Nursing Process and Standards of Care PDF

Chapter The Nursing Process and 7 Standards of Care  Assessment Diagnosis Psychiatri c Nursing Planning Care Implementation Evaluation  Subjective Information What the patient states...

Chapter The Nursing Process and 7 Standards of Care  Assessment Diagnosis Psychiatri c Nursing Planning Care Implementation Evaluation  Subjective Information What the patient states HPI – history of present illness Assessme What the patient tells you regarding their reason for seeking treatment Includes all of the following: nt - Statement(s) regarding their reason for treatment Voluntary or Involuntary Thought Content and Perception Subjective Suicide Risk Assessment Subjective information regarding suicidal ideations Homicidal Risk Assessment Subjective information regarding homicidal ideations Hallucinations, Delusions, Illusions Obsessions, ruminations, Insight Understanding of their own condition Judgement Problem-solving ability Assessment – Subjective cont’d Psychiatric History Social History Developmental information Age of onset of symptoms Relationship history Age when sought treatment As a Child and adult Age received diagnoses and what diagnoses Do they have children Medication history Education Psychiatric Hospitalization Occupation Current living situation Suicide attempt/self-harm history Support Homicidal ideation history Legal history Medical History Trauma history Surgical History Substance Use History Current Medications Caffeine Allergies Nicotine Review of Systems Controlled Substances Subjective information related to disease or illness in any of Illicit Substances the body systems outside of the reason for seeking treatment  Assessment - Objective Objective Assessment What you observe or assess Does not include any subjective information Vital Signs Physical Assessment Diagnostic Tests Labs Scans Results of Screening Tools Mental Status Exam Mental Status Exam (MSE) Mental Status Exam Structured assessment used by healthcare professionals, particularly in mental health settings, to evaluate a patient's cognitive, emotional, and psychological functioning. Provides a snapshot of the patient’s current mental state and is crucial for diagnosis, treatment planning, and monitoring progress. Key Components of the MSE Appearance: Behavior: Speech: Mood and Affect: Observations about the Assessment of the patient’s Evaluation of speech Mood: The patient’s self- patient's physical appearance, behavior during the interview, characteristics, including rate, reported emotional state (e.g., grooming, dress, and hygiene. including motor activity, eye volume, articulation, and depressed, anxious). contact, and responsiveness. coherence (e.g., whether Affect: The observed speech is pressured, slurred, or emotional expression (e.g., flat, tangential). labile, appropriate). Thought Process: Thought Content: Perception: Cognition: Examination of the Content of thoughts, including Evaluation of the patient’s Assessment of the patient’s organization and coherence of any delusions, obsessions, or sensory experiences, such as cognitive abilities, including the patient’s thoughts (e.g., preoccupations. Assessment hallucinations (auditory, visual, attention, concentration, logical, flight of ideas, for suicidal or homicidal etc.) or illusions. memory, and orientation (e.g., circumstantial). ideation is also included. awareness of person, place, time). Insight: Judgment: The patient’s awareness and Evaluation of the patient’s understanding of their decision-making abilities and condition and need for their ability to understand the treatment. consequences of their actions. MSE - Example Appearance: Perceptions: A 25-year-old Black female appears to be of the stated age. Endorses auditory hallucinations of God commanding her to go to She is wearing paper hospital scrubs, which have been deliberately cut to California. expose her abdomen, revealing a vertical scar. Denies visual hallucinations. Multiple tattoos of various names are visible on her forearms bilaterally. Does not appear to be actively responding to internal stimuli Behavior: Cognition: Not in acute distress, difficult to redirect for interviewing, inappropriately Alert and oriented to person, place, and date laughing and smiling Motor Activity: Attention/concentration: Minimal psychomotor agitation present. Regular gait. Regular posturing. Poor. No tics, tremors, or extrapyramidal side effects present Unable to spell WORLD forward and backward Speech: Memory: Hyperverbal, fluent, pressured rate, regular rhythm, regular volume, happy Able to recall 3/3 objects immediately and after 1 minute. tone Recent memory - intact to breakfast this morning. Mood: Long-term memory - intact to what high school she attended. Fantastic Abstract reasoning: Affect: Intact with the ability to identify a bird and tree as both living Elated, inappropriate, incongruent Insight: Thought Process: Flight of ideas Poor Thought Content: Judgment: Denies suicidal ideations and homicidal ideations. Poor Grandiose delusions elicited of being an angel on a mission  Analyze assessment data to determine diagnoses, problems and areas of care and treatment focus, including level of risk Diagnosi Problem/potential problem (unmet need) Diagnostic Statement Probable cause (“due to”) s Components Supporting data (signs and symptoms/ “as evidenced by”) Disturbed Mood Regulation