ENGLISH
Introduction
Psychosomatic diseases and disorders require an interdisciplinary approach both at the stage of diagnosis and subsequent treatment and therapy. Epidemiological data show that about 30% of patients report to doctors of various specialties for somatic ailments that do not have an organic basis [1]. As a result, nurses also encounter patients with psychosomatic disorders in their professional practice. The role of the nurse in this case is not to conduct psychological therapy of such patients, but to effectively communicate interpersonally with the psychosomatic patient and provide professional social support. Therefore, it is particularly important to prepare nursing students well for interpersonal contact with a psychosomatic patient, in which psychology classes, in particular in practical forms, may be helpful. Simulation scenes based on case studies, during which students take on previously assigned roles, have great educational value. This gives the opportunity to acquire knowledge, shape skills and acquire competences necessary for future professional work.
Literature review
The concept of „psychosomatics” was introduced into medicine as early as 1818 by Heinroth. Mukharovskaya et al. treat psychosomatic disorders as, a group of conditions distinctive in the etiology and pathogenesis that characterize the interaction and crosstalk between the somatic and mental realms [2]. According to another approach, psychosomatic disorders include abnormalities in the functioning of various organs and body systems, with an important etiological role of emotional and psychosocial variables. Long-term experience of certain emotional states can lead to a disorder of normal body functions and the formation of lesions [3]. According to Boukdir et al. psychosomatic illnesses correspond to physical symptoms (with or without objectivable organic lesions), that psychological factors such as stress and personality type, would have a potential effect on their appearance, evolution and / or worsening. They are difficult to diagnose – the final diagnosis is often the result of consultations of doctors of various specialties and multiple medical examinations [4].
Over the years, many theories and concepts have arisen through which attempts have been made to explain the mechanism of the formation of diseases and psychosomatic disorders, e.g. histerical conversion model, the concept of personality profile of psychosomatic patients F. Dunbar, the concept of alexithymia, cortico-visceral theory or stress theory [2]. Wise draws attention to the future of psychosomatics, increasingly explained in the context of the relationship between psychosocial factors and biology [5]. The proper understanding of psychosomatic medicine is based on the assumption of the need for an integrated approach to diseases in biopsychosocial categories at the level of research and practice [6].
The mechanism of development of psychosomatic disorders presents Tylka. He draws attention to the significant role of strong, repeatedly experienced and long-lasting negative emotions in this process. Strong emotional tensions with poor coping skills result in experiencing stress. In turn, stress leads to a decrease in immunity and contributes to the development of diseases and psychosomatic disorders. Particular attention is paid to the role of the adrenal cortex hormone – cortisol, which in situations perceived as constantly threatening is produced constantly, which is very unfavorable for the body. Stressful situations lasting many months cause aggravation of pathological processes in the systems and organs of the body and impairment of their function. In the development of psychosomatic disorders, more importance is attributed to the constant and specific way of human response to stressors than to the type of stressors [6].
Psychosomatic disorders are a diverse group of health problems, hence different typologies are made in their area. The classic list of psychosomatic illnesses proposed by Alexander included: hypertension, thyrotoxicosis, bronchial asthma, rheumatoid arthritis, peptic ulcer, ulcerative colitis, and neurodermatitis [7]. Nowadays, two groups of psychosomatic disorders are indicated. In functional disorders, mental factors are often the only diagnosable cause of symptoms. Examples include nausea and psychogenic vomiting, psychogenic fainting, psychogenic cough, psychogenic constipation, psychogenic headaches, psychogenic paresis etc. In organic psychosomatic disorders, stress and personality variables are important etiopathogenetic factors. Examples are: peptic ulcer disease, ulcerative colitis, migraine, psoriasis, diabetes, glaucoma, hyperthyroidism, alopecia areata, rheumatoid arthritis [8].
Patients with psychosomatic disorders are a group showing the need for social support. The very fact of diagnosis of a psychosomatic disorder and the subsequent challenges associated with the treatment and therapy process are a difficult situation, requiring the mobilization of available resources. Research by Nettleton et al. has shown that people who live with medically unexplained illness experience significant stress, uncertainty and confusion due to the lack of diagnosis and prognosis of change in their social situation, the need for frequent hospitalizations or medical tests [9].
In the scientific literature, researchers point to the ambiguity of the function of social support and its role in coping with crisis situations and long-term life stress [10]. Social support has a beneficial effect on mental health and quality of life [11, 12]. Structurally formulated social support refers to objectively existing and accessible social networks that have a support function for people in difficult situations. The very fact of the existence of social contacts is crucial. There are so-called sources of support, which can be divided into non-professional (e.g. from family, friends, neighbors) and provided by people professionally prepared to provide help (e.g. therapists, doctors, psychologists) [10].
