation of relationship is identified also by Peplau is called Preconception.  Pattern of Knowing:Preconception Preconception often prevent people from getting to know one another. Conflicting personal beliefs and values might prevent the nurse from developing a therapeutic relationship. Example: Mr. Chan refused to be assigned to male student as he has a preconceived stereotyped idea that all male nurses are gays. On the other hand, the male nurse doesn’t like him as a Chinese client so he’s relieved that he refused to work with him. Both of them failed to do due to incorrect preconceptions.  Casper’s Pattern of Nursing Knowledge ( table 5.1pg 85) Casper(1978) identified four patterns in Nursing to provide the nurse with a clear method of observing and understanding every client’s interaction. 1. Empirical Knowing- derived from the science of Nursing. 2. Ethical Knowing- derived from moral knowledge of Nursing. 3. Personal knowing- derived from life experiences. 4. Aesthetic Knowing- derived from art of Nursing.  Johari Window (pg. 85) Quadrant1: Open/Public- self qualities knows about oneself and others. Quadrant2: Blind/Unaware- self qualities known only to others. Quadrant3: Hidden/Private- self qualities known only to oneself Quadrant 4: Unknown-an empty quadrant to symbolize qualities as yet undiscovered by oneslf or others.  Insert picture of Johari Window  TYPES OF RELATIONSHIPS SOCIAL RELATIONSHIP: primarily initiated for the purpose of friendship, socialization, companionship and accomplishment of task. Example: Greeting the client and asking the weather, sport events, news is a type of social interaction but for the nurse-client relationship to accomplish the goals, it must be limited. INTIMATE RELATIONSHIP: two people are emotionally committed, helping each other intimately. NO PLACE in nurse-client relationship. THERAPEUTIC RELATIONSHIP: Focuses on the needs, experiences, feelings and ideas of the client only. The nurse and the client agree about the areas to work on and evaluate the outcome. The nurse uses communication skills, personal strengths and understanding of human behavior to interact with the client. The nurse should not be concerned whether the client likes her or not, focus on the needs of the client only. PHASES OF ESTABLISHING A THERAPEUTIC RELATIONSHIP ORIENTATION PHASE begins when the nurse and client meet and end when the client begins to identify problems to examine. Before meeting the client, the nurse reads the background material, become more familiar with the medications, gather necessary paperwork and arrange for a quiet, comfortable setting. The nurse must examine preconceptions about the client and ensure to put them aside. It may be useful to discuss it with the instructors. DURING ORIENTATION PHASE 1. Build trust and understanding with the client by a. Sharing appropriate information about yourself (student nurse). You need to state your name and the school, reason for being in the unit as well as the duration of your stay. b. Listening closely to the client’s history, perceptions and misconceptions. c. Conveying sympathy or empathy when needed. At the beginning or first meeting, the client might show distrustful by using rambling speech to avoid discussing the real problems. It might take several sessions till the client believes that she can trust the nurse.  Nurse-Client Contracts Time, place and length of sessions When sessions will terminate Who will be involvedin the treatment plan( family members or health team) Client responsibilities( arrive on time and end on time). Nurse’s responsibilities (arrive on time and end on time). Maintain Confidentiality at all time, evaluate program and document sessions.  Working Phase A. Problem Identification - The client identifies the issues or concerns causing problems. B. Exploitation - The nurse guides the client to examine feelings and responses to develop better coping skills and a more positive self- image. The working phase is an intense exploration and elaboration. The nurse must be nonjudgmental and refrain from giving advice, should allow the client to analyze the situation but guide her/his patterns of behavior where expected response occurs suddenly.  Specific Tasks of Working Phase Maintain the relationship. Gather Data. Explore perceptions of reality. Develop positive coping mechanisms. Promote a positive self-concept. Encourage verbalization of feelings. Facilitate behavior change.  Working through resistance. Evaluate progress and redefine goals as appropriate. Provide opportunities for the client to practice new behavior. Promote independence. As the nurse and client work together, it is common for the client unconsciously transfer the feelings to the nurse as what she has from significant others. This is called transference.  A similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts which is called Countertransference. Again, self-awareness is important so that the nurse can identify when transference and countertransference might occur, being aware of the “hot spots” that the nurse has a better chance of responding appropriately rather than old unresolved conflicts interfere the relationship.  TERMINATION OR RESOLUTION PHASE Final stage of the nurse-client relationship. It begins when the problem are resolved and it ends when the relationship is ended. If the client shows anger or pretending that problems are unresolves as she wants to stay more with the nurse, the nurse must not give chance instead appreciate the client’s stay and the time spent together which will always be remembered. Do not agree to see the client outside the therapeutic relationship.  https://nightingale.edu/blog/ psychiatric-nurse.html Psychiatric Nurses are often referred to as Mental Health Nurses or Psych Nurses. The abbreviation PMHNs is also used when talking about Psychiatric Mental Health Nurses. For this reason, these terms will be used interchangeably throughout our discussion. Psychiatric Nurses are the second largest group of behavioral health professionals in the country. Even though they have more autonomy compared to other nurses, PMHNs do not work alone. They are often part of a larger healthcare team which includes physicians, psychiatrists, social workers, or other community or medical workforce members.  