Nursing Diagnosis: Hopelessness Application of NANDA, NOC, NIC

Nursing Diagnosis: Hopelessness
Gail B. Ladwig and Jill M. Barnes

NANDA Definition: A subjective state in which an individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy on own behalf

Defining Characteristics:Passivity; decreased verbalization; decreased affect; verbal cues (e.g., saying "I can't," sighing); closing eyes; decreased appetite; decreased response to stimuli; increased/decreased sleep; lack of initiative; lack of involvement in care; passively allowing care; shrugging in response to speaker; turning away from speaker

Related Factors:Abandonment; prolonged activity restriction creating isolation; lost beliefs in transcendent values/God; long-term stress; failing or deteriorating physiological condition

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Decision Making

·         Hope

·         Mood Equilibrium

·         Nutritional States: Food and Fluid Intake

·         Quality of Life

·         Sleep

Client Outcomes

·         Verbalizes feelings, participates in care

·         Makes positive statements (e.g., "I can" or "I will try")

·         Makes eye contact, focuses on speaker

·         Maintains appropriate appetite for age and physical health

·         Sleeps appropriate amount of time for age and physical health

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Hope Instillation

Nursing Interventions and Rationales

·         Monitor and document potential for suicide. (Refer client for appropriate treatment if potential for suicide is identified.) See care plan for Risk for self-directed Violencefor specific interventions. Hopelessness is directly associated with suicidal behavior and also with a variety of other dysfunctional personal characteristics (Fritsch et al, 2000). Previous suicide attempts and hopelessness are the most powerful clinical predictors of future completed suicide (Malone et al, 2000).

·         Assess the client for and point out reasons for living. Interventions that increase the awareness of reasons for living may decrease hopelessness and decrease risk for suicide (Malone et al, 2000).

·         Assess for impaired problem-solving ability and dysfunctional attitude. Impaired problem-solving ability and dysfunctional attitude have been shown to correlate with hopelessness (Cannon et al, 1999).

·         Evaluate client by realistically assessing the predicament or threat. Understanding the etiologic basis of the client's hopelessness is important in order to intervene (Wake, Miller, 1992). Unless there is a threat that is acknowledged and assessed, hope does not exist (Morse, Doberneck, 1995).

·         Determine appropriate approaches based on the underlying condition or situation that is contributing to feelings of hopelessness. Either encourage a positive mental attitude (discourage negative thoughts) or brace client for negative outcomes (i.e., client may need to accept some long-term limitations). Truthful information is generally preferred by families; surprise information regarding a change in status may cause the family to worry that information is being withheld from them (Johnson, Roberts, 1996). A person awaiting a transplant may need to express only hope or optimism, whereas a person with an injury with long-term effects, such as a spinal-cord injury, may need to prepare for possible negative outcomes and slow progress (Morse, Doberneck, 1995).

·         Assist client with looking at alternatives and setting goals that are important to him or her. Mutual goal setting ensures that goals are attainable and helps to restore a cognitive-temporal sense of hope (Johnson, Dahlen, Roberts, 1997). Clients who do not know what to hope for are without hope. Thus an integral part of developing hope is determining and setting goals. The significance of the goal to the individual is complex and critical to sustaining hope (Morse, Doberneck, 1995).

·         In dealing with possible long-term deficits, work with the client to set small, attainable goals. Mutual goal setting ensures that goals are attainable and helps to restore a cognitive-temporal sense of hope (Johnson, Dahlen, Roberts, 1997). Clients with spinal cord injury focused hope only on small gains, one step at a time. "Every little step I took was more important to me than what I had in the end" (Morse, Doberneck, 1995).

·         Spend one-on-one time with client. Use empathy; try to understand what a client is saying, and communicate this understanding to the client. Experiencing warmth, empathy, genuineness, and unconditional positive regard can inspire hope (Cutcliffe, 1998). Empathy allows the nurse to communicate understanding without expressing feelings of judgingment (Johnson, Roberts, 1996).

·         Encourage expression of feelings, and acknowledge acceptance of them. Active listening is a tool used by nurses to enable them to listen to all ideas and feelings without judgment. Active listening may help clients to express themselves (Johnson, Roberts, 1996). A client's ability to express a negative emotion can be a very healthy sign; strong emotions are potentially dangerous if not expressed (Barry, 1994).

·         Give client time to initiate interactions. After an appropriate amount of time is allowed, approach client in an accepting and nonjudgmental manner. Clients who have feelings of hopelessness need extra time to initiate relationships and sometimes are not able to. Approaching the client in an unhurried, nonjudgmental manner allows the client to feel secure and provides an atmosphere conducive to venting fears and asking questions (Anderson, 1992).

