Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice, 6th Edition - townsend2009

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 73 Nurses are constantly faced with the challenge of making Knowledge of the legal and ethical concepts present- difficult decisions regarding good and evil or life and death. ed in this chapter will enhance the quality of care the Complex situations frequently arise in caring for individu- nurse provides in his or her psychiatric/mental health als with mental illness, and nurses are held to the highest nursing practice, while also protecting the nurse within level of legal and ethical accountability in their professional the parameters of legal accountability. Indeed, the very practice. This chapter provides a reference for the student right to practice nursing carries with it the responsibility and practicing nurse of the basic ethical and legal concepts to maintain a specific level of competency and to practice and their relationship to psychiatric/mental health nursing. in accordance with certain ethical and legal standards of A discussion of ethical theory is presented as a foundation care. upon which ethical decisions may be made. The American Nurses’ Association (ANA, 2001) has established a code of CORE CONCEPTS ethics for nurses to use as a framework within which to make ethical choices and decisions (Box 5–1). Ethics is the science that deals with the rightness and wrongness of actions (Aiken, 2004). Bioethics is the Because legislation determines what is right or good term applied to these principles when they refer to within a society, legal issues pertaining to psychiatric/men- concepts within the scope of medicine, nursing, and tal health nursing are also discussed in this chapter. allied health. Definitions are presented, along with rights of psychiatric clients of which nurses must be aware. Nursing competen- Moral behavior is defined as conduct that results cy and client care accountability are compromised when from serious critical thinking about how individuals the nurse has inadequate knowledge about the laws that ought to treat others. Moral behavior reflects the way regulate the practice of nursing. a person interprets basic respect for other persons, such as the respect for autonomy, freedom, justice, B O X 5 – 1 American Nurses’ Association honesty, and confidentiality (Pappas, 2006). Code of Ethics for Nurses 1. The nurse, in all professional relationships, practices Values are ideals or concepts that give meaning to with compassion and respect for the inherent dignity, the individual’s life (Aiken, 2004). Values clarification worth and uniqueness of every individual, unrestricted is a process of self-exploration through which individ- by consideration of social or economic status, personal uals identify and rank their own personal values. This attributes, or the nature of health problems. process increases awareness about why individuals 2. The nurse’s primary commitment is to the patient behave in certain ways. Values clarification is impor- whether an individual, family, group or community. tant in nursing to increase understanding about why 3. The nurse promotes, advocates for and strives to protect certain choices and decisions are made over others the health, safety, and rights of the patient. and how values affect nursing outcomes. 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate A right is defined as, “a valid, legally recognized delegation of tasks consistent with the nurse’s obligation claim or entitlement, encompassing both freedom to provide optimum patient care. from government interference or discriminatory treat- 5. The nurse owes the same duties to self as to others, ment and an entitlement to a benefit or service” (Levy including the responsibility to preserve integrity and & Rubenstein, 1996). A right is absolute when there is safety, to maintain competence, and to continue no restriction whatsoever on the individual’s entitle- personal and professional growth. ment. A legal right is one on which the society has 6. The nurse participates in establishing, maintaining, and agreed and formalized into law. Both the National improving healthcare environments and conditions of League for Nursing (NLN) and the American Hospital employment conducive to the provision of quality Association (AHA) have established guidelines of healthcare and consistent with the values of the patients’ rights. Although these are not considered profession through individual and collective action. legal documents, nurses and hospitals are considered 7. The nurse participates in the advancement of the responsible for upholding these rights of patients. profession through contributions to practice, education, administration, and knowledge development. ETHICAL CONSIDERATIONS 8. The nurse collaborates with other health professionals and the public in promoting community, national, and Theoretical Perspectives international efforts to meet health needs. 9. The profession of nursing, as represented by associations An ethical theory is a moral principle or a set of moral and their members, is responsible for articulating nursing principles that can be used in assessing what is morally values, for maintaining the integrity of the profession right or morally wrong (Ellis & Hartley, 2004). These and its practice, and for shaping social policy. principles provide guidelines for ethical decision- SOURCE: Reprinted with permission from American Nurses making. Association, Code of Ethics for Nurses with Interpretive Statements, © 2001 American Nurses Publishing, American Nurses Foundation/ American Nurses Association, Washington, D.C.

74 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING Utilitarianism tendency of an acorn is to become an oak. What then is The basis of utilitarianism is “the greatest-happiness the natural potential, or tendency, of human beings? principle.” This principle holds that actions are right to Natural-law theorists focus on an attribute that is regard- the degree that they tend to promote happiness and ed as distinctively human, as separating human beings wrong as they tend to produce the reverse of happiness. from the rest of worldly creatures; that is, the ability to Thus, the good is happiness and the right is that which live according to the dictates of reason. It is with this abil- promotes the good. Conversely, the wrongness of an ity to reason that humans are able to choose “good” over action is determined by its tendency to bring about “evil.” In natural law, evil acts are never condoned, even unhappiness. An ethical decision based on the utilitarian if they are intended to advance the noblest of ends. view looks at the end results of the decision. Action is taken based on the end results that produced the most Ethical Egoism good (happiness) for the most people. Ethical egoism espouses that what is right and good is what is best for the individual making the decision. An Kantianism individual’s actions are determined by what is to his or Named for philosopher Immanuel Kant, Kantianism is her own advantage. The action may not be best for any- directly opposed to utilitarianism. Kant argued that it is one else involved, but consideration is only for the indi- not the consequences or end results that make an action vidual making the decision. right or wrong; rather it is the principle or motivation on which the action is based that is the morally decisive fac- Ethical Dilemmas tor. Kantianism suggests that our actions are bound by a An ethical dilemma is a situation that requires an indi- sense of duty. This theory is often called deontology (from vidual to make a choice between two equally unfavorable the Greek word deon, which means “that which is bind- alternatives (Catalano, 2006). Evidence exists to support ing; duty”). Kantian-directed ethical decisions are made both moral “rightness” and moral “wrongness” related out of respect for moral law. For example, “I make this to a certain action. The individual who must make the choice because it is morally right and my duty to do so” choice experiences conscious conflict regarding the (not because of consideration for a possible outcome). decision. Christian Ethics Ethical dilemmas arise when no explicit reasons exist A basic principle that might be called a Christian philos- that govern an action. Ethical dilemmas generally create a ophy is that which is known as the golden rule: “Do unto great deal of emotion. Often the reasons supporting each others as you would have them do unto you” and, alter- side of the argument for action are logical and appropri- natively, “Do not do unto others what you would not ate. The actions associated with both sides are desirable in have them do unto you.” The imperative demand of some respects and undesirable in others. In most situa- Christian ethics is to treat others as moral equals and to tions, taking no action is considered an action taken. recognize the equality of other persons by permitting them to act as we do when they occupy a position similar Ethical Principles to ours. Ethical principles are fundamental guidelines that influ- ence decision-making. The ethical principles of autono- Natural Law Theories my, beneficence, nonmaleficence, veracity, and justice are The most general moral precept of the natural law the- helpful and used frequently by health care workers to ory is “do good and avoid evil.” Based on the writings of assist with ethical decision-making. St. Thomas Aquinas, natural-law theorists contend that ethics must be grounded in a concern for the human Autonomy good. Although the nature of this “human good” is not The principle of autonomy arises from the Kantian duty of expounded upon, Catholic theologians view natural law respect for persons as rational agents. This viewpoint as the law inscribed by God into the nature of things—as emphasizes the status of persons as autonomous moral agents a species of divine law. According to this conception, the whose right to determine their destinies should always be Creator endows all things with certain potentialities or respected. This presumes that individuals are always capa- tendencies that serve to define their natural end. The ble of making independent choices for themselves. Health fulfillment of a thing’s natural tendencies constitutes the care workers know this is not always the case. Children, specific good of that thing. For example, the natural comatose individuals, and the seriously mentally ill are

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 75 examples of clients who are incapable of making informed Justice choices. In these instances, a representative of the individ- The principle of justice has been referred to as the “jus- ual is usually asked to intervene and give consent. However, tice as fairness” principle. It is sometimes referred to as health care workers must ensure that respect for an individ- distributive justice, and its basic premise lies with the right of ual’s autonomy is not disregarded in favor of what another individuals to be treated equally regardless of race, sex, person may view as best for the client. marital status, medical diagnosis, social standing, economic level, or religious belief (Aiken, 2004). The concept of Beneficence justice reflects a duty to treat all individuals equally and Beneficence refers to one’s duty to benefit or promote fairly. When applied to health care, this principle sug- the good of others. Health care workers who act in their gests that all resources within the society (including clients’ interests are beneficent, provided their actions health care services) ought to be distributed evenly with- really do serve the client’s best interest. In fact, some out respect to socioeconomic status. Thus, according to duties do seem to take preference over other duties. For this principle, the vast disparity in the quality of care dis- example, the duty to respect the autonomy of an individ- pensed to the various classes within our society would be ual may be overridden when that individual has been considered unjust. A more equitable distribution of care deemed harmful to self or others. Aiken (2004) states, for all individuals would be favored. “The difficulty that sometimes arises in implementing the principle of beneficence lies in determining what Veracity exactly is good for another and who can best make that The principle of veracity refers to one’s duty to always decision.” be truthful. Aiken (2004) states, “Veracity requires that the health care provider tell the truth and not intention- Peplau (1991) recognized client advocacy as an essen- ally deceive or mislead clients.” There are times when tial role for the psychiatric nurse. The term advocacy limitations must be placed on this principle, such as means acting in another’s behalf—being a supporter or when the truth would knowingly produce harm or inter- defender. Being a client advocate in psychiatric nursing fere with the recovery process. Being honest is not means helping the client fulfill needs that, without assis- always easy, but rarely is lying justified. Clients have the tance and because of their illness, may go unfulfilled. right to know about their diagnosis, treatment, and Individuals with mental illness are not always able to prognosis. speak for themselves. Nurses serve in this manner to protect the client’s rights and interests. Strategies A Model for Making Ethical Decisions include educating clients and their families about their The following is a set of steps that may be used in mak- legal rights, ensuring that clients have sufficient infor- ing an ethical decision. These steps closely resemble the mation to make informed decisions or to give informed steps of the nursing process. consent, and assisting clients to consider alternatives and 1. Assessment: Gather the subjective and objective data supporting them in the decisions they make. In addition, nurses may act as advocates by speaking on behalf of about a situation. Consider personal values as well as individuals with mental illness to secure essential mental values of others involved in the ethical dilemma. health services. 2. Problem Identification: Identify the conflict between two or more alternative actions. Nonmaleficence 3. Plan: Nonmaleficence is the requirement that health care a. Explore the benefits and consequences of each providers do no harm to their clients, either intentionally or unintentionally (Aiken, 2004). Some philosophers alternative. suggest that this principle is more important than benef- b. Consider principles of ethical theories. icence; that is, they support the notion that it is more c. Select an alternative. important to avoid doing harm than it is to do good. In 4. Implementation: Act on the decision made and com- any event, ethical dilemmas often arise when a conflict municate the decision to others. exists between an individual’s rights (the duty to pro- 5. Evaluation: Evaluate outcomes. mote good) and what is thought to best represent the A schematic of this model is presented in Figure 5–1. A welfare of the individual (the duty to do no harm). An case study using this decision-making model is presented example of this conflict might occur when administering in Box 5–2. If the outcome is acceptable, action continues chemotherapy to a cancer patient, knowing it will pro- in the manner selected. If the outcome is unacceptable, long his or her life, but create “harm” (side effects) in the benefits and consequences of the remaining alternatives short term.

76 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING Assessment of a Although many courts are supporting a client’s right Situation to refuse medications in the psychiatric area, some limi- tations do exist. Weiss-Kaffie and Purtell (2001) state: A problem that requires action The treatment team must determine that three criteria be met to force medication without client consent. The client must is identified exhibit behavior that is dangerous to self or others; the medica- tion ordered by the physician must have a reasonable chance Conflict exists between alternatives of providing help to the client; and clients who refuse med- ication must be judged incompetent to evaluate the benefits Action A Ethical Action B of the treatment in question. (p. 361) conflict exists Benefits Consequences Benefits Consequences The Right to the Least-Restrictive Treatment Alternative Consider principles of ethical theories Health care personnel must attempt to provide treat- ment in a manner that least restricts the freedom of 1. To bring the greatest pleasure to the most people clients. The “restrictiveness” of psychiatric therapy can 2. To perform one's duty: be described in the context of a continuum, based on severity of illness. Clients may be treated on an outpa- duty to respect the patient's autonomy tient basis, in day hospitals, or in voluntary or involun- duty to promote good tary hospitalization. Symptoms may be treated with duty to do no harm verbal rehabilitative techniques and move successively to duty to treat all people equally and fairly behavioral techniques, chemical interventions, mechani- duty to always be truthful cal restraints, or electroconvulsive therapy. The problem 3. To do unto others as you would have them do unto you appears to arise in selecting the least restrictive means 4. To promote the natural laws of God among involuntary chemical intervention, seclusion, and 5. To consider that which is best for the decision maker mechanical restraints. Sadock and Sadock (2007) state: Select an alternative Distinguishing among these interventions on the basis of Take action and communicate restrictiveness proves to be a purely subjective exercise fraught with personal bias. Moreover, each of these three Evaluate the outcome interventions is both more and less restrictive than each of the other two. Nevertheless, the effort should be made to Acceptable Unacceptable think in terms of restrictiveness when deciding how to treat patients. (p. 1376) FIGURE 5–1 Ethical decision-making model. are reexamined, and steps 3 through 7 in Box 5–2 are repeated. Ethical Issues in Psychiatric/Mental LEGAL CONSIDERATIONS Health Nursing In 1980, the 96th Congress of the United States passed The Right to Refuse Medication the Mental Health Systems Act, which includes a Patient’s The AHA’s (1992) Patient’s Bill of Rights states: “The Bill of Rights, for recommendation to the States. An patient has the right to refuse treatment to the extent per- adaptation of these rights is presented in Box 5–3. mitted by law, and to be informed of the medical consequences of his action.” In psychiatry, refusal Nurse Practice Acts of treatment primarily concerns the administration The legal parameters of professional and practical nursing of psychotropic medications. “To the extent permitted by are defined within each state by the state’s nurse practice law” may be defined within the U.S. Constitution and act. These documents are passed by the state legislature and several of its amendments (e.g., the First Amendment, in general are concerned with such provisions as which addresses the rights of speech, thought, and expres- the following: sion; the Eighth Amendment, which grants the right to ● The definition of important terms, including the defi- freedom from cruel and unusual punishment; and the Fifth and Fourteenth Amendments, which grant due nition of nursing and the various types of nurses process of law and equal protection for all). In psychiatry, recognized “the medical consequences of his action” may include ● A statement of the education and other training or such steps as involuntary commitment, legal competency requirements for licensure and reciprocity hearing, or client discharge from the hospital.

