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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 05: Psychiatric Mental Health Nursing in Acute Care Settings Instructor’s Manual Thoughts About Teaching the Topic Some instructors assign this chapter early, sometimes as part of the course orientation or in preparation for clinical practice orientation. It provides excellent information about what to expect in the inpatient setting. Topics covered in the chapter may be easily interwoven into the orientation. The use of vignettes can help students better understand the topics presented. Key Terms and Concepts admission criteria clinical pathway elopement metabolic syndrome multidisciplinary treatment plan psychosocial rehabilitation Objectives Describe the population served by inpatient psychiatric care. Identify key features of the Canadian health care system and funding structure. List the criteria for admission to inpatient care. Discuss the purpose of identifying the rights of hospitalized psychiatric patients. Explain how the multidisciplinary treatment team collaborates to plan and implement care for the hospitalized patient. Explain the importance of monitoring patient safety during hospitalization. Describe the role of the nurse as advocate and provider of care for the patient. Discuss the managerial and coordinating roles of nursing on an inpatient acute care unit. Discuss the process for preparing patients to return to the community for ongoing care. Chapter Outline Teaching Strategies Acute Mental Health Care Mental illness is a significant problem faced by Canadians (20% will experience a mental illness during their life), and hospitalization continues to be a treatment option for some individuals with mental disorders and emotional crises (Health Canada, 2002). In fact, 3.8% of all general hospital admissions in 1999 had a mental disorder as the primary diagnosis (Health Canada, 2002, p. 19). Although most inpatient psychiatric treatment today takes place in the community or in general hospital psychiatric units, there continue to be provincial psychiatric hospitals serving individuals from some rural and northern catchment areas, as well as specialty populations such as forensic patients referred by the court for evaluation or treatment. Mental Health Funding Legislation Canada has a predominately publicly financed and administered health care system whereby all eligible residents have reasonable access to medically necessary hospital and physician services (referred to as “insured services”) (Aglukkaq, 2010). Federal government and provincial and territorial government roles and responsibilities for health care are set out, primarily, in the Medicare Act (1966) and the Canada Health Act (1984). Provincial and territorial governments are responsible for health care within their jurisdictions. The federal government is responsible for transferring health care funds to the provincial and territorial governments and for ensuring that insured health care services are publicly funded and administered by the provinces and territories according to five basic principles: public administration, comprehensiveness, universality, portability, and accessibility. The federal government maintains health care responsibility for select populations (First Nations communities, armed forces, RCMP, individuals in federal penitentiaries, refugees) and select functions (such as health promotion, disease surveillance, drug regulation). For instance, the federal government operates Operational Stress Injury Social Support (OSISS) programs across Canada for military members, veterans, and their families to help them cope with the psychological effects of stress and trauma associated with warfare. Inpatient Psychiatric Mental Health Care Entry to Inpatient Care Patients are most often admitted through a hospital ED or possibly as a direct admission arranged from another health care provider or institution. In the ED, the patient is generally evaluated by an emergency department physician and an emergency mental health consultant (nurse, social worker, or psychologist), who will determine if the patient meets criteria to justify admission. The admission criteria to a hospital begin with the premise that the person is suffering from a mental illness and include evidence of one or more of the following: Imminent danger of harming self Imminent danger of harming others Inability to care for basic needs, placing individual at imminent risk of harming self Patients who meet the admission criteria are then given the option of being admitted on a voluntary basis, which means that they agree with the need for treatment and hospitalization. The vast majority of patient admissions to psychiatric inpatient units are voluntary. If patients do not wish to be hospitalized but mental health care providers feel that admission is necessary, patients can be admitted against their wishes—commonly known as an “involuntary admission.” Rights of the Hospitalized Patient Involuntarily admitted patients still have rights: right to receive information on rights in a timely manner, right to retain counsel, and right to appeal their committal. All patients admitted to any psychiatric unit retain rights as citizens, which vary from province to province to territory, and are entitled