Population (Community) Health, Nurs 256
Population (Community) Health, Nurs 256 256
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Homelessness ● Introduction ● Poverty is a primary cause of vulnerability across racial groups ● The homeless present complex nursing needs ○ Nurses must recognize their own beliefs about this group and understand the issues surrounding these clients’ illness and/or personal situations ○ To interact effectively with the homeless the nurse must identify health care needs, barriers to care, and essential health care services for each client and, in some instances, for the client’s family as well ● Security and Safety ○ To not have the simple basic needs met, similar to shelter, food, and water, this provides little security or safety of a homeless person /people. ○ It is difficult to create long term plans while being homeless as it is an unpredictable way to live. ○ The homeless must constantly be aware of others who may steal what little possessions they have or hurt them physically. ○ The work of charities and government organizations is essential to provide some hope for the homeless to improve their position. ● Selfesteem ○ Many people experiencing chronic homelessness often have very few social connections. → viewed at faceless, nameless, invisible, and inaudible entities ■ This may be due to the lost of communication with family, friends and community contacts and the may become socially isolated. → important for the nurse to respect the individuality of all clients ○ The selfesteem of homeless people are usually very low, and may be aggressive towards support services because of their previous experiences. ■ If the person became homeless due to an abusive relationship, they would have to have support to overcome the feelings that could’ve been factors to lead to homelessness ;such as guilt, anger, fear and depression. After overcoming these emotions ,they can begin to rebuild their life. ● Sense of Identity ○ With no permanent residence, little or no wealth, and limited social connections, the homeless have little sense of identity. ○ It is easy for them to become nomads, and become unseen in today's society. With the help from services, organizations, compassion o f the society and the government their status of being homeless can be improved greatly. ○ Assisting this group to learn the necessary skills to gain employment, seek medical attention if needed, develop positive relationships and a secure accommodations is real important to the development of a positive sense of identity for the homeless. ● Concept of Homelessness ○ Difficult to know exactly how many people are homeless because it is hard to locate them since they typically sleep in boxcars, on roofs of buildings, or under freeways, plus many become nomadic; two common ways to determine the number of homeless people: ■ Pointintimecounts: counts the number of people who are homeless on a given day or during a given week ■ Period prevalence counts: counts the number of people who are homeless over a given period of time ○ Concept includes 2 broad categories: ■ Crisis poverty the lives of those involved are marked by hardship and struggle→ homelessness isepisodic ■ Persistent poverty those affected are typically chronically affected, and many have mental or physical disabilities. ● Causes of homelessness ○ More people living in poverty ○ Fewer affordable housing units; gentrification of neighborhoods and consequent increased costs for housing ○ Loss of singleroom occupancy buildings where people can rent a room on a longterm basis ○ Emergency demands on income ○ Alcohol and drug addiction ○ Limited number of transitional treatment facilities for deinstitutionalized mentally ill individuals; important since a sizable number of homeless people suffer from a significant mental illness ● Effects of homelessness on health ○ Can’t pay for medication if you don’t have money. If you do manage to get medication, it is hard to keep up with the schedule, get enough to eat and drink with the medication, and hard to get sleep and exercise. ○ Hypothermia and heatrelated illnesses ○ Infestations and poor skin integrity ○ Peripheral vascular disease and hypertension→ sleeping in weird positions on the street ○ Diabetes and nutritional deficits ○ Respiratory infection and chronic obstructive pulmonary diseases ○ Tuberculosis (TB) → crowded living conditions in shelters ○ HIV/AIDS→ many share or reuse needles ○ Trauma→ GSWs, stabbings, head trauma, suicide attempts, fractures, and minor trauma ○ Mental illness ○ Use and abuse of tobacco, alcohol, and illicit drugs→ exacerbates hypertension ● Homelessness and atrisk populations ○ Pregnant women→ high risk for complex health problems, less likely to initiate and sustain breastfeeding, fewer pre/post natal care visits, poorer birth outcomes due to nutrition, drug use, STD rate, etc. ○ Children→ experience more symptoms of acute illness, greater risk for higher levels of anxiety, worse nutrition, higher rates of school failure, higher rates of depression due to instability, delayed communication ○ Adolescents→ risk taking behaviors, higher risk for contracting serious communicable diseases, more likely to use alcohol and illicit drugs. ○ Older adults→ life expectancy is significantly lower, often suffer from untreated chronic conditions (TB, hypertension, CVD…) ● Levels of Prevention ○ Primary prevention ■ Affordable housing, housing subsidies, effective jobtraining programs, employer incentives, preventive health care services, multisystem case management, birth control services, safesex education, needleexchange programs, parent education, and counseling programs ○ Secondary prevention ■ Reducing the prevalence of pathological nature of a condition (supportive and emergency housing, soup kitchens, screening for depression) ○ Tertiary prevention ■ Restore and enhance functioning (support of affordable housing, promotion of psychosocial rehabilitation programs) ● Role of the Nurse ○ Create a trusting environment ○ Show respect, compassion, and concern ○ Do not make assumptions ○ Coordinate a network of services and providers ○ Advocate for accessible health care services ○ Focus on prevention ○ Know when to walk beside the client and when to encourage the client to walk ahead ○ Develop a network of support for yourself Teen Pregnancy ● Adolescent pregnancy is a key contributing factor to familial cycles of poverty, and the teen moms are more likely to remain poor themselves (which is why it is such a big concern) . ○ This may be due to lack of schooling which results in limited job opportunities which makes it harder to pay for family expenses. ● pregnant teens present complex nursing needs ● Nurses must recognize their own beliefs about this group and understand the issues surrounding the problem ● To interact effectively with pregnant teens the nurse must identify health care needs, barriers to care, and essential health care services for each client and, in some instances, for the client’s family as well ● Cultural Attitudes and Media Communication as Factors ○ Cultural attitudes are the beliefs and perspectives that a society values; perspectives about individual responsibility for health and wellbeing are influenced by prevailing cultural attitudes ○ The media communicate thoughts and attitudes through newspapers, films, TV, art, and literature ● To understand teen pregnancy, nurses must consider their own personal beliefs and attitudes, clients’ perceptions of their condition, and the social, political, cultural, and environmental factors that influence the client’s situation ● Trends in Adolescent Sexual Behavior and Pregnancy ○ The provision of reproductive health care services to teens requires sensitivity to the special needs of this agegroup, including awareness of state laws about confidentiality and services for birth control, pregnancy, abortion, and adoption ○ Factors such as a history of sexual victimization, family dysfunction, substance use, and failure to use birth control can influence whether a young girl becomes pregnant ○ The pregnant teen will need support during and after pregnancy from her family and friends and from the father of the baby ● Background factors ○ Teens do not feel the same way about life as adults do; they almost seem to feel invincible and may not see the risk to their behaviors ● Sexual activity, use of birth control, and peer and partner pressure ○ 32% of 9th grade students Have been sexually active, and it increases to over 60% by senior year. → out of the people in the survey, only 60% said they used a condom last time they had sex ○ The earlier someone’s 1st time is, the less likely they are to use birth control. ■ Some may think they are too young to by things like condoms ○ Teens are more likely to be sexually active if their friends are ○ Allowing for a pregnancy signifies love for one another ● Early identification of the pregnant teen ○ Late period, breast tenderness ○ Look especially for questions about fertile periods, or that you need not miss a period to be pregnant ○ Dont seek care because they hope the pregnancy will just go away, or avoid being reprimanded ● Special issues in caring for the pregnant teen ○ Cost, denial of pregnancy ○ More likely to have a low birthweight/premature baby ○ Teens are more likely to experience violence during their pregnancies may be due to their age and greater vulnerability ○ Nutritional needs are especially important ○ Maybe teens have cared for babies before, but they are not prepared for 24hr infant care ○ Have a harder time staying in school and getting a good education due to the time demands of a baby ● Levels of Prevention ○ Primary prevention ■ Affordable housing, housing subsidies, effective jobtraining programs, employer incentives, preventive health care services, multisystem case management, birth control services, safesex education, needleexchange programs, parent education, and counseling programs ○ Secondary prevention ■ Reducing the prevalence of pathological nature of a condition (supportive and emergency housing, soup kitchens, screening for depression) ○ Tertiary prevention ■ Restore and enhance functioning (support of affordable housing, promotion of psychosocial rehabilitation programs) ● Role of the Nurse ○ Create a trusting environment ○ Show respect, compassion, and concern ○ Do not make assumptions ○ Coordinate a network of services and providers ○ Advocate for accessible health care services ○ Focus on prevention ○ Know when to walk beside the client and when to encourage the client to walk ahead ○ Develop a network of support for yourself Mental Illness in the Community ● Types of Mental Illness ● Mental disorders are conditions characterized by alterations in thinking, mood, or behavior associated with distress or impaired functioning ● Definition Mental Illness refers collectively to all diagnosable mental disorders→ severe ○ Always Included in Definition: Schizophrenia, Major Depression, Bipolar Disorder ○ Sometimes Included: Severe Anxiety Disorders, Cognitive Disorders, Some Personality Disorders ● Deinstitutionalization moving many people from state psychiatric hospitals to communities ● At risk populations: ○ children and adolescents→ children are at risk for disruption of normal development by biological, environmental, and psychosocial factors that impair their mental health, interfere