COMPARE AND CONTRAST RANDOM ACTIVITYPlease go to .docx

COMPARE AND CONTRAST RANDOM ACTIVITY:
Please go to
https://www.random.org/lists/.
Copy and paste this list of random paired items I quickly
brainstormed as being ok for a simple compare and contrast
essay.
Then randomize it. Your job now is to take either the first two
or last two items of your new randomized list, and complete the
following steps.
1) Do a venn diagram to list out similarities and differences.
2) Figure out what the frame of reference for comparison is.
3) Come up with a thesis statement.
Eggs
Butter
Lincoln Logs
Legos
Digital Alarm Clock
Grandfather clock
Banana
Mango
Thumbtack
Clear scotch tape
.
Item:
Similarities

Item
List out differences for item one here.
Then here.
Then here.
Remember the differences should be paired with a list item
other the under item.
List out similarities here.
And here.
And here.
And here.
Corresponding item.
Corresponding item.
Corresponding item.
Corresponding item.

(I’d recommend writing it out on paper, and then transferring it
to the document… I couldn’t get the venn diagram to look
right… Sigh. If you are at all confused about venn diagrams, see
this video:
HERE.
What is the Frame of Reference?
Answer here.
THESIS: What is your thesis.
Write it here. Make an interesting argument.
What, if anything, did you learn/realize about compare/contrast
essays via this activity?
Answer goes here.
224 | Nursing Open. 2018;5:224–
232.wileyonlinelibrary.com/journal/nop2
1 | INTRODUC TION
Countless number of encounters occur in healthcare
organizations
every day. Encounter is a concept related to the words meeting,
ap-
pointment or relationship but diverges as the encounter
regularly
means more a personal contact between a few people that takes

place planned or unplanned, that come across and get in touch
with each other (Westin, 2008). Some healthcare encounters are
short and temporary while others are long- lasting and
recurring.
Short and temporary healthcare encounters between patients and
caregivers require more things to be taken care of in a short pe-
riod of time (Holopainen, Nyström, & Kasén, 2014). Lack of
time in
healthcare encounters can therefore be an obstacle to the
develop-
ment of a caring relationship, as they require a high level of
quality
communication between the patients and the professionals
(Nåden
& Eriksson, 2002).
To ensure a good healthcare encounter, there must be sufficient
time for communication, enough resources and opportunities for
patients and professionals to create a meaningful relationship,
re-
gardless of the duration of the encounter (Nygren Zotterman,
Skär,
Olsson, & Söderberg, 2015). From the patient’s perspective, a
mean-
ingful relationship is often described as individualized attention
fo-
cusing on his or her needs (Attree, 2001) that allows him or her
to be
involved in the decision- making process (Covington, 2005). A
good
and meaningful relationship, from the patient’s perspective, is
char-
acterized by gratitude and trust (Gustafsson, Gustafsson, &
Snellman,
2013). This is in line with a person- centred perspective, which

im-
plies working towards an integration of “being with,” the
relational
Received: 23 October 2017 | Accepted: 25 January 2018
DOI: 10.1002/nop2.132
R E S E A R C H A R T I C L E
Patients’ complaints regarding healthcare encounters and
communication
Lisa Skär1 | Siv Söderberg2
This is an open access article under the terms of the Creative
Commons Attribution License, which permits use, distribution
and reproduction in any medium,
provided the original work is properly cited.
© 2018 The Authors. Nursing Open published by John Wiley &
Sons Ltd.
1Department of Health, Blekinge Institute of
Technology, Karlskrona, Sweden
2Department of Nursing Sciences, Mid
Sweden University, Östersund, Sweden
Correspondence
Lisa Skär, Department of Health, Blekinge
Institute of Technology, Karlskrona, Sweden.
Email: [email protected]
Abstract
Aim: To explore patient- reported complaints regarding
communication and health-
care encounters and how these were responded to by healthcare

professionals.
Design: A retrospective and descriptive design was used in a
County Council in
northern part of Sweden. Both quantitative and qualitative
methods were used.
Methods: The content of 587 patient- reported complaints was
included in the study.
Descriptive statistical analysis and a deductive content analysis
were used to investi-
gate the content in the patient- reported complaints.
Results: The results show that patients’ dissatisfaction with
encounters and commu-
nication concerned all departments in the healthcare
organization. Patients were
most dissatisfied when they were not met in a professional
manner. There were dif-
ferences between genders, where women reported more
complaints regarding their
dissatisfaction with encounters and communication compared
with men. Many of
the answers on the patient- reported complaints lack a personal
apology and some of
the patients failed to receive an answer to their complaints.
K E Y W O R D S
communication, nurse–patient relationship, patient advisory
committee, patient complaints,
quality of health care
www.wileyonlinelibrary.com/journal/nop2
http://orcid.org/0000-0002-5731-2799
http://creativecommons.org/licenses/by/4.0/
mailto:[email protected]

| 225SKÄR and SÖdERBERG
part and “doing for,” the task- based part of nursing
(McCormack
& McCane, 2010). Person- centred care has been shown to have
a
significant impact on patient and caregiver interactions, health
out-
comes and patient satisfaction with care (Ekman et al., 2011).
Since
an encounter takes place between unique persons and in a
moment
of mutual recognition, no person can know how the other is
going
to experience an interaction due to the interpretive nature of
inter-
action (Nåden & Eriksson, 2002). Therefore, is it important to
focus
on communication and healthcare encounters between patients
and
healthcare professionals.
1.1 | Background
Patient- reported complaints showing that most complaints are
around communication and interaction with healthcare profes-
sionals (Montini, Noble, & Stelfox, 2008). Patient- reported
com-
plaints about healthcare encounters are an increasing issue
(Cave &
Dacre, 1999; Friele, Kruikemeier, Rademaker, & Lawyer, 2013;
Kline,
Willness, & Ghali, 2008; Wessel, Lynøe, & Helgesson, 2012),
despite
an increased focus on patient - centred care (Skålen, Nordgren,
&

Annerbäck, 2016). The number of patients who reported
complaints
about Swedish health care more than doubled between 2007–
2013
(Activity report Patients’ Advisory Committee 2014). From an
inter-
national perspective, patients’ complaints about healthcare
encoun-
ters are increasingly recognized in, for example, Germany
(Schnitzer,
Kuhlmey, Adolph, Holzhausen, & Schenk, 2012), United
Kingdom
(Lloyd- Bostock & Mulcahy, 1994; Nettleton & Harding, 1994),
USA
(Garbutt, Bose, McCawley, Burroughs, & Medoff, 2003;
Wofford
et al., 2004), Canada (Kline et al., 2008) and Australia
(Andersson,
Allan, & Finucane, 2001). However, today, there are no
comprehen-
sive international statistics regarding how widespread
dissatisfac-
tion is with healthcare encounters, care and treatment, as
patients’
complaints often are unstructured information expressed in the
patient’s own language and on their own terms to the healthcare
organization (Montini et al., 2008). According to Wessel et al.
(2012),
complaints tend to be underreported by those with negative
experi-
ences of healthcare encounters.
In Sweden, patients’ complaints are most often reported through
the Patients’ Advisory Committees (PAC). The PAC is
responsible for
handling patients’ complaints and they act on behalf of the

patients’
or their relatives and strive to solve the problems that have oc-
curred together with the involved healthcare professionals
(SOSFS,
National Board of Health and Welfare, 2005). The PAC also
aims to
restore the patients’ and relatives’ trust to the healthcare
system,
viewing complaints as a valuable source of information about
pa-
tients’ experiences. Complaints can thereby be used positively
to
identify adverse incidents and to improve quality of care in the
fu-
ture (Kline et al., 2008; Montini et al., 2008).
Research shows that patients’ reported complaints to the
PAC include descriptions of insufficient respect and empathy
(Jangland, 2011), experiences of neglect, rudeness, insensitive
treatment from healthcare professionals (Skär & Söderberg,
2012; Söderberg, Olsson, & Skär, 2012) and poor healthcare
provider–patient communication (Montini et al., 2008).
Negative
healthcare encounters cause patients to experience unnecessary
anxiety about their health and thus reduce their confidence in
the healthcare system. This diminished confidence is affected
by
healthcare providers’ lack of supportive patient- oriented
commu-
nication skills as well as by the fact that the patients and health-
care professionals have different goals, needs and expectations
related to the healthcare encounters (Jangland, Gunningberg, &
Carlsson, 2009). The lack of adequate information and commu-
nication between patients and healthcare providers has been
shown to have a negative impact on patients’ experiences of