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 77 B O X 5 – 2 Ethical Decision Making—A Case Study Step 1. Assessment 3. Alternative 3. A referral would respect the client’s auton- omy, would promote good, would do no harm (except Tonja is a 17-year-old girl who is currently on the psychiatric perhaps to Kimberly’s ego from the possible reprimand), unit with a diagnosis of conduct disorder. Tonja reports that and this decision would comply with Kimberly’s she has been sexually active since she was 14. She had an abor- Christian ethic. tion when she was 15 and a second one just 6 weeks ago. She states that her mother told her she has “had her last abortion,” Step 5. Select an Alternative and that she has to start taking birth control pills. She asks her nurse, Kimberly, to give her some information about the pills Alternative 3 is selected based on the ethical theories of and to tell her how to go about getting some. Kimberly utilitarianism (does the most good for the greatest number), believes Tonja desperately needs information about birth con- Christian ethics (Kimberly’s belief of “Do unto others as you trol pills, as well as other types of contraceptives; however, the would have others do unto you”), and Kantianism (to perform psychiatric unit is part of a Catholic hospital, and hospital pol- one’s duty), and the ethical principles of autonomy, benefi- icy prohibits distributing this type of information. cence, and nonmaleficence. The success of this decision Step 2. Problem Identification depends on the client’s follow-through with the referral and compliance with use of the contraceptives. A conflict exists between the client’s need for information, the Step 6. Take Action and Communicate nurse’s desire to provide that information, and the institution’s policy prohibiting the provision of that information. Taking action involves providing information in writing for Step 3. Alternatives—Benefits and Consequences Tonja, perhaps making a phone call and setting up an appoint- ment for her with Planned Parenthood. Communicating sug- 1. Alternative 1. Give the client information and risk gests sharing the information with Tonja’s mother. losing job. Communication also includes documentation of the referral in the client’s chart. 2. Alternative 2. Do not give client information and Step 7. Evaluate the Outcome compromise own values of holistic nursing. An acceptable outcome might indicate that Tonja did indeed 3. Alternative 3. Refer client to another source outside the keep her appointment at Planned Parenthood and is hospital and risk reprimand from supervisor. complying with the prescribed contraceptive regimen. It might also include Kimberly’s input into the change process in Step 4. Consider Principles of Ethical Theories her institution to implement these types of referrals to other clients who request them. 1. Alternative 1. Giving the client information would certainly respect the client’s autonomy and would An unacceptable outcome might be indicated by Tonja’s benefit the client by decreasing her chances of becoming lack of follow-through with the appointment at Planned pregnant again. It would not be to the best advantage of Parenthood or lack of compliance in using the contraceptives, Kimberly, in that she would likely lose her job. And resulting in another pregnancy. Kimberly may also view a rep- according to the beliefs of the Catholic hospital, the rimand from her supervisor as an unacceptable outcome, par- natural laws of God would be violated. ticularly if she is told that she must select other alternatives should this situation arise in the future. This may motivate 2. Alternative 2. Withholding information restricts the client’s Kimberly to make another decision—that of seeking employ- autonomy. It has the potential for doing harm, in that ment in an institution that supports a philosophy more con- without the use of contraceptives, the client may become sistent with her own. pregnant again (and she implies that this is not what she wants). Kimberly’s Christian ethic is violated in that this action is not what she would want “done unto her.” ● Broad statements that describe the scope of practice Types of Law for various levels of nursing (APN, RN, LPN) There are two general categories or types of law that are of most concern to nurses: statutory law and common ● Conditions under which a nurse’s license may be sus- law. These laws are identified by their source or origin. pended or revoked, and instructions for appeal Statutory Law ● The general authority and powers of the state board of A statutory law is a law that has been enacted by a leg- nursing (Fedorka & Resnick, 2001). islative body, such as a county or city council, state legis- lature, or the Congress of the United States. An example Most nurse practice acts are general in their terminology, of statutory law is the nurse practice acts. and do not provide specific guidelines for practice. Nurses must understand the scope of practice that is pro- tected by their license, and should seek assistance from legal counsel if they are unsure about the proper inter- pretation of a nurse practice act.

78 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING B O X 5 – 3 Bill of Rights for Psychiatric Civil Law Patients Civil law protects the private and property rights of indi- 1. The right to appropriate treatment and related services viduals and businesses. Private individuals or groups may in the setting that is most supportive and least bring a legal action to court for breach of civil law. These restrictive to personal freedom. legal actions are of two basic types: torts and contracts. 2. The right to an individualized, written treatment or service plan; the right to treatment based on such plan; Torts. A tort is a violation of a civil law in which an and the right to periodic review and revision of the individual has been wronged. In a tort action, one party plan based on treatment needs. asserts that wrongful conduct on the part of the other has 3. The right, consistent with one’s capabilities, to caused harm, and seeks compensation for harm suffered. participate in and receive a reasonable explanation of A tort may be intentional or unintentional. Examples of the care and treatment process. unintentional torts are malpractice and negligence 4. The right to refuse treatment except in an emergency actions. An example of an intentional tort is the touching situation or as permitted by law. of another person without that person’s consent. 5. The right not to participate in experimentation in the Intentional touching (e.g., a medical treatment) without absence of informed, voluntary, written consent. the client’s consent can result in a charge of battery, an 6. The right to freedom from restraint or seclusion intentional tort. except in an emergency situation. 7. The right to a humane treatment environment that Contracts. In a contract action, one party asserts that affords reasonable protection from harm and the other party, in failing to fulfill an obligation, has appropriate privacy. breached the contract, and either compensation or per- 8. The right to confidentiality of medical records (also formance of the obligation is sought as remedy. An exam- applicable following patient’s discharge). ple is an action by a mental health professional whose 9. The right of access to medical records except clinical privileges have been reduced or terminated in information received from third parties under promise violation of an implied contract between the professional of confidentiality, and when access would be and a hospital. detrimental to the patient’s health (also applicable following patient’s discharge). Criminal Law 10. The right of access to use of the telephone, personal Criminal law provides protection from conduct deemed mail, and visitors, unless deemed inappropriate for injurious to the public welfare. It provides for punish- treatment purposes. ment of those found to have engaged in such conduct, 11. The right to be informed of these rights in which commonly includes imprisonment, parole condi- comprehensible language. tions, a loss of privilege (such as a license), a fine, or any 12. The right to assert grievances if rights are infringed. combination of these (Ellis & Hartley, 2004). An exam- 13. The right to referral as appropriate to other providers ple of a violation of criminal law is the theft by a hospital of mental health services upon discharge. employee of supplies or drugs. SOURCE: Adapted from Mental Health Systems Act (1980). Legal Issues in Psychiatric/Mental Health Common Law Nursing Common laws are derived from decisions made in Confidentiality and Right to Privacy previous cases. These laws apply to a body of princi- The Fourth, Fifth, and Fourteenth Amendments to the ples that evolve from court decisions resolving various U.S. Constitution protect an individual’s privacy. Most controversies. Because common law in the United states have statutes protecting the confidentiality of States has been developed on a state basis, the law on client records and communications. The only individuals specific subjects may differ from state to state. An who have a right to observe a client or have access to example of a common law might be how different medical information are those involved in his or her states deal with a nurse’s refusal to provide care for a medical care. specific client. Until 1996, client confidentiality in medical records was Classifications Within Statutory and not protected by federal law. In August 1996, President Common Law Clinton signed the Health Insurance Portability and Broadly speaking, there are two kinds of unlawful acts: Accountability Act (HIPAA) into law. Under this law, civil and criminal. Both statutory law and common law individuals have the rights to access their medical have civil and criminal components. records, to have corrections made to their medical

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 79 records, and to decide with whom their medical informa- Most states have statutes that pertain to the doctrine tion may be shared. The actual document belongs to the of privileged communication. Although the codes dif- facility or the therapist, but the information contained fer markedly from state to state, most grant certain pro- therein belongs to the client. fessionals privileges under which they may refuse to reveal information about, and communications with, This federal privacy rule pertains to data that is called clients. In most states, the doctrine of privileged commu- protected health information (PHI) and applies to most indi- nication applies to psychiatrists and attorneys; in some viduals and institutions involved in health care. Notice of instances, psychologists, clergy, and nurses are also privacy policies must be provided to clients upon entry included. into the health care system. PHI are individually identifi- able health information indicators and “relate to past, In certain instances, nurses may be called on to testify present, or future physical or mental health or condition in cases in which the medical record is used as evidence. of the individual, or the past, present, or future payment In most states, the right to privacy of these records is for the provision of health care to an individual; and (1) exempted in civil or criminal proceedings. Therefore, it that identifies the individual; or (2) with respect to which is important that nurses document with these possibilities there is a reasonable basis to believe the information can in mind. Strict record keeping using statements that are be used to identify the individual” (U.S. Department of objective and nonjudgmental, having care plans that are Health and Human Services, 2003). These specific iden- specific in their prescriptive interventions, and keeping tifiers are listed in Box 5–4. documentation that describes those interventions and their subsequent evaluation all serve the best interests of Pertinent medical information may be released with- the client, the nurse, and the institution in case questions out consent in a life-threatening situation. If information regarding care should arise. Documentation very often is released in an emergency, the following information weighs heavily in malpractice case decisions. must be recorded in the client’s record: date of disclosure, person to whom information was disclosed, reason for The right to confidentiality is a basic one, and espe- disclosure, reason written consent could not be obtained, cially so in psychiatry. Although societal attitudes are and the specific information disclosed. improving, individuals have experienced discrimination in the past for no other reason than for having a history B O X 5 – 4 Protected Health Information of emotional illness. Nurses working in psychiatry must (PIH): Individually Identifiable Indicators guard the privacy of their clients with great diligence. 1. Names 2. Postal address information, (except State), including Informed Consent street address, city, county, precinct, and zip code According to law, all individuals have the right to decide 3. All elements of dates (except year) directly related to whether to accept or reject treatment (Guido, 2006). A an individual, including birth date, admission date, dis- health care provider can be charged with assault and bat- charge date, date of death; and all ages over 89 and all tery for providing life-sustaining treatment to a client elements of dates (including year) indicative of such when the client has not agreed to it. The rationale for the age, except that such ages and elements may be aggre- doctrine of informed consent is the preservation and gated into a single category of age 90 or older protection of individual autonomy in determining what 4. Telephone numbers will and will not happen to the person’s body (Guido, 5. Fax numbers 2006). 6. Electronic mail addresses 7. Social security numbers Informed consent is a client’s permission granted to a 8. Medical record numbers physician to perform a therapeutic procedure, before 9. Health plan beneficiary numbers which information about the procedure has been pre- 10. Account numbers sented to the client with adequate time given for consid- 11. Certificate/license numbers eration about the pros and cons. The client should 12. Vehicle identifiers and serial numbers, including receive information such as what treatment alternatives license plate numbers are available; why the physician believes this treatment 13. Device identifiers and serial numbers is most appropriate; the possible outcomes, risks, and 14. Web Universal Resource Locators (URLs) adverse effects; the possible outcome should the client 15. Internet Protocol (IP) address numbers select another treatment alternative; and the possible 16. Biometric identifiers, including finger and voice prints outcome should the client choose to have no treatment. 17. Full face photographic images and any comparable An example of a treatment in the psychiatric area that images requires informed consent is electroconvulsive therapy. 18. Any other unique identifying number, characteristic, or code There are some conditions under which treatment SOURCE: U.S. Department of Health and Human Services. may be performed without obtaining informed consent.

80 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING A client’s refusal to accept treatment may be challenged making or, if so, that the individual has a legal repre- under the following circumstances: (Aiken, 2004; Guido, sentative. 2006; Levy & Rubenstein, 1996; Mackay, 2001): 3. Free Will. The individual has given consent volunta- 1. When a client is mentally incompetent to make a deci- rily without pressure or coercion from others. sion and treatment is necessary to preserve life or Restraints and Seclusion avoid serious harm. An individual’s privacy and personal security are protected 2. When refusing treatment endangers the life or health by the U.S. Constitution and supported by the Mental of another. Health Systems Act of 1980, out of which was conceived 3. During an emergency, in which a client is in no con- a Bill of Rights for psychiatric patients. These include dition to exercise judgment. “the right to freedom from restraint or seclusion except 4. When the client is a child (consent is obtained from in an emergency situation.” parent or surrogate). 5. In the case of therapeutic privilege. In therapeutic In psychiatry, the term restraints generally refers to a privilege, information about a treatment may be with- set of leather straps that are used to restrain the extremi- held if the physician can show that full disclosure ties of an individual whose behavior is out of control and would who poses an inherent risk to the physical safety and psy- a. Hinder or complicate necessary treatment chological well-being of the individual and staff. b. Cause severe psychological harm Restraints are never to be used as punishment or for the c. Be so upsetting as to render a rational decision by convenience of staff. Other measures to decrease agita- tion, such as “talking down” (verbal intervention) and the client impossible chemical restraints (tranquilizing medication) are usually Although most clients in psychiatric/mental health facil- tried first. If these interventions are ineffective, mechan- ities are competent and capable of giving informed con- ical restraints may be instituted (although some contro- sent, those with severe psychiatric illness do not possess versy exists as to whether chemical restraints are indeed the cognitive ability to do so. If an individual has been less restrictive than mechanical restraints). Seclusion is legally determined to be mentally incompetent, consent another type of physical restraint in which the client is is obtained from the legal guardian. Difficulty arises confined alone in a room from which he or she is unable when no legal determination has been made, but the indi- to leave. The room is usually minimally furnished with vidual’s current mental state prohibits informed decision items to promote the client’s comfort and safety. making (e.g., the person who is psychotic, unconscious, or inebriated). In these instances, informed consent is The Joint Commission on Accreditation of Healthcare usually obtained from the individual’s nearest relative, or Organizations (JCAHO) has released a set of revisions to if none exist and time permits, the physician may ask the its previous restraint and seclusion standards. The intent court to appoint a conservator or guardian. When time of these revisions is to reduce the use of this intervention does not permit court intervention, permission may as well as to provide greater assurance of safety and pro- be sought from the hospital administrator. tection to individuals placed in restraints or seclusion for reasons related to psychiatric disorders or substance abuse A client or guardian always has the right to withdraw (Medscape, 2000). In addition to others, these provisions consent after it has been given. When this occurs, the provide the following guidelines: physician should inform (or reinform) the client about 1. In the event of an emergency, restraints or seclusion the consequences of refusing treatment. If treatment has already been initiated, the physician should terminate may be initiated without a physician’s order. treatment in a way least likely to cause injury to the client 2. As soon as possible, but no longer than one hour after and inform the client or guardian of the risks associated with interrupted treatment (Guido, 2006). the initiation of restraints or seclusion, a qualified staff member must notify the physician about the individ- The nurse’s role in obtaining informed consent is usu- ual’s physical and psychological condition and obtain a ally defined by agency policy. A nurse may sign the verbal or written order for the restraints or seclusion. consent form as witness for the client’s signature. 3. Orders for restraints or seclusion must be reissued by However, legal liability for informed consent lies with a physician every 4 hours for adults age 18 and older, the physician. The nurse acts as client advocate to ensure 2 hours for children and adolescents ages 9 to 17, and that the following three major elements of informed con- every hour for children younger than 9 years. sent have been addressed: 4. An in-person evaluation of the individual must be 1. Knowledge. The client has received adequate infor- made by the physician within 4 hours of the initiation of restraints or seclusion of an adult age 18 or older mation on which to base his or her decision. and within 2 hours for children and adolescents ages 2. Competency. The individual’s cognition is not 17 and younger. impaired to an extent that would interfere with decision