to certain privileges. Laws and regulatory standards require that patients’ rights be explained in a timely fashion after an individual has been admitted to the hospital and that the treatment team always be aware of these rights. Any instances of physical restraint, seclusion, or administration of medications against a person’s will must be documented, and actions must be justifiable. All mental health facilities provide a written statement of patients’ rights, often with copies of applicable provincial laws attached. Box 5-1 provides a sample list of patients’ rights, and Chapter 8 offers a more detailed discussion of this issue. Multidisciplinary Treatment Team Care planning and implementation are the responsibility of the interdisciplinary team of nurse, social worker, counsellor, psychologist, occupational and activities therapists, psychiatrist, medical doctor, pharmacist, and mental health workers. Nurses frequently convene and lead planning meetings. With so many disciplines needing to make assessments, timing becomes an important issue. The first to assess are usually the intake worker, nurse, and psychiatrist. The team meets within the first 2 to 3 days of admission to formulate a plan of care based on initial assessments, often by individualizing or customizing a standard care plan. Specific assessments, interventions, treatments, and outcomes are delineated along a designated timeline. The plan is monitored and facilitated by a specific caregiver, “primary nurse” or case manager. Nursing Care Admission Assessment The goal of the admission assessment is to gather information that will enable the treatment team to accurately develop a plan of care, ensure that safety needs are identified and addressed, identify the learning needs of the patient, and initiate the therapeutic relationship between the patient and the nurse. Ensuring Safety Nurses are responsible for vigilance regarding safety hazards; preventing and responding to fire; supervising the unit system for maintaining knowledge of whereabouts of every patient at all times; safety checks, both periodic and constant; sharp objects control; flow of visitors and objects onto the unit; prevention of illegal drug use; prevention of illicit sexual activity; prevention and containment of violence; prevention of elopement. Physical Health Assessment The psychiatric mental health nurse is in an excellent position to assess not only mental health but also physical health. Even if patients with mental illness have sought health care in the past, medical conditions may have been overlooked or ignored by health care professionals. The nurse is in an excellent position to assess not only mental health but also physical health. Rates of metabolic syndrome, diabetes, and heart disease are all higher for individuals with mental health problems. Metabolic syndrome is a set of metabolic abnormalities (weight gain, hypertension, hyperlipidemia) indicative of increased risk for heart disease and diabetes (Park, Usher, & Foster, 2011). Nurses can play a key role in assessing for these problems and initiating patient teaching and supports for prevention and management. Milieu Management The management of daily unit functioning is assumed by nurses even when a program manager or clinical coordinator exists. (Programmatic staff services include social services, activities, occupational therapy [OT], and specialized counselling services.) The nurse manager is responsible for unit safety, effectiveness of delivery of services, and integration of services of the treatment team. Nurses are responsible for maintaining the milieu by monitoring and keeping communication open and constructively honest, involving patients in some decisions and explaining decisions that must be left to the staff, and explaining and enforcing unit limits and rules. Structured Group Activities Experienced mental health nurses conduct specific, structured activities involving the therapeutic community, special groups, or families (e.g., goal-setting and goal-review meetings, community meetings, psychoeducational groups, and groups for creative expression). Documentation Documentation is the responsibility of the entire team. The system of documentation chosen must meet professional standards and legal, reimbursement, and accreditation requirements; it must lend itself to retrieval for quality assurance (QA), utilization review, and research. Medication Administration Nurses are responsible for safe administration and monitoring of medications. Administering prn medications is the responsibility of the nurse who weighs patient requests, does team planning, and attempts to use alternative coping strategies, using nursing judgement regarding timing and patient behaviour. Crisis Management Nurses anticipate, prevent, and manage emergencies and crises of a medical or behavioural nature on the unit. Medical crisis management calls for rapid assessment of common medical emergencies, cardiopulmonary resuscitation (CPR) skills, and use of basic emergency equipment. Behavioural crisis management requires rapid assessment, early intervention, and organized response to behavioural crises, such as violence or suicide attempts. Preparation for Discharge to the Community Nurses help patients and patients’ families learn coping skills that will help them avert future crises and hospitalization. Discharge planning begins at admission and seeks a seamless transition from hospital to community. