Inconsistency In Nursing

Introduction

The purpose of this paper is to analyze a concept on order to identify an inconsistency and area for practical research. A clinical experience will be used to illustrate a core curriculum concept. Consistency with our text will be explored. Next inconsistencies will be identified to provide the basis for a relevant research question in PICO format. The process of conducting research using the hierarchy of evidence will be discussed. A summary of research findings will be provided and used to support modifications in future nursing practice.

Primary Concept

The concept linked to this clinical experience is Mood and Affect. This concept explores how individuals experience and express emotions. Emotions are responses to stimuli

that can cause an individual to experience such emotions as joy and fear. This is what stimulates an individual to either stay or flee the situation. Pearson writes, “Mood is defined as a sustained emotional state and how one feels subjectively…Affect is the immediate and observable emotional expression of mood that people communicate verbally and nonverbally.” (Pearson 2011) This concept also covers how mood patterns and disorders develop and impact one’s overall wellbeing.
Background Information
The clinical experience took place on May 5, 2015 in an acute care med-surge unit. The patient (C.R.) is a 76-year-old white male. He lives in a nursing home and does not have a roommate. He has a history of stroke, diabetes, and asthma along with depression, which is described as non-suicidal. He is taking paroxetine for depression. He moved to the nursing home last year after his wife passed away, as she was his caregiver and he was very dependent on her. He was brought to the emergency department presenting with severe cough, tachypnea and shortness of breath. He was admitted to a med-surge unit for treatment of pneumonia.
Consistency with Baseline Knowledge of the Concept
The concept of Mood and Affect covers major symptoms of depression.

For example, it is stated that persons in a depressive state have limited interactions with others and tend to withdraw and lose interest in activities that were once enjoyable. This is exhibited in C.R., while talking to him, he reports that he has not participated in any activities and no longer plays golf or goes fishing like he did before his wife died and he moved to the nursing home. He spends his time in his room and does not participate in the facility’s activities and rarely sees his three sons despite them living a short distance away.

Also discussed in this concept are the theories of depression. Learning Theory states that patients experience depression as a result of a loss of control over one’s life. This could be a factor for C.R. in that he did not have control over his wife’s passing and his subsequent move to the nursing home. Another theory is Cognitive Theory, which states that those who are depressed focus on the negative aspects of life instead of the positive. C.R. has demonstrated that he sees the negative in situations instead of the positive. C.R. said, “I have nothing left to live for anymore so I don’t know why you bother” while performing nursing care. The text states regarding depression, “All present experiences are viewed as negative, and there is no hope for the future.” (Pearson 2011) The text also states that symptoms

