Running head:Using the Tools to Help Our Patients

Vulnerable Populations; Using the Tools to Help Our Patients Sandra St John-Kelleher University of Phoenix NUR/ 440 April 15, 2012 Maria Mendez MSN, RN, FNP-C

Using the Tools to Help Our Patients Vulnerable Populations: Using the Tools to Help Our Patients

A thorough assessment is the first step to nursing care; for without assessment there would be no knowledge of a patients needs, strengths, or weaknesses. A nurses ability to initiate meaningful interventions with measureable outcomes would be impeded without the first step of this process: assessment. To assess patients and their families, there are tools available which can narrow down the field, and allow the nurse to focus on areas in which change can have the most impact. Four tools which could assess needs for the Martin family, in The Neighborhood,(2011) are: Family Hardiness Index, The Beck Depression Inventory, Daily Hassles Scale and the StateTrait Anxiety . These three tools will be examined in detail, while applying to the needs of the Martin family. Each assessment will share additional information needed to assist this family while they try and support Anthony, who suffers from schizophrenia. Because of a mind-body connection, these assessment tools can also be a predictor of future illness, related to the high stress levels and/or depression a family member can feel. By identifying stress and depression, and providing interventions designed at reducing these levels, related illness can be averted. Enhancement of the Assessment-The Family Hardiness Assessment Tool The Family Hardiness assessment Tool is a self-reporting questionnaire, which describes how a family perceives their familys resilience with relation to stressors. Stressors can be from external or internal sources, in the Martin familys case, a combination of both- the severe mental illness of a family member is an external stressor, and their feelings about this situation are internal stressors. It would especially important to note how much stress the parents are feeling, as they are the primary caregivers in the family. Mr. and Mrs. Martin care for their other children and Mr. Martins elderly mother. Without strong self-esteem and organizational ability to connect their family, the Martins will lack the leadership to help hold family cohesiveness

Using the Tools to Help Our Patients solid. Lloyd,(2006), paraphrases Deveson, (2003) who acknowledges connectedness as one of the strongest factors to produce the resilience without which children fail to thrive, families become emotionally impoverished and communities fail to thrive (page 63,para 5).Anthonys sister is an adolescent, which is a hard stage to maneuver, without the added stress of a brother

who is so ill. She may need some assistance in understanding and coping with any social stigma that she feels is attached to her brothers, and ultimately her, situation. The familys hardiness score will provide insight into their ability to adapt to, and cope with stressors. In knowing which areas the family can use support, interventions can be tailored to areas which will improve the familys ability to cope with stressors. The Assessment Tool: Family Hardiness Index The Family Hardiness Index, (FHI),assessment tool was originally developed in 1986 by McCubbin, McCubbin and Thompson; it was developed to measure hardiness as a resource to resilience and as a way to cope with changes in life.(Bower, et al. 1998).To paraphrase Bower,(1998), it consists of 20 weighted questions, and measures four areas of a family. The first area is "Control", determining is a family feels in control of their life or if they feel that external forces beyond their control are limiting their choices. Bower, (1998), describes the second area of the FHI as family "Commitment", which is where the family assesses its ability to cooperate and depend on each other. Challenge is the third area of assessment; can the family act in a resourceful way and creatively solve problems together? (page 73,para 6).The fourth area assessed is Confidence, this is a familys ability to plan ahead, go through lifes hardships together and still be optimistic that life is good and there is meaning to be found in life. (Bower, 1998).This tool is only 20 questions, so it is not very time consuming, and the cost is minimal as