Nurses are also a very important source of support for various groups of patients and their families, which is confirmed by studies and analysis published in the world literature [13, 14, 15, 16]. This also applies to patients with psychosomatic symptoms [17]. Effective support includes building space for communication, understanding the patient’s needs and treatment requirements [13].
Social support can also be considered functionally, which allows to distinguish types of support. Emotional social support refers to the transmission of supportive, calming, caring and positive emotions towards the person in need of help in the course of a help interaction. It allows to express emotions such as sadness, anxiety, fear and get rid of emotional tension, gives a sense of care. It contributes to increasing self-esteem and improving well-being. Another type is information support, allowing for a better understanding of one’s situation or problem. It may also include feedback on the effectiveness of the remedial actions taken by the supported person. Instrumental support includes instruction on how to act in specific difficult situations. The last type of support concerns material, financial or direct physical actions for people in need. In a situation of terminal care, on the other hand, spiritual support becomes more important [10].
Of the types of support identified above, emotional support is the most expected and most often provided. Legg, based on a literature review, indicates that providing support and psychosocial care to cancer patients requires developed interpersonal communication skills, both verbal and non-verbal. What is needed is trust, openness, honesty, understanding, presence, respect, creating an environment in which the patient feels comfortable and safe [14]. Bradshaw et al. point out that emotional support to patients involves three elements: warmth and kindness, deep listening, social connection in the process of treatment [18]. Grochans et al. showed in their own studies a high demand for emotional support among patients undergoing hospitalization, which indicates increasing awareness and expectations from patients. The majority of respondents expected the nursing team to provide attentive care and safety, to provide kindness and cordiality, to ensure intimacy and personal dignity, and to communicate well. Patients’ expectations also included providing conversation and a smile, uplifting in moments of depression. Often, in the statements of patients, there were issues of interest in their situation or problems by the nursing team, questions about patients’ needs, showing empathy [19].
According to the standard of education preparing for the profession of nurse [20] a graduate of studies in the field of nursing should be able to:
assess human functioning in difficult situations (stress, frustration, conflict, trauma, mourning) and present elementary forms of psychological help (B.U3.)
identify errors and barriers in the communication process (B.U4.)
use verbal and non-verbal communication techniques in nursing care (B.U5.)
In turn, the skills of a graduate of studies leading to a master’s degree should include:
ability to indicate the role of social and psychological support in the care of a healthy and sick person (A.U1.)
ability to indicate methods of coping with stress (A.U3.)
The listed skills of nursing students can be developed during psychology classes, in particular based on case studies. This allows to emphasize the individuality of patients and go beyond the schematic treatment of their needs and difficulties. An example case study along with the educational aspects of the simulated situation will be presented later in the study.
Example of a simulation of a conversation with a patient with a psychosomatic disorder
The patient is a 42-year-old woman hospitalized for diagnosis due to severe headaches she has been experiencing for a long time. The diagnostic tests did not confirm the organic basis of the difficulties. The patient in contact logical, communicative, observed emotional tension, dominance of negative emotional reactions: fear, sadness, anxiety.
The basic task for the students is to provide the patient – in a simulated situation – with emotional support through a supportive conversation, using elements of non-verbal communication.
The simulation objectives include:
Recognition of the patient’s current well-being, including her emotional state.
Recognition whether and to what extent the patient is coping with her emotional situation.
Recognition of the patient’s needs.
Conversation about experienced psychosomatic difficulties.
Diagnosis of the scope of support experienced by the patient.
Presentation of psychotherapy as one of the forms of psychological help.
Showing care, interest, showing an empathetic approach.
The introductory part of the simulation scene may include:
Familiarizing students with the subject of simulation.
Familiarizing students with individual parts of the simulation and determining the approximate duration of the simulation and the place of the conversation.
Presentation of objectives planned to be achieved during the simulation.
Case study of a patient with psychosomatic disorder.
Proposal for the division of roles (patient with psychosomatic disorder – nursing team – observers).
Explain what the roles are.
I propose to assign the role of the patient to the person conducting the classes. Playing the role of someone in need of help can be emotionally difficult for students, and it is impossible to determine what are the life experiences and emotional situation of simulation participants, there is a risk of entering the role too deeply. In addition, acting as a patient by the person conducting the classes will contribute much more to the achievement of the planned simulation goals – it gives more control over the simulation and the ability to manage its course.
At this stage, it is worth explaining to students what psychosomatic disorders are, presenting their division, presenting etiological theories, emphasizing the needs of psychosomatic patients and methods of therapy for psychosomatic disorders (including one of the forms of psychological help, i.e. psychotherapy).