r/t emotional Example: dysregulation a.e.b. prolonged periods of mood irritability  Outcome criteria Identify expected outcomes that reflect the maximal level of Outcomes patient health that can realistically be achieved through Identificati planned nursing interventions on Principles Reflect a measurable desired change Provide direction for continuity of care Written in positive terms  Specific: Goals should be clearly defined and focused on a particular outcome. For example, instead of saying "improve mobility," state "patient will ambulate 50 feet using a walker." Measurable: Establish criteria for measuring progress. For instance, include quantifiable metrics (e.g., "will report pain level of 3 or less on a scale of 0-10"). Achievable: Outcomes Goals must be realistic and attainable based on the patient's condition, resources, and support systems. Consider the patient’s baseline abilities and limitations. Identificati Relevant: Goals should align with the patient's overall care plan and address their specific health issues or conditions. on Criteria Time-Bound: Assign a time frame for achieving the goals to provide urgency and allow for evaluation. For instance, "within three days." Patient-Driven: Involve the patient in goal-setting to ensure that their priorities, motivations, and preferences guide the objectives set. Flexible: Goals should allow for modifications based on ongoing assessments and changes in the patient's condition or situation.  Prescribe strategies to assist patient in attaining expected outcomes Planning Safe Principles to Compatible and appropriate consider when Realistic and planning care individualized Evidence-based Nursing Interventions Evidence-Based: Interventions should be supported by current research and best practices within the nursing profession. Interventions should be tailored to meet the specific needs, preferences, and circumstances of each patient. Individualized: Consider cultural, ethical, and personal factors. Interventions must prioritize patient safety and minimize risks. Assess for any contraindications or potential side Safe: effects. The availability of resources, time, and support must be considered. Interventions should be practical and Feasible: manageable within the healthcare setting. Holistic: Interventions should address the physical, emotional, psychological, and social aspects of the patient’s well-being. When necessary, involve other healthcare professionals to implement comprehensive care plans that may include Collaborative: interdisciplinary approaches. Patient-Centered: Engage the patient in the care planning process and ensure that their values and preferences are considered. Interventions should have defined outcomes that can be evaluated for effectiveness, allowing for adjustments as Measurable: needed.  Goal: Utilize 3 coping mechanisms to help with mood regulation by the end of the hospital Outcome stay. Interventions to meet goal: Identification Provide written and verbal education to and patient on dysregulated mood by end of first day of admission Implementati Discuss possible coping mechanisms to help with dysregulated mood by end of day two on Have patient identify 3 coping mechanisms they would like to use for dysregulated mood by end of day 3 Have patient demonstrate identified coping mechanisms throughout hospital stay when experiencing dysregulated mood Criteria for Evaluation Specificity: Measurability: Achievability: Relevance: Evaluate whether the patient Outcomes should be measurable Assess whether the goals set were Evaluate the relevance of the outcomes are specific and clearly to determine the degree of realistic given the patient's goals and outcomes in relation to defined as outlined in the nursing success. Use quantitative methods conditions, lifestyle, and available the patient’s current health goals. (e.g., lab values, vital signs) and resources. Consider the timeframe condition and overall treatment Each objective should provide qualitative observations (e.g., in which goals were set to plan. clarity on what is expected. patient self-reports) for determine if they were feasible. Ensure that they align with the assessment. patient's priorities. Timeliness: Documentation: Patient Engagement: Comparison Against Consider the timeframe for Document the evaluation findings Involve the patient in the Standards: achieving goals. Were the thoroughly, including any evaluation process by soliciting Compare the patient's outcomes timelines appropriate, and were modifications needed to the care their feedback on the perceived against established clinical the evaluations conducted at the plan based on outcomes. effectiveness of the interventions standards or norms. This helps to designated intervals? Proper documentation ensures and their own progress toward determine the effectiveness of continuity of care. goals. interventions in relation to best practices. Analysis of Factors Influencing Outcomes: Analyze any external factors that may have affected the outcomes, such as support systems, psychosocial factors, or adherence to the treatment plan. Chapter 8 Therapeutic Relationships  Patient-Centered Care Nurse- Dignity and respect Patient Information sharing Patient and family participation Relationshi Collaboration in policy and program development p Clear and appropriate boundaries  The therapeutic use of self Therapeuti refers to the conscious use of one's c Use of personality, experiences, and insights as a therapeutic tool in the helping process. Self emphasizing the importance of the nurse’s self-awareness and interpersonal skills to facilitate client growth and healing. can enhance the effectiveness of treatment by creating a more meaningful and impactful therapeutic relationship. ultimately facilitating positive client outcomes.  