CH=2 Emotions as a Healthcare Concern Persis Mary Hamilton, RN, CNS, MS, EdD COURSE OBJECTIVE: The purpose of this course is to provide information to healthcare professionals on the characteristics and functions of emotions, the neurology of emotions, management of primary emotions, and how caregivers can use emotional intelligence to communicate more effectively. LEARNING OBJECTIVES Upon completion of this course, you will be able to:       Identify characteristics of emotions. Describe the limbic system of the brain. Define emotions and their overall function. State the unique function of each of the primary emotions. Explain the management of each primary emotion. Discuss the capacities and skills of emotional intelligence. [H1] CHARACTERISTICS OF EMOTIONS What stirs our souls when we watch a glorious sunrise, depresses our mood when we suffer loss, enflames our passion when we see injustice, or sickens us when we see repulsive behavior? Emotions do. But what are emotions? Where do they come from? Did we learn them or were they inborn? Are they the product of thought or of something else? Can we control them or are they uncontrollable? How do emotions influence our choices and decisions? For centuries, prophets, poets, and philosophers have posed these questions. Modern-day psychologists and neurologists ask the same questions and have begun to apply scientific research to understand the origins and functions of emotions. Though recent studies reveal something about the anatomy and physiology of emotions, scientists have yet to agree on a single, comprehensive theory to explain the capacity of living creatures to experience and express this enigmatic thing we call an emotion (de Sousa, 2007). This course addresses these issues, describes the generally accepted characteristics of emotions, identifies neurologic structures and functions involved in emotional responses, offers a distinct model to explain the purpose and nature of the emotions, and suggests practical strategies healthcare professionals can use to help individuals manage emotions. Though scholars hold different views regarding a philosophical theory of emotions and the capacity to experience and express emotions, they agree on the following characteristics:  Emotions are conscious phenomena—that is, people are aware of them.         Emotions are more consistently demonstrated than other conscious states, such as fatigue. Emotions vary in several dimensions, such as intensity, type, and range. Emotions are reputed to be antagonists of objective, rational thought. Emotions play an indispensable role in determining the quality of life. Emotions contribute significantly when we define priorities in our lives. Emotions play a crucial role in the regulation of social life. Emotions protect us from excessively narrow rational thought. Emotions hold a central place in moral education and moral life. (de Sousa, 2010) 1. Which one of the following is not a characteristic of emotions? B a. Emotions hold a central place in the teaching of ethical behavior. b. Emotions are unconscious, in that people are not aware of them. c. Emotions vary in several dimensions, such as intensity, type, and range. d. Emotions protect us from excessively narrow rational thought. [H1] THE LIMBIC SYSTEM [http://painconsortium.nih.gov/symptomresearch/chapter_23/sec8/cahs8pg1.htm] Major Components of the Limbic System. (Source: National Institutes of Health.) [end caption] Neurologists have found that emotions are produced by a complex organization of the brain called the limbic system. The word limbic comes from the Latin word limbus, meaning “edge” or “border,” though its major structures are located in the center of the brain. The limbic system is the area of the brain that becomes active when humans experience an emotion from a past or present event. The system influences the formation of memory and integration of emotional states with physical sensations (Boeree, 2009). The following structures and functions of the cerebral cortex and subcortex of the brain are a part of the limbic system:  Amygdala: signals the cortex about stimuli that regard fear and rewards  Central nucleus of the amygdala: contains links to key brainstem areas that control autonomic functions  Hippocampus: participates in the formation of long-term memories; it includes the parahippocampal gyrus, which plays a role in the formation of spatial memory  Cingulate gyrus: regulates heart rate, blood pressure, and cognitive and attentional processing  Fornicate gyrus: encompasses the cingulate, hippocampus, and parahippocampal gyrus  Hypothalamus: regulates the autonomic nervous system by hormone production, affecting blood pressure, heart rate, hunger, thirst, sexual arousal, and the sleep-wake cycle  Mammillary body: participates in the formation of memory  Nucleus accumbens: participates in feelings of reward, pleasure, and addiction  Orbitofrontal cortex: takes a vital part in decision making  Thalamus: acts as the “relay station” to the cerebral cortex  Pituitary gland: produces thyrotropin and adrenocorticotropin, activating the thyroid and adrenal systems Using perceptions and thoughts, the structures of the brain’s limbic system store and retrieve information from memory, generate emotions, and provide feedback about appropriate social behavior. However, identifying and naming these structures is just the beginning. We need to know much more in order to understand emotions. Specifically, we need to define what we mean by emotions; then we need to learn their functions, numbers, qualities, intensities, and combinations. Most important, we need to learn how to manage our emotions. 2. The body system that stores and retrieves information from memory, generates emotions, and gives feedback about appropriate social behavior is the: C a. Lymphatic system. b. Sensory system. c. Limbic system. d. Endocrine system. [H1] WHAT ARE EMOTIONS? An emotion is “a complex sequence of events having elements of cognitive appraisal, feelings, impulses to action, and overt behavior; it is a feeling that accompanies an adaptive behavior for survival” (Plutchik, 1991). 3. An emotion is defined as a: D a. Stimulus that triggers a strong feeling. b. Behavior that results from a feeling. c. Thought that makes people upset. d. Sequence of events with an adaptive function. 