of depression include sadness, hopelessness, and powerlessness. This is true with C.R., he feels that he is powerless and is hopeless about his future. The nursing home staff reported about C.R., “he rarely smiles”.
Interrelated concepts of Stress and Coping and Grief and Loss both relate to this clinical experience. C.R. is dealing with a great amount of stress with living in the nursing home and having to live without his wife and his home. Environmental stressors such as a death to a loved one are among the types of stressors that can change or disrupt homeostasis. According to the text, he is likely experiencing complicated grief. This exists when the strategies to cope with the loss are maladaptive. Complicated grief is indicated by C.R.’s persistent guilt and lowered self-esteem. (Pearson 2011) He has not adapted well to his wife being gone and has let the stress of life impact his wellbeing.
Inconsistency with Baseline Knowledge of the Concept
The most salient point of this topic that is not covered in the text is that of companionship. Regular social interaction, like a roommate, can provide companionship for someone who is used to being alone. The text discusses that a death of a loved one can cause a depressed state and result in a withdrawal of activities and socialization, however, it does not discuss how having a companion can help with depression. It discusses CBT (Cognitive Behavioral Therapy) as a treatment option for depression but it doesn’t cover the effects of socialization on mood. The communication aspect of maintaining social interaction is also not covered. Patients who are isolated suffer from a lack of social interaction. It is concerning that C.R. spends so much time alone, especially after grieving the death of his wife and losing interest in activities he once enjoyed. He wasn’t always antisocial; he used to enjoy golfing with his work friends and taking his sons fishing. But with living in the nursing home and being isolated to his room, he is not getting sufficient social interaction. This made me question his isolation at the nursing home. I wondered why he didn’t have a roommate and this prompted me to research the effects of companionship on depression and overall mood and wellbeing. I wanted to know if C.R. could possibly benefit from having a roommate. I think that providing companionship to a patient during my nursing care and advocating for a patient to have a roommate or other companion can have a great impact on my patient’s mood and outlook and with research I can teach my patients about the importance of social interaction.
Evidence-Based Approach
In patients with depression, does having a roommate compared to not having a roommate positively influence a patient’s mood? Research indicates that having consistent companionship improves outcomes. One study found that two elderly female patients living solitarily in an assisted-living facility, both diagnosed with depression and dementia, exhibited massive improvements when paired together as roommates compared to living alone. “They both appeared less depressed and seemed more in tune with reality” (Zeltzer 2000), and their general states of alertness, responsiveness, and involvement improved greatly. This study shows the benefit that companionship can have on mental health and that it can even reverse some mental degradation. This could be helpful for C.R. to have a roommate at the nursing home. A study interviewed 65 nursing home residents who reported that causes of their depression “were loss of independence, freedom and continuity with their past life; feelings of social isolation and loneliness”. (Choi, Ransom, & Wyllie 2008) They also stated that they preferred programs that focused on improving their social interactions. Another study found “More positive bonds (between roommates) were associated with a greater number of positive emotions and greater satisfaction” when it came to long-term care. (Bitzan 2009) It also found that there is a positive impact of nursing interventions on relationships and bonds between roommates. This shows that nurses can make a difference when it comes to encouraging companionship and social interaction for patients.

Integration of Findings into Nursing Expertise
After researching the impact that having a roommate can have on a patient’s mood, I have identified nursing interventions that can be implemented.

In the case of C.R., I would make the recommendation to the nursing home that he have a roommate. I think it would prompt him to be more social and get back to the person he used to be before his wife died. He was not always antisocial with a negative outlook; it has been a development of the depression and grief. The companionship of a roommate could improve his depression or at least bring him out of his state of withdrawal. Another way of introducing companionship without having a roommate is to have a volunteer come to the hospital or nursing home to occupy C.R. by either playing a game or just

talking.
In my future nursing practice of patients with depression, I can use this new information to facilitate social interaction between patients and explain that it is beneficial to mood and overall wellbeing. I will encourage participation in activities and social gatherings and encourage outings with friends and family and the formation of friendships and the benefits of having a roommate in long-term care. When assessing patients, I would use the Beck Depression Inventory to identify a patient’s level of depression. This could determine the patient’s willingness to have a roommate or companion. With assessing patients with a mood disorder, it is important to ask many questions. This can help determine what type of companion may be best for the patient. A civil war veteran may enjoy chatting with someone who went through the same trials experiences or perhaps someone who enjoys golfing and fishing like C.R.. When diagnosing patients I would look for factors that cause the following: Social Isolation, Impaired Social Interaction, Ineffective Coping, and Impaired Communication. However, it is important to monitor patients to prevent them from getting to any of these diagnoses, but now that I have read these studies I know how to help patients. When planning, I would set such goals as ‘patient will have improved social isolation, patient will have improved social interaction, patient will develop three effective coping skills, and patient will have improved communication. Implementation to achieve these could be signing a resident up to play bingo, or take a trip to the senior center. I now know that encouraging social interaction improves mental and emotional status. Nurses can assist patients in referrals to community programs and coordinating for transportation to varies events. It’s also important to be sensitive to your patient’s specific needs and try to match up companions based on common interests and backgrounds. Evaluation of these patients would include that of whether the mood has improved as a result of adding companionship, working on social isolation, working on communication skills, and improved mood. I would re-assess the patient and determine if the patient specific goals are met.