Key Considerations in Mental Health Nursing
The care plans in this book have been created with certain fundamental concepts in mind. These key concepts are critical considerations in planning care and in working with mental health clients. In delineating these concepts and beliefs, we hope to stimulate the reader’s thinking about these aspects of working with clients, while providing a solid foundation for mental health nursing practice.
FUNDAMENTAL BELIEFS
A nurse provides only the care the client cannot provide for himself or herself at the time.
The client basically is responsible for his or her own feelings, actions, and life (see “Client’s Responsibilities”), although he or she may be limited in ability or need help.
The nurse must approach the client as a whole person with a unique background and environment, possessing strengths, behaviors, and problems, not as a psychiatrically labeled object to be manipulated.
The client is not a passive recipient of care. The nurse and the client work together toward mutually determined and desirable goals or outcomes. The client’s active participation in all steps of the nursing process should be encouraged within the limits of the client’s present level of functioning (see “Client’s Responsibilities”).
The predominant goal is the client’s health, not merely the absence or diminution of the disease process. The client’s eventual independence from the care setting and the staff must be a focus of care. If this is impossible, the client should reach his or her optimum level of functioning and independence.
Given feedback and the identification of alternative ways to meet needs that are acceptable to the client, he or she will choose to progress toward health with more appropriate coping mechanisms if he or she is able to do so.
Physical health and emotional health are interconnected, and physical health is a desirable goal in the treatment of emotional problems. Nursing care should include a focus on the client obtaining adequate nutrition, rest, and exercise, and the elimination of chemical dependence (including tobacco, caffeine, alcohol, and over-the-counter medications or other drugs).
The nurse works with other health professionals (and nonprofessionals) in an interdisciplinary treatment team; the nurse may function as a team coordinator.
The interdisciplinary team works within a milieu that is constructed as a therapeutic environment, with the aims of developing a holistic view of the client and providing effective treatment.
THERAPEUTIC MILIEU
Purpose and Definition
The therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic setting in which to work with clients. This milieu includes safe physical surroundings, all treatment team members, and other clients. It is supported by clear and consistently maintained limits (see “Limit Setting”) and behavioral expectations. A therapeutic setting should minimize environmental stress, such as noise and confusion, and physical stress caused by factors, such as lack of sleep and substance abuse.
Removal of the client from a stressful environment to a therapeutic environment provides a chance for rest and nurturance, a time to focus on developing strengths, and an opportunity to learn about the psychodynamics of problems and to identify alternatives or solutions to those problems. This setting also allows clients to participate in an interpersonal community in which they can share feelings and experiences and enjoy social interaction and growth as well as therapeutic interactions. The nurse has a unique opportunity to facilitate (and model) communication and sharing among clients in the creation of a continuing, dynamic, informal group therapy. This may be done by implementing various aspects of a given treatment program (e.g., for chemical dependence), by using therapeutic interactions based on individual clients’ care plans, by facilitating structured therapeutic groups, and so forth.
A therapeutic milieu is a “safe space,” a nonpunitive atmosphere in which caring is a basic factor. Clients are expected to assume responsibility for themselves within the structure of the milieu as they are able to do so. Feedback from staff and other clients and the sharing of tasks or duties within the treatment program facilitate the client’s growth. In this environment, confrontation may be a positive therapeutic tool that can be tolerated by the client. However, nurses and other treatment team members should be aware of their roles in this environment to maintain stability and safety, but they also should minimize authoritarian behavior (e.g., displaying keys as a reminder of status or control; see “Nursing Responsibilities and Functions”).
Maintaining a Safe Environment
One important aspect of a therapeutic environment is the exclusion of objects or circumstances that a client may use to harm himself or herself or others. Although this is especially important in a mental health setting, this should be considered in any health care situation. The nursing staff should follow the facility’s policies with regard to prevention of routine safety hazards and supplement these policies as necessary, for example:
Dispose of all needles safely and out of reach of clients.
Restrict or monitor the use of matches and lighters.
Do not allow smoking in bedrooms (clients may be drowsy owing to psychotropic drugs).
Remove mouthwash, cologne, aftershave, and so forth if substance abuse is suspected.
Listed below are very restrictive measures for a unit on which clients are present who are exhibiting behavior that is threatening or harmful to themselves or others. These measures may be modified based on assessment of the clients’ behaviors.
