Barkley Ch. 4: Theoretical Models, Therapy, and Nursing Theories

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General info, not specific Added info from ANCC book Ch. 2

Psychoanalytic theory

Freud
Role of unconscious is important and all behavior has meaning
Goal: make the unconscious conscious and strengthen the ego so it can focus less on instinctual drives and more in reality
2 types of normal drives: sexual/libido and aggressive

Psychoanalytic development

Past developmental and psychodynamic factors shape present behaviors
Behavior determined by: unconscious motivation, role of anxiety, defense mechanisms, and conflicts between instincts (survival vs aggression)
Used for personality & anxiety disorders

Psychosexual Stages of Development

People deal with associated feelings and seek gratification through the release of tension a drive produces. Different actions are used at different ages to discharge the tension from drives and seek gratification
1. Oral (birth-18 mos)- Establish trust
Discharge of drive + gratification: sucking, chewing, crying, feeding
Failure & associated d/o: schizophrenia, substance abuse, paranoia
2. Anal (18 mos- 3 years)- Striving for independence
Discharge of drive + gratification: sphincter control, activities of expulsion and retention
Failure & associated d/o: depressive disorders
3. Phallic (3-6 years)- Lays foundation for gender identity; ID with parent of same-sex
Discharge of drive + gratification: exhibitionism, masturbation with focus on oedipal conflict, castration anxiety, and female fear of lost maternal love
Failure & associated d/o: sexual ID d/o
4. Latency (6-12 years)- Focus on relationships with same-sex peers; sexually repressed
Discharge of drive + gratification: peer relationships, motor skills, learning, socialization
Failure & associated d/o: inability to form social relationships
5. Genital (12-adulthood)- Separation from parents; establishment of mature, nonincestuous relationships
Discharge of drive + gratification: integration and synthesis of behavior from earlier stages, primary genital based sexuality
Failure & associated d/o: sexual perversion disorders

Freud's structure of the mind & anxiety

An intrapsychic conflict of how to achieve gratification among these structures --> neurosis/anxiety. Conflict is is unconscious and anxiety functions to alert the conscious mind to the prescience of this conflict. Conflict is dealt with though use of defense mechanisms.
Id- Instinctual drives, pleasure principle, unconscious drives (sexual/aggressive), present at birth and motivates early infantile actions; "I want"
Ego- Rational self, reality of external world; maintains harmony, begins to develop at birth, use of defense mechanisms; "I think, I evaluate"
Superego- Perfection principle, internalizes values and moral sets, forms conscious, regulated by guilt and shame, begins to fully develop at age 6 though contact with external authority figures; "I should or I ought"

Defense mechanisms

Function of the ego, unconsciously called into action, used to reduce anxiety/increase safety, become part of the personality, promote self-esteem and sense of well-being, may be used episodically or become fixed (as in neurosis)
• Denial * - primitive/narcissistic; avoidance of unpleasant realities by unconsciously ignoring their existence
• Projection* - primitive/narcissistic; unconscious rejection of emotionally unacceptable personal attributes/actions by attributing them to other people/situations/events
• Regression
• Reaction formation - neurotic; unacceptable thought is consciously pushed from awareness by acting on the opposite thought/feeling/behavior
• Displacement
• Intellectualization
• Rationalization* - neurotic
• Repression - neurotic; unconscious exclusion of unwanted thoughts/emotions
• Suppression - mature; conscious analog of repression
• Identification
• Introjection
• Isolation
• Sublimation - mature; unconscious process of subsitiution of socially acceptable, constructive activity for strong unacceptable imoulse
• Undoing - neurotic
*According to Barkley, ANCC likes to test on these 3

Psychoanalytic techniques

Free association
Interpretation
Therapeutic alliance
Patterns in functioning
Gaps and inconsistencies in story
Infer meaning of behavior- principal of psychic determinis- even apparently meaningless, random behavior is actually motivated by unconscious mental content (most mental activity is unconscious)
Transference/countertransference
Dream Analysis
Disguised fulfillment of unconscious childhood wish that isn't readily accessible to conscious awareness

Interpersonal (IP) Theory

Harry Stack Sullivan (& Peplau)
Social context influences personality development
Anxiety = emotional dread, "chief disruption force" in IP relationships
Behavioral goals aim towards anxiety prevention
*Interpersonal security occurs once needs are met, relieving anxiety

