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Health Psychology Notes Ch. 10
Terms in this set (16)
The Hospital - Its History, Setting and Procedures
How the Hospital Evolved
The Roman military had separate barracks for the sick but the first institutions devoted to care were associated with Christian monasteries and were charitable in nature. Orphans and the poor might also find a home there.
On the 18 and 19 centuries these institutions changed in a couple of ways.
1. They restricted admission to the sick and members of the 'worthy poor' and no longer accepted the poor and the handicapped.
2. They became medically specialized with wards for different illnesses.
Prior to the 20 century hospitals had bad reputations giving poor care and making patients worse through the spread of infection.
By the 20 century this perspective changed and people from all social classes went to hospitals for treatment.
Now their role has expanded to include prevention, emergency treatment, rehabilitation and diagnostic testing.
The Organization and Functioning of Hospitals
Most hospitals have a board of trustees appointed from business and professional people in a community. Their role is usually limited to long range planning and fundraising.
Hospital administrators oversee the running of the institution purchasing supplies, paying bills, keeping records, providing services like food and cleaning.
The medical staff is responsible for patient care. It is headed by a chief of staff or medical director. The next level down are the staff or attending physicians. Most of these are not employed by the hospital but work for clinics or are self employed. In return for being allowed to admit their patients to a hospital they must perform certain duties at the hospital.
Teaching hospitals are an exception to this. They employ full fledged physicians whose duties include supervising the work of residents.
Below doctors are nurses who are generally salaried employees of the hospital. They generally spend more time with patients than doctors do.
Below the nurses - but not to far I wouldn't think - are allied health workers physical therapists, respiratory therapists and dietitians.
The Hospital - Roles Goals and Communication
Coordinating Patient Care
Years ago patients received care from a small team. Now treatment is much more fragmented. Hospitals try to limit this by appointing someone, usually a nurse, to coordinate treatment for each patient on a ward, though all major decisions are made in consultation with the primary care physician.
Health Hazards in Hospitals
Hospitals contain many dangerous chemicals and medications. Good communication lessens the danger that accidents related to these will happen and it ensures that all instruments are accounted for and anesthesia is administered in the proper place.
Infection is also a danger. Each year 5 % of patients acquire a nosocomial infection. Infection rates can be extremely high in intensive care units. MRSA is a difficult infection which resists antibiotic treatment.
Most hospitals have committees charged with lower rates of infection and promoting compliance with preventative procedures but in practice they tend to enforce with nurses and orderlies and less often with doctors.
The Hospital - The Impact of the Bottom Line
In the early days of Medicare hospitals had financial incentives to prolong treatment and extend patient stays.
With the adoption of the Prospective Payment System set fees based on the cost to treat a typical case were established. Should a patient recover before predicted, the hospital pockets the surplus but should the patient require extra care the hospital must eat the extra expense it self.
These changes have been linked to hiring too few and insufficiently trained nurses.
Most hospitals keep patients less than 30 days and are classed as short stay hospitals (acute care hospitals). In general hospital stays are shorter than before. This is because:
1. more procedures are done on an outpatient basis
2. medical procedures are becoming more efficient
3. patients are released sooner to home care, this does not appear to hurt recovery
Being Hospitalized - Relations With the Hospital Staff
Psychosocial Issues of Patients
Anxiety is the most common and pervasive emotion felt by hospitalized people. They have a lot to worry about. Including the fact that some experiences in the hospital are depersonalizing.
This depersonalization is sometimes caused by the health professionals desire to protect themselves from emotional attachment should the patient's condition worsen.
Burnout Among Health Care Professionals
All jobs have stress but health care has more than others. Workers suffering from burnout tend to experience less job satisfaction, higher absentee and turnover rates, and more substance abuse problems.
Symptoms of burnout include:
1. Emotional exhaustion - feeling emotionally drained
2. depersonalization - a lack of personal regard for others
3. perceived lack of professional accomplishment - low self-efficacy and falling below personal expectations
Nurse report less depersoanlization while doctors report less sense of not being accomplished. This might just reflect differences in pay scale.
In general, the more time spent directly with patients the greater the emotional exhaustion. One way to deal with this is to mix duties so there are periods spent away from patients.
The fear of nosocomial infection also has negative effects on job satisfaction and contributes to emotional exhaustion.
Being Hospitalized - Sick Role Behavior in the Hospital
Hospitals are new environments that patients must adjust to often when they are under stress from the uncertainties of their illness.
Patients often arrive with expectations about what their role should be active or passive. Active patients were more likely to complain about minor discomforts and argue with staff.
Patients perceived as good patients by the staff were passive and fit uncomplainingly into routines. Problem patients were those who had emotional responses and were so uncooperative that it was difficult for staff to carry out their duties in a routine manner.
