This paper focuses on use of Betty Neuman systems Model in practice using a case study. The model focuses to finding a solution for a patient is none compliance with his care at home after being discharged. This case is a case that involves a patent who is discharged from hospital after treatment for a cognitive heart failure. The patient none compliance involves the continuing with the habit of smoking. This habit results chest pains which are because of the smoking habits. This model is selected for the practice to reflect the congruency that exists between the practitioner’s values and the assumptions of the model.

The Neuman model perceived clients as being in a state of dynamic equilibrium with the environment. The environment is also considered a perceptual field that surrounds each person. Neumann has focused on the stress factors and the reaction of each person to the condition that bring about the stress. She brought forth the conviction that stress factors comprise the environment. The further argued that the disequilibrium in the body system that is caused the stress as a tension. This tension act as the stimuli, which has the potential of causing the illness to the individual that, is suffering from the stress.

The environment is subdivided into two components that include the internal and external factor. The internal factors comprises of the forces that occur within an individual or intrapersonal stress factor. In our case, the example is smoking which the patient is involved in after being discharged. The external environment consists of interpersonal stress factors that result from interaction with other individuals. This is in terms of changes in the roles that can bring about stress to an individual.

The physiological issues in patient perspective involve things like the ability to see, hear, and have mobility. There other things like the ability to breath, sleeping, feeling, eating, speaking, and the vital signs. This variable focuses on the physiological well being of the patient. By ensuring, that all this things are in appropriate in the patient the health can be guaranteed the way for them.

The psychological variables involve the non-verbal behavior, attitudes, coping pattern, and response to stress. These things focus on the psychological status of the patient. Therefore, by ensuring that the patient psychological status is appropriate one can be able to facilitate the things that ensure the well-being of the patient is considered. There are various expectations in this variable that are recognized through evaluation of the patient’s behaviors and the way the patient handle stress.

The social variable reflects much on the individual’s values and culture. This is by exploring the social and cultural functions of the individual. This can be mainly approached in terms of the way this functionality influences the life of the individual. There are certain cultural believes that affect the life of a given individual negatively in terms of undergoing the medication. This is by getting involved in things that affect their well-being after the discharge form hospital.

The other dimension is the developmental variable, which focuses on the process of life in an individual. This is in terms of the factors that are related to the present situation and they have an influence on the situation. The developmental dimensions in the human life make them to move from one stage in life to the other as time goes by. Therefore, the main objective of this variable is to determine how this change of development is affecting the particular patient in the problem.

The other variable, which is considered significant in the life of a patient, is the spiritual variable. This focuses on the aspect of spirituality on a continuum from entire awareness of an individual. The patient may also be in a condition of denial to a consciously developed high level of spiritual understanding. There is a lot of usefulness to understand the spiritual well being of the patient since it can also contribute to the provision of quality health care services that will be beneficial to them.

There is a way that a client perceives a stressor. In our case, the patient is concern about the fact that he had experienced the chest pain. This problem interfered with the way he undertook his daily activities before he was hospitalized. The patient can even find it hard to do all he wanted to do. This experience with a health problem is difficult to describe how he is planning to deal with other situation. His expectations are to carry on with his daily routine after being discharged from the hospital and recovering. It would be definitely be a source of stress if he does not manage to accomplish what he intend to after the experience with the illness.

There is also a way in which a nurse perceives the stressors which is different from the perspective of the patient. The perception is through assessment of the patient by the nurse concerning the problem he is experiencing. According to the nurse perspective, the patient is not able to alter the way of living after the hospitalization. This becomes the reason why the patient is still suffering from the chest pains. It is evident that is the patient is continuing with the initial habit of smoking he is still bound to continue experiencing the pains in the chest. This is despite the fact that the individual have never coped with the same problem in the past. Therefore, the nurse perceives the stressor as being the behaviors that the patient gets involved in after the discharge from the hospital.

There are short-term goals that the nurses focus on achieving in order for them to ensure that the patient has received quality health care. One of these goals is for the patient to stop suffering from this chest pains. The other goal is to make the patient to learn to live in a way that will facilitate his recovery. The next goal is to facilitate the increase of the tolerance of the patient to his daily activity. There are also some long-term goals that the nurses are focused on achieving in terms of treating the patient. These long-term goals entail the creation of an optimal degree of harmony and balanced between his external and internal environment. This is in terms seizing smoking habit, attaining the deal weight and development of a lifestyle which commensurate with a satisfying and fulfilling retirement.

The nurses are also bound to prevent the invasion of stressors by providing the resources that strengthen the patients system and coping with positive functioning. This is though motivating the patient and using stress as a positive intervention strategy. The nurses can also engage in mobilizing the patient’s internal and external resources focusing on the achieving stability. They can also seek to maintain the stability through educating and reorienting the patient’s system as required.

