Research Articles Base: Psychiatric Nursing

Principles and Practice of Mental Health Nursing

Principles and Practice of Mental Health Nursing               One of the strategies employed in addressing a number of psychological problems and illnesses is the use of different kinds of psychotherapy. Aside from pharmacology, many psychiatrists and psychologists practice different techniques in psychotherapy in order to lessen drug-dependence of clients suffering from mental disorders. One of the psychological therapies used is Cognitive Behavioral Therapy, which is a form of psychotherapy that addresses the change in the behavior and attitudes of an individual through mind conditioning. Based on the positive results following its use in the clinical and psychological field, this essay aims to discuss the development of Cognitive Behavior Therapy, and its role in the practice of Mental Health Nursing.   Historical and Developmental Background of CBT             It has been reported that the empirical foundations of cognitive-behavioral approaches to psychological problems can be traced back to the early part of this century (1998). Such cognitive behavioral approaches emphasized a specific learning that responses can be elicited through conditioning, involving positive and negative reinforcements. Since Beck first introduced cognitive behavior therapy for depression, there have been numerous studies demonstrating its efficacy. Beck’s CBT is based on the underlying theoretical rationale that an individual’s emotions, motivations, and behavior are largely determined by the way in which he or she constructs the world. According to Beck and his colleagues, some individuals develop maladaptive schemas that serve as vulnerability factors predisposing them to depression and other psychological disorders (2003). Due to the application of CBT in many fields, this therapy is extended likewise in the field of nursing. Before the 1950s, the medical model dominated psychiatric-mental health nursing practice. Physicians and psychiatrists assessed, diagnosed, and planned care for individuals with psychiatric disorders. Nurse practitioners were taught and supervised mainly by physicians and psychiatrists who incorporated the theories of individuals such as  into their practice. However, during this same period, nursing leaders began to emerge to provide impetus for the development of psychiatric nursing as an independent discipline. Since the 1970s, nursing theories based on caring, cultural care diversity and universality, modeling and role modeling, energy fields, and human becoming have emerged (2005). Along with such theories is the incorporation of Cognitive Behavior Therapy in the Mental Health Nursing practice. Incorporation of Cognitive Behavior Therapy in the nursing practice, particularly in mental health nursing was founded, based on Orem’s Behavioral Nursing Theory. His theory focuses on self-care deficit, and proposes that the recipients of nursing care are persons who are incapable of continuous self-care or independent care because of health-related or health-derived limitations. In relation to this theory is the perception of human beings, as being described as integrated wholes functioning biologically, symbolically, and socially. Because of an individual’s self-care deficits, a nurse, family member, or friend may educate or consult with the individual to improve the deficit. This theory is used in the psychiatric setting, where individuals may neglect self-care needs, such as eating, drinking, rest, personal hygiene, and safety because of their underlying psychological disorder (2005). In this regard, it can be perceived that the application of CBT in the field of nursing has been based on the studies of Beck and the theory of Orem, which provided the members in the medical and healthcare field adequate proof of the positive effects of cognitive behavior therapy.   Treatment of Depression Prior to CBT             Depression is not simple sadness or bereavement. It goes far beyond merely a sad or depressed mood, and differs from sadness or unhappiness in a variety of ways. The Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV defined depression as a recurring psychological disorder that involve disturbances in emotional, cognitive, behavioral, and somatic regulation, being not a normal reaction to life’s difficulties. A sad or depressed mood is only one of the many signs and symptoms of a clinical depression. In fact, the mood disturbance may include apathy, anxiety, or irritability in addition to or instead of sadness, along with the lack of interest or capacity for pleasure and enjoyment may be evident (1997). Treatment of depression, prior to CBT is through administering classical antidepressants, namely, MAOIs, TCAs, and SSRIs. Classically, pharmacological treatment of depression has consisted of agents that affect neurotransmission involving three monoamines, namely, serotonin, norepinephrine, and /or dopamine. From the 1950s through the 1980s, two classes of agents, the monoamine oxidase inhibitors or the MAOIs and the tricyclic antidepressants or TCAs, dominated the treatment of depression. However, while these two classes of agents are clearly effective in reducing depressive symptoms, including in those patients experiencing severe depression, their side-effect profiles include serious and potentially lethal effects on the cardiovascular system, as well as less dangerous but still troublesome side effects such as sedation, dry mouth, and weight gain. In the 1980s, a new class of agents called the serotonin selective reuptake inhibitors or SSRIs, was introduced. These agents appear to be as efficacious as the older drugs in controlled studies, and offer advantages in terms of simplicity of dosing and side effect profiles. However, the most prominent adverse effects of SSRIs include agitation, akathisia, panic attacks, insomnia, sexual dysfunction, gastrointestinal effects and headaches. These side effects, while generally not as troublesome as the cardiac toxicity and anticholinergic effects of the older agents, are nonetheless disagreeable and may lead to non-compliance (2003). In this regard, it can be understood that prior to the use of CBT in treating depression and other depressive disorders, pharmacology is the most used treatment.   