Among the problem patients some are seriously ill and so the trouble they caused was easily forgiven, but those who were less ill and still difficult were not so easily forgiven.
Staff sometimes respond to problem patients by sedating them.
Some patients try to be good patients because they fear alienating the staff and affecting the quality of their care.
Emotional Adjustments in the Hospital - Coping Processes in Hospital Patients
There are two broad ways of coping with stress: problem focused coping and emotion focused coping.
Problem focused coping attempts to alter the causes of the stress. Emotional focused coping tries to regulate the emotional response to the situation. This is the choice of people who believe they cannot change the medical situation that is causing their stress. The view that there is no medical hope is not always correct.
Cognitive Processes in Coping
Attributing blame is a key cognitive process for the ill. Is someone else responsible? Is it God's will? Am I to blame?
Blaming others and self correlate to poor adjustment but blaming others does make it worse, possibly because these people feel a stronger sense of injustice.
Patients often arrive with or develop feelings of helplessness that the hospital experience can acerbate even if the patient's health is improving.
Being a 'good patient' and the instilled sense of helplessness may make a patient more vulnerable to depression.
Helping Patients Cope
Anesthetized patients who received motivational messages during surgery recover better. This means in a broad way patients understand what they hear while under anesthesia so negative comments made by members of the surgical team are likely to be understood.
Heart patients who received brief counselling sessions for the three weeks of their hospital stay had faster recoveries, fewer complications and less sadness.
Being paired with a roommate who is recovering from the surgery a patient is waiting to undergo will reduce their level of anxiety. This may be because it cuts down on the shared worrying that two patients awaiting the same treatment might experience.
Emotional Adjustments in the Hospital - Preparing Patients for Stressful Medical Procedures
Psychological Preparations for Surgery
The most effective approaches are those that enhance the patient's feeling of control over the situation or the recovery process.
They are generally designed to give patients one of the following types of control.
behavioral control - performing certain actions - like breathing exercises - to to promote recovery,
cognitive control - knowing how to focus on the benefits of treatment
informational control - gaining knowledge about what to expect during the experience
Psychological Preparations for Non-Surgical Procedures
Often there are no preparations a patient can take to prepare themselves for procedures so efforts have to focus on informational and cognitive control.
Informational and cognitive measures can help but in situations where behavior aspects can be included they enhance the benefits of these other measures.
Coping Styles and Psychological Preparation
Studies show that patients who use avoidance strategies to minimize the impact of surgery or giving blood show better emotional adjustment.
Different people have different styles for coping with medical situations and those who are avoiders do not profit from being given extensive information whereas other patients might. It is important to match coping styles to coping help.
Attention copers, who like information, do worse when they are deprived of info.
Emotional Adjustments in the Hospital - When the Hospitalized Patient is a Child
Children are less able to understand what is happening to them than adults. This can be a blessing and a curse in that it can make some kids more frightened than need be and some less frightened than need be.
Hospitalized in the Early Years of Childhood
Toddlers often can adjust easily to the needs of medical treatment as they are often required to sit or stay immobile for longer periods than they like.
Many kids experience separation anxiety, this peaks at 15 months. Prolonged stays in hospitals can cause children to be more anxious at home once they have been discharged.
Very young children do not think logically and some may see their hospital stay as a punishment. They may be easily scared by disfigured patients or people who have experienced amputations.
Hospitalized School Age Children
The idea of illness as a punishment can continue in this age range but children this age have better cognitive development and this allows them to cope with illness better.
Four aspects of hospitalization become more difficult for children as they get older.
1. the older kids get the more self-control they are used to having and hospitalization takes this away
2. their increased cognitive abilities allow them to worry more about their outcomes and treatment
3. being away from friends can cause them to worry about permanent damage to their social lives
4. particularly after puberty, kids are more sensitive about exposing their bodies
Helping Children Cope With Hospitalization
Many children suffer long term fears after being hospitalized. Some hospitals try to prevent this by allowing a parent to bunk in with the sick child.
Other approaches involve pamphlets, films and information as well as puppet shows that demonstrate hospital procedures. These are effective in relieving stress in many children but not for all.
But age, experience and coping styles can affect when the best time to present this information to the child is.
How Health Psychologists Assist Hospitalized Patients
Psychologists working in hospitals perform the following services for patients.
1. consult with patients' specialists to provide diagnostic and counselling services
2. provide psychological counselling for stressful procedures
3. help patients adhere to treatment and medication regimens
4. supply behavioral programs for improving the client's self care skills
5. help in rehabilitation, career counselling and adjustment by family members
How Health Psychologists Assist Hospitalized Patients - Initial Steps in Helping
Initial Steps in Helping
Patients who need psychological help do not usually request it themselves. The request usually comes from a nurse involved in their treatment
The psychologist will confer with the referring nurse before actually meeting the patient. Meetings with family members and a review of the patient's history may also precede the meeting with the patient.
