NURS 6521 Advanced Pharmacology, module 1, week 1, Assignment: Ethical and Legal Implications of Prescribing Drugs

NURS 6521 Advanced Pharmacology, module 1, week 1, Assignment: Ethical and Legal Implications of Prescribing Drugs

NURS 6521 Advanced Pharmacology

 

Discussion: Pharmacokinetics and Pharmacodynamics

As an advanced practice nurse assisting physicians in the diagnosis and treatment of disorders, it is important to not only understand the impact of disorders on the body, but also the impact of drug treatments on the body. The relationships between drugs and the body can be described by pharmacokinetics and pharmacodynamics.

Pharmacokinetics describes what the body does to the drug through absorption, distribution, metabolism, and excretion, whereas pharmacodynamics describes what the drug does to the body.

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Photo Credit: Getty Images/Ingram Publishing

When selecting drugs and determining dosages for patients, it is essential to consider individual patient factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. These patient factors include genetics, gender, ethnicity, age, behavior (i.e., diet, nutrition, smoking, alcohol, illicit drug abuse), and/or pathophysiological changes due to disease.

For this Discussion, you reflect on a case from your past clinical experiences and consider how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug.

To Prepare
Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug. NURS 6521 Advanced Pharmacology, module 1, week 1, Assignment: Ethical and Legal Implications of Prescribing Drugs

Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
Think about a personalized plan of care based on these influencing factors and patient history in your case study.

By Day 3 of Week 1

Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.

 

Solution

Ethical and Legal Implications of Prescribing Drugs

Advanced nurses and other medical practitioners are responsible for providing quality care to patients. However, these practitioners should adhere to legal, professional, and ethical guidelines while performing their duties. In this case, the practitioner should comply with the ethical and legal standards as set by the state of Georgia while prescribing medicine to the patient. This paper will address the ethical and legal issues associated with the selected case study, measures for dealing with both disclosure and nondisclosure, strategies for influencing the practitioner’s decision, and the procedure of prescribing medications.

The Ethical and Legal Issues associated with the Selected Case

Both ethical guidelines and legal policies are applicable in the selected scenario. In this case, the medical practitioner has been authorized by a fried to prescribe medication for her. However, the client does not provide the practitioner with her medical history, which should act as a guide during the prescription. The state’s legal and ethical guidelines are against such actions since they are likely to expose patients to harm.

Georgia’s Prescription Drug Monitoring Program (PDMP) was enforced to govern the prescription of drugs primarily to reduce cases of drug abuse, thus enhancing the safety of the citizens. The newly enacted PDMP requires the pharmacist to record their prescriptions within 24 hours. This deadline was reduced from a period between 7 and 10 days (Rodriguez, 2017). This move will prevent individuals from purchasing the same drug from multiple pharmacies. The new law also emphasizes accountability. Physicians are required to check the system before prescribing drugs to the patients (Rodriguez, 2017). Thus, prescribing medication without a patient’s medical history would imply that the prescriber has acted against this policy. Furthermore, the action would compromise the patient’s physical and emotional health due to the ineffectiveness of the prescribed medication. According to Harrison et al (2016), the patient’s well-being is significantly affected by clinical errors. Additionally, the action would compromise the well-being of the patient’s family since the health status of their loved one will expose them to psychological torture. NURS 6521 Advanced Pharmacology, module 1, week 1, Assignment: Ethical and Legal Implications of Prescribing Drugs

The Georgia State Board of Pharmacy also requires the medical practitioner to adhere to the set ethical standards while prescribing drugs to the patients. Particularly, the board requires pharmacists to review the patient’s records before prescribing any medication (Pozgar, 2015). Additionally, the dispensing pharmacist is required to discuss with the client all issues pertaining to the drug such as possible side effects or any potential allergic reactions (Pozgar, 2015). Therefore, prescribing medication to the friend without her medical history would imply that both the prescriber and pharmacist have acted against this ethical standard. Also, the action would have a negative impact on the patient since the administered medication is likely to have some allergic reactions, thus deteriorating her health status further. The patient’s family will also be affected psychologically by the deteriorating health status of their loved one.

Approaches for Handling both Disclosure and Non-Disclosure

Healthcare practitioners should handle both disclosure and non-disclosure in the most effective manner to enhance the level of patient safety (Sorrell, 2017). In this scenario, mistakes are likely to arise if the practitioner prescribes drugs without reviewing the patient’s medical history. First, the prescriber can correct the error by informing the patient about it and possible harm. For instance, the ethical standards of conduct set by the State of Georgia require the prescriber or pharmacist to inform the client about various issues associated with the administered drug (Rodriguez, 2017). Thus, an error regarding drug allergic reaction or potential side effects can be corrected by informing the client about it. Disclosing about the error will, in turn, enhance the level of patient’s safety (Moffatt-Bruce et al., 2016). D On the other hand, the prescriber can address a non-disclosure by correcting the error without informing the patient about it. Taking this action will protect patient’s loyalty and trust towards the practitioner. For instance, the ethical standards of conduct set by the State of Georgia require the prescriber to review the patient’s records before prescribing any medication (Pozgar, 2015). Thus, any error in the prescription can be corrected by reviewing the health records of the client before administering any medication.

Strategies influencing Decision

As an advanced practice nurse, my decision making, in this case, is influenced by two strategies. In particular, the decision will be influenced by both ethical and legal guidelines. The set ethical standards require medical practitioners not to expose clients to any form of harm. Thus, I would disclose the error to the patient to prevent her from any harm that is likely to arise following a mistake in prescription. Additionally, the State’s law emphasizes accountability. Therefore, I would disclose the error and correct the mistake since I would be held accountable for my action.

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The Procedure for Prescribing Medication

Healthcare practitioners are mandated to prescribing drugs to patients. They should ensure minimum medication errors occur during the process. This goal can be achieved by adhering to the set ethical and legal standards regarding drug prescription. Physicians can minimize errors by adhering to the legal requirement of reviewing the medical history of the patient before any prescription. Additionally, errors can be reduced by complying with an ethical standard that requires practitioners to prevent patients from any form of harm.

The State of Georgia requires advanced nurses to adhere to the set ethical guidelines and legal policies during drug prescription. These standards were primarily set to minimize the cases of medical errors that are likely to occur during prescription. The nurses should be prepared to address both disclosure and non-disclosure medical errors to ensure the patient’s safety.

References

Harrison, R., Lawton, R., Perlo, J., Gardner, P., Armitage, G., & Shapiro, J. (2015). Emotion and coping in the aftermath of medical error: a cross-country exploration. Journal of patient safety11(1), 28-35.

Moffatt-Bruce, S. D., Ferdinand, F. D., & Fann, J. I. (2016). Patient safety: disclosure of medical errors and risk mitigation. The Annals of thoracic surgery102(2), 358-362. NURS 6521 Advanced Pharmacology, module 1, week 1, Assignment: Ethical and Legal Implications of Prescribing Drugs

Pozgar, G, D. (2015). Legal and Ethical Essentials of Health Care Administration (2nd Edition). Massachusetts: Jones & Bartlett Learning.

Rodriguez, J. (2017). New Law Aims To Combat Prescription Drug Abuse. Retrieved from https://www.gpbnews.org/post/new-law-aims-combat-prescription-drug-abuse

Sorrell, J. M., (2017). Ethics: Ethical Issues with Medical Errors: Shaping a Culture of Safety in Healthcare.  OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 2. NURS 6521 Advanced Pharmacology, module 1, week 1, Assignment: Ethical and Legal Implications of Prescribing Drugs

N3345 Transition to Professional Nursing Modules 3, 4 and 5

N3345 Transition to Professional Nursing Modules 3, 4 and 5

N3345 Transition to Professional Nursing Modules 3, 4 and 5

Module 3 Assignment: Information Retrieval Paper – Part 1

Submit by 2359 (CT) Saturday at the close of Module 3.

Name Date:

Overview: “Information Retrieval Paper – Part 1”

This Module you will begin to develop an Information Retrieval Paper. This Assignment focuses on identifying appropriate evidence-based nursing practices related to specific problems you may identify as you work in the healthcare/workplace setting.

The goals of an Information Retrieval Paper are to (1) practice using APA format, (2) summarize and examine the strengths and limitations of research articles, and (3) prepare you for the Nursing Research Course where you will write a research paper using the skills you have learned completing this Information Retrieval Paper. Each week, you are using the template provided, do not create a new word document. N3345 Transition to Professional Nursing Modules 3, 4 and 5

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As a part of your Information Retrieval Paper, you will begin development of a research question using PICO format.  Chapter 9 of the Role Development textbook explains PICO. Be sure to develop your research question and then just below your research question delineate what the P, I, C, and O components of your question are.

For this Module 3 Assignment you will prepare a Title Page in proper APA format for your Information Retrieval Paper, identify three peer-reviewed articles, and summarize each article using APA format.

It may be helpful to look at the outline for the entire paper before you begin this Module’s Assignment. Assignments in this Module plus in Modules 4 and 5 will address the Information Retrieval Paper.

Resources 

APA Modules:

1). UTA Library formatting guide: click the left-hand side menu under “home” to find resources and examples to help you. Please note, we are using the Professional Paper guidelines. N3345 Transition to Professional Nursing Modules 3, 4 and 5

https://libguides.uta.edu/apa/home

2). Purdue Writing Center: https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/general_format.html

3). UTA Library:   http://libraries.uta.edu/video/instruction/apaformatting/intro.htm

Review your course readings, lecture, and your Module 2 Resources before completing this module’s Assignment.

Performance Objectives

  • Identify a clinical problem in your workplace setting.
  • Develop an appropriate research question using PICO criteria and format.
  • Summarize 3 peer-reviewed, evidence-based articles/literature related to your clinical problem and research question. Articles must have been published within the past 5 years, unless they are a classic source.
  • Use correct grammar, punctuation, and APA format expected in writing professional papers.

Rubric and PICO Format

Use this rubric to guide work on the Module 3 assignment, “Information Retrieval Paper, Part 1.”

Research question must be stated in PICO format.  See Chapter 9 of the Role Development textbook for the formatting. Be sure to address all four PICO components of the question.

Task 

ê

Accomplished Proficient Needs Improvement
Task #1- Problem Identification
Research Question
Rationale for Question
Must be constructed in the PICO format.  


(Total 40 points)

Identifies a clinical problem in the workplace that would be under a nurse’s control in 2-3 well written sentences (15 points) 

 

Clearly states question and completes PICO format. Problem, Intervention, Comparator, and Outcome is appropriately stated. (15 points)

 

 

Clearly explains why research question was chosen (10 points)

Identifies a clinical problem in the workplace but it is not under the control of a nurse OR problem is stated in 1 sentence (8 points) 

 

Research question is stated and in PICO format but problem, intervention, comparator, and/or outcome are not clearly stated. N3345 Transition to Professional Nursing Modules 3, 4 and 5

(12 points)

 

 

Rationale is not clearly stated for the selection of a research question. (8 points)

Does not clearly identify a clinical problem in the workplace. 

(0 points)

 

 

Does not state question OR does not use PICO format when delineating the research question.

(5 points)

 

 

 

Provides no rationale for the selection of a research question. (0 points)

Task #2- Title Page (Total 10 points) Develops title page components in APA format with no errors. (10 points) Develops title page components in APA format with 1-2 errors. (7 points) Does not use Title Page or creates title page with more than 3 errors. (0 pts)
  


Task #3- APA References and Summaries


Summarize peer-reviewed, evidence-based literature related to a clinical problem.
(Total 30 points)

 

 

 

 

 

Use correct grammar, punctuation, and American Psychological Association (APA) format in writing professional papers. (Total 20 points)

 

Answers 2 questions in overview (Where did you search for articles? How did you decide what articles to include?)

(5 points)

 

Clearly and concisely summarizes 3 professional, peer-reviewed articles that address a research question. Articles have been published within the past 5 years (25 points)

 

 

 

Consistently uses correct mechanics and APA format in writing professional papers (no errors).

 

(20 points)

 

Answers 1 question in overview

(3 points)

 

Briefly summarizes 3 professional, peer-reviewed articles that address a research question. However, summaries are not clearly stated leading to confusion of the article addressed. (20 points)

 

 

Uses correct mechanics and APA format in writing professional papers (1-3 errors).

 

(15points)

 

Does not respond in overview section

(0 points)

 

Summarizes 1 or 2 professional, peer-reviewed articles that address a research question. (15 points)

OR

Articles are not peer reviewed

OR Articles are > 5 years old

 

Does not use correct mechanics and/or APA format in writing papers (4-5 errors).

 

(10 points)

 

Does not use correct mechanics and/or APA format in writing papers (6 + errors).

 

(0 points)

 

 

 

Preview of Information Retrieval Paper Criteria

In this module’s assignment, you will take the initial steps in composing an Information Retrieval Paper that you will complete in Modules 4 and 5. You are only completing the highlighted red sections this week. Because the assignment will be submitted in sections, may want to look at the entire paper in the table below, this gives you can overall idea of the 3-part assignment.

Content Criteria Timeline
Task #1- (Introduction) 

A.    Identification of clinical problem in a workplace setting

B.    Research question stated correctly

PICO format

C.    Rationale for question

D.    Discussion board

E.     Revision if necessary

Task #2-

     Title page

Task #3-

     Overview: Where did you search? How did      you decide on the 3 articles?

     Article #1- APA reference, summary

     Article #2- APA reference, summary

     Article #3- APA reference, summary

 

 

 

    

To Be Completed Module 3 (Now)
Critical Analysis 

Completeness of analysis

To Be Completed Module 4
Conclusion 

Synthesis of key points for the 3 articles

To Be Completed Module 5
Reference Page 

Alphabetized

Sources cited in APA format

References complete

To Be Completed Module 5

 

Task #1- Research Problem and Question using PICO Format

  1. In the space below, identify the clinical problem in the workplace setting that will serve as the focus of your information retrieval paper. Make sure that the problem is one that would be under your complete control as a nurseSummarize your thoughts, what would you like to see changed? Write 2-3 well written sentences for full credit. N3345 Transition to Professional Nursing Modules 3, 4 and 5

Clinical Problem (Type in box below)

 

  1. In the space below, compose a preliminary research question about the clinical problem that you identified in the workplace. Use this criteria in composing a preliminary research question:

– Question must relate to a clinical problem in the workplace.

– Question cannot be answered with a simple yes or no.

– The issue to be studied is under your complete control as a nurse.

– The question is open ended.

       Delineate the PICO components of your question.

Preliminary Research Question and Identified PICO Criteria (Type in box below)

  • State your question

 

  • Now, fill in the PICO format in each text box

P (problem) =

I (intervention) =

C (comparator) =

O (outcome) =

 

P (Problem) =

 

 

 

I (Intervention) =

 

 

 

C (Comparator) =

 

 

O (Outcome)=

 

  1. Why did you chose this? Compose rationale below.

Rationale for Selecting the Research Question (Type in box below)

 

 

  1. After completing this portion of the Assignment, go to this module’s Discussion,
    and follow the directions for sharing your research question. After receiving feedback from your colleagues, revise your research question, if necessary, in the space provided.

Revised Research Question (Type in box below)

  1. Complete after participating in the Module 3 Discussion. Type your revised Research Question in the box provided below. If no revision is needed, please restate your question here.

 

 

Task #2- Title Page Components

In this part of the Assignment, you will complete the title page for your Information Retrieval Paper by using the example shown below. N3345 Transition to Professional Nursing Modules 3, 4 and 5

 

***use the space on the page below as an example format- take the information, delete it, and replace with yours.

 

For additional guidance, refer to these two websites to view title page guidelines-

 

 

1

 

This Should be Your Unique Title Which Summarizes Your Main Idea.

 

It Needs to be Title Case, Bold, Double Spaced and 3-4 Lines Down from the Top Margin.

 

Your Name

 

Institution Name

 

Course Number and Name

 

Faculty’s Name

 

Assignment Due Date

 

Task #3- APA References and Summaries

  • Select three peer-reviewed, evidence-based articles that address your research question.
  • Articles must be published within the past 5 years (unless it is a classic source).
  • Compose an overview about your choice of the three articles. Answer these questions:
    1. Where did you search for articles?
    2. How did you decide what articles to include?
  • Post references to the three articles in APA format.
  • Summarize the article and how it addresses your research question.

Overview

Where did you search for articles? How did you decide what articles to include?

1). Where did you search for the articles?

2). How did you decide what articles to include?

 

Article 1

In the space below, post the reference for the first article in correct APA format.

In the space below, write a summary paragraph in APA format. Use scholarly writing to describe the article, the decision-making process you used to select the article, and how it addresses your research question. Use professional writing style.

 

Article 2

In the space below, post the reference for the second article in correct APA format.

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In the space below, write a summary paragraph in APA format. Use scholarly writing to describe the article, the decision-making process you used to select the article, and how it addresses your research question. Use professional writing style.

 

Article 3

In the space below, post the reference for the third article in correct APA format.

 

In the space below, write a summary paragraph in APA format. Use scholarly writing to describe the article, the decision-making process you used to select the article, and how it addresses your research question. Use professional writing style.

 

Submit this Assignment Document into Canvas for grading.

N3345 Transition to Professional Nursing Modules 3, 4 and 5 Module 4 Assignment: Information Retrieval Paper – Part 2

Submit by 2359 (CT) Saturday at the close of Module 4.

Name Date:

Overview: “Information Retrieval Paper – Part 2”

In Module 4 Assignment, you will continue to work on your Information Retrieval Paper. The focus of this Part 2 of the Information Retrieval Paper is complete a critical analysis of each of your chosen articles.  Space is provided in this document for you to enter your analysis of each article using the correct APA format. Each week, you are using the template provided, do not create a new word document.

 

Performance Objectives 

  • Critically analyze a research article for strengths and limitations.
  • Use correct grammar, punctuation, and American Psychological Association (APA) format in writing professional papers.

Rubric

Use this rubric to guide your work on the Module 4 assignment, “Retrieval Paper – Part 2.”

Task
ê
Accomplished Proficient Needs Improvement Missing Information
Part 2: Information Retrieval Paper – Part 2
(Total 100 points) 
Critically analyze a research article for strengths and limitations.
(Total 60 points)
 

 

 

References and APA-

Use correct grammar, punctuation, and American Psychological Association (APA) format in writing professional papers.

 

 

Use of in-text citations


(Total 40 points)

 

Critically analyzes 3 research articles for strengths and limitations.
(60 points)

 

Consistently uses correct mechanics and APA format in writing professional papers (0 APA errors in references and 0 grammatical errors).

(30 points)

 

Uses 3 properly formatted in-text citations to support thoughts.

 

(10 points)

 

Critically analyzes 2 research articles for strengths and limitations.
(40 points)

 

 

Uses correct mechanics and APA format in writing professional papers (1-2 APA errors in references and/or 1-2 grammatical errors noted).

(25 points)

 

Uses 2 properly formatted in-text citations to support thoughts OR 1-2 APA errors r/t citations

(7 points) N3345 Transition to Professional Nursing Modules 3, 4 and 5

 

Analyzes 1 research article.
(20 points)

 

3-4 APA errors in references and/or 3-4 grammatical errors noted.

(15 points)

 

 

 

Uses 1 properly formatted in-text citations to support thoughts OR 3-4 APA errors r/t citations

(3 points)

 

 

 

Does not analyze any articles

(0 points)

 

 

Does not use correct mechanics and/or APA format (more than 5 APA errors in references and/or more than 5 grammatical errors noted).

 

(0 points)

 

 

No use of in-text citations to support thoughts OR >5 APA errors r/t citations

(0 points)

 

Week 4 Application

Information Retrieval Paper: Part 2

In this week’s assignment, you will complete your Information Retrieval Paper. Review the outline for the entire assignment before you begin.

APA Format Elements Timeline
Title Page in APA format Completion Timeline
APA format 

Citations in the body of the paper

Headings

Applicable each time sections are submitted
Writing style 

Grammar

Spelling

Paragraphs of at least three well-written sentences

Organization and flow

Applicable each time sections are submitted
Content Criteria Timeline
Introduction: 

Identification of clinical problem in a workplace setting

Research question stated correctly

Rationale for question

Completed Module 3
Summary of 3 peer-reviewed articles 

Overview: Where did you search? How did you decide on the 3 articles?

3 article summaries

Completed Module 3
Critical Analysis 

    Completeness of analysis

Complete in Module 4 (now)
Conclusion 

Synthesis of key points for the 3 articles

To be completed Module 5
Reference Page 

Alphabetized

Sources cited in APA format

References complete

To be completed Module 5

 

 

Part 2: Information Retrieval Paper – Part 2

Guidelines for Critical Analysis of an Article

You completed your article summaries in Module 3. The next step is to complete a critical analysis of each article.  For each article, ask yourself these questions when completing this section of your Information Retrieval Paper.

  • What were the strengths of the research? Were a significant number of participants studied in an appropriate setting that can be applied in a broader sense?
  • What were the limitations of the research? Was the environment controlled?
  • What did the author leave out?
  • Were barriers identified and addressed?
  • Could the findings be implemented with purpose and expected outcomes?

Article 1

In the space below, post the reference for the first article in correct APA format.  If you made errors in formatting your reference for this article in Module 3, now is the time to make the appropriate changes so you do not make the same formatting error over and over. N3345 Transition to Professional Nursing Modules 3, 4 and 5

 

In the space below, write a one-paragraph critique of your first research article.  Apply correct APA format and scholarly writing style as you critique the article’s strengths and limitations related to your stated research question. Use 1 correctly cited in-text citation for full credit.

Article 2

In the space below, post the reference for the second article in correct APA format If you made errors in formatting your reference for this article in Module 3, now is the time to make the appropriate changes so you do not make the same formatting error over and over.

 

In the space below, write a one-paragraph critique of your second research article.  Apply correct APA format and scholarly writing style as you critique the article’s strengths and limitations related to your stated research question. Use 1 correctly cited in-text citation for full credit.

 

Article 3

In the space below, post the reference for the third article in correct APA format. If you made errors in formatting your reference for this article in Module 3, now is the time to make the appropriate changes so you do not make the same formatting error over and over.

