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allnurses: A Nursing Community for Nurses - Nursing Articles http://allnurses.com Nursing articles written by our members. Read about nursing tips, advanced nursing, life experiences, nursing experience, and much more. en Wed, 25 Nov 2009 19:27:46 GMT vBulletin 60 http://img.an-file.info/misc/rss.jpg allnurses: A Nursing Community for Nurses - Nursing Articles http://allnurses.com Dear preceptor http://allnurses.com/nursing-articles/dear-preceptor-439443-new.html Mon, 16 Nov 2009 21:50:57 GMT Ok, so this is a vent. I apologize for the length of this post. Please note that this is not meant... Ok, so this is a vent. I apologize for the length of this post. Please note that this is not meant to be a general statement of my opinion on a whole group of people. Dont flame me. Im mad and tired and dont have anyone else to tell. ;)

Dear preceptor.. I came to you smiling, full of energy and ready to tackle the last leg of my orientation journey, with your guidance of course. I haven't really gotten any inclination on where that guidance is at. You tell me what patients to take, and I take them. Then when I am at the bedside, communicating with the family (you know that rapport thing?), you decide that it is a great time to tell me *not to touch the patient*, or the machines for that matter unless you are there. What? I did not fall off of the nursing school wagon yesterday. I am new to your facility, but not a new grad. I did get a smug sense of satisfaction when the family told you it was fine and I was handling things.

I see that you do not have any intention of assessing my skill level or evaluating areas in which I need assistance. In your eyes, I have no skill level or even brain stem function because every action on my part is met by you with some sort of resistance or interrogation. You cant wait for me to come out of the bathroom before you call the doc... making me look like some sort of fool that cant call the doctor. Lo and behold the toilet flushes and I am greeted with 75 orders, all of which you *write* but make me *do*. Although I am a critical care nurse, and am comfortable with bedside procedures, it is *imperative * on your part to ensure that I am educated on sterile fields and how to open packages. That makes me feel so great, especially with the doc at the bedside.

Precepting with you has given me a great opportunity to practice dealing with "the cold shoulder, being aloof and unapproachable." I *know* that you aren't any of those things, just preparing me for when I run into someone who is. Thanks! I am now well versed in forced conversation, fake enthusiasm, and being lonely but not alone.

I have been practicing my mental, telepathic and psychic abilities... seeing as how there isn't any verbal interaction between us, its time to take it up a notch. *places fingertips to temples* Can you hear me now?

Here is an interesting thought. You breeze in, tell me how the lights have to be like this, and these lines need to be like this and so on. I am respectful of those requests. I like things a certain way too.. try to be mindful of that. The road goes both ways here. The same goes for documentation. Maybe you could ask me why I wrote a cetain thing before you scratch it out and write error... although all the extra embellishments make my flow sheet look freakin fantastic, right?

When I ask you about something, especially when its a policy and the rationale for not following it... I just love when you get mean and flash those *knowing* looks to all your friends at the desk.

Precepting with you has been quite the experience, and as life goes, all things must come to an end. Now that our journey is finished, know that I will *never* forget you.

Love, your preceptee ]]> Nursing Articles Ivanna_Nurse http://allnurses.com/nursing-articles/dear-preceptor-439443.html Society Needs Care Too http://allnurses.com/nursing-articles/society-needs-care-438500-new.html Wed, 11 Nov 2009 21:08:13 GMT *Society Needs Care Too *Replacing Patient-Centred Nursing with Society-Centred Nursing in Mental... Society Needs Care Too

Replacing Patient-Centred Nursing with Society-Centred Nursing in Mental Health Care Settings

Overview
Patient-centred nursing care is problematic in mental health settings because it may lead to inward looking therapeutic activity, sick role development and inertia. Interventions may over-emphasise psychiatric and psychological issues at the expense of serious re-socialisation programmes, while an imbalance of service user rights and service user responsibilities may effectively disable the practitioner. For these reasons, rehabilitation often fails service users, leaving them in bed blocked and ‘warehoused’ situations.
Society-centred care moves the focus from individual problem-solving to the demands of social life as a whole, using the institutions of society as the basic building blocks of therapy. A grounded understanding of society is seen as essential before service users can be expected to enter a full social life, and emphasis is given to the basic knowledge, skills and attitudes which are needed for successful reintegration. As society functions on a reciprocal basis, it is considered crucially important that an awareness of individual rights is balanced with a sense of social responsibility, or the rehabilitation process will fail. Society-centred care is a ‘top-down’ approach, which begins with the needs and rewards of society, and enables individuals to reach them.