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 81 5. Minimum time frames for an in-person re-evaluation commitments are made for various reasons. Most states by a physician include 8 hours for individuals ages 18 commonly cite the following criteria: years and older, and 4 hours for individuals ages 17 1. In an emergency situation (for the client who is dan- and younger. gerous to self or others). 6. If an individual is no longer in restraints or seclusion 2. For observation and treatment of mentally ill persons. when an original verbal order expires, the physician 3. When an individual is unable to take care of basic per- must conduct an in-person evaluation within 24 hours of initiation of the intervention. sonal needs (the “gravely disabled”). Clients in restraints or seclusion must be observed and Under the Fourth Amendment, individuals are protected from unlawful searches and seizures without probable assessed every 10 to 15 minutes with regard to circula- cause. Therefore, the individual seeking the involuntary tion, respiration, nutrition, hydration, and elimination. commitment must show probable cause why the client Such attention should be documented in the client’s should be hospitalized against his or her wishes; that is, the record. person must show that there is cause to believe that the person would be dangerous to self or others, is mentally False imprisonment is the deliberate and unautho- ill and in need of treatment, or is gravely disabled. rized confinement of a person within fixed limits by the use of verbal or physical means (Ellis & Hartley, 2004). Emergency Commitments. Emergency commitments Healthcare workers may be charged with false imprison- are sought when an individual manifests behavior that is ment for restraining or secluding—against the wishes of clearly and imminently dangerous to self or others. the client—anyone having been admitted to the hospital These admissions are usually instigated by relatives or voluntarily. Should a voluntarily admitted client decom- friends of the individual, police officers, the court, or pensate to a point that restraint or seclusion for protec- health care professionals. Emergency commitments are tion of self or others is necessary, court intervention to time-limited, and a court hearing for the individual is determine competency and involuntary commitment is scheduled, usually within 72 hours. At that time the court required to preserve the client’s rights to privacy and may decide that the client may be discharged; or, if freedom. deemed necessary, and voluntary admission is refused by the client, an additional period of involuntary commit- Commitment Issues ment may be ordered. In most instances, another hearing Voluntary Admissions is scheduled for a specified time (usually in 7 to 21 days). Each year, more than one million persons are admitted to healthcare facilities for psychiatric treatment, of The Mentally Ill Person in Need of Treatment. A second which approximately two thirds are considered volun- type of involuntary commitment is for the observation tary. To be admitted voluntarily, an individual makes and treatment of mentally ill persons in need of treat- direct application to the institution for services and ment. Most states have established definitions of what may stay as long as treatment is deemed necessary. He constitutes “mentally ill” for purposes of state involun- or she may sign out of the hospital at any time, unless tary admission statutes. Some examples include individu- following a mental status examination the health care als who, because of severe mental illness, are: professional determines that the client may be harmful ● Unable to make informed decisions concerning treat- to self or others and recommends that the admission status be changed from voluntary to involuntary. ment Although these types of admissions are considered vol- ● Likely to cause harm to self or others untary, it is important to ensure that the individual ● Unable to fulfill basic personal needs necessary for comprehends the meaning of his or her actions, has not been coerced in any manner, and is willing to proceed health and safety with admission. In determining whether commitment is required, the court looks for substantial evidence of abnormal conduct— Involuntary Commitment evidence that cannot be explained as the result of a physi- Because involuntary hospitalization results in substantial cal cause. There must be “clear and convincing evidence” restrictions of the rights of an individual, the admission as well as “probable cause” to substantiate the need for process is subject to the guarantee of the Fourteenth involuntary commitment to ensure that an individual’s Amendment to the U.S. Constitution that provides citi- rights under the Constitution are protected. The U.S. zens protection against loss of liberty and ensures due Supreme Court in O’Connor v. Donaldson held that the process rights (Weiss-Kaffie & Purtell, 2001). Involuntary existence of mental illness alone does not justify involun- tary hospitalization. State standards require a specific impact or consequence to flow from the mental illness that involves danger or an inability to care for one’s own needs. These clients are entitled to court hearings with represen- tation, at which time determination of commitment and

82 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING length of stay are considered. Legislative statutes govern- Should it be determined that an individual is gravely ing involuntary commitments vary from state to state. disabled, a guardian, conservator, or committee will be appointed by the court to ensure the management of the Involuntary Outpatient Commitment. Involuntary outpa- person and his or her estate. To legally restore compe- tient commitment (IOC) is a court-ordered mechanism tency then requires another court hearing to reverse the used to compel a person with mental illness to submit to previous ruling. The individual whose competency is treatment on an outpatient basis. A number of eligibility being determined has the right to be represented by an criteria for commitment to outpatient treatment have attorney. been cited (Appelbaum, 2001; Maloy, 1996; Torrey & Zdanowicz, 2001). Some of these include: Nursing Liability 1. A history of repeated decompensation requiring invol- Mental health practitioners—psychiatrists, psychologists, psychiatric nurses, and social workers—have a duty untary hospitalization to provide appropriate care based on the standards of 2. Likelihood that without treatment the individual will their professions and the standards set by law. The standards of care for psychiatric/mental health nursing deteriorate to the point of requiring inpatient com- are presented in Chapter 9. mitment 3. Presence of severe and persistent mental illness (e.g., Malpractice and Negligence schizophrenia or bipolar disorder) and limited aware- The terms malpractice and negligence are often used ness of the illness or need for treatment interchangeably. Negligence has been defined as: 4. The presence of severe and persistent mental illness contributing to a risk of becoming homeless, incarcer- The failure to exercise the standard of care that a reasonably ated, or violent, or of committing suicide prudent person would have exercised in a similar situation; 5. The existence of an individualized treatment plan likely any conduct that falls below the legal standard established to to be effective and a service provider who has agreed protect others against unreasonable risk of harm, except for to provide the treatment conduct that is intentionally, wantonly, or willfully disre- Most states have already enacted IOC legislation or cur- gardful of others’ rights. (Garner, 1999) rently have resolutions that speak to this topic on their Any person may be negligent. In contrast, malpractice is agendas. Most commonly, clients who are committed into a specialized form of negligence applicable only to pro- the IOC programs are those with severe and persistent fessionals. mental illness, such as schizophrenia. The rationale behind the legislation is to reduce the numbers of readmissions Black’s Law Dictionary defines malpractice as: “An and lengths of hospital stays of these clients. Concern lies instance of negligence or incompetence on the part of a in the possibility of violating the individual rights of psy- professional. To succeed in a malpractice claim, a plain- chiatric clients without significant improvement in treat- tiff must also prove proximate cause and damages” ment outcomes. One study at Bellevue hospital in New (Garner, 1999). In the absence of any state statutes, com- York found no difference in treatment outcomes between mon law is the basis of liability for injuries to clients court ordered outpatient treatment and voluntary outpa- caused by acts of malpractice and negligence of individ- tient treatment (Steadman et al., 2001). Other studies have ual practitioners. In other words, most decisions of neg- shown positive outcomes, including a decrease in hospital ligence in the professional setting are based on legal readmissions, with IOC (Ridgely, Borum, & Petrila, 2001; precedent (decisions that have previously been made Swartz et al., 2001). Continuing research is required to about similar cases) rather than any specific action taken determine if IOC will improve treatment compliance and by the legislature. enhance quality of life in the community for individuals with severe and persistent mental illness. To summarize, when the breach of duty is character- The Gravely Disabled Client. A number of states have ized as malpractice, the action is weighed against the statutes that specifically define the “gravely disabled” professional standard. When it is brought forth as negli- client. For those that do not use this label, the descrip- gence, action is contrasted with what a reasonably pru- tion of the individual who, because of mental illness, is dent professional would have done in the same or similar unable to take care of basic personal needs is very similar. circumstances. Gravely disabled is generally defined as a condition in which an individual, as a result of mental illness, is in dan- Marchand (2001) cites the following basic elements of ger of serious physical harm resulting from inability to a nursing malpractice lawsuit: provide for basic needs such as food, clothing, shelter, 1. The existence of a duty, owed by the nurse to a medical care, and personal safety. Inability to care for one- self cannot be established by showing that an individual patient, to conform to a recognized standard of care lacks the resources to provide the necessities of life. Rather, it is the inability to make use of available resources.

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 83 2. A failure to conform to the required nursing standard For confining a client against his or her wishes, and of care outside of an emergency situation, the nurse may be charged with false imprisonment. Examples of actions 3. Actual injury that may invoke these charges include locking an individ- 4. A reasonably close causal connection between the ual in a room; taking a client’s clothes for purposes of detainment against his or her will; and retaining in nurse’s conduct and the patient’s injury mechanical restraints a competent voluntary client who For the client to prevail in a malpractice claim, each of demands to be released. these elements must be proved. Juries’ decisions are gen- erally based on the testimony of expert witnesses, Avoiding Liability because members of the jury are laypeople and cannot be Hall and Hall (2001) suggest the following proactive expected to know what nursing interventions should nursing actions in an effort to avoid nursing malpractice: have been carried out. Without the testimony of expert 1. Responding to the patient witnesses, a favorable verdict usually goes to the defen- 2. Educating the patient dant nurse. 3. Complying with the standard of care 4. Supervising care Types of Lawsuits that Occur in Psychiatric 5. Adhering to the nursing process Nursing 6. Documentation Most malpractice suits against nurses are civil actions; 7. Follow-up that is, they are considered breach of conduct actions on In addition, it is a positive practice to develop and main- the part of the professional, for which compensation is tain a good interpersonal relationship with the client and being sought. The nurse in the psychiatric setting should his or her family. Some clients appear to be more “suit be aware of the types of behaviors that may result in prone” than others. Suit-prone clients are often very crit- charges of malpractice. ical, complaining, uncooperative, and even hostile. A nat- ural response by the staff to these clients is to become Basic to the psychiatric client’s hospitalization is his or defensive or withdrawn. Either of these behaviors increas- her right to confidentiality and privacy. A nurse may be es the likelihood of a lawsuit should an unfavorable event charged with breach of confidentiality for revealing aspects occur (Ellis & Hartley, 2004). No matter how high the about a client’s case, or even for revealing that an individ- degree of technical competence and skill of the nurse, his ual has been hospitalized, if that person can show that or her insensitivity to a client’s complaints and failure to making this information known resulted in harm. meet the client’s emotional needs often influence whether or not a lawsuit is generated. A great deal depends on the When shared information is detrimental to the psychosocial skills of the health care professional. client’s reputation, the person sharing the information may be liable for defamation of character. When the CLINICAL PEARLS information is in writing, the action is called libel. Oral ● Always put the client’s rights and welfare first. defamation is called slander. Defamation of character ● Develop and maintain a good interpersonal involves communication that is malicious and false (Ellis & Hartley, 2004). Occasionally, libel arises out of relationship with each client and his or her critical, judgmental statements written in the client’s family. medical record. Nurses need to be very objective in their charting, backing up all statements with factual SUMMARY AND KEY POINTS evidence. ● Ethics is the science that deals with the rightness and Invasion of privacy is a charge that may result when a wrongness of actions. client is searched without probable cause. Many institu- ● Bioethics is the term applied to these principles when tions conduct body searches on mental clients as a routine intervention. In these cases, there should be a physician’s they refer to concepts within the scope of medicine, order and written rationale showing probable cause for nursing, and allied health. the intervention. Many institutions are reexamining their ● Moral behavior is defined as conduct that results policies regarding this procedure. from serious critical thinking about how individuals ought to treat others. Assault is an act that results in a person’s genuine fear and apprehension that he or she will be touched without consent. Battery is the unconsented touching of another person. These charges can result when a treatment is administered to a client against his or her wishes and out- side of an emergency situation. Harm or injury need not have occurred for these charges to be legitimate.

84 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING ● Values are ideals or concepts that give meaning to the ● Examples of ethical issues in psychiatric/mental health individual’s life. nursing include the right to refuse medication and the right to the least-restrictive treatment alternative. ● A right is defined as, “a valid, legally recognized claim or entitlement, encompassing both freedom from gov- ● Statutory laws are those that have been enacted by leg- ernment interference or discriminatory treatment and islative bodies, and common laws are derived from an entitlement to a benefit or service.” decisions made in previous cases. Both types of laws have civil and criminal components. ● The ethical theory of Utilitarianism is based on the premise that what is right and good is that which pro- ● Civil law protects the private and property rights of duces the most happiness for the most people. individuals and businesses, and criminal law provides protection from conduct deemed injurious to the pub- ● The ethical theory of Kantianism suggests that actions lic welfare. are bound by a sense of duty, and that ethical decisions are made out of respect for moral law. ● Legal issues in psychiatric/mental health nursing cen- ter around confidentiality and the right to privacy, ● The code of Christian ethics is to treat others as moral informed consent, restraints and seclusion, and com- equals and to recognize the equality of other persons mitment issues. by permitting them to act as we do when they occupy a position similar to ours. ● Nurses are accountable for their own actions in relation to these issues, and violation can result in malpractice ● The moral precept of the Natural Law theory is “do lawsuits against the physician, the hospital, and the nurse. good and avoid evil.” Good is viewed as that which is inscribed by God into the nature of things. Evil acts ● Developing and maintaining a good interpersonal are never condoned, even if they are intended to relationship with the client and his or her family advance the noblest of ends. appears to be a positive factor when the question of malpractice is being considered. ● Ethical egoism espouses that what is right and good is what is best for the individual making the decision. For additional clinical tools and study aids, visit DavisPlus. ● Ethical principles include autonomy, beneficence, nonmaleficence, veracity, and justice. ● An ethical dilemma is a situation that requires an indi- vidual to make a choice between two equally unfavor- able alternatives.

CHAPTER 5 ● ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING 85 REVIEW QUESTIONS Self-Examination/Learning Exercise Match the following decision-making examples with the appropriate ethical theory: 1. Carol decides to go against family wishes a. Utilitarianism and tell the client of his terminal status because that is what she would want if she were the client. 2. Carol decides to respect family wishes b. Kantianism and not tell the client of his terminal status because that would bring the most happiness to the most people. 3. Carol decides not to tell the client about c. Christian ethics his terminal status because it would be too uncomfortable for her to do so. 4. Carol decides to tell the client of his d. Natural law theories terminal status because her reasoning tells her that to do otherwise would be an evil act. 5. Carol decides to tell the client of his e. Ethical egoism terminal status because she believes it is her duty to do so. Match the following nursing actions with the possible legal action with which the nurse may be charged: 6. The nurse assists the physician with a. Breach of confidentiality electroconvulsive therapy on his client b. Defamation of character who has refused to give consent. c. Assault d. Battery 7. When the local newspaper calls to inquire why the mayor has been admitted e. False imprisonment to the hospital, the nurse replies, “He’s here because he is an alcoholic.” 8. A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. 9. Jack recently lost his wife and is very depressed. He is running for reelection to the Senate and asks the staff to keep his hospitalization confidential. The nurse is excited about having a Senator on the unit and tells her boyfriend about the admission, which soon becomes common knowledge. Jack loses the election. 10. Joe is very restless and is pacing a lot. The nurse says to Joe, “If you don’t sit down in the chair and be still, I’m going to put you in restraints!”

86 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING REFERENCES Aiken, T.D. (2004). Legal, ethical, and political issues in nursing (2nd Marchand, L. (2001). Legal terminology. In M.E. O’Keefe (Ed.), ed.). Philadelphia: F.A. Davis. Nursing practice and the law: Avoiding malpractice and other legal risks. Philadelphia: F.A. Davis, pp. 23–41. American Hospital Association (AHA). (1992). A Patient’s Bill of Rights. Chicago: American Hospital Association. Medscape Wire (2000). Joint Commission releases revised restraints standards for behavioral healthcare. Retrieved June 17, 2008 from http://www. American Nurses’ Association (ANA). (2001). Code of ethics for nurses medscape.com/ viewarticle/411832 with interpretive statements. Washington, DC: ANA. Mental Health Systems Act. P.L. 96-398, Title V, Sect. 501.94 Stat. Appelbaum, P.S. (2001, March). Thinking carefully about outpatient 1598, Oct 7, 1980. commitment. Psychiatric Services, 52(3), 347–350. Pappas, A. (2006). Ethical issues. In J. Zerwekh & J.C. Claborn Catalano, J.T. (2006). Nursing now! Today’s issues, tomorrow’s trends (4th (Eds.), Nursing today: Transition and trends (5th ed.). New York: ed.). Philadelphia: F.A. Davis. Elsevier, pp. 425–453. Ellis, J.R., & Hartley, C.L. (2004). Nursing in today’s world: Challenges, Peplau, H.E. (1991). Interpersonal relations in nursing: A conceptual issues, and trends (8th ed.). Philadelphia: Lippincott Williams & frame of reference for psychodynamic nursing. New York: Springer. Wilkins. Ridgely, M.S., Borum, R., & Petrila, J. (2001). The effectiveness of Fedorka, P., & Resnick, L.K. (2001). Defining nursing practice. In involuntary outpatient treatment: Empirical evidence and the experience M.E. O’Keefe (Ed.), Nursing practice and the law: Avoiding malpractice of eight states. Santa Monica, CA: Rand Publications. and other legal rights. Philadelphia: F.A. Davis, pp. 97–117. Sadock, B.J., & Sadock, V.A. (2007). Synopsis of psychiatry: Behavioral Garner, B.A. (Ed.). (1999). Black’s law dictionary. St. Paul, MN: West sciences/clinical psychiatry (10th ed.). Philadelphia: Lippincott Group. Williams & Wilkins. Guido, G.W. (2006). Legal and ethical issues in nursing (4th ed.). Upper Schwarz, M., Swanson, J., Hiday, V., Wagner, H.R., Burns, B., & Saddle River, NJ: Prentice-Hall. Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52(3), 325–329. Hall, J.K. & Hall, D. (2001). Negligence specific to nursing. In M.E. O’Keefe (Ed.). Nursing practice and the law: Avoiding malpractice and Steadman, H., Gounis, K., Dennis, D., Hopper, K., Roche, B., other legal risks. Philadelphia: F.A. Davis, pp. 132–149. Swartz, M., & Robbins, P. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Levy, R.M., & Rubenstein, L.S. (1996). The rights of people with mental Services, 52(3), 330–336. disabilities. Carbondale, IL: Southern Illinois University Press. Torrey, E.F. (2001). Outpatient commitment: What, Why, and for Mackay, T.R. (2001). Informed consent. In M.E. O’Keefe (Ed.), Whom. Psychiatric Services, 52(3), 337–341. Nursing practice and the law: Avoiding malpractice and other legal risks. Philadelphia: F.A. Davis, pp. 199–213. Weiss-Kaffie, C.J., & Purtell, N.E. (2001). Psychiatric nursing. In M.E. O’Keefe (Ed.), Nursing practice and the law: Avoiding malprac- Maloy, K.A. (1996). Does involuntary outpatient commitment work? tice and other legal risks. Philadelphia: F.A. Davis, pp. 352–371. In B.D. Sales & S.A. Shah (Eds.), Mental health and law: Research, policy and services. Durham, NC: Carolina Academic Press, pp. 41–74.