 

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In the space below, write a one-paragraph critique of your third research article.  Apply correct APA format and scholarly writing style as you critique the article’s strengths and limitations related to your stated research question. Use 1 correctly cited in-text citation for full credit.

 

Submit this Assignment Document into Canvas for grading.

Module 5 Assignment – Information Retrieval Paper, Part 3

Submit by 2359 Saturday at the close of Module 5 (Last week of the course)

Name Date:

Overview:  “Information Retrieval Paper: Part 3”

This week, you will complete Part 3 of the Information Retrieval Paper, which you worked on in Module 3 and 4. You are using the template provided, do not create a new word document.

So far, you have developed a research question, identified the PICO components of your research question, included your rationale for selecting your research question, created a title page for your paper in APA format, located three peer-reviewed articles, summarized each article in APA format, and critically analyzed the articles.

In this module, you will summarize and synthesize the key points of the peer reviewed, evidence based articles and develop a reference page in APA format.

Be sure to review the previous assignments that relate to the Information Retrieval Paper. Incorporate your Coach’s suggestions and corrections so you won’t make the same mistakes again in this last section of the Information Retrieval Paper.

Performance Objectives:  

  • Synthesize the key points of peer reviewed, evidenced based articles.
  • Develop a reference page in APA format.
  • Use correct grammar, punctuation, and American Psychological Association (APA) format in writing professional papers.

Rubric

Use this rubric to guide your work “Information Retrieval Paper, Part 3.”

Task 

ê

Accomplished Proficient Needs Improvement Missing Information
Week 5 Application:
“Information Retrieval Paper: Part 3” (100 points total)
Task #1:
Conclusion: Summarize Key Points (Total 60 points)
Key findings are identified and discussed relating to the identified research question studied.  Well written with at least 3 sentences per topic. Scholarly writing is fully observed. (60 points) N3345 Transition to Professional Nursing Modules 3, 4 and 5 

 

Key findings are identified and minimally linked to the identified research question studied. Two sentences written per topic and scholarly writing is predominately observed. (40 points) Key findings are not fully identified or discussed as related to the peer research question. One sentence per topic noted and scholarly writing is not observed. (20 points) 

 

Does not complete. 

(0 points)

Task  #2:
Reference Page and In-text Citations(Total 40 points) 

 

Correct Grammar and APA Format are graded heavily.

 

 

 

References are cited in APA format, alphabetized and complete. 

(30 points)

 

 

 

Uses 3 properly formatted in-text citations to support thoughts.

 

(10 points)

Uses correct mechanics and APA format in writing professional papers (1-2 APA errors). 

 (25 points)

 

 

 

Uses 2 properly formatted in-text citations to support thoughts OR 1-2 APA errors r/t citations

(7 points)

3-4 APA and/or grammatical errors noted. 

 

(15  points)

 

 

Uses 1 properly formatted in-text citations to support thoughts OR 3-4 APA errors r/t citations

(3 points)

Does not use correct mechanics and/or APA format (more than 5 APA and grammatical errors). 

(0 points)

 

No use of in-text citations to support thoughts OR >5 APA errors r/t citations

(0 points)

 

 

 

Week 5 Application

Information Retrieval Paper: Part 3

In this week’s assignment, you will complete your Information Retrieval Paper. Review the outline for the entire assignment  before your begin.

APA Format Elements Timeline
Title Page in APA format Completion Timeline
APA format 

Citations in the body of the paper

Headings

Applicable each time sections are submitted
Writing style 

Grammar

Spelling

Paragraphs of at least three well-written sentences

Organization and flow

Applicable each time sections are submitted
Content Criteria Timeline
Introduction: 

Identification of clinical problem in a workplace setting

Research question stated correctly

Rationale for question

Title page

Completed Module 3
Summary of 3 peer-reviewed articles 

Overview: Where did you search? How did you decide on the 3 articles?

3 article summaries

Completed Module 3
Critical Analysis 

Completeness of analysis

Completed Module 4
Conclusion 

    Synthesis of key points for the 3 articles

To be completed Module 5 (now)
Reference Page 

    Alphabetized

    Sources cited in APA format

    References complete

To be completed Module 5 (now)

 

Task #1 – Conclusion: Summarize Key Points

 

In this part of the Information Retrieval Paper, you will synthesize the main points from the three peer reviewed, evidence based articles.

 

Directions:

In this section write a paragraph or two to synthesize the key points of the articles.  Consider this section a conclusion of your findings.

For full credit, each of the 3 articles needs a minimum of 3 sentences. Each article topic requires an in-text citation (3 total).

Synthesis Points from Articles (Type below)

 

 

Task #2 – Reference Page

 

In this part of the Information Retrieval Paper, you will create the reference page for the entire paper in APA format.

 

Directions:

  • Develop the reference page for your Information Retrieval Paper. Make sure that references are:

– cited in APA format.

– alphabetized.

  • Complete the reference page in the space below.

– Must have 3 peer-reviewed, evidence based articles

 

Reference Page (Type Below)

 

Submit this Assignment Document into Canvas for grading. N3345 Transition to Professional Nursing Modules 3, 4 and 5.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

In this course, you develop a comprehensive Course Project: Promoting Health Care Quality. To initiate this project, this week you examine the systems and structures of an organization with which you are familiar.

Organizational Systems and Structures, Part 1

Section 1: Organizational Systems and Structures Evaluation

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

When a problem related to health care quality and patient safety arises, there can be an inclination to focus on a specific event rather than to examine the larger context surrounding it. Analyzing the systems and structures within an organization provides a foundation for generating a fuller understanding of how and why the event occurred and

for developing strategies to address the underlying issues. Perhaps more importantly, such an analysis can be used to proactively identify potential challenges and improve organizational systems and structures in order to promote positive outcomes. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

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In the first section of your Course Project, you analyze the systems and structures of a health care organization with which you are familiar.

To prepare:

Identify a health care organization with which you are familiar; one that you will be able to sufficiently analyze to complete the full scope of the Course Project. (Refer to the Course Project Overview as needed.) NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Select two or more of the following frameworks:

· Learning organizations

· Complex adaptive systems (CAS)

· Clinical microsystems

· Good to great

· The 5 Ps

With these frameworks in mind, analyze the systems and structures of the organization. Be sure to research and consider:

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

· Mission, vision, and values

· Strategic plan, goals, and objectives, if possible

· Key operational processes and patterns

· Information technology use

· Organizational priorities and investments, as indicated by financial data

Week 4: Organizational Systems and Structures, Part 2

Section 1: Organizational Systems and Structures Evaluation

As you continue your evaluation of a health care organization, it is essential to pay attention to culture. Organizational culture provides the context in which all interactions and processes occur and is therefore central to any effort to enact change.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To prepare:

Continue to analyze your selected organization, as indicated in Week 3 (Section 1 of the Course Project).

Continue to analyze essential elements of organizational culture and evaluate the influence of culture on the ability to achieve goals within your selected organization. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To complete:

Write a 3- to 5-page paper in which you:

· Provide a description of the organization that you selected

· Present your analysis of the organization with attention to:

· Its mission, vision, values

· Strategic plan, goals, and objectives

· Key operational processes and patterns

· Information technology use

· Organizational priorities and investments, as indicated by financial data

· The essential elements of the organization’s culture

· The influence of culture on meeting organizational goals

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Section 2: Quality Improvement Issue

To help you move forward with your Course Project, this week you identify a quality issue that you would like to address and submit a description of this issue for Instructor feedback.

Your proposed issue should reflect a genuine need for improvement within your selected health care organization. Through your Course Project, you will analyze this issue and propose strategies to improve outcome(s), including the redesign of a related process. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To prepare:

· Review the six quality improvement aims from the Institute of Medicine (IOM)

· Safe: Avoiding harm to patients from the care that is intended to help them.

· Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).

· Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

· Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.

· Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.

· Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

· Conduct a search of the literature to help you identify a specific issue that warrants attention and action to promote quality improvement. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

· Consider what you have surmised thus far through your analysis of the organization

that you selected. What have you noticed that could help you identify a quality related need for improvement? For instance:

· What has captured your attention in meetings, reports, and/or daily activities?

· Have you noticed discrepancies between activities in the organization and

recommendations in the research literature, quality standards, and/or the

organization’s stated policies and procedures?

· If so, what do you think could be the reason(s) for variations or gaps between

what you have observed and what is recommended? NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Identify a quality improvement issue that you would like to investigate for this project.

Note: Review the Course Project Overview/full instructions, located in the Week 3

Learning Resources, as needed to identify a quality improvement issue that is viable for

completing the full scope of this project. Once you receive a response from your

Instructor on the quality improvement issue that you submit, be sure to integrate his or

her feedback before moving forward with Section 3 of your Course Project.

To complete:

Write a brief description of the quality improvement issue that you would like to address

for your Course Project. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

In this course, you develop a comprehensive Course Project: Promoting Health Care Quality. To initiate this project, this week you examine the systems and structures of an organization with which you are familiar.

Week 3: Organizational Systems and Structures, Part 1

Section 1: Organizational Systems and Structures Evaluation When a problem related to health care quality and patient safety arises, there can be an inclination to focus on a specific event rather than to examine the larger context surrounding it. Analyzing the systems and structures within an organization provides a foundation for generating a fuller understanding of how and why the event occurred and for developing strategies to address the underlying issues. Perhaps more importantly, such an analysis can be used to proactively identify potential challenges and improve organizational systems and structures in order to promote positive outcomes. In the first section of your Course Project, you analyze the systems and structures of a health care organization with which you are familiar. To prepare:

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Identify a health care organization with which you are familiar; one that you will be able to sufficiently analyze to complete the full scope of the Course Project. (Refer to the Course Project Overview as needed.) This may be the same organization that you addressed in this week’s Discussion.

 Select two or more of the following frameworks: o Learning organizations o Complex adaptive systems (CAS) o Clinical microsystems o Good to great o The 5 Ps

You may use the same frameworks that you addressed in this week’s Discussion.

 With these frameworks in mind, analyze the systems and structures of the organization. Be sure to research and consider: o Mission, vision, and values o Strategic plan, goals, and objectives, if possible o Key operational processes and patterns o Information technology use o Organizational priorities and investments, as indicated by financial data. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

In Week 4, you will receive instructions for integrating an analysis of organizational culture into development of Section 1 of your Course Project. Once you have completed your evaluation, you will write a 3- to 5-page paper, which is due by Day 7 of Week 4.

Week 4: Organizational Systems and Structures, Part 2 Section 1: Organizational Systems and Structures Evaluation

As you continue your evaluation of a health care organization, it is essential to pay attention to culture. Organizational culture provides the context in which all interactions and processes occur, and is therefore central to any effort to enact change. To prepare: NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Continue to analyze your selected organization, as indicated in Week 3 (Section 1 of the Course Project).

 In addition, consider the ideas and information exchanged in this week’s Discussion. Continue to analyze essential elements of organizational culture and evaluate the influence of culture on the ability to achieve goals within your selected organization. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To complete: Write a 3- to 5-page paper in which you:

 Provide a description of the organization that you selected

 Present your analysis of the organization with attention to: o Its mission, vision, values o Strategic plan, goals, and objectives o Key operational processes and patterns o Information technology use o Organizational priorities and investments, as indicated by financial data o The essential elements of the organization’s culture o The influence of culture on meeting organizational goals. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Due by Day 7. Section 2: Quality Improvement Issue To help you move forward with your Course Project, this week you identify a quality issue that you would like to address and submit a description of this issue for Instructor feedback. Your proposed issue should reflect a genuine need for improvement within your selected health care organization. Through your Course Project, you will analyze this issue and propose strategies to improve outcome(s), including the redesign of a related process. To prepare:

 Review the six quality improvement aims from the Institute of Medicine (IOM) presented in Chapter 3 of the Sadeghi, Barzi, Mikhail, and Shabot text. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Conduct a search of the literature to help you identify a specific issue that warrants attention and action to promote quality improvement.

 Consider what you have surmised thus far through your analysis of the organization that you selected. What have you noticed that could help you identify a quality- related need for improvement? For instance:

o What has captured your attention in meetings, reports, and/or daily activities? o Have you noticed discrepancies between activities in the organization and

recommendations in the research literature, quality standards, and/or the organization’s stated policies and procedures?

o If so, what do you think could be the reason(s) for variations or gaps between what you have observed and what is recommended? NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Identify a quality improvement issue that you would like to investigate for this project. Note: Review the Course Project Overview/full instructions, located in the Week 3 Learning Resources, as needed to identify a quality improvement issue that is viable for completing the full scope of this project. Once you receive a response from your Instructor on the quality improvement issue that you submit, be sure to integrate his or her feedback before moving forward with Section 3 of your Course Project. To complete: Write a brief description of the quality improvement issue that you would like to address for your Course Project. Submit by Day 7. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Week 6: The Quality Movement

Section 3: Quality Measurement and Assessment

Measuring and assessing quality provides a foundation for identifying needs for improvement, developing effective interventions, and then monitoring progress toward desired results.

In this section of the Course Project, you focus on what you would measure—and how you would measure it—relative to your previously identified quality improvement issue. Note: This section of the Course Project will serve as the Portfolio Assignment for this course.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To prepare:

 Review the Learning Resources. Also conduct a search of the literature related to your selected quality improvement issue and complete the “Evidence Matrix” document (provided in this week’s Learning Resources).

 Evaluate the evidence presented in the research literature and the quality standards proposed by various organizations, including the IOM’s six aims for quality improvement.

 Based on this review and your knowledge of the organization that you have selected, determine appropriate measures and indicators of performance related to your identified quality improvement issue.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Consider how you could gather and use historical evidence of the organization’s performance related to the quality improvement issue. Also consider methods for gathering and assessing current quantitative and qualitative data, including those currently in use by the organization (e.g., chart audit data, staff surveys, quality indicators that are monitored, observations). If possible, examine actual data to assess your selected organization’s performance related to the issue. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Think about what, specifically, you would like to achieve related to this issue. Establish realistic, evidence-based quality performance targets. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Analyze gap(s) between the organization’s current performance and the performance targets.

 As you do this, you may wish to create a graphic organizer / alignment chart for your own use that illustrates:

o The measures and indicators that you would evaluate o Current and historical data related to this quality issue —either actual data or

methods for how you would collect and analyze the data o Methods for collecting and analyzing data in the future (including when you

would do this) o Realistic, evidence-based targets

Additional instructions for Section 3 are presented in Week 7. To complete this Assignment, you will write a paper introducing your quality improvement plan. This Assignment is due by Day 7 of Week 8.

Week 7: Improvement Science Section 3: Quality Measurement and Assessment Continue working on Section 3, introduced in Week 6. To prepare: NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Think about the quality improvement issue that you are addressing and the associated plan you are developing. Consider the following:

o What is the overall purpose, or aim, of doing this work?

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

o What would you hope to achieve for the organization by undertaking this project? What are the objectives of this initiative?

o What value would this work add to the organization? o How would this work improve practice and create outcomes with impact?

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 Review Chapter 7 of the Sadeghi, Barzi, Mikhail, and Shabot course text. Consider how addressing this quality improvement issue would align with the organization’s mission, vision, values, and strategic goals and objectives. How does it relate to regulatory issues, and other matters that are significant for the organization? If you notice a misalignment, use this as an opportunity to refine your focus.

 With this in mind, continue to hone your development of this Assignment, integrating the concepts addressed here into Section 3. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To complete: Write a 3- to 5-page paper that includes:

 An introduction to your quality improvement plan, including the overarching aim of this initiative and an explanation of how it aligns with the mission, vision, values, and strategic goals and objectives of the organization, as well as regulatory issues and other matters that are significant for the organization

 An overview of the current situation with regard to this quality improvement issue in the organization

 A description of measures and indicators

 A presentation on data related to this issue, including: o Actual historical and current data and / or a description of the methods you

would use to collect and analyze the data o Methods for collecting and analyzing data in the future, including when you

would do this

 A description of realistic, evidence-based targets Be sure to cite evidence from the literature to justify your selection of the measures and indicators, as well as the performance targets. Note: This section of the Course Project serves as the Portfolio Assignment for this course. Due by Day 7 of Week 8. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Section 4: Quality Improvement Strategies Start to think about quality improvement methods/strategies (these relate to bridging the gap between current performance and targets as established in Section 3). NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To prepare:

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Refer to the modified Donabedian model (access, structure, process, outcome, and patient experience) presented in Chapter 9 of the Sadeghi, Barzi, Mikhail, and Shabot text.

 Recall the performance targets that you identified for Section 3 (in Week 6). What does the recommendation that performance-driven planning should “begin with the end in mind” suggest given your established goals?

 Review the information presented in Chapter 9 of the Sadeghi, Barzi, Mikhail, and Shabot text, and think about how you would assess the organization’s strengths and weaknesses related to the performance gaps that you identified in Section 3 (Week 6). NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Based on the above, start to think of specific evidence-based strategies that could be implemented to close / minimize the performance gaps that you have identified. Consider both interventions (what) and processes (how). Focus on strategies that are supported by the latest research and could create systems-level change. These may be tentative for now, but be sure to identify at least one that specifically lends itself to a change in process (i.e., practice, protocol, pathway, activity). NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Additional instructions for Section 4 are presented next week. To complete this Assignment, you will create a process map and write a paper describing quality improvement strategies. This Assignment is due by Day 7 of Week 8.

Week 8: Process Mapping Section 3: Quality Measurement and Assessment Review the complete Assignment description presented in Weeks 6 and 7. Submit Section 3 by Day 7. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Section 4: Quality Improvement Strategies

For this section of your Course Project, you create a process map to examine a current process related to your quality improvement issue. You will use the results of the process mapping to redesign a process to help minimize or close the performance gap(s). As you proceed, keep in mind the importance of maintaining a patient-centered focus so the patient experience is not negatively affected by any changes in process. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To prepare:

 Review the instructions provided in the Learning Resources for creating a process map.

 With your quality improvement issue in mind, as well as the other work you have completed on your Course Project thus far, think about how creating a process map could help you to better understand your quality improvement issue and redesign an associated process.

 Create a process map using Microsoft Word or PowerPoint.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Refine the strategies for promoting systems-level change to minimize or close the performance gap(s) that you began to think about in Week 7. As part of this, identify a way to redesign at least one process based on your analysis of the process map you have created.

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To complete:

 Write a 2- to 3-page paper in which you describe quality improvement strategies that you selected related to your quality improvement issue.

 Finalize your process map, which will be submitted along with the paper. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Submit your paper and process map by Day 7.

Week 9: Evaluating Outcomes Section 5: Evaluation Plan

To prepare:

 Review the information on evaluation, including data representation and quality monitoring, presented in the Learning Resources. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Review your work on the Course Project thus far, particularly Sections 3 and 4.

 Think about how your quality improvement initiative could be evaluated. Consider the following: o Which stakeholders need information related to this initiative? What do they need

this information for? o How would you assess the outcomes in the short-term and long-term? o How would you analyze related processes, including but not limited to the one

you redesigned in Section 4? o How should an analysis of organizational structures be integrated into your

evaluation? o How would you identify and evaluate any unintended consequences that may

arise? o What metrics should the organization use to gauge progress and the

effectiveness of the quality improvement initiative? How would these metrics incorporate the measures and indicators you identified in Section 3? Are there additional measures and indictors that you now think should be included? NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

o How should the organization track and display data for an interdisciplinary audience? How could the use of a dashboard or balanced scorecard be of value?

o How could the organization create an integrated view of performance that links finance and quality?

To complete: Develop a 2- to 3-page evaluation plan that includes the following:

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 An outline of the methods that you would propose for evaluating the quality improvement initiative and the financial implications

 A description of specific metrics that integrate your previously identified measures and indicators and any others you have deemed important

 A recommendation of how the organization could represent data related to this quality improvement issue for ongoing monitoring and to determine the value or success of the initiative

 An explanation of how the organization could create an integrated view of performance that links finance and quality

This Assignment is due by Day 7 of Week 10.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Section 6: Quality Improvement Plan

In this section of the Course Project, you synthesize your analysis and recommendations into an action plan for implementing the quality improvement initiative. To prepare:

 Begin to develop a plan for implementing your quality improvement initiative, including the redesigned process that you identified in Section 3. Consider the following: o How would you undertake the process of determining a timeline for planning,

implementing, and evaluating this quality improvement plan? o What are some reasonable milestones for this initiative? What are the daily,

weekly, monthly steps/goals? To complete: NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

 Write a 2- to 3-page summary of your quality improvement action plan.

This Assignment is due by Day 7 of Week 10. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Week 10: Interdisciplinary Collaboration Section 5: Evaluation Plan Review the complete Assignment description presented in Week

Discussion: Using Improvement Science Models to Promote Quality and Safety
…while all changes do not lead to improvement, all improvement requires change.

—United States Agency for International Development

Improvement science models bring together research and evidence-based practice to identify the most effective ways to promote quality and safety in health care. As a
central tenet of quality improvement, attention must be paid to the processes that contribute to outcomes.
In this Discussion, you examine quality improvement models and evaluate how they could be applied to address specific issues within health care organizations. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

To prepare:

Review the improvement models presented in the Learning Resources.
Evaluate each of the models and select two on which to focus for this Discussion.
Consider how each of the two models could be utilized in a health care organization to promote quality and safety. Think about the following:
How does the model bring together research and evidence-based practice to facilitate quality improvement?
How does the model contribute to a culture of quality and safety?
How does it address changes in process?
Reflect on the quality improvement issue and the health care setting that you are addressing for your Course Project. Of the two models that you have selected,
determine which one you, as a nurse leader-manager, would use to address this issue. Also consider how this would relate to one or more of the IOM’s six aims for
quality and safety. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Post your analysis of how the two improvement models that you selected could foster a culture of quality and patient safety and facilitate changes in process that
promote positive outcomes. Explain how you would use one of these models to address the quality improvement issue in the organization that you have selected for your
Course Project, and how doing so would relate to one or more of the IOM’s six aims for improving quality and safety.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Read a selection of your colleagues’ responses.
Respond to at least two of your colleagues on two different days using one or more of the following approaches:
Offer additional strategies for using your colleague’s selected model to address the IOM’s six aims for quality.
Share insights for engaging frontline staff using your colleague’s selected improvement model.
Compare the steps in the improvement model that you selected with your colleague’s.
Suggest an alternative model for your colleague to utilize in his or her identified health care organization. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Required Readings

Hickey, J. V., & Brosnan, C. A. (2012). Evaluation of health care quality in advanced practice nursing. New York, NY: Springer Publishing Company.
Review Chapter 6, “Evaluating Health Care Information Systems and Patient Care Technology” (pp. 113–133) (assigned in Week 6)
This chapter examines federally mandated use of health information technology to improve health care and care delivery. In addition, technology competencies are
discussed along with strategies for evaluating health information technologies in coordination with nurse informaticists. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Chapter 7, “Evaluation of Patient Care Standards, Guidelines, and Protocols” (pp. 135–158) (assigned in Week 4)
How can you know if an organization is delivering the best possible care? This chapter explores evaluation methods for patient care and discusses methods used to
evaluate innovations that can lead to practice changes.
Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. M. (2013). Integrating quality and strategy in health care organizations. Burlington, MA: Jones & Bartlett Learning.
Chapter 7, “Understanding Quality and Performance” (pp. 133–160)
Chapter 9, “Closing the Gaps” (pp. 179–194)
Altmann, T. K. (2007). An evaluation of the seminal work of Patricia Benner: Theory or philosophy? Contemporary Nurse: A Journal for the Australian Nursing Profession,
25(1/2), 114–123. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers
Retrieved from the Walden Library databases.