the quality of care they received (Attree, 2001). When patients
do not understand the information being given to them about
their health, it might be difficult to ask questions about care and
participate in decision- making for treatment or caring
(Jangland
et al., 2009; Skär & Söderberg, 2012). High- quality
communica-
tion between patients and healthcare professionals is therefore
significant for increasing patients’ satisfaction with healthcare
encounters and participation in decision- making (Kourkouta &
Papathanasiou, 2014; Petronio, DiCorcia, & Duggan, 2012;
Torke
et al., 2012).
Patient- reported complaints may be part of the process of im-
proving the quality of healthcare encounters (Montini et al.,
2008).
Moreover, it is not only the issues that gave rise to the patient-
reported complaints that are important; the way that the
complaints
are handled and responded to is likewise important. Veneau and
Chariot (2013), stated that answers to complaints are often
based
on medical information, lack comprehensiveness and show that
the
healthcare organizations have little intention to investigate the
issue
further. However, there is a lack of knowledge of how
healthcare
professionals communicate and respond to patient- reported
com-
plaints (Andersson, Frank, Willman, Sandman, & Hansebo,
2015).
Such knowledge may be used to improve the quality of
healthcare
encounters and provide insight into how healthcare

professionals
can create meaningful healthcare encounters. The aim of this
study
was to explore patient- reported complaints regarding
communica-
tion and healthcare encounters and how these were responded to
by healthcare professionals.
2 | THE STUDY
2.1 | Design
A retrospective and descriptive study design was used to
examine
patient- reported complaints.
2.2 | Method
This study includes quantitative and qualitative approaches to
achieve the study aim. The quantitative approach was chosen
to statistically describe the character of the reported complaints
to the PAC. The qualitative deductive content analysis was cho-
sen to enhance the understanding of the written text of the
226 | SKÄR and SÖdERBERG
complaints, focusing on the communication between the
patients,
the involved healthcare professionals and the administrators
from
the local PAC.
2.3 | Data collection

The study was conducted in collaboration with two adminis-
trators from the local PAC in the County Council of northern
Sweden, a region with five hospitals and 33 primary healthcare
centres. The criteria for inclusion were patient- reported com-
plaints concerning encounters and communication reported by
adult (over 18 years) patients themselves during January 2010–
December 2012. The chosen time period was based on that PAC
stored 3 years of complaints at a time. For some complaints,
parts
of the patients’ records were attached. All identifying patient
details have been omitted in the presentation of this study’s re-
sults to protect the patients’ anonymity, in accordance with the
Helsinki declaration. The patient- reported complaints filed at
the
PAC were covered by confidentiality. The results of the study
are
therefore presented only at a group level and individuals cannot
be identified.
During the chosen time period, the PAC received 1792 patient-
reported complaints concerning issues related to the following
areas: i) encounters and communication; ii) medical
maltreatment
and iii) organizational issues regarding rules/regulations. The
admin-
istrators at the PAC sorted and classified the complaints in the
file
archive based on the above- described areas. This sorting was
part of
the PACs normally classification of complaints and it was
performed
without a standardized system. To ensure that all complaints
that
contained dissatisfaction with encounters and communication
were
included in the analysis all submitted complaints (N = 1792)

regard-
less of the area where the Patients’ Administrators had sorted
them
in, were read through. This reading resulted in that all (N =
625) re-
ported complaints containing descriptions of dissatisfaction
with
encounters and communication were selected for the analysis. In
38
of the 625 selected reports, only a short note indicating the date
of
a phone call to the patient was found and thus these reports
were
excluded from the analysis. The remaining 587 complaints were
in-
cluded in the analysis.
2.4 | Statistical analysis
Statistical Package for Social Science (version 22.0; SPSS Inc.,
Chicago IL, USA) was used for the statistical analyses. Data in
the
patient- reported complaints regarding gender, the type of
organiza-
tion, clinical department, reason for the complaint and the type
of
healthcare professionals who were the focus of the complaint,
were
extracted to a data template and thereafter included in the SPSS
form. Descriptive statistics were used to describe the content
and
frequencies and a Pearson’s Chi Square test was used to
determine
the relationships and significant differences between the
patient’s
gender and the type of units and professions cited in the patient-

reported complaints.
2.5 | Deductive content analysis
The written text in the complaints was analysed in parallel with
the
statistical analysis, using deductive content analysis (Elo &
Kyngäs,
2007). Deductive content analysis may be used when the
structure
of the analysis is based on a specific structured knowledge such
as
a theory or a model. In this study, the analysis was framed in
terms
of pre- existing area; encounters and communication, used by
the
administrators at the PAC when they filed the patient- reported
com-
plaints into the file archive.
The first step in the analysis was to develop a categorization
matrix based on the pre- defined area encounters and communi-
cation. Then, all the complaints were reviewed for content and
coded for correspondence with one of the field in the area (cf.,
Elo
& Kyngäs, 2007). This means that all text in the patient-
reported
complaints that describe any form of meetings, appointments
and
relationships were sorted in the field encounters and that the
con-
tent in the patient- reported complaints that describe any form
of
information exchange, communication in form of a written
dialog
between the patient and the healthcare professionals involved

were sorted in the field communication. The content in each
field
was then compared based on differences and similarities and
cat-
egories were formulated. The analysis resulted in two categories
in each field. The analysis process was non- linear and involved
repeated readings of the complaints. To reach a consensus in the
analysis, the two authors moved back and forth between content
in the complaints and the categories in the field and discussed
the content to ensure that the results covered all content in the
complaints.
2.6 | Ethics
The authors obtained access to the local PAC file archive after
the
study received ethical approval from the Regional Ethical
Review
Board in Sweden (Dnr 06- 050M).
3 | RESULTS
The patient- reported complaints (N = 587) each contained a
writ-
ten letter from a patient describing the situation that had
occurred
and indicating dissatisfaction with the healthcare encounter and/
or communication. Each complaint also contained a summary
writ-
ten by the local PAC administrator as well as a checklist for
actions
to solve the situation. Furthermore, the reported complaints
con-
tained an answer from the healthcare professionals involved in
the
situation and a conclusion regarding how the report was handled

and the outcome. Below presents a descriptive summary of the
patient- reported complaints characteristics and categories from
the deductive content analysis in the two fields; encounters and
communication. The qualitative findings are supported by
quota-
tions from the text in the complaints, written with italic style in
the text.
3.1 | Characteristics of patient- reported complaints
Of the 587 patient- reported complaints, 336 (57%) of these
were
made by women. The 587 complaints concern all units in the
health-
care organization and the clinical department that contained
most
complaints was consultation outpatient visits (N = 195),
followed
by surgery (N = 171). The complaints described different
groups of
healthcare professionals who were the focus of the complaint
and
the most common professions the complaints focus on were
phy-
sicians (N = 357), followed by healthcare managers (N = 100)
and
nurses (N = 79). Men’s complaints were more often directed
against
physicians than were women’s complaints (72% vs. 53%), while
women were more likely than men to direct their complaints
against
healthcare managers (22% vs. 11%). Healthcare manager could

be
both a ward manager or a person in a higher management level
not
based in a particular ward or clinic area. Significant differences
were
found between the professional groups the complaints addressed
and the patient’s gender (p = .001) (Table 1).
The result further shows that physicians (N = 221) were most
involved in complaints in hospital care followed by healthcare
managers (N = 65) and nurses (N = 51). Significant differences
were
found between the different professional groups the complaints
in-
tended to address and the type of organization (p = .001) and
clini-
cal department (p = .001) the complaint reflect. An overview of
the
units and the professions that the complaints addressed is
provided
in Table 2.
A description of the content, frequency and professions
involved
in the patient- reported complaint is described in Table 3. The
re-
sults show that 337 of the complaints describe negative
attitudes/
behaviour and were distributed as lack of empathy (77%) and
non-
chalant treatment (23%). Physicians and nurses reportedly
showed
the greatest lack of empathy (79% vs. 69%), while healthcare
manag-
ers were most responsible for patients not feeling involved in

their
care (60%). No significant differences were noted between
profes-
sionals (p = .419 vs. .552). In the field communication (N =
333), most
of the complaints were about the patients’ experiences of not
being
involved/lack of participation in the care (55%), followed by a
lack
of information and lack of possibilities for communication
(45%).
No significant differences were noted between women and men
(p = .906 vs. .891).
3.2 | Areas and categories of the deductive
content analysis
3.2.1 | The field: Encounters
In the field encounters, two categories were identified; Lack of
em-
pathy and Non- chalant treatment.
Category: Lack of empathy
The complaints often began with a summary of the reasons for
the
patients’ unhappiness with the meeting. Patients were most
dissat-
isfied when they were not met in a professional manner. The
com-
plaints describe that inadequacies in meetings generated
feelings
of not being met with respect, not being understood and not
being
welcomed to the healthcare setting. Not being met with respect
was

described when healthcare professionals did not value the
patient as
a person. Another reason for reporting a complaint was that
health-
care professionals could only attend to patients’ most necessary
needs when patients found the healthcare environment stressful.
The complaints described situations when the patients felt
ignored
by the healthcare professionals due to insufficient time
throughout
the caring encounter. One reported complaint described: “there
was
no time for healthcare professionals to listen to my story so I
had to
prioritize which needs I should present”. This meant that the
patients
were dissatisfied with the meeting as focus was only at one of
their
health instead of all their problems.
The complaints gave also examples of how patients liked to be
met
by healthcare professionals such as through commitment and a
genuine
interest by being seen as an important person. In the complaints,
the
patients further expressed a desire for a resolution to the
situation and
to prevent it from happening again, either to themselves or to
other pa-
tients. The patients’ need for justice was another important
reason for
TABLE 1 Units and professions that the patient- reported
complaint concerns