Do not have glass containers accessible (e.g., drinking glasses, vases, salt and pepper shakers).
Be sure mirrors, if glass, are securely fastened and not easily broken.
Keep sharp objects (e.g., scissors, pocketknives, knitting needles) out of reach of clients and allow their use only with supervision. Use electric shavers when possible (disposable razors are easily broken to access blades).
Identify potential weapons (e.g., mop handles, hammers, pool cues) and dangerous equipment (e.g., electrical cords, scalpels, Pap smear fixative), and keep them out of the client’s reach.
Do not leave cleaning or maintenance carts, which may contain cleaning fluids, mops, and tools, unattended in client care areas.
Do not leave medicines unattended or unlocked.
Keep keys (to unit door and medicines) on your person at all times.
Be aware of items that are harmful if ingested (e.g., mercury in manometers).
Immediately on the client’s admission to the facility, treatment team members should search the client and all of his or her belongings and remove potentially dangerous items, such as wire clothes hangers, ropes, belts, safety pins, scissors and other sharp objects, weapons, and medications. Keep these belongings in a designated place inaccessible to the client. Also, search any packages brought in by visitors (it may be necessary to search visitors in certain circumstances). Explain the reason for such rules briefly and do not make exceptions.
The Trust Relationship
One key to a therapeutic environment is the establishment of trust. Trust is the foundation of a therapeutic relationship, and limit setting and consistency are its building blocks. Not only must the client come to trust the nurse, but the nurse must trust himself or herself as a therapist and trust the client’s motivation and ability to change. Both the client and the nurse must trust that treatment is desirable and productive. A trust relationship between the nurse and the client creates a space in which they can work together, using the nursing process and their best possible efforts toward attaining the goals they have both identified (see Care Plan 1: Building a Trust Relationship).
Building Self-Esteem
Just as a physically healthy body may be better able to withstand stress, a person with adequate self-esteem may be better able to deal with emotional difficulties. Thus, an essential part of a client’s care is helping to build the client’s self-esteem. However, because each client retains the responsibility for his or her own feelings, and one person cannot make another person feel a certain way, the nurse cannot increase the client’s self-esteem directly.
Strategies to help build or enhance self-esteem must be individualized and built on honesty and the client’s strengths. Some general suggestions are as follows:
Build a trust relationship with the client (see Care Plan 1: Building a Trust Relationship).
Set and maintain limits (see “Limit Setting”).
Accept the client as a person.
Be nonjudgmental at all times.
Provide structure (i.e., help the client structure his or her time and activities).
Have realistic expectations of the client and make them clear to the client.
Provide the client with tasks, responsibilities, and activities that can be easily accomplished; advance the client to more difficult tasks as he or she progresses.
Praise the client for his or her accomplishments, however small, giving sincere appropriate feedback for meeting expectations, completing tasks, fulfilling responsibilities, and so on.
Be honest; never insincerely flatter the client.
Minimize negative feedback to the client; enforce the limits that have been set, but withdraw attention from the client if possible rather than chastising the client for exceeding limits.
Use confrontation judiciously and in a supportive manner; use it only when the client can tolerate it.
Allow the client to make his or her own decisions whenever possible. If the client is pleased with the outcome of his or her decision, point out that he or she was responsible for the decision and give positive feedback. If the client is not pleased with the outcome, point out that the client, like everyone, can make and survive mistakes; then help the client identify alternative approaches to the problem. Give positive feedback when the client takes responsibility for problem solving and praise his or her efforts.
Limit Setting
Setting and maintaining limits is integral to a trust relationship and to a therapeutic milieu. Effective limits can
provide a structure and a sense of caring that words alone cannot. Limits also minimize manipulation by a client and secondary gains such as special attention or relief from responsibilities.
provide a structure and a sense of caring that words alone cannot. Limits also minimize manipulation by a client and secondary gains such as special attention or relief from responsibilities.
Before stating a limit and its consequence, you may wish to review the reasons for limit setting with the client and involve the client in this part of care planning, possibly working together to decide on specific limits or consequences. However, if this is impossible, briefly explain the limits to the client and do not argue or indulge in lengthy discussions or give undue attention to the consequences of an infraction of a limit. Some basic guidelines for effectively using limits are as follows:
State the expectation or the limit as clearly, directly, and simply as possible. The consequence that will follow the client’s exceeding the limit also must be clearly stated at the outset.