4. The overall purpose or function of an emotion is: B a. Reproduction of the species. b. Survival. c. Rejection of harmful circumstances. d. Exploration of the environment for safety. [H2] Primary Emotions Studies of the emotions have identified four positive and four negative emotions relative to the pleasure or displeasure they bring. EMOTIONS Primary Emotions Positive Acceptance (love, trust) Anticipation (hope) Surprise (shock) Degrees of Feeling Adoration-acceptancetoleration Vigilance-anticipationhope Amazement-surprisedistraction Joy (happiness) Ecstasy-joy-pleasure Terror-fearNegative Fear (terror) apprehension Anger (wrath) Rage-anger-annoyance Disgust Loathing-disgust(revulsion) boredom Sadness (sorrow) Grief-sadnesspensiveness Source: Adapted from Plutchik, 1991; Lazarus, 1991. Life-Preserving Functions Incorporation of sustenance Exploration of the environment for safety Orientation to an unexpected and possibly dangerous event Reproduction of the species Protection from harm Destruction of the enemy Rejection of whatever may be harmful Reintegration to wholeness Emotions serve life-preserving functions for the survival of the human species, including: incorporation of what is helpful, exploration of the environment, orientation for the sake of safety, reproduction for continuation of the species, protection against harm, destruction of danger, rejection of what may be harmful, and reintegration to wholeness when wounded. 5. Which one of the following is not a primary emotion? D a. Acceptance b. Fear c. Surprise d. Distrust 6. The function of the emotion of acceptance is: D a. Reproduction. b. Surprise. c. Anticipation. d. Incorporation. 7. The function of the emotion of fear is: C a. Orientation. b. Destruction. c. Protection. d. Reintegration. [H2] The Sequence of an Emotion An emotion is a chain reaction beginning with the perception of a stimulus event, followed by cognition (appraisal), then feeling, then impulse to act, and finally action. All of this occurs to increase the likelihood of survival. These steps are illustrated as follows: 1. Stimulus event: A disheveled man steps off the elevator on the pediatric unit of the hospital, carrying a gun. He approaches the nurses’ station and says, “I’ve come to get Danny. He’s my son. You can’t have him and neither can his mother!” 2. Perception: The nurse sees the man’s crazed facial expression and the gun and hears his order. 3. Cognition: She thinks, This man is dangerous. He could hurt me and the patients. 4. Feelings: The nurse feels intense fear. The emotion serves a survival function, mobilizing her mind and body to protect itself. 5. Impulses to action: She wants to escape from the danger. Epinephrine from her adrenal glands increases her heart rate and blood floods her body. She remembers the emergency button beside the telephone on the counter. 6. Action: The nurse presses the emergency button, lowers her voice, and speaks to the man as calmly as she can manage. EXAMPLES OF EMOTIONS AS CHAIN REACTIONS Stimulus Event Cognition Feeling Behavior Denial of need or Confrontation Anger (fury) Lash out, attack, want with denier destroy Function Destruction Threat from Danger enemy Loss of valued Isolation, person or thing loneliness Sickening food Nastiness, or behavior harmfulness Introduction of a Attraction, potential mate interest Unfamiliar, Need to quickly shocking event appraise situation Event with an Challenge unknown future Beneficial act of Affiliation with caring/kindness nurturing other Source: Adapted from Plutchik, 2002. Fear (fright) Run/escape Protection Sadness (grief) Cry for help, comfort Expel, vomit, turn from, vomit Sexual signaling Reintegration Stop: take in new information Mental mapping Orientation Disgust (revulsion) Joy (happiness) Surprise (astonishment) Anticipation (hope) Acceptance (love, trust) Rejection Reproduction Anticipation Holding, feeding, Incorporation grooming [H2] Intensity and Complexity Each emotion has varying degrees of intensity. For example: [note symbols]  Annoyance → Anger → Rage  Boredom → Disgust → Loathing  Pensiveness → Sadness → Grief  Apprehension → Fear → Terror  Distraction → Surprise → Amazement  Pleasure → Joy → Ecstasy  Hopefulness → Anticipation → Vigilance  Toleration → Acceptance → Adoration In addition to intensity, emotions often combine to form more complex emotions, such as:          Disappointment = Sadness, surprise Jealousy = Sadness, anger, fear Remorse or guilt = Sadness, disgust Contempt or blame = Disgust, anger Shame = Fear, disgust Submissiveness = Fear, acceptance Awe = Fear, amazement Love and trust = Joy, acceptance Optimism = Anticipation, joy Although emotions may be called positive or negative, in themselves they are neither good nor bad. Even so, the behavior people exhibit and the action they take when they experience emotions may be harmful or helpful to themselves or others. For example, unmodulated joy may become mania; uncontrolled anger may beget violence and cruelty; unresolved sadness may lead to depression and suicide; and unfocused or inappropriate fear may become anxiety, phobia, and paranoia. For this reason, to live a balanced life people must learn to manage their emotions, accepting their reality but controlling the actions they take. [H1] MANAGING EMOTIONS Emotions play a powerful role in the lives of individuals. Consider the capacity of anger to destroy, fear to protect, acceptance to nurture, disgust to repel, sorrow to enervate, hope to challenge, surprise to amaze, and joy to cheer. By understanding and managing these powerful capacities, people can achieve extraordinary personal goals or create great personal tragedy. We will look at each primary emotion, its definition, the stimulus events that produce it, thoughts people have as a result of an emotion, feelings they experience, the function of each emotion, its manifestations, behaviors, and strategies for management. [H2] Anger Definition: Anger is an emotion designed to eliminate an obstacle to the satisfaction of an important need, such as striking down a barrier, defeating an opponent, or carrying out symbolic acts of destruction, such as cursing or belittling another person. Stimulus event: Anger occurs when people realize someone or something is blocking the fulfillment of a need, desire, or value. Thoughts (cognitions): Individuals think of ways they can eliminate the barrier to their desire. Feelings (relative to intensity): People feel annoyance, frustration, anger, and intense rage. Aim or function: The function of anger is to eliminate or destroy an obstacle or overcome a barrier to a desire. Manifestations of anger: People may grimace and experience muscle tension and/or sympathetic nervous response. Behaviors/actions: Physical assault, verbal assault, and passive-aggressive statements and/or actions. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING ANGER Ask yourself: What is the obstacle? How powerful is it? Should I fight, take flight, or compromise? The rational-emotive approach of Albert Ellis suggests that before individuals act, they should carefully consider the emotion-triggering event, examine their belief about the event, and consider the consequences of various actions they might take (1985). ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO ANGER Step A — Identify the activating event. B — Identify your belief about the event and the emotion related to the event. C — Consider the consequences. D — Discuss/debate various courses of action. E — Examine the effect of your action (Ellis & Bernard, 1985). Example As Sam enters the hospital employee parking lot, another car pulls in front of him and take the last space. Now he will have to drive to the auxiliary lot and may be late for work. Sam believes he deserves the space; he got there first and the other driver took something that was rightfully his. He is angry. Sam considers how he can make the driver of the other vehicle relinquish the parking space. He debates whether he should confront the driver or just drive to the other parking lot. Sam examines the effect of each possible action. He concludes that he has better things to do. He will let go of his anger and drive to the other lot. Research studies show that fully expressing and “letting it all out” escalates anger rather than decreasing it; therefore such action is not recommended (Travis, 1989). More effective is a cognitive-behavioral strategy—wait, cognate, officiate—as demonstrated in the following example: [extract] When the driver of the other car rushes past Sam and takes the parking space, Sam waits, then cognates (thinks through his options), then officiates. He decides that confrontation may lead to harm for himself, his automobile, or his reputation at the hospital. Sam takes a deep breath, looks away from the offending driver, shrugs his shoulders, and lets go of his anger. [end extract] 8. Research studies indicate that the “letting it all out” strategy to manage anger is: A a. Not recommended because it merely escalates anger. b. Exceptionally effective with prisoner populations. c. More useful with educated individuals. d. Especially effective with adolescent children. [H3] CHEMICAL STRATEGIES FOR MANAGING ANGER When individuals are unable to manage anger using intuitive, cognitive, or behavioral strategies, violent behavior may bring them to the attention of law enforcement and healthcare. They may be referred to anger-management classes, and antianxiety drugs such as chlorazerpate (Tranxene), chlordiazepoxide (Librium), and lorazepam (Ativan) may be prescribed. When individuals exhibit psychotic symptoms, antipsychotic medications such as chlorpromazine (Thorazine), haloperidol (Haldol), and clozapine (Clozaril) may be prescribed. When such individuals are able to think rationally, they may be able to learn anger management strategies. [H3] ANGER MANAGEMENT IN A HEALTHCARE ENVIRONMENT People who are ill, in pain, and experiencing exceptional stress are more likely to experience anger than those who are well and comfortable. It is no surprise, then, that healthcare professionals often encounter angry, hostile people. To respond to verbal expressions of anger, caregivers need to:       Lower the volume and slow the pace of their voice Acknowledge the angry person and thereby demonstrate respect Ask what the person wants or needs and what is preventing him/her from obtaining it Restate the problem until the person has clearly identified it Offer to seek a solution or to find someone who can Demonstrate accurate empathy, genuineness, and nonpossessive To respond to aggressive physical behavior, caregivers should:      Call for help Protect themselves and others from harm (remember, safety comes first) Maintain access to a door or other avenue of escape Use calm verbal interactions as described above Express a willingness to listen with genuineness and accurate empathy [H2] Fear Definition: Fear is a strong emotion intended to avoid harm and protect individuals. It is the opposite of anger; its purpose is to escape danger. Stimulus event: Fear occurs when people perceive a threat of harm to themselves, their loved ones, or their property. Thoughts (cognitions): Individuals believe they and/or their property are in danger. Feelings: People feel frightened, upset, and anxious. Aim or function: The function of fear is to protect individuals and help them escape dangerous or harmful forces. Manifestation of fear: Adrenal system floods the body with epinephrine and stress hormones; as a consequence, the heart races, blood pressure rises, breathing quickens, the liver releases glucose, digestion stops, skin chills, and blood diverts to muscles. Behaviors/actions: Taking defensive action (fight, flight, or withdrawal). [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING FEAR Ask yourself: Who is the enemy? How much threat is there? What will reduce the threat? Use the rational-emotive ABCDE approach: ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO FEAR Step Example A — Identify the activating Mary is a new employee at the local hospital, working nights on event. a medical unit. She just discovered she has given Jim Malo the oxazepam ordered for John Malo and given the temazepam ordered for Jim to John. B — Identify your belief Mary is gripped with fear. She is not sure what might happen to about the event and the the patients due to her error. She also believes that because of the emotion related to the event. error she will lose her job and perhaps even lose her license to practice, especially if the patients are harmed. C — Consider the Mary can either report the error and face the consequences or not consequences. report it and live in fear her error will be discovered. If she fails to report her error and take action, the patients may be also harmed. D — Discuss/debate various Mary wants to escape the consequences of her action and courses of action. considers her options. She realizes that the proper professional response is to report her error immediately, fill out an unusual occurrence form, and face the consequences. E — Examine the effect of Mary