Rationale of Principles and Practice of CBT             It has been reported that the use of CBT involves two central tenets, where one emphasizes that one’s cognitions have a controlling influence on his or her emotions and behavior, and the other is that one’s actions or behavior can strongly affect his or her thought patterns and emotions (2006). Because one’s behavior and emotions holds a strong control on the pattern of his or her thoughts and actions, it can be perceived that a therapeutic relationship between a nursing practitioner and a mental patient can be difficult to achieve, most especially in terms of addressing problems in relation to depression. It has been emphasized that in the context of a therapeutic relationship, the relationship that must be formed between the nurse and the client must be characterized by warmth, accurate empathy, and genuineness. Building trust and rapport are crucial ingredients when treating depressed clients with CBT. It is also important to elicit client feedback regularly in order to check and the client’s understanding of the therapy and to assess for any adverse reactions that may impede the therapy process (2003). However, certain protocols and strategies must be done in line with the use of CBT as treatment of a depressed client. It has been mentioned that depression is characterized by certain behaviors, such as irritability, which may lead to aggression when provoked, or the lack of interest or capacity for pleasure and enjoyment, which can lead to apathy. Given these two situations, the application of CBT can be tested.             A depressed client can be observed to exhibit irritability that may lead to aggression, when provoked by a certain situation. Such behavior is provoked through the memories of the client, which is being refreshed by certain objects or situations. Rather than create new memories, cognitive therapy for depression attempts to limit the ease with which these memories are activated by the current environment. One feature of depression is that negative mood changes are elicited by a wide range of stimuli. Clients respond to many relatively harmless situations as though these situations contained enormous potential for various psychological and physical threats. The nursing practitioner can infer the content of these representations by systematically gathering data about the situations that elicit depression or irritability in a person and about the person’s reactions to such situations. By drawing attention to the client’s apparent assumptions and challenging these with the use of logic and behavioral experimentation, the nursing practitioner can help the client develop new rules for discriminating situations that are truly threatening from those that merely arouse the feeling of being threatened ( 1996). In relation to apathy and the lack of interest for pleasure and enjoyment, the interacting cognitive subsystems theory can be used, which suggests that the function of therapy is to disrupt the repeated synthesis of high-level schematic models containing generic meanings prototypical of previous depressing situations or the so-called depressive interlock. Disruption of interlock may be achieved in a number of ways. For example, if the models were continually being activated by ongoing stress, problem-solving training aimed at resolving the stress might effectively deactivate them. Physical exercise might alter a person’s body state and create a new element capable of disrupting the particular pattern of interlock ( 1996). As such, the negative actions associated with depression, such as irritability and apathy can be replaced by positive behaviors through the different examples and strategies mentioned. Limitations of CBT             Despite the success of CBT in treating depression, both in the psychological and nursing fields, a number of limitations can be recognized in relation to a wider mental healthcare provision. It has been mentioned that in order to make CBT work, an effective and efficient therapeutic relationship must exist between the nursing practitioner and the client. However, a therapeutic relationship may not be as successful, based on a number of reasons. Primarily, the therapeutic relationship would not be effective in achieving healthy outcomes without the trust of the client to the nursing practitioner. If the client has schematic beliefs of mistrusting other people, then the nurse would have a hard time encouraging the client to disclose information. In this regard, the genuineness of the nurse must be observed, which has to do with confidence, appearing relaxed and at with one’s self, thus, presenting the therapy in a way that it would not sound artificial to put up a barrier between the therapist and the client ( 1995). Another hindrance to the practice is the lack of sensitivity on the part of the nurse. If the nurse is not sensitive enough for the needs of the client, then the client would not be able to obtain the best treatment that would help him or her to improve and develop as an individual. It is not enough that probing and collaboration with the client must be done, but the client must be able to feel the care and concern of the nursing practitioner. Therapeutic relationship is also not enough if there is incompatibility between the client and the nurse. Incompatibility can be observed through the incompatibility of the approaches of the nursing practitioner, and incompatibility on the response of the client that hinders adequate and effective assessment. In addition, the time allotted by the nurse also counts in cognitive behavior therapy. However, psychotherapies, such as cognitive behavior therapy takes a lot of time and effort on both the client and the nurse, are a time-consuming process, and its full analysis may take several years (1988). The problem that can be encountered due to the slow and time-consuming process is that the client or the nurse may get tired, given the slow development of the client. In this case, psychotherapeutic activities must be done simultaneously to ensure the speedy improvement and treatment of the client.   Relevance of CBT in Mental Health Nursing and Nursing Practitioner             The nursing practitioner would be able to learn new skills and information regarding the nursing practice, thus, making nurses more involved and knowledgeable in their field. Because CBT is used in treating psychological disorders, nursing practitioners can help alleviate the psychological sufferings of clients and their families, as treatment for psychological disorders is a tedious process. Through knowledge of CBT, nursing practitioners would be able to provide assurance to the clients and to the client’s family that help is on their way and they are not being abandoned by medical and healthcare institutions. In addition, in the future, the work of nurses would not only be focused in providing medical and healthcare to known medical conditions, but also in providing talk therapies and therapeutic communication to clients with psychological disorders.   Credit:ivythesis.typepad.com