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 06: Psychiatric Mental Health Nursing in Community Settings Instructor’s Manual Thoughts About Teaching the Topic Psychiatric nursing faculty who teach in undergraduate degree or diploma programs often have more inpatient psychiatric nursing experience than current community nursing experience. As a result, faculty may need to investigate opportunities for student experience in the community. Alternatives to inpatient experiences may not be available in great numbers but still can be used by assigning selected students to observe and participate to the extent permitted by the agency. Students who are assigned to these experiences should understand that they are expected to share their observations with classmates in structured discussions. Communitybased nurses may be reluctant to take on the role of preceptor to students in addition to the duties of their busy practice world. As a result, students’ experiences may become more observational than direct practice. The simplicity of expectations associated with the role can be reinforced by holding a short preceptor-preparation workshop. In many educational settings, preceptors cannot be paid, and many settings may not even offer tuition benefits. Thus, it is helpful to the process of obtaining and retaining preceptors to offer as many social amenities as possible (e.g., letters of appointment as unpaid adjunct faculty, personal notes of thanks, letters of appreciation to be placed in personnel files, refreshments served at meetings, etc.). Since time may not permit in-depth classroom exploration of local mental health resources, the process of students independently learning about the resources of the community should be encouraged. Key Terms and Concepts assertive community treatment (ACT) barriers to treatment biopsychosocial model case management continuum of psychiatric mental health treatment decompensation ethical dilemmas paternalism recovery serious mental illness Instructor’s Manual 6-2 Objectives Explain the evolution of the community mental health movement. Identify elements of the nursing assessment that are critically important to the success of community treatment. Explain the role of the nurse as the biopsychosocial care manager in the interprofessional team. Discuss the continuum of psychiatric treatment. Describe the role of the community psychiatric mental health nurse in disaster preparedness. Describe the role of the psychiatric nurse in four specific settings: partial hospitalization program, psychiatric home care, assertive community treatment, and community mental health centre. Identify two resources to assist the community psychiatric nurse in resolving ethical dilemmas. Discuss barriers to mental health treatment. Examine influences on the future of community psychiatric mental health nursing. Chapter Outline Teaching Strategies The Evolution of Psychiatric Care in the Community Between 1960 and 1980, patients began to leave psychiatric hospitals in huge numbers. Several factors contributed to this shift, including financial pressures on the provincially funded psychiatric hospitals, changing societal values, and new mental health treatment philosophies. Caring for patients with serious mental illness (chronic mental illness with ongoing symptoms) in the community presented many challenges in the early years after deinstitutionalization. At the time, few choices existed for outpatient treatment—usually a community mental health centre or therapy in a private office. Funding for community mental health centres began in the 1970s, but unfortunately, it was too limited for the level of system integration required to provide housing and case-management support for people with chronic mental illnesses (Lurie, 2005). Government promises to expand funding for community services were not kept, mental health funding continued to decline, and patients outnumbered resources. Many patients with serious mental illness resisted treatment with available providers, so providers began to use up scarce resources for the less mentally disabled but more committed population. Through the 1990s, advocacy by the CMHA and others continued. Increasing awareness resulted in increasing pressure on government to redesign the mental health system in Canada and to ensure adequate community supports. The 2006 senate report led by Michael Kirby and Wilbert Keon, Out of the Shadows at Last, was an optimistic step toward transforming the delivery system of mental health care. In 2007, the Mental Health Commission of Canada was formed, and, in 2009, it issued a mental health strategy for Canada, focused on an underlying recovery principle for mental health care. In short, over the past 30 years—with advances in psychopharmacology and psychosocial treatments—psychiatric care in the community has become more sophisticated, with a continuum of care that provides more settings and options for people with mental illness. The role of the community psychiatric mental health nurse has grown to include service provision in a variety of these treatment settings, and nursing roles have developed outside traditional treatment