Learn — Development across the life span & the patient

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Development across the life span — Erikson and Piaget

Human development is the orderly, lifelong sequence of physical, cognitive, emotional and social change from conception to old age, driven by maturation and shaped by experience, and studied in stages — prenatal, infancy, early and late childhood, adolescence, early, middle and late adulthood — each with its own tasks. The stage theories asked in the paper are Erikson's eight psychosocial crises and Piaget's four stages of cognitive development, with Kohlberg's moral stages beside them, and the nurse uses them to explain, teach and comfort at the level the patient's age can use.

Principles of development: it is continuous but not uniform, proceeds from the head downwards (cephalocaudal) and from the trunk outwards (proximodistal), from general to specific and from simple to complex, follows a predictable sequence at an individual rate, has critical periods when a function must develop or is lost, and results from heredity and environment acting together.
Erikson's psychosocial stages, each a crisis with a virtue: trust versus mistrust (0 to 1 year — hope, from consistent care), autonomy versus shame and doubt (1 to 3 — will, from toilet training and choices), initiative versus guilt (3 to 6 — purpose, from play), industry versus inferiority (6 to 12 — competence, from school), identity versus role confusion (12 to 18 — fidelity), intimacy versus isolation (young adulthood — love), generativity versus stagnation (middle adulthood — care) and integrity versus despair (old age — wisdom, from life review).
Piaget's cognitive stages: sensorimotor (0 to 2 years — the world through senses and action, object permanence by 8 to 12 months), preoperational (2 to 7 — symbols and language, egocentrism, animism, magical thinking, no conservation), concrete operational (7 to 11 — logical thought about concrete things, conservation, reversibility, classification) and formal operational (11 years onwards — abstract and hypothetical reasoning); a preschool child who believes the injection is a punishment is thinking exactly as Piaget predicts.
Kohlberg's moral development: pre-conventional (obedience to avoid punishment, then self-interest), conventional (good-boy or good-girl approval, then law and order) and post-conventional (social contract, then universal ethical principles); Havighurst's developmental tasks list what society expects at each age, and failure at one task hampers the next.
Adolescence (WHO 10 to 19 years) brings puberty, the growth spurt, identity formation, peer influence, abstract thought, risk-taking and the need for privacy and respect; middle age brings the empty nest, menopause and generativity; old age brings retirement, bereavement, physical decline and the life review of integrity versus despair — each a predictable stress for which the nurse can prepare the person.
Development can be delayed or derailed by prenatal insults (infection, malnutrition, alcohol, drugs), birth injury, chronic illness, hospitalisation, deprivation and abuse; the child rows carry the milestones and their red flags, and the psychology angle is that a hospitalised child regresses a stage and recovers it when the parent, play and routine are restored.
Applications: explain to a toddler with a doll and to an adolescent with facts and privacy, let the preschooler handle the equipment through play, give the school-age child tasks and praise for industry, protect the adolescent's identity and body image, involve the middle-aged patient's need to provide and the elderly patient's need to review and be respected — the level of the explanation is set by the stage, not by the diagnosis.

Mental hygiene, guidance and counselling

Mental hygiene is the science and practice of preserving and promoting mental health and preventing mental disorder, at every age and in every setting, in the way physical hygiene preserves the body; guidance is the help given to a person to understand himself and choose wisely in education, work and personal life, and counselling is a purposeful, confidential relationship in which a trained helper enables a person to explore a problem and find his own solution. All three are nursing functions, asked in the paper for their principles, and practised in every long conversation at a bedside.