Introduction
Although the central principles of mental health community care in the U.K. include reintegration and normalisation (Department of Health 1989, 1998), there is considerable doubt whether service users always benefit from this approach (Glenister and Hopton 1995, Hadley and Clough 1997). A variety of explanations have been offered for the failures of community care, including the assertion that individualized and normalising care approaches are implicitly culture biased, alienating some service users (Narayanasamy 2002). These views suggest that alternative cultural settings should be available for service users who have little commitment to the values and priorities of conventional capitalist society, but they do not explain why service users who appear committed to mainstream society and conventional rehabilitation, are still failing within it. Accordingly, this discussion focuses on those service users who share the values and beliefs of mainstream society, but fall short of meaningful reintegration, involvement and inclusion.
It provisionally commends two clear principles:
 society should be restored to the centre of mental health rehabilitation therapy
 society itself needs care

The Problems of Patient-Centred Rehabilitation Approaches in Mental Health Settings.
It may be argued that ‘patient-centred’ approaches can fail certain groups of service users in mental health rehabilitation settings because they can lead to inward looking therapies which have often residually confirmed the individual’s sense of ‘clinical difference’ from members of regular society. Therapies focused on the individual may breed under-confidence, sick role self imagery and insularity, because the person in therapy is bound to be discriminated from others during the ‘individualising’ process. In short, the patient-centred process may become preoccupied with individual problem-solving, rather than constructive social activity, and the day to day ethos of individualized mental health care may degenerate into specialist and rarefied clinical practices, dislocated from regular ‘outside’ society (e.g. multidisciplinary meetings, Care Programme Approach meetings, key worker discussions, ward rounds)
Because the individualist nursing approach overlaps with the powerful individualist medical model (Robinson 1991) and individualist psychotherapies, mental health rehabilitation may simply drift into top-heavy psychiatric and behavioural approaches which leave serious re-socialisation interventions until ‘later’. As re-socialisation interventions are often conducted by social service agencies (in day centre, outreach, or hostel settings), and these are usually only reached through care manager or financial arrangements, service users may spend long periods in health care settings waiting for their social care referrals to be processed. This is the critical point where service users may lose momentum, and begin to see the clinic as ‘home’.
The problems of over-dependency, sick role development and insularity, are likely to be much worse where service users are exposed to lengthy in patient admissions, and where they are surrounded by individuals with similarly intractable difficulties. In these cases, the insularity of individualized therapies may be compounded by a suffocating culture of asocial and anti-social clinical behaviours within the immediate environment.
It may be further contended that an imbalance of service user rights and service user responsibilities in rehabilitation settings has often crippled the reintegration process. Clinicians and managers have become extremely vulnerable to criticism from users, advocates, user groups and relatives in situations where they insist on capable but reluctant service users taking more responsibility for themselves and others. In most orthodox rehabilitation settings, there is very little that can be done if a service user simply refuses to contribute, even though there may be no clinical reason why the user remains disinclined. In these situations, users may demonstrate sophisticated skills and significant motivation in the domain of leisure, but very little interest and activity in the domain of work, leaving rehabilitation practitioners both powerless and frustrated (Leighton 2002).
Most disturbingly, some service users have an almost encyclopaedic knowledge of their own rights if pressed by staff, yet remain almost insensible of their basic human responsibilities in society. They can exhibit the profoundest innocence of such things as the work ethic, taxation as the source of state benefits, and the reciprocal organisation of society. There is often no serious expectation that service users in this situation will ever use the skills they possess, and rehabilitation becomes a euphemism for continuing care, ‘warehousing’ and bed blocking. Service users are then likely to remain alienated from society, displacing their frustrations into a variety of institutional coping strategies (Leighton 2002), while practitioners ‘go through the motions’ with political correctness and the red tape of defensive documentation. Paradoxically, service users often become isolated and dissipated by their own ‘rights’, inheriting the cruelty of policy makers’ kindness.
For the above reasons, this book suggests that mental health rehabilitation should pursue an assertive society-centred approach, which uses naturalistic social therapies alongside necessary clinical interventions, as soon as practically possible in the rehabilitation process. It is imperative in a situation where legal rights overwhelm legal responsibilities, that service users entering a rehabilitation setting should immediately sense the normality of social involvement, responsibility and reward, before a clinical syndrome of sick role, over-dependence and inertia can develop. In short, it is only by restoring society itself to the moral and practical centre of therapeutic activity, that the community care principle will thrive. This is a ‘top-down’ approach, which uses the basic communal principles of a democratic society as the primary source of individual rehabilitation therapy.

