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PubMed1999

Moral distress, advocacy and burnout: theorizing the relationships.

Burnout is a major contributor to shortages of experienced nurses. The research literature shows a correlation between moral distress and burnout in critical care nurses. This paper reports on part of an interpretive interactionist study concerning nurses' experiences of moral distress which prompted attempts to advocate for vulnerable patients. One critical incident is used as an example of the qualitative findings of the study. In this paper, we theorize about what happened when nurses advocated for their patients by challenging medical treatments which the nurses believed to be both inappropriate and to contributing to patient suffering. When attempts at advocacy were unsuccessful, the nurses experienced intensified moral distress, frustration and anger. Being an unsuccessful advocate resulted in nurses being relocated within the hospital, nurses being scapegoated and/or burning out. The theoretical links which this paper makes between advocacy, moral distress and burnout are supported by empirical data from the study.

Adult↗

PubMed1989

Hostility in group psychotherapy.

To run a psychodynamic group therapeutically, the leader must understand the meanings and functions of hostility. Fundamental to this task is the leader's awareness of his or her bias toward hostility as a constructive or destructive feeling and willingness to serve as a lightening rod for it. This paper discusses the sources of hostility during different stages of group development. The therapeutic handling of hostility is discussed under the following topics: theoretical considerations, defensive functions, and communicative functions. Case examples illustrate the proper handling of contractual violations, scapegoating, and narcissistic injury. Countertransference reactions to anger and rage in the group are discussed.

Countertransference↗

PubMed2000

Narcissistic leadership in psychotherapy groups.

Narcissistic leaders in groups are capable of impeding progress of their patients and, at worst, can produce iatrogenic effects. Significant interferences may occur when the therapist is unable to tolerate the expression of negative transferences and when they need to be idealized by their patients. The rare therapist who is a malignant narcissist is capable of inflicting severe damage by sadistically exploiting the group to satisfy his or her own pathological needs. Less severe interferences consist of inhibition in making transference interpretations, reluctance to seek out training or supervision, and a difficulty in protecting patients against being scapegoated as a result of the displacement of negative feelings toward the therapist onto a member. The universality of these issues among therapists is discussed and possible remediation is proposed.

Humans↗

PubMedDate not supplied

Moral survival in a nontherapeutic environment.

The aim of this study was to examine the ethical decision-making process used by a group of psychiatric and mental health nurses in Canada. Researchers used the constant comparative method of grounded theory to simultaneously collect and analyze data. Data were collected through the use of focus groups of experienced psychiatric and mental health nurses. In addition to focus groups, participant observation and a number of formal and informal interviews were conducted. The contingency for the nurses in this study was the degree of support for professional nursing practice within the cultural context in which they worked. Moral survival in nontherapeutic environments was identified as the basic social process by which the nurses attempted to manage or ameliorate their ethical difficulties in their workplaces. Survival strategies included the doctor-nurse game, covering your backside, running interference, doctor-bashing, administration bashing, scapegoating, and the breakdown of teamwork. The findings revealed nursing strategies that were aimed at surviving in what were perceived as nontherapeutic environments. These strategies are morally significant because the dilemmas concern a moral responsibility that cannot be delegated to others. The moral dilemmas are whether to (a) promote one's own survival or to take care of patients, and (b) be held responsible for one's own actions or to place responsibility on others.

Adaptation, Psychological↗

PubMedDate not supplied

Nationalities in Europe: the risk of war and medical responsibility.

War is often considered to be a way of solving political or economic problems. On the psychological level, war and acts of war are correlated with fear and guilt. In dealing with fear and guilt projection is a common defence mechanism, whereby others are scapegoated as the cause for one's own problems. This article presents an analysis of the relations between socio-political and economic problems, fear and guilt, and armed conflicts and wars. An alternative strategy is described, whereby people accept responsibility for the situation and work out solutions, based on a mature identity and by democratic processes. Conditions to promote this strategy are discussed. In the introduction some consequences of the last world war and of the work of the National Institute for the Victims of War in the Netherlands are described.

Aged↗

PubMed1978

Self-destructive behavior on an inpatient ward.