Women Men Total
p valueN/% N/% N/%
Type of organization
Hospital care 201/60 159/63 360/61
Primary health
care
119/35 83/33 202/35
No specific
organization
16/5 9/4 5/4
Total 336/100 251/100 587/100 .610
Type of clinical department
Consultation
outpatient
visits
115/34 80/32 195/33
Medicine 77/23 71/28 148/25
Surgery 110/33 61/24 171/30
Psychiatry 20/6 28/11 48/8
No specific
inpatient

care
14/4 11/4 25/4
Total 336/100 251/100 587/100 .038
Professionals involved
Physicians 177/53 180/72 357/61
Healthcare
managers
73/22 27/11 100/17
Nurses 53/16 26/11 79/13
No specific
profession
33/10 18/7 51/9
Total 336/100 251/100 587/100 .001
p ≤ .05 (Pearson’s Chi Square test).
many of the complaints. One patient perceived in the complaint
that: “I
had to wait longer than other patients for treatment or care”,
another
patient describe: “I got less examinations then others”.

Category: Non- chalant treatment
The complaints described situations when healthcare profession-
als had shown negative attitudes in their behaviour towards the
patients. In some complaints, the patients were referred to as a
diagnosis rather than as a person when healthcare professionals
were talking among themselves, saying things such as “the bro-
ken leg”, “the painful lady” or “the mentally ill”. The patients
de-
scribe in their complaints that these kinds of negative attitudes
and bad behaviour affected their dignity. The patients expressed
in the complaints that they would have become healthier sooner
Physician Healthcare managers Nurse
No specific
profession
p valueN/% N/% N/% N/%
Type of organization
Hospital care 221/62 65/65 51/67 –
Primary
health care
136/38 28/28 23/30 –
No specific
organization
– 7/7 2/2 –
Total 357/100 100/100 76/100 .001
Type of clinical department

Consultation
outpatient
visits
132/33 30/49 25/18 1/100
Medicine 115/30 3/4 30/20 –
Surgery 109/28 17/28 45/30 –
Psychiatry 26/6 1/1 22/14 –
No specific
inpatient
care
14/3 11/18 25/18 –
Total 396/100 62/100 147/100 1/100 .001
TABLE 2 Organizations, type of clinical
department and involved professionals in
the patient- reported complaints
TABLE 3 Analysis fields and categories descriptions of
frequencies according patients gender and profession involved
in the patient-
reported complaints
Analysis fields and
categories
Women Men Total

p value
Physician Healthcare managers Nurse
p valueN/% N/% N/% N/% N/% N/%
Field: Encounter
Categories:
Lack of empathy 158/77 101/76 259/77 163/79 41/79 34/69
Non- chalant
treatment
47/23 31/24 78/23 44/21 11/21 15/31
Total 205/100 132/100 337/100 .906 207/100 52/100 49/100
.419
Field: Communication
Categories:
Not being
involved in care
99/55 82/54 181/55 111/51 40/60 14/56
Answers to the
patient’s
complaints
82/45 70/46 152/45 105/49 27/40 11/44

Total 181/100 152/100 333/100 .891 216/100 67/100 25/100
.552
if they had been warmly greeted and seen as individuals in their
encounters with healthcare professionals. The written text in the
complaints indicated that it was unacceptable that the healthcare
professionals engaged in this negative behaviour in their
meetings
with patients.
Dissatisfaction with attitudes and/or negative behaviour in
meetings was also described in situations where the patients
per-
ceived that they were not met in a professional manner. The
com-
plaints contained examples of caring situations where the
patients
received insufficient respect, such as a “lack of empathy” and
“non-
chalant treatment from professionals who ignored their
symptoms
and illnesses”. Such complaints described how the patients felt
lost
and ignored in their meetings with healthcare professionals,
which
in turn led to anxiety. Examples of insufficient respect were
also de-
scribed in meetings when healthcare professionals talked about
the
costs of treatment and drugs rather than about the actual

treatment
of the patients’ symptoms and illnesses. One patient expressed
in
the written complaints that: “these kinds of attitudes and/or be-
haviours, where they were not met in a professional way,
negatively
affected their health”. As a result, the patients expressed in the
com-
plaints that their confidence in health care began to diminish.
3.2.2 | The field: Communication
In the field communication, two categories were identified; Not
being involved in care and Answers to the patient’s complaints.
Category: Not being involved in care
The complaints described that patients experience insufficient
infor-
mation: “I was not given an opportunity to receive adequate
infor-
mation or participate in decision- making about my care”.
Insufficient
information was highlighted because of the language deficits of
the
provided care. The patients- reported complaints contained
exam-
ples of situations when the patients suffered due to the methods
the healthcare professionals used to inform them. It was for
example
of situations where: “healthcare professionals use a medical
termi-
nology that I didn’t understand” or “information was given
during
stressful circumstances with no time for questions”. The
patients ask
therefore in their complaints for more information that could

explain
their circumstances in a way they could understand.
The complaints further indicated that the patients felt that they
were not invited to participate in the communication about their
treatment and care. One patient expressed in the complaints
that:
“it is difficult to take part in decision- making about care
alternatives
when you not be invited”. The patients asked for more
communi-
cation and their complaints gave examples of situations when
the
professionals provided information without taking care of the
pa-
tient’s individual needs. The content in the complaints describe
that
the patients asked for questions about their needs and personal
conditions and an invitation for discussions of alternative treat-
ments. One patient’s complaints described: “I know best how I
feel
so they (the professionals) should ask me”. The patient’s
complaints
described further that healthcare professional lack interest about
their situation and the patient- reported complaints expressed
the
patients’ disappointments.
Category: Answers to the patient’s complaints
The administrators at the PAC clearly documented the
procedure
for how the complaints should be handled as well as the
resulting
outcomes, describing the way they contacted the patients by
phone

or mail to gather complementary information regarding the
situa-
tions that had occurred. A checklist described how the
administra-
tors should further handle the complaints, for example, asking
for
the patient’s record to get more information about the situation
and
contacting the involved healthcare professionals. The
administra-
tors at the PAC always requested an answer and response from
the
healthcare professionals concerned in the complaints, but
responses
were received in only 490 cases (83%) of the total 587
complaints.
The distribution of answers in response to women’s and men’s
com-
plaints was relatively equal (84% vs. 82%; p = .429).
The administrators at the PAC forwarded the physicians’ or re-
sponsible healthcare managers’ responses to the patients
together
with a brief accompanying letter. The responses were often
written
in a neutral and impersonal tone, such as “Mr. Karlsson, Your
com-
plaint will be forwarded to the healthcare professional
responsible
for your care.” About 264 (54%) of the answers were expressed
in
an understanding tone, such as “Dear Mrs. Svensson, thanks for
your complaint. We understand your complaint and the
described
situation.” Furthermore, 58 answers (12%) were expressed in an
apologetic manner, for example, “Dear Mrs. Jonsson, Thanks

for
your complaint. We apologize for the situation that occurred.
We
will investigate the situation that occurred and will return to
you
as soon as possible.” A frequent tone in the responses suggested
that the healthcare professionals were not responsible for the
situ-
ation, which, they explained, had occurred because the
healthcare
professionals had followed established healthcare routines; for
in-
stance: “Mrs. Larsson, Thanks for your complaint. The
healthcare
professional your complaint applies to has followed routines for
the
examination and treatment and they can therefore not be held
re-
sponsible for the situation you are experiencing.” In 461 (94%)
of the
total 490 answers, the healthcare professionals showed no
intention
to act or correct the situation. The patient- reported complaints
also
described that this lack of responsibility for the situation
contributed
to the patients’ feeling that they had been treated with
disrespect.
In 29 (5%) of the total 587 patient- reported complaints, a suc-
cessful handling of the situation was described. This occurred
when
the healthcare professionals involved in the situations contacted
the
patients and personally apologized to them. The healthcare
manager