It is also important to have a practical reference, i.e. to indicate how participation in the simulation will contribute to providing professional and effective care for patients diagnosed with psychosomatic disorder in the future. In other words, what students will gain from participation in classes, e.g. awareness of the emotional situation of a patient diagnosed with psychosomatic disorder, developing the ability to effectively communicate with the patient, self-observation in terms of their own emotional well-being during contact with a psychosomatic patient in need of support, identifying their own strengths during the conversation and areas of skills that should be further worked on.
When preparing students to participate in the simulation scene, a discussion can be proposed around the following questions:
How to start a conversation with a patient diagnosed with a psychosomatic disorder?
What can a patient who has been diagnosed with a psychosomatic disorder feel? Why?
What can a patient with a diagnosis of psychosomatic disorder need?
How should the conversation be conducted and what should be paid attention to so that the patient experiences the interest and care of the nursing team?
What can be the emotional support provided to a patient with a psychosomatic problem by the nursing team?
What aspects of non-verbal communication are particularly important in the process of providing emotional support to the patient?
In the main part, the teacher and students take part in the simulation – on the basis of the information, knowledge and skills they have, they play previously assigned roles.
After completing the simulation, refer to what happened during the simulation. It is possible to stimulate students to reflect by formulating various questions, e.g.
How did it feel to play the role of a member of the nursing team?
How do you perceive the patient’s behavior (verbal, non-verbal)?
Did the patient cope with her emotional situation and to what extent?
How do you evaluate your cooperation with other members of the nursing team?
Is it easier for you to work in a team? Would you prefer to conduct the discussion yourself? Why?
Did you feel stress during the conversation? If so, what was the stressor for you?
If you had the opportunity to take part in this simulation again, would you change anything in your behavior (verbal, non-verbal)?
After participating in this simulation, do you see anything in yourself that you would like to work on? If so, what skills or competences would you like to improve?
How do you feel now as we discuss this conversation? Remember that you are no longer in the role and we have completed the simulation.
It is worth including observers in the discussion, asking about their observations on the simulation.
For exercise purposes, students can be presented with an example of the course of the conversation – developed for the needs of the class. Here is an example:
Patient: Good morning. I’d like to talk.
Nurse: Good morning. How can I help you?
P: As you know, I’m leaving the hospital tomorrow. Well, maybe that’s a good thing, I’ll be home eventually. But something is wrong with me... It was explained to me, but I don’t really know what it is.
N: If I understood correctly, you don’t quite understand the diagnosis. What do you know about the diagnosis?
P: I have been diagnosed with psychogenic headaches. I guess it’s because of my emotions...
N: Yes, emotional and psychosocial factors such as stress play the most important role in psychogenic problems. How do you feel at the moment?
P: Tolerably. Headaches are slightly less severe. The diagnosis was difficult for me, I still can’t come to terms with it. I thought I had a tumor in my head, but now they’re talking about psychosomatics. It’s hard for me to understand how emotions can lead to something like this.
N: In your situation, support is important – both from relatives and professionals, such as a psychologist or psychotherapist.
P: I need help. They explained to me that I could go to a psychologist. There was talk of some kind of psychotherapy. I really don’t know what it is. I read a little, but there is different information about this psychotherapy.
N: Psychotherapy is one of the forms of psychological help. The person providing psychotherapy, has undergone additional training and knows how to help a patient with a psychosomatic disorder.
P: Well, I don’t really have anyone to talk to or get advice. My husband does not understand me, he stopped talking to me, we have a lot of problems.
N: You can talk to our psychologist. First of all, you will have an opportunity to clarify any doubts related to the psychotherapy process. In addition, you will be able to tell about your family situation. Psychologist provides professional psychological support.
P: Okay, thank you. I’ll go there soon.
N: The psychologist is available on the first floor, office no. 205. Today he is available until 6 p.m. Is there anything else I can do to help? …
At the end of the class, students should be thanked for their effort and commitment to implement the simulation as intended.
Conclusions
The education of future nurses to practice such a demanding profession should go beyond medical aspects. The growing awareness of patients, better access to knowledge or the possibility of sharing their experiences in the online space contribute to higher and higher requirements and expectations for nursing care. Features such as effective interpersonal communication (both at the verbal and non-verbal level), the ability to individualize interactions and provide social support to patients, as well as awareness of the need for an interdisciplinary approach to the health situation of patients should characterize modern nurses.
Therefore, the offer of a higher education program in the field of nursing should include subjects in the field of psychology, especially in practical forms. This gives the opportunity to design and then implement simulation scenes regarding psychological situations that students will encounter first during their internships, and then during their professional career.
