SELF-CONCEPT

Self-concept is one’s mental image of oneself. A positive self-concept is essential to a person’s mental and physical
health. Individual with a positive self-concept are better able to develop and maintain interpersonal relationships and
resist psychologic and physical illness.
Nurses have responsibility to assess clients for a negative self-concept and to identify the possible causes in order to help
them develop a more positive view of themselves.
It involves all of the self-perception- appearance, values and beliefs- that influence behaviour and are referred to when
using the words I or me. It is a complex idea that influences the following:
▪ How one thinks, talks and acts
▪ How one sees and treat another person
▪ Choices one makes
▪ Ability to give and receive love
▪ Ability to take actions and to change things.

Dimensions of self-concept
1. Self-knowledge – the knowledge that one has about oneself, including insights into one’s abilities, nature and
limitations.
2. Self-expectation – what one expects of oneself; maybe realistic or unrealistic
3. Social self – how a person is perceived by others and society
4. Social evaluation – the appraisal of oneself in relationship to others, events, or situations

Self-awareness – refers to the relationship between one’s perception of himself or herself and others’ perception of him
or her. Thus, a nurse who is very self-aware has perceptions that are very congruent.

Components of Self-concept
1. Personal identity - is the conscious sense of individuality and uniqueness that is continually evolving throughout
life. It also includes beliefs and values, personality and character
2. Body image – or the image of physical self. It is how a person perceives the size, appearance and functioning of
the body and its parts. It has both cognitive (knowledge of the material body) and affective (sensation of the
body like pain, fatigue, pleasure, physical movement). It also includes clothing, make-up, hairstyle, jewelry and
other things. BODY DISTURBANCE, DEFORMITY, MALFUNCTION
3. Role performance – what a person does in a particular role in relation to the behaviours expected of that role.
▪ Role mastery – performance of role behaviours that meet social expectations
▪ Role development – involves socialization into a particular role.
▪ Role ambiguity – unclear role expectations; people do not know what to do or how to do it and are
unable to predict the actions of others to their behaviour
▪ Role strain – a generalized state of frustration or anxiety experienced with the stress of role conflict and
ambiguity
▪ Role conflicts – a clash between the beliefs or behaviour imposed by two or more roles fulfilled by one
person.
4. Self-esteem – the value one has for oneself.
a. Global self-esteem – how much one likes oneself as a whole
b. Specific self-esteem – how much one approves of a certain part of oneself.

Factors that Affect Self-Concept

1. Stage of development
2. Family and culture
3. Stressors
4. Resources
5. History of success and failure

Enhancing self-esteem
1. Encourage clients to appreciate the situation and express their feelings
2. Encourage clients to ask questions
3. Provide accurate information
4. Became aware of distortions, inappropriate or unrealistic standards and faulty labels in clients’ speech
5. Explore clients’ positive qualities and strengths
6. Encourage client to express positive self-evaluation more than negative self-evaluation
7. Avoid criticism
8. Teach client to substitute negative self-talk with positive self-talk. Negative self-talk reinforces a negative self-
concept
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STRESS AND ADAPTATION

Stress is a condition in which the person experiences changes in the normal balance state.
Stressor is any event or stimulus that causes an individual to experience stress.

Sources of Stress
• Internal stressors – originate within a person (infection, feeling of depression)
• External stressors – originate outside the individual (move to another city, death in a family)
• Developmental stressors –occurs at predictable times throughout an individual’s life
• Situational stressors – unpredictable and may occur anytime during life (maybe positive or negative)
Ex. Death of a family member, marriage or divorce, birth of a child, new job, illness

Effects of stress
• Physical – threaten a person’s physiologic homeostasis
• Emotional – can produce negative or nonconstructive feelings about the self
• Intellectual – can influence a person’s perceptual and problem-solving abilities
• Social – can alter a person’s relationship with others
• Spiritual – can challenge one’s beliefs and values.

Indicators of stress
• Physiologic indicators – results from activation of the sympathetic and neuroendocrine systems of the body
Clinical Manifestations of Stress
▪ Pupils dilate to increase visual perception when serious threats to the body arise
▪ Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism.
▪ Heart rate and cardiac output increase to transport nutrients and by-products of metabolism more
efficiently
▪ Skin is pallid due to constriction of peripheral blood vessels, an effect of norepinephrine
▪ Sodium and water retention increase due to release of mineralocorticoids, which increases blood
volume
▪ Rate and depth of respirations increase due to dilation of the bronchioles, promoting hyperventilation
▪ Urinary output decreases
▪ Mouth may be dry
▪ Peristalsis of the intestines decreases, resulting in possible constipation and flatus
▪ For serious threats, mental alertness improves
▪ Muscle tension increases to prepare for rapid motor activity or defense
▪ Blood sugar increases because of release of glucocorticoids and gluconeogenesis
• Psychologic indicators
▪ Anxiety and fear
▪ Anger
▪ Depression
▪ Ego defense mechanism
▪ Problem solving

• Cognitive indicators – thinking responses

▪ Structuring
▪ Self-control (discipline)
▪ Suppression
▪ Fantasy

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Coping – dealing with change- successfully or unsuccessfully. A coping strategy (coping mechanism) is a natural or
learned way of responding to a changing environment or specific problem or situation.

Types of coping strategies

• Problem-focused coping refers to efforts to improve a situation by making changes or taking some action
• Emotion-focused coping includes thoughts and actions that relieve emotional stress. It does not improve the
situation but the person often feels better.
• Long-term coping strategies can be constructive and realistic
• Short-term coping strategies can reduce stress to a tolerable limit temporarily but are ineffective ways to
permanently deal with reality.
Coping strategies vary among individuals and are often related to the individual’s perception of the stressful event. Three
approaches to coping with stress are to alter the stressor, adapt to the stressor, or avoid the stressor. A person’s coping
strategies often change with a reappraisal of the situation. There is never only one way to cope. Some people choose
avoidance; others confront a situation as a means of coping. Still others seek information or rely on religious beliefs.