was sometimes included in these personal meetings, to provide
an
opportunity for all invited parties to discuss the situation. The
results
of the meeting were documented in the patient- reported
complaints
and describe that the patients were satisfied with the meetings
when the healthcare professionals listened to them and their
expe-
riences. Furthermore, they were pleased that they had identified
a
solution together regarding how to have more caring encounters
in
the future. In other examples, the involved healthcare
professionals
who participated in follow- up meetings had expressed their
regret
about the situations that had occurred and explained why the pa-
tient was treated inadequately. Another example of a case that
was
successfully handled was when the involved healthcare
professional
and the healthcare management met with the patient personally
and
apologized for the professional’s lack of empathy.
In 19 (3%) of the 587 patient- reported complaints, the admin-
istrators at PAC had documented how the patients’
dissatisfaction
with their healthcare encounters and communication should be
used

in the future to improve health care and, furthermore, become a
part
of the healthcare professionals’ continuing education to prevent
similar situations from occurring with other patients.
4 | DISCUSSION
This study explored patient- reported complaints regarding
commu-
nication and healthcare encounters and how these were
responded
to by healthcare professionals. The results indicate that the
com-
plaints concerned all departments in the healthcare
organizations
and were most common in hospital care. This corresponds with
the
results of Kline et al. (2008), which indicated that patients’
com-
plaints are often associated with short and temporary healthcare
visits and encounters with higher clinical complexity.
Furthermore,
these results show that while different healthcare professionals
were involved in the complaints, the most commonly involved
pro-
fessionals were physicians, followed by healthcare managers
and
nurses. Physicians and healthcare managers were most involved
in
hospital care complaints related to consultation outpatient
visits,
whereas nurses were most involved in complaints regarding
surgery.
Schnitzer et al. (2012) noted that patients’ complaints about
health-
care shortcomings to a higher extent involved physicians. A

negative
relationship outcome between the physician and patient is
described
to be characterized by disrespect or insensitivity (Falkenstein et
al.,
2016). However, to preserve credibility in the patient–physician
rela-
tionship, patients need support to handle experiences of
shortcom-
ings in their healthcare encounters (Petronio et al., 2013).
The results that described satisfaction with encounters with
phy-
sicians were based on receiving information through a dialogue
that
included both empathy and listening. When patients receive
informa-
tion about their health conditions, it is of great importance that
the
information includes empathy and an invitation to participate in
care
decision- making (Skär & Söderberg, 2012; Söderberg et al.,
2012).
People who are ill seek information and explanations that will
help
them to make meaning and form a coherent understanding
regard-
ing what will happen to them (Nygren Zotterman, Skär, Olsson,
&
Söderberg, 2016). A new patient law (The Patient Act
2014:821) was
implemented in Sweden in 2015 that aims to reinforce and
clarify the
patient’s position and facilitate patients’ integrity, autonomy
and par-
ticipation in care by being informed about their conditions and

avail-
able treatments. However, patients are often not the focus of
their care
because of deficiencies in communication, lack of continuity in
care
and collaboration between several healthcare providers
(Jangland,
2011). As a result, patients who lack information about their
health
conditions or not participate in decision- making, have
difficulties in
achieving good treatment results (SOSFS, National Board of
Health
and Welfare, 2005:12). Explanations and information about
their ill-
ness may validate a person’s experience, while a lack of
explanations
negatively influences their experience of being ill (Attree,
2001).
The results further show that the most common dissatisfaction
with healthcare meetings involved being dissatisfied with
profes-
sionals’ attitudes or approaches. The complaints described how
the patients were ignored and treated with indifference.
Uncaring
behaviour affects patients’ dignity and thereby their health and
well- being (Eriksson, 2006). To protect and respect patients’
dignity,
healthcare professionals need to be aware of patients’
vulnerabil-
ity and the power they have in their meeting with patients
(Croona,
2003). By recognizing patients’ expression of dissatisfaction,
re-

search shows that activities that are critically examined
prepared
healthcare professionals to change caring routines (Skålen et
al.,
2016).
The results show further differences between genders, where
women reported more complaints regarding their dissatisfaction
with encounters and communication compared with men, which
Schnitzer et al. (2012) also noted in their study. Research
(Williams,
Bennett, & Feely, 2003) shows that women are sometimes
treated
different than men when seeking care. However, following a
person-
centred approach, every patient should receive individualized
care
(McCormack & McCane, 2010). This requires providing
individual-
ized and holistic care, encouraging patient participation in the
pro-
cess (Andersson et al., 2015), fostering empowerment and
treating
the patients’ needs with respect and dignity despite type of
illnesses
or gender (Leplege et al., 2007). When a healthcare
organization
adopts a patient- centred approach to handling complaints and
pre-
venting litigation due to mishandled healthcare communication,
the
quality of care can improve (McCormack & McCane, 2010).
The results show that many of the answers on the patient-
reported complaints lack a personal apology and that some of
the

patients not even received an answer to their complaints. This
indi-
cates that professionals often do not take responsibility for how
they
handle patients and behave in the context of health care.
Research
by Gallagher, Waterman, Ebers, Fraser, and Levinson (2003)
has
shown that following an adverse event, patients want an
apology,
an explanation of what happened and someone to take
responsibil-
ity, but there is a wide variation in whether healthcare
profession-
als choose to apologize or not (Robbennolt, 2009). One reason
that
professionals may avoid giving patients a personal apology is
that
admitting mistakes increases the risk of being sued (Butcher,
2006).
Therefore, according to Kaldjian, Jones, and Rosenthal (2006)
will
many physicians never admit their mistakes.
An apology can have powerful effects for both the person of-
fering it and the recipient and it contributes to improving the
phy-
sician–patient relationship (Robbennolt, 2009). By considering
specific types of disclosure strategies, such as talking through
short-
comings in encounters and discussing possible feelings of guilt
and
shame with colleagues, professionals are more likely to
personally

come to terms with a negative patient relationship (Petronio et
al.,
2012). Conversely, not receiving an apology following
unsatisfactory
treatment or mistakes could affect patients negatively and create
suffering that prevents them from receiving emotional closure
in the
situation. If a healthcare meeting lacks meaning for the patient,
he or
she can experience great suffering (Eriksson, 2006). From a
patient-
centred perspective, patient participation and involvement and
re-
spect for the patient as an individual could be the first steps
towards
a meaningful and dignified relationship (Kitson, Marshall,
Bassett,
& Zeitz, 2012). Many complaints could easily be avoided with
im-
proved communication and changed attitudes among healthcare
professionals (Jangland et al., 2009; Kourkouta &
Papathanasiou,
2014). Therefore, healthcare professionals need knowledge
about
the consequences of negative encounters for the individual pa-
tients (Croona, 2003). Professionals should realize that an
apology
is interpreted as a signal that steps will be taken to avoid
similar
consequences in the future (Robbennolt, 2009). There is also a
con-
sensus that disclosing information regarding healthcare
mistakes is

advantageous for patients, professionals and healthcare
organiza-
tions in terms of reducing dissatisfaction with healthcare
encoun-
ters and communication and increasing patients’ satisfaction
with
quality health care (cf., Mazor et al., 2004). Therefore, it is
import-
ant that the healthcare organization develops communication
plans
and strategies to handle patients’ complaints (Coombs,
Frandsen,
Holladay, & Johansen, 2010).
4.1 | Limitations
The limitations of this study are the subjective experiences
reported
by patients in the complaints and that data were collected from
one
single PAC in northern part of Sweden. However, a strength of
this
study was the number of complaints during a time period of 3
years
included in the analysis. This retrospective and descriptive
study in-
cluded both a qualitative and quantitative design which resulted
in a
deep description of the findings. Furthermore, the analysis was
con-
ducted jointly and reviewed independently by both authors,
which
added rigour to the study (Creswell & Plano Clark, 2007).
However,
even though the study was based on data in a Swedish
healthcare

context, there are overarching implications that match existing
healthcare encounters and communication knowledge and
practice
internationally.
5 | CONCLUSIONS
To conclude, this retrospective and descriptive study including
both
qualitative and quantitative approaches shows that patient-
reported
complaints regarding provided care stem from asymmetric
commu-
nication, where the patients are not met in accordance with their
individual needs. From a person- centred perspective, this can
have a
significant impact on patients’ satisfaction with healthcare
encoun-
ters and experiences of quality of care. The results also revealed
that not all patients received closure in the form of an answer or
personal apology in response to their complaint. Transparency
of
the shortcomings in healthcare encounters could help patients to
overcome negative experiences. These results stressed therefore
that patient- reported complaints should be used to identify why
shortcomings that have been highlighted for several years
persist,
as well as, why healthcare professionals do not take responsibil-
ity for the complained- about matter. However, more knowledge
is
needed about how healthcare organizations could address
patient
complaints to improve the quality of care.
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PSYCHOSOCIAL
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ation. The reader is advised always to check product
information (package inserts) for
changes and new information regarding dose and
contraindications before administering
any drug. Caution is especially urged when using new or
infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Gorman, Linda M.
Psychosocial nursing for general patient care / Linda M.
Gorman, Donna F. Sultan. —
3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1784-1
ISBN-10: 0-8036-1784-4
1. Psychiatric nursing—Handbooks, manuals, etc. 2. Nursing—
Social aspects—
Handbooks, manuals, etc. I. Sultan, Donna. II. Title.
[DNLM: 1. Nursing Care—psychology—Handbooks. 2. Nurse-
Patient Relations—
Handbooks. 3. Nursing Assessment—Handbooks. WY 49 G671p
2008]
RC440.G659 2008
616.89′0231—dc22 2007040704