Conclusively, this model is considered to provide a reliable guide of different levels of nursing education. The models have managed to incorporate all the significant variables that enable the patient to improve in their conditions. The model lastly focuses on the way the patient can be encouraged to be involved in a good lifestyle.

Individuals with a learning disability are able to lead a full and satisfying life in the community, with support as many do, however, for others they find themselves being isolated, pushed away to the boundaries of society.

Research has shown that a significant number of people with a learning disability diagnosis encounter prejudice, bullying, and discrimination in some form or another, at some time in their life. Such treatment has a very damaging impact on a person’s to lead a productive, full and inclusive lifestyle. In order for these attitudes to change and if we are to achieve our goal of a modern society in which everyone is valued and has the chance to be included in all aspects of community life. There has been some progress, often through the efforts of families, voluntary organisations and people with learning disabilities themselves but so much more still needs to be done.

People with learning disabilities are amongst the most vulnerable and socially excluded group in our society. Research has shown that few have meaningful employment, hold their own tenancy or live in their own homes, or have choice where they live and who provides care and support for them. These needs to change: people with learning disabilities must no longer be marginalised or excluded. Valuing People sets out how the Government will provide new opportunities for children and adults with learning disabilities and their families to live full and independent lives as part of their local communities.

What is a Learning Disability?

Learning disability is one of the most common forms of disability and affects up to 1.5 million (2% of the population) people in the UK. It is a lifelong condition.

There are several definitions of learning disability used in the UK. A commonly used one is from Valuing People: a new strategy for learning disability for the 21st century, the government White Paper for England about health and social care support for people with a learning disability (2001). It explains that a learning disability includes the presence of:

1. a significantly reduced ability to understand new or complex information or to learn new skills;
2. a reduced ability to cope independently;
3. An impairment that started before adulthood, with a lasting effect on development.

This means that the person will find it harder to understand, learn and remember new things, and means that the person may have problems with a range of things such as communication, being aware of risks or managing everyday tasks.

In addition, they may have multiple disabilities, which can include impairments of vision, hearing and movement as well as other challenges such as epilepsy and autism. Most people in this group need support with mobility and many have complex health needs requiring extensive support. People with profound intellectual and multiple disabilities may have considerable difficulty communicating

In UK education services, the term ‘learning difficulty’ includes children and young people who have ‘specific learning difficulties’, for example dyslexia, but who do not have a significant general impairment of intelligence. The Special Educational Needs codes also use the terms ‘moderate learning difficulty’, ‘severe learning difficulty’ and ‘profound multiple learning difficulty’, which relate to general impairments in learning of different severity.

Learning disabilities may affect a person’s ability to learn, to communicate and carry out everyday tasks. The Department of Health (2001)

World Health Organization (WHO) has defined learning disabilities as a state of arrested or incomplete development of mind. Somebody with a general learning disability is said to have a significant impairment of intellectual, adaptive and social functioning. A learning disability is not acquired in adulthood and is evident from childhood.

But what does this mean to the public as a whole. What are people’s understandings of learning disabilities?

A study is going to be conducted to determine lay terms of what people think a learning disability is. The study will take place at Ystrad Mynach College and will involve ay willing participants aged between 16-65. To collect sufficient data 100 people will be asked.

Survey

Aim; to gain a broad understanding of people’s perceptions of the term learning disability and how attitude can contribute to social exclusion and access to mainstream services.

Method

Surveyed 100 people categorising between the ages of; Ages: 16 – 20, 21-25, 25- 30, 31-45, 46-65.

Asked; Age Range – To determine how people’s understanding changes with maturity, experience, knowledge?

Asked; Nationality – Does culture play a part in understanding?

Asked; Open Question – How would you define learning disability?

Gives an opportunity to write an understanding of the term in your own words. Test if education, knowledge and discussions have played a part in changing attitudes or have in fact attitudes changed at all?

Part One

Age 16-20

Age 21-30

Age 31-45

Age 46-65

The above was all tick boxes, (closed questions)

Part Two

Nationality at Birth (Open Question)

Part Three

How would you define a learning disability? Open question – As opening questions in a conversation, as it makes it easy for the other person to answer, and doesn’t force them to reveal too much about themselves. An open question is likely to receive a long answer. . I used open questions for this part because; They ask the respondent tothinkand reflect. They will give youopinionsandfeelings. They hand control of the conversation to therespondent. When opening conversations, a good balance is around two/three closed questions to one open question. The closed questions start the conversation going and summarise progress, whilst the open question gets the other person thinking and talking opening up discussion.

Evaluation

Diversity – The diversity, age, nationality, background, within and between individuals of lay people must not be overlooked.

Knowledge – It is recognised that lay people ‘may’ lack knowledge about the subject in question or may have a good understanding but may not know the ‘key words’, ‘buzz words’.

Power relationships (perceived) between researcher and researched may prevent lay involvement.

Resources – lack of time can be barriers to active lay involvement in research.