Sullivan's Self-system

Total components of one's personality traits; Collection of experiences or security measures to protect against anxiety; denial of these feelings is used to relieve anxiety, but can lead to serious implications for d/o in adult life
Integration of good me (positive feedback, pleasure, gratification), bad me (negative feedback, anxiety, discomfort, distress), and not me (intense anxiety, horror, dread, awe)
*2 drives for an individuals behavior: 1. drive for satisfaction (basic- sleep/sex/hunger) 2. drive for security (conforming to social norms)
Illness occurs when need for satisfaction and security is interfered with by the self-system

4 themes of IP Theory

1. Grief
2. Role disputes- conflicts with significant others
3. Role transitions
4. IP conflicts- inability to initiate or sustain close relationships

IP coping strategies

Security operations (measures to reduce anxiety and enhance security; making up a system of defense against anxiety), selective inattention (not attending to the meaningful details of one's life that may cause anxiety), dissociation (putting threatening thoughts or feelings outside of one's awareness before triggering overwhelming/intolerable anxiety)

IP therapeutic strategies

Focus on IP relationships and social support
TX of depression, anxiety
Therapeutic alliance is extremely important
Nonjudgmental stance
IP issues: withdrawal, attachment, models
Techniques- highly directive interventions

Sullivan's Stages of Development

1. Infancy (birth-18 mos)- Oral gratification; anxiety occurs for 1st time
2. Childhood (18 mos- 6 years)- Delay of gratification
3. Juvenile (6 years-9 years)- Forming peer relationships
4. Pre-adolescent (9-12 years)- Same sex relationships
5. Early Adolescent (12-14 years)- Opposite sex relationships
6. Late adolescent (14-21 years)- Self-identity developed

Transactional Analysis (TA)

Eric Berne
Defined as description of what people do and say themselves and to each other
Focuses on past and current decisions made by client
Emphasis on behavioral, thinking, and feeling personality aspects
Goal is to assist the client ti make new decisions about present behavior and life
Designed to gain both emotional and intellectual insight

Ego states of TA

1. Parent- Should, oughts; intriject of parents, judgemental stance
2. Adult- Data processing, objective part of person, not emotional or judgmental
3. Child- Feelings, impulses, spontaneous acts
Goal is to have individuals working in the same ego states

TA terms to know

Strokes = forms of recognition (positive, conditional, negative, unconditional)
Game = a series of transactions that is complementary (reciprocal), ulterior, and proceeds towards a predictable outcome. Played b/t the 3 ego states
Rackets = dual strategy of getting "permitted feelings," while covering up feelings which we truly feel, but which we regard as being "not allowed". More technically, a racket feeling is "a familiar set of emotions, learned and enhanced during childhood, experienced in many different stress situations, and maladaptive as an adult means of problem solving".
Life scripts = A person begins writing his/her own life story (script) at a young age, as he/she tries to make sense of the world and his place within it. Although it is revised throughout life, the core story is selected and decided upon typically by age 7. As adults it passes out of awareness.

TA therapeutic strategies

Structural analysis- person becomes aware of the content and functioning of the parent, adult, and child ego states
Transactual analysis- description of what people do and say, to themselves and to others
Family modeling
Analysis of rituals and pastimes
Analysis of games and rackets- means for understanding transactions with others
Script analysis- life patterns identified and analyzed

Gestalt Therapy

Frederick Perls
Whole is more important than sum of parts
Individual is responsible for finding one's way in life and accepting personal responsibility to achieve mastery
Focus is on the now- must use full awareness of what is happening
ACTIVE therapist role
Deal with unfinished business or it will nag until no longer avoided.
Layers of neurosis: superimposed "growth disorders" (phony, phobic, impasse, implosive, and explosive)

Gestalt therapeutic strategy:

Existential encounter with others increases self awareness. Therefore, there is a focus on:
Pt feelings
Awareness of moment
Body messages
Energy
Avoidance
Blocks to awareness

Gestalt therapeutic techniques

Dialogue exercise
Empty chair
Making the rounds
Unfinished business
"I take responsibility"
"I have a secret"
Played projection
Reversals
The rhythm of contact and withdrawal
Rehearsal
Exaggeration

