PHYSICAL HEALTH FOLLOWING A COGNITIVE BEHAVIOR
INTERVENTION
INTRODUCTION
Scientific and social changes of the 21st century have brought a radical change in the Health care delivery system. Medical and nursing intervention is an important component of the health care delivery system and the role of a doctor and nurse in patient welfare has no boundaries for praise. The medical and nursing profession have evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles. The nursing practice has undergone a positive shift from that of a vocation to a professional status today. That is to say, nursing has a more active role to play in the health care delivery system than the past and nursing, as a profession is ‘accountable’ today. Florence Nightingale, the founder of modern nursing established the nursing philosophy based on health, maintenance and restoration. Nursing has evolved with time right from the days of Florence Nightingale, who saw the role of nursing as having “change of somebody’s health” based on the knowledge of “how to put the body in such a state to be free of disease or to recover from disease”. The civil war (1860-65) enhanced the growth of nursing in United States and the two World Wars saw the ‘nobility’ of the medical practice.
Communication is the pulse of medical practice with the elements of intimacy and reflective practice. Communication barriers of the mentally and cognitively impaired patients seem to erode the quality of medical care due to assumptions and attitudes. Non-verbal communication seems to be effective in such settings. Continuity of care seems to be a significant factor in psychiatric care as documented by research studies (Backrush, 1981). Continuity of caregivers where a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings (Fuller Torrey 1986) seem also to complement continuity of care with improved cognitive function self-care skills. Is it so because of the importance of the ultimate care providers after the doctors treat the patients. Various theories on practice of nursing also touch upon this aspect of care. Cognitive impairments pose a serious barrier on the reliability of geriatric assessments. Effects of cognitive impairment on the reliability of geriatric assessments has been studied recently (Phillips et. al, 1993) to explore the relationship between cognitive status and reliability of multidimensional assessment data. The studies have proved that the reliability of the patients communication and sensory ability are affected by cognitive status. Hence caution should be exercised in treating cognitively impaired patients. The cognitive impairment that contributes to unreliable assessment of patients includes those related to communicating, vision and hearing. Communication problems of hearing impaired patients have been studied as well (Hines, 2000). The studies have proved that such patients are seriously disadvantaged by the disability. The major factor contributing to the disadvantage has been the inadequacy in training of both nurse and doctors in deaf awareness and associated communication skills. Other factors include the patient’s concealing their disability, work pressure and poor communication of the staff.
INTERVENTIONS
The patient’s inability to provide an accurate history of his problem and to participate in self-care blocks the usual process of care, often resulting in medical uncertainty inadequacy and frustration for the physician (Wendy L., et.al, 2005). This shifts the goal from cure to care and shifting the goal of care from “curing” the patient’s illness to “caring” for the patient’s quality of life is problematic. The doctor–patient relationship changes dramatically often with ethical dilemmas related to patient autonomy and decision-making. Use of non-verbal communication skills (NVC) to improve patient care, especially with mentally ill and cognitively impaired people who have learning disability seems to be the key to care in such settings. The observation has brought out the fact that nurses can be important in enhancing the non-verbal skills of the patient to help them communicate. The medical profession demands that the nurse, in the process of care, has to interact with the patients, the medical fraternity and the health care workers. Hence, communication is an absolute necessity to uphold the professional standards of medical care. Caring mentally ill patients undergoing therapy with antipsychotic drugs like clozapine and benzodiazepines involves careful monitoring of the patient’s physiological condition as well. Such drugs have marked side effects like sedation, hyper salivation, increase in transaminases, EEG changes, cardiovascular respiratory dysregulation, overweight, mild Parkinsonism, akathisia, tardive dysakinesia, increase of liver enzymes, hypotension, fever, ECG alterations, tachycardia, and delirious states. These drugs also pose the risk of seizures. With medical litigations on the rise, the interventions should be based on the competence of the patient. However in psychological cases there seems to be a group of individuals who are marginally competent. This group seems to lie in-between the two extremes of competence and incompetence and competence in this case thus appears to be a matter of degree. Mentally retarded persons who have some understanding of the reality and are able to express their wishes and desires can also be considered marginally competent. Mentally ill individuals whose illness has not completely impaired their understanding and capacity to express their wishes and desires are also considered marginally competent. These individuals are not incompetent though they suffer from specific deficits due to destroyed faculties. These marginally competent individuals make a significant group and recognizing the existence of such group of marginally competent individuals will help define competence better towards the documentation of informed consent and advance directives during interventions.