Self-Awareness: Therapists must be aware of their own beliefs, values, feelings, and experiences. This awareness allows them to recognize how their personal characteristics can influence the therapeutic relationship. Concepts of Authenticity: Being genuine in interactions helps build trust with clients. Authenticity promotes a safe environment where clients feel comfortable Therapeuti sharing their thoughts and feelings. Empathy: The ability to understand and share the feelings of another is critical in c Use of creating a connection with clients. Empathetic responses foster a supportive atmosphere. Self Boundary Setting: Maintaining professional boundaries while still being approachable is crucial. This balance ensures that the therapeutic relationship remains focused on the client's needs. Reflection and Supervision: Engaging in reflective practice and seeking supervision can help therapists process their experiences and improve their effectiveness in using their selves in therapy. Cultural Competence: Understanding and respecting diverse backgrounds and perspectives enhances the therapeutic relationship and helps tailor interventions to meet clients' unique needs.  Refers to the professional bond between a therapist and a client, which plays a Therapeuti critical role in the c effectiveness of therapy. Relationshi ps Characterized by trust, respect, empathy, and collaboration. Key Components of Therapeutic Relationships Empathy and Support and Trust and Genuine Nonjudgment Active Understandin Collaboration: Boundaries: Encourageme Safety: Connection: al Attitude: Listening: g: nt: A foundation of Nurse/ Authentic Creates an Collaborative Essential for a Involves being Empowers trust allows Therapist communication environment process where healthy fully present, clients to clients to feel demonstrates fosters a where clients both therapist therapeutic reflecting back explore their safe in empathy by genuine can openly and client work relationship. what clients feelings, set expressing striving to connection. discuss their together Ensures the say, and goals, and their thoughts understand the Therapists are concerns towards the focus remains responding make positive and feelings. client’s encouraged to without fear of client’s goals. on the client’s thoughtfully. changes. Vital for perspective be themselves criticism or Active needs and Enhances effective and while shame. participation well-being. communication exploration of experiences. maintaining from the client and fosters issues. Helps clients professionalis is encouraged. deeper feel validated m, enhancing insights. and the rapport understood. between therapist and client. Transference Occurs when a client projects feelings, attitudes, and expectations about significant figures in their life onto the nurse/therapist. This may involve emotions related to past relationships, such as those with parents, partners, or authority figures. Examples: A client may begin to see the nurse/therapist as a parental figure and express dependency or resentment that reflects past experiences. If a client had a critical teacher, they might react to the nurse/therapist with anxiety or defensiveness even in the absence of critical comments from the therapist. Impact on Therapy: Provides valuable insights into the client’s emotional and relational patterns. It can help the nurse/therapist address unresolved issues from the client’s past, facilitating deeper exploration and healing. Countertransference Refers to the therapist's emotional reactions to the client, which can be influenced by the therapist’s own history, feelings, and unresolved issues. This may include feelings of attraction, frustration, protective instincts, or even personal biases. Examples: A therapist might feel overly protective of a client whose background mirrors their own traumatic experiences. If a therapist is reminded of someone they dislike, they may exhibit bias or withdraw emotionally from the client, potentially affecting the therapy process. Impact on Therapy: Nurses/Therapists must remain aware of their own feelings and seek supervision or consultation when countertransference issues arise to ensure they do not impede the client’s progress.  