Person-Centered Therapy

Carl Rogers
Self direction, self-actualization- client has potential for becoming aware of problems and the means to resolve them
Focus is on the development of self-direction and the ability to explore things in a safe/trusting environment
Health = congruence of ideal self and real self

Person-Centered therapeutic strategies

Safe environment for self-exploration
Enable client to move toward: Openness, greater trust in self, willingness to process, and increased spontaneity
Relationship is of primary importance- unconditional positive regard

Person-Centered therapist qualities

Genuine, warm, accurate empathy, respect, permissiveness, and unconditional positive regard

Person-Centered therapy techniques

ATTITUDE of therapist- active listening and hearing
Reflection of feelings, clarification, and "being there"
Does NOT include: DX testing, interpretation, taking HX, and questioning/probing for information

Behavioral Therapy

Skinner, Bandura, Pavlov, Wolpe
Broad range of procedures with differing theoretical rationales/frameworks, but there are 2 overriding principals:
1. Understanding human behavior differs fundamentally from psychodynamic model
2. Emphasis on scientific method to include an overt and testable conceptual framework that has measurable outcomes (goal: objective evidence, not proposed motives)

3 main approaches to behavioral therapy...

1. Applied behavior analysis
2. Neobehavioristic mediational stimulus response model (S-R model)
3. Social cognitive theory

1. Applied behavior analysis

Extension from BF Skinner's radical behaviorism
Operant conditioning: all behavior is the result of its consequences
Uses reinforcement, punishment, extinction, and stimulus control

2. Neobehavioristic mediational stimulus response model (S-R model)

Based on Pavlov, Guthrie, ect.
Operates primarily on the principal of classical conditioning
Incremental model of mediating and intervening variables that create consequences and affect behaviors
Techniques: flooding and systematic desensitization

3. Social cognitive theory

Behavior is based on 3 separate but interacting regulatory systems:
1. External stimulus events
2. External reinforcement
3. Cognitive mediational processes
Person is agent of change
Assumption = change a person's interpretation of an experience; have therapeutic success

Behavioral therapy assumptions

Change cognition, affect, and behaviors to: learn new coping skills, improve communication, change self-defeating emotional conflicts, and break maladaptive habits.
Abnormal behaviors are not seen as illnesses or pathological, but rather "problems of living" that need to be adjusted.
HERE-AND-NOW focus- understanding why a behavior exists or insight into early childhood is not necessary
TX is tailored individually to each client- specific/comprehensive assessment of behaviors with focused examples of behavior and occurrence

Behavioral problem identification and assessment

Detailed info about the pt's presenting problem- initial onset, severity, frequency. How/when/where/what Q's are more helpful than why! Aims to help uncover the thoughts associated with the specific event.

Behavioral techniques

Self-monitoring- daily records of events and reactions. This helps facilitate understanding of the behavioral pattern.
Behavioral observation- done by the therapist in the client's actual environment
Psychometric evaluations- checklists and questionnaires help to ID and clarify the problem (does not use projective tests or standard psychological tests)
Assertiveness and social skills training- pts learn & practice behaviors to improve their sense of power and control

Cognitive restructuring

Behavioral therapy assumes that emotional disorders or "problems in living" are based at least in part by dysfunctional thinking. The goal is to alter dysfunctional thinking to improve affect and behavior.

Rational-Emotive Behavioral Therapy (REBT)

Albert Ellis
Neurosis = irrational thinking and behaving
Emotional disturbances are rooted in childhood, but continue though re-indoctrination in the now
The client's belief system is the cause of emotional problems, therefore they must examine the validity of certain beliefs

Rational-Emotive Behavioral Therapy strategies

Goal: eliminate self-defeating outlook on life
Assist the client to get a more tolerant/rational view of life
Therapist = teacher; client = student. Personal relationship is NOT necessary.
Client gains insight into problems, then practices to change self-defeating behaviors

Rational-Emotive Behavioral Therapy techniques

1. Cognitive: Disputing irrational beliefs, cognitive HW, and changing language and thinking patterns
2. Emotive: Role playing, imagery, and shame-attacking exercises
3. Behavioral: wide range that is tailored to client

Cognitive Behavioral Therapy (CBT)

Aaron Beck
Based on the personality theory that asserts how one things largely determines how one feels and behaves
Goal: reframing of the mind. Shift the processing of information to a functional position that neutralizes basic beliefs that create misinterpretation.
Cognitive distortions are created by depression, anxiety, etc and create a "systematic bias" (ex: negative narcissism- always feel guilty and less than --> assimilate external events that way)