with education, social interactions, and keep them from realizing their full potential. ○ Adults→ stress contributes to adults’ mental health status (sources: multiple role responsibilities, job insecurity, lack of or diminishing resources, etc.) ○ Older adults ● Symptoms of Mental Illness ○ Feeling sad or down ○ Confused thinking or reduced ability to concentrate ○ Excessive fears or worries, or extreme feelings of guilt ○ Extreme mood changes of highs and lows ○ Withdrawal from friends and activities ○ Significant tiredness, low energy or problems sleeping ○ Detachment from reality (delusions), paranoia or hallucinations ○ Inability to cope with daily problems or stress ○ Trouble understanding and relating to situations and to people ○ Alcohol or drug abuse ○ Major changes in eating habits ○ Sex drive changes ○ Excessive anger, hostility or violence ○ Suicidal thinking ○ Must experience several at one time, for a long period of time/ if it affects daily living ● Causes of Mental Illness ○ Biological CausesMental illness is more common in people whose blood relatives also have a mental illness. Certain genes may increase your risk of developing a mental illness, and your life situation may trigger it. Neurotransmitters are naturally occurring brain chemicals that carry signals to other parts of your brain and body. When the neural networks involving these chemicals are impaired, the function of nerve receptors and nerve systems change, leading to depression ○ Environmental EffectsExposure to environmental stressors, inflammatory conditions, toxins, alcohol or drugs while in the womb can sometimes be linked to mental illness. ○ Interaction of Biology and Environment ● Biology of Serious Mental Illnesses ○ Brain Disorder ■ Causes of Brain Disorder: Genetics, Viral Theories, Brain Injury ○ The Role of Environment ■ Some Disorders May Be Learned ○ Some Result from Trauma ○ Anatomy ○ Function (metabolism) ○ Chemistry ● Environment Affects the Course of the Disorders ○ Stigma ● Treatment of Mental Illness ● Intervention Goals ○ Remission of Symptoms ○ Positive ○ Negative ○ Maintenance of Stability ○ Enhanced Quality of Life ○ Role Recovery ● Medications ○ Antipsychotics classpsychiatric medicat primarily used to manapsychosi (including delusion,hallucinatio,paranoia odisordered thoug), principally schizophren and bipolar disor, and are increasingly being used in the management of nonpsychotic disorders (ATC code N05A). ○ Antidepressants ○ Mood Stabilizers ○ AnxiolyticsAn anxiolytic is a medication or other intervention that inhibits anxiety. ● Side Effects Medications ○ Drowsiness, Dry Mouth, Blurred Vision, Dizziness, Tremors, Sexual Dysfunction, High Heart Rate, Weight Gain, Slurred Speech, Sensitivity to Sun ■ Some Are Addictive ● Psychosocial Interventions ○ Assessment ○ Education about Illness Self Management ○ Counseling/Therapy ■ Individual ■ Group ■ Crisis Intervention ○ Rehabilitation ○ Social Skills ■ Vocational ○ Family Services ○ Education ○ Family Therapy ● Case Management ● Illness Self Management/ Patient Education ● Giving Information about the Illness ○ Symptoms ○ Treatment ○ Course ● Helping Client Learn to Manage Own Illness ○ Management Skills for Recovery ○ Medication Adherence ○ Healthful Lifestyle ○ Therapeutic Environment ● Illness Monitoring ○ Relapse Prevention ○ Medication Adherence ■ Adherence = “Sticking to” the Medication Plan ■ Barriers to Adherence ● The Person’s Condition ● Chronic Illness ● Complex Medication Plan ● What Is Illness Monitoring? ○ Watching for Signs of Relapse ○ Mapping Illness Cycles ● Importance of Illness Monitoring ○ Indicate Possible Need for Medication Adjustment ○ Helps Measure Effects of Treatment ● Relapse Checklist* ○ Medication Change ○ Physical Illness ○ A Stressful Event or Overstimulation ○ Alcohol or Drugs ○ Sugar, Caffeine, or Change of Diet ○ Too Many Fluids ● Taking Action ○ Ensure Compliance with Meds Seek Medical Treatment & Rest ○ Daily Relaxation Skills ○ Decrease Stimulation ○ Avoid Drugs & Alcohol ○ Cut Caffeine, Sugar & Fluids ○ Consult MD for Possible Medication Adjustment ● Psychotherapy and Counseling ○ Reality Based ○ Reallife Problem Solving ○ Individual Coping with Illness ○ Group Support and Peer Learning ○ Flexible Participation Standards ○ Crisis Intervention ○ Skills Training ○ Social Skills ○ Academic Skills ○ Vocational Skills ● Psychiatric Rehabilitation ○ Readiness Assessment ○ Readiness Development ● Choosing Rehabilitation Goals ○ Living ○ Learning ○ Working ○ Socializing ● Crisis Stabilization Facility ○ Group Treatment Setting ○ Family Living ○ Supported Living Apartments ○ Independent Living ○ Continuum of Learning Environments ● Hospital Treatment ○ Partial Hospitalization Services ○ Outpatient Therapies ○ Clubhouse ○ Adult Education ○ Supported Education ● Continuum of Working Opportunities ○ Prevocational Training ○ Vocational Training ○ Volunteer Jobs ○ Jobs in Mental Illness Facilities ○ Supported Employment ○ Transitional Employment ○ Parttime and Fulltime Regular Employment ○ Consumerrun Business ○ Family Services ○ Support ● Education ○ Consultation ○ Therapy ○ Case Management ○ Service Coordination ● Linkage ● Connection to One Person ● Help with Basic Needs ● Broad View of Service Plan ● Interacting with a Person with Mental Illness Symptoms: Communication Skills ○ Give clear directives ○ Ask openended questions ○ Check out the whys of behavior ○ Express empathy; reflect feelings ○ Use nochoice choices ○ Criticize behavior not person ○ Use “I” statements ○ Express caring and support ○ Use parroting ○ Be concrete and brief ○ Watch for signs of fading ○ Be lowkey and low “EE” ○ Avoid power struggles ● Interacting with a Person