Society-Centred Care
Effective rehabilitation mental health services should reflect society as closely as possible in their philosophy, objectives and interventions. This will then ensure that service users receive the most appropriate overall therapy for rebuilding their lives and returning to society as contributing and rewarded members. Ideally, society itself should be the main setting for therapy, rather than the hospital or other clinical settings.
According to this perspective, physical, psychiatric and psychological cares have to be augmented with effective social interventions so that service users can increase their social involvement, social understanding, meaningful occupation, and sense of social responsibility. If comprehensive social interventions are omitted or devalued, service users may remain alienated from society, leading to inward looking activity, clinical stagnation and rehabilitation failure. In particular, an over-emphasis of physical, psychiatric and psychological concerns, at the expense of social issues, may promote over-dependence, ‘sick role’ development, and de-motivation amongst service users who then perceive the clinic as their ‘norm’, and society as remote.
Putting society back at the centre of therapy means that service users should become aware of the basic pattern of social life, including simple facts about the role of education, work, leisure, family, religion, media and culture. This should be linked to progressive ‘hands on’ experience of these institutions in natural or naturalistic settings (e.g. regular educational groups in local colleges, real work experience, current affairs discussions on the unit). Society-centred rehabilitation recognises that more people understand social life, the less they will fear it, and the more socially involved they are likely to become, so it recommends a ‘grounded’ approach, where society is entered, experienced and explained in a way central to the rehabilitation process. This is in direct contrast with rehabilitation approaches which look at individual psychiatric and psychological problems in comparative isolation, and then struggle to reconnect the person to society because of intervening sick role development.
Rehabilitation which puts society at the centre of care is in many ways a ‘functional’ approach which must involve people in constructive activity. It is essential to remind service users throughout the rehabilitation process that they have responsibilities as well as rights, and that they should contribute as well as receive. If this balance is lost, rehabilitation therapy will invariably fail, because service users will be incapable of dealing with normal reciprocal relationships in society. For that reason, work should be an implicit and ever present part of the culture of the unit. Work should not be the final goal, it should be the first and most continuous therapy (see Richmond 1999).
This again contrasts with rehabilitation approaches which see work as an ideal outcome, rather than as an essential method. Constructive activity within these systems may remain a distant prospect, because the idea of work is undermined during the early stages of therapy by service users who fear future commitments.
This philosophy of society-centred care encourages a positive environment, where goal directed constructive activity is the day-to-day norm, not the exception. It anticipates a culture of rich social activity, not medical incapacitation and institutional lethargy. It expects therapy to be partly directive, driven, and relatively short term, in a fully social context.
Society-centred rehabilitation may be mediated through a number of mental health care models, but the recovery model (Turner-Crowson and Wallcraft 2002) appears to be one of the most suitable for service users who have previously experienced severe mental health problems.