From the survey it is evident that lay and more ‘professional’ views of the term are expressed through different vocabularies and knowledge bases. For the purpose of this experiment I have divided the categories up in the first instance into four different parts;

• General
• Categorised
• Understanding
• Other.

General

Key words or Phrases used to compartmentalise the ‘general’ understanding of the term learning disability, which briefly means in considering or including only the main features or elements of something; not exact or detailed.

synonyms:

broad , imprecise , inexact , rough , sweeping , overall , loose , basic , approximate , non-specific , unspecific , vague , hazy , fuzzy , woolly , ill-defined , indefinite , unfocused ; (English Dictionary)

Generalised Terms

– inability to learn fluently, affects learning, one step behind, hard to learn, inhibits learning, time to learn, struggle learning, unable to learn same way as other people, hard to learn, help with tasks, needs assistance, needs support, learns differently, not in mainstream services, problems learning new skills.

32% General understanding.

21% 16-20

6% 21-30

4% 31-45

2% 46-65

Categorised –

categorise

Verb

Past tense:categorised; past participle:categorised

Place in a particular class or group.

synonyms:

classify , class , group , grade , rate , designate , label , tag , brand ;(English dictionary)

Categorising


– abnormal, a condition, unable, prevents, negative, trouble, problems with reading, problems with writing, difficulty, can’t concentrate, misunderstands, poor literacy , poor, mentally challenged, stops you working, can’t study ‘as well as they could’, problem with words, illness, lack normal development, no understanding, not a straightforward situation, stop doing things, take longer to understand, can’t cope with others, not understanding the situation, limit, workability, not academic, affect day to day life, simple, mental basics, special education,

Negative words

29%

21% 16-20

3% 21-30

2% 31-45

3% 46-65

Some Understanding


– handicap, mental issue prohibits development, handicap, those who need support with individual learning needs, disability which affects learning, impairment, need help, impacts ability to learn, requires extra help, help with topic, reach their full potential cognitive social impairment, capabilities,

19% showed some understanding

12% 16-20

3% 21-30

4% 31-45

Unable to Identify


.

16-20 Welsh – “Retardation, slow, mentally challenged”

16-20 British – “Problem”

16-20 British – “illness”

16-20 British – “Problems and can’t do anything”

16-20 Chinese – “It’s ok”

16-20 British – “Someone or something that doesn’t learn as quickly as others”

16-20 British – “Can’t walk or speak properly”

31-45 Black African – “Someone who needs a special education”

8% of total surveyed was unable to identify with the term or its meaning.

7% 16-20

1% 31-45

Selected Quotes

16-20 British “it’s a word that defines who you are”

16-20 British “I would define it as difficult”

16-20 British “Dyslexic”

16-20 British “Unable to learn the same way as other people”

16-20 British “Cause you to learn differently”

16-20 British “May stop you from doing something you want to do”

16-20 British “When something is harder for you than others”.

21-30 Welsh “Just got to work with it”

7% of 16-20 year olds in this category showed a good understanding, lack of discrimination and non compartmentalise of ‘disability’.

1% of 21-30 as above.

Putting the literature into categories into the chosen sections seemed, at first, to be a straightforward task. But once the gathering of information had started, it became clear that it would not be so simple. Each category overlapped in some ways and each answer had different interpretations depending on who was reading the survey forms. The generalised format of the survey form may have made it more difficult to determine one definitive answer, each answer raised another question and was another point of discussion and reflection, or maybe that was my intention?

I considered different ages of people, targeting other students, lecturers, staff within the college environment, on reflection I would have broadened my group to include possibly 25% of each age group and asking a broader area of the general public. What became obvious from my survey is how the understanding of the term learning disability has changed in the age group 16 – 20 with a high percentage actually having a clear understanding of what it means and actually explains it in a positive way. I we consider these students being involved in the social care field it is refreshing to think that they do not see disability as a barrier to learning but just a different way to learn. These 16-20 year olds may be our next teachers, social workers, nurses, advocates etc, or a proportion may have a diagnosis and may explain some of the heartfelt quotes in section 5 of the survey, two which I found to be most pertinent, 16-20 British “I find it difficult to be on my own”, 21-30 Welsh “Just got to work with it”.

On hindsight I should have broadened my subject and sent surveys to; schools, carers group, statutory services, voluntary services but even then I suppose it is still difficult to ensure that you reach within an acceptable margin of individuals within the same age range across the board.

I considered whether to add more specific questions to the survey i.e. name, occupation, gender, religion, I struggled with this for several days before coming to a decision. My research showed me that now most surveys are anonymous, they tend not to record either the name of the respondent, or the name of anybody that the person may represent. This may been seen as inconvenient if you realise that you may need more specific data after collecting responses, or clarification on a comment/answer, or investigating subsequent research questions. I had considered asking for an email address, but stress that this should be optional. The drawback is if email addresses are collected, your data will then be subject to the terms of the Data Protection Act and open to all kinds of legislation?

