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list aspects of diversity
age, sexual orientation, colour, culture, physical/mental disability, political views, gender, sex, religion , social class, education
why is diversity important in health care?
- different groups have:
- - different health problems
- - different lifestyles that impact on health
- - want different types of health care services
- - hold different health beliefs
- - have different access to health care
what are stereotypes and why does everyone have them?
- stereotypes are social schemata
- we need schemata to organise knowledge - they allow us to make assumptions about new situations
- part of cognitive model of psychology
when are we most likely to rely on stereotypes?
- information overload
what are in group/out group attributions?
- more likely to focus on negatives of people from other social groups
- and positive attributes of own social group
how do stereotypes lead to discrimination?
- stereotypes are cognitive component and ignore individuality
- pre-judice is the evaluative component and is often based on negative types
- discrimination is the behavioural component where you treat someone differently solely based on the group to which they belong
definition of culture
“Culture is defined by each person in relationship to the group or groups with whom he or she identifies. An individual’s cultural identity may be based on heritage as well as individual circumstances and personal choice. Cultural identity may be affected by such factors as race, ethnicity, age, language, country of origin, acculturation, sexual orientation, gender, socio-economic status, religious/spiritual beliefs, physical abilities, occupation.
These factors may impact behaviours such as communication styles, diet preferences, healthbeliefs, family roles, lifestyle, rituals and decision making processes.
All of these beliefs and practices,in turn can influence how patients and heath care professionals perceive health and illness and how they interact with one another”
what is the biomedical model?
- focus on biological processes
- mind-body split
- machine metaphor
- disease orientated not focused on health
describe the biopsychosocial model
- takes into account the different factors involved in health and illness
- bio - physiology, genetics, pathogens...
- psycho - cognition, emotion, motivation...
- social - social class, employment, support...
describe the transactional model of stress
stress as a process
potential stressor > primary appraisal (is the event a threat? how bad can it be?) > secondary appraisal (do i have the resources to cope?) > IF NO > stress
how does the transactional model of stress account for the fact that some people experience stress while others in the same situation don't?
- stress is subjective
- depends on the way a person appraises the potentially stressful event and the resources they have to cope
the way we appraise and the situation is unique
how can stress impact on health?
- physical damage - effects on CVS
- psychoneuroimmunology - short term immune system up regulated long term it is depressed by excess cortisol
- increase unhealthy behaviour
- increase risk of mental health problem
how do we cope with stress?
5 strategies and examples
- cognitive - hypothesis testing
- behavioural - skills training eg. time management
- emotional - counselling, social support
- physical - relaxation training, exercise
- non-cognitive - drugs
how is stress an example of the biopsychosocial model?
the experiences people have and how they react to them can have a physiological impact
what is coping?
reducing the gap between the primary and secondary appraisals of the transactional model in order to reduce stress
what are the two coping styles and give examples?
- emotion focused coping : change the emotion
- behavioural - talk to friend, alcohol, find distraction
- cognitive - denial, focus on positives
- problem focused coping : change the problem / resources
- make a plan, give up other things to focus on problem
how do we aid peoples ability to cope?
- increase/mobilise social support
- increase personal control
- - increase patient choices
- - self-management
- prepare patients for stressful events
- - give patients the info THEY want
- - pair with post -op patient
- stress management techniques - think coping strategies
emotional state characterised by low mood, sadness, loss of interest, feelings of worthlessness, disturbed sleep pattern.
common in chronic illness
problems with sex studies
- purposeful distortion
what is sexual dysfunction?
the sexual dysfunctions are characterised by a disturbance in sexual desire and the psychophysiological changes that characterise the sexual response cycle and cause marked distress and interpersonal difficulty
what is the sexual response cycle?
list some sexual dysfunctions and the part of the sexual response cycle that they effect
- lack/loss/excess desire
- arousal - erectile dysfunction, sexual arousal disorder (F)
- orgasm - rapid ejaculation, inhibited orgasm (often possible alone but not with partner)
- other - dyspareunia - pain, vaginismus - phobic of penetration muscles contract.
describe the psychological model for assessment and formulation of sexual problems
- - predisposing factors - early experiences- traumatic experience, inadequate information, restrictive upbringing
- - precipitants - events/experiences with initial dysfunction - childbirth, infidelity, depression, illness
- - maintaining - intervening factors that allow the problem to continue - performance anxiety, guilt, poor communication, restricted foreplay
what are the main components of psychosexual therapy?
