Psychosocial Integrity Study Guide for the NCLEX-RN Exam

Cultural Awareness and Influence on Health

Nurses must understand, evaluate, and respect the role of different cultural, ethnic, and racial perspectives with regard to both health and the process of giving care. The culturally competent nurse must recognize the patient’s world view in the context of his or her own to provide care that is appropriate for the patient’s needs. Be flexible and willing to incorporate new ideas and knowledge into the patient’s care plan.

Listening With Respect

Discuss with patients what their viewpoints, and listen carefully to what they say. Learn more about their beliefs on both health and illness, doing so with tolerance and understanding. Be open to incorporating potential non-traditional processes and practices into your care plan at the patient’s request.

Surmounting Language Barriers

Identify language barriers and use medically-licensed interpreters to better gather and understand information about the patient’s cultural practices and preferences. Be sure to document how a patient’s individual language needs were met.

Providing Culturally Appropriate Care

Because a person’s culture is such an integral part of his or her overall health and perception of care, it is essential to provide care and services that are in-line with a patient’s cultural beliefs. Nurses must be culturally competent and respectful, even if a patient’s beliefs do not coincide with their own. This type of care improves the patient’s quality of care and outcome. Some examples of cultural competence include allowing dietary restrictions based on faith (i.e., Hindu/beef, Jewish/kosher); respecting family hierarchy (i.e., patriarchy, decisions made by elders); and providing religious support (i.e., access to priest/chaplain, ability to perform prayer positioning).

If a nurse’s personal beliefs are so drastically different than the patient’s and the nurse does not believe that he or she can adequately care for the patient, the nurse is allowed to speak with a supervisor to ask for a change of assignments. However, if no other skilled, trained nursing staff is available or if the patient would be at a health disadvantage with the nurse’s change in assignments, it is the assigned nurse’s responsibility to provide the best care. Actions otherwise may be perceived as an abandonment of the patient or neglect.

Evaluation of Effectiveness

Always evaluate the effectiveness of your care plan with your patients. Always take the time to listen to the patients, their view of health, illness, and/or treatments. Remember to use the resources available to the nurses and patients such as interpreting services, support groups, and cultural education.

End-of-Life Care

Every patient will have a different view of end of life based on personal, religious, and cultural backgrounds or experiences. Nurses tailor end-of-life care based upon these individual factors.

Patient Rights

Nurses must impartially relay medical information and treatment options, provide support, and educate patients or caregivers when necessary. It is important to remember that every patient has the right to make an informed decision for treatment as well as theright to refuse it altogether. Allowing patients some control in their choices in how to spend their last days of life may reduce anxiety and fear with the process. Discuss the patient’s individual goals and wishes with him or her (and family), and then respect those wishes and priorities.

Communication with Patient and Family

Nurses help to prepare patients and families regarding end-of-life expectations. This will include physical, emotional, and psychological changes; decline or deterioration; and the act of dying itself. Also be prepared to help the patient’s family deal with increasing anxiety as death approaches. This includes the expression that the healthcare team is doing all it can to make the patient comfortable at the end of life.

Post-Death Responsibilities

After a patient dies, a nurse must acknowledge the loss, express sympathy to the family, and then, only after asking if they wish to do so, provide an opportunity for the family to view the patient’s body. Care of the deceased patient continues as nurses then prepares the body, completes post-mortem washing, shrouding, and transporting to appropriate facilities (i.e., morgue, funeral home, operating room if organ donation is indicated).

Family Dynamics

Each family and family member will have unique strengths and weaknesses in the setting of patient care. Ideally, a patient’s family should support, listen to, and empathize with one another. However, most families will have some level of dysfunctional communication. When this is severe, it can lead to impairment, which may require nursing intervention such as care conferences, individual conversations, and outsourcing to support teams/groups.

Causes and Signs of Dysfunctional Families

The reasons for family dysfunction are numerous and varied. They may include: genetics, developmental stages of each family member, family history, composition of family members (i.e., parents, children, grandparents, stepparents, stepchildren, etc.), and the lifestyle of the family. Signs of dysfunction can include poor communication (often resulting in anger, hostility, or silence), poor coping mechanisms, and lack of or poor use of outside support systems.

The Nurse’s Role

The nurse must observe and assess for signs of family dysfunction. If present, this needs to be incorporated into the patient’s treatment plan. Interventions may include group or family therapy and single or multidisciplinary healthcare conferences if indicated. Nurses should encourage participation and discuss realistic strategies to help the family’s function improve. Discuss, teach, and model appropriate communication skills and help to identify and utilize the appropriate support systems.

Grief and Loss

Grieving is a natural, human response to loss. Every person grieves in different ways. Grief may have physical, mental, emotional, spiritual, and social impacts. As a nurse, first recognize and analyze any personal feelings about death and dying before assisting others through their grief and loss-processing.

Stages of Grief

A few different conceptual frameworks and theories describe the process of both normal and unresolved/complicated grieving. The most popular is perhaps Elizabeth Kubler-Ross’s Stages of Grieving. In her theory, a person moves through five different stages during the grieving process: denial, anger, bargaining, depression, and acceptance.

These stages are considered fluid and do not always occur in order. Patients may experience each stage once, skip stages along the way, or flow back and forth between stages before finally achieving acceptance. Each stage is met with nursing responsibilities unique to that grieving process. Monitoring and recognizing where patients or their caregivers are at in the stages of grief can help to tailor interventions to best support them.

Differences in Reaction

Grief reaction differs among all people. Factors, including age, developmental stage, gender, cultural influences, personal strengths, and emotional and physical reserves, influence how a person perceives grief. Grieving may also occur in anticipation of a devastating health diagnosis or outcome. This is called anticipatory grief.

Legal Topics

In addition to the physical, emotional, and psychological support nurses provide during end-of-life care, there are also numerous legal processes that nurses must follow prior to and after a patient passes.

Advance directives— Be familiar with and respectful of a patient’s wishes. If no advance directive exists, nurses must educate and discuss this with the patient and family.

Autopsies— In some cases, autopsy after death is a legal requirement. In others, it may be a specific wish of the patient and/or family.

Organ donation— The patient’s wishes for his or her physical remains after death can be added to his or her advance directive.

DNR orders— “Do not resuscitate” orders are often part of a patient’s advance directives. Ideally, the patient has discussed this previously with the family, but if unable to do so, the nurse should do so.

Other Nurse Responsibilities

Nurses must support both patients and their families during the difficult time of end of life. Be familiar with the following additional nursing responsibilities:

Ideas for relief— Patients and families will experience a range of emotions. Provide active listening, guidance, and support through anxiety, fear, loneliness, and exhaustion.

Patient sense of security— It is common for a patient to feel a loss of control during this time. Optimize opportunities for control, give patients choices, and provide reassurance when necessary.

Acceptance of loss— Encourage patients and family members to openly discuss their feelings. Know of and refer family members to available outside support, counseling, and bereavement groups.

Physical comfort— Measures can include pain control, sedation, positioning, etc.

Emotional support— Discuss emotional reactions and affirm if they are normal. Educate and reassure that the grieving process needs to occur and is a healthy response to what is happening.

Patient and family expression— Spend time with the patient and family, and listen to them. Again, reassure that the grieving process is normal, and provide additional support with outside referrals as indicated.