How Management Of Mental Illnesses to Clinical Practice ?
The theories of nursing are structured pieces of ideas that present a systematic method of a situation in nursing (Alligood, 2013). The various actions in the profession of nursing is based on set of theories. Theory offers an individual with perspective to view a particular situation and act on it purposefully and systematically. Nurses use theory to gain a perspective to view a client situation, organise relevant data of clients encountered on a day-to-day care, and to analyse and interpret the information (King, 1981). Theories include general proposition as a principle of explanation that ensures clarity in action and patient outcomes. In nursing practice, “Mid-range nursing theories,” are commonly used. These theories are more concrete in nature and presents concepts at a specific level and lower level of abstraction. These theories hold great promise in nursing profession in promoting “theory based research”. These theories improve nursing practice strategies (Riegel et al., 2012). These theories explain specific patient care phenomena such as pain management, and explain the concepts related to the phenomena. The applicability of the theory depends on the clarity of concepts, simplicity, and generalisability such that it can easily fit into practice (Townsend, 2014).
Management of mental illnesses is significant to clinical practice. According to Rogers and Pilgrim, (2014) mental illness can be defined as any condition or disease that influences an individual’s ability to think, behave, feel, relate to others and surrounding. Serious mental illnesses can lead to severe distress and disability which detoriates the quality of life. The syndromes, which are considered as serious mental illnesses, includes eating disorder, schizophrenia spectrum, personality and anxiety disorders (O'Donnell et al., 2011). There are range of factors causing mental illness including genetic, environmental stressors, biology and psychological trauma.
Mental illness is the matter of grave concern due to its rapidly increasing rate worldwide. One-third world’s population is comprised of children’s and adolescents. It was reported by Kieling, (2011, p.1515) that neuropsychiatric disorders are the leading cause of health related burden. Mental illness accounts for “disability-adjusted life-years” (DALYs) lost in 15-30% of the cases the first thirty years of life. The report by Kieling, (2011, pp.1518) mentioned that universal interventions both selective and indicated are directed at all children particularly focusing on those who are at high risk for developing mental disorders either due to the proximal risk factors or other clinical symptoms. However, the challenges of these interventions are the characterisation of the patients at whom the interventions will be targeted. Kieling, (2011) suggested that the children and adolescents can be benefitted both concurrently as well as in the long run by early interventions for their mental illness.
According to Doornbos, (2002, p.2) Doorknob’s Family Health Theory, families can provide substantial amount of care for their young adults with persistent mental illness more than a mental health care professionals. It was mentioned by Sieloff & Frey (2007) that family members undergo severe stress dealing with their young adults having mental illness, which in effects their own mental health. Therefore, Family Health Theory suggests identification of the factors predicting family health. This action will assist in developing interventions for promoting the family health and support them in critical work of caregiving. Corrigan et al. (2014) explained that the effect of “family-perceived stigma” on care seeking may be mediated by family burden, and includes both subjective (mental distress due to illness ) and objective (daily constraints life) components. There is a lack of adequate government mental health policies for children worldwide. Therefore, it hampers guiding the system implementation, service development and undermines efforts to ensure the accountability of the allocated resources for programme development. Therefore on “World Fit For Children” the UN resolution endorses the commitment that every child has the right to develop to its maximum potential in order to gain sound physical, emotional and mental health (Kieling, 2011).
This report particularly deals with Doorknob’s Family Health Theory (FHT) (2000). The theory is critically analyzed using the guidelines of Chinn and Krammer’s (2015). The critical analysis of the theory is provided in terms of clarity of concept, accessibility and strength and weakness of the theory for improving nursing performance. The analysis will reveal possible interventions for “adults with persistent mental illness” and ways to enhance family caregiving.
Dr. Mary Molewyk Doorknobs proposed the “Family Health Theory (FHT) in the families of adults with persistent mental illness”. The propositions of the theory highlight the importance of the role played by the family in caregiving and its impact on the health of the family system. This middle range theory developed from the “King’s systems framework of family health in these families” (Mary, 2000). As a family struggles to manage the mental illness of their young adults, they undergo a change in their own health system. This theory predicted some of the factors directly related to the family’s health. It includes family’s perception of the client’s symptomatology, coping, professional communication, stressors, and time since diagnosis of the mental illness. Thus, the goal of the theory is to develop nursing interventions to assist family in their role of care giving (Doornbos, 2002).