It is helpful to realize that our values and beliefs Nurse’s Reflect our own culture or subculture Derived from a range of choices Self- Chose values stem from religious, cultural, and societal forces. Awarenes Values guide us in making decisions and taking actions that we hope will make our s lives meaningful, rewarding, and fulfilled. Being self-aware helps in accepting the uniqueness and differences in others. Hildegard Peplau Developed a theoretical framework for the nurse-patient relationship that emphasizes the interpersonal aspects of nursing care. Interpersonal Relations: Emphasized the importance of communication and interpersonal relationships in nursing. The nurse's ability to connect with patients on an emotional level is essential for healing. Nurse's Role: The nurse acts not only as a caregiver but also as a resource, educator, and advocate. Nurses are expected to facilitate patient insight, coping strategies, and independence. Patient-Centered Care: Promotes a collaborative, patient-centered approach, recognizing the patient's role in their own care and recovery. Phases of the Nurse-Patient Relationship Preorientation Termination Orientation Phase: Working Phase: Phase: Phase: Researching the In this initial phase, This phase involves The relationship patient’s history both the nurse and active collaboration culminates in this Recognizing one’s the patient meet between the nurse phase, where the own thoughts and and begin to and the patient. focus is on feelings about establish a rapport. Goals for therapy evaluating progress meeting this patient The patient are identified, and and discussing the Anticipating and discusses their interventions are attainment of goals. setting ground rules needs and implemented. The nurse assists before the first concerns. The nurse supports the patient in meeting The nurse assesses the patient in preparing for the the patient's needs, exploring thoughts end of the gathers information, and feelings, relationship, and helps the fostering personal reinforcing skills patient understand growth, and learned and the purpose of the encouraging self- planning for future relationship. awareness. challenges. May be resistance to change by patient and/or family Chapter 9 Therapeutic Communication Therapeutic Communication Refers to the purposeful and professional This type of communication aims to promote interaction between a healthcare provider, a therapeutic relationship and facilitate: particularly a nurse or therapist, and a patient. Understanding Healing Support for the patient Techniques in Therapeutic Communication 1 2 3 4 5 Active Listening Empathy Open-Ended Clarification Reflection Fully concentrate on the Demonstrating Questions Seeking to understand the Mirroring back what the speaker, showing interest understanding and Asking questions that patient’s message by patient has said to help and engagement. This compassion for a patient’s encourage elaboration and asking questions or them explore their involves not only hearing feelings and experiences. discussion rather than paraphrasing their thoughts and feelings the words but also This helps validate the simple yes or no statements to ensure further. understanding the patient’s emotions and responses. accuracy. Example: "You seem to message behind them. fosters trust. Example: "Can you tell me Example: "When you say feel that no one Example: Nodding and Example: "It sounds like more about what you’ve you’re feeling blue, could understands your situation. maintaining eye contact you’re feeling really been experiencing?" you explain what that Can you tell me more while the patient talks. overwhelmed; that must means for you?" about that?“ be difficult."  Silence Allowing pauses in conversation to give patients time to think, feel, or reflect. Silence can be a powerful tool in letting patients gather their thoughts. Example: After asking a significant question, waiting patiently for the patient to respond. Techniques Focusing Directing the conversation towards specific issues or concerns, which helps in manage the flow of dialogue and keeps discussions relevant. Example: "Let’s talk more about how your medication is affecting your energy Therapeutic levels." Validation Communica Acknowledging and affirming the patient’s feelings or experiences to demonstrate understanding and acceptance. Example: "It’s perfectly normal to feel anxious in this situation, and many tion cont’d others feel the same way." Humor When appropriate, using light humor can help reduce tension and create a more relaxed environment, fostering connection and rapport. Example: Sharing a light-hearted comment about a common healthcare experience. Exploring The purpose of exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication. Example: “So tell me more about what led you to make that decision about moving out.” Techniques in Therapeutic Communication cont’d Barrier Presenting Making an Identification Empowerment Reality/Reorient Summarization Observation and Addressing ation: Recognizing and Encouraging patients an objective, non- involves providing Condensing the main addressing barriers to to take an active role judgmental statement patients with factual points of the communication, such in their care and about a patient's information or conversation to as language decision-making, behavior, appearance, clarification to help reinforce differences or cultural which fosters a sense or emotional state. them understand their understanding and beliefs, enhancing of control and This technique helps situation more ensure that the key understanding and confidence. convey interest and accurately. issues have been connection. Example: "What are awareness, facilitating Useful for patients covered. Example: "I notice your thoughts about a deeper exploration who may be Example: "So, if I that some of the this treatment option? of the patient’s experiencing understand correctly, medical terms may be Your voice is important feelings and hallucinations, you’ve been feeling confusing. Let’s go in making this experiences. delusions, or distorted anxious about your through them decision.