- educative counselling
- modifications of attitudes/beliefs
- facilitation of communication
- specific directions for sexual behaviour - sensate focus
what are the stages and purposes of sensate focus for sexual dysfunction?
- purposes - remove anxiety, relax as a couple, increase confidence
- stages - ban on intercourse by the therapist - general pleasuring ... genital pleasuring ... intercourse
describe attachment theory
- infant forms first mental model of relationship based on interactions with their primary care giver
- critical period = 1st year, problems may occur if separated up until the age of 4
- insecure attachment in infancy may lead to short or longer term problems
what are the social stages of development in infancy?
- newborns show preference for human faces
- 6 weeks - first social smile
- 3 months - distinguish strangers, show preference for non-strangers, allow any caring adult to handle them
- 7-8 months - specific attachments formed, misses key people and shows distress in their absence, wary of strangers (proximity seeking behaviour)
Describe Bowlby's pattern of behaviour in children separated from their mothers
- - protest - cry, look for mother, cling to substitute
- - despair - withdrawn, helplessness, cry intermittently
- - detachment - become more interested in surroundings, when carer returns they are remote and apathetic
second two phases are often mistaken for recovery.
explain attachment styles
- - avoidant - withdrawn act the same with strangers
- - resistant - clingy and needy
- - disorganised
what are the effects of separation?
- less play
- less sleep
- less adherence to treatment
- increased pain levels
list the stages of childhood cognitive development
- must pass through these stages in order but ages vary
- 1.SENSORI-MOTOR 0-2yrs (organise sensory info, develop motor co-ordination, develop body schema and object constancy)
- 2.PRE-OCUPATIONAL 2-7yrs (egocentric speech, overgeneralisation, reversibility, conservation)
- 3. CONCRETE OPERATIONAL 7-12yrs (struggle with abstract thought eg metaphors, like collecting info on favourite topic)
- 4. FORMAL OPERATIONAL 12+yrs (capable of abstract thought, develop hypotheses)
ways in which you can best communicate with a child?
- smile or look sad as appropriate
- maintain eye contact
- acknowledge and greet the child
- talk to parents first allows child time and space to relax
- observe wait and listen
- give simple clear instructions
- state expectations clearly
- give them choices
- acknowledge feelings
- have quick fixes eg.stickers
advantages of using relations as interpreters?
- patient may feel more comfortable
- in a chronic condition this may give consistency
- same accent
disadvantages of using relations as interpreters?
- lack of confidentiality
- may not give direct translation
- patient may not disclose
advantages of using professional interpreters?
- better explanations
- all info translated
- no bias
- confidentiality maintained
- patient may feel less embarresed
disadvantages of using professional interpreters?
- lack of trust from patient
- lack of doctor patient relationship
- takes time to organise
things that are important when using an interpreter?
- talk directly to patient
- make use of written material
- appear attentive when patient is speaking
- pause frequently
- address patient in 2nd person
what are the three types of psychological therapies?
A psychological treatment as a intergral part of mental health care - a good psych comm nurse
B eclectic psychological therapy and counselling - less structured, very common
C formal psychotherapies eg. CBT, psychoanalytic/psychodynamic therapies, systemic and family therapies
what is CBT?
- combination of cognitive and behavioural therapy
- relief of symptoms by altering maladaptive thoughts beliefs and behaviour
- symptom orientated
- addresses things that can be measured
techniques used in CBT
- behavioural - graded exposure to feared situations, activity scheduling, reinforcement and reward, role play
- cognitive - education, monitoring of thoughts / behaviours / feelings / contexts, challenging negative thoughts, behavioural experiments, rehersals for coping with difficult situations
when is CBT used?
- mood disorders
- anxiety states
- eating disorders
- sexual dysfunction
- an extra treatment in psychosis
who is CBT suitable for?
- patients keen to be active participants
- engage - homework etc.
- those who can accept a model including their feelings
- those who can articulate their problems and are practically seeking solutions
what are psychoanalytic/psychodynamic therapies?
- divided in to focal and analytic
- focal - briefer, identifies conflicts arising from early life that are re-enacted in later life use the therapist to resolve these issues - test out situations with the therapist as a substitute
- analytic - long term - allows unconscious conflicts to be re-enacted and interpreted in relationship with the therapist
- hard for the therapists, must act as a blank canvas, therapist must be in thrapy
who is psychoanalytic/psychodynamic therapy suitable for?