Principles and Practice of Mental Health Nursing

Principles and Practice of Mental Health Nursing One of the strategies employed in addressing a number of psychological p...

Medication Administration

Action Plan   Self Reflection We live in a time when mental health has been increasingly failing for many individuals. Many situations that are reflected in our societies today re increasingly convincing me, helping me to come to realize that mental health nurses matter, are essential healthcare providers, and will continue to be needed in the future. Mental health nurses are in the right position to grow in the understanding of mental health and to better identify the constructs and care practices that promote, strengthen, and protect the mental health of individuals and families. Mental health can be a very challenging area to work in and as an experienced student nurse, I have a great admiration for the skills and commitment registered mental health nurses give. There are many qualities that a registered mental health nurse must possess. Personally, I feel that I have already developed some of these qualities given the time and experience that I have spent in the mental health field. To illustrate my capabilities, I will outline in the succeeding paragraphs the qualities that I have developed as well as the situations where I have applied them. These are experiences that I have encountered 6 months prior to registration. A registered mental health nurse must adopt a quality of mental health practice. The nurse systematically enhances the quality and effectiveness of nursing practice (2004). As a student nurse, I have demonstrated quality by documenting the application of mental health nursing process in a responsible, accountable, and ethical manner. I also use creativity and innovation in nursing practice in order to improve the delivery of care. When I feel that the desired outcomes of quality are not achieved, I start to plan that I should incorporate new knowledge to initiate the desirable changes that are needed in the mental health area.             However, I have also reflected that the quality of mental health care or of health care for that matter also rests on other aspects. Quality of patient care is threatened by the acute shortage of nursing staff and at times a less than optimum mix of skills and experienced staff. The consequences are felt by patients or their families as well as nurses and have implications for clinical responsibilities and vulnerability to litigation.             Patients with chronic mental alterations can restore or maintain their health through a variety of strategies aided by the mental health nurse. Sometimes, mental health patients require medications to maintain or stabilize their health. A medication is a substance used in diagnosis, treatment, relief, cure, or prevention of health alterations ( 2004).             As a student nurse, I am aware that medication administration and evaluation are essential to nursing practice. We need to have knowledge about the actions and effects of the medications we deliver to the mental health patients. Given the delicate condition of the patient, the administration of medications to mental health patients is a more difficult task.             I have also reflected that in order to administer medications, it is essential for the mental health nurse to have an understanding of basic arithmetic to calculate medication doses, mix solutions, and perform a variety of other activities. This skill is important because medications are not always dispensed in the unit of measure in which they are ordered ( 2004). The registered mental health nurse must therefore be aware of approximate equivalents in all major measurement systems.             I have used my knowledge learned from many disciplines when administering medications. It is this knowledge that helps me understand why a particular medication has been prescribed for a patient and how this medication will alter the patient’s condition and behavior.             I have to admit that my weakness lies in the fact that as a nursing student I have limited experience with medication administration as it applies to professional practice. The clinical provides me as a student the opportunity to use the nursing process as it applies to medication administration. As I gain more experience in the field of medication administration, my psychomotor skills become more refined. I have learned that the attitudes of patients, knowledge, physical and mental status and responses can make medication administration a complex experience.         Standards             Standards are those actions that ensure safe nursing practice. Registered mental health nurses should be aware of nursing standards called the six rights of medication administration in order to ensure safe medication administration to mental health patients ( 2004). All medication administration errors can be linked in some way to any inconsistency in adhering strictly to the six rights of medication administration. These six rights are as follows: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The right medication</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The right dose</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The right patient</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The right route</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The right time</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The right documentation</li> </ul>   Maintaining Patient’s Rights             Because of the potential risks related to medication administration, the patient is also given rights. It is the patient’s right to be informed of the medication’s name, purpose, action, and potential undesired effects. The patient can also refuse medication regardless of consequences. The patient also has the right to be properly advised of the experimental nature of medication therapy and to give written consent for its use. The patient has the right to receive appropriate supportive therapy in relation to medication therapy. However, in the case of the mental health patient who may have impaired reasoning, the family of the patient can decide instead and take over the right of the patient.   Ways to Prevent Medication Administration Errors             The table below can help serve as a guide for nurses in avoiding errors in medication administration. PRECAUTION RATIONALE   Read medication labels carefully.     Be aware of medications with similar names.   When new or unfamiliar medication is ordered, consult resource.     Do not administer medication ordered by a nickname or unofficial abbreviation.   Do not attempt to decipher illegible handwriting.       Know patients with same last names. Also have the patients state their full names, or ask their families if you cannot talk to the patient.   Many products come in similar containers, colors, and shapes.   There are many medication names that sound alike.   If prescriber is also unfamiliar with the drug, there is greater risk for inaccurate being ordered.   