Altmann summarizes the foundational work of Benner’s novice to expert theory, reviews critiques, and outlines how Benner’s concepts are important in nursing.
Dixon-Woods, M., Bosk, C. L., Aveling, E. L., Goeschel, C. A., & Pronovost, P. J. (2011). Explaining Michigan: Developing an ex post theory of a quality improvement
program. The Milbank Quarterly, 89(2), 167–205. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers
Retrieved from the Walden Library databases.

NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

This article discusses evidenced-based practice and how it relates to quality improvement in healthcare.
Ernst, M. M., Wooldridge, J. L., Conway, E., Dressman, K., Weiland, J., Tucker, K., & Seid, M. (2010). Using quality improvement science to implement a
multidisciplinary behavioral intervention targeting pediatric inpatient airway clearance. Journal of Pediatric Psychology, 35(1), 14–24.
Retrieved from the Walden Library databases. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Researchers applied a Plan-Do-Study-Act (PDSA) quality improvement model in completing an evidenced based study of pediatric patients with cystic fibrosis.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Retrieved from the Walden Library databases.

Review as needed (assigned in a previous week). This report outlines the Institute of Medicine’s (IOM’s) six aims to improve the quality of health care.
Maguad, B. A. (2011). Deming’s ‘profound knowledge’: Implications for higher education. Education, 131(4), 768–774. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers
Retrieved from the Walden Library databases.

The author of this article describes Deming’s System of Profound Knowledge as it relates to higher education.
Murphree, P., Vath, R. R., & Daigle, L. (2011). Sustaining Lean Six Sigma projects in health care. Physician Executive, 37(1), 44–48.
Retrieved from the Walden Library databases. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

Lean Six Sigma is a quality improvement model that is frequently used in health care. The authors of this article provide strategies for monitoring improvement
projects in order to sustain improved quality outcomes.
Polk, J. D. (2011). Lean Six Sigma, innovation, and the change acceleration process can work together. Physician Executive, 37(1), 38–42.
Retrieved from the Walden Library databases.

Dr. Polk describes both the Lean process and the Six Sigma process and explains how health care organizations combine these two improvement models to promote quality
outcomes. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers
Improvement Science Research Network. (n.d.). What is improvement science? Retrieved March 13, 2013, from http://isrn.net/about/improvement_science.asp

As indicated in this resource, improvement science focuses on research about what improvement strategies are most effective for promoting health care quality and
safety.
Institute for Healthcare Improvement. (2012a). How to improve. Retrieved from http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

The Institute for Healthcare Improvement outlines each step in the Plan-Do-Study-Act (PDSA) model as described in The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance. Click on the links to read each section.
Nursing Theories. (2011). From novice to expert: Patricia E. Benner. Retrieved from
http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html

This website presents an overview of the basic elements of Benner’s Novice to Expert Theory.
U.S. Department of Health & Human Services Agency for Healthcare Research and Quality. (2012). AHRQ health care innovations exchange. Retrieved from
http://www.innovations.ahrq.gov. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

The Innovations Exchange was established to help health care providers “solve problems, improve health care quality, and reduce disparities.” This website presents
evidence-based innovations and QualityTools along with articles and up-to-date research findings.
United States Agency for International Development. (n.d.). The science of improvement. Retrieved March 13, 2013, from
http://www.hciproject.org/improvement_tools/improvement_methods/science

The USAID organization provides a concise overview of improvement science and its application to improving health care quality.
Required Media
Laureate Education (Producer). (2013a). Improvement science defined. Retrieved from https://class.waldenu.edu. NURS 6231- Midterm And Final Exam Study Guide Questions And Answers

PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for knowledge and acceptance of a diversity of faith expressions.

The purpose of this paper is to complete a comparative ethical analysis of George’s situation and decision from the perspective of two worldviews or religions: Christianity and a second religion of your choosing. For the second faith, choose a faith that is unfamiliar to you. Examples of faiths to choose from include Sikh, Baha’i, Buddhism, Shintoism, etc. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

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In your comparative analysis, address all of the worldview questions in detail for Christianity and your selected faith. Refer to Chapter 2 of Called to Care for the list of questions. Once you have outlined the worldview of each religion, begin your ethical analysis from each perspective. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

In a minimum of 1,500-2,000 words, provide an ethical analysis based upon the different belief systems, reinforcing major themes with insights gained from your research, and answering the following questions based on the research:

  1. How would each religion interpret the nature of George’s malady and suffering? Is there a “why” to his disease and suffering? (i.e., is there a reason for why George is ill, beyond the reality of physical malady?)
  2. In George’s analysis of his own life, how would each religion think about the value of his life as a person, and value of his life with ALS?
  3. What sorts of values and considerations would each religion focus on in deliberating about whether or not George should opt for euthanasia? PHI 413V Ethical and Spiritual Decision Making in Health Care Essay
  4. Given the above, what options would be morally justified under each religion for George and why?
  5. Finally, present and defend your own view.

Support your position by referencing at least three academic resources (preferably from the GCU Library) in addition to the course readings, lectures, the Bible, and the textbooks for each religion. Each religion must have a primary source included. A total of six references are required according to the specifications listed above. Incorporate the research into your writing in an appropriate, scholarly manner.

Prepare this assignment according to the guidelines found in the APA Style Guide. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Case Study: Fetal Abnormality

Jessica is a 30-year-old immigrant from Mexico City. She and her husband Marco have been in the U.S. for the last three years and have finally earned enough money to move out of their Aunt Maria’s home and into an apartment of their own. They are both hard workers. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay. Jessica works 50 hours a week at a local restaurant and Marco has been contracting side jobs in construction. Six months before their move to an apartment, Jessica finds out she is pregnant. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Four months later, Jessica and Marco arrive at the county hospital, a large, public, nonteaching hospital. A preliminary ultrasound indicates a possible abnormality with the fetus. Further scans are conducted and it is determined that the fetus has a rare condition in which it has not developed any arms, and will not likely develop them. There is also a 25% chance that the fetus may have Down syndrome. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Dr. Wilson, the primary attending physician, is seeing Jessica for the first time, since she and Marco did not receive earlier prenatal care over concerns about finances. Marco insists that Dr. Wilson refrain from telling Jessica the scan results, assuring him that he will tell his wife himself when she is emotionally ready for the news. While Marco and Dr. Wilson are talking in another room, Aunt Maria walks into the room with a distressed look on her face. She can tell that something is wrong and inquires of Dr. Wilson. After hearing of the diagnosis, she walks out of the room wailing loudly and praying aloud. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Marco and Dr. Wilson continue their discussion, and Dr. Wilson insists that he has an obligation to Jessica as his patient and that she has a right to know the diagnosis of the fetus. He furthermore is intent on discussing all relevant factors and options regarding the next step, including abortion. Marco insists on taking some time to think of how to break the news to Jessica, but Dr. Wilson, frustrated with the direction of the conversation, informs the husband that such a choice is not his to make. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay. Dr. Wilson proceeds back across the hall, where he walks in on Aunt Maria awkwardly praying with Jessica and phoning the priest. At that point, Dr. Wilson gently but briefly informs Jessica of the diagnosis, and lays out the option for abortion as a responsible medical alternative, given the quality of life such a child would have. Jessica looks at him and struggles to hold back her tears. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Jessica is torn between her hopes of a better socioeconomic position and increased independence, along with her conviction that all life is sacred. Marco will support Jessica in whatever decision she makes, but is finding it difficult not to view the pregnancy and the prospects of a disabled child as a burden and a barrier to their economic security and plans. Dr. Wilson lays out all of the options but clearly makes his view known that abortion is “scientifically” and medically a wise choice in this situation. Aunt Maria pleads with Jessica to follow through with the pregnancy and allow what “God intends” to take place, and urges Jessica to think of her responsibility as a mother. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Case Study: End of Life Decisions

George is a successful attorney in his mid-fifties. He is also a legal scholar, holding a teaching

post at the local university law school in Oregon. George is also actively involved in his teenage

son’s basketball league, coaching regularly for their team. Recently, George has experienced

muscle weakness and unresponsive muscle coordination. He was forced to seek medical

attention after he fell and injured his hip. After an examination at the local hospital following his

fall, the attending physician suspected that George may be showing early symptoms for ALS

(amyotrophic lateral sclerosis), a degenerative disease affecting the nerve cells in the brain and

spinal cord. The week following the initial examination, further testing revealed a positive

diagnosis of ALS. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

ALS is progressive and gradually causes motor neuron deterioration and muscle atrophy to the

point of complete muscle control loss. There is currently no cure for ALS, and the median life

expectancy is between three and five years, though it is not uncommon for some to live 10 or

more years. The progressive muscle atrophy and deterioration of motor neurons leads to the loss

of the ability to speak, move, eat, and breathe. However, sight, touch, hearing, taste, and smell

are not affected. Patients will be wheelchair bound and eventually need permanent ventilator

support to assist with breathing. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

George and his family are devastated by the diagnosis. George knows that treatment options only

attempt to slow down the degeneration, but the symptoms will eventually come. He will

eventually be wheelchair bound, and be unable to move, eat, speak, or even breathe on his own.

In contemplating his future life with ALS, George begins to dread the prospect of losing his

mobility and even speech. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay. He imagines his life in complete dependence upon others for basic

everyday functions, and perceives the possibility of eventually degenerating to the point at which

he is a prisoner in his own body. Would he be willing to undergo such torture, such loss of his

own dignity and power? George thus begins inquiring about the possibility of voluntary

euthanasia. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

PHI-413V Topic 5 Case Study on Death and Dying

PHI-413V Topic 5 Case Study on Death and Dying
Ethical and Spiritual Decision Making In Health Care – Intervention and Ethical Decision Making
Grand Canyon University

 

The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for knowledge and acceptance of a diversity of faith expressions.
The purpose of this paper is to complete a comparative ethical analysis of George’s situation and decision from the perspective of two worldviews or religions: Christianity and a second religion of your choosing. For the second faith, choose a faith that is unfamiliar to you. Examples of faiths to choose from include Sikh, Baha’i, Buddhism, Shintoism, etc.
In your comparative analysis, address all of the worldview questions in detail for Christianity and your selected faith. Refer to Chapter 2 of Called to Care for the list of questions. Once you have outlined the worldview of each religion, begin your ethical analysis from each perspective. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay
In a minimum of 1,500-2,000 words, provide an ethical analysis based upon the different belief systems, reinforcing major themes with insights gained from your research, and answering the following questions based on the research:
1. How would each religion interpret the nature of George’s malady and suffering? Is there a “why” to his disease and suffering? (i.e., is there a reason for why George is ill, beyond the reality of physical malady?)
2. In George’s analysis of his own life, how would each religion think about the value of his life as a person, and value of his life with ALS?
3. What sorts of values and considerations would each religion focus on in deliberating about whether or not George should opt for euthanasia?
4. Given the above, what options would be morally justified under each religion for George and why?
5. Finally, present and defend your own view. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay
Support your position by referencing at least three academic resources (preferably from the GCU Library) in addition to the course readings, lectures, the Bible, and the textbooks for each religion. Each religion must have a primary source included. A total of six references are required according to the specifications listed above. Incorporate the research into your writing in an appropriate, scholarly manner.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Faith Diversity and Health Care Professionals The term of spirituality and worldview can mean something different for each individual. It is a connection to something that a person views bigger than them and gives a meaning to life. There are several concepts of spirituality that coexist together in a society. These concepts help guide us in our personal and health care professional views/decisions when dealing with society. It is very important for health care professionals to keep an open mind when faced with patients from all walks of faith. Nurses treat patients from a holistic view that involves mental, physical, and spiritual approaches. PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

Ethical and Spiritual Decision Making

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The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for knowledge and acceptance of a diversity of faith expressions.

The purpose of my work is to complete a comparative ethical analysis of George’s situation and decision from the perspective of two worldviews or religions: Christianity and any other second religion. For the second faith, I have to choose a faith that is unfamiliar to me. Examples of faiths to choose from include Sikh, Baha’i, Buddhism, Shintoism, etc.
In the comparative analysis, I need to address all of the worldview questions in detail for Christianity and the second selected faith. The questions are: PHI 413V Ethical and Spiritual Decision Making in Health Care Essay
1.Describe a worldview
2.Define the four major concepts of the nursing metaparadigm according to the modern, postmodern and biblical worldviews
3.Describe how this struggle between worldviews affects your nursing practice
4.Identify the worldview reflected in a nursing theory

Provide some ethical analysis based upon the different belief systems, reinforcing major themes with insights gained from any research, and answering the following questions based on the research:
1. How would each religion interpret the nature of George’s malady and suffering? Is there a “why” to his disease and suffering? (i.e., is there a reason for why George is ill, beyond the reality of physical malady?)
2. In George’s analysis of his own life, how would each religion think about the value of his life as a person, and value of his life with ALS? PHI 413V Ethical and Spiritual Decision Making in Health Care Essay
3. What sorts of values and considerations would each religion focus on in deliberating about whether or not George should opt for euthanasia?
4. Given the above, what options would be morally justified under each religion for George and why?
5. Finally, present and defend your own view.
Support your position by referencing at least three academic resources.

PHI 413V Ethical and Spiritual Decision Making in Health Care Essay

NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study

NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study

Gastrointestinal (GI) and hepatobiliary disorders affect the structure and function of the GI tract. Many of these disorders often have similar symptoms such as abdominal pain, cramping, constipation, nausea, bloating, and fatigue. Since multiple disorders can be tied to the same symptoms, it is important for advanced practice nurses to carefully evaluate patients and prescribe treatment that targets the cause rather than the symptom. Once the underlying cause is identified, an appropriate drug therapy plan can be recommended based on medical history and individual patient factors. NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study. In this Discussion, you examine a case study of a patient who presents with symptoms of a possible GI/hepatobiliary disorder, and you design an appropriate drug therapy plan. NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study

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Consider the following case study:

Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs: NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study

  • Synthroid 100 mcg daily
  • Nifedipine 30 mg daily
  • Prednisone 10 mg daily
To prepare:
  • Review this week’s media presentation on pharmacology for the gastrointestinal system.
  • Review the provided case study. Reflect on the patient’s symptoms, medical history, and drugs currently prescribed.
  • Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms are the result of a disorder from another system or other factors such as pregnancy, drugs, or a psychological disorder.
  • Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed. NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study

With these thoughts in mind:

Post an explanation of your diagnosis for the patient including your rationale for the diagnosis. Then, describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed. NURS 6521 Week 7 Gastrointestinal (GI) and Hepatobiliary Disorders Case Study

NU310-6:Synthesize research evidence for best practice to improve patient outcomes.

NU310-6:Synthesize research evidence for best practice to improve patient outcomes

NU310-6:Synthesize research evidence for best practice to improve patient outcomes.

The purpose of this assignment is for you to incorporate research evidence into a clinical model for a practice change. Using the Iowa Model for Evidence Based Practice as a guide, develop a concept map/schematic that shows the pathways necessary for a clinical change that you would like to see implemented in your current practice setting.

The concept map should include the 7 steps below in schematic format:

1. Formulate a clinical problem that is nursing sensitive and patient focused. Develop a PICO statement to articulate a research question>

P=Population (Who is your population of interest to be affected?)

I= Intervention (What intervention will you implement to address the clinical problem?)

C= Comparison (Will you be comparing one intervention with another or an intervention with existing protocols?)

O= Outcome (What is the desired outcome from the intervention?) NU310-6:Synthesize research evidence for best practice to improve patient outcomes.

T= Time (How long will the change take to implement?)

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2. Determine organizational commitment

3. Develop a team to gather and appraise evidence

4. Determine if reasonable evidence exists to implement the clinical change

5. Implement a pilot change to test the feasibility

6. Evaluate the change/plan

7. Disseminate the results.

The schematic/concept map should fit on one page. On a separate page, explain the rationale and process of each step of your model (briefly), incorporating references as cite sources in correct 6th edition APA style and format. You do not need to include a title page for this assignment. Provide your reference list on a separate page, with between 4-5 current scholarly references. The total submission should be no more than 3 pages. Record the hours that you spent completing each aspect of this assignment (preparation, reading, writing, etc.) on the Practice Experience Log. Submit this log along with your assignment to the Dropbox. NU310-6:Synthesize research evidence for best practice to improve patient outcomes.

Unit 10: Create an Evidence-Based Model

Introductory Emergent Practiced Proficient/Mastered Score Weight Final Score
0 -1.9 2 – 2.9 3 – 3.9 4
PICO statement Content is missing or incomplete The PICO statement is vague, incomplete and does not address the article being reviewed The PICO statement is correct, some details may be omitted The PICO statement is correcly written with consice and appropriate wording and length 15% 0.00. NU310-6:Synthesize research evidence for best practice to improve patient outcomes.
Determine organizational priorities Content is missing or incomplete • Student vaguely addresses organizational/clinical priorites and policies • Student appropriately addresses organizational/clinical priorites and policies; some details omitted • Student clearly and completely addresses organizational/clinical priorites and policies; 12% 0.00
Essemble a team to gather evidence Content is missing or incomplete • Student vaguely addresses who team members will be • Student appropriately addresses who team members will be; some details omitted • Student clearly and completely addresses who team members will be 12% 0.00
Determine if evidence supports the practice change Content is missing or incomplete • Student vaguely addresses research evidence student includes evidence support; some details missing • Student clearly and completely addresses supportive evidence 12% 0.00
steps to Pilot the change Content is missing or incomplete • Student vaguely addresses steps of implementation. NU310-6:Synthesize research evidence for best practice to improve patient outcomes. student includes steps for implementation ; some details missing • Student clearly and completely addresses pilot steps 12% 0.00
Evaluate Content is missing or incomplete • Student vaguely addresses evaluation of process student includes steps for evaluation ; some details missing • Student clearly and completely addresses how model will be evaluated 12% 0.00
dissemination Content is missing or incomplete provides vague explanation of how model will be disseminated student includes steps for dissemination ; some details missing • Student clearly and completely addresses how model will be disseminated 12% 0.00
Presentation Style incomplete or missing Schematic may not flow logically and/or includes 25-50% of content Schematic flows logically including over 50% of required content Schematic is correct and flows logically; is legible and contains all required content 6% 0.00
Format/Style Did not follow APA format Major errors with APA formatting; less than2 references included A separate reference page included with less than 3 scholarly references follows APA guidelines. No grammar, word usage or punctuation errors. Overall style is consistent with professional work. 4-5 scholarly references included 7% 0.00
100% 0.00
Final Score 0
Percentage 0.00%
Total available points = 150 4
NU310-6:Synthesize research evidence for best practice to improve patient outcomes.

NRS490 Week 1 Assignment: Individual Success Plan

NRS490 Week 1 Assignment: Individual Success Plan

Planning is the key to successful completion of this course and your overall program of study. The Individual Success Plan (ISP) assignment requires early collaboration with the course faculty and your course mentor. You will need to establish a plan for successful completion of (1) deliverables associated with weekly course objectives, (2), required practice immersion hours, and (3) deliverables associated with your capstone project.

Access the “Individual Success Plan” resource in the Topic Materials. Read the information in the resource, including student expectations and instructions for completing the ISP document.

Use the “Individual Success Plan” to develop a personal plan for completing your practice hours and how topic objectives will be met. Include the number of hours you plan to set aside to meet your goals.

A combination of 100 supervised clinical hours in community health and leadership areas will be obtained through the application of the objectives listed in the Guidelines for Undergraduate Field Experiences manual.

Practicum immersion experiences are required in a community health setting. Community-based settings should encourage community integration and involvement; expand accessibility of services and supports; promote personal preference, strengths, dignity; and empower people to participate in the economic mainstream.

According to HealthyPeople.gov, educational and community-based programs and strategies are designed to reach people outside of traditional health care settings. These settings may include schools, worksites, health care facilities, and communities. Community health and leadership practice immersion can occur in the same site and in conjunction with the evidence-based project in the NRS-490 course.

If you are a registered nurse in Washington, your practicum experience must include a minimum of 50 hours in a community health setting. NRS490 Week 1 Assignment: Individual Success Plan

Students should apply concepts from prior courses to critically examine and improve their current practice. Students should also integrate scholarly readings to develop case reports that demonstrate increasingly complex and proficient practice

Consider the challenges you expect to encounter as you continue the practice hour and competency requirements throughout this course. How might you overcome these challenges?

You can renegotiate these deliverables with your faculty and mentor throughout this course and update your ISP accordingly. NRS490 Week 1 Assignment: Individual Success Plan latest 2018

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Once your ISP has been developed and accepted by your course faculty, you will have your course mentor sign it at the beginning of, and upon completion of, each assignment that incorporates practice immersion hours. You will track all course practice immersion hours in the ISP.

APA format is not required, but solid academic writing is expected.

You are not required to submit this assignment to Turnitin.