Suicidal and self-destructive behavior on a psychiatric inpatient service are said to be related to the degree of staff demoralization and dissension. Staff factors that may permit or encourage self-destructive acts include poor communications, staff disagreements, scapegoating of patients, poor staff judgment, staff self-preoccupation, and reversal of staff-patient roles. However, it is also possible that a major contributory factor is not individual patient or staff psychopathology, but rather the destruction of the underlying traditions and values of the ward which occurs at times of major change. The thesis is presented that the ritualization of ward values, when operative, provides a coherent world-view which renders the therapeutic activities, and life itself, meaningful, and that such ritualization can provide a framework of stability in times of critical staff turnover. Without such tradition and ritualization, however, therapeutic activities become hollow and meaningless, and fail to provide self-destructive patients a reason to view their life more positively.

Hospitals, Psychiatric↗

PubMed1979

Racism as a response to change. The introduction of residents onto a psychiatry ward.

An outbreak of violence among inpatients coincident with the beginning of a residency training program is described. The phenomenon is viewed as an example of covert staff disagreement resulting in the scapegoating of black patients. Suggestions are made as to how to avoid the occurrence of similar phenomena through a process of re-education of ward staff.

Acting Out↗

PubMedDate not supplied

Phantoms and fabrications:young children's detection of implausible lies.

The present study investigated whether young children are gullible and readily deceived by another's lies. Specifically, this study examined whether young children believe a lie teller's statement when the statement violates their developing knowledge of a distinction between reality and fantasy. In the first three experiments 3- to 6-year-olds (N = 293) were presented with either a story or a live staged event in which an individual made an implausible statement about a misdeed (claiming that a ghost jumped out of a book and broke a glass). A significant age effect was obtained: 5- and 6-year-olds tended to report that the individual who made the implausible statement had actually committed the misdeed, whereas 3- and 4-year-olds tended to accept the claim of the protagonist. Experiment 4 revealed that 5- and 6-year-olds (N = 43) not only disbelieved an individual's implausible statement but also inferred that the individual was lying and had a deceptive intent. In contrast, Experiment 5 revealed that 3- and 4-year-olds (N = 41) had difficulty disbelieving an individual's implausible claim about an inanimate object (i.e., the claim that a chair came alive and broke the glass). The findings suggest that 5- and 6-year-olds are not so gullible as previously thought, and that they use their well-developed real-world knowledge to detect scapegoating lies. In contrast, many younger children tend to believe another's implausible lies, perhaps due to the fact that the knowledge needed to detect such lies has not yet been consolidated.

Child↗

PubMed1988

Psychiatric and social problems among immigrants.

High rates of mental morbidity among migrants are common but not universal. Differences in rates may reflect factors in: (a) the country of origin; (b) the actual move; (c) the country of settlement. About 1.8 million people came to Britain in 1950-1970 from the West Indies and Indian subcontinent. They resembled Gastarbeiters in other European countries, except that as Commonwealth citizens they had the right of permanent residence. With their children (many of whom are now adults) they are 3.5% of Britain's population. Britain does not have a liberal cosmopolitan culture in which newcomers are welcomed, and the situation has deteriorated in response to high unemployment, constrained public expenditure, and widening gulfs between income-groups. Minority groups are scapegoated, and racial prejudice is more apparent than ever. Black people face obstacles in education and employment. Immigration laws which curtail the right to live in Britain have created insecurity, which is aggravated by insensitive policing and irresponsible press reporting. Institutions and authorities have been slow to respond to the different needs of new cultures. Riots receive more publicity than the daily violence which black people experience, which includes implicit contempt expressed as negative stereotypes, and explicit physical harassment. In this situation a high incidence of stress-related disporders might be predicted. There has been insufficient community-based research but one study of Indian and Pakistani samples showed them to have less mental and emotional disorder than indigenous controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Acculturation↗

PubMedDate not supplied

Under assault: the experience of work-related anger in female registered nurses.

This article is Part I of a three part article. Part I describes work-related experiences of anger of female registered professional nurses (N = 9) who participated in phenomenological interviews. Participants ranged in age from 29 to 56 and had practiced nursing for a period of 7 to 34 years. Nurses described being "under assault" in a hostile environment. Military metaphors and similes permeated all the interviews. Subtheme of "under assault" included scapegoating, disrespectful treatment, and lack of support. Anger was a weapon used by the nurse to defend or advocate for patients or self, as well as to attack doctors, peers, patients, and self. Factors within the self such as control versus powerlessness influenced nurses' anger experience and expression. Infighting within the profession prevents mobilization of resources to confront the larger issues of healthcare reform. Nurses must reframe anger as a constructive means of empowerment, rather than a weapon to defend against assault. Part II addresses anger experiences of male registered nurses, and Part III provides recommendations for channeling anger constructively.