Many prescribers refer to commonly ordered medications by nicknames or unofficial abbreviations.   When in doubt, ask the prescriber. Unless nurse questions order that is difficult to read, chance of misinterpretation is very high.   It is common to have two or more patients in the hospital with the same or similar last names. Special labels n a medication book can warn off potential problems.         Risk Management Process and Action Plan   Mental health nursing is a profession in which “genuine human to human connection should be of particular interest and priority” ( 1995). The identity of mental health nurses should be continually sought and defined in the relationship. However, it has been argued that mental health nursing is in danger of losing its identity if mental health nurses become puppets and just simply imitate psychiatry’s footsteps, particularly after the field of psychiatry has debated the wisdom of an exclusive focus on explanations and treatments in the realm of biology (2003). The action plan should also include how as a registered mental health nurse I was able to educate my patients and their families. First it is important that as a registered mental health nurse I am aware of nursing theories that are applicable to the mental health patient. One such theory that is important is the preventive theory. Preventive theory as developed by  (1964) has three dimensions: primary, secondary, and tertiary. Primary prevention emphasizes health promotion and prevention of disability or disease. Education is the principal vehicle for this kind of prevention. Early case detection and prompt treatment if disease occurs constitute secondary prevention. Tertiary prevention refers to minimizing the severity and residual effects of the disability or disease. Rehabilitation is the principal method for this kind of prevention.             Certain social, political, and economic actions on behalf of a patient’s mental health are inherently compatible with professional values, and should be considered by all mental health nurses. Nurses can be excellent participants and leaders on community action boards, bringing to them special healthcare system knowledge.   Corporate Level             Various health groups in different countries have set up policy and health program developments, and strategic goals in relation to minimizing risk for errors when it comes to medication administration. Various health services and agencies have come up with a clinical guideline for medication administration risk assessment and prevention of errors.             The answer to reducing the prevalence of medication administration errors lies not in implementing any one strategy, but in providing an institution-wide prevention program. Assessments need to be repeated regularly throughout a patient’s hospital stay and when there is a significant change in health status. A number of risk-assessment tools can be used (2004).   Organization Level A major challenge in many areas of medical practice is to successfully implement guidelines for clinical practice. A recent review of effective strategies for implementing guidelines against medication administration errors concluded that active strategies were more successful in reducing the rates. The most effective strategies used targeted educational sessions and, in particular, multiple approaches.             To formulate the action plan on this level, hospitals and other health care organizations can develop reporting and feedback processes for tracking medication administration to mental health patients and the occurrence of errors. Health care organizations can also develop and implement a comprehensive education program for nursing staff on assessment, identification of risk and management of medication administration.   Project Level Healthcare professionals must work together in groups or teams in the care of a mental patient especially when it comes to administering medications.   Nursing director: The nursing director has the role of getting reports from the head nurse. These reports would include statistics of how many incidents of errors in administration of medication to mental health patients are occurring in the hospital and how it is prevented according to new research. In addition, the nursing director also has the responsibility of providing qualified nurses and offers them new courses for continuing education.   Head nurse: The head nurse plays an important role to prevent the incidence of medication administration errors. The head nurse has the responsibility of providing the policy and procedure in the unit for all staff; as well as making the staff understand the need and importance of such policies and procedures. The head nurse must also distribute enough staff nurses to cover all shifts in the hospital unit because a shortage of nurses may cause bad care for the patients that could lead to an increase in the incidence of medication administration errors in the unit.   Clinical instruction: Education and clinical instruction of mental patients and their caregivers is an important function of health care professionals, especially of the nurses (2004). Also, the caregivers of the mental patients should be the ones that should be more educated about the situation since mental health patients could have deficits in their understanding level. There are times that the caregiver should be the one to administer medications to the mental health patient. There are a variety of educational tools, including videotapes and written materials that can be used by the nurse when mental health teaching patients and their caregivers or family to prevent the errors in medication administration. Patient instruction should be individualized for each patient, depending on the degree of mental health impairment of the patients.   Nurse: The nurses are responsible for regularly monitoring patients and giving them the correct medication. However, the nurse does not have the sole responsibility for medication administration. The prescriber and pharmacist also help ensure the right medication gets to the right patient. But still, the registered mental health nurse administering medications is accountable for knowing which medications are prescribed, their therapeutic and nontherapeutic effects, and the medications associated to nursing implications. The registered mental health nurse is also responsible for knowing why the patient needs the medication and determining if the patient and their family require supervision with administration and education about the medication and its effects.   Individual Level             All health care professionals should receive relevant training or education in medication administration and the prevention of errors in the field. Health care professionals with recognized training the administration of medications should cascade their knowledge and skills to their local health care teams. An inter-disciplinary approach to the training and education of health care professionals should be adopted.                           Credit:ivythesis.typepad.com