sites. Community Psychiatric Mental Health Nursing Psychiatric nursing is markedly different in the community from psychiatric nursing in hospital settings. It requires the nurse to know about many community resources, to be flexible in problem solving with patient and family, and to assess support systems and living needs. The nurse is a guest in the environment of the patient who requests consultation. Transition to the community setting is an acculturation process involving value clarification. The goal is to empower the patient and support self-management towards a notion of recovery. Roles and Functions The roles and functions of the community psychiatric nurse are fluid but to some extent dependent upon level of preparation. Biopsychosocial assessment and treatment or interventions, as well as interdisciplinary team work, crisis intervention, case management and often group or clinic work are often involved. Skilled communication and assessment capabilities are a must with these roles, which are generally quite autonomous. Biopsychosocial Assessment Assessment in the community requires enhanced understanding of the patient’s ability to cope with the demands of living in the community. The nurse assesses the patient’s needs in areas such as his or her ability to access community resources independently; financial circumstances, including ability to afford treatment and purchase medication; availability of safe, affordable housing; access to activity; ability to afford and prepare nutritious food; and legal entanglements. Individual characteristics such as culture and language may require use of an interpreter or cultural consultant. Treatment Goals and Interventions In hospital settings, the focus of care is on stabilization and is determined by the staff. In community settings, treatment goals and interventions are negotiated, not imposed. Interventions are often directed not only at symptoms but toward facilitation of access to, and continuation of support for, basic needs such as housing and food. Instead of working with hospital staff, the nurse works with community-resource people, such as the police, clergy, and landlord. The use of case management helps achieve positive outcomes. Multidisciplinary Team Member Psychiatric mental health nurses were identified in 1963 as core members of the multidisciplinary team. Increasingly, advancedpractice nurses are assuming multidisciplinary-team leadership—a role once reserved for psychiatrists. Biopsychosocial A role that is increasingly fulfilled by nurses is that of biopsychosocial Care Manager care manager. This role includes coordination of mental health, physical health, social service, educational service, medication management, and vocational aspects of care and the services required. Care management is essential to cost-effective care. Community Settings Community mental health settings are varied. Nurses are providing primary mental health care at therapeutic day care centres, partial hospitalization programs, and shelters. There are also newer environments for care, including forensic settings and drug and alcohol treatment centres, where psychiatric nurses are caring for patients. Mobile mental health units have been developed, and a growing number of communities and mental health programs are collaborating with other health or community services to provide integrated approaches to treatment. Technology is also contributing to the changes in community settings by providing services such as telephone crisis counselling, telephone outreach, and even the Internet to enhance access to mental health services. The services the psychiatric nurse can provide include counselling, promotion of selfcare activities, psychobiological interventions, health teaching, and case management. Partial Hospitalization Programs Partial hospitalization programs (PHPs) offer short-term intensive treatment and education for patients. The patient is receiving care for a part of the day and then is able to remain living in the community for part of the day. The criteria for referral to a PHP can include a need to prevent hospitalization or as a step-down from acute inpatient treatment. The patient usually attends a PHP for 5 or 6 hours daily. Some programs operate 7 days a week, and patients will attend the PHP for approximately 1 month. Some of the goals the multidisciplinary team may identify for patients are: patient able to identify medications or patient able to identify triggers to a relapse of disease symptoms. Patient goals can also include work toward self-control and patient perception of support from health care providers. Have the student utilize the vignettes in the text to explore in more detail some of the nursing skills utilized by psychiatric nurses in PHP programs. Psychiatric Home Care For patients who are homebound or who would otherwise avoid care, home care improves the potential to receive treatment. To make contact with suspicious or reclusive patients, however, the nurse may need to be accompanied by a relative or friend of the patient. It is important to note that in the home, the patient is in charge, and the nurse must use nonauthoritarian strategies, such as persuasion and negotiation, to intervene. Utilize the text vignettes to help students become more familiar with home care