with Mental Illness Symptoms: ○ Safety ○ Remain calm ○ Speak slowly and clearly ○ Avoid invading personal space ○ Do not move quickly, especially toward the person ○ Do not touch the person ○ Do not challenge the person ● Special Issues for Homeless People with Mental Illness ○ Lack of Trust ○ Hierarchy of Needs ○ Disability Caused by Mental Illness ● Effect of active symptoms ○ No energy to accomplish daily tasks ○ Inability to plan ○ Consistent Need for Support ● Interventions for Mental Illness ○ No One Intervention Is Sufficient, We Have to Approach from All Directions Drug and Alcohol Abusers ● Substance abuse is the numberone national health problem, causing more deaths, illnesses, and disabilities than any other health condition ● The substance abuser not only is at risk for personal health problems but also may be a threat to the health and safety of family members, coworkers, and other members of the community ● Definitions ○ Alcohol, tobacco, and other drugs (ATOD): serves as a reminder leading drug problems involve alcohol and tobacco ○ Substance abuse: use of any substance that threatens a person’s health or impairs his or her social or economic functioning ○ Drug dependence: physiological change in central nervous system as a result of chronic drug use ○ Drug addiction: pattern of abuse characterized by an overwhelming preoccupation with obtaining and using a drug; high tendency for relapse if drug is removed ● Scope of the Problem ○ ATOD abuse and addiction can cause multiple health problems for individuals ● Factors that contribute to substance abuse problems: lack of knowledge about use of drugs; acceptance of certain drugs (alcohol, nicotine, caffeine) as nondrugs; lack of quality control of illegal drugs; drug laws that label certain drug users as criminals ● Every culture has beliefs and attitudes toward ATOD that are influenced by the way society categorizes drugs as either “good” or “bad” ● Harm Reduction Model ○ New approach to ATOD problems; recognizes that: ■ Addiction is ealt problem ■ Any psychoactive drug can be abused ■ Accurate information can help people make responsible decisions about drug use ■ People who have ATOD problems can be helped ■ Model accepts that psychoactive drug use (including alcohol and tobacco) is endemic and focuses on pragmatic interventions, especially education, to reduce adverse consequences of drug use and get treatment for addicts ● Psychoactive Drugs ● Psychoactive drugs: drugs that affect mood by altering emotions, perception, and thought ○ Used for enjoyment in social and recreational settings and for personal use to selfmedicate physical or emotional discomfort ○ Divided into categories according to their effect on the CNS and the general feelings or experiences the drugs may induce ■ Depressants Drugs that reduce the activity of the CNS (high doses induce sleep, low doses may produce a feeling of stimulation ● Lower the body’s overall energy level, reduce sensitivity to outside stimulation; ● In general, depressants decrease HR, RespR, muscular coordination, and energy while dulling the senses ● Higher doses can lead to coma and, if vital functions shut down, death ● Major categories include alcohol, barbiturates, benzodiazepines, and opioids (this chapter discusses alcohol and heroin) ● Other depressants ○ Alcohol Oldest and most widely used psychoactive drug in the world (About twothirds of American adults drink alcohol) ■ Binge drinking highest among those who are 2125 ■ Chronic alcohol abuse is multiple metabolic and physiological effects on all organ systems→ abuse is actually part genetic ○ Heroin (illicit drug) Most common opioid taken for recreational use ■ Tolerance and physical dependence develops quickly ■ Serious complications result from unsanitary administration of the drug and complications due to overdose or the intoxication it can cause ● Psychoactive Drugs: Stimulants ○ Drugs that increase the activity of the CNS, causing wakefulness ○ Cause the nerve fibers to release noradrenaline and other stimulating neurotransmitters ○ Do not give the persmore energy; they make the body expend its own energy sooner and in greater quantities than it normally would ○ Nicotinethe addictive element of tobacco→ as addictive as heroine because of how fast the chemical gets to the brain ■ Tolerance can develop in hour, while it takes days in heroine ■ There are 69 carcinogenic chemicals in cigarettes that cause cancer in nearly all of the organs in the body ● Second hand smoke causes almost as many cancers as actually smoking ○ Cocaine can be used intravenously, or orally when miked in soft drinks (most common route is snorting) ■ Effects vary with the mode of use ● Injected/smoked produces hyperstimulation, alertness, euphoria, and feelings of competence and power ○ Abuse can lead to neurotransmitter depletion which results in sadness and lack of joy. ○ Can be laced with other drugs ○ Caffeine one of the most widely used psychoactive drugs in the world ■ Moderate doses increase alertness and probably have minimal health effects ■ Higher doses can lead to anxiety, insomnia, irritability, cardiac dysrhythmia, and GI disturbances ● Regular high doses can lead to dependence and withdrawal symptoms ○ Amphetamines class of stimulants similar to cocaine, but the effects last longer and the drugs are cheaper ■ Chemical structure similar to that of adrenaline→ popular for people who need to stay up for long hours to do work or study ● Cause an elevation in mood, increase wakefulness, alertness and concentration ■ Can be in ills, injected, snorted, or smoked ○ Marijuana one of the most widely used illicit drugs in the US ■ Has little toxicity compared to other drugs, and