PRACTICE IMMERSION 

 

Complete Contact Information
Student Information GCU
Name:
E-mail:
Phone Number:
Course Faculty Information GCU
Name:
E-mail:
Phone Number:
Practicum Mentor Information Practice Setting
Name:
E-mail:
Phone Number:
MOU signed & uploaded to Instructor in LoudCloud via Individual Forum Yes ?? No ?? 

If no, is an existing Affiliation Agreement on file? _____

ISP Instructions

Use this form to develop your Individual Success Plan (ISP) for NRS-490, the Professional Capstone and Practicum course. An individual success plan maps out what you, the RN-to-BSN student, needs to accomplish in order to be successful as you work through this course and complete your overall program of study. You will also share this with your mentor at the beginning and end of this course so that he or she will know what you need to accomplish.

Application-based learning assignments are listed in the course syllabus with a Practice Portfolio Statement requirement element noted within the assignment itself. In order for you to successfully complete and graduate from the RN-to-BSN Program you must meet the following programmatic requirements: (1) completion of 100 practice immersion hours, and (2) completion of work associated with all program competencies.

In this ISP, you will identify all of the objectives, tasks, and/or assignments relating to the 100 practice immersion hours you need to complete by the end of this course. Specify the dates by which you will complete each tasks and/or assignments. Your plan should include a self-assessment of how you met all applicable GCU RN-to-BSN Domains & Competencies (see Appendix A).

ALL course assignments listing a “Practice Hours Portfolio” statement must be included in the ISP and are worth and recorded here as approximately 10 hours each. Actual clock hours must be recorded on this time log. NRS490 Week 1 Assignment: Individual Success Plan latest 2018

General Requirements

Use the following information to ensure successful completion of each assignment as it pertains to deliverables due in this course:

• Use the Individual Success Plan to develop a personal plan for completing your practice immersion hours and self-assess how you will meet the GCU RN-to-BSN University Mission Critical Competencies and the Programmatic Domains & Competencies (Appendix A) related to that course.

Show all of the major deliverables in the course, the topic/course objectives that apply to each deliverable, and lastly, align each deliverable to the applicable University Mission Critical Competencies and the course-specific Domains and Competencies (Appendix A).

Completing your ISP does not earn practice hours, nor does telephone conference time, or time spent with your mentor.

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• Within the Individual Success Plan, ensure you identify all course assignments which may include the following: Memorandums of Understanding (MOU)(if Affiliation Agreement is not required); comprehensive log of practice immersion hours applied to baccalaureate level learning outcomes; evaluations from faculty and mentors; your evaluations of your mentor; scholarly activity report; competency self-assessment (part of your ISP); reflective journal (Submitted in Week 10 but covering all weeks in the course); course goals and plan for how competencies and practice immersion hours will be met; and both faculty and mentor approvals of course goals and documented practice immersion hours.

Application-based Learning Course Assignments List of Current Course Objectives Number of Clock Hours Associated with Each Assignment Assignment 

Date Due

Self-Assessment: 

GCU RN-to-BSN

University Mission Critical Competencies and

Programmatic Domains & Competencies

(see Appendix A)

Date 

Assignment

Completed

By typing in his/her signature below, the student agrees to have read, understood, and be accountable for the instructions, assignments, and hours shown above and that all questions have been satisfactorily answered by the faculty and/or program director.

Mentors will sign upon initial receipt and at the end of the course to confirm that assignments have been complete with your guidance. NRS490 Week 1 Assignment: Individual Success Plan latest 2018

Student Signature

Name:

Date:

Mentor Signature [Upon Initiation of Course]

Name:

Date:

Mentor Signature [Upon Completion of Course]

Name:

Date:

APPENDIX A:

GCU RN-to-BSN Domains & Competencies

A. University’s Mission Critical Competencies

How does this Individual Success Plan support the GCU Mission?

MC1: Effective Communication: Therapeutic communication is central to baccalaureate nursing practice. Students gain an understanding of their ethical responsibility and how verbal and written communication affects others intellectually and emotionally. Students begin to use nursing terminology and taxonomies within the practice of professional and therapeutic communication. Courses require students to write scholarly papers, prepare presentations, develop persuasive arguments, and engage in discussion that is clear, assertive, and respectful.

MC2: Critical Thinking: Courses require students to use critical thinking skills by analyzing, synthesizing, and evaluating scientific evidence needed to improve patient outcomes and professional practice.

MC3: Christian Worldview: Students will apply a Christian worldview within a global society and examine ethical issues from the framework of a clearly articulated system of professional values. Students will engage in discussion of values-based decisions made from a Christian perspective.

MC4: Global Awareness, Perspectives, and Ethics: The concept of global citizenship is introduced to baccalaureate students in the foundational curriculum. Some courses will focus on the human experience across the world health continuum. The World Health Organization (WHO) definitions of health, health disparities, and determinants of health are foundational to nursing practice.

MC5: Leadership: Students will apply a Christian worldview within a global society and examine ethical issues from the framework of a clearly articulated system of professional values. Students will engage in discussion of values-based decisions made from a Christian perspective.

B. Domains and Competencies

How does this Individual Success Plan support the Program Domains and Competencies?

Domain 1: Professional Role

Graduates of Grand Canyon University’s RN-BSN program will be able to incorporate professional values to advance the nursing profession through leadership skills, political involvement, and life-long learning.

Competencies:

1.1: Exemplify professionalism in diverse health care settings.

1.2: Manage patient care within the changing environment of the health care system.

1.3: Exercise professional nursing leadership and management roles in the promotion of patient safety and quality care.

1.4: Participate in health care policy development to influence nursing practice and health care.

1.5: Advocate for autonomy and social justice for individuals and diverse populations.

Domain 2: Theoretical Foundations of Nursing Practice

Graduates of Grand Canyon University’s RN-BSN program will have acquired a body of nursing knowledge built on a theoretical foundation of liberal arts, science, and nursing concepts that will guide professional practice.

Competencies:

2.1: Incorporate liberal arts and science studies into nursing knowledge.

2.2: Comprehend nursing concepts and health theories.

2.3: Understand and value the processes of critical thinking, ethical reasoning, and decision making.

Domain 3: Nursing Practice

Graduates of Grand Canyon University’s RN-BSN program will be able to utilize the nursing process to provide safe quality care based on nursing best practices.

Competencies:

3.1: Utilize the nursing process to provide safe and effective care for patients across the health-illness continuum: promoting, maintaining, and restoring health; preventing disease; and facilitating a peaceful death.

3.2: Implement patient care decisions based on evidence-based practice.

3.3: Provide individualized education to diverse patient populations in a variety of health care settings.

3.4: Demonstrate professional standards of practice.

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Domain 4: Communication/Informatics

Graduates of Grand Canyon University’s RN-BSN program will be able to manage information and technology to provide safe quality care in a variety of settings. In addition, graduates will be able to communicate therapeutically and professionally to produce positive working relationships with patients and health care team members.

Competencies:

4.1: Utilize patient care technology and information management systems.

4.2: Communicate therapeutically with patients.

4.3: Professionally communicate and collaborate with the interdisciplinary health care teams to provide safe and effective care.

Domain 5: Holistic Patient Care

Graduates of Grand Canyon University’s RN-BSN program will be able to provide holistic individualized care that is sensitive to cultural and spiritual aspects of the human experience.

Competencies:

5.1: Understand the human experience across the health-illness continuum.

5.2: Assess for the spiritual needs and provide appropriate interventions for individuals, families, and groups.

5.3: Provide culturally sensitive care.

5.4: Preserve the integrity and human dignity in the care of all patients. NRS490 Week 1 Assignment: Individual Success Plan latest 2018

NRS 490 Grand Canyon University COVID19 Care Planning Team Summary

NRS 490 Grand Canyon University COVID19 Care Planning Team Summary

Description

 

 

This document describes the scholarly activity elements that should be included in a five paragraph summary. You may use this resource to help guide the preparation of the Scholarly Activities assignment, due in Topic 10.

Overview

This section consists of a single paragraph that succinctly describes the scholarly activity that you attended/participated in, the target market for the activity, and the benefit of the activity to you.

Problem

This section consists of either a short narrative or a list of bullet points that concisely identifies the problems the scholarly activity is designed to solve. Educate: What is the current state of the activity topic? Explain why this is a problem, and for whom is it a problem? Inspire: What could a nurse achieve by participating in the scholarly activity? Use declarative sentences with simple words to communicate each point. Less is more.

Solution

This section consists of either a short paragraph or a list of bullet points that concisely describes the solution to a proposed practice problem that the scholarly activity addressed and how it addresses the problem outlined in the previous section.

Opportunity

This section consists of short paragraphs that define the opportunity that the scholarly activity is designed to capture. It is important to cover the objectives and goals that were met. How will attending/participating in this scholarly activity help you grow as a nurse? NRS 490 Grand Canyon University COVID19 Care Planning Team Summary

Program Competencies Addressed

This section consists of a list of program competencies that were addressed in this scholarly activity. Please use the list from the ISP.

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Overview

The scholarly activity, I have participated in were Nursing Council Meeting (NCM) and Care Team Conference (CTM). The NCM is schedule to meet quarterly, while CTM every week on Tuesday. The NCM reviews the Kardex for the patients in the ICU, which contains summary of patient orders, demographic information and other nursing care instructions for individual patients. The NCM team members are ICU nurses, quality manger, and Director Of Nursing (DON). The CTM is an interdisciplinary team meeting that has practitioners from health professions such as case manager, rehab director, physicians, pomologist, nurses, dietician, pharmacist, wound care nurse etc. The team meet weekly to make the future plan of care and has an established ongoing communication (e.g., a daily rounding on patients) among team members to ensure that various aspects of patients’ healthcare needs are integrated, aligned, addressed, and met in a time-efficient manner.

Problem

The Kardex holds the day to day information on the patient conditions per shift. It carries information such as patient’s mental, phycological, daily activities etc. Also, it has information on type of tube feeding, iv site and date of change, diagnoses, status of Foley catheter, fall risk, tracheostomy, ventilation, tele monitor etc. During the Kardex review, the team members reviews all information on the patient and updates the missing information. Some of the issues find out as patient fall, missing the iv site, Foley catheter, and tracheostomy care and dressing change date. Also, any missing information find on the Kardex is updated and make a note, so it can be monitor in future. The issue find is the family member is unaware of the physiological and psychological condition change or improvement in it or future discharge planning.

Solution

As all missing information reviewed, corrected, and noted, than reported to quality manger. The quality manger will look at the issue individually and research if any policy requires to change. The patient fall status and occurrence mainly focused too, and assessed based on the root cause analysis. To improve over all care for patient, continuous education on the related subject such as all types of tub care and attain the needs of high fall risk patients provided and it is mandatory to attend. The CTM meeting reviewed on the any problems related to the patients’ physiological and psychological conditions during the stay and plan the future care in order to improve the patient conditions. Also, discussed on the patient improvement, discharge planning, PT/OT activity to get the strength back for daily activities etc. In the TCM meeting the family members are involved for the particular patient and made aware of the patient day to day condition and future planning.

Opportunity

This activity added to my knowledge base on how the Kardex reviewed and its importance for all healthcare professionals to review daily changes in the patient. Also, it helps me to understand the how the policies can be change to improve the patient care and its work flow.   I was able to meet the competency of profession role (Domain 1) by experiencing the collaboration of physician, nursing leaders and leaders from other disciplines in addressing issues in a wide range of health care settings (1.1) and assuming management and leadership roles in promoting patient safety and quality care (1.3) and participate in health care policy development to influence nursing practice (1.4). This scholarly activity allowed me to explore the theoretical foundations of nursing practice (Domain 2) by advancing my understanding and value the processes of critical thinking, ethical reasoning and decision making (2.3).  The TCM meeting helped me to address the domain of Communications/Informatics (Domain 4) by witnessing the professional communications and collaborations between interdisciplinary health care professionals to provide safe and effective care (4.3). Overall this experience will help me begin to see the importance of my nursing position as a larger picture of health care improvement in patient outcome. NRS 490 Grand Canyon University COVID19 Care Planning Team Summary

Program Competencies Addressed

1.1, 1.3, 1.4, 2.3, 4.3

Hours

3.5 hours

Practicum – Assessing Client Progress Assignment

Practicum – Assessing Client Progress Assignment

Practicum – Assessing Client Progress Assignment

Assignment 2: Practicum – Assessing Client Progress
Learning Objectives
Students will:
• Assess progress for clients receiving psychotherapy
• Differentiate progress notes from privileged notes
• Analyze preceptor’s use of privileged notes
To prepare:
• Reflect on the client you selected for the Week 3 Practicum Assignment.
• Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format.Practicum – Assessing Client Progress Assignment
The Assignment
Part 1: Progress Note
Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):
• Treatment modality used and efficacy of approach
• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)Practicum – Assessing Client Progress Assignment
• Modification(s) of the treatment plan that were made based on progress/lack of progress
• Clinical impressions regarding diagnosis and/or symptoms
• Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
• Safety issues
• Clinical emergencies/actions taken
• Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
• Treatment compliance/lack of compliance
• Clinical consultations
• Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
• Therapist’s recommendations, including whether the client agreed to the recommendations
• Referrals made/reasons for making referrals
• Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)Practicum – Assessing Client Progress Assignment
• Issues related to consent and/or informed consent for treatment
• Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
• Information reflecting the therapist’s exercise of clinical judgment
Note: Be sure to exclude any information that should not be found in a discoverable progress note.

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Part 2: Privileged Note
Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.
• The privileged note should include items that you would not typically include in a note as part of the clinical record. Practicum – Assessing Client Progress Assignment
• Explain why the items you included in the privileged note would not be included in the client’s progress note.
• Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.
SEE THE ATTACHED WEEK 3 PRACTICUM ASSIGNMENT WRITTEN BY ME TO WORK ON

NOTE
SELECT COGNITIVE BEHAVIOR THERAPY (CBT ) TO WORK ON MY CLIENT. READ THE ASSIGNMENT WK-3 ATTACHED WELL.Practicum – Assessing Client Progress Assignment

Assignment 2: Practicum – Assessing Client Progress

Learning Objectives

Students will:

  • Assess progress for clients receiving psychotherapy
  • Differentiate progress notes from privileged notes
  • Analyze preceptor’s use of privileged notes

To prepare:

  • Reflect on the client you selected for the Week 3 Practicum Assignment.
  • Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format.Practicum – Assessing Client Progress Assignment

The Assignment

Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

  • Treatment modality used and efficacy of approach
  • Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
  • Modification(s) of the treatment plan that were made based on progress/lack of progress
  • Clinical impressions regarding diagnosis and/or symptoms
  • Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
  • Safety issues
  • Clinical emergencies/actions taken
  • Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)Practicum – Assessing Client Progress Assignment
  • Treatment compliance/lack of compliance
  • Clinical consultations
  • Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
  • Therapist’s recommendations, including whether the client agreed to the recommendations
  • Referrals made/reasons for making referrals
  • Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)Practicum – Assessing Client Progress Assignment
  • Issues related to consent and/or informed consent for treatment
  • Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
  • Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

 

 

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.

  • The privileged note should include items that you would not typically include in a note as part of the clinical record. Practicum – Assessing Client Progress Assignment
  • Explain why the items you included in the privileged note would not be included in the client’s progress note.
  • Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.

By Day 7

Week 7: Supportive and Interpersonal Psychotherapy

Amelia, a 16-year-old high school sophomore, presents with symptoms of weight loss and a very obvious concern for her weight. She has made several references to being “fat” and “pudgy” when, in fact, she is noticeably underweight. Her mother reports that she is quite regimented in her eating and that she insists on preparing her own meals as her mother “puts too many fattening things in the food” that she cooks. After discovering that during the past 3 months Amelia has lost 15 pounds and is well under body weight for someone of similar age/sex/developmental trajectory, the psychiatric mental health nurse practitioner diagnosed Amelia with anorexia nervosa.Practicum – Assessing Client Progress Assignment

Evidence-based research shows that clients like Amelia may respond well to supportive psychotherapy and interpersonal psychotherapy. So which approach might you select? Are both equally effective for all clients? In practice, you will find that many clients may be candidates for both of these therapeutic approaches, but factors such as a client’s psychodynamics and your own skill set as a therapist may impact their effectiveness.Practicum – Assessing Client Progress Assignment

This week, you continue exploring therapeutic approaches and their appropriateness for clients as you examine supportive psychotherapy and interpersonal psychotherapy. You also assess progress for a client receiving psychotherapy and develop progress and privileged psychotherapy notes for the client.

Photo Credit: Laureate Education

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

  • Chapter 5, “Supportive and Psychodynamic Psychotherapy”Practicum – Assessing Client Progress Assignment (pp. 238–242)
  • Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

Note: You will access this text from the Walden Library databases.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

 

Note: You will access this resource from the Walden Library databases.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)Practicum – Assessing Client Progress Assignment

 

Note: You will access this article from the Walden Library databases.

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

 

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

 

Note: For this week, view Reality Therapy, Feminist Therapy, and Solution-Focused Therapy only. You will access this media from the Walden Library databases.

Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.Practicum – Assessing Client Progress Assignment

 

Note: You will access this media from the Walden Library databases. The approximate length of this media piece is 110 minutes.

5

Supportive and Psychodynamic Psychotherapy

KATHLEEN WHEELER

This chapter begins with an overview of the underlying assumptions of psychodynamic psychotherapy, the history, and evidence-based research. Psychodynamic psychotherapy is discussed as on a continuum, with supportive, expressive, and psychoanalytic approaches considered. Rationale is provided for choice of approach based on developmental considerations for clinical decision making.Practicum – Assessing Client Progress Assignment How to develop a case formulation and the working through phase of treatment is examined, as is working with alliance ruptures and dreams. Guidelines for brief psychodynamic psychotherapy are provided with case studies illustrating concepts and techniques throughout the chapter. Those skilled in psychodynamic psychotherapy recognize the difficulties in suggesting specific standardized techniques, because technique is driven by the context of the interaction.Practicum – Assessing Client Progress Assignment

In the current environment of managed care, in which a course of psychotherapy is often three to six sessions, practicing any meaningful relationship-based work is difficult, if not impossible. With these limitations in mind, an overview of relevant concepts and technical considerations is presented. The chapter ends with information about postmaster’s training and certification requirements for psychodynamic psychotherapy. Chapter 4 reviews the basic concepts of transference, countertransference, and resistance, which are foundational to understanding psychodynamic psychotherapy.

With the American Psychiatric Association’s (2008) mandate that all psychiatric residency training programs teach long-term psychodynamic psychotherapy to meet standards of accreditation, the relevance and importance of this type of therapy were affirmed by the psychiatric establishment (Gabbard, 2010). Knowledge about psychodynamic psychotherapy is essential for all advanced practice psychiatric nurses (APPNs) to deepen understanding about development and how the patient’s history is reenacted in the nurse–patient relationship in therapy and in life. Even if the APPN is using another approach, it is still important to understand the person’s dynamics to inform decisions about treatment. The patient does not necessarily need to achieve dynamic insights to experience symptom reduction and personal growth, but developmental considerations, anxiety, transference, countertransference, implicit memory (unconscious), defenses, motivation, and resistance are relevant in any therapeutic encounter. Knowledge about psychodynamic theory is also important for APPNs to communicate with other mental health disciplines. The literature in nursing reiterates the importance of psychodynamic theory for understanding the psychodynamics in the nurse–patient relationship and the inner world of both the nurse and the patient (Gallop & O’Brien, 2003). These authors stress that without knowledge of psychodynamic psychotherapy, nurses are at a tremendous disadvantage and at risk for acting inappropriately and not in the patient’s best interests.Practicum – Assessing Client Progress Assignment

Psychodynamic psychotherapy requires intensive teaching and experience to attain competency. This chapter lays the foundation for the APPN who wishes to understand the basics of this approach. Competencies in psychodynamic psychotherapy include using developmental models to understand personality and psychopathology, formulating a psychodynamic explanation and plan treatment, tracking the issue that is the focus of treatment, implementing the process of therapy, and managing the relationship (Binder, 2004).

UNDERLYING ASSUMPTIONS OF PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy is derived from psychoanalytic psychotherapy, which was developed by Sigmund Freud at the end of the 19th century. This type of therapy is also referred to as insight-oriented, intensive, exploratory, expressive, and depth psychotherapy. Underpinnings of psychodynamics are rooted in developmental theory, with the basic premise that what has happened in the past determines what we are doing today. It is thought that through understanding these factors, the person is empowered and then free to make more conscious decisions and consequently live a more satisfying and useful life.Practicum – Assessing Client Progress Assignment

Blagys and Hilsenroth (2000), in an extensive review of the literature, identify factors that distinguish psychodynamic from cognitive behavioral therapy (CBT). These include emphasis on the past; focus on expression of emotion; identification of patterns in actions, thoughts, feelings, experiences, and relationships; emphasis on past relationships; exploration of and working with resistances that impede treatment; exploration of intrapsychic issues through asking about wishes, dreams, and fantasies; and emphasis on the transference and the working alliance. Gabbard (2010) identifies seven key concepts of psychodynamic psychotherapy: the unconscious, a developmental perspective, transference, countertransference, resistance, psychic determinism, and unique subjectivity. Gabbard explains unique subjectivity as the therapist’s challenge to pursue the patient’s subjective truth and true self, which most likely has been thwarted by parents who cannot recognize, validate, and appreciate this self. This is based on the underlying premise that we do not really know ourselves and that much of what determines our behavior is governed by unconscious memories.

Most psychodynamic schools emphasize the centrality of conflict among powerful desires, wishes, and fears. Psychodynamic clinicians believe that to help the person, it is essential to understand how these conflicts are enacted in the present. Psychodynamic theorists agree that understanding unconscious psychological structures and patterns in daily life, as well as how they interact and maintain each other, are essential ingredients to understanding the person (McWilliams, 2011; Wachtel, 2011). Wachtel points out that a key characteristic of this pattern is irony; the person ends up in the very position that he or she was trying hard to avoid. For example, the person who is fearful of feelings of anger may act overly nice, unassertive, and maintain a passive stance toward others. This allows others to ignore his or her needs and, consequently, he or she begins to feel frustrated and devalued, which leads to more anger and more anxiety, and the pattern is repeated. Another example is a person who fears hostility from others and interprets every interaction as potentially hostile, preemptively acting in self-protective hostility toward others, which evokes hostility from others, which leads to more anxiety, and so on (Figure 5.1)Practicum – Assessing Client Progress Assignment.