Encouraging Health promotion Strategies

1. Exercise
2. Nutrition
3. Rest and sleep
4. Time management

SENSORY FUNCTIONING
Components of the Sensory Experience
1. Sensory reception is the process of receiving stimuli or data
a. External stimuli
• Visual (sight)
• Auditory (hearing)
• Olfactory (smell)
• Tactile (touch)
• Gustatory ( taste)
b. Internal stimuli
• Kinesthetic refers to awareness of the position and movement of body parts
• Visceral refers to any large organ within the body which may produce stimuli that make a person
aware of them
2. Sensory perception involves the conscious organization and translation of the data or stimuli into meaningful
information.
a. Stimulus – an agent or act that stimulates a nerve receptor
b. Receptor – a nerve cell acts as a receptor by converting the stimulus to a nerve impulse.
c. Impulse conduction – the impulse travels along nerve pathway to the spinal cord or directly to the brain.
d. Perception – or awareness, and interpretation of stimuli, takes place in the brain, where specialized brain
cells interprets the nature and the quality of the sensory stimuli.

Awareness is the ability to perceive environmental stimuli and body reactions and to responds appropriately through
thought and action.

States of Awareness
STATE DESCRIPTION
Full consciousness Alert; oriented to time, place, person; understands verbal and written words
Disoriented Not oriented to time, place or person
Confused Reduce awareness, easily bewildered; poor memory, misinterprets stimuli; impaired
judgement
Somnolent Extreme drowsiness but will respond to stimuli
Semicomatose Can be aroused by extreme or repeated stimuli
Coma Will not respond to verbal stimuli

Sensory Alterations
1. Sensory deprivation – insufficient sensory stimulation for a person to function
2. Sensory overload – occurs when a person is unable to process or manage the amount or intensity of sensory
stimuli. These factors contribute to sensory overload:
▪ Increased quantity or quality of internal stimuli (pain, dypsnea, anxiety)
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 ▪ Increased quantity or quality of external stimuli (noisy health care setting, contacts with many strangers)
▪ Inability to disregard stimuli selectively, perhaps as a result of nervous system disturbances or
medications that stimulate the arousal mechanism
3. Sensory deficits – partial or complete impairment of any sensory organ

Sensory Deprivation: Clinical Manifestations

• Excessive yawning, drowsiness, sleeping
• Decreased attention span, difficulty concentrating, decreased problem solving
• Impaired memory
• Periodic disorientation, general confusion, or nocturnal confusion
• Preoccupation with somatic complaints, such as palpitations
• Hallucinations or delusions
• Crying, annoyance over small matters, depression
• Apathy, emotional lability

Sensory Overload: Clinical Manifestations

• Complaints of fatigue, sleeplessness
• Irritability, anxiety, restlessness
• Periodic or general disorientation
• Reduced problem-solving ability and task performance
• Increased muscle tension
• Scattered attention and racing thoughts

Factors affecting sensory function

• Developmental stage
• Culture
• Level of stress
• Medication and illness
• Lifestyle and personality

SPIRITUALITY
Spirituality Described
The word spiritual derives from the Latin word spiritus, which means “to blow” or “to breath,” and has come to connote
that which gives life or essence to being human. Spirituality refers to that part of being human that seeks
meaningfulness through intra-, inter-, and transpersonal connection. Spirituality generally involves a belief in a
relationship with some higher power, creative force, divine being, or infinite source of energy.

Spirituality includes the following aspects:

• Meaning (having purpose, making sense of life)
• Value (having cherished beliefs and standards)
• Transcendence (appreciating a dimension that is beyond the self)
• Connecting (relating to others, nature, Ultimate Other)
• Becoming (which involves reflection, allowing life to unfold, and knowing who one is).

Spiritual Needs
All clients have needs that reflect their spirituality. These needs are often accentuated by an illness or other
health crisis.
Examples of Spiritual Needs:
• Need for love
• Need for Hope
• Need for trust
• Need for forgiveness
• Need to be respected and value
• Need for dignity
• Need for meaning to the fullness of life
• Need for values
• Need for creativity
• Need to connect with God or Higher Power or Being greater than oneself.
• Need to belong to a community

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Nurses need to be sensitive to indications of the client’s spiritual needs and respond appropriately

Spiritual Well-Being
Spiritual health, or spiritual well-being, is manifested by a feeling of being “generally alive, purposeful, and fulfilled”.
According to Pitch (1988) spiritual wellness is “a way of living, a lifestyle that views and lives life as purposeful and
pleasurable, that seeks out life-sustaining and life-enriching options to be chosen freely at every opportunity, and that
sinks its roots deeply into spiritual values or and/or specific religious beliefs”.

Characteristics Indicative of Spiritual Well-Being

• Sense of inner peace
• Compassion of others
• Reverence for life
• Gratitude
• Appreciation of both unity and diversity
• Humor
• Wisdom
• Generosity
• Ability to transcend the self
• Capacity for unconditional love
Relating to one’s inner self or soul may be achieved by conducting an inner dialogue with a higher power or with oneself
through prayer or meditation, by analyzing dreams, by communing with nature, or by experiencing the inspiration of art.
The expression of a person’s spiritual energy to others, joy and laughter, participation in religious services and
associated fellowship gatherings and activities, and by expression of compassion, empathy, forgiveness and hope.