WHO defines mental health as a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to the community; the mentally healthy person accepts himself and others, has realistic goals, satisfying relationships, the capacity to work, play and love, and tolerates frustration.
The mental hygiene movement began with Clifford Beers, whose book A Mind That Found Itself (1908) described his own asylum experience and led to the National Committee for Mental Hygiene in 1909; its principles are self-knowledge, self-acceptance, realistic goals, a balance of work, rest and recreation, emotional expression, sound relationships and the early treatment of trouble.
Mental hygiene runs through the life cycle as prevention: prenatal care and a wanted pregnancy; a secure, consistent infancy; a home without violence and a school without humiliation; guidance in adolescence about identity, sex and career; marriage preparation and parenting education; retirement planning; and care of the bereaved and the old — and at three levels, primary (promotion and prevention), secondary (early detection and treatment) and tertiary (rehabilitation and prevention of disability).
Guidance is educational (choice of subjects and study habits), vocational (fitting aptitude and interest to work) and personal-social (adjustment, relationships, health); it uses interviews, tests, records and information, and it advises, whereas counselling does not.
Counselling is client-centred (Rogers): the counsellor offers empathy, genuineness (congruence) and unconditional positive regard, and the client, treated as capable, moves towards his own solution; directive counselling (Williamson) has the counsellor lead, non-directive counselling has the client lead, and eclectic counselling uses both as the problem demands.
The process: build rapport and a contract; let the client tell the problem (active listening, open questions, reflection of feeling, paraphrase, silence, summarising); explore and clarify; set a goal; consider alternatives and choose; act; and end with follow-up — the counsellor keeps confidentiality except where there is danger to life, does not judge, advise, moralise or rescue, and refers when the problem is beyond her competence.
Nurses counsel every day — the newly diagnosed diabetic, the antenatal mother, the relative of a dying patient, the adolescent with an unwanted pregnancy, the HIV test before and after (pre-test and post-test counselling) — and the skills are the same: privacy, time, listening more than talking, and leaving the decision with the person.

The sick role and the hospitalised patient — reactions to illness

The sick role (Talcott Parsons) is the set of expectations society attaches to a person who is ill — he is exempted from normal duties and from blame for his illness, and in return is expected to want to get well and to seek and cooperate with competent help — and illness behaviour is the way a person perceives, evaluates and acts on symptoms, which decides whether and when he arrives for care. Hospitalisation then adds its own psychology: the loss of privacy, control, role and identity that produces the anxiety, regression, dependence, anger and grief the nurse meets on every admission.

Parsons' sick role has two rights — exemption from normal social roles in proportion to the illness, and freedom from responsibility for being ill — and two duties: to regard being sick as undesirable and try to get well, and to seek technically competent help and cooperate with it; a patient who enjoys the exemptions without the duties is said to be in secondary gain, and a society that denies the exemptions (the labourer who cannot afford to be ill) produces late presentation.
Suchman's stages of illness experience: symptom experience (something is wrong), assumption of the sick role (seeking validation from family), medical care contact (the diagnosis), the dependent-patient role (treatment and its restrictions) and recovery or rehabilitation (giving up the role, which some cannot); illness behaviour (Mechanic) is shaped by the symptom's visibility and severity, its interference with life, the person's knowledge, culture and past experience, and the cost and availability of care.
Reactions to illness are predictable: anxiety and fear (of pain, death, disfigurement, the unknown), denial, anger and hostility (often displaced onto staff), regression and dependence (a normal retreat that becomes a problem when it persists), guilt and shame, depression and withdrawal, and grief for the lost function or future; Kübler-Ross's stages — denial, anger, bargaining, depression, acceptance — describe the response to a fatal diagnosis and to any major loss, in no fixed order.
Hospitalisation itself is a stressor: a strange place and routine, loss of privacy and control (over food, sleep, clothes, visitors, even the toilet), separation from family and work, exposure of the body, waiting without information, the sight and sound of others' suffering, and the loss of identity into a bed number; the effect is greatest in children, the elderly, the poor and those admitted as emergencies.
The hospitalised child passes through protest (crying, clinging), despair (quiet, withdrawn, mourning) and detachment (apparently settled, but indifferent to the parent — the most damaging stage) when separated from the mother (Bowlby, Robertson), which is the case for rooming-in, play therapy and preparation for admission; the elderly patient is at risk of delirium, falls and a loss of function from bed rest and the strange environment.
Factors that shape the reaction: age and developmental stage, personality, previous experience of illness and hospitals, the meaning of the illness (a heart attack to a labourer, a mastectomy to a young woman), its severity and prognosis, the culture's explanation of disease, the family's response and the economic loss; the same appendicectomy is a minor event and a catastrophe to two different patients.
The nurse's response is to restore what hospitalisation took away: orientation and information in plain words, choices wherever possible (the time of the bath, the food, the position), privacy and dignity in every procedure, a name instead of a number, continuity of the same staff, family presence and rooming-in for children, honest answers, an explanation before every intervention, and attention to the fear behind the anger.

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