is one of the safest therapeutic agents ■ Psychological dependency can occur with chronic use, but little is known about any potential physical dependence. ■ Because of illegal status, there is no quality control, and a user may consume contaminated marijuana ■ Despite its beneficial effects, especially in treating pain, the only legal access to this medicine has been through the FDA’s Compassionate ● Hallucinogens Drugs that stimulate the nervous system and produce varied changes in perception and mood ○ Can cause intoxication and lead to altered perception and impaired judgment ○ Responses is related to user’s mood, basic emotional makeup, and expectations, including the ability to cope with perceptual distortions and immediate surroundings ○ Chronic use can lead to psychological effects and impaired judgment, which can in turn lead to dangerous decisions or accidents ■ Indole hallucinogens; hallucinogens that resemble adrenalin and amphetamines ○ MDMA (Ecstasy) commonly taken as a pill and is both a stimulant and a depressant ■ Overheating at parties raises the side effects of confusion, anxiety, depression, raises pulse, and BP. ● Other effects are dehydration, heat stroke, muscle cramping, blurred vision, heart and kidney failure. ○ Inhalants Substances, often common household chemicals, that are inhaled by drug users; may be inhaled from bottles, aerosol cans, or soaked cloth ○ Often among the first drugs that young children use ○ User can get high several times in short period since inhalants are shortacting and have a rapid onset ■ Depending on dose, user may feel slight stimulation or lowered inhibition or may lose consciousness ○ Link exists between school performance and use of inhalants ● Predisposing/Contributing Factors ○ In addition to the spedrug being used, two major variables influence the particular drug experiencese andsetting all three factors must be considered to understand the various patterns of drug use and abuse ● Drug (see previous bullets) ○ Set: refers to the individual using the drug, as well as their person’s expectations ○ Setting: the influence of the physical, social, and cultural environment within which the use occurs ● Primary Prevention ○ Promotion of healthy lifestyles and resiliency factors ○ Assisting clients to achieve optimal health ○ Teaching assertiveness and decisionmaking skills ○ Teaching stress reduction and relaxation techniques ○ Drug education ○ Emphasizing to clients that no drug is completely safe and that any drug can be abused ○ Helping clients make informed decisions about drug use to minimize potential harm ● Secondary Prevention ○ Assessing for ATOD Problems ○ Drug testing Highrisk groups ■ Adolescents, Older adults, Injection drug users ● Use of drugs during pregnancy basically most drugs can have a negative effect on fetuses, so discourage the use of all drugs (caffeine should be included) ○ Women who are depressed during pregnancy are more likely to use drugs during pregnancy. ● Use of illicit drugs the “just say no to drugs” slogan is actually hurting you ● Codependency and family involvement ○ Drug addiction is often a family disease because people close to the drug user often develop unhealthy coping mechanisms to continue the relationship (codependence) ■ Codependant try to meet the addicts needs at the expense of their own, usually results in enabling ■ Nurses can spot the addiction and help them confront the addicted manner ● Tertiary Prevention ○ Detoxification clearing of one or more drugs from the person’s body and managing withdrawal symptoms ○ Addiction Treatment focuses on the addiction process helps patients vier addiction as a chronic disease ○ Harm reduction –an effective approach to treating drug addiction. Of punishment – get treatment nd and 2 chance ○ Smoking cessation programs ○ Support groups ■ Alcoholics Anonymous (AA) ■ AlAnon and Alateen ■ Narcotics Anonymous (NA) ■ Pills Anonymous (for persons with polydrug addictions) ■ Overeaters Anonymous ■ Gamblers Anonymous ● Nurse’s Role ○ Nurse’s knowledge of community resources and how to mobilize them can significantly influence the quality of care clients receive ○ Brief interventions by a nurse can be as effective as treatment ○ Nurses can play a key role in developing community prevention programs ○ Nurses are in ideal roles to assist with tertiary prevention for addicted person and the family Children of Incarcerated Women ● The vast majority have experienced childhood abuse and neglect ○ Many develop coping strategies associated with escape and survival that can take the form of or lead to criminal behavior ○ Their survival strategies are criminalized, such as work in the sex trade, stealing to feed their children, or prosecution for welfare fraud because a fulltime minimum wage job cannot support a family. ○ Criminal behavior of women is typically part of an overall coping strategy that has its roots in childhood abuse or neglect, followed by leaving home early, dropping out of school, and substance abuse as a coping mechanism. ● Women in Trouble with the Law typically survive with lives characterized by: ○ Poverty, Inadequate housing, Abusive or exploitative partners, Instability ○ Many: Left school before graduation, Had their first child as a teenage are Unemployed, They have few job skills and therefore: ■ Are reliant on welfare, Or have lowpaying jobs, Or criminal sources of income ● Compared with men in prison they: ○ Have high rates of serious drug problems ○ And even with serious mental health issues find themselves in prison rather than in a more appropriate residential placement. ● Children of Women in Prison ○ Exactly how many children are affected is unknown (and most