Practice of Intersectionality in the Nursing Environment and Patient's Treatment

Introduction

As I walked out of the nursing station I noticed Waker sitting alone at the corner of the hallway just peering out the window to the courtyard, he noticed the nursing students entering the common area and waived us over. My fear and anxiety of psychiatric patients debilitated me, it allowed all of the prior stigma and biased opinions of these patients to embody me and my judgment. I am not proud of that, however it allowed me to see that by just taking the time out to sit with a person such as Walker that the stigma isn’t created by a patient with mental illness, rather on those without it.

Walker’s Background and Medical History

Walker, a 63 year old caucasian male who was civilly committed for the fourth time in 2004. He was admitted after legal issues involving reported stalking of a female neighbor who resembled a local newscaster, whom he believed was his wife for many years. Before the stalking began he was arrested for arson in 1995, where he set fire to his own apartment with no one in it but himself, due to the voices in his head speaking to him and encouraging him to do so. The voices he stated were telling him to “set the apartment on fire to stop the FBI and CIA from watching his every move”. The voices he hears don’t only speak to him and promote his behaviors by encouraging his actions, but they also transmit feelings and ideas through nonverbal communication by eliciting feelings upon him.

He has an extensive history of mental illness dating back to 1985, in 1995 after the arson charge he was found not guilty by reason of insanity. Walker has a history of auditory hallucination, persistent delusions of external control and grandeur delusions about future accomplishments. His delusions and hallucinations are in part due to the chemical and neurotransmitter imbalance found within the Broca’s and Wernicke’s area of the brain which is responsible for speech and understanding of speech (Hoffman, R. E., Hampson, M., Wu, K., Anderson, A. W., Gore, J. C., Buchanan, R. J., & Krystal, J. H, 2007). His delusions and hallucinations are relatively treatment resistant despite multiple trials and current polypharmacy. Past treatment consisted of Clozapine which failed due to intractable hypertension during the trial. Prognosis is considered poor to fair with persistent delusions with poor reality checks. In his record he stated in 2006 -I hear voices all the time, but now they are not as strong as they once were.

Intersectionality

Intersectionality is a point of framework to help distinguish privileges and disadvantages, it allows a nurse to better understand a patient's entire profile relating back to gender, race, socio economic profile, and class. By understanding intersectionality nurses are able to better incorporate the proper mechanics of patient care for each individual patient rather than a stereotyped group. (Herk, K. A., Smith, D., & Andrew, C, 2011). Some people may have multiple disadvantages such as female gender, poor socioeconomic status, any cognitive impairment, their sexual orientation, and being of a minority group (Alemán, R, 2018, April 25). In Psychiatric facilities nurses face some of the most stigmatized and disadvantaged patients out there, with mental and cognitive impairment being of one of the biggest stereotypes in our nation today it is found difficult to mold a new foundation for patients own perspectives and of their support groups (Mora-Rios, J., Ortega-Ortega, M., & Natera, G., 2016).

While there is no one factor that predetermines a person's susceptibility to Schizophrenia such as gender, race, sexual preference, or socioeconomic status it is known that each one of these social determinants play an impacting role in the coping mechanisms of patients. A patient with Schizophrenia or any other mental illnesses are engulfed into a world full of stigma against mental health patients, with each determinant comes an underlying factor that contributes to self perception and self actualization for these patients, may they be negative or positive outcomes. These social determinants underlie each person as a whole rather than an individual encircled around predetermined stigma which then encompasses a bias perspective of these patients. With one or more negative notions of social determinants a person of mental illness may and will be more susceptible to other issues such as depression and suicide, by desensitizing these perspectives of others and self we as a community can build upon better criterias for personalizing a patient rather than grouping (Herk, K. A., Smith, D., & Andrew, C.,2011).

Socio-Economic Status

“I’m married, but my wife and I cannot be seen together”- Patient W. This statement was not only made by the patient during our conversation, but was also documented in his evaluation charts. Why was this one statement so haunting? Outside of the dimensions of his hallucinations and altered perceptions laid a foundation of reality to this statement. He didn’t believe that in our society today that his upper class, African American, wealthy wife, could ever be seen with a middle-to-lower class Caucasian man with no mental or financial stability today. This perception was infused into his hallucinations and molded into a form of coping for him, he saw his “wife” trying to protect him from societal factors projecting negative connotations onto him.

The inverse relationship between the aspects of socio-economic status and Schizophrenia have been studied and proven to have a connection between the two. A higher percentage of people who have Schizophrenia have either been raised in a deprived socio-economic population or resided in one after diagnosis (Werner, S., Malaspina, D., & Rabinowitz, J., 2007). This relationship between the two was linked to the belief that exposure of a poor socio-economic population increased the risk factors of Schizophrenia through the inability to climb up the social ladder and/or failure to rise above their social cohort in a low level educational environment (Hudson, C. G., 2005). With comprehensive evaluation comes rebuttal that states that socioeconomic status, as it may play a role in one number of the schizophrenic population is not a well enough determined co-factor in the prognosis or advancement of the disorder, rather is seen as a consequence of it (Von Dem Knesebeck, O., Mnich, E., Daubmann, A., Wegscheider, K., Angermeyer, M. C., Lambert, M.,& Kofahl, C, 2013).