Spiritual Distress
It refers to a challenge to the spiritual well-being or to the belief system that provides strength, hope, and meaning to
life. Some factors may be associated with or contribute to a person’s distress include physiologic problems, treatment-
related concerns, and situational concerns

Related Concepts
Because spirituality is a reflection of inner experiences that is expressed individually, it includes as many representations
as there are human beings. Concepts related to spirituality include religion, faith, hope, transcendence, and forgiveness

• Religion is an organized system of beliefs and practices. It offers a way of spiritual expression that provides
guidance for believers in responding of life’s questions and challenges. According to Vardey (1995), the
organized religions offer:
sense of community bound by common beliefs
the collective study of scripture (the Torah, Bible, Koran, or others)
the performance of ritual
the use of disciplines and practices, commandments, and sacraments
ways of taking care of the person’s spirit (such as fasting, prayer, and meditation).

▪ Agnostic is a person who doubts the existence of God or a supreme being or believes the
existence of God has not been proved.
▪ Atheist is one without belief in a God.
▪ Monotheism is the belief in the existence of one God
▪ Polytheism is the belief in more than one god.

• Faith is to believe in or be committed to something or someone. Fowler (1981) describes faith as being present
in both religious and nonreligious people. Faith gives life meaning, providing the individual with strength in
times, of difficulty.

• Hope is a concept that incorporates spirituality. Stephenson (1991) suggested this definition: ”a process of
anticipation that involves the interaction of thinking, acting, feeling, and relating, and is directed toward a future
fulfillment that is personally meaningful”.

• Transcendence is often used interchangeably with self-transcendence, which Coward (1990) defined as: “the
capacity to reach out beyond oneself, to extend oneself beyond personal concerns and to take a broader life
perspectives, activities, and purposes”.

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 • The concept of forgiveness is receiving increased attention among health care professionals. For many clients,
illness or disability bring a sense of shame or guilt. The health problem is interrupted as a punishment for past
sins.

Spiritual practices affecting nursing care

1. Holy Days
A holy day is a day set aside for special religious observance, and all the world religions observe certain holy days.
Christians observe Easter and Christmas
Jews observe Yom Kippur and Passover
Buddhists observe the birthday of the Buddha
Muslims observe the month-long holy period of Ramadan
Hindus observe Maha Shivaratri, a celebration of Lord Shiva.
Many religions require fasting, extended prayer, and reflection or ritual observances on sacred (or high holy) days

2. Sacred Writings
Each religion has sacred and authoritative scriptures that provide guidance for its adherents’ beliefs and behaviors; in
addition, sacred writings frequently tell instructive stories of the religion’s leaders, kings, and heroes.
Christians rely on the Bible, Jews on the Torah and Talmud, and Muslims on the Koran. Scriptures generally set forth
religious law in the form of admonitions and rules for living.

3. Sacred Symbols
It includes jewelries, medals, amulets, icons, totems, or body ornamentation that carry religious or spiritual significance.
They may be worn to pronounce one’s faith, to remind the practitioner of the faith, to provide spiritual protection, or to
be a source of comfort or strength.

4. Prayer and Meditation

Prayer is a spiritual practice; for many, it is also a religious practice. An encyclopedia of religion defines prayer simply as
“human communication with divine and spiritual entities”. Prayer is intention plus love, often communicated with
“Absolute,"; that is, prayer is a loving wish or thought for oneself or another, and not an invocation of positive or
negative forms of magic.

Different types of prayer experience

Ritual – memorized prayer that can be repeated
Petitionary – intercessory prayers when one is requesting something of the divine
Colloquial – conversational prayer
Meditational – moments of silence focused on nothing, a meaningful phrase, or certain aspect of the
divine
Meditation – is the act of focusing one’s thoughts or engaging in self-reflection or
contemplation.

5. Beliefs Affecting Diet and Nutrition

Many religions have proscriptions regarding diet. There may be rules about which foods and beverages are allowed and
which are prohibited.
Orthodox Jews are not allowed to eat shellfish or pork
Muslims are not to drink alcoholic beverages or eat pork
Older Catholics may choose not to eat meat on Fridays

6. Beliefs Related to Healing

Clients may have religious beliefs that attribute illness to a spiritual disruption. Healing for such clients may appear to be
unrelated to current treatment practices.

7. Beliefs Related to Dress

Many religions have laws or traditions that dictate dress.
Orthodox and Conservative Jewish men believe that it is important to have their heads covered at all
times.
Orthodox Jewish women cover their hair with a wig or scarf as a sign of respect to God.
Hindu women dressed in saris.

8. Beliefs Related to Birth

For all religions the birth of a child is an important event giving cause for celebration.

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 In the Christian faith, baptism and christening ceremonies may take place after the birth of a child to
confirm that the “infant was born into a Christian family as part of the organism of the church”
In the Jewish religion, the ritual circumcision conducted on male children on the eight day after birth is
an expression of the religious bond between the prophet Abraham.

9. Beliefs Related to Death

Many believe that the person who dies transcends this life for a better place or state of being.
Roman Catholic priests perform the Sacraments of the Sick when clients are very ill or near death.
Jews have the tradition of burial within 24 hours following death, except on the Sabbath, draping any
mirrors in black to ensure that guests are focused on memory of the deceased rather than themselves.

Assessing
Data about a clients’ spiritual beliefs are obtained from the client’s general history; through a nursing history; and by
clinical observations of the clients’ behavior, verbalization and mood.

Clinical Assessment
Cues to spiritual and religious preferences, strengths, concerns, or distress may be related by one or more of the
following:
• Environment. Does the client have a Bible?
• Behavior. Does the client appear to pray? Does the client have sleep disturbances or express anger at religious
representatives?
• Verbalization. Does the client mention God? Does the client express fear of death, concern with the meaning of
life, inner conflict about religious beliefs?
• Affect and attitude. Does the client appear lonely, depressed, angry, anxious, agitated, apathetic, or
preoccupied?
• Interpersonal relationships. Who visits? How does the client respond to visitors? Does a minister come? How
does the client relate to other clients and nursing personnel?