women in prison are mothers) so approximately 147,400 children in the U.S. have a mother in prison ○ Consensus in the field that children with mothers in prison are exposed to many risk factors including: ■ Loss of preincarceration living arrangements because most children lived with their mothers just before incarceration ■ Loss of main parentchild relationship ■ Loss of consistent source of daily care and financial support ■ Disruption of current living arrangements ■ Loss of contact with their main care giver and security ■ Unmet needs of each age group, individual temperament, gender and with no chance to build coping skills ● Child Stresses Due to Incarceration of Mothers ○ Economic strain in children’s households ■ Defined as lowincome with an unemployed caregiver and a lower standard of living or inability to meet the child’s needs ○ Increased risk that children’s households will become unstable ○ Multiple, frequent moves ○ Introduction of unrelated parental figures into the households ○ Increased divorce rate ○ Nonroutine school changes ● Children’s Contact With Incarcerated Mother ○ Maintaining family contact during incarceration can be beneficial to both children and their parents ○ Maintaining parentchild contact through personal visits during incarceration is important for the wellbeing of many children ○ Some research indicates that visiting is important in maintaining parentchild relationships and increases the likelihood of successful reunification after release ○ Several studies found that maintenance of family ties during incarceration is linked to postrelease success, defined as lower rates of recidivism and fewer parole violations ■ The Bureau of Justice Statistics study examined the types and frequency of contacts between prison inmates of minor children and the children of these inmates, including their adult children: ○ Almost 79% of state inmate parents had some kind of contact with at least one of their children since admission ○ Also 56% of mothers in state prison reported at least weekly contact with a child, in the form of letters, telephone calls or visits. ○ Relatively few inmates reported regular personal visits from at least one of their children ■ In state prison 14.6% of mothers reported personal visits from a child at least once a month. ■ And 58 % of mothers had no personal visits from any of their children. ● Barriers to Frequent Contact ○ Corrections policy In theory, corrections officials encourage visiting and maintenance of family ties. In practice, however, prison rules to ensure safety and security often impede such visits. ○ Childunfriendly facilities The prison environment can be frightening and traumatic for children, both in the attitudes and behavior of prison staff and the physical setting. Visits can include long waits ○ Rude treatment by Officials hot, dirty and crowded visiting rooms with no activities for children. These conditions do not encourage frequent visits between incarcerated parents and their children. ○ Parentcaregiver relationships One of the most important factors that affect whether and how often a child has contact with an incarcerated parent is the relationship between the parent and the children’s current caregiver. The caregiver may feel that further contact with the imprisoned parent could harm the child and therefore might prevent or discourage such contact. ○ Child welfare policy and practice Placement of a child in foster care poses unique barriers to visitation with incarcerated parents. In the context of federal and state policies that discourage reunification when a child has been in foster care for an extended period, caseworkers have little incentive to arrange visits or to work to preserve parentchild relationships. ● How Children in Foster Care are Affected by Incarceration ○ Children in foster care and their parents face challenges created by child welfare law, policy and practice. ■ Most serious of these challenges is the risk that the legal parentchild relationship will be permanently severed through legal action by a child welfare agency. ● The 1997 federal Adoption and Safe Families Act, requires states to file a petition to terminate parental rights on behalf of any child who has been abandoned or who has been in foster care for 15 of the most recent 22 months ● Law provides exceptions to this requirement in the following cases: ○ At the option of the state, the child is being cared for by a relative, ○ The state has documented a compelling reason for determining that termination of parental rights would not be in the child’s best interest ○ The state has not provided the child’s family with services that the state deems necessary for the safe return of the child to his or her home. ○ Although the Adoption and Safe Families Act does not explicitly require a termination of parental rights filing against incarcerated parents, the 15 of 22 months provision technically would apply in cases where reunification is delayed beyond 15 months due to a parent’s incarceration, even if the parent is receiving services to facilitate reunification ○ Because the typical sentence for an incarcerated woman is from 80 to 100 months, most imprisoned mothers of children in foster care are at some risk of losing their parental rights. ● Problems of REentry for Former Women Prisoners ○ Compared to male former inmates, women are more likely to be dealing with the psychological effects of past trauma and abuse ○ Are more likely to have abused drugs, alcohol or both at the time of imprisonment ○ Reunification with children is likely to be a more important part of reentry for women than it is for men ● Problems with Reentry for Children ○ Prisoner reentry also can