Preconceived notion on his own economic status of a middle aged caucasian man that was raised in a middle class family within a lower economic environment molded this foundation of his low self esteem. While no one can fully determine the actual causation of his fantasy, it is my belief through research that his perception of low self worth due to his socioeconomic status led to the significant details within his hallucinations.

Gender

Living in a male dominated society may have its perk for some situations, while others have situations have their downfalls. Studies have shown that the onset of Schizophrenic episodes and first set of psychosis in patients remains undefeated among the male population. Male’s have a higher incidence rate of schizophrenia than females do, this is related to the more enhanced cognitive and social functioning abilities in women than men (Ochoa, S., Usall, J., Cobo, J., Labad, X., & Kulkarni, J., 2012). Males have a higher chance and incidence rate of substance misuse which is also correlated to the higher ratings of first set psychosis in the male population (Ochoa, S., Usall, J., Cobo, J., Labad, X., & Kulkarni, J., 2012). My patient is a male who had no know substance misuse in his medical history, but just by being a male he was subjected to a lower level of social and cognitive function according to this study which led to his early onsets of psychosis in relation to females with the same prognosis. Taking into considerations the biological and physiological differences of males and females, my patient was inherently at a higher risk of relapses and pre-morbidities of his disease, this is how the intersectionality of his gender played a contributing factor to his social determinant (Canuso, C. M., & Pandina, G, 2007).

It is more common for women to receive a higher level of care and sympathy in comparison to men for this preconceived notion, men have been found to receive a lower level of care due to their gender bias. In retrospect men are also less likely to seek medical attention to their own preconception of masculinity which leaves them vulnerable to increasing risks concerning their mental health. Coping strategies differ between the two as well, while women are found to internalize and compartmentalize issues of depression and illness, men are known to be more expressive and externalize their issues of mental health in different ways such as substance misuse (Rosenfield, S., & Mouzon, D.,2013). My patient Walker isa heterosexual male caucasian man who showed no signs of overbearing masculinity, he was respectful and pleasant to speak too, so how does his gender relate to this? His gender creates a social determinant for him to be conceived and reviewed against, this in turn makes him vulnerable to a lower level of care based upon it (Rosenfield, S., & Mouzon, D.,2013).

Standards of Care

Behind each nurse is their license, which is a law abiding documentation to uphold the utmost respect and care for each patient and person under care. This is one of the most binding forms of contracts in health care, for each patient the quality of care must be upheld to the standards and scope of practice, whether they be a terminally ill patient, an acute care patient, or mentally ill patient, each nurse has a duty to achieve and bring forth an upstanding quality of care through their practice. Under the American Psychiatric Nurses Association Scope of Practice Standards lie a list of methods and standards that must be used by each nurse, standard 8 on education and standard 10 of quality of practice are personally two of the most important standards within the scope (Psychiatric-mental health nursing: Scope and standards of practice, 2014).

Retaining information and education beyond the nurses scope of practice is essential for implementing the best standards of practice for each patient. Through continuing education throughout one’s career a nurse is a better and more competent source of care through their practice and are better able to pass that knowledge along to their patients and families. Educating patients on their outcomes and evaluations is one standard that must always be upheld with the most current evidenced based knowledge available, by embarking these qualities into each standard of practice health care is able to grow beneficially. Reviewing societal factors that contribute to the understanding of my patient W. I am better able to comprehend him as a patient versus stigmatic views that I may have had otherwise. Through the standards of practice scope on education mental illness and stereotypes can become desensitized allowing patients to better understand themselves and their level of care (Kane, C., 2015).

Quality of practice is a promise we make as nurses, to uphold care despite any factors that contribute to qualities of a person, race, group, or gender (Psychiatric-mental health nursing: Scope and standards of practice, 2014). Practicing with no forbearing judgment or bias on anyone allows the equal opportunity of care each person deserves. Empathy cannot be taught, but it can be used in practice, each nurse has a duty to implement empathy into their care which is under their scope and standards on quality of practice. By using standards of quality each individual patient is given a chance at care despite any alleviating factors they may have (Kane, C.,2015). Using this method of practice patient W. is given his fair chance at health care, despite any societal factors that may have contributed to his intersectionality, he is given care based on his diagnosis, medical issues, and best interest. By embracing this standard in all levels of care I as a future nurse will be able to provide better standards of practice for each patient of my own, allowing me to be the best empathetic nurse I can possible be.

Conclusion

Having Schizophrenia isn’t a punishment, it isn’t a disease that is caused by bad parenting, schizophrenia doesn’t occur in someone due to bad choices in the past. The pathophysiology of schizophrenia relates back to a genetic predisposition inherited during a woman’s pregnancy. It has been found to be inherited in a child during their embryonic stages related to alterations in the brain and can be exacerbated through many outside cofactors throughout a patient’s lifetime, including: traumatic injuries, drug induced factors, stress during childhood to adulthood, and environmental factors which no one person can prevent from occuring. Studies have been conducted to help find links to measures that may decrease the risks of developing schizophrenia, but till today there is no way to prevent or cure Schizophrenia.