“ Example: “I see that perceptions upcoming surgery and together." you are avoiding eye Example: “I know you concerned about contact and have a think you are seeing recovery.“ frown on your face. Is the image of a man in there something the corner, but I do bothering you?” not see anyone there.”  Factors that can affect communication Age and Cultural Language Personal Beliefs Emotional State Developmental Background Proficiency and Values Stage Influence: Different Influence: A patient's Influence: Emotions Influence: Individual Influence: cultures have distinct language proficiency such as anxiety, fear, beliefs about health, Communication styles communication styles, can affect their ability sadness, or anger can wellness, and can differ based on beliefs, and practices. to understand medical hinder effective treatment can shape age and Variations in language, terminology and communication, how patients developmental stages, gestures, and social express their making it difficult for communicate about with children, adults, norms can impact concerns. individuals to express their conditions and and elderly individuals understanding. Consideration: Use themselves clearly or respond to healthcare often requiring Consideration: simple language; to listen attentively. advice. different approaches. Cultural sensitivity is provide translation Consideration: Consideration: Consideration: crucial; healthcare services or materials Recognize and Respect and Adjust communication providers should be in the patient's address the patient’s acknowledge patients' techniques to be age- aware of cultural preferred language emotional state; beliefs and values appropriate; simplify diversity and adapt when necessary. create a supportive while providing care; explanations for their communication environment that engage in discussions children and ensure accordingly. encourages open to find common clarity for older adults. dialogue. ground. Factors that can affect communication cont’d Gender Education Level Personality Traits Experience and Health Status Previous Influence: Traits such as Interactions Influence: Past Influence: Patients with Influence: Gender can Influence: A patient's influence communication level of education can introversion, extroversion, experiences with acute or chronic health styles, preferences, and affect their understanding openness, and healthcare providers can conditions may have comfort levels in of medical information and assertiveness can affect shape a patient's difficulty concentrating or discussing personal issues their ability to engage in how individuals engage in expectations and processing information, or health concerns. discussions about their conversations and express willingness to affecting communication. health. their feelings. communicate openly. Consideration: Assess the Consideration: Be aware of potential differences in Consideration: Tailor Consideration: Adapt Consideration: Build patient’s health status and communication based on communication to match communication rapport by encouraging tailor conversations to gender and create a the patient’s approaches to feedback and discussing address their immediate respectful environment for comprehension level, accommodate different previous experiences, needs and capabilities. all patients. avoiding medical jargon personality types; for demonstrating and complex explanations. example, allow more time understanding and for introverted individuals willingness to listen. to share their thoughts. Chapter 34 Therapeutic Groups Group Group Interconnected and interdependent set of individuals who come together for a shared purpose Therapeutic Group Group of people who meet for personal development and psychological growth Group Therapy Shared purpose Mental Health Disorder DBT – Skills group for borderline personality disorder, post-traumatic stress disorder AA – group for alcohol use disorder Trauma groups Grief groups Advantages vs Disadvantages of Group Therapy Advantages Multiple members can be in treatment at the same time, thereby reaching more patients and reducing personnel costs. Members of a therapeutic group benefit from the knowledge, insights, and life experiences of both the leader and the participants. A therapeutic group can be a safe setting to learn new ways of relating to other people and to practice new communication skills. Groups can promote feelings of cohesiveness. Disadvantages Individual members may feel cheated of participation time, particularly in large groups. Concerns over privacy. Disruptive group members reduce a group’s effectiveness. Group norms may discourage personal opinions. Not all patients benefit from group treatment. Yalom’s Curative Factors Group Work Terms Group content: All that is verbalized in the group Example: The group’s topics Group process: The dynamics of interaction among the members Example: Interaction, facial expressions, body language, and progression of group work. Group norms: Expectations for behavior in the group that develop over time and provide structure Example: Rules about starting on time, not interrupting. Group themes: Members’ expressed ideas or feelings that recur and share a common thread. The leader may clarify a theme to help members recognize it more fully. Feedback: Providing group members with feedback about how they affect one another. Conflict: Open disagreement among members. Positive conflict resolution within