6 CHAPTER Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health Nursing CHAPTER OUTLINE OBJECTIVES SPIRITUAL CONCEPTS CULTURAL CONCEPTS ASSESSMENT OF SPIRITUAL AND RELIGIOUS NEEDS HOW DO CULTURES DIFFER? SUMMARY AND KEY POINTS APPLICATION OF THE NURSING PROCESS REVIEW QUESTIONS KEY TERMS CORE CONCEPTS curandera folk medicine culture curandero shaman ethnicity culture-bound stereotyping religion territoriality spirituality syndromes yin and yang density distance OBJECTIVES After reading this chapter, the student will be able to: 1. Define and differentiate between culture g. Arab Americans and ethnicity. h. Jewish Americans 4. Apply the nursing process in the care 2. Identify cultural differences based on six of individuals from various cultural characteristic phenomena. groups. 5. Define and differentiate between 3. Describe cultural variances, based on the spirituality and religion. six phenomena, for 6. Identify clients’ spiritual and religious a. Northern European Americans. needs. b. African Americans. 7. Apply the six steps of the nursing c. Native Americans. process to individuals with spiritual and d. Asian/Pacific Islander Americans. religious needs. e. Latino Americans. f. Western European Americans. 87

88 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING CORE CONCEPTS Why is this important? Cultural influences affect human behavior, its interpretation, and the response to it. Culture describes a particular society’s entire way of Therefore, it is essential for nurses to understand the living, encompassing shared patterns of belief, feel- effects of these cultural influences if they are to work ing, and knowledge that guide people’s conduct and effectively with the diverse U.S. population. Caution are passed down from generation to generation. must be taken, however, not to assume that all individu- Ethnicity is a somewhat narrower term, and relates to als who share a cultural or ethnic group are identical, or people who identify with each other because of a exhibit behaviors perceived as characteristic of the group. shared heritage (Griffith, Gonzalez, & Blue, 2003). This constitutes stereotyping, and must be avoided. Many variations and subcultures occur within a culture. CULTURAL CONCEPTS The differences may be related to status, ethnic back- ground, residence, religion, education, or other factors What is culture? How does it differ from ethnicity? Why (Purnell & Paulanka, 2003). Every individual must be are these questions important? The answers lie in the appreciated for his or her uniqueness. changing face of America. Immigration is not new in the United States. Indeed, most U.S. citizens are either immi- This chapter explores the ways in which various cul- grants or descendants of immigrants. The pattern contin- tures differ. The nursing process is applied to the delivery ues because of the many individuals who want to take of psychiatric–mental health nursing care for individuals advantage of the technological growth and upward mobil- from the following cultural groups: Northern European ity that exists in this country. A breakdown of cultural Americans, African Americans, Native Americans, Asian/ groups in the United States is presented in Figure 6–1. Pacific Islander Americans, Latino Americans, Western European Americans, Arab Americans, and Jewish Griffin (2002) states: Americans. Most researchers agree that the United States, long a desti- nation of immigrants, continues to grow more culturally HOW DO CULTURES DIFFER? diverse. According to the U.S. Census Bureau, the number It is difficult to generalize about any one specific group in of foreign-born residents in the country jumped from a country that is known for its heterogeneity. Within our roughly 19.8 million to a little more than 28 million between American “melting pot” any or all characteristics could 1990 and 2000. What’s more, experts predict that Caucasians, apply to individuals within any or all of the cultural who now represent about 70 percent of the U.S. population, groups represented. As these differences continue to be will account for barely more than 50 percent by the year integrated, one American culture will eventually emerge. 2050. (p. 14) This is already in evidence in certain regions of the coun- try today, particularly in the urban coastal areas. Native Hawaiian or However, some differences still exist, and it is important Pacific Islander for nurses to be aware of certain cultural influences that (0.1%) may affect individuals’ behaviors and beliefs, particularly Asian Ot(h5e.2r %ra)cemoT(1rwe.9or%aoc)res as they apply to health care. (4.2%) Giger and Davidhizar (2004) suggest six cultural phe- American Indian or nomena that vary with application and use but yet are Alaska Native evidenced among all cultural groups: (1) communication, (0.8%) (2) space, (3) social organization, (4) time, (5) environ- mental control, and (6) biological variations. African American (12.2%) Communication All verbal and nonverbal behavior in connection with Hispanic or Latino another individual is communication. Therapeutic com- (14%) munication has always been considered an essential part White of the nursing process and represents a critical element in (61.6%) the curricula of most schools of nursing. Communication has its roots in culture. Cultural mores, norms, ideas, and FIGURE 6–1 Breakdown of cultural groups in the United States. customs provide the basis for our way of thinking. (Source: U.S. Census Bureau, 2006.) Cultural values are learned and differ from society to society. Individuals communicate through language (the spoken and written word), paralanguage (the voice

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 89 quality, intonation, rhythm, and speed of the spoken is met only if the individual has control of a space, can word), and gestures (touch, facial expression, eye move- establish rules for that space, and is able to defend the ments, body posture, and physical appearance). The space against invasion or misuse by others (Giger & nurse who is planning care must have an understanding Davidhizar, 2004). Density, which refers to the number of of the client’s needs and expectations as they are being people within a given environmental space, can influence communicated. As a third party, an interpreter often com- interpersonal interaction. Distance is the means by which plicates matters, but one may be necessary when the client various cultures use space to communicate. Hall (1966) does not speak the same language as the nurse. identified three primary dimensions of space in interper- Interpreting is a very complex process, however, that sonal interactions in Western culture: the intimate zone requires a keen sensitivity to cultural nuances, and not (0 to 18 inches), the personal zone (18 inches to 3 feet), just the translating of words into another language. Tips and the social zone (3 to 6 feet). for facilitating the communication process when employ- ing an interpreter are presented in Box 6–1. Social Organization Cultural behavior is socially acquired through a process Space called acculturation, which involves acquiring knowledge Spatial determinants relate to the place where the commu- and internalizing values (Giger & Davidhizar, 2004). nication occurs and encompass the concepts of territori- Children are acculturated by observing adults within ality, density, and distance. Territoriality refers to the their social organizations. Social organizations include innate tendency to own space. The need for territoriality families, religious groups, and ethnic groups. B O X 6 – 1 Using an Interpreter Time An awareness of the concept of time is a gradual learning When using an interpreter, keep the following points in mind: process. Some cultures place great importance on values • Address the client directly rather than speaking to the that are measured by clock time. Punctuality and efficiency are highly valued in the United States, whereas some cul- interpreter. Maintain eye contact with the client to tures are actually scornful of clock time. For example, ensure the client’s involvement. some peasants in Algeria label the clock as the “devil’s mill” • Do not interrupt the client and the interpreter. At times and have no notion of scheduled appointment times or their interaction may take longer because of the need to meal times (Giger & Davidhizar, 2004). They are totally clarify, and descriptions may require more time because indifferent to the passage of clock time and despise haste of dialect differences or the interpreter’s awareness that in all human endeavors. Other cultural implications the client needs more preparation before being asked a regarding time have to do with perception of time orien- particular question. tation. Whether individuals are present-oriented or • Ask the interpreter to give you verbatim translations so future-oriented influences many aspects of their lives. that you can assess what the client is thinking and understanding. Environmental Control • Avoid using medical jargon that the interpreter or client The variable of environmental control has to do with may not understand. the degree to which individuals perceive that they have • Avoid talking or commenting to the interpreter at control over their environment. Cultural beliefs and length; the client may feel left out and distrustful. practices influence how an individual responds to his or • Be aware that asking intimate or emotionally laden her environment during periods of wellness and illness. questions may be difficult for both the client and the To provide culturally appropriate care, the nurse should interpreter. Lead up to these questions slowly. Always ask not only respect the individual’s unique beliefs, but permission to discuss these topics first, and prepare the should also have an understanding of how these beliefs interpreter for the content of the interview. can be used to promote optimal health in the client’s • When possible, allow the client and the interpreter to environment. meet each other ahead of time to establish some rapport. If possible, try to use the same interpreter for succeeding Biological Variations interviews with the client. Biological differences exist among people in various • If possible, request an interpreter of the same gender as racial groups. Giger and Davidhizar (2004) state: the client and of similar age. To make good use of the interpreter’s time, decide beforehand which questions you will ask. Meet with the interpreter briefly before going to see the client so that you can let the interpreter know what you are planning to ask. During the session, face the client and direct your questions to the client, not the interpreter. SOURCE: Gorman, L.M., Raines, M.L., & Sultan, D.F. (2002). Psychosocial Nursing for General Patient Care (2nd ed.). Philadelphia: F.A. Davis. With permission.

90 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING The strongest argument for including concepts on biological APPLICATION OF THE NURSING variations in nursing education and subsequently nursing prac- PROCESS tice is that scientific facts about biological variations can aid the nurse in giving culturally appropriate health care. (p. 136) Background Assessment Data These differences include body structure (both size and A format for cultural assessment that may be used to shape), skin color, physiological responses to medication, gather information related to culture and ethnicity that is electrocardiographic patterns, susceptibility to disease, important for planning client care is provided in Box 6–2. and nutritional preferences and deficiencies. B O X 6 – 2 Cultural Assessment Tool Client’s name _________________________________________________ Ethnic origin____________________________________ Address ______________________________________________________ Birthdate _____________________________________________________ Name of significant other________________________________________ Relationship________________________________________ Primary language spoken________________________________________ Second language spoken____________________________ How does client usually communicate with people who speak a different language?_______________________________________ Is an interpreter required?________________________________________ Available?_______________________________________ Highest level of education achieved:_______________________________________________________________________________ Occupation:________________________________________________________________________________________________________ Presenting problem:____________________________________________________________________________________________ Has this problem ever occurred before?_______________________________________________________________________________ If so, in what manner was it handled previously?__________________________________________________________________ What is the client’s usual manner of coping with stress?______________________________________________________________ Who is (are) the client’s main support system(s)?____________________________________________________________________ Describe the family living arrangements:___________________________________________________________________________ Who is the major decision maker in the family?_____________________________________________________________________ Describe client’s/family members’ roles within the family._____________________________________________________________ _____________________________________________________________________________________________________________ Describe religious beliefs and practices:____________________________________________________________________________ Are there any religious requirements or restrictions that place limitations on the client’s care?_____________________________ If so, describe:________________________________________________________________________________________________ Who in the family takes responsibility for health concerns?___________________________________________________________ Describe any special health beliefs and practices:____________________________________________________________________ ____________________________________________________________________________________________________________ From whom does family usually seek medical assistance in time of need?________________________________________________ Describe client’s usual emotional/behavioral response to: Anxiety: ____________________________________________________________________________________________________ Anger: _____________________________________________________________________________________________________ Loss/change/failure:__________________________________________________________________________________________ Pain:_______________________________________________________________________________________________________ Fear:_______________________________________________________________________________________________________ Describe any topics that are particularly sensitive or that the client is unwilling to discuss (because of cultural taboos):______________________________________________________________________________________________ Describe any activities in which the client is unwilling to participate (because of cultural customs or taboos):_____________________________________________________________________________________________________ What are the client’s personal feelings regarding touch?______________________________________________________________ What are the client’s personal feelings regarding eye contact?_________________________________________________________ What is the client’s personal orientation to time? (past, present, future)_________________________________________________ Describe any particular illnesses to which the client may be bioculturally susceptible (e.g., hypertension and sickle cell anemia in African Americans):_________________________________________________________________________ Describe any nutritional deficiencies to which the client may be bioculturally susceptible (e.g., lactose intolerance in Native and Asian Americans)_______________________________________________________________________ Describe the client’s favorite foods:________________________________________________________________________________ Are there any foods the client requests or refuses because of cultural beliefs related to this illness (e.g., “hot” and “cold” foods for Latino Americans and Asian Americans)? If so, please describe: _____________________________________________________ Describe the client’s perception of the problem and expectations of health care:________________________________________________________________________________________________________

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 91 Northern European Americans States at the time of its settlement. Personal space tends Northern European Americans have their origins in to be smaller than that of the dominant culture. England; Ireland; Wales; Finland; Sweden; Norway; and the Baltic states of Estonia, Latvia, and Lithuania. Their Patterns of discrimination date back to the days of language has its roots in the language of the first English slavery, and evidence of segregation still exists, usually in settlers to the United States, with the influence of immi- the form of predominantly black neighborhoods, grants from around the world. The descendants of these churches, and schools, still visible in some U.S. cities. immigrants now make up what is considered the domi- Some African Americans find it too difficult to try to nant cultural group in the United States today. Specific assimilate into the mainstream culture and choose to dialects and rate of speech are common to various regions remain within their own social organization. of the country. Northern European Americans value ter- ritory. Personal space is about 18 inches to 3 feet. In 2005, 31 percent of African American households were headed by a woman (U.S. Census Bureau, 2006). With the advent of technology and widespread mobil- Social support systems may be large and include sisters, ity, less emphasis has been placed on the cohesiveness of brothers, aunts, uncles, cousins, boyfriends, girlfriends, the family. Data on marriage, divorce, and remarriage in neighbors, and friends. Many African Americans have a the United States show that 43 percent of first marriages strong religious orientation, with the vast majority prac- end in separation or divorce within 15 years (Centers for ticing some form of Protestantism (Harris, 2004). Disease Control [CDC], 2001). The value that was once placed on religion also seems to be diminishing in the African Americans who have assimilated into the dom- American culture. With the exception of a few months inant culture are likely to be well educated, professional, following the terrorist attacks of September 11, 2001, and future-oriented. Some who have not become assimi- when attendance increased, a steady decline in church lated may believe that planning for the future is hopeless, attendance was reported from 1991 to 2004 (Barna given their previous experiences and encounters with Research Online, 2004). Punctuality and efficiency are racism and discrimination (Cherry & Giger, 2004). They highly valued in the culture that promoted the work may be unemployed or have low-paying jobs, with little ethic, and most within this cultural group tend to be expectation of improvement. They are unlikely to value future oriented (Murray & Zentner, 2001). time or punctuality to the same degree as the dominant cultural group, which often causes them to be labeled as Northern European Americans, particularly those who irresponsible. achieve middle-class socioeconomic status, value preven- tive medicine and primary health care. This value follows Some African Americans, particularly those from the along with the socioeconomic group’s educational level, rural South, may reach adulthood never having seen a successful achievement, and financial capability to main- physician. They receive their medical care from the local tain a healthy lifestyle. Most recognize the importance of folk practitioner known as “granny,” or “the old lady,” or regular physical exercise. Northern European Americans a “spiritualist.” Incorporated into the system of folk have medium body structure and fair skin, the latter of medicine is the belief that health is a gift from God, which is thought to be an evolutionary result of living in whereas illness is a punishment from God or a retribu- cold, cloudy Northern Europe (Giger & Davidhizar, tion for sin and evil. Historically, African Americans have 2004). turned to folk medicine either because they could not afford the cost of mainstream medical treatment or Beef and certain seafoods, such as lobster, are regarded because of insensitive treatment by caregivers in the as high-status foods among many people in this culture health care delivery system. (Giger & Davidhizar, 2004). Changing food habits, how- ever, may bring both good news and bad news. The good The height of African Americans varies little from that news is that people are learning to eat healthier by of their Northern European American counterparts. Skin decreasing the amount of fat and increasing the nutrients color varies from white to very dark brown or black, in their diets. The bad news is that Americans still enjoy which offered the ancestors of African Americans protec- fast food, and it conforms to their fast-paced lifestyles. tion from the sun and tropical heat. African Americans Hypertension occurs more frequently, and sickle cell The language dialect of many African Americans is dif- anemia occurs predominantly, in African Americans. ferent from what is considered standard English. The Hypertension carries a strong hereditary risk factor, origin of the black dialect is not clearly understood but is whereas sickle cell anemia is genetically derived. thought to be a combination of various African languages Alcoholism is a serious problem among members of the and the languages of other cultural groups (e.g., Dutch, black community, leading to a high incidence of alcohol- French, English, and Spanish) present in the United related illness and death (Cherry & Giger, 2004). The diet of most African Americans differs little from that of the mainstream culture. However, some African Americans follow their heritage and still enjoy what has come to be known as “soul” food, which includes poke salad, collard greens, beans, corn, fried chicken, black-eyed