Authorization to photocopy items for internal or personal use,
or the internal or personal
use of specific clients, is granted by F. A. Davis Company for
users registered with the
Copyright Clearance Center (CCC) Transactional Reporting
Service, provided that the fee
of $.10 per copy is paid directly to CCC, 222 Rosewood Drive,
Danvers, MA 01923. For
those organizations that have been granted a photocopy license
by CCC, a separate sys-
tem of payment has been arranged. The fee code for users of the
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00Gorman(F)-FM 11/8/07 10:54 AM Page ii
iii
Preface
Having worked in a variety of specialty areas over the years as
staff nurses, clin-
ical nurse specialists, educators, therapists, and managers, we
realize that nurses
aspire to become highly proficient in their area of practice. But
psychosocial skills
are often more difficult to perfect. Very often nurses feel
inadequately prepared
to deal with complex behaviors and psychiatric problems on top
of the demands
of providing physical care for the patient and family. Even
nurses who practice in
the psychiatric setting find themselves dealing with unique
situations that chal-

lenge their level of expertise. And yet, a large percentage of a
nurse’s time is spent
dealing with these issues.
Psychosocial Nursing for General Patient Care bridges the gap
between the
information contained in the large, comprehensive psychiatric
texts and the infor-
mation needed to function effectively in a variety of healthcare
settings. The cli-
nician can refer to this book to find the information to
effectively handle specific
patient problems. The nursing student can use this book as a
supplement to other
texts and will be useful throughout nursing school curriculum.
The concise, quick reference format used throughout this book
allows the
nurse to easily find information on a specific psychosocial
problem commonly
seen in practice. In addition to common psychosocial problems,
psychiatric dis-
orders are explained and discussed. Each chapter is organized to
provide easy
access to information on etiology, assessment, age-specific
implications, nursing
diagnosis and interventions, patient/family education,
interdisciplinary manage-
ment including pharmacology, and community based care. The
fast-paced health-
care environment we are all experiencing demands quick
assessment and
treatment plans that are realistic, cost-effective, and outcome
driving. The infor-
mation contained in this book is readily applicable to all patient
care settings.

Each psychosocial problem includes a section on common
nurses’ reactions to
the patient behaviors that may result from the problem. Nurses
often think they
should only have acceptable and “proper” emotional reactions to
their patients.
Nurses may deny certain feelings and have unrealistic
expectations of themselves.
These factors impact how the nurse then responds to the
patient’s problems. The
more aware the nurse becomes of how one reacts to the patient’s
behaviors, the
easier it will be to accept one’s own feelings and understand
how these feelings
affect the patient and influence interventions.
In this third edition we have added two new chapters that reflect
concerns
faced by many nurses. The Homeless Patient with Chronic
Illness reflects the
increasingly frequent encounters that nurses in all areas of the
country are facing.
Disaster Planning and Response–Psychosocial Impact provides
the nurse with
tools to prepare for the emotional impact of a natural or man-
made disaster.
Throughout this third edition we have updated information on
patient safety,
pharmacologic interventions, and psychiatric diagnoses and
treatment. We con-
00Gorman(F)-FM 11/8/07 10:54 AM Page iii

tinue to include information that will apply to the inpatient
hospital setting, long-
term care, and outpatient care.
We wish to thank our contributors Yoshi Arai and Margaret
Mitchell who
revised their chapters from the second edition. We also thank
our new contribu-
tors Bill Whetstone and Carl Magnum. Particular thanks go to
our editors
Annette Ferrans and Joanne DaCunha of FA Davis. This was our
third collabo-
ration with Joanne and she remains a dynamic force that keeps
us on track.
For those of you familiar with our earlier two editions, you will
notice the
name of author Marcia L. Raines, RN, PhD is missing. Marcia
died in 2006 after
a long illness. Marcia was the consummate nurse who strove for
excellence
throughout her career. She started as a psychiatric nurse,
became a clinical nurse
specialist, was an educator and administrator, and faculty
member and chair of a
university school of nursing. She inspired countless nurses over
the years with her
wise and gentle approach. She strove for excellence in all
aspects of her career.
Working with her on the previous two editions was always a joy
because of her
genuine love of the work and her enthusiasm to produce an
outstanding book.
Marcia wrote many of the original chapters from the first and
second edition
including chapters on anxiety, sexual dysfunction, confusion,

pain, and sleep. We
have strived to carry on in her memory but know the nursing
world has lost a
great one. This edition is dedicated to Marcia.
Linda M. Gorman
Donna F. Sultan
iv Preface
00Gorman(F)-FM 11/8/07 10:54 AM Page iv
v
Contributors
Yoshinao Arai, RN, MN, CNS
Senior Mental Health Counselor, RN
Carl Magnum, RN, MSN, PhD(c), CHS, FF
Assistant Professor of Nursing
Emergency Preparedness Coordinator
The University of Mississippi Medical Center
Jackson, Mississippi
Margaret L. Mitchell, RN, MN, MDIV, MA, CNS
Senior Mental Health Counselor, RN
William R. Whetstone, RN, CNS, PhD
Professor, Nursing

Clinical Nurse Specialist, Adult Psychiatric Mental Health
Nursing
California State University, Dominguez Hills
Carson, California
00Gorman(F)-FM 11/8/07 10:54 AM Page v
00Gorman(F)-FM 11/8/07 10:54 AM Page vi
vii
Reviewers
Michael Beach, MSN, APRN, BC, ACNP, PNP
Instructor
University of Pittsburgh
Pittsburgh, Pennsylvania
Dorie V. Beres, PhD, MSN, ANP-C
Associate Professor and Coordinator
Vitterbo University
La Crosse, Wisconsin
Earl Goldberg, EdD, APRN, BC
Assistant Professor
LaSalle University
Philadelphia, Pennsylvania
Barbara A. Jones, RN, MSN, DNSc
Professor
Gwynedd-Mercy College
Gwynedd Valley, Pennsylvania

Nancy L. Kostin, MSN, RN
Associate Professor
Madonna University
Livonia, Michigan
Karen P. Petersen, RN, CCRN, MSN
Nursing Instructor
Chemeketa Community College
Salem, Oregon
Glenda Shockley, RN, MS
Director of Nursing
Connors State College
Warner, Oklahoma
Ellen F. Wirtz, RN, MN
Faculty
Chemeketa Community College
Salem, Oregon
Margaret A, Wetsel, PhD, MSN
Associate Professor
Clemson University
Clemson, South Carolina
00Gorman(F)-FM 11/8/07 10:54 AM Page vii
00Gorman(F)-FM 11/8/07 10:54 AM Page viii
ix

Contents
SECTION I— Aspects of Psychosocial
Nursing
1 Introduction to Psychosocial Nursing for
General Patient Care
...................................................................1
2 Psychosocial Response to
Illness............................................7
3 Psychosocial Skills
.....................................................................15
4 Nurses’ Responses to Difficult Patient Behaviors............33
5 Crisis
Intervention......................................................................43
6 Cultural Considerations: Implications for
Psychosocial Nursing
Care......................................................49
SECTION II— Commonly Encountered
Problems
7 Problems with Anxiety
.............................................................57
The Anxious Patient
............................................................................57
8 Problems with Anger
................................................................73
The Angry
Patient.................................................................................73
The Aggressive and Potentially Violent
Patient.........................83

9 Problems with Affect and
Mood...........................................99
The Depressed Patient
......................................................................99
The Suicidal Patient
..........................................................................113
The Grieving Patient
.........................................................................129
The Hyperactive or Manic
Patient...............................................142
10 Problems with
Confusion.......................................................157
The Confused Patient
......................................................................157
00Gorman(F)-FM 11/8/07 10:54 AM Page ix
11 Problems with Psychotic Thought Processes...................177
The Psychotic
Patient.......................................................................177
12 Problems Relating to Others
.................................................191
The Manipulative Patient
................................................................191
The Noncompliant
Patient.............................................................204

