THE CLIENT FROM A DIFFERENT CULTURE
an imbalance of too much yin and requests yang foods and beverages.
DSM-IV-TR DIAGNOSIS: Major depressive disorder, moderate, without psychotic features
ASSESSMENT: Personal strengths: Alert, oriented to person, place, and time; supportive roommate; self- care ability intact; previous good adjustment to role as college student; recognition of illness along with expla- nation about illness that is congruent with her culture WEAKNESSES: Suicidal thoughts; current inability to function in usual role; sleep disturbance and physical complaints
Mai, a 22-year-old Chinese female, was brought to the college health offi ce by her roommate, who was con- cerned because Mai had stopped going to class, slept only 2 hours per night, and complained of headaches and stomach pains. The roommate stated that this behavior began after Mai received a D grade on an important paper. Mai verbalized to the college health nurse that she wanted to kill herself. After psychiatric evaluation, Mai was then admitted into the psychiatric inpatient unit, accompanied by her aunt. Nursing admis- sion assessment reveals that the client’s appearance is neat and clean, she maintains minimal eye contact, and she speaks softly in brief responses to any questions.
She tells the nurse that she believes she is ill because of
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CHAPTER 4 Spiritual, Cultural, and Ethnic Issues 45
NURSING DIAGNOSIS: Risk for Self-Directed Violence related to thoughts of suicide secondary to receiving a poor grade
OUTCOME: Within 72 hours, the client will state that she wants to live.
PLANNING/IMPLEMENTATION RATIONALE
Implement suicide precautions, respecting the client’s version of acceptable eye contact and personal space requirements.
Individuals at high risk for suicide need constant supervision and limitation of opportunities to harm self.
Encourage the client to discuss recent stressful events in her life.
The client needs to identify and express the feelings that underlie the suicidal behavior or thoughts.
Contact family members (after obtaining the client’s permission) and encourage visits.
Increasing the client’s support system may help decrease future suicidal behavior.
Administer ordered antidepressant medication, teaching the client about action and side effects.
Chemical control can help the client regain self-control while exploring feelings and problems.
NURSING DIAGNOSIS: Ineffective Coping related to receiving a poor grade and as evidenced by various physical complaints and the client’s belief that imbalance of yin-yang has occurred
OUTCOME: Within 72 hours, the client will verbalize decreased complaints of physical symptoms and improved sleep.
PLANNING/IMPLEMENTATION RATIONALE
Respect the client’s beliefs about meaning of symptoms.
Showing respect demonstrates interest and caring.
Ask the client about specifi c foods and beverages that would be acceptable dietary practices and yang remedies.
Involving the client in her plan of care demonstrates respect of her cultural beliefs and can help to increase a sense of responsibility and control.
Maintain sleep chart to document actual sleep patterns.
Clients with clinical symptoms of depression often experience insomnia due to erratic sleep patterns, daytime napping, or underlying anxiety.
Teach the client relaxation techniques, encouraging use when experiencing headache or stomach pain.
Relaxation techniques are used to reduce stress and minimize somatic symptoms.
EVALUATION: The client’s aunt and cousin participated in family conference and were helpful in facilitating the client’s adopting more realistic view of poor grade received. The client verbalized wish to live and was able to sleep 6 hours each night. Foods that were acceptable were provided by dietary department. Discharge plans included referral to the college counselor for follow-up treatment along with recommendation to continue antidepressant medication.
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46 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing
KEY CONCEPTS
Spirituality is an aspect of every human being that refers
•
to a person’s belief in a higher power apart from one’s own existence. It has been defi ned as the core of who one is and entails issues of meaning and purpose, healthy rela- tionships and connectedness with others, transcendence of self, and belief in a relationship with God or a divine being. It is a personal quality that strives for inspiration, reverence, awe, meaning, and purpose in life. Spirituality is not confi ned to architectural designs.
Although the terms
• spirituality and religion are often used interchangeably, they have different meanings. Religion is an organized system of beliefs, rituals, and practices with which one identifi es and associates. A client may consider himself or herself to be both spiritual and religious, spiri- tual but not religious, or religious but not spiritual.