Society-Centred Interventions
Service users will develop the most appropriate skills and attitudes for returning to society, if society itself forms the basis of interventions. Interventions should reflect society as far as possible, taking their lead from the institutions which make up social life: education/training, the family, work, leisure, health, media, norms and values.
Ideally, rehabilitation work should be set within the mainstream settings of society (e.g. real workplaces, natural families), with practitioners acting as guides and models, but where service user skills and attitudes are too challenged for natural settings, there is then a role for preparatory work in specialist day centres and residential settings. On that basis, rehabilitation units should provide (a) residential therapy for service users who cannot access suitable day centres, and (b) care co-ordination for service users who require a combination of community day centre activities.
The recovery model implies that service users should receive a balanced cross-section of interventions which reflect the structure of mainstream society. Critical factors within this perspective are:
 education
 conventional norms and values
 work
Service users may require basic re-education in literacy, numeracy, geography, history/culture and science before they can be properly involved in society. Without these keystones they will not understand society, or be motivated to fully participate in it. Interventions should be a combination of simple general discussions (e.g. basics of arithmetic, locating home town on a map of the U.K., explaining how medication helps, etc.), and focused practical exercises (e.g. speaking clearly, counting change, finding places in home town using a local map and bus routes, practising self-medicating procedures). This will gradually restore a sense of grounding and belonging which many service users have lost.
Service users should be constantly exposed to mainstream norms and values through outside social activities, one to one reminders, and group work. These norms and values should include self-respect, respect for others, rights and responsibilities in society, and the need to compromise and reciprocate. Interventions should include coaching in basic manners and social skills (e.g. please and thank you habits, turn-taking in conversation, shopping routines), role play on how to compromise and co-operate in social situations (e.g. making decisions, sorting out disputes, dividing work fairly), practising how to budget with money, and broader discussions on the reciprocal nature of society (e.g. why people work – to provide food, shelter, clothes etc.; why we should help – because we receive from others, because it gives a feeling of worth, and so on).
Service users should take personal responsibility for their rooms and appearance, and they could be involved with the day-to-day upkeep of the unit, using a domestic job roster agreed at community meetings. One to one therapy should develop individual constructive interests (e.g. cooking, gardening), and regular groups should be used to discuss basic work processes in society (e.g. food production, manufacturing, building, office work) with associated visits to increase understanding.
Day centre referrals should be included for low level training and re-socialisation activities, and mainstream further education centres should be used for more specific and progressive courses. Community based work experience should be accessed through local Health Trust and Social Service initiatives, the Learning Skills Council, and other similar organisations.
Interventions based on education, norms and values, and work would be essential for a realistic rehabilitation service, because without them service users would remain over-dependent and alienated. However, the family, media, and leisure institutions of society would also provide important opportunities for re-socialisation (e.g. improving family dynamics, discussing current affairs, visiting working museums etc.), while psychological, psychiatric and physical issues would remain significant, but not overpowering, factors.

Summary and Conclusion
This discussion has focused on the potential problems of orthodox patient-centred rehabilitation approaches in mental health settings in the U.K., proposing an alternative society-centred perspective.
It may be argued that the pendulum of individualized care and patient rights in mental health has now swung too far, and that it is in danger of leaving behind the communal principles of society at large, and the important rights of other groups - health care users elsewhere in the N.H.S. who are receiving under-financed care, rehabilitation practitioners who can make no headway with users who have simply ‘opted out’, and tax payers who blindly fund the often ineffective health care system (Halle and Day 2001). This reflects a much bigger problem in the U.K., where individualism has slowly eroded many of the communal principles on which a fair and democratic society should be based (Winship 1998).
It may now be time to revisit the ethics of a collective conscience, and to put increasing clinical emphasis on opting in, rather than out.
Society needs care too. :redbeathe

