IPE Exam 3

culture

Values, beliefs, knowledge, art, morals, laws and customs acquired by individuals and groups

culture redefined

the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics. Culture is dynamic in nature, and individuals may identify with multiple cultures over the course of their lifetimes.

Acculturation

Transfer of values and customs; move from culture to another

• Multicultural environments

• Categories include: language spoken, culture orientation, religious affiliation

• References made about United States as melting pot vs. salad bowl

Communication Effectiveness

Health care providers and organizations recognize and bridge cultural

differences that can contribute to miscommunication

• Reasons given based on IOM report titled “Unequal Treatment:

Confronting Racial and Ethnic Disparities in Health Care”

Cultural Competence Continuum

cultural destructiveness, cultural incapacity, cultural blindness, cultural percompentence, cultural competence, cultural proficiency

continuum of cultural competency

aspects of culture

• values and norms

• beliefs and attitudes

• relationship patterns

• communication and language

• daily actives

Movement on Continuum

• 1 – valuing differences, awareness, self-assessment

• 2 – understanding cross-cultural dynamic

• 3 – building cultural knowledge

• 4 – adapting practice to reflect patient cultural context

Culturally Competent

• Value individuals in own right

• Hold few fixed judgements about any individuals/groups

• Have multiple exposures to differences of others

• Have reference groups which value cultural differences

Culturally Sensitive Communication

• Demonstrates understanding and respect

• Providers need to be able to reflect upon their own values, beliefs,

preferences, assumptions & cultures as well as understand others

• More education is needed at all levels

National Standards for Culturally and

Linguistically Appropriate Services in Health and

Health Care

Office of Minority Health – U.S. Department of Health and Human

Services 2011 developed blueprint standards of care to be

implemented in order to improve health care in the US and decrease

health disparities

CLAS Standards

• Standard 1 – provide effective, equitable, understandable, and

respectful quality care and services

• Standard 2 – advance and sustain governance and leadership that

promotes CLAS and health equity

• Standard 3 – recruit, promote, and support a diverse governance,

leadership, and workforce

• Standard 4 – Educate and train governance, leadership, and

workforce in CLAS

• Standard 5 – offer communication and language assistance

• Standard 6 – inform individuals of the availability of language

assistance

• Standard 7 – ensure the competence of individuals providing language

assistance

• Standard 8 – provide easy-to-understand materials and signage

• Standard 9 – infuse CLAS goals, policies, and management

accountability throughout the organization’s planning and operations

• Standard 10 – Conduct organizational assessments

• Standard 11 – collect and maintain demographic data

• Standard 12 – conduct assessments of community health assets and

needs

• Standard 13 – partner with community

• Standard 14 – create conflict and grievance resolution processes

• Standard 15 – communicate the organization’s progress in

implementing and sustaining CLAS

Ethics in Health Care

• The field of applied ethics that is concerned with the moral decision-

making situations that arise in the practice and policy of healthcare

• Promotes the consideration of values in the prioritization and

justification of actions by health professionals, researchers and

policymakers that may impact the health and well-being of patients,

families and communities

Ethical Communication

• Involves all the relevant information, true and accurate

• Avoids language that manipulates, discriminates or exaggerates

• Accuracy of information

• Avoid withholding crucial information

• Conveying the point without offending

Unethical Communication

• Plagiarism – stealing someone else’s work and claiming it as your own

• Selective Misquoting – deliberately omitting damaging or unflattering

comments to paint a better (but untruthful) picture

• Misrepresenting numbers – increasing or decreasing numbers, altering

statistics or omitting numerical data

• Distorting visuals – making a product look bigger or changing the scale

of graphs and charts to exaggerate or conceal the differences

Health Communication

• Should adhere to the principles of beneficence, non-maleficence,

respect for personal autonomy, and justice

• The exchange between health professional and patients should

involved informed consent regarding the purpose and nature of the

intervention and possible alternatives.

• There should be respect, freedom from intimidation and suitable

language understandable to patients

Beneficence

• Obligation to produce benefit

• Act of doing good; kindness

• Active contribution towards welfare of others

Non-maleficence

• Do no harm

• Omission of harmful action

• Do not kill

• Do not cause pain or suffering

• Do not incapacitate

• Do not cause offense

Respect for Autonomy

Free to make choices and

act voluntarily according to

their values, beliefs and

preferences

Justice

Treated in a manner that is

equitable and fair

Code of Ethics

• All associations and societies

• AMA Code of Medical Ethics

• ANA Code of Ethics

• Hospitals and Health Care Organizations Code of Ethics

Ethics Committee

• Gives advice on moral questions in clinical care, educates staff and

public on issues in medical ethics

• Develops policies related to patient care in regards to ethics

• Provide consultations to resolve ethical conflicts

• Protocols related to research studies

• Regulatory requirement

Confidential communication

Personal or private matters that are revealed to a provider who cannot by

compelled by law to repeat communication or be a witness against the patient.