Anxiety is central to understanding these difficulties, and even if the person does not feel particularly anxious, defenses and characterological personality traits embedded in implicit memory systems bind the person to a life that is restrictive as compromises are made to keep anxiety at bay. Specific anxieties arise at every level of development, with various theorists positing different tasks based on various theoretical models (Tables 5.1 through 5.3). For each developmental stage, anxiety revolving around a specific issue is negotiated, and if successful, the fear surrounding that phase is assuaged so that the person is then able to proceed to the next stage without being preoccupied by that threat (McWilliams, 1999). For example, in early infancy, a major preoccupation is security, with annihilation the threat if the attachment to the mother is threatened or not present; for early childhood, the issue is autonomy, with the concomitant anxiety revolving around separation (i.e., how to be an independent agent and still maintain a relationship with the caregiver); for later childhood, issues of identity must be resolved, with fears of punishment, injury, and loss of control important to resolve. To regulate the anxiety associated with each stage and other painful affects, defense mechanisms develop in implicit memory networks through interaction with caregivers and interpersonal experiences.

FIGURE 5.1 Cyclical psychodynamics.

The job of the psychodynamic therapist is to help the person understand how fears and inhibitions in early life have led him or her to react to healthy feelings as if they were a threat and how this plays an active role in generating his or her difficulties in the present. The person inadvertently and consistently brings about consequences that are not consciously intended. The psychodynamic therapist uses interpretations to expose the person to previously avoided experiences combined with empathy in a safe therapeutic environment. Chapter 4 discusses interpretation. The focus of the interpretation depends on the school of psychodynamic thought the therapist subscribes to. This exposure is not just aimed toward intellectual understanding but emotional experiencing at a gradual pace. Re-experiencing painful affects allows adaptive processing so that dissociated or disconnected memory networks can be integrated with other, more adaptive neural networks (Cozolino, 2010)Practicum – Assessing Client Progress Assignment.

HISTORY

The history and theory of psychodynamic psychotherapy since Freud’s time are complex, and his ideas have undergone numerous permutations and iterations. This evolution has paralleled paradigm shifts in science in the 20th century, which emphasize interconnections, mutual interactions, and subjectivity of phenomenon (Curtis & Hirsch, 2003). Each psychodynamic model evolved from the others before establishing a new perspective placing different emphases on human development and motivation for behavior. New perspectives addressed what was seen as the failure of Freud’s theory (Mitchell, 1988). These competing schools of thought—Freudian, ego, self, existential, Lacanian, analytic, object relations, interpersonal, relational, and intersubjective—are somewhat insular and fragmented in that each seems to take little notice of the others. Each school developed its own theoretical constructs and techniques. The following overview highlights selected theorists and does not do justice to the complexity, richness, and nuances of psychoanalytic theory.Practicum – Assessing Client Progress Assignment

TABLE 5.1 Freud’s Psychosexual Stages

Adapted from Sadock, Sadock, and Ruiz (2009).

Sigmund Freud’s classic model of psychoanalytic psychotherapy is based on drive theory; that is, all behavior is determined by unconscious forces or instincts, either sexual or aggressive. Freud’s structural model of the id, ego, and superego explains the idea of psychic conflict. Symptoms are thought to develop through a conflict between an instinctual wish (id) and the defense against the wish (ego). The superego is part of the unconscious that is formed through internalization of moral standards of parents and society, and the superego acts to censor and restrain the ego. The concept of psychic determinism is embedded within this model and refers to the idea that nothing happens by chance and that everything on a person’s mind and all behavior, pathological and nonpathological, has a cause and is multiply determined. Freud delineated the psychosexual stages of development based on the idea that libidinal energy shifts from various erogenous zones in each stage. Freud posited that if a person had not successfully negotiated the previous stage, specific problematic character traits or psychopathology would continue throughout life (see Table 5.1).

In the 1960s, the scope of psychoanalysis was widened by interpersonal theorists such as Harry Stack Sullivan, Karen Horney, and Eric Fromm, who stressed the importance of relationship. Sullivan believed that the details of the patient’s interactions with others provided insight into what would help resolve intrapsychic difficulties. Using Sullivan’s framework, Hildegard Peplau developed the psychodynamic interpersonal model for psychiatric nursing. Sullivan’s perspective of the therapist as participant–observer expanded the prevailing paradigm. Sullivan believed that the therapist was not just a passive observer of what was going on in the patient but was a participant in the process of psychotherapy.Practicum – Assessing Client Progress Assignment

TABLE 5.2 Mahler’s Stages of Separation–Individuation

Adapted from Mahler, Pine, and Bergman (1975).

Ego psychology and object relation theorists such as Margaret Mahler followed with increased emphasis on relationship in producing change. Mahler’s object relation theory evolved from her observations of infants and children and analysis of this qualitative data (Mahler et al., 1975). Stages of development based on separation–individuation were described and explanations were offered about how children develop a sense of identity separate from their mothers (see Table 5.2). The infant is described as being totally dependent, with relatively little self–other differentiation, and the child develops through a relationship into a separate person with a high degree of differentiation.

Klein and Fairburn combined intrapsychic theory and drive theory with the idea that the primary motivation of the child is to seek objects (Curtis & Hirsch, 2003). Object means the internalization of experiences with other people. Object relation theorists posit that people are primarily motivated to seek other people and that this is the central motivating force in development rather than drive gratification (Winnicott, 1976). Winnicott (1976) speculated that for a child to develop a healthy, genuine self, as opposed to a false self, the mother must be a good enough mother, who relates to the child with primary maternal preoccupation. The child then can grow and explore without overwhelming anxiety feeling that the world is safe. The child develops a sense of me and those aspects that are not part of him or her create a potential space between himself or herself and the mother. This is the area of play and is an important dimension of the developing self. Winnicott (1976) said that the therapist’s chief task is to provide a holding environment for the patient so that the patient can have the opportunity to meet neglected ego needs and allow the true self to emerge. In contrast to the good enough mother, the not good enough mother is thought to create a dynamic in subsequent relationships in adult life, in which the person feels never good enough. Alice Miller (1981) in her widely recognized book, The Drama of the Gifted Child, describes eloquently the adverse effects of certain types of parenting on the development of the child’s true self.Practicum – Assessing Client Progress Assignment

Building on Freud’s ideas about intrapsychic conflict, Erik Erikson, a lay psychoanalyst, expanded the theory of development to encompass the entire life cycle. He conceptualized life as a struggle of conflicting needs in the quest toward self-actualization (Erikson, 1964). These conflicting needs revolved around the need for stability versus the need for growth at each stage of development. Table 5.3 shows Erikson’s stages of development. As we move from infancy to old age, Erikson posited that we face a stage-specific conflict that involves themes of inhibition versus desire. Although similar symptoms may be experienced in each stage, each of the eight stage-specific conflicts may have a different meaning, depending on unique issues and emotions for that particular stage, and success at resolution depends on how successfully the person has negotiated the previous stages.

TABLE 5.3 Erikson’s Psychosocial Stages

Adapted from Erikson (1964, 1968).

For example, a 21-year-old woman came to therapy after being raped in college. She had become significantly depressed and attempted suicide shortly after the rape. Her depression reflected a loss of identity that was shattered beyond repair. She had previously functioned as her parents expected her to and was generally motivated to meet others’ expectations. Her depression precipitated an exploration of her own values and who she really was, a process that gradually allowed her to rebel against the need to conform. Finding her own voice was integral to the treatment, and she eventually was able to articulate the differences between her opinions and those of her parents. Her depressive symptoms represented the conflicting need for stability and conformity versus the need for self-awareness and growth.Practicum – Assessing Client Progress Assignment

Significantly departing from the idea of intrapsychic conflict, Heinz Kohut developed self psychology based on a deficit model of development. Kohut posited that the self was the central organizing frame of reference and that the self seeks out responses from others to maintain self-cohesion (Kohut & Wolf, 1978). Contrary to Freud’s conception of the individual as primarily being driven by the quest for pleasure, Kohut’s self strives for competence, self-esteem, and order, and these are the sine qua non motivators of behavior. Others serve self-object functions for the individual, and these include mirroring, idealizing, and alter-ego experiences. Individuals never lose the need for self-object experiences throughout life. However, if self-object experiences are less than adequate in early life, the person may later in life have difficulty with self-soothing, self-regulation, and maintenance of self-cohesion. Kohut based this idea on the clinical observation that a certain subgroup of patients developed an idiosyncratic transference in therapy, which he called the narcissistic transference. These patients, unlike the typical analytic patient, needed mirroring and idealized the analyst. Those with this type of self-pathology formed attachments based on these needs. Kohut posited that empathy played a central role in the psychotherapy of those with narcissistic psychopathology.

The relational model evolved in the 1980s from object relations, self, interpersonal, existential, and feminist models. This significant shift in the psychoanalytic paradigm changed what was called a one-person psychology to a two-person psychology (Gabbard, 2010). This awareness of two separate minds interacting with one another is also referred to as intersubjectivity. The therapist is considered a coparticipant in the co-construction of the relationship, not an outside observer. It is only in the present moment as the process is unfolding that both participants’ understanding is deepened. The need for relationship derives from the physical closeness to the mother and is thought to be the prime motivator for behavior. The presence of the other is necessary and inescapable in human development and in the therapeutic relationship. Self-regulation results from mutually regulatory interactions with caretakers and evolves within the mother–infant dyad. Relational psychodynamic theory heightens our understanding about the need for attachments for psychophysiologic stability.Practicum – Assessing Client Progress Assignment

Schore’s (2012) neurobiologic research and theory on attachment provides a scientific basis for the importance of relationship to therapeutic action in psychotherapy. The growing capacity to self-regulate is contingent on transformations of underdeveloped functions that exist in the infant through early attachment experiences that assist the developing psychobiologic, homeostatic regulatory processes. Cumulative early attachment problems are thought to produce chronic dysregulation in central and autonomic arousal, with deficits in mind and body. Chapter 2 discusses the neurophysiology underlying this dysregulation. Problems in self-regulation include difficulties in tension regulation, such as in addictive disorders, eating disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder, and mood disorders.

A basic tenet of the contemporary relational model is that the therapist and patient are always participating in a relational configuration and that understanding this process is how change occurs. Before relational theory, much discussion ensued about the differences between the transference relationship and the real relationship between the therapist and patient. The transference and the patient’s feelings toward the therapist were artifacts of the past, whereas the real relationship was what was going on in the present. In the relational model, however, this is irrelevant because there are multiple truths and there is no real relationship, only a co-constructed interaction that is at best subjective (Gabbard, 2010). This interaction coupled with mindfulness is the agent of change, and developing and repairing problems in the therapeutic alliance are considered the work of relational psychodynamic psychotherapy.Practicum – Assessing Client Progress Assignment

Embedded in this idea of multiple truths is the concept of multiple selves; there is no unitary true self, but each person is constructed with many self-states. Different self-states are based on the various states of consciousness that we flicker in and out of throughout the day. Chapter 2 discusses the neurophysiology supporting this idea. These shifting, multiple self-states elicit complementary self-states in others through relationship. Dissociated self-states that are experienced as potentially dangerous are kept from the person’s awareness. By potentially dangerous, Safran and Muran (2000) explain that these states are associated with actual traumatic experiences or disruptions of relatedness to significant others. Assisting the patient to experience and accept the various dimensions of the self through enhanced awareness of these traumatic states is considered crucial to the relational psychodynamic therapy process.Practicum – Assessing Client Progress Assignment

A synthesis of the literature on the relational model reveals significant differences between Freudian psychodynamic psychotherapy and relational psychodynamic therapy. Table 5.4 compares and contrasts these models.

EVIDENCE-BASED RESEARCH

Studies of the efficacy of psychodynamic psychotherapy began in earnest only within the past 10 years because this type of therapy developed outside of universities and the academic world (Shedler, 2010, 2011). Education and training in psychoanalysis took place in institutes that were open only to medical doctors and excluded psychologists who are trained in research methodology. However, several compendiums of psychoanalytic research published within the past 10 years have attempted to address this deficiency by presenting reviews of psychodynamic research (Fonagy 2002; Levy & Ablon, 2009). These volumes report positive results for psychoanalytic psychotherapy.

TABLE 5.4 Comparison of Classical Psychodynamic Therapy With Relational Psychodynamic Therapy

The late start for research on psychodynamic therapy does not demonstrate that this approach is not effective, but it may more accurately reflect the difficulties in experimental controlled design for this approach. Numerous methodological problems for research on psychodynamic psychotherapy have been identified, because psychodynamic techniques do not lend themselves to the precision required for a clinical trial (Curtis & Hirsch, 2003; Gabbard, 2010). The problems cited in the literature include the following:

  1. 1.  Manualized, structured protocols, such as CBT and interpersonal psychotherapy (IPT), are easier to systematically evaluate.Practicum – Assessing Client Progress Assignment
  2. 2.  There is great difficulty in randomizing subjects, which is the gold standard of experimental design. Patients who want to engage in psychodynamic psychotherapy must be motivated to engage in the self-reflected exploration needed and are self-selected.
  3. 3.  If the treatment is long term, which some psychodynamic therapies are, the costs would be too great to follow patients over time.
  4. 4.  Funding is lacking for studies in psychodynamic psychotherapy.
  5. 5.  The complexity and variety of psychodynamic approaches and technique make adherence to a specific model for intervention in an experimental design difficult.
  6. 6.  Because subjectivity and context are embedded in the psychodynamic process, it is not possible to study by traditional objective scientific inquiry.
  7. 7.  Most psychodynamic research consists of case studies, which limits the ability to generalize to other situations and populations.
  8. 8.  Outcomes involve internal change for psychodynamic psychotherapy, which is difficult to quantify.
  9. 9.  Randomized clinical trials focus on patients with one specific diagnosis and symptom measurement. Patients treated with psychodynamic therapy present with complex problems that usually are not limited to one disorder.

Despite the above limitations, many randomized clinical trials in the literature report positive results. The most compelling evidence includes meta-analytic studies of randomized clinical trials which are considered the most effective statistical method for synthesizing the findings of many studies through using effect size as a comparison. Effect size is the difference between the control and experimental groups with a 0.8 indicating a large effect size, 0.5 a moderate effect size, and 0.2 a small effect size. A review of meta-analytic studies of psychodynamic studies reveals overall large effect sizes for pretreatment to post-treatment outcomes. See Table 5.5 for selected meta-analytic studies. The large effect sizes for psychodynamic psychotherapy 0.69 to 1.46 are impressive but even more so when compared with studies of the U.S. Food and Drug Administration (FDA) research, which found effect sizes for fluoxetine (Prozac) of 0.26, for sertraline (Zoloft) of 0.26, citalopram (Celexa) at 0.24, and escitalopram (Lexapro) at 0.31 (Turner et al., 2008).

In addition, larger effect sizes are reported for follow-up outcomes than immediate post-tests after treatment for those studies that included this measure (Shedler, 2010). What this suggests is that the patient continues to change for the better after leaving therapy. This indicates that the changes are enduring and extend beyond symptom remission. As a result of this research, numerous practice guidelines include psychodynamic psychotherapy as a treatment for various psychiatric disorders (see Table 5.6).Practicum – Assessing Client Progress Assignment

PSYCHODYNAMIC CONTINUUM

Psychodynamic psychotherapy can be seen as a continuum from supportive psychotherapy to expressive to psychoanalysis using the practice treatment hierarchy from Chapter 1Figure 1.6, as an overall framework for practice. The goals and focus of each type of psychodynamic psychotherapy differ, with the supportive end of the continuum aimed toward stabilization through restoring functioning, reducing anxiety, strengthening defenses, and more effective problem solving, whereas the psychoanalytic end of the continuum is aimed toward processing through interpreting unconscious conflict and gaining insight (Gabbard, 2010).Practicum – Assessing Client Progress Assignment

Expressive and psychoanalytic therapies involve more emotional processing than supportive psychotherapy with periods of stabilization alternating with processing, and therapy often shifts back and forth along this continuum. Chapter 1 (Figure 1.8) addresses the treatment process spiral that illustrates the process of psychotherapy. The degree to which the therapy is supportive versus psychoanalytic is based on the focus on transference issues and the frequency of sessions (Gabbard, 2010). In moving toward the psychoanalytic end of the continuum, the transference interpretations increase, as does the number of sessions per week. Through transference, unconscious conflicts are illuminated and then worked through. By increasing the number of sessions per week, it is thought that the transference intensifies, which is desired in psychoanalytic psychotherapy.Practicum – Assessing Client Progress Assignment

Along this continuum, some therapeutic communication techniques may be more appropriate for stabilization and others aid in processing. See Figure 5.2 on treatment hierarchy, psychodynamic continuum, and communication. Briere and Scott (2013) describe the therapeutic window of emotional processing and say that activation of emotion must accompany the narrative to process the trauma. The APPN helps the patient to modulate experience through questions that increase or decrease activation. As described in Chapter 4, the communication techniques considered to be more supportive are less emotionally laden and appropriate for stabilization, whereas those higher on the treatment triangle may trigger processing and implicit neural networks. Without the proper resources, this may be experienced as overwhelming accompanied by unmanageable feelings. The supportive techniques are considered to be resource building and less anxiety provoking. Thus, for patients who require primarily stabilization through supportive psychodynamic psychotherapy, the communication techniques toward the lower level of the treatment hierarchy are most often used. Supportive communication alternating with those communication techniques higher on the treatment hierarchy are appropriate for the emotional processing that occurs in expressive and psychoanalytic psychotherapies.Practicum – Assessing Client Progress Assignment

TABLE 5.5 Selected Meta-Analytic Studies of Psychodynamic Psychotherapy

Adapted from Shedler (2010).

BT, behavior therapy; CBT, cognitive behavioral therapy; PT, psychodynamic psychotherapy; sx, symptoms; tx, treatment.

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TABLE 5.6 Practice Guidelines for Psychiatric Disorders

FIGURE 5.2 Psychodynamic case formulation.

Using communication techniques that are expressive to increase arousal may be needed for avoidant patients. These techniques may include immediacy, interpretation, observation, and focusing, depending on the psychotherapy approach being used. Another strategy to increase activation is to ask the person to go over the memory slowly in detail using the present tense. The amygdala is thought to hold memory in the present tense because it has not yet been processed. The narrative naturally shifts from what is happening to what did happen after processing has occurred. The greater the detail of the event narrated in the present tense, the greater the activation and the processing of traumatic material (Briere & Scott, 2013).

Processing involves exposure to the trauma and assisting the person in constructing a narrative through the exploration of the meaning of significant small and large traumas that impair functioning. The emotional dimension of the memory is essential for full processing to occur. Emotions are embedded in body sensations so that both in tandem are experienced during processing. Talking about the event without the attending emotions or body sensations may be an intellectual exercise only and preclude total processing. Briere and Scott (2013) emphasize that much of trauma activation and processing occurs at implicit, nonverbal, often relational levels.Practicum – Assessing Client Progress Assignment

Abreactions are intense emotional reactions to painful experiences that have been repressed. Chu (2011) delineates common phases that occur during abreactions: increased symptoms; intense internal conflict; acceptance and mourning; and mobilization and empowerment. Patients who do not have the capacity to withstand the intense feelings that occur during abreaction may instead use dissociation, substance abuse, distraction, and other avoidance responses (Chu, 2011). Avoidance responses may take the form of missing sessions, lateness to sessions, increased distress, or self-injurious or impulsive behaviors after sessions. Therapists not skilled in working with abreactions should heed these signs as indicators that the therapeutic window for processing has been exceeded.

When overactivation or abreaction occurs, suggestions include shifting the focus away from the trauma with breathing exercises or relaxation techniques; directing the person’s attention to less disturbing material; focusing on only one aspect or dimension of the experience such as the sounds or body sensations; distraction; using supportive communication techniques that are dearousing and supportive (see Figure 5.2) emphasizing intensity of emotion as doing good work; explaining activation before and after processing to normalize the person’s reactions; problem solving with the person to help mediate hyperarousal; using the safe place or container exercises (see Appendices 1.7 and 1.8); conveying optimism; and stabilizing with other affect management strategies (Briere & Scott, 2013). If the person is abreacting, do not touch the person or make any sudden moves, and allow for personal space.Practicum – Assessing Client Progress Assignment

Periods of processing are often followed by periods of destabilization. The APPN paces and structures treatment so that work on traumatic material alternates with resources, such as grounding and containment. “Trauma should not be the focus of session after session. Instead, as material is retrieved, it is much more important to process that material in a manner that allows the patient to remain stable than it is to move on to find and/or deal with more material” (Kluft, 1999, p. 15). As Kluft points out, slower is faster because the overall therapy time is reduced if treatment is relatively stable. Periods after processing may include feelings of increased sadness, anxiety, loss of control, or confusion. Sometimes, normal functioning is impaired, and the person may become suicidal or unable to function, especially if there are memories of childhood abuse. More sessions per week sometimes offer more support, and the person then can have the opportunity to move beyond crisis intervention to address deeper underlying difficulties (Kluft, 1999).

The APPN emphasizes the importance of maintaining supportive relationships and regular activities because these provide a positive sense of self and allow the work to continue. If the crisis is not averted quickly, this is an indication that the patient is not ready to continue with emotional processing. Hospitalizing the person to process trauma only furthers regression and is counterproductive unless needed to ensure patient safety. As illustrated in Figure 1.8 in Chapter 1, the treatment process often looks more like a spiral alternating interventions aimed at stabilization and then processing leading toward integration and future visioning. As life happens and job loss, serious illness, and other events may lead to destabilization, it may be necessary to stop processing and move to stabilizing again in the course of treatment.Practicum – Assessing Client Progress Assignment

Siegel (2012) posits that coherent narratives facilitate processing and interhemispheric integration. The left brain, which is language based, interprets the emotion-based autobiographical content of the right brain. Chapter 2 discusses right- and left-brain functions. The narrative in psychotherapy as told to an empathic other links self-states that have become dissociated due to trauma (Howell, 2005). This integration is considered the heart of mental health, with the successful resolution of trauma creating a deep sense of coherence (Siegel, 2012). The narrative helps the person to reconstruct a chronology to make sense of the experience by providing a context for time with a beginning, middle, and end. Research supports that through the reconstruction of the narrative, posttraumatic symptoms are reduced (Amir et al., 1998). Because the disturbing experience is disconnected from other dimensions of the person’s experience, it is important that the person integrate the event into his or her life and create meaning, allowing for closure. The literal recall is not as important as the meaning of the event to the person and how his or her sense of self or identity has been impacted.