Should I have incorporate demographic data, age, gender, education etc, but felt that this should be minimised, did I need it, should you collect any demographic data unless it is related to a specific research question? In my case a little more ‘specific’ information may have clarified my findings.

However, again demographic data may include personal details that would bring your research within the terms of the Data Protection Act, in which case precautions need to be considered, and more specific, closed questions prevent some people from completing the survey if they think that they can be identified from their answers, would an honest answer be given at all ?.

It should be explained to participants that voluntary completion of a questionnaire or interview can be taken as consent for this data to be used in research and that nobody should ever be compelled to participate in a research survey, for example, the students from Ystrad Mynach College should not be required to participate in research as a condition of for example their course grading. This was another reason why I used general non identifiable questions and participants could see the simplicity of the survey and that no personal data is collected.

Research has shown that only a percentage of the participants that are approached via a database to carry out surveys will complete them, figures suggest between 5% to 50%. I had considered this prior to setting up my survey and wanted to ensure that I had my 100% completed. I took a more pro-active approach where I physically approached every single person, told them what I wanted to achieve from the survey, (ideally my results would have been more applicable to a larger number of people beyond those that I was able to interview in the time-scales), but at the time I felt I had a representative sample, (I am not so sure now).

The other positive, although more time consuming doing the face-to-face interviews you can be sure that those who did respond have given the answer themselves, they are not biased, researched or influenced by others. Also, if a person refuses to complete the survey you may be able to establish what are the reasons why they may not respond, might these be related to any of the questions?

I would still use closed questions as a basis for statistical comparisons, either investigating differences between groups within the sample, or correlations between responses to questions. Survey responses are not generally particularly sensitive measures, so the statistical techniques available might not be straightforward as I have found out. Much debate surrounded my open questions, and how I should draw conclusions about the patterns or trends across their answers? I found the most appropriate way involved creating a set of coding categories, assigning each answer to one or more categories, and dealing with those that fell outside the coding scheme, are ambiguous and so on. I asked a second person to re-code the same data, to make a statistical inter-related reliability analysis, (second opinion), brainstorming.

It was the case that I did not have a research hypotheses relating to the open questions which did cause conflict in my thinking and analysis. On reflection it is probably unwise to collect large amounts of verbal data without having a firm plan in advance of how it will be analysed.

Ages of People Surveyed.

16-20 69%

21-30 13%

31-45 12%

46-65 6%

Nationality

Welsh 2%

Chinese 1%

Black 1%

British 96%

What did my Survey tell me?

There is no right way or wrong way to carry out a survey

There is no right or wrong answer

Answers are open to interpretation depending on age, nationality, education, status

There were more people that had an understanding of the term learning disability, in a positive manner which may mean that attitudes to ‘difference’ is changing

Younger people, 16-20 year olds seem to have the most understanding which may suggest a change teaching methods, embracing difference, education, knowledge, discussion, openness to change, changing times, understanding appears more specific

21 – 45 attitudes appeared more general to categorising, (labelled the person, saw the disability and then the person). Most had some understanding but their responses were more ‘text-book’ definition.

46-65 year olds in the majority had more ‘preconceived’ ideas again saw the disability and not the person.

Appendix One

Healthy People 2020: Increase Juvenile Residential Facilities that Screen for Mental Health

Abstract

Healthy People 2020 (HP 2020) defines mental health as being vital to personal well-being familial and interpersonal relationships, and allowing for the capacity to successfully contribute to one’s community and society. (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [HHS], (2010). The main goal of the HP 2020 mental health status initiative is to improve mental health through prevention services and increase screening to ensure accurate diagnosis, effective treatment.This paper will focus on the  HP 2020 MHMD-7 objective, which aims to increase the amount of juvenile residential facilities that screen admissions for mental health problems.

One of the most effective ways to respond to the mental health treatment needs of youth in the Juvenile Justice System (JJS) is to systematically assess and identify unmet needs with the use of mental health screening tools. The majority of youth who come into contact with the JJS have a diagnosable mental or substance use disorder. It is important to screen youth for mental health problems as it greatly affects their development.

Nonetheless, there are still some juvenile residential facilities that still do not provide adequate mental health screenings and assessments. As a result, many people, especially vulnerable populations including minority populations get diagnosed and screened for mental health problems at lower rate and suffer from a higher risk of mental and substance abuse disorders raising significant bioethical issues, primarily in the form of beneficence, non-maleficence, and justice.

History of Mental Health Screenings

Screening is defined as a brief process conducted by non-clinical staff to identify youth mental or emotional conditions and to identify if they might have a behavioral health disorder. (Grisso, 2001) Research has demonstrated that serious mental health and substance use disorders can greatly affect the rehabilitation of youth who come into contact with the juvenile justice system. Behavioral health screening measures and procedures must be in place to identify mental illness and substance use disorder needs.