The Demanding, Dependent
Patient.........................................219
13 Problems with Substance
Abuse.........................................231
The Patient Abusing Alcohol
.........................................................231
The Patient Abusing Other Substances
....................................250
14 Problems with Sexual Dysfunction
.....................................273
The Patient with Sexual Dysfunction
.........................................273
15 Problems with Pain
..................................................................291
The Patient in
Pain............................................................................2 91
16 Problems with Nutrition
.........................................................315
The Patient with Anorexia Nervosa or
Bulimia.......................315
The Morbidly Obese Patient
.........................................................330
17 Problems Within the
Family...................................................341
Family
Dysfunction............................................................................
341
Family Violence

..................................................................................351
18 Problems with Spiritual
Distress..........................................369
The Patient with Spiritual Distress
..............................................369
Margaret L. Mitchell, RN, MN, MDIV, MA, CNS
SECTION III— Special Topics
19 Nursing Management of Special Populations ................387
The Patient with Sleep
Disturbances.........................................387
The Chronically Ill
Patient...............................................................400
The Homeless Patient with Chronic
Illness.............................410
William R. Whetstone, RN, CNS, PhD
The Dying
Patient..............................................................................421
x Contents
00Gorman(F)-FM 11/8/07 10:54 AM Page x
20 Disaster Planning and Response–Psychosocial
Impact
.........................................................................................435
The Disaster Victim/Patient

The Disaster Responder/Nurse
...................................................435
Carl Magnum, RN, MSN, PhD(c), CHS, FF
21 Psychopharmacology: Database for Patient
and Family Education on Psychiatric Medications........451
Yoshinao Arai, RN, MN, CNS
References..............................................................................
...........487
Index......................................................................................
..............513
Contents xi
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1
SECTION I Aspects of
Psychosocial Nursing
1Introduction to Psychosocial
Nursing for General
Patient Care
Learning Objectives

• Define psychosocial nursing care.
• Describe the impact of patient behavior problems in a
managed-
care setting.
• Describe the role of patient education in psychosocial care.
• Name the resources the nurse can use when planning for
patients across
care settings.
Every day, nurses are confronted with patient problems and
crises that fall in
the realm of the psychosocial, and they must find a way to deal
with them.
The Agency for Healthcare Research and Quality found in 2004
that one in four
stays in U.S. hospitals for patients 18 and over involved
depressive, bipolar, schiz-
ophrenia, and other mental disorders or substance abuse. Nurses
often must care
for patients with:
• Intense emotional responses to illness
• Personality styles that make care difficult
• Psychiatric disorders
• Stresses and family problems that affect patients’ reactions to
illness or hos-
pitalization
Nurses can be proficient in managing patients’ physical health
problems and
yet be less prepared to manage emotional problems. The ability
to recognize

01 Gorman(F)-01 11/5/07 4:53 PM Page 1
behaviors that suggest psychosocial problems and to develop
skills to manage
them effectively not only improves the patients’ chances of
healing but can also
reduce frustration for nurses.
Psychosocial care emphasizes interventions to assist individuals
who are having
difficulty coping with the emotional aspects of illness, with life
crises that affect
health and health care, or with psychiatric disorders. For
example, problems with
depression, anger, substance abuse, or grief can influence a
patient’s response to
illness or to the interventions of the health-care system. In
psychosocial care, the
nurse focuses on the effects of stress in psychological or
physiological illness and
on the intrapsychic and social functioning of individuals
responding to stress.
The nurse has a responsibility to facilitate each patient’s
adaptations to his or
her unique stresses by helping and supporting the person in his
or her environ-
ment, level of wellness, and adjustment to the illness or
condition. Identifying the
patient’s coping responses, maximizing strengths, and
maintaining integrity will
help the nurse meet this responsibility.

NURSES’ POSSIBLE REACTIONS
A factor whose importance cannot be overlooked in
psychosocial care is aware-
ness of one’s own reactions to patient behaviors. These
reactions will influence
the nurse-patient relationship, assessment findings, and
selection of potential
interventions. They can help or hinder the relationship.
Recognizing the influence
of these reactions can help the nurse to:
• Increase awareness of the reactions that influence objectivity
• Identify reactions frequently experienced by other nurses to
ease feelings of
guilt and resentment
• Increase understanding of colleagues’ reactions to enhance the
work envi-
ronment
• Facilitate self-support by reducing self-criticism and
reinforcing skills
• Select better assessment tools to identify patients’ dilemmas
and responses
• Recognize how personal reactions to patients can influence
assessment,
planning, and effective interventions
In coming chapters, “Possible Nurses’ Reactions” will be
presented as boxed
text, so that you can easily find and refer to it.
THE ROLE OF PSYCHOSOCIAL NURSING
IN MANAGED-CARE SETTINGS

Patients with psychosocial and psychiatric problems often
require many more
resources than patients without such problems. A patient’s
emotional reactions can
increase his or her length of stay in the hospital or under a
nurse’s care, can con-
tribute to the patient’s not complying with care, and can drain
physical and emo-
2 Chapter 1 ■ Introduction to Psychosocial Nursing
01 Gorman(F)-01 11/5/07 4:53 PM Page 2
tional resources. Once these patient problems are identified, the
nurse needs to use
skills to meet the patient’s needs while making judicious use of
available resources.
In the managed-care system, controls are exerted over access,
use, quality, and
effectiveness of health services. Managed care is now the
dominant form of health
care in the United States (Shoemaker & Varcarolis, 2006). It
has led to shortened
hospital stays and limitations in available resources. Outpatient
programs and
home health care are now being used more to address problems
in place of inpa-
tient care. To work within this system, the nurse must quickly
identify the patient’s
needs, establish a realistic plan of care, implement
interventions, and evaluate out-
comes, all within a predetermined length of time. Psychosocial

and psychiatric
patient problems complicate the demands made on the nurse in
an already
stretched health-care environment and can negatively affect
patient outcomes.
When the nurse has skills readily at hand to identify problems
and intervene effec-
tively, patient outcomes can be improved and nurse satisfaction
will be enhanced.
Managed care has also intensified the focus on outcome-based
interventions
to address key problems within a shorter timeframe. Clinical
pathways or clini-
cal practice guidelines are often used to drive this process.
These pathways are
evidence-based approaches to plans of care, and their focus is
on outcomes. Psy-
chosocial and psychiatric problems often have to be addressed
to keep on target
with the pathway.
PATIENT SAFETY
The incorporation of methods to improve patient safety is an
important consid-
eration for all levels of patient care today. The Joint
Commission on Accreditation
of Healthcare Organizations (JCAHO) has spearheaded a
national movement,
which includes avoiding the use of abbreviations that can be
confused with one
another, using universal protocol to prevent surgical error
involving “wrong site,
wrong procedure, and wrong person,” and the development of
National Patient

Safety Goals (JCAHO, 2007). Psychosocial care incorporates
these patient safety
measures as a routine part of practice by maintaining open
communication with
the patient and health-care team.
LIFE SPAN ISSUES
Although each individual is unique, we all share certain patterns
and common
links throughout the life cycle. Psychosocial development
proceeds through a
series of stages and crises. Each phase of the life span presents
new challenges,
experiences, and problems. Many psychosocial problems have
their origins in
developmental crises that remain unresolved or that are resolved
with negative
outcomes. Problems such as depression and grief affect
individuals differently in
each stage of life. Childhood, adolescence, and old age are
times of particular
vulnerability to psychosocial dysfunction. Look for this heading
in the coming
chapters indicating discussions of life span issues.
Chapter 1 ■ Introduction to Psychosocial Nursing 3
01 Gorman(F)-01 11/5/07 4:53 PM Page 3
Interventions in this book are geared to adults, but many of
them can be
adapted to the care of children. To adapt an intervention to a
pediatric population,

the nurse must consider children’s developmental and cognitive
levels, and incor-
porate them in the care plan as well as consult specialists in
pediatrics, if necessary.
COLLABORATIVE MANAGEMENT
Our complex health-care system relies on a variety of health-
care professionals to
meet patients’ needs. Obviously, the nurse does not work in a
vacuum but must
participate in the interdisciplinary team and be aware of other
disciplines as
resources for psychosocial intervention. The nurse also needs to
know when
work needs to be shared or delegated through referrals. For
example, social
workers may be helpful because they are often familiar with
psychotherapists and
community support groups for emotional problems. The nurse
should be aware
of agency policies regarding referrals to psychotherapists. Some
may require a
doctor’s order.
Other resources include physicians, advanced practice nurses,
pharmacists,
clergy, dietitians, and others, depending on the specialty and
setting. Knowing
when and how to access them and work effectively with them
will improve
patient outcomes and enhance the working environment.
Collaborative manage-
ment is addressed throughout the book in terms specific to the
topic discussed in
each chapter.

