NURS 3500 Module 2 Active Learning Guide (Sean Whitfield)

N3500 Psychiatric and Mental Health Nursing Module 2 Active Learning Guide Chapter 2 Biological Implications Chapter 5 Relationship Development and Therapeutic Communication Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentra...

N3500 Psychiatric and Mental Health Nursing Module 2 Active Learning Guide Chapter 2 Biological Implications Chapter 5 Relationship Development and Therapeutic Communication Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentrate on applying and analyzing knowledge to provide a context concerning the course and career skills. Students should review the active learning guide before engaging with the module content, then work to complete the guide both during and after engaging with the content. An active learning guide is not the same as a study guide or a test blueprint. It serves as a guide to help the student navigate the course and content. The active learning guide is not a complete composite of the information needed for the exam but a guide to navigating the content delivery. The F.A. Davis Personalized Teaching Plans (PTPs) that are included in the F.A. Davis website will also help learners grasp the material. They are interactive and thorough. Instructions The learner should review the active learning guide before reading and engaging with other content in the module. Looking at the questions beforehand, the student should preview the information, including the key concepts and takeaways. While working through the module content, one should complete the active learning guide. Some questions may be reflective and require finishing all content before providing a response. Students will turn in the completed learning guide at the conclusion of the module. Faculty will review and award points and return them to the student to review prior to the exam. There are 10 points possible for this learning guide. Reading Focus Areas 1. Describe how psychological factors influence the immune system. Psychoneuroimmunology (PNI) Normal Immune Response Cells responsible for nonspecific immune reactions include neutrophils, monocytes, and macrophages. They work to destroy the invasive organism and initiate and facilitate healing of damaged tissue. If these cells are not effective in accomplishing a satisfactory healing response, specific immune mechanisms take over. Cytokines are one such mechanism. These molecules, which regulate immune and inflammatory responses, are active when an individual is fighting an infection or any other condition that creates inflammation in the body. Research has demonstrated that cytokines are part of an essential and complex system of responses that are crucial for reducing inflammation and bolstering the immune response, and they are active in mood disorders such as depression and bipolar disorder (Mao et al., 2018). Studies are also attempting to identify what happens when inflammation is not resolved and when cytokines remain active or cross the blood-brain barrier; there is evidence that these maladaptations may trigger a multitude of illnesses (Ratnayake et al., 2013). Implications of the Immune System in Psychiatric Illness Studies of the biological response to stress (Salleh, 2008) have shown that individuals become more susceptible to physical illness following exposure to a stressful stimulus or life event (see Chapter 1, N3500 Psychiatric and Mental Health Nursing “Mental Health and Mental Illness”). This response is thought to be due to the effect of increased glucocorticoid release from the adrenal cortex following stimulation from the hypothalamic-pituitaryadrenal axis during stressful situations (“axis” refers to the complex interactions among these three glands). The result is a suppression in lymphocyte proliferation and function. Studies have shown that nerve endings exist in tissues of the immune system (Dantzer, 2018). The CNS has connections in both bone marrow and the thymus, where immune system cells are produced, and in the spleen and lymph nodes, where those cells are stored. GH, which may be released in response to certain stressors, may enhance immune functioning, whereas testosterone is thought to inhibit immune functioning. Increased production of epinephrine and norepinephrine occurs in response to stress and may decrease immunity. Serotonin has been described as an immunomodulatory because it has demonstrated both enhancing and inhibitory effects on inflammation and immunity (Arreola et al., 2015). Studies have correlated a decrease in lymphocyte functioning with periods of grief, bereavement, and depression, associating the degree of altered immunity with severity of the depression (Buckley et al., 2012; Pasco et al., 2010). A number of research studies have been conducted attempting to correlate the onset of schizophrenia to abnormalities of the immune system. These studies have considered autoimmune responses, viral infections, and immunogenetics (Boland & Verduin, 2022). A link has been identified between toxoplasmosis and psychiatric disorders such as schizophrenia, bipolar disorder, and suicidal/aggressive behaviors (Del Grande et al., 2017). Toxoplasma gondii, the parasite responsible for toxoplasmosis, has an affinity for brain tissue where it causes brain inflammation and may affect neurotransmitters such as dopamine. Immunological abnormalities have also been investigated in a number of other psychiatric illnesses, including alcoholism, ASD, and neurocognitive disorder. Psychopharmacology and the Brain Understanding the brain and the biological processes involved in thinking, feeling, and behaving has positive ramifications beyond better understanding of psychopharmacological treatment options. As mentioned earlier, future research may continue to demonstrate the impact of psychological interventions on brain activity and neurotransmitters, which would open opportunities to hone psychological treatments and avoid some of the troubling side effects that accompany many medications. Furthermore, continued research in areas