This section deals with different concepts and relationships that are to be taken into consideration, as nurses tend to develop effective interventions to reach one goal that is management of mental illness and assistance to the family. It includes three dynamic interacting systems mentioned by King, (1995) - “personal, interpersonal and social”.
The theory of family health emphasise on the role of family in understanding the client’s illness. It explains the relationship between the family functioning and the client symptoms. It is crucial in nursing practice to consider the family perception and verify together with the perception of the nurses to specific goals. This is an essential step as it pertains to the “family’s perception of the client symptomatology” (King, 1981). For instance, in a case of schizophrenia one family is burdened with the member’s distortion of the normal function whereas some other family is burdened with the loss of function symptom in the member. Therefore, King, (1983) stated that the family burden is increased to a greater level with the perceived degree and the frequency of the symptomatology. The variable of time in families of adults with persistent mental illness, plays an important role in understanding the responses of the family to the illness over time (King, 1990). The time variable helps in assisting the family member by understanding their cumulative experience since the time of diagnosis of illness. FHT emphasise the nurses to help the family members to cope up with the event of the mental health problem by categorising their various coping methods into positive or negative. Implementing FHT in nursing practice requires nurses to be effective in identifying and addressing family and client stressors by effective intervention. Stressors are common in family burdened with the mental illness of their member which include employment, marital, intrafamily, financial, grief, loss, legal, and mental health (Lazarus & Folkman, 1984).
The vital concept in the nursing practice is “professional communication”. It is essential to meet the greatest need of the families of person with persistent mental illness which is “communication between themselves and health care professionals”. Nurses can decrease the family burden by attending and actively listening their concerns, supporting them in their efforts to cope up with the member’s mental disorder (Alligood, 2010). Educational interventions and providing critical information increases family functioning and client outcome, which is the major goal for nursing practice (Webb et al., 2016). As the family members undergoes tremendous stress dealing with the mental illness. Therefore, the goal of the nurses is to help and restore families’ health according to King’s theory (1990) and enhance their adaptive capabilities and strengths.
According to Doornbos, (2002) the theory is based on the following assumptions-
FHT was developed from the King’s conceptual system using a deductive approach. In 1981, King’s framework was developed based on the concept of three interacting system which are- “personal, interpersonal and social system”. FHT has selected six of these concepts, which are “perceptions, coping, time, stressors, communication and health”. Each of these was then applied to address the families of young adults suffering from persistent mental illness. The theory was empirically tested twice and underwent several changes. First concept was changed from family’s perception of “client level of health” to family’s perception of “client’s symptomatology” keeping the concept of “perception” consistent from the King’s theory. There was a change in the theoretical definition of the term “family health” maintaining consistency with the King’s conceptualisation. It presently emphasises more on the family’s satisfaction rather than their ability with their functioning. After the first empirical testing, the concept of “professional communication” was added to FHT realising this essential and informational component of the human interactions.
Doorknob’s Family Health Theory (2000) utilizes comprehensive terminologies, and the ideas applicable to understand the focal theme was quite rational. She made use of the primary variables constituting a range of factors to assess the outcomes of health in family members of the adults suffering from persistent mental health illness. Each of the five variables comprising of the family perception of client’s symptomatology, family coping, professional communication, family stressors and time since diagnosis of mental illness has been discussed in elaboration. All the three potential vulnerable population including the client, the family and the professional intervention has been well addressed. The understanding of the sociology of mental health and illness in connection with the immediate responses from the family members is imperative to foster quality healthcare service to the patient and necessary support to the family as well. Prevention of mental disorder and promotion of mental health has been unanimously accepted as the best remedy to cure the ensuing illness (Rogers & pilgrim, 2014). The theme of perceptions and beliefs associated with the persons with mental health disorder has been identified as essential to ensure better recovery (Løvvik eta l., 2014). The variability to one’s reaction to a particular condition, different adaptive mechanisms and professional intervention are further highlighted as important determinants of mental health outcomes (Furnham & Kirkcaldy, 2015). The theory further corroborated with the ideas of predicting the health status of the family members relating to the stressors in the concerned members that is very much realistic. Overall, all the propositions are discussed in an impeccable and easy manner that aids to the understanding of the key issues and thereby has implications for translation into research.