92 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING peas, grits, okra, and cornbread. These foods are now con- in the hospital. Clients may sometimes receive hospital sidered typical Southern fare and are regularly consumed passes to participate in a healing ceremony held outside and enjoyed by most individuals who live in the Southern the hospital. Research studies have continued to show the region of the United States. importance of each of these health care systems in the overall wellness of Native American people. Native Americans The Bureau of Indian Affairs (BIA) recognizes 563 Native Americans are typically of average height with Indian tribes and Alaska Native groups in the U.S. today reddish-tinted skin that may be light to medium brown. (Wikipedia, 2007). Some 250 tribal languages are spoken Their cheekbones are usually high and their noses have and many are written (Office of Tribal Justice, 2007). high bridges, probably an evolutionary result of living in Fewer than half of these still live on reservations, but very dry climates. most return home often to participate in family and tribal life and sometimes to retire. Touch is an aspect of com- The risks of illness and premature death from alco- munication that is not the same among Native Americans holism, diabetes, tuberculosis, heart disease, accidents, as in the dominant American culture. Some Native homicide, suicide, pneumonia, and influenza are greater Americans view the traditional handshake as somewhat for Native Americans than for the U.S. population as a aggressive. Instead, if a hand is offered to another, it may whole (Indian Health Service [IHS], 2001). Alcoholism is be accepted with a light touch or just a passing of hands a significant problem among Native Americans (National (Still & Hodgins, 2003). Some Native Americans will not Institute on Alcohol Abuse and Alcoholism [NIAAA], touch a dead person (Hanley, 2004). 2004). It is thought to be a symptom of depression in many cases and to contribute to a number of other seri- Native Americans may appear silent and reserved. ous problems such as automobile accidents, homicides, They may be uncomfortable expressing emotions spouse and child abuse, and suicides. because the culture encourages keeping private thoughts to oneself. Nutritional deficiencies are not uncommon among tribal Native Americans. Fruits and green vegetables are The concept of space is very concrete to Native often scarce in many of the federally defined Indian geo- Americans. Living space is often crowded with members graphical regions. Meat and corn products are identified of both nuclear and extended families. A large network of as preferred foods. Fiber intake is relatively low, while fat kin is very important to Native Americans. However, a intake is often of the saturated variety. A large number of need for extended space exists, as demonstrated by a dis- Native Americans living on or near reservations recog- tance of many miles between individual homes or camps. nized by the federal or state government receive commodity foods supplied by the U.S. Department The primary social organizations of Native Americans of Agriculture’s food distribution program (U.S. Depart- are the family and the tribe. From infancy, Native ment of Agriculture, 2004). American children are taught the importance of these units. Traditions are passed down by the elderly, and chil- Asian/Pacific Islander Americans dren are taught to respect tradition and to honor wisdom. Asian Americans comprise approximately 4 percent of the U.S. population. The Asian American culture Native Americans are very present-time oriented. includes peoples (and their descendants) from Japan, Time sequences, in order of importance, are present, China, Vietnam, the Philippines, Thailand, Cambodia, past, and future, with little emphasis on the future (Still Korea, Laos, India, and the Pacific Islands. Although this & Hodgins, 2003). Not only are Native Americans not discussion relates to these peoples as a single culture, it is ruled by the clock, some do not even own clocks. The important to keep in mind that a multiplicity of differ- concept of time is very casual, and tasks are accom- ences regarding attitudes, beliefs, values, religious prac- plished, not with the notion of a particular time in mind, tices, and language exist among these subcultures. but merely in a present-oriented time frame. Many Asian Americans, particularly Japanese, are Religion and health practices are intertwined in the third- and even fourth-generation Americans. These Native American culture. The medicine man (or woman) individuals are likely to be acculturated to the U.S. cul- is called the shaman, who may use a variety of methods ture. Ng (2001) describes three patterns common to in his or her practice. Some depend on “crystal gazing” to Asian Americans in their attempt to adjust to the diagnose illness, some sing and perform elaborate healing American culture: ceremonies, and some use herbs and other plants or roots 1. The Traditionalists. These individuals tend to be the to concoct remedies with healing properties. The Native American healers and U.S. Indian Health Service have older generation Asians who hold on to the traditional worked together with mutual respect for many years. values and practices of their native culture. They have Hanley (2004) relates that a medicine man or woman strong internalized Asian values. Primary allegiance is may confer with a physician regarding the care of a client to the biological family.

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 93 2. The Marginal People. These individuals reject the tra- medicine, the opposites are expressed as “hot” and ditional values and totally embrace Western culture. “cold,” and health is the result of a balance between hot Often they are members of the younger generations. and cold elements (Wang, 2003). Food, medicines, and herbs are classified according to their hot and cold prop- 3. Asian Americans. These individuals incorporate tradi- erties and are used to restore balance between yin and tional values and beliefs with Western values and yang (cold and hot), thereby restoring health. beliefs. They become integrated into the American culture, while maintaining a connection with their Asian Americans are generally small of frame and ancestral culture. build. Obesity is very uncommon in this culture. Skin color ranges from white to medium brown, with yellow The languages and dialects of Asian Americans are very tones. Other physical characteristics include almond- diverse. In general, they do share a similar belief in har- shaped eyes with a slight droop to eyelids and sparse monious interaction. To raise one’s voice is likely to be body hair, particularly in men, in whom chest hair is interpreted as a sign of loss of control. The English lan- often absent. Hair on the head is commonly coarse, thick, guage is very difficult to master, and even bilingual Asian straight, and black. Americans may encounter communication problems because of the differences in meaning assigned to non- Rice, vegetables, and fish are the main staple foods of verbal cues, such as facial gestures, verbal intonation and Asian Americans. Milk is seldom consumed because a speed, and body movements. In Asian cultures, touching large majority of Asian Americans experience lactose during communication has historically been considered intolerance. With Western acculturation, their diet is unacceptable. However, with the advent of Western accul- changing, and unfortunately, with more meat being con- turation, younger generations of Asian Americans accept sumed, the percentage of fat in the diet is increasing. touching as more appropriate than did their ancestors. Eye contact is often avoided as it connotes rudeness and Many Asian Americans believe that psychiatric illness lack of respect in some Asian cultures. Acceptable is merely behavior that is out of control and view it as a personal and social spaces are larger than in the dominant great shame to the individual and the family. They often American culture. Some Asian Americans have a great attempt to manage the ill person on their own until they deal of difficulty expressing emotions. Because of their can no longer handle the situation. It is not uncommon reserved public demeanor, Asian Americans may be per- for Asian Americans to somaticize. Expressing mental ceived as shy, cold, or uninterested. distress through various physical ailments may be viewed as more acceptable than expressing true emotions (Ishida The family is the ultimate social organization in the & Inouye, 2004). Asian American culture, and loyalty to family is empha- sized above all else. Children are expected to obey and The incidence of alcohol dependence is low among honor their parents. Misbehavior is perceived as bringing Asians. This may be a result of a possible genetic intoler- dishonor to the entire family. Filial piety (one’s social ance of the substance. Some Asians develop unpleasant obligation or duty to one’s parents) is held in high regard. symptoms, such as flushing, headaches, and palpitations, Failure to fulfill these obligations can create a great deal on drinking alcohol. Research indicates that this is due to of guilt and shame in an individual. A chronological hier- an isoenzyme variant that quickly converts alcohol to archy exists, with the elderly maintaining positions of acetaldehyde and the absence of an isoenzyme that is authority. Several generations, or even extended families, needed to oxidize acetaldehyde. The result is a rapid may share a single household. accumulation of acetaldehyde that produces the unpleas- ant symptoms (Wall et al., 1997). Although education is highly valued among Asian Americans, many remain undereducated. Religious Latino Americans beliefs and practices are very diverse and exhibit influ- Latino Americans are the fastest growing group of peo- ences of Taoism, Buddhism, Confucianism, Islam, ple in the United States, comprising approximately Hinduism, and Christianity (Giger & Davidhizar, 2004). 14 percent of the population (U.S. Census Bureau, 2006). They represent the largest ethnic minority group. Many Asian Americans are both past- and present- oriented. Emphasis is placed on the wishes of one’s ances- Latino Americans trace their ancestry to countries tors, while adjusting to demands of the present. Little such as Spain, Mexico, Puerto Rico, Cuba, and other value is given to prompt adherence to schedules or rigid countries of Central and South America. The common standards of activities. language is Spanish, spoken with a number of dialects by the various peoples. Touch is a common form of commu- Restoring the balance of yin and yang is the funda- nication among Latinos; however, they are very modest mental concept of Asian health practices (Spector, 2004). and are likely to withdraw from any infringement on Yin and yang represent opposite forces of energy, such as their modesty (Murray & Zentner, 2001). Latinos tend to negative/positive, dark/light, cold/hot, hard/soft, and be very tactful and diplomatic and will often appear feminine/masculine. When there is a disruption in the balance of these forces of energy, illness can occur. In

94 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING agreeable on the surface out of courtesy for the person dialects are noticeable. Western Europeans are known to with whom they are communicating. It is only after the be very warm and affectionate people and tend to be fact, when agreements may remain unfulfilled, that the physically expressive, using a great deal of body language, true context of the interaction becomes clear. including hugging and kissing. Latino Americans are very group-oriented. It is Like Latino Americans, Western European Americans important for them to interact with large groups of rela- are very family-oriented. They interact in large groups, tives, where a great deal of touching and embracing and it is not uncommon for several generations to live occurs. The family is the primary social organization and together or in close proximity of each other. A strong includes nuclear family members as well as numerous allegiance to the cultural heritage exists, and it is not extended family members. The nuclear family is male uncommon, particularly among Italians, to find settle- dominated, and the father possesses ultimate authority. ments of immigrants clustering together. Latino Americans tend to be present-oriented. The Roles within the family are clearly defined, with the concept of being punctual and giving attention to activi- man as the head of the household. Western European ties that relate to concern about the future are perceived women view their role principally as mother and home- as less important than present-oriented activities that maker, and children are prized and cherished. The cannot be retrieved beyond the present time. elderly are held in positions of respect and often are cared for in the home rather than placed in nursing Roman Catholicism is the predominant religion homes. among Latino Americans. Most Latinos identify with the Roman Catholic Church, even if they do not attend serv- Roman Catholicism is the predominant religion for ices. Religious beliefs and practices are likely to be strong the French and Italians, Greek Orthodox for the Greeks. influences in their lives. Especially in times of crisis, such A number of religious traditions are observed surround- as in cases of illness and hospitalization, Latino Americans ing rites of passage. Masses and rituals are observed for rely on priest and family to carry out important religious births, first communions, confirmations, marriages, rituals, such as promise making, offering candles, visiting anniversaries, and deaths. shrines, and offering prayers (Spector, 2004). Western Europeans tend to be present-oriented with Folk beliefs regarding health are a combination of ele- a somewhat fatalistic view of the future. A priority is ments incorporating views of Roman Catholicism and placed on the here and now, and whatever will happen in Indian and Spanish ancestries. The folk healer is called a the future is perceived as God’s will. curandero (male) or curandera (female). Among tradi- tional Latino Americans, the curandero is believed to have Most Western European Americans follow health a gift from God for healing the sick and is often the first beliefs and practices of the dominant American culture, contact made when illness is encountered. Treatments but some folk beliefs and superstitions still endure. used include massage, diet, rest, suggestions, practical Spector (2004, p. 285) reports the following superstitions advice, indigenous herbs, prayers, magic, and supernatu- and practices of Italians as they relate to health and ral rituals (Gonzalez & Kuipers, 2004). Many Latino illness: Americans still subscribe to the “hot and cold theory” of 1. Congenital abnormalities can be attributed to the unsat- disease. This concept is similar to the Asian perception of yin and yang discussed earlier in this chapter. Diseases isfied desire for a particular food during pregnancy. and the foods and medicines used to treat them are clas- 2. If a woman is not given food that she craves or smells, sified as “hot” or “cold,” and the intention is to restore the body to a balanced state. the fetus will move inside, and a miscarriage can result. 3. If a pregnant woman bends or turns or moves in a cer- Latino Americans are usually shorter than the average member of the dominant American culture. Skin color tain way, the fetus may not develop normally. can vary from light tan to dark brown. Research indicates 4. A woman must not reach during pregnancy because that there is less mental illness among Latino Americans than in the general population. This may have to do with reaching can harm the fetus. the strong cohesiveness of the family and the support that 5. Sitting in a draft can cause a cold that can lead to is given during times of stress. Because Latino Americans have clearly defined rules of conduct, fewer role conflicts pneumonia. occur within the family. This author recalls her own Italian immigrant grand- mother warming large collard greens in oil and placing Western European Americans them on swollen parotid glands during a bout with the Western European Americans have their origins in mumps. The greens most likely did nothing for the France, Italy, and Greece. Each of these cultures pos- mumps, but they (along with the tender loving care) felt sesses its own unique language, in which a number of wonderful! Western Europeans are typically of average stature. Skin color ranges from fair to medium brown. Hair and eyes are commonly dark, but some Italians have blue eyes and blond hair. Food is very important in the Western European American culture. Italian, Greek, and French