WHEN AND WHO TO CALL FOR HELP
Many difficult, challenging situations require a number of
complex skills. While
continuing to gain knowledge in identifying psychosocial issues
and intervening
in cases in which patients require psychosocial care, nurses also
need to recognize
their own limitations and be able to recognize patient behaviors
that may precede
or currently signal a dangerous or emergency situation.
Knowing when to seek
out resources and who to call for help are essential factors in
providing quality,
cost-effective care.
When and who to call for help will also be set inside a box in
coming chap-
ters so that you can easily reference it.
PATIENT EDUCATION
Patient education is an important component of psychosocial
care. Nurses are
required to incorporate appropriate patient education in their
practice. To provide
adequate education, the nurse needs to be aware of how
psychosocial issues influ-
ence learning. For example, assessing the patient’s anxiety level
or disturbed
thoughts will influence the timing of teaching as well as the
type of information
the nurse tries to convey. Patient education can enhance the
patient’s independence
and control, involvement of the patient and his or her family in

the treatment plan,
01 Gorman(F)-01 11/5/07 4:53 PM Page 4
and help prepare the patient for possible emotional changes,
coping skills needed,
and responses to medications. Patient education can be
influential in reducing
length of stay and helping patients to take more responsibility
for their own care.
Many factors can affect effective patient education, including
patients’ cultural
beliefs and language, as well as knowledge of and access to
computer technology.
CHARTING TIPS
Changes in patients’ emotional responses and behaviors, and
their responses to
interventions and education are significant and must be noted in
the medical
record. The increased use of computerized documentation can
present new
challenges to nurses who are trying to identify and record
behavioral problems
succinctly.
Charting tips are given in each chapter for specific situations
and are identified
with a chapter heading.

COMMUNITY-BASED CARE
Many patients require care that crosses settings, for instance
from hospital-based
care to home nursing care. In most cases, acute hospital care is
now a small part
of the treatment plan and eventually ends. To ensure continuity
of care, planning
for the next level of care should begin as early as possible.
While the patient is in
the acute setting, this planning needs to begin on admission.
Long-term care, out-
patient rehabilitation, other outpatient programs, and home
health care are now
used for many patients. Nurses in all these settings must also
consider planning
for the next level of care.
Home health agencies may have nurses with psychiatric
backgrounds on staff.
Box 1–1 lists possible interventions by psychiatric home care
nurses. These nurses
can be helpful in evaluating patients’ responses to psychotropic
medications,
confusion, psychotic behavior, and suicide risk. Patients may
need referrals to
other types of care, such as psychiatric hospitalization or
convalescent care, and
Chapter 1 ■ Introduction to Psychosocial Nursing 5
BOX 1–1
Interventions by Psychiatric Home Care Nurses
• Crisis intervention
• Suicide risk assessment
• Management of psychiatric medications and blood level

monitoring
• Administration of long-acting injectable psychiatric
medications
• Counseling and education
• Assessment of patient and family coping
• Safety assessment
01 Gorman(F)-01 11/5/07 4:53 PM Page 5
assistance with financial support. Other professionals such as
social workers,
case managers, and counselors can help ensure safe and
effective home care.
Other resources including support groups, hotlines, and even
telemedicine
increase access to care. For a patient to be eligible for
psychiatric home care, usu-
ally the patient has to be homebound, have a psychiatric
diagnosis, and have a
need for the skills of a psychiatric nurse (Shoemaker &
Varcarolis, 2006).
PATIENT PRIVACY AND RIGHT TO CONFIDENTIALITY
Patient rights are becoming increasingly emphasized in all
health-care settings.
These rights generally include autonomy, informed consent,
treatment with dig-
nity and respect, and confidentiality. The Health Insurance
Portability and
Accountability Act (HIPAA) enacted in 2003 established a
number of mechanisms
to maintain privacy, including the requirement that health-care
professional

obtain permission from the patient to share information with
persons who are not
directly involved in the patient’s care, and that medical records
be viewed only by
people directly involved in patient’s treatment. The American
Nurses’ Association
Code of Ethics also requires a nurse to protect confidential
information.
DSM-IV-TR
The American Psychiatric Association (APA) has developed a
classification sys-
tem for mental disorders. It is the most widely accepted system
in the United
States today and is published and revised periodically as the
Diagnostic and Sta-
tistical Manual. The fourth edition was published in 1994 and is
referred to as
DSM-IV. In 2000, the APA published a revised version called
DSM-IV-TR, mean-
ing text revision that is also referenced in this book. These
references provide cli-
nicians with guidelines, specific criteria, and accepted
terminology. Throughout
this book, you will see references to the criteria published in
DSM-IV and DSM-
IV-TR. These criteria are used to prevent negative labeling or
incorrect catego-
rization of patient behaviors as psychiatric disorders.
OVERVIEW OF THE BOOK
Chapters 2 through 6 cover basic skills and emphasize aspects
of Psychosocial
Nursing including assessment and culturally sensitive care.

Chapters 7 through 18
address Commonly Encountered Problems. Nursing
interventions are provided
for major nursing diagnoses. Chapters 19 through 21 cover
Special Topics, includ-
ing care of patients who belong to special populations, care in
the face of disaster,
and medications that the nurse may be using to manage
behavioral symptoms.
Many of the topics addressed in this opening chapter appear in
the coming
chapters, so readers should quickly be able to discern the
pattern of approach and
will be able to use this book not only as a textbook but also as a
reference in their
future care of patients with psychosocial problems.
01 Gorman(F)-01 11/5/07 4:53 PM Page 6
2
7
Psychosocial
Response to Illness
Learning Objectives
• Describe the role of self-esteem, body image, powerlessness,
and guilt
in the patient’s emotional response to illness.

• Describe the role of Maslow’s Hierarchy of Needs in
explaining a
patient’s response to illness.
• Define defense mechanisms and give examples of each.
• Describe commonly used coping mechanisms.
Psychological impact is present in any illness. Illness threatens
the individual
and evokes a wide array of emotions, such as fear, sadness,
anger, depression,
despair, and loss of control. Each individual who faces an
illness responds differ-
ently according to personality, previous life experiences, and
coping style.
Extreme denial, noncompliance, aggression, and threats of
suicide are some of the
more maladaptive responses that the nurse may face in caring
for ill individuals.
Most often these responses are temporary and subside with time.
However, they
can also be chronic maladaptive behavioral responses that the
patient uses when-
ever he or she experiences a stressful situation. There is often
no way of knowing
on first meeting a patient whether his or her response is
temporary or habitual.
All behavior is an attempt to communicate needs. To determine
a person’s
underlying motivation, identifying the need can be a first step
to understanding.
Maslow’s Hierarchy of Needs (1954) provides a framework
within which to
begin examining the motivation a person may have for a

behavior (Fig. 2–1).
Maslow identified five levels of needs. Each type of need,
starting at the most
basic physiological level, must be met before one can move on
to the next level.
Professional nursing uses a holistic framework by which it
views the individ-
ual and his or her environment in its entirety. The influence of
the mind as well
as the body is recognized in the development of and response to
illness. It is
known that the response to stress involves the immune and
neuroendocrine sys-
tems. Emotional response to stress suppresses the immune
system, stimulates the
cardiovascular system, and alters secretions of hormones that
influence the body’s
response to the illness.
02 Gorman(F)-02 11/5/07 4:55 PM Page 7
Stress cannot be avoided. It is a normal part of living. It does
not matter if
a stressor is pleasant, such as an upcoming holiday, or
unpleasant, such as illness,
disability, or hospitalization. What is critical is the individual’s
perception of
the intensity of the stressor requiring readjustment and his or
her capacity to
adjust to it.
KEY ISSUES IN RESPONSE TO ILLNESS