such as psychoneuroimmunology may reveal causes of mental illness, which would provide the opportunity for primary prevention. In spite of these potential opportunities, psychopharmacology remains a primary treatment modality for mental disorders, and current evidence suggests that early medication treatment of schizophrenia at the first signs of psychosis may prevent the damaging effects of multiple psychotic episodes on the brain (Nasrallah, 2018). Understanding, as best we can with current evidence, the biological mechanisms at work in psychoactive drugs is essential to nursing practice. See Chapter 4, “Psychopharmacology,” for further discussion of the influence of psychoactive drugs on neurosynaptic transmission. Implications for Nursing Psychiatric mental health nurses must integrate knowledge of the biological sciences into their practices if they are to ensure safe and effective care for people with mental illness. Much progress has been made in understanding the biochemical, neuroanatomical, and genetic influences in mental illness, but much remains theoretical. Further, there is evidence that psychosocial influences, particularly a history of trauma such as abuse and neglect, interact significantly with an individual’s biological vulnerabilities in the development of these illnesses. N3500 Psychiatric and Mental Health Nursing To ensure a smooth transition from a strictly psychosocial focus to one of biopsychosocial emphasis, nurses must have a clear understanding of the following:  Neuroanatomy and neurophysiology: The structure and functioning of the various parts of the brain and their correlation to human behavior and psychopathology.  Neuronal processes: The various functions of the nerve cells, including the role of neurotransmitters, receptors, synaptic activity, and informational pathways.  Neuroendocrinology: The interaction of the endocrine and nervous systems and the role that the endocrine glands and their respective hormones play in behavioral functioning.  Circadian rhythms: The regulation of biochemical functioning over periods of rhythmic cycles and its influence in predicting certain behaviors.  Genetic influences: The hereditary factors that predispose individuals to certain psychiatric disorders.  Psychoneuroimmunology: The influence of stress on the immune system and its role in the susceptibility to illness.  The impact of trauma: Both physical trauma (traumatic brain injury) and psychosocial trauma (especially early childhood trauma such as abuse, neglect, and abandonment) are influential in the development of several mental illnesses. (See Chapters 12, 19, and 28 for further discussion of trauma and trauma-informed care.)  Psychopharmacology: The widespread use of psychotropic drugs in the treatment of mental illness demands knowledge of psychopharmacological principles and nursing interventions necessary for safe and effective management.  Diagnostic technology: The importance of keeping informed about the latest in technological procedures for diagnosing alterations in brain structure and function. Fill in the Blanks to complete the sentence: 2. Psychotropic medications act at the neural synapse to affect neurotransmitter activity and have been associated with improvement in symptoms of many mental disorders. Summary and Key Points  It is important for nurses to understand the interaction between biological and behavioral factors in the development and management of mental illness.  Psychobiology is the study of the biological foundations of cognitive, emotional, and behavioral processes.  The limbic system has been called the “emotional brain.” It is associated with feelings of fear and anxiety; anger, rage, and aggression; love, joy, and hope; and sexuality and social behavior. N3500 Psychiatric and Mental Health Nursing  The three classes of neurons include afferent (sensory), efferent (motor), and interneurons. The junction between two neurons is called a synapse.  Neurotransmitters are chemicals that convey information across synaptic clefts to neighboring target cells. Many neurotransmitters have implications in the etiology of emotional disorders and in the pharmacological treatment of those disorders.  Major categories of neurotransmitters include cholinergic neurotransmitters, monoamines, amino acids, and neuropeptides.  The endocrine system plays an important role in human behavior through the hypothalamic-pituitary-adrenal axis.  Hormones and their circadian rhythm of regulation significantly influence a number of physiological and psychological life-cycle phenomena, such as moods, sleep and arousal, stress response, appetite, libido, and fertility.  Research continues to validate the role of genetics in mental illness.  Familial, twin, and adoption studies suggest that genetics may be implicated in the etiology of schizophrenia, bipolar disorder, depressive disorder, panic disorder, anorexia nervosa, alcoholism, and OCD. Genetics studies, however, fail to entirely explain the complex factors involved in the development of mental disorders.  Psychoneuroimmunology (PNI) examines the relationship between psychological factors, the immune system, and the nervous system.  Evidence exists to support a link between psychosocial stressors and suppression of the immune response.  Technologies such as magnetic resonance imaging (MRI), computed tomographic (CT) scan, positron emission tomography (PET), and electroencephalography (EEG) are used as diagnostic tools for detecting alterations in psychobiological functioning.  Psychotropic medications act at the neural synapse to affect neurotransmitter activity and have been associated with improvement in symptoms of many mental disorders.  Integrating knowledge of the expanding biological focus into psychiatric nursing is essential if nurses are to meet the changing needs of today’s psychiatric clients. 