Adaptation, Psychological↗

PubMed2002

Considering justice: an exploratory study of family therapy with adolescents.

Feminist approaches to therapy with adolescents emphasize an empowering focus on the strengths of adolescents while simultaneously insisting that therapists become aware of their own biases toward today's adolescents. However, a review of the family therapy literature finds little mention of feminist approaches for addressing injustices (e.g., family scapegoating, negative societal views of adolescents, and gender oppression) that arise in family therapy with adolescents. Therefore, this study explores clinical approaches and resources suggested by a surveyed group of self-identified feminist family therapists. In addition, we also recommend several approaches and resources that will aid family therapists in creating a more just climate for family therapy with youth.

Adolescent↗

PubMed1987

Does the community mental health movement have the momentum needed to survive?

The current community mental health movement, struggling under the misnomer "deinstitutionalization," is a worthy effort that can succeed if given adequate support and unburdened of pessimism and scapegoating. Existing and emerging programs for the severely mentally ill have the potential for success but will require renewed commitment and advocacy on the part of mental health professionals.

Attitude of Health Personnel↗

PubMed1994

The favoured child?

This case conference concerns a child who has been in care following a diagnosis of emotional abuse and a serious incident of physical abuse. She wants to return home again, and her parents, who had previously scapegoated her, now blame the family's previous ills on her sister instead. The Children Act 1989 gives considerable weight to the child's wishes, but what if the child returns home and is re-abused? In this case conference a child psychiatrist, a philosopher and a lawyer discuss the issues of clinicians' responsibilities, moral luck, and child care law.

Australia↗

PubMed1984

Evolution of child psychiatric teamwork in a somatic hospital.

This paper outlines the evolution of child psychiatric team work within the context of a general hospital. It focuses especially on the professional challenges and systemic problems arising during this 8 year long process. The question of what happens when two cultures meet in the same arena is discussed, and the process whereby a minority becomes a reality in a well-established majority system is described. Special attention is devoted to those principles appearing to play a major role in the evolutionary process. Prominent among these are: (1) operating within the already established; (2) transforming the 'ugly duckling into a swan', and (3) breaking into the established. The paper concludes with a brief discussion of the problems associated with maintaining enthusiasm in the team, scapegoating, and 'burn out'.

Child↗

PubMed1983

An approach to psychiatric referrals in pediatric patients. Psychosomatic complaints.

Psychiatric referral is an important aspect of clinical pediatric practice. This paper discusses referral to a family-oriented psychiatrist of difficult families with children who have an acute or chronic psychosomatic complaint. It is the responsibility of primary care physicians to develop facility in making psychiatric referrals. In this way the physician will be equipped to deal effectively with cases requiring attention beyond his time and expertise, as well as cases that he will manage alone. The paper considers five decision-points relevant for pediatricians making effective referrals of children with somatic complaints. (1) The pediatrician decides whether to conduct the evaluation on an outpatient or inpatient basis. In either case the work-up should be completed rapidly. A diagnostic hospitalization, whereby the parents agree to accept the results of a clearly defined evaluation as definitive, may be used with inpatient evaluations. The proposal of such a diagnostic hospitalization is considered. (2) After the medical evaluation is completed, the pediatrician decides whether to manage the case alone or to make a psychiatric referral. (3) A family conference can be used to initiate pediatric management or to make a psychiatric referral. A joint meeting, with both pediatrician and psychiatrist present, may be a crucial part of the management of difficult psychosomatic cases. The four stages of a typical joint meeting are described. (4) The utility of giving indirect rather than direct explanations of the meaning of a somatic symptom is described. By scapegoating the symptom rather than either the child or the parents, indirect explanations are often less threatening and more acceptable to the family. (5) Similarly, psychiatric involvement is often best proposed by recommending evaluation rather than treatment, since evaluation is less binding and takes into account the natural reluctance of many families to see the psychiatrist. After the referral has been made, ongoing contact between psychiatrist and pediatrician is important.