As patients begin to accept what has happened, new perspectives about long held assumptions begin to shatter. Those who have suffered abuse typically have conflicts in many areas of life. For example, one young woman who had been sexually abused by her father as a child felt intense shame about not having been good enough to stop the abuse. She had both love and hate for her father and, consequently, for herself. Her ambivalence was reflected in many areas: “I was loved/I was hated; I was powerless/it was my fault.” These intense ambivalent feelings were extremely painful, repressed, and reflected entrenched neural networks of thought, emotion, and sensations. As she began to see her father more realistically, she was able to reformulate a more accurate view of herself. Over time, she began to see herself as a survivor instead of a victim. The reworking of traumatic material occurs over time in different ways. The person begins to understand the various elements of what happened and then understands the same event and sense of self in a different way at a later date.Practicum – Assessing Client Progress Assignment

Another patient, a man who suffered horrific physical abuse from his sadistic father, examined various aspects of this situation. First, he understood and experienced the betrayal and pain he felt because of his father and, subsequently, he also understood the event as betrayal and humiliation by his neglectful mother, who did not intercede and passively witnessed his abuse. He then examined how this reverberated into all areas of his life, such as his feelings about himself in relationships, difficulty setting boundaries, inability to make decisions, lost job opportunities, self-esteem issues, somatic symptoms, difficulty managing feelings and self-soothing, and poor coping skills. Changes in physical and emotional responses occurred as the fragments of the traumatic memory from the past were integrated with other more adaptive networks. The emotions elicited from the retelling are likely to be intense, and this expression is encouraged. Eventually, the events no longer increase emotional arousal after they are fully processed. Over time, memories are woven into a narrative reflecting the integration of neural networks as new information is learned.

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Educating the person about relapse prevention is important. The patient may always be vulnerable to symptoms when re-exposed to stress because high states of arousal may promote retrieval of state-dependent memories, sensory information, or behaviors associated with prior disturbing experiences if the memories have not been fully processed. A plan for how to manage these times should be discussed, and this includes reviewing resource materials to enhance coping skills and booster sessions at vulnerable times. Explain to the patient that these high-risk periods may include developmental changes, periods of elevated stress, or reminders of partially processed traumas. Traumas that have not been previously identified may also be triggered at these vulnerable times. Resources should be increased prophylactically during these times.Practicum – Assessing Client Progress Assignment

Supportive Psychotherapy

Frequently, supportive psychotherapy is recommended, and it is assumed that the therapist knows what this entails without training. Supportive psychotherapy is psychodynamic in that it is based on a knowledge of the patient’s psychodynamics, which shapes the approach, but the goals of treatment differ considerably. Whereas psychoanalytic psychotherapy aims to restructure defenses and change personality organization through interpreting feelings, fantasies, and beliefs, supportive psychotherapy aims to strengthen defenses, promote problem solving, restore adaptive functioning, and provide symptom relief. Left-brain frontal cortex problem-solving abilities are greatly impaired in some patients because of personality organization structure or current life stressors that have precipitated regression to an earlier stage of functioning. Supportive psychotherapy is indicated to assist the person in stabilization, as illustrated by the treatment hierarchy in Figure 1.6 in Chapter 1. This involves increasing external and internal resources.

In A Primer of Supportive Psychotherapy, Pinkster (1997) says that the supportive model is the preferred model for most patients and that it is only when the goals of treatment cannot be met through this model that more expressive therapies should be employed. Although Figure 5.3 indicates that supportive therapy is for those who are on the psychotic end of the continuum, it is the treatment of choice for healthier patients too. Most clinicians believe that the decision about whether to use supportive psychodynamic psychotherapy should be based on the person’s ego strength and weaknesses, coping skills present, highest level of functioning previously achieved, recent losses, and other life stresses and circumstances (Hollender & Ford, 2000). In a seminal article, 16 basic strategies are identified as supportive (Misch, 2000) (see Table 5.7).Practicum – Assessing Client Progress Assignment

In assessing ego strength, it is important to identify the primary defenses the person uses to ward off anxiety. McWilliams (2011) lists the types of defenses most commonly associated with those in the psychotic level of personality organization and says these defenses are preverbal. These include denial, projection, splitting, primitive idealization and devaluation, withdrawal, omnipotent control, and dissociation. These defenses protect the person who is terrified of annihilation, lacks a basic security in the world, and is vulnerable to psychotic disorganization. Those in this end of the developmental continuum struggle with identity issues and confusion about who they are. Even if not overtly psychotic, the person is thought to be functioning at the symbiotic level of development, with little self–other differentiation. Some relational psychodynamic psychotherapists, such as Searles, Sullivan, and Fromm-Reichmann, advocate working with severe psychiatric disturbances such as schizophrenia using this model (Curtis & Hirsch, 2003).

Attachment research provides additional data for determining whether to use supportive or expressive interventions based on the person’s attachment style (Levy et al., 2011). See Table 2.1 in Chapter 2Attachment style describes the person’s fear of rejection, yearning for intimacy, and preference of interpersonal distance in relationships. Determining the person’s attachment style assists the APPN in understanding about where to intervene on the psychodynamic continuum. The Adult Attachment Interview (AAI) is a semistructured interview that measures attachment style by analyzing how the patient describes childhood experiences (see Chapter 3). Those who are characterized as unresolved/disorganized are unable to form a coherent narrative about their life, due to lapses in memory or reasoning; those with preoccupied attachment styles seem overwhelmed with early relationship experiences and are unable to elaborate a coherent narrative without being flooded with emotion; while securely attached individuals are able to communicate with coherence and emotional genuineness about difficult childhood experiences.Practicum – Assessing Client Progress Assignment

An unresolved/disorganized attachment style may need more active interventions that facilitate emotional expression and connection, whereas a preoccupied style may need more supportive interventions that help the person contain overwhelming emotions; those with a secure attachment are able to work productively anywhere on the continuum without customizing psychotherapy interventions. Preoccupied attachment has been strongly correlated with borderline personality disorder (BPD; Fonagy et al., 1996). Not surprisingly, the patient’s attachment style predicts the nature of therapeutic alliance and the outcomes of treatment. The therapist’s attachment style also influences treatment. One study found that therapists who measured as insecure on attachment tools tended to worry more about rejection and were less empathic with patients (Rubino et al., 2000).

TABLE 5.7 Basic Strategies of Dynamic Supportive Therapy

Strategy #1: Formulate the case Serves as a roadmap for future interventions; why does this person have this problem now; evolves as more information becomes available; involves a developmental assessment
Strategy #2: Be a good parent “…to the extent that the patient is functioning at a childlike level in significant domains of life, the supportive therapist assumes a parental role” (p. 175)
Strategy #3: Foster and protect the therapeutic alliance First and primary goal throughout the therapy; respect the patient with compassion, empathy, and commitment; align with the healthy parts of the person; collaboratively set goals and strategies to attain these; interpersonally active treating the patient as the therapist would want to be treated
Strategy #4: Manage the transference Do need to explore the childhood experiences that underlie negative transference feelings but they must be corrected or the person may leave treatment; therapist acknowledges openly, explicitly, and nondefensively and/or apologizes
Strategy #5: Hold and contain the patient Provide empathy, understanding, soothing, helping the person to modulate affect, set limits when necessary, restrict acting out and impulsivity; may require medication and/or hospitalization; securing social services and so on while protecting the person’s autonomy
Strategy #6: Lend psychic structure Help as needed with reality testing, problem solving, impulse control, affect modulation, interpersonal awareness, social skills, and empathy
Strategy #7: Maximize adaptive coping mechanisms Support high level of defenses such as humor, altruism, sublimation, rationalization, and intellectualization and decrease use of denial, splitting, projection, and acting out; enhance coping skills such as mindfulness, dialectical behavior therapy and cognitive behavioral strategies to build distress tolerance skills and emotional regulation
Strategy #8: Provide a role model for identification Use judicious self-disclosure; be present, available, and real
Strategy #9: Decrease alexithymia Help the person to identify and name feelings; focus on somatic sensations associated with particular emotions; encourage use of metaphor to describe feelings
Strategy # 10: Make connections Make associations between an event or situation and the person’s feelings such as how false negative beliefs about himself or herself have undermined self-esteem and prevented the person from setting and/or achieving goals, seeking out healthy relationships, and so on
Strategy #11: Raise self-esteem Foster competency in real skills; role play skills; correct cognitive distortions; unravel unconscious guilt; normalize thoughts, feelings, and behaviors; explain why counterproductive behavior in the present may have been adaptive attempts to deal with earlier adverse life situations Practicum – Assessing Client Progress Assignment
Strategy #12: Ameliorate hopelessness Use CBT, reframing, case management such as helping the person to obtain disability, housing, job, transportation, community resources
Strategy # 13: Focus on the here and now Address primary issues: (1) safety, (2) therapy interfering behaviors, (3) future-foreclosing events or plans, (4) treatment noncompliance, (5) negative transference
Strategy #14: Encourage patient activity Help the person to take action through setting concrete behavioral goals, devising a plan of action, behavioral rehearsal, role playing, relaxation, visualization, imagery, graded exposure, and serving as cheerleader for patient efforts
Strategy #15: Educate the patient and family Teach about medication(s) side effects and so on, diagnosis/illness, relapse symptoms, specific tasks or functions that the person cannot do on his or her own
Strategy #16: Manipulate the environment Intervene as appropriate with agencies or persons in order to advocate for the person; do for the person what he or she cannot do for himself or herself always with an aim toward maximum independence and growth

In supportive psychodynamic psychotherapy, the content of sessions most often focuses on feelings, life stresses, and problem solving, rather than on defenses. The therapeutic techniques most helpful in supportive psychotherapy are on the lower end of the continuum of therapeutic communication. Although giving advice is not on the continuum, it is sometimes prudent to offer a suggestion when the person cannot problem solve. Suggesting that someone see an attorney if it is apparent that there is an impending legal problem and suggesting that a patient see a medical specialist if those services are necessary are two examples of situations in which it is appropriate and necessary to offer a strong suggestion. It would be remiss in these situations to not offer this type of advice. In contrast, the therapist should not offer suggestions in some cases: suggesting that someone go to church, take a vacation, join a singles club, go back to school, or try online dating. These types of suggestions are imposing the APPN’s values on the patient, and shifting the responsibility away from the patient to the therapist, which also encourages dependency and regression. Another way to help the person problem solve without giving advice is to explore alternatives of action, expanding the possibility of choices with the person.Practicum – Assessing Client Progress Assignment

Often, supportive psychotherapy is most useful for people who need clarification and help in sorting out issues that they would be able to do under other circumstances. Patients may need to discuss situations, sort out the alternatives, and express feelings. Supportive psychotherapy focuses on safety, education, and assisting with enhancing coping skills. For example, Mrs. J came to therapy on the suggestion of her friend because of a crisis in her marriage. She recently found out her husband was having an affair and was quite despondent. She felt lonely, isolated, and useless. The therapist listened attentively as Mrs. J described her 30 years of marriage, the early years of their relationship, and her inability to forgive her husband. She felt stuck in her grief and anger and could not decide what course of action, if any, to take. The therapist suggested that it is sometimes better to wait to make decisions until feelings are clearer and that they would together explore the possible consequences of various courses of action. Through expressing her anger toward her husband in therapy, she felt somewhat better and was only then able to begin to examine other dimensions of disappointment that had been present in their relationship for a long time.

Sometimes, catharsis is all the person wants or needs from the therapy, without resolution of conflict. This is true especially in grief and the mourning process. Expression of feelings can be the first step in acknowledging other, more painful affects. For example, anger often masks underlying hurt, and anxiety often masks underlying anger. Through empathic exploring and open-ended questions, the person is gently guided to a full expression of the nuances of emotion. One caveat is warranted: With patients who are histrionic or overly emotional, emotion may need to be contained rather than freely expressed, and affect regulation strategies may be needed before encouraging emotional expression. Chapters 13 and 14 discuss specific affect management strategies. The objective for supportive psychotherapy is to restore emotional equilibrium as quickly as possible.Practicum – Assessing Client Progress Assignment

Expressive Psychotherapy

The psychodynamic treatment of choice for those with borderline character structure is expressive psychotherapy (McWilliams, 2011). The American Psychiatric Association (APA) guidelines for BPD state that psychodynamic psychotherapy is the psychotherapy of choice, along with dialectical behavior therapy (APA, 2010). Oldham (2005) reaffirms in a Guideline Watch that psychotherapy represents the core or primary treatment for BPD, with symptom-targeted psychopharmacology a secondary helpful adjunct. Those with borderline character structure as defined by McWilliams do not necessarily have a DSM-IV-TR diagnosis of BPD but may encompass BPD and a wider diversity of diagnostic categories that rely on primitive and immature defenses and include those with BPD. These individuals are not consistently in the mature spectrum of healthy defenses, and under stress, they may even appear psychotic; hence, the term borderline is used. Defenses predominately include projection, acting out, and splitting when under stress, but higher-level defenses may also be used.

Some theorists speculate that the genesis of difficulties occurs around 18 months of age in the rapprochement phase of separation–individuation (Masterson, 1976). It is thought that the child who still needs reassurance about his or her budding autonomy is thwarted developmentally by an unavailable caretaker or one who discourages separation. The child learns that independence equals loss of love (i.e., abandonment) and that closeness is associated with dependence and therefore fears of loss of control (i.e., engulfment). These early attachment issues can lead to a variety of adult relational problems and reflect unresolved attachment trauma. The ability to form and sustain reciprocal interpersonal relationships is notably disrupted in individuals who have experienced early traumatic attachment patterns (Schore, 2012). This essential dilemma gets played out in all subsequent relationships, including the psychotherapeutic relationship, creating chaos and unstable ego states.Practicum – Assessing Client Progress Assignment

Attachment trauma produces chronic problems in relationships, and processing relational trauma occurs largely through the therapeutic relationship. These individuals have difficulty in determining their own needs or sense of self and engaging in introspection. The relationally traumatized person has had to be hypervigilant, other directed, and accommodating to survive. This focus on other precludes the inner work needed to develop a coherent sense of self (Briere & Scott, 2013). The child who has been emotionally or physically abused or neglected in early life learns that he or she is not worth it and, due to cognitive immaturity, arrives at the conclusion that he or she must deserve such treatment. Consequently, the person views himself or herself as weak, helpless, and inadequate, existing at the whims of an inherently rejecting, unavailable, and hurtful other. These implicit schemas of worthlessness and helplessness become powerful organizing determinants of personality. Sometimes, an exaggerated façade of independence, willfulness, and self-sufficiency develops to counter these vulnerable feelings.

Most often, those with borderline personality structure are anxious, depressed, self-harm in crisis, and unable to tolerate ambivalence or defer gratification. These are individuals who are notoriously difficult to engage in treatment. Often, the precipitant for treatment is not because the person wants to change his or her personality, but because others have urged the person to seek help. These patients come to therapy with anxiety, depression, and dissatisfaction with their relationships. The challenge for the novice APPN is sorting out what to address first and what will be the focus of treatment. Because the person with borderline personality structure can appear to be high functioning and reality functioning seems intact, the nature of the underlying difficulties may not be readily apparent at intake.Practicum – Assessing Client Progress Assignment

As the transference evolves, it may take the form of idealizing or devaluing. The therapeutic relationship itself becomes a source of interpersonal triggers for implicit memories as the caring, empathic therapist often activates fears of abandonment. The growing feeling of emotional attachment to the therapist activates emotional responses from earlier childhood neglect or abuse experiences. These responses are often intense and may seem irrational and inappropriate. The therapist’s first clue of a rupture in the therapeutic alliance may be the person’s reaction to a comment that is intended to be helpful but the patient reacts as if attacked. For example, a man who is describing how angry he is that his boss is critical of him is asked by his therapist, “Does your boss remind you of anyone?” A higher functioning patient would most likely consider the question and answer, whereas the person with borderline personality structure may hear this as an accusation or criticism and feel angry at the therapist’s perceived lack of attunement and “judgmental” comment.

However, it is important to note that processing may be on an implicit level and may not always occur in words (Briere & Scott, 2013). Emotional processing can occur without higher processing systems of the brain that involve explicit memory. For example, conditioned responses of shame or anger associated with abandonment and/or self-hatred present in implicit memory as a consequence of relationship or attachment trauma are triggered through relationships in the present with the therapist as well as with significant others. Within the safety of the therapeutic relationship, counterconditioning occurs so that over time these schemas are not reinforced and the positive feelings of the therapeutic relationship allow new learning to occur.Practicum – Assessing Client Progress Assignment

Expressive psychodynamic therapy provides a vehicle for processing relational trauma through an ongoing therapeutic relationship over time. Briere and Scott (2013) identify healing components inherent in this approach:

  1. 1.  The therapist offers consistent support for introspection through exploration, which allows the patient to develop an articulated and accessible sense of self.
  2. 2.  The relationship itself provides a safe forum for activating and providing exposure to relational trauma.
  3. 3.  The disparity between the therapeutic relationship and the expectation of abuse or neglect is demonstrated and experienced.
  4. 4.  Counterconditioning occurs when the patient perceives safety, nurturance, and acceptance in the session and, consequently, fear is diminished.
  5. 5.  Desensitization occurs as relationships are no longer perceived as dangerous, and triggers of fear, anger, distrust, and avoidant behaviors are changed so that relationships are seen as a source of support rather than pain.

As the therapeutic relationship deepens over time, the inevitable dependency of the patient provides an opportunity to rework these implicit memories so that new learning can occur. The therapist does not encourage dependency but does provide support and caring in a nurturing environment so that the patient can safely re-experience childhood implicit relational memories.

McWilliams (2011) says that the overall goal for expressive psychodynamic psychotherapy is the development of an integrated, complex, and positively valued self. This means that the person is able to tolerate ambivalent feelings and self-regulate emotions. Although there is no universal agreement about how to work with patients who have borderline character structure, several general principles of working in expressive psychodynamic psychotherapy with these individuals have been delineated: establishing consistent boundaries, using empathy before all interpretations, focusing on the here and now, asking the patient for help, rewarding assertiveness, discouraging regression and dependency, decreasing arousal levels so that communication can be heard, and understanding countertransference.

Countertransference is particularly challenging in working with those with borderline character organization. Even experienced therapists seek supervision when working with these individuals. It is thought that powerful unconscious communication occurs with these patients, even more so than with those psychotically or neurotically organized. The right-brain-to-right-brain communication often is more helpful in understanding the patient than what is actually said. Psychodynamic therapists call projective identification a specific type of countertransference that deepens the therapist’s understanding of the patient.Practicum – Assessing Client Progress Assignment

Projective identification is considered a defense mechanism and a countertransference constellation. It essentially involves behaving in such a way that subtle interpersonal pressure is placed on the therapist to take on dimensions of an experience or unconsciously identify with aspects of the patient (Gabbard, 2010). Projective identification is a type of concordant countertransference, as described in Chapter 4, in which the therapist identifies with an aspect of the patient’s experience (empathy). For example, a therapist may begin to feel afraid of the patient as the person is talking, which does not seem related to what the person is talking about. This out of the blue feeling may reflect the patient’s own fear being projected onto the therapist, and the patient does not have the feeling, but the therapist does. Not only fear can be projected, but also anger, boredom, intrusiveness, passivity, and other feelings.

Or the therapist may identify with an experience that has been projected, which is known as complementary countertransference. For example, the therapist begins to behave, think, and feel whatever the patient is projecting and as significant others felt when with the person. The therapist can identify whether this is occurring if the therapist begins to feel or act unlike herself. For example, the therapist begins to feel angry or is verbally abusive toward the patient. The challenge is for the APPN to identify the powerful feelings that occur during the session.

Although projective identification has been touted as a useful tool to deepen therapists’ understanding of patients, savvy therapists know that any feeling that may come up during a session may be from their own unconscious and not from a patient. Therapists should trust their own instincts but only after taking emotional inventory and responsibility for their own dynamics. Sometimes, projective identification is so powerful that the therapist may feel confused, and on reflection between sessions or with supervision, the therapist begins to sort out her contributions from that of the patient. Contemporary psychoanalysts feel that countertransference and transference are co-constructed, and as such, the therapist uses her own feelings as a barometer to understand the patient’s internal world only after considerable self-reflection. Relational psychodynamic psychotherapists believe that all transference–countertransference phenomena are forms of projective identification, in that the therapist unwittingly always lives out the reciprocal role of the significant other in the patient’s early life.Practicum – Assessing Client Progress Assignment

Psychoanalytic Psychotherapy

Patients who are considered ideal candidates for psychoanalytic psychotherapy are those with neurotic-to-healthy personality organization, who primarily rely on mature defenses. Some primitive defenses may be present, but along with these, mature defenses are also evident. These individuals have a sense of who they are, generally are in touch with reality, and have achieved object constancy. Object constancy refers to the capacity to be alone. When asked to describe others, they are able to give a fairly detailed account of the other person so that the APPN can get a clear picture of the person’s characteristics. The patient with a neurotic-level personality most likely has had some satisfying relationships and is experienced by the therapist as able to engage in a therapeutic alliance. These persons may come to treatment because of obstacles in love or work that they are uncomfortable about. Usually, they are the people who seek help without being forced. Problems for individuals with neurotic-level personality organization are often experienced as ego dystonic (i.e., alien to how they experience themselves). For example, patients may be troubled by disturbing thoughts about harm coming to them or loved ones. These experiences are felt as different from themselves, as ego alien. In contrast, persons with psychotically organized personality may be more likely to experience their problems as ego syntonic. This means that the problem is compatible with who they are, and these individuals often feel that it is others who have the problem, and they want reassurance, for example, that they have good reason to be paranoid or acting out.