DIAGNOSING
• Spiritual Issues as the diagnostic label
Spiritual Distress is “impaired ability to experience and integrate meaning and purpose in life through a
person’s connectedness with self, others, art, music, literature, nature, or a power greater than
oneself”.
Readiness for Enhanced Spiritual Well-Being recognizes that spiritual well-being is the “ability to
experience and integrate meaning and purpose in life through a person’s connectedness with self,
others, art, music, literature, nature, or a power greater than oneself”.
Risk for Spiritual Distress is defined by NANDA (2003) as being “at risk for an altered sense of
harmonious connectedness with all of life and the universe in which dimensions that transcend and
empower the self may be disrupted”.

• Religious Issues as the diagnostic label

Impaired religiosity: “Impaired ability to exercise reliance on religious beliefs and/or participate in rituals
of a particular bath tradition”
Readiness for enhanced religiosity: Ability to increase reliance on religious beliefs and/or participate in
rituals of a particular faith tradition”

• Spiritual or Religious Distress as the Etiology

Spiritual distress may affect other areas of functioning and indicate other diagnoses. In these instances, spiritual
becomes the etiology.
Fear related to apprehension about soul’s future after death and unpreparedness for death
Chronic or Situational Low Self-esteem related to failure to live within the precepts of one’s faith
Disturbed Sleep Pattern related to feelings of abandonment by God and loss of religious faith
Decisional Conflict related to conflict between treatment plan and religious beliefs.

PLANNING
Planning in relation to spiritual needs should be designed to do one or more of the following:
• Help the client fulfill religious obligations.
• Help the client draw on and use inner resources more effectively to meet the present situation.
• Help the client maintain or establish a dynamic, personal relationship with a supreme being in the face of
unpleasant circumstances.
• Help the client find meaning in existence and the present situation.

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 • Promote a sense of hope.
• Provide spiritual resources otherwise unavailable.

IMPLEMENTING
Nursing actions to help clients meet their spiritual needs include:
• providing presence
• supporting religious practices
• assisting clients with prayer
• referring clients for spiritual counseling.

EVALUATING
Using the measurable desired outcomes developed during the planning stage, the nurse collects data needed to
judge whether client goals and outcomes have been achieved

LOSS – an actual or potential situation in which something that is valued is changed or no longer available
- Body image
- Significant others
- Sense of well-being
- Job
- Personal possession
- Beliefs
Death – fundamental loss, both for the dying person and those who survive

Types of loss
1. Actual loss – can be recognized by others
2. Perceived loss – experienced by one person but cannot be verified by others
2.1 Psychologic loss
3. Anticipatory loss – experienced before the loss actually occurs
Loss can be viewed as situational (loss of job, death of a child, etc.) or developmental (retirement from career, death
of aged parents, etc.).

Sources of loss:
1. Loss of an aspect of oneself (body part, physiologic function or psychologic attribute)
2. Loss of an object external to oneself
a. Loss of inanimate objects that have importance in a person
Ex. Money, house, car
b. Loss of animate (live) objects such as pets that provide love and companionship
3. Separation from familiar environment
4. Loss of a loved or valued person
Ex. Illness, divorce, separation, death

BEREAVEMENT – the subjective response experienced by the surviving loved ones after the death of a person with
whom they have shared a significant relationship.

MOURNING – the behavioural process through which grief is eventually resolved or altered; It is often influenced by
culture, spiritual beliefs, and custom.

GRIEF – the total response to the emotional experience related to loss. It is manifested in thoughts, feelings and
behaviour associated with overwhelming distress or sorrow.

Types of Grief Responses

1. Abbreviated grief – brief but genuinely felt
2. Anticipatory grief – experience in advance of the event
3. Disenfranchised grief – occurs when a person is unable to acknowledge the loss to other persons.
Ex. Suicide, abortion, giving a child for adoption
4. Complicated (pathologic) grief – exists when the strategies to cope with the loss are maladaptive
Ex. Sudden death, prior traumatic loss, strained relationship between survivor and the
deceased, etc
4.1 Unresolved or chronic grief – extended in length and severity. Have difficulty expressing the grief, may
deny the loss, or may grieve beyond the expected time.
4.2 Inhibited grief – many of the normal symptoms of grief are suppressed, and other effects, including
somatic, are experienced instead.
4.3 Delayed grief – occurs when feelings are purposely or subconsciously suppressed until much later time.
4.4 Exaggerated grief – occurs when a survivor appears to be using dangerous activities as a method to
lessen the pain of grieving

The normal process of reacting to a loss

• Loss of loved one
• Sense of one’s own nearing death
• Loss of familiar home environment
• Loss of bodily functions (Activities of Daily Living)

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• Loss of privacy and independence.
Everyone responds differently.

Why talk about the grief process?

➢ It effects everyone
➢ It helps us, our patients, and their families to cope with stressful events
➢ It is important to identify those who struggle with this process

Factors Influencing the Loss and Grief Responses

• Age
• Culture
• Spiritual beliefs
• Gender
• Socio-economic status
• Support system
• Cause of loss or death

Stages of Grief
DENIAL
➢ involves patient and/or family members
➢ Unable to handle reality
➢ Helps person survive loss
➢ Protects from being overwhelmed
Why the Denial?
Shock. Is this true? Are they gone?
Unable to handle reality
Helps person survive loss
Protects from being overwhelmed

ANGER
➢ May occur once patient faces reality
➢ Questions: Why? How? Now?
➢ Anger towards deceased, healthcare workers, or oneself
How to respond to anger?
➢ Allow patient to talk and express feelings
➢ Engage patient in exercise or activities
➢ Don’t keep it in!
➢ It won’t last forever

BARGAINING
➢ The “What If” stage
Example: If I spend the rest of my life helping the poor, God will let my husband live.
➢ Provides temporary escape and hope
➢ Allows time to adjust to reality

DEPRESSION
➢ Occurs when reality really sinks in
➢ Sadness, decreased sleep and decreased appetite are common
➢ No sustained functional impairment
➢ Rare to have suicidal thoughts
Remember, this is normal after loss
➢ Give patient the time they need in this stage
➢ Group discussion may help patients express their feelings

ACCEPTANCE
➢ Accepting reality and the fact that nothing can change the reality
➢ Does Not mean patient is okay with loss
➢ Learning to move on
➢ Final stage of healing

Range of Responses
>Sadness >Denial
> Anger > Confusion
> Guilt > Obsession with memories of deceased
>Helplessness > Difficulty with concentration
>Numbness > Sleep and appetite changes
>Yearning > Nightmares
> Relief > Crying
>Loneliness > Social isolation
> Fatigue

How long is the grieving process?