HIPPA

Health Insurance Portability and Accountability Act privacy

rule

Anonymity

Right of the patients to have their identity

protected from is being known to others.

Privacy

Right of patients to limit any knowledge

about themselves to become known to

others.

Legal and Ethical

Perspective

Patient safety, Liability, Incident reports and Malpractice litigation

Communication

PerspectivePatients

Patients to maximize their privileges of

choice and execute our responsibilities.

Truth-Telling

Patient Self-Determination Act (PSDA)

• Federal law that informs patients of their rights regarding

decisions surrounding their medical care.

• Includes protection from deception

Provider Discomfort in Truth-Telling

• don’t want to give patients a diagnosis and prognosis if they are not 100% sure

• they do not know the patient’s emotional stability

• there has not been a conversation with the patient in terms of what they wanted to know or even when for that matter

Exception to Truth-Telling

Patient has explicitly said they do not want to know their diagnosis or

 prognosis.

• Patient cannot handle cognitively, emotionally, or mentally the

  information.

• not all health care team members are authorized to give information

Informed Choice and Informed Consent

• Truth-telling is linked to patient’s informed choice and consent

• Health care providers are ethically and morally obligated to respect the

individuality of all patients who are recipients of their care

• Same goes for health care leaders and their employees

Advance Care Directives

the PSDA gives us

• The right to participate in and direct their own health care decisions.

• The right to accept or refuse medical or surgical treatment.

• The right to prepare an advance directive

• Information on the provider’s policies that govern the utilization of these rights.

Legal Duty to Provide Care

• Consumer rights outlined by American Hospital Association (AHA)

• Right to safety

• Right to be informed

• Right to choose

• Right to be heard

Providers Who Refuse to Provide Care

why providers can refuse care:

• personally held moral or religious belief

• physical risk

• care to be given violates patient autonomy and rights to self determination

• religious and /or moral issue that causes provider to objec

encounters

routines, ceremonies and drams

family

 Definition of family today is much different than what it looked like in the past

 A group of one or more parents and their children living together as a

unit

 Group of two or more persons related by birth, marriage or adoption who live together

 Family can be made up of anyone a person considers their family

 Family shares emotional bonds, common values, goals and responsibilities

Family Stress Theory

 Views the family in evolving stressful situations where stressors occur and resolve throughout the life of the family

 Developed by sociologist Reuben Hill in 1949 – interested in how families were impacted by World War II and looked into how war- induced separations and reunifications shifted families

 Stressors affect how a family will adapt to illness and disease

 The kind of stress and amount of time a family takes to process that event can directly influence the relationships the family members share

 Overall dynamics are shaken after being in a highly challenging situation

Hill’s Family Stress Theory Model

ABC-X Model for family stress theory – many variations of the

family stress model but this one is the most used, accepted, and understood

 A: The Event that has put the family under stress

 B: Resources available that act as stress buffers

 Internal – stress and anger management skills, conflict resolution skills, communication skills, ability to self-regulate, mindfulness, self-awareness

 External – financial, access to food and medical care, social and communal support,

physical or practical assistance, emotional and psychological support including therapy

 C: Perception of the stressor; different kinds of stressors and each one is understood as either dangerous or challenging or constructive hurdle

 X: Outcome – stands for the result or outcome/likelihood of the family crisis

Duvall’s Family Development Theory

 Families move through stages in a particular order across time

 Theory is based on the traditional, nuclear, intact family

 Stages:

 Married couple without children

 Childbearing families with the oldest child between birth and 30 months

 Families with preschool children

 Families with school-age children

 Families with adolescents

 Launching families (first to last child is leaving home)

 Middle-age families (“empty nest” to retirement)

 Aging families (retirement to death of both spouses)

Classic Resiliency Model

Premise is by intervening to help families, providers can

have a positive impact on the resilience of the family,

enabling an opportunity for balance to be achieved while

decreasing the buildup of unresolved stress

Perspectives on the Family

 Family as a resource (protective)