Using the Tools to Help Our Patients it is self-reporting, and only requires the nurse to evaluate results to place interventions. The results may require social work interventions and development of community resources. The Beck Depression Inventory It would be very important to assess depression for both Anthony and his family. Anthony has had a recent suicide attempt, so a baseline assessment would be helpful to use as a measurement for any improvement in mood. The Martin family also has been depressed; Mr Martin has been drinking to escape his pain, while Mrs. Martin suffers in silence. She has much guilt because she cannot help her son, Anthony. It would be beneficial to screen all family

members for depression. People can become depressed from stressful situations; this is not just a feeling of sadness, but feelings of hopelessness. With Anthony suffering from a mental illness, other family members may be feeling like they are walking on eggshells, because they lack the support and knowledge to know what to do. In finding out who in the Martin family is depressed, treatment could start, and they may be able to improve their ability to cope with stressors in their lives . The Assessment Tool: The Beck Depression Inventory This assessment tool was originally developed in 1961, and has been revised into the Beck Depression Inventory II, (BDI-II),in 1996, (Hagan, 2007, pages 108-109,para 5). This assessment tool is easy to use, it is self-administered, takes approximately ten minutes to take and is appropriate for use with adolescents, aged 13 and up to adulthood, (Hagan,2007, page 109, para 3). Hagan, (2007) writes about the BDI-II with regard to validity, support for the BDI appears to lie in its ease of use, widespread utilization, very good internal reliability, high content validity when compared with the DSM-IV criteria for depression, and a somewhat stable factor structure( page 110, para 4) The BDI-II is the most used tool to screen and assess for

Using the Tools to Help Our Patients depression; part of the reason is the ease of use, and the fact that it is so easy to

interpret.(Hagan,2007, page 109, para 5). Because no tool is perfect, according to Hagan,(2007), BDI conceptually locates the source of the problem of depression or disorder within the individual, and may blind us to everything the BDI is not measuring that occurs within the larger context of the individual.(page 113, para 8). A nurse should be able to look at a patient and the family in a holistic sense, so the assessment tool should not be the entire focus; it is simply a way to measure an aspect of the problems. Numeric measurements are typically used when setting interventions and goals related to results found from assessment tools; but they are not the only gauge for success. A patients report of internal peace and happiness may not show up as well on a test which addresses external stressors, and contextual questions which have a cultural, age or gender bias, etc. Enhancement of the Assessment: The Daily Hassles and the State-Trait Anxiety Scales The third choice for assessment tools was between two; both could add value to an assessment. The Daily Hassles Scale identifies small stressors as compared to life events; Daily hassles are those which according to Wright, et al.,(2010). that come when interacting with family or friends, occur with regular frequency, and have less readily identifiable beginnings and endings.(page 220, para1). To paraphrase Brannon and Feist,(2010) there is research, which suggests that daily irritants or hassles can be more detrimental to a persons psychological wellness because they are continual, unlike a major life event which is an episode of stress.(page 7, para 10) This would be an appropriate assessment for the Martins, simply because of work, caregiving to an elderly parent, raising an adolescent and having a loved family member with a serious mental illness, whose situation is tenuous at best.

Using the Tools to Help Our Patients The State-Trait Anxiety Scale is used to assess whether the anxiety is caused from external

stressors, or if it is from an inherent trait of an individual. Anxiety can be caused by physical and biochemical events ( University of Maryland Medical center, 2008). This assessment tool may be especially pertinent with this family, related to studies which suggest there is a genetic link between schizophrenia and anxiety disorders. Additionally, the study suggests that there is a familial aspect related to genetics for these disorders. ( Petersen and Grohol, 2010). According to Pletnikov, (2009), a John Hopkins researcher, who is quoted in the article, cited above, "In the study, mice who were predisposed to schizophrenia actually developed mood and anxiety disorders instead. This finding suggests that one gene mutation can lead to another kind of mental illness"( page 1, para3). The State-Trait Anxiety Scale would be beneficial in screening for any kind of anxiety disorders in the Martin Family. The Assessment Tools- The Daily Hassles and the State-Trait Anxiety Scales Both of these tools have ease of use in common. They are both self-administered with instructions to patients. Both assessment tools are relatively quick; the Daily Hassles Scale, (originated in 1981; was revised in 1996) is 56 questions and easy to understand. Paraphrasing Brannon and Feist, (2010), a validity measure for this tool can be its reliability in prediction of future illness,( page 110. Para 9). This scale does have a direct correlation between predicting illness and how high the score is; equaling a higher amount of daily hassles, (Brannon and Feist,2010) According to Tilton, (2008), the State-Trait Anxiety Scale is twenty questions and takes 10to-20 minutes to complete. It is relatively reliable with trait anxiety scores on test-retest, but the state anxiety varied; this is thought to be driven by specific external circumstances on the day of the retest, which can be variable from day-to-day, ( page 2, para 4). The cost is low, about $10.00

Using the Tools to Help Our Patients

per person and the test is written at the sixth grade level, in 48 languages, so its use is widespread and for different populations.