➢ Varies for each individual
➢ Generally, 6-12 months
➢ Longer if complicated by major depression

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Role of healthcare worker
➢ Help patient and family to be aware of emotions they may encounter in the grief process
➢ Encourage patient and or family to express their feelings
➢ Encourage healthy coping mechanisms such as exercising or gardening
➢ Identify changes in behaviour, communication, mood, eating and sleeping pattern
➢ Identify those with poor coping mechanism.
May need grief counselling or anti-depressant treatment. Early Intervention should be done

Struggling with the grief process

Poor coping mechanisms can lead to:
➢ Major depressive disorder and or anxiety.
20% of grieving individuals 2 months after death of loved one are diagnosed with major depression
➢ Poor physical health
Grieving individuals stop taking care of themselves
➢ Suicide
Widows and widowers have 8-50 times higher suicide rate than the overall population

Risk factors for poor outcomes in bereavement

➢ Male
➢ Young, Age <46
➢ Pre-existing psychopathology (depression)
➢ Poor physical health
➢ Sudden or unexpected loss
➢ No social support
➢ Loss of child, especially adult child
➢ Dependent or ambivalent relationship with deceased
*Information obtained from Schum, Jennifer, Ph.D.; Lyness, Jeffrey MD; King, Deborah, Ph.D. Bereavement in late life: Risk factors for complicated bereavement. Geriatrics. 60(4)

Client Responses and Nursing Implications in Kubler-Ross’s Stages of Grief

*Information obtained from Schum, Jennifer, Ph.D.; Lyness, Jeffrey MD; King, Deborah, Ph.D. Bereavement in late life: Risk factors for complicated bereavement. Geriatrics. 60(4)

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DYING AND DEATH
Definitions and Signs of Death
The traditional clinical signs of death were cessation of the apical pulse, respirations and blood pressure. It is also
referred as heart-lung death. The World Medical Assembly (1968) adopted the following guidelines for physicians as
indications of death:
▪ Total lack of response of external stimuli
▪ No muscular movement, especially breathing
▪ No reflexes
▪ Flat encephalogram (brain waves)
Another definition of death is cerebral death or higher brain death which occurs when the higher brain center, the
cerebral cortex, is irreversibly destroyed

Death-Related Religious and Cultural Practices

Various cultural and religious traditions and practices associated with death, dying and the grieving process help
people cope with these experiences. Nurses are often present through the dying process and at the moment of death.
Knowledge of the client’s religious and cultural heritage helps nurses provide individualized care to clients and their
families, even though they may not participate in the rituals associated with death.

The Dying Person’s Bill of Rights 8. I have the right to have my questions
1. I have the right to be treated as a living answered honestly.
human being until I die. 9. I have the right not to be deceived.
2. I have the right to maintain a sense of 10. I have the right to have help from and for my
hopefulness however changing its focus may family in accepting my death.
be. 11. I have the right to die in peace and with
3. I have the right to express my feelings and dignity.
emotions about my approaching death in my 12. I have the right to retain my individuality and
own way. not be judged for my decisions which may be
4. I have the right to participate in decisions contrary to the beliefs of others.
concerning my care. 13. I have the right to be cared for by caring
5. I have the right to expect continuing medical sensitive, knowledgeable people who will
and nursing attention even though cure goals attempt to understand my needs and will be
must be changed to comfort goals. able to gain some satisfaction in helping me
6. I have the right to die alone. face my death.
7. I have the right to be free from pain.
*From “The Dying Person’s Bill of Rights” by A.J. Barbus, 1975, created at the workshop The Terminally Ill Patient and the Helping Person, Lansing MI: South Western Michigan Inservice Education Council.

The major nursing responsibility for clients who are dying is to assist the client to a peaceful death. Specific
Responsibilities are:
▪ To minimize loneliness, fear and depression

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 ▪ To maintain the client’s sense of security, self-confidence, dignity and self-worth
▪ To help the client accept losses
▪ To provide physical comfort

Hospice and palliative Care

Hospice care focuses on support and care of the dying person and family, with the goal of facilitating a peaceful and
dignified death. It is base on holistic concepts, emphasizes care to improve quality of life rather than cure, supports
the client and family through the dying process, and support the family through bereavement.
Palliative care (WHO) is an approach that improves the quality of life of clients and their families facing the
problem associated with life threatening illness, through the prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and
spiritual. Palliative care:
▪ Provides relief from pain and other distressing symptoms
▪ Affirms life and regards dying as a normal process
▪ Intends neither to hasten nor postpone death
▪ Integrates the psychological and spiritual aspects of client care
▪ Offers a support system to help the family cope during the client’s illness and in their own bereavement
▪ Uses a team approach to address the needs of clients and their families, including bereavement counselling, if
indicated
▪ Will enhance quality of life, and may also positively influence the course of illness
▪ Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life
such as chemotherapy or radiation therapy; and includes those investigations needed to better understand
and manage distressing clinical complications.

Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death. It results from lack of adenosine
triphosphate (ATP), which causes the muscles to contract, which in turn immobilizes the joints. The nurse need to
position the body, place dentures in the mouth and close the eyes and mouth before rigor mortis sets in.

Algor mortis is the gradual decrease of the body’s temperature after death.