be challenging and stressful for children ○ Children grow ○ Change ○ Form relationships with new parental figures during a parent’s incarceration ■ These parental figures and other family members are reluctant to allow a child to reestablish a relationship with a parent upon release ■ These family conflicts can destabilize already fragile families and leave children confused and torn ○ The return of a possible violent offender can increase the risk that a child will be subjected or exposed to domestic violence ● To Prevent Termination of Parental Rights – Incarcerated Women Face Three Challenges. ○ First, regular contact, preferably visitation, with a child in foster care is critical unless termination of parental rights is clearly in the child’s best interest, a court will be less likely to terminate the rights of a parent who can demonstrate ongoing positive contact with a child and involvement in his or her life ○ Second, incarcerated women who want to avoid termination of parental rights should participate to the fullest extent possible in their children’s dependency proceedings, including case planning, hearings and court orders. Mothers are often dependent upon incommunicative caseworkers ○ Third, incarcerated women parents often need access to reunification services, such as substance abuse treatment, mental health services and parenting classes ● Difficulties in Reuniting with Children ○ Only a few states have legislation aimed at strengthening the parenting skills of incarcerated mothers ■ Most provisions address the parenting skills of mothers of very young children, including those who give birth while in prison or jail ○ Some laws provide prisonbased nursery programs, allow temporary release of inmate mothers to communitybased alternatives to incarceration, or both. ● State Laws about Reuniting Incarcerated Mothers and Children ○ Most states have some kind of laws but they are focused on very young children and do not deal with the complexities of coordination of child welfare, foster care, the needs of the released mothers and the complexities of taking on the responsibilities of their abandoned children ● How Can Nurses Help? ○ Maintenance of a safe environment in prison ○ Understanding the prison culture ○ Addressing health issues in prison populations ○ Screen upon entry into the facility ■ Healthcare triage process includes physical and mental health history ○ Care for chronic and communicable diseases ○ HIV, hepatitis B and C, and tuberculosis ○ Address reentry needs – parenting classes etc. ○ Advocacy ● Future Efforts ○ The many issues that face children of incarcerated parents and their families are complex and cross the jurisdictional boundaries of multiple agencies and service systems ○ Thoughtful policymaking in this area is hindered by lack of reliable data on the characteristics of these children and a paucity of sound research on both the effects of parental incarceration and the effectiveness of interventions (Nurses could champion research in this area) ○ A growing number of state policymakers are taking an active interest in helping children of incarcerated parents(Nurse lobbyists could target this issue) Violence and Human Abuse Victims ● Violence: non accidental acts, interpersonal or intrapersonal, that result in physical or psychological injury to one or more of the people involved ● Violence is a community nursing concern; significant mortality and morbidity result from violence ○ Nurses often care for the victims, the perpetrators, and witnesses of physical and psychological violence ○ Nurses can also take an active role in developing community responses to violence through working on public policy and needed resources ● Abuse by Family Structure ○ Cycle of Violence ■ Tension building phase—Tension builds over common domestic issues like money, children or jobs. Verbal abuse begins. The victim tries to control the situation by pleasing the abuser, giving in or avoiding the abuse. None of these will stop the violence. Eventually, the tension reaches a boiling point and physical abuse begins. ■ Acute battering episod—When the tension peaks, the physical violence begins. It is usually triggered by the presence of an external event or by the abuser’s emotional state—but not by the victim’s behavior. This means the start of the battering episode is unpredictable and beyond the victim’s control. However, some experts believe that in some cases victims may unconsciously provoke the abuse so they can release the tension, and move on to the honeymoon phase. ■ The honeymoon phase—First, expresses remorse, tries to minimize the abuse and might even blame it on the partner. He may then exhibit loving, kind behavior followed by apologies, generosity and helpfulness. He will genuinely attempt to convince the partner that the abuse will not happen again. This loving and contrite behavior strengthens the bond between the partners and will probably convince the victim, once again, that leaving the relationship is not necessary. ● Social and Community Factors Influencing Violence ○ Work Work can be fulfilling and add to sense of wellbeing; or it can be frustrating and unfulfilling, contributing to stress, which may lead to aggression and violence ○ This frustration and resentment may contribute to violent behavior ○ Workers may have difficulty separating feelings generated at work from those at home ○ People hesitate to give up jobs even if they are frustrating, boring, or stressful ■ Particularly true in times of economic downturns ● Education ○ In recent years, schools have assumed many responsibilities traditionally assigned to the family (sex education, discipline) ○ Corporal punishment (at home and