decides to call the physician and the evening supervisor your action. and report the error. Much to her relief, the physician affirms the patients were not harmed, and the supervisor helps her fill out the unusual occurrence form. Behavioral strategies can also include relaxation exercises and the creation of a safe environment. [H3] CHEMICAL STRATEGIES FOR MANAGING FEAR When individuals experience a single fearful event, they may not need medication. However, some events are so horrifying that post-traumatic stress disorder results. In these cases, as well as in cases of chronic anxiety, physicians may prescribe antianxiety (antiolytic) agents such as benzodiazepine (Xanax), oxazepam (Serax), and diazepam (Valium). Behavioral strategies such as meditation, self-hypnosis, and exercise help reduce or eliminate the need for antianxiety agents. [H3] FEAR MANAGEMENT IN A HEALTHCARE ENVIRONMENT Often patients are unfamiliar and fearful of hospitals and what goes on there. They may have seen gruesome pictures, heard or read horrific stories, or experienced painful procedures there. They know that in the hospital they are not in control of their person or property and consequently, they are afraid. Healthcare professionals can help reduce fear in patients by:       Explaining and describing in advance planned test, treatments, or procedures Speaking and behaving respectfully toward patients Reducing stress-producing stimuli, such as sights, sounds, or extreme room temperatures Identifying oneself and others who are working with the patient Staying with patients or providing some means for them to call for help Giving accurate empathy, unconditional positive regard, nonpossessive warmth, and genuineness 9. Fear management for hospitalized patients includes all but one of the following actions. Select the inappropriate action by caregivers. C a. Reduce stress-producing stimuli such as bright lights and loud noises. b. Provide some means for patients to call for help. c. Give your phone number to patients in case they need you. d. Give patients accurate empathy, nonpossessive warmth, and genuineness. [H2] Sadness Definition: Sadness is an emotion associated with the loss of someone or something of value to a person. It is the opposite of joy and signals a cry for help. The accompanying mild to moderate depression provides a time of healing. Stimulus events: People feel sadness when they suffer loss of valued people or things. Thoughts (cognitions): People who are sad realize they are deprived of the lost person or object. Feelings: Individuals feel pensive, sorrowful, alone, numb, and mild to moderate depression. Aim or function: The function of sadness is to provide a time of healing and reintegration. Manifestations of sadness: In order to give people time to heal, the body and the mind respond to loss by slowing down. When there is a major loss, all of the activities of daily living are affected, both mental and physical. Behaviors/actions: Crying, weeping, neglect of personal hygiene, changes in sleep pattern, and social isolation. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING SADNESS Acknowledge the loss, large or small. When loss is large and grief profound, give yourself permission and time for “grief work.” Though grief work has been defined in many ways, in essence, the term means working through the tasks of healing emotional wounds. Those tasks have been variously named: acclimation and adjustment, emotional immersion and deconstruction, and reclamation and reconciliation.  Acclimation and adjustment: Dealing with the initial emotional shock and disorientation of loss  Emotional immersion and deconstruction: Contending with reality, developing insight, reconstructing personal values and beliefs, acceptance, and letting go  Reclamation and reconciliation: Developing social relationships, making decisions about changes in lifestyle, renewing self-awareness, and accepting responsibility (Rich, 1999) [box] GRIEF WORK EXERCISE Set aside at least 30 to 60 minutes every day to grieve. During this time, give yourself permission to weep and experience the loss. Actively remember the lost one. At the end of each grieving period, close that chapter of grief and return to normal activities of daily living. Gradually, reduce the number and extent of the grieving sessions until you no longer feel the need for those sessions. If the experience of loss suddenly returns, do some more grief work. [end box] 10. “Grief work” means: B a. Working for a counseling agency. b. Working through the tasks of healing emotional wounds. c. Consciously avoiding any thought of loss. d. Dissociation from uncomfortable or frightening situations. ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO SADNESS Step Example A — Identify the activating Jane’s husband of fifty-one years died after a brief illness. Until event. his death they had shared everything, reared three children, and never been apart except for brief periods. B — Identify your belief Jane is overwhelmed by her loss. She does not believe she can about the event and the live without her husband. Everything in her life seems surreal. emotion related to the event. C — Consider the Jane withdraws from all her normal social contacts and becomes consequences. more and more depressed. She walks around in a daze of confusion and pain. D — Discuss/debate The hospice worker who attended her husband suggests Jane join various courses of action. a grief support group sponsored by the hospice agency. Jane is hesitant to expose her feelings to strangers, but her daughter urges her to attend. Finally, Jane agrees to go to at least one meeting. E — Examine the effect of Jane is welcomed by the group and receives comfort and support your action. from its members. She learns about grief work and decides to continue attending until she no longer feels the need. [H3] CHEMICAL STRATEGIES FOR MANAGING SADNESS In some circumstances, physicians may prescribe sedatives or antianxiety drugs such as temazepam (Resterol) and diazepam (Valium) for individuals in crisis due to a loss. Sometimes, they prescribe antidepressants such as paroxetine (Paxil), sertraome (Zoloft), and venlafaxine (Effexor). For uncomplicated bereavement, physicians are reluctant to prescribe drug to which people may become dependent. Instead, they may refer people to grief counselors. [H3] SADNESS MANAGEMENT IN A HEALTHCARE ENVIRONMENT Sadness, like all emotions, is a normal human response and is experienced in