Culture is a broad term referring to a set of shared beliefs,
•
values, behavioral norms, and practices that are com- mon to a group of people sharing a common identity and language. A subculture is a smaller group that exists within a larger society. Members of a subculture may share commonalities such as age, gender, race, ethnicity, socioeconomic status, religious or spiritual beliefs, sexual orientation, occupation, and even health status.
An individual is infl uenced by membership in her or his
•
culture as well as by membership in multiple subcultures.
The client and the nurse can share or differ in member- ship in both culture and subculture. When cultural mem- bership differs between the nurse and the client, there is a need for increased knowledge and sensitivity regarding the impact of these differences on nursing care.
The nurse is responsible for identifying, understanding, and
•
providing care to clients from diverse ethnic groups. Ethno- centrism, or the tendency to believe that one’s own way of thinking, believing, and behaving is superior to that of oth- ers, is counteracted by the nurse’s use of self-analysis.
The nurse provides culturally congruent nursing care
•
so that the client’s cultural perspective is preserved or maintained and negotiates with the client when changing the client’s practices is necessary for health.
Many diverse ethnic groups in the United States do not
•
use the services of the mental health system because of factors such as differences in language, values, and beliefs between providers and clients.
Many people from diverse ethnic groups in the United States
•
have limited fi nancial resources and experience increased incidence of mental health problems associated with lower socioeconomic status. The need for mental health services is increased; however, statistics indicate that people from these groups do not take advantage of services.
Many people from diverse ethnic groups believe that mental
•
health problems are related to spiritual issues or are evidence of an imbalance in the natural order of the human body or nature. Culturally congruent nursing care respects these views and accommodates the client’s and family’s beliefs.
Specifi c cultures may express mental distress in unique
•
ways that are known as culture-bound syndromes.
Ethnicity and cultural factors infl uence the metabolism
•
of drugs and can infl uence effects, adverse effects, and recommended dosage. The nurse applies knowledge of ethnopharmacology when administering medications to individuals from diverse ethnic groups.
The nurse considers the role of the family, social network,
•
and ethnic healers in planning care for the client with a mental illness.
Communication with people who do not speak English is
•
facilitated by the use of translators.
The nurse assesses membership in a cultural or ethnic
•
group, composition of the family, religious and spiritual practices, cultural beliefs about cause of mental illness, and practices that are considered helpful in treating the client with a mental illness.
Implementation of nursing interventions for clients from
•
diverse ethnic groups includes measures that are helpful in establishing trust, communicating with the client and family, and incorporating cultural beliefs.
For additional study materials, please refer to the Student Resource DVD-ROM located in this textbook.
Critical Thinking Questions
1. With what culture or ethnic group do you identify?
Interview your parents, grandparents, and other relatives regarding beliefs about mental illness, including causa- tion and treatment.
2. What infl uence, if any, do you anticipate that this knowl- edge will have on your ability to provide care for cultur- ally diverse clients in the psychiatric clinical setting?
3. Research a particular ethnic culture common in your community. Determine members’ beliefs about health, ill- ness, and practices that are considered health enhancing,
especially in relation to mental health. Has your nursing education addressed these issues? If not, what changes can be made to incorporate this information into your psychiatric nursing clinical experience?
Refl ection
Reread the quote at the beginning of the chapter and then research the plan of care of a culturally diverse client. Do the nursing interventions facilitate effective transcultural mental health care? If not, what changes can be made to implement culture-specifi c care?
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CHAPTER 4 Spiritual, Cultural, and Ethnic Issues 47
NCLEX-Style Questions
1. The nurse interviews a client who expresses the cultural belief that mental illness is caused by offending one’s ancestors. When planning care for this client, which of the following has priority in order to increase the chances of successful treatment?
a. questioning the validity of the belief
b. expecting poor response to psychiatric treatment c. respecting this belief
d. seeking assistance of competent family members 2. A client from Korea is admitted to the inpatient psychi-
atric unit. Immediately you assess that he has diffi culty speaking English. Which of the following interventions would be the best plan of action?
a. communicating with gestures and pictures b. evaluating the client’s understanding of written
English
c. planning to assign the client to a private room d. using the services of a translator
3. A Hispanic client requests that a curandero visits the psy- chiatric unit to perform a healing ceremony. The nurse facilitates this visit by advocating for the client in the treatment team meeting. According to Madeline Lein- inger’s model, the nurse is demonstrating
a. accommodation/negotiation.
b. preservation/maintenance.
c. repatterning/restructuring.
d. supporting/providing.