Management of mental illness is a vast and complicated subject. Therefore, theories related to this subject are also complicated for a reader. FHT is a complex theory with six components that is family’s perception of client symptomatology, coping, stressors, time since diagnosis of the mental illness, professional communication and family health. The difficulty lies in execution of the guidelines of the theory. There is a lack of clear establishment of the linkage between the “family health and family care giving efforts”. Therefore, it is difficult for the nurses to develop interventions without understanding the mutual relationship between these concepts (Chinn & Kramer, 2015). Some of the concepts are well understood such as the need of professional communication between the nurses and the family and its significance in achieving health related goals. In addition, there is also a direct relationship between the family’s perception of the client’s health and stressors and consequently the experience of family health. Overall, it is a complex theory involving six concepts which may prevent development of supporting interventions to sustain family’s health. A theory with two to three concepts would have been ensured simplicity and uts applicability in nursing practice and research.
Family health theory is generalisable to apply to families with different mentally ill members. The theory signifies the role of family in caregiving their members with persistent mental illness. This theory . However, this theory is not generalisable to other settings such as rehabilitation and primary care where the goal is to encourage mentally ill patients to self-care and be independent. This theory cannot be generalised for various populations who might experience mental illness such as older adults. Moreover, the linkage between the “family health and family care giving efforts” is not well understood. In addition, there is lack of more representative sample in terms of family’s socioeconomic status, gender of the household respondents, and cultural diversity which is also limiting factor in the generality of the theory. The proponent of the theory recommends further investigations for future practice. Mental health nurses can apply this theory in research and practice to see it effects on families who can provide better care to their loved ones with mental illness based on this theory. Additional research can be carried out to develop instrumental and supporting interventions for families to deal with mentally ill. Thus, this theory influences the caregiving abilities of the families by addressing their basic needs (Doornbos, 2002).
The reach of the family health theory is very far as it effectively addresses the empiric indicators of health outcomes of the adult family members with persistent mental illness patient. The health outcome predictors as suggested in the theory are both quite easily detectable and accessible. In the theory three pivotal dynamic and interacting systems comprising of personal, interpersonal and social. The battle of the family with persistent mental illness has been the topic of research for many in the past few decades. Green et al. (2014) have suggested guidelines for the future patient centered treatment and empirical research in connection with the patient with serious mental illness within a learning mental health care system that might be liked with this theory. Further research has indicated that the response of the family to critical illness might affect the carergiving actions rendered by them to the ill person (Davidson, Jones & Bienvenu 2012). Thus the manner in which these family members are incorporated into decision making and care regime through adequate support and professional communication of the healthcare workers will cause a great impact upon the health outcomes as well. Thus verification of the information regarding the beliefs and notions of the concerned family members starting from the time since diagnosis of mental illness is necessary to forecast the health outcomes. The healthcare practitioners has immense scope of applying the assumptions as discussed in the theory to harbor better clinical outcomes and foster holistic mode of care to the desired population without encountering any significant issues whatsoever. With the rising global burden for mental disorders consideration of all the aspects of the family health theory shows promise in rendering quality delivery of care. The prioritization of the physical health problem over mental health issue has added to the agony of the family and hence increasing the stress component in them. However, case appropriate and prudent intervention mostly through education and awareness from the healthcare workers’ and nursing professionals’ ends might alter the situation. The improvement in the caregiver’s health can be directly correlated with the alleviation of the probable stress factors. Thus prevention programs as designed by the healthcare personnel might relive the economic burden of mental illness for the family as well and creating a positive impact on them (Ditton, 2013).
The propositions of the theory are thus relatable to the nurses and other healthcare workers engaged in mental health care setting. The explanation of the ideas and concepts is very much consistent and may be suitable for predicting and providing beneficial health outcomes in the family with persistent mental health illness patient.