 Family as a deficit (contributor or threat to illness)

 Family and the course of illness (adaptive or

maladaptive)

 Family and the impact of illness (burden and

stress)

Family Adaptation to Injury and Illness

 Any health condition that threatens the functioning

and well-being of the patient also threatens the

family

 Family’s response to patient’s condition highly

influenced by previous experiences

Assessing Family Health and Family

Relationships

 Information can come from:

 1. Family’s previous experience and beliefs about

patient’s condition

 2. Their knowledge and understanding of the health

condition

 3. Actual health and medical concerns of other family

members (families are informants of current and past

medical conditions)

 4. Family relationship and roles

Areas Needing Clarity

 Quality and communication between the patient and specific

designated responsible parties

 Patient’s role in the family and alterations in role functioning as a

result of the onset or progression of illness

 Factors that may inhibit communication in the family

 Patients define their own family unit:

 This can include what information is said or not said

 Legal responsible could be someone completely different

The Chaotic Family

 Structuring communication:

 1. Structure the topics, direction, and duration of the

interview

 2. Speak clearly and gain and maintain control of the

flow of communication and discussion

 3. Appeal to the designated leader(s) of the family to

follow-up on recommendations

 4. Establish definite timelines for follow-up

crsis

 Defined as “a time of intense stress or difficulty”

 False assumptions:

 People in crisis area always incapacitated

 People in crisis is that people experience crisis alone

 Leads to a long lasting psychological breakdown

 Crisis is the same as the stressor or stimulus-provoking

response

Dysfunctional Aspects

 Crisis is usually accompanied by anxiety

 Physical signs and symptoms:

 Restlessness

 Shortness of breath

 Trembling

 Shaking

 Facial expressions and gestures

 Struggle with communication

Family in Crisis

Experiencing incapacitating trauma

 Providers have trouble communicating with family

 Responses may include: anger, rage, fear, panic, blame, guilt,

despair

 Level of cooperation is a concern

 Lives disrupted by mental health or acute or chronic

physical illness

 Equilibrium that potentially renders them unable to fulfill their roles

and make informed decisions, at least temporarily

 Primary therapeutic response – allow them time to express

their emotions

Disturbances

 In Perception

 Happen as a result of overstimulation

 Rapid or excessive barrage of stimuli that exceeds one’s particular

tolerance

 In Expression

 Individual’s capacities to express thoughts, ideas and feelings

in a complete & coherent manner affected

 In Processing Stimuli

 Inability to process stimuli

Stress Theories and Understanding

Crisis

Lazarus and Folkman (1984)

 Stress Definition

 “the demands placed on us from either internal or external sources that are perceived as

taxing or as exceeding the resources of the individual”

 Stress and stressors studies as well as coping and adaptation skills

 Holmes and Rahe (1967)

 Stress results from change

 Any change (large or small) that requires readjustment in a person’s life causes

stress

 Demand impact of events accumulates over time (how many stressful events occur

to a person in a specific timeframe)

maladaptive coping responcses

emotionally based; strategies in which further

problems are created without addressing the problems causing the stressful life event

adaptive

problem-solving based

Stress-resistance resources

both the internal and external elements a person employs to deal with and resolve the problems that are creating stress

Situational crisis

Situations that have affected in either a negative or

positive way

Existential crisis

Where you are questioning your everyday existence

Developmental Crisis

1. trust vs mistrust

 2. autonomy vs shame and

doubt

 3. initiative vs guilt

 4. industry vs inferiority

 5. identity vs role confusion

 6. intimacy and solidarity vs

isolation

 7. generativity vs self-

absorption or stagnation

 8. integrity vs despair

Phases of Crisis Resolution

Initial sign = anxiety

 Then, accompanied by physical signs of distress –

restlessness, muscle tension, trembling, swaying,

dizziness, headaches, and palpitations

 Sleep deprivation

 Could progress where person is a threat to themselves

Managing Crisis Behaviors

 Clarify the patient’s problems and needs

 Foster supportive interpersonal encounters

 Encourage patients to seek additional support

 Refer patients to therapists that can address and

monitor coping mechanisms

General Guidelines

 Crisis victims should not be revictimized in the

process of being helped

 An emotional or psychological connection with the

patient is critical

 Crises are responses to real or imagined threats

 Crisis is not merely a single event

Communicating with Agitated and/or Confused Patients

 Agitation and confusion commonly occur with

patients in crisis

 Disturbances in orientation and intellectual

impairment

Stages of Adaptation to Illness or Injury: discovery

Carries with it emotional reactions of denial & disbelief.