a range of intensities, from profound grief to pensiveness. It is demonstrated in a variety of ways, such as weeping and withdrawing. Caregivers can help individuals and families manage the sadness of loss in the following ways:        Encourage patients to talk about their hopes and fears, feelings, and beliefs. Listen when people want to talk about their successes, failures, gains, and losses. Offer to call family members, friends, or spiritual comforters. Give unconditional positive regard, accurate empathy, genuineness, and nonpossessive warmth. When individuals are fatally ill, refer them and their family to hospice care. Watch for suicide plans or actions, such as giving away valuables, reckless behavior, statements about death, and hopelessness. Call authorities to intervene if suicide seems imminent; do not leave the person alone. [H2] Disgust Definition: Disgust is an emotion that arises from contact with something that is repulsive— physically, mentally, or morally. Disgust triggers rejection of an offensive object, idea, or person and is the opposite of acceptance. Stimulus event: People contact something that is physically, socially, or morally abhorrent to them, such as spoiled food, foul odors, sexual promiscuity, rude behavior, and drunkenness. Thoughts (cognitions): The repulsive object or person is sickening and repugnant. Feelings: Individuals feel contempt, rejection, and repulsion. Aim or function: The function of disgust is to reject whatever is spoiled, foul, or offensive. Manifestations of disgust: People may show signs of avoidance, disassociation, and expulsion. Behaviors/actions: Verbally or physically turning away or condemning a rejected object. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING DISGUST Identify the disgusting object, idea, or person. Evaluate your judgments. Use the ABCDE rational-emotive approach: ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO DISGUST Step Example A — Identify the Sue takes great pride in her slim figure, careful grooming, and her activating event. certificate as a wound-care specialist. She works in a clinic serving poor clients, many of whom receive food stamps and Medicaid. Yesterday, a grossly obese patient named Maude, with diabetes and open sores on her lower legs, arrived in a wheelchair. Sue grimaced as she removed the stinking bandages. Maude noticed Sue’s reaction and said, “I know. I’m a disgustin’ old woman . . . don’t know why I keep on livin’.” B — Identify your belief Sue did not comment, but she thought to herself that Maude was not about the event and the only disgusting, but also a glutinous leach on society, using free emotion related to the medical care and taxpayer-provided food. event. C — Consider the Because of her feelings about Maude, Sue did a minimal job of consequences. treating the wounds, telling herself that Maude wouldn’t follow directions anyway. As Sue prepared to leave, Maude looked up at her and said, “Thank you. I ain’t never had nobody take care o’ me before.” D — Discuss/debate Sue had been offered a position in a private office, serving wellvarious courses of action. groomed, educated people who would not disgust her. Sue found herself thinking about Maude and the other obese, uncultured folk in the clinic, their hardships and gratitude. Sue had rejected them because they did not meet her standards, yet she began to realize their appreciation of and need for care. She decided to stay on in the clinic. E — Examine the effect Sue changed her view of the clinic patients from disgusting slobs to of your action. needy individuals whose lives could be changed with the expert care and education she could give. [H3] CHEMICAL STRATEGIES FOR MANAGING DISGUST Medications to reduce disgust are not available. [H3] DISGUST MANAGEMENT IN A HEALTHCARE ENVIRONMENT Caregivers can manage their own feelings of disgust by the following:     Identify the event that triggers the emotion of disgust. Identify the belief that is behind the feeling of disgust and resultant rejection. Consider thoughtfully the consequences of this belief. Reevaluate your commitment to the ethical principle of beneficence. 11. The purpose or function of disgust is: D a. Acceptance. b. Anticipation. c. Orientation. d. Rejection. [H2] Joy (Happiness) Definition: Joy is a transient emotion of pleasure, enthusiasm, action, and attainment of objectives. It is the opposite of sadness and loss. Many theorists link joy to sexual excitement, creative activity, energy, and innovation. Stimulus event: These are times when people experience fulfillment, inspiration, and sexual attraction. Cognition (thoughts): Individuals experience self-actualization, recognition, and achievement. Feelings: People may feel energy, elation, sexuality, and pride in accomplishments. Aim or function: The function of joy is reproduction, fulfillment, and self-actualization. Manifestations of joy: Individuals may experience enthusiasm, creativity, energetic enterprise, and sexuality. Behaviors/actions: Sexual activities, dancing, singing, talking, inventing, and creating. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING JOY Recognize, acknowledge, and enjoy an expansive outlook on life and good energy level. Individuals channel their energy productively, modifying their behavior through reason. Use the ABCDE approach: ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO JOY Step Example A — Identify the Ann woke up early; it was a beautiful morning and she felt activating event. wonderful. The night before she had a date with Tom, a senior at the college where she was a nursing student. They had gone to the musical Funny Girl, and the words of one of the songs kept running through her head: she “liked the feeling going through her, down her spine.” Like the singer, Ann felt energetic, enthusiastic, and full of joy. B — Identify your belief Her future looks bright. She loves being with Tom and was quite about the event and the sure he feels the same way about her. She is doing well in all her emotion related to the courses and looks forward to her next rotation in pediatric nursing. event. C — Consider the consequences. D — Discuss/debate various courses of action. E — Examine the effect of your action. Because of her joyful state of mind, Ann didn’t get annoyed with her roommate, even when she found dirty dishes in the sink of their tiny kitchen. Instead, Ann hummed the tune from Funny Girl and cleaned up the mess. Because she felt so good, she was tempted