Psychosocial Integrity Study Guide for the NCLEX-RN Exam

Dependencies

Addiction of any sort can be an impairment to a patient’s ability to function properly. Unfortunately, addictions are common. They can also be extremely challenging to treat effectively because of both the physical and psychological dependency they produce.

Substance Use Disorder

Substance use disorder is defined as the recurrent use of either alcohol and/or drugs, which produces clinical and/or functional impairment that manifests as chronic health problems, physical disability, and/or failure to meet one’s responsibilities at work, home, or school. It is usually classified as mild, moderate, or severe depending on how many diagnostic criteria are met. The criteria include evidence of loss of control, risky behaviors, social impairment, and pharmacological criteria.

Other Dependencies

In addition to substance abuse, patients may have addictions to gambling, sex, and pornography in addition to others. These are defined as non-substance-related disorders, but their treatments may be similar to that for substance abuse.

The Nurse’s Role

The nurse’s role in a patient’s treatment will be to provide support in the following areas:

Physiological stability— Provide physical symptom relief with appropriate measures for withdrawal and/or toxicity. An example would be giving methadone for heroin withdrawal.

Patient safety— Physical symptoms of withdrawal can be painful and difficult. At all times, patients must be kept safe via the use of physical restraints, even when it goes against their wishes.

Patient education— Be an educational resource on the potential health, social, and occupational dangers of substance abuse and other forms of dependency.

Referral and follow-up— Patient recovery may include outside referrals and follow-up visits to assess continued improvement and treatment success. Nurses are often heavily involved in this process.

Intervention— Support and encourage patients to continue in various intervention processes such as counseling and group therapy.

Friend and family education— Recovering addicts need strong social support to have continued treatment success. Nurses can help friends and family understand ways they can support the patient and encourage group therapy participation throughout their recovery.

Evaluation of response— Take the time to discuss the outcome and effectiveness of the treatment plan with the patient and help evaluate the need for changes, if indicated.

Support Systems

Support systems are a network of people that a patient uses when emotional, moral, or other types of practical support are needed. Support systems have been shown to improve patient recovery rates, allow improved communication and education, and assist in the care of the patient. A support system can also help patients remain accountable for maintaining any new lifestyle changes that their condition or treatment requires. Support systems are critical in the care of patients with chronic illness, especially in the event of illnesses that cause decreased mental cognition (i.e., Alzheimer’s disease).

A nurse may also have to ensure that all caregivers involved in their patient’s support system have the access that they need to outside resources, such as support groups for families caring for loved ones, those experiencing caregiver fatigue, and respite care.

Therapeutic Communication

Therapeutic communication is more than just talking. It is an interactive, planned, and goal-oriented process that is tailored for each patient. The overall aim is to establish an avenue of open, constructive communication by forming a trustful, positive, and beneficial relationship with the patient. Therapeutic communication incorporates listening to and understanding the patient and promotes better understanding by providing necessary clarification and insight. Without therapeutic communication, a patient’s healing can be impaired. The nurse should encourage the patient to verbalize feelings such as fear, discomfort, and hope. Patients should also be allowed to openly ask questions and participate in their plan of care.

It is also important to recognize that nonverbal communication is a part of this process as well. Nonverbal communication is often more powerful than what is said because it may reveal a person’s underlying feelings and attitudes. Signs of this type of communication include movements, facial expressions, and body positioning. Regardless of how a patient communicates, the nurse should regularly evaluate the effectiveness of communications between the client, caregivers, and healthcare team.

Foundations

The foundations for a therapeutic relationship and therapeutic communication are:

Understanding communication factors— Understand the patient’s developmental level, age, level of consciousness and understanding, ability to communicate effectively, culture, values, perceptions and perspectives.

Nonverbal communication— Remember that body positioning, eye contact, and other physical cues are more powerful than the spoken word.