a group is key to successful outcomes. Group Phases and Leader Group Phases Represent distinct periods or stages in the process of group development. Similar to therapeutic relationship Planning Phase Orientation Phase Working Phase Termination Phase Group Leader Specific roles and challenges to address Support of positive interaction, growth, and change. Group Phases Planning The name of the group Objectives of the group Types of individuals (e.g., diagnoses, age, gender) for inclusion Group schedule (frequency, times of meetings) Physical setting Seating configuration Description of leader and member responsibilities Methods or means of evaluating outcomes Orientation Group Forms Leader lays ground rules – respect, confidentiality, and trust Participants start to interact – may be more reserved Group Phases cont’d Working Leader facilitates communication, flow of processes, and conduct Group May revert to earlier phases with conflict Storming Disagreements, attempts at dominance, and personality conflicts addressed Leader’s ability and authority questioned Norming Personality clashes and disagreements are resolved Cooperation emerges Performing Established norms and roles Focus on achieving goals Termination Leader Summarizes accomplishments to each participant and to group as a whole Shares insights and identifies future goals Encourages positive and negative feedback from group Participants May experience grief as group comes to a close May direct feelings to other participants or the leader Roles of the Group Communication Techniques Leadership Styles Autocratic leaders Exert control over the group and do not directly encourage much interaction among members. Does not ask for feedback from group. Democratic leaders Support extensive group interaction in the process of problem solving. Lead the group, but encourage interaction and support the narrative of the group. Laissez-faire leaders Allow the group members to behave in any way they choose and do not attempt to control the direction of the group. Minimal directive from leader and allow group to be in control Chapter 35 Family Interventions Family Structure Nuclear family: Children living with two parents who are married to each other and are each the biological or adoptive parents to all the children in the family. Single-parent family: Children living with a single adult of either gender. Unmarried biological or adoptive family: Children living with two unmarried parents who are the biological/adoptive parents to all the family’s children. Blended family/stepfamily: Children living with one biological/adoptive parent and that parent’s spouse. Cohabitating family: Children living with one biological/adoptive parent and that parent’s unmarried cohabitating partner. Extended family: Children living with at least one biological/adoptive parent and at least one related nonparent adult (age 18 or older), such as a grandparent or adult sibling. Grandparent family: Children living with one or more grandparents. Childless family: Consists of partners living together and working together. They may have extensive involvement with pets and children of siblings and friends. “Other” family: Children living with related or unrelated adults who are not biological or adoptive parents. This includes children living with grandparents and foster families. Family Functions: Management Management Typically, parent(s) Make decisions Power Resource allocation Rule-making Finances Can be overwhelming, especially in single-parent families or in dysfunctional families Family Functions: Boundaries Boundaries Defined as limit setting Three types: Clear, Diffuse, and/or Rigid Clear Adaptive and healthy All family members understand expectations Firm, but flexible Provide structure that responds and adapts to change Diffuse Unclear and lack independence Families have difficulty with defining themselves Co-dependency on each other No one is in a place of authority Differentiation Discourage self-identity Discourage members from providing their opinion Parent/child relationship blurry Group think mentality Rigid Adherence to expectations No room for discussion or change Disengaged family members Difficulty with insight into feelings due to rigid structure Dysfunctional Communication Manipulating Action designed to influence or control another person Usually underhanded or unfair manner Distracting Add additional information that is not relevant Used to diffuse conflict Generalizing Global statements Used to no apply blame to anyone, but address the topic in an unspecified way Blaming Place accountability on others instead of self Placating Appease or pacify to avoid conflict Family Therapy Concepts Identified patient Regarded as the “problem” Focus of the family’s concern May be used to divert attention from ignored/hidden problem Behavior violates boundaries Triangulation Third person brought into the problem Can be seen as manipulation Two against one mentality Causes splitting Family Dynamics Terms Risk vs Benefit of Family Therapy Risk Not beneficial if there is risk for harm, physically or emotionally Benefits Reduce dysfunctional behaviors Resolve/reduce intrafamily relationship conflicts Mobilize family resources Problem-solving Increase awareness and sensitivity Coping mechanisms Improve integration of family system and society Promote appropriate psychosocial development of members