Historically, the mental health needs of children and adolescents have been inadequately addressed both in policy and practice. In the early 1990s, mental health screening within the juvenile justice system was nonexistent. It was viewed as more optional than the rule; it was intended to be superficial and non-standardized. Institutional settings were more punitive and attempting to treat behavioral issues with harsher punishments for crimes. It took a much deeper understanding of mental health-related issues among youth within juvenile justice settings before reform could happen. During the late 1990s, the Office of Juvenile Justice and Delinquency Prevention’s (OJJDP) goal was to shift from extreme punishments to an approach that emphasized community health and rehabilitation. The number of youth diagnosed with  mental illness and their level of unmet need is now being recognized.   Mental health screenings became mandated for the first time in 1998, as more research studies were conducted. (Center for Mental Health Services, 1998)

In the current day, The OJJDP recommends a health screening to be performed during the intake process as youth first enter a juvenile residential facility. According to Underwood and his colleagues (2016), screening must be research-based and standardized and should be conducted fairly early in the process. In recent years, more light has been shed on the mental health needs of youth in the JJS at the Federal level. In the last couple of years, the Civil Rights Division of the U.S. Department of Justice investigated the inadequacy of mental health care and services in juvenile correctional facilities in various states (Butterfield, 1998). In addition, U.S. Department of Health and Human Services’ Center for Mental Health Services developed the first national survey of juvenile justice facilities which identifies current mental health services (Center for Mental Health Services, 1998). Moreover, Congress took into consideration many bills that mandate the use of mental health screenings and treatment programs for youth in the JJS. (Manisses Communications Group, Inc., 1999). Mental health screening, assessment, and treatment did not become mandatory until the early 2000s.

Thomas Grisso. and his colleague Richard Barnum from the University of Massachusetts developed a mental health screening tool at a time when mental health screening tools were not normalized. This tool was known as the Massachusetts Youth Screening Instrument-Second Version. (MAYSI-2) It was developed in the late 1990’s and was used for routine use for all youth who came in contact with juvenile justice facilities. This the  most widely used behavioral health screening tool within JJS to-date.(Grisso & Barnum, 2000, 2006). This mental health screening tool is used in over forty states; within juvenile probation and correction programs. (Project, NYSA 2003)

Epidemiology of Mental Health/Illness

According to NAMI, approximately 50% of chronic mental health conditions begin by age 14 and 75% begin by age 24. In terms of prevalence rates, youth who are diagnosed with mental disorders within the JJS is found to be much higher than the general population of adolescents (Grisso, 2000) Among two million youth, approximately 50% to 75% of youth meet the criteria for a mental health disorder within the JJS. In those findings, at-least 5% to 30% have been diagnosed with depression. (Underwood & Washington, 2016) Multiple studies confirm that two thirds of youth in detention or correctional settings have at least one diagnosable mental health problem. Dembo (1996) found that the prevalence psychiatric disorders in adolescents were about 16.5%. Moreover, youth in the JJS are at high risk for mental health problems which has contributed to criminal behavior and may interfere with rehabilitation (Wasserman & Larkin, 2005). From the 1960s through the 1990s, Roberts et al found that the mean prevalence of psychiatric disorders in the general adolescent population ranged between  6.2%–41.3%. In comparison, prevalence rates in the juvenile justice population range from 50% to 100% when disruptive behavior disorders are included. Youth with psychiatric diagnoses can have more than 1 psychiatric diagnosis (comorbidity) or co-occurring psychiatric and substance abuse disorders. In addition, minority youth may be more reluctant to admit to experiences with mental illness, or they or their families may have a cultural bias against seeking care.

Research Findings

Policies and Programs

The Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) law requires states to provide Medicaid-eligible children regular mental health screenings. Substance Abuse and Mental Health Services Administration (SAMHSA) developed an  initiative to improve policies and programs for youth in contact with JJS with com-morbid disorders. Six states are dedicated to policies and programs for screening youth with mental health disorders (Arkansas, Michigan, Minnesota, Mississippi, South Carolina, and Virginia) Some states even have community-based treatment programs for youth who are not considered a danger to society and at risk of for their psychological disorder.

Virginia and Texas legislation requires the JJS to mandate continuity of care for mental health, substance use, and other therapeutic treatments for youth who come in contact with the JJS. (NCSL, 2011)

Surveillance & Measurement

HP2020 is measuring and identifying the mental health problems experienced by youth within the juvenile justice system via the Youth Risk Behavior Surveillance instrument. The data from that survey are found that at least half of youth reported problems with anxiety, anger, and loneliness, and approximately ⅕ had a previous suicide attempt. (Morris et al., 1995)

Most recently Massachusetts Youth Screening Instrument (MAYSI)is one of the most widespread mental health screening tools developed to identify mental health & substance abuse among youth. MYSI is a 52-item self-report instrument, that requires a 5th grade level of reading & takes 10 minutes to complete. The instrument measures six different scales which include substance abuse, anger, depression/anxiety  and suicidal thoughts.