4. Ethnopharmacology is the study of how ethnicity and cultural factors affect drug metabolism. Which enzyme is responsible for the difference in the rate of biotransfor- mation of medication?
a. cytochrome b561 b. hepatic cholecystokinin c. cytochrome P450 d. peptidase
5. The nurse uses which of the following when determining problem areas for the client with a mental illness who is from a foreign country or a different culture?
a. yes–no direct questioning b. indirect questioning c. confrontational strategies d. family-provided information
6. A client of Native Indian descent is found to have the culture-bound syndrome of ghost sickness. Which of the following would the nurse expect to assess?
a. uncontrollable crying and shouting b. preoccupation with death and the deceased c. indigestion and anorexia
d. mental fatigue e. dissociative episodes f. illness due to a hex
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Andrews, M. M., & Boyle, J. S. (2008). Transcultural concepts in nurs- ing care (5th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.
Bigony, L. (2008). Exploring spiritual care: When should I refer? Jour- nal of Christian Nursing, 25(3), 142–147.
Carpenito-Moyet, L. J. (2008). Handbook of nursing diagnosis (12th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
DiCicco-Bloom, B. (2000). Practical approaches to developing cul- tural competency. Home Health Care Management and Practice, 12(2), 30–39.
Ferrante, J. (2001). Cross cultural psychiatry. American Journal of Psychiatry, 158(1), 155–156.
Gooden, M. B., Porter, C. P., Gonzalez, R. I., & Mims, B. L. (2001).
Rethinking the relationship between nursing and diversity.
American Journal of Nursing, 101(1), 63–65.
Guarnaccia, P. (1998). Multicultural experiences of family caregiving: A study of African American, European American and Hispanic Amer- ican families. In H. Lefl ey (Ed.), Families coping with mental illness:
The cultural context (pp. 45–61). San Francisco, CA: Jossey-Bass.
Hunt, R. (2001). Introduction to community-based nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
Kavanagh, K. (2008). Transcultural perspectives in mental health. In M.
Andrews & J. S. Boyle (Eds.), Transcultural concepts in nursing care (5th ed., pp. 226–260). Philadelphia, PA: Lippincott Williams & Wilkins.
Kudzma, E. C. (1999). Culturally competent drug administrations.
American Journal of Nursing, 99(8), 46–51.
Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York, NY: National League for Nursing Press.
Lin, K. M. (1996). Psychopharmacology in cross-cultural psychiatry.
Mount Sinai Journal of Medicine, 63, 283–284.
Lin, K. M., Poland, R. E., Wan, Y., Smith, M. W., & Lessner, I. M.
(1996). The evolving science of pharmacogenetics: Clinical and ethnic perspectives. Psychopharmacology Bulletin, 32, 205–217.
Lipson, J. G., Dibble, S. L., & Minarik, P. A. (1998). Culture & nursing care: A pocket guide. San Francisco, CA: UCSF Nursing Press.
Maslow, A. H. (1987). Motivation and personality (3rd ed.). New York, NY: Harper and Brothers.
Mitchell, H. B. (2004). Roots of wisdom (4th ed.). Belmont, CA: Wadsworth.
Moffi c, H. S., & Kinzie, D. (1996). The history and future of cross- cultural psychiatric services. Community Mental Health Journal, 32(6), 581–592.
Mohr, W. K. (1998). Cross-ethnic variations in care of psychiat- ric patients: A review of contributing factors and practice considerations. Journal of Psychosocial Nursing and Mental Health Services, 36(5), 16–21.
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48 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing
Taylor, E. J. (2007). Spiritual pain. ADVANCE for Nurses, 8(21), 13–16.
U.S. Bureau of the Census. (1993, July). The foreign-born population in the United States, 1990 census of the population. Washington, DC:
United States Department of Commerce.
U.S. Bureau of the Census. (1999, March). The uninsured. Washing- ton, DC: United States Department of Commerce.