If the person wants to understand himself or herself deeply and significantly change, psychoanalysis may be indicated. Psychoanalysis is more intense than psychoanalytic psychotherapy in that session frequency is increased and the transference is intensified. Sometimes, the person comes to treatment and has some initial psychotherapy and then decides to deepen the work and undergo psychoanalysis. Psychoanalysis generally takes three to five sessions each week and requires the amount of time for natural or normal maturational change (3–7 years). Many of the candidates for psychoanalysis are those in training programs to become psychoanalysts. Therapists who want to work in a deeper way with patients and understand that knowing themselves is a prerequisite to this work sometimes seek their own psychoanalysis without the structure of a formal training program. Traditionally, the basic methods of psychoanalysis involve free association by the patient lying on the couch, with the therapist sitting in back of the patient while listening and interpreting resistance and transference as these elements are manifested in dreams and considering what the patient says or does in and outside of sessions.Practicum – Assessing Client Progress Assignment

The development and facilitation of what is called the transference neurosis are integral to the process of Freudian psychoanalysis. The transference neurosis is a rerun of the developmental process through an intense relationship with the therapist. The patient feels toward the analyst feelings that were similarly expressed toward significant others in early development. This enactment and resolution of the transference are the work of psychoanalysis. The deep analysis of the relationship with the therapist distinguishes psychoanalytic therapy from other types of therapies. The transference is intensified with the increased frequency of sessions and the neutrality of the analyst. The analyst listens with evenly hovering attention, which means without preconceptions, absorbing what the person says with an attitude of nonjudgmental, empathic neutrality designed to create a safe environment. As the transference unfolds, the patient and analyst work together in understanding unconscious processes that are triggered in the therapeutic relationship.

CASE FORMULATION

In order for the APPN to decide on a relevant therapeutic focus, realistic expectations of treatment, and the appropriate type of psychodynamic psychotherapy to use, a dynamic case formulation is essential. In general, the shorter the length of the psychotherapy, the more intense the pressure to determine a therapeutic focus, and this is done through a psychodynamic formulation. Safran and Muran (2000) state: “It is the establishment of a dynamic focus and the consistent interpretation of that focus over time, as it emerges in a variety of different contexts that facilitates the working through process and allows the client to integrate treatment changes into his/her everyday life” (p. 178). As addressed in Chapter 1Figure 1.6, the hierarchy of treatment aims is helpful in this regard, but a more sophisticated psychodynamic understanding of development and defenses further refines treatment choice and informs the work of psychodynamic psychotherapy. The case formulation identifies a central issue that underlies the person’s presenting problem that is related to the person’s early developmental history. This involves conceptualizing presenting issues developmentally and understanding intrapsychic conflict. Three personality organization levels have been identified—neurotic to healthy, borderline, and psychotic—based on a synthesis of major developmental theories (McWilliams, 2011) (Figure 5.3).Practicum – Assessing Client Progress Assignment

These developmental levels may be thought of as a continuum ranging from neurotic to psychotic and that cuts across all diagnostic categories, because virtually all diagnoses are represented at each level. Some diagnostic categories are more heavily represented on one end of the continuum or the other, depending on the primary category of the defense used: primitive, immature, neurotic, or mature. Chapter 2 lists defenses in each category. In general, the person who uses primarily primitive defenses is more likely in the psychotic range of the continuum, and the person who primarily relies more on mature, higher-level defenses more likely is in the neurotic-to-healthy range. However, given enough stress, anyone can veer toward the psychotic end of the continuum. For example, the person with narcissistic traits can be primarily in the neurotic-to-healthy range, but with enough stress, the individual can slip into the psychotic end of the continuum. Under stress, we revert to methods of coping from earlier levels of development that feel similar to the current situation. Implicit memory networks of defenses are triggered by biochemical states reflecting state-dependent learning.

FIGURE 5.3 Case formulation and psychodynamic therapy.

McWilliams (1994) says that dynamically oriented therapists make an assessment based on the following: “People with a vulnerability to psychosis may be understood as fixated on the issues of the early symbiotic phase; people with borderline personality organization are comprehensible in terms of their preoccupation with separation–individuation themes; and those with neurotic structure can be usefully construed in more oedipal terms” (p. 53). The importance of determining the primary defenses of the patient and assessing ego functions in light of these developmental levels is to determine a dynamic case formulation and what type of treatment can be most helpful for the person at this time. Chapter 3 explains how to assess ego development. The core conflicts of the patient inform how to proceed psychodynamically with treatment more than a formal Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis.Practicum – Assessing Client Progress Assignment

A summary of the dynamic formulation should be shared with the patient and should be tentative, with some idea about how the therapist sees the nature of the work to be accomplished. For example, Michele, a 27-year-old French woman, came to therapy because she felt “confused, depressed, and was losing control.” She had several recent panic attacks accompanied by paranoid ideation, fearing that she might be attacked and possibly raped. At the end of the first session after taking her history, the therapist said: “The recent loss of your boyfriend has contributed to you feeling increasingly sad and panicky. We need to work on shoring up your resources so you can feel more in control when bad things happen. How does that sound to you?” The APPN felt that relational psychodynamic psychotherapy would be helpful but was careful to not overwhelm Michele with too much information in the first session. Later in treatment, after an alliance was more firmly established, the APPN fleshed out the dynamic formulation to Michele by suggesting: “Most likely, the absence of your mother’s presence in your early life and your father’s anger made you feel unsafe and prevented you from learning and developing the coping skills you need to stay on an even keel. It would be helpful to deepen your understanding of how you seem to end up in relationships that are not good for you.”

WORKING THROUGH

Working through is considered the heart of the therapeutic work. Freudian psychoanalysts see the working-through process as observing, clarifying, and interpreting defenses as manifested by the resistances and transferences again and again. However, relational psychodynamic psychotherapists emphasize working through as restructuring the person’s relational schemas through working with therapeutic impasses or ruptures in the therapeutic alliance. This “involves a recognition of how the relationship with the therapist reflects relationships from childhood and current extratransference relationships” (Gabbard, 2010, p. 170). Working through is the consistent interpretation of this dynamic focus over time. Rarely is there one insightful comment or interpretation that changes things dramatically. Rather, it is the repeated, consistent interpretation of the same themes and patterns as they are manifested in myriad situations and relationships. Both Freudian and relational psychodynamic therapists conceive that change occurs gradually and includes changing internal and external representations. Patterns of interactions are significantly changed with other people, and this is accompanied by changes in the patient’s internal representations or how the person perceives himself or herself and others. This change reflects adaptive information processing of memory networks that have been dysregulated or dissociated in implicit memory systems.Practicum – Assessing Client Progress Assignment

Emphasis in relational psychodynamic psychotherapy in the working-through process is on facilitating the development of the capacity for mindfulness (Safran & Muran, 2000). Mindfulness is the ability to observe internal processes and actions in relation to other people. This goal is conveyed to the patient at the outset of therapy. The APPN explains to the patient that how he or she feels with the therapist can also occur outside of therapy in other relationships. The patient is asked to monitor what dimensions of this situation are true or occur for him or her. The relational psychodynamic psychotherapist points out to the patient that with the therapist and with those outside of therapy, patterns of relating are similar and that these are fueled by the person’s early experiences. The therapist observes characteristic patterns of implicit relatedness and shares these observations with the patient, providing a new perspective that is different from the person’s own subjective impressions. Pointing out the person’s tendency to be controlling, demanding, dependent, or passive increases awareness of implicit modes of relatedness and the impact of these behaviors on others (Gabbard, 2010). This awareness often brings the patient a much greater sense of mastery, so that patterns of behavior can be reflected on before enacted in future relationships.

However, more than interpretations about relationships create change. The psychotherapeutic relationship itself provides a different relationship experience for the person so that new neural connections can be made. This inevitably leads to disillusionment as the person comes to accept his or her own separateness and that of the therapist, and it involves a mourning process in that the patient gives up an old way of being. Curtis and Hirsch (2003) state, “Salubrious new experience can only develop in a context in which old experience is first repeated, perhaps mourned, and let go of” (p. 81). Mourning the loss of possibilities and unhealthy relationships with significant others is considered curative because more energy is freed for current relationships. Unfulfilled desires are identified, tolerated, and then relinquished in a safe relationship.Practicum – Assessing Client Progress Assignment

The working-through process assists the person in recovering split off and dissociated aspects of the self that developed to maintain a relationship with parents. The person who has not been attuned to or who suffered trauma in early life has had to comply to survive, and a false self is thought to have developed. This false self lacks spontaneity and may result in a pervasive sense of unreality, futility, and lack of vitality (Safran & Muran, 2000). Relational theorists posit that there is not one false self, but multiple selves that need to be re-appropriated for the person to feel real and alive. These ways of being are embedded in important early relationships and templates of neural networks that at one time were adaptive. For example, the patient who was connected to her mother through chaos and unpredictability will experience sadness at giving up this state of consciousness, because this way of being is embedded in the fundamental attachment to the caretaker that ensured survival.

Various exploratory communication techniques assist in the working-through process. These include asking patients about their fantasies, daydreams, dreams, early memories, and ideas about what they perceive others are thinking, including what they imagine the therapist to be thinking. One way to help patients reflect on interactions outside of therapy involves helping them to experience situations fully by comments such as: “Imagine being there right now” (Curtis & Hirsch, 2003). Another exploratory technique is to observe and reflect what seems to be happening for the patient. For example: “You sound very angry today. I wonder what this is about?” Gabbard says this increases mentalization (i.e., mindfulness), which is the person’s ability to think about his or her own experiences and feelings, which invites further differentiation of emotions (2010). In a similar vein, if the patient reports an impulsive act, the therapist may ask what was going on just before that happened. Using open-ended, exploring communication allows patients to deepen their capacity for reflection. As a patient integrates emotional information that has been dissociated, a more robust sense of self develops that is grounded in the person’s own experience.Practicum – Assessing Client Progress Assignment

In contrast to cognitive therapy, in which there is a structured agenda for each session, psychodynamic psychotherapy is based on psychic determinism (Binder, 2004). This means that the patient’s spontaneous verbalizations will reveal affectively charged themes and that the person does not need to have a specific topic in mind but talks about whatever is on his or her mind that is relevant to the agreed problem focus. Those that are the most emotionally arousing and meaningful are current problematic relationships or past ones. This free association is thought to allow space so that the person’s own experience and ways of interacting can emerge. The therapist listens with the idea of discerning latent themes related to the person’s underlying conflicts and issues. The therapist asks herself: “What is the central issue here? What is going on now?” It is the therapist’s job to track salient themes and goals that were set at the outset of the treatment. Each session then is a continuation of the one before. What this means is that themes reverberate, threading throughout sessions, and what is talked about in the current session reflects issues that were salient at the end of the previous session. Taking good process notes at the end of each session helps in tracking these themes.

Integral to the working-through process is pointing out positive change and supporting the person’s strengths. The therapist points out positive changes to the patient and reframes experiences. For example, one patient who was struggling with rejection, neediness, and failed relationships was told by her therapist: “It is sad that things did not work out with Jim, but it seems that unlike past situations, you were able to see much sooner that your needs were not being met and to say what you wanted, rather than just hanging in there, hoping that things would change.” Encouraging risk taking and tolerating anxiety-producing situations through such comments provides the support needed and points toward positive change. Tempered comments without cheerleading are most effective; making the therapist happy is not the point of therapeutic gains. The idea that the patient changes to please the therapist is known as transference cure, and the therapist needs to be vigilant to ensure that the patient’s autonomy and self-actualization are the goal (Curtis & Hirsch, 2003).

Structuring challenging situations through gradual tolerance of anxiety-provoking situations can be done through psychoeducation, role playing, imagery, rehearsal, and modeling. For example, a man who came to treatment for marital problems was extremely passive in his relationship with his wife and often expected her to know what he wanted without articulating his needs. He grew up the youngest of six children with an angry father and depressed mother, and he spent much time alone in his room, withdrawing passively from the chaos around him. This typical response to conflict, coupled with his fear of rejection and his wife’s anger, paralyzed him in addressing anything with her that he was unhappy about. The therapist role-played a typical scenario, with the patient playing the role of his wife and the therapist playing his role. This exercise provided a new way of responding that he eventually was able to try at home. The role playing helped to build his confidence, see new ways of relating, and enabled him to deepen his understanding about his anxiety in a safe context.

Because problems in relating to others are a core focus in relational psychodynamic psychotherapy, the therapist helps the person to understand his impact on others, deepening understanding of other people, too (Wachtel, 2011). Flexibility in relationships is considered a sign of health, with healing defined as the ability to assimilate new experiences and to transcend the unhealthy identifications with others and constraints of the past (Curtis & Hirsch, 2003). For example, in the previous situation, the therapist pointed out to the patient “Given what you have told me about your wife, she seems to strike out and get angry when she is feeling neglected, and she likely feels neglected when you withdraw and do not communicate.” This type of comment enables the patient to see the cyclical nature of the patterns of relating that perpetuate the difficulties that the person is experiencing. In this situation, the patient’s passivity created the very situation that he was trying to avoid: his wife’s rejection and anger.Practicum – Assessing Client Progress Assignment

REPAIRING ALLIANCE RUPTURES

Many relational psychodynamic theorists believe that alliance ruptures are inevitable in therapy and that resolving these ruptures creates positive change (Binder, 2004; Safran et al., 2011). Any psychotherapy that goes too smoothly is thought to be an accommodation of the person’s false self to the therapist and is likely to remain superficial without really changing anything. In general, the therapeutic alliance may be stable from session to session, but there may be instances of strained interpersonal interactions between the therapist and patient. If the therapy is particularly brief, alliance ruptures may not develop because of the limitations of the treatment. The key to resolution lies in the experience for the patient of a collaborative conflict resolution with an emotionally significant other that is different from what the person expects (Binder, 2004). This is accomplished with the consistency and empathic attunement of the therapist.

Immediacy, a therapeutic communication technique described in Chapter 4, is useful in relational psychodynamic psychotherapy, especially in the throes of an alliance rupture. For example, one patient, a 46-year-old woman named Susan, came to therapy for depression because of a series of failed relationships. Her history revealed early deprivation with both parents, who were extremely self-involved and neglectful of their children. Her experience was one of chronically feeling devalued, which reinforced her schema that she was not lovable and not worth it. This theme played out in all her relationships in that no one could ever meet her needs or be there in the way she needed them to be. Chronic dissatisfaction and feelings of deprivation permeated every situation as she upped the ante, no matter what was offered to her. Whatever was given was not enough, providing proof of the person’s neglect or ill intentions. She presented an unpaid bill demanding to be paid in every interpersonal encounter. This was repeated in therapy, with Susan wanting more time, continuing to talk at the end of sessions, making frequent demands for changes of appointment times, and offering relentless criticisms of others. The therapist began to feel demoralized and tense up before each session, almost as if to shore up in order to withstand the barrage of negativity. The therapist felt hopeless and helpless, caught in the throes of a negative transference–countertransference enactment. After discussing the situation in supervision, the therapist understood that she was feeling as Susan must have felt, devalued in her family and hopeless, and the therapist offered this interpretation in the next session: “Perhaps you are feeling that I am not giving you what you need here.” This helped bring the process into the here and now, focusing on the therapeutic relationship, which allowed Susan to explore the reasonableness of her needs and her inevitable disappointment and hurt when she felt slighted. An interpretation is considered timely and relevant if it opens a productive avenue of therapeutic inquiry. The therapist encouraged and explored, listening empathically and nondefensively. She stated: “It is so hard to be here and feel so vulnerable and not get what you want or need.”Practicum – Assessing Client Progress Assignment

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Negative Therapeutic Reaction

A negative therapeutic reaction is a specific type of therapeutic impasse in which the patient gets worse and becomes entrenched in maintaining his or her problems despite the help of the therapist. Gabbard (2010) says that these reactions likely result from revenge fantasies, in that the therapist serving as parent in the transference is defeated by the patient by not getting better. This reaction is usually unconscious. The patient is often not aware of ill intentions, only that he or she is stuck or unhappy in treatment. In relational psychotherapy, this situation is not one-sided. The therapist may have too much invested in helping the person and begin to feel demoralized because nothing seems to be helpful. It is often necessary for the therapist engaged in the throes of a negative therapeutic reaction with a patient to seek supervision and consultation to sort out the situation. Evaluating the relational dynamics with a colleague can be helpful, but sometimes even then, the only solution is to refer the patient to someone else. The patient sometimes makes significant improvements only after treatment is terminated.

WORKING WITH DREAMS

Research on dreams has confirmed the importance and relevance of dreams for understanding the unconscious and implicit memory (Solms & Turnbull, 2002). Dreams are the brain’s attempt to process information and to integrate the day’s residue into the existing memory networks. Dreams represent current conflicts, and work on dreams focuses on the here and now, rather than the past, although current conflicts usually have roots in the past. Many psychodynamic psychotherapists consider dream work a useful tool to assist patients in deepening their understanding about themselves. A basic tenet of dream work is that dreams represent wishes, fears, and conflicts, as well as the person’s attempt to master unresolved issues and process traumatic experiences. Dreams are fertile ground for work in psychodynamic psychotherapy.Practicum – Assessing Client Progress Assignment

As in communication, there is the manifest content and the latent content. The manifest content is what the dreamer says the dream is about, and the latent content is the meaning of the dream. The latent content is disguised by defenses so that the person will not awaken. Although dream symbol books are interesting, they are not particularly useful in interpreting dreams, because all meaning and symbols in dreams are highly idiosyncratic and not universal. Dreams have multiple levels of meaning, and the symbols represented in the dream are unique for that person. Two people may have the same exact dream, and it may mean completely different things to each individual. However, dreaming about a house or type of house may symbolize the person and feeling about himself or herself. The other theme that seems to appear for many people is going someplace in a car or train, which sometimes heralds movement or change in therapy or in people’s lives. There are often transferential dimensions to the dream; the dream may reflect feelings the dreamer has about the therapist, albeit in disguised form. Dreams can reveal feelings that have arisen in the therapeutic relationship that have not been addressed (Curtis & Hirsch, 2003).

Dream interpretation is a little like trying to understand a poem or a work of art. It is undoubtedly a right-brain endeavor, and it is helpful to use right-brain functions when working with dreams. This can sometimes be accomplished through a mindful state, whereby the APPN attends by suspending usual left-brain problem-solving thinking by listening with empathic receptivity and resonance. Dreams are not linear in that time and space are suspended. To understand the patient’s dream, it is important to know the basic mechanisms associated with dreams. These include secondary revision, symbolic representation, condensation, and displacement (Gabbard, 2010). Secondary revision refers to the right-brain implicit message being translated into a coherent story. Symbolic representation refers to an image that represents a complex set of emotions that may be highly charged. Condensation is a mechanism that combines more than one wish, feeling, or impulse into one image. Displacement is similar to defense in that feelings for one person are displaced onto another person in the patient’s life.Practicum – Assessing Client Progress Assignment

Working with dreams can be introduced to the patient by asking in the assessment about recurring dreams, memorable childhood dreams, and recent dreams. It is helpful to suggest that the patient keep a dream log next to the bed so that he or she can jot down significant dreams on wakening. These dreams can be helpful in gaining insight. Even if patients do not usually remember their dreams, they can be trained to do so by beginning to keep track of their dreams in this way. After discussing the idea of working with dreams with patients, it is better to not bring up the subject again and to allow patients to report dreams when they are ready. Not all patients are able to remember their dreams. Alexithymic patients in particular have great difficulty in remembering their dreams because of their impoverished ability to symbolize (Hollender & Ford, 2000).

Bringing in the first dream often heralds a deepening of the therapeutic alliance and should be positively acknowledged by the APPN. The first dream often illustrates the dynamic focus for the work of treatment. For example, one woman, who came to treatment with significant long-term depression but who was fairly high functioning, had suffered significant attachment trauma from her early relationship with her mother, who had BPD. The patient reported her first dream in the sixth session: “My daughter and I are taking care of a baby, a baby girl, about 2 years old. She is dead and in parts, and we can’t seem to get her back together. I am trying to call the funeral home but can’t get through, and for some reason, I have only 45 minutes. That is not enough time. I wake up thinking that I won’t be able to put her together in such a short time.” Her thoughts about the dream were that the baby was her and the 45 minutes was the length of our session time. This was a graphic illustration of how the patient felt about herself and the work that needed to be accomplished in therapy.

Although dreams can advance the work of therapy, they can also serve as a resistance. If the patient comes in with several dreams and floods the session with dream material, it may not be possible to examine any dimension of the dream in the detail needed to be helpful. As with all therapy, the process or context should be dealt with first. What is going on in the process of psychotherapy that causes the person to overwhelm the therapist with so much material now? If a dream is reported in a session, the whole session’s latent content usually is about the dream, even if the dream content itself is not the topic of conversation. Asking the person: “What are your thoughts about the dream?” is often a good way to start getting the patient’s associations about the dream. Another way to work is to ask the person what stands out the most about the dream or what was the worst part of the dream. If the dream is readily understood and the manifest content is obvious, it is considered transparent, which may sound like a derogatory term, but it means that the content is not highly disguised or defended against. In contrast, the dream that is difficult to understand may reflect the strength of the defense against this implicit material coming to consciousness. Sometimes, novice therapists are hesitant to do dream work because they feel they must come up with a grand interpretation at the end. Often, however, the therapist gets only the person’s thoughts on the dream without much comment. It is thought that relating the dream is therapeutic because this translates right-brain material into left-brain information, which is integrative in and of itself. It is not incumbent on the therapist to make sense of the dream; after all, it is the patient’s dream, and it is his or her thoughts about it that count. The following example illustrates the concepts and how to work with dreams.Practicum – Assessing Client Progress Assignment

Sarah, a 22-year-old English woman from an orthodox Jewish family, was seen for depression and low self-esteem. She described her mother as depressed, sometimes staying in bed for weeks, and her father as hypersensitive, depressed, tense, and domineering. Sarah moved to the United States to go to school the previous year. Sarah began her 15th psychotherapy session by saying that she was too hard on herself and that she always feels she is going to be judged because she sees others as superior to her and wonders how they will perceive her. She wanted to be different but was anxious about changing. Her parents always implied that they knew the real Sarah and that she was too introspective. Her older sister was always down on everything and saw Sarah as emotional, selfish, and a troublemaker, and Sarah tended to agree with her. She then reported the following dream: “I was at home in my parents’ house in London. Dad died in the dream and was out in the front yard without his head. Blood was pouring out of his neck, but he was still talking. I was crying ‘no, no, no.’ I felt awful that he had died.”