This self-report instrument requires no clinical expertise to administer or interpret; is low cost and can be used by a range of ages, different ethnic groups, and both genders; and demonstrates reliability and validity. (Grisso, 2001) It is a tool supported by heavy evidence-based research, that has been adopted for use among 49 states for probation and correctional settings.

Improvement over Baseline

In 2006, the baseline for the Healthy People 2020 objective was 58% of youth within juvenile residential facilities were screened admissions for mental health disorders. The target goal of this objective is a 10% improvement and a target of 64% of residential  facilities screenings for mental health disorders. Baseline hasn’t changed since the Healthy People 2020 launch, so it is highly unlikely the goal of 64% will be reached by 2020.

Ethical Issues: Four Principles

Justice is affected when fairness and the distribution of who receives care comes into play. Mental health care cannot be solely for youth within the general population. Opportunities have to be distributed fairly amongst society at large.

Beneficence/non-maleficence is addressed in that not having access to mental health screenings negatively affects those in need. The idea to do no harm is exemplified by offering screenings in all facilities to those who require it. This is malevolent since we know the importance of how mental health affects the overall health of youth. To protect those with diminished autonomy especially within a vulnerable population such as youth within JJS.

Vulnerable Populations

Epidemiological studies have shown that youth are  at increased risk for mental health problems come from low-income households, those in the child welfare and juvenile justice systems. (Howell, 2004) Incarcerated Black youth have the lowest rate of mental health diagnoses and have less mental health care than their White counterparts. (Howell, 2008) Minority youth may be more reluctant to admit to experiences with mental illness.Adolescent females reveal greater persistence of emotional problems and worse outcomes. Youth who come from poorer neighborhoods and have lower socioeconomic status. Research has found that socioeconomic status (SES) plays a significant role for black and Hispanic youth and poverty is likely to be the underlying factor that most influences trends in juvenile crime.

Current Case Connection

In 2016, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) conducted an analysis on mental health screenings within juvenile residential facilities. Findings suggests that six out of ten (60%) reporting facilities evaluated all youth for mental health needs in 2016. Seventy-percent of private facilities were more likely than public facilities (50%) to evaluate all youth, while 67% of state facilities were more likely than local facilities to evaluate all youth.

Long-term secure facilities were the most likely to evaluate all youth in 2016. Shelters and detention centers were compared  and it was found that shelters are least likely to evaluate youth than detention centers. Figure 1. Shows the number of facilities that screen for mental health needs among youth by facility type.

Youth involved in the juvenile justice system have a strong need for behavioral health services, especially related to mental disorders. In 2006, Mental Health and Juvenile Justice (NCMHJJ) also conducted a very comprehensive study measuring the prevalence of  youth involved with the juvenile justice system. Results show that the majority (70.4%) of youth in the juvenile justice system meet the criteria for at least one mental health disorder. Findings suggest a need to increase the number of juvenile justice facilities to screen for mental health. It ultimately identified youth who are most in need of treatment, which are girls and certain minority groups. (Shufelt & Cocozza, 2006)

Figure 1. Juvenile Residential Facility Census 2016

Conclusion

Mental health is an important factor in successful everyday functioning and long-term health outcomes. Despite an increased emphasis on mental health care and access to services, the U.S. has made little progress in reaching their Healthy People 2020 goal. However, research suggests that the juvenile justice system cannot rely on other systems to provide information on the previous use of mental health screening services for all youth at entry. There is a need for more juvenile residential facilities to implement early screening processes. There is a strong need for more research to create narratives regarding the mental health needs of youth and implement the best policies to respond to their mental and behavioral health.

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• Shufelt, J. L. M. S., Cocozza, J. J. P. D., & National Ctr for Mental Health and Juvenile Justice c/o Policy Research Associates 345 Delaware Avenue Delmar NY 12054. (2006). Youth with Mental Health Disorders in the Juvenile Justice System: Results From a Multi-State Prevalence Study. United States of America.
• Teplin LA.,Abram KM.,McClelland GM.,Dulcan MK.,Comorbid psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry. 2003;60(11):1097–1108
• Wasserman, Gail A., Larkin S. McReynolds, Prudence Fisher, and Christopher P. Lucas, C. P. 2005.“Diagnostic Interview Schedule for Children: Present State Voice Version.” In T. Grisso, G. Vincent, and D. Seagrave (eds.). Mental Health Screening and Assessment in Juvenile Justice. New York, N.Y.: Guilford Press, 224–239
• Underwood LA, Washington A. Mental Illness and Juvenile Offenders. Int J Environ Res Public Health. 2016;13(2):228. Published 2016 Feb 18. doi:10.3390/ijerph13020228
• US DEP’T OF HEALTH & HUMAN SERVS., Mental health and mental disorders. In: Mental Health and Mental Disorders: Overview (updated Feb. 2016).
• Wolpaw, J., Ford, J., Newman, E., Davis, J., & Briere, J. (2005). Trauma symptom checklist for children. In T. Grisso, G. Vincent, & D. Seagrave (Eds.), Mental health screening and assessment in juvenile justice (pp. 152-165). New York: Guilford Press
• 
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• 
  https://www.ojjdp.gov/ojstatbb/corrections/qa08540.asp?qaDate=2016
  
  Retrived August 7, 2019.