Stages of Adaptation to Illness or Injury: acute and chronic

Anger, depression, beginning resolution

Stages of Adaptation to Illness or Injury: terminal

Ultimate resolution and acceptance

Principles to Guide Observations

 Patients do have emotional reactions to their illnesses and

injuries

 These reactions change over time

 The process is not as linear as we thought

 Fear, Anxiety and Disorganization

Emotions and Reactions

 Anger and Hostility

 Anger is a reaction to stress and a statement of protest

 Depression

 Most patients will experience sometime during their illness

 Depression + hopelessness = prime candidates for suicide

Resolution and Acceptance

• most talked about when facing end of life

• behavior and cognitive control

Helplessness

Condition that is both perceived

any and induced in patients who

are experiencing illness

Powerlessness

Patients’ recognition that they

have no control to affect a

specific outcome.

Hopelessness

Being without hope - can result in

declining physical and mental

status

Therapeutic Responses to Chronically Ill

Patients

 Types of Coping Functions:

 Problem-focused coping

Those that manage or alter the problem or source of

stress

 Emotion-focused coping

Those that regulate the stressful emotions that are

brought on by stress

Cognitive Appraisal

 Patients’ perceptions of and processing of

health-related problems will determine their

emotional reactions

 Impact of familial, cultural and religious beliefs

Levels of Denial- first

denial of the facts

Levels of Denial- second

denial of the implications of the facts

Levels of Denial- third

Denial of the ultimate outcome of the illness or prognosis.

Approaches to Truth Telling

• Provider-patient-family relationship is

  based on mutual respect and trust.

• Provider’s concern about telling bad

  news is that it will lead to more fear and

  stress.

Tips for Communicating with Mental

Health Patients

 Avoid speaking on their behalf. If pause or delay, wait for them to respond.

 Avoid talking about complex emotional topics in their presence, especially in

times of crisis

 Use non-verbal communication such as silence and listening to give patient

acknowledgement and sense of control

 Leaning forward, facing the patient and maintaining eye contact are ways to

actively listen

 Stay calm and be patient

 Listen but respect personal space and be cautious

 Avoid assuming what they are thinking about, their wants or needs

 Talk with the person with mental illness, not about them

 Be warm and empathetic

 Positive regard and appreciation for little efforts

5 Things to NEVER Say to Someone with

Mental Illness

 1. Stop acting crazy! Don’t be insane! You are seriously unhinged!

 2. Just don’t worry about it! Calm down! Don’t sweat the small stuff!

 3. This makes me want to kill myself! I wish I were dead! This makes me want

to commit suicide!

 4. Therapy is for people who are weak! I just don’t see the point of therapy!

Can’t people just solve things on their own?

 5. Things will be better in the morning. Tomorrow is another day. Cheer up!

Expressed Emotion

 The style of communication that the family follows when talking to the person

with mental illness.

 It involves five components, any or multiples of which could be reflected in the

communication styles of the family members:

 Criticality

 Hostility

 Over-involvement

 Positive regard

 Warmth

 First 3 are negative expressed emotions

 Last 2 are positive expressed emotions

End-of-life & Decision-making

Conversations

 Terminal illness and discussions about type of care desired

at end of life

 Range of issues – DNR, do not hospitalize, nutrition,

hydration, discontinuing all care, comfort measures, pain

management)

 Advance directives, Living Will, Physician Orders for Life-

sustaining Treatment (POLST), Medical Orders for Life-

sustaining Treatment (MOLST)

 Comfort care, palliative care, hospice care, transitional care

Decisional Conflict

 State of uncertainty about a course of action more

likely when person and/or family confronted with

decisions – conflicts within the family or with the

patient

 Emotional

Depression

Chronic Illness

 Healthy People 2020 addresses

 Along with hopelessness –

prime candidate for suicide

 Negatively affects how you feel,

the way you think and how you

act

 Feelings of sadness and/or loss

of interest in activities

Symptoms of Depression

 Feeling sad

 Lost of interest or pleasure

 Changes in appetite

 Changes in sleep

 Loss of energy and/or increased

fatigue

 Increase in purposeless physical

activity or slowed movements/speech

 Feeling worthless or guilty

 Difficulty thinking, concentrating, or

making decisions

 Thoughts of death and suicide

Caregiver Burden

 Physically and emotionally drained from caring for the patient

 Angry and frustrated by the prospect of endless caregiving responsibilities

 Frustrated about the program of caregiving and the numerous demands without

clear signs of patient improvement or progress

 Powerlessness over the disease, its course, and the ability to make changes for

the better

 Angry at the patient for significantly altering their personal independence and

autonomy and, therefore, quality of life

Functional Health Literacy

 Defined as the skills and knowledge necessary to

understand illness and treatment, and the ability to

navigate the health care system

 Low literacy associated with:

 Poor understanding of medical advice

 Adverse patient outcomes

 Negative effects on health

 = Substandard care

 Health literacy is not necessarily related to years of

education

Healthy People 2010

the degree to which individuals have the capacity to obtain,

process and understand basic health information and

services needed to make appropriate health decisions

healthy people 2030

• increase the proportion of adults who’s health care provider checked their understanding

• decrease the proportion of adults who report poor communication ith their health care provider

• increase the proportion of people who say their online medical record is easy to understand

• increase the proportion of people who say their online medical record is easy to understand

• increase the proportion of adults which limiter English proficiency who say their providers explain things clearly

• increase health literacy of the population

Barriers to Health Literacy

 Individual-level patient barriers

 Demographic

 Health status

 Complexity of illness and treatment

 Illness experience

 Health care system exposure

 Provider-patient-family relationship barriers

 Number and length and quality of encounters

 System-level barriers

 Mission of institution

 Organization of services

 Proportion of providers and patients

 Time and schedule of care activities

population most at risk for health illiteracy

 Youth

 Elderly

 Low Income

 Minority

 Vulnerable Populations

 Medically and Cognitively Impaired

 Underserved

Deficits in Patients’ Understanding Health

Conditions

• Patients do not

  recognize what

  they do not

  know.

• Patients think

they know but

do not know.

Communication Interventions

• Time to construct reading

materials using plain

language and

illustrations.

• Opportunity to test and

evaluate all written

materials and medical

instruction info sheets.

• Provider-patient time to

communicate to exceed

6-10 mins.

• Advocacy for health

literacy in the

organization and

recognition of the value of

assessing health literacy.

• Providers knowledgeable

and skilled in concepts of

and assessment of

limited literacy.

• Opportunity to conduct

feedback loop.

• Development of

population-based health

literacy best practices.

Assessing Health Literacy

• test of Functional Health

  Literacy in Adults

• REALM-R

• Short assessment of health literacy for Spanish speaking adults

• newest vital sign

Use of “Plain Language”

 Presenting important points first

 Organizing complex thoughts and ideas into

understandable parts

 Using simple terminology and language, defining

technical terms

 Using the active voice when making statements to

patients

patients should be able to state

• what are you going to day?

• what is your problem?

• what am I supposed to do?

• why is it important for me to do this?

CONFRONTATION

Deliberate use of statements or questions with patients to point out discrepancies

• Motivates patients to change what they are or are not doing

• Differences between what is said versus what is done

• Differences in statements or behaviors observed over time

• Differences between what patients should do and what they are actually doing

• Offers providers’ and patients’ alternative views about what is really going on

levels of confrontation

Firsthand experience of behavior or Present factual data that provides patients with info and feedback

before using confrontation

• establish relationship built on trust and caring

• use empathy, postive regard,respect, warmpth, active listening and genuinesess

• lay the foundation for the poupose for adressing unique concerns

• avoid appering overly critical when no emergent threats are present

• identify obvious discerpancies and plan approach to communicate them

• define provider role and level of commitment

orders and commands as explicit

• Directives are absolute statements made to patients about a preferred

course of action

• Expected to be followed

• Orders and commands elicit change by insistence and should not be perceived

as a choice

• Orders are a directive that patients must follow, does not have to be

immediate

• Commands are also directives that must be followed, but they demand

immediate action

advice

• Can frequently appear as a directive

• The less direct the advice, the less likely pts will resist taking it

• Providers must be an open style – a willingness for their advice to be rejected

• Advice that MUST be followed is not advice, but a command or directive

SUMMARIZING DIRECTIVES

• assess what has been understood and how it was interpreted

• use teach-back method

• focus on shared understanding and plans raising from discussions

• summarize important points and directives given

• make patients aware session is ending so they can ask questions or clarify points

• note gains ir progress made in attempt to patients following directives