Medication Administration

Action Plan Self Reflection We live in a time when mental health has been increasingly failing for many individuals. Many situation...

Health Counseling for a Client with Depression

Health Counseling for a Client with Depression PART A Introduction A nurse counselor assists clients in identifying and clarifying health problems and in choosing appropriate courses of action to solve those problems. A counselor is responsible for providing information, listening objectively, and being supportive, caring, and trustworthy ( 2004). Counselors therefore do not make decisions; they help clients reach decisions that best suit them. Clients and families often require assistance in first identifying and clarifying a problem affecting health. To assist clients in need of counseling techniques, the nurse must be able to identify the need for counseling and possess communications skills to develop a therapeutic relationship. For this paper, a clinical scenario is given wherein health counseling skills are applied and discussed.   Clinical Scenario Juliet is a 34-year old woman who works as a teller on a busy bank in the city. Juliet has been married to Kevin for 10 years and has two sons, aged 8 and 5 years. Juliet says that while they are seemingly happily married she has lately begun to fear that Kevin is having an affair and will leave her. Juliet came for counseling after her physician recommended that she seek counseling for her depression. Juliet went to the outpatient department initially for lack of energy and vague gastrointestinal symptoms. Her medical examination had found no physical cause and a discussion into her mood with the nurses on duty had uncovered feelings of depression for the past 4 months. Juliet is the eldest of four children. When she was 8 years old her parents divorced and she and her sister and twin brothers moved to a different home with her mother. Her father moved back to Indonesia where he is originally from. Juliet describes how her mother became depressed after the divorce and seemed to withdraw emotionally from the children. Juliet recalls feeling great sadness over not seeing hr father and of feeling alone in their new home. Juliet describes how she took on the role of helping her mother to look after her younger siblings and begun to worry a lot about whether her mother would be okay. Her mother had remarried some years later.   Application of Health Counseling skills Many counseling techniques are used to foster cognitive, behavioral, developmental, experiential, and emotional growth in clients. Depending on what kind of problem the client is experiencing, the nurse can select from different counseling strategies and identify a kind of therapy in general. In the case of Juliet, her depression must first be identified before a counseling plan can be formulated. The type of depression that Juliet felt is that of exogenous depression. This kind of depression refers to factors outside of the individual which contribute to the individual’s negative feelings and stress, and which contribute to the depressive state (1997). An example of such factors and one which contributed to Juliet’s state is marital stress. Juliet’s depression is just a normal psychological response to her fear of her husband cheating. But it is not healthy to not do anything about this, that’s why there is a need for intervention in the form of a therapy. Juliet is thus undergoing a crisis in life, and based on nursing literature (2004), the counseling strategy to be used should be crisis intervention in the form of Family Systems Therapy. The use of family therapy can repair family relationships and solve problems that have been eating away at families for years and family therapy can also become part of the solution if just one member of the family is having problems, just like the case of Juliet. Family therapy is often recommended in many situations including families with problems across generational boundaries. As a general rule the therapist should invite all the family members living in the household (1988). However, in specific cases others significant to the problem should also be convened, for example, members of the extended family, office staff, neighbors, etc. At the start, a genogram can be constructed by the nurse counselor. The genogram can provide an overall view of complex family constellations in an extremely concise and efficient form (1988). A genogram should include names and ages of family members in Juliet’s family; dates of birth, marriage, separation, divorce, death, and other significant life events; notations, with dates, about occupation, places of residence, illness, and other changes in life course; and information on three or more generations. From this basic format and the concepts about relationships plus some ingenuity, it is possible to map out a diagram of most families seen in counseling (1988). The counseling will start with hearing about what each family member thinks about the presenting problem. The children can be asked about how they felt with their mother behaving that way. The husband could also be asked about his views. Juliet can be asked about why she felt that her husband is having an affair. But this kind of marital issues should be asked without the children present. As this proceeds, the problem tends to be enacted in the session. How the problem is connected to life as a family now and in the previous generation is then available for exploration. Initial meetings will focus on figuring out what is not working and why, and goals for the therapy will be agreed upon.  Often families need some help with conflict mediation, learning how to communicate more clearly, and developing more effective ways of coping with stress. During the course of the counseling, the nurse should not in any way display any sign of condemnation or judgment about the client’s behavior. The nurse should be objective at all times as possible. The nurse should only think of what is the best course to help the client.   Discussion Juliet attended counseling and described feeling down and depressed most of the time. She said she would burst into tears frequently, without knowing why. She said it was difficult to motivate herself to go to work and stopped going for most social activities. She said she felt on edge and agitated when she mixed with people because she felt she had to pretend to be happy all the time. She had also noticed she felt short-tempered with her sons and did not feel strong enough to spend much time with them. Juliet has to undergo a Family Systems Therapy with the nurse counselor. The counseling and therapy should involve not only Juliet but the whole family since in reality each member of the family has played a part in the dysfunction or depression on the part of Juliet. Perhaps Juliet’s husband acted strangely which led her to believe he is having an affair. Juliet’s past also contributed to her state at present. Juliet, being the eldest, took on the role of helping her mother to look after her younger siblings and begun to worry a lot about whether her mother would be okay.             Culturally competent family therapy with a particular case proceeds along the same steps as most other forms of counseling: Intake, diagnostic assessment, designing a therapeutic strategy, carrying out and monitoring the process and outcomes. What distinguishes this form of counseling, however, is that the family’s cultural programs are high priority for the counselor throughout the therapeutic process (1999).             Behind the scenes, culture plays important roles in the creation of family -mediated distress in the individual (1999). The environment where Juliet grew up and lived perhaps scorn on the situation which she is in. This in return created her depression and evidently affected how she functions in the family. Culture also partly dictates the attempted solutions. Culturally acceptable and unacceptable ways of becoming “sick” and how to recover or be cured are present in Juliet’s society. And the way her society behaves and views things can contribute to Juliet’s cure. Culture must therefore be made a part and parcel of family counseling theory and methodology (1999).             In addition to attending to cultural diversity and social justice issues, a fundamental part of the multicultural equation consists of the therapist attitudes that incorporate beliefs about individual and family resilience, and support clients’ personal agency and creativity. Counseling must not become a form of social and cultural reductionism, whereby a client’s gender, race, or social class automatically explains that person’s beliefs, attitudes and behavior. Although interlaced with historical moments, cultural discourses, and sociopolitical forces, the client’s biography is always unique ( 2003).   PART B             To me, the experience with Juliet is quite an extraordinary one wherein I have helped a client and at the same time the client was able to help me learn and grow as a nurse counselor. I have encouraged a client to examine her life and chose between alternatives. To me it seems that I have helped her bring back her life. It is a wonderful opportunity to be able to help other people bring back their healthy lives. I am also thankful that I have been given the opportunity to counsel Juliet since I have learned many things from her and her family. Juliet on her part is quite thankful for the help and support that I have given her. She has finally overcome her depression with the use of crisis intervention and family systems therapy. At the start, we both felt uneasy, especially on her part when I had to prod private information from her. But I assured her that everything she will say is confidential and will only be used in the context of the counseling sessions. Later on, Juliet became at ease with my presence and my questions. In the end, Juliet felt happy that she has decided to undergo counseling. She said so herself and it is seen in the way she talks and moves. She now develops a sense of control and is able to better manage stress. She is able to find time to spend with her family in spite of the busy schedule that her work gives her. She is also able to manage the stress that she encounters at work. She and Kevin have also talked over about their problems and so Juliet does not feel any insecurities after the counseling. All in all, Juliet feels like she has been given a second chance in life and she wants to do it right this time. She feels happy and thankful of the counseling experience.             Since the whole counseling sessions with Juliet has been a success, I thought that if I had to do it again, I would not change a thing. If I will have another client with much like Juliet’s problem, I might employ some of what I have learned in Juliet’s case. The relationship between me as the counselor and Juliet as the client is one of the factors that has contributed to the success of our counseling sessions and thus in my next counseling projects, I will start with the fostering of good relationships with clients.             During the counseling sessions with Juliet, I have learned a lot of things. I have learned things regarding the process of counseling and chief among them is the importance of relationships in the counseling process. Aside from that, I have learned additional knowledge about counseling that is beyond the scope of books. This knowledge I have gained from practice alone. Experience itself is a very good contributor to ones learning. I have also gained an understanding on how big a role a nurse counselor plays in the life of a client. A nurse counselor has the power to help or to destroy a client, and thus a nurse counselor has to be careful at all times and think only of what is best for the client. Credit:ivythesis.typepad.com

Health Counseling for a Client with Depression

Health Counseling for a Client with Depression PART A Introduction A nurse counselor assists clients in identifying and clarifying hea...