CBT strategies

Collaborative empiricism- therapist and client ID dysfunctional interpretations and modify them. Client is a practical scientist who needs to examine where thoughts have become illogical and reformulate more appropriate thought processes.
Guided discovery- guide the client to understand origins of thinking. Understanding the development of thinking patterns helps to facilitate change.
Cognitive therapy- each disorder has its own cognitive distortions, requiring individualized treatment approaches. This differs from REBT in the fact that REBT asserts all psychopathology has similar underlying, irrational beliefs.

CBT techniques

Link s/s, conscious beliefs, and current experiences though talk therapy to alter old patterns
Highly structured, lasts 12-16 wks
Present centered, action oriented, problem solving approach

Trauma Informed Care

Stressful events get stores dysfunctionally in the brain --> patterns of behavior that compromise functioning --> psych/physical issues
Patterns of behavior are influences by: nature of trauma, frequency, age, genetic and acquired vulnerability, prenatal factors, gender, cognitive capacity, emotional maturity, coping skills, relational capacity, ect.
S/S: hyperarousal, avoidance, intrusive thoughts, disassociation
Goals of TX: safety, developing awareness through mindfulness, and managing physiological arousal
Healing is a process: constructing a narrative though mourning, meaning, transcendence, and incorporation of the trauma into one's life

Evidence-based TX for trauma informed care (2)

CBT
Eye movement desensitization and reprocessing (EMDR)- goal is to reach a adaptive resolution. Guide the pt in processing affective, cognitive, or somatic material though bilateral stimulation in the form of eye movements, alternating sounds, or alternating tapping on hand and knee.
Adjunctive: Body/energy work/massage, debriefing, CAM TX- yoga

Brief Individual Psychotherapies

Increased demand after WWII
Gained legitimacy in 1950s
Avnet Report in 1969- efficacy of TX with short-term therapy that was paid for by commercial insurance; set foundation for 3rd party reimbursement!

Brief Individual Psychotherapies- client selection

Goal: solve focal problem (circumscribed complaint that is within their control)
Motivated for change
Psychologically-minded
Able to use ideas of therapist- flexible interactions

Brief Individual Psychotherapies- phases

Brevity of time = framework
Therapy occurs in the moment
Pretreatment: client determines what is to be accomplished, how therapy is expected to help, and how long it will take
Beginning: rapport, alliance, resistance, negative transference, identifying focus/issue, setting limits, contracting for # of sessions/$, HW
Middle: working though, increasing awareness, clarifying/redefining focus, confrontation (if applicable), interpretation of resistance (if applicable), applying lessons outside of session, monitoring progress
End/termination: extraction of therapist from successful therapeutic alliance

Characteristics of a therapeutic NP-Pt relationship

1. View and respect each other as a distinctive person
2. End purpose: education and growth through assisting the pt in finding a solution to their issue.

Peplau's 6 Nursing Subroles

1. Mother-surrogate- Provide basic needs
2. Technician- Perform technical aspects of nursing
3. Manager- Manage environment for health improvement
4. Socializing agent- Enhance patient's social life
5. Health teacher- Educate patient, family, and community on health issues
6. Counselor or psychotherapist- Assist pt in developing adaptive coping skills; PMHNP role should be focused on this role

Peplau's phases of nurse/pt relationship: Orientation

1. Orientation/introduction(1 meeting): NURSE: establish trust & rapport, parameters of relationship (boundaries, roles, goals, contracting, confidentiality, termination), providing diagnostic evaluation, setting mutually-agreed upon TX objectives
CLIENT: Initial hesitancy to participate fully; approach avoidance

Peplau's phases of nurse/pt relationship: Working

2. Working/Identification & exploration: NURSE: clarifying client expectations and mutually set goals, further data collection (DX further as you go along), implement TX plan, enhance self-esteem, support positive changes in behavior, work though resistance (client resistance to change or care practices), develop adaptive coping skills, clarify expectations, plan of action, exploitation, maintain trust & rapport, promote insight on reality, problem-solving for goals, measure and evaluate progress, undertake preventative care, and set groundwork for termination
**phase in which Transference & countertransference occurs