Keep in mind that consequences should be simple and direct, with some bearing on the limit, if possible, and should be something that the client perceives as a negative outcome, not as a reward or producer of secondary gain. For example, if the consequence is not allowing the client to go to an activity it will not be effective if the client did not want to go anyway, or the client is allowed to watch television or receives individual attention from the staff, which the client may prefer.
The consequence should immediately follow the client’s exceeding the limit and must be used consistently, each time the limit is exceeded and with all staff members. One staff member may be designated to make decisions regarding limits to ensure consistency; however, when this person is not available, another person must take responsibility, rather than deferring the consequences.
Remember, although consequences are essential to setting and maintaining limits, they are not an opportunity to be punitive to a client. The withdrawal of attention is perhaps the best and simplest of consequences to carry out, provided that attention and support are given when the client meets expectations and remains within limits, and that the client’s safety is not jeopardized by the withdrawal of staff attention. If the only time the client receives attention and feedback, albeit negative, is when he or she exceeds limits, the client will continue to elicit attention in that way. The client must perceive a positive reason to meet expectations; there must be a reward for staying within limits.
Regarding limits, do not delude yourself in thinking that a client needs the nurse as a friend or sympathetic person who will be “nice” by making exceptions to limits. If you allow a client to exceed limits, you will be giving the client mixed messages and will undermine the other members of the treatment team as well as the client. You will convey to the client that you do not care enough for the client’s growth and wellbeing to enforce a limit, and you will betray a lack of control on your part at a time when the client feels out of control and expressly needs someone else to be in control (see “Nursing Responsibilities and Functions”).
SEXUALITY
Human sexuality is an area in which the feelings of treatment team members are often evoked and must be considered. Because it is basic to everyone, sexuality may be a factor with any client in a number of ways. Too often the discomfort of both the nurse and the client interferes with the client’s care; you, the nurse, can significantly overcome this discomfort by dealing with your own feelings and approaching this facet of the client’s life in a professional way.
Client problems involving sexual issues or sexuality may be related to the following:
A change in sexual habits or feelings, such as first sexual activity, marriage, or the loss of a sexual partner (see Care Plan 51: Disturbed Body Image)
Injury, illness, or disability (see Care Plan 51: Disturbed Body Image)
Being the victim of a traumatic experience that involved a sexual act, such as incest or rape (see Care Plan 31: Post-Traumatic Stress Disorder and Care Plan 49: Sexual, Emotional, or Physical Abuse)
Being charged with or convicted of a crime that is associated with sexual activity, such as incest, exhibitionism, or rape (see “Clients With Legal Problems”)
Impotence or menopausal symptoms
Experiencing sexual feelings that are uncomfortable, confusing, or unacceptable to the client or significant others
Feeling guilty about masturbation or sexual activity outside of marriage
Lack of social skills in the area of social and intimate relationships
Side effects from psychotropic (or other) medications that impair sexual functioning (frank discussion regarding this problem can help prevent noncompliance with medications by possibly identifying alternative medication[s] or helping the client to adapt to the side effects in the interest of treatment goals)
These problems may be difficult for a client to reveal initially or to share with more than one staff person or with other clients. In situations like these, it is often helpful to the client if the nurse asks about problems related to sexuality in the initial nursing assessment and care planning. Be sensitive to the client’s feelings, and remember that both male and female clients have a human need for sexual fulfillment. A matter-of-fact approach to sexuality on your part can help to minimize the client’s discomfort.
Sexual activity or sexually explicit conversations may occur on the unit, posing another challenge related to sexuality. This may include clients being sexual with one another, a client making sexual advances or displays to others, or a client
masturbating openly on the unit. Sexual acting-out on the unit can be effectively managed by setting and maintaining limits (see “Limit Setting”), as with other acting-out situations. Again, a matter-of-fact approach is often most effective.
masturbating openly on the unit. Sexual acting-out on the unit can be effectively managed by setting and maintaining limits (see “Limit Setting”), as with other acting-out situations. Again, a matter-of-fact approach is often most effective.
In residential or long-term care facilities, clients’ needs for intimate relationships and sexual activity can pose sensitive, complex issues. It is important to develop policies that incorporate legal considerations regarding clients’ rights to sexual relations and obligations to protect clients from harm. These policies may include guidelines for criteria to determine the client’s ability to consent to sexual activity and to provide for privacy (e.g., for masturbation or other sexual activity); client education (regarding social skills for developing intimate relationships, saying “no” to unwanted attention or advances, basic anatomy and sexuality, birth control, and prevention of HIV infection and other sexually transmitted diseases); and so forth.