References
Department of Health, (1989). Caring for People – Community Care in the Next Decade and Beyond. London: H.M.S.O.
Department of Health. (1998). Our Healthier Nation: Modern, Dependable. London: H.M.S.O.
Glenister, D. and Hopton, J. (1995). The Illusion of Progress. Nursing Times. August 2nd.Vol.91.No.31.
Hadley, R. and Clough, R. (1997). Care in Chaos: Frustration and Challenge in Community Care. London: Cassell.
Halle, M. and Day, M. (2001). £10 Billion, That’s How Much N.H.S. Wastes of Your Money Every Year. The Daily Express. London: Express Newspapers.
Leighton, K. (2002). A Sociological Study of Bed Blocking in Psychiatric Rehabilitation Units. Journal of Psychiatric and Mental Health Nursing. Vol.9. No.4. August. pp. 447-457.
Leighton, K. (2003). A Social Conflict Analysis of Collective Mental Health Care: Past, Present and Future. Journal of Mental Health. Vol.12. No.5.Oct. pp.474-489.
Leighton. K. (2004). Anglo-American nursing theory, individualism and mental health care: a social conflict perspective. International Journal of Nursing Studies. Vol.41. January. pp.21-28.
Narayanasamy. A. (2002). The Access Model: A Transcultural Nursing Practice Framework. British Journal of Nursing. May 9-22. 11(9). pp.643-650.
Richmond, L. (1999). Work as a Spiritual Practice. London: Piatikus.
Robinson, J. (1991). Power, Politics and Policy Analysis in Nursing. In Perry A. and Jolley M. (Eds.) Nursing - A Knowledge Base for Practice. London: Edward Arnold.
Turner-Crowson, J. and Wallcraft, J. (2002). The Recovery Vision for Mental Health Services and Research: A British Perspective. Psychiatric Rehabilitation Journal. Winter. Vol.25.no.3. pp.245-254,
Webb C. (1991). Action Research. In Cormack D.F.S. (Ed.). The Research Process in Nursing. Oxford: Blackwell.
Winship, G. (1998). Democracy in Psychiatric Settings: Collectivism v. Individualism. In Barker P. and Davidson B. (Eds.). Psychiatric Nursing - Ethical Strife. London: Arnold.

]]> Nursing Articles leovineknight http://allnurses.com/nursing-articles/society-needs-care-438500.html Why am I doing this, anyway? http://allnurses.com/nursing-articles/why-am-i-436902-new.html Thu, 05 Nov 2009 05:43:19 GMT “@#$!, @#$!, @#$!, @#$!!” I had not realized up until that point that subvocalized cursing could be... “@#$!, @#$!, @#$!, @#$!!” I had not realized up until that point that subvocalized cursing could be so loud, but even though the only sounds he could make were the "sh" and the "t", he was going to say it. He was young, he was angry – he was a brand new quad who had woken up to find himself paralyzed, trached, and in a strange hospital in a strange town. Worse yet, nobody was listening to him – and he did have something to say besides the continuous recitation of his favorite word.

“Good luck, dude, you’re gonna love this one,” the charge nurse told me as he handed out the patient assignments for the day. “You win the lottery this morning – dude needs a guy cause he’s really inappropriate with the female staff. Really.” Oh, wonderful, I thought to myself. A frontal type TBI patient who is also a quad – this ought to be fun. As I took report from the off going nurse, and she told me that the kid’s mother was also going to be around – a LOT – I started seriously questioning my choice of career. And as I heard the continuous fecal refrain from the room, I knew I should have studied computer science instead.

“@#$!, @#$!, @#$!, @#$!!” “You’re a dumb@#$.” “@#$! off.” He couldn’t vocalize, but he spoke loud and clear. It took me about half the shift to realize that his anger was neither triggered by nor directed towards me – though I was the nearest available object with ears. It took a little less time than that for me to recognize that he could not control the repetitive speech – it was like a nervous tic. The more stressed he got, the worse it became.

So I stopped responding to him with dismissal or anger – I took my feelings out of the equation – and listened to him. What I began to hear was a spirit in agony – and a person who not only had been robbed of all power in his own mind; his caregivers had robbed him of all power as well. We were not listening to him, we were not giving him any say in his own treatment, and we certainly were not willing to entertain the idea that behind the repetition of the curse words there might just be a devastated, emotionally shattered, kid – who was terrified.

I spent a week working with this young man – and I learned a lot about myself in the process. I learned that I needed to discard my ingrained thought processes with him, and do some real thinking outside the box. I learned that sometimes life changes occur quickly, and dramatically, in the tinkling of shattered glass and the groaning of twisted steel – and sometimes much more slowly, in the gradual transition from total dependence to having a voice in one’s care, from bedfast to chair trips downstairs and outside – from constant infusions of sedatives and antipsychotics to vent weaning and Passy-Muir valve.