U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Washington, DC: Depart- ment of Health and Human Services, Substance Abuse and Men- tal Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
Vink, C. (2003). Towards a defi nition of spirituality. [Slide presenta- tion.] Retrieved March 8, 2005, from http://www.cappe.org/
presentations/presentation2003_fi les/outline.htm
Yamamoto, J., Silva, J. A., Justice, L. R., Chang, C. Y., & Leong, G. B.
(1993). Cross-cultural psychotherapy. In A. Gaw (Ed.), Culture, ethnicity and mental illness (pp. 104–114). Washington, DC:
American University Press.
Munoz, C., & Hilgenburg, C. (2005). Ethnopharmacology. American Journal of Nursing, 1055(8), 40–48.
Offi ce of Minority Health. (2000). Assuring cultural competence in health care: Recommendations for national standards and an outcomes-focused research agenda. Action: Final. Federal Regis- ter, 63(247), 80865–80879.
Rutledge, B. J. (2007). Cultural factors affect use of psychiatric medica- tions in developing countries. Clinical Psychiatry News, 35(8), 2.
Sadock, B.J., & Sadock, V. A. (2003). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (9th ed.). Phila- delphia, PA: Lippincott Williams & Wilkins.
Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing plans (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Smith, M. W., & Mendoza, R. P. (1996). Ethnicity and pharmacoge- netics. Mount Sinai Journal of Medicine, 63, 285–290.
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censusscope.org/us/chart_race.html
SUGGESTED READINGS
Axley, L. (2008). Missions: Nursing in diverse cultures: Helping undergrads go global. Journal of Christian Nursing, 25(3), 153–157.
Bensing, K. (2006). Cultural barriers. ADVANCE for Nurses, 7(11), 25–26.
Brown, D. (2000, September 29). Nation’s uninsured down margin- ally. Citizen’s Voice, 23(19), 12.
Cerra, A., & Fitzpatrick, J. J. (2008). Research: Can in-service educa- tion help prepare nurses for spiritual care? Journal of Christian Nursing, 25(4), 222–223.
Eldridge, C. R. (2007). Meeting your patients’ spiritual needs. American Nurse Today, 2(10), 51–52.
Killian, P. K., & Waite, R. (2007). Cultural diversity: Best practices.
ADVANCE for Nurses, 8(26), 33–36.
Killian, P. K., & Waite, R. (2008). Weaving culture with care.
ADVANCE for Nurses, 9(8), 15–16.
Mendyka, B. (2000). Exploring culture in nursing: A theory-driven practice. Holistic Nursing Practice, 15(10), 32–41.
O’Brien, A. (2007). Spiritual sensitivity: Question and answer.
ADVANCE for Nurses, 8(14), 334.
O’Reilly, M. L. (2004). Feature Article: Spirituality and mental health clients. Journal of Psychosocial Nursing and Mental Health Services, 42(7), 44–53.
Prunell, L., & Paulinka, B. (2003). Transcultural health care: A cultur- ally competent approach. Philadelphia, PA: F. A. Davis.
Salladay, S. A. (2008). Christian ethics: Secularizing spiritual care.
Journal of Christian Nursing, 25(4), 227–228.
Sweat, M. T. (2008). FAQs in spiritual care: Is diversity a barrier to spiritual care? Journal of Christian Nursing, 25(1), 54.
Waite, R., & Killian, R. (2008). Hispanic culture and patient outcomes.
ADVANCE for Nurses, 9(14), 21–22.
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5
49
5
Advance psychiatric directives
Assault Autonomy Battery Benefi cence
Bill of Rights for Registered Nurses
Civil commitment Client confi dentiality Client privacy
Code of Ethics for Nurses Defamation
Diminished capacity Doctrine of Charitable
Immunity Ethics
Failure of duty to warn False imprisonment Fidelity
Forensic psychiatry Genetic testing Guilty but mentally ill Incompetent
Informed consent Intentional tort Involuntary admission Libel
Malpractice Miranda warning Negligence
Not guilty by reason of insanity
Nurse Practice Act Omnibus Reconciliation
Act Paternalism Quality assurance Risk management Sentinel event Slander
Tarasoff decision Veracity
Voluntariness hearing Writ of habeas
corpus
KEY TERMS LEARNING OBJECTIVES
After studying this chapter, you should be able to:
1. Explain the relationship between state Nurse Practice acts and the concepts of risk management and quality assurance.
2. Construct the six-step model of ethical nursing care designed by Chally and Loriz.
3. Articulate why nurses must become knowledgeable about genetics and the issues surrounding this topic.
4. Recognize fi ve forms of nursing malpractice.
5. Discuss implications for psychiatric care related to the Tarasoff ruling of duty to warn.
6. Compare the criteria for voluntary and involuntary admission to a psychiatric facility.
7. Interpret the concept of competency.
8. Compare the legal rights of adults and minors admitted to psychiatric facilities.
9. Discuss the impact of the Omnibus Reconciliation Act (OBRA) on the placement of clients with psychiatric disorders in long-term care facilities.
10. Distinguish the legal phrases diminished capacity, not guilty by reason of insanity, and guilty but mentally ill.
11. Explain forensic psychiatry and the role of the forensic nurse.
Ethical and Legal Issues
Along with the privilege of providing professional health care services to consumers, the professional nurse has a commensurate degree of responsibility and accountability to follow ethical principles and standards of care integral to the profession.
—SHEEHY, 2006
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50 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing Historically, the care of those deemed mentally ill included
questionable practices and involved the loss of individual rights. Ethical and legal issues concerning nurse–client rela- tionships were identifi ed and subsequently addressed by the nursing profession. For example, nursing as a profession is infl uenced in each state by legislative acts referred to as Nurse Practice Acts. Overseen by each state board of nursing, these acts shield the public from unqualifi ed and unsafe nursing practice. They direct entry into nursing practice, defi ne the scope of practice (see Chapter 2), and establish disciplinary procedures. State boards of nursing have the responsibility and authority to protect the public by determining who is compe- tent to practice nursing. The National Council of State Boards of Nursing, founded in 1978, provides leadership to advance regulatory excellence for public protection.
The Doctrine of Charitable Immunity, also referred to as the Good Samaritan Act, originated in Great Britain during the 19th century. Initially, this doctrine provided immunity from prosecution for individuals who worked in charitable organi- zations such as hospitals, churches, and parochial schools. The doctrine prevented an individual from suing a caregiver or res- cuer for injuries arising from negligence when receiving emer- gency care. In 1959, California became the fi rst state to enact Good Samaritan legislation. Since that time, all states have implemented similar legislation to protect health care provid- ers who render assistance at the scene of an emergency without threat of a legal action (Morrison & Bagalio, 2004).
The concept of health care risk management, a systematic approach to the prevention of fi nancial loss due to allegations of malpractice, evolved in the mid-1970s. Professional Risk Management Services, a major medical malpractice insurer, reports that suicide and attempted suicide are the most fre- quently identifi able causes of liability payments. Other causes of claims include incorrect treatment, drug reactions, incorrect diagnosis, improper supervision, unnecessary commitment, and breach of confi dentiality. Risk management systems and activities are based on the premise that many injuries to clients are preventable. The goal of risk management is to decrease liability exposures, integrate risk reduction strategies, and ulti- mately create a risk-free environment (Charles, 2007; Miranda, Saliba, Cerimele, Lowery, & Riegel-Gross, 2004).
Quality assurance is another program that was devel- oped to evaluate and monitor professional nursing practice in terms of the quality of client care and organizational man- agement. It is a proactive program that promotes responsibil- ity and accountability to deliver high-quality care, evaluates and improves client care, and provides an organized means of problem solving. The use of such a program effectively reduces the professional nurse’s exposure to liability, identifi es educa- tional needs, and improves the documentation of care provided (Sheehy, 2006). (See Chapter 8 for additional information on quality assurance.) Preventive law in medicine was addressed and standards of psychiatric–mental health clinical nursing practice were developed during this same time period.
The everyday practice of psychiatric–mental health nurs- ing is full of value-laden decisions requiring the use of critical
thinking skills. Such decisions demand a knowledge of the law, particularly the rights of clients, their legal status, and the pre- scribed quality of their care. This chapter discusses the major ethical and legal issues that occur in psychiatric–mental health nursing.