Altered Self-Esteem
Self-esteem is the individual’s personal judgment of his or her
own worth. The
roots of self-esteem are in early parental and social
relationships as well as in the
person’s perception of goal attainment and his or her own ideal.
Maslow places
self-esteem at a very high level, indicating that this need can be
accomplished only
when the more basic needs are fulfilled. Self-esteem increases
as the individual
achieves personal goals. High self-esteem indicates that the
individual has
accepted his or her good and bad points and knows that he or
she is loved and
respected by others. High self-esteem also implies a sense of
control over personal
destiny. Feeling good about one’s self influences many aspects
of life, including
dealing with others, managing conflict, standing up for one’s
own beliefs, taking
risks, and believing in one’s ability to handle adversity.
8 Chapter 2 ■ Psychosocial Response to Illness
FIGURE 2–1. Maslow’s Hierarchy of Needs.
02 Gorman(F)-02 11/5/07 4:55 PM Page 8
Throughout life, both internal and external factors influence
self-esteem. For
instance, falling in love or graduating from school promotes
positive self-esteem,
whereas illness can represent a threat to self-esteem. Illness and

disability often
require a person to alter or even abandon personal goals and
may strongly influ-
ence the person’s view of himself or herself. Some people are
able to adjust readily
and create new, more realistic goals with little impact on self-
esteem. Others may
struggle with the changes and be unable to regain the previous
level of self-esteem.
Serious illnesses such as prostate or breast cancer, heart
disease, or stroke not only
require adaptation of personal goals but often distort the deeper
sense of self. This
is a major contributor to depression. But the desire to maintain
a strong sense of
self is a powerful drive, and over time many people adapt to
changes in health.
Altered Body Image
Body image is the mental picture a person has of his or her own
body. It signifi-
cantly influences the way a person thinks and feels about his or
her body as a
whole, about its functions, and about the internal and external
sensations asso-
ciated with it. It also includes perceptions of the way others see
the person’s body
and is central to self-concept and self-esteem. Often a person’s
belief about his or
her body mirrors self-concept. This is evident when an
individual seeks out cos-
metic surgery to alter his or her appearance. However, when the
self-concept is
poor, even cosmetic surgery may not change the person’s body
image. This per-
son may continue to struggle with low self-esteem even though

the physical
“imperfections” are changed.
A person’s body image changes constantly. Illness, surgery, and
weight loss or
gain can have a major influence on the view of self.
Amputation, colostomy, and
dependence on equipment such as dialysis are examples of
obvious external
changes that influence body image. Some conditions such as a
myocardial infarc-
tion may not cause obvious external body changes, but the
individual may now
view his or her body as weak or damaged. Altered body image
can contribute to
lowered self-esteem and, possibly, depression.
Powerlessness
Powerlessness is a perceived lack of personal control over
certain events and over
one’s self. Individuals need to maintain a sense of power and
control over their
destiny and environment. Loss of this sense of control can
negatively affect an
individual’s view of his or her effectiveness. Illness
consistently forces the indi-
vidual to face his or her powerlessness over a situation.
Entry into the health-care system adds to this sense of
powerlessness. Now, in
addition to facing the feeling of helplessness over the illness,
the person is being
subjected to following the orders of strangers, complying with
others’ schedules,
and losing privacy. When an individual is hospitalized and
gives up his/her

clothes and puts on a hospital gown, a sense of powerlessness
within this new
role can occur quite quickly. Resisting a doctor’s orders and
even refusing pain
medication suggest that the patient is attempting to maintain
some sense of
control and fight off feelings of powerlessness. Helping these
patients to maintain
Chapter 2 ■ Psychosocial Response to Illness 9
02 Gorman(F)-02 11/5/07 4:55 PM Page 9
some sense of power and control is an important nursing
intervention. Individu-
als who chronically view themselves as helpless may be more
prone to depression
and vulnerable to victimization by others who try to control
them.
Loss
Actual or potential loss is any situation in which something a
person values is
rendered or threatened to be rendered inaccessible. Loss occurs
throughout life as
we experience changes in relationships, inability to reach an
expected goal, and
disappointment in others. Any time we have an emotional
investment in someone
or something, we are vulnerable to losing it. This includes loss
of a body part or
body function. All losses in life can contribute to loss of hopes,
dreams, and goals
and require some period of grieving as the individual adapts to

the new situation.
The degree of response to the loss depends on the amount of
value the individual
places on whatever is lost. Eventually the individual will go on
to develop new
attachments and goals. Maladaptive responses to loss can
include anger, guilt,
depression, and, possibly, suicidal thoughts.
Hopelessness
Hope is fundamental to life. No matter how bad the situation
may be, the abil-
ity to hope for improvement will help an individual get through
it. Hopelessness
is the sustained subjective state in which an individual sees no
alternatives or per-
sonal choices available to solve problems or to achieve desired
goals. Lack of
hope can develop from an overwhelming loss of control and is
related to a sense
of despair, helplessness, apathy, and depression.
The person without hope is unable to mobilize enough energy to
even estab-
lish personal goals and may be unable to recognize or accept
help or new ideas.
Serious illness alone usually does not cause hopelessness.
Usually deep personal
feelings of loss, depleted emotional reserves, and an
overwhelming sense of pow-
erlessness also contribute. To regain a sense of hope, the
individual needs to view
the situation differently, alter negative goals and expectations,
and, possibly, cre-
ate new ones. For example, a terminally ill patient, rather than
hoping to cure the

illness, may need to refocus on achieving a pain-free state or
making contact with
family members. For some individuals, hopelessness can lead to
discovery of
alternatives that will add meaning and purpose to life. Spiritual
crises may be
related to hopelessness as well.
Guilt
Guilt is self-blame and regret for some real or perceived action.
It is a painful
emotion that can negatively influence feelings, behaviors, and
relationships with
others. Conflicts within relationships can occur when an
individual feels guilty
about resentment that his or her needs are not being met.
Nurses frequently observe behavior in patients or their families
that seems to
be motivated by guilt. Family members may display guilt
behaviors when they
suddenly become very involved in the care of an ill patient they
have not seen in
02 Gorman(F)-02 11/5/07 4:55 PM Page 10
years. Examples of this may include hovering over this patient
or making numer-
ous demands on the staff. Self-blame is another frequent
behavior motivated by
guilt. For example, a wife may blame herself for not taking her
husband to the

doctor sooner or a patient may blame himself for the stress his
illness is causing
his wife. Survivor guilt is often seen in people who survive
traumatic events in
which others are killed or injured.
Anxiety
Anxiety is a universal, primitive, unpleasant feeling of tension
and apprehension.
It may be an early warning signal of possible danger. Anxiety is
an important
motivator of behavior that makes people act or change to reduce
the uncomfort-
able feelings of tension. Low to moderate levels of anxiety can
enhance learning
and action. More severe anxiety may be reduced by using
defense or coping
mechanisms as the unconscious self tries to protect us from this
discomfort.
DEFENSE MECHANISMS
Defense mechanisms protect the individual from threats,
feelings of inadequacy,
and unacceptable feelings or thoughts. They are unconscious
mental processes
used to reduce anxiety and conflict by modifying, distorting,
and rejecting reality
(Table 2–1). Because they are unconscious, the individual is not
aware of how
these mechanisms affect thoughts, feelings, and behavior. In
some ways, they are
used to alter reality to make the situation more acceptable.
Without these mech-
anisms, the threatening feelings might overwhelm and paralyze
the individual and

interfere with daily living. Essential, adaptive defense
mechanisms help to lower
anxiety so that goals can be achieved. We could not survive
without them. How-
ever, when they are used too extensively, they can contribute to
highly distorted
perceptions and interfere with normal functioning and
interpersonal relation-
ships. Excessively distorted defense mechanisms can be
characterized as psychi-
atric disorders.
An individual’s repertoire of defense mechanisms is learned
through childhood
experiences. Each time a defense mechanism reduces
uncomfortable anxiety feel-
ings, it provides positive reinforcement.
COPING MECHANISMS
Coping mechanisms are usually conscious methods that the
individual uses to
overcome a problem or stressor. They are learned adaptive or
maladaptive
responses to anxiety based on problem-solving, and they may
lead to changed
behavior. They involve higher levels of emotional and ego
development than
defense mechanisms. However, overuse of coping mechanisms
such as overeating
or smoking can create problems. In addition, unconscious
mechanisms can also
play a role in using or selecting a specific coping mechanism.
Inappropriate

02 Gorman(F)-02 11/5/07 4:55 PM Page 11
TABLE 2–1
Common Defense Mechanisms
Defense
Mechanism Definition Example
Denial
Displacement
Identification
Intellectualization
Isolation
Attempt to remove an
experience or a feeling
from consciousness
The belief that one would
be in great danger if true
feelings about someone
were known to that per-
son, which causes the
individual to discharge
or displace feelings onto
a third person or object

Accepting the other per-
son’s circumstances as
though they were one’s
own
Separating emotion from
an idea or thought
because emotionally
it is too painful
Blocking out feelings asso-
ciated with an unpleas-
ant or threatening
situation or thought
After a diagnosis of termi-
nal condition, the patient
does not exhibit any
expected emotional reac-
tion and states that diag-
nosis is not true.
A family member is angry
at the patient for not tak-
ing better care of himself
and feels too guilty to
express this to the ill per-
son. Instead, he expresses
anger at the nursing staff
for giving inadequate
care.
A man’s wife died a very
painful death from can-
cer. When he is diagnosed
with cancer, he experi-

ences extreme anxiety
because he has accepted
his wife’s experiences as
if he had lived them.
A patient discusses the
physiology of his
leukemia at length
without any emotional
reaction.
A nurse caring for a criti-
cally ill patient who is the
same age provides care
without experiencing
the emotions related to
tragedy of the patient’s
situation.
02 Gorman(F)-02 11/5/07 4:55 PM Page 12
Defense
Mechanism Definition Example
Projection
Rationalization
Reaction
formation
Regression

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