3. Complete the table: N3500 Psychiatric and Mental Health Nursing Influencers in the Development of Psychiatric Disorders Brain Physiology Etiologies Acetylcholine Example Decreased levels: Alzheimer’s disease, Huntington’s disease, Parkinson’s disease Increased levels: Depression Genetics Risk factors for early-onset Alzheimer’s disease have been linked to mutations on chromosomes 21, 14, and 1 (National Institute on Aging, 2019). Other studies have linked a gene in the region of chromosome 19 that produces apolipoprotein E with late-onset Alzheimer’s disease. One large study (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013) found similar genetic variations in five mental health disorders that were previously considered completely distinct. These disorders—ASD, attention deficithyperactivity disorder (ADHD), bipolar disorder, major depression, and schizophrenia—all showed some common gene variations, including differences in two genes that regulate the flow of calcium into cells. Endocrine Function Antidiuretic Hormone→ The main function of antidiuretic hormone (ADH) is to conserve body water and maintain normal blood pressure. The release of ADH is stimulated by pain, emotional stress, dehydration, increased plasma concentration, and decreases in blood volume. Polydipsia; altered pain response; modified sleep pattern Immune system Response to stress→ increased glucocorticoid release from the adrenal cortex following stimulation from the hypothalamicpituitary-adrenal axis during Depression. Anxiety disorders. PTSD. N3500 Psychiatric and Mental Health Nursing Influencers in the Development of Psychiatric Disorders Etiologies Example stressful situations. Psychosocial Factors Evidence exists to support a correlation between psychosocial stress and the onset of illness. More research is needed to determine the specific processes involved in stressinduced modulation of the immune system. there is evidence that psychosocial influences, particularly a history of trauma such as abuse and neglect, interact significantly with an individual’s biological vulnerabilities in the development of these illnesses. Depression. Anxiety disorders. PTSD. Environmental Factors Melanocyte-Stimulating Hormone → The release of melatonin appears to depend on the onset of darkness and is suppressed by light. Studies of this hormone have indicated that environmental light can affect neuronal activity and influence circadian rhythms (Marcheva et al., 2013). Correlation between abnormal secretion of melatonin and symptoms of depression has led to the implication of melatonin in the etiology of seasonal affective disorder, in which individuals become depressed only during the fall and winter months when the amount of daylight decreases. 4. Why is it important for the professional nurse to understand psychobiological concepts of psychiatric mental health nursing? The interrelationship between psychosocial adaptation and physical functioning has been established. Integrating biological and behavioral concepts into psychiatric nursing practice is essential for nurses to meet the complex needs of patients with mental illness. Psychobiological perspectives must be incorporated into nursing practice, education, and research to attain evidence-based outcomes necessary for the delivery of competent care. 5. Describe the therapeutic nurse-patient relationship. N3500 Psychiatric and Mental Health Nursing The Therapeutic Nurse-Patient Relationship Therapeutic nurse-patient relationships are goal oriented. Ideally, the goal is mutually agreed on by the nurse and patient and is directed at learning and growth promotion. Travelbee (1971), who expanded on Peplau’s theory of interpersonal relations in nursing, stated that it is only when each individual in the interaction perceives the other as a human being that a relationship is possible. She refers not to a nurse-patient relationship but to a human-to-human relationship, which she describes as a “mutually significant experience.” That is, both the nurse and the recipient of care have needs met when each views the other as a unique human being, not as “an illness,” “a room number,” or “all nurses” in general. Therapeutic relationships are goal oriented. Ideally, the nurse and patient decide together what the goal of the relationship will be. Most often, the goal is directed at learning and growth promotion in an effort to bring about some type of change in the patient’s life. In general, the goal of a therapeutic relationship may be based on a problem-solving model. Ex. Goal The patient will demonstrate more adaptive coping strategies for dealing with (specific life situation). Intervention Identify what is troubling the patient at this time. Encourage the patient to discuss changes the patient would like to make. Discuss with the patient which changes are possible and which are not possible. Have the patient explore feelings about aspects that cannot be changed and alternative ways of coping more adaptively. Discuss alternative strategies for creating changes the patient desires to make. Weigh the benefits and consequences of each alternative. Assist the patient to select an alternative. Encourage the patient to implement the change. Provide positive feedback for the patient’s attempts to create change. Assist the patient to evaluate outcomes of the change and make modifications as required. Therapeutic Use of Self Travelbee (1971) described the instrument for delivery of the process of interpersonal nursing as the therapeutic use of self, which she defined as “the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions” (p. 19). Use of the self in a therapeutic manner requires that the nurse have a great deal of self-awareness and self-understanding, having arrived at a philosophical belief about life, death, and the overall N3500 Psychiatric and Mental Health Nursing human condition. The nurse must understand that the ability to, and the extent to which one can, effectively help others in time of need is strongly influenced by this internal value system—a combination of intellect and emotions. Conditions Essential to Development of a Therapeutic Relationship Rapport Getting acquainted and establishing rapport are the primary tasks in