Some aspects of the client’s sexuality or lifestyle may be disturbing to treatment team members, even though the client may not be experiencing a problem or believe that the issue is a problem. For example, sexual activity in the young or elderly client, sexual practices that differ from those of the staff member, transvestism, or homosexuality, may evoke uncomfortable, judgmental, or other kinds of feelings in treatment team members. Again, it is important to be aware of and deal with these feelings as a part of your responsibility rather than create a problem or undermine the client’s perception of himself or herself by defining something as a problem when it is not. Providing nonjudgmental care to a client is especially important in the area of sexuality because the client may have previously encountered or may expect censure from professionals, which reinforces guilt, shame, and low self-esteem.
Homosexuality is not a mental health disorder. Clients who are gay or lesbian may feel positive about their homosexuality and have no desire to change. If a client who is homosexual seeks treatment for another problem (e.g., depression), do not assume that this problem is related to the client’s homosexuality. However, being a homosexual in our society can present a number of significant stresses to an individual, and these may or may not influence the client’s problem. Aside from societal censure in general, the client faces possible loss of familial support, employment, housing, or children by revealing his or her homosexuality. A client who is lesbian or gay often must deal with these issues on a daily basis, but even these stresses must not be confused with the client’s sexuality per se.
Clients may choose not to reveal their homosexuality or other sexual issues to treatment team members, family members, or others (e.g., employers) in their lives. Confidentiality is an important issue in this situation because of the potential losses to the client should his or her homosexuality become known, and must be respected by the nursing staff. Regardless of whether or not a client’s sexual orientation is spoken, his or her primary support persons may be a partner, a lover, a roommate, or friends, rather than family members. It is important to respectfully include this client’s significant others in care planning, discharge planning, teaching, and other aspects of care, just as family members are included in the care of clients who are heterosexual. Remain aware of your own feelings about homosexuality and take responsibility for dealing with those feelings so that you are able to provide effective, nonjudgmental nursing care for all clients.
Sexual concerns also may conflict with the religious beliefs and cultural values of both clients and treatment team members. It is important that the nurse is aware of the client’s cultural background and its implications for the client’s treatment as well as the nurse’s own cultural values and how these can influence care provided to the client. It may be helpful to involve a chaplain or other clergy member in the client’s treatment. Having respect for the client, examining your own feelings, maintaining a nonjudgmental attitude, encouraging expression of the client’s feelings, and allowing the client to make his or her own decisions are the standards for working with clients in situations with a moral or religious dimension, whether the issue is abortion, celibacy, sterilization, impotence, transsexualism, or any other aspect of human sexuality.
SPIRITUALITY
Spirituality can encompass a person’s beliefs, values, or philosophy of life. The client may consider spirituality to be extremely important or not at all a part of his or her life. The spiritual realm may be a source of strength, support, security, and well-being in a client’s life. However, the client may be experiencing problems that have caused him or her to lose faith, to become disillusioned, or to be in despair. Or, the client’s psychiatric symptoms may have a religious focus that may or may not be related to his or her spiritual beliefs, such as religiosity.
Spiritual belief systems differ greatly among people. These systems can range from traditional Western, Eastern, and Middle Eastern religions to alternative, ancient, or New Age beliefs, or they may reflect individual beliefs and philosophy unrelated to a traditional religion or structured set of beliefs. As with other aspects of a client, it is important to assess spirituality in the client’s life, particularly as it relates to the client’s present problem. It also is important to be respectful of the client’s beliefs and feelings in the spiritual realm and to deliver nonjudgmental nursing care regardless of the client’s spiritual beliefs. Spiritual issues often are closely linked to the client’s cultural background, so you need to be aware of the client’s cultural values and of your own feelings in order to avoid giving negative messages about the client’s spirituality. Remember that the client has a right to hold his or her own beliefs and it is not appropriate for you to try to convince the client to believe as you do or to proselytize your beliefs in the context of care.