Livor mortis is the discoloration of the skin caused by breakdown of the red blood cells; occurs after blood circulation
has ceased; appears in the dependent areas of the body.

Postmortem Care
Postmortem care is the care of the body after death. Nursing personnel should be responsible for this and should be
carried out according to the policy of the hospital or agency

Concepts and Principles of Partnership, Collaboration and Teamwork

Partnership – state of being a partner and an association of two or more people as partner.
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 Collaboration – a collegial working relationship with another health care provider in the promotion of health care.
Teamwork – the ability to function effectively within the nursing and interpersonal team, fostering open
communication, mutual respect, and shared decision-making.

A. Development of teamwork and collaboration

1. Self-awareness – refers to the relationship between one’s perception of himself or herself and others’ perception of
him or her. DYAD - two person’s groups.
The word "dyad" comes from the Greek "dyas" meaning the number two. In psychology, a dyad refers to a pair of
persons in an interactional situation.
https://www.medicinenet.com/script/main/art.asp?articlekey=12897
2. Group – two or more people who have shared needs and goals, who take each other into account in their
actions, and are held together and set apart from others by virtue of their interactions.
3. Team –Delivery of coordinated care to individual clients by a group of health providers
4. Health care team is the group of professionals who contribute to your care and treatment as a patient.
5. Multidisciplinary team is a group of health care workers who are members of different disciplines each providing
specific services to the patient. The activities of the team are brought together using a care plan

B. Role of a Registered Nurse in a healthcare team

The primary role of a nurse is to advocate and care for individuals of all ethnic origins and religious backgrounds and
support them through health and illness. Collaborate with team to plan for patient care
 Provide and coordinate patient care
 Record patient’s medical histories and symptoms
 Administer patients’ medicines and treatments
 Set up plans for patients’ care or contribute to existing plans
 Observe patients and record observations
 Role of a Registered Nurse in a healthcare team
 Consult and collaborate with doctors and other members of the healthcare team
 Operate and monitor medical equipment
 Help perform diagnostic tests and analyze the results
 Educate patients and the public about health conditions
 Provide advice and emotional support to patients and their family members
https://creakyjoints.org/about/what-is-the-healthcare-team/

Concept of leadership
A. Role of the nurse as a leader/manager
Manager – the nurse manages the nursing care of individuals, families and communities. The nurse-manager also
delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance
Role of the nurse as a manager
- Managing small or large teams of nurses
- Overseeing or coordinating the training of staff
- Supervising nurses’ patient care
- Collaborating with other managers to offer a range of health care services
- Using evidence-based health care practices

Leader – a leader influences others to work together to accomplish a specific goal. Effective leadership is a learned
process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership
skills, and the interpersonal skills to influence others.
Role of the nurse as a leader
- Acting as the strategic lead for patient care initiatives
- Directing a group of nurse managers
- Influencing others through effective communication and interpersonal skills
- Implementing evidence-based practices and rolling them out to other nurses and health care staff
- Mentoring other nurses
americansentinel.edu/blog/2020/02/29/leadership-management-in-nursing-whats-the-difference/

B. Positive Practice Environment

Positive practice environments are health care settings that support excellence and decent work.
http://www.whpa.org/news-resources/positive-practice-environment-toolkit

Elements of Positive practice:

- Safe staffing levels
- Support and supervision
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 - Open communication and transparency
- Recognition programmes
- Access to adequate equipment, supplies and support staff
- Demands that fit the resources of the person
- Positive Practice Environment
- A high level of predictability
- Good social support from colleagues and managers and access to education and professional development
opportunities
- Meaningful work
- A high level of influence
- A balance between effort and reward

Positive practice environments are characterised by:

- Innovative policy frameworks focused on recruitment and retention.
- Strategies for continuing education and upgrading.
- Adequate employee compensation.
- Recognition programmes.
- Sufficient equipment and supplies.
- A safe working environment
- Positive Practice Environment
https://www.slideshare.net/roducado/positive-practice-environment-for-nurses

Concept of Continuing Professional Development

Continuing professional development (CPD) encompasses experiences, activities and processes that contribute towards
the development of a nurse or midwife as a health care professional. CPD is, therefore, a lifelong process of both
structured and informal learning.
https://www.nmbi.ie/Standards-Guidance/Scope-of Practice/Considerations-in-Determining-Scope/Continuing-Professional-Development

A. Lifelong learning
Refers to the voluntary decision to enroll in educational courses or to study a topic on one's volition. While the term may
seem to apply especially to those who have already earned a college degree or entered the workforce, lifelong learning
is vital for everybody, no matter the age or level of education.
https://study.com/academy/popular/importance-of-lifelong-learning.html

B. Career path/development map

A career path comprises a group of (typically related) jobs that an individual works on the path toward their career
goals.
https://learn.g2.com/career-path

A career development plan is a personalized action plan used by individuals to map their careers. It is like a road map,
consisting of:
- starting point (Where Am I Now?)
- destination (Where Do I Want to Go?)
- route (how Will I Get There?)

A personalized career development plan will assist you to identify career goals and put strategies in place to attain them.
It is your road map to your desired career.