How Health Psychologists Assist Hospitalized Patients - Test For Psychological Assessment of Medical Patients
Here are some of the most commonly used tools used in assessing a patient's needs:
Assessing Emotional Adjustment
Many CVD patients suffer from depression and pessimism which predicts slower recovery and poorer outcomes. They may suffer from high anxiety and lower levels of personal control.
Generally two methods are used for assessing emotional adjustment, diagnostic interviews and questionnaires
Many of these interviews are set out or guided by the DSM . Clinicians sometimes apply a less formal interview instead but these time saving measures tend to be less useful.
Two types of questionnaires are used in assessing emotional difficulties. One focuses on a single disorder and the other screens for a range of disorders, the best know is the MMPI.
The MMPI has ten scales that assess specific disorders. Three of these scales are particularly relevant for providing psychological help to medical patients.
1. Hypochondriasis which assesses peoples preoccupation and complaints about their physical health
2. Depression which measures feelings of unhappiness, pessimism and hoplelessness
3. Hysteria which assesses people's tendency to cope with problems through avoidance strategies and developing physical symptoms
Specialized Tests for Medical Patients
There are tests that measure Type A and Type B behavior.
The Millon Behavioral Medicine Diagnostic contains 165 questions that measure coping styles, negative health habits and stress moderators.
The Psychological Adjustment to Illness Scale is another test designed for use with medical patients. It is designed to test seven psychological characteristics of a patients life. The PAIS appears able to measure adjustment problems in patients with kidney disease, hypertension, and cancer.
How Health Psychologists Assist Hospitalized Patients - Promoting Patients' Health and Adjustment
When the Illness is Terminal - The Patient's Age
Terminal death is often drawn out and painful. Age is a key factor in how patients respond to a terminal diagnosis.
Terminally Ill Child
Children under five often do not have an accurate concept of death and think of it as a visit to another place that can be returned from.
By 8 most kids understand that death happens to everyone and involved the end of bodily functions. Some parents will not tell their children that the child is facing a terminal illness but often the child recognizes something is seriously wrong and exhibit more anxiety than children with less serious interviews.
The Terminally Ill Adolescent or Young Adult
By this age patients understand what death is and many feel that it is unjust for them to die so young. Their condition can be a threat to the cohesiveness of the family and parents often feel guilty. This is the age that the greatest amount of resentment manifests toward death.
Terminal Illness in Middle Ages and Older Adults
Dying seems to become less difficult as people pass through middle age into old age. For one reason terminal illness comes as less of a shock. Many of their peers have passed on or are in declining health.
When the Illness is Terminal - Psychological Adjustment to Terminal Illness
How People Cope With Terminal Illness
There are three types of stress the physically ill face:
1. they must cope with their worsening condition
2. their life styles often become restricted and they become dependent on others
3. they intuitively realize the end is near and worry about the loss of intimacy with loved once them will lose forever
Does Adapting to Dying Happen in Stages
Elisabeth Kubler-Ross found in interviews with 200 terminally ill patients that there are five stages that the dying go through.
But further research has shown that many people do not go through these stages in as precise a sequence that some may linger, others skip and some repeat the different steps.
When the Illness is Terminal - Medical and Psychological Care of Dying Patients
The technology exists to prolong life in the legal sense for long periods after patients have entered a coma. Most western physicians favor withdrawing life support if it is clear that it is being done in sync with the patient's wishes.
When the patient has reached the point where no treatment is available that can reverse the trajectory of the disease the illness is said to be in its palliative phase where the emphasis is on reducing pain and discomfort.
This phase can be stressful for patients, family and care providers who entered the field with the goal of saving lives not supervising their end. Some health providers deal with this by distancing themselves from the patients and not inquiring about their health.
Still many terminally ill patients face depression and anxiety and benefit from medication, support groups and psychological counselling.
When the Illness is Terminal - A Place to Die - Hospital Home or Hospice
Most people in developed nations die in hospitals or nursing homes. The environment is often unfamiliar and void of family and friends.
Home Health Care for the Dying Patient
Terminally ill people can receive good care at home if they have access to proper medical care and their family members are well trained. But caring for an ill family member is emotionally draining and physically demanding. Many people who have cared for dying relatives say it is a rewarding experience.
Hospice Care for the Dying Patient
The hospice tries to combine professional health care support with the kind of loving care that would arise in a family environment.
The founder of the hospice movement Cicely Saunders listed several important elements of the approach:
1. The ill person should be in a place of choice
2. they should be in an environment that encourages them to maximize their potential
3. the needs of all family members should be addressed
Some studies show reduced anxiety on the part of hospice patients as well as greater satisfaction among their family members.
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