Peplau's phases of nurse/pt relationship: Termination

3. Termination/resolution (occurs when goals of therapy realized): review of therapeutic accomplishment, establishing long-term plan of care/ways to sustain and grow in mental health, focusing on self-management strategies, make referrals, establish guidelines of future communication, and recognize and explore feelings about termination
CLIENT: anticipate regression, resistance to termination, and the reemergence of s/s or new problems

Therapeutic Milieu

Assumptions: Pt self-esteem enhanced in group settings (democratic structure and peer pressure create an environment for social skill enhancement). Beneficial to observe social behaviors among a diverse group of patients; helps with TX planning.
Conditions that promote therapeutic environment:
Structure- basic needs met, structured activity, and privilege systems
Involvement- promotes social interaction
Containment- safe environment, acceptable forms of self expression, and correction of ineffective behavior
Support- allowing for mental health growth with monitoring and observation as needed
Validation- symptoms and illness taken seriously and pt's self-worth is acknowledged

Roles of PMHNP in the Milieu

Ensure physiological needs met
Encouraging independence
Reality orientation
Med management
One-to-one relationship
Setting limits
Teaching

Group Therapy

Individuals with shared values, interests, norms, or purpose; focus is on group relations and interaction of members. Aim to develop adaptive coping skills and promote mental health.
Ideal: no barriers b/t participants and 5-10 members.
Close-ended: predetermined members with a fixed time-frame
Open-ended: can come/go at anytime

Yalom's Curative Factors of Group Therapy

1. Instillation of Hope- encouragement that recovery is possible
2. Universality- feeling of having problems similar to others, not alone
3. Imparting Information- teaching about problem and recovery
4. Altruism- helping and supporting others
5. Corrective recapitulation of family unit- identifying & changing the dysfunctional patterns or roles one played in primary family
6. Development of Socializing Techniques- learning new ways to talk about feelings, observations and concerns
7. Imitative Behavior- modeling another's manners & recovery skills
8. Interpersonal Learning- finding out about themselves & others from the group
9. Group Cohesiveness- feeling of belonging to the group, valuing the group
10. Catharsis- release of emotional tension
11. Existential Factors- accepting responsibility for one's own life; finding direction

Autocratic Leadership

Leader is focus
Members encourage to adopt leader ideas
Member participation is limited
Individual creativity is low
Low group cohesiveness
Low productivity

Democratic Leadership

**Most effective type of leader
Focus on members
Group problem solving is the task
Member participation is unlimited
Indivudal creativity is high/unlimited
High group cohesiveness
Productivity is high

Laissez-Faire

Undetermined focus
No defined tasks
Member participation is inconsistent
Individual creativity is not addressed
Low group cohesiveness
Low productivity

Initial/orientation phase of group therapy

Group activities: leader & members establish rules
Leader expectations: orients to group process, encourages participation, promotes environment of trust
Member behavior: fear of rejection, overly polite

Working phase of group therapy

Group activities: completion of tasks, problem-solving, decision-making, cooperation with differences, disagreements controlled and resolved
Leader expectations: role decreases, facilitator, helps resolve conflicts, fosters cohesiveness
Member behavior: accepts criticism, subgroups may form, and conflict managed by the group

Termination phase of group therapy

Group activities: sense of loss
Leader expectations: encourages reminiscing, review of goals and discussion of actual outcomes, discussion of feelings of loss
Member behavior: loss responses, grief

Family Systems Theory- definitions

Murray Bowen
Anxiety: reaction of an emotional unit in re: to a real or imagined threat.
Fusion: ways that people borrow or lend self to another
Cutoffs: immature separation of people from each other
Emotional reactivity: tendency to react without separating feelings/emotions from thoughts. MUST learn to manage one's reactivity/anxiety.
Triangles- building blocks of any emotional system. A person focuses on a third object/idea/person to manage anxiety b/t themselves and another. Analyzing and de-triangulating allows for increased differentiation of self and decreased emotional reactivity
Nuclear family emotional system
Multigenerational transmission
Family projection processes
Sibling position

Family Systems Theory- techniques

Develop a solid sense of self to stand up against anxiety and triangles
Genogram (3 generations)- ed: on triangles
Focus on relationships, not individuals
"I think" > "I feel"
Therapy often occurs without the entire family present
TX goal is to reduce anxiety by: Increasing awareness of emotional systems functions and increasing levels of differentiation of self. As individuals learn about the emotional processes within the family, they can establish themselves as an individual with their own beliefs within the family.