The family health theory in the context of families of adults with persistent mental health illness has got great implication in terms of estimating the health outcomes and recommending necessary measures to mitigate the perpetual and nagging issues due to mental health illness. There lie immense opportunities for the nursing professional to undertake both verbal and non-verbal mode of communication as mentioned in the theory to effectively interact and extract optimum benefit out of such communication and alleviate the stress levels in the vulnerable family members who are endowed with the negative thoughts and perceptions. The health related goals can be further effectively addressed by means of following the useful propositions of the theory. Taking clues from the theory derived ideas similar studies pertinent to the recent times may be referred to where adequate emphasis has been laid upon strengthening the family resilience in order to achieve the expected clinical outcome. Facilitation of the family resilience by virtue of passage through crisis, transition and persistent challenges has been the focus of such research in an effort to combat the highly demanding situations due to mental health illness (Walsh, 2015). Hence the nursing schools and institutes must arrange for relevant learning modules and teaching strategies that will empower the nursing students to effectively apply the ideas retrieved from the family health theory into clinical practice. The knowledge regarding appropriate professional intervention through either interactive approach or other psychotherapeutic techniques will enable them to better understand and act accordingly for the caregivers who are encountering issues due to mental illness in the patient in the family.
The greatest significance of the theory may be perceived from the fact that it takes into consideration multiple issues that probably undermines the dormant factors causing adversity for the caregivers to care for the patients with mental illness. The stigma linked to mental illness often impedes the caregivers and other people associated to provide care for the patient to seek and participate in mental health program. Stigma has been defined as a complex constructs that encompass self, public and structural constituents influencing the mental illness victim, their supporting team consisting of the family members, healthcare network and community resources. Advocacy of mental health literacy in conjunction with cultural competence and family recruitment in the care regime will therefore lessen the impact of mental health issue and associated health costs in case of the caregivers due to prolonged association with the problem. In this respect policy change is encouraged to address the issue and promote mental health awareness program (Corrigan, Druss, & Perlick, 2014). The fundamental goal of nursing to help out individuals and groups with their distinct needs to attain, maintain and restore health may be achieved through this theory by paying attention to the circumstances of the family members of patients with persistent mental health illness. A study examined the efficacy of the family intervention program to educate the relatives of the patients with schizophrenia and thereby helping them to cope better with the situations generated positive outcomes. The findings indicated that the relapse rate could be effectively minimized by incorporating the family into the treatment program and hence accounted for decreasing the load of mental pressure on the caregivers to a large extent (Pitschel-Walz et al., 2015). Thus the theory has the potential to enable the nursing professionals with enough training and expertise to deal with the family members of persistently mentally ill patients that might add to their improved health outcomes and quicker recuperation from the distressed state.
The family health theory is a distinguished and holistic theory that is driven by the fundamental principles that can very reasonably attend to the family health outcomes in the concerned population where persisting mental health illness is a prevalent issue. One of the vital strength of the theory arises from the attention being laid upon the independent predictors of family health ranging from the adaptive mechanisms of the family, perceptions of the family regarding the symptoms in the patient, stressors affecting the situation and other associated factors. The propositions of the theory may be corroborated with the research findings that lay importance in collaborative trail of progress including the family members together with the client and the therapist to ensure that the goals of clinical intervention has been attained (Bitter, 2013). Thus, this theory may be implemented in nursing practice in the form of succinct guidelines to facilitate rapid learning outcomes among the nursing students.
Unlike any other theory, the family health theory also has its own limitations and loopholes. The foremost identifiable drawback is concerned with the factor that consider the time since diagnosis of mental illness for the family to predict their health outcomes. The impact of this variable has generated contradictory responses through empirical research findings that relate the variation in results due to passage of time with either increased or decreased burden of mental health illness in the client. The cumulative experience of the family has not been addressed satisfactorily in the theory and therefore requires further extrapolation and elaboration for future consideration. Another less understood aspect of the theory attribute to the concept of stressors that underpin the family health outcomes. Although certain specific type of stressors such as the ones including intrafamily, financial, employment, marital, illness related, grief and loss, legal transition and mental healthcare system stressors have been mentioned, yet the degree and exact impact of this factor has not been well assessed (Bush et al., 2015). Therefore psychiatric mental health nursing with the concepts matching evidence based practice to devise suitable nursing intervention is of utmost necessity to resolve the issues because of the impact of stress (Townsend, 2014). However, careful consideration of all the confounding factors can help to mitigate the negative health outcomes in the family of patients with persistent mental health illness thereby promoting health and wellness among them (Riegel, Jaarsma, & Strömberg 2012). The specific mental health issues those are likely to impact the behaviors and health outcomes of the family also need to be appropriately identified in order to render quality healthcare facility in such cases.