psychiatric nursing. Assertive Community Treatment Assertive Community Treatment (ACT) teams or mobile treatment teams work with those mentally ill patients who cannot effectively use traditional services. Patients can be referred from inpatient or outpatient facilities where the health care workers find a pattern of repeated hospitalization for severe symptoms along with an inability to participate in more traditional treatments. Treatment is delivered in many sites such as a fast food restaurant or other community sites. The outcomes related to nursing care on an ACT team may include: Patient avoids alcohol and recreational drugs and performs treatment regimen as prescribed. Patients will also need to use health services congruent with their needs and will exhibit reality-based thinking. Again, utilize the vignettes in the text to help students understand the role of the psychiatric nurse as a member of the ACT team. Community Mental Health Centres Community mental health centres also use interprofessional teams. The psychiatric mental health nurse may carry a caseload of 60 to 80 patients, each of whom is seen one to four times a month. Patients are either self-referred or referred by inpatient units or primary care providers for short-term or long-term follow-up. Patients may attend the clinic for years or be discharged when they improve and reach desired goals. Each clinic varies in design of service delivery; the nurse sees the majority of patients in the clinic but often will see patients in other settings such as primary care offices or their homes. Disaster Prepared- ness The community mental health nurse provides crisis management for victims and volunteers who arrive to assist in disaster relief efforts. The community mental health nurse finds individuals whose care has been disrupted and helps to link them back to the health care system. The nurse administers “psychological first aid” by assisting victims to meet basic needs, providing support to those who need to share their stories, directing individuals to needed agencies, and providing compassion and appropriate hope. Ethical Issues Ethical dilemmas are common in disciplines that care for the vulnerable and disenfranchised. There is often dissonance between what is best for the individual and what is best for the community. The role of the nurse is to act, as far as possible, in the best interests of both the patient and society. Professional nursing organizations can be used as resources by individual practitioners when dilemmas related to issues of patient care and ethical dilemmas arise. Future Issues: Barriers to Treatment and Nursing Education The current health care environment offers a variety of services to the mentally ill patient, but some mentally ill individuals are still not receiving the mental health care they need. There remain barriers to care, such as the stigma of mental illness and geographical, financial, and systems factors that impede access to psychiatric care. To meet the needs of mentally ill individuals in this country, nurse educators need to increase the focus on leadership development, include principles of home health nursing, increase content on gerontology, and introduce basic community health concepts. This will enable RNs who choose to work in the community psychiatric nursing field to work closely with primary health care practitioners, community members, and agencies and be better equipped to utilize creative sites and services to meet the needs of psychiatric mental health patients who need mental health services in community settings. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 07: Cultural Implications for Psychiatric Mental Health Nursing Instructor’s Manual Thoughts About Teaching the Topic Concepts introduced in this chapter relate to world view and associated assessment and intervention techniques that can be reinforced by considering the dynamics of caring for a diverse caseload of patients with dissimilar beliefs and values. An emphasis should be on self-awareness and creating a culturally safe, respectful, and responsive helping relationship. One way of helping learners operationalize the concepts associated with cultural diversity and cultural safety is to compile several short vignettes with questions for classroom discussion. Journaling and writing about awareness of privilege and cultural dominance are also useful activities to make links to potential issues of culture in nursing practice. Key Terms and Concepts Aboriginal peoples acculturation assimilation colonization cultural competence culture cultural concepts of distress enculturation ethnicity ethnocentrism ethnopharmacology medicine wheel multiculturalism refugee social determinants of health somatization stereotyping Western tradition world view Objectives Discuss the development of cultural competence in the history of psychiatric mental health nursing. Identify tensions that exist in the provision of culturally sensitive nursing care. Compare and contrast dominant Western beliefs and values with the beliefs and values of nondominant diverse cultures. Consider the world view and cultural beliefs of the First Nations people in Canada and their relation to mental health and mental illness. Explain the unique mental health and mental illness issues of refugee and immigrant