·         Encourage client to participate in group activities. Group activities provide social support and help the client to identify alternative ways to problem-solve.

·         Encourage exercise of the mind to alleviate boredom. Watching or listening to the news, listening to music, and writing letters help to relieve the monotomy of hospitalization. Focusing attention outside the self can decrease thoughts of hopelessness (Wake, Miller, 1992). Boredom may become a serious problem, leading to apathy, loss of hope, and depression (Anderson, 1992).

·         Review client's strengths with client. Have client list own strengths on a note card and carry this list for future reference. Having individual worth affirmed inspires hope (Cutcliffe, 1998). Listing strengths provides reinforcement of positive self-regard.

·         Use humor as appropriate. Humor is an effective intervention for hopelessness (Hunt, 1993).

·         Involve family and significant others in plan of care. The importance of the need for hope has been emphasized by families during the critical illness of a family member (Johnson, Roberts, 1996). Frequent meetings between the staff and family can creat a safe, positive atmosphere for the discussion of feelings (Anderson, 1992).

·         Encourage family and significant others to express care, hope, and love for client. Helping the family to provide client reinforcement, to understand the client's feelings, and to be physically present and involved in care are strategies that enable the family to alter the client's hope state (Wake, Miller, 1992). Clients awaiting transplants had only one alternative, and that was hoping to receive a transplant. These clients solicited mutually supportive relationships. They sought social and emotional support from staff, family, clergy, and friends, and it was the intensity of these social relationships that enabled them to survive the precarious nature of their physical conditions (Morse, Doberneck, 1995).

·         Use touch, if appropriate and with permission, to demonstrate caring, and encourage the family to do the same. Human touch and human presence may in some way directly and/or indirectly restore the human-centered dignity and affirmation of being that is necessary for the emergence of hope (Cutcliffe, 1998).

·         For additional interventions, see care plans for Spiritual distress, Readiness for enhanced Spiritual well-being, and Disturbed Sleep pattern.

Geriatric

·         Assess for clinical signs and symptoms of depression; differentiate depression from functional or organic dementia. Hopelessness and suicidal wishes in older adults are present with high levels of depressive symptoms suggestive of treatable pathology (Uncapher et al, 1998). It can be difficult to distinguish depression from dementia in people >65 years of age because some symptoms (e.g., disorientation, memory loss, and distractibility) may suggest dementia. Concurrent medical illnesses, prescription medications, and concealed alcohol or substance abuse can also appear to be dementia (Agency for Health Care Policy and Research, 1993).

·         If depression is suspected, confer with primary physician regarding referral for mental health. In older adults, hopelessness and suicidal wishes are present with high levels of depressive symptoms suggestive of treatable pathology (Uncapher et al, 1998).

·         Take threats of self-harm or suicide seriously. The elderly have the highest rate of completed suicide of all age groups (Uncapher et al, 1998). Hopelessness is often linked to depression and suicidal ideation in the elderly. Elderly people who are depressed or have experienced recent losses and live alone are at the highest risk (Uncapher et al, 1998).

·         Identify significant losses that might be leading to feelings of hopelessness.

·         Discuss stages of emotional responses to multiple losses.

·         Use reminiscence and life-review therapies to identify past coping skills. Help clients acknowledge positive accomplishments and review survival of past illnesses to promote hope for dealing with current illness (Johnson, Dahlen, Roberts, 1997). Reminiscence can activate past sources of self-esteem and aid coping (Nugent, 1995). Memories and reminiscence have been used successfully with elderly persons to evoke pleasure and achieve therapeutic goals (Woods, Ashley, 1995).

·         Express hope to client, and give positive feedback whenever appropriate. Sharing hope with a client who is experiencing hopelessness was identified as helpful for redirecting thoughts (Wake, Miller, 1992).

·         Identify client's past and current sources of spirituality. Help client explore life and identify those experiences that are noteworthy. Clients may want to read the Bible or have it read to them. Spirituality is often identified by clients as a bridge between hopelessness and a sense of meaning (Fryback, Reinert, 1999).