Communication skills— Communication styles and skills vary. Assess the patient and adjust message and communication sessions to best fit the patient’s needs.

Causes of ineffective communication— Be aware of and adjust accordingly to avoid ineffective communication (language barriers, education level, distractions, etc.)

Ability to participate— Always ensure that the patient can participate in this process as it is interactive. A patient with aphasia, for example, will need special considerations and adjustment to ensure this happens.

Conditions

The following factors must be present in the therapeutic relationship:

Empathy— an understanding and sharing of someone else’s feelings

Respect— acceptance and regard for someone else, even if he or she has a different viewpoint

Genuineness— showing and expressing honest, sincere concern for the concerns and questions of another

Self-disclosure— sharing personal views and experiences in order to improve the mental and/or emotional state of another person

Concreteness and specificity— using very specific and direct terms when communicating rather than general or vague ones

Appropriate Confrontation— (Only in a long-established patient-nurse relationships) Gently, and in an accepting way, discuss the patient’s need to deal with a specific issue or problem.

Barriers

There are many potential barriers to a therapeutic relationship that will need to be avoided. They may include:

Listening problems— Make the proper time to communicate and minimize potential distractions. Listening problems include misinterpretation, distracted listening, and failure to listen.

Improper decoding— This means failing to recognize the true, intended message of the patient.

Nurse’s needs first— There is always too much to do and too little time. Consider the patients’ needs as a priority to listen and communicate effectively.

Stereotyping, probing, challenging, or rejecting— These are all counterproductive to the therapeutic relationship and show a lack of respect to the patient.

Being defensive— Being defensive may be perceived as a response to real or perceived failures or shortcomings. It is not therapeutic or in the best interest of the patient.

Changing the subject— Identify personal feelings about difficult subjects and cope with them prior to attempting discussion. Changing the subject to deal with personal stress or uneasiness is inappropriate.

Passing judgment— The nurse must listen and understand, not pass judgement. Do not place a negative or positive value on the patient’s message.

Therapeutic Responses

The nurse’s response to the information or feelings that patients shares can be helpful in building effective, therapeutic communication. Some techniques to use are:

Silence— Silence allows for the patient to speak while the nurse listens, considers, and conveys acceptance of the message. It also allows the patient to take the lead in the exchange of information.

Using leads— Broad opening statements can initiate discussions between the patient and nurse. It allows the patient to feel the nurse is interested in the patient’s feelings, concerns, and values. It also allows the patient to choose the direction of the conversation.

Clarification— Specific techniques such as exploring, paraphrasing, reflecting, and restating can help ensure that the patient’s message is being heard correctly and understood. Clarification reduces nurse bias and false assumptions about the patient.

Reflecting— Reflecting is a specific technique where the nurse reflects the patient’s emotions (not exact words) back to the patient in conversation. This allows the patient to further explore specific feelings and express unspoken ones as well.

Therapeutic Environment

Provide care and interventions that help patients better adapt to their environment so that they can make a full recovery to the best of their ability. This will require the nurse to meet a variety of patient needs. Consider if patients can care for themselves, have any unmet needs, or are having difficulty adapting to the care environment. Provide and maintain a therapeutic milieu that is supportive and safe for your patient’s recovery. This includes eliminating all extraneous and avoidable stressors.

Nursing and Psychosocial Integrity

The nurse will use the nursing process of assessment, diagnosis, planning, implementation, and evaluation to support and care for the psychosocial integrity of every patient. By doing this, the nurse will convey respect for, empathy toward, and understanding of the patient’s experience with illness, injury, or crisis. Using the nursing process in this way also allows the patient to maintain autonomy and take an active role in his or her care plan.

Nurses are in a unique role as they use their knowledge of psychopathology, observation skills, and close patient interaction to intervene and help their patients avoid negative psychosocial reactions that the stressors of illness, disease, treatment, and hospitalization can bring. In this way, nursing care protects the psychosocial integrity of all patients.