PROMOTING / DEVELOPING RECOVERY IN MENTAL HEALTH

PROMOTING / DEVELOPING RECOVERY IN MENTAL HEALTH   Introduction               The clinical area where I am working is the neuropsychiatry department, specifically working on brain injury patients. This is the department of the hospital wherein patients with mental disorders that are somewhat related to nervous system diseases are being treated. From the fact alone, that nurses deal with patients that have mental disturbances or disorders, the nurse deals with a very difficult role. Issues such as asking for consent and the confidentiality of patient records is of particular importance.             As a newly qualified nurse on my first job, a preceptorship experience is needed. In my preceptorship experience in the area of mental health, I have learned a lot of things. Specifically, I was dealing with patients recovering from brain injuries. The reason why I chose this topic for preceptorship experience is that injuries to the brain can create very unpleasant experience for both the patients and their families and presents a challenge to nurses. Nurses can help the patients and families through providing care. Survivors of brain injuries face many challenges as they recover from their initial injuries and strive to regain function. At the same time, the family members of the patient face challenges as they adjust to permanent changes in their family roles and functions. It is therefore a challenge for the nurses and other members of the healthcare team to work together to effectively meet both the needs of patients and their families. My experience in the preceptorship focused more on involving the family in the rehabilitation process. Family support is defined as assistance provided by nurses to patient and family. Family support is an intervention that assists the family in realistically assessing the impact of the head injury event on the patient and family. In providing family support, the critical care nurse engages the family so it can expand, contract or stabilize (1996).             The diagnostic and treatment procedures experienced by brain injury patients during life-threatening illness are major sources of distress for the patient and the family. Procedural distress may be defined as unpleasant physical sensations and negative psychological states associated with specific diagnostic or treatment procedures. Physically invasive procedures involve objects such as needles, catheters or probes entering the body. It is believed that procedures that are physically invasive cause more distress than do procedures that do not penetrate the skin or a body orifice (1996). Using a structured critical pathway that addresses the common needs of patients and family members can assist in organizing care and ensuring that important issues are not overlooked (2006).     Main Body   The importance of this chosen theme RECOVERY in the context of national and local mental health policies               Nurses who care for patients with brain injuries face unique challenges, especially when it comes to caring for the patient during recovery. Patient care can be time consuming and complex, with appropriate treatment and rehabilitation varying from patient to patient. Interactions with patients’ families place further demands on nurses’ time and energy. Ineffective communication between anxious family members and healthcare providers has been identified as a major source of stress for both nurses and families ( 2003), as well as a factor in the success or failure of a patient’s recovery.             Contemporary changes in the healthcare setting have created further challenges not only for the nurses but also for the patient recovering from the brain injury. Nursing shortages have led to increased patient care loads, and managed care has led to shorter hospitalizations. The result is that less time is available for healthcare providers to anticipate and meet the needs of those family members assuming caregiver responsibilities. Nurses require specialized training and resources to help families cope with the effects of brain injury upon recovery.             Neuroscience nurses practicing in the community or within rehabilitation programs are well-positioned to assess and comprehensively refer and manage the brain injury survivor upon recovery. It is important to note that there are some negative effects on the patient after the brain injury. Physical changes may include sensory deficits (e.g., visual or heating impairment), diminished coordination and muscle control, fatigue, seizure disorders, and headaches. The physical changes are generally the most easily recognized by others. In addition, typical emotional changes include emotional lability, decreased inhibition, increased anger, depression, frustration, and anxiety. These post- brain injury alterations become most apparent to family members or co-workers. Cognitive changes post- brain injury may create additional rehabilitation needs and include decreased short-term memory, inability to maintain attention/concentration, difficulty with receptive and/or expressive communication, and poor organization/planning. These changes once again are most noticeable to those who have close contact with persons who have brain injury (1990). Pharmacotherapies may be indicated, yet there is no substantive evidence on the most effective drugs. Because primary depression is best treated when pharmacotherapies are combined with strengthening interpersonal relationships, similar strategies should be employed with this population (2000). (1990) described cognitive changes with greater specificity by discussing the pervasive limitations that impaired executive functioning may present. Diminished executive functioning is connected to frontal lobe damage, and simply put, is “an organically based inability to plan, put into action, and carry through with an appropriate course of action.” An unemployed person manifesting executive dysfunction may claim he/she wants to go to work, but has no idea how to initiate, plan, or complete a job search. Additional behaviors related to executive dysfunction include difficulty sequencing events, loss of self-monitoring ability, and inability to analyze social situations and self adjust. When a person demonstrates such behaviors, he/she may have difficulty interacting with others and may be identified as cognitively impaired, unmotivated, and disinterested. Such residuals from diminished executive functioning create pervasive social and vocational problems that the nurse should help address. Once professionals have identified common residuals, brain injury professionals can design services to meet these specialized needs.             Critical evaluation of the rationale for introducing this development and the theoretical framework used   It is well established that irreversible tissue damage following brain trauma is a result of primary and secondary processes. The primary injury occurs at the time of the traumatic event and encompasses mechanical processes such as neuronal shearing, transection and axonal injury. Obviously, these primary events cannot be prevented once the trauma has occurred. However, secondary injury develops over time following the primary traumatic insult. Recent evidence suggests that much of the irreversible damage after brain injury is actually caused by these secondary events initiated at the time of trauma but taking hours to days after the insult to resolve. The time factor involved in the secondary injury process suggests that irreversible brain injury may be prevented or at least attenuated. As such, understanding the role of these secondary mechanisms in the injury process permits the implementation of nursing care practices that may potentially minimize irreversible tissue damage (1999).               