relationship development. Rapport implies special feelings on the part of both the patient and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non–health-related topics. Travelbee (1971) states, [To establish rapport] is to create a sense of harmony based on knowledge and appreciation of each individual’s uniqueness. It is the ability to be still and experience the other as a human being —to appreciate the unfolding of each personality one to the other. The ability to truly care for and about others is the core of rapport. Trust To trust another, one must feel confidence in that person’s presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested. As discussed in Chapter 29, “Concepts of Personality Development,” available online at fadavis.com, trust is the initial developmental task described by Erikson. If the task has not been achieved, this component of relationship development becomes more difficult. That is not to say that trust cannot be established but only that additional time and patience may be required on the part of the nurse. Trust cannot be presumed; it must be earned. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the patient. These interventions are initiated simply and concretely and are directed toward activities that address the patient’s basic needs for physiological and psychological safety and security. Psychiatric patients with thought disorders, such as schizophrenia, may also have difficulty thinking abstractly (a symptom called concrete thinking) so it becomes even more important that the nurse communicate and behave in a simple, concrete manner to promote the development of trust.  Examples of nursing interventions that would promote trust in an individual who is thinking concretely include the following:  Providing a blanket when the patient is cold  Providing food when the patient is hungry  Keeping promises  Being honest (e.g., saying, “I don’t know the answer to your question, but I’ll try to find out”) and then following through  Simply and clearly providing reasons for certain policies, procedures, and rules  Providing a written, structured schedule of activities  Attending activities with the patient who is reluctant to go alone  Being consistent in adhering to unit guidelines N3500 Psychiatric and Mental Health Nursing  Listening to the patient’s preferences, requests, and opinions and making collaborative decisions concerning care Trust is the basis of a therapeutic relationship. The nurse working in psychiatry must perfect the skills that foster the development of trust. Trust must be established in order for the nurse-patient relationship to progress beyond the superficial level of tending to the patient’s immediate needs. Ensuring confidentiality; providing reassurance that what is discussed will not be repeated outside the boundaries of the health-care team Respect To show respect is to believe in the dignity and worth of an individual regardless of unacceptable behavior. The psychologist Carl Rogers called this unconditional positive regard (Raskin et al., 2014). The attitude is nonjudgmental, and the respect is unconditional in that it does not depend on the behavior of the patient to meet certain standards. The nurse, in fact, may not approve of the patient’s lifestyle or pattern of behaving. However, with unconditional positive regard, patients are accepted and respected for no other reason than that they are considered to be worthwhile and unique human beings. Many psychiatric patients have very little self-respect. Lack of self-respect may be related to the low self-esteem that accompanies illnesses such as clinical depression or it may be related to rejection and stigmatization by others. Recognition that patients are being accepted and respected as unique individuals on an unconditional basis can serve to elevate feelings of self-worth and selfrespect. The nurse can convey an attitude of respect in the following ways:  Calling the patient by their preferred name, pronouns, and title  Spending time with the patient  Allowing for sufficient time to answer the patient’s questions and concerns  Promoting an atmosphere of privacy during therapeutic interactions with the patient or when the patient may be undergoing physical examination or therapy  Always being open and honest with the patient, even when the truth may be difficult to discuss  Listening to the patient’s ideas, preferences, and requests, and making collaborative decisions concerning his or her care whenever possible  Striving to understand the motivation behind the patient’s behavior, regardless of how unacceptable it may seem Genuineness The concept of genuineness refers to the nurse’s ability to be open, honest, and “real” in interactions with the patient. To be real is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be apparent in the therapeutic relationship. When one is genuine, there is congruence between what is felt and what is being expressed (Raskin et al., 2014). The nurse who possesses the quality of genuineness responds to the patient with truth and honesty rather than with responses that may be considered more “professional” or that merely reflect the “nursing role.” N3500 Psychiatric and Mental Health Nursing Genuineness may call for a degree of self-disclosure on the part of the nurse. This is not to say that the nurse must disclose to the patient every feeling or all personal experiences that may relate to what the patient is going through. Indeed, care must be taken when using self-disclosure to avoid reversing the roles of the nurse and patient. For example, when a patient tells the nurse “I just get so upset when someone disrespects me, sometimes you just have to smack someone to teach them a lesson,” the nurse might respond, “I get upset by that, too. Let’s talk about some different ways to respond to this anger rather than hitting someone.” In this example the nurse acknowledges a common feeling while maintaining a focus on the patient’s need for problem-solving. When the nurse uses self-disclosure, a quality of “humanness” is