Strategic Family Therapy- concepts

Jay Haley- "the solution can be a part of the problem"
Families develop strategies to solve problems, but sometimes these strategies become problems themselves.
Focuses on the current expression of dysfunction rather than the history of/development of the problem.

Strategic Family Therapy- techniques

Therapist develops novel strategies for family
Paradoxical interventions- aimed at indirectly changing problematic family behaviors

Structural Family Therapy- conepts

Salvador Minuchin- patterns of interaction define the system
3 elements of family organization:
1. Structure- family organization and interdependent functioning; pervasive automatic expectations of behavior
2. Subsystem- subgroups that connect to perform family function; individuals may behave differently in subgroups
3. Boundaries- emotional walls that control amount and level of interpersonal interaction. Diffuse boundaries have more chaos (enmeshed) vs. rigid boundaries have less emotional support (disengaged)

Structural Family Therapy- techniques

Challenge maladaptive expectations of behavior
Establish a unified view on important family issues/develop clear boundaries through discipline, responsibilities, and appropriate behavior
Open communication within family
TX goal: change structure in family

Neuman

Health care systems model
View person as complete system
Subparts are interrelated: Psychological, physiological, sociocultural, spiritual, and developmental factors
Application in practice: promote health by strengthening subsystem functions and preventing risk factors of the subsystem

Roy

Theory of Adaptation- humans are adaptive systems who cope with environmental changes though a process of adaptation
Behavior is the result of an individual adpating to internal or environmental forces
4 Subsystems: 1) Physiologic needs 2) Self-concept 3) Role function 4) Interdependence
Application in practice: use of support groups, prediction of physiological needs reduce length of inpatient stay

Rogers

Unitary human beings- viewed as more than the sum of our biological, physical, social, and psychological parts
Nursing is devoted to the study of the nature and direction of unitary human development
Application in practice: focus on social and psychological needs other than chief complaint

Parse

Theory of human beings
Humans are an open system who choose to give meaning to a situation
Encourages pts to share thoughts
Application in practice: Pts may make their own decisions to promote their health by being encouraged to share their thoughts

Orem

Self-care model
Individual is able to perform self-care- activities that maintain life, health, and well-being
Nursing goal is to help people meet their own self-care demands
Application in practice: Assess pt needs that require self-care (ex: ostomy or trach care)

Levine

Conservation model- Individual is holistic being
Nursing goal is to maintain person's wholeness
Application in practice: Help pts cope with new health problems (ex: pain control for those with arthritis)

King

Open systems model
A personal, interpersonal, and social system exist
Application in practice: pts can be supported to promote their health by nurse-pt perception, communication, and interaction

Ajzen

A theory of reasoned action
A relationship exists between a person's attitude, intention, and behavior
Application in practice: ed. pts to create intention toward health promotion

Lazarus

**Theory of stress and coping
Internal/external stress which exceeds a person's resources, and endangers their well-being
Application in practice: assist pts in exploring and evaluating coping strategies and amend them as needed

Mishel

Uncertainty in illness theory
Uncertainty = pts ability to determine meaning of illness related event
Uncertainty will mobilize individuals to use resources to adapt to a situation
Application in practice: use family support of assist in a newly DX's pt

Watson

**Caring Theory
Caring is central theme, and is ONLY effective when practiced inter-personally
Clients need holistic care that enhances humanism, health, and quality of living
"Carative factors"- promote healing and relationships; guides the core of nursing

Henderson

Pt is individual requiring help toward independence
Problem-solving process: assessment, planning, revising, and implementing
Nurse assists in implementation phase to help pt preform activities to maintain health, heal after illness, or attain a peaceful death

Pender

Health Promotion Theory
Explains behavior that enhances health and prevents disease

Peplau

Therapeutic Nurse-Client Relationship/IP Theory
1st significant psychiatric nursing theory
Based in-part on IP theory (Sullivan)
Nursing = interpersonal process in which all interventions occur
Developed the 3 phases of the nurse-pt relationship

Leininger

Theory of Cultural Care
Health & well-being can be predicted through cultural care
Regardless of culture, care is the unifying focus and the essence of nursing

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