It is not the advanced technology and medicines but the cordiality expressed by a caring health care takers which makes the difference in the quality of care for the patient. Adding support to the view, the importance of improving communication by touch has been documented (Vortherms, 1991) in a recent study. The article views touch as an integral aspect of nursing care, with the language of touch including tactile symbols of duration, location, action, intensity, frequency and sensation. The article classifies touch as affectional, functional and protective. The negative influence of elderly patients mental impairment on nurse patient interaction has also been documented using the Clifton Assessment Procedure (Armstrong et, al 1986) in another research study substantiating this view. 23 patients were assessed under three categories of lucid, slightly confused and demented. Data on interactions with nursing staff were gained by direct observation. These studies have concluded that nurses interact less with confused category them lucid category. Most of the nurses were more directed in the physical care of the patients them the psychological interaction or restorative activity. Communication problems seems to erode nurse commitment to care of mentally ill. The non-verbal communication in such settings includes patient-directed eye gaze, affirmative head nod, smiling, learning forward, touch and instrumental touch (Wilma, 1999). If has been observed that these non-verbal communication have as tremendous impact on the patient’s well-being and comfort. The nurses seem to eye gaze, head nod and smile to establish a good relationship. A caring touch is an important form of non-verbal but often effective communication. It can be understood that the nurse should be able to perceive the expressions of the ill to provide maximum comfort. The needs of these patients can be effectively addressed only then. Studies on demented ill patients to evaluate the time care givers provide for direct patient care have showed that more time is being spent with non demented than with the demented. The patients were shown to react in five categories of communication types during such interactions.
The patients enjoyed contact
Patient avoided contact
The patient was aggressive
Showed only slight reaction and
5. Does not react.
These observations highlight the use of non-verbal communication skills (NVC) to improve nursing care, especially with people who have mental disabilities and has been assessed and proved in a recent study (Chambers, 2003). The study outlines a nursing diagnosis of altered non-verbal communication and a new wellness diagnoses for enhanced non-verbal communication with detailed discussion on use of NVC with people with comprehension difficulties. The study stresses on the fact that nurses can be important in enhancing the non-verbal skills of the patient to help them communicate. Adding support to the view, the importance of improving communication by touch has been documented (Vortherms, 1991). Most of the nurses in the mental unit were more directed in the physical care of the patients than the psychological interaction or restorative activity. Pain evaluation in individuals who are cognitively impaired is further more difficult and these individuals do not respond to traditional approach to pain assessment (Weiner et. al, 1999). Monolingual and Bilingual communication between patients with dementia and their care gives have been studied and have shown that the relationship between a demented terminally ill patient and the care giver is an important factor which forms the foundation of the interaction between them. This communications is complex with different aspects of perception and practice (Sirkka, 1996). Non-speaking patients are the worst affected and it is important to improve their communication to allow them receive care and comfort. Research studies pertaining to factors related to nurse communication with elderly people have shown that the educational level of nurses influenced nurses communication with elderly patients (Wilma MCM et.al, 1999). Cognitively impaired or comatose are often neglected. Studies have found that, a nurse patient conversation is usually duty oriented like giving instructions to the patients (Jarret, 1995). Some studies have shown that nurses do not have time to talk to these patients and feel the stressful nature of the conversation (Wilkinson, 1988).
A Randomized controlled trial to test the effectiveness of multifactorial intervention after a fall in older patients with cognitive impairment and dementia attending the accident and emergency department has shown that Multifactorial intervention was not effective in preventing falls in older people with cognitive impairment and dementia presenting to the accident and emergency department after a fall (Fiona E Shaw, 2003). A Psychological well being was shown to be enhanced by the humanistic personal interaction with the nurse and the professional interaction was shown to enhance physical well being. The patients feelings of well being always depended on the psychological well being according to the study. (Jane, 2002). Another studies on communication with severely demented patients by the nurses have shown that care of such patients need clear communication during care procedure and the nurses were vogue in their verbal communication and some patients were verbally active after the nurse leaving the bed side.
CONCLUSION
A small scale pilot study has explored the educational base and needs of qualified care givers with reference to terminally ill patients with learning disability. The study has shown the lack of
knowledge and skills in nurses to deal with the LD patients. The study has also recommended the introduction of communication and interpersonal skills in the care and Management of terminally ill patients with LD in the nursing curriculum. The role of communication in nursing care for elderly as documented by a literature review (Varhellan et, al. 1997) indicate a lack of observational instruments to effectively evaluate the interactive nature of nurse-patients communication especially with reference to reliability and validity.
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