revealed to the patient, creating a role for the patient to model in similar situations. The patient may then feel more comfortable revealing personal information to the nurse. Most individuals have an uncanny ability to detect other people’s artificiality. When the nurse does not bring the quality of genuineness to the relationship, a reality base for trust cannot be established. These qualities are essential to helping the patient actualize their potential within the nurse-patient relationship and for change and growth to occur (Raskin et al., 2014). Empathy Empathy is the ability to see beyond outward behavior and to understand the situation from the patient’s point of view. With empathy, the nurse can accurately perceive and understand the meaning and relevance of the patient’s thoughts and feelings. The nurse must also be able to communicate this perception to the patient by attempting to translate words and behaviors into feelings. It is not uncommon for the concept of empathy to be confused with that of sympathy. The major difference is that with empathy the nurse “accurately perceives or understands” what the patient is feeling and encourages the patient to explore these feelings. With sympathy the nurse actually becomes emotionally involved in what the patient is feeling and experiences a need to alleviate distress. Empathy is considered to be one of the most important characteristics of a therapeutic relationship. Accurate empathetic perceptions on the part of the nurse assist the patient to identify feelings that may have been suppressed or denied. Positive emotions are generated as the patient realizes the feeling of being understood by another. As the feelings surface and are explored, the patient learns aspects of self about which they may have been unaware. This exploration contributes to the process of self-awareness and the promotion of positive self-concept. With empathy, while understanding the patient’s thoughts and feelings, the nurse is able to maintain sufficient objectivity to allow the patient to achieve problem resolution with minimal assistance. With sympathy, the nurse actually feels what the patient is feeling, objectivity is lost, and the nurse may become focused on relief of personal distress rather than on helping the patient resolve the problem at hand. The following example describes an empathetic and sympathetic response to the same situation. Rapport, trust, respect, genuineness, and empathy all are essential to forming therapeutic relationships, and they can certainly be assets in social relationships, too. The primary differences between social and therapeutic relationships are that therapeutic relationships always remain focused on the health-care needs of the patient, they are never for the purpose of addressing the nurse’s personal needs, and they progress through identified phases of development for the purpose of helping the patient to solve health-related problems. Phases of a Therapeutic Nurse-Patient Relationship N3500 Psychiatric and Mental Health Nursing Psychiatric nurses use interpersonal relationship development as the primary intervention with patients in various psychiatric mental health settings. Developing an interpersonal relationship with the patient is congruent with Peplau’s (1962) identification of counseling as the major subrole of nursing in psychiatry. Sullivan (1953), after whom Peplau patterned her own interpersonal theory of nursing, strongly believed that many emotional problems were closely related to difficulties with interpersonal relationships. With this concept in mind, this role of the nurse in psychiatry becomes especially meaningful and purposeful —an integral part of the total therapeutic regimen. The therapeutic interpersonal relationship is the means by which the nursing process is implemented. Through the relationship, problems are identified and resolution is sought. Tasks of the relationship have been categorized into four phases:  Preinteraction phase → Explore self-perceptions Obtaining available information about the patient from their chart, significant others, or other health team members. From this information, the initial assessment is begun. This initial information may also allow the nurse to become aware of personal responses to knowledge about the patient. Examining one’s feelings, fears, and anxieties about working with a particular patient. For example, the nurse may have been reared in an alcoholic family and have ambivalent feelings about caring for a patient who is alcohol dependent. All individuals bring attitudes and feelings from prior experiences to the clinical setting. The nurse needs to be aware of how these preconceptions may affect their ability to care for individual patients.  Orientation (introductory) phase → Establish trust and formulate contract for intervention During the orientation phase, the nurse and patient become acquainted. Tasks include the following: Creating an environment for the establishment of trust and rapport Establishing a contract for intervention that details the expectations and responsibilities of both the nurse and patient Gathering assessment information to build a strong patient database Identifying the patient’s strengths and limitations Formulating nursing diagnoses Setting goals that are mutually agreeable to the nurse and patient Developing a plan of action that is realistic for meeting the established goals Exploring feelings of both the patient and nurse in terms of the introductory phase Introductions often are uncomfortable, and the participants may experience some anxiety until a degree of rapport has been established. Interactions may remain on a superficial level until anxiety subsides. Several interactions may be required to fulfill the tasks associated with this phase.  