On the day he finally could fully vocalize, I put the Passy-Muir cap on his trache tube and braced myself for the now familiar refrain. Instead, I heard “Thank. You. Thanks.” I knew then that computer science would never bring that kind of lump to my throat, or ever feel that fulfilling.

This is where I belong. ]]> Nursing Articles TDFlMedicRN http://allnurses.com/nursing-articles/why-am-i-436902.html Nurse Heal Thyself http://allnurses.com/nursing-articles/nurse-heal-thyself-436030-new.html Sun, 01 Nov 2009 16:58:13 GMT After I wrote the initial article about my decision to have reconstructive surgery 17 years after... After I wrote the initial article about my decision to have reconstructive surgery 17 years after surviving breast cancer (“Quest for Girls” published on this site) the preliminary work was done. Now it was time to complete the final phase of my project to become whole again and receive my final implants. This experience proved to be much more enlightening than my past surgical experience of initial reconstruction, and I couldn’t imagine how it would change me both physically and emotionally.

Arriving with full knowledge of what the procedure entailed and with promised results being nothing less than glowing, I was experiencing a kind of anxious, queasy feeling that day. After giving health care for over thirty years, anyone would have a slightly “different” reaction to being a patient and quite frankly it is not something most of us old nurses are good at. No one really ever wants to be on this side of the coin but we are grateful to our colleagues when there is a time of need.

Saying “goodbye” to my best friend, who has been my support person through this so called project, I followed my admit nurse back to the surgical suite to wait my turn. After an hour delay, and partially out of boredom, I found myself watching the different OR teams closely. When I graduated from nursing school for the second time and completed an RN program 17 years ago my intent was to become an OR nurse. I watched as they followed through with all the stringent protocols of checking names and confirming allergies and procedures with each individual patient, and an unexpected feeling of envy and sadness came over me. For the past 15 years I had put my heart and soul into long term care management positions and each day given some of myself to each of my “special friends.” I rarely, if ever, had given much thought to what could have been different had life dealt to me a different set of circumstances…quite possibly, had cancer not derailed me, I would have been working in this capacity all these years. This was very much an “in your face” reality check, and at a very un-anticipated time.

When it came my turn things did not progress as smoothly as my nurse anesthetist anticipated. When the shot in my IV failed to give me a nice glow, I quickly mentioned this to her as they were wheeling me down to the OR. I was wide awake and should have been far off in the land of La. A quick assessment revealed that my IV was not patent, so when I arrived in the OR a new one was promptly placed. During this process, a caring special nurse made every effort to make me comfortable, giving me kind words and explaining the basics of what was happening around me as I could hear the team moving about setting up equipment and getting me ready for surgery. I thought, “Wow! I am a nurse and I understand all of these processes. I can’t even imagine how a lay person would feel right now.”

This is a perfect example of why nurses play a special role because no one in that OR team had any idea that I was a colleague. To them I was just another case that they were doing their best to keep safe, secure and bring through a surgical procedure to return home for recovery. Given the emotional ups and down I had experienced that day, this nurse was there to ease me into my experience and was doing a fantastic job. As a fellow nurse, it meant the world to me; as an OR lay person, it meant everything.

A few days into my recovery process my thoughts went back to that surgical team quite often. “What if” is always something that will be in my mind about my success as an OR nurse but in a few weeks I will return to my “special friends” and my real world of nursing. As I look in the mirror I feel whole again and realize that while I will always wonder, the sadness about this “what if” moment has already started to subside and I truly believe that we all have a purpose and find them sometimes by fate, sometimes by force. The right person there to guide us at just the right time can make a world of difference, and one way or another that was my fate. As this thought sets in, the mirror reflects my smile on the inside as well as on the outside. ]]> Nursing Articles Lindsey McGraw http://allnurses.com/nursing-articles/nurse-heal-thyself-436030.html