groups in Canada. Identify culturally sensitive assessments that recognize inherent risk factors of nondominant cultural groups and barriers to culturally sensitive psychiatric mental health nursing care. Develop culturally sensitive nursing care plans for people from diverse cultures. Chapter Outline Teaching Strategies Cultural Competence in Psychiatric Mental Health Nursing Canada is a multicultural society. Multiculturalism informs nursing practice and challenges nurses to educate themselves to deliver culturally sensitive, competent, holistic care, as required by nursing care standards at provincial and national governance levels. To meet this challenge, nurses must develop selfawareness, monitor their ethnocentrism (perception that one’s own values, beliefs, and behaviours are superior), and be open to diverse world views and conceptualizations of mental health and illness, which will increasingly become part of their practice (Registered Nurses’ Association of Ontario, 2007). All nurses and their clients with mental illness, whether from a dominant or nondominant cultural group, have an ethnic background and a culture influencing their perspectives and choices. All culture exists within a societal context that has the potential to affect the mental well-being of individuals and of groups. The social determinants of health influence culture and its effects on mental health and mental illness. Understanding these contexts and the particular contexts and cultural concerns of patients in practice is part of competent nursing practice and crucial to psychiatric mental health care. Demographic Shifts in Canada Census data from 2006 indicates that the percentage of foreignborn people in Canada had reached 19.6%, representing one in five Canadians (Natural Resources Canada, 2009). Immigration patterns have changed, with Asian and Middle Eastern immigrants composing 59.4% of recent immigrants to Canada, decreasing numbers of European immigrants with the exception of Romanians, and an increase in African and South American immigrants. These rapid and massive shifts are concentrated in Toronto, Vancouver, and Montreal. In addition, Aboriginal peoples constitute an increasing proportion of the Canadian population, with 4.4% of the Canadian population identifying some form of Aboriginal ancestry (Library of Parliament, 2006). World Views and Psychiatric Mental Health Nursing Western science and European–American norms for mental health have grown out of a long history, the history of Western civilization. However, many people of the world have very different philosophical histories and traditions. The Eastern cultures of Asia are based on the philosophical thought of Chinese and Indian philosophers and the spiritual traditions of Confucianism, Buddhism, and Taoism. The traditional world views of Canadian Aboriginals concur with the holistic paradigm, with overlap into the magico-religious view. Concepts of interconnectedness, balance, harmony, spirituality, and kinship are central to Aboriginal peoples’ world views, as represented by the medicine wheel (see Figure 7-1). The medicine wheel is an ancient symbol that can be interpreted in many ways: the four directions, the four grandfathers, the four components of human nature (physical, mental, spiritual, and emotional). It represents a holistic world view of health and illness based on deep personal connections to the natural world and the tribe (Bopp, Bopp, Brown, et al., 1984). A broad variety of traditions have inspired different views of what it means “to be a person.” Mental health nurses must recognize that nursing theories and methods are themselves part of a cultural tradition. When a nurse understands that many of the concepts and methods of care found in psychiatric mental health nursing are based in Western cultural care ideals, the nurse begins the process of becoming culturally competent. Culture and Mental Health The pervasive experience of day-to-day cultural interactions shapes the mental health of both client and health care provider and influences how assessments and observations are conducted. Understanding the cultural norms of ethnic groups is necessary to accurately assess behaviours, affect, and cognitions within the context of culture. For example, in Western culture, emotional expressiveness is valued, but some other cultures consider such expressiveness a sign of immaturity. Culture is transmitted to its members through a process called enculturation. Children learn from parents which behaviours, beliefs, values, and actions are “right” and which are “wrong.” The culture outlines its acceptable range of options. Deviance from cultural expectations is problematic and frequently is labelled “illness.” Mental health is perceived as the degree to which a person fulfills the expectations of the culture. The culture defines which differences are within the range of normal (mentally healthy) and which are outside the range of normal (mentally ill). Cultural interpretation of behaviours creates challenges for the nurse in conducting appropriate assessments and treatments. Professional socialization and ethnocentrism may cause nurses to unintentionally impose their own cultural norms on members of other cultural groups. Ongoing self-awareness can provide clarity about personal and