Working phase → Promote patient change N3500 Psychiatric and Mental Health Nursing The therapeutic work of the relationship is accomplished during this phase. Tasks include the following: Maintaining the trust and rapport that was established during the orientation phase Promoting insight and perception of reality Problem-solving using the model presented earlier in this chapter Overcoming resistance behaviors as the level of anxiety rises in response to discussion of painful issues Continuously evaluating progress toward goal attainment  Termination phase → Evaluate goal attainment and ensure therapeutic closure Termination of the relationship may occur for a variety of reasons: the mutually agreed-on goals may have been reached; the patient may be discharged from the hospital; or, in the case of a student nurse, it may be the end of a clinical rotation. Termination can be a difficult phase for both the patient and nurse. The main task involves bringing a therapeutic conclusion to the relationship. The relationship concludes when the following occur: Progress has been made toward attainment of mutually set goals. A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and patient. Feelings about termination of the relationship are recognized and explored. Both the nurse and patient may experience feelings of sadness and loss. The nurse should share feelings with the patient. Through these interactions, the patient learns that it is acceptable to have these feelings at a time of separation. Through this knowledge, the patient experiences growth during the process of termination. This is also a time when both nurse and patient may evaluate and summarize the learning that occurred as an outgrowth of their relationship. 6. List the preexisting conditions that affect communication. Which 2 do you think are the most important? Why? The Impact of Pre-existing Conditions Values, Attitudes, and Beliefs Values, attitudes, and beliefs are learned ways of thinking. Children generally adopt the value systems and internalize the attitudes and beliefs of their parents. Children may retain this way of thinking into adulthood or develop a different set of attitudes and values as they mature. Values, attitudes, and beliefs can influence communication in numerous ways. For example, prejudice is expressed verbally through negative stereotyping. One’s value system may be communicated with behaviors that are more symbolic in nature. For example, an individual who values youth may dress and behave in a manner that is characteristic of one who is much younger. Persons who value socioeconomic status may choose large homes, luxury cars, and other expensive personal possessions. In each of these situations, a message is being communicated. Culture and Religion N3500 Psychiatric and Mental Health Nursing Communication has its roots in culture. Cultural mores, norms, ideas, and customs provide the basis for our way of thinking. Cultural values are learned and differ from society to society. For example, in some European countries (e.g., Italy, Spain, and France), men may greet each other with hugs and kisses; in the United States or England, shaking hands is a more culturally accepted style of greeting among men. Religion also can influence communication. Priests and ministers who wear clerical collars publicly communicate their mission in life. The collar also may influence the way in which others relate to them, either positively or negatively. Other symbolic gestures, such as wearing a cross around the neck or wearing a hijab (a religious veil worn by some Muslim women in public), also communicate an individual’s religious beliefs. Social Status Studies of nonverbal indicators of social status or power have suggested that high-status persons are associated with gestures that communicate their higher-power position (Hall et al., 2005; Ridgeway et al., 1985). For example, they use more eye contact, have a more erect and open posture, use louder voice pitch, and talk more, dress more formally, and interact at closer interpersonal distance. Gender Gender influences the manner in which individuals communicate. Most cultures have gender signals that are recognized as either masculine or feminine and provide a basis for distinguishing between members of each gender. Examples include differences in posture, both standing and sitting, between many men and women. In the United States, generally, men tend to expand in their physical space, whereas women are more likely to cross legs and arms and reduce their physical space. Men tend to lean away from a speaker, whereas women are more likely to lean toward a speaker and use more eye contact (Valamis, 2021). It should be reinforced, though, that these are generalizations rather than absolute differences. Roles have historically been identified as either male or female. For example, in the United States, masculinity typically was communicated through such roles as husband, father, breadwinner, doctor, lawyer, and engineer. Traditional female roles included wife, mother, homemaker, nurse, teacher, and secretary. Gender signals are changing in U.S. society as gender roles become less distinct. Behaviors that once were considered typically masculine or feminine may now be generally accepted in members of both genders. Words such as nonbinary communicate a desire by some individuals to diminish the distinction between the genders and minimize the discrimination of either. Gender roles are changing as both women and men enter professions that once were dominated by members of the opposite gender. Age or Developmental Level Age influences communication, and it is especially evident during adolescence. In their struggle to separate from parental confines and establish their own identity, adolescents generate a unique pattern of communication that changes from generation to generation. Words such as dude, dope, lit, and wasted have had special meaning for different generations of adolescents. The technological age has produced a whole new language for today’s adolescents. Communication by N3500 Psychiatric and Mental Health Nursing text messaging includes such acronyms as BRB (“be right back”), BFF (“best friends forever”), and YOLO (“you only live once”). Developmental physiological alterations may also influence communication. For