If the client is experiencing spiritual distress, it may be appropriate to contact your facility’s chaplain or to refer the client to a leader of his or her faith for guidance. Nursing care can then continue in conjunction with the recommendations of this specialist to meet the client’s needs in a respectful manner. The nurse’s role is not limited to alleviating spiritual distress, but also includes viewing spirituality as an integral aspect of the client’s overall plan of care.
CULTURE
Although many people think of culture in terms of race, ethnicity, ancestry, or country of origin, culture includes other aspects of a person’s background and sense of self or identity, including values, practices, and beliefs. Cultural identity is made up of many components related to religion, language, age or peer group, socioeconomic status, community (e.g., urban, suburban, or rural), gender, sexual orientation, social or family situation (e.g., marital status), physical ability or disabilities, political beliefs, work and educational experience, and so forth. Therefore, a person’s cultural background can be seen as multidimensional; a person also may belong to several cultural groups. For example, a client may be female, white, agnostic, lesbian, rural, a nurse, a young adult, and so on. In addition, there are differences within cultural groups, including variations among subgroups and among individuals. For example, there is not one Asian culture but many cultures, and within each of these are factors that influence an individual’s cultural orientation and the extent to which he or she identifies with traditional cultural values or has adopted other values and beliefs. Some cultural differences are quite obvious, but others are so subtle that they often are overlooked entirely.
Delivering nursing care that is culturally sensitive requires an awareness of both the client and oneself as cultural beings. This awareness should include recognition that while an individual’s cultural orientation influences many aspects of life and this influence can be extremely strong, many people do not acknowledge cultural influences as such. Nurses need to maintain their own cultural awareness on a daily basis with all clients because of the multilevel nature of cultural orientation. Maintaining awareness of possible cultural differences and of what the client’s culture means to him or her is essential if the nurse is to adequately assess the client and plan care that is culturally appropriate.
Nurses may have different perceptions and expectations of clients and their behavior based on the client’s and the nurse’s cultural backgrounds, particularly when the differences between them are more pronounced. The greatest danger in this situation is if this occurs without the nurse’s awareness. Always evaluate your own attitude toward and expectations of each client, especially if you do not expect full participation or recovery from a particular client.
The client may also have expectations and perceptions of the staff and of health care based on cultural differences and on experiences with health care and providers. For example, the client may be fearful or guarded and may need reassurance, especially if great cultural or language differences exist.
The client’s culture may have a strong effect on the client’s view of his or her illness, treatment, and expectations for recovery. For example, psychiatric illness may be associated with shame, guilt, or social ostracism in some cultures, or may be accepted fatalistically or with equanimity in other cultures. Similarly, a client from one cultural background may have high expectations of health and may view recovery as a process for which he or she is primarily responsible, whereas a client from a different background may see illness as his or her fate or as being controlled by an external force or being. The latter can lead to clients believing that they will never recover or that they have no influence on their own recovery.
The client’s cultural orientation can largely determine what he or she considers “normal” behavior and can provide the framework for interpreting “abnormal” behavior. At times, therapeutic treatment goals (e.g., expressing feelings of anger toward one’s parents) are in opposition to cultural norms (e.g., parental authority must always be respected). In addition, clients from different cultural backgrounds may pursue treatments that are quite different from therapeutic interventions of the dominant culture, including consulting alternative health care practitioners and using herbal or traditional medicines. This type of data must be assessed and integrated into the client’s plan of care. There are many culturally specific explanations for illness, particularly mental illness (Giger & Davidhizar, 2008). It is important to consider the client’s cultural context when assessing behaviors and expecting behavior change and to remember that chances for treatment success are enhanced when expectations and interventions are culturally appropriate.
Remember that members of a dominant culture often expect those from other cultures to adopt the values of the dominant culture, whether consciously or unconsciously. In fact, many people think that their cultural values represent “the right way” to live and feel quite judgmental about others not accepting those values. As in all other aspects of nursing care, this kind of judgment and expectation is inappropriate; nurses need to examine their own thoughts and feelings and provide nonjudgmental care to all clients. You can use the following questions to begin your own self-examination and to make sure your self-awareness continues as you deliver care:
How do I see this client?
How is this client different from me?
How is this client’s cultural background different from mine?
What is the best way to approach this client?
What do I expect from this client? (Note: Ask this question regarding the client’s behavior, participation in the treatment plan, expected outcomes, etc.)
How are my expectations of this client different from my expectations of other clients?
What am I basing my expectations on?
Do my values conflict with the client’s values and beliefs?