Implement and monitor using nursing care for clients with chronic health problems

PART A

Asthma is a chronic disease of the airways. Asthma causes the muscles in the airways to tighten and the lining of the airway becomes swollen and inflamed, producing sticky mucous. These changes cause the airways to become narrow, making it difficult to breathe. This may lead to wheezing, shortness of breath and coughing. Most people with asthma only have symptoms when they inhale a ‘trigger’ such as pollen, exercise without the right preparation, or if they catch a cold or flu.

The triggers and causes for asthma symptoms vary for different people.

Some common asthma triggers are:

• Allergy triggers such as house dust mites, pollens, pets and moulds, wood dust, chemicals
• Family history of asthma
• Upper respiratory tract infections
• Hay fever or eczema
• Cigarette smoke
• Viral infections – for example, colds and flu
• Cold air or changes in the weather
• Some medicines
• Exercise
• Foods to which the child is allergic

Typical asthma symptoms include:

• Coughing
• Tight feeling in the chest
• Wheezing – whistling noise when breathing
• Shortness of breath
• Struggling to breathe

During an asthma attack, people often experience difficulty breathing. This occurs because persons’ airways get swollen and narrower and it becomes a lot harder for air to get in and out of the lungs. Sometimes the swollen airways produce extra mucus, which may clog up the airways of your lungs which makes it even more difficult to breath. It can feel like the person is breathing through a straw. A person with asthma may also wheeze (a whistling sound when he or she

Asthma can take a psychological as well as a physical toll on a person’s life. Factors that contribute to the psychological effects of asthma include the severity of the illness and the extent to which activities are limited by the disease, the quality of social and family support available, the age at which the disease began the person’s knowledge about the illness and the sufferer’s coping style, skills and overall personality.

For most people, it is uncomfortable to have feelings of being different from other family members, friends or classmates. In social situations, people with asthma may feel self-conscious about using an inhaler or having to be careful to avoid triggers that can set off an asthma attack.

The desire to “fit in” can lead people with asthma to ignore their disease or fail to take care of it properly. This is the case with Jason as he prefers not to take his ventolin in front of his classmates as it makes him feel “different”. This is an issue as he suffers from frequent severe episodes of asthma which requires him to take his medicine appropriately otherwise his health will be jeopardize.

Chronic asthma doesn’t just affect the person with the condition, it also affects their family. Major changes in schedules and priorities must be made to manage the family, work and the life of child which can cause great stress. Parents may struggle with taking time off to care for Jason when he is unwell or needs to attend one of his frequent medical appointments. His activities may be limited, and, in many cases, their families must change how they live to accommodate the child. As for Jason, his school and social inclusion may be restricted. He may feel excluded from their school friends if they cannot take part in games, sports and social activities. Because of his chronic illness, Jason will feel “different” than other children which have caused him to not take his ventolin. If the chronic asthma is not managed properly, Jason’s quality of life will be impacted. The condition can lead to fatigue, underperformance or absence from school due to medical appointments or hospitalisation,

psychological problems

, including stress, anxiety and depression.

PART B


Nursing Care Plan (Diagnosis, Planning, Intervention)

Diagnoses	Goals/Expected Outcomes	Intervention
Ineffective airway clearance related to airway spasm, secretion retention, amount of mucus.	The patient is able to demonstrate deep coughing to assist in clearing the airway. The patient’s airway is patent and free of secretions, as evidenced by clear lung sounds, and ability to effectively cough up secretions after treatments and deep breaths teachings. Patient will verbalize understanding that allergens like dust, fumes, animal fur, pollen, and extremes oftemperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided	1. Airway management by freeing the airway through suction, monitoring the chest wall retraction and respiratory rate. 2. Listen to lung sounds monitor oxygen delivery. 3. Assess colour, consistency and amount of sputum. 4. Encourage deep coughing/breathing 5. Educate client on the different factors that can trigger that can cause asthma attacks
Ineffective breathing pattern related to chest wall distention, and fatigue due to increased work of breathing.	Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnoea. Patient’s breathing pattern is maintained as evidenced by: eupnoea, normal skin colour, and regular respiratory rate/pattern. Patient will be able to verbalize the understanding of appropriate measures to maintain a patent airway at all times by discharge.	1. Monitor the frequency, rhythm and depth of breathing. 2. Encourage deep coughing/breathing 3. Position the client’s chest semi-Fowler position. 4. Distract people from thinking about the state of anxiety and teach how to breathe effectively. 5. Reassure the client and give support when dyspnoea.
Activity intolerance	Patient will demonstrate skill in conserving energy while carrying out activities of daily living (ADLs). Patient will have no shortness of breath, weakness and fatigue on exertion. Report/demonstrate a measurable increase in tolerance to activity	1. Energy management by determining the causes of fatigue, monitoring respiratory (respiration, dyspnoea, pallor) 2. Monitor response of breathing during activity; assess abnormal response in respiration, blood pressure, pulse. 3. Evaluate patient’s response to activity. 4.Help clients choose the activities that can be done 5. Explain importance of rest in treatment plan and necessity for balancing activities with rest.