people who are deaf or hearing impaired, American Sign Language may be their preferred method of communication. Individuals who are blind at birth never learn the subtle nonverbal gestures that typically accompany language and can totally change the meaning of the spoken word. Environment in Which the Transaction Takes Place The place where the communication occurs influences the outcome of the interaction. Some individuals who feel uncomfortable and refuse to speak during a group therapy session may be open and willing to discuss problems privately with the nurse. Territoriality, density, and distance are aspects of environment that communicate messages. Territoriality is the innate tendency to own space. Individuals lay claim to areas around them as their own. This influences communication when an interaction takes place in the territory “owned” by one or the other. Interpersonal communication can be more successful if the interaction takes place in a “neutral” area. For example, with the concept of territoriality in mind, the nurse may choose to conduct the psychosocial assessment in an interview room rather than in an office or in the patient’s room. Density refers to the number of people within a given environmental space, and it has been shown to influence interpersonal interaction. Some studies indicate that a correlation exists between prolonged high-density situations and certain behaviors, such as aggression and withdrawal, but Regoeczi (2002) identifies support for the notion that this relationship is nonlinear based on variation in individual self-selected behaviors. Distance is the means by which various cultures use space to communicate. Hall (1966) identified four kinds of spatial interaction, or distances, that people maintain from each other in their interpersonal interactions and the kinds of activities in which people engage at these various distances.  Intimate distance is the closest distance that individuals will allow between themselves and others. In the United States, this distance, which is restricted to interactions of an intimate nature, is 0 to 18 inches.  Personal distance is approximately 18 to 40 inches and is reserved for interactions that are personal in nature, such as close conversations with friends or colleagues.  Social distance is about 4 to 12 feet away from the body. Interactions at this distance include conversations with strangers or acquaintances, such as at a cocktail party or in a public building.  Public distance is one that exceeds 12 feet. Examples include speaking in public or yelling to someone some distance away. This distance is considered public space, and communicants are free to move about in it during the interaction. 7. Define territoriality, density, and distance. Territoriality (Territory) → is the innate tendency to own space. Individuals lay claim to areas around them as their own. This influences communication when an interaction takes place in the N3500 Psychiatric and Mental Health Nursing territory “owned” by one or the other. Interpersonal communication can be more successful if the interaction takes place in a “neutral” area. For example, with the concept of territoriality in mind, the nurse may choose to conduct the psychosocial assessment in an interview room rather than in an office or in the patient’s room. Density → refers to the number of people within a given environmental space, and it has been shown to influence interpersonal interaction. Some studies indicate that a correlation exists between prolonged high-density situations and certain behaviors, such as aggression and withdrawal, but Regoeczi (2002) identifies support for the notion that this relationship is nonlinear based on variation in individual self-selected behaviors. Distance → is the means by which various cultures use space to communicate. Hall (1966) identified four kinds of spatial interaction, or distances, that people maintain from each other in their interpersonal interactions and the kinds of activities in which people engage at these various distances.  Intimate distance → is the closest distance that individuals will allow between themselves and others. In the United States, this distance, which is restricted to interactions of an intimate nature, is 0 to 18 inches.  Personal distance → is approximately 18 to 40 inches and is reserved for interactions that are personal in nature, such as close conversations with friends or colleagues.  Social distance → is about 4 to 12 feet away from the body. Interactions at this distance include conversations with strangers or acquaintances, such as at a cocktail party or in a public building.  Public distance → is one that exceeds 12 feet. Examples include speaking in public or yelling to someone some distance away. This distance is considered public space, and communicants are free to move about in it during the interaction. 8. What are the components of non-verbal expression? Nonverbal Communication Various studies have identified nonverbal communication as more reliable than verbal communication in expressing one’s attitudes and feelings, and some describe it as the single most powerful way in which communication occurs (Heathfield, 2019). Some aspects of nonverbal expression were discussed in the previous section on pre-existing conditions that influence communication. Other components of nonverbal communication include physical appearance and dress, body movement and posture, touch, facial expressions, eye behavior, and vocal cues or paralanguage (such as intonation, pitch, and speed; a more detailed description follows). These nonverbal messages vary from culture to culture. Physical Appearance and Dress Physical appearance and dress are part of the total nonverbal stimuli that influence interpersonal responses, and, under some conditions, they are the primary determinants of such responses. Body coverings—both dress and hair—are manipulated by the wearer in a manner that conveys a distinct message to the receiver. Dress can be formal or casual, stylish or unkempt. Hair can