to take the day off, go shopping at the mall, go for a hike, and maybe ask Tom if he’d like to join her. Instead, Ann decided to use her energy to prepare for her next clinical assignment. Even though Ann’s joyful elation lessened as the day progressed, her feeling of satisfaction continued. Had her joy increased to a state of mania, Ann’s judgment would have been impaired and she would not have been able to focus her energy productively. [H3] CHEMICAL STRATEGIES FOR MANAGING JOY Extremes of any of the emotion—even joy—can cause problems. When joy is accompanied by unusual energy, quick wittedness, and creativity, it is called hypomania. When psychic energy spins out of control and individuals become hyperactive, irritable, and irrational, their condition is called mania. Typically, mania swings to depression in a manic-depressive illness called bipolar disorder. Often, an episode of mania brings people to the attention of law enforcement and medical care. [correction made on live course 5-24-2012] The most common medication used to treat bipolar disorder is lithium, effective for 75% of individuals afflicted with the disorder (Freeman et al., 2009). In addition, mood stabilizers such as carbamazepine (TigertonTegretol), divalproex (Depakote), and gabapentin (Neurontin) may be prescribed. When patients exhibit psychotic symptoms, antipsychotic drugs may be indicated. [H3] MANAGEMENT OF JOY IN A HEALTHCARE ENVIRONMENT It is important for healthcare professionals to monitor the mood of patients, noting whether they seem inappropriately elated and hyperactive or extremely withdrawn and depressed. In either case, caregivers need to enter into a conversation with these individuals to assess their mood. When mania or depression is observed, it should be noted and reported to the attending physician. 12. The extremes of behavior reflecting joy and sadness are: A a. Mania and depression. b. Hope and hopelessness. c. Identification and repulsion. d. Love and hate. [H2] Acceptance (Love) Definition: Acceptance is the opposite of disgust and rejection. It is the emotion of incorporation and nurturance. It involves accepting a beneficial stimulus from the outside world, as in eating, grooming, mating, parenting, or affiliation with members of one’s social group (Plutchik, 1980). Stimulus event: These are time of nurturance, when people identify with others and care for others as they do themselves. Cognition (thoughts): Individuals acknowledge and recognize others, both to give and receive. Feelings: People feel positive regard for others. Aim or function: The function of acceptance is to confirm inclusion, assimilation, and merger— ultimately, for the survival of the species. Manifestations of acceptance: Embracing, recognizing, including, nurturing, eating, befriending. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING ACCEPTANCE Accepting people as they are, not as you want them to be, is made possible by empathetic listening, genuineness, and identifying with them as fellow humans. Recognize feelings of positive regard and identification with another person or object and then use the ABCDEF approach: ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO ACCEPTANCE/LOVE Step Example A — Identify the Amy gave birth to her third child, a boy she named Paul. Amy had activating event. difficulty bonding with the baby. He seemed like a stranger to her, a toy, something apart, not an extension of herself, as her two girls had seemed. Amy decided not to breastfeed the baby and went back to work when he was 7 weeks old. One day Paul spiked a high fever and was admitted to the hospital. Amy took time off from work to stay with him. Day and night she held him, fed him, and watched over him until he recovered. During that time Amy’s attachment to her son changed. B — Identify your belief Amy came to accept her baby boy and identity with him. She about the event and the believed his illness had brought a wonderful change in their emotion related to the relationship. event. C — Consider the As a result of the experience of watching over and caring for her consequences. son, Amy was able to accept and embraced all three of her children as never before. D — Discuss/debate Before Paul’s illness, Amy had not bonded with her baby boy as she various courses of action. had with her girls. When he recovered, she found she had a different relationship with him. Paul was now as dear to her as herself. E — Examine the effect By recognizing her boy as unique yet precious extensions of herself of your action. and her husband, Amy became a better parent to all three of her children. [H3] CHEMICAL STRATEGIES FOR MANAGING ACCEPTANCE Acceptance of others nurtures both those who do the accepting and those who are accepted. While medications are not used to foster acceptance, specific strategies have been found to foster acceptance by mothers and infants (see below). [H3] MANAGEMENT OF ACCEPTANCE IN A HEALTHCARE ENVIRONMENT The healthcare specialties in which acceptance and nurturance are of great importance are maternal-child and pediatric care. When parents accept and bond with infants, babies are more likely to thrive. By definition, bonding is the intense attachment that develops between parents and infants. It makes parents want to protect and nourish their infant and give their child the loving care it needs. To foster such bonding, caregivers encourage parents to:      Hold, touch, and caress infants in skin-to-skin contact Breastfeed babies when possible, and if not, hold them for every feeding Spend time making eye-to-eye contact with infants Talk to babies; let them listen to the parents’ voices Interact with infants as they imitate parents’ facial expressions and voices In hospital pediatric units, restrictive visiting hours are a thing of the past. Parents are encouraged to stay with their children, hold or touch them, read to them, and engage them in conversations. By so doing, children and their family members experience acceptance, love, and nurturance. Similarly, in hospital adult and elderly units, visitors play an important role in supporting and nurturing patients. Their presence affirms the value, acceptance, and love of family and friends. For this reason, caregivers facilitate visitation rather than restrict it. [H2] Anticipation (Hope) Definition: Anticipation is the emotion of investigation, exploration, and hope. It is the opposite of unexpected shock, astonishment, or surprise. It may include some elements of anxiety. When individuals anticipate and investigate circumstances, they are not caught off guard and are able to cope more effectively with challenges to their survival (Plutchik, 2002). Stimulus event: People experience anticipation when they are in unfamiliar territory and feel the need to explore and investigate a situation. These are times of excitement and challenge. Cognition (thoughts): Individuals think about potential goals and consequences; they investigate, explore, and anticipate end results. Feelings: Anticipation is a feeling of hope and excitement, as well as a feeling of fear and dread. Aim and function: The function of anticipation is exploration, mental mapping, and investigation about likely outcomes. Manifestations of anticipation: Alertness, excitement, curiosity. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING ANTICIPATION Become aware of feelings, consider future possibilities. Use relaxation measures to guard against or reduce anxiety, such as deep breathing, physical exercise, and meditation. Use the ABCDE approach: ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO ANTICIPATION Step Example A — Identify the activating Hope reads a notice on the staff bulletin board inviting event. applications for a new position as In-service Education Director. B — Identify your belief She has just completed her MS degree and believes she is about the event and the qualified and ready for the challenge. emotion related to the event. C — Consider the The position would give Hope recognition and career consequences. advancement, the very reasons she went to graduate school. D — Discuss/debate various If she gets the position, Hope will earn more money, join the courses of action. management team, and gain professional prestige. However, she will be required to work full-time instead of half-time and will have to deal with some difficult people in management. E — Examine the effect of Hope decides to apply for the position. If she gets the job, she your action. will enjoy all the benefits it offers and will learn to cope with its difficulties. If she doesn’t get it, she will look for other opportunities to advance her career. [H3] CHEMICAL STRATEGIES FOR MANAGING ANTICIPATION Anticipation enlivens and increases alertness in individuals, especially when the consequences are great. For this reason, there is an element of anxiety in anticipation, and for brief periods of time, those experiencing anxiety may need anxiolytic medications such as benzodiazepine (Xanax), oxazepam (Serax), and diazepam (Valium). Fortunately, behavioral strategies such as exercise, meditation, and self-hypnosis can reduce or eliminate the need for antianxiety agents. [H3] MANAGEMENT OF ANTICIPATION IN A HEALTHCARE ENVIRONMENT When patients seek medical help, they are often anxious about their health problem and do not know its outcome. When their anxiety is so great that it affects recovery, physicians may prescribe the anxiolytic drugs described above. Caregivers can also help reduce anxiety in patients by doing the following:  Explain and describe in advance planned test, treatments, or procedures.      Speak and behave respectfully toward patients. Reduce stress-producing stimuli, such as sights, sounds, or extreme room temperatures. Identify oneself and others who work with the patient. Stay with patients or provide some means for them to call for help. Give accurate empathy, unconditional positive regard, nonpossessive warmth, and genuineness. [H2] Surprise (Shock, Astonishment) Definition: The opposite of anticipation, surprise is an emotion of sudden shock, a response to new and unfamiliar stimuli, positive or negative. When startled, individuals must stop what they are doing, quickly reorient themselves, and take in information about the unexpected incident. When the stimulus has been evaluated, surprise changes to other emotions, such as fear, anger, or even joy. Stimulus event: Something unexpected occurs or an unfamiliar person or animal intrudes in the environment. 13. The school nurse just phoned a mother to report that the school bus had a head-on collision and that her son is on his way to the hospital in an ambulance. The mother’s emotion of shock functions to: D a. Punish the person who might have injured her son. b. Reject any person or thing that might prevent him from getting care. c. Heal any injury her son might have suffered in the accident. d. Orient her to the situation and help her decide what to do next. Thoughts (cognition): When such an unexpected event occurs, individuals tell themselves to exercise caution and evaluate the stimulus. Feelings: Individuals may experience startle, shock, astonishment, or arousal. Aims and function: The function of surprise is orientation, to allow people to pause and evaluate the environment. Manifestations (behaviors): Startle reaction, alertness, shock. The body’s response to shock is similar to that of fear. The adrenal system floods the body with epinephrine and stress hormones, the heart races, blood pressure rises, breathing quickens, the liver releases glucose, digestion stops, skin chills, and blood diverts to muscles. The alertness that results allows the person to take action. [H3] COGNITIVE-BEHAVIORAL STRATEGIES FOR MANAGING SURPRISE Become aware of feelings, consider what may happen next. Maintain control, take a deep breath, and exercise your best judgment, whether the shock and surprise turns to joy or fear. Use the ABCDE approach: ABCDEs OF THE RATIONAL-EMOTIVE APPROACH TO SURPRISE Step Example A — Identify the activating The dermatologist just informed Roger that the biopsy of a mole event. on his face indicates the lesion is a malignant melanoma. B — Identify your belief Roger becomes both frightened and angry. He believes he has just about the event and the received a death sentence. emotion related to the event. C — Consider the A 52-year-old carpenter, Roger has worked all his life and was consequences. just beginning to feel financially security. Suddenly, his life has been turned upside down; he has two kids in college and an employer who depends on him. Roger doesn’t know what he is going to do. D — Discuss/debate The dermatologist explains the surgery, but Roger cannot various courses of action. concentrate. He feels confused and disoriented. He tries to compose himself and consider his options. E — Examine the effect of The physician repeats what he said about the need for surgical your action. removal of the tumor and