Training and inclusion of the family in patient care is a concept that most nurses felt would lessen negative encounters. Approaching care from the perspective of the nurse-family team helped instill a sense of control in family members. It should be pointed out, however, that “not all families want to be involved in care. Some are scared, and some think that the nurses are not doing their job if they ask the family to help. Although family involvement in care is needed, the critical care environment can be intimidating during the early phases of care, so family members must be approached cautiously and individual circumstances carefully assessed when involving them in physical care of the patient.             We nurses also encountered some barriers to effective implementation of the pathway. The shortage of registered nurses necessitates increased patient loads and the use of temporary nursing staff, which could disrupt the continuity of care. To be most effective, the role of coordinator should be assigned to the patient and family educator or someone not involved in direct patient care. There is also emphasis on the need for consistent staff or someone to guide existing staff (2006).             The nurses also recommended that training be provided for all staff members involved in implementation of the critical pathway because it is difficult to maintain continuity of information with staff who had not been involved in the orientation phase of implementation. Because the pathway is an interdisciplinary tool, it has been suggested that all staff, from nursing assistants to physicians, be trained and roles clarified before pathway implementation. When there are multiple physicians, including subspecialists and residents, interacting with the families, information consistency is difficult to maintain. It is also recommended that weekly interdisciplinary team meetings including the families be instituted. These suggestions have been implemented as the program has grown and evolved.             The reason for incorporation of the family in the recovery process is that many family members do not understand the whole situation. In their recent investigation of common misconceptions held by family members of individuals with brain injury,  (1997) found that most family members did not really understand altered states of consciousness. Further, family members believed that personal motivation and hard work were the primary determinants of recovery of function, as opposed to extent and severity of the injury. Such misconceptions can be detrimental to the rehabilitation process and highlight the need for family education.             The family needs to be approached as an integral part of the team in rehabilitation. For this reason, they need to be well informed about all aspects of the patient’s program of care. They also need to be able to share their knowledge of the patient with the professional staff. Within the first week of a patient’s arrival at the facility, the family is scheduled to attend an introductory class that includes an overview of brain injury as well as an overview of the program. Any person identified as assuming a caregiver role with the patient receives a “learning needs and barriers to learning” assessment before attending the class.             More specifically, the integration of the family within the treatment can help a lot in the improvement. Sometimes strong families can provide a solid infrastructure to support and facilitate recovery of the person with brain injury (2002). Normally, the family initially is of minimal help as it manifested shock, disbelief, and are devastated by this event. Consequently, in my experience, the family appeared to be of little help to a brain injury patient’s recovery. However, we the interdisciplinary team educated the family on brain injury, described how daily functioning may be impaired, and learned how to implement simple strategies to enhance his time management skills, memory, spatial orientation, and social interactions.             However, the effectiveness of psychotherapies and support groups has been understudied. Studies indicate tremendous problems with social support, social isolation, and belonging. Strengthening social support and assisting the survivor to feel valued and connected to a group or person is imperative in rehabilitation. Educating support persons about the importance of their role in assisting the survivor maintain interpersonal relationships and appreciate the changes in ability and temperament is truly a challenge and not to be accomplished in a single session. Long-term follow-up for comprehensive management of the survivors and their support system is required (2000).   Implementation process, highlighting issues encountered and their resolution   The goal of a clinical pathway is to create a user-friendly tool for nurses that would meet both their needs and those of families. Neuroscience nurses involved in the trial implementation of the pathway can offer insights into the complexities of delivering holistic, structured care to patients and families. The opportunity to approach family care from a structured perspective can offer the nurses insights about their past feelings toward family care. A critical pathway designed and implemented to help nurses identify family needs during the acute and postacute phases of brain injury and to provide a structured approach to applying nursing interventions to address family needs was used during my preceptorship. The critical pathway presents a structured approach to family care from admission through discharge. Specific interventions, developed from the professional literature (2002), are indicated throughout phases of care: Phase 1 – admission, Phase 2 – acute critical care and hemodynamic stabilization, Phase 3 – acute critical care/mobility and weaning, and Phase 4 – postacute care/prerehabilitation or predischarge. The critical pathway addresses six aspects of family care adapted from the Brain Injury Family Intervention (BIFI) program ( 2002). Although the BIFI program was designed to focus primarily on rehabilitative care, the six interventions were constructed to meet the needs identified most frequently in Kreutzer, et al., by brain injury families across the continuum of care. Typical brain injury rehabilitation phases include acute medical services, acute rehabilitation services, and post-acute rehabilitation services. These phases target preserving life, increasing post- brain injury physical and daily functioning, and facilitating successful community reintegration, respectively. The ideal goal has been to provide necessary comprehensive rehabilitation services to assist with the successful reintegration of each person with brain injury into all areas of life. The increasing numbers of persons surviving brain injury have stimulated rehabilitation professionals (neuropsychologists, psychologists, and rehabilitation counselors) to more closely examine this population and deliver more comprehensive rehabilitation services. Physical, cognitive and emotional deficits serve as obstacles to community integration and vocational success for adults with brain injury (2001).             