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 95 cuisine is world famous, and food is used in a social man- Gender roles are clearly defined. The man is the head ner, as well as for nutritional purposes. Wine is consumed of the household and women are subordinate to men. by all (even the children, who are given a mixture of Men are breadwinners, protectors, and decision-makers. water and wine) and is the beverage of choice with meals. Women are responsible for the care and education of However, among Greek Americans, drunkenness engen- children and for the maintenance of a successful marriage ders social disgrace on the individual and the family by tending to their husbands’ needs. (Tripp-Reimer & Sorofman, 1998). The family is the primary social organization, and Arab Americans* children are loved and indulged. The father is the disci- Arab Americans trace their ancestry and traditions to the plinarian and the mother is an ally and mediator. Loyalty nomadic desert tribes of the Arabian Peninsula. The to one’s family takes precedence over personal needs. Arab countries include Algeria, Bahrain, Comoros, Sons are responsible for supporting elderly parents. Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Women, especially devout Muslims, value modesty, Arabia, Somalia, Sudan, Syria, Tunisia, United Arab which is expressed through their attire. Many Muslim Emirates, and Yemen. First-wave immigrants, primarily women view the hijab, “covering the body except for Christians, came to the United States between 1887 and one’s face and hands,” as offering them protection in sit- 1913 seeking economic opportunity. First-wave immi- uations in which men and women mix. grants and their descendants typically resided in urban centers of the Northeast. Second-wave immigrants Most Arabs have dark or olive-colored skin, but some entered the United States after World War II. Most are have blonde or auburn hair, blue eyes, and fair complex- refugees from nations beset by war and political instability. ions. Infectious diseases such as tuberculosis, malaria, This group includes a large number of professionals and trachoma, typhus, hepatitis, typhoid fever, dysentery, and individuals seeking educational degrees who have subse- parasitic infestations are common among newer immi- quently remained in the United States. Most are Muslims grants. Sickle cell anemia and the thalassemias are com- and favor professional occupations. Many second-wave mon in the eastern Mediterranean. Sedentary lifestyle Arab Americans have settled in Texas and Ohio. and high fat intake among Arab Americans place them at higher risk for cardiovascular diseases. The rates of Arabic is the official language of the Arab world. breast cancer screening, mammography, and cervical Pap Although English is a common second language, language smears are low because of modesty. and communication can pose formidable problems in health care settings. Communication is highly contextual, Arab cooking shares many general characteristics. where unspoken expectations are more important than the Typical spices and herbs include cinnamon, allspice, actual spoken words. Conversants stand close together, cloves, ginger, cumin, mint, parsley, bay leaves, garlic, maintain steady eye contact, and touch (only between and onions. Bread accompanies every meal and is viewed members of the same sex) the other’s hand or shoulder. as a gift from God. Lamb and chicken are the most pop- ular meats. Muslims are prohibited from eating pork and Speech is loud and expressive and is characterized by pork products. Food is eaten with the right hand because repetition and gesturing, particularly when involved in it is regarded as clean. Eating and drinking at the same serious discussions. Observers witnessing impassioned time is viewed as unhealthy. Eating properly, consuming communication may incorrectly assume that Arabs are nutritious foods, and fasting are believed to cure disease. argumentative, confrontational, or aggressive. Privacy is Gastrointestinal complaints are the most frequent reason valued, and many resist disclosure of personal informa- for seeking health care. Lactose intolerance is common. tion to strangers, especially when it relates to familial dis- ease conditions. Among friends and relatives, Arabs Most Arabs are Muslims. Islam is the religion of most express feelings freely. Devout Muslim men may not Arab countries, and in Islam there is no separation of shake hands with women. When an Arab man is intro- church and state; a certain amount of religious participa- duced to an Arab woman, the man waits for the woman tion is obligatory. Many Muslims believe in combining to extend her hand. spiritual healing, performing daily prayers, and reading or listening to the Qur’an with conventional medical Punctuality is not taken seriously except for business treatment. A devout client may request that his or her or professional meetings. Social events and appointments chair or bed be turned to face in the direction of Mecca tend not to have a fixed beginning or end time. and that a basin of water be provided for ritual washing or ablution before prayer. Sometimes illness is perceived *This section on Arab Americans is taken from Purnell, L.D. & as punishment for one’s sins. Paulanka, B.J. Guide to Culturally Competent Health Care. (2005). © F.A. Davis. Used with permission. Mental illness is a major social stigma. Psychiatric symptoms may be denied or attributed to “bad nerves” or evil spirits. When individuals suffering from mental distress seek medical care, they are likely to present with a variety of vague complaints such as abdominal pain, las- situde, anorexia, and shortness of breath. Clients often

96 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING expect and may insist on somatic treatment, at least “vita- Commandments. Children are expected to be forever mins and tonics.” When mental illness is accepted as a grateful to their parents for giving them the gift of life diagnosis, treatment with medications, rather than coun- (Purnell & Paulanka, 2005). The rite of passage into seling, is preferred. adulthood occurs during a religious ceremony called a bar or bat mitzvah (son or daughter of the commandment) Jewish Americans and is usually commemorated by a family celebration. To be Jewish is to belong to a specific group of people and a specific religion. The term Jewish does not refer to Jewish people differ greatly in physical appearance, a race. The Jewish people came to the United States pre- depending on the area of the world from which they dominantly from Spain, Portugal, Germany, and Eastern migrated. Ancestors of Mediterranean region and Europe (Schwartz, 2004). There are more than 5 million Eastern European immigrants may have fair skin and Jewish Americans living in the United States, and they blonde hair or darker skin and brunette hair, Asian are located primarily in the larger urban areas. descendants share oriental features, and Ethiopian Jews (Falashas) are Black (Schwartz, 2004). Four main Jewish religious groups exist today: Orthodox, Reform, Conservative, and Reconstructionist. Because of the respect afforded physicians and the Orthodox Jews adhere to strict interpretation and applica- emphasis on keeping the body and mind healthy, Jewish tion of Jewish laws and ethics. They believe that the laws Americans are health conscious. In general, they practice outlined in the Torah (the five books of Moses) are divine, preventive health care, with routine physical, dental, and eternal, and unalterable. Reform Judaism is the largest vision screening. Circumcision for male infants is both a Jewish religious group in the United States. The Reform medical procedure and a religious rite and is performed on group believes in the autonomy of the individual in inter- the eighth day of life. The procedure is a family festivity. It is preting the Jewish code of law, and a more liberal inter- usually performed at home, and many relatives are invited. pretation is followed. Conservative Jews also accept a less strict interpretation. They believe that the code of laws A number of genetic diseases are more common in the comes from God, but accept flexibility and adaptation of Jewish population, including Tay–Sachs disease, Gaucher’s those laws to absorb aspects of the culture, while remain- disease, and familial dysautonomia. Other conditions that ing true to Judaism’s values. The Reconstructionists have occur with increased incidence in the Jewish population modern views that generally override traditional Jewish include inflammatory bowel disease (ulcerative colitis laws. They do not believe that Jews are God’s chosen peo- and Crohn’s disease), colorectal cancer, and breast and ple, they reject the notion of divine intervention, and ovarian cancer. Jewish people have a higher rate of side there is general acceptance of interfaith marriage. effects from the antipsychotic clozapine. About 20 per- cent develop agranulocytosis, which has been attributed The primary language of Jewish Americans is English. to a specific gene that was recently identified (Purnell & Hebrew, the official language of Israel and the Torah, is Paulanka, 2005). used for prayers and is taught in Jewish religious education. Early Jewish immigrants spoke a Judeo-German dialect Alcohol, especially wine, is an essential part of reli- called Yiddish, and some of those words have become part gious holidays and festive occasions. It is viewed as of American English (e.g., klutz, kosher, tush). appropriate and acceptable as long as it is used in moder- ation. For Jewish people who follow the dietary laws, a Although traditional Jewish law is clearly male- tremendous amount of attention is given to the slaughter oriented, with acculturation little difference is seen today of livestock and preparation and consumption of food. with regard to gender roles. Formal education is a highly Religious laws dictate which foods are permissible. The respected value among the Jewish people. A larger per- term kosher means “fit to eat,” and following these guide- centage of Jewish Americans hold advanced degrees and lines is thought to be a commandment of God. Meat may are employed as professionals (e.g., science, medicine, law, be eaten only if the permitted animal has been slaugh- education) than that of the total U.S. white population. tered, cooked, and served following kosher guidelines. Pigs are considered unclean, and pork and pork products While most Jewish people live for today and plan for are forbidden. Dairy products and meat may not be and worry about tomorrow, they are raised with stories of mixed together in cooking, serving, or eating. their past, especially of the Holocaust. They are warned to “never forget,” lest history be repeated. Therefore, Judaism opposes discrimination against people with their time orientation is simultaneously to the past, the physical, mental, and developmental conditions. The main- present, and the future (Purnell & Paulanka, 2005). tenance of one’s mental health is considered just as important as the maintenance of one’s physical health. Children are considered blessings and valued treas- Mental incapacity has always been recognized as grounds ures, treated with respect, and deeply loved. They play an for exemption from all obligations under Jewish law active role in most holiday celebrations and services. (Purnell & Paulanka, 2005). Respecting and honoring one’s parents is one of the Ten A summary of information related to the six cultural phenomena as they apply to the cultural groups discussed here is presented in Table 6–1.

TABLE 6–1 Summary of Six Cultural Phenomena in Comparison of Various Cultural Groups Cultural Group and Communication Space Social Time Environmental Biological Countries of Origin National languages Territory valued Organization Future-oriented Control Variations Northern European Personal space: 18 inches Families: nuclear and Present-oriented Health concerns: (although many learn extended Most value preventive Cardiovascular disease Americans English very quickly) to 3 feet Religions: Jewish and Present-oriented medicine and primary Cancer (England, Ireland, Dialects (often regional) Uncomfortable with Christian health care through Diabetes mellitus English Organizations: social Present-oriented traditional health care Germany, others) More verbal than personal contact and community Past important and delivery system Health concerns: nonverbal touch Cardiovascular disease African Americans National languages Close personal space Large, extended families valued Alternative methods on Hypertension (Africa, West Indian Dialects (pidgin, Creole, Comfortable with touch Many female-headed the increase Sickle cell disease Gullah, French, Present-oriented Diabetes mellitus islands, Dominican Spanish) Large, extended space households Traditional health-care Lactose intolerance Republic, Haiti, Highly verbal and important Strong religious delivery system Jamaica) nonverbal Health concerns: Uncomfortable with orientation, mostly Some individuals prefer Alcoholism Native Americans 250 tribal languages touch Protestant to use folk practitioner Tuberculosis (North America, Alaska, recognized Community social organi- (“granny” or voodoo Accidents Large personal space zations healer) Diabetes mellitus Aleutian Islands) Comfortable with silence Uncomfortable with Families: nuclear and Heart disease Direct eye contact extended Home remedies Asian/Pacific Islander touch Children taught impor- Religion and health Health concerns: Americans considered rude tance of tradition Hypertension Close personal space Social organizations: tribe practices intertwined Cancer (Japan, China, Korea, More than 30 different Lots of touching and and family most impor- Medicine man or woman Diabetes mellitus Vietnam, Philippines, languages spoken tant Thalassemia Thailand, Cambodia, embracing (shaman) uses folk Lactose intolerance Laos, India, Pacific Comfortable with silence Very group-oriented Families: nuclear and practices to heal Islands, others) Uncomfortable with extended Shaman may work with Health concerns: modern medical Heart disease Latino Americans eye-to-eye contact Children taught importance practitioner Cancer (Mexico, Spain, Cuba, Nonverbal connotations of family loyalty and Traditional health care Diabetes mellitus Puerto Rico, other tradition delivery system Accidents countries of Central and may be misunderstood. Some prefer to use folk Lactose intolerance South America) Many religions: Taoism, practices (e.g., yin and Spanish, with many Buddhism, Islam, yang; herbal medicine; dialects Hinduism, Christianity and moxibustion) Community social Traditional health-care organizations delivery system Families: nuclear and large Some prefer to use folk extended families practitioner, called curandero or curandera Strong ties to Roman Catholicism Folk practices include “hot and cold” herbal Community social remedies organizations Continued on following page 97

98 TABLE 6 – 1 (Continued) Cultural Group and Communication Space Social Time Environmental Biological Countries of Origin National languages Close personal space Organization Present-oriented Control Variations Dialects Lots of touching and Past- and present- Western European Families: nuclear and large Traditional health-care Health concerns: Americans embracing extended families oriented delivery system Heart disease Very group-oriented Cancer (France, Italy, Greece) France and Italy: Roman Past, present and Lots of home remedies Diabetes mellitus Large personal space Catholic future-oriented. and practices based on Thalassemia Arab Americans Arabic between members of superstition (Algeria, Bahrain, English the opposite sex Greece: Greek Orthodox Health concerns: outside of the family. Families: nuclear and Traditional health-care Tuberculosis Comoros, Djibouti, delivery system Malaria Egypt, Iraq, Jordan, Touching common extended. Trachoma Kuwait, Lebanon, between members of Religion: Muslim and Some superstitious beliefs Typhus Libya, Mauritania, same sex. Authority of physician is Hepatitis Morocco, Oman, Christianity Typhoid fever Palestine, Qatar, Saudi seldom challenged or Dysentery Arabia, Somalia, Sudan, questioned. Parasitic infestations Syria, Tunisia, United Adverse outcomes are Sickle cell disease Arab Emirates, Yemen) attributed to God’s Thalassemia will. Cardiovascular disease Jewish Americans English, Hebrew, Yiddish Touch forbidden between Families: nuclear and Mental illness viewed as a (Spain, Portugal, opposite genders in extended social stigma. Health concerns: the Orthodox Tay-Sachs disease Germany, Eastern tradition. Community social Great respect for Gaucher’s disease Europe) organizations physicians. Emphasis Familial dysautonomia Closer personal space on keeping body and Ulcerative colitis common among mind healthy. Practice Crohn’s disease non-orthodox Jews preventive health care. Colorectal cancer Breast cancer Ovarian cancer SOURCES: Spector (2004); Purnell and Paulanka (2003, 2005); Murrary and Zentner (2001); and Giger and Davidhizar (2004).

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 99 Culture-Bound Syndromes 4. Has maintained weight by eating foods that he or she The Diagnostic and Statistical Manual of Mental Disorders, likes brought to the hospital by family members. 4th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000) recognizes various 5. Has restored spiritual strength through use of cultural symptoms that are associated with specific cultures and rituals and beliefs and visits from a spiritual leader. that may be expressed differently from those of the dom- inant American culture. Although presentations associ- Planning/Implementation ated with the major DSM-IV-TR categories can be found The following interventions have special cultural impli- throughout the world, many of the responses are influ- cations for nursing: enced by local cultural factors (APA, 2000). The DSM- 1. Use an interpreter if necessary to ensure that there are IV-TR defines culture-bound syndromes as follows: no barriers to communication. Be careful with non- Recurrent, locality-specific patterns of aberrant behavior verbal communication because it may be interpreted and troubling experience that may or may not be linked to a differently by different cultures (e.g., Asians and particular DSM-IV diagnostic category. Many of these pat- Native Americans may be uncomfortable with touch terns are indigenously considered to be “illnesses,” or at and direct eye contact, whereas Latinos and Western least afflictions, and most have local names. (p. 898) Europeans perceive touch as a sign of caring). It is important for nurses to understand that individuals 2. Make allowances for individuals from other cultures to from diverse cultural groups may exhibit these physical have family members around them and even partici- and behavioral manifestations. The syndromes are pate in their care. Large numbers of extended family viewed within these cultural groups as folk, diagnostic members are very important to African Americans, categories with specific sets of experiences and observa- Native Americans, Asian Americans, Latino tions (APA, 2000). Examples of culture-bound syn- Americans, and Western European Americans. To dromes are presented in Table 6–2. deny access to these family support systems could interfere with the healing process. Diagnosis/Outcome Identification 3. Ensure that the individual’s spiritual needs are being Nursing diagnoses are selected based on the information met. Religion is an important source of support for gathered during the assessment process. With back- many individuals, and the nurse must be tolerant of ground knowledge of cultural variables and information various rituals that may be connected with different uniquely related to the individual, the following nursing cultural beliefs about health and illness. diagnoses may be appropriate: 4. Be aware of the differences in concept of time among ● Impaired verbal communication related to cultural dif- the various cultures. Most members of the dominant American culture are future-oriented and place a high ferences evidenced by inability to speak the dominant value on punctuality and efficiency. Other cultural language. groups such as African Americans, Native Americans, ● Anxiety (moderate to severe) related to entry into an Asian Americans, Latino Americans, Arab Americans, unfamiliar health care system and separation from and Western European Americans are more present- support systems evidenced by apprehension and suspi- oriented. Nurses must be aware that such individuals cion, restlessness, and trembling. may not share their value of punctuality. They may be ● Imbalanced nutrition, less than body requirements, late to appointments and appear to be indifferent to related to refusal to eat unfamiliar foods provided in some aspects of their therapy. Nurses must be accept- the health care setting, evidenced by loss of weight. ing of these differences and refrain from allowing ● Spiritual distress related to inability to participate in usual existing attitudes to interfere with delivery of care. religious practices because of hospitalization, evidenced 5. Be aware of different beliefs about health care among by alterations in mood (e.g., anger, crying, withdrawal, the various cultures, and recognize the importance of preoccupation, anxiety, hostility, apathy, and so forth) these beliefs to the healing process. If an individual Outcome criteria related to these nursing diagnoses may from another culture has been receiving health care include: from a spiritualist, medicine man, granny, or curan- The client: dero, it is important for the nurse to listen to what has 1. Has had all basic needs fulfilled. been done in the past and even to consult with these 2. Has communicated with staff through an interpreter. cultural healers about the care being given to the 3. Has maintained anxiety at a manageable level by hav- client. ing family members stay with him or her during hos- 6. Follow the health care practices that the client views pitalization. as essential, provided they do no harm or do not interfere with the healing process of the client. For example, the concepts of yin and yang and the “hot