The propositions and assumptions of the theory attended to the causes for the burden among the family caregivers with patients of persisting mental health illness. In real life situations the degrees and frequencies of the onset of symptoms related to mental illness may further affect the stress generation of the family members or caregivers. The orientation and working of the family gets severely affected due to presence of such perpetual problems. The various novel coping methods as carried out by the family members culminate in producing either positive or negative effects that might cause easier management or subsequent deterioration of health as per the given circumstance. In this regard the refinement of the theory is appreciable to identify the accurate and case appropriate remedy that may be applied to treat the condition holistically. Hence design of suitable interventions is absolutely necessary to alleviate the hazards and improvise education and consultation including the patient and the family together. Research has revealed that certain serious mental illness such as schizophrenia, bipolar disorder or major depression may be effectively addressed through family incorporation into treatment protocol for making informed decisions (Burden, 2013). The theory may be well utilized under such circumstance to analyze the feasibility of the prospective interventional technique.
The three chief factors in the family health theory consisted of the client, family and professional component. Careful analysis and due importance given to each of the component will therefore ensure better health outcomes for the family as a whole. The theory may be used by the nurses to test the reliability and validity of the theoretical framework provided. Comparison of the efficacy of this theory with respect to other theories can hence highlight about the actual benefits of using the theory. Numerous current and previous empirical researches have brought to the forefront the importance of family accommodation representing clinical data that are worth evaluating, supervising and identifying in clinical care setting. Family health in such cases may be positively affected due to implementation of therapies targeting family accommodation (Lebowitz et al., 2014).
The applicability of the theory into real life practice has not been indicated anywhere. However, considering the utilities and clarity of the propositions mentioned in the theory itself it is expected that the nurses will abide by the theoretical guidelines to allow for the generation of positive outcomes. Prior to the actual trial of the theory into clinical practice the nurses may need to do a thorough and in depth investigation so as to be on guard against the possible drawbacks that might negatively impact the health outcomes in the family members having patients with persistent mental illness. In this context the reference may be cited for a study that inferred that need based “short term psycho educational intervention” meant for the family members of the schizophrenic patients might extract advance outcomes for both the family as well as the patient (Sharif, Shaygan, & Mani, 2012). Therefore, utilization of the family health theory into clinical practice will enhance the professional competency as well as pave the way for consecutive research on this topic.
Management of mental illness is debilitating for the family and other caregivers. It requires a holistic approach for the nurses to assist the family to maintain their health and ensure client outcomes. Implementing theory-based practice is a hallmark of professional discipline like nursing. The central theme of nursing mid range theories revolves around physical and social environment around the human beings with the goal of the health. The major element of the Family Health Theory is identified in the “interpersonal system” where the family and the health care professionals interact to seek help in restoring their health and in turn care for the young adults with the persistent mental illness.
After careful analysis of the FHT using the guidelines provided by Chinn & Kramer, (2015) it can be concluded that FHT is a clear theory constituting a range of factors to assess the outcomes of health in family members of the adults suffering from persistent mental health illness. The health care professionals, nurses and adult patients can all use this theory to harbor better clinical outcomes and foster holistic mode of care to the desired population. Although the theory has drawbacks it is significant to be applied in research and practice. The theory is important for nurse to understand their practice and develop best interventions necessary to alleviate the hazards and improvise education and consultation including the patient and the family together. The strength of the theory is the enhancement of the family caregiving role and their health as they struggle to cope with the illness. However, the complexity of the theory due to six concepts limits its applicability. This middle range theory provides a framework for this initiative as it integrates the client, family and professional components into the practice. Thus, it is an important initiative in nursing practice to protect the health of the families struggling with the mentally ill member. Formulation of such theory accompanied by empirical testing is promising to the science of nursing.
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