be long or short, and even the presence or absence of hair conveys a message about the person. Other body adornments that are considered potential communicative stimuli include tattoos, masks, N3500 Psychiatric and Mental Health Nursing cosmetics, badges, jewelry, and eyeglasses. Some jewelry worn in specific ways can give special messages (e.g., a gold band or diamond ring worn on the fourth finger of the left hand, a pin bearing Greek letters worn on the lapel, or the wearing of a ring that is inscribed with the insignia of a college or university). Some individuals convey a specific message with the total absence of any type of body adornment. Body Movement and Posture The way in which an individual positions his or her body communicates messages regarding selfesteem, gender identity, status, and interpersonal warmth or coldness. The individual whose posture is slumped, with head and eyes pointed downward, conveys a message of low self-esteem. Specific ways of standing or sitting are considered to be either feminine or masculine within a defined culture. To stand straight and tall with head high and hands on hips indicates a superior status over the person being addressed. Reece and Whitman (1962) identified response behaviors that were used to designate individuals as either “warm” or “cold” persons. Individuals who were perceived as warm responded to others with a shift of posture toward the other person, a smile, direct eye contact, and hands that remained still. Individuals who responded to others with a slumped posture, by looking around the room, drumming fingers on the desk, and not smiling were perceived as cold. Touch Functional-professional → This type of touch is impersonal and businesslike. It is used to accomplish a task.  Ex: A tailor measuring a customer for a suit or a physician examining a patient Social-polite → This type of touch is still rather impersonal, but it conveys an affirmation or acceptance of the other person.  Ex: A handshake Friendship-warmth → Touch at this level indicates a strong liking for the other person—a feeling of friendship.  Ex: Laying one’s hand on the shoulder of another Love-intimacy → This type of touch conveys an emotional attachment or attraction to another person.  Ex: Engaging in a strong, mutual embrace Sexual arousal → Touch at this level is an expression of physical attraction only.  Ex: Caressing or touching another with intent to create sexual arousal Facial Expressions Next to human speech, facial expression is the primary source of communication. Facial expressions primarily reveal an individual’s emotional states, such as happiness, sadness, anger, surprise, and fear. The face is a complex multi-message system. Facial expressions serve to complement and qualify other communication behaviors and at times even take the place of verbal N3500 Psychiatric and Mental Health Nursing messages. A summary of feelings associated with various facial expressions is presented in Table 5– 2. TABLE 5-2 Summary of Facial Expressions FACIAL EXPRESSION ASSOCIATED FEELINGS NOSE Nostril flare Anger; arousal Wrinkling up Dislike; disgust Lips Grin; smile Happiness; contentment Grimace Fear; pain Compressed Anger; frustration Canine-type snarl Disgust Pouted; frown Unhappiness; discontented; disapproval Disagreement Pursing Contempt; disdain Sneer BROWS Frown Anger; unhappiness; concentration Surprise; enthusiasm Raised TONGUE Stick out Dislike; disagree EYES Widened Surprise; excitement Narrowed; lids squeezed shut Threat; fear Stare Threat Stare, blink, then look away Dislike; uninterest Eyes downcast; lack of eye contact Submission; low self-esteem N3500 Psychiatric and Mental Health Nursing Eye contact (generally intermittent as opposed to a Self-confidence; interest stare) Eye Behavior Eyes have been called the “windows of the soul.” It is through eye contact that individuals view and are viewed by others in a revealing way, creating an interpersonal connection. In American culture, eye contact conveys a personal interest in the other person. Eye contact indicates that the communication channel is open, and it is often the initiating factor in verbal interaction between two people. Eye behavior is regulated by social rules. These rules dictate where, when, for how long, and at whom we can look. Staring is often used to register disapproval of the behavior of another. People are extremely sensitive to being looked at, and if the gazing or staring behavior violates social rules, they often assign meaning to it, such as the following statement implies: “He kept staring at me, and I began to wonder if I was dressed inappropriately or had mustard on my face!” 9. Differentiate therapeutic vs nontherapeutic communication techniques. Therapeutic Communication Techniques Hays and Larson (1963) identified a number of techniques to assist the nurse in interacting more therapeutically with patients. These are important “technical procedures” carried out by the nurse working in psychiatry, and they should serve to enhance development of a therapeutic nursepatient relationship. Table 5–3 includes a list of these techniques, a short explanation of their usefulness, and examples of each. Nontherapeutic Communication Techniques Several approaches are considered to be barriers to open communication between the nurse and patient. Hays and Larson (1963) identified a number of these techniques, which are presented in Table 5–4. Nurses should recognize and eliminate the use of these patterns in their relationships with patients. Avoiding these communication barriers will maximize the effectiveness of communication and enhance the nurse-patient relationship. 10. Review tables 5-3 and 5-4. Pick 2 that seem counterintuitive to social conversation and describe why you find them as such? Using Silence → To allow the other speaker to compose themselves and gather their thoughts seems to stop the flow of the conversation. It literally places a pause on the conversation. Giving False Reassurance → Is very condescending, patronizing and an act of belittling.