professional beliefs and encourage openness to alternative cultural explanations. Barriers to Quality The first part of this chapter focuses on the impact of culture on Mental Health Services mental health and illness in a theoretical way. This section focuses on providing care to culturally diverse patients. Communication Barriers Communication is a key to mental health care. Providing patients with interpreter services to meet communication needs is important to ensuring that patients are receiving adequate care. The interpreter should be matched as closely as possible to the patient in gender, age, social status, and religion. This can help the interpreter to not only translate the language but interpret nonverbal communication and cultural norms, serving as a “cultural broker” to help the nurse more fully understand the patient’s culture. Stigma of Mental Illness Many individuals in all sectors of American society associate mental health problems with moral weakness. In some cultural groups, the view is that mental illness is a failure of the family, which can bring shame and stigma as a result. Misdiagnosis Misdiagnosis can be an unfortunate outcome when inappropriate instruments are used to diagnose mental illness. Instruments need to be made for specific cultural groups so that cultural differences are utilized to diagnosis mental health disease. When the body and mind are considered as one in a specific culture, utilizing a tool to interpret mental illness in a patient from a different culture can result in a misdiagnosis. Therefore, some cross-cultural mental health experts are skeptical about using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for diagnosing mental illness in culturally diverse populations, since criteria are based predominately on people of European origins. Some examples in the text of culture-bound illnesses include ghost sickness, Hwa-Byung, and neurasthenia. These illnesses cannot be found in the DSM-5 but are prominent in certain cultural groups. Ethnic Variation in Pharmacodynamics The third clinical practice issue addressed here is the pharmacodynamics of variations in drug metabolism. There is a growing realization that many drugs vary in their action and effect along genetic–ethnic lines. These genetic variations in drug metabolism are documented for several classifications of drugs, including antidepressants and antipsychotics. Ethnopharmacology investigates these ethnic variations in drug pharmacokinetics. Making dosage variations in patients from different ethnic backgrounds is not enough to ensure appropriate dosing and treatment. Mental health nurses need to be aware that there are ethnic variations in drug metabolism, safety, and efficacy; they must take appropriate measures to ensure effective treatment that minimizes or prevents adverse effects. Populations at Risk for Mental Illness and Some of the challenges that diverse populations of mental health patients face can include issues related to the experience of being Inadequate Care an immigrant, the socioeconomic disadvantages of minority status, and the severe stigma associated with mental health problems found in some cultural groups. Aboriginal Peoples The legacy of colonization and history of residential schools have contributed to elevated rates of alcoholism, suicide, domestic violence, and community demoralization, in addition to the social problems experienced in many communities (Kirmayer, Tait, & Simpson, 2009). Societal changes, socioeconomic conditions, and interpersonal problems contribute to increased mental health needs (Law & Hutton, 2007). Suicide rates of Aboriginal youth are three to six times the rate of that of the general Canadian population, and in some communities, these youth suicides have occurred in clusters (Niezen, 2009). High rates of family violence, sexual abuse, incarceration, and emotional distress underscore the significance of historical trauma on the current mental health and societal problems facing many Aboriginal people (Statistics Canada, 2006). Despite a high proportion of mental health problems, mental health services are underused by Aboriginal people. Historical loss has caused anger, discomfort around the dominant culture, and mistrust of their intentions, which have impacted Aboriginal people’s use of services dominated by Western ideologies and non-Aboriginal professionals (Kirmayer, Brass, & Valaskakis, 2009). Immigrants While data on mental health problems and mental illness are sparse, certain factors may predispose immigrants to mental health problems. During their first ten years in Canada, 30% live in poverty, a known risk factor for developing mental health problems. Immigrants may experience acculturative stress in attempting to adapt to a new culture, negotiating new norms, and seeking meaningful employment. As immigrants, individuals face many unknowns upon arrival to this country. Their cultural traditions and values, which once provided them with stability, are challenged by new cultural norms. They encounter barriers to work and language barriers. During the period of adjustment to a new country, many immigrants find that the hope they first felt on arrival changes to anxiety and depression. The acculturation process may take several generations or may be more quickly realized. Some