·         Use simulated presence therapy (SPT). SPT is a personalized audiotape composed of a family member's or caregiver's portion of a telephone conversation and soundless spaces that correspond to the client's side of the conversation. On the SPT audiotape, a caregiver "converses" about cherished memories, loved ones, family antidotes, and other valued experiences of the client's life. The SPT audiotape is played by using headphones and a lightweight automatic-reverse cassette player that is inserted into a hip pack. (SPT is a patented product of SIM-PRES Inc., Boston, Massachusetts.) Recorded messages can be used for proximity enhancement. Proximity enhancement helps to remove the threat of distant loved ones at a time of trauma (Johnson, Roberts, 1996). SPT builds on strengths of cognitively impaired elderly people because it relies on their remote memory, which is more likely to be retained than their recent memory. SPT produces a positive environment for cognitively impaired elderly people; the selected memories of SPT seem to provide enough stimulation to evoke the elder's interest, involvement, and pleasure (Woods, Ashley, 1995).

·         Encourage visits from children. Children stimulate a sense of hope in many older adults (Gaskins, Forte, 1995).

·         Position clients by window, take them outside, or encourage activities such as gardening (if ability allows). Any change in environment breaks the monotony that can lead to hopelessness (Wake, Miller, 1992). Enjoyment of nature fosters hope (Gaskins, Forte, 1995).

Multicultural

·         Assess for the influence of cultural beliefs, norms, and values on the client's feelings of hopelessness. The client's expressions of hopelessness may be based on cultural perceptions (Leininger, 1996).

·         Assess the role of fatalism on the client's expression of hopelessness. Fatalistic perspectives, which influence health behaviors in some African-American and Latino populations, involve the belief that you cannot control your own fate (Phillips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).

·         Encourage spirituality as a source of support for hopelessness. Blacks and Latinos may identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Samuel-Hodge et al, 2000; Bourjolly, 1998; Mapp, Hudson, 1997).

·         Validate the client's feelings regarding the impact of health status on current lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

·         Assess for isolation within the family unit. Encourage client to participate in family activities. If client cannot participate, encourage him or her to be in the same area and watch family activities. If possible, move client's bed or primary sitting place to active household area. Participation in events increases energy and promotes a sense of belonging.

·         If depression is suspected, confer with primary physician regarding referral for mental health. In older adults, hopelessness and suicidal wishes are present with high levels of depressive symptoms suggestive of treatable pathology (Uncapher et al, 1998).

·         Reminisce with client about his or her life. Help clients acknowledge positive accomplishments and review survival of past illnesses to promote hope for dealing with current illness (Johnson, Dahlen, Roberts, 1997). Reminiscence can activate past sources of self-esteem and aid coping (Nugent, 1995).

·         Identify areas in which client can have control. Allow client to set achievable goals in these areas. Restoring control over the illness can increase the physiological sense of hope (Johnson, Dahlen, Roberts, 1997).

·         If illness precipitated the hopelessness, discuss knowledge of and previous experience with the disease. Help client to identify own strengths. Uncertainty is a danger when it results in pessimism. Knowledge of and previous experience with the disease decrease uncertainty.

·         Provide plant or pet therapy if possible. Caring for pets or plants helps to redefine the client's identity and makes him or her feel needed and loved.

·         Provide a safe environment so client cannot harm self. (See also no-suicide contract in following section). Provide one-to-one contact when necessary. Refer client for immediate mental health treatment if needed. Hopelessness is an accurate indicator of suicidal risk. A safe environment reassures the client.

Client/Family Teaching

·         Provide information regarding client's condition, treatment plan, and progress. Honest information regarding these issues in terms that the family can understand can give the family a sense of control and may allay some anxiety (Johnson, Roberts, 1996).

·         Teach use of stress reduction techniques, relaxation, and imagery. Many cassette tapes on relaxation and meditation are available. Assist the client with relaxation based on the client's preference from the initial assessment. These techniques reduce physical stressors, which in turn increases the physiological sense of hope (Johnson, Dahlen, Roberts, 1997). Relaxation techniques, desensitization, and guided imagery can help clients cope, increase their control, and allay anxiety (Narsavage, 1997).

·         Encourage families to express love, concern, and encouragement, and allow client to vent feelings. Helping the family to provide positive client reinforcement, to understand the client's feelings, and to be physically present and involved in care are strategies that enable the family to alter the client's hope state (Wake, Miller, 1992). One study showed that hope is partially sustained through relationships with the social network—families. The availability of significant sources of support can perpetuate hopefulness with cardiac transplant recipients (Hirth, Stewart, 1994).

·         Refer client to self-help groups such as I Can Cope and Make Today Count. These groups allow the client to recognize the love and care of others, and they promote a sense of belonging (Bulechek, McCloskey, 1992).

·         Supply a crisis phone number, and secure a no-suicide contract from the client stating that the crisis number will be used if thoughts of self-harm occur. A no-suicide contract is one type of intervention used with clients who have suicidal thoughts (Valente, 1989).