at school) → can be spanking ○ Schools are often places where stressors and frustrations that can contribute to violence are abundant; often violence is learned rather than discouraged in such settings ■ Also a place where bullying occurs ○ On the other hand, school can be a powerful contributor to nonviolence ● Media ○ Television programs and print articles can inform and increase public awareness about family violence ○ Abused women and rape victims benefit from media attention, which tends to lessen the stigma of such victimization and publicize available services ○ Media can indirectly lead people to choose violence ○ Ads for nonessential items can lead to viewers’ frustration about unfilled dream and unmet wishes ○ Media portrayal of the world as a violent place ○ Poor role modeling of anger management ● Organized Religion ○ Religion generally teaches nonviolent conflict resolution ■ Historically, however, a seemingly contradictory relationship has often existed between religion and violence ○ Some faiths support the victimization of women, or spouses, when they disapprove of divorces→ therefore some people may stay together even if there is war in the household bc their religion frowns upon divorce ● Population ○ A community’s structure can influence the potential for violence ■ Crowded conditions = greater potential for tension and violence ■ Lack of jobs or lowpaying jobs can lead to feelings of inadequacy, despair, and social alienation ○ Gangs ● Community Facilities ○ Communities differ in the resources and facilities they provide to residents ○ Some are more desirable places to live, work, and raise families and have facilities that can reduce the potential for crime and violence ■ Recreational facilities such as playgrounds, parks, swimming pools, movie theaters, and tennis courts provide socially acceptable outlets for a variety of feelings, including aggression ■ Spectator sports such as football, baseball, basketball, soccer, or hockey also allow for community members to express feelings of anger and frustration ● Violence Against Individuals or Oneself ○ Homicide: the killing of one human being by another ■ An alarming aspect of family homicide is that children may witness the murder or find the body of a family member→ these children are at great risk for emotional turmoil and for becoming involved in violence ● Assault: a violent physical or verbal attack ○ More females than males report injury related to physical assault, and women are 3x more likely to be killed by an intimate partner ● Sexual violence and Rape: sexual intercourse forced on an unwilling person by threat of bodily injury or loss of life ○ May go unreported because victims may be ashamed, embarrassed, or feel afraid ○ Many victims need a follow up mental health service to help them cope with the short term and long term effects ● Suicide: the act of taking one’s own life voluntarily and intentionally ○ Accounted for almost 40,000 deaths in the US in 2012 (10th leading cause of death) ○ Most frequent are by firearm, hanging, strangulation/suffocation, or poisoning ● Family Violence and Abuse (includes sexual, emotional, and physical abuse) ○ Development of abusive patterns ■ Nurses need to understand that the factors that characterize people who become involved in family violence include upbringing, living conditions, and increased stress, with the most predictable being previous exposure to abuse ■ Child may associate love with violence because it is usually the parent that hiss the kids first. ● Children may become hostile or distrustful of others ■ Any sort of stressor can begin the violence, and social isolation and reduced social support can decrease the family’s ability to cope with the stressor ● Types of family violence ○ Physical abuse actual hitting ○ Sexual abuse unwanted sexual actions ○ Emotional abuse verbally aggressive, name calling, belittling, screaming ○ Child abuse and child neglect tends to increase when there is increase of stress in the family ■ Parents at risk for abuse: low social support, a tendency toward high depression, multiple stressors, and a history of abuse ■ Nurse should teach normal parenting behavior and also address the underlying emotional needs of the parents ■ 2 categories of neglect: ● 1. Physical failure to provide adequate food, proper clothing, hygiene, or necessary medical care ● 2. Emotional omission of basic nurturing, acceptance and caring essential for healthy development ● Abuse of female partners ○ Signs of abuse: ■ Often have bruises and lacerations on the face, head, and trunk of the body (where it is easily disguised) from hitting, kicking, punching, burning, freezing, biting, etc. ■ Women tend to exhibit lower self esteem and depression, few are able to come right out and ask for help so the nurse has to communicate honestly, openly, and with sensitivity. ○ Abuse as a process ■ Initially she tries to minimize the seriousness of the situation (usually starts with a shove in the middle of a heated argument). Where there is physical aggression, both men and women tend to blame the incident on something external (stressful day, they were drunk). Men usually apologize for the incident, and the couple tries to improve the situation. Unfortunately the abuse increases in frequency and intensity over time. ■ The woman can either be counseled into leaving the relationship, or the male can attend a program for batterers. ● After the abuse has ended, a period of recovery ensues ● Abuse of older adults ○ Most cases go unreported because the elder is afraid to tell someone. ○ Can experience all forms of abuse (physical, sexual, emotional, and
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