individuals may become bicultural, whereas others suffer culture shock, not being able to adapt to new norms readily. Many families find that children adapt to a new cultural norm more easily than do adults. This sets the stage for intergenerational conflict. Refugees A refugee is a special kind of immigrant. Refugees have left their homeland to escape intolerable conditions and would have preferred to stay in their own culture if that had been possible. Many refugees feel imposed upon. Many from Southeast Asia, Central America, and Africa have been traumatized by war, genocide, torture, and other catastrophic events. The trauma and loss make them vulnerable to post-traumatic stress disorder. Cultural of Poverty Living in poverty subjects people to bias and discrimination that diminishes self-esteem and self-efficacy, contributing to exclusion and marginalization. Relative poverty refers to inequities in material resources across segments of the population—that is, between “the haves” and “the have-nots.” In Canada, this gap is widening, which is cause for concern for mental health and illness impacts. Culturally Competent Care This chapter describes why the nursing needs of culturally diverse patient populations may be different from the needs the nurse might otherwise assume. The cultural aspect of mental health care cannot be ignored if a nurse is to provide holistic care. How do nurses provide culturally competent care? Care should include attitudes and behaviours that enable a nurse to work effectively within the patient’s cultural context, according to the Office of Minority Health. Culturally competent care goes beyond culturally sensitive care; it adapts care to the patient’s cultural needs and preferences and addresses the patient’s experience of cultural safety. Campinha-Bacote recommends a blueprint with the Process of Cultural Competence in the Delivery of Healthcare Services model. In this blueprint, nurses view themselves as becoming culturally competent rather than being culturally competent. Nurses remain open to learning rather than considering themselves as culturally competent experts. The five constructs below are part of the model. Cultural Awareness This construct indicates that the nurse is committed to “cultural humility,” a lifetime commitment to self-evaluation and critique regarding one’s level of cultural awareness. Through cultural awareness, the nurse recognizes that during an encounter with a patient, three cultures intersect: the culture of the patient, the culture of the nurse, and the culture of the setting. In the nurse’s role as a patient advocate, the nurse negotiates and advocates on behalf of the patient’s cultural needs and preferences. Cultural Knowledge Nurses enhance their cultural knowledge by attending cultural events and programs, forging friendships with members of diverse cultural groups, and attending in-services at which members of diverse groups talk about their cultural norms. Nurses can also use Internet resources, such as the Evolve Web site, to enhance their knowledge level. Resources and guides can include world view, beliefs and values, nonverbal communication patterns, etiquette norms, family roles and psychosocial norms, cultural views about mental health and illness, and patterns related to health and illness. Cultural Encounters According to Campinha-Bacote, having multiple cultural encounters with diverse patients deters nurses from stereotyping. Each person is a unique blend of the many cultures that person belongs to. The nurse comes to know that although there are patterns that characterize a culture, members of the culture adhere to the culture’s norms in diverse ways. The best source of information about a patient’s culture is the patient. Cultural Skill Cultural skill is the ability to perform a cultural assessment in a sensitive way. The first step is to ensure meaningful communication. An interpreter, if needed, should be engaged. The nurse has many various cultural assessment tools available to help give an accurate assessment of the patient’s mental health. Areas that deserve special attention during a mental health assessment include ethnicity and religious affiliation, spiritual practices, degree of proficiency with speaking and reading English, dietary patterns, attitudes about pain and experiences with pain, attitudes about and experiences with Western medicines, and other cultural considerations. The nurse must develop a therapeutic plan that is mutually agreeable, culturally acceptable, and potentially capable of producing positive outcomes. Leininger suggests a preserve– accommodate–restructure framework for care planning. This framework helps the nurse preserve the aspects of the patient’s culture that promote health and well-being. The nurse also utilizes accommodation and restructuring to help patients establish a plan of care to provide the best outcome possible for the patient. Cultural Desire Cultural desire prompts the nurse to have a genuine concern for patient welfare and a willingness to listen until each patient’s viewpoint is truly understood. Cultural desire inspires openness and flexibility in applying nursing principles to meet the patient’s cultural needs. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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