the possibility of chemotherapy. Rogers shock changes to anger as he decides to fight the cancer with every means possible. [H3] CHEMICAL STRATEGIES FOR MANAGING SURPRISE Because the emotion of surprise lasts for such a brief time, medications are not an option. [H3] MANAGEMENT OF SURPRISE/SHOCK IN A HEALTHCARE ENVIRONMENT Because of the brevity of surprise, the greater concern becomes the emotions that follow. For example, immediately after a physician tells a man he has a fatal disease, the patient experiences shock and surprise. However, the patient then experiences other emotions such as anger and fear, or simply decides to deny the reality of the shocking event. For this reason, it is especially important to give individuals nonpossessive warmth, accurate empathy, genuineness, and unconditional positive regard (Rogers, 1961; Carkhoff, 1977). By so doing, caregivers support clients during disorienting events and help them clarify their needs and concerns. [H1] EMOTIONAL INTELLIGENCE (EI) In 1995, Goleman published Emotional Intelligence: Why It Matters More Than IQ, a text that posited that emotional intelligence is different than cognitive intelligence. Since that time, investigators have found that although emotional intelligence is different, it provides an important balance to rational thinking. Segal (2010) and others have identified special capacities of emotional intelligence and noted how these abilities and skills can be learned and applied in every arena of life. These capacities are especially important for healthcare professionals. Emotional intelligence can be defined as follows: [extract] Emotional intelligence (EI) is the ability to identify, use, understand, and manage emotions in positive and constructive ways, recognizing your own emotional state and the emotional states of others and engaging with others in ways that draw people to you (Segal, 2010). [end extract] [H2] Capacities of Emotional Intelligence Emotional intelligence consists of at least four special capacities:  Self-awareness: The ability to recognize your own emotions and know how they affect your thoughts and actions  Self-management: The ability to control impulsive feelings and actions, manage emotions in healthy ways, adapt to changing circumstances, take initiative, and follow through on commitments  Awareness and empathy for others: The ability to understand the needs and concerns of others, “walk in someone else’s shoes,” recognize emotional cues, feel comfortable socially, and recognize the power dynamics within a group of people  Relationship management: The ability to develop and maintain positive relationships, inspire and influence others, communicate clearly, work well in a team, and manage conflict (Goleman, 2006) [H2] Skills to Gain Emotional Intelligence Capacities Healthcare professionals need all four of the capacities of EI, but they are not inborn. They must be learned. The five specific skills needed to gain EI capacities are the abilities to:      Quickly reduce stress Recognize and manage your own emotions Connect with others using nonverbal communication Use humor and play to deal with challenges Resolve conflicts positively and with confidence (Segal, 2010) [H3] STRESS REDUCTION It is vital to learn to notice when you are stressed and how to calm yourself so that you can stay balanced, focused, and in control. This is necessary because when people are overwhelmed by stress, their ability to think rationally is compromised. One simple method to reduce stress is the one-minute relaxation exercise, as follows:   Find a quiet, separate space and, if possible, sit down. Close your eyes, take a deep breath; allow your mind to settle and your body to relax.   Remain in that moment of calm for a full minute as you let go of stress. Take a deep breath of renewed energy, open your eyes, and go about your work. [H3] MANAGEMENT OF EMOTIONS The second key skill of emotional intelligence is to become aware of your own emotions as described earlier. To do this:     Notice if you are experiencing physical sensations, such as in your stomach or chest. Identify the specific emotion you are experiencing, such as anger or fear. Note whether you are acting out an emotion so that your behavior is obvious to others. Consider whether your emotions are affecting your decisions. [H3] NONVERBAL COMMUNICATION The third key skill of emotional intelligence is connecting with others by means of nonverbal communication. This wordless form of communication is emotion-driven. It asks the question, “Are you listening?” and “Do you understand and care?” (Segal, 2010). To enhance your skill in recognizing nonverbal communication, pay attention to:      Eye contact Facial expressions Posture and gestures Tone of voice and timing of expression Touch or response to touch [H3] HUMOR AND PLAY The fourth key skill of emotional intelligence is using humor and play to deal with challenges. Research has found that laughter reduces stress and elevates mood. To enhance your skill in dealing with setbacks and difficulties with humor and play:     Take hardships as they come along; view them from a can-do perspective. Smooth over differences with gentle humor and a lighter touch. Relax and allow yourself and others to be reenergized. Become more creative; look at things from a new perspective. [H3] CONFLICT RESOLUTION The fifth key skill of emotional intelligence is the ability to resolve conflicts in a positive, trustbuilding way. Conflict resolution uses the first four skills. Having learned how to manage stress, stay present and aware, communicate nonverbally, and use humor and play, you are better equipped to handle emotionally charged situations and defuse conflicts before they escalate. To enhance your skill in conflict resolution:     Stay focused in the present. Choose your arguments. Protect yourself, but forgive and let go of the urge to punish. Disengage from conflicts that cannot be resolved. 14. Emotional intelligence means individuals have developed: B a. Knowledge so that they can diagnose psychiatric disorders when they see them. b. Self-awareness, self-management, empathy, and relationship management capacities. c. Insight into the personal problems of other people. d. The inborn ability to experience a full range of emotions, especially anger and fear. Indeed, caregivers everywhere need emotional intelligence. Happily, its development is within the grasp of everyone. 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