Does this client seem strange to me?
Do I have negative feelings about this client?
Am I frustrated with this client (or with his or her values or beliefs)?
Am I avoiding this client?
Do I have adequate knowledge of this client’s cultural orientation?
Are there culturally specific treatment options that may be appropriate or inappropriate in this client’s care?
Cultural differences and their effects can be obvious or subtle. In an increasingly multicultural society, a nurse may work with clients from many different cultural groups, and
he or she cannot expect to learn enough about each of these cultures to provide culturally competent care for each client. However, the nurse can and should try to learn about the cultures most frequently represented by clients in his or her area. Using that knowledge as a foundation, the nurse can assess each client with regard to his or her cultural background.
he or she cannot expect to learn enough about each of these cultures to provide culturally competent care for each client. However, the nurse can and should try to learn about the cultures most frequently represented by clients in his or her area. Using that knowledge as a foundation, the nurse can assess each client with regard to his or her cultural background.
Remember, however, that it may be falsely reassuring to the nurse to “learn” some aspects of a particular culture; the nurse may then apply that learning to all clients of that culture, which can lead to stereotyping. Remember also that it is not always desirable to match culturally similar staff with the client (i.e., in making nursing care assignments). Although this may be done with good intentions, the client may feel segregated, devalued, or stereotyped. In addition, both the client and the nurse can benefit from developing cross-cultural relationships.
The greatest obstacles to cross-cultural care are not in what the nurse might not know about the client’s culture beforehand, but in the nurse’s lack of cultural awareness, assumptions, and prejudices regarding the client; failure to acknowledge the need to learn about the client’s culture; or expectation that the client behave in ways that are incompatible with the client’s culture. Therefore, the nurse must adopt the practice of learning about each client’s unique cultural orientation to provide culturally sensitive care. This learning can be accomplished by gathering information from a variety of sources, including the client and his or her family or significant others. For example, the nurse may want to ask questions regarding the appropriateness or acceptability of certain communication techniques and interventions, or about expectations for recovery and the client’s view of his or her behavior or illness.
Good communication skills can help bridge cultural differences. For example, if the client seems uncomfortable with direct questions in certain areas, you might preface your questions by saying, “I know it may feel awkward to talk about these things, but it will help us care for you if you can tell me…,” and so forth. In addition, asking the client and the family or significant others about their culture can help to build a trusting relationship by demonstrating respect for and interest in the client and his or her culture. If you are honest about wanting to learn and state your awareness that you do not already know everything, it can help you form a partnership with the client for his or her treatment and encourage the client’s participation. It can also reassure a client who may have had negative experiences with health care providers or others from the dominant culture. Then, be sure to share what you learn with other treatment team members and incorporate it in the client’s written plan of care.
Nursing interventions also have cultural implications, and these cultural implications need to be considered when writing and implementing a client’s care plan. Some interventions may be especially sensitive, such as using touch to comfort a client who is distressed. However, other interventions and communication techniques may be culturally sensitive as well, such as using direct eye contact, speaking directly to the client regarding his or her illness, discussing emotional topics (e.g., sexuality), and so on. Because each nurse cannot have a complete knowledge of all the cultural nuances of all the clients with whom he or she may work, maintaining an awareness that there may be cultural implications and evaluating this at each step of the nursing process is the best strategy.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Complementary and alternative medicine (CAM) is a term that denotes a range of treatments, treatment disciplines, dietary supplements, vitamins, and health practices considered to be alternatives and supplements to conventional medical treatments and medications. There is a wide range of disciplines and substances included under this general term, and there is widespread and increasing use of these practices in the United States and many other countries. CAM services comprise traditional healing methods from many cultures, bodywork and physical activity practices, herbs, vitamins, and other dietary supplements, as well as medical disciplines like chiropractic, holistic, and naturopathic medicine.
Examples of CAM disciplines include acupuncture, chiropractic, osteopathic, Ayurvedic, homeopathic, and holistic practitioners; Tai Chi, Yoga, Pilates physical activity; massage therapies, Rolfing, Feldenkrais bodywork; behavioral feedback, mind/body, guided imagery, relaxation techniques; and herbs, Chinese medicine, dietary supplements, and nutritional therapies.