When the therapist asked what she thought about this dream, Sarah said she thought that she was trying to kill off parts of herself that were like her dad. She thought that the dream was telling her that she loved her father and did not really hate him and that she could love him after she was in control of herself and did not feel as if he controlled her. The therapist responded: “You care a great deal about your father, but you have issues to work out about yourself before you can improve your relationship with him.” In understanding the session in light of the dream, Sarah had started the session being concerned about being judged and perhaps wondered what the therapist would think of such a murderous dream. This is the latent transferential part of the session. By listening nonjudgmentally and accepting her thoughts about the dream, the therapist provided a different experience for her from the one she had in her family. The therapist offered no new interpretation but agreed and reflected what Sarah said about the dream. The following illustrates the basic mechanisms in Sarah’s dream:

Secondary revision: Sarah recounts the dream in story form.

Symbolic representation: The house in London may represent her childhood experiences. Condensation: She sees her anger at her father and her own murderous impulses toward him on the one hand; his death brings freedom from his tyranny. On the other hand, he is still talking, and this may reflect the embedded wish that she can still maintain a relationship with him despite her anger or that his words would continue to influence her even though he is dead. Perhaps his talking head reflects her wish that her anger would not kill him and he would still be alive.

Displacement: Sarah is in part displacing her own anger about herself toward her father. She focuses on her father as the source of her unhappiness in the dream, but in her associations to the dream, she says that she wants to kill off parts of herself that are like her dad, which illustrates the utility of the dream in illuminating her displacement.

BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

In contrast to psychoanalysis, brief psychodynamic psychotherapy takes place in fewer days per week and lasts for a shorter duration. Although techniques are similar, less regression is encouraged, and the patient is not encouraged to use the couch but to sit facing the therapist. For those wishing to work on a particular issue or conflict, shorter-term psychodynamic psychotherapy may be indicated. This approach is sometimes called focal psychodynamic psychotherapy. Although psychodynamic psychotherapy is frequently thought of as long-term therapy, brief psychodynamic psychotherapy is probably most often practiced given the current climate of managed care.Practicum – Assessing Client Progress Assignment

How many sessions constitute brief therapy? It could be one session, although we might question what this one session would consist of and how helpful it would be. Most often, 20 to 30 sessions are considered brief therapy. Even if brief, psychodynamic assumptions and techniques are the same as if longer-term treatment was conducted. There is no qualitative difference between brief and long-term psychodynamic psychotherapy. “There are not specific techniques that hold the key to the practice of brief therapy. Instead, the most expeditious means to achieve efficient and effective therapeutic outcomes is to practice ‘good’ psychotherapy, regardless of the anticipated or planned length” (Binder, 2004, p. 22). Wolberg (1977) developed general guidelines for conducting brief psychodynamic psychotherapy. A slightly modified version is provided in Box 5.1.

Proponents of brief psychodynamic psychotherapy believe that setting a termination date at the beginning of treatment assists in the progress and resolution of the patient’s problems. Setting the termination date is thought to provide a focus that can link or thread unrelated experiences together for the therapist and the patient. A termination date is thought to be integral to the treatment in that the patient is helped to work through the meaning of termination. This central issue in the therapy parallels the separation–individuation developmental issue of life. Loss is a central theme for everyone, along with the tension of connecting through relationship while at the same time being a self-agent. Termination in psychotherapy can be a forum for addressing and exploring these central dilemmas in life. Specific issues related to termination that frequently arise in therapy are abandonment fears, disappointments, and anger about not getting what a person hoped for. The therapist listens empathically, and this noncritical acceptance of the patient’s needs and wants helps the patient to accept the limitations of others. This approach is thought to help the person access dissociated wishes and needs that have been split off due to early relationships. Through the process of acknowledging and relinquishing the pursuit of an idealized, unattainable goal, the limitations and realities of relationships are accepted. However, there may not be enough time for transference to develop sufficiently, so the therapist can use the relationship to work through as just described. The focus of therapy then is on interpersonal relationships outside of the therapeutic relationship.

BOX 5.1

GENERAL PRINCIPLES FOR CONDUCTING BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

Establish a therapeutic alliance

Set a termination date (within 30 sessions)

Deal with initial resistances

Gather historical and other data

What is the most important problem? Why now? What has been done so far?

What does the patient think caused the problem? What does the patient want from therapy?

Select the symptoms (focus) most amenable to treatment within the first three sessions

Define the precipitating event

Identify developmental issues and defenses to understand how to proceed

Share the case formulation with the patient

Enlist the patient as an active participant through a verbal contract

Use the most effective techniques to help the patient

Identify resistances or alliance ruptures, and address them with the patient

Be sensitive to how the past is influencing the present

Examine countertransference feelings

Give homework (optional)Practicum – Assessing Client Progress Assignment

Stress the need for continuing work

Adapted from Wolberg (1977).

CASE EXAMPLE

Ms. S is a 32-year-old, intelligent, attractive woman who is very successful in her career. Her reason for seeking treatment is related to her dissatisfaction with her chronic tendency to choose men who eventually abuse her emotionally. Ms. S stated that her father had abused her sexually as well as other female relatives in the family. When Ms. S got older and objected to his advances, her father accused her of being uptight and compared her unfavorably to her younger and more compliant sister, who obviously had no problem because she willingly accepted his behavior. Ms. S had a good early relationship with her mother. The sexual abuse left Ms. S with a profound mistrust of men. She was active and controlling in relationships with men (e.g., she was always the one who initiated sex). When her partner expressed an interest in sex, it felt analogous to her father’s sexually controlling, intrusive, and abusive behavior. In addition to initiating sex, she was giving in other ways (e.g., gifts, dinners, and arranging activities for her and her boyfriend to enjoy). The unfortunate side of this behavior was that it obscured the essentially narcissistic character structure of these men. In other words, they were fine as long as they were on the receiving end. Inevitably, the relationship would founder when she risked expressing needs of her own.

Developmentally, her anxiety and conflict seemed to lie in the area of identity and loss of control in that she experienced much anxiety in relationships with men if she did not control what happened. Ms. S had good object constancy and could be alone without much separation anxiety, could self-soothe, was self-directed, and was fairly autonomous even though controlling in relationships. In Erikson’s framework, issues of intimacy versus isolation were apparent in that the crux of her problems was in establishing an intimate relationship. Neurotic-level defenses of displacement and rationalization were evident, as well as denial, which is considered a primitive defense. Her displacement took the form of an inability to recognize her own deep feelings of worthlessness, and she became a compulsive giver and cared about the needs of others to avoid the fact that she was being exploited in her relationships with men. She rationalized whenever she was not treated well in a relationship that she was needed and that only she could help her boyfriend feel better about himself. She should care for men and was plagued with guilt if she did not give more. The should often indicates oedipal issues in that a harsh superego predisposes the person to be overly hard on himself or herself. This, coupled with her denial about the selfish, exploitive characteristics in the men she chose to date, corresponded to her denial on some level of her father’s motives. Her high level of functioning with use of the defenses of humor and sublimation led her male therapist to conclude that she was probably a candidate for psychoanalytically oriented psychotherapy. Twice-weekly psychotherapy was conducted over a 2-year period.Practicum – Assessing Client Progress Assignment

Ms. S initially related to the therapist in a guarded, hypervigilant state, which sometimes made the therapist feel uneasy and constricted. At other times, she was quite seductive and incredulous that the therapist would not have sex with her. The following excerpt from a session illustrates the exploration of the importance of her sexual quest. She arrived characteristically late for her session and alluded to the previous session, which involved her declaring her sexual feelings for the therapist.

  Ms. S: I finally understand why you won’t have sex with me, and although it’s frustrating, at least I understand why you are doing this.
  Therapist: What is it that you understand?
  Ms. S: It’s your goddamn ethics, your code.
  Therapist: My code of ethics prevents me from having sex with you?
  Ms. S: Yes.
  Therapist: Anything else about me that may contribute to my not having sex with you?
  Ms. S: [after a long pause] Well maybe, just maybe you feel it would hurt me.
  Therapist: So, on the one hand, I want to have sex with you but don’t because of my ethical code, and on the other hand, I may care enough about you to not want to hurt you, as you have in the past been hurt.
  Ms. S: Perhaps I’m trying here to create a situation that is familiar to me.
  Therapist: Perhaps, but you also consider that I may have different, more caring motives, and that is very new for you.

This session highlights the use of the relational model of psychodynamic psychotherapy. Relational psychodynamic psychotherapy is based on the idea that problems are caused by disturbances in relationships with early caretakers that pattern subsequent relationships. The therapist’s understanding emerged over time as the relationship unfolded. The therapist initially explained to Ms. S the importance of mindfulness and observing her own thoughts and feelings in the therapy relationship as it is taking place in the present moment. In exploring other aspects of a relationship in the here and now with the therapist, Ms. S was able to consider that the therapist cared about her, which introduced a new hypothesis about what ingredients there are in relationships. She spent numerous sessions struggling with a shift in her thinking that someone would care about her and not want to exploit her. As she mourned the loss of the illusion of a loving father and saw her father more realistically, she was able to see men in her life more realistically, too. Over time, she developed better object choices in that she looked for indicators that the men who she dated overtly cared about her, and she was able to make a better assessment of their intentions. Her defenses were modified, and she no longer had to compulsively control and give in intimate relationships. New, more adaptive information in implicit memory networks was learned through the processing that took place in her relationship with the therapist.Practicum – Assessing Client Progress Assignment

POSTMASTER’S PSYCHODYNAMIC PSYCHOTHERAPY TRAINING AND CERTIFICATION REQUIREMENTS

Although there is no one certifying body or national certification in psychodynamic psychotherapy, there are many psychodynamic training programs in most major cities in the United States that offer certification. Psychodynamic training is most often offered at an analytic institute and requires the therapist’s own analysis, coursework, and supervised psychoanalytic treatment of a requisite number of patients, culminating in a written case presentation and an oral defense, much like an oral dissertation defense. There are a number of 2-year programs with a focus on psychodynamic psychotherapy and 4-year programs in traditional psychoanalysis. In the past, programs affiliated with the American Psychoanalytic Association limited training to doctors of medicine (MDs), but most of these programs now allow APPNs, social workers, and psychologists to matriculate into their programs.

The American Psychoanalytic Association (2008) sets standards for candidates eligible for admission and includes: doctors of osteopathic medicine, medical doctors, mental health professionals with a doctorate as well as those with a clinical master’s degree. The many institutes of psychodynamic psychotherapy represent the various schools of psychodynamic thought and their respective curricula reflect their orientation. These include ego psychology, self psychology, traditional Freudian psychoanalysis, intersubjectivity approaches, interpersonal therapy, and relational therapy. APPNs who wish to pursue this type of training are advised to obtain information about the institute’s orientation before matriculation, because the theoretical foundation and practice approach may differ greatly.

CONCLUDING COMMENTS

Psychodynamic psychotherapy is forging new connections with neurobiology to validate existing clinical practice as new knowledge about implicit unconscious processes continues to be generated. It is this meeting of psychology with physiology that Freud envisioned more than 100 years ago. The contemporary model of relational psychodynamic psychotherapy builds on the important contributions of interpersonal psychodynamic theory and is consistent with the centrality of relationship that nursing espouses. The interpersonal psychodynamic model of psychotherapy has been the dominant paradigm for psychiatric nursing for the past 3 decades, since Hildegard Peplau based her framework of psychiatric nursing on the work of Harry Stack Sullivan. The contemporary psychoanalytic theory discussed here for APPN psychotherapy practice is moored in the one-to-one relationship, which builds on that model. The evolving, expanding knowledge of psychodynamic psychotherapy is based on a developmental, neurophysiologic model that deepens the understanding of others and offers the APPN relevant principles important for clinical practice.Practicum – Assessing Client Progress Assignment

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DISCUSSION EXERCISES

  1. Diagram (as in Figure 5.1) and discuss the cyclical dynamics of a patient you are currently working with or have worked with in the past.
  2. Identify at least five reasons why evidence-based research is difficult to conduct in psychodynamic psychotherapy.
  3. Compare and contrast the developmental models (i.e., Freud, Mahler, and Erikson) presented in this chapter.
  4. Discuss the evolution of psychoanalytic thought.
  5. What is the relational psychodynamic model of psychotherapy, and how can you integrate the concepts and techniques described in this chapter in your work with patients?
  6. Using the diagram in Figure 5.3, present a case formulation for a specific patient, covering all the dimensions (e.g., anxiety, developmental issue, attachment schema, defenses, and developmental level), and then discuss what type of psychodynamic therapy you think would be appropriate and why.
  7. Describe supportive psychodynamic psychotherapy, and discuss the various techniques for this type of therapy.
  8. Discuss the dynamics of borderline personality organization, and describe general principles for how to work with patients with this character structure.
  9. A patient comes to you for brief psychotherapy, and you believe that psychodynamic psychotherapy would be helpful. Discuss the beginning steps of treatment, and elaborate on how you would go about establishing a therapeutic alliance.

REFERENCES

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Abbass, A., Kisely, S., & Kroenke, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders: Systematic review and meta-analysis of clinical trials. Psychotherapy and Psychosomatics, 78, 265–274. doi: 10.1159/000228247

American Psychiatric Association (APA). (2009). Practice guideline for the treatment of patients with panic disorder (2nd ed., p. 90). Washington, DC.

APA. (2010). Practice guidelines for treatment of patients with borderline personality disorder. Retrieved from www.psych.org

American Psychoanalytic Association. (2008). Principles and standards for education in psychoanalysis. Retrieved from www.apsa.org/About_APsaA/Ethics_Code.aspx

Amir, N., Stafford, J., Freshman, M. S., & Foa, E. B. (1998). Relationship between trauma narratives and trauma pathology. Journal of Traumatic Stress, 11, 385–393.

Anderson, E. M., & Lambert, M. J. (1995). Short-term dynamically oriented psychotherapy: A review and meta-analysis. Clinical Psychology Review, 15, 503–514. doi:10.1016/0272-7358(95)00027-M

Binder, J. L. (2004). Key competencies in brief dynamic psychotherapy. New York, NY: Guilford Press.

Blagys, M., D., & Hilsenroth, M. J. (2000). Distinctive of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice7, 167–188.

Briere, J., & Scott, C. (2013). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (2nd ed.). Thousand Oaks, CA: Sage.

Chu, J. A. (2011). Rebuilding shattered lives: Treating complex PTSD and dissociative disorders (2nd ed.). Hoboken, NJ: Wiley.

Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain (2nd ed.). New York, NY: W.W. Norton & Company, Inc.

Curtis, R. C., & Hirsch, I. (2003). Relational approaches to psychoanalytic psychotherapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theory and practice (pp. 69–106). New York, NY: Guilford Press.

de Maat, S., de Jonghe, F., Schoevers, R., & Dekker, J. (2009). The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry, 17, 1–23. doi: 10.1080/16073220902742476

Department of Veterans Affairs, Department of Defense. (2009). VA/DoD clinical practice guideline for management of major depressive disorder (MDD) (p. 199). Washington, DC.

Diener, M. J., Hilsenroth, M. J., & Weinberger, J. (2007). Therapist affect focus and patient outcomes in psychodynamic psychotherapy: A meta-analysis. American Journal of Psychiatry, 164, 936–941. doi: 10.1176/appi.ajp.164.6.936

Driessen, E., Ciujpers, P., de Maat, S. C., Abbass, A. A., de Jonghe, F., & Dekker, J. J. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30(1), 25–36.

Erikson, E. (1964). Insight and responsibility. New York, NY: W.W. Norton.

Erikson, E. (1968). Identity, youth and crisis. New York, NY: W.W. Norton.

Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., … Gerber, A. (1996). The relationship to attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology64, 22–31.

Fonagy, P. (2002). An open door review of outcome studies in psychoanalysis. Retrieved from www.ipa.org.uk/research/complete.htm

Gabbard, G. O. (2010). Long-term psychodynamic psychotherapy: A basic text (2nd ed.). Washington, DC: American Psychiatric Publishing, Inc.

Gallop, R., & O’Brien, L. (2003). Re-establishing psychodynamic theory as foundational knowledge for psychiatric mental health nursing. Issues in Mental Health Nursing24, 213–227.

Hollender, M. H., & Ford, C. V. (2000). Dynamic psychotherapy: An introductory approach. Northvale, NJ: Jason Aronson.

Howell, E. (2005). The dissociative mind. Hillsdale, NJ: The Analytic Press.

Horowitz, M. J. (2003). Treatment of stress response syndromes. Washington DC: American Psychiatric Publishing.

Kluft, R. P. (1999). Current issues in dissociative identity disorder. Journal of Practical Psychiatry and Behavioral Health5, 3–19.Practicum – Assessing Client Progress Assignment

Kohut, H., & Wolf, E. (1978). The disorders of the self and their treatment. International Journal of Psychoanalysis59, 413–425.

Levy, R. A., & Ablon, J. S. (2009). Handbook of evidence-based psychodynamic psychotherapy: Bridging the gap between science and practice. New York, NY: Humana Press.

Levy, K., Ellison, W., Scott, L. N., & Bernecker, S. L. (2011). Attachment style. In J. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York, NY: Oxford University Press.

Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160, 1223–1232.

Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551–1565.

Leichsenring, F., & Rabung, S. (2011). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: A meta-analytic approach. Clinical Psychology Review, 21, 401–419.

Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61, 1208–1216.

Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York, NY: Basic Books.

Masterson, J. F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York, NY: Brunner/Mazel.

McWilliams, N. (1994). Psychoanalytic diagnosis. New York, NY: Guilford Press.

McWilliams, N. (1999). Psychoanalytic case formulation. New York, NY: Guilford Press.

McWilliams, N. (2011). Psychoanalytic diagnosis (2nd ed.). New York, NY: Guilford Press.

Medicus J. (2012) Practice parameter for psychodynamic psychotherapy with children. Journal of the American Academy of Child & Adolescent Psychiatry51(5), 541–57.

Miller, A. (1981). The drama of the gifted child. New York, NY: Basic Books.

Misch, D. (2000). Basic strategies of dynamic supportive therapy. Journal of Psychotherapy Practice & Research, 9(4), 173–189.

Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press.

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National Institute for Health and Clinical Excellence (NICE). (2011). Self-harm: Longer-term management. London (UK): National Institute for Health and Clinical Excellence (NICE) (p. 41). (Clinical guideline; no. 133).

Oldham, J. M. (2005). Guideline watch: Practice guidelines for the treatment of patients with borderline personality disorder. Retrieved from www.psych.org

Pinkster, H. (1997). A primer of supportive psychotherapy. Hillsdale, NJ: The Analytic Press.

Rubino, G., Barker, C., Roth, T., & Fearon, P. (2000). Therapist empathy and depth of interpretation in response to potential alliance ruptures: The role of therapist and patient attachment styles. Psychotherapy Research10, 408–420.

Sadock, B. J., Sadock, V. S., & Ruiz, P. (2009). Kaplan & Sadock’s comprehensive textbook of psychiatry (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance. New York, NY: Guilford Press.

Safran, J. D., Muran, J. C., & Eubanks-Carrter, C. (2011). Repairing alliance ruptures. In J. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 224–238). New York, NY: Oxford University Press.

Schore, A. (2012). The science of the art of psychotherapy. New York, NY: W.W. Norton & Co.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist65(2), 98–109.

Shedler, J. (2011). Science or ideology? American Psychologist, 152–154.

Siegel, D. (2012). Pocket guide to interpersonal neurobiology: An integrative handbook of the mind. New York, NY: Norton.

Solms, M., & Turnbull, O. (2002). Dreams and the inner world. New York, NY: Other Press.

Town J. M., Abbass, A., Driessen, E., Diener, M., Leichsenring, F., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 69(3), 276–290.

Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. New England Journal of Medicine, 358, 252–260.

Wachtel, P. (2011). Therapeutic communication: Knowing what to say when (2nd ed.). New York, NY: Guilford Press.

Winnicott, D. W. (1976). The aims of psychoanalytic treatment. In The maturational processes and the facilitating environment (pp. 166–170). London: Hogwarth Press.

Wolberg, L. R. (1977). The technique of psychotherapy (3rd ed.). New York, NY: Grune and Stratton.

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(Wheeler)

Wheeler, Kathleen, PhD, APRN-BC, FAAN. Psychotherapy for the Advanced Practice Psychiatric Nurse, Second Edition, 2nd Edition. Springer Publishing Company, 20131211. VitalBook file.

The citation provided is a guideline. Please check each citation for accuracy before use.Practicum – Assessing Client Progress Assignment

PICOT Statement Assignment Paper

PICOT Statement Assignment Paper

PICOT Statement Assignment Paper

NRS 490 Grand Canyon Week 3 Assignment

PICOT Statement Paper

Details:

Review the PICO(T) resources listed in the topic readings.

Formulate a PICOT statement using the PICOT format used in the assigned readings. The PICOT statement will provide a framework for your Capstone Project.

In a paper of 500-750 words, clearly identify the clinical problem (from your Topic 1 approved Change Proposal) and how it can result in a positive patient outcome. PICOT Statement Assignment Paper

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Make sure to address the following on the PICOT statement:

Evidence-Based Solution

Nursing Intervention

Patient Care

Health Care Agency

Nursing Practice

Recall that a PICOT starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention should be an independent, specified nursing change intervention. The intervention cannot require a provider prescription or equipment change. Include a comparison to a patient population not currently receiving the intervention, and specify the timeframe needed to implement the change process.PICOT Statement Assignment Paper

While APA format is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.PICOT Statement Assignment Paper

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Portfolio Practice Hours

Students will track their practice hours throughout the course via the Practice Hours Completion Statement provided in this assignment.

Complete the following statement in a Word document and submit it to the instructor via the individual forum in LoudCloud.PICOT Statement Assignment Paper

Practice Hours Completion Statement NRS-490

I, (INSERT NAME), verify that I have completed (NUMBER OF) practice hours in association with the goals and objectives for this course. I also verify that all required course approvals are in place from my faculty and practice mentor.PICOT Statement Assignment Paper