Evaluation –


Ineffective airway clearance


related to airway spasm, secretion retention, amount of mucus

Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine of the goals for patient wellness have been met.

Goals/Expected Outcomes	Evaluation
The patient’s airway is patent and free of secretions, as evidenced by clear lung sounds, and ability to effectively cough up secretions after treatments and deep breaths teachings.	You will need to access the airway manually and note any obstructions. If patient requires suction, re-access the airway and listen to lung sounds to see whether it is clear or not. Note any breathing sounds such as wheezing as this could indicate an obstruction. You will also need to monitor the chest wall retraction and respiratory rate. Assess and evaluate changes in vital signs and temperature routinely as per require. Tachycardia and hypertension may be related to increased work of breathing. Fever may develop in response to retained secretions/atelectasis. Note presence of sputum; assess quality, colour, amount, odour, and consistency. May be a result of infection, bronchitis, chronic smoking, and others. A sign of infection is discoloured sputum (no longer clear or white); an odour may be present.
The patient is able to demonstrate deep coughing to assist in clearing the airway.	Assess cough for effectiveness and productivity – note the technique and the position of the patient. Patient should be sitting up right to promote full expansion of the thorax. Consider possible causes for ineffective cough: respiratory muscle fatigue, severe bronchospasm, thick secretions, and others.
Patient will verbalize understanding that allergens like dust, fumes, animal fur, pollen, and extremes oftemperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided	Ask the patient to provide examples of allergens that can irritate the airways and factors that can contribute to ineffective airway clearance. If the patient is unable to state the factors, the nurse will need to educate and provide appropriate information. Patient education will vary depending on the information stated as well as the patient’s cognitive level.

Client Education

Asthma self-management education is essential to the control of asthma and should be encouraged to all patients to take responsibility for his or her own care. If asthma symptoms are controlled, the patient should have fewer exacerbations, a higher quality of life, lower costs, slower progression of airway from inflammation, less morbidity, and lower risk of death from asthma.

Patient asthma education can also improve beyond symptom control, such as patient knowledge about asthma and patient satisfaction and feeling of self-control. Other benefits include reduced school absences or work days, fewer exacerbations, restrictions on activities, and emergency-department visits.

The burden of living with asthma can also result in depression and anxiety for the patient and/or family, and these psychological changes can compromise asthma control. Children will asthma are likely to feel embarrassed of their condition and may suffer low self-esteem. If the parent’s stress, social isolation, or anxiety increases, the likelihood of poor asthma control in the child increases.

However with proper education, psychological factors such as low self-esteem, isolation and anxiety can also be managed. Parents can help an asthmatic child avoid embarrassment by asking the school teacher and/or counsellor to support and encourage the child. Having a school nurse, teacher or outside educator talk to the students in the class about asthma can also be quite helpful. The more informed the children are about the illness, the less likely they will be to tease a child with asthma.

One other way for people with asthma to feel less anxious is to educate others about it. They can empower themselves by becoming an expert in the illness. When they share information with family members, friends, fellow students and co-workers, everyone benefits and becomes more understanding about what it’s like to live with asthma.

Community Resources available

1. 
   Asthma Australia
   

   Asthma Australia and member Foundations deliver high quality support to people with asthma and their careers. They offer support, training and resources to the primary health care sector and when treatment is required they ensure patients and their careers have the skills, information and power to be actively engaged in the decision making process.
   
   http://www.asthmaaustralia.org.au/Children_and_asthma.aspx
   

2. 
   National Asthma Council Australia
   

   To improve the quality of life and health outcomes of people with asthma and their careers, reduce the social and economic impact of asthma on the community and reduce the prevalence of asthma in the Australian community
   
   http://www.nationalasthma.org.au/
   

3. 
   The Asthma Foundation of Victoria (Support Group)
   

   Provide services to help people manage their Asthma and provide the whole Victorian community with an excellent service based on asthma advice, information and programs
   

   Home

4. 
   The Australian Lung Foundation (Victorian Support Groups)
   

   To provide caring, support and information for those with lung disease/s and for their careers and families.
   
   http://www.lungnet.com.au/