According to the National Center for Complementary and Alternative Medicine (NCCAM), nearly 40% of adults in the United States and 12% of children reported using CAM treatments or services in 2007 (NCCAM, 2007). Many clients encountered in psychiatric nursing have used, or currently use them, as well. It is important to include CAM treatments, supplements, and so forth, in your assessment of the client, as they may impact his or her condition, behaviors, and recovery. If the client is currently taking or has recently taken herbal or other dietary supplements, it is especially important to determine the details of these and to consult with a pharmacist about their effects and possible interactions with other medications the client may be taking. Because supplements fall under different government regulations than other medications, there may be limited research regarding dosage and efficacy and limited testing for safety and toxicity related to some products. Or, because these substances are sold over the counter, clients may not fully understand their potency and may believe that the suggested use guidelines can be far exceeded without danger. Many of these products are explicitly marketed for mood- or other psychiatrically related problems, such as depression, stress, memory, and insomnia; the client may have used them in an attempt to self-medicate and may believe strongly in their effectiveness or may prefer them to other medications because the client sees these products as more “natural” than traditional pharmaceutical medicines.
The client’s culture may influence his or her decision to use CAM resources and may be a strong factor in the client’s
belief in their efficacy. Because these practices, supplements, and practitioners may be important to and benefit the client, it is important for the nurse to be (or become) familiar with them when a client has used or is thinking of using them. If the client has used CAM resources in the past that have had a positive influence on his or her health, it may be helpful to suggest that the client continue or resume their use. As with other aspects of client care, it is essential to remain nonjudgmental about the client’s practices, while assisting the client to evaluate the benefits as well as precautions related to these resources.
belief in their efficacy. Because these practices, supplements, and practitioners may be important to and benefit the client, it is important for the nurse to be (or become) familiar with them when a client has used or is thinking of using them. If the client has used CAM resources in the past that have had a positive influence on his or her health, it may be helpful to suggest that the client continue or resume their use. As with other aspects of client care, it is essential to remain nonjudgmental about the client’s practices, while assisting the client to evaluate the benefits as well as precautions related to these resources.
There are many Web resources for CAM services and products, including government resources such as the National Center for Complementary and Alternative Medicine and the National Cancer Institute’s Office of Complementary and Alternative Medicine; professional associations and foundations, for example, the American Holistic Medicine Association and the Alternative Medicine Foundation; and information on specific disciplines, products, and services. The U.S. Food and Drug Administration provides information on dietary supplements, and the National Library of Medicine provides a Directory of Health Organizations Online (see Web Resources on thePoint).
THE AGING CLIENT
People are aging throughout life; developmental growth, challenges, changes, and concomitant losses occur on a continuum from birth to death. As people go through life stages, they experience changes in many aspects of their daily lives. Some of these changes are gradual and barely noticed; others may be sudden or marked by events that result in profound differences in one’s life. Aging necessitates adjustment to different roles, relationships, responsibilities, abilities, work, leisure, and levels of social and economic status; changes in self-image, independence, and dependence; and changes in physical, emotional, mental, and spiritual aspects of life. Adjustment from adolescence into early adulthood entails a major transition in terms of independence, roles, and relationships. Moving from young adulthood into middle age, older age, and becoming elderly results in many changes, some of which affect one’s self-esteem and body image, and which may entail significant losses over time. As one becomes increasingly aged, these losses may become major factors in one’s life. Loss of physical abilities, altered body image, loss of loved ones, loss of independence, economic security and social status, and the loss of a sense of the future may present significant problems to a client. For example, despair, spiritual disillusionment, depression, or suicidal behavior may occur, to which these life changes are major contributing factors. If the client’s presenting problem does not seem to be related to aging or factors associated with aging, developmental or adjustment issues still need to be assessed to gain a holistic view of the client.
Remember that the elderly client is a whole person with individual strengths and needs. Do not assume that a client over a certain age has organic brain pathology, no longer has sexual feelings, or has no need for independence. It is important to promote independence to the client’s optimal level of functioning no matter what the client’s age and to provide the necessary physical care and assistance without drawing undue attention to the client’s needs. An adult or elderly client may never have needed someone to care for him or her and may feel humiliated by being in a dependent position. The client may have previously been proud of his or her independence and may have gained much self-esteem from this. This client may experience both fear and despair at the thought of being a burden. Do not dismiss these feelings as inappropriate because of your own discomfort; instead, encourage the client to express these feelings and give the client support while promoting as much independence as possible (see Care Plan 25: Major Depressive Disorder, Care Plan 50: Grief, and Care Plan 51: Disturbed Body Image).