Conclusion A thorough assessment is the beginning for a plan of care formulation. It is important to use research based tools as well as interventions to achieve measureable goals. The assessment tools described all give the nurse the ability to take measurements prior to implementation of a plan of care and after the interventions have been in place for an interval of time. With tools available, that have proven validity and are research based to identify patients' needs, nurses are able to focus interventions to targeted problems and provide better care.

Using the Tools to Help Our Patients References Bower,A.,Chant,D., and Chatfield, S.,(1986). Hardiness in families with and without Downs syndrome children. Down Syndrome Research and Practice,Vol.5, No.2, retrieved on March 2,2011 from: http://www.down-syndrome.org/reports/79/reports-79.pdf

Brannon,L.,Feist,J,(2010).Part 2; Stress, pain and coping. Health Psychology; An Introduction to Behavior and Health. Wadsworth Publishing, California. Retrieved on March 4, 2011 from: http://books.google.com/books?id=NfCDR_Yl7f0C&pg=PA108&lpg =PA108&dq=daily+hassles+scale+kanner&source=bl&ots=K_rPo7hbKF&sig Gros, D.F., Antony, M. M., Simms, L.,J., and McCabe, R.E., ( 2007).Psychometric Properties of the StateTrait Inventory for Cognitive Somatic Anxiety (STICSA): Comparison to the StateTrait Anxiety and Inventory,(STAI). Psychological Assessment by the American Psychological Association.2007, Vol. 19, No. 4, Retrieved on March 04,2011 from: http://ehis.ebscohost.com/ehost/pdfviewer/pdfviewer?hid=121&sid=b2caa0727f39-443b-b383-3875bbc03fb1%40sessionmgr104&vid=4 Hagan,B.,(2007). Measuring melancholy: A critique of the Beck Depression Inventory and its use in mental health nursing. International Journal of Mental Health Nursing (2007) 16, 108115.Retrieved on March 2011 from: http://ehis.ebscohost.com/ehost/pdfviewer/pdfviewer?hid=115&sid=f16fda52-a11442cd-a5ef-95ea02d65d97%40sessionmgr110&vid=4 Lloyd, M.,(2006). Resilience promotion - its role in clinical medicine. Australian Family Physician Feb 1, 2006, Vol. 35, Issue 1/2, Retrieved on March 3,2011 from: http://ehis.ebscohost.com/ehost/detail?hid=121&sid=b49be128-0d93-41ae-a7bd

Using the Tools to Help Our Patients References

Petersen,T. and Grohol, J.,M., (2010). Gene mutation in schizophrenia linked to mood, anxiety disorders. Retrieved on March 5, 2011 from: http://psychcentral.com/news/2010/12/07/gene-mutation-in-schizophrenia-linked-tomood-anxiety-disorders/21492.html Tilton, S.R., (2008).Review of the State-Trait Anxiety Indicator, ( STAI). Ohio State University, NewsNotes, 2008. Volume 48, Issue 2. Retrieved on March 7,2011 from: http://www.theaaceonline.com/stai.pdf University of Maryland Medical Center,(2008). Mental Health -Anxiety Disorders. Retrieved on March 7, 2011 from: http://www.umm.edu/mentalhealth/anxiety.htm Wright,M.,Creeda,M.,and. Zimmer-Gembecka,M.J.,(2010).The development and initial validation of a brief daily hassles scale suitable for use with adolescents. European Journal of Psychological Assessment Volume 26, Issue 3, 2010, Retrieved on March 05, 2011from: http://www.sciencedirect.com/science?_ob=HomePageURL&_ method=userHomePage &_btn=Y&_zone=TopNavBar&_origin=article acct=C000050221