100 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING TABLE 6–2 Culture-Bound Syndromes Syndrome Culture Symptoms Amok Malaysia, Laos, Philippines, A dissociative episode followed by an outburst of violent, aggressive, or homici- Ataque de nervios Polynesia, Papua New dal behavior directed at people and objects. May be associated with psychotic Guinea, Puerto Rico episode. Latin American and Latin Mediterranean groups Uncontrollable shouting, crying, trembling, verbal or physical aggression, some- times accompanied by dissociative experiences, seizure-like or fainting episodes, Bilis and colera (muina) Latin American and suicidal gestures. Often occurs in response to stressful family event. Boufee delirante West Africa and Haiti Acute nervous tension, headache, trembling, screaming, stomach disturbances, and sometimes loss of consciousness. Thought to occur in response to intense Brain fag West Africa anger or rage. Dhat India Sudden outburst of agitated and aggressive behavior, confusion, and psychomo- tor excitement. May be accompanied by hallucinations or paranoia. Falling-out or blacking Southern United States and out the Caribbean Difficulty concentrating, remembering, and thinking. Pain and pressure around head and neck; blurred vision. Associated with challenges of schooling. Ghost sickness American Indian tribes Severe anxiety and hypochondriasis associated with the discharge of semen, Hwa-byung (anger Korea whitish discoloration of the urine, and feelings of weakness and exhaustion. syndrome) Southern and Eastern Asia Sudden collapse. May or may not be preceded by dizziness. Person can hear but Koro Malaysia, Indonesia cannot move. Eyes are open, but individual claims inability to see. Latah Latinos in the United States Locura Preoccupation with death and the deceased. Bad dreams, weakness, feelings of and Latin America danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of Mal de ojo (evil eye) Mediterranean cultures consciousness, confusion, feelings of futility, and a sense of suffocation. Nervios Latinos in the United States Insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, Pibloktoq and Latin America anorexia, dyspnea, palpitations, and generalized aches and pains. Attributed to Qi-gong psychotic Eskimo cultures the suppression of anger. China reaction Sudden and intense anxiety that the penis (in males) or the vulva and nipples (in Rootwork African Americans, European females) will recede into the body and cause death. Americans, Caribbean cul- Sangue dormido tures Hypersensitivity to sudden fright, often with echopraxia, echolalia, and dissocia- (“sleeping blood”) tive or trancelike behavior. Portuguese Cape Verde Shenjing shuairuo Islanders Incoherence, agitation, hallucinations, ineffective social interaction, unpre- (“neurasthenia”) dictability, and possible violence. Attributed to genetics or environmental China stress, or a combination of both. Shenkui (Shenkuei) China (Taiwan) Occurs primarily in children. Fitful sleep, crying, diarrhea, vomiting, and fever. Shin-byung Headaches, irritability, stomach disturbances, sleep difficulties, nervousness, easy Spell Korea tearfulness, inability to concentrate, trembling, tingling sensations, and dizzi- Susto (“fright” or “soul African Americans and ness. Occurs in response to stressful life experiences. loss”) European Americans in Abrupt dissociative episode accompanied by extreme excitement and sometimes southern United States followed by convulsions and coma lasting up to 12 hours. Taijin kyofusho Dissociative, paranoid, or other psychotic or nonpsychotic symptoms that occur Zar Latin America, Mexico, in individuals who become overly involved in the Chinese health-enhancing Central America, and South practice of qi-gong (“exercise of vital energy”) America Anxiety, gastrointestinal complaints, weakness, dizziness, fear of being poisoned or killed. Symptoms are ascribed to hexing, witchcraft, sorcery, or the evil Japan influence of another person. Pain, numbness, tremor, paralysis, convulsions, stroke, blindness, heart attack, North African and Middle infection, and miscarriage. Eastern societies Physical and mental fatigue, dizziness, headaches, other pains, concentration difficulties, sleep disturbance, memory loss, gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbance of the autonomic nervous system. Anxiety or panic, with dizziness, backache, fatigability, general weakness, insom- nia, frequent dreams, and sexual dysfunction. Attributed to excessive semen loss. Anxiety, weakness, dizziness, fear, anorexia, insomnia, and gastrointestinal prob- lems, with subsequent dissociation and possession by ancestral spirits. A trance state in which individuals “communicate” with deceased relatives or spirits. Not considered to be a folk illness, but may be misconstrued by clini- cians as a psychosis. Appetite and sleep disturbances, sadness, pains, headache, stomachache, and diarrhea. Attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness. Fear that one’s body, body parts, or its functions displease, embarrass, or are offensive to other people in appearance, odor, facial expressions, or movements. Dissociative episodes that include shouting, laughing, hitting head against a wall, singing, or weeping. Person may withdraw and refuse to eat. Symptoms are attributed to being possessed by a spirit. SOURCE: Diagnostic and Statistical Manual of Mental Disorders (4th ed.), Text Revision. © 2000, American Psychiatric Association. With permission.

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 101 and cold” theory of disease are very important to the Holistic Nurses Association in their Standards for well-being of some Asians and Latinos, respectively. Holistic Nursing Practice; and through the development Try to ensure that a balance of these foods are of a nursing diagnostic category, Spiritual Distress, by included in the diet as an important reinforcement for NANDA International (Wright, 2005). In addition, con- traditional medical care. temporary research has produced evidence that spiritu- 7. Be aware of favorite foods of individuals from differ- ality and religion can make a positive difference in health ent cultures. The health care setting may seem strange and illness. and somewhat isolated, and for some individuals it is comforting to have anything around them that is Smucker (2001) states: familiar. They may even refuse to eat foods that are Spirituality is the recognition or experience of a dimension unfamiliar to them. If it does not interfere with his or of life that is invisible, and both within us and yet beyond her care, allow family members to provide favorite our material world, providing a sense of connectedness and foods for the client. interrelatedness with the universe. (p. 5) 8. The nurse working in psychiatry must realize that psy- Smucker (2001) identifies the following factors as types chiatric illness is stigmatized in some cultures. of spiritual needs associated with human beings: Individuals who believe that expressing emotions is 1. Meaning and purpose in life unacceptable (e.g., Asian Americans and Native 2. Faith or trust in someone or something beyond our- Americans) will present unique problems when they are clients in a psychiatric setting. Nurses must have patience selves and work slowly to establish trust in order to provide 3. Hope these individuals with the assistance they require. 4. Love 5. Forgiveness Evaluation Evaluation of nursing actions is directed at achievement Spiritual Needs of the established outcomes. Part of the evaluation Meaning and Purpose in Life process is continuous reassessment to ensure that the Humans by nature appreciate order and structure in their selected actions are appropriate and the goals and out- lives. Having a purpose in life gives one a sense of con- comes are realistic. Including the family and extended trol and the feeling that life is worth living. Smucker support systems in the evaluation process is essential if (2001) states, “Meaning provides us with a basic under- cultural implications of nursing care are to be measured. standing of life and our place in it” (p. 6). Walsh (1999) Modifications to the plan of care are made as the need is describes “seven perennial practices” that he believes determined. provide meaning and purpose to life. He suggests that these practices promote enlightenment and transforma- CORE CONCEPT tion and encourage spiritual growth. He identifies the Spirituality seven perennial practices as follows: The human quality that gives meaning and sense of 1. Transform your motivation: Reduce craving and purpose to an individual’s existence. Spirituality exists within each individual regardless of belief system and find your soul’s desire. serves as a force for interconnectedness between the 2. Cultivate emotional wisdom: Heal your heart and self and others, the environment, and a higher power. learn to love. SPIRITUAL CONCEPTS 3. Live ethically: Feel good by doing good. Spirituality is difficult to describe. It cannot be seen, and 4. Concentrate and calm your mind: Accept the chal- it undoubtedly means something different to all people. Perhaps this is partly the reason it has been somewhat lenge of mastering attention. ignored in the nursing literature. This aspect is chang- 5. Awaken your spiritual vision: See clearly and recog- ing, however, with the following transformations occur- ring in nursing: The inclusion of nursing responsibility nize the sacred in all things. for spiritual care cited by the International Council of 6. Cultivate spiritual intelligence: Develop wisdom Nurses in their Code of Ethics; by the American and understand life. 7. Express spirit in action: Embrace generosity and the joy of service. (p. 14) In the final analysis, each individual must determine his or her own perception of what is important and what gives meaning to life. Throughout one’s existence, the meaning of life will undoubtedly be challenged many times. A solid spiritual foundation may help an individual confront the challenges that result from life’s experiences.

102 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING Faith Love Faith is often thought of as the acceptance of a belief in Love may be identified as a projection of one’s own good the absence of physical or empirical evidence. Smucker feelings onto others. To love others, one must first (2001) states, experience love of self, and then be able and willing to project that warmth and affectionate concern for others For all people, faith is an important concept. From childhood (Karren et al., 2002). on, our psychological health depends on having faith or trust in something or someone to help meet our needs. (p. 7) Smucker (2001) states: Having faith requires that individuals rise above that Love, in its purest unconditional form, is probably life’s which they can only experience through the five senses. most powerful force and our greatest spiritual need. Not Indeed, faith transcends the appearance of the physical only is it important to receive love, but equally important to world. An increasing amount of medical and scientific give love to others. Thinking about and caring for the needs research is showing that what individuals believe exists of others keeps us from being too absorbed with ourselves can have as powerful an impact as what actually exists. and our needs to the exclusion of others. We all have expe- Karren and associates (2002) state: rienced the good feelings that come from caring for and lov- Personal belief gives us an unseen power that enables us to do ing others. (p. 10) the impossible, to perform miracles—even to heal ourselves. Love may be a very important key in the healing process. It has been found that patients who exhibit faith become less Karren and associates (2002) state: concerned about their symptoms, have less-severe symptoms, People who become more loving and less fearful, who and have less-frequent symptoms with longer periods of replace negative thoughts with the emotion of love, are relief between them than patients who lack faith. (p. 485) often able to achieve physical healing. Most of us are famil- Evidence suggests that faith, combined with conven- iar with the emotional effects of love, the way love makes us tional treatment and an optimistic attitude, can be a very feel inside. But...true love—a love that is patient, trusting, powerful element in the healing process. protecting, optimistic, and kind—has actual physical effects on the body, too. (p. 479) Hope Some researchers suggest that love has a positive effect Hope has been defined as a special kind of positive expec- on the immune system. This has been shown to be true tation (Karren et al., 2002). With hope, individuals look at in adults and children, and also in animals (Fox & Fox, a situation, and no matter how negative, find something 1988; Ornish, 1998). The giving and receiving of love positive on which to focus. Hope functions as an energiz- may also result in higher levels of endorphins, thereby ing force. In addition, research indicates that hope may contributing to a sense of euphoria and helping to promote healing, facilitate coping, and enhance quality of reduce pain. life (Nekolaichuk, Jevne, & Maguire, 1999). In one long-term study, Werner and Smith (1992) Kübler-Ross (1969), in her classic study of dying patients, studied children who were reared in impoverished envi- stressed the importance of hope. She suggested that, even ronments. Their homes were troubled by discord, deser- though these patients could not hope for a cure, they could tion, or divorce, or marred by parental alcoholism or hope for additional time to live, to be with loved ones, for mental illness. The subjects were studied at birth, child- freedom from pain, or for a peaceful death with dignity. She hood, adolescence, and adulthood. Two out of three of found hope to be a satisfaction unto itself, whether or not it these high-risk children had developed serious learning was fulfilled. She stated, “If a patient stops expressing hope, and/or behavioral problems by age 10, or had a record of it is usually a sign of imminent death” (p. 140). delinquencies, mental health problems, or pregnancies by age 18. One-fourth of them had developed “very seri- Karren and associates (2002) state: ous” physical and psychosocial problems. By the time Researchers in the field of psychoneuroimmunology have they reached adulthood, more than three-fourths of them found that what happens in the brain—the thoughts and suffered from profound psychological and behavioral emotions we experience, the attitudes with which we face problems and even more were in poor physical health. the world—can have a definite effect on the body. An atti- But of particular interest to the researchers were the 15 tude like hope is not just a mental state; it causes specific to 20 percent who remained resilient and well despite electrochemical changes in the body that influence not only their impoverished and difficult existence. The children the strength of the immune system but can even influence who remained resilient and well had experienced a warm the workings of the individual organs in the body. (p. 518) and loving relationship with another person during their The medical literature abounds with countless examples first year of life, whereas those who developed serious of individuals with terminal conditions who suddenly psychological and physical problems had not. This improve when they find something to live for. research indicates that the earlier people have the benefit Conversely, there are also many accounts of patients of a strong, loving relationship, the better they seem able whose conditions deteriorate when they lose hope. to resist the effects of a deleterious lifestyle.