Feelings about aging can be strongly influenced by cultural backgrounds and spiritual beliefs. In addition, aging is a universal experience that involves multiple losses and grief. Therefore, it can be a difficult issue for treatment team members and can result in uncomfortable feelings, denial, and rejection of the client. With aging or aged clients, as with other difficult issues, discomfort on the part of the nurse influences care given to the client. Respect for the individual and awareness of your feelings and those of the client together contribute to good nursing care that maintains the client’s dignity.
LONELINESS
Loneliness is an emotional state of dissatisfaction with the quality or quantity of relationships. It has been described as a painful emotion related to unmet needs for intimacy. Clients who have psychiatric problems may experience loneliness as a result of their psychiatric illness (i.e., if earlier relationships deteriorate because of the client’s illness), or loneliness can be a contributing factor to the client’s illness. Loneliness also can be a problem for a client’s caregiver, especially if he or she is the primary or sole caregiver and if no one else lives with the client.
Feelings of loneliness can result from physically being alone, but they also encompass feelings of emotional isolation or a lack of connection to others. Although social isolation can be a contributing factor to loneliness, they are not the same thing. Loneliness is perceived by the individual as a negative, unpleasant, and undesired state. Social isolation or lack of contact with other people can occur without loneliness and may be a situation preferred and chosen by the client. A client may desire to be alone for a variety of reasons, which may or may not be related to psychiatric problems, yet not feel lonely or desire a change in this situation. Key factors in determining a client’s loneliness are that the client is dissatisfied and experiencing discomfort. Finally, a client may choose to be alone, yet also feel lonely; that is, the person may be dissatisfied with the feelings of loneliness that result from choosing to be alone.
The nurse needs to be aware of the risk for and situation of loneliness when working with clients in any setting. Assessment of inpatients should include the client’s history of loneliness as well as present feelings of loneliness in the facility. Risk factors for loneliness include mental illness (e.g., depression, schizophrenia), social isolation, certain age groups (e.g., adolescents, the elderly), chronic physical illness or impairment, alcohol or drug abuse, loss of significant other(s), change in residence, and loss of employment. However, loneliness can occur without these risk factors and although assessing risk factors may help identify loneliness, it is the client’s perception of his or her feelings that is the key in determining loneliness. Because it is an emotional state, it is not necessarily “rational.” That is, a client may appear to have a very supportive familial or social network, yet complain of feeling lonely. Conversely, the client may appear to have virtually no support system or relationships and may be content with that situation. Assessment for loneliness should include the intensity and duration of feelings of loneliness, the client’s perception of factors that contribute to the loneliness; the client’s perception of the quality of his or her relationships and of himself or herself within those relationships; the client’s perception of his or her connection to the community; the client’s spiritual beliefs and feelings of support from these beliefs and from the client’s relationship to a higher power; actions that the client has taken to relieve loneliness in the past; and the effectiveness of those actions.
A number of nursing interventions can be used in addressing the risk for or situation of loneliness, such as facilitating the client’s development of social, relationship, and leisure activity skills; promoting the client’s self-esteem; and identifying sources of social contact and support in the client’s living situation and community. These include interpersonal relationships, adopting a pet if the client is able to care for an animal, referral to supportive groups, placement in an appropriate group-living situation, identification of continued treatment resources, and so on. In addition, educating the client and significant others about loneliness, and teaching the client how to communicate needs for support and intimacy (e.g., helping the client learn how to tell others when he or she is feeling lonely, and helping the client’s significant others learn how to respond by listening or attending to the client) can be effective interventions (see Care Plan 8: Partial Community Support).
HOMELESSNESS
Homelessness represents a significant challenge to nurses and other health care professionals, as well as to society in general, and clients who are homeless may be encountered in any type of health care setting. Homeless persons with mental illness may be found in shelters and jails, as well as living on the streets. An estimated 20% to 40% of the homeless population in the United States have mental illness (American Psychiatric Association, 2010b) and as many as 50% have substance-related problems. Compared with homeless persons without mental illness, the mentally ill homeless are homeless longer, have less family contact, spend more time in shelters or in jail, and face greater barriers (National Coalition for the Homeless, 2009). For this population, professionals replace families as the primary source of help.
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