The Code of Ethics for Filipino Nurses was made after a consultation on October 23, 2013 at Iloilo City after accredited
professional organizations decided to adopt a new Code of Ethics under the RA 9173.
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 CODE OF ETHICS FOR NURSES
WHEREAS, the Board of Nursing (BON) has the power to promulgate a Code of Ethics for Registered Nurses in coordination
and consultation with the accredited professional organization (Sec. 9, (g), Art III of (Republic Act) No. 9173, known as the
“Philippine Nursing Act of 2002);

WHEREAS, in the formulation of the Code of Ethics for Registered Nurses, the Code of Good Governance for the
Professions in the Philippines was utilized as the principal basis thereof: All the principles under the said Code were
adopted and integrated into the Code of Ethics as they apply to the nursing profession;

WHEREAS, the promulgation of the said Code as a set of guidelines, regulations or measures shall be subject to approval
by the Commission (Sec. 9, Art. II of R.A. No. 9173); and

WHEREAS, the Board, after consultation on October 23, 2003 at Iloilo City with the accredited professional organization
of registered nurses, the Philippine Nurses Association, Inc. (PNA), and other affiliate organizations of Registered Nurses,
decided to adopt a new Code of Ethics under the afore-mentioned new law;

NOW, THERFORE, the Board hereby resolved, as it now resolves, to promulgate the hereunder Code of Ethics for
Registered Nurses:
ARTICLE I
PREAMBLE
SECTION 1.
Health is a fundamental right of every individual. The Filipino registered nurse, believing in the worth and dignity of each
human being, recognizes the primary responsibility to preserve health at all cost. This responsibility encompasses
promotion of health, prevention of illness, alleviation of suffering, and restoration of health. However, when the foregoing
are not possible, assistance towards a peaceful death shall be his/her obligation.
SECTION 2.
To assume this responsibility, registered nurses have to gain knowledge and understanding of man’s cultural, social,
spiritual, physiological, psychological, and ecological aspects of illness, utilizing the therapeutic process. Cultural diversity
and political and socio-economic status are inherent factors to effective nursing care.
SECTION 3.
The desire for the respect and confidence of clientele, colleagues, co-workers, and the members of the community
provides the incentive to attain and maintain the highest possible degree of ethical conduct.

ARTICLE II
REGISTERED NURSES AND PEOPLE
SECTION 4.
Ethical Principles
1. Values, customs, and spiritual beliefs held by individuals shall be respected.
2. Individual freedom to make rational and unconstrained decisions shall be respected.
3. Personal information acquired in the process of giving nursing care shall be held in strict confidence.
SECTION 5.
Guidelines to be observed:
REGISTERED Nurses must
1. consider the individuality and totality of patients when they administer care.
2. respect the spiritual beliefs and practices of patients regarding diet and treatment.
3. uphold the rights of individuals.
4. take into consideration the culture and values of patients in providing nursing care. However, in the event of
conflicts, their welfare and safety must take precedence.

ARTICLE III
REGISTERED NURSES AND PRACTICE
SECTION 6.
Ethical Principles
1. Human life is inviolable.
2. Quality and excellence in the care of the patients are the goals of nursing practice.
3. Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability.
SECTION 7.
Guidelines to be observed:
REGISTERED Nurses must

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 1. know the definition and scope of nursing practice which are in the provisions of R. A. No. 9173, known as the
“Philippine Nursing Act of 2002” and Board Res. No. 425, Series of 2003, the “Rules and Regulations
Implementing the Philippine Nursing Act. of 2002”, (the IRR).
2. be aware of their duties and responsibilities in the practice of their profession as defined in the “Philippine
Nursing Act of 2002” and the IRR.
3. acquire and develop the necessary competence in knowledge, skills, and attitudes to effectively render
appropriate nursing services through varied learning situations.
4. if they are administrators, be responsible in providing favorable environment for the growth and
developments of Registered Nurses in their charge.
5. be cognizant that professional programs for specialty certification by the BON are accredited through the
Nursing Specialty Certification Council (NSCC).
6. see to it that quality nursing care and practice meet the optimum standard of safe nursing practice.
7. ensure that modification of practice shall consider the principles of safe nursing practice.
8. if in position of authority in a work environment, be normally and legally responsible for devising a system of
minimizing occurrences of ineffective and unlawful nursing practice.
9. ensure that patients’ records shall be available only if they are to be issued to those who are professionally
and directly involved in their care and when they are required by law.
SECTION 8.
Ethical Principle
1. Registered Nurses are the advocates of the patients: they shall take appropriate steps to safeguard their
rights and privileges.
Guidelines to be observed:
REGISTERED Nurses must
1. respect the “Patients’ Bill of Rights” in the delivery of nursing care.
2. provide the patients or their families with all pertinent information except those which may be deemed
harmful to their well-being.
3. uphold the patients’ rights when conflict arises regarding management of their care.
SECTION 9.
Ethical Principle
1. Registered Nurses are aware that their actions have professional, ethical, moral, and legal dimensions. They
strive to perform their work in the best interest of all concerned.
SECTION 10.
Guidelines to be observed:
REGISTERED Nurses must
1. perform their professional duties in conformity with existing laws, rules regulations, measures, and generally
accepted principles of moral conduct and proper decorum.
2. not allow themselves to be used in advertisement that should demean the image of the profession (i.e.
indecent exposure, violation of dress code, seductive behavior, etc.).
3. decline any gift, favor or hospitality which might be interpreted as capitalizing on patients.
4. not demand and receive any commission, fee or emolument for recommending or referring a patient to a
physician, a co-nurse or another health care worker; not to pay any commission, fee or other compensations
to the one referring or recommending a patient to them for nursing care.
5. avoid any abuse of the privilege relationship which exists with patients and of the privilege access allowed to
their property, residence or workplace.

ARTICLE IV
REGISTERED NURSES AND CO-WORKERS
SECTION 11.
Ethical Principles
1. The Registered Nurse is in solidarity with other members of the healthcare team in working for the patient’s
best interest.
2. The Registered Nurse maintains collegial and collaborative working relationship with colleagues and other
health care providers.

SECTION 12.
Guidelines to be observed:
REGISTERED Nurses must
1. maintain their professional role/identity while working with other members of the health team.
2. conform with group activities as those of a health team should be based on acceptable, ethico-legal
statndards.
3. contribute to the professional growth and development of other members of the health team.
4. actively participate in professional organizations.
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 5. not act in any manner prejudicial to other professions.
6. honor and safeguard the reputation and dignity of the members of nursing and other professions; refrain
from making unfair and unwarranted comments or criticisms on their competence, conduct, and procedures;
or not do anything that will bring discredit to a colleague and to any member of other professions. PRC-BN
7. respect the rights of their co-workers.