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 103 Forgiveness the world (Bronson, 2005). Some individuals seek out Karren and associates (2002) state, “Essential to a spiritual various religions in an attempt to find answers to funda- nature is forgiveness—the ability to release from the mind mental questions that they have about life, and indeed, all the past hurts and failures, all sense of guilt and loss.” about their very existence. Others, although they may Feelings of bitterness and resentment take a physical toll regard themselves as spiritual, choose not to affiliate with on an individual by generating stress hormones, which an organized religious group. In either situation, how- maintained for long periods can have a detrimental effect ever, it is inevitable that questions related to life and the on a person’s health. Forgiveness enables a person to cast human condition arise during the progression of spiri- off resentment and begin the pathway to healing. tual maturation. Forgiveness is not easy. Individuals often have great Brodd (2003) suggests that all religious traditions mani- difficulty when called upon to forgive others, and even fest seven dimensions: experiential, mythic, doctrinal, eth- greater difficulty in attempting to forgive themselves. ical, ritual, social, and material. He explains that these Many people carry throughout their lives a sense of guilt seven dimensions are intertwined and complementary and, for having committed a mistake for which they do not depending on the particular religion, certain dimensions believe they have been forgiven, or for which they have are emphasized more than others. For example, Zen not forgiven themselves. Buddhism has a strong experiential dimension, but says lit- tle about doctrines. Roman Catholicism is strong in both To forgive is not necessarily to condone or excuse ritual and doctrine. The social dimension is a significant one’s own or someone else’s inappropriate behavior. aspect of religion, as it provides a sense of community, of Karren and associates (2002) suggest that forgiveness is belonging to a group, such as a parish or a congregation, which is empowering for some individuals. . . . a decision to see beyond the limits of another’s personal- ity; to be willing to accept responsibility for your own per- Affiliation with a religious group has been shown to be ceptions; to shift your perceptions repeatedly; and to gradu- a health-enhancing endeavor (Karren et al., 2002). A ally transform yourself from being a helpless victim of your number of studies have been conducted that indicate a circumstances to being a powerful and loving co-creator of correlation between religious faith/church attendance your reality. (p. 451) and increased chance of survival following serious illness, Holding on to grievances causes pain, suffering, and con- less depression and other mental illness, longer life, and flict. Forgiveness (of self and others) is a gift to oneself. It overall better physical and mental health. In an extensive offers freedom and peace of mind. review of the literature, Maryland psychologist John Gartner (1998) found that individuals with a religious It is important for nurses to be able to assess the spir- commitment had lower suicide rates, lower drug use and itual needs of their clients. Nurses need not serve the role abuse, less juvenile delinquency, lower divorce rates, and of professional counselor or spiritual guide, but because improved mental illness outcomes. of the closeness of their relationship with clients, nurses may be the part of the health care team to whom clients It is not known how religious participation protects may reveal the most intimate details of their lives. health and promotes well-being. Some churches Smucker (2001) states: actively promote healthy lifestyles and discourage behavior that would be harmful to health or interfere Just as answering a patient’s question honestly and with with treatment of disease. But some researchers believe accurate information and responding to his needs in a timely that the strong social support network found in and sensitive manner communicates caring, so also does churches may be the most important force in boosting high-quality professional nursing care reach beyond the the health and well-being of their members. More so physical body or the illness to that part of the person where than merely an affiliation, however, it is regular church identity, self-worth, and spirit lie. In this sense, good nurs- attendance and participation that appear to be the key ing care is also good spiritual care. (pp. 11–12) factors. CORE CONCEPT ASSESSMENT OF SPIRITUAL Religion AND RELIGIOUS NEEDS A set of beliefs, values, rites, and rituals adopted by a It is important for nurses to consider spiritual and reli- group of people. The practices are usually grounded gious needs when planning care for their clients. The in the teachings of a spiritual leader. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that nurses address Religion the psychosocial, spiritual, and cultural variables that Religion is one way in which an individual’s spirituality influence the perception of illness. Dossey (1998) has may be expressed. There are more than 6500 religions in developed a spiritual assessment tool (Box 6–3) about which she states:

104 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING B O X 6 – 3 Spiritual Assessment Tool The following reflective questions may assist you in assessing, • Can you forgive yourself? evaluating, and increasing awareness of spirituality in yourself • What do you do to heal your spirit? and others. These questions assess a person’s ability to connect in life-giv- Meaning and Purpose ing ways with family, friends, and social groups and to engage in the forgiveness of others. These questions assess a person’s ability to seek meaning and • Who are the significant people in your life? fulfillment in life, manifest hope, and accept ambiguity and • Do you have friends or family in town who are available uncertainty. • What gives your life meaning? to help you? • Do you have a sense of purpose in life? • Who are the people to whom you are closest? • Does your illness interfere with your life goals? • Do you belong to any groups? • Why do you want to get well? • Can you ask people for help when you need it? • How hopeful are you about obtaining a better degree of • Can you share your feelings with others? • What are some of the most loving things that others health? • Do you feel that you have a responsibility in maintaining have done for you? • What are the loving things that you do for other people? your health? • Are you able to forgive others? • Will you be able to make changes in your life to These questions assess a person’s capacity for finding meaning in worship or religious activities, and a connectedness with a maintain your health? divinity. • Are you motivated to get well? • Is worship important to you? • What is the most important or powerful thing in your life? • What do you consider the most significant act of worship Inner Strengths in your life? • Do you participate in any religious activities? These questions assess a person’s ability to manifest joy and • Do you believe in God or a higher power? recognize strengths, choices, goals, and faith. • Do you think that prayer is powerful? • What brings you joy and peace in your life? • Have you ever tried to empty your mind of all thoughts • What can you do to feel alive and full of spirit? • What traits do you like about yourself? to see what the experience might be? • What are your personal strengths? • Do you use relaxation or imagery skills? • What choices are available to you to enhance your • Do you meditate? • Do you pray? healing? • What is your prayer? • What life goals have you set for yourself? • How are your prayers answered? • Do you think that stress in any way caused your illness? • Do you have a sense of belonging in this world? • How aware were you of your body before you became These questions assess a person’s ability to experience a sense of connection with life and nature, an awareness of the effects sick? of the environment on life and well-being, and a capacity or • What do you believe in? concern for the health of the environment. • Is faith important in your life? • Do you ever feel a connection with the world or • How has your illness influenced your faith? • Does faith play a role in recognizing your health? universe? • How does your environment have an impact on your Interconnections state of well-being? These questions assess a person’s positive self-concept, self- • What are your environmental stressors at work and at esteem, and sense of self; sense of belonging in the world with others; capacity to pursue personal interests; and ability to home? demonstrate love of self and self-forgiveness. • What strategies reduce your environmental stressors? • How do you feel about yourself right now? • Do you have any concerns for the state of your • How do you feel when you have a true sense of yourself? • Do you pursue things of personal interest? immediate environment? • What do you do to show love for yourself? • Are you involved with environmental issues such as recycling environmental resources at home, work, or in your community? • Are you concerned about the survival of the planet? SOURCES: Dossey, B.M. (1998). Holistic modalities and healing moments, American Journal of Nursing, 98(6), 44–47. With permission. Burkhardt, M.A. (1989). Spirituality: An analysis of the concept. Holist Nurs Pract, 3(3), 69-77; Dossey, B.M. et al. (Eds.) (1995). Holistic nursing: A handbook for practice (2nd ed.). Gaithersburg, MD: Aspen.

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 105 The Spiritual Assessment Tool provides reflective ques- person’s connectedness with self, other persons, art, tions for assessing, evaluating, and increasing awareness of music, literature, nature, and/or a power greater than spirituality in patients and their significant others. The oneself. tool’s reflective questions can facilitate healing because Risk Factors they stimulate spontaneous, independent, meaningful ini- Physical. Physical/chronic illness; substance abuse/exces- tiatives to improve the patient’s capacity for recovery and sive drinking. healing. Psychosocial. Low self-esteem; depression; anxiety; Diagnoses/Outcome Identification/ stress; poor relationships; separate from support systems; Evaluation blocks to experiencing love; inability to forgive; loss; Nursing diagnoses that may be used when addressing racial/cultural conflict; change in religious rituals; change spiritual and religious needs of clients include: in spiritual practices. ● Risk for Spiritual Distress ● Spiritual Distress Developmental. Life change; developmental life changes. ● Readiness for Enhanced Spiritual Well-being Environmental. Environmental changes; natural ● Risk for Impaired Religiosity disasters. ● Impaired Religiosity ● Readiness for Enhanced Religiosity Risk for Impaired Religiosity The following outcomes may be used as guidelines Definition. At risk for an impaired ability to exercise for care and to evaluate effectiveness of the nursing reliance on religious beliefs and/or participate in rituals interventions. of a particular faith tradition. Risk Factors The client will: Physical. Illness/hospitalization; pain. 1. Identify meaning and purpose in life that reinforce Psychological. Ineffective support/coping/caregiving; hope, peace, and contentment. depression; lack of security. 2. Verbalize acceptance of self as worthwhile human Sociocultural. Lack of social interaction; cultural bar- being. rier to practicing religion; social isolation. 3. Accept and incorporate change into life in a healthy Spiritual. Suffering. manner. Environmental. Lack of transportation; environmental 4. Express understanding of relationship between diffi- barriers to practicing religion. Developmental. Life transitions. culties in current life situation and interruption in pre- A plan of care addressing client’s spiritual/religious vious religious beliefs and activities. needs is provided in Table 6–3. Selected nursing diag- 5. Discuss beliefs and values about spiritual and religious noses are presented, along with appropriate nursing issues. interventions and rationales for each. 6. Express desire and ability to participate in beliefs and activities of desired religion. Planning/Implementation Evaluation NANDA International (2007) information related to the Evaluation of nursing actions is directed at achievement diagnoses Risk for Spiritual Distress and Risk for of the established outcomes. Part of the evaluation Impaired Religiosity is provided in the subsections that process is continuous reassessment to ensure that the follow. selected actions are appropriate and the goals and out- comes are realistic. Including the family and extended Risk for Spiritual Distress support systems in the evaluation process is essential if Definition. At risk for an impaired ability to experience spiritual and religious implications of nursing care are to and integrate meaning and purpose in life through a be measured. Modifications to the plan of care are made as the need is determined.

106 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING Table 6–3 Care Plan for the Client with Spiritual and Religious Needs* NURSING DIAGNOSIS: RISK FOR SPIRITUAL DISTRESS RELATED TO: Life changes; environmental changes; stress; anxiety; depression EVIDENCED BY: Questioning meaning of life and own existence; inner conflict about personal beliefs and values Outcome Criteria Nursing Interventions Rationale Client will identify meaning 1. Assess current situation. 1–8. Thorough assessment is necessary to and purpose in life that rein- 2. Listen to client’s expressions of anger, force hope, peace, content- develop an accurate care plan for the ment, and self-satisfaction. concern, self-blame. client. 3. Note reason for living and whether it is 9. Trust is the basis of a therapeutic nurse- directly related to situation. client relationship. 4. Determine client’s religious/spiritual ori- 10. Helps client focus on what needs to be entation, current involvement, presence done and identify manageable steps to of conflicts, especially in current circum- take. stances. 5. Assess sense of self-concept, worth, ability 11. Helps client to understand that certain life to enter into loving relationships. experiences can cause individuals to ques- 6. Observe behavior indicative of poor rela- tion personal values and that this response tionships with others. is not uncommon. 7. Determine support systems available to and used by client and significant others. 12. Helps client find own solutions to con- 8. Assess substance use/abuse. cerns. 9. Establish an environment that promotes free expression of feelings and concerns. 13. Identifies strengths to incorporate into 10. Have client identify and prioritize cur- plan and techniques that need revision. rent/immediate needs. 14. Sharing of experiences and hope assists 11. Discuss philosophical issues related to client to deal with reality. impact of current situation on spiritual beliefs and values. 15. Journaling can assist in clarifying beliefs and values and in recognizing and resolv- 12. Use therapeutic communication skills of ing feelings about current life situation. reflection and active listening. 16. Provides insight into meaning of these 13. Review coping skills used and their effec- issues and how they are integrated into an tiveness in current situation. individual’s life. 14. Provide a role model (e.g., nurse, individ- 17. These activities will help to enhance inte- ual experiencing similar situation) gration of new skills and necessary changes in client’s lifestyle 15. Suggest use of journaling. 18. Client may require additional assistance 16. Discuss client’s interest in the arts, music, with an individual who specializes in these literature. types of concerns. 17. Role-play new coping techniques. Discuss possibilities of taking classes, becoming involved in discussion groups, cultural activities of their choice. 18. Refer client to appropriate resources for help. Continued on following page

CHAPTER 6 ● CULTURAL AND SPIRITUAL CONCEPTS 107 Ta b l e 6 – 3 (Continued) NURSING DIAGNOSIS: RISK FOR IMPAIRED RELIGIOSITY RELATED TO: Suffering; depression; illness; life transitions EVIDENCED BY: Concerns about relationship with deity; unable to participate in usual religious practices; anger toward God Outcome Criteria Nursing Interventions Rationale Client will express achieve- 1. Assess current situation (e.g., illness, hos- 1. This information identifies problems ment of support and personal satisfaction from spiritual/ pitalization, prognosis of death, presence client is dealing with in the moment that religious practices. of support systems, financial concerns) is affecting desire to be involved with reli- gious activities. 2. Listen nonjudgmentally to client’s expres- 2. Individuals often blame themselves for sions of anger and possible belief that ill- what has happened and reject previous ness/condition may be a result of lack of religious beliefs and/or God. faith. 3. This is important background for estab- 3. Determine client’s usual religious/spiri- lishing a database. tual beliefs, current involvement in spe- cific church activities. 4. Individual may withdraw from others in relation to the stress of illness, pain, and 4. Note quality of relationships with signifi- suffering. cant others and friends. 5. Individuals often turn to use of various 5. Assess substance use/abuse. substances in distress and this can affect the ability to deal with problems in a pos- 6. Develop nurse–client relationship in itive manner. which individual can express feelings and concerns freely. 6. Trust is the basis for a therapeutic nurse–client relationship. 7. Use therapeutic communications skills of active listening, reflection, and I-messages. 7. Helps client to find own solutions to problems and concerns and promotes 8. Be accepting and nonjudgmental when sense of control. client expresses anger and bitterness toward God. Stay with the client. 8. The nurse’s presence and nonjudgmental attitude increase the client’s feelings of 9. Encourage client to discuss previous reli- self-worth and promote trust in the rela- gious practices and how these practices tionship. provided support in the past. 9. A nonjudgmental discussion of previous 10. Allow the client to take the lead in initiat- sources of support may help the client ing participation in religious activities, work through current rejection of them as such as prayer. potential sources of support. 11. Contact spiritual leader of client’s choice, 10. Client may be vulnerable in current situa- if he or she requests. tion and needs to be allowed to decide own resumption of these actions. 11. These individuals serve to provide relief from spiritual distress and often can do so when other support persons cannot. *The interventions for this care plan were adapted from Doenges, Moorhouse, and Murr (2006). SUMMARY AND KEY POINTS space, social organization, time, environmental con- ● Culture encompasses shared patterns of belief, feeling, trol, and biological variations. ● Northern European Americans are the descendants of and knowledge that guide people’s conduct and are the first immigrants to the United States and make up passed down from generation to generation. the current dominant cultural group. They value ● Ethnic groups are bound together by a shared heritage. punctuality, a responsible work ethic, and a healthy ● Cultural groups differ in terms of communication, lifestyle.

108 UNIT II ● FOUNDATIONS FOR PSYCHIATRIC/MENTAL HEALTH NURSING ● African Americans trace their roots in the United Arabic is the official language of the Arab world and States to the days of slavery. Most have large support the dominant religion is Islam. Mental illness is con- systems and a strong religious orientation. Many have sidered a social stigma, and symptoms are often assimilated into and have many of the same character- somaticized. istics as the dominant culture. Some African ● The Jewish people came to the United States predomi- Americans from the rural South may receive health nantly from Spain, Portugal, Germany, and Eastern care from a folk practitioner. Europe. Four main Jewish religious groups exist today: Orthodox, Reform, Conservative, and Reconstructionist. ● Many Native Americans still live on reservations. The primary language is English. A high value is They speak many different languages and dialects. placed on education. Jewish Americans are very health They often appear silent and reserved and many are conscious and practice preventive health care. The uncomfortable with touch and expressing emotions. maintenance of one’s mental health is considered just Health care may be delivered by a medicine man or as important as the maintenance of one’s physical woman called a shaman. health. ● Culture-bound syndromes are clusters of physical and ● Asian American languages are very diverse. Touching behavioral symptoms that are considered as illnesses during communication has historically been considered or “afflictions” by specific cultures and recognized as unacceptable. Individuals may have difficulty express- such by the DSM-IV-TR. ing emotions and appear cold and aloof. Family loyalty ● Spirituality is the human quality that gives meaning is emphasized. Psychiatric illness is viewed as behavior and sense of purpose to an individual’s existence. that is out of control and brings shame on the family. ● Individuals possess a number of spiritual needs that include meaning and purpose in life, faith or trust in ● The common language of Latino Americans is someone or something beyond themselves, hope, love, Spanish. Large family groups are important, and touch and forgiveness. is a common form of communication. The predomi- ● Religion is a set of beliefs, values, rites, and rituals nant religion is Roman Catholicism and the church is adopted by a group of people. often a source of strength in times of crisis. Health ● It is one way in which an individual’s spirituality may care may be delivered by a folk healer called a curan- be expressed. dero, who uses various forms of treatment to restore ● Affiliation with a religious group has been shown to be the body to a balanced state. a health-enhancing endeavor. ● Nurses must consider cultural, spiritual, and religious ● Western European Americans have their origins in needs when planning care for their clients. Italy, France, and Greece. They are warm and expres- sive and use touch as a common form of communica- For additional clinical tools and study tion. The dominant religion is Roman Catholicism for aids, visit DavisPlus. the Italians and French and Greek Orthodoxy for the Greeks. Most Western European Americans follow the health practices of the dominant culture, but some folk beliefs and superstitions endure. ● Arab Americans trace their ancestry and traditions to the nomadic desert tribes of the Arabian Peninsula.