Mental Health Nurses have a very sensitive and crucial role in the healthcare industry. Their specialized knowledge and skills allow them to offer nursing care to people with mental health issues, mental health problems, psychiatric disorders, and/or substance use disorders. PMHNs are versed in caring for patients with anxiety disorders, depression, eating disorders, PTSD, psychotic disorders, alcohol or drug abuse, and much more. Clearly, the very vulnerable people they’re working with make the job all the more sensitive. In addition to caring for the individuals, Psychiatric Nurses work with families, groups, and communities with one overarching goal: to ensure good patient outcomes and support their recovery. The role of a Mental Health Nurse is, thus, invaluable. PMNHs help patients cope when they are at their worst. They help patients manage symptoms, re-gain good living skills, and find their inner strength in the face of disorders and disabilities, which, at times, may seem unconquerable.  ROLES OF THE MENTAL HEALTH NURSE IN A THERAPEUTIC RELATIONSHIP: TEACHER CAREGIVER ADVOCATE PARENT SURROGATE  As a Teacher The nurse must be honest about what information she can provide and how to refer the clients. This behavior build trust between them. The nurse must feel confident about the knowledge and must know the limitations. The nurse must be familiar with the hospital and community resources. The nurse must teach different coping skills and his medication regimen.  As a Caregiver The primary caregiving role in mental health setting is the implementation of the therapeutuc relationship to build trust, explore feelings, assist the client in problem solving and help the client meet the psychosocial needs. Some clients might confuse with physical care and intimacy which can erode therapeutic relationship. The nurse must consider the boundaries and parameters here.  As An Advocate Advocacy is the process of acting on the client’s behalf as she can’t do so due to her mental situation. AS A PARENT SURROGATE The nurse must be clear and firm, set limits during nurturing period, as like adult-adult communication to parent-child approach with an open,nonjudgmental easy-going attitude.  MENTAL HEALTH INTERDISCIPLINARY TEAM Pharmacist Psychiatrist Psychologist Psychiatric Nurse Psychiatric Social Worker Occupational Therapist Recreation Therapist Vocational Rehabilitation Specalist  CORE SKILLS OF THE TEAM The primary roles are described in box 4.6 pg 72 Interpersonal skills such as tolerance,patience and understanding. Humanity such as warmth, acceptance, empathy, genuineness and nonjudgmental attitude. Knowledge based about mental disorders,behavior and symptoms. Communication skills. Risk Assessment and management skills team work Personal qualities such as consistency, assertiveness and problem- solving abilities  LEARNING OBJECTIVE: By the end of this session, the students should be able to reflect and practice self-awareness related to clinical practice. WHAT ARE THE COMMON CONCERNS OF NURSING STUDENTS WHOSE ABOUT TO START A PSYCHIATRIC CLINICAL ROTATION?  STUDENT CONCERNS What if I say the wrong things? Show genuine interest and caring concern. Listen carefully to the client. Reply by restating or say, That didn’t come out right, “ what I meant was….”  STUDENT CONCERNS What will I be doing? The idea of just talking to client may likely feel the student not doing anything. The student must deal with her/his own anxiety as an approaching a stranger to talk about personal and sensitive issues. What will I be doing? Develop a therapeutic Nurse-Client relationship. Remember: Trust takes time, bear it with patience.  Student Concerns What if no one will talk to me? Students sometimes have a feeling of rejection from clients, thereby shows emotional distress behavior reclusively. Show to clients a welcome opportunity for them that “you” are willing to listen often and available to begin a significant interaction.  Student Concerns Am I prying when I ask personal questions? Normal to feel awkward but questions concerning personal issues should NOT be the first statement to be asked. Establish trust and rapport using therapeutic communication skills before addressing sensitive topics.  Student Concerns How will I handle bizarre or inappropriate behavior? Initially it’s shocking but the CI and staff will be available for you in such situations. Never feel that you might handle the situation alone. It is important to monitor one’s facial expressions and emotional responses so that clients do not feel rejected or ridiculed.  Student Concerns What happens if a client ask me for a date or displays inappropriate sexual behavior? Initially the student might be uncomfortable dealing with such behavior but with assistance from CI and staff, it will be easy to manage.  Set limits and maintain boundaries when client’s behavior shows sexually inappropriate during interaction. It is important for the student to clarify the boundaries of professional relationship ( refer to UNIT 2 Building the Nurse-Client Relationship Chapter 5 Therapeutic Relationships pp 80-97 Psychiatric-Mental Health Nursing 9th edition Sheila L. Videbeck (author)  Student Concerns Is my physical safety in jeopardy? Staff members are monitoring the clients with potential outburst of violence and students are not allowed to handle clients for safety reason. When talking to or approaching clients who are potentially aggressive, the student should sit in an open area with plenty of space and request the staff member or CI to be present.  Student Concerns What if I encounter someone I know being treated on the unit? It is essential in mental health that the client’s identity and treatment be confidential. The student should notify the instructor, talk to the client and reassure about the confidentiality. Reassure the client that his/her file will never be read and assign to the student.  Student Concerns What if I recognize that I share similar problems or backgrounds with the clients? It’s not easy although students knows that coping skills are a key part of mental health, we don’t know why some people have serious emotional problems and others do not. ( refer to Chapter 7 of same textbook) BREAK TIME NEXT SLIDE SHOW: PART 2 MENTAL HEALTH-ILLNESS CONTINUUM