- people with interpersonal difficulties and personality problems
- must have capacity to tolerate mental pain
- interest in self exploration
- can last for many years
what is systemic/family therapy?
- aim to facilitate resources within a system as a whole
- focus on relational context
what is humanistic/client-centred therapy
who is it suitable for?
- generalised counselling
- falls between types B and C
- can help with coping with an immediate crisis where patient is motivated and willing to problem solve
- mobilises patients own ability
recent onset mild to moderate difficulties eg. illness loss subclinical depression mild anxiety relationahip difficulties
how do you choose what psychotherapy is appropriate for the patient?
determined by both the problem and the patient
what is the cognitive therapy rationale?
- we are not passive recipients of stimuli - we interpret and re-interpret
- it is not situations that hurt us but the view we take of them
- changes in mood state are directly related to the way we make sense of events
hat is the cognitive model
what is the negative cognitive triad in depression?
- negative view of self
- negative view of world around
- negative view of future
what are our core beliefs (schema)?
- moral qualities
- general worth
what are common healing factors?
- confiding relationship with helpful person
- healing setting
- rationale that explains symptoms and gives hope
- combating sense of alienation
- new learning experiences
- allow processing of emotions
- enhance sense of self efficacy
how can we define psychotherapy?
the systematic use of a relationship between patient and therapist to produce changes in feelings cognition and behaviour
what are health related behaviours?
anything that may promote good health or lead to illness
what theories help explain health related behaviour?
- learning theories - classical conditioning, operant conditioning, social learning theory
- social cognition models - health belief model, theory of planned behaviour
- stages of change/ transtheoretical model
what is classical conditioning?
- pavlov's dogs
- associated response with break from work and smoking = relax
- smoking and drinking etc
can also be used to help change health related behaviour either by adversion techniques or changing normal patterns eg. elastic band on cigarette packed
what is operant conditioning?
rewards and punishments shape behaviour
it is hard to unlearn as initial pleasure is removed
what are the limitations of conditioning theories?
- based on simple stimuli-response associations
- no account of social context
- no account of cognitive processes knowledge, beliefs, memory, attitudes, expectations etc.
what is social leaning theory?
- we can learn by observation - women hit doll > child hit doll
- behaviour is focused on desired goals
- people are motivated to perform behaviours that are valued and that they believe they can achieve
- we learn behaviours that are rewarded
- influenced by role models
what are the health locus of control?
- internal - i am responsible
- external - fate/luck
- powerful others
peoples view on their impact on their health
what is the health belief model?
what are the limitations of the health belief model?
- do people only consider the consequences post the event
- are people making descisions or is it habit
- emotional factor
what is the theory of planned behaviour?
what are the 4 key elements
- 4 elements:
- attitude - eg taking regular exercise would improve my health & improving my health is important to me
- subjective norm - people who are important to me agree and this is important to me
- perceived control - exercising frequently would be easy for me
- intention - i intend to exercise regularly over the next 6 months
what is the problem with the theory of planned behaviour?
good indicator of predictions but poor indicator of behaviour
what is the stages of change (transtheorectical) model?
- intervention must be appropriate to patients stage
define motivational interviewing
client centred directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence - benefits vs. costs
what are the aims of Motivational interviewing?
- elicit patients own arguments for change
- increase motivation to change
what are the four main principles of motivational interviewing?
- express empathy
- develop discrepancy
- roll with resistance
- support self efficacy
what is the structure of a motivational interview?
- assess readiness to change
- explore importance
- build confidence
- ... if ready negotiate a plan
why do we talk about adherence and not compliance?
need for patient centred approach
what are the problems with measuring adherence?
- hard to get measurements
- patient self reports
- pill counts
- urine/blood tests
why don't patients adhere to medical advice or treatment?
- patient satisfaction
- patient understanding
- patient recall
- social factors
- administration of treatment
what is concordance?
- negotiation between patient and doctor over treatment regimes
- patient beliefs and priorities are respected
- patient plays an active role
concordance is argued to lead to better adherence
what is pain?
- a sensation or emotion?
- physical or mental?
what were the early biomedical theories of pain and what are the challenges to them?