ARTICLE V
REGISTERED NURSES, SOCIETY, AND ENVIRONMENT
SECTION 13.
Ethical Principles
1. The preservation of life, respect for human rights, and promotion of healthy environment shall be a
commitment of a Registered Nurse.
2. The establishment of linkages with the public in promoting local, national, and international efforts to meet
health and social needs of the people as a contributing member of society is a noble concern of a Registered
Nurse.
SECTION 14.
Guidelines to be observed: REGISTERED Nurses must
1. be conscious of their obligations as citizens and, as such, be involved in community concerns.
2. be equipped with knowledge of health resources within the community, and take roles in primary health
care.
3. actively participate in programs, projects, and activities that respond to the problems of society.
4. lead their lives in conformity with the principles of right conduct and proper decorum.
5. project an image that will uplift the nursing profession at all times

ARTICLE VI
REGISTERED NURSES AND THE PROFESSION
SECTION 15.
Ethical Principles:
1. Maintenance of loyalty to the nursing profession and preservation of its integrity are ideal.
2. Compliance with the by-laws of the accredited professional organization (PNA), and other professional
organizations of which the Registered Nurse is a member is a lofty duty.
3. Commitment to continual learning and active participation in the development and growth of the profession
are commendable obligations.
4. Contribution to the improvement of the socio-economic conditions and general welfare of nurses through
appropriate legislation is a practice and a visionary mission.
SECTION 16.
Guidelines to be observed:
REGISTERED Nurses must
1. be members of the Accredited Professional Organization (PNA).
2. strictly adhere to the nursing standards. PRC-BN
3. participate actively in the growth and development of the nursing profession.
4. strive to secure equitable socio-economic and work conditions in nursing through appropriate legislation and
other means.
5. assert for the implementation of labor and work standards.

ARTICLE VII
ADMINISTRATIVE PENALTIES, REPEALING
CLAUSE, AND EFFECTIVITY
SECTION 17.
The Certificate of Registration of Registered Nurse shall either be revoked or suspended for violation of any provisions of
this Code pursuant to Sec. 23 (f), Art. IV of R. A. No. 9173 and Sec. 23 (f), Rule III of Board Res. No. 425, Series of 2003, the
IRR.
SECTION 18.
The Amended Code of Ethics promulgated pursuant to R. A. No. 877 and P.D. No. 223 is accordingly repealed or superseded
by the herein Code.

SECTION 19.
This Code of Ethics for Nurses shall take effect after fifteen (15) days from its full and complete publication in the Official
Gazette or in any newspapers of general circulation.
Done in the City of Manila, this 14th day of July, 2004.
17
 (original signed)
EUFEMIA F. OCTAVIANO
Chairman

(original signed)
REMEDIOS L. FERNANDEZ
Member

(original signed)
LETTY G. KUAN
Member

(original signed)
ANESIA B. DIONISIO
Member

(original signed)
FLORENCE C. CAWAON
Member

ATTESTED:
(original signed)
CARLOS G. ALMELOR
Secretary, Professional Regulatory Boards

APPROVED

(original signed)
ANTONIETA FORTUNA-IBE
Chairperson

(original signed)
AVELINA A. DELA REA
Commissioner

(original signed)
LEONOR TRIPON-ROSERO
Commissioner

Filipino Patient’s Bill of Rights

1. The patient has the right to considerate and respectful care irrespective of socio-economic status.
18
 2. The patient has the right to obtain from his physician complete current information concerning his diagnosis,
treatment and prognosis in terms the patient can reasonably be expected to understand. When it is not
medically advisable to give such information to the patient, the information should be made available to an
appropriate person in his behalf. He has the right to know by name or in person, the medical team responsible in
coordinating his care.

3. The patient has the right to receive from his physician information necessary to give informed consent prior to
the start of any procedure and/or treatment. Except in emergencies, such information for informed consent
should include but not necessarily limited to the specific procedure and or treatment, the medically significant
risks involved, and the probable duration of incapacitation. When medically significant alternatives for care or
treatment exist, or when the patient requests information concerning medical alternatives, the patient has the
right to such information. The patient has also the right to know the name of the person responsible for the
procedure and/or treatment.

4. The patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be
informed of the medical consequences of his action.

5. The patient has the right to every consideration of his privacy concerning his own medical care program. Case
discussion, consultation, examination and treatment are confidential and should be conducted discreetly. Those
not directly involved in his care must have the permission of the patient to be present.

6. The patient has the right to expect that all communications and records pertaining to his care should be treated
as confidential.

7. The patient has the right that within its capacity, a hospital must make reasonable response to the request of
patient for services. The hospital must provide evaluation, service and/or referral as indicated by the urgency of
care. When medically permissible a patient may be transferred to another facility only after he has received
complete information concerning the needs and alternatives to such transfer. The institution to which the
patient is to be transferred must first have accepted the patient for transfer.

8. The patient has the right to obtain information as to any relationship of the hospital to other health care and
educational institutions in so far as his care is concerned. The patient has the right to obtain as to the existence
of any professional relationship among individuals, by name who are treating him.

9. The patient has the right to be advised if the hospital proposes to engage in or perform human experimentation
affecting his care or treatment. The patient has the right to refuse or participate in such research project.

10. The patient has the right to expect reasonable continuity of care; he has the right to know in advance
what appointment times the physicians are available and where. The patient has the right to expect that the
hospital will provide a mechanism whereby he is informed by his physician or a delegate of the physician of the
patient’s continuing health care requirements following discharge.

11. The patient has the right to examine and receive an explanation of his bill regardless of source of payment.
The patient has the right to know what hospital rules and regulation apply to his conduct as a patient.

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