Child↗

PubMed1996

Homeless women's perceptions about their families of origin.

The purpose of this study was to examine descriptively the families of origin of women who are, or who had been, homeless. The research was done using a descriptive qualitative research design; specifically, intensive interviewing. A feminist framework guided the research process. Lofland and Lofland's (1984) conceptualization of units of social settings was used as the basis for analysis of the data. The sample consisted of 20 women who had been homeless. Twelve of the women were interviewed individually. Six of those 12 women and an additional 8 women were later interviewed as part of two focus groups. Themes within each social unit included: meanings--homelesness, home, family of origin, lack of connectedness, and being without; practices--male privilege, transiency, and abuse issues; episodes--loss of family and being homeless; roles--traditional female-male, scapegoating, and little adult; and relationships--mother/daughter, father/daughter, and sibling. Within the mother/daughter relationships, the dominant themes were betrayal, devaluation of self, enmeshment, emotional void, longing for, emotional cutoff, and destructive coalitions. The themes from the father/daughter relationships social unit were abuse issues, differential treatment, idealized father figure, and banished daughter. Criteria for transferability and adequacy were used to determine scientific rigor.

Adult↗

PubMedDate not supplied

Building healthy communities with immigrants and refugees.

Immigration fueled by large population shifts across international borders will be an ongoing phenomenon throughout the world for the foreseeable future. Forces raising concern for the development of healthy immigrant communities in the United States are the scapegoating of immigrants as the cause of many of the problems of society, a growing lack of tolerance for diversity, and the need for rapid acculturation. A construct of what constitutes healthy communities for immigrants is discussed. The construct is built around the concepts of convergent stereotyping, solidarity, and agency. To help build healthy communities, transcultural nurses must assist other nurses and health care providers to function from a transcultural posture to develop culture competence, reconceptualize how immigrants are viewed, avoid reductionism of the immigrant experience into a psycho-emotional phenomenon, and actualize human development as part of community development.

Community Health Nursing↗

PubMed2000

Part 3: A community divided.

The task of those who seek to encourage and offer social support has become more difficult as the majority of social institutions, and the state have established, over time, stronger and more pervasive modes of communication. The intricacies of gay identity have been articulated largely by forces outside of the gay movement, with the inevitable result that GSOs and ASOs have occupied less space in the consciousness of gay men. Additionally, I hypothesize that men who are HIV-positive are engaging in fewer sexual contacts than men who are HIV-negative, and consequently lessening their attendance at venues where cruising is the main event. Financially and structurally, I shall demonstrate the disparity between GSOs and ASOs, and suggest that there is a natural intersection wherein the two SMOs could, and ought to cooperate, especially in the areas of fund-raising, joint program development, recruitment and political lobbying. However, their ideological bases appear to be sufficiently different to preclude such affiliations. These disparate ideologies are amplified by the mass media, and are consequently internalized by the members of the gay community. In the longer term, the divisiveness that manifests itself in the proliferation of numerous collectivities within the gay movement will contribute to the further isolation of gays from each other, and thwart any future attempts at coalition building, which could obviate the continued existence of a gay movement. Some writers suggest that the gay movement is going through a phase in an inevitable process of paradigm shifting, and in the end, the community will come back together-stronger and more unified than it was previously. However, if this is a phase it is clear that the gay movement is in the 'dark before the dawn' initial phase of this paradigmatic shift, and subsequent phases are by no means guaranteed. As AIDS spreads beyond marginalized groups, and infiltrates the social majority, it is possible that much of the discrimination that has positioned gay men as 'other' will be abandoned in favour of a more enlightened, pluralistic conviction of the humanity of gays as full-fledged members of a mosaic-type community structure. On the other hand, it is also possible that as AIDS spreads into mainstream Western communities, gays will be further vilified and scapegoated as the perpetrators of this deadly disease. Preventative action is required to offset this possibility-preventative action can be affected by building a strong and unified gay community ready to withstand the onslaught of the mainstream enmity. This action would frame AIDS and gayness such that this type of situation would not come about. What is required is a new mode of co-operation among ASOs and GSOs, a model which firstly puts the gay house in order, and is then suitably structured to be more inclusive of all gay men's needs, and positioned to assist in the second wave of HIV infection-the general public.

Acquired Immunodeficiency Syndrome↗