- physical damage is the sole cause of real pain
- more damage causes more pain
- only a role for psychology in this model is with aftermath of pain
- the problems are:
- - pain continuing after damage heals
- - pain with no physical damage
- - no feeling much pain despite severe injuries
- - some amputees experience phantom limb pain
- - variation in pain reports from people with the very similar injuries
describe the gate control theory of pain
- pain is a result of a 2 way process or communication between the brain and the tissue damage or nerve messages
- the extent that the gate is open or closed affects the number of pain messages that are recieved
- CLOSE: medication, counter sensation, exercise, relaxation, distraction, positive beliefs, active life
- OPEN: injury, over/under active, sensitivity of NS, stress, tension, focusing on pain, negative beliefs,
what is pain management?
- focus is improving quality of life
- pain relief is not a primary goal
- develop ways to cope, improve fitness/motility/posture
- improve communication skills
- reduce use of unhelpful aids and equiptment
how does the pain management programme run?
- individual assessment
- 1 day for 9 weeks / 2 half days for 6 weeks
- 4 MAIN PRONGS:
- - managing thought and feelings
- - active but pacing self
- - goal settings
- - relaxation
what criteria should be considered when considering a patient for a pain management programme
- 5 years of pain
- exhausted all other pain methods
- no mental health problems
- cognitive ability
- willing to be in a group environment
what inhibits patient from asking doctor about sexual health problem?
- gender, age, social class, culutral differences
- language barriers/terminology
- fear of judgement, discrimination
- may not feel it is relevant
- assumptions about lifestyle choices
- lack of trust
how can a doctor make it ok for the patient to talk about a sexual health problem?
- option to book an appointment with female/male doctor
- use non-specific partner gender terms
- use patients terminology
- reflective statements
- avoid rushing consultations
- create a relaxed environment without judgement
- assurance that confidentiality will be maintained
what are the main mental disorders in later life?
does memory get worse with age?
some aspects but not all
5 stages of grief model
Common initial reactions of terminal diagnosis
Is denial always bad?
- Patients have right to know but not a duty
- Written info may be useful
- Can lead to adherance problems
- Can be a way to cope
What is palliative care?
Improving quality of life not just right at the end
How to have a good death?
- Understand what can be expected
- Allow patient to retain control
- Give patient dignity and privacy- at home
- Access to Information and expertise
- Access to spiritual and emotional support
- Access to hospice care in any location
- Control over who is present and who shares the end
- Enable people to issue advanced directives
- Having time to say goodbye and other timing issues
- Not to have life prolonged pointlessly
What is meant by the medicalidation of death?
- Increasing the taboo
- Making it harder for people to cope
What is bereavement?
- Reaction to loss of a loved one
- Can cause physical symptoms through mechanism of stress
- Some people feel physical pain
What is grief?
- Complex reaction to bereavement
- The grieving process is unavoidable -disbelief and shock then awareness then resolution
- Funerals etc are important part of process
What is mourning?
observable expression of grief
What is normal grief?
- Large individual differences
- Individual feelings and needs
- Relapse at important dates are common eg anniversaries
What are risk factors for poor outcomes of bereavement
- Prior bereavements
- Prior mental health problems
- Type of loss eg violent
- Lack of social support
Symptoms of disturbed/chronic mourning
- Exagerated numbness
- Ongoing physical symptoms
What leads to complications in grief process?
- Expression of grief discouraged
- Ending of grief discouraged
How may doctors be affected by patient death?
- More likely to affect if identify with patient
- Feelings=pain,sadness, anger, guilt
- Coping= talk through colleagues, relatives, services
- Need to not always think of death as a defeat - important part of medicine
what is bad news?
any news that may alter a patients view of their future for the worse
what are typical situations in which bad news is given?
can we guarantee it will be bad news?
- terminal prognosis
- disabling condition
- traumatic/sudden death
- antenatal testing
- intra-uterine death
patient/carer may feel relief
why is it important to give patients bad news?
- maintain trust
- reduce uncertainty/stress
- prevent unrealistic expectations
- allow appropriate adjustment
- promote open communication
why it important to avoid collusion?
- it is unethical to keep truth away from patients
- promise not to give unwanted information
what is the model for breaking bad news?
- setting and listening skills
- patients perception
- invitation from patient
- strategy and summary
- - document the consultation