Post acute rehabilitation services may be appropriate and may be provided in many ways. The person may be afforded to continue with multidisciplinary rehabilitation services on an outpatient basis. This is desirable when the person is medically stable, is making progress, and the team collectively agrees more progress can be made. Also, referral to the state/federal mental support system to facilitate successful return to work or independent living services may be appropriate. Perhaps referral to innovative community based rehabilitation programs within many parts of the UK designed to facilitate community reintegration of persons with brain injury (2001) are possibilities. It should be emphasized that emergency medical treatment and the state/federal support system are accessible to most persons in the UK. The bulk of acute and post acute brain injury rehabilitation services are available on a limited basis, depending on one’s financial resources. Services are provided to achieve an overriding goal of functional independence. More specifically, comprehensive service provision is directed toward productive employment and independent living outcomes (2002). Chronological rehabilitation for recovery milestones important to the person’s overall recovery are noted. In one patient, one month after rehabilitation started, the patient gained and reported slight cognitive awareness of his current situation, diminished his aggressiveness, and expressed his needs verbally. This cognitive awareness was the beginning of ongoing improvements. Six weeks into rehabilitation this person is able to successfully participate in a family outing further encouraging the family to stay involved with his rehabilitation. However, at this time he was still under 24 hour supervision. After two months in the recovery process, the patient’s daily supervision was reduced to 16 hours (no supervision while sleeping). Furthermore, three months into his rehabilitation he only requires eight hours. During these times he is making small gains in his memory, daily routines, and social interactions from a combination of his therapeutic meetings (averaging three days a week) and family assistance. The therapeutic meetings focus on cognitive rehabilitation strategy to enhance his attention, memory, language skills, and personal awareness.             Fourth months into his rehabilitation and many changes have occured. Continued progress from the complementary professional and family involvement is observed. During the fifth month, the professionals work on preparing this person and his family for termination of the recovery program. Preparation for termination was completed and rehabilitaion interventions for this brain injury patient ended after six months. Many gains were made including the eradication of behavioral problems, but slight amnesia, impaired executive functioning, and limitations with independent completion of Activities of Daily Living. At termination, this person was referred to a protected education facility where he continued working on his social skills and independence.             When a patient does not show improvement that warrants continued inpatient rehabilitation, a family may decide to care for the injured family member at home. Even with the education they have received, the family takes on an overwhelming, 24-hour-a-day job that is both physically and emotionally draining (1999). Some temporary home health services may be available, but previous experience suggests that these services often do not have the expertise needed to work with this special population. Also, without a way to monitor and evaluate the ongoing status of the patient, family members may attach significant meaning to a patient response that is not truly indicative of a change in the patient’s neurological status. Moreover, important changes may go unnoticed and rehabilitation opportunities may be delayed or never recognized (2002). Additionally, an educational module can also be developed to train the nursing staff members participating in the implementation of the critical pathway. This approach was chosen because of the number of individuals who needed training and the difficulty of bringing them together. Each participant could complete the module individually at his or her own convenience. In addition the module served as a resource for information throughout the implementation period. The module included topics derived from the literature review, such as the concept of family-centered care, typical emotional responses of families following severe brain injury, research findings related to family needs, and use of the critical pathway to meet family needs. These topics were the most pertinent to families and those trying to address their needs (2006).             Evaluation of own role in the process of managing this development, lessons learned and areas for further development I have learned from my preceptorship that nursing strategies to structure the patient and family’s environment consist of organizing the patient’s immediate environment and providing for the physical comfort of the family. Critical care or trauma units are crowded with unfamiliar noise and technology. Resources provided in the critical care environment are a clear benefit to the patient. However, the environment may place additional demands on the family of a head injury patient. For example, equipment sense of crowding for the patient and family. People providing care and physically close to critically ill patients are usually strangers while those who are emotionally closest are kept physically distant by restricted visiting hours and the assembly of bedside equipment, tubes, wires, catheters and lines (1996).             As nurses, the nursing strategies are to structure the patient’s environment minimizing the amount of equipment. Interventions include those actions that enhance and respect the patient’s and family’s personal space and need to control the immediate environment. The family doesn’t know what to expect from the critical care environment. To facilitate environmental structuring, discuss items such as equipment and scheduling with the family.             Comfort measures that optimize family member’s participation in the care of the critically ill patient are found in an environment that is as pleasurable and attractive as possible. Comfort measures include couches large enough for a family member to recline and telephones near critical care. The family can designate a family member as the primary person responsible for communicating information about the patient’s condition to other family members. This will alleviate the nurse receiving telephone calls from other family members (1996). Nurses can expand their concept of the             patient with brain injury as an individual in a bed to that of a member of a family. It is important for the nurse to assess the needs of families of head injury patients during the crisis period. It is during the early phase of the crisis that the family can experience feelings of hopelessness. The ultimate outcome of a family’s attained and maintained hope is dependent upon the nurse developing successful hopeful interventions. By applying hopeful strategies to families, the nurse increases the family’s sense of hope in the present and the future. The nurse obtains information about the family’s past experience with critical illness, the family’s need for information and family readiness and/or ability to cognitively process information. Once this information has been obtained, the nurse can develop informational strategies. Informational strategies include providing information about the family’s loved one, explaining procedural distress from invasive procedures and/or treatments, providing instructional materials and establishing family meetings or rounds.   Conclusion               Nurses working with brain injured patients at the neuropsychiatry department face varied challenges from other nurses working with people who are mentally stable. For one, care for brain injured patients is very different and requires great effort and dedication. The care should include not only health care professionals but most especially the family of the brain injured patient. There are many ways by which the nurse can include the family in the care of the brain injured patient and the nurse should see to it that she performs these duties and not miss one of them for no matter how small it could be, such negligence can have a profound effect on the brain injured patient. Not only that, this could also affect the credibility of the nurse.   Credit:ivythesis.typepad.com

PROMOTING / DEVELOPING RECOVERY IN MENTAL HEALTH

PROMOTING / DEVELOPING RECOVERY IN MENTAL HEALTH Introduction The clinical area where I am working is the neuropsychi...